A Clinical Lecture ON THE ORTHOPAEDIC TREATMENT OF POLIOMYELITIS
Authors: H. A. T. Fairbank
Journal: BMJ (1921)

THE surgical treatment of politmyelitis includes a great deal which can be carried out by any practitioner, whether physician, surgeon, or both.It is customary for purposes of treatment to divide the course of a case into three stages: the early, acute stage, which lasts while there is pain and tenderness in the muscles; the second or convalescent stage, during which the recovery of power is taking place-it lasts to the end of the first and sometimes the end of the second year; and the third stage, which begins after the lapse of two years: tintil this stage all reconstructive surgery is delayed. FIRST STAGN.During the first stage the spinal cord is the seat of a .haemorrhagicinflammation, which is gradually subsiding.Those aonterior horn cells which have been only temporarily thrown out of action gradually return to health and perform their normal functions, while others which have been damaged too severely to recover degenerate.The flaccid paralysis affects a more or less wide range of muscles-very often a much wider range than would be suspected from an ex-amination of the patient a few months later.Unfortunately we cannot tell at first which muscles will recover rapidly, which will recover more or less completely though slowly, and which will remain com- pletely paralysed.Therefore we must treat all the muscles alike until such time as recovery indicates which require special care.The first essential of treatment is rest, both for the spinal cord and the affected muscles.All patients are best kept in bed for a time; Batten' insisted on three weeks, even in mild cases.Steps should be taken to provide absolute rest for all the affected muscles, and this involves rest for all their opponents as well should these not be paralysed.There seems to be a great tendency to delay doing anything, particularly in a bad case, until t1T acute stage has passed off.Thlis is, I think, a mistake.Splints or other fixation apparatus should be applied at the earliest possible moment, the limbs being fixed in the neutral position.Without fixation deformities are certain to occur.The apophthegtn, "Prevention is bettor than Cure," applies with as much force in this instance as in any Other.Tlle neutral position is one in which, as far as possible, no one muscle or group of muscles around a joint is favoured to the detriment of others.Thus the foot is put at a right angle, tlle knees are straight, the hips are straight and the spine flat.The position of the hip and knee joints can be assured by rest on a flat bed, with a towel and a couple of sandbags to keep the knee from flexing, but tlle feet require some simple splint of tin, wood or plaster-of-Paris to hold them at the riglht angle.As regards the arm, the best position is one of abduction of the shoulder, flexion of the elbow to a right angle, supination of the forearm and dorsiflexion of the wrist.This position is not entirely governed by a desire to find the neutral position, but partly with an eye to favouring those muscles which we know recover with difficulty, and of which the recovery is more important than that of tlleir opponents; for instance, the deltoid, hiceps, etc.This position can be retained by sandbags while the patient is lying flat, but a splint is necessary as soon as he sits or stands.The simplest splint is one made of tin.Such splints serve a double purpose-to give rest and to prevent deformity.