Having determined that the joint is in a condition in which the question of 'breaking down' may be legitimately considered - in other words, that the joint is not in a condition of bony ankylosis - the next point to be decided is whether the breaking down is practicable on the one hand and desirable on the other. With regard to practicability it may be at once conceded that any joint which has become stiff from any other condition than that of bony ankylosis can as a rule be broken down if sufficient force is used, provided that the anatomical relations of the parts are normal; but sometimes the strength of the adhesions is greater than the strength of the bone, in which case a fracture in or near the joint may occur instead of a breaking down of the adhesions.

In determining the desirability of the breaking down of a joint the following points require primary consideration: - 1. The history of the case. 2. The condition of the articulation. 3. The state of the soft parts around the joint. 4. The condition of the muscles acting on the joint. 5. The condition of the bones.

1. The History Of The Case

This is important in relation to the causes of the stiffness. Speaking generally, cases in which the history points to tubercle, to inflammation during malaria, and to disorganisation following upon enteric and the exanthemata may be regarded as unfavourable for sudden breaking down; cases, on the other hand, in which the history points to injury, rheumatism, pyaemia, osteo-arthritis, gonorrhoea, syphilis, and to various nondescript types of arthritis, may be regarded as favourable for the treatment, subject of course to the necessary modifications indicated by local conditions which will be dealt with presently.

2. The Condition Of The Articulation

The point of first importance here is that the relation of the articular surfaces should be normal, that there should in fact be no displacement, partial or complete. In the case of the knee the free mobility or fixation of the patella is of much moment, since, if the patella be fixed, the bone may be fractured during the bending of the joint, an accident which I have witnessed more than once; if the patella is freely movable it is perfectly safe from injury during forcible flexion of the knee.

Apart from the conditions just mentioned, the joint may be of normal temperature to the touch or it may be hot; further, it may contain fluid in excess or it may not. A heated joint without fluid is the least favourable for radical measures, since such a joint usually contains a limited tuberculous focus which upon the breaking down of the joint is almost certain to become acute and diffuse. Moderate heat with effusion is no bar to radical measures, indeed is at times a strong indication for their adoption, since the effusion and heat are often due to the dragging of adhesions, which, if broken through, cease to trouble. All other things being equal, the less the rigidity of a joint the more favourable it is for treatment by immediate forcible flexion, provided that the defect is inside the articulation. In some cases, when the defect is extra-articular, it is otherwise.

3. The State Of The Soft Farts Around The Joint

Scars, sinuses, and general adhesion of the soft parts about a joint do not as a rule contra-indicate forcible bending, if these conditions are confined to the extensor aspect and if no nerve is involved in the cicatrices. Should the parts be reduced merely to a thin ill-nourished scar area, of course the risk of splitting this ill-nourished tissue must be borne in mind. Contracted scars and shortened normal tissues on the flexor side of a joint which has been for a long time flexed are very important, and if the flexion is extreme the propriety of extending the joint forcibly must be carefully weighed. As a rule in such cases immediate forcible extension is contra-indicated, gradual extension by the aid of massage and gentle passive movements being preferable in consequence of the tendency of the contracted skin and subcutaneous tissues to split transversely during violent extension. I well remember a remarkable case of this kind occurring in the theatre of St. George's Hospital. A patient, whose knee had been flexed for some years, was placed under an anaesthetic for purposes of examination, as the defective joint, for sufficient reason, had either to be straightened or removed. A somewhat forcible attempt to extend the limb was followed by considerable success, but the soft parts across the middle of the popliteal space split transversely, leaving the main vessels and nerves exposed. Amputation was immediately performed. This case is an extreme one, but illustrates the point under discussion. In fact it is true generally that forcible flexion of stiff joints is not only more successful than forcible extension, but is comparatively devoid of risk if intelligently practised. The most difficult cases of stiff joint of all to deal with in my experience are those in which a nerve (usually the ulnar at the elbow) is involved in a cicatrix outside the joint. The pain in some of these cases makes anything like forcible bending quite impossible unless the nerve can be freed from the cicatrix in which it is involved - a measure which is sometimes impossible without producing paralysis, if it does not already exist, or increasing it if already present. I have under my care at the present moment a case of moderately stiff elbow from gun-shot wound, which so far as the joint itself is concerned is perfectly amenable to treatment; but, in consequence of some sloughing which occurred at the inner side of the articulation, the ulnar nerve is so densely implicated in scar tissue that any material movement excites intolerable pain and temporary paresis. The case is practically outside the limits of active surgical treatment, since the nerve cannot be freed from its scar tissue without suffering considerable damage, and the remaining alternative, excision of the joint, does not promise a result sufficiently better than the rather stiff joint which now exists to make it preferable. This again is an extreme case, but it is none the less instructive, particularly as the case was sent for treatment solely from the point of view of the stiff joint, the importance of the nerve complication not having been recognised. It is always well to bear in mind in cases of stiff joint that some of the greatest pain during the radical treatment may arise from conditions apart from the joint itself.