spoon and
gouge, the latter procedure being preferred in the case of the
_calcaneus_ to conserve the stability of the heel. When several bones
and joints are simultaneously affected, and there are sinuses with
mixed infection, amputation is usually indicated, especially in adults.

#Tuberculous dactylitis# is the name applied to a diffuse form of the
disease as it affects the phalanges, metacarpal or metatarsal bones. The
lesion presents, on a small scale, all the anatomical changes that have
been described as occurring in the medulla of the tibia or ulna, and
they are easily followed in skiagrams. A periosteal type of dactylitis
is also met with.

The _clinical features_ are those of a spindle-shaped swelling of a
finger or toe, indolent, painless, and interfering but little with the
function of the digit. Recovery may eventually occur without
suppuration, but it is common to have the formation of a cold abscess,
which bursts and forms one or more sinuses. It may be difficult to
differentiate tuberculous dactylitis from the enlargement of the
phalanges in inherited syphilis (syphilitic dactylitis), especially when
the tuberculous lesion occurs in a child who is the subject of inherited
syphilis.

[Illustration: FIG. 128.--Tuberculous Dactylitis.]

In the syphilitic lesion, skiagrams usually show a more abundant
formation of new bone, but in many cases the doubt is only cleared up by
observing the results of the tuberculin test or the effects of
anti-syphilitic treatment.

Sarcoma of a phalanx or metacarpal bone may closely resemble a
dactylitis both clinically and in skiagrams, but it is rare.

_Treatment._--Recovery under conservative measures is not uncommon, and
the functional results are usually better than those following upon
operative treatment, although in either case the affected finger is
liable to be dwarfed (Fig. 129). The finger should be immobilised in a
splint, and a Bier's bandage applied to the upper arm. Operative
interference is indicated if a cold abscess develops, if there is a
persistent sinus, or if a sequestrum has formed, a point upon which
information is obtained by examination with the X-rays. When a toe is
affected, amputation is the best treatment, but in the case of a finger
it is rarely called for. In the case of a metacarpal or metatarsal bone,
sub-periosteal resection is the procedure of choice, saving the
articular ends if possible.

[Illustration: FIG. 129.--Shortening of Mid