Nonoperative Orthopaedic Conditions

7	NONOPERATIVE ORTHOPAEDIC CONDITIONS Rebekah Belayneh and Kenneth A. Egol

I. Goals of Treatment and Outcome Expectations

The majority of musculoskeletal complaints are treated with nonoperative therapies. The primary goals of nonoperative management for an orthopaedic patient are to decrease pain, maximize functional outcomes, and restore the patient’s ability to perform daily activities of living in a timely manner after treatment. These goals can be accomplished with comprehensive understanding of the entire injury or condition, including fracture, bone deformities, soft-tissue injuries, skin manifestations, swelling, location of pain and/or tenderness, and the overall mechanical demands of the joint involved. Goals of treatment and expected functional and health-related quality of life outcomes can be established with a full appreciation of the injury.¹

For a nonoperative orthopaedic fracture patient, treatment should focus on anatomic reduction of the injury (if a fracture or dislocation) and its maintenance to prevent permanent effects and restore potential full functionality. Every attempt should be made to not only obtain reduction, but also maintain it throughout the period of fracture healing; even the smallest displacement, incongruity, or imperfect alignment may cause permanent issues with the affected limb.^2,3 Adequate pain management can be achieved through the use of pharmacologic therapies such as narcotics and other pain relievers. Other treatment modalities for orthopaedic fracture patients such as physical therapy, activity modification, ice, heat, and massage also contribute to the goals of adequate pain management and augmentation of functionality.

For orthopaedic patients with inflammatory conditions such as systemic lupus erythematosus or rheumatoid arthritis, treatment goals include reduction of pain, inflammation and stiffness, and preservation of the joints involved, specifically, the reduction or prevention of joint damage. This can be achieved pharmacologically with nonsteroidal anti-inflammatory drugs (NSAIDs), methotrexate, sulfasalazine, cyclosporine, and disease-modifying antirheumatic drugs. Strides should also be made in maintaining the functional ability of the joint and improving the joint’s range of motion, which can be accomplished with the use of physical therapy.4,5

For conditions of overuse such as osteoarthritis or low back pain, the goals of treatment are reduction of pain and inflammation as well as the maintenance of functionality of involved joints. This, too, can be achieved pharmacologically with the use of NSAIDs and corticosteroid injections as well as through physical therapy.

Outcome expectations are determined by the nature of the orthopaedic injury itself and the process of healing. However, for a patient with an orthopaedic injury treated nonoperatively, outcome expectations should be based on being pain free and regaining preinjury range of motion, with minimal or no limitations in ability to participate in exercise and sport. Patient outcome expectations are determined by the information patients are provided by physicians. Studies have demonstrated that relaying realistic goals and outcome expectations to patients not only contributes to the formation of patient expectations but can also optimally influence actual outcomes.^6–8

II. PHYSICAL THERAPY

Physical therapy is the cornerstone of injury rehabilitation, and it has the ability to improve outcomes of orthopaedic injuries with or without surgical management, although this largely depends on the location and nature of the orthopaedic injury or condition.^9–14 This treatment modality aims for preinjury functional restoration through increasing muscle strength, joint mobility, patient endurance, and improving muscle coordination and control. Strength training programs involve movement against resistance. Increased endurance, which improves capacity for activities of daily living (ADLs), is achieved through endurance exercises that involve continuous activity like walking and swimming. Range of motion and flexibility can be improved by prolonged, low-intensity stretching exercises. Physical therapy employs various other modalities to treat orthopaedic injuries as well such as acupuncture/dry needling, iontophoresis, cryotherapy, electrotherapy, and hot and cold packs. Physiotherapy should be discontinued when goals have been met or there is lack of progress. Examples of physical therapy orders for a variety of nonoperative orthopaedic injuries and conditions are provided in Table 7-1.

III. SPLINTING AND CASTING (ALSO SEE CHAPTERS 8 AND 11)

Management of a wide variety of musculoskeletal conditions, such as fractures, sprains, strains, and even postoperative treatment of soft-tissue repairs, requires use of a splint (Figure 7-1) or cast (Figure 7-2)Both splints and casts share several common purposes: immobilization, reduction of pain, protection from further injury, and correction of a particular musculoskeletal injury. Casts are circumferential immobilizers that provide superior immobilization to splints. Casts are circumferential immobilizers that provide superior immobilization. They are generally reserved for definitive fracture management owing to their ability to facilitate healing by maintaining bones in appropriate alignment for extended periods of time. Additionally, casts are best used for an injury where edema has resolved or is considered insignificant to proper immobilization. A patient’s extremity may not be ready for a cast owing to swelling until several days to weeks following acute injury. Splints, however, are noncircumferential devices used in acute scenarios that immobilize along three or fewer margins of an injured extremity. This contributes to the ability of splints to accommodate for swelling. This quality makes splints ideal for the management of a variety of acute musculoskeletal conditions in which edema inherent to the acute inflammatory response is imminent, such as acute fractures or sprains. Splints may also be used for the initial stabilization of reduced, displaced, or unstable fractures prior to orthopaedic surgical intervention.15(pp494-502),16

TABLE
7-1

Physical Therapy Orders for Common Nonoperative Orthopaedic Conditions

Common Orthopaedic Conditions	Physical Therapy Orders
Ankle sprain	Acute: rest, ice, compression, and elevation of injured area Subacute: partial weight bearing, sagittal plane exercises and movement, isometric exercises of peroneal muscles Postacute: range of motion and muscle strengthening exercises, weight bearing, and proprioceptive training with progression to functional activities^20,22
Ankle fracture	Acute: rest, ice, compression, and elevation of injured area Subacute: elevation, isometric exercises of immobilized muscles, strengthening of all other muscles Postacute: improvement of osteokinematic and arthrokinematic range of motion with progression to functional activities and weight bearing⁹
Trochanteric bursitis	Ultrasound, hydrocortisone-based coupling agent (phonophoresis), ionotophoresis, ice massage, and NSAIDs²³
Low back pain	Core stability and dynamic stabilization exercises. Core stability exercises target the core of the body, including the lower back, trunk, and abdominal muscles (ie, sit-ups, back extensions, and abdominal muscles). Dynamic stabilization exercises keep the core steady as at least one extremity is moved (ie, exercise balls and balancing machines)²⁴
Osteoarthritis of hip	Capsular stretch techniques and long axis distraction techniques for pain control and improvement in function^11,16
Impingement syndrome of the rotator cuff	Ice/heat, ultrasound/iontophoresis, massage, anterior–posterior gliding, long-term stretching, resistance exercises, and modification of activity¹⁵
Rheumatoid arthritis	Heat and cold, ultrasound, passive and active exercises for range of motion, dynamic exercise, rest with splinting, finger splinting, relaxation techniques²⁵
Ankylosing spondylitis	Heat and cold, postural training, range of motion stretching, hydrotherapy²⁶