Treatment of orthopaedic disorders

4 Treatment of orthopaedic disorders


Orthopaedic treatment falls into three categories:


1 no treatment – simply reassurance or advice

2 non-operative treatment

3 operative treatment.

In every case these three possibilities of treatment should be considered one by one in the order given. At least half of the patients attending orthopaedic out-patient clinics (excluding cases of fracture) do not require treatment: all that they need is reassurance and advice. In many cases the sole reason for the patient’s attendance is a fear that there may be cancer, tuberculosis, impending paralysis, crippling arthritis, or other serious disease. If reassurance can be given that there is no evidence of serious disease the patient goes away satisfied, and the symptoms immediately become less disturbing.


If active treatment seems to be required it is a good general principle that whenever practicable a trial should be given first to non-operative measures; though obviously there are occasions when early or indeed immediate operation must be advised. Most orthopaedic operations fall into the category of ‘luxury’ rather than life-saving procedures. Consequently the patient should seldom be persuaded to submit to operation: rather the surgeon should have to be persuaded to undertake it. When one is undecided whether to advise conservative treatment or operation it is wise always to err on the side of non-intervention.



METHODS OF NON-OPERATIVE TREATMENT



REST


Since the days of H. O. Thomas (p. 3), who, more than a century ago, emphasised its value in diseases of the spine and limbs, rest has been one of the mainstays of orthopaedic treatment. Complete rest demands recumbency in bed – which, for the most part, is deprecated today – or immobilisation of the diseased part in plaster. But by ‘rest’ the modern orthopaedic surgeon does not usually mean complete inactivity or immobility. Often he means no more than ‘relative rest’, implying simply a reduction of accustomed activity and avoidance of strain. Indeed complete rest is enjoined much less often now than it was in the past, because diseases for which rest was previously important, such as poliomyelitis or tuberculosis, can now be prevented or are more readily amenable to specific remedies such as antibacterial agents. Complete rest after operations, formerly favoured, has given place in most cases to the earliest possible resumption of activity.



SUPPORT


Rest and support often go together; but there are occasions when support is needed but not rest – for example, to stabilise a joint rendered insecure by muscle paralysis, or to prevent the development of deformity. When support is to be temporary it can be provided by a cast or splint made from plaster of Paris or from one of the newer splinting materials. When it is to be prolonged or permanent an individually made surgical appliance, or orthosis, is required. Examples in common use are spinal braces, cervical collars, wrist supports, walking calipers, knee and ankle orthoses, and devices to control drop foot (Figs 11.3–Figs 11.5, pp. 177–8).



PHYSIOTHERAPY


Physiotherapy in its various forms occupies an important place in the non-operative and post-operative treatments of orthopaedic disabilities. Emphasis on evidence-based practice has helped to produce an awareness among physiotherapists of the hazards as well as the merits of treatment. This has led to a correct emphasis being placed upon the value in many conditions of active rather than of passive treatment: in other words, of helping the patient to help him/herself. This approach is particularly rewarding in the rehabilitation of patients after injury or after operations, and in diseases such as poliomyelitis, cerebral palsy, hemiplegia, peripheral nerve palsies and mechanical low back pain. When it is used, physiotherapy should be pursued thoroughly. A number of different physiotherapy interventions have evolved over the years. These may be active, passive or a combination of the two. Passive approaches involve a range of different techniques carried out on the patient by the therapist. Active approaches require active involvement by the patient, either by exercising or changing behaviour.



Active intervention


Physiotherapists use the term physical activity, exercise and physical fitness to describe active interventions, but they are often used loosely and interchangeably. The term ‘exercise’ is used to include a range of methods from isometric stabilising exercise through to intensive aerobic fitness programmes. Exercise programmes aim to (1) strengthen specific muscles, (2) stretch soft tissues, (3) mobilise joints and (4) improve coordination of muscles. Exercise to improve coordination is of particular importance in cerebral palsy, multiple sclerosis, ankle and knee injuries.


Physical fitness is a multi-dimensional concept that has been defined as a set of attributes that people possess or achieve that relates to the ability to perform physical activity, and is comprised of skill-related, health-related and physiological components. Physical fitness programmes vary in intensity, design and delivery and are generally supervised in a group, but can be offered to patients on an individual basis. They usually include aerobic exercise with an aim to improve overall cardiovascular fitness, as well as specific exercises.



Hydrotherapy


Hydrotherapy is a valuable way of allowing active pain-free movements of all joints in warm water. The warmth and buoyancy of the water relieve the muscle spasm and can help to reduce pain and increase the range of movement. Hydrotherapy is often particularly useful in the treatment of rheumatoid arthritis.



Passive interventions


These techniques are carried out by the therapist and do not require any active participation by the patient. The chief use of passive movements, or ‘mobilisation’ is to preserve full mobility when the patient is unable to move the joint actively – i.e. when the muscles are paralysed or severed. They are important after nerve injuries, especially to preserve mobility in the hand, and in poliomyelitis in countries where it still occurs. Recently, the use of machines to provide continuous passive motion of joints after operation or injury has become popular to minimise complications and encourage healing of articular cartilage.



Manual therapy


Manual therapy includes a wide range of joint mobilisation and manipulation techniques used by osteopaths and chiropractors, as well as physiotherapists. It also includes mobilisation of soft tissue. The manipulation can be high-velocity thrust applied at the end of joint range (such as to spinal joints) or a more gentle passive low-velocity mobilisation applied in various parts of the available joint range.



Soft-tissue techniques


Soft-tissue techniques include interventions that aim to mobilise soft tissue, either by massage or passive stretching techniques. Massage techniques range from Swedish massage to deep connective tissue massage and stretching of neural tissue.



Traction


Traction for the spine is carried out both manually or using a motorised traction couch. The duration and magnitude of force can be varied, and if motorised traction is applied it can be carried out continuously or intermittently. The rationale for the use of traction therapy is based on the mechanical effects of traction on the spine, mainly stretching structures. These mechanisms are thought to cause separation of the vertebrae, widening of the intervertebral foramina, movement of the facet joints and stretching of spinal muscles and ligaments. The proposed mechanisms are not supported by research findings.



Electrotherapy


The theoretical basis for the use of these modalities is weak and they are not recommended in national or international guidelines. However, they continue to be used in clinical practice. Transcutaneous electrical nerve stimulation (TENS) and interferential therapy, short wave diathermy, laser therapy are all used by physiotherapists with the aim of providing pain relief. The interference effect uses two different medium-frequency alternating currents applied simultaneously through two electrodes to induce a current at the site of their interaction in the deep tissues. Transcutaneous nerve stimulation uses direct current pulses of adjustable frequency to stimulate the larger sensory nerve fibres selectively, and thereby to set up a gate control mechanism blocking the activity of the small fibres which conduct pain signals.



Ultrasound


Ultrasound waves at approximately 106 Hz can be projected as a beam from a transducer to induce a heating effect in deep tissues. They may also produce benefit from their mechanical and chemical effects on collagen and proteoglycans. Ultrasound is frequently used to reduce post-traumatic haematoma, oedema and adhesions of joints and their associated soft tissues.



ALTERNATIVE THERAPIES


There has been an increasing trend for patients to seek alternative therapy (i.e. chiropractic therapy, osteopathy, acupuncture, massage and homeopathy) to relieve musculoskeletal symptoms. However, no strong evidence has emerged over the last decade that suggests that alternative therapy is any more beneficial than physiotherapy.



LOCAL INJECTIONS


The indications for local injections fall into two groups:


1 osteoarthritis or rheumatoid arthritis, in which the substance (usually hydrocortisone with or without a local anaesthetic solution) is injected directly into the affected joint with rigid aseptic precautions

2 extra-articular lesions of the type often ascribed (for want of more precise knowledge) to chronic strain, as exemplified by tennis elbow, tendonitis about the shoulder, and certain types of back pain.

The response depends upon the nature of the basic lesion: permanent relief is often gained in extra-articular lesions such as tennis elbow, but in arthritis the benefit is often no more than temporary, and repeated injections are seldom to be recommended.



DRUGS


Drugs have rather a small place in orthopaedic practice. Those used may be placed in eight categories:


1 antibacterial agents and antibiotics

2 analgesics

3 sedatives

4 anti-inflammatory drugs

5 hormone-like drugs

6 anti-osteoporosis drugs

7 specific drugs

8 cytotoxic drugs.

Antibacterial agents are of immense importance in infective lesions, especially in acute osteomyelitis and acute pyogenic arthritis. To be successful treatment must be begun very early. These drugs are also of definite value in certain chronic infections, notably in tuberculosis.


Analgesics should be used as little as possible. Many orthopaedic disorders are prolonged for many weeks or months, and it is undesirable to prescribe any but the mildest analgesics continuously over long periods, except for incurable malignant disease.


Sedatives may be given if needed to promote sleep, but as with analgesics the rule should be to prescribe no more than is really necessary.


Anti-inflammatory drugs are those that damp down the excessive inflammatory response that may occur especially in rheumatoid arthritis and related disorders, by inhibiting the cyclo-oxygenase enzymes responsible for prostaglandin formation. Non-steroidal anti-inflammatory drugs are generally to be preferred – especially in the first instance – and they are a mainstay in the treatment of rheumatoid arthritis. Many of these drugs also have an analgesic action. The powerful steroids cortisone, prednisolone, and their analogues should be used with extreme caution and indeed should be avoided altogether whenever possible, because through their side effects they may sometimes do more harm than good. Nevertheless there are times when their use may be justified – as for instance in acute exacerbations of rheumatoid arthritis, and especially in polymyalgia rheumatica and giant-cell arteritis (see p. 166).


Hormone-like drugs include the corticosteroids noted above, and sex hormones or analogues used for the prevention of osteoporosis in post-menopausal women and for the control of certain metastatic tumours such as hormone-dependent breast and prostatic tumours. These are being increasingly replaced by the bisphosphonates, a family of drugs which block the resorption of bone mineral.


Anti-osteoporosis drugs. Hormone replacement therapy and the SERMS (selective oestrogen receptor modulators) have largely been replaced by the bisphosphonates which block bone resorption and by anabolic agents such as parathyroid hormone and strontium.


Specific drugs work well in certain special diseases. Examples are vitamin C for scurvy, vitamin D for rickets and salicylates for the arthritis of rheumatic fever.


Cytotoxic drugs form the basis of chemotherapy for malignant tumours. These anti-cancer drugs include cyclophosphamide, melphalan, vincristine, doxorubicin, and methotrexate. They have serious side effects and are used only under expert supervision.



MANIPULATION


Treatment by manipulation is practised widely by orthopaedic surgeons and by others in allied professions. Strictly, the term might legitimately be used to include the passive movements, or ‘mobilisations’, that form part of the daily activities of a physiotherapy department and which have already been referred to above: but it is used here in a more restricted sense, to describe passive movements of joints, bones, or soft tissues carried out by the surgeon – with or without an anaesthetic, and often forcefully – as a deliberate step in treatment.


The subject will be considered under three general headings:


1 manipulation for correction of deformity

2 manipulation to improve the range of movements at a stiff joint

3 manipulation for relief of chronic pain in or about a joint, especially in the neck or spine.


Manipulation for correction of deformity


In this category manipulation has its most obvious application in the reduction of fractures and dislocations. It is also used to overcome deformity from contracted or short soft tissues – as, for example, in congenital club foot. Yet another simple example is the forcible subcutaneous rupture and dispersal of a ganglion over the dorsum of the wrist.


Technique. An anaesthetic may or may not be required, according to the nature of the condition that is being treated. In many instances – as in manipulation for a fracture or dislocation – the aim is to secure full reduction at the one sitting; but in resistant deformities such as club foot repeated manipulation may be required at intervals of a week or so, a little further improvement being gained each time.


Subsequent management. After manipulation for a deformity that is liable to recur – as in most cases of displaced fracture and in chronic deformities of joints – the limb is usually immobilised on a splint or in plaster to maintain the correction. In cases of resistant deformity gradual yielding of the soft tissue allows re-application of the splint in a more favourable position each time it is changed.



Manipulation for joint stiffness


The type of case mainly concerned with here is that in which a joint shows serious limitation of movement after an acute injury – usually a fracture of a limb bone. ‘Frozen’ shoulder (periarthritis) in its non-active stage may also be included in this category. In such cases the stiffness is caused by adhesions either within the joint itself or, more often, in the soft tissues about or near the joint. Forcible manipulation by the surgeon is not required very often for stiffness of this type, because it will usually respond gradually to treatment by active exercises under the care of a physiotherapist, combined with increasing use of the limb.


The joint that is most amenable to manipulation is the knee. The shoulder and the joints of the foot may also respond. Manipulation of the elbow and of the joints of the hand may increase the stiffness and should not be attempted.


Technique

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Jun 5, 2016 | Posted by in ORTHOPEDIC | Comments Off on Treatment of orthopaedic disorders

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