Key conditions and principles of orthopaedic management

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Chapter 13
Key conditions and principles of orthopaedic management

Elaine Wylie¹ and Sonya Clarke²

¹ Craigavon Area Hospital, Craigavon, Northern, Ireland

² Queen’s University Belfast, Belfast, UK

Introduction

This chapter provides an overview of the knowledge required to promote optimal care for patients presenting with common orthopaedic conditions in the young adult (and child when appropriate), adult and older person. Osteoarthritis, arthropathies, rheumatoid arthritis, the metabolic condition osteoporosis, osteomyelitis, low back pain, scoliosis, spinal stenosis and intervertebral disc disease are considered. Each condition is discussed in relation to its definition, epidemiology, diagnosis, clinical presentation and management. It will have a central nursing focus but also within the wider context of the ‘specialist nurse’ and multidisciplinary team (MDT). Management and care options will be explored with reference to best available evidence and national guidance.

Arthritis is an umbrella term that covers all forms of joint and muscle pain. Musculoskeletal diseases are widespread in the community with around 20 million people in the UK suffering from one of the many forms of arthritis. An Arthritis Research Campaign report (2002) found that nearly nine million people (19% of the population) consulted their GP for arthritis in the previous year. These conditions result in higher levels of disability and patient self-reported limitations of quality of life than heart disease or cancer. They are the commonest cause of work-limiting health problems, long standing illness and sickness absence in the UK.

Osteoarthritis

The name ‘osteoarthritis’ (OA) (also known as osteoarthrosis/degenerative joint disease) comes from three Greek words meaning bone, joint and inflammation. It is a non-inflammatory disorder of synovial joints that results in loss of hyaline cartilage and remodelling of surrounding bone. It is a chronic, progressive disorder, commonly affecting hands, hips, knees, shoulders and spine. Approximately eight million people in the UK have OA but only around one million of them will seek treatment. It is estimated that more than six million people in the UK have painful OA of the knee and more than 650 000 have painful OA of the hips (Arthritis Research UK 2011). The condition is more common in women except in hip OA, which affects men equally (Doherty et al., 2006). The prevalence of radiographic and symptomatic OA increases with age (Fransen et al., 2010) although many people with radiological evidence of OA remain asymptomatic and it is, therefore, not an inevitable consequence of ageing.

Pathogenesis

OA is a dynamic process that involves tissue production and remodelling of the joints, with a loss of hyaline cartilage, typically at the point of maximum load-bearing rather than widespread destruction. Osteophyte formation (abnormal outgrowth of cartilage that becomes ossified) occurs at the joint margin and cysts may develop in the bone – small areas of osteonecrosis caused by increased pressure on the bone when the cartilage is no longer adequate in its load distributing function (Doherty et al., 2006). Other primary and secondary pathological changes include subacromial sclerosis, thickening of the joint capsule and evidence of osteochondral bodies in the synovium.

Primary OA has no known cause, although inheritance is a considerable factor, especially in the hands (Doherty et al., 2006). Other factors include:

being female
congenital joint abnormalities
genetic polymorphisms
ethnicity with susceptibility in particular joints varying between ethnic groups
ageing.

Secondary OA occurs as a result of:

obesity
high level/high impact sport or occupational activities
repetitive and long-term occupational factors, such as repeated kneeling, twisting and handling heavy weights while standing.

Signs and symptoms

The main symptoms of OA are pain and stiffness. In the early stages, pain may be transient or even absent and progression is often slow. Pain is variable with patients having good days and bad days with pain best at the start of the day or after rest and worst with joint use and at the end of the day. Severe OA can cause pain at rest and mobility, self-care and leisure. Morning stiffness or stiffness after a period of inactivity generally lasts less than 15 to 30 minutes. Pain is typically described as dull, aching or throbbing and localised to a specific region. Crepitus may be noticeable on movement due to roughened articular surfaces and the joint may be painful on palpation. Restricted movement can be caused by pain, joint capsule thickening or the presence of osteophytes.

Squaring of the first carpal metacarpal (CMC) joint may be evident in hand OA due to osteophyte formation. Changes often occur in the distal interphalangeal joints (Heberden’s nodes) and at the proximal interphalangeal joints (Bouchard’s nodes). Once nodes have fully formed, pain and tenderness at the distal interphalangeal joints and proximal interphalangeal joints often improve but pain at the CMC joint will not improve. Hand OA can reduce grip strength, having significant implications for numerous functional activities and cause considerable frustration for patients who are no longer able to perform tasks with the same precision and strength (Hill et al., 2010).

Pain from OA of the hip is typically felt in the groin, although it can radiate down to the knee. This is often associated with reduced lower limb muscle strength due to lack of use. Patients commonly have an abnormal pattern of walking caused by weakness of the abductor muscles. OA of the foot commonly affects the first metatarsal phalangeal joint and may result in a hallux rigidus or hallux valgus deformity. This, and associated deformities, can cause pain on walking or difficulty with finding appropriate footwear. Lack of comfortable footwear or diminished strength and fitness discourages many people from pursuing usual activities, such as shopping or going out walking.

Diagnosis is usually based on history and examination. The two most important diagnostic clues are the pattern of joint involvement and the presence or absence of fever, rash or other symptoms outside the joint. As part of the physical examination, the joint should be evaluated for swelling, limitations of range of movement, pain on movement and crepitus. There is no laboratory test that is specific for osteoarthritis. Treatment is usually based on the results of diagnostic imaging. In patients with OA, X-rays may indicate narrowed joint spaces, abnormal density of the bone and presence of subacromial cysts or bony spurs. The patient’s symptoms, however, do not always correlate with X-ray findings. It is important to exclude other medical conditions that may be present. Differential diagnoses may include pseudogout, bursitis, rheumatoid arthritis and reactive arthritis.

A management plan should be considered in relation to the person’s quality of life, functional limitations and pain experience. It should aim to reduce pain and maintain or improve the individual’s mobility and encourage self-management as this provides a greater sense of self-empowerment and reduces reliance on health services and pharmacological therapies. A range of options are available that can be used in multiple combinations to achieve maximum outcome for the individual. Core treatments recommended in the Clinical Guidelines for the Management of Osteoarthritis (NICE 2008a) include exercise, appropriate weight loss and access to information.

Exercise is important in managing OA irrespective of age, comorbidity, pain severity and disability because it may reduce pain and help to improve function. It can be designed to strategically improve general mobility, function and self-efficacy. An exercise programme needs to be carefully tailored to individual needs and preferences and should not hinder the persons’ ability and enthusiasm and, consequently, delay positive behavioural change. Many individuals experience an exacerbation of pain and stiffness after exercise, although most will not have any adverse reaction to controlled exercise (Hurley et al., 2007). A reduction in weight transferred through joints, such as knees, hips and feet, may reduce the severity of the symptoms a person experiences. This may be achieved through the transfer of weight by using a walking stick or through sensible weight loss if the patient’s body mass index is excessive. Patients should be encouraged to lose weight by eating healthily and adopting a sensible programme of exercise. However, this approach is difficult for many older people struggling with basic mobility or shopping and preparing meals. It is important to consider a holistic approach to OA and its effects on lifestyle and functional abilities before advocating strict regimes of diet and exercise. The use of insoles or knee braces can improve pain, stiffness and function in the knee, while hand splints can improve function in the hand and should be considered with those experiencing symptoms (NICE 2008a). Referral to orthotics and occupational therapy services can provide assessment of biomechanical problems and appropriate orthoses to support painful joints and reduce joint pain.

Pharmacological management

Medications helpful in the management of pain include simple analgesics, non-steroidal anti-inflammatory drugs (NSAIDs) and opioids. Paracetamol is usually the first line of pharmacological pain management as it has few side effects; although anti-inflammatories provide better pain relief, paracetamol has fewer side effects. Paracetamol and codeine combinations have no demonstrable benefit over paracetamol alone (NICE 2008a). NICE (2008a) recommends using non-steroidal anti-inflammatory drugs (NSAIDs) to manage pain, but around 10–20% of people who use oral NSAIDs experience dyspepsia and risk gastric complications, which are reduced when NSAIDs are used topically and these are now the first line of treatment (Zhang et al., 2010). The development of the Cox-2 selective anti-inflammatory drug has reduced the incidence of gastric effects, but add to the risk of thrombus formation. They are also associated with a slight increase in risk of renal failure (Adam 2011).

Opioids can be very effective but their benefits can be outweighed by side effects: nausea, vomiting, dizziness and constipation. Even though the use of extended release opioids in OA improves sleep, patients can be fearful about addiction. Intra articular steroid injections of knees can be an adjunct to other pain relieving treatments (NICE, 2008a). Hyaluronan acid can also be injected into the knee joint, however, there is a lack of placebo controlled trials and some trials suggest efficacy is limited and these are not recommended by NICE (Avouac et al., 2007). Capsaicin, a topical cream based on chilli peppers, causes localised burning pain, but is then followed by pain relief and has been shown to alleviate mild to moderate pain caused by OA knee (Kosuwon et al., 2010).

Steroid or hyaluronic acid injections into the knees can bring partial pain relief for up to three months (NICE 2008a). However, there is a lack of placebo controlled trials and some trials suggest efficacy is limited (Avouac et al., 2007). Capsaicin causes localised burning pain, but as it takes a while for the body to synthesise, the capsaicin period of burning is followed by pain relief. Using the cream twice daily often means the burning sensation does not return after the first application.

Transcutaneous electrical nerve stimulation

(TENS) and acupuncture have shown to be helpful in relieving pain (Itoh et al., 2008) with anecdotal reports suggesting the application of heat or cold to joints to provide short-term pain relief. Heat can be applied by immersion in warm water, heat packs heated at home in the microwave, heat pads and wax. Cold is usually applied with an ice massage or by applying cold packs to the affected area. It is essential that a safe system for delivery is used to prevent any damage to the skin and surrounding tissues.

Most people with OA are managed in the primary care setting. However, if OA becomes severe with progressive limitation of functional and recreational activities, the opinion of an orthopaedic surgeon should be sought. Joint replacement is considered when conservative measures are unsuccessful and there is substantial impact on the person’s quality of life (refer to Chapter 14 for elective care and arthroplasty of the hip, knee and shoulder).

Spondyloarthropathies

Spondyloarthropathies (SpA) are a group of common inflammatory rheumatic disorders, characterised by axial and/or peripheral arthritis associated with enthesitis, dactylitis and potential extra-articular manifestations, such as uveitis and skin rash. These conditions share a common genetic predisposition – the HLA-B27 gene. Ankylosing spondylitis (AS) and psoriatic arthropathy are the two most common forms; Table 13.1 lists additional arthropathies.

Table 13.1 Other spondyloarthropathies

Reactive arthritis	Usually manifests itself as arthritis two to four weeks following a urogenital or enteric infection, often in patients bearing the HLA-B27 antigen. The risk of developing reactive arthritis has been shown to occur up to fifty times higher in this population, as opposed to the HLA-B27 negative population following exposure to a preceding infection.
Inflammatory bowel disease	Associated arthritis is usually a peripheral, large joint, lower limb, asymmetric oligoarthritis. It accompanies inflammatory bowel disease in about 10% of patients and occasionally pre-dates the onset of IBD. (Salvarani & Fries 2009)
Undifferentiated spondyloarthropathy or spondyloarthritis (uSpA)	This term is used to describe manifestations of spondyloarthritis in patients who do not meet criteria for any well-defined spondyloarthropathy. There is a female predominance of 1:3 and the clinical manifestations of this type of spondyloarthropathy are basically similar to all other spondyloarthropathies with fewer extra-articular manifestations.

Ankylosing spondylitis (AS)

AS is a systemic, chronic inflammatory disease that affects the axial skeleton, causing inflammatory back pain, which can lead to structural and functional impairment. The condition has an insidious onset, often over a period of several years, and typically occurs before the age of 30; usually between the late teens and twenties with a male to female ratio of 3:1 (Sieper et al., 2002). It affects men and women differently; women experience less severe disease with less involvement of the spine than men. However, women have more symptoms in the knees, wrists, ankles, hips and pelvis, whereas men most commonly experience involvement of the spine, pelvis, chest wall, hips, shoulders and feet (NASS, 2004). The cause is unknown. There are two central features: inflammation and new bone formation, especially in the spine. Although inflammation is assumed to trigger new bone formation, there is no close correlation between inflammation and osteoproliferation. The principle signs and symptoms include:

Low back pain – of slow and gradual onset over several months and persistent in nature. Lower back pain in the lumbar spine and sacroiliac joints is often the initial complaint of approximately 90% of patients with the condition. Pain characteristically radiates to the buttocks or thighs, but never below the knee. Pain is worse in the morning or after a period of inactivity and may be relieved by mild physical exercise.
Sacroiliitis (bi-lateral inflammation of the sacroiliac joints) – traumatic disease occurring at the point of attachment of skeletal muscles to bone, where recurring stress causes inflammation and often fibrosis and calcification.
Stiffness – morning stiffness is a characteristic symptom, which may last for minutes to hours depending on disease severity and usually reduces during the day or is relieved by mild physical exercise.
Enthesitis – inflammation at the point of attachment between skeletal muscles and bone.
Peripheral arthritis – affecting about 10% of patients at presentation but eventually affects 40% of those with the condition. Peripheral arthritis is typically asymmetrical and predominantly affects the large joints of the appendicular skeletal system.
Fatigue – some individuals may experience significant systemic symptoms including loss of weight during the early stages of disease, anaemia and depression.
Acute anterior uveitis – inflammation of the eye occurs in 40% of patients on at least one occasion and 33% may experience recurring episodes which may lead to permanent damage and blindness if not treated promptly.
Restricted spinal movement – occurs in all three planes (flexion, extension, rotation).
Reduced costovertebral movement – results in reduced chest expansion and vital capacity.
Invertible osteoporosis and associated spinal fractures.
Aortic insufficiency.
Atrial ventricle block.
Pericarditis.
Pulmonary fibrosis.

There are currently no specific diagnostic interventions; rather investigations may be used to exclude other potential diagnoses. Laboratory investigations include C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) which may be mildly elevated. Rheumatoid factor and antinuclear tests are negative with 95% of people with ankylosing spondylitis HLA-B27 positive. Although this is present in about 8% of the British population, most individuals will not have the condition although there is a strong familial tendency in people with ankylosing spondylitis. X-rays are diagnostic only in established cases with MRI imaging being a more helpful diagnostic tool.

Although AS is determined through clinical diagnosis, it is essential that alternative possible diagnoses are excluded, including mechanical back pain, infection, neoplasms and other inflammatory conditions. The British Society for Rheumatology (2004) advocates the use of the modified New York criteria (Geijer et al., 2009) as a guide to diagnosis. The four-point grading reports grade 0 as normal; grade I with some blurring of the joint margins as suspicious; grade II as having minimal sclerosis with some erosion; grade III as definite sclerosis on both sides of joint/severe erosions with widening of joint space with or without ankylosis; and grade IV as complete ankylosis. Therefore a definitive diagnosis of ankylosing spondylitis requires radiological criteria:

when sacro-iliitis is greater than grade I bilaterally or grade III or IV unilaterally
plus at least one clinical criterion from either:
- low back pain and stiffness for more than three months that improves with exercise but is not relieved by rest
- limited motion of the lumbar spine in both sagittal and frontal planes or
- limited chest expansion compared to normal values correlated for age and sex.

A key element of the overall management for all patients is new evidence-based recommendations produced by the International Assessment in Ankylosing Spondylitis Working Group in collaboration with the European League Against Rheumatism (IAAS 2006). Physiotherapy may be beneficial but the best option is unclear. Many patients find hydrotherapy particularly beneficial. NSAIDs appear to improve spinal and peripheral pain and function along with intra-articular or peri-articular corticosteroid injections to the sacroiliitis in small groups. Local corticosteroid injections for peripheral arthritis and enthesitis in ankylosing spondylitis are widely used to good effect. Intravenous methylprednisolone is occasionally used in severe unresponsive cases, but this use may decline with the ability to use new medications like tumour necrosis factor inhibitors.

Drugs that inhibit tumour necrosis factor (TNF) have revolutionised the treatment of ankylosing spondylitis. Four different drugs are currently available:

etanercept – a recombinant TNF receptor
infliximab – a chimeric monoclonal antibody given by intravenous infusion
adalimumab and golimumab – both humanised monoclonal antibody to TNF given subcutaneously.

These drugs have rapid and substantial clinical effects, in significantly reducing spinal inflammation. The British Society of Rheumatology (2004) and NICE (2008b) have produced guidelines for the use of TNF inhibitors.

A large proportion of patients with AS develop hip arthritis. Hip replacements should be considered in patients with refractory pain or disability and with radiographic evidence of structural damage, independent of age. Spinal surgery may be of value in selected patients and is performed for a variety of reasons, including fusion procedures for segmental instability and wedge lumbar osteotomy for fixed kyphotic deformity. Patients with severe ankylosing spondylitis present anaesthetic difficulties and the risk and benefits of surgery need to be carefully considered.

Psoriatic arthritis (PA)

PA is an inflammatory arthritis associated with the skin disorder psoriasis. The exact aetiology is unknown, although more than 40% of people with the cutaneous disease of psoriasis are estimated to also have joint involvement. Although some patients with psoriasis may have coincidental osteoarthritis or rheumatoid arthritis, it is important to remember that psoriatic arthritis is prevalent in individuals with psoriasis. Psoriasis is believed to affect 1–3% of the population and psoriatic arthritis is believed to affect 1% and affects more than 7–42% of patients with psoriasis. The risk of psoriatic arthritis increases with a family history of spondyloarthropathy or nail pitting and the onset usually occurs between 30 and 55 years of age, affecting men and women equally. Psoriatic arthritis is considered a separate entity from rheumatoid arthritis because of the sero-negativity of rheumatoid factor and its tendency for asymmetrical involvement.

The exact aetiology has yet to be discovered. As with almost all autoimmune diseases, genetic, immunological and environmental factors are believed to play a part in the expression of psoriatic arthritis. Psoriatic arthritis is an inflammatory disease that manifests in both articular and extra-articular features. The disease can present with an arthritis affecting several joints of the hands or feet that is frequently symmetrical. This mimics the pattern of rheumatoid arthritis. Unlike individuals affected by rheumatoid arthritis, those with psoriatic arthritis often experience inflammation of the distal interphalangeal joints. Individuals affected may also present with inflammation of the spine and sacroiliitis. The disease can also present with a dactylitis: sausage-like digit or digits. Individuals with psoriatic arthritis can have arthritis of less than four joints, commonly of one large joint and three digits, or an arthritis affecting one joint, usually a large joint. Uncommonly, psoriatic arthritis can be an extremely aggressive and mutilating arthritis, resulting in joint destruction. Extra-articular features include psoriasis, iritis, mouth ulcers, colitis and aortic valve disease.

There is no single blood test to diagnose psoriatic arthritis, but it is recognised that individuals affected are usually rheumatoid factor negative and do not develop rheumatoid nodules. Markers of inflammation may be elevated in active psoriatic arthritis.

The medical management of psoriatic arthritis is similar to other inflammatory arthritides (see management of RA below). Jones et al. (2003) concluded that parenteral high dose methotrexate and sulphasalazine are two medications that showed demonstrable efficacy in psoriatic arthritis. Sulphasalazine alters bowel flora, inhibits folate metabolism and is generally well tolerated. It is considered effective, particularly in treating persistent peripheral arthritis.

Rheumatoid arthritis

Rheumatoid arthritis (RA) is a complex, chronic inflammatory condition, which has both articular and extra-articular effects. It is the most common inflammatory arthropathy and has the potential to cause a significant impact on quality of life. The predominant features of the condition are pain, swelling, stiffness of joints, reduced levels of function, fatigue and anaemia.

RA is a polyarthropathy and affects both sides of the body symmetrically with a fluctuating disease pattern and episodic disease flares. It commonly affects the small joints of the hands and feet, although larger joints can also be affected. RA has a prevalence of 1% in the population. Although people of any age can be affected, the peak age range for onset is 40–60 years and it affects women more frequently: 3:1 ratio. RA has a significant impact on life and can affect roles, relationships and levels of independence as the disease progresses.

The pathophysiology of rheumatoid arthritis is not fully understood and the initial trigger is unknown. It is an autoimmune condition where pro-inflammatory cytokines are known to have an important role in the pathogenesis causing chronic inflammation. Inflammation is the body’s normal response to tissue injury, whether caused by bacteria, trauma, chemicals, heat or other phenomenon. Inflammation usually subsides when its task is completed, but maintenance of the inflammation in RA is thought to be caused by an autoimmune reaction in inflammatory arthritis. Inflammation of the synovial membrane surrounding the joint capsules and tendon sheaths is called synovitis. The synovial membrane is the inner membrane of tissue that lines a joint and secretes synovial fluid. The main function of this fluid is to lubricate the joint. It has been suggested that pathological changes caused by synovitis occur in three stages (Hill and Ryan 2000):

Cellular stage – joint becomes warm, swollen and tender causing stiffness and restricted movement.
Inflammatory stage

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