Age

This will often help to distinguish degenerative conditions (elderly) from those related to an underlying congenital, birth-related or developmental problem (young).

Birth history

There may be a direct link between events around the time of birth and conditions such as upper limb weakness (traction injury to the brachial plexus), cerebral palsy (hypoxia) and dysplastic disease of the hip (more common in a breech delivery or first child).

Childhood

Abnormalities in the development of the growing skeleton may result in a range of conditions, some of which are associated with visible deformity. Sometimes, however, such apparent deformity is just a stage of normal development. For example, some children go through a phase of being bowlegged and anxious parents need to be reassured that this is a normal variation and not a disease.

Dominant hand

This is particularly relevant to upper limb conditions.

Occupation

Degenerative processes may be a consequence of, or at least exacerbated by, occupational use of the upper limb. The need to return a patient to employment may also affect the way and urgency with which a condition is treated.

Trauma

Many conditions follow a clearly defined episode of trauma, the nature and mechanism of which can help make the diagnosis. For example, sudden injury to the knee, with acute swelling followed by instability, is highly suggestive of anterior cruciate ligament (ACL) rupture.

Details of previous treatment

The condition may have been treated by means of physiotherapy, acupuncture, osteopathy, steroid injection and drugs over many years in primary care prior to referral to an orthopaedic surgeon. Previous operations performed on the same joint or limb may affect both the current options for surgery and the chance of success.

Past medical history

If operative intervention is planned, then general fitness for anaesthesia and surgery must be carefully assessed and the patient medically optimized. The consequences of other co-morbidity must also be considered. For example, the presence of open leg ulcers in a patient about to undergo a hip replacement will increase the risk of prosthetic joint infection and the ulcers should be healed, if possible, prior to surgery.

Drug history

With regard to analgesia, changing the dose or preparation may result in significant relief of symptoms. Other drugs, such as warfarin or clopidogrel, may need to be stopped prior to surgery. Some immunosupressive drugs increase the risk of infection; smoking and nonsteroidal anti-inflammatories can slow bone healing.

Look

In lower limb conditions, observe gait, the use of a stick, and the ability to get out of a chair unaided and walk across the consulting room. Observe any joint or limb asymmetry or limb wasting, deformity, malalignment or shortening. Look for scars from previous operations or trauma, which may give clues to the cause of the current problem. Note any colour changes in the skin.

Feel

Palpate around the joint or limb. Establish areas of pain, and try to relate these to anatomical structures (e.g. tendons, joint lines etc.). Establish the presence of any swelling and whether this is fluctuant or solid (Table 27.1). Test the neurovascular status of the limb (sensation to light touch and pinprick, and peripheral pulses) and compare with this to the other side.

Move (active and passive)

Ask the patient to move the affected part (actively) through its full range of movement. Observe limitations of movement, pain, difficulty or apparent weakness. Then (passively) move the limb or joint, stopping in response to pain or stiffness. Test power in relevant muscles and apply stress tests to the ligaments looking for instability.

There are specific provocative tests for most joints which are performed depending on the initial findings. Examples include testing for shoulder impingement (Hawkin’s test), asking the patient to stand on one leg to test the power of the abductor muscles of the hip (Trendelenburg test) and stressing the anterior cruciate ligament of the knee to look for a rupture (anterior drawer test).

Plain X-rays

Two views, in orthogonal planes including the joint above and below are generally used to evaluate almost all bone pathology and are performed weight-bearing whenever possible. Alignment (the degree of varus or valgus deformity), as well as true bone length, can be quantified. X-rays are also routinely used to confirm the correct position of bones, joints or prostheses after surgery.

Ultrasound

This is used frequently to evaluate soft tissue pathology (e.g. tendon ruptures, bleeds into soft tissues, other muscular or tendinous pathology) and to guide biopsy or injection. As a dynamic technique, it can be used to visualize the movements of tendons and muscles under direct vision.

Nerve conduction tests and electromyography (EMG)

These are used to evaluate nerve entrapment syndromes, nerve injuries, neuropathies and abnormalities of muscular contraction.

Computed tomography (CT)

CT provides excellent images of bone anatomy (Fig. 27.1) and can be used to supply three-dimensional images to help in the reconstruction of complex fractures. The thin axial slices are particularly useful as a guide for obtaining biopsy specimens

Fig. 27.1 A three dimensional CT showing a iliac wing fracture.

Magnetic resonance imaging (MRI)

MRI (Fig. 27.2) provides excellent images of soft tissue, joint and bone pathology without exposure to radiation. It is widely used in virtually all branches of orthopaedics for diagnosis and preoperative planning.

Fig. 27.2 An MRI scan of a shoulder through the level of the acromioclavicular joint and the glenohumeral joint.

Bone scans

These can be used to assess a number of bone conditions, including infection and tumours (Fig. 27.3).

Fig. 27.3 An example of a bone scan showing increased uptake of radioactive tracer in the clavicle: in this case, indicative of infection.

There are also increased areas of uptake in the shoulders and sternum.

Drug therapy

Simple analgesics, such as paracetamol, with or without the inclusion of nonsteroidal anti-inflammatory drugs (NSAIDs), are the mainstay of treatment. More powerful analgesic combinations may be introduced such as codeine or morphine, if simple analgesics prove inadequate.

Off-loading

This involves the use of aids, such as a walking stick and weight loss, aimed at reducing the forces passing through the joint. In the obese, weight loss is helpful as the load across a joint is three to six times body weight. Various insoles and splints are commonly used in orthopaedics to offload joints and are fitted by an orthotist.

Injections

Introducing a mix of a corticosteroid and local anaesthetic into the joint may reduce inflammation and ease pain. Injections of compounds of hyaluronic acid are increasingly used and are designed to supplement the natural joint levels of hyaluronic acid essential to normal functioning of articular cartilage. They work best in early OA but have little, if any, effect in late-stage disease.

Other conservative treatments

Physiotherapy and hydrotherapy both have a part to play in the control of symptoms, especially in early disease. Building up lost muscle bulk (frequently lost due to reduced activity) provides the joint with an increased degree of muscular control and may lead to considerable symptom improvement. Other treatment modalities, such as acupuncture, are recognized to have a role in the management of pain associated with OA. Failure of conservative methods normally leads to consideration of surgical intervention; in the patient unfit for surgery, benefit may be gained from referral to a pain therapist.

Osteotomy

This is useful in the younger patient, in whom joint replacement may not be advisable. The aim is to change the axis of the joint, so that a portion of the joint surface that has thus far been protected from wear and tear now forms the weight-bearing area. For example, with respect to the knee, although there may be severe OA of the medial compartment in conjunction with a varus deformity, the lateral compartment may have well-preserved articular cartilage. Over-correcting the varus deformity by means of osteotomy (removing wedges of bone from the tibia), so that body weight is now largely transmitted through the lateral compartment, may lead to significant improvement in symptoms, thus delaying the need for joint replacement (Fig. 27.9). Osteotomies generally use opening wedges (adding bone), closing wedges (removing bone) or may be translational or rotational.

Fig. 27.9 An example of an osteotomy to the proximal tibia.

A The osteotomy site has been fixed by a plate and screws. B The cut of the osteotomy lies between the top two screws and the bottom three screws.

Joint replacement

The hip, knee, ankle and shoulder, and indeed almost any joint, can now be partially or completely replaced in a number of different ways with varying degrees of success.

Hemi-arthroplasty

In this operation, only one-half of the joint is replaced, leaving half of the joint intact. It is normally the natural socket – for example, the acetabulum – that is left untouched. The most common example is following fracture of the femoral neck in the elderly. Such patients usually have low demand on the joint, and the hemi-arthroplasty (Fig. 27.10) gives adequate function without risking many of the complexities of a total hip replacement.

Fig. 27.10 An example of a hemi-arthroplasty of the hip, where only the femoral part of the hip joint has been replaced.

This type of procedure is commonly used after a displaced intracapsular fracture of the hip.

Total joint replacement

This entails resurfacing of both sides of a joint (Fig. 27.11). The choice of materials for the weight-bearing surfaces varies, depending on the joint and prosthesis in question. Currently, metal against a high-density polyethylene is the most common, although new prostheses involving metal and ceramics surfaces have been developed for use in young people (Fig. 27.12). Fixation of the implants may be with cement, or by encouraging bone to grow into or onto the surface of the implant. In small joints, such as those of the hand in patients with rheumatoid arthritis, silastic may be used as a buffer or spacer between the two joint surfaces.

Fig. 27.11 A total hip replacement.

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