Special Topics

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Chapter 18 Special Topics

Reflex Sympathetic Dystrophy

Reflex sympathetic dystrophy (RSD), now commonly referred to as complex regional pain syndrome 1 (CRPS), is a common disorder of unknown cause that often follows a relatively minor injury. It has been called by several names: Sudeck’s atrophy, causalgia, shoulder–hand syndrome, posttraumatic dystrophy, and others. The pathogenesis of the disorder is unclear, but a disturbance in the sympathetic nervous system apparently develops that leads to the characteristic symptoms and signs of intense pain (allodynia) and vasomotor disturbances. The condition usually affects the extremity rather than the torso. Early recognition is difficult. CRPS is divided into two types with similar clinical features, but type 2 is associated with more significant nerve injury, including causalgia and traumatic neuralgias.

CLINICAL FEATURES

The diagnosis of RSD can be difficult to make and is based primarily on history and examination. Clinical manifestations can be variable, but persistent burning pain that develops after an injury is the characteristic feature. Three stages (acute, dystrophic, and atrophic) are often described. The acute stage lasts up to 6 to 12 weeks and is characterized by the development of persistent burning pain. The injury is often trivial, but the pain is characteristically severe and out of proportion to the amount of trauma. Initially, the pain is localized to the area of the injury, but gradually it spreads throughout the extremity. Hypersensitivity to light touch is a frequent symptom. The extremity appears swollen and warm, and excessive perspiration may be present. In the later dystrophic and atrophic stages, motion in the affected joints becomes restricted, and the involved area becomes cool. Skin and muscle atrophy develop, and the skin appears dry, shiny, and glossy. Stiffness and intractable pain may persist for several weeks or months. RSD is commonly associated with anxiety and depression.

Although no imaging studies are diagnostic, plain roentgenograms may eventually reveal patchy osteoporosis (Fig. 18-1). The bone scan may be positive, showing regional uptake that is diagnostic and reflects increased blood flow.

FIG. 18-1 Roentgenogram of the ankle several weeks after a relatively minor sprain. Severe osteoporosis (Sudeck’s bone atrophy) of the lower portions of the tibia and fibula are present.

TREATMENT

RSD is best treated by prevention. All injuries should have immediate attention, and pain and swelling should be controlled. Early use of the extremity is also important. Once RSD develops, it is very difficult to treat. The most important aspect of therapy is restoration of motion by exercise. Active use of the extremity should be encouraged despite the pain. The edema may be controlled by elevation. Physical therapy in the form of passive range-of-motion exercises may be helpful but should not replace active home exercise by the patient. Smoking should be discouraged. Among the pharmacologic agents sometimes effective are antidepressants, corticosteroids, and calcium channel blockers. Repeated sympathetic blocks are sometimes helpful. The treatment is often prolonged, but most patients eventually improve.

Rotational Deformities of the Legs in Children

Developmental abnormalities of the lower extremities are common and are frequently a source of concern to parents. The cause of these deformities is unknown, but hereditary and persistent postnatal malpositioning play important roles. Most correct themselves spontaneously.

IN-TOEING

The in-toeing gait pattern seen in young children is the most common rotational deformity and is usually secondary to one or more of the following causes: (1) internal rotation deformity of the hip secondary to contracture or excessive femoral anteversion, (2) internal (medial) torsion of the tibia, or (3) metatarsus varus (adductus) of the foot. In-toeing is usually the result of metatarsus adductus in the infant, internal tibial torsion in the toddler, and increased femoral torsion in the child over the age of 10.

All three of these deformities are aggravated by positions or postures that are frequently assumed by the child or infant. Lying in the prone position with the legs extended and the feet internally rotated is often associated with in-toeing deformity. Sitting in the “reverse-tailor” position with the feet internally rotated beneath the buttocks is directly related to persistent tibial rotation and adduction of the forefoot (Fig. 18-2). Children may assume these positions for extended periods of time while sleeping, playing, or watching television.

FIG. 18-2 The reverse-tailor position.

Children with internal rotation deformities have a high incidence of bowing of the lower extremities. This is frequently more apparent than actual, because the lower limb is never visualized in the true anteroposterior plane but rather in the oblique plane. The gait is occasionally clumsy, and the appearance may be unsightly.

The treatment of metatarsus varus depends on whether the deformity is fixed. If the foot is flexible and the deformity easily overcorrectable, passive stretching exercises and a straight or reverse-last shoe are sometimes tried, although their effectiveness is unknown (Fig. 18-6). If the forefoot is rigid and passive correction of the deformity is not possible, early treatment with corrective casts may be indicated. The correction should begin shortly after birth. When the disorder is seen after the age of 1 or 2 years, operative intervention is occasionally necessary. Early diagnosis is therefore important.

FIG. 18-6 Stretching exercises for metatarsus varus (arrows). The heel is firmly grasped. The forefoot is then passively manipulated into the corrected position and held for 10 seconds. The exercise is repeated two to three times at regular intervals during the day.

OUT-TOEING

External rotation deformity of the lower extremities is usually caused by the following: (1) external rotation of the hip secondary to soft tissue contracture or femoral retroversion (external femoral torsion), (2) external tibial torsion, or (3) pes calcaneovalgus, or flatfeet. Out-toeing is often associated with a genu valgum deformity and may be aggravated by sleeping in the prone position (Fig. 18-7). The use of wide diapers or a children’s “walker” with a wide pad may potentiate an externally rotated gait.

FIG. 18-7 The prone sleeping position, which frequently potentiates external rotation deformities.

If femoral retroversion is the cause, examination reveals that external rotation of the hips is significantly greater than internal rotation. External tibial torsion is diagnosed by the marked posterior position of the lateral malleolus compared with the medial. The flatfoot deformity is frequently associated with eversion of the heels (see Chapter 12).

TREATMENT

Observation and reassurance are all that is indicated. Improper postural habits should be corrected. Wide diapers and walkers with wide canvas slings are avoided. Stretching exercises are begun for any hip deformity. Any additional treatment is not helpful, and surgery is rarely necessary.

Angular Deformities of the Legs in Children

GENU VARUM (BOWED LEGS)

Genu varum with mild internal tibial torsion is a common, almost normal finding in early childhood. With growth and weight bearing, this developmental bowing spontaneously corrects itself in more than 95% of patients. There is even a normal physiologic “swing” to a knock-knee deformity between the ages of 18 months and 3 years in many cases. The knock-knee deformity then usually corrects itself between the ages of 4 and 7 years.

The child is commonly brought to the doctor because of the wide space between the knees and the mild in-toeing gait. Other possible causes of bowing (such as rickets and Blount’s disease) can generally be ruled out by the child’s history. Roentgenograms may be necessary. There is usually no evidence of any intrinsic bone disease. The amount of genu varum can be determined by measuring the distance between the medial femoral condyles with the child standing and the medial malleoli touching.

Developmental genu varum is usually not severe and rarely requires any treatment. The family can be reassured that spontaneous correction usually occurs by the age of 3 years. Any associated metatarsus varus should be appropriately treated, however. Severe cases should be referred at a young age to rule out Blount’s disease.

This is an uncommon pathologic, developmental bowing that results from altered growth of the upper medial tibial epiphysis (Fig. 18-8). The cause is unknown, but abnormal pressure may play a role. Blount’s disease is more common in obese early walkers and children of short stature. It is also more common in blacks. It may be unilateral, in contrast to physiologic bowing, which is almost always bilateral. Two forms of Blount’s disease are described: an infantile type, which begins before age 3; and an adolescent form, which starts after age 8. Before the age of 2, the infantile form may be difficult to differentiate from physiologic bowing, especially if it is bilateral. Although physiologic bowing resolves with growth, Blount’s disease progressively worsens. A strong family history and severe bowing are indications for roentgenographic evaluation.

FIG. 18-8 Diagram of Blount’s disease, showing disturbance of the growth of the medial tibial epiphysis.

Early recognition (before age 2) and differentiation from physiologic bowing are important. Early referral is indicated for all children suspected of having the disorder. Bracing before age 3 may be effective. Otherwise, surgical correction is usually necessary.

GENU VALGUM (KNOCK-KNEE)

Knock-knee may be caused by a variety of disorders, including injury and metabolic disease. However, most genu valgum is present as one stage in the normal physiologic “swing” between developmental genu varum and normal alignment. It is usually bilateral and is most common between the ages of 2 and 4 years. The severity of the deformity can be determined by measuring between the medial malleoli or Achilles tendons with the child standing, the medial femoral condyles touching, and the patellae facing forward (Fig. 18-9). Similar measurements can be taken on return visits to confirm spontaneous correction if reassurance is needed.

FIG. 18-9 Measuring genu valgum.

Most patients need only reassurance and follow-up. The rare case that persists beyond the age of 7 years may require brace correction. If the deformity is excessive or unequal, a thorough search should be made for the underlying abnormality.

Leg Length Inequality

Limb length discrepancies in the lower extremities may result from several causes. The most common are fractures, osteomyelitis, neuromuscular disease, and vascular anomalies. Usually, the affected limb is shorter, but occasionally the inequality is the result of overgrowth because of epiphyseal stimulation by inflammation or injury. Frequently, no cause is found. The inequality may cause a mild limp and compensatory scoliosis.

In children, a thorough search should be made to determine the cause. If any is found, the appropriate treatment is instituted. If no cause is noted and the difference is less than 1 cm, the child is followed by repeated careful measurements until mature to determine whether the inequality is static or increasing. Both types of inequality require specialized care, and surgical correction of the asymmetry may be indicated. In children with growth remaining, equalization of the discrepancy may be accomplished either by lengthening the shortened extremity or by partially stopping epiphyseal growth on the longer extremity.

In the adult, the amount of leg length discrepancy that is clinically significant is controversial, but it appears that up to 2.0 cm of shortening is well tolerated. However, chronic low back pain that may be accompanied by a leg length discrepancy can be empirically treated with a shoe lift to compensate for some of the difference (1- to 1.5-cm correction for a 2-cm difference, for example). There are no scientific studies that correlate leg length discrepancy with low back pain, but occasionally patients experience some improvement with a shoe lift to equalize length.

Primary Bone Tumors

Primary bone tumors are relatively uncommon in comparison to metastatic or secondary neoplasms. Because such a great variety of tissues comprise bone, classification of neoplastic processes arising in the skeleton is often difficult. Most bone tumors or tumor-like conditions are benign, but some of these, such as giant cell tumor and osteoblastoma, often recur after local resection and can even metastasize. Sometimes, this type of tumor is classified as “intermediate” in nature between benign and malignant. These neoplasms are occasionally fatal, but normally, metastatases from this group are not life threatening. True malignant tumors of bone, on the other hand, are often difficult to eradicate.

BENIGN BONE TUMORS

Most common benign bony neoplasms are either fibrous or cartilaginous. Cystic lesions such the simple bone cyst (see Chapter 5) occur with some frequency but may not be true neoplasms. The benign lesions that occur with any frequency are as follows: (1) fibrous cortical defect; (2), nonossifying fibroma; (3) fibrous dysplasia; (4) enchondroma; and (5) osteochondroma. Most of these lesions are diagnosed by a specific clinical and radiographic presentation, often related to the age of the patient and the bone involved. And although the radiographic appearance may not always be pathognomonic in all cases, certain characteristics are highly suggestive of specific lesions. Radiologic or orthopedic referral is valuable to determine the significance of such lesions.

Enchondromas are benign tumors of cartilage usually located centrally in bone. The most common sites are the small bones of the hand and feet (Fig. 18-10). The enchondroma is the most common tumor of the bones of the hand. It most often occurs in patients between the ages of 10 and 50 years. Symptoms are nonspecific. The lesion is usually discovered incidentally or is identified after a pathologic fracture. Treatment is simple observation if the diagnosis is obvious. If enough bone weakness is present, leading to recurrent fracture, or if the diagnosis is uncertain, surgical intervention is indicated.

FIG. 18-10 Enchondroma of the phalanx. The lesion is well circumscribed. A pathologic fracture is present.

Osteochondromas are the most common of all benign bone growths. They may not actually be neoplasms but are more likely developmental abnormalities thought to be the result of some “pinching-off” of a portion of growth cartilage. This lesion begins to grow separately, and its growth ceases when the patient reaches skeletal maturity. The typical site of formation is on the metaphysis near the growth plate of the distal femur or proximal tibia, but they can be found on other long bones (Fig. 18-11). Most lesions consist of a stalk that is directed away from the growth plate from which it originated. The lesion is covered with a cartilaginous cap. Signs and symptoms are related to the presence of the mass, but most are only minimally symptomatic. The lesion is removed if producing symptoms. These lesions commonly regress when growth ceases.

FIG. 18-11 Osteochondroma of the humerus. The lesion is contiguous with the normal cortex, and there is no bony destruction.

Fibrous lesions of bone are common benign neoplasms that are usually discovered incidentally. Fibrous cortical defects are common in growing bone and have a characteristic radiographic appearance (Fig. 18-12). They are asymptomatic and do not require further investigation or treatment. The lesions most likely resolve within 2 to 3 years.

FIG. 18-12 Fibrous cortical defect (arrow).

Nonossifying fibromas are similar lesions histologically but are much larger (Fig. 18-13). Biopsy is not usually required, but treatment may be needed in large lesions that are painful. These often regress as well.

FIG. 18-13 Nonossifying fibroma of the distal tibia. The lesion is well circumscribed.

Fibrous dysplasia is a developmental disturbance of bone formation in which fibroplastic proliferation occurs. The disorder may be monostotic or polyostotic. Endocrine abnormalities may also be present. Marked deformities may develop over time. The tibia is commonly involved, and pathologic fracture may occur (Fig. 18-14). Referral for surgery is indicated when deformity or pathologic fracture develops.

FIG. 18-14 Fibrous dysplasia of the tibia with bowing and a pathologic fracture.

MALIGNANT BONE TUMORS

Primary malignant bone tumors are invasive, anaplastic, and have the ability to metastasize. Most arise from the marrow (myeloma), but tumors may develop from bone, cartilage, fat, and fibrous tissues. Leukemia and lymphoma are excluded from this discussion. Fibrosarcoma and liposarcoma are extremely rare. They are similar to those tumors arising in soft tissue. Osteosarcoma is an uncommon primary malignant tumor of bone characterized by malignant tumor cells that produce osteoid or bone. Several variants have been described: parosteal sarcoma, periosteal sarcoma, multicentric, and telangiectatic forms. Chondrosarcoma is a malignant cartilage tumor that may develop primarily or secondarily from transformation of a benign osteocartilaginous exostosis or enchondroma. Ewing’s sarcoma is a malignant tumor of unknown histogenesis, and multiple myeloma is a neoplastic proliferation of plasma cells.

Multiple myeloma is the most common tumor in bone. The age of onset is usually over 40. It may present as a systemic process or, less commonly, as a “solitary” lesion. Early manifestations include anorexia, weight loss, and bone pain; the majority of cases present initially with back pain that often leads to the detection of a destructive skeletal lesion. Other organ systems eventually become involved, resulting in more bone pain, anemia, renal insufficiency, and/or bacterial infections, usually as a result of the dysproteinemia typical of this disorder. Secondary amyloidosis may develop, leading to cardiac failure or nephrotic syndrome.

Osteosarcoma most often develops between the ages of 10 to 20. Most lesions originate in the metaphysis, 50% to 60% around the knee. Pain and swelling may be present, but otherwise the patient is healthy. Osteosarcoma may develop in conjunction with Paget’s disease, manifested primarily as a sudden increase in bone pain.

Chondrosarcoma most often involves the pelvis, upper femur, and shoulder girdle in patients over age 40. Painful swelling may be the only finding.

Ewing’s sarcoma is typically a disorder that develops between the ages of 10 to 15. A painful soft tissue mass is often present sometimes with increased local heat The midshaft of a long bone is usually affected (in contrast to other tumors). Weight loss, fever, and lethargy are associated findings.

EVALUATION

The evaluation and treatment of malignant bone tumors are complicated. Diagnostic studies and treatment should be supervised by an orthopedic cancer specialist and oncologist. The age of the patient and the initial radiographic features often determine the next appropriate diagnostic steps. Laboratory evaluation may be helpful. Alkaline phosphatase is often elevated in osteosarcoma. In Ewing’s sarcoma, the findings include: reflective of systemic reaction, symptoms include anemia, an increase in white blood cell (WBC) count, and an elevated sedimentation rate. In multiple myeloma, findings include the following: (1) Bence Jones protein in the urine; (2) anemia and elevated sedimentation rate; (3) characteristic dysproteinemia on serum protein electrophoresis; (4) the diagnostic feature of a peak in the electrophoretic pattern suggestive of a monoclonal gammopathy; (5) rouleaux formation in the peripheral blood smear; and (6) often, presence of hypercalcemia, but alkaline phosphatase levels usually normal.

Imaging studies are often diagnostic. Classic osteogenic sarcoma penetrates the cortex early in many cases. The radiographic findings may vary as follows. (1) a blastic (dense), lytic (lucent), or a mixed response may be seen in the affected bone. (2) An aggressive perpendicular sunburst pattern may be present as a result of periosteal reaction, and peripheral Codman’s triangles are often noted. (3) The margins of the tumor are poorly defined.

Speckled calcifications in a destructive radiolucent lesion are usually suggestive of chondrosarcoma. Ewing’s sarcoma is characterized radiographically by mottled, irregular destructive changes with periosteal new bone formation. The latter may be multilayered, producing the typical “onion skin” appearance.

The typical roentgenographic finding in multiple myeloma is the “punched-out” lesion with sharply demarcated edges (Fig. 18-15). Other characteristics include the following: (1) multiple lesions are usual; (2) diffuse osteoporosis may be the only finding in many cases; and (3) pathologic fractures are common.

FIG. 18-15 Multiple myeloma of a vertebral body (arrows).

TREATMENT AND DISPOSITION

In the past 20 years, dramatic improvements have been made in the treatment protocols for osteosarcoma with the use of adjuvant multidrug regimens and limb-sparing surgery.

Early diagnosis is important because most tumors have not metastasized at the time of the initial presentation. Five-year survival rates of 70% have been obtained in some series. The prognosis for multiple myeloma remains poor, despite new therapies. Complete remissions are uncommon. Survival with a solitary lesion may be long, but most patients succumb after a median of 3 years.

The prognosis for Ewing’s sarcoma has improved with a combination of chemotherapy, local resection, and radiation therapy. Chondrosarcomas are not sensitive to chemotherapy or radiation, and the prognosis depends on the grade of the tumor and the ability to obtain an adequate resection.

Spinal Cord Compression

Spinal cord compression is the neurologic loss of spinal cord function. Lesions may be complete or incomplete and develop gradually or acutely. Incomplete lesions often present as distinct syndromes, as follows: (1) central cord syndrome; (2) anterior cord syndrome; (3) Brown–Séquard syndrome; (4) conus medullaris syndrome; and (5) cauda equina syndrome.

CLINICAL FEATURES

Clinical findings reflect the amount of spinal cord involvement (Fig. 18-16): there are usually motor loss and sensory abnormalities. Babinski testing is usually positive, and clonus is commonly present. Gradual compression is often manifested by progressive difficulty walking, clonus with weight bearing, and involuntary spasm; development of sensory symptoms; bladder dysfunction is a late finding. The following list describes findings in various types of spinal cord syndromes:

1 Central cord syndrome results in a variable quadriparesis with the upper extremities more severely involved than the lower extremities; there is some sensory sparing.

2 Anterior cord syndrome results in motor, pain, and temperature loss below the lesion

3 Brown–Séquard syndrome is a spinal cord syndrome caused by injury to either half of the spinal cord and resulting in the loss of motor function, position, vibration, and light touch on the affected side. Pain and temperature sense are lost on the opposite side.

4 Conus medullaris syndrome results in variable motor loss in the lower extremities with loss of bowel and bladder function.

5 Cauda equina syndrome typically involves low back pain, weakness in both lower extremities, saddle anesthesia, and loss of voluntary bladder and bowel control (see Chapter 8).

FIG. 18-16 Spinal cord compression. A, Central cord syndrome. B, Anterior cord syndrome. C, Brown–Séquard syndrome.

ETIOLOGY

Among the most common causes of spinal cord syndromes are trauma, tumor, infection, and degenerative disc conditions with spinal stenosis. Sometimes the central cord syndrome develops from compression of the cord from the front by a bulging or degenerative disc and from the back by a buckled ligamentum flavum. The stenotic spine may be more susceptible. Other causes of cord compression are inflammatory processes, cystic abnormalities, and severe disc herniation.

EVALUATION

Spinal cord compression requires an immediate referral for radiographic and neurologic assessment. Laboratory results are usually unremarkable unless infectious or inflammatory causes are suspected, Imaging studies depend on the suspected etiology. Magnetic resonance imaging (MRI) is usually required.

TREATMENT AND DISPOSITION

Urgent surgical decompression is usually indicated as soon as the etiology is established. Important indicators regarding prognosis are as follows:

• The greater the distal motor and sensory sparing, the greater the expected recovery.

• When a plateau of recovery is reached, no further improvement is expected.

• The quicker the recovery, the greater the recovery.

Spinal Braces

Braces are appliances that allow partial movement of a joint. They perform several functions, including protection and stabilization. They are most commonly used to temporarily support and restrict motion in the treatment of painful disorders of the spine. There is no evidence that wearing a brace “weakens” the back, but the patient should always be encouraged to exercise and maintain proper muscular tone if the brace is being used for pain management only and not for fracture stabilization.

CERVICAL COLLARS

Cervical collars extend from the head to the thorax and are usually soft, although semirigid collars are also available (Fig. 18-17). The soft collar is usually more comfortable but restricts motion less than the other collars. These appliances are all used in the treatment of degenerative disc disease and minor ligamentous or muscular injuries of the cervical spine.

FIG. 18-17 Cervical collars. A, The soft foam collar. B, The adjustable collar. C, The Philadelphia collar.

TAYLOR BRACE

This is a fundamental back brace useful in dorsal and lumbar spine disease (Fig 18-18). It is a high, semirigid brace that may be modified. Degenerative disc disease and minor fractures may be treated with this brace or one of its modifications (long Taylor, modified Taylor, and short Taylor).

FIG. 18-18 Spinal braces. A, The Taylor brace. B, The Knight spinal (chairback) brace. C, The Jewett hyperextension brace. D, The lumbosacral support. (From Camp International, Inc, Jackson, MI. Used by permission.)

JEWETT (HYPEREXTENSION) BRACE

This three-point brace provides pressure over the lumbar spine, sternum, and symphysis pubis. It is used in minor fractures of the dorsal spine when extension is desired. It is also useful in the treatment of epiphysitis.

KNIGHT SPINAL BRACE (CHAIRBACK)

This is a rigid lumbar orthosis that is very useful in treating chronic low back pain when more support is required than a light lumbar support can provide. It is also used in the treatment of disc disease and spondylolisthesis.

LIGHT LUMBAR SUPPORTS

These supports are usually made of canvas and may be reinforced with metal stays. They are commonly used in the treatment of lumbar disc disease and chronic low back pain syndromes. They may also function to increase the intraadominal pressure, which may aid in the support of the lower portion of the back. They are more comfortable than the Knight spinal brace but provide less support.

Disability Rating

The physician is often called on to determine the amount of disability that is present as the result of musculoskeletal disease or injury. This determination is frequently used as the basis for settlement in workers’ compensation cases, as well as in personal injury litigation. However, it is usually the “physical impairment rating” expressed as a percentage rather than “disability” that must be determined. It is not the duty of the physician to determine how this impairment affects the patient socially or economically. Often, however, it is the impairment rating that is used as the sole basis for the determination of disability by those administrators responsible for it.

Disability may be defined in various ways and is not a medical term but rather an administrative one. It does not simply mean pain that has persisted for several months. (Pain without objectively validated limitations in daily activities has no impairment.) Medically, it is physical impairment that prohibits the performance of normal physical function. For Social Security purposes, disability means the inability to do any work for at least 12 months because of a physical impairment. Legally, it means permanent bodily injury for which restitution may be judged necessary. Under workers’ compensation statutes, disability is frequently divided into (1) temporary total disability, during which period of time the patient is under care and unable to work; (2) temporary partial disability, during which time recovery is sufficient that some employment may be begun; or (3) permanent disability, which is permanent loss of function after maximum recovery.

Physical impairment can usually be measured accurately on the basis of the loss of physical function. A careful clinical history and physical examination are mandatory. Laboratory and roentgenographic analysis may also be necessary.

For the determination of specific ratings for each impairment, the following manuals are excellent: Manual for Orthopedic Surgeons in Evaluating Permanent Physical Impairment, Guide to the Evaluation of Permanent Impairment (AMA), and Disability Evaluation Under Social Security. Patients need to understand that a disability rating follows them for life. Although there may be some short-term financial benefit, an impairment rating can sometimes adversely affect future employability.

Joint Replacement Surgery

Great advances have been made in the past 25 years in the surgical treatment of degenerative and rheumatoid arthritis. These advances have been primarily caused by improvements in the techniques of joint arthroplasty. This procedure is most commonly used for conditions of the hip and knee, but devices have been developed for use in almost every joint (Fig. 18-19). The indications for surgery are the presence of arthritis and failed medical management.

FIG. 18-19 A, Severe rheumatoid arthritis of the hand with dislocations of the metacarpophalangeal joints. B, Postoperative roentgenogram after metacarpophalangeal replacement. The alignment and function are markedly improved. The thumb has also been fused.

The basic purpose of these techniques is to implant a device into the joint that replaces the degenerated articular surfaces. Most joint replacement procedures use a hard plastic, high-density polyethylene for the socket (Fig. 18-20). This articulates with a metallic component, both components usually being fixed to the bone by a cementing compound, methylmethacrylate, or by an in-growth system.

FIG. 18-20 A, Degenerative arthritis of the knee. B, Postoperative roentgenogram after total knee replacement.

The goal of joint replacement surgery is to eliminate the disability that results from pain, loss of motion, and malalignment. It is suitable in patients with bilateral disease, and advanced age is no contraindication. It has been used successfully in almost every age group. Rehabilitation after a joint replacement is usually rapid. Patients older than 65 years of age can expect a 90% 15-year implant survival.

Mechanical problems with total knee replacement are slightly more common than those after total hip replacement, but the results are uniformly good in both procedures. More than 90% of patients undergoing arthroplasty have excellent relief of pain and improvement in motion. Short-term problems are those related to infection and venous thrombosis, both of which are treated prophylactically. Long-term concerns include aseptic loosening and osteolysis, a term used to describe an inflammatory response to particulate debris that can lead to bone loss and implant failure.

Compartment Syndromes of the Lower Leg

Compartment syndromes are disorders of the extremities in which increased tissue pressure compromises the circulation to the muscles and nerves within the space (see Chapter 15). These conditions are most common in the lower part of the leg, where four natural compartments exist (anterior, lateral, deep posterior, and superficial posterior). The anterior compartment is most commonly involved.

The disorder may be acute or chronic. Chronic cases may be confused with stress fractures, tendinitis, and other forms of “shin splints.” The acute case is associated with significantly greater morbidity.

CLINICAL FEATURES

The acute form of compartment syndome may follow fractures, burns, trauma, or vascular injury. Patients with peripheral vascular disease are at risk because poor tissue perfusion leads to ischemia and transudation of fluid, which increases compartment pressure. Extreme pain, numbness, and weakness are the most common complaints. The pain is often very severe because of muscle and nerve ischemia. The chronic case is usually related to exercise, and symptoms are generally mild. Weakness, hypoesthesia, and pain on passive stretch of the involved muscle are usually present. The affected area may also be swollen and tense. The peripheral pulse is often diminished. There is usually an increase in intracompartmental tissue pressure that can be measured directly.

Roentgenographic findings are usually normal (except in fractures) but should be obtained in chronic cases to rule out stress fracture.

TREATMENT

Chronic cases usually subside with rest, but fasciotomy is occasionally performed to prevent recurrence. The acute form requires immediate surgical decompression. Without treatment, necrosis of muscle and nerve may occur and result in permanent weakness, contracture, and nerve dysfunction similar to Volkmann’s ischemic contracture in the upper extremity (see Chapter 2).

Injection and Aspiration Therapy

Locally injected analgesics and steroids are frequently used in the treatment of musculoskeletal diseases. Their use in many specific disorders has been described in previous chapters. This section deals with their usage in other common conditions.

The ability of steroids to relieve pain and improve the function of inflamed joints, tendons, and bursae is unquestioned. And although a cellular inflammatory response is not always present in those disorders usually called “arthritis” and “tendinitis,” corticosteroid injections have been shown by randomized, controlled trials to provide excellent relief of pain in these conditions. The exact mechanism by which this is accomplished is unknown. It is theorized that these drugs reduce the local infiltration of those cells and compounds that mediate the inflammatory response. An increase in local blood flow and improvement in local tissue metabolism are other common explanations. A placebo effect is undoubtedly present in some cases. Systemic absorption is less after their use than it is with oral administration. However, some absorption does occur, and plasma cortisol levels can be suppressed for up to 1 week after injection. Markers of bone formation, such as osteocalcin, can also be depressed transiently but return to normal in 2 weeks after intraarticular use of a corticosteroid, while markers for bone resorption do not change, suggesting that there is no effect on bone resorption and only a temporary effect on bone formation.

Greater systemic absorption occurs when a given dose is divided equally and instilled into two joints than when administered into one joint. Although not well documented, subtle adverse effects of cortisone use may also be seen. (For example, joint injections may temporarily help other conditions such as hay fever and allegies.) It is known that absorption causes insomnia in some patients the first night after injection. Diabetes control may also be temporarily altered by the use of intraarticular cortisone. Diabetic patients should be made aware of the potential for transient hyperglycemia and the need to monitor themselves more closely for a few days. Because of the systemic absorption, 3 to 4 weeks should pass before reinjecting large joints.

There are very few negative effects associated with steroid injections, and the benefits far outweigh any potential risks. They are highly cost effective compared with other intraarticular injectable agents and are not associated with the side effects so commonly seen with nonsteroidal anti-inflammatory drugs (NSAIDs). There is, however, individual variability regarding the response to these drugs. Many of the concerns expressed by patients (and physicians) are often based on myth and misinformation. Among the causes of apprehension are (1) a general patient fear of needles, and (2) the belief that that steroid shots are painful. In general, they are no more or less painful than most intramuscular injections, depending on the volume of material injected and site of the injection. The experience of the physician also plays some role, as does the size of needle and speed of injection. (3) Fears of “steroids.” These fears are often related to the well-known side effects associated with long-term oral prednisone use. (4) Fear of infection or damage from the needle. These complications are rare, but may occur if proper preparation and technique are not followed. (5) That once started, injections are needed forever. Injections are not expected to “cure” arthritis but may help cure tendonitis, which often heals on its own eventually. (6) The belief that steroids make joints worse. There is no evidence that steroids accelerate degenerative changes in joints compared with control groups.

There is little to be gained by a “series” of shots or by repeating an injection to relieve a small amount of residual pain after a successful first shot. There is also nothing gained by giving a shot too early, and nothing is lost by trying other treatments first.

A variety of materials are available, but the most commonly used is 1% plain lidocaine, usually mixed with 1 mL of one of the various corticosteroids, either short- or long-acting. Many steroids are offered in different strengths, although the more concentrated solutions may offer no advantage over the less concentrated ones. The duration of action varies inversely with the degree of solubility. The stronger, less soluble forms should be avoided in superficial injections, because they are more likely to cause subcutaneous atrophy and depigmentation. (Dark skin depigmentation effects may be more apparent.) The more water-soluble compounds may cause less lipoatrophy but have a shorter duration of action. (Atrophy often reverts to normal when the steroid is absorbed. This may take up to a year.)

The lidocaine and steroid may be injected separately but are usually mixed together. The use of a small amount of lidocaine alone for skin and soft tissue infiltration may be necessary in the apprehensive patient. If a joint with a thick capsule is to be entered, the capsule may also need to be infiltrated because passing a larger needle through the capsule may be uncomfortable for the patient. Do not use the steroid mixture to anesthetize the site; use only the anesthetic. Otherwise, atrophy may occur. The anesthetic is best injected with a 25-gauge needle (⅝-inch or 1 ½-inch). This needle size may also be used to inject the steroid–lidocaine mixture, especially if the injection is superficial. A 22-gauge, 1 ½-inch needle is sometimes necessary in deeper injections. A “giving” sensation usually occurs as the needle penetrates the tough, fibrous capsule, especially in the knee. The needle should not be advanced once the joint has been entered to avoid joint trauma. Aspirating the syringe while withdrawing the needle may prevent residual drops of the mixture from contaminating the skin and subcutaneous tissue.

The dose of cortisone is usually based on volume; 1 to 2 mL is used for larger joints and lesser amounts for smaller joints (Table 18-1). Tendons, except the quadriceps and elbow epicondyles, usually are not directly injected. Instead, it is usually a space (joint, tendon sheath or subacromial space) that is injected. There should be little resistance when injecting a space. If resistance occurs, the needle tip is probably incorrectly placed in some soft tissue, and its position should be changed. The volume of fluid injected depends on the size of the joint or soft tissue area.

Table 18-1 Guidelines for Common Steroid Injections

If aspiration is necessary, as it sometimes is in the knee, an 18-gauge needle works best. It is less apt to be occluded by joint debris or synovium. As much fluid is removed as possible by expressing the fluid toward the needle. The pain of aspirating with the large-bore needle may be prevented by infiltrating the injection site first with lidocaine using a 25-gauge needle. Aspiration of some fluid also ensures proper needle placement for the injection of large joints such as the knee. If aspiration is performed, the needle may simply be left in position, and the syringe is exchanged for the one containing the medication.

A mild postinjection inflammation (“flare”) occurs in 5% of cases after the injection and may last 12 to 24 hours. It is characterized by increased local pain and begins several hours after the injection. (This excludes infection, which would be slower to develop.) It may be caused by poor technique or the steroid vehicle. It usually responds to ice, rest, and analgesics.

Facial flushing is an occasional side effect of intrasynovial steroid use. It begins within a few hours of injection and subsides in 1 to 2 days. It is more common with triamcinolone. (Triamcilolone may have the most side effects, but it also acts the longest.) It is benign and self-limited. It is more common in women.

Rarely, allergic or anaphylactic reaction to intraarticular steroids can occur, a situation which, paradoxically, may require the same drug for its treatment. The reaction may, in fact, be caused by carrier compounds.

If the diagnosis is correct, treatment failures are usually the result of an inaccurate injection. If there is no response to the first injection, it may be repeated in 2 to 3 weeks.

When using these compounds, it is important not to rely solely on their use in the treatment of any disorder. They are used only as an adjunct to the appropriate treatment of the underlying abnormality. Sufficient knowledge of the relevant regional anatomy is also essential, and no more than four to six injections should be given over a 6-month period.

NOTE: It has not been proven that there are any serious long-term systemic adverse effects to the occasional steroid injection, and the results of investigations into whether any local cartilage or soft tissue damage can occur are conflicted. Threshold doses among individuals regarding side effects seem to differ, but even short courses of treatment at high doses appears to have low risk. It has always been recommended that no more than three or four shots per year be given to the same joint. Although this limit seems sensible, it is not evidence based and is completely anecdotal. Some patients may require injections more often. If the patient’s symptoms are not well controlled with a reasonable frequency of injections, it may be necessary to reassess the disorder to be certain the diagnosis is correct and to even reevaluate other options.

GENERAL PRINCIPLES

1 Maintain strict sterile technique.

2 Avoid injection and aspiration in the presence of local infection. A needle passed into a joint through an area of cellulitis may spread the infection into the joint.

3 Avoid the injection of major weight-bearing tendons (patellar tendon, Achilles tendon). Small tender spots along the edge of the tendon can be safely injected.

4 Avoid injecting previously infected joints.

5 Avoid injecting markedly unstable joints.

6 Do not inject prosthetic joints.

7 Avoid injecting the skeletally immature patient (except those with known arthritis).

8 Inject slowly to avoid pain due to the volume effect.

9 Less absorption occurs if the area is rested for 48 hours,

10 Avoid reverse tracking of the steroid.

11 A “safe” dose of steroid cannot be determined due to individual patient variability.

12 There does not appear to be any added risk giving injections to patients taking warfarin or other anticoagulants.

SOFT TISSUE INJECTION

Painful disorders of the soft tissue include such conditions as bursitis, tendinitis, tenosynovitis, trigger points, and so-called fibrositis. Most of these conditions have been previously described. Injection therapy is a mainstay of their treatment program (Fig. 18-21) Trigger points, fibrositis, and other similar syndromes are poorly understood disorders that present with pain and localized tenderness. A common site for the development of these tender areas is the spine, especially the interscapular and lumbosacral areas. Injecting these tender points is a common practice, but symptomatic relief is hard to analyze.

FIG. 18-21 Injecting the subacromial space for rotator cuff tendinopathy. A, The sulcus between the acromion and humeral head is palpated. The finger may be kept in position and used as a guide for the needle, or the site may be marked with the fingernail. B, The needle is passed into the space, and it is injected. Fluid should flow freely. The tendon is not directly injected. The bicipital groove anteriorly and the acromioclavicular joint may also require injection.

The depth of the injection varies from 1.25 to 5 cm, and it may be necessary to inject several areas. The best relief is obtained when the area is well defined. If the area to be infiltrated lies directly over bone, it is usually safe to insert the needle until it touches bone. Fluid may be injected at this point, and the needle is then retracted for further infiltration. However, particular care should be exercised when the injected area does not lie over bone but rather over soft structures such as viscera.

JOINT INJECTION

There are often occasions when intraarticular injection, sometimes accompanied by aspiration, is helpful in the treatment of painful joint disorders. This is more easily performed when an effusion is present. Except for the shoulder and hip, most joints are entered on their extensor aspect (Fig. 18-22). The major neurovascular bundle is usually found on the flexor side. Fluid usually distends the joint most in the direction of the extensor side, which makes entrance easier.

FIG. 18-22 Knee joint injection. The knee should be placed in extension. A, The knee is injected in the groove between the patella and femur medially. The finger is used to establish the line of needle placement. B, The patellofemoral space is usually wider medially because of a slight tilt to the patella. The knee can also be injected with the patient sitting and the knee bent. The needle can be inserted beside the medial patellar tendon in this position and directed to the notch of the femur.

The knee is the joint most commonly entered. If fluid is present in the suprapatellar pouch, the joint may be entered through the area of maximum swelling. Otherwise, the medial or lateral surface is used so that the needle passes between the patella and femur with the knee extended. Relaxation of the extensor mechanism is necessary. Other joints, including the smaller joints, are entered in a similar manner. Distracting (traction) distally on a small joint often makes needle entry easier by slightly opening the joint.

Frostbite

The severity of injury produced by exposure to cold depends on many factors, some environmental and some host related. The most important are the duration of exposure and the degree of temperature. High humidity and wind also increase the amount of damage. Moisture also has a negative effect, because it allows for more rapid cooling of the involved part. In addition, previous cold injury and preexisting peripheral vascular disease increase the susceptibility to future injury. Other host factors include anemia, diabetes, and tobacco and alcohol use. Frostbite usually requires several hours of exposure to cold unless the exposure occurs at high altitudes where it occurs more rapidly.

Although any area can be affected the nose, ears, hands, and feet are the most common sites of involvement. The signs and symptoms depend on the amount of damage. Mild injury may cause only hyperemia and edema. Soft flesh is usually palpable beneath the frozen, stiff skin. Upon recovering from this degree of involvement, the part often becomes bright red and very painful. Vesicles may appear later.

With more severe injury, the part never recovers, and necrosis of varying degrees begins to appear after thawing. A sign that gangrene may develop is the appearance of heat, edema, and pain in the surrounding tissues. Even after recovery, the part often remains sensitive to cold, and permanent paresthesias and discomfort are often the end result.

TREATMENT

Cold injury can be prevented by avoiding tight-fitting clothing and by wearing several layers of loosely fitted clothing that is relatively windproof but not completely impervious to moisture. Long periods of immobility should be avoided, and socks and gloves should be kept dry.

Treatment of frostbite depends on the severity of involvement. Mild exposure is treated by removing all wet and constricting clothing in a sheltered area. The part is warmed by applying gentle pressure or, as in the case of the hands and feet, by placing the part under an armpit or on the abdomen beneath the clothing of another individual. The part should never be rubbed or massaged. Thawing should be avoided if there is any risk of refreezing. Nicotine and caffeine should be avoided.

More severe degrees of acute injury are treated by rapid warming. Smoking is not permitted because vasoconstriction impedes healing. Constriction is also avoided by keeping the patient well hydrated by drinking or even with intravenous fluids. Use of the part should always be avoided, and after transfer to the appropriate facility, the extremity is placed in warm water that is kept at 40°C to 42°C (104°F to 108°F) for 20 to 30 minutes. Higher temperatures or prolonged time are unnecessary and may even be harmful. The extremity should be temporarily removed whenever more warm water is being added. Touching the sides or bottom of the vessel should be avoided. The affected part should never be exposed to an open fire, excessive dry heat, or hot water. The extremity is insensitive and may be burned. Exercise should be avoided. Rewarming is often painful, and the patient may require narcotics. Injuries more than 24 hours old are not rewarmed.

After rewarming, the extremity is elevated to control the edema, and the area is exposed to the air. Refreezing should be prevented. Blisters should be left intact. Daily whirlpool baths at body temperature are begun with an antibacterial solution, and the injured part is observed for tissue demarcation that may take several weeks. Early debridement should be avoided because actual tissue loss is usually much less than initially estimated. Only the onset of infection with wet gangrene requires immediate surgery with removal of the site of sepsis. Antibiotics and tetanus prophylaxis are given as necessary.

Long-term postfrostbite sequelae, such as arthritis, sensitivity, paresthesias, edema, and secondary Raynaud’s phenomenon, are common. Neuropathic symptoms may benefit from sympathectomy.

NOTE: Remember, the feet may swell after the shoes are removed, and if the patient needs to be moved, the shoes might not be able to be placed back on the patient’s feet.

Rhabdomyolysis

This is a potentially life-threatening condition in which disintegration or dissolution of muscle tissue occurs, which leads to membrane lysis and leakage of muscle constituents into the circulation. Myoglobin, which is toxic to the kidneys, is eventually excreted in the urine. Renal damage can occur from tubular obstruction by myoglobin as well as hypovolemia.

The disorder can develop with muscle damage from trauma, exertional heat stroke, simple strenuous overexertion, prolonged seizure activity, electrical injury, pressure from lying without moving for a prolonged time (such as extensive spinal surgery), infectious and inflammatory myositis, and some metabolic myopathies. Other causes include compartment syndrome and malignant hyperthermia. Rhabdomyolysis may also be drug induced (statins, and amphetamines). It may also be a complication of a disorder called neuroleptic malignant syndrome. This is a potentially fatal idiosyncratic reaction to certain neuroleptic drugs, particularly haloperidol, characterized by fever, muscular rigidity, and altered consciousness.

CLINICAL FEATURES

The primary problem is myoglobin, which may cause renal failure when released in large amounts. Symptoms may range in severity. Muscle tenderness, fever, altered consciousness, painful muscle cramps, and acute weakness are often presenting features. Ischemic compartment syndromes may even result from plasma leakage into damaged muscle. The urine often becomes dark.

Laboratory testing usually reveals myoglobinuria, elevated creatine phosphokinase, and aldolase levels, hyperkalemia, and hyperphosphatemia. Screening for myogobinuria may be performed with a simple urine dipstick test using orthotoluidine or benzidine.

Treatment involves early aggressive intravenous fluid replacement to prevent acute renal failure and correct electrolyte imbalance. Early recognition can help prevent renal consequences, which occur in 30% of cases.

Disorders of Treatment

Several musculoskeletal problems develop with some frequency during treatment for other conditions. They often occur during hospitalization and can usually be prevented by simple means.

ULNAR NEURITIS

This condition may develop in the hospitalized patient and usually results from sleeping in the supine position with the elbows slightly flexed and resting on the bed. It often results when the elbows are used to push up from the bed. Pain and numbness along the ulnar nerve distribution are typical symptoms, and the nerve is tender to palpation at the elbow. The condition is often bilateral. It sometimes develops from the patient lying in supine position during surgery. The disorder is prevented by having the patient wear soft pads strapped to the elbow to prevent pressure. The patient is not allowed to lie with the elbows in slight flexion, and a trapeze should always be available so that the patient will not have to use the elbows for propping up. Once the symptoms occur, surgical treatment is occasionally necessary.

CRUTCH PALSY

Crutch palsy may occasionally result from the improper use of crutches. The patient often supports the weight of the body with the axillary portion of the crutch and may develop variable degrees of pain and paresthesias in the arm with prolonged usage. The symptoms are most frequently caused from pressure on the lower portion of the brachial plexus, and the ring and small fingers are typically affected. The condition is easily prevented by instructing the patient to apply pressure on the hand portion of the crutch and not on the axillary portion.

TROCHANTERIC BURSITIS

Bursitis over the greater trochanter is occasionally seen in the hospitalized patient as a result of prolonged recumbency in the lateral position. Pressure over the trochanter results in inflammation of the bursa. Ultrasound, hot packs, anti-inflammatory medication, and a local steroid injection are usually curative.

FROZEN SHOULDER

Inactivity of the shoulder, frequently in association with cardiac or pulmonary disorders, may lead to stiffness in the shoulder and reflex sympathetic changes in the upper extremity. The etiology of this condition, sometimes called shoulder–hand syndrome or adhesive capsulitis, is unclear. The stiffness, similar to that seen in frozen shoulder from other causes, is progressive, but fortunately, full, pain-free motion is the eventual outcome. The sympathetic component is manifested as pain, edema, osteoporosis, and dystrophic skin changes. The most important aspect of treatment is prevention. The patient is encouraged to move the shoulders as frequently as possible, and passive range of motion is also performed.

Rickets

This is a systemic disease of infancy and childhood in which mineralization of growing bone is deficient as a result of abnormal calcium, phosphorus, or vitamin D metabolism. (Osteomalacia is the same condition in the adult.) Renal osteodystrophy is a term that describes a similar condition in patients with chronic kidney disease. Certain forms of the disorder may respond only to very high doses of vitamin D and are referred to as vitamin D–resistant rickets.

PHYSIOLOGY

Normal serum levels of calcium are critical for healthy nerve and muscle function. Homeostasis is maintained by the following: (1) calcium absorption through the small bowel, (2) removal of calcium from the bone reservoir, or (3) renal reabsorption. All three mechanisms are controlled to varying degrees by a metabolite of vitamin D, 1,25-dihydroxyvitamin D, and parathyroid hormone (PTH). Phosphate levels are bound to those of calcium in great part in that when hydroxyapatite bone crystals are resorbed for calcium, phosphate is released as well. Phosphate levels are also under renal regulation. Tubular resorption is regulated by PTH, which can cause phosphate diuresis. Therefore, any disorder which raises PTH levels increases renal excretion of phosphate.

Vitamin D is a fat-soluble vitamin present in high concentrations in fatty fish (tuna, salmon), egg, butter fat, and cod liver oil. Most milk products are fortified with vitamin D. The vitamin is absorbed from the gastrointestinal tract with dietary lipids and stored in the liver. The daily requirement is 400 to 800 IU. Vitamin D requires sunlight to be converted to its active metabolites in the liver. Vitamin D enhances absorption of calcium from the small bowel, transfer of calcium from bone crystal, and proximal tubular resorption of calcium.

PTH mobilizes calcium and phosphorus from bone in response to low serum calcium levels and enhances calcium transfer in the small bowel and reabsorption by the renal tubules. When serum calcium levels are diminished, parathyroid activity is increased. Osteoclastic activity is enhanced (reflected by increased serum alkaline phosphatase levels), and normal serum calcium levels are restored. Ongoing resorption leaves soft osteoid behind (osteomalacia). In children, enchondral ossification is affected as well, leading to a decrease in longitudinal growth and deformity, especially at the knee. In severe cases of rickets, parathyroid enlargement may occur, and excess bone resorption may result in osteitis fibrosa.

ETIOLOGY

True classic vitamin D–deficient rickets is rare in Western society. Absorption of vitamin D, however, may be blocked in several gastrointestinal disorders. Similar conditions may also prevent absorption of calcium and phosphorus, but in the absence of these diseases, deficiencies of calcium and phosphorus are also rare.

A number of acquired or inherited renal tubular abnormalities may cause resorptive defects and result in rickets and osteomalacia. A number of separate syndromes have been identified, including classical vitamin D–resistent rickets, which is probably the most common form of rickets in general medicine.

Chronic renal failure can produce the condition sometimes referred to as renal rickets or renal osteodystrophy. The renal abnormalities result in retention of phosphate.

CLINICAL FEATURES

The child with classic rickets usually develops a number of specific abnormalities. Softening of the skull bones (craniotabes) may be present early in the disorder. Enlargement of the ribs at the costochondral junctions produces the rachitic rosary. Limb deformities and epiphyseal swelling are often present. The height of the child with rickets is often below the normal range. Children are often irritable and fatigue easily. Pigeon breast deformity is common, and there is often an indentation of the lower ribcage at the insertion of the diaphragm, which is sometimes referred to as Harrison’s grooves. Thoracic volume may actually be decreased, resulting in diminished pulmonary ventilation.

Physical findings in the adult with osteomalacia are more subtle. Malaise and bone pain may be present. Many patients are presumed to have osteoporosis.

SPECIAL STUDIES

In rickets, there are characteristic radiographic changes which occur at the ends of growing bones, which lead to widening and irregularity of the epiphyseal plate.

Roentgenographic abnormalities in the adult with osteomalacia are often confused with osteoporosis. Pseudofractures (Looser’s zones) may develop where major arteries cross bone. Insufficiency compression fractures are common in vertebral bodies.

The laboratory assessment of the various disorders of bone metabolism requires a high degree of interest. Many of the conditions are so similar that only a complicated laboratory evaluation may establish the diagnosis. Blood urea nitrogen, creatinine, alkaline phosphatase, calcium, and phosphorus levels should be determined in any patient in whom metabolic bone disease is suspected.

TREATMENT

Because of the complex nature of many of these disorders, a qualified endocrinologist and nephrologist should be consulted for treatment.

The need for orthopedic intervention is rare. Surgical care is indicated for slipped capital femoral epiphysis, which occurs commonly in renal rickets. Deformity may require bracing.

Paget’s Disease (Osteitis Deformans)

Paget’s disease is a nonmetabolic bone disorder of unknown origin characterized by repeated episodes of bone destruction (osteolysis) and excessive attempts at repair, which results in weakened bone of increased mass. Monostotic and polyostotic disease are both described. Males are affected twice as often as females.

The disorder is unusual before the age of 40, and up to 3% of patients older than 50 years may show localized lesions. Clinically important disease is much less common.

CLINICAL FEATURES

Bone pain is usually the first symptom, but in up to 70% of patients, the condition is asymptomatic and is discovered incidentally. The onset of the disease is variable, and symptoms result mainly from the effects of complications. Painful bowing of the long bones develops, sometimes leading to pathologic fractures. Half of the patients have hip or pelvic involvement, and hip pain is a common complaint. Secondary osteoarthritis may develop. Increased blood shunting in the extremity may cause warmth in the limb and lead occasionally to heart failure.

Characteristic bone hypertrophy leads to skull enlargement and bony overgrowth of the spine. This can produce neurologic complications (vision, hearing loss, radicular pain, and cord compression). Serum calcium and phosphate levels are normal, and the alkaline phosphatase level is elevated. Serum bone-specific alkaline phosphatase analysis may be most helpful. There is increased urinary excretion of pyridinoline, although this test is expensive and not usually needed in routine cases. Roentgenograms show dense expanded bones with characteristic radiolucency and opacity. (Fig. 18-23). Bone scanning reflects the extent and activity of the disease.

FIG. 18-23 Paget’s disease of the hip and pelvis.

TREATMENT AND PROGNOSIS

Bisphosphonates are the treatment of choice. They act to suppress bone resorption by osteoclasts. NSAIDs are usually helpful in controlling the bone pain. Patients should receive adequate amounts of vitamin D and calcium. Calcitonin and alendronate are among the drugs that also have some effectiveness. The general indications for treatment are as follows: (1) all symptomatic patients, (2) asymptomatic patients with high levels of metabolic activity, and (3) preoperatively, if surgery involves the pagetic site.

Many monostotic lesions probably remain asymptomatic, and the prognosis of the mild form is good. Progression of the disease is common. Malignant degeneration occurs in fewer than 1% of patients and should be considered when there is a sudden increase in pain. Bone biopsy may be needed in uncertain cases. Sarcomatous change carries a grave prognosis.

Surgical intervention may be required for neurologic complications or joint symptoms. Surgery is often associated with profuse blood loss. Elective cases benefit from preoperative treatment to suppress bone activity and vascularity.

Miscellaneous Neuromuscular Disorders

A variety of neuromuscular problems may present as “orthopedic” conditions with weakness, numbness, and/or pain. The following section describes some of the more common neuromuscular disorders that fit this category.

PERIPHERAL NERVE COMPRESSION SYNDROMES

Localized injury and compression of peripheral nerves are common problems. The more frequent disorders have been previously discussed. Other syndromes are similarly caused by trauma or inflammation (Table 18-2). Early recognition is the key to effective treatment. Frequently, only the distal sensory portion of the nerve is involved. If superficial, Tinel’s sign is usually positive. Minor sensory deficits are commonly present.

Table 18-2 Miscellaneous Peripheral Nerve Syndromes

POSTPOLIO SEQUELAE

Many victims of polio were left with varying degrees of weakness and deformity. Most of these patients are now more than 55 years of age, and in recent years, some have begun to experience new symptoms, mainly increased fatigue, difficulty swallowing, cognitive defects, weakness, and joint pain. Most of the time, their musculoskeletal complaints can be attributed to arthritic changes (wrist and knee especially) or other expected disorders such as carpal tunnel syndrome. Sometimes, the symptoms have no clear etiology, and the weakness and fatigue may even follow the same pattern as the original infection. This “syndrome” has received much media attention, sometimes alarming many patients. Among the possible causes for these symptoms are (1) “burnout” or overuse of a few surviving motor units; (2) progressive anterior horn cell loss; (3) age-related muscle and ligament weakness, which further compromises marginal muscle function; (4) improper or inappropriate braces and orthotics; (5) reactivated polio virus; (6) an amyotrophic lateral sclerosis (ALS)-like syndrome, and (7) decompensation of the balance between denervation and reinervation. The most likely factors involved are overuse, age-related progression, and the use of poor or outdated prosthetic devices.

MANAGEMENT

Reassurance and understanding are the most important tactics in treatment. Very few patients who have had polio have any serious progression of their weakness. The role of exercise has not been clearly established, but excessive physical strain should be avoided, and these patients probably benefit from a careful, nonfatiguing, resistive exercise program. Braces, orthotics, and other assistive devices should be evaluated and updated or modified as necessary.

CHARCOT–MARIE–TOOTH DISEASE

This is a heterogeneous group of noninflammatory inherited peripheral neuropathies sometimes called peroneal muscular atrophy, hereditary motor and sensory neuropathy (HMSN), or idiopathic dominantly inherited hypertrophic polyneuropathy. The etiology is chronic segmental demyelination of peripheral nerves with hypertrophic changes caused by remyelination. It is the most common inherited neuropathy.

CLINICAL FEATURES

The onset is usually between 10 and 20 years of age but can be delayed to age 50. The familial nature of the disease is positive in two thirds of cases and helps to establish the diagnosis. The presentation is variable from family to family, but affected individuals in a family tend to have similar symptomatology. Common complaints are those of gait abnormalities, frequent tripping, and problems with running and balance. The male/female ratio is 3:1.

The onset is usually gradual, and the condition typically runs a slowly progressive course. The lower extremities are primarily involved. Peroneal muscle weakness may be an early finding. A high arch (cavus) and hammered toes are characteristic developments. Atrophy of the lower legs often produces a stork-like appearance. Muscle wasting does not involve the upper legs. Hypertrophic changes may develop in some peripheral nerves. Sensory loss, painful paresthesias, or other neurologic signs may occur although the sensory loss is usually mild. Deep tendon reflexes are absent in many cases, and decreased proprioception often interferes with balance and gait. Poorly healing foot ulcers develop in some cases. Late in the disorder, the hands may become involved.

Electrophysiologic studies are often diagnostic and may also be helpful in defining various subtypes of this group of neuropathies. Occasionally, muscle and nerve biopsies are required, but the early onset, slow progression, and familial nature of the condition are usually sufficient to establish the diagnosis.

TREATMENT AND PROGNOSIS

Genetic counseling is needed. Occupational and physical therapy are helpful to preserve function. Bracing and surgery are indicated to add stability and restore a plantigrade foot. Proper foot care is important to avoid ulcers.

Disability is usually mild and compatible with a long life; 10% to 20% of patients are asymptomatic. A small number of patients are nonambulatory by the sixth or seventh decade of life, but the disorder is usually not life threatening.

SYRINGOMYELIA

This disease of the spine is characterized by the formation of fluid-filled cavities within the spinal cord, sometimes extending into the brain stem (see Chapter 16). The cause is unknown, but the condition is thought to be due to obstruction of the fourth ventricle, often associated with a Chiari I malformation, which causes fluid to be diverted down the central cord. Later in life, syrinxes may be caused by trauma or the result of an imtramedullary tumor.

CLINICAL FEATURES

The onset of syringomyelia is usually insidious, and symptoms may not develop until the third or fourth decade. The cervical spine is the most common area affected. Intrinsic hand atrophy, weakness, and sensory loss may develop. The latter may lead to unnoticed burns or other injuries in the hand. Neck involvement may cause the development of a Charcot joint in the shoulder or elbow. Reflexes are absent in the upper extremity and hyperactive in the legs. Trophic skin changes eventually occur.

Plain roentgenograms usually reveal widening of the bony canal in the region of involvement. Myelography, MRI, and other imaging studies are recommended.

The condition is slowly progressive in most cases, but the course may be quite variable, ranging from death in a few months to slow incapacitation over several years. Surgical intervention often halts progression but frequently does not lead to improvement in neurologic findings.

HERPES ZOSTER

This is a common condition also known as shingles. It develops from the reactivation of a varicella (chickenpox) virus, which often resides asymptomatically in dorsal root ganglia. As a result, the affected nerve root becomes painful, and a typical skin eruption develops along the distribution of the root. The thoracic region is more commonly involved, and the disorder often develops when the virus reemerges when there is a weakening of the immune system, often because of disease or age.

The skin rash may not develop for several days, which makes an early diagnosis difficult. In the early stages, the disorder may easily be confused with radicular pain of spinal origin. The pain is usually quite severe. The skin later becomes reddened, and eventually, clusters of vesicles appear. These, too, are painful and last for 1 to 2 weeks.

Treatment includes pain relief and oral antiviral agents.

MULTIPLE SCLEROSIS

Multiple sclerosis (MS) is a chronic demyelinating neurologic disorder of unknown etiology that presents with recurrent episodes of neurologic dysfunction. (Patients with pain in the legs frequently worry that their symptoms are from MS.) The early diagnosis is very difficult, due to the variability of presenting symptoms. The hallmark of MS is relapsing and remitting neurologic deficits. Pathologically, the lesions of MS are those of patchy loss of myelin in the white matter. Inflammation and edema may be present in the acute stage, and scarring occurs in the chronic phase.

The disease usually presents in the third decade, and females are more commonly affected than males. Pain is rare. Paresthesias, disturbances in sensation and gait, and visual and bladder dysfunction are the most common initial symptoms. Many of these mimic other disorders, which makes a diagnosis difficult to establish. Although the diagnosis is ultimately based on clinical evidence (objective neurologic findings, such as ataxia, incoordination, hyperactive reflexes, positive Babinski sign, visual loss, and Lhermitte’s sign—tingling paresthesias with neck flexion), a number of laboratory and imaging tests are helpful.

SPECIAL STUDIES

MRI is the preferred imaging modality. Typical abnormalities (periventricular plaques) are found in the majority of cases and, when combined with a positive history and neurologic examination, usually establish the diagnosis without further testing. The cerebrospinal fluid (CSF) usually has elevated protein and leukocyte levels. The gammaglobulin level is often increased (in 70% of cases), and agar gel electrophoresis of concentrated CSF often shows migration in a typical pattern called oligoclonal bands.

Evoked potentials (electrical responses to sensory stimulation recorded by surface electrodes) are often abnormal, although, like most other tests, they are not specific for MS.

PROGNOSIS

The long-term outcome is variable, although many (one third of all) patients have a relatively benign course. Predicting the prognosis for an individual patient is difficult.

Exercise and Good Health

Regular exercise is the key to good health. People who are physically fit have more energy, sleep better, and are less depressed. They suffer fewer illnesses and pains than average and enjoy a more positive sense of well-being. Exercise is just as important for the person who does heavy labor all day as it is for those who do desk work. Doing hard work does burn some calories and strengthen muscles, but it does little to make patients fit and may even cause chronic pain to muscles and back. Most patients need some kind of regular exercise, and the best is known as aerobic (literally with air). Before starting, a general physical examination may be needed if there is any indication of chronic illness.

AEROBIC EXERCISE

For the exercise to be considered aerobic, it must be fast enough to improve cardiovascular fitness. The heart rate is usually used to determine whether the exercise is sufficient to develop the aerobic effect. To be effective, the activity simply needs to raise the pulse to what is known as the target heart rate (THR) and sustain the THR during the exercise for at least 15 to 20 minutes.

The individual’s THR is determined by first subtracting the patients age from 220 to obtain that individual’s maximum heart rate (MHR). That figure is then multiplied by 0.60 to 0.80 to determine the target heart rate zone (Table 18-3). Exercise performed in this zone improves aerobic conditioning.

Table 18-3 Target Heart Rates (Measured at 60%–80%)*

WALKING AND JOGGING

These are certainly the simplest of aerobic exercises. Because it is “low impact” (no excessive jumping or pounding), brisk walking is easier on the back and legs and provides about the same benefits as jogging. Walking is also the least risky exercise for those individuals with chronic medical problems. In addition to improving cardiovascular function, walking may also (1) help slow bone loss, especially in women; (2) extend life (walking 12–20 miles per week will decrease the annual death risk by about 27%); (3) help control cholesterol levels; and (4) help control weight. As with all exercise, the activity should be begun slowly. Eventually, the patient should walk at least four times per week for about 45 to 60 minutes while pausing from time to time to check the heart rate. Usually, walking at a rate of 120 steps per minute is adequate. For walking, warming up is not necessary, but a “cool-down period” after finishing running is better than stopping abruptly.

Once the patient is comfortable walking, jogging may be tried. A slow pace is more than adequate.

OTHER EXERCISES

Swimming, cycling, rowing, cross-country skiing, and jumping rope are also excellent aerobic activities. Swimming removes the body weight and may be better in patients with painful joints. Swimmers should avoid any stroke that requires that the neck be extended and the chin raised, because this can irritate cervical disc disease. Goggles and snorkel help prevent excessive neck motions and subsequent pain. Swimming at a THR for 20 to 30 minutes three times per week is sufficient. If cycling is tried, the bike needs to fit properly so that the lower portion of the back does not become strained. Stretching exercises may be good before any vigorous exercise. Stretching should be done after warming up for 5 minutes by walking (see Chapter 15). Cold muscles should not be stretched.

EXERCISE FOR THE ELDERLY

More than 13% of the U.S. population is older than 65 years of age, and that percentage is increasing. As this group ages, the importance of exercise becomes a critical factor in overall health. Lack of physical activities contributes to thousands of deaths each year, but many health care providers never advise patients regarding physical exercise. They are also reluctant to recommend exercise for the more frail of the elderly, sometimes called the “old-old” (older than 75 years of age).

The decrease in physical functioning of the elderly is frequently not just the result of the aging process but instead is often related to simple inactivity. Deconditioning is a huge problem to overcome, but it has been shown that inactive elderly patients can actually lower their “physiologic” age as measured by aerobic capacity by taking part in an age-appropriate exercise program.

Only 25% of the elderly live in nursing homes, with the remainder living in the general community, often alone. This can present problems with transportation, although most exercise programs can be performed at home. Other factors to consider are cost, availability, and the normal reluctance of patients to take part in preventive health activities.

The etiology of the decline in function is multifactorial and includes the following: (1) “bias” against the elderly with limited expectations (“you’re just getting old”); (2) physical problems with pain, strength, and balance; (3) psychological factors, including depression; and (4) financial and social issues. Before considering such a program, there should be a full medical evaluation. In addition, environmental factors at home should be assessed. It may also help to set some realistic but specific goals, such as being able to walk without help to dinner. Once this is done, consideration can be given to addressing the individual patient’s needs and abilities. In general, there are several issues to consider: (1) increasing strength and conditioning, (2) improvement in flexibility, and (3) better balance with fewer falls. To be most helpful, a regular schedule of 45 to 60 minutes at least 4 days per week should be encouraged. Arrangements might be made for group sessions with a personal trainer at a convenient location to get things started. Eventually, most patients could be given a home program. The side benefits include more confidence, less depression with socializaion, improved sleep patterns, and fewer falls.

Strength and energy levels can be improved in a variety of ways from simple walking to regular swimming. The activity should be varied to prevent boredom. Simple weights using familiar things from home are invaluable for improving strength.

Flexibility exercises should start slowly. Those range-of-motion activities that occur with normal daily activities are not sufficient. Shoulder stretches (Chapter 5) are begun with the goals of being able to put the hand into the back pocket, comb the hair on the back of the head (both arms), and abduct the arm 90 degrees. Flexion of the hip is usually sufficient, but a mild flexion contracture may be present that may require extension exercises of the hip to improve gait and posture.

Balance may be able to be improved by activities sometimes called “movement therapies” or postural re-education. The most popular of these are toga, tai chi, and Pilates, especially those forms that emphasize slow smooth movement. Benefits from these nontraditional activities are hard to measure and are largely anecdotal but all of them are very popular. Meditation, relaxation, and breathing techniques are often part of the program. Most of these therapies are available with supervisors, but tapes and DVDs can also be purchased at a reasonable price.

Tai chi is Chinese in origin and emphasizes movements and postures. It is weight bearing in nature and teaches slow rhythmic exercise; there is more than one style of tai chi. Yoga originated in India, and several different forms are available from many different practitioners. Although considered a complete way of life encompassing spirit, social responsibility, and physical health, many forms of yoga practiced in the West concentrate on physical strength, flexibility, and relaxation through various postures. Pilates was developed by Joseph Pilates from experience with disabled soldiers. Body mechanics and whole-body conditioning are emphasized.

In summary, exercise programs can benefit all age groups, including the elderly. Many of the activities could even be performed as groups in an office setting using a qualified instructor. Remember that doing almost anything is better than doing nothing.

Local Soft Tissue Treatment

All musculoskeletal problems involve the soft parts at least to some degree. For purposes of discussion, they are divided into acute and chronic disorders.

TREATMENT OF ACUTE INJURIES

Acute soft tissue injuries are generally those of muscle strains of varying degrees, contusions, and ligamentous sprains. They are all accompanied by hemorrhage and swelling. For the first 24 to 72 hours, ice is applied for 30 minutes every hour. Rest, ice, soft compression, and elevation are also used (RICE). Crushed ice in a plastic bag is preferred to the chemical cold packs. These packs can cause blistering and severe chemical burns. After 3 days, gentle range-of-motion and stretching exercises are begun several times a day while cold is applied. Cold is maintained for about 5 minutes after the exercise.

Protected use of the part is allowed as tolerated. Heat in any form, vigorous stretching, massage, or exercise are avoided to prevent further injury. Hematomas that may form usually do not require aspiration. In the majority of cases, they absorb spontaneously over the course of several weeks.

(NOTE: Ice is also very helpful in cases of chronic “overuse” problems such as tendinitis. It is usually applied for 5 minutes after the offending activity.)

TREATMENT OF CHRONIC DISORDERS

Among the forms of “therapy” available for patient care are occupational and physical therapy and other rehabilitation services. In referring patients for these services, consultation with the therapist or physiatrist may be helpful. The diagnosis should be included, as well as specific instructions regarding the treatments and their frequency. In addition, a maximum time limit (usually 2–4 weeks) should be set to determine whether the treatments are truly effective. If the patient is hospitalized, the prescribed treatments are often given twice a day. For an outpatient, they are usually given once a day or every other day. For the therapy to be continued, the patient should show more than just temporary improvement. If not, the treatment should be stopped and the patient reevaluated.

Most therapeutic modalities have developed over the years on a purely empiric basis, and various treatments have been in vogue at various times. All of these treatments are expensive, and patient improvement is often anecdotal and short-lived. Modalities do not speed healing. A placebo effect because of the “hands-on” aspect of the care undoubtedly plays a considerable role. Among the more commonly used treatments available at this time are the following: (1) heat therapy for pain relief, (2) massage, (3) therapeutic exercises, and (4) traction.

HEAT THERAPY

Whether to use ice or heat therapeutically in the treatment of pain is an arbitrary judgment. Heat remains the most popular. Heat treatment is either superficial or deep. Although never proven, the theories behind thermotherapy are that it increases blood flow, helps resolve edema and inflammatory products, and increases the extensibility of collagen, thus producing pain relief and diminishing stiffness.

Superficial heat (1–5 mm) can be delivered at home as well as in a therapy office. Paraffin baths (usually for hands), infrared lamps, hot packs (such as hot water bottles and heating pads), and various forms of whirlpool “hydrotherapy” are available. Perhaps the simplest, least expensive is “moist heat” at home. A small towel is dampened and any excess moisture removed (many heat pads come with soft pads designed for this purpose). A plastic sheet is placed between the towel and heat source. Heat is then applied to the affected area for 1 to 2 hours one to two times a day or more as needed. Care should be taken not to raise the temperature level too high and cause a skin burn.

Deep heat is usually available as shortwave diathermy, microwaves, and ultrasound. Diathermy and ultrasound are more commonly used. The type must be specified.

The following points should be remembered when using any form of heat:

1 Patients should not fall asleep with their heating pad turned on high.

2 Heat before exercise (stretching especially) often enhances the effect of the exercise.

3 Heat should not be used in areas of cancer or near the gonads or a developing fetus.

4 Heat should be avoided in tissues without pain sensation or adequate circulation. The higher temperature increases the metabolic demand without the tissue’s ability to respond with increased vascular supply. Necrosis may then occur. This is of special concern in the foot in patients with diabetes or peripheral vascular disease.

MASSAGE

A number of various techniques are used for “spasm” or “nodules.” They are usually types of kneading and stroking and are most commonly used for spine pain.

THERAPEUTIC EXERCISE

In general, if stiffness is present (for example, frozen shoulder), stretching or gentle manipulation (sometimes preceded by deep heat) are recommended. If weakness is present, resistive exercises are taught to the patient so that they can be performed at home. New trends in the management of most soft tissue injuries emphasize progressive exercise and restoration of function over passive modalities such as heat and massage. After a short period of time, during which modalities and medicine may be needed for pain control, further rest is no longer justified in most cases and may even be counterproductive, leading to more atrophy and weakness. Exercises are taught, and, for the most part, the completion of the rehabilitation is up to the patient. It is costly and unnecessary to have the patient return to therapy for exercise.

TRACTION

Various forms of spinal “stretching” are used, generally in the treatment of chronic spine pain. There is no evidence that any real distraction of disc or facet joints ever occurs, although patients sometimes report symptomatic improvement with cervical traction.

OTHERS

Trigger point injections, phonophoresis (ultrasound with cortisone cream), dimethyl sulfoxide (DMSO, investigational), acupuncture, biofeedback, electrotherapy, ice massage, and manipulation are all available. Transcutaneous electrical nerve stimulation (TENS) seems to be helpful in some chronic problems with localized pain, although its effect seems to decline with time. TENS may alter pain perception by stimulation of certain afferent fibers to inhibit spinal cord transmission of painful stimuli. Phonophoresis is the process of attempting to “drive” molecules of hydrocortisone (in the cream form) into the soft tissue with the use of ultrasonic waves. It became popular with physical therapists because it gave them a means of administering medication in conjunction with physical therapy. Some studies have shown that cortisone does penetrate into the soft tissue with ultrasound but the studies are few, and the results are somewhat conflicting. More complete discussions of occupational therapy and other rehabilitation services may be found in some of the works cited in the bibliography.

CANES, CRUTCHES, AND WALKERS

Assistive devices are a tremendous benefit in both short- and long-term patient care. They can improve stability and relieve pain. However, the fitting of these devices and instructions regarding them are often insufficient and occasionally left to nonmedical personnel.

Use of the cane has long been advocated for pain relief in the treatment of arthritis of the lower extremity. Such arthritis often causes a painful and unsightly limp, which is usually fatiguing and may even cause low back pain. As advances have been made in orthopedic surgery and demands made by patients, both the patient and physician may too quickly opt for a high-technology joint replacement rather than succumb to the indignity of trying the most time-honored device for relieving pain and limp. Suggesting the use of a cane in an arthritic patient almost always requires some sensitive coaxing, and better education of the general public regarding the benefits of a cane would be helpful in this regard. It is usually the patient’s pride or the psychological aversion to using the cane that needs to be overcome. The positive aspects of cane use should be presented. Patients need to understand that they would probably look better using a cane that could eliminate their pain and limp than walking with the limp itself. An attractive cane formerly was a symbol of elegance and not a stigma of the aging process. If those attitudes could be encouraged, perhaps more patients could be treated nonsurgically.

Although it can be used on either side, the cane is almost always used in the hand opposite the leg with weakness or pathologic joint disease. If it is used on the same side, it can produce excessive trunk sway. The length of the cane should be such that the handle is at wrist level with the elbow flexed 30 degrees. It has been shown that for every pound of pressure applied to the cane, 8 pounds of weight are reduced on the affected hip.

Crutches, walkers, and four-poster canes are used for stability, as well as pain relief and protection from weight bearing. They provide a broad base that increases the base of support and decreases the precision of coordination necessary during ambulation. Four-poster canes can only be used to push in the downward direction. Crutches need to be accurately adjusted (Fig. 18-24). Crutches that are too long may cause pressure on the axillary structures and result in crutch palsy. The hand piece of the crutch or walker should be at the same height as the cane so that it lies at wrist level with the elbow flexed 30 degrees.

FIG. 18-24 Proper crutch fit. The length of the crutch should be such that with the crutch slightly ahead (4 cm) and to the side (10 cm), there should be three fingerbreadths between the axilla and the axillary pad. The underarm area should be fitted first. Then, the hand grip is placed so that the grip is at the level of the wrist with the elbow bent 30 degrees. The hand grip of other devices (walker, cane) should be adjusted in the same manner. To go up stairs, the good foot goes first, the affected foot second, and the crutches last. To go down stairs, the crutches go first, the affected foot second, and the good foot last.

Controversies in Orthopedic Surgery

The primary care physician is often asked by the patient to give advice regarding musculoskeletal care that may involve controversial issues. This is often regarding decisions about whether to have a particular surgical procedure. Even though referring physicians may not take part in the surgery, their opinion about the benefit and necessity of the procedure is highly valued. The following areas are some that seem to be the most contentious.

LUMBAR FUSION FOR DISC DEGENERATION

Fusion (arthrodesis) for arthritic conditions involving peripheral joints has been and remains an excellent procedure for the relief of pain and correction of deformity. It has been supplanted by total arthroplasty in some joints, but it remains the procedure of choice in others. Because of the great success with peripheral joint fusion, attempts have been made over the years to transfer that knowledge and technique to degenerative conditions of the lumbar spine in an attempt to cure low back pain. In years past, fusion was actually used by some surgeons each time a lumbar discectomy was performed. Because of the high failure rate in curing low back pain, arthrodesis of the spine for disc degeneration lost popularity, but recent technical advances in roentgenographic imaging techniques and internal fixation devices have rekindled interest in the procedure. However, some recent studies have questioned the appropriateness of these procedures and their cost. Lumbar fusion is clearly indicated for trauma, scoliosis, and spondylolisthesis, but considerable uncertainty remains regarding its efficacy for the relief of the common low back pain due to disc degeneration.

ARTHROSCOPY

With the advent of intraarticular endoscopic evaluation and surgery, tremendous advances have been made in patient care. Now, procedures such as meniscectomy, which used to require arthrotomy and hospitalization, can be routinely performed in the outpatient setting. As the role of arthroscopy evolved, the indications for the procedure were naturally broadened (partially because of tremendous public pressure). As with other rapidly advancing technical procedures, there remains some dispute regarding the indications for its use, especially in two areas, the arthritic knee and the knee with anterior pain (“chondromalacia”).

In the treatment of osteoarthritis of the knee, the most difficult patient case is the middle-aged, active person with minimal roentgenographic and clinical arthritis, whose mild disease and young age would make total replacement inappropriate, but who lacks evidence of meniscal injury. In years past, this patient may have had open debridement (the “housecleaning” procedure of Magnuson), in which osteophytes and degenerative cartilage were removed, and exposed bone was drilled to encourage the formation of new cartilage. The success of this operation was somewhat limited, but because the same procedure can be performed by the arthroscopic route, it has again attracted interest. The indications for the surgery are difficult to define. Young patients with mild disease do best. Patients with previous meniscectomy, extensive disease, or deformity do less well. Results may be equivocal and tend to deteriorate with time. It is uncertain how much the role of lavage and rest may play in the relief of pain. In some studies, joint lavage by itself was as effective as arthroscopic debridement after 1 year.

The second area of controversial arthroscopic use involves the disorder called anterior knee pain (Chapter 11). This “syndrome” typically occurs in many adolescents and may continue for years. Some of these patients may be found to have chondromalacia arthroscopically. They sometimes respond poorly to physical therapy, and there is a great tendency to try to find some surgical cure by shaving the articular cartilage in the back of the patella. Anterior knee pain and the pathologic changes of chondromalacia are probably unrelated, and even though conservative management has a high failure rate, arthroscopic investigation of the knee in such cases with or without debridement of cartilage lesions does not seem to be beneficial. Conservative care usually remains the treatment of choice.