REST

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

SUPPORT

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

PHYSIOTHERAPY

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

ALTERNATIVE THERAPIES

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

LOCAL INJECTIONS

The indications for local injections fall into two groups:

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

DRUGS

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

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

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

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

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

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

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

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

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

MANIPULATION

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

The subject will be considered under three general headings: