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Obstetric Vasculopathies
First Edition: 2013
9789350903629
Printed at
Books and friends should be few but good
Pain in the neck is such a common problem that it should have been felt by everybody at least once in their lifetime. Every day activities require frequent movements of the neck. The movements of the cervical spine are flexion, extension, rotations and lateral flexions. The rotations of the cervical spine take place at the atlantoaxial joint (C1, C2). Forward and backward bending occurs at the atlantooccipital joint; lateral flexions occur at the intervertebral joints between C2 and C7. Hence everyone has to move all these joints of the neck for activities of daily living.
In this chapter, we will discuss the three common clinical conditions that present with pain in the neck, as follows:
- Brachial neuralgia
- Fibromyalgia syndrome
- Cervical spondylosis.
BRACHIAL NEURALGIA
Brachial neuralgia is a shooting type of pain and is excruciating. It is usually acute in onset (sudden). Sometimes the doctor may be disturbed in the middle of the night to attend on such a patient who is restless with pain in the neck and arm.
Brachial neuralgia is a clinical condition where the pain originates in the neck and radiates along the arm; sometimes the pain radiates to the forearm and the fingers.
Clinical Examination
Brachial neuralgia is commonly seen in the middle age group. The pain is acute in onset, severe and usually radiates along the arm or forearm.
2The geographical distribution of the area where the pain is felt will clearly indicate the nerve root that it is involved:
Outer aspect of arm—C5
Thumb and index finger—C6, C7
Little and ring fingers—C8, T1
The patient may be involved in domestic or office work. The pain suddenly starts without any specific history of strain or injury. Sometimes the patient may narrate a history of jerks while riding two wheelers, travelling long distances in buses or occasionally lifting heavy weights (the unwary house wife).
On inspection, the neck is held stiff; the neck may be tilted to one side due to unilateral paraspinal muscle spasm (postural cervical torticollis). The paraspinal muscles of the cervical spine stand out prominently which can be seen clearly. On palpation, the muscles are firm (muscle spasm). One must palpate the spinous processes of the cervical vertebrae and the trapezius muscles for any tenderness. Due to the pain, the movements of the neck are restricted in all the directions. The reflexes (deep tendon reflexes) are depressed over the involved nerve roots.
Usually, there is no muscle wasting; the power of the muscles of the upper limb and the hand grip appear normal. One must examine the trapezius muscle for swellings and tender spots which indicate fibromyositis. The shoulder joint should be examined clinically for any associated lesion. Sensory disturbances over the corresponding dermatome may occasionally be seen.
The radial pulse should be felt on both sides and blood pressure should be examined on both upper limbs.
Investigations
Due to the painful condition of the neck, the paraspinal muscles of the cervical spine are in spasm. Hence, an X-ray of the cervical spine will be more informative. Loss of the normal cervical lordosis is the diagnostic finding in any painful condition of the neck. Fasting and postprandial values of blood sugar may be needed to rule out associated diabetes.
Pathogenesis
The intervertebral disk which lies between the bodies of the cervical vertebrae is usually intact. Sometimes, a sudden jerk can cause a prolapse and the disk may press upon the adjacent nerve roots. This causes brachial neuralgia (neuralgia means pain along the course of a nerve). The commonest level of prolapse is the C5-C6 intervertebral disk which presses on the C6 nerve root. The pain is felt on the outer border of forearm and thumb. The biceps reflex is diminished. The next common disk to prolapse is C6-C7 which involves the C7 nerve root.
Radiology
In brachial neuralgia due to cervical intervertebral disk prolapse, the lateral view of the cervical spine is very informative. The normal cervical spine has the posterior curvature which is termed as cervical lordosis. In cervical disk syndrome or in any painful condition of the neck, this normal lordosis is lost and the cervical spine appears straight in the lateral view.
Treatment
Since the pain is acute and excruciating, the patient must be confined to bed. He may be given cervical traction either intermittent or continuous, which will relieve the pain by alleviating the muscle spasm. Parenteral use of analgesics, antiinflammatory drugs and neuronal blockers along with muscle relaxants for a couple of days, will reduce the pain dramatically.
It is wise to use a combination of centrally acting analgesics, nonsteroidal anti- inflammatory drugs and muscle relaxants in a judicious combination. Tramadalol (50 mg tds) and paracetamol (500 mg tds) are safe centrally acting analgesics. One should remember that tramadalol may cause drowsiness. Of the non steroidal anti-inflammatory drugs aceclofenac (100 mg bd) is safe. Ibuprofen (400–600 mg tds) is also very effective, but gastric erosion leading to hematemesis is a troublesome side effect. Diclofenac (50 mg tds or 50 mg bd) is also used but has the potential side effect of causing renal impairment. The muscle relaxants that are being currently used are methocarbamol, etodolac, flupirtine and thiocolchicoside. But the use of diazepam (5 mg tds) has proved to be therapeutically effective as a muscle relaxant and an anxiolytic. Gabapentine (100–300 mg od) is the first line drug in the management of neuropathic pain especially in diabetic neuropathy. The other muscle relaxants are dantrolene (25 mg–100 mg od) which is directly acting on the muscles. But the side effects shown by this drug are muscle weakness, sedation and sometimes troublesome diarrhea. The centrally acting drugs are diazepam (5 mg tds oral) and baclofen (10 mg bd/tds), but the side effects are drowsiness and confusion.
4The popular selective serotonin reuptake inhibitor used is sertraline (10 mg bd oral), which is a neuronal blocker, but the side effects are anxiety and confusions.
When the pain subsides, the patient is advised to wear a hard cervical collar for about three weeks. During that period, he should be given local heat therapy with ultrasound, and analgesics may have to be continued. After that, he must be subjected to neck muscle strengthening exercises. Very rarely, a massive prolapsed disk may have to be removed by surgical excision.
CERVICAL SPONDYLOSIS
This is the commonest cause of pain in the neck that is seen in any hospital. Cervical spondylosis can present as pain in the neck, or pain neck along with radiating pain, or only giddiness. It is essentially a degeneration of the uncovertebral joints. These are the joints between the cervical vertebrae.
Pathogenesis
In the early stages, the degeneration begins in the posterior intervertebral joints. Constant friction, strain and degeneration lead to the formation of osteophytes. Subsequently the intervertebral disks degenerate and lose their viscosity and integrity. This leads to narrowing of the intervertebral space. This type of osteophyte can cause pressure on the arteries and nerve roots, strain of the muscles or even compression of the cord.
The clinical presentation can be:
- Vasculopathy (artery)
- Radiculopathy (nerve root)
- Arthropathy (joint)
- Myopathy (muscle)
- Myelopathy (spinal cord).
Clinical Picture
Cervical spondylosis usually occurs in the middle age or older age group of patients. It is equally prevalent in both males and females. It may present as isolated pain in the neck or may be associated with one or more of the aforementioned symptoms.
- Vasculopathy: The patient will have giddiness and that is felt more during change of posture; very rarely it is continuous. The patient does not feel giddy when he lies down.
- Radiculopathy: This is due to pressure on the nerve roots by the osteophytes. Depending on the nerve roots that have been impinged, the pain is felt along the arm (C5) or the forearm (C6, C7).
- Arthropathy: This is the pain due to degeneration of the uncovertebral joint. The pain is felt more on moving the neck, in one or more directions. Some patients complain of pain during office work or kitchen duties while some of them feel the pain during travel.
- Myelopathy: Very rarely, the patient may present with clinical features of compression of the spinal cord, viz, paraesthesia or weakness in the lower limbs.
During the initial phases of the disease process, the patient may complain of pain that is localized to the neck. As days roll by, he may present with one or more of the above symptoms which can be diagnosed by good history taking and meticulous clinical examination.
Since the patient is in the early stages of his old age, one must examine him for associated systemic diseases like hypertension, diabetes mellitus, hyperlipidemia, arteriosclerosis and cardiac problems.
Investigations
Most of the investigations meant for patients with cervical spondylosis are done to rule out other associated systemic disorders. Blood sugar, serum cholesterol, serum lipid profile, electrocardiogram (ECG) are some of them.
X-ray of the cervical spine, especially the lateral view reveals more information than the anteroposterior view to help the clinician arrive at a reasonable diagnosis. The loss of cervical lordosis, sclerosis of end plates, narrowing of disk spaces, osteophytes (sometimes large) and narrowing of the neural foramina are some of the radiological features of cervical spondylosis.
Computerized tomographic scan of cervical spine should be studied in the sagittal and transverse sections. These images will show the irregularity of the disk space, and the osteophytes that may be pressing on the nerve roots or the vertebral arteries.
Treatment
Most of the patients with cervical spondylosis who present in the early stages of the disease, with pain localized to the neck can be treated with analgesics, antiinflammatory drugs and muscle relaxants. If the patient has features of radiculopathy, he may require cervical traction and drugs (neuronal blockers) followed by a cervical collar.
Local pain relieving measures like ultrasound or interferential therapy reduce pain in the early phases. Cervical traction either intermittent or continuous will alleviate pain by reducing muscle spasm; this may be required just for a week or two.
Cervical collar is so common that it is often misused. The hard cervical collar is used in the initial phases; the soft collar may be recommended for another few weeks; later the collar may be used only during travel. But it must not be used after the symptoms subside. It can be used as a preventive measure to avoid undue strain to the neck which may happen during travel or prolonged desk work.
Only a rare patient may require surgical intervention in the form of disk excision or foraminotomy.
FIBROMYALGIA SYNDROME
Pain in the neck has been discussed so far with relation to the nerve (brachial neuralgia) and the bone (cervical spondylosis). The following lines will be discussing the cause of pain in the neck due to the fibrous tissue which is common in both the ligaments and the muscles.
Health care professionals have been using numerous procedures that are available in their armamentarium to alleviate the pain of the patient with little success, ultimately brewing frustration both for the patient and his physician. This imbroglio has provoked many a clinician to pass the buck to his psychiatric counterpart. Are we justified in adopting this approach? When we ponder more about this question and ruminate about the other tissues involved, many facts unravel themselves, and one question pops out of the maze, viz. Have we been neglecting the ubiquitous fibrous tissue?
Epidemiology
Invariably various orthopedic outpatient departments across the globe are frequented by patients with backache and ours is in no way diferrent. But we noticed a peculiar feature; the patients had backache localized to the interscapular region and occasionally 7it radiated to the shoulders. The patients belonged to two contrasting socioeconomic groups viz. the poor beedi worker (a middle aged female who sits cross legged and bends over to manufacture beedis from tobacco leaves) and the elite connoisseur who makes a living as a soft ware professional (he bends over the keyboard and mouse); the common feature being the posture during work.
Etiopathogenesis
Fibromyalgia is a medical disorder characterized by chronic widespread pain and allodynia (a heightened and painful response to pressure). Fibromyalgia symptoms are not restricted to pain, leading to the use of the most appropriate term fibromyalgia syndrome; the other symptoms are fatigue, sleep disturbances and joint stiffness. The abnormalities in the central nervous system are only incidental and not causative.
Genetic predisposition, stress and psychological disturbances have been quoted as some of the causative factors by many authors. Emotional distress, sleep disturbances, strenuous activities, worry and travel have also been blamed by many authors. But, we feel that these factors aggravate the existing pain and do not cause it.
Various theories have been postulated in a frantic endeavor to explain the etiology of fibromyalgia syndrome; dopaminergic dysfunction, impaired serotonin metabolism and deficient growth hormone are some that occupy many pages in numerous books.
Recent studies reveal that fibromyalgia syndrome is a neuroimmune endocrine disorder with cytokines like interleukins playing a nondescriptive role in this etiology. Increased release of CRP (C reactive protein) and release of proinflammatory molecules by mast cells are other theories presented by some workers. Many researchers have agreed that increased levels of substance P are found in the cerebrospinal fluids of these patients.
Clinical Picture
The patient is usually of middle age with the pain referred to the inter scapular region. We would like to emphasize the importance of the history of the occupation and posture of the patient during work. Invariably it would reveal that his job demands continuous bending of the neck and back. The pain is usually continuous and aggravated by forward bending. A careful clinical examination would elicit tenderness over the trapezius which is felt more, just adjacent to the medial border of the scapula. Palpable swellings in the trapezius and pain during shrugging of the shoulder are oft associated findings; the movements of the cervical spine are normal but for a reduced range of lateral flexion due to spasm of the ipsilateral trapezius.
Electromyographic study of the normal trapezius shows a normal recruitment pattern (normal amplitude). In patients who have fibrositis it is a reduced recruitment pattern which reveals increased fibrous tissue in the tender areas.
Fibromyalgia syndrome is a chronic illness that has frequently evaded the clinician. To add to the cup of woes of the patient, multiple sophisticated investigations leave him in the lurch, and the clinician frequently searching for a tissue to blame. Both the clinician and the radiologist tend to focus more on the discs and the vertebrae and in their hunt, the mechanical stability and functional utility of the spine are often ignored. Further the adjacent fibrous tissues in the muscles are not seen by 8the eyes of the machines. The confirmation of fibromyalgia syndrome is essentially a clinical diagnosis.
Treatment
As with many other medically unexplained syndromes wherein the exact cause cannot be identified, there is no known universally accepted treatment for fibromyalgia syndrome. In 2005, the American pain society provided the first comprehensive guidelines for the pain management. Some drugs have reduced some symptoms in patients, but they have to be weighed against their side effects. In a review, in the 2009 journal of rheumatology, fibromyalgia researcher HA Smythe writes, “patients do receive some benefits; but when side effects make the patient dull and lethargic neither their goals nor those of the society are satisfactorily met”.
The most widely accepted set of classification criteria for research purposes was elaborated by the multicenter criteria committee of the American College of Rheumatology (the ACR, 1990). But the ACR criteria were originally established as inclusion criteria for research and were not intended for clinical purposes. One of the lead authors of the committee now states “the harder you press, the more FM you find,” further, Fredric Wolfe, one of the authors of the 1990 ACR report has correlated stress, anxiety and depression to be the causative factor. But we would like to emphasize that bad posture is the cause and depression is the result. Some authors have suggested psychosocial factors in selected patients.
Pain relief is achieved with a combination of aceclofenac, paracetamol and neuronal blockers like gabapentine. Certain new drugs like sertraline (10mg oral bd) selective serotonin reuptake inhibitor and tapentadol. The side effects are the anxiety and the confusions. The pain tends to reappear once the drugs are stopped and the patient goes back to work. Hence she must be advised “postural therapy” which includes a set of simple spinal exercises and training the patient to adopt the right posture during work.
Other Causes of Pain in the Neck
- Occupational hazard
- Trauma
- Acute disk prolapse
- Old fracture
- Cervical rib
- Tuberculosis
- Ankylosing spondylitis
- Polymyalgia rheumatica
- Rheumatoid arthritis
- Diabetes mellitus with neuropathy
- Tumors in spinal cord.
Occupational hazard: Bad postures by people who bend their neck during work are more prone for pain in the neck. This is due to strain of the interspinous ligaments. If this is not treated, it may lead to early cervical spondylosis. These patients must be 9advised to sit straight and look straight. Neck muscle strengthening exercises are very useful in preventing recurrent pain.
Trauma:
- Acute disk prolapse: Acute prolapse of the intervertebral disk in the cervical region presents with clinical features of radiculopathy (root pain). Cervical traction, either intermittent or continuous, alleviates pain remarkably. Some surgeons use parenteral steroids in the early phases and later muscle relaxants.
- Old fractures: Trivial injuries to the neck can cause fractures of the appendages of the vertebra which may not be visible in the initial X-rays. These fractures will disturb the effective functioning of the longitudinal ligament and paraspinal muscles resulting in persistent pain.
Cervical rib: Involuntary movements of the neck in children are called Tics. Abnormal elongation of the transverse process of the C7 vertebra is called cervical rib. In the young adult it presents as dull aching pain. The compression of the arteries and nerves appears later in the third or the fourth decade, and the clinical picture is that of Thoracic outlet syndrome. The patient may have pain neck, radiation along the arm and signs of arterial compression.
Tuberculosis: Caries spine involving the cervical spine may also present as a dull aching pain.
Ankylosing spondylitis: Persistent pain in the neck in an adult male may be the presenting feature of anylosing spondylitis. Though it starts a low backache, some patients report with pain in the neck. The decreased chest wall expansion (<5 cm) is one of the early clinical signs.
Polymyalgia rheumatica: This is one of the common conditions that occurs in young females. The patient has vague pain in the neck, low backache and pain in various other major joints, but without syonovial thickening.
Rheumatoid arthritis: It occurs in old age females. But is usually affects the lumbar spine, rather than the cervical spine.
Diabetes mellitus with neuropathy: With the increased incidence of diabetes mellitus spanning the various age groups, early demyelination of the nerves in diabetes should also be contemplated.
Tumors in the spinal cord: Primary tumors of the bones of the cervical vertebra are rather rare. Tumors of the meninges may present as pain in the neck. Secondary tumors of the cervical vertebra can easily be traced to a primary malignant tumor of the thyroid.
Life is too short with no time to worry
Inflammatory diseases which affect the joints are very common in all the countries of the world. Though infection (septic arthritis) and degeneration (osteoarthritis) are very common in our country, chronic inflammatory diseases of joints like rheumatoid are also seen frequently by every clinician irrespective of his speciality. The pain, stiffness, and the resultant deformities disturb the activities of daily living for the patient.
Classification
Inflammatory diseases of the joints can be classified as follows:
- Infective arthritis
- Acute
- Acute septic arthritis
- Acute rheumatic arthritis
- Chronic
- Nonspecific pyogenic arthritis
- Tuberculous arthritis
- Inflammatory arthritis
- Rheumatoid
- Rheumatoid arthritis
- Juvenile arthritis
- Seronegative spondyloarthropathy
- Ankylosing spondylitis
- Reiter's disease
- Psoriatic arthritis
- Degenerative arthritis
- Primary osteoarthrosis
- Secondary osteoarthrosis
-
- Gout
- Pseudogout
- Diabetic arthropathy
- Miscellaneous arthritis
- Neuropathic joint
- Hemophilic arthritis
- Synovial chondromatosis
- Reactive arthritis.
RHEUMATOID ARTHRITIS
Rheumatoid arthritis is very common in western countries. Many institutions and international societies have been organized to evaluate the diseases process, its manifestations and to proclaim certain guidelines for their management. In India, it is not uncommon.
Collagen disorders are systemic diseases affecting all connective tissues (mesenchymal) in the body. The commonest collagen disease is rheumatoid arthritis. Since it is basically a connective tissue disorder, it affects multiple systems and hence the term Rheumatoid Disease is more descriptive, though the predominant clinical manifestations are obvious in the joints.
Pathogenesis
The exact etiology is still eluding our comprehension. Many theories have been suggested by various researchers, of which, genetic predisposition seems to be reasonable. Some workers have postulated the possibility of a virus producing the antigen.
Essentially it is an autoimmune disease of the connective tissues of the body. It is a response of the immune system to an unknown antigen. The antibody is immunoglobulin M (IgM) which is the rheumatoid factor, and is increased when the inflammatory response of the joint is active.
In the early stages, the disease attacks the synovial membrane of the joints. The synovial membrane becomes erythematous and edematous. This creates a joint effusion which is the cause for the swelling of the joint.
Later exudates are poured into the joint cavity and these cause thickening of the synovial membrane which is diagnostic of rheumatoid disease. Histologically, the synovial membrane is filled with chronic inflammatory cells and lymphoid follicles. Later there is a fibrinous exudate and neovascularization. This granulation tissue is termed “pannus”. This pannus invades and erodes the articular cartilage. The articular cartilage gets degenerated and fragmented. Pieces of the articular cartilage and the thickened synovium get separated and float in the edematous fluid. These constitute the “loose-bodies”. (These loose bodies may be palpable clinically, seen on X-rays and in the aspirates).
Later the inflammatory process spreads in the capsules and periarticular tissues. The pannus destroys both the articular surfaces, of the joint, grows in between them, resulting in growth of fibrous tissue between the articular surfaces. This is called fibrous ankylosis and there is marked restriction of the range of movements of the 14joints. The muscles adjacent to joint become wasted and atrophied due to the disease and disuse.
The stages of the disease process can be identified as:
- Synovitis
- Arthritis
- Deformity.
Clinical Features
Rheumatoid arthritis occurs more frequently in females. It usually affects women in the middle age group. The patient reports with pain in many small joints of both the hands. The pain and swelling are usually present for a few months or even years. The metacarpophalangeal and proximal interphalangeal joints of the fingers are commonly involved in rheumatoid. Occasionally one or more of the larger joints are also involved. The pain is continuous in nature and is aggravated by moving the joints. Sudden episodes of increased pain (acute exacerbations) occur periodically. The pain is usually felt more in the morning and is associated with stiffness (difficulty to move the joints). This morning stiffness is characteristic of rheumatoid disease. In many patients the polyarthritis is bilateral (symmetrical), viz., the pain and swelling are identical in both the hands.
Rarely, rheumatoid arthritis presents as pain and swelling in one major joint (Monoarticular Rheumatoid); usually the knee joint. But within a few weeks it spreads to other joints, both large and small.
On examination, the joint is swollen. There are clinical signs of effusion. Clinically, the thickened synovium is palpable and tender. There is joint line tenderness and both the active and passive movements are painful and are restricted. In the late stages there is deformity and ankylosis of the joints.
Some of the deformities seen in the joints of the hand are:
- The proximal interphalangeal joints are swollen: Later the distal interphalangeal joints are also involved.
- Intrinsic plus deformity which consists of flexion of the metacarpophalangeal (MCP) joints and extension of the interphalangeal (IP) joints. This is due to spasm of the lumbricals and interossei.
- Boutonniere deformity is flexion of the proximal interphalangeal joints (PIP) and extension of distal interphalangeal (DIP) joint.This is the button holding position and is due to rupture of the central slip of the extensor tendon.
- Swan neck deformity is extension of the proximal interphalangeal joint and flexion of distal interphalangeal joint.
- Ulnar drift occurs in the later stages of the disease. Due to extensive damage to the articular surfaces of the metacarpophalangeal joints, the fingers are deviated to the ulnar aspect of the hand.
Systemic Manifestations
Some patients have joint pain associated with extra-articular clinical manifestations, like:
- Lymphadenopathy, splenomegaly
- Rheumatoid nodules—Which are seen beneath skin especially in the forearm
- Bursitis, tenosynovitis
- Carpal tunnel syndrome
- Tennis elbow
- Painful heel syndrome
- Generalized muscle wasting
- Fibrositis of spinal muscles
- Peripheral neuropathy.
Investigations
Invariably all these patients with rheumatoid disease have anemia. The ESR is usually elevated. RA factor is detected by Rose-Waller test. The rheumatoid factor is IgM; it is positive in about 80 percent of the patients with rheumatoid disease (seropositive rheumatoid). But the absence does not rule out the possibility of rheumatoid disease. The RA factor is mainly of prognostic value than diagnostic. Similarly serum CRP(C reactive protein) is elevated only when the inflammatory process is in its active stage.
X-rays of the whole hand and the joints involved must be studied carefully. In the early stages there is narrowing of joint space with adjacent swollen soft tissue shadows. Later there is subchondral erosion, subchondral cyst, osteophytes and osteoporosis.
The synovial fluid, aspirated from the larger joints is turbid; on microscopic examination of the fluid, there is increased polymorph count and decreased glucose level. Histological examination of the synovial tissue obtained by biopsy will be diagnostic.17
Differential Diagnosis
- Systemic lupus erythematosus: Systemic lupus erythematosus (SLE) is a chronic inflammatory disorder which involves many joints. This is more often seen in young women. These patients sometimes have a hypopigmented patch in the chest wall. The disease process progresses to involve the kidneys in some of them.
- Osteoarthrosis: Degeneration of the articular surfaces and subchondral bone causes osteoarthrosis which is more common in the larger joints especially the knee joints. Systemic diseases like hypertension and arthritis of small joints are not seen in osteoarthrosis. On X-ray studies of the knee, lateral joint space is narrowed in rheumatoid, which is not so in early osteoarthrosis.
- Gout: Gout is a crystalline arthropathy. This is due to abnormalities of purine metabolism. Increased level of uric acid in the serum is diagnostic of gout. The metatarsophalangeal joint of the great toe is affected by gout. Moreover gout is more common in males.
- Reiter's syndrome: This is a clinical variant of rheumatoid disease and is common in the younger adults. The patient has active inflammation of many joints including some of the larger joints. In addition she has urethritis (chronic infection of lower urinary tract) and conjunctivitis. Antirheumatoid drugs may have to be supplemented with steroids for a few weeks.
Management
The actual treatment of these chronic painful diseases begins with proper education of the patient. She and her relatives have to adequately cooperate with the treating doctor to obtain a better functional outcome.
A highly nutritious food must be recommended. Associated anemia must be corrected by oral or parenteral hematinics.
The judicial combination of the following has proved to be very effective in the management and rehabilitation of patients with rheumatoid disease:
- Drug therapy
- Physiotherapy
- Surgical treatment
- Reassurance.
Drug Therapy
- Nonsteroidal antiinflammatory drugs (NSAIDs)
- DMARDs—Disease modifying antirheumatoid drugs
- Low dose methotrexate
- Gold salts
- Penicillamine
- Chloroquine
- Sulfasalazine
- Steroids
- Prednisolone, dexamethasone
- Intra-articular injection of methyl prednisolone in acute phases
- Deflazocort
- Cytotoxic drugs
- Azathioprine
- Leflunomide
- Cyclosporine
- Cyclophosphamide
- Newer drugs—Etanarcept, infliximabate
Certain Drugs used in Rheumatoid
- Methotrexate—Low dose (7.5 mg–15 mg). The side effects are oral ulcers and gastric problems.
- Penicillamine—(125 mg–250 mg od). The side effects are renal damage and bone marrow depression.
- Gold (6mg /day) as auronofin. The side effects are rash, hepatitis and alopecia.
- Chloroquine—150 mg/day). The serious problems are the retinal and corneal damage.
- Sulfasalazine—(1–3 mg/day), few side effects is the main advantage.
- Steroids—(5–10 mg) prednisolone to supplement NSAIDs. The side effects are gastritis, hypertension and cushingoid syndrome.
Cytotoxic Drugs
- Azathioprine (50 mg–150 mg/day). It is primarily used for its steroid sparing effect.
- Leflunomide. Loading dose (100 mg/day for three days followed by 20 mg od). The side effects are diarrhea, alopecia and chest infections.
- Cyclosporine (2.5mg/kg/day). The drawback of this drug is that it is highly nephrotoxic.
Physiotherapy
Local heat therapy, like wax bath reduces pain drastically. Physiotherapeutic measures must be started along with drug therapy. If the joints are very painful, rest by splinting may be useful, but mobilization must be started as soon as the pain subsides, because stiffness is difficult to correct. Moreover stiffness of the small joints of the hand disturbs the activities of daily living of the patient. If the stiffness is not prevented by early active and passive exercises, it leads to various deformities of the joints and fingers, which may later require multiple operations. Active mobilization exercises and muscle 19strengthening exercises must be performed throughout the course of the treatment to overcome stiffness. Passive mobilization exercises for the small joints of the fingers play a vital role in reducing the edema around the joints and thereby prevent stiffness. The patient must be encouraged to go back to work at the earliest, and both drug therapy and physiotherapy should be continued.
Some Useful Operations
Operations only help the drug therapy but do not cure the disease. Operative procedures are mainly done to reduce pain, to improve stability, to promote early ambulation and rehabilitation.
- Synovectomy: Since the synovial membrane of the joint is the primary target of the disease, synovectomy reduces pain and increases range of motion. Subtotal synovectomy of Wilkinson was performed some years ago. But this procedure has been replaced by joint replacement surgery.
- Arthroplasty: With the advent of joint replacement surgery, many patients are quite happy when they are able to walk around without pain. In this operation, the damaged articular surfaces are removed and replaced with artificial prosthetic implants. Total joint replacement in hip and knee has remarkable results in our country.
- Arthrodesis: Surgical fusion of the joint is arthrodesis. This is performed to reduce pain in small joints of the hand.
Tennis Elbow
Though this condition has not been reported in any popular tennis player, this eponym has been retained in orthopedics for many years. Tennis elbow may be an isolated clinical problem or part of rheumatoid disease. This is a painful elbow disturbing the work of the patient. In our country, this is common in middle aged women especially housewives. The patient visits the hospital with pain and points to the outer aspect of the elbow. The pain is aggravated by simple movements especially involving household chores.
The elbow joint is normal on clinical examination. There is tenderness over the lateral epicondyle of the humerus. The muscle belly (common extensor origin) arising from the lateral epicondyle is also tender. The radial head is tender in some patients. Forced dorsiflexion of wrist and fingers against resistance (stress movements) may elicit a similar pain.
Lateral epicondylitis is another term that is used for this condition. This is due to inflammation of the fibrous tissues around common extensor origin. The patients respond well with a course of anti inflammatory drugs. Local heat therapy with ultrasound or wax bath is very useful. Local injection of methyl prednisolone is needed only in a few patients.
DeQuervain's Disease
DeQuervain's disease is an extra-articular painful condition of the wrist. This is due to inflammation of the tenosynovium of the extensor pollicis longus and abductor pollicis brevis. On examination there is tenderness over the radial styloid. The patient narrates that the pain increases with the movement of the thumb. A combination of aceclofenac 20(100 mg bd), paracetamol (500 mg tds) and etodolac (200 mg bd) is therapeutically useful. Local injection of methyl prednisolone reduces the pain and inflammation, and helps early recovery. But this procedure should not be used often since local steroids tend to cause tissue necrosis.
Ganglion
Ganglion is a smooth rounded subcutaneous swelling which is painless. It is a cystic swelling that appears from the synovial membrane,that is well encapsulated by fibrous tissue. The commonest site is the dorsum of the wrist. It also occurs on the ventral aspect of the wrist and the dorsum of foot. Though the origin is spontaneous, the increase in size of the ganglion is due to repeated friction and pressure. Though local intralesional injections of drugs like steroids have been tried, en bloc excision of the ganglion is the right choice of treatment.
JUVENILE RHEUMATOID DISEASE
Juvenile rheumatoid is a clinical variant of rheumatoid disease. This commonly occurs in children below five years; sometimes in older children. The patient is brought with fever and polyarthritis. The child has lymphadenitis and splenomegaly. This condition is called Stills’ disease. Treatment is similar to that of the adult form of the disease.
Seronegative Spondyloarthropathy
Seronegative spondyloarthropathy is a common term which includes pain in various joints associated with pain neck and low back ache. The common feature is that though other investigations are positive, the rheumatoid factor is absent in serum. The two common conditions seen in our country are:
- Ankylosing spondylitis
- Reiter's disease.
Ankylosing Spondylitis
Ankylosing spondylitis is relatively common in the southern part of our country. It affects the spine and progresses rapidly.
It is more common in males between 15 to 30 years of age. It starts as a low back ache. Then the patient develops a forward bending of the spine and this kyphosis is fixed. He finds it difficult to stand straight, to look up or to lean backward. Later, the lumbosacral junction and the sacroiliac joints are involved. Sometimes he has pain in both the heels. The chest expansion is markedly reduced. The normal chest expansion is about 5 centimetres in adult males. This is reduced in patients with ankylosing spondylitis. X-rays in advance stages of disease reveal calcification of the longitudinal ligments and later the entire vertebral coloumn may appear as a bamboo spine.
Usually human leukocyte antigen (HLA–B27) is positive in serum. As the disease advances, the stiffness of the spine progresses resulting in reduced movements of the chestwall.
Live your life by choice and not by chance
Osteoarthrosis literally means degeneration of bones and joints (osis-degeneration). But in clinical practice, the word osteoarthritis is commonly used. One need not bother about the subtilities in terminology. Many books in orthopedics deal with osteoarthrosis as a disease of many joints. But in India, it is frequently seen in the knees. In fact, osteoarthrosis of the knee is the commonest clinical condition seen in any orhopedic outpatient department in our country.
OSTEOARTHROSIS OF KNEE
Osteoarthrosis of the knee is primarily a degeneration of the joint. It is a progressive disorder that disturbs the patient day in and day out.
Etiopathogenesis
As in many other degenerative disorders, no single factor can be accused of causing the problem. Osteoarthrosis is only a part of the ageing process of the entire human body.
Since the knee joint is a weight bearing joint and it is being used everyday, the degeneration sets in early and is painful even during simple movements like standing and sitting.
Initially there is wear and tear of the articular cartilage. This is due to the constant axial, compression and friction forces that act on the articular cartilage and thereby cause degeneration.
In old age, these forces are diversified in such a manner that the load distribution is uneven. This causes excess pressure on the medial compartment of the knee joint (medial tibiofemoral joint) which starts degenerating in the early phases of the process. The shearing forces that act on the patellofemoral joint cause degeneration of the articular surfaces of the patella and the femur. Later the lateral tibio femoral compartment is also involved resulting in tricompartmental osteoarthrosis.
25As age advances, the surface of the articular cartilage becomes irregular and rough. Later it is fragmented and this causes exposure of the subchondral bone to the friction forces. The adjacent synovial membrane is inflamed. Later this continuous degeneration causes incongruity of the articular surfaces and eventually deformity. During this process, pain appears due to synovitis (synovial inflammation), chondritis (inflammation of articular cartilage), capsulitis, and eventually arthritis.
If the disease process is not arrested by adequate treatment the movements are restricted and fibrous ankylosis sets in.
Clinical Picture
Osteoarthrosis of the knee occurs in the old age group of the population. Occasionally it is seen in people past middle age also. In our country, it is slightly predominant in females; obesity and lack of physical activity are the major factors that contribute to the progression of the degeneration and disease.
The pain is felt more on the medial aspect of the knee joint. The pain is more at rest and aggravated during sitting and squatting. The patient finds it difficult to stand up and walk the first few steps. It is interesting to note that the pain subsides on walking. During the later stage, the pain is continuous in nature.
Sometimes there is a crackling sound (crepitus due to irregular articular surfaces or loose bodies). Same patients have a swelling around the joint, due to synovial effusion or a localized swelling due to a focal bursitis.
If she presents during the later stages, she will have a deformity of the knee joint due to alteration of Q angle resulting in genu varum (inward bending of the legs).
Q angle is the angle that is formed between the long axis of the femur and the long axis of the tibia.
On examination, the gait is altered and painful. The altered gait due to pain in the knee is termed as genalgic gait. The patient has medial joint line tenderness; sometimes one can elicit tenderness of the patellofemoral joint. The thickened synovium can be palpated over the medial femoral condyle. When there is effusion in the joint, fluctuation may be present. Sometimes, the suprapetellar bursa may be distended due to the effusion; some patients have tenderness over the tibial insertion of the medial collateral ligament, which is due to inflammation of the bursa beneath the medial collateral ligament of the knee joint. If the synovial effusion persists for more than a few months, the synovial membrane is thickened further. The synovial fluid herniates along with the synovial membrane in the posterior aspect of the knee joint. This is clinically palpable as a fluctuant swelling in the popliteal fossa and is called Morrant Baker's cyst.
If there is no effusion a crepitus may be felt in both the tibiofemoral and patellofemoral joints; flexion of the knee joint is restricted due to the pain. It must be emphasized that the both the tibiofemoral and patellofemoral compartments of the knee should be examined in the standing and recumbent postures.
Investigations
X-rays of both the knees in both the views (anteroposterior and lateral) will be highly informative. Skyline views of the knee, to study the patellofemoral joints will show 27the irregularity and disparity of the articular surfaces of the patellar and femoral components of the patellofemoral joint. In the early phases there is narrowing of the medial joint space; later the irregularity of the articular surfaces of the tibiofemoral and patellofemoral joints can be seen.
In advanced stages, there will be osteophytes (bony outgrowths) and subchondral erosions. The genu varum or genu valgum can be accurately measured in anteroposterior X-rays.
The loose bodies may be seen on plain X-rays. But, if one plans to remove them, a CT scan of the knee joint will be useful.
Treatcment
In the early phases, the patients do well with simple analgesics like paracetamol. Non- steroidal antiinflammatory drugs may be required only for a few days. Local heat therapy with ultrasound or waxbath will alleviate the pain to some extent.
But the most important method in the management of osteoarthrosis of the knee is strengthening of quadriceps muscles. Knee bending exercises and quadriceps exercises must be continued throughout the course of the treatment. Even if one knee joint is involved, quadriceps strengthening exercises must be promoted for both the limbs.
Procedure
- With the patient sitting comfortably, one knee should be extended and then bent; this procedure improves the tone of the quadriceps and the laxity of the knee joint.
- With the knee extended, the patient is instructed to press a folded towel that is placed beneath the knee; this procedure improves the power of the quadriceps muscles.
- With the patient in the lying posture, he is instructed to raise the whole lower limb, with the knee extended; this exercise improves the power and tone of the quadriceps muscles.
If there is extensive degeneration or associated genu varum, then operative procedures will help the patient a lot. For genu varum corrective osteotomy like high tibial osteotomy may be done. If the pain and deformity are disturbing, total joint replacement surgery in the form of total knee arthroplasty is the treatment of choice. The results are appreciably good and this operation is now being done in many centers all over the world.
PERIARTHRITIS SHOULDER
Osteoarthrosis is essentially a degeneration of the articular surfaces of a joint. But, periarthritis, as the name signifies, is degeneration and consequent inflammation of the tissues around the joint. This is quite common in the shoulder joint.
Periarthritis of the shoulder is a condition that is frequently seen in the outpatient department. The patient, who is usually in the fourth or fifth decade, complains of pain in the shoulder and difficulty in moving the upper limb due to stiffness. The patient is not able to reach her back while bathing or combing her hair. On examination there is tenderness in the shoulder joint which is more in the subacromial region. Wasting of the deltoid muscle can be identified by the absence of the rounded contour 31of the shoulder.
There is restriction of abduction and external rotation of the shoulder joint. On examining the active and passive movements, it is also found that the other movements are also restricted to some extent. This stage of the disease has been labeled as adhesive capsulitis of the shoulder. In the advanced stages no active or passive rotation is possible and nearly all the movements are grossly restricted. This is the stage of frozen shoulder.
Many patients who have clinical features of periarthritis shoulder are found to be suffering from diabetes mellitus as well. It is important to note that periarthritis shoulder may be the first clinical presentation of diabetes mellitus.
33As mentioned above, periarthritis shoulder is degeneration and adhesion of the capsule and the pericapsular tendinous structures around the shoulder joint. There is little damage to the articular cartilage. Hence the term periarthritis is being used.
On X-rays, the bones of the shoulder joint appear to be normal. Some soft tissue calcification may be seen in the shadow of the region of the supraspinatus tendon.
Drugs like analgesics and antiinflammatory agents just reduce the pain. The use of an arm sling is of much help. Some patients do well with injections of methyl prednisolone in the sub acromial region. Manipulation under anesthesia may be required for patients who have frozen shoulder. After all these manouvres, active mobilization exercises form the mainstay of treatment. Initially, shoulder abduction exercises must be encouraged to strengthen the deltoid. Later, exercises to improve the range of movement of rotations may be advocated. The patient must be advised adequate treatment for the associated diabetes mellitus and to continue the exercises for a few months, till there is restoration of normal ROM of the shoulder.
Dream of things that never were and ask why not
Bones are blatantly radiopaque; hence no examination of any patient in orthopaedics is complete without an X-ray study of the involved limb. With gigantic advances in computer technology and software, the advanced imaging studies like computerized tomography (CT), ultrasound, magnetic resonance imaging (MRI) and positron emission tomography (PET scan) have found a cute place for themselves in clinical orthopaedics and have definitely improved our knowledge of the disease and fracture configuration that has eventually modified our treatment modalities.
At this juncture, it should be emphasized that no investigation can substitute a good clinical examination. Investigations should supplement one's clinical diagnosis and not substitute it. Again, the availability of an investigation facility is not an indication for its utility. If one can convince himself about the diagnosis with a simple X-ray, further investigations are futile. In this era of evidence based medicine, sophisticated investigations may be required either to alter the line of management or to operate on the patient.
ULTRASOUND
Sound (or pressure) waves in the 3 to 10 MHz frequency range are used for imaging the body by detecting the intensity of the reflected waves from various organs and displaying this reflected intensity as an image. The higher frequency (short wavelength) sound waves have less permeability; lower frequency waves produce poor resolution and the images are not clear. But the advantage of ultrasound is that it is nonionic and does not produce adverse biological effects.
Diagnostic ultrasound studies are commonly used in general surgery and obstetrics. In orthopedics, ultrasound has a limited but significant use in orthopedics since it is 36less harmful to the patient. Ultrasound images are not very useful to study the bone since bone absorbs the sound and does not produce an echo.
Soft tissues like bursae, tendons and muscles that are adjacent to bone can be better studied with ultrasound, than, with X-rays. Para articular problems are easily diagnosed with ultrasound.
Periarthritis shoulder, tennis elbow, carpal tunnel syndrome, trochanteric bursitis, bursitis around the knee and problems of tendoAchilles are some of the conditions that are easily identified by diagnostic ultrasound.
X-RAYS
The discovery of X-rays by Roentgen has definitely revolutionized every branch of medicine, especially orthopaedics. Since bone is radio opaque, every bone in the body can be seen through X-rays.
An X-ray is a discrete bundle of electromagnetic energy called a photon. The energy of a light photon is of the order of 1 electron volt (eV),whereas the average energy of an X-ray photon in a diagnostic X-ray beam is of the order of 30 kiloelectron volts (keV) and its wavelength is smaller than the diameter of an atom. An X-ray beam is a group of photons travelling at the speed of light. The electron current produced in an X-ray beam is measured in milliamperes and is termed mA.
Bones appear white on an X-ray film because photoelectric absorption of X-rays is greater in bone, than in soft tissue due to the higher atomic number of bone. A lower kilovoltage gives a greater image contrast but long exposure time and increased patient exposure. Hence lead which has a higher atomic number is used as a shielding screen in X-ray departments to protect the staff from unnecessary exposure.
Another type is digital radiography which utilizes a cassette with a photostimulatable phosphor material that stress the X-ray image. The digital image has a pixel size of less than 0.2 mm. This image can be modified and be magnified; it can also be stored for further reference.
It should be emphasized that X-rays should be used with great caution in everybody, especially in pregnant women.
Requisition: As clinicians, we send a request to the radiographer or the radiologist to have an X-ray study of the patient. But every clinician must express himself clearly to avoid exposure to radiation hazards, repetition and unnecessary expenditure. In the request form, the region to be studied and the views required should be mentioned clearly. In addition, when we write for an X-ray of the long bones it is wise to include the adjacent joints both for identification and comprehension, e.g. if we send a ruquest for an X-ray of the arm, one view should include the shoulder and the other the elbow. Similarly, when we wish to see the spine, the specific region of the spine should be mentioned.
Cervical spine: The lateral view of the cervical spine is more informative than the anteroposterior view. The bodies of the vertebrae, intervertebral disk space and the posterior elements are better visualized in the lateral view. The anterooblique views show the neural foramina, through which the roots of the brachial plexus emerge. The common condition, cervical spondylosis can easily be diagnosed with an X-ray. 37Osteophytes, irregularity of the borders and disk spaces, and narrowing of neural foramina are some of the radiological findings seen in the X-ray that are diagnostic of cervical spondylosis.
Dorsal spine: The lateral view of the dorsal spine is useful in the study of infections like tuberculosis and injuries like fractures. The anteroposterior view is very useful in studies of scoliosis (lateral bending of spine), which is common in the adolescent age.
Lumbar spine: When one has to scrutinize an X-ray of lumbar spine, it is essential to include the first lumbar vertebra (L1) and the lumbosacral junction (LS junction).
38Both these components should be included in both the views. The texture of the bony trabeculae is better seen in X-rays especially when one has osteoporosis in mind. The lateral view will provide adequate information regarding the height of the vertebra (reduced in fractures), the intervertebral disk space, the pedicles, laminae and the spinous processes. The facetal joints (between the adjacent articular processes) are visible in the oblique views. It is interesting to note that in most instances, plain X-ray of the lumbar spine will guide us along the right path to study further expensive investigations like tomograms.
Sacrum and coccyx: Fracture of the coccyx with coccygodynia is a common clinical condition that can easily be diagnosed with X-rays.
Shoulder: Anteroposterior view of the shoulder is highly informative in cases of dislocation of shoulder, fractures of head of humerus, fractures of lateral end of clavicle and acromion process; periarthritis shoulder and many tumors like exostosis can be easily diagnosed with plain X-rays. Axial views of the shoulder joint are required in cases of shoulder instability.
Elbow: Good X-rays of elbow in both the views are sufficient to diagnose any problem either injury, inflammation or infection. Apart from fractures and dislocations of the joint, radioopaque shadows in the bulk of the brachialis muscle that indicate myositis ossificans are also visible in a simple X-ray of the elbow.
Wrist and hand: Any X-ray of the hand should include the wrist which has the carpal bones. If one suspects fractures of the scaphoid or problems of the lunate, in addition to the anteroposterior and lateral views, an oblique view of the wrist joint will give us more information. The scaphoid is completely seen in the oblique view; and the lunate and other carpal bones are seen in the other views. To study the metcarpals and phalanges of the hand, one must have anteroposterior, lateral and oblique views to see all the nineteen bones. Fracture of the base the thumb, viz. Bennett's fracture is seen in oblique views. Similarly dislocations of the metacarpophalangeal joint of index and thumb are seen in lateral views.
Pelvis: In accidents involving high speed vehicles, the bones of the pelvis are fractured more frequently. Injuries vary from simple fracture of one ramus to total disruption of the pelvic ring. Any view of the pelvis must include both the sacroiliac joints and the hip joints.
Hip: Even when the patient presents with a problem of one hip, it is mandatory that X-ray studies should include both the hip joints for better comprehension by comparison. Fractures, dislocations, tumors and dysplasias are easily seen with simple X-rays.
Knee joint: X-rays of the knee joint are commonly sought for fractures or degeneration within the knee. It is preferable to have the 39anteroposterior and lateral views; in addition, another anteroposterior view of the knee joint with the patient standing is useful to study joint space narrowing. The patellofemoral joint is well delineated in a skyline view which is useful to identify osteoarthrosis and patellar maltracking.
Ankle and foot: The ankle and the foot cannot be studied adequately in the same film. It is but essential to have two views separately for the ankle joints and three views for the foot, since the tibial mortise and the tarsal bones are in different planes.
At this juncture, it is worth to remind the reader, that he should familiarize himself with normal views of normal joints so that the abnormalities can meet the eye.41
CT SCAN
A tomogram means an image of a section of the human body. Gregory Hounsfield used X-rays to study a sliced section of the whole body. A CT uses a computer to reconstruct mathematically, a cross sectional image of the body from measurements of X-ray 42transmission through thin slices of patient tissue.
Hence CT displays each imaged slice separately. Most CT units allow slice thicness specifications between 0.5 and 10 mm. The images are oriented such that the observer is looking at the patient from below. CT is very useful in studies of the skeleton, since bone details and calcifications are better seen in CT than in MRI. CT is extensively used by the orthopedician in studies of the spine. Views of the various sections and a computer generated three dimensional reconstruction of the bone make CT very useful in spine, pelvis and joints. Since CT provides a complete configuration of the fractured vertebra, it is essential when one plans to operate on the spine.
43CT is also useful in tuberculosis of the spine. Moreover some of the bony tumors like secondaries, multiple myeloma and osteoblastoma which occur in spine are better seen in CT of the spine.In the case of intraarticular fractures, CT is very useful especially for adequate preoperative planning.
BONE DENSITOMETRY
With the increasing number of senior citizens in the population the incidence of osteoporosis is rapidly increasing. Patients with osteoporosis are prone for pathological fractures. Simple X-ray studies of the bones in osteoporotic patients reveal decreased trabecular pattern of the long bones. But bone densitometry studies are required to confirm the diagnosis and to evaluate the quantity of bone mineral density. The common tests that are currently used are dual energy X-ray absorptiometry (DEXA) and peripheral dual energy X-ray absorptiometry (PDXA). These are non invasive tests to measure the bone mineral density. DEXA measures the density in spine, hip or the total body. PDXA measures the density in the wrist, heel or the fingers. The WHO has laid down certain guidelines for the diagnosis of osteoporosis based on the T score. T score values of 1 – 2.5 are suggestive of osteopenia while > 2.5 is diagnostic of osteoporosis. Also see annexure I.
MAGNETIC RESONANCE IMAGING
The nuclei of the hydrogen atoms in the body have an angular momentum called spin, which causes them to behave like tiny spinning magnets.
When the body is exposed to a strong external magnetic field (0.02 to 4 tesla), these protons take a further spin and then relax to a resting position. This relaxation time is measured as T1 and T2. These changes are converted into images by competent computer software. MR analyses multiple tissue characteristics and is the best modality to study the soft tissue contrast. Most tissues can be differentiated by significant differences in their characteristic T1 and T2 relaxation times. MR produces images in any anatomical plane. The greatest advantage is the absence of ionizing radiation. But it is contraindicated in patients who have electrically, magnetically or mechanically activated implants like cardiac pacemakers.
Since soft tissue delineation is very good with MR images, it is highly useful in studies of ligaments, cartilage and epiphysis. It has proved to be a great boon to study the prolapsed intervertebral disk; whether the disc material obliterates the neural foramen or it presses on the spinal cord. Hence, MR is mandatory if one plans to operate on the intervertebral disk for prolapse or sequestration. MR is also useful in slipped capital femoral epiphysis, avascular necrosis of head of femur and in articular cartilage diseases.
Failing to plan is planning to fail
The science of orthopedics has seen marked changes in the management of fractures over the last few years. Advances in metallurgy, biomechanics and computer technology have completely changed the methods of management of fractures. The use of image intensifier television, computer assisted navigation, minimally invasive implant fixation, interlocking nails and locking plates are some of the many techniques that we use presently in fracture surgery.
46With the tremendous increase in vehicular traffic in our roads, there is a proportionate increase in road traffic accidents. This has resulted in increase in the incidence of multiple injuries (polytrauma) involving head injuries, multiple fractures and soft tissue trauma.
Management of shock in polytrauma patients is beyond the scope of this book. But, it is mandatory for any student in any branch of medicine to have a comprehensive knowledge about first aid in emergencies.
FIRST AID IN INJURIES
Action at an Emergency
- Act quickly and methodically and assess priorities.
- Inform officials and call for available help.
- Shift the patient to a safe place.
- Check airway, breathing and circulation.
Wounds and Bleeding
- Look at the wound carefully for any foreign body.
- Remove it if you are confident or else cover it with a clean cloth.
- Cover the wound with a clean cloth preferably a handkercheif.
- Apply a compression bandage over it, tight enough to arrest bleeding.
- Do not use a tourniquette if you are not sure, for that aggravates blood loss.
- If the wound is small,wash it well with running water and then bandage it or use soap.
- In the case of large wounds, apply tight bandage and keep the limb elevated.
- If the hand is injured, as in industrial accidents, cover the hand and give a triangular sling to elevate the limb.
- In case of foot, remove all foreign material and wash well before bandaging.
- Do not apply any foreign material like cow dung, coffee powder or mother earth.
- Arrange for the patient to be shifted to the nearest hospital in a stretcher.
Fractures
- In fractures of the upper limb, support the limb in a triangular sling.
- If available you may use splints like wooden rulers.
- If the lower limb is fractured, use a long pole as splint and bandage it as a support.
- The patient with a fracture must be shifted in a stretcher.
- If you suspect the spine to be injured use a plank to shift him.
This chapter does not help the reader to know everything about every possible fracture and dislocation in detail. Instead, the next few pages will give one a bird's eye view on the salient features of fractures, the complications that one should be aware and what is the procedure that the orthopedic surgeon may perform. A comprehensive knowledge about the common fracture will help the student or the practitioner to guide the patient and to advise him accordingly.
We shall know about the current concepts employed in the management of common bony injuries that are encountered in this part of our country.47
Definition
Fracture is a break in the anatomical continuity of bone. Sprain is the term used when a ligament is injured.
GREENSTICK FRACTURE
This occurs in young children due to a simple fall. The child has pain and deformity (bending of the limb). A greenstick fracture is a break of one cortex with the opposite cortex intact; this is the classical finding that is visible in the X-ray. Correction of the fracture by manipulation under anesthesia and immobilization of the limb in a posterior plaster slab for three weeks, will suffice for restoring the normalcy of the limb.
STRESS FRACTURES
Stress fracture is seen due to repetitive trivial trauma, which occurs during unusual strenuous exercises. This is commonly seen in policemen and army personnel during their training period. Stress fractures are commonly seen in the upper third tibia and the metatarsals.
Clinically, a young person involved in strenuous, vigorous and unusual exercises about a few weeks reports with pain over the involved area. He narrates that the pain is more during active exercises like running or jumping. On examination, there is marked tenderness over the fracture, especially medial aspect of upper third of tibia or the neck of the second metatarsal. X-rays reveal a fracture line that is incomplete.
This fracture can be treated conservatively with rest, drugs and local heat therapy followed by exercise therapy.’
CONSERVATIVE MANAGEMENT
Operative techniques in fracture surgery have grown at a tremendous pace. The last decade has seen giant stridesin the procedures which are mainly aimed in conserving the fracture hematoma. The periosteum of the fractured bone and the fracture hematoma are the two main contributors to the formation of the healing tissue of the fracture. This healing tissue of the fracture is termed callus. This callus is the conspicuous sign of fracture healing.
The principles of fracture treatment are:
- Reduction
- Immobilization
- Preservation of blood supply
- Active mobilization.
Reduction
Restoration of normal anatomical alignment of the fracture fragments by manipulation is termed reduction. This is essential in displaced fractures and comminuted fractures. Reduction must be obtained by conservative methods or operative intervention. In conservative management, it is wise to use adequate anesthesia.48
Immobilization
Fractures of long bones take sometime to unite. Approximately, it is three weeks for upper limb and six weeks for lower limb in children. In adults, six weeks are required for fractures of the upper limb and about twelve weeks for the lower limb bones to unite.
During this period, the fracture bone and the limb are immobilized using plaster of paris.
Once it has been decided to treat the fracture conservatively, the fracture is reduced by traction and manipulation. When anatomical alignment has been achieved, the limb is immobilized in a plaster slab. The limb is adequately padded with cotton and the moist slab is applied on the limb with the traction in force. The slab is anchored to the limb with moist encircling bandages. It is must be emphasized that the slab is applied in such a manner, that it immobilizes one joint above fracture and one joint below it. The limb is then elevated with a broad arm sling (upper limbs) or pillows (lower limbs). After the edema subsides, the slab is converted into a cast or a fresh cast is applied.
Position of Function
The main aim in treatment of fractures is to give the patient a painfree and functional limb. Joints tend to become stiff during the period of immobilization, even if it is just a little more than a week. Hence, it is but wise to immobilize the joints in the position of function, while applying plaster casts; this permits early restoration of function of the limb after the plaster has been removed.
Active Mobilization
The fingers (or toes) are actively mobilized as soon as the patient recovers from anaesthesia. This active mobilization must be continued during the entire period of immobilization. These exercises maintain the muscle tone, prevent muscle wasting and maintain the joints supple. Active contraction of the muscles over the fracture improves the blood supply to the fracture and thereby promotes fracture healing. If the patient does not cooperate with the exercises, he may develop muscle wasting and joint stiffness. Inadequate care of the plaster cast, improper padding and poor hygiene may lead to many problems. This is termed plaster disease which consists of blisters, excoriations, eczema and ulcers of skin, muscle wasting, joint stiffness, osteopenia of the involved bone and disuse of the limb. Hence limb in plaster requires continuous care and appropriate advice during the periodical visits.
Callus
Callus that grows from the periosteum is the bridging callus, and that which grows from the medullary tissue is the anchoring callus. Both are required for a good bony union.
Callus is radiopaque on X-rays. It is interesting to note that the radiopacity of plaster of paris and the fresh callus is rather identical. Hence, during the follow-up visits, after the adequate duration, X-rays of the limb with the plaster are but futile. The plaster should be removed and the limb examined clinically, and radiologically.
The callus may be palpable as a local thickening of bone. There is no pain or tenderness at the fracture site. On attempted stress, there is no abnormal mobility at the fracture site. These are the clinical signs of the fracture union. Then the patient 49must be advised adequate exercise therapy to promote joint mobility, to improve range of movement, develop muscle power and to restore the function of the limb.
SOME COMMON FRACTURES
A brief account of some of the fractures that are seen in our wards follow:
Fracture of Clavicle
Mechanism of Injury
The most common bony injury sustained due to fall on the outstretched hand is fracture of the clavicle. The common site of fracture is the junction of the outer and middle third of the bone.
Clinical Features and Diagnosis
The diagnosis is quite easy both clinically and radiologically. The patient carries the injured upper limb with the opposite hand. Local examination reveals a swelling and marked tenderness over the clavicle. The fracture is quite obviously seen on anteroposterior X-ray.
Treatment
The treatment of fracture of the clavicle is highly rewarding since the bone unites very well. The fracture is reduced with the bracing of both shoulders and immobilized with a figure of ‘8’ bandage. Some surgeons use a clavicle brace.
The figure of 8 bandage is a perfect panacea for fracture of the clavicle. In rare occasions it may have to be operated with implants like titanium elastic nail or plates and screws.
Fracture of Humerus
Fracture of the Proximal Humerus
Mechanism of injury: The humerus is another bone that has a high regard for the orthopedic surgeon. A fall on the outstretched hand causes a fracture neck of the 51humerus. High velocity injuries involving the shoulder may cause a communited fracture head of humerus. Injury due to a forced abduction violence can cause a fracture of the greater tuberosity. Since the greater tuberosity of the humerus is pulled off by the abductor muscles of the shoulder, it is termed as avulsion fracture.
Clinical features: Pain is often not severe, since often the fracture is firmly impacted. One should look for axillary nerve and brachial plexus injuries.
Treatment: If these fractures are undisplaced, they heal well with a chest arm bandage and a broad arm sling. But if, the fragments are parted, they may require closed manipulation under image intensifier and internal fixation with cancellous screws.
Fracture Shaft of Humerus
Clinical features: The arm is swollen, local signs like tenderness, abnormal mobility and crepitus are present. It is important to test for radial nerve injury, which is adjacent to the shaft of humerus.
Treatment: Certain fractures of the shaft of the humerus have to be operated and fixed with implants, especially if they are displaced or angulated. When anatomical reduction is obtained, plaster U casts for a period of six weeks is sufficient for simple fractures of the shaft of the humerus.
If a fracture of the shaft of the humerus is associated with radial nerve injury, invariably it requires operative intervention.
Fracture of the shaft of the humerus at the spiral groove does not injure the radial nerve. On the contrary, the radial nerve is more often injured when the fracture occurs at the junction of the middle and lower thirds of the shaft of the humerus. This is because of the radial nerve that is closely anchored to the shaft of the humerus by the lateral intermuscular septum. Hence, injuries to the radial nerve are more common at this site.
Fractures of the shaft of the humerus, that are angulated, displaced or rotated, may have to be operated. Open reduction and internal fixation with a dynamic compression plate and cortical screws provides good union. In osteoporotic bone, a locking compression plate may have to be used. Some surgeons prefer to reduce the fracture under image control and fix it with closed intramedullary interlocking nails.
Supracondylar Fractures of the Humerus
Mechanism of injury: One of the common injuries around the elbow in children is the supracondylar fracture of the humerus. This occurs due to a fall on the outstretched hand.
Clinical features: The child is brought into the hospital with excruciating pain and a huge swelling around the elbow. The limb must be handled carefully. The radial pulse should be examined in both the upper limbs to compare the volume of the pulse. If radial pulse is weak in the injured limb the fractured upper limb must not be flexed. Instead, the limb should be immobilized in a posterior long arm plaster slab with the elbow in extension.
53Treatment: Conservative management: After complete evaluation, the fracture must be reduced under general anesthesia. In many instances the volume of the radial pulse is restored when reduction is obtained. Then the limb is immobilized in an above elbow posterior slab.
Supracondylar fractures of the humerus in children that are minimally displaced or angulated can also be treated conservatively. Under general anesthesia and image intensifier control accurate reduction is obtained by traction and manipulation. One must be gentle while negotiating the lower fragment, lest over enthusiastic manipulations aggravate the spasm of the brachial artery. Once reduction has been obtained, a well padded above elbow slab is applied with the elbow in flexion. Supracondylar fractures of the humerus in children heal well within three weeks. Then the plaster slab is removed and the patient is taught active mobilization exercises of the elbow. During the phase of mobilization therapy, one should resist the temptation of passively stretching the elbow because this causes myositis ossificans.
Surgical treatment: Sometimes, if the manipulation and reduction do not achieve anatomical alignment, the resulting malunion may result in a cubitus varus. Hence to avoid this deformity of the elbow, the fragments may have to be stabilized by a couple of Kirschner wires introduced percutaneously under image intensifier control.
Complications: The attending surgeon must be very careful in preventing the complications of supracondylar fractures of the humerus.Some of the important complications are:
- Malunion with cubitus varus
- Volkmann's ischemic contracture
- Myositis ossificans.
In supracondylar fractures of the humerus especially when the fragments are angulated or displaced, the brachial artery may be compressed or kinked.
54If this is not corrected properly, it leads to Volkmann's ischemic contracture which is the result of mismanaged fractures. The problem is aggravated especially when indigenous bandages have been applied for a few days.
Similary, massage of fracture hematoma leads to myositis ossificans which is another troublesome complication.
Cubitus Varus
Mismanagement of supracondylar fracture of the humerus by untrained people and failure to obtain accurate anatomical reduction by the orthopedic surgeon causes the fracture to unite in the deformed position. If the fracture unites with the lower fragment laterally displaced or medially rotated, the patient develops a cubitus varus deformity. This is otherwise termed as gun stock deformity of the elbow. More than the axial diaplacement it is the medial rotation deformity which causes cubitus varus of the elbow.
Clinically, this can be diagnosed by thicknening and irregularity of the supracondylar ridges and reduction in the angle between the long axis of the arm and the long axis of the forearm. The normal upper limb has a cubitus valgus which is slightly more in females. Malunited supracondylar fracture of the humerus results in a cubitus varus deformity which is not cosmetically acceptable. Cubitus varus deformity can be corrected by supracondylar closing wedge osteotomy (Modified French Osteotomy).
Myositis Ossificians
Though myositis ossificians is not a direct bony injury, it is one of the dreaded complications due to massage of the fracture by untrained osteopaths. Massage of a supracondylar fracture of the humerus or any bony injury around the elbow causes myositis ossificans.
Pathology: This is due to intramuscular hematoma within the substance of the brachialis muscle. This fracture hematoma later gets calcified. This condition is termed as myositis ossificans.
Clinical features: In the early stages, the child has a painful elbow. Attempted passive movements aggravate the pain; simple rest to the elbow with an above elbow posterior slab along with analgesics is usually sufficient. If the child is brought after a few weeks or months, there is a marked restriction of the movements of the elbow. On examination, there is a palpable bony mass in the anterior aspect of the elbow joint which may be tender. The elbow is held in a fixed flexion position and both active and passive movements are painful. There is marked restriction of the movements of the elbow. This condition is termed as myositis ossificians.
Diagnosis: X-rays of the injured elbow reveal scattered areas of calcification in the shadow of the brachialis muscle and they appear as a radiopaque mass anterior to the elbow joint.
Treatment: The treatment is usually conservative and requires active gentle exercises. The recovery is slow and hence, the therapist must be patient.55
Volkmann's Ischemic Contracture
Despite many recent public awareness programs, a section of the people still go to suffer in the hands of traditional bone setters who are neither trained nor do they know the intricate anatomy. They massage the fracture site and apply compressive bandages supplemented with bamboo splints. This procedure is very detrimental to the viability and the function of the limb as well. Most of the patients who have Volkmann's ischemic contracture have had these type of bandages. At the outset the orthopedic surgeon must remove these bandages and support the limb in a posterior slab with the elbow in extension and elevate the limb. The decision to manage the fracture should be delayed by a few hours till the edema subsides and the movement of the fingers are restored.
Pathology: Indigenous bandages compress the fracture hematoma. In addition, the displaced fragments also increase the pressure. Both these factors cause spasm of the brachial artery which results in Volkmann's ischemia. This is due to relative ischemia of the muscles of the flexor compartment of the forearm.
Clinical features: Ischemia can be clinically diagnosed by passively extending the fingers which causes severe pain of muscles. This is the Volkmann's sign. If this is present, the flexor compartment must be decompressed by an emergency extended fasciotomy of the flexor compartment of the forearm.
If this ischemia has not been corrected and the patient reports after a few weeks or months, VIC results. The patient has scars of bandages around the elbow. The skin over the forearm is dark and unhealthy. Marked wasting of the muscles of the forearm is conspicuous. The wrist and the interphalangeal joints of the fingers are held in flexion contracture. Attempted passive extension is restricted. This is the classical clinical picture of VIC. The treatment is surgical lengthening of the contracted forearm muscles. The rehabilitation to restore the functions is strenuous and prostrated.
Fractures of the Distal End of Humerus in Adults
Of the fractures of the distal end of humerus, isolated fractures of the condyle and intercondylar fractures require anatomical reduction for restoration of effective function. Hence it is wise to operate and fix these fractures with well designed implants.
Simple undisplaced supracondylar fractures of the humerus can be treated with above elbow plaster slab for six weeks.
Fracture of the Forearm
Clinical Anatomy
In the forearm, the radius and ulna are functionally connected to each other by the superior and inferior radioulnar joints. The interosseous membrane constitutes the intermediate radioulnar joint which is essential for smooth supination and pronation.
Monteggia and Galeazzi Fractures
Injuries to the radius and ulna have different patterns. When there is isolated fracture of the upper third of the ulna, one should examine the head of radius with good X-rays. If the fracture of the ulna is associated with dislocation of the head of radius it is called Monteggia fracture dislocation.
Similarly when one encounters an isolated fracture of the radius, one should carefully examine the wrist. Dislocation of the inferior radioulnar joint with fracture of radius is termed Galeazzi fracture dislocation. Both these types of fracture dislocations must be treated by operations (open reduction and internal fixation). It must be emphasized that conservative methods are not successful, in the management of Monteggia and Galeazzi fractures, since they involve the radioulnar joints as well.
Fracture Both Bones Forearm
Fractures of both bones of the forearm are invariably angulated or rotated.
In children, fracture both bones forearm can be diagnosed by the pain, swelling and angular deformity. Under anesthesia, the fracture is reduced by traction and an above elbow slab is applied. Once the pain and oedema have subsided, the slab is converted into a cast. The above elbow cast is used for three weeks. After removal, active exercises are commenced for both the elbow and the wrist.
An operation of open reduction and internal fixation with plates and screws, is the treatment of choice in fracture both bones of the forearm in adults. When one treats fractures of the bones of forearm, it is mandatory to maintain the interosseus space, since it is essential for supination and pronation, the movements which are essential for effective functioning of the forearm.
Colles’ Fracture
The common fracture of the lower end of the radius in old age is Colles fracture.
Clinical Features
This is the commonest fracture seen in any hospital. A senior lady gives a history of trivial fall and reports with pain and swelling of the wrist. Clinically, the patient has a 57pain and swelling around the wrist joint.
On examination, there is tenderness of the lower end of the radius and a dinner fork deformity. X-rays reveal a fracture of the lower end of the radius with a dorsal displacement and angulation.
Treatment
This fracture can be treated conservatively with closed reduction and a below elbow cast for six weeks. Operations are needed only when there is comminution of the lower end of the radius. A radial external fixateur reduces the fracture adequately with the principles of ligamentotaxis and provides a stable fixation.
Fractures in the Hand
General Principles
Fractures of the short long bones are usually simple injuries. Occasionally when the hand is injured in an industrial accident, multiple tissues like skin, bone and tendons are injured. In such cases the hand should be washed thoroughly and properly bandaged. The limb should be elevated till definitive plans can be executed.
In the management of any hand injury, proper follow-up with adequate physiotherapy involving local heat like wax bath must be ensured. Active mobilization exercises must be encouraged to prevent stiffness of the small joints.58
Fractures of the Phalanx
Isolated fractures of the phalanx can be reduced and immobilized by strapping the injured finger to the adjacent finger (buddy taping). While reducing a fracture of the phalanx one must be careful to correct the rotational deformity of the fragments. This can be verified by checking the alignment of the pulps of the fingers. These fractures heal well in three weeks.
Fractures of the Metacarpals
Fractures of the metacarpals should be immobilized with a below elbow slab. Adequate care should be taken to apply a volar slab (not a dorsal) since the edema tends to appear on the dorsum of hand. Multiple fractures and unstable fractures may require internal fixation with Kirschner wires. When many metacarpals are fractured it is wise to operate and correct the angulation or displacement. The fractures are stabilized by kirschner wires. Whether the fracture is treated conservatively by a plaster slab or it is stabilized by wires, the patient is encouraged to actively mobilize the other joints as early as pain permits. The slab or the wires may be removed in three weeks and active mobilization exercise therapy is advocated.
Remember: A stiff finger is as useless as an injured finger.
Fracture Neck of Femur
Mechanism of Injury
In elderly patients, the neck of femur is more prone for fractures. It is a pathological fracture since it is due to senile osteoporosis. Hence it is said that the patient sustains the fracture and then falls down. In other words the fall did not cause the fracture, instead the fracture caused the fall.
Clinical Features
The patient usually has associated systemic illnesses like diabetes mellitus and hypertension. A senior patient is brought with the history of a trivial injury and is not able to move the limb. Clinically there is tenderness in the hip joint and attempted passive movements are painful. The lower limb lies externally rotated.
Treatment
There is no role for conservative management in fracture neck of femur. Since the blood supply of the head of the femur is from distal to proximal a fracture of the neck of the femur is more prone for non union and avascular necrosis of the head of the femur. 60In the present era, there is no role for conservative management. Hence the fracture must be treated by operations.
In the middle aged, the fracture may be reduced under image control and fixed with AO cancellous screws.
If the patient is above sixty years, the head of the femur is avascular and the fracture results in non union. Hence the head of the femur is removed and replaced with metallic femoral head prosthesis. This partial replacement of the joint is called Hemiarthroplasty. Depending on the strength of the bone, Austin Moore prosthesis or cemented Thomson prosthesis is used. Over the last two decades a bipolar femoral endoprosthesis is used.
The advantage of metallic replacement of the head of the femur is that the patient is allowed nonweight bearing ambulation with walking aids, within a few days of the operation. Walking with weight bearing on the operated limb is decided by the prosthesis used and the quality of the bone.
Fracture of Trochanter
Clinical Anatomy
The fractures of the trochanter occur in a cancellous bone which has a rich blood supply. Hence the rate of fracture healing is usually not compromised. But there are powerful muscles acting on the fragment causing distraction and angulation of the fragments of the fracture. The proximal fragment is dragged to abduction by the gluteus medius while the lower fragment is flexed and abducted by the psoas and abductors. Hence anatomical reduction and stable internal fixation are required for good union.
If nonunion is the complication of the neck of the femur, malunion is the complication of mismanaged fractures of the trochanter.
Clinical Features
The limb is in the attitude of external rotation. Swelling and tenderness present over the trochanteric region and attempted passive movements are painful.
Complications
The forces that act on the fracture fragments result in a reduction of the neck-shaft angle of the femur. Hence, malunion, with reduced neck-shaft angle results, which is coxa vara. This deformity results in a weak abductor mechanism leading on to a Trendelenberg gait. If anatomical reduction is not obtained the resulting coxa vara is quite disabling. There is shortening of the limb. Patients walking with a short limb and Trendelenburg gait are more prone for early degeneration of the hip joint which is termed secondary osteoarthrosis. Hence clever surgeons choose to operate on fractures of the trochanter since the results are invariably good.
Treatment
Using a fracture table and image intensifier, the fracture is reduced and fixed with specialized implants like dynamic hip screw or proximal femoral nailing. But, since the patient and the bone are old and weak, weight bearing is allowed only after twelve weeks.
Fracture Shaft of Femur
Mode of Injury
The femur is the longest and strongest bone in the body. If the shaft of femur is broken it means it is due to a high velocity injury. Hence, when one receives a patient with a fracture of the shaft or the condyles of femur, the primary management is very important.
Treatment
Initial management: The injured limb should be initially immobilized in a Thomas splint. Adequate intravenous fluids and if necessary, blood transfusion and nasal oxygen should be administered to combat shock. The patient should be examined meticulously for any other major injury involving the pelvis, the bladder or the spine.
Definitive treatment: The era of conservative treatment in the management of fractures of the shaft of the femur is slowly fading and internal fixation of the fracture with intramedullary interlocking nails is the state of the art.
Minimally invasive techniques with the use of the image intensifier (C arm) have revolutionized fracture surgery. The only tissue with a great healing capacity and which helps the surgeon is the fracture hematoma. With modern closed techniques, 63this fracture hematoma is preserved.
In addition the blood supply to the fracture fragments is preserved. Hence the fracture is stabilized by a nail passed through the medulla that is approached from the proximal end.
The nail is locked to the bone both above and below the fracture. This is the principle of intramedullary interlocking nail and is now widely used all over the world. Since this is a closed technique, the muscles are not incised; the periosteum is not damaged; and the fracture hematoma is preserved. Hence when a fracture of shaft of the femur is operated and stabilized by a closed interlocking nail, the union is good.
Beautifully designed nails are available for the femur, and the pain subsides within a day or two after the operation. The patient is trained in knee bending exercises within a week. Since posttraumatic stiffness of the knee will cause an awkward gait, the patient is ambulated within six weeks with walking aids.64
Fracture of the Patella
The patella is a sesamoid bone in the quadriceps femoris muscle. It forms part of the extensor mechanism.
Clinical Features
Fracture of the patella is common in road traffic accidents and in sports injuries. The knee joint which is distended due to hemoarthrosis has to be aspirated.
Treatment
In the initial phases the injured knee is immobilized in a posterior tube slab or a knee brace. Since, distraction forces constantly act on the fragments, conservative management does not yield good results.
65Internal fixation of the fracture of the patella restores the power of the quadriceps muscles and the extensor mechanism. Cancellous screws and stainless steel wires are applied using the tension band principle. Vigorous knee bending and quadriceps exercises are necessary to prevent adhesions and knee stiffness.
Fracture both Bones of Leg
Two wheeler drivers who meet with an accident have their legs hit by the crash guards resulting in fracture of both bones of the leg.
Closed Fracture
If the fracture is closed (no external wound near the fracture), it heals very well with closed interlocking nail of the tibia. The patient is allowed to walk with nonweight bearing ambulation within a few days. Full weight bearing is allowed when there is no tenderness clinically and there is radiological evidence of callus. This is possible by about 12 weeks.
Open Fracture
If there is a wound over the fracture then it is termed as compound or open fracture. These fractures have to be approached very cautiously. Within the first one hour, the wound should be washed well with normal saline, chlorhexidine and povidone iodine solutions. The skin should be repaired depending on the availability. The skin is just anchored adequately to provide soft tissue cover for the bone. The tibia is stabilized using an AO external fixator or limb reconstruction system (LRS). The fixator is used for a few weeks till the skin, fascia and muscles heal with proper antibiotics and other drugs. When the skin and soft tissues have healed well, the external fixator is removed and the tibia is stabilized with a conventional interlocking nail.
66But it should be borne in mind that compound fractures take a longer time to heal and hence skilled physiotherapy is required during the convalescence period.
Rehabilitation
Hip abduction exercises, knee bending exercises, toe exercises and quadriceps strengthening exercises must be promoted judiciously for both the lower limbs. Active mobilization exercises for the upper limbs help in early recovery since the patient may have to use a walking aid or axillary crutches for a few weeks.
Foot and Ankle
Fractures of the malleoli are quite common in sports injuries. Isolated fracture of one malleolus is due to a slip on the staircase. It is interesting to note that ligamentous injuries around the ankle are more painful than fractures of the malleoli.
Clinical Features
The fractures of the malleoli are usually associated with ligamentous injuries. Hence the swelling appears immediately. The ankle is extremely painful and the patient is not able to put the foot on the ground. Immobilization of the limb in a below knee slab and elevation of the limb reduces the pain and swelling.
Treatment
Fracture of one malleolus or both, require internal fixation with specially designed malleolar screws or reconstruction plates.
Fractures of the Metatarsals
Principles of management: While treating any fracture in the foot, either by conservative or operative methods great care should be taken to maintain the medial longitudinal arch of the foot, by proper moulding of the plaster slabs.
Treatment: Fractures of the metatarsals can be stabilized by simple Kirschner wires. But the limb should be supported in a below knee slab till the pain and edema subside. Fractures of the metatarsals which are associated with dislocation of the tarso metatarsal joints (Lisfranc's) are complicated injuries and require extensive skilled operative procedures.
Fractures of the Spine
Mode of Injury
Fractures of the vertebra are usually due to a high velocity injury or a fall from a height. If a spinal injury is not treated properly, it could be detrimental because of the resultant injury to the spinal cord and sometimes it could be even fatal.
Clinical Features
Due to the involvement of the spinal cord, devastating neurological deficits like quadriplegia and paraplegia are also seen and add to the misery of the patient. Injury to the cord causing paraplegia disturbs the function of the urinary bladder and the bowel as well.
Treatment
Initial management: When a patient sustains a spine injury, he is brought to the hospital in a state of shock. There should be proper care in not aggravating the problem by carelessly shifting the patient (as for the sake of investigations). Shifting the patient in the recumbent posture, nasal oxygen therapy, intravenous fluids, bladder drainage by indwelling catheter and continuous monitoring of the vital functions are some of the simple measures employed during the first few hours which can go a long way in saving the life of the patient and in preventing further damage to the spinal cord which can cause paraplegia.
Fracture L1 vertebra: The first lumbar vertebra (L1) is more frequently fractured than the others. This is because it lies between the dorsal kyphosis and the lumbar lordosis which are two different curves of the normal spine. Once the general condition has been stabilized, X-rays and CT scans of the dorsolumbar junction are scrutinised to understand the configuration of the fracture. Reduction of the anterior height of the vertebra is quite often seen. This is termed compression fracture of the vertebra. The posterior half of the vertebral body are also studied to search for any fragments that have moved posteriorly. If so, they are culpable of damaging the spinal cord. MRI studies of the injured region reveal the damage to the spinal cord.
68Operative procedures have produced remarkably good results in the management of fractures of the vertebrae. A simple laminectomy of the fractured vertebra decompresses the spinal cord and thereby improves its blood supply. That segment of the vertebral column is stabilized by a pedicle screw system which connects the bones above and below the fractured vertebra. This procedure of internal fixation has revolutionized the treatment of these fractures since the patient need not have to be hospitalized for more than a few weeks.
Complications of Fractures
The process of fracture union is indeed a roller coaster ride during which the patient is relatively apprehensive. Despite the dexterity and desire of the surgeon, complications can creep into the healing process which jeoparadize the callus and the reputation of surgeon.
They are:
- Joint stiffness: This is due to extra articular ankylosis.
- Mal union: Union of the fracture fragments in a nonanatomical position.
- Non union: The fracture fragments have not united. By definition nonunion is a state of fracture healing wherein all reparative processes of fracture healing have come to a standstill. Nonunion can be classified as avascular and hypervascular nonunion.
- Infection: Due to the open wound, the fractured fragments and the adjacent soft tissues may be infected with bacteria resulting in delay of healing of the wound and the fracture. One should always bear in mind the dreaded complications of gas gangrene and tetanus, while addressing an open fracture.
- Osteomyelitis: Persistent infection that is resistant to the treatment administered, can invade the bone, resulting in osteomyelitis which is an orthopedic surgeon's nightmare.
- Open wounds: The loss of soft tissue over the fracture can defy local dressing, and may require secondary operative procedures, like split skin graft or flap covers.
- Segmental loss of bone: Loss of complete or part of a segment of the bone requires multiple operative procedures, like limb reconstruction, bone grafts and skin flaps.
- Incomplete amputation: When the soft tissue injury accompanying the fracture is extensive, the arteries of the limb may be injured resulting in ischemia of the limb, distal to the fracture.
- Crush syndrome: In a compound fracture, sustained due to a run over by a vehicle, or when the limb is crushed in an industrial accident, the bone is broken into multiple pieces. The skin is avulsed, lacerated and contaminated. In addition, the muscles and tendons are also lacerated or contused. If a wound has these features, it is notorious for initiating a Crush syndrome. Here, the damaged muscle tissues release myohemoglobin, which is secreted into the blood circulation. This causes a sudden systemic collapse, azotemia, shock and acute renal failure. To save the life of the patient, an amputation may have to be performed as an emergency procedure. Hence one must be extremely cautious while treating a compound fracture with the injured muscles crushed.69Hence, compound fracture or open fracture is a surgical emergency. Compound fractures are more common in the leg involving both the tibia and the fibula. The accompanying soft tissue injury can vary from a punctured wound or an incomplete amputation. This distinction can be evaluated by adhering to the various types of classifications advocated by pioneers in the field of traumatology. But, the classification described by Gustilo and Anderson (1976) gives us the guidelines for evaluation, management and the ensuing functional outcome of the limb.
- Fat embolism.
- Compartment syndrome.
- Shortening.
- Avascuar necrosis.
- Causalgia.
- Volkmann's ischemic contracture.
- Myositis ossificans.
The higher you go up in life the more mental balance is required
Ligament is a thickened structure that is a condensed part of the capsule of the joint. The ligaments are responsible for the stability of the joint. When the joint is subjected to undue strains, the ligaments are the first structures to be injured.
When the violence imparted on the joint stops with the ligaments, the patients sustains a ligament injury. This is called “strain” of a ligament. In common english, the term “sprain” is used to denote this injury. If the violence that caused the injury is of a greater velocity, all the ligaments of the joint are injured which results in a dislocation of the joint. Hence a ligament injury or a strain is due to an undue and incomplete violence imparted on the joint.
Ligament injuries have to be diagnosed and treated early, to prevent instability of the joint and degeneration of the articular surfaces of the joint.
The common sprained ankle is a domestic injury of the ligaments of the ankle joint. Games and sports injuries cause excessive strains on the ligaments of the joints leading to their rupture. The ligaments of the knee joint are more often injured during sports activities like football and kabbadi. The ligaments of the shoulder and elbow joints are more prone to be injured in tennis and badminton players.
It is interesting to note that ligamentous injuries are more painful than simple fractures. The pain and swelling appear immediately over the injured ligament. The patient is not able to tolerate the pain and is restless. The swelling increases rapidly due to the collection of the increasing hematoma. Clinically there is marked tenderness over the inured ligament. The patient is not able to actively move the joint and any attempted passive movement is restrained by pain.71
WRIST
Due to a domestic fall on the outstretched hand, the radial and ulnar collateral ligaments of the wrist joint are injured individually or together. Another broad ligament which is present on the palmar aspect of the wrist joint is the Volar radiocarpal ligamentous complex, which may also be injured.
Clinically, localized tenderness elicited by digital pressure over the joint line is proof enough to diagnose injuries of the ligaments of the wrist. But, associated intra articular fractures, and fractures of the carpal bones have to be excluded before definitive planning of the treatment. X-ray of the wrist joint in all the three views should be carefully studied to rule out fractures. An elastocrepe bandage or a volar BE slab with analgesics is sufficient to reduce pain. The healing time of any soft tissue injury including the ligament is about three weeks. Hence the BE slab should be retained for at least three weeks, following which local heat therapy and gentle mobilization exercises help in regaining the functions of the wrist.
Caution: Fracture of the scaphoid bone can be diagnosed clinically by tenderness over the anatomical snuff box, but has to be confirmed by oblique views of the X-ray of the wrist.
ELBOW
Since the lower end of the humerus is relatively not so thick, fractures of the lower end of the humerus are more common than isolated injuries of the ligaments of the elbow joint.
The Pulled Elbow is a common condition that is often seen in children. This is a strain of the annular ligament which connects the head of the radius to the upper end of the ulna. In our homes, adults hold the forearms of the children and play with them. Sometimes the adult swings the child in circles by grasping by the forearm of the child. This stretching violence causes the strain of the annular ligament. Sometimes, the head of the radius subluxates from the superior radial ulnar joint. This clinical condition is called a pulled elbow. The child is brought with the severe pain around the elbow.
72When coaxed, the child points to the lateral aspect of the elbow joint, which is more painful. The head of the radius is tender and movements of the forearm are painful. Gentle passive supination and pronation movements correct the displacement and there is a dramatic relief of pain immediately. The child requires a neck and wrist sling for a few days.
SHOULDER JOINT
The acromioclavicular ligaments which are just adjacent to the shoulder joint are more often injured. The acromioclavicular ligaments are injured in road traffic accidents, especially when the patient falls on the point of the shoulder. If the violence is of a greater magnitude, it can cause a subluxation or dislocation of the acromioclavicular joint. Anteroposterior X-rays of the shoulder will reveal the dislocation. Isolated injuries of the acromioclavicular ligament should be immobilized with the Robert Jones strapping and a broad arm sling. The injured acromioclavicular ligaments heal within three weeks. Later shoulder mobilization exercises and pendulum exercises along with local heat therapy are advised for restoration of the functions of the shoulder joint.
KNEE
The knee joint is a complex joint which performs flexion, extension and a certain degree of rotation. This rotatory movement is responsible for the stability of the knee joint (locking), while standing erect. This stability is provided by the anterior cruciate ligament. The other movements of flexion and extension are stabilized by the medial and lateral collateral ligaments.
Medial Collateral Ligament of Knee
The medial collateral ligament of the knee joint is thick and wide, connecting the tibia and the femur in the inner aspect of the knee joint. Sportsmen indulging in games and athletic activities are more prone for the injuries of the medial collateral ligament of the knee. Clinically, the patient may come walking but with a definite limp. When questioned about the site of pain, he points to the inner aspect of the knee. If the patient reports within a few hours of the injury, there is a painful swelling on the medial tibio femoral joint. There is a localized tenderness and attempted passive movement is painful.
After a few hours or days, the knee joint develops an effusion due to traumatic synovitis of the knee. On examination, the knee is swollen and all the parapatellar fossae are distended. Clinical signs of effusion like fluctuation and patellar tap are positive. But the tenderness is localized to the medial collateral ligament.
As soon as the patient sustains the injury, local cryotherapy reduces the pain and swelling. Immobilization of the knee joint in a POP tube slab or a knee brace is sufficient for good healing of the injured ligament. If the patient has an effusion, it may have to be aspirated and the patient may require an elastocrepe bandage in addition to 73the knee brace. This immobilization, along with static quadriceps exercise is continued for a minimum period of three weeks. The patient is allowed partial weight bearing ambulation with the walking aid. By about the fourth week, knee bending exercises and quadriceps strengthening exercises are advocated.
Anterior Cruciate Ligament of Knee
The anterior cruciate ligament is the strongest ligament within the knee joint. It is responsible for the stability of the knee joint, while walking, climbing and turning around. Hence injury of the anterior cruciate ligament results in instability of the knee joint. The patient describes his incapacity as “giving way” of the knee joint while walking or climbing steps.
The patient sustains an injury to his knee joint by a fall with the knee in a flexed position. This type of injury can occur in games, sports and two-wheeler vehicular accidents. Surprisingly, the patient feels the pain, but is able to get up from the site of injury and walk away. He develops a swelling of the knee joint after a couple of days, and later he feels the instability while running or climbing stairs.
Within a few days, the collection in the knee joint should be aspirated. It is usually frank blood. This is called hemarthrosis. After aspiration, intra-articular injection of steroids does not help much. The knee joint is immobilized with a knee brace. An elastocrepe bandage may be wrapped around the knee to reduce pain. A week of analgesics and local heat therapy may be needed.
The patient is taught isometric exercises within the first few days. He is advised to continue quadriceps exercises for a few weeks, to prevent wasting of the quadriceps. Exercise is essential because weakness and wasting of the quadriceps aggravates the instability of the knee and disturbs the other operative procedures that may be performed later.
Once the swelling and pain subside, the knee joint should be examined for clinical signs of instability. With the patient lying down on the couch and the knee slightly flexed, the upper third of the leg is grasped and pulled away from the knee. If the tibia could be moved from the femur this test is positive. This clinical sign is called Lachman test. The advantage of Lachmann test is that it can be performed within a few days even with a painful knee. After a few days or weeks, the knee is examined for the anterior drawer sign. Here, with the patient lying down on the couch and the knee flexed fully, when the clinician pulls the tibia apart, it slips anterior to the femoral condyles. This is the positive anterior drawer sign, which is diagnostic of anterior cruciate ligament injury.
Sometimes, if the velocity causing the ligamentous injury is of greater intensity, the medial collateral ligament and the medial meniscus are also injured along with the anterior cruciate ligament of the knee.
Most of the injuries of the ligaments of the knee can be diagnosed by the clinical signs of tenderness, effusion and tests of instability; but confirmatory investigations are required in certain situations. In these cases the injuries of the anterior curciate ligament and the collateral ligaments of the knee are better diagnosed by the MRI study of the knee joint.
74Incomplete tears of the anterior curciate ligament heal well with conservative methods of management. But, to confirm the structural damage and the extent of the injury, an arthroscopic examination is mandatory.
The Arthroscope is a sophisticated instrument with a lens system of 4mm diameter and cold light source. This is called key hole surgery. The arthroscope is used for diagnosis of internal derangement of the knee. Certain trained surgeons repair the injured menisci and the ligaments through the arthroscope.
Complete tears of the anterior curciate ligament do not heal with conservative management. They have to be repaired by arthroscopic techniques.
SPRAINED ANKLE
A sprained ankle is the most common domestic injury. A simple slip on the floor twists the ankle and this causes a rupture of the anterior talofibular ligament, which is a part of the lateral collateral ligament of the ankle.
The pain is very severe and the patient is not able to walk even a single step beyond. He has to limp to his bed and is not able to bear weight on the injured ankle.Clinically there is a large swelling of the ankle more on the outer aspect.The tenderness is below and anterior to the lateral malleolus. Any attempted passive movement is restricted by pain.The anteroposterior X-ray of the ankle should be studied carefully for any associated fracture of the lateral malleolus.
It is interesting to note that ligamentous injuries around the ankle are more painful than fractures of the malleoli. Sir Watson Jones has quipped that it is better to break your ankle than to sprain it. The commonest injury around the ankle (sprained ankle) is an injury of the lateral anterior talofibular ligament. This injury heals well with three weeks of immobilization in a below knee plaster cast.
The ankle is immobilized in a below knee plaster slab with the ankle in neutral position.The patient is allowed to walk around with crutches without bearing weight on the injured foot. After three weeks, gentle ankle mobilization exercises are advised. Soon after the injury local cryotherapy reduces the pain and swelling. But the ankle must be immobilized in plaster for good healing and a normal gait.
DISLOCATIONS
Injury to one or more of the ligaments of the joint causes pain and instability of the joint. But, if the injuring violence continues, all the ligaments that connect both the bones of the joint, rupture. This complete tear of all the ligaments of the joint causes the bones to move away from each other and this is dislocation of the joint.
Definitions
Dislocation
Dislocation is an injury to a joint that results in total loss of congruity between the aricular surfaces of the joint.75
Subluxation
Subluxation is an incomplete injury to the joint resulting in incomplete loss of congruity with partial contact between the articular surfaces.
Dislocation is a joint injury that heals well when treated early and good function of the joint restored. Though there are different schools of thought regarding the duration of immobilization, it must be remembered that ligaments need about three weeks to heal adequately. So, after reduction of the dislocation any joint must be immobilized for at least three weeks, for restoration of the stability of the joint.
The traumatic dislocation of the any joint should be examined clinically for the loss of the normal contour of the joint. The X-rays of the joint should be studied in both the views for the following reasons.
- To establish the diagnosis.
- To study the position of the dislocated bones; this will guide us in choosing the method of treatment.
- To rule out intra-articular fractures and avulsion fractures.When the bone is dislocated from the joint, the shearing force may cause small fragments to be fractured from the articular surfaces. These fragements may lie loose within the joint cavity and can prevent adequate reduction. If the separated fragments are large an operative procedure may be required to reduce the fragment to restore the integrity of the articular surfaces.
- Many a time, the ligaments that are attached to the edges of the long bones may pull a fragment of bone. This fracture is called an avulsion fracture.
X-rays of the dislocated joint should be studied carefully for any associated intra- articular fracture or avulsion fracture. These associated injuries require additional care and management. Depending on the anatomical position of distal bone of the dislocated joint, dislocations are classified as anterior, posterior or central. Some of the dislocations that are frequently seen are described below:
Dislocation of the Shoulder Joint
Anterior dislocation of the shoulder joint is due to fall on the outstretched hand. It also happens in sports men who play football, rugby and kabadi. A traumatic anterior dislocation of the shoulder is usually a single episode. It usually heals well with adequate treatment.
Anterior dislocation of the shoulder is quite common in young men. The patient has pain and swelling over the shoulder joint and he supports the injured arm with the palm of the opposite hand. He is able to feel that the head of the humerus is out of place. On examination the normal contour of the shoulder is lost and the rounded head of the humerus can clinically be palpated 76anterior to glenoid fossa. The axillary nerve which is adjacent to the humerus is occasionally injured. Hence, the power of the deltoid muscle should also be examined clinically.
The dislocation is obvious in anteroposterior X-ray of the shoulder. X-rays should be studied carefully for associated intra-articular fractures and avulsion fractures, of which, the avulsion of the greater tuberosity of the humerus is usually seen.
Closed reduction of the dislocation under general anesthesia by Kocher's method restores the joint congruity. This can be clinically and radiologically confirmed. The arm is immobilized in the position of aduction and internal rotation for about three weeks. Later, shoulder mobilization exercises and then deltoid strengthening exercises are also needed.
Some patients especially epileptics, drug addicts and alcoholics tend to dislocate their shoulder often. This is called Recurrent dislocation of the shoulder. Recurrence of the dislocation may be due to injury of ligament or the bones. Recurrent anterior dislocation of the shoulder requires operative procedures to strengthen the ligaments and reinforce the capsule of the shoulder joint.
The choice of the operative procedure is decided by the abnormality that caused the recurrence.
Elbow Joint
Of the injuries around the elbow, supracondylar fractures of the humerus are common in children, while posterior dislocation of the elbow occurs more in adults.
It is due to a violent fall on the outstretched hand. The radius and the ulna are dislocated posterior to the humerus. Clinically, there is a huge swelling around the elbow and the abnormal position of the olecranon is palpable, posterior to the lower end of the humerus.
77A good lateral view X-ray is necessary to confirm the dislocation and to exclude associated bony injuries like fractures of the coronoid process.
Under general anesthesia, reduction by axial traction in the position of the forearm reduces the dislocation adequately. The entire limb is immobilized in an above elbow plaster slab, with the elbow in flexion for three weeks. Later, elbow flexion exercises are advised. Though extension movement may be difficult, the therapist must resist his temptation to move the joint passively. Active flexion and extension exercises of the elbow joint are encouraged. Passive stretching exercises aggravate the elbow stiffness.
HIP
The hip joint is the largest ball and socket joint of the human body. Though it is very stable, it offers a wide range of movement in all directions permitting us to walk, run and dance.
Dislocation of the hip joint is relatively rare. This is invariably due to a high velocity injury as occurs in road traffic accidents. Young adult males are more prone to sustain dislocation of hip (older people are more prone to sustain fractures of the neck and trochanter of the femur). Since, the dislocation of the hip is a high velocity injury, the patient is brought in with severe pain, and sometimes even in shock. The shock should be corrected first with oxygen therapy, IV fluids and other drugs. Then the patient must be shifted for X-rays. He must be meticulously examined from head to foot, to exclude injuries of other systems.
Of all the various types of dislocations, the posterior dislocation of the hip is more often seen. The lower limb is held in the position of flexion, adduction and internal rotation. The femoral arterial pulse is weak (vascular sign of Nareth). The globular head of the femur is palpable in the gluteal region.
The X-ray of the pelvis should include both the hip joints and it should be studied carefully for associated fractures of the posterior wall of the acetabulum. If the dislocation of the hip is associated with a fracture of the head of femur or the wall of acetabulum, reduction is either difficult or unstable. Hence, dislocations of the hip that are associated with fractures may have to be operated.
Simple closed posterior dislocation of the hip can be reduced by conservative methods. Bigelow's method of reducing the hip, is a reversal of the original forces that caused the dislocation, and has always achieved good reduction. The other techniques may be used in difficult situations.
Closed reduction should be performed under adequate anesthesia and the reduction must be confirmed by a check X-ray. Then the limb should be immobilized with skin traction in a Thomas splint. Isometric quadriceps exercises are continued. After three weeks, nonweight bearing ambulation is allowed; the hip abductors and quadriceps are strengthened for the next few weeks, and then the patient is allowed normal walking.
Sit straight to avoid low backache; think straight to avoid tight corners
Ever since the Neanderthal man evolved into homo sapiens, he has been suffering from low backache. If kindness is the rent that we pay for the space that we occupy on this earth, low backache is the fee that we pay for standing erect. Low backache has transcended social barriers and has been perceived by both the rural beedi worker and the elite software executive.
Low backache is the commonest pain that every human being has experienced at least once in his lifetime. The erect posture of man is maintained by the vertebral column which is supported by the pelvis. But the vertebral column is not straight like a ruler. Instead it has three curvatures cervical and lumbar lordosis with a dorsal kyphosis in between.
These alternating curves are maintained by a complex group of muscles called erector spinae. Together these maintain the erect posture and the functional balance of the spine in the various postures. When excessive compression and torsional forces are applied to the vertebral column as in standing, lifting heavy weights, turning and bending during work, the maximum strain is born by the tissues around the lumbosacral region. Hence, the patient has a low backache in the lumbosacral region. The intensity of pain depends on the degree of damage to the tissues in that region. The nerves supplying the lower limb emerge from the neural foramina.
When they are irritated or strained the pain radiates along the course of the nerve and this is called Sciatica (commonly L5, S1 nerve roots). The pathomechanics of low backache and sciatica differ. Pain due to bone, disk, ligament or facetal joint is localized to the back. But if any of these structures causes compression or irritation to the nerve root the pain radiates along the lower limbs. This fundamental difference should be clearly understood to study the disease or damage.79
FUNCTIONAL UNIT OF SPINE
- Intervertebral disk
- Neural foramen
- Pedicle
- Facetal joint
- Supraspinous ligament.
The bodies of the adjacent vertebrae are held together by an intervertebral disk. Hence this joint between the bodies is a fibrous joint (Syndesmosis). The pedicle which projects posteriorly and outward has proved to be very useful in instrumentation of the spine (Arthur D Steffee). The transverse processes provide attachment to the strong muscles of the back. The laminae and the spinous processes form the posterior wall of the hollow column which houses the spinal cord. These are further strengthened by the ligamentum flavum.The inferior articular process of the superior vertebra and the superior articular process of the inferior vertebra articulate with each other to form the facetal joint which is a synovial joint (zygoapophyseal joint). This is obliquely placed in the coronal plane. The facetal joints restrict the angle of lateral flexion but permit forward flexion. The nerve roots emerge through the neural foramen which is posterior to the disk space and is formed by the various components of the vertebra mentioned above.
Adequate knowledge of this functional unit of the spine is essential to identify the cause of low backache and to plan the management.
Causes
There are hundreds of causes which can cause low backache.
During the course of clinical examination one should bear in mind the following features:
- Posture
- Obesity
- Pendulous abdomen
- Organs in the abdomen
- Urogenital system
- Functional low backache.
A detailed history about the nature of work and the posture during the work is absolutely essential to identify the cause. In a patient with low backache all the features of the nature of pain should be recorded like location of pain, nature of pain, factors that aggravate it and how is it alleviated, the distribution of radiation, any associated weakness or numbness in the lower limb are some of them. Before the actual physical examination, if the clinician is armed with these answers, he can identify the tissue that has caused the low backache.
Generalized diseases like neuropathy, neuritis and diabetes mellitus which affect the nerves should always be considered. When examining a patient with low backache, 80one should also bear in mind, problems of the spinal cord like neurofibroma or other tumors of the cord and meninges.
- Congenital
- Spina bifida
- Hemivertebra
- Anomalies of the vertebra like sacralization of L5.
- Infective
- Bacterial osteitis
- Infective discitis
- Tuberculosis
- Herpes zoster.
- Inflammatory
- Rheumatoid spondylitis
- Ankylosing spondylitis
- Fibrositis
- Myositis
- Sacroiliac arthritis.
- Traumatic
- Ligamentous strain
- Fracture of the bony component
- Prolapse, herniation and rupture of the disk
- Spondylolisthesis
- Secondary strain (dorsal scoliosis).
- Neoplastic
- Secondary tumors
- Primary tumors-multiple myeloma, osteoid osteoma, osteoblastoma.
- Degenerative
- Lumbar spondylosis
- Facetal arthropathy
- Disk degenerative disease
- Osteoporosis.
- Psychogenic
- Abdominal and pelvic organ disease.
Clinical Features
Low backache appears in different but definite pattern in various age groups. The common clinical features that are seen in the three segments of the population will be dealt with here.
Young Adults
In females of the teenage group, many of the above mentioned causes can be present. But, a simple dull aching pain in the teenage group, is often due to lumbosacral strain, fibrositis or myositis which may be diagnosed by the localized tenderness on the muscle or the interspinous space. The movement is not much restricted. Spondylolysis which is the weakness of the pedicle of L5 vertebra is occasionally seen in the young female. If the pain radiates along the nerve, then the stretch tests for nerves should 81be performed. When a teenage girl presents with low backache, it is mandatory to examine the dorsal spine and also the levels of the shoulders and the scapula. There would be a lateral curve of the dorsal spine and the shoulders would not be at the same level. These features are suggestive of adolescent scoliosis of the dorsal spine and that can be the cause of a dull aching low backache.
In the young adult male, occupational hazards, especially travelling in two wheelers aggravate pain. Usually he gives a history of trivial strain or a flexion strain as a sudden, catchy pain while lifting a heavy weight from the floor or continuous work in bad postures as we often see in computer personnel. Strain of the ligament and fibromyositis can easily be diagnosed by localized tenderness.
If he complains of the pain radiating along the back of the thigh to the calf muscle it is sciatica. Then the clinician must examine for a prolapsed intervertebral disk.
When the disk is herniated it presses on the nerve root and the following features are then observed:
- History of a flexion strain
- Pain radiating along the nerve root
- Pain aggravated by movements
- Loss of lumbar lordosis
- Bilateral paraspinal muscle spasm
- Restriction of the movements of the spine
- Tenderness along the course of sciatic nerve (Valliex points)
- Straight leg raising (SLR-flexing the hip with extended knee) is restricted by pain
- Weakness of extensor hallucis longus (EHL) or other motor functions.
In central disk prolapse, these tests may be positive in both lower limbs. The corresponding knee reflex (L3L4) and the ankle reflex (L5S1) are diminished. Many a time, sensory disturbances are present over the skin supplied by the nerve root (dermatome).
In patients who have early ankylosing spondylitis, there will be tenderness over the spinous processes and marked tenderness of the sacroiliac joints. The movements of the spine are restricted. Stretch tests for the sacroiliac ligaments are positive. There is a progressive decrease in the movement which affects ADL (the activities of daily living). The chest expansion which is normally about five centimeters is typically reduced. X-rays of the lumbar spine would reveal sclerosis around the sacroiliac joint and calcification of the intervertebral ligaments which are diagnostic of ankylosing spondylitis.
The pain is excruciating in infective discitis. The patient has fever; he may not be able to stand or move around. There would be marked tenderness over the spinous processes and paraspinal muscle spasm. Usualy the patient reports to the hospital before the onset of any neurological deficit.
Middle Age
If bad postures and trivial trauma are the main causes of low backache in the younger age group, obesity and pendulous abdomen are to be considered when examining a middle aged patient.
In middle aged males lumbosacral strain,fibromyositis and prolapsed intervertebral disk are some of the common causes. If a prolapsed or degenerated disk has not been 82treated effectively the biomechanics of the functional unit are altered, and the patient develops secondary changes in the facetal joints. If the adjacent nerves have been impaled or insulted, the nerve roots develop perineural edema. This can be clinically evaluated by the nerve stretching tests like SLR test. Hence, the clinical features of a prolapsed disk mentioned above may be seen. In addition, the pain may be aggravated more on sitting or standing for long hours. If the disk material has encroached into the space of the cord, the patient has a pain that increases on walking. The patient perceives the pain in the muscles of the leg and is forced to stop to sit for a few minutes; walking for even a few meters is difficult for him. This is neurogenic claudication and is due to lumbar canal stenosis.
The same factors must be considered while examining a middle aged female. In addition, central obesity and weak anterior abdominal muscles (due to pregnancy) must be looked for. Many women who have had a delivery, by caesarean section tend to blame the spinal anesthetic that had been administered. This is not true. In many instances, confined bed rest in the postnatal period causes weakness of the spinal muscles which increases the strain on the ligaments and the intervertebral disk and the clinical picture reveals findings of both. When the longitudinal ligaments of the spine are strained, the patient has paraspinal muscle spasm. There is a painful restriction of forward bending and the clinician would be able to elicit tenderness in the interspinous spaces of the lumbar spine.
Rheumatoid arthritis has been dealt with in detail in chapter two. When the disease process affects the spine, it is termed rheumatoid spondylitis and is not uncommon in middle aged females. The constitutional symptoms may not be present. Clinical features of arthritis may be seen in one or more joints of the limbs. The movements of the lumbar spine are restricted, but neurological deficit is rather rare.
Anterior translation of one vertebra over another is called Spondylolisthesis. This is quite common in middle aged females. The patient presents with low backache and sciatica. The pressure on the exiting nerve roots and the altered mechanics of the functional unit causes the pain to persist and restrict various movements of the lumbar spine. Clinical features of pressure on the nerve roots are also present. Usually, the patient has weakness of the muscles of the back and those of the anterior abdominal wall.
Low backache due to disease or degeneration of the sacroiliac joint is quite common in the middle and older age groups. The sacroiliac joint can cause low backache in both males and females. In males it is a mechanical strain of the sacroiliac ligaments (incidently this is the strongest ligament in the body) or due to ankylosing spondylitis. Tuberculosis is also notorious for infecting the joint, and is seen both in the young and middle age patients.
In females, the laxity of the ligaments associated with pregnancy causes sacroiliac strain. Sometimes due to breastfeeding the bones and the pelvis are concomitantly weak. The pain is relatively severe and forces the patient to bedrest. This condition is called Osteitis condensans ilii.
When examining a middle aged female with low backache infections of urogenital system should also be borne in mind.83
Old Age
With the increase in the average age of the general population many senior citizens visit the hospitals with lowbackache. The causes seem to be common in both males and females except osteoporosis which is more prevalent in older ladies. Most of the symptoms are due to degeneration of the various compartments of the functional unit like disc, end plates, facetal joints and so on.
Since the degeneration occurs simultaneously in all the components, the different terms that we use here are only to guide the student. Global degeneration of the lumbar spine is called Lumbar spondylosis.
The patient has a dull aching low backache of a few months or years duration. The backache is more on movement, such that he finds it difficult even to pick up a pen from the floor. Clinical examination reveals interspinous tenderness. Paraspinal muscle spasm is felt when the pain is increased (The adjacent nerve roots have been irritated).The nerve stretch tests like SLR are positive.
Lateral flexion movements are restricted in facetal arthropathy. Persistent pain reduces the quality of life especially in females who find it difficult to sit or squat on the floor. The pain is more when she tries to get up from the sitting posture. If the osteophytes from the facetal joint encroach the neural foramen, irritation of the nerve roots can manifest as radiculopathy or motor deficit.
In disk degenerative disease, the pain is localized to the back. It is not aggravated by movement, rather it is felt more when he sits or stands for quite sometime. Walking around for a few minutes will relieve the pain to some extent.
In women of the perimenopausal age group and in those who have attained menopause, the incidence of osteoporosis is quite common. In the older age group it is termed Senile osteoporosis. Osteoporosis literally means bone filled with holes. The bone is qualitatively normal, but structurally weak. Hence the vertebra is more prone for compression fracture (pathological fracture). Some women present with a dull aching pain of a few weeks’ duration while some may report with pain due to a simple injury. The pain is continuous and more on movement. They are not able to sit without support and tend to lean for some support within a few minutes. Change of posture is relatively difficult. On clinical examination the lumbar lordosis is lost or even a dorsolumbar kyphosis could be seen. If the patient has sustained a pathological compression fracture, the spinous process of the involved vertebra is tender and more prominent (Gibbus). The bulk of the paraspinal muscles is thinned due to muscle wasting. The neurological picture depends on the nerve roots irritated 84or attenuated. Some patients come to the hospital with a compression fracture of one or more vertebrae. This is pathological fracture due to osteoporosis and the patient has senile kyphosis.
CONSERVATIVE MANAGEMENT
In this era of spine surgery, there are many specialized institutions where they deal with only spinal problems. Operative procedures from epidural steroid injections to total prosthetic replacement of the vertebrae are very common today. In spite of the extensive strides made in the techniques of spine surgery, it is interesting to note that most of the patients with low backache recover very well with conservative management.
Acute Discitis
The patient with the acute discitis is usually brought in with severe pain and a high fever; he may not even be able to stand. He must be given absolute bed rest. He must be given intravenous broad spectrum antibiotics. The pain should be controlled with narcotic analgesics like tramadalol. Sometimes he may require pentazocine and diazepam.
Spondylolysis
This is one of the common causes for low backache in teenage girls. The diagnosis may be confirmed by oblique views of the lumbosacral spine which reveals a break in pedicle of L5 vertebra. These girls require simple analgesics like paracetamol and muscle relaxants like thiocholchicosides or flupirtine for a few days. Once the pain subsides the lumbosacral spine should be strengthened by spinal exercises. Spinal extension exercises (raising the pelvis with the hip and knee flexed) and spinal flexor exercises (raising the leg with knee extended) are very useful and may have to continued for a few months.
Thoracolumbar Scoliosis
When teenage boys and girls complain of dull aching pain in the low back region, it could be the effect of adolescent thoracolumbar scoliosis. The management is decided by the angle of the curvature (Cobb's angle) as measured in the X-rays with antero posterior views of the dorsal spine. A few weeks of local heat therapy like ultrasound or short wave diathermy coupled with intermittent pelvic traction invariably reduce the pain. Later the scoliosis can be corrected by shoulder bracing exercises, spinal extension exercises and spinal extensor exercises; or by corrective spinal orthosis.
Fibromyalgia Syndrome
The management of this condition is discussed in detail in chapter 1.
Acute Disk Prolapse
The young or middle-aged patient walks in with a low backache of sudden onset and the diagnosis can be confirmed with some simple clinical tests mentioned above.
The patient must be confined to bed. Absolute bed rest for a few days is advised. Analgesics and antiinflammatory drugs combined with muscle relaxants should be administered. Some surgeons prefer to use intravenous soluble methyl prednisolone 85for a few days.
Local therapy like ultrasound or shortwave diathermy will help to reduce the paraspinal spasm.
Continuous pelvic traction has proved to be very useful in many centers. Macnab, one of the pioneers in the management of low backache states that continuous pelvic traction confines the patient to bed. But it has been proved to be effective in reducing the paraspinal muscle spasm. (Continuous or intermittent pelvic traction does not distract the vertebrae apart!).
Once the pain and paraspinal muscle spasm have subsided, gentle supervised spinal exercises should be advised. Some surgeons are quite sceptical about the role of lumbar belts. But experience has proved that a properly designed lumbosacral corsette alleviates the apprehension of the patient, reduces the pain, prevents untoward strain to the lumbar spine and builds the confidence of the patient during work. Only about thirty percent of patients with acute disk prolapse especially with a nerve root involvement may require surgical intervention.
Many spine surgeons are now apprehensive about the ambiguity and the utility of the scans in view of the cost and innocuous abnormalities that supplement the clinician's confusions. Deyo has frequently stressed that back pain is mostly mechanical. He further criticizes the diagnostic values of CT and MRI, a concept that the author wishes to authentically reaffirm. Scott Boden emphasizes clearly that back pain is not necessarily correlated or associated with morphogenic or biomedical changes in the intervertebral disk.
Osteitis Condensans Ilii
Osteitis condensans ilii usually occurs in young mothers especially following the first delivery. Since she has to attend to the newborn baby this pain is really disturbing. The pain is increased on change of posture, turning around in bed and getting up from the chair. Since she is a breast feeding mother, drugs like analgesics and NSAID's should be used with extreme caution. The pain is remarkably reduced by the use of lumbosacral corsette. She requires oral calcium, a therapeutic supplementation which 86is administered in the form of tablets and foods with a rich calcium content. After about six weeks, when the pain has considerably reduced spinal muscle strengthening and exercises to strengthen the anterior abdominal wall are taught.
Spondylolisthesis
This usually occurs in middle age women. Early anterior translation presents with localized low backache. If it is not treated properly, the spondylolisthesis progresses. This progress has been classified by Meyerding. The grading of the listhesis can be measured with a lateral view X-ray of the lumbosacral spine. This condition may be treated with analgesics and other drugs. The patient must be advised to wear a lumbosacral corsette especially during standing, walking and working. If the patient is not treated adequately, the translation increases and the patient may present with radiculopathy within a few months. This indicates grade III or IV of listhesis of Meyerding. These conditions usually do not respond to conservative management. The patients improve with operations like decompression laminectomy, posterior stabilization using pedicular screw system and interbody fusion.
Disk Degeneration
Degeneration of the lumbar intervertebral disk is not an individual problem. It forms a part of the degenerative process of all the components of the vertebral column in the lumbar region. Being the only soft component of the functional unit, the intervertebral disk degenerates earlier in the old age. Sometimes this process of degeneration is accentuated in the middle age due to a injury or disease. If the prolapsed intervertebral disk has not been treated adequately it is prone for early degeneration. Patients with degeneration of the disk also have changes of degeneration in the adjacent facetal joints. The pain is usually localized and aggravated by movement. The patient is comfortable at rest in the lying or sitting posture, but finds it difficult to get up from the chair or the bed.
87Once she stands up she is comfortable and begins to walk. Continuous walking sometimes increases the pain and this is called neurogenic claudication.
The diagnosis can be confirmed by plain X-rays and CT scan of the lumbar spine. The treatment is mainly conservative, which includes centrally acting analgesics for pain and muscle relaxants for the associated paraspinal muscle spasm. Some women feel comfortable with a lumbosacral corsette. They must be advised to wear the corsette during work and travel. Once the pain subsides and the patient is comfortable, she must be started on a schedule of spinal muscle strengthening excercises. Continuous use of the lumbosacral corsette can cause weakness of the paraspinal muscles of the lumbosacral region resulting in dependence of the patient on the corsette. If the degenerated disk material has sequestrated it may press on the spinal cord or may be lying within the spinal canal. This situation requires surgical excision of the protruded disk material and removal of the degenerated disk. In recent years some surgeons use prosthetic disk replacements after disk excision.
Lumbar Spondylosis
The majority of the patients in the older age group who report to the hospital with persistent low backache have lumbar spondylosis. Here there is degeneration of the disk, ligaments, end plates of the vertebrae and facetal joints. Some of the osteophytes may press on the adjacent nerve roots.Hence the patient may present to us with continuous dull aching low backache. The pain does not alter with change of posture. The patient is not comfortable even in the lying posture. Radiation of the pain along the thigh or the leg indicates pressure on the nerve roots by the osteophytes. Lumbar spondylosis can be diagnosed with simple X-rays. Narrowing and irregularity of the disk space, sclerosis of the end plates, osteophytes at the ends of the bodies and sclerosis of the facetal joints are certain radiological findings which are diagnostic of lumbar spondylosis. Pelvic traction either continuous or intermittent should be used along with local heat therapy. Electrical stimulation of the paraspinal muscles by using TENS along with short wave diathermy, helps in reducing the pain. Centrally acting analgesics and muscle relaxants also help in the management. Spinal support with lumbosacral corsette helps the patient to move around. Spinal extension exercises are taught for early recovery of the patient. But persistent radiculopathy and neurogenic claudication may demand operative interventions like foraminotomy, laminectomy and stabilization by pedicular screw system.
Sacroiliac Arthritis
As clinicians, when we proceed to examine a patient with a low backache, many a time our concentration is directed towards the innocent intervertebral disk. In our frantic search to find some culprit, we tend to ignore the sacroiliac joint that connects the vertebral column to the pelvis. The sacroiliac joint permits 88gliding movements and is strengthened by the sacroiliac ligament which is the strongest ligament in the body.
Degenerative processes and inflammatory changes which occur in the lumbar spine can also cause serious dysfunction of the sacroiliac joint resulting in persistent low backache. Ankylosing spondylitis, a chronic inflammatory disease of the bones and ligaments of the vertebral column begins its long journey of fusion in the sacroiliac joint. When a young adult male has clinical features of sacroiliac arthritis, ankylosing spondylitis must be contemplated. Chronic granulomatous diseases like tuberculosis and brucellosis are also known to infect the sacroiliac joint. Sustained degeneration of the lumbar vertebrae alters the biomechanics of the sacroiliac joint resulting in further degeneration of that joint.
Clinically the tenderness is distinctly felt just lateral to the dimple of the sacroiliac joint. SLR test is painful halfway through. Pump handle test is positive in the affected side.
Drugs to treat the specific cause for the sacroiliac arthritis must be administered along with analgesics. Lumbosacral corsettes bind the sacroiliac joint as well as reduce the pain by preventing extraordinary strain on the ligaments and the muscles. Spinal extension exercises and hip abduction exercises strengthen the sacroiliac joint and help in pain free ambulation of the patient.
Tuberculosis (Caries Spine)
Quite often tuberculosis of the vertebral column involves the dorsolumbar junction (D12-LI) or the vertebrae of the dorsal spine. But it is not uncommon in the lumbar vertebra. Tuberculosis occasionally involves the lumbar spine and the sacroiliac joint. A patient who has continuous low backache should be examined in detail for other clinical evidences of caries spine. The pain is dull aching, and the intensity does not alter with change of posture as we see in other diseases of the lumbar spine. On clinical examination, the tenderness over the lumbar spine and the loss of lumbar lordosis are obvious. This is associated with bilateral paraspinal muscle spasm (loss of lumbar lordosis). This is also well seen in lateral views of the X-rays of the lumbar spine. Narrowing of the intervertebral disk space in X-rays and raised ESR are enough to confirm the diagnosis of caries spine. The investigations and the management are discussed in detail in chapter nine.89
Ankylosing Spondylitis
Ankylosing spondylitis, a chronic inflammatory disease of the bones and ligaments of the spine can present as persistent low backache. The reduced movements of the spine, decreased chest expansion and sacroiliac tenderness are some of the clinical findings of ankylosing spondylitis. X-rays of the spine reveal calcification of the longitudinal ligaments.
Osteoporosis
Old aged females with a thin frame are prone for osteoporosis. Women who have attained menopause and those who have had a hysterectomy are also prone for osteoporosis. Osteoporosis is a silent disease with continuous bone loss but without symptoms. The old woman with a crouched back and a walking stick seen on the streets has osteoporosis. She reports to the hospital only after a fall. Elderly women who cannot sit straight, who tend to sit down often and those who take more than ten seconds to get up from a chair are patients with osteoporosis. Clinically, they have loss of height and a kyphosis. The clinical signs of a pathological fracture are obvious. On X-rays the vertebral body is concave, flattened and collapsed. Due to loss of the bony trabeculae, the body has a ground glass appearance. Bone mineral density studies (annexure I) help to distinguish between osteopenia and osteoporosis. Dietary supplements with high protein content and rich calcium are beneficial. Drugs like bisphosphonates, selective estrogen receptor modifiers and calcitonin are also used. Hormonal replacement therapy is also used in postmenopausal women. Spinal support reduces the pain, but brisk exercises like walking help the bone in regaining its strength.
Secondary Tumors in Spine
Since the vertebrae are cancellous bones with a rich blood supply they form a fertile soil for seeding of malignant cells from a primary tumor occurring in the visceral organs.
The lumbar vertebrae are affected by secondary tumors which have originated 90from primary malignancies of the kidney like renal cell carcinoma. Carcinoma of the prostrate in males and carcinomas of the cervix and uterus in females deposit secondaries in the lumbar vertebrae. Many a time the symptoms of the genitourinary malignancy may not be clinically obvious and require further investigations. The patient has a continuous low backache that does not respond to drugs or any other form of conservative management. If the affected vertebra is collapsed due to a pathological fracture, tenderness over the spinous process is quite obvious. Adjacent paraspinal muscle spasm and a gibbus are associated clinical findings. Ultrasound studies of the abdominal organs will be helpful in identifying the source of the primary tumor, in addition to the specific changes in their serum values. The lateral view of the X-rays confirm the diagnosis. The diseased vertebra is osteoporotic and its anterior vertical height is decreased indicating a pathological fracture. Advanced investigations like CT and MRI of the lumbar spine are necessary to plan the operative interventions.
OPERATIONS FOR LOW BACKACHE
As mentioned earlier it is essential for the undergraduate student and the practitioner to be aware of some of the operative procedures that are performed to alleviate pain in the poor patient with low backache.
Surgical removal of the lamina is termed laminectomy. This is useful in lumbar canal stenosis. While performing this laminectomy the thickened ligamentum flavum which compresses on the cord can also be removed.
Patients who have sciatica or radiculopathy may have osteophytes from the facetal joints pressing the nerve roots as they come out through the neural foramen. Excision of the osteophytes and widening of the foramen is called foraminotomy.
If the MRI studies reveal the prolapsed intervertebral disk to be pressing on the spinal cord the protruded disk material has to be removed. This disk excision is also necessary in massive central disk prolapse and in sequestered disk. In certain advanced spine centers the protruded disk is approached through endoscopic spine techniques. Thawing and removal of the disk material is called coblation therapy.
In degenerative disk diseases and spondylolisthesis the protruding disk material has to be removed. Additional support to the functional unit may be required. This is provided by a complex system of screws and rods called pedicular screw system. In patients with advanced stages of spondylolisthesis this pedicular system is augmented by adding bone graft. This is called PLIF or posterior lumbar interbody fusion.
METHODS TO PREVENT LOW BACKACHE
Since low backache is a global phenomenon, it is the social and professional responsibility of every physician and therapist to advise the patients to modify some activities of their day to day life. If we fail to do so, the patient will be shooting multiple questions during every visit. Here are some suggestions which may be offered to the patients to avoid a low backache:
Standing
People, whose occupation demands standing for long hours, must stand straight with their shoulders braced backwards and the eyes facing straight. They should not bend 91forward or lean on a wall. If the work demands to stand for a longer period like women in the kitchen and men working in the machines they should be advised to have one foot elevated on a foot rest which should be slightly raised.
Sitting
One should not slouch on the sofa. During work or rest one should sit straight in a straight back chair. The back support of the chair should extend above the shoulders and the elbows should be rested on the arms of the chair. The use of a sloping writing pad will avoid forward bending of the lumbar spine and thereby unnecessary strain of the ligaments and muscles of the back. Sitting on the floor in the squatting or cross leg posture is not good for the back.
Work
Nowadays nearly all the offices have computer systems. Those who have to work with these systems have to make sure that the monitor of the computer is at the level of the eyes, and that the monitor is just straight to the body. If the system is on a side table continuous bending of the lumbar spine is required. This is not good for the lumbar spine.When one sits for long hours it is advisable to have the feet slightly elevated on a foot rest.
Driving
Youngsters, who travel to work or study, use two wheelers. During driving they have to bend their entire spine forward. Travelling in this posture for months together can cause undue strain on the ligaments and muscles of the lumbar spine. While driving a two wheeler they must be advised to sit straight and hence the hand bars should be modified and raised. Those who drive cars should be advised to have the back rest of the driving seat straight, rather than slanting. The driver's seat should be as close to the foot pedals as possible. Use of a seat belt prevents unnecessary strain of the back.They must be advised to avoid long rides and bumpy roads.
Sleeping
There is a wrong notion in this country that sleeping on the floor will prevent low back- ache. This is not so. One should use a firm mattress. One should be lying down straight and not on the abdomen. If you turn to one side make sure that the hip and knee are flexed and the limb rests on a pillow.
Lifting
Lifting heavy objects from the floor is one of the common causes for disk prolapse. All of us will perform this movement everyday without realizing the impact of the strain that we throw on our low back region. Even picking up a pen or a comb from the floor can cause a low backache. If you want to lift a heavy object, it is advisable to bend the hips and knees with the back straight. Women who carry pots of water and men who carry luggage should be advised to carry equal weights in both the hands.92
Excercises
Physical exercises are essential for the well-being of every man on this earth. Breathing exercises improve the general health of the individual. One should inhale about five counts, hold the breath for another five counts and then breathe out for about eight counts. This should be performed as a daily routine. Simple exercises that stretch or strengthen the muscles of the low backache should be performed on everyday by everybody. But patients who have had a lowback ache must be cautioned adequately to perform the exercises after consultation with the doctor or the physiotherapist. Exercise therapy has proved to be very effective in preventing the recurrence of low backache in patients treated either conservatively or by operative methods.
Properly controlled exercise program is a simple but effective modality when combined with the other therapeutic approaches. Exercise therapy should be commenced in the early phases of the treatment. The results are better in patients treated with combination of more than one approach, rather than those treated with a single modality.
- Spinal flexion exercises (Williams)Flexing the trunk and stretching the back extensors reduces stress on the lumbar spine and strengthens the muscles of the anterior abdominal wall.
- Spinal extension exercises
- Promote normal physiological lumbar lordosis thereby allowing it to withstand axial compression forces (White and Panjabi).
- Improve the posture and mobility of the spine.
Hence the patient must be advised to start on spinal flexion exercises initially. Once he is confident, spinal extension exercises are advocated.
Spinal Support
Spinal support in the form of a well contoured lumbosacral corsette has a definite role in the management of low backache. There are certain views that discourage the use of lumbosacral corsette blaming that it is reduces muscular activity resulting weakness of paraspinal muscles. The advantages of using a spinal support are:
- It maintains normal lumbar lordosis and provides adequate support.
- Provides partial immobilization and avoids undue strains on the lumbar spine.
- It offers adequate reassurance to the patients.
But, spinal exercises must be promoted and the patient must be advised to gradually wean himself and stop wearing the corsette.
Mckenzie Technique
Based on the response of the patient to the repetition of all basic movements of the lumbar spine and maintenance of normal lumbar lordosis, Mckenzie has staged the progress of low backache as dearangement, disfunction and postural syndromes. His method has gained popularity and has proved objectively effective in various conditions that cause low backache. He advises correction of back postures with emphasis on maintaining normal lumbar lordosis in all the situations. The exercise therapy is begun as an extension exercise and when the acute pain subsides flexion exercises are included.
Convert your wounds into windows of wisdom
Invasion of the bones and joints by pathogenic microorganisms is quite common, despite the discovery of generations of antibiotics. Infection of a joint is termed as septic arthritis; when the long bones are infected, we call it osteomyelitis, since the cortex and medullary cavity of the bone are damaged by the infective process.
Infections of a soft tissue organ by the pyogenic bacteria cause an abscess, that is well sealed off the host tissue. But when it occurs in bone, infection of the cortex and medulla destroys the inherent architecture of both, damages the periosteum and spreads well within the configuration of the bone. This causes obvious alteration of the texture and quality of the infected bone. This process is radically different in acute and chronic osteomyelitis. There is marked difference between the disease occurring in the child and adult resulting in varied clinical picture, behaviour of the disease, radiological findings and the ensuing sequelae.
This chapter will discuss the following:
- Children
- Acute osteomyelitis
- Chronic osteomyelitis
- Adults
- Acute osteomyelitis
- Chronic osteomyelitis
- Infective arthritis.
ACUTE OSTEOMYELITIS IN CHILDREN
Acute osteomyelitis is frequently seen in children especially the newborn. The source of infection is intrapartum, viz. mismanaged labor, poor sterilization techniques during delivery conducted outside the hospital and poor hygiene in the immediate postpartum period are some of the causes.
94The infant is brought within a few days of delivery; the child is febrile and toxic; the affected limb is swollen. The whole limb may be swollen. The segment of the limb involved is angry looking; the skin is stretched and shiny. Any attempted passive movement is extremely painful. The child does not move the limb (pseudoparalysis). Tenderness is marked and one should be gentle in handling the limb and the child.
X-rays will not be very useful in the diagnosis of acute osteomyelitis in children since the bone appears normal. The only positive and clinically useful radiological sign is a soft tissue swelling which is seen in the muscle shadow (muscle sign).
This is a real medical emergency and the help of a pediatrician should be sought immediately. The fever and shock should be treated with intravenous fluids, analgesics and antipyretics. Broad spectrum antibiotics should be started immediately. One gram of ceftriaxone is injected intravenously; sometimes one of the aminoglycosides like amikacin (500 mg) may also be added, without waiting for the culture reports. Then, under adequate anesthesia, the pus should be drained from the bone as well. The limb should be immobilized in a posterior plaster slab or a Thomas splint. The wound should be dressed daily till the pain subsides and the discharge stops. With proper medical care the child recovers adequately, without any residual deformity.
CHRONIC OSTEOMYELITIS IN CHILDREN
Chronic infection of the bone is secondary to a septic focus elsewhere in the body. The child initially has infection in the ear (chronic suppurative otitis media), tooth (caries) or lungs (bronchitis). If that primary source of infection is not treated adequately, the pathogenic bacteria travel through the blood stream (hematogenous spread) and reach the bone.
In the long bones, the bacteria reach the metaphysis which is the widened ends of the bones and have a rich blood supply. The pathogenic organisms lodge themselves in the metaphysis and spread their infective process at a rapid pace in all directions.
Fig. 8.2: X-ray of the patient in Figure 8.1
95This infective process increases the intraosseous pressure, which inturn causes vasoconstriction.This causes tissue ischemia and results in necrosis resulting in further spread of the infection. Hence a vicious cycle develops, and the infection spreads within the bone. When the intraosseous pressure is increased the cortex and the periosteum are destroyed. From the medullary cavity the infection expands to destroy the adjacent cortex and the periosteum. The periosteum is raised off the cortex and thickened. Later it gives way; hence the purulent material reaches the skin through the broken periosteum and forms a sinus which has a discharge constantly. A sinus over a bone is a diagnostic sign of chronic osteomyelitis.
In the meantime, the bone loses its original shape and is thickened and irregular. This continuous process of infection destroys the anatomical configuration of the bone. The long bones receive their blood supply mainly from the periosteum. When the periosteum has been elevated from the bone this blood supply is jeopardized. Hence a segment of the bone becomes ischemic and necrotic. This necrotic piece of bone is called sequestrum. The sequestrum lies in the cavity that has been caused by the infective process.
The clinical picture is pain and deformity in the affected part of the limb. The skin is dark and may have one or more sinuses with discharge of pus or seropurulent material. The bone is tender, thick and irregular, which is obvious in the metaphyseal region. One of the diagnostic features is that the sinus is adherent to the underlying bone. There may be associated muscle wasting and certain degree of stiffness of the adjacent joints.
The X-ray is very typical. The metaphyseal region is thick and irregular. The cortico-medullary distinction is lost. Scattered areas of irregular bony trabeculae are seen. Cavities are seen as osteolytic areas; sequestrae appear to be osteosclerotic on X-rays, and they are seen lying within the cavities. The periosteum is thickened and the bone appears irregular.
Treatment
Culture and antibiotic sensitivity studies of the discharge will help in choosing the right drug, which would be beneficial if administered intravenously for a few days. The limb must be immobilized adequately to reduce the pain. Under appropriate antibiotic umbrella, the patient may have to be operated. During the operative procedure, the roof of the bony cavity is excised and the sequestrum is removed. The walls of the cavity are scraped well until fresh bleeding occurs which is a sign of a healthy bone. Systemic antibiotics and limb support have to be continued for at least six weeks. Then the additional support, either braces or plaster slabs should be removed and gentle active exercises of the joints of the limb are commenced. Periodical clinical and radiological evaluation is necessary for the next few months.
Some of the common antibiotics which are used intraveneously are:
- Quinolones like ciprofloxacin (500–750 mg/bd). The patient must be cautioned about gastric disturbances.
- Penicillins like ampicillin (0.5 g–2 g IV/oral qd). Diarrhea is an occasional side effect. One should be cautious to use the drug only after adequate test dose.
- Cephalexin/Cefotaxime (0.25 g–1 g bd). This can be started initially intraveneously and later changed to oral drugs.
- Gentamicin (3–5 mg/kg/day). The side effects are ototoxicity and nephrotoxicity.
- Linezolid 600 mg bd oral/IV. The side effects are very few.
- Vancomycin (500 mg IV qd/oral qd). The side effects are the ototoxicity and nephrotoxicity.
ACUTE OSTEOMYELITIS IN ADULTS
With the advent of powerful antibiotics, acute osteomyelitis of the long bones is relatively rare in adults. But, some cases are being reported; acute osteomyelitis of the long bones of the limbs is now seen in immunocompromised patients and in denervated limbs as occurs in diabetic patients with chronic peripheral neuropathy. The treatment includes appropriate antibiotics and drainage of pus.
CHRONIC OSTEOMYELITIS IN ADULTS
About two decades ago, chronic osteomyelitis of the long bones in adults was due to deposition of pathogenic organisms from the blood stream. But now, the occurrence of chronic osteomyelitis in adults has taken a new but ugly version. Infection of the bone that has been seeded from a septic focus elsewhere is relatively rare with other pyogenic bacteria except in tuberculous osteomyelitis wherein the bacteria travel from the lung tissue to the blood to reach the bone, the destination of the damage.
The incidence of chronic osteomyelitis of long bones in adults is now invariably due to open fractures or compound fractures, where the injury that caused the fracture has also caused a laceration of the tissues overlying the bone. The injuring force that breaks the bone also damages the adjacent muscles and strips the periosteum there by exposing the bone to further infection. This is more common in the long bones of the limbs. The short long bones of the hands and feet are infected mostly due to industrial accidents.
Clinically the patient gives a history of a road traffic accident or a fall from a height; the bones had been exposed through the wounds; the patient did not receive adequate treatment or the initial injury had been mismanaged.
On examination the limb is deformed due to the improper and inadequate fracture healing. He may not be able to use the limb or move the joints. The skin over the limb has multiple scars and is dark and discolored. There may be many sinuses with discharge of pus or bony chips. The sinus is adherent to the underlying bone and there is associated muscle wasting of the limb.
The X-ray of the limb reveals irregular sclerosis of the bone with scattered areas of osteolysis. The radiological distinction between the cortex and the medulla is lost. The shape of the bone is disfigured.
Prevention
As mentioned earlier, the commonest cause for the chronic osteomyelitis is an open fracture that has not been treated adequately. Hence the onset of chronic osteomyelitis in a compound fracture, can be prevented by effective management of the wound and the fracture, during the initial phases of treatment.
When the patient with a compound fracture is received in the causalty ward, his vital functions must be stabilized, and the shock corrected by adequate intravenous fluids. Antibiotic drugs, like cephalosporins should be administered intravenously (Gustilo). The choice of the drug may be altered after a few days based on the culture and sensitivity studies of the discharge or pus. The wound is washed well with copious quantities of normal saline and chlorhexidine (wound lavage). Necrotic pieces of tissues like skin, fascia and muscle are excised. Loose fragments of bone lying scattered in the mangled wound must not be removed if they have some soft tissue attachment, for they will provide the desired callus. The normal skin surrounding the wound must be cleaned with povidone-iodine solution. Adequate care must be taken to avoid pouring the povidone solution on the raw tissues of the wound.
If conditions are quite satisfactory, the wound may be closed by suturing the skin edges together. But one must be cautious to avoid stretching of the skin and tension on the sutures, as both aggravate infection.
98The fractured long bone must also be reduced and immbobilized. If possible, posterior long arm or long leg slabs should be applied. Openings (windows) on the encircling bandage are made to help in daily care and dressing of the wound. Later the slab may need to be converted into plaster casts.
But this is cumbersome and the immobilization provided by the plaster casts may not be sufficient to stabilize the fractured fragments of the bone. Hence, in the recent years we use an external fixateur to hold the fragments of the bone together. The fixateur of great advantage and that is being widely used all around the world is the universal AO fixateur (Arbeitsgemeinschaft Fur Osteosynthese Fragen). The external fixateur can be used as uniplanar or biplanar design for better fixation. Various studies and our experience have proved that proper healing of the wounds of the soft tissue are accelerated when the fragments are held stable together by an external fixateur. The wound can be addressed daily and adequate dressing for the wound may be provided daily. Even when the wound requires a second operative procedure like Split Skin Graft or skin flap, the fixateur provides excellent stability, till the wounds are well covered and healthy.
Treatment
The treatment of established chronic osteomyelitis is a tedious procedure and the results are not so satisfactory. Antibiotics have to be administered based on the culture studies of the discharge which can be purulent or seropurulent over a protracted period. The anemia and hypoproteinemia have to be corrected.
The patient may require one or more operations.
- Systemic antibiotics have proved to be useful, but the side effects and adverse effects have to be tackled judiciously. Hence various centers including ours, use intravenous and intralesional antibiotics. Antibiotics like Vancomycin (2 g for 40 mg bone cement), Gentamicin (400 g for 40 mg bone cement) and Tobramycin (400 mg in 40 mg bone cement) are presently available. The systematic side effects are few. The drug is incorporated in bone cement, polymethyl methacrylate and moulded into beads. These antibiotic impregnated cement beads are placed on the bone for about six weeks.
- The infected bone is sclerotic and it requires drilling of multiple holes in the cortex. These numerous holes that are made stimulate bleeding within the bone. Blood is the best tissue to heal any wound. These holes drilled stimulate osteogenesis or growth of healthy bone.
- If sequestrate are seen in the X-rays they have to be removed and the cavity must be scraped well.
- If the patient had been operated earlier for the fracture, the infected bone will have the implants which will be loose or exposed. These implants are potential sources for infection. Hence, all metallic implants must be removed at the earliest opportunity.
- With all the above measures the bone may be weakened or the rate of healing at the fracture site may be delayed. Hence the bone has to be stabilized by a limb reconstruction system (LRS). If the fracture is comminuted, segmental or if there is loss of bony tissue, there would be a gap between the ends of the two fragments which will not allow fracture healing. In such a situation, LRS is of great advantage.99It has proved to be useful in the management of compound fractures because it stabilizes the fragments of the fractured bone, promotes soft tissue healing and permits transport of segments of bone.
INFECTIVE ARTHRITIS
Infection of a joint by pyogenic bacteria is otherwise called septic arthritis. Though it is rather rare in adults, septic arthritis is frequently seen in children.
The pathogenesis is the same as that was discussed in osteomyelitis. The joint can be infected by blood stream or through open injuries over the joint.
Septic arthritis is seen in neonates and children. It is frequently seen in the hip and knee joints. The child has high fever; the joint is angry looking, swollen and painful. Any attempted passive movement is extremely painful. The diagnosis is mostly based on clinical findings since no abnormality is seen in the X-rays, except for widening of the joint space.
The pus within the joint cavity can damage the synovium and the articular cartilage. If not treated adequately, the infective process can cause serious damages to the articular cartilage and growth plate which may result in deformity, shortening or bony ankylosis.
Hence the pus must be drained. It is wise to have a preoperative diagnostic aspiration under image intensifier control to confirm the position of the needle and the contents of the joint. Then under anesthesia, an arthrotomy is performed and all the pus is drained. Fragments of the necrotic synovium are removed. The joint is lavaged well and the wound is closed. Immobilization of the limb will reduce the pain. The joint that has been operated must be mobilized, initially by passive exercises and later by active mobilization exercises. Failure of this crucial step will result in the dreaded complication of septic arthritis, viz., bony ankylosis, where both the articular surfaces are fused by bone.
Kindness to a fellow human being will make your world happy
Few decades ago, many people died of pulmonary tuberculosis when no effective bactericidal antibiotic was available. When the bones and joints were involved by the disease process there was extensive damage and it was called consumption disease. Many, rapid advancements were possible after the discovery of the causative organism by Robert Koch. Tuberculosis or TB as it is commonly mentioned is a chronic disease that is caused by Mycobacterium tuberculosis. This bacteria is a gram-positive, rod-shaped and acid fast bacillus. Tuberculosis initially affects the mesenchymal tissue of lungs, as it is spread by the airborne route. Many patients suffer from pulmonary tuberculosis.
From the mesenchyme of the lungs, the disease spreads through the blood to the various organs, of which bone is the commonest. Of all the bones the vertebrae are commonly involved.
When the vertebral coloumn is infected there is extensive destruction of the bodies of the vertebrae and the disk material. Hence it is also called Caries spine or Pott's spine (because it was described by Sir Percival Pott). Apart from the spine the hip, knee and the other joints are also involved. When the long bones are involved we call it Tuberculous osteomyelitis. Sometimes the short long bones of the hand, like metacarpals and phalanges are affected. This is termed tuberculous dactylitis.
ETIOPATHOGENESIS
The gram-positive, Mycobacterium tuberculosis initially causes pulmonary tuberculosis. From the mesenchyme of the lung it spreads through the blood stream (Hematogenous spread). The vertebrae are cancellous bones with a rich blood supply. Hence the bacteria reach the adjacent vertebra on either side of the disk.
101There they cause caseation necrosis. This cuts off the nutritional supply to the disk and hence it degenerates. The necrosis also causes collapse of the end plates of the adjacent vertebrae. This leads to narrowing of the disk space which is a diagnostic feature of tuberculosis of spine on X-rays.
The necrotic material and debris spread further. The collection of the various cells, macrophages, necrotic material and serum cause the cold abscess which is characteristic of the caries spine. When the abscess spreads, it can press upon the adjacent meninges or the spinal cord. If it affects the spinal cord and the arteries that supply the cord, it results in paraparesis or even paraplegia.
Sometimes the cold abcess can travel laterally along the nerve roots. This then manifests clinically as a swelling in the paraspinal region or along the tract of the involved nerve.
Due to the axial compression forces, the collapsed vertebra begins to angulate. This posterior angulation is clinically obvious as a gibbus. The posterior shift of the angulated vertebra can also press on the spinal cord thereby causing neurological deficit or even complete paraplegia.
HISTOLOGY
When the mycobacteria infects the mesenchyme of any organ, it causes a central area of caeseation necrosis. This is surrounded by neutrophils and macrophages. Some of the macrophages fuse to form the typical Langhan's gaint cells. Surrounding these cells, lymphocytes and fibrocytes are seen. This is the typical tubercle from which the disease derives its name.
The bacteria is a rod shaped bacillus which is gram-positive and acid fast. The biopsy tissue is obtained from the sputum or caseous material have to be cultured in Lowenstein Jensens medium (contains egg yolk) to see the bacteria. But paradoxically the content of the cold abscess rarely contains the bacilli.
Clinical Features
Caries spine is rather notorious, since it affects patients of all age groups. We have seen Pott's spine in children and in people of seventh and eighth decades. The patient presents with a dull aching backache which is usually insidious in onset. The pain persists for a few months or even years. Sometimes, the patient may attribute the backache to a trivial injury which has to be taken with a pinch of salt. The pain is continous and is aggravated by movement and change of posture; even lying down on a mattress does not provide the desired relief.
Occasionally the patient may present with a swelling without any evidence of a backache. The swelling is the infamous cold abscess which may be present mostly in the paraspinal region namely on either side of the midline of the back. Depending on 102the vertebrae that are primarily infected by the disease, the location of the cold abscess varies as follows:
- If the upper cervical vertebra are infected the cold abscess presents itself in the retro pharyngeal area.
- Infections of the lower cervical vertebra produce a cold abscess in the region of the neck either in the anterior or posterior triangles of the neck; occasionally it is seen in the suprasternal notch.
- Infections of the upper dorsal vertebra(above D4) present as a paraspinal abscess which is better visible in an X-ray of the chest as a V-shaped shadow and not so clear on clinical examination.
- Tuberculosis of the lower dorsal vertebra(below D4) reveals a cold abscess either in the paraspinal region or in the intercostal spaces of the chest wall.
- If the upper lumbar vertebra are involved, cold abscess may be present in the anterior abdominal wall, inguinal region or femoral triangle; most of the cold abscesses which originate from the lumbar vertebra present themselves as Psoas abscess which is seen either in the inguinal region, femoral triangle or the medial aspect of the thigh.
Invariably all the patients with clinical features of caries spine have a history of having had a pulmonary tuberculosis as evidenced by cough with expectoration, hemoptysis (blood stained sputum), loss of weight and loss of appetite in addition to evening rise of temperature. Some patients, who have been partly cured, may narrate that they have been taking drugs on empty stomach early in the morning for a few months. But, one has to remember that many patients who present with caries spine do not have the clinical constitutional symptoms like fever, loss of weight and appetite, because the number of circulating pathogenic bacilli are few in caries spine (paucibacillary).
One need not expect a cold abscess in every patient who has a caries spine. Many patients walk into the hospital with just a dull aching backache which has been present for a few months. On examination, the clinician finds that there is straightening of the back in the lumbar region due to loss of lordosis.
There would be associated paraspinal 103muscle spasm, Gibbus which is the characteristic clinical sign of caries spine is due to the posterior protrusion of the diseased vertebrae. A gibbus can be seen on inspection, or palpation. The gibbus is tender when tapped with a finger. The muscles adjacent to the gibbus are also tender on palpation.
Radicular pain is also a common feature which is associated with caries spine. Weakness of one movement may be due to involvement of one nerve. But that is usually progressive and we often see patients with partial weakness of both lower limbs which is called paraparesis. It is not uncommon to meet patients with paraplegia due to caries spine. In such conditions the patient is brought in a stretcher with grade 0 power in both lower limbs, scattered areas of loss of sensation and weakness of bladder and bowel.
Investigations
Though there are many pointers towards a clinical diagnosis, caries spine has to be confirmed by investigations which reveal typical results.
- Blood investigations:
- Hemoglobin-most of the patients are anemic
- Total count
- Differential count-lymphocytosis is conspicuous
- ESR-this is characteristic and invariably raised markedly; this is of real prognostic value and raised ESR indicates persistence of the disease.
- Mantoux-usually positive in children but not relevant in adults
- Sputum for acid fast bacillus (AFB).
- Chest X ray-reveals evidences of tuberculosis of the lung.
- Serum TB antigens-IgM and IgG are raised.
- Plain X-rays of the spine-AP view of the diseased spine reveal the fusiform radiopaque shadow on either side of the spine, which is diagnostic of a cold abscess.
The lateral view reveals narrowing of the intervertebral disk space which is a diagnostic feature of caries spine.
The disk space is absolutely normal in all other similar conditions like secondary tumors or osteoporosis. In addition the end plates may be sclerosed, the bodies of the vertebrae may be collapsed. The vertebrae are osteoporotic. The anterior height of the collapsed vertebrae may be reduced. There is posterior angulation of the bodies of the vertebrae causing the Gibbus and it is one of the causes for neurological deficit.
- CT—Vertical sections of the CT reveal destruction of the end plate, osteoporosis and collapse of the vertebrae.Transverse sections are useful to study the structure of the vertebrae.
- MRI—The spinal cord is well seen in MRI.This is mandatory to evaluate the causes of neurological deficit and in planning the operative procedures.
Fig. 9.4: MRI images of caries spine D12-L1 with collapse of the body and compression of cord by cold abcess
Treatment
Though the pain and paraplegia are the presenting features it must be remembered that tuberculosis is about an infection by a bacillus, hence antitubercular antibiotics form the mainstay of the treatment. During the choice of the drug schedule, it is wise to include both bacteriocidal and bacteriostatic drugs. It should also be clearly explained to the patient that the drugs should be continued till the clinical and radiological features restore to normalcy. During the course of the chemotherapy it is the duty of the treating doctor to educate the patient about the common side effects of the drugs that are used.
Drugs
Some of the common antituberculous drugs are mentioned below:
- Isoniazid (5 mg/kg/day for > 50 kg it is 300 mg. The side effect is Peripheral neuropathy (Vitamin B12 shouldbe included in the regimen).
- Rifampicin (10 mg/kg/day) for > 50 kg 600 mg. The side effect is orange coloration of the urine and hepatotoxicity.
- Ethambutol (15 mg/kg/day) for > 50kg 1000 mg. Disturbance in eye sight is one the common side effect.
- Streptomycin (15 mg/kg/day) for > 50 kg 1000 mg. Toxic to kidney
- Pyrazinamide (25 mg/kg/day) for> 50 kg 1500 mg.
A combination of these drugs must be used. Some of the other drugs that are used are kanamycin, ethionamide, thioacetasone, cycloserine and amikacin.
SPINAL ORTHOSIS
Support to the spine reduces the pain dramatically. In addition this spinal support prevents collapse, progression of the disease and prevents neurological deficit. Spinal orthosis also helps in ambulation; when the patient is walking alone he has a feeling of well-being.This spinal support is termed ASH Brace-Anterior Spinal Hyperextension 105Brace. This supports the trunk anteriorly thereby providing a good three point stabilization. (Also read chapter 16).
OPERATIONS
To operate or not? Is the question that every surgeon has to face. The indications for operative intervention have been clearly mentioned by Shanmugasundaram and Kumar, pioneers in the field of tuberculosis of the spine. Some of these are acute onset paraplegia, cold abscess, bony fragments pressing on the spinal cord and patients who do not show neurological recovery with chemotherapy.
This again leads to the question when to operate. The middle path regime advocated by SM Tuli has now been widely accepted. In this regime the patient is administered a combination of antitubercular drugs, methylcobalamin, analgesics and protien supplements. He is advised to wear an ASH Brace which will support the spine. He is permitted ambulation and domestic activities. If the neurological deficit persists or progresses then he is taken up for an operation. This is the widely accepted middle path regime of SM Tuli.
With the newer drugs available and specialized implants, nowadays it is quite easy to operate on most of the patients with tuberculosis of the spine. The procedure involves removal of the caseous material, the necrotic debris, the bony spicules and the cold abscess. The weak vertebrae that have been destroyed by the disease are also removed. Any tissue pressing on the cord is also removed. Adequate space is provided for the spinal cord. The gap between the vertebrae is filled with bone graft or metallic implants (vertebral CAGES).106
In addition the vertebral column is strengthened by a pedicular screw system with rods that connect the healthy vertebra above and below the defect.
Though we are able to operate in any verterbra right from the cervical to the sacrum, adequate preoperative planning for the operative procedure and rehabilitative methods during the postoperative period should be discussed and decided, well ahead of the operation. Drugs which include antituberculous antibiotics, methylcobalamin and analgesics should be continued till there is absolute recovery.
The cold abscesses may be drained earlier before any major sugery is planned. This will reduce the pain and prepare the patient for a major spine surgery.
REHABILITATION
Tuberculosis of the spine debilitates the patient to a remarkable extent over a period of time. The patient is anemic, weak and emaciated. The pain during movement disturbs him further. Whether we choose conservative or operative methods, the patient finds it difficult during the recovery phase.
Hence rehabilitation plays a major role in providing absolute cure. The patient is advised high protein food with vitamin supplements.The spinal support must be continued till the patient is able to perform his excercises. Spinal muscle strengthening excercises like extension excercises and spinal flexor excercises should be continued for many months.
107He must be encouraged to help himself in activities of daily living. In the case of recovering paraplegics gait training, cycling and swimming excercises are very useful. The rehabilitation team should include the nursing staff, physiotherapist, orthotist and occupational therapist. The confidence that the surgeon builds in the patient is the cornerstone of recovery. During every visit the doctor must reassure the patient and promote his sense of well-being.
When do you tell the patient that he is free of the disease? Basically, the patient must feel healthy and energetic, he should be walking and working without any pain, the ESR should revert to the normal values. There should be no tenderness on palpation of the spine and plain X-rays should show the reappearance of the normal trabercular pattern.
Take the road less travelled to discover your destiny
Deformities that are present during birth are called congenital anomalies. Defects in the eye, cleft lip and cleft palate are still seen. Congenital anomalies in the heart like valvular diseases and septal defects are also not rare. Children born with defects and deformities in the limbs are brought to the orthopedic department.
Some of the congenital anomalies like congenital talipes equino varus (Clubfoot), pes planus (tarsal coalition), congenital pseudoarthrosis of the tibia, congenital dislocation of the hip (acetabular dyplasia), congenital scoliosis, polydactyly (more than five fingers or toes) and syndactyly (fusion of adjacent fingers) are frequently seen. The other congenital anomalies are relatively rare. Of these anomalies, clubfoot creates panic in the families on the day of the birth itself.
CLUBFOOT—CONGENITAL TALIPES EQUINOVARUS
Congenital anomalies of the limb are present in about 3 per 1000 live births. Of these the commonest deformity in children clubfoot. The word ‘Talipes’ is derived from talus and pes wherein the talus is rested on the ground as the foot (pes). Though many new techniques in plaster application and operative procedures have been introduced into the orthopedic arena not many health care professionals have ventured to educate the public, so as to eradicate the misconceptions regarding the causes, the prognosis and the easy cure of clubfoot.
It is our social responsibility to spread the message loud and clear that clubfoot is neither a divine curse nor the fate of the young mother but it is only a simple deformity of the small bones and joints of the kid.109
Etiology
The exact cause of this deformity is not known. Etiology of idiopathic clubfoot are:
- Mechanical theory: The abnormal intrauterine position of the fetus.
- Genetic theory: Primary germ plasm defects in the talus causes hypoplasia of this bone with subsequent soft tissue changes in the joints and musculotendinous complexes.
Clubfoot can be associated with other conditions like paralytic disorders such as poliomyelitis, spina bifida, myelodysplasia, Friedreich's ataxia. Arthrogryposis multiplex congenita is another developmental disorder of the muscle associated with clubfoot.
Pathomechanics
Clubfoot is a deformity of the foot and ankle. It is characterized by a foot plantarflexed (equinus meaning plantar flexion) at the ankle, inverted at the subtalar joint (joint between talus and calcaneum) and adducted at the midtarsal joints mainly at the talo-navicular joint (varus deformity is inversion and adduction at midtarsal joints). In addition there is forefoot cavus deformity as a result of excessive arching of foot at the midtarsal joints.
The bones of the foot are smaller than normal. The neck of talus is angulated so that head of talus faces downwards and medially. The calcaneum is small and concave medially.
The muscles of the calf are underdeveloped ,as a result the following muscle-tendon units are contracted: POSTERIORLY—Tendo-Achilles, MEDIALLY—Tibialis posterior, flexor hallucis longus, flexor digitorum longus. All the ligamentous structures of the posteromedial aspect of the foot are contracted especially the plantar fascia, spring ligament, deltoid ligament and the deep plantar ligaments. The capsules of subtalar, ankle, talonavicular and naviculocuneiform joints are also contracted.
The skin develops adaptive shortening on the medial side of the sole. There are deep creases on the medial side. The lateral malleolus is very prominent while the medial malleolus is buried in a depression. In long standing cases, callosities and bursae develop on the lateral aspect of the dorsum of the feet.110
Clinical Features
When a child is brought with a clubfoot deformity, it is mandatory to question the parents in detail. Usually there is a history of consanguinous marriage (marriage between cousins of the first blood). Sometimes, there would be a history of repeated miscarriages (abortions), some congenital illnesses in other members of the family or drug intake by the mother during the period of pregnancy. Hence medicare personnel should be extremely cautious in prescribing any drug to a newly married lady, especially if she is pregnant.
Though the deformity appears soon after birth the child is brought to the orthopedic surgeon after a couple of days. The general condition of the child should be examined by a pediatrician for other associated congenital anomalies and neuromuscular disorders. The spine should be examined for a swelling with hair or a dimple in the lumbosacral region which is suggestive of spina bifida.
On clinical examination, the foot is in equinus, varus and adduction and this can be judged by the inability to dorsiflex the foot until it touches the anterior shin of the tibia which is normally possible in case of a newborn. There are increased number of creases on the medial aspect of the sole of the foot. The medial border is concave and the lateral border is convex.The lateral malleolus is more prominent than the medial malleolus. The head of the talus that has been dislocated from the talonavicular joint can be clinically palpated as a smooth swelling in the dorsum of the proximal half of the foot. The heel is small and the tendoAchilles is tight. The calf muscles are comparatively thinner. Tibial torsion may be identified in some children.
The clinician should passively manipulate the foot to detect whether the foot could be brought to the neutral position or even more to distinguish between supple and rigid deformities. Deformity of the club foot which can be passively corrected is termed supple and that foot which cannot be brought to neutral position is termed rigid. If there is no other clinical cause like spina bifida it is called idiopathic clubfoot or intrinsic deformity. If it is due to systemic illnesses it is called secondary clubfoot or extrinsic deformity.
Differential Diagonosis
Equinovarus deformity at birth may be associated with spinal defects like meningomyelocele (neurogenic), congenital abnormalities of muscle (myogenic) or congenital skeletal defects like tibial hemimelia (osteogenic). In a child seen after neonatal period, the possibility of the deformity being secondary to lateral popliteal nerve palsy, poliomyelitis or cerebral palsy must be thought of.
Investigations
Since the basic abnormality of clubfoot is talonavicular dislocation, X-rays of the foot both anteroposterior and lateral view are very useful. The talocalcaneal angles (this is an angle between long axes of talus and calcaneum—also called as Kite's angle), in both AP and lateral in a normal foot is between 20–40 degrees, but in CTEV these are reduced. But, it requires an experienced person to study the images of the small bones.111
Treatment
The main principle is to correct the deformity and to maintain the foot in corrected position. The treatment should start as early as possible, i.e. in the first week of life would give better results. The different components of the deformity should be corrected in the proper sequence,the midfoot adduction first then the hindfoot varus before correcting the equinus. Failure to follow the correct sequence may break the foot in the midtarsal region, creating a highly refractory “rocker-bottom” deformity Forcible manipulation should not be employed.When casting fails surgical management is indicated from 3–4 months of age and can be delayed upto 1 year.
Conservative Management
Club foot is a relative emergency. Adequate corrective methods must be deployed from the day of birth itself. Most of the deformed feet respond well, if the treatment is commenced at the earliest. If managed properly, the child with supple clubfoot regains plantigrade foot at a reasonable period. Once the metatarsals of the feet and tarsals become stronger, the correction is rather difficult. A complete evaluation of the child on the day of birth is mandatory. Manipulation of the foot should be commenced on the first day. By passive stretching, the foot should be brought to the neutral position or even the over corrected (dorsiflexion and eversion) position. This manipulation exercise must be performed for about twenty times after every breast feed. Since the mother would be apprehensive, it is wise to teach and train the grandmother. This manipulation must be continued for the first 3 weeks.
At the beginning of the second week, the foot is held in the neutral position by adhesive plaster taping. This is ROBERT JONES strapping. This strapping is changed weekly. The corrective manipulation must be continued even while the foot is in the Jones’ strapping. At the end of six weeks, the foot is evaluated with X-rays. Later the foot is manipulated and plaster casts, preferably above knee casts are applied with the foot in neutral position and the ankle and the knee in ninety degrees. This plaster cast must be changed once in two weeks, with proper skin hygiene . This serial casting may be continued till the end of the fourth month.
During the fifth month, when reasonable correction has been obtained, the feet may be held in corrected position by a Dennis Browne splint. The Dennis Browne splint is advantageous, because the exercise can be continued. Adequate care of skin hygiene can be maintained. In addition it does not hamper the longitudinal growth of the metatarsals and thereby the foot.
112Once the child attains the age of about nine months it begins to tread the earth. During this stage the child should be encouraged to walk with a club- foot boot. This provides excellent support and adequate correction. The parents must be convinced that it is useful for the child if he wears the clubfoot boot till he achieves a plantigrade foot which may be by about four years.
PONSETI METHOD
This new technique has been widely accepted over the past few years. A closed tenotomy of the tendo-Achilles is performed during the first week. An above knee plaster cast is applied by reducing the talonavicular joint primarily. The plaster casts are changed every week and the forefoot adduction is corrected initially. During the third or fourth casts the equinus deformity is corrected. Much care is taken to correct the fore foot adduction and hind foot inversion during the application of the plaster casts. Usually full correction is obtained by eight weeks.
Operations
Most of the supple feet are corrected by the serial cast methods mentioned above followed by the splints and clubfoot boot.
But the rigid feet are rather difficult to correct by conservative methods. Hence, by about six weeks, one should assess the deformity and plan for operative intervention. The following operative procedures have been successful in our hands:
- Tendo-Achilles lengthening: The tendo-Achilles may be lengthened by closed tenotomy procedures. If necessary, the tendo-Achilles is exposed and lengthened by the Z plasty technique.
- Posteromedial release (Modified Turco's procedure): Under tourniquet control all the contracted structures on the medial side of the foot and ankle are released. The contracted talonavicular capsule (Henry's knot) is released. The long tendons are lengthened by Z plasty technique.
- Dilwyn Evans—calcaneocuboid fusion: If the forefoot adduction is due to deformity of the tarsal bones, calcaneocuboid fusion corrects it satisfactorily.
- Triple arthrodesis: This is surgical fusion (arthrodesis) of the talonavicular, subtalar and calcaneocuboid joints. This procedure, if performed well, provides a painless plantigrade foot. But the deformity of the foot decides the timing of this surgery.
OTHER COMMON CONGENITAL ANOMALIES
Congenital Pseudoarthrosis of Tibia
The next common anomaly, in children that presents often is congenital pseudoarthrosis of the tibia. The child may be brought soon after delivery or after a few weeks or months. Usually the higher functions, movements of the limbs and developmental milestones are normal. The child is brisk, active and has normal feeds. The mother brings the child for a deformity in the leg. This is a familial condition characterised by an area of deossification at the junction of the middle and distal third of tibia leading to bending fracture. On examination there is an anterior angulation of the leg in the middle third. This is due to pseudoarthrosis of the tibia. Here there is failure of the development of the cortex of the tibia resulting in anatomical discontinuity of the bone. This condition usually requires corrective operations and the results are fairly good.
Classification
Boyd has classified this condition into 6 types:
- Type 1: Pseudoarthrosis with anterior bowing and a defect in tibia at birth
- Type 2: Psuedoarthrosis with anterior bowing and an hourglass constriction
- Type 3: Pseudoarthrosis which develops in a congenital cyst
- Type 4: Pseudoarthrosis which develops in a sclerotic segment of bone
- Type 5: Pseudoarthrosis tibia with dysplastic fibula
- Type 6: Pseudoarthrosis develops as an intraosseous neurofibroma.
Treatment
The principal treatment methods are excision of fibrous mass, massive bone grafting and internal fixation.
CONGENITAL PES PLANUS DUE TO TARSAL COALITION
When the child learns to walk it is about ten to twelve months old. During that stage the arches of the foot are not developed.
Due to walking, the longitudinal and transverse arches develop within the next few months. If the arches do not develop beyond twenty four months the medial border of the sole of the foot also rests on the ground while standing and walking. This condition is called pes planus.114
Etiology
- Biomechanical causes:
- Congenital:
- Infantile or physiological
- Congenital vertical talus.
- Acquired:
- Occupational
- Obesity
- Postural
- Secondary to anatomical defect elsewhere—external rotation of limb, genu valgum, equinus deformity of ankle, varus deformity of foot.
- Other causes:
- Paralytic: Flaccid flatfoot
- Spasmodic: Due to peroneal spasm
- Arthritic: Rheumatoid arthritis
- Traumatic: Fracture calcaneum.
CONGENITAL DISLOCATION OF HIP
Dislocation of the hip at birth is due to poor development of the acetabulum and this condition is otherwise called acetabular dysplasia. The head of the femur is dislocated from the acetabulum and lies superior and posterior to the acetabulum. This condition has been discussed extensively in many textbooks because it is prevalent in the western countries. In India the mothers carry their children on their hips. In that position the hip of the child is flexed and abducted.
Etiology
- Hereditary predisposition to joint laxity
- Hormone induced joint laxity
- Breech malposition.
Pathology
The femoral head is dislocated upwards and laterally, its epiphysis is small and ossifies late. The femoral neck is excessively anteverted. The acetabulum is shallow with a 115steep sloping roof. The ligamentum teres is hypertrophied. The fibrocartilaginous labrum of the acetabulum may be folded into the cavity of the acetabulum (inverted limbus). The capsule of the hip joint is stretched. The muscles around the hip undergo adaptive shortening.
Clinical Features
Congenital dislocation of hip can be diagonosed by certain external features like shortening of leg, limitation of hip abduction, asymmetry of groin-creases or an audible click. Clinically dislocation of hip is examined by two tests:
- Ortolani's test: With the baby on its back, the hip and knee are held flexed and the limb is slowly abducted at the hip. If the hip is dislocated, the head of the femur is felt to slip into the acetabulum with a click.
- Barlow's test: Is one in which the head could be pushed out of the acetabulum with a click with the hip in flexion and adduction. In an older child the following clinical signs are looked for:
- Galeazzi's sign: The level of knees are compared in a child lying with hips flexed to 70 degrees and knees flexed. There is a lowering of knee on the affected side.
- Trendelenburg's test is positive: When the child is asked to stand on affected side the ASIS of normal side dips down.
- The limb is short and externally rotated. Lordosis of lumbar spine is present.
- Telescopy positive: In a case of a dislocated hip, it will be possible to produce an up and down piston-like movement at hip. A child with unilateral dislocation exhibits Trendelenburg's gait in which the body lurches to the affected side as the child bears weight on it. In a child with bilateral dislocation, there is alternate lurching on both sides (waddling gait).
Diagonosis
X-rays and CT scans are enough to confirm the diagnosis. The following are the X-ray findings in a case of CDH:
- Delayed appearance of the ossific center of the head of the femur
- Retarded development of the ossific center of the head of the femur
- Sloping acetabulum
- Lateral and upward displacement of the ossific center of the femoral head
- A break in Shenton's line.
Treatment
The main aim of the treatment is to achieve reduction of head into the acetabulum and to maintain it, until the hip becomes clinically stable and a round acetabulum covers the head. The treatment is age related and depends on the age at which the child is brought.
- Infants below three months: Plaster casts especially frog-leg or Batchelor's cast or Von Rosen's and Pavlik harnesses are applied to retain the position of the head till stability is achieved.
- Three to six months: The dislocation is reduced by gentle manipulation under general anesthesia and immobilized in plaster cast, with the hip at 90 degrees flexion and 45 degrees abduction.
- One to three years: After premilinary traction surgical open reduction will be required to reduce the femoral head into the acetabulum. A femoral varus derotation osteotomy is done for stability in cases with excessive valgus and anteversion of the femoral neck.
- Three to six years: After open reduction of the hip and femoral osteotomy, an osteotomy of the innominate bone is also performed.
- Above ten years: Schanz osteotomy is done in neglected cases where patient presents with hip pain and unstable gait.
Complication of forceful reduction of hip in childhood is avascular necrosis of the head of the femur.
CONGENITAL RADIAL CLUB HAND
The forearm and hand develop from the limb bud during the intra uterine period. During development, the forearm bud splits into radial and ulnar segments. Poor development of the radial bud of the forearm results in anomalies of the radius, wrist and thumb. This condition is called Congenital radial club hand or radial meromelia. The distal half of the entire shaft of the radius is absent. The radial group of muscles of the forearm are poorly developed. The hypothenar muscles are not properly developed. The thumb is either abnormal or hypoplastic. Since the ulnar component of the limb bud grows normally the ulna and the medial three fingers grow better resulting in a curvature of the ulna and weakness of the hand grip. This condition requires many operations to reconstruct the thumb and to restore the function.
POLYDACTYLY AND SYNDACTYLY
The presence of more than five fingers in one hand is called polydactyly.
117If two adjacent fingers of the same hand are fused together it is called syndactyly. Supernumary digits or polydactyly is quite often seen. It is usually another little finger or an extra thumb. This extra finger has rudiments of the muscle components of the thenar or hypothenar groups. One or two phalanges may also be present in the finger. Rarely, the sixth finger may be fully developed, but with poor function. In our country superstitions are as common as the trees. Many people with polydactyly, refuse to have that finger removed by surgical excision. But in this era of computers with QWERTY keyboards some patients request an excision. Excision of this extra finger requires good preoperative planning and skilled surgeons.
Do not be a prisoner of your past; but be an architect of your future
In all the other tissues in the body, inherent primary tumors, either benign or malignant are common. The tumors originate from the cells contained in that organ like thyroid, breast or stomach. Whereas in the bone, secondary deposits of primary tumors growing elsewhere are more common. Primary tumors originating from bone are relative rare. Bone tumors account for only two percent of all malignant tumors in the body.
SECONDARY TUMORS OF BONE
The vertebrae are essentially cancellous bones with a good blood supply. Hence they provide a fertile soil for the malignant cells that are transported from primary tumors of other organs. Hence the vertebral column is the commonest site for secondary tumors in the body. And of the tumors of bone, secondary tumors are more common than primary bone tumors.
Tumors of the thyroid cause secondaries in the cervical spine; secondary tumors from breast and bronchus get deposited in the dorsal spine; the lumbar vertebrae get their share from cancers of the uterus and cervix in females and from the prostate in males.
In many occasions the patient comes to the hospital for dull aching pain in the back. The clinician detects the fracture of the vertebra due to the secondary 119deposit (pathological fracture). Then the search for the primary tumor begins and in many instances it may not be detected till the last hour.
The clinical features of the secondary tumor in the vertebra are pain and localized tenderness over the spinous process. Paraspinal muscle spasm is bilateral and an associated finding. If a gibbus is palpable, it is diagnostic of a pathological fracture. The X-ray of the spine shows collapse of the vertebra (the vertical height is reduced). But the height of the intervertebral disk space is normal. The pain is treated with analgesics; further pain and collapse can be prevented by the use of an anterior spinal brace. If the primary tumor has been identified it has to be treated by adequate chemotherapy or surgical resection.
PRIMARY TUMORS OF BONE
The histology of bone very much resembles the character of an orthopedic surgeon. Though it appears hard on the exterior, the bone has wet soft tissue medulla inside. Bone is essentially a mesenchymal tissue. Hence in addition to osteocytes or bone cells, it contains cartilage, marrow cells, vascular tissue and connective tissue. Tumors that originate from these tissues present as bony tumors. They can be classified as benign or malignant (cancer or sarcomas).
Other tumors that rarely occur in bone are neurofibroma, chondroma, fibrosarcoma and adamantinoma.
In this chapter, we will learn something about the bony tumors, that we encounter often in our departments.
Benign | Malignant | |
|---|---|---|
Bone | Osteoma Osteoid osteoma | Osteosarcoma |
Cartilage | Osteochondroma Enchondroma Chondromyxoid fibroma | Chondrosarcoma |
Marrow (round cell) | Ewing's sarcoma Lymphoma Myeloma | |
Vascular | Hemangioma | Haemangiosarcoma |
Giant cell | Osteoclastoma |
OSTEOID OSTEOMA
Osteoid osteoma occurs in males below thirty years. It presents as a localized pain in any one of the long bones and is felt more at night. It is interesting to note that, that pain subsides with aspirin. Usually the swelling is not clearly palpable and tenderness over the bone may be the only clinical finding. It is often seen in long bones. Radiologically it appears as an osteolytic lesion surrounded by a rim of sclerosis. Enbloc excision is the treatment of choice.
OSTEOCHONDROMA
Osteochondroma or exostosis is more commonly seen than any other tumor. It is a benign tumor and usually appears in the young teenage adults. It presents as a painless swelling in the lower end of femur, upper end of tibia and upper end of humerus (these are the rapidly growing ends of the long bones).
121It is essentially a growth disorder. A group of cells grow away from the growth plate (physis) carrying with them a cartilagenous cap. This grows beyond and away from bone (Exostosis).
Clinically the child presents with a painless swelling that has been noticed for a few months and it is not painful. It may be discovered accidentally. It can be palpated as a smooth, bony hard swelling arising from the metaphysis. Occasionally it may be painful due to an adventitious bursitis or due to pressure on an adjacent nerve.
Radiologically it appears as a well-defined outgrowth of bony tissue with a pedicle. It grows in the metaphyseal region of the long bone and appears to grow away from the joint. If there is more than one exostosis it is termed as diaphysis achalasia or osteochondromatosis.
This tumor does not respond to any drug. The answer is total excision which is successful if performed when the boy is around twenty years of age. If the tumor is removed before skeletal maturity, the chances of recurrence are more.
SOLITARY BONE CYST
Simple bone cyst or unicameral bone cyst appears near the upper ends of humerus or femur in adolescent children. It appears in the metaphyseal region of the bone. Sometimes the child sustains a fall and the bone fractures through the cyst resulting in a pathological fracture.
MALIGNANT BONE TUMORS
Of the malignant bone tumors, giant cell tumors and osteosarcoma are the ones that are common.
GIANT CELL TUMOR
Giant cell tumor or osteoclastoma occurs in men and women between thirty and forty years of age. It is commonly seen near the ends of the long bones around the knee joint and sometimes in the distal end of radius.
The patient presents with a painless 123swelling that has been slowly increasing in size with occasional pain. The swelling is bony hard and is felt on only one aspect of the bone (eccentric).
Radiographs show an epiphyseometaphyseal eccentric expansion of bone that is osteolytic. The cavity has bony septae (soap bubble). The treatment consists of surgical resection and replacement by cancellous bone graft. Sometimes the cavity may be curreted and filled with bone cement.
OSTEOSARCOMA
Osteosarcoma is a really malignant tumor of bone, both clinically and histologically. It is also called osteogenic sarcoma because the tumor cells produce malignant osteoid.
It occurs in the adolescent male between fifteen and twenty five years. It appears frequently near the ends of long bones. The predominant presenting symptom is pain; the patient may be brought in crying with pain.
124The patients reveal a history of rapidly growing swelling. On examination, the patient has a large swelling of the limb which is usually near the joint (lower end of the femur and uppcer and of the tibia are the common sites). The skin is stretched, shiny and shows engorged veins. The swelling is warm, tender and variable in consistency. The overlying skin is adherent to the underlying swelling. Sometimes there may be sinuses and ulcers on the swelling, which are signs of progressive rapid degeneration.
Radiologically, it appears as a metaphyseal central area of irregular bony rarefaction with scattered sclerosis. The periosteum is raised and reactive new bone is laid perpendicular to the long axis of the bone (sunray appearance). By the time the patient reports to the hospital, he may have extended lesions in the same bone (skipped lesions), and secondaries in the lung. Hence an X-ray of the chest must be studied carefully before starting any treatment.
Bone scan with Tc99 or Str85 will reveal the extent of the tumor and spread in the other bones.
Blood investigations reveal anemia and raised ESR. Serum alkaline phosphatase is raised markedly and is one of the confirmatory tests in the diagnosis of osteosarcoma.
Fig. 11.11: X-ray of the same patient as in Figure 11.10
Since the tumor is potentially fatal, it is absolutely essential to obtain a biopsy to confirm the diagnosis. The histology reveals multinucleated giant cells and numerous spindle shaped cells scattered in a malignant osteoid.
The treatment should be multifaceted and comprehensive including chemotherapy and surgical intervention. A combination of drugs including methotrexate (15–30 mg/day oral) and folic acid supplementation is must to prevent myelosuppression, adriamycin (15 mg/kg IV daily) the side effects are the vomiting and diarrhea and vincristine (1.5 mg–2 mg IV weekly) is used. The side effects are peripheral neuropathy and alopecia. These drugs are administered in various cycles (T10 protocol). The surgical excision of the tumor is based on Enneking's classification. Limb Salvage Surgery is the new concept advocated by Enneking which consists of removal of the tumor and retaining the limb. Even after removal of the tumor or dismembering of the limb (amputation surgery) chemotherapy has to be continued. This is called neoadjuvant chemotherapy. Hence, presently, the accepted method of treatment for osteosarcoma is a combination of adjuvant chemotherapy, surgical excision and neoadjuvant chemotherapy.
EWING’S SARCOMA
Ewing's sarcoma presents with such a classical clinical picture that is hard to miss. It occurs in boys between five and fifteen years; it is insidious in onset and is usually associated with fever. Conspicuously the boy has a pain and swelling in the diaphyseal region of a long bone.
On clinical examination the patient has a smooth swelling all around the limb in the diaphyseal region of a long bone. It is warm, tender and variable in consistency. Sometimes the swelling may extend to either end of the bone.
The radiological picture is so clear to confirm the diagnosis. There is a fusiform swelling of the diaphyseal region of the bone with scattered areas of osteolysis. The 126periosteum is raised and thickened in layers which gives the diagnostic onion peel appearance.
The treatment consists of multidrug chemotherapy with local resection. Many tumors respond well to radiotherapy.
MULTIPLE MYELOMA
Multiple myeloma is a common primary tumor of bone, but the sad part of the story is that it presents to the orthopedic surgeon with many a complication.
Clinically, an old person presents with persistent backache. Sudden increase in pain is invariably due to a pathological fracture. There is associated marked loss of weight and anemia. Sometimes medical renal disease and renal failure may bring the patient to the hospital and the bony tumor in the vertebra is diagnosed later.
The X-ray reveals multiple punched out osteolytic lesions with out surrounding sclerosis. These lesions are seen in the vertebrae which may be collapsed. The other flat bones like pelvis and skull have to be studied radiologically for similar lesions.
The laboratory findings are so informative that multiple myeloma appears to be more of a malignant tumor of the blood tissue. The hemoglobin is very low; the ESR is raised (> 100 mm/hr). The level of the serum proteins is low and altered; the albumin level is decreased and the globulin is increased. An abnormal protein (gammaglobulin) is detected on electrophoretic study of serum proteins as M band. Constant destruction of the bony tissue by the malignant process depletes the bone of its calcium content resulting in serum hypercalcemia and calciuria. Bence Jones protein is detected in the urine in many patients.
Numerous round cells with a cart wheel like nuclei are diagnostic of multiple myeloma. Histological studies of the tissue obtained from the bone marrow biopsy show these cells crowded in a stroma of loose fibrous and hemopoietic tissue.
The management of multiple myeloma is multipronged. The renal complications have to be addressed properly and adequately. The patient may need frequent blood transfusions. Since the renal functions are impaired, analgesics should be used judiciously. Spinal support in the form of anterior brace reduce the back pain to some extent. Some of the drugs that are being used in the management of multiple myeloma are melphalan, prednisolone and cytotoxic agents.
The clinical presentation of multiple myeloma may be as a medical renal disease or persistent low backache.
Success is not a destination rather it is a journey
Obesity is a term that is presently being used in many medical and social societies, and in thousands of websites. Millions of people around the world are now discussing this physical and social problem.
Being fat is totally different from being obese. The former is physiological, while the latter is definitely pathological. Obesity is not a physical form or shape, but rather it is a disease. With the alarming increase in the proportional population of obese individuals, it is essential for us to know something more about obesity than what we learn by cursory reading and surfing.
The World Health Organization estimates that around one billion people throughout the world are overweight and that three hundred million of these are obese and if these current trends continue, the number of obese people on this globe will be 1.5 billion by 2015. In India, about thirty percent of the adults are obese, and women in particular are more affected by this disease. For some unknown reason, Indians are susceptible to fat deposition around the waist.
It is also alarming to note that the incidence of obesity in children is increasing day by day. This can be attributed to the following factors:
- Reduced physical activities
- Spending more time watching television
- Less games and sports
- Sitting continuously with computers
- Eating junk foods.
PATHOPHYSIOLOGY
Obesity by definition is a diseased state of excessive adipose tissue. Obesity is fat deposition in the abdominal, gluteal and thigh regions. This dysregulation of body weight is due to abnormal neuronal and hormonal signals.
128Appetite is determined by physiological, cultural and psychological factors. It is regulated by hormones like insulin and leptin which act on the hypothalamus. Incidentally, it has to be remembered that people with diabetes mellitus who have decreased circulating insulin have increased appetite. Increased intake of food due to disease or habit is one of the prime causes for increased fat deposition and obesity.
If any obese lady is asked “Do you eat more?”, instantly she darts back with a firm “No”. But this is a blatant lie. This lie is being repeated by every obese individual all over the world. Social circumstances force them to hide the habit of over eating. It has been proved by many studies that obese people eat more than three meals a day and their intake consists mostly of snacks, oily and fried food at frequent intervals, in between their regular meals.
DISEASES CAUSING OBESITY
The causes of obesity can generally be classified as:
- Genetic predisposition
- Nutritional abundance
- Sedentary lifestyle.
Though obesity is mainly considered to be idiopathic, some systemic illnesses are often associated with this disease. They are:
- Polycystic ovaries
- Cushing's syndrome
- Hypothyroidism
- Hypothalamic dysfunction
- Tumors of the uterus
- Diabetes mellitus
- Hyperlipidemia
- Cirrhosis of liver
- Alcoholism.
Alcohol
There is a wrong notion doing the rounds in medical and social circles that alcohol is good for the heart. This is absolutely wrong. Alcohol in any form has far more detrimental effects on the general well-being of the individual, than what meets the eye.
The predominant problem with alcohol intake is addiction. This leads to a cascade of sequences ruining the physical, mental and social health of the individual.
Alcohol causes psychiatric illnesses, osteoporosis, ulcers in the esophagus and stomach, degenerative diseases of the liver and gout.
Consumption of alcohol over a considerable period of time poses a problem in addition to addiction. Increased waist circumference (or belly) causes various health problems. This is called central obesity. In common English parlance it has been said that the longer your belt line, the shorter your life line. Hence, whether the patient is a social or a habitual drinker, absolute cessation is the first step in the management of obesity.129
DISEASES AS A RESULT OF OBESITY
Many medical personnel and health workers believe that obesity just causes disturbances in daily activities and relative laziness. But there are many more systemic diseases of which obesity is the prime predisposing factor.
They are:
- Male hypogonadism: This causes erectile dysfunction and sometimes male infertility
- Diabetes mellitus (Type 2): As mentioned earlier,decreased levels of circulating insulin leads to increased appetite and subsequently obesity. Obese individuals are more prone to develop type 2 Diabetes mellitus.
- Gynecomastia: This is enlargement of the subcutaneous tissue beneath and around the nipples in adolescent boys. Though this may be associated with endocrinal abnormalities, this is quite disturbing and may require surgical excision.
- Menstrual disorders: The menstrual cycle is invariably disturbed in middle aged women who are obese and adds to the cup of woes of the individual.
- Polycystic ovaries: Many women who are obese have polycystic ovaries. This is a common endocrine disorder in women and one of the commonest causes for female infertility. About 15–20 percent of infertile women have polycystic ovaries. Polycystic ovaries are associated with peripheral insulin resistance and decreased ovulation. Obesity aggravates the degree of both these abnormalities. Recent studies have proved that substantial reduction in weight, improves the endocrine profile and increases the likelihood of ovulation and pregnancy.
- Coronary artery diseases: In addition to decreased physical activity, obesity itself can disturb the effective functioning of the coronary arteries. Hyperlipidemia causes narrowing of the coronary vessels, thereby predisposing to myocardial infarction and other ischemic heart diseases.
- Hypertension: Obese individuals are more prone for systemic or essential hypertension. The increased intake of fatty and fried foods causes increased levels of cholesterol in the serum. All these factors when associated with obesity cause systemic hypertension.
- Cerebrovascular accidents: Obese people are relatively more susceptible to cerebrovascular accidents like thromboembolic phenomena and cerebral arteriolar ruptures.These lead on to stroke which can eventually result in aphasia, dysarrthria and hemiplegia.
- Lung disorders: People suffering from obesity have decreased movement of muscles of the chestwall and the diaphragm.This reduces the compliance of the bronchioles and the alveoli and results in chronic obstructive pulmonary disease or COPD.
- Sleep apnea: The increased circumference of the waist (central obesity) and decreased chest wall expansion in obese people causes reduction in the respiratory rate during sleep and this can cause them to sit up and gasp for breath.
- Gallstones: Most of the obese patients have disturbances in lipid metabolism resulting in hyperlipidemia and dysfunction of the gallbladder; eventually they develop cholelithiasis or gallstones which clinically present as jaundice, pain abdomen or disturbances in consumption of food.
- Spondylosis: Lumbar spondylosis and degeneration of the lumbar intervertebral disk are more common in middle aged people who are obese. This may be due 130to the axial compression forces on the disks and the vertebrae. But this disease process is aggravated by the hypotonia of the muscles of the anterior abdominal wall, increased fat deposition around the waist and reduced function of the spinal muscles. All these factors accelerate the degeneration of the lumbar spine resulting in persistent low backache.
- Osteoarthrosis: It is quite a common sight in our part of the country to see older men and women walking around with bilateral genu varum and antalgic gait. Most of them are obese and have osteoarthrosis of one or both the knees. Obesity is a conspicuous hurdle in the effective management of osteoarthrosis of knee. The overweight causes a constant degeneration of the tibiofemoral joint. Hence obesity should be corrected before one dares to operate on a patient with osteoarthrosis of the knee.
Diagnosis
The three important criteria that we use in the evaluation and treatment of obesity are weight, body mass index and levels of serum cholesterol.
Weight
Though the weight of an individual is a phenomenon that is related to race, culture and height, in clinical evaluation, we have been using the weight of the individual in relation to the height.
The average physical appearance of an individual with which we are familiar is not an indication to initiate treatment. Certain investigations are required to distinguish between overweight and obesity.
The chart given below gives us an arbitrary idea about the body proportions.
Height (cm) | Ideal weight | Overweight |
|---|---|---|
140 | 39.2–43.1 | > 49.0 |
142 | 40.3–44.4 | > 50.4 |
144 | 41.5–45.6 | > 51.8 |
146 | 42.6–46.9 | > 53.3 |
148 | 43.8–48.2 | > 54.8 |
150 | 45.0–49.5 | > 56.3 |
152 | 46.2–50.8 | > 57.8 |
154 | 47.4–52.2 | > 59.3 |
156 | 48.7–53.5 | > 60.8 |
158 | 49.9–54.9 | > 64.0 |
160 | 51.2–56.3 | > 64.0 |
162 | 52.5–57.7 | > 65.6 |
164 | 53.8–59.2 | > 67.2 |
166 | 55.1–60.6 | |
168 | 56.4–62.1 | > 70.6 |
170 | 57.8–63.6 | > 72.3 |
172 | 59.2–65.1 | >74.0 |
174 | 60.6–66.6 | >75.7 |
176 | 62.0–68.1 | >77.4 |
178 | 63.4–69.7 | >79.2 |
180 | 64.8–71.3 | >81.0 |
182 | 66.2–72.9 | >82.8 |
184 | 67.7–74.5 | >84.6 |
186 | 69.2–76.1 | >86.5 |
188 | 70.7–77.8 | >88.4 |
190 | 72.2–79.4 | >90.3 |
Body Mass Index
The World Health Organization and various medical schools have accepted body mass index (BMI) as a diagnostic method to measure obesity.
BMI = Weight/Height2
The normal BMI for an average individual is 19 to 26 kg /meter2. BMI provides some reasonable guidelines for the treatment of obesity.
Not obese – 25
Grade I – 25–29
Grade II – 30–40
Grade III – > 40
Biochemical Values
Of the various biochemical parameters serum cholesterol and blood sugar are reasonable disease indicators in obesity.
Serum Cholesterol
The level of cholesterol in the serum is an ideal indicator for planning the diet therapy in the management of obesity. A lipid profile study should be done and the levels should be compared with the following chart.
Serum Cholesterol | |
|---|---|
HDL (GOOD) | >50 |
LDL | <130 |
VLDL | <30 |
TGL | <150 |
Blood Sugar
Any person who is overweight or a patient who is obese must be examined clinically for the features of diabetes mellitus. Some of the common symptoms suggestive of diabetes are increased thirst, increased appetite and frequent micturition (polydypsia, polyphagia and polyuria). Persistently raised blood sugar levels and urine sugar values are highly suggestive of diabetes mellitus.
TREATMENT
Due to mass of adipose tissue in the subcutaneous and the intermuscular planes, human beings can survive without food for several months. So, contrary to the popular belief, starvation is not the answer for obesity. On the other hand it does not mean that we all should be lean like a danseuse or muscular like a body builder. It is the delicate balance between the intake of food and the expenditure of energy that determines our body mass.
The treatment schedule is based on the BMI criteria:
- Grade I: These patients are very cooperative and reduce their weight by proper diet therapy and excercises.
- Grade II: The patients in this group require counselling by the doctor and the dietician. With a little moral support and proper treatment they usually do well.
- Grade III: These patients pose a challenge and hence, a vigorous regimen should be employed and the treatment program should be scheduled accordingly. It may take a few months or even years.
The treatment of obesity is not so difficult, but it requires patience on the part of the doctor, perseverance by the patient and enthusiastic support by the family members. Based on the grading of the body mass index, the following guidelines are useful.
- Identify: The cause of obesity and if there is a predisposing systemic illness, that disease should be treated first, by a physician before one advises excercise therapy and diet therapy, because untoward physical exertion may precipitate cardiac and respiratory disturbances.
- Drugs: Some of the drugs that are presently available are Phentormin, Sibutramine (10 mg od) the side effects are dry mouth, constipation, anxiety. Fenfluramine 20–40 mg bd) leathergy and drowsiness are the side effects and orlistat, the side effects are the steatorrhea and flatulence. Though there is enthusiastic marketing of these drugs, there is no substantial evidence to prove their utility value in the treatment of obesity.
- Exercises: The exercises that are performed by a normal healthy individual differ from those that are prescribed for an obese individual. Exercise is a therapy. As we titrate the dose of any drug that we prescribe, exercises also should be advised in a phased manner. Due to the physical inability, the patient may sometimes be non- cooperative. It is the responsibility of the treating physician to recommend exercises that suit the individual. The family members must be counselled to cooperate with the patient. They must be advised not to make fun of the patient.The patient must be advised to start simple exercises like walking. She must be advised to walk at a normal speed and not to compete with others. Similarly the duration also should be about just twenty minutes a day for the first few months 133and then it may be increased gradually to about forty minutes a day. During this period the patient may complain of aches in the legs. This is due to poor tone of the muscles of the lower limbs. Hence gentle hip abduction exercises, knee and ankle exercises should be coupled with the phases of walking. Once the patient believes that exercises will reduce her weight, she becomes cooperative. Then, exercises to reduce the abdominal girth and to improve the power of the spinal muscles may be started. Exercises to strengthen the muscles of the anterior abdominal wall like raising the head in the supine posture and raising the lower limbs should be performed. Once the patient feels comfortable with the exercises and herself, then she may be advised to attend a gymnasium which must be supervised by a qualified therapist.Swimming offers a very good exercise for the muscles of the trunk and the limbs. Some patients feel more secure when they walk on the treadmill. But they must be cautioned not to increase the speed or the duration. Cycling is also a wonderful and fruitful exercise in the weight reduction program.But one must remember that exercise therapy must be coupled with diet therapy.
- Modification of lifestyle: Patients must be advised to use the staircase (not the lift for the first two floors). Walking on small errands keeps one brisk. If his occupation demands that the patient has to sit for long hours he must be advised to walk for five minutes for every hour. He must be reassured adequately such that he feels comfortable with himself and accepts the methods advocated. This requires frequent interactions by the treating physician and the patient. It is our responsibility to reassure him and encourage him to cooperate with the exercise therapy and diet therapy.
- Diet therapy: There are more misconceptions about diet therapy than facts. As was mentioned earlier obese people do eat more and they eat often at frequent intervals.A successful diet therapy begins with making the patient understand that the prescribed exercises will be fruitful only with the diet therapy (since the word therapy is being used it means that both exercises and diet should be measured and administered).
The following food stuffs must be avoided:
- Alcohol
- Fried food
- Fatty foods
- Pickles /soup
- Eggs
- Milk and milk products
- Nonvegetarian food
- Junk food.
The patient must be advised to avoid eating snacks in between the regular meals. At the same time it must be emphasised that starvation will not help in reducing the weight.
134The recommended diet should have increased vitamins, minerals and low calories. This diet therapy should be continued for at least three months to perceive significant results. Fruits and vegetables provide high fiber content and vitamins with low fat. Any form of sugar may cause increase in weight. Some of the suggested recipes include vegetable salads, dry chappathi, thin dhal, idli, steamed food, greens porial; coffee and tea may be consumed without milk and sugar. A healthy diet should include a variety of foods with whole grain products, moderate fat, sugar and salt with plenty of vegetables and fruits.
This combination of food stuff is recommended for a healthy individual not as a treatment for obesity.
CONCLUSION
With the recent rise in obesity awareness and the increased understanding of the importance of physical activity promoting overall health, greater emphasis has been placed on improving physical fitness to enhance the quality of life. The mushrooming of yoga centers, health clubs, exercise and fitness centers and the diet awareness camps are the proof of this statement.
The author wishes to emphasise that there is no shortcut in the path of reducing weight. No single drug therapy or food substitute is effective. The treatment of obesity is a lifelong program.
Live your life by the moment and not by the calendar
In this era of congested traffic involving high speed vehicles, road traffic accidents result in multiple injuries with damage to bone, muscle and nerve in addition to the ghastly open wounds that are bleeding. Eventually, the nerves are crushed and the resultant paralysis is usually extensive; and repair of nerve forms part of the complete reconstructive procedure of bone, blood vessel and the limb.
The other causes of nerve injuries in clinical practice are:
- Cut injuries
- Impalement by bone
- Tight bandages
- Tourniquette palsy
- Systemic illnesseses
- Hansen's disease
- Diabetes mellitus
- Alcoholism
- Injection palsy.
CUT INJURIES
The peripheral nerves are injured when the limb sustains a cut injury by sharp weapons. When the patient is brought to the hospital with a cut injury of the limb, 136management of shock takes priority. The bleeding is arrested and the limb is splinted. The nerve can be repaired during the initial phase, provided the following conditions are fulfilled:
- Wound must be clean.
- Limb must be viable.
- The fractured bone must be stabilized by either internal fixation or external fixator.
Arterial injury, if any must be repaired. During primary repair, if the surgeon is experienced, he may go ahead with an end to end repair. This is ‘primary repair of the nerve’. The nerve may be repaired using operating microscope and nonabsorbable 6–0 material like prolene or nylon.
If the cut ends are smudged and approximation is rather difficult, the ends of the nerve should be anchored to each other by black silk. Later, when the acute inflammatory process settles down, the nerve can be repaired during the second week. This is ‘secondary repair’. During this period the injured limb must be supported with proper splints, to prevent retraction of the nerve ends and to accelerate wound healing.
IMPALEMENT BY BONE
Sometimes, the violence that caused the injury would have broken the bone. In turn the displaced ends of the fractured bone can impale, stretch, pierce or squeeze the adjacent nerve resulting in paralysis of that nerve, e.g., a fracture of the humerus at the junction of the middle and lower thirds of the shaft may injure the radial nerve, a fracture of the neck of the fibula may damage the lateral popliteal nerve.
If such is the situation, the patient must be taken up for surgery at the earliest. Under adequate anesthesia and tourniquette control, the fracture can be reduced and stabilized by appropriate implants or external fixators. Then, the nerve is identified by adequate tissue dissection and released from adjacent soft tissues and repaired by the aforementioned techniques; or repositioned in between bulky muscles, as is commonly done in anterior transposition of the ulnar nerve. The limb should be provided with additional support to provide rest to the joints and muscles.
TIGHT BANDAGES
Traditional bone setters are prevalent in any section of the society. When they meet a patient with a fracture, they apply indigenous bandages which are improper and very tight. These tight bandages compress the fracture hematoma, the arteries and the nerves. When the arteries are compressed by the bandages, the muscles in the distal part of the limb are deprived of their blood supply and Volkmann's ischemic contracture results. When the nerves are primarily compressed for a few hours or days, initially there is excruciating pain and within a couple of days, weakness of the muscles supplied by the nerve sets in. The patient is not able to move the distal joints (motor paralysis). Passive stretching movements would be painful (Volkmann's sign).
The treatment should be initiated on an emergency basis. All the tight bandages should be removed. The limb should be immobilized in a posterior slab with the elbow (or knee) extended and the limb should be elevated to bring down the edema. Anti-edema measures, analgesics and antiinflammatory drugs should be administered. If 137the distal blood circulation does not improve with these measures, the arterial pulses become weak or are not felt. Soon the sensation diminishes and the pulps of the fingers turn pale, bluish and edematous. This is a sure sign for an operative intervention like extended fasciotomy of the forearm.
If the paralysis persists, the nerve may require decompression (neurolysis). During this procedure, the fracture is reduced and stabilized by adequate implants or Kirschner wires. Mismanaged supracondylar fracture of the humerus in children is the commonest cause for Volkmann's ischemic contracture.
TOURNIQUETTE PALSY
As with any other iatrogenic problem, prevention of tourniquette palsy is always better, by being very cautious while using the tourniquette. During many orthopedic operations in the limbs, the surgeon uses a tourniquette to obtain a bloodless field. This tourniquette should be applied at a proper level, with adequate padding and appropriate pressure. This is usually applied in the arm and thigh. If the techniques are not properly followed, tourniquette palsy sets in. Inadequate padding, improper tourniquettes, especially with Esmarch bandages, and prolonged use of the touniquette can cause touniquette palsy. Occasionally tourniquette palsy occurs even with sophisticated pneumatic tourniquettes. Hence the duration of the operation done under tourniquette control, should not exceed sixty minutes in the upper limb and ninety minutes in the lower limb.
Also undue pressure should be avoided on applying a tourniquette.There is a risk of high compression pressures on the nerve.This can be avoided somewhat by the use of pneumatic tourniquettes.The ideal tourniquette pressure in the upper limb is 50 mm of Hg above the systolic pressure and that in the lower limb is twice the systolic pressure.
Sometimes, destiny can defy both the surgeon and the patient. If precautions are ignored, touniqeutte palsy sets in soon, and can be diagnosed within minutes after recovery from the anesthesia. The patient is not able to perform any movement of the fingers and passive movements are painful; this is due to ischemia of all the three nerves of the upper limb. Clinical diagnosis is possible within a few hours after surgery.
The treatment again involves removal of tight bandages and limb elevation. Steroids should be used albeit judiciously. If the postoperative wound permits, nerve stimulation may be initiated within a few days. When the pain and edema have subsided, gentle active exercises must be started and continued progressively for the next few weeks till adequate functions of the fingers are restored.
There is also an entity known as posttourniquette syndrome primarily due to prolonged tourniquette time.This syndrome encompasses all the manifestations of the nerve palsy associated with skin ulceration and distal edema.
SYSTEMIC ILLNESSES
Hansen's Disease
Of the various systemic illnesses that damage the peripheral nerves, it is leprosy that presents with extensive involvement of peripheral nerves and multiple deformities. Lepromatous leprosy and polyneuritic leprosy cause extensive deformities of the hands and feet. The ulnar, median and lateral popliteal nerves are commonly involved. The 138predilection for these superficial nerves arises from the fact that these regions have the ideal temperature for the proliferation of the bacilli. Ulnar claw hand, total claw hand and foot drop are the common conditions for which the patient seeks the help of the orthopedic surgeon and the physiotherapist.
Diabetes Mellitus
If diabetes mellitus persists for a few years, the peripheral nerves, especially the sensory nerves are damaged irrespective of the treatment schedule. The patient presents with symptoms varying from paraesthesia to trophic ulcers and numbness and even paralysis of fingers, toes or both.
Alcoholism
Chronic alcoholism is a disease (not a habit!). The patient has numbness of hands and feet. Occasionally, he may present with radial nerve palsy due to compression of the radial nerve in the arm when he sleeps with his arm on a hard surface (Saturday night palsy).
INJECTION PALSY
Intramuscular injection administered in the upper limb should be given in the belly of the deltoid muscle. Neglecting this common precaution may result in injection palsy. Occasionally, a patient with pain along the upper limb and weakness of dorsiflexion of the wrist after an intramuscular injection in the arm is brought to the orthopedic department. This is due to paralysis of the radial nerve when the untrained person injects the drug into the triceps and not into the deltoid which is the proper place. It is not the mechanical injury by the tip of needle, but the neurotoxic oil based drug that paralyses the radial nerve. This is termed chemical neuritis. The unfortunate patient walks in with pain along the arm and forearm with clinical signs of radial nerve paralysis. Usually, these patients recover with a few weeks of conservative management.
CLINICAL PICTURE
When a peripheral nerve is injured or diseased, the patient presents with motor or sensory disturbances depending on the nerve fibers it carries. The resultant weakness due to motor paralysis makes the patient more apprehensive. The common clinical presentation of some of the nerve palsies are:
RADIAL NERVE
The radial nerve is occasionally damaged in injuries of the arm involving the humerus. It may be cut, crushed or compressed by the injury or the fracture of the shaft of the humerus at the junction of the middle and lower thirds. It is also seen in alcoholics (Saturday night palsy); but rarely involved in Hansen's disease.
Radial nerve compression syndromes (Radial tunnel syndrome) also can occur the common sites of compression being
- Origin of extensor carpi radialis brevis
- Adhesions around the radial head
- Arcade of Frohse near the supinator.
The patient has the following clinical features:
- Wrist drop due to paralysis of extensor carpi radialis longus and extensor carpi ulnaris.
- Thumb drop due to paralysis of extensor pollcis longus and abductor pollicis longus.
- Finger drop due to paralysis of extensor digitorum communis.
- Loss of sensation over the dorsum of the first interosseus space.
ULNAR NERVE
Ulnar nerve is more commonly involved in Hansen's disease and in injuries around the elbow like fracture medial condyle of humerus or posterior dislocation of the elbow joint. Compression neuropathy of the ulnar nerve,termed “Cubital tunnel syndrome” can occur around the elbow joint.
The patient has the following clinical features:
- Froment's sign—Weakness of the adductor pollicis as elicited by the book test.
- Ulnar claw—Extension of MCP and flexion of IP joints of ring and little fingers due to paralysis of the lumbricals.
- Card test—Paralysis of the interossei causes weakness of adduction and abduction of the fingers and hence the patient is not able to hold the card.
- Loss of sensation over little finger and ulnar half of ring finger.
- Wasting of hypothenar muscles.
MEDIAN NERVE
When a patient has median nerve palsy as in carpal tunnel syndrome or cut injuries of the forearm, he has the following clinical features:
- Weakness of flexion of the interphalangeal joint of the thumb due to paralysis of flexor pollicis longus.
- Pointing index-paralysis of the long flexors of index finger causes weakness of flexion of the index finger.
- Loss of opposition-not able to touch the pulp of the fingers with the pulp of the thumb due to paralysis of opponens pollicis.
- Loss of sensation over the index finger.
- Wasting of muscles of the thenar eminence.
LATERAL POPLITEAL NERVE
The lateral popliteal nerve is usually paralysed by injuries of the knee, tight bandages and fractures of the neck of fibula.
The patient has foot drop; hence he has a high stepping gait. He is not able to actively dorsiflex his ankle and he has weakness of the extension of the toes. There is loss of sensation over the dorsum of the first interosseus space of foot.
CLASSIFICATION OF NERVE INJURIES
Nerve injuries have been classified by Seddon and Sunderland. Clinically, Seddon's classification is useful in the diagnosis while, Sunderland classification is useful in the management.
Seddon's Classification
Neuropraxia
Temporary mild compression of the nerve will lead to conduction block of the nerve. This is due to edema of the nerve fiber and the myelin sheath. This is otherwise called a physiological block.
Axonotmesis
Severe compression injury of the nerve causes damage to the myelin sheath and the axonal fibers resulting in degeneration of the axon. There is distal Wallerian degeneration.
Neurotmesis
Complete disruption of all the tissues of the nerve fiber as that occurs in cut injury of the nerve is neurotmesis. This is anatomical discontinuity of the nerve. This causes degeneration of the fibers and sheath of the distal component of the injured nerve.Here the endoneurium is completely disrupted with varying degrees of perineurial and epineurial damage.
141The Sunderlands classification is an extension of the the Seddon's classification with more importance to the integrity of the epineurium,endoneurium and perineurium.
DIAGNOSTIC TESTS
In most of the situations, the diagnosis of the injury of nerve can be made, based on the aforementioned clinical tests. In certain situations, the following methods may have to be employed:
Sweat Test
The area of the skin that has to be studied, can be heated with Infra red radiation and the beads of sweat that appear can be seen with a +20 lens of the ophthalmoscope. In dermatomes that have been denervated, the skin is dry and the sweats drops are few or absent. Absence of sweat on the skin indicates diminished conduction of the sensory fibers of the mixed nerve.
Electromyogram
Effective functioning of the muscles can be studied by EMG (electromyogram). If the nerve has been injured, the muscles that have been supplied will show low amplitude signals.
The electromyography is a diagnostic technique that is of great value in studying the function of the nerves and muscles. The study of the electrical activity of the contracting muscles provides information concerning the structure and function of motor units. Motor units are composed of one anterior horn cell, one axon, its neuro muscular junction and all the muscle fibers innervated by the axon. The nerve cell and the muscle fibre it supplies are defined as a motor unit. Whenever a muscle fiber contracts the surface membrane undergoes depolarization so that an action potential is recorded from the fibre. When the fibers of a motor unit are activated, the potential known as motor unit action potential is recorded. Electromyography studies help to localize the site of the problem, either muscle or nerve. Electromyography is a technique by which the action potentials of contracting muscle fibers and motor units are recorded and displayed.
ABNORMAL SPONTANEOUS POTENTIALS
As a normal muscle at rest exhibits electrical silence, any activity seen during the relaxed state is considered as abnormal. These activities are termed as spontaneous because these are not produced by the voluntary contraction of the muscles. The common abnormal spontaneous activities are:
Fibrillation Potential
Fibrillations are spontaneously occurring action potentials from a single muscle fiber. Fibrillation potential is seen in the denervated muscle as they give spontaneous discharges due to circulating acetyle choline. Fibrillation potential is indicative of low motor neuron disorders such as peripheral nerve injuries, anterior horn cell damage, radiculopathy and axonal degeneration due to poly neuropathy.
Positive Sharp Waves
Positive sharp waves are found in denervated muscles at rest and are usually accompanied by fibrillation potentials. This is recorded as a biphasic wave with a sharp initial positive deflection followed by slow negative phase.
Fasciculation Potential
Fasciculation potentials are random twitching of muscle fibers that may be recorded in the muscle. These are spontaneous potentials seen with irritation or degeneration of anterior horn cells, nerve root compression and muscle spasm.
The EMG is an effective diagnostic tool in the study of neurogenic and myogenic disorders.
In neuropraxia, there is normal conduction above and below the block. Nerve conduction shows increased latency across the blockage.
In axonotmesis, there will be fibrillation potential and positive sharp waves in the EMG study. This appears after two to three weeks following degeneration.
In neurotmesis, a nerve conduction velocity test cannot be performed because no evoked response can be obtained. In EMG, spontaneous potentials appear with the muscle at rest and no activity is recorded with attempted voluntary contraction.
EMG studies are also useful in diabetic neuropathy, alcoholic neuropathy, peripheral neuropathy due to vitamin B12 deficiency and in Hansen's disease. There are typical fibrillation potentials, positive sharp waves and fasciculations.
In primary muscle diseases such as muscular dystrophy or polymyositis, the motor unit remains intact but degeneration of the muscle fibers is evident. The typical findings are decreased duration and amplitude of motor unit potential and a full recruitment pattern during attempted contraction.
NERVE CONDUCTION VELOCITY
All peripheral nerves conduct impulses. This nerve conduction can be studied by the application of an electric current along the course of the nerve, using surface electrodes. The speed of this conduction can be measured and this is termed as nerve conduction velocity. The nerve conduction velocity of the mixed nerves in the upper limb is 40–60 ms/sec. A delay in this speed indicates disruption of the conduction. Nerve conduction velocity has also been discussed in Annexure 1.143
Treatment
An elaborate account of the management of nerve palsies in specific injuries has been detailed in the earlier pages of this chapter.
OPERATIVE PROCEDURES
- Nerve repair
- End to end repair-neurorrhaphy
- Epiperineurorrhaphy.Proper approximation of the individual fascicles is a must and the use of a binocular loupe is essential for a good repair. If the ends of the nerve are crushed, then 1 mm cuts at the ends are made until a clean nerve cross section is reached.
- Nerve transposition
- Anterior transposition of ulnar nerve
- Neurolysis
- Decompression of the nerve in Hansen's disease
- Nerve grafting
- When there is a gap between the nerve ends, the sural nerve is use as a graft
- Tendon transfers
- When there is complete paralysis of a muscle resulting in loss of function, the tendons of the synergestic muscles may be transferred by operative procedures to restore the function.
CONSERVATIVE METHODS
Though the injured nerve can be repaired by one or more of the above mentioned operative techniques, skilled physiotherapy and patient cooperation are absolutely essential in restoring muscle action and function of the limbs. Beavor's theory postulates that the brain appreciates the movements of the limbs and not the actions of the individual muscles. Hence, all physical modalities must be aimed to reeducate the patient and his muscles that had been paralysed.
The aims of physiotherapy are:
- To maintain muscle tone
- To improve muscle power
- To promote nerve conduction
- To prevent joint stiffness
- To improve the function of the limb
- To reassure the patient.
Drugs
When a nerve is totally injured the axons from the proximal end grow spontaneously and then orient themselves into the neurilemma sheaths that develop at the distal end. No drug has been discovered yet to promote this axonal growth.
Systemic steroids are helpful in reducing the nerve edema in patients with neuropraxia and brachial plexus injuries, although to a limited extent.
Splints
If motor paralysis persists for a protracted period of time, the muscle loses its strength and tone, resulting in stretching of its tendon which delays active contraction and effective function of the muscle. Hence splints are provided to the limbs to immobilize the joints. Splints, if used properly maintain the joints in the position of function, prevent stretching of muscles and protect the tone of the muscle. Splints play an important role in the management of nerve injuries.
When reinnervation occurs, muscles regain their strength and if the joints remain supple, active movements of the limb are restored. Hence, the weak and paralysed joint must be immobilized with splints to prevent stretching and laxity of the tendons.
Splints can be made of plaster of paris, aluminium or polyvinyl chloride, provided they are tailor-made and properly fit the contour of the paralysed limb.
- Lateral poptileal nerve: Paralysis of the lateral poptileal nerve causes weakness of dorsiflexion of the ankle and toes; this results in foot drop. Hence, a foot-drop splint is used to maintain the ankle in neutral position.
- Radial nerve: Paralysis of the radial nerve causes wrist drop, thumb drop and finger drop. This can be prevented by a wrist drop splint. Wrist drop splints are either static splints or dynamic splints. Static wrist drop splint is made of POP or polyvinyl. Dynamic wrist drop splints help movements of the fingers thereby maintaining the small joints supple.
- Ulnar nerve: Clawing of the ring and the little fingers is due to ulnar nerve paralysis. The hyperextension of the MCP joint and flexion of the IP joints are corrected by the use of knuckle bender splints.
Exercises
- Passive—To keep joints supple
- Active—To promote muscle activity and to improve muscle strength.
Electrical Stimulation
Although electrical stimulation therapy has been shown to be effective in improving muscle power, there are no data to suggest that the use of neuromuscular electrical stimulation (NMES) in a normal healthy human result in substantial improvement in muscle strength compared with that achieved by voluntary isometric exercises.
But NMES has a therapeutic advantage in augmenting the skeletal muscles which are weak, to attain maximal volitional contraction. Not only has NMES shown to increase muscle strength, it has also been shown to improve functional performance. NMES (30 Hz) using surface electrodes prevent disuse atrophy in quadriceps muscle.
In nerve injuries, electrical stimulation, if initiated early maintains normal motor unit, but does not help the process of reinnervation. NMES can be utilized as a neural orthosis as it maintains the tone of the denervated muscle. The role of electrical stimulation in nerve injuries is also discussed in chapter 14.
PRINCIPLES OF PHYSIOTHERAPY IN NERVE INJURIES
First Three Weeks
After a thorough evaluation, the treatment program is planned on an individual basis.
- In the presence of anesthesia of the skin, the basic principle in the care is the protection of the desensitized area. This will prevent damage by burns and trophic ulcers.
- Maintanence of the ROM to avoid contractures and deformities. A proper resting splint is given to avoid undue strenuous movements.
- Control inflammation and swelling by gentle movements (active or relaxed passive) and elevation. Controlling edema is more important in injuries of multiple tissues of the limb.
- Improving muscle-power, endurance and flexibility, especially of the involved muscles.
- Reduction of pain by cryotherapy or TENS is used.
After Three Weeks
- Electro-diagnostic test is conducted to assess the degree of the nerve damage, by electrical Reaction of Degeneration (RD) test, to plan accurate regime of electrotherapy.
- Maintenance of the laxity of tendons and capsules of the joints by gentle stretching exercises.
- Modifications in the splints to maintain joints in the position of function.
- Electrical stimulation plays an important role in preventing muscle fibrosis and atrophy.
- Motor re-education—Correct methods of exercises to re-educate muscle function are extremely important as soon as the recovery is indicated by diagnostic tests. The method of Voss and Knott (1968) is very effective. Bilateral symmetrical patterns are of special significance.
- As the voluntary movement returns, the splint can be modified to provide resistive exercises (e.g. Dynamic Wrist Drop Splint).
- Electrodiagnostic test should be repeated at regular intervals to know the response to treatment. If no recovery is seen even after 18 months to 2 years, surgery should be contemplated.After complete initial assessment the treatment measures are planned as per the requirements of the patient's condition.
- During early stages
- During the stage of recovery
- Late stage.
- During early stage (first 3 weeks)This is the stage of paralysis and all the symptoms of early injury to the nerve are present. The treatment measures are:
- Reduction of inflammation.
- First priority is to prevent or reduce edema by limb elevation.
- Vigorous movements—Active or passive movements to improve circulation
- Diapulse, exercise to adjacent joints and muscles.
- Reduction of pain. TENS can be effective in reducing pain. In the areas with sensory impairement, the electrodes may be placed over the nearest area with intact sensation over the nerve trunk.
- Splint. A splint is fabricated to provide rest and optimal support to the area of involvement. Its fitting and use need to be explained. One has to be careful while advising splints in the presence of the anesthetic and pressure areas.
- Exercises.
- Active and resistive exercises to the muscles, which are unaffected, should be repeated as often as possible.
- Relaxed full range passive movements should be given to the affected joints. Muscle imbalance due to the paralysis of muscle groups, needs to be observed for the over activity of intact antagonists. This is the common cause of tightness and contractures leading to the deformity. The patient should be educated on simple but correct methods of repeated passive stretching of these contracted muscles and joints.
- Accessory passive movements are also effective in preventing joint stiffness and should be included.
- During the stage of recovery (3 weeks onwards)
- Re-education of movements. Reassessments will give indication regarding recovery. Electrodiagnostic tests at this stage are of primary importance to diagnose the extent of the nerve injury. This is the most important phase to hasten the rate of recovery.As there is recovery in the voluntary contractions of the paralysed muscle, it recovers initially in its action against as a synergist, which should be assisted from outer part of the middle range. PNF techniques are extremely valuable at this stage (Voss and Knott 1968).
- Splint. A splint, which was initially static should be modified to dynamic. Whenever possible, the splint should provide resistance to the returning muscle power, offering passive stretching of the contracture prone muscles and joints.It provides optimal stability and assistance in muscle re-education.Simple functional tasks should be introduced so that movements can be repeated in a natural manner.Exercise program should be made intensive till good function returns.
- Sensory re-education: It is one of the important responsibilities of the physiotherapist during this stage.
- Sensory re-education in patients with total sensory loss is difficult. It should be incorporated with electrical stimulation and simultaneous active efforts by the patient. Initially it should be incorporated with passive educative movements. While giving stimulation, electrodes should be placed on the nerve trunk and the proximal area of skin where sensation is in tact.
- Sensory re-education is easy in patients where partial voluntary movement is present. Active effort by the patient to produce the recovering movement is reinforced with visual and auditory feedback.
- Attempted self correction of the blindfold responses alternated with visual feedback techniques are also used for sensory re-education. The patient's concentrated and repeated efforts are needed to practise these techniques.
- The technique of the biofeedback can be used to the greatest advantage.
- Late stageWhen the chances of recovery are poor, surgery is indicated. Physiotherapy will depend upon the type of the surgical procedure.Physiotherapy following suture:During immobilization (1–3 weeks)Immediately following surgery:Limb elevation and measures to reduce inflammationDiapulse can be given through immobilization for early healing.Vigorous active movements to other joints, that have not been immobilized, to improve circulation and to prevent contractures.
Mobilization (3–6 Weeks)
Movement should be intensified and active movements should be encouraged to mild resistive exercises and intrinsic self developed tension exercises.
Relaxed passive movements to be carried out to full range (ROM).
Accessory passive movements can be added. Sensory re-education should be added.
Restoration
The whole program of mobilization and strengthening should be made intensive by:
Initiating progressive resistive exercises (PRE).
Functional activities should be made vigorous and vocation oriented.
Deep friction massage to the surgical scar to avoid its adherence.
By 8–10 weeks adequate return of function should be achieved.
Physiotherapy Following Tendon Transfers
If the recovery of the nerve following nerve suture is not enough to carry out functional tasks, tendon transfer procedures are undertaken.
The basic objective of physiotherapy is to re-educate the transferred tendon for its altered function.
It is essential that the donor muscle must be strong enough, at least grade 4 (MRC grading). After transfer its power is usually reduced at least by 1 grade. Therefore, if the power of the donor muscle is less than 4, that tendon should not transfered. Instead, the tendon of another synergistic muscle may be used to restore the function of the paralysed muscle.
PREOPERATIVE ASSESSMENT AND TRAINING
Donor muscles are put under vigorous sessions of isometric strengthening exercise to reach the requisite muscle power of grade 4. The patient is educated on the new expected action of the muscle after transfer. This is done best by demonstrating and practising the expected movement in the contraleteral good hand.
After surgical transfer, routine measures are taken to reduce the postoperative inflammation.
As soon as the soft tissue healing is sufficient, the process of re-education is started.
- Guide the patient initially by performing relaxed passive ROM exercises in the exact groove of the expected movement from the donor muscle.
- Dynamic splint should be so fabricated that it offers adequate stabilization as well as assistance to the expected movement.
- Low faradic stimulation synchronised with active voluntary efforts to initiate the movement provides excellent therapeutic method.
- EMG. Biofeedback technique is very effective in the re education of the muscle of the transferred tendon.
- Active assisted efforts should be progressed to active movements.
- Functional exercises promoting the accurate use of the donor muscle are very useful.
- Hydrotherapy with under water exercise in warm water is also very effective.
- Deep friction massage with therapeutic ultrasound may be used as an adjunct to improve the extensibility of the tendon and to avoid adherent scar formations.
- Passive movements should be performed by the therapist to the full range of the specific movement of the joint.
- Exercise should be encouraged during the following visits and later the patient is taught passive resistance exercises.
SOME COMMON OPERATIVE PROCEDURES
The route and insertion of an active muscle tendon are transferred to restore the weak movement. This is termed Tendon transfer. In certain situations, we correct the capsule of the joint (Capsuloplasty) or surgically fuse the joint (Arthrodesis). But, tendon transfers have stood the test of time and have proved to be effective in restoring the lost functions of the paralyzed limb. But it must be emphasized, that tendon transfers should be considered only after two years and must be undertaken only when all the pre-operative conditions have been fulfilled.
Median Nerve
In median nerve paralysis, opposition of the thumb has to be restored. The FDS of the ring finger is transferred and anchored to the capsule of the IP joint of the thumb (Riordan's technique).
Ulnar Nerve
Clawing of the ring and little fingers has to be corrected and flexion of IP joints of these fingers has to be restored. Transferring the FDS of index finger to the capsules of the ulnar two metacarpophalangeal joints is the procedure of choice (Modified Bunnel's technique). Some surgeons perform Zancolli capsuloplasty the MCP joint.
Radial Nerve
A patient with paralysis of the radial nerve has wrist drop, thumb drop and finger drop. Hence
- To restore extension of wrist: Transfer the pronator teres to the extensor carpi radialis brevis.
- To restore extension of fingers: Transfer the flexor carpi radialis to the extensor digitorum communis.
- To restore thumb extension: Transfer the Palmaris longus to the extensor pollicis longus.
Lateral Popliteal Nerve
A patient with paralysis of the lateral popliteal nerve has a footdrop.
Transferring the posterior tibial tendon to the extensor hallucis longus and extensor digitorum longus corrects foot drop and restores the dorsiflexion of the foot.
There is always a little fragrance that clings to the hand that donates roses
The aims of treatment for an orthopedic patient are to alleviate the pain, to make the limb stable, to improve the functions of the joints and muscles, and to promote ambulation and to make him physically fit to go back to his normal life. Apart from the drugs, plasters and operative procedures, physiotherapy plays a vital role in achieving these goals.
The primary aim of the medical personnel is to alleviate the pain of the patient.
Pain is an unpleasant disturbed sensation, which accompanies the activation of nociceptors. Pain is a subjective phenomenon with multiple dimensions.
Nociceptors are sensory receptors, which carry the pain stimulus. Any, physical, chemical, thermal or mechanical stimulus like heat, cold or pressure activates these nociceptors. These are free nerve endings found in all body tissues. They carry pain stimulus to the higher centers. Once a nociceptor is stimulated, it releases a neuropeptide, which initiates the electrical impulses along the afferent fibers towards the spinal cord. These afferent fibers are of two types:
- A delta fibers: Fast conducting small diameter myelinated fibres, which conduct with a velocity of 5–30 m/s
- C fibers: Slow conducting small diameter nonmyelinated fibers, which conduct with a velocity of 2–5 m/s
151The gate control theory of pain was first postulated by Melzack and Wall in 1965. Afferent input is mainly through posterior root of the spinal cord and all afferent information passes through synapses in the substansia gelatinosa and nucleus pulposus of the posterior horn. It is at this level that the pain gate operates and presynaptic inhibition by Trans Electrical Nerve Stimulation (TENS) and Interferential therapy (IFT) work.
In physiotherapy we use physical agents to produce a therapeutical response in diseased tissue. They include heat, cold, water, sound, electricity and electromagnetic waves. These techniques provide adjunctive treatment rather than primary curative treatments.These modalities should be handled with caution by a qualified physiotherapist who should be a professional blended with skill, compassion and empathy.
The various modalities of physiotherapy that we currently use are:
- Heat
- Superficial heat
- Deep heat
- Cryotherapy
- Hydrotherapy
- Interferential therapy
- Electrical stimulation
- TENS
- Faradic stimulation
- Galvanic stimulation
- Direct current for fracture healing
- Exercise therapy
- Active
- Passive
- Massage
- Traction
- Gait training
- Pilates.
HEAT
From time immemorial, everybody has applied local heat over a painful region to relieve pain and to provide comfort. When superficial heat is applied, it produces vasodilatation, which washes away the P substance thereby reducing pain. Physical heat is used as:
Superficial Heat
Infrared Radiation
The infrared lamps are now a common sight in every hospital and in many households. The infrared rays are electromagnetic waves with wavelengths of 750 nm to 400000 nm. It is beyond the red wave of the visible spectrum. Sun is the natural source of infrared radiation. It is also produced in the flames of the domestic gas stoves.
The lamp that we use in the hospital is a nonluminous artificial generator. Infrared radiation produces mild heating of the superficial tissues. It also causes a sedation 152of the sensory nerve endings. The increased temperature of the tissues also causes relaxation of muscles and thus reduces pain.
Precaution: Undue exposure may cause skin burns.
Wax Bath
The heat produced on the superficial tissues of the body by infrared rays is by radiation, but that produced by wax bath is by transmission of heat to the skin by conduction. Wax bath therapy is administered on the painful part of the limb, by the application of molten paraffin wax. Paraffin wax is mixed with liquid paraffin or mineral oil and is heated to 40–44 degree Celsius. A towel immersed in molten paraffin wax is used to apply the therapy.
Paraffin wax therapy is useful in the treatment of painful joints, due to rheumatoid arthritis and osteoarthrosis. It also helps to reduce joint stiffness and adhesions. The treatment is given for 10–20 minutes.
Contraindication: Open wounds and skin rashes.
Heating Pads
Electric heating pad provides superficial heat to the part where it is applied. It raises the temperature of the body to 40–45 degree Celsius. It contains an electric heating element that is regulated by a rheostat. The main advantage of using electrical heating pads is that they can be used by the patient himself at home. The common effects produced are increase of local temperature and relief of muscle spasm and pain.
Deep Heat
Ultrasound Therapy
Ultrasound is a physical modality that is used widely by the medical fraternity for both diagnosis and therapy.
Ultrasound refers to the mechanical vibrations which are essentially the same as sound waves but of a higher frequency. Such waves are beyond the range of human hearing and therefore called Ultrasonic sounds. Ultrasonic energy is any vibration above the audible sound range, i.e. 20–20000 Hz. In physiotherapy, we use a frequency of 1 MHz.
Ultrasonic energy generated at 1MHz is transmitted through the more superficial tissue and absorbed primarily in the deeper tissues at depths of about 3–5 cm.
Ultrasound waves are absorbed by the human tissue and are converted into heat.
Ultrasound helps to remove the traumatic exudates and prevents adhesions. The heat produced by ultrasound reduces pain by the gate control mechanism. Hence it is used in soft tissue injuries, joint adhesions, chronic edema and in the early diagnosis of stress fractures.
Short Wave Diathermy
(Dia–through; Thermo–heat)
153The electricity that we use in nerve injuries and muscle training is low frequency currents like faradic or galvanic. But the electricity that we use to heat tissue is provided by high frequency currents like shortwave diathermy.
Shortwave diathermy is the use of high frequency electromagnetic waves of the frequency between 107 to 108 Hz and a wavelength between 30 and 3 m to generate heat in the body tissue. Shortwave diathermy provides the deepest form of therapeutic heat.
The treatment dose should have an intensity that causes sufficient warmth of the tissues and the duration should be 20–30 minutes everyday. The therapeutic advantages of using shortwave diathermy are:
- Increased vasodilatation in various inflammatory conditions like osteoarthritis, tenosynovitis and rheumatoid arthritis and capsulitis
- Reduction of pain
- Reduction of muscle spasm.
The increased local temperature of the tissue improves the vascularity and hence used to relieve muscle spasm in cervical spondylosis and periarthritis shoulder.
Precaution: Skin burns, Dose of current.
CRYOTHERAPY
Use of cold temperature in management of pain is also time tested. Ice cubes, covered with a piece of lint cloth or towels, when applied over an injured area, provide instant comfort. Prepared ice packs are available commercially. Application of ice cubes reduces pain in acute injuries like ankle sprains, ligament injuries and muscle hematomas. The cold temperature causes vasoconstriction followed by vasodilation. Ice cubes should not be applied directly over the skin and use of cryotherapy is contraindicated in limbs with peripheral vascular disease.
The ice cubes covered with cloth are applied on the skin over the painful area for about 20–30 minutes. The advantages of cryotherapy are:
- Produces local analgesia
- Reduces tissue edema
- Reduces the local blood flow
- Reduces temperature of the local tissue and thereby the pain
- Reduces the conductivity along the sensory and motor nerves.
HYDROTHERAPY
The treatment of painful conditions using hot water is an ancient traditional Indian house hold method. Brass vessels containing hot water were used over the painful areas. Now, we use hot water baths and contrast baths. The use of rubber bags with hot water is a common sight in many hospitals. In conditions like painful heel syndrome, both the feet are immersed in a basin of hot water and the water is allowed to cool to room temperature. In contrast bath therapy, two adjacent containers have cold and hot waters respectively. The patient is asked to immerse the limb in both the containers alternatively. This change of temperature stimulates the peripheral vessels resulting in the much needed increased vascularity.154
INTERFERENTIAL THERAPY
Interferential currents are also known as Nermec's currents. The principle of interferential therapy is that two medium frequency currents are used to produce a low frequency current effect. Interferential therapy works on the principle of interferential effect of two medium frequency currents crossing in the patient's tissues. By varying the frequency of the carrier currents, it is possible to produce a frequency in the range of 1–250 Hz. Hence it produces the desired effects in the tissue where they are required without unnecessary skin stimulation. Hence interferential therapy can be used to relieve pain as well as to stimulate muscles.
Advantages
It does not produce sensory nerve irritation, in spite of varying amplitudes. There is absolutely no burning sensation of skin.
- It is used for treating tissues at a deeper level like muscles, tendons and bursae.
- The current can be localized more effectively.
- If the limb has metallic implants short wave diathermy is a contraindication, whereas interferential therapy can be used.
- Pain relief is substantial with the use of interferential therapy by two mechanisms:
- Gate control theory of Wall and Melzack
- The stimulation of muscles increases the vascularity of the painful tissue and thereby washes away the exudates. This effect is better with interferential therapy than with any other form of electrotherapy.
ELECTRICAL STIMULATION
Transcutaneous Electrical Nerve Stimulation (TENS)
Transcutaneous electrical nerve stimulation is the application of low frequency currents in the form of pulsed rectangular currents through surface electrodes on the patient's skin. A small battery operated machine, which has a specific stimulatory effect is used to provide the low frequency current.
The effect of TENS depends on the gate control theory and pain modulation. The TENS stimulates the larger diameter myelinated fibers as these are highly sensitive to electrical stimulation and quickly conduct the electrical impulse to the spinal cord. The A delta and C fibers are unable to transport the painful stimulus to the spinal cord earlier than the larger fibers.
High TENS: High Frequency, 100–150 Hz and low intensity electrical stimulation causes the impulse to be carried along the larger fibers.
Low TENS: Low Frequency, 1–5 Hz and high intensity pulses give a muscle twitch and releases endorphins.
TENS is widely used in low backache, painful conditions of the neck, phantom limb pain and in reflex sympathetic dystrophy (causalgia).155
Faradic Current
Faradic current is a low frequency current. It is a short duration interrupted direct current of frequencies 50–100 Hz and is used for the stimulation of innervated muscles.
In electrotherapy, faradic current is surged to produce a near normal tetanic-like contraction and relaxation of muscle.
Galvanic Current
This is also a low frequency current but of a longer duration upto 300–600 ms. In electrotherapy, interrupted galvanic current is the most effective modality. Intermittent galvanic current is used to stimulate denervated muscles.
The therapeutic effects of low frequency currents (Rennie) are:
- Pain relief
- Decreased inflammation and swelling
- Muscle re-education
- Increased local circulation
- Facilitation of tissue healing.
Indications for using low frequency currents:
- Initiation of muscle action.When the patient is unable to volitionally contract a muscle, electrical stimulation is used to assist voluntary contraction.
- Re-education of muscle action.According to Beavor's theory, the brain appreciates movements of the joints and not the actions of individual muscles. Hence re-education is required in prolonged disuse of muscle. Stimulation by faradic current produces contraction and restores the sense of movement. Active contractions must be attempted along with electrical stimulation for faster re-education.
- Training a muscle.Faradic stimulation is used to teach or train a muscle to perform a new function as in thumb reconstructive procedures and after tendon transfer operations.
- Increasing range of movement.Faradic stimulation is useful in improving the range of movement of a joint as in scarring and contraction of the adjacent fibrous tissues.
- Strengthening a muscle.Low frequency currents enhance the function of weak muscles.
- Stimulation of sensory nerves.Faradic current stimulates the sensory nerves by producing a mild pricking sensation. Intermittent galvanic current also stimulates the sensory nerves, but being a long duration impulse it produces a burning sensation.
- Stimulation of motor nerve.Faradic current stimulates the motor nerve and if it is of sufficient intensity, it stimulates the muscles supplied by that nerve. Galvanic current produces muscle fatigue and hence not beneficial in motor nerve injuries.
-
Electrical stimulation of motor nerves causes muscle contraction that is similar to a voluntary contraction. This restores the inherent properties of the muscle, increases its metabolic activity and improves its venous return.
- Stimualtion of a denervated muscle.Denervated muscle requires an electrical impulse of >1ms to produce a contraction. This strength of impulse cannot be tolerated by the patient. Hence faradic stimulation is not useful for stimulating denervated muscles. Therapeutically intermittent galvanic current of sufficient duration and intensity is used to produce an effective contraction.
SPECIFIC INDICATIONS
Adequate education of the patient is essential prior to electrotherapy. Absolute confidence and cooperation of the patient are required. The therapist must explain the advantages, duration, the course of treatment and the prognosis. The therapist must also be cautious while choosing the type of current, pulse, frequency, duration and treatment time.
Median Nerve
The median nerve is stimulated by placing the electrodes over the medial epicondyle of humerus for inactive muscles, and over specific motor points for active muscles: Both faradic and intermittent galvanic currents are used.
Ulnar Nerve
Surged faradic in neurapraxia and intermittent galvanic current in axonotmesis have proved to be therapeutically efffective. The electrodes are placed above the injury in neurapraxia, and below the site of injury in axonotmesis and neurotmesis.
Radial Nerve
Surged faradic current is used in neurapraxia and intermittent galvanic current (10–30 contractions) in axonotmesis or neurotmesis for the correction of wrist drop and finger drop.
When the human tissue is stimulated with faradic current, the patient feels a pricking sensation and when stimulated with intermittent galvanic current he feels a stabbing sensation.
Piezo-Electricity
A specialized battery operated device that delivers piezo electricity is used in promoting healing of fractures. This device delivers direct current which is used in the treatment of delayed union of fractures when supplemented with plaster casts. This method is rarely used in the management of fractures.
EXERCISE THERAPY
Early ambulation of the patient helps him to regain his movements, his occupation and his original position in the society, which is the essential purpose of rehabilitation. 157To achieve movements of the limbs, he needs to have strong and healthy muscles and supple joints. Exercises help to improve the power of the muscles and to maintain the joints supple. But, the type of exercises and period of treatment should be modified for the individual patient. Hence exercise is advised as a therapy and not at random.
Muscle wasting of the limbs occurs in many conditions like:
- Nerve injuries
- Muscle diseases (Fibromyalgia Syndrome)
- Diseases of joints
- Plaster immobilization
- Disuse atrophy of muscles
- Chronic low backache.
Joint stiffness occurs in:
- Infection of joints (e.g. septic arthritis)
- Degeneration of joints (e.g. osteoarthritis)
- Pericapsular adhesions (e.g. periathritis shoulder)
- Prolonged immobilization
- Diseases of ligaments (Ankylosing Spondylitis)
Exercises are of two types:
- Active: Exercises performed by the patient are termed as active exercises. He voluntarily contracts his muscles and moves the joints, guided by the therapist. Active exercises help in restoring the power and tone of the muscles.
- Passive: Exercises performed by the physiotherapist are termed as passive exercises. Here the physiotherapist holds the limb of the patient and moves the joints through the entire range of possible movement. Passive movements prevent joint stiffness.
We shall study the uses of exercises in the various situations that have been mentioned above:
Nerve Injuries
Along with splints and the selected electrical stimulation, active exercises must be taught to the patients with nerve injuries and advised to continue them regularly, till normal power and adequate function is restored.
For weakness of forearm and hand muscles due to paralysis of the nerves, picking up and putting down small objects like marbles, coins or dice; grasping and squeezing a rubber ball; closing the hand to make a fist and opening it gently; touching the tips of the fingers with the pulp of thumb; flexing and extending each finger individually; wrist extension and flexion are some of the exercises that are helpful. The patient is advised to perform the above exercises actively which will help in regaining the functions of the hand like holding, hooking, grasping and pinching.
In addition to foot drop splints, active dorsiflexion and plantar flexion exercises, with the foot over a beam, develop the paralysed muscles and the intrinsic foot muscles, in cases of foot drop due to lateral popliteal nerve injury.
In all these instances, the active movements may be supported by faradic stimulation which is also called an electrical splint.158
Fibromyalgia Syndrome
Inflammation of the fibrous and muscular tissues of the trapezius disturbs the activities of daily living like combing, eating and dressing. Active shrugging of the shoulders and shoulder bracing exercises have proved to be very useful in reducing the pain and promoting the strength of the trapezius.
Chronic Arthritis
In any joint disease, the muscles acting on the joint, the muscles which are proximal to the joint and the muscles which are supplied by the same nerve roots as the joint, proceed to early wasting, e.g. quadriceps wasting in chronic arthritis of the knee and biceps wasting in diseases of the elbow. The wasting of the muscle starts within a few days of onset of the disease and is an associated clinical feature of chronic arthritis.
This type of muscle wasting can be corrected with active exercises. If the biceps is weak, active flexion exercises of the elbow are started as soon as the pain subsides and the patient is cooperative. Wasting of the quadriceps occurs in diseases and disuse of the knee joint. This weakness causes an awkward gait. Active quadriceps exercises, if started early prevent this disability. Active knee bending exercises in the sitting posture and raising the extended knee in the lying posture help in quadriceps recovery. A folded towel is placed beneath the knee and the patient is instructed to press it with his knee joint. These exercises adequately restore the power of quadriceps.
Plaster Immobilization
When the limb is immobilized with plaster of paris slabs or casts, as in conservative management of fractures, the muscles that do not act, become weak in three weeks. If the limb is immobilized for an extended period, the muscles become wasted. This must be prevented by diligent care and patient counselling.
The toes or fingers distal to the POP must be actively mobilised by the patient (passive movements do not help) from the day of application of the plaster. The other joints of the limb that are not immobilized by the plaster should also be actively mobilized from the beginning. For example, if the patient has a below elbow cast the fingers, elbow and the shoulder joint must be actively moved continuously everyday till the plaster is removed and after.
The exercises, not only help to restore normal function of the limb after removal of the cast, but also prevent edema and undesired complications of the limb which is called Plaster disease.
In limbs that have been operated with implants, active exercises are advised as soon as the conditions permit, so that the patient regains movements and functions of the limb, and recovers early.
Disuse Atrophy
In patients who have diseases of the central nervous system, prolonged disuse of the muscles of the limbs cause them to atrophy. This is called an upper motor neuron lesion in textbooks of medicine. Hemiplegia, monoplegia, paraparesis and paraplegia are some of the conditions that require exercise therapy. Cerebral palsy occurs in 159children who have intracranial cellular damage. All these types of patients require exercise therapy and enthusiastic cooperation of the relatives and energetic attitude of the physiotherapist.
Passive mobilization exercises by the physiotherapist will help the muscles to regain their tone and to maintain the joints supple. These joints should be moved through their entire range of permissible movements everyday. A combination of drug therapy, electrotherapy and exercise therapy has changed the life of many patients who were on the verge of depression.
Low Backache
Certain simple stretching and strengthening exercises for the muscles of the back are required for the good postures even in the normal person.
But people who have suffered a low backache and have been treated by conservative methods or those who have been operated, require a regime of supervised exercise therapy for restoration of the normal posture.
The paraspinal muscles, the psoas muscles and the muscles of the anterior abdominal wall support the lumbar spine. Once the cause of low backache has been treated and the pain has subsided the spinal extensors must be strengthened soon for early convalescence. Later the psoas muscles are strengthened by actively raising the straight legs individually. Raising the head in the lying posture will strengthen the muscles of the anterior abdominal wall. Raising both the legs with the knees extended will also strengthen the abdominal wall muscles. These exercises should be continued daily for a few weeks for restoration of functions of the low back region. After the patient regains the pain free normal postures, lateral flexion, rotation and back muscle strengthening exercises are advised.
It is wise to proceed cautiously and to modify the exercise therapy for each individual patient according to his problem, his attitude and cooperation. Also see chapter 7.
Stiff Joints
Even when treated adequately, acute infections of joints like septic arthritis and chronic arthritis like tuberculosis or rheumatoid disease heal, but the patient is not able to use the limb effectively due to the resultant joint stiffness. The other causes of joint stiffness have been mentioned above. The stiffness is due to contraction of the joint capsule, wasting of adjacent muscles and sometimes intraarticular adhesions (ankylosis). Septic arthritis heal by bony ankylosis while chronic arthritis heal by fibrous ankylosis. Both these complications can be prevented by appropriate exercises. Exercise therapy plays a major role in restoring the function of the joint and the limb.
During the early phases, the joint should be passively mobilized. Passive stretching exercises of the joint by the physiotherapist will make the capsule lax, and improve the range of movements. Passive exercises require supplementation by local heat therapy or interferential therapy. The physiotherapist should move the joint gently throughout its range of movement. Once the pain is subsided, the patient must be encouraged to perform active exercises of the diseased limb. Active exercises improve the power and coordination of the muscles.160
Degeneration of Joints
In osteoarthritis of the knees, the quadriceps especially the vastus medialis becomes weak within a few days. Early restoration of the strength and function of the quadriceps, reduces the pain, improves the range of movements and restores the normal gait. Knee bending exercises can be advised during the first visit and quadriceps strengthening exercises are taught when the pain subsides.
After operative fixation of fractures around the knee and even after total knee replacement, these exercises play an important role in enhancing early recovery.
Periarthritis Shoulder
Pericapsular adhesions and adhesions between the tendons of the rotator cuff and the shoulder result in adhesive capsulitis or periarthritis shoulder. Along with drugs, heat therapy and electrotherapy, exercise is the most important therapy in regaining the functions of the shoulder. Initially active abduction exercises are taught. Later, external rotation exercises and internal rotation exercises of the shoulder help a lot. After the pain has subsided and a reasonable range of movement has been regained, exercises to strengthen the deltoid are advised. The primary aims of exercise therapy in periarthritis of the shoulder are regaining the range of movements of the shoulder joint and restoration of the power of the deltoid muscle.
Passive stretching of the shoulder should be performed with extreme caution or else we may create an iatrogenic fracture.
Ankylosing Spondylitis
Calcification of the ligaments of the spine causes marked restriction of the movements of nearly all the segments of spine in a patient with ankylosing spondylitis. Hence active mobilization exercises should be commenced even in the early phases of treatment. Active breathing exercises and chest wall strengthening exercises are absolutely essential, as the restricted chest wall movements cause complications of the lung parenchyma which can be fatal.
MASSAGE
In many painful conditions of the back, digital massage by the therapist reduces muscle spasm and to some extent, pain. Contact pressure, kneading and rolling are some of the techniques that are used. But one must be extremely cautious in massaging, or else wrong techniques can aggravate the painful condition.
Massaging techniques relieve pain in painful conditions of the back. Massages with a deep and sedative effect like effleurage, circular kneading and friction over the paraspinal muscle have proved to reduce pain considerably. Manipulation of the spine in certain conditions of low backache and the shoulder in periarthritis shoulder are occasionally performed under anesthesia by certain trained people.
Massage is the scientific manipulation of the soft tissues of body with the palmar aspect of hand(s) and or fingers.
Classification of Massage
On the basis of character of technique:
161According to the nature of character of technique classical/manual massage techniques are classified into following four basic groups. Each group has more than one subgroup.
- Stroking manipulations: Superficial stroking, effleurage
- Pressure manipulations: Kneading, petrissage, friction
- Tapotment/percussion manipulations
- Vibratory manipulations.
Stroking Manipulations
The technique of this group consists of linear movements of relaxed hand along the whole length of segment known as Strokes, which usually cover one aspect of the entire segment at a time. An even pressure is applied throughout the strokes, which are repeated in rhythmical way. According to the amount and direction of applied pressure, it is divided into two techniques.
Superficial stroking: It is the rhythmical linear movement of hand or a part thereof over the skin in either direction that is proximal to distal or vice versa, without any pressure.
Effleurage: It is the linear movement of hand, over the external surface of body in the direction of venous and lymphatic drainage, with moderate pressure.
Pressure Manipulations
In this group of techniques, the hand of the therapist and skin of the patient move together as one and fairly deep localised pressure is applied to the body. The techniques are directed towards the deeper tissue. The aim is to achieve the maximal mechanical movement of different fibres with the application of that maximum pressure, which a patient /subject can tolerate comfortably.
Kneading: Circular movements of soft tissue, parallel to the long axis of underlying bone, with constant touch and intermittent pressure.
Petrissage: Circular movements of the soft tissues, perpendicular to the long axis of underlying bone with constant touch and intermittent pressure.
Friction: Small range to and for movement of soft tissue with constant touch and constant deep pressure.
Vibratory Manipulations
In this group of techniques, the mechanical energy is transmitted to the body by the vibrations of the distal part of upper limb that is hand or fingers, which are in constant contact with the subject skin, using the body weight and generalised cocontraction of the upper limb muscles. This technique is mainly directed towards the lung and other hollow cavities.
Vibration: In this technique, the fine vibrations are produced, which tend to produce fine movement of hand in upwards and downwards direction.
Shaking: In this technique coarse vibrations are produced, which tend to produce fine movement of hand in sideway direction.162
TRACTION
- Cervical traction can be used along with analgesics and muscle relaxants. Cervical traction is a modality of choice for many cervical dysfunctions and painful conditions of the neck. It is applicable in a wide range of problems from ligamentous sprain to cervical spondylosis. Cervical traction may be used as continuous or intermittent therapy. Continuous cervical traction is applied with a cervical halter and pulley system. The traction force is just about 3-6 kg. Intermittent cervical traction produces the effects of massage on the muscular and ligamentous tissues. It promotes circulation, reduces inflammation, spasm and pain. It also helps in the breakdown of adhesions. The period of treatment by traction depends on the requirements of the underlying problems and the response of the patients.
- Pelvic traction provides a marked reduction in the pain. This is because the patient is confined to bed (Macnab) and all unnecessary movements are avoided. Though this concept is popular, continuous balanced traction in bed has other promising advantages. The stiff muscles which are in spasm are stretched and along with the drugs, pain and muscle spasm subside markedly. The traction force exerted by the weights does not pull the vertebrae apart. Instead, the traction produces relaxation of the muscles that are in spasm, relieves pressure on the nerve roots and thereby reduces pain. The direction of the pull must be from underneath the pelvis, so that there is posterior tilting of the pelvis decreasing the lumbar lordosis. Continuous pelvic traction provides stability and muscle relaxation. It is of a great therapeutic advantage in patients with excruciating localised or radiating type of low back ache. The traction force of 8–16 kg is adequate for pain relief. It is applied continuously with the patient lying supine, for several hours with the foot end of the bed raised to provide counter traction. This is otherwise called balanced traction. Continuous pelvic traction reduces pain in many of the aforementioned conditions. Intermittent pelvic traction is the most popular method in the management of low backache. It has vascular massaging effect and relaxation is produced in the tight ligaments and muscles. Moreover, intermittent pelvic traction is well accepted by the patients as compared to continuous traction.
Though some authors claim that traction offers positive decompression, drawing the protruded disk towards the centre, this hypothesis has not been accepted by many spine surgeons. The author would like to state that traction definitely alleviates pain but does not treat the cause of the pain. A combination of the following modalities is effective in conservative management of low backache:
GAIT TRAINING
Gait is defined as the anterior translation of the erect human body by alternate bipedalism. In common english it can be termed as the method of walking. Gait consists of the stance phase and the swing phase. The stance phase comprises the duration of contact of the foot with the ground, and the swing phase is the duration when the foot is off the ground and is put forward.
Patients who have painful joints, due to infection or inflammatory diseases, patients who are recovering from prolonged immobilization and those who have had operations for fractures in the lower limb are those who find it difficult to start walking. These are the patients who require the help and guidance of the therapist. Gait training comprises of promoting the muscles, improving the functions of the joints and teaching the patients to walk normally.
During the initial phases of recovery, nonweight bearing mobilization exercises are started. Then, the patient is trained to use walking aids like walkers or axillary crutches. The patient is encouraged to strengthen his muscles, the hip abductors and the quadriceps, simultaneously. Once the pain has subsided and the muscles are relatively powerful, he is allowed partial weight bearing with the help of walking aids. Once the fracture is healed well, or the disease has settled, he is allowed full weight bearing on the injured limb. During this phase, he is trained to walk in between parallel bars with mirrors; wooden steps and hand rails are also useful in this phase. Patients who are recovering from paraparesis should be taught standing balance initially and then they should be encouraged to start walking gradually.
PILATES
Pilates is a physical fitness system developed early in the twentieth century by Joseph Pilates of Germany. Pilates called his method Contrology, because he believed that his method uses the mind to control the muscles instead of reflexes.
Pilates is a body conditioning routine that helps build flexibility and long, lean muscles, strength and endurance in the legs, abdominals, arms, hips, and back. It puts emphasis on spinal and pelvic alignment, breathing to relieve stress and allow adequate oxygen flow to muscles, developing a strong core or center and improving coordination and balance. Pilates’ flexible system allows for different exercises to be mentioned in range of difficulty from beginning to advances. Intensity can be increased over time as the body conditions and adapts to the exercises. No muscle group is under or over trained.
Though this system has been developed in Europe and the American continents, it very much resembles the ancient Indian yoga, which is a system of spiritual and physical therapy for the well-being of the entire human body and the mind. The term yogasana refers to the various postures in the exercise schedule and the term pranayama refers to the various breathing exercises.
Menezes method is a modification of Pilates’ contrology exercises. Pilates originally developed his method as mat exercises, but now other physical apparatus are used to get the method in the human body. These mechanical devices promote resistance training. Uses of springs results in “progressive resistance”, meaning the resistance increases as the spring is stretched. In contemporary pilates other modified mechanical 164devices are used. Pilates demands intense focus: “you have to concentrate on what you are doing. All the time, and you must concentrate on your entire body”.
We breathe on an average around 18,000–23,000 breaths per day. In Pilates method this breathing is regulated. This breathing exercise is of considerable value in increasing the intake of oxygen and the circulation of this oxygenated blood to every part of the body. This is very much similar to the Indian system of pranayama.
CAUTION
Any form of spinal exercises must be performed under the guidance of a trained physiotherapist. Spinal exercises are contraindicated in pregnant women.
Plan as if you're going to live forever but live as if you are going to die tonight
Any student of medicine must spend sometime to train his fingers to apply a bandage. If knowledge of orthopedics is a skill, the skill of bandaging is an art. The bandages on a limb for a patient must serve its purpose. It must be firm but not tight. Tight bandages applied by the untrained osteopath have played havoc with the limbs and lives of thousands of patients. Hence the importance of this chapter need not be exaggerated.
BANDAGES
Sir Hugh Owen Thomas, the father of modern orthopedics has given his life for the development of this science. In addition to his numerous magnificent contributions, he has designed the Thomas splint. The use of Thomas splint had saved hundreds of lives during the second world war. Bandages made of lint or gauze are rolled over the limbs of the Thomas splint. The ring is prepared with adequate padding. This Thomas splint is used in immobilizing the lower limb in any painful condition, be it injury, infection, or inflammation. It can be used to reduce the pain and to provide rest to the limb in infection or inflammation of the hip and the knee. With strapping and traction tapes the Thomas splint can be used to immobilize the limbs with fractures of the long bones of the lower limb.
The commonest bandage used in the orthopedic department is the neck and wrist sling. In Indian parlance, this is called cuff and collar (without a shirt!). This cuff and collar supports the upper limb by elevating it. It is useful in any painful condition of the upper limb when added to a plaster slab.
A triangular sling or a tailor made arm pouch is used to elevate the upper limb. This extends from the elbow to beyond the wrist. An arm sling reduces pain and edema.
STRAPPING
The universal adhesive tape or plaster can be very useful if applied properly. Pain in certain fractures of the ribs can be reduced by the use of strapping the chest wall of one hemithorax.
In children who have a fracture of the humerus (birth injuries) simple strapping of the arm to the trunk for a week produces good fracture healing. In neonates who have a fracture shaft of femur, the thigh is flexed to the abdominal wall and strapped to it. This reduces pain and heals the fracture. In older children, adhesive plasters are applied in both lower limbs and anchored to the end of the cot.
Adhesive plaster is used in the early phases of treatment of club foot. This technique was introduced by Sir Robert Jones who is the nephew of HO Thomas. Robert Jones strapping maintains the foot in plantigrade position with the knee flexed. This permits corrective manipulation exercises during the period of immobilization.
Fractures of the lateral end of the clavicle, subluxations of the acromioclavicular joint and fractures of the acromion are adequately immobilized by Jones strapping which holds the flexed elbow to the shoulder joint. This has to be supplemented with the neck and wrist sling.
Strapping is widely used in the treatment of hand injuries. In isolated fractures of the phalanges and the dislocation of the interphalangeal joints, the injured finger is immobilized by strapping to the adjacent normal finger. Padding with cotton in the web space is essential to prevent skin diseases.167
ELASTOCREPE BANDAGES
Elastocrepe bandages are those which have elastic threads incorporated in them. These permit stretching of the bandages. When an elastocrepe bandage is applied on a limb it reduces the swelling and edema, which are the additional causes for the pain and discomfort. Pain and swelling due to soft tissue injuries like contusion, muscular hematoma and and sprain of the ligaments can be effectively reduced by the judicious use of the elasto crepe bandage. The edema due to the injury subsides well when the crepe bandage is applied with intertwining. Care must be taken to avoid constricting folds of the bandage which can prevent the venous return and aggravate the edema. Elastic bandages are very useful in effusions of the knee especially in traumatic and inflammatory synovitis. But it must be remembered, that elasto crepe bandages provide some but not adequate immobilization of the joint.
Limb elevation remarkably brings down the edema and swelling. Slings in the case of upper limb and the pillows for the lower limb are simple measures to elevate the limb. The surgeon must not hesitate to educate the patient about the importance of limb elevation.
PLASTER OF PARIS (POP)
No orthopedic surgeon has walked this earth without having his fingers dipped in plaster of Paris. Its use in orthopedics is universal. Plaster of Paris is anhydrous Ca2SO4. This chemical is incorporated in bandages and can be moulded to the contour of the limb and the desire of the surgeon. When immersed in water anhydrous calcium sulfate is converted into hydrated crystals with emission of heat. This is the solid form of plaster and it maintains its integrity until disturbed by anything else.
The plaster of Paris used to support a limb can be applied as:
- Slab: About six to eight layers of POP are prepared as a slab. This slab covers less than two-thirds of the circumference of the limb. This is applied on the limb with adequate cotton padding over the skin and the bony prominences and encircling bandages.
- Cast: When the plaster of Paris is encircled to cover the entire circumference of the limb, it is termed as cast.
Slab
A slab is used to immobilize the limb in certain simple fractures as a definitive management. It is also useful to immobilize joints in injuries to ligaments. If there is a fracture in the long bone, the slab is used to maintain the anatomical alignment obtained by reduction. During the initial phases, the fracture hematoma increases causing pain and edema. If a slab is applied it covers only a part of the circumference of the limb. Hence there is room for the swelling and edema. Antiinflammatory drugs and active exercises reduce the distal edema. Later, when the signs of active immobilization subside, the slab may be converted into a cast.
Cast
A cast made of palster of paris is often used in the definitive management of ligament injuries and in many fractures. Since a cast covers the entire circumference of the limb, the inherent hydrostatic pressure holds the fractured fragments in situ.
For adequate healing of the fracture, the plaster should be applied on the limb such that it immobilizes one joint above the fracture and one joint below, e.g. in fracture both bones forearm, an above elbow cast is used to immobilize the elbow and the wrist.
Precautions
The limb is immobilized with plaster of Paris to provide immobilization of the fractured fragments so that they heal to unite. During this period, one joint above and one below the fracture are also immobilized. This may cause stiffness of the joint and difficulty during the stage of physiotheraphy and rehabilitation. Hence, a joint should always be immobilized in the position of function.
The treating surgeon has the liberty of applying a plaster cast or slab. But he has a professional responsibility of instructing the patient about proper care of the plaster and the limb.
The fingers/toes distal to the plaster must be actively mobilized from the very day that the plaster has been applied. These exercises must be performed continuously.
- These exercises prevent edema, joint stiffness and muscle wasting. Moreover the blood circulation of the limb is increased. This accelerates the rate of fracture healing. Hence the clinician must understand the important role of exercises and educate the patient properly.
- The limb in plaster must be constantly elevated to reduce dependent edema.
- The plaster should not become wet. The patient must be advised not to spill water on the plaster, lest it loses its strength.
- In the event of any discomfort like swelling of fingers, increase in pain or numbness of distal part of the limb, he must report to the hospital immediately. The clinician must remove the plaster and examine for any constricting band, elevate the limb and give him analgesics, local heat and active mobilization exercises to bring down the edema. If the discoloration and numbness persist after these measures doppler study of the arteries of the limb must be performed. If vascularity is compromised, extensive fasciotomy should be performed as an emergency procedure to save the limb.
Terms used in ortho wards:
Below Elbow (BE): A slab or a cast applied in the fore arm: It extends from below the elbow crease to just short of the heads of the metacarpals.
Above Elbow (AE): A slab or a cast applied in the upper limb. An AE slab or cast immobilizes both the elbow and the wrist joints. This extends from the upper third of the arm to the hand just short of the heads of the matacarpals.
Below Knee (BK): A slab or a cast applied in the leg. It extends from below the popliteal crease to just short of the heads of the metatarsals. This immobilizes the ankle joint and the tarsal bones and the metatarsals.
Above Knee (AK): A slab or a cast applied in the lower limb. An AK slab or cast immobilizes both the knee and the ankle joints. This extends from the upper third of the thigh to the foot just short of the heads of the metatarsals.
SPECIFIC CASTS
Scaphoid Cast
This is a modified BE cast. Scaphoid cast is exclusively used in the conservative management of fractures of the scaphoid bone. This cast extends from below the elbow crease and immobilizes the wrist joint, in addition to an extension applied to the interphalangel joint of the thumb with the wrist in dorsi flexion and the thumb in abduction (Tumbler holding position). Since the scaphoid is a weak bone, this cast may have to be used for eight weeks.
PTB Cast
This is a Patellar Tendon Bearing Cast. This was introduced by Sarmiento and sometimes this eponym is used. This extends from just above the patella to just short of the heads of the metatarsals. The proximal end of the cast is modified such that anteriorly it extends above the patella and posteriorly below the popliteal crease. When the cast is moist indendations are made on either side of the ligamentum patellae. This cast permits active flexion and extension exercises of the knee joint. This exercise is continued during the period of fracture healing. This is called Functional Cast Bracing. This principle of functional cast bracing improves the power and tone of the muscles, while the fracture fragments are immobilized. Hence the vascularity to the fracture site is improved and fracture healing is promoted. The complications of joint stiffness and muscle waisting are avoided by this Sarmiento cast.
Hip Spica
The hip spica, made of POP, resembles full pants with one of its legs cut above the knee. This is applied from the trunk of the body at the level of the umbilicus. The spica on the injured limb extends to the full length of the limb upto the metatarsals.
171On the normal side it extends to just above the knee. Hence it is called one and a half hip spica. This hip spica immobilizes the hip joint on the contralateral side, and the hip, knee and ankle joints on the injured side.
This hip spica provides excellent immobilization in fractures of the shaft of the femur in children. This is not so often used in adults, except in rare situations. McMurray's osteotomy is an operation performed in the trochanter as a treatment for fracture neck of the femur, though occasionally. The one and a half hip spica provides good immobilization after McMurray's osteotomy.
Ponseti Cast
Ponseti cast is a modified above knee cast which is used in the management of congenetial talipes equino varus. The reduced dislocation of the talonavicular joint is held in position with correction of the fore foot adduction. This Ponseti cast is changed weekly. During the last few years, many centers have produced good results in the management of club foot, with the use of Ponseti cast.
Happiness is experienced in work and not in rest
The ultimate aim of the science of orthopedics and the work of an orthopedic surgeon is to restore the stability and mobility of mankind. Any pain, stiffness or discomfort during the movement of the trunk or limbs compromises the function of the limb and the individual. Injury, infection or weakness of the skeletal and neuromuscular systems will disturb activities of daily living (ADL) of the patient.
The treatment of a patient by an orthopedic surgeon does not stop short with the recovery from the disease. It is his professional and social responsibility to mobilize him and restore him to his rightful place in the society. Besides the role of the physiotherapist, occupational therapist and the social worker, the art and skill of a prosthetic technician are of abundant value during this phase of rehabilitation.
DEFINITIONS
Orthosis
An orthosis is a mechanical device which supports a weak or painful part of the limb or body.
For example, the common spectacles is an orthosis which supports the impaired function of the eye.173
Prosthesis
A prosthesis is a mechanical device which replaces the missing part of the limb or body.
For example: The artificial limbs used in amputees, valvular replacement in heart diseases and joint replacement are technically prostheses.
ORTHOSIS
The orthotic technician is an active member of the rehabilitation team in the management of an orthopedic patient. Orthotic devices should be made especially for the individual patients, with appropriate measurements. These devices help to:
- Reduce pain by supporting the weak limb
- Prevent stretching of muscles and joint capsule
- Help to improve the function of the limb
- Prevent deformities
- Prevent disuse muscular atrophy.
Upper Limb Orthosis
The universal neck and wrist sling and the broad arm sling serve to support the painful limb and to reduce edema.
In Erb's palsy and other types of brachial plexus injuries, the shoulder joint is held in the adducted position due to paralysis of the shoulder abductors. If the other therapeutic measures like electrotherapy and exercise therapy have to be effective, the shoulder is held in an abducted position with the aid of an Abduction splint.
A patient has wrist drop and finger drop when his radial nerve is paralysed. This causes hypotonia and wasting of the dorsiflexors of the wrist, and extensors of the thumb, and extensors of the fingers. Hence, the wrist and fingers are held in extension by a static wrist drop splint. A static splint prevents hypotonia of the extensor muscles and stretching of the tendons.
A dynamic wrist drop splint is an aluminium splint which has rubber bands that are attached to the fingers and are held in extension. These bands permit active resisted flexion movements of the fingers which help in early recovery of the power of the extensors of the wrist and the fingers.
Individual fingers can be effectively immobilized using finger splints or finger cots. These are pre fabricated moulded splints which can be taped to the individual finger. Finger splints are very useful in fractures of the phalanges. A finger splint immobilizes only the injured finger, and does not unnecessarily disturb the function of the other fingers. Hence the uninjured fingers of the hand may be actively mobilized from the first day of treatment, which is a great boon in the early recovery of all the functions of the injured hand.
Mallet finger is a traumatic condition in which, the distal interphalangeal joint is held in painful flexion. This is due to rupture of the dorsal capsule and the central slip of the extensor tendon. Many a time, an occasional flake of bone from the terminal phalanx may be avulsed by the extensor tendon. A mallet finger splint holds the distal interphalangeal joint in extension, a position which reduces pain and promotes healing of the ruptured tendon.
174Knuckle bender splints are used in claw hand deformity. A knuckle bender splint holds the metacarpophalangeal joint in flexion.
Important
When splints are used, any painful or weak joint must be held in the position of function by the splints. This is essential for better function of the hand. The position of function is dorsiflexion of the wrist, flexion of the metacarpophalangeal joints and extension of the interphalangeal joints.
Lower Limb
About two decades ago, poliomyelitis was common in our country. Due to the sustained health education program the incidence of paralysis due to poliomyelitis is now relatively rare. More, lower limbs were affected by the virus than the upper limbs. Lower limbs with marked wasting of muscles, weakness and deformities of the joints, and weakness of the spinal muscles with scoliosis and pelvic tilt caused difficulty in walking and awkward gaits. These children were able to walk with the help of lower limb orthosis or caliper. This is usually made of aluminium rods, locks, leather straps and boots. These are of three types:
HKAFO | – | Hip knee ankle foot orthosis |
KAFO | – | Knee ankle foot orthosis |
AFO | – | Ankle foot orthosis |
As these terms indicate, the calipers are named according to the joints supported by the orthoses. These calipers provide an additional support to the weak and flail limb, thereby helping in ambulation of the patient.
175Another modification of the HKAFO is the weight relieving caliper. The upper end of the above knee strap is modified to support the pelvis by abbutting on the ischial tuberosity. The foot is held above the sole of the foot wear so that it does not touch the ground. Weight relieving caliper is a useful tool in early rehabilitation of painful conditions of the leg and knee as in delayed union of fractures, infected nonunion and arthritis of knee and hip. Weight relieving calipers are also used by some in Perthes disease of hip.
Spinal Orthosis
A mechanical device that is used to support the vertebral column is called spinal orthosis. This is of three types: Cervical collar, spinal orthosis and lumbosacral corsette.
The long orthosis that supports the dorsal and lumbar spine is otherwise called spinal brace. About a few years ago, a brace was applied on the posterior aspect of the trunk and fitted with straps that go beneath the axilla and around the pelvis. This is Taylor's brace, and it is not often used now.
Presently, adequate support to the spine is provided by the Anterior Spinal Hyperextension (ASH) brace. The human vertebral column has a tendency for forward leaning. In patients with fractures of the vertebrae and caries spine, this kyphotic bend is aggravated. If this progressive forward bending is not arrested, the diseased bony components may protrude posteriorly, thereby causing damage to the spinal cord. When the ASH brace is applied anterior to the trunk, it provides a solid strut to the vertebral column. This anterior brace has a definite mechanical advantage since it supports the forward bending spine. Hence the utility of ASH brace has now increased in early rehabilitiation of the patients.
ASH brace, by virtue of its mechanical support prevents further collapse of the vertebrae, supports the ligaments and muscles of the spine, provides a sense of comprehensive stability, reduces pain and thereby helps in early and comfortable ambulation.
SOMI Brace
Sterno occipito mandibular immobilization collar provides a near rigid immobilization of the cervical spine. This is used to prevent any untoward movement of the cervical spine during the phase of ambulation in cervical spine injuries. It is used in whiplash injuries, certain fractures or dislocations involving the cervical spine. SOMI brace helps in ambulation and early rehabilitation of the patient with a cervical spine injury.
CERVICAL COLLAR
The cervical spine may be adequately immobilized by the use of a cervical collar. Though certain consultants are sceptical about the role of cervical collar, its use in orthopedics 176has stood the test of time. Cervical collar is of two types—Hard and Soft.
A hard cervical collar is used in painful conditions of the neck like cervical disk syndrome and cervical spondylosis. It relieves muscle spasm and reduces painful movements of the neck. A hard cervical collar also reduces the impact on the cervical spine due to travel on bumpy roads. The soft cervical collar is useful for office and domestic work. But prolonged use of the cervical collar causes wasting of the paraspinal muscles of the neck. Hence cervical collar must be used along with drugs and other physiotherapeutic measures till the pain subsides. The patient is encouraged to strengthen the muscles of the neck by appropriate exercises and then advised to avoid the collar. Also see chapter 1. The Philadelphia collar is a modification of the hard cervical collar, which has extensions to the chin and occiput. This provides a slightly better immobilization of the cervical spine than the ordinary collar.
LUMBOSACRAL CORSETTE
Next to the spectacles, the lumbosacral corsette is the most widely used othosis. It is often called the lumbar belt. The design and the purpose of a lumbosacral corsette are distinctly different from the abdominal binders which are used in mothers soon after delivery. The abdominal binder holds the lax muscles of the anterior abdominal wall, whereas the lumbosacral corsette supports the lumbar spine. It usually fits well if it is tailor-made for the specific patient. (Also see chapter 7).
AXILLARY CRUTCHES
Axilliary crutches are used when the situations do permit the patient to bear weight on the injured or diseased lower limb, while the other limb is normal. When axillary crutches are used, most of the weight of the body is borne by the upper limb through the axillae. A pair of axillary crutches allows the patient to walk around, without seeking the help of another person.
Axillary crutches are mostly used in amputees. Early ambulation of the patient with crutches help to promote healing of the stump, regain the power and tone of muscles of the stump and above all brings back the self confidence of the patient. Axillary crutches are also used temporarily for a few weeks, during fracture healing, after internal fixation or any other operative procedures in the lower limbs. Axillary crutches help in the non-weight bearing or partial weight bearing phase of the ambulation and recovery.
Though walking with axillary crutches appears to be easy, the patient requires standing balance and gait training during the first few days by a physiotherapist, just like learning to cycle in the teenage.177
ELBOW CRUTCH
When the patient uses axillary crutches, most of the weight of the body is transmitted to the ground from the axilla through the crutches.
But when we want the patient to throw some of his weight in the limb that is recovering, an elbow crutch comes in handy. Here, the weight of the body is transmitted through the stick which is supported by the entire forearm. Since the weight is borne by the entire forearm, the patient feels more stable and comfortable than with the common walking cane (The one used by older people).
TRIPOD WALKING AID
The principle and uses of the tripod walking aid are similar to those of the elbow crutch. The subtle difference being, while the entire forearm bears the weight while using an elbow crutch, it is the wrist and hand that support the body when walking with a tripod walking aid.
Walker
The advantages of using a walker are: Both the upper limbs are used, the hand grip on the walker is firm, and the patient feels confident while standing and walking.
Walkers are more advantageous especially in older patients, during the phase of rehabilitation of many lower limbs that are operated especially hemiarthroplasty, trochanter fractures and fractures of the long bones.
Footwear
A normal chappal with microcellular rubber (MCR) sole and raised heel reduces the pain in painful conditions of the heel like plantar fasciitis, bursitis and retrocalcaneal bursitis.
The sole of the foot wear is manufactured with a medial arch support for the patient with flatfoot or pes planus. This is very useful in children and avoids pain in the foot; but the child must be encouraged to practise intrinsic foot muscle exercises.
All diabetic patients should be educated about proper care and hygiene of the foot. They must be advised to wear covered foot wear like shoes or boots. Trivial injuries over desensitized toes can cause chronic diabetic ulcers. Hence, shoes with toe box protect the toes while walking. The sole of the shoe should be made of MCR.
Modified foot wear are very useful in numerous abnormal conditions of the foot, like painful heel syndrome, pes planus, metatarsalgia and diabetic foot. The heel and sole of the foot wear are made of alternate layers of hard rubber and microcellular rubber. This MCR provides a cushioning effect, thereby reducing the pressure exerted on the weight bearing points of the foot.
KNEE BRACE
The knee joint is adequately immobilized by a knee brace. This is a long leg brace that is made of canvas with steel rods incorporated. This can be fitted to the lower limb and is fastened by Velcro straps. This knee brace provides an excellent immobilization for the knee joint. This is very useful in ligamentous injuries of the knee, intra-articular fractures and in the postoperative management of fractures of the tibial condyles. The advantage of the knee brace over the POP cast is that, it can be removed daily for proper hygiene of the skin and permits quadriceps exercises. Since it is light weight, the patients feel more comfortable during the phase of gait training.
FOOT DROP SPLINT
Weakness of dorsiflexion of the ankle disturbs normal walking. The patient is not able to raise his toes and hence has a high stepping gait, to prevent injury to the dorsum of the toes. Similarly, an equinus contracture of the tendoachilles does not help in recovery of the normal gait. A foot drop splint prevents this equinus deformity. A detachable foot drop splint is made of aluminium with straps and Velcro fasteners. A foot drop splint is useful in the management of lateral popliteal nerve injuries. Since it can be removed and reapplied it does not disturb electrical stimulation and exercise therapy.
AMPUTATIONS
Amputation is severing or dismembering a part or whole of the limb. Amputation is no more considered to be a mutilating surgery. Instead, it is a reconstructive surgery by which a dead, dying or a dangerous limb is converted into a functional organ called stump.
- Gas gangrene
- Crush injury with loss of distal viability
- Vascular injury with impending gangrene
- Gangrene due to diabetes, atherosclerosis etc.
- Incomplete amputation by the injury
- Malignant tumors where limb salvage is not possible
- Certain congenital anomalies and deformed limbs.
Types of Amputation
- Guillotine amputation
- Regular amputation.
Guillotine Amputation
Sectioning the distal part of the limb and leaving the proximal end open is termed guillotine amputation. In life threatening situations, guillotine amputation is performed as an emergency procedure, where the limb is sacrificed to save the life of the patient. After guillotine amputation, when the systemic shock is corrected with fluids, drugs and blood transfusion, the general condition improves.
Revision of the guillotine stump is performed as a reconstructive procedure at a later date, when the general condition of the patient and local condition of wound have improved.
Regular Amputation
Regular or revision amputation is an operative procedure by which, after dismembering the distal part of limb at the desired level, the proximal part of the limb or the stump is reconstructed with adequate muscle flaps and skin cover.
The commonest procedure that any orthopedic surgeon would have performed is the below knee amputation. The operative procedure of below knee amputation was described by Burgess. After sectioning the tibia and fibula, the bulk of the gastrosoleus muscles are used to cover the ends of the bones. Long skin flaps are used to provide a good and healthy skin cover.
Because of the advanced tech-niques of fabrication of the pros-thesis, the length of the stump is not relevant nowadays. But an ideal stump is a healthy stump if it has the following features:
- Good skin cover that is healthy
- Scar devoid of sinus and adhesions
- Bulky muscle cover
- Muscles that move the stump should have adequate power
If the above conditions are fulfilled, an appropriate prosthesis can be worn. If the stump and prosthesis match each other well, the patient will have a near normal gait.
PHANTOM PAIN
During the procedure of amputation, the motor and sensory nerves that were supplying the distal part of the limb are also cut. But the surgical cut does not prevent the sensory and mixed nerves from sending impulses to the brain. Moreover, the cortex of the brain has to “learn” the absence of the missing part of the limb.
If the nerves have not been cut properly, the cut ends are smudged. This causes a ‘Stump neuroma’ and there is persistent pain at the tip of the stump.
Certain patients feel the presence of the limb after it has been removed. When they close their eyes, they feel that the limb is there and they even try to move the “missing part”. Some patients feel and are even able to move the individual toes of the limb. They have to see and realize the loss of the limb. This feeling of the presence of the amputated part of the limb is called phantom sensation, e.g. a patient with a below knee stump may feel an itching sensation in his great toe.
Some patients feel a dull aching or even an excruciating pain in the missing limb. Though, when alert, he realises the structural absence of the limb, he insists the presence of the limb and pain in the missing segment of the limb. This is called Phantom pain. Some patients mention about the discomfort due to pain even when they are awake or alert. Though they realise the absence of the segment of the limb, they insist that they feel the pain.
The feeling of the presence or the pain in the missing segment of the limb is not functional or malingering. Many hypotheses have been postulated for the phantom limb and phantom pain. The crushing of the cut ends of the large nerves, or entangling of the fresh axons in the fibrous tissue causes disturbances in nerve conduction. The cut end of the mixed nerve sends continuous abnormal impulses to the brain resulting in the patient feeling the presence of the limb. This seems to be one of the acceptable reasons.
Drugs like carbamazepine (200 mg–400 mg tds oral) the side effects are the rashes, water retention and hyponercemia. Gabapentine (300 mg–600 mg od), the side effects are the sedation and tiredness along with diazepam (10 mg tds) are used in the initial phases of phantom pain. Electrotherapy and cryotherapy have also been tried. TENS has proved to be effective in substantially reducing phantom pain, since it stimulates the larger diameter nerve fibers and thereby prevents the smaller diameter fibers from transmitting the impulses of pain to the posterior column of the cord. Adequate reassurance and counselling will improve the confidence and morale of the patient. Early ambulation with walking aids and fitting of the appropriate prosthesis are effective methods in the management of phantom pain.
Caution: Great caution should be exercised when amputations are performed in the upper limb. When situations demand amputation of the fingers, the end of the stump should be covered adequately to restore the prehensile sensation.181
PROSTHESIS
A mechanical device that replaces the missing part or the whole of the limb is the prosthesis.
Upper Limb
God's finest creation is the human hand. It is so unique, that no man made hand can substitute for the original human hand, which can draw paintings, play the veena and dextrously design computers.
Most of the prostheses that are fabricated for the upper limb serve the purpose of the cosmetic replacement. The mechanical hand is designed with polymers of various colors which resemble the opposite hand.
Some of the functional prosthetic hands have mechanical devices which can perform the “hook” function of the hand. Advanced techniques have ventured to improve the mechanical hand to perform specialized functions. Most of these operate with the aid of computer technology incorporated in them.
Lower Limb
The above knee prosthesis that is used for an above knee stump has a mechanical knee joint and a foot with solid ankle cushion heel. The various types of mechanical joints that have been improved with various craftsmanship and electronics, permit movement with stability.
The Symes amputation is performed for crush injuries and gangrene of the foot. In this procedure, the foot is disarticulated at the level of the ankle joint and the end of the stump is well covered by the heel pad. A prosthesis that is designed to accommodate the bulky end of the stump and which has a normal cushion foot that suits the stump of Symes amputation is termed Symes prosthesis.
Below Knee Prosthesis
Since accidents and vascular diseases damage the leg and foot more frequently, a below knee amputation is the commonly performed amputation, when compared to other dismembering procedures. Hence the below knee stump is common and the prosthesis that is fabricated for it has been designed with many fascinating features.
A few years ago, the tip of the stump was resting on the upper end of the prosthesis. When walking with this prosthesis the patient had to press on the hollow of the prosthesis with his stump. Hence this was called “End bearing prosthesis”. The constant pressure and friction caused during walking, damaged the skin over the stump leading to many complications like skin diseases, ulcers, abrasions and even osteomyelitis of the end of the sectioned bone.
182To avoid all these complications, now we use a “Side-bearing prosthesis”. When a patient wears a side-bearing prosthesis, the pressure of the stump and the limb are exerted through the sides of the stump. This decreases the pressure and friction over the end, avoiding many complications of the stump. Side bearing prosthesis is used in both the above knee and below knee models.
A modification of the side-bearing principle is the patellar-tendon-bearing (PTB) prosthesis. The skin over the end of the stump does not touch the prosthesis. Instead a modification of the proximal end of the prosthesis is designed to establish a firm contact with the ligamentum patellae or patellar tendon. Hence, when the patient wears the prosthesis and stands, the weight of the body is transmitted to the prosthesis through the patellar tendon. There is no pressure exerted on skin, muscle or bone of the stump. Hence, the tissues of the stump are protected and remain healthy. This type of a below knee prosthesis is called a PTB prosthesis. The leg component has a pylon. The SACH (solid ankle cushion heel) foot is attached to the pylon which permits a near normal gait.
During the early years of fabrication of lower limb prosthesis, this rubber foot was painted with skin colors. Hence patients were forced to wear covered foot wear like shoes or boots for cosmetic purposes. In India, chappals and slippers are more often used than shoes, for both social and religious reasons. Hence the appearance, texture and the consistency of the artificial foot were modified.
The appearance of the dorsum of the artificial foot is designed to resemble normal toes, tendons and even the venous arches. This type of prosthetic foot is the Jaipur foot. The mechanical foot is manufactured with alternating layers of rubber which permit dorsi flexion and plantar flexion.
BONE MINERAL DENSITOMETRY
A detailed explanation of bone mineral densitometry is available in chapter 4. According to the World Health Organization (WHO) guidelines, the study is based on the T-score.
Normal: T-score at or above –1 SD
Osteopenia: T-score between –1 and –2.5 SD
Osteoporosis: T-score at or below –2.5 SD
Here we have the BMD studies of three patients, using the Lunar DPX DXA System: Normal, Osteopenia and Osteoporosis.
Nerve Conduction Velocity
Nerve conduction velocity test determines the speed with which a peripheral nerve conducts an impulse. Along with EMG, nerve conduction velocity study together, provide a complete information about the extent of the nerve injury or disease of the muscle. Nerve conduction velocity can be tested for any superficial nerve that can be stimulated through the skin at two different points. NCV tests are commonly performed on the ulnar, median, peroneal and posterior tibial nerves. Since the radial, femoral and sciatic nerves are located deeper, NCV tests performed on these nerves are not so accurate.
Motor nerve conduction velocity is calculated by measuring the distance between the two points of stimulation and divided by the latency difference. The nerve conduction velocity is expressed in metres/second (m/sec).
The NCV for a sensory nerve can be measured orthodromically or antidromically. In orthodromic conduction, a distal portion of the nerve, e.g. distal nerve is stimulated and sensory nerve action potential (SNAP) is recorded at a proximal point along the nerve. In antidromic sensory nerve conduction, the nerve is stimulated at a proximal point and nerve action potential is recorded distally. 185
The H-reflex is useful in radiculopathy and peripheral neuropathy. It is a monosynaptic reflex elicited by stimulation of the tibial nerve and recorded from the calf muscles. The H-reflex is also useful in diseases of the central nervous system.
The F wave is very useful to study the conduction at the most proximal portion of the axon. It is elicited by stimulating the peripheral nerve at a distal site, leading to both orthodromic and antidromic impulses. While the orthodromic impulse travels to the distal muscle, the antidromic response travels to the anterior horn cell. The 186F wave studies are valuable in conditions like Guillain Barre syndrome, brachial plexus injuries and radiculopathies.
Page numbers followed by f refer to figure and t refer to table
A
Abdominal and pelvic organ disease
Above knee
caliper f
cast f
Acetabular dysplasia
Acid fast bacillus
Activities of daily living
Acute
discitis
disk prolapse , ,
osteomyelitis
in adults
in children
rheumatic arthritis
septic arthritis
Adolescent scoliosis
Amikacin
Amputations
Ankle and foot
Ankylosing spondylitis , , , , , , , ,
Anterior
cruciate ligament of knee
dislocation of shoulder f
drawer sign
spinal hyperextension
Arthritis ,
Arthrodesis
Arthropathy
Arthroplasty
Arthroscope
Austin Moore prosthesis f
Avascuar necrosis
Avulsion fracture
Axillary crutches
Axonotmesis
Azathioprine
B
Bacterial osteitis
Bandages
Barlow's test
Below
elbow cast f
knee
caliper f
cast f
prosthesis , f
Bilateral
congenital talipes equinovarus f
genu varum f
paraspinal muscle spasm
Ponseti casts f
sacroiliac arthritis f
Bipolar hemiarthroplasty f
Blood sugar
Body mass index
Bone
and joint infections
densitometry
mineral densitometry
tumors
Boutonniere deformity
Brachial neuralgia
Bursitis
C
Calcification of ligaments f
Callus
Card test
Central disk prolapse
Cervical
collar , f
rib ,
spine f,
spondylosis , , f
traction
Chloroquine
Chondritis
Chondromyxoid fibroma
Chronic
arthritis
low backache
osteomyelitis
in adults
in children
left femur f
of tibia f
Cincinnati procedure
Cirrhosis of liver
Classification of
massage
nerve injuries
Closed fracture
Clubfoot boot f
Cobb's angle
Cold abscess , f
Colles’ fracture , f
Comminuted fracture of left trochanter f
Common
congenital anomalies ,
nerve palsies
Compartment syndrome
Complications of fractures
Compound fracture both bones leg f
Congenital
dislocation of hip
pes planus
pseudoarthrosis of tibia
radial club hand
talipes equinovarus
Connective tissue disorder
Conservative
management , ,
methods
Consumption disease
Coronary artery diseases
Crush syndrome
Cryotherapy ,
Cubitus varus ,
Cushing's syndrome
Cut injuries
Cyclophosphamide
Cyclosporine
Cytotoxic drugs
D
Deep heat
Degeneration of
joints ,
sacroiliac joint
Degenerative arthritis
Dequervain's disease
Dexamethasone
Diabetes mellitus , , , , ,
Diabetic arthropathy
Direct current for fracture healing
Diseases
causing obesity
modifying antirheumatoid drugs
of joints
of ligaments
Disk
degeneration
degenerative disease ,
excision
Dislocation of shoulder joint
Disuse atrophy
of muscles
Dorsal
scoliosis
spine
Drug therapy
E
Elastocrepe bandage f
for wrist joint f
Elbow ,
crutch , f
joint
Electrical stimulation , ,
Electrocardiogram
Electromyogram
End bearing prosthesis
Ethambutol
Ewing's sarcoma ,
Exercise therapy
Exostosis
F
Facetal
arthropathy ,
joint
Faradic
current
stimulation
Fasciculation potential ,
Femoral prosthesis in TKR f
Fibromyalgia syndrome , , , , ,
Fibrositis
Fibrous ankylosis
Figure of 8 bandage f
Finger
drop
multiple deformities f
Flexion strain
Foot
and ankle
drop splint f,
Footwear
Foraminotomy
Fracture
both bones
forearm
of leg
in hand
neck of femur , f
of bony component
of cervical vertebra f
of clavicle
of forearm
of humerus
of left clavicle f
of metacarpals
of metatarsals
of patella
of phalanx
of proximal humerus
of spine
of trochanter
shaft of
femur
humerus , f
trochanter fixed with dynamic hip screw f
Froment's sign
Frozen shoulder
Functional
cast bracing
low backache
unit of spine
G
Gait training ,
Galeazzi's sign
Gallstones
Galvanic
current
stimulation
Ganglion
Generalized muscle wasting
Giant cell tumor
of lower end of radius f
of upper end of fibula f
Gold salts
Gout
Greenstick fracture
Guillotine
amputation
stump of leg f
Gynecomastia
H
Hansen's disease ,
Heating pads
Hemangioma
Hematogenous spread
Hemiarthroplasty
Hemivertebra
Hemophilic arthritis
Herpes zoster
Hip ,
spica , f
Hydrotherapy ,
Hyperlipidemia
Hypertension
Hypothalamic dysfunction
I
Ideal food pyramid f
Immobilization
Infection of joints
Infective
arthritis ,
discitis ,
Inflammatory arthritis
Injection palsy ,
Injuries of ligaments
Interferential therapy ,
Interlocking nail of tibia
Intervertebral disk
Intrinsic plus deformity
Irregular articular surfaces of patellofemoral joint f
Isoniazid
J
Jaipur foot f
Joint stiffness ,
Juvenile
arthritis
rheumatoid disease
K
Kirschner wires
Knee
brace ,
joint
Kocher's method
L
Lachman test
Laminectomy
Lateral popliteal nerve , ,
Leflunomide
Ligamentous strain
Limb reconstruction system
Linezolid
Loose bodies f
Loss of
lumbar lordosis
lumbar lordosis in caries spine f
Low
backache ,
dose methotrexate
Lower limb ,
Lumbar
spine
spondylosis , ,
Lung disorders
Lymphoma
M
Magnetic resonance imaging ,
Male hypogonadism
Malignant bone tumors
Malleolar screw f
McKenzie technique
Medial
collateral ligament of knee
joint
line tenderness f
space narrowing f
Median nerve , ,
Menstrual disorders
Metabolic arthritis
Methotrexate
Miscellaneous arthritis
Mode of injury
Modified Turco's procedure
Monteggia
and Galeazzi fractures
fracture dislocation
Morning stiffness
Morrant Baker's cyst
MRI of spine f
Multiple myeloma
Muscle
diseases
sign
spasm
Mycobacterium tuberculosis
Myeloma
Myelopathy ,
Myositis ossificans. , f, ,
N
Nerve
conduction velocity ,
injuries ,
Neural foramen
Neurogenic claudication ,
Neuromuscular electrical stimulation
Neuropathic joint
Neuropraxia
Nonspecific pyogenic arthritis
Nonsteroidal antiinflammatory drugs
Normal lordosis f
O
Obesity
Occupational hazard
Old fracture ,
Open
fracture
wounds
Operation for drainage of psoas abscess f
Operative
photographs of total knee replacement f
procedures
Organs in abdomen
Orthosis ,
Ortolani's test
Osteoarthritis
Osteoarthrosis , ,
of knee
Osteoblastoma
Osteochondroma ,
of femur f
Osteoid osteoma , ,
of tibia f
Osteomyelitis ,
of left femur f
Osteophytes ,
Osteoporosis , ,
Osteosarcoma ,
of humerus f, f
P
Pain neck
Painful heel syndrome
Paraparesis
Patellar-tendon-bearing
cast f
prosthesis
Patellofemoral
joint f
osteoarthrosis f
Pedicular screw system f,
Pelvic traction
Pelvis
Pendulous abdomen
Penicillamine
Periarthritis shoulder , ,
Pericapsular adhesions
Peripheral neuropathy
Phantom
pain
sensation
Physiotherapy ,
Plaster
immobilization ,
of Paris
Polycystic ovaries ,
Polydactyly
Polymyalgia rheumatica ,
Ponseti
cast
method
Popliteal nerve palsy f
Position of function
Positive sharp waves ,
Positron emission tomography
Posterior dislocation of elbow f
Postural cervical torticollis
Prednisolone
Primary
osteoarthrosis
repair of nerve
tumors of bone
Prosthesis ,
Proximal interphalangeal joints
Pseudogout
Pseudoparalysis
Psoriatic arthritis
Pulled elbow
Pyrazinamide
Q
Quadriceps exercises
R
Radial
meromelia
nerve , , ,
Reaction of degeneration test
Reactive arthritis
Regular amputation
Reiter's
disease ,
syndrome
Restoration
Restriction of movements of spine
Rheumatoid
arthritis , , ,
nodules
spondylitis
Rifampicin
Right below elbow cast f
Robert Jones strapping
S
Sacroiliac
arthritis ,
ligament
Scaphoid cast
Sciatica
Secondary
osteoarthrosis
strain
tumors
in spine
of bone
Seddon's classification
Segmental loss of bone
Septic arthritis ,
Seronegative spondyloarthropathy ,
Severe spondylosis f
Short wave diathermy
Shortening of leg
Shoulder joint
Side-bearing prosthesis
Skeletal tuberculosis
Sleep apnea
Solitary bone cyst
Somi brace
Spina bifida ,
Spinal
cord
orthosis ,
Splints
Spondylolisthesis , ,
Spondylolysis ,
Spondylosis
Sprained ankle ,
Static wrist drop splint f
Stiff joints
Stills’ disease
Straightening of cervical spine f
Streptomycin
Stress fractures
Sulfasalazine
Superficial heat
Supracondylar fracture
fixed with dynamic compression screw f
of humerus
Supraspinous ligament
Swan neck deformity
Sweat test
Swelling of pip joint of long finger f
Syndactyly ,
Synovectomy
Synovial chondromatosis
Synovitis
Systemic lupus erythematosus
T
Tendo-achilles lengthening
Tennis elbow ,
Tenosynovitis
Thompson's prosthesis f
Thoracolumbar scoliosis
Thumb drop
Tight bandages ,
Total joint replacement
Tourniquette palsy ,
Transelectrical nerve stimulation
Transcutaneous electrical nerve stimulation
Trendelenburg's test
Triple arthrodesis
Tuberculosis , , ,
Tuberculous
arthritis
dactylitis
Tumors
in spinal cord ,
of uterus
Types of amputation
U
Ulnar
claw hand with hypothenar wasting f
drift of fingers f
nerve , , ,
Ultrasound therapy
Unicameral bone cyst of fibula f
Upper limb orthosis
Urogenital system
V
Vancomycin
Vasculopathy
Vibratory manipulations
Volkmann's
ischemic contracture , , ,
sign
W
Walker f
Wasting of thenar eminence f
Wax bath
Weight relieving caliper
Wound lavage
Wrist drop
X
X-ray of
ankle f
extensive osteoarthrosis f
fracture
neck of femur with screws f
of patella f
shaft of femur f
GCT of upper end of fibula f
lumbar spine f
normal elbow f
total knee replacement f