Orthopaedic Conditions

Acute Septic Arthritis

• Keep the joint in position of comfort.
• Aspiration of the joint for gram staining, culture and sensitivity.
• If aspirate is purulent drainage of the joint on an emergency basis.
• Drain the joint even if the joint aspiration is doubtful in the presence of a strong clinical suspicion, because the risks of negative arthrotomy are far too less than not draining an infected joint having pus. The latter situation may be disastrous for the joint resulting in lifelong permanent disability to the patient.
• After drainage splint the joint with a POP slab or skin traction to relieve pain and prevent contractures till the patient is afebrile, pain free and the joint is clinically quiescent. Intermittent mobilization is permitted to preserve the range of movement of the joint.

Pharmacological

The choice of antibiotics, duration of therapy and monitoring of the therapy are same as mentioned in the section on acute pyogenic osteomyelitis

References

1. Osteomyelitis and Septic Arthritis. In: Nelson’s Textbook of Paediatrics Waldo E Nelson, Richard E Berhman, Robert M Kliegman, et al (eds), 15th Edition, 1996, WB Saunder Company (Printed in India-Prism Books Pvt. Ltd., Bangalore) 1996.
2. Bone and Joint Sepsis. In: Lovell and Winter’s Paediatric Orthopaedics, Morissy RT, Weinstein SL, Vol. 4, 1996, Lippincott Raven, Philadelphia.

Acute Pyogenic Osteomyelitis

1. Inj. Cloxacillin 50-100 mg/kg/day in four divided doses for 1-2 weeks
2. Inj. Gentamicin 5-7.5 mg/kg/day in 2 divided doses for 1-2 weeks Or Inj. Amikacin 15 mg/kg/day in 2-3 divided doses if resistant Pseudomonas aeruginosa.
   Or
   1. Inj. Ceftriaxone 100 mg/kg/day in 2 divided doses for 1-2
   weeks(maximum dose 2 g/day).
   Or
   Inj. Cefotaxime 100-200 mg/kg/day by I V infusion or IM or IV in 2-4
   divided doses for 1-2 weeks.
   Or
   If patient is hypersensitive to penicillins and cephalosporins,
   Inj. Clindamycin 40 mg/kg/day in 4 divided doses for 1-2 weeks.
   Or
   If Methicillin resistant Staph. aureus suspected , Inj. Vancomycin by IV infusion 500 mg over atleast 60 minutes every 6 hours or 1g over at least 100 minutes every 12 hours; Neonates upto 1 week 15 mg/kg initially then 10 mg/kg every 12 hours; Infant 1-4 weeks 15 mg/kg initially then 10 mg/kg every 8 hours; child over 1 month 10 mg/kg every 6 hours.
3. Oral/Inj. Paracetamol for fever (see section on fever).

• Duration of antibiotics therapy may be required for a few weeks depending upon the response.
• Plaster (or any other splintage) might be required for prolonged periods.
• Not to make the child walk (in case of lower limb bone involvement) unless permitted.

1. A Comparative Study of Osteomyelitis and Purulent Arthritis with Special Reference to Aetiology and Recovery Infection, 1984, pp 12: 75.
2. Osteomyelitis and Septic Arthritis. In: Nelson’s Textbook of Paediatrics, Waldo E. Nelson, Richard E. Berhman, Robert M. Kliegman et al (eds), 15th Edition, 1996, W.B. Saunder Company, (Printed in India-Prism Books Pvt. Ltd., Bangalore).
3. Bone and Joint Sepsis. In: Lovell and Winter’s Paediatric Orthopaedics, Morissy RT, Weinstein SL (eds), Vol. 4, 1996, Lippincott – Raven, Philadelphia.

Sprains

• Restrict the movement of the affected area.
• Apply cold compresses immediately (this will help to reduce swelling).
• Avoid using ice directly on the skin.
• Elevation of the limb above the level of the heart- especially at night while sleeping.
• In a grade I sprain, apply a compression bandage for a period of 5-7 days, patient may be allowed to bear weight after a week.
• In a grade II sprain, splintage (slab later on converted to cast) may be used to restrict joint motion, but the patient has to remain non-weight bearing for 4-6 weeks.

1. Tab. Ibuprofen 400 mg 3 times a day for 5-7 days.
   Or
   Tab. Diclofenac sodium 50 mg 3 times a day for 5-7 days.
   Or
   Tab. Nimesulide 100 mg 2 times a day for 5-7 days.
   Refer the patient to an Orthopaedic Surgeon if a fracture is suspected or if there has been a serious injury (grade III sprain with instability) or persistent pain (delayed recovery of grade I or II sprain), there is an audible popping sound and immediate difficulty in using the joint and distal neurovascular status is doubtful.

• Don’t massage the area or do hot fomentation in acute stage. It will increase the swelling
• To give rest to the injured area until the pain subsides (usually 7 to 10 days for mild sprains and 3 to 5 weeks for severe sprains.
• Avoid activities that cause pain or swelling.
• Practice moderation in physical activities.
• If the pain and swelling decreases within 48 hours after a sprain, move the affected joint in all directions.
• To avoid high heeled shoes (for ankle sprains).

Apley’s System of Orthopedics and Fractures, 6th edition,1982, Butterworths and Co. London.

Cervical And Lumbar Spondylosis

• In acute painful situation rest, moist heat in cold weather and light massage (improves tone, circulation & elasticity) to paraspinal muscles. Cervical traction in the position of maximum comfort to neck (5-10 pounds) for 10-15 minutes. Ultrasonic exposure on painful trigger points in cervical & shoulder muscles. Removable soft cervical collar/back corset/ back belt for symptomatic relief.
  (No exercises in acute painful situation).
• In chronic pain mobilization and strengthening exercises, moist heat and cervical traction.

• In cervical spondylosis avoid prolonged desk work, if must, then intermittent rest is required and proper writing, typing, sitting posture (avoid low table, use tilt table) and care of the neck.
• In lumbar spondylosis explain the patient how to manage weight since extra weight puts greater stress on the back muscles and to maintain proper body alignment while standing with feet slightly apart. When standing for long periods, use a small stool to keep one foot up with knee bent.
• Do not tense up or concentrate on standing up straight, just stand naturally.
• Try to avoid carrying heavy bags on shoulders.
• Care of back while sitting by using well designed fully adjustable chair to provide plenty of support to the lower back. If chair is uncomfortable use a rolled up towel or small pillow to support the back. When sitting for long periods rest your feet on low stool and use arm rests to support weight of your body. Try not to sit in the same position for long periods.
• If prolonged sitting is must take rest for a minute or two every hour.
• To lift weight cautiously by keeping the back as much upright (vertical) and straight (not hunched over) as one can. Not to bend over at waist to pick up the object instead squat, get under or next to object not on top of it. Lift with your leg muscles rather than back or abdominal muscles. Hold the object close to your body while lifting and carrying and do not twist your body.
• To sleep safely on a firm bed. While sleeping supine legs should be supported with pillows. Not to sleep on your stomach. Sleeping on your side with knees bent and hips tilted forward is probably the best.
• Refer to a higher centre in case of severe pain that disturbs sleep/not responding to conservative treatment for more than 2 weeks/associated with severe restriction of neck or back movements or torticollis or sciatic pain or constitutional symptoms/neurological symptoms with back or neck pain.

Rheumatoid Arthritis (RA)

1. In acute inflammation any of the NSAIDs as given in section on osteoarthritis may be given except paracetamol. The anti-inflammatory action of the NSAIDs may take 2-4 weeks to become evident.
   Prediction of response to a particular disease modifying antirheumatic drugs (DMARD) is not possible. It takes 4-6 weeks to show its effect.
   Reduced NSAID dosages have to be used in the elderly and in patients with impaired renal function. Concomitant use of more than one NSAID only increases toxicity, and has no additional benefit. Patient not responding to one NSAID may still show a good response to another.
2. Topical applications- containing salicylates, capsaicin, nicotinates, menthol, camphor, NSAIDs in various combinations may provide symptomatic relief.
3. Refer to a specialist (physician) at a higher centre. Begin DMARD early in the disease.
4. Tab Methotrexate 7.5 mg to 15 mg every week. Concomitant Folic acid 1 mg/day reduces side effects.
   (CAUTION: Nausea, mouth sores, liver damage, increase in incidence of chest infection, macrocytic anaemia. Regular monitoring of LFT is required. Avoid alcohol during therapy).
5. Only in patients with severe disease, affecting activities of daily living and not responding to adequate trial of NSAIDs and DMARD for sufficient duration:
   Tab. Prednisolone 40-60 mg/day for 2-4 weeks. Review periodically and possibly taper down slowly. If required for a longer duration administer at doses of 5-10 mg/day.
   Intra-articular corticosteroids: Methylprednisolone acetate, 20-80 mg be needed in selected cases with predominantly monoarticular arthritis of a large joint.

• The disease can be controlled but no curative agent is known. There can be remissions and exacerbations.
• At the onset of disease it is difficult to predict the natural history of an individual patient’s illness.
• No characteristic features of patients have emerged that predict responsiveness to a particular DMARD.
• Life style modification may be required depending on the degree of disability.
• Regular mild exercises as prescribed by the doctor helps in prevention of deformity, maintain range of motion of the joints and muscle strength.
• Magic drug for rheumatic arthritis might contain steroids. Better to consult a qualified doctor before taking it.

1. Rheumatoid Arthritis. In: Harrison’s Principles of Internal Medicine. Fauci AS, Braunwald E., Kurt J Isselbacher et al (eds), 14th Edition, 1998, McGraw Hill Company Inc., International Edition.
2. Rheumatoid Arthritis. In: Conn’s Current Therapy. Robert E. Rakel (ed), 1999, WB Saunders Company, Philedelphia.

Osteoarthritis (OA) Knee

• Weight reduction (if overweight); ice fomentation for acutely swollen knee, however, hot fomentation may give symptomatic relief to some chronic patients.
• Supervised non-traumatic muscle conditioning and rehabilitation regimens e.g. Isometric quadriceps strengthening exercise (all vigorous exercises to be avoided in acutely swollen/painful knee).
• Compressive bandage or crepe bandage for effusion.
• Assistive devices like cane (to be held in the hand contralateral to more painful side), walker for patients with severe deformities or unsteady gait.

1. Topical applications- containing salicylates, capsaicin, nicotinates, menthol, camphor, NSAIDs in various combinations may provide symptomatic relief.
   (CAUTION: Avoid hot fomentation immediately after topical applications).
2. Non-steroidal antiinflammatory drugs (NSAIDs) for pharmacological pain palliation. The choice of NSAID depends upon dosing convenience, physician and patients comfort, price and the past experience on its frequency and severity of side effects as all are equipotent in full therapeutic dose. (Avoid intraarticular or oral steroids).
   
   Table 1. Commonly used NSAIDs for OA Knee

   A. Acute painful situation/moderate pain (for initial 7-14 days), preferably take NSAIDs after meals Tab. Paracetamol 500 mg 4-6 hourly (maximum daily dose 4000 mg). Or Tab. Ibuprofen 400 -600 mg 2 or 3 times a day (maximum daily dose 3200 mg). Or Tab. Diclofenac sodium 50 mg 3 times a day or 75 mg 2 times a day (maximum daily dose 200 mg). Or Tab. Nimesulide 100 mg 2 times a day (maximum daily dose 400 mg). Or Tab. Aspirin 350 mg 2 tablets 4-6 hourly (maximum daily dose 5000 mg).B. For mild to moderate pain/chronic pain control (for 3-6 weeks and then SOS). All above medicines in reduced frequency of dosages. Or Alternative forms -Tab. Diclofenac sodium 100 mg/75 mg sustained release once a day. Or Tab. Piroxicam 20 mg once a day. Or Tab. Nimesulide 100 mg 2 times a day.

   All patients do not uniformly respond to a particular NSAID. It is not unusual for several different NSAIDs to be tried before a suitably effective and well-tolerated agent is identified for a particular patient.
   (CAUTION: The NSAIDs may cause dose related gastric irritation, nausea, vomiting and dyspepsia, GI ulceration, perforation and haemorrhage, however, one third remain asymptomatic. NSAIDs can interfere with antihypertensive therapy due to salt and water retention).

3.  In case of epigastric burning or nausea or vomiting either discontinue and switch over to safer NSAID or administer Cap. Omeprazole 20 mg half an hour before        breakfast and half an hour before dinner.

In patients on prolonged therapy with NSAIDs monitor haemoglobin, stool for occult blood as these drugs may also cause leukopenia,
thrombocytopenia and agranulocytosis.

Refer the patient to an orthopaedic surgeon in case of persistent swelling, presence of constitutional symptoms or mechanical symptoms like locking or frequent giving away sensations. Surgical intervention may be required for severe deformities, contractures, and advanced disease with intractable pain, severe enough to affect independent performance of activities of daily living, for prolonged periods.

• There is no curative pharmacological agent for osteoarthritis knee and the disease is irreversible.
• Nonpharmacological treatment has a major role to play in treatment.
• Take minimal possible medication that provide symptomatic relief and to wait for 1-2 weeks, for drug to show its effect.
• Topical applications do not penetrate into the joint through skin directly.
• Intra-articular steroid Injections give only temporary relief and risks of repeated intra-articular injections far outweigh its advantages.
• To avoid those activities which exacerbate pain like sitting cross legged or squatting on floor.
• To use ramp instead of stairs wherever feasible.
• Not to do vigorous exercises with acutely inflammed knee.
• To report back if recurrent effusions in knee or systemic symptoms.
  Former may be caused by mechanical disorder along with OA knee like loose body or meniscal tear. Later situation could be caused by diseases of knee other than OA.

References

1. Acetabular Bone Destruction Related to Non Steroidal Antiinflammatory Drugs. Lancet 1985, pp 2: 11-4.
2. Osteoarthritis. In: Harrison’s Principles of Internal Medicine, Vol 2, 14th Edition, 1998, McGraw Hill Company Inc., International Edition.
3. Osteoarthritis. In: Conn’s Current Therapy, Robert E Rakel (ed), 1999, WB Saunders Company, Philedelphia.