Office Orthopedics for Primary Care: Treatment issue orthopedics, general practice

328 Pages·2006·17.53 MB·English

by  Bruce Carl Anderson

1600 John F.Kennedy Blvd.
Ste 1800
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OFFICE ORTHOPEDICS FOR PRIMARY CARE:TREATMENT ISBN 1-4160-2206-6
Copyright © 2006, 1999, 1995 by Elsevier Inc.
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Notice
Knowledge and best practice in this field are constantly changing.As new research and experience
broaden our knowledge,changes in practice,treatment,and drug therapy may become necessary or
appropriate.Readers are advised to check the most current information provided (i) on procedures
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responsibility of the practitioners,relying on their own experience and knowledge of the patients,to
make diagnoses,to determine dosages and the best treatment for each individual patient,and to take
all appropriate safety precautions.To the fullest extent of the law,neither the Publisher nor the
Editors assumes any liability for any injury and/or damage to persons or property arising out of or
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Library of Congress Cataloging-in-Publication Data
Anderson,Bruce Carl.
Office orthopedics for primary care:treatment / Bruce Carl Anderson.—3rd ed.
ISBN 1-4160-2206-6
1.Orthopedics. 2.Primary care (Medicine) I.Title.
RD732.A53 2006
616.7—dc22
2005046537
Acquisitions Editor:Rolla Couchman
Developmental Editor:Matthew Ray
Publishing Services Manager:Frank Polizzano
Project Manager:Lee Ann Draud
Design Direction:Karen O’Keefe Owens
Printed in the United States of America
Last digit is the print number:9 8 7 6 5 4 3 2 1
Office Orthopedics for Primary Care: Treatment (Third Edition)
Copyright © 2006 Elsevier Inc. All rights reserved
Author(s): Bruce Carl Anderson, MD
ISBN: 978-1-4160-2206-0
Table of Contents
Copyright Page iv
Dedication Page v
Prefac, e Pages vii-viii
Acknowledgm, ents Page ix
Section I: The 67 Most Common Outpatient Orthopedic Conditions
Chapter 1 - ,N eck Pages 2-16
Chapter 2 - Shoulder Pages 17-49
Chapter 3 - E, lbow Pages 50-64
Chapter 4 - W, rist Pages 65-85
Chapter 5 - H, and Pages 86-103
Chapter 6 - C, hest Pages 104-110
Chapter 7 - Back Pages 111-125
Chapter 8 - Hip Pages 126-145
Chapter 9 - Knee Pages 146-177
Chapter 10 - Ankle and Lower Leg Pages 178-209
Chapter 11 -, Foot Pages 210-224
Section II: Fractures, Diagnostic Procedures, and Rehabilitative Care
Chapter 12 - Fractures Frequently Encountered in Primary Care Pages 226-241
Pages 242-244
Chapter 13 - Radiology and Procedures
Chapter 14 - The Most Commonly Used Supports, Braces, and Casts Pages 245-264
Pages 265-293
Chapter 15 - Exercise Instruction Sheets
Appendix - Fractures, Medications, and Laboratory Values Pages 294-300
References Pages 301-313
Index Pages 315-324
To the pioneering work of
P. Hume Kendall of the Department of Physical Medicine,
Guy’s Hospital,London,England
and
Joseph L.Hollander of the Arthritis Section,
Department of Medicine,Hospital of the University of Pennsylvania,
Philadelphia,Pennsylvania
P R E F A C E
Over the last 60 years, corticosteroids have been used hydrocortisone by local injection has proved of great
to treat acute and chronic inflammation of a wide variety value in the treatment of isolated joint and soft-tissue
of diseases.Cortisone was originally identified and subse- disease.”And “It is considered that the over-all incidence
quently purified from animal adrenal glands in the 1930s. and morbidity of the side-effects following the local use
Fifteen years later, cortisone and hydrocortisone were of hydrocortisone are so low as not to constitute a
synthesized from bile acids, setting the stage for the contraindication to this method of treatment.”(Ann Phys
clinical application of the glucocorticoid hormone in the Med 4:170–175,1961).
late 1940s.Injectable hydrocortisone was originally used Yet this early enthusiasm about the clinical application
by the rheumatology group at the Mayo Clinic to treat of cortisone for arthritis and local musculoskeletal con-
patients suffering from the acute and chronic inflamma- ditions was short lived.Through the 1960s and 1970s a
tion of rheumatoid arthritis. Soon thereafter, having series of publications appeared that emphasized the
documented hydrocortisone’s dramatic benefit in this serious side effects that occurred when large doses of
select group of patients,the novel treatment was extended cortisone were given over prolonged periods of time.
to the treatment of other arthritic conditions and even- In addition, a number of reports—nearly all single-case
tually to local orthopedic conditions. Over the next 30 reports or anecdotal series of five patients or fewer—
years, hydrocortisone and its derivatives (triamcinolone, showed that local injection of tendons and other soft
methylprednisolone,dexamethasone,and betamethasone) tissue conditions were not without hazard.Local cortisone
were used to treat the entire gamut of conditions charac- injection was implicated in postinjection tendon rupture,
terized by acute and chronic inflammation, from the postinjection atrophy of tissue,and postinjection avascular
mildly inflammatory osteoarthritis and focal tendinitis necrosis of the hip. The constant stream of negative
to the intensely inflammatory gout and systemic lupus reports had the net effect of overshadowing the extensive
erythematosus. Percy Julian—a black educator born in research published by Kendall and Hollander from the
Alabama—is credited with the synthesis of cortisone from 1950s and cast a dark cloud over the use of cortisone,
soy beans in the 1950s. especially local injection of cortisone, over the next 2
The Mayo Clinic pioneered the use of cortisone as an decades.
effective anti-inflammatory medication in the late 1940s Thirty-five studies were published through the 1960s
and early 1950s. Kendall, Henoch, and Slocumb first and 1970s, all of which intimated a direct relationship
administered cortisone by daily injection to patients with between the injection of cortisone and the reported
rheumatoid arthritis.Their results (Mayo Clin Proc 24:181, adverse clinical outcome. However, a closer analysis of
1949), along with those of the studies later published these case reports suggests that other factors may have
by Hollander, Brown, Frain, Udell, and Jessar (JAMA been equally important in affecting the outcome. For
147:1629-1635,1951;J Bone Joint Surg Am 35A:983-990, example,a review of the 23 case reports on postinjection
1953;Am J Med 15:656-665,1953),were so significant that tendon rupture,representing 50 combined patients (the
cortisone was originally proclaimed as a “cure for arthritis.” largest published series of 5 patients was published in
Because of its early success with arthritic patients, the Western Journal of Medicine), shows that half of
injectable cortisone was also pursued as a possible anti- these 50 patients were taking systemic steroids at the time
inflammatory treatment for a variety of local orthopedic of injection. More than half of these patients had an
conditions.Kendall,Lapidus,and others published studies underlying connective tissue disease,mostly rheumatoid
in the late 1950s and early 1960s demonstrating cortisone’s arthritis and systemic lupus erythematosus. In addition,
remarkable ability to arrest the persistent inflammation details of the procedures and rehabilitation methods
of tendinitis, bursitis, and other local musculoskeletal were not disclosed in detail in these reports. None of
conditions (Industr Med Surg 26:234-244, 1957; BMJ the studies provided information assessing the severity
1:1500–1501,1955;Ann Phys Med 6:287–294,1962;BMJ of the condition.None provided radiographic studies to
1:1277–1278,1956). determine whether degenerative changes or partial tears
These initial studies were summarized in publications were present. None of the studies supplied details of
and editorials in the early 1960s.Hollander published his the exact method of injection, whether peritendinous,
10-year experience in 1961.His research group performed intratendinous, and so forth. Lastly, none of the 23
100,000 intra-articular injections with a remarkable safety publications provided any detail of the management of the
profile;only a 1 in 10,000 risk of postinjection infection patient following the injection,either to what degree the
was noted (Bull Rheum Dis 11:239–240, 1961). Kendall joint was protected after the injection or the specific
came to the same conclusion,having analyzed 6700 injec- rehabilitation exercises required for recovery.
tions over a 3-year period between March 1954 and March Interestingly,only four tendons were described in these
1957.“Because it exerts a powerful local action and does reports,including the Achilles,patellar,biceps,and rotator
not appear to give rise to any general hormonal effects, cuff tendons (the four largest tendons under the greatest
viii PREFACE
degree of tension and, more important, the tendons important post-treatment rehabilitation exercises are
that undergo a slow degenerative process [mucinoid de- included. Although local corticosteroid injection has
generative thinning] when exposed to chronic inflamma- been emphasized,this book was not intended to be simply
tion, contributing directly to the well-known fact of an “injection manual.”Injection of corticosteroids can be
traumatic rupture).This is in sharp contrast to the tendons exceedingly helpful in assessing and reducing the local
that were not described, namely, the gluteus medius inflammatory reaction to tissue injury. However, it must
tendon at the hip and the intermediate or small tendons not take the place of simpler, less invasive treatments.
of the distal extremities.This disparity begs the question In any given patient,the anti-inflammatory effects of injec-
whether the injection of cortisone or the chronic inflam- tion are as important as restricting use by immobilization
mation and degenerative processes were more important and the physical therapy exercises of stretching and
in the process of tendon disruption. toning.Treatment must be individualized for each patient.
The relationship of corticosteroid injection to avascular There are as many ways to accomplish the same treat-
necrosis of the hip is even more tenuous.Only one publi- ment goals in the field of musculoskeletal medicine as
cation alleges a relationship of local injection to avascular there are conditions. Differences in technique and
necrosis of the hip (Am J Med 77:1119-1120,1984).In this approach are widespread in this overlooked field of
case report, the patient had been treated with multiple medicine.I hope this book can serve as a starting point
injections over an 18-year period.The patient had received for those interested in expanding their expertise in the
at least 200 injections of methylprednisolone at weekly treatment of musculoskeletal disease in outpatients. In
intervals at the trochanteric bursa, upper neck, and addition,I hope that the information contained herein can
olecranon bursa. At the time this patient suffered the bridge the gaps among the disciplines of rheumatology,
acute vascular event, he was frankly cushingoid. Since orthopedics,neurology,and physiatry.
systemic steroids are a well-known cause of avascular Kendall summarized his opinion on the use of corti-
necrosis, the validity of the causal relationship between costeroid injection for local orthopedic conditions by
single injection and avascular necrosis of the hip seems saying,“It is perhaps surprising that an empirical treat-
doubtful.Three publications described local subcutaneous ment such as local corticosteroid injection therapy has
atrophy following injection of corticosteroids (Ann Intern received wide acceptance for the treatment of all the
Med 65:1008-1019, 1966; BMJ 3:600, 1967; J Bone Joint rheumatic diseases. Nevertheless, as an adjunct to the
Surg Am 61A:627-628, 1979). These all occurred in over-all management of these conditions it is now firmly
superficial areas—hand,forearm,and anterior knee.British established and is invaluable.Perhaps the greatest credit
researcher Ann Beardwell commented, “Though local for this can be given to the safety factor:side-effects are
atrophy cannot be regarded as a serious complication so unusual that even should injection prove of no value
of corticosteroid therapy,it is unsightly and may persist the physician may feel secure that harm will seldom
for several years.” result.” After 27 years of clinical practice and residency
Certainly, local corticosteroid injection is not without teaching and the administration of more than 50,000 local
potential problems. However, adverse outcomes can be corticosteroid injections, I agree with his conclusions.
minimized by thoroughly assessing the patient,screening However,I would add that local corticosteroid injection
patients who are at higher risk for infection or tendon for local musculoskeletal conditions is one of the most
rupture,performing a standardized method of injection, predictably successful treatments to reduce and arrest the
prescribing individualized postinjection aftercare instruc- body’s exaggerated inflammatory response to injury only
tions, and adjusting recovery exercises based on close when combined with specific periods of rest, selective
follow-up examinations. The development of ever- use of immobilization, and sequential recovery physical
improving technical skill is extremely important in therapy exercises.
ensuring a favorable response. Fortunately, the pessimism of the 1960s and 1970s is
This expanded third edition has emphasized a com- fading, in large part because of the number of clinical
prehensive approach to the evaluation and treatment of studies that have been published over the last 10 to 15
each individual orthopedic and arthritic condition.When years.Clinicians and researchers of the late 20th and early
more than one technique of injection is possible, the 21st centuries have taken Hollander’s and Kendall’s
safest approach and the ease of administration have been opinions to heart and have reinvestigated the utility of
chosen.The “step-care”treatment protocols; the specific local corticosteroid injection. Longitudinal outcome
postinjection management guidelines;the physical therapy studies and controlled, double-blind studies evaluating
exercise instruction sheets;the illustrations of the various the efficacy of corticosteroids have been published in
braces,casts,and supports;and the detailed descriptions such diverse areas as cervical and lumbar radiculopathy,
of local injection techniques allow the clinician to carpal tunnel, rotator cuff tendinitis, frozen shoulder,
effectively “office manage”90% to 95% of the outpatient lateral epicondylitis, olecranon bursitis, trigger finger, de
medical orthopedic problems while minimizing adverse Quervain’s tenosynovitis, trochanteric bursitis, Morton’s
outcomes.Treatment guidelines provide details on specific neuroma,and gout.Studies reporting on these and other
restrictions. The length of time for immobilization is topics are tabulated in the reference section of the book.
both efficacious and practical. The appropriate timing
and anatomic details of local injection and the extremely Bruce Carl Anderson,MD
A C K N O W L E D G M E N T S
This book represents the outgrowth of 27 years of post- Eastmoreland Hospital,Legacy Emanuel Hospital,and the
residency education and clinical experience, including Sisters of Providence teaching hospitals for their constant
more than 50,000 local procedures,that would not have encouragement, contributions, and critical appraisal of
been possible without the support and encouragement the content of the book.I also wish to thank the medical
from many sources.I wish to thank all the members of directors of the various Portland, Oregon, teaching
the departments of medicine, family practice, physiatry, hospitals for their support,namely,Dr.Nancy Loeb at Pro-
neurosurgery,and surgical orthopedics at the Sunnyside vidence St.Vincent Medical Center, Dr. Steven Jones at
Medical Center, especially Dr. Ian MacMillan of the De- Legacy Emanuel Hospital, and Dr. Don Girard at the
partment of Medicine for his support and assistance in Oregon Health Sciences University.Lastly,I wish to thank
developing the medical orthopedic department,and the Dr. David Gilbert, director emeritus of the Providence
surgeons of the Department of Orthopedics, Dr. Steven Portland Medical Center—my internal medicine residency
Ebner,Dr.Edward Stark,and Dr.Stephen Groman,for their director—for his stimulation to excellence,his encourage-
stimulating feedback.I also wish to thank my extremely ment to examine ever deeper into clinical problems,
capable physician assistant,Linda Onheiber,for her steady and his support and inspiration in my return to clinical
contributions to the medical orthopedic department research.
and all the medical residents of the graduating classes of
2003 and 2004 at Oregon Health Sciences University, Bruce Carl Anderson,MD
CHAPTER 1: NECK
DIFFERENTIAL DIAGNOSIS OF NECK PAIN
Diagnoses Confirmations
Cervical strain (most common diagnosis)
Stress Socioeconomic or psychological issues
Whiplash and related injuries Motor vehicle accident or head and neck trauma
Dorsokyphotic posture Typical posture seen in the elderly or in patients with
depression
Fibromyalgia Confirmation by exam: multiple trigger points;
normal laboratory results
Osteoarthritis of the neck X-ray—cervical series (lateral view)
“Reactive cervical strain” Underlying spinal column, nerves, or cord are
threatened
Radiculopathy Neurologic testing
Vertebral body fracture Bone scan or MRI
Spinal cord injury or tumor MRI
Cervical radiculopathy
Foraminal encroachment X-ray—cervical spine x-rays (oblique views);
electromyogram
Herniated nucleus pulposus MRI
Cervical rib X-ray—cervical series (anteroposterior view)
Thoracic outlet syndrome Nerve conduction velocity/electromyogram
Epidural process MRI
Greater occipital neuralgia Local anesthetic block
Referred pain
Coronary arteries Electrocardiogram, creatine phosphokinase,
angiogram
Takyasu’s arteritis Erythrocyte sedimentation rate, angiogram
Thoracic aortic aneurysm Chest x-ray
Thyroid disease Thyroid-stimulating hormone, thyroxine, erythrocyte
sedimentation rate, thyroid scan
2
NECK 3
CERVICAL STRAIN
Enter the upper trapezius muscle at the point of
maximum tenderness; the angle is perpendicular
to the skin.
Needle: 11/2-inch, 22-gauge
Depth: 1 to 11/2 inches
Volume: 3 to 4 mL of anesthesia, 1 mL of D80, or
both
NOTE: Lightly advance the needle to feel the outer
fascia, then enter the body of the muscle.
Triamcinolone should not be used because of the
greater chance of atrophy of muscle or overlying
subcutaneous tissue.
FIGURE 1–1. Trigger point injection of the paracervical or upper
trapezial muscles.
DESCRIPTION Cervical strain is an irritation and EXAM Each patient is examined for the degree of
spasm of the cervical and upper back muscles.Physical muscle spasm,for the specific points of irritation in the
and emotional stress, whiplash-like injuries, cervical upper back and lower cervical muscles (referred to as
arthritis,dorsokyphotic posture,and underlying abnormal trigger points),and for the extent of loss of normal neck
cervical alignment are common causes. Spinal nerve or range of motion.
spinal cord irritation or injury is a much less common
cause of cervical strain.The upper portion of the trapezius
muscle and the levator scapulae, rhomboid major and
EXAM SUMMARY
minor, and long cervical muscles are most commonly
affected. Symptoms are bilateral in most cases. Several
1. Trigger points (upper back, paracervical, and
names are used to describe this condition,depending on
rhomboids)
cause,the length of time symptoms have been present,and
2. Reduced ipsilateral rotation and contralateral
anatomic predominance: neck strain, whiplash, trapezial
bending of the neck,passively performed
strain,wry neck,torticollis,fibromyalgia,and fibrositis.
3. Normal neurologic exam
4. No bony tenderness
SYMPTOMS The patient complains of pain,stiffness,
and tightness in the upper back or shoulder.The patient
characteristically places the hand over the upper back (1)Trigger points are seen most frequently in the middle
or base of the neck and rubs the affected area when portion of the upper trapezius muscle,in the long cervical
describing the symptoms. muscles at the base of the neck (at the C6-C7 vertebral
level), and in the rhomboid muscles along the medial
“Oh,my aching neck.” scapular border.The tenderness may be localized to a
small, quarter-sized area or may affect a diffuse area of
“My neck is just a bunch of knots.”
muscle in chronic cases.(2)The range of motion of the
“My neck is so tight and tender.” neck may be limited, correlating well with the degree
of muscle spasm.As muscle spasm increases,greater loss
“At the end of a hard day,my neck is so full of tension.”
of ipsilateral neck rotation and of contralateral neck
“My upper back feels like it has been tightened in a vise.” bending is seen. (Normal rotation of the neck is 90
degrees;normal lateral bending is 45 degrees.) Flexion and
“My upper shoulder gets so stiff and tight.”
extension of the neck are affected in extreme cases and
“If I sleep wrong, I wake up with a stiff neck and then in cases in which there is underlying arthritis.(3) In an
I get this horrendous headache.” uncomplicated case, the neurologic exam of the upper
4 THE 67 MOST COMMON OUTPATIENT ORTHOPEDIC CONDITIONS
extremities is normal. (4) Bony structures of the neck, Discuss stress reduction and how stress contributes
shoulder,and upper back usually are not tender. to symptoms.
Prescribe a nonsteroidal anti-inflammatory drug
(NSAID) (e.g.,ibuprofen [Advil,Motrin]) and note
X-RAYS A cervical spine series (including postero- its secondary role (inflammation is not a prominent
anterior, lateral, odontoid, and oblique views) is recom- part of cervical strain).
mended.Mild to moderate cases of cervical strain show
normal findings or nonspecific arthritic changes on
x-rays.Changes specific for cervical strain are seen only in STEP 2 (3 TO 4 WEEKS FOR PERSISTENT CASES)
moderate to severe cases.The normal cervical lordotic Order x-rays of the neck.
curve can be replaced by a straightened or even a re- Prescribe therapeutic ultrasound for persistent strain.
versed curve.Loss of normal vertebral alignment is best Recommend deep massage for palliative care.
evaluated on the lateral view of the neck.Severe torticollis Prescribe gentle cervical traction,beginning at 5 lb for
may cause a lateral deviation of the cervical spine,which 5 to 10 minutes once a day (p.245).
is best seen on the posteroanterior view of the neck. Prescribe a soft cervical collar or a soft Philadelphia
collar to be worn during the day,especially when
involved in physical work (p.245).
SPECIAL TESTING MRI and electromyogram are used
for cases complicated by persistent or moderate to severe
radicular symptoms (p.7). STEP 3 (6 TO 8 WEEKS FOR CHRONIC CASES)
Perform trigger point injection with a local
anesthetic. This can be combined with a long-acting
DIAGNOSIS The diagnosis is based on a history and corticosteroid.
on physical findings of localized upper back and neck Prescribe a tricyclic antidepressant for long-term
tenderness, the characteristic aggravation of symptoms control of pain.
by ipsilateral rotation and contralateral bending of the Consider referral to physical therapy for a transcuta-
neck, and the absence of evidence of radiculopathy by neous electrical nerve stimulator unit or to a pain
history or exam.Plain x-rays of the cervical spine are used clinic for long-term control of refractory pain.
to assess the severity of the condition and to exclude
underlying bony pathology. Regional anesthetic block
into a trigger point may be helpful in complex cases to PHYSICAL THERAPY Physical therapy is fundamental
differentiate referred pain from cervical radiculopathy or in the treatment and prevention of cervical strain.
subscapular bursitis.
PHYSICAL THERAPY SUMMARY
TREATMENT The goals of treatment are to reduce
muscle irritability and spasm and to re-establish the nor-
1. Ice
mal cervical lordosis.Ice applications,a muscle relaxant
2. Heat before stretching of the neck and upper back
at night for 7 to 10 days,and physical therapy exercises are
muscles
the treatments of choice.
3. Deep-muscle massage
4. Therapeutic ultrasound
5. Gentle vertical cervical traction, performed
STEP 1 Perform a thorough exam of the neck,
manually or with a traction unit
measure the baseline range of motion of the neck,
obtain routine cervical series x-rays if symptoms
are severe or long-lasting, and consider ordering
MRI if symptoms and signs of sensorimotor Acute Period Heat, massage, and gentle stretching
radiculopathy are present. exercises are used to reduce muscular irritation.These
Suggest simple changes in lifestyle, including sitting exercises should be performed daily at home.Heat and
straight with the shoulders held back, sleeping massage to the upper back and to the base of the neck
with the head and neck aligned with the body (a provide temporary relief of pain and spasm.These can be
small pillow under the neck),driving with the arms combined with a nighttime muscle relaxant for greater
slightly shrugged (arm rests), and avoiding straps effects. Stretching exercises always are recommended
over the shoulders. to regain flexibility and to counteract muscular spasm.
Recommend ice applications to the base of the neck Heat and a muscle relaxant may enhance the effects of
and upper back for temporary relief of pain and stretching.More advanced or protracted cases may need
muscle spasm in acute cases. deep-pressure massage or ultrasound treatment from a
Begin gentle stretching exercises that are to be licensed therapist.
performed daily, including shoulder rolls, scapular
pinch,and neck stretches (p.268).
Prescribe a muscle relaxant for nighttime use. Recovery and Rehabilitation Muscular stretching
Recommend heat and massage for the upper back and exercises and cervical traction are used to treat persistent
the base of the neck (p.267). or chronic cases.Stretching exercises must be continued