Presentation \200 Acute monoarthritis in feet or hands is most common, but can also occur in large joints such as knee or shoulder. The joint is very painful, hot and red. Pat ients often refuse to bear weight or move the joint. The patient can look unwell and someti mes has a fever Chronic tophi (usually painless) over \201 nger joints and in ears can occur, associated with a chronic arthritis. Sometimes mistaken for other more common arthritides Olecranon bursitis \200 Uric acid kidney stones Investigations \200 During an acute attack serum uric acid may be normal or high \200 W BC , ESR , and CRP are usually high or very high \200 Joint \202 uid : May be cloudy or frankly purulent on visual inspection \200 Microscopy shows many in \202 ammatory cells \200 Under polarized light, negatively birefringent uric acid crystal s are seen in joint \202 uid or in phagocytes X-rays are usually normal (rarely see small punched-out erosions in \201 ngers in chronic tophaceous cases) The main aim is to exclude an infective arthritis. 2If in doubt, consider using iv antibiot ics until cultures are negative. Treatment \200 For acute gout : \200 Use paracetamol with a course of NSAIDs (consider gastric protection) \200 If you have ruled out infection, local steroid injections are of ten effective (eg methylprednisolone 40mg intra-articular) If NSAIDs are contraindicated (eg renal impairment) use a short course of oral steroids (eg prednisolone 40mg od for 7 days) or colchicine 0.5mg stat then 0.5mg every 6 \200\2238hr u ntil pain is controlled or diarrhea/vomiting side effects prohibit further use. Colchicine is an effective drug but dif \201 cult to use correctly \200\224 you will need to explain this protocol carefully to patient/carers For chronic arthritis with or without tophi: treat with allopurinol or uricosuric drugs (probenecid and sul \201 npyrazone). Uricosuric drugs are contraindicated in renal stones GOUT 483 Prevention One or two attacks of gout probably do not warrant prophylaxis (espe- cially as such drugs can precipitate further attacks). Instead, try: \200 Changing drugs (stop thia zides and aspirin) \200 Lifestyle advice: Reduce alcohol (beer is preferable to lager or wine) \200 Reduce dietary purines (meat) \200 Lose weight Do not leave patients on long-term NSAIDs. Very early use of NSAIDs or colchicine can abort a severe attack of gout Several attacks of gout merit slow introduction of allopurinol or urico- suric agents. This may cause a \202 are of acute gout \200\224 cover the introduction of therapy with NSAI Ds or low-dose colchicine. 484 CHAPTER 17 Musculoskeletal system Pseudogout Features This is an acute, episodic synovitis closely resembling gout except tha t: \200 Calcium pyrophosphate rather than uric acid crystals (with positive rather than negative birefringence) are found Large joints are more commonly affected (especially knees but also shoulder, hips, wrists and elbows) It is not associated with tophi, bursitis, or stones \200 X-rays often show calci \201 c ation of articular cartilage \200\230chondrocalcinosis \200\231 in the affected joint It doesn \200\231t respond to allopurinol or uricosuric agents \200\224 so consider this diagnosis where recurrent attacks persist despite allopurinol As with gout the patient has an acutely in \202 amed joint which is very painful to move. They may be systemically unwell with a fever and highly elevated in \202 ammatory markers. Serum calcium is normal. 2Consider this diagnosis in the post-acute patient with a hot swo llen wrist. Management Make a con \201 dent diagnosis. This usually involves immediate synovial \202 uid sampling and urgent microscopy to exclude infection and gout. Effective treatments for acute pseudogout include: Intra-articular steroid injections \200 Oral NSAIDs \200 Oral corticosteroids \200 Co lchicine Long-term preventative treatment is very rarely needed. CONTRACTURES 485 Contractures Contractures are joint deformities caused by damaged connective tissue. Where a joint is immobilized (through depressed conscious level, loss of neural input, or local t issue damage) the muscle, ligaments, tendons, and skin can become inelastic and shortened c ausing joints to be \202 exed. Common causes worldwide include polio, cerebral palsy, and leprosy; in geriatric medicine c ommon causes include stroke, dementia, and musculoskeletal conditions, eg fracture. Contrac tures are an under- recognized cause of disability \200\224 they occur to some degree in a bout a third of nursing home residents and it is still not uncommon to \201 nd patients w ho are bedbound and permanently curled into the fetal position. Problems \200 Pain : especially on moving joint but can occur at rest \200 Hygiene : sk in surfaces may oppose (eg the hand after stroke or groins in abduction/ \202 exion contra ctures) making it dif \201 cult for carers and painful for the patient to keep clean and o dorless Pressure areas : abnormal posture increases risk \200 Esthetics : although the lack of mo vement causes most disability the abnormal posture/appearance can be more noticeable Function : chronic bedbound patients may become so \202 exed that they are unable to sit out in a chair Prevention \200 Where immobilization is short term, eg after a fracture, passive stretching followed by exercise regimens should be initiated promptly \200 All healthcare staff should understand the importance of maintaining mobility (including sitting out of bed for short periods) and positioning of immobile patie nts Preventative measures are rarely successful at preventing contractures in joints with long- term immobility, eg in residual hemiparesis after stroke. Splinting might help mold the pos ition Treatment \200 Periodic injection of botulinum toxin may be helpful where muscle spasticity is the major problem. There are no real adverse effects but some patients develo p an antibody response after repeated treatment, which renders therapy less effective. Newe r preparations are less immunogenic There is little point using muscle relaxants except to help with pain. Even then drugs such as baclofen, dantrolene, tizanidine, and diazepam usually cause side e ffects of drowsiness before they reach therapeutic levels. Occasionally assist with physiot herapy stretches Surgery eg tendon division has a place in severe cases \200 Physiotherapy can to some ext ent reverse established changes, especially if not severe and of relatively recent onset Repositioning with serial plaster casts takes a long time and is really only used in younger patients 486 CHAPTER 17 Musculoskeletal system Cervical spondylosis and myelopathy Degeneration in the cervical spine causes neurological dysfunction with both radiculopathy (compression of nerve roots leaving spinal foramina) an d myelopathy (cord compression). The resulting mixture of lower (nerve root) and upper (cor d) nerve damage causes pain, weakness and numbness. Progress is usually gradual but can be sudden (especially fol- lowing trauma). The disease is unusual before the age of 50. Mild f orms are very common in the elderly population. History \200 Neck pain and restricted movement may be present but are neither speci \201 c nor sensitive markers of nerve damage. Pain may radiate to shoulder, chest or arm in a d ermatomal distribution (see b Appendix, \200\230Dermatomes \200\231, p.686) Arms and hands become clumsy especially for \201 ne movements (eg doing up buttons). Weak ness, numbness and paraesthesia can occur \200 Leg symptoms usually occur later, with a U MN spastic weakness and a wide-based and/or ataxic gait, often with falls Urinary dysfunction is unusual and late \200 Rarely can cause vertebrobasilar insuf \201 ciency symptoms Signs \200 Arms have predominantly lower motor signs with weakness, muscle wasting, and s egmental re \202 ex loss. The classical \200\230inverted supinator \200\231 sign is due t o a C5/6 lesion where the supinator jerk is lost but the \201 nger jerk (C7) is augmented : when the wrist is tapped, the \201 ngers \202 ex Legs may have brisk re \202 exes, increased tone, clonus, and upgoing plantars. In severe cases a spastic paraparesis with a sensory level can develop Differential diagnosis This is wide and includes: \200 Syringomyelia \200 Motor neuron disease (look for signs above the neck and an absence of sensory symptoms/signs) Peripheral neuropathy (no UMN signs) \200 Vitamin B12 de \201 ciency \200 Other causes of spastic gait disorders Investigations \200 Plain X-rays in older people almost always show degenerative changes, which correlate poorly with symptoms. They are only useful in excluding other pathology or in demonstrating spinal instability \200 MRI scanning is the investigation of choice. Bon e and soft tissue structures and the extent of cord compression are all well demonstrated CT scanning may also be useful in diagnosis and planning treatment \200 Nerve conduction studies can help con \201 rm the clinical impression and exclude other pathology CERVICAL SPONDYLOSIS AND MYELOPATHY 487 Management Cervical collars do not in \202 uence progression but can sometimes help with r adicular pain and may provide partial protection from acute decline following trauma. The o nly de \201 nitive treatment is surgical : laminectomy with fusion for stabilization. Surg ery is indicated for: Progressive neurology (especially if rapidly progressive \200\224 consider steroids while surgery is arranged) Severe pain unresponsive to conservative measures \200 Myelopathy more than radiculopathy Discuss the risks and bene \201 ts with the patient \200\224 function is rarely restored once lost but pain improves and further damage is usually avoided. 488 CHAPTER 17 Musculoskeletal system Osteomyelitis Infection of the bone that is commonest in the very young and the very old. I t is important in geriatric practice because it complicates conditions that are common in o lder patients yet presentation is often non-speci \201 c and indolent, so the diagnosis ma y be missed. Vertebral osteomyelitis \200 Most common in older patients \200 Usually affects the tho racolumbar spine \200 Patients complain of mild back ache and malaise and will often have local tenderness. When examining a patient with pyrexia of unknown origin (PUO), always \200\230walk \200\231 the examining \201 ngers down the spine, applying pressure to \201 nd local bony pain Vertebral osteomyelitis (commonly T10 \200\22311) may lead to: \200 Perivertebral abscess with a risk of cord compression \200 Vertebral body collapse with angular kyphosis Discitis occurs when the infection involves the intervertebral disc. The patient is relativ ely less septic, and X-rays appear normal until disease is very advanced (at which point en d-plate erosion can occur). Occurs after surgery or disc space injections Haematogenous spread is most common, often after urinary tract infection, catheterization, iv cannula insertion, or other instrumentation Commonly due to Staphylococcus aureus (with a rising proportion of these being MRSA), less commonly Gram-negative bacilli, rarely tuberculosis Osteomyelitis of other bones \200 Generally more common in children, but arise in older p atients in some circumstances: \200 As a complication of orthopedic surgery \200 As a complication of ulceration (venous or pressure ulcers) 2 Always consider osteomyelitis in non-healing ulcers; may be present in as many as 25 % In susceptible individuals (eg diabetic patients with vascular disease and neuropathy are prone to osteomyelitis in small bones of the feet) Organisms include Staph. aureus, Staphylococcus epidermidis (especially with prostheses), Gram-negative bacilli, and anaerobes Clinical features of osteomyelitis \200 Pain is usual but may be missed if there is a pre -existing pressure sore, or the patient has peripheral neuropathy and foot osteomyelitis (e g diabetics) Malaise is common \200 Fever may be absent OSTEOMYELITIS 489 Investigations \200 Blood cultures should be taken in all, and are positive in around hal f \200 Leucocytosis is variable \200 ESR and CRP are usually raised (although very non- speci \201 c) \200 X-ray changes lag behind clinical changes by about 10 days. Initially normal, or showing soft tissue swelling. Later develop classic changes: periosteal reaction , sequestra (islands of necrosis), bone abscesses, and sclerosis of neighboring bone Radioisotope bone scanning will show a \200\230hot spot \200\231 with osteomyelitis, but w ill not distinguish this from many other conditions (eg fracture, arthritis, non-infectious in \202 ammation, metastases, etc.). MRI is the most sensitive and speci \201 c test. Ch anges may be diagnostic, even in early disease Biopsy or \201 ne needle aspiration (FNA) of bone is required to guide antibiotic therapy \200\224 this may be done through the base of an ulcer, or using radiol ogical guidance (ultrasound is useful here) Wound swabs reveal colonizing organisms, and are often misleading Treatment \200 General measures such as analgesia and \202 uids if needed \200 The jo int/bone should be immobilized where possible \200 Obtaining tissue specimens permits bac terial culture and determination of antimicrobial sensitivity. Duration of therapy is usual ly long, and identi \201 cation of the organism allows antibiotic precision to reduce side effects. After specimens are obtained but prior to results, \200\230best guess \200\231 t herapy may be started after microbiological advice (eg clindamycin and fusidic acid for hae matogenous spread, and a broader spectrum antibiotic when a complication of pressure sores) Surgical drainage should be considered after 36hr if systemic upset continues, or if there is deep pus on imaging (required in 30 % ) Treatment is initially intravenous, often later converted to oral therapy \200 Total trea tment duration is usually many weeks or months (depending on sensitivity of organism and extent and location of infection) Complications \200 Metastatic infection \200 Suppurative arthritis \200 Chronic osteo myelitis infection becomes walled off in cavities within the bone, discharging to the surfa ce by a sinus. Symptoms relapse and remit as sinuses close and reopen. Bone is at risk of p athological fracture. Management is long and dif \201 cult \200\224 this is a miserable c omplication of joint replacement. Culture organisms and use appropriate antibiotics to limi t spread. Surgical removal of infected bone and/or prosthesis is required for cure. Involve specialist bone infection teams if possible \200 Malignant otitis externa occurs when ot itis externa spreads to cause osteomyelitis of the skull base. Occurs particularly in frail , older diabetic patients. Caused by Pseudomonas and anaerobes. Facial nerve palsy develops in half, with possible involvement of nerves IX \200\223XII. Requires prolonged antibiotic s, specialist ENT input, and possible surgical debridement 490 CHAPTER 17 Musculoskeletal system The elderly foot Foot problems are very common ( > 80 % over 65) and can cause major disabi lity including increased susceptibility to falls. A particular problem in older people beca use: \200 Multiple degenerative and disease pathologies occur and interact \200 Many ol der people cannot reach their feet: monitoring and basic hygiene (especially nail cutting) may be limited Patients think foot problems are a part of ageing or are embarrassed by them and do not seek treatment Health professionals often neglect to examine feet and are too slow to refer for specialist foot care. It is common to \201 nd a patient naked under a hospital gown but still with thick socks on Inappropriate footwear may be worn \200\224 most older people cannot afford or refuse to wear \200\230sensible \200\231 shoes such as trainers Simple chiropody services are not available on the NHS (rationed to diabetic patients and t hose with peripheral vascular disease in most areas) Nails \200 Very long nails can curl back and cut into toes \200 Nails thicken and becom e more brittle with age. This is worsened by repeated trauma (eg bad footwear), poor circulation, or diabetes. Ultimately the nail lo oks like a ram \200\231s horn ( onychogryphosis ) and cannot be cut with ordinary nail clip pers Fungal nail infection ( onychomycosis ) produces a similar thickened, discolored nail Ingrowing toenails can cause pain and recurring infection Skin \200 Calluses (hard skin) \200 Corns (painful calluses over pressure points with a nucleus/core) \200 Cracks and ulceration (see b \200\230Leg ulcers \200\231, p.593) \200 Cellulitis Between the toes Fungal infection ( \200\230athlete \200\231s foot \200\231) is very common . The skin maceration that results is a common cause of cellulitis. Bone/joint disease \200 A bunion (hallux valgus) is an outpointing deformity of the big t oe, which can overlap the second toe Hammer toes are \202 exion deformities of proximal interproximal (IP) joints Claw toes have deformities at both IP joints \200 Osteoarthritis or gout of the metatarso phalangeal joint causes pain and rigidity Neuropathic foot : longstanding severe sensory loss in a foot (eg diabetics, tabes dorsalis) with multiple stress fractures and osteoporosis disrupting t he biomechanics of the joints ( Charcot \200\231s joint ). The foot/ankle is swollen and re d but painless with loss of arches ( rockerbottom foot ) THE ELDERLY FOOT 491 Circulation impairment Common. Assess vasculature (including an ABPI, see b \200\230HOW TO Measure ABPI \200\231, p.305) if there is pain, ulceration, infection, or skin chang es. Sensory impairment Touch, pain, and joint position sense are all important to maintaining n ormal feet. Other foot problems Obesity, oedema and skin disorders. HOW TO Care for the elderly foot Prevention \200 Inspect both feet frequently (at least every other day). A hand mirror as sists inspection of the sole. 2If a patient cannot see, reach, or feel their feet, someone else should be helping them regularly Examine for swelling, discolouration, ulcers, cuts, calluses, or corns \200 If these are identi \201 ed, consult a health professional (podiatrist, nurse or doctor) promptly Wash feet daily in warm water with mild simple soap. If feet are numb, check that the water temperature is not too hot with a hand or with a thermometer (35 \200\22340 C is best) After washing, dry feet thoroughly, particularly between the toes \200 Change socks or st ockings daily \200 Dry, hard or thick skin should be softened with emollients such as liquid and white soft paraf \201 n ointment ( \200\23050:50 \200\231) Footwear should be supportive but soft. Take particular care with new footwear, inspecting feet frequently after short periods of wear to ensure that no sore s have developed Avoid barefoot walking \200 Cut nails regularly, cutting them straight across and not too short Treatment \200 Quali \201 ed podiatrists or chiropodists will debride calluses/corns and use dressings and pressure relieving pads to prevent them recurring. Availability on the N HS has been severely restricted recently (only diabetics qualify in most regions) so cost m ay deter patients \200 Treat athlete \200\231s foot (eg clotrimazole cream bd for one wee k) \200 Distinguish between thick discolored nails due to onychomycosis from simple onychogryphosis by sending nail scrapings for microscopy for fungal hyphae. Top ical antifungal treatment is often not practical and tablet treatment (eg terbina \201 ne) can take months to be effective so the vast majority of elderly patients remain untreated. If you do decide to use terbina \201 ne, monitor liver function and be wary of drug inter actions Surgery may be used to remove nails or correct severe bone deformity 492 CHAPTER 17 Musculoskeletal system The elderly hand Hand problems are common in older people, and may lead to functional probl ems ( \201 nding it hard to perform necessary activities of daily living) as well as socia l and cosmetic problems (eg unable to wear a wedding ring). Hand function can be assessed b y: \200 Opening and closing hand \200\224 looking for smooth and full movement \200 As sessing grip strength \200 Assessing ability to make a pincer grip \200 Asking the pati ent to perform \201 ne motor tasks (eg doing up a button) Hand deformity \200 Heberden \200\231s nodes (at distal IP) and Bouchard \200\231s nodes (at proximal IP) are common in older hands, and have X-ray appearances of OA. They are rare ly painful, but hands may become clumsy or dif \201 cult to use \200 Mallet \201 nger is a \202 exion deformity of the distal IP joint, usually after trauma (due to tendon rup ture). Splinting acutely can correct the problem Trigger \201 nger arises because of digital tendinitis and tenosynovitis (in \202 ammation of tendons and tendon sheaths of the hand, often with \201 brosis). Mo re common in people with diabetes. The \201 nger may lock in \202 exion, suddenly exten ding with a snap. Treat with rest, splinting and NSAIDs. Steroid injection may help, or sur gical release can be done Swan-neck deformity occurs classically in rheumatoid arthritis (but also with other tendon problems) and involves hyperextension of the proximal IP joint with \202 exion of the distal IP joint. Can cause signi \201 cant disability, and surgery may help Boutonni re deformity is \202 exion of the proximal IP joint and hyperextension of the d istal IP joint, due to tendon rupture, dislocation, fracture, osteoarthritis, and rheumatoi d arthritis. Early splinting may help, but surgery is rarely useful Dupuytren s contracture is progressive contracture of the palmar fascial bands, producing \202 exion deformities of the \201 ngers. Occurs mainly in older men, with diabetes, alc oholism, or epilepsy. Autosomal dominant inheritance (incomplete penetrance). Steroid injec tion may help early disease; advanced disease requires surgery Common hand symptoms \200 Cold hands are commonly reported in older patients, and indeed hands may feel cold, despite good vascular supply. Reassure, and use simple measures (glove s, warm soaks) to provide relief Numb hands should prompt assessment for nerve entrapment or peripheral neuropathy, but symptoms may be present in the absence of these. Patients will d escribe intermittent pins and needles or just a lowered sense of touch and may be clumsier. Use of warm soaks, analgesia, stretching exercises, and reassurance can be helpful Hand cramps can be troublesome especially at night. Try warm soaks, hand stretches, or calcium supplements to relieve Dropping objects in the absence of demonstrable pathology is common and may result from subtle changes in proprioceptive ability THE ELDERLY HAND 493 Repetitive strain injury This is becoming more common in older people, often from excessive use of computers. Treatment is with rest, analgesia and modi \201 cation of the precipita ting behavior. Carpal tunnel syndrome \200 More common with age, OA, rheumatoid arthritis, diabetes, hypothyroidism, obesity, smokers or those who apply repetitive strain to the wrist Have hand and wrist pain with paraesthesia and numbness in the median nerve distribution The patient will often wake at night with burning or aching pain, numbness, and tingling; shaking the hand provides relief Reduced sensation in the median nerve distribution and weak thumb abduction are common and suggestive Check for Tinel s sign (tingling in the median nerve region, elicited by tapping the palmar surface of the wrist over the median nerve site in the carpal tunnel) Thenar muscle atrophy occurs late \200 Older patients will often have multilevel nerve en trapment (cervical as well as at the wrist) Treatment is initially with splinting and analgesia. Steroid injections can help, but surge ry is usually curative. Consider this even in frail older patients in whom function (eg abi lity to hold their frame) is impaired \200\224 the procedure can be done under local anest hesia Complex regional pain syndrome \200 Also known as re \202 ex sympathetic dystrophy, or s houlder hand syndrome Occurs in the extremities, characterized by pain, swelling, limited range of motion, vasomotor instability, skin changes, and patchy bone demineralization Frequently begins following an injury, surgery, or vascular event such as a MI or stroke Pathophysiology poorly understood \200 Think of the diagnosis where there is intense thro bbing arm pain with an alteration in skin temperature Autonomic testing is abnormal, and bone scans show increased uptake early in the disease. X -rays may show osteopenia and MRI may show skin and tissue changes later in the disease Early mobilization after a stroke helps prevent this condition \200 Early disease can be treated with smoking cessation, topical counterirritants (eg capsaicin), oral NSAIDs and st eroids. Bisphosphonates help prevent bone loss and provide pain relief \200 More advanced disease may respond to regional sympathetic nerve blocks, and generally require specialist pain team input 494 CHAPTER 17 Musculoskeletal system The painful hip 2The important diagnosis not to miss in the frail elderly is fracture. Havi ng a low threshold of suspicion and for investigation is key. Hip fracture \200 The absence of a recent fall and ability to weight-bear should not put you off obtaining an X-ray if recent onset, or severe pain In any bed-bound patient after a fall look for inability to lift the leg off the bed and pa in on movement (especially rotation) even if they are not \201 t to stand. A shortened ex ternally rotated leg is a useful sign but will occur in many who have replacement hips and is not seen in all Some patients can walk on a fractured hip \200 Always: Get two views (anteroposterior and lateral) of the pelvis and proximal femur Have the X-rays reported by a radiologist \200\224 changes can be subtle \200 Check for pubic ramus fractures as well as fractures of the femoral head and shaft If initial \201 lms are normal but clinical suspicion is high, consider repeating X-ray i n a few days (bone fragments can move apart) or proceed to an MRI or bone scan. It is impor tant to make the diagnosis early \200\224 do not be afraid to argue your case with radiolo gy Almost all hip fractures require surgical repair no matter how frail the patient (conservat ive management with or without traction is painful and has a massive morbidity and mortalit y). By contrast, low-energy pelvic fractures in older people rarely require surgery (see b \200\230HOW TO Manage non-operative fractures \200\231, p.471). Even with surgery th e 30-day mortality for a fractured neck of femur is high ( > 10 % ). Remember to initiate o steoporosis treatment. Osteoarthritis \200 Pain is \200\230boreing \200\231 and stiffness occurs after rest \200 Restriction of movement occurs in all planes \200 OA can signi \201 cantly increas e chance of falls \200 Total hip replacement is now widely available and very effective Consider referral for radiographic moderate/severe disease with ongoing pain or disability despite trial of conservative treatment \200 There is a 1 % mortality but older people of ten have a good long- term result. Revision surgery is rarely needed because activity levels are lower than in yo unger people (and life expectancy less) Other causes of hip pain \200 Paget \200\231s disease : also causes secondary osteoarthri tis \200 Radicular pain referred from spine \200 Metastases \200 Septic arthritis : r are and dif \201 cult diagnosis to make but consider joint aspiration under ultrasound if your patient appears septic with a very painful hip, especially after recent hip surgery Referred pain from the knee \200 Psoas abscess THE PAINFUL HIP 495 The role of the orthogeriatrician Mainly focuses on patients with femoral fractures. Models of care include an orthogeriatric ian visiting the trauma ward, joint care on a joint ward, or care being provided on a geria tric ward, with the trauma surgeons performing the surgery only. The NHS has recently intro duced a \200\230best practice tariff \200\231 for femoral fractures, where trusts are paid more if there is (among other things) joint orthogeriatric/trauma care. Preoperative interventions These include: \200 Taking a history, including clarifying cau se for the fall \200 Examination looking for \202 uid balance, or other conditions that may have caused the fall Review of drugs (eg suspending diuretics, ACE inhibitors if dry) \200 Management of speci \201 c perioperative drug issues (eg warfarin cessation) Weighing of bene \201 ts of certain tests (eg echocardiogram) before surgery (will rarely alter management) Optimizing \202 uid balance \200 Ensuring adequate and appropriate pain relief \200 R eviewing importance of normalizing electrolytes (eg K=2mmol/L is more of a priority that a Na of 130mmol/L) Talking to the patient and relatives Operative interventions These include collaborating wi th surgical and anesthetic colleagues to determine the optimal time for surgery. \200\230F itness \200\231 for surgery is rarely achieved, and it is often a question of judging the l east risky time to proceed \200\224 usually as soon as possible. The geriatrician can prov ide a prompt assessment to facilitate this. Post-operative interventions These include: \200 Promoting early mobilization by MDT work ing \200 Ensuring that pain management is effective and safe \200 Identifying delirium, dementia, depression and alcohol misuse with initiation of appropriate treatment Multidisciplinary falls assessment and link with the falls service where appropriate Rationalizing medications \200 Initiating osteoporosis prevention measures \200 Determi ning optimal venue for rehabilitation, optimizing the chances of returning to the previous place of residence Advising on complex ethical issues including end-of-life care and cardiopulmonary resuscitation Being involved in morbidity and mortality review with the orthopedic and anesthetic teams Being involved in training and audit, together with the development of evidence-based pathways and guidelines 496 CHAPTER 17 Musculoskeletal system The painful back Assessment \200 History should include position, quality, duration, and radiation of pain as well as associated sensory symptoms, bladder, or bowel problems and a systems review Undress the patient and look for bruising and deformity \200 Apply pressure to each verte bra in turn looking for local tenderness \200 Look for restriction of movement and gait a bnormality \200 Always check neurology and consider bowel/bladder function 2 \200\230Red \202 ags \200\231 for serious pathology include acute onset, leg weakness, fever, weight loss, bowel and bladder dysfunction (including a new catheter). Causes \200 Osteoarthritis of the facet joints becomes more common than disc pathology with advancing age (disks are less pliable and less likely to herniate) Osteoporosis and vertebral crush fractures can cause acute well-localized pain, chronic pain or no pain at all Metastatic cancer should always be considered especially if pain is new or severe, there ar e constitutional symptoms such as weight loss, or pain from an apparent fracture fails to i mprove Vertebral osteomyelitis and infective discitis should be considered in those with fever and raised in \202 ammatory markers especially if they are immunosuppress ed (eg rheumatoid arthritis on steroids) 2Not all back pain comes from the spine. Differential diagnoses that should not be missed i nclude pancreatitis or pancreatic cancer, biliary colic, duodenal ulcer, aortic aneurysm, r enal pain, retroperitoneal pathology, pulmonary embolism, Guillain \200\223Barr syndrome or MI. Investigations \200 FBC, ESR (myeloma screen if raised), CRP, ALP, calcium, PSA (in men) \200 MRI is good at identifying serious pathology, eg cancer, infection, compression syndromes CT can be done if unable to have MRI but is less good \200 Bone scan is useful especially if there are multiple sites of pain \200 Plain X-rays may reveal diagnosis but \200\230 wear and tear \200\231 changes are very common and correlate poorly with pain. May miss ser ious pathology Treatment First, make a diagnosis to guide therapy. Speci \201 c therapies include: Bisphosphonates or calcitonin for osteoporotic collapse \200 Radiotherapy is very effecti ve for metastatic deposits \200 Urgent surgery or radiotherapy should be considered for c ord compression, with high-dose iv steroids in the meantime THE PAINFUL BACK 497 General therapies for most diagnoses include: \200 Standard analgesia ladder (see b \200 \230Analgesia \200\231, p.140) \200 Physiotherapy is often helpful in improving pain and function or at least preventing deconditioning Exercise and weight loss (if obese) are dif \201 cult to achieve but will help \200 TENS can help some and is without side effects \200 Antispasmodics, eg diazepam 2mg if muscul ar spasm is prominent \200 Consider referral to pain specialist for local injections, eg facet joints or epidurals Once serious pathology has been excluded a chiropractor/osteopath can sometimes help 498 CHAPTER 17 Musculoskeletal system The painful shoulder The shoulder joint has little bony articulation (and hence little arth ritis) but lots of muscle and tendon which is prone to damage. Many condi- tions become chr onic and examining elderly people will reveal a high prevalence of pain and restricted move ment. Patients compensate (eg by avoiding clothes that need to be pulled over head) and may not report symptoms. Before diagnosing one of the conditions that follow, exclude systemic problems such as poly myalgia rheumatica and rheumatoid arthritis. Remember that neck problems, diaphragmatic pat hology, apical lung cancer, and angina can also produce shoulder pain. Frozen shoulder/adhesive capsulitis \200 Usually idiopathic but sometimes follow trauma a nd stroke \200 More common in people with diabetes \200 Loss of rotation (internal and external) and abduction \200 Painful for weeks to months then stiff (frozen) for further 4 \200\22312 months \200 Mainstay of treatment is physiotherapy/exercise \200\224 avoid rest \200 Intra-articular steroids may help pain and improve tolerance to early mobilization Bicipital tendonitis \200 Pain in speci \201 c area (anterior/lateral humeral head) aggr avated by supination on the forearm while elbow held \202 exed against body \200 Treatm ent is rest and corticosteroid injection followed by gentle biceps stretching exercises Rotator cuff tendonitis \200 Dull ache radiating to upper arm with \200\230painful arc \200\231 (pain between 60 and 120 when abducting arm) Rest, occasionally with immobilization in a sling, and corticosteroid injection Physiotherapy and exercises may help \200 Arthroscopic decompression can sometimes reliev e pain Rotator cuff tear \200 May occur following trauma \200 Reduced range of active and pass ive movements of shoulder \200 Ultrasound and MRI diagnostic \200 Treat with rest and c orticosteroid injection \200 Physiotherapy and exercises may help \200 Surgical repair possible in some cases Shoulder dislocation \200 May occur after a fall (usually anterior) or seizure (may be po sterior) \200 Shoulder is painful, appears deformed, and X-rays will con \201 rm \200 Check for neurovascular damage; arrange pain relief and joint reduction by manipulation THE PAINFUL SHOULDER 499 Glenohumeral OA \200 Uncommon site for arthritis \200\224 there is usually previous trau ma \200 Presentation and examination similar to frozen shoulder \200 Classic examinatio n \201 ndings are of: Local glenohumeral joint line tenderness and swelling anteriorly \200 Loss of range of mo tion of external rotation and abduction \200 Crepitation \200 X-rays will con \201 rm \200 Initial treatment is with analgesia and mobilization \200 Joint injection with ste roids can be useful \200 Failure to respond to conservative measures should prompt consideration of surgical referral for joint replacement \200\224 this is highly successfu l in appropriate patients This page intentionally left blank 501 Chapter 18 Pressure injuries Pressure sores 502 Compression mononeuropathy 504 Rhabdomyolysis 505 502 CHAPTER 18 Pressure injuries Pressure sores Areas of skin necrosis due to pressure-induced ischaemia found on sacrum, he els, over greater trochanters, shoulders, etc. Also known as decubitus ulcers or bedsores. Incidence higher in hospital (new sores form during acute illness) but prevalence higher in long-stay community settings (healing takes months/years). Average hospital prevalence 5 \200\22310 % despite drives to improve education and preventative strategies. The \201 na ncial and staf \201 ng resource burden of pressure sores is huge. Grading 0 Skin hyperaemia I Non-blanching erythema II Broken skin or blistering (epidermis 9 dermis only) III Ulcer down to subcutaneous fat IV Ulcer down to bone, joint or tendon 22 hrs of tissue ischaemia is suf \201 cient for the subsequent development of an ulcer and the causative insult often occurs just prior to or at the time of admission (on ED trolleys , intraoperative, at home). There is consid- erable lag between the ischaemic insult and th e resulting ulcer. Grade I erythema often progress to deep ulcers over days/weeks without f urther ischaemic insult. Inspect sacrum and heels at least daily. Risk factors Include age, immobility (especially postoperative), low or high body weight, m alnutrition, dehydration, incontinence, neurological damage (either neuropathy or decreased conscious level), sedative drugs, vascular impairment. Several scoring systems (eg Waterlow score) combine these factors to stratify risk. They aid/prompt clinical judgment of individual patient risk. Mechanisms \200 Pressure \200\224 normal capillary pressure 24 \200\22334mmHg \200\224 pressures exceeding 35mmHg compress and cause ischemia. This pressure is easily exceeded on a simple foam mattress at pressure points such as heels Shear \200\224 where skin is pulled away from \201 xed axial skeleton small blood vessel s can be kinked or torn. When a patient is propped up in bed or dragged (eg during a lift o r transfer) there is considerable shear on the sacrum Friction \200\224 rubbing the skin decreases its integrity especially at moving extremitie s, eg elbows, heels. Avoid crumbs, drip sets and debris between patient and sheets. Massage of pressure areas no longer recommended Moisture \200\224 sweat, urine, and feces cause maceration and decrease integrity PRESSURE SORES 503 Management \200 Prevention \200\224 demands awareness \200\224 NICE guidelines suggest all patients are risk assessed within 6hr of admission ( M www.nice.org.uk , clinical guide line 29 (2005)). Regular reassessment during hospital admission should occur especially if condition of patient changes Turning and handling \200\224 there is no evidence to suggest how often