Chapter 15

Orthopaedic
Conditions in the
Elderly
Upper limb
Spine
Lower limb

Orthopaedic Conditions in the Elderly 533

 Classification
Upper limb conditions
Shoulder and arm-R o t a t o r c u f f d e g e n e r a t i o n
Frozen shoulder
Ruptured long head of biceps

Elbow - Tennis and golfer's elbow

Wrist -Carpal tunnel syndrome

de Quervain’s syndrome

Hand - Osteoarthritis 1st carpo-metacarpal joint

Trigger finger
Heberden's nodes
Rheumatoid arthritis
Dupuytren's contracture
Spinal conditions
Cervical spondylosis
Senile kyphosis
Low back strain and disc protrusion

Lower limb conditions

Hip - Osteoarthritis

Knee - Osteoarthritis
Genu varum and valgum

Foot - Chronic footstrain

Plantar fasciitis and plantar neuroma
Hallux valgus and claw toes
Hallux rigidus
Anterior metatarsalgia

534 A Simple Guide to Orthopaedics

Introduction
It is the purpose of this chapter merely to
highlight the most common conditions seen in
the elderly patient and to refer the reader
to the relevant section elsewhere in the
book.
In the elderly, degenerative joint disease
is common. Osteoarthritis may be primary due
to an unknown cause or secondary to trauma,
avascular necrosis or rheumatoid arthritis.
Multiple repeated injuries, combined with
inadequate synovial lubrication of the joints,
are prob-ably the most common aetiological
factors. Total hip and knee replacements are
the most common joint replacements. Where
possible, the aim should be joint mobility
rather than arthrodesis.
Neck and spinal conditions are often due
to a combin-ation of intervertebral disc
degeneration and osteoporotic collapse.
Foot problems are commonly due to obesity
and poor muscle tone. Suitable orthotic foot
supports, plus physiotherapy, good hygiene
and suitable shoes are all that are needed
in most cases.
Degeneration of tendons may lead to rupture
of the quadriceps, rotator cuff or long head
of biceps. Partial tears of tendons may lead
to ‘tennis’ or ‘golfer’s’ elbow.
Irritation under the flexor sheath may
cause conditions such as carpal tunnel
compression of the median nerve and
constriction of tendon sheaths leading to
trigger finger or de Quervain’s tenovagini-
tis.

Orthopaedic Conditions in the Elderly 535

Upper Limb Conditions
Shoulder and arm
Rotator cuff degeneration and frozen
shoulder
Rupture of rotator cuff muscles secondary to
osteoarthritis of the shoulder is common.
Operative repair may be indicated in early
cases of complete rupture. Frozen shoulder,
often secondary to cervical spondylosis, may
also occur.
Ruptured long head of biceps
Rupture of the long head of biceps may be
secondary to osteoarthritis of the shoulder
but causes little disability and does not
require treatment.
Elbow
Tennis and golfer’s elbow
‘Tennis’ and ‘golfer’s’ elbow are usually
due to partial rupture of a few fibres at
the origins of the extensors or flexors
respectively of the wrist and hand and are
seldom due to sport. They can be treated by
a support just below the elbow, but over 80%
of patients find relief by injection of hydro-
cortisone acetate into the tender area.
Wrist and hand
Carpal tunnel syndrome
In elderly patients irritation of the median
nerve, producing a carpal tunnel syndrome,
may be secondary to a previous Colles’ frac-
ture, rheumatoid arthritis or osteo-
arthritis. Conservative measures such as rest
may fail, and decompression of the nerve by
division of the flexor retinaculum is usually
very effective.
536 A Simple Guide to Orthopaedics
 Upper Limb
Conditions

© Huckstep 1999

© Huckstep 1999

Ruptured biceps Frozen shoulder

tendon

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© Huckstep 1999

Tennis elbow Cortisone injection

Orthopaedic Conditions in the Elderly 537

de Quervain’s tenosynovitis
de Quervain’s tenosynovitis is due to an
inflammation or constriction of the tendons
of extensor carpi radialis brevis and abductor
pollicis longus over the radial styloid.
There is tenderness over the radial styloid
exacerbated by abduction of the wrist and
thumb against resistance and full adduction
of the thumb across the palm for 30 seconds
(Finglestein’s test). This may respond to
an injection of hydrocortisone but is usually
best treated by division of the tendon sheath.
Osteoarthritis
Osteoarthritis of the carpometacarpal joint
of the thumb is common and may require a
support and physiotherapy and occasionally
an arthroplasty
Trigger finger
Trigger finger, due to constriction of the
flexor sheath over the metacarpo-phalangeal
joint, may respond to a hydrocortisone in-
jection, otherwise division of the sheath.

Spinal Conditions
Cervical spondylosis
Irritation of the cervical nerve roots is
due to narrowing of the intervertebral
foramina from osteophyte formation and disc
degeneration, often between C4/5 or C5/6
vertebrae. Irritation of the C5 and C6 nerve
roots may cause stiffness, pain radiating
down the arm and occasional sensory-motor
impairment. There is usually a triad of tender
areas over the base of the neck, the inser-
tion of the deltoid and the extensor muscle
mass ( not origin) in the forearm. Treatment
is conservative, with analgesics and anti-
inflammatory drugs as well as a collar,
heat, exercises and occasionally neck traction
with rotation and flexion to the affected
side.

538 A Simple Guide to Orthopaedics

 Upper Limb Conditions

© Huckstep 1999

© Huckstep 1999

X-ray appearance de Quervain’s

of a Colles’ tenosynovitis
fracture

Spinal conditions

© Huckstep 1999

Treatment:
© Huckstep 1999

physiotherapy,
supportive
X-ray appearance of collar and
cervical spondylosis traction
Orthopaedic Conditions in the Elderly 539
Senile kyphosis
A senile kyphosis due to osteoporotic col-
lapse is common, usually in the thoracic
spine, and leads to deformity and chronic
back pain. The differential diagnosis, es-
pecially in isolated collapse, is metastatic
deposits (Chapter 11).
Low back strain and disc protrusion
Apart from osteoporotic collapse of the
vertebrae themselves and possible secondary
deposits, low back strain is common in the
elderly. This is often due to obesity, poor
muscle tone and an inadequate diet. Disc
degeneration is common in the lower lumbar
region, especially in the L4/5 and L5/S1
disc spaces, with irritation of the L5 and
S1 nerve roots causing sciatic pain.
Treatment in the acute stage is usually
conservative with bed rest, heat and
exercises. Traction on both legs or the pelvis
or an epidural injection of local anaesthet-
ic and hydrocortisone for sciatic irritation
may be indicated followed by gradual
mobilisation with a back support.
Occasionally removal of a protruding disc
causing root pressure may be indicated and
this can be done either by a limited
laminectomy approach or by a nucleotome. A
nucleotome is similar to a knee arthroscope
and allows a disc to be removed through a
small tube without a major operation. In
acute disc protusions injection of the disc
with chymopapain (which digests the disc)
may occas-ionally be effective. There is,
however, an appreciable complication and
failure rate.
Long term treatment is by heat, back
exercises (including swimming), education re-
garding diet, a firm mattress, upright chairs
and education regarding safe lifting tech-
niques. A back support may also be indicated
(Chapter 11).

540 A Simple Guide to Orthopaedics

 Spinal Conditions
Thoracic Spine

© Huckstep 1999 © Huckstep 1999

Kyphosis X-ray appearance of

senile osteoporosis

Lumbar Spine

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X-ray appearance of a X-ray appearance of

prolapsed intervertebral collapsed vertebrae
disc
Orthopaedic Conditions in the Elderly 541
Lower Limb Conditions
Hip conditions
Osteoarthritis
Osteoarthritis of the hip is common in the
elderly and may be unilateral or bilateral.
It is often associated with osteoarthritis
of the knee and low back strain due to the
excessive compensatory strain caused by the
flexed and adducted hip.
Physiotherapy with short wave diathermy,
exercises and a raise on the heel to compen-
sate for the flexed hip and shortened leg
should be tried initially in mild cases. In
elderly patients with advanced osteoarthri-
tis a total hip replacement is the procedure
of choice.

Knee conditions
Osteoarthritis and genu valgum and
varum
Osteoarthritis of the knee is common,
especially after a meniscus injury. This may
lead to an increasing varus or valgus deformity
of the knee which sometimes causes
increasingly asymmetrical wear on the ar-
ticular cartil-ages in either the medial or
the lateral joint compartments. This leads
to increased pain, synovitis and stiffness.
A trial of physiotherapy with short wave
diathermy and exercises plus a knee support,
analgesics and anti-inflammatory drugs may
be all that is required in mild cases.
Severe osteoarthritis is usually treated
with a valgus or varus osteotomy of the tibia
or femur or a total knee replacement.

542 A Simple Guide to Orthopaedics

 Lower Limb Conditions

© Huckstep 1999

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X-ray appearance of X-ray appearance of

osteoarthritis a total hip
replacement

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© Huckstep 1999

X-ray appearance X-ray appearance of a

ofosteoarthritis total knee replacement
Orthopaedic Conditions in the Elderly 543
Foot
Chronic foot strain
Obesity and poor muscle tone often lead to
painful feet in the elderly. Chronic foot
strain with collapse of the longitudinal arch
is common and is often improved with molded
longitudinal arch supports.
Plantar fasciitis and plantar neuroma
Plantar fasciitis with pain under the heel,
and anterior metatarsalgia with tenderness
under prominent second and third metatarsal
heads is common and is often relieved by
supporting insoles. A plantar neuroma be-
tween the metatarsal heads may require exci-
sion.
Hallux valgus and claw toes
Hallux valgus and clawing of the toes are
often relieved by suitable shoes,
physiotherapy and relieving pads, but may
require operative correction.
Vascular insufficency due to
atherosclerosis or spasm secondary to
hypertension or smoking may lead to ischae-
mic changes and ulceration. Diabetes may lead
to peripheral neuritis and poor healing of
sores, particularly if foot hygiene is
inadequate.
Foot conditions are discussed in further
detail in Chapter 14.

544 A Simple Guide to Orthopaedics

 Lower Limb Conditions

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© Huckstep 1999
Hallux valgus
Plantar Treatment: ‘bunion’ pad
fasciitis-heel or operation
pad
Treatment of metatarsalgia

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© Huckstep 1999

Anterior metatarsal
support Excision of neuroma

Orthopaedic Conditions in the Elderly 545

546 A Simple Guide to Orthopaedics