General Principles

and Spesific Methods

of Musculoskeletal
Treatment

Dr. Su Djie To Rante, M. Biomed, Sp.

OT
General Principles of Treatment
In the practice of medicine, general principles are
formulated from natural laws (“laws of nature”) –
laws of the behavior of body tissues under various
conditions as well as laws of human behavior – laws
that you must constantly respect

It is important not only to know what you are doing or

planning to do but also to know the reason why
 General Principles of Treatment
1. First do no harm (primum non nocere)
• Although methods of treatment have a potential for great
benefit, they also have a potential for great harm
• In planning a method of treatment for your patients, its
potential benefit must be weighed against its potential harm

2. Base treatment on an accurate diagnosis and prognosis

• You will not be helping your patients as much as you
should if you treat only a secondary manifestation of their
disease (a symptom or a sign) without making an accurate
diagnosis of the underlying or primary disease
 General Principles of Treatment
3. Select treatment with specific aims
• Chief complaints of patient with musculoskeletal disorders and injuries
are :
a) Pain
b) A decrease in function
c) The physical appearance of either a deformity or an abnormal gait
• The musculoskeletal treatment will have as its specific aim one or more
of the following
a) The relief of pain
b) The improvement of function
c) The prevention or correction of deformity
d) The improvement of gait

4. Cooperate with the laws of nature

• Must appreciate the natural laws of the behavior of body tissue under
various circumstances in order to work with them through the
appropriate choice of a general type of treatment as well as the specific
method and particular technique of treatment
 General Principles of Treatment
5. Be realistic and practical in your treatment
• Certain methods of treatment that may seem attractive
in theory may be neither realistic nor practical for your
particular patient.

6. Select treatment for your patient as an individual

General Forms of Treatment
Treatment sometimes described as :
Conservative (Non operative)
Radical (Operative)
 General Forms of Treatment
1. Psychological considerations

2. Therapeutic drugs

3. Orthopaedic apparatus and appliance

4. Physical and occupational therapy

5. Surgical manipulation

6. Surgical repair and reconstruction

7. Electrical stimulation

8. Continuous passive movement

9. Radiation therapy
 1. Psychological
Consideration
Ought not treat the body without the mind (Socrates,
400BC)

For patients with minor disorders or musculoskeletal

variations of normal, the only type of treatment
needed may be reassurance
 2. Therapeutic Drugs
Analgesics

Nonsteroid Anti-inflammatory Drugs (NSAID)

Chemotherapeutic Agents

Corticosteroids

Vitamins

Specific Drugs
3. Orthopedic Apparatus and Appliances

A. Rest
 Prolonged immobilization of a limb and its synovial
joints is associated with many harmful effects :
 Disuse atrophy of local muscles and resultant muscle
weakness
 Disuse atrophy of local bone (localized osteoporosis)
 Local venous thrombosis with resultant edema
 The complication of pressure sores (cast sores)
 Muscle contractures
 Joint capsule contractures
 Intra-articular adhesions
 3. Orthopaedic Apparatus and Appliances

 Relative rest :
1. Preventing its usual function with a sling for an upper limb
2. Crutches for the relief of weight bearing in a lower limb. A sling
for the lower limb may be used with crutches
3. Continuous traction :
a) To stretch gradually soft tissues that have become shortened
secondary to a long-standing joint deformity or dislocation (ex :
continuous traction prior to reduction of a congenital dislocation of
the hip)
b) To relieve painful muscle spasm associated with joint inflammation
or injury
c) To maintain length of the limb and alignment of fracture fragments
in unstable fractures of the shafts of long bone
3. Orthopaedic Apparatus and Appliances

 A useful method of supporting a painful or irritable,

hip or knee that enables the patient to move the
affected joint freely  combination of slings and
springs
 Fairly rigid and continuous local rest (immobilization)
 plaster of Paris casts  is used to maintain or
stabilize the position of a fracture, a dislocation after
reduction, maintain desired position of a part
following injury, surgical manipulation, or surgical
operation.
 3. Orthopaedic Apparatus and Appliances

 Harmful effects for prolonged immobilization of a limb and its

synovial joint :
1. Disuse atrophy of local muscles and resultant muscle weakness
2. Disuse atrophy of local bone (localized osteoporosis)
3. Local venous thrombosis with resultant edema
4. The complications of pressure sores (cast sores)
5. Muscle contractures, joint capsule contractures, intra-articular
adhesion

 If the limb has been immobilized more than 1 or 2 months,

especially after intra-articular injury or operation, the joint may
never recover completely and may develop secondary post-
traumatic arthritis
 3. Orthopaedic Apparatus and Appliances

B. Support for Muscle Weakness and Joint Instability

 Extensive muscle weakness in the upper limb 
functional braces
 A weak or unstable and painful spine  spinal brace
 Hypermobile joints in the feet  temporary support by
arch supports and sole wedges
 Mild soft tissue injuries of joints  temporary support
with adhesive tape strapping

C. Prevention and Correction of Deformity

 3. Orthopaedic Apparatus and Appliances

C. Prevention and Correction of Deformity

 When development of a joint deformity is anticipated,
as with muscle imbalance in either spastic or flaccid
paralysis or with muscle spasm in chronic arthritis 
prevent deformity by means of intermittent
immobilization in a removable splint made of plaster
of Paris
 Following correction of a joint deformity and the
subsequent period of immobilization  may necessary
to use a removable splint for intermittent
immobilization to prevent recurrence of the deformity
4. Physical and Occupational Therapy

The aims is to regain and maintain joint motion, to

increase muscle strength and to improve
musculoskeletal function.

Physical therapy  focus on gross motor function

Occupational therapy  fine motor skills

4. Physical and Occupational Therapy

Joint motion
 The safest method of regaining motion in a painful stiff
joint  active movement
 Intermittent passive movement in a painful stiff joint is
potentially dangerous, especially if it is forceful
 Intermittent passive movement are great in maintaining
joint motion and preventing deformity in a joint that
the patient cannot move actively because of paralysis
4. Physical and Occupational Therapy

Muscle strength
 A muscle is strengthened only by active exercise
 Even when a limb is immobilized (as in cast), muscle can be
strengthened by isometric exercise (muscle action without
joint motion)
 Isotonic exercise (producing joint motion)  increase
muscle strength and helping regain motion
 When muscle has an intact nerve, but inhibited following
injury or operation, it can be electrically stimulated to
contract by faradic current applied to its motor nerve
 When muscle has lost its nerve supply gradually atrophies
and undergoes fibrosis, but there is hope of nerve recorvery,
these change can be minimized pending nerve recorvery by
galvanic current that stimulate muscle fibers diretly
4. Physical and Occupational Therapy

Improvement of musculoskeletal function

Functional training involves coordination of muscles in
skillful and purposeful activity by patient.
 5. Surgical Manipulation
 The aims are to correct deformity either in a bone or
in a joint, and to regain motion
 The great majority of fracture and dislocation can be
treated by manipulation of the part into a satisfactory
position (closed reduction)
 6. Surgical Operations
 Surgical operations have a potential for providing
great benefit to the patient, but they also have a
potential for producing great harm to that patient
 The aims of surgical operation for musculoskeletal
condition :
1. Relief pain
2. Improvement of function and ability
3. Prevention or correction of deformity

 The general methods of operative treatment by which

these aims, are achieved involve various combination
of repair, release, resection, reconstruction, and
replacement of involved tissues
 6. Surgical Operations
Operations on Muscles, Tendons, and Ligaments
 Fasciotomy (relieved closed muscle compartment)
 Tenorrhaphy (a cut tendon is repaired by suture)
 Free tendon graft (replaced a segment of the tendon that irreparably
damaged by unimportant tendon such as tendon of the plantaris muscle)
 Tenolysis (to free tendon that is tethered by adhesions)
 Tenotomy or Tendon lenghtening (correction of a shortened muscle)
 Muscle transfer or tendon transfer (paralyzed or damaged muscle replace
by transferring the tendinous insertion (Origin) of a nearby muscle to
improve muscle balance
 Tenodesis (in order to check an undisered joint motion, the tendon of a
muscle may be separated from its muscle and implanted into the bone to
serve as a ligament
 Ligamentous repair
 Ligamentous reconstruction (replace major ligament that are irreparably
damaged by a tendon or free graft of fascia lata)
 6. Surgical Operations
Operations on Nerves
 Nerve suture
 Nerve graft
 Neurolysis or decompressed
 Laminectomy (removing part of the lamina on
protruded intervertebral disc / nucleus pulposus)
 Transposition of a nerve (change the course of the
nerve by transposing to the flexor aspect of the joint,
example on ulnar nerve with a cubitus valgus
deformity)
 6. Surgical Operations
Operations on Joints
 Arthrotomy (open the joint)
 Capsulorrhaphy (elongated fibrous capsule of the joint is tightened and
repaired, example : reccurent disloction, congenital dislocation)
 Capsulotomy (divided or release the shortened fibrous capsule, in sever
joint contracture)
 Capsulectomy (resect the shortened fibrous capsule)
 Synovectomy (resect the diseased synovial membrane)
 Arthroplasty (a reconstructive operation designed to regain or maintain
motion in a chronically painful joint, by means of altering or replacing
one or both joint surfaced)
 Arthrodesis (fuse single joint by producing bony union across it)
 6. Surgical Operations
Prosthetic Joint Replacement (Total Artificial Joint)
 The pioneer of modern-day prosthetic join replacement was Sir John
Charnley of England (1962), develpoed low friction arthroplasty of the
hip joint
 Prosthetic hip joint repalcement is indicated primarily for :
1. Severe arthritis in patient > 60 years old, and have an average life
expectancy of only 1 or 2 decades.
2. For younger patient with disabling arthrits and serious generalized disease
with limited life expeectancy
Contraindicated for children, healthy young and middle aged adult
 Complication of prosthetic hip joint :
• Loosening of component of the prosthesis
• Fatigue fracture
• Dislocation
• Infection
 6. Surgical Operations
Osteocartilaginous Allografts
• Gross and Langer used small Osteocartilaginous
Allografts from fresh cadaver since 1971 on patient
with one side of joint is arthritic
 6. Surgical Operations
Arthroscopic Surgery
• Removal of loose body
• Partial or total meniscectomy
• Repair of peripheral tears in menisci
• Drilling defect in the articular surface
• Abrading area of chondromalacia
• Synovectomy
• Reconstruction of a torn ACL
 6. Surgical Operations
Operations on Bones
• Bone drilling (draining pus from the metaphysis)
• Sequestrectomy
• Sauceration (removing cortex on one side)
• Bone resection (removing all part of the bone)
• Osteotomy (division of a bone with a sharp instrument)
• Surgical lengthening of a bone by the Ilizarov technique which involve
Callotasis (delayed and slow distraction of callus)
• Open reduction of a fracture and internal skeletal fixation
• Epiphyseal plate stimulation, Ephipyseal plate arrest, epiphyseodesis,
epiphyseal plate stapling (in leg length discrepancy)
• Bone grafting
• Amputation (remove part or all of the limb through bone)
• Disarticulation (remove part or all of the limb through joint)
 6. Surgical Operations
Microsurgery
• developed since 1960
• possible to replant completely severed digits and limbs
Electrical Stimulation of Fracture Healing

Constant direct current through percutaneous wire

cathodes

Constant direct current through implanted electrodes

and power pack

Inductive coupling through electromagnetic coil

 Continuous Passive
Movement
Indications for post operative CPM (in adolescent and adult
patients)
 Arthrotomy, capsulotomy, debridement, and arthrolysis of joints
with painful restriction of motion secondary to post-traumatic
arthritis
 Open reduction of intra-articular fractures as well as metaphyseal
and diaphyseal fractures
 Patellectomy
 Repair of ligamentous injuries
 Synovectomy for rheumatoid arthritis and hemophilic arthropathy
 Arthrotomy and drainage (combined with appropriate antibiotics)
for acute septic arthritis
 Biological resurfacing (with periosteal graft) for a major defect in
joint surface
 Surgical repair of a complete laceration of a tendon
 Rigid internal fixation of a metaphyseal osteotomy
 Total prosthetic joint replacement
 Radiation Theraphy
Used empirically in treatment :
• Langerhans cell histiocytosis
• Ankylosing spondylitis
• Vinonodullar synovitis

o Most serious effect on normal skeletal tissue :

• Epiphyseal plate damage
• Pathological fracture
• Malignancy
 Rehabilitation
The broad aim of rehabilitation is to correct physical,
mental, social problem of the patient in order that his
or her life may be changed

Require coordination of a large group, include

rehabilitation physician, the orthopaedic surgeon,
nurse, physical therapist, orthotist and prosthesist.
Thank You
Thank You