If the joint is thought to be the pathology causing the symptoms the clinician will have to decide the likely process. Of the three major diagnostic categories one is arthritis of an inflammatory cause, involving the synovial joint linings and the bone-ligament and bone-tendon junctions (the entheses). The function and structure of a joint can be affected by arthritic changes not of an inflammatory nature, secondary to meniscal or articular cartilage damage or caused by other joint changes which can be from a number of causes.

The third possibility is joint pain or arthralgia in the absence of significant pathology, such as fibromyalgia or with sub clinical changes that have yet to declare themselves. Different types of joint disorders can occur in the same joint with inflammatory disorders typically destabilising a joint and leading to structural abnormality. Pain is a significant symptom of these joint disorders and in inflammatory conditions the pain is present whether the joint is moving or still, with it typically being worse as the movement is started. With arthritic changes that are not secondary to inflammation pain occurs typically with movement and improves with resting.

If the arthritic changes become very advanced in the spine or major joints patients may suffer pain even when they are resting and also at night. Larger joint pain is less clearly localised to the joint than pain from smaller joints, with hip pain possibly referred to the buttock, lateral thigh, groin or front of thigh. Stiffness is common with arthritis and a difficult symptom to define, but it means difficulty moving a joint, especially after a period of resting, which goes off with movement. Inflammatory joint stiffness may last longer, for example half an hour to an hour, while osteoarthritic stiffness may ease after 10-15 minutes.

Joints often exhibit swelling which can occur in several different ways. In inflammatory disease excessive fluid is secreted by the synovial lining of the joint, causing an effusion which is a collection of fluid within a joint cavity, capable of being drawn off with a needle. Osteoarthritic or other non-inflammatory changes respond by forming bony outgrowths at the joint margins which make the joint enlarge in a knobbly fashion. Loss of some of the joint’s movement is common either from inflammation and pain, damage to the structure of the joint or soft tissue contracture.

Activities of daily living are often affected by arthritic change such as dressing, self care and stair climbing, often secondary to muscle weakness and atrophy. If pain accompanies weakness the cause is likely musculoskeletal rather than neurological or due to muscle pathology. Weakness can cause functional problems such as gripping things, getting up and down from sitting or walking safely. In systemic arthritis the whole person is involved in the disease and malaise and fatigue are common. An arthritis can develop slowly or can come on quickly, joint symptoms occurring over a few hours, in response to injury, infection or crystal deposition.

The develop of joint symptoms over weeks to months is more common and is the case in osteoarthritis and rheumatoid arthritis, the two most common conditions. If symptoms are present less than six weeks they are acute, from 6 to 12 weeks they are sub-acute and over 12 weeks they are termed chronic, although this is not a rigid classification. Joint involvement varies with different patterns, such as episodes of joint pain with pain-free times in between as in gout, to the persistence of joint problems as further joints are involved. Arthritis is also classified by the number of joints affected with polyarthritis affecting five or more, oligoarthritis two to four and monoarthritis one joint only.

Non-symmetrical and symmetrical joint patterns of involvement can occur. SLE and rheumatoid arthritis tend to affect the same joints on each side of the body in a symmetrical pattern while psoriatic arthritis and reactive arthritis involve different joints on each side of the body, the asymmetrical pattern. Joints may be involved in different patterns also, for example distal finger joints in osteoarthritis and psoriatic arthritis but not in rheumatoid arthritis.

Most of us spend a lot of time sitting,so posture makes a big difference to our backs. Here are six ways to improve posture 1. Feet flat on the floor. Keep one foot, and preferably both feet, flat on the floor. Try this: Sit down and if you have a chair with a moving back, lock it in the upright position. Rest your hands in front of you on the desk, as if you are typing. Concentrate on the shape of the lower spine. Straighten your legs and place the feet on ground, on the heels of your shoes. See how your lower spine has changed shape-it’s moved slightly from the back of the chair. The muscles in the mid section of your back have to work to keep you sitting up straight. Now notice the lower back’s shape when you put your feet flat on the floor, with your knees at a 90 degree angle. It’s in contact with the back of the chair. Your mid-section back muscles are relaxed.

2. Back straight-don’t slump. By resting your arms on the desk, you take some of the load from your back. Relaxing your shoulders as much as you can prevents tense neck and shoulder muscles. Try to be aware when you lift your shoulders and remind yourself to drop them. Don’t work with a twisted spine-work with the computer screen so that it’s right in front of you and you face it directly.

3. Don’t twist and stretch to the side at the same time. If you need to get something out of your desk drawer or off the floor, turn your body to face the object. If you cant reach something without leaning out of your chair, then rather stand up to get it.

4. Get up and walk every 1-2 hours-don’t sit continuously. Walk around for a few minutes-go and get some water. You could work standing for a while eg reading some documents or files. Another option is to write some ideas or notes on your tasks on on your whiteboard. Think of ways to break continuous sitting.

5. Good posture when standing up and sitting down. Don’t overlook this, as you can strain your back if you arch it when you getting up or sitting down. Try not to move your back as you sit and stand.Keep good posture and lean forward at the hips. Don’t lift your chin and arch the back when standing. Rather look slightly down and remember to keep the back straight, not arching it as you stand.

6. Picking up objects. A very common way on which people hurt their backs is through incorrect posture and technique when picking up something, especially a heavy object, from the floor. Always bend your knees Keep your back straight. Slightly tense your abdominal muscles Let your arms hold the object tight whilst most of the lifting is done by your legs. Feel your leg muscles- mainly your hamstrings, doing the work.

If used for permanent fixation pins and wires are usually chosen if very little load is going through the fracture site or they are adding to the stability of a plate or an external fixator. Typical uses for wires or pins are to fix finger fractures, hand fractures, shoulder fractures and wrists. K-wires are often used to assist with the fixation in fractures of the patella, elbow and ankle. A device known as an image intensifier is often used to insert the device under x-ray guidance, allowing insertion of the pin or wire through the skin without operation.

Larger than wires and able to be threaded, Steinmann pins are typically employed to apply traction skeletally for one of the long bones, mostly in the leg. They are driven through the bone and attached to a weight via a stirrup-like device which applies the traction to maintain bony alignment until sufficient callus has formed for the traction to be removed. Traction is used much less often now as this technique has been overtaken by more advanced methods of internal fixation which allows us to avoid the negative consequences of long term bed rest needed for traction.

Screws

A basic tool in the armoury of managing orthopaedic and trauma injuries and conditions is the use of bone screws to effect fixation or to aid other techniques of fixation. Pre-drilling can be performed before insertion or a self tapping implant used. The amount of physical stress which can pull a screw out of the bone is affected by a series of matters of which the most influential is the density of the bone into which it is implanted. The surface area of contact between the bone and the screw threads determines a degree of the fixation achieved. Screw insertion is performed in a clockwise direction either along a drilled path or self tapped and produces force once the hard bone cortex is contacted by the head of the screw.

The tension forces imposed by insertion of the screws are adapted to by bone which is a living and dynamic tissue, leading to a reduction in the desired fixation forces with time. The fractures typically heal however before the tension reduction becomes functionally relevant. For the harder and denser bone of the cortices, the outer parts of long bones, cortical screws are used. For the less dense bone of the bone ends cancellous screws are chosen. Cancellous screws have a greater contact surface area between the threads and the bone and are designed to make an effective level of purchase in the softer structure of cancellous bone.

Pre-drilling or tapping is not generally needed in cancellous bone due to its porosity and ease of insertion. Lack of tapping is often better as the insertion of the screw compresses the bone and may increase the local density of the bone, making the screw purchase more secure. Positional screws are used to attach an implant device such as a plate to the bone by compressing between the bone and the plate. Typical insertion involves drilling a pilot hole with a matching bit for the screw size and an appropriate thread tap is used unless self tapping screws are to be inserted.

A degree of compression can be produced by inserting lag screws across the line of a fracture to increase alignment and stability of a long bone fracture and to produce and maintain reduction of a fracture across a joint. To provide the greatest degree of stability requires the screw to be placed at right angles to the line of the break. It is unlikely that lag screws will give sufficient stability alone so they are often supplemented with added stability from an external fixator or a plate.

Cannulated screws are another type of fixation, inserted over a guide wire which has already been inserted under x-ray control, allowing the initial wire fixation to be precisely completed by the final fixation. They can be used in a percutaneous way, without open operation, such as with hip fracture pinning. Cannulated screws can also be used in operations with limited open technique to minimise the size of the operation and the consequent soft tissue damage. Modern designs both drill and tap themselves on insertion and these hollow design screws are much more expensive than non-cannulated versions.