Primary survey positive patients

Musculoskeletal injuries will rarely lead to a primary survey positive patient, except in major trauma. There are however immediately life-threatening problems that might mimic a musculoskeletal condition. These pose a trap for the unwary and are:

leaking abdominal aortic aneurysm (AAA) presenting as back pain

aortic dissection presenting as inter-scapular pain

perforation/peritonitis presenting as shoulder tip pain

acute myocardial infarction (MI) presenting as shoulder or arm pain.

A high index of suspicion and assessment of the ABCs can help identify these important conditions. A careful history will usually reveal no episode of trauma and a very acute onset of pain.

A leaking AAA presents acutely with abdominal and lower back pain with or without collapse and features of hypotension. The pain of an aortic dissection is described as tearing. Ischaemic chest pain is classically tight or band-like. Diaphragmatic irritation from a ruptured hollow viscus can cause shoulder pain, particularly on lying flat. Patients with these suspected conditions need urgent transport to a facility with the capabilities to fully manage these problems.

Immediate management will consist of essential interventions only. Administer oxygen, obtain intravenous access and give analgesia and possibly cautious fluid resuscitation en route. Do not delay transport to perform these procedures.

Assessment of the stable patient

The assessment is carried out according to the recognised system (SOAPC) outlined in Chapter 2. The first step is to decide if the problem is due to trauma or one of the many causes of non-traumatic limb or spinal pain. The spectrum of diagnoses is very different in these two groups.

Trauma vs no history of trauma

Patients who present with no history of trauma should alert the clinician to the possibility of missing Referred pain, Ischaemic syndromes, Sepsis and Kids problems such as epiphyseal abnormalities. Remember the mnemonic RISK. These are the conditions commonly overlooked and can indicate limb- or even life-threatening problems such as cardiac pain, a slipped upper femoral epiphysis or a septic joint.

Subjective information gathering – the history

Definite trauma

Acute trauma is caused by a single, clear event. This can lead to a wide spectrum of injury from minor self-limiting sprains to fractures and/or dislocations of joints. The features of a fracture are pain, swelling, loss of function and bony tenderness. Dislocations are usually more obvious with similar features to fractures plus an abnormal joint morphology with deformity. In the absence of these features then a soft tissue injury is more likely but consider damage to other structures such as ligaments, tendons, nerves and vessels (Box 13.3).

Box 13.3 The elements of history taking in acute trauma

Mechanism of injury

Symptoms and progress of symptoms over time

Previous episodes of injury

Past medical history/drugs/allergy

Level of activity in job or sport

Mechanism of injury

A clear history of the mechanism of injury is essential to accurate diagnosis in trauma. Elicit the magnitude and direction of the forces causing the injury. Simple errors are made by a failure to follow this advice. For example, if the only history obtained was ‘hurt neck in road traffic accident’ the clinician might jump to the conclusion the injury was likely to be a simple neck sprain. However, consider how different your actions might be if a full history were to be obtained such as ‘hurt neck in road traffic accident, was unrestrained front seat passenger in car which overturned at speed’ (Fig. 13.1).

Fig. 13.1 A history of ‘hurt neck in road traffic accident’ can mean anything from the injury being sustained in a minor rear end shunt to a major high speed and high risk impact. Always try to gain a clear mental picture of the mechanics of the injury.

Symptoms and progress

Pain, swelling and loss of function are the main symptoms following injury. Ask if these symptoms have progressed since the incident. A sudden and complete loss of function at time of impact increases the risk for a more severe injury. Ask about associated symptoms such as paraesthesia and trauma elsewhere.

Past history and previous injuries

Ask the patient if they have any other significant medical conditions or are taking any medication. Most injuries are acute, but some are an acute episode complicating a chronic problem. The investigation and treatment of an ‘acute on chronic’ injury may be slightly different.

Level of activity

Patient expectations are an important consideration in the management of musculoskeletal injuries. A professional athlete will demand as near 100% function as is possible post-injury but most patients will manage very well with minor ligament instability as long as they have good protective neuromuscular function. Nevertheless it is important to consider occupation, hobbies and handedness so that expectations and needs can be identified.

No definite trauma

Patients who present with a limb or spinal pain but with no history of trauma can present diagnostic problems. In the majority of patients the illness will be minor and self-limiting or of a chronic nature not needing urgent treatment or investigation. However a minority of patients with these ‘minor’ symptoms may be suffering from life- or limb-threatening pathology. The mnemonic ‘RISK’ highlights the categories of serious diagnoses that may require exclusion (Box 13.4). Always consider the RISK diagnoses – failure to do so will lead to them being missed.

Box 13.4 ‘RISK’ diagnoses in non-traumatic limb and spinal pain

R Referred pain from chest/abdomen/spine^*

I Ischaemia/vascular problems/DVT

S Sepsis

K Kids problems such as an epiphyseal injury

*Examples include shoulder pain due to irritation of the diaphragm or knee pain due to hip pathology.

The ‘OPQRST’ of pain

See Box 13.5.

Box 13.5 ‘OPQRST’ history taking of the symptom of pain

O – onset

P – provoking and palliative factors

Q – quality

R – referred pain

S – systemic symptoms/associate symptoms

T – timing

O – Onset

A very sudden onset of pain is often associated with a vascular problem such as occlusion or referred pain from cardiac ischaemia or a leaking aortic aneurysm. Sudden pain waking the patient at night is a worrying symptom. Some mechanical problems do cause a sudden onset of pain in the absence of definite trauma, examples include an acute intervertebral disc prolapse or a loose body in a joint. Many other causes of limb pain will cause a gradual onset or intermittent symptoms.

P – Provoking or palliative factors

Ask if the patient has participated in any unusual activity in the period leading up to the onset of symptoms, or has recently significantly increased the level of an activity (e.g. doubling their running distance) which would be unusual for that patient. Note other aggravating or relieving factors.

Q – Quality of pain

Is the pain throbbing in nature, toothache-like, or sharp and associated with certain movements? How severe is the pain?

R – Radiation and site

Ask if the pain radiates either proximally or distally in the limb. This may be an indication that the problem lies more centrally. Common examples are:

arm pain radiating from the neck or heart

shoulder pain from irritation of the diaphragm

knee pain from the hip and leg pain from the lumbar spine.

S – Systemic symptoms/associated symptoms/ previous history

Does the patient have markers of a systemic illness such as fever, chills, loss of appetite or weight loss?

Joint problems are sometimes associated with systemic illnesses. Ask if there are any other symptoms such as back problems (ankylosing spondylitis), eye problems, inflammatory bowel symptoms, genitourinary symptoms, recent illnesses, and respiratory tract infection. Some types of acute arthritis are part of complex syndromes, e.g. Reiter’s syndrome.

Note previous medical history, especially if there have been similar problems in the past. Exclude problems with other joints or a history of arthritis. Exclude many of the more common diseases such as diabetes. Does the patient take warfarin or have any coagulopathy?

T – Timing

Does the pain keep the patient awake at night? Is it worse first thing in the morning or after exercise?

Objective information gathering – the examination

Develop a systematic method of musculoskeletal examination:

joint above

look

feel

move

function

nerves and vessels.

Have the patient in a relaxed position. Start by examining the joint proximal to the injury (or spine if indicated). Follow standard orthopaedic practice, using the ‘look, feel, move, function’ system. Finish by checking the circulation to the limbs and test neural function distal to the injury.

Where there is no history of trauma, follow the same system but check vital signs and look for other clinical signs as summarised in Box 13.6.

Box 13.6 Clinical signs to look for when there is no history of trauma

Vital signs – particularly temperature and pulse rate

Stigmata of systemic disease or of systemic arthritis

Skin rashes

Proximal joints

Neurovascular examination

Spine

(Chest and abdomen if indicated)

Objective information – tests

X-Rays – indications

If a fracture or dislocation is suspected then the patient needs referral to hospital. Many will need immediate referral, but if there is no deformity, no neurovascular compromise and the injured limb can be effectively immobilised (including non weight bearing for the lower limb) the patient might be referred for X-ray at a more convenient time. Outpatient referral to the radiology department of the local hospital allows non-urgent X-rays to be performed. Many departments have a system of ‘hot reporting’ so that X-rays are reviewed immediately. If abnormalities are seen the patient is referred to the appropriate hospital team. If X-rays are normal the patient may return to their GP for further treatment.

Use local guidelines and policy to decide when an X-ray is indicated. The definite fractures are easy to diagnose but unfortunately many fractures are undisplaced and it is difficult to confidently exclude a fracture without an X-ray. Many experienced clinicians would advise ‘X-ray when in doubt’. Other indications include suspected foreign body within a wound, e.g. glass or metal. For further information see the Royal College of Radiologists guidance on www.rcr.ac.uk and ‘Making the best use of a Department of Clinical Radiology’.⁷

There are other excellent reference sources available for the need to X-ray certain anatomical areas such as the ankle. Probably the best known are the Ottawa ankle rules⁸ used to help decision making in the assessment of acute ankle injuries that may either be sprained (the majority) or fractured (Fig. 13.2).

Fig. 13.2 Ottawa ankle rules.

Other decision rules exist for similar use in acute knee⁹ and neck¹⁰ injuries.

Be aware that many of these decision tools have limited applicability to groups such as the elderly, whose bones may fracture more easily, and very young children, where epiphyseal injuries may be more common. The Ottawa ankle rules have however been validated in children down to the age of 6 years.

In January 2000 the Ionising Radiation (Medical Exposures) Regulations came into force to protect patients undergoing exposure to X-rays. Any clinician ordering X-rays independently needs to be accredited and attend training on this subject. For further information on IRMER legislation see the Department of Health website (www.dh.gov.uk/assetRoot/04/05/78/38/04057838.pdf).

Trauma

A ‘sprain’ is a tear in a ligament and the term covers a huge spectrum of injury, from the minor partial tear of a part of a ligament to a permanently disabling injury. A careful history and examination allows the definition of the severity and builds an accurate picture of the likely damage caused:

grade 1 sprain is where a few fibres of part of the ligament are torn

grade 2 sprain is complete rupture of part of the ligament complex, e.g. rupture of the anterior talo-fibular ligament of the ankle lateral ligament complex

grade 3 sprain is complete disruption of the ligament complex with associated instability.

Great difficulty arises in the grading of ligament injury. Grade 3 injuries are usually clinically obvious, with much more bruising and swelling. Instability is the main concern mandating aggressive treatment, splintage, referral, repair and/or physiotherapy. A repeat examination after 5 days may be needed to establish the true extent of some injuries. Use a ‘wait-and-see’ policy as long as you have excluded a potentially serious injury.

Muscle tears or strains are common and usually self-limiting. Some muscles and tendons can rupture completely; the most common closed ligament injury is rupture of the Achilles tendon. This diagnosis may be missed if not specifically tested.

Fractures are often easy to diagnose but are difficult to exclude. Pitfalls include the scaphoid fracture in adults, hip fractures in the elderly and spinal fractures. Osteogenesis imperfecta (brittle bone disease) should lead to a very high index of suspicion for fracture even with minimal trauma.

No definite trauma

Common diagnoses are osteoarthritis (OA) and degenerative disease. Ask about previous symptoms (these are discussed below).

Consider referred pain, ischaemia, sepsis and kids (RISK) as causes of pain when no other cause seems apparent. Limb pain could be due to a septic joint, a critical ischaemia or referred from spine, abdomen or chest.

Causes of a ‘hot joint’ include gout, pseudogout, infection, acute arthritis and haematological conditions – see below.

Beware children. The slipped upper femoral epiphysis is the classic pitfall where minimal or no trauma is involved yet a significant pathology occurs that needs to be appreciated as early as possible for corrective treatment to commence.

Back pain

One very common problem is acute mechanical back pain, this usually occurs in young fit people. The pain usually starts suddenly and is often severe. However, if there are no ‘red flag’ symptoms (Box 13.7), advice is given to try to stay mobile and good analgesia prescribed. Cases with unusual or continuing severe symptoms should be reviewed early by their GP.

Box 13.7 ‘Red flags’ that might indicate serious spinal pathology

History

age <20 or >50 at onset

Trauma (fall from height/RTA)

Thoracic pain

Constant, progressive pain

Weight loss

PMH

Carcinoma

Steroid use

Drug abuse/HIV

Examination

Systemically unwell

Persisting severe restriction of lumbar flexion

Widespread neurology

Structural deformity (scoliosis/step)

Pain radiating down the back of the leg to below the knee may indicate sciatic nerve irritation. A careful neurological examination is needed. Refer for early review by the GP.¹¹ If there is pain down both legs or any disturbance of motor power, bladder or bowel function, then refer to hospital immediately.

There are many other causes of back pain. Severe pain, an insidious onset, systemic symptoms and onset with no history of trauma should all lead to consideration of other causes such as referred pain, infection, tumour and spinal cord compression. An acute onset with collapse, sweatiness and pallor should alert you to the possibility of a leaking AAA. Always take seriously any altered sensory or motor findings in the lower limbs. The examination of the lower back is not complete without a full neurovascular assessment, abdominal examination and an examination of the saddle area for sensation. (Rectal examination to assess tone is usually advised but may be difficult in the community setting.)

Consider referral if the cause is not completely clear for further assessment and possible X-ray, FBC, ESR, CRP and even CT or MRI scanning in certain cases. Remember to complete a full systems examination first, documenting important findings such as the pulse rate and temperature.

Box 13.7 shows ‘red flags’ that might indicate serious spinal pathology in back pain (adapted from the Report of Clinical Standards Advisory Group on Back Pain¹¹).

Neck pain

Causes include whiplash injury, torticollis, referred pain, degenerative disease and infection. As with back pain, a good history of trauma will allow an assessment of the neck for injury such as fracture dislocation. Guidance on how to ‘clear the C-spine’ after trauma has been issued by NICE¹² and Stiell¹⁰ and is summarised by Wardrope¹³ (Box 13.8).

Box 13.8 ‘Clearing the C-spine’ after trauma

Patients fulfilling these criteria will have a very low incidence of unstable spinal injury and may not need an X-ray:

Younger than 65

Alert and orientated (GCS = 15)

No ‘dangerous mechanism of injury’:

– fall from a height above 1 metre, fall from 5 or more stairs

– axial load to the head such as diving or contact sports

– RTA at high speed, rollover of vehicle or ejection of patient

– RTA involving bicycle or recreational vehicle

– rear-end shunt by a bus, vehicle at high speed or where car has been shunted into oncoming traffic

– in young children have a lower index of suspicion in falls

No midline spinal tenderness

No neurological symptoms or signs

Patient can rotate neck 45 degrees to left and right

Absence of a distracting injury (e.g. long bone fracture)

Whiplash is very common after minor road traffic accidents. Pain comes on after a period of time, usually several hours to days. It is classically aching and worse on one side than the other. Sometimes it is entirely unilateral but is more usually bilateral. Assess for range of movement and neurovascular problems. Treatment is by gentle mobilisation, NSAIDs, advice and an explanation that symptoms often worsen before they begin to improve and will commonly take weeks to months to settle fully.

Torticollis is an acute neck pain with associated muscle spasm. It occurs most commonly in young fit patients who often wake up with the pain, stiffness and greatly decreased range of movement. Muscle spasm is seen and felt in the corresponding neck muscles unilaterally. There is no history of trauma or of infection. Treat with NSAIDs and gentle mobilisation of the neck.

Infection and tumour are rare. Consider them in the same manner as such conditions anywhere else in the body and have a low threshold for referral to hospital if suspected from the history or unusual physical findings such as fever, systemic symptoms or unexplained tachycardia.

Degenerative disease/osteoarthritis

These chronic progressive conditions can affect any region of the body, but most commonly are encountered in the hip, knee and cervical and lumbar spine. They may present as a new problem, an acute flare up of the chronic condition after relatively minor trauma, or as a more significant injury or infection superimposed on coincidental findings of degenerative disease.

Ask about trauma stiffness or problems with other major joints. Check other joints for swelling, stiffness and crepitus on movement. An arthritic joint is more likely to become inflamed after trauma and symptoms and signs may be harder to interpret than in the non-arthritic joint.

The classic example of this is the elderly patient who has fallen and has hip pain. The diagnosis to exclude is a fractured neck of femur. Contrary to popular belief, patients can walk on such injuries, especially if the fracture is impacted and stable. If not X-raying, consider early review to ensure good mobility and settling symptoms.

Rib injuries

These injuries are common and often present after relatively minor trauma. Acute rib injuries are very painful and present with pain that is often apparently out of proportion to the initial injury. Presentation is often several days after the injury when the pain may be worse than at the time of injury. Fracture is not as common as bruising and soft tissue injury to the chest wall, but the features can be almost identical. ‘Spring’ the chest wall in a lateral and antero-posterior (AP) direction to assess for pain and crepitus. This is also felt when the patient takes a deep breath with the examining hand held firmly over the injured area. Listen for areas of reduced air entry or added sounds suggesting underlying pneumothorax, contusion or early infection. Examine the abdomen in cases of lower rib injury. Check pulse, temperature, respiratory rate and oxygen saturation (SaO₂) if available.

Rib X-rays are not routinely indicated but arrange a chest X-ray if the patient is short of breath at rest or on minimal exercise, if there is suspicion of a pneumothorax, there is clinical suspicion that multiple ribs are fractured, there is a flail segment present or infection has complicated the injury. For uncomplicated rib injury the management includes advice on breathing exercises and good analgesia.

Patients may need referral, particularly the elderly or those with pre-existing lung disease and a poor respiratory reserve. They may need stronger analgesia and supplemental oxygen.

The acutely hot/swollen/painful joint

Pain, swelling and redness in the region of a joint may be due to a condition within the joint (acute arthritis) or in the tissues around the joint (periarthritis).

The commonest problems causing an acutely swollen, hot joint are the crystal arthropathies of gout and pseudogout and acute inflammatory conditions such as rheumatoid arthritis. Sepsis is relatively rare but is a diagnosis not to be missed. Acute haemarthrosis is uncommon without a history of trauma, coagulopathy or anticoagulant treatment.

Bursitis is a common condition that presents with pain, swelling and redness around joints. However there is no swelling in the joint itself and a reasonable range of joint movement is retained. Very common examples are olecranon bursitis behind the elbow and pre- and infra-patellar bursitis at the knee. Sometimes degenerative changes in tendons lead to calcium pyrophosphate crystals developing in the tendon. This can give a clinical picture of a red, hot, swollen area over a joint.

Degenerative disease such as osteoarthritis often causes joint swelling but the joint is not usually hot and red (Box 13.9).

Box 13.9 Causes of an acute hot swelling in or around a joint

Acute arthritis

Gout

Pseudogout

Sero-positive arthritis (e.g. rheumatoid)

Sero-negative arthritis (e.g. Reiter’s syndrome)

Sepsis

Haemarthrosis

Peri-arthritis

Bursitis

CPPDD (calcium pyrophosphate deposition disease)

Gout occurs when crystals of uric acid from the blood precipitate in a joint, causing an intense and acute inflammation of the joint. Pseudogout is a very similar condition caused by deposition of calcium pyrophosphate crystals. Both can present as a red, hot, painful and swollen joint. The skin overlying a gouty joint is often tight, red and shiny. The pain has a classic deep, gnawing character and the patient often has suffered previous attacks. It commonly affects the first metatarsophalangeal joint of the foot but also affects the ankle and less commonly the knee. Pseudogout tends to affect the wrist, where calcification is sometimes seen in the triangular ligament on X-ray; and the knee, where calcification may be apparent in the meniscal cartilage.

Where the patient has a clear history of previous gout, treatment is with non-steroidal anti-inflammatory drugs (NSAIDs). In a typical case of gout or pseudogout where the patient is well, has no systemic symptoms of infection and is apyrexial, give a short course of NSAIDs and arrange next day review by the GP.

The diagnoses not to miss are osteomyelitis and septic arthritis. Septic arthritis can arise de novo or from spread from an area of osteomyelitis into the joint. They both present in a similar way. There is either no history of trauma or a history of insignificant trauma for the degree of pain. There may be a history of joint penetration, either in an accident or caused by a medical intervention. The patient cannot move the joint at all and strongly resists any passive movements. Early in the course of these illnesses, all these classical findings may not be present. Consider sepsis a possibility in any acute joint problem and arrange for early review. If in doubt refer for a further opinion to the patient’s GP, rheumatology or A&E.

Haemophilia and sickle cell disease are both haematological disorders that can result in acute joint pain from either bleeding into the joint or ischaemia and infarction of tissues around the area. Refer urgently if the patient has a history of these conditions.