The assessment and care of musculoskeletal problems

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Chapter 13 The assessment and care of musculoskeletal problems

Chris Fitzsimmons, Jim Wardrope

Introduction 224
The primary survey 224
Primary survey positive patients 224
Patients with a normal primary survey but obvious need for hospital attendance 225
Secondary survey patients 226
Assessment of the stable patient 226
Trauma vs no history of trauma 227
Subjective information gathering – the history 227
Objective information gathering – the examination 231
Objective information – tests 231
Analysis and differential diagnosis 233
Trauma 233
No definite trauma 233
Plan 234
Communication 234
Specific problems 234
Back pain 234
Neck pain 235
Degenerative disease/osteoarthritis 236
Rib injuries 237
The acutely hot/swollen/painful joint 237

Introduction

Musculoskeletal problems account for an estimated 3.5 million Emergency Department (ED) attendances each year. More patients will consult their general practitioner (GP) or treat the problem themselves. The majority of these conditions (sprains, bruises and aches) will be self-limiting, requiring clinical diagnosis, and straightforward treatment and advice.

However, there are diagnostic dilemmas facing the practitioner on the ‘front line’. Even simple injuries often need hospital assessment, usually for X-rays. Some problems are rare but important to diagnose if life- or limb-threatening problems are to be avoided. The skill is to recognise those conditions where urgent referral and treatment are required. The aim of this chapter is to arm the practitioner with these skills (Box 13.1). Major trauma is not covered here.

Box 13.1 Chapter objectives

image The recognition of life- or limb-threatening problems
image The identification of those patients requiring obvious hospital transfer
image The principles of a secondary survey relevant to musculoskeletal problems
image Differentiation between injury and non-injury presentations
image Differential diagnoses in non-injury musculoskeletal problems including pitfalls
image Follow-up arrangements
image An overview of the following will be included:

image functional anatomy
image forces causing injury and the injury spectrum
image indications/regulations for X-rays

image Specific conditions to be covered:

image back pain
image neck pain
image rib injury
image degenerative disease/osteoarthritis
image hot joints

The primary survey

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:

image leaking abdominal aortic aneurysm (AAA) presenting as back pain
image aortic dissection presenting as inter-scapular pain
image perforation/peritonitis presenting as shoulder tip pain
image 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.

TIP

For further details on all these conditions see Chapters 3 and 9

Patients with a normal primary survey but obvious need for hospital attendance

Certain conditions pose a serious threat to life or limb and must not be missed when considering a ‘wait-and-see’ approach. The conditions listed in Box 13.2 are the ‘red flag’ conditions of the musculoskeletal system.

Box 13.2 ‘Red flag’ conditions requiring immediate hospital treatment

Trauma

image obvious fracture/dislocation
image open fracture
image severe pain not relieved by simple analgesia
image suspected compartment syndrome
image neurovascular compromise

Non-trauma

image referred pain from chest or abdomen
image ischaemia/vascular problems/suspected DVT
image septic arthritis/invasive soft tissue infections
image ‘kids’ problems such as slipped epiphysis
image neurological deficit, e.g. cauda equina syndrome

A major joint dislocation should be reduced as soon as possible, particularly if there is no distal circulation or sensation to the limb. Acutely ischaemic limbs need to have circulation restored within 4 hours to prevent irreversible muscle and nerve damage. Therefore make one gentle effort at relocation. Otherwise the limb needs to be splinted in its current position and urgent transfer arranged.

Compartment syndrome is caused by swelling in a myofascial compartment leading to a critically impaired circulation to the enclosed muscles in that compartment and possible distal ischaemia. There will usually be a good history of trauma. The hallmark of this condition is pain out of all proportion to the examination findings and exquisite pain on passive stretch of the muscles in the affected compartment. These patients require urgent transfer because surgical decompression is necessary as soon as possible, but certainly within 4 hours.

A septic joint is usually hot, swollen and very tender. All movements are restricted and it may be virtually impossible to move the joint due to pain. Typically the patient is systemically unwell and complains of the pain keeping them awake at night and being of a throbbing nature. These patients require urgent transfer to hospital because they need early surgery to remove the infection and preserve the joint.

Patients with objective neurological deficit due to nerve root compression or due to other spinal pathology should be referred immediately. Consider the diagnosis of a cauda equina syndrome. The lumbar and sacral nerve roots lie in the spinal canal below the level of L1/2. A central disc prolapse between the levels of L3 to S1 can compress these nerve roots causing retention of urine and weakness of the legs. The patient will present with lower back pain and neurological symptoms and signs. These include saddle area sensory loss and a reduced or absent anal tone on rectal examination. Depending on the level of the injury there will also be obvious neurological deficits in the motor assessment of the lower limbs.

The minimum necessary interventions should be carried out on these patients but could include administration of oxygen or entonox, splinting, dressing open wounds, IV analgesia and controlled traction or reduction of neurovascularly compromised extremities. These procedures should not delay transfer arrangements.

TIP

For further information on the treatment of compartment syndrome and crush syndrome see the ATLS manual1 and Wardrope.2 For dislocations, septic joints and neurovascular compromise see Wardrope,2 Apley,3 and McRae4

Secondary survey patients

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.

TIP

The first step in the assessment of musculoskeletal symptoms is to decide if the problem is due to an episode of trauma or a non-traumatic problem

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

image Mechanism of injury
image Symptoms and progress of symptoms over time
image Previous episodes of injury
image Past medical history/drugs/allergy
image 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).

image image

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

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