The assessment and care of musculoskeletal problems

Chapter 13 The assessment and care of musculoskeletal problems





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.




The primary survey




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.



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.





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).





Jun 14, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on The assessment and care of musculoskeletal problems

Full access? Get Clinical Tree

Get Clinical Tree app for offline access