Self-Directed Learning Modules

Advanced Musculoskeletal Physiotherapy Self-directed Learning Modules: Emergency Department 2014

Module 1: Musculoskeletal Conditions

Prepared by Alfred Health on behalf of the Victorian Department of Health and Health Workforce Australia 2014 Module 1: Musculoskeletal Condition s

Contents

Module 1: Musculoskeletal Conditions...... 2 1.1 Shoulder & Upper Arm...... 4 Theme 1 History taking for shoulder and upper arm problems/injuries...... 4 Theme 2 Focused clinical assessment of shoulder and upper arm problems/injuries...... 6 Theme 3 Common investigations for shoulder and upper arm problems/injuries. 8 Theme 4 Common pharmacology for the management of shoulder and upper arm injuries/problems...... 10 Theme 5 Management of shoulder and upper arm injuries/problems...... 12 1.2: Elbow...... 15 Theme 1 History taking of elbow problems/injuries...... 15 Theme 2 Focused clinical assessment of elbow injuries...... 17 Theme 3 Common investigations for elbow problems/injuries...... 19 Theme 4 Common pharmacology for the management of elbow injuries/problems...... 21 Theme 5 Management of elbow injuries/problems...... 23 1.3 Wrist...... 27 Theme 1 History taking for wrist injuries/problems...... 27 Theme 2 Focused clinical assessment of wrist problems/injuries...... 29 Theme 3 Common investigations for wrist injury/problems...... 31 Theme 4 Common pharmacology for the management of wrist injury/problems...... 33 Theme 5 Management of wrist injuries/problems...... 35 1.4 Hand...... 39 Theme 1 History taking for Hand injury/problems...... 39 Theme 2 Focused clinical assessment of hand injury/conditions...... 41 Theme 3 Common investigations for hand injuries/conditions...... 43 Theme 4 Common pharmacology for the management of hand injuries/problems ...... 45 Theme 5 Management of hand pain/injury...... 47 1.5: Hip...... 51 Theme 1 History taking specific to hip injuries/conditions...... 51 Theme 2 Focused clinical assessment specific to hip injuries/conditions...... 53 Theme 3 Common investigations specific to hip injuries...... 56 Theme 4 Common pharmacology specific to hip injuries/conditions...... 58 Theme 5 Management of specific to hip injuries/conditions...... 60 1.6: Knee...... 63 Theme 1 History taking specific to knee injuries/conditions...... 63 Theme 2 Focused clinical assessment specific to knee injuries...... 65 Theme 3 Common investigations specific to knee injuries/conditions...... 68 Theme 4 Common pharmacology specific to knee injuries/conditions...... 70 Theme 5 Management of specific to knee injuries/conditions...... 72 1.7: Ankle...... 76 Theme 1 History taking specific to ankle injuries/conditions...... 76 Theme 2 Focused clinical assessment specific to ankle injuries/conditions...... 78 Theme 3 Common investigations specific to ankle injuries/conditions...... 80 Theme 4 Common pharmacology specific to ankle injuries/conditions...... 82 Theme 5 Management of ankle injuries/conditions...... 84 1.8: Foot...... 87 Theme 1 History taking specific to foot injuries/conditions...... 87 Theme 2 Focused clinical assessment specific to foot injuries/conditions...... 89 Theme 3 Common investigations specific to foot injuries/conditions...... 91 Theme 4 Common pharmacology specific to foot injuries/conditions...... 93 Theme 5 Management of foot injuries/conditions/...... 95 1.9: Cervical Spine...... 99 Theme 1 History taking for cervical spine pain & injury...... 99 Theme 2 Focused clinical assessment of cervical spine pain & injury...... 103 Theme 3 Common investigations for cervical spine pain, & injury...... 106 Theme 4 Common pharmacology for the management of cervical spine pain, & injury...... 109 Theme 5 Management of cervical spine pain & injury...... 111 1.10 Thoracic spine...... 114 Theme 1 History taking for thoracic spine pain & injury injury...... 114 Theme 2 Focused clinical assessment of thoracic spine pain& injury...... 118 Theme 3 Common investigations for thoracic spine pain &injury...... 120 Theme 4 Common pharmacology for the management of thoracic spine pain & injury...... 122 Theme 5 Management of thoracic spine pain & injury...... 124 1.11 Lumbar Spine...... 127 Theme 1 History taking for lumbar spine pain & injuries...... 127 Theme 2 Focused clinical assessment of low back pain & injuries...... 130 Theme 3 Common investigations for lumbar spine pain & injuries...... 133 Theme 4 Common pharmacology for the management of lumbar spine pain & injury...... 135 Theme 5 Management of low back pain & injury...... 137 1.1 Shoulder & Upper Arm

Theme 1 History taking for shoulder and upper arm problems/injuries

LEARNING OBJECTIVES:

1. Identify the key principles of history taking of shoulder and upper arm problems/injuries in the context of the ED setting 2. Review the importance of mechanism of injury in shoulder and upper arm 3. Differentiate early, presentations of the shoulder of non musculoskeletal origin that may require inter-disciplinary care 4. Formulate a preliminary differential diagnoses ASSUMED KNOWLEDGE: Routine physiotherapy subjective assessment of the upper limb and cervical spine

KNOWLEDGE:  Discuss the relevance of the following areas to mechanism of injury of the shoulder in the context of the ED setting1-3, 5 o Crush o Direct trauma o Fall on outstretched hand (FOOSH) o Fall from standing o Fall from height/bike o Cause of fall o Associated injuries such as headstrike, LOC o Axial loading or “jamming”, o Position of arm o Compression/distraction, varus/valgus forces o Direction of force including position of distal joints o Skin integrity o Time of injury, ability to move arm post injury o Symptoms such as numbness, pins and needles , ‘dead arm’ , tingling o Consider other sites for injury/pain and relevant associated questions required o Facial/head/neck/thorax injury o Chest/Jaw/arm/hand pain  What key information is required to assess for red flags?4,6,10  What key information is required in the setting of chronic shoulder and upper arm problems?5,9  What key information would you ask to differentiate atraumatic shoulder/upper arm pain from non musculoskeletal causes?5  What key information in a patient’s past medical history is important in shoulder and upper arm problems/injuries? 5  What are important risk factors should be identified in a patient’s history that may indicate non musculoskeletal causes of shoulder and arm pain?5,6 Module 1.1: Musculoskeletal Conditions – Shoulder and upper arm 4  What key information in a patient’s medication history is important in shoulder and upper arm problems/injuries? 5,8  What key information in a patient’s social history is important in shoulder and upper arm problem/injuries? 5  What is the relevance of determining any intervention or treatment to date?  What is the relevance of determining the compensable status or health insurance status of the patient?  What is the relevance of determining the first aid/pre hospital treatment?  What is the relevance of determining the last intake of food or fluids?7

RECOMMENDED RESOURCES

1. Egol, K, Koval, K & Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins. Chapter 11, Shoulder and upper arm.

2. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. The shoulder.

3. Purcell, D (2010) Minor Injuries A Clinical Guide. Churchill Livingstone Elsevier: UK Chapter 4, The neck and upper limbs, p78-91.

4. WorkCover SA (2013) Red Flags: Identify red flags in low back pain http://www.workcover.com/health-provider/injury-management-by-health- discipline/red-flags

5. Anderson, B. (2012). Evaluation of the patient with shoulder complaints http://www.uptodate.com/contents/evaluation-of-the-patient-with-shoulder- complaints?source=preview&anchor=H5&selectedTitle=1~150#H5

6. Goodacre, S., Locker, T., Morris, F., & Campbell, S. (2002). How useful are clinical features in the diagnosis of acute, undifferentiated chest pain?. Academic Emergency Medicine, 9(3), 203-208. http://onlinelibrary.wiley.com/doi/10.1197/aemj.9.3.203/pdf

7. Smeton G, V et al (2014) Pre-operative medical evaluation of the healthy patient http://www.uptodate.com/contents/preoperative-medical-evaluation-of-the-healthy- patient?source=search_result&search=preoperative+evaluation&selectedTitle=2%7E150

8. FitzGerald, R. J. (2009). Medication errors: the importance of an accurate drug history. British journal of clinical pharmacology , 67 (6), 671-675. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2723207/pdf/bcp0067- 0671.pdf#page=1&zoom=auto,0,780

9. BurBanK, K. M., StevenSon, J. H., Czarnecki, G. R., & Dorfman, J. (2008). Chronic shoulder pain: part I. Evaluation and diagnosis. American family physician, 77(4).http://www.aafp.org/afp/2008/0215/p453.html

10. Mitchell, C., Adebajo, A., Hay, E., & Carr, A. (2005). Shoulder pain: diagnosis and management in primary care. BMJ: British Medical Journal, 331(7525), 1124. Module 1.1: Musculoskeletal Conditions – Shoulder and upper arm 5 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1283277/pdf/bmj33101124.pdf

Theme 2 Focused clinical assessment of shoulder and upper arm problems/injuries

1. Identify the key aspects in clinical assessment of shoulder and upper arm problems/injuries in the ED setting 2. Formulate key findings to support/refute preliminary differential diagnosis? 3. Differentiate early, presentations of the shoulder of non musculoskeletal origin that may require inter-disciplinary care ASSUMED KNOWLEDGE  Anatomy of the shoulder and upper arm: bones, joints, muscles, tendons, ligaments.  Routine physiotherapy objective assessment of the shoulder including:  Cervical spine assessment  Upper limb neurological assessment including peripheral nerves

KNOWLEDGE:  Name the vascular supply of the upper limb3  How would you assess the neurovascular status of the upper limb?5  How do assess the integrity of the glenohumeral joint?11  What is the relevance of any local skin changes / open wounds to the upper limb?  How would differentiate shoulder/arm pain originating from the cervical spine?13  How you would differentiate musculoskeletal shoulder pain from non musculoskeletal shoulder pain?10  What are the most common non-musculoskeletal presentations of shoulder pain10 o What does your clinical assessment need to include if non- musculoskeletal causes are suspected? o What findings you would you expect to see on assessment? o What action needs to be taken? o Discuss abdominal , cardiovascular, thoracic, neurological causes http://www.uptodate.com/contents/image? imageKey=EM/55507&topicKey=EM %2F238&source=preview&rank=undefined

1. Brukner and Khan (2012) Clinical Sports Medicine. 4th Edition. McGraw-Hill Medical.

2. Cameron P, Jelinek G, Kelly A, Murray L, Brown A, & Heyworth J, (2004) Adult Emergency Medicine. Churchill Livingston, Sydney. p132-6.

3. Drake, R, Vogl, W & Mitchell, A (2005) Gray’s Anatomy for Students. Churchill Module 1.1: Musculoskeletal Conditions – Shoulder and upper arm 6 Livingstone Elsevier. Chapter 7, Upper limb, p707-728.

5. Judge, NL (2007) Neurovascular assessment. Nursing Standard. Vol 21, No 45, 39- 44 http://www.snjourney.com/ClinicalInfo/Systems/PDF/NeuroVas%20Assessment.pdf

8. Walsh & Sadowski (2001), Systemic Disease Mimicking Musculoskeletal Dysfunction: A Case Report Involving Referred Shoulder Pain. Journal of Orthopedic Sports Physical Therapy. 31, (12), p696-701. http://www.jospt.org/issues/articleID.310,type.2/article_detail.asp

9. Zuluga, M (1995) Sports Physiotherapy – Applied Science and Practice. Churchill Livingstone, Melbourne.

Up to date 10. Anderson, B & Anderson,R (2012) Evaluation of the patient with shoulder complaints http://www.uptodate.com/contents/evaluation-of-the-patient-with-shoulder- complaints?view=print

11. Dixon, J & Simons, S (2013) Physical examination of the shoulder http://www.uptodate.com/contents/physical-examination-of-the-shoulder? source=search_result&search=shoulder&selectedTitle=2%7E150

12. Gelb (2012) Neurological exam http://www.uptodate.com/contents/the-detailed-neurologic-examination-in-adults? source=search_result&search=elbow&selectedTitle=55%7E150

13. Issac, A & Anderson, B (2013) Evaluation of the patient with neck pain and cervical spine disorders http://www.uptodate.com/contents/evaluation-of-the-patient-with-neck-pain-and- cervical-spine-disorders?source=see_link

Module 1.1: Musculoskeletal Conditions – Shoulder and upper arm 7 Module 1.1: Musculoskeletal Conditions – Shoulder and upper arm 8 Theme 3 Common investigations for shoulder and upper arm problems/injuries LEARNING OBJECTIVES:

1. Discuss the common investigations available for shoulder and upper arm problems/injuries

KNOWLEDGE:  When would you consider obtaining an X-ray for a patient with a shoulder and upper arm problem/ injury?6,7  When would a CT scan be indicated for a patient with a shoulder and upper arm problem/injury? 4,7,9  When would an MRI scan be indicated for a patient with a shoulder and upper arm problem/injury? 4,7,9,11,12  When would an ultrasound be indicated for a patient with a shoulder and upper arm problem/ injury? 4,7,9  When would blood investigations be indicated for a patient with a shoulder and upper arm problem/injury?8  What are other investigations that may be indicated in a patient with shoulder and upper arm pain? 7

CLINICAL APPLICATION:

Describe the normal x-ray of an shoulder and upper arm1 Complete the online interactive radiology tutorial and quiz3,11,12,13

1. Anderson, J, Read J (2008) Atlas of Imaging in Sports Medicine. 2nd Edition. McGraw- Hill.

2. Begg, J (2005) Accident and Emergency X-rays Made Easy. Churchill Livingstone. Chapter 7, The upper limb, p143-185.

3. Gay, S, Kuntz, A, Lai, W, Norton, P, Yao, L (Date Unknown) Skeletal Trauma Radiology, University of Virginia Health Sciences Centre. http://www.med-ed.virginia.edu/courses/rad/ext/index.html

4. Government of Western Australia, Department of Health (2012) Diagnostic Imaging Pathways – Shoulder Pain/Instability. http://www.imagingpathways.health.wa.gov.au/index.php/imagingpathways/musculoskeletal-trauma/musculoskeletal/shoulder-injury?tab=ct#pathway-

Module 1.1: Musculoskeletal Conditions – Shoulder and upper arm 9 home 5. Jan van der Woude, H & Smithuis, R (2012) Shoulder MR – Anatomy, Normal anatomy, Variants and Checklist, Radiology Assistant, Rijnland Assistant http://www.radiologyassistant.nl/en/p4f49ef79818c2/shoulder-anatomy.html

6. Raby, N, Berman, L, de Lacey, G (2005) Accident and Emergency Radiology: A Survival Guide 2nd edition. Elsevier Saunders. Chapter 4, Shoulder, p68-89

Up to date 7. Jude, C & Modarresi (2012) Radiological evaluation of the shoulder http://www.uptodate.com/contents/radiologic-evaluation-of-the-painful-shoulder? source=search_result&search=shoulder&selectedTitle=8%7E150

8. Helfgott, S. M. (2013) Evaluation of the adult with monoarticular pain http://www.uptodate.com/contents/evaluation-of-the-adult-with-monoarticular-pain? source=search_result&search=joint+infection&selectedTitle=5%7E150

9. Baccei, S, Kim, C, & Weissman, B (2013) Diagnostic imaging of joint pain http://www.uptodate.com/contents/diagnostic-imaging-of-joint-pain?source=see_link

10. Bruyn, G (2013) Ultrasound guided injection and aspiration of joints http://www.uptodate.com/contents/musculoskeletal-ultrasonography-guided-injection- and-aspiration-of-joints-and-related-structures? source=search_result&search=elbow&selectedTitle=11%7E150

11.Shoulder MRI Anatomy, Radiology Assistant http://www.radiologyassistant.nl/en/p4f49ef79818c2/shoulder-mr-anatomy.html

12. Shoulder MRI Bankart Lesions, Radiology Assistant http://www.radiologyassistant.nl/en/p4963d77684ef7/shoulder-mr-bankart- lesions.html

13. Radiology Masterclass: upper limb http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x- ray_trauma_upper_limb/upper_limb_trauma_x-ray_start.html

Module 1.1: Musculoskeletal Conditions – Shoulder and upper arm 10 Theme 4 Common pharmacology for the management of shoulder and upper arm injuries/problems LEARNING OBJECTIVES:

1. Discuss and compare the common pharmacological agents for shoulder and upper arm injuries KNOWLEDGE:  Analgesic agents1-8 o What is appropriate for pain control in the patient with minor shoulder and upper arm injury/problem? o What is appropriate for pain control in the patient with moderate to severe pain with shoulder and upper arm injury/problem?  Anti-inflammatory agents5, 8, 10,11 o What and when is it appropriate to use anti-inflammatory agents?  Antibiotics9,12 o When is antibiotics indicated for shoulder and upper arm injuries and why?  Tetanus immunoglobulin and vaccinations12,13,14 o When would you consider this?

1. Australian and New Zealand College of Anesthetists and Faculty of Pain Medicine (2006) Managing Acute Pain A Guide for Patients. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/managingacutepain. pdf

2. Bryant, B., Knights, K (2011) Pharmacology for Health Professionals. 3rd edition. Mosby Elsevier. Chapter 15, Analgesics, p277-307/

3. Egol, K, Koval, KJ, & Zuckerman, JD (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins. Chapter 7, Orthopaedic Analgesia, p63-76.

4. eTG complete (2013) Therapeutic Guidelines (subscribed) http://online.tg.org.au/ip/

5. Hamilton, B, Milne, C, Orchard, J, & Paoloni, J (2009) Non-steroidal anti-inflammatory drugs (NSAIDs) in sports medicine. Guidelines for practical but sensible use. British Journal of Sports Medicine (subscribed). http://bjsm.bmj.com/content/early/2009/06/21/bjsm.2009.059980.full.pdf

Module 1.1: Musculoskeletal Conditions – Shoulder and upper arm 11 6. Macintyre, P, Scott, D, Schug, S, Visser, E, & Walker, S (2010) Acute Pain Management: Scientific Evidence, Third Edition, Australian and New Zealand College of Anesthetists and Faculty of Pain Medicine. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp104_3.pdf\

7. Neal, M (2009) Medical Pharmacology at a Glance. 6th edition. Wiley-Blackwell. Chapter 29, Opioids and analgesics, p64-65; Chapter 32, NSAIDs, p70-71.

8. Vargus Schaffer (2010) Is the WHO analgesic ladder still valid? Canadian Family Physician. 56, 6, p514-517. http://www.cfp.ca/content/56/6/514.full.pdf+html

Up-to-date 9. Helfgott, S. M. (2013) Evaluation of the adult with monoarticular pain http://www.uptodate.com/contents/evaluation-of-the-adult-with-monoarticular-pain? source=search_result&search=joint+infection&selectedTitle=5%7E150

10. Lexicomp (2013) Ibuprofen: Drug Information http://www.uptodate.com/contents/ibuprofen-drug-information? source=see_link&utdPopup=true

11. Solomon, D (2012) NSAIDs: mechanism of action http://www.uptodate.com/contents/nsaids-mechanism-of-action? source=search_result&search=pharmacology&selectedTitle=5%7E150

Tetanus 12. Ball and Younggren (2007) Emergency Management of Difficult Wounds: Part I. http://www.mdconsult.com/das/article/body/385344101- 2/jorg=journal&source=&sp=18944593&sid=0/N/577108/s0733862707000041.pdf? issn=0733-8627

13. Royal Children’s Hospital, clinical practice guidelines http://www.rch.org.au/clinicalguide/guideline_index/Management_of_tetanusprone_wounds/

14. Lexicomp (2014) Tetanus immune globulin (human): Drug information http://www.uptodate.com/contents/tetanus-immune-globulin-human-drug-information? source=search_result&search=tetanus&selectedTitle=7%7E150

Module 1.1: Musculoskeletal Conditions – Shoulder and upper arm 12 Theme 5 Management of shoulder and upper arm injuries/problems

1. Identify and discuss the common management principles for shoulder and upper arm injuries/problems in the context of the ED setting

ASSUMED KNOWLEDGE:  Physiotherapy management of acute, sub-acute and chronic shoulder, upper arm and cervical pain of a musculoskeletal origin  Simple first aid management of shoulder and upper arm injuries  Application of slings to the shoulder and advice re: use of slings

KNOWLEDGE:  Discuss the signs, symptoms and management in the ED setting of2-6, 8-12, 14 - 18 o Fracture of the clavicle o Fracture of the body of the scapula o Fracture of the neck of the scapula o Fracture of the acromion process o Fracture of the coracoid process o Dislocation of the sterno-clavicular joint o Strain of the sterno-clavicular joint o Subluxation and dislocation of the acromio-clavicular joint o Strain of the acromio -clavicular joint o Subluxation/Dislocation of the shoulder and associated injuries . Anterior, posterior, inferior (luxatio erecta) o Rupture of the rotator cuff o Chronic labral tear o Degenerative tear of rotator cuff o Rotator cuff – full and partial tear o Supraspinatus tendonopathy o Acute calcific tendinitis o Subacromial bursitis o Impingement o Winging of the scapula o Fracture of the neck of the humerus o Fracture of the greater tuberosity o Fracture of the shaft of the humerus o OA/RA/AVN of the shoulder o Thoracic outlet syndrome o Adhesive capsulitis o Cervical/thoracic referred pain Module 1.1: Musculoskeletal Conditions – Shoulder and upper arm 13 o Brachial plexus neuritis o Supra-scapular nerve entrapment o Biceps rupture  For the conditions above consider: o What conditions need to be referred to or managed together with the ED Medical team? o What type of injury would require the involvement of the Orthopaedic team?4,5 o How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review? o How would you control swelling of the affected area? (remember removal of jewellery) o When would IV fluids be indicated?19 o When would an ECG be indicated?19 o Describe the types of immobilisation used for the management of shoulder injuries/problems15  How would you provide adequate pain control on discharge?

 Describe how your management of a shoulder injury will vary if your patient is: o Diabetic13 o On anti-coagulants1, 2

1. Chan, T. Y. (1005). Adverse interactions between warfarin and nonsteroidal anti- inflammatory drugs: mechanisms, clinical significance and avoidance. Ann Pharmacother 29(12): 1274-83. http://www.ncbi.nlm.nih.gov/pubmed/8672833

2. Dossett, L. A., Riesel, J. N., Griffin, M. R. & Cotton, B. A. (2011). Prevalence and Implications of Preinjury Warfarin Use, an analysis of the National Trauma Databank, Arch Surg 146(5): 565-570. http://archsurg.jamanetwork.com/article.aspx?articleid=407366

4. McRae, R & Esser, M (2008). Practical Fracture Treatment. 5th Edition. Churchill Livingstone, Edinburgh.

6. Purcell, D. (2010) Minor Injuries A Clinical Guide. Churchill Livingstone Elsevier UK. Chapter 4, The neck and upper limbs, p78-91.

7. Wilson, S (2013) Shoulder dislocation in the Emergency Department. Medscape Module 1.1: Musculoskeletal Conditions – Shoulder and upper arm 14 reference. http://emedicine.medscape.com/article/823843-overview

Up to date 8. Bassett, R (2012) Midshaft humeral fractures in adults http://www.uptodate.com/contents/midshaft-humeral-fractures-in-adults?view=print

9. Bassett, R (2013) Stress fractures of the humeral shaft http://www.uptodate.com/contents/stress-fractures-of-the-humeral-shaft?view=print

10. Bassett, R (2013) Proximal humeral fractures in adults http://www.uptodate.com/contents/proximal-humeral-fractures-in-adults?view=print

11. Clugston, J, Hatch, R & Taffe, J (2013) Clavicle fractures http://www.uptodate.com/contents/clavicle-fractures?view=print

12. Dixon, J & Simons, S (2013) Biceps tendinopathy and tendon rupture http://www.uptodate.com/contents/biceps-tendinopathy-and-tendon-rupture? view=print

13. Hordon, L. D. (2013) Musculoskeletal complications in diabetes mellitus http://www.uptodate.com/contents/musculoskeletal-complications-in-diabetes- mellitus?source=search_result&search=diabetes+mellitus&selectedTitle=9%7E150

14. Koehler, S (2013) Acromioclavicular joint disorders http://www.uptodate.com/contents/acromioclavicular-joint-disorders?view=print

15. Kronfol, R (2012) Splinting of musculoskeletal injuries http://www.uptodate.com/contents/splinting-of-musculoskeletal-injuries? source=search_result&selectedTitle=18%7E150

16. Kruse, D & Rotator cuff tendinopathy (2012) http://www.uptodate.com/contents/rotator-cuff-tendinopathy?view=print

17. Prestgaard, T (2013) Frozen shoulder (adhesive capsulitis) http://www.uptodate.com/contents/frozen-shoulder-adhesive-capsulitis?view=print

18. Schaider, J & Sherman, S (2012) Shoulder dislocation and reduction http://www.uptodate.com/contents/shoulder-dislocation-and-reduction?view=print

19. Smeton G, V et al (2014) Pre-operative medical evaluation of the healthy patient http://www.uptodate.com/contents/preoperative-medical-evaluation-of-the-healthy- patient?source=search_result&search=preoperative+evaluation&selectedTitle=2%7E150 Module 1.1: Musculoskeletal Conditions – Shoulder and upper arm 15 1.2: Elbow

Theme 1 History taking of elbow problems/injuries

1. Identify the key principles of history taking of elbow problems/injuries in the context of the ED setting 2. Review the importance of mechanism of injury to the elbow 3. Differentiate early, presentations of the elbow of non musculoskeletal origin that may require inter-disciplinary care 4. Formulate a preliminary differential diagnoses

ASSUMED KNOWLEDGE:  Routine physiotherapy subjective assessment of the elbow

KNOWLEDGE:  Discuss the relevance of the following areas to mechanism of injury of the elbow1-3, 5 o Crush o Direct trauma o Fall on outstretched hand (FOOSH) o Fall from standing o Fall from height/bike o Cause of fall o Associated injuries such as headstrike, LOC o Axial loading or “jamming”, o Position of arm o Compression/distraction, varus/valgus forces o Direction of force including position of distal joints o Skin integrity o Time of injury, ability to move arm post injury o Symptoms such as numbness, pins and needles , ‘dead arm’ , tingling o Consider other sites for injury/pain and relevant associated questions required  What key information is required to assess for red flags?4  What key information is required in the setting of chronic elbow problems?5  What key information would you ask to differentiate atraumatic elbow pain from non musculoskeletal causes?5  What key information in a patient’s past medical history is important in elbow problems/injuries? 5  What key information in a patient’s medication history is important in elbow injuries? 5,8  What key information in a patient’s social history is important in elbow Module 1.2: Musculoskeletal Conditions – Elbow 16 problem/injuries? 5  What is the relevance of determining any intervention to date? 5  What is the relevance of determining the compensable status or health insurance status of the patient?  What is the relevance of determining the first aid/pre hospital treatment?  What is the relevance of determining the last intake of food or fluids?7

1. Egol, K, Koval, K, & Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins. Chapter 11, Shoulder and Upper arm; Chapter 12, Elbow and Forearm.

2. McRae, R. (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. The elbow.

3. Purcell, D. (2010) Minor Injuries A Clinical Guide. Churchill Livingstone Elsevier: UK Chapter 4, The neck and upper limbs, p78-96.

5. Anderson, B (2013), Evaluation of elbow pain in adults http://www.uptodate.com/contents/evaluation-of-elbow-pain-in-adults? source=search_result&search=history+elbow&selectedTitle=1%7E150

6. Chorley, J (2012). Elbow injuries in the young athlete http://www.uptodate.com/contents/elbow-injuries-in-the-young-athlete? source=search_result&search=history+elbow&selectedTitle=2%7E150

9. Aaron, D. L., Patel, A., Kayiaros, S., & Calfee, R. (2011). Four common types of bursitis: diagnosis and management. Journal of the American Academy of Orthopaedic Surgeons, 19(6), 359-367. http://www.jaaos.org/content/19/6/359.abstract

Module 1.2: Musculoskeletal Conditions – Elbow 17 Theme 2 Focused clinical assessment of elbow injuries

1. Identify the key aspects in clinical assessment of the elbow in the ED setting 2. Formulate key findings to support/refute preliminary differential diagnosis? 3. Differentiate early, presentations of the elbow of non musculoskeletal origin that may require inter-disciplinary care ASSUMED KNOWLEDGE  Anatomy of the elbow: bones, joints, muscles, tendons, ligaments.  Routine physiotherapy objective assessment of the elbow including:  Cervical spine assessment when indicated  Upper limb neurological assessment including peripheral nerves

KNOWLEDGE:  Name the vascular supply of the upper limb.3  How would you assess the neurovascular status of the upper limb?5  How do assess the integrity and stability of the elbow joint? 9  What are the relevance of any local skin changes / open or puncture wounds to the upper limb?15  How you would differentiate musculoskeletal elbow pain from non musculoskeletal elbow pain? 9,11,12,15  What are the most common non-musculoskeletal presentations of elbow pain 9,11,12,13 o What does your clinical assessment need to include if non-musculoskeletal causes are suspected? o What findings you would you expect to see on assessment? o What action needs to be taken?

2. Cameron P, Jelinek G, Kelly A, Murray L, Brown A, & Heyworth J, (2004) Adult Emergency Medicine. Churchill Livingston, Sydney. p132-6.

3. Drake, R, Vogl, W & Mitchell, A (2005) Gray’s Anatomy for Students. Churchill Livingstone Elsevier. Chapter 7, Upper limb, p707-728.

5. Judge, NL (2007) Neurovascular assessment. Nursing Standard. Vol 21, No 45, 39-44 http://www.snjourney.com/ClinicalInfo/Systems/PDF/NeuroVas%20Assessment.pdf

6. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Module 1.2: Musculoskeletal Conditions – Elbow 18 Elsevier. The shoulder.

9. Anderson, B & Anderson R ( 2012) Evaluation of elbow pain in adults http://www.uptodate.com/contents/evaluation-of-elbow-pain-in-adults?view=print

10. Gelb, D (2012) The detailed neurological examination in adults http://www.uptodate.com/contents/the-detailed-neurologic-examination-in-adults? source=search_result&search=elbow&selectedTitle=55%7E150

11. Goldenberg, D & Sexton, D (2013) Septic arthritis in adults http://www.uptodate.com/contents/septic-arthritis-in-adults? source=search_result&search=septic+arthritis&selectedTitle=1~150

12. Helfgott, S (2013) Evaluation of the adult with monarticular pain http://www.uptodate.com/contents/evaluation-of-the-adult-with-monoarticular-pain? source=search_result&search=elbow&selectedTitle=27%7E150

13. Kalunian, K (2012) Clinical manifestations of osteoarthritis http://www.uptodate.com/contents/clinical-manifestations-of-osteoarthritis? source=search_result&search=ankle+osteoarthritis&selectedTitle=2~150

14. Maini, R & Venables, P (2012) Differential Diagnosis and differential diagnosis of rheumatoid arthritis http://www.uptodate.com/contents/diagnosis-and-differential-diagnosis-of- rheumatoid-arthritis?source=search_result&search=rheumatoid&selectedTitle=1~150

15. NICE guideline (2010): olecranon bursitis http://cks.nice.org.uk/olecranon-bursitis#!topicsummary

Module 1.2: Musculoskeletal Conditions – Elbow 19 Theme 3 Common investigations for elbow problems/injuries

1. Discuss the common investigations available for elbow problems/injuries

KNOWLEDGE:  When would you consider obtaining an X-ray for a patient with an elbow problem/ injury?1,4,5,9  When would a CT scan be indicated for a patient with an elbow problem/injury? 1,6  When would an MRI scan be indicated for a patient with an elbow problem/injury? 1,6,8  When would an ultrasound for a patient with an elbow problem/ injury? 6  When would you consider obtaining blood investigations for a patient with an elbow problem/injury?7 CLINICAL APPLICATION:

Describe the normal x-ray of an elbow Complete the online interactive radiology tutorial and quiz3,8,10 RECOMMENDED RESOURCES (Refer to the Radiology Module)

1. Anderson, J & Read, J (2008) Atlas of Imaging in Sports Medicine. 2nd Edition. McGraw- Hill.

2. Begg, J (2005) Accident and Emergency Xrays Made Easy. Churchill Livingstone. Chapter 7, The upper limb, p143-185.

3. Gay, S, Kuntz, A, Lai, W, Norton, P, & Yao, L (Date Unknown) Skeletal Trauma Radiology. University of Virginia. http://www.med-ed.virginia.edu/courses/rad/ext/index.html

4. Raby, N, Berman, de Lacey, G (2005) Accident and Emergency Radiology: A Survival Guide, 2nd edition. Elsevier Saunders. Chapter 5, Elbow, p90-107.

5. Grayson, D. E. (2005, July). The elbow: radiographic imaging pearls and pitfalls. In Seminars in roentgenology (Vol. 40, No. 3, pp. 223-247). WB Saunders. http://www.med.uottawa.ca/radiology/assets/documents/msk_imaging/articles/The %20Elbow%20-%20Radiographic%20Imaging%20Pearls%20and%20Pitfalls.pdf

Up To Date 6. Bacccei, S, Kim, C & Weissman, B (2013) Diagnostic imaging of joint pain http://www.uptodate.com/contents/diagnostic-imaging-of-joint-pain?source=see_link

Module 1.2: Musculoskeletal Conditions – Elbow 20 8. Elbow MRI, http://www.radiologyassistant.nl/en/p520a87cf627d9/elbow-mri.html 9. Nicholson, D. A., & Driscoll, P. A. (1993). ABC of emergency radiology. The elbow. BMJ: British Medical Journal, 307(6911), 1058. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1679241/pdf/bmj00044-0046.pdf

Module 1.2: Musculoskeletal Conditions – Elbow 21 Theme 4 Common pharmacology for the management of elbow injuries/problems LEARNING OBJECTIVES:

1. Discuss and compare the common pharmacological agents for elbow injuries

KNOWLEDGE:  Analgesic agents1-8 o What is appropriate for pain control in the patient with minor elbow injury/problem? o What is appropriate for pain control in the patient with moderate to severe pain with elbow injury/problem?  Anti-inflammatory agents5,8,10,11,16 o What and when is it appropriate to use anti-inflammatory agents?  Antibiotics9,15 o When is antibiotics indicated for elbow injuries and why?  Tetanus immunoglobulin and vaccinations12,13,14 o When would you consider this? RECOMMENDED RESOURCES (Refer to the Pharmacology Module)

6. Macintyre, P, Scott, D, Schug, S, Visser, E, & Walker, S (2010) Acute Pain Management: Scientific Evidence, Third Edition, Australian and New Zealand College of Anesthetists and Faculty of Pain Medicine. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp104_3.pdf\ Module 1.2: Musculoskeletal Conditions – Elbow 22 7. Neal, M (2009) Medical Pharmacology at a Glance. 6th edition. Wiley-Blackwell. Chapter 29, Opioids and analgesics, p64-65; Chapter 32, NSAIDs, p70-71.

Tetanus 12. Ball and Younggren (2007) Emergency Management of Difficult Wounds: Part I. http://www.mdconsult.com/das/article/body/385344101- 2/jorg=journal&source=&sp=18944593&sid=0/N/577108/s0733862707000041.pdf? issn=0733-8627

13. Royal Children’s Hospital, clinical practice guidelines http://www.rch.org.au/clinicalguide/guideline_index/Management_of_tetanusprone_wounds/

14. Lexicomp (2014) Tetanus immune globulin (human): Drug information http://www.uptodate.com/contents/tetanus-immune-globulin-human-drug-information? source=search_result&search=tetanus&selectedTitle=7%7E150

15. NICE guideline (2010): olecranon bursitis http://cks.nice.org.uk/olecranon-bursitis#!topicsummary

16. NICE Guideline (2013) NSAIDs: Prescribing issues http://cks.nice.org.uk/nsaids-prescribing-issues

17. Green, S., Buchbinder, R., Barnsley, L., Hall, S., White, M., Smidt, N., & Assendelft, W. J. J. (2001). Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults. Cochrane Database Syst Rev, 4. http://summaries.cochrane.org/CD003686/non-steroidal-anti-inflammatory-drugs- nsaids-for-treating-tennis-elbow-pain-in-adults

Module 1.2: Musculoskeletal Conditions – Elbow 23 Theme 5 Management of elbow injuries/problems

1. Discuss the common management principles for elbow injuries/problems in the ED setting

ASSUMED KNOWLEDGE:  Physiotherapy management of acute, sub-acute, chronic elbow and cervical injuries/problems of a musculoskeletal origin  Simple first aid management of elbow injuries  Application of slings to the elbow and advice re: use of slings

KNOWLEDGE:  Discuss the signs, symptoms and management in the ED setting of:3-14,16-18 o Supracondylar fracture of the humerus o Radial head fracture, name the types and management. o Radial neck fracture o Olecranon fracture o Medial and lateral epicondylar fracture o Capitellum fracture o Intercondylar Y or T fractures o Elbow dislocation o Medial or lateral collateral ligament injury

o Subluxation and Dislocation of radial head o Olecranon bursitis o Epicondylitis o Monteggia fracture o Galeazzi fracture o Essex-Lopresti fracture o Loose bodies/ osteochondritis dissecans (OCD) o Tendinopathy o Calcific tendonitis o Nerve entrapments o Rheumatology joint conditions  For the conditions above consider: o What type of injury would require the involvement of the Orthopaedic team?5,6 o How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review? o How would you control swelling of the affected area? (remember removal of jewellery) o When would IV fluids be indicated?19 o Describe the types of immobilisation used for the management of elbow Module 1.2: Musculoskeletal Conditions – Elbow 24 injuries/problems16 o How would you provide adequate pain control on discharge?  What are the complications of trauma to the elbow to be aware of?21,22,23 o Consider examples such as compartment syndrome and Volkmans ischemia  Describe how your management of elbow conditions will vary if your patient is: o Diabetic15 o On anti-coagulants1,2 o Mechanism was a crush injury21 o Has associated facial, head, neck or chest wall injuries/pain o Past history of IVDU20

1. Highlight the important aftercare advice for patients with plaster casts, and what are the differences between care for a back slab and a full cast.

2. What is the aftercare advice for patients with broad arm slings and undisplaced radial head fractures?

CLINICAL ASSESSMENT OF PROCEDURAL SKILL . Application of a above elbow cast Refer to Plastering Module

3. Egol, K, Koval, K & Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins. Chapter 12, Elbow and Forearm.

4. Harding P, Rasekaba T, Smirneos L, Holland AE. Early mobilisation for elbow fractures in adults (Review). Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD008130. DOI: 10.1002/14651858.CD008130.pub2 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008130.pub2/pdf

5. McRae, R & Esser, M (2008) Practical Fracture Treatment. 5th edition. Churchill Livingstone Elsevier. The elbow.

6. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. The elbow.

Module 1.2: Musculoskeletal Conditions – Elbow 25 7. Purcell, D. (2010) Minor Injuries A Clinical Guide. Churchill Livingstone Elsevier: UK. Chapter 4, The neck and upper limbs, p92-96.

8. Rommens, P & Kuchle, R (2004) Olecranon fractures in adults: Factors influencing outcome. Injury. 35, (11), p1149-1157.

9. Strujis, P & Smit, G (2007) Radial head fractures: effectiveness of conservative treatment versus surgical intervention. A systematic review. Archives of Orthopaedic & Trauma Surgery. 127, (2), p125-130.

Up to date: 10. Bothner, J & Moore, B (2012) Radial head subluxation (nursemaid’s elbow) http://www.uptodate.com/contents/radial-head-subluxation-nursemaids-elbow? source=search_result&search=elbow&selectedTitle=6%7E150

11. Chorley, J (2012) Elbow injuries in the young athlete http://www.uptodate.com/contents/elbow-injuries-in-the-young-athlete? source=search_result&search=elbow&selectedTitle=3%7E150

12. Doherty, T (2012) Ulnar neuropathy at the elbow and wrist http://www.uptodate.com/contents/ulnar-neuropathy-at-the-elbow-and-wrist? source=search_result&search=elbow&selectedTitle=5%7E150

13. Harvey, B & Hergenroeder, A (2012) Clinical manifestations and diagnosis of osteochondritis dissecans (OCD) http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of- osteochondritis-dissecans-ocd? source=search_result&search=elbow&selectedTitle=9%7E150

14. Harvey, B & Hergenroeder, A (2012) Management of osteochondritis dissecans (OCD) http://www.uptodate.com/contents/management-of-osteochondritis-dissecans-ocd? source=search_result&search=elbow&selectedTitle=15%7E150

16. Kronofol, R (2012) Splinting of musculoskeletal injuries http://www.uptodate.com/contents/splinting-of-musculoskeletal-injuries? source=search_result&selectedTitle=18%7E150

17. Sheon, R (2011) Bursitis: An overview of clinical manifestations, diagnosis, and management http://www.uptodate.com/contents/bursitis-an-overview-of-clinical-manifestations- diagnosis-and-management? source=search_result&search=elbow&selectedTitle=12%7E150

Module 1.2: Musculoskeletal Conditions – Elbow 26 18. Slabaugh, M (2013) Radial head and neck fractures http://www.uptodate.com/contents/radial-head-and-neck-fractures-in-adults? source=search_result&search=elbow&selectedTitle=8%7E150

20. Horowitz, D. L., Katzap, E., Horowitz, S., & Barilla-LaBarca, M. L. (2011). Approach to septic arthritis. American Family Physician, 84(6), 653-660. http://www.aafp.org/afp/2011/0915/p653.pdf

21. McQueen, M. M., & Gaston, P. (2000). Acute compartment syndrome WHO IS AT RISK?. Journal of Bone & Joint Surgery, British Volume, 82(2), 200-203. http://www.bjj.boneandjoint.org.uk/content/82-B/2/200.full.pdf+html

22. Beiner, J. M., & Jokl, P. (2002). Muscle contusion injury and myositis ossificans traumatica. Clinical orthopaedics and related research, 403, S110-S119.

23. O'DRISCOLL, S. W., Morrey, B. F., KORINEK, S., & An, K. N. (1992). Elbow subluxation and dislocation: a spectrum of instability. Clinical orthopaedics and related research, 280, 186-197.

Module 1.2: Musculoskeletal Conditions – Elbow 27 1.3 Wrist

Theme 1 History taking for wrist injuries/problems

1. Explain the key principles of history taking of wrist injury/problem in the context of the ED setting 2. Review the importance of mechanism of injury at the wrist 3. Differentiate early, presentations of the wrist of non musculoskeletal origin that may require inter-disciplinary care 4. Formulate a preliminary differential diagnoses ASSUMED KNOWLEDGE: Routine physiotherapy subjective assessment of the wrist

KNOWLEDGE:  Discuss the relevance of the following areas to mechanism of injury of the wrist:5 o Direct trauma o Crush o Fall on outstretched hand (FOOSH) o Fall from standing o Fall from height/bike o Cause of fall o Direction of force - axial loading or “jamming”, o Position of hand – flexion/extension/ulnar or radial deviation o Skin integrity o Time of injury, ability to move arm post injury o Symptoms such as numbness, pins and needles , ‘dead arm’ , tingling o Consider other sites for injury – particular shoulder, elbow and forearm  What key information is required to assess for red flags?4  What key information is required to assess for yellow flags?4  What key information is required in the setting of chronic wrist problems?5  What key information would you ask to differentiate atraumatic wrist pain/injury from non musculoskeletal causes? 5  What key information in a patient’s past medical history is important in wrist injuries/problems? 5  What key information in a patient’s medication history is important in wrist injuries/problems? 5,6  What key information in a patient’s social history is important in wrist injuries/problems? 5  What is the relevance of determining any intervention to date? 5  What is the relevance of determining the compensable status or health insurance status of the patient?  What is the relevance of determining the first aid/pre hospital treatment?  What is the relevance of determining the last intake of food or fluids?

Module 1.4: Musculoskeletal Conditions – Wrist 28 RECOMMENDED RESOURCES

1. Egol, K, Koval, K &Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins. Chapter 23, Wrist, p281-304.

2. McRae, R. (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. The wrist

3. Purcell, D. (2010) Minor Injuries A Clinical Guide. Churchill Livingstone Elsevier: UK Chapter 4 The neck and upper limbs. P96-130

4. WorkCover SA (2011) A guide to assessing and managing red and yellow flags for workcover compensation patients http://www.workcover.com/health-provider/injury-management-by-health- discipline/red-flags

Up to date 5. Anderson, B (2012) Evaluation of the adult patient with wrist pain http://www.uptodate.com/contents/evaluation-of-the-adult-patient-with-wrist-pain? source=search_result&selectedTitle=103%7E150

Module 1.4: Musculoskeletal Conditions – Wrist 29 Theme 2 Focused clinical assessment of wrist problems/injuries

1. Identify the key aspects in clinical assessment of the wrist in the ED setting 2. Formulate key findings to support/refute preliminary differential diagnosis? 3. Differentiate early, presentations of the wrist of non musculoskeletal origin that may require inter-disciplinary care ASSUMED KNOWLEDGE  Anatomy of the wrist: bones, joints, muscles, tendons, ligaments.  Routine physiotherapy objective assessment of the wrist including: - Cervical spine assessment when indicated - Upper limb neurological assessment including peripheral nerves - Finklestein’s test - Tinel’s test - Phalen’s test - Watson’s test - TFCC test

KNOWLEDGE:  Name the vascular supply of the upper limb3.  How would you assess the neurovascular status of the wrist and hand?3  What are the relevance of any local skin changes / open or puncture wounds to the upper limb?7,8,9  When is an assessment of vital signs indicated?  What are the most common non-musculoskeletal presentations of wrist pain? 10,12,13 o What does your clinical assessment need to include if non-musculoskeletal causes are suspected? o What findings you would you expect to see on assessment? o What action needs to be taken?

2. Egol, K, Koval, K, & Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins. Chapter 12, Elbow and Forearm.

3. Judge, NL (2007) Neurovascular assessment. Nursing Standard. Vol 21, No 45, 39-44 http://www.snjourney.com/ClinicalInfo/Systems/PDF/NeuroVas%20Assessment.pdf

4. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. The Elbow.

5. Purcell, D (2010) Minor Injuries A Clinical Guide. Churchill Livingstone Elsevier: UK Module 1.4: Musculoskeletal Conditions – Wrist 30 Chapter 4, The neck and upper limbs, p78-91.

7. Grey, J. E., Enoch, S., & Harding, K. G. (2006). Wound assessment. British Medical Journal, 7536, 285. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360405/

8. Leaper, D. J. (2006). ABC of wound healing: Traumatic and surgical wounds. BMJ: British Medical Journal, 332(7540), 532. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1388134/

9. Nicks, B. A., Ayello, E. A., Woo, K., Nitzki-George, D., & Sibbald, R. G. (2010). Acute wound management: revisiting the approach to assessment, irrigation, and closure considerations. International journal of emergency medicine, 3(4), 399-407. http://link.springer.com/article/10.1007/s12245-010-0217-5

Up to date 10. Helfgott, S (2013) Evaluation of the adult with monarticular pain http://www.uptodate.com/contents/evaluation-of-the-adult-with-monoarticular-pain? source=search_result&search=elbow&selectedTitle=27%7E150

11. Kalunian, K (2012) Clinical manifestations of osteoarthritis http://www.uptodate.com/contents/clinical-manifestations-of-osteoarthritis? source=search_result&search=ankle+osteoarthritis&selectedTitle=2~150

12. Maini, RN & Venables, PJW (2012) Diagnosis and differential diagnosis of rheumatoid arthritis http://www.uptodate.com/contents/diagnosis-and-differential-diagnosis-of- rheumatoid-arthritis?source=search_result&search=rheumatoid&selectedTitle=1~150

13. Becker (2013) Pseudogout. Clinical manifestations and diagnosis of calcium pyrophosphate crystal deposition disease http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-calcium- pyrophosphate-crystal-deposition-disease?source=see_link

Theme 3 Common investigations for wrist injury/problems Module 1.4: Musculoskeletal Conditions – Wrist 31 LEARNING OBJECTIVES:

1. Discuss the common investigations available for wrist injury/problems

KNOWLEDGE:  When would you consider obtaining an X-ray for a patient with wrist injury/condition?1,7,11  What special views may be required? 1.7.9  When would a CT scan be indicated for a patient with wrist injury/problem? 1,9  When would an ultrasound for a patient with wrist injury/problem? 9  When would you consider obtaining blood investigations for a patient with wrist injury/problem?10

CLINICAL APPLICATION: Describe the normal x-ray of wrist Complete the online interactive radiology tutorial and quiz3,4,6,12

RECOMMENDED RESOURCES 1. Anderson J., Read J. (2008). Atlas of Imaging in Sports Medicine. 2nd Edition. McGraw- Hill.

2. Begg, J.D. (2005) Accident and Emergency X-rays Made Easy. Churchill Livingstone. Chapter 7 The upper limb.p143-185.

3. Chesaru, I & Gilula, L (2005) Wrist- Carpal instability. Research Assistant. http://www.radiologyassistant.nl/en/p42a29ec06b9e8/wrist-carpal-instability.html

4. Gay, S, Kuntz, A, Lai, W, Norton, P & Yao, L (date unknown) Skeletal Trauma Radiology. University of Virginia. http://www.med-ed.virginia.edu/courses/rad/ext/index.html

5. Government of Western Australia Department of Health (2012) Diagnostic Imaging Pathways. http://www.imagingpathways.health.wa.gov.au/index.php/imagingpathways/musculoskeletal-trauma

6. Smithuis, R (2008) Wrist – Fractures. Research Assistant. http://www.radiologyassistant.nl/en/p476a23436683b/wrist-fractures.html

7. Raby, N., Berman, L., de Lacey, G. (2005) Accident and Emergency Radiology: A Survival Guide 2nd edition. Elsevier Saunders. Chapter 7 Hand and Fingers.p130-143.

8. Wikiradiography (2010) DISI and VISI deformities http://www.wikiradiography.com/page/DISI+and+VISI+Deformities

Up To Date 9. Baccei, S, Kim, C & Weissman, B (2013) Imaging techniques for evaluation of the Module 1.4: Musculoskeletal Conditions – Wrist 32 painful joint http://www.uptodate.com/contents/diagnostic-imaging-of-joint-pain?source=see_link

10. Helfgott, S. M. (2013) Evaluation of the adult with monoarticular pain http://www.uptodate.com/contents/evaluation-of-the-adult-with-monoarticular-pain? source=search_result&search=joint+infection&selectedTitle=5%7E150 Refer to the Radiology module

11. Hodgkinson, D. W., Kurdy, N., Nicholson, D. A., & Driscoll, P. A. (1994). ABC of emergency radiology. The wrist. BMJ: British Medical Journal, 308(6926), 464. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2539548/pdf/bmj00427-0050.pdf

Module 1.4: Musculoskeletal Conditions – Wrist 33 Theme 4 Common pharmacology for the management of wrist injury/problems

1. Discuss and compare the common pharmacological agents for wrist injury/problems

KNOWLEDGE:  Analgesic agents1-4, 6, 8 o What is appropriate for pain control in the patient with minor wrist pain/injury? o What is appropriate for pain control in the patient with moderate to severe pain with wrist pain/injury?  Anti-inflammatory agents5, 7,9,12,14,15 o What and when is it appropriate to use anti-inflammatory agents?  Antibiotics9 o When is antibiotics indicated for wrist pain/injury and why?  Anaesthetic agents used for reduction of a wrist fracture o When would you consider the different modalities of applying anaesthetics and why?16,17 o Describe a Bier’s block10. o What is a haematoma block  Tetanus immunoglobulin and vaccinations9,11, ,13 o When would you consider this? RECOMMENDED RESOURCES

1. Australian and New Zealand College of Anesthetists and Faculty of Pain Medicine (2006) Managing Acute Pain A Guide for Patients. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/managingacutepain .pdf

2. Bryant, B., Knights, K (2011) Pharmacology for Health Professionals. 3rd edition. Mosby Elsevier. Chapter 15, Analgesics, p277-307

4. eTG complete (2013) Therapeutic Guidelines (subscribed)http://online.tg.org.au/ip/

5. Hamilton, B, Milne, C, Orchard, J, & Paoloni, J (2009) Non-steroidal anti-inflammatory drugs (NSAIDs) in sports medicine. Guidelines for practical but sensible use. British Journal of Sports Medicine (subscribed). http://bjsm.bmj.com/content/early/2009/06/21/bjsm.2009.059980.full.pdf Module 1.4: Musculoskeletal Conditions – Hand 34 6. Macintyre, P, Scott, D, Schug, S, Visser, E, & Walker, S (2010) Acute Pain Management: Scientific Evidence, Third Edition, Australian and New Zealand College of Anesthetists and Faculty of Pain Medicine. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp104_3.pdf\

9. Ball, V & Younggren, B (2007) Emergency Management of Difficult Wounds: Part I. Emergency Medicine Clinics of North America 25, 101-121. http://www.mdconsult.com/das/article/body/385344101- 2/jorg=journal&source=&sp=18944593&sid=0/N/577108/s0733862707000041.pdf? issn=0733-8627

10. Brill et al (2004). Bier’s block; 100 years old and still going strong! Acta Anaesthesiol Scand 2004; 48: 117—122 http://onlinelibrary.wiley.com/doi/10.1111/j.1399-6576.2004.00280.x/pdf

11.eTG complete (2013) Therapeutic guidelines: Tetanus http://online.tg.org.au/ip/

13.. Royal Children’s Hospital, clinical practice guidelines http://www.rch.org.au/clinicalguide/guideline_index/Management_of_tetanusprone_wounds/

Up to date 14 Lexicomp (2013) Ibuprofen: Drug Information http://www.uptodate.com/contents/ibuprofen-drug-information? source=see_link&utdPopup=true

15. Solomon, D (2012) NSAIDs: Mechanism of action http://www.uptodate.com/contents/nsaids-mechanism-of-action? source=search_result&search=pharmacology&selectedTitle=5%7E150

16. Ritchie, J. V., & Munter, D. W. (1999). Emergency department evaluation and treatment of wrist injuries. Emergency medicine clinics of North America, 17(4), 823-842.

17. Wardrope, J., Flowers, M., & Wilson, D. H. (1985). Comparison of local anaesthetic techniques in the reduction of Colles' fracture. Archives of emergency medicine, 2(2), 67-72. http://emj.bmj.com/content/2/2/67.full.pdf+html Module 1.4: Musculoskeletal Conditions – Hand 35 Theme 5 Management of wrist injuries/problems

1. Discuss the common management principles for wrist injuries/problems in the context of the ED setting

ASSUMED KNOWLEDGE:

 Physiotherapy management of acute, sub-acute and chronic wrist injuries  Simple first aid management of elbow injuries  Application of slings to the arm and advice re: use of slings

KNOWLEDGE: For the following list of injuries discuss the signs and symptoms, and consider:  What management is appropriate in the ED setting?  What type of injury would require the involvement of the Orthopaedic team?4,5  How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?4,5  How would you control swelling of the affected area? (remember removal of jewellery)  When would IV fluids be indicated?28  Describe the types of immobilisation used for the management of wrist injuries/problems and for what indications23  How would you provide adequate pain control on discharge?

o Colles’ fracture o Smith’s fracture o Barton’s fracture o Scaphoid fracture o Ulnar styloid fractures o Shaft of radius/ulnar fractures o Radio-ulnar joint injury/dislocation o Fracture of the carpal bones o Flake fracture of Triquetral o Fracture of the lunate o Fracture of the hook of hamate o Fracture of the trapezium o Fracture of pisiform o Kienbock’s disease of the lunate. o AVN (capitate and scaphoid) o Wrist complex instabilities (DISI/VISI) o Dislocation of lunate/perilunar o Repetitive strain injury o Acute extensor tenosynovitis (infective) o Wrist sprain Module 1.4: Musculoskeletal Conditions – Hand 36 o TFCC sprain/tear o Carpal tunnel syndrome o Ganglions o Scaphoid-lunate instability o OA of the wrist o CRPS o Nerve entrapments – Guyon’s cannel o Carpel tunnel syndrome o De Quervains syndrome o Inflammatory arthropathies  Describe how your management of wrist conditions will vary if your patient is: o Diabetic24 o On anti-coagulants1,2 o Mechanism was a crush injury o Mechanism of a fall with unknown cause o Has associated facial, head, neck or chest wall injuries/pain o Past history of IVDU25,26,27 CLINICAL APPLICATION: 1. Plastering of wrist injuries

CLINICAL TASK . Application of a back slab to the upper limb . Application of a full cast to the upper limb . Application of a scaphoid cast

Refer to Plastering Module

3. Egol, K.A. , Koval, K.J., and Zuckerman, J.D. (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins. Chapter 12 Elbow and Forearm.

4. McRae, R., Esser, M. (2008) Practical Fracture Treatment. 5th edition. Churchill Livingstone Elsevier. Chapter 9 The wrist and hand.p195-236

5. McRae, R. (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. The wrist

6. Phillips et al (2004) Diagnosis and management of scaphoid fractures Am Family Module 1.4: Musculoskeletal Conditions – Hand 37 Physician. Sep 1;70(5):879-884 http://www.aafp.org/afp/2004/0901/p879.html

Up to date 7. deWebber (2013) Lunate fractures http://www.uptodate.com/contents/lunate-fractures? source=search_result&selectedTitle=71%7E150

8. deWebber, K (2013) Scaphoid fractures http://www.uptodate.com/contents/scaphoid-fractures? source=search_result&selectedTitle=74%7E150

9. Doherty, T (2012) Ulnar neuropathy at the elbow and wrist http://www.uptodate.com/contents/ulnar-neuropathy-at-the-elbow-and-wrist? source=search_result&search=elbow&selectedTitle=5%7E150

10. Eiff (2013) Capitate fractures http://www.uptodate.com/contents/capitate-fractures? source=search_result&selectedTitle=72%7E150

11. Eiff, P (2013) Hamate fractures http://www.uptodate.com/contents/hamate-fractures? source=search_result&selectedTitle=67%7E150

12. Eiff, P (2013) Overview of carpal fractures http://www.uptodate.com/contents/overview-of-carpal-fractures? source=search_result&selectedTitle=32%7E150

13. Eiff, P (2012) Pisiform fractures http://www.uptodate.com/contents/pisiform-fractures? source=search_result&selectedTitle=69%7E150

14. Eiff, P (2013) Trapezium fractures http://www.uptodate.com/contents/trapezium-fractures? source=search_result&selectedTitle=68%7E150

15. Eiff, P (2013) Trapezoid fractures http://www.uptodate.com/contents/trapezoid-fractures? source=search_result&selectedTitle=70%7E150

16. Eiff (2013) Triquetral fractures http://www.uptodate.com/contents/triquetral-fractures? source=search_result&selectedTitle=73%7E150

Module 1.4: Musculoskeletal Conditions – Hand 38 18. Keyser, F & Sheon, R (2012) Ganglions and nodules http://www.uptodate.com/contents/ganglia-and-nodules? source=search_result&search=wrist&selectedTitle=37%7E150

19. Kothari (2013) Etiology of carpal tunnel syndrome http://www.uptodate.com/contents/etiology-of-carpal-tunnel-syndrome? source=search_result&selectedTitle=85%7E150

20. Kothari (2013) Treatment of carpal tunnel syndrome http://www.uptodate.com/contents/treatment-of-carpal-tunnel-syndrome? source=search_result&selectedTitle=16%7E150

21. Petron, D (2013) Distal radius fractures in adults http://www.uptodate.com/contents/distal-radius-fractures-in-adults? source=search_result&selectedTitle=144%7E150

22. Abdi (2013) Prevention and management of complex regional pain syndrome in adults http://www.uptodate.com/contents/prevention-and-management-of-complex- regional-pain-syndrome-in-adults? source=search_result&search=wrist&selectedTitle=87%7E150

23. Kronfol, R (2012) Splinting of Musculoskeletal injuries http://www.uptodate.com/contents/splinting-of-musculoskeletal-injuries? source=search_result&selectedTitle=18%7E150

24.. Hordon, L. D. (2013) Musculoskeletal complications in diabetes mellitus http://www.uptodate.com/contents/musculoskeletal-complications-in-diabetes- mellitus?source=search_result&search=diabetes+mellitus&selectedTitle=9%7E150

25.. Sexton, D (2012) Infective tenosynovitis http://www.uptodate.com/contents/infectious-tenosynovitis? source=search_result&search=wrist&selectedTitle=81%7E150

26. Horowitz, D. L., Katzap, E., Horowitz, S., & Barilla-LaBarca, M. L. (2011). Approach to septic arthritis. American Family Physician, 84(6), 653-660. http://www.aafp.org/afp/2011/0915/p653.pdf

27. McQueen, M. M., & Gaston, P. (2000). Acute compartment syndrome WHO IS AT RISK?. Journal of Bone & Joint Surgery, British Volume, 82(2), 200-203. http://www.bjj.boneandjoint.org.uk/content/82-B/2/200.full.pdf+html

28. Smeton G, V et al (2014) Pre-operative medical evaluation of the healthy patient http://www.uptodate.com/contents/preoperative-medical-evaluation-of-the-healthy- patient? source=search_result&search=preoperative+evaluation&selectedTitle=2%7E150

Module 1.4: Musculoskeletal Conditions – Hand 39 1.4 Hand

Theme 1 History taking for Hand injury/problems

1. Identify the key principles of history taking of hand injury/problem in the context of the ED Setting 2. Review the importance of mechanism of injury of the hand 3. Differentiate early, presentations of the hand of non-musculoskeletal origin that may require inter-disciplinary care 4. Formulate a preliminary differential diagnoses

ASSUMED KNOWLEDGE: Routine physiotherapy subjective assessment of the hand

KNOWLEDGE:  Discuss the relevance of the following areas to mechanism of injury of the hand: 5,6,8 o Crush o Direct trauma o Fall on outstretched hand (FOOSH) o Fall from standing o Fall from height/bike o Cause of fall o Direction of force - axial loading or “jamming”, o Position of hand – flexion/extension/ulnar or radial deviation o Skin integrity o Time of injury, ability to move arm post injury o Symptoms such as numbness, pins and needles , ‘dead arm’ , tingling o Consider other sites for injury – particular shoulder, elbow and forearm o Lacerations/bites/exposure to contamination o Implications of punching injuries involving exposure to mouth/teeth o Involvement of the nail bed  What key information is required to assess for red flags?4  What key information is required to assess for yellow flags? 4  What key information is required in the setting of chronic hand problems?5  What key information would you ask to differentiate atraumatic hand injury/problem from non musculoskeletal causes? 5,6  What key information in a patient’s past medical history is important in hand injury/problem? 5  What key information in a patient’s medication history is important in hand injury/problem? 5,6.7  What key information in a patient’s social history is important in hand injury/problem? 5,6 Module 1.4: Musculoskeletal Conditions – Hand 40  What is the relevance of determining any intervention to date? 5,6  What is the relevance of determining the compensable status or health insurance status of the patient?  What is the relevance of determining the first aid/pre hospital treatment?9  What is the relevance of determining the last intake of food or fluids?9

1. Egol, K, Koval, K & Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins. Chapter 24, Hand, p305-323.

2. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. The hand, p111-129.

3. Purcell, D (2010) Minor Injuries A Clinical Guide. Churchill Livingstone Elsevier: UK. Chapter 4, The neck and upper limbs, p96-130.

4. WorkCover SA (2011) A guide to assessing and managing red and yellow flags for workcover compensation patients. http://www.workcover.com/health-provider/injury-management-by-health- discipline/red-flags

Up to date 5. Anderson, B (2012) Evaluation of the patient with hand pain http://www.uptodate.com/contents/evaluation-of-the-patient-with-hand-pain? source=search_result&selectedTitle=1%7E150

6. Bray, J & Neal, S (2013) Evaluation of the patient with thumb pain http://www.uptodate.com/contents/evaluation-of-the-patient-with-thumb-pain? source=search_result&selectedTitle=4%7E150

8.Cheung, K., Hatchell, A., & Thoma, A. (2013). Approach to traumatic hand injuries for primary care physicians. Canadian Family Physician, 59(6), 614-618. http://www.cfp.ca/content/59/6/614.full.pdf+html

Module 1.4: Musculoskeletal Conditions – Hand 41 Theme 2 Focused clinical assessment of hand injury/conditions

1. Identify the key aspects in clinical assessment of the hand in the ED setting 2. Formulate key findings to support/refute preliminary differential diagnosis? 3. Differentiate early, presentations of the hand of non musculoskeletal origin that may require inter-disciplinary care ASSUMED KNOWLEDGE  Anatomy of the hand: bones, joints, muscles, tendons, ligaments, volar plate.  Routine physiotherapy objective assessment of the hand including:  Cervical spine assessment when indicated  Upper limb neurological assessment including peripheral nerves

KNOWLEDGE:  Name the vascular supply of the upper limb.3  How would you assess the neurovascular status of the wrist and hand? 5  What are the relevance of any local skin changes / open or puncture wounds to the hand?9,10,11  What are the most common non-musculoskeletal presentations of hand pain? 11,12,13,14,15  When is an assessment of vital signs indicated?  How would you assess a nail injury with subungual haematoma?12,13

RECOMMENDED RESOURCES 1. Brukner and Khan (2012) Clinical Sports Medicine. 4th Edition. McGraw-Hill Medical.

2. Cameron P, Jelinek G, Kelly A, Murray L, Brown A, & Heyworth J, (2004) Adult Emergency Medicine. Churchill Livingston, Sydney.

4. Egol, K, Koval, K & Zuckerman, J (2010) Handbook of Fractures. 4th edition. Lippincott Williams and Wilkins.

5. Judge, N (2007) Neurovascular assessment. Nursing Standard. 21, 45 39-44. http://www.snjourney.com/ClinicalInfo/Systems/PDF/NeuroVas%20Assessment.pd

6. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. The hand.

Module 1.4: Musculoskeletal Conditions – Hand 42 8. Zuluga, M (1995) Sports Physiotherapy – Applied Science and Practice. Churchill Livingstone, Melbourne.

12. Meek, S., & White, M. (1998). Subungual haematomas: is simple trephining enough?. Journal of accident & emergency medicine, 15(4), 269-271. http://emj.bmj.com/content/15/4/269.full.pdf+html

13. Mignemi, M. E., Unruh, K. P., & Lee, D. H. (2013). Controversies in the Treatment of Nail Bed Injuries. The Journal of hand surgery. http://www.jhandsurg.org/article/PIIS036350231300525X/fulltext

Up to date 14. Helfgott, S (2013) Evaluation of the adult with mono-articular pain http://www.uptodate.com/contents/evaluation-of-the-adult-with-monoarticular-pain? source=search_result&search=elbow&selectedTitle=27%7E150

15. Maini, R & Venables, P (2012) Diagnosis and differential diagnosis of rheumatoid arthritis http://www.uptodate.com/contents/diagnosis-and-differential-diagnosis-of- rheumatoid-arthritis? source=search_result&search=rheumatoid&selectedTitle=1~150

Module 1.4: Musculoskeletal Conditions – Hand 43 Theme 3 Common investigations for hand injuries/conditions

1. Discuss the common investigations for hand injuries/problems

KNOWLEDGE:  When would you consider obtaining an X-ray for a patient with hand injuries/problems?6,7  When would you consider obtaining an ultrasound for a patient with hand injuries/problems? 7,9  When would you consider obtaining blood investigations for a patient with hand injuries/problems? 7,8

Describe the normal x-ray of the hand Complete the online interactive radiology tutorial and quiz3,10

1. Anderson J & Read J (2008) Atlas of Imaging in Sports Medicine. 2nd Edition. McGraw- Hill.

3. Gay, S, Kuntz, A, Lai, W, Norton, P & Yao, L (Date Unknown) Skeletal Trauma Radiology. University. http://www.med-ed.virginia.edu/courses/rad/ext/index.html

4. Government of Western Australia Department of Health (2012) Diagnostic Imaging pathways – Musculoskeletal/Trauma. http://www.imagingpathways.health.wa.gov.au/index.php/imagingpathways/musculoskeletal-trauma

5. Raby, N, Berman, L, & de Lacey, G (2005) Accident and Emergency Radiology: A Survival Guide 2nd edition. Elsevier Saunders. Chapter 7, Hand and Fingers, p130-143.

6. Hughes, T., & Chan, O. (2005). ABC of emergency radiology: Hand. BMJ: British Medical Journal, 330(7499), 1073. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC557237/pdf/bmj33001073.pdf

Up to Date 7. Baccei, S, Kim, C & Weissman, B (2013) Imaging techniques for evaluation of the

Module 1.4: Musculoskeletal Conditions – Hand 44 painful joint http://www.uptodate.com/contents/diagnostic-imaging-of-joint-pain?source=see_link

8. Chung, K, Ono, S & Sebastian, S (2012) Overview of hand infections http://www.uptodate.com/contents/overview-of-hand-infections? source=search_result&search=hand&selectedTitle=4%7E150

9.Chau, C. L. F., & Griffith, J. F. (2005). Musculoskeletal infections: ultrasound appearances. Clinical radiology, 60(2), 149-159

Refer to Radiology module

Module 1.4: Musculoskeletal Conditions – Hand 45 Theme 4 Common pharmacology for the management of hand injuries/problems

1. Discuss and compare the common pharmacological agents for hand injuries/problems

KNOWLEDGE:  Analgesic agents1-4 o What is appropriate for pain control in the patient with minor hand injuries/problems ? o What is appropriate for pain control in the patient with moderate to severe pain with hand injuries/problems ?  Anti-inflammatory agents 5, 6, 8, 10, 11 o What and when is it appropriate to use anti-inflammatory agents?  Antibiotics9, o When is antibiotics indicated for hand injuries/problems and why?  Tetanus immunoglobulin and vaccinations9,12,14 a. When would this be indicated?

6. Macintyre, P, Scott, D, Schug, S, Visser, E, & Walker, S (2010) Acute Pain Management: Scientific Evidence, Third Edition, Australian and New Zealand College of Anesthetists and Faculty of Pain Medicine. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp104_3.pdf\

Module 1.4: Musculoskeletal Conditions – Hand 8. Vargus46 Schaffer (2010) Is the WHO analgesic ladder still valid? Canadian Family Physician. 56, 6, p514-517. http://www.cfp.ca/content/56/6/514.full.pdf+html

9. Ball, V & Younggren, B (2007) Emergency Management of Difficult Wounds: Part I. Emergency Medicine Clinics of North America. 25 (2007), 101-121 Theme 5 Management of hand pain/injury

1. Discuss the common management principles for hand injuries/problems in the ED setting

ASSUMED KNOWLEDGE:  Physiotherapy management of acute, sub-acute and chronic hand injuries  Simple first aid management of hand injuries  Application of slings to the arm and advice re: use of slings

KNOWLEDGE: For the list of injuries/problems below consider:  What management is appropriate in the ED setting? 5,6  What type of injury would require the involvement of the Orthopaedic /Plastics team?5,6  How would you know when to refer to hand therapy or outpatients, and/or for further imaging as an outpatient or request for an urgent review?  How would you control swelling of the affected area? (remember removal of jewellery)  When would IV fluids be indicated?  What types of immobilisation are used for the management of hand injuries/problems and for what indications27 - What is the position of safe immobilization  How would you provide adequate pain control on discharge?  How would your management of wrist conditions vary if your patient is: - On anti-coagulants2,3 - Mechanism was a crush injury29 - Manual worker/musician etc

 Discuss the signs, symptoms and management of1, 4-27 o Bennett’s fracture o Rolando fracture o CMC OA o Ulnar collateral ligament injury (skiers thumb) o Extensor or flexor tendon injury to the hand o Metacarpal fractures and dislocation o Proximal phalangeal fractures o Middle phalangeal fractures o Distal phalangeal fractures o Digit Joint dislocation o Volar plate injury

Module 1.4: Musculoskeletal Conditions – Hand 47 o Mallet deformity, o Boutonnieres deformity, o Swan neck deformity o Carpal injury o Repetitive strain injury o Tenosynovitis (+/- infective) o Carpel tunnel syndrome o Ganglions o Digital neurofibroma o Trigger thumb and trigger finger o Subungual haematoma o Dupuytrens contracture o De Quervains syndrome9 o Inflammatory arthropathies

CLINICAL TASK - Plastering/splinting of hand injuries 1. Application of a thumb spica 2. Application of a mallet finger splint 3. Application of a volar cast

Refer to Plastering module

1. Bonisteel, P (2008) Trephining subungual haematoma. The College of Family Physicians of Canada. May 2008 vol. 54 no. 5 693. http://www.cfp.ca/content/54/5/693.full.pdf+html

4. Egol, K, Koval, K, & Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins. Chapter 12 Elbow and Forearm.

5. McRae, R & Esser, M (2008) Practical Fracture Treatment. 5th edition. Churchill Livingstone Elsevier. Chapter 9, The wrist and hand, p195-236.

6. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. The hand. Module 1.4: Musculoskeletal Conditions – Hand 48 7. Ng, C & Oliver, C (2009) Fractures of the proximal interphalangeal joints of the fingers

Bone Joint Surg Br June 2009 vol. 91-B no. 6 705-712. http://www.bjj.boneandjoint.org.uk/content/91-B/6/705.full

8. Zuluga et al (1995) Sports Physiotherapy – Applied Science and Practice. Churchill Livingstone. Chapter 25 The wrist and hand.

9. Ilyas, A. M., Ast, M., Schaffer, A. A., & Thoder, J. (2007). De quervain tenosynovitis of the wrist. Journal of the American Academy of Orthopaedic Surgeons, 15(12), 757-764.

Up to date: 10.. Abdi, S (2013) Prevention and management of complex regional pain syndrome in adults http://www.uptodate.com/contents/prevention-and-management-of-complex-regional- pain-syndrome-in-adults?source=search_result&search=wrist&selectedTitle=87%7E150

11. Aggarwal, R & Anderson, B (2012) de Quervain’s tenosynovitis http://www.uptodate.com/contents/de-quervains-tenosynovitis? source=search_result&search=hand&selectedTitle=8~150

12. Anderson, B (2013) Trigger finger (stenosing flexor tenosynovitis) http://www.uptodate.com/contents/trigger-finger-stenosing-flexor-tenosynovitis? source=search_result&search=hand&selectedTitle=6%7E150

13. Anderson, B (2012) Ulnar collateral ligament injury (gamekeeper's or skier's thumb) http://www.uptodate.com/contents/ulnar-collateral-ligament-injury-gamekeepers-or- skiers-thumb?source=search_result&selectedTitle=16%7E150

14. Antevy, P & Saladino, R (2012) Management of fingertip injuries http://www.uptodate.com/contents/management-of-fingertip-injuries? source=search_result&search=finger&selectedTitle=6~150

15. Bassett, R (2013) Distal phalanx fractures http://www.uptodate.com/contents/distal-phalanx-fractures? source=search_result&selectedTitle=7%7E150

16. Bassett, R (2012) Proximal phalanx fractures http://www.uptodate.com/contents/proximal-phalanx-fractures? source=search_result&selectedTitle=10%7E150

17. Bassett, R (2012) Middle phalanx fractures http://www.uptodate.com/contents/middle-phalanx-fractures? source=search_result&selectedTitle=11%7E150

18. Bloom, J (2012) Metacarpal neck fractures http://www.uptodate.com/contents/metacarpal-neck-fractures? source=search_result&selectedTitle=9%7E150 Module 1.4: Musculoskeletal Conditions – Hand 49 19. Bloom, J (2012) Metacarpal base fractures http://www.uptodate.com/contents/metacarpal-base-fractures? source=search_result&selectedTitle=29%7E150

20. Bloom, J (2013) Metacarpal head fractures http://www.uptodate.com/contents/metacarpal-head-fractures? source=search_result&selectedTitle=30%7E150

21. Bloom, J (2012) Metacarpal shaft fractures http://www.uptodate.com/contents/metacarpal-shaft-fractures? source=search_result&selectedTitle=31%7E150

22. Bothner, J & Fastle, R (2012) Subungual haematoma http://www.uptodate.com/contents/subungual-hematoma? source=search_result&search=nail+bed+injury&selectedTitle=2~150

23. Chung, C, Ono, S & Sebastin, S (2012) Overview of finger, hand and wrist fractures. http://www.uptodate.com/contents/overview-of-finger-hand-and-wrist-fractures? source=search_result&search=hand&selectedTitle=3%7E150

24. Eiff, P (2013) Overview of carpal fractures http://www.uptodate.com/contents/overview-of-carpal-fractures? source=search_result&selectedTitle=32%7E150

25. Joshi, S (2013) Digit dislocation reduction http://www.uptodate.com/contents/digit-dislocation-reduction? source=search_result&search=finger&selectedTitle=42~150

26. Keyser, F & Sheon, R (2012) Ganglions and nodules http://www.uptodate.com/contents/ganglia-and-nodules? source=search_result&search=wrist&selectedTitle=37~150

27. Kronfol, R (2012)Splinting of musculoskeletal injuries http://www.uptodate.com/contents/splinting-of-musculoskeletal-injuries? source=search_result&selectedTitle=18%7E150

28. Sexton, D (2012) Infective tenosynovitis http://www.uptodate.com/contents/infectious-tenosynovitis? source=search_result&search=wrist&selectedTitle=81~150

29. McQueen, M. M., & Gaston, P. (2000). Acute compartment syndrome WHO IS AT RISK?. Journal of Bone & Joint Surgery, British Volume, 82(2), 200-203. http://www.bjj.boneandjoint.org.uk/content/82-B/2/200.short

Module 1.4: Musculoskeletal Conditions – Hand 50 1.5: Hip

Theme 1 History taking specific to hip injuries/conditions

1. Identify the key principles of history taking of hip injuries/conditions 2. Review the importance of mechanism of injury in hip injuries 3. Differentiate early, presentations of the hip that may require inter-disciplinary care and/or presentations of non-musculoskeletal origin 4. Formulate a preliminary differential diagnoses

KNOWLEDGE:  What group of patients are predisposed to hip injuries or pain and why?8  What medications may predispose patients to fractures and why? 4  What is the importance of determining if there are any associated injuries? 8  What are the most common mechanisms for acute hip injuries? 8  What is the relevance/importance of establishing of the mechanism of injury for acute hip injuries? 3,8  What is the relevance of establishing any sensations felt at the time of injury (ie pop, crack) and timing of onset of symptoms? 8  What is the relevance of establishing any other symptoms felt since the initial injury (ie referred symptoms such as groin/leg pain, neurology,)? 8  What is the relevance of determining the type of activity which led to the hip injury/condition? 8  What is the relevance of determining the patient’s ability to weight bear at the time of injury? 8  What is significant about a fall from a height? 8  What is the relevance of determining the neurovascular status of the leg? 8  What key information is important to assess for red flags? 6  What key information is important to determine in the setting of chronic hip pain? 8,9  What key information is important in the setting of atraumatic hip pain? 7,4  What key information in a patient’s past history is important for patients presenting with a hip injury/condition? 7,8  What key information in a patient’s medication history is important for patients presenting with a hip injury/condition? 7.,8  What key areas of social history are important for patient’s presenting with hip injury/pain? 8  What is the relevance of determining any previous intervention or treatment for patients presenting with a hip injury/pain? 8  What is the relevance of determining the compensable status or health insurance status of the patient?  What is the relevance of determining the first aid/pre hospital treatment?  What is the relevance of determining the last intake of food or fluids?11

RECOMMENDED RESOURCES Module 1.5: Musculoskeletal Conditions – Hip 51 1. Egol, K, Koval, K & Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins. Chapter 11, Shoulder and upper arm.

2. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. The shoulder

3. McRae, R & Esser, M (2008) Practical Fracture Treatment. 5th Edition. Churchill Livingstone, Edinburgh.

4. Porrino, J, Kohl, C, Taljanovic, M & Rogers, L (2010) Diagnosis of Proximal Femoral Insufficiency Fractures in Patients Receiving Bisphosphonate Therapy. AJR. Vol. 194 No. 4

5. Purcell, D (2010) Minor Injuries A Clinical Guide. Churchill Livingstone Elsevier: UK

6. Workcover SA (2011) A guide to assessing and managing red and yellow flags for workers compensation patients. Government of South Australia. http://www.workcover.com/health-provider/injury-management-by-health- discipline/red-flags

Up To Date: 8. Anderson, B (2012) Evaluation of the adult with hip pain http://www.uptodate.com/contents/evaluation-of-the-adult-with-hip-pain? source=related_link

9. Kalunian, K (2012) Diagnosis and classification of osteoarthritis http://www.uptodate.com/contents/diagnosis-and-classification-of-osteoarthritis? source=related_link

10. Mohler, E (2012) Clinical features, diagnosis, and natural history of lower extremity peripheral artery disease http://www.uptodate.com/contents/clinical-features-diagnosis-and-natural-history-of- lower-extremity-peripheral-artery-disease?source=related_link

Module 1.5: Musculoskeletal Conditions – Hip 52 Theme 2 Focused clinical assessment specific to hip injuries/conditions

1. Identify the key aspects in clinical assessment specific to hip injuries/conditions in the ED setting 2. Formulate key findings to support/refute preliminary differential diagnosis? 3. Differentiate early, presentations of the hip of non musculoskeletal origin that may require inter-disciplinary care ASSUMED KNOWLEDGE:  Anatomy of the hip and pelvis: bones, joints, muscles, tendons, ligaments.  ROM and strength assessment of the hip.  Ligament integrity assessment of the hip.  Meniscal integrity assessment of the hip.  Tendon/muscle assessment of the hip.  Gait and functional assessment of the lower extremity  Palpation of the bones, tendons, ligaments, joints.  Nerve supply of the hip and lower leg KNOWLEDGE  Name the vascular supply of the hip and lower leg. 3  How would you determine the neurovascular status of the hip and lower leg? 5  Describe the relevance of any local skin changes / open wounds to the hip and lower leg.  Describe when an assessment of vital signs is indicated  Outline what you would include in a hip assessment for a patient presenting with an acute injury unable to weight bear? 9  What special tests of the hip/groin area would you conduct and at what stage in the assessment? 9  What assessment findings might suggest a non-musculoskeletal cause of symptoms? 7, 8, 10,12,13  What are the most common differential diagnosis of hip pain for 10,17 o Acute traumatic injuries o Non traumatic injuries (include non-musculoskeletal diagnoses)?  What nerve injury can cause a patch of numbness on the lateral aspect of the thigh? 10  What are the diagnoses not to be missed for presentations of hip pain16

1. Brukner & Khan (2012) Clinical Sports Medicine. 4th Edition. McGraw-Hill Medical.

3. Drake, R, Vogl, W & Mitchell, A (2005) Gray’s Anatomy for Students. Churchill Livingstone Elsevier.

Module 1.5: Musculoskeletal Conditions – Hip 53 4. Egol, K, Koval, K & Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins. Chapter 11, Shoulder and upper arm.

5. Judge, N (2007) Neurovascular assessment. Nursing Standard. 24, 45, p39-44. http://www.snjourney.com/ClinicalInfo/Systems/PDF/NeuroVas%20Assessment.pdf

7. Tibor, L, & , Sekiya J (2008) Differential diagnosis of pain around the hip joint. Arthroscopy. 12,1407-21.

8. Troum, O, & Crues, J (2004) The Young Adult With Hip Pain: Diagnosis and Medical Treatment. Clinical Orthopaedics & Related Research. 418, p9-17.

9. Zuluga et al (1995) Sports Physiotherapy – Applied Science and Practice. Churchill Livingstone, Melbourne.

Up to Date: 10. Anderson, B (2012) Evaluation of the adult with hip pain http://www.uptodate.com/contents/evaluation-of-the-adult-with-hip-pain? source=related_link

11. Kalunian, K (2012) Diagnosis and classification of osteoarthritis http://www.uptodate.com/contents/diagnosis-and-classification-of-osteoarthritis? source=related_link

12. Brooks, D, Hawn, M & Obeid, A (2013) Classification, clinical features and diagnosis of inguinal and femoral hernias in adults http://www.uptodate.com/contents/classification-clinical-features-and-diagnosis-of- inguinal-and-femoral-hernias-in-adults? source=search_result&search=groin+pain&selectedTitle=3%7E25

13.Mohler, E (2012) Clinical features, diagnosis, and natural history of lower extremity peripheral artery disease http://www.uptodate.com/contents/clinical-features-diagnosis-and-natural-history-of- lower-extremity-peripheral-artery-disease?source=related_link

14.Sexton, D (2012) Pelvic osteomyelitis http://www.uptodate.com/contents/pelvic-osteomyelitis?source=see_link

15. Yu, D (2012) Clinical manifestations of ankylosing spondylitis in adults http://www.uptodate.com/contents/clinical-manifestations-of-ankylosing-spondylitis- in-adults?source=search_result&search=groin+pain&selectedTitle=16%7E25

16. Dominguez, S., Liu, P., Roberts, C., Mandell, M., & Richman, P. B. (2005). Prevalence of traumatic hip and pelvic fractures in patients with suspected hip fracture and negative initial standard radiographs—a study of emergency department patients. Academic emergency Module 1.5: Musculoskeletal Conditions – Hip 54 medicine, 12(4), 366-369. http://onlinelibrary.wiley.com/doi/10.1197/j.aem.2004.10.024/pdf 17. Tibor, L. M., & Sekiya, J. K. (2008). Differential diagnosis of pain around the hip joint. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 24(12), 1407-1421. http://journalsconsultapp.elsevier-eprints.com/uploads/articles/arthro1.pdf

Module 1.5: Musculoskeletal Conditions – Hip 55 Theme 3 Common investigations specific to hip injuries

1. Discuss the common investigations available and specific to hip injuries/conditions

KNOWLEDGE:  When would you consider ordering an x-ray for a patient with a hip injury or hip pain?4, 5, 6, 8, 9  Outline the features of a normal and abnormal hip x-ray7,13  When would a CT be indicated for a patient with a hip injury or pain? 9  When would an MRI be indicated for a patient with a hip injury or pain?9  When would an ultrasound be indicated for a patient with a hip injury or pain?9  When would pathology tests be required for a patient with a hip injury or pain? 5,12  When would a urinalysis be indicated for a patient with hip pain?1

CLINICAL APPLICATION: Website – interactive radiology tutorial and quiz http://www.med-ed.virginia.edu/courses/rad/ext/index.html http://www.radiologyassistant.nl/en/p431c8258e7ac3/hip-arthroplasty.html http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x- ray_trauma_lower_limb/lower_limb_trauma_x-ray_start.html

1. American Association for Clinical Chemistry (2013) Urinalysis: Three types of examinations http://labtestsonline.org/understanding/analytes/urinalysis/ui-exams/start/2

2. Anderson, J & Read, J (2008) Atlas of Imaging in Sports Medicine. 2nd Edition. McGraw- Hill.

4. Government of Western Australia Department of Health (2012) Diagnostic Imaging pathways – Suspected hip fracture http://www.imagingpathways.health.wa.gov.au/index.php/imagingpathways/musculoskeletal-trauma/bone-and-joint-trauma/suspected-hip- fracture#pathway

5. Government of Western Australia Department of Health (2012) Diagnostic Imaging pathways – Non-traumatic hip or knee pain Module 1.5: Musculoskeletal Conditions – Hip 56 http://www.imagingpathways.health.wa.gov.au/index.php/imagingpathways/musculoskeletal-trauma/musculoskeletal/non-traumatic-hip-or-knee- pain#pathway

6. Government of Western Australia Department of Health (2012) Diagnostic Imaging pathways – Avascular necrosis of the hip http://www.imagingpathways.health.wa.gov.au/index.php/imagingpathways/musculoskeletal-trauma/musculoskeletal/avascular-necrosis-of-the- hip#pathway

7. Raby, N, Berman, L & de Lacey, G.(2005) Accident and Emergency Radiology: A Survival Guide. 2nd Edition. Elsevier Saunders, Philadelphia.

Up to date 8. Jude, C & Modaressi, S (2013) Radiologic evaluation of the hip in infants, children and adolescents. http://www.uptodate.com/contents/radiologic-evaluation-of-the-hip-in-infants- children-and-adolescents?source=see_link

9. Jude, C & Modaressi, S (2013) Radiological evaluation of hip pain in adults http://www.uptodate.com/contents/radiologic-evaluation-of-the-painful-hip-in-adults? source=related_link

10.Baccei, S, Chu, K & Weissman, B (2013) Imaging techniques for evaluation of the painful joint http://www.uptodate.com/contents/imaging-techniques-for-evaluation-of-the-painful- joint?source=see_link

11.Bruyn, G (2013) Musculoskeletal ultrasonography: Clinical applications http://www.uptodate.com/contents/musculoskeletal-ultrasonography-clinical- applications?source=related_link

13. Sanville, P., Nicholson, D. A., & Driscoll, P. A. (1994). ABC of emergency radiology. The hip. BMJ: British Medical Journal, 308(6927), 524. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2542791/pdf/bmj00428-0050.pdf

14. Masterclass Radiology: Lower Limb http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x- ray_trauma_lower_limb/lower_limb_trauma_x-ray_start.html

Refer to the Radiology and Pathology Module

Module 1.5: Musculoskeletal Conditions – Hip 57 Theme 4 Common pharmacology specific to hip injuries/conditions

1. Discuss and compare the common pharmacological and non-pharmacological agents specific to hip injuries/conditions

KNOWLEDGE:  Analgesic agents1-4, 6-8 o What is appropriate for pain control in the patient with minor hip pain/injury? o What is appropriate for pain control in the patient with moderate to severe pain with hip pain/injury?  Anti-inflammatory agents5, 7, 8,10,11,12 o What and when is it appropriate to use anti-inflammatory agents?  Antibiotics9 o When is antibiotics indicated for hip pain/injury and why?  Tetanus immunoglobulin and vaccinations9,13,14 o When would this be indicated?

RECOMMENDED RESOURCES (Refer to the Pharmacology Module)

1. Australian and New Zealand College of Anesthetists and Faculty of Pain Medicine (2006) Managing Acute Pain A Guide for Patients. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/managingacutepain.pdf

6. Macintyre, P, Scott, D, Schug, S, Visser, E, & Walker, S (2010) Acute Pain Management: Scientific Evidence, Third Edition, Australian and New Zealand College of Anesthetists and Faculty of Pain Medicine. Module 1.5: Musculoskeletal Conditions – Hip 58 http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp104_3.pdf\

10.Lexicomp (2013) Ibuprofen: Drug infomation http://www.uptodate.com/contents/ibuprofen-drug-information? source=see_link&utdPopup=true

11. Solomon, D (2012) NSAIDs mechanism of action http://www.uptodate.com/contents/nsaids-mechanism-of-action? source=search_result&search=pharmacology&selectedTitle=5%7E150

14. eTG complete (2013) Therapeutic guidelines: Tetanus http://online.tg.org.au/ip/

Refer to Pharmacology Module

Module 1.5: Musculoskeletal Conditions – Hip 59 Theme 5 Management of specific to hip injuries/conditions

1. Identify and discuss the common management principles specific to hip injuries/conditions 2. Present patient education and health promotion aspects specific to hip injuries ASSUMED KNOWLEDGE  Safe prescription of gait aids  Application of ZKS with appropriate patient education  Simple first aid management of hip injuries  Physiotherapy treatment of acute, sub-acute and chronic musculoskeletal hip injuries/conditions

KNOWLEDGE:  What type of injury would require the involvement of the ED Medical team?  What type of hip presentation would require the involvement of the Orthopaedic team at the time of assessment?7,8  What type of hip presentation would require referral on to an Orthopaedic specialist for further assessment at a later date?7,8  How would you provide adequate pain control if required at the time of assessment?  Describe how your management of a hip injury/condition will vary if your patient is: - Diabetic18 - On anti-coagulant therapy1, 2  Describe the signs, symptoms and management of 3-7, 9-10, 12-17, 19-25 o Avulsion injuries around the pelvis (ASIS, AIIS, ischial tuberosity) o Thigh haematoma o Groin strain o Hamstring strain o Quadriceps strain/rupture o Osteitis pubis o Acute labral tear o Chronic labral tear o Femoroacetabular impingement o Bursitis of the hip (trochanteric, ischial, iliopectineal) o Occult hernia / conjoint tendon strain o Osteoarthritis of the hip o Acute AVN of the femoral head o Chronic AVN of the femoral head o Perthes disease o Snapping hip o Nerve entrapments around the hip (ilioinguinal, lateral cutaneous nerve of the thigh)  What signs and symptoms would suggest the lumbar spine as a likely source of hip pain?  What signs and symptoms may be suggestive of a late presentation hip or pelvis fracture?4  Discuss the patient education required for follow up care

RECOMMENDED RESOURCES Module 1.5: Musculoskeletal Conditions – Hip 60 1. Chan, T. Y. (1005). Adverse interactions between warfarin and nonsteroidal anti-inflammatory drugs: mechanisms, clinical significance and avoidance. Ann Pharmacother 29(12): 1274-83. http://www.ncbi.nlm.nih.gov/pubmed/8672833

3. Egol, K, Koval, K & Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins.

4. Bruner, L & Eshilian-Oates, L (2003) Hip Fractures in adults. Am Fam Physician. 1, 67(3), p537- 542. http://www.ncbi.nlm.nih.gov/pubmed/12588076

5. Cochrane Database osteoarthritis guidelines (2008) http://www.cochrane.org.au/files/OAGuidelines_key210708_.pdf

6. Lohn, K (2012) Bursitis. Medscape reference. http://emedicine.medscape.com/article/822693-overview

8. McRae, R (2004). Clinical Orthopedic Examination. 4th Edition. Churchill Livingstone, Sydney.

9. NHMRC Guidelines for the non surgical management of hip and knee osteoarthritis management (2009) http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp117-hip-knee- osteoarthritis.pdf

10. OARSI guidelines for hip and knee osteoarthritis http://www.oarsi.org/pdfs/oarsi_recommendations_for_management_of_hip_and_knee_oa.pdf

11. Purcell, D. (2010) Minor Injuries A Clinical Guide. Churchill Livingstone Elsevier UK.

12. Zhang, W. et al (2005): EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Inculding Therapeutics (ESCISIT), Ann Rheum Dis, 64: 669-681. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1755499/pdf/v064p00669.pdf

Up to date 13. Anderson, B (2012) Trochanteric Bursitis http://www.uptodate.com/contents/trochanteric-bursitis?source=related_link

14. Best, T & Classie, J (2013) Osteitis pubis http://www.uptodate.com/contents/osteitis-pubis? source=search_result&search=groin+pain&selectedTitle=6%7E25 Module 1.5: Musculoskeletal Conditions – Hip 61 15. Brooks, D (2012) Sports related groin pain or ‘sports hernia’ http://www.uptodate.com/contents/sports-related-groin-pain-or-sports-hernia? source=search_result&search=groin+pain&selectedTitle=1%7E25

16. Copland, S, Field, C & Tipton, J (2013) Hamstring Injuries http://www.uptodate.com/contents/hamstring-injuries? source=search_result&search=compartment+syndrome+ thigh&selectedTitle=22~150

17. Hammerberg, E & Stracciolini, A (2013) Acute compartment syndrome of the extremities http://www.uptodate.com/contents/acute-compartment-syndrome-of-the-extremities? source=search_result&search=compartment+syndrome+thigh &selectedTitle=1~150

18. Hordon, L. D. (2013) Musculoskeletal complications in diabetes mellitus http://www.uptodate.com/contents/musculoskeletal-complications-in-diabetes-mellitus? source=search_result&search=diabetes+mellitus&selectedTitle=9%7E150

19. Kalunian, K. C. (2013) Clinical manifestations of osteoarthritis http://www.uptodate.com/contents/clinical-manifestations-of-osteoarthritis? detectedLanguage=en&source=search_result&search=OA&selectedTitle= 3%7E150&provider=noProvider

20. Kalunian, K. C. (2013) Diagnosis and classification of osteoarthritis http://www.uptodate.com/contents/diagnosis-and-classification-of-osteoarthritis? source=related_link

21. Kalunian, K. C. (2013) Risk factors and possible causes for osteoarthritis http://www.uptodate.com/contents/risk-factors-for-and-possible-causes-of-osteoarthritis? detectedLanguage=en&source=search_result&search=OA&selectedTitle=4%7E150& provider=noProvider

22. Kienstra, A & Macias, C (2012) Slipped capital femoral epiphysis (SCFE) http://www.uptodate.com/contents/slipped-capital-femoral-epiphysis-scfe? source=related_link

23. Nigrovic, P (2012) Haemarthrosis http://www.uptodate.com/contents/hemarthrosis?source=search_result&search = knee+injuries&selectedTitle=25~35

24. Nigrovic, P (2012) Overview of hip pain in childhood http://www.uptodate.com/contents/overview-of-hip-pain-in-childhood

25. Sheon, R (2011) Bursitis: An overview of clinical manifestations, diagnosis, and management http://www.uptodate.com/contents/bursitis-an-overview-of-clinical-manifestations-diagnosis- and-management?source=search_result&search=bursitis&selectedTitle=1%7E125

Module 1.5: Musculoskeletal Conditions – Hip 62 1.6: Knee

Theme 1 History taking specific to knee injuries/conditions

1. Identify the key principles of history taking of knee injuries/condtions in the context of the ED setting 2. Review the importance of mechanism of injury in knee injuries 3. Differentiate early, presentations of the knee that may require inter- disciplinary care and/or presentations of non-musculoskeletal origin 4. Formulate a preliminary differential diagnoses KNOWLEDGE:  What group of patients are predisposed to knee injuries/pain and why?  What medications may predispose patients to fractures and why?  What is the importance of determining if there are any associated injuries?5  What are the most common mechanisms for acute knee injuries? 5  What is the relevance/importance of establishing of the mechanism of injury for acute knee injuries? 7  What is the relevance of establishing any sensations felt at the time of injury (ie pop, crack) and timing of onset of swelling? 5  What is the relevance of establishing any other symptoms felt since the initial injury (ie giving way, locking, instability, onset of swelling)? 5  What is the relevance of determining the type of activity which led to the knee injury? 5  What is the relevance of determining the patient’s ability to weight bear at the time of injury? 5  What is the relevance of determining the neurovascular status of the knee or lower leg?  What key information is important to assess for red flags?4  What key information is important to determine in the setting of chronic knee pain? 5  What key information is important in the setting of atraumatic knee pain? 5  What key information is important in the setting of a swollen knee without trauma? 5  What key information in a patient’s past history is important for patients presenting with a knee injury/pain? 5  What key information in a patient’s medication history is important for patients presenting with a knee injury/pain? 5,10  What key areas of social history are important for patient’s presenting with knee injury/pain?5  What is the relevance of determining any treatment to date for patients presenting with a knee injury/pain? 5  What is the relevance of determining the last intake of food or fluids?9  What is the relevance of determining the compensable status or health insurance status of the patient?

Module 1.6: Musculoskeletal Conditions – Knee 63 RECOMMENDED RESOURCES

2. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. The shoulder

Up To Date 5. Anderson, B & Anderson, R (2012) General evaluation of the active adult with knee pain http://www.uptodate.com/contents/general-evaluation-of-the-adult-with-knee-pain

6. Hergenroeder, A (2012) Approach to the young athlete with acute knee pain or injury http://www.uptodate.com/contents/approach-to-the-young-athlete-with-acute-knee- pain-or-injury?source=search_result&search=actue+knee+injuries&selectedTitle=3~35

7. Hergenroeder, A (2012) Traumatic cases of acute knee pain and injury in the young athlete http://www.uptodate.com/contents/traumatic-causes-of-acute-knee-pain-and- injury-in-the-young-athlete? source=search_result&search=actue+knee+injuries&selectedTitle=5~35

8. Hergenroeder, A. (2013) Approach to the young athlete with chronic knee pain or injury http://www.uptodate.com/contents/approach-to-the-young-athlete-with-chronic-knee- pain-or-injury?detectedLanguage=en&source=search_ result&search=knee+pain&selectedTitle=2%7E101&provider=noProvider

11. Griffin, L. Y., Agel, J., Albohm, M. J., Arendt, E. A., Dick, R. W., Garrett, W. E., ... & Wojtys, E. M. (2000). Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. Journal of the American Academy of Orthopaedic Surgeons, 8(3), 141-150. Module 1.6: Musculoskeletal Conditions – Knee 64 Theme 2 Focused clinical assessment specific to knee injuries

1. Identify the key aspects in clinical assessment specific to knee injuries/conditions in the context of the ED setting 2. Formulate key findings to support/refute preliminary differential diagnosis? 3. Differentiate early, presentations of the knee of non musculoskeletal origin that may require inter-disciplinary care ASSUMED KNOWLEDGE:  Anatomy of the knee: bones, joints, muscles, tendons, ligaments.  ROM assessment of the knee.  Ligament integrity assessment of the knee.  Meniscal integrity assessment of the knee.  Tendon/muscle assessment of the knee.  Strength assessment of the knee.  Gait and functional assessment of the lower extremity  Palpation of the bones, tendons, ligaments, joints.  Nerve supply of the knee and lower leg KNOWLEDGE  Name the vascular supply of the knee and lower leg.3  How would you determine the neurovascular status of the knee and lower leg? 5  Describe the relevance of any local skin changes / open wounds to the knee and lower leg.9,10,11  Describe when an assessment of vital signs is indicated12,13,14  Describe how the presence and location of swelling relates to the type of injury6  Describe the Wells criteria and when it’s use is indicated8  How do you differentiate a DVT from a musculoskeletal condition?16,17,18,19  How do you differentiate a septic arthritis from a swollen knee20

5. Judge, N (2007) Neurovascular assessment. Nursing Standard. 24, 45, 39-44. http://www.snjourney.com/ClinicalInfo/Systems/PDF/NeuroVas%20Assessment.pdf

Module 1.6: Musculoskeletal Conditions – Knee 65 6. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. The shoulder.

7. Zuluga et al (1995) Sports Physiotherapy – Applied Science and Practice. Churchill Livingstone, Melbourne.

8. Wolf, S. J., McCubbin, T. R., Feldhaus, K. M., Faragher, J. P. & Adcock, D. M (2004). Prospective validation of wells criteria in the evaluation of patients with suspected pulmonary embolism, Annals of Emergency Medicine, 44(5): 503-510.

12. Helfgott, S (2013) Evaluation of the adult with mono-articular pain http://www.uptodate.com/contents/evaluation-of-the-adult-with-monoarticular-pain? source=search_result&search=elbow&selectedTitle=27%7E150

13. Goldenberg, D. L., Sexton, D. J., & Baron, E. L. (2010). Septic arthritis in adults. http://www.uptodate.com/contents/septic-arthritis-in-adults

14 Becker (2013) Clinical manifestations and diagnosis of gout http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-gout? source=search_result&search=gout&selectedTitle=2~143

15. Mandell, B. F. (2008). Clinical manifestations of hyperuricemia and gout. Cleveland Clinic journal of medicine, 75(Suppl 5), S5-S8. http://ccjm.org/content/75/Suppl_5/S5.full.pdf+html

16 Kane, D., Balint, P. V., Gibney, R., Bresnihan, B., & Sturrock, R. D. (2004). Differential diagnosis of calf pain with musculoskeletal ultrasound imaging. Annals of the rheumatic diseases, 63(1), 11-14. http://ard.bmj.com/content/63/1/11.full.pdf+html

17. Wells, P., Hirsh, J., Anderson, D., Lensing, A. A., Foster, G., Kearon, C., ... & Ginsberg, J. (1995). Accuracy of clinical assessment of deep-vein thrombosis. The Lancet, 345(8961), 1326-1330.

18. http://archinte.jamanetwork.com/article.aspx?articleid=484970 Module 1.6: Musculoskeletal Conditions – Knee 66 Anderson, D. R., Wells, P. S., Stiell, I., MacLeod, B., Simms, M., Gray, L., ... & Flowerdew, G. (1999). Thrombosis in the emergency department: use of a clinical diagnosis model to safely avoid the need for urgent radiological investigation. Archives of internal medicine, 159(5), 477.

19. Wells, P. S., Anderson, D. R., Rodger, M., Stiell, I., Dreyer, J. F., Barnes, D., ... & Kovacs, M. J. (2001). Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Annals of Internal Medicine, 135(2), 98-107.http://annals.org/article.aspx?articleid=714645&atab=11

20. Goldenberg et al (2013) Septic Arthritis in Adults http://www.uptodate.com/contents/septic-arthritis-in-adults

Module 1.6: Musculoskeletal Conditions – Knee 67 Theme 3 Common investigations specific to knee injuries/conditions

1. Discuss the common investigations available and specific to knee injuries

KNOWLEDGE:  When would you consider ordering and x-ray for a patient with a knee injury or knee pain?1,8  What special views may you require8  What are the Ottawa Knee rules and what is the relevance of these? 4  When would a CT be indicated for a patient with a knee injury or knee pain? 1,8  When would an MRI be indicated for a patient with a knee injury or knee pain? 1,8  When would an ultrasound be indicated for a patient with a knee injury or knee pain? 8  When would pathology tests be required for a patient with a knee injury or knee pain?7  When is it appropriate for an aspiration of a knee to be conducted?7,10

CLINICAL APPLICATION: Website – interactive quiz http://www.med-ed.virginia.edu/courses/rad/ext/index.html http://www.radiologyassistant.nl/en/p42daafe92b280/knee-meniscal-pathology-1.html http://www.radiologyassistant.nl/en/p4b98adddb76db/knee-meniscal-pathology-2.html http://www.radiologyassistant.nl/en/p42764e8fe927e/knee-non-meniscal- pathology.html http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x- ray_trauma_lower_limb/knee_x-ray.html

RECOMMENDED RESOURCES (refer to the Radiology Module)

1. Anderson J & Read J (2008) Atlas of Imaging in Sports Medicine. 2nd Edition. McGraw-Hill.

4. Government of Western Australia Department of Health (2012) Diagnostic imaging pathways – Musculoskeletal/trauma http://www.imagingpathways.health.wa.gov.au/index.php/imagingpathways/musculoskeletal-trauma

Module 1.6: Musculoskeletal Conditions – Knee 68 5. Raby, N, Berman, L & de Lacey, G (2005) Accident and Emergency Radiology: A Survival Guide. 2nd Edition. Elsevier Saunders, Philadelphia.

6. Suffolk Orthopaedic & Sports Injury Clinic (Date Unknown) Guidelines for the management of acute knee injuries

Up To Date 7. Helfgott, S. M. (2013) Evaluation of the adult with monoarticular pain http://www.uptodate.com/contents/evaluation-of-the-adult-with-monoarticular-pain? source=search_result&search=joint+infection&selectedTitle=5%7E150

8. Jude, C & Modaressi, S (2012) Radiologic evaluation of the acutely painful knee in adults http://www.uptodate.com/contents/radiologic-evaluation-of-the-acutely-painful-knee-in- adults?source=search_result&search=actue+knee+injuries&selectedTitle=9~35

9. Jude, C & Modaressi, S (2012) Radiologic evaluation of the chronically painful knee in adults http://www.uptodate.com/contents/radiologic-evaluation-of-the-chronically-painful- knee-in-adults? source=search_result&search=radiologic+evaluation+of+knee&selectedTitle=1~150

10. Zuber, T. J. (2002). Knee joint aspiration and injection. American family physician, 66(8), 1497.http://www.aafp.org/afp/2002/1015/p1497.pdf

Module 1.6: Musculoskeletal Conditions – Knee 69 Theme 4 Common pharmacology specific to knee injuries/conditions

1. Discuss and compare the common pharmacological and non-pharmacological agents specific to knee injuries KNOWLEDGE:  How would you go about the prescription of and administration of relevant medication for patients with knee injuries?

o What is appropriate for pain control in the patient with minor knee injury/conditions? o What is appropriate for pain control in the patient with moderate to severe pain with knee injuries/conditions?  Anti-inflammatory agents6, 7, 8,10,11 o What and when is it appropriate to use anti-inflammatory agents?  Antibiotics9 o When is antibiotics indicated for knee injuries /conditions and why? o When would you consider the administration of an ADT vaccine?14,15 o What is the pharmacological management of acute gout?12,13

RECOMMENDED RESOURCES (refer to the Pharmacology Module)

1. Australian and New Zealand College of Anesthetists and Faculty of Pain Medicine (2006) Managing Acute Pain A Guide for Patients. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/managingacutepain.pdf

6. Macintyre, P, Scott, D, Schug, S, Visser, E, & Walker, S (2010) Acute Pain Management: Scientific Evidence, Third Edition, Australian and New Zealand College of Anesthetists and Faculty of Pain Medicine. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp104_3.pdf\

Module 1.6: Musculoskeletal Conditions – Knee 8. Vargus Schaffer (2010) Is the WHO analgesic ladder still valid? Canadian Family 70 Physician. 56, 6, p514-517. http://www.cfp.ca/content/56/6/514.full.pdf+html

Up-to-date 9. Helfgott, S. M. (2013) Evaluation of the adult with monoarticular pain Theme 5 Management of specific to knee injuries/conditions

1. Discuss the common management principles specific to knee injuries/conditions in the context of the ED setting 2. Present patient education and health promotion aspects specific to knee injuries ASSUMED KNOWLEDGE  Safe prescription of gait aids  Application of ZKS with appropriate patient education  Describe the first aid management of knee injuries KNOWLEDGE:  What types of injuries to the knee would require the involvement of the Medical team in the ED?34  What types of injuries to the knee would require the involvement of the Orthopaedic team in the ED?12,13  What types of knee injuries or knee pain presentations would require referral for future involvement of the Orthopaedic team?  Describe how your management would alter if the patient was on anticoagulants2, 4, 8, 18  Describe the signs, symptoms and management of 1, 3, 5-7, 9-17, 19-33 o Collateral ligament sprain (Grades 1-3) o Acute meniscal injury including discussion on when the Orthopaedic team would need to be consulted o Chronic meniscal injury including discussion on when the Orthopaedic team would need to be consulted o Cruciate ligament injury o Acute posterolateral corner of the knee injury o Tibial plateau #. o Tibial tubercle #. o Quadriceps tendon rupture. o Patella tendon rupture. o Patella fracture, including what types of patella fracture would require the opinion of the Orthopaedic team o Patella dislocation. o Bursitis at the knee (prepatellar or infrapatellar) o Septic knee o Gout of the knee o OA of the knee o Patellofemoral pain of the knee  Describe the types of splints or casts used for the management of knee injuries.  Discuss the following types of casts and the indications of use o Above knee POP o ZKS  Discuss patient education required for o Plaster of Paris care o Follow up plan CLINICAL APPLICATION: Module 1.6: Musculoskeletal Conditions – Knee 71 Click here to view reference : Splinting of musculoskeletal injuries

1. Bradish, C, Coakley, G, Field, M, Jones, A, Kingsley, G, Matthews, C, McLachlan, A, Mohammed, R, Phillips, M & Weston, V (2006) Guidelines for management of the hot swollen joints in adults. Rheumatology. 45, p1039-1041. http://www.ncbi.nlm.nih.gov/pubmed/16829534

2. Chan, T. Y. (1005). Adverse interactions between warfarin and nonsteroidal anti-inflammatory drugs: mechanisms, clinical significance and avoidance. Ann Pharmacother 29(12): 1274-83. http://www.ncbi.nlm.nih.gov/pubmed/8672833

3. Cochrane Database osteoarthritis guidelines (2008) http://www.cochrane.org.au/files/OAGuidelines_key210708_.pdf

5. Egol, K, Koval, K & Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins

6. Fagan H, (2005). Approach to the Patient with Acute Swollen/Painful Joint. Clinics in Family practice. 7(2), p305-319.

7. Fitzgerald et al (2012) 2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis care and research. 64, (10), p1431-1446. http://onlinelibrary.wiley.com/doi/10.1002/acr.21772/abstract;jsessionid= D41FFEDCA32CC34BD292A81897A0A323.d03t01

8. Hay, S. M., Allen, M. J. & Barnes, M. R. (1002). Acute compartment syndrome resulting from anticoagulation treatment, BMJ, 305:1474-5.

9. Monu, J & Pope, T (2004) Gout: a Clinical and Radiologic Review. Radiologic clinics of North America. 42, (1), p169-184. http://www.ncbi.nlm.nih.gov/pubmed/15049530

10. Jordan, K. M. et al (2003): EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeuetic Trials (ESCISIT) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1754382/pdf/v062p01145.pdf

11. Lohr, K (2012) Bursitis. Medscape reference. http://emedicine.medscape.com/article/822693-overview

12. McRae, R (2004). Clinical Orthopedic Examination. 4th Edition. Churchill Livingstone, Sydney.

Module 1.6: Musculoskeletal Conditions – Knee 72 13. McRae, R & Esser, M (2002) Practical Fracture Treatment. 4th Edition. Churchill Livingstone, Edinburgh.

14. New Zealand guidelines group (2003) Diagnosis and management of soft tissue knee injuries: Internal derangements. http://www.health.govt.nz/publication/diagnosis-and-management-soft- tissue-knee-injuries-internal-derangements

15. NHMRC Guidelines for the non surgical management of hip and knee osteoarthritis management (2009) http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp117- hip-knee-osteoarthritis.pdf

16. OARSI guidelines for hip and knee osteoarthritis http://www.oarsi.org/pdfs/oarsi_recommendations_for_management_of_hip_and_knee_oa.pdf

17. Purcell, D. (2010) Minor Injuries A Clinical Guide. Churchill Livingstone Elsevier UK.

18. Riley, S. A. & Spencer, G. E. (1987). Destructive monoarticular arthritis secondary to anticoagulant therapy. Clin Orthop Relat Res. 223: 247-51.

Up To Date 19. Anderson, B (2013) Meniscal injury of the knee http://www.uptodate.com/contents/meniscal-injury-of-the-knee? source=search_result&search=actue+knee+injuries&selectedTitle=8~35

20. Anderson, B (2012) Knee bursitis http://www.uptodate.com/contents/knee-bursitis? source=search_result&search=knee+injuries&selectedTitle=23~35

21. Blount, J (2012) Patella fractures http://www.uptodate.com/contents/patella-fractures? detectedLanguage=en&source=search_result&search =patella+fracture&selected Title=1%7E3&provider=noProvider

22. Bothner, J & Moore, B (2013) Recognition and initial management of lateral patella dislocations http://www.uptodate.com/contents/recognition-and-initial-management-of-lateral-patellar- dislocations

23. Dexter, W (2013) Medial collateral ligament injury of the knee http://www.uptodate.com/contents/medial-collateral-ligament-injury-of-the-knee? source=search_result&search=actue+knee+injuries&selectedTitle=7~35

24. Fields, K (2012) Fibular fractures http://www.uptodate.com/contents/fibular-fractures? source=search_result&search=knee+injuries&selectedTitle=21~35

25. Fields, K (2012) Overview of tibial fractures http://www.uptodate.com/contents/overview-of-tibial-fractures-in-adults? source=search_result&search=knee+injuries&selectedTitle=28~35 Module 1.6: Musculoskeletal Conditions – Knee 73 26. Fields, K (2012) Proximal tibial fractures in adults http://www.uptodate.com/contents/proximal-tibial-fractures-in-adults? source=search_result&search=actue+knee+injuries&selectedTitle=14~35

27. Friedberg, R (2013) Anterior cruciate ligament injury http://www.uptodate.com/contents/anterior-cruciate-ligament-injury? source=search_result&search=actue+knee+injuries&selectedTitle=11~35

28. Hergenroeder, A (2012) Treatment of knee injuries in the young athlete http://www.uptodate.com/contents/treatment-of-knee-injuries-in-the-young-athlete? source=search_result&search=knee+injuries&selectedTitle=3~35

29. Hergenroeder, A. (2012) Causes of chronic knee pain in the young athlete http://www.uptodate.com/contents/causes-of-chronic-knee-pain-in-the-young-athlete? detectedLanguage=en&source=search_result&search=chronic+knee+young&selected Title=1%7E150&provider=noProvider

30. Kalunian, K. C. (2013) Clinical manifestations of osteoarthritis http://www.uptodate.com/contents/clinical-manifestations-of-osteoarthritis? detectedLanguage=en&source=search_result&search=OA&selectedTitle= 3%7E150&provider=noProvider

31. Kalunian, K. C. (2013) Diagnosis and classification of osteoarthritis http://www.uptodate.com/contents/diagnosis-and-classification-of-osteoarthritis? source=related_link

32. Kalunian, K. C. (2013) Risk factors and possible causes for osteoarthritis http://www.uptodate.com/contents/risk-factors-for-and-possible-causes-of-osteoarthritis? detectedLanguage=en&source=search_result&search=OA&selectedTitle=4%7E150& provider=noProvider

33. Mulvaney, S & O’Connor, F (2013) Patellofemoral pain syndrome http://www.uptodate.com/contents/patellofemoral-pain-syndrome? source=search_result&search=knee+injuries&selectedTitle=12~35

34. Goldenberg, D. L., Sexton, D. J., & Baron, E. L. (2010). Septic arthritis in adults. http://www.uptodate.com/contents/septic-arthritis-in-adults

Module 1.6: Musculoskeletal Conditions – Knee 74 1.7: Ankle

Theme 1 History taking specific to ankle injuries/conditions

1. Identify the key principles of history taking of ankle injuries/condtions in the context of the ED Setting 2. Review the importance of mechanism of injury in ankle injuries/conditions 3. Differentiate early, presentations of the ankle that may require inter-disciplinary care and/or presentations of non-musculoskeletal origin 4. Formulate a preliminary differential diagnoses KNOWLEDGE:  What group of patients are predisposed to ankle injuries and why?10  What medications may predispose patients to fractures and why?11  What medical conditions may predispose patients to present with ankle injuries?5  What is the importance of determining if there are any associated injuries? 5  What are the most common mechanisms of injury for acute ankle injuries? 5  What is the relevance/importance of establishing of the mechanism of injury for acute ankle injuries? 5  What is the relevance of establishing any sensations felt at the time of injury (ie pop, crack)? 5  What is the relevance of determining the type of activity which led to the ankle injury? 5  What is the relevance of determining the patient’s ability to weight bear at the time of injury? 5  What is the relevance of determining the neurovascular status of the ankle? 5  What key information is important to assess for red flags? 4  What key information is important to determine in the setting of chronic ankle pain? 5  What key information is important to in the setting of atraumatic ankle pain? 5,6,7  What key information in a patient’s past history is important for patients presenting with ankle pain/injury? 5  What key information in a patient’s medication history is important for patients presenting with ankle pain? 5,9  What key areas of social history are important for patient’s presenting with ankle pain/injury?5  What is the relevance of determining any intervention to date? 5  What is the relevance of determining the compensable status or health insurance status of the patient?  What is the relevance of determining the last intake of food or fluids?8

Module 1: 7Musculoskeletal Conditions – Ankle 75 1. Egol, K, Koval, K & Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins

2. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. The ankle

Up-to-date 5. Chorley, Powers, C.A. (2013). Clinical features and management of ankle pain in young adults http://www.uptodate.com/contents/clinical-features-and-management-of-ankle- pain-in-the-young-athlete? source=search_result&search=ankle+pain&selectedTitle=1%7E39

6.Kalunian, K (2012) Clincal manifestations of osteoarthritis http://www.uptodate.com/contents/clinical-manifestations-of-osteoarthritis? source=search_result&search=ankle+osteoarthritis&selectedTitle=2~150

7. Maini, R & Venables, P (2012) Diagnosis and differential diagnosis of rheumatoid arthritis http://www.uptodate.com/contents/diagnosis-and-differential-diagnosis-of- rheumatoid-arthritis?source=search_result&search=rheumatoid&selectedTitle=1~150

8. Smeton G, V et al (2014) Pre-operative medical evaluation of the healthy patient http://www.uptodate.com/contents/preoperative-medical-evaluation-of-the-healthy- patient? source=search_result&search=preoperative+evaluation&selectedTitle=2%7E150

10. Beynnon, B. D., Murphy, D. F., & Alosa, D. M. (2002). Predictive factors for lateral ankle sprains: a literature review. Journal of athletic training, 37(4), 376. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC164368/pdf/attr_37_04_0376.pdf

11. Van Staa, T. P., Leufkens, H. G. M., Abenhaim, L., Zhang, B., & Cooper, C. (2000). Use of oral corticosteroids and risk of fractures. Journal of Bone and Mineral Research, 15(6), 993-1000. http://onlinelibrary.wiley.com/doi/10.1359/jbmr.2000.15.6.993/pdf

Module 1: 7Musculoskeletal Conditions – Ankle 76 Theme 2 Focused clinical assessment specific to ankle injuries/conditions

1. Identify the key aspects in clinical assessment specific to ankle injuries/conditions in the context of the ED setting 2. Formulate key findings to support/refute preliminary differential diagnosis? 3. Differentiate early, presentations of the ankle of non musculoskeletal origin that may require inter-disciplinary care ASSUMED KNOWLEDGE:  Anatomy of the ankle and lower leg: bones, joints, muscles, tendons, ligaments.  ROM assessment of the ankle.  Ligament integrity assessment of the ankle.  Tendon assessment of the ankle.  Strength assessment of the ankle.  Palpation of the bones, tendons, ligaments, joints.

KNOWLEDGE:  Name the nerve supply of the ankle, foot and lower leg.3  Name the vascular supply of the lower leg, ankle and foot. 3  How would you determine the neurovascular status of the lower leg? 5  Describe the relevance of any local skin changes / open wounds to the ankle.2,12,13,14  Describe how the presence and location of swelling relates to the type of injury1,11  Describe what your assessment might include if your patient is a diabetic?10

7. Purcell, D (2010) Minor Injuries A Clinical Guide. Churchill Livingstone Elsevier: UK Module 1: 7Musculoskeletal Conditions – Ankle 77 8. Zuluga, M (1995) Sports Physiotherapy – Applied Science and Practice. Churchill Livingstone, Melbourne.

Up To Date 9. Chorley, J & Powers, C (2012) Evaluation of foot and ankle pain in the young athlete http://www.uptodate.com/contents/evaluation-of-foot-and-ankle-pain-in-the-young- athlete?source=search_result&search=foot+and+ankle+pain&selectedTitle=1~150

Module 1: 7Musculoskeletal Conditions – Ankle 78 Theme 3 Common investigations specific to ankle injuries/conditions

1. Discuss the common investigations available specific to ankle injuries

KNOWLEDGE:  When would you consider ordering an x-ray for a patient with an ankle injury?1-3, 5,8  What other anatomical areas may you need to x-ray with an acute ankle injury and why?  What are the Ottawa Foot/Ankle rules and what is the relevance of these?1,9  When would a CT be indicated for a patient with an ankle injury?1  When would an ultrasound be indicated for a patient with an ankle injury?1  When would pathology tests be required for a patient with an ankle injury?6,7

Website (interactive radiology tutorial and quiz): http://www.med-ed.virginia.edu/courses/rad/ext/index.html

WA Diagnostic Imaging Pathways – Ankle injury http://www.imagingpathways.health.wa.gov.au/index.php/imagingpathways/musculoskeletal-trauma/bone-and-joint-trauma/ankle-injury

Radiology Masterclass – ankle http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x- ray_trauma_lower_limb/ankle_fracture_x-ray.html

RECOMMENDED RESOURCES (Refer to Radiology Module)

1. Anderson, J & Read, J (2008) Atlas of Imaging in Sports Medicine. 2nd Edition. McGraw-Hill.

2. Begg, J (2005) Accident and Emergency X-rays Made Easy. Churchill Livingstone.

4. Evans, J & Schucany, W (2006) Radiological evaluation of a high ankle sprain Proceedings (Baylor University Medical Centre). 19, (4), p402–405. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1618742/? report=reader#__ffn_sectitle Module 1: 7Musculoskeletal Conditions – Ankle 79 5. Raby, N, Berman, L & de Lacey, G.(2005) Accident and Emergency Radiology: A Survival Guide. 2nd Edition. Elsevier Saunders, Philadelphia.

Up-to-date 6. Helfgott, S. M. (2013) Evaluation of the adult with monoarticular pain http://www.uptodate.com/contents/evaluation-of-the-adult-with-monoarticular- pain?source=search_result&search=joint+infection&selectedTitle=5%7E150

7.Baccei, S, Kim, C & Weissman, B (2013) Imaging techniques for evaluation of the painful joint http://www.uptodate.com/contents/diagnostic-imaging-of-joint-pain? source=see_link

8. O'Keeffe, D., Nicholson, D. A., Driscoll, P. A., & Marsh, D. (1994). ABC of emergency radiology. The ankle. BMJ: British Medical Journal, 308(6924), 331. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2539279/pdf/bmj00425-0053.pdf

9 Bachmann, L. M., Kolb, E., Koller, M. T., Steurer, J., & Riet, G. T. (2003). Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. Bmj, 326(7386), 417. http://www.bmj.com/content/326/7386/417.pdf%2Bhtml

Module 1: 7Musculoskeletal Conditions – Ankle 80 Theme 4 Common pharmacology specific to ankle injuries/conditions

1. Discuss and compare the common pharmacological and non-pharmacological agents specific to ankle injuries/conditions

KNOWLEDGE:  Analgesic agents1-4, 6-8 o What is appropriate for pain control in the patient with minor ankle pain/injury? o What is appropriate for pain control in the patient with moderate to severe pain with ankle pain/injury?  Anti-inflammatory agents6, 7, 8,10,11 o What and when is it appropriate to use anti-inflammatory agents?  Antibiotics9 o When is antibiotics indicated for ankle pain/injury and why? o When would you consider the administration of an ADT vaccine?12,13

RECOMMENDED RESOURCES (Refer to Pharmacology Module)

6. Macintyre, P, Scott, D, Schug, S, Visser, E, & Walker, S (2010) Acute Pain Management: Scientific Evidence, Third Edition, Australian and New Zealand College of Anesthetists and Faculty of Pain Medicine. Module 1: 7Musculoskeletal Conditions – Ankle 81 http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp104_3.pdf\

10.Lexicomp (2013) Ibuprofen: Drug information http://www.uptodate.com/contents/ibuprofen-drug-information? source=see_link&utdPopup=true

13. eTG complete (2013) Therapeutic guidelines: Tetanus http://online.tg.org.au/ip/

Refer to Pharmacology Module

Module 1: 7Musculoskeletal Conditions – Ankle 82 Theme 5 Management of ankle injuries/conditions

1. Discuss the common management principles specific to ankle injuries/conditions in the context of the ED setting 2. Present what patient education and health promotion aspects specific to ankle injuries/conditions are required ASSUMED KNOWLEDGE  Safe prescription of gait aids  Management of a Grade 1 or 2 lateral ligament sprain  RICE First aid management KNOWLEDGE:  What type of ankle presentation would require the involvement of the Orthopaedic team at the time of assessment?6,7  What type of ankle presentation would require referral to the Orthopaedic team for assessment at a future date?6,7  Describe the signs, symptoms and management of 1, 8-9 o Grade 3 lateral ligament sprain. o Syndesmosis injury. o Talar dome injury. o Maisonneuve fracture. o Achilles tendon rupture o Achillies tendon partial tear o Malleolar fractures (single, bi and tri)  Describe the Weber classification of ankle fractures and the management of each.4  Discuss the following types of casts and the indications of use12 o Below knee backslab o Full below knee cast o CAM boot  Describe how your management of an ankle injury will vary if your patient is: o Diabetic11 o On anti-coagulants2, 4 o Mechanism was a crush injury13  Discuss patient education required on discharge for o CAM boot care o Plaster of Paris care o Follow up plan  When would IV fluids be indicated for a patient with an ankle injury?14  When would an ECG be indicated for a patient with an ankle injury?14

 Attend plastering workshop with Orthotics  Attend CAM boot fitting workshop with Orthotics  Read UpToDate : splinting of musculoskeletal injuries:

Module 1: 7Musculoskeletal Conditions – Ankle 83 http://www.uptodate.com/contents/splinting-of-musculoskeletal-injuries? source=search_result&search=plaster+of+paris&selectedTitle=8~49  Refer to plastering module  Demonstrate skill in - Application of below knee backslab - Application of below knee volar slab - Application of CAM boot

Refer to the Plaster Module and Fracture Management Module

1. Brukner, P & Slimmon, D (2010) Sports ankle injuries Assessment and management. Australian family physician. http://www.racgp.org.au/afp/201001/201001slimmon.pdf

5. McRae, R (2004) Clinical Orthopedic Examination. 4th Edition. Churchill Livingstone, Sydney.

7. Purcell, D. (2010) Minor Injuries A Clinical Guide. Churchill Livingstone Elsevier UK

Up to Date 8. Eiff, P & Koehler, S (2013) Overview of ankle fractures in adults http://www.uptodate.com/contents/overview-of-ankle-fractures-in-adults? detectedLanguage=en&source=search_result&search=ankle+fractures&selectedTitle=1% 7E15&provider=noProvider

9. Ham, P & Maughan, K (2013) Achilles tendinopathy and tendon rupture http://www.uptodate.com/contents/achilles-tendinopathy-and-tendon-rupture? detectedLanguage=en&source=search_result&search=achilles+tendonopathy&selectedTi tle=1%7E96&provider=noProvider

10. Hammerberg, M & Stracciolini, A (2013) Acute compartment syndrome of the extremities Module 1: 7Musculoskeletal Conditions – Ankle 84 http://www.uptodate.com/contents/acute-compartment-syndrome-of-the-extremities? source=search_result&search=compartment+syndrome+leg&selectedTitle=1~150

11. McCulloch, D (2012) Evaluation of the diabetic foot http://www.uptodate.com/contents/evaluation-of-the-diabetic-foot? source=search_result&search=acute+injuries+in+the+diabetic+patient&selectedTitle=17 ~150

12. Kronfol, R (2012)Splinting of musculoskeletal injuries http://www.uptodate.com/contents/splinting-of-musculoskeletal-injuries? source=search_result&selectedTitle=18%7E150

13. McQueen, M. M., & Gaston, P. (2000). Acute compartment syndrome WHO IS AT RISK?. Journal of Bone & Joint Surgery, British Volume, 82(2), 200-203. http://www.bjj.boneandjoint.org.uk/content/82-B/2/200.short

Module 1: 7Musculoskeletal Conditions – Ankle 85 1.8: Foot

Theme 1 History taking specific to foot injuries/conditions

1. Identify the key principles of history taking specific to foot injuries/conditions in the context of the ED setting 2. Review the importance of mechanism of injury to foot injuries/conditions 3. Differentiate early, presentations of the foot that may require inter-disciplinary care and/or presentations of non-musculoskeletal origin 4. Formulate a preliminary differential diagnoses KNOWLEDGE:  What group of patients are predisposed to foot fractures and why?  What medications may predispose patients to fractures and why?13  What medical conditions may predispose patients to present with foot injuries?  What is the importance of determining if there are any associated injuries?2  What are the most common mechanisms of injury for acute foot fractures?6  What is the relevance/importance of establishing of the mechanism of injury for acute foot injuries? 6,12  What is the significance of a foot injury sustained from a fall from a height >1m?2,11  What mechanisms would suggest clearing other regions of the body?2,11  What is the relevance of establishing any sensations felt at the time of injury (ie pop, crack)? 6  What is the relevance of determining the type of activity which led to the foot injury? 6  What is the relevance of determining the patient’s ability to weight bear at the time of injury? 6  What is the relevance of determining the neurovascular status of the foot? 6  What key information is important to assess for red flags?4  What key information is important to determine in the setting of chronic foot pain? 6,5  What key information is important to determine in the setting of atraumatic foot pain? 6,5,7,10  What key information of medical history is important for patient’s presenting with foot pain/history? 6,9  What key areas of social history are important for patient’s presenting with foot pain/injury? 6  What is the relevance of determining any intervention to date?  What is the relevance of determining the compensable status or health insurance status of the patient?  What is the relevance of determining the first aid/pre hospital treatment?8  What is the relevance of determining the last intake of food or fluids?8 RECOMMENDED RESOURCES

1. Egol, K, Koval, K & Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott

Module 1.8: Musculoskeletal Conditions – Foot 86 Williams and Wilkins.

2. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier.

Up to Date 5. Becker, M (2012) Clinical manifestations and diagnosis of gout http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-gout? source=search_result&search=gout&selectedTitle=2~150

6. Chorley, J & Powers, C (2012) Evaluation of foot and ankle pain in the young athlete http://www.uptodate.com/contents/evaluation-of-foot-and-ankle-pain-in-the-young- athlete?source=search_result&search=foot+and+ankle+pain&selectedTitle=1~150

7. Goldenberg, D & Sexton, D (2013) Septic arthritis in adults http://www.uptodate.com/contents/septic-arthritis-in-adults? source=search_result&search=septic+arthritis&selectedTitle=1~150

10. Mandell, B. F. (2008). Clinical manifestations of hyperuricemia and gout. Cleveland Clinic journal of medicine, 75(Suppl 5), S5-S8. http://ccjm.org/content/75/Suppl_5/S5.full.pdf+html

11. Mitchell, M. J., McKinley, J. C., & Robinson, C. M. (2009). The epidemiology of calcaneal fractures. The Foot, 19(4), 197-200. http://www.ncbi.nlm.nih.gov/pubmed/20307476

12. Norkus, S. A., & Floyd, R. T. (2001). The anatomy and mechanisms of syndesmotic ankle sprains. Journal of athletic training, 36(1), 68. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC155405/pdf/attr_36_01_0068.pdf

13. Van Staa, T. P., Leufkens, H. G. M., Abenhaim, L., Zhang, B., & Cooper, C. (2000). Use of oral corticosteroids and risk of fractures. Journal of Bone and Mineral Research, 15(6), 993-1000.http://onlinelibrary.wiley.com/doi/10.1359/jbmr.2000.15.6.993/pdf Module 1.8: Musculoskeletal Conditions – Foot 87 Theme 2 Focused clinical assessment specific to foot injuries/conditions

1. Identify the key aspects in clinical assessment specific to foot injuries/conditions in the context of the ED setting 2. Formulate key findings to support/refute preliminary differential diagnosis? 3. Differentiate early, presentations of the foot of non musculoskeletal origin that may require inter-disciplinary care

ASSUMED KNOWLEDGE:  Anatomy of the foot: bones, joints, muscles, tendons, ligaments.  ROM assessment of the foot.  Ligament integrity assessment of the foot.  Tendon assessment of the foot.  Strength assessment of the foot.  Palpation of the bones, tendons, ligaments, joints.

KNOWLEDGE:  Name the nerve supply of the foot. 3  Name the vascular supply of the foot. 3  How would you determine the neurovascular status of the foot? 5  Describe the relevance of any local skin changes / open wounds to the foot13,14,15.  Describe what your assessment should include if the mechanism was a fall from a height >1m?6,17  Describe what your assessment should include if your patient is a diabetic? 10,12  What findings on assessment would warrant escalation for an immediate medical review?10,17  When would you need to take vital signs?15,12,13,16

2. Cameron P, Jelinek G, Kelly A, Murray L, Brown A, & Heyworth J, (2004) Adult Emergency Medicine. Churchill Livingston, Sydney

3. Drake, R, Vogl, W & Mitchell, A (2005) Gray’s Anatomy for Students. Churchill Livingstone Elsevier. Chapter 7,

5. Judge, NL (2007) Neurovascular assessment. Nursing Standard. Vol 21, No 45, 39- 44

Module 1.8: Musculoskeletal Conditions – Foot 88 http://www.snjourney.com/ClinicalInfo/Systems/PDF/NeuroVas%20Assessment.pdf

6. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier.

9. McRae, R & Esser, M (2002) Practical Fracture Treatment. 4th Edition. Churchill Livingstone, Edinburgh

Up To Date: 10. McCulloch, D (2012) Evaluation of the diabetic foot http://www.uptodate.com/contents/evaluation-of-the-diabetic-foot? source=search_result&search=acute+injuries+in+the+diabetic+ patient&selectedTitle=17~150

11. Chorley, J & Powers, C (2012) Evaluation of foot and ankle pain in the young athlete http://www.uptodate.com/contents/evaluation-of-foot-and-ankle-pain-in-the-young- athlete?source=search_result&search=foot+and+ankle+pain&selectedTitle=1~150

17. Hatch and Dean (2014) Calcaneus Fracture http://www.uptodate.com/contents/calcaneus-fractures

Module 1.8: Musculoskeletal Conditions – Foot 89 Theme 4 Common pharmacology specific to foot injuries/conditions

1. Discuss and compare the common pharmacological and non-pharmacological agents specific to foot injuries/conditions

KNOWLEDGE:  Analgesic agents1-4, 6-8 o What is appropriate for pain control in the patient with minor ankle pain/injury? o What is appropriate for pain control in the patient with moderate to severe pain with ankle pain/injury?  Anti-inflammatory agents5, 7, 8,10,11 o What and when is it appropriate to use anti-inflammatory agents?  Antibiotics10 o When is antibiotics indicated for ankle pain/injury and why?  When would you consider the administration of an ADT vaccine?13,14

 What medication is indicated for a patient with a working diagnosis of gout?9  RECOMMENDED RESOURCES (refer to Pharmacology Module)

1. Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2006) Managing Acute Pain A Guide for Patients. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/managingacutepain.pdf

2. Bryant, B., Knights, K (2011) Pharmacology for Health Professionals. 3rd edition. Mosby Module 1.8: Musculoskeletal Conditions – Foot 90 Elsevier. Chapter 15, Analgesics, p277-307/

6. Macintyre, P, Scott, D, Schug, S, Visser, E, & Walker, S (2010) Acute Pain Management: Scientific Evidence, Third Edition, Australian and New Zealand College of Anesthetists and Faculty of Pain Medicine. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp104_3.pdf

Up-to-date 9. Becker, M. A. (2013) Treatment of acute gout http://www.uptodate.com/contents/treatment-of-acute-gout? source=search_result&search=gout&selectedTitle=1%7E150

11. Lexicomp (2013) Ibuprofen: Drug information http://www.uptodate.com/contents/ibuprofen-drug-information? source=see_link&utdPopup=true

Module 1.8: Musculoskeletal Conditions – Foot 91 14. eTG complete (2013) Therapeutic guidelines: Tetanus http://online.tg.org.au/ip/

Module 1.8: Musculoskeletal Conditions – Foot 92 Theme 5 Management of foot injuries/conditions/

1. Discuss the common management principles specific to foot injuries/conditions in the context of the ED setting 2. Present what patient education and health promotion aspects of foot injuries/conditions is required in the ED

ASSUMED KNOWLEDGE:  Safe prescription of gait aids  First aid management of foot injuries

KNOWLEDGE:  What type of foot condition would require the involvement of the Orthopaedic team on the day of assessment?2  What type of foot condition would require referral to the Orthopaedic team for assessment at a later date?2  Describe the management of a foot injury without fracture seen on x-ray where the patient is weightbearing.  Describe the management of a foot injury without fracture seen on x-ray where the patient is non weightbearing.  Describe the signs, symptoms and management of1-15 o Acute Lisfranc injury. o Chronic Lisfranc injury. o Turf toe injury. o Acute Achilles tendon rupture. o Acute calf tear. What other medical conditions may mimic an actue calf tear? o Acute navicular fracture o Navicular stress fracture o Cuboid fracture o Undisplaced metatarsal fractures o Base of 5th metatarsal fracture o Minor avulsion fracture of the talus/type 1 talar neck fracture o Type 2, 3, and 4 talar neck fracture o Lateral process of the talus fracture o Calcaneal fracture including types of fracture, other body areas requiring consideration/clearing o Describe the types of base of 5th metatarsal fractures and their respective management regimes o Phalangeal fracture or dislocation o Gout in the foot/toe o Morton’s neuroma  Describe how your management of an ankle injury will vary if your patient is: o Diabetic15,16 o On anti-coagulants18,19 Module 1.8: Musculoskeletal Conditions – Foot 93 o Mechanism was a crush injury17  Describe the types of splints or casts used for the management of foot injuries  Discuss the following types of casts and the indications of use o Below knee backslab o Below knee volar slab o Full below knee cast o CAM boot  Discuss patient education required on discharge for follow up plan  Discuss when would IV fluids be indicated for a patient with a foot injury20  Discuss what referrals maybe indicated for a patient with a foot injury

CLINICAL APPLICATION:  Attend plastering workshop with Orthotics  Attend CAM boot fitting workshop with Orthotics  Read UpToDate : splinting of musculoskeletal injuries http://www.uptodate.com/contents/splinting-of-musculoskeletal-injuries? source=search_result&search=plaster+of+paris&selectedTitle=8~49  Demonstrate skill in - Buddy strapping toes - Application of below knee backslab - Application of below knee volar slab - Application of CAM boot  Refer to Fracture Management Module and Plastering Module

4. Purcell, D. (2010) Minor Injuries A Clinical Guide. Churchill Livingstone Elsevier UK. Chapter 4, The neck and upper limbs, p78-91.

5. Monu, J & Pope, T (2004) Gout: a Clinical and Radiologic Review. Radiologic Clinics of North America. 42, 1, 169-184. http://www.ncbi.nlm.nih.gov/pubmed/15049530

Up to Date: 6. Alsobrook, J & Hatch, R (2013) Proximal 5th metatarsal fractures http://www.uptodate.com/contents/proximal-fifth-metatarsal-fractures? source=search_result&search=5th+metatarsal+fractures&selectedTitle=1~150

Module 1.8: Musculoskeletal Conditions – Foot 94 7. Boutis, K (2013) Foot fractures (other than metatarsal or phalangeal) in children http://www.uptodate.com/contents/foot-fractures-other-than-metatarsal-or-phalangeal- in-children?source=see_link&anchor=H20#H20

8. Buchbinder, R (2013) Plantar fasciitis and other causes of heel pain http://www.uptodate.com/contents/plantar-fasciitis-and-other-causes-of-heel-pain

9. Clugston, J & Hatch, R (2012) Stress fractures of the metatarsal shaft http://www.uptodate.com/contents/stress-fractures-of-the-metatarsal-shaft? source=search_result&search=stress+fractures&selectedTitle=2~86

10. Chorley, J & Powers, C (2012) Clinical features and management of foot pain in the young athlete http://www.uptodate.com/contents/clinical-features-and-management-of-foot-pain-in- the-young-athlete?source=search_result&search=foot+pain&selectedTitle=1~52

11. Dossett, L. A., Riesel, J. N., Griffin, M. R. & Cotton, B. A. (2011). Prevalence and Implications of Preinjury Warfarin Use, an analysis of the National Trauma Databank, Arch Surg 146(5): 565-570.

12. Gravlee, J & Hatch, R (2013) Toe fractures in adults http://www.uptodate.com/contents/toe-fractures-in-adults? source=search_result&search=toe+fracture&selectedTitle=1~10

13. Gravlee, J & Hatch, R (2013) Sesamoid fractures of the foot http://www.uptodate.com/contents/sesamoid-fractures-of-the-foot? source=search_result&search=sesamoid+fractures&selectedTitle=1~5

14. Ham, P & Maughan, K (2013) Achilles tendinopathy and tendon rupture http://www.uptodate.com/contents/achilles-tendinopathy-and-tendon-rupture? detectedLanguage=en&source=search_result&search=achilles+tendonopathy &selectedTitle=1%7E96&provider=noProvider

15. McCulloch, D (2012) Evaluation of the diabetic foot http://www.uptodate.com/contents/evaluation-of-the-diabetic-foot? source=search_result&search=acute+injuries+in+the+diabetic+patient&selectedTitle=17~150

16. Hordon, L. D. (2013) Musculoskeletal complications in diabetes mellitus http://www.uptodate.com/contents/musculoskeletal-complications-in-diabetes-mellitus? source=search_result&search=diabetes+mellitus&selectedTitle=9%7E150

17.Hammerberg, M & Stracciolini, A (2013) Acute compartment syndrome of the extremities http://www.uptodate.com/contents/acute-compartment-syndrome-of-the-extremities? source=search_result&search=compartment+syndrome+leg&selectedTitle=1~150

18. Chan, T. Y. (1005). Adverse interactions between warfarin and nonsteroidal anti- inflammatory drugs: mechanisms, clinical significance and avoidance. Ann Pharmacother Module 1.8: Musculoskeletal Conditions – Foot 95 29(12): 1274-83. http://www.ncbi.nlm.nih.gov/pubmed/8672833

Module 1.8: Musculoskeletal Conditions – Foot 96 1.9: Cervical Spine

Theme 1 History taking for cervical spine pain & injury

1. Identify the key principles of history taking of cervical spine pain, conditions and injuries in the context of the ED setting 2. Review the importance of mechanism when injury has occurred 3. Differentiate early, presentations of cervical spine pain that maybe beyond the scope of the advanced musculoskeletal physiotherapist (eg high risk mechanisms or other red flag features), require inter-disciplinary care or presentations of non- musculoskeletal origin 4. Formulate a preliminary differential diagnoses 5. Outline the differences between the primary and secondary role in relation to spinal injury. 6. Perform a secondary consultation to a ‘dizzy’ patient cleared by medical staff for any sinister pathology ASSUMED KNOWLEDGE:  Inclusion/exclusion criteria for primary contact musculoskeletal physiotherapy role  Routine physiotherapy subjective assessment of the cervical spine, including upper cervical spine, 5 D’s, VBI testing  Dizziness subjective questioning (nb these patients would only be seen as secondary consultation )

KNOWLEDGE: Possible Red flag escalators (all significant cervical trauma should only be seen as a secondary consultation)  When obtaining a history discuss the implications of the following key areas and what associated questions may need to be asked to assess for red flags: 6-8, 10, 14, 15 o Mechanism of injury –direction of forces e.g. flexion, flexion-rotation, extension, vertical compression o Mechanism of spinal cord trauma- transection, compression, contusion, vascular injury o MVA details e.g . speed, direction of impact, use of seatbelts, o MBA/cyclist details e.g . damage to helmet, speed o Fall – from height (e.g. 1m, 3m, 5m) vs standing (force of impact) - Headstrike, loss of consciousness o Skin integrity (wounds) o Time of injury, ability to move arms/ legs post injury, o Mental status such as intoxicated at time of injury? o Limb symptoms such as numbness, pins and needles , ‘dead” arm or leg’, tingling, weakness, foot drop o Bladder bowel disturbance (both post injury and current)

Module 1.9: Musculoskeletal Conditions – Cervical spine 97 o Other sites of injury and potential for organs to be involved o head//thorax/scapula/lumbar spine/ pelvic/ upper or lower limb  What other key information is required to assess for red flags?4,20  What key information would suggest an upper motor neuron lesion/ cord compression or spinal syndrome? 6—10, 16  When one spinal fracture is present what else should you look for?17, 18  When is a spinal fracture classified as stable or unstable?17, 18  If a spinal fracture is suspected during history taken what action should be taken prior to proceeding with a clinical examination?17,18  What key information is required to assess for vascular insufficiency or carotid artery dissection?19  What key information is required to assess dizziness?5  What key information would you ask to differentiate cervicogenic headache from non-musculoskeletal causes in the ED setting?2

Other  What key information is required in the setting of chronic neck pain problems in the ED? 3,10  What key information in a patient’s past medical history is important in neck pain/injuries in the ED setting? 10  What key information in a patient’s medication history is important in neck pain/injuries in the ED setting? 10,21,22  What key information in a patient’s social history is important in neck pain/injuries in the ED setting?10  What is the relevance of determining the first aid/pre hospital treatment (where appropriate)?  What is the relevance of determining the compensable status or health insurance status of the patient?

1. Egol, K, Koval, K, & Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins. Chapter 9. The cervical spine.

2. Faragher, M (2009) Catastrophic and Sinister Headache in: Selvaratnum et al, Headache Orofacial Pain and Bruxism. Churchill Livingstone Elsevier. Chapter 2.

3. Goodman, C & Snyder, T (2013) Differential diagnosis for physiotherapists. 5th Ed. Saunders Elsevier. Chapter 14, Screening the head, neck and back, p546-604.

4. Greenhalgh, S & Selfe, J (2006) Red flags: A Guide To Identifying Serious Pathology of the Spine. Churchill Livingstone Elsevier.

5. Kerber, K (2009) Vertigo and Dizziness in the Emergency Department. Emergency

Module 1.9: Musculoskeletal Conditions – Cervical spine 98 medicine clinics of North America. 27, (1), p39-50.

6. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. The cervical spine. Chapter 3.

7. Purcell, D (2010) Minor Injuries A Clinical Guide. Churchill Livingstone Elsevier: UK. Chapter 4, The neck and upper limbs, p78-91.

8. Rosenfeld, J (2012) Practical Management of Head and Neck Injury. Elsevier Australia.

9. Clinical Knowledge summaries (2009) Neck pain – cervical radiculopathy. National institute for health and care excellence. http://www.cks.nhs.uk/neck_pain_cervical_radiculopathy/management/scenario_diagn osis/red_flags

Up to date 10. Anderson, B & Isaac, Z (2013) Evaluation of the patient with neck pain and cervical spine disorders http://www.uptodate.com/contents/evaluation-of-the-patient-with-neck-pain-and- cervical-spine-disorders? source=search_result&search=cervcal+spine&selectedTitle=1%7E150

11. Arcasoy, S, Jett, J & Schild, S (2013) Superior pulmonary sulcus (pancoast) tumors http://www.uptodate.com/contents/pancoasts-syndrome-and-superior-pulmonary- sulcus-tumors?source=search_result&search=pancoast&selectedTitle=1%7E39

12. Currier, B & Schur, P (2012) Cervical subluxation in rheumatoid arthritis http://www.uptodate.com/contents/cervical-subluxation-in-rheumatoid-arthritis? source=search_result&search=cervical+spine&selectedTitle=18%7E150

13. Cutrer, M (2013) Evaluation of the adult with headache in the emergency department http://www.uptodate.com/contents/evaluation-of-the-adult-with-headache-in-the- emergency-department? source=search_result&search=carotid+artery+dissection&selectedTitle=4%7E33

14. Decker, J & Hergenroeder, A (2012) Overview of musculoskeletal neck injuries in the young athlete http://www.uptodate.com/contents/overview-of-musculoskeletal-neck-injuries-in-the- young-athlete? source=search_result&search=cervical+spine+injury&selectedTitle=6%7E59

15. Decker, J & Hergenroeder, A (2013) Approach to the young athlete with neck pain or injury http://www.uptodate.com/contents/approach-to-the-young-athlete-with-neck-pain-or- injury?source=see_link

16. Decker, J & Hergenroeder, A (2012) Overview of cervical spinal cord and cervical peripheral nerve injuries in the young athlete Module 1.9: Musculoskeletal Conditions – Cervical spine 99 http://www.uptodate.com/contents/overview-of-cervical-spinal-cord-and-cervical- peripheral-nerve-injuries-in-the-young-athlete?source=see_link

17. Hockberger, R & Kaji, A (2012) Spinal column injuries in adults: Definitions, mechanisms and radiographs http://www.uptodate.com/contents/spinal-column-injuries-in-adults-definitions- mechanisms-and-radiographs? source=search_result&search=cervcal+spine&selectedTitle=4%7E150

18. Kockberger, R & Kaji, A (2013) Evaluation and acute management of cervical spinal column injuries in adults http://www.uptodate.com/contents/evaluation-and-acute-management-of-cervical- spinal-column-injuries-in-adults? source=search_result&search=cervical+spine&selectedTitle=2%7E150

19. Liebeskind, D & Saver, J (2013) Spontaneous cerebral and cervical artery dissection: clinical features and diagnosis http://www.uptodate.com/contents/spontaneous-cerebral-and-cervical-artery- dissection-clinical-features-and-diagnosis? source=search_result&search=carotid+artery+dissection&selectedTitle=1%7E33

20. Welch W,C, Smit D & Gerszter P,C (2013) Spinal Tumors http://www.uptodate.com/contents/spinal-cord-tumors

22. Van Staa, T. P., Leufkens, H. G. M., Abenhaim, L., Zhang, B., & Cooper, C. (2000). Use of oral corticosteroids and risk of fractures. Journal of Bone and Mineral Research, 15(6), 993-1000.http://onlinelibrary.wiley.com/doi/10.1359/jbmr.2000.15.6.993/pdf

Module 1.9: Musculoskeletal Conditions – Cervical spine 100 Theme 2 Focused clinical assessment of cervical spine pain & injury

1. Identify the key aspects in clinical assessment of cervical spine pain, conditions and injury in the ED setting 2. Formulate key findings to support/refute preliminary differential diagnosis? 3. Explain when not to examine or perform limited examination of the cervical spine. 4. Differentiate early, presentations of the spine of non musculoskeletal origin that may require inter-disciplinary care ASSUMED KNOWLEDGE  Anatomy of the cervical spine: bones, facet joints, discs including vertebral endplates, muscles, ligaments, and the different anatomy of the upper cervical spine compared to C3-7.  Anatomy of the nervous system including spinal cord, nerve roots, brachial plexus, peripheral nerves.  Routine physiotherapy objective assessment of the cervical spine including: o Upper limb neurological assessment of lower motor neurone including dermatomes, myotomes, tendon reflexes; and assessment of upper motor neuron lesion including Babinski sign, clonus, Hoffman’s sign, spasticity, hyperreflexia, ) o Testing of neural dynamics eg passive neck flexion, ULTT, Slump o Shoulder joint screening o Palpatory assessment o Assessment of the dizzy patient o Assessment of vascular insufficiency in the cervical spine o Testing for thoracic outlet syndrome

KNOWLEDGE:  Describe the anatomy of the vascular structures in the neck including vertebrobasilar system and carotids, including common sites of entrapment4  Describe classification of spinal column injuries in the cervical spine and common fractures and dislocations in the cervical spine region, including method of injury and clinical signs and symptoms5, 14  Describe common ligamentous injuries and SCIWORA (spinal cord injury without radiographic abnormality), including method of injury and clinical signs and symptoms.12, 13  In the setting of suspected spinal column injury, discuss if you would examine the spine, and if so how you would examine the spine?12, 13  How would you assess the vascular status of the upper limbs?11  How would you assess for carotid artery dissection if this was suspected?11  How would you assess for cervical cord compression if this were suspected?11  What is the relevance of any local skin changes / open wounds to the neck?11  When is an assessment of vital signs indicated?11  How you would differentiate musculoskeletal cervical spine pain from non musculoskeletal cervical spine back pain?10  How would you differentiate a peripheral neuropathy from a radiculopathy/ brachialgia when only upper limb symptoms are present?15 Module 1.9: Musculoskeletal Conditions – Cervical spine 101  What are the most common non-musculoskeletal presentations of cervical pain10 o What does your clinical assessment need to include if non-musculoskeletal causes are suspected? o Discuss cardiovascular, vascular, visceral and neurological causes o What findings you would you expect to see on assessment? o What action needs to be taken? (For example discuss cardiovascular, vascular, visceral, neurological causes)

1. Balster, S, Pizzari ,T & Watson, l (2009) Thoracic Outlet Syndrome part 1: clinical manifestations, differentiation and treatment pathways. Manual therapy. 14, p586-595.

3. Carlesso, L, Flynn, T, Hing, W, Kerry, R, Rivett, D & Rushton, A, (2012) International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention. International Federation of orthopaedic manipulative physical therapists. http://www.ifompt.com/site/ifompt/files/pdf/Standards%20Committee/Standards %20Committee%20Documents//IFOMPT%20Examination%20cervical%20spine %20doc%20September%202012%20definitive.pdf

5. Egol, K, Koval, K, & Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins. Chapters 8 and 9 General spine and Cervical spine.

6. Kerry, R, Taylor, A (2006) Cervical arterial dysfunction assessment and manual therapy. Manual Therapy. 11, p243–253. http://whitmorephysiotherapy.com/downloads/Level_3_Upper/Kerry %201%20vertebral%20artery.pdf

7. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. Chapter 3, The cervical spine.

Up to date 10. Anderson, B & Isaac, Z (2013) Evaluation of the patient with neck pain and cervical spine disorders http://www.uptodate.com/contents/evaluation-of-the-patient-with-neck-pain-and- cervical-spine-disorders? Module 1.9: Musculoskeletal Conditions – Cervical spine 102 source=search_result&search=cervical+spine&selectedTitle=1%7E150#H17

11. Decker, J & Hergenroeder, A (2013) Field care and evaluation of the young athlete with acute neck injury http://www.uptodate.com/contents/field-care-and-evaluation-of-the-young-athlete- with-acute-neck-injury? source=search_result&search=cervical+spine&selectedTitle=11%7E150

12. Eisen, A (2012) Anatomy and localization of spinal cord disorders http://www.uptodate.com/contents/anatomy-and-localization-of-spinal-cord- disorders?source=search_result&search=thoracic+spine&selectedTitle=3%7E150

13. Hansebout, R & Kachur, E (2013) Acute traumatic spinal cord injury http://www.uptodate.com/contents/acute-traumatic-spinal-cord-injury? source=search_result&search=cervical+spine&selectedTitle=9%7E150

14. Hockberger, R & Kaji, A (2012) Spinal column injuries in adults: Definitions, mechanisms and radiographs http://www.uptodate.com/contents/spinal-column-injuries-in-adults-definitions- mechanisms-and-radiographs? source=search_result&search=cervical+spine&selectedTitle=6%7E150

15. Kothari, M & Robinson, J (2013) Clinical features and diagnosis of cervical radiculopathy http://www.uptodate.com/contents/clinical-features-and-diagnosis-of-cervical- radiculopathy?source=search_result&search=cervical+spine&selectedTitle=10%7E150

Module 1.9: Musculoskeletal Conditions – Cervical spine 103 Theme 3 Common investigations for cervical spine pain, & injury

1. Discuss the common investigations for cervical spine pain, conditions and problems/injuries KNOWLEDGE:  When would an X-ray be indicated for a patient with a cervical spine injury? And which views?1,6,14  When would an X-ray be indicated for a patient with a cervical spine pain without history of trauma?1,7  When would a CT scan be indicated for a patient with cervical spine problem/injury?1,6, 7  When would an MRI be indicated for a patient with a cervical spine problem/ injury? 1,6, 7  When would blood investigations for a patient with a cervical spine problem/ injury be indicated?13,15  What are other investigations that may be indicated in a patient with cervical spin pain/ injury?

 Describe the normal x-ray of the cervical spine (lateral, A-P, oblique, open mouth and swimmers view) including appearances of atlas, axis and typical vertebrae C3-71,16  Review online Radiology interactive tutorials and quiz4,5,6,7,10,11, RECOMMENDED RESOURCES (refer to the Radiology Module)

1. Anderson, J & Read, J (2008) Atlas of Imaging in Sports Medicine. 2nd Edition. McGraw-Hill. Chapter 8.

3. Brison, R, Cass, D, Clement, C, De Maio, V, Dreyer, J, Eisenhauer, M, Greenberg, G, Laupacis, A, Lesiuk, H, MacPhail, I, McKnight, R, Morrison, L, Reardon, M, Stiell, I, Vandemheen, K, Verbeek, R, Wells, G & Worthington, J (2001) The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients. The Journal of the American Medical Association. 286, 15, 1841-8. http://www.emergencymedicine.utoronto.ca/Assets/EmergeMed+Digital+Assets/ Prehospital+Research/ Publications/JAMA.+2001+286%2815%29+1841-8.pdf

4. Flanders, A (2008) Spine – cervical injury. Radiology Assistant. http://www.radiologyassistant.nl/en/p49021535146c5/spine-cervical-injury.html

5. Gay, M, Kuntz, A, Lai, W, Norton, P & Yao, L (Date unknown) Skeletal Trauma Radiology. University of Virginia. http://www.med- Module 1.9: Musculoskeletal Conditions – Cervical spine 104 ed.virginia.edu/courses/rad/ext/index.html

6. Government of Western Australia Department of Health (2012) Diagnostic imaging pathways – Cervical spine injury http://www.imagingpathways.health.wa.gov.au/index.php/imagingpathways/musculoskeletal-trauma/bone-and-joint-trauma/cervical-spine-injury

7. Government of Western Australia Department of Health (2012) Diagnostic imaging pathways – Non traumatic neck pain http://www.imagingpathways.health.wa.gov.au/index.php/imagingpathways/musculoskeletal-trauma/musculoskeletal/non-traumatic-neck-pain

8. Hoffman, J, Mower, W, Todd, K, Wolfson, A & Zucker, M (2000) Validity of a Set of Clinical Criteria to Rule Out Injury to the Cervical Spine in Patients with Blunt Trauma. The New England Journal Of Medicine. 343, 2, p90-99. http://www.ncbi.nlm.nih.gov/pubmed/10891516

9. Raby, N, Berman, L & de Lacey, G (2005) Accident and Emergency Radiology: A Survival Guide 2nd edition. Elsevier Saunders.

10. Smithuis, R (2005) Disc Nomenclature. Radiology Assistant. http://www.radiologyassistant.nl/en/p423d18702d2bd/disc-nomenclature.html

11. Radiology Masterclass – axial skeleton http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_spinal/x- ray_fracture_start.html

Up to date 12. Hockberger, R & Kaji, A (2013) Evaluation and management of cervical spinal column injuries in adults http://www.uptodate.com/contents/evaluation-and-acute-management-of-cervical- spinal-column-injuries-in-adults? source=search_result&search=cervical+spine&selectedTitle=2%7E150

13. Sexton and Mac Donald (2013) Vertebral Osteomyelitis and Discitis http://www.uptodate.com/contents/vertebral-osteomyelitis-and-discitis

15. Anderson, B & Isaac, Z (2013) Evaluation of the patient with neck pain and cervical spine disorders http://www.uptodate.com/contents/evaluation-of-the-patient-with-neck-pain-and- cervical-spine-disorders? source=search_result&search=cervical+spine&selectedTitle=1%7E150#H17 Module 1.9: Musculoskeletal Conditions – Cervical spine 105 16. Driscoll, P. A., Ross, R., & Nicholson, D. A. (1993). ABC of emergency radiology. Cervical spine--I. BMJ: British Medical Journal, 307(6907), 785. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1696431/pdf/bmj00040-0045.pdf

Module 1.9: Musculoskeletal Conditions – Cervical spine 106 Theme 4 Common pharmacology for the management of cervical spine pain, & injury

1. Discuss and compare the common pharmacological agents for cervical spine problems/ injuries

KNOWLEDGE:  Analgesic agents1-4, 6-8 o What is appropriate for pain control in the patient with minor musculoskeletal cervical spine pain? o What is appropriate for pain control in the patient with moderate to severe pain with cervical spine injury/problem? o What is appropriate pain control for the patient with brachialgia/ neuropathic pain?  Anti-inflammatory agents6-8,10-11 o What and when is it appropriate to use anti-inflammatory agents?  Antibiotics12 o When would antibiotics indicated for cervical spine pain/injuries and why?  Muscle relaxants9 o When would muscle relaxants be indicated for cervical spine pain/ injuries and why, or why not? o When would neuropathic pain medication be indicated for cervical spine pain / injuries?

RECOMMENDED RESOURCES (Also refer to the Pharmacology module)

1. Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2006) Managing Acute Pain A Guide for Patients. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/managingacutepa in.pdf

4. eTG complete (2013) Therapeutic Guidelines (subscribed) http://online.tg.org.au/ip/ (search acute pain)

5. Hamilton, B, Milne, C, Orchard, J, & Paoloni, J (2009) Non-steroidal anti-

Module 1.9: Musculoskeletal Conditions – Cervical spine 107 inflammatory drugs (NSAIDs) in sports medicine. Guidelines for practical but sensible use. British Journal of Sports Medicine (subscribed). http://bjsm.bmj.com/content/early/2009/06/21/bjsm.2009.059980.full.pdf

Up to date 9. Anderson, B, Devine, J & Isaac, Z (2012) Treatment of neck pain http://www.uptodate.com/contents/treatment-of-neck-pain? source=search_result&search=cervical+spine&selectedTitle=7%7E150

10.Solomon, D (2012) NSAIDs: mechanism of action http://www.uptodate.com/contents/nsaids-mechanism-of-action? source=search_result&search=pharmacology&selectedTitle=5%7E150

Module 1.9: Musculoskeletal Conditions – Cervical spine 108 Theme 5 Management of cervical spine pain & injury

1. Discuss the common management principles for cervical spine pain, conditions, injury in the ED setting ASSUMED KNOWLEDGE:  Physiotherapy management of acute, sub-acute and chronic cervical spine and referred arm pain of a musculoskeletal origin KNOWLEDGE:  What type of cervical spine condition would require the involvement of the ED medical team?14  What type of cervical spine condition would require the involvement of the Orthopaedic or Neurosurgical team on the day of assessment?14  What type of cervical spine condition would require referral to the Orthopaedic or Neurosurgical team for assessment at a future date?14  How would you provide adequate pain control if required?  Describe how your management of a cervical spine injury will vary if your patient is: o Diabetic8 o On anti-coagulants15,16  Describe the signs, symptoms and management of 2-7, 9-13 o Stable fractures (secondary consult) o Acute wry neck o Cervical radiculopathy / brachialgia with and without neurological signs o Cervical canal stenosis with and without neurological signs o Cervicogenic headache o Thoracic outlet syndrome3,6 o Chronic neck pain with signs of centralized pain mechanisms o Acute neck pain with yellow flags o Suspected pathological fracture o Suspected discitis o Cervical muscle or facet joint sprain/strain o Whiplash injury or whiplash associated disorder  Discuss the patient education required for follow up care RECOMMENDED RESOURCES

1. Purcell, D (2010) Minor Injuries A Clinical Guide. Churchill Livingstone Elsevier, UK. Chapter 4, The neck and upper limbs, p78-91.

3. Watson, L, Balster, S & Pizzari, T (2009) Thoracic Outlet Syndrome Part 2: Conservative management of thoracic outlet. Manual Therapy journal. 15, 4, p305-314. http://www.manualtherapyjournal.com/article/S1356-689X%2810%2900038-

Module 1.9: Musculoskeletal Conditions – Cervical spine 109 X/abstract

Up to date: 4. Anderson, B, Devine, J & Isaac, Z (2012) Treatment of neck pain http://www.uptodate.com/contents/treatment-of-neck-pain? source=search_result&search=cervical+spine&selectedTitle=7%7E150

5. Decker, J & Hergenroeder, A (2012) Overview of musculoskeletal neck injuries in the young athlete http://www.uptodate.com/contents/overview-of-musculoskeletal-neck-injuries-in-the- young-athlete?source=search_result&search=whiplash&selectedTitle=4%7E21

6. Goshima, K & White, M (2012) Overview of thoracic outlet syndromes http://www.uptodate.com/contents/overview-of-thoracic-outlet-syndromes? source=search_result&search=thoracic+outlet&selectedTitle=1%7E25

7. Hockberger, R & Kaji, A (2013) Evaluation and acute management of cervical spinal column injuries in adults http://www.uptodate.com/contents/evaluation-and-acute-management-of-cervical- spinal-column-injuries-in-adults? source=search_result&search=cervical+spine&selectedTitle=2%7E150

9. Kothari, M & Robinson, J (2013) Treatment of cervical radiculopathy http://www.uptodate.com/contents/treatment-of-cervical-radiculopathy? source=search_result&search=cervical+spine&selectedTitle=5%7E150

10. Levin, K (2012) Cervical spondylotic myelopathy http://www.uptodate.com/contents/cervical-spondylotic-myelopathy? source=search_result&search=cervical+spine&selectedTitle=8%7E150

11. Patient information editors – names unknown (2013) Neck fracture- the basics http://www.uptodate.com/contents/neck-fracture-the-basics?source=see_link

12. Patient information editors – name unknown (2013) Whiplash- the basics (patient information) http://www.uptodate.com/contents/whiplash-the-basics? source=search_result&search=whiplash&selectedTitle=2%7E21

14. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. Chapter 3, The cervical spine Module 1.9: Musculoskeletal Conditions – Cervical spine 110 15. Chan, T. Y. (1005). Adverse interactions between warfarin and nonsteroidal anti- inflammatory drugs: mechanisms, clinical significance and avoidance. Ann Pharmacother 29(12): 1274-83. http://www.ncbi.nlm.nih.gov/pubmed/8672833

Module 1.9: Musculoskeletal Conditions – Cervical spine 111 1.10 Thoracic spine

Theme 1 History taking for thoracic spine pain & injury injury LEARNING OBJECTIVES:

1. Identify the key principles of history taking of thoracic spine pain, conditions and injury in the context of the ED setting 2. Review the importance of mechanism when injury has occurred 3. Differentiate early, presentations of thoracic spine pain that may be beyond the scope of the advanced musculoskeletal physiotherapist (eg high risk mechanisms or other red flag features), require inter-disciplinary care or presentations of non- musculoskeletal origin 4. Formulate a preliminary differential diagnoses 5. Outline the differences between the primary and secondary physiotherapy role in relation to spinal injury

ASSUMED KNOWLEDGE:  Inclusion/exclusion criteria for primary contact musculoskeletal physiotherapy role  Routine physiotherapy subjective assessment of the thoracic spine, including costovertebral joints, costochondral joints and ribs  See also lumbar spine module for thoracolumbar fractures

KNOWLEDGE: Possible Red flag escalators (all significant spinal trauma should only be seen as a secondary consultation)  When obtaining a history discuss the implications of the following key areas and what associated questions may need to be asked to assess for red flags: 5-9, o Mechanism of injury –direction of forces e.g. flexion, flexion-rotation, extension, vertical compression o Mechanism of spinal cord trauma- transection, compression, contusion, vascular injury o MVA details e.g . speed, direction of impact, use of seatbelts, o MBA/cyclist details e.g . damage to helmet, speed o Fall – from height (e.g. 1m, 3m, 5m) vs standing (force of impact) - Headstrike, loss of consciousness o Skin integrity (wounds) o Time of injury, ability to move arms/ legs post injury, o Mental status such as intoxicated at time of injury? o Limb symptoms such as numbness, pins and needles , ‘dead” arm or leg’, tingling, weakness, foot drop o Bladder bowel disturbance (both post injury and current) o Other sites of injury and potential for organs to be involved o head//thorax/scapula/lumbar spine/ pelvic/ upper or lower limb

Module 1.10: Musculoskeletal Conditions – Thoracic spine 112 (calcaneum)  What other key information is required to assess for red flags?2,3,20,12  What key information would suggest an upper motor neuron lesion/ cord compression or spinal syndrome? 6—10, 16  When one spinal fracture is present what else should you look for?8,9  When is a spinal fracture classified as stable or unstable?8,9  If a spinal fracture is suspected during history taken what action should be taken prior to proceeding with a clinical examination?8,9  What key information would suggest an upper motor neurone lesion/ cord compression?6,11  What key information would you ask to differentiate musculoskeletal thoracic pain from non musculoskeletal causes?2, 3, 10-13,16  What key information is required in the setting of chronic thoracic pain problems in the ED? 2,3,4,11  What key information in a patient’s past medical history is important in thoracic pain/injuries in the ED setting?  What key information in a patient’s medication history is important in thoracic pain/injuries in the ED setting?,14,15  What key information in a patient’s social history is important in thoracic pain/injuries in the ED setting?  What is the relevance of determining the first aid/pre hospital treatment (where appropriate)?  What is the relevance of determining the compensable status or health insurance status of the patient?

1. Egol, K, Koval, K & Zuckerman, J (2010) Handbook of Fractures. 4th edition. Lippincott Williams and Wilkins. Chapter 10, The thoracolumbar spine.

3. Greenhalgh, S & Selfe, J (2004) Margaret: a tragic case of spinal Red Flags and Red Herrings. Physiotherapy. Chartered Society of Physiotherapy. 90, 2, p73-76. http://www.sciencedirect.com/science/journal/00319406/90/2

4. Goodman, C & Snyder, T (2013) Differential diagnosis for physiotherapists. 5th Ed. Chapter 14, Screening the head, neck and back, p 546-604; Chapter 17, Screening the chest, breast and ribs, p 673-712.

5. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. Chapter 8 The thoracic and lumbar spine.

Up to date Module 1.10: Musculoskeletal Conditions – Thoracic spine 113 6. Eisen, A (2012) Anatomy and localization of spinal cord disorders http://www.uptodate.com/contents/anatomy-and-localization-of-spinal-cord- disorders?source=search_result&search=thoracic+spine&selectedTitle=3%7E150

7. Hammel, J & Legome, E (2013) Initial evaluation and management of chest wall trauma in adults http://www.uptodate.com/contents/initial-evaluation-and-management-of-chest-wall- trauma-in-adults?source=search_result&search=thoracic+spine&selectedTitle=9%7E150

8. Hockberger, R & Kaji, A (2012) Evaluation of thoracic and lumbar spinal column injury http://www.uptodate.com/contents/evaluation-of-thoracic-and-lumbar-spinal-column- injury?source=search_result&search=thoracic+spine&selectedTitle=1%7E150

9. Hockberger, R & Kaji, A (2012) Spinal column injury in adults: Definition, mechanisms and radiographs http://www.uptodate.com/contents/spinal-column-injuries-in-adults-definitions- mechanisms-and-radiographs? source=search_result&search=cervcal+spine&selectedTitle=4%7E150

10. Parikh, S & Steinman, T (2012) Pain syndromes in autosomal dominant polycystic kidney disease http://www.uptodate.com/contents/pain-syndromes-in-autosomal-dominant- polycystic-kidney-disease? source=search_result&search=back+pain&selectedTitle=10%7E150

11. Schiff, D (2012) Clinical features and diagnosis of neoplastic, epidural, spinal cord compression including cauda equine syndrome http://www.uptodate.com/contents/clinical-features-and-diagnosis-of-neoplastic- epidural-spinal-cord-compression-including-cauda-equina-syndrome? source=search_result&search=thoracic+spine&selectedTitle=33%7E150

12. Wise, C (2012) Major causes of musculoskeletal chest pain http://www.uptodate.com/contents/major-causes-of-musculoskeletal-chest-pain? source=search_result&search=thoracic+spine&selectedTitle=23%7E150

15. Van Staa, T. P., Leufkens, H. G. M., Abenhaim, L., Zhang, B., & Cooper, C. (2000). Use of oral corticosteroids and risk of fractures. Journal of Bone and Mineral Research, 15(6),

Module 1.10: Musculoskeletal Conditions – Thoracic spine 114 993-1000.http://onlinelibrary.wiley.com/doi/10.1359/jbmr.2000.15.6.993/pdf

Module 1.10: Musculoskeletal Conditions – Thoracic spine 115 Theme 2 Focused clinical assessment of thoracic spine pain& injury

1. Identify the key aspects in clinical assessment of thoracic spine pain, conditions and injury in the ED setting 2. Formulate key findings to support/refute preliminary differential diagnosis? 3. Outline when not to examine or perform limited examination of the thoracic spine 4. Differentiate early, presentations of the spine of non musculoskeletal origin that may require inter-disciplinary care

ASSUMED KNOWLEDGE  Anatomy of the thoracic spine: bones, facet joints, discs including vertebral endplates, muscles, ligaments, costovertebral and costochondral joints, and ribs  Anatomy of the nervous system including spinal cord, nerve roots, peripheral nerves.  Routine physiotherapy objective assessment of the thoracic spine including: o Lower limb neurological assessment of lower motor neurone pathology o Upper motor neurone assessment o Neural dynamics assessment o Palpatory assessment

KNOWLEDGE:  Describe classification of spinal column injuries in the thoracic spine and common fractures and dislocations in the thoracic spine region, including method of injury and clinical signs and symptoms1, 3, 4, 7  Describe common ligamentous injuries, including method of injury and clinical signs and symptoms.4  In the setting of suspected spinal column injury, discuss if you would examine the spine, and if so how you would examine the spine?4  How would you assess for thoracic cord compression if this were suspected? And what would you expect to find in comparison to cord compression in the cervical spine?2  What is the relevance of any local skin changes / open wounds to the thorax?  How you would differentiate musculoskeletal thoracic spine pain from non musculoskeletal thoracic spine pain?5  What are the most common non-musculoskeletal presentations of thoracic pain 5, 6,8-10 o What does your clinical assessment need to include if non-musculoskeletal causes are suspected? o What findings you would you expect to see on assessment? o What action needs to be taken? o For example discuss common cardiac, pulmonary, renal, gastrointestinal, oncologic, neurological, infective/ inflammatory causes RECOMMENDED RESOURCES Module 1.10: Musculoskeletal Conditions – Thoracic spine 116 1. Egol, K, Koval, K, & Zuckerman, J (2010) Handbook of Fractures. 4th edition. Lippincott Williams and Wilkins. Chapter 10, The thoracolumbar spine.

2. Fuller, G (2013) Neurological examination made easy. 5th edition. Churchill Livingstone.

3. McRae, R. (2010) Clinical Orthopaedic Examination. 6th edition. Churchill Livingstone Elsevier. The thoracolumbar spine.

Up to date 4. Hockberger, R & Kaji, A (2012) Spinal column injuries in adults: Definitions, mechanisms and radiographs http://www.uptodate.com/contents/spinal-column-injuries-in-adults-definitions- mechanisms-and-radiographs? source=search_result&search=cervical+spine&selectedTitle=6%7E150

5. Cottrell, D & Meisel, J (2013) Differential diagnosis of chest pain in adults http://www.uptodate.com/contents/differential-diagnosis-of-chest-pain-in-adults? source=search_result&search=thoracic+disc&selectedTitle=2%7E4

6. Manning, W (2012) Clinical manifestations and diagnosis of aortic dissection http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-aortic- dissection?source=search_result&search=back+pain&selectedTitle=50%7E150

7. Rosen, H (2013) Clinical manifestations and treatment of osteoporotic thoracolumbar vertebral compression fractures http://www.uptodate.com/contents/clinical-manifestations-and-treatment-of- osteoporotic-thoracolumbar-vertebral-compression-fractures? source=search_result&search=back+pain&selectedTitle=43%7E150

Module 1.10: Musculoskeletal Conditions – Thoracic spine 117 Theme 3 Common investigations for thoracic spine pain &injury

1. Discuss the common investigations for thoracic spine pain, conditions and injury

KNOWLEDGE:  When would you consider obtaining an X-ray for a patient with a thoracic spine injury? 1, 5, 7, 8  When would you consider obtaining an X-ray for a patient with a thoracic spine pain without history of trauma?1  When would a CT scan be indicated for a patient with thoracic spine problem/injury?1, 5  When would an MRI be indicated for a patient with a thoracic spine problem/ injury?1, 5  When would blood investigations be indicated for a patient with a thoracic spine problem/ injury?11  What are other investigations that may be indicated in a patient with thoracic spine pain/ injury?

Describe the normal x-ray of the thoracic spine (lateral and A-P views)10

Review online Radiology interactive tutorials and quiz3,4,5,9 RECOMMENDED RESOURCES (Refer to Radiology module)

1. Anderson, J & Read, J (2008). Atlas of Imaging in Sports Medicine. 2nd Edition. McGraw-Hill. Chapter 8.

3. Flanders, A (2009) Spine – Thoracolumbar injury. Radiology Assistant. http://www.radiologyassistant.nl/en/p4906c8352d8d2/spine-thoracolumbar- injury.html

4. Gay, M, Kuntz, A, Lai, W, Norton, P & Yao, L (Date Unknown) Skeletal trauma radiology. University of Virginia. http://www.med- ed.virginia.edu/courses/rad/ext/index.html

5. Government of Western Australia Department of Health (2012) Diagnostic imaging pathways – Thoraco-lumbar Spine injury http://www.imagingpathways.health.wa.gov.au/index.php/imaging- Module 1.10: Musculoskeletal Conditions – Thoracic spine 118 pathways/musculoskeletal-trauma/bone-and-joint-trauma/thoraco-lumbar-spine- trauma

6. Raby, N, Berman, L & de Lacey, G (2005) Accident and Emergency Radiology: A Survival Guide. 3rd edition. Saunders Elsevier.

Up to date 7. Hockberger, R & Kaji, A (2012) Evaluation of thoracic and lumbar spinal column injuries http://www.uptodate.com/contents/evaluation-of-thoracic-and-lumbar-spinal- column-injury? source=search_result&search=thoracic+spine&selectedTitle=1%7E150

8. Hockberger, R & Kaji, A (2012) Spinal column injuries on adults: Definitions, mechanisms and radiographs http://www.uptodate.com/contents/spinal-column-injuries-in-adults-definitions- mechanisms-and-radiographs? source=search_result&search=cervical+spine&selectedTitle=6%7E150

9. Radiology Masterclass – axial skeleton http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x- ray_trauma_spinal/x-ray_fracture_start.html

10. Driscoll, P. A., Nicholson, D. A., & Ross, R. (1993). ABC of emergency radiology. Thoracic and lumbar spine. BMJ: British Medical Journal, 307(6918), 1552. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1679576/pdf/bmj00051-0051.pdf

Module 1.10: Musculoskeletal Conditions – Thoracic spine 119 Theme 4 Common pharmacology for the management of thoracic spine pain & injury LEARNING OBJECTIVES:

1. Discuss and compare the common pharmacological agents for thoracic spine pain, conditions and injury KNOWLEDGE:  Analgesic agents1-4, 6-8 o What is appropriate for pain control in the patient with minor musculoskeletal thoracic spine pain? o What is appropriate for pain control in the patient with moderate to severe pain with thoracic spine injury/problem? o What is appropriate pain control for the patient with neuropathic pain?  Anti-inflammatory agents6-8,12,13 o What and when is it appropriate to use anti-inflammatory agents?  Antibiotics o When would antibiotics indicated for thoracic spine pain, conditions and injury and why?11  Neuropathic pain medication9,10 o When would neuropathic pain medication be indicated in thoracic pain conditions / injuries?

RECOMMENDED RESOURCES (Refer to Pharmacology module

1. Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2006) Managing Acute Pain A Guide for Patients. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/managingacutepain. pdf

Module 1.10: Musculoskeletal Conditions – Thoracic spine 120 6. Macintyre, P, Scott, D, Schug, S, Visser, E, & Walker, S (2010) Acute Pain Management: Scientific Evidence, Third Edition, Australian and New Zealand College of Anesthetists and Faculty of Pain Medicine. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp104_3.pdf

9. Dworkin, R. H., Backonja, M., Rowbotham, M. C., Allen, R. R., Argoff, C. R., Bennett, G. J., ... & Weinstein, S. M. (2003). Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations. Archives of neurology, 60(11), 1524-1534. http://archneur.jamanetwork.com/article.aspx?articleid=784895

10. Dworkin, R. H., O'Connor, A. B., Audette, J., Baron, R., Gourlay, G. K., Haanpää, M. L., ... & Wells, C. D. (2010, March). Recommendations for the pharmacological management of neuropathic pain: an overview and literature update. In Mayo Clinic Proceedings (Vol. 85, No. 3, pp. S3-S14). Elsevier. https://admere.net/training/help/Pain_Management_Guidelines.pdf

Up to date 11. Sexton and Mac Donald (2013) Vertebral Osteomyelitis and Discitis http://www.uptodate.com/contents/vertebral-osteomyelitis-and-discitis

12.Solomon, D (2012) NSAIDs: Mechanism of action http://www.uptodate.com/contents/nsaids-mechanism-of-action? source=search_result&search=pharmacology&selectedTitle=5%7E150

13. Lexicomp (2013) Ibuprofen: Drug infomation http://www.uptodate.com/contents/ibuprofen-drug-information? source=see_link&utdPopup=true

Module 1.10: Musculoskeletal Conditions – Thoracic spine 121 Theme 5 Management of thoracic spine pain & injury

1. To identify and discuss the common management principles for thoracic spine pain, conditions and injury in the ED setting

ASSUMED KNOWLEDGE:  Physiotherapy management of acute, sub-acute and chronic thoracic spine and referred pain of a musculoskeletal origin

KNOWLEDGE: For the list of conditions below, consider:  What type of thoracic spine conditions would require the involvement of the Orthopaedic or Neurosurgical team at the time of assessment?  What type of thoracic spine conditions would require referral to the Orthopaedic or Neurosurgical team for assessment at a future date?  How would you provide adequate pain control if required?  Describe how your management of a lumbar spine injury will vary if your patient is: o Diabetic9 o On anti-coagulants2, 3 o Pregnant o Osteoporotic  Describe the signs, symptoms and management of 1, 4-8, 10-15 o Rib fractures o Thoracic nerve root impingement with and without neurological signs o Thoracic canal stenosis with and without neurological signs o Thoracic outlet syndrome o Rib pain o Chronic thoracic pain with signs of centralized pain mechanisms o Acute thoracic pain with yellow flags o Suspected pathological fracture o Suspected discitis/ osteomyelitis o Thoracic muscle or facet joint or costovertebral/chondral sprain/strain

1. Brukner, P and Khan, K (2012) Clinical Sports Medicine. 4th Edition. McGraw-Hill Medical, Australia. Chapter 26.

Module 1.10: Musculoskeletal Conditions – Thoracic spine 122 3. Dossett, L. A., Riesel, J. N., Griffin, M. R. & Cotton, B. A. (2011). Prevalence and Implications of Preinjury Warfarin Use, an analysis of the National Trauma Databank, Arch Surg 146(5): 565-570. http://archsurg.jamanetwork.com/article.aspx? articleid=407366

4. Egol, K, Koval, K & Zuckerman, J (2010) Handbook of Fractures. 4th edition. Lippincott Williams and Wilkins. Chapter 10, The thoraco-lumbar spine.

5. Lee, D (2003) The thorax- an integrated approach. Orthopedic physical therapy products, Canada.

6. McRae, R & Esser, M (2008). Practical Fracture Treatment. 5th Ed. Churchill Livingstone, Edinburgh. Thoracic and Lumbar spine fractures, p 260-6.

Up to date 7. Hockberger, R & Kaji, A (2012) Evaluaton of thoracic and lumbar spinal column injury http://www.uptodate.com/contents/evaluation-of-thoracic-and-lumbar-spinal-column- injury?source=search_result&search=thoracic+spine&selectedTitle=1%7E150

10. Karlson, K (2013) Initial evaluation and management of rib fractures http://www.uptodate.com/contents/initial-evaluation-and-management-of-rib- fractures?source=search_result&search=rib+fractures&selectedTitle=1%7E64

11. McDonald, M & Sexton, D (2013) Vertebral osteomyelitis and discitis http://www.uptodate.com/contents/vertebral-osteomyelitis-and-discitis? source=search_result&search=discitis&selectedTitle=1%7E38

12. Rosen, H (2013) Clinical manifestation and treatment of osteoporotic thoracolumbar vertebral compression fractures http://www.uptodate.com/contents/clinical-manifestations-and-treatment-of- osteoporotic-thoracolumbar-vertebral-compression-fractures? source=search_result&search=back+pain&selectedTitle=43%7E150

13. Sexton, D (2012) Epidural abscess http://www.uptodate.com/contents/epidural-abscess? Module 1.10: Musculoskeletal Conditions – Thoracic spine 123 source=search_result&search=lumbar+radiculopathy&selectedTitle=24%7E27

14. Up to date Editors and doctors (2013) Vertebral compression fracture (the basics) http://www.uptodate.com/contents/vertebral-compression-fracture-the-basics? source=see_link

15. Wise, C (2012) Major causes of musculoskeletal chest pain http://www.uptodate.com/contents/major-causes-of-musculoskeletal-chest-pain? source=search_result&search=thoracic+disc&selectedTitle=1%7E4#H8

Module 1.10: Musculoskeletal Conditions – Thoracic spine 124 1.11 Lumbar Spine

Theme 1 History taking for lumbar spine pain & injuries

1. Identify the key principles of history taking of lumbar spine pain, conditions and injuries in the context of the ED setting 2. Review the importance of mechanism when injury has occurred 3. Differentiate early, presentations of low back pain that may be beyond the scope of the advanced musculoskeletal physiotherapist (eg high risk mechanisms or other red flag features), require inter-disciplinary care or presentations of non- musculoskeletal origin 4. Formulate a preliminary differential diagnoses 5. Outline the differences between the primary and secondary role in relation to spinal injury ASSUMED KNOWLEDGE:  Inclusion/exclusion criteria for primary contact physiotherapy role  Routine physiotherapy subjective assessment of the lumbar spine, including ability to establish a directional pattern if present. KNOWLEDGE: Discuss the relevance of the following factors with respect to the mechanism of injury with lumbar spine (particularly focussing on possible red flag escalators)2, 5,-8 o Direction of forces involved (axial compression, axial distraction, translation) o Rotational forces involved o Position of the spine when the load was applied? o Intensity of force applied e.g. fall, fall from height, MVA, o Presence or absence of direct trauma o Skin integrity, bruising, haematoma o Area of pain e.g. thoracolumbar vs low lumbar o Time of injury, ability to move arms/ legs post injury o Limb symptoms such as numbness, pins and needles , ‘dead leg’ , tingling, weakness, foot drop, o Bladder or bowel disturbance (both post injury and current) o Mental status o Other sites for injury and relevant questioning required o head /neck /thorax/pelvis /abdomen / lower limb  What other key information is required to assess for red flags?1, 4, 8  What key information is required regarding bladder/ bowel function?1, 4, 8  What key information would you ask to differentiate musculoskeletal low back pain from non musculoskeletal causes?3,8,10-14,17  What key information would you ask to differentiate vascular claudication from neurogenic claudication?3,18  What key information would suggest an upper motor neuron lesion? 5  What key information is required in the setting of chronic low back pain problems?9 Module 1.10: Musculoskeletal Conditions – Lumbar spine 125  What key information in a patient’s past medical history is important in low back pain/injuries?  What key information in a patient’s medication history is important in low back pain/injuries?16,17  What key information in a patient’s social history is important in low back pain/injuries?  What is the relevance of determining the previous treatment or intervention (where appropriate)?  What is the relevance of determining the compensable status or health insurance status of the patient? RECOMMENDED RESOURCES

1. de Vet, H, Henschke, N, Irwig, L, Macaskill, P, Maher & Ostelo, R (2013) Red flags to screen for malignancy in patients with low-back pain (review). The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd. http://onlinelibrary.wiley.com/store/10.1002/14651858.CD008686.pub2/asset/CD008 686.pdf?v=1&t=hdwp0ita&s=558cc7cc8ef7cb5bfa86e46c4953cdc852b519ac

2. Egol, K, Koval, K, & Zuckerman, J.D.(2010) Handbook of Fractures. 4th edition. Lippincott Williams and Wilkins. Chapter 10, The thoracolumbar spine, p123-140.

3. Goodman, C & Snyder, T (2013) Differential diagnosis for Physical Therapists. 5th edition. Chapter 14, Screening the head, neck and back pages.

5. Haswell, K (2008) Clinical Decision Rules for Identification of Low Back Pain Patients With Neurologic Involvement in Primary Care. Spine. 33, 1, p68–73.

6. McRae, R (2010) Clinical Orthopaedic Examination. 6th edition. Churchill Livingstone Elsevier. Chapter 8, The thoracic and lumbar spine.

Up to date 7. Hockberger, R & Kaji, A (2012) Evaluation of thoracic and lumbar spinal column injury http://www.uptodate.com/contents/evaluation-of-thoracic-and-lumbar-spinal-column- injury?source=search_result&search=lumbar+spine+injuries&selectedTitle=1%7E3

8. Jim, J & Thompson, R (2013) Clinical features and diagnosis of abdominal aortic aneurysm http://www.uptodate.com/contents/clinical-features-and-diagnosis-of-abdominal- aortic-aneurysm?source=search_result&search=back+pain&selectedTitle=45%7E150

9. Levin, K (2012) Lumbar spinal stenosis: Pathophysiology, clinical features and diagnosis http://www.uptodate.com/contents/lumbar-spinal-stenosis-pathophysiology-clinical- features-and-diagnosis? Module 1.10: Musculoskeletal Conditions – Lumbar spine 126 source=search_result&search=lumbar+radiculopathy&selectedTitle=4%7E27

10.Mohler, E (2012) Epidemiology, risk factors, pathogenesis and natural history of abdominal aortic aneurysm http://www.uptodate.com/contents/epidemiology-risk-factors-pathogenesis-and- natural-history-of-abdominal-aortic-aneurysm? source=search_result&search=thoracic+spine&selectedTitle=48%7E150

11.Parikh, S & Steinman, T (2012) Pain syndromes in autosomal dominant polycystic kidney disease http://www.uptodate.com/contents/pain-syndromes-in-autosomal-dominant- polycystic-kidney-disease? source=search_result&search=back+pain&selectedTitle=10%7E150

12.Schiff, D (2012) Clinical features and diagnosis of neoplastic epidural spinal cord compression, including cauda equine syndrome http://www.uptodate.com/contents/clinical-features-and-diagnosis-of-neoplastic- epidural-spinal-cord-compression-including-cauda-equina-syndrome? source=search_result&search=thoracic+spine&selectedTitle=33%7E150

13. Sexton, D (2012) Epidural abscess http://www.uptodate.com/contents/epidural-abscess? source=search_result&search=lumbar+radiculopathy&selectedTitle=24%7E27

16. Van Staa, T. P., Leufkens, H. G. M., Abenhaim, L., Zhang, B., & Cooper, C. (2000). Use of oral corticosteroids and risk of fractures. Journal of Bone and Mineral Research, 15(6), 993-1000.http://onlinelibrary.wiley.com/doi/10.1359/jbmr.2000.15.6.993/pdf

18. Genevay, S., & Atlas, S. J. (2010). Lumbar spinal stenosis. Best Practice & Research Clinical Rheumatology, 24(2), 253-265. http://www.sciencedirect.com/science/article/pii/S1521694209001247#

Theme 2 Focused clinical assessment of low back pain & injuries

LEARNING OBJECTIVES: Module 1.10: Musculoskeletal Conditions – Lumbar spine 127 1. Identify the key aspects in clinical assessment of low back pain, conditions and injuries in the ED setting 2. Formulate key findings to support/refute preliminary differential diagnosis 3. Differentiate when not to examine, perform limited examination, or when further examination required out of scope eg PR/anal tone examination

ASSUMED KNOWLEDGE  Anatomy of the lumbar spine: bones, facet joints, discs including vertebral endplates, muscles, ligaments.  Anatomy of the nervous system including spinal cord, nerve roots, peripheral nerves  Routine physiotherapy objective assessment of the lumbar spine including: o Lower limb neurological assessment of lower motor neurone pathology o Upper motor neurone assessment o Neural dynamics assessment o Hip joint screening o SIJ provocation tests o Establishment/ confirmation of directional pattern where appropriate o Palpatory assessment

KNOWLEDGE:  Describe the thoraco lumbar spinal column injury classification8, 9  Describe common fractures in the thoraco lumbar region including mechanism of injury, clinical signs and symptoms2, 8, 9, 12  How would you assess the vascular status of the lower limbs?18  How would you assess for abdominal aortic aneurysm if this was suspected?10, 11  How would you assess for cauda equina syndrome if this was suspected?3  What is the relevance of any local skin changes / open wounds to low back?  When is an assessment of vital signs indicated?16  How would you differentiate a lower motor neuron lesion from a peripheral nerve lesion when lower limb pain only is present?13  How you would differentiate musculoskeletal low back pain from non musculoskeletal low back pain?5  What are the most common non-musculoskeletal presentations of low back pain 10, 11,14-17 o What does your clinical assessment need to include if non-musculoskeletal causes are suspected? o Discuss abdominal , cardiovascular, pelvic, oncological, neurological, infective/ inflammatory causes o What findings you would you expect to see on assessment? o What action needs to be taken?

1. Brukner, P and Khan, K (2012) Clinical Sports Medicine. 4th Edition. McGraw-Hill Medical, Australia.

Module 1.10: Musculoskeletal Conditions – Lumbar spine 128 2. Egol, K, Koval, K & Zuckerman, J (2010) Handbook of Fractures. 4th edition. Lippincott Williams and Wilkins. Chapter 10.

3. Fuller, G (2013) Neurological examination made easy. 5th edition. Elsevier Health Sciences.

4. McRae, R (2010) Clinical Orthopaedic Examination. 6th edition. Churchill Livingstone Elsevier. Chapter 8.

Up to date: 5. Armon, C, Hsu, P & Levin, K (2013) Lumbosacral radiculopathy: pathophysiology, clinical features and diagnosis http://www.uptodate.com/contents/lumbosacral-radiculopathy-pathophysiology- clinical-features-and-diagnosis? source=search_result&search=lumbar+radiculopathy&selectedTitle=1%7E27

6. Eisen, A (2012) Anatomy and localization of spinal cord disorders http://www.uptodate.com/contents/anatomy-and-localization-of-spinal-cord- disorders?source=search_result&search=thoracic+spine&selectedTitle=3%7E150

7. Gelb, D (2012) The detailed neurologic examination in adults http://www.uptodate.com/contents/the-detailed-neurologic-examination-in-adults? source=related_link

8. Hockberger, R & Kaji, A (2012) Spinal column injuries in adults: Definitions, mechanisms and radiographs http://www.uptodate.com/contents/spinal-column-injuries-in-adults-definitions- mechanisms-and-radiographs? source=search_result&search=lumbar+spine+anatomy&selectedTitle=1%7E150

9. Hockberger, R & Kaji, A (2012) Evaluation of thoracic and lumbar spinal column injury http://www.uptodate.com/contents/evaluation-of-thoracic-and-lumbar-spinal-column- injury?source=search_result&search=lumbar+spine+injuries&selectedTitle=1%7E3

10. Manning, W (2012) Clinical manifestations and diagnosis of aortic dissection http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-aortic- dissection?source=search_result&search=back+pain&selectedTitle=50%7E150

11. Mohler, E (2012) Epidemiology, risk factors, pathogenesis and natural history of abdominal aortic aneurysm http://www.uptodate.com/contents/epidemiology-risk-factors-pathogenesis-and- natural-history-of-abdominal-aortic-aneurysm? source=search_result&search=thoracic+spine&selectedTitle=48%7E150

12. Rosen, H (2013) Clinical manifestations and treatment of osteoporotic thoracolumbar

Module 1.10: Musculoskeletal Conditions – Lumbar spine 129 vertebral compression fractures http://www.uptodate.com/contents/clinical-manifestations-and-treatment-of- osteoporotic-thoracolumbar-vertebral-compression-fractures? source=search_result&search=back+pain&selectedTitle=43%7E150

13. Rutkove, S (2013) Overview of lumbar extremity peripheral nerve syndromes http://www.uptodate.com/contents/overview-of-lower-extremity-peripheral-nerve- syndromes? source=search_result&search=lumbar+radiculopathy&selectedTitle=3%7E27

14. Schiff, D (2012) Clinical features and diagnosis of neoplastic epidural spinal cord compression, including cauda equine syndrome http://www.uptodate.com/contents/clinical-features-and-diagnosis-of-neoplastic- epidural-spinal-cord-compression-including-cauda-equina-syndrome? source=search_result&search=thoracic+spine&selectedTitle=33%7E150

15.Welch W,C, Smit D & Gerszter P,C (2013) Spinal Tumors http://www.uptodate.com/contents/spinal-cord-tumors

Module 1.10: Musculoskeletal Conditions – Lumbar spine 130 Theme 3 Common investigations for lumbar spine pain & injuries

1. Discuss the common investigations for lumbar spine pain, conditions and injuries

KNOWLEDGE:  When would an X-ray be indicated for a patient with a lumbar or thoraco lumbar injury? And which views?3, 5, 8  When would an X-ray be indicated for a patient with a lumbar or thoraco lumbar pain without history of trauma?5, 8  When would a CT scan be indicated for a patient with a lumbar or thoraco lumbar problem/injury?1, 3, 5, 8  When would an MRI be indicated for a patient with a low back problem/ injury?1, 3, 5, 8  When would blood investigations be indicated for a patient with a thoracic spine problem/ injury?13  What are other investigations that may be indicated in a patient with low back pain?5, 8,13,14

Describe the normal x-ray of a lumbar spine (AP and lateral views)12 Review online Radiology interactive tutorials and quiz3,4,5,7,11 RECOMMENDED RESOURCES (Refer to Radiology module)

1. Anderson J & Read J (2008). Atlas of Imaging in Sports Medicine. 2nd Edition. McGraw-Hill. Chapter 8.

3. Flanders, A (2009) Spine – Thoracolumbar injury. Radiology Assistant. http://www.radiologyassistant.nl/en/p4906c8352d8d2/spine-thoracolumbar-injury.html

4. Gay, M, Kuntz, A, Lai, W, Norton, P & Yao, L (Date Unknown) Skeletal trauma radiology. University of Virginia. http://www.med-ed.virginia.edu/courses/rad/ext/index.html

5. Government of Western Australia Department of Health (2012) Diagnostic imaging pathways – Low back pain. http://www.imagingpathways.health.wa.gov.au/index.php/imagingpathways/musculoskeletal-trauma/musculoskeletal/low-back-pain

6. Raby, N, Berman, L, de Lacey, G (2005) Accident and Emergency Radiology: A Survival Guide. 2nd edition. Elsevier Saunders.

7. Smithuis, R (2005) Disc Nomenclature. Radiology assistant. Module 1.10: Musculoskeletal Conditions – Lumbar spine 131 http://www.radiologyassistant.nl/en/p423d18702d2bd/disc-nomenclature.html

Up to date 8. Deyo, R, Gatewood, M, Staiger, T & Wipf, J (2012) Diagnostic testing for low back pain http://www.uptodate.com/contents/diagnostic-testing-for-low-back-pain? source=search_result&search=lumbar+spine&selectedTitle=5%7E150

9. Hockberger, R & Kaji, A (2012) Evaluation of thoracic and lumbar spinal column injury http://www.uptodate.com/contents/evaluation-of-thoracic-and-lumbar-spinal-column- injury?source=search_result&search=lumbar+spine&selectedTitle=2%7E150

10. Hockberger, R & Kaji, A (2012) Spinal column injuries on adults: Definitions, mechanisms and radiographs http://www.uptodate.com/contents/spinal-column-injuries-in-adults-definitions- mechanisms-and-radiographs? source=search_result&search=cervical+spine&selectedTitle=6%7E150

11. Radiology Masterclass – axial skeleton http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_spinal/x- ray_fracture_start.html

12. Driscoll, P. A., Nicholson, D. A., & Ross, R. (1993). ABC of emergency radiology. Thoracic and lumbar spine. BMJ: British Medical Journal, 307(6918), 1552. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1679576/pdf/bmj00051-0051.pdf

14. Simerville, J. A., Maxted, W. C., & Pahira, J. J. (2005). Urinalysis: a comprehensive review. American family physician, 71(6). http://www.aafp.org/afp/2005/0315/p1153.html

Module 1.10: Musculoskeletal Conditions – Lumbar spine 132 Theme 4 Common pharmacology for the management of lumbar spine pain & injury

1. Discuss and compare the common pharmacological agents for low back pain and conditions KNOWLEDGE:  Analgesic agents1, 3, 5-8, 10, 11 o What is appropriate for pain control in the patient with minor musculoskeletal low back pain? o What is appropriate for pain control in the patient with moderate to severe pain with low back injury/problem?  Anti-inflammatory agents4, 7, 9, 11,14,15 o What and when is it appropriate to use anti-inflammatory agents?  Antibiotics13 o When would antibiotics indicated for low back pain/injuries and why?  Muscle relaxants2 o When would muscle relaxants be indicated for low back pain and why (or why not)?  Neuropathic pain medication11,12 o When would neuropathic pain medications be indicated for lumbar spine pain / injury? RECOMMENDED RESOURCES (Refer to Pharmacology module)

1. Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2006) Managing Acute Pain A Guide for Patients. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/managingacutepain.pdf

2. Bouter, L, Furlan, A, Solway, S, Touray, T & van Tulder, M (2008) Muscle relaxants for non-specific low-back pain (review). The Cochrane Library. Wiley Publishers. 4. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004252/abstract

4. Deyo, R, Koes, B, Roelofs, P, Scholten, R & van Tudler, M (2011) Non-steroidal anti- inflammatory drugs for low back pain (review). The Cochrane Library. Wiley Publishers. 2. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000396.pub3/abstract

6. eTG complete (2013) Therapeutic Guidelines (subscribed) http://online.tg.org.au/ip/ Module 1.10: Musculoskeletal Conditions – Lumbar spine 133 7. Hamilton, B, Milne, C, Orchard, J, & Paoloni, J (2009) Non-steroidal anti-inflammatory drugs (NSAIDs) in sports medicine. Guidelines for practical but sensible use. British Journal of Sports Medicine (subscribed). http://bjsm.bmj.com/content/early/2009/06/21/bjsm.2009.059980.full.pdf

10. Vargus Schaffer (2010) Is the WHO analgesic ladder still valid? Canadian Family Physician. 56, 6, p514-517.

11. Dworkin, R. H., Backonja, M., Rowbotham, M. C., Allen, R. R., Argoff, C. R., Bennett, G. J., ... & Weinstein, S. M. (2003). Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations. Archives of neurology, 60(11), 1524-1534. http://archneur.jamanetwork.com/article.aspx?articleid=784895

12. Dworkin, R. H., O'Connor, A. B., Audette, J., Baron, R., Gourlay, G. K., Haanpää, M. L., ... & Wells, C. D. (2010, March). Recommendations for the pharmacological management of neuropathic pain: an overview and literature update. In Mayo Clinic Proceedings (Vol. 85, No. 3, pp. S3-S14). Elsevier. https://admere.net/training/help/Pain_Management_Guidelines.pdf

Up to date 13. Sexton and Mac Donald (2013) Vertebral Osteomyelitis and Discitis http://www.uptodate.com/contents/vertebral-osteomyelitis-and-discitis

14.Solomon, D (2012) NSAIDs: Mechanism of action http://www.uptodate.com/contents/nsaids-mechanism-of-action? source=search_result&search=pharmacology&selectedTitle=5%7E150

15. Lexicomp (2013) Ibuprofen: Drug infomation http://www.uptodate.com/contents/ibuprofen-drug-information? source=see_link&utdPopup=true

16. Chou, R (2012) Subacute and chronic low back pain: Pharmacologic and noninterventional treatment http://www.uptodate.com/contents/subacute-and-chronic-low-back-pain-pharmacologic- and-noninterventional-treatment?source=related_link

Theme 5 Management of low back pain & injury Module 1.10: Musculoskeletal Conditions – Lumbar spine 134 LEARNING OBJECTIVES:

1. Discuss the common management principles for low back pain, conditions and injury in the ED setting

ASSUMED KNOWLEDGE:  Physiotherapy management of acute, sub-acute and chronic low back pain of a musculoskeletal origin

KNOWLEDGE:  Consider what conditions are appropriate for you to manage in the ED setting and what conditions should be managed by the ED medical team?5  What type of lumbar spine condition would require the involvement of the Orthopaedic or Neurosurgical team at the time of assessment?5  What type of lumbar spine condition would require referral to the Orthopaedic or Neurosurgical team for assessment at a future date?5  How would you provide adequate pain control if required?  Describe how your management of a lumbar spine injury will vary if your patient is: - Diabetic15 - On anti-coagulants2, 3 - Is pregnant7  Describe the signs, symptoms and management of 1, 5-14, 16-21  Osteoporotic wedge fracture of the lumbar spine  Pars interarticularis defect or fracture  Lumbar radiculopathy with and without neurological signs  Suspected acute disc herniation with low back pain only  Suspected acute disc herniation with neurological signs  Chronic low back pain with signs of centralized pain mechanisms  Acute low back pain with associated yellow flags  Suspected pathological fracture  Discitis  Upper motor neuron lesion  Lumbar muscle or facet joint sprain / strain  Discuss the patient education required for follow up care

1. Brukner, P and Khan, K (2012) Clinical Sports Medicine. 4th Edition. McGraw-Hill Medical, Australia. Chapter 26.

3. Dossett, L. A., Riesel, J. N., Griffin, M. R. & Cotton, B. A. (2011). Prevalence and Module 1.10: Musculoskeletal Conditions – Lumbar spine 135 Implications of Preinjury Warfarin Use, an analysis of the National Trauma Databank, Arch Surg 146(5): 565-570. http://archsurg.jamanetwork.com/article.aspx?articleid=407366

4. Egol, K, Koval, K, and Zuckerman, J (2010) Handbook of Fractures. 4th edition. Lippincott Williams and Wilkins. Chapter 10.

5. McRae, R & Esser, M (2008). Practical Fracture Treatment (5th Ed). Churchill Livingstone, Edinburgh.

Up to date: 6. Armon, C, Hsu, P & Levin, K (2012) Acute lumbosacral radiculopathy: prognosis and treatment http://www.uptodate.com/contents/acute-lumbosacral-radiculopathy-prognosis-and- treatment?source=search_result&search=back+pain&selectedTitle=23%7E150

7. Bermas, B (2013) Musculoskeletal changes and pain during pregnancy and post partum http://www.uptodate.com/contents/musculoskeletal-changes-and-pain-during- pregnancy-and-postpartum? source=search_result&search=back+pain&selectedTitle=25%7E150

8. Chou, R (2013) Low back pain in Adults (Beyond the basics) http://www.uptodate.com/contents/low-back-pain-in-adults-beyond-the-basics? source=search_result&search=back+pain&selectedTitle=15%7E150

9. Chou, R (2012) Subacute and chronic low back pain: Nonsurgical interventional treatment http://www.uptodate.com/contents/subacute-and-chronic-low-back-pain-nonsurgical- interventional-treatment?source=related_link

10. Delitto, A & Sowa, G (2013) Exercise-based therapy for low back pain http://www.uptodate.com/contents/exercise-based-therapy-for-low-back-pain? source=search_result&search=back+pain&selectedTitle=8%7E150

11. Deyo, R, Knight, C, Staiger, T & Wipf, J (2012) Treatment of acute low back pain http://www.uptodate.com/contents/treatment-of-acute-low-back-pain? source=search_result&search=back+pain&selectedTitle=2%7E150

12. Hansebout, R & Kachur, E (2013) Acute traumatic cord injury http://www.uptodate.com/contents/acute-traumatic-spinal-cord-injury? source=search_result&search=lumbar+spine+fracture&selectedTitle=3%7E4

Module 1.10: Musculoskeletal Conditions – Lumbar spine 136 13. Hockberger, R & Kaji, A (2012) Evaluation of thoracic and lumbar spinal column injury http://www.uptodate.com/contents/evaluation-of-thoracic-and-lumbar-spinal-column- injury?source=search_result&search=thoracic+spine&selectedTitle=1%7E150

16. Levin, K (2012) Lumbar spinal stenosis: Treatment and prognosis http://www.uptodate.com/contents/lumbar-spinal-stenosis-treatment-and-prognosis? source=search_result&search=back+pain&selectedTitle=44%7E150

17. McDonald, M & Sexton, D (2013) Vertebral osteomyelitis and discitis http://www.uptodate.com/contents/vertebral-osteomyelitis-and-discitis? source=search_result&search=discitis&selectedTitle=1%7E38

18. Rosen, H (2013) Clinical manifestations and treatment of osteoporotic thoracolumbar vertebral compression fractures http://www.uptodate.com/contents/clinical-manifestations-and-treatment-of- osteoporotic-thoracolumbar-vertebral-compression-fractures? source=search_result&search=back+pain&selectedTitle=43%7E150

19. Shekelle, P (2012) Spinal manipulation in the treatment of musculoskeletal pain http://www.uptodate.com/contents/spinal-manipulation-in-the-treatment-of- musculoskeletal-pain? source=search_result&search=back+pain&selectedTitle=24%7E150

20. Up to date doctors and editors (2013) Herniated disc (The Basics) http://www.uptodate.com/contents/herniated-disc-the-basics? source=search_result&search=lumbar+radiculopathy&selectedTitle=27%7E27

21. Up to date doctors and editors (2013) Radiculopathy (The Basics) http://www.uptodate.com/contents/radiculopathy-the-basics? source=search_result&search=lumbar+radiculopathy&selectedTitle=26%7E27

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