Leading the world to better health MUSCULOSKELETAL CLINICAL VIGNETTES A CASE BASED TEXT Department of Orthopaedic Surgery, RCSI Department of General Practice, RCSI Department of Rheumatology, Beaumont Hospital O’Byrne J, Downey R, Feeley R, Kelly M, Tiedt L, O’Byrne J, Murphy M, Stuart E, Kearns G. (2019) Musculoskeletal clinical vignettes: a case based text. Dublin, Ireland: RCSI. ISBN: 978-0-9926911-8-9 Image attribution: istock.com/mashuk CC Licence by NC-SA MUSCULOSKELETAL CLINICAL VIGNETTES Incorporating history, examination, investigations and management of commonly presenting musculoskeletal conditions 1131 Department of Orthopaedic Surgery, RCSI Prof. John O'Byrne Department of Orthopaedic Surgery, RCSI Dr. Richie Downey Prof. John O'Byrne Mr. Iain Feeley Dr. Richie Downey Dr. Martin Kelly Mr. Iain Feeley Dr. Lauren Tiedt Dr. Martin Kelly Department of General Practice, RCSI Dr. Lauren Tiedt Dr. Mark Murphy Department of General Practice, RCSI Dr Ellen Stuart Dr. Mark Murphy Department of Rheumatology, Beaumont Hospital Dr Ellen Stuart Dr Grainne Kearns Department of Rheumatology, Beaumont Hospital Dr Grainne Kearns 2 2 Department of Orthopaedic Surgery, RCSI Prof. John O'Byrne Department of Orthopaedic Surgery, RCSI Dr. Richie Downey TABLE OF CONTENTS Prof. John O'Byrne Mr. Iain Feeley Introduction ............................................................. 5 Dr. Richie Downey Dr. Martin Kelly General guidelines for musculoskeletal physical Mr. Iain Feeley examination of all joints .................................................. 6 Dr. Lauren Tiedt Dr. Martin Kelly Upper limb ............................................................. 10 Department of General Practice, RCSI Example of an upper limb joint examination ................. 11 Dr. Lauren Tiedt Shoulder osteoarthritis ................................................. 13 Dr. Mark Murphy Adhesive capsulitis (frozen shoulder) ............................ 16 Department of General Practice, RCSI Dr Ellen Stuart Shoulder rotator cuff pathology .................................... 19 Dr. Mark Murphy Acromioclavicular joint injury ........................................ 22 Department of Rheumatology, Beaumont Hospital Lateral epicondylitis ...................................................... 24 Dr Ellen Stuart Dr Grainne Kearns Carpal tunnel syndrome ................................................ 26 Department of Rheumatology, Beaumont Hospital Lower Limb ............................................................ 28 Dr Grainne Kearns Examples of lower limb joint examinations ................... 29 Hip osteoarthritis .......................................................... 34 Hip labral tear ............................................................... 36 Developmental dysplasia of the hip .............................. 39 Perthes disease ............................................................. 41 Slipped upper femoral epiphysis ................................... 43 Hip fracture ................................................................... 44 Avascular necrosis of the femoral head ......................... 47 Transient synovitis of the hip ........................................ 50 Septic arthritis of the hip ............................................... 53 Knee osteoarthritis ........................................................ 55 Anterior cruciate ligament rupture ................................ 58 Posterior cruciate ligament rupture ............................... 61 Medial collateral ligament injury ................................... 64 Meniscal knee injury ..................................................... 67 2 3 2 Deep vein thrombosis post total hip replacement ......... 69 Spine ....................................................................... 72 Examples of spinal examinations ................................... 73 Cervical radiculopathy ................................................... 75 Whiplash injury ............................................................. 80 Lumbar radiculopathy ................................................... 82 Spondylolisthesis .......................................................... 85 Lumbar pain (with possible red flags) ............................ 88 Non-specific low back pain ............................................ 92 Spinal stenosis .............................................................. 95 Appendices ............................................................ 98 Appendix 1: Important facts and figures around spinal history and examination ............................................... 99 Appendix 2: Diagnostic criteria in musculoskeletal medicine ..................................................................... 102 Appendix 3: Abbreviations .......................................... 105 Appendix 4: Notes ....................................................... 107 The symbol * is used in each section when an elaboration on the test/ diagnostic criteria listed is available in the relevant Appendix at the end of the document. 4 Deep vein thrombosis post total hip replacement ......... 69 INTRODUCTION Spine ....................................................................... 72 Examples of spinal examinations ................................... 73 Cervical radiculopathy ................................................... 75 This document was generated by the Department of Orthopaedic Surgery and the Department of General Practice Whiplash injury ............................................................. 80 in conjunction with the Department of Rheumatology in the Lumbar radiculopathy ................................................... 82 Royal College of Surgeons Ireland (RCSI). Spondylolisthesis .......................................................... 85 Lumbar pain (with possible red flags) ............................ 88 Musculoskeletal conditions are an extremely common Non-specific low back pain ............................................ 92 presentation to general practitioners, emergency departments and hospitals. Although the clinical examination for each joint Spinal stenosis .............................................................. 95 involves a similar approach (the ‘Look, Feel, Move’ format), be ............................................................ 98 it the shoulder, hip or knee, many students can find the subtle Appendices differences between each examination difficult. They may also Appendix 1: Important facts and figures around spinal struggle to generate an appropriate differential diagnosis, history and examination ............................................... 99 based upon the history and examination. Appendix 2: Diagnostic criteria in musculoskeletal medicine ..................................................................... 102 Commonly presenting musculoskeletal conditions in general practice and orthopaedics are presented in the form of clinical Appendix 3: Abbreviations .......................................... 105 vignettes in this document. Each vignette starts by Appendix 4: Notes ....................................................... 107 summarising the typical history and examination findings for each condition. The main positive clinical examination findings are outlined in bold and other possible findings in normal font. A list of differential diagnoses are then given followed by sub- headings illustrating why one diagnosis is more likely and The symbol * is used in each section when an elaboration others less so for each case. Appropriate investigations and on the test/ diagnostic criteria listed is available in the management for the general practitioner or orthopaedic relevant Appendix at the end of the document. surgeon are listed to complete each vignette. The Appendices at the end of the document contain some useful additional information. We hope this learning tool helps develop your musculoskeletal skills during your medical studies in RCSI. 4 5 GENERAL GUIDELINES FOR MUSCULOSKELETAL PHYSICAL EXAMINATION OF ALL JOINTS Musculoskeletal disorders are extremely prevalent, causing significant morbidity for patients. For example, up to 20% GP consultations relate to a musculoskeletal condition. Musculoskeletal conditions coexist with many other medical and surgical conditions, necessitating all doctors to have an in depth knowledge of musculoskeletal history taking, examination, diagnosis and management. The section will briefly outline the general steps of how best to perform a musculoskeletal examination of a joint: Introduction • Appropriate introduction to patient (full name and role) • Communication: Explain examination and gain consent from patient • Ask the patient if they have any pain before you start • Ask the patient to report any pain or discomfort during the examination • Look at the patient while examining them. Avoid causing them discomfort or pain Approach • Wash hands • Expose area under examination adequately. • Ideally the joint above and below should be visible and you can offer to examine them at the end of the examination • Always compare one side with the other for peripheral joint examination. • For simplicity, follow the “Look, Feel, Move, Special Tests” approach to each joint examination. Look/ Feel/ Move/ Special Tests • When looking, always ‘look’ from the front, the side and the back of any particular joint. • When feeling, ‘feel’ the front, back and side of any joint also. Use the back of your hand to assess 6 GENERAL GUIDELINES FOR MUSCULOSKELETAL temperature