CRFitzSimmons,JWardrope

Transcription

1 68 See end of artile for authors affiliations Correspondene to: Mr C R FitzSimmons, Aident and Emergeny Department, Sheffield Children s Hospital, Western Bank, Sheffield S10 2TH, UK; hris.fitzsimmons@ sh.nhs.uk The ABC of ommunity emergeny are 9 ASSESSMENT AND CARE OF MUSCULOSKELETAL PROBLEMS M CRFitzSimmons,JWardrope Emerg Med J 2005; 22: doi: /emj usuloskeletal problems aount for an estimated 3.5 million emergeny department (ED) attendanes eah year. More patients will onsult their general pratitioner (GP) or treat the problem themselves. Most of these onditions (sprains, bruises, and ahes) will be self limiting, requiring linial diagnosis, and straightforward treatment and advie. However, there are diagnosti dilemmas faing the pratitioner on the front line. Even simple injuries often need hospital assessment, usually for radiographs. Some problems are rare but important to diagnose if life threatening or limb threatening problems are to be avoided. The skill is to reognise those onditions where urgent referral and treatment are required. The aim of this series is to arm the pratitioner with these skills (see box 1). Major trauma is not overed in this artile. Box 1 Objetives of this artile The reognition of life threatening or limb threatening problems The identifiation of those patients requiring obvious hospital transfer The priniples of a seondary survey relevant to musuloskeletal problems Differentiation between injury and non-injury presentations Differential diagnoses in non-injury musuloskeletal problems inluding pitfalls Follow up arrangements An overview of the following will be inluded Funtional anatomy Fores ausing injury and the injury spetrum Indiations/regulations for radiographs Speifi onditions to be overed Bak pain Nek pain Rib injury Degenerative disease/osteoarthritis Hot joints PRIMARY SURVEY Primary survey positive patients Musuloskeletal injuries will rarely lead to a primary survey positive patient, exept in major trauma. There are however immediately life threatening problems that might mimi a musuloskeletal ondition. These pose a trap for the unwary and are listed below. Leaking abdominal aorti aneurysm (AAA) presenting as bak pain Aorti dissetion presenting as inter-sapular pain Perforation/peritonitis presenting as shoulder tip pain Aute myoardial infartion (MI) presenting as shoulder or arm pain A high index of suspiion and assessment of the ABCs an help identify these important onditions. A areful history will usually dislose no episode of trauma and a very aute onset of pain. A leaking AAA presents autely with abdominal and lower bak pain with or without ollapse and features of hypotension. The pain of an aorti dissetion pain is desribed as tearing. Ishaemi hest pain is lassially tight or band-like. Diaphragmati irritation from a ruptured hollow visus an ause shoulder pain, partiularly on lying flat. Patients with these suspeted onditions need urgent transport to a faility with the apabilities to fully manage these problems. Immediate management will onsist of essential interventions only. Administer oxygen, obtain intravenous aess, and give analgesia and possibly autious fluid resusitation en route. Do not delay transport to perform these proedures. Emerg Med J: first published as /emj on 20 Deember Downloaded from on 17 September 2018 by guest. Proteted by opyright.

2 PATIENTS WITH A NORMAL PRIMARY SURVEY BUT OBVIOUS NEED FOR HOSPITAL ATTENDANCE Certain onditions pose a serious threat to life or limb and must not be missed when onsidering a wait and see approah. The onditions listed in table 1 are the red flag onditions of the musuloskeletal system. For further details on all these onditions, their presentations, and treatment look under the emergeny mediine setion at A major joint disloation should be redued as soon as possible partiularly if there is no distal irulation or sensation to the limb. Autely ishaemi limbs for whatever ause have about four hours to be revasularised before irreversible musle and nerve damage ours. Therefore make one gentle effort at reloation. Otherwise the limb needs to be splinted in its urrent position and urgent transfer arranged. Compartment syndrome is aused by swelling in a myofasial ompartment leading to a ritially impaired irulation to the enlosed musles in that ompartment and possible distal ishaemia. There will usually be a good history of trauma. The hallmark of this ondition is pain out of all proportion to the examination findings and exquisite pain on passive streth of the musles in the affeted ompartment. These patients require urgent transfer beause surgial deompression is neessary as soon as possible, but ertainly within four hours. A septi joint is usually hot, swollen, and very tender. All movements are restrited and it may be virtually impossible to move the joint beause of pain. Typially the patient is systemially unwell and omplains of the pain keeping them awake at night and being of a throbbing nature. These patients require urgent transfer to hospital beause they need early surgery to remove the infetion and preserve the joint. Patients with objetive neurologial defiit due to nerve root ompression or due to other spinal pathology should be referred immediately. Consider the diagnosis of a auda equina syndrome. The lumbar and saral nerve roots lie in the spinal anal below the level of L1/2. A entral dis prolapse between the levels of L3 to S1 an ompress these nerve roots ausing retention of urine and weakness of the legs. The patient will present with lower bak pain and neurologial symptoms and signs. These inlude saddle area sensory loss and a redued or absent anal tone on retal examination. Depending on the level of the injury there will also be obvious Table 1 Red flag onditions requiring immediate hospital treatment Trauma Obvious frature/disloation Open frature Severe pain not relieved by simple analgesia Suspeted ompartment syndrome Neurovasular ompromise Non-trauma Referred pain from hest or abdomen Ishaemia/vasular problems/ suspeted DVT Septi arthritis/invasive soft tissue infetions Kids problems suh as slipped epiphysis Neurologial defiit, for example, auda equina syndrome neurologial defiits in the motor assessment of the lower limbs. The minimum neessary interventions should be arried out on these patients but ould inlude administration of oxygen or entonox, splinting, dressing open wounds, intravenous analgesia, and ontrolled tration or redution of neurovasularly ompromised extremities. These proedures should not delay transfer arrangements. For further information on the treatment of ompartment syndrome and rush syndrome see the ATLS manual, 1 Wardrope, 2 or the emediine web site ( emediine.om). For disloations, septi joints and neurovasular ompromise see Wardrope, 2 Apley, 3 and MRae. 4 SECONDARYSURVEYPATIENTS Assessment of the stable patient The assessment is arried out aording to a reognised system (SOAPC) now familiar to readers of this series. The first step is to deide if the problem is attributable to trauma or one of the many auses of non-traumati limb or spinal pain. The range of diagnoses is very different in these two groups. The first step in the assessment of musuloskeletal symptoms is to deide if the problem is attributable to an episode of trauma or a non-traumati problem. Trauma ompared with no history of trauma Patients who present with no history of trauma should alert the liniian to the possibility of missing Referred pain, Ishaemi syndromes, Sepsis, and Kids problems suh as epiphyseal abnormalities. Remember the mnemoni RISK. These are the onditions ommonly overlooked and an indiate limb threatening or even life threatening problems suh as ardia pain, a slipped upper femoral epiphysis, or a septi joint. SUBJECTIVE INFORMATION GATHERING THE HISTORY Definite trauma Aute trauma is aused by a single, lear event. This an lead to a wide range of injury from minor self limiting sprains to fratures and/or disloations of joints. The features of a frature are pain, swelling, loss of funtion, and bony tenderness. Disloations are usually more obvious with similar features to fratures plus an abnormal joint morphology with deformity. In the absene of these features then a soft tissue injury is more likely but onsider damage to other strutures suh as ligaments, tendons, nerves, and vessels. Mehanism of injury A lear history of the mehanism of injury is essential to aurate diagnosis in trauma. Eliit the magnitude and diretion of the fores ausing the injury. Simple errors are made by a failure to follow this advie. For example, if the only history obtained was hurt nek in road traffi aident 69 Emerg Med J: first published as /emj on 20 Deember Downloaded from on 17 September 2018 by guest. Proteted by opyright.

3 70 the liniian might jump to the onlusion the injury was likely to be a simple nek sprain. However, onsider how different your ations might be if a full history were to be obtained suh as hurt nek in road traffi aident, was unrestrained front seat passenger in ar whih overturned at speed (see fig 1). Box 2 Elements of history taking in aute trauma Mehanism of injury Symptoms and progress of symptoms over time Previous episodes of injury Past history/drugs/allergy Level of ativity in job or sport Symptoms and progress Pain, swelling, and loss of funtion are the main symptoms after injury. Ask if these symptoms have progressed sine the inident. A sudden and omplete loss of funtion at time of impat inreases the risk for a more severe injury. Ask about assoiated symptoms suh as paraesthesia and trauma elsewhere. History and previous injuries Ask the patient if they have any other signifiant medial onditions or are taking any mediation. Most injuries are aute, but some are an aute episode ompliating a hroni problem. The investigation and treatment of an aute on hroni injury may be slightly different. Level of ativity Patient expetations are an important onsideration in the management of musuloskeletal injuries. A professional athlete will demand as near 100% funtion as is possible after injury but most patients will manage very well with minor ligament instability as long as they have good protetive neuromusular funtion. Nevertheless it is important to onsider oupation, hobbies, and handedness so that expetations and needs an be identified. No definite trauma Patients who present with a limb or spinal pain but with no history of trauma an present diagnosti problems. In most patients the illness will be minor and self limiting or of a hroni nature not needing urgent treatment or investigation. However, a few patients with these minor symptoms may be suffering from life or limb threatening pathology. The mnemoni RISK highlights the ategories of serious diagnoses that may require exlusion, Referred pain, Ishaemi or vasular problems, Sepsis, and Kids or hildhood problems (see box 3) Consider the RISK diagnoses. Failure to even onsider them WILL lead to them being missed. Box 3 RISK diagnoses in non-traumati limb and spinal pain R Referred pain from hest/abdomen/spine* I Ishaemia/vasular problems/dvt S Sepsis K Kids problems suh as an epiphyseal injury *Examples inlude shoulder pain due to irritation of the diaphragm or knee pain due to hip pathology. History in non-traumati limb and spinal pain The most ommon symptom is pain. PQRST is a good mnemoni to help remember the questions that should be asked about pain (see below). Many serious pathologies ause severe pain with few findings on examination. Pain at Figure 1 A history of hurt nek in road traffi aident an mean anything from the injury being sustained in a minor rear end shunt to a major high speed and high risk impat. Always try to gain a lear mental piture of the mehanis of the injury. Emerg Med J: first published as /emj on 20 Deember Downloaded from on 17 September 2018 by guest. Proteted by opyright.

4 night that keeps the patient awake is of speial signifiane. It usually indiates a severe inflammatory proess and should always be taken seriously. Severe pain at night onsider severe pathology The PQRST of pain P provoking or palliative fators Ask if the patient has partiipated in any unusual ativity in the period leading up to the onset of symptoms, or has reently signifiantly inreased the level of an ativity (for example, doubling their running distane) that would be unusual for that patient. Note other aggravating or relieving fators. Q quality of pain Is the pain throbbing in nature, toothahe-like, or sharp and assoiated with ertain movements? How severe is the pain? R radiation and site Ask if the pain radiates either proximally or distally in the limb. This may be an indiation that the problem lies more entrally. Common examples are arm pain radiating from the nek or heart. Shoulder pain from irritation of the diaphragm. Knee pain from the hip and leg pain from the lumbar spine. S systemi symptoms/assoiated symptoms/ history Does the patient have markers of a systemi illness suh as fever, hills, loss of appetite, or weight loss? Joint problems are sometimes assoiated with systemi illnesses. Ask if there are any other symptoms suh as bak problems (ankylosing spondylitis), eye problems, inflammatory bowel symptoms, genitourinary symptoms, reent illnesses, and respiratory trat infetion. Some types of aute arthritis are part of omplex syndromes, for example, Reiter s syndrome Note medial history, espeially if there have been similar problems in the past. Exlude problems with other joints or a history of arthritis. Exlude many of the more ommon diseases suh as diabetes. Does the patient take warfarin or have any oagulopathy? T timing Does the pain keep the patient awake at night? Is it worse first thing in the morning or after exerise? Objetive information gathering the examination Develop a systemati method of musuloskeletal examination: Box 4 PQRST history taking of the symptom of pain P provoking and palliative fators Q quality R referred pain S systemi symptoms/assoiate symptoms T timing Joint above Look Feel Move Funtion Nerves and vessels Have the patient in a relaxed position. Start by examining the joint proximal to the injury (or spine if indiated). Follow standard orthopaedi pratie, using the look, feel, move, funtion system. Finish by heking the irulation to the limbs and test neural funtion distal to the injury. Where there is no history of trauma, follow the same system but hek vital signs and look for other linial signs as summarised in box 5. Box 5 Summary of vital signs and linial signs See artile 2 of this series on examination, inluding the musuloskeletal system. See also Wardrope, 2 Cyriax, 5 and MRae 6 for a fuller examination desription of anatomial regions. Vital signs partiularly temperature and pulse rate Stigmata of systemi disease or of systemi arthritis Rashes Proximal joints Neurovasular examination Spine (Chest and abdomen if indiated) Objetive information tests Radiographs indiations If a frature or disloation is suspeted then the patient needs referral to hospital. Many will need immediate referral, but if there is no deformity, no neurovasular ompromise, and the injured limb an be effetively immobilised (inluding nonweight bearing for the lower limb) the patient might be referred for radiography at a more onvenient time. Outpatient referral to the radiology department of the loal hospital allows non-urgent radiographs to be performed. Many departments have a system of hot reporting so that radiographs are reviewed immediately. If abnormalities are seen the patient is referred to the appropriate hospital team. If radiographs are normal the patient may return to their GP for further treatment. Use loal guidelines and poliy to deide when a radiograph is indiated. The definite fratures are easy to diagnose but unfortunately many fratures are undisplaed and it is diffiult to onfidently exlude a frature without a radiograph. Many experiened liniians would advise radiography when in doubt. Other indiations inlude suspeted foreign body within a wound, for example, glass or metal. For further information see the Royal College of Radiologists guidane ( and guidelines for dotors. 7 There are other exellent referene soures available for the need for radiography of ertain anatomial areas suh as the ankle. Probably the best known are the Ottawa ankle rules 8 used to help deision making in the assessment of aute ankle injuries that may either be sprained (most) or fratured (fig 2). 71 Emerg Med J: first published as /emj on 20 Deember Downloaded from on 17 September 2018 by guest. Proteted by opyright.

5 72 (A) Posterior edge or tip of lateral malleolus (C) Base of 5th metatarsal Figure 2 Lateral view Ottawa ankle rules. Malleolar zone Midfoot zone Medial view (B) Posterior edge or tip of medial malleolus (D) Naviular Other deision rules exist for similar use in aute knee 9 and nek 10 injuries. Be aware that many of these deision tools have limited appliability to groups suh as the elderly population whose bones may frature more easily and very young hildren where epiphyseal injuries may be more ommon. The Ottawa ankle rules have however been validated in hildren down to the age of 6 years. In January 2000 the Ionising Radiation (Medial Exposures) Regulations ame into fore to protet patients undergoing exposure to radiographs. Any liniian ordering radiographs independently needs to be aredited and attend training on this subjet. For further information on IRMER legislation see the Department of Health web site ( Investigations no definite trauma Many patients will not require any immediate investigation and may be referred to their GP for further assessment. However, if you suspet any of the RISK diagnoses, investigations suh as blood tests, examination of joint fluid, ultrasound, bone sans, and omputed tomography or magneti resonane imaging may be required. In addition, radiographs of the area may be required, but note that many serious onditions may have an initially normal radiograph. ANALYSIS AND DIFFERENTIAL DIAGNOSIS Trauma A sprain is a tear in a ligament and the term overs a huge range of injury, from the minor partial tear of a part of a ligament to a permanently disabling injury. A areful history and examination permits the definition of the severity and builds an aurate piture of the possible damage aused. A grade 1 sprain is where a few fibres of part of the ligament are torn. A grade 2 sprain is omplete rupture of part of the ligament omplex, for example rupture of the anterior talofibular ligament of the ankle lateral ligament omplex. A grade 3 sprain is omplete disruption of the ligament omplex with assoiated instability. Great diffiulty arises in the grading of ligament injury. Grade 3 injuries are usually linially obvious, with muh more bruising and swelling. Instability is the main onern mandating aggressive treatment, splintage, referral, repair, and/or physiotherapy. A repeat examination after five days may be needed to establish the true extent of some injuries. Use a wait and see poliy as long as you have exluded a potentially serious injury. Musle tears or strains are ommon and usually self limiting. Some musles and tendons an rupture ompletely; the most ommon losed ligament injury is rupture of the Ahilles tendon. This diagnosis may be missed if not speifially tested (see fig 3). Fratures are often easy to diagnose but are diffiult to exlude. Pitfalls inlude the saphoid frature in adults, hip fratures in the elderly patient, and spinal fratures. Osteogenesis imperfeta (brittle bone disease) should lead to a very high index of suspiion for frature even with minimal trauma. No definite trauma Common diagnoses are osteoarthritis (OA) and degenerative disease. Ask about previous symptoms. These are disussed later in the artile. Figure 3 Simmond s test. Emerg Med J: first published as /emj on 20 Deember Downloaded from on 17 September 2018 by guest. Proteted by opyright.

6 All patients with apparent musuloskeletal problems Consider soial aspets (elderly, safety, falls, mobillity, transport, soial support, et) Primary survey positive Neurovasular problem Sepsis Any suspiion of AAA AMI Perforation Aorti dissetion Essential interventions only Urgent hospital referral and transport Primary survey normal but obvious transfer needed Definite frature Definite disloation Septi joint Need for radiography/rule out? frature NOF Splint analgesia Non-urgent hospital referral and transport? frature? FB Referral for radiography Stable patients seondary survey Consider referred pain, ishaemia, sepsis, and kids (RISK) as auses of pain when no other ause seems apparent. Limb pain ould be attributable to a septi joint, a ritial ishaemia, or referred from spine, abdomen, or hest Causes of a hot joint inlude gout, pseudogout, infetion, aute arthritis, and haematologial onditions see below. Beware hildren. The slipped upper femoral epiphysis is the lassi pitfall where minimal or no trauma is involved yet a signifiant pathology ours that needs to be appreiated as early as possible for orretive treatment to start. PLAN Many musuloskeletal problems an be treated by simple advie, analgesia, and review by the patient s GP. The flow diagram (fig 4) shows a system for deision making and safe disposal in musuloskeletal problems. Most minor musulosketetal injuries an be treated by advising the patient to rest the injured area for the first hours, to take regular analgesia, to elevate the injured part if possible. Sometimes the appliation of old ompresses may redue swelling. However, the most important advie is to try and retain mobility by gentle exerise and a gradual return to full funtion. Tell the patient to seek further review if the pain gets worse or does not start to improve in three to five days. It may take weeks for symptoms to subside fully. COMMUNICATION The suessful management of most minor musuloskeletal injuries depends on the patient understanding the importane of phased rehabilitation as desribed above. Equally Full history and examination 'Red flags'? Nek pain Bak pain Joint pain Not trauma related? 'Red flags'? Yes No Definite injury with mo Probable Wait and see Re-evaluate GP referral Minor STI, sprain, bruise Advie RICER Analgesia Disharge Seek GP help if not improving in seven days Figure 4 Flow hart for the assessment of musuloskeletal problems. they should be enouraged to seek early review by their general pratitioner if the symptoms are worsening. SPECIFIC PROBLEMS Bak pain One very ommon problem is aute mehanial bak pain, this usually ours in young fit people. The pain usually starts suddenly and is often severe. However, there are no red flag symptoms (see box 6). Advie is given to try and stay mobile and good analgesia presribed. Cases with unusual or ontinuing severe symptoms should be reviewed early by their GP. Pain radiating down the bak of the leg to below the knee may point to siati nerve irritation. A areful neurologial examination is needed. Refer for early review by the GP. 11 If there is pain down both legs or any disturbane of motor power, bladder, or bowel funtion then refer to hospital immediately. There are many other auses of bak pain. Severe pain, an insidious onset, systemi symptoms, and onset with no history of trauma should all lead to onsideration of other auses suh as referred pain, infetion, tumour, and spinal ord ompression. An aute onset with ollapse, sweatiness, and pallor should alert you to the possibility of a leaking AAA. Always take seriously any hanged sensory or motor findings in the lower limbs. The examination of the lower bak is not omplete without a full neurovasular assessment, abdominal examination and an examination of the saddle area for sensation. (Retal examination to assess tone 73 Emerg Med J: first published as /emj on 20 Deember Downloaded from on 17 September 2018 by guest. Proteted by opyright.

7 74 is usually advised but may be diffiult in the ommunity setting.) Consider referral if the ause is not ompletely lear for further assessment and possible radiography, full blood ount, erythroyte sedimentation rate, C reative protein, and even omputed tomography or magneti resonane imaging in ertain ases. Remember to omplete a full systems examination first, reording important findings suh as the pulse rate and temperature. Box 6 shows red flags that might point to serious spinal pathology in bak pain (adapted from the Report of Clinial Standards Advisory Group on Bak Pain. 11 ) Box 6 Red flags that might point to serious spinal pathology in bak pain History Age,20 or.50 at onset Trauma (fall from height/rta) Thorai pain Constant, progressive pain Weight loss PMH Carinoma Cortiosteroid use Drug misuse/hiv Examination Systemially unwell Persisting severe restrition of lumbar flexion Widespread neurology Strutural deformity (soliosis/step) Nek pain Causes inlude whiplash injury, tortiollis, referred pain, degenerative disease, and infetion. As with bak pain, a good history of trauma will permit an assessment of the nek for injury suh as frature with or without disloation. Guidane on how to lear the C-spine after trauma has been issued by NICE 12 and Stiell 10 and is summarised by Wardrope. 13 Box 7 Clearing the C-spine after trauma Patients fulfilling these riteria will have a very low inidene of unstable spinal injury and may not need radiography Younger than 65 Alert and orientated (GCS = 15) No dangerous mehanism of injury * No midline spinal tenderness No neurologial symptoms or signs Patient an rotate nek 45 degrees to left and right Absene of a distrating injury (for example, long bone frature) *Fall from a height above one metre, fall from five or more stairs; axial load to the head suh as diving or ontat sports; RTA at high speed, roll over of vehile, or ejetion of patient; RTA involving biyle or rereational vehile; rear end shunt by a bus, vehile at high speed, or where ar has been shunted into onoming traffi; in young hildren have a lower index of suspiion in falls. Whiplash is very ommon after usually minor road traffi aidents. Pain omes on after a period of time, usually several hours to days. It is lassially ahing and worse on one side than the other. Sometimes it is entirely unilateral but is more usually bilateral. Assess for range of movement and neurovasular problems. Treatment is by gentle mobilisation, non-steroidal anti-inflammatory drugs (NSAIDs), advie, and an explanation that symptoms often worsen before they begin to improve and will ommonly take weeks to months to settle fully. Tortiollis is an aute nek pain with assoiated musle spasm. It ours most ommonly in young fit patients who often wake up with the pain, stiffness, and greatly dereased range of movement. Musle spasm is seen and felt in the orresponding nek musles unilaterally. There is no history of trauma nor of infetion. Treat with NSAIDs and gentle mobilisation of the nek. Infetion and tumour are rare. Consider them in the same manner as suh onditions anywhere else in the body and have a low threshold for referral to hospital if suspeted from the history or unusual physial findings suh as fever, systemi symptoms, or unexplained tahyardia. Degenerative disease/osteoarthritis These hroni progressive onditions an affet any region of the body, but most ommonly are enountered in the hip, knee, and ervial and lumbar spine. They may present as a new problem, an aute flare up of the hroni ondition after minor trauma, or as a more signifiant injury or infetion superimposed on oinidental findings of degenerative disease. Ask about trauma stiffness or problems with other major joints. Chek other joints for swelling, stiffness, and repitus on movement. An arthriti joint is more likely to beome inflamed after trauma and symptoms and signs may be harder to interpret than in the non-arthriti joint. The lassi example of this is the elderly patient who has fallen and has hip pain. The diagnosis to exlude is a fratured nek of femur. In ontrast with popular belief, patients an walk on suh injuries espeially if the frature is impated and stable. If not radiographing, onsider early review to ensure good mobility and settling symptoms. Rib injuries These injuries are ommon and often present after minor trauma. Aute rib injuries are very painful and present with pain that is often apparently out of proportion to the initial injury. Presentation is often several days after the injury when the pain may be worse than at the time of injury. Frature is not as ommon as bruising and soft tissue injury to the hest wall, but the features an be almost idential. Spring the hest wall in a lateral and anteroposterior (AP) diretion to assess for pain and repitus. This is also felt when the patient takes a deep breath with the examining hand held firmly over the injured area (see fig 5). Examine the hest also, listening for areas of redued air entry or added sounds suggesting underlying pneumothorax, ontusion, or early infetion. Examine the abdomen in ases of lower rib injury. Chek pulse, temperature, respiratory rate and oxygen saturation (SaO 2 ) if available. Rib radiographs are not routinely indiated but arrange a hest radiograph if the patient is short of breath at rest or on minimal exerise, if there is suspiion of a pneumothorax, there is linial suspiion that multiple ribs are fratured, Emerg Med J: first published as /emj on 20 Deember Downloaded from on 17 September 2018 by guest. Proteted by opyright.

8 Figure 5 Springing the ribs. there is a flail segment present or infetion has ompliated the injury. For unompliated rib injury the management inludes advie on breathing exerises and good analgesia. Patients may need referral, partiularly the elderly or those with pre-existing lung disease and a poor respiratory reserve. They may need stronger analgesia and supplemental oxygen. The autely hot/swollen/painful joint Pain, swelling, and redness in the region of a joint may be attributable to a ondition within the joint (aute arthritis) or in the tissues around the joint (periarthritis). The ommonest problems ausing an autely swollen, hot joint are the rystal arthropathies of gout and pseudogout and aute inflammatory onditions suh as rheumatoid arthritis. Sepsis is rare but is a diagnosis not to be missed. Aute haemarthrosis is unommon without a history of trauma or of oagulopathy or antioagulant treatment. Bursitis is a ommon ondition that presents with pain, swelling, and redness around joints. However, there is no swelling in the joint itself and a reasonable range of joint movement is retained. Very ommon examples are oleranon bursitis behind the elbow and pre-patellar and infra-patellar bursitis at the knee. Sometimes degenerative hanges in tendons lead to alium pyrophosphate rystals developing in the tendon. This an give a linial piture of a red, hot, swollen area over a joint (see table 2). Degenerative disease suh as osteoarthritis often auses joint swelling but the joint is not usually hot and red. Gout ours when rystals of uri aid from the blood preipitate in a joint, ausing an intense and aute inflammation of the joint. Pseudogout is a very similar ondition aused by deposition of alium pyrophosphate rystals. Both an present as a red, hot, painful, and swollen joint. The skin overlying a gouty joint is often tight, red, and shiny. The pain has a lassi deep, gnawing harater and the Table 2 joint Aute arthritis Gout Pseudogout Causes of an aute hot swelling in or around a Sero-positive arthritis (for example, rheumatoid) Sero-negative arthritis (for example, Reiter s syndrome) Sepsis Haemarthrosis Peri-arthritis Bursitis CPPDD (alium pyrophosphate deposition disease patient often has suffered previous episodes. It ommonly affets the first metatarsophalangeal joint of the foot but also affets the ankle and less ommonly the knee. Pseudogout tends to affet the wrist, where alifiation is sometimes seen in the triangular ligament on radiography; and the knee, where alifiation may be apparent in the menisal artilage. Where the patient has a lear history of previous gout, treatment is with NSAIDs. In a typial ase of gout or pseudogout where the patient is well, has no systemi symptoms of infetion, and they are not feverish, give a short ourse of NSAIDs and arrange next day review by the GP. The diagnoses not to miss are osteomyelitis and septi arthritis. Septi arthritis an arise de novo or from spread from an area of osteomyelitis into the joint. They both present in a similar way. There is either no history of trauma or a history of insignifiant trauma for the degree of pain. There may be a history of joint penetration, either in an aident or aused by a medial intervention. The patient annot move the joint at all and strongly resists any passive movements. Early in the ourse of these illnesses, all these lassi findings may not be present. Consider sepsis a possibility in any aute joint problem and arrange for early review. If in doubt, refer for a further opinion to the patient s GP, rheumatology, or aident and emergeny. Haemophilia and sikle ell disease are both haematologial disorders that an result in aute joint pain from either bleeding into the joint or ishaemia and infartion of tissues around the area. Refer urgently if the patient has a history of these onditions. Web referenes Emediine ( Royal College of Radiologists ( Department of Health ( Authors affiliations C R FitzSimmons, Aident and Emergeny Department, Sheffield Children s Hospital, Sheffield, UK J Wardrope, Aident and Emergeny Department, Northern General Hospital, Sheffield, UK Funding: none. Conflits of interest: none delared. REFERENCES 1 Amerian College of Surgeons Committee on Trauma. ATLS manual. 6th ed. Chiago: Amerian College of Surgeons, Wardrope J, English B. Musulo-skeletal problems in emergeny mediine. 1st ed. Oxford: Oxford University Press, Apley AG, Solomon L. Apley s system of orthopaedis and fratures. 7th ed. Oxford: Butterworth-Heinemann, Emerg Med J: first published as /emj on 20 Deember Downloaded from on 17 September 2018 by guest. Proteted by opyright.

9 76 4 MRae R. Pratial frature management. 3rd ed. Edinburgh: Churhill Livingstone, Cyriax JH, Cyriax PJ. Cyriax s illustrated manual of orthopaedi mediine. 2nd ed. Oxford: Butterworth-Heinemann, MRae R. Clinial orthopaedi examination. Edinburgh: Churhill Livingstone, Royal College of Radiologists. Making the best use of a department of linial radiology guidelines for dotors. 5th ed. London: Royal College of Radiologists, Stiell IG, Greenberg GH, MKnight RD, et al. A study to develop linial deision rules for the use of radiography in aute ankle injuries. Ann Emerg Med 1992;21: Clinial Evidene Call for ontributors 9 Stiell IG, Greenberg GH, Wells GA, et al. Prospetive validation of a deision rule for the use of radiography in aute knee injuries. JAMA 1996;275: Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286: Clinial Standards Advisory Group. Report of the Clinial Standards Advisory Group on bak pain. London: HMSO, National Institute for Clinial Exellene. Head injury: triage, assessment, investigation and early management of head injury in infants, hildren and adults. Clinial pratie algorithm no 4. London: NICE, Wardrope J, Ravihandran G, Loker T. Risk assessment for spinal injury after trauma. BMJ 2004;328: Clinial Evidene is a regularly updated evidene-based journal available worldwide both as a paper version and on the internet. Clinial Evidene needs to reruit a number of new ontributors. Contributors are healthare professionals or epidemiologists with experiene in evidene-based mediine and the ability to write in a onise and strutured way. Areas for whih we are urrently seeking authors: N Child health: noturnal enuresis N Eye disorders: baterial onjuntivitis N Male health: prostate aner (metastati) N Women s health: pre-menstrual syndrome; pyelonephritis in non-pregnant women However, we are always looking for others, so do not let this list disourage you. Being a ontributor involves: N Seleting from a validated, sreened searh (performed by in-house Information Speialists) epidemiologially sound studies for inlusion. N Doumenting your deisions about whih studies to inlude on an inlusion and exlusion form, whih we keep on file. N Writing the text to a highly strutured template (about words), using evidene from the final studies hosen, within 8 10 weeks of reeiving the literature searh. N Working with Clinial Evidene editors to ensure that the final text meets epidemiologial and style standards. N Updating the text every six months using any new, sound evidene that beomes available. The Clinial Evidene in-house team will ondut the searhes for ontributors; your task is simply to filter out high quality studies and inorporate them in the existing text. N To expand the topi to inlude a new question about one every months. If you would like to beome a ontributor for Clinial Evidene or require more information about what this involves please send your ontat details and a opy of your CV, learly stating the linial area you are interested in, to Klara Brunnhuber (kbrunnhuber@ bmjgroup.om). Call for peer reviewers Clinial Evidene also needs to reruit a number of new peer reviewers speifially with an interest in the linial areas stated above, and also others related to general pratie. Peer reviewers are healthare professionals or epidemiologists with experiene in evidene-based mediine. As a peer reviewer you would be asked for your views on the linial relevane, validity, and aessibility of speifi topis within the journal, and their usefulness to the intended audiene (international generalists and healthare professionals, possibly with limited statistial knowledge). Topis are usually words in length and we would ask you to review between 2 5 topis per year. The peer review proess takes plae throughout the year, and our turnaround time for eah review is ideally days. If you are interested in beoming a peer reviewer for Clinial Evidene, please omplete the peer review questionnaire at or ontat Klara Brunnhuber (kbrunnhuber@bmjgroup.om). Emerg Med J: first published as /emj on 20 Deember Downloaded from on 17 September 2018 by guest. Proteted by opyright.