MSK eBook

Question 1

Bones

Answer 1

Bones – Provide support for soft tissues, protect internal organs from injury, assist in movement, mineral homeostasis, blood cell production and triglyceride storage.

Question 2

Muscles

Answer 2

Muscles – Skeletal muscles normally work in pairs (via contraction and relaxation) to move the bones of the skeleton.

Question 3

Joints

Answer 3

Joints – Any join between two or more bones in the body – they are divided into three main types: fibrous, cartilaginous and synovial joints

Question 4

Fibrous joints

Answer 4

Fibrous joints – These lack any form of synovial cavity, and are held together closely by dense connective tissue. Examples include joints between the bones of the skull and teeth being held in place in the jaw.

Question 5

Cartilaginous joints

Answer 5

Cartilaginous joints – Again these joints lack a synovial cavity, however the bones are connected by a layer of cartilage allowing little or no movement. The intervertebral joints of the spine are an example of this type of joint.

Question 6

Synovial joints

Answer 6

Synovial joints – These are distinguished by the synovial cavity between the articulating bones. This cavity is filled with synovial fluid and allows a joint to be freely movable. Knees, hips, elbows, the metacarpophalangeal (MCP) joints of the fingers are all examples of synovial joints.

Question 7

Ligaments

Answer 7

Ligaments – Dense collagen fibres that attach to the periosteum of the articulating bones.
The ligament’s flexibility allows for movement, it’s inherent tensile strength holds the joint in place and prevents dislocation.

Question 8

Tendons

Answer 8

Tendons – Attach muscle to bones allowing for movement of the skeleton.

Question 9

Bursa (pl. Bursae)

Answer 9

Bursa (pl. Bursae) – A small fluid filled sac-like capsule consisting of connective tissue lined with a synovial membrane. They are strategically located to reduce friction at certain joints e.g. shoulder or knee. They can be located between skin and bone, tendons and bones, muscles and bones or ligaments and bone.

Question 10

Joint Capsule

Answer 10

The sleeve-like area that encapsulates a synovial joint. It consists of two layers, an outer fibrous membrane that includes the ligaments and the inner synovial membrane.

Question 11

Synovial Fluid

Answer 11

Secreted by the synovial membrane, a viscous clear or pale yellow liquid that contains various constituents including hyaluronic acid and interstitial fluid. It aids in
joint movement and cushioning.

Question 12

However it is not uncommon to see a young patient in a
pharmacy with musculoskeletal problems. This is normally down to one of four main
causes:

Answer 12

1) Trauma
2) Overuse
3) Genetic Factors
4) Iatrogenic causes

Question 13

Trauma

Answer 13

Trauma is probably the most common cause of soft tissue injury amongst young people.
This can range from car accidents, sporting injuries or simple sprains that occur in everyday life. The extent of injury is dependent on the force of impact, the direction of impact and the inherent strength of an individual’s musculoskeletal system.
Fractures occur when a bone is subjected to a force greater than its inherent strength.
Fractures of major bones will very rarely present in a community pharmacy, however it can be quite common to see fractures of the phalanges or metatarsals. Referral to an appropriate location should always be made when someone presents with this sort of injury.

Question 14

Overuse

Answer 14

Overuse injuries are common in athletes who repeatedly use the same sets of muscles such
as long-distance runners and tennis players. However, manual workers can often also be subject to similar injuries. These tend to have an insidious onset and are generally termed as ‘chronic’. Treatment is similar to that used for acute injuries, and it also possible to have
an ‘acute on chronic’ problem. Common examples include tennis elbow, shin splints or stress fractures.

Question 15

Genetic Factors

Answer 15

There are a number of conditions affecting young people that are inherited such as juvenile idiopathic arthritis and Perthe’s disease. Also certain musculoskeletal conditions affect one gender more than another, e.g. women are more prone to rupturing their anterior cruciate ligament because of the female hip alignment.

Question 16

Iatrogenic causes

Answer 16

Both drugs and inappropriate medical intervention can lead to musculoskeletal problems.
Corticosteroids reduce bone mineral density and thus increase the risk of fracture. If a bandage, support or plaster is applied too tightly this may lead to symptoms and conditions such as numbness, paraesthesia, tissue strangulation or compartment syndrome.

Question 17

Soft Tissue Injuries types

Answer 17

Strain

Sprain

Question 18

Strain:

Answer 18

Where a muscle has been stretched beyond its elastic limit. This can be further divided into a genuine strain, a tear, or a complete rupture of the muscle.

Question 19

Sprain:

Answer 19

Where a ligament or joint capsule is stretched beyond its elastic limit. This tends to cause joint instability or joint laxity. Again these can be sub-divided into three distinct grades.

Grade 1 – Minor tissue damage with no joint laxity
Grade 2 – Some joint laxity however the connective tissue is intact
Grade 3 – Rupture, surgical repair is case dependent

Question 20

Contusion:

Answer 20

An injury to the muscle caused by a direct blow, which causes localised damage and bleeding.

Question 21

Examples of referral criteria for a patient with a musculoskeletal injury

Answer 21

• When there is obvious deformity
• If a patient cannot bear any weight on the joint
• If the patient reports numbness or paraesthesia
• Where there is severe pain and disproportionate swelling
• If there is no improvement after a few days
• If there is any doubt about the severity of the injury

Question 22

Compartment Syndrome

Answer 22

If a muscle injury is associated with damage to its blood supply or the soft tissue is severely damaged a condition known as compartment syndrome may occur. Some muscle groups (particularly in the calf) are contained within a rigid fascia, known as a compartment. If the muscle swells or blood leaks into this compartment the internal pressure may rise and cut off the blood supply to the muscle. Over a few hours the muscle may die and be replaced by fibrous tissue that contracts leaving a useless withered
clawed limb known as Volkmann’s ischaemic contracture.
Symptoms include extreme pain, paraesthesia and swelling in the affected muscle. Treatment involves RICE in mild cases caused by exercise. In more severe cases an operation known as a fasciotomy may have to be performed to save the limb. This involves splitting the fascia to allow the muscle room to expand; the wound is then sewn up over a period of a few days.

Question 23

Myositis Ossificans

Answer 23

Following a direct blow to the periosteum and
muscle, bone plaques may be deposited in the
muscle. This may also occur as a result of joint replacement surgery. This is a very painful condition where the patient has a feel of density in the tissues alongside movement limitation.
Diagnosis may include x-ray, MRI scan or ultrasound.
Treatment involves absolute rest and pain relief until
the bone plaque stabilises; inflammation is minimised. Once the bone is stable or surgically removed, physiotherapy can commence to restore the full range of movement.

Question 24

The main treatment principles of soft tissue injury include

Answer 24

PRICE = Protection, Rest, Ice, Compression, Elevation
RICE = Rest, Ice, Compression, Elevation
MICE= Movement, Ice, Compression, Elevation
POLICE = Protection, Optimum Loading, Ice, Compression, Elevation
Protection may be an assisted device e.g. crutches or a support or high lace top shoes.

Question 25

Pharmacological Treatment for Soft Tissue Injuries

Answer 25

Analgesics:
Paracetamol: 1g four times a day is useful for most soft tissue injuries if pain is a problem.
Codeine: Can be sold OTC as co-codamol 8/500, this offers little advantage over
paracetamol for musculoskeletal injuries.

Non-steroidal Anti-inflammatory drugs (NSAIDs)
In theory NSAIDs should be slightly more useful than simple analgesics as their mode of action relieves the inflammation associated with soft tissue injuries. However their use is somewhat controversial. Inflammation is an integral part of the healing process and preventing or reducing this in the acute phase of the injury (first 48 hours) may lead to increased healing times. Multiple studies have shown that NSAIDs have a similar analgesic benefit as paracetamol in acute musculoskeletal injuries and that adding them to
paracetamol does not provide a significant increase in analgesia.

Question 26

NSAIDs should not be sold to the following:

Answer 26

• Patients who have asthma
• Patients with history of gastric or duodenal ulcer
• Patients with a history of renal failure
• Patients with hypertension

Question 27

Topical Agents

Answer 27

Topical NSAIDs (e.g. Ibuleve®)

Rubefacients (e.g. Deep Heat®)
These work primarily by counter-stimulation, they produce a warming effect via vasodilation in the area to which they are applied that takes the patient’s mind off the pain. They should only be applied to unbroken skin. NICE guidance does not recommend rubefacients for
osteoarthritis. See also CKS information on sprains and strains relating to avoiding H.A.R.M. in the first 72 hours after the injury.

Question 28

Pharmacological Treatments for other musculoskeletal conditions

Answer 28

Corticosteroid Injections
Intra-articular corticosteroid injections can be used to relieve pain and increase mobility in inflammatory joint conditions. They act by supressing the tissue’s inflammatory response to injury but also have a catabolic effect that breaks down tissue. They are particularly useful in areas where the muscles, tendons and ligaments attach to the dense connective tissue
covering the bone at articular surfaces. Joint injections increase the risk of developing septic arthritis, and corticosteroids mask the signs of infection which is a risky combination.
As a result the injection should always be carried out with strict aseptic technique, and never been undertaken on a previously infected joint. Due to their catabolic properties tendon rupture has been reported following injection.

Muscle Relaxants
Often following falls or whiplash injuries muscles can go into spasm (involuntary contraction) this can result in very painful musculoskeletal conditions. Conventional
painkillers are of little use in these conditions. Benzodiazepines (most commonly low dose diazepam) are useful in these cases as they have a direct relaxant effect. Methocarbamol is also licensed for short-term use in these injuries.

Capsaicin
Capsaicin does not cause vasodilation; it depletes the neurotransmitter substance-P which results in reduced pain signal transmission from the injured area; a 0.025% preparation is licensed as a POM for the treatment of osteoarthritis.

Question 29

Osteoarthritis

Symptoms

Answer 29

• Pain
• Stiffness – also known as gelling, particularly towards the end of the day
• Crepitus - a grating or grinding sensation when the joint moves
• Swelling – which can be either soft or hard
• Asymmetrical nature of joints affected

Question 30

WOMAC score

Answer 30

The WOMAC score is a diagnostic test used to determine the functionality of a hip or knee joint. This provides a basis to decide on future treatment options.

Question 31

Non-pharmacological management osteo

Answer 31

Exercise and manual therapy
Weight loss
Electrotherapy
Aids and devices e.g. insoles, joint supports
Surgery

Question 32

Pharmacological management osteo

Answer 32

Oral analgesics
Topical treatments (but NOT rubefacients)
NSAIDs or highly selective COX-2 inhibitors (excluding etoricoxib 60mg) co-prescribed with a
PPI
Intra-articular injections

Question 33

There are three main risks associated with orthopaedic surgery

Answer 33

• Infection
• Dislocation
• VTE – Venous thromboembolism

Question 34

infection

Answer 34

The best way to treat infection is to prevent it! Prophylactic antibiotics and aseptic procedures are standard for orthopaedic surgery. Bone infections (osteomyelitis) are notoriously difficult to treat; patients may require six week courses of intravenous
antibiotics. Drugs such as ciprofloxacin and sodium fusidate are commonly used as these tend to concentrate in bone more than conventional antibiotics. A second antistaphylococcal antibiotic is usually required to be given with sodium fusidate to prevent the
emergence of resistance.

Question 35

Dislocation

Answer 35

Dislocation is prevented by a comprehensive rehabilitation programme involving input from all members of a multiprofessional team. Post-surgery exercise education is crucially important as patients must avoid certain activities including driving, for several weeks postsurgery (timescales vary dependant on the activity and the patient). Occupational therapy is
also extremely important as patients may require adaptations such as raised toilet seats to live at home following surgery.

Question 36

Venous thromboembolism (VTE)

Answer 36

VTE is the most common cause of death following orthopaedic surgery due to pulmonary embolism (PE). However, it will more commonly present as a deep vein thrombosis (DVT). Hip fracture surgery carries the greatest risk for VTE (followed by hip replacement and knee replacement) than any other lower limb surgery.

Question 37

How to prevent a VTE

Answer 37

How to prevent a VTE
There are basically two methods: mechanical and pharmacological. Mechanical methods aim to aid venous return and prevent pooling of blood in the legs, pharmacological treatment inhibits clotting factors.

Pharmacological prophylaxis consists of drugs that reduce the risk of clotting taking place.
NICE guidance (CG92) has advocated the use of low molecular weight heparins, unfractionated heparin, fondaparinux, dabigatran etexilate, rivaroxaban. Also see NICE TA245 regarding apixaban.
Pharmacological treatment does pose some problems, it increases the risk of post-op bleeding, especially from the wound site; this increases the risk of infection and prevents mobilisation post-op which in turn increases the risk of DVT. In general, treatment with pharmacological agents should continue for 28-35 post–op for hip surgeries and 10-14 days post knee replacement (except Apixaban). Upper limb surgeries do not routinely require prophylaxis unless the patient is at high risk for another reason.