MSK medicine Flashcards
Musculoligamentous strain/back pain - explanation
- Mechanism of injury
- Simple description of structures involved
- Discuss likely course of recovery, i.e. most improvement in first 10-14d, and then usually settles quickly (usually within 2-3 wks)
- Discuss need to look after back in future bc possibility of re-injury (40-70% recur)
Musculoligamentous strain/back pain - mx
- Appropriate analgesia, consider paracetamol or NSAIDs
- Keep mobile and active
- Possible use of codeine or tramdadol short term, only up to 3 wks
- Early physiotherapy and then ongoing to give appropriate exercises and rehabilitation.
- Encourage exercises as soon as possible. Spinal stretching, mobilisation or manipulation effective and advisable when spasm settles
- Reassurance about good outcome is important
- Review in 7d
b. Long-term
1. Provide ongoing psychological and physiotherapy support
Musculoligamentous strain/back pain - prevention
- Give back education, especially about lifting (occupational considerations)
- Red flags for lower back pain = significant trauma, night pain, neurological changes, weight loss, fever, sphincter disturbance…
- Smoking
- Alcohol
Cervical sprain - explanation
- Mechanism of injury = hyperextension followed by hyperflexion. Possibly use analogy of ‘sprain’ - e.g. sprained ankle with strained ligaments and bruising
- Emphasise that there are no fractures visible on X-ray
- Simple description of structure involved
- Discuss likely time/course of recovery - most improvement in first 2-3 wks with slow improvement after that. Could take months
- Describe how most pts feel tense and depressed for about 2 wks. Emotional rxn of anger and frustration
Cervical sprain - mx
a. Immediate
1. Appropriate use of analgesia with possibility of NSAIDs for first 2 wks
2. Possible use of soft collar for 2-3d if pain is severe
3. Possible use of codeine or tramadol if severe pain, use for up to 3 wks only
4. Advise about time off work (how long?)
5. Keep neck warm, i.e. warm towels or hot showers (cold packs reserved for first 2-3d)
6. Early exercise therapy is a high priority. Physiotherapy guidance helpful
7. Mobilisation good but manipulation contraindicated for at least 8wks
Long-term
1. Provide ongoing psychological and physiotherapy support
Cervical sprain - prevention
- Smoking
- Alcohol
- Weight loss/diet
- Exercise
etc.
Sciatica - dx
- X-ray findings - demonstrate by reference to X-ray, model of spine or diagram (L5-S1 disc narrowing)
- Nerve root pressure
- Probability of disc prolapse
Prognosis
- Likely to be excellent but can recur
- Reduce anxiety about future
- Should be able to maintain present occupation (taxi driver)
Sciatica - mx
a. Immediate
1. Relative rest for 2-3d - lying on firm surface, avoid sitting in deep, soft chirs
2. Encourage early return to routine daily activities ASAP
3. Problem of self-care if no partner/partner working full-time
4. Adequate analgesia - paracetamol, NSAIDs. Codeine or tramadol if pain severe (only up to 3 wks)
5. Time off work. Uncertain today, approximately 2 wks. Appropriate medical certificate written
6. Give exercise program
b. Long-term
1. Follow up response to treatment within 1 wk
2. Maintain contact by phone
3. Domiciliary visit may be necessary
4. Average course of sciatic pain 12 wks, surgery in 10%
5. Consider phone call after 3d. Review in 1 wk.
If response response inadequate, consider:
- Physio referral before more invasive therapy
- Epidural injection
- Spinal traction (form of decompression therapy, performed manually or mechanically)
- Consider orthopedic referral if pain worsening or neurological deficit. Many may argue that a neurosurgeon is a better referral pathway, or at least an ortho who does a lot of backs
- Mention red flags - sphincter disturbance, fever, neurological changes distally
Other
- Further ix (?)
- Consider acupuncture
- Spinal manipulation inappropriate but mobilisation OK
Sciatica - prevention
- Back education - lifting, sitting, other aspects
- Continue exercise program
- Smoking, alcohol
- Ulcer prevention (if pt has PHx ulcer and is using NSAIDs)
Gout - explanation
- Type of arthritis caused by uric acid crystal deposition in the joint space, causing inflammation
- Multiple causes. Any sudden rise in uric acid (dehydration, thiazide diuretics/aspirin/cyclosporin, with trauma, exercise, or alcohol) or any sudden fall in uric acid (common in women) can precipitate an attack of gout
- Dx is clinical even if serum uric acid is normal
Gout - mx
a. Immediate
1. Ideal mx = aspirate joint to confirm crystal arthropathy (under polarising microscopy) and inject corticosteroid into joint (if sepsis eliminated). Consider digital block to toe
2. Start indomethacin (NSAID) and cease as gout settles. May require short term antacid, H2 antagonist or PPI for dyspepsia. Make sure pt takes indomethacin after food
3. Consider cessation of diuretic. Avoid aspirin
4. Eliminate or modify beer/alcohol intake
5. Drink plenty of water
6. Wear comfortable shoes
7. DO NOT give allopurinol
8. Review in 2-3d then in 4 wks, to ax blood tests
b. Long-term
1. Review uric acid level (may be normal during attack)
2. If further analgesia required, suggest colchicine or alternative NSAID (e.g. naproxen or diclofenac) with PPI cover. Consider steroids.
3. Give dietary advice. Low purine diet - avoid organ meats, anchovies and shellfish. Drink plenty of fluids
Gout - prevention
- Encourage pt to eliminate alcohol intake
