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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 Conditions

Contents

Module 1: Musculoskeletal Conditions..................................................................................21.1 Shoulder & Upper Arm......................................................................................4

Theme 1 History taking for shoulder and upper arm problems/injuries................4Theme 2 Focused clinical assessment of shoulder and upper arm problems/injuries....................................................................................................6Theme 3 Common investigations for shoulder and upper arm problems/injuries. 8Theme 4 Common pharmacology for the management of shoulder and upper arm injuries/problems..................................................................................................10Theme 5 Management of shoulder and upper arm injuries/problems..................12

1.2: Elbow.............................................................................................................15Theme 1 History taking of elbow problems/injuries............................................15Theme 2 Focused clinical assessment of elbow injuries......................................17Theme 3 Common investigations for elbow problems/injuries...........................19Theme 4 Common pharmacology for the management of elbow injuries/problems..................................................................................................21Theme 5 Management of elbow injuries/problems..............................................23

1.3 Wrist...................................................................................................................27Theme 1 History taking for wrist injuries/problems............................................27Theme 2 Focused clinical assessment of wrist problems/injuries................29Theme 3 Common investigations for wrist injury/problems...............................31Theme 4 Common pharmacology for the management of wrist injury/problems.................................................................................................33Theme 5 Management of wrist injuries/problems.............................................35

1.4 Hand...................................................................................................................39Theme 1 History taking for Hand injury/problems..............................................39Theme 2 Focused clinical assessment of hand injury/conditions........................41Theme 3 Common investigations for hand injuries/conditions...........................43Theme 4 Common pharmacology for the management of hand injuries/problems..............................................................................................................................45Theme 5 Management of hand pain/injury..........................................................47

1.5: Hip....................................................................................................................51Theme 1 History taking specific to hip injuries/conditions.................................51Theme 2 Focused clinical assessment specific to hip injuries/conditions...........53Theme 3 Common investigations specific to hip injuries....................................56Theme 4 Common pharmacology specific to hip injuries/conditions.................58Theme 5 Management of specific to hip injuries/conditions...............................60

1.6: Knee.................................................................................................................63Theme 1 History taking specific to knee injuries/conditions...............................63Theme 2 Focused clinical assessment specific to knee injuries...........................65

Theme 3 Common investigations specific to knee injuries/conditions................68Theme 4 Common pharmacology specific to knee injuries/conditions...............70Theme 5 Management of specific to knee injuries/conditions.............................72

1.7: Ankle................................................................................................................76Theme 1 History taking specific to ankle injuries/conditions..............................76Theme 2 Focused clinical assessment specific to ankle injuries/conditions......78Theme 3 Common investigations specific to ankle injuries/conditions...............80Theme 4 Common pharmacology specific to ankle injuries/conditions..............82Theme 5 Management of ankle injuries/conditions.............................................84

1.8: Foot................................................................................................................87Theme 1 History taking specific to foot injuries/conditions................................87Theme 2 Focused clinical assessment specific to foot injuries/conditions..........89Theme 3 Common investigations specific to foot injuries/conditions.................91Theme 4 Common pharmacology specific to foot injuries/conditions................93Theme 5 Management of foot injuries/conditions/..............................................95

1.9: Cervical Spine..................................................................................................99Theme 1 History taking for cervical spine pain & injury....................................99Theme 2 Focused clinical assessment of cervical spine pain & injury..............103Theme 3 Common investigations for cervical spine pain, & injury..................106Theme 4 Common pharmacology for the management of cervical spine pain, & injury..................................................................................................................109Theme 5 Management of cervical spine pain & injury......................................111

1.10 Thoracic spine.............................................................................................114Theme 1 History taking for thoracic spine pain & injury injury........................114Theme 2 Focused clinical assessment of thoracic spine pain& injury...............118Theme 3 Common investigations for thoracic spine pain &injury....................120Theme 4 Common pharmacology for the management of thoracic spine pain & injury..................................................................................................................122Theme 5 Management of thoracic spine pain & injury......................................124

1.11 Lumbar Spine.................................................................................................127Theme 1 History taking for lumbar spine pain & injuries.................................127Theme 2 Focused clinical assessment of low back pain & injuries...................130Theme 3 Common investigations for lumbar spine pain & injuries..................133Theme 4 Common pharmacology for the management of lumbar spine pain & injury..................................................................................................................135Theme 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 Crusho Direct traumao Fall on outstretched hand (FOOSH)

o Fall from standing o Fall from height/bikeo Cause of fallo Associated injuries such as headstrike, LOC

o Axial loading or “jamming”, o Position of arm o Compression/distraction, varus/valgus forceso Direction of force including position of distal jointso Skin integrityo Time of injury, ability to move arm post injuryo Symptoms such as numbness, pins and needles , ‘dead arm’ , tinglingo Consider other sites for injury/pain and relevant associated questions

requiredo 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

Module 1.1: Musculoskeletal Conditions – Shoulder and upper arm4

indicate non musculoskeletal causes of shoulder and arm pain?5,6

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 painhttp://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 patienthttp://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


http://www.aafp.org/afp/2008/0215/p453.html

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2723207/pdf/bcp0067-0671.pdf#page=1&zoom=auto,0,780




http://www.uptodate.com/contents/preoperative-medical-evaluation-of-the-healthy-patient?source=search_result&search=preoperative+evaluation&selectedTitle=2~150



http://onlinelibrary.wiley.com/doi/10.1197/aemj.9.3.203/pdf

http://www.uptodate.com/contents/evaluation-of-the-patient-with-shoulder-complaints?source=preview&anchor=H5&selectedTitle=1~150#H5

http://www.uptodate.com/contents/evaluation-of-the-patient-with-shoulder-complaints?source=preview&anchor=H5&selectedTitle=1~150#H5

http://www.workcover.com/health-provider/injury-management-by-health-discipline/red-flags


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.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.




http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1283277/pdf/bmj33101124.pdf

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, 39-44http://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 examhttp://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


http://www.uptodate.com/contents/evaluation-of-the-patient-with-neck-pain-and-cervical-spine-disorders?source=see_link

http://www.uptodate.com/contents/evaluation-of-the-patient-with-neck-pain-and-cervical-spine-disorders?source=see_link

http://www.uptodate.com/contents/the-detailed-neurologic-examination-in-adults?source=search_result&search=elbow&selectedTitle=55~150


http://www.uptodate.com/contents/physical-examination-of-the-shoulder?source=search_result&search=shoulder&selectedTitle=2~150

http://www.uptodate.com/contents/physical-examination-of-the-shoulder?source=search_result&search=shoulder&selectedTitle=2~150

http://www.uptodate.com/contents/evaluation-of-the-patient-with-shoulder-complaints?view=print

http://www.uptodate.com/contents/evaluation-of-the-patient-with-shoulder-complaints?view=print

http://www.jospt.org/issues/articleID.310,type.2/article_detail.asp

http://www.snjourney.com/ClinicalInfo/Systems/PDF/NeuroVas%20Assessment.pdf

Theme 3 Common investigations for shoulder and upper arm problems/injuriesLEARNING 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/imaging-pathways/musculoskeletal-trauma/musculoskeletal/shoulder-injury?tab=ct#pathway-home


http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/musculoskeletal/shoulder-injury?tab=ct#pathway-home

http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/musculoskeletal/shoulder-injury?tab=ct#pathway-home

http://www.med-ed.virginia.edu/courses/rad/ext/index.html

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 date7. Jude, C & Modarresi (2012) Radiological evaluation of the shoulderhttp://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 painhttp://www.uptodate.com/contents/diagnostic-imaging-of-joint-pain?source=see_link

10. Bruyn, G (2013) Ultrasound guided injection and aspiration of jointshttp://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 Assistanthttp://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


http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_upper_limb/upper_limb_trauma_x-ray_start.html


http://www.radiologyassistant.nl/en/p4963d77684ef7/shoulder-mr-bankart-lesions.html

http://www.radiologyassistant.nl/en/p4963d77684ef7/shoulder-mr-bankart-lesions.html

http://www.radiologyassistant.nl/en/p4f49ef79818c2/shoulder-mr-anatomy.html

http://www.uptodate.com/contents/musculoskeletal-ultrasonography-guided-injection-and-aspiration-of-joints-and-related-structures?source=search_result&search=elbow&selectedTitle=11~150



http://www.uptodate.com/contents/diagnostic-imaging-of-joint-pain?source=see_link

http://www.uptodate.com/contents/evaluation-of-the-adult-with-monoarticular-pain?source=search_result&search=joint+infection&selectedTitle=5~150


http://www.uptodate.com/contents/radiologic-evaluation-of-the-painful-shoulder?source=search_result&search=shoulder&selectedTitle=8~150

http://www.uptodate.com/contents/radiologic-evaluation-of-the-painful-shoulder?source=search_result&search=shoulder&selectedTitle=8~150

http://www.radiologyassistant.nl/en/p4f49ef79818c2/shoulder-anatomy.html

Theme 4 Common pharmacology for the management of shoulder and upper arm injuries/problems


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


http://bjsm.bmj.com/content/early/2009/06/21/bjsm.2009.059980.full.pdf

http://online.tg.org.au/ip/

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\

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-date9. 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 actionhttp://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 guidelineshttp://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


http://www.uptodate.com/contents/tetanus-immune-globulin-human-drug-information?source=search_result&search=tetanus&selectedTitle=7~150


http://www.rch.org.au/clinicalguide/guideline_index/Management_of_tetanusprone_wounds/

http://www.mdconsult.com/das/article/body/385344101-2/jorg=journal&source=&sp=18944593&sid=0/N/577108/s0733862707000041.pdf?issn=0733-8627



http://www.uptodate.com/contents/nsaids-mechanism-of-action?source=search_result&search=pharmacology&selectedTitle=5~150


http://www.uptodate.com/contents/ibuprofen-drug-information?source=see_link&utdPopup=true




http://www.cfp.ca/content/56/6/514.full.pdf+html

http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp104_3.pdf%5C

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 scapulao Fracture of the neck of the scapulao Fracture of the acromion processo Fracture of the coracoid processo Dislocation of the sterno-clavicular jointo Strain of the sterno-clavicular jointo Subluxation and dislocation of the acromio-clavicular jointo Strain of the acromio -clavicular jointo 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 cuffo Rotator cuff – full and partial tearo Supraspinatus tendonopathyo Acute calcific tendinitiso Subacromial bursitiso Impingemento Winging of the scapulao Fracture of the neck of the humeruso Fracture of the greater tuberosityo Fracture of the shaft of the humeruso OA/RA/AVN of the shoulder


o Thoracic outlet syndromeo Adhesive capsulitiso Cervical/thoracic referred paino Brachial plexus neuritiso Supra-scapular nerve entrapmento 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.



http://archsurg.jamanetwork.com/article.aspx?articleid=407366

http://www.ncbi.nlm.nih.gov/pubmed/8672833

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 reference.http://emedicine.medscape.com/article/823843-overview

Up to date8. 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 injurieshttp://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/frozen-shoulder-adhesive-capsulitis?view=print

http://www.uptodate.com/contents/rotator-cuff-tendinopathy?view=print

http://www.uptodate.com/contents/splinting-of-musculoskeletal-injuries?source=search_result&selectedTitle=18~150


http://www.uptodate.com/contents/acromioclavicular-joint-disorders?view=print

http://www.uptodate.com/contents/musculoskeletal-complications-in-diabetes-mellitus?source=search_result&search=diabetes+mellitus&selectedTitle=9~150


http://www.uptodate.com/contents/biceps-tendinopathy-and-tendon-rupture?view=print

http://www.uptodate.com/contents/biceps-tendinopathy-and-tendon-rupture?view=print

http://www.uptodate.com/contents/clavicle-fractures?view=print

http://www.uptodate.com/contents/proximal-humeral-fractures-in-adults?view=print

http://www.uptodate.com/contents/stress-fractures-of-the-humeral-shaft?view=print

http://www.uptodate.com/contents/midshaft-humeral-fractures-in-adults?view=print

http://emedicine.medscape.com/article/823843-overview

http://www.uptodate.com/contents/shoulder-dislocation-and-reduction?view=print






http://www.uptodate.com/contents/shoulder-dislocation-and-reduction?view=print

1.2: Elbow

Theme 1 History taking of elbow problems/injuriesLEARNING OBJECTIVES:

1. Identify the key principles of history taking of elbow problems/injuries in the context of the ED setting2. Review the importance of mechanism of injury to the elbow3. 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 Crusho Direct traumao Fall on outstretched hand (FOOSH)

o Fall from standing o Fall from height/bikeo Cause of fallo Associated injuries such as headstrike, LOC

o Axial loading or “jamming”, o Position of arm o Compression/distraction, varus/valgus forceso Direction of force including position of distal jointso Skin integrityo Time of injury, ability to move arm post injuryo Symptoms such as numbness, pins and needles , ‘dead arm’ , tinglingo 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

Module 1.2: Musculoskeletal Conditions – Elbow17

What key information in a patient’s social history is important in elbow 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,









http://www.uptodate.com/contents/elbow-injuries-in-the-young-athlete?source=search_result&search=history+elbow&selectedTitle=2~150

http://www.uptodate.com/contents/elbow-injuries-in-the-young-athlete?source=search_result&search=history+elbow&selectedTitle=2~150

http://www.uptodate.com/contents/evaluation-of-elbow-pain-in-adults?source=search_result&search=history+elbow&selectedTitle=1~150

http://www.uptodate.com/contents/evaluation-of-elbow-pain-in-adults?source=search_result&search=history+elbow&selectedTitle=1~150



19(6), 359-367. http://www.jaaos.org/content/19/6/359.abstract

Theme 2 Focused clinical assessment of elbow injuries


1. Identify the key aspects in clinical assessment of the elbow in the ED setting2. 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 careASSUMED 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 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.




http://www.jaaos.org/content/19/6/359.abstract





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

10. Gelb, D (2012) The detailed neurological examination in adultshttp://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 bursitishttp://cks.nice.org.uk/olecranon-bursitis#!topicsummary


http://www.uptodate.com/contents/diagnosis-and-differential-diagnosis-of-rheumatoid-arthritis?source=search_result&search=rheumatoid&selectedTitle=1~150


http://www.uptodate.com/contents/clinical-manifestations-of-osteoarthritis?source=search_result&search=ankle+osteoarthritis&selectedTitle=2~150


http://www.uptodate.com/contents/evaluation-of-the-adult-with-monoarticular-pain?source=search_result&search=elbow&selectedTitle=27~150


http://www.uptodate.com/contents/septic-arthritis-in-adults?source=search_result&search=septic+arthritis&selectedTitle=1~150




http://www.uptodate.com/contents/evaluation-of-elbow-pain-in-adults?view=print


Theme 3 Common investigations for elbow problems/injuriesLEARNING OBJECTIVES:

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


Describe the normal x-ray of an elbowComplete 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 Date6. Bacccei, S, Kim, C & Weissman, B (2013) Diagnostic imaging of joint painhttp://www.uptodate.com/contents/diagnostic-imaging-of-joint-pain?source=see_link






http://www.med.uottawa.ca/radiology/assets/documents/msk_imaging/articles/The%20Elbow%20-%20Radiographic%20Imaging%20Pearls%20and%20Pitfalls.pdf

http://www.med.uottawa.ca/radiology/assets/documents/msk_imaging/articles/The%20Elbow%20-%20Radiographic%20Imaging%20Pearls%20and%20Pitfalls.pdf


8. Elbow MRI, http://www.radiologyassistant.nl/en/p520a87cf627d9/elbow-mri.html9. 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





http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1679241/pdf/bmj00044-0046.pdf

http://www.radiologyassistant.nl/en/p520a87cf627d9/elbow-mri.html

Theme 4 Common pharmacology for the management of elbow injuries/problems LEARNING OBJECTIVES:

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


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\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.



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


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 guidelineshttp://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 bursitishttp://cks.nice.org.uk/olecranon-bursitis#!topicsummary

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

http://cks.nice.org.uk/olecranon-bursitis#!topicsummary















http://summaries.cochrane.org/CD003686/non-steroidal-anti-inflammatory-drugs-nsaids-for-treating-tennis-elbow-pain-in-adults




Theme 5 Management of elbow injuries/problems LEARNING OBJECTIVES:

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 fractureo Olecranon fracture o Medial and lateral epicondylar fractureo Capitellum fractureo Intercondylar Y or T fractureso Elbow dislocationo Medial or lateral collateral ligament injury

o Subluxation and Dislocation of radial heado Olecranon bursitiso Epicondylitis o Monteggia fractureo Galeazzi fractureo Essex-Lopresti fractureo Loose bodies/ osteochondritis dissecans (OCD)o Tendinopathyo Calcific tendonitiso Nerve entrapmentso 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 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/paino 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.pub2http://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 Module 1.2: Musculoskeletal Conditions – Elbow28

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008130.pub2/pdf



Elsevier. The elbow.

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 athletehttp://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 wristhttp://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 injurieshttp://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 managementhttp://www.uptodate.com/contents/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=12~150






http://www.uptodate.com/contents/management-of-osteochondritis-dissecans-ocd?source=search_result&search=elbow&selectedTitle=15~150

http://www.uptodate.com/contents/management-of-osteochondritis-dissecans-ocd?source=search_result&search=elbow&selectedTitle=15~150

http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-osteochondritis-dissecans-ocd?source=search_result&search=elbow&selectedTitle=9~150



http://www.uptodate.com/contents/ulnar-neuropathy-at-the-elbow-and-wrist?source=search_result&search=elbow&selectedTitle=5~150


http://www.uptodate.com/contents/elbow-injuries-in-the-young-athlete?source=search_result&search=elbow&selectedTitle=3~150

http://www.uptodate.com/contents/elbow-injuries-in-the-young-athlete?source=search_result&search=elbow&selectedTitle=3~150

http://www.uptodate.com/contents/radial-head-subluxation-nursemaids-elbow?source=search_result&search=elbow&selectedTitle=6~150

http://www.uptodate.com/contents/radial-head-subluxation-nursemaids-elbow?source=search_result&search=elbow&selectedTitle=6~150

source=search_result&search=elbow&selectedTitle=12%7E150

18. Slabaugh, M (2013) Radial head and neck fractureshttp://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.


http://www.bjj.boneandjoint.org.uk/content/82-B/2/200.full.pdf+html

http://www.aafp.org/afp/2011/0915/p653.pdf



http://www.uptodate.com/contents/radial-head-and-neck-fractures-in-adults?source=search_result&search=elbow&selectedTitle=8~150

http://www.uptodate.com/contents/radial-head-and-neck-fractures-in-adults?source=search_result&search=elbow&selectedTitle=8~150


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 wrist3. 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 traumao Crusho Fall on outstretched hand (FOOSH)o Fall from standing o Fall from height/bikeo Cause of fallo Direction of force - axial loading or “jamming”, o Position of hand – flexion/extension/ulnar or radial deviationo Skin integrityo Time of injury, ability to move arm post injuryo Symptoms such as numbness, pins and needles , ‘dead arm’ , tinglingo 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 the first aid/pre hospital treatment?

Module 1.4: Musculoskeletal Conditions – Wrist31

What is the relevance of determining the last intake of food or fluids?


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 date5. Anderson, B (2012) Evaluation of the adult patient with wrist painhttp://www.uptodate.com/contents/evaluation-of-the-adult-patient-with-wrist-pain?source=search_result&selectedTitle=103%7E150







http://www.uptodate.com/contents/evaluation-of-the-adult-patient-with-wrist-pain?source=search_result&selectedTitle=103~150

http://www.uptodate.com/contents/evaluation-of-the-adult-patient-with-wrist-pain?source=search_result&selectedTitle=103~150



Theme 2 Focused clinical assessment of wrist problems/injuries


1. Identify the key aspects in clinical assessment of the wrist in the ED setting2. 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 careASSUMED 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 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.




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



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 date10. 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 diseasehttp://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-calcium-pyrophosphate-crystal-deposition-disease?source=see_link


http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-calcium-pyrophosphate-crystal-deposition-disease?source=see_link

http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-calcium-pyrophosphate-crystal-deposition-disease?source=see_link








http://link.springer.com/article/10.1007/s12245-010-0217-5

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1388134/


Theme 3 Common investigations for wrist injury/problems


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 wristComplete the online interactive radiology tutorial and quiz3,4,6,12

RECOMMENDED RESOURCES1. 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/imaging-pathways/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.


http://www.radiologyassistant.nl/en/p476a23436683b/wrist-fractures.html

http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma



http://www.radiologyassistant.nl/en/p42a29ec06b9e8/wrist-carpal-instability.html

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

Up To Date9. Baccei, S, Kim, C & Weissman, B (2013) Imaging techniques for evaluation of the painful jointhttp://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%7E150Refer 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









http://www.wikiradiography.com/page/DISI+and+VISI+Deformities

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).

Module 1.4: Musculoskeletal Conditions – Hand37




http://bjsm.bmj.com/content/early/2009/06/21/bjsm.2009.059980.full.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\



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—122http://onlinelibrary.wiley.com/doi/10.1111/j.1399-6576.2004.00280.x/pdf

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


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

Up to date14 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









http://onlinelibrary.wiley.com/doi/10.1111/j.1399-6576.2004.00280.x/pdf







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+htmlTheme 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 fractureso Radio-ulnar joint injury/dislocationo Fracture of the carpal boneso Flake fracture of Triquetral o Fracture of the lunateo Fracture of the hook of hamateo Fracture of the trapeziumo Fracture of pisiformo Kienbock’s disease of the lunate. o AVN (capitate and scaphoid)o Wrist complex instabilities (DISI/VISI)o Dislocation of lunate/perilunaro Repetitive strain injury


http://emj.bmj.com/content/2/2/67.full.pdf+html

o Acute extensor tenosynovitis (infective)o Wrist spraino TFCC sprain/tearo Carpal tunnel syndromeo Ganglionso Scaphoid-lunate instabilityo OA of the wristo CRPSo Nerve entrapments – Guyon’s cannelo Carpel tunnel syndromeo De Quervains syndromeo Inflammatory arthropathies

Describe how your management of wrist conditions will vary if your patient is:o Diabetic24


o Mechanism was a crush injuryo Mechanism of a fall with unknown causeo Has associated facial, head, neck or chest wall injuries/paino 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 Physician. Sep 1;70(5):879-884http://www.aafp.org/afp/2004/0901/p879.html

Up to date7. deWebber (2013) Lunate fractureshttp://www.uptodate.com/contents/lunate-fractures?source=search_result&selectedTitle=71%7E150

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

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

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

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

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

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

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

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

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


http://www.uptodate.com/contents/triquetral-fractures?source=search_result&selectedTitle=73~150

http://www.uptodate.com/contents/triquetral-fractures?source=search_result&selectedTitle=73~150

http://www.uptodate.com/contents/trapezoid-fractures?source=search_result&selectedTitle=70~150

http://www.uptodate.com/contents/trapezoid-fractures?source=search_result&selectedTitle=70~150

http://www.uptodate.com/contents/trapezium-fractures?source=search_result&selectedTitle=68~150

http://www.uptodate.com/contents/trapezium-fractures?source=search_result&selectedTitle=68~150

http://www.uptodate.com/contents/pisiform-fractures?source=search_result&selectedTitle=69~150

http://www.uptodate.com/contents/pisiform-fractures?source=search_result&selectedTitle=69~150

http://www.uptodate.com/contents/overview-of-carpal-fractures?source=search_result&selectedTitle=32~150


http://www.uptodate.com/contents/hamate-fractures?source=search_result&selectedTitle=67~150

http://www.uptodate.com/contents/hamate-fractures?source=search_result&selectedTitle=67~150

http://www.uptodate.com/contents/capitate-fractures?source=search_result&selectedTitle=72~150

http://www.uptodate.com/contents/capitate-fractures?source=search_result&selectedTitle=72~150



http://www.uptodate.com/contents/scaphoid-fractures?source=search_result&selectedTitle=74~150

http://www.uptodate.com/contents/scaphoid-fractures?source=search_result&selectedTitle=74~150

http://www.uptodate.com/contents/lunate-fractures?source=search_result&selectedTitle=71~150

http://www.uptodate.com/contents/lunate-fractures?source=search_result&selectedTitle=71~150



18. Keyser, F & Sheon, R (2012) Ganglions and noduleshttp://www.uptodate.com/contents/ganglia-and-nodules?source=search_result&search=wrist&selectedTitle=37%7E150

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

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

21. Petron, D (2013) Distal radius fractures in adultshttp://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 adultshttp://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 tenosynovitishttp://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.bjj.boneandjoint.org.uk/content/82-B/2/200.full.pdf+html


http://www.uptodate.com/contents/infectious-tenosynovitis?source=search_result&search=wrist&selectedTitle=81~150






http://www.uptodate.com/contents/prevention-and-management-of-complex-regional-pain-syndrome-in-adults?source=search_result&search=wrist&selectedTitle=87~150



http://www.uptodate.com/contents/distal-radius-fractures-in-adults?source=search_result&selectedTitle=144~150

http://www.uptodate.com/contents/distal-radius-fractures-in-adults?source=search_result&selectedTitle=144~150

http://www.uptodate.com/contents/treatment-of-carpal-tunnel-syndrome?source=search_result&selectedTitle=16~150

http://www.uptodate.com/contents/treatment-of-carpal-tunnel-syndrome?source=search_result&selectedTitle=16~150

http://www.uptodate.com/contents/etiology-of-carpal-tunnel-syndrome?source=search_result&selectedTitle=85~150

http://www.uptodate.com/contents/etiology-of-carpal-tunnel-syndrome?source=search_result&selectedTitle=85~150

http://www.uptodate.com/contents/ganglia-and-nodules?source=search_result&search=wrist&selectedTitle=37~150




http://www.uptodate.com/contents/preoperative-medical-evaluation-of-the-healthy-patient?source=search_result&search=preoperative+evaluation&selectedTitle=2%7E150

1.4 Hand

Theme 1 History taking for Hand injury/problemsLEARNING OBJECTIVES:

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 hand3. 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 Crusho Direct traumao Fall on outstretched hand (FOOSH)o Fall from standing o Fall from height/bikeo Cause of fallo Direction of force - axial loading or “jamming”, o Position of hand – flexion/extension/ulnar or radial deviationo Skin integrityo Time of injury, ability to move arm post injuryo Symptoms such as numbness, pins and needles , ‘dead arm’ , tinglingo Consider other sites for injury – particular shoulder, elbow and forearmo Lacerations/bites/exposure to contaminationo Implications of punching injuries involving exposure to mouth/teetho 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

What is the relevance of determining any intervention to date? 5,6


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 date5. Anderson, B (2012) Evaluation of the patient with hand painhttp://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 painhttp://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







http://www.uptodate.com/contents/evaluation-of-the-patient-with-thumb-pain?source=search_result&selectedTitle=4~150

http://www.uptodate.com/contents/evaluation-of-the-patient-with-thumb-pain?source=search_result&selectedTitle=4~150

http://www.uptodate.com/contents/evaluation-of-the-patient-with-hand-pain?source=search_result&selectedTitle=1~150

http://www.uptodate.com/contents/evaluation-of-the-patient-with-hand-pain?source=search_result&selectedTitle=1~150




Theme 2 Focused clinical assessment of hand injury/conditionsLEARNING OBJECTIVES:

1. Identify the key aspects in clinical assessment of the hand in the ED setting2. Formulate key findings to support/refute preliminary differential diagnosis?3. Differentiate early, presentations of the hand of non musculoskeletal origin that


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 RESOURCES1. 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.






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 date14. 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







http://emj.bmj.com/content/15/4/269.full.pdf+html





Theme 3 Common investigations for hand injuries/conditionsLEARNING OBJECTIVES:

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 handComplete 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/imaging-pathways/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 Date7. Baccei, S, Kim, C & Weissman, B (2013) Imaging techniques for evaluation of the painful jointhttp://www.uptodate.com/contents/diagnostic-imaging-of-joint-pain?source=see_link

8. Chung, K, Ono, S & Sebastian, S (2012) Overview of hand infectionshttp://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

Theme 4 Common pharmacology for the management of hand injuries/problems


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


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




http://www.uptodate.com/contents/overview-of-hand-infections?source=search_result&search=hand&selectedTitle=4~150

http://www.uptodate.com/contents/overview-of-hand-infections?source=search_result&search=hand&selectedTitle=4~150


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC557237/pdf/bmj33001073.pdf

a. When would this be indicated?









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

10. Hamilton, B, Milne, C, Orchard, J & Paoloni, J (2009) Non-steroidal anti-inflammatory drugs (NSAIDs) in sports medicine. Guidelines for practical but sensible use.http://bjsm.bmj.com/content/early/2009/06/21/bjsm.2009.059980.abstract


http://bjsm.bmj.com/content/early/2009/06/21/bjsm.2009.059980.abstract










11.Australian Medicines Handbook (2013) Australian Medicines Handbook: Nitrous Oxidehttps://www.amh.net.au/online/view.php?page=chapter2/monographnitrous-oxide.html

12.eTG complete (2013) Therapeutic guidelines: Tetanushttp://online.tg.org.au/ip/



Up to date15.Lexicomp (2013) Ibuprofen: Drug infomationhttp://www.uptodate.com/contents/ibuprofen-drug-information?source=see_link&utdPopup=true

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

Refer to Pharmacology module

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









https://www.amh.net.au/online/view.php?page=chapter2/monographnitrous-oxide.html

https://www.amh.net.au/online/view.php?page=chapter2/monographnitrous-oxide.html

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 fractureo Rolando fractureo CMC OAo Ulnar collateral ligament injury (skiers thumb)o Extensor or flexor tendon injury to the hand o Metacarpal fractures and dislocationo Proximal phalangeal fractureso Middle phalangeal fractureso Distal phalangeal fractureso Digit Joint dislocationo Volar plate injury o Mallet deformity, o Boutonnieres deformity, o Swan neck deformityo Carpal injuryo Repetitive strain injuryo Tenosynovitis (+/- infective)o Carpel tunnel syndromeo Ganglionso Digital neurofibromao Trigger thumb and trigger fingero Subungual haematomao Dupuytrens contractureo De Quervains syndrome9

o Inflammatory arthropathies


CLINICAL TASK - Plastering/splinting of hand injuries1. Application of a thumb spica2. 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.

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 adultshttp://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


http://www.uptodate.com/contents/de-quervains-tenosynovitis?source=search_result&search=hand&selectedTitle=8~150

http://www.uptodate.com/contents/de-quervains-tenosynovitis?source=search_result&search=hand&selectedTitle=8~150



http://www.bjj.boneandjoint.org.uk/content/91-B/6/705.full




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 injurieshttp://www.uptodate.com/contents/management-of-fingertip-injuries?source=search_result&search=finger&selectedTitle=6~150

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

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

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

18. Bloom, J (2012) Metacarpal neck fractureshttp://www.uptodate.com/contents/metacarpal-neck-fractures?source=search_result&selectedTitle=9%7E150

19. Bloom, J (2012) Metacarpal base fractureshttp://www.uptodate.com/contents/metacarpal-base-fractures?source=search_result&selectedTitle=29%7E150

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

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

22. Bothner, J & Fastle, R (2012) Subungual haematomahttp://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?


http://www.uptodate.com/contents/overview-of-finger-hand-and-wrist-fractures?source=search_result&search=hand&selectedTitle=3~150

http://www.uptodate.com/contents/subungual-hematoma?source=search_result&search=nail+bed+injury&selectedTitle=2~150

http://www.uptodate.com/contents/subungual-hematoma?source=search_result&search=nail+bed+injury&selectedTitle=2~150

http://www.uptodate.com/contents/metacarpal-shaft-fractures?source=search_result&selectedTitle=31~150

http://www.uptodate.com/contents/metacarpal-shaft-fractures?source=search_result&selectedTitle=31~150

http://www.uptodate.com/contents/metacarpal-head-fractures?source=search_result&selectedTitle=30~150

http://www.uptodate.com/contents/metacarpal-head-fractures?source=search_result&selectedTitle=30~150

http://www.uptodate.com/contents/metacarpal-base-fractures?source=search_result&selectedTitle=29~150

http://www.uptodate.com/contents/metacarpal-base-fractures?source=search_result&selectedTitle=29~150

http://www.uptodate.com/contents/metacarpal-neck-fractures?source=search_result&selectedTitle=9~150

http://www.uptodate.com/contents/metacarpal-neck-fractures?source=search_result&selectedTitle=9~150

http://www.uptodate.com/contents/middle-phalanx-fractures?source=search_result&selectedTitle=11~150

http://www.uptodate.com/contents/middle-phalanx-fractures?source=search_result&selectedTitle=11~150

http://www.uptodate.com/contents/proximal-phalanx-fractures?source=search_result&selectedTitle=10~150

http://www.uptodate.com/contents/proximal-phalanx-fractures?source=search_result&selectedTitle=10~150

http://www.uptodate.com/contents/distal-phalanx-fractures?source=search_result&selectedTitle=7~150

http://www.uptodate.com/contents/distal-phalanx-fractures?source=search_result&selectedTitle=7~150

http://www.uptodate.com/contents/management-of-fingertip-injuries?source=search_result&search=finger&selectedTitle=6~150

http://www.uptodate.com/contents/management-of-fingertip-injuries?source=search_result&search=finger&selectedTitle=6~150

http://www.uptodate.com/contents/ulnar-collateral-ligament-injury-gamekeepers-or-skiers-thumb?source=search_result&selectedTitle=16~150

http://www.uptodate.com/contents/ulnar-collateral-ligament-injury-gamekeepers-or-skiers-thumb?source=search_result&selectedTitle=16~150

http://www.uptodate.com/contents/trigger-finger-stenosing-flexor-tenosynovitis?source=search_result&search=hand&selectedTitle=6~150

http://www.uptodate.com/contents/trigger-finger-stenosing-flexor-tenosynovitis?source=search_result&search=hand&selectedTitle=6~150

source=search_result&search=hand&selectedTitle=3%7E150

24. Eiff, P (2013) Overview of carpal fractureshttp://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 noduleshttp://www.uptodate.com/contents/ganglia-and-nodules?source=search_result&search=wrist&selectedTitle=37~150

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

28. Sexton, D (2012) Infective tenosynovitishttp://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


http://www.bjj.boneandjoint.org.uk/content/82-B/2/200.short







http://www.uptodate.com/contents/digit-dislocation-reduction?source=search_result&search=finger&selectedTitle=42~150

http://www.uptodate.com/contents/digit-dislocation-reduction?source=search_result&search=finger&selectedTitle=42~150



http://www.uptodate.com/contents/overview-of-finger-hand-and-wrist-fractures?source=search_result&search=hand&selectedTitle=3~150

1.5: Hip

Theme 1 History taking specific to hip injuries/conditions


1. Identify the key principles of history taking of hip injuries/conditions2. Review the importance of mechanism of injury in hip injuries3. Differentiate early, presentations of the hip that may require inter-disciplinary

care and/or presentations of non-musculoskeletal origin4. 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 first aid/pre hospital treatment? What is the relevance of determining the last intake of food or fluids?11

Module 1.5: Musculoskeletal Conditions – Hip55



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





http://www.uptodate.com/contents/clinical-features-diagnosis-and-natural-history-of-lower-extremity-peripheral-artery-disease?source=related_link


http://www.uptodate.com/contents/diagnosis-and-classification-of-osteoarthritis?source=related_link


http://www.uptodate.com/contents/evaluation-of-the-adult-with-hip-pain?source=related_link








http://www.ajronline.org/doi/full/10.2214/AJR.09.3383

http://www.ajronline.org/doi/full/10.2214/AJR.09.3383

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 careASSUMED 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.



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

6. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. The shoulder. 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 painhttp://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 adultshttp://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


http://www.uptodate.com/contents/clinical-manifestations-of-ankylosing-spondylitis-in-adults?source=search_result&search=groin+pain&selectedTitle=16~25

http://www.uptodate.com/contents/clinical-manifestations-of-ankylosing-spondylitis-in-adults?source=search_result&search=groin+pain&selectedTitle=16~25

http://www.uptodate.com/contents/pelvic-osteomyelitis?source=see_link



http://www.uptodate.com/contents/classification-clinical-features-and-diagnosis-of-inguinal-and-femoral-hernias-in-adults?source=search_result&search=groin+pain&selectedTitle=3~25








standard radiographs—a study of emergency department patients. Academic emergency medicine, 12(4), 366-369. http://onlinelibrary.wiley.com/doi/10.1197/j.aem.2004.10.024/pdf17. 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


http://journalsconsultapp.elsevier-eprints.com/uploads/articles/arthro1.pdf

http://onlinelibrary.wiley.com/doi/10.1197/j.aem.2004.10.024/pdf

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 quizhttp://www.med-ed.virginia.edu/courses/rad/ext/index.htmlhttp://www.radiologyassistant.nl/en/p431c8258e7ac3/hip-arthroplasty.htmlhttp://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



4. Government of Western Australia Department of Health (2012) Diagnostic Imaging pathways – Suspected hip fracturehttp://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/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


http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/bone-and-joint-trauma/suspected-hip-fracture#pathway

http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/bone-and-joint-trauma/suspected-hip-fracture#pathway


http://labtestsonline.org/understanding/analytes/urinalysis/ui-exams/start/2

http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_lower_limb/lower_limb_trauma_x-ray_start.html


http://www.radiologyassistant.nl/en/p431c8258e7ac3/hip-arthroplasty.html


http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/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 hiphttp://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/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 date8. 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 applicationshttp://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







http://www.uptodate.com/contents/musculoskeletal-ultrasonography-clinical-applications?source=related_link

http://www.uptodate.com/contents/musculoskeletal-ultrasonography-clinical-applications?source=related_link

http://www.uptodate.com/contents/imaging-techniques-for-evaluation-of-the-painful-joint?source=see_link

http://www.uptodate.com/contents/imaging-techniques-for-evaluation-of-the-painful-joint?source=see_link

http://www.uptodate.com/contents/radiologic-evaluation-of-the-painful-hip-in-adults?source=related_link

http://www.uptodate.com/contents/radiologic-evaluation-of-the-painful-hip-in-adults?source=related_link

http://www.uptodate.com/contents/radiologic-evaluation-of-the-hip-in-infants-children-and-adolescents?source=see_link

http://www.uptodate.com/contents/radiologic-evaluation-of-the-hip-in-infants-children-and-adolescents?source=see_link

http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/musculoskeletal/avascular-necrosis-of-the-hip#pathway

http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/musculoskeletal/avascular-necrosis-of-the-hip#pathway



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 When is antibiotics indicated for hip pain/injury and why? Tetanus immunoglobulin and vaccinations9,13,14

oWhen would this be indicated?

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\




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

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



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

Refer to Pharmacology Module













Theme 5 Management of specific to hip injuries/conditions


1. Identify and discuss the common management principles specific to hip injuries/conditions2. 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 haematomao Groin straino Hamstring straino Quadriceps strain/ruptureo Osteitis pubiso Acute labral tearo Chronic labral tearo Femoroacetabular impingemento Bursitis of the hip (trochanteric, ischial, iliopectineal)o Occult hernia / conjoint tendon straino Osteoarthritis of the hipo Acute AVN of the femoral heado Chronic AVN of the femoral heado Perthes diseaseo Snapping hipo 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



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 osteoarthritishttp://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 date13. Anderson, B (2012) Trochanteric Bursitishttp://www.uptodate.com/contents/trochanteric-bursitis?source=related_link

14. Best, T & Classie, J (2013) Osteitis pubis


http://www.uptodate.com/contents/trochanteric-bursitis?source=related_link

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1755499/pdf/v064p00669.pdf

http://www.oarsi.org/pdfs/oarsi_recommendations_for_management_of_hip_and_knee_oa.pdf

http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp117-hip-knee-osteoarthritis.pdf



http://www.cochrane.org.au/files/OAGuidelines_key210708_.pdf




http://www.uptodate.com/contents/osteitis-pubis?source=search_result&search=groin+pain&selectedTitle=6%7E25

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 Injurieshttp://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


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 osteoarthritishttp://www.uptodate.com/contents/diagnosis-and-classification-of-osteoarthritis?source=related_link

21. Kalunian, K. C. (2013) Risk factors and possible causes for osteoarthritishttp://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 childhoodhttp://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


http://www.uptodate.com/contents/bursitis-an-overview-of-clinical-manifestations-diagnosis-and-management?source=search_result&search=bursitis&selectedTitle=1~125

http://www.uptodate.com/contents/bursitis-an-overview-of-clinical-manifestations-diagnosis-and-management?source=search_result&search=bursitis&selectedTitle=1~125

http://www.uptodate.com/contents/overview-of-hip-pain-in-childhood

http://www.uptodate.com/contents/hemarthrosis?source=search_result&search

http://www.uptodate.com/contents/slipped-capital-femoral-epiphysis-scfe?source=related_link

http://www.uptodate.com/contents/risk-factors-for-and-possible-causes-of-osteoarthritis?detectedLanguage=en&source=search_result&search=OA&selectedTitle=4~150&%20provider=noProvider





http://www.uptodate.com/contents/clinical-manifestations-of-osteoarthritis?detectedLanguage=en&source=search_result&search=OA&selectedTitle=%203~150&provider=noProvider





http://www.uptodate.com/contents/acute-compartment-syndrome-of-the-extremities?source=search_result&search=compartment+syndrome+thigh&selectedTitle=1~150

http://www.uptodate.com/contents/acute-compartment-syndrome-of-the-extremities?source=search_result&search=compartment+syndrome+thigh&selectedTitle=1~150

http://www.uptodate.com/contents/hamstring-injuries?source=search_result&search=compartment+syndrome+%20thigh&selectedTitle=22~150

http://www.uptodate.com/contents/hamstring-injuries?source=search_result&search=compartment+syndrome+%20thigh&selectedTitle=22~150

http://www.uptodate.com/contents/sports-related-groin-pain-or-sports-hernia?source=search_result&search=groin+pain&selectedTitle=1~25

http://www.uptodate.com/contents/sports-related-groin-pain-or-sports-hernia?source=search_result&search=groin+pain&selectedTitle=1~25

http://www.uptodate.com/contents/osteitis-pubis?source=search_result&search=groin+pain&selectedTitle=6~25

http://www.uptodate.com/contents/osteitis-pubis?source=search_result&search=groin+pain&selectedTitle=6~25

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 setting2. Review the importance of mechanism of injury in knee injuries3. Differentiate early, presentations of the knee that may require inter-disciplinary care and/or presentations of non-musculoskeletal origin4. 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 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



Module 1.6: Musculoskeletal Conditions – Knee69



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



Up To Date5. 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 injuryhttp://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 injuryhttp://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,









http://www.uptodate.com/contents/approach-to-the-young-athlete-with-chronic-knee-pain-or-injury?detectedLanguage=en&source=search_%20result&search=knee+pain&selectedTitle=2~101&provider=noProvider



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



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

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

http://www.uptodate.com/contents/general-evaluation-of-the-adult-with-knee-pain



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.

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


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.




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),


http://ard.bmj.com/content/63/1/11.full.pdf+html

http://ccjm.org/content/75/Suppl_5/S5.full.pdf+html

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


http://www.uptodate.com/contents/septic-arthritis-in-adults







1326-1330. 18. http://archinte.jamanetwork.com/article.aspx?articleid=484970Anderson, 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 Adultshttp://www.uptodate.com/contents/septic-arthritis-in-adults



http://annals.org/article.aspx?articleid=714645&atab=11

http://archinte.jamanetwork.com/article.aspx?articleid=484970

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 quizhttp://www.med-ed.virginia.edu/courses/rad/ext/index.htmlhttp://www.radiologyassistant.nl/en/p42daafe92b280/knee-meniscal-pathology-1.htmlhttp://www.radiologyassistant.nl/en/p4b98adddb76db/knee-meniscal-pathology-2.htmlhttp://www.radiologyassistant.nl/en/p42764e8fe927e/knee-non-meniscal-pathology.htmlhttp://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/imaging-pathways/musculoskeletal-trauma





http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_lower_limb/knee_x-ray.html

http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_lower_limb/knee_x-ray.html

http://www.radiologyassistant.nl/en/p42764e8fe927e/knee-non-meniscal-pathology.html

http://www.radiologyassistant.nl/en/p42764e8fe927e/knee-non-meniscal-pathology.html

http://www.radiologyassistant.nl/en/p4b98adddb76db/knee-meniscal-pathology-2.html

http://www.radiologyassistant.nl/en/p42daafe92b280/knee-meniscal-pathology-1.html


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 Date7. 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

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 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



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



http://www.uptodate.com/contents/radiologic-evaluation-of-the-acutely-painful-knee-in-adults?source=search_result&search=actue+knee+injuries&selectedTitle=9~35

http://www.uptodate.com/contents/radiologic-evaluation-of-the-acutely-painful-knee-in-adults?source=search_result&search=actue+knee+injuries&selectedTitle=9~35



RECOMMENDED RESOURCES (refer to the Pharmacology Module)









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 actionhttp://www.uptodate.com/contents/nsaids-mechanism-of-action?













source=search_result&search=pharmacology&selectedTitle=5%7E150

12. Becker (2013) Management of acute gout http://www.uptodate.com/contents/treatment-of-acute-gout?source=search_result&search=gout&selectedTitle=1~143

13. Jordan, K. M. (2012). Up-to-date management of gout. Current Opinion in Rheumatology, 24(2), 145-151.







http://www.uptodate.com/contents/treatment-of-acute-gout?source=search_result&search=gout&selectedTitle=1~143



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 injuriesASSUMED 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 consultedo Chronic meniscal injury including discussion on when the Orthopaedic team would

need to be consultedo Cruciate ligament injuryo Acute posterolateral corner of the knee injuryo 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 teamo Patella dislocation.o Bursitis at the knee (prepatellar or infrapatellar)o Septic kneeo Gout of the kneeo OA of the kneeo 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 POPo ZKS

Discuss patient education required foro Plaster of Paris careModule 1.6: Musculoskeletal Conditions – Knee78

o Follow up planCLINICAL APPLICATION:

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



http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1754382/pdf/v062p01145.pdf


http://onlinelibrary.wiley.com/doi/10.1002/acr.21772/abstract;jsessionid


http://www.cochrane.org.au/files/OAGuidelines_key210708_.pdf



http://www.uptodate.com/contents/splinting-of-musculoskeletal-injuries?source=search_result&search=plaster+of+paris&selectedTitle=8~49

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


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 osteoarthritishttp://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 Date19. 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 fractureshttp://www.uptodate.com/contents/fibular-fractures?source=search_result&search=knee+injuries&selectedTitle=21~35


http://www.uptodate.com/contents/fibular-fractures?source=search_result&search=knee+injuries&selectedTitle=21~35

http://www.uptodate.com/contents/fibular-fractures?source=search_result&search=knee+injuries&selectedTitle=21~35

http://www.uptodate.com/contents/medial-collateral-ligament-injury-of-the-knee?source=search_result&search=actue+knee+injuries&selectedTitle=7~35

http://www.uptodate.com/contents/medial-collateral-ligament-injury-of-the-knee?source=search_result&search=actue+knee+injuries&selectedTitle=7~35

http://www.uptodate.com/contents/recognition-and-initial-management-of-lateral-patellar-dislocations

http://www.uptodate.com/contents/recognition-and-initial-management-of-lateral-patellar-dislocations

http://www.uptodate.com/contents/patella-fractures?detectedLanguage=en&source=search_result&search

http://www.uptodate.com/contents/patella-fractures?detectedLanguage=en&source=search_result&search

http://www.uptodate.com/contents/knee-bursitis?source=search_result&search=knee+injuries&selectedTitle=23~35

http://www.uptodate.com/contents/knee-bursitis?source=search_result&search=knee+injuries&selectedTitle=23~35

http://www.uptodate.com/contents/meniscal-injury-of-the-knee?source=search_result&search=actue+knee+injuries&selectedTitle=8~35

http://www.uptodate.com/contents/meniscal-injury-of-the-knee?source=search_result&search=actue+knee+injuries&selectedTitle=8~35

http://www.oarsi.org/pdfs/oarsi_recommendations_for_management_of_hip_and_knee_oa.pdf



http://www.health.govt.nz/publication/diagnosis-and-management-soft-tissue-knee-injuries-internal-derangements

http://www.health.govt.nz/publication/diagnosis-and-management-soft-tissue-knee-injuries-internal-derangements

25. Fields, K (2012) Overview of tibial fractureshttp://www.uptodate.com/contents/overview-of-tibial-fractures-in-adults?source=search_result&search=knee+injuries&selectedTitle=28~35

26. Fields, K (2012) Proximal tibial fractures in adultshttp://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 athletehttp://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 athletehttp://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 osteoarthritishttp://www.uptodate.com/contents/diagnosis-and-classification-of-osteoarthritis?source=related_link

32. Kalunian, K. C. (2013) Risk factors and possible causes for osteoarthritishttp://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



http://www.uptodate.com/contents/patellofemoral-pain-syndrome?source=search_result&search=knee+injuries&selectedTitle=12~35

http://www.uptodate.com/contents/patellofemoral-pain-syndrome?source=search_result&search=knee+injuries&selectedTitle=12~35









http://www.uptodate.com/contents/causes-of-chronic-knee-pain-in-the-young-athlete?detectedLanguage=en&source=search_result&search=chronic+knee+young&selected%20Title=1~150&provider=noProvider



http://www.uptodate.com/contents/treatment-of-knee-injuries-in-the-young-athlete?source=search_result&search=knee+injuries&selectedTitle=3~35

http://www.uptodate.com/contents/treatment-of-knee-injuries-in-the-young-athlete?source=search_result&search=knee+injuries&selectedTitle=3~35

http://www.uptodate.com/contents/anterior-cruciate-ligament-injury?source=search_result&search=actue+knee+injuries&selectedTitle=11~35

http://www.uptodate.com/contents/anterior-cruciate-ligament-injury?source=search_result&search=actue+knee+injuries&selectedTitle=11~35

http://www.uptodate.com/contents/proximal-tibial-fractures-in-adults?source=search_result&search=actue+knee+injuries&selectedTitle=14~35

http://www.uptodate.com/contents/proximal-tibial-fractures-in-adults?source=search_result&search=actue+knee+injuries&selectedTitle=14~35

http://www.uptodate.com/contents/overview-of-tibial-fractures-in-adults?source=search_result&search=knee+injuries&selectedTitle=28~35

http://www.uptodate.com/contents/overview-of-tibial-fractures-in-adults?source=search_result&search=knee+injuries&selectedTitle=28~35

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/conditions3. Differentiate early, presentations of the ankle that may require inter-disciplinary


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 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





Module 1: 7Musculoskeletal Conditions – Ankle82

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-date5. 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



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


http://onlinelibrary.wiley.com/doi/10.1359/jbmr.2000.15.6.993/pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC164368/pdf/attr_37_04_0376.pdf












http://www.uptodate.com/contents/clinical-features-and-management-of-ankle-pain-in-the-young-athlete?source=search_result&search=ankle+pain&selectedTitle=1~39





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


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












Up To Date9. Chorley, J & Powers, C (2012) Evaluation of foot and ankle pain in the young athletehttp://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















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


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/imaging-pathways/musculoskeletal-trauma/bone-and-joint-trauma/ankle-injury

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

RECOMMENDED RESOURCES (Refer to Radiology Module)


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/?


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1618742/?report=reader#__ffn_sectitle


http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_lower_limb/ankle_fracture_x-ray.html

http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_lower_limb/ankle_fracture_x-ray.html

http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/bone-and-joint-trauma/ankle-injury

http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/bone-and-joint-trauma/ankle-injury


report=reader#__ffn_sectitle



7.Baccei, S, Kim, C & Weissman, B (2013) Imaging techniques for evaluation of the painful jointhttp://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


http://www.bmj.com/content/326/7386/417.pdf%2Bhtml







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


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?



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. 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
















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 ruptureo Achillies tendon partial tearo 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 backslabo Full below knee casto CAM boot

Describe how your management of an ankle injury will vary if your patient is:o Diabetic11



Discuss patient education required on discharge foro CAM boot careo Plaster of Paris careo 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: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 Date8. Eiff, P & Koehler, S (2013) Overview of ankle fractures in adultshttp://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&selectedTitle=1%7E96&provider=noProvider


http://www.uptodate.com/contents/achilles-tendinopathy-and-tendon-rupture?detectedLanguage=en&source=search_result&search=achilles+tendonopathy&selectedTitle=1~96&provider=noProvider



http://www.uptodate.com/contents/overview-of-ankle-fractures-in-adults?detectedLanguage=en&source=search_result&search=ankle+fractures&selectedTitle=1~15&provider=noProvider





http://www.racgp.org.au/afp/201001/201001slimmon.pdf



10. 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

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 injurieshttp://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






http://www.bjj.boneandjoint.org.uk/content/82-B/2/200.short



http://www.uptodate.com/contents/evaluation-of-the-diabetic-foot?source=search_result&search=acute+injuries+in+the+diabetic+patient&selectedTitle=17~150



http://www.uptodate.com/contents/acute-compartment-syndrome-of-the-extremities?source=search_result&search=compartment+syndrome+leg&selectedTitle=1~150


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/conditions3. Differentiate early, presentations of the foot that may require inter-disciplinary


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 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



1. Egol, K, Koval, K & Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott Module 1.8: Musculoskeletal Conditions – Foot93

Williams and Wilkins.

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



Up to Date5. Becker, M (2012) Clinical manifestations and diagnosis of gouthttp://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 athletehttp://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 adultshttp://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

Module 1.8: Musculoskeletal Conditions – Foot94


http://ccjm.org/content/75/Suppl_5/S5.full.pdf+html
















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

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,





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 foothttp://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 athletehttp://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
















http://www.uptodate.com/contents/evaluation-of-the-diabetic-foot?source=search_result&search=acute+injuries+in+the+diabetic+%20patient&selectedTitle=17~150




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


http://www.uptodate.com/contents/calcaneus-fractures

Theme 3 Common investigations specific to foot injuries/conditions


1. Discuss the common investigations specific to foot injuries

KNOWLEDGE: When would you consider ordering an x-ray for a patient with a foot njury?1-3, 5,8,10

What other anatomical areas may you need to x-ray with an acute foot 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 a foot injury?1

When would an ultrasound be indicated for a patient with a foot injury?1

When would pathology tests be required for a patient with a foot injury?6,7

Describe Bohler’s angle and its significance to calcaneal #’s.13,14


Website (radiology interactive tutorial and quiz): http://www.med-ed.virginia.edu/courses/rad/ext/index.htmlhttp://www.radiologyassistant.nl/en/420a20ca7196bhttp://radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_lower_limb/foot_fracture_x-ray.html

RECOMMENDED RESOURCES (Refer to Radiology Module)




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


Up-to-date6. Helfgott, S. M. (2013) Evaluation of the adult with monoarticular pain





http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_lower_limb/foot_fracture_x-ray.html

http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_lower_limb/foot_fracture_x-ray.html

http://www.radiologyassistant.nl/en/420a20ca7196b


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 jointhttp://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

10. Landsman, D. P. M. (2009). Imaging of the Foot. http://www.weil4feet.com/research/publications/imaging-foot.pdf

11, Loucks, C., & Buckley, R. (1999). Bohler's angle: correlation with outcome in displaced intra-articular calcaneal fractures. Journal of orthopaedic trauma, 13(8), 554-558.

12. Nicholson, D. A., O'Keeffe, D., & Driscoll, P. A. (1993). The ABC of emergency radiology. The foot. BMJ: British Medical Journal, 307(6910), 997. http://www.bmj.com/highwire/filestream/364404/field_highwire_article_pdf/0/997

13. Bohlers angle http://radiopaedia.org/articles/bohlers-angle-2

14. Hatch and Dean (2014) Calcaneus Fracturehttp://www.uptodate.com/contents/calcaneus-fractures


http://www.uptodate.com/contents/calcaneus-fractures

http://radiopaedia.org/articles/bohlers-angle-2

http://www.bmj.com/highwire/filestream/364404/field_highwire_article_pdf/0/997

http://www.weil4feet.com/research/publications/imaging-foot.pdf

http://www.bmj.com/content/326/7386/417.pdf%2Bhtml





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


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?



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 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-date9. 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
















http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp104_3.pdf

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 fractureo Navicular stress fractureo Cuboid fractureo Undisplaced metatarsal fractureso Base of 5th metatarsal fractureo Minor avulsion fracture of the talus/type 1 talar neck fractureo Type 2, 3, and 4 talar neck fractureo Lateral process of the talus fractureo Calcaneal fracture including types of fracture, other body areas requiring

consideration/clearingo Describe the types of base of 5th metatarsal fractures and their respective

management regimeso Phalangeal fracture or dislocationo Gout in the foot/toeo Morton’s neuroma

Describe how your management of an ankle injury will vary if your patient is:o Diabetic15,16




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 backslabo Below knee volar slabo Full below knee casto 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 injurieshttp://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

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 painhttp://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 athletehttp://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 foothttp://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








http://www.uptodate.com/contents/achilles-tendinopathy-and-tendon-rupture?detectedLanguage=en&source=search_result&search=achilles+tendonopathy

http://www.uptodate.com/contents/achilles-tendinopathy-and-tendon-rupture?detectedLanguage=en&source=search_result&search=achilles+tendonopathy

http://www.uptodate.com/contents/sesamoid-fractures-of-the-foot?source=search_result&search=sesamoid+fractures&selectedTitle=1~5

http://www.uptodate.com/contents/sesamoid-fractures-of-the-foot?source=search_result&search=sesamoid+fractures&selectedTitle=1~5

http://www.uptodate.com/contents/toe-fractures-in-adults?source=search_result&search=toe+fracture&selectedTitle=1~10

http://www.uptodate.com/contents/toe-fractures-in-adults?source=search_result&search=toe+fracture&selectedTitle=1~10

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

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

http://www.uptodate.com/contents/stress-fractures-of-the-metatarsal-shaft?source=search_result&search=stress+fractures&selectedTitle=2~86

http://www.uptodate.com/contents/stress-fractures-of-the-metatarsal-shaft?source=search_result&search=stress+fractures&selectedTitle=2~86

http://www.uptodate.com/contents/plantar-fasciitis-and-other-causes-of-heel-pain

http://www.uptodate.com/contents/foot-fractures-other-than-metatarsal-or-phalangeal-in-children?source=see_link&anchor=H20#H20

http://www.uptodate.com/contents/foot-fractures-other-than-metatarsal-or-phalangeal-in-children?source=see_link&anchor=H20#H20



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 occurred3. 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 diagnoses5. 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 pathologyASSUMED 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, speedo Fall – from height (e.g. 1m, 3m, 5m) vs standing (force of impact)

- Headstrike, loss of consciousnesso 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 dropo Bladder bowel disturbance (both post injury and current)

Module 1.9: Musculoskeletal Conditions – Cervical spine106

o Other sites of injury and potential for organs to be involvedo 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)?



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 spine107

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_diagnosis/red_flags

Up to date10. Anderson, B & Isaac, Z (2013) Evaluation of the patient with neck pain and cervical spine disordershttp://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 arthritishttp://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 departmenthttp://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 athletehttp://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 injuryhttp://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


http://www.uptodate.com/contents/approach-to-the-young-athlete-with-neck-pain-or-injury?source=see_link

http://www.uptodate.com/contents/approach-to-the-young-athlete-with-neck-pain-or-injury?source=see_link

http://www.uptodate.com/contents/overview-of-musculoskeletal-neck-injuries-in-the-young-athlete?source=search_result&search=cervical+spine+injury&selectedTitle=6~59



http://www.uptodate.com/contents/evaluation-of-the-adult-with-headache-in-the-emergency-department?source=search_result&search=carotid+artery+dissection&selectedTitle=4~33



http://www.uptodate.com/contents/cervical-subluxation-in-rheumatoid-arthritis?source=search_result&search=cervical+spine&selectedTitle=18~150

http://www.uptodate.com/contents/cervical-subluxation-in-rheumatoid-arthritis?source=search_result&search=cervical+spine&selectedTitle=18~150

http://www.uptodate.com/contents/pancoasts-syndrome-and-superior-pulmonary-sulcus-tumors?source=search_result&search=pancoast&selectedTitle=1~39

http://www.uptodate.com/contents/pancoasts-syndrome-and-superior-pulmonary-sulcus-tumors?source=search_result&search=pancoast&selectedTitle=1~39

http://www.uptodate.com/contents/evaluation-of-the-patient-with-neck-pain-and-cervical-spine-disorders?source=search_result&search=cervcal+spine&selectedTitle=1~150



http://www.cks.nhs.uk/neck_pain_cervical_radiculopathy/management/scenario_diagnosis/red_flags

http://www.cks.nhs.uk/neck_pain_cervical_radiculopathy/management/scenario_diagnosis/red_flags

peripheral nerve injuries in the young athletehttp://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 radiographshttp://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 adultshttp://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 diagnosishttp://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 Tumorshttp://www.uptodate.com/contents/spinal-cord-tumors









http://www.uptodate.com/contents/spinal-cord-tumors

http://www.uptodate.com/contents/spontaneous-cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis?source=search_result&search=carotid+artery+dissection&selectedTitle=1~33



http://www.uptodate.com/contents/evaluation-and-acute-management-of-cervical-spinal-column-injuries-in-adults?source=search_result&search=cervical+spine&selectedTitle=2~150



http://www.uptodate.com/contents/spinal-column-injuries-in-adults-definitions-mechanisms-and-radiographs?source=search_result&search=cervcal+spine&selectedTitle=4~150



http://www.uptodate.com/contents/overview-of-cervical-spinal-cord-and-cervical-peripheral-nerve-injuries-in-the-young-athlete?source=see_link

http://www.uptodate.com/contents/overview-of-cervical-spinal-cord-and-cervical-peripheral-nerve-injuries-in-the-young-athlete?source=see_link

Theme 2 Focused clinical assessment of cervical spine pain & injury LEARNING OBJECTIVES:

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


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, Slumpo Shoulder joint screeningo Palpatory assessmento Assessment of the dizzy patient o Assessment of vascular insufficiency in the cervical spineo 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

What are the most common non-musculoskeletal presentations of cervical pain10


o Discuss cardiovascular, vascular, visceral and neurological causeso 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


http://whitmorephysiotherapy.com/downloads/Level_3_Upper/Kerry%201%20vertebral%20artery.pdf

http://whitmorephysiotherapy.com/downloads/Level_3_Upper/Kerry%201%20vertebral%20artery.pdf

http://www.ifompt.com/site/ifompt/files/pdf/Standards%20Committee/Standards%20Committee%20Documents//IFOMPT%20Examination%20cervical%20spine%20doc%20September%202012%20definitive.pdf



10. Anderson, B & Isaac, Z (2013) Evaluation of the patient with neck pain and cervical spine disordershttp://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

11. Decker, J & Hergenroeder, A (2013) Field care and evaluation of the young athlete with acute neck injuryhttp://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 disordershttp://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 injuryhttp://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 radiographshttp://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 radiculopathyhttp://www.uptodate.com/contents/clinical-features-and-diagnosis-of-cervical-radiculopathy?source=search_result&search=cervical+spine&selectedTitle=10%7E150


http://www.uptodate.com/contents/clinical-features-and-diagnosis-of-cervical-radiculopathy?source=search_result&search=cervical+spine&selectedTitle=10~150

http://www.uptodate.com/contents/clinical-features-and-diagnosis-of-cervical-radiculopathy?source=search_result&search=cervical+spine&selectedTitle=10~150

http://www.uptodate.com/contents/spinal-column-injuries-in-adults-definitions-mechanisms-and-radiographs?source=search_result&search=cervical+spine&selectedTitle=6~150



http://www.uptodate.com/contents/acute-traumatic-spinal-cord-injury?source=search_result&search=cervical+spine&selectedTitle=9~150

http://www.uptodate.com/contents/acute-traumatic-spinal-cord-injury?source=search_result&search=cervical+spine&selectedTitle=9~150

http://www.uptodate.com/contents/anatomy-and-localization-of-spinal-cord-disorders?source=search_result&search=thoracic+spine&selectedTitle=3~150


http://www.uptodate.com/contents/field-care-and-evaluation-of-the-young-athlete-with-acute-neck-injury?source=search_result&search=cervical+spine&selectedTitle=11~150



http://www.uptodate.com/contents/evaluation-of-the-patient-with-neck-pain-and-cervical-spine-disorders?source=search_result&search=cervical+spine&selectedTitle=1~150#H17



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


http://www.radiologyassistant.nl/en/p49021535146c5/spine-cervical-injury.html

http://www.radiologyassistant.nl/en/p49021535146c5/spine-cervical-injury.html

http://www.emergencymedicine.utoronto.ca/Assets/EmergeMed+Digital+Assets/%20Prehospital+Research/

http://www.emergencymedicine.utoronto.ca/Assets/EmergeMed+Digital+Assets/%20Prehospital+Research/

5. 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

6. Government of Western Australia Department of Health (2012) Diagnostic imaging pathways – Cervical spine injury http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/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/imaging-pathways/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 skeletonhttp://radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_spinal/x-ray_fracture_start.html

Up to date12. 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 Discitishttp://www.uptodate.com/contents/vertebral-osteomyelitis-and-discitis


15. Anderson, B & Isaac, Z (2013) Evaluation of the patient with neck pain and





http://www.uptodate.com/contents/vertebral-osteomyelitis-and-discitis




http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_spinal/x-ray_fracture_start.html


http://www.radiologyassistant.nl/en/p423d18702d2bd/disc-nomenclature.html


http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/musculoskeletal/non-traumatic-neck-pain

http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/musculoskeletal/non-traumatic-neck-pain

http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/bone-and-joint-trauma/cervical-spine-injury

http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/bone-and-joint-trauma/cervical-spine-injury


cervical spine disordershttp://www.uptodate.com/contents/evaluation-of-the-patient-with-neck-pain-and-cervical-spine-disorders?source=search_result&search=cervical+spine&selectedTitle=1%7E150#H1716. 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







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


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 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)



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 spine116




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

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 date9. Anderson, B, Devine, J & Isaac, Z (2012) Treatment of neck painhttp://www.uptodate.com/contents/treatment-of-neck-pain?source=search_result&search=cervical+spine&selectedTitle=7%7E150

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

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








http://www.uptodate.com/contents/treatment-of-neck-pain?source=search_result&search=cervical+spine&selectedTitle=7~150





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


Describe the signs, symptoms and management of 2-7, 9-13

o Stable fractures (secondary consult)o Acute wry necko Cervical radiculopathy / brachialgia with and without neurological signso Cervical canal stenosis with and without neurological signso Cervicogenic headacheo Thoracic outlet syndrome3,6

o Chronic neck pain with signs of centralized pain mechanismso Acute neck pain with yellow flagso Suspected pathological fractureo Suspected discitiso Cervical muscle or facet joint sprain/straino Whiplash injury or whiplash associated disorder

Discuss the patient education required for follow up careRECOMMENDED 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-X/


http://www.manualtherapyjournal.com/article/S1356-689X(10)00038-X/abstract

abstract

Up to date:4. Anderson, B, Devine, J & Isaac, Z (2012) Treatment of neck painhttp://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 athletehttp://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 syndromeshttp://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 adultshttp://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 radiculopathyhttp://www.uptodate.com/contents/treatment-of-cervical-radiculopathy?source=search_result&search=cervical+spine&selectedTitle=5%7E150

10. Levin, K (2012) Cervical spondylotic myelopathyhttp://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 basicshttp://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



http://www.uptodate.com/contents/whiplash-the-basics?source=search_result&search=whiplash&selectedTitle=2~21

http://www.uptodate.com/contents/whiplash-the-basics?source=search_result&search=whiplash&selectedTitle=2~21

http://www.uptodate.com/contents/neck-fracture-the-basics?source=see_link

http://www.uptodate.com/contents/cervical-spondylotic-myelopathy?source=search_result&search=cervical+spine&selectedTitle=8~150

http://www.uptodate.com/contents/cervical-spondylotic-myelopathy?source=search_result&search=cervical+spine&selectedTitle=8~150

http://www.uptodate.com/contents/treatment-of-cervical-radiculopathy?source=search_result&search=cervical+spine&selectedTitle=5~150

http://www.uptodate.com/contents/treatment-of-cervical-radiculopathy?source=search_result&search=cervical+spine&selectedTitle=5~150






http://www.uptodate.com/contents/overview-of-thoracic-outlet-syndromes?source=search_result&search=thoracic+outlet&selectedTitle=1~25

http://www.uptodate.com/contents/overview-of-thoracic-outlet-syndromes?source=search_result&search=thoracic+outlet&selectedTitle=1~25

http://www.uptodate.com/contents/overview-of-musculoskeletal-neck-injuries-in-the-young-athlete?source=search_result&search=whiplash&selectedTitle=4~21

http://www.uptodate.com/contents/overview-of-musculoskeletal-neck-injuries-in-the-young-athlete?source=search_result&search=whiplash&selectedTitle=4~21





Elsevier. Chapter 3, The cervical spine






1.10 Thoracic spine

Theme 1 History taking for thoracic spine pain & injury injuryLEARNING 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 occurred3. 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 diagnoses5. 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, speedo Fall – from height (e.g. 1m, 3m, 5m) vs standing (force of impact)

- Headstrike, loss of consciousnesso 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 dropo Bladder bowel disturbance (both post injury and current)o Other sites of injury and potential for organs to be involved

Module 1.10: Musculoskeletal Conditions – Thoracic spine121

o head//thorax/scapula/lumbar spine/ pelvic/ upper or lower limb (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)?



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.


http://www.sciencedirect.com/science/journal/00319406/90/2

Up to date6. Eisen, A (2012) Anatomy and localization of spinal cord disordershttp://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 adultshttp://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 injuryhttp://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 radiographshttp://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 diseasehttp://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 syndromehttp://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 painhttp://www.uptodate.com/contents/major-causes-of-musculoskeletal-chest-pain?source=search_result&search=thoracic+spine&selectedTitle=23%7E150









http://www.uptodate.com/contents/major-causes-of-musculoskeletal-chest-pain?source=search_result&search=thoracic+spine&selectedTitle=23~150

http://www.uptodate.com/contents/major-causes-of-musculoskeletal-chest-pain?source=search_result&search=thoracic+spine&selectedTitle=23~150

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=33~150



http://www.uptodate.com/contents/pain-syndromes-in-autosomal-dominant-polycystic-kidney-disease?source=search_result&search=back+pain&selectedTitle=10~150






http://www.uptodate.com/contents/evaluation-of-thoracic-and-lumbar-spinal-column-injury?source=search_result&search=thoracic+spine&selectedTitle=1~150


http://www.uptodate.com/contents/initial-evaluation-and-management-of-chest-wall-trauma-in-adults?source=search_result&search=thoracic+spine&selectedTitle=9~150





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 spine4. 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 pathologyo Upper motor neurone assessmento Neural dynamics assessmento 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 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



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 date4. Hockberger, R & Kaji, A (2012) Spinal column injuries in adults: Definitions, mechanisms and radiographshttp://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 adultshttp://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 dissectionhttp://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 fractureshttp://www.uptodate.com/contents/clinical-manifestations-and-treatment-of-osteoporotic-thoracolumbar-vertebral-compression-fractures?source=search_result&search=back+pain&selectedTitle=43%7E150










http://www.uptodate.com/contents/clinical-manifestations-and-treatment-of-osteoporotic-thoracolumbar-vertebral-compression-fractures?source=search_result&search=back+pain&selectedTitle=43~150



http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-aortic-dissection?source=search_result&search=back+pain&selectedTitle=50~150


http://www.uptodate.com/contents/differential-diagnosis-of-chest-pain-in-adults?source=search_result&search=thoracic+disc&selectedTitle=2~4

http://www.uptodate.com/contents/differential-diagnosis-of-chest-pain-in-adults?source=search_result&search=thoracic+disc&selectedTitle=2~4




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



http://www.radiologyassistant.nl/en/p4906c8352d8d2/spine-thoracolumbar-injury.html


imaging pathways – Thoraco-lumbar Spine injury http://www.imagingpathways.health.wa.gov.au/index.php/imaging-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 date7. Hockberger, R & Kaji, A (2012) Evaluation of thoracic and lumbar spinal column injurieshttp://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 radiographshttp://www.uptodate.com/contents/spinal-column-injuries-in-adults-definitions-mechanisms-and-radiographs?source=search_result&search=cervical+spine&selectedTitle=6%7E150


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














http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/bone-and-joint-trauma/thoraco-lumbar-spine-trauma



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


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












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 date11. Sexton and Mac Donald (2013) Vertebral Osteomyelitis and Discitishttp://www.uptodate.com/contents/vertebral-osteomyelitis-and-discitis

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

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







https://admere.net/training/help/Pain_Management_Guidelines.pdf

http://archneur.jamanetwork.com/article.aspx?articleid=784895




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 Pregnanto Osteoporotic

Describe the signs, symptoms and management of 1, 4-8, 10-15

o Rib fractureso Thoracic nerve root impingement with and without neurological signs o Thoracic canal stenosis with and without neurological signso Thoracic outlet syndromeo Rib paino Chronic thoracic pain with signs of centralized pain mechanismso Acute thoracic pain with yellow flagso Suspected pathological fractureo Suspected discitis/ osteomyelitiso 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.



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 date7. Hockberger, R & Kaji, A (2012) Evaluaton of thoracic and lumbar spinal column injuryhttp://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 fractureshttp://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 discitishttp://www.uptodate.com/contents/vertebral-osteomyelitis-and-discitis?source=search_result&search=discitis&selectedTitle=1%7E38


http://www.uptodate.com/contents/vertebral-osteomyelitis-and-discitis?source=search_result&search=discitis&selectedTitle=1~38


http://www.uptodate.com/contents/initial-evaluation-and-management-of-rib-fractures?source=search_result&search=rib+fractures&selectedTitle=1~64

http://www.uptodate.com/contents/initial-evaluation-and-management-of-rib-fractures?source=search_result&search=rib+fractures&selectedTitle=1~64











12. Rosen, H (2013) Clinical manifestation and treatment of osteoporotic thoracolumbar vertebral compression fractureshttp://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 abscesshttp://www.uptodate.com/contents/epidural-abscess?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 painhttp://www.uptodate.com/contents/major-causes-of-musculoskeletal-chest-pain?source=search_result&search=thoracic+disc&selectedTitle=1%7E4#H8


http://www.uptodate.com/contents/major-causes-of-musculoskeletal-chest-pain?source=search_result&search=thoracic+disc&selectedTitle=1~4#H8

http://www.uptodate.com/contents/major-causes-of-musculoskeletal-chest-pain?source=search_result&search=thoracic+disc&selectedTitle=1~4#H8

http://www.uptodate.com/contents/vertebral-compression-fracture-the-basics?source=see_link

http://www.uptodate.com/contents/vertebral-compression-fracture-the-basics?source=see_link

http://www.uptodate.com/contents/epidural-abscess?source=search_result&search=lumbar+radiculopathy&selectedTitle=24~27





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 occurred3. 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 diagnoses5. Outline the differences between the primary and secondary role in relation to

spinal injuryASSUMED 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 involvedo 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 traumao Skin integrity, bruising, haematomao Area of pain e.g. thoracolumbar vs low lumbaro Time of injury, ability to move arms/ legs post injuryo 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 statuso 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

Module 1.10: Musculoskeletal Conditions – Lumbar spine 136

problems?9

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)?



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/CD008686.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 date7. Hockberger, R & Kaji, A (2012) Evaluation of thoracic and lumbar spinal column injuryhttp://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 aneurysmhttp://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/clinical-features-and-diagnosis-of-abdominal-aortic-aneurysm?source=search_result&search=back+pain&selectedTitle=45~150

http://www.uptodate.com/contents/clinical-features-and-diagnosis-of-abdominal-aortic-aneurysm?source=search_result&search=back+pain&selectedTitle=45~150

http://www.uptodate.com/contents/evaluation-of-thoracic-and-lumbar-spinal-column-injury?source=search_result&search=lumbar+spine+injuries&selectedTitle=1~3


http://onlinelibrary.wiley.com/store/10.1002/14651858.CD008686.pub2/asset/CD008686.pdf?v=1&t=hdwp0ita&s=558cc7cc8ef7cb5bfa86e46c4953cdc852b519ac

http://onlinelibrary.wiley.com/store/10.1002/14651858.CD008686.pub2/asset/CD008686.pdf?v=1&t=hdwp0ita&s=558cc7cc8ef7cb5bfa86e46c4953cdc852b519ac

http://www.uptodate.com/contents/lumbar-spinal-stenosis-pathophysiology-clinical-features-and-diagnosis?source=search_result&search=lumbar+radiculopathy&selectedTitle=4%7E27

10.Mohler, E (2012) Epidemiology, risk factors, pathogenesis and natural history of abdominal aortic aneurysmhttp://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 diseasehttp://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 syndromehttp://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 abscesshttp://www.uptodate.com/contents/epidural-abscess?source=search_result&search=lumbar+radiculopathy&selectedTitle=24%7E27





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#


http://www.sciencedirect.com/science/article/pii/S1521694209001247#
















http://www.uptodate.com/contents/epidemiology-risk-factors-pathogenesis-and-natural-history-of-abdominal-aortic-aneurysm?source=search_result&search=thoracic+spine&selectedTitle=48~150



http://www.uptodate.com/contents/lumbar-spinal-stenosis-pathophysiology-clinical-features-and-diagnosis?source=search_result&search=lumbar+radiculopathy&selectedTitle=4~27



Theme 2 Focused clinical assessment of low back pain & injuries LEARNING OBJECTIVES:

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 diagnosis3. 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 pathologyo Upper motor neurone assessmento Neural dynamics assessmento Hip joint screeningo SIJ provocation testso 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 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.

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 diagnosishttp://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 disordershttp://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 adultshttp://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 radiographshttp://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 injuryhttp://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 dissectionhttp://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 aneurysmhttp://www.uptodate.com/contents/epidemiology-risk-factors-pathogenesis-and-







http://www.uptodate.com/contents/spinal-column-injuries-in-adults-definitions-mechanisms-and-radiographs?source=search_result&search=lumbar+spine+anatomy&selectedTitle=1~150



http://www.uptodate.com/contents/the-detailed-neurologic-examination-in-adults?source=related_link

http://www.uptodate.com/contents/the-detailed-neurologic-examination-in-adults?source=related_link



http://www.uptodate.com/contents/lumbosacral-radiculopathy-pathophysiology-clinical-features-and-diagnosis?source=search_result&search=lumbar+radiculopathy&selectedTitle=1~27



natural-history-of-abdominal-aortic-aneurysm?source=search_result&search=thoracic+spine&selectedTitle=48%7E150


13. Rutkove, S (2013) Overview of lumbar extremity peripheral nerve syndromeshttp://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 syndromehttp://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 Tumorshttp://www.uptodate.com/contents/spinal-cord-tumors














http://www.uptodate.com/contents/overview-of-lower-extremity-peripheral-nerve-syndromes?source=search_result&search=lumbar+radiculopathy&selectedTitle=3~27








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/imaging-pathways/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.


http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/musculoskeletal/low-back-pain

http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/musculoskeletal/low-back-pain



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

Up to date8. Deyo, R, Gatewood, M, Staiger, T & Wipf, J (2012) Diagnostic testing for low back painhttp://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 injuryhttp://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 radiographshttp://www.uptodate.com/contents/spinal-column-injuries-in-adults-definitions-mechanisms-and-radiographs?source=search_result&search=cervical+spine&selectedTitle=6%7E150


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










http://www.uptodate.com/contents/evaluation-of-thoracic-and-lumbar-spinal-column-injury?source=search_result&search=lumbar+spine&selectedTitle=2~150

http://www.uptodate.com/contents/evaluation-of-thoracic-and-lumbar-spinal-column-injury?source=search_result&search=lumbar+spine&selectedTitle=2~150

http://www.uptodate.com/contents/diagnostic-testing-for-low-back-pain?source=search_result&search=lumbar+spine&selectedTitle=5~150

http://www.uptodate.com/contents/diagnostic-testing-for-low-back-pain?source=search_result&search=lumbar+spine&selectedTitle=5~150

http://www.radiologyassistant.nl/en/p423d18702d2bd/disc-nomenclature.html

Theme 4 Common pharmacology for the management of lumbar spine pain & injury LEARNING OBJECTIVES:

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 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

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

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



http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000396.pub3/abstract

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004252/abstract







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 date13. Sexton and Mac Donald (2013) Vertebral Osteomyelitis and Discitishttp://www.uptodate.com/contents/vertebral-osteomyelitis-and-discitis

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

15. Lexicomp (2013) Ibuprofen: Drug infomationhttp://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 treatmenthttp://www.uptodate.com/contents/subacute-and-chronic-low-back-pain-pharmacologic-


http://www.uptodate.com/contents/subacute-and-chronic-low-back-pain-pharmacologic-and-noninterventional-treatment?source=related_link






https://admere.net/training/help/Pain_Management_Guidelines.pdf

http://archneur.jamanetwork.com/article.aspx?articleid=784895




and-noninterventional-treatment?source=related_link

Theme 5 Management of low back pain & injury


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.

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


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 treatmenthttp://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 partumhttp://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 treatmenthttp://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 painhttp://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 painhttp://www.uptodate.com/contents/treatment-of-acute-low-back-pain?source=search_result&search=back+pain&selectedTitle=2%7E150


http://www.uptodate.com/contents/treatment-of-acute-low-back-pain?source=search_result&search=back+pain&selectedTitle=2~150

http://www.uptodate.com/contents/treatment-of-acute-low-back-pain?source=search_result&search=back+pain&selectedTitle=2~150

http://www.uptodate.com/contents/exercise-based-therapy-for-low-back-pain?source=search_result&search=back+pain&selectedTitle=8~150

http://www.uptodate.com/contents/exercise-based-therapy-for-low-back-pain?source=search_result&search=back+pain&selectedTitle=8~150

http://www.uptodate.com/contents/subacute-and-chronic-low-back-pain-nonsurgical-interventional-treatment?source=related_link

http://www.uptodate.com/contents/subacute-and-chronic-low-back-pain-nonsurgical-interventional-treatment?source=related_link

http://www.uptodate.com/contents/low-back-pain-in-adults-beyond-the-basics?source=search_result&search=back+pain&selectedTitle=15~150

http://www.uptodate.com/contents/low-back-pain-in-adults-beyond-the-basics?source=search_result&search=back+pain&selectedTitle=15~150

http://www.uptodate.com/contents/musculoskeletal-changes-and-pain-during-pregnancy-and-postpartum?source=search_result&search=back+pain&selectedTitle=25~150



http://www.uptodate.com/contents/acute-lumbosacral-radiculopathy-prognosis-and-treatment?source=search_result&search=back+pain&selectedTitle=23~150

http://www.uptodate.com/contents/acute-lumbosacral-radiculopathy-prognosis-and-treatment?source=search_result&search=back+pain&selectedTitle=23~150



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

13. Hockberger, R & Kaji, A (2012) Evaluation of thoracic and lumbar spinal column injuryhttp://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 prognosishttp://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 discitishttp://www.uptodate.com/contents/vertebral-osteomyelitis-and-discitis?source=search_result&search=discitis&selectedTitle=1%7E38


19. Shekelle, P (2012) Spinal manipulation in the treatment of musculoskeletal painhttp://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


http://www.uptodate.com/contents/herniated-disc-the-basics?source=search_result&search=lumbar+radiculopathy&selectedTitle=27~27

http://www.uptodate.com/contents/herniated-disc-the-basics?source=search_result&search=lumbar+radiculopathy&selectedTitle=27~27

http://www.uptodate.com/contents/spinal-manipulation-in-the-treatment-of-musculoskeletal-pain?source=search_result&search=back+pain&selectedTitle=24~150








http://www.uptodate.com/contents/lumbar-spinal-stenosis-treatment-and-prognosis?source=search_result&search=back+pain&selectedTitle=44~150

http://www.uptodate.com/contents/lumbar-spinal-stenosis-treatment-and-prognosis?source=search_result&search=back+pain&selectedTitle=44~150








http://www.uptodate.com/contents/acute-traumatic-spinal-cord-injury?source=search_result&search=lumbar+spine+fracture&selectedTitle=3~4

http://www.uptodate.com/contents/acute-traumatic-spinal-cord-injury?source=search_result&search=lumbar+spine+fracture&selectedTitle=3~4

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


http://www.uptodate.com/contents/radiculopathy-the-basics?source=search_result&search=lumbar+radiculopathy&selectedTitle=26~27

http://www.uptodate.com/contents/radiculopathy-the-basics?source=search_result&search=lumbar+radiculopathy&selectedTitle=26~27