Office orthopedics for primary care: diagnosis issue orthopedics, general practice

308 Pages·2006·22.26 MB·English

by  Bruce Carl Anderson

Office Orthopedics for Primary Care: Diagnosis
Copyright © 2006 Elsevier Inc. All rights reserved
Author(s): Bruce Carl Anderson, MD
ISBN: 978-1-4160-2207-7
Table of Contents
Copyrig, ht Page iv
Dedicat,i on Page v
Prefac, e Pages vii-viii

Acknowledgm, ents Page ix
Chapter 1 - ,N eck Pages 1-18
Chapter 2 - Sho, ulder Pages 19-49
Chapter 3 - Upper Back Pages 50-65
Chapter 4 - E,l bow Pages 66-81
Chapter 5 - W, rist Pages 82-100
Chapter 6 - Thumb Pages 101-117
Chapter 7 - Hand Pages 118-136
Chapter 8 - Chest Pages 137-148
Chapter 9 - Lumbosac,r al Spine Pages 149-171
Chapter 10 ,- Hip Pages 172-194
Chapter 11 - ,K nee Pages 195-221
Chapter 12 - Ankle Pages 222-249
Chapter 13 - Foot Pages 250-276
Referenc, es Pages 277-293
Inde,x Pages 295-301
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ISBN 987-1-4160-2207-7
OFFICE ORTHOPEDICS FOR PRIMARY CARE:DIAGNOSIS ISBN 1-4160-2207-4
Copyright ©2006 by Elsevier Inc.
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Notice
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our knowledge,changes in practice,treatment and drug therapy may become necessary or appropriate.
Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the
manufacturer of each product to be administered to verify the recommended dose or formula,the method
and duration of administration,and contraindications. It is the responsibility of the practitioners,relying on
their own experience and knowledge of the patients,to make diagnoses,to determine dosages and the best
treatment for each individual patient,and to take all appropriate safety precautions. To the fullest extent of
the law,neither the Publisher nor the Editors assumes any liability for any injury and/or damage to persons
or property arising out or related to any use of the material contained in this book.
Library of Congress Cataloging-in-Publication Data
Anderson,Bruce Carl.
Office orthopedics for primary care:diagnosis / Bruce Carl Anderson.—1st ed.
p. ; cm.
ISBN 1-4160-2207-4
1. Orthopedics—Diagnosis. 2. Primary care (Medicine) I. Title.
[DNLM:1. Musculoskeletal diseases--diagnosis. 2. Family Practice—methods. 3.
Fractures—diagnosis. WE 141 A545oa 2006]
RD732.A52 2006
616.7′075—dc22
2005049901
Acquisitions Editor:Rolla Couchman
Developmental Editor:Dylan Parker
Design Direction:Karen O’Keefe Owens
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To the pioneering work of
E C Kendall, biochemist and researcher at the
Mayo Clinic of Rochester, Minnesota,
and winner of the 1950 Nobel Prize in Biochemistry
for the synthesis of cortisone from bile acids.
P R E F A C E
This is the first edition of Office Orthopedics for Primary tailed examinations that allows for a definitive diagnosis
Care: Diagnosis,the companion book to Office Orthopedics for and subsequent specific treatment guidelines.
Primary Care: Treatment. This two-volume set provides the Traditionally local musculoskeletal diagnosis has relied
clinician with the concise information to diagnose, treat, upon combining the patient’s description of pain, the
and determine the need for surgical referral on the most demonstration of loss of function, and the results of phys-
common conditions affecting the musculoskeletal system. ical examination with the changes either on plain radio-
Emphasis has been placed on those conditions that are graphs or specialized imaging (MRI, CT, bone scanning)
most likely to present to the primary care physician, includ- to distinguish involvement of the joint from involvement
ing the most common joint and soft tissue diagnoses as well of the soft tissues or bone. In general, this is an effective
as the noncatastrophic, uncomplicated fractures that fre- approach when evaluating patients with degenerative
quently present to the primary care office. arthritis or advanced tendon and ligament injuries where
The book has been formatted in a unique manner, de- characteristic changes on plain radiographs or special
pending on the needs of the clinician and the time allotted imaging are unequivocal. However, the combination of
for evaluation of the musculoskeletal complaints. For the history, examination, and imaging fails to accurately diag-
clinician interested only in screening the patient, each sec- nosis up to one-third of joint and soft tissue conditions
tion begins with the most effective maneuvers that allow a (see the table below) because of the nonspecific nature of
rapid and effective triage of the patient to radiographic or the complains, the overlap of physical signs, and the lack
laboratory testing or general treatment guidelines. By con- of diagnostic changes on radiographic testing. Previous
trast, for the clinician interested in the complete manage- publications have failed to address this inadequacy by
ment of the patient’s musculoskeletal complaints, the failing to emphasize the importance of diagnostic local
screening maneuvers of each section are followed by the de- anesthetic block and synovial and bursal fluid aspiration
TABLE 1 SUMMARY: DIAGNOSTIC TESTING FOR 183 LOCAL MUSCULOSKELETAL CONDITIONS
JOINT X-RAY CT/MRI BONE SCAN EXAM LOCAL ANESTHESIA ASPIRATION SURGERY
Neck 3 4 — 3 1 — —
Shoulder 6 2 — 3 3 3 —
Upper Back 3 3 — 3 1 — —
Elbow 3 1 — 2 3 6 —
Wrist 4 1 1 2 2 5 —
Thumb 2 — — 2 3 — —
Hand 3 — 1 8 1 — 1
Chest 1 — 1 1 4 2 —
Back 4 5 1 2 2 — —
Hip 5 1 3 2 4 2 —
Knee 5 2 — 1 5 5 2
Ankle 7 — 2 8 2 1 —
TOTALS 47 21 10 40 37 25 3
26% 11% 5% 22% 20% 14% 2%
This table summarizes the diagnostic testing used to confirm the most common musculoskeletal conditions described in this book, the conditions that
present to the primary physician in an outpatient setting. When more than one method of confirming the diagnosis is possible, the most reliable
method was chosen. Local anesthesia refers to confirming the diagnosis by the accurate placement of lidocain or bipivacaine within the joint, bursa,
or along the tissue plane adjacent to the tendon, ligament, or nerve. Aspiration uniformly refers to the removal of joint or bursal fluid for laboratory
analysis.
VIII PREFACE
and analysis. For example, anserine bursitis frequently Table 1 also emphasizes the relative infrequent need to re-
complicates medial compartment osteoarthritis of the fer to the orthopedic surgical service for specific diagnostic
knee. Both conditions are characterized by impaired gait, testing. Only 2 percent of diagnoses require surgical inter-
medial knee pain, and medial knee tenderness. Neither vention to complete the diagnostic workup; namely those
plain radiographs or special imaging effectively distin- conditions that require arthroscopy for confirmation
guishes one from another. However, pain relief and (meniscal tear, ACL tear, and osteochondritis dissecans).
improved ambulation after placing local anesthetic either Hopefully, this new edition will provide the practitioner
intra-articularly or intrabursal is the only means of effec- with the means to manage the wide range of conditions that
tively distinguishing the role of each. Similarly, local anes- commonly affect the musculoskeletal system. With a more
thetic block is often necessary to distinguish trochanteric accurate means of diagnosis available to the clinician more
bursitis from L4-5 radiculopathy, rotator cuff tendonitis effective and timely provided treatment will result in better
from the referred pain of C4-5 radiculopathy, de Quervain’s patient outcomes.
tenosynovitis from carpometacarpal osteoarthritis, and so
forth. Bruce Carl Anderson, MD
CHEST IX
A C K N O W L E D G M E N T S
This book represents the outgrowth of 27 years of postres- Eastmoreland Osteopathic Hospital, and Emmanual-Legacy
idency education and clinical experience with over 50,000 and Providence teaching hospitals, for their constant encour-
local procedures that would not have been possible without agement, contributions, and critical appraisal of the content
the support and encouragement from many sources. I wish of the book. I also wish to thank the medical directors of the
to thank all the members of the departments of medicine, various Portland, Oregon, teaching hospitals for their sup-
family practice, physiatry, neurosurgery, and surgical ortho- port; namely, Dr. Nancy Loeb at Sisters of Providence
pedics at the Sunnyside Medical Center, especially Dr. Ian St. Vincents hospital, Dr. Steven Jones at Emmanual-Legacy
MacMillan of the department of medicine for his support hospital, and Dr. Don Girard at the Oregon Health Sciences
and assistance in developing the medical orthopedic depart- University. Lastly, I wish to thank Dr. David Gilbert, direc-
ment and the surgeons of the department of orthopedics, Dr. tor emeritus of the Sisters of Providence Glisan hospital—my
Steven Ebner, Dr. Edward Stark, and Dr. Stephen Groman, internal medicine residency director—for his stimulation to
for their stimulating feedback. I also wish to thank my ex- excellence, his encouragement to examine ever deeper into
tremely capable physician assistant, Linda Onheiber, for her clinical problems, and his support and inspiration in my re-
steady contributions to the medical orthopedic department, turn to clinical research.
and all the medical residents of the graduating classes of
2003 and 2004 at Oregon Health Sciences University, Bruce Carl Anderson, MD
CHAPTER 1: NECK
DIFFERENTIAL DIAGNOSIS
Diagnoses Confirmations
Cervical strain (most common diagnosis)
Stress Socioeconomic or psychological issues
Whiplash and related injuries Motor vehicle accident or head and neck trauma
Dorsokyphotic posture Typical in older adults or in patients with depression
Fibromyalgia Confirmation by exam: multiple trigger points,
normal lab
Osteoarthritis of the neck X-ray: cervical series (lateral view)
Reactive cervical strain Underlying spinal column, nerves, or cord are
threatened
Radiculopathy Neurologic testing
Vertebral body fracture Bone scan or magnetic resonance imaging (MRI)
Spinal cord injury or tumor MRI
Cervical radiculopathy
Foraminal encroachment X-ray: cervical spine x-rays (oblique views);
electromyography (EMG)
Herniated nucleus pulposus MRI
Epidural process MRI
Thoracic outlet syndrome Nerve conduction velocity (NCV) and EMG
Cervical rib X-ray: cervical series (anteroposterior view)
Greater occipital neuralgia Local anesthetic block
Temporomandibular joint syndrome Exam or local anesthetic block
Referred pain
Coronary arteries Electrocardiogram, creatine phosphokinase,
angiogram
Takayasu’s arteritis Erythrocyte sedimentation rate (ESR), angiogram
Thoracic aortic aneurysm Chest x-ray
Thyroid disease Thyroid-stimulating hormone, thyroxine, ESR,
thyroid scan
1
2 OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS
INTRODUCTION Cervical strain and osteoarthritis are SYMPTOMS Patients complain of neck pain, muscle
the two dominant conditions affecting the neck. Cervical spasm, stiffness or loss of range of motion, or upper ex-
strain caused by tension, stress, dorsokyphotic posture, or tremity sensorimotor symptoms reflective of radiculopathy.
whiplash is a nearly universal condition early in life. In later Most patients describe a combination of symptoms.
life cervical strain is still common but rivaled by os- Patients with moderate to severe cervical strain may experi-
teoarthritis affecting the facet and paravertebral joints, also ence reversible sensory radiculopathy. Conversely, patients
a nearly universal condition. In the sixth and seventh with radiculopathy often describe symptoms reflective of
decades these two processes combine to cause the progres- the accompanying reactive cervical strain.
sive stiffness and forward position of the head typical of Neck pain is the most common presenting symptom. It
older adults. is most often described at the base of the cervical spine or
The diagnosis of an uncomplicated cervical strain caused along the upper border of the trapezius muscle. Reactive
by tension, stress, poor posture, or mild whiplash is not dif- cervical strain—irritation and spasm of the muscles of the
ficult. Signs and symptoms are limited to the supporting neck or upper back—is the principal cause of this pain.
muscles of the neck, the trapezius and paraspinal muscles. Although cervical strain is most commonly caused by the
The muscles are tender, the range of motion is reduced by ordinary emotional and physical stresses of everyday life,
muscular spasm, and there is a conspicuous absence of bony poor posture, or poor sleeping habits, it is also the body’s fi-
tenderness and radicular signs in the upper extremities. This nal common pathway for any process that threatens the in-
is in stark contrast to reactive cervical strain, which is the di- tegrity of the spinal column, spinal nerves, or spinal cord;
rect result of an underlying threat to the spinal column. thus, cervical strain often accompanies whiplash, arthritis of
Bony disorders, spinal nerve compression, or the rare con- the cervical spine, or radiculopathy.
ditions affecting the spinal cord directly cause severe Patients also complain of neck stiffness. Varying degrees
trapezial and paraspinal muscle spasm. The challenge to the of neck stiffness often accompany cervical strain. Moderate
primary care provider is to distinguish simple cervical strain to severe neck stiffness is typical of cervical degenerative
from the severe muscular spasm that is a reaction to a seri- arthritis; facet and paravertebral joint osteophyte formation
ous underlying neurologic process. and articular cartilage thinning correlate directly with the
Cervical arthritis is the second most common neck con- symptoms of stiffness and the measurable loss of neck flex-
dition, increasing in prevalence and degree with advancing ibility, most notably in rotation and extension.
age. Symptoms can range from simple stiffness and loss of Numbness, tingling, and pain down the arm are the
range of motion to radiculopathy from foraminal encroach- common symptoms of cervical radiculopathy (“I think I
ment and spinal cord compression from spinal stenosis. have a ‘pinched nerve’”). Cervical radiculopathy is caused
Osteoarthritic wear occurs at the paravertebral facet joints by spinal nerve compression due to cervical arthritis in 90%
and between the lateral margins of the vertebral bodies, the of cases. As the paravertebral and facet joints gradually wear,
Luschka joints. bony osteophytes gradually enlarge, compromising the exit
Both cervical strain and cervical osteoarthritis are in- neuroforamina (foraminal encroachment). If the overall sur-
volved in the development of cervical radiculopathy, or face area is reduced by 50%, the spinal nerve is at risk. It
compression of the spinal roots or nerves. Ninety percent of takes only a small degree of cervical strain to incite (pain
spinal nerve compression results from neuroforaminal nar- and paresthesias) or impair (hypesthesias or motor weak-
rowing by osteophyte overgrowth, foraminal encroachment ness) the spinal nerve. Cervical radiculopathy is caused by a
disease. With this threat to the spinal nerve, reactive cervi- herniated disk in 10% of cases (younger, more acute, and
cal strain develops, compounding the nerve irritation. Only greater degrees of motor involvement on average), and less
10% of cervical radiculopathy is caused by a herniated nu- than 0.1% is caused by spinal cord encasement by large os-
cleus pulposus (HNP), whereas 90% of radiculopathy in the teophytic bars (spinal stenosis).
lumbar spine is caused by HNP. Spinal stenosis is the most Some patients complain of a unilateral headache with
dramatic form of cervical radiculopathy. numbness or tingling of the scalp. This unique headache
Upper extremity neurologic impairment can also result pattern is the result of intense or chronic paraspinal muscle
from brachial plexus nerve compression or inflammation. pain at the base of the neck. Greater occipital neuralgia re-
Loss of upper extremity sensation or motor function can be sults from the irritation of this sensory nerve as it penetrates
caused by thoracic outlet (cervical rib, hypertrophy of the these paraspinal muscles at the base of the skull.
scalenus anticus or pectoralis minor, or Pancoast’s tumor) or Lastly, involvement of the vertebral bodies by fracture,
brachial plexopathy. tumor, or infection typically causes severe localized neck
Greater occipital neuritis is a unique problem arising painand dramatic cervical muscle spasm.
from the neck. It is also related directly to cervical strain.
The greater occipital nerve must traverse the upper cervical
muscles to enter the subcutaneous tissue on its way to in- EXAMINATION The examination of the neck begins
nervating the scalp. Persistent muscle spasm is the principal with the observation of the general movement of the head,
irritation of this nerve. neck, and eyes. The posture and general movements of the
Pain referred to the neck is uncommon. Intrinsic shoul- neck, whether rigid and guarded or loose and free, should be
der conditions can incite reactive cervical strain. Diseases of consistent during the interview phase as well as during the
the heart, major vessels of the chest, or thyroid (coronary actual examination. Lack of consistency can be a clue to ma-
artery disease, Takayasu’s arteritis, thoracic aortic aneurysm, lingering in the case of whiplash or cervical radiculopathy
thyroid disease) will cause pain in the jaw or, rarely, neck that is under litigation. Measurement of the range of motion
pain. of the neck, especially neck rotation and lateral bending,is