Musculoskeletal assessment

always consider spinal injury, and act to prevent further injury. Log role for examination

History taking
• recent trauma; • underlying orthopaedic condition; •
relevant medical history; •
current medications;
• known allergy.
Ask >mechanism of injury and the degree of force used,- Inconsistencies between the history and injury should raise
suspicion of abuse Ask >and document, pain or sensory loss— pain distal to the injury may suggest vascular involvement
- any sensory loss distal to the injury may indicate neurological insult.

The five Ps
When assessing an injured extremity, use the ‘five Ps’:
• Pain
; • Pallor;
• Pulselessness;
• Paraesthesiae;
• Paralysis.

PE
Inspection
• skin colour, any bruising, abrasions, laceration,puncture wounds, or critical skin.
• Note any deformity, swelling, or oedema around the wounded area, and compare it with the uninjured limb.
• Observe for pain and the patient’ ability to move the affected limb.
-If there is gross deformity (e.g. joint dislocation) This is an orthopaedic emergency.
Palpation
- skin temperature and specific areas of pain; feel for pulses, and capillary refill. Absence of pulses or sensation, particularly
if distal to the injury, suggests neurovascular compromise If neurovascular compromise is identified, help immediately.

Nursing interventions.
General nursing management of musculoskeletal injuries should focus on the following.
• Pain. Immobilizing the area may give initial relief, opiate analgesia indicated in bony injuries.
• Vital signs. Record BP, pulse rate, RR, temperature, and O2 saturation.
-If there is a history of dizziness or blackout prior to the injury, record ECG and CBG.
• Establishing IV access, and blood tests for FBC, U&E, coagulation studies, and group and save. infusion of fluids,
• Immobilization. Various splints may be used, but vascular status prior to application, and access to pulse points must be
ensured for ongoing monitoring.
If there is no apparent neurovascular injury, the injured limb should be immobilized in its presenting position.
• Elevation of the injured limb aids venous return and helps to minimizeswelling.
• Remove jewellery and tight clothing. If jewellery needs to be cut off,where possible, obtain written consent from the
patient or a relative.

Additional interventions

• request X- rays. • Any open wounds should be covered with sterile dressings, until they aseptically cleaned.
• Patients who have open fractures should be given IV antibiotics. Ensure that medications are given, as prescribed.
• The patientstetanus status, and, where there isdoubt, a booster should be given
• Assist with manipulation of the fracture and the application of a plaster cast or traction.
• Ensure pressure area care
• Reassure and comfort the patient, and keep their relatives informed.
• Administer analgesia, as prescribed, and evaluate its effect
Fractures
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-A fracture is a partial or complete breach in the continuity of a bone.
-Fractures can be open or closed, and displaced or undisplaced.
Any of the following types of fracture may occur.
• Simple— single transverse fracture of bone, with only two main fragments.
• Transverse— at 90° to the axis of the bone.
• Oblique— at 45° to the axis of the bone, with only two main fragments.
• Spiral— seen in long bones as a result of twisting injuries and twists
• Comminuted— complex fracture resulting in >2 fragments.
• Crush— loss of bone due to compression.
• Burst— comminuted compression fracture with scattering of fragments.
• Impacted— bone ends driven into each other.
• Avulsion— bony attachment of a ligament or muscle is pulled off.
• Hairline— barely visible lucency, with no discernible displacement.
• Greenstick— buckling or bending of immature bones, most commonly seen in children.
• Pathological— fracture due to underlying disease (e.g. osteoporosis, Paget’s disease).

Upper limb injuries

Humeral shaft fractures
Fractures to the neck and shaft of the humerus are commoner in older ♀ ,due to osteoporosis. radial nerve should be assessed.
• If any deficit or displacement is found, referred to the orthopaedic team immediately.
• If the fracture is minimally displaced and there is no neurological deficit, place in a collar and cuff, and refer to the fracture clinic.
• Severe angulation or displacement of the humeral head referred to the orthopaedic team.
Elbow injuries
Elbow injuries are a common presentation in the ED. Full range of movement usually excludes serious injury. A recent study1 suggests
that, if thepatient has normal extension, flexion, and supination, they do not require emergency elbow radiographs.
Supracondylar humeral fracture
• Assess the neurovascular status of the limb. radial and median nerves, as well as the brachial artery.
• Normally, the arm is very swollen and deformed around the elbow.
• give analgesia; place the patient in a comfortable position, and request an X- ray.
• Place in above- elbow back slab, and refer to the orthopaedic team.
Dislocated elbow
associated with significant force,
• Make the patient comfortable; give IV analgesia, and request X- ray.
• Perform neurovascular observations.
• Obtain senior support, reduction will be needed under controlled conditions.
Epicondylitis
Commonly known as ‘tennis elbow’ or ‘golfer’s elbow’, this results from overuse or strain of the common tendinous insertions of the
extrinsic extensor and flexor muscles of the lateral and medial epicondyles of thehumerus. Treatment includes analgesia, rest, and
supportive measures. If symptoms persist, physiotherapy and referral to a soft tissue clinic for steroid injections may be required.
Radial head fractures
complain of pain on pronation and supination of the forearm. Fracturesmay not be obvious on X- ray, but evidence of an effusion (fat
pad sign) is indicative of a bony injury. Loss of full extension of the forearm should also raise the suspicion of a fracture. Treatment
consists of a collar and cuff or broad arm sling, analgesia, and follow- up in the fracture clinic. If there is significant
angulation>orthopaedic opinion.
Radial and ulnar shaft fractures
These fractures cause significant deformity or angulation of the [Link] require immediate assessment and analgesia. Ensure that
there is noneurovascular deficit, and place the arm in a broad arm sling or rest on a pillow. Refer the patient for X- rays. Always ensure
that X- rays are taken of the whole forearm, thus ensuring that Monteggia and Galeazzi fractures are
not missed. It is important to note that neurovascular injury is common in
adults. These patients will require referral to an orthopaedic surgeon.
• A Monteggia fracture is a fracture of the ulna with associated dislocation of the radial head within the elbow joint.
• A Galeazzi fracture is a fracture of the radius with an associated injury to the distal radioulnar joint of the wrist
Wrist injuries
often age- dependent:
• <10y: often present with greenstick/ buckle fractures, with transverse fractures through the metaphysis;
• 10– 16y: associated with a fracture through the epiphysis, usually Salter–Harris type II fracture
• 17– 40y: more likely to be a scaphoid fracture;
• ≥40y: more likely to present with a Colles’ or Smith’s fracture.
Colles’ fracture
This is usually associated with obvious clinical signs— the wrist is often deformed and swollen; the patient is unable to pronate or
supinate their wrist, and pain.
• Give analgesia.
• Place the wrist in a broad arm sling.
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• Perform neurovascular observations.
• Send the patient to X- ray.
• This fracture is associated with dorsal angulation, which produces the classical ‘dinner fork deformity’ on the lateral view. It is normally

associated with an avulsion of the ulnar styloid [Link] displaced,.

• Manipulation under LA using either a haematoma block or a Bier’s block.
• A Bier’s block procedure must be performed in a controlled environment. An ECG and consent must be obtained before

Smith’s fracture
Smith’s fracture of the wrist is associated with a palmar or volar angulation of the distal radius. It often requires surgical intervention
Barton’s fracture
This is a fracture of the joint of the anterior margin of the distal radius, with proximal displacement. Treat in a volar slab, and refer to the
orthopaedic team.
Hutchinson’s fracture
This is an undisplaced fracture of the ulnar styloid, commonly seen in the anteroposterior (AP) projection. Patients present with a history of a
Paronychia
This is an infection of the lateral border of the nail .
-Causes simple trauma such as nail biting. Artificial nails
. A paronychia usually starts as a cellulitis but often progresses to abscess formation, which requires incision and drainage.
Infection can sometimes spread under the nail, causing a subungual abscess that requires trephining.
Subungual haematoma
trauma to the distal phalanx that causes bleeding under the nail. The presence of a subungual haematoma is suggestive of a
nail bed injury and an underlying distal phalangeal fracture. It is important to identify such injuries,
. Trephining the nail provides instant pain relief and is not contraindicated, even in the presence of a fracture to the distal
phalanx. However, it should be done under sterile conditions, and it is important to consider appropriate wound care, tetanus
prophylaxis, and antibiotic therapy.
Back pain
Simple back pain usually attributed to heavy lifting or manual work, and must be differentiated from nerve root pain or
back pain that is attributed to a more serious pathology. Simple back pain is usually attributable to muscle or ligamentous ‘strain’. The
patient may present as follows:
• presentation between the age of 20 and 55y;
• pain in the lumbosacral region;
• no tenderness in the spinous process;
• pain that is ‘mechanical’ in nature;
• pain that varies with physical activity and over time;
• the patient is generally well;
• no numbness or tingling in the legs;
• no bowel or bladder problems.
Simple back pain accounts for about 90% of all episodes of back pain. Around 90% of patients make a full recovery within 4– 6wk.
Management of simple back pain
• If the patient has no ‘red flags’, reassure them, .
• Encourage early light activity.
• Advise them to use NSAIDs, muscle relaxants, and simple analgesia (this is as effective as opiates).
• Refer them for early physiotherapy.
Nerve root pain
requires a medical assessment. The patient may present with the following:
• unilateral leg pain that is worse than low back pain;
• pain generally radiating to the foot or toes; • numbness and paraesthesiae in the same distribution;
• nerve irritation signs; • reduced straight leg raising (SLR), which reproduces back pain;
• motor, sensory, or reflex change; • limited to one nerve root.
Around 50% of patients recover from an acute attack within 6wk
Red flags: possible serious pathology
These patients must be seen by a doctor or an advanced practitioner.
• Presentation under 20y of age, or onset over 55y of age. • Violent trauma (e.g. fall from a height, road traffic accident).
• Constant, progressive, non- mechanical pain. • Thoracic pain..• Patient is taking systemic steroids. • Drug abuse.
• HIV.• Patient is systemically unwell. • Weight loss. • Persistent severe restriction of lumbar flexion.
• Widespread neurological signs and symptoms. • Structural deformity. • Bowel and bladder disturbance.
Fracture of neck of femur
This is common in the elderly, especially in women, following relatively minor trauma. The risk i because of osteoporosis and
osteomalacia, and also because of the higher incidence of falls.
• give patients with suspected fractures effective analgesia (e.g. morphine sulfate) prior to X- ray.
• An inpatient bed should also be arranged at this time.
• Blood loss is significant, so establish IV access and fluids, as early hydration reduces mortality.
• Take blood samples for FBC, U&E, and cross- matching.
• Monitor vital signs regularly to ensure haemodynamic stability is maintained.
• Record the ECG to exclude MI or other arrhythmia.
• Obtain a Waterlow score, and initiate pressure area care in the ED, as these patients are very vulnerable to pressure ulcers.
• Apply skin traction early if the patient is not going to theatre
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 Knee injuries
consider the following factors.
• Mechanism of injury— a twisting injury may suggest injury to the menisci.
• Valgus or varus strain may cause damage to the medial or lateral collateral ligament, respectively.
• Rapid swelling of the knee after injury is usually an acute haemarthrosis
• A more gradual swelling suggests an effusion.
Anterior cruciate ligament
This may be injured in a twisting or hyperextension movement. Use the drawer test to assess the cruciate ligaments. For the anterior
drawer test, the patient’s knee must be flexed to 90°. Fix the patient’s foot in slight external rotation (by sitting on the foot), and then
place your thumbs at the tibial tubercle and your fingers at the posterior calf. Ensure that the patient’s hamstring muscles are relaxed,
and then pull anteriorly and assess anterior displacement of the tibia (anterior drawer sign).
Posterior cruciate ligament
less frequently injured than the ACL. For the posterior drawer test, the injured knee must be flexed to 90°observe for posterior
displacement of the tibia (‘posterior sag sign’). Then fix the patient’s foot in the neutral position (by sitting on it); position your thumbs
at the tibial tubercle, and place your fingers on the posterior calf. Push posteriorly, and assess for posterior displacement of the tibia.
Ottawa knee rules
An X- ray is only required for acute knee injuries with one or more of the following findings:
• age ≥55y;• tenderness at the head of the fibula;• isolated tenderness of the patella;• inability to flex to 90°;
Patellar fracture
as a result of a fall on to the knee. The patient presents with pain, swelling, crepitus, effusion, and extension block. Inability to
straight leg raise may suggest rupture of the quadriceps or patellar tendon.
Treatment
• Immobilize in a non- weight- bearing cast, and ensure that the patient is given written instructions about the plaster cast.
• analgesia .
• Arrange early follow- up in the fracture clinic.
Patellar dislocation
This results from a direct blow to the medial aspect of the knee. presents with lateral deformity, medial tenderness, and pain on
attempted movement. Haemarthrosis may also be evident.
Treatment
• The patella can be relocated by extension of the knee. Analgesia and muscle relaxants should be used to relieve pain prior to the
procedure.
• patella has been relocated, a supportive bandage, such as a Robert Jones bandage, or a cricket pad splint should be applied