Common Musculoskeletal Problems

Voorwerk

Chapter 1. Introduction

Abstract

This book differs from other texts on the market. It is not meant to serve as a ­comprehensive text for all musculoskeletal conditions; rather, it has been produced to act as an off-the-shelf guide to assist healthcare providers evaluating patients ­presenting with common musculoskeletal complaints in the primary care setting. It is best used at the point of care and should not be considered a primary reference text.

James M. Daniels, M. Rebecca Hoffman

Chapter 2. The Cervical Spine

Abstract

Figure 2.1 illustrates the surface anatomy of the cervical spine (C-spine). The C-spine consists of seven vertebrae (C1–C7) and supports the weight of the head (approximately 14 pounds). The first two vertebrae are called the axis and atlas, respectively, and do not have a disc between them, but are closely bound together by a complex of ligaments. The C1 (axis) “ring” rotates around the odontoid or “peg” of C2 (atlas), allowing for almost 50% of total cervical rotation. The spinal canal is housed within the cervical vertebrae and is widest between the C1 and C3 levels (A-P diameter 16–30 mm) and narrows as it progresses caudally (14–23 mm). When the neck is fully extended, this canal can narrow an additional 2–3 mm.

James M. Daniels, Joel Kary

Chapter 3. The Shoulder

Abstract

Figures 3.1 and 3.2 illustrates the surface anatomy of the glenohumeral joint of the shoulder. The shoulder is a ball and socket joint whose structure allows for an impressive range of motion (ROM), but at a cost. Unlike the very stable hip joint, which has a deep socket, the glenoid fossa is relatively shallow, and the humeral head is oversized with respect to the fossa. The labrum, a rim of cartilage around the glenoid fossa, helps increase the depth and stability of the shoulder joint, but the other soft tissues of the shoulder provide most of the joint’s stability. In order for proper functioning to occur, all these tissues (muscles, tendons, ligaments, and the labrum) must be functioning at proper tension. Disruption in any one of these can lead to dysfunctional shoulder motion and subsequent problems [1, 2].

James M. Daniels

Chapter 4. The Elbow

Abstract

Figures 4.1 and 4.2 illustrates the surface anatomy of the elbow. The elbow functions as a hinge joint that allows the transfer of kinetic energy from the body to the upper extremity. The joint is composed of three articulations: the trochlea of the humerus articulates with the ulnar notch, the capitellum of the humerus articulates with the radial head, and the radius articulates with the stationary ulna (see Fig. 4.3). The elbow joint is held together by a capsule of connective tissue, which is thickened medially and laterally, where it is called the ulnar and radial ligaments, respectively.

Jerry Goddard, Matthew Goddard

Chapter 5. The Hand and Wrist

Abstract

Figures 5.1–5.3 illustrates the surface anatomy of the proximal wrist. The wrist is composed of distal radius and ulna, which articulate with each other to form the radioulnar joint. The distal radius also articulates with the scaphoid and lunate bones [1]. The distal ulna articulates with the triangular fibrocartilage complex (TFCC), which functions much like the meniscus of the knee. The TFCC also has ligamentous attachments to the lunate, capitate, and triquetrum [1]. The distal wrist is composed of the eight carpal bones arranged in two rows. The proximal carpals (scaphoid, lunate, triquetrum, and pisiform) are closely approximated to the radius, while the distal carpals (trapezium, trapezoid, capitate, and hamate) are closely associated with the metacarpal bones. When the wrist ­deviates radially or dorsiflexes, the scaphoid flexes palmarly, which puts it in a precarious position to be injured when a patient falls, particularly when the patient falls on an outstretched hand [2]. Figure 5.4 shows the basic anatomy of the wrist.

James M. Daniels, Bill Shinavier

Chapter 6. Lumbosacral Spine

Abstract

Figure 6.1 illustrates the surface anatomy of the LS spine. The LS spine is typically composed of five vertebrae (see Fig. 6.2). Unlike the cervical spine, whose facets allow for multidirectional movement, the primary motion of the L spine is flexion and extension with some side bending. The spinal cord itself ends around L1 or L2, but spinal nerves continue down the canal as the cauda equina. Each nerve root exits the bony spinal canal hugging the pedicle and is named for that vertebra. At each level, the exiting nerve leaves the canal just above the disk, and another traversing nerve exits at the next level. When disk herniations occur, the traversing nerve usually is affected, while if the facet joints are involved, the exiting nerve root will be affected. (See Fig. 6.3) [1–3].

James M. Daniels, Per Freitag, Eric Ley

Chapter 7. The Hip

Abstract

>The hip is a ball and socket joint composed of the articulation of the head of the femur with the acetabulum (see Fig. 7.1). Its range of motion (ROM) includes flexion, extension, adduction, abduction, and internal and external rotation [1]. Nerves coursing through the hip region include the sciatic nerve and the lateral femoral cutaneous nerves, both of which can cause pain in the hip region. It is important to realize that nonmusculoskeletal systems may produce “hip pain,” such as the urologic and genital systems, as well as vascular structures.

Jared Price, Erica Miller

Chapter 8. The Knee

Abstract

Figures 8.1 and 8.2 illustrates the surface anatomy of the knee joint. The knee is essentially a hinge joint between the femur and the tibia, with the patella riding anterior to and slightly superior to the joint. The knee joint (and therefore knee pathology) can be thought of in terms of three anatomic compartments, the medial, lateral, and patellofemoral (anterior) compartments.

M. Rebecca Hoffman, Becky J. Hanna

Chapter 9. The Ankle

Abstract

Figures 9.1–9.4 illustrates the surface anatomy of the design of the ankle joint which allows humans to have a multifunctional gait. While walking, the foot is mostly in dorsiflexion, and this allows the widest part of the talus to fit securely into the ankle mortise joint formed by the fibula and tibia. This is a very stable position for the joint, and although it is a slower gait, it allows us to walk easily on uneven terrain, unlike many nonprimate mammals.

James M. Daniels, Joe Cygan, M. Rebecca Hoffman

Chapter 10. Pediatric Musculoskeletal Complaints

Abstract

Pediatric musculoskeletal concerns can be challenging for the clinician because of the age and communication ability of the patient. In addition, pediatric orthopedic conditions are of particular concern to parents and healthcare providers alike, as the presence of growth plates leads to concerns about lifelong consequences to poor healing. There are certainly many pediatric conditions which are best cared for by pediatric orthopedic specialists, but many other conditions can be safely managed in the primary care clinician’s office. A reasonable general rule of thumb is to refer pediatric patients with musculoskeletal complaints that are potentially serious, difficult to diagnose, or involve joints or areas which are prone to poor healing or poor outcomes.

K. Anjali Singh, Keith Gabriel

Chapter 11. The Acute Swollen/Painful Joint

Abstract

This chapter focuses on the evaluation of the adult patient with an acutely swollen, painful joint. A major concern with these patients is the possibility of infection of the joint space itself, which, untreated, can lead to permanent joint damage. Thus, the goal in the evaluation of these patients is to determine the etiology as quickly as possible.

M. Rebecca Hoffman, J. Kevin Dorsey, Jerry E. Kruse

Chapter 12. Musculoskeletal Radiology

Abstract

Since musculoskeletal complaints are very common, it is important for primary care providers to be familiar with when and how to order radiographic studies. Radiographs or “good old-fashioned X-rays” can be a useful extension of, but not a substitute for, a good history and physical examination. This chapter provides guidance regarding the appropriate ordering of studies as well as outlining a few pitfalls that can be encountered.

David Olysav

Chapter 13. Soft Tissue Injuries

Abstract

Injury to soft tissue encompasses a vast array of entities due to an assortment of mechanisms. The etiology of an injury can include physical, biological, thermal, metabolic, and chemical means. A sports medicine précis of soft tissue injuries includes sprains, strains, contusions, hematomas, and tendinitides. There are commonalities across this wide assortment of maladies however. The application of mechanical force to human tissue can cause one of two changes: a change in shape (deformation) or a change in velocity (deceleration or acceleration). If tissue tolerance is exceeded, a push can cause contusions, hematomas, and fractures while a pull results in sprains, strains, and dislocations. A large magnitude of force applied to tissue results in macrotrauma, such as sprains, strains, and crush injuries. Smaller forces that recur over long and/or repetitive sequences result in microtrauma, such as stress fractures and overuse syndromes.

James M. Lynch, Sue Stanley-Green

Chapter 14. The Preparticipation Physical Exam

Abstract

The preparticipation evaluation (PPE) is a necessary, yet controversial and regulated, function that serves several purposes for athletic participants. At its core, the PPE is a screening tool used to identify potentially life-threatening or debilitating conditions that may manifest as a result of athletic participation. However, there are many other objectives of the PPE that are of great importance and less controversial. This chapter will discuss the pertinent details in performing an adequate PPE with special attention to the most common life-threatening conditions. Examples of medical history ­questions, exam techniques, and clearance issues will be provided.

Timothy Von Fange, Jill K. Wirth

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