Non-traumatic musculoskeletal conditions

Many patients with non-traumatic limb pain present to Emergency Departments but most are neither accidents nor emergencies.  In many cases the most appropriate management is to refer the patient back to their GP.  However, some patients have been referred by their GP and other patients may be appropriate for Emergency Department follow up for various reasons. Do not bring patient back to clinic for advice if there is a senior ED doctor in the department 
Upper limb            
Rotator cuff problems    
- Analgesics /NSAIDs if not contraindicated
- Broad arm sling for short period of time, but only if in severe pain  
- Encourage gentle (e.g. pendulum) movements  +/- physio
- Follow up by GP  
Acute calcific peri-arthritis of shoulder  
- Analgesia
- Broad arm sling if necessary
- Review clinic 1 week      

Septic olecranon bursitis  
- Antibiotics; flucloxacillin.  
- Collar & cuff
- Review clinic 48 hrs -
If very severe may need admission for IV antibiotics
- Not for aspiration 
Non-infected olecranon bursitis  
- NSAIDs if not contraindicated
- Follow up in Review clinic at 1 week or by G.P.      

Tennis elbow/Golfers Elbow  
- NSAIDs  
- Follow up by G.P.   
Tenosynovitis crepitans (DeQuervain’s)  
- POP back slab
- Analgesics/NSAID as necessary
- Review clinic 10 days POP off on arrival 
- Refer to GP for OPD referral if necessary 
Carpal Tunnel syndrome  
- Consider possible underlying cause
- Futura splint for night time use only 
- Refer to GP for OPD referral 
Trigger finger/thumb    
-  GP for OPD referral  
Stuck trigger thumb  Most common in young children    
- Needs surgical release.  
- Ask advice     

Lower limb 
Hip pain in young children (Limp)    
Most commonly due to transient synovitis but need to out-rule more serious conditions such as septic arthritis and Perthes Go to page 125 
Slipped upper femoral epiphysis
Suspect in any pre-pubertal child with pain between hip and knee. More common in overweight children. Often follows minor trauma
- Need an AP and frog lateral X-ray of hip  
- Refer orthopaedics 
Greater Trochanter pain/bursitis  
- Analgesia, NSAIDs
- Follow-up by GP 
Acute synovitis knee
Atraumatic painful swollen +/- hot knee  
- Check temperature.
- D/W senior Doc
- If cannot O/R septic arthritis refer orthopaedics.
- Otherwise NSAIDs and refer to back to GP 
Loose Body knee    
History of intermittent locking or giving way. No recent trauma
- X-ray, do intercondylar (tunnel) view
- Refer back to GP for referral to ortho OPD 
Osgood Schlatter's Disease  
Atraumatic pain localised to tibial tuberosity exacerbated by activity. Stops when child stops growing
- Advise as to nature of disease
- Symptomatic treatment  
- Rest when pain is severe and exercise when pain is better.
- Refer to G.P.    
Pre-patellar/ Infra patellar bursitis. 
Treat as for olecranon bursitis (page 42). 
Suspected stress fracture leg  
May not show on initial X-ray
- Ask advice
- If neck of femur, CT +/- refer orthopaedics
- Symptomatic treatment
- Review clinic 10 to 14 days        

Plantar Fasciitis    
Atraumatic pain sole of foot usually localised with point tenderness to anterior part of heel pad
- Give patient a horseshoe shaped pad of orthopaedic felt to take weight off painful spot.
- Advise exercises to stretch calf muscles
- Refer GP for consideration of steroid/local anaesthetic injection. 
Suspected Stress Fracture in foot (March fracture)
- Most commonly 2nd metatarsal
- May not show on initial x-rays
- Symptomatic treatment
- Review Clinic 2 weeks 
- Refer back to GP for OPD referral 
Ingrowing toe nail  
- If grossly infected remove nail under LA
- Ask advice on how to do this
- Otherwise refer back to GP   
- Treat with topical salicyclic acid preparation
- Refer back to GP 
Podagra (Acute gout of MTP joint of big toe)
- Acute hot red swollen 1st MTP joint
- Treat with diclofenac.