Applications in Musculoskeletal Disorders - part 10 ppsx

Department of Family MedicineOregon Health & Science University School of Medicine Portland, Oregon Associate Editors Professor and Chairman Professor and Vice Chairman Department of Fam

Taylor’s Musculoskeletal Problems and Injuries

Department of Family Medicine

Oregon Health & Science University

School of Medicine

Portland, Oregon

Associate Editors

Professor and Chairman Professor and Vice Chairman Department of Family and Department of Family Medicine Community Medicine Oregon Health & Science University Medical College of Wisconsin School of Medicine

Milwaukee, Wisconsin Portland, Oregon

Professor and Chairman Clinical Professor

Department of Family Medicine Department of Family and

University of Mississippi Preventive Medicine

School of Medicine University of California,

Jackson, Mississippi San Diego School of Medicine

San Diego, California

With 53 Illustrations

Professor Emeritus

Department of Family Medicine

Oregon Health & Science University

School of Medicine

Portland, OR 97239-3098, USA

Associate Editors

Alan K David, M.D Scott A Fields, M.D.

Professor and Chairman Professor and Vice Chairman

Department of Family and Department of Family Medicine

Community Medicine Oregon Health & Science University Medical College of Wisconsin School of Medicine

Milwaukee, WI 53226-0509, USA Portland, OR 97201-3098, USA

D Melessa Phillips, M.D Joseph E Scherger, M.D., M.P.H.

Professor and Chairman Clinical Professor

Department of Family Medicine Department of Family and Preventive Medicine University of Mississippi School University of California, San Diego

Jackson, MS 39216-4500, USA San Diego, California 92103-0801, USA

Library of Congress Control Number: 2005935915

ISBN-10: 0-387-29171-7 Printed on acid-free paper.

ISBN-13: 978-0387-29171-0

© 2006 Springer Science +Business Media, LLC

All rights reserved This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science +Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden.

The use in this publication of trade names, trademarks, service marks and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights.

While the advice and information in this book are believed to be true and accurate at the date

of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made The publisher makes no warranty, express or implied, with respect to the material contained herein.

Printed in the United States of America (SPI/EB)

9 8 7 6 5 4 3 2 1

After more than a quarter century as a primary care educator, I amconvinced that our graduates enter practice inadequately trained inthe diagnosis and management of musculoskeletal problems andinjuries One reason for this perceived deficiency is the relativelyshort duration of primary care training—typically three years forfamily medicine, general internal medicine, and general pediatrics.During this time, there are just not enough months to teach all a cli-nician needs to know about diseases and trauma involving the mus-culoskeletal system This inadequacy is compounded by thesometimes quirky nature of the problems: that is, for example, theincreased risk of nonunion in a fracture of the carpal navicular(scaphoid) bone or the maneuver that can magically reduce a child’sradial head subluxation

The chapters in this book are from the edited reference book Family Medicine: Principles and Practice, 6th edition, which is widely used

by family physicians in the United States and abroad The publisherand I believe that, in addition to family physicians, the chapters in thisbook will also be useful to other clinicians providing broad-basedcare: general internists, general pediatricians, emergency physicians,nurse practitioners, and physician assistants When compared to thelarge, comprehensive book, this volume will be preferred by somereaders because of the physically smaller size and perhaps by thelower cost

In selecting chapters to include in the book, I have includedproblems involving all areas of the skeleton and related musculature,

in both children and adults Athletic injuries are included because,after all, primary care clinicians manage most sports injuries I haveincluded a chapter on acute lacerations, which often accompany othertypes of injuries In addition to sprains, strains, and fractures, there arechapters covering illnesses affecting the musculoskeletal system:

various types of arthritis, fibromyalgia, and the complex regional painsyndrome.

I hope you find this book useful in daily practice; comments arewelcome

Robert B Taylor, M.D.

Portland, Oregon, USA

vi Preface

Clinical Practice

Notice

Everyone involved with the preparation of this book has worked veryhard to assure that information presented here is accurate and that itrepresents accepted clinical practices These efforts include confirm-ing that drug recommendations and dosages discussed in this textare in accordance with current practice at the time of publication.Nevertheless, therapeutic recommendations and dosage scheduleschange with reports of ongoing research, changes in government rec-ommendations, reports of adverse drug reactions, and other newinformation

A few recommendations and drug uses described herein have Foodand Drug Administration (FDA) clearance for limited use in restrictedsettings It is the responsibility of the clinician to determine the FDAstatus of any drug selection, drug dosage, or device recommended topatients

The reader should check the package insert for each drug to mine any change in indications or dosage as well as for any precau-tions or warnings This admonition is especially true when the drugconsidered is new or infrequently used by the clinician

deter-The use of the information in this book in a specific clinical setting orsituation is the professional responsibility of the clinician The authors,editors, or publisher are not responsible for errors, omissions, adverseeffects, or any consequences arising from the use of information in thisbook, and make no warranty, expressed or implied, with respect to thecompleteness, timeliness, or accuracy of the book’s contents

Preface v

Clinical Practice Notice vii

Contents ix

Contributors xi

1 Disorders of the Back and Neck 1

Walter L Calmbach 2 Disorders of the Upper Extremity 35

Ted C Schaffer 3 Disorders of the Lower Extremity 59

Kenneth M Bielak and Bradley E Kocian 4 Osteoarthritis 89

Alicia D Monroe and John B Murphy 5 Rheumatoid Arthritis and Related Disorders 97

Joseph W Gravel Jr., Patricia A Sereno, and Katherine E Miller 6 Selected Disorders of the Musculoskeletal System 127

Jeffrey G Jones and Doug Poplin 7 Musculoskeletal Problems of Children 147

Mark D Bracker, Suraj A Achar, Todd J May, Juan Carlos Buller, and Wilma J Wooten 8 Osteoporosis 181

Paula Cifuentes Henderson and Richard P Usatine

9 Gout 197

James F Calvert, Jr.

Michael L Tuggy and Cora Collette Breuner

Bryan J Campbell and Douglas J Campbell

Allan V Abbott

Index 281

x Contents

Walter L Calmbach, M.D., Associate Professor of Family and

Community Medicine, Director of Sports Medicine Fellowship andSouth Texas Ambulatory Research Network (STARNET), University

of Texas Health Science Center, San Antonio, Texas

Disorders of the Back and Neck

James F Calvert Jr, M.D., Associate Professor of Family Medicine,

Oregon Health & Science University School of Medicine, Portland;Cascades East Family Practice Residency Program, Klamath Falls,Oregon

Gout

Bryan J Campbell, M.D., Assistant Professor of Family and

Preventive Medicine, University of Utah School of Medicine, SaltLake City, Utah

Care of Acute Lacerations

Douglas J Campbell, M.D., Community Attending Physician, Good

Samaritan Regional Family Practice Center, Yavapai RegionalMedical Center, Prescott, Arizona

Care of Acute Lacerations

Joseph W Gravel, Jr, M.D., Assistant Clinical Professor of Family

Medicine and Community Health, Tufts University School ofMedicine, Boston; Director, Tufts University Family PracticeResidency Program, Malden, Massachusetts

Rheumatoid Arthritis and Related Disorders

Paula Cifuentes Henderson, M.D., Clinical Instructor of Family

Medicine, University of California – Los Angeles School ofMedicine, Los Angeles, California

Osteoporosis

Jeffrey G Jones, M.D., M.P.H., Medical Director, St Francis

Traveler’s Health Center, Indianapolis, Indiana

Selected Disorders of the Musculoskeletal System

Bradley E Kocian, M.D., Sports Medicine Fellow, University of

Tennessee -Knoxville Medical Center, Knoxville, Tennessee

Disorders of the Lower Extremity

xii Contributors

Todd J May, D.O., Lieutenant Commander, Medical Corps, United

States Naval Hospital, Camp Pendleton, California

Musculoskeletal Problems of Children

Katherine E Miller, M.D., Assistant Clinical Professor of Family

Medicine and Community Health, Tufts University School ofMedicine, Boston; Faculty, Tufts University Family PracticeResidency Program, Malden, Massachusetts

Rheumatoid Arthritis and Related Disorders

Alicia D Monroe, M.D., Associate Professor of Family Medicine,

Brown Medical School, Providence; Memorial Hospital of RhodeIsland, Pawtucket, Rhode Island

Osteoarthritis

John B Murphy, M.D., Professor of Family Medicine, Brown Medical

School, Providence, Rhode Island

Osteoarthritis

Doug Poplin, M.D., M.P.H., Medical Director, Saint Francis

Occupational Health Center, Indianapolis, Indiana

Selected Disorders of the Musculoskeletal System

Ted C Schaffer, M.D., Clinical Assistant Professor, Department of

Family Medicine and Clinical Epidemiology, University of PittsburghSchool of Medicine; Director, UPMC – St Margaret Hospital FamilyPractice Residency Program, Pittsburgh, Pennsylvania

Disorders of the Upper Extremity

Patricia A Sereno, M.D., M.P.H., Assistant Clinical Professor of

Family Medicine and Community Health, Tufts University School ofMedicine, Boston; Hallmark Family Health Center, Malden,Massachusetts

Rheumatoid Arthritis and Related Disorders

Michael L Tuggy, M.D., Clinical Assistant Professor of Family

Medicine, University of Washington School of Medicine; Director,Swedish Family Medicine Residency Program, Seattle, Washington

Athletic Injuries

Contributors xiii

Richard P Usatine, M.D., Professor of Clinical Family Medicine and

Assistant Dean of Student Affairs, University of California – LosAngeles School of Medicine, Los Angeles, California

Osteoporosis

Wilma J Wooten, M.D., M.P.H., Associate Clinical Professor of

Family and Preventive Medicine, University of California-San DiegoSchool of Medicine, La Jolla, California

Musculoskeletal Problems of Children

xiv Contributors

2 Walter L Calmbach

for the development of low back pain include heavy lifting and ing, bodily vibration, obesity, and poor conditioning; however, low

In cases of more severe back pain, occupational exposures aremuch more significant, including repetitive heavy lifting, pulling, orpushing, and exposures to industrial and vehicular vibrations If eventemporary work loss occurs, additional important risk factors includejob dissatisfaction, supervisor ratings, and job environment (i.e., bor-

back pain include traumatic origin of first attack, sciatic pain, ographic changes, alcohol abuse, specific job situations, and psy-chosocial stigmata

radi-Of patients with acute low back pain, only 1.5% develop sciatica(i.e., painful paresthesias and/or motor weakness in the distribution of

a nerve root) However, the lifetime prevalence of sciatica is 40%, andsciatica afflicts 11% of patients with low back pain that lasts for more

truck driving, cigarette smoking, and repeated lifting in a twisted ture It is most common in the fourth and fifth decades of life, andpeaks in the fourth decade Most patients with sciatica, even those

Despite the incidence and prevalence of low back pain and sciatica,

National Center for Health Statistics estimates that 5.2 millionAmericans are disabled with low back pain, of whom 2.6 million are

to low back pain are incurred by the 4% to 5% of patients with

back pain include poor health habits, job dissatisfaction, less ing work environments, poor ratings by supervisors, psychological

These same factors are associated with high failure rates for ments of all types

treat-Natural History

Recovery from nonspecific low back pain is usually rapid.Approximately one third of patients are improved at one week, and twothirds at seven weeks However, recurrences are common, affecting 40%

of patients within six months Thus, “acute low back pain” is increasingly

Low back pain may originate from many structures, including avertebral musculature, ligaments, the annulus fibrosus, the spinalnerve roots, the facet joints, the vertebral periosteum, fascia, or bloodvessels The most common causes of back pain include musculoliga-mentous injuries, degenerative changes in the intervertebral discs and

The natural history of herniated lumbar disc is usually quite able Only about 10% of patients who present with sciatica have suf-ficient pain at six weeks that surgery is considered Sequentialmagnetic resonance imaging (MRI) shows gradual regression of theherniated disc material over time, with partial or complete resolution

changed little from its description in the classic article of Mixter andBarr: the annulus fibrosus begins to deteriorate by age 30, which leads

to partial or complete herniation of the nucleus pulposus, causing

her-niation is in the posterolateral position, producing unilateralsymptoms Occasionally, the disc will herniate in the midline, and alarge herniation in this location can cause bilateral symptoms Morethan 95% of lumbar disc herniations occur at the L4–L5 or L5–S1 lev-

toe extensors and dorsiflexors of the foot, and sensory loss at the sum of the foot and in the first web space Involvement of the S1 nerveroot results in a diminished ankle reflex, weakness of the plantar flex-ors, and sensory loss at the posterior calf and lateral foot

dor-Among patients who present with low back pain, 90% recover within

patients with symptoms of acute low back pain return to work within

six months, and only 1% at one year However, symptoms of low backpain recur in approximately 60% of cases over the next two years.Demographic characteristics such as age, gender, race, or ethnicity

do not appear to influence the natural history of low back pain.Obesity, smoking, and occupation, however, are important influ-

Occupational factors that prolong or delay recovery from acute lowback pain include heavier job requirements, job dissatisfaction, repe-titious or boring jobs, poor employer evaluations, and noisy or

impor-tant role in the natural history of low back pain, modulating response

to pain, and promoting illness behavior The generally favorable ural history of acute low back pain is significantly influenced by a

nat-1 Disorders of the Back and Neck 3