Orthopedics and Musculoskeletal Medicine
Orthopedics and Musculoskeletal Medicine tests fracture recognition, back pain red flags, osteoarthritis and osteoporosis, and regional limb problems. Expect to decide what can be managed in primary care and what needs imaging or referral.
Core rules
- Ottawa ankle rules: X-ray if pain near the malleoli plus inability to bear weight or bone tenderness.
- Low back pain: most is mechanical. Red flags include age over 50 with new pain, weight loss, fever, night pain, neurological deficit, and bowel or bladder dysfunction. Cauda equina needs emergency MRI.
- Osteoarthritis: exercise and weight loss first-line; topical NSAIDs before oral in knee OA; avoid long-term opioids.
- Osteoporosis: DEXA T-score ≤−2.5 defines osteoporosis. Treat with calcium, vitamin D, and an antiresorptive, and review fall risk.
- Septic arthritis: hot swollen joint with fever needs urgent aspiration; do not treat as gout without excluding infection.
Worked example
A 70-year-old woman falls on an outstretched hand and has a painful, dorsally displaced wrist. Reasoning: this is a Colles fracture. Check the distal neurovascular status, immobilize, and arrange X-ray. Because the fracture is a fragility fracture, assess bone health: a DEXA T-score of −2.8 confirms osteoporosis, so start calcium, vitamin D, and a bisphosphonate, and review falls.
Traps
- Missing cauda equina because pain is the only complaint.
- Prescribing NSAIDs to an elderly patient with CKD or heart failure.
- Assuming a swollen joint is gout.
- Ignoring a growth-plate injury in a child.