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Level 1 Content for the 2019 Alternative PANRE: Musculoskeletal

Today we’re going to talk about the red light content for the musculoskeletal system. Musculoskeletal content used to be 10% of the PANRE, now it’s 9%, which is still pretty significant. What are the things that you have to notify your supervising doc immediately about? With these level one or red light situations, we have to recognize the most likely diagnosis using signs, symptoms, and risk factors, and then refer appropriately.

When we talk about the musculoskeletal system, here are the topics that are considered red light content for your boards. In the back, it’s cauda equina syndrome, kyphosis, scoliosis, and spinal disc herniation. There’s also SCFE (slipped capital femoral epiphysis), SLE (systemic lupus erythematosus), osteomyelitis, avascular necrosis, and compartment syndrome. In the shoulder, you need to know rotator cuff tears. Interestingly, fractures and dislocations are considered red light content, and that’s of the knee, patella, ankle, foot, forearm, wrist, hand, shoulder, hip, and spine.

Let’s go through those topics.

In the Back

Cauda Equina Syndrome

This is a sinister diagnosis that is very easily missed. We talk about this at our emergency medicine conferences and at our board review conferences, because in every single back pain case that you manage for the rest of your PA career, you have to defend yourself against cauda equina syndrome. I recently had a PA message me and say, “John, can I talk to you?” There was some urgency, so I called her. She said, “John, I just got a certified letter saying that they are accusing me of missing cauda equina syndrome on a patient.” She eventually was dismissed from this, but cauda equine syndrome is very real because there are long-term sequelae that are very debilitating.

A lot of different things can cause it, but cauda equina syndrome is severe back pain. They can have bilateral or unilateral leg symptoms. The classic symptom is saddle anesthesia. Where they sit on a horse, they have numbness and tingling in their inner thighs and the peritoneum. They classically have problems with bowel or bladder, meaning either incontinence of retention of stool. If you’re concerned about that loss of sphincter tones, this is going to be someone who has back pain that’s severe and some kind of neurological decrease in sensation in their saddle-like distribution. Classically, it’s with incontinence or retention of urine or stool. That’s an immediate referral.

Kyphosis and Scoliosis

These diseases are just curvature of the spine. There’s not really much as a PA we can do about that and the degree of curvature is what’s going to determine the degree of treatment that’s necessary. If the spine is curved, we would refer onto our doc.

Spinal Disc Herniation

Spinal disc herniation is classically either in the C-spine or in the lumbosacral spine. The patient will have some kind of deficit going into an extremity. If you have a spinal herniation, you can have paresthesias down one of the arms, or weakness or pain down one of the arms. In the lumbosacral spine, it’ll be some kind of symptoms down the leg. Straight leg raises would help reproduce that and exacerbate it. If it’s a spinal disc herniation, manipulation of the neck is going to reproduce those symptoms. Either one of those herniations, we’re going to refer immediately to a supervising doc.

Musculoskeletal System

SCFE (Slipped Capital Femoral Epiphysis)

This happens in approximately 13-year-old males, typically on the heavier side, African-American, and athletic. What happens is they present with this dull ache and a limp because their growth plate at the top of the hip bone or the femur slipped off. The treatment’s going to be surgery. When a kid comes in with knee pain, always, always, always look at the hip. Always look at the hip. If you have a kid that comes in limping and there’s no trauma, and the mom thinks it’s a knee, you have to think it’s a hip and talk to your doc.

SLE (Systemic Lupus Erythematosus)

This is a very, very, very tricky disease. I believe it is the trickiest disease that PAs have to deal with. It’s a very complicated diagnosis and these patients can present with a menagerie of symptoms. Initially, it’s a younger female, approximately 30 to 40 years old. They’ll have all sorts of symptoms, classic with the malar rash. Lupus can affect every part of their body, including their eyes, heart or kidneys, so this is a very tricky disease. If you have a female 30 to 40 with weird symptoms that you have a tough time putting together, you have to think lupus. That would be someone we would consult immediately on.

There are a number of medications that give you a lupus-like rash and the pneumonic I teach is MN to Q, put a chip in the agent, or “MQ CHIP.” It’s methyldopa, quinidine, chlorpromazine, isoniazid, and procainamide. Those are the medications that give you a lupus-like rash. Know that lupus can have a false positive for syphilis and exacerbates in the sun.

Acute/Chronic Osteomyelitis

Osteomyelitis is a bone infection, classically Staph aureus. Bone pain, a lot of times is seeded from some other area. Look for IV drug use. A lot of times, they’re immunocompromised. X-ray is the preliminary diagnosis, but if you have someone who has bone pain and fever or signs of an infection, we would talk to our doc. Culture is always a definitive test, but understand that CAT scan will be helpful to really look at the bone.

Avascular Necrosis

When a bone doesn’t get blood flow, it can die. We classically talk about that in places like the scaphoid bone and if a thumb spica is not put on the wrist accordingly in anybody who falls and has pain in the anatomical snuffbox. We need to prevent avascular necrosis in the scaphoid bone.

Avascular necrosis can happen at any bone in the body, but we classically like to talk about it in the hips, where the distal portion of the femur doesn’t get blood supply and it dies. This is classically bilateral and in adults; it’s a gradual onset over a couple of months. If it occurs in a child, it’s called a Legg-Calve-Perthes syndrome. In adults, the bisphosphonate medicines like Fosamax help to build up the bone and strengthen it but know at times these adults will need surgery. With children, this is typically something that resolves on its own.

Compartment Syndrome

Compartment syndrome is a lack of blood flow in a body compartment that can lead to muscle damage. There’s severe pain, but something would have caused this increased pressure, like a fracture. If you have pain in a long bone, that’s when we would really want to refer to an orthopedic surgeon to check for compartment syndrome.

Shoulders: Rotator Cuff Tears

A rotator cuff tear can occur from an acute traumatic injury or multiple repetitive injuries. X-rays will be normal, so no fractures, dislocations or separations, but they have the persistent pain and limited range of motion. The Hawkins test and the Neer test are helpful to diagnose the shoulder. If you have a dislocated shoulder, PAs manage that. We pop them back in. But if you have someone who’s got laxity or pain with consistent range of motion, that’s something we refer on to orthopedic surgery for an evaluation and possibly an MRI.

Fractions and Dislocations

Knee and Patella

Why is this so important? The popliteal artery is right there. If you have a fracture of the proximal tibia and/or the patella-like area, you have to think vascular compromise.

Ankle and Foot

Ankle and foot fractures and dislocations need to be sedated and reduced, but we immediately talk to our doc about that. You always want to check for vascular flow, neuro-sensation, and muscular function. Oftentimes, it’s quite deformed.

Forearm, Wrist and Hand

Fractures and dislocation of the wrist, forearm, and hand need to be referred on because the brachial artery is right there and if we don’t manage this appropriately, they can go on to a Volkmann’s contracture, which is a permanent claw-like deformity of the forearm. By the initial criteria that the NCCPA is putting out, we don’t even need to know that we would do an X-ray, we just have to go, “Holy cow, I think there’s a really bad Colles’ fracture.” By definition, we have to go talk to our doc or orthopedic surgeon, but we’d have to refer appropriately.

Shoulder, Hip and Spine

Any of those fractures or dislocations, we would talk to our doc about, okay?

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