Hi Everyone!

How are your muscles and joints feeling today? Take a moment now to stand up and roll your ankles, roll your wrists, roll your shoulders and stretch your neck. If you haven’t seen them already, check out Bob and Brad on Youtube. They are a physiotherapy duo who provide excellent information about stretching and back health. I particularly find this video excellent – https://bit.ly/2GM0lnX. Your body is just as important as your mind – take the time throughout the day to nourish it with stretching and movement.

This article is about musculoskeletal medicine and rheumatology.

Most people with obvious fractures bypass the GP practice and head straight for the emergency department. It is generally the GP’s responsibility to provide repeat x-ray forms at 4-6 weeks post-fracture and to coordinate with the fracture clinic for ongoing care. There are times when, especially in particularly stoic patients, that the GP may have to investigate and/or manage finger fractures (“punched a wall on the weekend, Doc”), rib fractures (“slipped in the bath!”) or stress fractures (“I want to run again, please!”). Either way, it’s important to have a good understanding of fracture management and who to call for further advice.

Rheumatological issues are often a mystery. Their presentations come with a cluster of symptoms such as joint aches, rash, fatigue and/or sicca symptoms. It’s important to know the investigations for these conditions – particularly ESR, rheumatoid factor, anti-CCP and ANA which are a good starting point if you are ever unsure. Borderline elevated ANA can be a confounding finding on investigation, and shouldn’t distract. Therapeutic guidelines are an excellent resource for understanding rheumatology.

One of my more complicated patients over the last couple of years is a female patient with Sjogren’s disease. She has typical sicca symptoms with chronic dry eyes and dry mouth. She has developed renal tubular acidosis and subsequent hypokalaemia. The treatment for the hypokaelamia, potassium citrate, causes the production of renal stones and consequently biliary colic. She has been treated also with prednisolone which has given her a cushingoid appearance. The last I have heard, the rheumatologists have given her a diagnosis of systemic lupus erythematosis. It goes to show that even to rheumatologists, these conditions are not simple.

Be kind to yourself, and give your body a good stretch regularly throughout the day!

Dr Andrew Harris

Director of Amadeus Education.

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Important conditions:

These are the common conditions that should be reviewed for this topic:

Topics	Important reading
Arthritis – including osteoarthritis, rheumatoid arthritis, viral arthritis.	– Guideline for the management of knee and hip osteoarthritis. RACGP, 2018. (https://bit.ly/2TW7YLf) – Osteoarthritis of the knee clinical care standard. Australian Commission on Safety and Quality in Health Care, 2017. (https://bit.ly/2pZfXZ1) – Osteoarthritis. AFP, September 2010. (https://bit.ly/2DXM2Zn) – Osteoarthritis: Where are we for pain and therapy in 2013. AFP, November 2013. (https://bit.ly/2IkoS4W) – Osteoarthritis: Management options in general practice. AFP, September 2010. (https://bit.ly/2Iz12Cu) – Viral arthritis. AFP, November 2013. (https://bit.ly/2tCQCI5) – Rheumatoid arthritis. AFP, September 2010. (https://bit.ly/2BK378X) – Arthritis disease: The use of complementary therapies. AFP, September 2010. (https://bit.ly/2EkxrZK) – Clinical guidelines for MSK disease (OA< RA, JIA, OP)
Fracture management – including stress fractures, clavicle, scaphoid, NOF	– Sports med Australia- injury sheets – Persistent foot pain. AFP, September 2009. (https://bit.ly/2Ne0VLy) – The challenge of managing mid-foot pain. AFP, March 2015. (https://bit.ly/2Ndqg8c) – Hip fracture – Challenges in prevention and management. AFP, December 2017. (https://bit.ly/2TWgREM)
Gout	– The management of gout: Much has changed. AFP, May 2016. (https://bit.ly/2IpXQJo)
SLE	– Systemic lupus erythematosus: When to consider and management options. AFP, October 2013. (https://bit.ly/2Sgt99v)
Scleroderma	– Red flags in scleroderma. AFP, October 2008. (https://bit.ly/2DWUeJs) – Antinuclear antibody test. AFP, October 2013. (https://bit.ly/2BIY60x)
Polymyalgia rheumatica	– Polymyalgia rheumatica: clinical update. AFP, June 2014. (https://bit.ly/2SWq9U7).
Scoliosis	– About scoliosis – causes, symptoms, treatment. (https://bit.ly/2zt7m7B)
Fibromyalgia	– Fibromyalgia: Should we be testing and treating for vitamin D deficiency? AFP, September 2011. (https://bit.ly/2E14a4C)
Injuries – including knee, shoulder, spine, hands	– Injury fact sheets. Sports Medicine Australia. (https://bit.ly/2NfY9FJ) – Sports ankle injuries: Assessment and management. AFP, January/February 2010. (https://bit.ly/2T6nO91) – Shin pain in athletes: Assessment and management. AFP, January/February 2010. (https://bit.ly/2twNEV6) – Sports knee injuries: Assessment management. AFP, January/February 2010. (https://bit.ly/2DYZTyP) – Ottawa knee rules: A useful clinical decision tool. AFP, April 2012. (https://bit.ly/2Necqm5) – Meniscal tear: Presentation, diagnosis and management. AFP, April 2012. (https://bit.ly/2GOVy46) – Shoulder injuries: Management in general practice. AFP, April 2012. (https://bit.ly/2TTKeax) – Anterior shoulder dislocation: Seated versus traditional reduction technique. AFP, March 2011. (https://bit.ly/2XepsEH) – Cervical spine: Assessment following trauma. AFP, April 2012. (https://bit.ly/2ElIeTh) – Upper cervical spine injuries in elderly patients. AFP, January/February 2009. (https://bit.ly/2V67rXh) – Hands, fingers, thumbs: Assessment and management of common hand injuries in general practice. AFP, April 2012. (https://bit.ly/2BF0Hsc) – Mallet finger: Management and patient compliance. AFP, January/February 2011. (https://bit.ly/2GwDahn)
Seronegative arthropathies – including ankylosing spondylitis, psoriatic arthritis, reactive arthritis, Reiter’s syndrome, juvenile idiopathic arthritis	– Ankylosing spondylitis: An update. AFP, November 2013. (https://bit.ly/2T4ZAfj) – Juvenile idiopathic arthritis. AFP, September 2010. (https://bit.ly/2Gzk89U)
Bone tumours	– Painful swollen wrist: A case study. AFP, May 2013. (https://bit.ly/2tq8DZY)
Tendon disorders	– Tendon injuries: Practice tips for GPs. AFP, April 2013. (https://bit.ly/2IpWcrv) – Heel pain: a practical approach. AFP, March 2015. (https://bit.ly/2ScVIED)
Paediatric orthopaedics	– Slipped upper femoral epiphysis in children: Delays to diagnosis. AFP, March 2010. (https://bit.ly/2tsyHDH)
Osteomyelitis	– Back pain with lower limb paresis: A case study. AFP, October 2012. (https://bit.ly/2Xeof07)
Sjogren’s	– Dry mouth: Xerostomia and salivary gland hypofunction. AFP, July 2016. (https://bit.ly/2TVO3fJ)

Medication doses:

These are the medications and doses that should be learned for the exam:

Condition	Medication
Pain	Paracetamol 1g orally QID PRN Ibuprofen 400mg orally TDS PRN Oxycodone 5mg orally PRN
Polymyalgia rheumatica	Prednisolone 15mg orally daily for 4 weeks, then reduce by 2.5mg every 4 weeks to 10mg daily, then reduced by 1mg every 4-8 weeks to stop.
Gout	Acute (options): Ibuprofen 400mg orally TDS for 3-5 days Prednisolone 25mg orally daily for 3-5 days Colchicine 1mg initially, then 500mcg 1 hour later Prevention: Allopurinol 50mg orally daily for 4 weeks then increase to achieve target of <0.36 (or <0.3 if tophi present)
Rheumatoid arthritis	Methotrexate 5-10mg (up to 20mg) orally or subcutaneous weekly. Folate 5mg weekly (not on day of methotrexate)

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Checks:

Here are the list of recommended Checks that would be useful in your study for GP exams (accessed via subscription from http://gplearning.racgp.org.au):

• Sports medicine, September 2016
• Bones/Joints, August 2015
• Sports medicine, October 2013

Copyright © 2021 Andrew Harris