Transcript: Ortho in Primary Care: Hacks for New Nurse Practitioners

​Liz Rohr:
I've been getting a lot of questions about orthopedic complaints in primary care, especially in the context of doing telemedicine. I know in the future I'll be making specific videos for certain areas, shoulder, wrist, knee, things like that, but I think because of all of those questions, I wanted to do a general video about orthopedic hacks in primary care. I have some real talk in here, and so that might ruffle some feathers. If you don't agree with me, I would love to hear from you, because I'm always expanding my orthopedic knowledge.
But, if you are new here, I'm Liz Rohr from Real World NP, and you're watching NP Practice Made Simple, the weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients.
 

Just to start, I recommend a triage approach and when it comes to orthopedic problems, and in general. That's how I generally approach all of my patients, is that triage kind of approach, which comes from your history, which you can get through telemedicine.
 

The first step is really, is this acute or is it chronic? Did it start in the last couple of days, or has it been weeks, months or years? Because if it's weeks, months or years, you can usually lower your stress level by quite a bit, because most of those are less urgent of an issue.
 

The next step is about trauma. Is it traumatic, or is it non-traumatic? The vast majority of what I see in primary care is chronic and non-traumatic, and those two things together definitely ease my anxiety even more, because I'm just going to be honest here. I actually like orthopedics. I find it very interesting, but I find I did not always. I think a lot of nurse practitioners feel that way, because it feels overwhelming. It feels like there's a lot to know, because there is. It's a huge depth of knowledge you need to have about different anatomical things, and diagnoses, and all that kind of stuff.
 

Hopefully, that will bring your anxiety level down. And so, again, is it acute or chronic, traumatic or not traumatic, and what are the red flags? Those are the first things to start with. Even if you don't feel that comfortable with orthopedics, stepping back for a second, one of the ways that I've developed my orthopedic knowledge, is really just seeing what's in front of me, learning as I go, developing my knowledge further, because we all learn about things in school. But, it doesn't come as readily, unless you've seen a patient with that problem.
 

For example, I had a patient recently that I had never seen in four years, a nasal injury, and I had a nasal injury. Basically what I did, is I consulted my resources and looked up, using that framework of acute or chronic, traumatic or non-traumatic, and looking at the red flags associated with that particular symptom, that particular area. When it comes to red flags, there's both the symptoms, but the area specific red flags, shoulder, wrist, knee, back, et cetera. But, then there's also these global overall red flags, and especially when it comes to chronic pain or chronic orthopedic issues, there tends to be three main branches of red flags.
 

One, is infection. You always want to think about that, and that tends to be more of an acute issue, less of a chronic. But, you always want to think about that. Do they have signs of infection? Do they have redness, the warmth, fevers, chills, things like that, like a septic joint? What are the risk factors for infection? Do they use IV drugs? That's one thing to think about.
 

Another red flag is about malignancy, and then that is dependent on patient age. Higher age is more associated with malignancy. Have they had a previous cancer that could be a new metastasis to their spine, or something like that?
 

Then the third one has to do with the loss of function. That's typically region dependent as well, and that comes with looking things up as they come to you. Hopefully, you can kind of have a general knowledge of the most common ones, back, shoulder, knee. Those are the main ones that I see. Wrist.
 

Loss of function, for example, when it comes to low back pain. That specifically, you're worried about Cauda Equina syndrome. And so, whenever you have those patients, you always want to ask those red flag symptoms, subtle anesthesia, the numbness in the pelvis area, bowel or bladder incontinence, weakness, numbness. Those are typically the chronic ones, possibly some acute.
 

For the acute traumatic ones, I'm actually not really talking a ton in this video, because I don't see that much of it. And so, I typically always consult when I have something. For example, they're just a lot more nuanced and there is a lot more risk involved. For example, things that I've seen are finger fracture. And, for example, if you get a finger fracture and it's in the joint space, that's very urgent and you'd need to know that, put that particular piece of knowledge. It's not really a general rule, but anyway. That's a little bit more nuanced. So, I always recommend if it's an acute traumatic injury, they either need to be seen in person if you're trying to do telemedicine, or you're consulting with somebody for expertise. And I have some orthopedic contacts, and I also have my supervisor and my colleagues to help me out with that. So, I do ask about those.
 

Three other things I want to mention though. One, is just the general pathway of orthopedic management. You might not like this if you're in orthopedics. Maybe I'm oversimplifying, but this is a general hack of orthopedics, is that most things, especially not acute traumatic, but chronic non-traumatic issues tend to have a four-step pathway.
 

Step number one is NSAID, so nonsteroidal anti-inflammatory medications, to manage inflammation and pain. I couldn't find any great evidence. Anecdotally, I've seen specialists recommend this and heard this, where it's an around-the-clock use of nonsteroidal anti-inflammatories for a longer period of time, between one and four weeks. In terms of the evidence behind that, I didn't have a ton that came up, but that's definitely something I'm going to investigate further. But anecdotally speaking, I've heard that from orthopedic specialists as well. And I think it's injury-dependent as well. Or, if it's a low back strain or something like that.
 

But, usually with patients when it comes to nonsteroidal anti-inflammatories, the first thing to think about, is do they have any contraindications for you to recommend that to them. Do they have chronic kidney disease? They have hypertension that's uncontrolled? It's a risk/benefits discussion with the patient. If they have controlled hypertension and add anti-inflammatories like Naproxen or ibuprofen, in terms of raising their blood pressure as a risk. So, it's helpful for inflammation as well as pain. It's something to talk about for them, because if you give them things like Tylenol or opiates, we try not to use opiates, first of all. And also, they're not going to help with any inflammation, so risk/benefit discussion.
 

There's a couple other contraindications to think about. If they have a history of GI bleeding. Older adults, you want to be very careful with, geriatric adults. The other thing is that you want to think about using the lowest possible dose that has an effect if possible. Typically, my go-to is Naproxen, and either two 50 milligrams twice a day, or 500 twice a day, and it just depends on their risk factor profile. Also, history of heart disease is one to think about as well.
 

The first step is nonsteroidal anti-inflammatories, and you make that discussion with the risks and benefits of using that. And that alone sometimes can help with an acute worsening of a chronic problem, something like that, or a low back pain, something like that.
 

The next step is physical therapy. Most of the time, part of the reason I didn't love orthopedics, especially at first, is because it felt like I did all of this reading and learning, and the moral of the story was that they were still just going to do physical therapy and that was the treatment. So, why do I have to learn about all of these things? I don't feel that way anymore, because the more I learn, the more it's fun to actually know what you're doing in terms of diagnosis.
 

Anyway, step one is NSAIDS, if it's appropriate for them. Step two is physical therapy, so referring them. And, they usually do about twice a week, two to three times a week, over the course of about six weeks. I usually prepare patients, tell them that to prepare them of what to expect going into it. And, most patients are resistant to that because it's a commitment, and they just want it to go away and not put in that extra effort. At least that's my own experience.
 

What I do is, I have to sell it a little bit. And the way that I sell it to them, is by telling them about examples of patients that I've sent, and their chronic neck pain goes away. It is really effective, and I acknowledge this does take time out of your day. But, if those are not helping you, the next steps are, which is step three, sending you to orthopedics where they may do some sort of injection or procedure for you. Then the step four is surgery. So, I usually paint that picture for patients. I even explain it just like I'm explaining it right now.

There's four steps to managing your chronic shoulder pain: NSAIDS, physical therapy, orthopedics for either injections or surgery. And when I say that to them, they tend to be a little bit more amenable to it, versus if they want to go see orthopedics, I'll definitely say to them, they probably are going to advise you to do physical therapy if you haven't done it already, if it's a chronic pain problem without any red flags.
 

The reasons not to refer to physical therapy. Well, first, NSAIDS. You don't want to use NSAIDS if there's contraindications. And number two, you don't want to send to physical therapy if their pain is really, in my experience, when pain is really severe, and they're not able to participate in physical therapy. Then, you can send them right to orthopedics and deciding about imaging. And then, imaging is a whole nother topic, but it depends on the practice that you work in. My imaging knowledge is also developing, and typically I leave it to the orthopedics to order the appropriate imaging. But, if you feel comfortable with the imaging, you can also order that too, but you also need to know how to interpret it.
 

The last thing I want to say is just a comment about the special tests, because I think that a lot of new nurse practitioners will say things like, just feeling overwhelmed with the orthopedic exam and how to do the posterior drawer, and the anterior drawer, and Lachman's maneuvers, and all that kind of stuff. Two Real World notes that I want to make about that is, one, I have a very close friend who's an orthopedic surgeon, and his take on it is that the only way that he really mastered those tests was as a medical student and resident, and doing those tests on patients with real pathology in the setting of an OR, like pre-surgery. That's his perspective, is that it takes a lot to feel comfortable with that.
 

The other thing that I have noticed in primary care, is if you have an acute injury, or acute worsening of their underlying chronic problem, you try to do those tests and there's swelling and discomfort. I haven't been able to fully even try to do those, because they're in so much discomfort. The recommendation that I have is to do your very best, and really just generally looking at their history of what happened. Is it traumatic or not traumatic, the mechanism of the injury, where they're having pain. Just doing a really good job with your physical assessment otherwise, and then making the determination, can they even participate in physical therapy and take NSAIDS, versus do you need orthopedics to further help you clarify if this is something that needs more urgent management, especially if it's traumatic, especially if it's acute. And then, collaborating with your colleagues and your supervisor as well in terms of ordering imaging, as needed.
 

Hopefully, this has been helpful. It's a little bit of Real World talk, and hopefully it's just a general, helpful overview for you. And, like I said, I'm definitely going to be making specific videos about specific conditions. Typically, what I'm seeing is chronic pain management though, for shoulder, wrist, knee, back, stuff like that.
 

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