Review of Inpatient Musculoskeletal Consults

Utilizing Musculoskeletal Ultrasound

Mindy Loveless, MD

Clinical Assistant Professor

University of Washington

Disclosure

• I have NO RELEVANT financial disclosures

Outline

• Introduction• Demographics• Review of Consults• Outcomes

Introduction

• RIC inpatient musculoskeletal consult service offered in July 2013

• This is a retrospective review of consults completed between July 2013 – December 2014

Demographics

• 50 patients

• 51 consults

• Gender:• 23 Female (46%)• 27 Male (54%)

• Average Age: 59 (range 18-90)

Admission Information

• Average length of stay: • 40 days (range 10-109 days)

• Average time from admission to consult: • 16 days (range 0-78 days)

• Average time to completion of consult: • 3 days (range 0-13 days)• All but 1 completed within 1 week

Primary Rehab Diagnosis

40%

18%

12%

6%

6%

4%4%

4%

2% 2% 2% Stroke, N=20

Tetraplegia, N=9

Medically Complex, N=6

Other Neurologic, N=3

Paraplegia, N=3

TBI, N=2

Ortho, N=2

Non-Traumatic Brain Injury, N=2

Polytrauma, N=1

Burn, N=1

Amputation, N=1

Reason for MSK Consult

63%14%

4%

4%2%2%

2%2% 2%2%2% 2% Shoulder Pain, N=32

Knee Pain, N=7Foot Pain, N=2Hip Pain, N=2Knee Swelling, N=1Shoulder Weakness, N=1Evaluate Biceps Tendon, N=1Thigh Pain, N=1Elbow Pain, N=1Chronic Pain, N=1Wrist Pain, N=1Arm Pain, N=1

MSK Consult Diagnoses

• Shoulder• Rotator cuff tear• Arthritis (glenohumeral and

acromioclavicular)• Adhesive capsulitis• Bursitis• Pain due to weakness, atrophy,

spasticity, and/or subluxation• Calcific tendinopathy• Possible brachial plexopathy• Myofascial pain/trigger points• Tendinopathy• Slow-healing fracture (in setting of

female athlete triad)

• Arm• Critical illness myopathy/neuropathy

• Elbow• Heterotopic ossification

• Wrist• Tendonitis

• Hip• Osteoarthritis• Greater trochanteric pain syndrome

• Knee• Osteoarthritis• Bursitis• ACL tear• Muscle strain• Possible lumbar radicular pain

• Foot• Morton’s neuroma• Trauma

Injections Performed

•Glenohumeral (N=16)

•Subacromial (N=7)

•Knee (N=4)

•Hip (N=2)

•Trigger point (N=2)

•Gluteus medius tenotomy (N=1)

•Biceps tendon sheath (N=1)

Reasons for No Injection

• Not Indicated (N=12)• Recommended further work-up (N=5)• Recommended supportive measures (N=4)• No pain (N=3)

• Patient Declined Offered Injection (N=5)

• Timing of Prior Injection (N=1)

OUTCOMES

POST-STROKE SHOULDER PAIN

Post-Stroke Shoulder Pain

• 14/20 stroke consults had shoulder pain–12/14 hemiplegic side

8/12 underwent injection –6 glenohumeral, 2 subacromial

4/12 declined offered injection–2/14 non-hemiplegic side

Both underwent subacromial injection

Outcomes: Hemiplegic Shoulder Pain

-20 -15 -10 -5 0 5 10 15 200

1

2

3

4

5

6

Upper Extremity Dressing FIMsHemiplegic Shoulder Pain - Injection

Days From Injection

-20 -15 -10 -5 0 5 10 15 200

1

2

3

4

5

6

7

Upper Extremity Dressing FIMsHemiplegic Shoulder Pain – No Injection

Days From Consult

Outcomes: Non-Hemiplegic Shoulder Pain

-20 -15 -10 -5 0 5 10 15 200

1

2

3

4

5

6

Upper Extremity Dressing FIMsNon-Hemiplegic Shoulder Pain - Injection

Days From Injection

LOWER EXTREMITY PAIN

Outcomes: Consults withLower Extremity Complaints• 12 consults for lower extremity pain• 7/12 received injections

–4 knee, 2 hip, 1 gluteus medius tenotomy

• 5/12 did not receive injection–2 recommended further work-up–2 had no indication for injection–1 declined offered injection

Outcomes: Consults withLower Extremity Complaints

-25 -15 -5 5 15 250

1

2

3

4

5

6

7

Ambulation FIMs – No Injection

Days From Consult

-25 -20 -15 -10 -5 0 5 10 15 20 250

1

2

3

4

5

6

7

Ambulation FIMs - Lower Extremity Injection

Days From Injection

OTHER OUTCOMES

Outcomes: Pain – All Consults

•7 patients had no post-consult pain • 5 received injection• 2 did not receive injection

•12 patients had ≥ 2 point reduction in maximum pain score post-consult • 9 received injection• 3 did not receive injection

Outcomes: Medications – All Consults

• 15 patients who received injection were on opiates prior–3/15 (20%) discontinued use of opiates

following injection

• One patient discontinued use of lidocaine patch and one reduced use of acetaminophen

Summary

• 51 consults completed over 18 months• Most common primary rehab diagnosis

was stroke• Most common reason for consultation was

shoulder pain• Improvements in FIM scores seen post-

injection• Several patients discontinued opiates and

many had significant improvement in pain