Sir Robert Peel Community Hospital

INTRODUCTION: Frozen shoulder is a common condition, and current guidelines state that it is a diagnosis of exclusion. Along with a history and clinical examination, routine X-ray is mandated, to rule out any "masquerading" pathology such as fracture, dislocation, metastatic lesions or severe osteoarthritis. Despite the certainty of the guidelines there is a lack of evidence to support the use of routine X-rays in this situation. METHODS: A retrospective review was performed of all X-rays obtained in the diagnosis of frozen shoulder between February 2014 and August 2017 in an integrated musculoskeletal interface service. Results were screened and the prevalence of masquerading pathology was determined. RESULTS: A total of 350 shoulder X-rays that had been performed for patients with a provisional diagnosis of frozen shoulder were reviewed. Of these, 213 were from female patients (60.9%), the mean age was 57.7 (standard deviation 10.4) years and 342 (97.7%) did not have any concerning features. Six (1.7%) had severe osteoarthritis, one (0.3%) had a fracture and one (0.3%) had a lucency. All eight patients with masquerading pathology had findings from the history and clinical examination which would have warranted an X-ray, regardless of a differential diagnosis of frozen shoulder. CONCLUSIONS: The findings of this retrospective review of a large number of X-rays do not support the requirement of a routine X-ray to rule out masquerading pathology to confirm the diagnosis. The data suggest that it is unnecessary for patients without a relevant clinical history suggestive of serious or masquerading pathology to undergo routine imaging.

INTRODUCTION: Arthritis is a common diagnosis for people presenting to healthcare reporting joint pain and stiffness. It is estimated that around 10 million people in the United Kingdom are thought to have arthritis. National Guidance states that patients with osteoarthritis should be offered three core treatments: information, exercise and weight loss advice. The Osteoarthritis Self-management and Independent-living Support (OASIS) group is a programme of progressive exercise and educational advice. METHODS: This service evaluation was to determine if the OASIS group was improving functional and reported pain-level outcomes of patients with lower limb osteoarthritis between 2016 and 2018. Routinely collected data were analysed to determine its effects on a number of functional and self-reported outcomes. Ethical approval was not required following local National Health Service (NHS) Trust approval (Reference e2020-08). RESULTS: During the 3-year period of the review between 2016 and 2018, a total of 339 patients were invited to attend the OASIS group. A total of 196 (57.8%) patients improved their overall pain score. Of the patients who attended all six sessions, 96.7% (174) improved in at least one of the functional outcome measures, and 90% (162) improved in at least two functional outcomes. CONCLUSION: On evaluation of the OASIS group, it has shown to be effective at improving pain and functional performance of patients with lower limb osteoarthritis, whilst remaining cost-effective. In comparison with other similar initiatives, the results are comparable, and it is implemented over a shorter time period, enhancing the cost-effectiveness for the NHS.

Parents often bring children with a fever to primary and emergency care settings. This article uses a case study to explore the assessment of children with a fever in pre-hospital settings using the three-minute toolkit, National Institute for Health and Care Excellence fever guidelines and the baby check score. It also highlights some educational resources for parents, designed to help them recognise when to seek clinical advice for their children.

As the number of antibiotic-resistant strains of bacteria rises, it becomes crucial that decisions about the use of antibiotics are based on sound evidence. This article offers a case study to explore the treatment of patients with sore throat who present to minor injury settings. It describes some 'red flag' presentations, discusses the pros and cons of prescribing antibiotics for sore throat, and describes some scoring systems that can help differentiate between bacterial and viral throat infections.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Tackling delayed diagnosis in degenerative cervical myelopathy (DCM) is a global research priority. On average, it takes 2-5 years, leading to worse outcomes from surgery and greater disability. Many countries in the UK use interface triage units run by specialist physiotherapists that sit between primary and secondary care termed musculoskeletal services. Their role in the efficient diagnosis of DCM is unknown. The aim of this study was to map the journey of the patient in the musculoskeletal service and to establish the presenting signs and symptoms. METHODS: A retrospective review of 2.5 years of clinical notes was performed in a musculoskeletal service. Process mapping was utilised to visualise the patient's journey and identify delays to diagnosis and presenting signs and symptoms. RESULTS: Twenty-seven cases were reviewed. Patients spent an average of three months in the service. There was a wide variety of presenting symptoms. DCM was more often suspected if patients had both upper limb symptoms and gait disturbance or pathological reflexes. Delays occurred when patients had no gait disturbance or a normal or incomplete neurological assessment. Longest delays occurred when patients received electrophysiology tests for differential diagnosis of peripheral neuropathies. Delays were also seen with incorrect triaging of MRI results. CONCLUSIONS: Where DCM is the principal differential diagnosis, diagnosis was faster. Incomplete examination, misinterpretation of MRI findings or delays in other investigations contributed to delays. Improved awareness and protocols of care within musculoskeletal services represent an opportunity to accelerate diagnosis in DCM.

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ANN WILKINSON’S article (Emergency Nurse, March) was interesting and included good use of evidence-based tools and a broad literature review about the physical aspects of managing patients attending with a sore throat.