NON-ARTICULAR RHEUMATISMMusculoskeletal and Soft-tissue Emergencies 327Conditions include:
● Torticollis (wry neck)
● Frozen shoulder
● Rotator cuff tear: supraspinatus rupture
● Supraspinatus tendonitis
● Subacromial bursitis
● Tennis and golfer’s elbow
● Olecranon bursitis
● de Quervain’s stenosing tenosynovitis
● Carpal tunnel syndrome
● Housemaid’s knee.
Torticollis (wry neck)
DIAGNOSIS AND MANAGEMENT
1 Torticollis is abnormal involuntary contraction of the neck musculature
lateralizing to one side, resulting in the neck being held in a twisted or bent
position.
2 Ask the patient about recent trauma, particularly if elderly.
3 Direct the physical examination to identifying an underlying aetiology, as
well as documenting the degree of neck movement.
4 Look specifically for local sepsis such as tonsillitis, quinsy and a submandib-
ular abscess, or for sensory or motor signs suggesting a cervical disc prolapse.
5 Remember to exclude drug-induced dystonia such as an oculogyric crisis due
to metoclopramide, phenothiazines or butyrophenones such as haloperidol.
(i) Give benztropine (benzatropine) 1–2 mg i.v. followed by 2 mg
orally once daily for up to 3 days if dystonia is likely.
6 Request a plain X-ray of the cervical spine if bony trauma or cervical path-
ology is suspected.
7 Manipulate the neck into the neutral position in the absence of any alterna-
tive causes suggested above, and immobilize in a soft collar. Try diazepam
2–5 mg ora lly if muscular spasm is severe.
8 Give an analgesic such as paracetamol 500 mg and codeine phosphate 8 mg
two tablets orally q.d.s. and/or a non-steroidal anti-inf lammatory analgesic
such as ibuprofen 200 –400 mg ora lly t.d.s. or naproxen 250 mg ora lly t.d.s.
9 Return the patient to the care of the GP.
Frozen shoulder
DIAGNOSIS AND MANAGEMENT
1 This can occur spontaneously, following local trauma, or following disuse of
the arm after a fracture, cerebrovascular accident, myocardial infarction or
even shingles. It is more common in the elderly.