15.4 MSK Procedures and Nonpharmacologic Care
Key Takeaways
- The official TCO lists nonpharmacologic intervention — procedures, splinting, and imaging — as an Implementation skill, not a side note to a prescription.
- Splint acute, still-swelling injuries; a circumferential cast is not the first FNP move on a swollen limb. Sugar-tong, ulnar gutter, thumb spica, and posterior ankle splints match specific injuries, then you refer.
- Ottawa knee and ankle rules decide imaging after trauma; physical therapy is first-line for many osteoarthritis and nonspecific back-pain presentations.
- Use topical NSAID before systemic NSAID in older adults with knee OA; opioids, if used at all for acute MSK pain, are last-line and short.
- DXA identifies who needs bone treatment; fall-prevention exercise, balance work, and home safety prevent the fracture the T-score is trying to predict.
Domain IV of the current FNP-BC Test Content Outline explicitly scores non-pharmacologic intervention and treatment, and the parenthetical list includes procedures, splinting, biopsies, sutures, and imaging. Musculoskeletal care is where that line becomes concrete. You will be asked when to splint, when to image, when to send to physical therapy, and when a pill is the wrong first move.
Acute soft-tissue care: PRICE versus PEACE & LOVE
Classic teaching used PRICE — Protection, Rest, Ice, Compression, Elevation — for the first 48–72 hours after a sprain or strain. Newer sports-medicine language uses PEACE & LOVE: Protection, Elevation, Avoid anti-inflammatories in the earliest phase if the goal is not to blunt useful inflammation, Compression, Education, then Load, Optimism, Vascularisation (pain-free movement that restores blood flow), and Exercise. You do not need to worship an acronym on the exam. You do need the concept: protect the injured tissue, control swelling, then load it progressively. Prolonged rest in a sling or on a couch creates stiffness that lasts longer than the sprain. Ice is analgesia and swelling control, not a 20-minute-every-hour religion. Education — “this is a sprain, most people walk more each day, here is what sends you back” — is itself a nonpharmacologic intervention.
A grade I ankle sprain in a 20-year-old gets a functional brace or taping, crutches only as needed for a day or two, and early protected weight-bearing. A grade III sprain with frank instability still gets protection, but it also gets a posterior splint or walking boot and a short orthopedic leash.
Splint versus cast, and the four splints the FNP should name
A splint is rigid on one or more sides and wrapped with an elastic bandage. It accommodates swelling. A cast is circumferential and is applied after swelling has peaked, usually by orthopedics or a skilled casting clinician. The FNP in primary care splints and refers for suspected fracture, instability, open injury, neurovascular compromise, or any injury that needs a definitive reduction. Applying a tight circumferential cast to an acutely swollen forearm is how you create compartment syndrome.
| Splint | Position (concept) | Typical FNP use |
|---|---|---|
| Sugar-tong | U-shaped slab from the dorsal metacarpals around the elbow to the volar palm; limits pronation and supination | Distal radius or ulna injury, some forearm fractures — splint, then ortho |
| Ulnar gutter | Slab along the ulnar forearm to the fourth and fifth digits; MCP flexed | Fourth or fifth metacarpal injury (boxer’s fracture pattern) |
| Thumb spica | Forearm slab that incorporates the thumb | Snuffbox tenderness (scaphoid), first-metacarpal or thumb-UCL injury |
| Posterior ankle (short-leg) | Posterior slab from the fibular head area to the metatarsal heads; ankle at 90 degrees | Severe ankle sprain, suspected distal fibula or unstable ankle — then imaging and referral |
Scaphoid is the trap. Fall on an outstretched hand plus anatomic-snuffbox tenderness is a scaphoid fracture until repeat films or dedicated imaging say otherwise. Place a thumb-spica splint and refer even if the first radiograph is negative. Missing a scaphoid fracture is how you gift someone avascular necrosis of the proximal pole.
Check skin, capillary refill, sensation, and motor function before and after every splint. Pad bony prominences. Teach ice, elevation, and the compartment-syndrome return precautions (pain out of proportion, rising pain on passive stretch, pallor, paresthesia). Do not send a numb, dusky hand home in a tight sugar-tong.
Ottawa imaging, physical therapy, and joint injection
Ottawa knee and ankle rules (detailed in 15.3) are an Implementation skill as much as a Diagnosis skill: they are how you decide to obtain the radiograph the TCO lists next to splinting. If a rule is positive, image. If a rule is negative in a reliable adult, you may defer the film and treat as a soft-tissue injury with close follow-up. Rules do not apply cleanly to intoxicated patients, multiple injuries, or children — when in doubt, image or refer.
Physical therapy is first-line for knee and hip osteoarthritis and for nonspecific and radicular back pain without red flags. Land-based exercise, supervised strengthening, and neuromuscular training beat a month of “rest and hydrocodone.” Weight loss of even 5–10% of body weight unloads a painful knee. A written home program is acceptable when access is limited; “I mentioned stretching” is not a program. Refer sooner to PT after immobilization, after a rotator-cuff-sparing shoulder strain, and after a grade II+ ankle sprain.
Intra-articular corticosteroid injection is a skill some FNPs perform and many refer. Use it for an osteoarthritic knee flare or for adhesive capsulitis when infection has been excluded and the patient understands temporary benefit. Do not inject a possibly septic joint. Do not inject the same joint monthly; a common practical ceiling is a few injections per joint per year. Refer hips, uncertain landmarks, anticoagulated patients you are not equipped to inject, and any joint that needs ultrasound or fluoroscopy. Hyaluronic acid is not a first-line FNP reflex; evidence is mixed and it is not the exam’s nonpharmacologic headline.
DXA follow-through, falls, topical NSAIDs, and opioids last
Ordering a DXA is only half of osteoporosis care. The nonpharmacologic half is fall prevention: strength and balance exercise (Tai Chi and supervised gait/balance programs have the best story), vision correction, home hazard removal (rugs, dim halls, missing grab bars), vitamin D when deficient, and a medication review that deprescribes benzodiazepines, sedative-hypnotics, and high-anticholinergic agents in older adults. A perfect T-score does not prevent a fall down unlit stairs. After a fragility fracture, treat the bone and the fall risk; a hip-fracture survivor who goes home without a balance plan is an incomplete discharge.
For older adults with knee osteoarthritis, start a topical NSAID (diclofenac gel is the usual example) before a systemic NSAID. ACR and geriatric prescribing both support that sequence because systemic NSAIDs add GI bleeding, blood-pressure rise, heart-failure decompensation, and acute kidney injury — especially when the patient already takes an ACE inhibitor and a diuretic. If you must use an oral NSAID, use the lowest dose for the shortest time and consider GI protection. Acetaminophen is an option for those who cannot use NSAIDs, with a hard ceiling and alcohol caution; it is not dramatically effective but it is safer for many frail patients than standing ibuprofen three times daily.
Opioids are last and short. They are not first-line for osteoarthritis, chronic back pain, or fibromyalgia. If you use one for acute severe injury or postoperative-range pain, prescribe a few days, set a stop date, avoid co-prescribing benzodiazepines, offer naloxone when risk is present, and plan the non-opioid regimen that will take over. A 90-day “just in case” bottle after an ankle sprain is how primary care creates harm the Evaluation domain will later ask you to undo.
Put the whole visit together. A 78-year-old with medial knee OA gets a topical NSAID, a PT referral, a weight and assistive-device conversation, a review of last DXA, and a home-safety screen. She does not get a sugar-tong, she does not get a three-month opioid, and she does not get a hip injection you are not trained to perform. That is TCO Implementation: the procedure you do, the procedure you refer, and the medicine you deliberately withhold.
A 34-year-old falls on an outstretched hand. The wrist radiograph today is read as normal, but the anatomic snuffbox is exquisitely tender. What immobilization is indicated while you arrange orthopedic follow-up?
A 79-year-old with hypertension and stage 3 chronic kidney disease has activity-related medial knee pain, crepitus, and osteophytes on a prior radiograph. What is the preferred initial pharmacologic adjunct to exercise and weight-loss counseling?
A 41-year-old has 10 days of nonspecific lumbar pain after yard work, no red flags, and a normal neurologic exam. What is the best nonpharmacologic plan?
You are immobilizing a suspected distal-radius injury 2 hours after a fall. The wrist is already swollen. Why choose a sugar-tong splint rather than a circumferential cast in clinic today?