ECOS 1 Final Clinical Flashcards
1
Q
AC Separation
A
step off at the acromioclavicular joint- seen in x ray
Somatic dysfunction: Superior AC Joint somatic dysfunction
Resists/Direct Barrier: inferior pressure to distal clavicle
2
Q
AC vs SC joint glide
A
AC joint likes to posteriorly glide while the SC joint moves anteriorly glide
3
Q
The most sensitive and specific test for shoulder impingement is
A
painful arc
When you raise your arm to shoulder height, the space between the acromion and rotator cuff narrows. The acromion can rub against (or “impinge” on) the tendon and the bursa, causing irritation and pain
Painful Arc Test:
Patient abducts arm starting at their side.
(+) Test: Pain is elicited within 60 and 120 degrees of shoulder abduction.
Indicates sub acromial impingement and /or rotator cuff injury.
4
Q
What is the most sensitive indicator of joint disease?
A
ROM
5
Q
Rotator Cuff Tear
A
most common cause of shoulder pain
Painful Arc Test
Patient abducts arm starting at their side.
(+) Test: Pain is elicited within 60 and 120 degrees of shoulder abduction.
Highest positive LR of all Rotator cuff maneuvers
Lowest Negative LR of all rotator cuff maneuvers
Indicates sub acromial impingement and /or rotator cuff injury
6
Q
Reflex grading scale
A
0- reflex absent
1- somewhat diminished, low normal
2- average, normal,
3- brisker than average, possibly but not necessarily indicative of disease
4- very brisk, hyperactive, with clonus
7
Q
Lateral Epicondylitis
A
pain with resisted wrist extension with elbow in full extension
+ test = pain/tenderness around lateral epicondyle
8
Q
Radial Head Dysfunction
A
fall prone = posterior radial head glide
fall supine = anterior radial head glide
Ex: patient fell prone-
so posterior radial head, in MET physician will place patient forearm in supination, patient will try to pronate
9
Q
Medial Epicondylitis
A
Pain with resisted wrist flexion with elbow in full extension
+ test = pain/tenderness around the medial epicondyle
10
Q
Phalen’s sign
A
special test: wrist
place dorsal aspects of the patient’s hands together and force in wrist flexion. Hold for 60 seconds.
+test= any reproduction of symptoms paresthesia in the distribution of the median nerve (supplies thumb, index finger, and middle fingers on palmar aspect AND top 1/3 of index finger and middle finger on dorsal aspect)
indication: carpal tunnel syndrome
11
Q
Deep Tendon Reflexes for UE/Dermatomes
A
bicep: C5-6
tricep: C6-7
brachioradialis: C5-6
tricep, thumb: C6-7
lateral forearm: C6
medial forearm: C8
nipples: T4
umbilicus: T10
12
Q
Cervical Spondylosis
A
refers to degenerative changes of the spine- degenerative discs and osteophytes
most common cause of acute and chronic neck pain in adults. chances of getting it increases with age
it can generate general neck pain, radiculopathy, and myelopathy
13
Q
Meningitis
A
fever, headache, photophobia, neck pain
positive Brudzinski’s sign
can DEFINITIVELY diagnose with lumbar puncture
14
Q
Contraindication to HVLA
A
A. Anticoagulants/arthritis B. Bones- osteoporosis/disruption C. Carotid/PVD disease/risks D. Down syndrome L. Local Metastases, Ligament disruption
15
Q
Spina Bifida
A
Spine and spinal cord don’t form properly. It’s a type of neural tube defect.
Risk factors:
- -FmHx of neural tube defects
- -Folate Deficiency
- -Diabetes
- -Increased body temperature
- -Obesity
- -Medications
Spina bifida occulta: “Occulta” means hidden. It’s the mildest and most common type.
Meningocele: a sac of fluid comes through an opening in the baby’s back & protrusion of meningitis. No nerves protrude.
Myelomeningocele: the most severe type. Protrusion & spinal canal is open along several vertebrae in the lower or middle back. The membranes and spinal nerves push through this opening, exposing tissues and nerves. Life-threatening infections, may lead to paralysis and bladder and bowel dysfunction.
16
Q
Scoliosis
A
Lateral curve of the spine greater than 10 degrees with vertebral rotation.
Classification: Congenital, Neuromuscular, or Idiopathic (85% are idiopathic)
- -Adolescent Idiopathic Scoliosis (AIS) is MC form. Doesn’t progress, don’t need to screen.
- —> AIS evaluation is based on angle of trunk rotation (ATR)>7°and Cobb angle >10°
Risk factors: 2-4% of adolescents. M=F to have minor scoliosis (~10°) However, F more likely to progress to severe disease.
If both parents have AIS, kids are 50Xs more likely to require treatment than the general population.
Variable accuracy of Adam’s Forward Bend Test. Bend & find spinal rotation and rib hump.
PE: shoulder height difference, posterior scapula, leg lengths equal. Dextrose is MC (right sided curve, right shoulder higher, creases on left)
Scoliosis progress tracked by Risser sign (amount of calcification present in the iliac apophysis and measures the progressive ossification from anterolaterally to posteromedially. Increased grade with progression)
Red Flags
- -Onset before age 8
- -Severe pain
- -Rapid curve progression >1 degree per month
- -Unusual Left thoracic curve (convex to the left) –MC is dextrose.
- —> Left is associated with neurological defects, abnormal reflexes, numbness, paresthesia, spinal cord tumors
- -Neurological deficits or findings –midline hairy patch (spina bifida), etc.
17
Q
Lower Back Pain (LBP)
A
MC reason for doctor’s visit
5th most common reason for all physician visits
Onset at 20-40 y/o
Can be self-limited, resolve with little intervention.
Acute LBP: 6 to 12 weeks of pain b/t the costal angles and gluteal folds that may radiate down one or both legs (sciatica). Nonspecific and no definite cause.
common causes of low back pain:
Cauda Equina Syndrome, short leg syndrome, psoas syndrome, back sprain/sprain
18
Q
Compression Fractures
A
Vertebrae can collapse (shorter in height), fragments affect spinal cord & nerves, decreasing blood & O2 to spinal cord
Elderly white females (pain worse with flexion, going supine to sitting, & sitting to standing)
Age, prolonged use of steroids, hx of osteoporosis
Trauma, post-menopause, having one fracture puts you at risk for more, osteoporosis
Diagnosis: Weak: Vertebral tenderness, limited spine range of motion
19
Q
Herniated Nucleus Pulposus
A
Aka a herniated (also called bulged, slipped, or ruptured) disc: part of the disc is pushed out of the annulus into spinal canal
Arm or leg pain, numbness or tingling, weakness.
Pain originates from the lumbar spine and radiate down the leg into the foot “sciatica”
Sharp burning pain -electric quality
Weakness in affected myotome(decreased reflexes), decreased sensation to affected dermatome
Causes: Obesity, occupation, genetics, smoking.
diagnosed by MRI
Spine structures cause Sacroiliac joint pain (pain to the thigh)
Lumbar root (irritation, impingement, or compression) causes leg pain than back pain.
- -L4: Patellar reflex, knee
- -L5 : Toe Thumb sensation, heel walk
- -S1 –Achilles reflex, toe walk, Pinky toe
- Red flags*: Rely on comprehensive clinical approach over red flags because patient can have red flags but not have a serious condition of back pain.
- Red flags* = TUNA FISH
T = Trauma U = Unexpected weight loss N = Neurologic symptoms A = Age > 50
F = Fever I = IVDU S = Steroid Use H = History of Cancer (prostate, Renal, Breast, Lung)
20
Q
Cauda Equina Syndrome
A
Disc herniation (@ L4-5) compresses sacral nerve roots (S2-S4)
Symptoms: low back pain, radiates down the leg, numbness around the anus, and loss of bowel or bladder control.
Impingement of S2-4 causes
- Bowel dysfunction (decreased rectal tone)
- Bladder dysfunction
- Sexual dysfunction
- Saddle anesthesia
Emergent surgery is imperative!!!!!!
Delay can result in irreversible paralysis.
Life threatening
21
Q
Lumbosacral Strains and Sprains
A
Strain: muscles and tendons that support the spine are twisted, pulled or torn. From single improper lifting or overstressing, or chronic (repetitive overuse)
Sprain: ligament stretch or tear. From fall, sudden twist, or block to body
Patient points to muscle, not bone (like with compression fracture)
Symptoms: Pain worse with movement, muscle cramps or spasms, pop or tear at injury, difficulty walking, bending, standing straight
Diagnosis: Discrete tender points in the lumbar tissue/paraspinal muscle region. No neurological deficits
22
Q
Psoas Syndrome (Flexion Contracture of the Iliopsoas)
A
Causes: injury/shortening/spasm of iliopsoas muscle, jumping and running athletes, backpackers, sitting and stand up abruptly
Symptoms: Lower back pain (MC symptom), pain in butt, groin, down leg, limping or shuffling stride
Diagnosis: Tender point at iliacus (medial to ASIS), +Thomas test, +FABER
23
Q
Short Leg Syndrome
A
discrepancy in leg lengths resulting in chronic leg and back pain, tilts the pelvis down on one side placing abnormal stress on the muscles and spine.
Anatomical short leg: one leg is longer and can be corrected with a heel lift in the shoe of the short leg.
- OMT for heel raise: raises pelvis and straightens spinal curves (which orginally compensated for tilted pelvis)
Functional short leg: an apparent short leg although structurally both legs are the same length when measured.
24
Q
Sacroiliitis (inflammation of either or both iliac & sacral joints)
A
Pain in butt, lower back, down leg(s), pain with standing, climbing stairs, weight on one leg, running, big stride (like athletes)
Positive FABER test with buttock pain, not groin pain.
Positive Straight Leg Raise at >70
25
Spinal Stenosis
Narrowing of spine, pressure on nerves
Lower back and neck
Over 50 y/o
Degenerative lumbar stenosis is common in elderly
Some patients experience *Neurogenic claudication* (low back pain, leg pain, numbness, and motor weakness that starts or intensifies on standing or walking and is eased by sitting or lying down)
-- Vascular claudication if patient has SOB
More leg pain than back pain, improves with rest or flexed spine (opens canal)
Unilateral (foraminal stenosis) or bilateral (central or bilateral foraminal stenosis)
26
Osteoarthritis (Spondylosis)
Associated with osteophytes (causing jagged points), seleroris (bone grows together and solidifies), borrowed discs
Onset of symptoms (20-50 y/o)
Lumbar spondylosis MC with over 40 y/o
Causes: Aging, genetics, injuries
Symptoms: Pain, stiffness, occasional numbness
27
Spondylolysis
Small stress fracture of vertebrae
More in younger people (teen-age growth spurt), student athletes (constant hyperextending spine)
Typically diagnosed at 15-16 y/o, more males. May go undiagnosed.
Symptoms: MCC of LBP in less than 26 y/o, worses with spine extension
Dx: oblique view of lumbar spine. Fracture of par interarticularis or “Collar of Scotty Dog” usually at L5/S1
28
Spondylolisthesis
Anterior displacement of vertebral body, might press on nerve
All ages, may go undiagnosed
Degenerative spondylolisthesis for over 40 y/o. With aging, the discs lose water, becoming less spongy and less able to resist movement by the vertebrae.
Symptoms: MC is lower back pain, feels like muscle strain, tight hamstrings (short strides with knees bent), leg pain (better with rest or flexed spine, worse with standing)
Dx: step off sign, palpate lumbar spinous process, lateral view of x ray
29
Connective tissue diseases
General Presentation?
Two subtypes?
General Presentation: Multiple joint arthralgia, fever, weight loss, fatigue, other joint tenderness
Rheumatoid Arthritis (RA): MC connective tissue (autoimmune) diseases, inherited. Systemic disorder, immune cells attack and inflame the membrane around joints. Back and hand pain.
Systemic Lupus Erythematosus (aka. Lupus or SLE ): systemic autoimmune disease Inflammation caused by lupus can affect joints, skin, kidneys, blood cells, brain, heart and lungs.
30
Spondyloarthropathies
forms of arthritis that usually affects the bones in your spine and nearby joints.
Arthralgia means pain in a joint.
Oligoarticular means affecting a few joints (< 4 or 5)
Polyarthralgia means pain in several joints (two or more)
Dx: physical signs of articular inflammation or the physical or X-ray signs of osteoarthritis.
Arthritis causes inflammation (swelling, redness and pain) in your body’s joints.
Intermittent pain at night, morning pain and stiffness, inability to reverse from lumbar lordosis (arched back) to lumbar flexion (bend forward).
31
Spondyloarthropathies: Ankylosing spondylitis (MC form)
Prevalence of HLA-B27
White males, 15-40 y/o
Inflammatory back pain, gradual onset and a dull quality, radiates into the gluteal regions. Worse in the morning, improves with activity, and has a nocturnal component. Associated with sacroiliitis. Symmetric joint distribution.
Bamboo spine
32
Spondyloarthropathies: Reactive Arthritis
After an UTI or infection of the digestive system.
Tends to attack asymmetrical LE joints.
Swelling in joints
Looks like STI or eye infection
Males in late teens to early adulthood, nail changes (onycholysis), skin lesions (not plaques), Reiter’s syndrome (Eye, Urethra and Joint inflammation-(Uveitis, urethritis/cervicitis, arthritis))
33
Spondyloarthropathies: Psoriatic Arthritis
Affects major joints of the body, as well as the fingers and toes, along with the back and pelvis. Typically asymmetric.
Causes: Psoriasis or FmHx of it
M/F (1:1) age 35-45
Symptoms: nail changes (pitting, onycholysis), skin lesions, can also have uveitis
34
Malignancy (Cancer metastasizes to bone)
Signs/Symptoms: Pain worsens in prone position, recent weight loss, fatigue
Exam: Typically have spinous process tenderness with metastasis to the spine.
Life threatening
35
Vertebral diskitis/Osteomyelitis
Inflammation between discs, swelling, pain with pressure
Osteomyelitis: from infection
Causes: Diabetes, any immune deficiency, and vascular disease, **IV Drug abuse**, and alcoholism
Symptoms: Severe back pain **with or without fever** and local tenderness in the spinal column. Nerve root pain radiating from the infected area. Weakness of voluntary muscles and bowel/bladder dysfunction.
Dx: Constant pain, spinous process tenderness, often no fever.
36
Scurvy
Vitamin C deficiency
37
Osteogenesis Imperfecta
Blue sclera, multiple fractures
38
Ehler-Danlos Syndrome
Collagen dysfunction, joint hypermobility, stretchy skin, multiple join pains, droopy eyelids, myopia, antimongoloid slant
39
Alport Syndrome
deafness, kidney dysfunction
40
Menkes Disease
Copper deficiency- kinky hair, growth failure, deterioration of nervous system
41
Shoulder Pain
3rd most common musculoskeletal complaint
Prevelance 16% to 34% of the general population
* *The only joint in the human body where tendons (rotator cuff) pass between bones (acromion and humerus)**
- -great flexibility
- -Great Susceptibility to injury
Traumatic causes: Fractures, dislocations, soft tissue injuries (ligamentous, tendon, or myofascial injuries), joint cartilage or capsule injury
Atraumatic causes:
Extrinsic:
- -> Referred no shoulder pathology at all
- -> Shoulder exam normal despite shoulder pain
Intrinsic:
- The shoulder as a whole
- ->Intra-articular
- ->Extra-articular
42
Fractures
Clavicle Fractures
most occur in kids and young adults
Proximal humerus fractures
most commonly in the elderly
Scapular fracture
Associated with blunt trauma
43
Glenohumeral Dislocation (Dislocated Shoulder)
50 percent of all major joint dislocations
3 types:
Anterior dislocation
most common
accounting for 95 to 97 percent of cases
Posterior dislocation
2 to 4 percent
```
Inferior dislocation (luxatio erecta, which means "to place upward")
0.5 percent
```
usually described as sudden, sharp pain
44
Acromioclavicular Joint Injuries
usually occurs from direct trauma to the superior or lateral aspect of the shoulder (acromion) with the arm adducted, such as a direct blow or falling onto the shoulder
Spectrum of injuries:
AC sprain, AC ligament rupture, and then sprain and rupture of the stronger coracoclavicular (CC) ligaments
Physical Exam:
tenderness directly over the AC joint, possibly associated with deformity, pain with ROM (especially abduction)
Diagnostic testing: a single anterior-posterior (AP) radiographs including both AC joints or US
45
Rotator Cuff Injuries
Supraspinatus is most often injured
Repetitive overhead activity in sport or work is a major risk factor
Symptoms: shoulder pain (over the lateral deltoid) more prevalent with overhead activity and at night, weakness
Impingement syndrome:
-->symptoms resulting from compression of the rotator cuff tendons and the subacromial bursa between the greater tubercle of the humeral head and the lateral edge of the acromion process
Tendon Injury:
- ->Sprain or Tear (partial or complete)
- ->occur as the end result of chronic subacromial impingement, progressive tendon degeneration, traumatic injury, or a combination of these factors.
- ->Most injuries occur primarily in the supraspinatus tendon
Tendinopathy
- -> chronic injury to the supraspinatus (abduction) and/or infraspinatus (external rotation) tendons.
- -> develops as a consequence of repetitive activity, generally at or above shoulder height, which leads to tendon degeneration and microvascular insult.
Specialty test: painful arc test (most sensitive and specific), Neer impingement sign, Hawkins impingement sign, Empty can test, Drop arm test
46
Extrinsic (Referred) Causes of Shoulder Pain
```
Neurologic:
Cervical radiculopathy (C5-C6)
Brachial plexus lesions
Herpes Zoster
Spinal cord lesion
Cervical Spine DJD
Thoracic Outlet Syndrome
```
Abdominal:
Hepatobiliary disease
Diaphragmatic irritation
Intraperitoneal blood, perforated viscus
Cardiovascular:
Acute Myocardial Infarction
Axillary vein thrombosis
Pulmonary:
Upper lobe Pneumonia
Apical lung tumor
Pulmonary Embolism
47
Intrinsic Causes of Shoulder Pain
```
Overuse injuries
Shoulder instability
Rotator cuff tendinopathy or impingement syndrome
Subarcomial bursitis
Synovitis
Adhesive capsulitis
Bicepital tendinitis
Osteoarthritis
Myofascial pain
Septic arthritis
Gout/pseudo gout
```
48
Most common causes of Shoulder Pain
ACUTE
Acute:
-Rotator cuff injuries
the most common cause of shoulder pain in primary care
Fractures/dislocations
-->Fractures (clavicle and proximal humerus)
-->Dislocations
(glenohumeral joint)
Acromioclavicular joint injuries
-->Sprains, tears
*Myofascial injury*
49
Most common causes of Shoulder Pain
CHRONIC
Chronic (greater than 6 mos):
Rotator cuff disorders
Adhesive capsulitis
Shoulder Instability
Shoulder Arthritis
50
Most common causes of Shoulder Pain
LIFE THREATENING
Life Threatening:
```
Septic Arthritis
Referred Pain
Acute MI
Intraperitoneal Hemorrhage
Lung pathology
```
51
Common causes of elbow pain
```
Anterior capsule strain
Osteoarthritis
Bicep tendinopathy
Gout
Rheumatoid arthritis
Lateral epicondylitis
Medial epicondylitis
Cubital tunnel syndrome
Ulnar collateral ligament injury
Osteoarthritis
Olecranon bursitis
Fracture
Triceps tendinopathy
```
52
Subluxation of the radial head
aka Nursemaid's elbow
Also known as nursemaid’s elbow
Most common in children, usually for children ages 1 to 5
Cause: sudden pulling, falling and arm twisting
The annular ligament slips out of the radial head and gets trapped in the radiohumeral joint
Classic presentation/ exam findings: arm close to the body w/ elbow slightly flexed or fully extended with the forearm pronated
53
Medial Epicondylitis
aka golfer’s elbow
Also known as golfer’s elbow
Cause: Overuse injury from repeated motion such as playing golf
Acute or chronic inflammation of flexor tendons due to some form of strenuous activity
Classic presentation/ Exam findings:
Pain on medial aspect of the elbow over the medial epicondyle, tenderness with passive extension of the wrist and resisted flexion of wrist
54
Lateral Epicondylitis
aka Tennis Elbow
Also known as Tennis Elbow
Cause: Overuse injury from repeated motion such as playing tennis, excessive hyperextension
Acute or chronic inflammation of extensor tendons due to incorrect stroke mechanics
Classic presentation/ Exam findings:
- ->Pain on lateral aspect of the elbow
- ->Pain on palpation of the lateral epicondyle, tenderness with resisted wrist extension
55
Olecranon Bursitis
aka Miner's elbow or Student's elbow
Also known as miner’s elbow, students elbow
Causes: inflammatory arthritis, gout, trauma, hemorrhage or sepsis
Inflammation of the olecranon bursa which is located in the posterior aspect of the olecranon process of the ulna
Classic presentation/ Exam findings:
- ->pain and swelling on olecranon bursa, may be inflammatory versus infectious.
- ->Able to distinguish between bursitis versus effusion (fluid), if able to fully extend at elbow without severe pain then bursitis without effusion. If effusion presents, pain with extension due to increased pressure at the joint
56
Carpal Tunnel syndrome
Condition that is caused by the compression of the median nerve
Causes: multifactorial but risk factors includes, Obesity, hypothyroidism, DM, Repetitive movement /workplace factors, pregnancy, genetic, connective tissue disorder, female gender
Classical presentation/ Exam findings:
-->pain and paresthesia along the first three and half digits which the distribution of along the route of median nerve is being compressed
Specialty exam:
Tinels – compression of the median nerve by tapping on the nerve
Phalens- flexion of the wrist to compress the nerve
57
De Quervain Tenosynovitis
Recurrent inflammation of the tendon and synovial sheath covering extensor pollicis brevis and abductor pollicis longus
Classic presentation/ exam findings:
--> Radial wrist pain (over the radial styloid) at base of thumb especially with movement of thumb
Specialty exam: Positive finkelstein test (good sensitivity and specificity)
Causes: recurrent movements (new mother’s picking up child), idiopathic
58
Trigger Finger
Also known as stenosing flexor tenosynovitis
Classic presentation/Exam finding:
- -> Pain, locking and clicking of MCP joint. Common in the 5th and 6th decade of life. Most common on ring finger but may occur on any finger
- -> Thickening of the flexor tendon which causes the first annular pulley to not work properly
Causes: common, idiopathic, risk factors include Diabetes, amyloidosis, rheumatoid arthritis hypothyroidism, over use trauma, etc.
59
Dupuytren’s contracture
Fibrosis of the palmar fascia which causes progressive stiffening of the joint and inability to full extend the finger.
Cause: idiopathic. Thickening of the palmer fascia due to fibroblastic proliferation and collagen deposition
Classic presentation/exam finding:
- -> More common in white males and presents as a thickening on the palmer surface, painful or painless
- -> On exam, cord-like structure and flexed digit w/ palpable cord
60
Scaphoid Fracture
Common upper extremity injury
Classic presentation:
--> Pain on the radial aspect of the wrist and reduced grip strength after fall on outstretch hand (FOOSH) .
Specialty test/ exam finding:
- ->Tenderness on anatomic snuff box is highly sensitive for this particular fracture.
- ->Tenderness with scaphoid compression and on scaphoid tubercle is also sensitive but more specific
Cause: fall on outstretched hand which causes hyperextension of the wrist
The scaphoid has poor blood supply therefore nonunion is complication
61
Boxer’s Fractures
Fracture of the metacarpal neck (usually the fifth digit but can involve the fourth
Classic Presentation/exam finding:
--> pain on the dorsum of the hand after direct trauma (recent fight, etc.)
--> Swelling and bruising may be present on dorsum of hand
-->Tenderness over fracture site
Causes: caused by direct injury/trauma to the clenched fist
XR used to diagnose fracture
62
Colles Fracture
Most common fracture of the upper extremity
Classic Presentation:
- -> Wrist pain with possible deformity (dinner fork deformity but can appear normal on exam
- -> Tenderness over fracture site on radial aspect of wrist, possibly see bruising or swelling
- -> Seen in young patient usually due to sports injury i.e. soccer, rugby, skiing, dancing, etc.
- -> White female >50 yo due to increase risk of osteoporosis
Cause: falling on outstretched Hand (FOOSH) with wrist in extension. Risk factor is osteoarthritis in older patients
63
Rheumatoid arthritis
An inflammatory polyarthritis causing deformity of the joints through the damage of the bone and cartilage. Most commonly affects the MCP and PIP joints of the finger but can effect large and small joints
Classic Presentation/ exam findings:
- ->morning stiffness, swelling and pain of the MCP and PIP, 3 or more joints affected
- ->Deformity of the digit (see images)
Causes: autoimmune, unknown etiology
Test for antibodies (RF, CCP, ANA), Acute phase reactants
64
Neck Pain
Neck pain is the #4 cause of disability in the United States
10% to 20% of the adult general population has neck pain at any given time
65
Traumatic Neck Pain
myofascial injury (muscle strain, whiplash, etc.)
cervical fracture
ligamentous injury
Disc injury
Cord or nerve root injury
SCIWORA
spinal cord injury without radiographic abnormality
66
Myofascial neck pain
Very Common!!!
may or may not be traumatic!
Symptoms can include pain, spasm, loss of range of motion in the neck, and occipital headache.
Pain can be persistent with little identifiable abnormality seen on MRI, computed tomography (CT), radiograph, or bone scan imaging
Example: whiplash, muscle strain, etc.
67
Cervical Fractures
Occur in approximately 3% of blunt trauma patients
Most are Stable
All require at least neurosurgical consultation
Must determine if stable or unstable
--> Generally done with imaging (CT and/or MRI), radiological and neurosurgical consultation
Document:
- History: any neurologic complaint (numbness, weakness, etc.)
- Physical Exam: Initial presence and level of sensory and motor loss, rectal tone
68
Spinal cord injury without radiographic abnormality (SCIWORA)
Need a high degree of suspicion to diagnose
Pt has normal plain films and normal CT of the cervical spine but continues to have neurologic signs or symptoms
Must keep spine immobilized until MRI and evaluation/consultation with a neurosurgeon
More common in kids and elderly
Kids – spine is very flexible and head is large
Elderly – restriction of motion secondary to DJD
69
Atraumatic Neck Pain
Musculoskeletal:
The vast majority of atraumatic neck pain!!
**Cervical spondylosis (degenerative changes)*, discogenic pain, myofascial pain, whiplash, torticollis, facet osteoarthritis
Combination of the above
Neurologic:
Radiculopathy and/or Myelopathy
Nonspinal causes:
Think systemic disease or referred pain
**thoracic outlet syndrome**, coronary artery disease, malignancy, neurologic conditions, referred shoulder pain, rheumatologic conditions, fibromyalgia, visceral etiologies, Infection (meningitis)
70
Torticollis
aka twisted neck SCM
Congenital:
usually arises from muscular fibrosis of the SCM muscle and less commonly from neurologic or bony abnormalities.
Adult:
- ->Acquired, typically results from SCM or trapezius muscle injury or inflammation.
- ->A wide variety of conditions can also cause torticollis due to cervical muscle spasm or cervical nerve irritation
Life threatening causes of torticollis:
- -> retropharyngeal abscess, C-spine injury, CNS tumor
- -> Spinal epidural hematoma
71
Cervical Spondylosis (Degenerative Changes)
"Spondylosis"
A general term used to describe degenerative changes in the spine
Degenerative discs and osteophytes
the most common cause of acute and chronic neck pain in adults!!!!!
Incidence increases with age
Often asymptomatic
Can cause general neck pain, radiculopathy, and myelopathy
72
Cervical Myelopathy
any neurologic deficit related to the **spinal cord**
Signs & Sx’s: bilateral or distal sx’s (weakness/numbness), may complain of clumsy hands, gait disturbances, sexual dysfunction, bowel or bladder dysfunction
Needs emergent MRI
73
Cervical Radiculopathy
any neurologic deficit occurring at or near the **nerve root**
Signs & Sx’s: sharp, burning, pain radiating to the trapezius, periscapular area, or down the arm. Weakness or paresthesias may develop weeks after pain onset.
C5-C6 followed by C6-C7 are the most common
Urgent workup, non-emergent MRI, NSAIDS, OMM, PT
74
Meningitis
Symptoms and Signs include fever, malaise, headache, photophobia, neck pain and stiffness, AMS, rash (petechiae and purpura) and meningismus
Nuchal rigidity, Kernig’s & Brudzinski’s signs of meningeal inflammation
Causes
Bacterial: Hemophilus, Strep. Pneumonia
Neiserria menigitidis
- ->Less prevalent since vaccine
- ->Gram neg dipplococci
Viral, other
Overall: Diagnosed by Lumbar Puncture!!
75
Thoracic Outlet Syndrome
The thoracic outlet:
-->confined space between the clavicle and first rib
-->Structures that pass through this region include the nerves of the brachial plexus, the subclavian artery, and the subclavian vein
Thoracic outlet syndrome:
compression of the neurovascular bundle by various structures in the area just above the first rib and behind the clavicle, within the confined space of the thoracic outlet
Symptoms: arm pain, numbness, and weakness.
reproducibly aggravated by any activity that requires elevation or sustained use of the arms or hands above the head
Vasculogenic and neurogenic TOS
Neurogenic (95%)
Vascular (5%) arterial or venous
Tests:
Roo’s/EAST test
Adson’s test
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Hangman’s Fracture
The resulting hyperextension caused the traumatic spondylolisthesis of C2 (axis) tearing of the ligaments between C2 and C3 and fracture of the vertebral arch of C2 (pedicle). The injury is often referred to as “hangman’s fracture.”
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Specific Lesions: Cranial Nerve III
Ptosis: (drooping of eyelid past the upper margin of the pupil) due to levator palpebrae weakness
Pupillary dilation or asymmetry: due to disruption of the of the ciliary plexus, specifically the parasympathetic innervation of the pupil responsible for pupil constriction (Miosis). If severe will see a fixed/dilated pupil.
Ophthalmoplegia: Denervation of majority of extraocular muscles (superior rectus, inferior oblique, medial rectus, inferior rectus). “DOWN AND OUT”
Presentation: Sudden, unilateral ptosis and ophthalmoplegia. Diplopia symptoms could be masked by severity of ptosis.
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Specific Lesions: CN IV
Esotropia: eye position drifts medially
Weakness of downward gaze: (due to the weakness of the Superior Oblique muscle), eye will drift upwards
Vertical diplopia: double vision that increases when looking down
Head tilting: to opposite side of the lesion
Presentation: Vertical diplopia, difficulty with reading or walking down-stairs. Symptoms of torticollis may occur secondary to head tilting.
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Specific Lesions: CN VI
Most Common isolated CN palsy due to its long peripheral course. Seen often in patients with subarachnoid hemorrhage, late syphilis and trauma.
CN VI lesions result in:
- ->Convergent (medial) strabismus (esotropia): inability to abduct the eye. Due to Lateral Rectus muscle weakness.
- ->Horizontal diplopia- maximal separation of the images when looking toward the paretic lateral rectus muscle.
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Specific Lesions: CN V
Decreased sensation of face and mucous membranes
Loss of corneal reflex
Weakness of the muscles of mastication
Jaw deviation toward the weak side (due to unopposed action of the opposite lateral pterygoid muscle)
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Clinical Note CN V – Trigeminal Neuralgia (TN)
Recurrent brief episodes of unilateral shock-like pains along one or more distributions of the trigeminal nerve
Can be debilitating and often triggered by innocuous stimuli
Most patients have a ”trigger” and pain can be reproduced on physical exam by stroking dermatome with light tough.
~90% of cases are caused by aberrant vein or artery compression on the nerve.
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Specific Lesions: CN VII
Paralysis of the muscles of facial expression (upper and lower portions of the face) seen as a widened palpebral fissure and increased nasolabial fold. ( Bell’s Palsy).
Loss of corneal reflex – (efferent limb)
Hyperacusis – (increased sensitivity to sound)
Crocodile tears syndrome – due to aberrant regeneration of nerve after trauma – patient sheds tears when chewing
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Clinical Notes: CN VII
Bell’s Palsy (peripheral facial paralysis) can be caused by trauma or infection, but in most cases is idiopathic (unknown etiology).
Bilateral facial palsies can occur in variant of Guillain-Barre Syndrome.
Supranuclear (central) facial palsy spares the upper face and usually is associated with hemiplegia (weakness to one side of the body). ***This is important in determining if the weakness is central or peripheral in nature.***
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Specific Lesions: CN VIII
Vestibular Division lesions result in:
Disequilibrium (imbalance)
Nystagmus – rapid involuntary and rhythmic movement (or oscillation) of the eye.
_______
Cochlear Division lesions:
Destructive lesions lead to sensorineural hearing loss. Ex. acoustic neuroma
Irritative lesions can cause tinnitus (ringing in ears). Ex. Medications (aspirin, some antibiotics etc)
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Specific Cranial Nerve Issues: Nystagmus
Nystagmus = rhythmic oscillation of the eyes
2 phases:
1. slow drift away from object of focus
2. saccade (quick reaction back)
**Nystagmus is named for saccade phase**
Usually can be seen in extreme laterality of gaze. Can be three types:
Horizontal
Vertical
Rotatory
Potential causes:
Vision impairment at early age, Disorder of labyrinth or cerebellar systems, Drug toxicity
Occurs in normal physiology (normal gaze-evoked nystagmus) and pathologically (Vestibular, downbeat, opsoclonus, accentuated gaze-evoked nystagmus)
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Specific Lesions: CN IX
Loss of gag reflex
Loss of sensation in pharynx & posterior 1/3 of tongue
Slight dysphagia (Dysphagia is the medical term for swallowing difficulties)
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Specific Lesions: CN X
Dysphonia (speaking)
Dysphagia (swallowing)
Dyspnea (breathing)
Loss of gag or cough reflex
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Patterns of Sensory Loss
Single nerve: Loss limited to distribution of a single nerve
Root or roots: Loss is in different nerve distributions with a common root
- ->C5, C6, C7 common in arms
- ->L4, L5, S1 common in legs
Spinal cord: Complete transverse section, hemi-section of the cord, posterior column, anterior spinal syndrome
Brainstem: Crossed findings with ipsilateral loss in the face and contralateral in the body
Thalamic: Hemisensory loss of all modalities
Cortical loss: Intact primary sensations but loss of cortical sensations
Functional loss: Non-anatomical distribution
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Meningeal Signs
Nuchal rigidity: Neck stiffness with resistance to flexion
Approximately 84% patients with acute bacterial meningitis
21-86% patients with subarachnoid hemorrhage
Most reliable meningeal present in meningeal irritation but overall diagnostic accuracy low
Make sure there is no injury or concern for vertebral fracture before testing nuchal rigidity
_________________
Brudzinski sign: Patient supine, examiner slowly flexes patient’s neck (chin to chest)
Positive sign – Involuntary flexion of patient’s hips and knees flex in response
______________
Kernig Sign: Examiner flexes patient’s hip and knee, then slowly extend leg and straighten knee keeping the hip flexed
Positive sign – pain or increased resistance to knee extension, can also cause passive flexion of the neck
Pain behind the knee can occur due to tight hamstrings, so don’t interpret this as a positive test.
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ASSOCIATED SYMPTOMS for Eye Complaints
```
Pain
Drainage
Itching/burning
Vision change
Blurry vision
Flashing lights
```
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Diseases associated with eye complaints
Glaucoma
Diabetes
Thyroid
ASCD
Collagen Vascular Disease
HIV
IBS
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Ptosis:
Ptosis: Drooping of the upper eyelid due to muscle abnormality
Congenital:
Absent levator, Marcus Gunn Jaw Winking Syndrome
Mechanical:
Inflammation, eyelid tumors, dermoid cysts
Aponeurotic:
Dehiscence of aponeurosis connecting levator muscle to eyelid
Neurologic
-->CNIII palsy- ptosis, diplopia, ophthalmoplegia (Down and Out)
-->Horner’s Syndrome: Disruption of sympathetic pathway leading to triad of anhidrosis, miosis and ptosis
-->Multiple other causes:
Botulinum toxin and Myasthenia Gravis
Myogenic – rare muscle disorders involving mitochondrial disease, myotonic dystrophy and oculopharyngeal muscular dystrophy
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CHALAZION
Blocked Meibomian gland
Generally nontender and nonpainful unless becomes inflamed
IN THE LID
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HORDEOLUM (stye)
Bacterial infection of the meibomian gland (inner margin)
Tender/Painful
ALONG THE LASHLINE
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Blepharitis
Inflammation at eyelid margin, resulting in eye irritation
Cause:
Bacterial (s. aureus) most common
Inflammatory Skin conditions (psoriasis, **seborrheic dermatitis**, rosacea, eczema)
Allergens: Cosmetics, contact lens
Symptoms:
Red, swollen, itchy eyes
Gritty/burning sensation
May have excessive tearing
May have blurred vision that improves with blinking
-->Will have signs of flaking/scaling eyelids
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Clinical: : Lacrimal Apparatus
“Clogged tear duct”
Transient, very common in infants
keep eye clean, use warm compress 2-3 x daily
Most infants ”out-grow” this issue
______________
Dacrostenosis:
Stenosis (narrowing) of nasolacrimal duct
Can be treated my “milking” the duct
Some cases require opening of the duct with a probe
________________
Dacrocystitis:
Infections of the lacrimal duct
Most commonly occurs in newborns vs older folks
Requires systemic antibiotics and occasional probing of lacrimal duct by ophthalmology
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Clinical: Conjunctiva
Lower the lower eyelid and patient look up
Raise the upper eyelid and patient look down
Should be “clear”
Consider inversion of the upper eyelid if concern for foreign body
Common abnormal findings:
- Erythema -- subconjunctival hemorrhage- blood in eye
- Purulence -- “pink eye”, conjunctivitis
- Pterygium – tissue growth on the conjunctiva
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Conjunctivitis
Allergic: Mild, bilateral symptoms of gritty, pruritic, irritated eyes with clear discharge.
Viral: Mild-moderate bilateral symptoms, gritty, burning, irritated eyes with clear discharge. Eyes will be matted shut in the morning.
Bacterial: Usually unilateral, with copious amounts of purulent drainage throughout the entire day. Purulent drainage will reaccumulate minutes after “cleaning”.
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Clinical: Cornea
Corneal abrasions are seen a lot in the ER, urgent care and primary care offices
Quite painful
Fluorescein stain and a blue light to visualize
Important to look for and remove foreign body
Herpes Simplex Keratitis
- ->Pathognomonic dendritic lesion
- ->Leading cause of blindness worldwide
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Cataracts
Lens should be clear/ transparent
Yellow or gray – cataract?, can be normal in persons with increased melanin, but should be symmetric
Brown speckles -- ?cataract
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Acute Angle Closure Glaucoma
Medical Emergency
Sudden increase in intraocular pressure
Failure of aqueous to flow from ciliary body, into the irido-corneal junction, resulting in increased pressure.
Acute, severe pain associated with decreased vision
Pupil will be dilated and fixed
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Clinical: Sclerae
Should be white
Brown or gray spots can be birthmarks–
- ->Increased melanin in sclera
- ->Can be associated with increased risk for glaucoma, rarely melanoma
Blue – inherited, seen frequently in brittle bone disease
Yellow = “Icterus”, causes: Neonatal, liver disease, pancreatic cancer, GB disease
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Esotropia vs Esotropia
Strabismus
Like somatic dysfunctions, name tropia for where it likes to live!
Esotropia – eye turned in
Exotropia – eye turned out
They both are forms of strabismus, commonly called “lazy eye” referring to weak extraocular muscles
When identified in young children, patching sometimes helps
When patching fails, surgery
If not treated, brain will choose to focus with unaffected eye and other eye will lose vision (also cosmetic appearance makes kids different, social issues may result)
This loss of vision is amblyopia, also called “lazy eye” by some but now referring to weak vision.
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Papilledema
Papilledema: Indicates increased intracranial pressure that results in intra-axonal edema along the optic nerve, leading to swelling and engorgement of the optic disc.
Think intracranial hemorrhage, meningitis, trauma, mass lesion
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Glaucomatous Cupping
Increased intraocular pressure within the eye leads to increased cupping (backward depression of he disc) and atrophy.
Base of the enlarged cup is pale.
Normal cup to disc ratio is 0.4. Ratios of 0.7 suggest possible glaucoma
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Cotton Wool Spots
White or grayish, ovoid lesions with irregular “soft” borders.
Moderate in size but smaller than the disk.
Result from extruded axoplasm from retinal ganglion cells caused by microinfarcts of the retinal nerve fiber layer.
Seen in hypertension, **diabetes**, HIV and other conditions.
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Drusen bodies
Yellowish, round spots that vary from tiny to small. The edges may be soft of hard.
Haphazardly distributed but may concentrate at the posterior pole between the optic disc and the macula.
Consist of dead pigment epithelial cells.
Seen in normal aging and age-related ***macular degeneration****
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Retinal Detachment
Painless vision loss
Initial warning signs of Posterior Vitreous Detachment (PVD)
Transient floaters/flashes of light
Persistent symptoms, of vision loss or ”black dots” are more concerning
Curtain over portion of the visual field is the classic/ominous sign of retinal detachment
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PERRLA
Pupils equally round and reactive to light and accommodation.
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Basic Types of Primary Headache
Tension-type HA
Migraine HA
Cluster HA
Other (i.e. cold stimulus HA)
Tension HA is the most frequent headache in population-based studies, but migraine is the most common diagnosis in patients presenting to clinicians with complaint of headache
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Tension Headache
Duration: minutes-days
Location: bilateral, starts at posterior of head and radiates anteriorly
Characteristics: pressures that waxes and wanes
Patient Presentation: More if a nuisance, usually able to remain active
Other symptoms: +/- MSK cervical pain
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Migraine Headache
Duration: 4 – 72 hours
Location: Typically unilateral (temporal/frontal) in adults, can occur bilaterally (more common in pediatric population)
Characteristics: May have aura, gradual onset, with increase in pain symptoms from onset. Typically pulsatile and severe.
Patient Presentation: Ill appearing. Patient prefers room with no stimulus
Other symptoms: Aura, photo/phonophobia, nausea/vomiting; may cause rarer symptoms: photopsia, vertigo, scalp tenderness, seizure like activity
Migraine patient’s who become pregnant are at higher risk of developing eclampsia or cerebral venous embolism
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Cluster Headache
Duration: 15minutes – 3 hours
Location: Typically involves eye and/or temple region. Always unilateral.
Characteristics: Quick onset, sharp stabbing pain of significant intensity. Often see tearing of eye. “Ice pick headache”
Patient Presentation: Active, but in obvious discomfort
Other symptoms: Tearing, rhinorrhea, sweating, irritation
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SNOOP = Danger
These could represent a space-occupying mass, vascular lesion, infection, metabolic disturbance or systemic problem
S Systemic symptoms, illness, or condition (Fever, weight loss, cancer, pregnancy, immunocompromised state)
N Neuro symptoms or abnormal signs
O Older onset (particularly for age > 50 years)
O Onset sudden (thunderclap headache)
P Papilledema, Precipitated by Valsalva, Positional provocation, Progression or change in HA history
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Headaches- need for emergency evaluation
Sudden “thunderclap” HA
Acute or subacute neck pain or HA with Horner syndrome (results in a decreased pupil size, a drooping eyelid and decreased sweating on the affected side of your face) and/or neuro deficit
HA with suspected meningitis or encephalitis
HA with global or focal neurologic deficit or papilledema
HA with orbital or periorbital symptoms
HA and possible carbon monoxide exposure
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Vertigo
Patients describe a sensation of self-motion when they are not moving or a distorted self-motion during normal head movement.
Vertigo can be:
Result of asymmetry within the vestibular system
Disorder of peripheral labyrinth of its central connections
Distinction between vertigo and dizziness has limited clinical usefulness
____________________
Peripheral Causes:
Benign Paroxysmal Positional Vertigo (BPPV): Transient symptoms of vertigo due to canalith movement in the semicircular canals.
Meniere Disease: Spontaneous vertigo symptoms associated with unilateral hearing loss. Caused by increased endolymphatic pressure in the inner ear.
Otosclerosis: Bony overgrowth of the stapes that results in spontaneous vertigo and conductive hearing loss.
________________________
Central Causes:
Vestibular Migraine: Vertigo symptoms associated with migraine headache.
Cerebrovascular disease: Vertigo symptoms associated arterial occlusion (think vertebrobasilar system).
Mass at Cerebellopontine Angle: schwannoma, brainstem glioma, medulloblastoma, neurofibromatosis
_________________________
Other causes:
Medication Induced: Persistent episodes of vertigo with no other explainable symptom while taking suspicious medication
Psychiatric*: Often associated with anxiety, depression, bipolar
Orthostatic: Not true vertigo, but rather pre-syncopal symptoms
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TiTrATE workup for diagnosing
TiTrATE consists of three distinct components of workup:
Timing of the symptom (onset, duration and evolution of symptoms)
Triggers that provoke the symptom (actions, movements or situations)
And a Targeted Examination
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Syncope
temporary loss of consciousness caused by a fall in blood pressure.
Orthostatic hypotension: Positional changes that result in acute drop in blood pressure
- ->May be exacerbated my medication (Beta-blockers)
- -> Volume depletion
- -> Autonomic failure from 10 (MS, Parkinson's) or 20(diabetes, spinal cord injury)
________________
Neuro mediated (reflex):
--> Carotid sinus syndrome: Head rotation accompanied by pressure to the carotid artery resulting in stimulation carotid sinus resulting in reflexive ventricular pause and possible syncope
--> Vasovagal: Occurs as an over correction to stimulus of SNS (panic, pain, sight of blood) resulting in rebound over stimulation of PNS, resulting in bradycardia and vasodilation.
--> Situational: Occurs when a scenario (standing, coughing, micturition) triggers a neural reflex resulting in transient bradycardia and vasodilation resulting in syncope.
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Primary lesions
Primary lesions
Flat: cannot palpate for (macule <1cm, patch >1cm)
Raised & fluid filled (vesicle <1cm, bulla >1cm)
Raised & not fluid filled (papule <1cm, plaque >1cm)
