EO 09.02 Flashcards
Neck pain is classified in 2 groups:
- Pain mainly from joint and associated ligaments or muscles
- Sign of radiculopathy (nerve root) (radicular pain) or, Sign of myelopathy (spinal cord lesion, stenose, compression)
Cervical soft tissue injuries MOI
MOI:
- Mechanical Neck Disorders (activity related)
- Neck strain, sprain, acceleration-deceleration injury, hyperextension/flexion, whiplash
- MVCs, falls, sports, work-related injuries precipitate most cases
Acute or chronic
Cervical soft tissue injuries Clinical Presentation
- Pain and stiffness
- Deep, dull aching, often episodic
- Hx excessive activity/sustaining awkward posture
- May be no hx specific injury
- Ligament/muscle pain localized & asymmetric
- Pain from upper segments referred twd head; lower segments twd upper limb girdle
- Symptoms aggravated by movement, relieved by rest
Cervical soft tissue injuries Common Management Strats
- Improvement with minimal intervention
*Act as usual, avoid activities that cause pain - NSAIDs, muscle relaxants
- Opiates (significant pain)
- F/U to determine need for physical/manual therapies
Cervical hyperextension flexion (Whiplash) MOI
- Sudden acceleration-deceleration that occurs when unaware victim in a stationary vehicle struck from behind
Cervical hyperextension flexion (Whiplash) Clinical Presentation
- Typically pain delayed following accident
- Pain, stiffness, tender paracervical muscles
- Uncommon/highly variable:
Headache, vertigo, dizziness, spatial instability, dysphagia, hoarseness
** Brain, spinal cord, or carotid or vertebral artery dissection should be considered whenever neurologic findings are seen after whiplash injury**
Cervical hyperextension flexion (Whiplash) Common Management Strategies
- Similar to cervical soft tissue inj
- Maintain motion as tolerated
- Analgesics
- Muscle relaxants
Pathophysiology – Cervical Hyperextension/Flexion
- Upward/backward injury to frontal head, jaw, face
May involve: - Soft tissue (whiplash, strain, sprain)
- Vertebral structures
Spinal cord*
Vascular
Central cord sydrome (CCS) most devastating complication
Clinical presentation - Cervical Hyperextension/Flexion (Whiplash)
- Neck pain, stiffness
- Headaches
- Paresthesia/numbness
- Shoulder pain, spasms, tenderness
- ↓ ROM
- Radicular signs
- Forehead/face/jaw abrasion, laceration, or contusion
Cervical hyperextension/flexion Common management strategies
- If soft-tissue same management as cervical soft-tissue inj – NSAIDS, muscle relaxants, possible referral to physical/manual therapies. Pt education
- CCS without instability:
Bed rest with soft collar 4-6 wks
IV steroid - Surgery considered with deterioration/ ↑
Stable fractures
Rigid collar 8-14 wks fol by mobilization - Unstable fractures
Surgery - Vascular dissection
Cerebral angiogram and anticoagulation (prevent ischemic embolic events)
Cervical Spondylosis Patho
- Progressive, degenerative condition
- Presents as loss of cervical flexibility, neck pain, occipital neuralgia (nerve damaged/inflamed), radicular pain (radiation pain from spine>back> legs), or progressive myelopathy (severe compression; occasional)
- Progressive degeneration of ligaments, disks, facet joints
- Osteoarthritis of the neck and Degenerative Disk Disease common terms used for this condition
Cervical Spondylosis Clinical Presentation
- Neck pain/soreness with radiation twds occiput/ shoulder and scapular region
- Loss of neck extension
- Lateral flexion limited
- Headache
- Cervical spondylotic radiculopathy (sharp, tingling, burning)
- Cervical spondylotic myelopathy, gait disturbance, loss of upper fine motor control, bowel/bladder dysfunction (late)
Cervical Spondylosis Common Management
- Pt education
- Activity restrictions
- Soft cervical collar
- Analgesics, muscle relaxants
- Physio – ultrasonic tmt with muscle stimulation
- Avoidance of activities that produce strain/pain
Spasmodic Torticollis Patho
Torticollis is involuntary contractions/spasms of the neck muscles causes the neck to turn from its usual position.
Spasmodic Torticollis is usually Idopathic
the head tilt and rotation are involuntary movement
Most common cervical dystonia
Some causes may be:
- Muscular damage from inflammatory disease
- Age (20-60)
- Cervical spine injuries
- Cervical spondylosis
- Ocular disorder
- Tumor
Spasmodic Torticollis Clinical Presentation
- Head tilt to affected side; chin rotates to opposite side
- Initial neck stiffness, progressing to pain & head jerking
- Painful spasms
- C-spine tenderness
- ROM restrictions with pain
Spasmodic Torticollis Common Management
- Physical measure – light touch (sensory biofeedback) on jaw on same side as head tilt / any light touch.
- Soft cervical collar
- Heat/ice
- Bed rest
- Analgesics/muscle relaxant
- Botulism Toxin type A & B
- Rarely, emotional problems contribute - psychiatric tmt indicated.
Mechanical Lower Back Pain Physiopathology
AKA Non-specific back pain
- Anatomic/functional abnormality in absence of neoplastic (benign or malignant mass (CA)), infectious, or inflammatory disease
- Usually acute (<3month), idiopathic, benign & self-limiting
- Represents 97% of symptomatic LBP
- Commonly work related
- Risk factors
- Heavy lifting / improper lifting
- Poor conditioning
- Obesity
- Often arises from muscle/ligament injury
Typical mechanism minor exertion/lifting
Mechanical Lower Back Pain Clinical Presentation
- Paraspinal muscle/facet tenderness
- Paraspinal muscle spasm may present with absent lumbar lordosis
- Mild-mod pain with movement ; relieved by rest
- No motor/sensory loss/reflex abnormalities
Mechanical Lower Back Pain Common Management
Continue daily activities (using pain as limiting factor)
- Ice/heat
- Analgesic, manipulation, physio
- Monitor 4-6 wks; 80-90% pt’s symptoms will resolve on own without requiring a diagnostic evaluation.
- Acetaminophen / NSAIDs
- Opioid (mod-severe pain)
- Pt Education** (red Flags)
Lumbar Disc Herniation Physiopathology
Disk herniations occurs as the nucleus pulposus protrudes through the posterior annulus fibrosis, producing either an acute radiculopathy or, occasionally, a myelopathy.
Lumbar Disc Herniation Clinical Presentation
- Dx suspected clinically and confirmed with non-urgent MRI
- Pts complain of radicular symptoms more than back pain
- > 95% occur at L4-L5/ L5-S1
- Localization of pain & neurological deficit in unilateral single nerve root (usually L5/S1)
- Straight leg raise
- ↑ pain with coughing, valsalva, sitting
- Pain relieved by lying supine
Lumbar Disc Herniation Common Management
- Pt education!
- Similar tmt as Mech LBP
- Routine activity as limited by pain
- Physio
- Oral Meds (acetaminophen, -NSAIDs, opiates, muscle relaxant)
- Ice/heat
Sciatica Pathophysiology
- “sciatica” is used for radicular back pain following the lumbar or sacral nerve root
- Often accompanied by sensory or motor deficits
- Only occurs in 1% of pts with back pain, however is present in 95% pts with symptomatic herniated disc
- Usually seen at L4-L5 or L5-S1 disk space
- Most common cause of sciatic pain – compresses or impinges on spinal nerve roots, cauda equine* or spinal cord
Sciatica Common Management
- If no risk factors for serious disease, treat conservatively similar to herniated disk
- If tmt ongoing with no improvement, surgery may be considered
- Steroids…widely used, however little measurable benefit
If the patient has a demonstrable neurologic deficit, consider obtaining plain radiographs to look for other possible causes for symptoms such as tumor, fracture, spondylolisthesis, and infection.
Lumbar Disc Disorders Pathophysiology
- Many pts with LBP have lumbar disc disease & involvement surrounding spinal ligaments, muscles, skeleton
- Over time may progress to disc degeneration, herniation, spinal narrowing, arthritic growth
- In younger pts
Source likely due to mech compression/ chemical irritation - In older pts (>55)
Spinal stenosis likely to be etiology
Lumbar Disc Disorder Clinical Presentation
- Variable pain
- Pain may radiate in nerve root dist
- Back pain ↓ at night
- Pain ↑ sitting/standing
- Sciatica can occur w/out back pain
- Paresthesias/numbness in extremities
- Occasional muscle group weakness
Lumbar Disc Disorder Clinical Common Management
- Conservative tmt 4-6 wks
- Minimize bed rest, activity as tolerated, heat, analgesic, NSAID, muscle relaxant, physio, (Symptomatic relief)
- Chronic nonradicular pain
Improve physical fitness, after pain controlled begin progressive walking prgm - Surgical consult
Persistent/severe pain & neuro deficits
Nerve Root Disorders Pathophysiology
- AKA radiculopathies
Precipiated by chronic pressure on a root in or adjacent to the spinal column - Most common: Herniated disc
- Bone changes (RA or OA) may compress/isolate nerve roots
- Infectious disorders sometimes affect nerve roots
Nerve Root Disorders Clinical Presentation
- Radicular pain & neurologic deficits
- Muscle weakness/atrophy
- Sensory impairment (dermatomal)
- DTRs may be diminshed/absent
- Electric shock-like pains
- Pain exacerbated by movement
- Lesions of cauda equine
- Radicular symptoms bilat, impaired sphincter and sexual function
Nerve Root Disorders Common Management
Depends on cause but includes symptomatic relief
- Analgesics
- NSAIDs
- MRI/CT
- Tricyclic antidepressants/anticonvulsant
- Physio/ Mental health consult
- Alternative medical tmts
Red Flags for Back Pain
- Saddle paresthesia
- Fecal incontinence; Decreased anal tone and reflex
- Urinary retention
- Usually bilat lower leg weakness – motor/sensory loss
- Males may experience erectile dysfunction – Priaprism
Rotator Cuff Muscles/Joints
Consist of 4 muscles and 4 joints
- Muscles: Supraspinatus, Infraspinatus, Terres minor, subscapularus
All originate on scapula, transverse the glenohumeral joint, and insert on proximal humerus
- Joints: Glenohumeral, acromioclavicular, sternoclavicular, scapulothoracic
Movement responsibility: SITS
Supra – elevates abducts shoulder (with help from bicep tendon)
Infra – primarily external rotator
Teres – external rotation with infra
Subscap – internal rotation
Rotator Cuff Injury Patho
Rotator Cuff Injury presents with shoulder pain after acute trauma, chronic injury, or acute extension of chronic impingement
- Chronic impingement in pts >40 account for great majority of tears
- Seen in younger populations who engage in heavy labour & overhead sports
- Healthy rotator cuff tendons resistant to acute injury and usually occur as result of significant trauma forced/extreme hyperabduction/hyperextension (fall on out stretched arm), lifiting/catching heavy object as it falls
Rotator Cuff Injury Tear Classifications (2)
- Partial thickness tear (conservative TMT)
- Full thickness tear (Surg TMT)
Rotator Cuff Injury Clinical Presentation
- Gradual and progressive pain, initially worse at night
- Pain eventually becomes persistent
- Commonly localized to lateral aspect upper arm
- Freq, intensity, duration symptoms ↑ = less responsive to TMT
- Shoulder dysfunction worsens and interferes with daily activities
- Arm elevation, external rotation, lifting of even light objects worsen symptoms
- Pt may report “tearing” sensation
- Severe pain/ disability
- Inability to raise arm
- Asymmetry due to significant local swelling
- Drop arm test
Rotator Cuff Injury Clinical Common Management
- Sling until acute symptoms subsides
- NSAIDs
- Analgesics
- Ice (acute)
- Gentle ROM exercises (physio) initially slowly progressing in difficulty
- Consider need for Ortho/surgical consult
Rotator Cuff Injury Clinical Presentation (Chronic)
- Palpation may produce discomfort at the lateral aspect or in the subacromial region.
- Most patients with rotator cuff tears have weakness and pain on abduction, elevation, and, most commonly, external rotation.
+ drop test if unable to hold arm/lower extended arm at 90 degrees - Crepitus & pain with ROM
- Assess ROM – active and passive and strength
- Muscle atrophy may be noted
Rotator Cuff Injury Clinical Presentation (Acute)
- Pt may report “tearing” sensation
- Severe pain / disability
Inability to raise arm - Asymmetry due to significant local swelling
- Active motion is limited, with inability to abduct or externally rotate the arm against even minimal resistance.
- Drop arm test
- Palpation may produce discomfort at the lateral aspect of the upper arm or in the subacromial region.
AC Joint Injury Patho
- Range from mild sprain- complete disruption
- Mechanism usually direct trauma from fall with arm adducted
- Indirect mech is FOSH with transmission of force to AC joint (scapula and shoulder girdle driven inferior while clavicle remains
AC Joint Injury Clinical Presentation
- Dx is clinical
- Mech of injury, tenderness, deformity when compared to opposite clavicle is confirmatory
- X-rays useful for identifying #s and determining severity
AC Joint Injury
- Type I & II
-Rest, ice, analgesics, immobilization, early ROM excercises (physio 7-14 days) - Type III
-Conservative vs operative; based on age, occupation, activity level - Type IV, V, VI
-Surgical repair
Impingement Syndrome Patho
- Repetitive overhead of arm/shoulder causes enroachment on subacromial space by humeral head
- Repetetive subacromial impingement produces pathologic changes of bursa, rotator cuff, biceps tendon
- Loss of normal gliding mechanism between the RC and related soft tissues within the coracoacromial arch
Impingement Syndrome Term for which conditions (4)
- Subacromial bursitis
- Rotator cuff tendonitis
- Suprapsinatus tendonitis
- Painful arc syndrome
Impingement Syndrome Clinical Presentation
- Pain develops insidiously over wks-mos
- Located over anterolateral acromion and radiates to lateral mid- humerus
- Night pain, deep, aching interfering with sleep
(lies on shoulders or arms above head) - Secondary to pain Weakness, stiffness shoulder
- O/E disuse atrophy if disuse
- Crepitus/ catching during ROM
Impingement Syndrome Common Management
- Relative rest & activity modification- avoid aggravating activities, minimize overhead, ROM 3-4x/day. AVOID immobilization!
- Meds: Pain management– NSAID Rx 7-21 days, short term opioits for mod-severe pain
- Ice – 10-15m 3-4x daily aid reduce inflammation
- Gentle ROM exercises –pendulum swing 5-10m 3-4x daily & walk fingers up wall arm extended to level of pain tolerance 3-4 x daily
- Stretching & strengthening – as directed by physical therapist – Rx by clinician
- Corticosteroid injections – effective pain relief but comes with possible ++adverse effects (muscle atrophy, weakness, tissue degeneration, necrosis and rupture (Inj by primary care/orthopedist)
- Follow-up – in 7-14 days
Impingement Syndrome (Stage 1)
- Reversible edema & hemorrhage around rotator cuff
- Classically seen <25 athletes
- Pts c/o dull ache anterolateral shoulder aggravated by activity, improved by rest
- If pts continue aggravating activities and do not follow tmt, impingement can progress to stage 2…
Impingement Syndrome (Stage 3)
Rotator cuff tears
Rupture of long head of biceps
Subacromial spurs
Pts have history of progressive symptoms, disability
Often require surgical decompression on subacromial space
Impingement Syndrome (Stage 2)
- Edema, hemorrhage advance to tendonitis of rotator cuff
- Typically seen in pts 25-40 yrs
- Prolonged duration/recurrence of symptoms make Dx
- Chronic aching pain with daily activities, pain with vigorous activity, night pain
- Continued overuse leads to stage 3…
Sternoclavicular Joint Injury Patho
- Most frequently moved non-axial joint
- Joint stability depends on integrity of surrounding ligaments
- Majority injuries simple sprains
- Forcing shoulder fwd or applying medially direct force may result in sprain
- If shoulder rolled fwd at time of impact, posterior dislocation may result
- If shoulder rolled back at time of impact anterior dislocation may result
- Posterior less common than anterior
Sternoclavicular Joint Injury Clinical Presenation
Sprain: pain, swelling localized to joint
Dislocation:
Severe pain worsened with motion/ laying supine
Shoulder appears shortened and rolled forward
Anterior dislocation:
Prominent medial clavicle end visible & palpable (swelling, tenderness may impede Dx)
Posterior Dislocation:
Medial clavicle end less visible and often not palpable
Pt may have S/S impingment of superior mediastinal contents (med emerg)
Sternoclavicular Joint Injury Common Management
Sprain: ice, sling, analgesics
Anterior Dislocation:
- Clavicular splinting, ice, analgesics, ortho referral
- Pt with uncomplicated dislocations may be discharged without an attempted reduction as injury has little/no impact on function
Posterior Dislocation:
May be associated with life threatening injuries to adjacent structures, including pneumothorax/ compression or laceration of surrounding great vessels, trachea, esophagus
Ortho consult is necessary for closed/open reduction (performed in OR with trauma/vascular surgery avail)
Biceps Tendonitis Patho
May result from
- Progressive impingement
- Isolated tendon inflammation
- Injury
- Tendon may become inflamed or partially displaced out of the bicipital groove, or may rupture altogether.
- The labrum may be torn near the long head insertion
- These injuries know as SLAP lesions (superior labrum anterior-posterior)
Biceps Tendonitis Clinical Presentation
- Characterized by acute, intense, localized pain anterior aspect of shoulder
- Repetitive overhead arm motion = inflammation chronically or a superior labrum anterior-posterior lesion acutely, particularly in athletes
- Pain at rest, night and on rotation
- Rupture almost always proximal - due to micro tears/age
- Intense pain on palp of tendon in groove; heard ‘snap’ / felt ‘pop’
- Pain with forearm especially with supination
- Resisted forearm supination may cause subluxation (misalignment; move out of place; Speeds Test)
Biceps Tendonitis Common Management
Biceps Tendinitis and subluxation conservative TRT
- Sling, rest, ice, elevation, analgesic, NSAID, physio, F/U
- Mobilization and stretching initiated early + primary care appt.
Usually resolves with conservative therapy* - FU 1 week
Ortho consult reserved for severe case (SLAP lesions) that do not respond to conservative tmt within 1-2 weeks
Surgery: tendon rupture – Ortho consult 24-28 hr
DDx for Shoulder Disorders
- Arthritis – degenerative, inflammatory, trauma, endocrine
- Bursitis/tendonitis- degenerative, inflammatory, trauma,
- Impingement Syndrome- inflammatory, trauma,
- Adhesive capsulitis (frozen shoulder) -idiopathic, autoimmune, iatrogenic, trauma, endocrine, inflammatory, stroke
- Shoulder instability - degenerative, inflammatory, trauma,
- Cervical disc disease/radiculopathy - degenerative, inflammatory, trauma,
- AC joint injury- trauma
Lateral Epicondylitis Patho Types (2)
AKA “Tennis Elbow”
- Lateral epicondyle serves as origin for forearm, wrist, and digit extensors/supinators
- Overuse syndrome affecting soft tissues
- Result of any repetitive mvmt involving said muscle groups
- Usually occurs unilaterally (dominant arm)
AKA “Golfer’s Elbow”
- Less common counterpart to lateral epicondylitis
- Involves forearm, wrist, and digit flexors/pronators
- Pts may develop ulnar neuropathy given the proximity of the ulnar nerve to the medial epicondyle
Lateral Epicondylitis Clinical Presentation
Lateral:
- Tenderness over lateral epicondyle
- Pain with forced extension/supination of forearm against resistance
Medial:
- Tenderness over medial epicondyle
- Pain with forced flexion/pronation of forearm against resistance
→ In both, the ROM is normal.
Lateral Epicondylitis Common Management
- Rest, ice, NSAID, counterforce brace/immobilization
- Corticosteroid/Surgery may be indicated in cases that are resistant to tmt
- Physio - post acute pain for eccentric strength training and grip exercises.
- ↓ aggravating activities*
DDx For Elbow Disorders
- Arthritis - degenerative, inflammatory, trauma, endocrine
- Bursitis -trauma, infection, inflammatory
- Muscle strain - trauma
- Fractures of the epicondyles - trauma
- Posterior Interosseous nerve entrapment (lateral) –idiopathic, trauma, ioatrogenic
- Ulnar neuropathy (medial) -inflammatory, trauma, endocrine ioatrogenic
Carpal Tunnel Syndrome Patho
- Results from compression of median nerve at wrist where it traverses the carpal tunnel
- Injury due to repetitive use
Carpal Tunnel Syndrome Clinical Presentation
- Classic signs - Pain, paresthesias, numbness in dist of median nerve – palmer aspect thumb, index, middle, radial aspect of 4th finger
- Preserved sensation in 5th digit; unlar 4th digit
- Positive Tinel sign
- Positive Phalen
maneuver
Carpal Tunnel Syndrome Common Management
- Initial treatment conservative: behavior modification is recommended - weight loss, decrease caffeine, nicotine and alcohol; modify activity, workplace ergonomics, NSAID, wrist splint
- Close F/U with physician (pts at risk for long term disability)
If conservative tmt fails, corticosteroid injection/surgical release - Wrist splint, oral steroids, U/S therapy, yoga – short term
- F/U with clinician
Scaphoid Fracture Patho
- Most common carpal bone fractured
- Results from fall on outstretched dorsiflexed (FOOSH) hand or by axial load directed along thumb’s metacarpal
- Associated injuries may include the radius, neighboring carpal bones, a carpal instability pattern, or a dislocation.
** Can develop avascular necrosis (loss of bld supply to area) of the proximal fracture segment that can lead to disabling arthritis; Snuff box test**
- 2/3 scaphoid surface is articular = difficult to heal
Complications if improperly healed:
- Avascular necrosis
- Delayed union, nonunion, malunion
- Subsequent early degenerative arthritis
Scaphoid Fracture Clinical Presentation
- Pain along radial aspect of wrist
- Localized tenderness in anatomic snuffbox
- Axial pressure along thumb’s metacarpal
Scaphoid Fracture Common Management
- Nondisplaced and clinically suspected treated in short-arm thumb spica
- Splinting in dorsiflexion & radial deviation helps compress fracture fragements
- Unstable placed in long arm thumb spica and seen promptly by Ortho
Boxer’s Fracture Patho
- Fracture of the fifth metacarpal neck
- Caused by direct impaction force
- Usually unstable with volar angulation (relating to the palm)
- If >40degree anngulation, reduction should be attempted
Boxer’s Fracture Common Management
- Splinted in ulnar gutter cast- from tips of fingers to mid-forearm
- Position prevents tightening during immobilization/secondary stiffness of joint
- Explain to pts that bone (boxers Fx) will heal with abundant callus they will have a bump over the dorsum of the hand because the callus is subcutaneous.
Colles Fracture Patho
- Results most often from fall on outstretched hand (FOOSH)
- Produces distal radial metaphysis fracture dorsally angulated displaced proximally and dorsally (Figure 266-17).
- Fracture line may be comminuted
- Fracture of the ulnar styloid often present
Colles Fracture Clinical Presentation
- Characteristic “dinner-fork” deformity
- Palmar paresthesias may present from pressure on the median nerve
- Unstable have >20 degrees angulation
Colles Fracture Common Management
Stable:
- Compression drsg & splint until seen by ortho
- Most can be treated with closed reduction and sugar tong splint
- Unstable #s may require aggressive ortho tmt short-arm cast is applied - bivalved to allow for edema
DDx for Hand and Wrist Disorders
- Cervical Spondylosis - degenerative; inflammation
- Sprain- trauma
- Fracture - trauma
- Tendonitis – trauma, inflammatory
- Generalized peripheral neuropathy - trauma, infection, endocrine, autoimmune, iatrogenic, drugs, neoplastic
- Pronator Syndrome inflammatory, trauma, degenerative, neoplastic, autoimmune
- Ganglion cyst- Idiopathic, trauma, autoimmune
Types of Fractures
1.Common Fractures
2. Pathologic Fractures
3. Stress Fractures
4. Salter Fractures
5. Frontal Fractures
6. Orbital Fractures
7. Zygomatic Fractures
8. Le Forte Fractures
9. Mandible Fractures
10. Open Fracture
Orthopedic emergencies
- Open fracture
- Subluxation/dislocation
- Neurovascular injury
Orthopedic Emergencies
Management and Tx Plan
- Referral to orthopedic surgeon
- Take active measures to reduce swelling and bleeding
- Analgesics as necessary
- Antibiotics as necessary (open fracture)
- Withholding oral intake
- Pre-reduction X-rays unless time crucial
- Reduction (MO Procedure)
- Post Reduction X-Rays
- Splinting / immobilization
Three phases of fracture healing
- Inflammatory Phase
- Reparative Phase
- Remodeling Phase
