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Ortho II Test 2 > Evaluation of the Patient with Thoracic/ Rib Pain > Flashcards

Evaluation of the Patient with Thoracic/ Rib Pain Flashcards

1
Q

When screening for non-orthopedic medical conditions what systems are you looking at?

A 
Cardiovascular
Pulmonary 
GI 
Integumentary 
Neurological
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2
Q

What could you see when looking at patients with potential cardiovascular problems?

A

Pt. diagnosed with heart disease- eval risk factors: BMI, BP, HR
Presence of fever (pericarditis)- auscultate for pleural rub
Problem is 1/3 of pts with MI do not have chest pain usually

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3
Q

With pulmonary conditions what are you looking for?

A 
Hx of CA
Smoker
Productive cough
Fever (pneumonia) 
Sharp stabbing pain on inhalation (pleurisy or pneumothorax)- auscultate so no mobs 
Recent sx or immobility (PE)
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4
Q

GI complications include?

A

hx of Ca
Nausea/vomiting (cholecystitis)- pain RUQ
Unexplained wt loss- greater than 10 lbs/month
Symptom relief with antacids
use of NSAIDs (gastric ulcers)- use greater than 3 months at doses more than 1600 mg/day
Melena: black tarry stool (gastric ulcers)

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5
Q

If you have GI pain and want to determine the relationship to eating how would you do that?

A

Pain relieved by eating: Duodenal ulcer
Pain increased with eating: Gastric Ulcer
Pain increases after eating fatty foods: Cholecystitis

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6
Q

With integumentary considerations what should you be aware of?

A
  1. Rash on extensor surfaces- Psoriasis
  2. Rash in dermatomal distribution on thorax (shingles)- herpes zoster
  3. Any scars or incisions: you need to know why they are there.
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7
Q

What are the two main things you are looking for with neurological considerations?

A

UMN signs: LE reflexes, clonus, Babinski, Hoffmanns (wont see with lower thoracic)
Bladder/bowel changes

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8
Q

Give the 5 fractures and deformities you might see in the thoracic/rib area.

A
  1. Acute Spinal Fx
  2. Fx due to Osteoporosis
  3. Rib Fx
  4. Schuermann’s Disease
  5. Idiopathic Scoliosis
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9
Q

Compression, burst, fracture-dsilocation, and flexion-distraction are all under what subheading?

A

Acute Spinal Fx

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10
Q

Compression fx includes which column? Is the neurological system disturbed?

A

Anterior column; usually no neurological deficit
These are stable as long as kyphotic angle is not above 20.
Acute pain in thoracolumbar/ or pain in apex of curve.
Ex: Osteoporotic fx

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11
Q

A burst fx includes which column? Is there a neurological injury present?

A

Middle column; 50% have neuro injury.
Retropulsion of bone fragment may compromise canal
Most often involves the thoracolumbar junction

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12
Q

Fracture-dislocation involves which column? Is there a neurological injury present?

A

All 3 columns involved; 75 % have neuro injury
Follows application of considerable force and often involves rotation and shear.
This has a high incidence of associated intra-abdominal injury

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13
Q

Flexion-distraction involves which columns? What can make the spine unstable?

A

Posterior column or all 3 columns; fulcrum associated anterior to spine; unstable if ALL fails

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14
Q

Extension injuries are compression of ______ and are usually _______.

A

Posterior elements; stable

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15
Q

How would you treat thoracic fractures?

A

Sx intervention dep. on degree of cord compromise, potential instability, deformity.
Rigid bracing potentially

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16
Q

What column is usually associated with osteoporotic fx? Why are they susceptible to more fx?

A

Anterior column; Caused by decrease in bone. Osteoporotic bone has a thinner cortex and is more porous.

17
Q

What clinical signs and symptoms are associated with osteoporosis fx?

A

Acute pain in the thoraco-lumbar region
Usually no neuro signs
Kyphosis- can be progressive

18
Q

What can you use to diagnose osteoporosis?

A

X-ray: shows bone loss greater than 30-50%, doesn’t always show
Dual X-Ray Absorption (DEXA) calculates t-score and compares BMD to optimal.

19
Q

What t score is shown if a patient has osteoporosis?

A

-2.5 or lower

Osteopenia: -1.1 to -2.4

20
Q

Give the surgical options for patient with an osteoporotic fx.

A
  1. Fusion sx: in .05% of cases b/c neuro deficit

2. Kyphoplasty: injection of collapsed vertebrae with bone cement.

21
Q

What are some medical (non-ex) options for patients suffering from osteoporotic fx?

A
  1. Analgesics for acute pain
  2. Anti-resorptive agents: estrogen, alendronate Sodium (fosamax), risedronate sodium (Actonel), Raloxifene (Evista), Calcitonin (Miacalcin), Zoledronic (Reclast)
  3. Bone Reformation Agents: Teriparitide (Forteo)
  4. Diet: Calcium (1000-1200mg/ day), Vitamin D&K, magnesium, phosphorus
22
Q

How can PTs best help a patient dealing with pain from an osteoporosis fx?

A 
Rigid Orthosis if tolerated- acutely 
Ext. exercises as tolerated
Strengthen paraspinals (avoid flexion loading) 
Walking program
Balance exercises: fall prevention 
Postural correction
Breathing exercises: changes led to 9% decreases in FVC 
Education
23
Q

What are some risk factors associated with osteoporosis?

A 
Caucasian
Early menopause
Thin
Bedridden
Decreased Calcium intake 
Smoking 
Caffeine or alcohol consumption 
Liver/Thyroid/Renal disease
24
Q

When should a PT recommend that a patient be screened for osteoporosis?

A
  1. Presence of risk factors
  2. Over 65
  3. Loss of height, increased kyphosis, or protuberant abdomen
  4. Hx of chronic LBP
  5. Hx of wrist fx

**Increase in # of risk factors= # of reasons to have them screened

25
Q

What are three mechanisms of injury for rib fractures?

A
  1. Traumatic: fall, MVA, usually adult b/c kids bones absorb more shock
  2. Pathological
  3. Stress fx: elite athletes (rowers, UE athletes)
    You will have pain with inspiration, point tender on rib, may feel defect/crepitus
26
Q

What is the condition causing kyphosis of the t-spine and vertebral wedging?

A

Schuermanns Disease

27
Q

What are Schmorl’s nodes?

A

Disc material herniated into the vertebral body- cause pain with ext. and rotation.

28
Q

What is the main complaint of Schuermanns? How would you treat this disease?

A

Main complaint: Postural deformity
Treatment: exercise to prevent further development of kyphotic deformity (with or without brace), also give them postural exercises

29
Q

What are the 3 types of idiopathic scoliosis?

A

Infantile, Juvenile, and Adolescent - lateral deviation of the spine

30
Q

Name the 3 subtypes of idiopathic scoliosis.

A
  1. Functional: result of muscle imbalance
  2. Structural: Vertebral body causing restriction
  3. Sciatic: Shift from pain and changes so you compensate for pain.
31
Q

What are some of the soft tissue causes of thoracic pain?

A 
Intervertebral Discs
Thoracic Zygapophyseal Joints 
Costotransverse Joints 
Muscular Sources 
Autonomic Nervous System
32
Q

Describe the pain pattern when it comes to intervetebral discs.

A

All thoracic disc pain will be increased with flexion
At least 2/4 movements will be limited:
Passive rotation will be most painful
Sidebending decreases with age

33
Q

What should be suspected if SB away from painful side is painful and rotation is pain free?

A

A neuroma or neoplasm

34
Q

Thoracic zygapophyseal joints are innervated by? What kind of stress are they under and why would nocioceptors develop?

A
  1. Innervated by: medial branches of thoracic dorsal rami
  2. Under considerable rotary stress
  3. Development of nocioceptors with degenerative changes
35
Q

Costotransverse Joints are affected by what? It can be associated with what other condition? Why would it have unusual symptoms?

A

Affected: AS and RA
Likely to be associated with SI pain.
May have unusual symptoms due to proximity of sympathetic trunk.

36
Q

Primary thoracic pain is what?

A

Source of symptoms is a lesion of a muscular attachment in thoracic area

37
Q

Secondary thoracic muscular pain is?

A

Lumbar injury that causes reflex spasm of the erector spine causing pain to be perceived in the thoracic area.

Ortho II Test 2 (2 decks)

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