MS pathologies pt. 2 Flashcards
Scoliosis patho ?
Lateral curvature of spine ( from looking behind )– usually painless until severe
Scoliosis structural ?
vertebrae rotate on each other, rib cage deformity too
Scoliosis functional ?
compensation for unequal leg lengths. Gone with flexion of spine
** little bit tipped but not true scoliosis **
Scoliosis: measures degree of angulation = ____ angle
Cobb
**where it goes off midline and where it come back
doing it serially to see if it is progressing or getting worse **
Scoliosis dx ?
- clinically – Adam’s forward bend tes
- confirm with x-ray
MRI or CT – if need spinal canal evaluation
**look to see if the heights of the ribs are the same or not and tells you if you should get an xray or not and they are usually asxs.
xray to monitor it every 6 mo to see if it is progressing
CT or MRI if very sxs. **q
Scoliosis – Tx: <10-20 ?
observe
Scoliosis – Tx: >20 ?
brace 16-23/ day
**keep them as straight as possible so they do not needle surgery
16-23 hours and until the bones ossifies ( months)**
Scoliosis – Tx: >40 ?
Harrington rods
Scoliosis – Tx: +60 ?
resp c/o’s
Scoliosis newer devices ?
Expandable subcutaneous rods
Vertebral stapling
Allow for growth until skeletal maturity
Permanent fixation often still ultimately required
instead of rigid nodes they not have exbndible ones that grow with the patient or verebral stapes ?
Spinal Stenosis patho ?
Some narrowing of spinal canal with age is physiologic and asymptomatic - degenerative
starting to get bony growths and it taking up space where the cords need to go and everything distal to that is affected
Spinal Stenosis slow onset of ?
- Diffuse episodic pain, bilateral paresthesias,
↓strength, “pseudoclaudication” - Pain with position changes – worse with lumbar
extension and better with lumbar flexion
“ Opposite of herniated disc” ( better with flexion) - Balance disturbances
Spinal Stenosis own notes ?
they can develop posture changes to reduce pain
Neg SLR
L2-L4 is where the canal is the narrowest
herniated disc versus spinal stenosis
narrowing of the tube of the spinal cord
slow onset cause it is bone growth taking over the space and it is diffuse pain cause many nerve roots involved and it is often bilateral
pseudo claudication worse and worse as they more or are stimulated
Spinal stenosis tx ?
ASA, NSAID’s – but NOT narcotics as long term use needed and we dont want them to develop dependance
Epidural steroids – 50% success
Surg – decompressive laminectomy - definitive long term tx. - it increase volume ( removing posterior laminates to increase space ))
not a guarantee cause there can be permanent damage
Ankylosing Spondylitis aka ?
spondyloarthropathy – a type of fusing arthritis
Ankylosing Spondylitis patho ?
Chronic inflammatory disease of axial skeleton, insidious
**especially the SI joints
causes restrictive lung disease**
Ankylosing Spondylitis sxs. ?
AM stiffness
Males> females
Uveitis - come i with sunglasses
**hips thrusted forward and knees bent trying to see **
Ankylosing Spondylitis in the neck ?
immobile neck
Ankylosing Spondylitis in the back ?
-Flattened lumbar curve when upright, or
-Persistence of lumbar lordosis with
flexion
Ankylosing spondylitis labs ?
XR
vertebral body “squares off”
Bridging osteophytes - joint fusion can result
syndesmophytes
Ankylosing spondylitis Tx ?
– ROM exercises to prevent fusion
- anti-inflammatories
- biologics
- surgery
Spondylolysis patho ?
2-4% of population
Bony defect – vertebrae breaks down
Loosening of pars articularis or lamina
“Scottie dog with collar”
Spondylolysis most common at __ ?
L5
Spondylolysis epidemiology ?
↑ incidence in gymnasts, football players,
weight lifters, et. al. who put lumbar spine in
hyperextension
**spine in hyper extension **
Spondylolysis sxs. ?
may be asymptomatic or back/leg pain
Spondylolysis Tx ?
back exercises, PT, bone graft
No heavy lifting
Spondylolisthesis patho ?
Slipping forward of one vertebra on another
“Scottie dog decapitated” ( not a collar it is now completely separated)
**palpate down and the woah! one slips in **
Spondylolisthesis most common at ?
L5 on S1
L4 on L5
Spondylolisthesis: types ?
congenital - bony deformity
degenerative (from spondylolysis that has progressed)
traumatic
pathologic from metastatic disease
Spondylolisthesis complications ?
May compress spinal cord
Spondylolisthesis Tx ?
bracing, PT, fusion depending on severity ( to hold vertebra in line)
avoid sports
Spondylolisthesis Grade 1 ?
<25 % slippage
Spondylolisthesis Grade 2 ?
25-50 % slippage
Spondylolisthesis Grade 3 ?
50-75% slippage
Spondylolisthesis Grade 4 ?
> 75% slippage
Avascular Necrosis of Femoral Head (AVN) or ?
Osteonecrosis
Avascular Necrosis of Femoral Head (AVN) or Osteonecrosis Etiology ?
- often unknown
- sometimes due to a direct injury to femoral head (hip dislocation, femoral neck fx)
- nontraumatic causes – ETOH, systemic steroids, ↑Lipids, bone marrow disease, hypercoagulopathy
**as it slips out of acetabulum it can cut off blood supply **
AVN: Cartilage is nonvascular, so problem is ___________ ( gets nutrients from synovial fluid)
subchondral
AVN: Osteoclasts ?
get rid of bone
AVN: Osteoblasts ?
builders - lay down new bone but it is a big joint and weight bearing but it is not as strong it causes femoral head flattening and this is called the cresent sign
New bone is susceptible to fx – DJD and crescent sign
AVN tx ?
THA ( total hip arthroplasty)
Hip fracture usually in ?
elderly
Hip fracture patients usually have a hx of ?
osteoporosis and a fall
Hip fracture sxs and PE ?
Leg is shortened & externally rotated
Pain with ROM
**the leg is shorted and externally rotated **
Hip fracture tx ?
Surg –
if trochanteric fx – rod, pins
- if femoral neck fx – rod, screws,
or joint replacement
**femoral neck fracture treated with screws **
3 Bursae of the hip ?
Trochanteric bursitis
Iliopsoas bursitis
Ischial bursitis
- *fluid filled sac at points of friction, sleeping on side to much or trauma anything that causes bursa irritation
- *
Trochanteric bursitis sxs ?
Pain in lateral aspect of thigh
↑ with prolonged sitting, lying on affected side,
May radiate down lateral thigh to knee
Trochanteric bursitis PE, signs ?
pain, and resistance to abduction
Trochanteric bursitis Tx ?
rest, ice, anti-inflammatories, intrabursal steroid injection sometimes
Iliopsoas bursitis where is it located ?
Bursa lies behind iliopsoas muscle, anterior to hip joint,
lateral to femoral muscles ( deep in the joint)
**hard to palpate in there cause so may tissue an can resemble arthritis , usually it will settle down **
Iliopsoas bursitis sxs. ?
pain in groin and ant. thigh, worse with hip ext, better with flexion
Iliopsoas bursitis Tx ?
ster inj., conservative tx
if recurrent – excise bursa
Ischial bursitis location ?
Bursa lies between ischium and gluteus maximus
Ischial bursitis causes ?
Inflames with trauma or prolonged sitting
**prolong sitting or trauma **
Ischial bursitis sxs ?
Pain may radiate down back of thigh
Point tender over ischial tuberosity - laying on side with hip and knee flexed you can palpate right over that and they will be tender
Ischial bursitis Tx ?
anti-inflam,
injections, seat cushion
Chondromalacia patellae aka ?
Patellofemoral syndrome
Chondromalacia patellae patho ?
Medial facet of patella doesn’t contact with medial facet of femur
Results in external rotation of patella and degenerative changes
Undersurface becomes roughened
**softening of the cartilage on the under surface of the patella , maybe one side of the quad is strong and causes displacement of the patella **
Patellofemoral syndrome sxs. ?
pain with stairs, hills
-instability with walking, running
**pain with climbing stairs cause the quad contracted and pulls on the patella causing it to grind more **
Patellofemoral syndrome PE, signs ?
+Clark’s test-
pain with quadriceps contracture (extended leg), crepitus
Patellofemoral syndrome labs ?
X-ray – Merchant or Sunrise view
**see if joint spaces are equal **
Patellofemoral syndrome Tx ?
- Improve quad strength to help stabilize joint ( balance strength)
- Weight loss, if overweight
- Knee orthotics, to limit extension- keeps patella in line
- Anti-inflammatories
**malalignment **
Meniscal tear types ?
Crescent
Bucket handle
Parrot beak
Partial or complete tear
Meniscal Tears patho ?
repetitive or sudden
Medial more frequently torn since more securely attached
during directio changes and enough to just sheer off the meniscus
my knee pop or clicks or locks up
Meniscal Tears sxs. ?
popping, clicking, locking, pain, especially during directional changes
Meniscal tears PE, signs ?
+ McMurray’s
+ Apley grind
**palpate of the knee joint as you extend mcmurrays **
Meniscal tears dx ?
MRI, arthroscopy
Meniscal tears tx ?
depends on
- type and severity of tear
- activity level of patient
Ligamentous injuries: which is more common ?
Medial collateral more often injured than lateral collateral
Medial collateral injury caused by ?
+ laxity with valgus stress ( of medial ligament) - put the knee in knock knee more valgus
Lateral collateral injury caused by ?
+ laxity with varus stress ( stretch the lateral collateral)
**it the inside of the knee to damage the lateral collateral **
Anterior Cruciate Tear PE, signs ?
+ Lachman - more specific
+ Anterior drawer easier to do — lower leg come out towards you
Posterior Cruciate ( not as common) PE, signs ?
+ Posterior drawer ( push lower leg )
+ Sag test - laying supine and holding feet and looking to see if the tibia drops more on one side
**need to do these actually when the injury happened cause they swell pretty fast
do the better knee first to see what is normal**
Unhappy Triad : Common injury combination involving
?
ACL
MCL
Medial meniscus
Ligamentous injuries ( MCL, meniscus, LCL, ACL, PCL) tx ?
depends on
- Degree of instability
- Age
- Desired level of activity
Strengthening vs. Surgery
**tailored to the patient
partial tear will hear over a long time **
Plica Band Syndrome: What is a plica ?
A plica is a fold, pleat, band or shelf of synovial tissue. It allows movement and is usually asymptomatic ( redundancy of synovial tissue)
How many plica in the knee ? And which one causes problems ?
4 folds exist in the knee, only the medial one typically causes problems
**distal pain of the knee
from the lower patella border to the medial epichondyle - may be able to feel pleat or band and it will be point tender **
Plica Band Syndrome Epidemiology ?
certain exercises (biking, stepper), repetitive motions or direct injury
Plica Band Syndrome sxs. ?
pain, snapping, palpate a inflamed band
Plica Band Syndrome dx ?
MRI – to rule out other conditions
Plica Band Syndrome Tx.: conservative ?
- stop offending activity
- ice
- cortisone/lidocaine injection
Plica Band Syndrome Tx: surgery ?
Scope – definitive dx and tx (remove the fold)
(Pes) Anserine Bursitis location ?
Bursa located medial and slightly distal to tibial tuberosity
(Pes) Anserine Bursitis patient position where is is best examined ?
Best examined with patient seated and knee flexed
- *very common and often over looked
- *
(Pes) Anserine Bursitis epidemiology ?
assoc with DJD, females, overweight, new exercise program, pregnancy
(Pes) Anserine Bursitis sxs ?
knee pain, worse with going up stairs, rising from sitting, AM stiff, leg “gives way”, tender to palpation
worse with stair so we think chondromalacia but this is not positive clarks test
(Pes) Anserine Bursitis labs ?
X-ray – often reveals DJD
MRI – enlarged bursa
(Pes) Anserine Bursitis Tx ?
local injection of anesthetic and steroid
rest
anti-inflamm
stretching exercises
Baker’s cyst patho ?
Cyst in popliteal fossa, caused by extension of knee’s synovial cavity
**extension of the knee synovial cavity outside the joint space
can be pin point or diffuse
because bakers are staying all the time **
Baker’s cyst best seen when ?
when patient is standing
Baker’s cyst occurs because ?
Usually occurs due to pathology in the knee
Bakers Cyst Tx ?
aspirate,
determine cause
but will come back unless you put compression wrap on it
Osgood Schlatter’s Disease patho ?
Osteochondrosis of tibial tuberosity – avulsion of osteochondral fragment, pulled off by patellar tendon
Osgood Schlatter’s Disease epidemiology ?
11 y.o., athlete
**preadolescentt over weight athlete is classic , patella tendon is strong than the bone and cause confusing fragments **
Osgood Schlatter’s Disease sxs. ?
intermittent pain x several months,
worse with stairs cause as they climb the quads pull the patella tendon and cause tibia tuberosity to tear more
Osgood Schlatter’s Disease prognosis ?
May last 2 years (or until they fully ossify) , but prognosis is excellent
May have lifelong prominence of tibial tubercle
Prepatellar bursitis aka ?
“Housemaid’s knee” - due to frequent kneeling
**right over top of the patella **
Prepatellar bursitis sxs. ?
stiff, limited movement, pain on palpation of bursa
Prepatellar bursitis PE ?
If marked swelling – aspirate and apply compression or else it will refill
**carpet layers pushing thing with knee so the carpet lays flat **
Prepatellar bursitis caution when ?
If skin is abraded, bursal fluid can become infected
Do C&S of aspirate
Prepatellar bursitis prevention ?
knee padding
Hallux valgus patho ?
Abnormal abduction of great toe in relation to first metatarsal
**valgus deformity **
Hallux valgus ?
bunion formation
Hallux valgus – bunion formation location ?
Head of first
metatarsal
may enlarge
on medial side
Pressure point- can inflame
**bony enlargemnt of the tarsal head
tailors if on 5th **
Hallux valgus and bunion causes ?
Primary causes – pointed toe shoes and familial tendency
Females>males 10:1
Hallux valgus and bunion tx ?
pt. education
shoe modification
surgery (osteotomy)
Pes planus (Flat feet) patho ?
Normal variant (in some cases - black line need to be straight ) vs. posterior tibial tendon dysfunction
Longitudinal arch flattens and sole touches (or nearly touches) the floor
Check shoes for medial wear
Pes planus types ?
Aysymptomatic flexible flat foot
Rigid or symptomatic flat foot
Pes planus: Aysymptomatic flexible flat foot ?
– raise on toes, concavity reappears, normal variant, no tx needed
Pes planus: Rigid or symptomatic flat foot ?
– may become tender, swollen. Need orthotics to support arch , exercises
Hammer toe location and patho ?
Hyperextension
at MTP and
flexion of PIP
Usually 2nd toe
**hyperextension and the flexion , extra pressure point on top of toes usually the second toes **
Hammer toe sxs and PE ?
Increased pressure over PIP jt.
Can cause hyperkeratosis (callus)
(A callus with an inward point is a corn)
Hammer toe tx ?
wide soft shoe, maybe surgery
Metatarsalgia patho ?
Pain under metatarsal head
c/o “a stone in my shoe”
Metatarsalgia causes ?
high heels, overuse, toe deformity.
Metatarsalgia pain due to ?
Pain is often due to callus formation
Metatarsalgia etiologies ?
plantar wart, callus, etc.
Metatarsalgia: Plantar wart ?
tender with lateral pressure, contain black dots
tender with lateral pressure, and contain black dots with are the thombosed capillaries
Metatarsalgia: Callus ?
nontender when squeezed or tender with direct pressure. Thickened skin from recurrent pressure
not tender when squeezed from the sides, maintains normal skin lines and no black dots)
Metatarsalgia: Callus tx ?
paring (shaving without blood), pumice after shower, shoe pad
Achilles tendon rupture patho ?
Sudden, forceful dorsiflexion as gastroc-soleus is contracted ( pulling it in opposite directions)
Achilles tendon rupture epidemiology ?
30-50 y.o. “weekend warrior”
**common is people who uses steroids or who do not stretch before activity **
Achilles tendon rupture sxs. ?
audible pop with immediate weakness
Achilles tendon rupture PE, signs ?
Palpable defect over tendon ( on posterior ankle)
Can’t plantar flex against
resistance
+ Thompson’s squeeze test ( squeezing calf and there is not dorsal flexion of the foot )
Achilles tendon rupture Tx ?
depends on degree of tear
Serial casting – better for sedentary, but higher rate of rerupture (better now with MRI to monitor healing) - for a partial tear
Surgery – better for active pt., but wound healing problems because of thin overlying skin
Morton’s Neuroma patho ?
Plantar surface tenderness, radiates to toes
Fibrosis around nerve due to repetitive irritation
Morton’s Neuroma between ?
Between 3rd and 4th metatarsal heads
Plantar fasciitis patho ?
Painful plantar aspect of foot or heel
**“heal spures”
F:M 2:1
over 70 **
Plantar fasciitis sxs ?
Worst in AM or after prolonged walking, standing
↑ pain with dorsiflexion, tender to palpation
Plantar fasciitis labs ?
X-rays - negative ( cause it is soft tissue)
Plantar fasciitis tx ?
activity modification, PT, stretching exercises, roll a golf ball, or bag of frozen peas under foot
Can become chronic
Rarely – surgical release of fascia
**can last for weeks **
