MSK: Part 6 Flashcards
Why do we need to be precautioned with Mechanical Lower Back pain
- Very common
2. Sinister causes of backspin include malignancy, infection or inflammatory causes
What are the red flags for serious lower back pain/spinal pathology
- Age of onset less than 20 or greater than 55
- Violent trauma (car accident)
- Constant, progressive, non-mechanical pain
- Thoracic pain
- Systemic steroids, drug abuse or HIV
- Systemically unwell, weight loss
- Persisting severe restriction of lumbar flexion
- Widespread neurology
- Structural deformity
What activities can cause common back pain
- Stooping
- Twisting whilst lifting
- Exposure to whole body vibration
- Psychosocial distress
- Smoking
- Dissatisfaction with work
Main causes of back pain
- Lumbar disc prolapse
- Osteoarthritis
- Fractures
- Spondylolisthesis
- Heavy manual handling
- Stooping and twisting whilst lifting
- Exposure to whole body vibration
Risk factors for back pain
- Smoking
- Work
- FEMALE (recurrent)
- AGE (recurrent)
- Pre-existing chronic widespread pain - fibromyalgia (recurrent)
- Psychosocial factors
Clinical presentation for back pain
- Back is stiff and a scoliosis (where spine twists and curves to the side) may be present when patient is standing
- Muscular spasm is visible and palpable + causes local pain and tenderness
- Pain is unilateral
- Episodes are short-lived and self-limiting
- Sudden onset
- Morning stiffness is absent
- Excersise aggravates pain
What structures can be a source of lower back pain
- Spinal movement occurs at the disc and posterior facet joints - stability achieved by spinal ligaments and muscles
Where do lesions in lumbar spondylosis occur
Intervertebral disc
Role of the intervertebral disc
Rotation and bending of spine
Describe the structure of an intervertebral disc
Fibrous structure whose tough capsule inserts into the rime of the adjacent vertebra
At what age do changes in the disc start to happen in lumbar spondylosis
- Teenage years or early twenties and increases in age
What happens to the inner gel layer of the intervertebral disc
Gel changes chemically, breaks up, shrinks and loses its compliance
What happens to the surrounding fibrous zone of the intervertebral disc
Develops circumferential issues
Clinical presentation of Lumbar spondylosis
Initially asymptomatic but visible on MRI as decreased hydration
Later - discs become thinner and less compliant
How does the changes in the intervertebral disc effect the intervertebral ligaments
Causes circumferential bulging
What happen in the adjacent vertebra of lumbar spondylosis
Reactive changes develop: bone becomes sclerotic and osteophytes form around the rim of the vertebra
What are the most common sites for lumbar spondylosis
L5/S1 and L4/L5
What is seen in young people with lumbar spondylosis
- Disc prolapse through adjacent vertebral end-plate produces SCHMORL’s NODE on X-ray
Consequence of Schmrol’s node
Painless but accelerates disc degeneration
What can lumbar spondylosis cause if not asymptomatic
- Episodic spinal pain
- Progressive spinal stiffening
- Facet joint pain
- Acute disc prolapse, with or without nerve too irritation
- Spinal stenosis
What syndrome is caused by lumbar spondylosis
- Secondary osteoarthritis of misaligned facet joints
When is pain in facet joints worse
Bending backwards and when straightening from flexion
Where is pain felt in facet joint syndrome
Lumbar
Uni or bilateral and radiates to the buttocks
Diagnosis of facet joint syndrome
MRI - shows facet joints and osteoarthritis, an effusion or ganglion cyst
Treatment of facet joint syndrome
Direct corticosteroids injections under imaging
Physiotherapy to reduce weight
What is fibrositic nodulous
- Tender nodules in upper buttock and along iliac crest
Where is pain felt in fibrositic nodulous
- Unilateral and bilateral low back and buttock pain
Treatment of fibrositic nodulous
- Local intraleisonal corticosteroid injections
Why is low back pain common in pregnancy
- Altered spinal posture and increased ligamentous laxity
How is low back pain in pregnancy treated
- Weight control, pre and postnatal excursuses are helpful + settles after delivery
- AVOID analgesics and NSAIDs
How does posture cause chronic back pain
Poor sitting posture - obesity and muscular weakness
Differential diagnosis of lower back pain
Raised ESR and CRP could show polymyalgia rheumatica
How is back pain diagnosed if red flags are present
- Spinal X-rays
- MRI over CT (better for bone pathology )
- Bone scans
How is lower back pain treated if red flags are present
1, Urgent neurosurgical referral
- Analgesia (PARACETAMOL or CODEIEN)
- Combined physiotherapy, back muscle trainmen regimens and manipulations
- Acupuncture
- Excessive rest AVOIDED
- Re-edcation in lifting and exercises to prevent further attacks of pain
- Comfortable sleeping position using a mattress of medium (not hard) firmness
What are high risk activities for MSK problems
- Heavy manual handling
- Lifting above shoulder height
- Lifting below knee height
- Incorrect manual handling technique
- Forceful repetitive work
- Poor posture
After back pain, what is he most common type of MSK pain
Mechanical tension neck
What define chronic mechanical tension neck
More than 6 months
What is thoracic outlet syndrome
Pain or tingling down arms or blanching of fingers related to posture of arms
Wasting of hands
What causes thoracic outlet syndrome
- Compression of the brachial plexus or subclavian artery/vein in th neck
- Cervical rib, cervical band or other abnormalities in the neck
What environmental factors are associated with thoracic outlet syndrome
- Poor posture, loading of shoulders and working at a keyboard
- Roos sign
- X-ray neck, MRI scan
How is thoracic outlet syndrome treated
Surgery
What is rotator cuff tendonitis
- Rotator cuff tendon tears leading to swelling and further impingement beneath arch
Risk factors for rotator cuff tendonitis
- Heavy manual handling
- Lifting above shoulder height
- Thorwing
What gender is carpal tunnel syndrome more common in
Females
How is carpal tunnel syndrome caused
- Compression of median nerve by flexor tendons - gives pain, numbness, tingling and weakness + wasting of muscles supplied by median nerve
What diseases are associated with carpal tunnel syndrome
- Obesity
- Short stature
- Pregnancy
- Diabetes
- Hypothyroidism
.6. RA
What occupations have th biggest risk for carpal tunnel syndrome
- Repetitive work with abnormal wrist postures - extremes of flexion-extension of wrist
In which gender is tenosynovitis more common
FEMALES
What is tenosynovitis
Local tenderness and swelling of tendons in the wrist
Clinical presentation of tenosynovitis
Crepitus
- Pain on resisted movements
- High risk job is one with forceful and repetitive hand movements (hammering)
- Finkelstein’s test (Pull thumb in ulnar devaluation and should cause pain along extensor policies brevis)
How is tenosynovitis treated
NSAIDs, steroid injections and rest
What is hand-arm vibration syndrome
Raynaud’s phenomenon of industrial origin caused by hand-transmitted vibration
Eligible for state benefit
What is medial and lateral epicondylitis
- Medial - pain against flexion of wrist
2. Lateral - pain against resisted extension of the wrist
Risk factors for epicondylitis
- Tennis (lateral epicondylitis)
2. Golfers
treatment of epicondylitis
- NSAIDs
- Steroid injection
- Rest and surgery
What are infections of the joint usually caused by
Bacteria
What is septic arthritis
Acutely inflamed joints that can destroy a joint in under 24 hours!!
What joint tends to be affected in septic arthritis
Knee
how do joints become infected in septic arthritis
Direct injury or blood-bourne infection from infected skin lesion or other site
Main causes of septic arthritis
- STAPHYLOCOCCUS AUREUS
- Streptococci
- Neisseria gonorrhoea
- Haemophilus influenza in children
- Grma-negative bacteria (e.coli or pseudomonas aerguinosa)
Risk factors for epic arthritis
- Pre-existing joint disease - especially RA (chronically inflamed joints are at more risk of infection than normal joints)
- Diabetes mellitus
- Immunosuprresion
- Chronic renal failure
- Recent joint surgery
- Prosthetic joints
- IV drug abuse
- Over 8- and infants
- Recent intra-articular steroid injection
- Direct/penetrating trauma
Clinical presentation of septic arthritis
- PAIN, red, swollen and hot joint in young
- In elderly, signs are muted
- Might not use joint - children (limping)
- Fever
- Monoarthritis
- Knee, hip and shoulder
What is seen in early infection of septic arthritis
- Wound inflammation/discharge, joint effusion, loss of function and pain
What is seen in late infection of septic arthritis
Presents with pain or mechanical dysfunction
Differential diagnosis of septic arthritis
- Gout - monosodium urate crystals
2. Pseudogout - calcium pyrophosphate crystals
Diagnostics of septic arthritis
- JOINT ASPIRATION
- FBC
- Polarised light microscopy
- X-ray
Results of joint aspiration in septic arthritis
- Send fluid for urgent gram-stating and culture
2. Thick fluid due though WCC
When are antibiotics given for septic arthritis
After ASPIRATION of joint
FBC result for septic arthritis
ESR, CRP and WCC raised (CRP may not always be raised)
X-ray results for septic arthritis
- Loosening or bone loss around a previously well fixed implant will suggest infection
Treatment for septic arthritis
- STOP methotrexate and anti-TNF alpha
- DOUBLE prednisolone dose if already on prednisolon
- Joint should be IMMOBILISED early with physiotherapy to prevent stiffness and muscle wasting
- DOUBLE IV ANTIBIOTICS after aspiration
- Joint drainage repeatedly oil effusion stops - PAIN RELIEF
- NSAIDS
What antibiotics are given in septic arthritis
- IV FLUCLOXACILLIN (gram-negatives)
- IV ERYTHROMYCIN/CLINDAMYCIN (if allergic to penicciln)
- IV CEFOTAXIME (gram-NEGATIVES or gonococcal)
- IV VANCOMYCIN (MRSA)
If immunocompromised, what antibiotics are given in septic arthritis
IV FLUCLOXACILLIN + GENTAMYCIN
How long are antibitotcsi given for
2 weeks
How is antibiotics effecacity monitored
ESR and CRP
Surgical washout vs joint drainage repeatedly
More pleasant and comfortable
What is a rare cause for joint infection in INFANTS due to standard childhood immunisation schedule in the UK
Haemophilus influenza
What causes gonococcal arthritis
GRAM NEGATIVE
Neisseria Gonorrhoea
What joints does gonococcal arthritis involve
Joints secondary to genital,r ectal or oral infections
What is the most common cause of septic arthritis in fit young adults
gonorrhoea infection
Clinical presentation of gonococcal arthritis
Fever
Characteristic pustules on distal limbs as well as polyarthralgia and tenosynovitis
Diagnosis of gonococcal arthritis
- Culture blood + fluid
Treatment of gonococcal arthritis
- ORAL PENICILLIN
- CIPROFLOXACIN
- DOXYCYCLINE
for 2 weeks
What is meningococcal arthritis
- migrating polyarthritis
2. results from deposition of circulating immune complexes containing meningococcal antigens
Treatment of meningococcal arthritis
PENICILLIN
Clinical presentation of epicondylitis
- Cozen’s test (extending wrist against will - pain in lateral epicondyle)
- Weakness in grip
- Pain in lateral or medial epicondyle
What is repetitive strain disorder mistaken for
- Tenosynovitis and epicondylitis
Clinical presentation of rotator cuff problems
Hawkins sign
Pain
What is Hawkin’s sign
Inward movement of the arm while the rotator cuff is kept still
