MSK Pathophys Flashcards
Spinal Pathologies
lower spine vertebral column anatomy
- lumbar: 5 vertebral bodies; L1-L5
- sacrum: 5 segements (fused w/out discs)
- coccyx: 3-4 fused segments
Spinal Pathologies
label anatomy of vertebrae
okay
Spinal Pathologies
ligaments of spine
- anterior longitudinal ligament: connects vertebral bodies anteriorly
- posterior longitudinal ligament: connects vertebral bodies posteriorly
- ligamentum flavum: yellow ligament; connects lamina posteriorly
Spinal Pathologies
anatomy of lumbar discs
- purpose: cushioning between vertebral bodes
- named by vertebral body above/below (L4-5 disc is between L4/L5)
- Annulus Fibrosis: fibrous outer ring of disc
- Nucleous Pulposus: soft inside of disc
Spinal Pathologies
anatomy/phys of spinal cord
- purpose is to transmit information to and from rest of body
- begins at craniocervical junction and ends between T12-L2
- end of sinal cord: conus medullaris (conus)
- cauda equina: end of conus there are spinal nerves that go to LE and bowel/bladder
Spinal Pathologies
nerve roots of spinal cord numbering
- cervical: nerve roots exiting are name based on vertebral body below foramen (except C8 which exits in C7-T1 forament)
- Thoracic/Sacral: named for vertebral body above foramen
Spinal Pathologies
describe spurling test of cervical spine
- dx cervical HNP or spondylosis
- pt seated, laterally flex head, apply pressure downward to increase axial load & cause pain down ipsilateral arm
Spinal Pathologies
describe hoffman reflex for cervical spine
- tests for long tract spinal cord involvement in neck
- pathologic reflex (indicates abnormality w/in cervical spinal cord or higher like UMN lesion or pyramidal sign) for ALS< MS, spinal cord compression
- pos reflex: flexion and adducting the thumb/index finger after flicking the middle finger
Spinal Pathologies
lumbar spine tests
- gait (barefoot) look at Trendelenburg (pelvis level on one foot = normal hip abductor)
- heel-toe walking (tests L4-5, S1 innervated muscles)
- calf/thigh circumfrence/atrophy (asymmetric or atrophy = weakness)
Spinal Pathologies
lumbar SLR tests
- seated SLR: pos test causes pt to lean back
- Supine SLR (lesegue): pos test is radicular pain in leg, not back (HNP or compression) sx at 20deg or less is suggestive of sx amplification
- Slump test: seated, hands behind back, then slump in relaxed position w/ chin to chest; extend leg, dorsiflex fully. examiner gives slight pressure to back of head. pos test is impingement on dura, spinal cord, nerve roots
Spinal Pathologies
red flags in HPI/PE
8
- fever/chills/wt loss (malignancy)
- hx of IV drug use
- progressive weakness; decreasing pain in face of increasing deficit; paraparesis
- bowel/bladder dysfunction; distended/palpable bladder
- trauma
- increasing pain not controlled by simple analgesia
- saddle anesthesia
- unexplained neuro deficits
distended/palpable bladder
lordosis vs kyphosis vs scoliosis
- lordosis: increased lumbar curvature
- kyphosis: increased thoracic curvature
- scoliosis: abnormal sideways curves
Spinal Pathologies
myelopathy vs radiculopathy vs stenosis
- myel: injury/compression of spinal cord
- radi: injury/compression of nerve root
- stenosis: narrowing of passage for spinal cord/nerve root
Compartment Syndrome
causes of compartment syndrome
4
- long bone fractures (tibia or humerus)
- severe contusion/crash injuries
- reperfusion injury after vascular repair
- restrictive cast/dressing
Compartment Syndrome
compartments of LE
- anterior
- lateral
- superficial posterior
- deep posterior
Contents
* each compartment covered by fascia (resistant to expansion and stretch)
* each compartment contains muscles, blood vessels, nerves
Compartment Syndrome
pathogenesis
- interruption of hemostatic pressure gradient causes a disruption in flow and capillary perfusion pressure
- build up of fluid outside of the capillaries increases pressure w/in myofascial compartment
- distribution of oxygen/nutrients and CO2 removal disrupted leading to muscle ischemia and necrosis
Compartment Syndrome
reversibility of sx based on duration?
- < 4 hrs: reversible muscle injury
- > 8 hrs: irreversible muscle injury
- nerve conduction loss: 2 hrs
- irreversible nerve injury: > 8 hrs
Compartment Syndrome
describe procedure of emergency fasciotomy
- long incision to release pressure in affected compartment and adjacent compartments
- wounds are left open and a 2nd procedure for debridement is performed w/in 48-72 hrs
- wound closure w/in 7-10d +/- skin grafting
Osteomyelitis
common bacteria of non-hematogenous vs hematogenous
- Non-Hematogenous Polymicrobial (S. aureus, S.epidermidis, streptococcus spp, gram neg, anaerobes)
- Hematogenous monomicrobial (S. aureus, streptococcus, gram neg, p. aeruginosa, serratia, candida)
Osteomyelitis
bacterial causes due to specific risk factors
- no risk factors: s. aureus
- sexually active: n. gonorrhoeae
- cat/dog bites: p. multocida
- IVDU: p. aeruginosa, s. aureus, candida
- sickle cell: salmonella
- neonates: group b strep
Osteomyelitis
pathophys
- overall poorly understood
- several factors: host immune status, underlying disease, virulence of organisms, vascularity and location of bone
Osteomyelitis
which part of bone most commonly affected in hematogenous spread?
- metaphysis
- due to rich vascular supply of growth plates
Osteomyelitis
XR findings/limitations
- 1st line imaginge, but may not show chagnes in the first 2wks (so normal XR cannot r/o dz)
- disease must extend at least 1 cm and compromise 30-50% of bone mineral content to produce noticeable changes in plain radiographs
- findings: regional osteopenia, loss of trabecular architecture, bone destruction, soft tissue gas, new bone apposition (cortical thickening; increase in diameter of bone)
Septic Arthritis
bacteria associated w/ infection
- S. aureus most common overall
- s. epidermidis
- streps: pyogenes, pneumoniae, agalactiae)
- gram neg: p. aeruginosa, e. coli, k. kingae, n. gonorhoeae (sexually active young pt), h. flu, salmonella (sickle cell)
DeQuervain’s Tenosynovitis
Finkelstein tests
place thumb into palm and ulnar deviate
pain is pos result (expected w/ DeQuervain’s)
Arthritis
purpose of articular cartilage
lings bones, allows for protection and gliding movement
Arthritis- Wrist
what bones are removed w/ proximal row carpectomy
scaphoid, lunate, triquetrum
Trigger Finger
why don’t you release A1 pulley in RA
can cause further ulnar drift
Common Fractures
metacarpal fractures- describe when rotational deformity may be present
- most common in oblique and spiral fracture types
- PIP joints at 90deg flexion normally converage at a point in the proximal carpal bones (scaphoid)
- deviation of 1+ lines suggests a metacarpal fracture
Common Fractures
components of neurovascular for fractures
- repetitively evaluate motor + sensory nerve function and assess for vascular insufficiency
- neuro exam: assess median nerve, AIN, and radial nerve
- vascular exam: temp, color, cap refill
Common Fractures
specifics of neuro exams
- Median: assess for abduction of thumb or flexion of distal phalanx of thumb
- Ant. Interosseous Nerve (AIN): assess for flexion of distal phalanx (OK sign)
- Radial: extension of wirst
Common Fractures
specifics of vascular exam
- eval for color, warmth, cap refill
- eval both radial and ulnar arteries
- emergent surg if: cold, pale, pulseless
Common Fractures
Weber Classification
- describe fibular fracture relative to syndemosis
- A: below syndesmosis
- B: level of syndesmosis
- C: above level of syndesmosis
Common Fractures
Bohler Angle (calcaneal)
- formed by intersection of 2 lines
- Line 1: drawn from superior aspect of post calcaneal tuberosity to the superior subtalar articular surface
- Line 2: drawn from the superior subtalar articular surface to the superior aspect of anterior calcaneal process
Shoulder Disorders
types of shoulder separations
6
- Type I: ligament stretched
- Type II: partial rupture of AC ligaments
- Type III: complete rupture of AC/CC ligaments
- Type IV: clavicle displaced posteriorly over acromion
- Type V: clavicle displaced up (just under skin)
- Type VI: clavicle underneath coracoid (rare, but serious)
Shoulder Disorders
Subacromial impingement/bursitis: describe Neer and Hawkins tests
- Neer Impingement Sign: arm up to ear and rotate, pain w/ flexion and pronation. subacromial impingement or rotator cuff tear.
- Hawkin Impingement Test: to test for subacromial impingement or rotator cuff tendonitis abduct the shoulder to 90 deg, forward flex to 30 deg, and forcibly internally rotate (induced pain!)
Shoulder Disorders
rotator cuff muscles & their jobs
- supraspinatus: abduction
- infraspinatus: external rotation
- teres minor: external rotation
- subscapularis: internal rotation
Shoulder Disorders
Pos PE tests for rotator cuff tears + describe them all
4
- Neer Impingement Sign: arm up to ear and rotate, pain w/ flexion and pronation. subacromial impingement or rotator cuff tear.
- Hawkin Impingement Test: to test for subacromial impingement or rotator cuff tendonitis abduct the shoulder to 90 deg, forward flex to 30 deg, and forcibly internally rotate (induced pain!)
- Drop Arm Test: from fully abducted position, slowly lower the arm to the side, noting pain starting at approx 90deg followed up sudden drop of arm.
- Empty Can Test: supraspinatus muscle isolation; with arm straight and shoulder abducted to 90deg and forward flexed 30deg, point thumb at ground and lift arm against resistance
Shoulder Disorders
Pos PE tests for labral tear
- Apprehension Test: shoulder abducted to 90 deg and elbow flexed to 90 deg, examiner then externally rotates the shoulder and looks for signs of apprehension on pt’s face
Shoulder Disorders
Pos PE tests for shoulder dislocation
- Apprehension Test: shoulder abducted to 90 deg and elbow flexed to 90 deg, examiner then externally rotates the shoulder and looks for signs of apprehension on pt’s face
Shoulder Disorders
dislocated shoulder appearances on XR
- posterior: humeral head appears superior to glenoid cavity on AP film
- anterior: humeral head appears inferior to glenoid cavity on AP film (MUCH MORE COMMON)
Shoulder Disorders
posterior approach for shoulder joint aspiration
- palpate posteior lateral edge of acromion process
- mark spot 2cm inferior to edge
- inject shoulder w/ 10mL of anestetic targeting coracoid process
Shoulder Disorders
ways to reduce anterior shoulder dislocations
- Stimson
- Scapular Manipulation
- Leidelmeyer
- Milch
- Traction-counter traction
Shoulder Disorders
describe Stimson reduction
- Prone position
- Arm hanging
- Traction in forward flexion using 5, 10 or 15 pound weight (15-30 min)
- Use with scapular manipulation