MSK - Red Flags Flashcards
What are the red flag pathologies?
Myelopathy (central/SC compression)
Cervical arterial dysfunction (CAD)
Malignancy
Systemic inflammatory disorders eg. RA
Deep vein thrombosis
Infections
Fractures - RED-S
Cauda Equina syndrome (CES)
Red flags
Myelopthay, what is it?
Common symptoms -
Term used to describe any neurological deficit relate to the SC
Usually due to compression of the SC. Most commonly localised in the cervical spine, but it can also occur in the thoracic and lumbar spines.
Symptoms - muscle weakness
Altered muscle tones
Sensory loss (in trunk and legs) and spasticity
Impaired coordination
Gait disturbances
Spinal pain
Urinary disturbances
Red flags
Cervical artery dysfunction (CAD) - what is it?
Pathology -
Umbrella term used to cover a range of vascular pathologies which may lead to cervical-cranial ischaemia (reduced blood flow to brain)
Inclusive of all known vascular pathologies and anatomical structures that may be comprised by movement or manual therapy
These pathologies range from pre-existing underlying anatomical anomalies, vasospams, atherosclerosis, through to giant cell arteritis or arterial dissection. All can lead to potential cranio-cerebral ischaemia which can originate and manifest in many ways.
Presentations range:
Pain, cranial nerve dysfunctions, sympathetic nerve dysfunction (eg. Horners syndrome), blindness, stroke or at worst, death.
Red flags
Cervical artery dysfunction
Risk factors -
Previous trauma to cervical spine
Migraine type headaches
High cholesterol
Cardiac disease/vascular disease
Diabetes
Blood clotting disorders
Anti-coagulant therapy
Long term use of steroids
Smoking history
Recent infection
Immediately post partum
Absence of plausible mechanical explanation of symptoms
Red flags
Malignancy, what is it? (How does cancer occur)
Cancer occurs when normal cells change, grow and divide in an uncontrolled way, forming malignant tumours
Most start in one place - primary tumour
May then spread to nearby areas, pushing their way into healthy parts of the body - local spread
May spread to distant part of the body (via blood or lymphatic system), meaning these cells may start growing in new areas forming secondary tumours - metastases
Red flags
Malignancy, metastatic spinal cord compression, what is it?
Oncological emergency which needs precise assessment of symptoms, urgent investigations and immediate treatment
Correct early management can potentially improve functional outcome
If not caught early enough, can lead to permanent paralysis from the level of compression
Most commonly occurs in patients with metastatic lung, breast or prostate cancer, lymphoma and multiple myeloma.
Most common compression site is the thoracic spine followed by lumbosacral.
Red flags
Malignancy, metastatic spinal cord compression
Signs and symptoms -
Non mechanical pain - no aggs and eases
Constant night pain
Unexplained weight loss
General fatigue or feeling unwell
Previous history of cancer
Night sweats
Unusual lumps/bumps/swelling
Red flags
DVT, what is it?
Deep vein thrombosis type of venous thrombosis involving the formation of a blood clot in a deep vein, most commonly in the legs or pelvis
Minority of DVT’s occur in the arms
Red flags
DVT, symptoms -
Pain
Swelling
Redness
Enlarged veins in affected area
Some have no symptoms
Asymmetric oedema
Red flags
DVT, risk factors -
What can it lead to?
Viachows triad:
Vessel injury, venous stasis and hypercoaqulability
Pregnancy
Obesity
Malignancy
Oral contraception
Major surgery/being hospitalised
Genetics
Can lead to pulmonary oedema
Clots form=thrombis
These can dislodge=embolis. This may travel up to heart and may lodge into pulmonary arteries, therefore risk of pulmonary embolism
Red flags
Inflammatory conditions, what does this mean?
What can it result in?
Inflammation refers to the biological response to stimuli interpreted by the body to have a potentially harmful effect.
Inflammation is normal, healthy response to injury, infection or certain medical conditions
However,
Inflammatory disorder = immune system mistakenly attacks you bodies own cells or tissues
Caused abnormal inflammation that can result in chronic pain, redness, swelling, stiffness and damage to otherwise healthy body tissues
Red flags
Inflammatory conditions - rheumatoid arthritis, what is it?
Systematic autoimmune disease characterised by inflammatory arthritis with extra-articular involvement
Synovial is infiltrated by immune cells
Fibroblasts and inflammatory cells lead to osteoclast generation resulting in bone erosion and loss of joint integrity
Systemic inflammation and autoimmunity in RA begin long before the onset of joint inflammation - this is why diagnosis can take years!
Red flags
Inflammatory conditions - RA
Epidemiology -
Risk factors -
Epidemiology - more common in females than males 2-3:1
Increased with age
In paeds… idiopathic artheritis
Risk factors - genetic factors
Smoking
Air pollution
Obesity
Low vitD
Red flags
Inflammatory conditions - RA
Clinical presentation -
Management -
Prevention - polyarthritis of small joints in hands - PIP,MCP,RCJ
Indisidous onset over period of months
Other commonly affected areas - elbows, shoulders, hips, knees, ankles, MTP
Joint stiffness in morning - as they get moving, symptoms will improve
Fatigue, deformity, pain and weakness and restricted mobility in affected joints
If cervical spine involved, can lead to instability between C1-2
*can have specific triggers for RA flares
Management - goal of treatment is symptoms management
Pharmacological management - disease modifying anti-rheumatic drugs (DMARDs)
Nutrition - pain influenced by foods… inflammatory and anti-inflammatory diet
Physio - strengthen around joints and help find ways to manage flare ups
Red flags
Infections -
Microorganism enters a persons body and causes harm - uses body to sustain itself, reproduce and colonise
Known as pathogens - spread in variety of different ways
Bacteria, viruses, fungi and parasites can all lead to infection
Macrophages swallow pathogen and encourage inflammation
**PATHO 1 IMMUNITY, WILL NEED TO KNOW!
Red flags
Infections
Risk factors -
Taking steroids/other meds that suppress immune system, eg. Anti-rejection drugs for transplant
Have HIV/AIDS
Certain types of cancer or other disorders that affect immune system
Open surgery
Poor nutrition
Stress
Lack of sleep
Red flags
Infections
Signs and symptoms -
Depends on the type of disease
Some sign affect the whole body generally, eg.. fatigue, los of appetite, weight loss, fevers, night sweats, chills, aches and pains, swelling, pus formation and increased temp
Others specific to body parts- skin rashes, coughing or a runny nose
Red flags
Fractures, risk factors -
Age and gender
Smoking
Diabetes
Alcohol
RA
Trauma
Steroid use
Other systemic diseases
Red flags
Fractures - types
Transverse
Linear
Oblique non displaced
Oblique displaced
Spiral
Green stick
Comminuted
*go over these in patho 1
Red flags
fractures , management -
None - most rib fractures
Sling - many clavicular raptures
Cast - many forearm fractures
Internal fixation - most hip fractures
External fixation
Then eventually physio to help restore ROM, strength and function depending on patient goals.
Red flags
RED-S - what is it?
Relative energy deficiency in sport
Syndrome in which disordered eating (or low energy availability) and decreased bone mineral density (osteoporosis and osteopenia) are present
Caused by eating too little food to support amount of energy being expended by an athlete
Often at urging of an authority figure in sports believed extremely lean body type is best
- may develop stress fractures for eg.
Serious illness, lifelong health consequences and can be fatal
Massive mental impact - may need psychologist
Red flags
RED-S, signs and symptoms -
Dull pain along bone which can increase with activity
Potentially mild swelling around affected area
Tenderness along affected area
Red flags
RED-S - management -
Often multidisciplinary - general practitioner, dietician and physio for stress fractures
Potential for sports psychologist
Physio provide guidance in two ways - advice and education and technique
Red flags
Cauda equina syndrome - what are the Cauda equina?
SC usually terminates between L1-L2 vertebra forming the conus medullas.
Emerging from this is a bundle of lumbar and sacral roots called the Cauda equina
These nerves serve sphincter muscle, sexual function, perineal sensation, sensation and motor functions through lower limbs
Red flags
Cauda equina syndrome- causes -
Most common cause of compression in 45% of cases is herniated lumbar intervertebral disc
Other causes:
Epidural abscess, spinal epidural hematoma, diskitis, tumor (either metastatic or primary CNS cancer), trauma
Spinal stenosis and aortic obstruction
Red flags
Cauda equina - sings and symptoms -
Ask about these for ALL lumbar patients!!!
-Saddle anaesthesia - loss of feeling/around the anus and/or genital area
-Back pain - severe lower back pain with uni or bilateral weakness and/ or loss of sensation in the legs
-Bladder dysfunction (be specific with questions) urinary retention or inconinence
Inability/difficulty in urinating
Loss of sensation
- bowel dysfunction - faecal incontinence
Constipation
Loss of anal tone or sensation
Others: numbness and leg weakness, foot drop, absent/altered relfexes in knees/ankles
Painful restricted straight leg raises
Red flags
Cauda equina syndrome- management -
Early neurosurgical review for urgent decompression must be initiated!!!! Esp for those with incomplete CES
All acute CES will be recommended for surgical decompression - aiming to prevent sphincter and LL dysfunction - should take place asap
In certain, rarer cases, such as malignancy, radiotherapy and/or chemo may be used - esp if patient is not suitable for surgery
