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Ortho and Rheum > Neck, Shoulder, Arm and Low back > Flashcards

Neck, Shoulder, Arm and Low back Flashcards

1
Q

What should nocturnal neck pain raise suspicion of? x3

A

Nerve root pain, bony pathology or underlying malignancy

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2
Q

What does radiation of pain distally from upper arm or elbow suggest?

A

Neck or peripheral neurological problem

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3
Q

What is neck pain usually due to?

A

Poorly defined mechanical influences

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4
Q

Red flags for malignancy with neck pain?

A

Hx of cancer, signs of cancer, unexplained deformity, mass or swelling

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5
Q

Red flags for infective cause of neck pain

A

Fever, systemically unwell, redness and swelling

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6
Q

Signs of unreduced shoulder dislocation

A

Hx of trauma, epileptic fit, electric shock, loss of rotation and normal shape

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7
Q

Drop arm sign indicates what?

A

Rotator cuff tear

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8
Q

What is normally the cause of bilateral shoulder pain with or without neck pain and with early morning stiffness?

A

PMR, RA or GCA

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9
Q

Cause of rapid shoulder swelling after trauma

A

Haemarthrosis of shoulder

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10
Q

What happens with radicular pain? (from nerve root)

A

Neck pain that radiates into shoulder girdle and/or arm

with paraesthesia or numbness in root distribution

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11
Q

What are signs of cervical myelopathy? (compression of spinal cord) due to herniated disc and is emergency

A

hx of difficulty walking, lower limb symptoms or bladder and bowel dysfunction
Also increased reflexes and tone, sensation losses

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12
Q

Treatment of neck pain

A

Generally favourable diagnosis and usually responds to simple analgesia, mobilisation and physiotherapy

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13
Q

What is essential for treating neck pain

A

Mobilisation
Especially mobilisation in whiplash injuries
Gentle exercises can help

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14
Q

Medication for neck pain

A

Limited evidence for use of paracetamol, opioids, NSAIDs and antidepressants

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15
Q

When do you do surgery for neck pain

A

Radiculopathy or myelopathy

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16
Q

Causes of shoulder pain x5

A 
Rotator cuff problems
Adhesive capsulitis 
GHJ problems
Referred pain from elsewhere 
Regional or diffuse pain syndromes
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17
Q

What are most shoulder complaints due to?

A

Rotator-cuff complaints (60-70%)

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18
Q

What is common with the rotator cuff?

A

Asymptomatic cuff tears found on scanning - increasing incidence with age - implies might be a part of aging

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19
Q

Who are rotator cuff disorders common in?

A

Young people playing sports involving overhead activities

Middle and older age

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20
Q

Symptoms of rotator cuff disease

A

Pain in shoulder or lateral aspect of upper arm
Worse with overhead activities and at night
Especially worse when lying on affected side

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21
Q

Examination signs of rotator cuff disease

A

Pain in mid-range of shoulder abduction and on resisted shoulder abduction
Passive motion is normal

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22
Q

What is sign of rotator cuff impingement

A

Pain when patient places hand on their contralateral shoulder and push up against resistance

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23
Q

Sign of large or complete rotator cuff tear

A

Drop arm test
Can’t lower arm slowly and controlled
Will drop when reach a certain point

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24
Q

What is a rotator cuff problem in women aged 30-50 years and how does it present?

A

Calcific tendinitis - formation and resorption of calcium deposits in the cuff
Acute onset of severe pain - occasionally with fever and severe limitation of movement due to pain

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25
Q

Diagnosis of rotator cuff disease

A

Usually made clinically

Limited diagnostic utility of scanning because of the amount of asymptomatic rotator cuff tears

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26
Q

Treatment aims of rotator cuff disease

A

Control pain with analgesics

Restore movement and function

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27
Q

Analgesia in rotator cuff disease

A

Paracetamol with mild opiates - codeine phosphate - if needed
NSAIDs can be good short-term
Steroid injections provide rapid relief but not maintained

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28
Q

Physiotherapy in rotator cuff disease

A

Combination of mobilisation techniques and strengthening exercises

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29
Q

What can be needed if physio and analgesia don’t work in rotator cuff disease

A

Surgery - decompression of subacromial space, with or without rotator cuff repair

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30
Q

Treatment of calcific tendinitis? x4

A

Subacromial steroid injections
Needling of calcific deposits
Percutaneous needle aspiration and lavage by US guidance

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31
Q

What is adhesive capsulitis?

A

Frozen shoulder

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32
Q

Incidence of adhesive capsulitis and in whom is it more common?

A

2-5% of population
Slightly more common in women
Much more common in diabetes patients and it is also more severe

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33
Q

What age does frozen shoulder usually occur?

A

5th and 6th decades

Rare before 40 years old

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34
Q

Phases of frozen shoulder?

A

Initial gradual development of diffuse severe pain - 2-9months
Stiff phase with less severe pain but global stiffness and severe loss of shoulder movement 4-12 months
Recovery phase with gradual return to movement over 5-24months

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35
Q

Diagnosis of frozen shoulder

A

Clinically

Restriction of both active and passive movement in all planes of movement

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36
Q

Treatment of frozen shoulder

A

Analgesia - same as for rotator cuff disease
Steroid injections again provide rapid but not sustained pain relief
Physiotherapy can be helpful after the painful stage

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37
Q

Interventional management of frozen shoulder

A

Arthrographic distention of GHJ or hydrodilatation performed under radiological guidance - using anaesthetic, saline and corticosteroid
Can have sustained benefit on pain, function and ROM

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38
Q

Other possible pain reliefs in frozen shoulder x3

A

Short course of oral steroids
Suprascapular nerve blocks
Manipulation under anaesthesia with possible debridement of adhesions - if all other options have failed (associated risks)

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39
Q

Where in shoulder does OA affect?

A

Acromioclavicular joint

Rare in GHJ but can occur if previous trauma

40
Q

Where in shoulder is affected by RA

A 
Sternoclavicular joint (can be presenting site of RA)
GHJ in connection with PMR
41
Q

What is Milwaukee shoulder?

A

Severe destructive apatite-associated arthropathy - presents with shoulder pain, limited movements and large joint effusion
Aspiration shows blood-tinged synovial fluid
Mainly effects elderly women

42
Q

What is tennis elbow?

A

Lateral epicondylitis

43
Q

Incidence of Lateral epicondylitis?

A

4-7 per 1000 patients in GP

44
Q

Most common age for Lateral epicondylitis?

A

40-50

45
Q

Cause of Lateral epicondylitis?

A

Thought to be overload injury at origin of common extensors from lat.epicondyle
Tennis is only the cause in 5%

46
Q

Risk factors for Lateral epicondylitis?

A

Wrist turning or hand gripping

47
Q

What is Golfer’s elbow?

A

Medial epicondylitis

48
Q

Symptoms of epicondylitises?

A

Pain and tenderness over epicondyle
Aggravated by repetitive movement and lifting
May be night pain and early morning stiffness
Stiffness after periods of inactivity

49
Q

Diagnostic test for epicondylitis

A

Pain on resisted movement (eg. resisted dorsiflexion of wrist or middle finger or both in Lateral epicondylitis)

50
Q

Prognosis of Lateral and medial epicondylitis?

A

Self-limiting normally, recover within a year or so

51
Q

Treatment of Lateral and medial epicondylitis?

A

Rest in acute phase and Splinting can help
Topical and oral NSAIDs
Corticosteroid injections for short relief
Physiotherapy (US, deep friction massage and exercise)

52
Q

Arthritis which affects elbow

A

RA, Seronegative arthritis, gout or pseudogout - rarely septic arthritis
OA only really if trauma

53
Q

Symptoms and cause of olecranon bursitis?

A

“students elbow” - acute or repetitive trauma

Discrete swellng, pain and inflammation at posterior point of elbow

54
Q

Inflammatory arthritis signs in elbow

A

Pain when try to extend the arm - if effusion

55
Q

DDX in olecranon bursitis

A

Exclude septic arthritis

56
Q

Treatment of olecranon bursitis due to inflammatory or crystal arthritis

A

Steroid injection

57
Q

Treatment of infective olecranon bursitis

A

Broad-spectrum antibiotics and possibly open drainage and lavage

58
Q

What is a sclerotome?

A

Deep somatic track innervated by the same spinal nerve - when tissue is irritated in this sclerotome - it is experienced as originating from all the tissues innervated by the same nerve

59
Q

Difference between sciatica low back pain and sclerotomal low back pain?

A

Sclerotomal pain is non-dermatomal in distribution and also radiates to lower extremities but not below the knee (whereas sciatica goes below the knee)
Also no paraesthesia with sclerotomal pain as in sciatica

60
Q

What causes the majority of lower back pain?

A

Mechanical pain which is from anatomical abnormality, increases with physical activity and decreases with rest

61
Q

Most common cause of mechanical low back pain

A

Degenerative change - eg. lumbar spondylosis (lumbar OA) - degenerative changes in IV disc and facet joint

62
Q

What can disc herniation result in occasionally?

A

Nerve root impingment causing sciatica

63
Q

Which are the most common clinically significant herniations?

A

L4-L5 and L5-S1 - 95% are these two

64
Q

Which nerve root is commonly impinged in herniations? eg. with L4-L5

A

The caudal nerve root therefore will be L5 root in L4-5 herniation

65
Q

What is a rare surgical emergency with disc herniation

A

Cauda equina syndrome with a large midline herniation
- altered saddle section, rectal/perineal pain, reduced bladder sensations, difficulty walking, urinary retention with overflow incontinence and faecal incontinence

66
Q

What is spondylolisthesis?

A

Anterior displacement of a vertebra on the one beneath it
Usually due to secondary degenerative changes but may result from developmental defect in pars interarticularis of vertebral arch

67
Q

Symptoms of spondylolisthesis?

A

Can be asymptomatic if mild - can have mechanical low back pain
If larger displacement that can have sciatica or spinal stenosis

68
Q

What is spinal stenosis?

A

Narrowing of spinal canal and its lateral recesses and neural foramina

69
Q

What are symptoms of spinal stenosis?

A

Can cause compression of lumbosacral nerve roots
Results in pseudoclaudication (neurogenic claudication), - bilateral pain, weakness and sometimes paraesthesiae in buttocks thighs and legs
Symptoms induced by standing and walking - unsteadiness of gait is common

70
Q

What causes spinal stenosis?

A

Normally occur due to degenerative changes

71
Q

What stature can result from spinal stenosis?

A

Simian stance because forward flexion increases the canal diameter

72
Q

Signs of low back pain being due to infection or neoplasm

A

Non-mechanical

Especially when accompanied by nocturnal pain

73
Q

Signs of low back pain being due to spondyloarthropathy

A

Night-time waking with pain and stiffness

Prolonged morning stiffness that improves with exercise but not with rest

74
Q

What are functional and structural scoliosis

A

Structural scoliosis is secondary to structural changes of vertebral column. Functional scoliosis is usually the result of paravertebral muscle spasm or leg-length discrepancy

75
Q

Examination to differentiate between functional and structural scoliosis?

A

Functional disappears with spinal flexion but structural does not

76
Q

Examination sign of spondylolisthesis?

A

Palpable step off between adjacent spinous processes

77
Q

What sort of pain does hip arthritis usually cause?

A

Groin pain and occasionally referred back pain

78
Q

What does the straight leg raise test do?

A

Places tension on sciatic nerve and stretches nerve roots - patients with existing nerve root irritation eg. impingement will experience radicular pain that extends below the knee

79
Q

Problem with investigations in LBP

A

Many of the causes are present in asymptomatic patients - some are equally present in patients with LBP as they are in patients without LBP

80
Q

General treatment for LBP

A

Analgesia, education, back exercises, aerobic conditioning and weight control

81
Q

Different classifications of LBP for treatment purposes

A

Patients either have acute LBP (3 months) or chronic or nerve root compression syndrome

82
Q

Treatment of acute LBP

A

Activity is encouraged - bed rest discouraged
Paracetamol and NSAIDs
Muscle relaxants may help

83
Q

Treatment once acute LBP episode has resolved

A

Regular back exercises, aerobic conditioning and loss of excess weight to prevent recurrences

84
Q

Treatment of chronic LBP

A

Pain relief - complete relief is unrealistic goal - paracetamol and NSAIDs may provide analgesia, low dose tricyclics may help some
Exercises, aerobic conditioning and weight loss
Back surgery not helpful

85
Q

Treatment of nerve root compression syndromes - disc herniation

A

Treat conservatively as for acute LBP - for the first 6 weeks unless severe or progressive neurological defect and 90% will improve
Surgery may be considered if neurological defect = laminotomy with limited discectomy

86
Q

Treatment of nerve root compression syndromes -spinal stenosis

A

Symptoms remain stable in most patients - analgesics, loss of excess weight and exercises - also epidural glucocorticoids may help with symptoms
Surgery to decompress neural elements if disabling symptoms

87
Q

Type of pain presentation with disc prolapse

A

Seized by severe pain on coughing, sneezing or twisting - a few days after back strain

88
Q

Signs of disc prolapse

A

Forward flexion and extension are limited
Lateral flexion may also be limited unilaterally
L5/s1 prolapse get calf pain and weak foot plantar flexion
L4/l5 hallux is weak

89
Q

Causes of rotator cuff tears

A

Trauma or degenerative changes

90
Q

What joints are ACJ and GHJ?

A

GHJ - synovial

ACJ - fibrous

91
Q

Fluid on shoulder MRI

A

White - due to a tear - can be partial/complete

92
Q

Conservative management of cuff tear

A

Analgesia, steroids, physio

93
Q

Impingement treatment

A

Conservative (physio, analgesia, rest)
Steroid injections
Decompression - bursectomy, acromioplasty

94
Q

Association of frozen shoulder

A

Diabetes
Hypo and hyperthyroidism
Autoimmune

95
Q

Posterior dislocation position

A

Internally rotated and abducted

96
Q

What should you examine for in posterior shoulder dislocation

A

Hyper laxity and other collagen problems

Ortho and Rheum (13 decks)

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