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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
Diagnosis of rotator cuff disease
Usually made clinically | Limited diagnostic utility of scanning because of the amount of asymptomatic rotator cuff tears
26
Treatment aims of rotator cuff disease
Control pain with analgesics | Restore movement and function
27
Analgesia in rotator cuff disease
Paracetamol with mild opiates - codeine phosphate - if needed NSAIDs can be good short-term Steroid injections provide rapid relief but not maintained
28
Physiotherapy in rotator cuff disease
Combination of mobilisation techniques and strengthening exercises
29
What can be needed if physio and analgesia don't work in rotator cuff disease
Surgery - decompression of subacromial space, with or without rotator cuff repair
30
Treatment of calcific tendinitis? x4
Subacromial steroid injections Needling of calcific deposits Percutaneous needle aspiration and lavage by US guidance
31
What is adhesive capsulitis?
Frozen shoulder
32
Incidence of adhesive capsulitis and in whom is it more common?
2-5% of population Slightly more common in women Much more common in diabetes patients and it is also more severe
33
What age does frozen shoulder usually occur?
5th and 6th decades | Rare before 40 years old
34
Phases of frozen shoulder?
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
35
Diagnosis of frozen shoulder
Clinically | Restriction of both active and passive movement in all planes of movement
36
Treatment of frozen shoulder
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
37
Interventional management of frozen shoulder
Arthrographic distention of GHJ or hydrodilatation performed under radiological guidance - using anaesthetic, saline and corticosteroid Can have sustained benefit on pain, function and ROM
38
Other possible pain reliefs in frozen shoulder x3
Short course of oral steroids Suprascapular nerve blocks Manipulation under anaesthesia with possible debridement of adhesions - if all other options have failed (associated risks)
39
Where in shoulder does OA affect?
Acromioclavicular joint | Rare in GHJ but can occur if previous trauma
40
Where in shoulder is affected by RA
``` Sternoclavicular joint (can be presenting site of RA) GHJ in connection with PMR ```
41
What is Milwaukee shoulder?
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
What is tennis elbow?
Lateral epicondylitis
43
Incidence of Lateral epicondylitis?
4-7 per 1000 patients in GP
44
Most common age for Lateral epicondylitis?
40-50
45
Cause of Lateral epicondylitis?
Thought to be overload injury at origin of common extensors from lat.epicondyle Tennis is only the cause in 5%
46
Risk factors for Lateral epicondylitis?
Wrist turning or hand gripping
47
What is Golfer's elbow?
Medial epicondylitis
48
Symptoms of epicondylitises?
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
Diagnostic test for epicondylitis
Pain on resisted movement (eg. resisted dorsiflexion of wrist or middle finger or both in Lateral epicondylitis)
50
Prognosis of Lateral and medial epicondylitis?
Self-limiting normally, recover within a year or so
51
Treatment of Lateral and medial epicondylitis?
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
Arthritis which affects elbow
RA, Seronegative arthritis, gout or pseudogout - rarely septic arthritis OA only really if trauma
53
Symptoms and cause of olecranon bursitis?
"students elbow" - acute or repetitive trauma | Discrete swellng, pain and inflammation at posterior point of elbow
54
Inflammatory arthritis signs in elbow
Pain when try to extend the arm - if effusion
55
DDX in olecranon bursitis
Exclude septic arthritis
56
Treatment of olecranon bursitis due to inflammatory or crystal arthritis
Steroid injection
57
Treatment of infective olecranon bursitis
Broad-spectrum antibiotics and possibly open drainage and lavage
58
What is a sclerotome?
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
Difference between sciatica low back pain and sclerotomal low back pain?
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
What causes the majority of lower back pain?
Mechanical pain which is from anatomical abnormality, increases with physical activity and decreases with rest
61
Most common cause of mechanical low back pain
Degenerative change - eg. lumbar spondylosis (lumbar OA) - degenerative changes in IV disc and facet joint
62
What can disc herniation result in occasionally?
Nerve root impingment causing sciatica
63
Which are the most common clinically significant herniations?
L4-L5 and L5-S1 - 95% are these two
64
Which nerve root is commonly impinged in herniations? eg. with L4-L5
The caudal nerve root therefore will be L5 root in L4-5 herniation
65
What is a rare surgical emergency with disc herniation
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
What is spondylolisthesis?
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
Symptoms of spondylolisthesis?
Can be asymptomatic if mild - can have mechanical low back pain If larger displacement that can have sciatica or spinal stenosis
68
What is spinal stenosis?
Narrowing of spinal canal and its lateral recesses and neural foramina
69
What are symptoms of spinal stenosis?
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
What causes spinal stenosis?
Normally occur due to degenerative changes
71
What stature can result from spinal stenosis?
Simian stance because forward flexion increases the canal diameter
72
Signs of low back pain being due to infection or neoplasm
Non-mechanical | Especially when accompanied by nocturnal pain
73
Signs of low back pain being due to spondyloarthropathy
Night-time waking with pain and stiffness | Prolonged morning stiffness that improves with exercise but not with rest
74
What are functional and structural scoliosis
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
Examination to differentiate between functional and structural scoliosis?
Functional disappears with spinal flexion but structural does not
76
Examination sign of spondylolisthesis?
Palpable step off between adjacent spinous processes
77
What sort of pain does hip arthritis usually cause?
Groin pain and occasionally referred back pain
78
What does the straight leg raise test do?
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
Problem with investigations in LBP
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
General treatment for LBP
Analgesia, education, back exercises, aerobic conditioning and weight control
81
Different classifications of LBP for treatment purposes
Patients either have acute LBP (3 months) or chronic or nerve root compression syndrome
82
Treatment of acute LBP
Activity is encouraged - bed rest discouraged Paracetamol and NSAIDs Muscle relaxants may help
83
Treatment once acute LBP episode has resolved
Regular back exercises, aerobic conditioning and loss of excess weight to prevent recurrences
84
Treatment of chronic LBP
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
Treatment of nerve root compression syndromes - disc herniation
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
Treatment of nerve root compression syndromes -spinal stenosis
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
Type of pain presentation with disc prolapse
Seized by severe pain on coughing, sneezing or twisting - a few days after back strain
88
Signs of disc prolapse
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
Causes of rotator cuff tears
Trauma or degenerative changes
90
What joints are ACJ and GHJ?
GHJ - synovial | ACJ - fibrous
91
Fluid on shoulder MRI
White - due to a tear - can be partial/complete
92
Conservative management of cuff tear
Analgesia, steroids, physio
93
Impingement treatment
Conservative (physio, analgesia, rest) Steroid injections Decompression - bursectomy, acromioplasty
94
Association of frozen shoulder
Diabetes Hypo and hyperthyroidism Autoimmune
95
Posterior dislocation position
Internally rotated and abducted
96
What should you examine for in posterior shoulder dislocation
Hyper laxity and other collagen problems

Ortho and Rheum (13 decks)

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