Ortho Block 1 Flashcards

1
Q

What are the types of amputations?

A
Toe Amputation
Ray Resection 
Midfoot Amputation- at transmetatarsal or tarsometatarsal level
Hindfoot Amputation 
Ankle Disarticulation - Syme ankle diart. 
BKA
Knee Disarticulation 
AKA 
Hip Disarticulation
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2
Q

If Ulcer/Skin Infection occurs on an amputation stump, how is it managed?

A

From inadequate soft tissue envelope/poor fitting prosthetic
Stop use and modify/add non-bulky dressing
ABX only if systemic Sxs present
Resistant/lingering/exposed soft tissue=surgery

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3
Q

How are irritative skin conditions that develop on an amputated limb manged?

A

Keep dry w/ non-talcum powder/cream
Tx Folliculitis w/ warm soak/compress
Cellulitis= PO ABX
Chronic folliculitis/cystic lesions= surgery
Hyperemic/weeping- topicals, ABX and adjustment of prosthetic

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4
Q

What are the 4 types of sensation issues felt w/ amputations?

A

Non-painful- telescoping sensation
Residual- pain in remaining limb from prosthetic, spurs or Sx nerve endings; modify prosthetic or surgery
Phantom- 55-85% of ALL PTs, Tx w/ Gaba/Pregabalin and transcutaneous electrical stimulation for flare ups
Neck/Back- more function limiting than phantom or residual, Tx w/ PT, rehab and stretching

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5
Q

What are the leading causes of amputations:

A

Systemic Dz: DM, PVD, Infections

Trauma

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6
Q

Define OA

Where is it most commonly seen and affecting?

It’s associated with what 4 factors?

A

Irreversible loss of articular cartilage of lower extremities/spine

Most common arthritis and leading cause of impaired mobility of elderly PTs

Genetics, Obesity, Age, Trauma

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7
Q

What are the common Sxs of OA

Where is it commonly and rarely seen?

A

Pain*, stiffness (Loss of A/PROM), Deformity

Common= Finger, Knee, Spine
Rare= Ankle, Wrist, Elbow
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8
Q

A knee effusion from OA will have what type of lab results returned?

What are the nodules seen on the hands form OA?

A

Mild Pleocytosis, Normal Viscosity, slightly elevated protein

DIP- Heberden
PIP= Bouchard

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9
Q

What is the most common location in the hand for OA to be found?

Where is OA commonly found in the feet?

A

1st carpometacarpal joint w/ swelling and dec ROM

1st metatarsophalangeal joint: Hallux valgus and rigidus

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10
Q

Where does OA like to reside within the knee?

What derm issue can be seen from OA?

A

Genuine Varum- Medial compartment between femur and fibia

Baker’s Cyst- communicates between gastrocnemius and semimembranous muscles

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11
Q

PTs w/ OA in their hip will demonstrate what type of walking gait?

Where will they have radiating pain to?

A

Toe out walking w/ limited/decreased medial rotation

Groin or anterior knee

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12
Q

What four findings will be seen on x-rays of PTs w/ OA

What is the Kellgren-Lawrence Grading scale for OA

A

Sclerosis, Osteophytes, Narrowing of joint space and Subchondral Cysts

0- no OA
1- doubtful; questionable spurs/narrowing
2- minimal; spurs and mild narrowing
3- moderate; spurs and narrowing 50% or more
4- severe; severely impaired spacing and sclerosis of subchondral bone

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13
Q

What are the general management strategies of OA?

A
Weight management*
Avoidance of impact/torsion exercises
PT for strength/ROM
PO NSAIDs
Hyaluronic injection
Definitive= arthroplasty
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14
Q

Define Rheumatic Arthritis

What joints does it effect?

What body systems can be affected?

A

Autoimmune d/o of inflammation and excess of synovium around eroded capsules

Joints of hands (DIP spared), wrist, knees, feet and ankles

Pulmonary, CV, MSK, Ocular

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15
Q

What are the Sxs of RA that brings PTs in to be seen

What is the College of Rheumatology’s definition of RA

A

Pain, Morning stiffness +60m (warm up period), Swelling, Systemic Sxs

Unexplained inflammatory arthritis in one peripheral joint and short duration of Sxs that would find relief from early intervention

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16
Q

What will be seen upon exam in PTs w/ RA?

What are the four criteria included in the Dx of RA??

A

Synovial hypertrophy causing boggy feeling of joints

Joint involvement, Serology, Acute phase reactants, PT self reporting

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17
Q

What are common sites effected by RA?

What cervical issues can be seen due to the erosion process?

A

Periarticular osteopenia and erosion of joint margins that correlates to insertion site of the synovium

C1-C2 instability from erosion of ligaments holding onto the odontoid process
Caution during intubation/surgery to prevent internal decapitation

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18
Q

What lab tests would be seen on an RA PT?

A

Rheumatic factor, which is IgM Ab agonist Fc portion of IgG, will be inc x 75-90%
Anti-CCP- as sensitive as RF and more specific
CRP and ESR correlate to degree of inflammation
Elevated platelets in acute flare ups
Dec serum albumin and correlates w/ Dz

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19
Q

PTs w/ RA with often develop what other Ortho related Dz?

Why does this Dz present?

A

Osteoporosis

Dz process and non-biological DMARDs used during treatment that lower PTs immune system

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20
Q

What is the main treatment for RA?

Why do Seronegative Spondyloarthropathies have the term “seronegative” in the name?

A

Non-biological DMARDs= first line Tx choice

Negative RF

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21
Q

Seronegative Spond. Encompasses what four disease processes?

All of these will have PTs presenting of ? Issue?

A

Ankylosis Spondylitis
Arthritis associated IBDz
Psoriatic arthritis
Reiter Syndrome

Back pain- some form of SI impact that works superiorly
Enthesitis- inflammation at tendon attachment site on bone

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22
Q

Arthritis associated IBDz PTs will present with what Hx of issues?

How does Psoriatic Arthritis present and what caution/investigation needs to be done?

A

Crohns, UC, enthesitis

Skin lesion, Nail involvement, Dactylitis, Iritis, Enthesitis
Little kids shouldn’t have psoriasis at birth, check FamHx

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23
Q

Reiter Sydrome is AKA ?

What Hx do these PTs all have?

A

Reactive arthritis

Recent STI causing systemic reaction
“Can’t See, Can’t Pee, Can’t Bend the Knee”

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24
Q

What will be seen on x-ray of “bamboo spine”

What creates the “poker” spine?

Lab results on any of the Seronegative Spondyloarthropathies will show what results?

A

Anterior and Posterior vertebrae fusions

Ossification of anterior long. ligament and autofusion of facets= poke spine

Negative RF, Anti-CCP, Anti-nuclear Abs
Pos HLA-B27- genetic markers specifically for Seronegative Spond., strongest association w/ Ank.Spon at 88%

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25
What peripheral joints are commonly affected by ankylosing spondylitis? What are the common predecessors to Reiters?
Ankle, Hip, Shoulder Chlamydia, Shigella, Salmonella, Yersinia, C Diff, Campylobacter
26
What radiograph finding of the hands is seen in psoriatic arthritis How is Psoriatic Arthritis treated? How is Reiter’s treated?
Resorption of terminal phalanges Biological DMARD Derm w/ phototherapy Treat underlying STI
27
What general treatments are given for PTs w/ Seronegative Spondyloarthropathies
NSAIDs- Indomethacin A-TNF inhibitors Etanercept, Infliximab, Adalimumab for Ank. Spond not responding to NSAIDs Sulfasalazine for chronic reactive arthritis Phototherapy for Psoriatic Arth. Arthroplasty for end stage pain
28
What are the re flags for referrals of Seronegative Spondyloarthropathies How much pressure is needed for a Dx of Compartment Syndrome?
PTs w/ kyphosis Pain at rest/night in weight bearing joint Eye/Derm/Pulm referral 35mmHg
29
What are the two most common sites for Compartment Syndrome? How is a Dx made?
Forearm and Calf Measuring compartment pressure before and after exertion
30
What are the 6 Ps used to Dx acute Compartment Syndrome What measurements are used to Dx Chronic Exertional Compartment Syndrome?
Pain OOP, Pallor, Paresthesia, Paresis, Poikilothermia (cool distal extremity) and no pulse (pulseless and paresis- late findings) Exercise on treadmill: Resting pressure +15mmHg 30mmHg or higher after 1m of exercise 20mmHg or higher after 5m of exercise
31
Complex Regional Pain Syndrome is AKA ? What are the two different types?
Reflex Sympathetic Dystrophy Algodystrophy- burning sensation Causalgia Type 1- RSD, algodystrophy if no identifiable nerve injury Type 2- causalgia, if nerve lesion exists
32
How is the presentation of CRPS different than other issues seen in Ortho
CRPS= entire limb involvement START: Swelling, Temp, Agony, Redness, Tremors Hot, swollen, alloy if and manifested autonomic dysfunction Hallmark= burning, searing, tearing throbbing pain
33
How is CRPS treated?
``` PO sympatholytics PT for AROM Contrast baths TENS therapy Iontophoresis ```
34
What are the two Crystalline Disorders All of these PTs will have elevated ? But not all will have elevated ?
Pseudo/Gout All gout PTs have elevated hyperuricemia, not all hyperuricemia PTs have gout
35
Gout is a product of ? Metabolism How does UA come into the gout algorithm
Purines Classifies PTs as over producers or under secretors
36
Gout is an accumulation of ? Crystals and causes what manifestations Pseudo gout is accumulated ? Crystals
Mono sodium urate monohydrate (needles), negative birefringence; monoarticular arthritis in 1st MTP (1st), knee (2nd) or ankle (3rd) Ca pyrophosphate (thromboids), positive birefringence; mono/oligoarticular arthritis in knee (1st) or wrist (2nd)
37
How is gout and pseudo gout treated? Lab results screen for what contents of serum?
Gout- Colchicine, Indomethacin*, NSAIDs (w/in 1st 48hrs of Sx onset), Allopurinol (Can worsen if Sxs aren’t controlled) Pseudo- Aspiration, intra-articular steroids, NSAIDs Ca, Phosphorous, Mg, Alkaline phosphatase, Ferritin, Fe, Transferrin, TSH
38
Chronic hyperuricemia can lead to what two kidney issues? End stage arthritis is possible with what form of CDDz but is rare
Nephropathy and Renal stones CPPD
39
What are the typical findings of x-rays of gout and pseudo gout? The goal of long term gout management is limiting hyperuricemia with dugs such as what two?
Bone spurs in toe Pseudo- subtle; calcifies in meniscus of knee or any cartilage joint Probenecid and Allopurinol- don’t give to acute issues, will worsen Sxs
40
What can be done as Dx and TX for pseudo gout? What are the 3 parts of Virchow’s Triad?
Aspiration followed by steroid injection if 1 or 2 joints are involved PO NSAID or Colchicine if multiple joints involved Venous stasis, Hypercoagulability, Venous damage
41
How do PTs present w/ DVTs? What is the most preventable cause of in-hospital deaths and are #3 cause of death in poly trauma PTs?
Pain distal to block and worse pain when fluid is pushed through (squeezing calf) PEs
42
What is one of the first screening assessments for DVTs? What imaging modality is used in PTs w/ suspected DVT Sxs such as edematous limb?
US Venography- Dx test EKG, CXR, Ventilation Perfusion Scan
43
What DVT prophylaxis is used during hip or knee arthroplasty? What is used in poly trauma or long bone Fxs? Which one is better for PTs w/ renal issues?
Enoxaparin Enoxaparin and heparin Heparin
44
What is used for short and long term prophylaxis against DVTs? What is the goal INR range?
Enoxaparin, Warfarin (most commonly use for anti-coag), ASA 2-2.5
45
Warfarin has been shown best at preventing what types of clots? What is the mechanical prophylaxis used during DVT treatment?
Better at preventing proximal clots- popliteal and superior Compression devices
46
Define DISH
Idiopathic disease characterized by striking osteophyte formation in the spine PTs have ossification spanning 3 or more discs/4 vertebral bodies usually in thoracic or thracolumbar Ossification usually follow anterior longitudinal ligament and peripheral disc margins
47
What is the principal Sx of DISH What Sx is seen if DISH spreads to cervical area?
Stiffness, especially in morning and evening Dysphasia from osteophyte on anterior cervical spine pressing behind esophagus
48
What lower extremity finding my be seen on exam in PTs with DISH How does DISH differ from Spondyloarthropathies
Reduced hip motion or knee arthritis No posterior fusions/involvement No HLA association Exception- cervical spine posterior ligament may ossify Spondyloarthropathies works inferior to superior, DISH move out from a common point
49
What are the two most common causes of cervical myelopathy How is DISH treated?
1- cervical spondylitis 2- DISH Exercise program- 1st NSAIDs
50
What post-surgical hip issue is seen in PTs w/ DISH? What are the 3 Sxs of Fibromyalgia
Hetertrophic ossification Generalized pain, fatigue and tender areas of soft tissue
51
What makes the Dx criteria for fibromyalgia specific
Pain in 4 quadrants w/ waxing and waning x 3mon Pain/tenderness needed at 11 or more of the 18 sites with 4kg of pressure PT must say palpitation was painful and not tender
52
What are the 3 FDA approved drugs for treating fibromyalgia? What other treatments have been shown to help with Sxs?
Pregablain, Duloxetine, Milnacipran ``` Anti depressant/convulsants Non-bentos Relaxants Dopamine agonists NSAIDs Needling and infiltration w/ lidocaine Electrical stimulation Cryotherapy ```
53
Where does osteomyelitis usually occur in Peds and Adult PTs?
Peds= hematogenous etiology most commonly in metaphysic of long bones with more than half of cases in PTs under 5y/o Adults- organisms gain acces from open Fx or from surgical fixation of Fxs
54
How do osteomyelitis infections present? What microbes are most likely the culprits?
Older PTs/adults- fever, pain, swelling at site Previous open Fx- drainage or substantial delay of healing Kids- present MORE sick w/ Systemic Sxs, deep/poorly localized pain Adults- Staph A, Pseudomonas Aeruginosa Peds- Staph A, GAS, Hemo. Influenza but less often due to imms Immunocompromised- atypical microbes
55
How are osteomyelitis infections best seen on imaging? How are these infections seen for Dx?
MRI- sensitive and specific NucMed bone scan- high sensitivity, low specificity, used to differentiate from Charcot Arthropathy- destructive condition from denervated limbs but can be confused as osteomyelitis
56
What type of lab results will be seen in PTs with osteomyelitis infections? How are these infections Tx?
Acute=Elevated leukocytes Chronic= normal leukocytes Both have elevated CRP and ESR Surgical excision- definitive ABX- impregnated methyl methacrylate beads after surgery- key
57
What are the two types of septic arthritis? What are the 3 ways the infections originate?
Pyogenic, Suppuarative Direct innoculation Hematogenous spread from infection Extension of rom bone infection
58
What is the most likely microbe of septic arthritis in adults and kids over 2yrs old Septic arthritis in kids is usually occurring from ?
Staph Aureus Hematogenous spread
59
What are the hallmark Sxs of septic arthritis? What will labs are ordered?
Tenderness, Effusions, Erythema w/ limited PROM WBC w/ differential EST CRP
60
Septic arthritis joints MUST be aspirated and tested for ? If it’s a native joint w/ an infection, what results is diagnostic?
Crystals, Gram stain, cell count, Cultures w/ sensitivity WBC higher than 50,000^3
61
What is the sequence of treatment for septic arthritis? What are the adverse outcomes of this issue and can even occur w/ TX?
Aspirate, ABX, surgery ``` Degeneration of joint Soft tissue injury/contracture Osteomyelitis Fibrous/bony ankylosis Sepsis/death ```
62
WHat’s the difference in presentation of septic arthritis and bursitis/cellulitis
Septic arthritis= swollen, painful joint w/ dec PROM Cellulitis/Bursitis- no decreased ROM
63
Lyme Dz is what microbe and carried by ? Bug What are the 3 phases of this Dz?
Borrelia Burgdoreri Ixodes Dammini Early localized- viral Sxs Early disseminated- cardiac/neuro involvement (meningitis, cranial neuropathy, radiculopathy) Bell’s palsy- most common neuro manifestation Late- Arthritis and Neurlogic manifestation, Lyme encephalopathy, radicular pain and distal paresthesia
64
What is the characteristic feature of early localized Lyme Dz? Any PT presenting with this finding should be investigated for ?
Erythema Migrans Synovits and restricted joint motion
65
Which joints are heavily affected by Lyme Dz? What other adverse outcomes can occur?
Heavy weight bearing Facial paralysis, Chronic Fatigue, Concentration defects, Cardiac block, Peripheral neuritis
66
What ABX are used to TX Lyme Dz?
Doxy 100mg BID x 28 days Amoxicillin 500mg TID x 28 days Peds under 8yrs- Amoxicillin 20mg/kg
67
What are the two types of Osteoporosis
Primary- post-menopausal and 6x more common in women than men Hormone changes causing bone loss Secondary- senile osteoporosis, occurs twice as much in men and commonly in PTs older than 70 Metabolic, bone doesn’t form Also commonly seen in long term steroid use PTs
68
How is osteoporosis identified in clinic?
Pt seeks help for back pain, Fx, loss of height or spinal deformity ID’d through DEXA scan Fx risk assessment- FRAX from bone density and other 10yrs Fx risk assessment
69
What are the ranges of DEXA results for normal, -penia and -porosis Other than metabolic and steroid use, what other issues can lead to Secondary Osteoporosis?
0- -1= normal - 1 - -2.5= osteopenia - 2.5 or more= osteoporosis Hypo/per thyroid Multiple myeloma- neoplastic issues Osteomalacia- metabolic Osteogenesis imperfecta- CT d/o
70
What are the common Fxs from osteoporosis Overuse Syndrome is AKA ?
Compression Fx, Hip and FOOSH Cumulative trauma d/o Repetitive strain injury
71
In order for the Dx tendinitis to be give, what part of the tendon has to be involved? Define Apophysitis Define Epiphysiolysis
Epitenon A- inflammation at the growth plate E- traumatic widening of the physis
72
How is overuse syndrome Tx? How are sprains classified/graded?
Progressive exercise helps treat tendinitis NSAIDs Analgesic creams 1- partial tear, no instability of joint; Sx Tx only 2- partial tear with some laxity; Tx by motion protection 3- complete tear w/ laxity; Tx by protected motion or repair
73
How are strains classified/graded?
1- <10% muscle fibers torn w/ intact fascia 2- 10-50% torn w/ intact fascia 3- all muscle fibers torn but fascia intact 4- all muscle fibers torn and disrupted fascia
74
# Define sprain Define strain
Injured ligaments connecting bones together Trauma to muscle or musculotendinous unit
75
How should sprains and strains be evaluated in clinic? How are their Dx confirmed/severity evaluated?
Sprain- joint examined for stability Strain- stretch injured muscle to identify muscle defects Most sensitive for soft tissue eval, used sparingly to grade and evaluate suspected ruptures or severe sprains
76
How are sprains/strains TX? When are these referred due to red flags?
PRICE is mainstay Early cryotherapy NSAIDs Minor sprains- elastic compression bandages Strains- immobilized w/ muscle in stretched position Grade 4 strains Grade 3 sprains Severe grade 2 sprain/strain
77
What is the treatment protocol/time frame for strains
Acute- Day 1-5= limit swelling/hemorrhage After day 5= prevent adhesions Subacute- Day 3-3wks= gain, pain, full AROM Remodeling- 1-6wks= strength, flexibility Function- 2wks-6mon= return to duty Return- 3wks-6mon= avoid reinjury
78
Osteoid osteoma
Benign/incidental finding In long bones and posterior elements of the spine Age: 10-35 Appears sclerotic w/ <1cm lucent nidus; “drill hole” in cortex of bone PT presents w/ night pain that is responsive to NSAIDs/ASA
79
Osteochondroma
Mushrooms growing off of metaphysis and point away from bone | Child/young adults
80
Fibrous Dysplasia
Late childhood-young adult and can appear on any bone Polyostotic fibrous dysplasia earlier Muddled appearance w/ poorly defined edges
81
Osteosarcoma
Obliterates cortex of bone and appears like ray burst on x-ray
82
What imagine modalities are used for assessing bones and their issues?
X-ray: bone lesions MRI: soft tissue and marrow CT: bone detail (cortical continuity, erosion, endosteal scalloping) Bone scans: infection, trauma, tumor but don’t show if activity is related to trauma, infection or tumor
83
Who is more likely to be seen for growing pains? How is it treated?
Boys, ligamentous laxity, 2-5yrs old usually noticed/increased at night Education, stretches and analgesics
84
How is pediatric complex regional pain syndrome managed? What child demographic is more likely to be abused?
Rehab- first TCAs- Amitriptyline Pain management Under 3yrs old- first, premature, step children, handicapped
85
When gathering history of suspected child abuse, how is the change added to the note? What images are taken for these cases?
Revised date and recorded as an addendum to the record AP/Lat of all long bones, hands, feet, spine, chest and skull are all standard for PTs under 2yrs
86
What types of Fxs are considered highly suspicious of abuse? What two factors present in a home increase the risk of abuse?
Posterior ribs, scapula, spinous processes, sternum Fxs Chip/Corner Fxs of metaphysis of long bones from traction/downward pulling of extremity Alcohol, maternal cocaine use
87
What imaging modality can be used to assess for suspected rib Fxs that have healed? What is the down side of this modality?
Bone scan Difficult detecting Fx of skull or long bones
88
What radiological findings are more indicative of an accident than abuse? What type of Fx is rarely the result of abuse?
Walking age w/ spiral Fx of tib/fib are accident, not abuse, indicative Buckle Fx- usually result from simple falls and can present late due to low amount of pain
89
What other imaging test is ordered for suspected child abuse during the head to toe exam with positive abdominal tenderness of elevated LFT results? How are kids MSK sprains treated differently than adults?
Abd CT Kids don't sprain, they break Any sprain treated as a Fx, f/u 7-10 days w/ repeat films
90
How fast are ped Fx healed? What Fxs are casted?
4-6wks Salter 1 and 2 3-4= surgery w/ 1yr f/u Minimally displaced= immobilization 15y/o+ male, 13yo+ female= mild displacement acceptable because if premature arrest occurs, little growth is remaining to be completed
91
Displaced peds Fxs older than __ should not be reduced because ? What is a healing risk that is seen in open Fxs in peds?
7 days Reinjury to growth plate Physeal bars
92
Lecture skipped
``` Juvenile Idiopathic arthritis Osteochondritis dissecans Osteomyelitis Septic arthritis Seronegative spondyloarthropathies ```
93
# Define Radiculopathy Define Myelopathy
Dz of nerve roots after exiting main body of spinal cord Dz of the spinal cord
94
What is the distal end of the spinal cord called and where does it terminate? What is below this ending?
Conus medullaris, @ L1-2 Cauda equina, contains L2-L4 nerve roots
95
# Define Cauda Equina What unique Sx does this present with?
Lumbar problem, Compression of nerves while in the canal distally to conus medularis Paralysis w/out spasticity Changes in S2-S4- bowel/bladder, saddle anesthesia,
96
What are the 4 causes of Cauda Equina How quickly does it develop?
Herniation, Abscess, Hematoma, Trauma Immediate- Fx Over time
97
What are the Sxs present w/ Cauda Equina?
Radicular pain/numbness in both legs but more severe in one leg Stumbling gait, difficulty standing (quad/hip extensor weakness), + symmetric foot drop
98
What imaging modalities can be used to Dx Cauda Equina Are Sxs limited to myatomes or dermatomes?
MRI- compression of thecal sac CT/myelogram- if unable to do MRI No, crosses both
99
Look into/check if numerous | "what are surgical emergencies?
Look up
100
# Define Cervical Radiculopathy What causes these in young and older PTs?
Pain in cervical nerve root/s w/ possible numbness, weakness or loss of reflexes Young- herniation Older- osteophytes, stenosis, arthritis of uncovertebral joint
101
What are the S/Sxs of Cervical Radiculopathy What imaging modality is used for Dx
Weakness, lack of coorindation, changes in handwriting and decreased grip Unilateral numbness/parasthesia of upper extremity Axial MRI CT w/ myelogram
102
What type of ROM is decreased with cervical radiculopathy What movements will cause increased pain and indicate further eval needed of ? nerves
Lordosis Extension/axial rotation C5-T1
103
How is cervical radiculopathy Tx? What are the red flags for referral?
Radicular pain- NSAID w/ traction therapy Avoid narcotics and spine manipulation ``` Non-surgical Tx failure Atrophy, weakness, myelopathy Demyelinatings Sxs Infection Tumor ```
104
# Define Cervical Spondylosis What can cause this?
Degenerative disc dz Osteophyte growth Buckling/thickening of ligamentum flavum Herniation
105
What Sxs will PTs with Cervical Spondylosis present with? What does this do to their ROM
Neck pain that inc w/ upright activity Dec palmar sensation- difficult buttoning shirts Gait changes seen by tandem walking Dec AROM and PROM
106
What nerve roots need to be assessed in PTs w/ Cervical Spondylosis Define Lhermitte sign What other signs may be seen?
C5-T1 (degernation usually occurs at C5-7) and L1-S1 Flexion of neck produces electrical shocks down spine/arm/leg Hoffmann, clonus, hyperflexia, Babinski
107
When do cervical spondylosis PTs need MRIs? How are they treated?
Progressive neurological Sxs ``` NSAIDs Anti-depressants Cervical pillow/roll w/ rehab No opioids Long term/definitive= fusion ```
108
# Define Cervical Strain What usually causes these?
Muscle/ligament injury of the neck Acceleration-deacceleration MVAs causing rapid flexion-extension
109
What are the Sxs of Cervical Strains Where do PTs complain of pain?
Pain worse w/ motion and possible paraspinal spasm Occipital HAs- can linger x months From base of skull to cervicothoracic junction
110
What findings may be seen on imaging of cervical strain PTs? How much instability is concerning?
Anterior displacement of pharyngeal shadow= soft tissue swelling from spinal Fx, disc injury or Ant. Ligament Translation of vertebral body more than 3.5mm and/or 11* of angulation of adjacent vertebrae
111
How are cervical strains treated? What rehab care is contraindicated in these PTs?
1-2wks= NSAIDs, relaxants, soft collar Short term use of Anti-depressants Unstable Fxs= surgery Spinal manipulation
112
How much anterior swelling is allowed/considered non-pathological in cervical strains What if increased swelling is seen beyond an acceptable/non-pathological amount?
1/3 width of C3 vertebral body MRI stat, no flex ion/extension films
113
What are the common causes of cervical Fxs? When are the majority of these Fxs missed?
MVA, Fall, diving accident Obtunded from closed head injury, unconscious, intoxicated
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What are the 3 most common presenting Sxs of Cervical Fxs? What types of Sxs suggest an involved spinal cord injury?
Pain, Paraspinous spasms, point tenderness Global sensory/motor deficits
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What does a gap/step off found in the cervical spine suggest? What follow on sensory tests need to be performed?
Injury and instability to the posterior ligament outs complex Perinatal, sphincter and bulbocavernosus reflex
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What is the most important image needed when assessing multiple injuries in a PT w/ potential cervical Fxs? If PTs w/ a normal radiograph and neurological exam but still have persistent pain should take what precaution?
Cross table lateral x-ray from C1-T1 Odontoid Wear cervical collar x 7-10 days
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When can a trauma PT be declared to have a cleared C-spine? What type of rehab can be started once they’re cleared and released?
Completion of exam on coherent/conscious PT Neck stretching and strengthening w/ scapular stabilization
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When are suspected cervical Fxs referred? What area is of the most concern when looking at thoracic/lumbar Fxs
Instability Dislocations/subluxations Any neurological deficit during coherent exam Posterior 1/3 of vertebral body Anterior half involvement and burst Fxs usually considered stable
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Thoracic/lumbar Fxs are often associated with that other injury? What is the most common presenting Sx? What may be delayed symptom in these PTs?
Abdominal- bowel lacerations Pain that is exacerbated by motion Bowel ileus
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What are the hallmark signs of an unstable flexion-distraction or burst Fx in a thoracic/lumbar Fx? What types of imaging modality is used?
Hematoma and step off/gap CT modality of choice, AP/Lat x-rays of thoracic/lumbar Anything other than simple compression Fx needs additional studies
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What type of imaging modality offers the best/most amount of info for PTs w/ suspected thoracic/lumbar Fxs? How are these types of Fxs treated?
CT w/ reconstruction Compression Fx less than 20* and no posterior involvement= thoracolumbosacral orthosis for 8-10wks Unstable burst, flexion-distraction, fracture-dislocation= internal fixation and fusion
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# Define Acute Lower Back pain What feature does the PT present with?
Ligamentous injury involving annulus fibrosis w/ no hernia Timon causing pulposus to leak and irritate nerves Self-splinting: limited movement to reduce pain
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How is acute lower back pain treated? When does acute pain transfer to the category of chronic?
W/ or w/out sciatic Sxs and no neurological defects= Initial phase- Sx relief Second phase- return to activity Pain longer than 3mon
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What is the hallmark PE finding for chronic lower back pain? What do x-rays show in these PTs?
Pain radiating down one/both buttocks w/ lumbar/sacroiliac tenderness AP/Lat x-rays, osteophytes, and reduced disk height
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Degenerative disc disease may show what odd finding on x-rays and MRI? PTs w/ chronic lower back pain need to be evaluated by what specialists?
Nitrogen gas in disc spaces Spine, internist, Family Med, Gyn
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How do lumbar herniations occur? Where are they more common to occur?
Posterior part of annulus fibrosis weakens and allows herniations through causing herniated disc syndrome (sciatica) L4-5, L5-S1
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What PE exam has a high correlation to a lumbar herniations? When are images ordered?
Pos contralateral straight leg raise Pain longer than 4wks, neurological defect, pre-op eval
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What are the difference between vascular and neurogenic claudication?
Neurogenic: Pain relieved w/ sitting-flexed Numb, aching, sharp pain No bruit Vascular: Pain relieved w/ standing Cramping/tight pain Skin is shiny and no hair
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How are lumbar herniations treated?
PO NSAID Limited seating, standing Keep walking
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# Define lumbar stenosis How does it normally present?
Impingement of space for spinal cord canal usually at L2-L5 Neurogenic claudication that causes radicular Sxs in legs
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What special test may be positive in PTs w/ lumbar stenosis How is it treated?
+ Romberg test Keep them mobile w/: Water exercise/PT Epidural steroid injections
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When are lumbar stenosis PTs referred for surgery? Lumbar stenosis is a progressive degenerative dz associated w/ ?
Non ambulatory or decreased QOL OA
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Spinal metastatic dz often originate from ? What types of tumors are common and rare?
Breast, thyroid, lung, prostate, colon, kidney Primary- rare, originate from 6 above areas Metastatic- common
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Most likely etiology of spinal metastatic DMS are ? Spread and are deposited into the ? What are the 4 ways these present and are found?
Heatogenous Batson’s plexus- collateral connections of IVC and lacks valves Stenosis Known primary tumors, evaluated via MRI/CT Neurological finding w/ or w/out Hx Pain in PTs unaware they had CA
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What type of symptom is highly suspicious for neoplasms What PE exam can be done to magnify pain and point out focus to a neoplasm?
Pain that prevents sleep and persists through the night Percussion on spinal processes
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What x-ray sign is seen in spinal metastasis? When would bone scans be ordered?
Winking owl sign Tc-99 scan to assess depth of tumor involvement and see if it’s spread to pelvis or extremities
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What is the treatment for spinal metasteses What are common post-surgical issues with these PTs?
Chemo, Hormone therapy, Radiation in ASx tumors Radiation for painful tumors Wound complications if surgery follows radiation or if PT is on steroids
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# Define scoliosis What part of the spine is affected
Lateral/coronal curvature of spine that can involve axial and sagittal planes Radicular pain from L4-5 compression Rarely have neurological Sxs
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What it’s he chief presenting complaint/Sx of PTs with scoliosis How is scoliosis decompression evaluated?
Progressive spine deformity or they’re Getting shorter Measuring distance of plumb line from C7 deviates to L/R of gluteal fold
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What type of images are taken to assess scoliosis How is it treated?
Weight bearing PA and lateral on 36” cassette NSAIDs and exercise, starting w/ water therapy, trunk strengthening,
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When are scoliosis PTs referred for surgery
Progressive neurological deterioration Can’t walk 2 block due to pain Respiratory dysfunction Weakness
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Define Spondylolisthesis
Forward slippage of L4 or 5 vertebral body due to degeneration/alteration of the facet joint and disk but keep laminate and pars interarticularis intact
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What type of PE findings will be seen in PTs w/ Spondylolisthesis What type of images are needed?
Pain worse w/ lifting, twisting Diminished knee/ankle reflexes Decreased strength in toe/heel walking or toe extension AP and Lateral radiographs
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How is Spondylolisthesis treated? Define Isthmic Spondylolisthesis
NSAIDs Exercise/weight loss Usually in football/cheerleader kids at L5-S1 from cyclical loading event (fatigue Fx) that fails to heal Once slippage occurs, classified as isthmi
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What are the S/Sxs of Spondylolisthesis Isthmic How is this Dx on imaging?
Back pain radiating posterior lay to/below knees and worse w/ standing Hamstring spasms limit forward bending Scotty dog only on oblique x-ray
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What are the 3 steps of the development of Isthmic Spondylolisthesis Due to the young age of PTs this present in, what imaging modality is used to assess the back?
Pars interarticularis- Scotty dog has collar Spondylolysis- Spondylolisthesis- decapitated Scotty dog SPECT scan
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How is Isthmic spondylolisthesis treated?
Young/still developing- rigid brace | NSAIDs/exercise
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? And ? Are bacterial infections in kids involving anterior elements of the spine What PT populations are these seen in ?
Discitis and Osteomyeltis Discitis- Kids under 5y/o Vertebral Osteomyelitis- older kids/adolescents Most commonly from Staph A Could be: Kingella, GAS, E Coli
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What are the most common causes of pediatric thoracic and lumbar pain What type of info leads us to believe these are result of mechanical cause or organic cause
Muscle strain Mechanical=Pain during/after activity that is relieved w/ rest Organic= neuro, systemic Sxs (neuro may be late findings)
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What type of PE tests can be done to assess Peds back pain?
Hyper extension- loads posterior elements in compression (spondylolysis) and spinal flex ion that loads anterior column in compression (discitis, compression Fx)
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What types of images are gathered when assess Peds back pain? What labs are drawn?
Weight bearing PA and lateral x-rays of entire spine CBC w/ differential ESR CRP RF, Lyme titer, HLA, anti-nuclear Ab
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What are common clinical Sxs in kids w/ discitis What special tests are done?
Fever, malaise, back pain Percussion and passive spinal flexion to compress anterior elements and causes pain
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What is the imaging modality of choice in kids w/ discitis What labs are drawn?
MRI- proves involvement and assess potential rare complications Serum culture WBC w/ differential ESR/CRP
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What is a common adverse outcome of Peds discitis How is Peds discitis Tx
Persistent disc space narrowing and spontaneous fusion of adjacent vertebrae Admitted and IV ABX
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# Define normal range of Peds Kyphosis What are the most common causes of hyperkyphosis
20-50* w/ Cobb angle from T3-12 Greater than 50*= hyperkyphosis Postural- flexability d/o in females corrected w/ passive treatment Scheurmann Dz- common in boys and not passively correctable
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What special tests are done for Peds kyphosis What is the difference of kyphosis between Scheuermann and postural?
Adams forward bend test- Scheuremann- sharp angulation at apex Postural- genial curvatures at apex
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What images are taken for Peds kyphosis Adverse outcomes are ? And seen at ?*
AP lateral radiographs while standing Back pain, rarely neuro Sxs, decreased pulmonary function +90*
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How is Scheuermann Dz treated How is congenital kyphosis treated?
Skeletal immature- brace (Milwaukee brace) >70*= surgery Surgery
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# Define Peds scoliosis What are the 3 classifications
Curvature worse on coronal plane, >10* on Cobb angle more common in girls Infantile: birth - 3yrs Juvenile: 3-11 Adolescent: 11+
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What is the predominant effect of Peds scoliosis deformities? What two symptoms are rarely seen in these cases?
Loss of sitting balance, possible respiratory function impairment Pain and neuro Sxs
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What additional exams/findings need to be evaluated in Peds w/ scoliosis?
``` Trunk and lower extremeties Cafe-au-lait spots Auxiliary freckling Lesions on spine Cavus feet- suggest neuromuscular dz Limb length discrepancy Joint laxity- suggests Marfan’s ```
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What is the standard method for quantifying degree of curvature in pediatric scoliosis What test is the most sensitive for screening?
Cobb angle Adam forward bend test
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What cases of Peds scoliosis need MRIs?
Age- infant/juvenile Abnormal finding- pain/neurological findings X-ray findings- L sided curvature, excessive thoracic kyphosis, widening of spinal canal, erosive vertebral changes, rib abnormalities
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How is Pediatric scoliosis managed and treated? How are progressive/Sx curves treated?
Observation- immature/less than 25* 25-45*= immature soft brace 25-45* Stable neuromuscular d/o- braces 25-45* and skeletal mature= PT and observe Soft spinal orthosis
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When are Peds scoliosis referred to surgery? When are Peds w/ scoliosis referred to Ortho?
Immature PTs w/ curves greater than 45* Skeletal mature PTs- greater than 50* Upon giving Dx, all scoliosis PTs go for monitoring and tracking
166
How often do Peds w/ scoliosis f/u with orthO
6mon w/ neuromuscular conditions expected to progress rapidly Annually if not expected to progress
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When is amitryptyline the first line choice of treatment in PTs not responding to conservative methods?
Fibromyalgia