Ortho Block 1 Flashcards
What are the types of amputations?
Toe Amputation Ray Resection Midfoot Amputation- at transmetatarsal or tarsometatarsal level Hindfoot Amputation Ankle Disarticulation - Syme ankle diart. BKA Knee Disarticulation AKA Hip Disarticulation
If Ulcer/Skin Infection occurs on an amputation stump, how is it managed?
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
How are irritative skin conditions that develop on an amputated limb manged?
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
What are the 4 types of sensation issues felt w/ amputations?
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
What are the leading causes of amputations:
Systemic Dz: DM, PVD, Infections
Trauma
Define OA
Where is it most commonly seen and affecting?
It’s associated with what 4 factors?
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
What are the common Sxs of OA
Where is it commonly and rarely seen?
Pain*, stiffness (Loss of A/PROM), Deformity
Common= Finger, Knee, Spine Rare= Ankle, Wrist, Elbow
A knee effusion from OA will have what type of lab results returned?
What are the nodules seen on the hands form OA?
Mild Pleocytosis, Normal Viscosity, slightly elevated protein
DIP- Heberden
PIP= Bouchard
What is the most common location in the hand for OA to be found?
Where is OA commonly found in the feet?
1st carpometacarpal joint w/ swelling and dec ROM
1st metatarsophalangeal joint: Hallux valgus and rigidus
Where does OA like to reside within the knee?
What derm issue can be seen from OA?
Genuine Varum- Medial compartment between femur and fibia
Baker’s Cyst- communicates between gastrocnemius and semimembranous muscles
PTs w/ OA in their hip will demonstrate what type of walking gait?
Where will they have radiating pain to?
Toe out walking w/ limited/decreased medial rotation
Groin or anterior knee
What four findings will be seen on x-rays of PTs w/ OA
What is the Kellgren-Lawrence Grading scale for OA
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
What are the general management strategies of OA?
Weight management* Avoidance of impact/torsion exercises PT for strength/ROM PO NSAIDs Hyaluronic injection Definitive= arthroplasty
Define Rheumatic Arthritis
What joints does it effect?
What body systems can be affected?
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
What are the Sxs of RA that brings PTs in to be seen
What is the College of Rheumatology’s definition of RA
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
What will be seen upon exam in PTs w/ RA?
What are the four criteria included in the Dx of RA??
Synovial hypertrophy causing boggy feeling of joints
Joint involvement, Serology, Acute phase reactants, PT self reporting
What are common sites effected by RA?
What cervical issues can be seen due to the erosion process?
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
What lab tests would be seen on an RA PT?
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
PTs w/ RA with often develop what other Ortho related Dz?
Why does this Dz present?
Osteoporosis
Dz process and non-biological DMARDs used during treatment that lower PTs immune system
What is the main treatment for RA?
Why do Seronegative Spondyloarthropathies have the term “seronegative” in the name?
Non-biological DMARDs= first line Tx choice
Negative RF
Seronegative Spond. Encompasses what four disease processes?
All of these will have PTs presenting of ? Issue?
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
Arthritis associated IBDz PTs will present with what Hx of issues?
How does Psoriatic Arthritis present and what caution/investigation needs to be done?
Crohns, UC, enthesitis
Skin lesion, Nail involvement, Dactylitis, Iritis, Enthesitis
Little kids shouldn’t have psoriasis at birth, check FamHx
Reiter Sydrome is AKA ?
What Hx do these PTs all have?
Reactive arthritis
Recent STI causing systemic reaction
“Can’t See, Can’t Pee, Can’t Bend the Knee”
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?
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%
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
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
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
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
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
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
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
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
How is CRPS treated?
PO sympatholytics PT for AROM Contrast baths TENS therapy Iontophoresis
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
Gout is a product of ? Metabolism
How does UA come into the gout algorithm
Purines
Classifies PTs as over producers or under secretors
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)
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
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
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
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
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
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
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
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
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
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
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
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
What are the two most common causes of cervical myelopathy
How is DISH treated?
1- cervical spondylitis
2- DISH
Exercise program- 1st
NSAIDs
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
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
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
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
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
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
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
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
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
What are the hallmark Sxs of septic arthritis?
What will labs are ordered?
Tenderness, Effusions, Erythema w/ limited PROM
WBC w/ differential
EST
CRP
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
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
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
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
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
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
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
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
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
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
What are the common Fxs from osteoporosis
Overuse Syndrome is AKA ?
Compression Fx, Hip and FOOSH
Cumulative trauma d/o
Repetitive strain injury
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
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
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
Define sprain
Define strain
Injured ligaments connecting bones together
Trauma to muscle or musculotendinous unit
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
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
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
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
Osteochondroma
Mushrooms growing off of metaphysis and point away from bone
Child/young adults
Fibrous Dysplasia
Late childhood-young adult and can appear on any bone
Polyostotic fibrous dysplasia earlier
Muddled appearance w/ poorly defined edges
Osteosarcoma
Obliterates cortex of bone and appears like ray burst on x-ray
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
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
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
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
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
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
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
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
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
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
Lecture skipped
Juvenile Idiopathic arthritis Osteochondritis dissecans Osteomyelitis Septic arthritis Seronegative spondyloarthropathies
Define Radiculopathy
Define Myelopathy
Dz of nerve roots after exiting main body of spinal cord
Dz of the spinal cord
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
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,
What are the 4 causes of Cauda Equina
How quickly does it develop?
Herniation, Abscess, Hematoma, Trauma
Immediate- Fx
Over time
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
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
Look into/check if numerous
“what are surgical emergencies?
Look up
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
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
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
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
Define Cervical Spondylosis
What can cause this?
Degenerative disc dz
Osteophyte growth
Buckling/thickening of ligamentum flavum
Herniation
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
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
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
Define Cervical Strain
What usually causes these?
Muscle/ligament injury of the neck
Acceleration-deacceleration MVAs causing rapid flexion-extension
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
How are lumbar herniations treated?
PO NSAID
Limited seating, standing
Keep walking
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
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
When are lumbar stenosis PTs referred for surgery?
Lumbar stenosis is a progressive degenerative dz associated w/ ?
Non ambulatory or decreased QOL
OA
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
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
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
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
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
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
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
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,
When are scoliosis PTs referred for surgery
Progressive neurological deterioration
Can’t walk 2 block due to pain
Respiratory dysfunction
Weakness
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
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
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
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
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
How is Isthmic spondylolisthesis treated?
Young/still developing- rigid brace
NSAIDs/exercise
? 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
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)
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)
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
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
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
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
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
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
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*
How is Scheuermann Dz treated
How is congenital kyphosis treated?
Skeletal immature- brace (Milwaukee brace)
>70*= surgery
Surgery
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+
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
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
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
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
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
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
How often do Peds w/ scoliosis f/u with orthO
6mon w/ neuromuscular conditions expected to progress rapidly
Annually if not expected to progress
When is amitryptyline the first line choice of treatment in PTs not responding to conservative methods?
Fibromyalgia
