Patho Test 1: Thoracic and Ribs Flashcards
Salter-Harris Classification: Type I
Seperation - complete separation of epiphysis in relation to metaphysics w/out fracture to bone (infants)
Salter-Harris Classification:
Type II
Fracture/Seperation - Seperation of the growth plate with a small wedge broken off
Salter-Harris Classification:
Type III
Fracture of Epiphysis - Transverse and Perpendicular fracture resulting in a completed disrupted piece of bone that will be compromised to have new growth
Salter-Harris Classification:
Type IV
Fracture of a portion of the epiphysis and metaphysics: Same as type 3 but has piece extending into the shaft of the bone; requires surgery.
Salter-Harris Classification:
Type V
Crushing of the epiphyseal plate, no displacement but can cause gross deformity (fixator if necessary)
Osteochondritis Dissecans(OCD)
a joint condition in which a piece of cartilage, along with a thin layer of the bone beneath it, comes loose from the end of the bone (idiopathic)
Sever’s Disease
“osgood spatter’s of the heel” - weakening in the growth plate
Nerve Root Compression: Causes
- Facet joint inflammation
- disc herniation
- disc degeneration
- osteophytes pressing on nerve
- decreased lateral foramen diameter
- muscle spasm, swelling
Clinical Evaluation
- Patient History
- Posture screening
- Neuro screen
- AROM assess
- PROM assess
- Manual Muscle test
- Palpation for irritability
- Special Tests: Provocation tests
- Functional Testing/questionnaires
- GOALS: MD needed or not?
On Field Evaluation
- Emergency Care #1 priority
- Breathing
- bleeding
- broken bones
- EMS? (subjective)
- No:
- Neuro
- Palpate for deformity
- AROM
- joint stability tests
Patho-anatomic vs. Biomechanical Diagnosis
Found structure/injury vs. found biomechanism of the injury
Local MOI vs. Regional Interdependence
MOI: Mechanism of Injury
RI: some other body party overcompensating leading to injury
Orthopedic Assessment in Clinical Setting
- History
- Posture
- Neuro Screen
- Palpate
- AROM
- PROM
- Osteokinematic motion
- Arthrokinematic motion
- Muscle Length
- Strength
- Girth(swelling/atrophy or leg length measure
- Special Tests
- Functional Tests
Red Flags for Ortho Exams
- Severe unremitting pain
- Pain unaffected by meds or change in position
- Severe night pain
- Severe pain with no history of injury
- Saddle area numbness
Patient’s History Questions
- Age, Gender, Occupation
- Past surgeries/Any Med DX
- Chief complaint/S&S
- MOI
- Date of onset
- Pain intensity(1-10)
- Pain description
- What alleviates pain?
- What aggravates pain?
- Previous injuries?
- Valsalva sign?
- Saddle area numb?
- Prev Medical tests?
- Medications?
- DONT FORGET TO OBSERVE PATIENT
Upper Motor Neuron Lesions vs. Lower Motor Neuron Lesions
Upper: Problem with brain or spinal cord
- Hyper-reflexia DTR (increase in stretch reflex)
- Spasticity DTR
- Minimal muscle atrophy
- Altered Consciousness
- Altered Cognition
- Impaired vision, speech
Lower: Outside of spinal cord; Dorsal or Ventral nerve root
- Decreased sensation
- Decreased strength
- DTR will be diminished or absent
- May see significant muscle atrophy
Dermatome Screening
*patients eyes closed
L1 - Over greater trochanter
L2 - front of thigh
L3 - across the knee
L4 - Medial shin, dorsum of foot
L5 - Lateral aspect of shin, lateral foot
S1 - posterior shin, plantar aspect of foot
Myotome Screening
L1-L2 = hip flexors L3 = Quadriceps (not in full Ext) L4 = anterior tibialis L5 = EHL or peroneals (big toe) S1 = Gastroc (calf raises) S2 = Hamstrings
DTR: Lower lesion vs. Upper lesion
Lower: PNS
- Decreased response
- ie. herniated lumbar disc on a nerve root
Upper: CNS
- Increased response
- Brain or spinal cord disease or injury interferes with inhibitory inter neurons
- ie. MS, central spinal stenosis
DTR Grading scale
Knee jerk: L3, L4 Achilles: S1 0= absent 1= diminished 2= normal 3= hyper reflexic 4= clonus(MS)
Adverse neural tension test(SLR) vs. Well’s SLR
Adverse SLR: lift to at least 30 degrees to elicit response = would cause sciatic burning in leg that is lifted
Well’s SLR: lifting leg causes burning in opposite leg due to a possible injury to the disc(puts pressure on the nucleus on the other side
Cyriax’s end feel: Normal vs. Abnormal
Normal:
1. Bony
2. Soft tissue approximation
3. Tissue stretch
Abnormal:
1. Bony - shows up where it shouldn’t be (Ca+ deposit)
2. Empty - ROM is limited from pain (muscle guarding)
3. Hard - restriction from muscular tightness (not pain)
4. Springy - rare; likely from a cartilage tear
5. Capsular - inflammatory cells in capsule (frozen shldr)
Kendall’s testing scale for Manual Muscle testing
5 = normal 4 = Good, breaks with mod resistance 3 = Fair, complete ROM against Gravity only 2+ = Poor plus = initiates motion against gravity only 2 = Poor: full ROM gravity eliminated 2- = Poor minus; initiates ROM gravity eliminated 1 = Trace evidence of a twitch under your palpating hand 0 = Nothing
Special Test: Specificity and Sensitivity
Specificity = Rules diagnosis in (SPIN)
Sensitivity = Rules diagnosis out (SNOUT)
-Fasle positives: test is positive even though the condition does not exist
-False Negatives: Test shows that the problem is not there, but in fact the person really does have the problem
Nagi Model of Disability
- Pathology: Interruption or interference with normal process
- Impairments: Anatomical, physiological, mental or emotional abnormality or loss
- Functional Limitations: Limitation in performance at the level of the person
- Disability: Limitation in performance of socially defined roles and tasks within the environment
Spondylosis
Osteoarthritis of the spine
Spondylolysis
Crack, stress fracture; also called a Pars Stress Reaction
Spondylolisthesis
Stress fracture worsens, the vertebral body slips forward off of the vertebrae below
Wiltse’s Classifcation: Dysplastic
Congenital abnormality of upper sacrum
Wiltse’s Classifcation: Spondylolytic
a pars lesion
Wiltse’s Classifcation: Degenerative
pars, facet instability
Wiltse’s Classifcation: Traumatic
non-pars fracture; force pushes V forward
Scotty Dog Fracture
Fracture of the Pars Interarticularis
-Caused by hyper extensive forces
Meyerding’s Spondylolisthesis Classification
Grade 0 = Break Grade 1 = 1/4 off Vert Grade 2 = 1/2 off vert Grade 3 = 3/4 off vert Grade 4 = completely off Vert
Diagnosing Spondylolisthesis
- History
- Horizontal muscle banding standing
- Painfree FB
- Painful return from FB
- Painful extension and rotation and SB
- Step Deformity
- Referred pain - pain in a different area than injury
- Shortened stride
- Neurological involvement in grade 2 or Greater
- Imaging tests: Xray (Stress fx won’t show up first two weeks) and/or Bone Scan(will present fx immediately)
Treatment of Pars Stress RXN
- Restricted activity to pain free limit of motion
- antilordotic bracing 8-12 weeks
- min of 4-6 weeks conditiong post bracing: 1.) start with FLEXION ROM
2. ) Local core training(TrA and Multifidi first, then obliques)
3. ) Global core-gluteals, lats
4. ) Work back into extension ROM
5. ) Gradual return to ground reaction forces
Spinal Stenosis: Central vs. Lateral
Central(CNS) - results in myelopathy(spinal cord compression) or caudal equina syndrome
Lateral(PNS) - results in radiculopathy(nerve root compression)
Causes of Spinal Stenosis
- Degenerative changes are most common
- Facet hypertrophy, buckling of ligamentum flavum
- Disc bulge, osteophytes
- Bony metastases from cancer
Lumbar Stenosis Diagnosis
- History: most common among 65 years and older
- Claudicant pain - sitting at rest(no pain), stands up (pain arises)
- Relief in flexion, Pain in extension
- Hyper or Hypo DTR
- Lower extremity sensory loss
- Lower extremity weakness
- Possible bowel/bladder involvement
- Saddle area numbness
- Imaging
Spinal stenosis treament
Work on activities that increase mobility and decrease spinal compression:
- Stretching, massage
- Increase FLEXION ROM
- positional distraction to open lumbar facets
- Traction possibly
- Endurance exercises that don’t compress or extend the spine
Lumbar Nerve Root Impingement: Radiculopathy
- Irritation of one or more lumbar nerve roots due to compression
- Most common = L5 and S1
- Most frequent cause is a herniated/ruptured disc
- Other causes: facet arthritis, local inflammation, and tumors
Lumbar Radiculopathy: Symptoms
- Low back pain
- Radicular pain(shooting)
- Loss of sensation in dermatomes
- LE weakness(myotomes)
- Pain worsens with cough
- Intolerance to sitting
- Flexion or Extension pain pattern
Lumbar Radiculopathy Diagnosis
- History
- Neuro screen: Dermatomes, myotomes, diminished DTR, positive Well SLR test(contra leg, 95% specific)
- Possible lateral shift
- Positive Imaging tests
Disc Herniation: Protrusion
- slight outstretching of posterior aspect of annulus and also the neuromuscular capsule
- S/S: instability, ligament pain behavior, occasional leg pain
Disc Herniation: Protrusion treatment
- Postural/Mechanics correction
- Mckenzie approach may work with this type
- Stabilization exs= Core exs and Dynamic stablization exs
- Endurance exs
Disc Herniation: Prolapse
S/S: similar to protrusion, only now, leg pain may be more frequent and neurological signs may be present(dermatome, myotome, DTR)
-BOTH FB or BB may increase symptoms
Disc Herniation: Prolapse Treatment
- Determine what makes leg pain better/worse: May indicate McKenzie extension exercises will be helpful
- Work on decreasing the radicular S/S first, then back pain
- Posture will need to be corrected
- Stabilization exercises
- Endurance exercises
- Behavioral and occupation/sport changes
Disc Herniation: Extrusion
- Outer annulus torn, nucleus starting to escape
- S/S: LBP, worse in sitting, FB or BB may increase leg pain; Neuro S/S present; possible lateral shift; Significant disability
Disc Herniation: Extrusion treatment
Acute: Rest, Ice, Back brace or leukotape in neutral
- Goal is for 2 weeks to allow outer annulus to heal
- After 2 weeks: work on leg pain = Positional distraction, manual traction, mechanical traction, modalities for pain
Disc Herniation: Sequestered Nucleus
S/S: same as Extrusion but worse Surgery preferred: - discectomy - disc removed - Laminectomy - Lamina removed - Fusion - can be best option for radiculopathy
Facet Syndrome
Caused by:
- Trauma causing synovitis; joint swells causing local muscle spasm
- Trauma or awkward mvmt causing facet to be entrapped= Use Quadrant testing
Facet Syndrome Diagnosis
- History
- Palpate for malalignment or local muscle spasm
- Assess spinal segment mobility
- Rule out other spine pathologies
- Determine the level and side of the problem
Facet Syndrome Treatment
- Ice, e-stim first, IF for local muscle spasm
- Joint Manipulation
- Positional Distraction to open facet
- Manual or mechanical traction to open facet
- Corrective exercises once facet motion is restored
Chronic Low Back Pain (CLBP)
- 10-20% of patients with acute LBP develop chronic pain
- Does not have a confirmed spinal pathology
- Often has a physical and cognitive-behavioral component
- Instability at one or more segments within the neutral zone within 10 degrees in either direction(Flex/Ext); i.e.. segment has wobble
- Abberrant motor control(struggle to fire muscles) and segment instability?
CLBP diagnosis
- History: present > 3 months
- Clincal testing: Other dx have been ruled out and a presence of a segmental instability
- Manual spinal segment mobility test
- EMG: needle place in multifidi
- Videofluoroscopy: imagining test
CLBP treatment
- Medical intervention: NSAIDS
- Cognitive-Emotional counseling
- Improve aerobic fitness
- Core stabilization grouping
Treatment Classifcation Groups
- Specific exercise
- Extension Syndrome (Postural preference for extension)
- Flexion syndrome (Postural preference for flexion)
- Mobilization: Unilateral LBP with segmental HYPOmobility (manipulation)
- Traction: Radiculopathy w/ or w/out lateral shift
- Immobilization: segmental HYPERmobility (Core training exercises)
5 Criteria for Prediction Rule
- Duration of current episode of LBP 1 lumbar hypo mobile segment 1 hip with > 35 degrees of internal oration ROM
Form vs. Force Closure
Form closure - if all is healthy you should have a closing effect of the ligaments and muscles
Force closure - if injury is present then you are going to have to recruit more muscles to close the chain
Costochondral seperation
= Seperation of costocartilage where it attaches to the rib or sternum S/S: "pop" at injury site, with sharp localized pain/deformity MGMT: - 3-4 weeks rest - NSAIDS - local steroid injections - Bracing - Submax aerobic exercise - low impact
Rib Fractures
Flail Chest = 3-4 ribs fractured - one side does not move in inspiration/expiration
- 5-9 most common
Rib Fractures: S&S
- localized pain, discoration, swelling
- Increased pain with inspiration
- Shallow breathing
- painful spring test
- SB toward fx side
- Increased pain with SB and Rot away
Rib Fractures: MGMT
Bracing
- Multiple fx ribs= out for season
- 1-2 rib fx = out for 4-8 weeks depending on sport. Painfree full inhalation and spring tests; Return with flakjacket
Costochondritis
=Idiopathic inflammation of the costochondral junction usually ribs 2-4
-S&S: inflammation, raised rib cage(no MOI though), coughing increases S&S
Tx: Rest, MHP, US; goes away on own
Scoliosis
Iiopathic: 75-85% of cases
Neuropathic: Nuerofibramatosis = calcium deposits around SC
Osteopathic: Arthrogyrposis = muscles on one side of spine is fibrotic(bent joint disease)
Scoliosis: Severity
Mild = < 20 degrees Moderate = 20 - 40 degrees Severe = > 40 degrees
Scoliosis: Treatment
- Early detection vital
- Bracing 12/hrs a day
- Stretch convex muscles/ Strengthen concave muscles
- Surgery: Harrington rods for severe curves
Scheurmann’s Disease
-Epiphyseal plate region of the Thoracic Vertebral bodies: Necrosis of anterior aspect of Vertebral body
- Sagittal plane disorder(idiopathic)
-Complaints of achy back and excessive kyphosis at early age
TX: bracing and back extension exercises
Spina Bifida
- Congenital abnormality of the spine
- 2 per 1,000 births
- Incomplete closure of one or more neural arches embryologically
Spina Bifida Occulta
- Hidden, mild: small parts of vertebra don’t close
- Fawn’s Beard
- No contraindications for contact sports
Spina Bifida with meningocele
-Meninges forced into gaps of the vertebra
Spina Bifida Meningmyelocele
This type of spina bifida often results in the most severe complications.[12] In individuals with myelomeningocele, the unfused portion of the spinal column allows the spinal cord to protrude through an opening. The meningeal membranes that cover the spinal cord form a sac enclosing the spinal elements.
