Scenario 20: Betty's Sore Back Flashcards
1
Q
What is sway back?
A
Hips sway forwards and overextend so chest collapses inwards increasing the thoracic kyphosis and the neck and neck scoops to create a poking chin. The overall result brings the head back in line with the pelvis but creates a sharp angle at the lower part of the spine
2
Q
What is a compression fracture of the vertebral column?
A
Direct loading of the spine combined with flexion or extension when the spine is overloaded or weakened (e.g. by osteoporosis). Most common type of fracture and occurs most frequently in the thoracic region
3
Q
What is the ankle position during swing phase?
A
It moves into dorsiflexion until the forefoot is clear off the ground and then the neutral position is adopted prior to heel contact
4
Q
What is the function of levator scapulae?
A
Elevates the scapula
5
Q
What is needed from muscles in the running gait cycle?
A
Must generate more power both to raise the HAT higher and to balance and support HAT. Muscles and joints must absorb increased energy generated.
6
Q
What is flat back?
A
Often people do this to conceal size of buttocks and breasts. Knees are flexed when standing and shoulders are stooped over. Causes loss of lumbar lordosis
7
Q
Which are the intermediate intrinsic muscles of the back (the erector spinae)?
A
Iliocostalis, longissimus, spinalis
8
Q
How may the vertebra be injured by over-flexion?
A
The vertebra is displaced forward of the adjoining vertebra, usually occurs in lower area of the neck. May be bi or unilateral
9
Q
Describe the annulus fibrosus
A
Highly ordered lamellae of collagen type I. Thicker anteriorly and more tightly packaged posteriorly.
10
Q
What is the function of rotatores?
A
Stablises vertebral column
11
Q
What is ideal posture?
A
Shoulders back and down, abdominal wall in good tone and kept straight, neck should be straight but not rigid, the head should be aligned. If there was a vertical line drawn through the body it should go through the mastoid process, just in front of the shoulder, through the hip joint, just in front of knee joint and 5cm in front of ankle joint.
12
Q
What is the function of the pedicles of the vertebra?
A
They connect the posterior elements of the vertebra and the body of the vertebra. The posterior elements are adapted to resist twisting or sliding forces which are channeled toward the body by pedicles so resist unwanted movements
13
Q
What is the ankle position at heel contact?
A
Neutral, heel slightly inverted, foot slightly supinated
14
Q
What are the features of sacral vertebrae?
A
Fuse at 25 years, an upside down triangle with apex pointing inferiorly
15
Q
What is the function of multifidus?
A
Stabilises vertebral column and rotates
16
Q
What brings the knee and hip joints into line so that the hip joint is closer to the centre of gravity?
A
The valgus angle of the femur
17
Q
Which ligament of the vertebra is stretched in extension?
A
Anterior longitudinal ligament
18
Q
How do children walk up until the age of about 2?
A
They walk on a wider base, have no reciprocal arm swinging, no proper heel strike as they plant the foot flat on the ground, have straight knees and laterally rotated legs
19
Q
What are the inertial forces?
A
Arise from the inertial properties of the body segments and is proportional to but in the opposite direction of acceleration.
20
Q
What is the function of the rhomboids?
A
Retract and rotate scapula
21
Q
Describe the nucleus pulposus
A
The consistency of toothpaste, a few cartilage cells and collagen fibres. The fluid nature allows it to be deformed.
22
Q
Where does the centre of pressure move during gait?
A
Moves from posteriorly at the ankle to the ball of the foot anteriorly
23
Q
What are the horse tail nerves?
A
Those which branch from the lower part of the spinal cord, lumbar and sacral
24
Q
What are the features of the cervical vertebrae?
A
2 foramen for spinal nerves, bifurcating spinous process (not C7) triangular vertebral foramen
25
What are the 5 stance phases?
Heel strike, foot flat, midstance (body weight over supporting limb) heel off, toe off
26
How many cervical vertebrae are there and which are palpable?
7, with only C7 being palpable
27
How many sacral vertebrae are there?
5
28
What are the external forces present in stance phase?
Inertia, gravity and ground reaction forces
29
What are the symptoms of spondylolisthesis?
Painless in children but in adults causes backache made worse by exercise. There is a classic scottie dog and collar fracture seen on x-ray.
30
How can nucleus extrusion or annulus protrusion occur?
A bending movement stretches and thins the annulus reducing it's strength. If a compression force is simultaneously applied the pressure is raised in the nucleus and it can herniate or the annulus may collpase outwards
31
What does horizontal trabeculae loss with old age cause?
Buckling of the vertebrae
32
What is the function of latissimus dorsi?
Extends, adducts and medially rotates upper limb
33
What is the function of iliocostalis, longissimus and spinalis?
Unilaterally flexes vertebral column, bilaterally extends vertebral column and head
34
What is the period of double support in gait?
Occurs in walking when the lower extremity of one side is beginning its stance and the other extremity is ending it
35
Which are the deep intrinsic muscles of the back?
Semispinalis, multifidus, rotatores,
36
What is lacking in the gait cycle of running compared to walking?
There is no period of double support so there are float periods
37
What allows the knee joint to absorb shock?
The trabecular pattern ensures the forces are transmitted over the whole surface of the knee joint and the menisci increase the shock absorbing qualities of the knee
38
How can the vertebral column undergo trauma?
Via compression, distraction, over flexion and extension, rotation or by shear direct trauma
39
What is the function of serratus posterior inferior?
Depresses ribs 9-12
40
What is the function of the vertebral end plate?
Form a permeable barrier between the nucleus and the bone through which water and nutrients may pass. Mechanically they prevent the nucleus bulging into the vertebral body
41
What are the features of lumbar vertebrae?
Largest of all the vertebrae, large kidney shaped vertebral bodies, triangular foramen
42
What is the function of trapezius?
Elevates and rotates scapula
43
How does osteopenia affect the hip joint?
Cause weakness of bone and may lead to failure of the hip joint
44
What is the function of the ligamentum flavum of the vertebra?
Formed of elastic tissue, this ligament permits the separation of lamina during flexion but that the same time halts it to prevent it reaching its limit too quickly protecting the disc from injury
45
What are the features of the thoracic vertebrae?
Two demi facets for articulation with the rib inferior to it. A circular vertebral foramen, spinous processes slanted anteriorly and inferiorly
46
How many lumbar vertebrae are there?
5
47
How does gait change in the elderly?
There tends to be an increase in the walking base, either a greater step width or more usually, a greater toe out angle. The length of stride is usually decreased, as is the cadence. Finally there is absence of arm swing
48
What is spondylolysis?
Idopathetic defect on both sides of the neural arch on L5 and sometimes L4. May be result of fatigue fracture and can cause back pain
49
What supports the head, arm and trunk in locomotion?
Must be balanced over one extremity then transferred from one to the other
50
What is the stance phase of the gait cycle?
Begins the instant that one extremity contacts the ground and continues as long as some part of the foot is in contact with the ground
51
Which are the superficial intrinsic muscles of the back?
Splenius capitis, splenius cervicis
52
What is postural sway?
The shifting of the centre gravity during standing leads to pulling of spindles irregularly to prevent fatigue and assist venous return. Prevent overbalancing. More in children, elderly and when eyes are closed.
53
What will excessive forward tilt of the pelvis lead to?
Protruding abdomen, swayed back
54
Describe the vertebral end plate
Formed of hyaline cartilage and surrounds the nucleus pulposus
55
How may the vertebra be injured by over-extension?
Uncommon- extension sublaxation is where the anterior longitudinal ligament is ruptured by severe trauma forcing the vertebral bodies anterior parts apart.
56
What is the posture like at 8, 16, 16 and 52 weeks of age?
8 weeks- rounded back, head raised well
16 weeks- straightening back
26 weeks- sitting supported by hands
52 weeks- stand with furniture, walk if supported
57
Which ligament of the vertebra is stretched in flexion?
Posterior longitudinal ligament
58
What is the function of the laminae of the vertebra?
Protect contents of vertebral column, transmits force from articular processes to the body
59
What are the symptoms of cauda equina syndrome?
Severe back pain, saddle anesthesia, bladder and bowel dysfunction, sciatica, lower limb and muscle weakness.
60
When do most children begin to walk?
12-15 months dependant on neural maturation
61
How can compression cause of disc failure?
Compression in loading damages vertebral end plate before intervertebral disc. The end plate damage is caused by the nucleus pulposus causing the end plate to bulge into the vertebrae.
62
Which four conditions must be met for walking?
Balance must be maintained, each leg must support the body without collapsing, the swinging leg must be able to advance to a position where it can support the body, there must be power
63
What is the ankle position after heel contact?
Ankle plantar flexes, bringing foot flat onto ground and moving into pronation. Anterior tibial muscles resist this to slow contact.
64
How does the body position change during the gait cycle?
The body moves forwards fastest during double support, the trunk twists with the pelvis and shoulder girdle rotating in opposite directions. Arm s swing out of phase with legs. Whole trunk rises and falls (lowest during double support, highest at mid stance)
65
What are the stages of the stair gait cycle?
Weight acceptable, pull up, forward continuance, foot clearance, foot placement
66
What factors affect posture?
Familial effects, nutrition, height (tall hunch, short stand straight) training (dancers/gymnasts stand straight but rigid, boxers/wrestlers are hunched, swimmers are slouched and relaxed), work conditions (students hunched)
67
When is spinal fusion indicated in spondylolisthesis?
If there is neurological compression or if there are symptoms in young adults
68
How does osteoporosis affect the hip joint?
May cause it to fail due to reduction in bone mass
69
What is the function of serratus posterior superior?
Elevates ribs 2-5
70
What is the function of splenius capitis and cervicis?
Rotates head when acting alone, acting together extend head and neck
71
Where does the ligamentum flavum of the vertebra run?
Connects the lamina of adjacent vertebrae extending from the articular capsules to the place where the lamina joins the spine
72
What may cause a fractured atlas?
A vertical force acting through the skull may force the bony ring open by the impact of the occipital condyles
73
What is hollow back?
The hips are flexed, buttocks thrust backwards, abdomen hangs forwards giving greater lumbar curvature.
74
What are the parts of a vertebra?
Body, spinous process, pedicles, lamina, transverse processes, superior and inferior articular processes, vertebral foramen
75
How many thoracic vertebrae are there?
12 which increase in size as you go down the back
76
What is the starting point of the gait cycle?
The heel strike
77
What is spondylolisthesis?
Vertebral displacement when lamina falls. Almost always between L4 and L5 or L5 and sacrum.
78
Which muscles are active in maintaining the erect posture?
Soleus (+ sometimes gastrocneuminus, deep posterior leg muscles) counteract forward pull, iliopsoas, gluteus medias and tensor fascia lata counteract postural sway, erector spinae counteract forward pull
79
Describe the joints between the laminae
Typical synovial joints with two articular surfaces covered in hyaline cartilage enclosed by synovial membrane and joint capsule
80
What is the purpose of superior and inferior articular processes of the vertebra?
Paired superior and inferior processes bearing synovial joints permit a limit amount of movement as the orientation of joints changes
81
What assessments should we do following spinal injury?
Palpation if safe to do so, neurological assessment of light and heavy touch, spinal x-ray, AP and PEG view, flexion and extension views, CT, MRI
82
How can the stability at the atlanto-occipital joint be lost?
If the anterior arch of the atlas or the transverse ligament are damaged
83
Why is the vertebral column so stable yet flexible?
It is a series of body segments connected by discs and ligaments, allowing a small displacement of multiple linkages
84
What kinds of bone is a vertebra formed of?
Outer shell of cortical bone and trabecular inner structure
85
What is the treatment for a fractured atlas?
Collar or halo for 3 months
86
What is the ankle position as stance phase progresses?
Tibia moves forward over foot and ankle changes from plantar flexion to dorsi flexion. The tibia also rotates externally which moves the foot at the subtalar joint from pronation to supination
87
What is the most important force in locomotor activities?
The ground reaction force which is the force of the ground on the foot. It is equal in magnitude and opposite to the force that the foot applies to the floor.
88
How does the knee joint move throughout the gait cycle?
Flexes and extends twice during each cycle. The knee is fully extended before heel contact, flexes early in the stance phase and this adjustment again minimises the rise in centre of gravity. Extends again around mid stance phase and then starts flexing again reaching a peak early in the swing phase. Finally it extends prior to heel contact.
89
What movements are possible at the vertebral column?
Flexion, rotation, lateral flexion and extension
90
What is the function of intervertebral discs?
To allow the flat vertebrae to rock against one another, which is needed for flexion and extension movements. They also act as shock absorbers with collagen fibres that run in different directions
91
What is an unstable spinal injury?
Further displacement may occur. E.g. loss of 50% vertebral height, thoraco-lumbar angulation of 20 degrees, failure of at least 2 of Denis's columns, compression of 3 sequential vertebrae
92
Which are the superficial extrinsic muscles of the back?
Trapezius, latissimus dorsi, the rhomboids
93
What will excessive backward tilt of the pelvis lead to?
Stretch of anterior muscles and shortened hamstrings
94
What is cadence?
The number of steps in given time
95
Where does the anterior longitudinal ligament of the vertebra run?
Extends along the anterior surface of vertebral bodies to the occipital bone and upper sacrum. Has longitudinal fibres fixed onto intervertebral discs and margins of vertebral bodies
96
Why is the cervical spine most likely to be injured?
Most mobile part of vertebral column so prone to injuries like dislocation and fracture dislocatia
97
Which muscles keep the body erect in locomotion?
Erector spinae, external and internal obliques, gluteus maximus and minimus
98
What is the ankle position at heel off?
The hindfoot is lifted and the ankle angle changes to plantar flexion until toe off
99
What kind of joint is the one between vertebral discs?
Secondary cartilaginous
100
What would be the treatment for a fractured dens?
Posterior displacement would be fatal. Anterior displacement can be treated with immobilisation and a halo cast
101
When to children begin to walk like adults?
At age 15, stride length and velocity increase so cadence decreases
102
How does the hip joint move throughout the gait cycle?
Flexes and extends once during the cycle. Limit of flexion reached about the middle of swing phase and thigh kept flexed until the beginning of stance phase.
103
Which are the intermediate extrinsic muscles of the back?
Serratus posterior inferior and superior
104
What are the features of the intervertebral discs?
Nucleus pulposus, annulus fibrosus and vertebral end plate
105
How does the arrangement of bone in a vertebrae aid resistance in load bearing?
The cortical bone on the outer layer is compressible but shatters easily, the grate of trabecular bone inside makes the vertebra stiff, resisting stress and adding resistance. to the structure. There are also blood filled channels between trabeculae which aid in absorbing the load.
106
Where should the vertebral column be curved?
Convex cervically and in the lumbar region with the thoracic region being concave
107
What is a stable spinal injury?
Vertebral components won't be displaced by normal movement, undamaged spinal cord not in danger, no development of incapacitating deformity or pain,
108
What dictates the mobility of the vertebral column?
The movements possible between articular joints of the laminae, the shape and direction of these joints dictates the direction and range of movements that are possible between adjacent vertebrae
109
What is the swing phase of gait?
Begins as soon as the toe of one extremity leaves the ground and ceases just prior to heel strike or contact of the same extremity
110
What is the function of semispinalis?
Extends and rotates head and vertebral column
111
How do children walk up until the age of 4?
They walk on a wider base, have no reciprocal arm swinging
112
What is the function of the transverse and spinous processes of the vertebra?
Provide an area for muscle attachment
113
Where does the posterior longitudinal ligament of the vertebra run?
Lies inside vertebral canal on the posterior side of the bodies and extends from the axis to the sacrum attaching to intervertebral discs and margins of vertebral bodies
114
What can cause cauda equina syndrome?
Compression, trauma or tumour of the back
115
What are the 3 swing phases?
Acceleration: begins when toe leaves ground and continues until mid swing
Midswing: extremity passes below body
Deceleration: tibia passes beyond perpendicular and the knee is extending in preparation for heel strike
116
What is the function of the annulus fibrosus?
Lattice construction gives the disc strength and ability to resist deformation from the nuclear pressure and load from vertebral body
117
What are the functions of the vertebral column?
Axial support for body, attachments for skull, thorax and pelvic girdle, protection of spinal cord, flexibility of trunk movements
