Trauma ortho 1 Flashcards
Shoulder problems Elbow problems Spinal problems Back pain problems
Name 5 categories of LBP causes
- Spondylogenic - originating in the spine
- Neurogenic
- Viscerogenic
- Vascular
- Psychogenic
Mechanical back pain is managed in ______.
Investigations:
should you offer lumbar spine x-ray?
When should you offer MRI?
Mechanical back pain is managed in primary health care
Investigation: lumbar spine x-ray should not be offered
Offer an MRI only if result likely to change management or sinister causes are suspected
Mechanical back pain: first-line treatment approach (3)
- Reassurance, explanation
- NSAIDs (+PPI over 45)
- Avoid bed rest, keep active, early return to work
Mechanical back pain: second-line treatment approach
If fails to settle, physiotherapy
Alternative therapies e.g. facet joint injections, acupuncture
Persistent mechanical back pain: third line treatment approach
Rehabilitation programmes
Pain clinics
Prolapsed intervertebral disc
What can happen to the…
Annulus
Nucleus pulposus
Annulus can tear
Nucleus can prolapse
Resulting in cord/nerve root compression
Prolapsed intervertebral disc
Which ligaments are involved
Anterior longitudinal ligament
Posterior long ligament
Prolapsed intervertebral disc
Disc changes in normal aging - name 4
Physiological and on imaging
- Decreased water content of discs
- Disc space narrowing
- Degenerative x-ray changes
- Degenerative changes in facet joints
Prolapsed intervertebral disc
What social factor can aggravate this?
Normal degenerative disc changes can be aggravated by smoking
Prolapsed intervertebral disc
Pathological disc changes 6
Tearing of annulus fibrosis, prolapse of nucleus
Osteophytes causing nerve root compression
Central spinal stenosis
Abnormal movement - trauma
Spondylosis
Spondylolisthesis
Nerve root pain
- distribution of pain
- progression/prognosis
- 2 modalities of treatment
- when to refer
Distribution of pain - radicular, along nerve root Prognosis: usually settles in 3 months 2 modalities of treatment: - Physiotherapy - Strong analgesia Refer after 12 weeks and do MRI
4 types of disc problems
Which one is the most common, asymptomatic?
Which one involves desiccated disc material free in canal?
Which one is caused by weakened but intact annulus?
Bulge - common, asymptomatic
Protrusion - weakened annulus but intact
Herniation - through annulus but still in continuity
Sequestration - desiccated disc material free in canal
Cervical disc prolapse
Which nerve roots
C5-6
Thoracic disc prolapse
Which nerve roots
T11-12
Lumbar disc prolapse
Most common nerve root involvement
L4/5
Lumbar disc prolapse
Which ligament weakening causes posterolateral lumbar disc prolapse?
PLL
3 types of thoracic disc prolapse and herniations
Central
Posterolateral
Lateral
Cauda Equina Syndrome (CES)
Name 6 causes
Which is the most common cause
- Central lumbar herniated disc
- Tumours
- Trauma
- Spinal stenosis
- Epidural abscess
- Iatrogenic
Name 3 iatrogenic causes of CES
Spinal manipulation
Spinal epidural
Spinal surgery
Name 4 clinical features of Cauda Equina Syndrome (CES)
Investigation of choice
If this is contraindicated, what investigative modalities are used? (2)
- Injury or precipitating event
- Location of symptoms
- Bilateral buttock and leg pain, varying dyasthesia and weakness - Bowel and bladder dysfunction
- urinary retention, incontinence - Saddle anaesthesia - loss of anal tone, loss of anal reflex
Investigation of choice - MRI
If contraindicated, use CT or pyelogram
Cauda Equina Syndrome (CES)
Treatment
Prognosis after surgery
Treatment - surgery outcome good if surgery within 48 hours
Prognosis after surgery - third will not regain function of bladder/sensory/motor deficit
Degenerative cervical spondylosis
Why might a patient lose consciousness in this situation
Osteoarthritis
Vertebral artery passing through foramina transversarium may get occluded in cervical spondylosis
Degenerative cervical spondylosis
Name 5 clinical features excluding referred pain
What are the 3 areas of referred pain?
Complications [2]
Cervical pain worsened by movement Retro-orbital or temporal pain Numbness, paresthesia of upper limbs Limited ROM of cervical spine Poorly localized tenderness Referred pain - occiput - between shoulder blades - upper limb
Complications include radiculopathy and myelopathy.
Degenerative cervical spondylosis
Investigation largely dependent on clinical or imaging
What can imaging show to confirm dx (2)
Largely clinical diagnosis but x-ray can show osteophytes and narrowing disc space with
encroachment of intervertebral foramina
What will be an indication of MRI at early stage of investigation (4)
Neurological symptoms:
Progressive myelopathy
Radiculopathy
Intractable pain
What is Lhermitte’s sign
Neck flexion causing electric shock like sensation radiating down spine
Degenerative cervical spondylosis Treatment approaches (3)
Wait and see
Avoid bed rest, keep active
Physiotherapy - after 4-12 weeks of not resolving pain
Spinal stenosis/claudication
Presentation (4)
Bilateral - usually
Sensory dyasthesiae
Weakness - foot drop
Takes several minutes to ease after stopping walking (mimicking claudication)
Spinal stenosis/claudication
Which factors improve/worsen symptoms
Worse walking down hills - extension
Better walking uphill, riding bicycle - flexion
Spinal stenosis/claudication - Lateral recess stenosis
Tx (4)
Non-operative measures
Nerve root injection
Epidural steroid injection
Surgery
Spinal stenosis/claudication - Central stenosis
Tx (3)
Non-operative measures
Epidural steroid injection
Surgery
Spinal stenosis/claudication - foramina stenosis
Tx (4)
Non-operative measures
Nerve root injection
Epidural injection
Surgery
Spondylosis definition (1)
defect of pars interarticularis
Spondylolisthesis definition (1)
anterior displacement of vertebral body
Spondylosis
2 symptoms
- LBP
2. Radicular symptoms occasionally
Spondylosis
Investigations - 4
Treatment - 3 modalities
X-rays CT MRI Bone scan Treatment - Non-operative measures - Injection therapy - Surgery
Spondylolisthesis
Wiltse Classification 5 categories
Congenital Isthmic Degenerative Traumatic Pathologic
Spondylolisthesis Surgical indications (2)
Indicated in persistent pain and/or nerve root entrapment
According to ASIA classification of SCI, which grade has completely no chance of recovery
ASIA Grade A
What fracture causes tetraplegia or quadriplegia
Cervical fracture
In tetraplegia/quadriplegia, respiratory failure is due to loss of innervation of what? What nerve is this and state nerve roots
In tetraplegia/quadriplegia, respiratory failure is due to loss of innervation of diaphragm
Phrenic nerve C3-5
Paraplegia definition (1)
Partial or total loss of use of the lower limbs
What is spared in paraplegia
Arm function spared
What are 2 partial cord syndromes
Central cord syndrome
Anterior cord syndrome
Which patients and which type of injuries are typically affected in central cord syndrome
Elderly patients with arthritic neck with hyperextension injury (low velocity)
What injury can cause central cord syndrome
Hyperexentension injury
Clinical features of central cord syndrome
What is typically preserved? (2)
Weakness of arms > legs
Dyasthesias
Perianal sensation and lower extremity power preserved
Anterior cord syndrome Presentation What type of injury causes this (2) Damage to what causes this? What is preserved
Profound weakness
Type of injury causing this - hyperextension injury, anterior compression fracture
Damage to anterior spinal artery
Fine touch and proprioception preservaed
Management of SCI
Prevent secondary insult/further damage
ABCD management
What is ABCD management
Airway and c-spine
Breathing
Circulation
Disability - PR, peri-anal sensation
Spinal shock definition Clinical features (2)
Transient depression of cord function below level of injury lasting several hours-days after injury
Clinical features
Flaccid paralysis
Areflexia
Neurogenic shock
Cause (2)
3 clinical signs
2 causes of neurogenic shock: - Injuries above T6 - Secondary to disruption of sympathetic outflow leading to loss of sympathetic tone 3 Clinical signs - Hypotension - Bradycardia - Hypothermia
How to differentiate radiculopathy and named nerve pathology like ulnar nerve palsy?
Radiculopthy follows a dermatomal distribution, unlike named nerve pathology. The pattern of sensory loss cannot be explained by a single named nerve.
