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15021998-MSK > week 3 > Flashcards

week 3 Flashcards

1
Q

how many vertebrae in spine and where?

A

33

7c, 12t, 5l, 5s, 4c

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2
Q

what is c7 called?

A

vertabra prominans

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3
Q

what do atlas and axis allow?

A

head rotation

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4
Q

what is significant feature of c7?

A

No foramena transeverse process (veretbral artery)

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5
Q

which vertabrae has odontoid process?

A

c2

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6
Q

which vertebrae have no intervertebral disc

A

c1-c2

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7
Q

what is the disease process in spondylitis and OA? what exacerbates pain?

A

intervertrbal disc loses water, overloads facet joints, pain is worse on extension of spine (as facet joint takes pressure when leaning back )

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8
Q

what can help specific level OA in spine?

A

Facet joint injections under fluoroscopy

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9
Q

what makes up an intervertberal disc?

A

Outer annulus fibrosis and inner gelatinous nucleus pulposus

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10
Q

where does intervertebral disc degeneration most occur?

A

L4/5 or L5/S1

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11
Q

why is MRI not diagnostic in diagnosing disc degeneration/nerve root compression?

A

because many people have bulging discs, disc extusion or asymptomatic nerve root compression

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12
Q

why does acute disc prolapse occur?

A 
MOST AT L4/5 or L5/S1
Lifting heavy object  Annulus tear  “twang”
Rich innervation outer annulus
Pain on coughing
Most settle by 3 months
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13
Q

spinal cord ends at L1 becoming what?

A

cauda equina

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14
Q

with disc prolapse which nerve root is usually compressed

A

the transersing nerve root (e.g.: root L5 for L4/L5 prolapse)

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15
Q

from where does the sciatic nerve arise?

A

L4-S3

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16
Q

what can nerve root compression cause?

A

radiculopathy (pain down sensory distortion of nerve)

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17
Q

learn dermatomes

A

learn myotomes

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18
Q

segmental innervation of hip (myotomes)

A

hip flexion L2,3

hip extention L5,S1

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19
Q

segmental innervation of knee(myotomes)

A

knee flexion L3,4

knee extension L5,S1

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20
Q

segmental innervation of foot (myotomes)

A

inversion L4,L5

eversion L5,S1

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21
Q

segmental innervation of ankle (myotomes)

A

dorsiflexion L4,5

planterflexion S1,2

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22
Q

what is spinal stenosis?

A

compression of nerve roots by osteophytes and hypertrophied ligaments in OA

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23
Q

what is classic sign of spinal stenosis?

A

radiculopathy or burning leg pain on walking = neurogenic claudication

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24
Q

treatment of spinal stenosis

A

surgical decompression (some patients)

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25
Q

what causes cauda equina syndrome?

A

compression on all lumbroscaral nerve roots (usually prolapsed disc)

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26
Q

signs of cauda equina syndrome?

A

bilateral lower motor neurone signs, bladder/bowel dysfunction, saddle anaesthesis and loss of anal tone

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27
Q

muscles of the spine

A

many

3 main = Iliocostalis, Longissimus thoracis, Spinalis thoracis (erector spinae = source of sprains and strains)

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28
Q

what is a chance #?

A

very unstable, where posterior ligaments are disrupted (+/- # of posterior elements) - due to sudden flexion

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29
Q

where is lumbar puncture performed and why?

A

L4-S2 (less likely to hit nerve)

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30
Q

what are causes of back pain?

A

bone (#, tumour, OM), joint, (Oa,spondylosis, spinal stnosis) muscle/ligaments (sprain and strains), disc (sciatica, CES, discogenic back pain)

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31
Q

monteggia and galeazzi #

A

ulnar #, radial head dislocation (at elbow) and Galeazzi # is opposite (radial # and dislocation at distal ulnar joint)

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32
Q

where does sciatic pain radiate to

A

BELOW knee (question if not)

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33
Q

what is a sprain, what is a strain?

A

strain = muscle/tendon

sprain = ligament

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34
Q

where can mechanical back pain go to?

A

buttock/thigh

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35
Q

what is treatment for sciatica

A

conservative for 3 months then consider surgery

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36
Q

what is childrens development of lower limb

A

normal variation (overlaping toes, vaglus/varus, instep foot…)

bow-legged, to knock-kneed, to corrected;

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37
Q

what is classed as a deformity in kids?

A

a harmful/likely to presist defect (creating physical/mental problems)

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38
Q

how do bones grow?

A

length = from physis by endochondrial ossification

circumference= from periosteum by appositional growth

(some bone grow > others - shoulder and knee greater growth)

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39
Q

what are factors affecting bone growth?

A

diet/nutrition, VitD, injury, illness, hormones (GH)

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40
Q

when is the pubertal growth spurt?

A

female = 12

male = 14

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41
Q

what is considered in children of small stature

A

lots of kids with few pathological reasons. gentics (percent height), nutrition,

dysmorphic features= genetic or endocrine disorder

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42
Q

what are normal growth milestones?

A

crawling- 6/9months

stands- 8/12months

walks- 14/17months

jumps- 24months

manages stairs by self - 36months

(beware over-anxiety and over-treatment- missing one is fine, several is concern)

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43
Q

what are the two problems with knee alignments kids?

A

genu varus - bow legged

genu valgum - knock knee

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44
Q

genu varus treatment/assessment

A

mild familial condition. reassure,

may be abnormal if unilateral, severe angle, short stature or painful

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45
Q

what causes pathological genu varus

A

SKELETAL DYSPLASIA, rickets, tumour (endochrondrima), BLOUNTS DISEASE, trauma (to physis)

familial/idiopathic

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46
Q

what is Blounts disease?

A

common cause of genu varus

growth arrest over medial growth plate, unknown aetiology, “beak-like protrusion X-ray”

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47
Q

genu valgum assesment

A

most people slightly knock-kneed naturally (peak at 3 year 6 months of age - chart change if concerned)

refer if ever, painful, asymmetrical. get surgery

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48
Q

causes of genu valgum

A

tumours, rickets, NEUROFIBROMATOSIS, idiopathic

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49
Q

what is in-toeing also known as? When is it made more prominent?

A

pigeon-toes

accentuated when running

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50
Q

what are three common causes of in-toeing?

A

femoral neck anteverions, tibial shaft torsion, metatarsus adductor.

[vast majority of all resolve if severe then surgery/casting may occur in adolescence.]

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51
Q

treatment of in-toeing

A

reassure, define cause, chart/photogrpah, review,, discharge unless severe/persistent then refer

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52
Q

Flat feet pathogenesis

A

born with flat feet and lack of medial arch development (tibias posterior doesn’t strenghten) = 20% people

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53
Q

how to determine between fixed and flexible flat feet

A

get to stand on toes.

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54
Q

flat feet AKA

A

pes planus or fallen arches

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55
Q

treatment flat feet

A

usually asymptomatic, determine type of flat foot, may resolve/no help using orthotics.

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56
Q

what increases likelihood of flat feet?

A

hypermobility

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57
Q

curly toes: which toes? when they resolve by? treatement?

A

common, usually 3/4th toe, vast majority resolve by age 6, splintage/stapping ineffective. flexor tenotomy [rarely] if persisting

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58
Q

what causes anterior knee pain?

A

stairs, squatting, jumping

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59
Q

who normally gets anterior knee pain?

A

sporty female adolescents

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60
Q

PC of anterior knee pain

A

localised patellar tenderness

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61
Q

investigating anterior knee pain

A

examination + radiograpahy.

remember to check HIPS (femur problems transmitted by obturator nerve giving knee pain as PC)

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62
Q

treatment of anterior knee pain

A

physio, resolves over time

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63
Q

what score is used to assess hyper mobility?

A

Beighton Score

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64
Q

what can rigid flat foot be cause by? treatment for this?

A

rare condition cause by underlying bony connection known as tarsal coalition - surgery if painful

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65
Q

things to consider in back pain Hx

A

onset, previous, site, nature, radiation, neurology, age, occupation.

(back pain is often insidious in nature beware patient with exact date)

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66
Q

what are the red flag symptoms for back pain?

A

<20/>60, non-mechanical back pain, systemic upset, new/major neurological deficit, saddle anaesthesia (+/- bladder/bowel upset), persistent at night, Hx of cancer/steroid use, severe pain >6 weeks, fever/malaise/weight loss. structural deformity

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67
Q

what to examine in back pain patient

A

Observation
Range of movement
Neurological assessment (myotomes, dermatomes, reflexes)
Nerve root irritation (straight leg test and see if pain changes)
Distraction testing

68
Q

myotomes of hip flexion, knee extension, foot dorsiflexion+ EHL, ankle plantar flexion

A

L1/2 hip flexion
L3/4 knee extension
L5 foot dorsiflexion & EHL
S1/2 ankle plantarflexion

69
Q

investigating back pain

A

xray useless (unless severe)

MRI gold standard but beware false positives

Also, Diagnostic facet injection, Contrast enhanced CT, Provocation discography, Selective nerve block / ablation

70
Q

what is sciatica?

A

Buttock and / or leg pain in a specific dermatomal distribution accompanied by neurological disturbance.

71
Q

what is disc prolapse?

A

slipped disc, Variety of syndromes and presentations (Leg pain and neurology unpredicatable)

Surgery is for the leg pain

72
Q

disc prolapse common PC

A

episodic back pain with onset of leg pain +/- neurology. Leg pain then becomes dominant (seen down myotomes/dermatomes)

73
Q

slipped disc/disc prolapse treatment

A

not emergency (unless CES).

conservative treatment as 70% settle in 3 months + 90% in 2 years. Surgery is for the leg pain and carries risk

74
Q

management of backache First line

A

short bed rest, anti-inflammatory +/- muscle relaxant, mobile thereafter. physio and return to normal activity.

75
Q

management of backache second line

A

educate, reassure, osteopathy/chiropractic, TENS/psycology + pain clinic then surgery

76
Q

what causes adjacent segmental disease?

A

preys back surgery + natural underlying problems causes fusion of joints.

77
Q

CES

A

Fracture with deteriorating neurology

Time sensitive = < 24 hours to treat, urinary/bowel problem

78
Q

how to assess spinal # initially?

A

immoblise, Xray/CT, don’t forget other injuries

79
Q

what to look for in neurological exam after spinal #?

A

motor, sensory, pay attention to saddle area

80
Q

what to do for suspected C-spine injury

A

rigid collar, X-ray/CT (include C7/T1), soft tissue shadow indicated concern, remember other injuries

81
Q

what to do for suspected T-spine injury, where is it most commonly?

A

rigid spine board, visualise whole spine, neurological, most commonly T12/L1, emember other injuries

82
Q

factors to consider in spinal cord involvement

A

location, size of spinal canal, bone pinching?, contact pressure (bone/disc), Xray can seem fine with major involvement

83
Q

what occurs in secondary cord damage?

A 
Cord  swelling
Oedema
Ischaemia
Thrombosis  of  small  vessels
Venous  obstruction
84
Q

why is moving the patient with a spinal injury okay?

A
  • rarely cause a problem.
  • Hypoxia, hypoxaemia, and poor perfusion carry a much greater risk of precipitating neurological damage in compromised tissue
85
Q

what are the patterns of spinal cord injury?

A

complete

incomplete (central, anterior cord and Brown-Sequard)

86
Q

what is a good prognostic sign in complete cord injury?

A

saddle sparing

87
Q

central cord injury: due to what, prognosis and PC?

A

Typically hyperextension injury

Arms worse than legs

Prognosis variable but generally good

88
Q

Brown-Sequard: PC, prognosis and cause

A

Paralysis on ipsilateral side
Hypaesthesia on contralateral side

due to trauma/#

best prognosis

89
Q

anterior cord injury: PC, causes and prognosis

A

Motor loss, Loss of pain and temperature sense; Deep touch, position and vibration preserved.

May have traumatic or vascular cause (Eg;post-surgery)

Prognosis poor

90
Q

why does secondary cord damage occur?

A

stretching, comprssion, undue movemtn, hypotension, innaporoprate surgery, infection

91
Q

what is the role of surgery in the incomplete cord injury?

A

controversial (due to risks)

92
Q

what is the role of surgery in the complete cord injury?

A

little place for it

93
Q

what is the role of surgery in the c-spine injury?

A

reduction and wiring

94
Q

what is the role of surgery in the Thoracolumbar injury?

A

little place, occasionally decompression

95
Q

when is spinal surgery performed

A

1 week later (swelling reduced),

96
Q

what are options for spinal surgery

A

fixation and grafting,

short segment fixation

97
Q

when would a patient be worse off in a collar?

A

if have AS - rigid spine with C-spine kyphosis don’t force collar. immobilise in natural position and get CT ASAP

98
Q

what needs to be assumed if patient has AS and injury

A

, until CT has proven otherwise

99
Q

what needs special attentions to in children spinal injury?

A

Ring epiphysis (weak point)

Damage to a growth plate cause premature fusion and cessation of growth. In the spine this can lead to kyphosis.

100
Q

what needs special attentions to in adolescent spinal injury?

A

chance # and variants.

[very unstable injury, particularly seen in adolescents, due to the presence of growth plates and cartilaginous rims to the various parts of the vertebrae.]

101
Q

PC of lower back pain

A

pain (localised/lumbar), referred pain (sciatica), stiffness, loss of sleep, LOF

102
Q

Hx of back pain

A

pain, LOF, trauma(recent + past), previous surgery, symptoms suggesting other pathology (pancreatic, resp, GI, GU…).

103
Q

investigating back pain

A

usually none; blood =ESR/PV/alk phos; rarely Xray unless trauma, MRI (sciatica, red flags…)

104
Q

red flags for back pain

A 
known cancer, significant trauma, persistent fever, weight loss, estabilshed osteoporosis. Age <20 or >50
Thoracic pain
Previous carcinoma (breast, bronchus, prostate)
Immunocompromise (steroids, HIV)
Feeling unwell
Weight loss
Widespread neurological symptoms
Structural spinal deformity
105
Q

when is MRI used in back pain?

A

if red flags, if surgery being considered, spinal stenosis, non-resolving sciatica

106
Q

what is seen on Xray for OA?

A

LOSS OF JOINT SPACE

OSTEOPHYTES

SCLEROSIS

SUBARTICULAR CYSTS

107
Q

causes of back pain?

A

Mechanical/non-specific - >90%

Tumour/metastases – 0.7%

Ankylosing spondylitis – 0.3%

Infection – 0.01%

108
Q

yellow flags for back pain

A 
Low mood
High levels of pain/disability
Belief that activity is harmful
Low educational level
Obesity
Problem with claim/compensation (secondary gain) 
Job dissatisfaction
Light duties not available at work
Lot of lifting at work
109
Q

management of back pain

A

do no harm is key

EXPLANATION

REASSURANCE

ENCOURAGE TO MOBILIZE

CULTIVATE PMA (POSITIVE MENTAL ATTITUDE)

ANALGESICS – PARACETAMOL,CO-ANALGESICS,OPIATES

NSAID’S – SHORT TERM

MUSCLE RELAXANTS EG DIAZEPAM- SHORT TERM

PHYSIOTHERAPY

OSTEOPATHY AND CHIROPRACTIC

REFERRAL

110
Q

secondary care/specialised investigation for back pain

A

MRI, facet joint injection, contrast CT, provocation discography, selective nerve block/ablation.

111
Q

treating prolapsed disc surgically

A

microdiscectomy, most settle without surgery [time scale variable], phased return to work.

112
Q

what condition causes spinal claudication

A

spinal stenosis

113
Q

difference between spinal claudication and vascular claudication

A

spinal = Relieved by flexing,Uphill often relieves, Cycling easy.

vascular= standing helps, uphill bad, cycling bad.

Myelogram can help tell difference

114
Q

spinal claudication PC

A

limited excretes capacity, stooping/sitting/leanforward helps. easier going uphill than downhill. get tired/heavy legs after certain distance.

115
Q

what is dudes to investigate spinal claudication?

A

Xray, Hx, Myelogram can help tell difference

116
Q

surgery for spinal claudication?

A

nerve root decompression or fusion/stabilisation

117
Q

discogenic pain PC

A

segmental instability, worsened by: as day goes on, flexion, activity.
Pain = deep seated central back pain(toothache like)

118
Q

surgery for discogenic back pain

A

Graf ligament Stabilisation/anterior fusion

119
Q

PC of facet arthropathy

A

stiff in morning, loosen up routine, restless pain, difficulty sitting/driving/standing. worse on extension and better with activity. pain often radiates to buttock/legs

120
Q

treatment for facet joint arthropathy

A

can’t replace so remove and fuse.

121
Q

PC of bone/joint infections

A

red, heat, pain, swelling, LOF

122
Q

basic principle of joint/bone infections (regarding antibiotics and investigations)

A

dont start antibiotic until know what you’re treating. get specimen for culture and specify. don’t overly rely on tests. choose investigations carefully

123
Q

investigating potential joint/bone infection

A

BLOODS: CRP, PV, [ESR, WBC, Blood cultures (occasionally)]

IMAGING: Xray, technetium scan, MRI.

124
Q

what is included in joint/bone infection

A

septic arthritis, OM, soft issue infections, infected arthroplasty

125
Q

Acute OM commonly occurs why and what organism

A

post-trauma/open causes innoculation.

S.aureus

126
Q

what is tour of infection in acute OM in children/IC?

A

haematogenous [Hemophilus in kids]

127
Q

treating acute OM

A

let pus out, get sample as any bug can cause OM

128
Q

chronic OM invesigations

A

blood unhelpful

MRI, plain X-ray good.

129
Q

treatment of chronic OM

A

surgery not always necessary(bugs behave differently)

130
Q

chronic OM Pathology

A

get bone abscess/brodie’s cyst.

can cause necrotic bone (sequestrum)

131
Q

how can septic arthritis occur

A

direct innocukatino, direct haemoatogenous, metaphyseal spread

132
Q

what is treatment for cellulitis

A

best guess antibiotics to cover Staph + Strep (benzylpenicillin and Fluclo)

133
Q

what is a specific feature of necrotising fascitis

A

crepitus under skin (crunching gravel), due to gas producing organism.

134
Q

when to suspect discitis. common organism

A

common cause of back pain in children. s.aureus

135
Q

treatment for discitis

A

antibiotics (as surgery risky)

136
Q

when would you suspect infected arthroplasty and what type of infection is it?

A

“never painless post-op”.

deep infection

137
Q

investigations for infected arthroplasty

A

CRP, joint aspiation, bone scan, Xray.

138
Q

what is seen on Xray in infected arthroplasty

A

demarkation due to loossening due to infection

139
Q

why do antibiotics not work in infected arthroplasty

A

biofilm formed

140
Q

what is a clear sing of infected arthroplasty

A

sinus swelling

141
Q

how is infected arthroplasty avoided

A

clean air theatre, local and systemic antibiotics, duration of surgery, neat surgery, hand washing, theatre disipline, antibiotics i bone cement. (EG: co-amoxiclav, fluclox, gent, Clind, co-trimoxazole)

142
Q

what are common childhood hip conditions

A

DDH, perthes, infection, transient synovitis, SUFE.

143
Q

DDH PC

A

0-18months. early = extra skin fold on thigh, or late = limp

144
Q

DDH risk factors

A

breach position, FHx, other MSK abnormalities. >Girls

145
Q

DDH stands for?

A

Developmental dysplasia of the hip

146
Q

DDH: what is seen on Exam

A

feel for click/clunk, look for assymetry, check abduction

147
Q

DDH: imaging

A

Xray (hard to see as not ossified), US

148
Q

DDH: treatment

A

diagnosed early = Pavlik harness

late= manipulation/open reaction

very late= major surgery (osteotomy of femur and acetabulum)→ never have normal hip→ OA

149
Q

limp in pre-school child DD

A

infection, transcient synovitis, late presenting DDH

150
Q

limping preschooler due to infection: PC

A

PC - pain at rest or movement, resistance to movement, associated fever, susceptible individual, infection elsewhere

151
Q

limping preschooler due to infection: investigations

A

blood (WBC, ESR, CRP, blood culture), US for effusion, Te bone scan

152
Q

limping preschooler due to infection: treatment

A

antibiotics, aspiration/arthrotomy

153
Q

transient synovitis:[irritable hip] PC

A

limping preschooler (2-5years), pyrexia low grade, generally well, slight pain/resiitance to movement.

154
Q

transient synovitis:[irritable hip] investigation and management

A

normal bloods, US reveal effusion, resolves with rest

155
Q

late presenting DDH; PC and how to diagnose?

A

painless limp, short leg, associated creases, trendelenberg limp - do Xray

156
Q

what is Perthes and what is the disease process?

A

idiopathic AVN.

necrosis/sclerosis→ fragmentation → reossification → remodelling .

157
Q

Perthes PC [who and what]

A

small active boys(5-10 years) (often have ADHD), mild pain in hip, knee or groin

158
Q

treatment for perthes

A

aim to influence shape of femoral head, contain it within mould of acetabulum.

maintain hip abduction, rest and activity modification(all),, bracing (some), surgery (few)

159
Q

outcome of perthes

A

variable on shape of head at end, younger onset= better prognosis. early onset OA may occur

160
Q

SUFE means what?

A

Slipped capital femoral epiphysis

161
Q

SUFE PC

A

10-16 years, adolescent growth spurt, commoner in obese back males. 20% bilateral. pain in hip, buttock or solely in knee/distal thigh pain.

162
Q

SUFE pathogenesis

A

thyroid H, GH, Sex Hormones cause weakened physis.

163
Q

what sign is seen of Xray if SUFE

A

Trethowan’s sign

164
Q

two types of SUFE

A

acute - unstable, sudden onset, rapid progression to severe = fix quick as can lose hip due to reduced blood.

chronic - stable, insidious, slowly progressive and mild. 90%

165
Q

SUFE treatment

A

pin (open/closed) or THR if too late.

166
Q

how can AVN be treated?

A

THR, Core decompression

15021998-MSK (19 decks)

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