week 3 Flashcards
how many vertebrae in spine and where?
33
7c, 12t, 5l, 5s, 4c
what is c7 called?
vertabra prominans
what do atlas and axis allow?
head rotation
what is significant feature of c7?
No foramena transeverse process (veretbral artery)
which vertabrae has odontoid process?
c2
which vertebrae have no intervertebral disc
c1-c2
what is the disease process in spondylitis and OA? what exacerbates pain?
intervertrbal disc loses water, overloads facet joints, pain is worse on extension of spine (as facet joint takes pressure when leaning back )
what can help specific level OA in spine?
Facet joint injections under fluoroscopy
what makes up an intervertberal disc?
Outer annulus fibrosis and inner gelatinous nucleus pulposus
where does intervertebral disc degeneration most occur?
L4/5 or L5/S1
why is MRI not diagnostic in diagnosing disc degeneration/nerve root compression?
because many people have bulging discs, disc extusion or asymptomatic nerve root compression
why does acute disc prolapse occur?
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
spinal cord ends at L1 becoming what?
cauda equina
with disc prolapse which nerve root is usually compressed
the transersing nerve root (e.g.: root L5 for L4/L5 prolapse)
from where does the sciatic nerve arise?
L4-S3
what can nerve root compression cause?
radiculopathy (pain down sensory distortion of nerve)
learn dermatomes
learn myotomes
segmental innervation of hip (myotomes)
hip flexion L2,3
hip extention L5,S1
segmental innervation of knee(myotomes)
knee flexion L3,4
knee extension L5,S1
segmental innervation of foot (myotomes)
inversion L4,L5
eversion L5,S1
segmental innervation of ankle (myotomes)
dorsiflexion L4,5
planterflexion S1,2
what is spinal stenosis?
compression of nerve roots by osteophytes and hypertrophied ligaments in OA
what is classic sign of spinal stenosis?
radiculopathy or burning leg pain on walking = neurogenic claudication
treatment of spinal stenosis
surgical decompression (some patients)
what causes cauda equina syndrome?
compression on all lumbroscaral nerve roots (usually prolapsed disc)
signs of cauda equina syndrome?
bilateral lower motor neurone signs, bladder/bowel dysfunction, saddle anaesthesis and loss of anal tone
muscles of the spine
many
3 main = Iliocostalis, Longissimus thoracis, Spinalis thoracis (erector spinae = source of sprains and strains)
what is a chance #?
very unstable, where posterior ligaments are disrupted (+/- # of posterior elements) - due to sudden flexion
where is lumbar puncture performed and why?
L4-S2 (less likely to hit nerve)
what are causes of back pain?
bone (#, tumour, OM), joint, (Oa,spondylosis, spinal stnosis) muscle/ligaments (sprain and strains), disc (sciatica, CES, discogenic back pain)
monteggia and galeazzi #
ulnar #, radial head dislocation (at elbow) and Galeazzi # is opposite (radial # and dislocation at distal ulnar joint)
where does sciatic pain radiate to
BELOW knee (question if not)
what is a sprain, what is a strain?
strain = muscle/tendon
sprain = ligament
where can mechanical back pain go to?
buttock/thigh
what is treatment for sciatica
conservative for 3 months then consider surgery
what is childrens development of lower limb
normal variation (overlaping toes, vaglus/varus, instep foot…)
bow-legged, to knock-kneed, to corrected;
what is classed as a deformity in kids?
a harmful/likely to presist defect (creating physical/mental problems)
how do bones grow?
length = from physis by endochondrial ossification
circumference= from periosteum by appositional growth
(some bone grow > others - shoulder and knee greater growth)
what are factors affecting bone growth?
diet/nutrition, VitD, injury, illness, hormones (GH)
when is the pubertal growth spurt?
female = 12
male = 14
what is considered in children of small stature
lots of kids with few pathological reasons. gentics (percent height), nutrition,
dysmorphic features= genetic or endocrine disorder
what are normal growth milestones?
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)
what are the two problems with knee alignments kids?
genu varus - bow legged
genu valgum - knock knee
genu varus treatment/assessment
mild familial condition. reassure,
may be abnormal if unilateral, severe angle, short stature or painful
what causes pathological genu varus
SKELETAL DYSPLASIA, rickets, tumour (endochrondrima), BLOUNTS DISEASE, trauma (to physis)
familial/idiopathic
what is Blounts disease?
common cause of genu varus
growth arrest over medial growth plate, unknown aetiology, “beak-like protrusion X-ray”
genu valgum assesment
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
causes of genu valgum
tumours, rickets, NEUROFIBROMATOSIS, idiopathic
what is in-toeing also known as? When is it made more prominent?
pigeon-toes
accentuated when running
what are three common causes of in-toeing?
femoral neck anteverions, tibial shaft torsion, metatarsus adductor.
[vast majority of all resolve if severe then surgery/casting may occur in adolescence.]
treatment of in-toeing
reassure, define cause, chart/photogrpah, review,, discharge unless severe/persistent then refer
Flat feet pathogenesis
born with flat feet and lack of medial arch development (tibias posterior doesn’t strenghten) = 20% people
how to determine between fixed and flexible flat feet
get to stand on toes.
flat feet AKA
pes planus or fallen arches
treatment flat feet
usually asymptomatic, determine type of flat foot, may resolve/no help using orthotics.
what increases likelihood of flat feet?
hypermobility
curly toes: which toes? when they resolve by? treatement?
common, usually 3/4th toe, vast majority resolve by age 6, splintage/stapping ineffective. flexor tenotomy [rarely] if persisting
what causes anterior knee pain?
stairs, squatting, jumping
who normally gets anterior knee pain?
sporty female adolescents
PC of anterior knee pain
localised patellar tenderness
investigating anterior knee pain
examination + radiograpahy.
remember to check HIPS (femur problems transmitted by obturator nerve giving knee pain as PC)
treatment of anterior knee pain
physio, resolves over time
what score is used to assess hyper mobility?
Beighton Score
what can rigid flat foot be cause by? treatment for this?
rare condition cause by underlying bony connection known as tarsal coalition - surgery if painful
things to consider in back pain Hx
onset, previous, site, nature, radiation, neurology, age, occupation.
(back pain is often insidious in nature beware patient with exact date)
what are the red flag symptoms for back pain?
<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
what to examine in back pain patient
Observation
Range of movement
Neurological assessment (myotomes, dermatomes, reflexes)
Nerve root irritation (straight leg test and see if pain changes)
Distraction testing
myotomes of hip flexion, knee extension, foot dorsiflexion+ EHL, ankle plantar flexion
L1/2 hip flexion
L3/4 knee extension
L5 foot dorsiflexion & EHL
S1/2 ankle plantarflexion
investigating back pain
xray useless (unless severe)
MRI gold standard but beware false positives
Also, Diagnostic facet injection, Contrast enhanced CT, Provocation discography, Selective nerve block / ablation
what is sciatica?
Buttock and / or leg pain in a specific dermatomal distribution accompanied by neurological disturbance.
what is disc prolapse?
slipped disc, Variety of syndromes and presentations (Leg pain and neurology unpredicatable)
Surgery is for the leg pain
disc prolapse common PC
episodic back pain with onset of leg pain +/- neurology. Leg pain then becomes dominant (seen down myotomes/dermatomes)
slipped disc/disc prolapse treatment
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
management of backache First line
short bed rest, anti-inflammatory +/- muscle relaxant, mobile thereafter. physio and return to normal activity.
management of backache second line
educate, reassure, osteopathy/chiropractic, TENS/psycology + pain clinic then surgery
what causes adjacent segmental disease?
preys back surgery + natural underlying problems causes fusion of joints.
CES
Fracture with deteriorating neurology
Time sensitive = < 24 hours to treat, urinary/bowel problem
how to assess spinal # initially?
immoblise, Xray/CT, don’t forget other injuries
what to look for in neurological exam after spinal #?
motor, sensory, pay attention to saddle area
what to do for suspected C-spine injury
rigid collar, X-ray/CT (include C7/T1), soft tissue shadow indicated concern, remember other injuries
what to do for suspected T-spine injury, where is it most commonly?
rigid spine board, visualise whole spine, neurological, most commonly T12/L1, emember other injuries
factors to consider in spinal cord involvement
location, size of spinal canal, bone pinching?, contact pressure (bone/disc), Xray can seem fine with major involvement
what occurs in secondary cord damage?
Cord swelling Oedema Ischaemia Thrombosis of small vessels Venous obstruction
why is moving the patient with a spinal injury okay?
- rarely cause a problem.
- Hypoxia, hypoxaemia, and poor perfusion carry a much greater risk of precipitating neurological damage in compromised tissue
what are the patterns of spinal cord injury?
complete
incomplete (central, anterior cord and Brown-Sequard)
what is a good prognostic sign in complete cord injury?
saddle sparing
central cord injury: due to what, prognosis and PC?
Typically hyperextension injury
Arms worse than legs
Prognosis variable but generally good
Brown-Sequard: PC, prognosis and cause
Paralysis on ipsilateral side
Hypaesthesia on contralateral side
due to trauma/#
best prognosis
anterior cord injury: PC, causes and prognosis
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
why does secondary cord damage occur?
stretching, comprssion, undue movemtn, hypotension, innaporoprate surgery, infection
what is the role of surgery in the incomplete cord injury?
controversial (due to risks)
what is the role of surgery in the complete cord injury?
little place for it
what is the role of surgery in the c-spine injury?
reduction and wiring
what is the role of surgery in the Thoracolumbar injury?
little place, occasionally decompression
when is spinal surgery performed
1 week later (swelling reduced),
what are options for spinal surgery
fixation and grafting,
short segment fixation
when would a patient be worse off in a collar?
if have AS - rigid spine with C-spine kyphosis don’t force collar. immobilise in natural position and get CT ASAP
what needs to be assumed if patient has AS and injury
, until CT has proven otherwise
what needs special attentions to in children spinal injury?
Ring epiphysis (weak point)
Damage to a growth plate cause premature fusion and cessation of growth. In the spine this can lead to kyphosis.
what needs special attentions to in adolescent spinal injury?
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.]
PC of lower back pain
pain (localised/lumbar), referred pain (sciatica), stiffness, loss of sleep, LOF
Hx of back pain
pain, LOF, trauma(recent + past), previous surgery, symptoms suggesting other pathology (pancreatic, resp, GI, GU…).
investigating back pain
usually none; blood =ESR/PV/alk phos; rarely Xray unless trauma, MRI (sciatica, red flags…)
red flags for back pain
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
when is MRI used in back pain?
if red flags, if surgery being considered, spinal stenosis, non-resolving sciatica
what is seen on Xray for OA?
LOSS OF JOINT SPACE
OSTEOPHYTES
SCLEROSIS
SUBARTICULAR CYSTS
causes of back pain?
Mechanical/non-specific - >90%
Tumour/metastases – 0.7%
Ankylosing spondylitis – 0.3%
Infection – 0.01%
yellow flags for back pain
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
management of back pain
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
secondary care/specialised investigation for back pain
MRI, facet joint injection, contrast CT, provocation discography, selective nerve block/ablation.
treating prolapsed disc surgically
microdiscectomy, most settle without surgery [time scale variable], phased return to work.
what condition causes spinal claudication
spinal stenosis
difference between spinal claudication and vascular claudication
spinal = Relieved by flexing,Uphill often relieves, Cycling easy.
vascular= standing helps, uphill bad, cycling bad.
Myelogram can help tell difference
spinal claudication PC
limited excretes capacity, stooping/sitting/leanforward helps. easier going uphill than downhill. get tired/heavy legs after certain distance.
what is dudes to investigate spinal claudication?
Xray, Hx, Myelogram can help tell difference
surgery for spinal claudication?
nerve root decompression or fusion/stabilisation
discogenic pain PC
segmental instability, worsened by: as day goes on, flexion, activity.
Pain = deep seated central back pain(toothache like)
surgery for discogenic back pain
Graf ligament Stabilisation/anterior fusion
PC of facet arthropathy
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
treatment for facet joint arthropathy
can’t replace so remove and fuse.
PC of bone/joint infections
red, heat, pain, swelling, LOF
basic principle of joint/bone infections (regarding antibiotics and investigations)
dont start antibiotic until know what you’re treating. get specimen for culture and specify. don’t overly rely on tests. choose investigations carefully
investigating potential joint/bone infection
BLOODS: CRP, PV, [ESR, WBC, Blood cultures (occasionally)]
IMAGING: Xray, technetium scan, MRI.
what is included in joint/bone infection
septic arthritis, OM, soft issue infections, infected arthroplasty
Acute OM commonly occurs why and what organism
post-trauma/open causes innoculation.
S.aureus
what is tour of infection in acute OM in children/IC?
haematogenous [Hemophilus in kids]
treating acute OM
let pus out, get sample as any bug can cause OM
chronic OM invesigations
blood unhelpful
MRI, plain X-ray good.
treatment of chronic OM
surgery not always necessary(bugs behave differently)
chronic OM Pathology
get bone abscess/brodie’s cyst.
can cause necrotic bone (sequestrum)
how can septic arthritis occur
direct innocukatino, direct haemoatogenous, metaphyseal spread
what is treatment for cellulitis
best guess antibiotics to cover Staph + Strep (benzylpenicillin and Fluclo)
what is a specific feature of necrotising fascitis
crepitus under skin (crunching gravel), due to gas producing organism.
when to suspect discitis. common organism
common cause of back pain in children. s.aureus
treatment for discitis
antibiotics (as surgery risky)
when would you suspect infected arthroplasty and what type of infection is it?
“never painless post-op”.
deep infection
investigations for infected arthroplasty
CRP, joint aspiation, bone scan, Xray.
what is seen on Xray in infected arthroplasty
demarkation due to loossening due to infection
why do antibiotics not work in infected arthroplasty
biofilm formed
what is a clear sing of infected arthroplasty
sinus swelling
how is infected arthroplasty avoided
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)
what are common childhood hip conditions
DDH, perthes, infection, transient synovitis, SUFE.
DDH PC
0-18months. early = extra skin fold on thigh, or late = limp
DDH risk factors
breach position, FHx, other MSK abnormalities. >Girls
DDH stands for?
Developmental dysplasia of the hip
DDH: what is seen on Exam
feel for click/clunk, look for assymetry, check abduction
DDH: imaging
Xray (hard to see as not ossified), US
DDH: treatment
diagnosed early = Pavlik harness
late= manipulation/open reaction
very late= major surgery (osteotomy of femur and acetabulum)→ never have normal hip→ OA
limp in pre-school child DD
infection, transcient synovitis, late presenting DDH
limping preschooler due to infection: PC
PC - pain at rest or movement, resistance to movement, associated fever, susceptible individual, infection elsewhere
limping preschooler due to infection: investigations
blood (WBC, ESR, CRP, blood culture), US for effusion, Te bone scan
limping preschooler due to infection: treatment
antibiotics, aspiration/arthrotomy
transient synovitis:[irritable hip] PC
limping preschooler (2-5years), pyrexia low grade, generally well, slight pain/resiitance to movement.
transient synovitis:[irritable hip] investigation and management
normal bloods, US reveal effusion, resolves with rest
late presenting DDH; PC and how to diagnose?
painless limp, short leg, associated creases, trendelenberg limp - do Xray
what is Perthes and what is the disease process?
idiopathic AVN.
necrosis/sclerosis→ fragmentation → reossification → remodelling .
Perthes PC [who and what]
small active boys(5-10 years) (often have ADHD), mild pain in hip, knee or groin
treatment for perthes
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)
outcome of perthes
variable on shape of head at end, younger onset= better prognosis. early onset OA may occur
SUFE means what?
Slipped capital femoral epiphysis
SUFE PC
10-16 years, adolescent growth spurt, commoner in obese back males. 20% bilateral. pain in hip, buttock or solely in knee/distal thigh pain.
SUFE pathogenesis
thyroid H, GH, Sex Hormones cause weakened physis.
what sign is seen of Xray if SUFE
Trethowan’s sign
two types of SUFE
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%
SUFE treatment
pin (open/closed) or THR if too late.
how can AVN be treated?
THR, Core decompression
