Clin Ortho - Lecture Exam 1 Review

Main causes of TOS:

Cervical rib Abnormal scalene Compromised rib or clavicle Traumatic injury (whiplash) Repetitive microtraumas (overhead activities) Poor posture Weight gain Swollen lymph nodes Tumor

What is Dejerine's Triad? What is the purpose of the test and its positive signs/symptoms?

Coughing, sneezing and bowel movement (straining). Purpose --> HNP, space-occupying lesion, spinal cord tumor/compression fracture (+) --> Reproduction of numbness/tingling/paresthesia with pain as well as dural pressure noted either uni or bilateral with coughing, sneezing, or while bearing down.

Adhesive capsulitis is also known as?

Frozen shoulder

What are the characteristic symptoms a patient will have when presenting with Meningitis?

Headache, fever, stiff neck

A pt presents with red flags. What next?

Red flags --> refer out *green/yellow --> ok to see/treat

What are some causes of cervical myelopathy?

Spinal stenosis Trauma Infections Diseases Oncological/neurological/congenital disorders

What is adhesive capsulitis (aka: frozen shoulder)?

Stiffness and pain in the shoulder joint that gradually worsens over time and then resolves. AROM and PROM tend to share same characteristic findings Diabetes patients are higher risk to get

Differentiate between a Sprain and a Strain?

Strain = stretching/tearing of a muscle/tendon Sprain = stretching/tearing of a ligament Strain = pain on active ROM Sprain = pain on passive ROM

What functions to prevent anterior displacement of C1 over C2 and acts as the main stabilizer for the odontoid process in order to prevent it from posterior migration?

Transverse ligament

Cubital tunnel syndrome is AKA?

Ulnar neuritis

Match the type of pain to its structure: 1. Dull/aching/cramping 2. Dull/aching 3. Sharp/shooting 4. Deep/nagging/dull

--> Muscle --> Ligament/joint capsule --> Nerve root --> Bone

Match the type of pan to its structure: 1. Throbbing and diffuse 2. Sharp, severe / intolerable 3. Sharp/bright/ "electric" or "lightning-like" 4. Burning, pressure-like, stinging, aching

--> Vasculature --> Fracture --> Nerve --> Sympathetic nerve

What is Cluster of Wainner? What is the purpose?

1) ULTT - Upper Limb Tension Test --> median nerve bias --> positive test would recreate sx 2) Cervical distraction test --> palliative* / reduction of sx 3) Spurling's A --> positive test would recreate sx 4) Cervical rotation <60º --> less than 60 rotation would be positive finding Order performed does not matter. This cluster is performed to rule in Cervical radiculopathy. 4/4 being positive findings results in over 90% diagnostic match for C.R.

Hill-Sachs lesion:

A small defect usually located on the posterior aspect of the articular cartilage of the humeral head; most commonly caused by the impact of the humeral head on the glenoid fossa as the humerus dislocates. Defect is diagonal to anterior glenoid when shoulder is in functional position

Most cases of meningitis in the U.S. are caused by what?

Viral infection *bacterial, fungal and parasitic are also causes

Myelopathy can be in what two areas of the spine? Which is more prevalent?

Cervical and thoracic. Cervical is most prevalent.

Cervical radiculopathy is a pain and/or sensorimotor deficit syndrome that is defined as being caused by compression of what?

Cervical nerve root

A pt presents w pain, numbness, and tingling in the upper extremity. She describes the pain as "electric and sharp" and even says it feels like muscle weakness too. What is the most likely diagnosis?

Cervical radiculopathy

Physical exam findings of Klumpke's palsy?

Characteristic claw hand - deficit of all small intrinsic hand muscles (ulnar and median nerves) - wrist in extreme extension d/t unopposed wrist flexors - hyperextension of MCPs - flexion of IP joints

What is cervical myelopathy?

Condition resulting from severe compression of the spinal cord in the cervical spine. Typically a gradually degenerative process occurring over time and with characteristic bilateral symptoms.

What is Erb's Palsy?

Congenital brachial plexus injury of C5/C6 (mostly C5*) upper level lesion; results from contralateral flexion of head and depression of ipsilateral shoulder (pulling motion of the arm in adduction and internal rotation)

What is radial tunnel syndrome? Which nerve(s) affects motor vs. sensory function?

Entrapment of the radial nerve involving the supinator muscle. Posterior interosseous nerves --> motor function Radial nerve --> motor and sensory function

Arthrokinematics of C0 on C1 (atlas):

Extension Posterior roll, anterior glide Flexion Anterior roll, posterior glide

Normal cervical spine ROM:

Flexion 60º Extension 75º Rotation 80º Lateral flexion 45º

Normal Elbow ROM?

Flexion 130-160º Extension 0º Pronation and supination 80-90º

What is a Jefferson fracture and its types?

Fracture of Atlas (C1) caused by axial loading, vertical compression, blow to top of the head Type 1 - pure ligament tear (needs surgical fix) Type 2 - avulsion rupture (needs halo vest to immobilize)

What are nociceptors and what is their relevance regarding the nature of pain?

Free nerve endings in the skin/joints/fascia/tendons/ligaments and muscle fascia that all respond to intense, potentially damaging stimuli via specific mechanisms.

What are the Grades for Elbow instability?

Grade 1 - Stretch Grade 2 - Minimal tearing Grade 3 - Full tear (this is often painless after the fact) Grade 4 - Avulsion fracture

Grading of patients suffering from neck pain:

Grade 1 --> No signs of major pathology; little to no interference with ADLs Grade 2 --> No signs of major pathology; interference with ADLs Grade 3 --> Pain w/ neurological signs and sx of nerve compression (radiculopathy) Grade 4 --> Signs of major pathology presents (e.g., instability, infection)

Evidence-based article regarding Lateral epicondylitis showed what findings?

Grip strength test --> 83%, 80% specific Based on literature review, none of the described tests can provide adequate certainty to rule in or out a disease based on diagnostic accuracy. Performing a combination of tests is essential*.

What are some clinical symptoms someone suffering from cervical fracture/instability could present with?

Headache Dizziness Neck/facial pain Drop attacks Swallowing/GI problems Hearing/vision problems Nerve compression Sharp/electrical and deep/achy pain

What chemicals increase pain transmission?

Histamine Bradykinin Acetylcholine Serotonin Substance p

Pathology of cervical radiculopathy?

IVF closure via nerve root compression causes paresthesia down the arm/hand

Pathologic gait:

Impairment of an individual's ability to walk, typically associated with altered mechanics and reduced efficiency.

What is Olecranon bursitis?

Inflammation of the bursa at the elbow

What is Meningitis?

Inflammation of the meninges (the three thin layers of tissue that protect the brain and spinal cord).

What is Klumpke's palsy?

Injury resulting from compression/traction of the lower brachial plexus C8/T1 (mostly C8*) - much less common - characterized by paralysis of the hand and wrist muscles (also known as claw hand deformity)

What is the most common MOA of plexopathy?

Injury to the brachial plexus most commonly caused by trauma

What differentiates cervical radiculopathy from thoracic outlet syndrome?

Injury to the thoracic outlet bundle which occurs past the level of the nerve root.

Nystagmus:

Involuntary rapid eye movements

Rupture of the TL (transverse ligament) may occur in what?

Jefferson fracture (C1 fracture)

Anesthesia:

Loss of feeling or sensation

Ataxia:

Loss of muscle coordination, inability to perform controlled movements

Evidence-based article regarding MCL insufficiency and tests performed showed what findings?

Medial elbow pain most commonly found in overhead athletes that often results in one or all of the following: point tenderness over the MCL, sharp pain, "pop", and/or an inability to throw. *Moving valgus stress test --> 100% sensitive, 75% specific Valgus stress (for pain) --> 65% sensitive, 50% specific Valgus stress (for ligament laxity) --> 19% sensitive, 100% specific Based on literature review, none of the described tests can provide adequate certainty to rule in or out a disease based on diagnostic accuracy. Performing a combination of tests is essential*.

Describe the symptomatology of Cervical disc herniation*: *posterolateral protrusion only*

Most commonly bilateral pain, can be unilateral Usually affects several dermatomes Pain on extension - increases Pain on flexion - decreases Pain relieved by rest: No Age: m/c 18-60 y/o Onset: Sudden Most commonly found at: C5/6

Which of the following conditions are required for referrals?

Myelopathy Meningitis Cervical fracture

TOS pathologies and their symptoms:

Neurogenic - 95% - Paresthesia in hands/fingers - pain/weakness in shoulder/arm - peripheral muscle wasting - loss of intrinsic muscles Venous - 5% - effort thrombosis - swelling, heaviness - bluish discoloration - mottled color of upper extremity* Arterial - 1% - cold skin - pale skin - peripheral weakness

Characteristic symptoms for a stinger/burner injury?

Numbness of shoulder, arm and/or hand Tingling/burning paresthesias down arm Regional muscle weakness with inability to extend or raise wrist/hand properly

What is "Ape Hand"?

Occurs when the median nerve has been injured via proximal median nerve lesion. D/t loss of opponens pollicis mm. function, resulting in paralyzed flexors of the wrist and an unopposable thumb

What typically happens before the transverse ligament ruptures?

Odontoid process fracture

What is Naffziger's test and what is it used for?

Orthopedic test used to help evaluate the cervical, thoracic and lumbar spine for evidence of nerve root compression (radiculopathy).

What is discogenic pain?

Pain felt due to an association between intervertebral disc pathology. - Decreased intervertebral disc height - decreased intervertebral foramen space (stenosis) - increased osteophyte formation (also leads to stenosis)

What are polymodal nociceptors?

Pain receptors (nociceptors) that respond to all three of the types of stimuli - Mechanical - Chemical - Thermal

What are the most common symptoms associated with radiculopathy?

Paresthesia down affected dermatomal distribution and/or radiating arm pain

What alone can diagnose cervical radiculopathy in over 75% of cases?

Patient history.

Systemic illnesses that cause stinger/burner pathophysiology?

Polyarteritis nodosa Lymphoma SLE (lupus) Temporal arteritis Ehlers-Danlos Can also be caused by viral and bacterial infections

Upon cervical extension, the cervical facets glide in which directions?

Posterior and inferior

Upon cervical lateral flexion, the facets move in what directions?

Posterior and inferior

Upon cervical rotation, the facets on the side of ipsilateral rotation move in what directions?

Posterior and inferior

Functional anatomy of TOS/Plexopathy:

Scalenes (middle and anterior) Clavicle 1st rib Pec minor Brachial plexus Subclavian artery (runs between anterior and middle scalene) Subclavian vein (runs in front of anterior scalene)

What is Rusts sign? What does it suggest?

Self immobilization of the neck/cervical spine to relieve symptoms. Pt wraps their hands around the posterior aspect of their neck (elbows in front) Purpose --> Cervical instability or fracture

What is Ulnar Neuritis (cubital tunnel syndrome)?

Sharp/shooting pain caused by inflammation and involvement of the ulnar nerve

What are some causes of cervical radiculopathy?

Stenosis Disc bulge/herniation Tumor/space occupying lesion Osteophyte formation Bone spurs Facet joint hypertrophy

Stinger/burner injury:

Stretch/avulsion/complete rupture of a nerve secondary to trauma. Most commonly associated with high-impact sports athletes.

Drop attack:

Sudden spontaneous falls while standing or walking, with complete recovery in seconds or minutes. No loss of consciousness.

What are the 3 locations of a dislocated shoulder leading to plexopathy?

Supraclavicular --> most common - involves roots/trunks - most severe Retroclavicular - least common - involves divisions Infraclavicular - involves cords/terminal branches

Characteristic symptoms of Systemic pain vs. MSK pain:

Systemic - pain at night - pain at rest - deeper/throbbing MSK - pain with movement - aggravated by mechanical stress - superficial

IRRST (internal rotation resisted strength test)

Tests for shoulder impingement. Strength in E.R. and weakness while doing I.R. = positive

What is intrathecal pressure and what causes it to be raised?

The intrathecal space is the space that holds cerebrospinal fluid (CSF). Increased intrathecal pressure means there is swelling/inflammation within the intrathecal space leading to expansion of dura matter within the brain and spinal cord. It is most commonly due to an afflicted trauma, space-occupying lesion/tumor, and hemorrhage.

The compression leading to cervical radiculopathy can occur as a result of?

Disc herniation Spondylosis Instability Trauma (rarely) Tumor

The foramina are largest in what segment of the cervical spine?

Upper cervical; gradually narrow distally, with the C7/T1 foramina being the most narrow.

What is Plexopathy?

Disorder/damage affecting a network of nerves, blood vessels, or lymph vessels. The region of nerves it affects are at the brachial or lumbosacral plexus'. Symptoms include pain, loss of motor control, and sensory deficits.

Dyesthesia:

Distortions of somesthetic sensation (usually associated with a partial loss of sensory innervation)

Transverse ligament laxity is present upwards of 14-22% in what patients?

Down syndrome patients

Cervical fracture/instability is upwards of 99% what?

Trauma-induced

T/F. Substance P is one of the chemicals that is responsible for pain transmission.

True. Substance P is a neurotransmitter and modulator of pain perception by altering cellular signaling pathways.

Labrum SLAP tear classifications:

Type 1 --> fraying of superior labrum and biceps tendon at glenoid rim Type 2 --> detachment of labrum and biceps tendon from glenoid rim Type 3 --> bucket handle tear of the superior labrum without extension into the biceps Type 4 --> bucket handle tear of the superior labrum with tearing of the biceps tendon

Pain that would be considered from a systemic origin might have which of the following descriptions?

Deep aching / throbbing Constant Disturbs sleep

What is the most common type of plexopathy?

Erb's palsy

What is Valsalva maneuver? What is the purpose of the test and its positive signs/symptoms?

A forced expiration against a closed glottis test associated with increased intrathoracic and intra-abdominal pressure. Purpose --> Cervical radiculopathy (+) --> Reproduction of numbness/tingling/paresthesia with pain as well as dural pressure noted with coughing, sneezing, or bearing down.

What's a very common strain/sprain injury in weightlifters or people who consistently lift overhead?

AC joint sprain (ligamentous)

Paresthesia:

Abnormal tactile sensation often described as creeping, burning, tingling, or numbness most commonly as a result of nerve compression

Pain timings and their names?

Acute 7 - 10 days Subacute 10 days to 7 weeks Chronic 7+ weeks

Physical exam findings of Waiter's tip deformity?

Adduction (due to loss of deltoid and supraspinatus for abd) Internal rotation (due to loss of infraspinatus for ER) Extended elbow (due to loss of biceps and brachialis for flexion) Flexion of the wrist

List of symptoms associated with cervical spine pathology?

Anesthesia Ataxic gait Drop attack Nystagmus Dyesthesia Asymmetry Sweating or lack thereof Tender muscles/bones/sclap Transient loss of hearing/consciousness/sight Upper

Upon cervical flexion, the cervical facets glide in which directions?

Anterior and superior

Upon cervical rotation, the facets on the side of contralateral rotation move in what directions?

Anterior and superior

Bankart lesions:

Anteroinferior labrum tears --> from traumatic anterior dislocation

List of signs associated with cervical spine pathology?

Arm/leg pain Auditory/speech disturbances Depressed mood Diplopia Fatigue/dizziness Gait disturbance Headache Paresthesia Stiff neck Vertigo

SLAP lesions happen where anatomically in the glenohumoral joint?

Between "9 and 3 'clock"

What are similar symptoms a patient could present with regarding a sprain or a strain?

Both present with dull, achy pain *but muscles only will typically present with cramping/spasm too*

Describe the symptomatology of Cervical spinal stenosis:

Unilateral or bilateral Usually affects several dermatomes Pain on extension - increases Pain on flexion - decreases Pain relieved by rest: Yes Age: m/c 30-60 years Onset: Slow (often accompanied by spondylosis and/or disc hern) Most commonly found at: cervical levels vary by case

Describe the symptomatology of Cervical Spondylosis:

Unilateral pain Distribution of pain into affected dermatomes Pain on extension - increases Pain on flexion - decreases Pain relieved by rest: No Age: M/c 65+ Onset: Slow Most commonly found at: C5/6 and C6/7

Lateral and medial Epicondylitis pathology and symptoms:

D/t overuse or trauma --> inflammation of tendons surrounding the epicondyle dull, achy localized pain

What are non-trauma related ways plexopathy can occur?

Diabetes mellitus Malignancy Infections (both bacterial and viral) Idiopathic

The cervical spine nerves are named in relation to what?

The vertebral body below the nerve in question

Tendinopathy:

Thickening hypertrophy of a tendon most commonly d/t chronic condition

What's the pathophysiological process of feeling pain?

Transduction (initial trauma) --> converts painful stimuli into a message Transduction --> passes that message received from the nociceptor along to the spinal cord Modulation --> transcribes the signal into the spinal cord via neurotransmitters Perception (actual feeling of pain) --> the brain understands the stimuli message and interprets it as pain

What ligament prevents anterior displacement of C1 over C2?

Transverse ligament

Tendinitis:

inflammation of the tendon; typically an acute process that results d/t excessive or unusual use of the joint