Orthopedics
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| Low Back Pain: lifetime prevalence: | 60-80%
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| Leading cause of work related disability = | Low Back Pain
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| Low Back Pain Risk factors | obesity, sedentary, improper biomechanics
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| Low Back Pain: Prognosis | 70% improved in <1 week & asymptomatic in <1 month; 90% asymptomatic in 6-12 wks
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| Vertebral Disk contains: | central nucleus pulposus; peripheral annulus fibrosis
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| Disc degeneration MOA: | degeneration overloads facet joints in verts
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| Disc herniation MOA: | herniation impinges nerve roots
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| Anterior Mxs: | Abdominal & Psoas
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| Posterior Mxs: Superficial: | Erector Spinae, Iliocostal, longissimus & spinalis
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| Posterior Mxs: Middle: | Multifida
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| Posterior Mxs: Deep: | Intersegmental
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| Anterior & posterior muscles alternate to: | control trunk movement
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| Sensory Dermatomes: Lumbar & sacral n. innervate: | lower extremities
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| Pain: Simple sprains & strains = | Nonspecific pain in lower back or one or both buttocks
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| Nerve root pain: | Brief, sharp, shooting, increased by cough, standing, & sitting.
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| Pain: Neoplasm, Infection: | Severe, constant pain persisting at night
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| Pain: Red Flags | > 50 y.o.; kids; Night Pain; Fever, malaise, wt loss; Bladder/ bowel dysfunction; Progressive deficit; Prior ca; Pain > 1 month
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| LBP Hx: | C/C, meds, allergies
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| LBP HPI: | Initiating event, MOA; Site of pain; OLDCARTS; priors, tx, studies
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| LBP: PE: Inspection: | Gait; Posture; Deformity
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| LBP: PE: Palpation: | Bony; Soft Tissue; Pulses
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| LBP: PE: ROM: | Flex, ext, lateral flex, rotation
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| LBP: PE: Other Tests: | SLR; FABER test; Neuro Exam (Sensory, Motor, DTRs)
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| SLR test: | Pain on straight leg flexion reproduces radicular pain
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| Bragards test: | Foot dorsiflexion increases pain
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| Cross SLR test: | Raising contralateral leg causes radicular pain on ipsilateral leg
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| FABER test: | Pain in SI joint
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| LS Spine Exam: inspection: | Symmetry/ Deformity/ Scars
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| LS Spine Exam: motor: L1: | Hip flexion
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| LS Spine Exam: motor: L2: | Hip adductors
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| LS Spine Exam: motor: L3: | Knee extension
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| LS Spine Exam: motor: L4: | Ankle dorsiflexion
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| LS Spine Exam: motor: L5: | Hallicus Longus extension
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| LS Spine Exam: motor: S1: | Hallicus Longus flexion
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| LS Spine Exam: sensory: L1: | Upper outer thigh
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| LS Spine Exam: sensory: L2: | Mid anterior thigh
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| LS Spine Exam: sensory: L3: | Below patella
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| LS Spine Exam: sensory: L4: | Medial ankle
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| LS Spine Exam: sensory: L5: | First web space
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| LS Spine Exam: sensory: S1: | Lateral ankle
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| LS Spine Exam: DTRs: Knee: | L2,3,4
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| LS Spine Exam: DTRs: Ankle: | S1
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| Waddell Signs: Tenderness: | Superficial skin tenderness over wide area; Non-localized deep tenderness
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| Waddell Signs: Simulations Tests: | Axial load should not cause LBP
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| Waddell Signs: Distraction Tests: | Flip test
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| Waddell Signs: Regional Disturbances: | Widespread muscle pain in various groups
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| Waddell Signs: Over-reaction: | Pain out of proportion
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| Lumbar Strain: Hx: | MOI; site of pain
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| 70% of LBP = | Lumbar Strain
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| Lumbar Strain: PE: | Tender paravertebral or erector spinae mx; min radiation
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| Lumbar Strain: Rx : | Pain relief, modified activity, exercise, education, & encouragement; Injection with trigger point pain; PRICEMMM
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| 4% of LBP = | HNP
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| HNP: DDx: | Infection, tumor
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| HNP: Evaluation: | MRI / CT
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| HNP: MRI/CT: asymptomatic disc herniation found in: | 17-36%
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| HNP: Lumbar nerve root compression: L1-3 nerve roots: | 5%, pain & numbness above knee
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| HNP: Lumbar nerve root compression: L4 nerve root (L3-4 disk space): | 5%, numbness to shin, weak ankle dorsiflexion
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| HNP: Lumbar nerve root compression: L5 root: | 67%, weakness of EHL & numbness top of foot and 1st web space
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| HNP: Lumbar nerve root compression: S1 root: | 28%, numb lateral foot, weak plantarflexion
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| HNP: Lumbar nerve root compression: Rx: | Conservative, NSAIDs, mx relaxants, Exercise & Education
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| HNP: Lumbar nerve root compression: 10% require: | surgery d/t progressive neurologic deficit
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| Pharma Tx of Acute LBP: Pain relief: | NSAID; Cox-2, Celebrex; Narcotic; Lidoderm patch; Anti-inflammatory; mx relaxants; Steroids
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| Pharma: LBP: Pain: NSAID: | Ibuprofen 800 q6-8h pc; Naprosyn 500 BID
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| Pharma: LBP: Pain: Narcotic: | Percocet 5/325 q4-6h Vicodin 5/500 q 4-6h
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| Pharma: LBP: Pain: Anti-inflammatory: | NSAID, Cox-2
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| Pharma: LBP: Pain: Muscle relaxants: | Flexeril; Skelaxin; Soma, Robaxin
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| Pharma: LBP: Pain: Steroids: | Hold NSAIDs; Burst of oral steroids; consider trigger point
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| Sacroiliac Dysfn: | Acute or chronic injury to SI joint
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| Sacroiliac Dysfn: Sx: | Pain in SI area, Pos FABER, No discogenic pain
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| Sacroiliac Dysfn: Lab: | consider CBC, ESR, ANA, RF, HLA-B27
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| Sacroiliac Dysfn: RX: | Ice, Stretch, NSAIDs, injection
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| Cauda Equina Syn: affects: | L2-L4 nerve roots
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| Cauda Equina Syn: Mechm: | Compression of nerve roots causes paralysis without spasticity (LMN)
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| Cauda Equina Syn: Etiology: | Central disc herniation, abscess, hematoma
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| Cauda Equina Syn: Sx: | Loss of bladder/ bowel control, bilateral LE weakness & sensory deficits
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| Cauda Equina Syn: Rx: | Emergent Surgical Decompression
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| Lumbar Spinal Stenosis = | Progressive degeneration of disc & facet joints; Narrowing of canal; Compression of n. roots
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| Lumbar Spinal Stenosis: Signs: | Neurogenic claudication, radicular sx; Pain increased w/ sitting or spinal ext; Pain relieved w/ flexion, pt walks stooped-over
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| Lumbar Spinal Stenosis PE: | Sensory changes, dec DTR, mild weakness
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| Lumbar Spinal Stenosis: Course: | Deficits may progress
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| Lumbar Spinal Stenosis: Xray: | may show narrowing of the IVD, old burst fx; MRI demonstrates stenosis
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| Lumbar Spinal Stenosis: Rx: | PT, core strength, NSAIDs, dec impact & bending, surgical decompression for progressive dz
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| Spondylolysis = | Pars interarticularis stress fx
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| Spondylolysis: Prevalence | 5%-8 % of population; Dancers, gymnasts, lifters
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| Spondylolysis: occur most often at: | L5
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| Spondylolysis: S/S | Pain adjacent to midline, inc with extension & rotation
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| Spondylolysis: xray | Scotty dog collar only on oblique xray
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| Spondylolysis: Rx: | modify activity, core exercise, gradual RTP
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| Spondylolisthesis = | Vertebral sliding (Dancers, gymnasts)
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| Spondylolisthesis: PE: | Step-off, may be asx.
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| Spondylolisthesis: Grading | Grade I – V (25 to >100%); Isthmic, degenerative
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| Spondylolisthesis: xray | Lateral film shows slip
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| Spondylolisthesis: Rx: Asx: | no restriction, core exercise
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| Spondylolisthesis: Rx: Symptomatic: | no restriction, core exercise, consider brace; Surgery for progressing slips or deficit
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| Piriformis Syndrome = | Irritation of sciatic n. (L4,5, S1,2,3) beneath piriformis mx
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| Piriformis Syndrome: etiology | Trauma, spasm, anatomic
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| Piriformis Syndrome: PE: | FROM of lumbar spine; Sciatic notch tenderness
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| Piriformis Syndrome: DDx: | HNP
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| Piriformis Syndrome: RX: | Rest, ice, meds, stretch, injection
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| Lateral spine curvature = | Scoliosis
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| Scoliosis: < 10 degree: tx | observe
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| Scoliosis: < 20 defree: tx | conservative Rx
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| Scoliosis: Occurs where: | T or L spine
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| Scoliosis: most common cause: | Idiopathic
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| Scoliosis: prevalence | Girls 7x > than males
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| Scoliosis: Adults: | secondary dz & pain
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| Scoliosis: Surgical Rx: | Fusion & Rod
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| Scoliosis: Exam: | Forward flexion; Look for spine, scapula or hemi-thorax asymmetry
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| Scoliosis: Xray Cobb angle: | Measure angle from tilted vertebrae above & below apex of curve
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| 50% of pts with solid tumors have: | mets to spine
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| Tumor: Highest prevalence: | BrCa, lung, prostate, colon, thyroid, kidney ca (hematogenous spread)
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| Tumor: Sx: | Night pain, n. root compression
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| 10% of spinal bone tumors are: | primary
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| Spinal bone tumors: in children, 20% are: | malignant
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| Spinal bone tumors: Primary malignant: | Osteosarcoma, Ewing Sarcoma, Chondrosarcoma
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| Degenerative joint dz = | loss of articular cartilage & growth of new bone around facet joint
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| Facet Syndrome = | n. root compression by loss of disc height & facet hypertrophy
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| Osteoarthritis: X-ray: | joint narrowing, sclerosis, osteophytes
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| Osteoarthritis: Rx: | Wt reduction, pt education; Pain relief
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| Ankylosing Spondylitis: involves: | SI joint, and spine
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| Seronegative spondyloarthropathy: | HLA-B27 usually positive
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| Ankylosing Spondylitis: Sx: | Chronic low back pain in young adults; morning stiffness, improves with movement; 20% peripheral joint sx (Enthesopathies common; 25% with anterior uveitis)
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| Ankylosing Spondylitis: PE: | Schobers test (normal is 5 - 7 cm movement)
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| Ankylosing Spondylitis: X-ray: | Erosion & sclerosis on plain films
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| Ankylosing Spondylitis: Rx: | PT, NSAIDs, Sulfasalazine, Infliximab
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| Testing Spinal Mobility: | Schobers Test
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| Schobers Test: | 2 midline marks 10 cm apart starting at PSIS (dimple of Venus); remeasure w/ lumbar spine at maximal flexion
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| Schobers Test: Less than 5 cm difference suggests: | pathology
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| Ankylosing Spondylitis = | Calcification btw vertebral bodies at edge of discs; gives appearance of bamboo stalk; sclerosis of SI joint
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| Osteoporosis = | Reduction in bone mass (Low peak mass; inc bone loss; hyperparathyroid, chronic steroids)
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| Visceral Causes: prevalence in LBP | 2% of LBP
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| LBP: Visceral Causes: Referred pain from: | GB; Pancreas; AAA; Endometriosis; Chronic PID; Prostate CA; Renal stones or pyelonephritis
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| LBP: Need for imaging | Rarely needed in nontraumatic, recent onset ALBP
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| LBP: Imaging: when | Plain films approp: trauma/ longstanding sx ; if conservative Rx fails
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| LBP: Imaging: Order: | AP / Lateral; Obliques; Flex & Ext
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| LBP: MRI study of choice for: | discopathy
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| LBP: Tc 99m bone scan for: | primary tumors, metastatic disease, or infection
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| Reading Spine Films: looking for: | Fx; Disc space changes; Arthritic changes; Listhesis; Tumors
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| Spine Film: Frontal View: each vert resembles: | an owls head, straight on; each eye = pedicle; beak = spinous process
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| Spine Films/ Frontal: Horizontal displacement may = | fx or dislocation
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| Spine Films/ Frontal: Decreased intervertebral space = | Fx, DDD, HNP
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| Spine Films/ Frontal: Vert body (owl head) for: | Missing eye (destrn); pedicle
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| Spine Films/ Frontal: Vert body: Crack in owls eye: in = | Chance fx (seat belt fx)
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| Spine Films/ Frontal: Vert body: Inc space btw owls eyes: in = | Burst fx
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| Spine Films/ Frontal: Vert body: Dec head height: in = | Burst fx
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| Spine Films/ Frontal: Vert body: Open bea, or inc distance btw 2 beaks: in = | Chance fx or spinous process fx
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| Spine Films: Oblique: each vert = Scotty Dog: look for: | a collar
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| Spine Films: Oblique: Scotty Dog: front & hind legs = | inf intervertebral articular processes
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| Spine Films: Oblique: Scotty Dog: Ears & tail = | superior intervertebral articular processes
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| Spine Films: Oblique: Scotty Dog: Dog body = | the lamina
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| Spine Films: Oblique: Scotty Dog: dogs eye = | a pedicle
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| Spine Films: Oblique: Scotty Dog: nose = | a transverse process
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| Spine Films: Oblique: Scotty Dog: Neck = | the pars interarticularis
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| Spine Films: Oblique: Scotty Dog: If the tail is to your right, you are looking at: | right lamina (& vice versa for left)
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| Spine Film: Lateral View: Vert alignment: displacement seen in: | fx & listhesis.
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| Spine Film: Lateral View: decreased intervert disc space in: | fx, DDD, & HNP
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| Spine Film: Lateral View: Cf ant & post vert body cortex for: | changes in ht cf to the others (Burst or wedge fx)
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| Spine Film: Lateral View: fx lines in spinous processes = | black (lucent) fx lines
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| Spine films: stable fxs = | Wedge fx; spinous process fx
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| Spine films: unstable fxs = | Burst fx; Chance fx
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| Chance fx: Unstable: best seen on what film? | lateral
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| Chance fx: MOI | MVA: lap belt immobilizes pelvis & thorax is forcefully flexed forward
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| Chance fx: Seen on AP = | crack thru eyes (pedicles), or open beak (crack through spinous process)
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| Burst fx: Unstable = | Collapse of vert body
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| Burst fx: Unstable: seen on lateral view as: | smaller vertebral body
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| Burst fx: Unstable: on AP = | inc distance btw pedicles
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| Burst fx: MOI: | fall from a ht, landing on feet or buttocks
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| Burst fx: Fragments: | may extend into spinal canal causing neuro S/S
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| Wedge fx: Stable = | Collapse of ant vert body w/ an intact posterior wall
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| Wedge fx: Stable: result of: | hyperflexion injury and / or osteoporosis.
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| Spinous Process fx: Stable: on lateral view = | Lucency thru spinous process
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| Most common Spinous Process fx found in: | C-spine (Clay Shovelers fx)
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| Spinous Process fx: MOI: | sudden forceful ligamentous traction on spinous process, or a direct blow to the process
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| Coccyx fx: MOI | Fall on coccyx
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| Coccyx fx: PE: Do: | rectal to R/O hematoma, displaced fx
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| Coccyx fx: mild trauma: xray = | Radiographs not indicated
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| Lower Back Rehab to: | Ctrl pain; Reduce inflame; relative rest; Pain free ROM; correct inflexibilities & strengthen core mx; aerobic conditioning; wt reductn; correction of biomechanics; prevent recurrence
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| LBP Prevention | Regular strength/ flexibility exer; correct lifting & moving tech; posture standing/ sitting; proper body wt
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| LBP tests | xrays if pain >4 wks; MRI/CT sens > xray for infxn, ca, hern disk, stenosis; CBC, ua, Ca, PO4, ESR, alk phos
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| LBP: anemia, ESR | anemia w/MM, high ESR in malig, infxn, CTD
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| most common hip problems | Trochanteric & gluteus medius bursitis, OA, femur fx
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| Lateral hip pain that is aggravated by direct pressure = | trochanteric bursitis
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| Meralgia paresthetica affects the _____ nerve | lateral femoral cutaneous nerve
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| LBP: most common site of disk herniation | L5-S1 (also L4-L5)
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| Osteoporosis: prevalence in LBP | Causes 4% of LBP
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| Disc degeneration MOA: | degeneration overloads facet joints in verts
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| Sciatic nerve neurapraxia: | with L-S spine, pelvic, hip Fx, or HNP
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| Disc herniation MOA: | herniation impinges nerve roots
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| Coccyx fx: PE: Do: | rectal to R/O hematoma, displaced fx
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| Coccyx fx: mild trauma: xray = | Radiographs not indicated
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| Bragard test: | Foot dorsiflexion increases pain
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| Cross SLR test: | Raising contralateral leg causes radicular pain on ipsilateral leg
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| Waddell Signs = | Non-organic Physical Signs in LBP; TTP, axial load, flip test, Pain out of proportion
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| Lumbar Strain: PE: | Tender paravertebral or erector spinae mx; min radiation
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| HNP = | Herniated Nucleus Pulposus
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| HNP: most common = | L4-5, L5-S1
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| HNP: MOI: | Flexion & rotation; Tears in annulus
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| HNP: Sx: | Sciatica (radiating pain, numbness & weakness to LE)
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| HNP: Signs: | Pos SLR, Flip sign, Pain worse on back ext
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| Pharma Tx of Acute LBP: Pain relief: | NSAID; Cox-2, Celebrex; Narcotic; Lidoderm patch; Anti-inflammatory; mx relaxants; Steroids
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| Female exam, asymmetric posterior chest wall or uneven scapula height with forward bending | Scoliosis (> 25 degree Cobb angle = surgery)
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| Subluxation of vertebral body = | Spondylolisthesis
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