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Clin Path II > Thoracic > Flashcards

Thoracic Flashcards

1
Q

Where does breast cancer metastasis?

A
  • thoracic spine most commonly
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2
Q

Who get compression fractures due to osteoporosis?

A

Older patients with stopped posture

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3
Q

What can cause viscerosomatic referral to thoracic?

A
  • GI (palpate abdomen - esophageal, gallbladder, pancreas)
  • heart (acute coronary syndrome - auscultate heart)
  • lung (cancer - auscultate lungs)
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4
Q

Where can heart and esophageal issues refer?

A

Between shoulder blades - esophageal more narrow

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5
Q

Where can the gallbladder refer

A

Just distal to the inferior border of the scapula and on superior aspect of shoulder (upper traps)

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6
Q

Where can the pancreas refer

A

Thoracolumbar area

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7
Q

Where can and ulcer refer

A

Lower left rib cage wrapped from from to back

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8
Q

What is schepelmann’s sign?

A

Patient seated arms fully abducted and raised over head. Instruct patient to laterally flex thoracic spine to the left and right

positive
= pain on concave = intercostal neuritis
= or convex side = pleuritis (fibrous inflammation of the pleura), or intercostal myofascitis (MFTP)

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9
Q

What is shingles? What causes it? Who is at highest risk?

A

Painful rash typically in a dermatomal distribution (usually unilateral)

Viral infection - herpes zoster

Patients > 50 and immunocompromised patients

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10
Q

What is the progression of signs/symptoms for shingles?

A

Itching or tingling, then pain (often severe, burning, stabbing, or shock-like) in the area 1-5 days BEFORE the blisters develop

The rash lasts 7-10 days, the vesicles become yellowish, flatten and dry out. Complete healing in 2-4 weeks

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11
Q

About one in _____ people will have an episode of shingles during their lifetime

A

Four

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12
Q

What is the possible complication of shingles? Who is more at risk?

A

Postherpetic neurologia

Damaged nerves cause severe pain after the rash clears, lasting for weeks, months or years.

The risk of PHN increases with age

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13
Q

How is shingles treated? (4)

A
  1. Cover the rash with clothing or non-adherent dressing. Calamine lotion may help relieve the itching. The rash is contagious until the last blister has scared over
  2. Medical treatment for pain: paracetamol, ibuprofen or codeine
  3. Antiviral medication (acyclovir 800mg 5X/d for 7-10 days) if administered within 72 hours of onset, can shorten the duration and lower the risk of PHN
  4. Patients >50 should consider getting the vaccine for prevention
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14
Q

What is Scheuermann’s disease? Where is it located in the spine?

A

Results in progressive structural thoracic hyperkyphosis (<40-45 degrees) in children

The hyperkyphosis does not correct with flexion or hyperextension

75% thoracic, 25% thoracolumbar

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15
Q

What does sheuermann’s disease look Ike on xray?

A

Calcification of vertebral epiphysis characterized by

1) notching of vertebral endplates
2) wedging of vertebral bodies

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16
Q

When is the onset of sheuermann’s disease? Who gets it more M/F? What percent of general pop?

A

Puberty 13-17 yo

M>F

4-8.3% of population affected depending on type of diagnosis (clinical vs radiograph)

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17
Q

_____% of patients with sheuermann’s have an associated scoliosis

A

30-40

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18
Q

What should you do the the physical exam for sheuermanns disease?

A
  • Have child supine on bolster/foam roller under the apex of the deformity and assess for reducibility
  • neuro screen for evidence of spinal cord involvement (DTRs, pathologic reflexes, superficial abdominal reflexes, presence of hypertonia, lower extremity sensory abnormalities, muscle weakness, altered sphincter function)
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19
Q

When should you consider non-surgical treatment of a sheuermann’s patient?

A
  • curvature >40 but <65 degrees
  • curve is reducible
  • there is >1 year of spinal growth remaining
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20
Q

How do you manage a patient with sheuermann’s?

A
  • bracing/ casting/ physical therapy
  • CMT and mobilize to promote extension
  • In acute phase -(LIMIT WEIGHT BEARING ACTIVITY AND CONTACT SPORTS)
  • postural training (brueggers)
  • home care - enhance extension and core strength
  • stretch hamstrings (may aggravate symptoms)
  • reduce myospasm with STM, heat, possible electro therapy
  • Traction or distractions therapies
  • assess nutrition
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21
Q

What are mechanisms of injury for the thoracic spine?

A
  • trauma, repetitive trauma/overuse, etc.
  • forward head carriage (especially overloading T5)
  • Push/pull activities
  • rotational activities
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22
Q

What are causes of nerve root lesion for the thoracic spine?

A
  • stenosis,
  • Tumor
  • disc herniation (super rare so in third place)
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23
Q

What are lesions of the intercostal neural (intercostal neuritis) of the thoracic spine?

A

Trauma, neuritis, shingles

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24
Q

What are lesions of the thoracic cord of the thoracic spine?

A
  • stenosis
  • tumor
  • disc herniation (rare so number 3 on the list)
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25
Q

What is the low neuro screen for the thoracic spine? When do you do a low neuro screen?

A
  • when the patient has localized pain

Light touch on the back bilaterally

*no sharp dull, muscle testing, reflexes

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26
Q

What is a high index neuro screen of the thoracic spine? When do you need to do a high neuro screen?

A

If the pain is over a wider area or wrapping around the ribs anterior/posterior or worried of spinal cord

  • Light touch & sharp/dull along dermatome
  • vibration on sternum (maybe) (do it at the end of the dermatome - the sternum)
  • reflex: Beevor’s sign, superficial abdominal reflex
27
Q

How do you perform beevor’s sign? What can does it tell you is wrong?

A

Partial sit up - look for umbilicus deviation

  • nerve root OR spinal cord
28
Q

How is the superficial abdominal reflex done? What can it tell you?

A

Lightly brush along abdomen and navel, look for skin twitching or umbilicus deviation

  • nerve root OR spinal cord issue
29
Q

If you suspect tumors, stenosis or disc herniation, what does the neuro screen involve in the lower extremity?

A
  • sensory (sharp/dull, vibration/position sense/Romberg)
  • reflex (DTR’s, Babinski/clonus)
  • motor (lower extremity strength (include hip flexors))
30
Q

What the ddx for nerve root lesion of thoracic?

A

Stenosis, tumor, disc herniation

31
Q

What is the ddx for spinal cord for thoracic?

A

Stenosis, tumor, disc herniation

32
Q

What is the ddx for intercostal nerve for thoracic spine?

A

Herpes zoster, intercostal neuritis (other viral infection), trauma (rib fracture, intercostal muscle strain)

33
Q

What is the ddx for trauma to the thoracic spine?

A
  • thoracic sprain/strain (or facet syndrome/ disc derangement but not as common)
  • costovertebral sprain, rib fracture)
  • spinal fracture or contusion
  • intercostal sprain

*there is a diagnostic code for a bruise so list it too!

34
Q

What is the ddx for repetitive stress injuries?

A
  • scapulocostal syndrome (SICK) snapping scapula
  • thoracic joint dysfunction
  • rib joint dysfunction
  • facet syndrome, disc herniation, postural sprain/syndrome
  • intercostal/scapular MFTPs
35
Q

What are causes for pleuritic pain (pain with inspiration) associated with ribs, spine, intercostal muscles, lungs)

A
  • ribs (fracture, sprain, joint dysfunction)
  • thoracic spine (fracture, sprain, joint dysfunction)
  • intercostal muscles (strain, spasm) MFTP not common to cause pain with breathing
  • lungs (pleuritis, pulmonary embolism)
36
Q

What can cause referred pain to between the shoulder blades from the cervical spine?

A
  • Cervical dorsalgia (joint problems in neck causing pain between the shoulder blades)
  • visceral: Heart, lung, esophagus, ulcer,
37
Q

How can doorbell sign, or rotation with overpressure into extension, help you if it causes referred pain between the shoudler blades?

A

Just tells you the referred pain is coming from something in the neck

38
Q

The rate of vertebral body fractures begins to steadily increase as patients reach their mid _____ (due to ______)

A

Mid 60s

Osteoporosis

39
Q

LBP and deformity can be the results of __________

A

Compression fractures

40
Q

How does a patient get a compression fracture?

A
  • possible trauma with sudden pain and “snapping” sound
  • spontaneous compression fracture in patients over 70 with sudden non-traumatic LBP
  • in patients over 50 with only low or moderate old especially if peri or post menopausal or or other indications of possible osteoporosis

*order radiographs for these patients

41
Q

Almost _____ of spinal compression fractures are never diagnosed because many patients think their back pain is just _________

A

2/3

A sign of aging and arthritis

42
Q

Pain due to a compression fracture is aggravated by what? Relieved by what?

A
  • standing, walking, with activity

- rest or lying down

43
Q

Your patient who has a compression fracture may experience _________ for ____days, causing digestion issues. What can you recommend to help them with this?

A

Paralytic ilium (a temporary stoppage of intestinal peristalsis) for 2-3 days

  • liquid diet and especially no bulky foods
44
Q

Corticosteroids are a risk for ______. The most rapid period of this occurs within the first ______ months

A

Osteoporosis

- most rapid bone loss occurs in the first 6 months (10-20% loss)

45
Q

What are findings in a physical exam for a compression fracture? (3)

A
  • AROM all decreased (especially flexion, and standing straight may be difficult as well)
  • muscle guarding/splinting in the beginning
  • tenderness to palpation or sharp lingering pain with spinal percussion over involved segment
  • do a neuro exam to rule out nerve root or spinal cord damage
46
Q

If you suspect a fracture when should you order a radiograph? What can you do before ordering a radiograph?

A

Before joint plays or orthopedic tests!

  • AROM, neuro screen
47
Q

Are compression fractures stable or unstable?

A
  • most are stable and heal on their own
48
Q

How do you manage a compression fracture?

A
  • refer to orthopedist for medicolegal reasons although management is primarily conservative
  • after the acute phase, co-treat for subsequent joint dysfunction and myospasm avoiding the fracture
49
Q

A compression fracture collapse of _____% is a surgical case

A 
>50% = surgical 
<50% = conservative
50
Q

What is a schmorl’s node? Is it usually painful?

A

Thoracic intervertebral disc herniated through vertebral endplates, directly into adjacent vertebral bodies

  • usually does not cause symptoms but an inflammatory, foreign body-type reaction can occur causing severe pain
51
Q

What is the criteria for a T4 syndrome diagnosis? What other symptoms may the patient have?

A
  • rule out TOS, carpal tunnel syndrome, cervical radiculopathy

CRITERIA

  • joint dysfunction around T4 level
  • glove paresthesia in upper extremity (NON DERMATOMAL) (may be accompanied by hyperalgesia to pin prick) (may be in hands and even up to elbow)

EXTRA

  • pain generalized in upper back, scapula, arms and or forearms (may be reproduced by thoracic P-A glide)
  • skin near joint dysfunction may be hypersensitive
  • sometimes generalized headache in “helmet” distribution (sometimes occipital)
  • may report grip weakness (but muscle tests are normal), temp changes in hands, and Raynaud’s like phenomenon
  • may wake up at night with symptoms or worse in the morning (shaking involved extremity may offer temporary relief)
52
Q

What can happen to ribs?

A
  • sprain (trauma or overuse)
  • fracture/contusion (trauma or minimal trauma if osteoporosis)
  • joint dysfunction
53
Q

How does a rib fracture occur

A
  • Blunt trauma (MVA, slip and fall, sports) or strenuous Repetitive activities (rowers, discus throwers, golfers)
  • secondary to pathology/osteoporosis (may be triggered by coughing)
54
Q

What is a sign that the rib is fractured?

A
  • pain aggravated by inspiration/coughing

- pain with palpation, tuning fork or percussion

55
Q

What are the radiographs ordered for a fractured rib?
What is the sensitivity?
When would a fractured rib show up on an xray?
What is the next step?

A
  • AP and lateral
  • 50%
  • non-displaced fx may not show up for 3 weeks
  • need to follow up with another xray in 3 weeks or and immediate CT (which is more sensitive)
56
Q

What are you worried about with a fractured rib? What additional exam procedures should you do to screen for each?

A

Displaced fracture may puncture kidney (UA), spleen (palpate abdomen) or puncture lung (auscultate)

57
Q

What can cause a rib sprain or joint dysfunction?

A
  • trauma or overuse
58
Q

What are rib sprain or joint dysfunction signs?

A
  • sharp pain with point sensitivity

- may be significantly aggravated by breathing, especially a deep breath

59
Q

How to you manage a rib sprain or joint dysfunction

A
  • manipulation of joint can be very effective but painful (use light force, especially in osteoporotic patients)
  • sprains can be taped with kinesiotape, but should NOT be braced!
60
Q

What is scapulocostal syndrome? What can cause it?

A

Myofascial syndromes involving soft tissue between the scapula and rib cage (scapulocostal interspace)
- traumatic or mechanical irritation the soft tissue contained within the scapular interspace (scapularis muscle and decreased viscosity of the serous fluid minimizing friction in the interface to lubricate the movement)

61
Q

What are symptoms of scapulocostal syndromes?

A
  • local pain along vertebral border and deep to the scapula
  • pain commonly referred down the posterior shoulder and arm
  • dysesthesia in arm & forearm common
62
Q

What are exam findings of scapulocostal syndromes? (4)

A
  • possible painful tenderness and decreased shoulder abduction
  • MFTP and tenderness along the vertebral border of the scapula
  • associated costotransverse joint dysfunction
  • predisposed postural distortions (forward head carriage, rolled shoulders)
63
Q

What is SICK scapula?

A
  • a scapulocostal syndrome
  • acronym to look for scapular malposition
  • Scapular malposition
  • Inferior/medial border winging
  • Coracoid tenderness
  • dysKinesis (aberrant movement)
64
Q

What is the ddx for neuropathy in the thoracic spine? What are the symptoms and the part of the nervous system causing it?

A
  • T4 syndrome (symptoms in arms, ANS)
  • herniated disc, spinal stenosis, tumor (Sx in legs, CORD) (intercostal Sx, NRs) (abdominal wall signs such as beevors sign or superficial abdominal reflex, CORD or NRs)
  • thoracic OR rib fracture (sx in legs, CORD) (intercostal sx, NRs) (abdominal wall sx, CORD or NRs)
  • intercostal neuritis (intercostal sx, INTERCOSTAL NERVES)

Clin Path II (18 decks)

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