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AGACNP > Musculoskeletal injuries 2 > Flashcards

Musculoskeletal injuries 2 Flashcards

1
Q

Cervical spine injury: MRI indication

A

MRI is indicated in cervical fractures that have spinal canal involvement, clinical neurologic deficits or ligamentous injuries. MRI provides the best visualization of the soft tissues, including ligaments, intervertebral disks, spinal cord, and epidural hematomas.

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2
Q

Cervical spine injury: Advantages of MRI imaging

A
  1. excellent soft tissue constrast, making it the study of choice for spinal cord survey, hematoma, and ligamentous injuries.
  2. provides good general overview because of its ability to show information in different planes (e.g. sagital, coronal, etc.).
  3. ability to demostrate vertebral arteries, which is useful in evaluating fractures involving the course of the vertebral arteries.
  4. no ionizing radiation.
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3
Q

Cervical spine injury: Disadvantages of MRI imaging

A
  1. loss of bony details.
  2. relatively high cost.
    * Not always feasible 2/2 time, cost, and lack of resources
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4
Q

Cervical strain: MOI, S/Sx, Assessment, Tx

A

MOI: MVC, head injuries, daily life
S/Sx: paraspinal pain, lack of vertebral TTP, no motorsensory deficits
Assessment: Exam, imaging if clinically indicated
TX: NSAIDs, Ice/Heat, PT

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5
Q

Cervical discogenic pain: MOI, S/Sx, Assessment, Tx

A

MOI: Degenerative changes, prolonged sitting w/ poor postures
S/Sx: Axial pain > extremity pain, no neurological deficits
Assessment: imaging shows derangement of disc architecture, no herniation, +/- inflammatory changes
*MRI is the study of choice
Tx: NSAIDs, PT, prevention

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6
Q

Cervical facet syndrome: MOI, S/Sx, Assessment, Tx

A

MOI: Flexion/extension injury, whiplash
S/Sx: axial pain > extremity pain,
Assessment: Normal neuro exam, CT can often help Dx
Tx: NSAIDs, ice/heat, PT

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7
Q

Whiplash: MOI, S/Sx, Assessment, Tx

A

MOI: low speed, rear-end, stationary vehicle
S/Sx: Midline or paraspinal pain; multiple muscles & ligaments involved; commonly involve trapezius muscle; pain can persist and become chronic; women > men
Tx: PT is the best option

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8
Q

Cervical myofascial pain: MOI, S/Sx, Assessment, Tx

A

MOI: Thought to occur following either overuse (ie repetitive movement) or trauma to the muscles (e.g. MVA) that support the shoulders and neck
S/Sx: Non-specific muscular pain
Assessment: Trigger points and tight bands present
Tx: Massage therapist can be helpful; NSAIDs (avoid narcotic)

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9
Q

Cervical radiculopathy: MOI, S/Sx, Assessment, Tx

A

MOI: Disc herniation, Lyme Dz, DM
S/Sx: Weakness, pain (paraspinal, ipsilateral)
Assessment: Tenderness (paraspinal, ipsillateral) upon palpation; diminished reflex, MRI imaging
Tx: ice, NSAIDs, PT, epidural injection (steroid + local anesthetic can often relieve pain for few wks), TCA

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10
Q

Cervical spinal fracture patterns (5)

A
  1. Flexion
  2. Flexion/rotation
  3. Extension
  4. Vertical compression
  5. Odontoid
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11
Q

Cervical spinal fracture: Flexion (5)

A
  1. Wedge- stable, anterior loss of height, prevertebral swelling, ligaments intact. Tx w/ C-colar.
  2. Teardrop- unstable, it disrupts ant/post ligament & bone. All 3 columns affected.
  3. Ant subluxation- affects post ligamentous complex. Radiographically increased disc space, loss of contour. Usually Tx as unstable
  4. Clay shovelers- flexion w/ muscular contraction of upper body fxs spinous process. Considered as stable.
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12
Q

Cervical spinal fracture: flexion/rotation

A

Unilateral facet dislocation- Disrupts post but considered stable; vertebrate locked in place. Ortho consult for c-spine traction

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13
Q

Cervical spinal fracture: Extension

A
  1. Hangman’s- bilateral C2 pedicle fxs via hyperextension; unstable but SCI rare
  2. Teardrop- diving is common MOI; unstable
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14
Q

Cervical spinal fracture: Jefferson (aka Burst)

A

Jefferson- Burst of C1

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15
Q

Cervical spinal fracture: Odontoid

A

Type I: oblique fracture through the upper part of the odontoid process
Type II: Fx occurring at the base of the odontoid as it attaches to the body of C2
Type III: Fx line extends through the body of the axis
*SCI (spinal cord injury) is common in an odontoid fx
*Miami J & Aspen collars are useful (soft collar is useless)

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16
Q

What do you need to look for when a Pt has spinous process fx?

A

Tear drop fx

*Spinous process fx is not too serious, but tear drop fx is

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17
Q

Low back pain DDx

A 
Myofascial pain
Spinal stenosis
Radiculitis (sciatica)
Disc disease
Fractures / SCI
Compression fractures
Coccyx fractures: rectal exam is useful
Other causes to consider as part of the DDx (Renal colic; Aneurysmal disease/ Dissection)
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18
Q

Spinal stenosis (LBP); S/Sx

A

S/Sx: Psudo-claudication; pain w/ ambulating, better w/ rest; may have radicular Sx
Assessment: weakness & sensory loss may be present; plain films; MRI if stenosis is evident

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19
Q

LBP: sciatica

A

S/Sx: Pain radiates to ankle foot; burning

Assessment: Straight leg test

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20
Q

Straight leg test

A
  1. Have the patient lay supine with legs extended
  2. Place your hand beneath the lumbar spine to ensure there is no compensatory lordosis
    - Observe the lumbar spine during the exam because a change in the curve invalidates the test results
    - Also make sure the pelvis does not rise from the table
  3. Ask the patient to relax their leg
  4. Grasp the ankle of the leg and place your other hand on the front of the thigh to maintain the knee in full extension
  5. Slowly raise the leg until the patient complains of pain or maximal flexion has been achieved (30-60 degrees)
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21
Q

LBP: Compression fx

A

MOI: Osteo, low mech trauma
*Often occur at T12/L1.
Suspicion if young Pt, higher than T4 –> consider bone Dz, metastatic Dz.
Can take up to 3 months to heal.
Use pain management, bracing (limited data), vertebroplasty/kyphoplasty is NOT recommended

22
Q

LBP: red flags

A

Recent significant trauma, or mild trauma with pain disproportionate to history/exam
Age >50
Unexplained weight loss
Unexplained fever/ Immunosuppression –> possible epidural abscess
History of cancer –> spine tumor
Intravenous drug abuse –> spinal infection
Osteoporosis
Prolonged use of glucocorticoids
Focal neurologic deficit or truly disabling symptoms
Duration greater than 6 weeks

23
Q

Complete SCI: S/Sx

A

Paralysis, sensory deficits, priapism, urinary retention, loss of reflexes

24
Q

Incomplete SCI: S/Sx

A

Sensory preservation below the level of injury, some motor preservation, sacral sparing (the sacral nerves are sometimes spared: “S2, S3, S4, keep 3 P’s off the floor!”)
3Ps: pee, poop, penis

25
Q

SCI: Central cord syndrome S/Sx

A

Spondylosis, UE deficits > LE deficits

26
Q

SCI: Anterior cord syndrome S/Sx

A

Variable motor loss, pain/sensation

27
Q

SCI: Brown Sequard syndrome S/Sx

A

Ipsilateral motor deficit, contralateral sensory (pain/temperature) deficit

28
Q

SCI: Spinal cord concussion S/Sx

A

Usually temporally

29
Q

SCI: Characteristics

A
  • There is usually a clinical history compatible with a mechanism capable of causing it, it is seldom from very minor trauma
  • Pain is present at or above the level of injury, with midline tenderness and possibly a palpable deformity to the spinous process
  • There is sometimes evidence of incomplete, then complete injury (related to inflammatory changes immediately following the injury)
30
Q

Neurogenic shock: Characteristics

A
  • Can occur in SCI at or above level of T6
    Is a syndrome of autonomic dysfunction
  • Bradycardia with hypotension
  • Peripheral vasodilation causing hypothermia
31
Q

Neurogenic shock: Management goals

A

SBP > 90, use dopamine (mixed alpha and beta agonism)
HR > 80 bpm
Keep warm, give warmed IVF
Immobilize
Insert foley, acute urinary retention is common

32
Q

Neurogenic shock: Tx

A
  1. Methylprednisolone (not evidence based, but still often advised)
    - Load: 30 mg/kg IV
    - Continuous infusion: 5.4 mg/kg/h over 23 h; begin IV infusion 45 min after conclusion of bolus
  2. Consults
33
Q

SCI: Causes

A

MVC, Falls, Penetrating trauma, sports (esp. football)

34
Q

SCI: Risks

A

Spondylosis, congenital anomalies, osteoporosis, rheumatoid arthritis, atlanto-axial instability (e.g. Down syndrome)

35
Q

SCI: Pathophysiology

A

Protrusion of bones into the spinal cords causing injury to the nerve tracts

36
Q

Spinal cord: location

A 
Foramen magnum (ie base of the skull) to L1
*Beyond L1, it diverges and becomes the Cauda Equina
37
Q

Spinal cord: Anterior column

A

Ventral (motor) roots
The cell body (ie, soma) is in the anterior horn within the cord parenchyma. Clinically relevant reflex center levels are as follows (spinal reflex center levels are presented in parentheses and take into account anatomic variations in innervation):

Biceps - C5/6
Brachioradialis - C5/6
Triceps - C7 (C6-8)
Finger flexors - C8 (C7-T1)
Knee - L3 (L2-L4)
Ankle - S1 (L5-S2)
38
Q

Spinal cord: Dorsal column

A

Dorsal (sensory) roots
The cell bodies of the sensory nerves are located in the dorsal root ganglia. Each dorsal root contains the input from all the structures within the distribution of its corresponding body segment (ie, somite). Dermatomal maps portray sensory distributions for each level.

Important dermatomes:
C2 and C3 - Posterior head and neck
C4 and T2 - Adjacent to each other in the upper thorax
T4 or T5 - Nipple
T10 - Umbilicus
Upper extremity - C5 (anterior shoulder), C6 (thumb), C7 (index and middle fingers), C 7/8 (ring finger), C8 (little finger), T1 (inner forearm), T2 (upper inner arm), T2/3 (axilla)
Lower extremity - L1 (anterior upper-inner thigh), L2 (anterior upper thigh), L3 (knee), L4 (medial malleolus), L5 (dorsum of foot), L5 (toes 1-3), S1 (toes 4, 5; lateral malleolus)
S3/C1 - Anus

39
Q

Spinal shock: Characteristics

A
  • Transient loss mimicking complete cord injury

- Recovery is usually complete, but there can be residual spasticity

40
Q

Spinal shock: Etiology

A 
- Caused by localized inflammation/edema to a specific part of the spinal cord
 # Extracellular hyperkalemia resulting in disruption of axonal function
41
Q

Spinal shock: Tx

A

The immediate treatment is the same as for neurogenic shock:

  1. Methylprednisolone (not evidence based, but still often advised)
    - Load: 30 mg/kg IV
    - Continuous infusion: 5.4 mg/kg/h over 23 h; begin IV infusion 45 min after conclusion of bolus
  2. Consults
42
Q

SCI: Lab workups

A
  1. ABG - May be useful to evaluate adequacy of oxygenation and ventilation
  2. Lactate levels - To monitor perfusion status; can be helpful in the presence of shock
  3. Hemoglobin and/or hematocrit levels - May be measured initially and monitored serially to detect or monitor sources of blood loss
  4. Urinalysis - Can be performed to detect any associated genitourinary inju
43
Q

SCI: Imaging studies

A
  1. Plain radiography - Radiographs are only as good as the first and last vertebrae seen, therefore, radiographs must adequately depict all vertebrae
  2. CT - Reserved for delineating bony abnormalities or fracture; can be used when plain radiography is inadequate or fails to visualize segments of the axial skeleton
  3. MRI - Used for suspected spinal cord lesions, ligamentous injuries, and other soft-tissue injuries or pathology
44
Q

SCI: Tetraplegia (definition)

A

Injury to the spinal cord in the cervical region, with associated loss of muscle strength in all 4 extremities

45
Q

SCI: Paraplegia (definition)

A

Injury in the spinal cord in the thoracic, lumbar, or sacral segments, including the cauda equina and conus medullaris

46
Q

SCI: Neurogenic shock (definition)

A

Neurogenic shock refers to the hemodynamic triad of hypotension, bradycardia, and peripheral vasodilation resulting from severe autonomic dysfunction and the interruption of sympathetic nervous system control in acute spinal cord injury. Hypothermia is also characteristic. This condition does not usually occur with spinal cord injury below the level of T6 but is more common in injuries above T6 (MedScape)

47
Q

SCI: Spinal shock (definition)

A

Complete loss of all neurologic function, including reflexes and rectal tone, below a specific level that is associated with autonomic dysfunction. That is, spinal shock is a state of transient physiologic (rather than anatomic) reflex depression of cord function below the level of injury, with associated loss of all sensorimotor functions (MedScape)

48
Q

SCI: Long term autonomic dysfunctions

A

Autonomic dysfunction continues to be a problem long after the initial period of shock

  • Autonomic dysreflexia
  • Problems with temperature regulation
  • Urinary retention
  • Fecal impaction
49
Q

SCI: Long term problems related to immobilization

A

Pneumonia
Pulmonary embolism
Pressure sores/skin breakdown

50
Q

SCI: Long term problem (other consideration)

A

Pain

AGACNP (21 decks)

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