orthopedics Flashcards
what should be inspected in ms injuries?
Gait and strength as the patient enters the room and/or moves onto the exam table Antalgia- pain with movement Symmetry Deformity Inflammation/infection Edema Ecchymosis- bruisingMuscular wasting- result of denervationTrauma
what should be palpated in ms injuries?
All structures of the joint: At bony landmarks Articular surfaces Muscles Tendons/ligaments Bursae Palpate for: Tenderness Temperature- infection warms skinEffusion- extra fluid within jointsDiscontinuity of bones Crepitus Muscle tone and spasm Induration Soft tissue masses
what are 4 universal orthopedic tests?
cms: circulation, motion, sensation; assessing around joint assessing neuro, assessing reflexes
most common reason for spinal injuries?
blunt trauma: MVA
c-spine injuries are ___% of all spinal injuires
61%
T or F: injuries to the spine and spinal cord are often associated with other injuries- Spinal immobilization is important to prevent secondary injury.
T
what mechanisms of injury have a high risk of spinal injury?
automobile or motorcycle accidents, falls and diving accidents (axial load)
in a non emergent situation, what would make you think that a person may have a spinal injury?
Any patient complaining of neck pain, weakness, paresthesias or paralysis should be considered to have a spinal cord injury
any patient with a history of trauma and an altered ________ should always be treated as if spinal cord injury was present.
level of consciousness
T or F: Athletes wearing helmets and shoulder pads should NOT be immobilized in their equipment
false–they should be immobilized in it
what are cervical collars poor at limiting?
rotation
what are the NEXUS criteria for c-spine clearance?
1-No posterior midline cervical tenderness (spinous process) 2-Normal level of alertness (i.e., GCS = 15) (awake, talking to you, not intoxicated)
3-No focal neurological deficit 4-No painful distracting injuries (i.e., any condition thought by the clinician to be producing pain sufficient to distract the patient from realizing they may have a second injury)
5-No evidence of intoxication
what is the canadian c-spine rule?
for alert, stable patients, suspect c-spine injury based on force and mechanism of injury:
A dangerous mechanism is considered to be: a fall from an elevation > 3 ft or 5 stairs
landed on head or an axial load to the head/spine (e.g., diving)
a motor vehicle collision at high speed (>100 km/hr or 60 mph) or with rollover or ejection or if air bags went off
Not a simple rear-end motor vehicle collision (excludes being pushed into oncoming traffic, being hit by a bus or a large truck, a rollover, and being hit by a high-speed vehicle)
a collision involving a motorized recreational vehicle (ATVs, motorcycles) a bicycle collision
which is more accurate? nexus or canadian c-spine clearance?
canadian c-spine clearance
what is the initial test for c-spin injury? what is the std view?
plain film; AP, lateral, odontoid
what are the 3 most important lines to evaluate in a lateral c-spine?
Anterior longitudinal ligament line (anterior vertebral line)
Posterior longitudinal ligament line (posterior vertebral line) -A change of 11 degrees or more in the angle of this line at an interspace should be considered evidence of ligament injury. Spino-laminar line -The line connecting C1 with C3 should pass within 1 mm of the Spino-laminal junction of C2. -More than 1 mm displacement suggests anterior or posterior displacement of the odontoid, or a “ Hangman’s fracture” .
what should be evaluated in a c-spine film?
1) All 7 cervical vertebral bodies must be seen, including C7-T1 junction. 2) Evaluate proper alignment of the posterior cervical line and the four lordotic curves (anterior longitudinal ligament line, posterior longitudinal ligament line, spinlo-laminal line and tips of spinous processes). 3) Evaluate predental space (3 mm in adults, 4-5 mm in children). 4) Evaluate each vertebra for fracture and increased or decreased density (i.e. suggestive of compression fracture, metastatic lesion or osteoporosis). 5) Evaluate the intervertebral and interspinous processes (abrupt angulation of more than 11 degrees at a single interspace is abnormal). 6) Evaluate for fanning of the spinous processes, suggestive of posterior ligament disruption. 7) Evaluate the prevertebral soft-tissue distance: ->7 mm at C2 is considered abnormal. ->21 mm at C6= abnormal -In children
what’s normal for pre dental space?
This space should be no more than 3 mm in an adult and 5 mm in a child
what’s normal for soft tissue amounts in neck?
Greater than 7 mm soft tissue at C2 or 21 mm at C6 result in a sensitivity of 53% and a specificity of 95% for detecting spinal injury
One “ step off” at 4-5th cervical vertebrae is normal, more than that or higher up in neck is abnormal and suggests
what should be evaluated in an odontoid view of a c-spine?
the dens should be centered between the lateral masses of C1. The lateral masses of C1 should be directly over the lateral portions of C2 Rotation of the head can cause abnormalities- typically between the dens and lateral bodies of C1To check for rotation, ensure the dens is in line with the space between the central incisors. There are 3 types of odontoid fracture 3- least stable of the three types- abrupt hyperflexion injury- shearing injury 1- MC type
what is important to ask about in the HPI regarding m/s pain?
a. Pain:
i. Is the pain localized or diffuse?
ii. Does the pain become worse with certain activities or in certain positions?
iii. How long has the pain been present, acute vs. chronic?
iv. How has it changed over time- better, worse or same?
b. Associated Symptoms:
i. Stiffness
ii. Perceived loss of ROM
c. Is there numbness or weakness associated with pain? (usu numbness 1st, then weakness)
i. If so, is it associated with one dermatome?
ii. Peripheral nerve root compression:
1. Acute pain initially
2. Paresthesia/tingling along nerve distribution
3. Weakness
d. Any indications of distal neurological findings? saddle paresthesia in genital area?
e. Is there any associated change in bowel or bladder function?-
i. nerves from lower sacral vertebrae control the pelvic floor and sphincters
f. Treatments tried: NSAIDS (understand what they are taking), Ice/Heat, other pain relievers, Chiropractic, are they in other people’s meds or street drugs to deal with the pain? Ask about CAM.
g. ADL: How does their pain affect ADL’s, work?
h. Imaging: what, if any has been done? Take a look at it if possible.
what kinds of PMH, social history questions should be asked about in the history of someone with M/S PAIN?
- PMHx: Fracture, Sprain/Strain, Disc Herniation-
a. Determine if the patient has a prior workup - SHx: Smoking, Occupation, Hobbies- smokers have a higher incidence of low back pain, maybe because of compromised blood flow to the spine from nicotine use, work-related- injury might be exaggerated
what is malingering? why should we be wary of it?
Malingering is intentional deceptive behavior, not a medical or psychiatric disorder. The diagnosis of malingering rests upon the identification of an external or “secondary” gain being present as the main motivation for the behavior.
what are signs of malingering?
if >3/5 of the following, suspect malingering: skin discomfort on light palpation or crossing non anatomical boundaries, pain on axial loading (like pressing on head) or by simulating rotating–rotating pelvis and shoulders together should not be painful), distracted straight leg raise with no pain (they’ll have pain on straight leg raise but not if you extend their knee while sitting at a different time), non anatomic sensory changes: sensory loss of an entire limb or side of the body or inconsistent weakness that is “jerky”, overreaction to a stimulus that is not evoked later
