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PHTH 623: Differential Dx and Management > ToS, WAD, Facilitated segment > Flashcards

ToS, WAD, Facilitated segment Flashcards

1
Q

what are the three primary outlets for ToS?

A

scalene triangle
costoclavicular space
subcoracoid space

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2
Q

what is in the scalene triangle?

A

subclavian artery

brachial plexus - lower roots

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3
Q

what is in the costoclavicular space?

A

brachial plexus - lower trunk
subclavian artery
subclavian vein

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4
Q

what are the boundaries of the costoclavicular space?

A

first rib
clavicle
costoclavicular ligament
middle scalene

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5
Q

what are the boundaries of the subcoracoid space?

A

pec minor
coracoid process
posterior ribs

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6
Q

what is in the subcoracoid space?

A

brachial plexus - lower cords
subclavian artery
subclavian vein

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7
Q

name three functional causes of costoclavicular TOS

A

poor posture (drooping shoulders, protracted and FHP)
carrying heavy objects, backpack
repetitive overhead arm movements (sports, etc)

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8
Q

what are some things to rule out with TOS type symptoms?

A

Cx spine spondylosis -> referred pain, neuromeningeal
Cx radiculopathy
peripheral nerve entrapment
pancoast tumour

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9
Q

TOS can be neurological or vascular (artery or nerve), but which is the most common?

A

neurological, 95% of cases

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10
Q

what kind of symptoms would you expect in true neurological TOS?

A
  • pain and paraesthesia in neck, chest, and U/E
  • neuro exam (+) but not as pure as nerve root compression
  • ULNT1 usually positive too
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11
Q

what kind of symptoms would you expect to see in symptomatic TOS?

A
  • pain/paraesthesia in ulnar areas
  • provoked with prolonged arm above shoulder height positions
  • neuro exam (-)
  • ULNT1 (+) in ulnar sometimes
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12
Q

how many special tests need to be positive to be indicative of symptomatic TOS?

A

3/5? even though we only learned 4?

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13
Q

Name four special tests for TOS?

A

Adson
Roos
Hyperabduction (for symptoms or for pulse)
Tinels at supraclavicular nerve

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14
Q

name some symptoms of arterial TOS?

A
  • cold sensitivity -> Raynaud’s phenomenon

- decreased pulse and BP in arm, esp in hyperabduction or Adson position

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15
Q

what are some symptoms of venous TOS?

A
  • edema, engorgement
  • cyanosis
  • fatiguability
  • U/E stiffness
  • Adson positive
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16
Q

what does Adson test for - neurologic or vascular TOS?

A

trick! tests for both - will get loss of pulse in vascular, paraesthesia in neurologic

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17
Q

what else should you assess when looking at TOS

A 
posture
ULNT
deep neck ms
breathing pattern
first rib
scapular postioning
18
Q

your patient is positive in Adsons for neurological TOS. You repeat the test with her scapula in a corrected position, and the symptoms improve. What does this mean?

A

they are a good candidate for rehab

19
Q

name some treatment ideas for TOS

A
  • EDUCATION ABOUT POSTURE
  • scap position, strengthening stretching taping
  • spine mobs
  • deep neck stabalizers
  • breathing pattern
  • nerve glides
20
Q

what kind of disc lesion can happen in whiplash?

A

rim lesion - very irritable, need MRI to confirm

21
Q

how long will recovery usually take with WAD?

A

half of people will still have pain at 3 months, 35% at 12 months…

44% people recovered after 1mo
65% after 12mo
75% 5yrs

22
Q

at what grade of WAD will there be physical signs of decreased ROM and point tenderness?

A

grade II - separated into IIA (no psychological distress), IIB (psychological distress), and IIC (acute post-traumatic stress)

23
Q

at what stage do neurological signs appear for WAD

A

grade III

24
Q

what are some high risk factors that means you should get an xray post WAD?

A 
over 65
fall from height over 3ft or 5 stairs
axial load to head
MVA over 100km/hr
MVA motorcycle
MVA bicycle
numbness or tingling in extremities
25
Q

what are some indicators of a poor prognosis?

A
  • high initial pain intensity, catastrophizing, high self-rated injury intensity
  • low self efficacy, low educational level, anxiety
  • increased sensitivity to cold, reduced ROM of neck
26
Q

what kind of red flags should be searched for?

A
  • CNS
  • VB
  • Cranial nerve
27
Q

what 5 elements should be done in a WAD exam?

A
  • CNS
  • perpheral nerves
  • VB
  • Cr-Vx ligaments
  • concussion
28
Q

your patient is complaining of dizziness post WAD injury, but you suspect a concussion. What would be some signs to look for?

A
  • memory impairment
  • depression
  • fatiguability
  • insomnia
  • mood swings
29
Q

nausea and vomiting may be from what (not vestibular)

A

cranial nerve involvement

30
Q

what should always be done before ROM of neck in WAD?

A

neuro exam to rule out SC lesion

31
Q

are collars recommended for WAD?

A

NO! if they are ever used it should be for less than 48hrs

32
Q

the facilitated segment theory postulates that constant afferent input can lead to:

A

“central segmental excitation”

33
Q

what type of pain do facilitated segments cause?

A

referred pain, dermatomal. can also cause hyperalgesia and hyperesthesia (increased sensitivity to deep and light touch).

34
Q

other than pain, what else can a facilitated segment cause?

A

tenderness, hypertonicity of key muscles, and soft tissue changes

35
Q

when there is a constant neural input by a facilitated segment, the synaptic resistance is ______ while neuronal transmission is ______

A

lowered

facilitated

36
Q

name three possible causes of a facilitated segment

A 
vertebral dysfunction (hypermobility)
visceral disease
peripheral joint dysfunction
37
Q

name 4 possible motor changes that one may see with facilitated segment

A
  • hypertonicity
  • stiffness
  • exaggerated reflexes
  • fatiguability
38
Q

what three autonomic changes may happen with a facilitated segment?

A
  • vasoconstriction
  • sweating
  • orange peel skin
39
Q

what can you do (Ax) to test for:

a) motor changes
b) sensory changes
c) autonomic changes

A

a) muscle stretch, palpation at rest, RISOM, reflexes
b) light touch and pinprick
c) scratch test for vasoconstriction, drag test for sudation, skin rolling test for orange peel/thicker skin

40
Q

what is the most common facilitated segment level? what are 3 findings of this problem?

A

C5/6 hypermobility leading to C6 facilitated segment.

  • pain over lateral epicondyle and ECR muscle
  • resisted wrist extensor muscle -> fatiguable/painful
  • wrist extensors stiff & painful

PHTH 623: Differential Dx and Management (7 decks)

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