9/6/18 OBJECTIVES: • Identify the gross anatomy of the upper extremities, spine, and lower extremities. • Perform a thorough and accurate orthopaedic ORTHOPAEDIC EXAMINATION examination of the upper extremities, spine, and lower extremities. • Review the presentation of common spine and Angela Pearce, MS, APRN, FNP-C, ONP-C extremity diagnoses. Robert Metzger, DNP, APRN, FNP - BC • Determine appropriate diagnostic tests for common upper extremity, spine, and lower extremity problems REMEMBER THE BASIC PRINCIPLES OF MUSCULOSKELETAL EXAMINATION Comprehensive History Comprehensive Physical Exam THE PRESENTERS • Chief Complaint • Inspection • HPI OLDCART • Palpation HAVE NO CONFLICTS OF INTEREST • PMH • Range of Motion TO REPORT • PSH • Basic principles use a goniometer to assess joint ROM until you can • PFSH safely eyeball it • ROS • Muscle grading • Physical exam one finger point • Sensation to maximum pain • Unusual findings winging and atrophy SPINAL COLUMN SPINAL CORD / NERVES • Spinal cord • Begins at Foramen Magnum and • Consists of the Cervical, Thoracic, continues w/ terminus at Conus Medullaris near L1 and Lumbar regions. • Cauda Equina • Collection of nerves which run from • Specific curves to the spinal column terminus to end of Filum Terminale • Lordosis: Cervical and Lumbar • Nerve Roots • Kyphosis: Thoracic and Sacral • Canal is broader in cervical/ lumbar regions due to large number of nerve roots • Vertebrae are the same throughout, • Branch off the spinal cord higher except for C1 & C2, therefore same than actual exit through the nomenclature is applicable to all intervertebral foramen areas of the spine. • 1st root exits between C0/C1; 8th cervical root between C7/T1 • 1st thoracic and so on exit below the vertebral body 1 9/6/18 DERMATOMES LIGAMENTS (BRIEF OVERVIEW) • Areas of skin innervated by sensory fibers from a single spinal nerve • Anterior Longitudinal Ligament • Posterior Longitudinal Ligament • Ligamentum Flavum (noncontinuous, yellow color) • Interspinous Ligament (connects the SPs) • Supraspinous Ligament (connects the tips of the SPs) • Intertransverse Ligament (connects the TPs) INTERVERTEBRAL DISCS INTERVERTEBRAL DISCS • 2 Components • Discs are located between the endplates of the vertebral • Annulus Fibrosus bodies • Outer part of the disc • Collagen fibers w/ water and • Most important and unique articulating system in the spine, proteoglycans allowing for multiplanar motion • Layered in concentric layers called Lamellae which are • Make up ¼ of the total length of the spine column, run from thicker and more numerous in C2/3 to L5/S1 the anterior portion of disc • Nucleus Pulposus • Largest avascular structure in the human body • Interior substance of the disc • Cartiliginous joint of the motion segment (gelatinous) • Increased water and • Shock absorbers of the spine which are so strong that w/ proteogylcan content (85% compression, the vertebral bodies will fail before the discs Water content) CERVICAL SPINE • C3 – C7: Similar in structure • Cervical Spine consists of • Foramen 7 vertebrae • Vertebral: triangular • C1 (Atlas) shaped • Supports the weight of the skull • Intervertebral: Exiting nerve root occupies about • Ring shaped vertebrae 75% of space • C2 (Axis) • Uncovertebral Joints • Provides a pivot point for the Atlas • Spinal Processes • Projection into the C1 • C2-6: Bifid processes body, called the Odontoid (Dens) • C7: Vertebrae prominens 2 9/6/18 DIAGNOSTICS X-rays SPECIAL DIAGNOSTICS: CT MYELOGRAM • Provides basic evaluation of bone and disc spacing allowing visualization of degeneration, • Needle is introduced into the subarachnoid space and contrast is fractures, and instability of the spine injected Magnetic Resonance Imaging (MRI SCANS – non-radiation) • Magnet causes Hydrogen atoms in the tissue to line up, then radio waves bounce off the H+ • Patient is then tilted on the table so the dye will go to the specific atoms to provide a picture region we are testing • Adept at evaluation of soft tissue pathology (i.e. nerves, spinal cord, and discs) • AP/Lat views of spine are taken • Order w/ contrast if prior surgery has been done to r/o scar tissue involvement or tumor • Can be performed unless pt has pacemaker/defib implant, aneurysm clips, other motor run • Contrast appears white w/ neural structures dark implants, spinal cord stimulators, or bullet close to the spine • Compression or displacement of neural elements may be Computed Tomography (CT SCANS – high radiation) visualized • Thin beams of xrays pass through the pt. to a detector which transmits images to a computer • Particularly good for detecting bony tissue pathology • Painful procedure • May consider CT if patient had prior hardware and there’s concern for artifact on MRI DIAGNOSTICS FOR CERVICAL EVALUATION: TYPICAL DIAGNOSES OF THE CERVICAL SPINE: • X-RAYS • AP / Lateral 1. Cervical Disc Degeneration (spondylosis) • Flexion / Extension – evaluation for instability or movement of spine • Odontoid Views – Evaluation of the C1 & C2 bodies (especially fractures) 2. Cervical Disc Protrusions • MRI SCANS 3. Cervical Radiculopathy • Evaluation for radiculopathy / disc protrusions / stenosis • Typically, pt should have neurological involvement 4. Cervical Stenosis • CT SCANS 5. Cervical Myelopathy • Performed if pt is unable to undergo MRI imaging or if major concern is bone 6. Cervical Fractures • Myelogram • Performed if pt is unable to undergo MRI imaging and concern for possible 7. Combination of Above stenosis DISC HERNIATION • Most frequent surgically treated pathologies of the spine • Commonly occurs at C4/5, C5/6, C6/7 & L4/5, L5/S1 (regions w/ great ROM and axial loading) • Internal disruption to the disc is permanent due to the disc being avascular • Four degrees of herniation 1. Fissure / Bulging 2. Protrusion 3. Extrusion 4. Fragmented / Segmented 3 9/6/18 DEGENERATIVE DISC DISEASE (DDD) • Loss of normal tissue structure and • Symptoms function due to the aging process. • Asymptomatic • Usually is a gradual process, however • Neck pain / Low back acute trauma will accelerate the process pain • Changes within the intervertebral disc • Radiculopathy into upper • Water and proteoglycan decrease in extremities / lower the nucleus first, then the annulus extremities • Fibers of the annulus become • Cauda Equina Syndrome distorted, tears may occur in the lamellae decreasing the strength of • Foot Drop the disc • Loss of • Most common levels are C5/6 and L4/5 Bowel/Bladder • By age of 50, 95% of people will have Function evidence of DDD • Effects the entire motion SPINAL STENOSIS segment • Stenosis is “narrowing of a tube” • Facet joints override and • Spinal stenosis refers to narrowing of the spinal canal wear at the hyaline cartilage and/or lateral foramen • Disc shrinks and the disc • Developmental or Acquired (most common) space narrows • Degenerative stenosis • Loads are transferred from disc to the endplates • Found in older population • Osteophytes may develop • L3/4, L4/5 are most involved lumbar segments and encroach on neurological structures • C5/6, C6/7 are most involved cervical segments • Occasionally associated with spondylolithesis • Occurs most often in lower cervical / lower lumbar spine. SPINAL STENOSIS • Symptoms SPINAL STENOSIS • Associated with LBP, • Cervical stenosis occasionally will have buttock, leg pain (bilat) • Presents more with history of neck trauma • Neurogenic claudication • Most patients present with radiculopathy of C5, C6, or C7 nerve • Most important sx roots • Worse w/ standing/ walking upright • Important to watch for MYELOPATHY • Alleviated with bending forward (flexing) • Symptoms of myelopathy are altered gait, diminished fine • Differentiate between vascular motor coordination, sensory changes, muscle weakness, and claudication in late cases, bowel / bladder incontinence 4 9/6/18 SPINAL FRACTURES COMPRESSION FX ODONTOID FX • Most common fractures seen in an outpatient setting: • Compression / Burst • Associated with falls from greater than 6 feet or any fall in a patient with osteoporosis • Transverse Process / Spinous Process • Odontoid (Dens) & Facet fractures are more common in emergent settings • Trauma to spine implies injury to any or all anatomical structures: bony elements, soft tissues, and neurological structures NEUROLOGICAL EXAMINATION KEYPOINTS SPINAL FRACTURES C5 M Shoulder Abduction (Deltoids), Elbow Flexion (Biceps) R Biceps Reflex S Lateral portion of Deltoid and Upper Arm to Elbow • Instability - loss of normal relationship between C6 M Wrist Extension R BrAchiorAdiAlis Reflex anatomic structures with alteration in natural function S Lateral Forearm (below elbow) including Thumb, Index Finger, and ½ of Middle Finger • Dislocation – misalignment of normal structure of the C7 M Elbow Extension (Triceps), Wrist Flexion, Finger Extension anatomic components R Triceps Reflex S Middle Finger • Fracture / dislocations may occur in any region of C8 M Finger Flexion R NONE the spine and are associated with high degree of S MediAl ForeArm (up to elbow), Ring Finger, And Pinky Finger neurologic injury. T1 M Finger Abduction And Adduction R NONE S MediAl ForeArm And MediAl Upper Arm SPECIAL TESTS (CERVICAL): SPECIAL TESTS (CERVICAL) – CONT.: • Llhermitte’s – • Myelopathy Signs / Tests • Look up – Look down (Touch your chin to your chest) : Causes electrical shocks • Finger Escape Test – Have pt close all fingers together while flexed. Positive – down the spine, and occasionally into the legs, if positive pinky will continue to move away from the remaining