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Includes the Adobe Acrobat Reader for reading and printing publications.

Numerous illustrations and matrices.

Contains the following key public domain (not copyrighted) U.S. Government publication(s) on one CD-ROM in both Microsoft PowerPoint and Adobe Acrobat PDF file formats:

TITLE:

Orthopedic Shoulder Hip and Spine Disorders, 284 Slides

SLIDE TOPICS, SUBTOPICS and CONTENTS:

Learning Objectives
Disorders Of The Shoulder
Anatomy Of The Shoulder Review
Bones

Scapula

Clavicle

Proximal Humerus
Bones
Scapula
Spans ribs 2 to 7
Three main processes
Spine
Acromion
Coracoid

Bones
Clavicle
Connects the sternum to the acromion
"S" shaped

Bones
Proximal humerus (parts)
Head
Anatomic neck
Surgical neck (distal to the anatomic neck)
Bones
Proximal humerus (parts)
Greater tuberosity (rotator cuff insertion - supraspinatus, infraspinatus, teres minor)
Lesser tuberosity (rotator cuff insertion - subscapularis)
Bones
Proximal humerus (parts)
Intertubercular groove (bicipital groove) – Long head of the biceps
Joints
Glenohumeral joint
Sternoclavicular joint
Acromioclavicular joint
Scapulothoracic joint
Glenohumeral Joint
Ball (Humeral head) and socket (Glenoid)
Muscles provide the primary support
The labrum lines the glenoid cavity and deepens the socket
Ligaments - glenohumeral (inferior glenohumeral is the most important), coracohumeral, capsular
G-H Joint
Sternoclavicular Joint
Gliding joint
The only bony attachment to the Axial skeleton is the S-C Joint
Articular disc interspaced between surfaces
Rotates 30 degrees with glenohumeral motion
Ligaments - anterior and posterior sternoclavicular, capsular

Acromioclavicular Joint
Gliding joint

Disc interspaced between surfaces

Anchors the lateral clavicle

A-C Joint
Ligaments

A-C

C-C
A-C Joint
A-C Joint
Scapulothoracic Joint

Soft-tissue joint

Allows for scapular translation

Muscles
Spine connectors
Trapezius (Upper, Middle & Lower)
Latissimus dorsi
Rhomboids (Major & Minor)
Levator scapulae
Scalenes
Thoracic connectors
Pectoralis major
Pectoralis minor
Subclavius
Serratus anterior

Muscles
Shoulder movers
Deltoids (abduction, flexion, extension, horizontal AB/ADduction)
Teres major (adduction, internal rotation)
Supraspinatus (abduction, external rotation)
Infraspinatus (external rotation)
Muscles
Shoulder movers
Teres minor (external rotation)
Subscapularis (internal rotation)
Coracobrachialis (flexion)
Biceps long head (flexion)
Muscles
Rotator cuff muscles ("SITS")
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
Movers and dynamic stabilizers
Rotator Cuff
Rotator Cuff
Nerves

Brachial plexus

Brachial Plexus
Vessels
Subclavian artery
Axillary artery (divided in thirds by the pectoralis minor)
Anterior Humeral circumflex artery: primary blood supply to the humeral head
Vessels
Range-of-motion
Abduction 170 to 180
Flexion and Elevation 160 to 180
Scapular Elevation 170 to 180
Lateral (External) Rotation 80 to 90
Medial (Internal ) Rotation 60 to 100
Range-of-motion
…Cont’
Extension 50 to 60
Adduction 50 to 75
Horizontal AB/ADduction 130
Circumduction 200
Neurovascular Examination

Sensation

Axillary nerve (C5) lateral arm
Reflexes
Reflexes

Biceps (C5)

Brachioradialis (C6)

Triceps (C7)
Reflexes
Reflexes
Reflexes
Dislocations/Separations
Dislocations/Separations
Dislocations/Separations
Classification
AMBRI -- Atraumatic, Multi-directional, Bilateral, Rehabilitation, Inferior Capsular Shift
Dislocations/Separations
Dislocations/Separations
Apprehension Test
Relocation/Release
Dislocations/Separations
Dislocations/Separations
Dislocations/Separations
Associated Injuries
Hill- Sachs defect - impression fracture in the posterolateral humeral head

Bony Bankhart lesion - anterior inferior glenoid rim injury

Greater tuberosity fracture - especially in older patients

Hill – Sachs Lesion
Bony Bankhart Lesion
Associated Injuries
Associated fractures:
Reverse Hill - Sachs defect (hatchet - shaped anterior humeral head impression fracture)
Reverse Bankart lesion (posterior glenoid rim)
Lesser tuberosity fracture

Dislocations/Separations
Dislocations/Separations
Dislocations/Separations
Dislocations/Separations

Dislocations/Separations
Prognosis
If pt’s age is < 30, redislocation rate is higher…….Surgery
If pt’s age is > 30, redislocation rate is lower…..Rehabilitation
Dislocations/Separations
Dislocations/Separations
Dislocations/Separations
Anterior Dislocation
Mechanism of Injury
Forced abduction and rotation
Signs/Symptoms – Acute Pain, flattened Deltoid, anterior fullness, natural splinting, short squared shoulder
Anterior Dislocation
Radiology- True AP, Axillary lateral or West Point and Scapular Y views

Anterior Dislocation
Special tests
+ Anterior drawer/ translation
+ Apprehension test
+ Reduction/ release test

Anterior Dislocation
Treatment
Immediate reduction
Ice, rest
NSAIDs, ASA, Tylenol®
Shoulder Immobilizer or Sling & Swathe
PT - early gentle ROM
Anterior Dislocation
Treatment -- Surgical
Arthroscopic
Bankhart repair
Capsular shift
Open
Bankhart repair
Capsular shift
Usually a combination
Posterior Dislocation
Mechanism of Injury - Fall on the adducted and internally rotated arm

Posterior Dislocation
Signs/Symptoms - Severe Acute Pain, Prominent Coracoid Process, Arm will be adducted, internally rotated
Posterior Dislocation
Radiology- Shoulder series will indicate head of humerus posterior to the labrum
Posterior Dislocation

Special tests
+ Jerk Test
+ Reduction test

Posterior Dislocation
Treatment
Immediate reduction
Ice, rest
NSAIDs, ASA, Tylenol®
Shoulder Immobilizer or Sling & Swathe
PT - early gentle ROM
Posterior Dislocation
Treatment – Surgical
Arthroscopic
Reverse Bankhart repair
Capsular shift
Open
Reverse Bankhart repair
Capsular shift
Usually a combination
Inferior & Multidirectional Dislocation
Shoulder examination shows instability in multiple directions
Patients often display hyperelasticity (MP joints, elbow, shoulder, etc. )
Inferior & Multidirectional Dislocation
Inferior & Multidirectional Dislocation
Inferior & Multidirectional Dislocation
Inferior & Multidirectional Dislocation
Treatment
Nonoperative treatment favored
If Surgery – Capsular Shift
Acromioclavicular Separations

Acromioclavicular injuries (the so-called separated shoulder) can be classified into six types, and treatment is based on the specific type
A-C Separations
Mechanism of Injury: FOOSH or Fall onto the tip of the shoulder
A-C Separations
A-C Separations
Type I – AC ligament is partially disrupted; coracoclavicular (CC) ligament is intact
Type II – AC ligament is completely torn CC ligament is partially torn
Type III – AC & CC ligaments are completely torn & there is complete separation of clavicle from the acromion.
Types IV – VI are uncommon
A-C Separations
Signs and Symptoms
Pain over A-C joint & lifting of the arm
Swelling
With Type III & higher…there is an obvious and cosmetically displeasing deformity
A-C Separations
A-C Separations
A-C Separations
Diagnosis
AP Xrays of both shoulders will confirm Type II or higher A-C separations (with & without weights)
A-C Separations
Type II
A-C Separations
Treatment
Type I & II:
Rest & Ice
Sling, Sling & Swath, Shoulder Immobilizer or Figure-of-8-clavicle brace X 4-6 Weeks
NSAIDs, ASA or Tylenol®
Analgesics esp. at night
A-C Separations
Treatment
Type III is controversial – Most are treated nonoperatively with good results
A-C Separations
Immobilizing devices
A-C Separations
Surgical repairs
Rotator Cuff Syndrome
Rotator Cuff Syndrome
Rotator Cuff Syndrome
Rotator Cuff Syndrome
Rotator Cuff Syndrome
Rotator Cuff Syndrome
PE
+ Drop-arm test
+ Lift-off test
Rotator Cuff Syndrome
Rotator Cuff Syndrome
Diagnosis cont’
Rotator Cuff Syndrome
Rotator Cuff Syndrome
Rotator Cuff Syndrome
Treatment: Surgical
Arthroscopic
Open

Impingement Syndrome
Impingement between the rotator cuff tendons and subacromial bursa between the humeral head, greater tuberosity and the acromion occurs when the arm is elevated. This causes inflammation and edema and therefore increased impingement, in a self-perpetuating cycle……
Impingement Syndrome Classification
Stage I: Pt’s < 25 with reversible
edema & hemorrhage
Stage II: Pt’s 25 – 40 with fibrosis,
tendonitis & recurring pain
with activity
Stage III: Pt’s > 45 with bone spurs
or osteophytes & rotator
cuff tendon rupture
Impingement Syndrome
Differential Diagnosis
Subacromial Bursitis
Supraspinatus Tendonitis
A-C Arthritis
Bicipital Tendonitis
Calcific Tendonitis
Adhesive Capsulitis
Thoracic Outlet Syndrome
Subacromial Bursitis
Signs and Symptoms
Inability to use the arm in the overhead position (Flexed & Internally rotated or Abduction) due to pain, stiffness, weakness & catching
Pain with sleeping on the affected side
Pain in the acromial area
Subacromial Bursitis
Physical Exam
+ Neer Impingement Sign
+ Hawkins Impingement Sign
+ Impingement Sign
Differential Diagnosis
Impingement Test

Subacromial Bursitis
+ Neer Impingement Sign
Subacromial Bursitis
+ Modified Neer Impingement Sign
Subacromial Bursitis
+ Hawkins Impingement Sign

Subacromial Bursitis
Impingement Test – instill 10cc 1% plain local anesthetic into the subacromial space followed by impingement testing

Subacromial Bursitis
Complete pain relief supports a diagnosis of impingement syndrome
To demonstrate supraspinatus weakness compare using the supraspinatus test – If initially patient was weak but strong post injection then inflammation & fibrosis is consistent vs rotator cuff tear

Subacromial Bursitis
TX: Conservative
Rest & Ice
Avoidance of overhead activities
PT (ROM ex’s & Rotator cuff strengthening ex’s)
Ultrasound/Phonophoresis/ Iontophoresis
NSAIDs, ASA or Tylenol®
Corticosteroid injections
Subacromial Bursitis
Treatment: Surgical
Bursectomy
Acromioplasty (Decompression)
Arthroscopically or Open
Supraspinatus Tendonitis
Signs and symptoms are identical to subacromial bursitis except the inflammation is within the tendon vs bursa
+ Supraspinatus test but no weakness
Supraspinatus Test
Supraspinatus Tendonitis
Treatment: Conservative
Rest & Ice
Avoidance of overhead activities
PT (ROM ex’s & Rotator cuff strengthening ex’s)
Ultrasound (Phonophoresis or Iontophoresis)
NSAIDs, ASA or Tylenol®
Corticosteroid injections
Supraspinatus Tendonitis
Treatment: Surgical
Arthroscopic (Debridement & Acromioplasty)
Open (Acromioplasty, Debridement & RC repair)
Acromioclavicular (A-C) Arthritis/Arthropathy
Signs and Symptoms
A-C joint tenderness
DJD change on Xrays
Physical Exam
+ Cross-body Adduction
Diagnosis
Lidocaine injection into the A-C Joint
Acromioclavicular (A-c) Arthritis/Arthropathy
+ Cross- Body Adduction Test
Acromioclavicular (A-C) Arthritis/Arthropathy
Xrays: DJD changes & possible osteolysis or bone cysts
Diagnosis: Lidocaine injection into the A-C Joint
Acromioclavicular (A-C) Arthritis/Arthropathy
Treatment: Conservative
Rest & Ice
Avoidance of overhead activities
PT (ROM ex’s & Rotator cuff strengthening ex’s)
Ultrasound (Phonophoresis or Iontophoresis)
NSAIDs, ASA or Tylenol®
Corticosteroid injections
Acromioclavicular (A-C) Arthritis/Arthropathy
Treatment: Surgical
Open (Acromioplasty & distal clavicle resection using Mumford procedure)
Bicipital Tendonitis
Signs and Symptoms
Pain to palpation over bicipital groove or tendon
Physical Exam
+Speed’s Test
+Yergason’s Test

Bicipital Tendonitis
+ Speed’s Test
Bicipital Tendonitis
+ Yergason’s Test
Bicipital Tendonitis
Treatment: Conservative
Rest & Ice
Avoidance of overhead activities
PT (ROM ex’s & Rotator cuff strengthening ex’s)
Ultrasound (Phonophoresis or Iontophoresis)
NSAIDs, ASA or Tylenol®
Corticosteroid injections (BEWARE!)
Bicipital Tendonitis
Treatment: Surgical
Arthroscopic
Open
Calcific Tendonitis
Signs and Symptoms
Localized tenderness
Associated with impingement from increased size of the tendon

Calcific Tendonitis
Diagnosis
Xrays
Calcific Tendonitis
Treatment: Nonoperative
Physical therapy
Needling calcification with local anesthetic
Radiotherapy
Treatment: Operative
Surgical excision

Adhesive Capsulitis
“Frozen Shoulder”
Idiopathic loss of both active and passive motion
Most commonly affects patients between 40 & 60
Most common risk factor is DM Type I

Adhesive Capsulitis
Patients typically have 2 phases
“freezing” phase with pain & progressive loss of motion
“thawing” phase of decreasing discomfort associated with a slow but steady improvement in range-of-motion
Adhesive Capsulitis
Physical Exam -- reveals significant reduction in both active & passive range-of-motion, at least 50%, when compared with the opposite normal shoulder
Motion is painful, especially at the extremes
Pain & tenderness are common at the deltoid insertion
Adhesive Capsulitis
Treatment
NSAIDs
Non-narcotic analgesics
Moist Heat
Stretching program 3-4 x daily
? Consider a corticosteroid injection
Thoracic Outlet Syndrome
Thoracic outlet syndrome - compression of a portion of the brachial plexus, most commonly the lower portion [C8, T1], and the axillary artery
Thoracic Outlet Syndrome
Etiology
Compression by the scalene muscles/first rib on the lateral cord of the brachial plexus and the subclavian artery
Thoracic Outlet Syndrome
Signs/Symptoms
Related to overuse- paresthesias to hand and arm, pain in upper extremity and neck, weakness of extremity, drooping of shoulder girdle, clear correlation with posture and position

Thoracic Outlet Syndrome
Diagnosis
Adson's Maneuver
Wright's Test
Roos Test
Thoracic Outlet Syndrome
Adson's maneuver -
shoulder extension and head rotation to the ipsilateral side while holding a breath leads to loss of the radial pulse
Thoracic Outlet Syndrome
Modified Adson's (Wright's) test
Shoulder extension, abduction to 90 degrees, and external rotation with the head rotated to the contralateral side leads to loss of the radial pulse
Thoracic Outlet Syndrome
Roos test ‑ the arms elevated past 90 degrees and the hands opened and closed rapidly 15 times leads to cramping/tingling of the hands (claudication)
Thoracic Outlet Syndrome
Treatment options
Nonoperative - physical therapy, postural training
Operative - first rib resection, others
Summary
Steps in the general examination of the anterior shoulder
Mechanisms of injury, clinical signs and symptoms, diagnostic tests, and treatment for common shoulder disorders

Common Orthopedic Hip Disorders
Learning Objective
Identify the etiology, clinical presentation, laboratory and radiologic studies, evaluation and treatment for the following hip conditions:
Aseptic/Avascular Necrosis or Osteonecrosis
Fractures and Dislocations
Slipped Capital Femoral Epiphysis
Legg-Calve-Perthes Disease
Disorders Of The Hip
Aseptic Necrosis (AVN or Osteonecrosis)
Fractures & Dislocations
Slipped Capital Femoral Epiphysis (SCFE)
Legg-Calve-Perthes Disease
Osteonecrosis
Also commonly referred to as avascular necrosis (AVN)

Represents death of bony tissue
Osteonecrosis
Most common site involved is the hip (femoral head)

Death of subchondral bone leads to collapse of overlying cartilage and flattening of the femoral head (crescent sign)

Crescent Sign
Crescent Sign
Osteonecrosis
Treatment Options
Activity modification
NSAIDs, Tylenol® or ASA
Cane or Crutches
Total hip arthroplasty for advanced cases
Controversial
Core decompression
Vascularized fibula graft
Osteonecrosis
Osteonecrosis

Bilateral hip involvement is very common (50% to 80%), so one needs to rule this out and follow over time in patients with what appears to be unilateral hip ON
Osteonecrosis
Etiologies
Idiopathic (Chandler’s Disease)
Post-traumatic
Steroid-induced
Alcohol-induced
Dysbarism (Caisson’s Disease)
Storage diseases (such as Gaucher’s Disease)
Osteonecrosis
Evaluation
Careful history for risk factors (to assess etiology)
Physical examination
Decreased joint range of motion
Clinical Suspicion
Femoral Neck Fracture
Garden Classification
Type I -- incomplete or valgus impacted fracture

Femoral Neck Fracture
Type II -- complete fracture without displacement
Femoral Neck Fracture

Type III -- complete fracture with partial displacement of fracture fragments
Femoral Neck Fracture
Type IV -- complete fracture with total displacement of the fragments which allows the femoral head to rotate back into anatomic position

Femoral Neck Fracture

Types I & II = nondisplaced
Types III & IV = displaced
Femoral Neck Fracture
Signs and Symptoms
Inability to bear weight

Femoral Neck Fracture
Affected leg appears shortened and is externally rotated from the contraction of the iliopsoas and gluteus maximus muscles
Femoral Neck Fracture
Tx Principles
Nondisplaced fx’s should be internally stabilized with lag screws or pins placed parallel
Femoral Neck Fracture
Tx Principles
Displaced fractures
Closed/open reduction and internal fixation in younger patients
Primary prosthetic replacement in older patients
Femoral Neck Fracture
Complications associated with femoral neck fractures:
Loss of fixation
Infection
Non-Union
Osteonecrosis
Dislocation
Prosthetic loosening
Pain related to acetabular erosion
Hip Dislocations
Posterior-most common
Ortho Emergency -- due to risk of AVN, early DJD or Vascular insufficiency
Hip Dislocations
Hip Dislocations
Clinical findings:
Shortened limb
Internally rotated
Adducted
Hip Dislocations
Tx:
Reduction using Allis maneuver (Both Anterior & Posterior dislocations)
Hip Dislocations
If Irreducible or recurrent dislocations:
ORIF -- THR
Slipped Capital Femoral Epiphysis (SCFE)
Femoral head remains in the acetabulum and the neck displaces through the growth plate in the anterior direction
Caused by weakness of the perichondrial ring and a slip through the hypertrophic zone of the developing growth plate
Slipped Capital Femoral Epiphysis (SCFE)
SCFE most commonly seen in obese adolescent boys
Most common with a + FMHX
Slipped Capital Femoral Epiphysis (SCFE)

Bilateral is not uncommon
Assoc with hypothyroidism & renal disease
Slipped Capital Femoral Epiphysis (SCFE)
Presents with hip or knee pain and an externally rotated LE with decreased ROM of the hip especially internal rotation
Slipped Capital Femoral Epiphysis (SCFE)
Slipped Capital Femoral Epiphysis (SCFE)
Slip is classified based on the degree of slippage and best seen on the frog-leg lateral view
Grade I -- 0 to 33%
Grade II -- >33 to 50%
Grade III -- > 50%
Slipped Capital Femoral Epiphysis (SCFE)
Frog-Leg View
Slipped Capital Femoral Epiphysis (SCFE)

Tx:
Pinning across the capital femoral epiphysis to prevent further slippage
Slipped Capital Femoral Epiphysis (SCFE)
Legg-Calve-Perthes Disease
Noninflammatory deformity of the WB surface of the femoral head
Results from a vascular insult or abnormality
Legg-Calve-Perthes Disease
Vascular insult leads to osteonecrosis of the proximal femoral epiphysis
Most common in boys 4 - 8 years old
Legg-Calve-Perthes Disease
Pain in hip or knee
Decreased ROM esp. Abduction & Internal Rotation
Can occur bilaterally
Legg-Calve-Perthes Disease
Pathologic process include
Necrosis of bone

Legg-Calve-Perthes Disease
X-ray findings vary with the stage of disease
2 most common staging systems are
Caterall
Salter-Thompson
Legg-Calve-Perthes Disease
Salter-Thompson
Stage A -- No involvement of the lateral pillar of the femoral head; prognosis generally good
Stage B -- Lateral pillar of the femoral head is involved; prognosis generally poor
Legg-Calve-Perthes Disease
Caterall
Stage I -- 25% of the femoral head in the anterior central region is involved
Stage II -- 50% of the femoral head including the anterior lateral region is involved
Legg-Calve-Perthes Disease
Caterall
Stage III -- Approx. 75% of femoral head involved with formation of a large sequestrum; large medial pillar usually uninvolved
Stage IV -- Entire femoral head involved, with widespread collapse of epiphysis
Legg-Calve-Perthes Disease
Crescent sign represents a pathologic fracture with collapse of subchondral bone in the resorbing femoral head
Legg-Calve-Perthes Disease
Legg-Calve-Perthes Disease
Treatment Goal:
To maintain the sphericity of the femoral head
Treatment for Caterall Stage I & II or Salter-Thompson Stage A is usually observation

Legg-Calve-Perthes Disease
Tx for Caterall Stage III & IV or Salter-Thompson Stage B is early ROM followed by containment of the femoral head within the acetabulum using an abduction brace or surgery
Summary
Etiology, clinical presentation, laboratory and radiologic studies, evaluation and treatment for the following hip conditions:
Aseptic/Avascular Necrosis or Osteonecrosis
Fractures and Dislocations
Slipped Capital Femoral Epiphysis
Legg-Calve-Perthes Disease

Common Orthopedic Conditions of the Spine
Learning Objective
Given a scenario describing a patient with symptoms suggestive of an orthopedic or musculoskeletal condition, formulate a treatment plan after ordering and interpreting diagnostic tests and making a preliminary diagnosis.
Learning Objective
Identify the etiology, clinical presentation, lab/radiologic studies, evaluation, and treatment for the following spine conditions:
Back Strain/Sprain
Ankylosing Spondylitis
Cauda Equina
Learning Objective
Identify the etiology, clinical presentation, lab/radiologic studies, evaluation, and treatment for the following spine conditions:
Herniated Nucleus Pulposus (HNP)
Spinal Stenosis
Kyphosis/Scoliosis
Low Back Pain (LBP): Spondylolysis, Spondylolisthesis

Disorders Of The Back/Spine
Back Strain/Sprain
Ankylosing Spondylitis
Cauda Equina
Herniated Nucleus Pulposus (HNP)
Spinal Stenosis
Kyphosis/Scoliosis
Low Back Pain (LBP): Spondylolysis, Spondylolisthesis
Back Strain/Sprain
LBP is the most frequent cause of lost work time and disability in adults <45 years
Most symptoms of limited duration
85% of patients improve and returning to work within 1 month
Back Strain/Sprain
The 4% of patients whose symptoms persist longer than 6 months generate 85% to 90% of the costs to society for treating low back pain
Back Strain/Sprain
By strict definition, a low back sprain is an injury to the paravertebral spinal muscles. However, the term also is used to describe ligamentous injuries of the facet joints or annulus fibrosus
Back Strain/Sprain
Repeated lifting and twisting or operating vibrating equipment most often precipitates a back sprain
Back Strain/Sprain
Other risk factors include poor fitness, poor work satisfaction, smoking, and hypochondriasis
Recurrent episodes are separated by many months or years; more frequent recurrences suggest degenerative disk disease
Back Strain/Sprain – Clinical Symptoms
Patients report the acute onset of low back pain, often following a lifting episode
Lifting may be a trivial event, such as leaning over to pick up a piece of paper
Pain often radiates into the buttocks and posterior thighs
Back Strain/Sprain – Clinical Symptoms
Patients may have difficulty standing erect, may need to change position frequently for comfort
Condition often first occurs in the young adult years

Back Strain/Sprain
Clinical Symptoms - First Major Episode
May show signs of nonorganic behavior, such as exaggerated responses, generalized hypersensitivity to light touch, or facial grimacing
Physical Examination
PE reveals diffuse tenderness in the low back or sacroiliac region
ROM of the lumbar spine, particularly flexion, is typically reduced and elicits pain
Physical Examination
The degree of lumbar flexion and the ease with which the patient can extend the spine are good parameters by which to evaluate progress
The motor and sensory function of the lumbosacral nerve roots and lower extremity reflexes are normal
Back Strain/Sprain
Diagnostic Tests
Plain radiographs usually are not helpful for patients with acute low back strain, as they typically show changes appropriate for their age
Back Strain/Sprain
Diagnostic Tests (cont’)
Adolescents/young adults, have little or no disk space narrowing. Adults older than age 30 years, have variable disc space narrowing and/or spurs
Back Strain/Sprain
Diagnosis
For patients with atypical symptoms, such as pain at rest or at night or a history of significant trauma, AP and lateral radiographs are necessary
These views help to identify or rule out infection, bone tumor (visualize up to T10), fracture, or spondylolisthesis
Back Strain/Sprain
Differential Diagnosis
Ankylosing spondylitis (family history, morning stiffness, limited mobility of lumbar spine)
Drug-seeking behavior (exaggerated symptoms, inconsistent and nonphysiologic examination)
Extraspinal causes: ovarian cyst, nephrolithiasis / pancreatitis/ ulcer disease
Back Strain/Sprain
Differential Diagnosis
Fracture of the vertebral body (major trauma or minimal trauma with osteoporosis)
Herniated nucleus pulposus or ruptured disc (unilateral radicular pain symptoms that extend below the knee and are equal to or greater than the back pain)
Back Strain/Sprain
Differential Diagnosis
Infection [fever, chills, sweats, elevated erythrocyte sedimentation rate (ESR)]
Myeloma (night sweats, men older than age 50 years)
Back Strain/Sprain-Treatment
Focuses on relieving symptoms, short period of bed rest (1 to 2 days)
NSAIDs, other non-narcotic pain medications (7 to 14 days)
Back Strain/Sprain-Treatment
Muscle relaxants may be helpful in the first 3 to 5 days, but narcotic analgesics/sedatives should be avoided
Back Strain/Sprain - Treatment
Treatment
Couple medications with reassurance
Once the acute pain has diminished, emphasize aerobic conditioning and strengthening regimens
Goal is to assist patient in returning to normal activity within 4 weeks
Ankylosing Spondylitis

Ankylosing Spondylitis

Men
3rd to 4th decade of life
Insidious onset of back and hip pain
Morning stiffness
+ HLA-B27
Ankylosing Spondylitis

Ankylosing Spondylitis

Ankylosing Spondylitis
Systemic:
Pulmonary fibrosis
Iritis
Aortitis
Colitis
Arachnoiditis
Amyloidosis
Sarcoidosis
Ankylosing Spondylitis - Treatment
Physical Therapy
NSAIDs, Tylenol or ASA
Hip-THA
Spine-Corrective osteotomies for flexion deformities

Neurological Syndromes
44 yo F w/ 2 yr h/o LBP but new bilateral sciatica, saddle numbness
Onset: p moving furniture
PE: distressed; sensory loss L5-S4 (anal area); weakness in feet DF/PF
W/U: emergent MRI & surgical referral
Cauda Equina Syndrome
Distal end of the spinal cord, the conus medullaris, terminates at the Ll-2 level
Below this, spinal canal is filled with L2-S4 nerve roots, known as the cauda equina
Cauda Equina Syndrome
Compression of roots distal to the conus causes paralysis without spasticity
RARE : <1-2% of HNP or spinal masses
L5/S1 is the most common level
Involves bilateral sacral roots
Cauda Equina Syndrome
A massive central herniation of a lumbar disc that presents with
Bilateral sciatica +/- foot weakness
Progressive motor weakness and numbness
Saddle anesthesia (buttock anesthesia)
Loss of bowel and bladder control
This represents a surgical emergency!

Herniated Nucleus Pulposus (HNP) of the Lumbar Spine
Displacement of the central area of the disc (nucleus) resulting in impingement on a nerve root
HNP of the Lumbar Spine
Classification based on degree of disc displacement

Most commonly involves the L4-5 disc (L5 nerve root)
Disc Pathology

HNP of the Lumbar Spine
History
Radicular leg pain
May also have lower back pain

HNP of the LS – Physical Findings
Motor weakness
L4 nerve root—tibialis anterior weakness
L5 nerve root—extensor hallicis longus weakness
S1 nerve root--achilles tendon weakness
HNP of the LS – Physical Findings
Physical findings cont’d:
Asymmetric reflexes
Knee jerk (L4)
Tibialis Posterior or Medial Hamstring tendon reflex (L5)
Ankle jerk (S1)
HNP of the Lumbar Spine
Sensory findings
Light touch
Sharp Dull
HNP of the Lumbar Spine
Positive tension signs
Straight Leg Raise (Supine & Sitting)
HNP of the Lumbar Spine
Diagnostic tests
Magnetic resonance imaging (MRI)
Myelography
Electromyography/nerve conduction studies
HNP of the Lumbar Spine
Treatment (most sxs resolve with time)
Symptomatic
Physical therapy
NSAIDs, Tylenol or ASA
Aerobic conditioning
Lumbar epidural steroids
Neurological Syndromes
71 yo M w/ long ho LBP & 6 mos. R buttock > calf pain w/ vague numbness

Worse: Standing, walking

Improves: Stooping, sitting, forward bending
Spinal Stenosis
HNP/Spinal Stenosis Comparisons
HNP vs Stenosis
Age: 30-50 vs >50
Sciatica: Classic for HNP vs Atypical for Stenosis
Aggravated: Flexion/Sitting vs Extension & Standing
HNP/Spinal Stenosis Comparisons
HNP vs Stenosis (cont’)
Nerve Tension Signs (SLR): Usual vs Unusual
Prognosis: Worse, More Chronic in Stenosis
HNP and Spinal StenosisTreatment
NSAIDs (COX-2 inhibitors), Tylenol or ASA
“Muscle relaxants”
Narcotics
Tramadol [generic]
Corticosteriods (including spinal injections)
HNP/Spinal Stenosis Treatment
Decompression
Laminectomy
Foraminotomy
Fusion
Kyphosis
Defined: abnormally increased convexity in the curvature of the thoracic spine as viewed from side
Scheuermann’s Disease
Hyperkyphosis that does not reverse on attempts at hyperextension
Scheuermann’s Disease
Most common in adolescent males
Scheuermann’s Disease
Dx made by X-ray
45 degrees
With 5 degrees or more of vertebral wedging at 3 sequential vertebrae
Scheuermann’s Disease (cont’)
Treatment
Observation
+/- Bracing
Spinal Fusion
Scoliosis

Scoliosis - Defined
Lateral curvature of the spine of greater than 10 degrees, usually thoracic or lumbar, associated with rotation of the vertebrae and sometimes excessive kyphosis or lordosis
Scoliosis
Idiopathic scoliosis
Lateral deviation and rotation of the spine without an identifiable cause
Scoliosis
Assoc. rib hump with forward bending
Scoliosis
Assoc. rib hump with forward bending
Scoliosis
Curve description – curve described by its apex (position and direction [right or left] that it points to
Scoliosis
Right thoracic curves -- apex at T7 or T8 (MC)
Double major curves -- right thoracic curve with left lumbar curve
Left lumbar curves, Right lumbar curves
Scoliosis

Scoliosis
Curve measurement

Most common method used is Cobb method

Measurements are made on standing PA X-rays
Scoliosis
Determination of skeletal maturity
Risser staging -- based on ossification of iliac crest apophysis
Risser staging is graded 0 (least mature) to 5 (most mature)
Scoliosis
Adolescent idiopathic scoliosis
Presents between ages 10 & 18
MC form of idiopathic Scoliosis
Curve progression is most likely with
Curve > 20 degrees
Age at dx < 12
Risser stage of 0 or 1
Scoliosis
Approx. 75% with curves of 20 - 30 degrees progress at least 5 degrees
Severe curves of 90 degrees or more are assoc. with cardiac & pulmonary impairment
Left thoracic curves are rare and require eval of spinal cord with MRI
Scoliosis
Treatment options include:

Observation

Bracing
Scoliosis
Surgery
Based on likelihood of curve progression
Curve Magnitude
Age at DX
Skeletal Maturity
Presence of Menarche
Curve progression during observation period
Scoliosis
Scoliosis
Scoliosis
Scoliosis
Scoliosis
Adolescent idiopathic scoliosis is typically not painful, and the child presenting with a painful curvature should be given a thorough w/u
Low Back Pain
Spondylolysis
Defect in pars interarticularis (Unilateral)
MC cause of lower back pain in children and adolescents
Low Back Pain
Spondylolysis
Unilateral Pars defect is the result of a fatigue fx from repetitive hyperextension
Low Back Pain
Most common in gymnasts and football lineman
Low Back Pain
Low Back Pain
Spondylolysis
Treatment
Modification of activity
NSAIDs, Tylenol/ASA
Physical therapy
Flexibility & strengthening exercises
Thoracolumbosacral orthosis
Low Back Pain
Spondylolisthesis
Bilateral Pars Interarticularis defect
Forward slippage of one vertebra on another
Usually L5-S1
Low Back Pain
Most common in children involved in hyperextension activities
Low Back Pain
Spondylolisthesis
Meyer Classification
Low Back Pain
Spondylolisthesis
Treatment
Modification of activity
NSAIDs, Tylenol, ASA
Physical therapy
Flexibility & strengthening exercises
Thoracolumbosacral orthosis

Low Back Pain
Spondylolisthesis
Treatment
Severe pain not responding to non-operative management requires surgical decompression and/or stabilization

Summary
Symptoms suggestive of an orthopedic or musculoskeletal condition, formulation of a treatment plan after ordering and interpreting diagnostic tests, and making a preliminary diagnosis
Summary
Etiology, clinical presentation, lab/radiologic studies, evaluation, and treatment for the following spine conditions:
Back Strain/Sprain
Ankylosing Spondylitis
Cauda Equina

Summary
Etiology, clinical presentation, lab/radiologic studies, evaluation, and treatment for the following spine conditions:
Herniated Nucleus Pulposus (HNP)
Spinal Stenosis
Kyphosis/Scoliosis
Low Back Pain (LBP): Spondylolysis, Spondylolisthesis