Orthopedics I

Thoracolumbar junction (50% of all vertebral fxes, 40% of all spinal cord injuries occur at T11-L2)

- Posterior bony arch
- Spinous process, facets, lamina, pedicle - posterior bony arch
- Interconnecting posterior ligamentous structures
- Supraspinous ligament, interspinous ligament, lligamentum flavum, facet joint capsule

- Anterior longitudinal ligament
- Anterior portion of annulus fibrosus
- Anterior vertebral body

- Posterior vertebral body
- Posterior portion of annulus fibrosus
- Posterior longitudinal ligament

Intact posterior and middle column - prevent hyperflexion, extrusion of bone/disc into canal, prevents agains significant subluxation

Two of three columns are injured, associated with pain but no neurological involvement

Middle column

Damage to all 3 columns

- Fracture of the anterior portion
- Middle column is intact
- 2 mechanisms - anterior or lateral flexion
- Posterior column may be disrupted in tension as upper segments hinge forward on intact middle column
- Can be caused by significant axial loading ( jumping out of window and landing on feet), flexion injuries (anterior compression fractures)or sidebending injuries (lateral flexion injuries)
- Can involve superior or inferior end plates or both or buckling of anterior cortex

- Disruption of posterior wall of vertebral body (middle column) and anterior column
- Mechanism - axial loading
- Neurologic injury
- Can be accompanied by lamina and pedicles fractures

Failure of posterior and middle columns in tension
- Anterior column serves as fulcrum and stays intact
- Mechanism - seat belt injury in MVA (w/out use of shoulder belt)

- Involves all 3 columns
- Differentiated from flexion distraction by disruption of anterior longitudinal ligament
- Result of compression, tension, rotation or shear forces
- Associated with highest incidence of neurologic defficits
- Very unstable, always need surgical treatment

Structural lateral curvature with rotation that occurs at or near puberty and for which no cause has been identified

Suspect by presence of body asymmetry best seen on Adams forward bending test,confirm by presence of at least 10 degree curvature by Cobb method on standing PA radiograph of the spine

Find start of curve and use superior vertebra to make aline, find end of curve and use inferior surface to make a line - take angle

Overall female predominance of 3.6 :1, for small curves in the range of 10 degrees prevalence is equal, in curves of larger magnitude overwhelming female predominance

RED FLAG - spinous anomaly like tumor - get MRI

Right thoracic and left lumbar

By the area of spine in which apex is located

Double curve

- Thumb MCP joint hyperextension
- Finger MP joint extension
- Elbow hyperextension
- Knee hyperextension
- Increased dorsiflexion of ankle

Mitral valve prolapse

Look for cafe-au-lait spots, hemangiomas, neurofibromas, dimples, abnormal hair patches - suggest congenital intraspinal pathologies

Defined by amount of calcification present in iliac apophysis
1- 25 % ossification
2- 50% ossification
3- 75% ossification
4- 100% ossification
5- iliac apophysis has fused with iliac crest after 100% of ossification

5 degrees and 10 for small curves

Smoking
Obesity
Occupational hazards

Disk herniation

Radicular pain goes below knee and sciatic pain doesnt go below knee

Pelvic rock test
Faber test
Direct palpation - best test

STORD
Simulation
Tenderness
Over-reaction
Regional disturbances
Distraction

- OA (spondylosis)
- Back sprain/strain
- Cancer (mets or primary)
- Infection
- Fracture (compression or traumatic)

- Lumbosacral radiculopathy
- Spinal stenosis
- Facet disease
- SI dysfunction
- Myofascial pain

- Saddle anesthesia (groin and upper inner thighs numbness)
- Diminished neurological responses (decreased reflex)
- Bladder retention
- Lax anal sphincter
- Foot drop or other major muscle weakness in legs, ankles or feet
- SURGICAL EMERGENCY!!!!!!!!

- Fever/chills
- Unexplained weight loss
- Persistent NIGHT PAIN
- > 50 y.o
- Previous history of cancer

- Fever with or w/out chills
- Worsening back pain especially at night
- Increased risk with IV drug users, immunocompromised, recent bacterial infections

- MRI
- Fever
- Progressive neurological problems
- Localized tenderness over abscessed bone

- Sudden searing intensifying pain from back to legs
- Abdominal ultrasound
- Vascular consult

L4-L5, L5-S1

L3/4 - anterior thigh pain
L5 - top of foot and great toe
S1 - pain in posterior calf, sole and/or lateral foot

- Over 50 years old (usually 60-70)
- Low back pain and leg pain with walking
- Unilateral or bilateral
- Increased pain with downhill walking and better with walking uphill
- Pos shopping cart sign

Pain - ANTEROLATERAL ASPECT OF THIGH

Sensory impairment-LATERAL ASPECT OF THIGH

Muscle weakness- HIP FLEXORS

Reflexes decreased - ADDUCTOR

Pain - ANTEROMEDIAL ASPECT OF THIGH

Sensory impairment-MEDIAL ASPECT OF KNEE

Muscle weakness- THIGH ADDUCTORS

Reflexes decreased - ADDUCTOR/PATELLAR

L4
Pain - POSTERIOR ASPECT OF THIGH, LATERAL ASPECT OF LEG
Sensory impairment-LATERAL ASPECT OF LEG, BIG TOE
Muscle weakness- EXTENSOR HALLUCIS LONGUS, TIBIALIS ANTERIOR
Reflexes decreased -TIBIALIS POSTERIOR

Pain - ANTERIOR THIGH
Sensory impairment-PRETIBIAL REGION
Muscle weakness- QUADRICEPS
Reflexes decreased - PATELLAR

L4
Pain - POSTERIOR ASPECT OF THIGH AND LEG
Sensory impairment-OUTER BORDER OF FOOT, SOLE, HEEL
Muscle weakness- TRICEPS SURAE (GASTROCNEMIUS + SOLEUS), GLUTEUS MAXIMUS
Reflexes decreased -ANKLE, MIDPLANTAR

Radicular pain results from stretching nerve root compressed by herniation