Orthopaedics
Seán Keenan
2022
,The Neck
Neck and Orthopaedics in General
Imaging - Bone contour (Fractures)
- Imaging Modalities o Obs: Intervertebral; Pedicles; Vertebral body
o CT: 1L if there is a clear spinal cord injury - Cartilages
o MRI: Fractures; Subluxation; Disc injury o Obs: Disc margins
o Evaluate: ABCS Acronym - Soft tissues
- Alignment o Obs: Retropharyngeal shadows
o Obs: Vertebral bodies; Spinal canal; Spinous process
o NB: 40 % <7 YO have pseudosubluxation of C2-3
n
Cervical Spondylosis (see neurology notes)
Description Presentation
- Prevalence: 90 % of Men >60 YO + Women >50 YO - Asx: Usually asymptomatic
- Path: Degenerative changes in cervical spine - Nerve: Paraesthesia; Pain in neck and arms
- NB: Narrows spinal canal and intervertebral foramina - Cc: 10 % of Sx develop cervical myelopathy
Cervical Spondylolisthesis
Causes Description
- Odontoid process - Path: One vertebrae slips forward over one below
o Congenital: Failure in fusion of dens with axis - NB: Result of untreated cervical spondylosis
o Dens: Fracture (skull, atlas and dens slip forward) Management
- Transverse ligament of atlas - Basic: Immobilisation in plaster jackets
o Inflammation: RA; Complicating throat infection Complications
o NB: Inflammation softens ligament - Instability: Can increase in severity post-trauma
Cervical Rib
Description Investigations
- Incidence: 1:500 have cervical rib abnormality - Exam: Weak radial pulse ± Forearm cyanosis
- Congenital: Development of costal process of C7 - Arteriography: Subclavian compression
Presentation - XR: May or may not show abnormality
- Scalenus / 1st Rib Syndrome - NB: Fibrous bands may cause sx so XR not useful
o Features: Similar Sx; No radiological abnormality Management
o NB: May be caused by fibrous band - Physio: May improve symptoms
- Thoracic Outlet Compression (TOC) - Surgery: Rib removal or fibrous band division
o Features: See below
- UL Pain or Paraesthesia
o Features: Often affects ulnar side
o NB: hand muscle weakness / wasting LT
, Thoracic Outlet Syndrome
Description Investigations
- Age: AOO peaks at 40 YO - Adson Manoeuvre: Extend + rotate neck
- Path: Compression at thoracic outlet - NB: ↓ RA Pulse on inspiration
- NB: Affects Brachial plexus; Subclavian artery/vein - Rule Out: Cervical spondylosis; Carpal tunnel
Classifications - XR: Osseus abnormalities
- Soft Tissue: 70 % of TOC; Scalenus m. banding - CT/MRI: Rules out tumours and cervical lesions
- Osseous: 30 % of TOC; Cervical rib - Vascular: Venography; Arteriography
- Neurogenic: 90 % of TOC presentations Management
- Vascular: 10 % of TOC presentations - 1L: Physiotherapy + Rehabilitation if neurogenic
Presentation - Surgery: If there is a physical abnormality
- Trauma: Preceding neck trauma Hx
- Neurogenic: Numbness; Paraesthesia; Cold hands
- Vein: Arm swelling; Distended veins
- Artery: Arm claudication (Pain); Ulcers; Gangrene
- NB: Worse on arm abduction
Spasmodic Torticollis (Cervical Dystonia)
Description Management
- Prevalence: Commonest adult focal dystonia - Medical: Botox; Deep brain stimulus
Presentation - Surgical: Selective ramisection
- Features: Episodes of a sudden stiff painful neck Prognosis
Causes - Recovery: Spontaneous recovery in 20 % in 5 yrs
- Torticollis: Sternocleidomastoid or Trapezius spasm - Life-long: Generally a life-long condition
Infantile Torticollis
Description Management
- Age: Typically affects 1-36 MO - Limiting: Self-limiting in 97 %
- Path: birth damage to sternocleidomastoid - Persistent: Physiotherapy if persistent
Seán Keenan
2022
,The Neck
Neck and Orthopaedics in General
Imaging - Bone contour (Fractures)
- Imaging Modalities o Obs: Intervertebral; Pedicles; Vertebral body
o CT: 1L if there is a clear spinal cord injury - Cartilages
o MRI: Fractures; Subluxation; Disc injury o Obs: Disc margins
o Evaluate: ABCS Acronym - Soft tissues
- Alignment o Obs: Retropharyngeal shadows
o Obs: Vertebral bodies; Spinal canal; Spinous process
o NB: 40 % <7 YO have pseudosubluxation of C2-3
n
Cervical Spondylosis (see neurology notes)
Description Presentation
- Prevalence: 90 % of Men >60 YO + Women >50 YO - Asx: Usually asymptomatic
- Path: Degenerative changes in cervical spine - Nerve: Paraesthesia; Pain in neck and arms
- NB: Narrows spinal canal and intervertebral foramina - Cc: 10 % of Sx develop cervical myelopathy
Cervical Spondylolisthesis
Causes Description
- Odontoid process - Path: One vertebrae slips forward over one below
o Congenital: Failure in fusion of dens with axis - NB: Result of untreated cervical spondylosis
o Dens: Fracture (skull, atlas and dens slip forward) Management
- Transverse ligament of atlas - Basic: Immobilisation in plaster jackets
o Inflammation: RA; Complicating throat infection Complications
o NB: Inflammation softens ligament - Instability: Can increase in severity post-trauma
Cervical Rib
Description Investigations
- Incidence: 1:500 have cervical rib abnormality - Exam: Weak radial pulse ± Forearm cyanosis
- Congenital: Development of costal process of C7 - Arteriography: Subclavian compression
Presentation - XR: May or may not show abnormality
- Scalenus / 1st Rib Syndrome - NB: Fibrous bands may cause sx so XR not useful
o Features: Similar Sx; No radiological abnormality Management
o NB: May be caused by fibrous band - Physio: May improve symptoms
- Thoracic Outlet Compression (TOC) - Surgery: Rib removal or fibrous band division
o Features: See below
- UL Pain or Paraesthesia
o Features: Often affects ulnar side
o NB: hand muscle weakness / wasting LT
, Thoracic Outlet Syndrome
Description Investigations
- Age: AOO peaks at 40 YO - Adson Manoeuvre: Extend + rotate neck
- Path: Compression at thoracic outlet - NB: ↓ RA Pulse on inspiration
- NB: Affects Brachial plexus; Subclavian artery/vein - Rule Out: Cervical spondylosis; Carpal tunnel
Classifications - XR: Osseus abnormalities
- Soft Tissue: 70 % of TOC; Scalenus m. banding - CT/MRI: Rules out tumours and cervical lesions
- Osseous: 30 % of TOC; Cervical rib - Vascular: Venography; Arteriography
- Neurogenic: 90 % of TOC presentations Management
- Vascular: 10 % of TOC presentations - 1L: Physiotherapy + Rehabilitation if neurogenic
Presentation - Surgery: If there is a physical abnormality
- Trauma: Preceding neck trauma Hx
- Neurogenic: Numbness; Paraesthesia; Cold hands
- Vein: Arm swelling; Distended veins
- Artery: Arm claudication (Pain); Ulcers; Gangrene
- NB: Worse on arm abduction
Spasmodic Torticollis (Cervical Dystonia)
Description Management
- Prevalence: Commonest adult focal dystonia - Medical: Botox; Deep brain stimulus
Presentation - Surgical: Selective ramisection
- Features: Episodes of a sudden stiff painful neck Prognosis
Causes - Recovery: Spontaneous recovery in 20 % in 5 yrs
- Torticollis: Sternocleidomastoid or Trapezius spasm - Life-long: Generally a life-long condition
Infantile Torticollis
Description Management
- Age: Typically affects 1-36 MO - Limiting: Self-limiting in 97 %
- Path: birth damage to sternocleidomastoid - Persistent: Physiotherapy if persistent
