MSK red flags PDF

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MSK red flags...

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Red flags

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Only involved in the triage stage for red flags Every time you see the patient it’s a good idea to check for red flags Ask how are you feeling? Are things getting better or worse?

Cervical Arterial dysfunction -

Vertebrobasilar insufficiency describes patients with posterior circulation ischemia Due to the perceived anatomical vulnerability of the posterior cervical arterial system it has traditionally been the focus Important to incorporate the anterior arterial system – internal carotid arteries - Carries majority of blood flow to the brain - Pathological changes are very common - ICA blood flow influenced directly by neck movement - Influenced by movement of the cervical spine extension > rotation - ICA goes through many structures that are affected by rotation.

Vertebral artery dissection Clinical presentation Non-ischemic signs and symptoms

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One sided neck pain and/ occipital headache (rare) C2-C6 root impairment

Ischemic signs and symptoms -

Hind-brain transient ischemic events – 5D’S and 3N’s, Facial numbness Ataxia Vomiting Hoarseness of voice Loss of short term memory Vagueness Hypotonia Weakness Anhidrosis (loss of facial sweating) Hearing disturbances Malaise Perioral dysthesia Papillary changes Clumsiness Agitation Hind-brain stroke (Wallenberg’s syndrome, locked-in syndrome)

Carotid artery dissection Non-ischemic signs and symptoms - Homer’s syndrome - Pulsatile tinnitus - Cranial nerve palsies Less common - Ipsilateral carotid bruit - Scalp tenderness - Neck swelling - CN VI palsy -

Orbital pain Anhidrosis (facial dryness)

Ischemic signs and symptoms - TIA - Ischemic stroke - Retinal infarction - Amaurosis fugax

Tests: -

Sustained rotation in sitting Pupils focused on you at all times Sustain for at least 10 seconds Wait 10 seconds in neutral between sides (latency) Constantly ask how they feel during test

Positive test responses: - Dizziness - Nystagmus which does not settle within a few seconds - Pre-syncope - Feeling ‘unwell’ - Any of the 5D’s cease testing if symptoms not set within seconds and/or getting worse - Lack of focus in pupils Cranial nerve tests Link to nerve examination: https://www.youtube.com/watch?v=PG4zrRfocoQ&ab_channel=DoctorKhalid

Transverse ligament - Enlocates dens - Protects the spinal cord - MOI: forced flexion

Alar ligament - Occipital and atlantal portions - Primary restraint for rotation and lateral flexion - MOI: lateral flexion and flexion

Tectorial Membrane - Extension of the posterior longitudinal ligament - Ligament tightens in 30 degrees of CSP flexion - Mechanism of injury – traction or forced flexion. Commonly seen in high velocity MVA’s (including in children.

Clinical presentation of upper cervical instability Symptoms are variable and a neurological deficit is not always the most apparent clinical sign - HPC - Include generalized neck pain – low and severe - Limited Csp mobility - Torticollis - Neurological symptoms - Headache: occipital and frontal Past medical history - RA – JIA - Past trauma - Hx of instability - Congenital Pain description – subjective & objective -

Clunking or crunching with csp flex/ext +/- associated pain Neck pain with sustained postures Weakness of the neck Altered ROM Pain at back of head and or neck Sensory and motor changes in the upper limbs CAD/VBI symptoms Lips and tongue sensory disturbances – paresthesia, pain along length of tongue Symptoms of spinal cord compromise – Upper motor neuron Cervical radicular symptoms Reduced Csp lordosis

Neurological examination -

Neuro integrity: Babinski, Hoffman signs, clonus, reflexes, sensation View imaging – CT, MRI and radiography especially C1/2

Upper cervical spine clinical tests -

Lots of tests Sharp-purser test Alar ligament test Transverse ligament test Lateral stability Reliability of these tests? Not very reliable

Imaging -

Radiographs main diagnostic tool in adults and paeds Lateral (flex and ext), open mouth odontoid views Reference for measurement is the atlas dens interval (ADI)

Adults: - >2.5mm to 3mm adults - 4-5mm indicates secondary restrains intact - >10-12mm destruction of all ligamentous restrains Children: - >4.5mm to 5mm in children

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If seen anything urgent then refer to MRI MRI regarded as gold standard but often reserved for more detailed complex analysis (congenital and neurological) - CT scan Posterior atlanto-dens interval (PADI): distance between the posterior surface of the odontoid peg and the anterior margin of the posterior ring of the atlas - More accurate measure of risk of neurological compromise - Normal 17-29mm - Abnormal...