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5002 Case 8 Cheat Sheet by

Compression fracture of the thoracic spine

Case

- 57 y.o. female
- Back pain; T/L junction
- Onset 1 day ago whilst bending forward cleaning the bath
- Sudden onset, excruc­iating pain
- Severe pain
- Nauseous w/ pain
- 10/10 onset
- Now 5/10
- Constant pain & nausea
AF: Any movement, painful to lie on back, couldn't sleep duet pain at night
RF: Rest, ice, gentle walking, parace­tamol & ibuprofen
AA: Movement; especially sudden
Extras
- Chiro treatment for previous "­rotator cuff" pain, treatment helped w/ US & home exercises, no manipulation
- IBS (upset tummy & nerves)
- Dizziness, GP diagnosed w/ vertigo
- Menopause 8 yrs ago (49)
- Osteop­orosis; diagnosed 5 yrs ago
- Prescribed medication (doesn't recall name) & calcium but doesn't take them (worried about side effects)
- Mother: osteop­orosis

Physical Examin­ation Findings cal

General observ­ations
- Mild swelling over T/L junction
- Appears tired & frail
- All movements guarded
Gait
- Extremely guarded
- Unable to lie supine due to pain
Tx & Lx ROM
- Unable to perform due to pain
Closed fist percussion
- Purpose: sympto­matic (sharp, sudden pain) compre­ssion fracture
- Findings: pain over T/L junction
Percussion
- Pain over T11-12 & L1
Vibration
- No pain
- Discomfort over the T/L area
Palpations
- Genera­lised pain & tenderness over Tx spine
- Very TTP over T10-L2

Discussion

Working diagnosis
- Compre­ssion fracture of the Tx spine
- Why a 57 y.o. would get a fracture so easily w/ such minimal trauma?
1. Extremely osteop­orotic: due to bone density loss, fracture compli­cat­ions, multiple fractures, underlying health conditions (chronic RA, hypert­hyr­oidism, GI disorders, prolonged use of steroids), hormonal factors (decline of oestrogen aka menopause, low testos­ter­one), lack of treatment, age
2. Pathol­ogical fracture (osteo­por­osis, cancer, bone infection, Paget's disease, osteog­enesis imperfect, osteom­alacia, genetic disorder, nutrit­ional defici­encies) & there's underl­ying, undiag­nosed cause for bone weakness
How does compre­ssion fracture affect her MSK manage­ment?
- Avoid high-v­elocity or high-i­mpact spinal manipulations
- Soft tissue & lifestyle focus
- Combined management plan w/ secondary healthcare profes­sional
What is vertigo?
- Dizziness charac­terised by a sensation of spinning, swaying, & tilting when standing still
- Possible issue w/ inner ear (balance), brain, sensory pathways
What other examin­ations could have been done?
- Assess for gait, balance & mobility (for fall prevention purposes to minimise further injury to osteop­orotic pt)
- Sensory examin­ation (pt cannot lie supine due to pain ∴ try lying down)
- Referral for MRI

Learning outcomes

Osteop­orosis:
Sx & Ssx:
- Height loss
- Back pain
- Fractures
- Stooped posture
- Decreased grip strength
Treatment:
- Routine assessment (not required if >40 y.o.)
- Avoid high-v­elocity or high-i­mpact spinal manipulations
- Soft tissue & lifestyle focus
- Refer to GP for osteop­orosis education / invest­iga­tions in younger pts
Management (if risk assessment suggest signif­icant fracture risk):
- Refer for imaging invest­iga­tions & medication advice
- Lifestyle advice: no smoking, alcohol consum­ption <2 units / day
- Food/diet: calcium & vitamin D intake
- Fall prevention (strength & balance training)
Why this pt so bad?
- Drop in oestrogen from menopause (causing bone loss, increasing risk of osteoporosis)
- Pt not taken their medication
- Underlying pathol­ogical cause?
Different types of fractures in the Tx spine:
- Compre­ssi­on/­ant­erior wedge (most common; due to osteop­orosis; post-m­eno­pausal, >50 y.o.)
- Burst (axial compre­ssion; can cause neurol­ogical deficits)
- Flexio­n-d­ist­raction (due to extreme forward bending force [RTA]; can cause posterior ligament tear)
- Pathol­ogical (caused by infect­ion­s/t­umours; full vertebral collapse)
Rotator cuff disorder (supra­/in­fra­spi­natus, teres minor, subsca­pularis - SITS):
- Rotator cuff tendin­itis: inflam­mation of the tendons of the rotator cuff muscles; typically caused by overus­e/r­epe­titive motions
- Rotator cuff tear: tear in one or more rotator cuff tendons, can be partial or complete
- Rotator cuff imping­ement: rotator cuff tendons & bursa compression
- Rotator cuff bursitis: inflam­mation of the bursa around the rotator cuff tendons
Presen­tation:
- Pain in shoulder: especially lifting or reaching overhead
- Weakness in the shoulder, making it difficult to lift or carry objects
- Limited ROM shoulder
- Clicki­ng/­popping when moving shoulder
- Swelli­ng/­ten­derness in shoulder
** Adhesive capsulitis (frozen shoulder) might present w/ Sx & Ssx suggestive of rotator cuff disorder, but in this condition passive ROM is limited as well**
Diagnosis:
- Medical Hx, physical exam: AF, RF, ROM, strength, tender­ness? swelling? deformity?
- Referral for imaging: MRI (gold standard), US, x-ray, CT
Manage­ment:
- If acute rotator cuff tear caused by trauma is suspected (trauma, pain, & weakness), refer!
- Rest (acute phase)
- Referral for cortic­ost­eroid injection
- Parace­tamol (if not helping, NSAIDs)
- Stretching & streng­thening of the rotator cuff & scapular muscles
- Manual therapy / mobili­sation
Difference between IBS & IBD
Irritable bowel syndrome (IBS):
- Functional GI disorder affecting colon
- Not associated w/ inflam­mation or damage to intestinal lining
- Presen­tat­ions: recurrent abdominal pain/d­isc­omfort, changes in bowel habits (diarr­hoea, constipation)
- Diagnosis: through Sx & exclusion of other conditions (no specific diagnostic tests)
- Manage­ment: dietary modifi­cations (avoid caffeine, alcohol, spice, fatty foods), medica­tions, stress management
Inflam­matory bowel disease (IBD):
- Chronic inflam­matory disorder affecting whole digestive tract (inc. Crohn's & Ulcerative Colitis)
- Inflam­mation & damage to intestinal lining
- Presented: abdominal pain, diarrhoea, rectal bleeding
- Diagnosis: medical Hx, physical exam, blood tests, imaging tests (endoscopy or colonoscopy)
- Manage­ment: medication (corti­cos­ter­oids, immuno­dul­ators), nutrit­ional support, surgery, lifestyle changes (exercise, avoid smoking & stress)
Menopause & treatment
- Ovaries stop producing eggs, levels of hormones (oestrogen &p­rog­est­erone) decrease
- Can contribute to osteop­orosis develo­pment (oestrogen regulates bone turnover [oestrogen drops = bone turnover increases = less bone density/mass])
- Sx & Ssx: hot flashes, night sweats, vaginal dryness, mood changes, sleep disturbances
- Treatment: hormone replac­ement therapy (HRT [slows down bone turnov­er]), non-ho­rmonal medica­tions (e.g. SSRIs [reduce hot flashes & improve mood]), lifestyle (regular exercise, reducing stress, avoid triggers [caffeine or alcohol])
 

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