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Orthopedics Lab Exercise 1


I'm not going to rewrite the whole case, but I will summarize it here, then answer the questions. 38 yo male moves heavy stuff and wakes up one morning with a kink in his neck. It gets worse, with cramping, burning pain in his neck and shoulders. He can't sleep, and goes everywhere with his arm over his head (Bakody's sign) because that's the only position in which he gets relief from the pain. A day later he goes to the urgent care center and they prescribe narcotic pain meds and muscle relaxers, but the pt won't take them because he's a recovering addict. They don't take any xrays.

--dull ache shoots down left arm
--Bakody's sign
--thumb, index finger and half of middle finger feel numb on L
--tenderness T+2/4 in posterior cervicals and levator scapula, middle trap and scalenes, more on L than R
--cervical flexion is normal
--cervical extension causes pain in neck and down arm
--lateral bending normal "feels good"
--left rotation causes pain
--right rotation normal/pain-free
--Maximal cervical compression/Spurling's test to the left causes left neck pain that radiates to the shoulder, and worsens "numbness" in L hand
--light touch and sharp/dull are intact and equal bilaterally, even in the "numb" hand
--left biceps weak at +3/5 on L, 5/5 on R
--deltoids and triceps 5/5 bilaterally
--L wrist extensors 3/5, 5/5 on R
--finger and wrist flexors normal bilaterally, 5/5
--all reflexes normal +2/4 except L biceps which is +1/4

1. What is Bakody's sign? It a pt's tendency to support their arm in an elevated position, perhaps even going so far as to rest it on top of their head. It changes the pressure equilibrium in the spine, and in this case may be removing pressure from a pinched spinal nerve root.

2. What happened? I think the patient may have injured a disk in his cervical spine, specifically at the C6 level. The weak left biceps, wrist extensors, and numbness of the thumb all direct this suspicion. The reduced bicep reflex implicates the C5 and C6 roots, though the deltoids being fully functional narrows it to C6 yet again. It is not at the C7 level because the wrist flexors and triceps are fully functional.

3. The patient says part of his hand is numb because the sensation in it is altered and he has some loss of strength. He is experiencing hot pain, and probably also the "pins and needles" associated with limbs that "fall asleep".

4. Imagining that I am already a doctor and responsible for this patient, I would prescribe some form of anti-inflammatories that he could take without aggravating his addiction. I would probably also consider getting another option, or perhaps an xray, to confirm my suspicion of disc damage, as I am a new doctor. I would suggest specific exercises, to begin after the pain is resolved, that strengthen his core and correct any postural issues that contributed to the disc problem.

Comments

( 3 comments — Leave a comment )
neptunia67
Oct. 5th, 2008 07:53 pm (UTC)
Would you refer him to a chiropractor?
liveonearth
Oct. 5th, 2008 07:58 pm (UTC)
Yeah, that would be my first choice.
liveonearth
Jul. 5th, 2011 11:32 pm (UTC)
3 years later
I wouldn't refer him to a chiro anymore! I would have him get a CT if his insurance will cover it, and I would send him for an orthopedic consult if the imaging warranted. If not I would attempt conservative management for 6 weeks if pain levels allow, and reassess.
( 3 comments — Leave a comment )

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