Picture Frame Vertebra and Systemic Sclerosis

• Below are detailed study notes from the provided text.

Picture Frame Vertebra

• Picture frame vertebra is a radiographic feature.

Systemic Sclerosis (Scleroderma)

• This is a chronic connective tissue disease generally classified as one of the autoimmune rheumatic diseases.
• A 24-year-old female presenting with hand pain and shiny skin on the arms and hands where symptoms are provoked by cold environments and cryotherapy is likely suffering from sclerosis.
• Acro-osteolysis, calcinosis cutis, and systemic sclerosis are the three main indicators.
• Raynaud's Phenomenon, skin hardening, and increased ANA are all associated with this condition.
• Dysphagia, gastric problems, and pulmonary fibrosis are the most likely sequelae.

Prostate Issues and Low Back Pain

• A 62-year-old male presents with low back pain, difficulty initiating the urinary stream, and polyuria during the night.
• Positive labs would include: PSA, Acid Phosphatase and Alkaline Phosphatase.
• Differential diagnoses include: Paget's Disease, Blastic Metastasis and Hodgkin's Disease.
• The three best follow up procedures are: referral to an oncologist, CT of the spine, and a radio nucleotide scan.

Lumbar Radiculopathy

• A 45-year-old female presents with back pain that started when bending over.
• Pain is felt in the left medial knee and down to the left medial big toe.
• Lying on the floor is palliative.
• Kemp's test produces low back and medial left foot pain.
• SLR is positive with radiation down the leg.
• Best initial treatments in this case are: extension exercises, flexion distraction manipulation, and lumbar traction
• Additional clinical findings: decreased patellar reflex, weak leg muscles and decreased sensation over the medial malleolus.
• If untreated, atrophy of muscles, permanent sensation loss, and cauda equina syndrome are likely to occur.

Carpal Tunnel Syndrome

• A 32-year-old female secretary presents with bilateral finger and hand pain with numbness and tingling, symptoms which have been present for some time.
• Pain occurs at night, rated 3-5/10.
• Phalen's test is positive; Wright's and Adson's tests are negative.
• Likely diagnoses: median nerve entrapment, pronator teres syndrome, and carpal tunnel syndrome.
• Worsening can be determined by: decreased dynamometer readings, inability to perform the pinch grip test, and thenar atrophy.
• Best treatment options: adjust the carpal bones, transverse friction massage to the pronator teres, and evaluate work station ergonomics.

Multiple Sclerosis

• A 32-year-old female presents with bilateral leg weakness, vertigo, and a recently developed bladder problem, with a 10-year smoking history.
• Babinski is positive, SLR and Lasegue's are negative, and Lhermitte's is positive.
• ROM is within normal limits.
• The best follow up includes: MRI of the brain, referral to neurologist, and CSF exam.
• Most likely associated signs are: visual disturbances, muscle spasms, and a positive plantar reflex.
• Likely sequelae: scanning speech, intention tremor, and nystagmus.

Diffuse Idiopathic Skeletal Hyperostosis (DISH)

• A 56-year-old male presents with lower thoracic spine pain that started one year ago
• Pain is worse in the morning, gets better, then worse again at night.
• Symptoms improve with ibuprofen and rest, worsen with activity.
• ROM is decreased in all planes, and Yeoman's is positive bilaterally.
• Best diagnoses: Diffuse idiopathic skeletal hyperostosis, anterior longitudinal ligament calcification and ankylosing hyperostosis.
• Likely sequelae: dysphagia and hoarseness, osteophytic bridging, and hyperglycemia.
• Diagnosis can be confirmed via: MRI, elevated serum glucose, and increased glucose level in the urine.

Congenital Block

• A 36-year-old male presents with neck pain and headaches, progressively worsening over the past month.
• The pain is dull, rated 3-6/10, worsens with computer use and writing, improves with ice.
• Slight decrease in flexion and extension of the cervical spine.
• Hypertonic cervical flexor and suboccipital muscles, and anterior head carriage present.
• Relevant radiographic findings: rudimentary disc, congenital block, and wasp waist deformity.
• Etiology of pain: upper cross syndrome, tension headache, and blocked vertebra.
• Best initial treatment options: ergonomic re-training, stretch the pectoral muscles, and myofascial release.

Abdominal Aortic Aneurysm

• A 55-year-old male presents with back and abdominal pain, worsened when his grandson sits on his abdomen.
• The patient also reports difficulty sitting up.
• SLR pain reproduction at 85 degrees is present.
• Physical examination findings: abnormal auscultation of the abdomen, abnormal pulsations in the abdomen, and abdominal pain with deep palpation.
• Expected findings: smoker, history of hypertension, and male gender.
• Diagnosis confirmation: sonography, CT and MRA

Cervical Canal Stenosis/Central Disc Protrusion

• A 50-year-old male presents with right shoulder pain, reporting he recently hit his head on a shelf.
• Previous history includes college football and skin cancer on his forehead.
• Findings: Positive shoulder depressor test on the right, pain and decreased cervical ROM, normal upper extremity reflexes, positive Babinski test, weakness in the legs, and weak toe walking.
• Best diagnoses: canal stenosis, central disc protrusion, and upper motor neuron lesion.
• Complications: weakness in the lower extremities, paraplegia, and inability to heel and toe walk.
• Associated signs and symptoms: clonus, hyper-spasticity, and hyperreflexia in the lower extremity.

Infectious Discitis

• A 42-year-old male presents with mid back pain and hypertension.
• The pain is worse at night, better lying down and sitting up.
• The patient is diabetic, taking metformin.
• Valsalva is negative, Bechterew's is positive, and temperature is 99.8.
• Positive labs: ESR, CBC, and C Reactive Protein. ESR - erythrocyte sedimentation rate, CBC - complete blood count, CRP - C-reactive protein.
• Treatment: refer to family MD, bed rest and intravenous antibiotics.
• Most common sequelae: septic arthritis, endocarditis, and septicemia.

Hemivertebra

• A 22-year-old patient presents with back pain.
• Inspection reveals right rib humping and a dropped right PSIS.
• Upon forward flexion, the right mid thoracic curvature does not change.
• Likely cause: hemivertebra, costovertebral malformation, and vertebral bar.
• Likely clinical/physical findings: cardiac problems, genitourinary problems, and gastrointestinal problems.
• If the condition is switched to the left: Arnold Chiari malformation, syringomyelia, and spinal cord tumor.

Parkinson's Disease

• A 64-year-old male presents with difficulty walking, displaying a shuffling gait with no arm movement.
• Additional clinical findings observed: cogwheel rigidity, pill rolling tremors, and bradykinesia.
• Likely sequelae: constipation, esophageal dysmotility, and peripheral involvement.
• Best follow up steps: modify home to decrease falls, encourage continuation of daily activities, and anti-cholinergic drugs for tremors.

Spinal Canal Stenosis (Cauda Equina Syndrome)

• A 70-year-old male presents with BP of 162/98, respirations of 20 per minute, and low back/leg pain.
• Previous history of benign prostatic hypertrophy & hypertension
• Pain is achy in the low back and both legs, present for years with a gradual onset.
• Bowel incontinence, urinary dribbling, & difficulty initiating urination are present.
• SLR is positive at 50 degrees, Bechterew's test is negative, and the bilateral leg raiser is positive.
• Decreased ROM on lateral flexion on one side; likely diagnosis: spinal canal stenosis, facet arthrosis, and congenital shortened pedicles.
• Associated clinical findings: leg weakness, muscle atrophy, and decreased deep tendon reflexes.
• Best management options: refer to an emergency room, defer adjusting, and CT scan.

Rheumatoid Arthritis

• A 30-year-old female presents with an insidious onset of right knee pain in the popliteal fossa.
• Pain, inflammation, and swelling are present with no recent trauma.
• Swelling and redness of the metacarpophalangeal joints bilaterally.
• Pain is rated 5/10; pain on palpation of the popliteal fossa.
• Unable to flex knee past 90 degrees due to pain; Homan's is negative.
• Likely diagnoses: Baker's cyst, rheumatoid arthritis, and inflammatory arthritis.
• Additional tests should be: flexion/extension films, hand films, and RA latex.
• Additional findings expected: uniform joint space narrowing, Haygarth's nodes, and increased joint pain upon arising.

Diabetes Mellitus

• A 45-year-old female (210 pounds, 5'6") presents with tingling in both feet.
• Problems feeling the feet, frequent trips and falls, and unsteadiness present.
• Examination reveals normal ROM, normal DTR's in the LE's, positive Murphy's kidney punch on the left with paraspinal muscle spasms on the left.
• Orthopedic tests are negative, ROM is normal, and cholesterol is increased.
• Clinical findings: ketones in the urine, glucosuria, and polyuria.
• Most likely findings: decreased wound healing, increased vaginal infections, and insulin insensitivity.
• Appropriate treatment: low glycemic index diet, co-treat with an endocrinologist, and suggest swimming instead of walking.

Systemic Lupus Erythematosus (SLE)

• A 29-year-old female presents with low back pain and fatigue, progressively worsening over a long period.
• Sensitivity to sunlight is present. Murphy's punch is positive; decreased ROM in the wrist.
• Ulnar deviation of the phalanges which can be straightened with her hand on the table.
• Also reports a positive Becterew's and a positive Kemp's test
• Cellular casts, blood and protein are found in the urine, and alopecia is observed.
• Positive labs: ANA, Anti-DNA, and Thrombocytopenia
• Expected findings: malar rash, oral ulcers and discoid lesion
• Proper case management: chiropractic care, avoid the sun and activities to tolerance

Thoracic Outlet Syndrome

• A 35-year-old female presents with bilateral numbness in her arms and hands & severe neck pain.
• She has been a bank teller for 13 years, and shaking her hands makes them feel better, but nothing relieves the neck pain.
• Wright's and Adson's tests are positive.
• Etiology: cervical rib, hypertonic scalene muscles, and neurovascular compromise.
• Best-case management options: stretch the pectoralis muscles, neck retraction exercises and stretch the scalene muscles.
• If the patient doesn't experience improvement after the initial treatment, refer for surgical consultation, order neuro-diagnostics, and NCV study.

Osteoporotic Compression Fracture

• An 80-year-old female presents with a sudden onset of low back pain while gardening 18 hours prior.
• Sharp pain with movements is present, ice is palliative, pain severity is 8/10.
• No orthopedic exam could be performed due to pain.
• Best diagnosis: osteoporotic fracture, degenerative joint disease, and facet arthrosis.
• Best treatment/follow up: refer to orthopedist, modify activities of daily living, and brace the area.
• Likely progression include: postural changes, altered biomechanics and increased rate of degeneration.

Benign Bone Tumor

• A 12-year-old male with neck pain and decreased neck extension presents.
• Likely diagnosis: expansile bony lesion, benign bone tumor and enlarged bone growth lesion.
• Best treatment: surgical curettage, surgical excision and cyst drainage.
• Untreated findings: painful scoliosis, spinal cord compression and muscle spasm.

Torticollis

• A 19-year-old female presents with neck pain after waking up this morning.
• The head is tilted to the right side and appears to be looking at her left shoulder.
• She was on the phone last night for 2 hours while sitting by an open window.
• Hypertonic cervical extensor muscles are present.
• The pain is dull and 3-7/10.
• Decreased ROM in the cervical spine due to pain.
• Cervical distraction and compression increase symptoms but do not produce radiating pain.
• Best diagnosis: torticollis, myofascial pain syndrome and wry neck.
• Best initial treatment options/follow up steps would be: myofascial release technique, trigger point therapy and adjust to patient tolerance.
• If the patient continues to have a headache and also develops a fever: positive Kernig's test, increased WBC's and positive CSF examination and positive Brudzinski test.

Scheuermann's Disease

• A 16-year-old male presents with bilateral rounding of the shoulders.
• Thoracic spine pain that is worse when active and better with rest, but is never completely relieved.
• Radiographic findings: end plate irregularities, anterior body wedging and Schmorl's nodes.
• Likely diagnoses: vertebral epiphysitis, Scheuermann's, and juvenile hyperkyphosis.
• Best initial treatment: stop athletic activity, postural exercises and send out for a Milwaukee brace.

HADD & Shoulder Impingement Syndrome

• A 41-year-old female presents with chronic shoulder pain, worse when working overhead, and unable to reach behind her back.
• Pain is present with abduction and flexion of the shoulder. Adson's and Allen's tests are negative. Apley's and impingement are positive.
• Likely diagnoses: HADD, supraspinatus tendon calcification and shoulder impingement syndrome.
• Observed findings: positive empty can test, elevated humeral head, and positive Neer's test.
• Recommended for rehabilitation: Codman's exercises, adjust the shoulder and passive ROM exercises.

Benign Bone Tumor (Hemangioma)

• A 45-year-old female presents with a gradual onset of low back pain.
• Light secretarial work sometimes worsens it.
• Tight lumbar paraspinal muscles are present.
• Likely diagnoses: hemangioma, vascular neoplasm, and benign bone tumor.
• Observed findings: vertebral body collapse, spinal stenosis and skull enlargement.
• Treatment options: refer for orthopedic consultation, continue normal activities of daily living and adjust to patient tolerance.

Ollier's Disease with Multiple Enchondromas

• A 24-year-old male mechanic presents with painful and swollen fingers, which subsides then returns.
• A loss of grip strength with an inability to perform the dynamometer test.
• ROM is reduced due to swelling.
• Likely diagnoses: Ollier's disease, benign bone tumor and multiple enchondromas.
• Observed findings: geographic lesion, cortical thinning and expansile lesion.
• Likely sequelae: pathological fracture, malignant degeneration and permanent deformity.

Freiberg's Disease

• A 27-year-old female presents with foot pain that began insidiously after wearing narrowed toed new shoes.
• She describes a dull ache with stabbing sensations occasionally, rated 4-7/10.
• Pain upon palpation of the 3rd metatarsal head and some mild swelling.
• Best initial treatments: weight unloading, immobilization and boot cast.
• Likely sequelae: chronic metatarsalgia , DJD and foot deformity.
• Likely diagnoses: Freiberg's disease, osteochondritis and bone infarct.

Cervicogenic Headache & Upper Cross Syndrome

• A 32-year-old female presents with neck pain and a bilateral, suboccipital headache.
• The pain is worse with emotional stress and work, and she has anterior head carriage.
• Likely diagnoses: cervicogenic headache, tension headache and upper cross syndrome.
• Muscles to strengthen: longus coli, serratus anterior and rhomboids.
• Muscles to stretch: pectoralis major, levator scapulae and scalenes.

Bell's Palsy

• A 35-year-old male presents with heaviness of the face, unable to raise his left eyebrow, has pain/tenderness behind one ear and cannot close one eye.
• Also unable to smile symmetrically and has decreased sense of taste.
• Cervical ROM is within normal limits.
• Cervical orthopedics are negative.
• Likely lesion diagnoses: lower motor neuron lesion, Bell's Palsy and CN VII lesion.
• Potential unresolved sequelae: lacrimation while eating, decreased visual field and no control of saliva while eating.
• Proper treatment: eye patch, co-treat with a neurologist and recommend artificial tears.

Ankylosing Spondylitis & IBD Arthropathy

• A 47-year-old male presents with low back pain that he states has been occurring for the past 20 years on and off.
• Reports having gastrointestinal issues.
• Forrestier's Sign + and Chest Expansion is 1.25".
• Likely diagnoses : Ankylosing Spondylitis, Enteropathic Arthropathy and Reiter's syndrome.
• Likely progression: costochondritis, anterior uveitis, and carrot stick fractures.
• Best Management Options: dietary changes, breathing exercises and postural exercises.

Spondylolysis

• A 17-year-old female cheerleader presents with insidious onset of low back pain, a deep, dull ache, rated 4-6/10.
• Reports a Positive Standing Stork Test.
• Clinical Findings: increased lumbar lordosis, tight/hypertonic quadriceps, and hypertonic lumbar erectors.
• Best initial treatment: suspend normal activities and anti-lordotic bracing.
• Muscles to Strengthen: hamstrings, gluteus maximus and transverse abdominis.

Facet Syndrome

• A 54-year-old female presents with bouts of low back pain for the past several months.
• The pain is worse with lumbar extension, only in her low back and sometimes buttocks.
• Reports a 2-5 pain while resting and 7/10 while moving.
• Diagnosis: degenerative spondylolisthesis, facet syndrome and facet arthrosis.
• Additional findings: meniscoid entrapment, weak core muscles and decreased disc height.
• Best management: knee to chest stretches, heat and William's exercises.

Agenesis of the Posterior Arch

• A 24-year-old female presents with headaches and neck pain
• The pain and spasms are in the suboccipital region
• Best diagnoses: agenesis of the posterior arch, hypertrophy of the anterior tubercle and congenital anomaly
• Most likely associated: basilar impression, atlantoaxial instability, and neurological defects
• Best initial follow up: flexion/extension x-rays, neurological evaluation and avoid adjusting upper cervical region

Osteoarthritis of the Hip

• A 55-year-old male presents with hip pain, worse in the morning and at night, better about 30 minutes after getting up and moving around.
• Pain is worse after strenuous long distance walking and long standing.
• His father has a history of avascular necrosis.
• Limited ROM and tenderness/pain upon examination
• Normal ROM in the Thoracic and Lumbar
• Radiographic findings: non-uniform loss of joint space, subchondral cyst, and osteophytes.

Reflex Sympathetic Dystrophy (RSD)

• A 39-year-old female reports falling onto an outstretched hand 8 weeks prior, with worsening pain radiating up to the shoulder.
• Inflammation and color changes were noted in the hand and could not perform brachioradialis reflex due to pain.
• The patient reports a history of hypothyroid and that she is taking Synthroid; emotional stress and increased activity provokes symptoms further.
• Best diagnoses: Regional Complex Pain Syndrome, Sudeck's Atrophy and Reflex Sympathetic Dystrophy.
• The best indicated tests: Sympathetic Nerve Block, NCV/EMG and Thermography.
• The most likely sequelae: atrophic skin changes, hyperhydrosis and ulcerations of the skin.

Spontaneous Pneumothorax

• A 24-year-old male presents weighing 140lb and is 6'2, with a BP of 98/60 and left chest pain for 1 hour, as well as decreased breath sounds.
• Past history indicates he is an asthmatic which he uses a steroid inhaler for and states he is a former smoker.
• Possible diagnosis: spontaneous pneumothorax, asthma and free air in the pleural space.
• Possible Risk factors: associated with low weight , smoking and being a tall male.

Picture frame vertebra is a radiographic feature. Systemic sclerosis is a chronic connective tissue disease, an autoimmune rheumatic disease. Symptoms include hand pain and shiny skin, particularly when triggered by cold.