Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2685_Библиотеки_им_академика_М_И_Перельмана
.pdf
Chapter 20 • Limb Pain 261
https://t.me/med1917
Table 20-2
TEST DESCRIPTION FINDINGS
Shoulder
Yergason test Have patient supinate forearm against
Rotator cuff tear Ask patient to externally rotate and
Elbow
Tennis elbow Have patient resist forearm supination
Wrist
Finkelstein test Have patient flex fingers over a clenched
Tinel sign Tap over median nerve (palmar surface
Phalen test Ask patient to maintain palmar flexion for
Leg/Hip
Iliopsoas Have seated patient place heel of
Knee
Foucher sign Look for change in consistency of a mass
Bulge sign Apply lateral pressure to area adjacent to
Drawer sign With patient supine, flex knee 90 degrees
McMurray maneuver With patient supine, maximally flex knee
Collateral ligament
test
Lachman test
(cruciate
ligaments)
Selected Tests Used to Assess for Musculoskeletal Disorders
A positive test produces pain in bicipital
resistance.
abduct shoulder.
with elbow flexed 90 degrees.
thumb; then passively deviate wrist
ulnarly.
of wrist) to assess for compression
neuropathy.
1 minute with dorsal surfaces of each
hand pressed together.
affected leg on knee of other leg.
in popliteal fossa that hardens with
extension and softens with flexion.
patella.
and hip 45 degrees with foot on table;
apply slow, steady anterior pull, and in
same position gently push tibia back.
and hip; externally and internally rotate
tibia with one hand on distal end of
tibia; with other hand, palpate joint.
Extend knee with slight lateral pressure
with tibia internally rotated.
Extend knee with slight internal pressure
on tibia externally rotated.
Apply medial or lateral pressure when
knee is flexed 30 degrees and when it is
extended.
With knee flexed 30 degrees, pull tibia
forward with one hand while other hand
stabilizes femur.
groove and is suggestive of bicipital tendinitis.
In a partial tear, patient can raise arm but
cannot maintain position against resistance;
in a complete tear, attempts to abduct arm
will produce a shoulder shrug.
Pain with this movement indicates lateral
humeral epicondylitis.
Movement produces pain in de Quervain
disease (first dorsal compartment
tenosynovitis).
In a positive test, patient reports a tingling or
prickling sensation distal to site tapped
along first three digits, wrist pain, and
weak grip.
Test is positive if maneuver produces
numbness and paresthesia in fingers
innervated by median nerve.
Pain with this movement indicates muscle
iliopsoas tendinitis.
A positive sign indicates a popliteal tumor or
aneurysm; a negative sign indicates a
Baker cyst.
Medial bulge will appear if fluid is in knee
joint.
Tests for cruciate ligament stability;
abnormal anterior or posterior movement
of tibia on femur is a positive drawer sign
and indicates ligamentous instability.
Pain and a palpable or audible click are
positive findings and indicate a meniscus
injury.
Positive finding in this position indicates a
lateral meniscus injury.
Positive finding in this position indicates a
medial meniscus injury.
Medial or lateral collateral ligament sprain
will show laxity in movement and no solid
end points, depending on degree of sprain.
Positive test is a mushy or soft end feel
when tibia is moved forward, indicating
damage to anterior cruciate ligament.
262 Chapter 20 • Limb Pain
https://t.me/med1917
DIFFERENTIAL DIAGNOSIS OF Common Causes of Limb Pain
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Musculoskeletal Inflammation
Tenosynovitis
(tendinitis)
Bursitis History of overuse; aching
Fibrositis Pain in trigger sites
Osteomyelitis Presentation depends on
Joint Inflammation
Osteoarthritis Older adults; asymmetrical
Rheumatoid
arthritis
Juvenile
rheumatoid
arthritis
Septic arthritis History of systemic infection,
Gout Acute pain of large joint,
Musculoskeletal Pain Related to Trauma or Overuse
Shoulder
dislocation
Acromioclavicular
joint injury
Bicipital tendinitis History of overuse of biceps;
Rotator cuff tear Acute: younger persons,
Repetitive trauma activities;
pain with movement
pain over affected bursae
that radiates along limb
throughout body, joint
stiffness, disturbed sleep
age, location of infection;
history of infection, trauma,
penetration, invasive
procedure; refusal to bear
weight (hip); constant pain
joint pain and stiffness that
improves throughout day;
history of repetitive joint
trauma; obesity
Morning stiffness of small
joints; symmetrical
involvement; anorexia,
weight loss
Fatigue, weight loss, failure
to thrive, refusal to walk,
joint pain and stiffness
malaise, diaphoresis, refusal
to bear weight (hip), acute
joint pain
asymmetrical; males over
30 years, history of gout
History of trauma, pain Limited rotation, arm
History of trauma, pain Limited shoulder movement;
pain worse with movement
history of trauma, severe
pain; chronic: older, pain
worse with overhead
movement, sleep
disturbance
Swelling over tendon,
crepitus
Local tenderness, swelling;
limited joint motion; muscle
weakness
Fatty, fibrous nodules in
muscles; palpation of trigger points elicits pain
Fever, chills, vomiting; pain
localized over affected area
but progressively worsens;
soft tissue injury or abscess
DIP, PIP joints enlarged;
Heberden nodes; limited
cervical spine ROM
Fever, rheumatoid nodules,
ulnar deviation of wrists
Fever, rash, guarding of
joints, limited ROM; joint
swelling, nodules
Fever; red, swollen joint;
limited range of motion
Inflamed, swollen joint; tophi;
sodium urate crystals
abduction, and hand
supination
obvious deformity
Positive Yergason test;
pain localized over
intertubercular groove
Acute: inability to raise arm
laterally, shrug shoulders;
chronic: tenderness over
AC joint, crepitus,
weakness in external
shoulder rotation
None
None
None
Increased WBCs, ESR,
C-reactive protein;
radiographs
ESR; radiograph may reveal
osteophytes, loss of joint
space
Increased ESR, positive
rheumatoid factor, anemia
on CBC; radiograph shows
bony erosion
Elevated WBCs, ESR;
positive rheumatoid factor
and antinuclear antibody
WBCs, culture of joint
aspirate, ESR, C-reactive
protein, ultrasound of joint
Increased serum uric acid
level, ESR, WBCs
Radiograph of shoulder
with AP view and internal/
external rotation
Radiograph of shoulder
with AP view and internal/
external rotation
Radiograph (Fisk view)
Radiograph may reveal
humeral displacement
or spurs; MRI
Chapter 20 • Limb Pain 263
https://t.me/med1917
DIFFERENTIAL DIAGNOSIS OF Common Causes of Limb Pain—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Olecranon bursitis Repetitive motion of or
pressure to elbow;
localized pain
Lateral humeral
epicondylitis
Subluxation of
radial head
Wrist fracture History of fall on an
Finger fracture History of trauma or fall,
Ganglion Noticeable lump on dorsal
Slipped capital
femoral
epiphysis
Transient
synovitis of hip
Legg-Calvé-Perthes
disease (LCPD)
Iliopsoas tendinitis History of repetitive flexion
Proximal fibular
fracture
Stress fracture Younger ages, history of
Chondromalacia
patellae
Patellar tendinitis History of overuse,
Medial collateral
ligament sprain
History of repetitive
contraction of extensor
and supinator muscles;
pain over lateral
epicondyle that progresses
Occurs in children; pain in
elbow or arm
outstretched hand; pain
and swelling of forearm
and wrist
joint tenderness
surface of wrist
Children: during rapid
growth spurts; knee pain
worse with activity
Children less than 10 yr;
history of upper respiratory
tract infection; limp, pain
in anteromedial thigh and
knee
Boys 3-11 yr; groin or
medial thigh pain, limp
of hip; pain worse with
movement
History of direct trauma to
the fibula or ankle
overuse of lower
extremities
Adolescent females;
history of knee trauma or
misalignment, knee pain
worse with activity
especially running or
jumping; dull, achy knee
pain; click
History of valgus stress to
knee; limp; pain
Warmth, redness, and
swelling over joint; full ROM
Tenderness over lateral
epicondyle; palpation
produces pain, motion does
not; supination against
resistance worsens pain
Affected arm is flexed; child
cries when attempts are
made to move joint
Palpation of snuffbox
increases pain; observe for
joint deformity
Joint swelling, instability Three-view radiographs (PA,
Gelatinous filled nodule, soft,
transilluminates
Limitation of medial hip
rotation, limp
Tenderness on palpation over
anterior hip; hip movement
increases pain and is limited; low-grade fever
Decreased hip ROM AP and frog lateral
With patient sitting, place
heel of affected leg on knee
of other; test is positive if
pain is elicited
Pain on weight bearing,
edema and tenderness to
palpation over fracture
Pain with activity Radiography, MRI
Tenderness to palpation over
knee
Q angle .10 degrees in
males, 15 degrees in
females; clicking or popping with knee movement
Effusion and point tenderness
over knee; valgus and varus
pressure to assess instability
Radiograph to rule out
fracture of olecranon
process
None
Radiograph of elbow
Three-view radiographs to
determine scaphoid or
Colles fracture
lateral, and oblique)
None
Radiograph of epiphyseal
plate
Ultrasound, ESR
radiographs of hip; LCPD
may show increased
density of femoral head
None
Radiography, CT if soft
tissue injury is suspected
Four-view radiographs of
knees to rule out arthritis
None
AP and lateral radiographs
may reveal a ligament
avulsion of femoral origin
Continued
264 Chapter 20 • Limb Pain
https://t.me/med1917
DIFFERENTIAL DIAGNOSIS OF Common Causes of Limb Pain—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Medial meniscus
tear
Anterior cruciate
ligament tear
Osgood-Schlatter
disease
Baker cyst Fullness or swelling of
Ankle sprain History of inversion stress
Shin splints Ache or pain over medial
Achilles tendinitis Pain and tightness over
Plantar fasciitis History of chronic weight
Muscle Pain (Myalgia)
Viral infections History of upper respiratory
Psychogenic Pain is diffuse; varies in
Fibromyalgia Female 20-50 yr; history
History of twisting injury to
the knee, pain, difficulty
flexing, bearing weight,
clicking or catching of
knee with movement
History of twisting or exten-
sion knee injury; audible
“pop”
Adolescent males; knee pain
and swelling aggravated
by activity, limp
posterior knee, aggravated
by walking
with audible “pop,”
immediate swelling
tibia that is worse with
exercise, history of running
Achilles tendon, especially
with walking or running
bearing; aching feet,
muscle spasms, obesity
tract infection; malaise,
chills, cold symptoms,
general muscle aches
pattern of activity, setting;
history of depression or
anxiety
of depression, sleep
disturbance, chronic
fatigue, general muscle
and joint aches
Positive McMurray test,
clicking or locking during
joint movement
Swelling; positive Lachman
test
Tenderness, warmth, swelling
over anterior tibial tubercle
Negative Foucher sign;
normal joint examination;
positive Homans sign in
ruptured cyst
Swelling, soft tissue trauma,
able to perform active ROM
with ligament sprain
Tenderness over medial tibia AP and lateral radiographs
Tenderness over Achilles
tendon; pain worse with
dorsiflexion ankle; calf
weakness
Misalignment of foot
structures, especially talus,
calcaneus, and plantar
ligaments
Fever, ill-appearing adult or
child
Normal examination or
patient response to
examination maneuvers
disproportionate to
physical findings or
subjective complaints
Palpation of trigger points
will produce pain; normal
physical examination
Four-knee view radiographs
to rule out bony
abnormality; MRI
Radiograph to rule out
fracture; MRI
Radiograph with knee
rotated inward may show
soft tissue swelling
None
Radiograph needed only
with tenderness over the
lateral malleolus to rule out
fracture
may show a stress fracture;
a bone scan will be positive
with increased uptake along
the medial tibia
Lateral ankle radiograph
reveals enlarged
posterosuperior tuberosity
of the calcaneus
None
Viral serum titer
None
None
Chapter 20 • Limb Pain 265
https://t.me/med1917
DIFFERENTIAL DIAGNOSIS OF Common Causes of Limb Pain—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Systemic Disorders
Acute leukemia Hip pain in children, refusal
to walk
Sickle cell disease African American, family
history; appears after 6 mo
of age; acute pain with
swelling of hands and feet,
abdominal pain, decreased
appetite, malaise
Systemic lupus
erythematosus
Lyme arthritis History of exposure to
Neuroblastoma Under 5 yr; pain in bones Unexplained fever Urine for vanillylmandelic or
Osteogenic
sarcoma
Nerve Entrapment Syndromes
Thoracic outlet
syndrome
Carpal tunnel
syndrome
Peroneal
compression
Tarsal tunnel
syndrome
Neuritis Pain and sensory loss,
AP, anteroposterior; CBC, complete blood cell count; CT, computed tomography; DIP, distal interphalangeal; ESR, erythrocyte sedimentation
rate; MRI, magnetic resonance imaging; PA, posteroanterior; PIP, proximal interphalangeal; ROM, range of motion; WBC, white blood cell.
Female; transient arthritis of
small joints, malar rash
endemic areas of deer tick;
chills, diffuse joint pain
and swelling; often knee is
affected
Persons 10-25 yr;
intermittent pain of lower
femur, upper tibia; limp
History of sleeping with arm
against head; morning
shoulder pain; pain worse
with lifting; paresthesia,
weakness, or clumsiness
of hand; symptoms worse
at night
History of repetitive upper
extremity motion;
paresthesia, weakness, or
clumsiness of hand;
symptoms worse at night
History of pressure to knee
from a cast, sports injury,
or trauma; pain over head
of fibula; clumsy gait
Pain in ankle and proximal
foot; weakness of toe
flexors; ill-fitting shoes
usually of lower
extremities; history of
alcohol ingestion, diabetes
Fever, hepatosplenomegaly,
bruising
Normal examination Hemoglobin S genotype
Normal examination may
have joint tenderness
on palpation
Asymmetrical swelling,
warmth of joint; erythema
migrans; may have
myocardial involvement
Tenderness over affected
area
Bruit over supraclavicular
fossa; pallor, decreased
pulses of upper extremity,
weakness, skin and nail
atrophy
Positive Phalen test and Tinel
sign; weakness of hand;
dry skin over distribution of
median nerve
Unilateral footdrop None
Tapping posterior tibial nerve
elicits pain
Decreased sensory and pain
sensation
CBC
Kidney function tests,
antinuclear antibody, CBC
Serum IgM and IgG
antibodies, ESR
homovanillic acid; CT scan
Radiograph, serum alkaline
phosphatase
None
None
None
Liver function tests,
hemoglobin A1c to rule out
diabetes
266 Chapter 20 • Limb Pain
https://t.me/med1917
REFERENCES AND READINGS
Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J: Chronic
shoulder pain: part I. Evaluation and diagnosis, Am Fam Physician
77:453, 2008.
Edwards Jr PH, Wright ML, Hartman JF: A practical approach for
the differential diagnosis of chronic leg pain in the athlete, Am J
Sports Med 33:1241, 2005.
Fagan H: Approach to the patient with acute swollen/painful joint,
Clin Fam Pract 7:305, 2005.
Garbez R, Puntillo K: Acute musculoskeletal pain in the emergency
department: a review of the literature and implications for the
advanced practice nurse, AACN Clin Issues 16:310, 2005.
Goolsby MJ: Evaluating acute musculoskeletal complaints, J Acad
Nurs Pract 13:193, 2001.
Goroll AH, Mulley AG: Primary care medicine, ed 6, Philadelphia,
2009, Lippincott Williams & Wilkins.
Gutierrez K: Bone and joint infections in children, Ped Clin North
Am 52:779, 2005.
Leung AK, Lemay JF: The limping child, J Pediatr Health Care
18:219, 2004.
Logan K: Stress fracture in adolescent athlete, Ped. Ann 36:738,
2007.
Lowe R, Hashkes P: Growing pains a noninammatory pain syndrome
in early childhood, Nat Clin Pract Rheumatol 4:542, 2008.
Roberts DM, Stallard TC: Emergency department evaluation and
treatment of knee and leg injuries, Emerg Med Clin North Am
18:67, 2000.
Solomon DH, Simel DL, Bates DW, Katz JN, Schaffer JL: The rational
clinical examination. Does this patient have a torn meniscus or
ligament of the knee? Value of the physical examination, JAMA
286:1610, 2001.
C H A P T E R
https://t.me/med1917
21
Low Back Pain (Acute)
report of acute low back pain (ALBP), although
quite common, requires a thorough evaluation.
A
frequently multifactorial and includes both physiological
and psychological components. The most common
causes of ALBP relate to musculoligamentous injuries
and age-related degenerative processes. About 90% of
ALBP episodes in adults are related to mechanical causes
that resolve within 4 weeks without serious sequelae. A
smaller percentage of patients will continue to have
chronic symptoms without organic pathology or will
have underlying disease.
with age and with involvement in sports. Anthropometric variations in children place them at risk for
excess strain on the spine, producing back pain. These
variations include reduced hip mobility, decreased
lumbar extension and increased lumbar exion, poor
abdominal muscle strength, tight hamstring muscles,
and lumbar hyperlordosis.
lower back or back-related leg symptoms of less
than 3 months’ duration. The Agency for Healthcare
Research and Quality (AHRQ) guidelines provide the
following framework for causes of ALBP:
n Potentially serious conditions (e.g., spinal fracture,
n Sciatica, or leg pain and numbness of the lateral
n Nonspecic back problems such as musculoskeletal
n Nonspinal causes secondary to abdominal involve-
n Psychological causes such as stress, work environ-
The underlying pathophysiology of back pain is
In children, the prevalence of back pain increases
ALBP is dened as activity intolerance producing
tumor or infection, or cauda equina syndrome)
thigh, leg, and foot, suggesting nerve root compression (Figure 21-1)
strain, diskogenic pain, or bony deformity secondary to inammatory disease
ment (e.g., gallbladder, liver, renal, pelvic inammatory disease; prostate tumor; ovarian cyst; uterine
broids; aortic aneurysm; or thoracic disease)
ment (e.g., disability, workers’ compensation, secondary gains)
When evaluating ALBP, the goal of the clinician
is to rst identify signs and symptoms of potentially
serious conditions through a careful history and
physical examination. A holistic approach to the
patient is needed to appreciate the extent to which
pain affects the patient’s daily routine or workrelated activities. Because ALBP is a common
occupation-related complaint and a cause of disability and lost productivity, the clinician must
gain insight into the psychosocial and economic
situation of the patient to help arrive at a correct
diagnosis.
DIAGNOSTIC REASONING:
FOCUSED HISTORY
Is this a potentially serious cause of ALBP?
Key Questions
n Do you have a fever?
n Have you experienced any trauma to the spine or
back?
n Do you have any other health problems?
n Have you been treated for cancer?
n What is your age?
n Have you had loss of control of your bowels or
bladder?
n Are you taking any medications?
Fever
The presence of a fever indicates an inammatory
condition such as spondyloarthropathy or systemic
infection. Infection is a likely diagnosis when there
are chills and fever, weight loss, a recent history of
bacterial infection, intravenous drug use, or an immunosuppressed patient. Ewing sarcoma is a malignant
tumor and can mimic spinal infection, occurring as
back pain that can be accompanied by fever. Children
with diskitis will have a fever and refuse to walk
because of back pain.
267
268 Chapter 21 • Low Back Pain (Acute)
https://t.me/med1917
Nerve root
Pain
Numbness
Motor
weakness
Screening
exam
Reflexes
FIGURE 21-1 Testing for lumbar nerve root compromise. (From Bigos S et al:
Acute low back problems in adults, clinical practice guidelines, Quick Reference
Guide Number 14, Rockville, MD, 1994, Department of Health and Human Services, U.S. Public Health Service, Agency for Health Care Policy and Research,
AHCPR Publication No. 95-0643.)
L4 L5 S1
Extension of
quadriceps
Squat
and rise
Knee jerk
diminished
Dorsiflexion of
great toe and foot
Heel walking
None reliable
Plantar flexion of
great toe and foot
Walking
on toes
Ankle jerk
diminished
Trauma
Acute trauma to the spinal cord can result in fracture,
dislocation, or misalignment of muscles, ligaments,
and intervertebral disks. Trauma may be caused by
blunt impact, repetitive injury, or sudden stress caused
by lifting or pulling. Low back pain is the most common occupational injury reported. Injury to the back
usually results in contusions and abrasions but can
also cause spinal fracture if the force is major, such as
that sustained in a motor vehicle accident or fall. In
the elderly, an acute spinal fracture might result from
strenuous lifting when osteoporosis is present. Injuries
to the posterior structures of the spine account for
most cases of low back pain in adolescents who are
athletically active.
Injury to the spinal column should be suspected in
anyone whose level of consciousness is impaired after
an accident. Cervical spine fractures are sustained
during exion, extension, compression, rotation, or a
combination of forces.
Age
In the absence of trauma, the sudden onset of severe low
or middle back pain in persons older than 30 years might
suggest a dissecting aortic aneurysm. The pain will not
be alleviated by rest. Patients older than 50 years are
at increased risk for compression fracture as well as
cancer.
Systemic Disease
Metabolic disease, inammatory disorders, and bromyalgia can lead to back pain. Patients with a history
of cancer may have increased risk of a spinal tumor.
Neuroblastoma is common in young children, and
Chapter 21 • Low Back Pain (Acute) 269
https://t.me/med1917
although it occurs in the abdomen, metastases to the
spine may produce back pain. Systemic disease may
also be accompanied by unexplained weight loss.
Persons younger than 20 years and older than
50 years are at increased risk for tumor, as are those
with a history of cancer.
Bowel and Bladder Symptoms
Loss of urinary or stool continence indicates cauda
equina or S1-S2 nerve root compromise secondary to a
herniated disk, nerve root entrapment, spinal stenosis,
infection, or tumor. Constant lumbar puncture with
saddle anesthesia, urinary retention, and fecal incontinence are symptoms of cauda equina syndrome, which
is considered a surgical emergency.
Children are embarrassed to talk about urinary or
bowel habits and changes. Hidden spinal cord tumors
might have a relationship to developmental delays
in bladder and bowel control. Children under 4 years
of age who have back pain should be evaluated for
serious diseases, such as intraspinal tumors, dermoid
cysts, and malignant astrocytomas.
Medications
Long-term use of corticosteroids can lead to compression
fractures of the vertebrae. Use of intravenous drugs may
suggest infection as a cause.
What does the location of pain tell me?
Key Question
n Where does it hurt?
Location of Pain
In general, children are less specic than adults when
describing location of pain. Traumatic lesions are more
likely to occur in the cervical and lumbar portions of
the spine, where there is more motion and less protection. Generalized pain or pain over a fairly wide anatomical area is frequently seen with overuse problems
and inammatory conditions.
Sciatica pain is a sharp, burning pain that radiates
down the posterior and lateral leg to the foot or ankle.
Back pain with neck stiffness can indicate cervical osteomyelitis. Rheumatoid arthritis produces pain in the upper
back and neck. Localized pain is seen with spondylolysis
and tumors. Flank pain in adults may indicate a kidney
infection. Pain of gallbladder disease radiates to the
subscapular areas. Compression fractures of vertebrae
associated with osteoporosis or malignancy may produce
pain over the midthoracic area.
Children with traumatic low back derangement will
have pain and muscle spasm in the lumbar area from
the pressure and shock of an impact injury collision.
What does the pattern of pain tell me?
Key Questions
n When did the pain start?
n How long have you had this pain?
n What does the pain feel like?
n Does it interfere with sleep?
n Have you had this pain before?
Onset
The onset of ALBP is sudden, and more than half of
patients with this symptom do not associate it with a
specic precipitating event or injury. The vast majority
of cases of ALBP resolve with conservative treatment
in 4 weeks, and radiographic or further diagnostic studies are not recommended until then.
Children are frequently poor historians and parents
may have a difcult time remembering when the pain
started. Association with events such as birthdays,
holidays, and activities is helpful in establishing the
onset of the pain. Pain that is mild and of short duration
(1 to 2 weeks) is rarely serious.
Back pain lasting longer than 4 weeks needs to be
reevaluated for further diagnostic studies.
Duration
Subacute back pain is of 6 to 12 weeks’ duration.
Chronic back pain is pain of more than 3 months’ duration. In persons under 40 years of age, the cause may be
postural or may indicate congenital spinal deformity,
such as scoliosis or ankylosing spondylitis. In older
persons, chronic back pain is more likely to indicate
degenerative disease, such as spinal stenosis or disk
herniation. In children, back pain present for more than
3 weeks is often due to organic and serious causes.
Pain Characteristics
In children, expression of pain depends on the child’s
ability to put feelings of pain into behavior; observing
for these behaviors is important. Ask children to rate
the pain using a 10-point pain scale with happy to sad
faces (see Chapter 2). Ask adults to rate pain from
0 (no pain) to 10 (worst pain ever) and assess how
270 Chapter 21 • Low Back Pain (Acute)
https://t.me/med1917
much the pain interferes with daily activities. Intractable back pain, especially night pain with constitutional ndings, is likely to indicate neoplastic disease.
Painful scoliosis and stiffness are common presenting
symptoms of a spinal tumor.
Night Pain
Nighttime back pain is a worrisome symptom that often
signals a serious problem, such as tumor, infection, or
inammation. Generally, muscle pulls, overuse injuries,
spondylolysis, spondylolisthesis, and Scheuermann disease (an exaggeration of the normal posterior convex
curvature of the thoracic spine) produce less pain at
night. Morning stiffness that improves as the day progresses suggests ankylosing spondylitis.
Nighttime back pain is unusual and indicates the
need for a complete and thorough workup.
Recurring Pain
Back pain in young children who have had previous
injuries or fractures may be a symptom of child abuse.
In the older adult, it may be an indication of compression fractures of the spine. As with young children, it
may also signal abuse by a caregiver.
Any child who has voluntarily given up a plea-
surable activity because of back pain has a severe
symptom.
Alleviating Factors
Back pain not associated with any activity and not
relieved by rest may indicate tumor. Back pain relieved
with aspirin or nonsteroidal anti-inammatory drugs in
children may indicate an inammatory cause. Pain that
is alleviated by rest and heat indicates a musculoskeletal cause. Pain of spinal stenosis is relieved on exion
of the spine.
Suspect spondylolisthesis, or forward slippage of
one vertebra over another, if the onset of pain is during
hyperextension, such as with a back handspring, buttery stroke in swimming, or a tennis serve. The defect arises from a stress fracture or stress reaction of
the isthmus of the pars interarticularis in the area of
L5-S1. The pain localizes to the low back and occurs
during a growth spurt and after engaging in sporting
events. The pain improves with rest and is worse with
standing.
What does radiation of pain tell me?
What does the pain in relation to activity
tell me?
Key Questions
n What makes the pain worse?
n What makes the pain better?
Aggravating Factors
Pain experienced in the lumbar area occurring after
strenuous sporting activities is usually the result of
trauma to the muscles and tendons, causing contusions
and sprain. It occurs when the patient pushes the muscles and ligaments past the normal level of tolerance.
Repeated injury can cause soft tissue scarring and
shortening.
Stress and fatigue fractures of the pars interarticularis, the region between the superior and inferior articulating facets of the vertebra, occur when lumbar lordosis
places more stress on the pars, such as in gymnastics and
tennis.
Pain that is aggravated by activity is usually musculoskeletal in origin. Pain of ankylosing spondylitis is
relieved with exercise. Spinal stenosis is associated with
increased pain with standing, sneezing, or coughing.
Key Questions
n Does the pain travel?
n Can you show me where the pain travels?
Radiation of Pain
Referred pain is of two types: (1) pain referred from
the spine into areas lying within the lumbar and upper
sacral dermatomes; and (2) pain referred from the
pelvic and abdominal viscera to the spine. Pain from
the upper lumbar spine usually radiates to the anterior
aspects of the thighs and legs, and that of the lower
lumbar spine radiates to the gluteal regions, posterior
thighs, and calves.
Pain from visceral disease is usually felt within the
abdomen or anks. Gallbladder pain radiates around
the trunk to the right scapula. Position does not affect
the pain.
Persons with spondylolysis, a destruction of vertebral structure, or spondylolisthesis, an anterior displacement of a vertebra, report hamstring tightness and
buttock discomfort as well as low back pain.
Pain that is sharp and burning and radiates down the
lateral or posterior aspect of the leg to the lateral ankle
or foot is called sciatica, and is a classic symptom of
Соседние файлы в папке Библиотека им академика М.И. Перельмана