CASE STUDY AND QUESTIONS: To be completed by the 12 th September.

Week 6: Case 6: Joe

Joe is a 60-year-old who works in IT.

Presenting Complaint
Joe presents with neck and right jaw pain of 3 weeks duration. The patient also complained of
headaches in the temporal area which have been present for the last 6 weeks. Within the last 2
weeks the intensity of the headaches has increased. These headaches are worse in the mornings.
The quality of the pain (of the headaches) is dull, throbbing, diffuse and aching. The headaches are
intermittent and may last up to 2-3 hours.

History of Presenting Complaint

He was driving home from work when another car ran a red light and struck his car on the left front
fender. He was wearing a seat belt, had some prior warning that the accident was going to occur,
and braced himself but was still thrown violently against his seat belt. His sunglasses flew off his
head. Estimated impact velocity was about 40 km/hr. Extensive damage was done to the front end
and the left front fender. The patient was able to get out of the car and take information from
witnesses but by the next morning he had developed severe midline neck pain and an inability to
move his right shoulder without discomfort.

Physical Examination
 Joe is an obese male.
 Vitals: pulse 80/min, normal volume; BP 160/95; respiratory rate 18/min; Temp 36.9
 Cervical ROM: He demonstrates limited forward flexion and incomplete extension of the
cervical spine. There is decreased motion on right rotation. Cervical range of motion is
otherwise full.
 The upper extremities demonstrate normal contours and no atrophy.
 There is no point tenderness along the right acromial border.
 Passive range of motion of the right shoulder is comfortable except on forward flexion beyond
90 degrees where there is pain in the acromial region.
 Upper extremity sensory and motor tests reveal no deficits. Supination of the forearm
against resistance (Yergason’s tests for bicipital tendinitis) is painless.
 TMJ examination revealing a translation to the right and difficult placing 3 fingers in his
mouth. There is crepitus and muscles spasm on palpation of masseters and temporalis
X-rays
Cervical and shoulder x-rays are unremarkable.

Questions

1. Describe the mechanism of the neck pain and its relationship to the findings.
Hyper flexion/extension injury and acceleration/deceleration injury
- Hyper extension, caused by sudden translation force that is applied to the body causing the
head to accelerate
 - When whiplash happens it causes the head to move beyond the normal ROM which
overstretches the anterior structure (particular the structures involved with stabilization,
ligament structures)
- Hyper extension is a more servious injury than hyperflexion due to the structures and there is
more ROM in flexion as well as not as many structure in the way. Suboccipitals generally get
effected.

2. How do you explain the lack of pain initially followed by severe pain later?
Usually a delay in onset of symptoms
- 65% <6hours
- 28% <24 hours
- 7% < 72 hours
- Delayed due to slow but gradual build up of oedema +/- haematoma
- Most patients (75%) will have symptoms which persist more than 6 month
- Severity:
- 95% of the injuries are classed mild. Px develops after interval of several hours or days, and
then intensifies.

3. What injuries of the neck and shoulder might occur in this type of accident, and how would they
be ruled in/out?
Hyperflexion injuries
- Muscle strains
- IVD (posterior tear or rupture)
- Ligament structures (Posterior Longitudinal ligament, ligament flavum, suboccipital
ligaments, interspinous ligaments)
- Facet Joint (sprain)
- TMJ sprain
Hyper Extension
- Ligament strain
- Muscle strain (SCM and longus colli)
- Strain of oesophagus and pharynx
- Nerve roots (traction which can cause oedema)
- Facet Joints (Impaction sprain, fracture or dislocation)

4. Does he have hypertension? Explain your answer.

Yes, his blood pressure is in the hypertension range as well as being obese
5. What signs would you look for, in order to determine if he has any complications related to his
elevated blood pressure. For each sign named, explain the pathology which it is related to.
Damage to sympathetic which can cause vertigo, blurred vision, nystagmus and tinnitus.
6. What are the possible causes for his headaches? Do you think that they may be related to?
a. His recent MVA?
Headache caused by injury or irritation to the cervical facets to and greater occipital nerve
this may produce tension headaches, migraine attack.
b. His elevated blood pressure?
Can cause increased pressure on the brain which can cause reduced blood flow to the brain
and cause HAs
7. How would you treat/manage this patient if he presented to your office
Management:
Should be initiated no more than 2-3 day after onset
- Possible soft collar to splint and gives the spine and head support (remove during to day to
allow for some normal movement of the neck)
- Try to rest the area as much as possible
- Ice for 10 minutes each hour can help to reduce the pain
- TMJ release (pterygoid muscles)
- Gentle mobilization helps to allow for motion through the ligament, joints and muscles
- Traction
- Advice on posture
Sub-acute phase (1-7wks)
- Active exercise (isotonic for ROM and isometric for muscle strength)
- Ice following exercises
- Gentle adjustments
- Postural advise
Chronic
- Follows subacute phase and similar management.

Study Guide Questions: 6.6

The questions for this week will focus on components of a cranial nerve and
TMJ assessment.

1. Which branches of the trigeminal nerve supply each region in the

image below?

A
B
A: Ophthalmic

B: Maxillary

C: Mandibular
C
CASE STUDY 6 CHIR13009

1. Complete the following table:

Examination Finding Nerve(s) involved

Wasting/weakness of Trigeminal nerve mandibular branch
temporalis and masseter
muscles

Weakness of jaw opening Trigeminal

– jaw deviates to side
Loss or diminished jaw Trigeminal
reflex

Loss of corneal reflex – Facial nerve

neither eyes blink
2. What is the possible cause of each of the following?

a. pain in the distribution of either V1, V2 or V3 when

touching that area
- Infection,
- Tumors
- Trauma
-

b. pain, vesicle formation and hyperaesthesia in the region

of V1, V2 or V3 - Herpes zoster
- Postherpetic neuralgia

The questions will now focus on components of cranial nerve IX, X,

XI and XII structure, function and significance of the findings.

3.Consider examination of the pharynx. Complete the following table:

Finding Possible significance

Uvula moves to one side
Uvula does not move on
saying ‘ahh’ or gag
Assessing cranial nerves IX, X and cranial
divisions of XI and XII(Pharynx problem)
Assessing cranial nerves IX, X and cranial
divisions of XI and XII possibly condition
affecting the nerve (Pharynx problem)

4.Consider examination of the larynx. Complete the following table:

Finding Possible significance
When asking patient to cough, it is Larynx issue involving cranial nerves IX, X
of gradual onset and cranial divisions of XI and XII
CASE STUDY 6 CHIR13009

‘Bubbly’ voice cranial nerves IX, X and cranial divisions of

XI and XII

Swallowing is followed by Looking for dysphasia

coughing

Hoarse voice Possible vocal cord issues

5.Consider examination of the spinal accessory nerve. Complete

the following table:

Finding Possible significance

Weakness of
sternocleidomastoid and
trapezius on the same side
Weakness of sternocleidomastoid
and trapezius on the same side,
plus
ipsilateral loss of gag reflex and
uvula deviation
Weakness of ipsilateral
sternocleidomastoid and
contralateral trapezius
Unilateral delayed shoulder
shrug
Bilateral wasting and weakness of
sternocleidomastoid

Unilateral sternocleidomastoid
abnormalities

Abnormal head position and

hypertrophy of neck muscles

6.Undertake some research of neurological disorders and name a condition

associated with each of the cranial nerve provided.

Neurological Disorders Name

CN V Lyme Disease
CN VII Dry eyes/corneal
CASE STUDY 6 CHIR13009

injury
CN VIII Vascular injury

C5-T1 Radial nerve palsy

C5-6 Erbs palsy

C7-8 C7-8 disc

lesion/herniation
T1 Klumpke palsy

7. What is the difference between mandibular deviation and mandibular

deflection when assessing the TMJ joint?
Deflection: movement away from midline during opening without return to
centre during movement
Deviation is movement away followed by return to midline

8. What are the articular surfaces in the TMJ joint covered by in order to reduce
the effects of compressive forces placed upon it.

9 Name the ligamentous structures in the TMJ joint

- Articular capsule
- Temporomandibular ligament
- Accessory ligaments (stylomandibular and
sphenomandibular)

10. How does the disc stay on the condyle while moving?
- Through the detrodiscal tissue and fibrocartilage

1. The muscles of mastication include

- Masseter
- Temporalis
- Medial and lateral pterygoids

true or false

12. The upper TMJ joint is a sliding joint (ginglymus)

F is lower
13. The disc of the TMJ joint is avascular and derives its nutrition from the
synovia?
T
14. The TMJ motion of depression is generated by the contraction of
CASE STUDY 6 CHIR13009

temporalis, masseter and medial pterygoids?

F it is hyoid and lateral pterygoids
15. What kind of head position may cause the mandible to close differently
than it should, thus causing mal- occlusion?
F
16. What are some of the symptoms that can occur with forward head posture
and TMJ mal occlusion?
- Facet joint load
- Ligament strain
- Neck pain
- Temporomandibular pain
- Musculoskeletal disorders

17. What is the cause of the noises heard in the TMJ like (popping, snapping,
clicking)?
Movement of disc or shifting of it inside the joint