Evaluation of the Patient with Thoracic/ Rib Pain Flashcards
When screening for non-orthopedic medical conditions what systems are you looking at?
Cardiovascular Pulmonary GI Integumentary Neurological
What could you see when looking at patients with potential cardiovascular problems?
Pt. diagnosed with heart disease- eval risk factors: BMI, BP, HR
Presence of fever (pericarditis)- auscultate for pleural rub
Problem is 1/3 of pts with MI do not have chest pain usually
With pulmonary conditions what are you looking for?
Hx of CA Smoker Productive cough Fever (pneumonia) Sharp stabbing pain on inhalation (pleurisy or pneumothorax)- auscultate so no mobs Recent sx or immobility (PE)
GI complications include?
hx of Ca
Nausea/vomiting (cholecystitis)- pain RUQ
Unexplained wt loss- greater than 10 lbs/month
Symptom relief with antacids
use of NSAIDs (gastric ulcers)- use greater than 3 months at doses more than 1600 mg/day
Melena: black tarry stool (gastric ulcers)
If you have GI pain and want to determine the relationship to eating how would you do that?
Pain relieved by eating: Duodenal ulcer
Pain increased with eating: Gastric Ulcer
Pain increases after eating fatty foods: Cholecystitis
With integumentary considerations what should you be aware of?
- Rash on extensor surfaces- Psoriasis
- Rash in dermatomal distribution on thorax (shingles)- herpes zoster
- Any scars or incisions: you need to know why they are there.
What are the two main things you are looking for with neurological considerations?
UMN signs: LE reflexes, clonus, Babinski, Hoffmanns (wont see with lower thoracic)
Bladder/bowel changes
Give the 5 fractures and deformities you might see in the thoracic/rib area.
- Acute Spinal Fx
- Fx due to Osteoporosis
- Rib Fx
- Schuermann’s Disease
- Idiopathic Scoliosis
Compression, burst, fracture-dsilocation, and flexion-distraction are all under what subheading?
Acute Spinal Fx
Compression fx includes which column? Is the neurological system disturbed?
Anterior column; usually no neurological deficit
These are stable as long as kyphotic angle is not above 20.
Acute pain in thoracolumbar/ or pain in apex of curve.
Ex: Osteoporotic fx
A burst fx includes which column? Is there a neurological injury present?
Middle column; 50% have neuro injury.
Retropulsion of bone fragment may compromise canal
Most often involves the thoracolumbar junction
Fracture-dislocation involves which column? Is there a neurological injury present?
All 3 columns involved; 75 % have neuro injury
Follows application of considerable force and often involves rotation and shear.
This has a high incidence of associated intra-abdominal injury
Flexion-distraction involves which columns? What can make the spine unstable?
Posterior column or all 3 columns; fulcrum associated anterior to spine; unstable if ALL fails
Extension injuries are compression of ______ and are usually _______.
Posterior elements; stable
How would you treat thoracic fractures?
Sx intervention dep. on degree of cord compromise, potential instability, deformity.
Rigid bracing potentially
What column is usually associated with osteoporotic fx? Why are they susceptible to more fx?
Anterior column; Caused by decrease in bone. Osteoporotic bone has a thinner cortex and is more porous.
What clinical signs and symptoms are associated with osteoporosis fx?
Acute pain in the thoraco-lumbar region
Usually no neuro signs
Kyphosis- can be progressive
What can you use to diagnose osteoporosis?
X-ray: shows bone loss greater than 30-50%, doesn’t always show
Dual X-Ray Absorption (DEXA) calculates t-score and compares BMD to optimal.
What t score is shown if a patient has osteoporosis?
-2.5 or lower
Osteopenia: -1.1 to -2.4
Give the surgical options for patient with an osteoporotic fx.
- Fusion sx: in .05% of cases b/c neuro deficit
2. Kyphoplasty: injection of collapsed vertebrae with bone cement.
What are some medical (non-ex) options for patients suffering from osteoporotic fx?
- Analgesics for acute pain
- Anti-resorptive agents: estrogen, alendronate Sodium (fosamax), risedronate sodium (Actonel), Raloxifene (Evista), Calcitonin (Miacalcin), Zoledronic (Reclast)
- Bone Reformation Agents: Teriparitide (Forteo)
- Diet: Calcium (1000-1200mg/ day), Vitamin D&K, magnesium, phosphorus
How can PTs best help a patient dealing with pain from an osteoporosis fx?
Rigid Orthosis if tolerated- acutely Ext. exercises as tolerated Strengthen paraspinals (avoid flexion loading) Walking program Balance exercises: fall prevention Postural correction Breathing exercises: changes led to 9% decreases in FVC Education
What are some risk factors associated with osteoporosis?
Caucasian Early menopause Thin Bedridden Decreased Calcium intake Smoking Caffeine or alcohol consumption Liver/Thyroid/Renal disease
When should a PT recommend that a patient be screened for osteoporosis?
- Presence of risk factors
- Over 65
- Loss of height, increased kyphosis, or protuberant abdomen
- Hx of chronic LBP
- Hx of wrist fx
**Increase in # of risk factors= # of reasons to have them screened
What are three mechanisms of injury for rib fractures?
- Traumatic: fall, MVA, usually adult b/c kids bones absorb more shock
- Pathological
- Stress fx: elite athletes (rowers, UE athletes)
You will have pain with inspiration, point tender on rib, may feel defect/crepitus
What is the condition causing kyphosis of the t-spine and vertebral wedging?
Schuermanns Disease
What are Schmorl’s nodes?
Disc material herniated into the vertebral body- cause pain with ext. and rotation.
What is the main complaint of Schuermanns? How would you treat this disease?
Main complaint: Postural deformity
Treatment: exercise to prevent further development of kyphotic deformity (with or without brace), also give them postural exercises
What are the 3 types of idiopathic scoliosis?
Infantile, Juvenile, and Adolescent - lateral deviation of the spine
Name the 3 subtypes of idiopathic scoliosis.
- Functional: result of muscle imbalance
- Structural: Vertebral body causing restriction
- Sciatic: Shift from pain and changes so you compensate for pain.
What are some of the soft tissue causes of thoracic pain?
Intervertebral Discs Thoracic Zygapophyseal Joints Costotransverse Joints Muscular Sources Autonomic Nervous System
Describe the pain pattern when it comes to intervetebral discs.
All thoracic disc pain will be increased with flexion
At least 2/4 movements will be limited:
Passive rotation will be most painful
Sidebending decreases with age
What should be suspected if SB away from painful side is painful and rotation is pain free?
A neuroma or neoplasm
Thoracic zygapophyseal joints are innervated by? What kind of stress are they under and why would nocioceptors develop?
- Innervated by: medial branches of thoracic dorsal rami
- Under considerable rotary stress
- Development of nocioceptors with degenerative changes
Costotransverse Joints are affected by what? It can be associated with what other condition? Why would it have unusual symptoms?
Affected: AS and RA
Likely to be associated with SI pain.
May have unusual symptoms due to proximity of sympathetic trunk.
Primary thoracic pain is what?
Source of symptoms is a lesion of a muscular attachment in thoracic area
Secondary thoracic muscular pain is?
Lumbar injury that causes reflex spasm of the erector spine causing pain to be perceived in the thoracic area.
