Exam 2 Flashcards
True/False: The Costal Cage provides the bony framework for protection of organs and vessels.
Ribs provide the structural integrity for respiration, but multiple rib fractures can lead to loss of rib function.
True
*paradoxical movement during lung inflation and deflation
Expansion of the costal cage during inhalation leads to _____ pressure within the thorax. This pulls in air, lymph, and venous drainage into the thoracic cavity and enhances flow.
Negative pressure
*sympathetic chain ganglia run along costovertebral joints – stimulated by motion
- True ribs are ribs ______. THey articulate directly to the sternum via the costal cartilage.
- False ribs are ribs _____. They articulate indirectly via the cartilage of the superior rib. They share costal cartilage.
- Floating ribs _____. have no connection to the sternum.
- True ribs
- -synovial (except R1) - False ribs
- -synovial joint - Floating ribs
The Costovertebral joint is formed by the head of the rib. The head has two articular facets:
- Superior costal facet which articulates with ______
- Inferior facet which articulates with
- Superior costal
- -articulates with vertebrae above - Inferior facet
- -articulates with numerically corresponding vertebrae
- The ______ make up the most prominent posterior portion of the rib
- The ____ is not located on the 1st or 12th rib. It is short on the 2nd and shallow on the 11th.
- rib angles
- Costal groove
* vein, artery, nerve
Atypical ribs are
1, 2, 10, 11, 12
Typical ribs have a head (w/ 2 articular facets), neck, tubercle, angle and shaft. List the typical ribs
All but 1, 2, 10, 11, 12
The shortest rib. It has a site for attachment of the anterior and middle scalenes. It is atypical because it only articulates with T1 and lacks an angle or a groove
Rib 1
Is a small atypical rib that has attachment sites for Serratus and Posterior scalene.
It has a large tuberosity on the shaft for the serratus anterior, but no non-articular tuburcle
Rib 2
________ is caused by Cervical Rib/Spasm of scalenus anterior muscle that compresses the subclavian artery and brachial plexus leading to ischemia and nerve pressure symptoms of the upper limb
Thoracic Outlet Syndrome
- Rib 10 articulates only with _____
- Rib 11 has a single articular facet, but no ____ and no ____
- Rib 12 has a single articular facet with no neck, no tubercle, no angle, and no costal groove. It is tapered.
- T10
2. no neck, no tubercle
True/False: The ribs protect the organs, provide attachment sites for respiratory muscles, and support postural mechanics.
They are connected to the upper extremity by the clavicle
True
Most commonly caused by trauma (e.g. motor vehicle accidents, assault, sports, CPR, etc.)
Clinical presentation includes focal tenderness, crepitus and ecchymosis.
Rib fracture
*cancer, stress fractures
Complications:
–pneumothorax, flail chest, pneumonia, etc.
NOTE: start w/ X-ray; CT is gold standard
Inhalation involves the External Intercostals, Interchondral intercostals, and what accessory muscles?
- sternocleidomastoid
- -elevates sternum - Scalenes
- -elevate upper ribs
*diaphragm: descends; elevates lower ribs
Pec minor
Serratus ant.
Latissimus dorsi
Exhalation occurs by passive recoil. However, forced expiration occurs by what muscles?
extrachondral internal intercostals and abdominals
The Diaphragm is the musculotendinous boundary between the negative pressure thoracic cavity and the positive pressure abdominal cavity.
It is innervated and supplied by
Phrenic nerve (C3-C5) Phrenic artery
*attaches to lower 6 ribs
Principle muscles of inhalation They originate on ribs 1-11 but insert on ribs 2-12.
They are responsible for elevation of the ribs and bending them open (expanding transverse dimensions of the thoracic cavity).
External Intercostals (elevate ribs; enlarge rib cage) and Intercatilaginous portion of Internal Intercostals (elevate ribs)
The diaphragm is divided intoperipheral andcentral attachments.
There are 3 Peripheral Attachments:
- Lumbar vertebrae and arcuate ligaments.
- ______ of ribs 7-12.
- _____ of the sternum.
- Costal cartilages of ribs 7-12
3. Xiphoid process
The Central attachments of the diaphragm are the R and L crura which arise from L1-L3 and their IVD’s.
The muscle fibers of the diaphragm combine to form a ______
central tendon
Accessory muscles involved in inhalation include the Scalenes and Sternocleidomastoid.
The Scalenes originate from C2-7 and insert on ribs ______.
The SCM originates on the manubrium and medial clavicle. It inserts onto the mastoid process and aids in ____
Scalenes: Ribs 1 and 2
SCM:
–insert: mastoid process
–lifts/elevates sternum
in addition to head sidebending towards/rotating away
Accessory muscles involved in inhalation include the Pectoralis Minor and Serratus Anterior
- The Pec minor originates on ribs ______ and inserts on the coracoid process. It acts to stabilize the scapula and rases ribs in inspiration.
- The serratus anterior originates on ribs ____. It inserts on the ant. medial border of the scapula. It functions to pull the scapula forward as well as lift ribs (when the shoulder girdle is fixed)
Pec minor: ribs 3-5
- -stabilize scapula
- -raises ribs in inspiration
Serratus anterior: ribs 1-9
- -pull scapula forward
- -lift ribs (girdle is fixed)
This is an accessory muscle to inhalation.
It originates at T7-L5, the Iliac crest and on Ribs 8-12.
It inserts on the floor of bicipital groove of humerus after spiraling around teres major
It functions in: extension, adduction and medial rotation of the arm, but its Costal attachment helps with deep inspiration.
Latissimus dorsi
True/False: Exhalation is usually quiet and passive. However, in active (forced exhalation) it involves the extrachondral internal intercostals and abdominal muscles.
True
During inhalation, the diameter increases in both the AP and transverse plane.
Anteriorly, there is upward motion of the _____ and _____. Posteriorly, there is caudal motion of the _____, and Laterally, there is upward and lateral motion of the ribs.
- Anterior
- -upward motion of ribs and sternum - POsterior
- -caudal motion of ribs - Laterally:
- -upward and lateral rib motion
- extension of spine
- external rotation of extremities
During exhalation, there is decreased diameter of the AP and transverse plane.
Anteriorly, there is _____ motion of the sternum and ribs. Posteriorly, there is ____ motion of the ribs. Laterally, there is downard and medial motion of the ribs.
- Anterior
- -downward motion - Posterior
- -upward motion - Lateral
- -downward and medial
- Flexion of spine
- Internal rotation of extremities
Pump Motion ribs are associated with _____ motion. They increase the A-P diameter and are dominant in the ____ ribs.
Anterior motion
- dominant in upper ribs 1-5
- palpated on ant. chest wall
Bucket motion ribs are associated with ____ motion. They increase transverse dimension and are dominant in _____ ribs.
Lateral motion
- lower ribs 6-10
- palpate on lateral chest wall
Ribs 11-12 are referred to as Caliper ribs. They have unique motion along a horizontal plane.
They are involved in _____ articulation only because they are single faceted with no tubercle, angle or groove
Costovertebral articulation only
When diagnosis Ribs, take into account
a. sources of chest pain (cardiac, GI)
b. review musculoskeletal syndromes
c. check vitals, history, physical
d. fix thoracics first
Answer: all of the above
Musculoskeletal chest pain is insidious, persistent and exacerbated by breathing and motion. It is NOT associated with systemic signs.
True/False: Attempting to reproduce the patients pain will be informative regarding diagnosis.
True
**Table Slide 36
Costal Cage Mechanics
Screening ribs steps:
- General inhalation/exhalation motion
- Check for tissue texture changes and tenderness
- Assess statically and dynamically
- Compare sides and look for asymmetry
- —–Anterior, superior, inferior, lateral - Segmentally test each rib while they take deep breaths – Try to assess which ribs are not moving fully into inhalation or exhalation.
Finger placement:
- Rib 1
- –Fingers placed supraclavicular fossa
- –May need to move traps out of way - Ribs 2-5 - pump
- –Mid clavicular line
- –Along superior anterior aspect of rib - Ribs 6-10 - bucket
- –Mid axillary line
- –Along lateral aspect of rib. - Ribs 11-12 – caliper
- –Patient prone
An_______ rib is caught in inhaled position (stuck up). It looks higher (anterior/lateral/cephalad) than the other side.
As the patient inhales, the rib may move superiorly, laterally or anteriorly, but as they exhale the rib will not go down as well.
Inhaled rib
- may be predominately pump rib (anterior) or bucket rib
- not spring as easily
Name: Side that is inhaled and Rib #’s
(e.g. Ribs 1-4 inhaled on Left)
The key rib for Inhalation dysfunctions is the ______ rib. The interspace below will be wider. The key rib must be treated first
*common to find group inhalation on the left
Bottom RIb
*BITE
(Bottom, Inhaled)
DX: Trace ribs down until find rib w/ normal exhalation. The rib just above that is the key rib
An ______ rib is caught in exhaled position (down; caudad, medial and posterior).
The rib will enter easily into exhalation, but will not move into inhalation.
Exhaled rib
- spring easily
- pump or bucket
Name: Side that cannot come into full inhalation; Exhaled dysfunction (e.g. Ribs 3-6 exhaled on the right)
Indications for Cervical Manipulation include:
a. pain & stiffness in neck torticollis b. tension headache c. pseudomigraine d. dizziness/vertigo symptoms e. symptoms in upper extremity flexion/extension injury (whiplash) f. Viscerosomatic reflexes from chronic head, neck, nose, sinuses or throat inflammation
Answer: All of the above
Typical Cervical Vertebrae are C3-C7.
Which of the following are features of typical cervical vertebrae?
a. No typical transverse processes (ant/post. tubercles)
b. transverse foramen for vertebral artery (C2-C6)
c. grooving of transverse process for cervical nerves
Answer: all of the above
- articular pillars b/t superior and inferior articular facets
- bifid spinous process
C2-7 articulations include:
a. synovial joints
b. articular pillars
c. superior articular facets that face up and back
d. 45 degree orientation (to transverse plane)
e. lack transverse processes
Answer: A-D
______ joints are found in the cervical region (posterior/lateral) corner of the vertebral body.
They act as guide rails for flexion-extension, and limit lateral translatory motion.
Uncovertebral joints (Luschka)
- Uncal processes elevate in childhood
- Joint develops secondarily (age 8-10)
- Initially functional advantage preventing disk herniation
- Later may be site for degeneration
Typical Cervical Mechanics Follow Type _____ Mechanics: non-neutral.
*Use lateral translation
Type II
- flexion/extension
- sidebending and rotation = same side
C2-C4: rotation
C5-C7: sidebending
Flexed Cervical Dysfunction:
Name the dysfunction for what it WILL do.
If it cannot extend or translate to the right, but CAN flex and translate to the left, then what is the dysfunction?
FSrRr
Tx: What it won’t do (Sidebend Left; Rotate Left)
For cervicals (C2-7), translation to the Left induces _____ sidebending. Translation to the right induces _____ sidebending.
Left translation: Right sidebending
Right translation: Left sidebending
Desribe screening of Cervical Spine
- Screen for restriction (via translation) in neutral at each segment by palpating the articular pillars
- Semi flex the patient’s neck and screen
- Repeat with the neck extended
- Give positional diagnosis
Ex: If dec. Left translation in Flexion, then it is Extended, SLRL (because it can translate to the right; Extension)
Describe Tx of the Cervicals
- Flex or Extend the head until the motion is felt at the segment
- Sidebend and rotate in the same direction to the barrier (patient pushes against hand)
- Repeat 3-5 times
- Re-check
*Do not lift patients head off the table (let chin drop to chest)
An extended dysfunction of the Cervicals means that the patient does not like to go into ______.
Treatment will involve what it won’t do.
Flexion
*prefers to stay in extension
When screening cervicals, How would you diagnose and treat a patient who fails to go into flexion and has difficulty translating to the right?
DX: ESRr
*they translate to the Left with ease, so SRr
Tx: FSRl
Atypical cervicals include
- C1 (atlas) - ring like, kidney shaped bone lacking a spinous process or body
- C2 (axis) - odontoid process (dens) that projects superiorly from the body.
The Atlanto-axial (AA) joint refers to 4 articulations between C1 and C2. What are these articulations?
- 2 lateral AA joints
- 2 median AA joints
- Inferior atlas facets are convex
- superior articular facets of axis are slightly convex
AA motion is primarily ______. Rotation and sidebending occur in the ______ directions.
50-60% of neck rotation occurs at the AA. Atlas rotates on the axis with pivot around the dens.
Primarily Rotation
Rotation and Sidebending occur in Opposite directions
NOTE: movement other than rotation is limited by anteriorly located odontoid process (dens) of axis
Describe Evaluation of the AA joint
- Flex cervical spine to 45 degrees
- Rotate head to left and right
- Assess Range of Motion and freedom or resistance
(compare degree of restriction) - Name by the direction it WILL go
(e. g. If it WILL rotate right, but NOTE Left: AA Rotated Right)
Describe Treatment of AA joint
- Restrict motion of C2-7 by flexing patient’s neck at least 45 degrees
- Rotate patient’s head to the barrier
- Perform ME by having the patient rotate their head back to the midline (3-5 times)
Atlanto-axial subluxation: Caution must be taken for HVLA with patient suffering from what ailments?
Rheumatoid arthritis or Down’s syndrome
*weakness of AA ligaments
The Occipito-atlantal joint (OA) joint articulates between the superior articular facets of the atlas and the 2 occipital condyles. THe joint is spherical, gliding on articular surfaces of the atlas.
Describe movment of the condyles to the facets
condyles: convex, diverge posterior
articular facets: concave
Primary motion of the OA joint is ______. It involves occipital motion on the atlas that is limited by muscular and ligamentous attachments.
Small amounts of sidebending and rotation may occur. This happens in ____ directions.
Primary motion: Nodding (flexion/extension)
Limited motion: 20-25 degrees (flexion/extension); 8 degrees lateral bending/side bending
Sidebending and rotation: OPPOSITE directions (Type I)
Evaluation of the OA involves palpation of cervical tissue over the OA in the suboccipital region (looking for TART).
Describe OA evaluation.
Remember: TYPE I MECHANICS (sidebending and rotation are OPPOSITE)
- Lie patient supine, physician forearms resting on table
- Screen for restriction w/ OA in neutral. Cradle head in hands (palms at base of occiput)
- Translate the OA in neutral
- Semi-flex patient’s neck and test w/ translation
- Repeat w/ extension
- Give positional diagnosis
(e. g. If OA does NOT translate Left, and is worse in Flexion – It translates Right and is thus: ESLRr)
NOTE: slide fingers downward from the Inion to suboccipital region, then laterally to sulcus
If the OA does NOT translate Left and is WORSE in FLEXION, what is the DX?
Extended, Sidebent L, Rotate R
*TYPE I
TX: Flexed, Sidebent R, Rotate L
Describe Tx of the OA joint if the Patient is Dx: OA FSrRl
Tx: ESlRr
- Position the patients head at the restrictive barrier
(localize motion to the segment being treated) - Apply a counterforce with opposite hand to create gentle isometric contraction
- After 1-2 seconds relaxation, take up the slack in all 3 directions
- Perform muscle energy 3-5 times
- Re-check
OA motion:
- Flexion of the occiput on the atlas results in _____ glide of occiput on atlantal facets.
- Extension of the occiput on the atlas results in _____ glide of the occiput on the atlantal facets
- Rotation/Sidebending results in the Left occipital condyle sliding _____ and the right occipital condyle sliding ____
- anterior glide of occiput on atlantal facets
- posterior glide of occiput on atlantal facets
- Left occipital condyle slide uphill (superior/posteriorly)
- Right occipital condyle slides downhill (inferiorly/anteriorly)
The complex of the OA and AA is known as the suboccipital articulation.
THe range of motion makes it function as a universal ____ joint. It is considered the final compensator of the spine by which the body adjusts to dysfunctions below.
Swivel joint
*NOTE: articulation of C3-C3 common area of chronic dysfunction due to tremendous stress being below final compensator and above remainder of spine
________ test involves compression of the head in neutral, extension w/ sidebending towards, and extension with sidebending away.
Positive test reproduced patients symptoms (pain in neck and arm along the nerve root)
Spurling’s test
*indicateds nerve root compression (cervical radiculopathy)
True/False: The Cervical Spine is the Most mobile region of the Spine. Combined ROM is:
Flexion/Extension: 145 degrees
Axial rotation: 180
Lateral flexion: 90
It has lower intrinsic stability and is vulnerable to excessive dynamic loading (injuries). Restriction often results in compensatory mobility elsewhere.
True
NOTE: vertebral artery especially vulnerable w/ neck rotation and extension
“Impairment of a central nerve root, usually causing radiating pain, numbness, tingling, or muscle weakness that corresponds with a specific nerve root”
Includes:
- Lumbar herniated discs
- Lumbar spinal stenosis
- Lumbar neuroforaminal impingement
Lumbar radiculopathy
“Pain, numbness, tingling in the distribution of the sciatic nerve, radiating down the posterior or lateral aspect of the leg, usually to the foot or ankle.”
Sciatica
Common postural Problems: True/False
- Anterior pelvic tilt is associated with a number of conditions including: pelvic cross syndrome (tight hip flexors), weak hip extensors and hamstrings and sacroiliac disfunction.
- Exaggerated posterior pelvic tilt w/ buttocks tucked in is associated w/ spondylolisthesis.
True
_______ is a lumbar radiculopathy characterized by weakening of the fibrous outer wall of the disc. The nucleus pulposes pushes outward, but does NOT rupture through.
It generally does not protrude far enough to compress on a nerve, but can progress to a herniated disc.
Bulging disc
> 90 deg of the total circumfrence of the disc and does not extend beyond the boundaries of the annulus fibrosus
A herniated disc is a lumbar radiculopathy characterized by rupture of disc material beyond the annulus fibrosus.
It can be subdivided into two types:
- ________: rupture of disc material in which the base is broader than the dome. Generally does NOT extend above or below disc spaces.
- _______: rupture of a disc where the dome is wider than the base “dumbell”. This can extend above or below the disc space.
* nerve root compression can occur
- Protrusion
- Extrusion
*NOTE: can produce a “free fragment” that can migrate out of the disc space
_______ describes herniation of the nucleus pulposes through cartilaginous and boney end plant on the body of adjacent vertebrae
Shmorl’s nodes
*lumbar
________ is a that can refer to one or more of the following:
- Narrowing of intraspinal (central) canal
- Narrowing of lateral recess
- Narrowing of the neural foramen
It can lead to lumbar radiculopathy (causing mechanical compression, inflammation, or ishemia of the nerve roots)
Lumbar spinal stenosis
- can be congenital or acquired
- usually age 60 or older
The following clinical presentation best describes what disorder?
- Neurogenic (or psuedo) claudication
- Symptoms (usually pain) exacerbated with walking, standing and/or maintaining certain postures, and relieved by sitting or lying
- Symptomatic when active
- Look for a patient with discomfort, sensory loss, and/or weakness in the legs that reflects the involvement of the spine nerve roots (see previous slides on this)
Lumbar spinal stenosis
Neurogenic (pseudo) claudication (Hallmark of lumbar spinal stenosis)
Arthritis of the spine. It is seen radiographically as disc space narrowing and arthritic changes of the facet joint
Spondylosis
“A fracture of the pars interarticularis where the vertebral body and the posterior elements protecting the nerves are joined.”
This fracture looks like a “scotty dog” with a broken neck.
Spondylolysis
- unilateral or bilateral defect
- “fatigue fracture” or acute overload on the joint and vertebrae
*athletes/overuse injuries
**Almost always at the 5th lumbar vertebrae (85 – 95% of the time)
There are different types of spondylolisthesis:
- ______: anterior displacement of a vertebral body relative to the one below.
- _____: posterior displacement of the vertebral body relative to the one below
- ______: anteriorlisthesis secondary to spondylolysis
- Anteriolisthesis
- Retrolisthesis
- Spondylolisthesis
Dysplastic type of spondylolisthesis (1 - 25% anterior slippage)
It is often due to congenital rounding of S1 vertebrae.
The more rounded, the greater the risk of slippage.
Type I spondylolisthesis
Isthmic type of spondylolisthesis (26 - 50% anterior slippage) . This is the MOST COMMON TYPE seen in athletes .
- Type II A: usually from that a stress fracture causing bilateral spondylolysis and with the anterior slippage.
- Type II B: repetitive fracture – healing causes the pars interarticularis to be elongated and then pretty much the same as above for II A
Rarely, rarely acute trauma can lead to this too
Type II spondylolisthesis
Type IIA: stress fracture; bilateral sponyloslysis w/ ant. slip
Type IIB: repetitive fracture; elongated pars articularis; ant. slip
Degenerative type of spondylolisthesis (51 – 75% anterior slippage).
It is NOT necessarily due to a fracture or insufficiency of the pars interarticularis. It is typically a segmental instability (usually L4 -5) that leads to such a fracture and significant anterior slippage
Classic patient for this is a female > 40 yo with super bad arthritis
Type III spondylolisthesis
*segmental instability leading to fracture and ant. slip
NOTE: Arthritis will destroy the contour of the facet joint leading to poor motion of the spine and chronic breakdown of the ligamentum flavum
*surgery sometimes
Traumatic type of Spondylolisthesis (76 – 100% slippage).
This is normally caused by high impact trauma, and leads to injury and fracture to way more than just the pars interarticularis.
Type IV spondylolisthesis
Lots of bony and ligamentous structures injured with this
This one is almost always surgical
Grading of spondylolisthesis is based on the Myerding classification. This categorizes spondylolisthesis lesions according to what percentage of the cephalad vertebral body extends beyond the anterior border of the caudal vertebra.
Explain grades 1-4.
Grade I: 1-25% slip
Grade II: 26-50% slip
Grade III: 51-75% slip
Grade IV: 76-100% slip
This is due to autoimmunity and the inflammatory process (HLA-B27 problem).
It is commonly diagnosed in men under 40 yo who present with back pain, morning stiffness that improves with exercise and pain at night.
These patients have terrible spinal mobility = Bamboo spine (vertebral fusion)
Ankylosing spondylitis
Problems may occur w/ the skeletal system, or others (Ex. Uveitis, inflammatory bowel problems, cardiovascular and pulmonary issues) and the long term issues associated with these
________ occurs from massive nerve compression due to herniation of multiple (Sometimes just one) intervertebral discs and spinal cord compression
Clinical presentation includes:
1. Pain 1st, then motor and sensory problems
“Saddle anesthesia”
- Bilateral leg weakness in multiple root distributions (L3 – S1 typically)
- Bowel, bladder, and/or erectile dysfunction (S2 – 4 typically)
Cauda Equina Syndrome
*NEUROLOGICAL EMERGENCY
The earlier this is diagnosed and treated, the better the long term outcome from this
- _______ curve refers to the outward curve of the thoracic spine (at ribs)
- _____ curve refers to the inward curve of the lumbar spine (above butt)
- _____ curve refers to sideways curve of the spine and is always abnormal
- Kyphosis (excessive: sherumann’s)
- Lordosis (excessive: Swayback)
- Scoliosis
