leccture 6- thorax Flashcards
3 respiratory muscles
-diaphragm
-intercostal muscles
-sternocleidomastoid
5 boundaries of the thorax
neck
diaphragm
thoracic vertebrae
ribs, sternum
muscles
Bones of the thorax
-12 thoracic vertebrae
-sternum
(manubrium, body, xiphoid process)
-12 pairs of ribs
Explain the attachments of the 12 thoracic ribs
1 to 7 attach to the sternum by individual cartilage (costochondral)
8, 9 and 10 share one attachment
11 and 12 are not attached to the sternum
contents of the thorax
lungs
heart
aorta and branches
superior vena cava
azygous vein
trachea
esophagus
vagus nerve
injuries: muscle strains
most common in running
intercostals, diaphragm and others
SSx:
-pain on deep inspriration, dypsnea
-tenderness
Tx:
rest, analgesics
injuries: rib fracture
direct blow, compression (tackle)
SSx:
severe inspiratory pain and dyspnea
costochondral sprain or dislocation
same Hx, Ssx, Tx as strain
plus crepitus deformity (surgery?)
life threatening injuries: pneumothorax (open vs closed)
open pneumothorax= air accumulates between chest wall and lung
**if open, there would be a puncture
closed= tear within lung
–> can happen spontaneously in very tall, skinny people
Pneumothorax SSx
severe dyspnea (running out of air), shock, cyanosis, rapid respiratory rate (RR)
life threatening injuries: flail chest
= multiple rib fractures
- paradoxical motion of part of chest wall
–> opposite motion of thoracic cage in place of injury!!! in and out in reverse of normal movement - SSx and Tx same as pneumothorax
Abdomen boundaries
diaphragm
pelvis
abdominal muscles
vertebrae
lower ribs
back muscles
abdomen quadrants
right upper quadrant/RUQ, LUQ, RLQ, LLQ
abdomen blood vessels
abdominal aorta, inferior vena cava
abdomen “visitors”
bladder if it is v full
uterus in pregnancy
Inguinal area contains
inguinal ligament
ASIS to pubic tubercle
What is above the inguinal ligament?
the inguinal canal!! which is the site of inguinal herniation
–> the inguinal ligament also has internal and external inguinal rings
The inguinal canal is a passage in the
lower part of the abdominal wall for spermatic cord in males or round ligament of uterus in females
What is below the inguinal ligament?
the femoral triangle!!!
–> femoral artery, nerve and vein
–> site of femoral herniation
Abdominal organs
liver RUQ
spleen LUQ
kidneys
abdominal intestines and glands
stomach, duodenum, ileum, jejunum, colon (appendix in RLQ)
pancreas, gallbladder
injuries: blow to coeliac (solar) plexus
(Hx, SSx, Tx)
Causes (Hx):
-trauma to central abdomen leads to nerve concussion
-transient paralysis (due to weakness, muscle control comes and goes periodically) of diaphragm
SSx:
Ache, shortness of breath/dyspnea, anxiety
Tx:
relaxation (short inhalation, long exhalation), reassurance, observe!!!
injuries: Side stretch
(Hx, SSx, Tx)
Hx:
strain or contusion of abdominal muslce
SSx: crampy pain, worse w inspiration
Tx: stretching, analgesics, rest
Injuries: herniae
definition and mechanism
= protrusion of abdominal contents through defect in muscle/fascia
mechanism:
-predisposition (weakness)
-valsalva or direct blow
Degrees of herniae (3)
- Reducible
- Incarcerated
- Strangulated
types of herniae
inguinal: mostly males
femoral: uncommon, mostly females
herniae SSx
- “pull” or weakness
- aching pain
- swelling, tenderness above (inguinal) or below (femoral) ligament
- pain swelling worse w valsalva or coughing?
herniae Tx
strengthen abdomen
surgery
Strangulated herniae
is an emergency!!!!
nausea, vomiting, intense pain
NPO, transport to hospital!!!!
injuries: sports hernia/athletic pubalgia
not the same as herniae!
same buildup as MTSS but occurring at the pubic bone
SSx: chronic groin pain, pain w twisting, hip extension, possible pain into testicle
AxL pt history, physical exam, MRI
tear of abdominal muscles or tendon at attachment to pubic tubercle
entrapment of inguinal or genitofemoral nerve
often labral tear with adductor strain
Tx: rest, surgery
mononucleosis
enlarged spleen
not allowed to play contact sports to protect the area
–> delayed abdominal pain after contusion to abdomen??? send to MD!!!!!
C spine anatomy
C1= altas (skull flexion/extension)
C2= axis (rotation, C1 pivots on C2)
C7= vertebra prominens
Spinal nerves
C1-C7 exit above the same vertebrae
C8 exits between C7 and T1
C5-T1 form brachial plexus
C3-C5 innervate diaphragm
facial bones are
Fragile (except mandible)
TMJ (temporomandibular joint; hinge and gliding joint)
common mechanism of injuries for neck (neck strains and sprains Hx)
- flexion/extension
- torsion
- compression
Neck injury SSx
SSx:
Pain, tenderness
Muscle spasm
Restricted ROM
Headaches
**check for neurological SSx
Neck injury management
- Stabilize
- If neurologic or severe trauma assume fracture/nerve damage. May lead to permanent brachial plexus or spinal cord injury
Neck sprain or strain Tx
- Rest, NSAIDs, physio, massage, flexibility, strengthening
- Recurrence is common
neck injury or concussion (what force?)
sprain or strain only require 4.5 G of force
concussions need 70 to 120 G of force
–> you CANNOT have a concussion without injuring your neck
concussion=
Immediate, transient, neurologic dysfunction due to trauma of the brain
Mild traumatic brain injury
the spreading depression phase is an —- problem
energetic management
Excitation phase
(ca+, k+, glutamate, glucose and blood flow)
calcium is elevated 500% for up to 6 days
potassium is elevated 400% within 12 minutes
glutamate elevated 133% for 6 miniutes
glucose elevated 200% of normal in first 20 min, then drops below normal for up to 10 days
40% decrease in cerebral blood flow
brain injury; grey and white matter
grey matter and white matter move at diff rates
causes shearing/damage of axons
neurometabolic cascade
dramatic increase in neurotransmitters after a brain inury
- excitation phase
- spreading depression phase
explain spreading depression phase
Na+/K+ pump maintains balance of Na+, Ca+ inside cells and K+ outside cells
requires ATP
BUT high level of Ca+ is poisonous for mitochondria
ENERGY crisis!!!!
- increased ATP demand by Na+/K+ pump
- decreased ATP production by mitochondria
why are people fatigued/not feeling good after a brain injury?
spreading depression phase results in decreased ATP production
3 categories of concussion SSx
- Physical
= headache, dizziness, ringing in ears, pressure in head, neck stiffness/pain, vision problems, balance problems, vomiting/nausea - Behavioural/emotional
=personality changes, concentration problems, confusion, fatigue, irritable, emotional, anxious, depressed - Thinking/cognitive
= memory, confusion, concentration, hard to find the words to say, slow to respond, disorientation, brain fog
SCAT 5
=sports concussion assessment tool
can we use imaging to determine if someone has had a concussion?
no
Concussion Tx:
Stabilize neck
ABCDs serial assessment
Rest
High carb diet
No absolute rest—light physical activity, gradually increase
Limit screen time
Don’t go in a dark room!
symptoms gone= recovered?!
we can indirectly measure ATP activity
full ATP recovery in the brain is 30 days or longer
return to sport before brain is metabolically recovered= inc risk of reinjury
FULL metabolic recovery from concussion takes
30 to 45 days!!!
concussion RTP
Absence of Sx before RTP
Clearance from medical professional
Physical testing
(Buffalo treadmill test and Blackhawk test)
gradually increasing intensity of exercise (walking on treadmill and using bike)
- fatigue will show us when mitochondria production fails
Return to school protocol before return to play protocol
concussion complications
- Epidural haematoa (arterial)
- Subdural haematoma (venous)
- Airway obstruction
- Skull fracture (leads to infection
–> Protein deposits in the brain (CTE)
- impacts blood brain barrier, depression, mood disorders
most dangerous movement for brain
rotational deceleration
NFL RTP protocol: 5 phases
Phase 1: symptoms limited activity
Phase 2: aerobic exercise
Phase 3: football specific exercise
Phase 4: club-based non-contact training drills
Phase 5: full football activity clearance
Mandibular fracture and/or temporomandibular dislocation
(Hx, SSx, Tx)
Hx: direct blow
SSx: deformity, spasm (airway is threatened)
Tx: ABCDs, stabilize, hospital ASAP
Nasal fracture
Hx: direct blow
SSx: pain, swelling crepitus, deformity, epistaxis, uneven air entry
Tx: cold compress, go to MD
Epistaxis
Hx: direct blow, sinusitis, “digital”= sticking finger up nose
Tx: elevation, cold, pressure
External ear contusion
Hx: direct blow
SSx: swelling, bruising, tenderness
Conplication: deformity
Tx: cold pack, compress
Prevention: ear protection
Eye injuries
Contusion
Foreign body, laceration, abrasion
Infection
go to MD
Tooth fracture
Save fragment (cold milk)
Go to dentist within 2 hours
