Rib Diagnosis Flashcards
What are the typical ribs ??
Ribs 3-10
Typical ribs have all of the following
- tubercle
- head
- neck
- angle
- shaft
- articulate with the sternum
What ribs are atypical?
1st
2nd
11th and 12th
sometimes rib 10 since it only articulates with T10
Why is rib 1 atypical?
Articulates with only T1 and has no angle
Why is rib 2 atypical?
Possess a large tuberosity on the shaft for attachment of serrates anterior
Why are ribs 11 and 12th atypical?
Articulate only with T11 and T12 respectively and lack tubercles
Which ribs are true
1-7
Which ribs are false?
8-10
technically 11 and 12 also but they are defined as floating ribs
What ribs have vertebrosternal attachments?
1-7
What ribs have vertebrochondral attachments
8-10
Where is the cervical pleura located with respect to the ribs?
Above rib 1
Where does the diaphragmatic cartilage begin with respect to the ribs?
6th-11/12th
Physiological/respiratory motion of the ribs
All ribs 1-10 exhibit both pump-handle AND bucket-handle motion
- Ribs 1-6 primary = pump handle (superior/anterior -inferior/posterior)
- ribs 7-10 primary = bucket handle (superior/medial - interior/lateral)
Ribs 11-12 exhibit caliper/pincer motions
Pump-handle motion specifics
predominant motion of ribs 1-6
Inhalation:
- anterior portion of the rib moves anterior/superior
- posterior angle moves posterior/inferior
Exhalation
- anterior portion of the rib moves posterior/inferior
- posterior angle moves anterior/superior
1) best palpated at the mid-claviicular level
2) plane of motion is in the sagittal plane
3) axis of motion is in the costovertebral-costtransverse line
Bucket handle motion specifics
predominant motion of ribs 7-10
Inhalation:
- lateral margin of the rib moves superior/lateral
- increase in transverse diameter
Exhalation
- lateral margin of the rib moves inferior/lateral
- decrease in transverse diameter
1) best palpated at the mid-axillary level
2) plane of motion is in the coronal plane
3) axis of motion is in the costovertebral-costosternal line
Caliper motion specifics
predominant movement for ribs 11-12
Inhalation:
- ribs move posterior/inferior
Exhalation
- ribs move anterior/superior
1) best palpated 3-5 cm lateral to the transverse process
2) plane of motion = transverse
3) axis of motion = vertical (cephalad-pedad )
Quiet breathing muscles
Diaphragm
External and internal intercostals
Rectus abdominis
External and internal obliques
During inspiration:
1) external intercostal = tonic contraction
2) internal intercostal = resists negative pressure
During expiration:
1) abdominis = tonic contraction
2) external and internal obliques = tonic contraction and maintain intra-abdominal pressures
Forced breathing muscles
SCM
- elevates sternum
Trapezius
Pectoralis minor
Scalenes
- elevates upper ribs
Rectus abdominis
Serratus posterior
Levatores costarum
External and internal obliques
Quadratics lumborum
- pulls ribs down during expiration
Internal intercostals
- pulls down on ribs during expiration
External intercostals
- elevates ribs during inspiration
During inspiration:
1) SCM/trapezius/pectoralis minor/scalenes = elevates the rib cage
During expiration:
1) abdominis = tonic contraction
2) external and internal obliques = tonic contraction and maintain intra-abdominal pressures
Prime muscles in both inhalation and exhalation
Inhalation
- diaphragm
- intercostal muscles
- scalenes
Exhalation
- intercostal muscles
- abdominal muscles
- quadrates lumborum
- note diaphragm is not prime mover in exhalation technically since it just relaxes
Inhalation somatic dysfunctions
TREAT BOTTOM RIB AND GO UP
Pump handle inhalation rib dysfunctions:
1) anterior portion of dysfunctional rib will stay anterior and not move inferior when patient exhales
2) posterior rib angle moves easier in posterior direction
3) AP diameter of rib cage at level of dysfunction is larger
Bucket handle inhalation rib:
1) lateral portion of dysfunctional rib will not move inferiormedial during exhalation (stays superiorlateral)
2) transverse diameter of the rib cage at the level of dysfunction is larger
Exhalation somatic dysfunctions
TREAT TOP FIRST AND MOVE DOWN
Pump handle exhalation rib dysfunctions:
1) anterior portion of dysfunctional rib will stay posterior and not move superior when patient inhales
2) posterior rib angle moves easier in anterior direction
3) AP diameter of rib cage at level of dysfunction is smaller
Bucket handle exhalation rib:
1) lateral portion of dysfunctional rib will not move superiorlateral during exhalation (stays inferiormedial)
2) transverse diameter of the rib cage at the level of dysfunction is smaller
Diagnosis of the 1st rib
Index finger is superior on the head of 1st rib
Middle finer is inferior on the head of the 1st rib
Thumb is on the anterior shaft
Assess the following
- static positions: are they equal in the anterior-posterior direction
- passive movement: gently spring the anterior rib posterior and assess movement of both sides (does one resist more than the other?)
- active movement: have patient inhale and exhale and assess pump handle motion by monitoring
Rib 1-6 costal-sternal boarder locations
this is the location of ribs 2-6 to assess diagnosis
Rib 1: upper portion of manubrium
Rib 2: attachment at the angle of Louis
Rib 3-6 each respective level below rib 2 cartilage at the levels of the respective vertebral segments
Inhalation somatic dysfunction & exhalation restriction
- rib stays superior/anterior, doesnt move inferior/posterior during exhalation
Exhalation somatic dysfunction & inhalation restriction
- rib stays inferior/posterior, doesn’t move superior/anterior during exhalation
BITE
The acronym for remembering which rib to treat first in rib treat emend based on exhalation on inhalation somatic dysfunctions
B: bottom
I: Inhalation
T: Top
E: Exhalation
Patient position of rib diagnosis based on section of ribs
1-10 = supine
11-12 = prone
Location of anterior ribs 7-11
Note: all are on the costal margin bilaterally except R11
Rib 7 = 1st notch palpable inferio-lateral to the xiphoid
Rib 8 = medial 1/3rd of the clavicle, halfway between R7 and 9
Rib 9 = midclavicular line on the costal margin
Rib 10 = lateral 1/3 of clavicle on the costal margin
Rib 11 = free floating tip in the mid axillary line just inferior to R10
Ribs 7-10 testing
Place fingertips on ribs 7-10 w/ pinky on rib 10 and index on rib 7
Inhalation somatic dysfunction & exhalation restriction
- rib stays superior/lateral, doesnt move inferior/medial during exhalation
Exhalation somatic dysfunction & inhalation restriction
- rib stays inferior/medial, doesn’t move superior/lateral during exhalation
Effects of OMT on thoracic cage
Improves breathing mechanics
Increases venous/lymphatic return to heart
Helps modulate the sympathetic nervous system
Decreases pain
Improves posture
