Thoracic and ribs Flashcards
Inferior angle of scapula =
T7/T8
T-spine Rule of 3’s
- T1-T3 are at same level as TPs
- T4-T6 are 1/2 vertebral level blow the TPs
- T7-T9 - full vertebral level blow
T10-T12 are at same vertebral level
Thoracic facet joint angles
Superior articulations oriented 60* from horizontal, 20* from frontal
Inferior articulations match the superior articulations and face anterior, inferior, slightly medial
Superior facet originate from superior vertebrae of t-spine
Thoracic disks
thinner compared to cervical and lumbar
Disc height ratios - cervical, thoracic, lumbar
Cervical: 2 to 5
Thoracic: 1 to 5
Lumbar 1 to 3
Ribs 1-7
True ribs because they attach to sternum
Heads to ribs 3-9 have 2 facets for attachment to corresponding demifacets on vertebral bodies
Superior facets to superior vertebral body, inferior attaches to numerically corresponding vertebral body
Ribs 8-12
False ribs because they attach distally to costochondral cartilage of superior rib
Rib 11 and 12 have no anterior atachment
1st, 10th, 11th, 12th rib
attach to only 1 facet on corresponding vertebral body
Ribs 11 and 12 do not attach to TP and do not have a costotransverse process
Upper thoracic rib joint style
Upper t/spine to T5/6 -rib portion is concave and transverse process is convex - more rotation and torsional movement
Lower t-spine - the costotransverse joints are planar. - more planar movement
Inspiration in upper vs. lower ribs
Upper rib cage flexes (rises) and lower ribs widen (abduct).
Trapezius
Oirigin: all thoracic SPs, external occipital protuberance, ligamentum nuchae, SP of C7
Action: assists with force coupling allowing for normal scapular upward rotation and posterior tipping during elvation of humerus.
Iliocostal thoracis
Origin: angel of ribs 7-12
Insertion: ascends to angles of ribs 1-6 and TP of C7
Iliocostalis lumborum
Originates: posterior aspect of sacrum and thoracolumbar fascia
Inserts: ascends to angles of ribs 6-12.
Erector spinae
Important role in health and function of spine
In t/s they maintain an upright, neutral thoracic curve
Spinal extensor weakness
Along with reduced muscle density has been associated with thoracic hyperkyphosis, osteoporosis, decreased quality of life, increased risk fo falling in older adults
Serratus anterior muscle
Orign: muscle arises from outer surface and superior border of upper 8th-10th ribs and fascia of associated external intercostal muscles
Insertion: Anterior surface of vertebral border of scapula
Action: protract scapula, assist in force couple for normal scapular upward rotation and posterior tipping
If scapula is fixed, SA will result in posterior directed force on ribs
Pec Major
3 proximal attachments: clavicle, sternum, costal cartilages of ribs 1-6
Distal: lateral lip of bicipital groove
Action: adduct and IR humerus
- Clavicular portion can assist the coracobrachilais and anterior delt with GH flexion
- When distal attachment is fixe with humerus flexed, pec will result in anterior, superior, and lateral force on rib cage
Pec Minor
Origin: anterior and superior surfaces of ribs 3-5
Insertion: medial superior coracoid process of scapula
Shortening and hypertonicity of this muscle can lead to protraction and anterior tipping of scapula, which can affect normal scapular motion during elevation of arm
Diaphragm
Primary muscle of inspiration
Broad MSK attachments to ribs and spine
3 parts:
- sternal
* origin: xiphoid process - costal
* internal surfaces of rib costal cartilages and adjacent parts of lower 6 ribs - lumbar
* first 2 or 3 lumbar vertebrae
Diaphragm and spine disorders
Lack of relaxed, diaphragmatic breathing is an impairment that often accompanies both acute and chronic spinal disorders and contributes to thoracic spinal mobility restrictions
Thoracic spinal nerves
- 12
- Divided into anterior and posterior rami - posterior rami are divided into medial and lateral branches
- exits below respective intervertebral disk
Thoracic dermatomes
*run in circumferential pattern inferior to corresponding thoracic vertebrae from posterior midline to anterior midline
Medial branch of upper 6 segments
supplies semispinalis and multifidus
Medial branch of lower 6 segments
Supplies transversospinalis and longissimus
Lateral branch
supplies longissimus, iliocastalis, costotransverse joints
Lower 6 segments
Emerge from iliocostalis lumborum and become cutaneous
Anterior rami
travel anterior in the intercostal space and are known as the intercostal nerves
12th anterior rami forms subcostal nerve below 12th rib
Muscular branches of intercostal nerves
supply the innermost incercostal, internal intercostal, subcostal, external intercostal, and serratus posterior muscles
Cutaneous branches of intercostal nerves
Supply the skin on the lateral an danterior aspect of the thorax and abdomen
Muscular branches of 7th through 11th intercostals and subocostals
Innervate abdominal muscles
Subcostal neve
supplies the skin of the abdominal wall, lateral hip, iliac crest
*potential avenue for nociceptive input arising from thoracolumbar junction that is referred to hip joint
Superior portion of 1st intercostal
forms part of brachial plexus
Lateral cutaneous branch of 2nd intercostal
Intercostobrachial nerve - supplies floor of axilla and joins the medial brachial cutaneous nerve to supply the medial arm as far as the elbow.
*allows potential for nociceptive input arising from upper thoracic spine to contribute to symptoms in UE
Sinuvertebral nerve
Recurrent branch of spinal nerve and anterior rami
Consists of both somatic and autonomic fibers and supplies the dura, outer fibers of IV disc, medial aspect of zygapophyseal joint and posterior longitudinal ligament
Spinal canal in t/s
- notably narrower than other regions
- T4-T9 = critical zone due to small diameter of spinal canal and reduced blood supply
-large herniated has the potential to cause spinal cord compression
T4 syndrome
- mobility impairments in thoracic spine associated with upper or lower quarter neurogenic and sympathetic s/s such as (B) extremity paresthesia and sweating
- origin is unknown and likely a result of amplification of nociceptive input into peripheral and central nervous systems
- targeting mobility impairments can assist with temporary reduction in s/s
Thoracic disc pathology
-capable of producing nociceptive input
-can be seen on x-ray and MRI
-pain in the thoracic and chest wall
- no studies reporting symptom referral pattern for thoracic disks
-could potentially create thoracic nerve root compression and radic
-
Thoracic flexion and extension
Motion in the sagittal plane gradually increases from T1-T12 as facets become more oriented in the sagittal plane
Degree of thoracic flexion and extension varies widely
mean = 7.7 flexion, 9.6* extension
T/S Flexion
Forward flexion: superior vertebrae translates forward and rotates, articular facets of superior vertebrae glide upward and forward no superior facets of inferior vertebrae
*flexion in t/s results in forward rotation of rib head at costoveretbral joint
T/S Extension
Posterior translation of superior vertebrae and backward rotation
Inferior facets glide down and back.
Posterior rotation of rib head and inferior glide at costotransverse joint
End range active (B) shoulder flexion is coupled with end range thoracic extension - particularly from lower t-s
T/S SB
- accompanied by small ipsilateral lateral translator movement of superior vertebrae
- gradually increases from T1-T12
T/S (R)SB
- (R) inferior facet of superior vertebrae glides inferolaterally and (L) inferior facet glides supermedially
- controversy over whether thoracic rotation couples C/L or I/L
- SB of thoracic spine leads to approximation of ribs on I/L side and separation of ribs on C/L side
T/S Rotation
- greatest in upper segments and reduced in lower segments
- accompanied by slight translation of superior motion segment to C/L side
Inspiration
-AP diameter expands and intercostal muscle contract, ribs move through axes and anterior ends of rib rise with sternum
Anterior superior motion = pump handle
Transverse diameter expands and ribs move laterally and superiorly = bucket handle
Expiration
- ribs move inferiorly in both anterior and lateral aspects
- pump handle motion is thought to predominate in upper ribs and bucket handle is more lower ribs
Upper rib pathomechanics
- can become dysfunction at either costovertebral or costotransverse articulations
- commonly occurs after traumatic injuries
- created by soft tissue tensiona nd postural guarding associated with pain (as opposed to a joint sublux)
- impaired mobility of 1st rib is associated with TOS
Middle and lower rib pathomechanics
- can occur in isolation or concurrently with T/S impairments
- reduced motion can contribute to impairments
- may result from aging, repetitive or postural strain, or muscle guarding following trauma
- hypermobility can also occur as a result of traumatic sprain or repetitive strain injuries
Visceral conditions that can refer pain to thoracic spine
- Myocardial ischemia
- dissecting thoracic aortic aneurysm, peptic ulcer, acute cholecystitis, renal colic, acute pyelonephritis
*majority of visceral organs are innervated by thoracic spinal nerves
dissecting thoracic aneurysm
- pain is usually felt in the chest and can radiate to the back
- pain is usually sudden, unrelenting, not relieved by position change
Myocardial ischemia
-accompanied by anterior chest pain/heaviness, occasional nausea, sometimes pain radiating to back
Thoracic/chest pain
-may also be from exertional or variant myocardial ischemia (stable or unstable angina)
Stable angina
-relieved with rest
Unstable angina
-occurs at random and is not related to activity - usually a progression from stable angina and is a risk factor for MI
CPR for CAD
- age/sex (female >/=65, male >/=55)
- known clinical vascular disease
- pain worse during exercise
- pain not reproduceable by palpation
- patient assumes pain is of cardiac origin
Sn = 0.98 if 2 predictors met
During external validation, CPR was ruled 89% sn
Peptic ulcer
- posterior wall of stomach or duodenum
- boring pain from epigastric area to middle of t/s
- t/s pain either triggered or relieved by eating
- can result from prolonged use of NSAIDs
cholecysititis
- (R) UQ pain and (R) infrascapular pain
- accompanied by moderate fever, nausea, vomiting
- one to two hours after ingestion of meal
Murphy sign = palpation of (R) subcostal region and asking patient to take deep breath, pain = +.
Kidney/renal pain
- referred to costovertebral angle or flank area
- fevere, nausea, vomiting, renal colic
Serious causes for thoracic pain
- infection
- fracture
- spinal metastases (from primary breast, lung, colon cancer)
- infections
Ankylosing spondylitis
- estimated prevalence of 0.18%
- predictor variables:
1. stiffness >30 mins in duration
2. improvement in back with exercise, but not rest
3. awakening because of pain during 2nd half of night only
4. alterenating buttock pain
Thoracic vertebral fractures - traumatic
- usually result of blunt trauma or injury
Thoracic vertebral fractures - osteoporosis
-aging population
-decreased bone mass
Risk factors:
1. Caucasian race
2. hx of smoking
3. early menopause
4. thin body build
5. sedentary lifestyle
6. steroid treatment
7. excessive consumption of caffeine or alcohol
Cervical rotation lateral flexion test
- sitting position
- cervical rotation passively and maximally away from side being tested - then side bent as far as possible (ear toward chest)
- reduction in SB mobility suggest evidence of first rib dysfunction on opposite side
Relationship between cervical and thoracic spine
- biomechanical link between the 2
- significant correlation between thoracic mobility deficits and neck pain
- thoracic spine manip potential alternative treatment approach to cervical manip
CPR - thoracic manip for neck pain
- symptoms <30 days
- no symptoms distal to shoulder
- looking up does not aggravate
- FABQPA <12
- diminished upper thoracic kyphosis
- cervical extension ROM <30*
6 - (+) LR - infinite, sp 1.0 5+ - (+) LR - infinite, sp 1.0 4+ - (+) LR 12, sp .97 3+ - (+) LR 5.49, sp. 86 2+ - (+) LR 2, sn .95, sp .56 1+ - (+) LR 1.2, sn 1.00
