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OMM M1T3E5 > Thoracic Spine & Rib Cage Pain > Flashcards

Thoracic Spine & Rib Cage Pain Flashcards

1
Q

What is the most part of the evaluation?

A

patient history

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2
Q

What is the coin test?

A
  • absent breath sounds
  • assistant places coin flat on anterior chest and strikes with edge of second coin
  • pneumothorax - rings like a bell - bell tempany
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3
Q

What is the most important xray to obtain?

A

AP chest xray

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4
Q

What do you have to include if there was trauma?

A

fracture, sprain, tendon tear, ligamentous rupture

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5
Q

What causes pneumothorax?

A
  • rib fracture
  • asthma
  • esophageal perforation
  • exercise induced
  • manipulative treatment
  • spontaneous
  • thoracic or cervical surgery
  • tracheobronchial perforation
  • ventilator (overinflated)
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6
Q

What are the symptoms of rib fracture?

A
  • pain is well localized

- pain is lancinating (sharp)

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7
Q

How do you evaluate the rib fracture?

A

Palpation

  • carefully palpate the site of indicated pain
  • carefully note the precise site
  • cartilage or bone
  • correlate image to physical findings
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8
Q

What would you hear upon auscultation of the heart?

A

pericardial friction rub if pericardium is involved
(leather rubbing)
- sounds like a balloon

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9
Q

What would you hear upon auscultation of the lung?

A
  • hear bony ends rubbing together

- pleural friction rub if irritated (at site of pain)

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10
Q

What is motion induction?

A

pain at fracture site with remote pressure on the rib cage

- push the side or back and pain in front will be elicited

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11
Q

What treatment would you use for rib fracture?

A
  • treat the opposite side to maximize pulmonary function
  • treat dysfunction in cervical C3-C5
  • bracing - unnecessary for healing but may help with pain
    Medication
  • opiate - low dose; high dose would repress respiratory function
  • no injections! makes it an open fracture
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12
Q

What is the history of fractured costal cartilage?

A

MVA from shoulder harness

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13
Q

What is the symptoms of fractured costal cartilage?

A
  • pain is well localized

- pain is lancinating (sharp)

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14
Q

What are appropriate tests for fractured costal cartilage?

A
  • Chest xray - pneumothorax
  • Bone Scan - increased uptake of radionuclide at fracture
    -Peritoneal Lavage - in case of hepatic or splenic injury
    No Rib Xray - cartilage doesn’t show
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15
Q

What treatment would you use for fractured costal cartilage?

A
  • treat the opposite side to maximize pulmonary function
  • treat dysfunction in cervical C3-C5
  • bracing - unnecessary for healing but may help with pain
    Medication
  • opiate - low dose; high dose would repress respiratory function
  • no injections! makes it an open fracture
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16
Q

What is the history of cough fracture?

A
  • bronchitis
  • pneumonia
  • interior is shattered in trabecular framework
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17
Q

What are the symptoms of cough fracture?

A
  • persistent pain at the level of the lower ribs posteriorly

- R11 or 12

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18
Q

What are the vital signs of cough fracture?

A
  • fever

- increased respiratory rate

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19
Q

What is seen upon inspection of a cough fracture?

A

decreased diaphragmatic breathing

- pain with deep inhalation or coughing

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20
Q

What are the appropriate tests for cough fracture?

A
  • Chest x-ray - search for pneumonia
  • Bone scan - shows stress fractures
  • MRI - usually will show better in feet, pelvis; difficult to get MRI of floating ribs and thorax
    Rib xray - not indicated
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21
Q

What is the treatment for cough fracture?

A
  • OMT - indirect myofascial; no counterstrain
  • Cough suppressant - increase risk of bronchitis»pneumonia
  • antibiotics
  • opiad analgesics
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22
Q

During evaluation, what does compression fractures of the spine cause?

A

acute angulation of kyphosis

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23
Q

How do you do motion induction?

A
  • active regional range of motion
  • passive regional range of motion
  • respiratory motion - increase of 3 inches with deep inhalation
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24
Q

What are some painful/painless conditions associated with motion loss?

A
  • cicatrix (scarring)
  • calcification of the costal cartilage
  • atrophy or myopathy
  • connective tissue disease
  • osteoarthritis
  • spondyloarthropathies
  • Scheuermann Disease
  • Somatic Dysfunction
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25
Q

What is cicatrix?

A

Scars

  • burns (kept getting pneumonia)
  • surgical scars (heart surgery as children - ribs restricted)
  • adhesions (between lung and rib cage)
  • lacerations (area of scar will be less mobile)
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26
Q

What is post-polio syndrome?

A
  • after polio contraction there is a new onset of weakness, fatigue, muscle fasciculations and pain with additional atrophy
  • axons die early
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27
Q

What is scleroderma?

A
  • skin becomes thickened and bound to underlying fascia
  • Raynaud’s phenomenon
  • skin is tight and shiny
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28
Q

What are the musculoskeletal features of scleroderma?

A
  • pain, swelling and stiffness of fingers and knees
  • symmetric polyarthritis similar to RA
  • thickening of tendon sheaths leads to carpel tunnel syndrome
  • resorption of bone - terminal phalanges, ribs, clavicle, angle of mandible
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29
Q

What are the pulmonary features of scleroderma?

A
  • exertional dyspnea
  • dry, non-productive cough
  • pulmonary fibrosis
  • bibasilar rates
  • restriction of chest movement by skin involvement
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30
Q

What are the cardiac features of scleroderma?

A
  • pericarditis
  • congestive heart failure
  • cardiomyopathy
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31
Q

What are the renal manifestations of scleroderma?

A
    • malignant hypertension
  • hematuria
  • proteinuria
  • oliguria
  • renal failure
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32
Q

What are the diseases of osteoarthritis?

A 
Spine - degenerative disc disease
- Zygapophyseal joint disease
Ribs - costotransverse joint
- chondrosternal joint
- chondrochondral joints
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33
Q

What are included in the spondyloarthropathies?

A
  • ankylosing spondylitis
  • psoriatic arthritis
  • reactive arthritis associated with IBD
    (Crohn’s Disease, Ulcerative colitis)
  • usually result in kyphosis
34
Q

What is counterindicated in ankylosing spondylitis?

A

HVLA

- get imaging first

35
Q

What is Scheuermann’s Disease?

A
  • increased kyphosis
  • rigid thoracic spine
  • X-ray: irregular endplates, vertebral wedging
  • show up in teen years
36
Q

A lot of rib cage pain is somatic dysfunction. This means your orthopedic evaluation will be?

A

normal but there will be tenderness, asymmetry, restricted range of motion, texture

37
Q

What are the physical finding of chest wall syndrome?

A
  • diffuse pain with pressure over the sternum
  • pain with shoulder motion
  • pain with cervical spine motion and nerve root impingement tests
38
Q

What are the symptoms of intercostal muscle spasm?

A
  • sharp pain - lasts 1-3 minutes
  • palpation - intercostal tenderness & firmness
  • may be an associated rib dysfunction
  • tenderness at serratus attachment
39
Q

How do you treat intercostal muscle spasm?

A
  • OMT
  • intercostal nerve block
  • trigger point injection
  • medication (analgesic, muscle relaxant)
40
Q

What is intercostal myositis?

A

more severe

  • pain with respiration
  • tender intercostal space
  • induration (firm or hard swelling)
  • fascial nodularity
41
Q

What are treatments of intercostal myositis

A
  • OMT- indirect technique
  • NSAIDS
  • corticosteroids
  • corticosteroid injection is localized to small enough area
42
Q

How do you differentiate costochondral pain from chondrosternal pain?

A

Chondrosternal - synovial

costochondral - fibrous

43
Q

What are the symptoms and physical findings of costochondral pain?

A
  • pain in anterior chest wall
  • tenderness at costochondral junction
  • can be separated due to trauma
44
Q

What is the treatment of costochondral pain?

A
  • OMT - correct rib dysfunction
  • counterstrain technique
  • analgesic medication
  • local corticosteroid injection
45
Q

Where is pain referred with shoulder girdle disorders?

A
  • from any shoulder girdle muscle attachment site

- may refer pain to the rib cage

46
Q

What is costochondritis?

A
  • pain is localized to the costal cartilages which are tender to palpation
  • dull in character
  • aggravated by shoulder motion
  • typically symmetric and effects 3, 4, 5th costochondral joints
47
Q

What is the treatment for costochondritis?

A

OMT - site of many trigger points for counterstrain but probably won’t work

  • treat any rib dysfunction
  • lidocaine patch
  • NSAIDs
  • oral or IM corticosteroids
48
Q

What is Tietze syndrome?

A
  • palpable fusiform swelling of costal cartilage
  • usually asymmetric
  • often involves 2 & 3rd costal cartilage
  • can be post viral syndrome (parvovirus B19)
49
Q

How would you treat Tietze?

A

OMT - thoracic pump and splenic stimulation to boost immune

  • correct any accompanying costal and thoracic segment
  • lidocaine patch
  • NSAIDs
  • Oral and IM corticosteroids
50
Q

What infectious disease can cause respiratory pain?

A
  • herpes zoster
  • pleurisy
  • epidemic pleurodynia
  • osteomyelitis
  • epidural abscess
  • infectious chondritis
  • periostitis
51
Q

What is the most common rib cage problem?

A

Herpes Zoster

52
Q

What are the signs for Herpes Zoster?

A
  • dermatomal rash
  • does not cross midline
  • neuralgia before rash
  • post-herpetic neuralgia
53
Q

What are the symptoms of intercostal neuralgia?

A

tenderness occurs at the cutaneous branches of the intercostal nerve

  • paraspinal
  • parasternal
  • mid-axillary
54
Q

When is highest incidence of herpes zoster?

A

50-70

Sixth to eighth decades

55
Q

Which dermatomes are most likely affected with herpes zoster?

A

T3-L3 dermatomes

56
Q

Describe the disease onset of herpes zoster.

A
  • pain may precede lesions by 48-72 hours
  • vesicles from for 3 -5 days
  • entire disease lasts 7 - 10 days
  • skin may take 2 -4 weeks to return to normal
  • rarely do they have the neuralgia without the rash
57
Q

What is treatment for herpes zoster?

A

OMT - painful but treat segmental and costal dysfunctions at the levels of the rash; prevents post-herpatic neuralgia

  • use thoracic pump and splenic stimulation to enhance immune response
  • antivirals (valacyclovir, famcyclovir, acyclovir)- administered within 72 hours of rash
  • pain - opiates, tricyclic antidepressants, nortriptyline,
58
Q

What do you use for post-herpatic neuralgia?

A

anti-seizure meds: Gabapentin, topiramate, lamotrigine

59
Q

What is pleurisy?

A
  • fever, CBC - leukocytosis
  • pleural friction rub
  • knife like shooting pain
  • parietal pleura is pain sensitive (visceral pleura is not)
60
Q

What is the treatment for pleurisy?

A
  • treat involved areas

- improved costal motion to prevent pleural adhesions

61
Q

Where would you feel pain if the pleural on the periphery of the diaphragm is involved?

A
  • periphery of diaphragm is innervated by T6 & T7 nerve roots
  • central tendon region is supplied by C3,4, 5 (ends up in neck and shoulder)
  • phrenic nerve innervates both thoracic side and abdominal side of diaphragm
62
Q

What is epidemic pleurodynia?

Devil’s grip, The Grip

A
  • severe paroxysms of thoracic and abdominal pain
  • fever
  • headache
  • mild pharyngitis
  • no leukocytosis
  • Coxsackie B
63
Q

What are the complications of epidemic pleurodynia?

A
  • pericarditis
  • orchitis
  • may end up in hospital due to hypoxia
  • CCU with Dx of R/O MI or dissecting aneurysm
64
Q

How do you diagnose epidemic pleurodynia?

A
  • blood work, viral titers
65
Q

What are some intercostal neuralgias?

A
  • tabes dorsalis (neurosyphilis)
  • neoplasm
  • pott disease
  • neurofibromatosis
  • fracture callous
66
Q

What is nostalgia paresthetica?

A

sensory neuropathy involving one of the dorsal cutaneous rami of upper thoracic region

67
Q

What are the symptoms of nostalgia paresthetica?

A
  • pruritis
  • local dysesthesia
  • local hyperesthesia
  • local skin hyperpigmentation/hypo
68
Q

How do you treat nostalgia paresthetica?

A

Relieves 40% of pain

  • OMT
  • lidocaine patch
  • paravertebral nerve block
  • Botox
  • anticonvulsant
  • TENS
69
Q

What is referred pain?

A
  • sensed deep in tissues, not the skin surface
  • not reproducible
  • look for Chapman’s reflex
70
Q

What is Xiphalgia?

A
  • painful prominent xiphoid process

- xiphisternal arthritis

71
Q

What is Dercum disease?

A

“adipose dolorosa”

  • painful obesity
  • peripheral stretch neuropathy from weight of the rolls of fat
72
Q

What is Mondor disease?

A
  • thrombophlebitis of the thoracoepigastric vein

- palpate a vertical cord

73
Q

What are some chest wall deformaties?

A
  • rachitic rosary
  • pectus excavatum
  • pectus carinatum
  • Harrison grooves
  • barrel chest
  • lumps, bumps, depressions
74
Q

What is rachitic rosary?

A

malnourished infant

  • where cartilage joins the bony rib
  • cure the rickets, lumps go away,
  • just swelling
75
Q

What is pectus excavatum and etiology?

A
  • sternum is deeply indented
  • genetic
  • rickets
  • marfan syndrome
  • acquired from cobbler chest
76
Q

What is associated with pectus excavatum?

A
  • Mitral valve prolapse (get echocardiogram)
  • women (27%) - mycobacterium avium complex (TB-like disease)
  • severe type can cause cardiopulmonary compromise
77
Q

What is pectus carinatum? etiology?

A

Pigeon breast

  • genetic
  • rickets
  • Marfan syndrome
  • Congenital Heart Disease
  • Severe Kyphoscoliosis
78
Q

What is the etiology of Harrison Grooves?

A

lower rib cage flares out

  • genetic
  • rickets
  • Young pregnancy
  • Prune Belly Syndrome
  • Wilm’s tumor
79
Q

What is the etiology of the barrel chest?

A
  • genetic
  • kyphosis
  • pulmonary emphysema
80
Q

What are the causes for lumps, bumps, depressions?

A
  • malnutrition (anorexia nervosa, bulimia)
  • cardiac enlargement (bulging precordium, rib cage, sternum)
  • rickets
  • aortic aneurysm
  • neoplasm
  • abscess

OMM M1T3E5 (4 decks)

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