Thoracic Spine and and Rib cage part 1

Question 1

How many patients will present will chest wall pain who have a myocardial infarction?

Answer 1

15%

Question 2

If there an absence of breath sounds on the right side what test should be done and what does that entail?

Answer 2

Coin test
Place flat coin on anterior of chest wall and strike it with a second coin
Places the chest piece of the stethoscope to the back of the same hemithorax

Question 3

What will be heard in the coin test in pneumothorax?

Answer 3

Clear ringing sound called Bell Tympani

Question 4

What is important x-ray to obtain in thoracic pain?

Answer 4

Chest (not ribs)

Question 5

What is one of the first question to ask a pt with a new symptom of chest pain?

Answer 5

Did this arise spontaneously or as a result of an injury?

Question 6

What are some etiologies of pneumothorax?

Answer 6

Asthma, esophageal perforation, exercise induced, manipulative treatment, rib fracture, spontaneous, thoracic or cervical surgery, tracheobronchial perforation, ventilator

Question 7

What are some symptoms of a rib fracture?

Answer 7

Pain is well localized to site of fracture

Pain lancinating

Question 8

What should be palpated in a rib fracture?

Answer 8

Careful palpation in indication of pain
Use layer by layer approach
Careful not to touch site of elicited tenderness

Question 9

What should be auscultated in a rib fracture?

Answer 9

Heart (pericardial friction rub)
Lungs
Chest wall (listen at pain site, pleural friction rub, fracture crepitance)

Question 10

What are the auscultation findings (pneumothorax) for a rib fracture?

Answer 10

Inaudible breath sounds
Inaudible spoken voice
Bell Tympani
Crepitance (at pain site)

Question 11

What are the physical findings for palpation in a rib fracture?

Answer 11

Exquisite local tenderness

Palpable crepitance

Question 12

What are the physical findings in motion induction for a rib fracture?

Answer 12

Pain at fracture site with remote pressure on rib cage

Question 13

What are the appropriate test for a rib fracture?

Answer 13

Chest x-ray (looking for pneumothorax)

Rib x-ray (look for fracture)

Question 14

What is the treatment for a rib fracture?

Answer 14

OMM done to the opposite side of the fracture and diaphragm to max remaining pulmonary function (C3-C5 dysfunction)
Bracing - rib belts not needed for fracture healing but can control pain

Question 15

What is the medication treatment for a rib fracture?

Answer 15

Analgesic

May require an opiate (but can suppress a respiratory function)

Question 16

Should an injection treatment be used for a rib fracture?

Answer 16

No

Question 17

What are chest injuries due to trauma?

Answer 17

Rib fracture
Fractured costal cartilage
Seperated costal cartilage
Subperiosteal hematoma 
Rib tip syndrome
Cough fracture

Question 18

What should you look for in a fractured costal cartilage history?

Answer 18

Common injury in MVAs and the seat belt

Question 19

What are the symptoms of a fractured costal cartilage?

Answer 19

Pain is well localized to site of fracture

Pain is lancinating or stabbing

Question 20

What are the physical findings like is a fractured costal cartilage?

Answer 20

All the same as rib fracture except in palpation there may be signs of hepatic or splenic enlargement or tenderness
(hepatic or splenic ruputre - tachycardia, hypotension, hypothermia)

Question 21

What are the appropriate tests to do for a fractured costal cartilage?

Answer 21

Chest x-ray (pneumothorax)
Rib x-ray not indicated
Bone scan (inc radionuclide at fracture site)
Peritoneal lavage (only for hepatic or splenic injury - use MRI if possible)

Question 22

What treatments should be used for a fractured costal cartilage?

Answer 22

The same as rib fracture

Question 23

What should be seen a history of a cough fracture?

Answer 23

Bronchitis or pneumonia

Question 24

What are the symptoms of a cough fracture?

Answer 24

Persistent pain at level of the lower ribs posterior (most commonly)

Question 25

What would you find a vital signs and inspection of someone with a cough fracture?

Answer 25

Fever Rapid respiratory rate Dec diaphragmatic breathing

Question 26

What would you find in the auscultation of pneumonia in a cough fracture?

Answer 26

Early - suppressed breathing sounds | Late - bronchial breathing and crepitant rales

Question 27

What would you find in the auscultation of bronchitis in a cough fracture?

Answer 27

Sibilant (hissing) Sonorous (ringing) Moist rales

Question 28

Would would be palpated and percussed in person with a cough fracture

Answer 28

Tender of involved rib(s) Often R11/R12 Percussion of pneumonia (dullness) or bronchitis (no dull)

Question 29

What occurs in motion induction in a cough fracture?

Answer 29

Loss of thoracic and rib motion Pain with deep inhalation/cough Restricted diaphragmatic breathing

Question 30

What are the appropriate test for a cough fracture?

Answer 30

Chest x-ray (pneumonia) Rib x-ray not indicated Bone scan (demonstrates stress fracture) MRI hard to get floating ribs

Question 31

What is the OMM treatment for cough fracture?

Answer 31

Indirect myofascial release technique only | Counterstrain technique cannot be used here due to bone pain

Question 32

How should the underlying condition of the cough fracture be treated?

Answer 32

Antibiotic Mucolytic Cough Suppressant

Question 33

How would a cough fracture be evaluated?

Answer 33

Pulmonary - look for consolidation | Spinous process - pain elicited could be a red flag for fracture, tumor or infection

Question 34

What does a compression fracture of the spine lead to?

Answer 34

Acute angulation of the kyphosis

Question 35

What would be seen in the evaluation in motion induction of a cough fracture?

Answer 35

Active Regional Range of Motion Passive Regional Range of Motion Respiratory Motion (3 inches deeps with inhalation)

Question 36

What are some conditions associated with loss of motion?

Answer 36

``` Cicatrix (scarring) Calcification of the Costal Cartilages Atrophy or Myopathy Connective Tissue Disease Osteoarthritis Spondyloarthropathies Scheuermann Disease Somatic Dysfunction ```

Question 37

What are some causes of cicatrix?

Answer 37

``` Burns Surgical Scars Adhesions Lacerations For all of these, if problematic, area of scar will be less mobile than all tissues around it ```

Question 38

Where would you see atrophy or myopathy?

Answer 38

Post-polio syndrome (Insidious onset) Onset of weakness, fatigue, muscle fasciculations, and pain with additional atrophy of the muscle group involved during the initial paralytic disease 20-30 years earlier

Question 39

What would bee seen in the connective tissue disease scleroderma?

Answer 39

``` Raynaud’s Phenomenon Puffy Fingers Edema is often accompanied by erythema Skin becomes thickened, and bound to the underlying fascia Skin becomes tight and shiny ```

Question 40

What are the musculoskeletal features of scleroderma?

Answer 40

Pain swelling and stiffness of fingers and knees Symmetric polyarthritis Thickening of tendon sheaths - carpal tunnel Resorption of bone (ribs and clavicle)

Question 41

What are the pulmonary features of scleroderma?

Answer 41

``` Exertional Dyspnea Dry, non-productive cough Pulmonary Fibrosis Bibasilar rales Restriction of Chest movement by skin involvement ```

Question 42

What are the cardiac features of scleroderma?

Answer 42

Pericarditis Congestive Heart Failure Cardiomyopathy

Question 43

What are the renal manifestations of scleroderma?

Answer 43

``` Malignant Hypertension Hematuria Proteinuria Oligouria Renal Failure ```

Question 44

What can occur in the spine in osteoarthritis?

Answer 44

Degenerative Disc Disease | Zygapophyseal Joint Disease

Question 45

What can occur in the ribs in osteoarthritis?

Answer 45

Costotransverse Joint Chondrosternal Joint Chondrochondral Joints

Question 46

What are some spondyloarthropathies?

Answer 46

Ankylosing Spondylitis Psoriatic Arthritis Reactive Arthritis Associated with Inflammatory Bowel Disease (Crohn Disease, Ulcerative Colitis)

Question 47

What are some characteristics of scheuermann disease?

Answer 47

Increased Kyphosis Rigid Thoracic Spine Characteristic X-ray Findings (Irregular endplates, Vertebral Wedging)

Question 48

What are the characteristics of chest wall syndrome (precordial catch)?

Answer 48

``` Intercostal muscle spasm Intercostal myositis Costochondral Pain Costal Somatic Dysfunction Shoulder Girdle Disorders ```

Question 49

What are the physical findings for chest wall syndrome?

Answer 49

Diffuse pain with pressure over the sternum Pain with shoulder motion Pain with Cervical Spine motion and nerve root impingement tests

Question 50

What occurs in intercostal muscle spasm?

Answer 50

Sharp pain lasting one to three minutes Intercostal tenderness and firmness May be associated rib dysfunction Often tenderness at serratus anterior

Question 51

What is the treatment for intercostal muscle spasm?

Answer 51

Osteopathic Manipulation Intercostal nerve block Trigger Point Injection Medication (Analgesic, Muscle Relaxant)

Question 52

What is the main symptom of intercostal myositis?

Answer 52

Pain with respiration

Question 53

What should be palpated for in intercostal myositis?

Answer 53

Tender intercostal space Induration (firm) Fascial nodularity

Question 54

What is the treatment for intercostal myositis?

Answer 54

OMT indirect Anti-inflammatory medication (NSAIDs, corticosteroid) Injection

Question 55

Describe shoulder girdle disorders

Answer 55

Pain may be referred from any shoulder girdle muscle attachment sites; also trigger points within the shoulder muscles may refer pain to the rib cage