Thoracic Spine & Rib Cage Pain Flashcards
(80 cards)
1
Q
What is the most part of the evaluation?
A
patient history
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
3
Q
What is the most important xray to obtain?
A
AP chest xray
4
Q
What do you have to include if there was trauma?
A
fracture, sprain, tendon tear, ligamentous rupture
5
Q
What causes pneumothorax?
A
- rib fracture
- asthma
- esophageal perforation
- exercise induced
- manipulative treatment
- spontaneous
- thoracic or cervical surgery
- tracheobronchial perforation
- ventilator (overinflated)
6
Q
What are the symptoms of rib fracture?
A
- pain is well localized
- pain is lancinating (sharp)
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
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
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)
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
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
12
Q
What is the history of fractured costal cartilage?
A
MVA from shoulder harness
13
Q
What is the symptoms of fractured costal cartilage?
A
- pain is well localized
- pain is lancinating (sharp)
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
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
16
Q
What is the history of cough fracture?
A
- bronchitis
- pneumonia
- interior is shattered in trabecular framework
17
Q
What are the symptoms of cough fracture?
A
- persistent pain at the level of the lower ribs posteriorly
- R11 or 12
18
Q
What are the vital signs of cough fracture?
A
- fever
- increased respiratory rate
19
Q
What is seen upon inspection of a cough fracture?
A
decreased diaphragmatic breathing
- pain with deep inhalation or coughing
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
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
22
Q
During evaluation, what does compression fractures of the spine cause?
A
acute angulation of kyphosis
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
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
25
What is cicatrix?
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)
26
What is post-polio syndrome?
- after polio contraction there is a new onset of weakness, fatigue, muscle fasciculations and pain with additional atrophy
- axons die early
27
What is scleroderma?
- skin becomes thickened and bound to underlying fascia
- Raynaud's phenomenon
- skin is tight and shiny
28
What are the musculoskeletal features of scleroderma?
- 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
29
What are the pulmonary features of scleroderma?
- exertional dyspnea
- dry, non-productive cough
- pulmonary fibrosis
- bibasilar rates
* restriction of chest movement by skin involvement
30
What are the cardiac features of scleroderma?
* pericarditis
- congestive heart failure
- cardiomyopathy
31
What are the renal manifestations of scleroderma?
* - malignant hypertension
- hematuria
- proteinuria
- oliguria
* renal failure
32
What are the diseases of osteoarthritis?
```
Spine - degenerative disc disease
- Zygapophyseal joint disease
Ribs - costotransverse joint
- chondrosternal joint
- chondrochondral joints
```
33
What are included in the spondyloarthropathies?
- ankylosing spondylitis
- psoriatic arthritis
- reactive arthritis associated with IBD
(Crohn's Disease, Ulcerative colitis)
- usually result in kyphosis
34
What is counterindicated in ankylosing spondylitis?
HVLA
| - get imaging first
35
What is Scheuermann's Disease?
- increased kyphosis
- rigid thoracic spine
- X-ray: irregular endplates, vertebral wedging
- show up in teen years
36
A lot of rib cage pain is somatic dysfunction. This means your orthopedic evaluation will be?
normal but there will be tenderness, asymmetry, restricted range of motion, texture
37
What are the physical finding of chest wall syndrome?
- diffuse pain with pressure over the sternum
- pain with shoulder motion
- pain with cervical spine motion and nerve root impingement tests
38
What are the symptoms of intercostal muscle spasm?
- sharp pain - lasts 1-3 minutes
- palpation - intercostal tenderness & firmness
- may be an associated rib dysfunction
- tenderness at serratus attachment
39
How do you treat intercostal muscle spasm?
- OMT
- intercostal nerve block
- trigger point injection
- medication (analgesic, muscle relaxant)
40
What is intercostal myositis?
more severe
- pain with respiration
- tender intercostal space
- induration (firm or hard swelling)
- fascial nodularity
41
What are treatments of intercostal myositis
- OMT- indirect technique
- NSAIDS
- corticosteroids
- corticosteroid injection is localized to small enough area
42
How do you differentiate costochondral pain from chondrosternal pain?
Chondrosternal - synovial
| costochondral - fibrous
43
What are the symptoms and physical findings of costochondral pain?
- pain in anterior chest wall
- tenderness at costochondral junction
- can be separated due to trauma
44
What is the treatment of costochondral pain?
- OMT - correct rib dysfunction
- counterstrain technique
- analgesic medication
- local corticosteroid injection
45
Where is pain referred with shoulder girdle disorders?
- from any shoulder girdle muscle attachment site
| - may refer pain to the rib cage
46
What is costochondritis?
- 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
What is the treatment for costochondritis?
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
What is Tietze syndrome?
- palpable fusiform swelling of costal cartilage
* usually asymmetric
- often involves 2 & 3rd costal cartilage
- can be post viral syndrome (parvovirus B19)
49
How would you treat Tietze?
OMT - thoracic pump and splenic stimulation to boost immune
- correct any accompanying costal and thoracic segment
- lidocaine patch
- NSAIDs
- Oral and IM corticosteroids
50
What infectious disease can cause respiratory pain?
- herpes zoster
- pleurisy
- epidemic pleurodynia
- osteomyelitis
- epidural abscess
- infectious chondritis
- periostitis
51
What is the most common rib cage problem?
Herpes Zoster
52
What are the signs for Herpes Zoster?
- dermatomal rash
- does not cross midline
- neuralgia before rash
- post-herpetic neuralgia
53
What are the symptoms of intercostal neuralgia?
tenderness occurs at the cutaneous branches of the intercostal nerve
- paraspinal
- parasternal
- mid-axillary
54
When is highest incidence of herpes zoster?
50-70
| Sixth to eighth decades
55
Which dermatomes are most likely affected with herpes zoster?
T3-L3 dermatomes
56
Describe the disease onset of herpes zoster.
- 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
What is treatment for herpes zoster?
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
What do you use for post-herpatic neuralgia?
anti-seizure meds: Gabapentin, topiramate, lamotrigine
59
What is pleurisy?
- fever, CBC - leukocytosis
- pleural friction rub
- knife like shooting pain
- parietal pleura is pain sensitive (visceral pleura is not)
60
What is the treatment for pleurisy?
- treat involved areas
| - improved costal motion to prevent pleural adhesions
61
Where would you feel pain if the pleural on the periphery of the diaphragm is involved?
- 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
What is epidemic pleurodynia?
| Devil's grip, The Grip
- severe paroxysms of thoracic and abdominal pain
- fever
- headache
- mild pharyngitis
- no leukocytosis
- Coxsackie B
63
What are the complications of epidemic pleurodynia?
- pericarditis
- orchitis
- may end up in hospital due to hypoxia
- CCU with Dx of R/O MI or dissecting aneurysm
64
How do you diagnose epidemic pleurodynia?
- blood work, viral titers
65
What are some intercostal neuralgias?
- tabes dorsalis (neurosyphilis)
- neoplasm
- pott disease
- neurofibromatosis
- fracture callous
66
What is nostalgia paresthetica?
sensory neuropathy involving one of the dorsal cutaneous rami of upper thoracic region
67
What are the symptoms of nostalgia paresthetica?
- pruritis
- local dysesthesia
- local hyperesthesia
- local skin hyperpigmentation/hypo
68
How do you treat nostalgia paresthetica?
Relieves 40% of pain
- OMT
- lidocaine patch
- paravertebral nerve block
- Botox
- anticonvulsant
- TENS
69
What is referred pain?
- sensed deep in tissues, not the skin surface
- not reproducible
- look for Chapman's reflex
70
What is Xiphalgia?
- painful prominent xiphoid process
| - xiphisternal arthritis
71
What is Dercum disease?
"adipose dolorosa"
- painful obesity
- peripheral stretch neuropathy from weight of the rolls of fat
72
What is Mondor disease?
- thrombophlebitis of the thoracoepigastric vein
| - palpate a vertical cord
73
What are some chest wall deformaties?
- rachitic rosary
- pectus excavatum
- pectus carinatum
- Harrison grooves
- barrel chest
- lumps, bumps, depressions
74
What is rachitic rosary?
malnourished infant
- where cartilage joins the bony rib
- cure the rickets, lumps go away,
- just swelling
75
What is pectus excavatum and etiology?
- sternum is deeply indented
- genetic
- rickets
- marfan syndrome
- acquired from cobbler chest
76
What is associated with pectus excavatum?
- Mitral valve prolapse (get echocardiogram)
- women (27%) - mycobacterium avium complex (TB-like disease)
- severe type can cause cardiopulmonary compromise
77
What is pectus carinatum? etiology?
Pigeon breast
- genetic
- rickets
- Marfan syndrome
- Congenital Heart Disease
- Severe Kyphoscoliosis
78
What is the etiology of Harrison Grooves?
lower rib cage flares out
- genetic
- rickets
- Young pregnancy
- Prune Belly Syndrome
- Wilm's tumor
79
What is the etiology of the barrel chest?
- genetic
- kyphosis
- pulmonary emphysema
80
What are the causes for lumps, bumps, depressions?
- malnutrition (anorexia nervosa, bulimia)
- cardiac enlargement (bulging precordium, rib cage, sternum)
- rickets
- aortic aneurysm
- neoplasm
- abscess
