OPP Final

_________ is the only bony attachment between the axial skeleton and the upper extremities

sternoclavicular joint

What is located anterior to the head of the ribs?

Sympathetic chain ganglia

sharp stabbing pains in the chest in children and younger adults

precordial catch syndrome

True ribs

1-7

attach directly to the sternum via costochondral cartilage

False Ribs

8-10

Attach via a synchondrosis to the costochondral cartilage of rib 7

Floating Ribs

11-12

Do not attach to sternum

typical ribs

3-9, sometimes 10

demifacets (10 has full facet)

atypical ribs

1, 2, 11, 12

The 2 facets on the head of the rib articulate with the ___________ on the body of ____________________________ and with the __________________ on the body of the vertebra above.

superior facet, its own vertebra, inferior facet

What’s the sympathetic innervation of the ribs?

T1-L2

What’s the parasympathetic innervation of the ribs?

OA, C1, C2

What nerve exits through the jugular foramen and contributes to the parasympathetic innervation to the ribs?

Vagus N.

Naming: Intercostal spaces are numbered according to the rib forming their

superior boundary

Ex) ICS 3 is between ribs 3 and 4

What is the order of the vessels within the costal groove?

VAN

1. vein

2. artery

3. nerve

Intercostal Neuralgia

• Intercostal Neuralgia - pain along the distribution of an intercostal nerve

  • Can be caused by somatic dysfunction

  • Intercostal neuralgia symptoms in the absence of structural rib dysfunctions should alert you to search for other causes of pain

    • Herpes zoster (Shingles)

    • Cord tumor

    • Inflammatory or neoplastic disease of thoracic viscera

Somatovisceral Reflex vs. Viscerosomatic Reflex

•Rib Cage somatic dysfunction can also cause visceral dysfunction by impinging on these sympathetic chain ganglia

-Somato - visceral reflex

•Visceral upset can also lead to musculoskeletal somatic dysfunction in the ribs or thoracic spine due to irritation of the sympathetic ganglia

-Viscero - somatic reflex

What are the attachments for the left and right crus?

Left crus- attaches to L1, L2

Right Crus- attaches to L1, L2, L3

When does lymph and blood flow more easily upwards?

During inspiration

Describe the diaphragmatic motion in regards to lymph.

As Diaphragm contracts and relaxes it milks the lymphatic channels enabling the lymph to move more freely into the thoracic duct

During inspiration, while there is negative intrathoracic pressure in the lungs, lymph and blood flows more easily upward into chest

Describe diaphragmatic motion in regards to inspiration and expiration.

• Inspiration:

  • Diaphragm contracts, flattening out

  • Ribcage expands in 3 planes

    • Vertical

    • Anterior-Posterior

    • Transverse Diameter

  • Creates negative intrathoracic pressure

  • Increases intra-abdominal pressure (organs pushed inferiorly)

  • Air more freely flows into lungs

  • Lymphatic and venous fluids flow from the body to the upper thoracic area

• Expiration:

  • Diaphragm relaxes, becoming a dome (forms a zone of apposition)

  • Increases intrathoracic pressure

  • Air forced out of lungs

At what points can diaphragmatic somatic dysfunction occur?

• ribs 6-12

• Thoracolumbar junction (T12-L1)

• Crura of Diaphragm

What nerve controls the diaphragm?

Phrenic

What muscles moves the rib superiorly producing rib cage expansion?

External intercostals

What are the accessory muscles involved in inspiration?

SCM & Scalenes

Attachments for Scalenes

Anterior and Middle → 1st rib

Posterior → 2nd rib

Pec Minor Attachment

coracoid process
ribs 3-5

Pectoralis Major Attachments

ribs 2-6

Serratus Anterior

Attaches to ribs 1-8/9

Latissmus Dorsi

With arm above head, activation of this muscle pulls ribs 11 & 12 superiorly and laterally

Serratus Posterior Superior

Originates on the spinous process of C7-T3 and inserts on ribs 2-5

Elevates ribs 2-5

What results from passive recoil of the lungs?

Quiet breathing

During active breathing what muscles depress and retracts the ribs?

Internal Intercostals

During active breathing what muscles forces the abdominal contents superiorly?

Rectus Abdominis

During active breathing what aids in forced expiration?

Internal and External Oblique abdominals

Quadratus Lumborum Attachments

•Pulls ribs 11 & 12 inferiorly

•Will also stabilize during inspiration

Latissimuss Dorsi aids in

expiration

Serratus Posterior Inferior Action

Depresses ribs 9-12

What ribs perform the pump handle action?

1-5

What ribs perform the bucket handle?

Ribs 6-10

What ribs perform the caliper function?

11-12

Ribs 11 and 12 assist by pulling the back of the diaphragm down  so they go out and down in inspiration

Describe the anterior and posterior effects of the pump handle motion.

-Inhalation

•Anterior aspect of rib moves superiorly (cephalad)

•Posterior aspect of rib moves inferiorly (caudad).

-Exhalation

•Anterior aspect of rib moves inferiorly (caudad)

•Posterior aspect of ribs moves superiorly (cephalad)

What plane of motion does the pump handle exist in?

predominantly saggital plane

Describe the motion of bucket handle ribs.

-Inhalation

•Ribs elevate and increase transverse diameter

-Exhalation

•Ribs depress and decrease transverse diameter

What plane of motion does the bucket handle exist in?

coronal plane

Describe the caliper motion of ribs.

-Inhalation

•Moves outward (laterally) and increases transverse diameter

-Exhalation

•Moves inward (medially) and decreases transverse diameter

What plane does caliper motion exist in?

Transverse plane

Somatic dysfunction usually characterized by a rib being held in a position of _______

when

Motion toward inhalation is more free

Motion toward exhalation is restricted

inhalation

Somatic dysfunction usually characterized by a rib being held in a position of ___________.

when

Motion toward exhalation is more free

Motion toward inhalation is restricted

Exhalation

Inhalation Rib Dysfunction

“Key Rib” is bottom rib in group

Associated with extension in thoracic spine

Its motion will stop early in expiration.

Pain with full expiration & may cause rapid shallow breathing

Prominently Anteriorly

Exhalation Rib Dysfunction

“Key Rib” is top rib in group

Associated with flexion in thoracic spine

Its motion will stop early in inspiration.

Difficulty taking a full breath in inspiration

Prominently posteriorly.

What diseases might cause an inhaled rib?

Obstructive Lung Disease; COPD, Emphysema, Chronic Bronchitis, Asthma

Pneumonia

What diseases might cause an exhaled rib?

Restrictive lung disease: Pulmonary fibrosis, Pneumonitis

Neuromuscular disorders

Pneumonia (coughing)

If pain increases when patient inhales indicates

exhalation rib somatic dysfunction

If pain increases when patient exhales indicates

inhalation rib somatic dysfunction

If right ribs have an increased 6th intercostal space (ICS), then at this point either rib 6 is ______ or rib 7 is ______.

inhaled, exhaled

If right ribs have a decreased 6th intercostal space (ICS), then at this point either rib 6 is ______ or rib 7 is ______.

exhalation, inhalation

Muscles used to treat ribs 1-12.

Rib 1: Anterior and middle scalene

Rib 2: Posterior Scalene

Ribs 3 – 5: Pectoralis Minor

Ribs 6 – 8: Serratus anterior

Ribs 9 – 10: Latissimus Dorsi

Rib 11 and 12: Quadratus Lumborum

What bones make up the thoracic inlet?

Consists of the manubrium of the sternum, the proximal clavicles anteriorly, the first ribs laterally and the body of T1-T4 posteriorly

What are the three osteopathic goals in regards to treating ribs and thoracic outlet?

1. Improve Ventilation Mechanics

2. Normalize Autonomics

3. Improve Lymphatics

What must be done first before any lymphatic treatment?

Thoracic Inlet

Majority of patients with TOS are between ________________ years of age.

20 and 50

____________ present with vascular TOS more often than adults.

Adolescents

What are risk factors that lead to TOS.

• Anatomic abnormalities (cervical ribs, prominent C7 transverse process, anomalous ligaments or bands)

• Acute trauma, especially automobile accidents

• Repetitive motion/stress injury, including occupational factors such as poor posture/prolonged computer use, and overhead athletic activities.

Thoracic Cavity Contents

Trachea, Esophagus

Boundaries of the Anatomic Thoracic Inlet

T1 vertebra – posterior

1st ribs and costal cartilages – laterally

Superoposterior border manubrium- anterior

What covers the thoracic Inlet?

Cervicothoracic (diaphragm) fascia

Sibson’s Fascia

What are the boundaries of the thoracic outlet?

Scapula, 1st rib, clavicle

What can be compressed through the scalene triangle as it travels through the neck?

1. Subclavian Artery

2. Subclavian Vein

3. Brachial Plexus

What are the three distinct locations that things may be compressed in the thoracic outlet?

Interscalene space: between the first rib and the anterior and middle scalenes

Costoclavicular space: between the first rib and the clavicle

Subcoracoid space: between the pectoralis minor muscle and the 3^rd-5^th ribs

_________ TOS involves compression of brachial plexus nerve roots (C5-T1)

Neurogenic

Lower plexus (C8-T1) is most often affected

_________ TOS involves compression of the subclavian artery

Arterial

Almost always associated with trauma or osseous abnormality (typically presence of a cervical rib)

Partial occlusion results in intimal injury, thrombosis, distal embolism, or post-stenotic dilatation, and aneurism

Complete occlusion rare

_______ TOS involves compression of the subclavian vein

Venous

Typically occurs in the costoclavicular space (between the first rib, costoclavicular ligament, and the subclavius tendon)

Commonly occurs in persons participating in physical activities involving repetitive arm and shoulder movements

Persistent trauma of repetitive arm movements injures the vein (inflammation, focal intimal fibrosis, stenosis, blood flow stasis)

Osseous Abnormalities associated with TOS.

• Cervical rib

• Prominent C7 transverse process

• Exostoses (benign bony growth extending outward from surface

• Trauma-related abnormalities (displaced first rib, callus from fracture, malunion of fracture, AC or SC joint injury or dislocation)

Soft Tissue Abnormalities associated with TOS.

• Hypertrophy of scalene muscles

• Fibrosis from trauma

• Atypical scalene anatomy

• Anomalous ligaments or bands

Tumors and Lymphadenopathy can also be associated with

TOS

Symptoms such as dermatomal pain, Neck Pain, Headaches, paresthesia, weakness, hand coldness, finger swelling, and/or color changes (due to overactive sympathetic nervous system, not ischemia) could point to a differential diagnosis of

Neurologic TOS

Symptoms such as Unilateral symptoms in extremity (typically), Pain in hand or arm (does not follow a dermatomal pattern), Coolness/pallor (arterial), Arm swelling and cyanosis (venous), Arm pain and heaviness could point to a differential diagnosis of

Vascular TOS

What provocative tests are used to diagnose TOS?

Adson, Wright, Halstead (Reverse Adson), Roo

What tests are used to confirm or rule out Neurogenic TOS?

Electrodiagnostic studies

Nonpharmacological interventions for TOS generally consist of ___________________

Nonpharmacological interventions generally consist of patient education, activity modification, and physical therapy

Pharmacological interventions for TOS generally consist of ___________________

Oral agents: NSAIDs, muscle relaxants, TCAs, SSRIs, anticonvulsants

Injections of anesthetic botulinum toxin type A, or steroids may be considered, but are reported to have varying levels of success

What are indications for operative management of TOS?

• Neurogenic TOS recalcitrant to 5-6 months of nonoperative management

• Symptomatic arterial TOS with evidence of arterial pathology

• Acute, chronic, or intermittent venous TOS.

What is Virchow’s Triad?

Virchow's triad refers to a set of three factors that are believed to contribute to the formation of blood clots (thrombus).

Adson’s Test

Radial pulse of the affected extremity is palpated and the patient’s arm is externally rotated and extended

The patient is then instructed to extend, rotate and side bend their head towards the affected side

The maneuver is held for 15-30 seconds while the clinician observes for onset of symptoms and obliteration of the pulse.

Halstead Maneuver (Reverse Adson)

Radial pulse of the affected extremity is palpated and the patient’s arm is externally rotated and extended

The patient is then instructed to extend, rotate and side bend their head away from the affected side

The maneuver is held for 15-30 seconds while the clinician observes for onset of symptoms and obliteration of the pulse.

Wright’s Test

Radial pulse of the affected extremity is palpated and the patient’s arm is abducted and extended (or arm is abducted and elbow is flexed)

The maneuver is held for 15-30 seconds while the clinician observes for onset of symptoms and obliteration of the pulse.

Roo’s Test

The upper extremity is held in the "stick-'em-up" position with the arms abducted and elbows flexed (both at 90°) for 3 minutes

Patient simultaneously and vigorously flexes and extends the fingers

Considered positive if the patient cannot complete the full 3 minutes.