THORACIC SPINE AND RIBS Orthopaedic tests and joint examination

RIBS
Joint examination: Observe for hyperkyphosis, sternal deformities, bruising, difficulty breathing. Rib excursion (upper and lower) palpate bilaterally over the rib angles and ask the patient to breath in; feel and observe for a difference in movement. Can try to determine if its held in in/expiration. Palpate for tenderness over rib angles and intercostal spaces, and costochondral joints, sternum, costal margin, xiphoid where applicable. Palpate the diaphragm and assess the pliability of the ribs. Orthopaedic tests: Fracture The most commonly fractured ribs are the middle ribs, 7 10. Rib one is rarely fractured because it is protected by the clavicle, but fractures of ribs 1 3 can cause damage to the neurovascular vessels to the arm. These injuries are more associated with head and arm trauma. In more severe cases the ribs may visibly flap or appear distorted. Procedure: Percuss the rib far from the suspected fracture site. Apply tuning fork on rib 3 4 inches from site of pain. If either aggravate the symptoms, consider referral for confirmation of fracture.

THORACIC SPINE
Joint examination: Observe for shape (including wedging), scoliosis, muscle tone, areas of facilitation, immobility. Passive examination is sitting, prone or supine. Especially relevant to scoliosis: check pelvic levels and for LLD. Orthopaedic tests: Adsons Test Adsons test is no longer considered a conclusive test for TOS, but it can be used to determine compression of the neurovascular bundle somewhere along its route. Procedure: 1. Check for presence of radial pulse. 2. Continue palpating it as you draw the arm into abducted extension (pectoralis). 3. Ask patient to turn head to ipsilateral side (scalenes). 4. Ask patient to take a deep breath in (rib). A positive result is definite diminishment or obliteration of the pulse. Fracture Test for point tenderness in the thoracic vertebra. Bear in mind that you cannot really rule fracture out, so if you truly suspect it, refer. Observing flexion for scoliosis Though pretty unreliable, one general rule is that if the curve is retained on flexion, it is a structural scoliosis.