Orthopaedic Assessments

THORACIC (DORSAL) SPINE

Agenda Introduction Applied anatomy Patient history Observation Examination Active ROM Passive ROM Isometric resisted ROM Special tests

Thoracic Spine - Introduction

-Most rigid part of the spine due to the ribs -Must include examination of the ribs as well as the areas above and below

Thoracic Spine - Introduction

-The thoracic spine serves to protect organs (ie. heart, lungs) -Primary curve – kyphosis -Lumbar and cervical spine are secondary curves (lordoses)

Thoracic Spine – Applied Anatomy

-The spinal canal is small and circular -Smallest at T1-3, largest at T12 -Facets are located on the TVPs and the bodies (costotransverse and costovertebral joints) -Superiorly to inferiorly, the TVPs reduce in size from large, wing-like structures to become more short and blunt

Thoracic Spine – Applied Anatomy

The SPs: -T1-3: are in the transverse plane as the same body and TVP -T4-6: project downward slightly and are on a plane halfway b/w their own TVP and TVP of vertebrae below -T7-9: project downward and are on a plane of the TVP below -T10: similar to T9 -T11: similar to T6 -T12: similar to T3

Thoracic Spine – Applied Anatomy

Thoracic Spine – Applied Anatomy

-T7 has the greatest spinous process angulation -Sometimes classified as a transitional vertebra b/c it is the point at which the lower limb axial rotation alternates with the upper limb axial rotation ie. Gait: axial rotation of the spine going from one side to the other during gait

Thoracic Spine – Applied Anatomy

Thoracic Spine – Applied Anatomy

COSTOVERTEBRAL JOINTS -b/w the ribs and vertebral bodies -24 joints -ribs 1, 10, 11 & 12 articulate with a single vertebra -ribs 2-9 articulate with two adjacent vertebrae and the intervening IVD

Thoracic Spine – Applied Anatomy

COSTOTRANSVERSE JOINTS -b/w the ribs and the TVPs of the vertebra of the same level for ribs 1-10 -ribs 11 & 12 do not articulate with the -TVPs so there is no costotransverse joint associated for ribs 11 & 12

Thoracic Spine – Applied Anatomy

Thoracic Spine – Applied Anatomy

COSTOCHONDRAL JOINTS -b/w the ribs and costal cartilages STERNOCOSTAL JOINTS -b/w the costal cartilage and the sternum

Thoracic Spine – Applied Anatomy

Transitional vertebrae -T1(facets are similar to that of the cervical spine) -T11-12 (facets are similar to that of the lumbar spine)

Thoracic Spine – Applied Anatomy

Facet Joints of the T-Spine
Resting Pos'n midway b/w flexion and extension extension side flexion and rotation equally limited, then extension

Close Packed Pos'n Capsular Pattern

Thoracic Spine – Applied Anatomy

The Ribs
-Articulate with the demifacets on vertebrae T2-9 -T1 & T10 possess a whole facet for ribs 1 & 10, respectively -Rib 1 articulates with T1 only -Rib 2 articulates with T1-2, Rib 3 articulates with T2-3, etc

Thoracic Spine – Applied Anatomy

Ribs 1-7 = TRUE RIBS (articulate with the sternum directly) Ribs 8-10 = FALSE RIBS (articulate directly with the costocartilage of the rib above) Ribs 11 & 12 = FLOATING RIBS (do not articulate to either the sternum or the costal cartilage at their distal ends)

Thoracic Spine – Applied Anatomy

At the top of the rib cage, the ribs are relatively horizontal As the rib cage descends, the ribs run more obliquely downward By rib 12, they are more vertical than horizontal

Thoracic Spine – Applied Anatomy

Thoracic Spine – Applied Anatomy

Thoracic Spine – Applied Anatomy

INSPIRATION: ribs are pulled upward and forward Increases the AP diameter of the ribs Ribs 1-6 – PUMP HANDLE -rotate about their long axes -during inspiration, they rotate upwards

Thoracic Spine – Applied Anatomy

Thoracic Spine – Applied Anatomy

Ribs 7-10 – BUCKET HANDLE -Increase in a lateral (transverse) dimension -With inspiration, they move upward, backward and medially Ribs 8-12 – CALIPER ACTION -Move laterally, to increase lateral diameter

Thoracic Spine – Applied Anatomy

Thoracic Spine – History

Review relevant section in Magee

Scheuermann's Disease
-Aka: Juvenile Kyphosis -Vertebral bone tissue dies causing kyphotic deformity -Cause: unknown -Boys more affected than girls

Thoracic Spine – History

Thoracic Spine – History

Spinal posture -Kyphosis -Scoliosis

Thoracic Spine – Observation

Thoracic Spine – Observation

KYPHOSIS -Most prevalent in the thoracic spine -May be visually fooled by the musculature or position of the scapulae into thinking there is excessive kyphotic curvature

Thoracic Spine – Observation

KYPHOSIS ROUND BACK: BACK -Thoracolumbar or thoracic kyphosis and decreased pelvic inclination (20°) -Secondary to prolonged postural stresses or growth disturbances (ie. Scheuermann's disease) that have altered the centre of gravity

Thoracic Spine – Observation

Thoracic Spine – Observation

KYPHOSIS HUMP BACK: BACK -Localized, sharp, posterior angulation = GIBBUS -Usually structural -Anterior wedging to one or two vertebral bodies -Pelvic inclination usually normal (30°)

Thoracic Spine – Observation

Thoracic Spine – Observation

KYPHOSIS FLAT BACK: BACK -Pelvic inclination decreased (20°) -Similar to round back except the T/S remains mobile -Although a kyphosis is or should be present, it does not have the appearance of an excessive kyphotic curve

Thoracic Spine – Observation

KYPHOSIS DOWAGER'S HUMP: HUMP -Secondary to postmenopausal osteoporosis -Osteoporosis causes anterior wedge fractures to several vertebrae, usually in the upper to middle thoracic spine

Thoracic Spine – Observation

Thoracic Spine – Observation

Thoracic Spine – Observation

SCOLIOSIS -One or more lateral curvatures to the thoracic and/or lumbar spine(s) -Structural vs. Non-Structural

Thoracic Spine – Observation

Structural Scoliosis -Structural change to the bone(s) of the spine with associated loss of normal flexibility -Vertebral bodies rotate towards the convexity of the curve
Genetics, idiopathic, congenital problem (wedge vertebra, hemivertebra, failure of vertebral segmentation)

Thoracic Spine – Observation

Non-Structural Scoliosis -No structural changes and is more amenable to correction -Poor posture, nerve root irritation, inflammation in the spine, LLI, hip contractual

Thoracic Spine – Observation

Scoliotic Curves -Designated according to the level of the apex of the curve and in relation to the convex side -Cervical scoliosis (aka. Torticollis), the apex is b/w C1-C6 -Cervicothoracic scoliosis, the apex is at C7 or T1

Thoracic Spine – Observation

Scoliotic Curves -Thoracic scoliosis, the apex is b/w T2T11 -Thoracolumbar scoliosis, the apex is at T12 or L1 -Lumbar scoliosis, the apex is b/w L2L4 -Lumbosacral scoliosis, the apex is at L5 or S1

Thoracic Spine – Observation

Scoliotic Curves Example: A right thoracic curve has a convexity toward the right (concavity is towards the left), and is in the thoracic spine.

Thoracic Spine – Observation

Scoliotic Curves -because the vertebral bodies rotate towards the convexity, in the thoracic spine, this rotation will cause the ribs on the convex side to push posteriorly -Rib “humping” -Thoracic cage narrows on the convex side

Thoracic Spine – Observation

Scoliotic Curves -Rotation of the vertebral bodies to the convexity causes the SPs to deviate towards the concavity -Ribs on the concave side move anteriorly causing Rib “hollowing” and the thoracic cage widens

Thoracic Spine – Observation

Thoracic Spine – Observation

-Observe how the patient sits -Sits tall or sags -Breathing pattern -Children tend to breathe abdominally -Women tend to do upper thoracic breathing -Men tend to be upper and lower thoracic breathers

Thoracic Spine – Observation

Chest Deformities Pectus Carinatum (pigeon chest) -Sternum projects forward and downward -Increases the AP dimension of the chest -Impairs breathing by restricting ventilation volume

Thoracic Spine – Observation

Thoracic Spine – Observation

Chest Deformities Pectus Excavatum (funnel chest) -Sternum is pushed posteriorly by an overgrowth of the ribs -AP dimension of the chest is decreased and the heart may be displaced -May result in kyphosis

Thoracic Spine – Observation

Thoracic Spine – Observation

Chest Deformities Barrel Chest -Sternum projects forward and upward so that the AP diameter is increased -Seen in pathological conditions such as emphysema

Thoracic Spine – Observation

Thoracic Spine – Examination

-Examination may include cervical spine, lumbar spine, pelvis, upper limbs and lower limbs -Active movements are usually performed with the client standing. -Watch for trick movements in the hips. If seeing a lot of cheating ... ... Performing the Active ROM in the sitting position would help decrease or eliminate hip involvement

Thoracic Spine – Examination

Active ROM Forward flexion 20° – 45° Extension 25° – 45° Lateral flexion 20° – 40° Rotation 35° – 50° Costovertebral expansion 3 – 7.5 cm Rib motion (pump handle, bucket handle, caliper) Combined, repetitive, & sustained movements and postures (if necessary)

Thoracic Spine – Examination

Forward flexion 20° – 45° -Can use a tape measure to attain an indication of overall movement -First measure the length of the spine from the SPs of C7 to T12 (normal standing posture) -Ask client to bend forward and measure again A 2.7cm (1.1”) difference is considered normal

Thoracic Spine – Examination

Forward flexion 20° – 45° -May also measure from the SPs of C7 to S1 -Ask client to bend forward and measure again A 10cm (4”) difference is considered normal Note: this measurement includes measuring movement in the L/S as well as in the T/S

Thoracic Spine – Examination

A third method: May also measure from the fingertips to the floor PROBLEMS: must be absolutely certain that you are isolating movement in the T/S (vs. the L/S and hips). With this method, movement could be occurring completely in the hips

Thoracic Spine – Examination

Active ROM (cont'd) -During forward flexion, observe for the spine from the “skyline” view -A non-structural scoliosis will disappear -A structural scoliosis will remain -Look for rib humping on the side of convexity and rib hollowing on the side of concavity -The thoracic spine should flex smoothly and evenly. Look for any apparent tightness or sharp angulation

Thoracic Spine – Examination

Extension 25° – 45° -May use a tape measure using the SPs of C7 and T12 A 2.5cm (1.1”) difference (standing) is considered normal -Thoracic curve should curve backward or straighten in a smooth, even manner -A client with excessive kyphosis will continue to demonstrate a kyphosis during extension

Thoracic Spine – Examination

-If uncertain as to whether or not the kyphosis exists during extension, have the client perform extension from the prone position Rotation 35° – 50° -Have client place hands on opposite shoulders -To eliminate hip involvement, may perform sitting

Thoracic Spine – Examination

Costovertebral expansion (method 1) -Therapist places tape measure around the chest at the level of the fourth intercostal space -Client is asked to exhale as much as possible, and therapist measures -Client is then asked to inhale as much as possible and hold the breath while the therapist measures Normal difference: 3-7.5cm (1-3”)

Thoracic Spine – Examination

Costovertebral expansion (method 2) -Same as method 1, except measurements are taken at (1) under the axilla (apical expansion) (2) nipple line (midthoracic expansion) (3) T10 rib level (lower thoracic expansion)

Thoracic Spine – Examination

Rib Motion -Client supine with therapist's hands placed in a relaxed fashion over the upper chest, middle chest and lower chest -If a rib stops moving relative to the other ribs on inhalation = DEPRESSED RIB -If a rib stops moving relative to the other ribs on exhalation = ELEVATED RIB

Thoracic Spine – Examination

Rib Motion ... -Restriction of one rib will restrict the adjacent ribs -If a depressed rib is the problem, it is usually the highest restricted rib that is the problem -If an elevated rib is the problem, it is usually the lower restricted rib that is the problem

Thoracic Spine – Examination

Passive ROM Forward flexion Extension Lateral flexion Rotation

tissue tissue tissue tissue

stretch stretch stretch stretch

Passive movements of the T/S are performed by assessing each pair of vertebrae

Thoracic Spine – Examination

Passive ROM -Client seated -Therapist places one hand on the head of client and the other palpates over and b/w the SPs of the lower cervical and upper thoracic spine (C5T3) -Feel for movement while guiding the head into flexion/extension/lateral flexion/rotation

Thoracic Spine – Examination

Passive ROM ... -For levels b/w T3 and T11, have client clasp hands behind head and the elbows together in front -Therapist: place one hand and arm around the client's elbows while palpating over and b/w the SPs -Feel for movement while guiding the torso into flexion/extension/lateral flexion/rotation

Thoracic Spine – Examination

Isometric Resisted ROM -Client seated -Test with spine in a neutral position -With a pillow between you and the client, wrap your arms around the client and place one leg behind the client's buttocks -Test for: flexion/extension/lateral flexion/ rotation

Thoracic Spine – Examination

SPECIAL TESTS Slump Test First Rib Mobility Test

Special Tests – Neurological Dysfunction SLUMP TEST (aka. Sitting Dural Stretch)

Thoracic Spine – Examination

-Series of steps performed sequentially -Only progress to the next step if no positive was elicited -Perform test: Start with non-affected side, then repeat on affected side, then repeat with both sides simultaneously. POSITIVE FINDING: Reproduction of the symptoms INDICATION OF: Dural, cord and/or nerve root impingement

Thoracic Spine – Examination

-Client seated at the edge of table with their hands behind their back -Ask client to “slump” the back into flexion -Therapist supports client's chin in the neutral position (no head or neck flexion) -Therapist applies gently overpressure across shoulders -Ask client to bring their “chin to chest”

Thoracic Spine – Examination

-Therapist again applies overpressure by placing hand over the head -With the other hand, therapist dorsiflexes client's foot maximally -Client is asked to actively straighten the knee as much as possible -If unable to extend knee, release overpressure to neck

Thoracic Spine – Examination

SPECIAL TESTS - Thoracic
First Rib Mobility Test (Method 1)
-Client supine: Palpate 1st rib, bilaterally -Note movements with deep breaths in -Palpate one side and passively side flex head to opposite side -Note range and movement -Asymmetry may be due to rib hypomobility or same side scalene tightness

SPECIAL TESTS - Thoracic
First Rib Mobility Test (Method 2) -Palpate rib with thumb -Reinforce thumb with other thumb. Place caudal force noting movement, end feel, pain -Test opposite side

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