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Thorax and Abdomen. Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C. Clinical Anatomy. Thorax – bone cavity Formed by 12 pairs of ribs that join posteriorly with the thoracic spine and anteriorly with the sternum Thoracic Cavity:

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thorax and abdomen

Thorax and Abdomen

Orthopedic Assessment III – Head, Spine, and Trunk with Lab

PET 5609C

clinical anatomy
Clinical Anatomy
  • Thorax – bone cavity
    • Formed by 12 pairs of ribs that join posteriorly with the thoracic spine and anteriorly with the sternum
  • Thoracic Cavity:
    • Lined with a thin layer of tissue (pleura)
    • One lung in each thoracic cavity
    • Mediastinum is between the chest cavity
      • Heart, Aorta, Superior and Inferior Vena Cava, Trachea, Major Bronchi, and Esophagus
    • Spinal cord – protected by vertebral column
clinical anatomy1
Muscles of Inspiration:

Diaphragm:

Separates thoracic and abdominal activities

Innervation: phrenic nerve

Inhalation – diaphragm contracts enlarging the thoracic cavity and reducing intra-thoracic pressure (air drawn into lungs)

Exhalation – diaphragm relaxes and air is exhaled by elastic recoil of the lungs

Clinical Anatomy
clinical anatomy3
Clinical Anatomy
  • Muscles of Inspiration:
    • Intercostal muscles:
      • External intercostal muscles: (outside of the ribcage)
        • Elevate the ribs and expand the transverse dimensions of the thoracic cavity (aid in quiet and forced inhalation)
      • Internal intercostal muscles: (inside the ribcage)
        • Depress the ribs decreasing the transverse dimensions of the thoracic cavity (aid in forced expiration)
    • Scalene muscles:
      • Elevate the 1st and 2nd ribs
    • SCM, trapezius, serratus anterior, pectoralis major/minor and latissimusdorsi (secondary muscles)
  • Muscles of Expiration:
    • Abdominal muscles (rectus abdominis, internal/external obliques, transverse abdominis
clinical anatomy4
Clinical Anatomy
  • Respiratory Tract Anatomy:
    • Trachea:
      • Connects larynx to 2 principle bronchi
      • Left bronchus → 2 segmental bronchi (2 lobes)
      • Right bronchus → 3 segmental bronchi (3 lobes)
    • Pleura:
      • Parietal pleura – lines thoracic wall
      • Visceral pleura – surrounds lungs
    • Alveoli:
      • Terminal branches of bronchioles
      • Gas exchange
      • Capillary system → blood exchanged (pulmonary arteries and veins)
clinical anatomy5
Clinical Anatomy
  • Digestive Tract Anatomy:
    • Esophagus:
      • Carries food/liquid to stomach
    • Small intestine:
      • Duodenum, jejunum, ileum
    • Large intestine:
      • Cecum, ascending colon, transverse colon, descending colon, sigmoid colon
    • Rectum and Anus
clinical anatomy6
Lymphatic Organ Anatomy:

Spleen:

Left upper quadrant (level of 9th-11th ribs)

Solid organ

Function:

Produce and destroy red blood cells

Blood reservoir

Increased risk of injury → mononucleosis

Clinical Anatomy
clinical anatomy7
Clinical Anatomy
  • Urinary Tract Anatomy:
    • Kidneys:
      • Filter blood
      • Regulate electrolyte levels:
        • Maintain balance of water, sodium, potassium
      • Location:
        • Posterior part of the abdominal cavity: (level of T12 – L3 vertebrae)
          • Right kidney: sits below the diaphragm and posterior to the liver; sits slightly lower than left kidney
          • Left kidney: sits below the diaphragm and posterior to the spleen
          • Note: Lower portion of kidneys susceptible to trauma (unprotected by ribs)
clinical anatomy8
Clinical Anatomy
  • Urinary Tract Anatomy:
    • Ureters:
      • Muscular ducts that propel urine from the kidneys to the urinary bladder
        • Length: 10-12 inches (adults)
    • Urinary Bladder:
      • Solid, muscular, and elastic organ
      • Collects urine excreted by the kidneys
      • Urine enters the bladder via the ureters and exits by urethra
    • Urethra:
      • Tube connects urinary bladder to outside the body
      • excretory function in both sexes (pass urine); reproductive function in males (passage for semen)
clinical anatomy9
Clinical Anatomy
  • Reproductive Tract Anatomy:
    • Testes:
      • Produce sperm and male sex hormones (testosterone)
    • Epididymis:
      • Coiled tube on posterior aspect of testes (stores sperm)
    • Ovaries:
      • Produce estrogen and progesterone and house reproductive eggs
    • Fallopian Tubes:
      • Tubules lead from ovaries to uterus
    • Uterus:
      • Accepts the fertilized ovum
clinical evaluation
Anatomy:

Abdominal cavity separated from the thorax by the diaphragm

Lined with a membrane (Peritoneum)

Lower portion of abdominal cavity: (Pelvic region)

Surrounded by pelvis, vertebrae, and sacrum

Clinical Evaluation
clinical evaluation2
Clinical Evaluation
  • History:
    • Location of Pain:
      • Musculoskeletal pain → ribs, costal cartilage, abdominal muscles (tender at injury site)
      • Injury to internal organs → diffuse pain; referred pain sites (Kehr’s sign)
    • Onset of Symptoms:
      • Gradual (internal bleeding can accumulate within cavity)
      • Pain ↑ with breathing (rib, abdominal injury)
    • Mechanism of Injury:
      • Direct blow (thoracic, abdominal, pelvic injuries)
clinical evaluation3
Clinical Evaluation
  • History:
    • Symptoms:
      • Pain, difficulty breathing
      • Diffuse abdominal pain
      • Nausea, dizziness
      • Vomiting of blood, blood in urine/stool
    • Medical History:
      • Not common (acute injury)
      • Exercise-induced asthma
      • Illnesses (mononucleosis)
    • General Medical Health:
      • Medications
clinical evaluation4
Inspection:

Start → observe patient’s posture

Throat:

Position of trachea and larynx

Breathing pattern:

Rate, respiration rate, depth, quality

Nail beds:

Capillary refill (cyanosis)

Inspection:

Muscle tone

Discoloration of skin:

Contusions, wounds, abrasion

Vomiting:

Presence of blood

Hematuria

Clinical Evaluation
clinical evaluation5
Inspection:

Auscultation:

Lungs:

Inhalation – smooth unobstructed sound

Absence: pneumothorax, collapsed lung

Rales: pneumonia

Abdomen:

Gurgling noises (peristalsis)

Clinical Evaluation
clinical evaluation6
Palpation:

Sternum:

Manubrium, body, xiphoid process

Costal cartilage and ribs:

Palpate anterior to posterior

Pain, crepitus, deformity

Clinical Evaluation
clinical evaluation7
Palpation:

Spleen:

Palpate for enlarged spleen under left rib cage

Have patient raise arms above head

Clinical Evaluation
clinical evaluation8
Palpation:

Kidneys:

Location → under posterolateral portion of rib cage

Right kidney rests more inferior than left

Clinical Evaluation
clinical evaluation9
Palpation: Liver

Method 1:

Place your fingers just below the costal margin and press firmly

Ask the patient to take a deep breath

May feel the edge of the liver press against or slide under your hand

Normal liver is not tender

Clinical Evaluation
clinical evaluation10
Palpation: Liver

Method 2:

Hands "hooked" around the costal margin from above

Instruct patient to breath deeply to force the liver down toward your fingers

Clinical Evaluation
clinical evaluation11
Palpation: McBurney’s Point

Location → one-third of way between right ASIS and naval

Tenderness → may indicate acute appendicitis

Clinical Evaluation
clinical evaluation12
Palpation: Abdomen

Rigidity:

Occurs secondary to muscle guarding or blood accumulation

Indication of internal injury

Rebound Tenderness:

Tests for peritoneal irritation.

Palpate deeply and then quickly release pressure

↑ pain = peritoneal irritation

Clinical Evaluation
clinical evaluation13
Palpation: Abdomen

Tissue density: Percussion

Patient position: hook-lying

Examiner: Lightly places one hand over abdomen (palm down); Index/middle fingers of opposite hand tap the DIP joints

Findings: (normal)

Solid organs have a dull thump

Hollow organs more resonant sound

Findings: (positive)

Hard, solid sounding echo over areas that should sound hollow

Internal bleeding

Clinical Evaluation
clinical evaluation14
Palpation: Percussion

Hollow Organs

Allow materials to pass through them (stomach, large intestine, small intestine, pancreas) or act as “holding tanks” (gall bladder and urinary bladder)

Less risk for injury when empty

Palpation: Percussion

Solid Organs:

Significant blood supply

Liver, Spleen, Pancreas, Kidney, Ovaries, Testes

Higher risk of injury

Bruising

Tearing

Clinical Evaluation
clinical evaluation15
Clinical Evaluation

Quadrant Pain: Right Left

clinical evaluation16
Vital Signs:

Heart Rate:

Pulse:

Regular / Irregular

Strong / Weak

Normal pulse is 60-100 beats per minute

Athletes tend to have a slower pulse than non athletes (well-conditioned strong heart)

Normal pulse is 60-100 beats per minute

Athletes tend to have a slower pulse than non athletes (40-60 bpm)

Abnormal:

Tacchycardia: > 100 bpm

Bradycardia: < 60 bpm

Clinical Evaluation
clinical evaluation17
Clinical Evaluation
  • Vital Signs: Blood Pressure
    • Patient position:
      • Seated or supine
    • Procedure:
      • Cuff secured over upper arm
      • Stethoscope placed over brachial artery
      • Inflate cuff to 180-200 mm Hg
      • Air slowly released
      • Note point at which 1st pulse sound is heard
      • Note point at which last pulse sound is heard
clinical evaluation18
Clinical Evaluation
  • Vital Signs: Blood Pressure
    • Affected by:
      • Decrease in blood volume (severe bleeding or dehydration) – Hypovolemic shock
      • Decreased capacity of vessels (shock)
        • Rapid/weak pulse; ↓ BP
      • Decreased ability of heart to pump blood
        • ↓ nutrients/oxygen to organs of body (anoxia)
clinical evaluation19
Vital Signs: Respiratory Rate

Normal: 12 – 20 bpm

Abnormal:

Rapid, shallow breaths:

Internal injury

Shock

Deep, quick breaths:

Pulmonary instruction

Asthma

Noisy, raspy breaths:

Airway obstruction

Clinical Evaluation
clinical evaluation20
Clinical Evaluation
  • Rib Fractures:
    • Most common injured:
      • 5th-9th ribs (anterior and lateral portions)
    • History:
      • Onset: acute (single traumatic blow)
      • Pain: over fracture site
        • ↑ pain with deep inspirations, coughing, sneezing, movement of torso
      • MOI:
        • Force (anteroposterior direction) – outward displacement
        • Force (lateral side) – inward displacement
          • Internal injury (i.e. lungs)
clinical evaluation21
Clinical Evaluation
  • Rib Fractures:
    • Inspection:
      • Splinting posture:
        • Holding the painful area to limit chest wall movement during inspiration
      • Discoloration / swelling
      • Shallow, rapid respirations (minimize chest movement)
    • Palpation:
      • Point tenderness, crepitus, possible deformity
    • Functional Tests:
      • Movement of torso causes pain
      • ↑ pain with deep respiration, coughing, sneezing
clinical evaluation22
Clinical Evaluation
  • Rib Fractures:
    • Stress Fractures:
      • Rowing, swimming, golf
      • Posterolateral portion of 4th-9th ribs
      • Causes:
        • Overtraining, sudden increases in training
        • Improper biomechanics
    • Special Tests:
      • Rib compression test:
        • Contraindicated in presence of obvious fracture/lung trauma
clinical evaluation23
Lateral Rib Compression Test:

Test position:

Subject supine

Action:

Examiner compresses the lateral aspect of the rib cage then quickly releases

Positive finding:

Pain with compression or release of pressure indicates possible rib fracture, contusion, or costochondral separation

Clinical Evaluation
clinical evaluation24
Anterior/Posterior Rib Compression Test:

Test position:

Subject supine

Action:

Compress rib cage anterior to posterior and quickly release

Positive test:

Pain with compression or release of pressure indicates possible fracture, rib contusion, costochondral separation

Clinical Evaluation
clinical evaluation25
Costochondral Injury:

MOI:

Overstretching the costochondral junction

Hyperflexion

Horizontal abduction

“Snap” or “pop” at time of injury

Symptoms:

Anterior pain (cartilage junction)

↑ pain with deep breathing, coughing, sneezing

Clinical Evaluation
clinical evaluation26
Clinical Evaluation
  • Pneumothorax:
    • Accumulation of air in pleural activity
    • Spontaneous pneumothorax:
      • Diagnosis dependent on signs/symptoms – rare condition
        • Chest pain, dyspnea, diminished breath sounds
        • Chest pain – usually localized to the side of the affected lung
          • Can radiate to shoulder, neck, back
      • Contributing Factors:
        • Family history, tall and thin body build
        • Sports-related spontaneous pneumothorax – documented in weight lifting, football, jogging
      • Primary spontaneous pneumothorax:
        • Primary cause: Bleb (imperfection in the lining of the lung) bursts causing lung to deflate
        • Tall thin men (ages 20-40)
      • Secondary spontaneous pneumothorax:
        • Chronic obstructive pulmonary disease (COPD)
clinical evaluation27
Pneumothorax:

Tension pneumothorax:

One-way valve is created from either blunt or penetrating trauma

Air can enter, CANNOT leave the pleural space

↑ Intrathoracic pressure will collapse the lung and ↑ pressure on mediastinum

Pressure will eventually collapse superior and inferior vena cava (loss of venous return)

Clinical Evaluation
clinical evaluation28
Pneumothorax:

Clinical Signs:

Apprehension / Agitation

Cyanosis

Diminished breath sounds

Distended neck veins / Tracheal deviation

Palpation:

Trauma induced – point tenderness

Vital Signs:

Labored, shallow respirations

BP drops rapidly

Clinical Evaluation

Right tension pneumothorax

clinical evaluation29
Hemothorax:

Blood enters the pleural space

Massive Hemothorax – at least 1500cc of blood loss into thoracic cavity

Penetrating injury

Can occur from blunt trauma

Blood accumulates → lung on the affected side is compressed

Mediastinum may shift away from hemothorax

Inferior and superior vena cava and contralateral lung may become compressed

Clinical Evaluation
clinical evaluation30
Hemothorax:

Clinical signs/symptoms:

Produced by hypovolemia and respiratory compromise

Anxiety, apprehension

Symptoms of hypovolemic shock

Decreased breath sounds or absence at injury site

Flat neck veins

Clinical Evaluation
clinical evaluation31
Clinical Evaluation
  • Spleen Injury:
    • History:
      • Acute (symptoms may take a few hours to develop)
      • Pain:
        • Upper left quadrant
        • Kehr’s sign – pain in upper left shoulder
      • Predisposing conditions:
        • Mononucleosis:
          • ↑ mass, ↓ elasticity
    • Inspection:
      • Impact site – contusion
      • Nausea and vomiting
clinical evaluation32
Clinical Evaluation
  • Spleen Injury:
    • Palpation:
      • Cold and clammy skin (shock)
      • Pont tenderness
      • Rebound tenderness
      • Distention in upper left quadrant
    • Functional Tests:
      • Kerh’s sign
      • Low blood pressure
clinical evaluation33
Clinical Evaluation
  • Kidney Pathologies:
    • Contused/Lacerated Kidney:
      • History:
        • Onset: acute
        • Pain: posterolateral portion of upper lumbar and lower thoracic region
        • MOI: blunt trauma or penetrating injury to kidney
      • Inspection:
        • Contusion or laceration
        • Hematuria:
          • Severe bleeding → noticeable blood
          • Laboratory analysis needed
        • Signs/symptoms of shock
clinical evaluation34
Clinical Evaluation
  • Kidney Pathologies:
    • Palpation:
      • Point tenderness
      • Abdominal rigidity
    • Functional Testing:
      • Pain with urination
    • Laboratory Testing:
      • Hematuria
clinical evaluation35
Kidney Stones:

Collection of incomplete kidney filtration

Crystals of uric acid, calcium

1mm – 2.5 cm

Causes:

Family history, stress, diet

Signs:

Pain with urination

Pain (stone passed from bladder through urethra)

Clinical Evaluation
clinical evaluation36
Clinical Evaluation
  • Urinary Tract Infections:
    • Bacterial infections of bladder or urethra
    • Similar signs/symptoms of kidney stones
    • Dysuria → frequent need to urinate
    • Hematuria (abnormal urine color)
  • Urethritis:
    • Inflammation of urethra
    • Causes: chlamydia, gonorrhea, syphilis
    • More common in males
clinical evaluation37
Appendicitis and Appendix Rupture: Anatomy

Location: Lower Right Quadrant of Abdomen

Elongated tube connected to the cecum (pouch-like structure of the colon)

Function of the human appendix is unknown

Considered to be a remnant of a portion of the digestive tract which was once more functional and is now in the process of evolutionary regression

Clinical Evaluation
clinical evaluation38
Appendicitis:

Cause:

Inflammation caused by fecal obstruction, lymph swelling, tumor

High incidence in males (ages 15 – 25)

If bursts can bleed into peritoneal cavity and cause bacterial infection

Signs and Symptoms:

Mild to severe pain in lower abdomen

Nausea, vomiting, fever, cramping, abdominal rigidity, point tenderness

McBurney’s Point – betweenASIS and umbilicus

Clinical Evaluation
clinical evaluation39
Clinical Evaluation
  • Hollow Organ Rupture:
    • Blunt trauma (non-rupture): able to absorb forces (deform/return to original shape without permanent injury)
    • Rupture:
      • Can be fatal (secondary to hemorrhage, peritoneal contamination)
    • MOI and Signs/Symptoms:
      • Blow to abdomen
      • Abdominal pain, possible nausea
      • Palpation reveals guarding, rigidity, tenderness (point, rebound)
      • Bowel sounds are absent (auscultation)
      • Blood in stool
clinical evaluation40
Clinical Evaluation
  • Gastritis:
    • Inflammation of stomach lining
      • Causes:
        • Aspirin or anti-inflammatory medications
        • Alcohol
        • Infection, bile entering stomach
  • Esophageal Reflux:
    • Backflow of gastric juices into esophagus
      • Heartburn, regurgitation of stomach acid
      • Ulcer-like pain
  • Intestinal Ulcers:
    • Irritation of duodenum (peptic ulcer)
      • Abdominal pain, nausea, vomiting, dark stools, fatigue
    • Causes:
      • Bacteria
      • Long-term use of aspirin or anti-inflammatory medications
slide68

Clinical Evaluation

  • Dyspepsia:
    • Pain in upper abdomen
    • Common causes: Gastroesophageal reflux disease (GERD), stomach ulcers
      • GERD – stomach acid splashes out of upper valve onto walls of esophagus
        • Burning pain in mid-upper abdomen / heartburn
      • Stomach Ulcers – wounds in lining of stomach
        • Common causes: Stress, virus, diet
        • Potential for bleeding if ulcers go untreated (open wounds)
clinical evaluation41
Clinical Evaluation
  • Colitis:
    • Inflammation of the large intestine
      • Symptoms:
        • Frequent diarrhea
        • Abdominal pain, increased bowel sounds, fever, painful defecation, nausea, vomiting
      • Causes:
        • Disease, irritation of bowel, ulcers, ischemia, bacteria, stress
  • Regional Enteritis (Crohn’s Disease):
    • Affects the ileum
    • Produces LRQ pain, cramping
  • Irritable Bowel Syndrome:
    • Alters motility of the muscles of large intestine
    • Alternating bouts of diarrhea and constipation
    • Abdominal pain
    • Gas build-up, nausea, vomiting
clinical evaluation42
Testicular Contusion:

MOI: Direct blow

Inspection:

Patient instructed to inspect for normal size/consistency

Ruptured testicle – soft, inconsistent texture

Testicular Torsion:

Spermatic cord and testicle twisted within scrotum

Symptoms:

Acute testicular pain, swelling, tenderness

Note: Immediate referral needed

Clinical Evaluation
clinical evaluation43
Clinical Evaluation
  • Menstrual Irregularities: (associated with physical activity)
    • Female Athlete Triad:
      • Combination:
        • Disordered eating
        • Amenorrhea
        • Osteoporosis
      • Disorder that often goes unrecognized
        • Lost bone mineral density
        • Premature osteoporotic fractures
        • Lost bone mineral density may never be regained
clinical evaluation44
Clinical Evaluation
  • Female Athlete Triad:
    • Disordered Eating:
      • Anorexia, Bulimia, ENDOS
    • Amenorrhea:
      • Related to athlete training/weight fluctuation is caused by changes in the hypothalamus
      • Result: Decreased levels of Estrogen
      • Primary Amenorrhea:
        • No spontaneous uterine bleeding:
          • By the age of 14 without development of 20 sexual characteristics
          • By the age of 16 with otherwise normal development
clinical evaluation45
Clinical Evaluation
  • Female Athlete Triad:
    • Amenorrhea:
      • Secondary Amenorrhea:
        • 6-month absence of menstrual bleeding in a woman with primary regular menses
        • 12-month absence with previous oligomenorrhea
    • Osteoporosis:
      • Loss of bone mineral density and inadequate formation of bone
      • Premature osteoporosis:
        • Risk for stress fractures
        • Fx of hip, vertebral column