Transcript Rib 1 - VCOMcc

Rib Review
Objectives
To review the basic function and anatomy of the
typical and atypical ribs
To review the manual diagnosis of somatic
dysfunction of the ribs
Review the Autonomic innervations
Dermatomes
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C5 – Clavicles
T4 – Nipples
T7 – Xiphoid process
T10 – Umbilicus
T12 – Inguinal or groin regions
Typical Ribs
• Ribs 3 to 9 are considered “Typical Ribs”
• They have:
1. Head that articulates with the
corresponding vertebra and the one
above.
2. Tubercle that articulates with the
corresponding transverse process
3. Neck
4. Angle
5. Shaft
Question #1
• A typical rib will have all of the following
landmarks EXCEPT?
• A) Tubercle
• B) Tuberosity
• C) Head
• D) Neck
• E) Angle
Two
demifacets
Articulate with:
•same vertebra
•the one above
Tubercle/facet for
articulating with
same numbered
transverse process
Costal groove - nerve and vessels
Question #2
• Which one of the following statements
concerning the thoracic vertebral attachments
of ribs 6-9 is true?
• A) Ribs 6-9 attach to T6-T10
• B) Ribs 6-9 attach to T6-T9
• C) Ribs 6-9 attach to T5-T9
• D) Ribs 6-9 attach to T5-T10
T5
COSTOVERTEBRAL
JOINTS
T6
COSTOTRANSVERSE
JOINTS
Thoracic Apertures: Inlet versus Outlet
 The thoracic cavity communicates with the neck and upper limb
through the superior thoracic aperture also known as the
(boney) thoracic inlet
 Trachea, esophagus, major vessels and nerves pass through
here
 Lymphatic drainage for the whole body drains into the venous
system immediately posterior to the medial end of the clavicle
and 1st rib
 Sibson’s fascia
 6.5 x 11 cm in the adult, sloping antero-inferiorly just like the ribs
do
Boundaries of Anatomic Thoracic Inlet:
 Posterior by T1 vertebra
 Laterally by medial margins of 1st ribs and costal cartilages
 Anteriorly by superior/posterior border of manubrium
Thoracic Inlet: Fascia
• The cervicothoracic (diaphragm) fascia covers the
thoracic inlet.
• It is the deep fascia of the scalenus muscle group
– Including variably fibrous bands, this fascia inconsistently includes
muscle fibers from scalenus minimus. This fascial covering of the
superior dome of the lung is also referred to as Sibson’s Fascia
(Grey’s Anatomy)
Thoracic Inlet & Outlet
Anatomical Thoracic
Inlet
• T1
• 1st Ribs
• Sternal Manubrium
Functional Thoracic
Inlet
• T1-T4
• Ribs 1 & 2
• Manubrium
Diaphragm
• Thoracic Cage Dimensions
– Vertical diameter
– Lateral diameter
– AP diameter
• Attachments
– Xiphoid process
– Lower six ribs
– L1,2,3
• Innervation
– C3,4,5 (Phrenic n.)
Diaphragmatic Function
• Pressure Gradients
– Inhalation
– Exhalation
• Venous Return
• Lymphatic Return
• Fascial Considerations
Lymphatics
• Extrapleural lymphatics
drain to intercostal
vessels, to axillary nodes
and then to the right or
left lymphatic duct
• Pleural sac and lung
tissues drain through the
pretracheal nodes and then
to the right lymphatic
duct.
Question #3
• Which of the following groups of ribs are
considered false?
• A) Ribs 1-8
• B) Ribs 7-10
• C) Ribs 6-10
• D) Ribs 8-10
• E) Ribs 7-11
Question #4
• Which of the following statements regarding
ribs 6-9 is true?
• A) All of the ribs are considered typical
• B) All of the ribs are considered typical except
rib 9
• C) All of the ribs are considered atypical
• D) All of the ribs are considered typical except
rib 6
Rib Groups:
Typical vs. Atypical
• “Typical” Ribs:
– Ribs 3-9
– All display both transverse
axis (pump handle) and AP
axis (bucket handle) motion
– Upper ribs prefer pump
handle
– Lower ribs prefer bucket
handle
• “Atypical” Ribs
– Ribs 1,2, 10, 11-12
Rib Groups:
True, False and Floating
• True ribs – 1-7
Ribs 1-7
• False ribs – 8-10
• Floating ribs – 11,12
Ribs 8-10
Ribs 11,12
Atypical Ribs
• Functionally ribs 1,2, 10, 11 and 12 are considered
atypical ribs
- Rib 1 is short, strong, and very curved
- Rib 2 is typical except for a large tuberosity that
allows it to attach to serratus anterior
- Rib 11 and 12 do no have tubercles and do not
attach to the sternum/costal cartilage
- Rib 10 is considered atypical because it only
articulates with only thoracic vertebrae 10.
Other Naming Conventions
• Anatomically, the typical Ribs can be divided into
three major groups:
• “True Ribs” – ribs 1-7 that articulate directly with the
sternum/manumbrium
• “False” or “Vertebral-Chondral Ribs” – ribs 8 thru 10
that merge into a single cartilaginous mass that
attaches to the sternum
• “Floating Ribs” – ribs 11 and 12 that do not
articulate with cartillage or bone anteriorly
Question #5
• Which of the following groups of ribs are
considered atypical?
• A) Ribs 1,2,3,11,12
• B) Ribs 1,2,3,12
• C) Ribs 1,3,12
• D) Ribs 1,2,11,12
• E) Ribs 1,2,12
Rib 1
• Type: Atypical
• Primary Motion:
Elevation and
Depression
• Muscles Used to Treat
Dysfunction: Anterior
Scalene and Middle
Scalene
Rib 2
• Type: Atypical
• Primary Motion:
Pump Handle
• Muscles Used to
Treat Dysfunction:
Posterior Scalene
Question #6
• Which one of the following statements concerning the
motion of ribs 6-9 is true?
• A) All of the ribs primarily move in a pump-handle motion
• B) All of the ribs primarily move in a bucket-handle motion
• C) All of the ribs move primarily in a caliper motion
• D) All of the ribs primarily move in a pump-handle motion,
except rib 9 which moves primarily in a bucket-handle
motion
• E) All of the ribs primarily move in a bucket-handle motion
except rib 6 which moves primarily in a pump-handle
motion
Pump Handle and Bucket Handle
Axes
– The angle between the spinous
process and the transverse process
(spinotransverse angle) decreases
as you move down the thoracic
spine
– When the more superior ribs
elevate, their movement expands
the ribcage in an A/P direction
• Pump handle  transverse
axis
– When the more inferior ribs
elevate, their movement expands
the ribcage in a lateral direction.
• Bucket handle  AP axis
Transverse Axis “Pump Handle” Motion
• Occurs more predominately in upper ribs
– Primarily Ribs 1-5
• Occurs around a functional transverse axis
– Axis passes through the posterior tubercle and the
head of the rib
• Increases AP diameter of rib cage
Pump Handle Motion
• As Inspiration occurs:
• Anterior Rib head moves
cephalad (superiorly)
• Posterior rib head moves
caudad (inferiorly)
Rib moving into inspiration in transverse “Pump Handle” axis
Rib moving into expiration in transverse “Pump Handle” axis
Resting Position
Inhalation
Bucket Handle Motion
• Occurs predominantly in the
lower ribs
– Primarily Ribs 6-10
• Occurs around a functional
anteroposterior (line AB) or
longitudinal axis
– Axis passes through the
posterior tubercle and the
anterior end of the rib
• Increases transverse
diameter of the rib cage
Bucket Handle Motion
• Anterior and posterior ends
of the axis act as pivots
• The rib shaft is the handle
of the bucket
• The intercostal space
separates during
inhalation and narrows
during exhalation
• motion is best palpated at
the mid-axillary line
Inhalation Somatic Dysfunction
• Think “Stuck in Inhalation”
– Rib is “stuck” in the inspiratory phase of the
respiratory cycle
– Anterior rib head has moved superiorly, while the
posterior head has moved inferiorly
– A group that doesn’t drop with exhalation
(inhalation SD) may be blocked by the most
inferior rib
Inhalation S/D: Rib(s) restricted in moving to exhalation position
Muscles Used for Inhalation Rib
Somatic Dysfunction
Muscle
Acts Upon
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….Ribs 1-2
….Ribs 3,4,5,(6)
….Ribs 6,7,8,9,10
….Ribs 9,10,11,12
….Rib 12 Indirectly
….Forced Exhalation
….Ribs 6-12
Scalenes
Pectoralis Minor
Serratus Anterior
Latissimus Dorsi
Quadratus Lumborum
Intercostales
Diaphragm
Muscles of Rib 1 & Rib 2
Muscles of Ribs 3 to 8
Muscles of Ribs 9 & 10
Muscles of Ribs 11 & 12
Question #7
• All of the following are secondary muscles of
respiration (during inhalation) except?
• A) Scalenes
• B) Pectoralis minor
• C) External intercostal
• D) Quadratus lumborum
• E) Latissumus dorsi
Exhalation S/D a.k.a. Expiratory Lesion
• Think “Stuck in Exhalation”
– Rib is “stuck” in the expiratory phase of the respiratory
cycle
– Anterior rib head has moved inferiorly, while the posterior
head has moved anteriorly
– a group that doesn’t rise with inhalation (exhalation SD) is
often due to most superior rib “pinning other down”
Exhalation S/D: Rib(s) restricted in moving to Inhalation position
Exhalation Somatic Dysfunction
Inhalation Somatic Dysfunction
Question #8
• In a pt with chest wall tenderness, rib 5 has
limited inhalation motion around an AP axis. The
best statement that describes the SD of rib 5 is?
• A) The shaft of rib 5 will approximate the shaft of
rib 4 at the mid clavicular line
• B) Rib 5 will feel more prominent anteriorly
• C) The shaft of rib 5 will approximate the shaft of
rib 6 in the mid-axillary line
• D) Rib 5 has a pump-handle exhalation SD
• E) The angle of rib 5 will feel more prominent
Caliper motion
• Primary motion of ribs 11
and 12
• Imagine that the left and
right ribs 11 and 12 are
your thumb and index
finger pinched together.
As you inhale they move
farther apart (unpinch),
and as you exhale, they
pinch together.
Treatment Tip
• When treating an inhalation somatic
dysfunction (“stuck in inhalation”)
– Treat the lowest rib of the group of ribs that is restricted
• When treating an exhalation somatic
dysfunction (“stuck in exhalation”)
– Treat the highest rib of the group of ribs that is restricted
Question #9 + 10
• A 25 y/o male comes to your office
complaining of R sided thoracic pain. The pain
started after a fall at work 1 week ago. The
pain is worse with maximum inhalation.
Motrin 4x per day helps. X-rays in the office
reveal no frx and the EKG shows normal sinus
rhythm. On exam, you notice that ribs 6-9 are
restricted with inhalation, therefore you
suspect a rib SD. Which of the following
statements correctly describes the dx and tx?
Question #9
• A) Inhalation SD and tx should be directed at
rib 9
• B) Exhalation SD and tx should be directed at
rib 9
• C) Inhalation SD and tx should be directed at
rib 6
• D) Exhalation SD and tx should be directed at
rib 6
Question #10
• Which muscle would be used to correct this
SD using ME
• A) Anterior scalene
• B) Posterior scalene
• C) Pectoralis minor
• D) Serratus anterior
• E) Latissimus dorsi
Rib Dysfunctions and the Nervous System
• Rib 1 dysfunction can compress the cervical plexus
– Thoracic outlet syndrome
• Each rib has a nerve associated with it
• The sympathetic chain ganglion lie anterior to the rib
heads
– What you treat with rib raising
Rib Dysfunctions and the Sympathetic
Nervous System
Thoracic Sympathetic Innervations
T1 – T4 ---T1 – T5 ---T2 – T7 ---T2 – T8 ---T11 – L2 ---T5 – T9 ----
T10 – T11---T11 – L2 ---T12
---T10 – T11---T12 – L1 ---T11 – L2 ----
Head and Neck
Heart
Lungs
Esophagus, Upper Extremities
Lower Extremities
Greater Splanchnic Nerve (ex. Stomach, part of the
Duodenum, Liver, Gallbladder, Spleen, part of the Pancreas)
Lesser Splanchnic Nerve (part of the Duodenum, Jejunum,
Ileum, part of the pancreas, Ascending Colon, Proximal 2/3
of the Transverse Colon)
Least Splanchnic Nerve (distal 1/3 of transverse colon,
Descending Colon, Sigmoid Colon, and Rectum)
Appendix
Kidneys, Upper Ureters
Lower Ureters
Bladder
Question #11
• Which OMT is the method of choice when
attempting to enhance arteriolar lung perfusion
and reduce autonomic hyperactivity associated
with pneumonia?
• A) The occipital decompression
• B) ME of C3-5
• C) The thoraco-abdominal diaphragm release
• D) HVLA to T2-4
• E) Rib raising
Osteopathic Treatment
Question #12
• In a pt with neck and upper thoracic pain, you
notice that the fifth cervical vertebrae is
extended and rotated right. Ribs 1-5 on the L
lag behind with deep inspiration. The thoracic
vertebrae, T1-5 have a lateral convexity to the
right. The transverse processes of these
vertebrae are posterior on the right, except for
T3 which has a posterior transverse process on
the L. Which of the following statements is
true regarding dx and tx.
Question #12
• A) The above pt has an exhalation SD, and initial tx should
be directed to rib 1
• B) T3 is SLRR and the pt would be asked to rotate their
torso to the right wen correction this SD using ME (direct)
technique
• C) The pt has an inhalation SD and HVLA thrust can be
directed at the rib angle of rib 5 to correct this SD
• D) C5 will resist translation to the right while the head is in
the flexed position. Therefore the head should be placed in
the flexed SL and RL position for a direct ME technique
• E) T1-5 are NSLRR. These vertebrae should be placed in R
sidebending and L rotation when using a direct tx
Question #13
• While examining a child, you notice a SD of rib 5 on the
right. The rib seems to lag with inhalation and move
easily into exhalation. Which of the following is the
best statement regarding the 5th rib?
• A) This pt will have limited cephalad motion of rib 5 at
the mid-axillary line
• B) This pt will have a TP in the pectoralis minor muscle
• C) This pt will display a winging of the scapula
• D) The 4th thoracic vertebrae is non-neutral SRRR
• E) The 4th thoracic vertebrae is non-neutral SLRL
Questions #14-15
• A 83 y/o female with severe COPD is having
dyspnea. You evaluate her costal motion with
deep breath while your hands are over her
chest wall. You find limited ROM of ribs 2-6
on the left during expiration. A 5 degree
levoscoliosis involving the T2-6 segments is
present
Question #14
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This type of palpatory assessment is called
A) Inherent respiration motion testing
B) Gross motion testing
C) Segmental motion testing
D) Vertebral motion testing
E) Passive motion testing
Question #15
• The most effective initial tx that would restore
costal motion would be directed at?
• A) Rib 2
• B) Rib 6
• C) Thoracic vertebrae – more correct
• D) Thoracic inlet
• E) Anterior scalene