Thorax and Abdomen

1. Thorax and Abdomen Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C

2. 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

4. 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

5. Clinical Anatomy

6. 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

8. 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)

13. 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

15. 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

16. 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)

18. 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)

20. 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

22. 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

23. Clinical Evaluation

24. 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)

26. 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

28. 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

29. Inspection: Auscultation: Lungs: Inhalation – smooth unobstructed sound Absence: pneumothorax, collapsed lung Rales: pneumonia Abdomen: Gurgling noises (peristalsis) Clinical Evaluation

30. Palpation: Sternum: Manubrium, body, xiphoid process Costal cartilage and ribs: Palpate anterior to posterior Pain, crepitus, deformity Clinical Evaluation

31. Palpation: Spleen: Palpate for enlarged spleen under left rib cage Have patient raise arms above head Clinical Evaluation

32. Palpation: Kidneys: Location → under posterolateral portion of rib cage Right kidney rests more inferior than left Clinical Evaluation

33. 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

34. 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

35. Palpation: McBurney’s Point Location → one-third of way between right ASIS and naval Tenderness → may indicate acute appendicitis Clinical Evaluation

36. 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

37. 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

38. 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

39. Clinical Evaluation Quadrant Pain: Right Left

40. 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

41. 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

43. 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)

44. 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

45. 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)

46. 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

47. 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

49. 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

50. 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