Download OMM 2- Thoracic Rib and Chest Wall SD Function of Ribs and Sternum

OMM 2- Thoracic Rib and Chest Wall SD
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Function of Ribs and Sternum
Respiration
Protection of vital organs
Pump for venous and lymphatic return
Support structure for the upper extremities
Embryology
The sternum develops independently in somatic mesoderm in the ventral body wall
Two sternal bands are formed on either side of the midline and later fuse to form cartilaginous models of the
manubrium, sternebrae, and xiphoid process
Sternum Anatomy
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Manubrium
Sternal Notch
 Anterior to T2
Angle of Louis
 Articulation of second rib
 Synchondrosis
 Anterior to T4
Gladiolus (Body)
Xiphoid Process
 Joint is anterior to T9
OMM 2- Thoracic Rib and Chest Wall SD
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Rib Nomenclature
True ribs: 1-7: Attach directly to the sternum via costochondral cartilage
False ribs: 8-10: Attach via a synchondroses to the costochondral cartilage of rib 7
Floating: 11-12: Do not attach to the sternum at all
Typical ribs (3-9) will have all of the following anatomical landmarks
 Tubercle- articulates with corresponding transverse process
 Head- articulates with corresponding and immediately superior vertebrae via demifacets
 Neck- between tubercle and head
 Angle- beginning of anterior curve, 5-6 cm lateral to head
 Shaft- AKA the body, contains costal grove inferiorly
Atypical ribs
 Rib 1 - articulates only with T1, has no angle and no costal groove
 Rib 2 – atypical because of large tuberosity on shaft for serratus anterior and lack of costal groove
 Rib 10 – atypical because articulates with corresponding vertebrae only
 Ribs 11,12 – articulates only with corresponding vertebrae and lack of tubercles (articulation laterally
with the vertebrae)
OMM 2- Thoracic Rib and Chest Wall SD
Rib Articulations
Costochondral
 Rib 1: Synchondrosis (non-synovial)
 Ribs 2-7: Synovial articulations
Posterior
 Three articulations
 Costotransverse joint
 Superior costovertebral joint (inferior costal facet)
 Inferior costovertebral joint (superior costal facet)
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Rule of Three’s
Rule of Threes – approximates the positions of the thoracic spinous processes in regard to the transverse
processes
T1-3—equal (SP compared to TP)
T4-6—1/2 level up
T7-9—1 level up
T10-12—Reverses each level
Muscles of Inspiration
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Principal
 Intercostalis int. & ext.
 Diaphragm
 Breathing takes up to 50% of your caloric expendature every day. Good function of these muscles, rib
and vertebral mechanics is vital to the efficiency of your respiration. Thus the importance of this area in
OMT
OMM 2- Thoracic Rib and Chest Wall SD
Diaphragm
 Central tendon makes up most of the horizontal aspect of the muscle
 Actual muscular portion of diaphragm is oriented vertically
 Efficient contraction relies on using the abdominal viscera as a fulcrum and the verticality of the muscle in
relation to the chest wall as a lever
Major Accessory muscles activated with inhalation
 Anterior and posterior serratus
 Serratus Anterior
Origin: outer aspects of upper 8 to 10 ribs
Inserts: anterior surface of vertebral (medial border of scapula
Action draws scapula forward & laterally; rotates scapula in raising arm
 Serratus Posterior
 External intercostals
 Levatores Costarum
 Sternocleidomastoid Muscle
 Attaches to clavicle & sternum from the base of the occiput/mastoid
 Scalenes
 Attaches from the cervical spine to the first two ribs
 Scalenus anterior
Origin: transverse process of 3rd to 6th cervical vertebrae
Inserts scalene tubercle of 1st rib
Raises ist rib bends neck forward and rotates to opposite side
 Scalenus Medius
Origin: TP of ist 6 cevical vertebra;
Inserts upper surface of 1st rib
Raises 1st rib bends neck to same side
 Scalenus Posterior
Oriigin: transverse process of 4th to 6th rib
Inserts: outer aspect of 2nd rib
Raises 1st & 2nd rib bends neck to same side.
 Scalenus Minimus
Origine tp 7th cerv vertebrae
Inserts 1st rib & Pleura
Tenses dome of the pleura
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Muscles of Exhalation
Active breathing
 Intercostalis int.
 Rectus abdominis
 Obliques, int. & ext.
 Transversus abdominis
Quiet breathing
 Results from passive recoil of the lungs
Rectus Abdominis
 Origin: crest & symphysis of pubis
 Inserts:xiphoid process; 5th to 7th costal cartilages
 Action: tenses abdominal wall, flexes vertebral column;
draws thorax downward
OMM 2- Thoracic Rib and Chest Wall SD
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Intercostal Muscles
External lower border of one rib to upper border of rib below
Draws ribs together
Internal lower border of rib; costal cartilage inserts
Upper border of rib and costal cartilage below
Draws ribs together
Intimi
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Internal surface of superior border of rib
Inserts internal surface of inferior border of rib above
Draws ribs together.
Latissimus Dorsi
Origin: Sp of Vertebrae T7 to S3, thoracolumbar fascia, iliac crest, lowere four ribs inferior angle of
scapula
Inserts: floor of intertubercular of humerus in bicipital groove
Adducts, extends, rotates arms medially.
Mechanical pump—fluid model
Pressure gradient between the thoracic and abdominal cavities allow lymphatic and venous fluids to flow from
the body to the upper thoracic area.
Contraction of muscles and pulsation of arteries also helps to propel lymphatic fluids
The diaphragm has been shown to play an important role in lymphatic absorption from the peritoneal cavity
Costal Lymphatics
 Parasternal (internal thoracic) lymph nodes
 Intercostal lymph nodes
 Diaphragmatic lymph nodes
Costal Nerves
 Intercostal nerves
 Lie on inferior portion of rib in the costal groove
 Derived from the sympathetic chain ganglia via white and grey rami communicantes
 Provide innervation to thoracic and abdominal walls (1 and 2 send fibers to upper extremities, subcostal
sends fibers to gluteals)
 Sympathetic chain ganglia lay just anterior to the rib heads bilaterally
Rib motion
Best detect motion far away from the axis (with ribs you will feel it move anteriorly better)
 Pump-Handle motion: Primarily ribs 1-5 (pull up in front, posterior goes down
 Ribs move anterior and superior with inhalation
 Motion predominantly in sagittal plane
 Best palpated at mid-clavicular line
 Axis of motion is costovertebral-costotransverse line
 As Inspiration occurs:
Anterior aspect moves cephalad (superiorly)
Posterior rib head moves caudad (inferiorly)
 Expiration: Opposite of inspiration!
OMM 2- Thoracic Rib and Chest Wall SD
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Bucket-Handle motion: Primarily ribs 6-10 (lift handle to the side to raise)
 Ribs move laterally and increase transverse diameter with inhalation
 Motion predominantly in coronal plane
 Best palpated at mid-axillary line
 Axis of motion is a costovertebral-costosternal line
 The rib shaft is the handle of the bucket
 Rib shaft lifts during inhalation, falls with exhalation
 Increases the transverse diameter of rib cage
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Caliper motion: Primarily ribs 11,12 (book closing and opening)
 Ribs externally rotate with inhalation
 Motion predominantly in transverse plane
 Best palpated 3-5 cm lateral to transverse processes
 Axis of motion is vertical line
Typical vs Atypical Motion
 “Typical” Ribs:
 Ribs 3-9 display both transverse axis (pump handle) and AP axis (bucket handle) motion
 Upper 1/3 ribs- predominant pump handle type mechanics around a transverse axis
 Middle 1/3 ribs- mix of pump and bucket handle mechanics
 Lower 1/3 ribs- predominant bucket handle mechanics around an AP axis
 “Atypical” Ribs
 Ribs 1,2, 10-12
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Rib Somatic Dysfunction
Impaired or altered function of related components of the somatic system (body framework): skeletal,
arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements.
Identified through palpation to determine the presence of tissue texture changes, asymmetry, restricted motion
(barrier) and tenderness
OMM 2- Thoracic Rib and Chest Wall SD
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Specific Structural Dysfunctions
 Superior subluxations (first rib)
 A/P subluxations
Respiratory Dysfunctions
 Inhalation SD Pump handle (exhalation restriction)
 Inhalation SD Bucket handle (exhalation restriction)
 Inhalation SD Caliper (exhalation restriction)
 Exhalation SD Pump handle (inhalation restriction)
 Exhalation SD Bucket handle (inhalation restriction)
 Exhalation SD Caliper (inhalation restriction)
Goal in Rib treatment
Improve Rib Motion
 Improved rib motion modulates sympathetic function
 Improved rib motion allows for improved respiration and improves diaphragmatic function
 Improved rib motion increases intrathoracic pressure during respiration, which increases lymphatic and
venous return to the heart
Decrease Pain
Improve spinal mechanics
Case Presentation
21 y/o college basketball player with recent injury to L rib cage shows fractured ribs on CXR. Improved with rest
and 6-8 weeks post injury returns to cardiovascular exercise with now chest pain and shortness of breath with
activity associated with sharp quality better with rest
Pt found to have T 6 Ext SLRL lesion
Pt with exhalation rib somatic dysfunction of ribs 6-9
Rib General Treatment Principles
First unclog the sink!!!(address the Thoracic inlet/CT junction)
Treat thoracic spine (especially Nonneutrals Type 2)
Warm up the soft tissues
Inhalation somatic dysfunction (stuck up need to be brought to knees/down a notch/humbled) – tx the lowest
rib
Exhalation somatic dysfunction (stuck down pull up by your bootstraps) tx the highest rib with dysfunction
Recheck and if not improved with tx focus to identify the key rib or tx the other side (Inhalation on R may be
Exhalation on L)
When treating an inhalation SD
(“stuck up in inhalation”)
Treat the lowest rib of the group of
ribs that is restricted
When treating an exhalation SD
(“stuck down in exhalation”)
Treat the highest rib of the group of
ribs that is restricted
OMM 2- Thoracic Rib and Chest Wall SD
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DDx of Thoracic Pain: Non-traumatic
Infection (pnuemonia/bronchitis, effusion/empyema, TB, herpes zoster)
Pleurisy or Costochondritis (inflammation)
Pneumothorax spontaneous
Tumor (Pulm CA, LN CA, distant metastasis, sarcoidosis)
Asthma/COPD (bronchospasm with inflammation)
Pulmonary embolus
Cardiac (ie MI, pericarditis, CHF, aneurysm)
Esophageal (ie GERD, Esophagitis, etc)
Viscerosomatic (Gallbladder, Pancreas, etc)
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DDx of thoracic Pain: Traumatic
Fracture
Pneumothorax (esp tension)
Costochondritis
Somatic Dysfunction
Pulmonary contusion
Effusion (cardiac tamponade, hemothorax)