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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:

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 Anatomy

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 Anatomy

Muscles of Inspiration:

Intercostal muscles:

External intercostal muscles: (outside of the ribcage)

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 ribs and expand the transverse dimensions of


the thoracic cavity (aid in quiet and forced inhalation)

Elevate the 1st and 2nd ribs

SCM, trapezius, serratus anterior, pectoralis


major/minor and latissimus dorsi (secondary
muscles)

Muscles of Expiration:

Abdominal muscles (rectus abdominis,


internal/external obliques, transverse abdominis

Clinical Anatomy

Respiratory Tract Anatomy:

Trachea:

Pleura:

Connects larynx to 2 principle bronchi


Left bronchus 2 segmental bronchi (2 lobes)
Right bronchus 3 segmental bronchi (3 lobes)
Parietal pleura lines thoracic wall
Visceral pleura surrounds lungs

Alveoli:

Terminal branches of bronchioles


Gas exchange
Capillary system blood exchanged (pulmonary
arteries and veins)

Heart
Chamber

Function

Right
Atrium

Receives deoxygenated blood via:


Superior vena cava (head, neck, upper
extremities)
Inferior vena cava (trunk and lower
extremities)
Role: Delivers blood to right ventricle

Right
Ventricle

Receives deoxygenated blood from right


atrium
Role: Delivers blood to lungs via left and
right pulmonary arteries

Left Atrium

Receives oxygenated blood from lungs via


right and left pulmonary veins
Role: Delivers blood to left ventricle

Left
Ventricle

Delivers oxygenated blood through aortic


valve to ascending aorta

Clinical Anatomy

Digestive Tract Anatomy:

Esophagus:

Small intestine:

Duodenum, jejunum, ileum

Large intestine:

Carries food/liquid to stomach

Cecum, ascending colon, transverse


colon, descending colon, sigmoid colon

Rectum and Anus

Clinical Anatomy

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

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 Anatomy

Urinary Tract Anatomy:

Ureters:

Muscular ducts that propel urine from the kidneys


to the urinary bladder

Urinary Bladder:

Length: 10-12 inches (adults)

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 Anatomy

Reproductive Tract Anatomy:

Testes:

Epididymis:

Produce estrogen and progesterone and house


reproductive eggs

Fallopian Tubes:

Coiled tube on posterior aspect of testes (stores sperm)

Ovaries:

Produce sperm and male sex hormones (testosterone)

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
Upper Right Quadrant
Liver
Kidney
Pancreas
Lung

Upper Left Quadrant


Heart, Lung
Spleen
Kidney
Stomach

Lower Right Quadrant


Appendix
Ureter
Bladder
Colon
Gonads

Lower Left Quadrant


Ureter
Bladder
Colon
Gonads

Clinical Evaluation

History:

Location of Pain:

Onset of Symptoms:

Musculoskeletal pain ribs, costal cartilage,


abdominal muscles (tender at injury site)
Injury to internal organs diffuse pain; referred
pain sites (Kehrs sign)
Gradual (internal bleeding can accumulate within
cavity)
Pain with breathing (rib, abdominal injury)

Mechanism of Injury:

Direct blow (thoracic, abdominal, pelvic injuries)

Clinical Evaluation

History:

Symptoms:

Medical History:

Pain, difficulty breathing


Diffuse abdominal pain
Nausea, dizziness
Vomiting of blood, blood in urine/stool
Not common (acute injury)
Exercise-induced asthma
Illnesses (mononucleosis)

General Medical Health:

Medications

Clinical Evaluation

Inspection:

Start observe
patients posture
Throat:

Capillary refill
(cyanosis)

Muscle tone
Discoloration of
skin:

Rate, respiration
rate, depth, quality

Nail beds:

Inspection:

Position of trachea
and larynx

Breathing pattern:

Vomiting:

Contusions,
wounds, abrasion
Presence of blood

Hematuria

Clinical Evaluation

Inspection:

Auscultation:

Lungs:

Inhalation smooth
unobstructed sound
Absence:
pneumothorax,
collapsed lung
Rales:
pneumonia

Abdomen:

Gurgling noises
(peristalsis)

Clinical Evaluation

Palpation:

Sternum:

Manubrium,
body, xiphoid
process

Costal cartilage
and ribs:
Palpate anterior
to posterior
Pain, crepitus,
deformity

Clinical Evaluation

Palpation:

Spleen:

Palpate for
enlarged spleen
under left rib cage
Have patient raise
arms above head

Clinical Evaluation

Palpation:

Kidneys:
Location
under
posterolateral
portion of rib
cage
Right kidney
rests more
inferior than
left

Clinical Evaluation

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

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

Palpation:
McBurneys Point

Location onethird of way


between right
ASIS and naval
Tenderness may
indicate acute
appendicitis

Clinical Evaluation

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

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

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
Quadrant Pain:
Left
Liver: Pain
Upper

Right

associated with
cholecystitis or
liver laceration
Gall bladder: Pain
without trauma
indicates gall
bladder disease

Lower

Appendix:
Rebound
tenderness
indicates
appendicitis
Colon: Colitis or
diverticulitis may
cause pain
Pelvic

Spleen: Rigidity
under the last
several ribs

Colon: Colitis or
diverticulitis may
cause pain
Pelvic
inflammation:
Diffuse tenderness

Clinical Evaluation

Vital Signs:

Heart Rate:

Pulse:

Normal pulse is 60-100 beats


per minute

Athletes tend to have a slower


pulse than non athletes (wellconditioned strong heart)

Normal pulse is 60-100 beats


per minute

Regular / Irregular
Strong / Weak

Athletes tend to have a slower


pulse than non athletes (4060 bpm)

Abnormal:

Tacchycardia: > 100 bpm


Bradycardia: < 60 bpm

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 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 Evaluation

Vital Signs:
Respiratory Rate

Normal: 12 20 bpm
Abnormal:

Rapid, shallow breaths:

Deep, quick breaths:

Internal injury
Shock
Pulmonary instruction
Asthma

Noisy, raspy breaths:

Airway obstruction

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 Evaluation

Rib Fractures:

Inspection:

Splinting posture:

Discoloration / swelling
Shallow, rapid respirations (minimize chest
movement)

Palpation:

Holding the painful area to limit chest wall


movement during inspiration

Point tenderness, crepitus, possible deformity

Functional Tests:

Movement of torso causes pain


pain with deep respiration, coughing, sneezing

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 Evaluation

Lateral Rib
Compression Test:

Test position:

Action:

Subject supine
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

Anterior/Posterior Rib
Compression Test:

Test position:

Action:

Subject supine
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

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

Pneumothorax:

Accumulation of air in pleural activity


Spontaneous pneumothorax:

Diagnosis dependent on signs/symptoms rare


condition

Contributing Factors:

Family history, tall and thin body build


Sports-related spontaneous pneumothorax
documented in weight lifting, football, jogging

Primary spontaneous pneumothorax:

Chest pain, dyspnea, diminished breath sounds


Chest pain usually localized to the side of the affected
lung
Can radiate to shoulder, neck, back

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 Evaluation

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

Pneumothorax:

Clinical Signs:

Palpation:

Apprehension / Agitation
Cyanosis
Diminished breath
sounds
Distended neck veins /
Tracheal deviation
Trauma induced point
tenderness

Vital Signs:

Labored, shallow
respirations
BP drops rapidly

Right tension
pneumothorax

Clinical Evaluation

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

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

Spleen Injury:

History:

Acute (symptoms may take a few hours to


develop)
Pain:

Predisposing conditions:

Upper left quadrant


Kehrs sign pain in upper left shoulder
Mononucleosis:
mass, elasticity

Inspection:

Impact site contusion


Nausea and vomiting

Clinical Evaluation

Spleen Injury:

Palpation:
Cold and clammy skin (shock)
Pont tenderness
Rebound tenderness
Distention in upper left quadrant

Functional Tests:
Kerhs sign
Low blood pressure

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 Evaluation

Kidney Pathologies:

Palpation:
Point tenderness
Abdominal rigidity

Functional Testing:

Pain with urination

Laboratory Testing:

Hematuria

Clinical Evaluation

Kidney Stones:

Collection of
incomplete kidney
filtration

Causes:

Crystals of uric acid,


calcium
1mm 2.5 cm
Family history, stress, diet

Signs:

Pain with urination


Pain (stone passed from
bladder through urethra)

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 Evaluation

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

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

McBurneys Point
between ASIS and
umbilicus

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 Evaluation

Gastritis:

Inflammation of stomach lining

Causes:

Esophageal Reflux:

Backflow of gastric juices into esophagus

Aspirin or anti-inflammatory medications


Alcohol
Infection, bile entering stomach

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

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 midupper abdomen /


heartburn

Stomach Ulcers
wounds in lining of
stomach

Common causes:
Stress, virus, diet
Potential for bleeding
if ulcers go untreated
(open wounds)

Clinical Evaluation

Colitis:

Inflammation of the large intestine

Symptoms:

Causes:

Disease, irritation of bowel, ulcers, ischemia, bacteria,


stress

Regional Enteritis (Crohns Disease):

Frequent diarrhea
Abdominal pain, increased bowel sounds, fever, painful
defecation, nausea, vomiting

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 Evaluation

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

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 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 2 0


sexual characteristics
By the age of 16 with otherwise normal
development

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