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

2. Clinical Anatomy Thorax – bone cavity Thoracic 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. 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

5. Clinical Anatomy

6. Clinical Anatomy Muscles of Inspiration: Muscles of Expiration:
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 latissimus dorsi (secondary muscles)
Muscles of Expiration:
Abdominal muscles (rectus abdominis, internal/external obliques, transverse abdominis

8. Clinical Anatomy Respiratory Tract Anatomy: Trachea: Pleura: Alveoli:
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)

10. 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

13. Clinical Anatomy Digestive Tract Anatomy: Esophagus: Small intestine:
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. 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

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: Urinary Bladder:
Muscular ducts that propel urine from the kidneys to the urinary bladder
Length: 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: Epididymis:
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. 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

23. Clinical Evaluation Upper Right Quadrant Upper Left Quadrant
Liver
Heart, Lung
Kidney
Spleen
Pancreas
Lung
Stomach
Lower Right Quadrant
Lower Left Quadrant
Appendix
Ureter
Bladder
Colon
Gonads

24. 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 (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: Medical History:
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. Clinical Evaluation Inspection: 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

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

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

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

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

33. 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

34. 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

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

36. Clinical Evaluation Palpation: Abdomen Rigidity: Rebound Tenderness:
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

37. 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

38. Clinical Evaluation Palpation: Percussion 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

39. Clinical Evaluation Upper Quadrant Pain: Right Left Lower
Liver: Pain associated with cholecystitis or liver laceration
Gall bladder: Pain without trauma indicates gall bladder disease
Spleen: Rigidity under the last several ribs
Lower
Appendix: Rebound tenderness indicates appendicitis
Colon: Colitis or diverticulitis may cause pain
Pelvic inflammation: Diffuse tenderness

40. Clinical Evaluation Vital Signs: Heart Rate: Pulse:
Regular / Irregular
Strong / Weak
Normal pulse is beats per minute
Athletes tend to have a slower pulse than non athletes (well-conditioned strong heart)
Athletes tend to have a slower pulse than non athletes (40-60 bpm)
Abnormal:
Tacchycardia: > 100 bpm
Bradycardia: < 60 bpm

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 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. Clinical Evaluation 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

45. Clinical Evaluation Rib Fractures: Most common injured: History:
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: Palpation:
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: Special Tests:
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. Clinical Evaluation 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

50. Clinical Evaluation 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

51. Clinical Evaluation Costochondral Injury: MOI: Symptoms:
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

52. 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)

53. 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)

54. Clinical Evaluation Pneumothorax: Clinical Signs: Palpation:
Apprehension / Agitation
Cyanosis
Diminished breath sounds
Distended neck veins / Tracheal deviation
Palpation:
Trauma induced – point tenderness
Vital Signs:
Labored, shallow respirations
BP drops rapidly
Right tension pneumothorax

55. 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

56. 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

57. Clinical Evaluation Spleen Injury: History: Inspection:
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

58. Clinical Evaluation Spleen Injury: Palpation: Functional Tests:
Cold and clammy skin (shock)
Pont tenderness
Rebound tenderness
Distention in upper left quadrant
Functional Tests:
Kerh’s sign
Low blood pressure

59. 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

60. Clinical Evaluation Kidney Pathologies: Palpation: Functional Testing:
Point tenderness
Abdominal rigidity
Functional Testing:
Pain with urination
Laboratory Testing:
Hematuria

61. Clinical Evaluation 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)

62. Clinical Evaluation Urinary Tract Infections: Urethritis:
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

64. 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

65. Clinical Evaluation Appendicitis: Cause: Signs and Symptoms:
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 – between ASIS and umbilicus

66. 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

67. Clinical Evaluation Gastritis: Esophageal Reflux: Intestinal Ulcers:
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
Bacteria
Long-term use of aspirin or anti-inflammatory medications

68. 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)

69. Clinical Evaluation Colitis: Regional Enteritis (Crohn’s Disease):
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

70. Clinical Evaluation Testicular Contusion: Testicular Torsion:
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

71. 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

72. 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

73. Clinical Evaluation Female Athlete Triad: Amenorrhea: Osteoporosis:
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