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Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C

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Presentation on theme: "Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C"— Presentation transcript:

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

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