Orthopedics Notes and Review

I. Definition of Thoracic Spine: Greek meaning corselet (type of armor that covered the chest a soldier that wore this was also referred to as a corselet ) or chest

· Spine means thorn

· Anatomy of the Thoracic Spine

· Largest area of the spine

· 12 vertebrae with rib articulations, and 12 ribs on each side

· most diverse and different motions

· most articulations

· rib cage helps to protect internal organs

· aids in respiration

· Articulations

· With the segment above and below

1. intervertebral discs (anterior)

2. facets (posterior)

3. ribs

4. posterior articulations

· R1, 10-12—at the costovertebral articulation only articulate with a single segment

· R2-9—double articulation ex: R2 articulates with T1 and T2 ex: R3 articulates with T2 and T3

5. The law of 13: palpate one body inch to find the transverse processes

· T1 and T12: 1 interspinous spaces

· T2 and T11: 1 interspinous spaces

· T6 and T7: 2 interspinous spaces

· T3-T5 and T8-T10: 1.5 interspinous spaces

· Ribs

1. begin at the costovertebral articulations—impossible to palpate on a live patient…synovial joint…held in place by radiate ligament

2. costotransverse articulation—synovial joint…held in place by costotransverse ligament

3. lateral and dive inferiorly—just lateral we have rib tubercles (lateral to costotransverse articulations)

4. begin wrapping to anterior aspect—rib angles—costochondral articulations—with cartilage (costochondral cartilage)—synovial joint

5. sternalcostal articulations—sternum w/cartilage—synchondrosis joint

6. How do ribs articulate w/the transverse process? By ligaments

7. How do ribs articulate w/the vertebra? By demifacets on the vertebral segments, they help to anchor the costovertebral articulations

· Rib attachment characteristics

· Ribs 1-6: true ribs (sometimes R7)—they have direct attachment to the sternum

· Ribs 8-10: false ribs (sometimes R7)—common cartilaginous insertion

· Ribs 11-12: free floating ribs—do not attach to the sternum

· Rib Motion—during respiration—cage elevates superiorly and opens A-P

· Ribs 1-7: pump handle motion—during respiration—more A-P motion w/some superior elevation

· Ribs 8-10: Bucket handle motion—during respiration—more superior motion

· Ribs 11-12: Caliper motion—during respiration—strictly A-P no superior motion

· Thoracic Neurology

· Route nerve roots (NR) can take providing cutaneous innervation

· NR b/w occiput and C1: it is the C1 NR

· NR b/w C1-C2: it is the C2 NR

· NR b/w C7-T1: it is the C8 NR

· NR b/w T1-T2: it is the T1 NR

· NR are segmental and dermatomal by nature

· Dermatomes

· C8—ring and pinky finger up to the elbow and sometimes medial arm into the axilla

· T1—1^st intercostal space, it exists at the posterior aspect and follows all the way to the anterior aspect and continues down the thoracic spine—also the axilla (armpits)

· T2—axilla

· T4—at the nipple line

· T7—at the xiphoid process

· T10—band circling around the umbilicus

· T12—ASIS—loop from the ASIS to the pubic symphysis and back upto ASIS and wraps from the posterior over the tops of the crests

II. Definition of Orthopedics: means straight foot

III. Proper Patient Work-up: HIPPIRONREL

H—History—taken during the consultation

1. Chief Complainant (C/C)

2. History of Present Illness (HPI)

3. Meds/Surgery/Family History/Work/Play/Activities

4. OPPQRST and SOAP notes

I—Inspection—look at the involved area, look at the skin—postural analysis (scars, skin lesions, bruising)

P--Percussion--spinous percussion to rule out a fracture

P--Palpate--motion palpation or static palpation

I--Instrumentation--vitals (height, weight, blood pressure, pulse, respiration, temperature)

R--Range of Motion--active, passive, resistive (flexion, extension, lateral bending, and rotation)

O--Orthopedic Test

N--Neurological Evaluation--dermatomes, myotomes, and deep tendon reflexes

E--x-ray--not necessary on all patients

L--Lab Tests--not necessary on all patients

IV. Chief Complaint

O--Onset: when it happened what you were doing at the time

P--Palliative: what makes it better

P--Provocative: what makes it worse

Q--Quality: on a scale of 1-10 w/10 being the worst, how would you rate the pain

R--Radiation: does the pain show up anywhere else

S--Site: point to the pain or discomfort

T--Time: when is it better morning or night or how long have you had it

(B)--Bruising: is there any bruising

V. SOAP Notes:

S: Subjective--what the patient tells you ex: "my neck hurts…it feels like a knife in my back"

O: Objective--what the doctor finds on the clinical inspection ex: spinous percussion (+) and fracture found

Upon x-ray

A: Assessment--Diagnosis

P: Plan--what you did to that patient or with that patient and what your treatment was for that day

VI. Spinous Percussion Test:

· Use it to rule out fracture--is used on entire spine

· If (+) do an x-ray immediately

· A (+) can exhibit sharp shooting stabbing excruciating pain--also bruising and swelling

· If do not do and x-ray immediately and perform a ROM, you may cause compression and possible paralysis, also may cause compound displaced fracture and trauma to the spinal cord

· If this occurs in the cervical spine, can kill the patient

· Have the patient roll shoulders forward and percuss the spinous processes

· If you ever suspect spinal cord injury ex: burning, lose bowel or bladder control, burning in the legs, parasthesia esp. bilateral…CALL 911

· Patient could have a fracture/laceration/acute injury like a contusion causing swelling and bruising (traumatic meningitis) w/parasthesia T1-T12

VII. Ankylosing Spondylitis

· Onset: 15 years

· Chief Complaint: low back pain and hip pain

· Findings: L4-L5, L5-S1 will into to SI for pain, no trauma involved, a lot of pain, difficulty sleeping, can't sit in school, standing hurts, NO POSITION IS COMFORTABLE

· Do x-rays

Review

· KNOW: classic diagnosis and exceptions

· UNDERSTAND: biomechanics involved and what possible conditions could render a test positive