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Structural Rib Dysfunctions
Structural Rib Dysfunctions are the type of rib somatic dysfunction that makes a person sure that they have broken a rib. but the x-ray fails to reveal a fracture. They have the following characteristics in common: (1) They are traumatically induced, (2) they are non-physiologic dysfunctions; their motion loss is significant. not just a diminution of the range of physiologic motion as seen in respiratory rib dysfunctions, and (3) They usually have accompanying vertebral dysfunction, altered myofascial tension, and autonomic dystonia as comorbidities.
First, a review of the anatomy of the thoracic spine, rib cage. and sternum. Recall that the primary determinant of rib motion is the attachment of the rib to the thoracic spine. Ribs with one's or two's in them (1, 2, 11, & 12) are atypical. One and two are less flexible, and attach anteriorly to the manubrium and manubriosternal joint, respectively, without a costal cartilage. Rib one attaches to the vertebral body of T1 by a unifacet. Rib two attaches to the body of T2 at its superior demifacet. Its tuberosity has an attachment to the proximal portion of the serratus anterior muscle.
2. Both 1 & 2 are intimately related to the neurovascular bundles exiting the thorax and the aortic arch. This relationship is the rationale behind the ATLS protocol that any disruption of ribs one or two in trauma calls for an immediate evaluation by a vascular surgeon (arch arteriogram).
3. Ribs 11 and 12 do not attach to an anterior costal cartilage or transverse process, but rather invest into the fascia and musculature of the lateral and posterior abdominal wall. 11 & 12 are described as having caliper motion, primarily influenced by their relationship to their muscular attachments.
The typical ribs (3-10) attach to two vertebral bodies: the segment above, the one of the same number, and the intervertebral disc between. For example. the 6th rib attaches to the lower demifacet of thoracic vertebra 5 & the upper demifacet of thoracic vertebra 6.
4. A-P Compression: Mechanism: occurs with a force compressing the chest wall from front and back...head on, rear end collisions, football tackles, etc. -Patients often relate a history of having "the wind knocked out of them, and then it continues to be hard to breathe. Diagnosis: The anterior and posterior landmarks are depressed, and the rib is prominent laterally. Treatment: Patient seated: stand opposite side, bring your arms around the pt, contacting the lateral aspect (prominent part) of the rib. Ask them to breathe in deeply, then let it out, hold it out, then sidebend into you as you resist by bringing the lateral aspect of the rib toward you (medially). This dysfunction is also seen more often in the lower ribs as it is a disruption of motion along the anteroposterior rib axis.
5. Aterrial ana internal Torsions: Mechanism: these are associated with vertebral dysfunctions, but become problems themselves. Recall the discussion of torsional rib movement, figure 10b. Diagnosis: The symptomatic rib is usually the externally torsed rib. The superior margin is prominent and sharp instead of the inferior margin. The spinal dysfunction is usually an ERS rotated to the side of the external torsion at the vertebra which articulates with the superior aspect of the head of the rib (e.g., T5 ERS right with an external torsion of the right 6th rib). There is tissue texture abnormality in the fourth layer muscles along the spine, at the costovertebral and costotransverse articulations and at the angle of the rib. Remember the nerve, artery, and vein run along the groove of the bottom of each rib. You can appreciate the asymmetry best at the rib angle. Anteriorly, it is the opposite of what you see in the back, but can be just as tender at the costochondral and chondrosternal joints. Treatment: Patient seated. hold the patient's elbow localized to the level you are treating and resist the patients' effort to lift and depress the elbow. Use your other thumb to contact and rotate the rib forward from the superior margin of the angle.
6. Superior Subluxation (1st Rib) Mechanism: this occurs in conjunction with hypertonic and shortened anterior and middle scalene muscles (the lateral scalene attaches to the 2nd rib). It is often induced by a sudden motion of the head and neck as in a rear end collision. Diagnosis: The rib is fully a thumbs breadth higher than its pair on the other side, viewed from behind with the patient seated. This is usually tender at the point of contact. The rib has come superiorly and posteriorly to sit on top of the transverse process of Ti. This often is associated with radicuiar symptoms and adverse neural tension along the C8 dermatome, 4th and 5th digits. Treatment: Patient seated. Inhibit the ipsilateral scalenes by taking tension off them and resist the patients' contraction of the opposite scalenes (reciprocal inhibition), then bring the rib forward and down. It will "klunk" into position and the tissue texture changes immediately. A caveat: It won't correct if it is on top of a laterally flexed 2nd rib.
7. Laterally flexed (2nd Rib): Mechanism: occurs with a sudden sidebending motion of the head and neck. History usually suggests the dysfunction to you, like a health care worker who caught a falling patient when his partner dropped them from the other side of the bed, or whiplash injury from the side. The rib's bucket handle motion is taken into an excessively superior range and gets stuck there. The primary muscle perpetuating the problem is the posterior scalene. This one is hard to treat. Diagnosis: major disability out of proportion to the apparent injury, pt can't let the shoulder drop, because that will give them thoracic outlet symptoms of parasthesia, dysesthesia, pain, and weakness in the upper extremity: They are exquisitely tender over and just medial to the coracoid process on the second rib and there is major motion loss of respiratory motion at that rib, and often above and below it. Adverse neural tension is present on examination of the involved extremity. Treatment: Patient supine. Approach the rib from the axilla. Side bend the C-spine maximally to that side and lower the scapula. Once you can get hold of the superior border of the 2nd rib with your finger pads, hold on. and side bend the neck back to upright. (figure 13). This will be painful! However, the relief is immediately apparent to the patient.
Most of these dysfunctions are treated in the seated position with muscle energy technique. The first rib can be treated supine as well, and the second laterally flexed rib is usually treated in the supine position. The torsions can be treated along with the ERS dysfunction's of the thoracic spine with a thrust or muscle energy procedure with the patient supine, also.
Similarities among these dysfunctions are exquisite pain, history of trauma, major motion loss, and loss of resilience to spring. If a patient has severe chest wall pain and you can't find a structural rib dysfunction, you need to consider a differential diagnosis which includes: herpetic neuralgia (shingles), thoracic spine tumors, metastatic retions in the ribs (breast and prostate most often), and referred pain from the myocardium, pericardium, pleura, or parenchyma of the lungs.
Onto the transverse process of the vertebra of the same number to form the costotransverse joint. Typical ribs have similar contours, and attach via the costochondrai joints to the costal cartilage anteriorly. The costal cartilages in turn attach to the sternum via the stemocostal joints. Taking a deep breath involves over 100 articulations in the thorax alone!.
Each rib has a unique axis of rotation that is determined by the angle between its attachment to the body and transverse process of the vertebra to which it relates. Pump handle motion is predominant in the upper rib cage and bucket handle motion is predominant in the lower rib cage.
The rib cage has the unique ability to increase its A-P diameter and its lateral dimension at the same time, with inhalation. The structure most responsible for the generation of negative intrathoracic pressure is the diaphragm. It has extensive attachments to the lower six ribs, the xiphoid process, the costal cartilages of the anterior chest wall, the vertebral bodies of T12, L1, L2, and L3, and the intervertebral discs between them. The crurae form passageways for the esophagus, aorta, inferior vena cave. thoracic duct, and vagus nerve, and then become continuous with the anterior longitudinal ligament and iliopsoas muscles. The innervation of the diaphragm. which migrates caudally in development, is the phrenic nerve (Cervical roots 3, 4, and 5)7.
Another important lower extremity muscle affecting rib cage motion is the quadratus lumborum, which originates from the iliolumbar ligament and the posterior part of the iliac crest, runs along the posterior lateral aspect of the vertebral column, and inserts on the transverse processes of the upper four lumbar vertebrae and the inferior aspect of the 12th rib on each side9.
The upper rib cage and muscles of the upper extremity and chest wall often play an important role in cervicobrachial syndromes, or thoracic outlet syndromes. Remember that upper extremity radicular symptoms and signs can originate from structures peripheral to the cervical cord and lateral recess of the uncovertebral joints of Luschka. Common points of entrapment are: (1) The scalenus anterior as it passes through .the brachial plexus, (2) the costoclavicular space between the 1st rib and the clavicle where the neurovascular bundle exits the chest , and (3) the pectoralis minor tendon where it passes over the bundle just distal to the 1st rib on its way to attach to the 3rd, 4th, and 5th ribs.
PHYSIOLOGIC RIB MOTION
The movement of the rib cage with respiration is often broken into components for description.15 All ribs have both bucket handle and pump handle motion, with the angle of the transverse process of the vertebra to which the rib is related determining the axis about which the rib moves (figure 7). The predominant motion of the superior ribs is pump handle, while the predominant motion of the lower ribs is bucket handle. However, the minor motion of the rib (e.g., bucket handle motion of ribs one and two) can play a major role in perpetuating motion loss. An example of this is the case of a laterally flexed second rib, which IntlII be presented in this section of the course.
The caliper motion of ribs eleven and twelve can be seen to be related to the near-vertical orientation of the small transverse processes of T11 and T12 as well as the way the ribs invest into the abdominal musculature, thoracolumbar fascia, and diaphragm.
To gain a dynamic, three dimensional perspective of the torso, it is useful to conceptualize the abdominal musculature and its relationship to the muscles and fasciae posteriorly as a continuous flexible muscular tube that stabilizes and balances the trunk and upper body.
DIAGNOSIS AND TREATMENT
1. Anterior Subluxation: Mechanism: this occurs when one or more ribs are hit from behind and the rib head and neck move anteriorly and medially with respect to the vertebral bodies. Diagnosis: The rib(s) is prominent anteriorly and is deep to ribs above and below posteriorly. Treatment: Patient seated: bring the rib posterior and lateral (pull-pull). This is more common in the upper rib cage where the movement is predominantly around the functional transverse axis.
2. Posterior Subluxation: Mechanism: this occurs when one or more ribs are hit from the front, as often happens with a seat belt, airbag, steering wheel, or football pad. The head and neck of the rib move posteriorly and laterally with respect to the vertebral bodies. Diagnosis: The rib is prominent at the angle of the rib (posterior and lateral) and is deep to ribs above and below anteriorly. The costochondral and costosternal joints are usually exquisitely tender, as well. Treatment: Patient seated: bring the rib anterior and medial. This is also more common in the upper rib cage where the movement is predominantly around the functional transverse axis.