Transcript Thoracic Spine What is the value of the “Sternal

Thoracic Spine
Lab Session DX 612
James J. Lehman, DC, MBA, DABCO
University of Bridgeport College of Chiropractic
Case Study

Actual case study
from a Chiropractic
College Clinic…
Clinical Presentation
Chief Complaints
1. Numbness both thighs
2. Mild LBP
3. Mild hand & foot pain
4. Headaches
5. Hypothyroidism
6. Diabetes
7. Left-sided chest pain
Secondary Symptoms





Dizziness while getting out of bed
Age-related fatigue
Daily shoulder stiffness
High blood pressure
Gas and heartburn
Additional History




Recent EKG normal
Past Hx of MI
Under financial stress
Thigh numbness with
standing & relieved
with sitting (past 6
months)
High Risk Patient


Is this guy a “walking
time bomb?”
Why?
Additional History


Chronic thoracic and
lumbar back pain for
years
Pain relief with mm
relaxants & back
support while sitting
up straight
History

Pain with use of arms
in forward elevation
Additional History

Infrequent headaches
resembled those that
he experienced as a
child.
Additional History

Reduced trunk ROM
with back tenderness
Past Medical History





Heart attack 1996, angioplasty?
Fractured C-spine 3 y/o
Controlled diabetes
Hypertension
Hypothyroidism & Synthroid Rx
Past Medical History

Numerous meds for
heart, high blood
pressure, seizures,
and acid reflux.
Past Medical History



20 year Hx of
chiropractic care
2 years since chiro
care
Some manipulations
helped but not the
drop table treatments.
Physical Examination





59 y/o male
72” height
301#
Hypesthesia anterior
right leg and thigh
Decreased LE DTR
Physical Examination


Left shoulder pain
with abduction with
reduced arterial return
Mild neck pain in all
ROM and with lifting
Can you name the
test?
Additional Examination

Would you prefer any
other testing prior to
assessment and
treatment of this
patient?
Intern/Clinician Assessment
Working Diagnosis

Myofascial thoracic
and lumbar pain
associated with
subluxation.
Assessment


Do you agree with
this assessment?
Why?
Your Opinion

Are you ready to treat
the patient?
Treatment Provided at
Chiropractic College Clinic


Prone T4 Carver
Bridge adjustment
Drop to the sacral
base
Outcome of Thoracic Adjustment

Immediate groaning
and lifting up of torso
off table with grasping
and clutching of
patient’s chest.
Post Manipulation Treatment
Cryotherapy

Supine posture with
ice reduced patient’s
pain.
Clinical Question

What happened?
Patient Comments

“I felt and heard
several popping
sounds from inside
my chest. I know my
ribs are broken”
Evaluation

Positive finger
pointing to anterior
costal margins and
exhibited signs of
dyspnea
New Revelation…


Patient fell off a building
several years prior. He
fractured several ribs at
his sternum. He never
went to a doctor for
treatment…
He forgot to mention this
injury when asked in
history x3.
Anatomy of Rib Cage



Check margins
Costal-cartilaginous
junctures
Sternal location
Working Diagnosis

What are your
differential
diagnoses?
Differential Diagnoses




Sprain/Separation
Costochondritis
Fracture
Coronary pain
Evaluation


Would you perform
orthopedic testing?
If yes, which tests?
Orthopedic Evaluation



Positive finger point
Palpation with
positive jump sign
Thoracic ROM testing
Orthopedic Evaluation


Sternal compression
Rib cage
compression
Imaging Study

Radiographic
examination of the
ribs is indicated…
Sternal Compression Test



Contact sternum
Apply AP force
Compress rib cage
gradually
Sternal Compression Test

What is the value of
the sternal
compression test?
Sternal Compression Test


Pronounces rib
fractures
Produces pain with
costochondritis
Scheplemann's Test

What is the value of
Scheplemann’s test?
Vital Signs

Corroborate historical
information with
physical examination
findings.
Subjective and Objective
Findings Are the Hoof Beats…

Look for horses when
you hear hoof beats,
Awareness Enhances Decision
Making…

not zebras, unless
you are in Africa…
Two years later…
Complaint Served with Allegations



Medical negligence
Failure to obtain
informed consent
Loss of consortium
pled by spouse
Cardiac Emergencies

Notice that cardiac
pain is not only on the
left side…