ATR 492A T&L-Spine Information
Thorax and Lumbar Spine Injury Management
Primary Survey
Check the
Scene
Check ABC’s
Check for
Gross
Deformities
Check for
Bleeding
Assess for
Shock
Is the scene safe for you to enter? Do you need to move that patient (risk
benefit analysis)?
Airway is clear? Patient is breathing? Circulation?
Scan the body. Manage appropriately.
Control bleeding
Types of Shock:
Respiratory Shock – Trauma to the respiratory tract (trachea, lungs) that causes
a reduction of oxygen and carbon dioxide exchange.
Neurogenic Shock – Injury or trauma to the nervous system (spine, brain). Nerve
impulse to blood vessels impaired, blood vessels remain dilated and blood
pressure decreases.
Cardiogenic Shock – Myocardial Infarction with damage to heart muscle; heart
unable to pump effecticely. Inadequate cardiac output
Hemorrhagic Shock – Severe bleeding or loss of body fluid from trauma, burn,
surgery, or dehydration from severe nausea and vomiting. BP decreases, this
blood flow is reduced to vital organ systems.
Anaphylactic Shock – Results from reaction to substance to which patient is
hypersensitive or allergic (allergen extracts, bee sting, medication, food).
Outpouring of histamine results in dilation of blood vessels throughout the
body.
Metabolic Shock-Body’s homeostasis impaired; acid-base balance disturbed
(diabetic coma or insulin shock); body fluids unbalanced.
Psychogenic Shock- Caused by overwhelming emotional factors. Sudden dilation
of bleed vessels results in fainting because of lack of blood supply to the brain.
Septic Shock – An acute infection, usually systemic, that overwhelms the body
(toxic shock syndrome). Poisonous substances accumulate in bloodstream and
blood pressure decreases, impairing blood flow to cells, tissues, and organs.
WC: #1
History
LBP RED
FLAGS when
taking history
Cancer
Unexplained weight loss
Immunosuppression
Prolonged use of steroids
Intravenous drug use
Urinary tract infection
Pain that is increased or unrelieved by rest
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ATR 492A T&L-Spine Information
Thorax and Lumbar Spine Injury Management
Fever
Significant trauma related to age (e.g., fall from a height or motor vehicle accident in a young patient,
minor fall or heavy lifting in a potentially osteoporotic or older patient or a person with possible
osteoporosis)
Bladder or bowel incontinence
Urinary retention (with overflow incontinence)
WC: #2
Gather personal Information (Name, sport, age, gender, doctor referral,
diagnosis, etc)
Ask simple open ended questions
Student uses P,Q,R,S, T format
Provocation
Quality
Region
Severity
Timing
REGION:
MOI
Hear anything
Previous History
Medications
What makes it better (easing factors)
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ATR 492A T&L-Spine Information
Thorax and Lumbar Spine Injury Management
What makes it worse (aggravating factors)
What have they done for it (may correlate with easing factors)
LBP RED
FLAGS for
Physical
Exam.
Saddle anesthesia
Loss of anal sphincter tone
Major motor weakness in lower extremities
Fever
Vertebral tenderness
Limited spinal range of motion
Neurologic findings persisting beyond one month
WC: #2
Observation
Visually looks for:
1. Uninjured limb first/then injured
2. Discoloration
3. Scars
4. Deformity
5. Postural abnormalities
6. Bleeding
7. Swelling
8. Atrophy
Body Positioning/posture?
Lordosis – C & L-spine curves.
Kyphosis – T-spine curve e.g. hyperkyphotic is a hunch-back deformity
Efficiency of Movement / Efficiency of Gait
Café’ au lait Macules
Spina Bifida Occulta
Step Deformity
Scoliosis
Palpation
Palpation
Boney
Palpation
Palpate:
1. Uninjured limb first/then injured
2. Point of tenderness
3. Deformity/Crepitus
4. Swelling
5. Temperature Change
Uninjured limb first/then injured:
Illiac Crest
Illiac Tubercle
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ATR 492A T&L-Spine Information
Thorax and Lumbar Spine Injury Management
Soft Tissue
Palpation
Articulation
Palpation
Anterior Inferior Illiac Spine
Anterior Superior Illiac Spine
Posterior Superior Illiac Spine
Ramus of the Pubis
Pubic Tubecle
Ischial Tuberosity
Greater Trochanter of the Femur
Lesser Trochanter of the Femur
Linea Aspera
Thoracic Vertebrae
Lumbar Vertebrae
Sacrum
Coccyx
Uninjured limb first/then injured
Supraspinous
Interspinous
Intertransverse
Posterior Longitudinal
Anterior Longitudinal
SI Joint
Lumbosacral Joint
Hip Joint
Thoracic Intervertebral
Lumbar Intervertebral
Costothoracic
Qualitative ROM Testing
Grossly check AROM for 4 motions of the trunk. Document pain
and/or decreased ROM.
Flexion &
Extension
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ATR 492A T&L-Spine Information
Thorax and Lumbar Spine Injury Management
Lateral
Flexion
Rotation
WC: #3
“Functional Tests”
Used as part of evalaution and/or when taking history – level of function with ADLs
For a physically active person, a fucntional test might be sport-specific
Sit to stand
Requires ~35 degrees of lumbar flexion
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ATR 492A T&L-Spine Information
Thorax and Lumbar Spine Injury Management
Putting on
socks
Requires ~56 degrees of lumbar flexion
Picking up an
object from
the floor
Requires ~ 60 degrees of lumbar flexion
WC: # 6
Quantitative ROM Testing
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ATR 492A T&L-Spine Information
Thorax and Lumbar Spine Injury Management
C7 SP is easy
to find, but
how to I find
the S1 SP?
WC: #6
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ATR 492A T&L-Spine Information
Thorax and Lumbar Spine Injury Management
Thoracolumb
ar flexion &
extension
Mark C7 & S1. Measure and record difference after movement using tape
measure. For flexion, make sure hips remain neutral if done standing (examiner
may hold hips to prevent anterior pelvic tilt). This measurement can be done
short sitting too as long as future measurements are consistent e.g. for progress.
evaluation. To target the lumbar segment only, mark & measure from S1-T12.
Again, keeping pelvis neutral.
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ATR 492A T&L-Spine Information
Thorax and Lumbar Spine Injury Management
Thoracolumb
ar Lateral
Flexion
Thoracolumb
ar Rotation
Standing. Prox. arm perpendicular to floor. Align distal arm to sp. C7. Have
patient side bend, preventing Sagittal movements. Norm: 18-38 degrees.
 Testing position: sitting , feet flat on the floor to stabilize the pelvis
 Testing motion: subject turn their body to one side as far as possible
keeping his trunk erect and feet flat on the floor. The end of the motion
occurs when the examiner feels the pelvis start to rotate. Motion occurs
in the transverse plane around the vertical axis
 Measurement: Center the fulcrum over the center of the cranial aspect
of the subjects head. Align the proximal arm parallel to an imaginary line
between the two prominent tubercles on the iliac crests. Align the distal
arm with an imaginary line b/w the two acromial processes
WC: #6
Manual Muscle Testing
Scapular
Motions to
remember
when testing
thoracic/inter
scapular
muscles:
WC: Unknown
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ATR 492A T&L-Spine Information
Thorax and Lumbar Spine Injury Management
Rhomboids
Test: Adduction and elevation of scapula with downward rotation (medial
rotation of inf. Angle). 90 degree abduction, IR rotation (5th finger up). Pressure:
forearm with downward direction.
Middle
Trapezius
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ATR 492A T&L-Spine Information
Thorax and Lumbar Spine Injury Management
Test: adduction of scapula with upward rotation (lateral rotation of inferior
angle), and without elevation of the shoulder girdle. 90 degrees abd. With ER
(thumb up). Pressure: toward ground.
Lower
Trapezius
Prone. The examiner gives fixation by placing one hand below the scapula on the
opposite side (not shown). Test: Adduction and depression of the scapula with
lateral rotation of the inferior angle. Thumb up. Pressure: against forearm in a
downward direction toward table.
WC: #4
Rectus
abdominis
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ATR 492A T&L-Spine Information
Thorax and Lumbar Spine Injury Management
Grade 5: no resistance needed (hands behind head)
Grades 4 and below: fold arms across chest
Grade 3: arms straight along side
Grade 2: arms at sides, patient rises head and cervical
spine from table. The scapulae remains in contact with
surface
Grade 1: no resistance at all
Rectus
abdominis –
leg lowering
Lay on table, arms across chest
Grade 5: patient can rise and lower legs on their own
Grade 4+: angle between lower extremities and table is 15 degrees when
posterior pelvic is tilt is lost
Grade 4: angle between lower extremities and table is 30 degrees when
posterior pelvic tilt is lost
Grade 4-: angle between lower extremities and table is 45 degrees when
posterior pelvic tilt is lost
Grade 3+: angle between lower extremities and table is 60 degrees
when posterior pelvic tilt is lost
Grade 3: angle between lower extremities and table is 70 degrees when
posterior pelvic tilt is lost
Grade 2: angle between lower extremities and table is greater than 75
degrees when posterior pelvic tilt is lost
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ATR 492A T&L-Spine Information
Thorax and Lumbar Spine Injury Management
Oblique Trunk
Flexors
Rectus abdominis, and by the External oblique on one side combined with the
Internal Oblique on the opposite side. This test is usually done after tests for
upper and lower abdominals have been done.
Beck
Extensors
In the trunk extension test, the Erector spinae (iliocostalis, longissimus, spinalis)
muscles are assisted by the Multifidus, Latissimus dorsi, Quadratus Lumborum,
and Trapezius. Examiner stabilizes firmly the posterior upper legs.
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ATR 492A T&L-Spine Information
Thorax and Lumbar Spine Injury Management
Quadratus
Lumborum
• Supine or prone with hip on side to be tested in slight
abduction and feet off end of the table and slightly lift the
pelvis on the side that is being tested.
• Apply resistance just proximal to ankle by inferior pull on
lower extremity
• Grade 5: patient maintains pelvic elevation against
maximum resistance
• Grade 4: patient maintains pelvic elevation against
moderate resistance
• Grade 3: patient maintains pelvic elevation against
minimum resistance
• Grade 2: patient elevates pelvis through full ROM without
resistance
• Grade 1: No motion, but a palpable contraction is present
• Grade 0: no motion or contraction is present
WC: #7
Gluteus
Maximus
Hip extension with flexed knee. Pressure: distal posterior thigh in direction of
hip flexion.
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ATR 492A T&L-Spine Information
Thorax and Lumbar Spine Injury Management
Gluteus
Medius
Underneath leg flexed at hip & knee & pelvis rotated slightly forward to place
the posterior glut. med. in an anti-gravity position. Test: Abd. Of hip with slight
extension & slight ER. Pressure: near ankle in the direction of adduction and
slight flexion, do not apply pressure against rotation component.
Gluteus
Minimus
Abd. In a position neutral between flexion and extension, and neutral regarding
rotation. Pressure: into adduction and very slight extension.
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ATR 492A T&L-Spine Information
Thorax and Lumbar Spine Injury Management
Tensor Fascia
Lata
Patient may hold table. Knee kept extended. Examiner may need to push pelvis
anteriorly on opposite side. Test: Abduction, flexion & IR or hip with knee
extended. Pressure: Against leg in the direction of extension and adduction. Do
not apply pressure against the rotation component.
Biceps
Femoris
Flexion of knee @ 50-70 degrees with thigh in slight ER. Pressure: against
proximal to ankle into knee extension.
Medial
Hamstrings:
Semitendinos
us &
Semimembra
nosus
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ATR 492A T&L-Spine Information
Thorax and Lumbar Spine Injury Management
Flexion of knee 50-70 degrees with slight IR of thigh. Pressure: Just distal to
ankle, in direction of knee extension.
Iliopsoas
Stabilize opposite iliac crest. Knee extended. Hip in slight abduction & ER
rotation. Pressure: into extension + slight abduction.
WC: #4
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