PART 6 Thoracic Injury

When you see Huan in the clinic again a couple of weeks later, you are happy to hear that her kidney
infection has resolved. She had to take some time off from tennis to rest. Unfortunately, after returning to
the court after her time off, she tried a particularly aggressive backhand shot and felt a twinge in her back
as she twisted. She has had a dull achy pain in the centre of her back in the mid-thoracic region ever since.
Sometimes it becomes incredibly sharp, like when she sneezes or coughs. You immediately think that she
likely has either a subluxated rib or an intercostal strain.
a) Describe the two types of costovertebral joints. What contributes to the stability of these joints?
A typical rib has two joints that articulate with the thoracic vertebrae. The two types of
costovertebral joints are the joints of the heads of the ribs and the costotransverse joints. The
difference between these two types are that the joints of the heads of the ribs articulates at the
intervertebral joints on the bodies of the vertebrae. The rib at this joint articulates at the
intervertebral disc, and the bodies of the superior and inferior ribs of that intervertebral joint. The
rib then runs posteriorly and articulates again at the transverse process and articular facet of the
more inferior rib of the intervertebral joint (if the joints of the heads of the ribs articulated at the
junction of vertebrae T6 and T7, the costotransverse joint would be at the T7).
These two types of joints are stabilized by the ligaments and muscles that surround them. The
ligaments that stabilize the joints of the heads of the ribs are the radiate and intra-articular
ligaments of the heads of the ribs and the ligaments that stabilize the costotransverse ribs are the
lateral and superior costotransverse ligaments. The intercostal muscles also support these joints
by keeping the intercostal spaces rigid and preventing them from bulging out during expiration
or from being drawn into the thoracic cavity during inspiration. These muscles include the
external, internal, and innermost intercostal muscles, the transversus thoracis, subcostal,
levatores costarum, and serratus posterior superior and inferior.

b) Describe the attachments and action(s) of the intercostal muscles.

Intercostal muscles
External Intercostal and Internal intercostal innermost begin at inferior borders of each rib and
inserts into the superior border of the inferior rib just below it. These muscles all have the same
origin and insertion but actions are all different. For External intercostal they have two different
part to the muscle being the interosseus part which depresses the ribs during forced respiration
and then the interchondral part of this muscle elevates the ribs during forced respiration. Internal
intercostals action is that during forced inspiration this muscle ends up elevating the ribs. Then
lastly from this group of muscles which are innermost intercostal also has two parts of the
muscle. The intraosseous part depresses the ribs and the Interchondral part elevates the ribs.
Transversus Thoracis is a very small muscle going from the posterior surface of the lower
portion of the sternum into the the internal surfaces of the costal cartilages of ribs 2-6, because
this muscle is so small it only weakly depresses the ribs. The subcostal muscle would be the next
muscle within the thoracic region, this muscle is a little bigger than transversus thoracis which
means it plays a bigger role in depressing the ribs. It origin is from the internal surfaces of the
lower ribs near the angle of the rib and inserting into the superior border of the 2nd or 3rd rib
below. They spend over one rib before inserting into the inferior rib. Lastly there's Levatores
costarum and serratus posterior superior and also serratus posterior inferior. Levator costarum is
deeper to serratus posterior muscles they start from the transverse processes of T7-T11 and insert
into the subjacent ribs between the tubercles and angle of the rib and this muscle helps with
elevating the ribs, also serratus posterior superior helps with elevation of the ribs. This muscle
origins from the nuchal ligament within the posterior neck and also the spinous process of C7-T3

of the vertebrae into the superior border of 2nd-4th ribs then lastly would be the adjacent muscle
to serratus posterior superior which would be serratus posterior inferior this muscle origins from
the inferior border of the 8th-12th ribs near their angles and into the spinous process of T11-L2
vertebrae, this muscle does the opposite action then serratus posterior superior being that it
depresses the ribs. These are all the muscles that are a part of the intercostal muscles group.
c) Use your knowledge of anatomy to explain why you immediately thought that she was probably
suffering from one of these two conditions.
A rib subluxation can be referred as a partial dislocation of the rib due to hypermobility
of the anterior ends of the false rib costal cartilages, which often leads to slipping of the affected
rib under the superior adjacent rib (Cavanaugh, 2005, pg. 120) . This slippage or movement
can lead to an irritation of the intercostal nerve, strain of the intercostal muscles, sprain of the
lower costal cartilage, or general inflammation in the affected area (Cavanaugh, 2005, pg. 120).
Discovering that the patient is an active tennis player and the coordinated rotation movements
involved can be a strong mechanism of injury. During rib subluxes, the rib is likely to move
superiorly and impinge a nerve superiorly which would cause sharp pains when excessive
rotation occurs. The pain that was caused during expiration and inspiration would be resulted in
the action of which the ribs perform during the respiratory movements. During inspiration the
ribs ribs attach to both the costovertebral and costotransverse joints of the vertebra and
move anteriorly and superiorly which may enhance the pain or impingement in the nerve
superior to the vertebral segment.
An intercostal strain is a tear in one or more of the muscles located in between the ribs
and is caused suddenly or over time (PhysioAdvisor, 2016). It mostly happens when there is

tension in the intercostal muscles due to too much repetition or high force. Patients tend to feel a
sudden sharp pain or a pulling sensation (PhysioAdvisor, 2016). This pain can occur suddenly or
over time (PhysioAdvisor, 2016). Some patients can continue with pain but others, have a hard
time with the activity such as twisting. Intercostal muscles such as levator costarum, serratus
posterior/superior and intercostorum are large contributors to elevation of the ribs during
inspiration and during rotation movements. When a patient, sneezes or coughs they may feel pain
due to elevation of the ribs. Because Huan twisted quickly, this could have caused the
costovertebral joint to be pulled out of the articulation with the vertebrae causing damage to the
supporting ligaments and muscles.

Reference
Cavanaugh, D.G, Doberstein, S.T, Gibson, M.H, Mayer, J.M, Murray, S.R & Udermann, B.E.
(2005).
Slipping rib syndrome in a collegiate swimmer: A case study, Journal of Athletic Training.
40(2), 120-122.

Moore, K. L., Agur, A. M. R., Dalley, A. F., II, & Moore, K. L. (2015). Essential clinical
anatomy (5th ed.). Philadelphia: Wolters Kluwer Health.
PhysioAdvisor Staff, (2016). Intercostal Strain. Retrieved from
http://www.physioadvisor.com.au/injuries/upper-back-chest/intercostal-strain/

MARKING RUBRIC
Thoracic Injury: Excellent submissions will thoroughly and accurately describe the relevant thoracic
anatomy. A reasonable explanation will be provided for part c) based on sound anatomical knowledge.
Submissions will be written in the groups own words and will be supported by credible resources.
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