Ernest Eckford Tucker
TWELFTH AND ELEVENTH MOVEMENT
The eleventh and twelfth ribs are simply joined to
the pedicles of their respective vertebrae, posterior to the bodies, at
some distance from the transverse processes, which are very short.
They stand as it were erect, without other bony support or limitation.
In these two ribs all movements are possible, limited
only by ligaments and muscles that attach to them. Of these the capsular
ligaments are the most strict, but have no effect on the varieties of motions
possible. Ligaments doubtless attach to the transverse processes,
and should be studied. The intercostals fascia is poorly represented.
The most effective of the ligamentous limitations, however, is this intercostals
aponeurosis, which in the twelfth rib extends down and in to the costal
process of the first lumbar, and above, up and out to the eleventh rib.
It draws the rib down and in, from the middle third, and up and out from
the spinal end.
Any movement of a character sufficiently extreme
to carry the base away from its articulation on the pedicle may create
a lesion. The tensions that hold the rib to its base draw not directly
to that base, but quartering toward the spine. When strained beyond
the normal articulation with the base, these tensions so draw it against
the articular surface that in trying to return to normal a wrinkle may
be made, which wrinkle may hold it as a lesion.
The lesion may be in any direction from the base.
The most usual direction is upward and forward, produced by blows from
behind and below (almost the only blows that reach it) or by wrenches in
which the shoulder is twisted backward on that side. In this movement
the tension of the abdominal muscles acting mostly on the tip, draws down
and forward, while the ligaments to the eleventh rib, together with the
intercostals muscles, draw upward near the head. The combined tensions
gap open the upper part of the articulation, twist the rib, slide it upward
in the twisting, and leave it as a lesion.
Diagnosis of lesion of this rib is made by comparison
with the opposite side, with ribs above, with the average normal, and by
sensitiveness and visceral disturbance traceable to it.
For those ribs, particularly the twelfth, exact technic
is perhaps the most difficult of all parts of the body, on account of the
absence of bony leverage by which to draw the rib away from its point of
Patient kneels on table, feet over edge, and sits
back on heels; clasps hands behind neck. Operator stands behind and
to side of lesion. Assuming right twelfth rib to be in lesionsóoperator
passes right hand under right axilla and places it over clasped hands of
patient; places left thumb on rib as near to head a possible; between it
and the eleventh if lesion is upward; below if lesion is downward.
Operator then swings patientís spine to right, so that he sinks off from
seat on heels to right; supporting weight with right hand and arm under
axilla; keeping neck as near the median line as possible. In this
position the spine is bent to the right to the limit of its motion, the
twelfth rib is drawn up at its outer extremity by the intercostal muscles
tensed by the raising of the arm; the intercostals aponeurosis below, acting
on the center of the rib, acts as a fulcrum, and the thumb pressing forward,
outward and downward, moves the head to its normal seat.
The same principle may be applied with patient seated
on table. Operator stands behind. Patient places left hand
behind neck, operator passes left hand under left axilla and places it
over patientís hand on back of neck, forearm supporting axilla. With
right hand he presses forward on eleventh dorsal vertebra until spine is
in full extension; then with right thumb on head of rib as above, he produces
side-bending to right, retaining neck as near median line as possible,
focusing motion at the twelfth rib. To this complete extension and
complete lateral flexion, then some rotation is added until the lesion
sis felt to be released. If not released, operator may then press
downward on neck, carrying spine suddenly to flexion, while maintaining
side-bending rotation and pressure with thumb; and may alternate extension
and flexion until correction is made.
The same principle may be employed with patient on
hands and knees.
In all of these forms of technic deep inspiration
may be of some assistance. In deep inspiration the intercostals muscles
are tensed, drawing up and to the spine, and the diaphragm is also tensed,
drawing up and on the tip of the rib and transversely across the body.
The technic for the other ribs in general may be
used for these ribs.
TENTH TO THIRD RIBS: MOVEMENTS
In inspiration the ribs turn slightly on the transverse
processes, and slide forward on the lower and backward on the upper facet
against the bodies of the vertebrae. From extreme expiration to extreme
inspiration the total of motion is rarely over two inches at the tips of
the longest ribs, and in some of this at least the vertebrae themselves
share; a maximum of two inches at the tip of the rib means very slight
motion indeed at the transverse processes and facets; even the slight apparent
motion being diminished by the motion of the vertebra itself and the yielding
of the elastic cartilages and ligaments.
In flexion and extension of the body the ribs move
as in inspiration and expiration.
In side-bending of the body each rib moves with the
vertebra to which it belongs, the vertebra above sliding on the superior
facet of the rib. It may even press the rib down on the concave side,
the rib sliding down and out on its inferior facet, and out on the tubercle
at the transverses process; doubtless this motion is in all cases exceedingly
slight; but it explains the discrepancy between the center of rotation
of the articular processes and that of the costal facets.
In this motion the tips of the ribs remain relatively
stationary on both sides, being fastened together in front, unless there
is inspiration at the same time; while on the convex side the extreme lateral
part in the axillary line moves relatively down (unless there be inspiration
at the same time) and on the concave side, up; with corresponding turning
at the transverse processes.
In rotation side-bending each rib moves with its
vertebra; transverse process of the vertebra moves up and out and forward
on the convex side, carrying with it the rib; but the ribs are all fastened
together in front by the cartilages attaching them to the sternum; so that
the ribs on the convex side must separate in the axillary line; but since
the spine turns relatively more than the ribs, these must slide upward
on the transverse processes; and on the concave side the reserve; giving
the downward motion to individual ribs as noted in preceding paragraph.
Any confusion of thought that arises here may be clarified by recalling
that the tubercle-transverse process joint is concave on the transverse
process, convex on the tubercle; so that, as in the shoulder, motion down
of the shaft means motion up in the socket. Since this is just the
point where lesions occur, the picture should be clear.
Limitations to motion are the ligaments of the joints,
and the intercostals aponeurosis, drawing down and in below and up and
out above, with a slightly greater distance from the spine on the lower
side; so that the general tendency is to upward luxations of ribs.
This is particularly true of the human subject, standing erect with the
full weight of ribs and muscles bearing downward on ends of ribs.
(This is the reverse of the general direction of pressure in the animal,
in which the pressure from weight of viscera carries ribs down and forward,
that from muscular effort toward the head). Lesions may, however,
be either up or down, at the tubercle. Lesions of the head, if they
exist, are indistinguishable from those at the tubercle.
The intercostals muscles, along the full length of
the rib, act in lesions so as to distribute the tension. Certain
fibres will be over-strained and others relaxed, those between remaining
normal. The latter should be found at the juncture of the middle
third with the anterior and posterior thirds, which are therefore apparent
centers of rotation.
The intercostals muscles so act, however, only when
on tension, which is not the usual state in the erect trunk of the human
subject. The position of a rib in lesion is therefore determined
usually by the position of the tubercle and of the head and tipówhen up
at the tubercle its lower edge will be exposed behind, its tip will be
drawn back and depressed. When all of the intercostals muscles are
on tension it tends to correct the lesion.
To become familiar with the motions of ribs, have
patient seated, operator standing behind; place thumbs of both hands on
corresponding ribs of two sides, thumbs as near the spine as it is possible
distinctly to feel the bone; place fingers on margins of same ribs, as
far along as they will reach. In this position have patient inhale
and exhale, and go through various movements; trying to distinguish the
bone from the contracted muscle. Then do the same things with passive
movements. Assume position to give the cork screw movement; place
thumb and fingers on rib as above; execute cork screw movement and various
other movements with the patient completely passive. It will be discovered
that the movements of ribs are quite complicated. It is probably
best to focus the mind on what is happening at the transverse process and
the position of the vertebra, tracing back from the points where the fingers
lie to those points with the imagination.
To develop an efficient technic it is not enough
to have done this once, but requires that it be done long enough to become
almost subconscious; and it should be rehearsed again with each case that
presents any difficult features.
Diagnosis of rib lesons is best made where it existsóat
the juncture of the rib with the transverse process. The rib is not
quite a continuation of the process, but extends out from its upper half
in the lower vertebrae, its center in the mid dorsals, and its lower half
in the upper dorsals. It will be remembered that these facets are
inclined, not flat with the spine; that they incline upward in the lower,
forward in the mid, and downward in the upper vertebrae. Lesion will
therefore carry them in these respective directions; in the lower chest,
they will be less prominent posteriorly if the lesion is downward, more
prominent if the lesion be upward; the reverse in the upper chest, and
neutral in the middle; except that the curve of the neck of the rib acts
to bring the angle to greater prominence in any lesion, from second or
third to ninth or tenth ribs; and that approximately to the rib above makes
a rib seem less prominent. Failure to form a mental picture of this
curved neck, in those ribs where it exists, may be responsible for much
confusion in diagnosis.
Secondary deviation may be found along the shaft
of the rib in lesion, but this may be masked by the tension of muscles,
especially in inspiration. In general, a rib that is up at the transverse
process will be down in front, its tip pointing at a greater angle; its
inferior border will be palpable behind, and it will be not parallel with
the ribs above and below. If the lesion be downward at the transverse
process, its tip will point more up than its fellows, its inferior border
behind will be half concealed and its upper border may be palpable.
If the vertebra to which it is attached is in lesion,
upward on the right, then the right rib will be raised as the transverse
process is raised, but will turn on the process and assume a position as
when it itself is in lesion upward. On the opposite side, the reverse.
If actual lesion then occurs between rib and transverse process, this tends
to offset the deviation.
Assuming a lesion of the eighth rib upward on the
right. Patient is seated on table; places right hand on left shoulder;
operator stands behind, facing right; places left axilla over patientís
shoulder and hand thereon, passes left arm around body and under patientís
elbow, places fingers on the eighth rib in front of the axillary line;
places right thumb on eighth rib as near the transverse process as possible,
the fingers as far along as possible. Exerting slight pressure on
the rib in all of these directions, he then executes the cork screw movement
a time or two, then bows the spine convex to the right to complete side-bending
of the eighth segment, at the same time rotating to left to complete limit
of rotation; and alternates bowing to this ribs. This technic is
available from the twelfth to the fourth side and rotation until the lesion
is felt to be released.
The effect of this technic is as follows: The
pressure with the right thumb and fingers carries the rib away from the
transverse process enough to overcome the catch or wrinkle that is
holding it in lesion; pressure by the fingers on the front end down in
and centrally, overcomes the resistance of the intercostals muscles and,
acting through the curved spring of the rib, still further aids in carrying
the rib from the transverse process (pressure back and in on the front
ends of ribs makes a fulcrum of the thumb in the back, and tends to gap
not only the articulation at the transverse process, but also that at the
head of the rib). The movements then act to tense all muscles, to
gap open the joint at the top, and with the pressure of thumb to carry
it to normal.
It is impossible to distinguish lesions at the headóif
indeed such lesions existófrom those at the transverse process; and the
technic seems to be the same. In any case in all of the most successful
technic for ribs, this element of pressure on both ends is evident.
As for instance, the following:
Patient seated, places right hand on top of head
(highest point). Operator stands behind, passes right arm under patientís
axilla, supporting it, places hand on top of patientís hand on head; places
left thumb on rib as near transverse process as possible; presses to right
and forward with thumb while carrying vertex to left and slightly back,
with lifting of axilla, to full limit of side-bending convex to right end
of extension of segment in lesion.
The effect of this treatment is as above, except
that in place of pressure by the fingers backward on the front end of the
rib we have traction backward and upward through the pectoral and intercostals
Caution. The neck should not be turned sharply
nor bent sharply, as is the natural tendency; it should be bent as little
as possible, the focus of motion being on the lifting of the ribs and the
bowing of the spine. The head should be slightly turned to right
to increase separation between transverse processes.
This technic is not strongly corrective, but is mild
and soothing for nervous cases. It is excellent for relaxation in
the upper dorsal region.
Many forms of this technic are in use, the patient
prone or supine or on side or against door jam, using the arms in different
ways; and doubtless each of them has its advantages which vary in different
cases. In all, caution must be used not to exceed the normal limits
of motion of the shoulder joint itself, which is much more sensitive than
most other joints of the bodyóprotected by more sensitive nerves because
of the somewhat greater danger of straining it. For instance in this:
Patient supine; operator stands at side of lesion;
assuming eighth rib of right side in lesion, stands at right side; places
fingers of right hand under angle of eighth rib, ready to press upward
and toward patientís head; grasps patientís right wrist with left hand,
carries it directly up in the axillary line with slight pressure backward,
to the limit of motion, while the patient inhales a deep breath; at the
same time pressing upward and toward the head with the finger on the affected
The effect of this position of the arm is to carry
the rib to the upper limit of motion on the transverse process, while the
front end is held down, controlled by the tensed serratus magnus muscle;
this gives it therefore an angle, at the top limit of its motionócauses
it to assume as nearly as possible the position of the lesion, or the position
it was in when it became a lesion, while yet all of the surrounding tissues
are exerting on it tension to the normal. The deep inhalation helps
in this effect. Slight lifting with the finger is thus often able
to release it from the catch.
Holding all in that position for a brief second while
the ligaments stretch, all is then reversed; the right hand is brought
forward, in front of shoulder and carried to full extension over the head;
the pressure of the finger on the rib is changed to lift the rib toward
the feet; the breath is released all at once. This tends to raise
the front end of the rib and lifts the tubercle on the transverse process
over the catch and toward normal. This is one of the oldest forms
of technic. Its chief drawback is the strain upon the shoulder.
This technic may be used with the patient prone,
the table supplying the pressure on the front ends of the ribs as in the
previous technic; or with a pillow placed against a door-jamb and the patientís
breast pressed against the pillow; or with an assistant pressing on the
front end of the rib; or, less accurately with the operatorís knee against
the back end of the rib, the fingers moving the front end, the other hand
moving the patientís arms.
FIRST AND SECOND RIBS: MOVEMENTS
The motion of these two ribs is much slighter than
that of the others. The motion of the sternum is forward, and up;
but the excursion of the lower part is much greater than that of the upper
part, leaving very little for these first two ribs. Beside this they
have a slight wing motion, under the traction of the scalene muscles, opposed
by the intercostals; little more than a ligamentous yielding.
On account of the thickness of the over-lying muscles
it is very difficult as a rule to examine effectively these two ribs except
at the sternal ends. Unevenness on the two sides in front argues
probability of a lesion, but to know which side is in lesion, one must
rely upon relative sensitiveness. Lesion upward at the transverse
process draws the sternal end backward, making it seem smaller than its
fellow, and making it also sensitive; lesion downward, the reverse.
About one inch of the first rib may be felt beneath the collar bone.
By drawing the shoulder blade away and slightly lifting it, in thin subjects
the spinal ends may sometimes be felt; but they bend almost directly forward
from the transverse process, leaving little surface for examination and
little certainty therein. With patient lying on side and shoulder
blade lifted, the thumbs may find and examine one side at a time.
As in the other ribs, lesions at the transverse processes
cannot be distinguished from those at the head, up and forward, down and
back if slight; but the curve if the latter exist. Lesions at the
transverse process are up and forward, down and back. They seem more
prominent if up, on account of the spacing, less so if down.
Assuming right first rib to be downward on transverse
process; patient seated on table; operator stands behind; places right
foot on table and places knee under patientís right axilla, arm hanging
loose; presses down on arm to carry shoulder blade away from spine and
to put upward tension on sub-clavius and pectoralis minor muscles; swings
knee with patient slightly to right to secure full extension of ribs; places
right thumb against the angle of rib where it leaves transverse process,
endeavoring to get beneath it, between it and the second rib; places left
hand on patientís head and carries to left to limit of motion to produce
tension on scalene muscles; in this position turns face first toward left
to lift transverse process and produce an angle between it and the rib,
then to right and backward to carry transverse process backward away from
rib, changing the angle. With gentle exaggerations of these tensions
the rib may be brought to normal. If necessary swing head and neck
in extreme side-bending from left to extreme right; repeat until lesion
A slightly different use of the pectoral muscles
may be made with the patient supine; operator draws patientís right arm
across breast, high up; places his sternum against elbow, ready to press
down; places left hand under first rib, knuckles against table, fingers
bearing up against rib; with right hand carries head to left side, then
to right; gentle exaggeration of all of these tensions will tend to bring
the rib to normal.
Patient may be seated, elbow against operatorís sternum,
technic as above.
If lesion is upward, it is a simple matter to exert pressure
from abaove and with technic as above, to carry it downward to normal.