of the thoracic cage and abdomen

Disorders of the thoracic cage and abdomen


Pain in the thorax or abdomen can be the result of a local problem of either the thoracic wall or the abdominal muscles but it is more often referred from a visceral structure or from another musculoskeletal source, most frequently a disc protrusion. Therefore, it is wise to remember the only safe approach in this area is to achieve a diagnosis by both positive confirmation of the lesion and exclusion of other possible disorders.

Referred pain

Pain referred from visceral structures

All visceral structures belonging to the thorax or abdomen may give rise to pain felt in this area (see Ch. 25). In that the discussion of these disorders is principally the province of internal medicine, only major elements in the history that are helpful in differential diagnosis from musculoskeletal disorders are mentioned here. Acute chest pain is summarized in Box 1.

Heart (Fig. 1)

Ischaemic heart disease

The innervation of the heart is derived from the C8–T4 segments. Pain is therefore not only felt in the chest but can also be referred to the ulnar side of both upper limbs, though more commonly to the left.

It is traditionally accepted that pain felt in the chest radiating into the left arm is indicative of myocardial ischaemia, especially when the patient reports it as pressure, constriction, squeezing or tightness. However, none of these descriptions, which are usually regarded as characteristic of ischaemia, is of definitive aid in the differential diagnosis from other non-cardiogenic problems in the thorax. Even relief of pain after the intake of glyceryl trinitrate does not offer absolute confirmation of coronary ischaemia. For clinical diagnosis, a combination of several elements must be present, of which the most important is pain spreading to both arms and shoulders initiated by walking, especially after heavy meals or on cold days.1


Pain that arises from the pericardium is the consequence of irritation of the parietal surface, mainly from infectious pericarditis, seldom from a myocardial infarction or in association with uraemia. When pericarditis is the outcome of one of the latter two causes it is usually only slight. Pain is normally located at the tip of the left shoulder, in the anterior chest or in the epigastrium and the corresponding region of the back. Three different types of pain can be present. First and most obvious, but rarely encountered, is pain synchronous with the heartbeat. Second is a steady, crushing substernal ache, indistinguishable from ischaemic heart disease. Third and most common is pain caused by an associated localized pleurisy, which is sharp, usually radiates to the interscapular area, is aggravated by coughing, breathing, swallowing and recumbency, and is alleviated by leaning forward.2


Pleuritic pain

Pleuritic chest pain is a common symptom and has many causes, which range from life-threatening to benign, self-limited conditions. Because neither the lungs nor the visceral pleura have sensory innervation, pain is only present if the parietal pleura is involved, which may occur in inflammation or in pleural tumour. Invasion of the chest wall by a pulmonary neoplasm also provokes pain.

Clinical presentation

Pleuritic pain is localized to the area that is inflamed or along predictable referred pain pathways. Parietal pleurae of the outer rib cage and lateral aspect of each hemidiaphragm are innervated by intercostal nerves. Pain is therefore referred to their respective dermatomes. The central part of each hemidiaphragm belongs to the C4 segment and therefore the pain is referred to the ipsilateral neck or shoulder.

The classic feature is that forceful breathing movement, such as taking a deep breath, coughing, or sneezing, exacerbates the pain. Patients often relate that the pain is sharp and is made worse with movement. Typically, they will assume a posture that limits motion of the thorax. Movements of the trunk which stretch the parietal pleura may increase the pain.

During auscultation the typical ‘friction rub’ is heard. The normally smooth surfaces of the parietal and visceral pleurae become rough with inflammation. As these surfaces rub against one another, a rough scratching sound, or friction rub, may be heard with inspiration and expiration. This friction rub is a classic feature of pleurisy.



This is characterized by a sharp superficial and well-localized pain in the chest, made worse by deep inspiration, coughing and sneezing. Viral infection is one of the most common causes of pleuritic pain.7 Viruses that have been linked as causative agents include influenza, parainfluenza, coxsackieviruses, respiratory syncytial virus, mumps, cytomegalovirus, adenovirus, and Epstein-Barr virus.8

Pulmonary embolism

Pulmonary embolism is the most common potentially life-threatening cause, found in 5–20% of patients who present to the emergency department with pleuritic pain.9,10

Predisposing factors for pulmonary embolism are: phlebothrombosis in the legs, prior embolism or clot, cancer, immobilization, prolonged sitting (aeroplane), oestrogen use or recent surgery.11

Symptoms and signs are mainly dependent on the extent of the lesion. A small embolus may give rise to effort dyspnoea, abnormal tiredness, syncope and occasionally to cardiac arrhythmias. A medium-sized embolus may lead to pulmonary infarction, so provoking dyspnoea and pleuritic pain. In a massive pulmonary embolus, the patient complains of severe central chest pain and suddenly shows features of shock with pallor and sweating, marked tachynoea and tachycardia. Syncope with a dramatically reduced cardiac output may follow. This is a medical emergency: death may follow rapidly.

Superior sulcus tumour of the lung (Pancoast’s tumour)

This warrants special attention because 90% of patients suffering from this disorder complain of musculoskeletal pain.12,13 It is frequently mistaken for a shoulder lesion or even for thoracic outlet syndrome, an error which leads to a delay in diagnosis and treatment.14

The superior pulmonary sulcus is the groove in the lung formed by the subclavian artery as it crosses the apex of the lung. Because most apical tumours have some relation to the sulcus, they are often called superior sulcus tumours. They frequently involve the brachial plexus and the sympathetic ganglia at the base of the neck and may destroy ribs and vertebrae.

Pain around the shoulder, radiating down the arm and towards the upper and lateral aspect of the chest is usual and is often worse at night.

Orthopaedic clinical examination produces an unusual pattern of clinical findings. There is often a complicated mixture of cervical, shoulder and thoracic signs. Passive and resisted movements of the cervical spine may be limited and/or painful, the result of involvement of the scaleni and sternocleidomastoid muscles. On examination of the shoulder girdle, a restriction of both active and passive elevation of the scapula may be present. More positive signs are detected during examination of the shoulder.15 Both active and passive elevations of the arm are limited because of spasm of the pectoralis major muscle. Passive shoulder movements may be considerably limited in a non-capsular way. Some resisted movements are weak.

The neurological examination of the upper limb shows weakness and atrophy of the muscles on which consequent is extension of the tumour to the lower trunks of the brachialis plexus (Fig. 2). The only abnormal finding during thoracic examination is pain and limitation on lateral flexion towards the unaffected side explained by putting the affected thoracic wall under stretch.

The clinical picture of Pancoast’s tumour may be completed by some typical findings that are caused by an ingrowth of neurological and vascular structures at the apex of the lung.16

These include:

All the symptoms and signs mentioned (summarized in Box 2), either singly or in combination, call for careful clinical chest examination followed by further investigation by chest radiography or other imaging methods.

Mediastinal problems

Oesophagus (Fig. 3)

Diaphragm (Fig. 4)

Stomach and duodenum (Fig. 5)

Liver, gallbladder and bile ducts (Fig. 6)

Jun 5, 2016 | Posted by in ORTHOPEDIC | Comments Off on of the thoracic cage and abdomen
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