Clavicle evaluation

Initial assessment of the CXR evaluates the quality of the film for patient rotation, inspiratory effort, and penetration. Rotation is assessed by evaluating symmetry of the clavicles and central placement of the Carina. Inspiratory effect is considered adequate if the diaphragms are pulled below the ninth rib. Lack of inspiratory effort and obesity lead to a poor-quality CXR, which makes it more difficult to assess the presence of pleural effusions and fluid in the costophrenic angles. Where possible, comparison with previous or baseline films is done to determine the quality of film and comparison of structures. 

Evaluation of the clavicle is discussed in Chapter 80 (Evaluation of the Shoulder). Because of the close relationship between the clavicle and the first rib, when first or second rib restriction is found, the clavicle must be evaluated. Its normal position, structure, and motions are all significant to normal functioning of the thoracic cage. 

Somatic dysfunction of the thorax may occur anteriorly, involving ribs, sternum, or clavicle, or posteriorly, involving costovertebral articulations or the scapulae. Muscle attachments connect the thoracic cage to the cervical spine, the thoracic spine, the lumbar spine, the innominate bones, and the upper extremities. These regions must be evaluated when problems occur in the thoracic cage. 

The lirst rib is probably the rib most commonly involved in somatic dysfunction of all the ribs. It is affected by trauma, stress, and posture as well as by dysfunction ofthe C7-T1 complex. The patient may report "shoulder" pain, stiff neck, upper back or neck pain, and an inability to turn the head while driving. The first rib can impinge the neurovascular bundle as it passes between it and the clavicle through the costoclavicular space. The anterior and middle scalene muscles, which raise the first rib, may likewise compress the brachial plexus when they are in spasm and result in thoracic outlet syndrome symptoms. The patient s symptoms are then described as pain, numbness, or paresthesias ofthe arm or hand on the involved side. The physician needs to be aware that this may cause confusion should the patient demonstrate a herniated cervical disc on magnetic resonance imaging [MRO. The symptoms may be caused by the rib dysfunction rather than the herniated disc, so evaluation ofthe rib for normal motion and treatment of any dysfunction should be performed in these cases. Osteopathic manipulation may save the patient unnecessary surgery. 

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