Inspection

Careful inspection is important since it may be possible to observe at a glance why the patient has thoracic pain. Note the symmetry, any scars, skin creases and deformities, 'flat spots' in the spine, the nature of the scapulae or evidence of muscle spasm. Look for kyphosis and scoliosis.

Kyphosis may be generalised, with the back having a smooth uniform contour, or localised where it is due to a collapsed vertebra such as occurs in an older person with osteoporosis. Generalised kyphosis is common in the elderly, especially those with degenerative spinal disease. In the young it may reflect the important Scheuermann's disorder.

The younger person in particular should be screened for scoliosis, which becomes more prominent on forward flexion (Fig 34.5). Look for any asymmetry of the chest wall, inequality of the scapulae and differences in the levels of the shoulders. A useful sign of scoliosis is unequal shoulder levels and apparent 'winging' of scapula. When viewed anteriorly a difference in the levels of the nipples indicates the presence of scoliosis, or other problems causing one shoulder to drop. Inspection should therefore take place with posterior, lateral (side) and anterior views.

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Fig. 34.5 Screening for adolescent idiopathic scoliosis: configuration of the thoracic spine on forward flexion

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