Gross Anatomy - Thorax

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What is the function of the thoracic wall: 1. Movement of gases
2.Protection of thoracic and abdominal viscera
3. Attachment of appendicular muscles (intercostals)
What is a distinguishing feature of thoracic typical vertebra: costal demifacets (full facets on atypical)
Which part of the rib is in contact with thoracic facets: Tubercle of the rib
Which thoracic vertebrae are typical? atypical?: atypical have 1 in them - 1 and 11, typical - 2-9
Describe typical ribs: 3d-9th
-Has head, neck, tubercle and body (shaft)
-Head articulates with corresponding vertebral bodies, IV discs and vertebral bodies above
-BODY is thin flat and turns sharply anteriorly at ANGLE and has COSTAL GROOVE on inferior internal surface of the rib and passes INTERCOSTAL VEIN,ARTERY,NERVE (VAN)
-TUBERCLE associates with transverse process (except ribs 11 and 12)
What type of joint is costovertebral joint: Plane synovial
Which ribs are atypical: 1st, 2nd, 10, 11
Describe 1st rib: -It is BROADEST and SHORTEST of true ribs
-Has single articular facet on head, which articulates with first thoracic vertebra
-Has SCALENE tubercle for insertion of anterior scalene muscle
-Has 2 GROOVES for subclavan artery and vein
Describe 2nd rib: -Has two articular facets which articulate with bodies of 1st and 2nd thoracic vertebrae
-twice as long as 1st rib, attachment for posterior scalene muscle
Describe 10th rib: -Has single facet for articulation with 10th thoracic vertebra
Describe ribs 11 and 12: -Have single articular facets on their head
-Have no neck or tubercle
What is the main function of ribs: Increase diameter of thorax from front to back and sideways (for breathing)
Which ribs are true ribs: First SEVEN ribs (1-7), attached to sternum by costal cartilages
Which ribs are false ribs: Lower FIVE ribs 8-12, ribs 8-10 are attached to costal cartilages immediately above them
Which are floating ribs: 11 and 12, attach only to vertebrae
What type of joint is sternoclavicular joint: Only bony attachment of upper limb to sternum
-SADDLE type synovial joint but has ball and socket movements
What type of joint is sternocostal joint: -Articulation of sternum with first seven ribs
-1st -SYNCHONDROSES
-2nd-7- PLANE SYNOVIAL
What type of joint is costochondral joint: Joint between rib and costal cartilage
-SYNCHONDROSES
What is the consequence of 1st rib fracture: Injury to brachial plexus and subclavian vessels
Distinguish rib dislocation from rib separation: Dislocation of the rib is disarticulation and sternocostal and intercostal jooints.
Separation of ribs is disarticulation at costochondral joints
What type of joint is intercostal joint: Plane synovial
Which three lines can be landmarks of thoracic wall: Midaxillary line - through middle of axilla
Midclavicular line-through middle of clavicle
Scapular line-through middle of scapula
Describe muscles of thoracic wall: -Serratus posterior
-Levator costarum
-Intercostals
-Subcostals
-Transversus thoracis
-Diaphragm
What is the main function of thoracic wall muscles: Respiration
What are three layers of intercostal muscles: External
Internal
Inner most
Describe external intercostals: -extend from tubercle of the rib to costochondral junction
-Originate at lower border of the rib in the space, insert at upper border of the rib below
-Innervated by internal costal nerve
-Blood supply internal costal artery
-keep intercostal space from blowing out or sucking in during respiration, elevate ribs in forced inspiration
-Orientation- putting hands in pockets
Describe internal intercostals: -originate at upper border of the rib, insert at lower border of the rib above
-from margin of sternum to the angle of the rib
-elevate and depress ribs during forceful inspiration
Describe inner most intercostals: originate at upper border of the rib, insert on inferior margin of the rib above
-have same orientation as internal but lie deep to neurovascular bundle
Describe subcostal muscles: -originate at angle of the rib and insert at angle 2-3 vertebrae above
-compress intercostal spaces, elevate ribs
Describe transversus thoracis: -originate at posterior sternum, insert between angle and tubercle
-compress thorax for forced expiration, pulls rib down
What innervates diaphragm: -Motor fibers from phrenic nerve (C3,4,5- keep men alive)
-Sensory from phrenic, intercostal and subcostal nerves
How does diaphragm assist inspiration: Descends when it contracts, causing increase in thoracic volume by increasing vertical diameter and decrease in lung pressure, which becomes negative and sucks air into lungs
Right crus: part of diaphragm, longer and larger then left crus
-originates at L1-L3 (left L1-L2)
Medial arcuate ligament: -attaches to body and transverse process of L1
Lateral arcuate ligament: extends from transverse process of L1 to rib12
What passes through diaphragm: -Vena cava opening- at level of T8, passes IVC, and sometimes right phrenic nerve
-Esophageal opening- T10, esophagus and anterior and posterior trunks of vagus nerve
-aortic hiatus - T12, aorta, azygus veins, thoracic duct
what is the consequence of lower rib fracture: tear in diaphragm, can have hernia of abdominal organs to chest
Name muscles used for quiet inspiration: Diaphragm + intercostal muscles
Name muscles used for deep inspiration: erector spinae (take deep breath, straighten back), diaphragm, rhomboids, serratus anterior, pec minor
Name muscles used for forced expiration: serratus posterior
subcostals
quadratus lumborum, transversothoracic abdominal wall (oblique rectus)
Patient has fracture of 1st and 2nd ribs. What is injured?: Subclavian artery, lower brachial plexus (C7 C8)
Define costoclavicular syndrome: compression of artery nerve between clavicle and 1st rib- numbness, pain of upper limb
Intercostal nerves: anterior rami of thoracic nerves
What is the name of the nerve that runs beneath 12th rib: subcostal nerve
Where do intercostal nerves run: Between inner and innermost layers of muscles with intercostal artery and vein (VAN), lodged in costal grooves of the rib, have lateral and anterior cutaneous branches and muscular branches
Describe internal thoracic artery: arises form FIRST PART OF SUBCLAVIAN ARTERY, descends directly behind first six costal cartilages
-gives rise to two anterior intercostal arteries in each of upper six intercostal spaces and terminates at sixth intercostal space by dividing into musculophrenic and superior epigastric arteries
Which veins drain body wall: Azygos
Which vein drains 1st intercostal space: 1st intercostal vein
Which veins drain intercostal spaces 2-4: superior intercostal veins
What is the level of male nipple: T4
What is the level of xyphoid process: T6
What is herpes zoster: Shingles, viral disease of spinal ganglia, distributed according to dermatomes
Intercostal nerve block: Need to inject into intercostal nerve, but there is overlap of dermatomes, so to get complete numbness, need to inject into two adjacent nerves, need to insert needle along inferior margin
What are three divisions of thoracic cavity: Left pulmonary
right pulmonary
mediastinum
Define pleura: Thin serous membrane that consists of parietal and visceral pleura
Name two types of pleura: Parietal and visceral
Where does parietal pleura go: lines inner surface of thoracic wall and mediastinum
Name parts of parietal pleura: Costal
Diaphragmatic
Mediastinal
What is the name for parietal cervical pleura: Cupula, dome of pleura, projects into neck above the neck of first rib
What is Sibsons fascia: Thickened portion of endothoracic fascia, attached to first rib and transverse process of seventh cervical vertebra
-PROTECTS TOP OF LUNG
What separates Sibsons fascia from thoracic wall: Endothoracic fascia which lines thoracic cavity
Is parietal pleura sensitive to pain: YES, very sensitive
What innervates parietal pleura: Intercostal and phrenic nerves
What supplies blood to parietal pleura: Internal thoracic, phrenic, superior and posterior intercostal arteries
Visceral pleura envelops..: surface of lung
Blood supply of visceral pleura: Bronchial arteries
What drains venous blood of visceral pleura: pulmonary veins
Is visceral pleura sensitive to pain: Insensitive to pain but sensitive to stretch. contains vasomotor and sensory vagal fibers involved in respiratory reflexes
Define pleurisy: INFLAMMATION OF PLEURA with exudation into cavity causing pleural surfaces to be rough and PLEURAL RUB can be heard with stethoscope. Forms adhesions later. Symptoms - chills followed by dry cough.
Treatment - pain killers or intercostal block with lidocaine
What kind of space is pleural cavity: POTENTIAL between pleural and visceral.Contains film of fluid only
What are two pleural reflections: STERNAL and COSTAL - areas where pleura changes direction
What are two pleural recesses: 1. Costodiaphragmatic - formed by reflection of costal and diaphragmatic pleurae, can accumulate fluid, allows lungs to be pulled in and expanded during inspiration
2. Costomediastinal - part of pleural cavity where costal and mediastinal pleurae meet
Which costomediastinal recess is larger - right or left: left
Define thoracocentesis, where should you do it, where to insert needle: surgical puncture of thoracic wall into pleural cavity for aspiration of fluid. Performed at or posterior to MIDAXILLARY LINE one or two intercostal spaces below the accumulation of fluid but not below ninth intercostal space. Ideal space is seventh eigth or ninth intercostal spaces, because avoid accidental puncture of lung, spleen, liver or diaphragm.
Needle should be inserted immediately above superior margin of rib to avoid injury to intercostal neurovascular bundle
Which lung is larger and heavier?: RIGHT
Which lung is longer?: LEFT
How many lobes does right lung have: 3 lobes - upper, middle, lower
Describe apex of right lung: projects into root of neck and is smaller then apex of left lung
What are the levels for root of the lung: T5-T7
How many lobes does left lung have: 2 - upper and lower
What is oblique fissure: Fissure that divides into uper and lower lobes, follows line of 6th rib, receives two bronchial arteries
Whats a lingula: tongue shaped portion of upper lobe of left lungthat corresponds to middle lobe of right lung
What is on surface of left lung: Cardiac impression
Cardiac notch (deep indentation on anterior border of superior lobe of left lung), grooves for various structures
How many fissures does left lung have: one- oblique
How many fissures does right lung hae: two - oblique and horizontal
At which level trachea bifurcates into two bronchi: level of sternal angle(T4-T5)
Which primary bronchus does foreign bodies go to Why?: Right, because its shorter wider and more vertical
How many secondary and tertiary bronchi does right lung have: 3 secondary and 10 tertiary
How many secondary and tertiary bronchi does left lung have: 2 secondary and 8 tertiary
What is the significance of carina: may be examined with bronchoscope, can be compressed and distorted by bronchogenic carcinoma
Which surface is irritated during cough reflex: Mucous membrane of carina, in trachea
Define atelectasis: Collapse of lung caused by blockage of the air passages
What is the main function of alveoli: Gas exchange
What blood does pulmonary trunk carry: Poorly oxygenated to lungs for oxygenation
Where does pulmonary trunk separates into right and left pulmonary arteries: at the level of sternal angle
Describe pulmonary veins: INTERSEGMENTAL
One coming out of each lobe of the lung - 5 veins
What kind of blood do pulmonary veins carry: OXYGENATED from alveoli
DEOXYGENATED from visceral pleura and part of bronchioles to LEFT ATRIUM
Where do bronchial arteries arise from: THORACIC AORTA
How mnay bronchial arteries go to right lung: ONE
How many bronchial arteries go to left lung: TWO
What kind of blood do bronchial arteries carry: OXYGENATED to conducting non respiratory tissues of lung and visceral pleura
PUlmonary embolism: obstruction of pulmonary artery by embolus - air, blood clot, fat, tumor cells or other foreign material.
Arise in deep veins of lower limb (DVT) or pelvic veins
Bronchial veins drain into: AZYGOS and HEMIAZYGOS
Superior mediastinum boundaries: 1st rib and sternal angle
Contents of superior mediastinum: SVC
Brachiocephalic veins
ARCH OF AORTA
thoracic duct
TRACHEA
esophagus
vagus nerve
phrenic nerve
left recurrent laryngeal nerve
thymus
Anterior mediastinum location: ANTERIOR to pericardium
POSTERIOR to sternum and transverse thoracic muscles
Contents of anterior mediastinum: Thymus
Fat
Lymph nodes
Connective tissue
Middle mediastinum location: Between right and left pleural cavities
COntents of middle mediastinum: HEART
pericardium
roots of great vessels(aorta, pulmonary arteries and veins, venae cavae)
ARCH OF AZYGOS VEIN
MAIN BRONCHI
Posterior mediastinum location: Posterior to pericardium, between mediastinal pleurae
Contents of posterior mediastinum: Esophagus
Thoracic aorta
Azygos and hemiazygos veins
Thoracic duct
Vagus nerves
Sympathetic trunk
Splanchnic nerves
What is the mnemonic for remembering contents of posterior mediastinum: DATES
D- descending aorta
A- azygos veins
T-thoracic duct
E-esophagus
S-sympathetic trunk+ganglia
Pericardium location: Middle mediastinum, encloses heart and roots of great vessels
Two parts of pericardium: Fibrous and Serous
Fibrous pericardium: Strong dense fibrous layer located outside of pericardium
Serous pericardium: Composed of PARIETAL - lines inner surface of fibrous pericardium
VISCERAL - forms epicardium of heart wall and roots of great vessels
Location of pericardium: Middle mediastinum
Two parts of serous pericardium: Visceral and parietal
Define pericarditis: Inflammation of pericardium, can result in cardiac tamponade,pericardial effusion, epigastric pain
Pericardial friction rub: Surfaces of pericardium become rough and result in sounds like rustling of silk which can be heard on auscultation
Name two sinuses of pericardium: Transverse and oblique
Why is transverse sinus important: It is of great importance to cardiac surgeon because while performing surgery on aorta or pulmonary artery, surgeon can pass finger and make ligature to stop blood circulation
Cardiac tamponade: Acute compression of heart caused by rapid accumulation of fluid in pericardial sac caused by wounds to heart or pericardial effusion
Results in DECREASE of cardiac output
Pericardial effusion: Accumulation of fluid in pericardial space resulting from inflammation of acute pericarditis
Describe pericardiocentesis: SURGICAL PUNCTURE OF PERICARDIAL CAVITY, done for aspiration of fluid, relieving pressure from heart
Where is needle inserted in pericardiocentesis: 5th intercostal space, left to sternum, 45 degrees angle ti xyphoid process
Why does needle in pericardiocentesis miss vital structures: Cardiac notch allows needle to miss pleura and lungs, but to penetrate pericardium
What vessel is in danger during pericardiocentesis: Internal thoracic artery
Blood supply to pericardium: Pericardiophrenic, epigastric and esophageal arteries - branches of internal thoracic
Innervation of pericardium: Vagus, phrenic and sympathetic chain nerves
What forms apex of heart: Left ventricle
Which atrium is larger: RIGHT
What is apex of heart significant for: Auscultating for mitral valve
Left border of heart
Coronary sulcus: Groove on external surface of heart, separates ventricles and atria
Rough part of right atrium: Primitive atrium and auricle with pectinate muscles
Smooth part of right atrium: Sinus venarum
Sinus venarum arises from: sinus venosus
Sinus venarum receives: SVC, IVC, coronary sinus, cardiac veisn
Fossa ovalis: Depresion in interatrial septum, former foramen ovalum that shunts blood right to left before birth
Crista terminalis: Separates sinus venarum from primitive atrium, origin of pectinate muscles, runs from SVC opening to IVC opening
Left atrium compared to right atrium: Smaller, has thicker walls, higher atrial pressure, walls are smooth unlike right atrium that has pectinate muscles
Where does left atrium receive blood from: Four pulmonary veins, oxygenated blood
What is the name of anastomosing muscular ridges in right ventricle: Trabeculae carnae cordis
Infundibulum in right ventricle: smooth part of right ventricle, leads to pulmonary trunk
Moderator band: in RIGHT ventricle, forms a bridge between IV SEPTUM and ANTERIOR PAPILARY MUSCLE
Tricuspid valve is also called: Right AV valve
Tricuspid valve is located: between right atrium and ventricle
Tricuspid valve can best be heard: at RIGHT LOWER PART of body of sternum
How does tricuspid valve work: Has three septal cusps, which are attached by cordae tendinae to papillary muscles that keep valves closed against pressure created by pumping heart
where is pulmonary valve most audible: Left second intercostal space lateral to sternum
What is the other name for bicuspid valve: Mitral or left AV valve
Where is mitral valve most heard: LEFT FIFTH intercostal space at midclavicular line
Valves are open in: DIASTOLE
Valves are closed in: SYSTOLE
Where is aortic valve best heard: Second intercostal space
What kind of cells present in conducting system: modified cardiac cells
Where is SA node located: Upper end of crista terminalis near opening of SVC to right atrium
What is the other name for SA node: Pacemaker
AV node is located: at interatrial septum
Name functions of cardiac skeleton: Keeps orifices of valves open
Site for attachment for myocardium
site for attachment of valves
Electrical isolation
Myocardium consists of: Atrial fibers
Ventricular fibers
Conducting fibers
Coronary arteries arise from: ASCENDING AORTA
Branches of Right coronary artery: SA nodal
Marginal
Posterior descending
AV nodal
Which artery is responsible for 70% of Coronary Artery occlusions: LAD - left anterior descending (anterior interventricular)
Two branches of Left Coronary artery: LAD
Circumflex
Right coronary artery supplies: most of RV, small part of LV, inferior 1/3 of IV septum, RA, part of LA and almost all of conducting system
Left coronary system supplies: most of LV, strip of RV, anterior 2/3 of septum and most of LA
What determined which coronary artery is dominant: Whichever gives rise to posterior descending artery, usually its RIGHT
Where does Great Cardiac vein come from: Originates from LAD and apex of heart
What is the largest vein draining heart: Coronary sinus
Where does coronary sinus lie: Coronary sulcus
What accompanies middle cardiac vein: Posterior descending artery (branch of Right coronary artery)
What is main function of thymus: Maturation of lymphocytes, not present in adults
Myasthenia Gravis: Immune disorder where antibodies are made against Ach receptors on muscles, associated with thymoma - take thymus out - get better
Blood supply to thymus: Internal thoracic artery
Coarctation of aorta: Aorta is abnormally constricted just inferior to ductus arteriosus. Collateral circulation develops - can be through intercostal, epigastric or scapular anastomosis
What is location of phrenic nerve in relation to vagus nerve: Phrenic nerve is always ANTERIOR to airway
VAGUS NERVE always POSTERIOR to airway
Injury to recurrent laryngeal nerve results in: respiratory obstruction, hoarseness, and inability to talk because of paralysis of vocal cords
How do you find thoracic duct: Its in the middle of the triangle made by ESOPHAGUS, AORTA, and AZYGOS VEIN
Thoracic aorta begins at: End of arch, level of T4
Thoracic aorta descends to: DIAPHRAGM and abdominal aorta, level of T12
Thoracic aorta gives rise to: intercostal arteries, subcostal arteries, bronchial arteries, esophageal arteries, pericardial arteries, mediastinal arteriesm superior phrenic artery
What compresses esophagus: DIAPHRAGM
LEFT PRIMARY BRONCHUS
AORTA (ARCH)
Blood supply to esophagus: Inferior thyroid
Bronchial
Esophageal
All branches of aorta
Also left gastric and inferior phrenic arteries
Innervation of esophagus: CNX, sympathetic chain branches
What forms hemiazygus vein: Left subcostal + ascending lumbar
Hemiazygos vein drains: 5 lower intercostal spaces
Beginning of thoracic duct: Cisterna chyli
First indicator of bronchiogenic carcinoma: Enlargement of supraclavicular lymph nodes

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