Diaphragm

Question 1

Shape

Answer 1

1. Large dome shaped fibromuscular partition separating thoracic from abdominal cavities
2. Convex upwards
3. Its right cupola is higher than its left cupola due to underlying large liver right lobe

Question 2

Origin

Answer 2

Wide origin from whole circumference of thoracic outlet inner aspect and vertebral column:
1. Sternal
2. Costal
3. Vertebral

Question 3

Sternal origin

Answer 3

Xiphoid process back by 2 fleshy slips

Question 4

Costal origin

Answer 4

Lower 6 costal cartilages deep surface by fleshy slips interdigitating with transversus abdominis origin

Question 5

Vertebral origin

Answer 5

1. 2 crura: right and left
2. 5 arcuate ligaments:
   - Median arcuate ligament
   - 2 medial arcuate ligaments
   - 2 lateral arcuate ligaments

Question 6

Right crus

Answer 6

1. From upper 3 lumbar vertebrae bodies
2. Larger than left crus (as it has to contract against liver)
3. Its fibers extend up to surround esophagus lower end forming physiological sphincter around stomach cardiac end

Question 7

Left crus

Answer 7

Smaller from upper 2 lumbar vertebrae bodies

Question 8

Median arcuate ligament

Answer 8

Lies in median plane, extending between both crura and arches over aorta

Question 9

2 medial arcuate ligaments

Answer 9

Extends from crus to tip of 1st lumbar vertebra transverse process and arches over Psoas major

Question 10

2 lateral arcuate ligaments

Answer 10

Extends from tip of 1st lumbar vertebra transverse process to last rib and arches over the quadratus lumborum

Question 11

Defects

Answer 11

Small defects between different parts of diaphragm origin, filled with loose areolar tissue:
1. Foramen of morgagni
2. Foramen of bockdalek (vertebrocostal triangle)

Question 12

Foramen of morgagni

Answer 12

1. Between sternal and costal origins transmitting superior epigastric vessels
2. May be site of anterior (parasternal) diaphragmatic hernia

Question 13

Foramen of bockdalek

Answer 13

1. Triangular gap mainly on left side between costal and vertebral origins where pleura costodiaphragmatic recess comes in contact with kidney posterior surface but separated from it by areolar tissue
2. May be site of posterior diaphragmatic hernia
3. It is pleuroperitoneal canal remnant in fetus

Question 14

Insertion

Answer 14

1. No bony insertion, but all fibers converge to be inserted into a central tendon which is strong semilunar aponeurosis formed of 1 median and 2 lateral folia (trifoliate)
2. Median lobe is related to pericardium and heart

Question 15

Nerve supply

Answer 15

1. Sensory
2. Motor

Question 16

Motor

Answer 16

Right and left phrenic nerves (C3, 4, and 5) arise in cervical region and descend to ramify on diaphragm inferior (abdominal) surface due to embryo folding

Question 17

Sensory

Answer 17

1. Lower 6 thoracic spinal nerves to peripheral parts
2. Phrenic nerves to central part

Question 18

Action

Answer 18

1. Chief muscle of respiration
2. Used to increase intra-abdominal pressure in parturition, coughing, defecation, and micturition

Question 19

Relations: superior surface

Answer 19

1. Right cupola
2. Left cupola
3. Central tendon

Question 20

Right cupola

Answer 20

Related to right pleura and lung

Question 21

Left cupola

Answer 21

Related to left pleura and lung

Question 22

Central tendon

Answer 22

Related to heart base and pericardium

Question 23

Relations: inferior surface

Answer 23

1. Stomach fundus
2. Spleen
   Right:
3. Liver right lobe
4. Right kidney
5. Right Suprarenal gland
   Left:
6. Liver left lobe
7. Left kidney
8. Left Suprarenal gland

Question 24

Openings

Answer 24

Major and minor

Question 25

Major openings

Answer 25

1. Aortic opening 2. IVC opening 3. Esophageal opening

Question 26

Aortic opening site

Answer 26

In middle line behind median arcuate ligament, T12 vertebra

Question 27

Structures passing through aortic opening

Answer 27

1. Aorta to left 2. Azygous vein to right 3. Thoracic duct in between

Question 28

IVC opening site

Answer 28

1 inch to right of middle line in central tendon T10 vertebra

Question 29

Structures passing through IVC opening

Answer 29

1. IVC 2. Right phrenic nerve 3. Lymphatics

Question 30

Esophageal opening site

Answer 30

1 inch to left of middle in right crus T10 vertebra

Question 31

Esophageal

Answer 31

1. Esophageal 2. 2 vagi 3. Esophageal branches of left gastric vessels

Question 32

Minor openings

Answer 32

1. Superior epigastric artery 2. Musculophrenic artery 3. Lower 5 intercostal nerves and vessels 4. Subcostal nerve And vessels 5. Quadratus lumborum 6. Sympathetic chain 7. Psoas major 8. Greater and lesser splanchnic nerves 9. Hemiazygous vein 10. Left phrenic nerve

Question 33

Superior epigastric artery

Answer 33

Between sternal and costal origins

Question 34

Musculophrenic artery

Answer 34

Between slips of origin from 7th and 8th costal cartilage

Question 35

Lower 5 intercostal nerves and vessels

Answer 35

Between costal digitations

Question 36

Subcostal nerves and vessels and quadratus lumborum

Answer 36

Behind lateral arcuate ligament

Question 37

Sympathetic chain and Psoas major

Answer 37

Behind medial arcuate ligament

Question 38

Greater and lesser splanchnic nerves

Answer 38

Pierce corresponding crus

Question 39

Hemiazygous vein

Answer 39

Pierces left crus to enter chest

Question 40

Left phrenic nerve

Answer 40

Pierces left cupola

Question 41

Arterial supply

Answer 41

1. Musculophrenic: internal thoracic artery 2. Pericardiophrenic: internal thoracic artery 3. Lower intercostals: thoracic aorta 4. Subphrenic: thoracic aorta 5. Inferior phrenic: abdominal aorta

Question 42

Applied anatomy

Answer 42

1. Parasternal hernia of morgagni: between sternal and costal origin 2. Hernia of bockdalek: between costal and vertebral origins 3. Hiatus hernia: stomach passes through esophageal opening