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SMP - Cardiopulmonary Lab Practical > Dissection of the Pectoral Region and Thoracic Cage > Flashcards

Dissection of the Pectoral Region and Thoracic Cage Flashcards

1
Q

To what vessel is the cannula attached on the cadaver to perfuse the cadaver?

A

Carotid artery

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2
Q

What does superficial fascia include?

A
  1. Fat
  2. Fibrous connective tissue
  3. Cutaneous vessels and nerves
    All coming from the thoracic wall, the axilla, and the neck
  4. Breasts in females
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3
Q

What verifies that the skin reflection is at the appropriate plane to separate it from the superficial fascia?

A

Dimpling on the undersurface of the skin

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4
Q

Why are the areola and nipple hard to identify on a cadaver?

A

Because there is loss of pigmentation

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5
Q

Which muscles do breasts overlie?

A

Pectoralis major muscles

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6
Q

Between what ribs do breasts lie?

A

2 and 6 (normally)

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7
Q

Why do boobs sag?

A

Loss of tensile strength of ligaments of Cooper

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8
Q

How many lactiferous sinuses?

A

15-20

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9
Q

What are the pectoralis major and minor and the subclavius muscles enveloped by? What does it attach to?

A

Clavipectoral fascia (type of deep fascia)

Attaches to clavicle above and floor of axilla below

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10
Q

What is the pectoral region?

A

Region external to the anterior thoracic wall that anchors upper limbs to trunk

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11
Q

What kind of modified glands are the breasts?

A

Modified sweat glands

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12
Q

What are the suspensory ligaments of Cooper continuous with?

A

Dermis of skin

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13
Q

What is the predominant component of breasts in nonlactating women?

A

Fat

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14
Q

What separates the breast from the clavipectoral fascia?

A

Retromammary space = layer of loose connective tissue

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15
Q

Transverse breast borders?

A

Midaxillary line and sternum

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16
Q

Can breast cancer occur in men?

A

Yes

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17
Q

How far can the axillary process of the breast extend? How?

A

As far as the apex of the axilla by perforating deep fascia

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18
Q

Innervation of the breast?

A

Anterior and lateral cutaneous branches of the 2nd to 6th intercostal nerves

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19
Q

Innervation of the nipple?

A

Lateral cutaneous branch of 4th intercostal nerve

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20
Q

Largest muscle of pectoral region?

A

Pectoralis major

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21
Q

Pectoralis major:

  1. Origin
  2. Insertion
  3. Innervation
  4. Function
A
  1. Medial half of clavicle, anterior surface of sternum, first 7 costal cartilages, aponeuris of external oblique
  2. Lateral lip of intertubercular sulcus of humerus
  3. Medial and lateral pectoral nerves
  4. Adduction, medial rotation, and flexion of the humerus at the shoulder joint
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22
Q

What is the deltopectoral triangle?

A

Area between the 2 muscles NOT covered by muscle

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23
Q

What 2 vessels are found in the deltopectoral triangle?

A
  1. Cephalic vein

2. Thoracoacromial artery

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24
Q

How to tell difference between arteries and nerves?

A

Nerves are FLAT

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25
Q

Pectoralis minor:

  1. Origin
  2. Insertion
  3. Innervation
  4. Function
A
  1. Anterior surfaces of the 3rd, 4th, and 5th ribs and deep fascia overlying the related intercostal spaces
  2. Coracoid process of scapula
  3. Medial pectoral nerve
  4. Depresses tip of shoulder and protracts the scapula
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26
Q

Subclavius:

  1. Origin
  2. Insertion
  3. Innervation
  4. Function
A
  1. Rib 1 at junction between rib and costal cartilage
  2. Groove on inferior surface of middle 3rd of clavicle
  3. Nerve to subclavius
  4. Pulls clavicle medially to stabilize sternoclavicular joint, and depresses the tip of the shoulder
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27
Q

Serratus anterior:

  1. Origin
  2. Insertion
  3. Innervation
  4. Function
A
  1. Lateral surfaces of upper 8-9 ribs and deep fascia of related intercostal spaces
  2. Costal surface of medial border of scapula
  3. Long thoracic nerve (on external surface)
  4. Protraction and rotation of the scapula around the rib cage, keeps medial border and inferior angle of scapula opposed to thoracic wall
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28
Q

What is the boxers’ muscle?

A

Serratus anterior

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29
Q

What would damage to the long thoracic nerve due to breast cancer surgery cause?

A
  1. “Winging” of the scapula when pushing forward with the arm because the medial border and inferior angle of the scapula will elevate away from the thoracic wall
  2. Normal elevation of the arm is no longer possible
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30
Q

Where do nerves, lymphatics, and vessels pass from the axilla to the pectoral region?

A

They pass through the clavipectoral fascia between the subclavius and the pectoralis minor OR under the inferior margins of the pectoralis major and minor

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31
Q

Where is the serratus anterior muscle located in relation to the pectoralis minor?

A

Deep to it

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32
Q

External intercostal:

  1. Superior attachment
  2. Inferior attachment
  3. Innervation
  4. Function
A
  1. Inferior margin of above rib
  2. Superior margin of below rib
  3. Intercostal nerves
  4. Inspiration to move rib superiorly and supports intercostal space
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33
Q

Internal intercostal:

  1. Superior attachment
  2. Inferior attachment
  3. Innervation
  4. Function
A
  1. Lateral edge of costal groove of above rib
  2. Superior margin of below rib deep to the attachment of the related external intercostal
  3. Intercostal nerves
  4. Expiration to move ribs inferiorly and supports intercostal space
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34
Q

Innermost intercostal:

  1. Superior attachment
  2. Inferior attachment
  3. Innervation
  4. Function
A
  1. Medial edge of costal groove of above rib
  2. Internal aspect of superior margin of below rib
  3. Intercostal nerves
  4. Probably elevate the ribs
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35
Q

What are the 4 types of intrinsic thoracic muscles? List from superficial to deep

A
  1. External intercostals
  2. Internal intercostals
  3. Innermost intercostals
  4. Transversus thoracis muscles (same plane as innermost intercostals)
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36
Q

Describe the orientation of external intercostal muscles.

A

From superior lateral to inferior medial (until reaching the external intercostal membrane) in an oblique manner

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37
Q

Function of external intercostal muscles? How?

A

Elevate ribs during inhalation

First rib is fixed by scalene muscles that anchor it to the bones of the neck

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38
Q

How many intercostal muscles?

A

11 of each 3 types

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39
Q

Describe the orientation of internal intercostal muscles.

A

Perpendicular to the external intercostals (until reaching the internal intercostal membrane)

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40
Q

Function of internal intercostal muscles? How?

A

Depress ribs during forceful expiration

12th rib is fixed by the quadratus lumborum to the vertebrae

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41
Q

Are intercostal muscles continuous around the chest?

A

NOPE, membranous layers help complete the spaces left unfilled by the muscles

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42
Q

Where do the nerves and vessels (artery + vein) of the intrinsic thoracic muscles travel? How are they arranged? What is the clinical significance of this?

A

Between the internal and innermost intercostal muscles underneath each rib

Superior to inferior: V, A, N

During a pleural tap, the needle is inserted on the upper border of the rib so as to minimize potential damage to nerves

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43
Q

Function of innermost intercostal muscles?

A

Probably elevate the ribs

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44
Q

Describe the orientation of innermost intercostal muscles.

A

Same as internal intercostal muscles

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45
Q

Which of the nerves and vessels (artery + vein) of the intrinsic thoracic muscles are most likely to be injured during an intercostal injury? Why?

A

Nerve because least protected by rib costal groove (most inferior)

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46
Q

How to tell the difference between rib bone and rib cartilage?

A

Difference in color between the two because there is no blood flow to cartilage

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47
Q

Are there external intercostals between costal cartilages?

A

Nope, the external intercostal membrane is there

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48
Q

What is the most anterior component of the superior mediastinum lying immediately posterior to the manubrium of the sternum?

A

Thymus

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49
Q

Describe the shape of the thymus.

A

Asymmetrical bilobed structure

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50
Q

Upper and lower borders of thymus?

A

Upper: can extend up in the neck to the thyroid gland

Lower: anterior mediastinum over pericardial sac

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51
Q

Size of thymus?

A

Large in child
Atrophies after puberty
Considerable size variation in the adult
Barely identifiable in elderly, consisting mainly of fat

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52
Q

Blood supply to thymus?

A

Small branches from right and left internal thoracic arteries

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53
Q

Venous drainage of thymus?

A

Into left brachiocephalic vein and internal thoracic veins

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54
Q

Why do we sometimes find ectopic parathyroid glands on the thymus?

A

Because they both develop from the third pharyngeal pouch so the thymus is sometimes the site for ectopic parathyroid hormone production

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55
Q

Lymphatic drainage of thymus?

A
  1. Parasternal nodes
  2. Tracheobronchial nodes
  3. Nodes in root of neck
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56
Q

Other name for internal thoracic arteries?

A

Mammary arteries

57
Q

From what arteries do the internal thoracic arteries branch?

A

Right and left subclavian arteries

58
Q

Blood supply of thoracic wall?

A

Anterior and posterior intercostal arteries

59
Q

From what arteries do the anterior and posterior intercostal arteries branch?

A
  1. Aorta
  2. Internal thoracic arteries
  3. Subclavian arteries
60
Q

From what arteries do the posterior intercostal arteries branch?

A
  1. Upper 2: supreme intercostal artery branching from the costocervical trunk of the subclavian artery
  2. Remaining 9: posterior surface of thoracic aorta
61
Q

On which side of the vertebral column is the aorta?

A

Left side

62
Q

Which vessels are longer: right of left posterior intercostal muscles for intercostal spaces 3-11? Why?

A

Right ones because they need to cross the midline as the aorta is on the left side of the vertebral column

63
Q

Which arteries of the thoracic wall supply more superficial regions?

A
  1. Anterior and posterior intercostal arteries

2. Internal thoracic arteries

64
Q

From what arteries do the anterior intercostal arteries branch?

A
  1. Upper 6: directly or indirectly from internal thoracic arteries
  2. Lower 5: from musculophrenic artery
65
Q

Describe the position of the internal thoracic arteries.

A
  1. From subclavian arteries they pass anteriorly over the cervical dome of the pleura
  2. Descend vertically through thoracic inlet and along deep aspect of anterior thoracic wall
  3. They lie posterior to the costal cartilages of the first 6 ribs and 1 cm from sternum
66
Q

Describe the terminal branching of the internal thoracic arteries.

A

At about the 6th intercostal spaces, they branch into:

  1. Superior epigastric artery continuing inferiorly into anterior abdominal wall
  2. Musculophrenic artery passing along the costal margin through the diaphragm and ending near the last intercostal space
67
Q

Which are larger: anterior or posterior intercostal arteries?

A

Posterior intercostal arteries

68
Q

Describe the venous drainage of the intercostal veins.

A
  1. Centrally: into the azygos system or the internal thoracic vein to the brachiocephalic veins
  2. Left superiorly/posteriorly: left superior intercostal vein to left brachiocephalic vein
  3. Right superiorly/posteriorly: right superior intercostal vein to azygos vein
69
Q

Function of transversus thoracis muscles?

A

Depress the ribs in midline + help attach vessels/veins to sternum and to the thoracic wall

70
Q

Transversus thoracis:

  1. Superior attachment
  2. Inferior attachment
  3. Innervation
  4. Function
A
  1. Inferior margins and internal surfaces of costal cartilages of 2nd to 6th ribs
  2. Inferior aspect of deep surface of body of sternum, xiphoid process, and costal cartilages or ribs 4-7
  3. Intercostal nerves
  4. Depresses costal cartilages
71
Q

Which nerve innervates both the pectoralis major and minor?

A

Medial pectoral nerve

72
Q

Is the superior border of the lung at rib 1?

A

NOPE, actually goes into the neck

73
Q

In which ICS is the nipple found in men?

A

5th

74
Q

What is the skin fold from the axilla to below the nipple called?

A

Anterior axillary fold

75
Q

What ARE intercostal nerves?

A

Ventral rami of the thoracic spinal nerves

76
Q

3 extrinsic pectoral muscles?

A
  1. Pectoralis major
  2. Pectoralis minor
  3. Serratus anterior
77
Q

What is an alternate function of the pectoralis minor muscle? How does it do this? When is this function particularly important?

A

It’s an accessory respiratory muscle that assists in elevating the ribs during forced inspiration, especially in patients with dypsnea

When the pectoralis minor acts in this way, it acts from the coracoid process. Thus, its insertion acts as its origin

78
Q

What gives shape to the breasts? Describe their location

A

The suspensory ligaments of Cooper

Extend perpendicularly from the deep fascia superficial to the pectoralis major to the skin

79
Q

Describe the pathway of milk in the breast.

A

Breast lobules produce milk => lactiferous ducts => lactiferous sinus => 12-15 ductal openings into the nipple

80
Q

Are lactiferous ducts found in all women?

A

NOPE, they disappear after menopause because they depend on hormones

81
Q

Role of areolar glands?

A

Sebaceous glands that enlarge during pregnancy to help lubricate the skin for breast feeding

82
Q

When do the nipple and areola become more pigmented? How come? In which population is this exacerbated?

A

During the last trimester of the 1st pregnancy

Due to increased amount of melanin

In African Americans

83
Q

Where is the ONLY muscle of the mammary gland located? What kind? When does it contract?

A

The areola - smooth muscle

Contracts upon stimulation

84
Q

What are the 5 arteries providing blood supply to the breasts?

A
  1. Internal thoracic artery branches (perforating anterior chest wall to 2-4th intercostals) to anteromedial portions
  2. Lateral thoracic artery branches
  3. Thoracodorsal artery (from subscapular artery)
  4. Intercostal artery (perforators)
  5. Thoracoacromial artery
85
Q

Is the breast affected by coronary bypass surgery in females in which the internal thoracic artery is harvested? Why/Why not?

A

NOPE, because of the extensive and redundant blood supply of the breast

86
Q

Describe the venous drainage of breasts.

A

Follows the same tracts as the arteries to axillary, internal thoracic, and intercostal veins

87
Q

What are the 4 types of lymph nodes that drain the breast? Which one is responsible for the majority of the lymphatic drainage?

A
  1. Axillary lymph nodes*** (75% of drainage)
  2. Supraclavicular lymph nodes
  3. Internal mammary lymph nodes
  4. Abdominal lymph nodes (25% of drainage)
88
Q

What is another name for internal mammary lymph nodes?

A

Parasternal lymph nodes

89
Q

Which breast lymph nodes are at greater risk for cancer metastases?

A

Supraclavicular lymph nodes

90
Q

How can breast cancer move from one breast to the other?

A

Via internal mammary lymph nodes through the pectoral major fascia

91
Q

What artery does the lateral thoracic artery branch from?

A

Axillary artery

92
Q

What artery does the internal thoracic artery branch from?

A

Subclavian artery

93
Q

Why can cancer spread easily from the breasts to the vertebral column/brain?

A

Because there are no valves between the intercostal veins and the vertebral veins

94
Q

Where do most breast cancers occur? In what lymph nodes do these drain?

A

Superior lateral quadrants

Drain into axillary lymph nodes

95
Q

What are 5 explanations for felt breast lumps? List in order of %

A
  1. Fibrocystic changes
  2. No disease
  3. Miscellaneous benign
  4. Cancer
  5. Fibroadenoma
96
Q

Incidence of lifetime breast cancer in women?

A

1:7 by age 90

most common visceral cancer in women

97
Q

When does breast examination indicate breast cancer? Explain each symptom.

A
  1. Skin dimpling because the cancer cells are attacking the suspensory ligaments of Cooper and shortening them
  2. Prominent vascular patterns because a fast-growing tumor will have a large vascular demand and will cause dilation of superficial veins
  3. Skin edema due to lymph accumulation in the skin (orange peel appearance) because the cancer is attacking the subcutaneous lymphatics
  4. Nipple retraction due to shortening of lactiferous ducts
  5. Cancer en cuirasse: hard, woody texture to skin (rare manifestation)
98
Q

What are breasts ultrasounds used for?

A

To distinguish fluid-filled cysts (light) from solid masses (dark)

99
Q

What are breasts MRI used for?

A

To evaluate how extensive the breast cancer is

100
Q

What is fibroadenoma?

A

Benign neoplasm of glandular epithelium with significant increase in connective tissue

101
Q

What color would a breast tumor appear as on a mammogram?

A

White

102
Q

Which 2 nerves are very important to preserve during a masectomy?

A
  1. Long thoracic nerve, which controls serratus anterior

2. Thoracodorsal nerve which controls latissimus dorsa

103
Q

How do surgeons performing masectomies or lumpectomies find the lymph nodes to remove?

A

Lymph mapping using an injection of dye in the breast where the tumor was which will travel to the proximal lymph nodes to the tumor

104
Q

What are the 2 methods of surgical repair following a radical masectomy? Explain each. Which works best?

A
  1. Transverse rectus abdominus myocutaneous (TRAM) flap surgery***: opposite rectus adbominus muscle is used to replace the mass lost and retains blood supply because it had both a superior and an inferior one
  2. Latissimum dorsi flap
105
Q

What is a radical masectomy?

A

Masectomy involving the removal of the pectoralis major and minor due to metastasis

106
Q

What are the 3 compartments of the thorax? What does each consist of?

A
  1. Right and left lateral compartment: pleural sacs and their respective lung
  2. Central compartment: mediastinum and its contents
107
Q

Are the right and left lateral thoracic compartments identical?

A

NOPE, the right side is wider and shorter than the left because of the liver pushing up on the right side and/or the heart pushing down on the left

108
Q

How are rib 11 and 12 anchored to the thoracic wall?

A

By abdominal wall muscles

109
Q

Can the extrinsic muscles be used for breathing?

A

YUP, but not main action

110
Q

Function of extrinsic muscles?

A

Moving upper limbs

111
Q

What are the 6 posterior extrinsic thoracic muscles?

A
  1. Trapezius
  2. Rhomboid major
  3. Rhomboid minor
  4. Latissimus dorsi
  5. Levator scapulae
  6. Posterior superior serratus
112
Q

What is the collateral branch of the intercostal vein, artery, and nerve?

A

Much smaller branches located above each rib

113
Q

What are the 2 types of breathing? 2 names for each

A
  1. Quiet inspiration = eupnea

2. Forced breathing = hypernea

114
Q

Describe eupnea.

A
  1. Inspiration by muscular contraction: diaphragm (deep breathing) or costal (shallow breathing) with external and innermost intercostals
  2. Expiration is a passive process without muscle contraction
115
Q

Describe hypernea.

A

Active inspiratory and expiratory movements:

  1. Inspiration: diaphragm (deep breathing) or costal (shallow breathing)
  2. Expiration: transversus thoracic, internal intercostals, and abdominal muscles
116
Q

Posterior surface projection of xiphisternal joint?

A

T9

117
Q

Posterior surface projection of suprasternal notch?

A

T2/T3

118
Q

Sensory/Dermatomal innervation of breasts?

A
  1. Thoracic intercostal nerves from T3-T5
  2. Supraclavicular nerves (upper and lateral breast)
  3. Lateral cutaneous branch of T4 (nipple)
119
Q

Are are the pectoralis major and minor used for respiration?

A

For inspiration with insertions acting as origins

120
Q

What is thoracic outlet syndrome? Example of cause?

A

Refers to a collection of signs and symptoms that arise from compression of the subclavian artery and vein, and trunks of the brachial plexus by various structures in the area just above the first rib behind the clavicle, within the confined space of the CLINICAL thoracic outlet (different from anatomical)

Possible cause: cervical ribs

121
Q

What plane passes through the sternal angle?

A

Transverse thoracic plane

122
Q

What is a portacath? What is it used for? How is it placed?

A

Subcutaneous reservoir from which a small catheter passes under the skin into the internal jugular vein

Can be used for delivering chemotherapy following breast cancer (placed on contralateral side of breast cancer if there has been axillary dissection as lymphatics would not be available to drain possible infection due to placement of the portacath)

Placement: use ultrasound to see axial image across root of neck to see common carotid artery and right internal jugular vein => identify the internal jugular vein: larger and demonstrates normal respiratory variation, compressibility and size dependent on position of patient => puncture => brachiocephalic vein => SVC

123
Q

Risk of placing a portacath?

A

Common carotid artery puncture or lung apex puncture

124
Q

Why is the portacath placed all the way in SVC?

A

To ensure proper mixing with blood because chemotherapeutic agents are severely toxic so this prevents thrombosis and vein wall irritation

125
Q

What do axillary nodes drain to?

A

Subclavian trunks

126
Q

What do parasternal nodes drain to?

A

Bronchomediastinal trunks

127
Q

4 types of axillary lymph nodes? List from inferior to superior.

A
  1. Pectoral
  2. Lateral
  3. Central
  4. Apical
128
Q

Breasts in men?

A

Small ducts composed of cords of cells that do not extend beyond the areola

129
Q

Where does breast cancer develop? 3 locations.

A
  1. Acini cells
  2. Lactiferous ducts
  3. Breast lobules
130
Q

What does staging a breast cancer mean?

A
  1. Size of primary tumor?
  2. Exact site of primary tumor?
  3. Number and sites of lymph node spread?
  4. Organs to which tumor has spread?
131
Q

3 posterior thoracic muscles that can alter the position of ribs and sternum and help breathing?

A
  1. Levatores costarum
  2. Serratus posterior superior
  3. Serratus posterior inferior
132
Q

Lymphatic drainage of thoracic wall?

A
  1. Parasternal nodes
  2. Intercostal nodes
  3. Diaphragmatic nodes
133
Q

Where are diaphragmatic lymph nodes located?

A

Posterior to xiphoid and where diaphragm attaches to vertebral column

134
Q

Where do intercostal nodes drain?

A
  1. Upper thorax: bronchomediastinal trunks

2. Lower thorax: thoracic duct

135
Q

What is the subcostal nerve?

A

Spinal nerve T12

136
Q

What is the largest branch of an intercostal nerve?

A

Lateral cutaneous branch that pierces anterior wall and divides into an anterior and posterior branch

137
Q

Other than innervating the thoracic wall, what else do intercostal nerves innervate?

A
  1. Anterior rami of T1: brachial plexus
  2. Lateral cutaneous branch of 2nd intercostal: medial surface of arm
  3. Lower intercostals: muscles, skin and peritoneum of abdominal wall
138
Q

What surgical procedures can be conducted without having to do a sternotomy?

A
  1. Lobectomy
  2. Lung biopsy
  3. Esophagectomy

SMP - Cardiopulmonary Lab Practical (11 decks)

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