Exam 3 Flashcards
Ribs 1-10 Articulate With
Sternum
Ribs 1-7 Articulate Via
Costal Cartilages
Ribes 8-10 Articulate Via
Cartilage from 7th Rib
Ribs 11-12
Floating Ribs/No Connection
Parts of Ribs
Head, Neck, Body, Tubercle
Head of Rib Articulates With
Bodies of Vertebrae and Intervertebral Disc; Costovertebral Joint
Tubercle of Rib Articulates With
Transverse Process of the Thoracic Vertebrae; Costotransverse Joint
Ribs that Articulate with only their own Vertebrae:
1st, 11th, 12th
Sternal End of Rib Articulates With
Costal Cartilage and the Sternum
First Rib
Scalene Tubercle on its Superior Surface, 2 grooves for Subclavian Artery, lower Brachial Plexus and Subclavian Vein, rarely fractured, would be dangerous for vessels
Cervical Rib
Remnant or development of a costal process on the C7 vertebra
Cervical Rib Problems
Thoracic Outlet Syndrome, compression of the subclavian artery and ischemic pain, lower brachial plexus compression and muscle weakness/pain, palpable mass in lower neck
Middle Rib Fractures
Most Common
Lower Rib Fractures
Damage the Pleura and Abdominal Viscera and even the kidney, liver, spleen
Flail Chest
Caused by multiple ribs fracture, thoracic wall moves freely (paradoxical), very painful with impaired ventilation
Parts of Sternum
Manubrium, Xiphoid Process, Body, Jugular Notch, Clavicular Notch, (8-9cm)
Sternal Angle
Angle of Louis, T4 vertebra level, manubiosternal joint
Sternal Puncture
Upper third of sternal body in the midline, bone marrow needle biopsy for bone marrow transfer or cytologic analysis
Median Sternotomy
Cut through the bone, procedure done to access the heart in coronary bypass or open heart surgery
Movements of Thorax
Widening for Inspiration and normal size for Expiration
How Thorax Moves:
Mobility in costovertebral joints, elevation of the sternum, mobility at manubrio-sternal joint, elasticity of costal cartilages, increased kyphosis of the thoracic column
Age Effect on Thorax Movement
Calcification of costal cartilage leads to loss of thoracic cage elasticity which restricts respiratory movements
Muscles that Elevate Thoracic Cage
Scalene Muscles, Sternocleidomastoid, Pectoralis Major/Minor
Scalene Muscles Function
Life upper ribs to move Thoracic Cage
Scalene Gap Contents
Subclavian Artery and Brachial Plexus
Intercostal Muscle Function
Elevate and Depress Ribs
Innervation: intercostal nerves
External Intercostal Muscle
Running obliquely, function during forced inspiration
Internal Intercostal Muscle
Running vertically, function both as expiratory and inspiratory muscles
Innermost Intercostal Muscles
May be missing, intercostal nerve, artery and vein are found between these muscles
Subcostalis Muscles
Fibers of the internal intercostal muscles that extend over several segments, function similarly to internal intercostals
Innervation: 4-11 intercostal nerves
Transversus Thoracis
Expiratory muscles from xiphoid process to the ribs on each side
Innervation: upper intercostal nerves
Muscles on Outside of Chest Wall
Pectorals Major/Minor, Serratus Anterior, REctus Abdominus, External/Internal Abdominal Obliques, Latissimus Dorsi, Trapezius
Internal Thoracic Artery
(IMA) Mammary Artery, origin is subclavian artery on each side, supplies thoracic wall, skin or region and back
Musculophrenic Artery
Starts in the sixth intercostal space, provides blood fro intercostal spaces 7, 8, 9
Superior Epigastric Artery
Originates from the Musculophrenic Artery, in the rectus sheath between the abdominal muscles
Inferior Epigastric Artery
Branch of the external iliac artery in the lower abdominal wall
Coarctation of the Aorta
Narrowing in the arch of the aorta compromising blood supply to thoracic, abdominal, and lower limb structures, arteries are dilated
Posterior Intercostal Arteries
Originate from thoracic artery, run in intercostal spaces
Thoracic Wall Veins
Posterior/Anterior Intercostal Viens drained by Azygos and Hemiazygous Viens drained into the Superior Vena Cava
Anterior and Posterior Intercostal Vessels
Internal thoracic Artery to Musculophrenic Artery,
Internal Thoracic Artery to Superior Epigastric Artery
Subcostal Nerve
Located in the intercostal space originates from T12, primary ventral rami of spinal nerves
Reasons to Enter Intercostal Spaces
Fractures of the ribs or Shingles
Procedure to Enter Intercostal Spaces
Intercostal nerve block, needle into lower border of rib, extreme care not to sever vessels and nerves
Tube Thoracotomy/Thoracocentesis
Draining pathologic air/gas from pleural cavity, entering needle close to upper border of rib, all layers pf pleura are punctured except for visceral pleura
Breast
Extends vertically from 2nd to 6th rib and transversely from sternum to the mid-axillary line, it extends into axilla where high percentage of tumors occur
Function: lactation
Tissue of Breast
Glandular tissue and Adipose tissue (contour and size)
Nipple Cell Type
Connective Tissue and Keratinizing Stratified Squamous Epithelium
Nipple at Puberty
Darkens due to melanin production and pigmentation
Internal Structure of Breast
Mammary Glands in adipose tide, ligaments of fibrous bands of tissue and superficial and deep fasciae for support
Suspensory Ligaments (of Cooper)
Extend from the skin to deep fascia and support the breast, tumor here may cause dimpling of skin.
Retromammary Space
Between breast and the deep fascia, tumor here may contract the pectoralis major and the breast may move superiorly
Mammary Glands
Exocrine and Apocrine glands, modified sweat glands, secreting part is the alveoli, each lobule is drained by a lactiferous duct which opens into the nipple
Alveoli
Lined with milk secreting cuboidal epithelium, controlled by hypothalamus
Innervation of Breast
Intercostal nerves, T4-T6
Dermatome of nipple is T4
Blood Supply of Breast
Internal thoracic, axillary and intercostal artery
Venous Drainage of Breast
End up with draining by axillary and azygous veins
Lymphatic Drainage of Breast
Axillary lymph nodes receive 75% of lymphatics, some in central group as well
Axillary Lymph Node Groups
Pectoral (medial), Lateral (humeral), Apical, Subscapular (posterior), Central
Left Side Lymphatics
Final drainage is Thoracic Duct
Right Side Lymphatics
Final drainage is larger veins at the venous angle
Progesterone
For the development of milk secreting lobules
Breast Cancer Sign
Dimpling (invagination) and thickening of skin especially if the lymphatic system is blocked, looks like an orange peel
Mastectomy
Removes breast completely, danger is in injury to long thoracic nerve
Lumpectomy
Surgery to remove cancer or other abnormal tissue from your breast
Gynecomastia
AKA Klinefelter’s Syndrome, men have one extra X chromosome, abnormally large breast in males, puberty and old age is when sign appear
Axillary Region Structures
Brachial Plexus, Axillary Artery, Vein, Lymph Nodes
Ultrasound Guided Infraclavicular Nerve Block
Anesthesia for surgery of the arm, forearm or hand, can be used for pain here as well (axillary region)
Mediastinum
The space between the right and left lungs: 1. Superior Mediastinum (supracardiac) 2. Inferior Mediastinum (anterior, middle and posterior)
Supracardiac Mediastinum
5 layers of structures.
- Thymus
- Great veins related to heart, the phrenic nerves, the thoracic duct and lymphatic trunks
- Arch of Aorta including its branches and the vagus nerves, sympathetic and parasympathetic nerves to the heart (cardiac plexus)
- Trachea and its bifurcation
- Esophagus, the recurrent laryngeal nerves
Pleura
Double layered membrane, serous membrane, produces serous fluid
Layers of Pleura
Visceral (inner) and Parietal (outer)
Other parts of Pleura
Costal, Cervical, Mediastinal, Diaphragmatic
Pleural Cavity
Serous fluid here serves as lubrication, no friction between lungs
Plural Cavity becomes wider near Diaphragm/Mediastinum
Costodiaphragmatic and Costomediastinal Recesses
Innervation of Pleura (Parietal Layer)
Somatic nerves, intercostal nerves, phrenic nerve
Innervation of Pleura (Visceral Layer)
Sensory autonomic nerves
Blood Supply of Parietal Layer
Intercostal and internal thoracic arteries, drained by same name veins
Lymphatics of Parietal Layer
Nodes of the internal aspect of the thoracic wall
Blood Supply of Visceral Layer
Lungs supply the blood here
Lymphatics of Visceral Layer
Follows the lungs, nodes in hilum of lungs
Significance of Intrapleural Pressure
Breathing Cycle = -3 cm H2O at rest, -6 cm H2O at inspiration, increase in both and elastic recoil strength of the lungs
Intrapleural Pressure is Disturbed
Interferes with respiration
Pneumothorax
Air is getting into the pleural cavity due to injury, pulmonary disease which leads to rupture of the visceral pleura, now positive pressure, which will collapse the lung and can be fatal
Puncturing the Intercostal Space Warnings
Always go superior to the inferior rib, not below the 9th intercostal space (danger to injure the liver on the right side)
Sucking Pneumothorax
Air enters and leaves the pleural cavity, mediastinal flutter which is the mediastinum shifted toward the normal side in inspiration and shifted to the injured side in expiration
Tension Pneumothorax
Air enters the pleural cavity and does not leave, increased intrathoracic pressures, patient now has dyspnea and/or cyanosis, seen by hyper-resonant percussion tone in radiolucent area in lung, in radiography.
Pneumothorax Surgical Procedure
Chest tube at -10cm H2O to reduce pneumothorax inserted anteriorly in 2nd intercostal space or if fluid is also present, in 5th-6th space (near posterior axillary line)
Inadvertent Damage to Pleura
Catheterization of the subclavian vein and brachial plexus block, injuries in the neck over the clavicle or during kidney surgery
Pleural Effusion
Excess fluid in the pleural cavity
Types of Pleural Effusion
Hydrothorax (eg: congestive heart failure)
Pyothorax (infection)
Chylothorax (injury to thoracic duct)
Hemothorax (blood in pleural cavity)
Pleuritis
Inflammation of the pleura, pain only if parietal pleura is involved, not the visceral layer
Respiratory System
Gaseous Exchange, blood pH, Blood Pressure, Protecting the Heart
Pharynx
Both respiratory and the digestive tract, merges into the esophagus at the level of the cricoid cartilage
3 Parts of Pharynx
Nasopharynx, Oropharynx and Hypopharynx (Laryngopharynx).
Lungs
Organs of respiration
Surfaces of Lung
Costal, Diaphragmatic, Mediastinal
Inferior Border of the Lungs
6th rib in midclavicular line, 8th rib in the midaxillary line, 10th rib in the scapular line
Children: one rib higher
Right Lung
3 lobes, larger and shorter
Left Lung
2 Lobes, upper lobe contains the cardiac notch and lingula is below the cardiac notch
Fissures of the Lungs
Oblique: T2 to 6th costochondral joint
Horizontal: from 4th costal cartilage level to the oblique fissure
Structures of the Hilum
Main bronchus, lobar bronchi, lower lobe brunches, pulmonary artery and veins, bronchial vessels, pulmonary plexus, lymph vessels, broncho pulmonary lymph node
Trachea
12 cm long and 2 cm wide, from C6 to T4, contains C-shaped cartilage rings, posteriorly has muscle layer covered by mucus membrane
Trachea Divides
Main Bronchi –> Lobar Bronchi –> Segmental Bronchi
Right Main Bronchus
Shorter (2.5 cm), wider and more vertical
Left Main Bronchus
Longer (5 cm), less steep
Bronchopulmonary Segments
10 in each lung, segments of bronchi branches
Bronchopulmonary Segments Contains
Segmental bronchus, branch of pulmonary artery and branch of bronchial artery run together
Right Lung Superior
Apical, Posterior, Anterior segments
Right Lung Middle
Lateral, Medial segments
Right Lung Inferior
Superior, Anterior Basal, Medial Basal, Lateral Basal, Posterior Basal segments
Left Lung Superior
Apical, Posterior, Anterior, Superior, Inferior segments
Left Lung Inferior
Superior, Anterior Basal, Medial Basal, Lateral Basal, Posterior Basal segments
Clinical Function of Bronchopulmonary Segments
Tributaries of the pulmonary vein, used as surgical markers
Blood Air Barrier
Thin membrane between capillaries and alveoli, gas exchange takes place here
Histology of Bronchioles
Simple ciliated columnar epithelium with goblet cells
Histology of Trachea
Pseudostratified ciliated columnar epithelium with goblet cells
Histology of Alveolar Ducts
Simple Squamous
Tidal Volume
.5 Liters
Inspiratory Reserve Volume
3 Liters
Expiratory Reserve Volume
1.2 Liters
Residual Volume
1.2 Liters
Vital Capacity or Forced Vital Capacity
4.7 Liters