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Block 2 Gross > Lecture 17: Thoracic wall; Pleura and Lungs Diaphragm > Flashcards

Lecture 17: Thoracic wall; Pleura and Lungs Diaphragm Flashcards

1
Q

What comprises the osseous (bony) part of the thoracic wall

A

Vertebral column, ribs, and sternum

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2
Q

What are the other non-osseous structures in the thoracic wall

A

muscle, cartilage, fibrous tissues

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3
Q

Compare the shapes of the thoracic cavities in adults and children

A

Adult- Oval

Child- Circular

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4
Q

What are the boundaries of the thoracic inlet

A

Clavicles, sternum, first ribs, and vertebral column

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5
Q

Which aspect of the thoracic inlet is higher, the dorsal or ventral

A

Dorsal is higher than ventral

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6
Q

What is the dorsal landmark of the thoracic inlet

A

T1

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7
Q

What is the ventral landmark of the thoracic inlet

A

Manubrium of sternum

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8
Q

Is T1 higher or lower than the manubrium of the sternum

A

higher

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9
Q

What does the difference in ventral and dorsal heigh of the thoracic inlet allow

A

Allows the apical portion of the lungs to rise into the root of the neck.

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10
Q

Why is it important to know that the lungs can extend into the root of the neck?

A

As physician- patient comes in with neck injuries, need to check if lungs are good

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11
Q

Boundaries of thoracic outlet

A 
Inferior- diaphragm
Posterior- T12
Lateral- Ribs 10-12
Anterior- Costal cartilages of ribs 7-10
As well as the junction between the body and xyphoid process of sternum
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12
Q

Which is wider the thoracic inlet or outlet

A

outlet

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13
Q

Jugular notch (or suprasternal notch)

A

notch at the midline of the manubrium

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14
Q

Sternal angle or Angle of Lewis

A

Acute angle that forms when the manubrium meets the sternal body

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15
Q

What is the clinical significance of the Angle of Lewis

A

The angle is easily palpable on all patients and is an important landmark for physical exams for using a stethescope

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16
Q

What are the vertebral levels of the Angle of Lewis

A

T4-5

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17
Q

Which costal cartilage attached the the sternal body inferior to the sternal angle?

A

Costal cartilage of rib 2 Important landmark for clinical exams

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18
Q

Describe the movements of the costosternal articulations

A

gliding type

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19
Q

At what vertebral level does the xiphoid process attach to the sternal body

A

T10

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20
Q

What is the most commonly fractured site on the sternum

A

sternal angle

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21
Q

Why are fractures to the sternum more common in kids than adults

A

Because in kids the sternum is not completely fused together (broken into segments) verses the adult sternum which is completely fused together

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22
Q

Why are features to the sternum uncommon

A

Forces at the sternum are dissipated into the ribs, which are not as strong as the sternum causing those to break instead

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23
Q

What injuries should you be concerned about if a patient comes in with a fractured sternum

A

diaphragmatic lacerations, herniation of abdominal contents into the thoracic cavity, heart trauma.

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24
Q

True ribs

A

Ribs 1-7: Ribs that have costal cartilages that attach directly to the sternum

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25
Q

False ribs

A

Ribs 8-9: Ribs have costal cartilages that attach to the superior adjacent costal cartilage.

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26
Q

Floating ribs

A

Ribs 11-12: These are a type of false rib. These ribs have no anterior articulation but still articulate posteriorly to the vertebral bodies and transverse processes

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27
Q

Why is it important to know which ribs are directly connected to the sternum

A

Because if a patient suffered a blow to the sternum you know you should look for breaks in the true ribs since theses are the ribs that dissipate the force

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28
Q

Know the anatomy of a typical rib

A

USE YO BONE BOX

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29
Q

Typical rib

A

2 facets with articulate with the same numbered vertebrae and with the vertebra superior to it. lateral the hear is a constricted area called the neck. An articular tubercle lies just dorsal to the junction of the neck and the rib body. The anterior sternal extremity is roughened to allow for the attachment of a costal cartilage. Superior surfaces of the ribs are round and smooth. Inferior surface is grooved

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30
Q

How are the neruovascular bundles arranged in the intercostal spaces

A

Inferior to a rib (VAN)- Vein, artery, nerve

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31
Q

When a patient suffers force to the side of the body and fractures a rib, what would you expect to see/feel from the fracture

A

May not be able to palpate the fracture but there could be a puncture into the pluera or lung

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32
Q

When a patient suffers force front the front of the body to the back (or vice versa) and fractures a rib, what would you expect to see/feel from the fracture

A

Would be able to palpate the fracture. Wouldn’t be as worried about damage to the thoracic wall

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33
Q

What connects the costal cartilage to the sternum

A

ligatments

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34
Q

What attaches the bony part of the rib to its costal cartilage

A

fibrous tissue

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35
Q

What is it called when the ligaments or fibrous tissue of the ribs is inflamed

A

Costochondritis

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36
Q

Why is it that people with back injuries have trouble breathing

A

because the ribs articulate with the vertebral column. Also after open heart surgery, many patients complain of back pain due to the forces appiled to the posterior attachments of the ribs because of cutting the sternum and retracting the rib cage.

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37
Q

What may occur if there is an obstruction (or coarctation (or narrowing)) of the aorta

A

Rib notching

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38
Q

Explain the mechanism of rib notching

A

When the aorta is constricted, pressure builds which causes the intercostal arteries to form “squiggles” resulting in notches to form on the inferior border of ribs

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39
Q

Why does rib notching occur on the inferior border of the ribs

A

because that is where the neuromuscular bundles lie

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40
Q

Why is it important to know that the neurovacqlar bundles are inferior to the rib?

A

Because when you need to insert a chest tube into a patient you need to make sure you puncture the intercostal space region without hitting the neuromuscular bundle

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41
Q

What are the consequences of hitting the neuromuscular bundle with a chest tube

A

hemothorax- blood will seep out of the vessels and into the lungs

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42
Q

Will we see rib notching taking place is collateral circulation is being utilized to to malfunctions in other arteries

A

Yes because more blood is being forced through these vessels, resulting in a greater build up of pressure and thus leading to notches in the inferior borders of the ribs

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43
Q

What is special about the first rib

A

It is the highest, widest, strongest, flattest, shortest, and most curved rib

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44
Q

Where does the first rib lie

A

Almost completely beneath the clavicle

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45
Q

What attaches to the undersurface of the first rib

A

subclavius m. and costoclavicular ligament

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46
Q

What may be the first sign of cancer in the breast or prostate gland and why

A

rib pain may be a first sign because ribs are frequent sits of metastisis

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47
Q

Why are rib fractures less common in children

A

The rib cage is more flexible at younger ages

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48
Q

What other injuries are rib fractures associated with in general

A

hemothorax and pneumothorax

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49
Q

What injuries are associated with lower rib fractures

A

tears in diaphragm

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50
Q

What are the two categories of costovertebral articulations

A
  1. Articulations of the rib heads with one or two vertebral bones
  2. Articulation of rib necks and tubercles with vertebral transverse processes
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51
Q

What type of joint does a typical rib form with a articular facet on the dorsolateral margin of 2 adjacent vertebra? And also between the articular surface of the tubercles and neighboring transverse processes.

A

Sliding joint

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52
Q

What are the ribs with costotransverse process articulations

A

ribs 1-10

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53
Q

For the true ribs, what type of joint is present between the costal cartilage and the sternum

A

Sliding (EXCEPT FOR THE FIRST RIB)

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54
Q

What is the type of joint present between the costal cartilage of the 1st rib and the sternum

A

synovial joint

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55
Q

What are the names of the 3 intercostal muscles

A

External and internal intercostal muscles, and innermost intercostal muscle

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56
Q

Which muscle comprises the most superficial layer of the intercostal space?

A

enternal intercostal m

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57
Q

What direction do the fibers of the external interacts muscles travel

A

from lateral to medial (same direction as the external oblique)

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58
Q

In which direction (anterior or posterior) is the external intercostal m. membranous and muscular

A

Membranous- anterior

Muscular- posterior

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59
Q

How are the internal intercostal muscle fibers arranged relative to the external intercostal fibers

A

Perpendicular to external intercostal m.

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60
Q

In which direction (anterior or posterior) is the internal intercostal m. membranous and muscular

A

Membranous- posterior

Muscular- anterior

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61
Q

Where do the internal intercostal muscles arise and end?

A

Arise at the sternum and extend to the midaxillary line (love handle side) where it ends in a membrane

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62
Q

What is unique about the membrane and muscular patterns of the internal and external intercostal muscles

A

They alternate, allowing you to differentiate between the two muscles without reflecting back a layer of the external intercostal muscles.

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63
Q

What muscles are deep to the internal intercostal m.

A

The innermost intercostal muscles

64
Q

Where are the innermost intercostal muscles located

A

Only at the midaxillary line (peters off at the enters anteriorly and posteriorly)

65
Q

What muscles are located in the same plane as but are more posterior to the innermost intercostal muscles

A

transversus thoracis muscles

66
Q

Function of the transversus thoracic muscles

A

Hold the internal thoracic (mammary) vessels in place

67
Q

How are the internal, external, and innermost intercostal muscles innervated and supplied

A

By their respective neuromuscular bundle

68
Q

Action of the intercostal muscles

A

Involved in inspiration and expiration: At one point it was thought that the external muscles were involved in inspiration and the internal where involved in expiration

69
Q

Do the true ribs and the false ribs move in the same directions during inspiration and expiration to expand and compress the chest cavity

A

No

70
Q

For the true ribs, what motion do the ribs along with the sternum move during inspiration and expiration

A

Like a pump handle (Anterior to posterior) to increase the A-P diameter of the chest.

71
Q

For the false ribs, what motion do the ribs along with the sternum move during inspiration and expiration

A

Like bucket handle which increases the width of the lower rib cage

72
Q

What dimensions of the chest cavity does the diaphragm enlarge during expiration and inspiration

A

the vertical dimensions

73
Q

What are the 2 main arterial supplies to the thoracic wall

A

The intercostal a. and the beaches coming off of subclavian and axillary arteries

74
Q

Where do the posterior intercostal arteries arise from for the lower 9 intercostal spaces

A

the thoracic aorta

75
Q

What are the upper 2 branches of the intercostal spaces on the posterior supplied by (since the lower 9 we know are supplied by the posterior intercostal a)

A

superior intercostal a

76
Q

What is the superior intercostal a a branch of

A

axillary a (block 1)

77
Q

What do the posterior intercostal arteries anastomose with

A

The anterior intercostal a.

78
Q

From what vessel do the anterior intercostal a. arise from

A

The internal thoracic a.

79
Q

What do the anterior intercostal arteries supply?

A

The intercostal spaces and overlaying skin

80
Q

At what intercostal space does the internal thoracic artery divide

A

6th

81
Q

What are the two branches of the internal thoracic a and where are they located

A

Musculophrenic a- thorax

Superior epigastric a- abdomen

82
Q

What is the internal thoracic artery a branch of?

A

Subclavian a

83
Q

Is an intercostal nerve also considered a ventral rami?

A

Yes (just given the name intercostal nerve due to its location)

84
Q

What does the posterior primary rams supply in the thorax

A

Intrinsic back muscles and skin

85
Q

Where does the ventral rams course in the thorax

A

Along the chest wall between the innermost intercostal m. and the internal intercostal m.

86
Q

When does the ventral ramus give off its lateral branch

A

At the midaxillary line

87
Q

What are the terminal branches of the lateral branch of the ventral ramus

A

porterior and anterior

88
Q

What does he lateral branch of the ventral ramus innervate

A

The overlaying muscle and skin

89
Q

Where are the terminal branches of the lateral branch of the ventral ramus given off to

A

overlaying skin

90
Q

When does the ventral rams give off its anterior terminal branch

A

At the lateral border of sternum

91
Q

What do the anterior terminal branches of the ventral rami innervvate

A

overlaying skin

92
Q

What are the 2 different branches of the anterior terminal branch of the ventral rami

A

lateral and medial branches

93
Q

What skin does the lateral and medial branches innervate?

A

The lateral and anterior respectively

94
Q

What are the 3 groups of lymph nodes in the thorax

A

Pectoral nodes, axillary nodes, and internal thoracic nodes

95
Q

Which lymph nodes are commonly associated with breast tumor metastasis

A

Internal thoracic nodes

96
Q

Pleura verses peritoneum

A

Same concept except pleura is in the thoracic cavity verses peritoneum which is in the abdomen

97
Q

Parietal and Visceral pleura

A

Visceral- touches the lungs

Parietal- Surrounds the inner wall of the thorax, diaphragm, and lateral structures of mediastinum

98
Q

Pleural cavity

A

Space between the visceral and parietal peritoneum. Serous fluid and no air present

99
Q

What is the condition where an individual has air in the pleural cavity

A

pneumothorax

100
Q

How is parietal pleura named

A

Based on its location, for example, the mediastinal pleura, diaphragmatic pleura

101
Q

What is the one part of the pleura that protrudes outside of the thoracic region and above the clavicle

A

Cupula- pleura over the apex of the lung and extends into the root of the neck

102
Q

Costodiaphragmatic recess

A

Reflection of parietal pleura off the diaphragm into the inner chest wall. This is the lowest point in the pleural cavity. Located between the ribs and diaphragm

103
Q

What is the name of the condition where the pleural cavity is compromise and blood enters the lungs

A

Hemothorax

104
Q

Where does the apex of the lung protrude into?

A

Above the first rib and clavicle into the root of the neck

105
Q

Where does the base of the lung rest

A

Superior surface of diaphragm

106
Q

What are the two major surfaces of the lungs

A

Costal surface and mediastinal surface

107
Q

Costal surface of the lings

A

Lies against the inner surface of the rib cage

108
Q

Where is the mediastinal surface located

A

Adjacent to the heart

109
Q

What is located on the mediastinal surface of the lungs

A

hilum

110
Q

What enters and leaves the hilum and in what order

A

(Alpha order): ABV: Artery, bronchi, and vein. The artery and veins are pulmonary arteries in veins. This goes from highest to lowest (most superior to inferior)

111
Q

What is unique about the pleura at the hilum

A

The visceral pleura is continuous with the parietal

112
Q

How many lobes does each lung have? How many fissures?

A

Right- 3 lobes 2 fissures

Left-2 lobes 1 fissure

113
Q

What are the names of the 2 fissures for the right lung

A
  • Oblique (major)

- Horizontal (minor)- separates the superior from the middle lobe

114
Q

What’s the name of the fissure for the left lung

A

-Oblique (major)

115
Q

What are the names of the 3 lobes of the right lung

A

-Superior, middle, inferior

116
Q

What are the names of the 2 lobes on the left liver

A

Superior and inferior

117
Q

Where could you put a stethoscope to hear the superior lobe of the right lung

A

On the anterior thoracic wall not bellow the sternum

118
Q

Where could you put a stethoscope to hear the middle lobe of the right lung

A

At the Xiphoid process of the sternum

119
Q

Where could you put a stethoscope to hear the inferior lobe of the right lung

A

On the back

120
Q

Where could you put a stethoscope to hear the superior lobe of the left lung

A

Front at the xiphoid

121
Q

Where could you put a stethoscope to hear the inferior lobe of the left lung

A

On back can go pretty high or low

122
Q

Make sure you look at radiographs of the lungs and can differentiate where each lobe is

A

Okay

123
Q

Look at slide 35 to see that different places where you put a stethoscope to hear the different lobes of the lungs

A

Okay

124
Q

When looking at the hilum of the longs other than where things are oriented, how can you tell what each hole is

A

By looking at the thickness of the walls. Bronchi have very thick walls and the vessels are much thinner

125
Q

What is the cardiac notch and which lung has it?

A

The cardiac notch is the place where the lateral border of the left ventricle has made contact with the lung. This is on the left lung

126
Q

What is the candy cane looking impression on the left lung

A

Groove for the descending aorta

127
Q

From the anterior, lateral, and posterior views, do the lungs and pleura extend down to the same height

A

No

128
Q

From the anterior view, what rib do the lungs extend to?

A

Rib 6

129
Q

From the lateral view, what rib do the lungs extend to?

A

Rib 8

130
Q

From the posterior view, what rib do the lungs extend to?

A

Rib 10

131
Q

From the anterior view, what rib does the pleura extend to?

A

Rib 8

132
Q

From the lateral view, what rib does the pleura extend to?

A

Rib 10

133
Q

From the posterior view, what rib does the pleura extend to?

A

Rib 12

134
Q

Knowing the extent of which the lung and pleura can extend follows what rule

A

the rule of twos

135
Q

Why is it important to know where the lungs and pleura extend

A

For pleural taps (example taking a needle and placing is inferior to rib 8 and posterior to rib 10 would be good from the lateral)

136
Q

What delivers deoxygenated blood to the lungs?

A

Pulmonary arteries

137
Q

What is the arterial supply to the lungs

A

bronchial a.

138
Q

Where do the bronchial a. deliver oxygenated blood to

A

parenchyma

139
Q

What returns oxygenated blood to the heart

A

Pulmonary veins

140
Q

What innervates the lungs and pleura

A

vagus n and the sympathetic nerve plexus

141
Q

Do the lungs receive parasympathetic or sympathetic innervation

A

Both

142
Q

Is the innervation to the pleural autonomic or somatic

A

Both

143
Q

What provides somatic innervation to the pleura

A

intercostal n, and the phrenic n.

144
Q

Which part of the diaphragm is normally higher and why

A

The right because of the large liver

145
Q

What comprises the periphery of the diaphragm and the center

A

Periphery- Skeletal muscle

Central- Tendinous (Central tendon)

146
Q

What arteries supply the superior surface of the diaphragm

A

Musculophrenic a (branch of internal thoracic a, pericardiophrenic a

147
Q

What supplies blood to the inferior surface of the diaphragm (Abdomen)

A

The inferior phrenic a.

148
Q

What nerve fibers innervate the diaphragm along the periphery

A

The intercostal n.

149
Q

Do intercostal nerves supply sensory or motor innervation

A

sensory

150
Q

What innervates the central portion of the diaphram

A

Phrenic n (C3,4,5)

151
Q

Does the phrenic nerve provide sensory or motor innervation?

A

Both

152
Q

Where does the phrenic give off sensory innervation? Motor innervation

A

Sensory- Central tendon

Motor- muscles of diaphragm

153
Q

Where does the inferior vena cava go through the diaphragm and why is this important?

A

At vertebral level T8 through the Inferior vena naval foramen. This foramen is located in the central tendon which is important because the IVC would be constricted each time the diaphragm contracted if it were located in the muscle

154
Q

Where does the esophagus go through the diaphragm and why is this important?

A

Through the esophageal hiatus at vertebral level T10. The hiatus is formed by two cura of the diaphragm. Here we want to have the esophagus surrounded by muscle of the diaphragm to create a sphincter

155
Q

Where does the aorta go through the diaphragm and why is this important?

A

At vertebral level T12 through the aortic hiatus. The aorta crosses posterior to the diaphragm and is therefore unaffected by contraction of the diaphragm.

Block 2 Gross (11 decks)

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