Session 1.1b - Workbook Notes (Surface Anatomy) Flashcards
How do you count the ribs?
- Identify the jugular notch
- Then palpate downwards on the sternum until a ridge is felt
- At this level is rib 2
- Then count downwards to identify the other ribs
What do you identify first when counting the ribs?
The jugular notch
What is the ridge felt when palpating inferiorly on the sternum from the jugular notch?
The sternal angle (manubriosternal joint)
What important anatomical landmark articulates with the sternal angle?
The costal cartilage of rib 2
What important anatomical landmark articulates with the manubriosternal joint?
The costal cartilage of rib 2
Where does the costal cartilage of rib 2 articulate with?
The sternum, at the sternal angle/manubriosternal joint
How is the lung separated on the left side?
The oblique fissure separates the left upper and lower lobes
The oblique fissure separates the upper and lower lobes, only, ____
ON THE LEFT SIDE.
How is the lung separated on the right side?
The horizontal fissure separates the right upper and middle lobes.
The oblique fissure separates the right lower lobe from the upper and middle lobes.
The horizontal and oblique fissure separate the upper and middle, and upper/middle and lower lobes, respectively, ____
ON THE RIGHT SIDE
Describe the lobe and fissure arrangement of the lungs.
LEFT: - oblique fissure separates upper and lower
RIGHT: - horizontal fissure separates upper and middle
- oblique fissure separates lower from upper and middle
The _______ fissure is found on either side
oblique
Where does the oblique fissure extend from?
The spinous process of T2 vertebra posteriorly to the 6th costal cartilage anteriorly.
Where does the oblique fissure originate?
Spinous process of T2 vertebra
Where does the oblique fissure insert?
6th costal cartilage anteriorly
What direction does the oblique fissure travel?
Anteroposteriorly.
The surface marking of the oblique fissure approximately follows ___
The medial border of the scapula when the arm is abducted.
The horizontal fissure is only present on the _____ ____
on the right side
The __________ fissure is only present on the right side
horizontal
Where does the horizontal fissure extend from?
The mid axillary line anteriorly along the 4th rib, to the anterior edge of the lung (separating the right upper & middle lobes)
Where does the horizontal fissure originate?
The mid axillary line anteriorly along the 4th rib
Where does the horizontal fissure insert?
The anterior edge of the lung
What does the horizontal fissure separate?
The right upper & middle lobes
Inferiorly, the lung does not ___?
Completely fill the thoracic cavity
The ________ _____ of the lung dips lower, extending down to the peripheral attachment of the diaphragm.
Parietal pleura
The parietal pleural of the lung dips further than the lung, forming ___?
The costo-diaphragmatic recess
The costo-diaphragmatic recess is formed by?
The parietal pleura
The lower edge of the lung lies where?
The level of rib 6 (in the MCL), rib 8 (mid axillary line) and rib 10 (scapular line).
Rib 6, rib 8 and rib 10 are points where ___
the LOWER EDGE OF THE LUNG lies.
The lower edge of the lung lies at the level of rib 6 at the ___
MCL
mid clavicular line?
The lower edge of the lung lies at the level of rib 8 at the ___
mid axillary line
The lower edge of the lung lies at the level of rib 10 at the ___
scapular line
The lower edge of the lung lies at the level of ___ in the mid clavicular line.
rib 6
The lower edge of the lung lies at the level of ___ in the mid axillary line.
rib 8
The lower edge of the lung lies at the level of ___ in the scapular line.
rib 10
Where does the pleural cavity lie?
It extends 2 ribs lower than the edge of the lung
i. e.
- rib 8 (MCL)
- rib 10 (mid axillary line)
- rib 12 (scapular line)
Rib 8, rib 10 and rib 12 are points where ___
THE PLEURAL CAVITY lies
The pleural cavity lies at the level of rib 8 at the ___
MCL
The pleural cavity lies at the level of rib 10 at the ___
mid axillary line
The pleural cavity lies at the level of rib 12 at the ___
scapular line
The pleural cavity lies at the level of ___ at the mid clavicular line.
rib 8
The pleural cavity lies at the level of ___ at the mid axillary line.
rib 10
The pleural cavity lies at the level of ___ at the scapular line.
rib 12
What organ is dome shaped?
THE DIAPHRAGM
What is the shape of the diaphragm?
Dome shaped
Where does the dome of the diaphragm lie?
- Level of the 5th rib on the right side
- Level of the 5th intercostal space on the left side
The diaphragm lies at the 5th rib on the ___ side
right
The diaphragm lies at the 5th intercostal space on the ___ side
left
What is clinically significant about the level of the diaphragm?
A penetrating injury of the lower chest can injure upper abdominal organs
For what organ is the biopsy needle introduced through one of the lower intercostal spaces?
Liver biopsy
- So as not to injure the diaphragm
How is a liver biopsy performed?
The biopsy needle is introduced through one of the lower intercostal spaces.
Why is the biopsy needle introduced through one of the lower intercostal spaces in a liver biopsy?
So as not to injure the diaphragm
Why learn surface marking?
It lets us “visualise” the underlying lung and is important in clinical examination (e.g. knowing where to auscultate the different lobes) and when carrying out investigative or therapeutic procedures.
What is the relevance of this anatomy?
- useful in clinical examination (percussion/auscultation)
- to understand disease/effects of trauma
- pleural effusion
- anatomy and imaging of the chest
- useful when performing diagnostic/therapeutic procedures
How is surface marking used in clinical examination?
Via percussion and auscultation
When should you hear dullness in percussion?
When you reach the level of the liver (liver dullness)
What lies at the level of the 5th rib on the right side?
The dome of the right hemi-diaphragm and the upper border of the liver
The dome of the right hemi-diaphragm and the upper border of the liver lies where?
At the level of the 5th rib on the right side.
What is the normal sound of lung percussion?
Resonance
Normal lung resonance is replaced by dullness where?
From the 5th intercostal space (ICS) downwards.
What should you hear when percussing the lung on the right side?
- Normal lung resonance
- Liver dullness from the 5th ICS downwards
In what condition might the lung still sound resonant from the 5th intercostal space downwards (when it should sound dull due to the liver)?
COPD
Why does the percussion of the thorax sound resonant at the 5th ICS in COPD (hint: it should sound dull).
In conditions like COPD, air trapping and over inflation of the lungs pushes the diaphragm and liver downwards. Therefore percussion note remains resonant below the 5th ICS (e.g. down to 6th or 7th or 8th ICS).
When does percussion sound dull in COPD?
Anywhere up until the 6th-8th ICS on the RHS.
(For healthy patients, it should sound dull at the level of the 5th ICS on the RHS due to the liver).
How can lung percussion be used to help diagnose COPD?
On a normal patient, when percussing the right hand side - the percussion will sound resonant until we have reached the level of the 5th intercostal space. The upper border of the liver lies here, and therefore changes the normal lung resonance into dullness.
In COPD, air trapping and over inflation of the lungs pushes the diaphragm and liver downwards. This means the percussion note remains resonant below the 5th ICS, up until the 6th-8th ICS.
Describe what difference you would hear in percussion for liver dullness, and liver dullness in COPD.
LIVER DULLNESS: liver would sound dull from 5th ICS downwards on RHS.
LIVER DULLNESS IN COPD: liver would sound dull from 6th-8th ICS downwards on RHS.
How is surface marking used for auscultation?
Surface marking is used to identify the lobes of the lungs, and where to listen for lung sounds.
How can surface anatomy help us understand disease?
- Local effects of lung cancer
- Other thoracic pathology
How can apical lung cancers affect the upper limb?
The apex of each lung extends into the root of the neck, and apical lung cancers can involve the subclavian artery, vein and brachial plexus causing neurological and vascular problems in the upper limb.
Which important structures affecting the upper limb lie in the root of the neck?
Subclavian artery, vein and brachial plexus.
What disease of the lung can cause neurological and vascular problems in the upper limb?
APICAL LUNG CANCERS
Involvement of the sympathetic chain affects sympathetic innervation to the head and can result in ___
Horner’s syndrome
more of this in H&N
How can Horner’s syndrome develop from lung pathology?
Involvement of the sympathetic chain affects sympathetic innervation to the head
Lung cancer or enlarged hilar lymph nodes can involve structures such as ___?
The recurrent laryngeal nerve, or phrenic nerve in the thorax
The recurrent laryngeal or phrenic nerve can be damaged due to which lung pathologies?
LUNG CANCER OR ENLARGED HILAR LYMPH NODES
What are some signs of trauma that can be detected in clinical examination?
- RIB FRACTURES AND FLAIL CHEST
- STAB WOUNDS OF THE LOWER NECK
- HAEMOTHORAX
- PNEUMOTHORAX
- PENETRATING INJURIES OF THE LOWER CHEST
Give 2 ways a pneumothorax can be caused.
- STAB WOUNDS OF THE LOWER NECK
- Cannulation of the subclavian vein
A pneumothorax can be caused via a stab wound of the lower neck, and cannulation of the subclavian vein. What is the mechanism of pneumothorax?
Stabbing or cannulation here may puncture the lung, causing leaking of air into the pleural cavity
What is a pneumothorax?
Leaking/entry of air into the pleural cavity/space.
What can injuries to the chest result in (in relation to the lung)?
Haemothorax (bleeding into the pleural space) and/or pneumothorax
What is a haemothorax?
Bleeding into the pleural space
What is air in the pleural cavity/space called?
A pneumothorax
What is blood in the pleural cavity/space called?
Haemothorax
How might you get a haemothorax?
Injuries to the chest
What can occur in penetrating injuries of the lower chest?
The dome shape of the diaphragm means that hte liver, spleen, parts of the stomach and upper kidneys which lie in the abdominal cavity are covered by the ribs, and penetrating injuries of the lower chest can injure these abdominal organs, in addition to causing pneumothorax or haemothorax.
What organs might be injured in a penetrating injury of the lower chest?
- Liver
- Spleen
- Parts of the stomach
- Upper kidneys
How can you get a pneumothorax or haemothorax?
Pneumothorax:
- stab wounds of the lower neck
- cannulation of the subclavian vein
- injuries to the chest
- penetrating injuries of the lower chest
Haemothorax:
- injuries to the chest
- penetrating injuries of the lower chest
What is a pleural effusion?
Collection of fluid in the pleural cavity
What is a collection of fluid in the pleural cavity called?
Pleural effusion
A pleural effusion is a collection of fluid in the pleural cavity. Where does this fluid collect?
In the costo-diaphragmatic space in the upright position.
Where does pleural effusion collect in the upright position?
In the costo-diaphragmatic space
When does pleural effusion collect in the costo-diaphragmatic space?
In the upright position
How is pleural effusion detected on a chest x-ray?
As a blunting costo-phrenic angle.
http://img.medscapestatic.com/pi/meds/ckb/07/16507tn.jpg
A blunting costo-phrenic angle on a chest x-ray is a sign of what?
Pleural effusion
What is the relevance of anatomy and imaging of the chest?
Anatomy is key to understanding and interpreting images of the chest.
What is at risk of injury during pleural aspirations?
The intercostal vessels and nerve
The intercostal vessels and nerve are at risk of injury during which procedures?
- During aspiration of pleural fluid
- When a tube is inserted into the pleural cavity to drain air or fluid
Where does the neurovascular bundle run?
IN THE COSTAL GROOVE
Why is the needle or tube in pleural aspirations inserted at the upper border of the rib?
To avoid causing injury to the neurovascular bundle running IN THE COSTAL GROOVE along the lower border of the rib,
What anatomical landmarks are found superior to rib 1?
The apex of the lung extends higher than the 1st rib, and into the root of the neck
What anatomical landmarks are found at the level of rib 2/T2?
The 2nd costal cartilage articulates with the sternum, at the level of the sternal angle. The sternal angle can be palpated!
The level of T2 is where the oblique fissure begins on the posterior.
What anatomical landmarks are found at the level of rib 4?
The horizontal fissure on the right side.
What anatomical landmarks are found at the level of rib 5?
The right dome of the diaphragm
The upper border of the liver
What anatomical landmarks are found at the level of the 5th ICS?
The left dome of the diaphragm
What anatomical landmarks are found at the level of rib 6/T6?
The lower border of the lung at the mid-clavicular line (rib 6)
The level of T6 is where the oblique fissure ends anteriorly
What anatomical landmarks are found at the level of rib 7?
Some of the peripheral muscular fibres of the diaphragm arise here (from rib 7-12)
The xiphisternal joint
What anatomical landmarks are found at the level of rib 8/T8?
The lower edge of the lung at the mid-axillary line (rib 8)
The inferior border of the pleural cavity at the mid-clavicular line (rib 8)
The level of T8 is where there is a diaphragm opening for the IVC.
What anatomical landmarks are found at the level of rib 10/T10?
The lower edge of the lung at the scapular line (rib 10)
The inferior border of the pleural cavity at the mid-axillary line (rib 10)
The level of T10 is where there is a diaphragm opening for the oesophagus.
What anatomical landmarks are found at the level of rib 12/T12?
The inferior border of the pleural cavity at the scapular line (rib 12)
The level of T12 is where there is a diaphragm opening for the aorta .
