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MD3001 > Thoracic Wall 1 and 2 > Flashcards

Thoracic Wall 1 and 2 Flashcards

Looking at the thoracic wall, ribs, blood supply, breast and diseases related to the thorax

1
Q

What are the functions of the thorax?

Include how does it helps in certain processes

A
  • Protection: of lungs, heart, liver, stomach, kidneys and spleen
  • Rigdity and elasticity: to allow movement when breathing
  • Respiration: Resists negative intrathoracic pressure and works with diaphragm and abdominal muscles.
  • Movement: Provices attachment for accesory muscles for respiration
  • Haematopoiesis
  • Connections of neck, upper limbs and abdomen
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2
Q

Describe the shape of the thorax

A
  • Truncated cone shape
  • Wider transversally than saggitally( wider from right to left than front to back)
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3
Q

What is the difference between the thoracic cage, the thoracic wall and the thorax?

A

The thoracic cage is the rib cage( bony part).
The thoracic wall consists of the thoracic cage, skin, muscles and breast
Thorax is everything in the thoracic cavity and its boundaries.

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4
Q

What does the thoracic cage consist of?

A
  • 12 pairs of ribs
  • Sternum
  • Thoracic vertebrae
  • Costal cartilages
  • Intervertebral discs
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5
Q

What does the thoracic wall consist of

A
  • Thoracic cage
  • Skin and subcutaneous tissue
  • Thoracic muscles and fascia
  • Intercostal muscles
  • Breast
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6
Q

-What are the actions that the thoracic vertebrae can and cannot do? Why?
-Why are they the least likely vertebrae to have herniation of intervertebral disc?

A
  • The T vertebrae can rotate due to the arcuate arrangements of the articular facets(sup. and inf.) They cannot extend or flex due to the spinous process being very vertical.
  • Because they cannot flex or extend, while the cervical and lumbar vertebrae can.
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7
Q

What are the 2 ways we can classify ribs?

Name the ribs involved in each classification

A
  1. True(1-7), false(8-10) and floating ribs(11-12).
  2. Typical(2-10) vs. atypical ribs. (1,11 and 12)
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8
Q

Characteristics of true, false and floating ribs.

A
  • True ribs attach directly to the sternum via their costal cartilages.
  • False ribs attach indirectly to the sternum via te costal cartilage of rib 7.(interchondral joints form)
  • Floating ribs do not attach to the sternum and have little to no costal cartilage.
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9
Q

What are the strucures that all typical ribs have, and what is their function?

A
  • Head: contains 2 articular facets which attach to the superior and inferior articular demifacets of the vertebrae they attach to. Separated by a ridge.
  • Neck
  • Tubercle: Where the rib articulates with the corresponding vertebrae transverse process.
  • Angle: Most lateral attachment of intrinsic back muscles.
  • Shaft
  • Costal groove: close to inferior border. Covers the intercostal neurovascular bundle.
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10
Q
  • Where are fractures most likely to occur in rib?
  • Why can’t we see costal cartilage when looking at bones in the DR?
A
  • In the angle of the rib
  • Because costal cartilage is lost in the maceration process.
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11
Q

State the characteristics of an atypical rib 1.

A
  • Deep and non-palpable as it lies behinf clavicle.
  • Anterior scalene muscle attaches to it by the scalene tubercle
  • Grooves for subclavian vein, subclavian artery and inferior trunk of brachial plexus.
  • ONE facet that articulate ONLY with T1 vertebrae
  • No costal groove. It is flat and horizontal so the structures pass under it.
  • Sharper angle
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12
Q

State the charaxteristics of atypical ribs 11 and 12

A
  • Don’t articulate with the sternum
  • Head has ONE articular surface that ONLY articulates with the corresponding vertebrae
  • Has no tubercle so no attachment ot transverse process of T11 or T12
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13
Q

Name the 3 parts the sternum is made up of

A
  • Manubrium (means sword handle)
  • Body of sternum (means sword)
  • Xiphisternum/xiphoid process
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14
Q

How might the XRay of the stenrum of a chiod differ from that of an adult?

A

In child, the sternum is still separated in 5 pieces called sternebrae while in an adult, all the sternebrae have fused so it would look like a whole bone.

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15
Q
  • What are some landmarks to find the sternal angle of sternum?
  • What is the sternal angle a landmark for?
  • What
A
  • Intervertebral disc between T4 and T5
  • It is the landmark to find the 2nd costal cartilage
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16
Q

What structures does the intervertebral disc act as a landmark for?

A
  • Beginnning and end of aortic arch
  • Carina(bifurcation) of the trachea
  • Superior limit of pulmonary trunk
    *Azygous vein going to Supervior Vena C.
  • Ligamentum arteriosum(between aortic arch and pulmonary artery)
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17
Q

What type of joint is present at the sternal angle?
What is the landmark for the xipisternum?

A
  • Symphysis(secondary cart. joint)
  • T6 dermatome
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18
Q

What processes take place in the sternum?

A

Haematopoiesis. So bone marrow from sternu can be extracted and donated.

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19
Q

-Why can’t we take bone marrow from a child’s sternum?
-Why is an XRay needed before taking bone marrow from the sternum of an adult?

A
  • Because child’s sternum is not unified yet, and the aspiration needle can perforate the spaces in between the sternebrae and damage the heart or vessels.
  • Because some patient’s unknowingly have a sternal foramen so ifdr doesn’t know that, the aspiraion needle could go through the foramen and puncture the heart. Xray is needed to know if patient has this condition or not.
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20
Q
  • What type of joints are costovertebral joints?
  • What type of joints are costochondral joints?
A
  • Costovertebral joints are synovial
  • Costochondral joints are primary cart. joints
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21
Q

Describe the facets of the 12 vertebrae involved in the costovertebral joints.

A
  • T1 has 1.5 costal facets: one for rib 1 and a demifacet for rib 2
  • T2-T10 have 2 costal demifacets. But variations can occur in T9/T10.
  • T11 to T12 have one oval costal facets
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22
Q
  • What are the costotransverse joints made up of?
  • Shape and movement of costotransverse joints
A
  • The tubercle of the rib and the transverse processs of the corresponding vertebrae.
  • CT joints 1-7 have curved facets that allow rotatory movement. CT joints 8-10 have flat facets that allow a gliding movement.
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23
Q
A
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24
Q
  • What are costochondral joints made up of?
  • What type of joints are they made up of?
A
  • Made up of ribs and costal cartilage
  • They are primary cart. joints
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25
Q
  • What are interchondral joints made up from?
  • What type of joints are there?
A
  • Made up from costal cartilages of ribs 8-10 articulating with the costal cartilage above to indirectly attach to the sternum via CC of rib 7.
  • Interchondral joints of ribs 7-9 are synovial. Interchondral joint between rib 9 and 10 is fibrous joint
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26
Q

Orientation of the costal cartilage as we go down the ribcage.

A

As we go down the ribcage, CC become more oblique:
-CC of ribs 1-4 are horizontal
-CC of ribs 5-10 become more oblique

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27
Q

Describe the thoracic inlet and its boundaries.

A
  • Bounded by the T1 vertebra, 1st rib and the manubrium.
  • Inexpandible ring
  • Slopes from posterior to anterior till level of T2/3.
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28
Q

What structures pass between the thorax and the neck?

A
  • Arteries and veins supplying the head and neck
  • Trachea
  • Oeophagus
  • Vagus and current laryngeal nerves
  • Phrenic nerves( relating to diaphragm)
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29
Q

What structures pass between the thorax and the upper limb and lie on 1st rib?

A
  • Subclavian vein
  • Subclavian artery
  • Inferior trunk of brachial plexus(C8, T1)
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30
Q

Why is the lung vulnerable from the thoracic inlet?

A

Because the apex of the lung extends 2-3 cm above the 1st rib anteriorly, which makes it vulnerable to injury.

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31
Q

Describe the thoracic outlet and its boundaries

A
  • Bounded by T12 vertebra, ribs 11 and 12, costal margin/arch and the xiphisternum.
  • Closed by the diaphragm
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32
Q

What structures transverses the diaphragm and therefore the thoracic outlet?

A
  • Oesophagus
  • Aorta
  • Inferior Vena Cava
  • Azygous veins
  • Nerves
33
Q
  • Describe the causes of the thoracic “outlet” syndrome
  • Why is it considered a misnomer?
A
  • The subclavian plexus or nerves corresponding to the inferior trunk of brachial plexus become compresed by muscles, narrow bony passages(e.g cervical rib) or pathology. Causing pain, paraesthesia, palor, pulselessness,etc.
  • It is a misnomer because it happens in the thoracic inlet.
34
Q

Symptoms of Thoracic Outlet syndrome

A

*Pain and paraesthesia in upper limb(UL)
* Oedema and discolouration in UL
* Throbbing lump near clavicle
* UL fatigue
* Cold and pale hands /fingers
* Lack of pulse in UL
* Raynaud’s phenomenon(blood stops flowing to fingers.

35
Q
  • What is the breast and what does it consist of?
  • Describe the aerola
A

*Modified sweat gland consisting of mammary glands, skin and connective tissue.

  • It consists of:
    -Areolar/Montgomery glands: They produce sebaceous so baby can get good suction on the nipple and seal during feeding.

-Montgomery tubercles: visible ends of the montgomery glands within the areola.

36
Q
  • Explain supernumerary nipples
  • How common are they?
A
  • In embryo, there are milklines, which are line where nipples and breast tissue can develop. Sometimes extra nipples can develop within those milklines.
  • 1 in every 500 babies.
37
Q

Describe the boundaries of the breast in adult females

A
  • Between ribs 2 and 6/7
  • Extends from lateral sternum to mid-axillary line
  • The upper lateral section extends towards the axilla and its called the axillary process or axillary tail of Spence
38
Q
  • What muscles do breast sit on?
  • Between which connective tissue is the breast located?
A
  • Pectoralis major, serratus anterior and external oblique muscles.
  • Between superficial and deep fascia
39
Q
A
39
Q

What is the retromammary space?
Why is it useful in plastic surgery?
Why can it be harmful?

A
  • Layer of loose connective tissue between deep layer of superficial fascia and deep fascia
  • Breast implants placed here during plastic surgery
  • It is a space, so an abcess can form there.
40
Q

Describe the structure of the breast

A
  • 15-25 lobes made up of lobule and ducts.
  • Lobes surrounded by fat and connective tissue.
  • Contains suspensory ligaments called Cooper’s ligaments which connect deep fascia to skin and supports the breast.
41
Q

What is the orange peel breast condition?

A

Pop marks appearance in breast caused by detachment of Cooper’s ligaments causing breast to look like an orange peel

42
Q
A
43
Q

Explain the 2 main supplies to the breast.

A
  • Internal thoracic artery: Branch to the subclaviannwhich passes down wither side of the sternum. Splits into mammary and anterior intercostal arteries.
  • Axillary artery: Splits into lateral thoracic artery (supplying lateral and superior parts) and thoracoacromial artery.
44
Q

Where does veins in the breast drain to?

A

Drain mainly to axillary and internal thoracic veins.

45
Q

Where does each quadrant of the breast drain their lymph into?

A
  • Areola and lateral quadrants drain into axillary lymph nodes
  • Medial quadrants drain into the parasternal lymph nodes and the opposite breast.

*Inferior quadrants drain to inferior phrenic lymph nodes.

46
Q
  • Explain the intercostal spaces
  • What should we avoid when inserting a needle through the intercostal spaces?
A
  • There are 11 intercostal spaces filled with 3 layers of muscles and membranes.

*Avoid intercostal nerves and vessels.

47
Q

Name the 3 intercostal muscles

A
  • External
  • Internal
  • Innermost
48
Q

Describe the external intercostal muscles

A
  • Extend from inferior edge of rib above to superior edge of rib below.
  • Anteriorly its external intercostal membrane and posteriorly its muscles.
  • Contracts during inspiration to raise ribcage
  • Prevents indrawing of the thoracic wall and intercostal space during inspiration
49
Q

Explain the internal intercostal muscles

A
  • Extend from lateral edge of costal groove of the rib above to the superior edge of the rib below.
  • Posteriorly it has internal intercostal membranes, and anteriorly it has muscle
  • Prevents indrawing during repiration
  • Depresses the ribcage by contracting during expiration

*Runs perpendicular to the external intercostal muscles.

50
Q

Explain the innermost layer of intercostal muscles

Describe what muscles form part of it

A

Made up from:
* Innermost intercostal
* Transversus thoracis
* Subcostalis

51
Q

Describe the innermost intercostal

A

-Works with the internal intercostal muscles
-Covered with endothoracic fascia
-Wraps around from sternal angle of the ribs to the sternum.
-Can be differentiated from the internal intercostal by the neurovascular bundle that runs between the 2.

52
Q

Describe the transversus thoracis

Part of the layer of the innermost intercostal muscles

A

-Lies posterior to sternum.
-Covers internal area of ribs+ costal cartilage 3-6, sternum, xiphisternum and costal margin
-Can depress ribs

53
Q

Describe subcostalis layer

A

-Lies on posterior wall
-Extends across more than 1 intercostal space(how to differentiate it)
-Goes from internal surface near angle of a rib to inner surface of the 2/3 ribs below.

54
Q

What structures form the intervertebral foramen?

A
  • Inferior vertebral notch of the vertebra above, vertebral body, intervertebral disc, superior vertebral notch of the vertebra below
55
Q

Possible causes of spinal nerve compression

A
  • Pathology
  • Fractures
  • Trauma to pedicle or articular facets
  • Herniation of vertebra
56
Q
  • How are the intercostal nerves formed? What is the exception to this?
  • Location and order of the intercosta; neurovascular bundle
A
  • The anterior rami of the thoracic spinal nerves maintain their segmental orientation without becoming nerve plexus and they become intercostal nerves.
    -Exception is T1 and lateral cutaneous branch of T2
  • They lie in the costal groove of rib, passing between innermost and internal intercostal muscles. The order is Vein, Artery, Nerve(VAN) Colateral branches can also travel in this space.
57
Q

Describe the formation of cutaneous branches from intercostal nerves.

A
  • Intercostal nerves give off lateral cutaneous branch
  • The rest travels in the costal groove and become superficial parasternally(near the sternum) to give off an anterior cutaneous branch.
58
Q

What other nerves/dermatomes supply the anterior thoracic wall?

A
  • Supraclavicular nerves( C3,4) which descends up to 2nd costal c.
  • T1 joins brachial plexus to supply medial upper limb
59
Q

What pattern do dermatomes follow in the thorax region?

A
  • Dermatomes follow the angle of the ribs.
  • Anteriorly dermatomes are more inferior than posteriorly.
  • Anteriorly, T1 nerve, does not supply cutaneously, only posteriorly.
  • T2 supplies axilla, medial part of upper limb.
  • T7-T12 supply skills and muscles of abdomen
60
Q

What structures does the ventral ramus of T1 supply?

A
  • Small muscles of hand
  • Medial skin of arm and forearm
  • Muscles of 1st intercostal space
61
Q

What structures does the ventral rami of T2-T11 supply?

A
  • Intercostal and abdominal muscles
  • Skin and parietal pleura
62
Q

List the arteries of the anterior thoracic wall

A

The subclavian artery gives way to the:
* Vertebral artery
* Thyrocervical trunk-supplies thyroid glands and neck
* Costocervical trunk: supplies 1st and 2nd intercostal space and branches into superior thoracic artery
* Internal thoracic artery: lies near sternum and gives off superior epigastric and Musculophrenic arteries.

63
Q

What structures are supplied by the superior epigastric and musculophrenic arteries?

A
  • Superior epigastric supplies anterior abdominal wall.
  • Musculophrenic supplies intercostal spaces at costal margin(near diaphragm).
64
Q
  • Landmarks of the thoracic aorta
  • Describe the parietal branches
A
  • Between T4 -T12 vertebrae
  • The branches are the following:
    -Intercostal arteries 3-11
    -Subcostal artery
    -Superior phrenic artery supplying diaphragm.
65
Q

Describe the anterior intercostal arteries

A
  • They come from the internal thoracic artery.
  • There are 2 arteries per intercostal space from intercostal space 1 -6.
  • Anterior intercostal artery 7-10 come from the musculophrenic artery.
  • 11 th intercostal space and subcostal have no supply because they don’t need costal margin.
66
Q
  • What is an aortic coartation?
  • How can blood supply be sent to the thorax if there is an aortic coartation?
A
  • Narrowing in the aorta.
  • Blood can be sent:
    -up the subclavian
    -down the internal thoracic arteries
    -Through anterior intercostals all the way around back of the aorta, distal to the coartation.
67
Q

Explain the venous drainage of thoracic wall

A
  • Anterior intercostal veins drain to the internal thoracic vein which drains to the brachiocephalic vein.

*Posterior intercostal veins drain to the brachiocephalic vein or the superior vena cava.

68
Q

Describe the azygous system

A
  • Begins from lumbar and subcostal veins to the inferior vena cava.
  • Passes behind diaphragm along with the aorta and thoracic duct.
  • Ascends in the posterior mediastinum, passes behind right lung hilium, arches and opens into the superior vena cava. Connects superior and inferior VC.
69
Q

List the posterior intercostal veins in the azygous system of the right and the vein they drain into

A
  • IcV 1: Supreme intercostal vein and then brachiocephalic vein
  • IcV 2,3,4: right superior intercostal vein and then azygous
  • IcV 5-11: Azygous vein
70
Q

List the posterior intercostal veins on the left and the veins they drain into

A
  • IcV 1: into brachiocephalic vein
  • IcV 2-4: into left superior intercostal brain then into brachiocephalic vein
  • IcV 5-8: into accessory hemiazygous vein
  • IcV 9-11: into hemiazygous vein and into azygous vein.
71
Q

Describe the hemiazygous vein

A
  • Connects with the left renal vein
  • Passes behind the diaphragm
  • Crosses to the right at the level of T9 vertebrae and joins azygous system
72
Q

Describe the accessory hemiazygous vein

Aka superior hemiazygous

A
  • Descends from 4th intercostal
  • Croses to the right at T8 vertebrae level
  • Opens into hemiazygous or/and azygous
73
Q

```

~~~

Describe the superior intercostal vein

A
  • Present in both left and right of azygous system
  • Drains intercostal space 2, 3,4
  • Right drains to azygous, Left drains to left brachiocephalic vein
74
Q

Describe the supreme intercostal vein

A
  • Present in both left and right of system
  • Drains rib space 1
  • Drains into brachiocephalic vein
75
Q

Describe the lymphatics of the thoracic wall

Include where lymph drains anteriorly, posteriorly and superficially

A
  • Anteriorly: parasternal nodes and bronchomedial trunks
  • Posteriorly: Intercostal nodes, thoracic duct(inferiorly), bronchomedial trunks(superiorly)
  • Superficially: Axillary and inferior phrenic nodes.
75
Q
  • What ribs are most likely to fracture?
  • Why not the first 2 ribs?
A
  • Ribs 4 and 10
  • Because they are covered in muscle and don’t move much.
76
Q
  • Why are ribs bound tightly when they fracture instead of using a plaster cast?
  • What would be the consequences of using a plaster cast?
A
  • They are bound tightly to limit movement, but still allow patient to breathe. If plaster cast were used, patient would not be able to breathe deeply and cause lungs to collect fluid and foreign particles.
  • Consequences of using a plaster cast would include: hemothorax, pneumithorax, pulmonary or splenic injury.

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