Thorax Flashcards
bony landmarks of the posterior thorax
spinous processes of thoracic vertebrae 1-12
costovertebral angle CVA
bony landmarks of the anterior thorax
jugular notch sternal angle 2nd rib ICS intercostal space costal margin costal angle interspaces 2-6
Identify the vertical lines of thorax (anterior, lateral, posterior) and describe location
anterior: anterior median (midsternal) line- thru sternum in midsagittal place midclavicular line (MCL)- thru midpoint of clavicle
lateral:
anterior axillary line-along anterior axillary fold formed by pec major
mid axillary line- thru apex of armpit
posterior axillar line - thru posterior axillary fold formed by latissimus dorsi and teres major
posterior:
posterior median (midspinal.midvertebral) line-thru spinous process in midsagital plane
scapular lines- thru inferior angles of scapula
Landmarks of auscultation posterior and anterior
posterior: auscultation alley (either side of posterior median)
anterior:
1. R 2nd ICS (aortic valve)
2. L 2nd ICS (Pulmonary valve)
3. Erb’s point (L 3rd ICS)
4. Left sternal border/4/5th ICS (Tricuspid valve)
5. Midclavicular apex Left 5th ICS (mitral valve)
bones of thoracic wall
ribs, thoracic vertebrae, sternum
function of thoracic wall
protect thoracic content: heart lungs BVs esophagus etc
Main structures of sternum:
manubrium
sternum
xiphoid
sub divisions of the ribs
true (1-7) attach directly to sternum
false(8-10) attach indirectly to sternum
floating(11-12) do not attach to sternum
typical ribs = 3-9
atypical ribs = 1,2,10,11,12
land marks on a typical rib
rib 3-9: head with two facets neck tubercle shaft costal angle
what makes the atypical ribs different?
1 and 2 have scalenes attached
10 11 12 articulate with the spine differently
common site for rib fracture
shaft
the head articulates with.. the tubercle articulates with..
two vertebrae: costal facets inferior and superior on vertebral bodies (except bottom 4 vertebrae)
transverse costal facets on the transverse process of spine (except 11 and 12 vertebral bodies)
landmarks of thoracic vertebrae
spinous process
transverse process (articulate by synovial joint to form rib)
costal facets (T1-8 have superior and inferior, T 9 -12 have only 1)
transverse costal facets (not found on T 11 or T 12)
describe the two apertures of the thorax
superior: esophagus, trachea, nerves and BVS that supply head neck and UE
inferior: allows esophagus, IVC, and aorta to pass inferior to abdominal cavity
Name and describe the joints of the posterior thorax
costovertebral (rib and vertebrae body)
costotransverse (rib and transverse process)
intervertebral joints of thoracic spine (disc and facets)
name and describe the joints of the anterior thorax
costochondral (rib and chondral cartilage)
sternocostal (costal cartilage and sternum)
sternoclavicular (sternum and clavicle) -only true synovial joint for UE
name and describe joints of anterior thorax
interchondral (articulation btwn costal cartilages of lower ribs (9to10 and 8 to 9) manubriosternal / sternal angle (manubrium to sternum) xiphosternal joint (xiphoid to sternum)
normal movement of inspiration:
up, out, and diaphragm down ward
increase AP and lateral diameter d/t “buckethandle” motion of ribs
increase superior and inferior length
muscles of inspiration at rest, exercise, intense exercise
rest = diaphragm
exercise = diaphragm and external intercostals
extreme exercise = diaphragm, external intercostals, scm, scalenes, pecs
muscles of expiration at rest and exercise
rest = none. - elastic recoil of lungs exercise = internal intercostals and abdominal muscles rectus abdominis, int/ext obliques
abnormal movement patterns of ventilation
- accessory pattern - shrug in COPD
2. asymmetry - pneumothorax or scoliosis (trauma to one lung)
list muscles of the thoracic wall
external intercostals
internal intercostals
innermost intercostals
transversus thoracis subcostal muscles levator costarum serratus posterior superior serratus posterior inferior diaphragm - central tendon and sternal region, costal region, lumbar region
describe actions of thoracic wall muscles
external intercostals-inspiration
internal intercostals-expiration
innermost intercostals-elevate (BV and nerves run btwn this and internal)
transversus thoracis - expiration(internal anterior thoracic cage)
subcostal muscles-inspiration (internal posterior thoracic cage)
levator costarum-inspiration (external posterior of thoracic cage attach to ribs and TP)
serratus posterior superior-inspiration
serratus posterior inferior-expiration
diaphragm - central tendon and sternal region, costal region, lumbar region -phrenic nerve C3-5 motor and sensory- INSPIRATION!! flattens diaphragm and pulls air into lungs
pathway of intercostal nerves
all 12 spinal nerves exit spinal intravertebral foramen (IVF) and branch into poterior and anterior rami
(anterior supplies the intercostal spaces with VAN = vein artery and nerve bundle)
what supplies the ICS ?
VAN of anterior rami thoracic spinal nerve
describe herpes zoster/shingles
dormant virus in single segmental nerve is activated
painful red vesicular lesions in dermatome pattern
common in thoracic region but will be seen in other regions too including face head and LE
Describe the artery system of thorax wall starting with 3 major sources of circulation
- thoracic aorta-
a. posterior intercostal artery -3-11 ICS-POSTERIOR and 10+11 ALL
b. subcostal artery-12th rib ALL (from inferior) - axillary artery
- subclavian artery
a. costocervicle trunk-> superior thoracic artery -ICS 1+2
b. internal thoracic artery->anterior intercostal artery -1-9 ICS-ANTERIOR
Describe venous drainage of thorax
intercostal spaces->intercostal veins-> anterior or posterior:
if anterior: ->internal thoracic vein->SVC (?)
if posterior: azygos system -> SVC
L: T1-4 skip azygos system and go to brachiocephalic L trunk vein ->SVC
L: T5-12 ->hemi or accessory hemi azygos-> Azygos vein->SVC
R:right side intercostals and hemi/accessory->azygos vein-> SVC
function of breast
reproductive role in female
landmarks of male breast and female breast
male = nipple
near 4th intercostal space
the apex of the heart is just inferior/medial to it
female= circular base (sternum to mid axillary line ribs 2-6)
axillary tail (extends along inferior border of pec towards axilla)
quadrants (for clinical documentation of cysts or tumors)
-clock-3 6 9 12 upper outer upper inner lower outer lower inner
-right and left have the same “clock” 3 on R (middle inner) is 9 on L (middle inner)
lymphatic drainage of breast
75% of lymph node (usually lateral) drain to axillary lymph nodes then on to the brachiocephalic system
the rest drains medially via the parasternal lymphnodes
important clinically for exam (palpate axillary region) and post surgical lymphedema
ID and describe the tracheobronchial tree
trachea begins inferior to larynx (cricoid cartilage)
D shaped cross section (incomplete C shaped rings of cartilage with membranous flat back - trachealis muscle
carina-bifurcates into r/l bronchi at sternal angle
r/l primary bronchi-lobar bronchi (3 R 2 L) - segmental bronchi (10 segments)-intersegmental bronchi (20-25 more)-bronchioles (Cartilage begins to disappear) -terminal bronchiole-respiratory bronchioles (gas exchange)- acinus: (one terminal bronchiole supplies whole acinus-many respiratory bronchioles-many alveolar ducts/sacs-alveoli)
ID and describe the 3 pulmonary pleurae
- visceral pleura- invests lungs
- parietal pleura- lines thoracic wall and diaphragm
- pleural cavity - space btwn two layers lubricated by serous pleural fluid
ID and describe the pleural recesses
- costodiaphragmatic recess- large, located in posterolateral region (back of lung)
- costomediastinal recess- small, located anterolateral region (front lateral of lung behind sternum)
what is thoracentesis?
removal of fluid in pleural cavity using hypodermic needle inserted thru intercostal space (its hard to breath because fluid is in the way)
ID and describe regions of the lungs
apex- superior
base- inferior sits on diaphragm
hilum/root- site where the lung becomes covered by visceral pleura!!
-contains: primary bronchus, pul veins, pul artery, bronchial vessels, pul nerves, lymph vessels
ID describe RIGHT lung
superior middle inferior lobes
horizontal fissure and oblique fissure
superior (3) middle (2) inferior (5) segments
ID and describe the LEFT lung
superior and inferior lobe oblique fissure Lingula where middle lobe would be cardiac notch in superior lobe 5 segments per lobe
ID and describe layers of heart wall
endocardium- inner layer of THIN smooth lining heart chamber
myocardium - cardiac muscle middle layer
epicardium - outer later blends into the visceral layer of serous pericardium
ID and describe pericardium
double wall fibroserous sac*
Outside sce=fibrous pericardium
- attaches to diaphragm via pericardiacophrenic ligamet
- attaches to sternum bia sternopericardial ligament
Inside sac=serous pericardium
- parietal layer is the outer layer that blends with fibrous pericardium
- visceral layer is the inner layer that blends with the epicardium
pericardial cavity is between the parietal serous and visceral serous pericardiums –has smooth serous fluid to allow heart to move freely within the pericardial sac
land marks of the R atrium
SVC IVC opening coronary sinus fossa ovalis tricuspid valve
landmarks of L atrium
foamen ovale
4 openings of pul veins
bicuspid valve
lndmarks of R ventricle
tricuspid valve
papillary muscle/chordae tendineae
pulmonary valve
landmarks of L ventricle
bicuspid valve
papillary muscle/chordae tendineae
aortic valve
ID and describe the fibrous skeleton
four fibrous raised rings around the surface of the orifices of the valves
- provides attachmnt for myocardium of atria and ventricles
- provides attachment for cardiac valves
- electrical insulation btwn atria and ventricles
pulmonary semilunar
aortic semilunar
L coronary artery bicuspid-tricuspid R coronary artery
ID and describe the tricuspid valve
R atria/ R ventricle
chordae tendineae and papillary muscles anchor cusps of the valves
auscultat along left sternal border 5th ICS
ID and describe Bicuspid valve
L atria/Lventricle
chrodae tenindeae and papillary muscles anchor cusps of the valve
auscultate along APEX (left 5th ICS)
ID and describe the pulmonary valve
R ventricle and Pulmonary trunk
auscultate along left 2nd ICS
ID and describe the aortic valve
L ventricle and Aorta
auscultate along right 2nd ICS
4 great vessels of the heart
SVC (returns blood to right atrium from areas above diaphragm except the heart and lungs) IVC (returns blood to the right atrium from areas below the diaphragm) Pulmonary trunk (sends unoxygenated blood from R ventricle to lungs) Pulmonary Veins R/L (returns oxygenated blood back to the left atrium from the lungs) Aorta (sends blood to body from L ventricle)
what is the origin and associated pressure gradient of the coronary arteries?
R/L coronary arteries originate in BASE OF THE AORTA
-aortic pressure causes back flow from early diastole/isovolumetric relaxation- blood goes into R/L coronary arteries not back into heart
Pathway of R and L coronary branches
R:
- nodal branches (supply SA/AV nodes)
- marginal branch (supplies R ventricle)
- posterior interventricular artery/right posterior descending (supplies R ventricle back)
L:
- anterior interventricular arterty/left anterior descending(major site of occlusion supplies septum and left ventricle)
- circumflex artery (supplies left atrium and left ventricle)
- marginal branch (supplies L ventricle)
pathways of coronary veins
most cardiac veins (great, middle small, oblique) drain into coronary sinus -> R atrium
anterior cardiac and smallest cardiac veins -> R atrium (not the coronary sinus)
describe conducting pathway of heart
SA node (sinoatrial)-> AV node (atrioventricular -1/10 sec delay for atrial contraction)-> AV bundle of His->L/R bundle branches-> purkinje fibers
describe the surfaces of the heart
- sternocostal/anterior surface
(mostly right ventricle) - diaphragmatic / inferior surface
(mostly L ventricle and some of R ventricle) - Pulmonary / left surface on the lung side
(mostly L ventricle) - APEX - tip -5th ICS at MCL (PMI point of maximal impact- “apical impulse”
- base- back of the heart mainly the L atrium nad some of the right
describe mediastium
region btwn r/l pleurae in thoracic cavity
3 ? regions: 1. superior, 2. middle (anterior middle posterior)
described in relation to the pericardium
content of the superior mediastinum
superior to the perocardium thymus arch of aorta great vessels trachea esophagus
content of anterior mediastinum
anterior to pericardium
internal thoracic vessels
fat
few lymphnodes
content of middle mediastinum
within in the pericardium
pericardium
heart
roots of great vessels
content of posterior mediastinum
posterior to pericardium
esophagus (descending thoracic aorta)
thoracic duct
lymphnodes
positions of the CXR
PA, lateral, lateral decubitus
TAKEN DURING INSPIRATION**
difference in heart shadow btwn pa and ap views
heart shadow is distorted/widened
landmarks of PA CXR
aortic arch l ventricle apex of heart l diaphragm right diaphragm right atrium ascending aorta trachea shadow right bronchi r/l hilum hilar points costophrenic recess/angle/costodiaphragmatic recess
lateral CXR landmarks
sternal angle heart shadow anterior mediastnum m mediastinum p mediastinum costophrenic recess r vs l diaphragm r is higher from liver under it!
