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Clinical Anatomy > Thorax I > Flashcards

Thorax I Flashcards

1
Q

How many pairs of ribs are there?

A

12 Pairs

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2
Q

What is the function of the rib cage?

A 
Protects internal organs (heart, lungs, blood vessels)
Facilitates respiration (breathing)
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3
Q

What bones make up the ribcage?

A

3 bones of anterior aspect:
Manubrium
Sternum
Xyphoid process

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4
Q

What are the clavicle’s articulations?

A 
Sternoclavicularjoint (top part of manubrium)
Acromioclavicular joint (acromion posteriorly)
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5
Q

Describe the types of ribs

A

True ribs - 1-7
False ribs - 8-10 (all connected to the same cartilage)
Floating ribs - 11&12 (don’t articulate w/ cartilage)

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6
Q

Where are the kidneys in relation to the ribs?

A

Kidneys sit just under floating ribs posteriorly

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7
Q

What do ribs articulate w/?

A

Articulate to transverses processes on vertebrae

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8
Q

How many of each type of vertebrae are there?

A

Cervical - 7
Thoracic - 12
Lumbar - 5
Breakfast at 7, lunch at 12 and dinner at 7

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9
Q

Describe the boundaries of the superior thoracic aperture

A

Ant border - manubrium
Post border - T1 vertebrae
Lateral border - 1st pair of ribs and cartilage

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10
Q

Anatomically the superior thoracic aperture is?

Clinically the thoracic aperture is?

A

Thoracic inlet

Thoracic outlet

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11
Q

Boundaries of inferior thoracic aperture?

AKA?

A

Ant border - Xiphi-sternal junction
Post border - 12th thoracic vertebrae
Lateral border - 12th ribs and costal margins
AKA = thoracic outlet

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12
Q

Thoracic outlet syndrome

A

Group of disorders
Pain and paresthesia in neck, shoulder. arms and hands
Caused by compression brachial plexus and or subclavian vessels as they pass through the thoracic outlet (anatomical thoracic inlet)

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13
Q

Ribs in younger people are…

A

Stronger and more flexible .˙. fractures in children uncommon

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14
Q

What is special about the first rib?

If injured what may it damage?

A

Rarely fractured - short and broad because it’s in a protected position
Cannot be palpated

May injure brachial plexus + subclavian vessels

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15
Q

How may rib fractures occur?
Where is it most likely to occur?
What can it cause?

A

May follow a direct blow
Following crush? injuries (indirectly)

At the angle -> point where direction of bone changes most sharply and hence at it’s weakest

Can cause flail chest - patient have difficulty breathing in and out

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16
Q

What can fracture of lower ribs cause?

A

Can cause lacerated spleen, kidneys or liver

BUT they rarely fracture because have more flexibility than upper and middle ribs

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17
Q

Describe the atypical ribs

A

Ribs 1, 11, 12

Have no neck, no major tubercle (as don’t articulate w/ anything) and no costal groove (except 12)

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18
Q

Describe the structures that go over the first rib

A

Anteriorly - vein
Posteriorly - artery (subclavian)
Muscle - anterior scalene (come from transverse processes of c spine - 3 heads? ant, middle and post)
Help divide brachial plexus (nerve supply) to upper limb and help with divisions between arterial and venous systems.

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19
Q

Cervical rib

A

Extra rib
Elongation of transverse process on cervical vertebrae
can impinge on brachial plexus and structures surrounding

Patients present w/ tingling sensation/ parasthesia in fingertips (1%)

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20
Q

Fractured rib

A

Can end up w/ flail chest if fractured along w/ pneumothorax
(entry of air in plural space)

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21
Q

Ossified Xiphoid process

A

People early 40s detect xiphoid process partly ossified and consult GP about hard lump in pits of stomach (epigastric fossae/ upper epigastric region)
Patient may fear have tumour/stomach cancer

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22
Q

Where is VAN on ribs?

A

In costal groove (protected by), along lower edge of ribs
Vein is most superior
Must be mindful when insert chest drain above rib (4th/5th intercostal space)

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23
Q

Thoracic Anaesthesia

A

Local anaesthesia in intercostal space given by injecting local anaesthetic agent around intercostal nerves bet. paravertebral line
(corresponds to tips of the transverse process)

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24
Q

Where does the nerve supply originate?

A

Within the spinal cord
roots come out and connect w/ rami and nerves coming alongside vertebral aspect, to the costal groove to supply ant. and post portion

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25
Q

Where do nerves go?

A

They pierce through fascia of muscles - posterior and anterior aspects fuse
Help supply all dermatome regions and skin distribution

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26
Q

What is the neurovascular bundle protected by?

A 
Muscles:
External 
Internal
Innermost 
VAN then in costal groove in rib
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27
Q

What is a dermatome?

A

Area of skin supplied by a single spinal nerve root

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28
Q

List some areas and their dermatome levels

A

Nipple line - T4

Umbilical area - T10

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29
Q

How can shingles present with respect to dermatomes?

A

Shingles (Herpes zoster) - infiltrates along the dermatome line = v. painful
Usually only along 1 dermatome line
12 thoracic dermatomes

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30
Q

Why does complete loss of sensation usually not occur across dermatomes?

A

As any area of skin usually receives innervation from 2 adjacent nerves - considerable overlapping of contiguous dermatomes occurs
.˙. complete loss of sensation doesn’t occur unless >2 intercostal nerves are anaesthetised

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31
Q

Which nerves supply the thoracic wall?

A

Medial and lateral pectoral nerves - branches of brachial plexus (C5-T1)
Help supply the muscles - pec. major
Lateral spreads out more

Long thoracic nerve - muscle = serratus anterior
Damage of nerve during chest surgery (breast) can cause paralysis of muscle + loss of shoulder movement + winged scapula

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32
Q

Other muscles in area

A

Subcostalis - below clavicle
Tenderline sheaths - underneath pec. major
Help protect vessels

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33
Q

What is the mid-axillary line and what is it significant for?

A

Line passes vertically down from apex of axilla
Important for drainage points from breast?
Safe point for insertion of drainage/chest drains

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34
Q

Important vertebral levels

A

T4/5 - Sternal angle
T3 - Manubriosternal joint
T9 - Xiphisternal jn - important for checking if ant and post are in line w/ each other.

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35
Q

Describe the orientation external intercostal muscles

A

Orientation = down and forward

Anteriorly become continuous with and is replaced by anterior intercostal membrane

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36
Q

What is the origin and insertion of the external intercostal muscles?

A 
Origin = inf. border of rib above 
Insertion = sup. border of rib below
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37
Q

What are the actions of the external intercostal muscles?

A

Elevates during forced inspiration

Supports intercostal spaces and thoracic cage

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38
Q

What is the innervation and blood supply of the external intercostal muscles?

A

Nerves = Intercostal nerves

Blood supply = Anterior and posterior aspect of the intercostal arteries

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39
Q

Describe the orientation of the internal intercostal muscles

A

Down and backward

Continuous with posterior intercostal membrane

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40
Q

What is the origin and insertion of the internal intercostal muscles?

A 
Origin = costal groove of the rib above 
Insertion = superior border of rib below
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41
Q

What is the action of the internal intercostal muscles?

A

Help relax the thoracic cage

Depress ribs during forced expiration

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42
Q

What is the innervation and blood supply of the internal intercostal muscles?

A

Nerves = intercostal nerves
Blood supply = ant. and post. intercostal arteries
Internal thoracic and musculophrenic arteries
Costocervical trunk

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43
Q

Describe the innermost muscles

A 
Origin = costal groove 
Insertion = supero-posterior border of the rib below 
Action = supports both external and internal intercostal muscles
Innervation = intercostal nerves, blood supply = same as internal
44
Q

How are the innermost muscles separated from the internal intercostals?

A

By a neurovascular bundle containing intercostal nerves and blood vessels

45
Q

What are the anterior and posterior continuations of the innermost intercostal muscles?

A

Anteriorly continued by transversus thoracis (sternocostalis) -> runs from posterior lower sternum to inner costal cartilage (rib 2-6)
Posteriorly - subcostalis muscles near angle of rib

46
Q

What side of the body is the arterial and venous system?

A

Left hand side = arterial, runs down

Right hand side = venous, runs up

47
Q

Which arteries make up the blood supply to the thoracic cage?

A

Internal thoracic artery
Have branches from subclavian artery
Descending/thoracic aorta (posteriorly) - terminates by branching
gives a post and ant distribution

48
Q

Where does the supreme intercostal artery come off?

A

The costocervical trunk of the subclavian artery - gives rise to 1st and 2nd posterior intercostal arteries - supply corresponding intercostal space

49
Q

How many posterior intercostal arteries are there in total?

A

11

50
Q

Where do the posterior intercostals branch from?

A

Thoracic aorta
intercostal spaces 3 - 11
Are small collateral branches along the superior border of the rib (costal groove)

51
Q

Where do the posterior intercostal arteries run?

A

Between innermost and internal intercostal muscles

terminal branches anastomose with anterior intercostals

52
Q

How many anterior intercostal arteries are there?

A

9

53
Q

Where do the anterior intercostal arteries originate?

What do they supply?

A

From the subclavian, branches of internal thoracic artery
Supply upper 6 intercostal spaces
Branch at the 6th space into superior epigastric and musculophrenic (supplies the diaphragm)
ICS 7-9 supplied by branches from musculophrenic (lower 9)

54
Q

Describe the pectoralis major muscle

A

Has clavicular head - attaches to medial half of clavicle
(top area)
Sternocostal head - anterior surface of the sternum, costal cartilages 1-6

55
Q

Where does the pec. major insert?

A

Crest of the greater tubercle of the humerus

56
Q

What is the action of pec. major?

A

Arm adduction, internal rotation, flexion (clavicular head), arm extension (sternocostal head)
Accessory muscle of inspiration when upper limb fixed

57
Q

What is the innervation and blood supply of pec. major?

A

Innervation = Medial and lateral pectoral nerves (C5-T1)
ie. entirety of brachial plexus

Blood supply = thoracoacromial artery and internal thoracic artery

58
Q

Describe pec. minor - origin, insertion, innervation, blood supply, action

A

Origin - anterior surface, costal cartilage of ribs 3-5
Inserts - coracoid process
Innervation - medial and lateral pectoral nerves (C5-T1)
Blood supply - thoracoacromial, superior and lateral thoracic artery (runs along lateral border of muscle)
Action - helps stabilise scapulothoracic joint, for stability in upper arm

59
Q

What else does pec. minor do?

A

It divides axillary artery into 3 parts - 1st, 2nd and 3rd branch

60
Q

Transversus thoracis - what is it and where does it originate?

A

Thin muscle in butterfly effect
Combo from sternal ends of costal cartilage of ribs 4-7
Fibres diverge superolaterally

61
Q

Describe serratus anterior
Innervation
Blood supply
Action

A

Dagger like projections coming off the ribcage
Innervation - Supplied by long thoracic nerve (C5-C7)
(SALT)
Blood supply - thoracodorsal and lateral thoracic arteries
Action - help rotate the scapula anterolaterally

Ends up merging with external oblique (lower down abdominal muscles)

62
Q

Describe the subclavius and the clavipectoral fascia

What is the function of the two?

A

Subclavius = Small triangular muscle - located between clavicle and the 1st rib
Clavipectoral fascia = located under cover of clavicular head of pectoralis major (between pec. minor and subclavius)
Both used to protect underlying brachial plexus and subclavian vessels from damage by a broken clavicle

63
Q

Platysma

A

Muscle that controls facial expressions

Bottom lip and lower corners of mouth

64
Q

Describe the diaphragm

Action

A

Tendoni sheath = muscular with a central tendon
Action = breathing - inspiration, expiration, both quiet and explosive
during exercise it’s going to expand and cause ribcage to contract more?

65
Q

How is the innervation of the diaphragm acquired?

A

Originates in the cervical area and moves down
As it descends (differential growth) past C3,C4,C5, tendon picks up parts of myotomes and innervation from these levels
Supplied by the phrenic nerve

66
Q

What are the accessory muscles of the diaphragm?

A

Scalene, SCM (from back of ear to sternum)

chronic smokers have gasp for breath, help facilitate expansion of ribs and open lungs

67
Q

How does the diaphragm carry out its fn?

A

Increases capacity in thorax
breathing in = contracts and goes flat (increase inter-thoracic size)
breathing out = relaxes and resumes dome shape (internal intercostal muscles help)

68
Q

Describe pump and bucket handle movements

A

Pump handle - when breathing in causes cage to expand outwards
Bucket handle - causes angle of rib to move up and down, raises and expands cage to allow lungs to open up

69
Q

Hiatus Hernia

A

Portion of stomach penetrates through weakness or tear in oesophageal hiatus in diaphragm

Congenital diaphragmatic hernia = defect in diaphragm
get a hole .˙. abdominal organs (eg. intestine, stomach and liver) move through and upwards into baby’s chest

70
Q

Say what you know about paralysis of the diaphragm

A

Hemidiaphragm - ˙.˙ injury to motor supply from phrenic nerve, doesn’t affect the other half as each dome has separate nerve supply
On X-ray paralysed dome appears higher

Instead of descending on inspiration, paralysed dome pushed superiorly by abdominal viscera that is being compressed by the active diaphragm
Falls during expiration in response to positive pressure in the lungs.

71
Q

Internal thoracic arteries and veins accompany arteries as…

A

…Venae comitantes
It refers to a vein that is usually paired, with both veins lying on the sides of an artery. They are found in close proximity to arteries so that the pulsations of the artery aid venous return.

72
Q

Where does the thoraco-acromial artery come off?

A

Comes off the second part of the axillary artery
Pectoralis major and minor muscles, the anterior part of the deltoid muscle, and dermal sensation overlying the clavipectoral fascia

73
Q

Where does the lateral thoracic artery come off?

A

Second part of the axillary artery

Supplies the serratus anterior muscle

74
Q

What is the positioning of the breast?

A

Overlies 2nd - 6th rib
2/3 rests on pec.major, 1/3 rests on serratus anterior
Also on ribs, pec.minor, chest wall

Extends from lateral margin sternum to midaxillary line
Lies in superficial fascia front chest

Lower medial edge overlaps upper part rectus sheath - because rectus sheath attaches lower potion of costal angle where everything fuses together

75
Q

What type of gland is the breast?

A

Mammary gland: simple and complex mammary gland

76
Q

Describe the simple and complex mammary gland

A 
Simple = consists all milk-secreting tissue leading to single lactiferous duct 
Complex = consists all simple mammary glands, serving one nipple
77
Q

What is the shape of the breast?

A

Conical shape

78
Q

What is the structure of the breast?

A

Has a base, apex, tail (axillary tail)

Has no capsule

79
Q

What is the important of the tail of the breast?

A

Where feel during examination for lymph nodes as main site for lymph tissue drainage/drainage of breast tissue

80
Q

Do males have breasts?

A

Have rudimentary glands and nipples

Mammary glands functionless and consist of few small ducts

Usually little fat is present and glandular system doesn’t develop

81
Q

What are the lobules of the breast?

A

Main area where things produced physiologically

Each lobule breast drained by lactiferous
duct usually opens independently on nipple

Collection acini ducts from all lobules merge

82
Q

What are the lactiferous ducts?

A

Gives rise to buds that form 15-20 lobules glandular tissue – which constitute the gland
Ducts converge toward nipple like spoke of bicycle wheel

83
Q

What is the areola?

A

Dark pink/brownish circular area of skin surrounds nipple

Contains numerous sebaceous glands that enlarge during pregnancy and secrete an oily substance – provides lubricant for areola and nipple

Has hair follicles
Devoid of fat

84
Q

What are the features of the nipple?

A

Conical/cylindrical prominences in centre of areolae
Emerges from anterior aspect of breast
Have no fat, hair or sweat glands
Contains smooth muscle fibres
Lies opposite 4th intercostal space
Carries narrow pores of lactiferous ducts

85
Q

What are the fibrous septae?

A

Aka. suspensory ligaments

Keeps breast tissue attached to wall thorax
Made of connective tissue

Mammary gland firmly attached to dermis overlying skin by suspensory ligaments (of Cooper) of breast

Ligaments extend from retromammary fascia to skin and provide support

86
Q

What occurs to the Cooper’s ligaments?

A

Overtime degrade because not as elastic and firm .˙. breasts can droop as age

87
Q

What is interspersed between lobes to keep the breast structure together?

A

Fatty tissue

88
Q

What is the retromammary layer?

A

Thin, fatty tissue behind the breast

89
Q

Describe the course of products made in the lobules

A

Made in lobule (in the acini), drain into duct from where it emerges in ampulla, goes to the nipple
From here it’s expressed as milk or whatever pathological process that’s occurring

90
Q

What is the axillary tail and the clinical significance?

A

Small part of mammary gland extends along edge of pec.major toward axilla

If it enlarges during menstrual cycle, may be confused with enlarged lymph node

91
Q

Where does the blood supply come from?

A

Has a high vascular supply from walls of ribs, pec. major and minor and suspensory ligaments

92
Q

List the blood supply of the breast

A
  1. thoracoacromial artery - from sup portion up to areolar portion
  2. lateral mammary artery (branch of lateral thoracic)
  3. medial mammary artery (branch of internal thoracic)
  4. mammary branches of intercostal arteries

Thoracoacromial and lateral thoracic are branches of axillary artery

93
Q

Describe the venous drainage of the breast

A

Follows blood supply
Circular venous plexus found at base nipple
Drain into subclavian and along middle border to go into SVC and axillary vein (+internal thoracic veins?)

94
Q

How are the lymph vessels arranged in the breast?

A

Into 5 groups lay in axillary fat

95
Q

What are the 5 groups of lymph vessels in the breast?

A
  1. Pectoral (ant) - Lies on pec major along lateral thoracic vessels
  2. Subscapular (post) - lies on posterior wall axilla on lower border subscapularis, along subscapular vessels
  3. Brachial - lateral wall of axilla along axillary vessels
  4. Central - lies in centre (base of axilla)
    v. close to axillary and subclavian vein
    drains into subclavian tail and goes medially + superiorly
  5. Apical - lies at apex axilla - try to feel for in breast exam
    60-70% drain in axillary tail/ lymph nodes
96
Q

What is the significance of the central group?

A

Dangerous because everything converges there
Can be used as a sign to see if cancer spread elsewhere
v. close to axillary and subclavian vein

Must feel for it when doing axillary sweep

97
Q

What is the subclavian lymph trunk?

A

Formed by union of efferent lymph vessels of apical group

Usually opens in subclavian vein, on left side opens into thoracic duct

98
Q

How can you remember the lymph nodes of the breast?

A 
APICAL 
A = anterior 
P = posterior 
I = infraclavicular 
C = central 
A = apical 
L - lateral
99
Q

Where do other lymph nodes drain?

A

Drain into parasternal lymph nodes/opposite breast - mostly from medial breast

100
Q

Where can shingles present?

A

Can present directly underneath the breast

101
Q

What is the innervation of the breast?

A

Ant and lateral cutaneous branches 4th - 6th intercostal nerves
sensory - skin, sympathetic - blood vessels/smooth muscle in skin over nipple

102
Q

What is the significance of breast cancer?

A

1 in 8 women

103
Q

In the case of breast cancer, how may the breasts change?

A

Interference of lymph drainage of chest by cancer may cause deviation of nipple and produce a leather like appearance of skin

104
Q

Where can breast cancer metastasise to?

A

Lymph nodes, bone, pleura lungs, liver and skin

This may occur in males also

105
Q

What tends to happen in male breast cancer?

A

Tends to infiltrate into deep pectoral fascia, pec major and apical group of axillary lymph nodes

106
Q

What is important if a mastectomy is to be done?

A

The pattern of blood supply must be understood to plan an incision for conservative breast surgery

Mastectomy need cauterisation/ligation w/ diatherapy major blood vessels to decrease blood loss

Clinical Anatomy (10 decks)

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