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Clinical Anatomy > Thorax II > Flashcards

Thorax II Flashcards

1
Q

How many compartments is the thoracic cavity divided into?

A

3 compartments:
Left, right and centre
˙.˙ positioning of heart, left and right may not have same dimensions

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2
Q

Why is the thoracic cavity larger than the actual lungs?

A

Allows expansion of the lungs up to a certain point eg. during exercise
= recess area

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3
Q

What is the pleural membrane?

A

Thin serous membrane that lines the thoracic cavity and envelopes the lungs

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4
Q

What are the types of pleural membrane?

A

Parietal - lines the inner wall of the thoracic cage and protects it
Allows expansion lungs

Visceral - lines the lungs
Continuous with mediastinal pleura at the root of the lung

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5
Q

List the subdivisions of the parietal pleura

A

Cervical - covers apex of lung
Costal - covers the thoracic wall
Mediastinal - covers mediastinum
Diaphragmatic - covers diaphragm

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6
Q

What is the pleural cavity?

A

Potential space between the parietal and visceral layers
Contains no structures
Kept moist by a small amount of pleural fluid

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7
Q

What is pleural fluid?

A

Small amount of lubrication that allows the lungs to expand without friction
Only when there is chest pain, get symptoms

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8
Q

Where is the pulmonary ligament and what does it do?

A

It is a fold of pleural membrane, that attaches the lungs, medially, to the mediastinum
It is inferior to the root of the lung

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9
Q

Describe the filling of the pleural recesses

A

Deep inspiration - lungs fill the pleural cavity

Quiet respiration - lungs don’t occupy some parts of the cavity - leave the pleural recess

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10
Q

Name the pleural recesses

A

Costo-diaphragmatic recess

Costo-mediatinal recess

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11
Q

What is a pneumothorax?

A

Entry of air in the pleural cavity

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12
Q

How does a pneumothorax occur?

A

Lungs and pleural sac may be injured through wounds to the neck
Causes air to enter the pleural space
Breaks the surface tension, usually keeps cavity (bet parietal and visceral pleura) open
Air pushes on the outside of the lung = lung collapse
.˙. pleural cavity (normally a potential space) becomes a real space

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13
Q

How can you treat a pneumothorax?

A

By inserting a needle/chest tube between the ribs to remove excess air = needle aspiration

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14
Q

What is a life threatening condition?

A

Tension pneumothorax

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15
Q

How is the lung positioned in the pleural sac?

A

Pushed into pleural sac like fist pushed into slack balloon

Allows structures to pierce through in lung cavity

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16
Q

What is the appearance of a healthy lung and an unhealthy lung?

A

Healthy = light pink
children and young people who live in a clean environment

Unhealthy = dark and mottled
People who live in urban or agricultural environments - esp. those who smoke
˙.˙ accumulation of dust and carbon, irritants inhaled in tobacco

BUT lungs are capable coping with considerable amounts of carbon w/o being adversely affected

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17
Q

What are the surfaces of the lungs?

A

Costal, Diaphragmatic and cardiac, vertebral

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18
Q

What are the borders of the lung?

A

Anterior, inferior (diaphragmatic side) and posterior borders

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19
Q

How many fissures do the right and left lung have?

A

Right - 2 fissures
Horizontal and oblique

Left - 1 fissure
Oblique fissure

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20
Q

Is the horizontal fissure always open?

A

No, it may be just a depression

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21
Q

What are the surface markings of the oblique fissure?

A

Left and right lung
Surface markings - spinous process at T4
Crosses 5th intercostal space laterally
Follows the contour of the right 6th rib anteriorly

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22
Q

What are the surface markings of the horizontal fissure?

A

Right lung only
Right 4th costal cartilage
meets oblique fissure approx. 5th intercostal space, mid-axillary line

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23
Q

How many lobes do the right and left lung have?

A

R = 3
L = 2
Left superior lobe runs all way down to lower end of heart
T5 dermatome - nipple line, have axilla separation of the lobes

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24
Q

What is the accessory lobe?

A

Azygous lobe - right lung
approx 1% people have it
In these cases azygous vein may arch over the apex of the right lung (and not over right hilum)
= isolation medial part apex as azygous lobe

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25
Q

What structures make impressions on the right and left lobe?

A

Right - azygous vein, subclavian artery, SVC

Left - arch aorta, left common carotid, subclavian arteries

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26
Q

What is the hilum of the lung?

A

Place where structures enter and leave the lung
Triangular depression - where connection between parietal pleura and visceral marks meeting point between mediastinum and pleural cavities
Separation of pericardium and pleura

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27
Q

What is the root of the lung?

A 
Collection of structures that connect the lung to the mediastinum
Include:
Pulmonary arteries and veins 
Primary bronchus 
Bronchial arteries
Pulmonary nerve plexus
Lymphatics
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28
Q

What level does the trachea bifurcate and into what?

A

At level T4
Into 2 main bronchi - L+R
1 for entering into each hila of the lungs

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29
Q

List the branching of the trachea

A

Trachea -> L+R primary bronchus -> lobar/ secondary bronchi -> segmental/tertiary bronchi

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30
Q

Is the branching at T4 symmetrical?

A

No, because of the positioning of the heart

Right bronchus more vertical than the left.

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31
Q

What is the clinical significance of the right bronchus being more vertical?

A

Important in paeds

Whatever children inhale, more likely to end up in right lung because it’s more vertical

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32
Q

Where may lymph nodes be found?

A

Bronchial lymph nodes may be found at the root.
Often black ˙.˙ pollution - deposition carbon-based particles in airway

Eventually results in endobronchial and parenchymal fibrosis
Non-smokers get anthrocosis

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33
Q

What is the positioning of the structures in the root?

A

Bronchus at back

Artery above vein

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34
Q

What is the cardiophrenic angle?

What is the costophrenic angle?

A 
Cardiophrenic = Angle between the heart and the diaphragm
Costophrenic = angle between diaphragm (-phrenic) and the ribs (costo-)
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35
Q

How many anterior ribs should you be able to count on an X-ray?

A

5-7 anterior ribs

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36
Q

What colour is air on an X-ray?

A

Black

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37
Q

What is the cardiothoracic ratio?

A

Comparison between cardiac diameter and the thoracic diameter
Cardiac diameter = apex of heart to right atrium
Thoracic diameter = one costal end to the other

Heart should be no larger than 50% of the thoracic diameter normally

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38
Q

What is a super-black region on an X-ray indicative of?

A

Air in the wrong area
Important when looking at lung parenchyma - to see if deep breath filling space
Pneumothorax X-rays can see an extra black region

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39
Q

What is the trachea composed of?

A

15-20 C-shaped cartilages/ tracheal rings
Have a septum at the back
Lined w/ ciliated columnar epithelium - helps beat mucus

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40
Q

What happens in lobar pneumonia?

A

Lobar areas affected, segmental bronchi collapse in areas and cause problems

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41
Q

Describe the course of the phrenic nerve over the lungs

L+R

A

Left - descends along left side subclavian artery, crosses the vagus nerve superficially as approaches aortic arch
crosses anterior to root left lung, descends across the pericardium to diaphragm

Right - lies lateral to right brachiocephalic vein and SVC
Runs ant to lung of the root, across pericardium to diaphragm

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42
Q

Describe the course of the vagus nerve

A

Runs posterior to the hilum of the lungs and gives branches to the oesophagus

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43
Q

What imprints on the right lung?

A

Azygous vein - drainage of post. intercostal and lower abdominal area
Can engorge when have issues with portal system

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44
Q

Where is the apex of the lung?

A

Sits slightly above the clavicle

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45
Q

What is significant about the inferior lobe of the lung?

A

Common area for fluid collection and pus can accumulate in pneumonia
eg. lower resp tract infection/upper resp tract infection
common cold

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46
Q

Outline the formation of the lungs

A

4-7 wk lungs begin to bud and heart begins to form
7-17 wk (pseudoglandular) - lobes begin to come together
17-26 wk (canilicular) - surfactant synthesis
primitive alveoli - type I & II cells
27-36 wk - sacular
36 wk (alveolar) - birth alveolar are mature by this stage
after 2 yrs will grow - as develop into adult

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47
Q

What is the mediastinum divided into?

A

Superior mediastinum – extends upwards, terminating at the superior thoracic aperture.
Inferior mediastinum – extends downwards, terminating at the diaphragm.

It is further subdivided into the anterior mediastinum, middle mediastinum and posterior mediastinum.

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48
Q

What are the boundaries of the superior mediastinum?

A 
Superior = manubrium, 1st thoracic vertebrae, 1st rib
Inferior = transverse thoracic plane between T4/5 intervertebral disc and sternal angle 
Anterior = Manubrium of sternum 
Posterior = Bodies of thoracic vertebrae 1-4
Lateral = lungs and mediastinal pleura
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49
Q

What does the superior mediastinum contain?

A 
Superior thoracic outlet 
Arch of aorta (3 major branches)
SVC and branches - brachicephalic vein, left superior intercostal vein, superior intercostal vein, azygous vein
L+R Vagus nerve pass through 
Phrenic nerve passes through 
Cardiac nerves and sympathetic trunk
Thymus 
Sternohyoid, sternothyroid
Trachea - bifurcates at level of sternal angle 
Thoracic duct 
Oesophagus
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50
Q

What are the borders of the inferior mediastinum?

A

Superiorly: transverse thoracic plane T4/5
Inferiorly: diaphragm and inferior thoracic aperture.
Laterally: mediastinal pleura and lungs.
Anteriorly: Manubrium of sternum.
Posteriorly: bodies of lower eight thoracic vertebrae, their transverse processes and associated ribs.

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51
Q

Structures in inferior mediastinum

A

Inferior thoracic outlet

Part of the arch of aorta and pulmonary trunk

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52
Q

How much of the mediastinum does the heart occupy?

A

2/3 inferior mediastinum

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53
Q

Divisions of the middle mediastinum?

A

Anterior: Anterior margin of the pericardium.
Posterior: Posterior border of the pericardium.
Laterally: Mediastinal pleura of the lungs.
Superiorly: Imaginary line extending between the sternal angle (the angle formed by the junction of the sternal body and manubrium) and the T4 vertebrae.
Inferiorly: Superior surface of the diaphragm.

54
Q

What structures are in the middle mediastinum?

A

Heart and pericardium
Vessels = Ascending aorta, Pulmonary trunk, SVC
Nerves = cardiac plexus, phrenic nerves
Lymph = tracheobronchial lymph nodes

55
Q

Borders of posterior mediastinum?

A

Lateral: Mediastinal pleura (part of the parietal pleural membrane).
Anterior: Pericardium.
Posterior: T5-T12 vertebrae.
Roof: Imaginary line extending between the sternal angle (the angle formed by the junction of the sternal body and manubrium) and the T4 vertebrae.
Floor: Diaphragm.

56
Q

What are the contents of the middle mediastinum?

A

Vessels = thoracic aorta, posterior intercostal arteries,
bronchial arteries, oesophageal arteries, superior phrenic arteries
Azygous vein, hemiazygous and accessory hemiazygous vein
Nerves = oesophageal plexus (branches from left and right vagus nerves), thoracic sympathetic trunk

Oesophagus

57
Q

Borders of anterior mediastinum?

A

Lateral borders: Mediastinal pleura (part of the parietal pleural membrane).
Anterior border: Body of the sternum and the transversus thoracis muscles.
Posterior border: Pericardium.
Roof: Continuous with the superior mediastinum at the level of the sternal angle.
Floor: Diaphragm.

58
Q

Contents of ant. mediatinum

A

Thymus

59
Q

Describe the position of the structures in the mediastinum when lying down

A

Arch aorta lies superior to transverse thoracic plane
Bifurcation trachea transected by plane
Central tendon diaphragm (diaphragmatic surface) lies at T9 (level of xiphisternal junction)

60
Q

Describe the position of structures in the mediastinum when standing

A

Arch aorta transected by thoracic plane
Tracheal bifurcation lies inferior to plane
Central tendon diaphragm may fall to level of middle of xiphoid process and T9/10 intervertebral disc

61
Q

Where does the pericardium sit?

A

On the diaphragm

62
Q

What is the transverse pericardial sinus?

A

Pericardial cavity behind the aorta and pulmonary trunk

63
Q

What are the practical implications of the pericardial sinus?

A

Important to cardiac surgeons, after pericardial sac is opened anteriorly, can pass things through transverse pericardial sinus, posterior to aorta and pulmonary trunk
During coronary artery bypass grafting
ie. surgical clamp/place ligature around vessels, inserting tube of bypass machine and then tightening ligature
surgeons can stop/divert circulation of blood from these arteries while performing cardiac surgery

64
Q

What do pericardial reflections do?

A

Link parietal and visceral pericardium
NB - continuity of parietal and visceral serous pericardium around roots of great vessels
Ascending aorta and pulmonary trunk are contained within fibrous pericardial sac and covered by serous pericardium

65
Q

What is constrictive pericarditis?

A

Thickening pericardial sac implies compression heart and subsequent heart failure

66
Q

What is the oblique pericardial sinus?

A

Blind-ending pericardial cul-de-sac behind the heart which opens into the pericardial space proper inferiorly

67
Q

What are the practical implications of the pericardium?

A

Pericarditis = inflammation of pericardium causes chest pain
Some inflammatory diseases may cause pericardial effusion - escape of fluid from pericardial capillaries into pericardial cavity
Cardiac tamponade = compression of the heart
Large volume of pericardial effusion accumulates, prevents heart from expanding fully, limiting inflow blood to ventricles
Eg. blood leaking from stab wound may limit expansion ventricles
Potentially lethal as fibrous pericardium tough, elastic and can’t expand - reduces cardiac output and blood circulation

68
Q

How is cardiac tamponade treated?

A

Pericardiocentesis - needle and catheter used to remove fluid

69
Q

What are the great vessels of the heart?

A

Ascending aorta, pulmonary trunk, brachiocephalic veins, SVC, IVC, R+L Pulmonary veins

70
Q

What is the pericardium?

A

Thin fibro-serous sac surrounds the heart and root of great vessels.

71
Q

What are the components of the pericardium?

A

Fibrous pericardium - Thick connective tissue surrounds heart and root of great vessels

Serous pericardium -

  • parietal layer - lines inner surface of fibrous pericardium
  • visceral layer - adheres to the heart and constitutes to the outer covering
72
Q

What allows frictionless beating of the heart?

A

Small amount of fluid between parietal and visceral layers

73
Q

Where does the pericardium sit?

A

On the diaphragm - wraps around structures and vessels that pierce through it, to incorporate them
ie. goes over part of the arch of aorta

74
Q

Describe the outer appearance of the heart

A

Shaped like sideways pyramid

Lies in middle of chest - has vase posteriorly and apex in 5th intercostal space

75
Q

Why may the heart be larger than normal?

A

Enlargement = cardiomegaly/ patient exercises

76
Q

Which side of the heart do the great vessels lie?

A

Vena cava - RHS (returns deoxygenated blood back to heart)

Arch aorta - LHS

77
Q

What is the auricle of the heart and what emerges from them?

A

Small flap on the atria - coronary arteries emerge from underneath
L+R coronary arteries major arteries that supply the hear

78
Q

Which ventricle is more anterior and lateral?

A

Right ventricle takes up more space anterolaterally

Left more posterior

79
Q

Why is the left ventricle thicker?

A

Left is thicker because need pump blood to body at higher pressure
Oxygenated blood comes in left side via pulmonary veins pulmonary trunk w/ blood from RHS passes blood to pulmonary system

80
Q

What are the surfaces of the heart?

A

4 surfaces -
Left and right pulmonary surfaces - where lungs are
Sternocostal surface - front
Diaphragmatic surface - inferiorly (sits on diaphragm)

81
Q

What is the apex of the heart?

A

Made up of left ventricle - moves laterally and downward from midline

82
Q

What is opposite the apex of the heart?

A

Base - mainly formed by left atrium and small portion right atrium

83
Q

What are the borders of the heart?

A

4 borders -
Superior - where major blood vessels emerge eg. arch aorta, pulmonary trunk
Left - made by left ventricle
Right - formed by right atrium
Inferior - formed by right ventricle at bottom

84
Q

Which vessel is most inferior?

A

Pulmonary vein is most inferior
then pulmonary trunk, arch of aorta goes over pulmonary trunk
This is important to distinguish where lungs are

85
Q

What is the coronary sinus?

A

Opening into right atrium
It is a opening on the posterior wall - collection of deoxygenated blood coming back into RA from the heart
(drains the heart)

86
Q

What is the crista terminalis?

A

Direct connection between orifice of IVC and SVC

Smooth surfaced, thick portion heart inc crescent - at opening right atrial appendage

87
Q

What are the musculi pectinati?

A

Muscular ridges on inner wall of auricular appendage

88
Q

What is the fossa ovalis?

A

Remnant of foramen ovale -> aperture between R+L atrium for blood to cross the aorta and bypass pulmonary circulation during foetal development
Closed in an adult - can see as a depression

89
Q

What are the features of the right ventricle?

A
  • Trabeculae - rounded or irregular muscular columns which project from the inner surface of the right and left ventricle of the heart.
  • Infundibulum (w/smooth walls) - conical pouch formed from the upper and left angle of the right ventricle, from which the pulmonary trunk arises.
  • Interventricular septum
  • Atrioventricular orifice – right atrioventricular valve
  • Ant, post (inf), septal cusps of atrioventricular valve
90
Q

How many cusps does the tricuspid valve have?

A 
3 cusps:
Anterior 
Septal 
Posterior
Look at picture
91
Q

What do the chordae tendinae attach to?

A

To papillary muscles (attachment area)

92
Q

What do the trabeculae carnae do?

A

Forms network

Contraction pulls on chordae tendinae - preventing insertion of mitral and tricuspid valve toward atrial chambers

93
Q

What is the journey of blood on the right side of the heart?

A

Comes down toward apex from atria to right side of ventricle

Then pushes up and out through pulmonary valve

94
Q

What are the features of the left atrium?

A
  • Smooth internal features
  • Septal wall w/ fossa ovalis depresson
  • Auricle w/ rudimentary musculi pectinati
  • Pulmonary vein orifices
  • Left atrioventricular orifice and mitral valve
95
Q

What is the mitral valve?

A

Bicuspid - has 2 cusps
Anterior and posterior
Passway from left atrium to left ventricle
Toward apex

96
Q

What are the features of the left ventricle?

A

• Ventricular cavity – cone shaped in normal heart
Narrows aortic vestibule
• Trabeculae carnae
• Left atrioventricular orifice (mitral valve)
• Chordinae tendinae and associated papillary muscles
• Aortic valves w/ semilunar cusps
• Atrioventricular groove
• Interventricular groove

97
Q

Why are the pathologies of the left ventricle different?

A

Has thicker walls

Blood passing into aorta from it

98
Q

What is the atrio-ventricular groove (coronary sulcus)?

A

Line where right atrium and ventricle meet

Contains branch of right coronary artery

99
Q

What is the interventricular groove?

A

Between right and left ventricles - front and back surfaces of heart
Contains branch of left coronary artery

100
Q

Describe the coronary artery and its passage

A

1st 2 branches of arch of aorta

Passes behind pulmonary trunk and emerges by auricles of heart

101
Q

Which artery passes down the anterior interventricular groove?

A

Left ant. descending/ anterior interventricular branch

Most common to get blocked- passes round down to apex

102
Q

What branches come off the left anterior descending artery?

A

Diagonal and marginal branches

103
Q

Which artery supplies the left atrium?

A

Left circumflex - passes round left auricle

104
Q

What do the ventricular marginal branches supply?

A

Ventricles

105
Q

What does the right coronary artery supply?

A

Supplies anterior and posterior aspect of heart

Gives branch to supply SAN

106
Q

What is the clinical significance of the right coronary artery?

A

Required for ECG - helps to know what position heart is in and what looking at

107
Q

List the major coronary arteries on the RHS

A

Right coronary artery - goes down right sulcus
Posterior interventricular artery
Marginal artery

108
Q

List major coronary arteries on LHS

A

Left coronary artery
Anterior interventricular arteries
Circumflex artery

109
Q

What is the corona?

A

Coronary blood vessels form a ring around the heart, known as corona

110
Q

What are some variations?

A

Variations in branching of coronary arteries:

Left coronary artery dominant in 15% people - posterior interventricular branch of circumflex artery
OR
Single coronary artery - circumflex branch arises from right aortic sinus
OR
Accessory coronary artery

Usually (70-80%) right CA dominant - post interventricular artery = branch of right CA
R+L CA share approx. equal blood supply to heart

111
Q

Are there collateral routes of blood supply to the heart?

A

No
Anastomoses exist between branches coronary arteries, sub-epicardial/myocardial and extra cardiac vessels. don’t provide adequate collateral route for continuation of heart function after MI/ clotted blood.

112
Q

List the coronary veins

A

Coronary sinus
Great cardiac vein
Middle cardiac vein
Small cardiac vein

113
Q

What is significant about the valves of the heart?

A

Only allow blood flow in one direction
2 atrioventricular (cuspid) valves - guarantee blood doesn’t return from ventricle to aorta
eg. mitral and tricuspid
2 arterial (semi-lunar) valves - avoid reflux blood from 2 arteries that leave heart
eg. pulmonary and aortic

114
Q

What is an aortic sinus?

A

Anatomic dilatations of the ascending aorta, which occurs just above the aortic valve, between the wall of the aorta and each of the three cusps of the aortic valve
˙.˙ pushing blood out into arch aorta

115
Q

What is a murmer?

A

Abnormal heart sound - problem w/ leaflet

116
Q

What is insufficiency and stenosis in the heart?

A

Insufficiency = poor functioning valve
Stenosis = Narrowing orifice ˙.˙ inability of valve to fully open
Both cases when affecting aortic valve and inducing reflux blood (regurgitation) signals severe heart failure

117
Q

What is the azygous vein?

A

Major vein of trunk

118
Q

Describe the entry of veins in the heart

A

R+L brachicephalic veins form SVC that flows into heart from above

Inf vena cava flows into heart from below - has all major tributaries from lower limbs and posterior abdominal structures

119
Q

What is the SAN?

A

Instigator for contraction of R+L atrium
In top right hand corner atrium
Sympathetic increases flight and fight

120
Q

What is the AVN?

A

Controls conduction jumps - goes down purkinje fibres to help contract down toward apex
Parasympathetic - slows down - rest and digest

121
Q

What are the plexi of the heart?

A

Deep and superficial cardiac plexus - help heart despite it being myogenic

122
Q

What type of system is the heart?

A

Dual suction/pressure pump that keeps blood circulating

123
Q

How can the heart contract spontaneously?

A

Musculature of atria and ventricles able to contract spontaneously
Nodes and networks specialised cardiac muscle cells (cardiac conduction system) coordinate contraction

124
Q

What does the ANS control?

A

Rate contraction and speed of conductivity
Increased by sympathetic and inhibited by parasympathetic
Linked to vagus nerve

125
Q

Which vagus nerve is longer?

A

Left as it loops under arch of aorta

126
Q

What do the branches of the vagus nerve contribute to?

A

Branches help supply superficial cardiac plexus

above arch aorta = sensory mechanism

127
Q

What do the deep cardiac branches supply?

A

Supplies region just over carina
Deeper branches from vagus
Important because need to expand airway to get more O2 during insp/exp in flight or fight

128
Q

Describe the course of the left vagus nerve

A

Left vagus runs posterior to hilum of lung

129
Q

Describe the relation with the sympathetic trunk

A

Cardiac plexi link directly with rami to sympathetic trunk - gives connection to spinal cord .˙. helps w/ control heartbeat
Nerves connect w/ ganglion from spinal cord linking systems w/in symp. trunk (ANS)
helps liase w/ and have effect on cardiac plexus to increase/decrease HR
.˙. have receptors over arch aorta and over trachea - help w/ control

Links in w/ part brbachial plexus .˙. get tingling sensation lower brachial plexus -> may complain pain down in arm
shares neuropathway

130
Q

Describe the course of the venous return via cardiac veins

A

Great cardiac vein goes down interventricular septum w/ LAD (any aspect)

Small cardiac vein on right side - helps supply

Middle cardiac vein

Contribute to coronary sinus that in turn empties into right atrium
Small veins anterior to right atruim drain directly into right atrium

131
Q

What are the implications of leaky valves?

A

Murmers - occur if valves don’t seal adequately
Leaky valves cause heart to enlarge - most time require surgery
Refer to notes for auscultation positions
Heart lies behind sternum

Clinical Anatomy (10 decks)

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