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73 Cards in this Set

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Nipple level
4th intercostal space; majority of lungs lie underneath this line
Kidney Level
Left: anterior to T12-L3

Right: T11-L4
Central compartment-- houses thoracic viscera, except lungs
Mediastinum
Diaphragm in relation to thorax?
diaphragm encloses the thoracic cavity inferiorly
True Ribs
vertebrocostal, 1-7
Attach directly to the sternum via costal cartilages
False Ribs
Vertebrochondral, 8–10
Attach to the costal margin
Floating Ribs
11 & 12
Do not attach to the sternum
(Atypical) ribs #1 and 2, Defining characteristics?
1st rib is broadest, shortest, and most sharply curved of the 7 trues.
Has grooves for subclavian vessels;
Only one articular facet on its head

2nd rib has
2 articular facets
Tubercles for muscle attachment
(Atypical) ribs #10-12, Defining characteristics?
Ribs 10-12 have, like 1st rib,
only 1 articular facet on their heads.


Ribs 11 & 12: short, floaters
No necks
No tubercles
Characteristic Features on Thoracic vertebrae
Bilateral costal facets (demifacets) on the bodies for articulation w heads of ribs [or one whole facet in atypical vertebrae]

Costal facets on transverse processes for tubercles of ribs [except for bottom 2-3]

Long slanted spinous process
Intervertebral Joint
and ligaments included
Symphysis; adjacent vert bodies bound by IV disc

*Ant and Post Longitudinal ligaments
Costovertebral Joint
and ligaments included
Synovial Plane of joint; Head of each rib W/ superior demifacet of corresponding vertebral body and inferior demifacet of vertebral body superior to it.

*Radiate and intra-articular lig's of head of rib

**Heads# 1,11,12 articulate only w corresponding vertebral body
Costotransverse joint
and ligaments incl
Synovial plane of joint; Tubercle of rib + Transverse Process of corresponding vertebra

*Lateral and superior costotransverse

*** Ribs 11 and 12 dont articulate w corresponding transverse processes
Sternocostal joint
1st: cartilaginous
1st costal cartilages w Manubrium

2-7th: synovial plane
Costal cartilages w Sternum

*Ant and Post Radiate Sternocostal ligaments
Sternoclavicular joint
Saddle; sternal end of clavicle W manubrium AND 1st costal cartilage

*Ant and Post sternoclavicular ligaments, Costoclavicular ligaments
Primary (Synchondrosis) ; Lateral end of costal cartilage W/ sternal end of rib

*cartilage and bone bound by PERIOSTEUM

**NO mvmt

Joint name??
Costochondral joint
synovial; costal cartilages of 6th-7th, 7th-8th, and 8th-9th ribs

**btwn 9th and 10th is FIBROUS

Joint name??
Interchondral joint

*Interchondral ligaments
Manubriosternal joint
Symphysis; manubrium + sternum body
What joint is divided into 2 compartments by articular disc?
Sternoclavicular joint
Prolong the ribs anteriorly and contribute to the elasticity of the thoracic wall
Costal cartilages
space below the 12th rib
&
Anterior ramus of spinal nerve T12
Subcostal space/ subcostal nerve
synchondrosis; Xipoid process + Sternum body
Xiphisternal joint
Joints that often fuse and become synostosis in old people
Manubriosternal and Xiphisternal joints
Superior and Inferior Angle of scapula
T2 (sup), T7 (inf) spinous process
Jugular Notch level
T2 spinous process
Sternal Angle level

aka angle of louis
where the 2nd costal cartilages attach. It lies at the level of the IV disc between T4 & T5
How does rib regenerate after surgical excision?
From osteogenic layer of preserved periosteum
Weakest part of rib
just anterior to its angle
Flail Chest
multiple rib fractures --> big part of thoracic wall moves freely, moving in and out during breathing

obvi painful, affects breathing
How are an atypical number of ribs formed?
Problems associated with them?
Failure of 12th rib pair to form or growth of extra cervical or lumbar rib.

C7 rib- may compress C8 and T1 spinal nerves, inferior trunk of brachial plexus, or subclavian artery (leading to ischemic muscle pain in upper limb)

Lumbar ribs- may confuse identification of vert levels in diagnostics
Bone Marrow needle biopsy
often from sternal body bc of its breadth and subQ position. Needle pierces thin cortic bone and enters spongy bone. Common for transplant or CA detection purposes
Pallor/ cold skin on upper limb & diminished radial pulse resulting from compression of the subclavian A btwn clavicle and 1st rib
Costoclavicular syndrome

(a type of thoracic outlet syndrome)
Slipping Rib Syndrome
Rib displacement of costal cartilage from Sternum; produces lump at dislocation
Rib Seperation
Dislocation of costochondral junction btwn rib and costal cartilage. Rib moves superiorly over the above rib.

In 3rd-10th ribs, this would tear perichondrium and periosteum.
Breast position
vertically over ribs 2-6
2/3 over pectoralis major
1/3 over serratus anterior

Retromammary space lies between pec fascia and breast, allows mvmt
Arterial Supply to boob
Lat thoracic a (Lateral Mammary Branches)
Internal thoracic a (Medial Mammary Branches)
Posterior intercostal a's (2nd, 3rd, and 4th intercostal spaces)
Venous Drainage of boob
Lateral mammary veins -> Axillary vein

Medial mammary veins -> internal thoracic veins

*Venous drainage can reach the azygous system via intercostal veins
Boob innervation
anterior and lateral cutaneous branches of the 2nd to 6th intercostal nerves

The nipple is innervated by the 4th intercostal nerve

These nerves conduct sensory fibers to the skin over the breasts, and to the smooth muscle of vessels
Lymph Drainage
from nipple, areola, and lobules to SUBAREOLAR lymphatic plexus

Most drains into axillary nodes. Eventually into right lymphatic or thoracic ducts

Most of medial quadrant drains into parasternal nodes and internal thoracic veins--> contralateral breast or drain to the lymphatic or thoracic duct.

lateral branches of posterior intercostal vessels--> azygous system and into the thoracic duct.

(some drainage to the subdiaphragmatic nodes & liver)
Risks of radical mastectomy
long thoracic nerve may be damaged because of its location on the lateral thoracic wall, resulting in winged scapula

The thoracodorsal nerve could also be damaged
3 Layers of Intercostal Muscles
External intercostals- Membranous anteriorly, Continuous with External Oblique

Internal intercostals- Membranous posteriorly, Continuous with Internal Oblique

Inner intercostals- Membranous anteriorly & posteriorly

Innervated by intercostal nerves
Muscles for Respiration
Intercostal muscles = main

Ohters: scalene muscles, Posterior serratus muscles, Deep back muscles, e.g. levator costorum, and transverse thoracic muscles
Posteriorly span 2-3 intercostal spaces & can be considered a counterpart of the transversus thoracis mm
Subcostal Muscles
Extension of the mammary gland of the upper outer quadrent
Axillary Tail
Simple vs Radical Mastectomy
Simple- breast removed down to retromammary space
Radical- removal of breast, pectorals, fat, fascia, and as many lymph nodes in the axilla and pec region as possible
Dyspnea -- common regulatory behavior?
(difficulty breathing)
When asthma/heart failure pt's struggle to breathe, accessory respiratory muscles assist the expansion of the cavity. They lean, to fix the pectoral girdle, so muscles are able to act on their rib attachments and expand the thorax
Arterial Supply for Thorax?
1. Thoracic Aorta --> Posterior Intercostal Artery
(Upper two originate from the superior thoracic artery, a branch from the costocervical trunk)

2. Internal Thoracic a.(--> Anterior Intercostal Arteries) --> superior epigastric a. and musculophrenic a.
Venous Drainage?
2 Routes:

Internal thoracic veins (Runs parallel to artery)-
Drain into brachiocephalic veins

The azygos system-
Drains into the superior vena cava
Contain sympathetic motor fibers to smooth muscle in the body wall vasculature, hair follicles, etc ?
Intercostal Nerves (Anterior rami of T1-11)
Intercostal Space - Nerve/ vessel arrangement
All pass from posterior to anterior, between innermost and internal intercostal muscles

"VAN" from superior to inferior, with collateral branches running right above the ribs
Structure passing through Diaphragm's central tendon at T8 level?
The inferior vena cava & right phrenic nerve and pericardiacophrenic artery
Structure passing through Diaphragm's muscular at T10 level?
The esophagus and vagus nerves
Structure passing through Aortic Hiatus (posterior to diaphragm) at T12?
The thoracic aorta and thoracic duct pass
Diaphragm blood supply
Largest: Abdominal Aorta

Others: Pericardiacophrenic, musculophrenic, branches from intercostals, and branches from thoracic aorta
Diaphragm Innervation
Phrenic nerve (C3-C5).

These penetrate the diaphragm and supply it from underneath
Thoracic Wall mvmt

(w inspiration and expiration)
During inspiration, diaphragm contracts.. the rib cage expands vertically, laterally, and in the anteroposterior dimension
"Bucket and Pump Handle".. :/

During expiration, the diaphragm relaxes and the rib cage contracts
At T5 – T7, the pleura reflects back on itself, creating the ______. The structures entering through this region make up the ________.
Hilum; Root of the lung
An extension of the two pleural layers continues inferior to the Hilium; allows for movement of the lung.
Pulmonary Ligament
Loose connective tissue layer separating the parietal pleura from the internal surface of the thoracic wall
Endothoracic fascia
allow for expansion during forced respiration and provides a place for fluid collection
RECESSES; Visceral & parietal pleura are separated in regions that are not invaded by lungs during quiet respiration
Differences between the 2 Lungs
Left Lung: 2 lobes (sup and inf) w Oblique Fissure btwn. Main bronchus is INFERIOR to the pulmonary artery

Right Lung: 3 lobes incl Middle Lobe and Horizontal Fissure. Main bronchus is POSTERIOR to pulmonary arteries
Anteriorly where the costal pleura and mediastinal pleura meet:
__________ Recess
Costomediastinal Recess
the largest subdivision of a lobe
Bronchopulmonary segment
Why can blood oxygenation never reach 100%?
Blood pumped by the Bronchial artery was returned to the Left atrium by pulmonary AND bronchial veins
Recess below 6th rib in the midclavicular line & 8th rib in the midaxillary line
Costodiaphragmatic recess
Parasympathetic fibers to the lungs and visceral plerua (-->constrict --> decrease heartrate)
Vagus Nerve
Hemidiaphragm: Cause, Detection
Each dome has different innervation, so injury to Phrenic nerve (motor) can paralyze half the diaphragm.

Xray will show paradoxical mvmt; instead of normally descending on inspiration, the paralyzed dome is pushed up by the abdominal viscera being compressed by the other side.
Also, the positive pressure from expiration will make that half fall
Intercostal Nerve Block
Local anesthesia of intercostal space; injection around intercostal nerve and collateral branches.

Complete loss of sensation does not occur (since areas of skin usually innervated by 2 adjacent nerves) unless 2 or more intercostal nerves in adjacent spaces are anesthetized
Entry of air into the pleural cavity; may be due to trauma, etc.
Pneumothorax
______ sends sympathetic messages to the lungs (--> dilate)
Sympathetic Trunks
Accumulation of fluid in the pleural cavity that may be due to pleural effusion
Hydrothorax
Obstruction of a pulmonary artery by a thrombus (blood clot) due to fat globule, air from leg vein.
Pulmonary Embolism

****The clot may block blood flow in part or completely – when the embolus is large, patient suffers acute respiratory distress due to a major decrease in the oxygenation of blood & may expire in minutes
Accumulation of blood in the pleural cavity; usually due to injury of the intercostal vessels
Hemothorax