Cpwk1 Anatomy Thoracic Wall 11-1

Front 1

What does the thorax include?
a. location relatively
b. contents (4 main ones)
c. primary divisions

Back 1

a. area between neck and abdomen (not chest)
b. thoracic cavity and thoracic wall surroundings
Include: primary organs of respiratory and circulatory system (heart, great vessels, lungs, trachea)
c.
i. Two pulmonary cavities (contain lungs and pleurae)
ii. Mediastinum, located centrally and contains (Heart, thoracic great vesses, trachea, thoracic esophagus, and thymus)

Front 2

Describe the following by what it includes, and functions to do...
thoracic wall
a. What it includes
b. functions (3 main)

Back 2

a. Includes: Thoracic cage, myofascial structures, neurovasculature structures
b.
1. protects thoracic and abdominal viscera
2. resists pressure of elastic recoil from lungs and inspiratory movements
3. muscular attachment for upperlimbs, abdomen, neck, and back

Front 3

Describe the following by what it includes, and functions to do...
thoracic cage boney components
a. general shape and function
b. includes 2 parts
c. supported by (two things)?
d. made up of (4 components)

Back 3

a. shaped like a domed bird cage that provides rigidity absorbs external blows and compression without fracture and changes shape for breathing
b. includes superior and inferior thoracic aperture
c. Sternum and 12 thoracic vertebrae
d. Made of:
i. 12 ribs, thin and flexible
ii. costal cartilages
iii. joints
iv. intercostal spaces

Front 4

Describe what the musculature of the thoracic wall includes...
a. Inspiration (principal muscles)

Back 4

Two divisions for Breathing (Expiration and Inpiration)
a. Inspiration
1. Principal
i. External intercostal muscles- are the principal muscles in inspiration...point anterio-inferiorly elevate ribs, increase width of thoracic
ii. interchondral part of internal intercostal muscles- same as above
iii.diaphragm- domes descend and increase longitudinal dimension of thoracic cavity also helps elevate lower ribs

Front 5

What does the musculature of the thoracic wall include... (2 general categories)

Back 5

Out into two groups (inspiration muscles and expiration muscles)
1. Inspiration
a. Accessory muscles
b. Principal muscles
2. Expiration
a. quiet breathing (no specific muscles just passive recoiling of lungs)
b. active breathing muscles

Front 6

Describe what the musculature of the thoracic wall includes...
a. Inspiration (accessory muscles)

Back 6

a. stenorcleidomastoid- elevates sternum
b. (Middle, anterior, posterior scalene)- elevate and fix upper ribs

Front 7

Describe what the musculature of the thoracic wall includes...
a. expiration (active breathing muscles)

Back 7

a. internal inercostals (except interchondral part)- lower ribs and decrease width of thoracic cavity
b. (Abdominals) -rectus abdominus, external oblique, internal oblique, transvers abdominis
- depress ribs and compress abdominal contents and push up diaphragm

Front 8

Describe Dyspnea and the use of additional musculature to assist with respiration
What is a position someone would be in that is showing signs of dyspnea and why?

Back 8

- difficult breathing- causes use of accessory respiratory muscles (Pectoralis major/minor, serratus anterior, scalene
muscles) to help expand thoracic cavity
- leaning foward hands on knees to fix pectoral girdle so muscles can expand thoracic wall
-

Front 9

Describe how surgeons get to extra pleura intrathoracic structures in the thorax?

Back 9

Endothoracic fascia is opened to gain access to extrapleural intrathoracic structures- such as arteries and satellite veins

Front 10

Differentiate intercostal membranes from endothoracic fascia

Back 10

intercostal- completes thoracic wall in areas where intercostal muscles are absent and fascia has continued
Endo- thin fibroareolar layer between internal aspect of thoracic cage and lining of pulmonary cavities (used for surgical access)

Front 11

What do the nerves of the thoracic wall come from?
What are the groups of Anterior Rami?

Back 11

- from spinal nerves
- 12 pairs- both sensory and motor
- Anterior rami-
a. T1-11 "intercostal" nerves in intercostal spaces
b. T12- "subcostal nerve"

Front 12

What are the branches of intercostal nerves (5)

Back 12

LAM RC
1. Lateral cutaneous
2. Anterior cutaneous
3. Muscular branches- intercostal, subcostal, transverse thoracic, levatores constarum, serratus posterior muscles
4. Rami communicantes- (communicating branches) connect to ipsilateral sympathetic trunk
5. Collateral branches- arise around rib angle, course along superior aspect of rib below

Front 13

Which branches of the posterior and anterior ramus does the cutaneous branches make the dermatomes?
What are reference points?

Back 13

anterior and lateral branches supply skin
T4- around nipples
T7- Xiphoid
T10- umbilicus
T12- Superior inguinal ligament

Front 14

What does herpes zoster have to do with dermatome?
How is it activated?

Back 14

Herpes is spinal ganglia so vesicular rash and sharp pain is in dermatome distribution
- reactivation of chickenpox (varicella zoster virus)

Front 15

Describe the course of the intercostal nerves posteriorly to laterally (typical intercostal nerves 1-6) and laterally to anteriorly

Back 15

Posteriorly-
Start-->
a. middle intercostal space within endothoracic fascia,
b. move between internal intercostal innermost intercostal muscles (near rib angle)
c. Moves within the costal grooves on inferior surface of rib
Laterally-
a. Becomes lateral cutaneous branches at midaxillary line
b. Divides to anterior/ posterior branches
Anteriorly
starts - On the internal surface of the internal intercostal muscles
a. Near sternum passes between the costal cartilages anteriorly
becomes anterior cutaneous branches finally Divides into medial/ lateral branches

Front 16

What is course of atypical intercostal nerves?

Back 16

give off lateral cutaneous branch, cross the costal margin and continue on the abdomen to become thoracoabdominal nerves
- Supply abdominal skin and muscles via muscular and anterior
cutaneous branches

Front 17

What is course of atypical intercostal nerves?

Back 17

give off lateral cutaneous branch, cross the costal margin and continue on the abdomen to become thoracoabdominal nerves
- Supply abdominal skin and muscles via muscular and anterior
cutaneous branches

Front 18

Label A-L

Back 18

a. Subclavian artery
b. Thoracic aorta
c. Posterior intercostal arteries
d. Superinter-costal artery
e. Costocervical trunk
f. Subclavian artery
g. Second posterior inter-costal artery
h. Posterior inter-costal artery
i. Thoracic aorta
j. Collateral branch
k. Posterior intercostal arteries
l. First posterior intercostal artery

Front 19

What are the three primary arteries of the thoracic wall and what do they include?
What does the vasculature of the Thoracic wall supply?

Back 19

Supply the intercostal m.,
pectoral m., breasts, skin
1. Thoracic aorta- includes
Posterior intercostal and subcostal
a.
2. Subclavian a.- includes
Internal thoracic and supreme
intercostal a.
3. Axillary a.
Superior and lateral thoracic a.

Front 20

In the posterior intercostal arteries where does the following vasculature arise from and how?
a. 1st and 2nd ribs
b. 3-11 and subcostal

Back 20

a. Arise from the supreme (superior) intercostal a.
--> Subclavian a. costocervical trunk supreme intercostal a.
b. Arise from the thoracic aorta
-->Right intercostal a. cross over the vertebrae

Front 21

What 4 things do all the posterior intercostal arteries have in common?

Back 21

1. Accompany the intercostal n. along its path in the costal groove
2. Give off posterior branches that accompanies the posterior ramus
3. Give off collateral branches that courses on superior surface of rib
4. Anastamose with anterior intercostal a.

Front 22

Where are internal thoracic arteries located and where do they orginate from? What are they used for?

Back 22

located lateral to sternum on internal surface of sternum
- from subclavian a.
- used to supply breasts
- used for Coronary Artery Bypass Graft (CABG) surgery (most common)

Front 23

Which artery supplies blood to pericardium?

Back 23

pericardiophrenic artery

Front 24

Where do the anterior intercostal arteries anastomose with the posterior intercostal arteries?

Back 24

around anterior axillary line

Front 25

Explain pathology in slide

Back 25

Rib Notching
Caused by coarctation of the aorta causes an increase in blood flow through the internalthoracic arteries and anterior intercostal a. along with a decrease in blood flow to the
posterior intercostal a.
This leads to dilation of the anterior intercostal arteries causing indentations in the inferior margin of the anterior part of the ribs.

Front 26

What does coarctation of the aorta cause?

Back 26

"rib notching"
causes an increase in blood flow through the internal thoracic arteries and anterior intercostal a. along with a decrease in blood flow to the
posterior intercostal a.
This leads to dilation of the anterior intercostal arteries causing indentations in the inferior margin of the anterior part of the ribs.

Front 27

Describe the course of the phrenic nerve and possible pathalogies associated with phrenic nerve problems...

Back 27

starts from in front of anterior scalene muscle and It courses in front of the root of the lung.
C3,4,5 keeps us alive
Problems: One half diaphragm can become paralyzed from injury to one phrenic n.
Causes:
Malignancy of the lung compressing the
nerve (Most common)
– Trauma/brachial plexus injury
– Cervical spondylosis
– Herpes zoster
– idiopathic

Front 28

If the diaphragm does not form correctly during embryogenesis what could likely happen? Which pleural cavity would we see this?
What does this lead to?

Back 28

Pleural cavities will not become separated from the peritoneal cavities resulting in congenital diaphragmatic hernia
– Usually the left pleural cavity
– Abdominal viscera herniates
up into the thorax
– Leads to pulmonary hypoplasia (no utero lung development)

Front 29

If someone comes in with chest pain described as "sharp, stabbing, especially with increased exertion and depth of breathing" and you ausculatate and hear something like a clump of hair being rubbed together... Diagnosis?
What may this problem lead to?

Back 29

pleuritis- inflammation of the lung
May cause pleural adhesions (Parietal and visceral layers adhere)

Front 30

Patient comes in with a Penetrating wound of parietal pleura or another patient comes in with a Rib fracture that tears visceral pleura and lung... What is differential diagnosis

Back 30

pneumothorax
The surface tension between the visceral and parietal pleura is broken and causes the lung to collapse
The surface tension between the visceral and parietal pleura is broken and causes the lung to collapse
– Tension pneumothorax can cause
displacement of mediastinum (mediastinal shift)

Front 31

What is hydro, hemo, and hemopneumo thorax and causes...

Back 31

hydrothorax- accumulation of fluid in pleural cavity

hemo- accumulation of blood (stab)

hemopneumo- accumulation of blood and air

Front 32

If someone has a pneumothorax or hemothorax

Back 32

Thoracostomy
small incision in 5th or 6th intercostal space (make that it does not connect to diaphram), on superior margin of rib, inferiorly so to drain fluid and superiorly to drain air,

Front 33

Someone is stabbed in the neck just above the clavicle and cannot breathe in a kid or infant

Back 33

I would be worried about a pneumothorax
• The cervical pleura reaches
a relatively higher level in infants and children because their necks are
short, so they are especially vulnerable to injury during the first few years after birth

Front 34

This is the trachea's last ditch effort to prevent aspiration..

Back 34

carina located between the orifices of the main bronchi

Front 35

Why might you be more likely to get a foreign body stuck on one side that the other bronchi?

Back 35

Right side- shorter, wider, and runs more vertically

Front 36

Patient respiratory distress, pregnant, and other hypercoaguable factors shown in history, acute onset also has thigh pain

Back 36

pulmonary embolism
Forms when a blood clot, fat
globule, or air bubble travels
from a leg vein to the lungs (after
it passes through the right side of
the heart)
• If large causes respiratory
distress
• If deprives blood to visceral
pleura it gets inflamed and
irritates parietal pleura pleuritic pain
• If deprives blood to visceral
pleura it gets inflamed and irritates parietal pleura pleuritic pain

Front 37

Where do the bronchial arteries arise from?
Anastomose with?

What about bronchial veins

Back 37

R. bronchial from posterior intercostal a.
2 Left bronchial artery from thoracic aorta

anastamose distally with pulmonary branches

Veins anastomose with anzygous (right side), and accessory hemizygous v (left side)

Front 38

When you have pain coming from the parietal pleura what might we see?
Why might someone have neck pain when they have injury to diaphragm part of parietal pleura?

Back 38

pain could be local or distribution to different dermotome, pain could be felt in other areas phrenic (which is c3,c4,c5) innervates such as the neck

Front 39

What contents does the superior mediastinum include?

Back 39

- Thymus- on top of trachea (fatty pad)
– Trachea- anterior to esophagus
– Esophagus
– Great vessels of heart
– Vagus n., recurrent laryngeal n., phrenic n., cardiac plexus
– Thoracic duct and lymphatic trunks

Front 40

Person comes in without ventilation and you need to put a tube down to open airway... what is it called and how do you place it?

Where does pressure need to be placed to intubate?

Back 40

Endotracheal tube
into airway at level of above of carina,

- amateurs put it in the stomach on accident

- apply pressure on cricoid cartilage to compress esophagus between trachea and vertebral column ensuring correct placement and no gastric regurgitation