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56 Cards in this Set

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Naming of intercostal spaces: How are they named? What is the subcostal space? What is the subcostal nerve?
*Spaces and neurovascular structures are named according to the rib forming the SUPERIOR border of the space; so there are 11 intercostal spaces and 11 intercostal nerves
* SUBCOSTAL SPACE is below the 12th rib
*ventral ramus of spinal nerve T12 is the SUBCOSTAL NERVE
True ribs
AKA vertebrocostal ribs

1st - 7th ribs; attach DIRECTLY to the sternum through their own costal cartilages
False ribs
AKA vertebrochondral ribs

8th - 10th ribs; have cartilages that are joined to the cartilage of the rib just superior; therefore have only INDIRECT connection to the sternum
Floating ribs
AKA free ribs

11th-12th and sometimes 10th ribs; have rudimentary cartilages that do not attach to sternum at all

end in abdominal musculature
superior part of the sternum

lies at level of T3 and T4 vertebrae


lateral to jugular notch are the paired CLAVICULAR NOTCHES

below clavicular notches, 1st rib articulates
Sternal angle (of Louis)
at level of IV disc between T4 and T5
Body of sternum
at level of T5-T9
Xiphoid process
at T10 level

Midline marker for superior level of liver, central tendon of diaphragm, inferior border of heart.
Superior thoracic aperture
AKA thoracic inlet

Posterior boundary is T1 vertebra

Lateral boundary = 1st pair of ribs/their costal cartilages

Anterior boundary = superior border of manubrium

Passing through to thorax: trachea, esophagus, vessels, nerves
Inferior thoracic aperture
AKA thoracic outlet

Diaphragm closes off thorax, separates it and abdomen here.

Structures passing through must go either:
1. through the diaphragm
-e.g., IVC and esophagus
2. posterior to diaphragm
-e.g., aorta
Inferior thoracic aperture: boundaries
-Posteriorly = T12 vertebra
-Posterolaterally = ribs 11 and 12
-Anterolaterally = costal margin
-Anteriorly = xiphisternal joint
Joints of thoracic wall
1. intervertebral joints
2. costovertebral joints
a. joints of the heads of ribs
b. costotransverse joints
3. Sternocostal joints
4. Sternoclavicular joints
5. Costochondral joints
6. Interchondral joints
7. Manubriosternal joints*
8. Xiphisternal joints*
*7. and 8. may be fused in older people.
Thoracic outlet syndrome
Actually refers to the superior thoracic aperture (the thoracic inlet). Here "outlet" emphasizes the fact that nerves and vessels pass through to lower neck and upper neck. Various types of syndromes exist that may affect these components.
Costoclavicular syndrome
A thoracic outlet syndrome. Compression of nerves/vessels passing to upper limb between the clavicle and 1st rib, leading to numbness, pallor of upper limb and diminished radial pulse. More noticeable when the angle between the neck and shoulder is increased.
Changes in thoracic dimensions during NORMAL INSPIRATION
-Thoracic volume INCREASES with INSPIRATION
-VERTICAL DIMENSION: increases when diaphragm contracts, compressing abdominal viscera
-ANTEROPOSTERIOR DIMENSION: increases when intercostal muscles contract; PUMP-HANDLE movement of ribs and sternum
-TRANSVERSE DIMENSION: increases slightly when intercostal muscles contract, raising the middle, lateralmost parts of ribs, especially lower ones; BUCKET-HANDLE MOVEMENT
Changes in thoracic dimensions during PASSIVE EXHALATION
-VERTICAL DIMENSION: decreases when diaphragm relaxes, returns to neutral position, relieving compression of abdominal viscera
-ANTEROPOSTERIOR DIMENSION: diminishes when intercostal muscles relax (PUMP-HANDLE MOVEMENT)
-TRANSVERSE DIMENSION: diminishes as intercostal muscles relax (BUCKET-HANDLE MOVEMENT)
Accessory muscles of breathing
PECTORALIS MAJOR, PECTORALIS MINOR, inferior part of ANTERIOR SERRATUS: expand thoracic cavity for deep, forceful inspiration

SCALENE muscles: elevate and fix ribs 1 and 2 during forced inspiration, allowing lower ribs to be more effectively elevated
Lateral cutaneous branches
Arise from about the midaxillary line; branches of intercostal nerves that supply thoracic dermatomes
Anterior cutaneous branches
Anterior continuation of intercostal nerves; they pass between the costal cartilages and enter the subcutaneous tissue.
Typical intercostal nerves
3rd - 6th intercostal nerves.
Run between the innermost intercostal muscles and the internal intercostal muscles, along the costal groove, along with and inferior to the intercostal artery and intercostal vein.
Atypical intercostal nerves
1st and 2nd: Pass on the internal surfaces of the 1st and 2nd ribs instead of along the inferior margins of the costal grooves.

7th - 11th: After giving rise to the lateral cutaneous branches, continue to supply the abdominal skin and muscles.
Arterial supply of intercostal spaces
With exception of 10th and 11th intercostal spaces, each is supplied by 3 arteries:
Arterial supply to the thoracic wall
1. Thoracic aorta
a. posterior intercostal aa.
b. subcostal aa.

2. Subclavian artery
a. internal thoracic aa.
b. supreme intercostal aa.

3. Axillary artery
a. superior thoracic aa.
b. lateral thoracic aa.
Intercostal grooves
Depression along the posteroinferior surface of the ribs along which run (from superior to inferior)
1. intercostal vein*
2. intercostal artery*
3. intercostal nerve*
*mnemonic: VAN (vein, artery, nerve--superior to posterior)
Veins of thoracic wall
Accompany intercostal aa. and nn.

*There are 11 INTERCOSTAL vv. and 1 SUBCOSTAL v. on each side.

Posterior intercostal vv. anastomose with anterior intercostal vv. (tributaries of internal thoracic vv.) and usually end in the AZYGOS/HEMIAZYGOS VENOUS SYSTEM
Endothoracic fascia: what is it?
Thin fibroareolar layer b/t internal aspect of thoracic cage and the lining of the parietal pleura.

Blends with periosteum of ribs/sternum and perichondrium of costal cartilages.
Endothoracic fascia: what does it invest?
Internal intercostals, innermost intercostals, and subcostal and transverse muscles.
Endothoracic fascia: clinical significance?
Forms cleavage plane so surgeon can separate parietal pleura from thoracic wall to access intrathoracic structures.
Parts of the parietal pleura
1. COSTAL -- separated from wall by endothoracic fascia
4. CERVICAL -- extends 2-3 cm above the medial 1/3 of the clavicle; reinforced by the suprapleural membrane
Suprapleural membrane
AKA Sibson fascia

Fibrous extension of the endothoracic fascia spanning the 1st rib and C7 vertebra.

Reinforces the cervical pleura.
Lines of pleural reflection
1. STERNAL: sharp; anterior line where costal and mediastinal pleura become continuous
2. COSTAL: sharp; inferior line where costal and diaphragmatic pleura become continuous
3. VERTEBRAL: rounder; posterior area where costal and mediastinal become continuous.
Potential pleural spaces
1. pleural cavity
2. costodiaphragmatic recess
3. costomediastinal recess
Pleural cavity
Potential space between parietal and visceral pleura. Normally only contains a small amount of serous fluid.
Costodiaphragmatic recess
"Gutter" around the outer edge of the pleural cavity where the diaphragmatic pleura and the costal pleura meet.
Formed by the upward convexity of the diaphragm--the lungs do not fully occupy the space (although occupy more when expanded for inspiration).
Costomediastinal recess
Smaller potential spaces located posterior to the sternum where costal pleura contacts mediastinal pleura.

Left is potentially bigger than right due to cardiac notch. (Left is good spot for thoracentesis b/c easily accessible).
Hilum of the lung
Area on the medial surface of the lung at where the structures forming the root enter and leave.
Root of the lung
Main bronchus, pulmonary vessels, bronchial vessels, lymphatic vessels; enter and leave the lung at the hilum, passing through the pleural sleeve.
Pleural sleeve
AKA mesopneumonium.

Area of continuity between the visceral pleura and the parietal pleura; encloses the root of the lung.
3 surfaces of the lung
1. costal
2. mediastinal
3. diaphragmatic
3 borders of the lung
1. ANTERIOR: where costal and mediastinal surfaces meet anteriorly and overlap the heart; CARDIAC NOTCH indents this on left
2. INFERIOR: circumscribes diaphragmatic surface, separates it from costal surface
3. POSTERIOR BORDER: where costal and mediastinal borders meet posteriorly; smooth and rounded
Bifurcation of the trachea
Occurs at the level of the sternal angle
Right main bronchus
wider, shorter, more vertical; passes directly to the hilum of the lung
Left main bronchus
passes inferolaterally; inferior to arch of aorta; anterior to esophagus and thoracic aorta
Lobar bronchi
AKA secondary bronchi

divide from main bronchi (primary bronchi)

3 on right; 2 on left; one to each lobe
Segmental bronchi
AKA tertiary bronchi

Divide from lobar bronchi

Supply the bronchopulmonary segments
Bronchopulmonary segments
pyramidal, with apex toward root and base at pleural surface

named according to segmental bronchus that supplies it

supplied by tertiary branch of pulmonary artery

drained by intersegmental parts of pulmonary veins

divide to 20-25 generations of branches ending in TERMINAL BRONCHIOLES

Surgically resectable units
Terminal bronchioles
divisions of bronchopulmonary segments

give rise to several generations of RESPIRATORY BRONCHIOLES
Respiratory bronchioles
Divisions of terminal bronchioles

Each one branches to 2-11 ALVEOLAR DUCTS, each of which gives rise to 5-6 ALVEOLAR SACS
Pulmonary alveolus
Structural unit of gas exchange in the lung
Arterial blood supply to lungs

One PULMONARY ARTERY toward root of each lung-->branches to superior lobe before entering HILUM-->descends POSTEROLATERAL to MAIN BRONCHUS-->branch into LOBAR aa.-->branch into SEGMENTAL aa.
Venous return from lungs

PULMONARY CAPILLARIES--> unite into larger and larger veins-->INTRASEGMENTAL VEINS-->INTERSEGMENTAL VEINS in the SEPTA-->one main vein drains each bronchopulmonary segment, usually on anterior surface of the corresponding bronchus-->two PULMONARY VEINS from each lung drain into the left atrium
Venous return from the VISCERAL PLEURA
Veins drain into the pulmonary veins
Venous return from the PARIETAL PLEURA
Veins drain join the systemic veins in adjacent parts of the thoracic wall
Bronchial arteries
Supply blood to structures making up the root of the lungs, the supporting tissues of the lung, and the visceral pleura
Origin of LEFT bronchial arteries
thoracic aorta
Origin of RIGHT bronchial arteries
Varies; may be