Thoracic Wall And Pleura Clinical Relevance

Front 1

Cervical ribs~ supernumerary rib

Back 1

Associated with Thoracic Outlet Syndrome

Compressed neurovasculature exiting Superior Thoracic Aperture

~0.5% - 2% population have a cervical rib

Leads to confusion of vertebral levels in diagnostic images

Front 2

Lumbar ribs ~supernumerary rib

Back 2

Rarely associated with any clinical condition

Articulates with ventral surface of the lumbar transverse processes

<1% of population

Misdiagnosed as Fx of L1 transverse process

Front 3

Flail chest

Back 3

Life-threatening and unstable injury of thoracic wall

Multiple rib fractures leads to detachment of thoracic wall to rib cage

Intra-pleural pressure leads to paradoxical motion in breathing cycle

Front 4

Pectus excavatum

"sunken chest"

Back 4

Concave depression

Congenital thoracic wall deformity: intrauterine pressure on the chest wall during development

Compression of heart and lungs

Front 5

Pectus carinatum

"pigeon chest"

Back 5

Protrusion of sternum and costal cartilages

Connective tissue disorder

Congenital thoracic wall deformity: Scoliosis and congenital heart disease

Front 6

Sternal fracture

Back 6

Injury to:

1. superior mediastinal structures

2. heart

3. lungs

4. major vessels

Front 7

Xiphoid process fracture

Back 7

Xiphisternal joint dislocation

Injury to:

1. Diaphragm

Broken pieces can puncture:

2. Heart

3. Liver

Poor CPR/contact sports

Front 8

Xiphisternal joint demarcates what?

Back 8

1. inferior limit of heart

2. central thoracic cavity

3. superior limit of liver

4. anterior diaphragm

5. Rib 7 attachment site

6. T10 vertebral body

7. T6 dermatome - xiphoid

Front 9

Weakest part of rib?

Back 9

Most fractures occur in anterior costal angle

Front 10

"Slipping rib" syndrome

Back 10

Rib dislocation

sternocostal joint displacement

Injury to diaphragm, liver, neurovasculature

Front 11

Rib separation

Back 11

costochondral joint dislocation

Separated rib may be displaced superiorly and often overrides the rib above

Front 12

Active inspiratory and expiratory accessory muscles?

Back 12

Active inspiration muscles: 1. sternocleidomastoid, 2. scalene muscle, 3. serratus anterior, 4. pectoral muscle

Active expiration muscles: 1. internal intercostal, 2. innermost intercostal, 3. abdomen intercostal

Front 13

Severe dyspnea

Back 13

Recruitment of accessory muscles of respiration in shortness of breath

1. strenuous activity

2. lung disease (you can see his sternocleidomastoid in use)

Front 14

Passive respiratory muscles?

Back 14

Inspiration: 1. Diaphragm mainly and 2. external intercostals

Expiration: elastic recoil in lungs (no muscles)

Front 15

Intercostal nerve block

Back 15

Nerve anesthetic

1. proximal mid-axillary line (same as chest tube)

2. Just before lateral cutaneous branches come off

Front 16

Herpes zoster

Back 16

Reactivation of chicken pox viruses which reside in Dorsal root ganglion

Segmental innervation of thoracic wall by intercostal nerves

Sx: sharp, burning pain, skin eruption in the strip of a dermatome

Front 17

Coronary Bypass Graft/Surgery

Back 17

Coronary arteries which supply the heart can be blocked and a vessel we can choose to bypass the artery is the internal thoracic artery

Remove a portion of internal thoracic artery to bypass coronary artery

Front 18

Posterior intercostal veins drain into?

Back 18

Azygous/Hemizygous system

T5-T12

Front 19

Anterior intercostal veins drain into?

Back 19

Internal thoracic vein

Front 20

Internal thoracic veins follow?

Back 20

Internal thoracic

arteries

Front 21

Rule of veins?

Back 21

Any vein that follows an artery that branches off Subclavian Artery drains into Brachiocephalic vein!!

ex) internal thoracic veins because they follow internal thoracic arteries which is a branch of subclavian

Front 22

What are the 4 Parietal pleura?

Back 22

1. Cervical/Cupula

2. Costal

3. Mediastinal

4. Diaphragm

Front 23

Cervical pleura (cupula)

Back 23

lung apex coming out of superior thoracic aperture

1st rib slopes inferiorly exposing pleura

pleural site prone to injury

**covered by Sibson's endothoracic fascia

Front 24

Right infrasternal angle

Back 24

pleura descending below the costal margins

pleural site prone to injury

infrasternal angle- site for pericardiocentesis (5th/6th left intercostal space)

Front 25

Costo-vertebral angle

Back 25

pleura exposed covering 12th rib

during surgery, gets damaged, ex) kidney surgery

Front 26

Pleural recess 2

Back 26

Ideal site for thoracentesis/pleural tap

only contains pleural fluids.

Located superiorly to diaphragmatic dome.

More pronounced from 8th to 10th ribs

Front 27

Pleural recess 1

(no clinical correlate; just know)

Back 27

Located posteriorly to sternum

Left recess markedly larger than on right side because of cardiac notch

Front 28

Pleuritis

Back 28

inflammation of pleura

irritation of parietal pleura innervated by intercostal nerves

sharp chest pain, deep breath, cough

auscultate and hear ROUGH, grating breathing sounds like fingers rubbing a hair strand

Front 29

Hydrothorax

Back 29

fluid in pleural cavity

Front 30

Hemothorax

Back 30

blood in pleural cavity

Front 31

Hemopneumothorax

Back 31

air and blood in pleural cavity

Front 32

Pyothorax

Back 32

pus in pleural cavity

Front 33

Chylothorax

Back 33

lymph in pleural cavity

~thoracic duct lymph

Front 34

Pleurodensis

Back 34

treatment for pneumothorax AND effusion

closing of the pleural cavity

Front 35

Pneumothorax

Back 35

Air entry into pleural cavity

1. trauma (bullet wound, stab)- thoracic wall opening- tension type

2. bronchopulmonary fistula- a communication between lung &pleural cavity //congenital - open type

Treatment: pleurodensis

Front 36

Pleural Tap

Back 36

7th midclavicular,

9th midaxillary

10th paravetebral intercostal space

wherever you feel comfortable counting ribs

Avoid diaphragm and point needle UPWARDS when taking pleura out of pleural cavity- costodiaphragmatic recess****

Front 37

Chest Tube/Chest drain

Back 37

5th or 6th intercostal space at midaxillary line at nipple line

"safe triangle"

1. Fluid removal: Tube directed inferiorly towards costodiaphragmatic recess

2. Air removal: Tube directed superiorly towards cervical pleura

Front 38

When do we need anesthesia to stop pain from occurring in thoracic wall? Where? Which nerves?

Back 38

When? Nerve block, Chest tube/drain, Pleural Tap (Thoracentestis)

Where? Pleural tap (Thoracentesis) & Chest tube- skin, superficial fascia, 3 intercostal muscles, endothoracic fascia, and parietal pleura

Nerve block: btwn internal and innermost ntercostal muscles

Which nerves? intercostal nerves- sensitive to pain

Front 39

Extrapleural Intrathoracic Surgical Access

Back 39

Endothoracic fascia- Natural parietal cleavage plane to separate parietal pleura from inner thoracic wall

Front 40

Sibson's fascia

Back 40

thickened endothoracic fascia protects cervical pleura/cupula that is prone to injuries above first rib to C7