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Transcript of 1 Tranatomy 2012 Thorax - · PDF fileTranatomy: Thorax 2012 ... Nipple, areola, Lobules (from...
Tranatomy: Thorax 2012 | Page 1 of 8
THORAX SKELTON (Ribs + Vertebrae + Sternum) Ribs
True (1-7)
Typical (3-9)
Anatomical
Articulation
False (8-9±10)
Atypical (res)
Floating (11-12±10)
Typical Ribs
Atypical Ribs
Costal Cartilages length from 1-7 length from 8-12 Intercostal Spaces Defined by rib making SUPERIOR border 11 spaces + subcostal space
Vertebrae Independent Typical T2-9
Body Arches
7 Processes Specific Properties of THORACIC Vertebrae Costal facets on body(bilateral, sup & inf, as demifacets, art with head of rib) Costal facets on transverse process (art with tubercle of same rib) Long spinous processes
Sternum
No Neck No Tubercle
T1:Art with Rib 1
Atypical (no demi facets)
T10: Art shared on body & pedicle
T11, 12: Art on pedicle
Tranatom
THO TH BordeSuperiInferio JO Costov
Sterno Other MU Access
Muscle Serr Po
Serr Po
LevatorCostaruExt IC Int IC Inm IC Subcos
TransveThoraciSP (spinInto (int1Btwn tu2During3Near a
my: Thorax 2012 | Page 2 o
ORAX
HORACIC APERTU
rs Post Aior T1 J
or T12 X
INTS (costoverte
vertebral Head of rib DemCostotransverse (ri1. Costotransve2. Lateral Costo3. Superior Cos
Movements Pump Hand Bucket Hand
ocostal Rib 1 = tight synchRib 2 to 7 = loose
Joints Xiphisternal (synchManubrosternal (sySternoclavicular (sa
USCLES
sory Muscles
Sup Attacost Sup SP C7 to T
ost Inf SP T11 to
r um
TP T7 to 1
Inf borde
tal Internal su
ersus is
Post lowesternum
nous process) TP (tranterosseous part) Intc (ubercle & angle g forced inspiration angle
Co
of 8
URES
Ant ug Notch
Xiphisternal Jt
ebral & sternocosta
mifacet of vert bodib to transverse proerse: neck of rib otransverse: tubercstotransverse: crest
le: Ribs 1 dle: Ribs 7
ondrosis (with clavsynovial
hondrosis) ymphysis) addle)
Pec Major Pec Minor Serratus Ant Scalenes1
ch Inf AttacT3 2nd to 4t
border L2 8th to 12t
border 11 Subjacen
er of ribs Sup borbe
urf ribs3 Sup bord3rd rib be
er Int surf c2 to 6
nsverse process) IC (int(intechondral part)
ostal groove (sup to inVein Artery Nerve
Lateral 1st Ribs 11th - 12th Ribs & 7th
al)
dy above and @ levocess)
cle of rib t of neck (to TP abo
to 6 to 12
vicle as well)
terior
ch Innervah ribs sup 2nd to 5
th rib inf Ant ramT12
nt ribs1 Post raT11
rder of rib elow
Ider 2nd or elow costal cart
tercostal)
f)
h - 10th Costal Cart
vel of
ove)
1Fix 1st & 2nd Ribs
ation Action 5th IC Proprioce
(elevate)mi T9 to Proprioce
(depress)mi C8 to Elevate ri
C
Elevate ri
Into: depIntc: elev
Depress (weakly)
eption
eption ) ibs
ibs2
press vate
ribs
NE 12 pairs Typical LocatioInitial Angle o
MAL AnterioSternum
Atypica T1
T1, 2 T2 3
T7-11 VA ArteryPosterioIC AnterioIC
Subcos
1Branch2Runs w3Muscu
ERVES
s of thoracic spinal nerExit as mixed nerve thAnt rami T1-11 IntePost rami hts, deeo
IC Nerves (3rd to 6th)on Position
Endothorof Rib Btwn int
or Rib m Pass btwn
to form a
al IC Nerves Property Branches into sSuperior BraInferior no aCourse along inIntercostobrachBranch @ MALCross costa ma
ASCULATURE
Origin or Space 1-2 Sup
Space 3-11 Tho
or Space 1-6 Int TSpace 7-9 MP3
tal Thoracic Ao
h of Subclavian with post ramus supplyulophrenic, branch of I
Course of Int. thoracic1. Branch of Subc2. Phrenic nerve 3. Desc post to c4. Desc ant to tra5. Terminate in 6
IC vein 11 B2, 3 4 S4-11 H 11 poste Anasto Receive
plexus)
rves hen separate into ant/prcostal Nerves (T12 = o back muscles, skin o
acic fascia innermost IC
n costal cartilage nt cut branches
uperior (large) and infchial plexus nt cut (often no lat cu
nternal surface (not grhial nerve (large lat cut pierce Serr Ant rgin just after MAL an
IC1
oracic Ao Poster Collate All ana
horacic1 Supply Travel Spaces Spaces Spaces Spaces Course Supply
ying cord, column, bacnt Thoracic
c artery clavian on inf border crosses near origin lavicle & 1st rib
ansversus thoracis th space by branching
st draining part Brachiocephalic Sup IC vein Hemi/azygous erior IC veins + subcosmose with ant IC veinses from post branch of
post rami subcostal nerve)
on back
Notes (btwn parietal pleura gives off collateral brasuperior border of rib gives off lateral cutan Supply Skin
ferior (small)
ut) roove) t)
axilla/arm nd become thoracoabd
rior branch2 eral branch runs alongastomose @ MCL withy anterior upper 9 spaalong margins of ribs
s 1,2 lie in endothoracs 3-6 separated by tras 7-9 from MP3 s 10-11 absent e along inf border of 1y to muscles of ant/lat
ck muscles, skin
g into superior epigast
2nd drain SVC SVC SVC
ostal vein s
of IC vein and vertebra
& int IC membrane) anches that travel alonbelow eous branch
dominal nerves
g sup border of rib h ant intercostal arterieaces s above & below ic fascia
ansversus thoracis
12th rib t abdo wall
ric & musculophrenic
l branch (draining ver
ng
es
arteries
rtebral
Tranatomy: Thorax 2012 | Page 3 of 8
THORAX BREASTS Properties Suspensory ligaments 15-20 lobules per mammary gland Drains into ducts into sinus Sebaceous glands in areola
Base 2/3 Pectoral fascia | 1/3 Serratus Anterior Separated from fascia by retromammary space Location 2nd to 6th ribs & Axillary process
Vasculature Arterial Arteries Origin Medial Mammary
Internal Thoracic Perforating Branches Anterior IC Lateral Thoracic Axillary Thoracoacromial Posterior IC Thoracic Ao
Lymphatic Nipple, areola, Lobules (from subareolar lymphatic plexus) Drainage area Lateral Medial Inferior Axillary nodes1
> 75% Parasternal nodes2
< 25% Inf phrenic nodes
< 25% Clavicular Subclavian
Trunk Bronchomediastinal
Trunk
Variable Termination
Merge and into r lymphatic duct Merge into thoracic duct Independently into r or l venous angle
1 From pectoral nodes or directly Sometimes interpectoral, deltopectoral, supraclavicular, inf deep cervical 2Or opposite breast
Skin (except nipple & areola) Ipsilateral axillary, inferior deep cervical, infraclavicular nodes Bilateral parasternal nodes
Nerves Ant & lateral cutaneous branched of 4th to 6th IC
SURFACE ANATOMY Clavicle Landmark for lymphatic drainage Above inf jugular nodes Below axillary nodes Landmark Body Disc Cartilage Underlying Structures Jugular Notch T2 (inf border) Manubrium T3-4 body Arch Ao on left/SVC on right 3rd SVC into RA Sternal Angle T4/5 Body T5-9 body Xiphisternal Jt T9 (inf border)
Venous Mostly axillary Some to internal thoracic
Lines Defining Feature AML Middle of anterior surface MCL Middle of Clavicle AAL Inferolateral border of Pec Major MAL Middle of axilla PAL Lat dorsi & Teres Major PML Middle of posterior surface SL Inferior angle scapula
Tranatom
THO TH Pleurae
Lines of
VASCU Pulmon Pulmon
Bronch
Bronch
my: Thorax 2012 | Page 4 o
ORAX
HORACIC CAVITY
e
f Pleural Reflection Sternal: costal meets mCostal: costal meets dDiaphragmatic: Vertebral: costal meet
LATURE OF LUNGS &
nary Arteries Pulmonary trunk fromSuperior lobar arteriePosterolateral to mainBecomes L inferior lobBranches with bronch
nary Veins Superior & Inferior L &Run indep of arteries Visceral pleural and b ie deoxygenated (Parietal pleural drains
ial Arteries Nutrition for lung roo
Left: 2x Right: 1
Branch to upper oesoDistal branches anasto
ial Veins Drain small portion ofDrain small portion of
R bronc L bronc
of 8
Y
mediastinal diaphragmatic
ts mediastinal
& PLEURAE
m RV branches into R &s arise before enteringn bronchus as it entersbar and R intermediat
hial tree (usually anteri
& R pulmonary veins (& bronchi
bronchial venous circulnot central and perihi
s to systemic veins in t
t, visceral pleura, suppx from thoracic Ao x from R 3rd Post IC (s
ophagus then travel poomose with pulmonar
f bronchial arteries (mf oesophageal veins chial vein azygous chial vein hemiazyg
1. Starts a 2. R & 3
& L @ sternal angle g hilum s lung e lobar or to)
(R middle lobe vein is
lation drain into pulmolar regions) horacic wall
portive tissue
sometimes Ao) osterior to bronchi to ry arteries in bronchio
ainly prox root)
gous or left superior IC
at Apex, travels inferom
& L meet at AML @ 2n
3a. L courses horizonta margin then costal m
3b. R follows costal
4. MCL @ 8th rib
5. MAL @ 10th rib
6. Horizontal po
7. Rises to T1
NB Eof p Thfasci Thphre
tributary of R superior
onary veins
supply them les
C
medial behind SCJ
nd rib (sternal angle)
ally @ 4th rib to left stemargin to 6th rib
margin to 6th rib
b
osteriorly to T12
Endothoracic fascia ouarietal pleura
icker at apex as supraa
inner at diaphragm asenicopleural fascia
r)
LUNG A Overvie Right L
Left Lun
TRACH GeneraTracheaMain BLobar BSegme
ConducTerminAlveolaAlveolu LUNG L Pulmon
(D
ernal
utside
apleura
s
ANATOMY
ew 3 surfaces: costal, med3 borders: Ant, Inf, Po
ung Superior, Middle, InfeSeparated by oblique
ng Superior, Inferior lobeSeparated by obliqueLingula represents an
EOBRONCHIAL TREE
ation a ronchi Bronchi ntal Bronchi
cting Bronchioles al Bronchioles
ar duct us
LYMPHATICS
nary Lymphatic Plexus
Lung parenchyma & Visceral pleura
Superficial Plexus Deep to visceral pleura
Bronc
Superior & Infe
(aro
R & L bro
Right Venous angle Or R lymphatic duc
diastinal, diaphragmatost
rior lobes and horizontal fissure
es fissure
t-inf part of sup lobe,
R Wider, Shorter, VertSupplies Lobe Largest subdivision ofPyramidal CT btwn each Indep a. supply 20-25 generations No cartilage 2-11 from each bronc5-6 from each duct
Ro
)
De(Submuco
perib
intrinsic p
chopulmonary nodes
erior Tracheobronchiaound bifurcation)
onchomediastinal trun
ct
tic
e
overlies of cardiac no
L
rtical 2
f lobe 8-10
chiole
oot of lung
eep Plexus osa of bronchi &
bronchial CT)
pulmonary nodes
al nodes
nks
Left Venous angle Or Thoracic Duct
NBTraothsh
otch
R 3
10
B LLL drains to Superioacheobronchial nodesher lobes drain as theyould
or s. All y
Tranatomy: Thorax 2012 | Page 5 of 8
THORAX THORACIC CAVITY LUNGS INNERVATION Pulmonary plexus Anterior and posterior to root of lung Parasympathetic Sympathetic Visceral Afferent Presynaptics from Vagus Synapse with ganglion in plexus & along bronchial tree
Postsynaptic Ganglion in sympth trunk
Reflexive (para) Nociceptive (sympth)
Bronchoconstrict Vasodilate Secretomotor
Bronchodilate Vasoconstrict Secretoinhibitory
Parietal Pleura Costal Intercostal Diaphragmatic (other) Diaphragmatic (central) Phrenic Mediastinal LUNG SURFACE ANATOMY
Lungs Parietal Pleura MCL 6 8 MAL 8 10 SL 10 12 PV 10 12
Fissures 1. Oblique: T2 6th costal cartilage (medial border of scapula when abducted) 2. Horizontal: 4th rib & costal cartilage from oblique fissure
MEDIASTINUM
MIDDLE MEDIASTINUM Pericardium Heart Root of great vessels PERICARDIUM Layers Fibrous Visceral Outer Inner Thick Single layer of mesothelium Inf: Central tendon of diaphragm
Sup: Tunica adventitia superiorly Ant: Sternoparicardial ligament ant Post: loose CT of mediastinum
Forms the epicardium
Areas of Continuity 1. Ao & Pulmonary trunk exit
2. SVC & IVC enter Structures enclosed Up to arch of Ao
All of Thoracic IVC
Pericardial Sinuses Sinus Transverse Oblique Anterior Ao & Pulm Trunk LA Posterior SVC Oesophagus Lateral Pulm veins, IVC Entry Lateral Inferior
Vasculature of the Pericardium Vessel Origin/Drainage Arterial Pericardiophrenic Int thoracic Musculophrenic Bronchl, oesph, sup phrenic Ao Coronary Arteries Veins Pericardiophrenic Brachicephalic Tributaries of Azygous
Innervation
Phrenic (C3-5) = sensory Vagus ? Fcn Sympth trunk = vasomotor
NB When ErectAo arch @ transverse plane Trach bifurcation below plan Central tendon @ xiphoid (T9/10 disc)
my: Thorax 2012 | Page 6 oof 8
Border StructureSup RA/LA/Anf RV > LV R RA/SVC/L LV > aur
rates A from V separates LV from RV
dium | Epicardium (vis
r AV valves) onets (for SL valves) part of IA & IV septum
A)
coronary sulcus
Ao oth post surface) gh ant surface) ernal) | Cristae Terminum
Pectinate muscle) is smooth
es interior orm Conus arteriosus t separates Trabeculaeulae inf IVS base ofundle branch)
finer & more numerouorm Aortic Vestibule (tmitral cusp
cker
uspid Valve Mit, Post, Septal An
: AP cusps t: PS cusps tal: SA cusps
AnPo
s or Right ior Right
RCA
Structure Lunule: Nodule Sinus a
ernum @ 4th and 5th sum @ 4th cartilage
@ 3rd space
se/Supply A (near sulcus terminalear opening of coronary muscles, RV t papillary muscles, LV
e Auricle
/IVC ricle
V
ceral pericardium)
m
Apex LV Left of 5th space (9Motionless
nalis (internal) (separat
(turns into pulm trunke from Conus f ant papillary muscle
us turns into Ao orifice)
tral Valve nt, Post
nt: AP cusps st: PA cusps
Left Left LCA
: free edge of cuff e: apex of lunule at origin of valves
Prevent sticking to waRCA & LCA originate
space
lis) ary sinus)
IV
cm from AML)
es smooth/rough)
k)
all of vessel in sinus
VS Membranous paof fibrous skeletoMuscular part (sathickness as LV)
VASCU Arterial ArteryRCA SA nodR margPost IV
AV nod ArteryLCA
Ant IV1
Lateral3
LCx
SA nodL marg
Post IV1LAD 2Domin3of Ant To ap*10% h
Venous Vein Great cAnterioMiddle Small CObliqueAnterioveins 1Near o2Insign
Lympha InnervaParasym Presy SynapAtria & Nega 1Inotro
art (part on) ame
LATURE OF THE HEA
Endocardium & subenRemainder through co
Supply
Origin R Ao sinus
dal @ Origin 60ginal @ Inf borde
@ Crux 67%
dal @ Crux 80%
Origin L Ao sinus
Cont of LCA
3 Ant IV @ Inf bordeauricle
dal LCx 40% inal LCx @ latera
border @ Crux 15%2
nance, 18% co-dominaIV artery (aka diagonex of heart ave anastomosis, rest
s Drainage Coronary sinus or smAnterior interventricu
Dra
cardiac vein Coror IV GreaCardiac1
CoroCardiac1 e vein of LA2 r cardiac RA
origin of carotid sinusifcant postnatally, defi
atics Subepicardial lymphat
ation Cardiac plexus located
mpathetic naptics from Vagus pse with ganglion in IAS tive1
opy, Chronotropy, Dro
RT
ndocardium passive doronary arteries (trave
Course Coronary sulcu
% Behind SVC r Inf margin 2 Post IV groove
Short
Course AV groove
Ant IV groove
Ant surface r L Coronary sulcu
Behind LA al L heart border
2 Same as whenCrux =
ance (post IV off RCA aal)
have potential
all veins directly into Rar vein
inage Cours
onary Sinus LCx at Cardiac Ant IV
onary Sinus Post IVR mar RV/RA
nes transition from gr
tic plexus tracheobr
d post to Asc Ao & PuSympathetic Presynaptic Ganglion in IML
Positive1 motropy
iffusion from chambeel deep to epicardium)
Distribution us RA
SA, Pulm trunRV, apex
e RV, LV, Post
AV
Distribution LA, LV, IVS, Abundle
e RV, LV, Ant 2
LV us LA, LV
SA, LA r LV
n RCA branch
and Ant IV is longer)
RA
se Distr
LCA V artery V artery RCArginal artery
LA A
reat cardiac to corona
ronchial nodes (right s
ulmonary trunk Sympathe
L T1-6 Postsyna Ganglion
Positive1
rs )
AnastomLCx
nk - IV branc
1/3 IVS Ant IV b@ apex-
AnastomAV RCA
2/3 IVS Post IV b@ apex RCA
- IV branc
ribution
supply
A supply
ry sinus
side btwn Pulm trunk &
etic aptic n in C/T sympth trunk
mosis*
ches ranches
mosis
branches
ches
& LA)
Tranatomy: Thorax 2012 | Page 7 of 8
THORAX MEDIASTINUM SUPERIOR MEDIASTINUM Anterior to Posterior 1. Thymus 2. Veins: brachiocepgalics (SVC lower down) 3. Arteries: Asc Ao, Arch and branches (BC, Common carotids) 4. Nerves: Vagus & Phrenic 5. Trachea 6. Oesophagus 7. Thoracic Duct
THYMUS Arterial: ant IC & ant mediastinal branches of Internal Thoracic Venous: L brachiocephalic Lymphatics: parasternal, brachiocephalic, tracheobronchial nodes GREAT VESSELS Venous Level Structure Drainage Above SCJ IJ & SC veins Head, Neck, Right Upper Limb SCJ L1 & R Brachiocephalic veins Inf border 1st right cartilage SVC Everything above diaphragm2 3rd right cartilage SVC enters RA3 1passes anterior to root of Ao branches 2Except heart & lungs 3Ant to trachea, Posterolateral to Asc Ao, Phrenic nerve on medial wall Arterial (Arch of Ao) Level Structure Surrounds R of sternal angle Arch Ao starts Ascending part Ant to R pulm a & trach bifurcation Apex Left side of trach & oesph T4 Descending part Over and post to root of left lung NB since Asc Ao is in pericardium, considered part of middle mediastinum Arterial (Branches of Arch Ao) Level Branch Surrounds Post to Manubrium Brachiocephalic trunk Ant to trachea
Post to L brachiocephalic vein R SCJ Divides into R SC & R CC Trachea on left Post/Left BC trunk L CC Ant to L SC
Ant then left of trachea L SC Post to LCC
Lateral to trachea
NERVES Vagus Exit neck Posterolateral to common carotid Enter superior mediastinum posterior to SCJ and brachiocephalic veins Descent Right Left Into Sup Mediastinum Ant over SC artery Descends Post to LCC
Recurrent Laryngeal Branch Loops under R SC
Loops under arch Ao (lateral to ligamentum arteriosum)
Ascends btwn trachea & oesophagus on r side
Into Inferior Mediastinum Forms R pulmonary plexus Leaves plexus as single nerve to oesophagus Forms Oesophageal plexus
Phrenic Nerve Motor and sensory (1/3) to diaphragm Sensory to pericardium and mediastinal pleura Descent Right Left Into Sup Mediastinum Btwn R SC artery & R BC vein Btwn LCC & LSC
Into Inferior Mediastinum
Ant to arch and lat to Vagus Anterior to Root Anterior to Root R side of BC vein, SVC, RA, IVC Ant to left Sup IC vein Ant to LA, LV
Diaphragm Pierces near caval opening Pierces left of pericardium TRACHEA Anterior to oesophagus Slightly right as it enters superior thoracic aperture Bifurcates at sternal angle OESOPHAGUS On vertebrae T1-4 veering left as it approaches Ao arch Centres due to Ao arch (with thoracic duct t lateral to oesophagus Descends behind root of left lung Displaced to right by thoracic Ao but travels anterior to it Enters diaphragm at oesophageal hiatus @ T10
3 impressions (narrowing) 1. Ao arch 2. L main bronchus 3. Diaphragm
Tranatom
THO ME POSTER
Thoraci Branche
Thoraci Level Intra-abDiaphraPosterioSuperio
my: Thorax 2012 | Page 8 o
ORAX
EDIASTINUM
RIOR MEDIASTINUM
T5-12
Posterior to Anterior Oesophagus & Thoracic Duct Thoracic Ao Posterior med Veins: azygous
ic Ao Starts left of inf bordeDescends T5-12 posteEnters diaphragm thro
es Described as 3 vascul 1. Anterior (midli
Supplie Oesoph Exceptions Superio Pericard
2. Lateral (paired
Supplie Bronch R usual
3. Posterolateral
Supplie Posterio
ic Duct & lymphatics Drains all but RUQ of
bdominal agm (T12) or Mediastinum or Mediastinum (T4,5 o
of 8
& nerve plexus
iastinal nodes s & hemiazygous
er T4 erior to root of L lung,ough Ao hiatus @ inf
ar plains in thoracic an
ne, unpaired) es gut hageal arteries (2 to 5
or phrenic = paired andial & mediastinal arte
) es viscera other than gial arteries (left, sometlly from 3rd R post IC a
(paired) es body wall or IC arteries x9 (ie no
body
Surrounds Chyle CisteEnters throAscends btw
or 6) Enters L ven
oesophagus, pericardborder T12 (with thora
nd abdominal Ao
)
nterior branches just aeries (supply nodes an
gut (eg lungs, kidney) times right) artery
ot 1st or 2nd space)
rn ugh Ao hiatus wn Ao (L), Az (R), Oesnous angle (sometime
dium acic duct & azygous ve
bove the diaphragm nd CT) = unpaired ante
sph (Ant) es L Subclavian)
vein)
erior
VESSELPosterio Azygou Azygou Hemiaz Accesso Superio
Nerves
ANTER SURFAC
LS & NODES or Mediastinal NodesFrom oesophagus, poDrain into R lymphatic
us system Drains back, thoracoaCollateral system betw
us Ascends on R side of Arches ant post ov
zygous Cont of asc lumbar veTravels on left borderThen joins azygous by
ory Hemiazygous Travels on left borderThen joins azygous byFrequently joined to sSometimes joins to he
or Intercostal Vein Drains Left IC veins 1-Drains into L brachioc
of Posterior MediastinThoracic sympathetic Location changes dow
Superio Mid tho Inferior
NB splanchnic nerves
IOR MEDIASTINUM
Thymus Loos CT Fat Lymphatic vessels, no
CE ANATOMY
osterior pericardium, dc duct or thoracic duct
bdominal wall, mediaween IVC and SVC
TT12T4 ver R root to SVC
eins and 9-11 + subcosof T12T9
y going post to Ao, Th
of T5T8 y going post to Ao, Thuperior intercostal vei
emiazygous
4 cephalic (even if joins a
num trunks are main supplwn mediastinum or thorax: head of ribs orax: Costovertebral jothorax: sides of vertesupply below diaphra
des
diaphragm, middle poct
astinal viscera, vertebra
stal veins
horacic duct, oesopha
horacic duct, oesophain
accessory hemiazygou
ly
s oints ebral bodies agm but ganglia from
sterior IC spaces
al plexus
gus
gus
us
T5-12