Thorax

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Sternum


Manubrium, body, xiphoid process



Jugular notch at T2



Sternal angle at T4/5



Xiphoid process at T9

Vertebral levels

Denver F. Sapo, MD

Ribs


TRUE ribs


Attach to sternum



Ribs 1 to 7

Rib fracture (Clinical correlation)
TYPICAL rib



• Ribs 3-9

ATYPICAL rib



• Ribs 1, 2




FALSE RIBS


Attach to costal cartilage above



Ribs 8 to 10



Ribs 10, 11, 12





No attachment anteriorly



Ribs 11 and 12

HPE—Paradoxical chest
movement

MC—ribs 5 to 10



Cx—?



Rx—intercostal nerve block



Rib 1 and 2 fracture means?



Lower rib fracture

Cervical rib (Clinical correlation)


From the transverse process of C7



Cx—thoracic outlet syndrome

Two separate fractures in ≥ 3 ribs


Costochondral junction



Angle



pulmonary contusion—major cause
of respiratory compromise



Rx—PEEP

Thoracic outlet syndrome (Clinical correlation)


Just anterior to the angle of the rib



FLOATING RIBS

Flail chest (Clinical correlation)




What do you call this maneuver?

Manubriosternal joint

Dermatome vs Vertebral level


Vertebral level
Xiphoid process at T9



Nipple at T4



Umbilicus at L4



Xiphoid process at T7



Umbilicus at T10



Inguinal ligament at L1

EKG electrode placement (Clinical correlation)



Sternal angle (of Louis)





At the level of…



V2—left 4th ICS



V3—?



V4—5th ICS MCL



V5—AAL (same level as V4)



V6—MAL (same level as V4)



Junction of superior and inferior
mediastina



Bifurcation of the trachea



T4/5 IV disk



Beginning and end of the aortic
arch



2nd costal cartilage



Azygous vein drains into the SVC

Dermatomal level





V1—right 4th ICS

Costovertebral and
costotransverse joints




Head↔vertebral body






Costochondritis (Clinical correlation)

Costovertebral joints

Corresponding

Above



Aka Teitz syndrome



Tenderness over the costochondral
joints



Treatment—?

Costotransverse joints
Tubercle↔transverse process


Corresponding

Thoracic outlet???


Superior thoracic aperture



Inferior thoracic aperture



Which aperture is affected in
thoracic outlet syndrome?

Intercostal muscles








Costal groove



“V-A-N”

Intercostal arteries


Posterior intercostal arteries



Superior intercostal artery (1-2)



Innermost intercostal

Intercostal arteries


Anterior intercostal arteries


Internal thoracic artery (1-6)



One finger breath lateral to
sternal margin



Divides in its terminal branches at
the 6th intercostal space



Musculophrenic artery (7-9)

Coarctation of the aorta (Clinical correlation)


Rib notching



PE?

Intercostal artery (3-11)

Subcostal artery

Intercostal space (Clinical correlation)
To enter the pleural cavity...



Posterior/Internal intercostal
membrane

Thoracic aorta





Anterior/external intercostal
membrane

Internal intercostal




Intercostal space

External intercostal

superior border of the rib

To perform intercostal nerve
block...


inferior border of the rib

Intercostal nerve block (Clinical correlation)


V-A-N



Cx


Pneumothorax



Hemorrhage

Needle thoracostomy (Clinical correlation)


Management for tension
pneumothorax



Anterior approach






Incision

2nd ICS MCL

Lateral approach


Tube thoracostomy (Clinical correlation)



Diaphragm

4th or 5th ICS (Snell)



5th or 6th ICS (Moore)



AAL or MAL

Indications

2nd ICS AAL







Air removal



Fluid drainage

Structures penetrated?

Diaphragm
Diaphragmatic apertures





Main muscle of respiration



Esophageal opening



Nerve supply?



Esophagus



Vagus nerve





THINK—”C3, 4, 5 keeps the
diaphragm alive”

Which is higher?

Trauma (Clinical correlation)


The dome of the diaphragm can
reach the 5th rib!


Injury below the nipple line may
involve abdominal and/or chest
organs



Septum transversum



Esophageal mesentery



Pleuroperitoneal membrane





Heart—T1-T4



Referred to intercostal nerves and
intercostobrachial nerve (T2)

Aortic hiatus



Aorta



Thoracic duct



Azygous vein



“aortic hiatus” (12 letters)



Caval opening



IVC



Right phrenic nerve



“vena cava” (8 letters)



Transverse diameter



AP diameter



Vertical diameter
Contraction of diaphragm

Intercostal nerve (Clinical correlation)


Mesoderm of body wall

Cardiac pain (Clinical correlation)

“Oesophagus” (10 letters)



Mechanics of respiration



Congenital diaphragmatic hernia
(Clinical correlation)



Herpes zoster


Etiology—VZV reactivation



Vesicular eruptions



Dermatomal pattern



Dormant within what structure?

Inferior mediastinum


Anterior mediastinum


Contents



Thymus



Sternopericardial ligament



Inferior wall MI



LN



Epigastrium



fat



Referred to epigastrium—



T7, 8, 9

Inferior mediastinum


Middle mediastinum



Heart



Thoracic aorta



Roots of great vessels



Esophagus



Primary bronchi



Azygos and hemiazygos vein



Phrenic nerve



Vagus nerve



Arch of azygous



Thoracic duct



Sympathetic trunk



SVC



Brachiocephalic veins



Arch of the aorta



(L) RLN



Thoracic duct



Esophagus



(R) and (L) vagus n



(R) and (L) phrenic nerve



Thymus

SVC syndrome (Clinical correlation)


Obstruction of SVC



MCC—malignant tumor (lung
cancer)



Thoracic aorta


Ascending aorta



Aortic arch



Formed behind the lower border of
the 1st costal cartilage



What is the other name of the
brachiocephalic vein?

Question


Descending aorta



Which part of the mediastinum?



What is the first branch of the
aorta?

Thoracic duct


Starts as the?



Enters what hiatus?



Identify its course in the
mediastinum?



Empties where?

What part of the mediastinum?


Vagus nerve



Phrenic nerve



(R) RLN

Aortic dissection (Clinical correlation)


THINK—”Know your ABC’s”



Contents

SVC

Pemberton sign



Posterior mediastinum

Contents

Contents







Superior mediastinum



Inferior mediastinum

Treatment?


Stanford classification



DeBakey classification


“B-A-D”

Azygos system


Communicates with the internal
(epidural) vertebral venous
(Batson) plexus


valveless

Azygos lobe (Clinical correlation)


Anomalous lateral course of the
azygous vein



Not a true lobe!



Incidental finding

Mediastinal masses
(Clinical correlation)

Mediastinal shift (Clinical correlation)


Tracheal shift



Atelectasis?



Pleural effusion?



Pneumothorax?



Asthma?



Pneumonia?



Diagnose?

Pleura


Parietal pleura



Visceral pleura



Sensitive to pain



Not sensitive to pain



Pleural fluid 5 to 10 mL (Snell)





Pneumothorax (Clinical correlation)

What is the lining epithelium?

Parietal pleura
Parts and innervation









Spontaneous pneumothorax


HPE



Pleura?
“Sucking chest wound”



Pleura?

Cervical/cupula



Costal



Diaphragmatic



Tension pneumothorax


“Ball-valve effect”



Clinical dx



Intercostal nerves



Central—phrenic nerve



Peripheral—intercostal nerve

Mediastinal




Medisatinal shift Æ ↓ VR

Sternal lines of reflection






Open pneumothorax


Phrenic nerve

Pleurisy (Clinical correlation)



Shoulder?



Anterior abdominal wall?

Costal and vertebral lines of reflection

Right


SC joint →midline at MS joint

Bottom of
lung

→XS joint


SC joint →midline at MS joint
→deviates laterally at the 4th
costal cartilage →6th costal
cartilage

6th rib

8th rib

MAL

8th rib

10th rib

Paravertebral
line

10th rib

12th rib



Pericardiocentesis (Clinical correlation)



Beck’s triad


Distended neck veins



Distant heart sounds



Decreased blood pressure

Intercostal approach




5th or 6th ICS near the
sternum—”bare area”

Cx—hemorrhage from internal
mammary artery or its branches

Bottom of
parietal pleura
(Costal line)

MCL

Left




Pleural cavity

Vertebral lines of pleural reflection
parallel the paravertebral lines from
T1 to T12

Water bottle heart


Initial management?



Definitive treatment?

Pericardiocentesis (Clinical correlation)


Xiphisternal approach



250 mL →diastolic filling is

Thoracentesis (Clinical correlation)


Site—9th ICS MAL

compromised

Pleural effusion (Clinical correlation)




Costodiaphragmatic angle


Posterior—most dependent



Lateral



Anterior—least dependent





Left shoulder pain



Splenic rupture →Hemorrhage
within the peritoneal cavity

300 mL

Endothoracic fascia


Kehr sign (Clinical correlation)

Respiratory system (Histology)

Loose connective tissue separating
the parietal pleura from the thoracic
wall
Suprapleural membrane—Sibson
fascia

Respiratory system (Histology)



Conducting portion



Respiratory portion



Upper respiratory tract



Lower respiratory tract

Clara cells

Trachea

Bronchi

Bronchiole



Club cell (January 1, 2013)

Pseudostratified
ciliated epithelium

Pseudostratified
ciliated epithelium

Simple cuboidal
epithelium



Bronchioles

C-shaped

Irregular plates

none



Function

Glands

++

+

none

Smooth muscle

yes

yes

yes

Epithelium
Cartilage



Differentiate terminal bronchiole
from respiratory bronchiole?

Alveoli


Type I pneumocyte




Simple squamous epitheliul

Type II pneumocyte


Cuboidal



Regenerate and divide



Synthesize surfactant






Surface tension



Compliace/Elasticity

Start at 20-24 weeks (Nelson)

Alveolar macrophage



Differentiate to ciliated cells



Secrete GAGs



Metabolize airborne toxins

Blood-gas barrier


What forms the blood-gas barrier?

Trachea


Extent?



What type of cartilage?

EA and TEF (Clinical correlation)


Type B


1%



AXR—gasless abdomen



Type D

8-10% (2nd MC)



SSx?



Dx—failure to pass NGT



AXR—gasless abdomen



EA and TEF (Clinical correlation)




Type C


EA + distal TEF



THINK—Common

85%

EA and TEF (Clinical correlation)


Type E—H-type


TEF without EA



THINK—Double connection



THINK—Eyts

2%

Principal/Primary/Main bronchi
Right







± excessive secretions

Eparterial bronchus


Right upper lobe bronchus

Narrower, longer, more horizontal



Tertiary/Segmental bronchus


8%

Left

Secondary/Lobar bronchus




Wider, shorter, more vertical



How many?
How many?

Foreign bodies tend to lodge in which
bronchi?

Endotracheal tube placement
(Clinical correlation)


Placement?



Complications?

Fissures


Fissures


Oblique/Major fissure




THINK—Atresia Alone

EA + proximal and distal TEF









Bronchi


Type A—Pure esophageal atresia

THINK—Blank

EA and TEF (Clinical correlation)




EA + proximal TEF





EA and TEF (Clinical correlation)

Preferred site for trachesotomy
tube insertion?


Root of the spine of the
scapula→6th rib →6th
costochondral junction

Horizontal/Minor fissure


4th costal cartilage →meets
the oblique fissure horizontally
at the MAL



THINK—RALeS

Lobes
Right lung








2 lobes



Right lung
Standing/sitting—posterobasal of
RLL



Supine—superior segment of
RLL



Right side-lying—middle lobe or
posterior segment of RUL

Segmental vein lies in the
connective tissue between adjacent
segments

Blood vessels of the lungs


Pulmonary artery



Pulmonary vein



Bronchial artery



Bronchial vein



Oxygen content?

Left side-lying—inferior lingular

Hampton’s hump
Wedge-shaped

Pancoast tumor (Clinical correlation)


Surgically resectable



Left lung






Lingula

Foreign body aspiration (Clinical correlation)


Independent functional and surgical
units

Cardiac notch






3 lobes

Left lung



Bronchopulmonary segments

Tumor of the apex of the lung


Horner syndrome



Ptosis



Anhidrosis



Mio

Westermark sign


Oligemia

Lymphatic drainage
Superficial plexus

Deep plexus
(pulmonary nodes)

Bronchopulmonary
nodes

Tracheobronchial
nodes

sis

Bronchomediastinal trunk

Right lymphatic duct or
thoracic duct

Pericardium


Fibrous pericardium




Indistensible!

Serous pericardium


Parietal pericardium



Visceral pericardium



Pericardial fluid—50 mL (Snell)



What is the difference between
visceral pericardium and
epicardium?


Lining epithelium?

Pericardial sinuses (Clinical correlation)


Oblique sinus



Transverse sinus


Allows clamping of great vessels
during cardiac surgery

Pericarditis (Clinical correlation)


Primitive heart tube

HPE


Pain?



Pericardial friction rub



EKG?



Rx?

Truncus arteriosus


Adult structure


Aorta



Pulmonary trunk

Persistent truncus arteriosus (Clinical correlation)


Neural crest cell Æ

AP septum

Transposition of great arteries


Nonspiral development of AP
septum



Most common cause of cardiac
cause of cyanosis in the neonatal
period

Tetralogy of Fallot (Clinical correlation)


Skewed development of AP septum



THINK—”PROVe”


PS



RVH



Overriding of the aorta



Ventricular septal defect



Trilogy?



Pentalogy?

Primitive ventricle and atrium


Adult structure






Partial development of AP septum

Egg-on-a-string sign

Bulbus cordis


Adult structure


Infundibulum/conus arteriosus



Aortic vestibule

Sinus venosus


Adult structure

Primitive ventricle →Trabeculated



Sinus venarum

part of the ventricles



Coronary sinus

Primitive atrium →Trabeculated



Oblique vein of LA*

part of the atrium

Fetal circulation


Ductus arteriosus






Remnant in adults



Functional closure--immedeately
(mediated by bradykinin)




Fetal circulation


Umbilical arteries?



Umbilical vein?

100% functional closure at 96
hours (Moore)

Anatomic closure--1 to 3 months


Foramen ovale


Functional closure--immedeately



Anatomic closure--1 year



Ductus venosus?



Foramen ovale?

Ductus arteriosus?



IVC →FO →LA



SVC →LV

*Langman

Borders

Surface projections



Right—RA



3rd right costal cartilage



Left—LV + LA



6th right costal cartilage



Inferior—RV



2nd left costal cartilage



Apex—LV



5th left ICS MCL

Surfaces


Base/Posterior—LA



Anterior—RV



Diaphragmatic—LV

Auscultation areas (Clinical correlation)


bicuspid valve



tricuspid valve



pulmonary valve



aortic valve



Triangle of auscultation?









Arterial supply of the heart


(L) 5th ICS

4th ICS to the (L) of the sternum

2nd ICS to the (L) of the sternum

2nd ICS to the (R) of the sternum

Internal features

LCA

RA



Circumflex artery



Anterior IV artery



Supplies


AV valves


S1—closure of AV valves

• vestibule

Rough

• Pectinate
muscles
(Auricle)

• Trabeculae
carnae
• papillar
y
muscle
• chordae
tendina
• Moderator
e
band

• Trabeculae
carnae
• papillary
muscle
• chordae
tendinae



Tricuspid--Anterior, septal, posterior




Semilunar valves—THINK—”LARP”


S2—closure of semilunar valves



Aortic—right, left, posterior





Mitral—Anterior, posterior

Pulmonary—anterior, right, left

Where do the coronary arteries
originate?

• Fossa ovalis
• Crista
terminali
s
• Sulcus
terminalis

• Pectinate
muscles
(Auricle)

• Supraventricular
crest

Arterial supply of the heart


LV

• Infundibulum
conus arteriosus

Unique features



RV

• Sinus venarum • Entrance of
PVs

IV septum?

Heart valves

LA

Smooth

RCA


Origin?



Marginal artery



Posterior IV artery



Supplies?


SAN, AVN



IV septum?

• Wall is 3x
thicker

Arterial supply of the heart


LCA


Circumflex artery



Anterior IV artery



Supplies


Myocardial infarction (Clinical correlation)


Occlusion



CABG





LAD > RCA > LCx
10-year patency


IV septum?








Diabetic



Elderly



Heart transplant patients

Infract localization
(Clinical correlation)

Septal wall MI



Lateral wall MI



Artery occluded?



Artery occluded?



Seen in what leads?



Seen in what leads?

Infract localization
(Clinical correlation)


Variations in arterial supply

Inferior wall MI


Artery occluded?



Seen in what leads?



Right dominant (80%)



Left dominant



Codominant



PDA arises from RCA



Venous drainage of the heart


Radial artery

Silent MI



Infract localization
(Clinical correlation)

IMA—95%

Long saphenous vein—50%

Coronary sinus

PDA arises from LCx

Septa


Interatrial septum



Interventricular septum



Great cardiac vein



Middle cardiac vein



Membranous—MC site of defect



Small cardiac vein



Muscular



Smallest cardiac vein (thebesian)



Anterior cardiac vein

Conduction system


Slowest velocity?



Fastest conduction?



Only connection



between atria and ventricles?

SAN

AVN

AV bundle

Bundle branches

Purkinje fibers

Triangle of Koch

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