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Anatomy for MRCS > Anatomy of the Thorax > Flashcards

Anatomy of the Thorax Flashcards

1
Q

Boundaries of root of neck / superior thoracic aperture?

A

Anterior aspect of body of T1, medial part of rib 1, manubrium anteriorly

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2
Q

Boundaries of inferior thoracic aperture?

A

Posteriorly = Vertebral body of rib 12.
Lower border of rib 12 and distal end of rib 11, cartilaginous ends of ribs 7-10
Xiphoid process anteriorly

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3
Q

Relation of subclavian vessels and brachial plexus at root of neck?

A

Subclavian vessels and brachial plexus all pass over rib one and underneath the clavicle

Subclavian vein is most superficial, on top of scalenus anterior
Subclavian artery sits between scalenus anterior and medius
Brachial plexus sits behind artery at level of rib 1 - also between the scalenus muscles

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4
Q

Rough structure of the breast?

Why does malignancy cause pitting of the skin?

A

Series of ducts and secretory tubules
These converge to form 15-20 lactiferous ducts
This is surrounded by connective stromal tissue
Areas where this tissue thickens = suspensory ligaments

Suspensory ligaments are continuous with dermis of the skin. In malignancy they tighten = pitting of skin

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5
Q

Blood vessels, innervation and lymphatics of breast?

A

Arterial:
Lateral = branches of axillary artery = sub scapular, lateral thoracic, superior thoracic + thoraco-acromial
Medial = Via internal thoracic (also called int. mammary), which is branch of subclavian

Venous = parallels

Innervation = intercostal nerves 2-6, nipple = 4th intercostal

LN’s = Mainly axillary, some parasternal

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6
Q

3 Muscles of the pectoral region?

A

Pectoralis major = adducts, flexes and medially rotates humerus at shoulder
Origin. = Medial half of clavicle and sternum
Insertion = lateral lip of intertubercular sulcus
Lateral and medial pectoral nerves

Pectoralis minor = protracts scapula, depresses tip of shoulder
Origin = anterior surface of ribs 3-5
Insertion = coracoid process
Medial pectoral nerve

Subclavius = Pulls clavicle medial to stabilise SCJ
Origin = Rib 1
Insertion = Groove on inferior third of clavicle
Nerve to subclavius

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7
Q

Order of structures in intercostal groove?

A

Vein is most superior
Then artery
Then nerve most inferior

Intercostal groove is on inferior margin of ribs

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8
Q

Rib one articulation with vertebrae and grooves?

A

Only has one articular surface for body of T1

Superior surface has distinct scalene tubercle which separates two grooves:

  • anterior = Subclavian vein
  • Posterior = subclavian artery
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9
Q

Why is rib 10 special?

A

Has single facet for articulation with its own vertebra

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10
Q

What articulation occurs on manubrium?

A

Two oval facets for clavicles
Immediately inferior = large facet for rib 1
Lower end is Demi-facets for rib 2

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11
Q

Angle of Louis?

Landmark for 4 things….

A

Manubriosternal joint = T4/T5

Costal cartilage of 2nd ribs
Arch of aorta + tracheal bifurcation
Union of azygous and SVC
Crossing of thoracic duct over the midline

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12
Q

Sternal facets for articulation?

A

Superiorly = 2 demifacets for rib 2
Facets for rib 3-6
Inferiorly = demifacets for rib 7

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13
Q

Xiphoid process facets for articulation?

A

Demifacets for rib 7

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14
Q

What ligament is routinely divided in midline sternotomy?

What vessels must we be wary of?

A

Interclavicular ligament

Brachiocephalic vein, is posterior at superior aspect of sternotomy incision

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15
Q

What is cervical rib?
How many are bilateral?
Classic signs?

A

Elongation of the transverse process of C7 = fibrous band attaches to Rib 1

70% bilateral

Neurological deficit and compression of subclavian can cause radial pulse absence

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16
Q

Intercostal muscles? - function, origin, insertion + innervation

A

External intercostals = assist inspiration, elevate ribs
Origin = inferior aspect of rib above
Insertion = superior aspect of rib below
Intercostal nerves

Internal intercostals = assist expiration, depress ribs
- deep to the external intercostals
Origin = Lateral edge of intercostal groove above
Insertion = Superior margin of rib below
Intercostal nerve

Innermost intercostals = assist internal intercostals = expiration
Origin = medial edge of costal groove above
Insertion = internal aspect of superior margin below
Intercostal nerves

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17
Q

Arteries and veins to thoracic wall?

A

Arteries = anterior and posterior intercostal arteries
POSTERIOR:
- upper two originate from supreme intercostal artery = branch of costocervical trunk
- Other 9 pairs originate from directly from posterior aspect of aorta

ANTERIOR:

  • All supplied in some way by internal thoracic (branch of subclavian)
  • upper 6 supplied directly
  • at 6th costal cartilage, the internal thoracic splits into Musculophrenic and superior epigastric artery
  • so lower 6 anterior ones are supplied by Musculophrenic arteries

Venous mirrors this

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18
Q

What do the upper posterior intercostal veins form and then drain into?

A

Form the superior intercostal vein
On right drains into azygous
On left into brachiocephalic

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19
Q

Embryology of the diaphragm?

A

Formed due to progressive fusion of septum transverse, pleuroperitoneal folds and muscular ingrowth

Septum transversum = Central tendon
Pleuro. folds = parietal membranes

Cervical somites C5-7 = muscular components

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20
Q

Where does central tendon attach superiorly, and what is its continuation posteriorly?

A

Superiorly attaches to pericardium

Posteriorly it forms median arcuate ligament

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21
Q

Apertures of the diaphragm?

A

I ate ten eggs at 12

IVC = T8 - right phrenic nerve too
Oesophagus = T10 - also have vagus here 
Aorta = T12 - also have thoracic duct here and azygous
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22
Q

Arterial supply of diaphragm?

A

Inferior and superior aspects

Superior = from pericardiophrenic and Musculophrenic = both branches of internal thoracic (subclavian)

Inferior = Superior phrenic from lower thoracic aorta directly + inferior phrenic from abdominal aorta

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23
Q

Diaphragmatic hernias?

A

Morgagni = right anterior, good prognosis, minimal disruption

Bochdalek = left posterior, scaphoid abdomen and pulmonary hypoplasia ± pulmonary HTN.
Poor prognosis and requires surgery

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24
Q

Which cell type lines the pleural cavity?

A

Mesothelial

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25
Q

What covers the parietal pleura of the lung superiorly?

A

Suprapleural membrane

Attaches laterally to medial part of first rib and transverse process of C7

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26
Q

at what level is the root of lung / pleural reflection?

A

T5-T7

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27
Q

Lobes and fissures of each lung?

A 
Right = 3 lobes + oblique and transverse fissure
Left = 2 lobes + oblique fissure
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28
Q

Inferior border of lungs?

A

6th rib MCL
8th rib MAL
10th rib posteriorly

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29
Q

What does the root of the lung contain, and its arrangement?

from the root, what is the inferior projection of the lung pleura called?

A

1 pulmonary artery
2 pulm. veins
1 main bronchus
Bronchial veins, arteries and nerves

Artery is superior
Veins inferior
Hilum posterior

Inferior to root of each lung, pleura projects inferiorly = pulmonary ligament

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30
Q

Right lung - arrangement of vessels etc medially?

A

Right:
Above hilum is azygous vein - feeds into SVC
Above this is groove for SVC and right innominate vein
Behind hilum is groove for oesophagus. Azygous sits posterior to this
Right bronchus = wider and straighter. = foreign body

Left:
Above hilum = furrow for aortic arch, superiorly = groove for left subclavian
Behind the hilum = vertical groove for descending aorta
Left main bronchus at T6

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31
Q

What level does the pulmonary trunk bifurcate?

Relations of left and right pulmonary arteries?

A

T4/5

Right has longer course crossing midline.

  • Anteroinferior to tracheal bifurcation
  • Passes posterior to right superior pulmonary vein, ascending aorta and SVC

Left:
Anteroinferior to tracheal bifurcation
Passes anterior to descending aorta
Posterior to superior pulmonary vein

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32
Q

Where does trachea start and what level is the tracheal bifurcation?

A

C6 - T4/T5

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33
Q

Tracheal relations in the neck vs thorax?

A

Neck:
Anterior = isthmus of thyroid, Sternohyoid and sternothyroid, cervical fascia and inferior thyroid veins + thyroid ima
Lateral = inferior thyroid arteries, common carotids and recurrent laryngeal
POSTERIOR =. OESOPHAGUS

Thorax:
Anterior = Manubrium
Aortic arch, left common carotids + deep cardiac plexus

Lateral - right = pleura and right vagus, left. = left recurrent nerve, aortic arch, left common carotids and subclavian arteries

34
Q

Divisions of the mediastinum?

A

Superior = above transverse line from angle of Louis

Inferior is below this, further subdivided into…..
Anterior, middle = pericardium, posterior

35
Q

Contents of each section of mediastinum?

A 
Superior:
SVC, brachiocephalic veins and arch of aorta
Trachea, oesophagus and thymus
thoracic duct
Vagus, phrenic and recurrent laryngeal

Anterior = LN’s and fat

Middle = pericardium, heart, origin of great vessels, main bronchi + arch of azygous

Posteiror:
azygous and thoracic aorta
Oesophagus
thoracic duct
Vagus, splanchnic and sympathetic
36
Q

Structure of pericardium?

A

Fibroserous sac

Fibrous layer = tough connective tissue

  • base is on diaphragm = central tendon
  • anteriorly connect to sternum via sternopericardial ligament
  • Apex continues with adventitia of vessels
  • Phrenic nerve passes via this fibrous layer.

Serous layer = inner parietal and visceral layers
- 2 reflections = oblique and transverse sinuses

37
Q

Which nerve passes through fibrous part of pericardium?

A

Phrenic nerve, as do the pericardiophrenic vessels

38
Q

Nerves and vessels of pericardium?

A

Arteries = internal thoracic, pericardiophrenic, Musculophrenic, and inferior phrenic

Veins enter azygous system

Nerve = phrenic. Referred pain to shoulder as C345

39
Q

What are the two external sulci of the heart and what runs in them?

A

Coronary sulcus:

  • Separates the atria from the ventricles
  • RCA, small cardiac vein, coronary sinus and LCx

Posterior interventricular sulcus = middle cardiac vein, PI artery

Anterior inter ventricular sulcus = Great cardiac vein, AI artery

40
Q

Where does the coronary sinus open into the RA?

A

Immediately medial to opening of SVC

41
Q

How is right atrium divided?

A

From line between IVC AND SVC

this line is marked internally by crista terminalis, and externally by the sulcus terminalis cordis

Space posterior to crista = sinus of venae
Space anterior = atrium proper

42
Q

What defines the atrium proper, and what are its walls covered in?

A

Anterior to crista terminalis = atrium proper

Atrium proper’s walls are covered in muscular ridges = pectinate muscles

43
Q

What does the inflow portion of RV have?

What do these attach to and what do they prevent?

A

Trabeculae carnae / papillary muscles

Some attach to the Chorda tendinae which connect to free edge of cusps of tricuspid valves = prevent eversion of valve with high ventricular pressure

44
Q

What is the outflow tract of the RV called?

A

Infundibulum / conus arteriosus

45
Q

How many cusps does pulmonary valve have, and what structure do these have to cause closure?

A

Three semi-lunar cusps

Each has a pocket like structure = fills with bloods after ventricular contraction recoils. blood = closure

46
Q

How does left atrial structure differ to right?

A

Contains musculi pectinate, BUT NOT CRISTA TERMINALIS

47
Q

How do the trabeculae in LV differ to the ones in RV?

How do papillary muscles differ?

A

They are finer and more delicate .

Papillary muscles = larger

48
Q

what location would metallic valves be on CXR?

A

R 3rd ICS = A
L 4th ICS = M
R 5th ICS = T

49
Q

Where does coronary sinus and sit and where does it receive what veins from?

A

Sits in coronary sulcus
Great cardiac vein comes from anterior interventricular groove
Middle comes from posterior

Small cardiac vein drains into right atrium directly

50
Q

What are the veins of Thesebius?

A

Small group of veins that drain directly into the RV and RA

51
Q

Where does RCA originate and what does it supply?

A

Originates from right aortic sinus from ascending aorta
Descends vertically in coronary sulcus to the posterior inter ventricular sulcus

SA node in 60%, AV node in 80%
posterior third of interventricular septum
Right atrium
Lower part of RV

52
Q

LCA - where it originates and what it supplies?

A

Originates from left aortic sinus of ascending aorta

Anterior 2/3rds of interventricular septum
other 40% of SA node
Most of LA and LV
part of RV

53
Q

Location of deep and superficial cardiac plexus?

A

Deep sits posterior to ascending aorta and anterior to bifurcation of trachea

Superficial sits superior to bifurcation of pulmonary trunk and inferior to aortic arch

54
Q

what gives parasympathetic supply to the heart?

A

Vagus

55
Q

What level does the pulmonary trunk divide, and relations of right and left branch?

A

T5/T6

Right passes posterior to ascending aorta and SVC + superior pulmonary vein. Anterior and inferior to tracheal bifurcation

Left passes anterior to descending aorta, anterior and inferior to tracheal bifurcation.
Posterior to superior pulmonary vein

56
Q

When does ascending aorta become aortic arch?

A

At second costal cartilage, where it enters superior mediastinum

57
Q

Superior mediastinum borders?

A

Transverse plane above sternal angle, oblique plane from sternal notch to T1
Posterior sternum and anterior body of thoracic vertebrae

58
Q

Contents of superior mediastinum?

A

TOT = trachea, oesophagus and thymus
Aortic arch, azygous vein, brachiocephalic trunk + SVC
Vagus, phrenic and recurrent laryngeal
Thoracic duct

59
Q

Thymus - where does it sit in the superior mediastinum, arterial supply and venous drainage?

Cellular make up of thymus?

A

Most anterior component of superior mediastinum
Arterial = internal mammary or pericardiophrenic (from internal thoracic)
Venous = left brachiocephalic

Cortex is tightly packed lymphocytes. Medulla is epithelial cells, concentrically arranged around a keratinised centre = HASSALLs Corpuscle

60
Q

Branches of aortic arch?

A 
First = brachiocephalic trunk
2nd = L common carotid 
3rd = L subclavian artery
61
Q

What is anterior trachea or oesophagus?

A 
Trachea = Towards the front
Oesophagus = Out back
62
Q

Vagus nerve: route of right vs left?

A

Right:
Enters sup. mediastinum between brachiocephalic trunk and vein
Crosses anterior to subclavian artery, at this point gives of recurrent laryngeal.
descending posterior to the trachea
Crosses lateral surface of trachea and passes posterior to the root of the right lung
Just before it reaches oesophagus it is crossed by azygous

Left:
Enters superior mediastinum posterior to left brachiocephalic vein, between the common carotid and subclavian artery
Crosses left side of aortic arch anteriorly. here it gives off recurrent laryngeal, just lateral to ligamentum arteriosum.
Descends posteriorly behind root of left lung

Both exit with the oesophagus at T10 In oesophageal hiatus

63
Q

Phrenic nerve: Root of right vs left?

A

Both enter posterior mediastinum lateral to vagus, and posterior to subclavian vein / anterior to anterior scalene / subclavian artery.

Right:
Continues inferiorly along right side of brachiocephalic vein and SVC
Descends on right side of pericardial sac, in fibrous membrane
Anterior to root of lung
Leaves thorax passing through diaphragm at T8 with IVC

Left:
Descends across the left lateral aortic arch, SUPERFICIAL to the vagus
Enters fibrous layer of pericardium, and passes anterior to left lung root
Leaves thorax piercing diaphragm near apex of heart

64
Q

Posterior mediastinum contents?

A

azygous and thoracic aorta
Oesophagus
thoracic duct
Vagus, splanchnic and sympathetic

65
Q

Oesophagus: route and relations posterior and anterior?

A

As it approaches diaphragm it moves left and anterior

Anterior = Right pulmonary and left main bronchus
+ left atrium

Posterior = Thoracic duct - high up is on left, lower down on right. Thoracic aorta sits on its left hand side

66
Q

4 narrowings of the oesophagus?

A

Border of pharynx
Aortic arch = superior mediastinum
Left main bronchus = posterior
Oesophageal hiatus = posterior

67
Q

thoracic aorta boundaries?

Branches?

A

T4-T12

Paired = posterior intercostal and superior phrenic
Un paired = Bronchial, pericardial, oesophageal and mediastinal

68
Q

When does subclavian artery become the axillary?

Branches of subclavian artery?

A

When it reaches lateral border of first rib

1st part = Vertebral, internal thoracic and thyrocervical
2nd part = Costocervical
3rd part = Dorsal scapular

69
Q

What does thyrocervical artery arises from, and where?

A

From first part of subclavian, at inner border of scalenus anterior

70
Q

How does brachiocephalic veins form?

How do these go on to form SVC?

A

Subclavian and internal jugular veins unite.

Right brachiocephalic Is posterior to medial clavicle and descends

Left brachiocephalic is posterior to medial clavicle, crosses over to the right and joins the right brachiocephalic.

71
Q

What is the left superior intercostal vein formed of and where does it drain to?

A

Formed by 2/3/4 posterior intercostal veins
Passes over left side of aortic arch
Passes between the phrenic and vagus = medial to phrenic and lateral to vagus

72
Q

Where does azygous vein join SVC?

A

Immediately before it enters right atrium

73
Q

What are the key landmarks of the IVC?

A

Forms at L5 by merging of common iliac veins
L1-5 = lumbar veins join
L2 = right gonadal vein joins (left joins into the L renal vein)
L1 = supra-renal veins and renal veins join
T8 = Hepatic vein, inferior phrenic and pierces diaphragm

74
Q

Is IVC to the right or left of midline?

A

Right

75
Q

What forms the azygous vein?

A

Union of right ascending lumbar and right subcostal veins at L1/L2

76
Q

How do thoracic duct and azygous vein enter thorax?

A

Both enter via the aortic hiatus

Azygous is on the right, thoracic duct on left

77
Q

Does azygous vein pass anterior or posterior to right lung root?

A

Anterior, to join SVC

78
Q

How is the semi-azygous vein formed and how does it enter thorax?

How far does it ascend?

How far does accessory nerve descend?

A

Via left ascending lumbar and left subcostal vein joining

Pierces diaphragm at left crus

T9

T8

79
Q

Whats thoracic duct a continuation of?

Where does it enter thorax?

How is it related to oesophagus?

A

Cisterna chyli in abdomen

T12

Posterior to oesophagus on right, crosses to left at T5 (angle of Louis)

80
Q

Where do left and right side of head and neck drain?

A

Left > subclavian and jugular . joins thoracic duct prior to inserting in left brachiocephalic vein

Right side > Subclavian and jugular trunks > right lymphatic duct. > mediastinal trunk > right brachiocephalic vein

81
Q

Thoracic vertebrae poets of attachment for ribs?

A

three sites:

  1. Oval facet at ed of each transverse process articulates with tubercle of rib.
  2. x2 demifacets on inferior and superior vertebral body. Superior articulates with head of its own rib, inferior with that of rib below.

Anatomy for MRCS (7 decks)

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