Lecture 17: Thoracic wall; Pleura and Lungs Diaphragm Flashcards Preview

Block 2 Gross > Lecture 17: Thoracic wall; Pleura and Lungs Diaphragm > Flashcards

Flashcards in Lecture 17: Thoracic wall; Pleura and Lungs Diaphragm Deck (155):
1

What comprises the osseous (bony) part of the thoracic wall

Vertebral column, ribs, and sternum

2

What are the other non-osseous structures in the thoracic wall

muscle, cartilage, fibrous tissues

3

Compare the shapes of the thoracic cavities in adults and children

Adult- Oval
Child- Circular

4

What are the boundaries of the thoracic inlet

Clavicles, sternum, first ribs, and vertebral column

5

Which aspect of the thoracic inlet is higher, the dorsal or ventral

Dorsal is higher than ventral

6

What is the dorsal landmark of the thoracic inlet

T1

7

What is the ventral landmark of the thoracic inlet

Manubrium of sternum

8

Is T1 higher or lower than the manubrium of the sternum

higher

9

What does the difference in ventral and dorsal heigh of the thoracic inlet allow

Allows the apical portion of the lungs to rise into the root of the neck.

10

Why is it important to know that the lungs can extend into the root of the neck?

As physician- patient comes in with neck injuries, need to check if lungs are good

11

Boundaries of thoracic outlet

Inferior- diaphragm
Posterior- T12
Lateral- Ribs 10-12
Anterior- Costal cartilages of ribs 7-10
As well as the junction between the body and xyphoid process of sternum

12

Which is wider the thoracic inlet or outlet

outlet

13

Jugular notch (or suprasternal notch)

notch at the midline of the manubrium

14

Sternal angle or Angle of Lewis

Acute angle that forms when the manubrium meets the sternal body

15

What is the clinical significance of the Angle of Lewis

The angle is easily palpable on all patients and is an important landmark for physical exams for using a stethescope

16

What are the vertebral levels of the Angle of Lewis

T4-5

17

Which costal cartilage attached the the sternal body inferior to the sternal angle?

Costal cartilage of rib 2 **Important landmark for clinical exams**

18

Describe the movements of the costosternal articulations

gliding type

19

At what vertebral level does the xiphoid process attach to the sternal body

T10

20

What is the most commonly fractured site on the sternum

sternal angle

21

Why are fractures to the sternum more common in kids than adults

Because in kids the sternum is not completely fused together (broken into segments) verses the adult sternum which is completely fused together

22

Why are features to the sternum uncommon

Forces at the sternum are dissipated into the ribs, which are not as strong as the sternum causing those to break instead

23

What injuries should you be concerned about if a patient comes in with a fractured sternum

diaphragmatic lacerations, herniation of abdominal contents into the thoracic cavity, heart trauma.

24

True ribs

Ribs 1-7: Ribs that have costal cartilages that attach directly to the sternum

25

False ribs

Ribs 8-9: Ribs have costal cartilages that attach to the superior adjacent costal cartilage.

26

Floating ribs

Ribs 11-12: These are a type of false rib. These ribs have no anterior articulation but still articulate posteriorly to the vertebral bodies and transverse processes

27

Why is it important to know which ribs are directly connected to the sternum

Because if a patient suffered a blow to the sternum you know you should look for breaks in the true ribs since theses are the ribs that dissipate the force

28

Know the anatomy of a typical rib

USE YO BONE BOX

29

Typical rib

2 facets with articulate with the same numbered vertebrae and with the vertebra superior to it. lateral the hear is a constricted area called the neck. An articular tubercle lies just dorsal to the junction of the neck and the rib body. The anterior sternal extremity is roughened to allow for the attachment of a costal cartilage. Superior surfaces of the ribs are round and smooth. Inferior surface is grooved

30

How are the neruovascular bundles arranged in the intercostal spaces

Inferior to a rib (VAN)- Vein, artery, nerve

31

When a patient suffers force to the side of the body and fractures a rib, what would you expect to see/feel from the fracture

May not be able to palpate the fracture but there could be a puncture into the pluera or lung

32

When a patient suffers force front the front of the body to the back (or vice versa) and fractures a rib, what would you expect to see/feel from the fracture

Would be able to palpate the fracture. Wouldn't be as worried about damage to the thoracic wall

33

What connects the costal cartilage to the sternum

ligatments

34

What attaches the bony part of the rib to its costal cartilage

fibrous tissue

35

What is it called when the ligaments or fibrous tissue of the ribs is inflamed

Costochondritis

36

Why is it that people with back injuries have trouble breathing

because the ribs articulate with the vertebral column. Also after open heart surgery, many patients complain of back pain due to the forces appiled to the posterior attachments of the ribs because of cutting the sternum and retracting the rib cage.

37

What may occur if there is an obstruction (or coarctation (or narrowing)) of the aorta

Rib notching

38

Explain the mechanism of rib notching

When the aorta is constricted, pressure builds which causes the intercostal arteries to form "squiggles" resulting in notches to form on the inferior border of ribs

39

Why does rib notching occur on the inferior border of the ribs

because that is where the neuromuscular bundles lie

40

Why is it important to know that the neurovacqlar bundles are inferior to the rib?

Because when you need to insert a chest tube into a patient you need to make sure you puncture the intercostal space region without hitting the neuromuscular bundle

41

What are the consequences of hitting the neuromuscular bundle with a chest tube

hemothorax- blood will seep out of the vessels and into the lungs

42

Will we see rib notching taking place is collateral circulation is being utilized to to malfunctions in other arteries

Yes because more blood is being forced through these vessels, resulting in a greater build up of pressure and thus leading to notches in the inferior borders of the ribs

43

What is special about the first rib

It is the highest, widest, strongest, flattest, shortest, and most curved rib

44

Where does the first rib lie

Almost completely beneath the clavicle

45

What attaches to the undersurface of the first rib

subclavius m. and costoclavicular ligament

46

What may be the first sign of cancer in the breast or prostate gland and why

rib pain may be a first sign because ribs are frequent sits of metastisis

47

Why are rib fractures less common in children

The rib cage is more flexible at younger ages

48

What other injuries are rib fractures associated with in general

hemothorax and pneumothorax

49

What injuries are associated with lower rib fractures

tears in diaphragm

50

What are the two categories of costovertebral articulations

1. Articulations of the rib heads with one or two vertebral bones
2. Articulation of rib necks and tubercles with vertebral transverse processes

51

What type of joint does a typical rib form with a articular facet on the dorsolateral margin of 2 adjacent vertebra? And also between the articular surface of the tubercles and neighboring transverse processes.

Sliding joint

52

What are the ribs with costotransverse process articulations

ribs 1-10

53

For the true ribs, what type of joint is present between the costal cartilage and the sternum

Sliding (EXCEPT FOR THE FIRST RIB)

54

What is the type of joint present between the costal cartilage of the 1st rib and the sternum

synovial joint

55

What are the names of the 3 intercostal muscles

External and internal intercostal muscles, and innermost intercostal muscle

56

Which muscle comprises the most superficial layer of the intercostal space?

enternal intercostal m

57

What direction do the fibers of the external interacts muscles travel

from lateral to medial (same direction as the external oblique)

58

In which direction (anterior or posterior) is the external intercostal m. membranous and muscular

Membranous- anterior
Muscular- posterior

59

How are the internal intercostal muscle fibers arranged relative to the external intercostal fibers

Perpendicular to external intercostal m.

60

In which direction (anterior or posterior) is the internal intercostal m. membranous and muscular

Membranous- posterior
Muscular- anterior

61

Where do the internal intercostal muscles arise and end?

Arise at the sternum and extend to the midaxillary line (love handle side) where it ends in a membrane

62

What is unique about the membrane and muscular patterns of the internal and external intercostal muscles

They alternate, allowing you to differentiate between the two muscles without reflecting back a layer of the external intercostal muscles.

63

What muscles are deep to the internal intercostal m.

The innermost intercostal muscles

64

Where are the innermost intercostal muscles located

Only at the midaxillary line (peters off at the enters anteriorly and posteriorly)

65

What muscles are located in the same plane as but are more posterior to the innermost intercostal muscles

transversus thoracis muscles

66

Function of the transversus thoracic muscles

Hold the internal thoracic (mammary) vessels in place

67

How are the internal, external, and innermost intercostal muscles innervated and supplied

By their respective neuromuscular bundle

68

Action of the intercostal muscles

Involved in inspiration and expiration: At one point it was thought that the external muscles were involved in inspiration and the internal where involved in expiration

69

Do the true ribs and the false ribs move in the same directions during inspiration and expiration to expand and compress the chest cavity

No

70

For the true ribs, what motion do the ribs along with the sternum move during inspiration and expiration

Like a pump handle (Anterior to posterior) to increase the A-P diameter of the chest.

71

For the false ribs, what motion do the ribs along with the sternum move during inspiration and expiration

Like bucket handle which increases the width of the lower rib cage

72

What dimensions of the chest cavity does the diaphragm enlarge during expiration and inspiration

the vertical dimensions

73

What are the 2 main arterial supplies to the thoracic wall

The intercostal a. and the beaches coming off of subclavian and axillary arteries

74

Where do the posterior intercostal arteries arise from for the lower 9 intercostal spaces

the thoracic aorta

75

What are the upper 2 branches of the intercostal spaces on the posterior supplied by (since the lower 9 we know are supplied by the posterior intercostal a)

superior intercostal a

76

What is the superior intercostal a a branch of

axillary a (block 1)

77

What do the posterior intercostal arteries anastomose with

The anterior intercostal a.

78

From what vessel do the anterior intercostal a. arise from

The internal thoracic a.

79

What do the anterior intercostal arteries supply?

The intercostal spaces and overlaying skin

80

At what intercostal space does the internal thoracic artery divide

6th

81

What are the two branches of the internal thoracic a and where are they located

Musculophrenic a- thorax
Superior epigastric a- abdomen

82

What is the internal thoracic artery a branch of?

Subclavian a

83

Is an intercostal nerve also considered a ventral rami?

Yes (just given the name intercostal nerve due to its location)

84

What does the posterior primary rams supply in the thorax

Intrinsic back muscles and skin

85

Where does the ventral rams course in the thorax

Along the chest wall between the innermost intercostal m. and the internal intercostal m.

86

When does the ventral ramus give off its lateral branch

At the midaxillary line

87

What are the terminal branches of the lateral branch of the ventral ramus

porterior and anterior

88

What does he lateral branch of the ventral ramus innervate

The overlaying muscle and skin

89

Where are the terminal branches of the lateral branch of the ventral ramus given off to

overlaying skin

90

When does the ventral rams give off its anterior terminal branch

At the lateral border of sternum

91

What do the anterior terminal branches of the ventral rami innervvate

overlaying skin

92

What are the 2 different branches of the anterior terminal branch of the ventral rami

lateral and medial branches

93

What skin does the lateral and medial branches innervate?

The lateral and anterior respectively

94

What are the 3 groups of lymph nodes in the thorax

Pectoral nodes, axillary nodes, and internal thoracic nodes

95

Which lymph nodes are commonly associated with breast tumor metastasis

Internal thoracic nodes

96

Pleura verses peritoneum

Same concept except pleura is in the thoracic cavity verses peritoneum which is in the abdomen

97

Parietal and Visceral pleura

Visceral- touches the lungs
Parietal- Surrounds the inner wall of the thorax, diaphragm, and lateral structures of mediastinum

98

Pleural cavity

Space between the visceral and parietal peritoneum. Serous fluid and no air present

99

What is the condition where an individual has air in the pleural cavity

pneumothorax

100

How is parietal pleura named

Based on its location, for example, the mediastinal pleura, diaphragmatic pleura

101

What is the one part of the pleura that protrudes outside of the thoracic region and above the clavicle

Cupula- pleura over the apex of the lung and extends into the root of the neck

102

Costodiaphragmatic recess

Reflection of parietal pleura off the diaphragm into the inner chest wall. This is the lowest point in the pleural cavity. Located between the ribs and diaphragm

103

What is the name of the condition where the pleural cavity is compromise and blood enters the lungs

Hemothorax

104

Where does the apex of the lung protrude into?

Above the first rib and clavicle into the root of the neck

105

Where does the base of the lung rest

Superior surface of diaphragm

106

What are the two major surfaces of the lungs

Costal surface and mediastinal surface

107

Costal surface of the lings

Lies against the inner surface of the rib cage

108

Where is the mediastinal surface located

Adjacent to the heart

109

What is located on the mediastinal surface of the lungs

hilum

110

What enters and leaves the hilum and in what order

(Alpha order): ABV: Artery, bronchi, and vein. The artery and veins are pulmonary arteries in veins. This goes from highest to lowest (most superior to inferior)

111

What is unique about the pleura at the hilum

The visceral pleura is continuous with the parietal

112

How many lobes does each lung have? How many fissures?

Right- 3 lobes 2 fissures
Left-2 lobes 1 fissure

113

What are the names of the 2 fissures for the right lung

-Oblique (major)
-Horizontal (minor)- separates the superior from the middle lobe

114

What's the name of the fissure for the left lung

-Oblique (major)

115

What are the names of the 3 lobes of the right lung

-Superior, middle, inferior

116

What are the names of the 2 lobes on the left liver

Superior and inferior

117

Where could you put a stethoscope to hear the superior lobe of the right lung

On the anterior thoracic wall not bellow the sternum

118

Where could you put a stethoscope to hear the middle lobe of the right lung

At the Xiphoid process of the sternum

119

Where could you put a stethoscope to hear the inferior lobe of the right lung

On the back

120

Where could you put a stethoscope to hear the superior lobe of the left lung

Front at the xiphoid

121

Where could you put a stethoscope to hear the inferior lobe of the left lung

On back can go pretty high or low

122

Make sure you look at radiographs of the lungs and can differentiate where each lobe is

Okay

123

Look at slide 35 to see that different places where you put a stethoscope to hear the different lobes of the lungs

Okay

124

When looking at the hilum of the longs other than where things are oriented, how can you tell what each hole is

By looking at the thickness of the walls. Bronchi have very thick walls and the vessels are much thinner

125

What is the cardiac notch and which lung has it?

The cardiac notch is the place where the lateral border of the left ventricle has made contact with the lung. This is on the left lung

126

What is the candy cane looking impression on the left lung

Groove for the descending aorta

127

From the anterior, lateral, and posterior views, do the lungs and pleura extend down to the same height

No

128

From the anterior view, what rib do the lungs extend to?

Rib 6

129

From the lateral view, what rib do the lungs extend to?

Rib 8

130

From the posterior view, what rib do the lungs extend to?

Rib 10

131

From the anterior view, what rib does the pleura extend to?

Rib 8

132

From the lateral view, what rib does the pleura extend to?

Rib 10

133

From the posterior view, what rib does the pleura extend to?

Rib 12

134

Knowing the extent of which the lung and pleura can extend follows what rule

the rule of twos

135

Why is it important to know where the lungs and pleura extend

For pleural taps (example taking a needle and placing is inferior to rib 8 and posterior to rib 10 would be good from the lateral)

136

What delivers deoxygenated blood to the lungs?

Pulmonary arteries

137

What is the arterial supply to the lungs

bronchial a.

138

Where do the bronchial a. deliver oxygenated blood to

parenchyma

139

What returns oxygenated blood to the heart

Pulmonary veins

140

What innervates the lungs and pleura

vagus n and the sympathetic nerve plexus

141

Do the lungs receive parasympathetic or sympathetic innervation

Both

142

Is the innervation to the pleural autonomic or somatic

Both

143

What provides somatic innervation to the pleura

intercostal n, and the phrenic n.

144

Which part of the diaphragm is normally higher and why

The right because of the large liver

145

What comprises the periphery of the diaphragm and the center

Periphery- Skeletal muscle
Central- Tendinous (Central tendon)

146

What arteries supply the superior surface of the diaphragm

Musculophrenic a (branch of internal thoracic a, pericardiophrenic a

147

What supplies blood to the inferior surface of the diaphragm (Abdomen)

The inferior phrenic a.

148

What nerve fibers innervate the diaphragm along the periphery

The intercostal n.

149

Do intercostal nerves supply sensory or motor innervation

sensory

150

What innervates the central portion of the diaphram

Phrenic n (C3,4,5)

151

Does the phrenic nerve provide sensory or motor innervation?

Both

152

Where does the phrenic give off sensory innervation? Motor innervation

Sensory- Central tendon
Motor- muscles of diaphragm

153

Where does the inferior vena cava go through the diaphragm and why is this important?

At vertebral level T8 through the Inferior vena naval foramen. This foramen is located in the central tendon which is important because the IVC would be constricted each time the diaphragm contracted if it were located in the muscle

154

Where does the esophagus go through the diaphragm and why is this important?

Through the esophageal hiatus at vertebral level T10. The hiatus is formed by two cura of the diaphragm. Here we want to have the esophagus surrounded by muscle of the diaphragm to create a sphincter

155

Where does the aorta go through the diaphragm and why is this important?

At vertebral level T12 through the aortic hiatus. The aorta crosses posterior to the diaphragm and is therefore unaffected by contraction of the diaphragm.