DR. ARAVINDAKSHAN.G.K.
APPLIED ANATOMY OF THORAX
The following bony prominences can usually be
palpated in the living subject:
• superior angle of the scapula (T2)
• upper border of the manubrium sterni, the suprasternal
notch (T2/3)
• spine of the scapula (T3)
• sternal angle (of Louis)— the transverse ridge at the
manubrio-sternal junction (T4/5)
• inferior angle of scapula (T8)
• xiphisternal joint (T9)
• lowest part of costal margin—10th rib (the subcostal line
passes through L3).
• The manubrium
corresponds to the 3rd
and 4th thoracic vertebrae
and overlies the aortic
arch, and that the
sternum corresponds to
the 5th to 8th vertebrae
and neatly overlies the
heart.
• The spinous processes of all the thoracic
vertebrae can be palpated in the midline
posteriorly, but it should be remembered that the
first spinous process that can be felt is that of….
C7 (the vertebra prominens).
• The position of the
nipple varies
considerably in the
female, but in the male
it usually lies in the 4th
intercostal space about
4in (10cm) from the
midline.
• The apex beat, which
marks the lowest and
outermost point at which
the cardiac impulse can
be palpated, is normally
in the left 5th intercostal
space 3.5in (9cm) from
the midline (just below
and medial to the
nipple).
• The trachea is palpable in the suprasternal
notch midway between the heads of the two
clavicles. It commences in the neck at the level
of the lower border of the cricoid cartilage
and runs vertically downwards to end at the
level of sternal angle of Louis.
The Ribs
The chest wall of the child
is highly elastic and
therefore fractures of the
rib in children are rare.
The Intercostal Spaces
CHEST WALL
The sternum and the marrow biopsy.
Under a local anesthetic, a wide-bore
needle is introduced into the marrow cavity
through the anterior surface of the bone. The
sternum may also be split at operation to
allow the surgeon to gain easy access to the
heart, great vessels, and thymus.
THE RIBS
1. Rib fractures.
2. Cervical rib.
3. Rib excision.
4. Rib Contusion.
THE INTERCOSTAL
NERVES
1. Skin Innervation of the Chest Wall
and Referred Pain.
2. Herpes Zoster.
3. Area of Anesthesia.
Thoracic Vertebrae
• Fractures of the spine most commonly
involve T12.
• The cause is usually a flexion–
compression type of injury (for example,
a fall from a height landing on the feet or
buttocks, or a heavy weight falling on the
shoulders),
• If, in addition to compression, there is
forceful forward movement, one vertebra
may displace forward on its neighbour
below with either dislocation or fracture
of the articular facets between the two
and with rupture of the interspineous
ligaments.
• Moreover the bodies of T5 & T8 are worth
nothing; and have relation with the
descending aorta. If the descending aorta
becomes aneurysmally dilated, these four
vertebral bodies become eroded by its
pressure.
COSTAL CARTILAGES
1. Chest Cage Distortion.
2. Chest Trauma.
3. Flail Chest.
4. Fractured Sternum.
5. Traumatic Injury to the Back of the
Chest.
6. Traumatic Injury to the Chest and
Abdominal Viscera.
The Diaphragm
The diaphragm is the dome shaped septum
dividing the thoracic from the abdominal
cavity.
has two portions
1. peripheral muscular.
2. centrally placed aponeurosis.
The Diaphragm
• Openings in the diaphragm
The three main openings in the diaphragm are:
– 1 the aortic (at the level of T12) which transmits the
abdominal aorta, the thoracic duct and often the azygos
vein
– 2 the oesophageal (T10) which is situated between the
muscular fibres of the right crus of the diaphragm and
transmits, in addition to the oesophagus, branches of the
left gastric artery and vein and the two vagi
– 3 the opening for the inferior vena cava (T8) which is
placed in the central tendon and also transmits the right
phrenic nerve.
THE DIAPHRAGM
1.
2.
3.
4.
5.
Hiccup.
Paralysis of the Diaphragm.
Penetrating Injuries of the Diaphragm.
Rupture of the Diaphragm.
Acquired Herniae.
THE CLAVICLE AND ITS RELATIONSHIP
WITH THE THORACIC OUTLET
1. The Thoracic Outlet Syndromes.
Disappearance or re-duction of the pulse, and
possibly coldness and paleness of the hand,
would indicate that the subclavian artery is
being
compressed by
the scalene muscles
and/or the first (or cervical) rib.
THE BREASTS
1. Witch’s Milk in the Newborn.
2. Supernumerary and Retracted Nipples.
3. CA of breast.
4. Polythelia.
5. Micromastia.
6. Macromastia.
7. Gynecomastia.
THE MEDIASTINUM
A space in which is sandwitched in between the
two pleural sacs.
THE MEDIASTINUM
• Deflection of Mediastinum.
• Mediastinitis.
• Mediastinal Tumors or Cysts.
The pleura
• The cervical pleura can be marked out on the
surface by a curved line drawn from the
sternoclavicular joint to the junction of the
medial and middle thirds of the clavicle; the apex
of the pleura is about 1 in (2.5cm) above the
clavicle.
• The lines of pleural reflexion pass from behind
the sternoclavicular joint on each side to meet in
the midline at the 2nd costal cartilage (the angle
of Louis). The right pleural edge then passes
vertically downwards to the 6th costal cartilage
and then crosses:
• the 8th rib in the midclavicular line;
• the 10th rib in the midaxillary line;
• the 12th rib at the lateral border of the erector
spinae.
• On the left side the
pleural edge arches
laterally at the 4th costal
cartilage and descends
lateral to the border of
the sternum, due, of
course, to its lateral
displacement by the
heart.
THE PLEURA
•
•
•
•
•
•
•
•
•
•
Pleural Fluid.
Pleurisy.
Pneumothorax.
Haemothorax.
Empyema.
Pluritis.
Hydropneumothorax.
Pyopneumothorax.
Hemopneumothorax.
By a stab wound or surgical wound.
sternum
1. Injury
2. Aspiration for the bone marrow specimen.
3. Operations on the thymus gland
The intercostal spaces
1. Local irritation of intercostal nerves by such
conditions as Pott’s disease.
2. Intercostal nerve block.
3. Thoracotomy.
trachea
1.
2.
3.
4.
Tracheal tug.
Tracheostomy.
Tracheal displacement.
Radiological findings.
The lungs
• The apex of the lung
closely follows the line of
the cervical pleura and the
surface marking of the
anterior border of the right
lung corresponds to that of
the right mediastinal
pleura.
• On the left side, however,
the anterior border has a
distinct notch (the cardiac
notch) which passes
behind the 5th and 6th
costal cartilages.
• The lower border of the lung
has an excursion of as much
as 2–3in (5–8cm) in the
extremes of respiration, but
in the neutral position
(midway between
inspiration and expiration) it
lies along a line which
crosses the 6th rib in the
midclavicular line, the 8th rib
in the midaxillary line, and
reaches the 10th rib adjacent
to the vertebral column
posteriorly.
• The oblique fissure, which divides the lung into
upper and lower lobes, is indicated on the
surface by a line drawn obliquely downwards
and outwards from 1in (2.5cm) lateral to the
spine of the 5th thoracic vertebra to the 6th
costal cartilage about 1.5in (4cm) from the
midline.
• The line of the oblique fissure then
corresponds to the position of the medial
border of the scapula.
• The surface markings of the transverse fissure
(separating the middle and upper lobes of the
right lung) is a line drawn horizontally along
the 4th costal cartilage and meeting the
oblique fissure where the latter crosses the 5th
rib.
Clinical Anatomy of Lung
• Usually, the infectn of a segment remains
restricted to it, although some infections like
TB, may spread one segment to another.
resection of a bronchopulmonary seg.
removal of one lobe- Lobectomy
removal of whole lung - Pneumonectomy
• Tumour of upper lobe of lung causes certain
press. Effects
-venous engorgement & oedema of face &
upper limb
-Diminished pulse
-Paralysis of the cupola
-Hoarseness of voice etc.
• Breath sounds from the upper lobe are best
heared infront & those from the lower lobe
best heared on the back.
• The middle lobe does not reach the chest wall
behind & auscultated infront b/n 4th and 6th
ribs.
• Breath sounds from all lobes are heared along
the mid-axillary line.
• Ds.s, such as silicosis, asbestosis, cancer and
pneumonia interfere with the process of
expanding the lung in inspiration.
bronchi
1. Aspiration of foreign bodies.
2. Widening & distortion of the angle between
the bronchi.