Thorax Dr.

Tan Yee 09-14-12 THORAX superior part of trunk located below neck and above the abdomen thoracic cavity confined within the thoracic wall THORACIC CAVITY DIVIDED INTO: 1. Pulmonary Cavity 2. Mediastinum Divided by transthoracic line ,located at the angle of Louis at the level of T3-T4 intervertebral space Extends superiorly from the superior inlet to the diaphragm inferiorly Anteriorly it starts in the posterior wall of the sternum up to thoracic vertebra 1. Superior Mediastinum CONTENTS: Superior vena cava Brachiocephalic vessels Distal part of the Trachea Esophagus Arch of the aorta Vagus nerve Left recurrent laryngeal nerve Remnant of the thymus gland Thoracic duct 2. Inferior Mediastinum - compartments are separated by pericardium (pericardium contains root of great vessels, heart, root of azygous vein and aorta) 1. Anterior (Contents: structures located in the thoracic cavity except lungs) 2. Middle(Contents: Main Bronchi) 3. Posterior(Contents: Esophagus, sympathetic chain, thoracic duct, hemi and accessory azygous)

Parietal Thoracic (Endothoracic) Fascia- thin layer of connective tissue 1. Lines the internal intercostal; subcostal; transverse thoracis M. 2. Blends with periosteum of ribs and sternum and costal cartilage Pleura 1. 2.

Visceral invests the lungs Parietal Pleura- lines the thoracic cavity ****Pleural cavity-potential space, between visceral and parietal pleura THORACIC CAVITY Capillary layer of serous pleural fluid

Constantly moving dynamic region of the Body

pyramidal shape, inserted at rib 1)

inferior

portion

CONTENTS 1. 2. 3. 4. 5. 6. 7. Heart and vessels lungs distal part of the trachea most of the esophagus thoracic duct nerves constantly moving- dynamic region of the body

THORACIC APERTURES 1. Superior thoracic Aperture/ thoracic inlet BOUNDARIES POSTERIORLY- first thoracic vertebra LATERALLY-first pair of ribs and costal cartilages ANTERIOR-suprasternal notch or jugular notch,superior border of manubrium sterni Inclined anteriorly Kidney shape if you look from above 6.5cm 12 cm on both sides Hylum thoracic vertebra Partly protected by SUPRAPLEURAL MEMBRANE (SIBSONS FASCIA-arises from transverse process of C7,

INFERIOR THORACIC APERTURE BOUNDARIES POSTERIOR- T 12 LATERAL 11,12 ribs; ANTEROLATERALY-costal cartilages of 7-10 ribs ANTERIOR-xiphisternal junction Covered by diaphragm with several openings that transmit organs from thorax to abdomen THORACIC WALL CONSISTS OF 1. 2. 3. 4. 5. 6.

skin fascia muscles vessels and nerves bones lined internally by thoracic fascia/pleura

parietal

FUNCTIONS 1.

Protects the contents of the thoracic cavity

2. 3.

4.

Provide mechanical function for breathing Attachment of muscles acting on upper limbs, neck muscles and abdominal muscles Hematopoeisis (Flat bones)

RIBS 1.

TYPICAL RIBS

BONY THORAX ( thoracic cage ) -FORMS AN OSTEOCARTILAGENOUS CAGE 1. 12 pairs of ribs 2. Costal cartilages (connects ribs to sternum) 3. 12 thoracic vertebrae and IV discs 4. Sternum SHAPE OF THE BONY THORAX 1. BIRTH TO 2 Y/O- circular/barell shape (Infants are diaphragmatic/ obliged abdominal breathers) ADULT- flattened from anterior to posterior 2. SPECIAL RIBS

2.

RIBS AND COSTAL CARTILGES TYPES 1.

2.

3.

TRUE RIBS(1-7 RIBS) - Costal cartilages directly attached to sternum FALSE RIBS(8-10 RIBS) - Indirectly attached to sternum - Their cartilages are attached to superior cartilage FLOATING RIBS(11,12 RIBS) - free ends are embedded w/in the posterior abdominal muscles

Typical ribs: Features - has a neck, tubercle, shaft, angle and costal groove Facets separated by crest of the head (The crest is an attachment of interventricular ligaments that are connected to IV disc) Superior Facet: connected just above the vertebra where the inferior facet articulates) Inferior Facets: articulates with numerical corresponding vertebra Neck 1 inch long, with ridges, connected to the body at the level of the tubercle,

COMPONENTS OF TUBERCLE

Non articulating- superiorly placed , rough (attachment of the lateral costo transverse ligament ) Articulating - inferiorly placed - transverse process of numerical corresponding vertebra), Body Curved and twisted, flattened from inside to outside, Has inner and outer surfaces, groove in the inner surface aka Costal groove protects neurovascular structures (VAN Veins, Arteries, Nerves) Terminal end tear drop shape, concave anteriorly to accommodate corresponding vertebra. Special Ribs/Atypical Ribs:

Tubercle which corresponds to the angle of the rib The shortest and the toughest among the true ribs Flattened from above downward Superior surface scalene tubercle or Lisfranc tubercle (attachment of scalene anterior) Superior surface has 2 grooves: for subclavian vein and artery (scalene anterior separates this vessels) Rough part: Insertion of scalene medius, origin of serratus anterior 2. Floating Ribs 10th, 11th and 12th rib 1 facet on their head and the costal groves especially in 11th and 12th is absent 11th and 12th dont have tubercle, T11 and T12 transverse process also no facet 10th rib uncertain rib the terminal end not attach to the costal cartilage(sometimes attached, sometimes unattached) ACCESSORY RIBS CERVICAL RIB arising from the tubercle of the transverse process of c7 occurs in 0.5% (Snell) 1% (Moore)of persons anterior end- maybe free; may be attached to the 1st rib by a fibrous band; may articulate w/ the 1st rib becomes clinically significant causing pressure on lower trunk of brachial plexus-( THORACIC OUTLET SYNDROME)- pain on medial aspect of forearm and hand; atrophy of hand may compress subclavian vessels

1. 1st ribs Has head but with 1 articular facet Has a very long neck and an angle that corresponds to the area where you can find your tubercle(Typical Ribs: Angle is located just anterior to the tubercle or where the maximum angle is found)

THORACIC VERTEBRAE Special features: 1. costal facets on the body for articulation w/ the head of the rib 2. costal facet on transverse processes except for inferior T11,T12

3. long spinous process 4. heart shaped body

CLINICAL CORRELATION: THORACIC OUTLET SYNDROME - consists of a group of distinct disorders that affect the brachial plexus (nerves that pass into the arms from the neck), and/or the subclavian artery and vein (blood vessels that pass between the chest and upper extremity) for the most part, these disorders are produced by compression of the components of the brachial plexus (the large cluster of nerves that pass from the neck to the arm), the subclavian artery, or the subclavian vein subtypes are referred to as neurogenic TOS, arterial TOS, and venous TOS

STERNUM occupy the middle part of anterior wall of the thoracic cage PARTS: MANUBRIUM STERNI - thickest and most massive part of the sternum 3 indention superiorly: jugular notch/ suprastrenal notch, clavicular notch (Below clavicular notch is a facet- accommodates the 1st costal cartilage. - 2 inches in length - T2-T3 vertebra - compared to a roman sword BODY 4 separate sternebrae (before birth) After birth, it fuse as one (presence of transverse ridges) Angle of Louis/Ludwig(Thorek) junction of body and manubrium Sides has 6 facets for the cartilages the 2nd to 7th ribs

Compression may be positional (caused by movement of the clavicle (collarbone) and shoulder girdle on arm movement) or static (caused by abnormalities or enlargement of the various muscles surrounding the arteries, veins and brachial plexus).

XIPHOID PROCESS - cartilaginous, ossified/incompletely ossified in later life - appearance may be prominent/embedded in the muscles of he abdomen - sometimes they may be bifid

FLAIL CHEST - a life-threatening medical condition that occurs when a segment of the chest wall breaks under extreme stress and becomes detached from the rest of the chest wall - it occurs when multiple adjacent ribs are broken in multiple places, separating a segment, so a part of the chest wall moves independently - 1 rib fracture is not clinically significant but a multiple fracture of 2 points (1 anterior and 1 posterior/lateral) it will be clinically significant

Fracture of ribs results in paradoxical respiration (Part of fracture will be sucked in when inspiration)

1. STERNUM AND MARROW BIOPSY 2. CARDIAC SURGERY Windows to the heart ANATOMIC CHANGES WITH AGING 1. rib cage-rigid and loss of its elasticity (resulting to poor respiration) 2. kyphosis- DECREASES CHEST CAPACITY

ANATOMIC CHANGES THORACIC CAGE DISTORTION 1. congenital anomalies of vertebral column or ribs 2. destructive disease of vertebral column producing lateral flexion 3. scoliosis