Tranatomy: Thorax 2012 | Page 1 of 8

  

THORAX SKELTON (Ribs + Vertebrae + Sternum) Ribs

True (1-7)

Typical (3-9)

Anatomical

Articulation

False (8-9±10)

Atypical (res)

Floating (11-12±10)

Typical Ribs

Atypical Ribs

  Costal Cartilages length from 1-7 length from 8-12 Intercostal Spaces Defined by rib making SUPERIOR border 11 spaces + subcostal space

Vertebrae Independent Typical T2-9

Body Arches

7 Processes Specific Properties of THORACIC Vertebrae Costal facets on body(bilateral, sup & inf, as demifacets, art with head of rib) Costal facets on transverse process (art with tubercle of same rib) Long spinous processes

Sternum

    

No Neck No Tubercle

 

T1:Art with Rib 1

Atypical (no demi facets)

T10: Art shared on body & pedicle

T11, 12: Art on pedicle

 

 

Tranatom

  

THO TH BordeSuperiInferio JO Costov

Sterno Other MU Access

Muscle Serr Po

Serr Po

LevatorCostaruExt IC Int IC Inm IC Subcos

TransveThoraciSP (spinInto (int1Btwn tu2During3Near a

my: Thorax 2012 | Page 2 o

ORAX

HORACIC APERTU

rs Post Aior T1 J

or T12 X

INTS (costoverte

vertebral Head of rib DemCostotransverse (ri1. Costotransve2. Lateral Costo3. Superior Cos

Movements Pump Hand Bucket Hand

ocostal Rib 1 = tight synchRib 2 to 7 = loose

Joints Xiphisternal (synchManubrosternal (sySternoclavicular (sa

USCLES

sory Muscles

Sup Attacost Sup SP C7 to T

ost Inf SP T11 to

r um

TP T7 to 1

Inf borde

tal Internal su

ersus is

Post lowesternum

nous process) TP (tranterosseous part) Intc (ubercle & angle g forced inspiration angle

Co

 

of 8

URES

Ant ug Notch

Xiphisternal Jt

ebral & sternocosta

mifacet of vert bodib to transverse proerse: neck of rib otransverse: tubercstotransverse: crest

le: Ribs 1 dle: Ribs 7

ondrosis (with clavsynovial

hondrosis) ymphysis) addle)

Pec Major Pec Minor Serratus Ant Scalenes1

ch Inf AttacT3 2nd to 4t

border L2 8th to 12t

border 11 Subjacen

er of ribs Sup borbe

urf ribs3 Sup bord3rd rib be

er Int surf c2 to 6

nsverse process) IC (int(intechondral part)

ostal groove (sup to inVein Artery Nerve

Lateral 1st Ribs 11th - 12th Ribs & 7th

al)

dy above and @ levocess)

cle of rib t of neck (to TP abo

to 6 to 12

vicle as well)

terior

ch Innervah ribs sup 2nd to 5

th rib inf Ant ramT12

nt ribs1 Post raT11

rder of rib elow

Ider 2nd or elow costal cart

tercostal)

f)

h - 10th Costal Cart

vel of

ove)

1Fix 1st & 2nd Ribs

ation Action 5th IC Proprioce

(elevate)mi T9 to Proprioce

(depress)mi C8 to Elevate ri

C

Elevate ri

Into: depIntc: elev

Depress (weakly)

eption

eption ) ibs

ibs2

press vate

ribs

NE 12 pairs Typical LocatioInitial Angle o

MAL AnterioSternum

Atypica T1

T1, 2 T2 3

T7-11 VA ArteryPosterioIC AnterioIC

Subcos

1Branch2Runs w3Muscu

 

ERVES

s of thoracic spinal nerExit as mixed nerve thAnt rami T1-11 IntePost rami hts, deeo

IC Nerves (3rd to 6th)on Position

Endothorof Rib Btwn int

or Rib m Pass btwn

to form a

al IC Nerves Property Branches into sSuperior BraInferior no aCourse along inIntercostobrachBranch @ MALCross costa ma

ASCULATURE

Origin or Space 1-2 Sup

Space 3-11 Tho

or Space 1-6 Int TSpace 7-9 MP3

tal Thoracic Ao

h of Subclavian with post ramus supplyulophrenic, branch of I

Course of Int. thoracic1. Branch of Subc2. Phrenic nerve 3. Desc post to c4. Desc ant to tra5. Terminate in 6

IC vein 11 B2, 3 4 S4-11 H 11 poste Anasto Receive

plexus)

rves hen separate into ant/prcostal Nerves (T12 = o back muscles, skin o

acic fascia innermost IC

n costal cartilage nt cut branches

uperior (large) and infchial plexus nt cut (often no lat cu

nternal surface (not grhial nerve (large lat cut pierce Serr Ant rgin just after MAL an

IC1

oracic Ao Poster Collate All ana

horacic1 Supply Travel Spaces Spaces Spaces Spaces Course Supply

ying cord, column, bacnt Thoracic

c artery clavian on inf border crosses near origin lavicle & 1st rib

ansversus thoracis th space by branching

st draining part Brachiocephalic Sup IC vein Hemi/azygous erior IC veins + subcosmose with ant IC veinses from post branch of

post rami subcostal nerve)

on back

Notes (btwn parietal pleura gives off collateral brasuperior border of rib gives off lateral cutan Supply Skin

ferior (small)

ut) roove) t)

axilla/arm nd become thoracoabd

rior branch2 eral branch runs alongastomose @ MCL withy anterior upper 9 spaalong margins of ribs

s 1,2 lie in endothoracs 3-6 separated by tras 7-9 from MP3 s 10-11 absent e along inf border of 1y to muscles of ant/lat

ck muscles, skin

g into superior epigast

2nd drain SVC SVC SVC

ostal vein s

of IC vein and vertebra

& int IC membrane) anches that travel alonbelow eous branch

dominal nerves

g sup border of rib h ant intercostal arterieaces s above & below ic fascia

ansversus thoracis

12th rib t abdo wall

ric & musculophrenic

l branch (draining ver

 

ng

es

arteries

rtebral

  

Tranatomy: Thorax 2012 | Page 3 of 8

  

THORAX BREASTS Properties Suspensory ligaments 15-20 lobules per mammary gland Drains into ducts into sinus Sebaceous glands in areola

Base 2/3 Pectoral fascia | 1/3 Serratus Anterior Separated from fascia by retromammary space Location 2nd to 6th ribs & Axillary process

Vasculature Arterial Arteries Origin Medial Mammary

Internal Thoracic Perforating Branches Anterior IC Lateral Thoracic Axillary Thoracoacromial Posterior IC Thoracic Ao

Lymphatic Nipple, areola, Lobules (from subareolar lymphatic plexus) Drainage area Lateral Medial Inferior Axillary nodes1

> 75% Parasternal nodes2

< 25% Inf phrenic nodes

< 25% Clavicular Subclavian

Trunk Bronchomediastinal

Trunk

Variable Termination

Merge and into r lymphatic duct Merge into thoracic duct Independently into r or l venous angle

1 From pectoral nodes or directly Sometimes interpectoral, deltopectoral, supraclavicular, inf deep cervical 2Or opposite breast

Skin (except nipple & areola) Ipsilateral axillary, inferior deep cervical, infraclavicular nodes Bilateral parasternal nodes

 Nerves Ant & lateral cutaneous branched of 4th to 6th IC

         

SURFACE ANATOMY Clavicle Landmark for lymphatic drainage Above inf jugular nodes Below axillary nodes Landmark Body Disc Cartilage Underlying Structures Jugular Notch T2 (inf border) Manubrium T3-4 body Arch Ao on left/SVC on right 3rd SVC into RA Sternal Angle T4/5 Body T5-9 body Xiphisternal Jt T9 (inf border)

 

Venous Mostly axillary Some to internal thoracic

 

Lines Defining Feature AML Middle of anterior surface MCL Middle of Clavicle AAL Inferolateral border of Pec Major MAL Middle of axilla PAL Lat dorsi & Teres Major PML Middle of posterior surface SL Inferior angle scapula

 

Tranatom

  

THO TH Pleurae

Lines of

VASCU Pulmon Pulmon

Bronch

Bronch

my: Thorax 2012 | Page 4 o

ORAX

HORACIC CAVITY

e

f Pleural Reflection Sternal: costal meets mCostal: costal meets dDiaphragmatic: Vertebral: costal meet

LATURE OF LUNGS &

nary Arteries Pulmonary trunk fromSuperior lobar arteriePosterolateral to mainBecomes L inferior lobBranches with bronch

nary Veins Superior & Inferior L &Run indep of arteries Visceral pleural and b ie deoxygenated (Parietal pleural drains

ial Arteries Nutrition for lung roo

Left: 2x Right: 1

Branch to upper oesoDistal branches anasto

ial Veins Drain small portion ofDrain small portion of

R bronc L bronc

of 8

Y

mediastinal diaphragmatic

ts mediastinal

& PLEURAE

m RV branches into R &s arise before enteringn bronchus as it entersbar and R intermediat

hial tree (usually anteri

& R pulmonary veins (& bronchi

bronchial venous circulnot central and perihi

s to systemic veins in t

t, visceral pleura, suppx from thoracic Ao x from R 3rd Post IC (s

ophagus then travel poomose with pulmonar

f bronchial arteries (mf oesophageal veins chial vein azygous chial vein hemiazyg

1. Starts a 2. R & 3

 

 

& L @ sternal angle g hilum s lung e lobar or to)

(R middle lobe vein is

lation drain into pulmolar regions) horacic wall

portive tissue

sometimes Ao) osterior to bronchi to ry arteries in bronchio

ainly prox root)

gous or left superior IC

at Apex, travels inferom

& L meet at AML @ 2n

3a. L courses horizonta margin then costal m

3b. R follows costal

4. MCL @ 8th rib

5. MAL @ 10th rib

6. Horizontal po

7. Rises to T1

NB Eof p Thfasci Thphre

tributary of R superior

onary veins

supply them les

C

medial behind SCJ

nd rib (sternal angle)

ally @ 4th rib to left stemargin to 6th rib

margin to 6th rib

b

osteriorly to T12

Endothoracic fascia ouarietal pleura

icker at apex as supraa

inner at diaphragm asenicopleural fascia

r)

LUNG A Overvie Right L

Left Lun

 

TRACH GeneraTracheaMain BLobar BSegme

ConducTerminAlveolaAlveolu LUNG L Pulmon

(D

ernal

utside

apleura

s

ANATOMY

ew 3 surfaces: costal, med3 borders: Ant, Inf, Po

ung Superior, Middle, InfeSeparated by oblique

ng Superior, Inferior lobeSeparated by obliqueLingula represents an

EOBRONCHIAL TREE

ation a ronchi Bronchi ntal Bronchi

cting Bronchioles al Bronchioles

ar duct us

LYMPHATICS

nary Lymphatic Plexus

Lung parenchyma & Visceral pleura

Superficial Plexus Deep to visceral pleura

Bronc

Superior & Infe

(aro

R & L bro

Right Venous angle Or R lymphatic duc

diastinal, diaphragmatost

rior lobes and horizontal fissure

es fissure

t-inf part of sup lobe,

R Wider, Shorter, VertSupplies Lobe Largest subdivision ofPyramidal CT btwn each Indep a. supply 20-25 generations No cartilage 2-11 from each bronc5-6 from each duct

Ro

)

De(Submuco

perib

intrinsic p

chopulmonary nodes

erior Tracheobronchiaound bifurcation)

onchomediastinal trun

ct

tic

e

overlies of cardiac no

L

rtical 2

f lobe 8-10

chiole

oot of lung

eep Plexus osa of bronchi &

bronchial CT)

pulmonary nodes

al nodes

nks

Left Venous angle Or Thoracic Duct

NBTraothsh

otch

R 3

10

B LLL drains to Superioacheobronchial nodesher lobes drain as theyould

 

or s. All y

  

Tranatomy: Thorax 2012 | Page 5 of 8

  

THORAX THORACIC CAVITY LUNGS INNERVATION Pulmonary plexus Anterior and posterior to root of lung Parasympathetic Sympathetic Visceral Afferent Presynaptics from Vagus Synapse with ganglion in plexus & along bronchial tree

Postsynaptic Ganglion in sympth trunk

Reflexive (para) Nociceptive (sympth)

Bronchoconstrict Vasodilate Secretomotor

Bronchodilate Vasoconstrict Secretoinhibitory

Parietal Pleura Costal Intercostal Diaphragmatic (other) Diaphragmatic (central) Phrenic Mediastinal LUNG SURFACE ANATOMY

Lungs Parietal Pleura MCL 6 8 MAL 8 10 SL 10 12 PV 10 12

Fissures 1. Oblique: T2 6th costal cartilage (medial border of scapula when abducted) 2. Horizontal: 4th rib & costal cartilage from oblique fissure

MEDIASTINUM

MIDDLE MEDIASTINUM Pericardium Heart Root of great vessels PERICARDIUM Layers Fibrous Visceral Outer Inner Thick Single layer of mesothelium Inf: Central tendon of diaphragm

Sup: Tunica adventitia superiorly Ant: Sternoparicardial ligament ant Post: loose CT of mediastinum

Forms the epicardium

Areas of Continuity 1. Ao & Pulmonary trunk exit

2. SVC & IVC enter Structures enclosed Up to arch of Ao

All of Thoracic IVC

Pericardial Sinuses Sinus Transverse Oblique Anterior Ao & Pulm Trunk LA Posterior SVC Oesophagus Lateral Pulm veins, IVC Entry Lateral Inferior

Vasculature of the Pericardium Vessel Origin/Drainage Arterial Pericardiophrenic Int thoracic Musculophrenic Bronchl, oesph, sup phrenic Ao Coronary Arteries Veins Pericardiophrenic Brachicephalic Tributaries of Azygous

Innervation

Phrenic (C3-5) = sensory Vagus ? Fcn Sympth trunk = vasomotor

NB When ErectAo arch @ transverse plane Trach bifurcation below plan Central tendon @ xiphoid (T9/10 disc)

my: Thorax 2012 | Page 6 oof 8

Border StructureSup RA/LA/Anf RV > LV R RA/SVC/L LV > aur

rates A from V separates LV from RV

dium | Epicardium (vis

r AV valves) onets (for SL valves) part of IA & IV septum

A)

coronary sulcus

Ao oth post surface) gh ant surface) ernal) | Cristae Terminum

Pectinate muscle) is smooth

es interior orm Conus arteriosus t separates Trabeculaeulae inf IVS base ofundle branch)

finer & more numerouorm Aortic Vestibule (tmitral cusp

cker

uspid Valve Mit, Post, Septal An

: AP cusps t: PS cusps tal: SA cusps

AnPo

s or Right ior Right

RCA

Structure Lunule: Nodule Sinus a

ernum @ 4th and 5th sum @ 4th cartilage

@ 3rd space

se/Supply A (near sulcus terminalear opening of coronary muscles, RV t papillary muscles, LV

e Auricle

/IVC ricle

V

ceral pericardium)

m

Apex LV Left of 5th space (9Motionless

nalis (internal) (separat

(turns into pulm trunke from Conus f ant papillary muscle

us turns into Ao orifice)

tral Valve nt, Post

nt: AP cusps st: PA cusps

Left Left LCA

: free edge of cuff e: apex of lunule at origin of valves

Prevent sticking to waRCA & LCA originate

space

lis) ary sinus)

IV

 

cm from AML)

es smooth/rough)

k)

all of vessel in sinus

VS Membranous paof fibrous skeletoMuscular part (sathickness as LV)

VASCU Arterial ArteryRCA SA nodR margPost IV

AV nod ArteryLCA

Ant IV1

Lateral3

LCx

SA nodL marg

Post IV1LAD 2Domin3of Ant To ap*10% h

 Venous Vein Great cAnterioMiddle Small CObliqueAnterioveins 1Near o2Insign

Lympha InnervaParasym Presy SynapAtria & Nega 1Inotro

art (part on) ame

LATURE OF THE HEA

Endocardium & subenRemainder through co

Supply

Origin R Ao sinus

dal @ Origin 60ginal @ Inf borde

@ Crux 67%

dal @ Crux 80%

Origin L Ao sinus

Cont of LCA

3 Ant IV @ Inf bordeauricle

dal LCx 40% inal LCx @ latera

border @ Crux 15%2

nance, 18% co-dominaIV artery (aka diagonex of heart ave anastomosis, rest

s Drainage Coronary sinus or smAnterior interventricu

Dra

cardiac vein Coror IV GreaCardiac1

CoroCardiac1 e vein of LA2 r cardiac RA

origin of carotid sinusifcant postnatally, defi

atics Subepicardial lymphat

ation Cardiac plexus located

mpathetic naptics from Vagus pse with ganglion in IAS tive1

opy, Chronotropy, Dro

RT

ndocardium passive doronary arteries (trave

Course Coronary sulcu

% Behind SVC r Inf margin 2 Post IV groove

Short

Course AV groove

Ant IV groove

Ant surface r L Coronary sulcu

Behind LA al L heart border

2 Same as whenCrux =

ance (post IV off RCA aal)

have potential

all veins directly into Rar vein

inage Cours

onary Sinus LCx at Cardiac Ant IV

onary Sinus Post IVR mar RV/RA

nes transition from gr

tic plexus tracheobr

d post to Asc Ao & PuSympathetic Presynaptic Ganglion in IML

Positive1 motropy

iffusion from chambeel deep to epicardium)

Distribution us RA

SA, Pulm trunRV, apex

e RV, LV, Post

AV

Distribution LA, LV, IVS, Abundle

e RV, LV, Ant 2

LV us LA, LV

SA, LA r LV

n RCA branch

and Ant IV is longer)

RA

se Distr

LCA V artery V artery RCArginal artery

LA A

reat cardiac to corona

ronchial nodes (right s

ulmonary trunk Sympathe

L T1-6 Postsyna Ganglion

Positive1

rs )

AnastomLCx

nk - IV branc

1/3 IVS Ant IV b@ apex-

AnastomAV RCA

2/3 IVS Post IV b@ apex RCA

- IV branc

ribution

supply

A supply

ry sinus

side btwn Pulm trunk &

etic aptic n in C/T sympth trunk

 

mosis*

ches ranches

mosis

branches

ches

& LA)

  

Tranatomy: Thorax 2012 | Page 7 of 8

  

THORAX MEDIASTINUM SUPERIOR MEDIASTINUM Anterior to Posterior 1. Thymus 2. Veins: brachiocepgalics (SVC lower down) 3. Arteries: Asc Ao, Arch and branches (BC, Common carotids) 4. Nerves: Vagus & Phrenic 5. Trachea 6. Oesophagus 7. Thoracic Duct

 THYMUS Arterial: ant IC & ant mediastinal branches of Internal Thoracic Venous: L brachiocephalic Lymphatics: parasternal, brachiocephalic, tracheobronchial nodes GREAT VESSELS Venous Level Structure Drainage Above SCJ IJ & SC veins Head, Neck, Right Upper Limb SCJ L1 & R Brachiocephalic veins Inf border 1st right cartilage SVC Everything above diaphragm2 3rd right cartilage SVC enters RA3 1passes anterior to root of Ao branches 2Except heart & lungs 3Ant to trachea, Posterolateral to Asc Ao, Phrenic nerve on medial wall Arterial (Arch of Ao) Level Structure Surrounds R of sternal angle Arch Ao starts Ascending part Ant to R pulm a & trach bifurcation Apex Left side of trach & oesph T4 Descending part Over and post to root of left lung NB since Asc Ao is in pericardium, considered part of middle mediastinum Arterial (Branches of Arch Ao) Level Branch Surrounds Post to Manubrium Brachiocephalic trunk Ant to trachea

Post to L brachiocephalic vein R SCJ Divides into R SC & R CC Trachea on left Post/Left BC trunk L CC Ant to L SC

Ant then left of trachea L SC Post to LCC

Lateral to trachea

NERVES Vagus Exit neck Posterolateral to common carotid Enter superior mediastinum posterior to SCJ and brachiocephalic veins Descent Right Left Into Sup Mediastinum Ant over SC artery Descends Post to LCC

Recurrent Laryngeal Branch Loops under R SC

Loops under arch Ao (lateral to ligamentum arteriosum)

Ascends btwn trachea & oesophagus on r side

Into Inferior Mediastinum Forms R pulmonary plexus Leaves plexus as single nerve to oesophagus Forms Oesophageal plexus

Phrenic Nerve Motor and sensory (1/3) to diaphragm Sensory to pericardium and mediastinal pleura Descent Right Left Into Sup Mediastinum Btwn R SC artery & R BC vein Btwn LCC & LSC

Into Inferior Mediastinum

Ant to arch and lat to Vagus Anterior to Root Anterior to Root R side of BC vein, SVC, RA, IVC Ant to left Sup IC vein Ant to LA, LV

Diaphragm Pierces near caval opening Pierces left of pericardium TRACHEA Anterior to oesophagus Slightly right as it enters superior thoracic aperture Bifurcates at sternal angle OESOPHAGUS On vertebrae T1-4 veering left as it approaches Ao arch Centres due to Ao arch (with thoracic duct t lateral to oesophagus Descends behind root of left lung Displaced to right by thoracic Ao but travels anterior to it Enters diaphragm at oesophageal hiatus @ T10

3 impressions (narrowing) 1. Ao arch 2. L main bronchus 3. Diaphragm

 

Tranatom

  

THO ME POSTER

Thoraci Branche

Thoraci Level Intra-abDiaphraPosterioSuperio

my: Thorax 2012 | Page 8 o

ORAX

EDIASTINUM

RIOR MEDIASTINUM

T5-12

Posterior to Anterior Oesophagus & Thoracic Duct Thoracic Ao Posterior med Veins: azygous

ic Ao Starts left of inf bordeDescends T5-12 posteEnters diaphragm thro

es Described as 3 vascul 1. Anterior (midli

Supplie Oesoph Exceptions Superio Pericard

2. Lateral (paired

Supplie Bronch R usual

3. Posterolateral

Supplie Posterio

ic Duct & lymphatics Drains all but RUQ of

bdominal agm (T12) or Mediastinum or Mediastinum (T4,5 o

of 8

& nerve plexus

iastinal nodes s & hemiazygous

er T4 erior to root of L lung,ough Ao hiatus @ inf

ar plains in thoracic an

ne, unpaired) es gut hageal arteries (2 to 5

or phrenic = paired andial & mediastinal arte

) es viscera other than gial arteries (left, sometlly from 3rd R post IC a

(paired) es body wall or IC arteries x9 (ie no

body

Surrounds Chyle CisteEnters throAscends btw

or 6) Enters L ven

oesophagus, pericardborder T12 (with thora

nd abdominal Ao

)

nterior branches just aeries (supply nodes an

gut (eg lungs, kidney) times right) artery

ot 1st or 2nd space)

rn ugh Ao hiatus wn Ao (L), Az (R), Oesnous angle (sometime

dium acic duct & azygous ve

bove the diaphragm nd CT) = unpaired ante

sph (Ant) es L Subclavian)

vein)

erior

VESSELPosterio Azygou Azygou Hemiaz Accesso Superio

Nerves

ANTER SURFAC

LS & NODES or Mediastinal NodesFrom oesophagus, poDrain into R lymphatic

us system Drains back, thoracoaCollateral system betw

us Ascends on R side of Arches ant post ov

zygous Cont of asc lumbar veTravels on left borderThen joins azygous by

ory Hemiazygous Travels on left borderThen joins azygous byFrequently joined to sSometimes joins to he

or Intercostal Vein Drains Left IC veins 1-Drains into L brachioc

of Posterior MediastinThoracic sympathetic Location changes dow

Superio Mid tho Inferior

NB splanchnic nerves

IOR MEDIASTINUM

Thymus Loos CT Fat Lymphatic vessels, no

CE ANATOMY

osterior pericardium, dc duct or thoracic duct

bdominal wall, mediaween IVC and SVC

TT12T4 ver R root to SVC

eins and 9-11 + subcosof T12T9

y going post to Ao, Th

of T5T8 y going post to Ao, Thuperior intercostal vei

emiazygous

4 cephalic (even if joins a

num trunks are main supplwn mediastinum or thorax: head of ribs orax: Costovertebral jothorax: sides of vertesupply below diaphra

des

diaphragm, middle poct

astinal viscera, vertebra

stal veins

horacic duct, oesopha

horacic duct, oesophain

accessory hemiazygou

ly

s oints ebral bodies agm but ganglia from

sterior IC spaces

al plexus

gus

gus

us

T5-12