Dr. Ágoston Szél
Ribs, Thorax, Diaphragm
Department of Anatomy, Histology and Embryology Semmelweis University 2019
1 I. Structure of the Thorax and the Ribs
Mellkas - Szél 2 The thorax is a topographical „coordinate system”
2nd rib
Sternal angle
auscultation percussion Costal arch palpation ….
Infrasternal angle 3 The thorax Superior thoracic aperture
Thoracic cavity
lung lung heart
Inferior thoracic aperture 4 Superior thoracic Scalenus aperture medius („Thoracic outlet”) Brachial plexus
Insertion of Scalenus medius Pleural cupule Scalenus Insertion of anterior Scalenus anterior
Inferior trunk of brachial plexus 1st rib Subclavian artery and vein 5 Thoracic Wall Skin Connect. tiss.
6 Thoracic Wall Skin Connect. tiss. Serratus ant.
7 Thoracic Wall Skin Connect. tiss. Serratus ant.
Costal groove
Intercostalis externus
Intercostalis internus 8 Thoracic Wall Skin Connect. tiss. Serratus ant.
Intercostal vein
Intercostal artery
Intercostal nerve
Intercostalis externus
Intercostalis internus Transversus thoracis 9 Thoracic Wall Skin Connect. tiss. Serratus ant.
Intercostal vein
Intercostal artery
Intercostal nerve
Endothoracic fascia
Intercostalis externus
Intercostalis Parietal pleura internus Transversus thoracis 10 Thoracic Wall Skin Connect. tiss. Serratus ant. Pleural cavity (virtual space)
Lung
Intercostal vein
Intercostal artery
Intercostal nerve
Endothoracic fascia
Intercostalis externus Visceral pleura
Intercostalis Parietal pleura internus Transversus thoracis 11 Thoracic Wall
Skin
Connective tissue
12 Thoracic Wall
Skin
Connective tissue
Serratus anterior
13 Thoracic Wall
Skin
Connective tissue
Intercostalis internus Serratus anterior
Intercostalis externus
14 Thoracic Wall
Skin
Connective tissue
Intercostalis internus Serratus anterior Transversus thoracis
Endothoracic fascia
Intercostal vein, Intercostalis artery and nerve externus
15 Thoracic Wall
Skin Lung Visceral pleura Connective tissue Pleural cavity (virtual space) Parietal pleura
Intercostalis internus Serratus anterior Transversus thoracis
Endothoracic fascia
Intercostal vein, Intercostalis artery and nerve externus
Pleura-punction (thoracocentesis)16 Orientation of FibersV of Intercostal Muscles
as seen from behind Posterior intercostal membrane Vertebral columnV
Rib
Internal intercostal muscle
External intercostal muscle
External
Cartilage intercostal (v) muscle Anterior intercostal as seen membrane (v) from in front
+17 II. Structure of the Diaphragm
Mellkas - Szél 18 Musculo-Tendinous Separation between Thoracic Cavity and Abdominal Cavity
Thorax (thoracic cavity)
„Heart saddle”
5th rib (right 5th intercostal dome) space (left dome)
Centrum Costal part Costal part tendineum
Abdominal cavity In breathing it (abdomen) works as a piston Diaphragm
Separates thoracic and Diaphrassein = barricade, abdominal cavities parition (Greek)
Most important respiratory muscle
Vessels and nerves traverse it
Important muscle of abdominal press Development and Composition
4-5 mm thick muscular plate (striated muscle), from cervical somites
Originates from septum transversum (connective tissue)
Innervation: phrenic nerve
(cervical plexus, C3-C4-C5) Central part is a clover- shaped (trilobed) plate of connective tissue (centrum tendineum) Serous Membranes in Connection with the Diaphragm
Parietal Fibrous pericardium pericardium (serous)
Parietal pleura Endothoracic fascia
Parietal peritoneum Transversalis fascia The Diaphragm as Seen from Left and from Above
Phrenic nerve
Fibrous pericardium Thoracic aorta
(Left Lung Diaphragm Removed) Syntopy of Lung, Pleura and Diaphragm
Lung Parietal pleura
Visceral pleura Diaphragm
Liver Syntopy of Diaphragm as Seen from the Side
Manubrium of Aortic arch sternum
Corpus of Heart sternum Thoracic aorta
Xyphoid process
Abdominal aorta Topography of Main Traversing Structures
Corpus of sternum Th8
Th9
Inferior vena Xyphoid cava Th10 process Esophagus Th11
Th12
Coeliac trunk L1
Thoracic / abdominal aorta The Diaphragm as Seen from Above Esophagus Inf. vena cava Thoracic aorta
Centrum tendineum Pericardium Costal part
Abdominal muscles Liver
Stomach Diaphragm as seen from above
Azygos vein
Hemiazygos vein Esophagus Thoracic aorta Inferior vena cava Divisions of Diaphargm
Vertebral column LUMBAR PART
Lateral crus Centrum tendineum Medial crus (clover-shaped)
COSTAL PART Cartilages of 6 lower ribs STERNAL PART Crus = leg, Fibrous pericardium Posterior surface of stem (Latin) xyphoid process Openings (Hiatuses) between Parts of Diaphragm
Hiatus of aorta Hiatus of esophagus Hiatus of inf. vena cava Lumbocostal foramen (Bochdalek)
Phrenicopericardial ligament connects Weak, triangular areas pericardium and filled out by diaphragm connective tissue
Fibrous pericardium Sternocostal foramen (Larrey) Superior epigastric artery (Internal thoracic artery, from the Subclavian artery) Traversing structures
Hiatus of aorta
& Thoracic duct (main lymphatic duct)
Hiatus of esophagus
& Right and left vagus Hiatus of inf. nerves – main vena cava parasympathetic & Right phrenicoabdominal vegetative nerves branch (of phrenic nerve) – & Left sensory nerve to peritoneum phrenicoabdominal branch (of phrenic nerve) – sensory nerve to peritoneum The Diaphragm as Seen from Below Inf. vena cava STERNAL PART
COSTAL PART Centrum tendineum Hiatus of esophagus Esophagus Hiatus of aorta
LUMBAR PART Medial arcuate lig. Lateral arcuate lig.
Abdominal muscles Medial crus (divided) * Psoas minor Psoas major
*Quadratus lumborum
Vertebral column The Diaphragm as Seen from Below
Vena caval foramen
Esophageal hiatus
Common hepatic artery
Aortic hiatus
Vertebra L1 Vertebra L2 Vertebra L3 Parts of the Diaphragm
COSTAL STERNAL PART PART
RIGHT LUMBAR LEFT LUMBAR PART PART
Right lateral Left lateral crus crus
Right medial Left medial crus crus Lumbar vertebrae Lumbar vertebrae (L1-L4) (L1-L3)
12th rib Processus costarius L1 Arcades of the Diaphragm
STERNAL Sternocostal PART foramen (Larrey)
COSTAL Superior epigastric PART artery (Internal thoracic artery - Subclavian artery) Lumbocostal foramen LUMBAR (Bochdalek) PART
12th rib Processus costarius L1
Median arcuate lig. Lateral arcuate lig. (aorta-hiatus) (quadratus-arcade) Medial arcuate lig. (psoas-arcade) Traversing Structures
STERNAL COSTAL PART PART Gap between medial LUMBAR crus and lateral crus PART Sympathetic trunk, Lesser splanchnic Lateral crus nerve
Medial crus
Gap within the right medial crus Gap within the left medial crus Azygos vein, right greater splanchnic Hemiazygos vein, left nerve greater splanchnic nerve The Diaphragm as Seen from Above
Hiatus of aorta Vertebral Hiatus of LUMBAR PART column esophagus Medial crus Hiatus of inf. vena cava Lateral crus
Centrum tendineum COSTAL PART
Pericardium fibrosum STERNAL PART The Diaphragm as Seen from Below
STERNAL PART COSTAL PART
Th11
Centrum tendineum L1 LUMBAR PART 12th rib Processus L3 costarius L1
Medial crus
L5 Lateral crus III. The Mechanism of Breathing
Mellkas - Szél 39 Inspiration (inhalation) Expiration (exhalation)
ribs elevate, transveral ribs sink, transversal diameter increases diameter decreases costal arch: obtuse angle 40 costal arch: acute angle Joints of ribs
Joint of head of rib Inhalation: the sternum elevates Inhalation: the rib The axis slants elevates backwards and sidewards Sternocostal joint Costotransversal joint
+41 Transversal (l-l) diameter of thoracic cage increases Movement of bucket handle Level of ribs elevates
Vertebra
The axis slants Sternum sidewards
Rib
42 Sagittal (a-p) diameter of thoracic cage increases
Movement of arm of well Axis slants backwards Sternum
Sternum and costal cartilage elevates Rib
43 Combination of the two movements (l-l, a-p)
Volume of thorax increases
Sternum and costal cartilage Level of ribs elevates elevates
44
The Bayle’s scheme VertebralV column Elevation of ribs - inhalation Intercostalis externus contracts
Resting phase – pause in respirations
Depression of ribs - V exhalation Intercostalis internus contracts
45 Upon deep inspiration the dorsal kyphosis flattens
•Erector spinae muscle contracts •The dorsal vertebral column becomes straight •The volume of thorax (in length) increases
Movement of piano harmonica
(accordion)
Expiration Inspiration
+46 The diaphragm is the most important breathing muscle
Inspiration Expiration
Costo-phrenic angle: larger Costo-phrenic angle: smaller Thoracic respiration (inspiration) •Ribs elevate, dorsal kyphosis straightens •Thorax-volumen (in all directions) increases Abdominal respiration (inspiration) •Diaphragm descends („piston”) •Abdominal muscles relax (belly rounds) •Thorax volumen (longitudinal) increases
48 IV. Further information
Forced breathing
Mellkas - Szél 49 abdominal respiration thoracic respiration
inspiration expiration expiration inspiration
abdominal wall thoracic wall retracts or bulges rises or falls back
50 Normal respiration (intercostal muscles, diaphragm)
Forced respiration (physical exercise, degeneration of thoracic joints, etc.) Forced inspiration Forced expiration thoracic, cervical abdominal muscles, muscles, posterior posterior inferior superior serratus serratus, quadratus lumborum
Asphyxia (dyspnoe), suffocation e.g. alien body, e.g. emphysema, stenosis of trachea bronchial asthma 51 Serratus post. Auxiliary respiratory muscles sup. (elevates the upper ribs) Levator costarum (elevates the ribs)
Serratus post. Quadratus lumborum inf. (depresses (depresses the 12th the lower ribs) rib) 52 Auxiliary respiratory muscles
Nasal muscles (nostrils widen)
Scalenus anterior, medius et posterior (elevates upper ribs)
Sternocleidomastoideus (elevates clavicle)
53 Auxiliary respiratory muscles
„coughing muscle”: in case of spasmodic coughing the stretching of the anterior edge of the muscle can be felt.
Latissimus dorsi (compresses the thorax)
Mellkas - Szél 54 Paralysis of phrenic nerve - paradoxical movement of diaphragm
Inspiration with Normal inspiration paralysis of right dome
Resting phase 55 Thoracic deformations
Pectus excavatum Pectus carinatum (funnel breast) (pigeon breast) 56 Bibliography
• Lippert H: Lehrbuch Anatomie, Urban & Fischer, München, 2000 • Mac Kinnon P, Morris J: Oxford Lehrbuch der klinischen Anatomie, Hans Huber, Bern, 1997 • Snell RS: Clinical Anatomy, Little, Brown & Co, Boston, 1995 • Moore KL, Dalley AF: Clinically Oriented Anatomy, Lippincott, 1999 • Kenhub: https://www.kenhub.com