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Ingrid Hodorová, Assoc. Prof., MD, Phd., Zuzana Kováčová MD

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Ingrid Hodorová, Assoc. Prof., MD, Phd., Zuzana Kováčová MD Ingrid Hodorová, Assoc. Prof., MD, PhD., Zuzana Kováčová MD THORAX – SKELETON, JOINTS, MUSCLES, ARTERIAL BLOOD SUPPLY, VENOUS AND LYMPHATIC DRAINAGE, INNERVATION, REGIONAL ANATOMY THORAX: - upper part of the trunk - box for vital organs Boundaries: external upper: 1/ jugular notch 2/ clavicule 3/ acromion of scapula 4/ spine of C7 (vertebra prominens) external lower: 1/ xiphoid process 2/ left and right costal arches 3/ vertebra Th12 internal upper: 1/ superior thoracic aperture (made from jugular notch, 1st pair of ribs, vertebra Th1) internal lower: 1/ inferior thoracic aperture (full filed by diaphragm, which extends on the right side to the 4th intercostal space (ICS), on the left side extends to the 5th ICS) ARTEFICIAL LINES ON THE THORAX: unpaired: 1/ anterior median line 2/ posterior median line paired: 1/ sternal line 2/ parasternal line 3/ mid-clavicular line 4/ anterior axillary line 5/ midddle axillary line 6/ posterior axillary line 7/ scapular line 8/ paravertebral line THORACIC WALL: 1st layer (proper thoracic wall): 1/ osteothorax (ribs, sternum, Th vertebrae + their joints) 2/ proper mm. of thoracic wall (intercostal muscles, transversus thoracis m., subcostalis m.) 3/ intrinsic mm. of the back (erector spinae m.) 4/ intercostal neuro-vascular bundle (vein, artery, nerve) 5/ endothoracic fascia 6/ parietal pleura 2nd layer (middle): 1/pectoral fascia 2/ thoracohumeral mm. 3/spinohumeral mm. 4/spinocostal mm. 3rd layer (superficial): 1/ skin 2/ subcutaneous tissue + mammary gland 3/ superficial structures (supraclavicular nn., intercostobrachial nn., thoracoepigastric vv.) OSTEOTHORAX: Thoracic vertebrae (12): 1/ body - costal facets, 2/ arch - vertebral notches – intervertebral foramen, vertebral foramen 3/ processes – transverse, sup. and inf. articular, spinous Ribs (12 pairs): 1/ head - articular facet of the head 2/ neck 3/ body – tubercle, articular facet, costal crest, costal sulcus 1st rib - groove for subclavian artery, tubercle for scalenus anterior m., groove for subclavian vein True ribs: 1st to 7th False ribs: 8th to 10th Floating ribs: 11th to 12th Sternum: 1/ manubrium ̶ jugular notch, clavicular notch, st nd costal notch (1 and 2 ribs) 2/ body (costal notches 2nd to 7th ribs) 3/ xiphoid process sternal angle - attachment the 2nd pair of ribs JOINTS OF THE RIBS: Costovertebral joints: 1/ joints of the heads of the ribs (head of the ribs to the body of the thoracic vertebrae) 2/ costotransverse joints (costal tubercle and transverse process) Sternocostal joints: 1st to7th ribs to sternum Interchondral joints: costal arch (cartilages of the 7th to 10th rib) CONNECTIONS OF THE VERTEBRAL COLUMN: Syndesmosis: short ligaments: interspinous, intertransverse, flava long ligaments: anterior and posterior longitudinal ligaments Synchondrosis: Intervertebral discs, - between vertebral bodies - nucleus pulposus, anulus fibrosus - total number 23, 1st between C1-C2, last one between L5-S1 Synostosis: sacrum Joints of vertebral column: between superior et inferior articular processes Curvatures of vertebral column: in sagittal plane - lordosis - cervical and lumbar - kyfosis - thoracic and sacral in frontal plane - scoliosis MUSCLES OF THE THORAX: Thoracohumeral muscles: 1/ pectoralis major 2/ pectoralis minor 3/ serratus anterior 4/ subclavius Mm. of proper thoracic wall: 1/ intercostal (external, internal, intimi) 2/ transverse thoracis m. 3/ subcostal mm. Diaphragm: muscular portion - sternal part, costal part, lumbar part oesophageal hiatus (Th10) – esophagus, vagus nn., oesophageal vv., phrenocoabdominal br. of left phrenic n. aortic hiatus (Th12) – aorta thoracic duct, central tendon opening for inferior vena cava (Th8) – inferior vena cava, phrenocoabdominal br. of right phrenic n. through crus of lumbar parts pass: azygos v., hemiazygos v., sympathetic trunk, splanchnic nn. (greater, lesser and least) innervation - phrenic nerve MUSCLES OF THE BACK: Spinohumeral mm.: 1st layer: 1/ trapezius 2/ latissimus dorsi 2nd layer 1/ levator scapulae 2/ rhomboid major 3/ rhomboid minor Spinocostal mm: 1/ posterior superior serratus 2/ posterior inferior serratus Intrinsic mm. of the back: 1/ m. erector spinae ARTERIAL BLOOD SUPPLY OF THE THORAX: Thoracic aorta: posterior intercostal aa. (for 3rd to 11th intercostal spaces) subcostal a. Subclavian artery : internal thoracic a. - anterior intercostal aa. - musculophrenic a. - superior epigastric a. (anastomoses with inferior epigastric a.) costocervical trunk - supreme intercostal a. (for 1st and 2nd intercostal spaces) Axillary artery: thoracoacromial a. lateral thoracic a. thoracodorsal a. VEINOUS DRAINAGE OF THE THORACIC WALL: Azygos v. - right posterior intercostal vv., right superior intercostal v., arch of azygos v., drains into superior vena cava Right supreme intercostal v. - drains into right brachiocephalic v. Hemiazygos and accessory hemiazygos veins - left posterior intercostal vv., drain into azygos v. Left superior intercostal v. - drains into left brachiocephaliv v. Left supreme intercostal v. - drains into left brachiocephalic v. Internal thoracic vv. - left drains into left brachiocephaic v., right drains into superior vena cava Thoracoepigastric vv. - they form lateral thoracic v., it drains into axillary v. Vertebral venous plexus - external and internal Veins of the thoracic wall form important cavo-caval and porto-caval anastomoses! NEUROVASCULAR BUNDLE IN INTERCOSTAL SPACES – VAN: VAN is made from (in kranio-caudal direction) posterior intercostal Vein posterior intercostal Artery intercostal Nerve Runs between (in dorso-ventral direction): endothoracic fascia and internal intercostal membrane inside internal intercostal mm., separates innermost (intimi) intercostal mm. between endothoracic fascia and internal intercostal mm. LYMPHATIC DRAINAGE OF THE THORACIC WALL: Parietal lymph nodes: intercostal l. nn. parasternal l. nn. phrenic l. nn. INNERVATION OF THE THORACIC WALL: Thoracic wall is supplied from nerves of brachial plexus and from intercostal nn. Sensory: 1/ intercostals nerves 2/ supraclavicular nerves 3/ intercostobrachial nerves Motor: 1/ phrenic n. (diaphragma) 2/ intercostals nn. (intercostal mm., transverse thoracic m., subcostal m.) 3/ long thoracic n. (serratus anterior m.) 4/ medial and lateral pectoral nn. (pectoralis major and minor) 5/ thoracodorsal n. (latissimus dorsi m.) 6/ dorsal brr. of spinal nerves (intrinsic muscles of the back) 7/ accessory n. (trapezius m.) 8/ subclavian n. (subclavius m.) MAMMARY GLAND: Blood supply: 1/ pectoral brr. of thoracoacromial a. 2/ lateral mammary brr. of lateral thoracic a. 3/ medial mammary brr. (perforating brr.) of internal thoracic a. Innervation: 1/ lateral mammary br., from intercostal nn. 2/ medial mammary br., from intercostal nn. 3/ medial and intermediate supraclavicular nn., from cervical plexus Lymphatic drainage: 1/ axillary (predominantly pectoral) lymph nodes (important for metastases) 2/ parasternal lymph nodes 3/ supraclavicular (deep cervical) lymph nodes 4/ superficial inguinal lymph nodes MEDIASTINUM - part of the thoracic cavity between two pleural cavities (right and left) Borders: ventral: sternum + costal cartilages + transverse thoracis m. dorsal: thoracic vertebrae (bodies) caudal: diaphragm lateral: mediastinal pleura right and left cranial: superior thoracic aperture Division: - horizontal line, which connects sternal angle and intervertebral disc between Th4-5 into: superior mediastinum inferior mediastinum – by pericardium is divided into: - anterior mediastinum - middle mediastinum - posterior mediastinum SUPERIOR MEDIASTINUM: - communicates with anterior mediastinum and posterior mediastinum Content: thymus right brachiocephalic vein left brachiocephalic vein + its tributaries superior vena cava + its tributaries right and left phrenic nerve – different passage right and left vagus nerve – different course, left recurrent laryngeal n. aortic arch – course, branches: brachiocephalic trunk, left common carotid a., left subclavian artery, bronchial aa. trachea (thoracic part) oesophagus thoracic duct superficial cardiac plexus sympathetic trunk (covered by endothoracic fascia) anterior mediastinal lymph nodes ANTERIOR MEDIASTINUM: - fissure behind the body of sternum and in front of pericardium, - it communicates with superior mediastinum Content: thymus parasternal lymph nodes superior et inferior sternopericardiac ligaments MIDDLE MEDIASTINUM: - it is separated by pericardium from other parts of mediastinum (from posterior mediastinum is also separated by bronchopericardiac membrane) Content: heart + pulmonary trunk ascending aorta left and right pulmonary veins superior et inferior vena cava deep cardiac plexus left and right phrenic nerves + pericardiacophrenic vessels (between pericardium and mediastinal pleura) tracheal bifurcation tracheobronchial lymph nodes POSTERIOR MEDIASTINUM: Borders: anterior - pericardium, bronchopericardiac membrane posterior - Th5-Th12 inferior - diaphragm superior - imaginary line: intervertebral disc Th4-5 and sternal angle, direct communication with superior mediastinum (important for the spreading of inflammation to the neck and to the abdominal cavity) Content: thoracic aorta oesophagus anterior et posterior vagal trunk thoracic duct azygos vein hemiazygos vein accessory hemiazygos vein sympathetic trunk (covered by endothoracic fascia!) greater, lesser et least splanchnic nerve posterior mediastinal lymph nodes THE HEART FUNCTION:
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