Chest Wall Anatomy

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CHEST WALL ANATOMY & MEDIASTINUM Luca Novelli, MD Physician – Pulmonary Medicine Unit Papa Giovanni XXIII Hospital, Bergamo, IT Sternum consists of the manubrium sterni, the corpus sterni, and the processus xiphoideus

The sternum and cartilage of ribs 1–10 represent the anterior chest wall.

The posterior part consists of 12 thoracic vertebrae and the posterior aspects of ribs 1–12.

Laterally the chest cavity consists of ribs 1–12 Free ribs (11th and 12th) The RIBS are divided into 1. real ribs (costae verae, 1–7) that have sternal joints 2. false ribs (costae spuriae, 8–10) with cartilagenous joints to the costal arch (arcus costalis) 3. free ribs (costae fluctuantes, 11–12) that end in the soft tissue of the lateral chest wall. The 12th rib is not always present.

The ribs move upwards during inspiration around their rib neck and downwards during expiration as well as by the interactions between the cartilage, sternum, and costal arch. The ribs move upwards during inspiration around their rib neck and downwards during expiration as well as by the interactions between the cartilage, sternum, and costal arch. Pectus Excavatum

It is the most common congenital abnormalities of chest wall. It is characterized by prominent indentation of the lower sternum, which is usually asymmetric to the right, and resulting decrease in AP diameter of the rib cage. The mean pectus index in a normal population is around 2.56.

Haller index is 3.7 (272.4/74.1) Pectus Carinatum

In contrast to pectus excavatum, pectus carinatum is an outward protrusion of the sternum resulting in increased AP diameter of the thorax. It is the second most common congenital chest wall deformity

Muscles Thoracic Wall

Intercostal muscles 1. External intercostal muscle 2. Internal intercostal muscle 3. Innermost intercostal muscle 4. Subcostalis 5. Transversus thoracis

Posterior Thorax 1. Levatores costarum 2. Serratus posterior superior and inferior muscles

Anterior/Superficial Thorax 1. Pectoralis major and minor muscles 2. Subclavius 3. Serratus anterior

Floor 1. Diaphragm At the neck, the chest is attached by the three scalene muscles, the intercostal muscles, and the muscles eminating from ribs 1 and 2 to the cervical vertebral bodies (1–7). They are responsible for the flexion of the upper spine anteriorly and for lifting the ribs during inspiration

As accessory inspiratory muscles, ascalene muscles (helps elevate the first and second ribs) and sternocleidomastoid muscle (assists in raising the sternum) Pectoralis major

The Pectoralis major muscle covers the upper and lateral part of the chestwall like a shelf. It originates from the medial clavicle, the sternum, the cartilages of ribs 5–7 as well as from rectus sheath

The lower edge of the muscle creates the anterior axillary plication. This muscle causes a strong adduction and rotation of the arm and as an auxillary breathing muscle Pectoralis minor muscle is completely covered by the Pectoralis major muscle. It derives from the ribs 3–5 and con- nects to the processus coracoideus of the shoulder.

This muscle pulls the shoulder anteriorly and downwards and also lifts the chest as an auxillary breathing muscle The muscles that make up the thorax wall include the three intercostal muscles (EXTERNAL, INTERNAL and INNERMOST or Intercostales intimi), the SUBCOSTALIS and the TRASVERSUS THORACIS)

Eleven pairs of intercostal muscles are in each of the intercostal spaces, arranged from superficial to deep The external intercostal muscles extend from the rib tubercle posteriorly During inspiration, the external and attach to the costochondral junction intercostals contract and raise the anteriorly where they continue as thin lateral part of the ribs, increasing connective tissue aponeuroses known as the transverse diameter of the the Anterior intercostal membrane thorax

The internal intercostal muscle forms the intermediate layer. They originate from the lateral aspect of the costal They depress the ribs and groove of the rib above and insert into subsequently reduce the thoracic the superior aspect of the rib below in a volume during forced expiration direction perpendicular to the external intercostal muscles

The innermost intercostal muscles originate from the medial aspect of the costal groove of the rib above and They are thought to act with the internal insert onto the internal aspect of the rib intercostal muscle during forced below. These muscles are lined internally expiration by the endothoracic fascia right above parietal pleura The subcostalis muscles are present in abundance in the lower regions of the posterior thoracic wall. They originate from the internal aspect of one of the lower ribs and insert onto the internal Both of these muscles aid in aspect of the second or third rib below. depressing the ribs during forced expiration. The transversus thoracis also originate from the lower posterior sternum, spread across the inner surface of the thoracic cage, and inserts onto ribs 2 through 6.

NORMAL EXPIRATION IS PASSIVE DUE TO ELASTIC RECOIL OF CHEST WALL Search - Upload Login Signup

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Be the first to comment + anatomy of the respiratory system 3 1. Systemic module Respiratory system Anatomy-3 Abbas A. A. Shawka Medical student (1st stage ) 2. Subjects • Thoracic wall Muscles Blood supply & venous+ anatomy drainage Innervation of the of r chestespiratory system 3 wall diaphragm 1. Systemic module Respiratory system Anatomy-3 Abbas A. A. Shawka Medical student (1st 3. Subjects • Intercostal muscles stage ) 4. External intercostal muscle • Origin : Inferior margin of rib above • Insertion : Superior margin 2. Subjects • Thoracic wall Muscles Blood supply & venous drainage Innervation of chest of rib below • Innervation : Intercosta l nerves T1-T11 • Function : Most active during inspiration; wall diaphragm supports intercostal space; moves ribs superiorly 5. internal intercostal muscle • Origin : Lateral edge of costal3. Subjects groove • •Insertion Intercostal : superior muscles margin of rib below deep to the attachment of related external inter4. costalExternal muscle. intercostal • Innervation muscle •: Origin : Inferior margin of rib above • Insertion : Superior margin Intercostal l nerves T1-T11 • Function : Most active duringof expiration rib below Support • Innervation inter costal : Inter costaspace l nerves T1-T11 • Function : Most active during inspiration; Moves ribs inferiorly supports intercostal space; moves ribs superiorly 6. innermost intercostal muscle • Origin : Medial edge of costal5. inter gnal roove inter ofcostal rib a musclebove • Insertion• Origin : :Lateral edge of costal groove • Insertion : superior margin Internal aspect of superior; margin of rib below Innervationof : ribInter belowcostal deep l nerves to the T1-T11 attachment • of related external intercostal muscle. • Innervation : Function : Acts with internal intercostal muscles Intercostal l nerves T1-T11 • Function : Most active during expiration Support inter costal space 7. Subcostal muscle Moves ribs inferiorly 8. Transverse thoracis muscle 6. innermost intercostal muscle • Origin : Medial edge of costal g roove of rib a bove • Insertion : 9. Chest wall blood supply • Anterior Subclavian a. internal thoracic a. internal intercostal a. Internal aspect of superior; margin of rib below Innervation : Intercostal l nerves T1-T11 • divided into 2 branches! 1- musclophrenic artery 2- epigastric artery Function : Acts with internal intercostal muscles 10. Chest wall blood supply • Posterior -First 2 intercostal spaces Subclavian a. Costocervical trunk Supreme intercostal a. internal intercostal a. 7. Subcostal muscle 11. Chest wall blood supply • Posterior - The rest of intercostal8. Transverse spaces thoracicthoracis aortamuscle internal intercostal a. *right intercostal arteries are longer than left 9.inter Chestcostal wall arteries, blood supplywhy?! • Anterior Subclavian a. internal thoracic a. internal intercostal a. 12. Venous drainage • Anterior Accompanies the correlatesdivided arteries! into 2 branches! 1- musclophrenic artery 2- epigastric artery 13. Venous drainage • posterior - Upper intercostal spaces10. Right Chest superior wall blood inter costalsupply vein • Posterior left -First 2 intercostal spaces Subclavian a. Costocervical superior intercostal vein Azygous vein Left brachiocephalictrunk vein Supr S. Veme. C. intercostal a. internal intercostal a. 14. Venous drainage • posterior - lower intercostal spaces11. Inter Chestcostal wall veins blood S. Vsupply. C. Azygous • Posterior - The rest of intercostal spaces thoracic aorta internal system of veins intercostal a. *right intercostal arteries are longer than left intercostal arteries, why?! 15. innervation Anterior rami Intercostal nerve Lateral cutaneous branch Anterior cutaneous 12. Venous drainage • Anterior Accompanies the correlates arteries! branch Medial branchLateral branch 1 1 2 2 3 3 4 4 6 5 5 6 13. Venous drainage • posterior - Upper intercostal spaces Right superior intercostal vein left 16. The intercostal nerves do not innervate the chest only! Intercostal nerves innervate other superior intercostal vein Azygous vein Left brachiocephalic vein S. V. C. regions: 1. The anterior ramus of T l contributes to the brachial plexus . 2. The lateral cutaneous branch o f the second intercostal nerve (the intercostobrachial14. V enousnerve) drainagecontributes • posterior to cutaneous - lower intercostal spaces Intercostal veins S. V. C. Azygous innervation of the medial surface of the upper arm. 3. The systemlower inter of veinscostal nerves supply the muscles, skin, and peritoneum of the abdominal wall. 15. innervation Anterior rami Intercostal nerve Lateral cutaneous branch Anterior cutaneous 17. Diaphragm • separates the thoracic cavity from the abdominalbranch Medial cavity branchLateral• It is attached branch 1 1 2 2 3 3 4 4 6 5 5 6 peripherally to the: 1. xiphoid process of the sternum, 2. costal16. The mar intergincostal of the nervesthoracic do wall, not innervate3. the chest only! Intercostal nerves innervate other ends of ribs XI and XII, 4. ligaments that span across structurregions:es of 1.the The posterior anterior abdominal ramus of Twall, l contributes to the brachial plexus . 2. The lateral cutaneous and 5. vertebrae of the lumbar region. • From these peripheralbranch attachments, o f the second muscle inter fiberscostal nerve (the intercostobrachial nerve) contributes to cutaneous converge to join the central tendon. The pericardium is attachedinnervation to the of middlethe medial part surfaceof the of the upper arm. 3. The lower inter costal nerves supply the 18. 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Inferior phrenic arteries fromtransverse abdominal pr ocessaorta. of( lar L1.gest • The lateral arcuate ligament continuing from the L12 transverse contribution ) *Venous drainage o f the diaphragm is by veins that generally parallel the arteries . process to the tip of the 12th rib. The veins drain into: • the brachiocephalic veins in the neck, • the azygos system of veins, or • 19. Arcuate ligaments abdominal veins (left suprarenal vein and inferior vena cava) . 20. Structure passing through it : I. V. C. T8 esophagus T10 aorta T12 Thoracic duct With aorta 22. Diaphragm innervation • The diaphragm is innervated by the phrenic nerves (C3 , C4, and C 5 ) , • penetrate the diaphragm and innervate it from its abdominalVagous nerve surface. With • Contractionesophagus Azygousof the and Hemizygous With aorta or with crura domes of the diaphragm flattens the diaphragm, thereby incr21. easingBlood supplythoracic of volume. diaphragm 1. pericardiacophrenic and musculophrenic arteries supply the Movements of the diaphragm are essential for normal breathing.diaphragm. Phrenic These nerves vessels ! are branches of the internal thoracic arteries. 2. Superior phrenic 23. Thank you arteries from thoracic aorta. 3. Inferior phrenic arteries from abdominal aorta. ( largest contribution ) *Venous drainage o f the diaphragm is by veins that generally parallel the arteries . The veins drain into: • the brachiocephalic veins in the neck, • the azygos system of veins, or • English Españolabdominal Português veins (left suprarFrançaisenal veinDeutsch and inferior vena cava) . About Dev & API 22. Blog Diaphragm Terms innervation Privacy • TheCopyright diaphragm Support is innervated by the phrenic nerves (C3 , C4, and C 5 ) , • penetrate, the diaphragm and innervate it from its abdominal surface. • Contraction of the domes of the diaphragm flattens the diaphragm, thereby increasing thoracic volume. Movements of the diaphragm are essential for normal breathing. Phrenic nerves ! 23. Thank you

English Español Português Français Deutsch About Dev & API Blog Terms Privacy Copyright Support , Levatores costarum originates from the transverse processes of C7 to T11 and inserts rib elevation during inspiration onto the rib below

The serratus posterior superior attaches to ribs 2 through 5 and elevates them during depress ribs during forced inspiration whereas the serratus posterior expiration inferior attaches the vertebrae to ribs 8 through 12

THE MAJOR MUSCLE OF INSPIRATION COMES FROM THE DIAPHRAGM

DIAPHRAGM Search - Upload Login Signup

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Be the first to comment + anatomy of the respiratory system 3 1. Systemic module Respiratory system Anatomy-3 Abbas A. A. Shawka Medical student (1st stage ) 2. Subjects • Thoracic wall Muscles Blood+ supply anatomy & venous drainageof the Innervationrespiratory of chest system 3 wall diaphragm 1. Systemic module Respiratory system Anatomy-3 Abbas A. A. Shawka Medical student (1st 3. Subjects • Intercostal muscles stage ) 4. External intercostal muscle • Origin : Inferior margin of rib above • Insertion : Superior margin 2. Subjects • Thoracic wall Muscles Blood supply & venous drainage Innervation of chest of rib below • Innervation : Intercosta l nerves T1-T11 • Function : Most active during inspiration; wall diaphragm supports intercostal space; moves ribs superiorly 3. Subjects • Intercostal muscles 5. internal intercostal muscle • Origin : Lateral edge of costal groove • Insertion : superior margin 4. External intercostal muscle • Origin : Inferior margin of rib above • Insertion : Superior margin of rib below deep to the attachment of related external intercostal muscle. • Innervation : of rib below • Innervation : Intercosta l nerves T1-T11 • Function : Most active during inspiration; Intercostal l nerves T1-T11 • Function : Most active during expiration Support inter costal space supports intercostal space; moves ribs superiorly Moves ribs inferiorly 5. internal intercostal muscle • Origin : Lateral edge of costal groove • Insertion : superior margin 6. innermost intercostal muscle • Origin : Medial edge of costal g roove of rib a bove • Insertion : of rib below deep to the attachment of related external intercostal muscle. • Innervation : Internal aspect of superior; margin of rib below Innervation : Intercostal l nerves T1-T11 • Intercostal l nerves T1-T11 • Function : Most active during expiration Support inter costal space Function : Acts with internal intercostal muscles Moves ribs inferiorly 7. Subcostal muscle 6. innermost intercostal muscle • Origin : Medial edge of costal g roove of rib a bove • Insertion : 8. Transverse thoracis muscle Internal aspect of superior; margin of rib below Innervation : Intercostal l nerves T1-T11 • 9. Chest wall blood supply • Anterior Subclavian a. internal thoracic a. internal intercostal a. Function : Acts with internal intercostal muscles divided into 2 branches! 1- musclophrenic artery 2- epigastric artery 7. Subcostal muscle 10. Chest wall blood supply • Posterior -First 2 intercostal spaces Subclavian a. Costocervical 8. Transverse thoracis muscle trunk Supreme intercostal a. internal intercostal a. 9. Chest wall blood supply • Anterior Subclavian a. internal thoracic a. internal intercostal a. 11. Chest wall blood supply • Posterior - The rest of intercostal spaces thoracic aorta internal divided into 2 branches! 1- musclophrenic artery 2- epigastric artery intercostal a. *right intercostal arteries are longer than left intercostal arteries, why?! 10. Chest wall blood supply • Posterior -First 2 intercostal spaces Subclavian a. Costocervical 12. Venous drainage • Anterior Accompanies the correlates arteries! trunk Supreme intercostal a. internal intercostal a. 13. Venous drainage • posterior - Upper intercostal spaces Right superior intercostal vein left 11. Chest wall blood supply • Posterior - The rest of intercostal spaces thoracic aorta internal superior intercostal vein Azygous vein Left brachiocephalic vein S. V. C. intercostal a. *right intercostal arteries are longer than left intercostal arteries, why?! 14. Venous drainage • posterior - lower intercostal spaces Intercostal veins S. V. C. Azygous 12. Venous drainage • Anterior Accompanies the correlates arteries! system of veins 13. Venous drainage • posterior - Upper intercostal spaces Right superior intercostal vein left 15. innervation Anterior rami Intercostal nerve Lateral cutaneous branch Anterior cutaneous superior intercostal vein Azygous vein Left brachiocephalic vein S. V. C. branch Medial branchLateral branch 1 1 2 2 314. 3 4 V 4enous 6 5 5 drainage6 • posterior - lower intercostal spaces Intercostal veins S. V. C. Azygous 16. The intercostal nerves do not innervate thesystem chest ofonly! veins Inter costal nerves innervate other regions: 1. The anterior ramus of T l contributes15. to innervation the brachial Anterior plexus rami . 2. TheInter lateralcostal cutaneousnerve Lateral cutaneous branch Anterior cutaneous branch o f the second intercostal nerve (the interbranchcostobrachial Medial branchLateral nerve) contributes branch to1 1cutaneous 2 2 3 3 4 4 6 5 5 6 innervation of the medial surface of the upper16. arm. 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Phrenic nerves ! 23.English Thank youEspañol Português Français Deutsch About Dev & API Blog Terms Privacy Copyright Support , English Español Português Français Deutsch About Dev & API Blog Terms Privacy Copyright Support , The Diaphragm originates from the lower chest aperture and the vertebral bodies 1–4 of the lumbar column.

The muscle measuring 3–5 mm thick which creates a dome with a tendon in the center.

Due to the elastic recoil the diaphragm lifts upwards creating the diaphragmatic dome which is slightly higher on the right side. The excursion can vary 6-7 cm increasing negative pressure of pleural cavity during inspiration

Besides respiration, the diaphragm also functions to aid abdominal straining and increase intra-abdominal pressure (i.e. defecation)

Liver in the chest (traumatic herniation) Diaphragm paralis detected by ultrasound Search - Upload Login Signup

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The muscles that comprise the thoracic wall and the posterior thorax are innervated by Chest X-Ray Principles Abbas Ahmed the intercostal nerves, which mainly come from the anterior rami of spinal nerves T1 to

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+ anatomy of the respiratory system 3 1. Systemic module Respiratory system Anatomy-3 Abbas A. A. Shawka Medical student (1st stage ) 2. Subjects • Thoracic wall Muscles Blood supply & venous drainage Innervation of chest wall diaphragm 3. Subjects • Intercostal muscles 4. External intercostal muscle • Origin : Inferior margin of rib above • Insertion : Superior margin of rib below • Innervation : Intercosta l nerves T1-T11 • Function : Most active during inspiration; supports intercostal space; moves ribs superiorly 5. internal intercostal muscle • Origin : Lateral edge of costal groove • Insertion : superior margin of rib below deep to the attachment of related external intercostal muscle. • Innervation : Intercostal l nerves T1-T11 • Function : Most active during expiration Support inter costal space Moves ribs inferiorly 6. innermost intercostal muscle • Origin : Medial edge of costal g roove of rib a bove • Insertion : Internal aspect of superior; margin of rib below Innervation : Intercostal l nerves T1-T11 • Function : Acts with internal intercostal muscles 7. Subcostal muscle 8. Transverse thoracis muscle 9. Chest wall blood supply • Anterior Subclavian a. internal thoracic a. internal intercostal a. divided into 2 branches! 1- musclophrenic artery 2- epigastric artery 10. Chest wall blood supply • Posterior -First 2 intercostal spaces Subclavian a. Costocervical trunk Supreme intercostal a. internal intercostal a. 11. Chest wall blood supply • Posterior - The rest of intercostal spaces thoracic aorta internal intercostal a. *right intercostal arteries are longer than left intercostal arteries, why?! 12. Venous drainage • Anterior Accompanies the correlates arteries! 13. Venous drainage • posterior - Upper intercostal spaces Right superior intercostal vein left superior intercostal vein Azygous vein Left brachiocephalic vein S. V. C. 14. Venous drainage • posterior - lower intercostal spaces Intercostal veins S. V. C. Azygous system of veins 15. innervation Anterior rami Intercostal nerve Lateral cutaneous branch Anterior cutaneous branch Medial branchLateral branch 1 1 2 2 3 3 4 4 6 5 5 6 16. The intercostal nerves do not innervate the chest only! Inter costal nerves innervate other regions: 1. The anterior ramus of T l contributes to the brachial plexus . 2. The lateral cutaneous branch o f the second intercostal nerve (the intercostobrachial nerve) contributes to cutaneous innervation of the medial surface of the upper arm. 3. The lower inter costal nerves supply the muscles, skin, and peritoneum of the abdominal wall. 17. Diaphragm • separates the thoracic cavity from the abdominal cavity • It is attached peripherally to the: 1. xiphoid process of the sternum, 2. costal margin of the thoracic wall, 3. ends of ribs XI and XII, 4. ligaments that span acr oss structures of the posterior abdominal wall, and 5. vertebrae of the lumbar region. • From these peripheral attachments, muscle fibers converge to join the central tendon. The pericardium is attached to the middle part of the 18. Arcuate ligaments • The right and left crura and the fibrous median arcuate ligament, which unites them as it arches over the anterior aspect of the aorta, form the aortic hiatus. • The diaphragm is also attached on each side to the medial and lateral ar cuate ligaments. The • medial arcuate ligament is spanning between the lumbar vertebral bodies and the tip of the transverse process of L1. • The lateral arcuate ligament continuing from the L12 transverse process to the tip of the 12th rib. 19. Arcuate ligaments 20. Structure passing through it : I. V. C. T8 esophagus T10 aorta T12 Thoracic duct With aorta Vagous nerve With esophagus Azygous and Hemizygous With aorta or with crura 21. Blood supply of diaphragm 1. pericardiacophrenic and musculophrenic arteries supply the diaphragm. These vessels are branches of the internal thoracic arteries. 2. Superior phrenic arteries from thoracic aorta. 3. Inferior phrenic arteries from abdominal aorta. ( largest contribution ) *Venous drainage o f the diaphragm is by veins that generally parallel the arteries . The veins drain into: • the brachiocephalic veins in the neck, • the azygos system of veins, or • abdominal veins (left suprarenal vein and inferior vena cava) . 22. Diaphragm innervation • The diaphragm is innervated by the phrenic nerves (C3 , C4, and C 5 ) , • penetrate the diaphragm and innervate it from its abdominal surface. • Contraction of the domes of the diaphragm flattens the diaphragm, ther eby increasing thoracic volume. Movements of the diaphragm are essential for normal breathing. Phrenic nerves ! 23. Thank you

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Innervation to the diaphragm comes from both the right and left phrenic nerves, which originate from the anterior rami of C3 to C5.

The phrenic nerve provides both the motor innervation to allow the diaphragm to contract during inspiration and sensory innervation to the parietal pleura and peritoneum covering the central aspect of the diaphragm Search - Upload Login Signup

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... Respiratory System Examination - OSCE Abbas Ahmed Abbas Ahmed, Medical student + Follow General Examination - OSCE (Y3 Medical Students) # $ % Abbas Ahmed

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+ anatomy of the respiratory system 3 1. Systemic module Respiratory system Anatomy-3 Abbas A. A. Shawka Medical student (1st stage ) 2. Subjects • Thoracic wall Muscles Blood supply & venous drainage Innervation of chest wall diaphragm 3. Subjects • Intercostal muscles 4. External intercostal muscle • Origin : Inferior margin of rib above • Insertion : Superior margin of rib below • Innervation : Intercosta l nerves T1-T11 • Function : Most active during inspiration; supports intercostal space; moves ribs superiorly 5. internal intercostal muscle • Origin : Lateral edge of costal groove • Insertion : superior margin of rib below deep to the attachment of related external intercostal muscle. • Innervation : Intercostal l nerves T1-T11 • Function : Most active during expiration Support inter costal space Moves ribs inferiorly 6. innermost intercostal muscle • Origin : Medial edge of costal g roove of rib a bove • Insertion : Internal aspect of superior; margin of rib below Innervation : Intercostal l nerves T1-T11 • Function : Acts with internal intercostal muscles 7. Subcostal muscle 8. Transverse thoracis muscle 9. Chest wall blood supply • Anterior Subclavian a. internal thoracic a. internal intercostal a. divided into 2 branches! 1- musclophrenic artery 2- epigastric artery 10. Chest wall blood supply • Posterior -First 2 intercostal spaces Subclavian a. Costocervical trunk Supreme intercostal a. internal intercostal a. 11. Chest wall blood supply • Posterior - The rest of intercostal spaces thoracic aorta internal intercostal a. *right intercostal arteries are longer than left intercostal arteries, why?! 12. Venous drainage • Anterior Accompanies the correlates arteries! 13. Venous drainage • posterior - Upper intercostal spaces Right superior intercostal vein left superior intercostal vein Azygous vein Left brachiocephalic vein S. V. C. 14. Venous drainage • posterior - lower intercostal spaces Intercostal veins S. V. C. Azygous system of veins 15. innervation Anterior rami Intercostal nerve Lateral cutaneous branch Anterior cutaneous branch Medial branchLateral branch 1 1 2 2 3 3 4 4 6 5 5 6 16. The intercostal nerves do not innervate the chest only! Intercostal nerves innervate other regions: 1. The anterior ramus of T l contributes to the brachial plexus . 2. The lateral cutaneous branch o f the second intercostal nerve (the intercostobrachial nerve) contributes to cutaneous innervation of the medial surface of the upper arm. 3. The lower inter costal nerves supply the muscles, skin, and peritoneum of the abdominal wall. 17. Diaphragm • separates the thoracic cavity from the abdominal cavity • It is attached peripherally to the: 1. xiphoid process of the sternum, 2. costal margin of the thoracic wall, 3. ends of ribs XI and XII, 4. ligaments that span acr oss structures of the posterior abdominal wall, and 5. vertebrae of the lumbar region. • From these peripheral attachments, muscle fibers converge to join the central tendon. The pericardium is attached to the middle part of the 18. Arcuate ligaments • The right and left crura and the fibrous median arcuate ligament, which unites them as it arches over the anterior aspect of the aorta, form the aortic hiatus. • The diaphragm is also attached on each side to the medial and lateral ar cuate ligaments. The • medial arcuate ligament is spanning between the lumbar vertebral bodies and the tip of the transverse process of L1. • The lateral arcuate ligament continuing from the L12 transverse process to the tip of the 12th rib. 19. Arcuate ligaments 20. Structure passing through it : I. V. C. T8 esophagus T10 aorta T12 Thoracic duct With aorta Vagous nerve With esophagus Azygous and Hemizygous With aorta or with crura 21. Blood supply of diaphragm 1. pericardiacophrenic and musculophrenic arteries supply the diaphragm. These vessels are branches of the internal thoracic arteries. 2. Superior phrenic arteries from thoracic aorta. 3. Inferior phrenic arteries from abdominal aorta. ( largest contribution ) *Venous drainage o f the diaphragm is by veins that generally parallel the arteries . The veins drain into: • the brachiocephalic veins in the neck, • the azygos system of veins, or • abdominal veins (left suprarenal vein and inferior vena cava) . 22. Diaphragm innervation • The diaphragm is innervated by the phrenic nerves (C3 , C4, and C 5 ) , • penetrate the diaphragm and innervate it from its abdominal surface. • Contraction of the domes of the diaphragm flattens the diaphragm, ther eby increasing thoracic volume. Movements of the diaphragm are essential for normal breathing. Phrenic nerves ! 23. Thank you

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1,424 views anatomy of the respiratory system 3 anatomy of the respiratory system 3 1,424 views Respiratory System ... Respiratory System Examination - ...OSCE Examination - OSCE Abbas Ahmed Abbas Ahmed Abbas Ahmed, Medical student Abbas Ahmed, Medical student + Follow General Examination - OSCE + Follow General Examination - OSCE (Y3 Medical Students) (Y3 Medical Students) # $ % Abbas Ahmed # $ % Abbas Ahmed

Published on May 5, 2017 Published on May 5, 2017 this lecture is about the anatomical features of the respiratory system . ...& this lecture is about the anatomical features of the respiratory system . ...& Published in: Health & Medicine Published in: Health & Medicine ' 0 Comments ♥ 13 Likes | Statistics * Notes ' 0 Comments ♥ 13 Likes | Statistics * Notes

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+ anatomy of the respiratory system 3 1. Systemic module Respiratory system Anatomy-3 Abbas A. A. Shawka Medical student (1st + anatomy of the respiratory system 3 stage ) 1. Systemic module Respiratory system Anatomy-3 Abbas A. A. Shawka Medical student (1st 2. Subjects • Thoracic wall Muscles Blood supply & venous drainage Innervation of chest stage ) wall diaphragm 2. Subjects • Thoracic wall Muscles Blood supply & venous drainage Innervation of chest 3. Subjects • Intercostal muscles wall diaphragm 4. External intercostal muscle • Origin : Inferior margin of rib above • Insertion : Superior margin 3. Subjects • Intercostal muscles of rib below • Innervation : Intercosta l nerves T1-T11 • Function : Most active during inspiration; 4. External intercostal muscle • Origin : Inferior margin of rib above • Insertion : Superior margin supports intercostal space; moves ribs superiorly of rib below • Innervation : Intercosta l nerves T1-T11 • Function : Most active during inspiration; 5. internal intercostal muscle • Origin : Lateral edge of costal groove • Insertion : superior margin supports intercostal space; moves ribs superiorly of rib below deep to the attachment of related external intercostal muscle. • Innervation : 5. internal intercostal muscle • Origin : Lateral edge of costal groove • Insertion : superior margin Intercostal l nerves T1-T11 • Function : Most active during expiration Support inter costal space of rib below deep to the attachment of related external intercostal muscle. • Innervation : Moves ribs inferiorly Intercostal l nerves T1-T11 • Function : Most active during expiration Support inter costal space 6. innermost intercostal muscle • Origin : Medial edge of costal g roove of rib a bove • Insertion : Moves ribs inferiorly Internal aspect of superior; margin of rib below Innervation : Intercostal l nerves T1-T11 • 6. innermost intercostal muscle • Origin : Medial edge of costal g roove of rib a bove • Insertion : Function : Acts with internal intercostal muscles Internal aspect of superior; margin of rib below Innervation : Intercostal l nerves T1-T11 • 7. Subcostal muscle Function : Acts with internal intercostal muscles 8. Transverse thoracis muscle 7. Subcostal muscle 9. Chest wall blood supply • Anterior Subclavian a. internal thoracic a. internal intercostal a. 8. Transverse thoracis muscle divided into 2 branches! 1- musclophrenic artery 2- epigastric artery 9. Chest wall blood supply • Anterior Subclavian a. internal thoracic a. internal intercostal a. 10. Chest wall blood supply • Posterior -First 2 intercostal spaces Subclavian a. Costocervical divided into 2 branches! 1- musclophrenic artery 2- epigastric artery trunk Supreme intercostal a. internal intercostal a. 10. Chest wall blood supply • Posterior -First 2 intercostal spaces Subclavian a. Costocervical 11. Chest wall blood supply • Posterior - The rest of intercostal spaces thoracic aorta internal trunk Supreme intercostal a. internal intercostal a. intercostal a. *right intercostal arteries are longer than left intercostal arteries, why?! 11. Chest wall blood supply • Posterior - The rest of intercostal spaces thoracic aorta internal 12. Venous drainage • Anterior Accompanies the correlates arteries! intercostal a. *right intercostal arteries are longer than left intercostal arteries, why?! 13. Venous drainage • posterior - Upper intercostal spaces Right superior intercostal vein left 12. Venous drainage • Anterior Accompanies the correlates arteries! superior intercostal vein Azygous vein Left brachiocephalic vein S. V. C. 13. Venous drainage • posterior - Upper intercostal spaces Right superior intercostal vein left 14. Venous drainage • posterior - lower intercostal spaces Intercostal veins S. V. C. Azygous superior intercostal vein Azygous vein Left brachiocephalic vein S. V. C. system of veins 14. Venous drainage • posterior - lower intercostal spaces Intercostal veins S. V. C. Azygous 15. innervation Anterior rami Intercostal nerve Lateral cutaneous branch Anterior cutaneous system of veins branch Medial branchLateral branch 1 1 2 2 3 3 4 4 6 5 5 6 15. innervation Anterior rami Intercostal nerve Lateral cutaneous branch Anterior cutaneous 16. The intercostal nerves do not innervate the chest only! Inter costal nerves innervate other branch Medial branchLateral branch 1 1 2 2 3 3 4 4 6 5 5 6 regions: 1. The anterior ramus of T l contributes to the brachial plexus . 2. The lateral cutaneous 16. The intercostal nerves do not innervate the chest only! Inter costal nerves innervate other branch o f the second intercostal nerve (the intercostobrachial nerve) contributes to cutaneous regions: 1. The anterior ramus of T l contributes to the brachial plexus . 2. The lateral cutaneous innervation of the medial surface of the upper arm. 3. The lower inter costal nerves supply the branch o f the second intercostal nerve (the intercostobrachial nerve) contributes to cutaneous muscles, skin, and peritoneum of the abdominal wall. innervation of the medial surface of the upper arm. 3. The lower inter costal nerves supply the 17. Diaphragm • separates the thoracic cavity from the abdominal cavity • It is attached muscles, skin, and peritoneum of the abdominal wall. peripherally to the: 1. xiphoid process of the sternum, 2. costal margin of the thoracic wall, 3. 17. Diaphragm • separates the thoracic cavity from the abdominal cavity • It is attached ends of ribs XI and XII, 4. ligaments that span acr oss structures of the posterior abdominal wall, and 5. vertebrae of the lumbar region. • From these peripheral attachments, muscle fibers peripherally to the: 1. xiphoid process of the sternum, 2. costal margin of the thoracic wall, 3. converge to join the central tendon. The pericardium is attached to the middle part of the ends of ribs XI and XII, 4. ligaments that span acr oss structures of the posterior abdominal wall, 18. Arcuate ligaments • The right and left crura and the fibrous median arcuate ligament, which and 5. vertebrae of the lumbar region. • From these peripheral attachments, muscle fibers unites them as it arches over the anterior aspect of the aorta, form the aortic hiatus. • The converge to join the central tendon. The pericardium is attached to the middle part of the diaphragm is also attached on each side to the medial and lateral ar cuate ligaments. The • 18. Arcuate ligaments • The right and left crura and the fibrous median arcuate ligament, which medial arcuate ligament is spanning between the lumbar vertebral bodies and the tip of the unites them as it arches over the anterior aspect of the aorta, form the aortic hiatus. • The transverse process of L1. • The lateral arcuate ligament continuing from the L12 transverse diaphragm is also attached on each side to the medial and lateral ar cuate ligaments. The • process to the tip of the 12th rib. medial arcuate ligament is spanning between the lumbar vertebral bodies and the tip of the 19. Arcuate ligaments transverse process of L1. • The lateral arcuate ligament continuing from the L12 transverse 20. Structure passing through it : I. V. C. T8 esophagus T10 aorta T12 Thoracic duct With aorta process to the tip of the 12th rib. Vagous nerve With esophagus Azygous and Hemizygous With aorta or with crura 19. Arcuate ligaments 21. Blood supply of diaphragm 1. pericardiacophrenic and musculophrenic arteries supply the 20. Structure passing through it : I. V. C. T8 esophagus T10 aorta T12 Thoracic duct With aorta diaphragm. These vessels are branches of the internal thoracic arteries. 2. Superior phrenic Vagous nerve With esophagus Azygous and Hemizygous With aorta or with crura arteries from thoracic aorta. 3. Inferior phrenic arteries from abdominal aorta. ( largest 21. Blood supply of diaphragm 1. pericardiacophrenic and musculophrenic arteries supply the contribution ) *Venous drainage o f the diaphragm is by veins that generally parallel the arteries . diaphragm. These vessels are branches of the internal thoracic arteries. 2. Superior phrenic The veins drain into: • the brachiocephalic veins in the neck, • the azygos system of veins, or • arteries from thoracic aorta. 3. Inferior phrenic arteries from abdominal aorta. ( largest abdominal veins (left suprarenal vein and inferior vena cava) . contribution ) *Venous drainage o f the diaphragm is by veins that generally parallel the arteries . 22. Diaphragm innervation • The diaphragm is innervated by the phrenic nerves (C3 , C4, and C The veins drain into: • the brachiocephalic veins in the neck, • the azygos system of veins, or • 5 ) , • penetrate the diaphragm and innervate it from its abdominal surface. • Contraction of the abdominal veins (left suprarenal vein and inferior vena cava) . domes of the diaphragm flattens the diaphragm, ther eby increasing thoracic volume. 22. Diaphragm innervation • The diaphragm is innervated by the phrenic nerves (C3 , C4, and C Movements of the diaphragm are essential for normal breathing. Phrenic nerves ! 5 ) , • penetrate the diaphragm and innervate it from its abdominal surface. • Contraction of the 23. Thank you domes of the diaphragm flattens the diaphragm, ther eby increasing thoracic volume. Movements of the diaphragm are essential for normal breathing. Phrenic nerves ! 23. Thank you English Español Português Français Deutsch About Dev & API Blog Terms Privacy Copyright Support English Español Português Français Deutsch , About Dev & API Blog Terms Privacy Copyright Support , Intercostal veins run together with the arteries and drain into the azygos vein posteriorly and anteriorly into internal mammary vein into the subclavian vein.

The remaining anterior intercostal arteries from the seventh to ninth intercostal spaces come from the branches of the musculophrenic artery, which is a terminal branch of the internal thoracic artery VAN

At the lower edge of the ribs, the structures are found in the following order: vein, artery, and nerve Layers of the Chest wall

The anterior and lateral parts of the chestwall in particular are easily accessible for invasive procedures. Therefore a deep knowledge the anatomy is mandatory. Three layers can be described: ■ Superficial layer consisting of skin, subcutaneous soft and fatty tissue (including the mammary gland, which is attached via the membrana sterni with the sternum ■ Middle layer consisting of muscles of the chest and the abdomen including their fascias ■ Deep layer consisting of the skeleton, intercostal muscles, blood vessels/nerves, fascia endothoracica (covers the inner surface of the chest wall), and parietal pleura.

Thoracentesis

ANATOMICAL REGIONS (defined by the chest wall’s surface): 1) Ventral: Regio pectoralis / mammaria, Regio infraclavicularis, Regio parasternalis, Regio hypchondriaca 2) Lateral: Regio axillaris 3) Dorsal: Regio suprascapularis, Regios scapularis, Regio infrascapularis

ORIENTATION during a examination and/or procedures:

•– Linea sternalis •– Linea parasternalis •– Linea medioclavicularis (MCL) •– Linea axillaris anterior, media, posterior •– Linea scapularis •– Linea paravertebralis MEDIASTINUM

The thoracic mediastinum is the compartment that runs the length of the thoracic cavity between the pleural sacs of the lungs. This compartment extends longitudinally from the thoracic inlet to the superior surface of the diaphragm .

BOUNDARIES OF MEDIASTINUM

Superior Thoracic outlet

Inferior Diaphragm Anterior Sternum

Posterior Thoracic vertebrae

Lateral Lungs & pleurae

DIVISIONS OF THE MEDIASTINUM

It is divided by a horizontal plane

extending from

sternal angle to lower border of 4th thoracic vertebra into:

1. Superior mediastinum (S): above the plane

2. Inferior mediastinum: below the plane,

Inferior mediastinum is subdivided into:

Middle mediastinum (M):contains heart

Anterior mediastinum (A):in front of heart

Posterior mediastinum (P):behind heart

BOUNDARIES OF MEDIASTINUM

Superior Thoracic outlet

Inferior Diaphragm Anterior Sternum

Posterior Thoracic vertebrae

Lateral Lungs & pleurae

DIVISIONS OF THE MEDIASTINUM

It is divided by a horizontal plane It is divided by a horizontal plane extending from sternal angle to lower extending frborderom of 4 thoracic vertebra into: sternal angle to lower border of 4th thoracSUPERIORic vertebra in to: INFERIOR

1. SuperINFERIORior mediastin uMEDIASTINUMm (S): above the pla nise divided by heart into: 2. Inferior mediastinum: below the plane, ANTERIOR POSTERIOR Inferior mediastinum is subdivided into: MIDDLE Mediastinum contains heart Middle mediastinum (M):contains heart

Anterior mediastinum (A):in front of heart

Posterior mediastinum (P):behind heart

Superior Mediastinum 4 ❖ Boundaries ❖ Superior: Thoracic outlet ❖ Inferior: Hor izontal plane ❖ Anterior: Manubrium of ster num ❖ Posterior: Upper 4 thoracic ver tebrae ❖ Lateral: lungs & pleurae The Mediastinum Thoracic duct ❖ Contents :Fr om superficial to deep: 3 ❖ It is a thick moveable partition between right & left pleural

❖ (1) Gland :Thymus gland sacs & lungs.

f ❖ (3) Veins: ❖ It includes all the structures which lie in the intermediate

u ❖ right & left brachiocephalic compartments of the thoracic cavity S ❖ superior vena cava ❖ (4) Arteries: ❖ Boundaries : ❖ arch of aorta & its branches ❖ Superior: Thoracic outlet: (manubrium, 1st rib &T1)

e ❖ brachiocephalic ar ter y

i ❖ Inferior: Diaphragm

e ❖ left common car otid

m ❖ Anterior: Sternum

e t ❖ left subclavian thymus

n I ❖ Posterior: 12 Thoracic vertebrae ❖ (4) Nerves: ❖ Lateral: Lungs & pleurae ❖ right & left vagus ❖ right & left phr enic ❖ (2) Tubes: ❖ Divisions

p ❖ Trachea

e e by a horizontal plane from sternal angle to lower border of T4 into: D ❖ Esophagus (most poster ior ) ❖ (1) Duct: thoracic duct (beside the eso1p. Shuapgeursi)or mediastinum (1 part) : above the plane ❖ Lymph nodes 2. Inferior mediastinum (3 parts) : below the plane Level of T4 Subdivided into: ❖ It is the Level of: 1. Ster nal angle ❖ Posterior mediastinum : behind the heart 2. Second costal cartilage ❖ Middle mediastinum : contains the heart ❖ Why the Level of T4 is important: 1. Bifurcation of tr achea ❖ Anterior mediastinum : in front of the heart 2. Bifurcation of pulmonary trunk 3. Beginning & ter mination of ar ch of aor ta Inferior mediastinum: 5 First part: Posterior Mediastinum

❖ Boundaries: ❖ Superior: Horizontal plane ❖ Inferior: Diaphragm ❖ Anterior: Heart ❖ Posterior: Thoracic vertebrae from T5 to T12 ❖ Lateral: Lungs & pleurae

Vagus nerve ❖ Contents: ❖ Esophagus (most anterior ) ❖ Right & left Vagus nerves: around esophagus ❖ Thoracic duct: posterior to esophagus ❖ Azygos vein: posterior & to the right of esophagus ❖ Descending aorta: posterior & to the left of esophagus ❖ Right & left sympathetic trunks ❖ Lymph nodes

Helpful Note : it contains one fr om each (ar tery,vein ,nerve ,duct ,tube, tr unk) Inferior mediastinum: 6 Second part: Middle Mediastinum

❖ Site: Between anterior & posterior mediastinum

❖ Contents: ❖ Heart & pericardium ❖ Ascending Aorta ❖ Pulmonary trunk ❖ Superior & inferior vena cava ❖ Right & left pulmonary veins ❖ Right & left phrenic nerves ❖ Lymph nodes Left pulmonary veins

Left phrenic nerve

Right pulmonary veins Inferior vena cava Inferior mediastinum: 7 Third part: Anterior Mediastinum ❖ Boundaries: ❖ Superior: Horizontal plane ❖ Inferior: Diaphragm ❖ Anterior: Body & xiphoid of sternum ❖ Posterior: Heart ❖ Lateral: Lungs & pleurae ❖ Contents: ❖ Thymus gland ❖ Lymph nodes

Note : lymph nodes present in all mediastinum region

IMPORTANT NOTE: Ther e are six structur e present in mor e than one r egion in mediastinum Three in super ior and poster ior mediastinum: ❖ Thoracic duct ,Esophagus , vagus nerves Two in superior and middle mediastinum: ❖ phr enic ner ves ,superior vena cava One in superior and anterior mediastinum: ❖ Thymus gland Important structures in Mediastinum

8 Vagus nerve Phrenic nerve Aorta

❖ It is the 10th cr anial ner ve. ❖ Root value: C3,4,5 ❖ Ascending aorta: ❖ The r ight vagus descends to the ❖ Course in thorax: They pass ❖ Beginning: at aortic or ifice of left r ight side of trachea, forms the through the Super ior & Middle ventr icle. poster ior esophageal plexus & mediastinum ❖ Cour se: in middle mediastinum continues in abdomen as posterior ❖ The right phrenic descends on the ❖ End: continues as arch of aor ta gastric nerve. right side of SVC (superior vena (at level of T4) ❖ The left vagus descends between cava )& heart. ❖ Arch of aorta: left common car otid & left ❖ The left phrenic descends on the ❖ Cour se: in superior mediastinum subclavian ar ter ies, forms the left side of hear t. ❖ End: continues as descending thoracic anterior esophageal plexus & ❖ Both nerves terminate in the aorta (at level of T4) continues in abdomen as anter ior diaphr agm ❖ Descending aorta: gastric nerve. ❖ Supply: ❖ Cour se: in poster ior mediastinum 1) Motor & sensory fibers to ❖ End: continues as abdominal aorta diaphr agm thr ough diaphragm 2) Sensor y fibers to pleur ae & pericar dium Lung cancer stadiation by lymph nodes Lymphatic vessels in thorax 9 ❖ Lymph fr om the right side of the head, neck, thorax, & upper limb dr ains into the Right lymphatic duct and ends in the r ight br achiocephalic vein ❖ Lymph fr om the lower half of the body dr ains into the Cysterna chyli then to the Thoracic duct ❖ Lymph fr om the left side of the head, neck, thor ax, & upper limb dr ains dir ectly into the Thoracic duct

Thoracic duct

Beginning: It is the continuation of Cysterna chyli at the level of L1 Course: It passes through the aor tic opening of diaphr agm. It ascends in the posterior mediastinum (poster ior to esophagus). It ascends in the superior mediastinum (to the left of esophagus). Tributaries: It r eceives Lymphatics from all body EXCEPT r ight side of( head & neck, thor ax, upper limb) as we mentioned before End: in the left brachiocephalic vein. From anatomy to differential diagnosis Vein occlusion and infiltration…