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The Structure and Function of Breathing
CHAPTERCONTENTS The structure-function continuum 1 Multiple Influences: biomechanical, biochemical and psychological 1 The structure and Homeostasis and heterostasis 2 OBJECTIVE AND METHODS 4 function of breathing NORMAL BREATHING 5 Respiratory benefits 5 Leon Chaitow The upper airway 5 Dinah Bradley Thenose 5 The oropharynx 13 The larynx 13 Pathological states affecting the airways 13 Normal posture and other structural THE STRUCTURE-FUNCTION considerations 14 Further structural considerations 15 CONTINUUM Kapandji's model 16 Nowhere in the body is the axiom of structure Structural features of breathing 16 governing function more apparent than in its Lung volumes and capacities 19 relation to respiration. This is also a region in Fascla and resplrstory function 20 which prolonged modifications of function - Thoracic spine and ribs 21 Discs 22 such as the inappropriate breathing pattern dis- Structural features of the ribs 22 played during hyperventilation - inevitably intercostal musculature 23 induce structural changes, for example involving Structural features of the sternum 23 Posterior thorax 23 accessory breathing muscles as well as the tho- Palpation landmarks 23 racic articulations. Ultimately, the self-perpetuat- NEURAL REGULATION OF BREATHING 24 ing cycle of functional change creating structural Chemical control of breathing 25 modification leading to reinforced dysfunctional Voluntary control of breathing 25 tendencies can become complete, from The autonomic nervous system 26 whichever direction dysfunction arrives, for Sympathetic division 27 Parasympathetic division 27 example: structural adaptations can prevent NANC system 28 normal breathing function, and abnormal breath- THE MUSCLES OF RESPIRATION 30 ing function ensures continued structural adap- Additional soft tissue influences and tational stresses leading to decompensation. -
Part 1 the Thorax ECA1 7/18/06 6:30 PM Page 2 ECA1 7/18/06 6:30 PM Page 3
ECA1 7/18/06 6:30 PM Page 1 Part 1 The Thorax ECA1 7/18/06 6:30 PM Page 2 ECA1 7/18/06 6:30 PM Page 3 Surface anatomy and surface markings The experienced clinician spends much of his working life relating the surface anatomy of his patients to their deep structures (Fig. 1; see also Figs. 11 and 22). The following bony prominences can usually be palpated in the living subject (corresponding vertebral levels are given in brackets): •◊◊superior angle of the scapula (T2); •◊◊upper border of the manubrium sterni, the suprasternal notch (T2/3); •◊◊spine of the scapula (T3); •◊◊sternal angle (of Louis) — the transverse ridge at the manubrio-sternal junction (T4/5); •◊◊inferior angle of scapula (T8); •◊◊xiphisternal joint (T9); •◊◊lowest part of costal margin—10th rib (the subcostal line passes through L3). Note from Fig. 1 that the manubrium corresponds to the 3rd and 4th thoracic vertebrae and overlies the aortic arch, and that the sternum corre- sponds to the 5th to 8th vertebrae and neatly overlies the heart. Since the 1st and 12th ribs are difficult to feel, the ribs should be enu- merated from the 2nd costal cartilage, which articulates with the sternum at the angle of Louis. The spinous processes of all the thoracic vertebrae can be palpated in the midline posteriorly, but it should be remembered that the first spinous process that can be felt is that of C7 (the vertebra prominens). The position of the nipple varies considerably in the female, but in the male it usually lies in the 4th intercostal space about 4in (10cm) from the midline. -
Slipping Rib Syndrome
Slipping Rib Syndrome Jackie Dozier, BS Edited by Lisa E McMahon, MD FACS FAAP David M Notrica, MD FACS FAAP Case Presentation AA is a 12 year old female who presented with a 7 month history of right-sided chest/rib pain. She states that the pain was not preceded by trauma and she had never experienced pain like this before. She has been seen in the past by her pediatrician, chiropractor, and sports medicine physician for her pain. In May 2012, she was seen in the ER after having manipulations done on her ribs by a sports medicine physician. Pain at that time was constant throughout the day and kept her from sleeping. However, it was relieved with hydrocodone/acetaminophen in the ER. Case Presentation Over the following months, the pain became progressively worse and then constant. She also developed shortness of breath. She is a swimmer and says she has had difficulty practicing due to the pain and SOB. AA was seen by a pediatric surgeon and scheduled for an interventional pain management service consult for a test injection. Following good temporary relief by local injection, she was scheduled costal cartilage removal to treat her pain. What is Slipping Rib Syndrome? •Slipping Rib Syndrome (SRS) is caused by hypermobility of the anterior ends of the false rib costal cartilages, which leads to slipping of the affected rib under the superior adjacent rib. •SRS an lead to irritation of the intercostal nerve or strain of the muscles surrounding the rib. •SRS is often misdiagnosed and can lead to months or years of unresolved abdominal and/or thoracic pain. -
Lab #23 Anal Triangle
THE BONY PELVIS AND ANAL TRIANGLE (Grant's Dissector [16th Ed.] pp. 141-145) TODAY’S GOALS: 1. Identify relevant bony features/landmarks on skeletal materials or pelvic models. 2. Identify the sacrotuberous and sacrospinous ligaments. 3. Describe the organization and divisions of the perineum into two triangles: anal triangle and urogenital triangle 4. Dissect the ischiorectal (ischioanal) fossa and define its boundaries. 5. Identify the inferior rectal nerve and artery, the pudendal (Alcock’s) canal and the external anal sphincter. DISSECTION NOTES: The perineum is the diamond-shaped area between the upper thighs and below the inferior pelvic aperture and pelvic diaphragm. It is divided anatomically into 2 triangles: the anal triangle and the urogenital (UG) triangle (Dissector p. 142, Fig. 5.2). The anal triangle is bounded by the tip of the coccyx, sacrotuberous ligaments, and a line connecting the right and left ischial tuberosities. It contains the anal canal, which pierced the levator ani muscle portion of the pelvic diaphragm. The urogenital triangle is bounded by the ischiopubic rami to the inferior surface of the pubic symphysis and a line connecting the right and left ischial tuberosities. This triangular space contains the urogenital (UG) diaphragm that transmits the urethra (in male) and urethra and vagina (in female). A. Anal Triangle Turn the cadaver into the prone position. Make skin incisions as on page 144, Fig. 5.4 of the Dissector. Reflect skin and superficial fascia of the gluteal region in one flap to expose the large gluteus maximus muscle. This muscle has proximal attachments to the posteromedial surface of the ilium, posterior surfaces of the sacrum and coccyx, and the sacrotuberous ligament. -
Approach to the Anterior Pelvis (Enneking Type III Resection) Bruno Fuchs, MD Phd & Franklin H.Sim, MD Indication 1
Approach to the Anterior Pelvis (Enneking Type III Resection) Bruno Fuchs, MD PhD & Franklin H.Sim, MD Indication 1. Tumors of the pubis 2. part of internal and external hemipelvectomy 3. pelvic fractures Technique 1. Positioning: Type III resections involve the excision of a portion of the symphysis or the whole pubis from the pubic symphysis to the lateral margin of the obturator foramen. The best position for these patients is the lithotomy or supine position. The patient is widely prepared and draped in the lithotomy position with the affected leg free to allow manipulation during the procedure. This allows the hip to be flexed, adducted, and externally rotated to facilitate exposure. 2. Landmarks: One should palpate the ASIS, the symphysis with the pubic tubercles, and the ischial tuberosity. 3. Incision: The incision may be Pfannenstiel like with vertical limbs set laterally along the horizontal incision depending on whether the pubic bones on both sides are resected or not. Alternatively, if only one side is resected, a curved incision following the root of the thigh may be used. This incision begins below the inguinal ligament along the medial border of the femoral triangle and extends across the medial thigh a centimeter distal to the inguinal crease and perineum, to curve distally below the ischium several centimeters (Fig.1). 4. Full thickness flaps are raised so that the anterior inferior pubic ramus is shown in its entire length, from the pubic tubercle to the ischial spine. Laterally, the adductor muscles are visualized, cranially the pectineus muscle and the pubic tubercle with the insertion of the inguinal ligament (Fig.2). -
Structure of the Human Body
STRUCTURE OF THE HUMAN BODY Vertebral Levels 2011 - 2012 Landmarks and internal structures found at various vertebral levels. Vertebral Landmark Internal Significance Level • Bifurcation of common carotid artery. C3 Hyoid bone Superior border of thyroid C4 cartilage • Larynx ends; trachea begins • Pharynx ends; esophagus begins • Inferior thyroid A crosses posterior to carotid sheath. • Middle cervical sympathetic ganglion C6 Cricoid cartilage behind inf. thyroid a. • Inferior laryngeal nerve enters the larynx. • Vertebral a. enters the transverse. Foramen of C 6. • Thoracic duct reaches its greatest height C7 Vertebra prominens • Isthmus of thyroid gland Sternoclavicular joint (it is a • Highest point of apex of lung. T1 finger's breadth below the bismuth of the thyroid gland T1-2 Superior angle of the scapula T2 Jugular notch T3 Base of spine of scapula • Division between superior and inferior mediastinum • Ascending aorta ends T4 Sternal angle (of Louis) • Arch of aorta begins & ends. • Trachea ends; primary bronchi begin • Heart T5-9 Body of sternum T7 Inferior angle of scapula • Inferior vena cava passes through T8 diaphragm T9 Xiphisternal junction • Costal slips of diaphragm T9-L3 Costal margin • Esophagus through diaphragm T10 • Aorta through diaphragm • Thoracic duct through diaphragm T12 • Azygos V. through diaphragm • Pyloris of stomach immediately above and to the right of the midline. • Duodenojejunal flexure to the left of midline and immediately below it Tran pyloric plane: Found at the • Pancreas on a line with it L1 midpoint between the jugular • Origin of Superior Mesenteric artery notch and the pubic symphysis • Hilum of kidneys: left is above and right is below. • Celiac a. -
Thoracic Cage EDU - Module 2 > Thorax & Spine > Thorax & Spine
Thoracic Cage EDU - Module 2 > Thorax & Spine > Thorax & Spine Thoracic cage • Protects the chest organs (the heart and lungs). Main Structures: The sternum (aka, breastbone) lies anteriorly. 12 thoracic vertebrae lie posteriorly. 12 ribs articulate with the thoracic vertebrae. Sternum • Manubrium (superiorly) • Body (long and flat, middle portion) • Xiphoid process - Easily injured during chest compression (for CPR). • Sternal angle - Where manubrium and body meet - Easily palpated to find rib 2 • Sternal indentations: - Jugular notch (aka, suprasternal notch) is on the superior border of the manubrium. - Clavicular notches are to the sides of the jugular notch; these are where the clavicles (aka, collarbones), articulate with the sternum. - Costal notches articulate with the costal cartilages of the ribs ("costal" refers to the ribs). Rib Types • True ribs - Ribs 1-7; articulate with the sternum directly via their costal cartilages. • False ribs - Ribs 8-12; do not articulate directly with the sternum. - Ribs 11 and 12 are "floating ribs," do not articulate at all with the sternum. 1 / 2 Rib Features • Head - Articulates with the vertebral body; typically comprises two articular surfaces separated by a bony crest. • Neck - Extends from the head, and terminates at the tubercle. • Tubercle - Comprises an articular facet, which is where the rib articulates with the transverse process of the vertebra. • Shaft - Longest portion of the rib, extends from tubercle to rib end. • Angle - Bend in rib, just lateral to tubercle. Rib/vertebra articulation • Head and tubercle of rib articulate with body and thoracic process of vertebrae. Intercostal spaces • The spaces between the ribs • House muscles and neurovascular structures. -
Iliopectineal Ligament As an Important Landmark in Ilioinguinal Approach of the Anterior Acetabulum
International Journal of Anatomy and Research, Int J Anat Res 2019, Vol 7(3.3):6976-82. ISSN 2321-4287 Original Research Article DOI: https://dx.doi.org/10.16965/ijar.2019.274 ILIOPECTINEAL LIGAMENT AS AN IMPORTANT LANDMARK IN ILIOINGUINAL APPROACH OF THE ANTERIOR ACETABULUM: A CADAVERIC MORPHOLOGIC STUDY Ayman Ahmed Khanfour *1, Ashraf Ahmed Khanfour 2. *1 Anatomy department Faculty of Medicine, Alexandria University, Egypt. 2 Chairman of Orthopaedic surgery department Damanhour National Medical Institute Egypt. ABSTRACT Background: The iliopectineal ligament is the most stout anterior part of the iliopectineal membrane. It separates “lacuna musculorum” laterally from “lacuna vasorum” medially. This ligament is an important guide in the safe anterior approach to the acetabulum. Aim of the work: To study the detailed anatomy of the iliopectineal ligament demonstrating its importance as a surgical landmark in the anterior approach to the acetabulum. Material and methods: The material of this work included eight adult formalin preserved cadavers. Dissection of the groin was done for each cadaver in supine position with exposure of the inguinal ligament. The iliopectineal ligament and the three surgical windows in the anterior approach to the acetabulum were revealed. Results: Results described the detailed morphological anatomy of the iliopectineal ligament as regard its thickness, attachments and variations in its thickness. The study also revealed important anatomical measurements in relation to the inguinal ligament. The distance between the anterior superior iliac spine (ASIS) to the pubic tubercle ranged from 6.7 to 10.1 cm with a mean value of 8.31±1.3. The distance between the anterior superior iliac spine (ASIS) to the blending point of the iliopectineal ligament to the inguinal ligament ranged from 1.55 to 1.92 cm with a mean value of 1.78±0.15. -
The Sacroiliac Problem: Review of Anatomy, Mechanics, and Diagnosis
The sacroiliac problem: Review of anatomy, mechanics, and diagnosis MYRON C. BEAL, DD., FAAO East Lansing, Michigan methods have evolved along with modifications in Studies of the anatomy of the the hypotheses. Unfortunately, definitive analysis sacroiliac joint are reviewed, of the sacroiliac joint problem has yet to be including joint changes associated achieved. with aging and sex. Both descriptive Two excellent reviews of the medical literature and analytical investigations of joint on the sacroiliac joint are by Solonen i and a three- movement are presented, as well as part series by Weisl. clinical hypotheses of sacroiliac joint The present treatise will review the anatomy of motion. The diagnosis of sacroiliac the sacroiliac joint, studies of sacroiliac move- joint dysfunction is described in ment, hypotheses of sacroiliac mechanics, and the detail. diagnosis of sacroiliac dysfunction. Anatomy The formation of the sacroiliac joint begins during the tenth week of intrauterine life, and the joint is fully developed by the seventh month. The joint In recent years it has been generally recognized surfaces remain flat until sometime after puberty; that the sacroiliac joints are capable of movement. smooth surfaces in the adult are the exception. The clinical significance of sacroiliac motion, or The contour of the joint surface continues to lack of motion, is still subject to debate. The role of change with age. 2m In the third and fourth decades the sacroiliac joints in body mechanics can be illus- there is an increase in the number and size of the trated by a mechanical analogy. A 1 to 2 mm. mal- elevations and depressions, which interlock and alignment of a bearing in a machine can cause ab- limit mobility. -
1 the Thoracic Wall I
AAA_C01 12/13/05 10:29 Page 8 1 The thoracic wall I Thoracic outlet (inlet) First rib Clavicle Suprasternal notch Manubrium 5 Third rib 1 2 Body of sternum Intercostal 4 space Xiphisternum Scalenus anterior Brachial Cervical Costal cartilage plexus rib Costal margin 3 Subclavian 1 Costochondral joint Floating ribs artery 2 Sternocostal joint Fig.1.3 3 Interchondral joint Bilateral cervical ribs. 4 Xiphisternal joint 5 Manubriosternal joint On the right side the brachial plexus (angle of Louis) is shown arching over the rib and stretching its lowest trunk Fig.1.1 The thoracic cage. The outlet (inlet) of the thorax is outlined Transverse process with facet for rib tubercle Demifacet for head of rib Head Neck Costovertebral T5 joint T6 Facet for Tubercle vertebral body Costotransverse joint Sternocostal joint Shaft 6th Angle rib Costochondral Subcostal groove joint Fig.1.2 Fig.1.4 A typical rib Joints of the thoracic cage 8 The thorax The thoracic wall I AAA_C01 12/13/05 10:29 Page 9 The thoracic cage Costal cartilages The thoracic cage is formed by the sternum and costal cartilages These are bars of hyaline cartilage which connect the upper in front, the vertebral column behind and the ribs and intercostal seven ribs directly to the sternum and the 8th, 9th and 10th ribs spaces laterally. to the cartilage immediately above. It is separated from the abdominal cavity by the diaphragm and communicates superiorly with the root of the neck through Joints of the thoracic cage (Figs 1.1 and 1.4) the thoracic inlet (Fig. -
The Pelvis Structure the Pelvic Region Is the Lower Part of the Trunk
The pelvis Structure The pelvic region is the lower part of the trunk, between the abdomen and the thighs. It includes several structures: the bony pelvis (or pelvic skeleton) is the skeleton embedded in the pelvic region of the trunk, subdivided into: the pelvic girdle (i.e., the two hip bones, which are part of the appendicular skeleton), which connects the spine to the lower limbs, and the pelvic region of the spine (i.e., sacrum, and coccyx, which are part of the axial skeleton) the pelvic cavity, is defined as the whole space enclosed by the pelvic skeleton, subdivided into: the greater (or false) pelvis, above the pelvic brim , the lesser (or true) pelvis, below the pelvic brim delimited inferiorly by the pelvic floor(or pelvic diaphragm), which is composed of muscle fibers of the levator ani, the coccygeus muscle, and associated connective tissue which span the area underneath the pelvis. Pelvic floor separate the pelvic cavity above from the perineum below. The pelvic skeleton is formed posteriorly (in the area of the back), by the sacrum and the coccyx and laterally and anteriorly (forward and to the sides), by a pair of hip bones. Each hip bone consists of 3 sections, ilium, ischium, and pubis. During childhood, these sections are separate bones, joined by the triradiate hyaline cartilage. They join each other in a Y-shaped portion of cartilage in the acetabulum. By the end of puberty the three bones will have fused together, and by the age of 25 they will have ossified. The two hip bones join each other at the pubic symphysis. -
Subcostal TAP, Rectus Sheath
Station 4: Traditional Transversus Abdominis Plane (TAP), Subcostal TAP, Rectus Sheath Station Faculty: Traditional TAP: Adam Amundson, MD David Olsen, MD Indications: o Surgeries that involve the lower abdominal segment (below umbilicus) ie: Pfannenstiel incision for cesarean-section. Ultrasound settings and Patient Position o High Frequency linear probe; Low Frequency linear probe if morbidly obese (38-50 mm footprint) o Supine, arms to sides, performed with patient either sedated or under general anesthesia Surface Anatomy landmarks o Rib cage, costal margin o Iliac Crest, pelvic brim o Mid-axillary line Sonoanatomy – o Start by placing the ultrasound probe between the iliac crest and costal margin at the mid-axillary line o Identify the 3 muscular layers (external oblique EO, internal oblique IO, transversus abdominis TA) and the peritoneum o TIPS: EO is generally hyperechoic, IO is the largest, TA is thin, Bowel/Peritoneum may move EO EO IO IO Superior Superior TA TA Bowel Bowel Suggested Injection Technique- TA o In-plane short axis approach, sonographically guide a 21 g 4 inch needle in between the fascial plane of the IO and TA in the posterior corner (see white arrow below). o Inject 20 mL of dilute long acting local anesthetic per side, or 30 mL if unilateral EO EO IO IO Superior Superior TA Bowel Bowel Bowel o TIP: When entering fascial planes between IO and TA the needle tip is often positioned deep and you may need to slowly pull the needle back while giving small aliquots of fluid to help define the spread of the fascial planes.