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THE THORAX

Bernadett Pua Velasco, M.D.


Thorax
 Chest
 Regionof the body between the neck and
abdomen
 Framework: thoracic cage
Surface landmarks of the thorax
ANTERIOR CHEST WALL
 Suprasternal notch
 Sternal angle (angle of louis)
 Xiphoid process
 Subcostal angle
 Costal margin
 Clavicle
 Ribs
 Nipple
Surface landmarks of the thorax
POSTERIOR CHEST WALL
 Spinous process of thoracic vertebrae
 Scapula
 Superior angle
 Spine
 Inferior angle
Lines of Orientation
 Midsternal
 Midclavicular
 Anterior axillary
 Posterior axillary
 Midaxillary
 Scapular
Lines of Orientation
 Midsternal
 Midclavicular
 Anterior axillary
 Posterior axillary
 Midaxillary
 Scapular
Lines of Orientation
 Midsternal
 Midclavicular
 Anterior axillary
 Posterior axillary
 Midaxillary
 Scapular
Thoracic Cage
 Anterior: sternum and costal cartilages
 Lateral: ribs and intercostal spaces
 Posterior: thoracic vertebrae
Thoracic Cage
 Protects
the lungs and heart
 Attachment for the muscles of thorax, UE,
abdomen and back
Thoracic Cavity
 Median: mediastinum
 heart

 Lateral
 Pleura and lungs
Openings of the Thorax
 Thoracic outlet (inlet)
 Anterior: superior part of manubrium sterni
 Lateral: 1st ribs
 Posterior: T1
Openings of the Thorax
Lower opening
 Anterior: xiphisternal joint
 Lateral: costal margin
 Posterior: T12
Structure of the Thoracic Wall
 Anterior: sternum and costal cartilages
 Lateral: ribs and intercostal spaces
 Posterior: thoracic vertebra
 Superior: suprapleural membrane
 Inferior: diaphragm
Sternum
 Flatbone
 3 parts:
 Manubrium sterni
 Body of the sternum
 Xiphoid process
Costal Cartilages
 Hyaline cartilage
 Connects the upper 7 ribs to the sternum
and the 8th-10th ribs to the cartilage above
them
 Function: gives elasticity and mobility of
the thoracic wall
Ribs
 12 pairs
 Attached posteriorly in the thoracic
vertebrae
 1st 7 pairs: attached anteriorly in the
sternum
 8th-10th pairs: attached to each other and
to 7th rib via costal cartilages
 11th-12th pairs: no anterior attachment
Typical Rib
 Long, twisted, flat bone
 Superior border: round and smooth
 Inferior border: sharp and thin, has costal
groove
Typical Rib
 Head
 Neck
 Tubercle
 Shaft
 Angle
Intercostal Spaces
3 muscles of respiration
 External intercostals
 Internal intercostals
 Innermost intercostals
External Intercostal Muscles
 Superficial layer
 Downward and forward
 tubercle to the costochondral junction
 Anterior intercostal membrance
Internal Intercostal Muscle
 Intermediate layer
 Downward and backward
 Sternum to the angle of the ribs
 Posterior intercostal membrane
Innermost Intercostal Muscle
 Deepest layer
 Incomplete muscle layer
 Crosses more than one intercostal space
 Internal: endotracheal fascia and parietal
pleura
 External: intercostal nerves and vessels
Suprapleural Membrane
 Dense fascial layer
 Lateral: medial border of 1st rib
 Superior: tip of C7 transverse process
 Medial: investing layer of the thorax into
the neck
 Functions: resists changes in intrathoracic
pressure and protects cervical pleura
Endotracheal Fascia
 Thin layer of connective tissue
 Function: separates parietal pleura to the
thoracic wall
Diaphragm
 Primarymuscle of respiration
 Dome shaped
 Openings:
 Aortic-thoracic duct, azygos vein
 Esophageal- vagus nerves, (L) gastric vessels
 Caval- terminal branches of ® phrenic nerve
Thoracic Cavity
 Median (mediastinum)
 Lateral
Mediastinum
 Movable partition
 Superior: thoracic outlet, root of the neck
 Inferior: diaphragm
 Anterior: sternum
 Posterior: T12
Mediastinum
 Content: thymus, heart and large blood
vessels, trachea, esophagus, thoracic duct
and LN, vagus and phrenic nerve,
sympathetic trunk
Mediastinum
 Superior
 Inferior
 Anterior
 Middle
 posterior
Superior Mediastinum
 Anterior:manubrium sterni
 Posterior: T1-T4
 Content: thymus, large veins and arteries,
trachea, esophagus, thoracic duct,
sympathetic trunk
Inferior Mediastinum
 Anterior:body of sternum
 Posterior: T5-T12
 Content: thymus, heart within the
pericardium, phrenic nerve, esophagus,
thoracic duct, descending aorta,
sympathetic trunk
Pleurae
 Parietal:lines the thoracic wall
 Visceral: covers the outer surface of the
lungs
Pleural Space
 Slitlikespace
 Filled with pleural fluid
 Function: covers the surface of the pleura
and minimizes friction
Visceral Pleura
 Approximates the surface of the lungs
 Pulmonary plexus (ANS)
 Sensitive to stretch
 insensitive to pain and touch
Parietal Pleura
 Cervical
 Costal
 Diaphragmatic
 Mediastinal
Parietal Pleura
 Sensitive to touch, pain, T, P
 Costal: intercostal nerves
 Mediastinal: phrenic nerves
 Diaphragmatic: phrenic nerves and lower
6 intercostal nerves
Costodiaphragmatic recess
 Scapular line: 2 inches
 MAL: 3 inches
 MCL: 1 inch
Surface Landmarks of the Pleura
 Cervical: 2.5cm above the junction of
medial and mid 3rd of clavicle
 Anterior:
 ®- behind the SCJ to the XS
 (L)- same as ®
4thCC= lateral margin of sternum (cardiac notch)
then going sharply to the XSJ
Surface Landmarks of the Pleura

 Posterior
 MCL: 8th rib
 MAL: 10thrib
 Lateral border of erector spinae: 12th rib
Trachea
 Mobile tube
 5 inches long, 1 inch in diameter
 Fibroelastic wall with U-shaped bars of
hyaline cartilage
 Lined with trachealis posteriorly
Trachea
 From the cricoid cartilage (C6) to the
sternal angle (T4)
 Bifurcates into bronchus (Carina)
 Branches of the vagus and recurrent
laryngeal nerves
 Sympathetic trunk
Trachea
 Anterior: sternum, thymus, (L)
brachiocephalic vein, origins of BC and (L)
CC artery, arch of aorta
 Posterior: esophagus, (L) recurrent
laryngeal nerve
 ®: azygos vein, ® vagus nerve, pleura
 (L): arch of aorta, (L) CC artery, (L)
subclavian artery, (L) vagus nerve, (L)
phrenic nerve, pleura
Right Main Bronchus
 Wider, shorter, more vertical
 2.5cm long
 Divisions
 Superior lobar
 Middle lobar
 Inferior lobar
Left Main Bronchus
 Narrower, longer, more horizontal
 5cm long
 Divisions:
 Superior lobar
 Inferior lobar
Lungs
 Conical in shape
 Situated on either side of the mediastinum
 Covered with visceral pleura
 Blunt apex
 Concave base
 Convex costal surface
 Concave mediastinal surface
Lungs
 Medially: hilum
 Left lung: cardiac notch
Right Lung
 Slightlylarger
 Divided:
 Upper
 Middle
 lower
Left Lung
 Divided:
 Upper
 Lower
Lung Fissures
 Oblique fissure:
 Inferior
border upward and backward across
the medial and costal surfaces until it reaches
the posterior border 2 ½ inches below the
apex
Lung Fissures
 Oblique fissure:
 Rootof the scapular spine, obliquely
downward, laterally and anteriorly, following
the course of the 6th rib to the 6th CC junction

Lung Fissures
 Horizontal fissure:
 Across the costal surface at the level of 4th
costal cartilages to meet the oblique fissure
in the MAL
Lung Fissures
 Horizontal fissure:
 4th CC to meet the oblique fissure in MAL
Bronchopulmonary Segment
 Anatomic,
functional and surgical units
 Components:
 Segmental bronchus
 Branch of pulmonary artery
 Lymphatic vessel
 Autonomic nerve supply
Bronchopulmonary Segment
 Primary (Main) bronchus
 Secondary (Lobar) bronchus
 Tertiary (Segmental) bronchus
Bronchopulmonary Segment
 Subdivision of the lung lobe
 Pyramid in shape
 Surrounded by connective tissue
 Has segmental bronchus, segmental
artery, lymph vessels, autonomic nerves
 Segmental vein lies between the adjacent
bronchopulmonary segment
 Can be removed surgically
Bronchopulmonary Segment
 Right lung
 Superior
Apical, posterior, anterior
 Middle
Lateral, medial
 Inferior
Superior (apical), medial basal, anterior basal,
lateral basal, posterior basal
Bronchopulmonary Segment
 Left lung
 Superior
Apical, posterior, anterior, superior lingular, inferior
lingular
 Inferior
Superior (apical), medial basal, anterior basal,
lateral basal, posterior basal
Bronchopulmonary Segment
 Main bronchus
 Lobar bronchus
 Segmental bronchus
 Bronchioles
 Terminal bronchioles
 Respiratory bronchioles
 Alveolar ducts
 Alveolar sacs
Respiratory Zone
 Respiratory bronchiole
 Alveolar duct
 Alveoli
Alveoli
 Alveolar duct
 Alveolar sac
 Alveolus
Lungs
 Bronchial arteries  descending aorta
 Bronchial veins azygos and hemiazygos
veins
 Pulmonary artery alveoli
 Pulmonary vein left atrium

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