Svaly II. Muscles II.

Thorax &back

Muscles of thorax Musculi thoracisthoracohumeralm. pectoralis majorm. pectoralis minorm. subclaviusm. serratus anteriorproper thoracic mm. intercostales (externi, interni, intimi)mm. subcostalesmm. levatores costarumm. transversus thoracisdiaphragma

Leonardo

Thoracohumeral muscles m. pectoralis majorpars clavicularispars sternocostalispars abdominalisRotation of insertion tendon 180

m. pectoralis minorfascia clavipectoralis

nn. pectorales (med.+lat.)

Leonardo

Thoracohumeral muscles m. serratus anteriorthoracoscapular musclen. thoracicus longus

m. subclaviusfascia clavipectoralisn. subclavius

Thoracic fasciaefascia pectoralis covering m. pectoralis majorfascia clavipectoraliscovering m. subclavius and m. pectoralis minorfossa ovalis infraclavicularis Mohrenheimi (for v. cephalica)fascia thoracica superficial fascia of all intercostal spacesfascia endothoracica (f. thoracis parietalis)lining the thoracic cavity

Fascia clavipectoralis

Developmental defectsPolland syndrom

absence of m. pectoralis majorlength reduction of fingers or syndactylia (obviously a defect of induction)3x more in

Breast implants

Proper thoracic muscles mm. intercostales externifrom tuberculum costae to cartilago costalisthen membrana intercostalis externa as far as sternuminspiration

mm. intercostales interni from sternum to angulus costaethen membrana intercostalis interna as far as vertebral columnmm. intercostales intimisimilar to interni, weakerinsertion internally to sulcus costae

expiration

Proper thoracic musclesm. transversus thoracis internal side of sternumexpirationinervation: nn. intercostales 1-6

Proper thoracic musclesmm. subcostales frequently rudimental at anguli costarum deep to mm. intercostales intimi inervation: nn. intercostales

Proper thoracic musclesmm. levatores costarum longi et brevebreves 12 x longi 4 (kaudal) inervation: rr. dorsales ramorum posteriorum nn. spinalium T1-12 !!!

Intercostal spacePunctionat superior margin of rib = at inferior margin of intercostal space

Diaphragma (phren in Greek)mammalia, crocodiles3-5 mm thickmuscular-tendinous membrane separates thoracic and abdominal cavitymain inspiration muscle: 6080% of labormaintain stabilization of thoraco-lumbar transition of vertebral column

Diaphragma developmentWeek 5-12: 4 sourcesseptum transversumorigin cranial to cardiogenic zone

pleuroperitoneal membrans (= primitive diaphragm)1+2 fuses in centrum tendineum

mesoesophageum dorsale crura diaphragmatis

ingrowth of mesenchyme from thedorsolateral body wall future muscles of dorsolateral part

Diaphragma inervation, shapeseptum transversum descensus n. phrenicus C3-5

firstly: frontal plane postitionlater: by growth of lungs and formation of pleural cavities (recessus costodiaphragmatici) typical cupular shape

Diaphragm vaults

right and left diaphragmatic vault 4th athd 5. intercostal space)centrum tendineumpars lumbaliscrus dextrum et sinistrumpars costalispars sternalis trigonum lumbocostale Bochdalekitrigonum sternocostale Morgagni s. Larreyimain inspiration muscleactive in exspiration, tooDiaphragma

Diaphragm vaultslig. arcuatum medianum (aortic arcade) unpairedhiatus aorticus

lig. arcuatum mediale (psoatic arcade) pairedfor m. psoas major

lig. arcuatum laterale (quadratic arcade) pairedfor m. quadratus lumborum

Level of diaphragmatic openingsforamen venae cavae T8hiatus oesophageus T10hiatus aorticus T12

Structures passing via diaphragm

pars lumbalis (crus sin. et dx.) truncus sympathicus, nn. splanchnici,(sometimes v. azygos et hemiazygos)hiatus aorticus (between crura diaphragmatis, border with lig. arcuatum medianum)aorta thoracica/abdominalis, ductus thoracicus (sometimes v. azygos et hemiazygos)hiatus oesophageus (within crura diaphragmatis)oesophagus, truncus vagalis ant.et post. (+ rr. gastrici), rr. oesophageales a. et v. gastricae sin.foramen venae cavae (within centrum tendineum)v. cava inf., rr. phrenicoabdominales n. phrenici dx.trigonum strenocostalenothingventrally to m. transversus thoracis: vasa thoracica interna vasa epigastrica superioratrionum lumbocostalenothing

Diaphragmatic herniaehiatus oesophageus sliding hiatus (hiatal) herniafalse hernia (without peritoneal cover) contains abdominal part of oesophagus, stomach, intestinepara-oesophageal hiatus (hiatal) herniatrue hernia sac appears between the wall of hiatus oesophageus and oesophageus trigonum lumbocostale (rarely)inborn failure of diaphragm parts fusionacquiredtrigonum sternocostale (rarely)

Diaphragmatic herniaesliding hiatus herniapara-oesophageal hiatus hernia

Diaphragmatic herniae

Hernia diaphragmatica posterolateralis congenitalis Bochdaleki

1801 Skipov 1883 LitomiceVincenz AlexanderBochdalek

Giovanni Battista Morgagni1682 1771Italyfounder of pathology

Break 5 minutes

Muscles of backMusculi dorsi

Vertebral columnColumna vertebralis

Developmentepaxial muscules = autochthonous deep dorsal musculesmyoseptum horizontale fish lamina media fasciae thoracolumbalishypaxial muscules = heterochthonous all other muscles:limbs, head, neck, thorax, abdomen + 3 superficial layer dorsal muscules

Development

CTlaminamediafasciaethoraco- lumbalisepaxialmuscles

Muscles of back (Musculi dorsi)4 layers:superficial (first) = spinohumeral musclessecond layer= spinoscapular musclesthird layer= spinocostal musclesfourth layer= deep (proper) dorsal muscles = epaxial muscles

Superficial (first) layerm. trapeziuspars descendenspars transversapars ascendensspeculum rhomboideum C7n. accessorius + C3-C4

m. latissimus dorsin. thoracodorsalisinsertion tendon inverted (180)

Second layerm. levator scapulae C3,4 + n. dorsalis scapulae (C5)

m. rhomboideus minorm. rhomboideus majorn. dorsalis scapulae

Third layerm. serratus posterior superiornn. intercostales 2-5

m. serratus posterior inferiornn. intercostales 9-11 + n. subcostalis

Deep (fourth) layerproper muscles of back

epaxial muscles derivates of somites segmental organization + inervation

inervation: rami posteriores nervorum spinalium

Somites42-44

ramiposterioresnervorumspinalium

Rami posteriores nervorum spinaliumsegmental arrangementno plexusesmixed nervesmotor deep muscles of backsensory skin medially to vertebral column

Deep (fourth) layerMusculi dorsi proprii3 systema due direct fibres:spinotransversal (form V)spinospinal (form I)transversospinal (form A)

short dorsal mmmm. interspinalesmm. intertransversarii

deep neck muscules

ANATOMICAL DEFINATEDMUSCULES

IVA

M. SPINALIS (shape I)thoracis, cervicis, capitisM. LONGISSIMUS (shape V)thoracis (pars lumbalis), cervicis, capitisM. ILIOCOSTALIS (shape V)lumborum (pars lumbalis, thoracica), cervicis

function: bilateral erection (extension) of vertebral column retroflexion of headunilateral lateroflexion and ipsilateral rotation of vertebral columnM. ERECTOR SPINAE

M. SPLENIUS (shape V)cervicis, capitis

function: retroflexion, rotationMM. SPINOSTRANSVERSALES

MM. TRANSVERSOSPINALESM. SEMISPINALIS (shape A)thoracis, cervicis, capitis

function: bilateral erection (extension) of vertebral column retroflexion of headunilateral lateroflexion of vertebral column and head and contralateral rotation

MM. TRANSVERSOSPINALES 2.MM. MULTIFIDI (shape A)lumborum, thoracis, cervicis

function: bilateral erection (extension) of vertebral column retroflexion of headunilateral lateroflexion of vertebral column and head and contralateral rotation

MM. ROTATORESLONGIBREVES(form A)lumborum, thoracis, cervicis

MM. TRANSVERSOSPINALESfunction:bilateral erection (extension)of vertebral column retroflexion of headunilateral lateroflexion of vertebral column and head and contralateral rotation

Deep and short muscles

MM. INTERTRANSVERSARIIMM. INTERSPINALES

function:small muscles contributing to lateroflexion and retroflexion

Suboccipital musclesm. rectus capitis posterior majorm. rectus capitis posterior minorm. obliquus capitis superiorm. obliquus capitis inferior

balance movements of head and C1, C2trigonum suboccipitale (trigonum a. vertebralis)

innervation: n. suboccipitalis (rmaus posterior nervi spinalis C1)

Trigonum suboccipitalecontent:

a. vertebralis (pars atlantica) - running in depth

n. suboccipitalis - emerging

n. occipitalis major passes superficially

Fascia thoracolumbalis3 layerslamina anteriorlamina media = (original myoseptum horizontale in fish)lamina posteriorcovers deep back muscles in lumbar region3 laminae merge laterallyorigin site for 2 (out of 3) lateral abdominal muscles + m. latissimus dorsi

Michaelis rhomboid Rhombus; Rhomboid; Quadrilateral; Sacral quadrangleGustav Adolf Michaelis(1798-1848)German obstetrician

regular rhomboid shape marks correct pelvic proportions and same length of both limbs

Michaelis rhomboid

Topography

Trigonum auscultationiscranially: m. trapeziuscaudally: m. latissimus dorsi laterally: margo medialis scapulae floor: m. rhomboideus major (partially)

6th+7th rib (in protraction of scapulae = anteflexion of vertebral column + crossed hand on chest- project of apex of inferior lobe of lungs- possible point for auscultation

Trigonum lumbale inferius Petiticaudally: crista iliaca (cca 2-3 cm) medially: m. latissimus dorsi laterally: m. obliquus externus abd. floor: m. obliquus internus abd.

inferior lumbal hernia

Trigonum lumbale superius Grynfeltti s. Lesshafticranially: m. serratus post. inf. (sometimes costa XII.) medially:m. iliocostalis lumborum laterally: m. obliquus internus abd. floor: aponeuross m. transversi abd. ceiling: m. latissimus dorsi resp. laterocranially: costa duodecima tetragonum Krausei

n. et vasa subcostalia emergen. iliohypogastricus superior lumbal hernia

Lumbal herniaBleichner herniain lumbar regionattention! danger of confusion with herniation of intervertebral discPetit herniavia Petit triangle (trigonum lumbale inferius) 5%Jean Louis Petit (16741750) French surgeon

Grynfeltt herniavia Grynfeltt-Lesshaft triangle (trigonum lumbale superius) 95 %Joseph Casimir Grynfeltt (18401913) French physicianPjotr Lesshaft Russian physician

Grynfeltt hernia

Petit hernia

Clinical notesbackache vertebrogenic disordersupper crossed syndromelower crossed syndrome

trigger points in muscle contractureslumbar herniaespondylosurgery

Case report, 32 years

year pyrosis (heartburn)last month gastro-oesophageal refluxlast week vomiting after drnking alcohol

normal blood testsnormal size of liver

Case reportdiagnosis:hiatus hernia

Thank you for your attentionDavid Kachlk, Praha 2012AlbinusVesalius

******************