the thorax - imulimul.pl/system/files/thorax - bones joints muscles.pdfthe ribs ribs are curved,...
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THORACICWALLBREAST
THETHORAX
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THETHORAX
• THORACICWALL
• BREAST
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THETHORAX
THORACICWALL
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THETHORAX
Thepartofthebodybetweentheneckandabdomen.Thethoraciccage(ribcage),withthehorizontalbarsformedbyribsandcostalcar;lages,isalsosupportedbythever>calsternum(breastbone)andthoracicvertebrae
THETHORAX-BONES&JOINTS
Thethoracicskeletonincludes:• 12pairsofribsandassociatedcostalcar>lages,• 12thoracicvertebraeandtheintervertebral(IV)discsinterposed
betweenthem,• andthesternum.
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THERIBS
Ribsarecurved,flatbonesthatformmostofthethoraciccage
THETHORAX-BONES&JOINTS
Therearethreetypesofribsthatcanbeclassifiedastypicaloratypical:• true(vertebrosternal)ribs(1st–7thribs)• false(vertebrochondral)ribs(8th,9th,andusually10thribs)• floa;ng(vertebral,free)ribs(11th,12th,andsome>mes10thribs)
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THERIBS
Therearethreetypesofribsthatcanbeclassifiedastypicaloratypical:• true(vertebrosternal)ribs(1st–7thribs):theyaWachdirectlytothesternumthroughtheirowncostalcar>lages.• false(vertebrochondral)ribs(8th,9th,andusually10thribs):theircar>lagesareconnectedtothecar>lageoftheribabovethem;thustheirconnec>onwiththesternumisindirect.• floa;ng(vertebral,free)ribs(11th,12th,andsome;mes10thribs):therudimentarycar>lagesoftheseribsdonotconnectevenindirectlywiththesternum;insteadtheyendintheposteriorabdominalmusculature.
THETHORAX-BONES&JOINTS
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THERIBS THETHORAX-BONES&JOINTS
Typicalribs(3rd–9th)havethefollowingcomponents:•Head:hastwofacets,oneforar>cula>onwiththenumericallycorrespondingvertebraandonefacetforthevertebrasuperiortoit.•Neck:connectstheheadoftheribwiththebodyatthelevelofthetubercle.•Tubercle:ar>culateswiththecorrespondingtransverseprocessofthevertebra,•Body(sha[):thin,flat,andcurved.
Typicalribs(3rd–9th)havethefollowingcomponents:•Head•Neck•Tubercle•Body
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THERIBS THETHORAX-BONES&JOINTS
ATYPICALRIBS(1st,2nd,and10th–12th)aredissimilar:• the1stribisthebroadest(i.e.,itsbodyiswidestandnearly
horizontal),shortest,andmostsharplycurved
• the1stribhasasinglefacetonitsheadforar>cula>onwiththeT1vertebraonly
• the1stribhastwotransverselydirectedgroovescrossingitssuperiorsurfaceforthesubclavianvessels
• the1stribhasthegroovesseparatedbyascalenetubercleandridge,towhichtheanteriorscalenemuscleisaWached.
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THERIBS THETHORAX-BONES&JOINTS
Atypicalribs(1st,2nd,and10th–12th)aredissimilar:• the2ndribishasathinner,lesscurvedbody• hastwofacetsforar>cula>onwiththebodiesoftheT1andT2
vertebrae
Atypicalribs(1st,2nd,and10th–12th)aredissimilar:• The10th–12thribs,likethe1strib,haveonlyonefacetontheirheadsandar;culatewithasinglevertebra.
Atypicalribs(1st,2nd,and10th–12th)aredissimilar:•The11thand12thribsareshortandhavenoneckortubercle.
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THECOSTALCARTILAGES THETHORAX-BONES&JOINTS
Costalcar;lagesprolongtheribsanteriorlyandcontributetotheelas>cityofthethoracicwall,providingaflexibleaWachmentfortheiranteriorends(>ps).
Intercostalspacesseparatetheribsandtheircostalcar>lagesfromoneanother
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THETHORACICVERTEBRAE THETHORAX-BONES&JOINTS
Characteris>cfeaturesofthoracicvertebraeinclude:• Bilateralcostalfacets(demifacets)onthevertebralbodies,usually
occurringininferiorandsuperiorpairs,forar>cula>onwiththeheadsofribs.
• Costalfacetsonthetransverseprocessesforar>cula>onwiththetuberclesofribs,exceptfortheinferiortwoorthreethoracicvertebrae.
• Long,inferiorlyslan>ngspinousprocesses.
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THETHORACICVERTEBRAE THETHORAX-BONES&JOINTS
Superiorandinferiorcostalfacetsoccurasbilaterallypaired,planarsurfacesonthesuperiorandinferiorposterolateralmarginsofthebodiesoftypicalthoracicvertebrae(T2–T9).
Atypicalthoracicvertebrae:• ThesuperiorcostalfacetsofvertebraT1arenotdemifacetsbecause
therearenodemifacetsontheC7vertebraabove,andrib1ar;culatesonlywithvertebraT1.T1hasatypicalinferiorcostalfacet.
• T10hasonlyonebilateralpairof(whole)costalfacets,locatedpartlyonitsbodyandpartlyonitspedicle.
• T11andT12alsohaveonlyasinglepairof(whole)costalfacets,locatedontheirpedicles.
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THESTERNUM THETHORAX-BONES&JOINTS
Thesternumistheflat,elongatedbonethatformsthemiddleoftheanteriorpartofthethoraciccage.
Thesternumconsistsofthreeparts:• manubrium,• body,and• xiphoidprocess
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THESTERNUM THETHORAX-BONES&JOINTS
Theeasilypalpatedconcavecenterofthesuperiorborderofthemanubriumisthejugularnotch(suprasternalnotch).
ThejugularnotchliesattheleveloftheinferiorborderofthebodyofT2vertebraandthespacebetweenthe1stand2ndthoracicspinousprocesses.
Themanubriumandbodyofthesternumlieinslightlydifferentplanessuperiorandinferiortotheirjunc>on,
themanubriosternaljoint;hence,theirjunc>onformsaprojec>ngsternalangle(ofLouis).
Inferolateraltotheclavicularnotch,thecostalcar>lageofthe1stribis>ghtlyaWachedtothelateralborderofthemanubrium–
-thesynchondrosisofthefirstrib
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THESTERNUM THETHORAX-BONES&JOINTS
Thebodyofthesternum,islonger,narrower,andthinnerthanthemanubrium,andislocatedattheleveloftheT5–T9vertebrae
Thexiphoidprocess,thesmallestandmostvariablepartofthesternum,isthinandelongated.ItsinferiorendliesatthelevelofT10vertebra.
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THESTERNUM THETHORAX-BONES&JOINTS
Thexiphisternaljointisamidlinemarkerforthesuperiorlimitoftheliver,thecentraltendonofthediaphragm,andtheinferiorborderoftheheart.
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JOINTSOFTHORACICWALL THETHORAX-BONES&JOINTS
• Intervertebral(ofvertebraeT1–T12)• Costovertebral(jointsofheadofrib)• Costochondral• Interchondral• Sternocostal• Sternoclavicular• Manubriosternal
• Xiphisternal
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JOINTSOFTHORACICWALL THETHORAX-BONES&JOINTS
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JOINTSOFTHORACICWALL THETHORAX-BONES&JOINTS
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THETHORAX-BONES&JOINTS
THETHORACICAPERTURES
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THETHORAX-BONES&JOINTS
Whilethethoraciccageprovidesacompletewallperipherally,itisopensuperiorlyandinferiorly.
THETHORACICAPERTURES
Themuchsmallersuperioropening(aperture)isapassagewaythatallowscommunica>onwiththeneckandupperlimbs.
Thelargerinferioropeningprovidesthering-likeoriginofthediaphragm,whichcompletelyoccludestheopening.
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THETHORACICAPERTURES
TheSUPERIORTHORACICAPERTUREisbounded:•Posteriorly,byvertebraT1,thebodyofwhichprotrudesanteriorlyintotheopening.•Laterally,bythe1stpairofribsandtheircostalcar>lages.•Anteriorly,bythesuperiorborderofthemanubrium.
THETHORAX-BONES&JOINTS
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THETHORACICINLETSpace-occupyingtumoursinthisloca>onmaycompressadjacentstructures,leadingtotheclinicalcondi>oncalledthoracicoutletsyndrome.
THETHORAX-BONES&JOINTSTHETHORACICAPERTURES
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Inferiorlythecavityofthethoraxisseparatedfromtheabdominalcontentsbyafibromuscularsheetcalledthediaphragm.
THETHORAX-BONES&JOINTSTHETHORACICAPERTURES
Thefloorofthethoraciccavity(thoracicdiaphragm)isdeeplyinvaginatedinferiorly(i.e.,ispushedupward)byvisceraoftheabdominalcavity.
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TheINFERIORTHORACICAPERTUREisboundedasfollows:•Posteriorly,bythe12ththoracicvertebra,thebodyofwhichprotrudesanteriorlyintotheopening.•Posterolaterally,bythe11thand12thpairsofribs.•Anterolaterally,bythejoinedcostalcar>lagesofribs7–10,formingthecostalmargins.•Anteriorly,bythexiphisternaljoint.
THETHORAX-BONES&JOINTSTHETHORACICAPERTURES
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THEMUSCLESOFTHETHORAX
MUSCLESOFTHORACICWALL
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THEMUSCLESOFTHETHORAX
MUSCLESOFTHEPECTORALREGION:• Pectoralismajor• Subclavius• Pectoralisminor
THETHORAX
• Lateralandmedialpectoralnerves
• Medialpectoralnerve
• Nervetosubclavius
Thepectoralismajormuscleisthelargestandmostsuperficialofthepectoralregionmuscles.
Thesubclaviusandpectoralisminormusclesunderliepectoralismajor:• subclaviusissmallandpasseslaterallyfromtheanteriorand
medialpartofribItotheinferiorsurfaceoftheclavicle;• pectoralisminorpassesfromtheanteriorsurfacesofribsIIItoVto
thecoracoidprocessofthescapula.
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THEMUSCLESOFTHETHORAX
Themusclesofthepectoralregionformtheanteriorwalloftheaxilla,aregionbetweentheupperlimbandtheneckthroughwhichallmajorstructurespass.
THETHORAX
Nerves,vessels,andlympha>csthatpassbetweenthepectoralregionandtheaxillapassthroughtheclavipectoralfasciabetweensubclaviusandpectoralisminororpassundertheinferiormarginsofpectoralismajorandminor.
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THEMUSCLESOFTHETHORAX
Thetruemusclesofthethoracicwallarethe:serratusposterior,levatorescostarum,intercostal,subcostal,andtransversusthoracis.
THEMUSCLES
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THEMUSCLESOFTHETHORAX
Thelevatorescostarummusclesare12fan-shapedmusclesthatelevatetheribs,buttheirrole,ifany,innormalinspira>onisuncertain.
THEMUSCLES
Theintercostalmusclesoccupytheintercostalspaces
Thesuperficiallayer-theexternalintercostals,theinnerlayer-theinternalintercostals.Thedeepestfibers-theinnermostintercostals.
Theexternalintercostalmuscles(11pairs)occupytheintercostalspacesfromthetuberclesoftheribsposteriorlytothecostochondraljunc>onsanteriorly.
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THEMUSCLESOFTHETHORAX
Theexternalintercostalmusclesarecon>nuousinferiorlywiththeexternalobliquemusclesintheanterolateralabdominalwall.
THEMUSCLES
Theinternalintercostalmuscles(11pairs)rundeeptoandatrightanglestotheexternalintercostals.
Betweentheribsposteriorly,medialtotheangles,theinternalintercostalsarereplacedbytheinternalintercostalmembranes.
Theinferiorinternalintercostalmusclesarecon>nuouswiththeinternalobliquemusclesintheanterolateralabdominalwall.
Theinnermostintercostalmusclesaresimilartotheinternalintercostalsandareessen>allytheirdeeperparts.
Theinnermostintercostalsareseparatedfromtheinternalintercostalsbyintercostalnervesandvessels
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THEMUSCLESOFTHETHORAX
Thesubcostalmusclesarevariableinsizeandshape,usuallybeingwelldevelopedonlyinthelowerthoracicwall.
THEMUSCLES
Thetransversusthoracismusclesconsistoffourorfiveslipsthatradiatesuperolaterallyfromtheposterioraspectoftheinferiorsternum.
Theexternalandinternalintercostalsareac>veduringinspira;onandexpira;on.Theroleofthesemusclesinproducingmovementoftheribsappearstoberelatedmainlytoforcedrespira;on.
Theprimaryroleoftheintercostalmusclesinrespira>onistosupport(increasethetonusorrigidityof)theintercostalspace.
Thediaphragmistheprimarymuscleofinspira>on.
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NERVESOFTHETHORACICWALL
The12pairsofthoracicspinal
nervessupplythethoracicwall.
THERESPIRATORYSYSTEM
AssoonastheyleavetheIVforaminainwhichtheyareformed,themixedthoracicspinalnervesdivideinto
anteriorandposterior(primary)ramiorbranches
TheanteriorramiofnervesT1–T11formtheintercostalnerves
thatrunalongtheextentoftheintercostalspaces.
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NERVESOFTHETHORACICWALL
Neartheanglesoftheribs,thenervespassbetweentheinternalintercostalandtheinnermostintercostalmuscles.Atthispoint,theintercostalnervespasstoandthencon>nuetocourseinorjustinferiortothecostalgrooves,runninginferiortotheintercostalarteries.
THERESPIRATORYSYSTEM
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NERVESOFTHETHORACICWALL
Thebranchesofatypicalintercostalnerveare:• Ramicommunicantes,orcommunica>ngbranches,thatconnect
eachintercostalnervetotheipsilateralsympathe>ctrunk.• Collateralbranchesthatariseneartheanglesoftheribs• LateralcutaneousbranchesthatariseneartheMAL• Anteriorcutaneousbranchespiercethemusclesandmembranes
oftheintercostalspace• Muscularbranchesthatsupplytheintercostal,subcostal,
transversusthoracis,levatorescostarum,andserratusposteriormuscles
THERESPIRATORYSYSTEM
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ARTERIESOFTHORACICWALL
Thearterialsupplytothethoracicwallderivesfromthe:• Thoracicaorta,throughtheposteriorintercostalandsubcostal
arteries.
• Subclavianartery,throughtheinternalthoracicandsupremeintercostalarteries.
• Axillaryartery,throughthesuperiorandlateralthoracicarteries.
THERESPIRATORYSYSTEM
Theintercostalarteriescoursethroughthethoracicwallbetweentheribs.
Eachintercostalspaceissuppliedbythreearteries:alargeposteriorintercostalartery(anditscollateralbranch)anda
smallpairofanteriorintercostalarteries.
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VEINSOFTHORACICWALL THERESPIRATORYSYSTEMVEINSOFTHORACICWALL
Thereare11posteriorintercostalveinsandonesubcostalveinoneachside.Theposteriorintercostalveinsanastomosewiththeanteriorintercostalveins(tributariesofinternalthoracicveins).Mostposteriorintercostalveins(4–11)endintheazygos/hemi-azygosvenoussystem,whichconveysvenousbloodtothesuperiorvenacava(SVC).Theposteriorintercostalveinsofthe1stintercostalspaceusuallyenterdirectlyintotherightandle[brachiocephalicveins.
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THEBREASTS
THERESPIRATORYSYSTEM
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BREASTSThebreastsconsistofglandularandsuppor>ngfibrous;ssueembeddedwithinafaWymatrix,togetherwithbloodvessels,lympha>cs,andnerves.
THEBREASTS
Themammaryglandsareinthesubcutaneous>ssueoverlyingthepectoralismajorandminormuscles.
Atthegreatestprominenceofthebreastisthenipple,surroundedbyacircularpigmentedareaofskin,theareola
Theroughlycircularbodyofthefemalebreastrestsonabedofthebreastthatextendstransverselyfromthelateralborderofthesternumtothemidaxillarylineandver>callyfromthe2ndthrough6thribs.
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FEMALEBREASTSTwothirdsofthebedareformedbythepectoralfasciaoverlyingthepectoralismajor;theotherthird,bythefasciacoveringtheserratusanterior.
THEBREASTS
Betweenthebreastandthepectoralfasciaisaloosesubcutaneous>ssueplaneorpoten>alspace–-theretromammaryspace.
Asmallpartofthemammaryglandmayextendalongtheinferolateraledgeofthepectoralismajortowardtheaxillaryfossa
(armpit),forminganaxillaryprocessortail(ofSpence).
ThemammaryglandsarefirmlyaWachedtothedermisoftheoverlyingskin,especiallybysubstan>alskinligaments,
thesuspensoryligamentsofCooper.
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FEMALEBREASTSThesecondensa>onsoffibrousconnec>ve>ssue,par>cularlywelldevelopedinthesuperiorpartofthegland,helpsupportthelobesandlobulesofthemammarygland.
THEBREASTS
Thelac;ferousductsgiverisetobudsthatdevelopinto15–20lobulesofthemammarygland,whichcons>tutetheparenchyma(func>onalsubstance)ofthemammarygland.
Thuseachlobuleisdrainedbyalac;ferousduct.
Eachducthasadilatedpor>ondeeptotheareola,thelac;feroussinus,inwhichasmalldropletofmilkaccumulates
orremainsinthenursingmother.
Theareolaecontainnumeroussebaceousglands,whichenlargeduringpregnancyandsecreteanoilysubstance
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FEMALEBREASTSThenipplesareconicalorcylindricalprominencesinthecentersoftheareolae.
THEBREASTS
Themammaryglandsaremodifiedsweatglands;therefore,theyhavenocapsuleorsheath.
Inmostwomen,thebreastsenlargeslightlyduringthemenstrualperiodfromincreasedreleaseofgonadotropichormones:follicle-s;mula;nghormone(FSH)andluteinizinghormone(LH)-ontheglandular>ssue.
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VASCULATUREOFBREASTSThearterialsupplyofthebreastderivesfromthe:• Medialmammarybranchesofperfora>ngbranchesandanterior
intercostalbranchesoftheinternalthoracicartery,origina>ngfromthesubclavianartery.
• Lateralthoracicandthoraco-acromialarteries,branchesoftheaxillaryartery.
• Posteriorintercostalarteries,branchesofthethoracicaortainthe2nd,3rd,and4thintercostalspaces.
THEBREASTS
Thevenousdrainageofthebreastismainlytotheaxillaryvein,butthereissomedrainagetotheinternalthoracicvein.
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VASCULATUREOFBREASTS THEBREASTS
Thelympha;cdrainageofthebreastisimportantbecauseofitsroleinthemetastasisofcancercells.
Lymphpassesfromthenipple,areola,andlobulesoftheglandtothesubareolarlympha;cplexus.
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VASCULATUREOFBREASTSFromthesubareolarlympha;cplexus:• mostlymph(>75%),especiallyfromthelateralbreastquadrants,
drainstotheaxillarylymphnodes,ini>allytotheanteriororpectoralnodesforthemostpart.
• mostoftheremaininglymph,par>cularlyfromthemedialbreastquadrants,drainstotheparasternallymphnodesortotheoppositebreast.
• lymphfromtheinferiorquadrantsmaypassdeeplytoabdominal
lymphnodes(subdiaphragma>cinferiorphreniclymphnodes).
THEBREASTS
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VASCULATUREOFBREASTSLymphfromtheaxillarynodesdrainsintoclavicular(infraclavicularandsupraclavicular)lymphnodesandfromthemintothesubclavianlympha;ctrunk,whichalsodrainslymphfromtheupperlimb.
THEBREASTS
Lymphfromtheparasternalnodesentersthebronchomedias>nallympha>ctrunks,whichalsodrainlymphfromthethoracicviscera.Thetermina>onofthelympha>ctrunksvaries.
Thesetrunksaredescribedasmergingwitheachotherandwiththejugularlympha;ctrunk,drainingtheheadandnecktoformashortrightlympha;cductontherightsideorenteringthetermina>onatthethoracicductonthele[side.
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VASCULATUREOFBREASTS
Thetrunksopenindependentlyintothejunc>onoftheinternaljugularandsubclavianveins,therightorledvenousangles,thatformtherightandle[brachiocephalicveins.
THEBREASTS
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NERVESOFBREASTSThenervesofthebreastderivefromanteriorandlateralcutaneousbranchesofthe4th-6thintercostalnerves.
THEBREASTS
Thebranchesoftheintercostalnervesconvey:• sensoryfibersfromtheskinofthebreast• sympathe;cfiberstothebloodvesselsinthebreastsandsmooth
muscleintheoverlyingskinandnipple.