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Anatomy of the Thorax

LSS Year 1
Anil Chopra

Contents..........................................................................................................................1 Thorax 1 Anatomy of the Chest Wall.........................................................................2 Thorax 2 Lungs, Pleura and Diaphragm..................................................................... Thorax ! "uperior #ediastinum and $reat %essels..................................................1& Thorax ' (rganisation of )er*es in the Thorax #on 2&th +e, 2--.....................!Thorax / Lymphati0 "ystem, 1reasts and 1reast Can0er ........................................'2 Thorax & The Posterior #ediastinum .......................................................................'.

Thorax 1 Anatomy of the Chest Wall

Anil Chopra 1. Demonstrate the position of the pe0toralis ma2or on the 0hest 3all. Large #us0le that 0o*ers the anterior 4front5 aspe0t of the 0hest 3all and has t3o heads.

2. Define the atta0hments of the pe0toralis ma2or. Consists of the 0la*i0ular head 4originates from the 0la*i0le5 and the sterno0ostal head 4originates from the sternum and 0ostal 0artilages5.

!. (utline the a0tions of the pe0toralis ma2or. 2

Contra0ts 3hen pushing. '. )ame the spa0e ,et3een ad2a0ent ri,s 6nter0ostal "pa0es /. )ame and summarise the fun0tions of the mus0les 3hi0h are found ,et3een ri,s 6nter0ostal mus0les. There are !7 8xternal inter0ostal mus0les arti0ulates do3n3ard and laterally 6nternal inter0ostal mus0les arti0ulates perpendi0ular to external inter0ostals. 6nnermost inter0ostal mus0les fairly tri*ial. Their 2o, is to mo*e the ri,s as 3ell as stiffen the 0hest 3all impro*ing effi0ien0y of ,reathing mo*ements. 9ust ,elo3 ea0h ri, in the Costal groo*e, starting from the top, there is the inter0ostal *ein, artery and then the ner*e 4%A)5.

&. 6dentify a ri, and ,e a,le to determine 3hi0h part of the ri, is pla0ed posteriorly and 3hi0h anteriorly. :ead of ri, is on posterior, then ne0; and angle. Costal 0artilage is anterior.


.. )ame the stru0tures 3ith 3hi0h a ri, arti0ulates. Posteriorly the ri,s arti0ulate 3ith the thora0i0 *erte,ra. 4T1<T125 Anteriorly =i, 1 has 0ostal 0artilage atta0hed to manu,rium. =i, 2 has 0ostal 0artilage atta0hed to the manu,riosternal 2oint. =i,s ! & ha*e 0ostal 0artilage atta0hed to ,ody of sternum. =i, . has 0ostal 0artilage atta0hed to xiphisternal 2oint. =i,s > 1- ha*e 0ostal 0artilage atta0hed to that of a,o*e ri,. =i,s 11 ? 12 do not 2oin to anything. All the 2oints ,et3een the 0ostal 0artilages and the sternum are smooth syno*ial 2oints. =i,s 1<. are True ri,s =i,s ><1- are +alse ri,s =i,s 11?12 are +loating ri,s

>. 6dentify the 0la*i0le and demonstrate ho3 it is positioned in the ,ody. Cla*i0le is also ;no3n as the @0ollar,oneA and is found on the anterior side of the ,ody, 2ust superior to the first ri,. #edially, it arti0ulates 3ith the manu,rium of the sternum 4,reast<,one5 at the sterno0la*i0ular 2oint. Laterally end it arti0ulates 3ith the a0romion of the s0apula 4shoulder ,lade5 at the a0romio0la*i0ular 2oint. . 6dentify the s0apula and demonstrate ho3 it is positioned in the ,ody. "0apula is also ;no3n as the @shoulder ,ladeA and is found on the posterior side of the ,ody. Together 3ith the 0la*i0le it ma;es up the pe0toral girdle. The s0apula 0onne0ts the humerus 4arm ,one5 3ith the 0la*i0le 40ollar ,one5.


1-. 6dentify a thora0i0 *erte,ra. There are 12 thora0i0 *erte,rae T1< T12. 8a0h 0orresponds to a ri,. 11. )ame the different parts of a thora0i0 *erte,ra.

12. 8xplain ho3 ri,s are related to the thora0i0 *erte,rae. 8a0h *erte,ra arti0ulates using the inferior and superior fa0ets 4at the head of the ri,5 and also the arti0ular part of the tu,er0le. The head of the ri, arti0ulates the superior demifa0et 4near the ,ody of the *erte,rae5 The arti0ulate part of the tu,er0le arti0ulates 3ith a fa0et on the trans*erse pro0ess 4the 3ing li;e pro2e0tions5 The arti0ulations ,et3een the thora0i0 *erte,rae and the ri,s are 0alled *erte,ro0ostal 2oints. The *erte,rae also atta0h to ea0h other *ia the fa0ets of the superior arti0ular pro0ess.

1!. 8xplain ho3 *erte,rae arti0ulate 3ith ea0h other and ho3 they support loads and a,sor, 2olts.

%erte,rae arti0ulate 3ith ea0h other ,y thin inter*erte,ral dis0s ,et3een them 43hi0h also limits mo*ement5 The dis; is made of 0artilage. 6t is therefore a syno*ial 2oint. 8a0h dis0 has an outer fi,rous ring 0onsisting of fi,ro0atilage 0alled annulus fi,rosus and an inner soft, pulpy, highly elasti0 su,stan0e 0alled the nu0leus pulposus. The dis0s form strong 2oints, permit *arious mo*ements of the *erte,ral 0olumn and a,sor, *erti0al sho0;. Bnder 0ompression, they flatten, ,roaden and ,ulge from their inter*erte,ral spa0es.


Thorax 2 Lungs, Pleura and Diaphragm

Anil Chopra 1. )ame the 0ontents of an inter0ostal spa0e.

6nter0ostal spa0e 0ontains7 8xternal inter0ostal mus0les 6nternal inter0ostal mus0les 6nnermost inter0ostal mus0les 6nter0ostal Vein 4in 0ostal groo*e5 6nter0ostal Artery 4in 0ostal groo*e5 6nter0ostal Ner*e 4in 0ostal groo*e5 Collateral ,ran0hes 2. Define the pleura. The pleura is a layer of flattened 0ells supported ,y 0onne0ti*e tissue that lines ea0h pleural 0a*ity and 0o*ers the exterior of the lungs.

!. )ame the layers of the pleura. Pleura 0onsist of 2 layers7 %is0eral Pleura7 this 0o*ers the surfa0e of the lungs and is the innermost layer. Parietal Pleura7 this lines the innermost surfa0e of the 0hest 3all and is in 0onta0t 3ith the ri,s and inter0ostal mus0les. 6t is the outermost layer. These 2 layers are separated ,y the pleural 0a*ity 3hi0h 0ontains serous fluid produ0ed ,y the 0ells in the pleura. This helps the lungs glide as they expand and 0ollapse. '. Define the extent of the lungs. The lungs are 0oni0al in shape7 The apex 4top5 of the lungs rea0h as high as !<' 0m a,o*e the first 0ostal 0artilage, in the ,ase of the ne0;. The ,ase 4,ottom5 of the lungs is 0on0a*e and rests on the diaphragm. /. Define the extent of the pleura

. The parietal pleura 0onsists of ' parts7 the part relating to the inter0ostal spa0es is the 0ostal part the part relating to the diaphragm is the diaphragmati0 part the part 0o*ering the mediastinum is the mediastinal part the part lining the 0er*i0al extension of the 0a*ity is the 0er*i0al pleura 6n the mediastinal part, there is a spa0e 3hi0h is made for the root or hilum of the lung. 1-

The visceral pleura is 0ontinuous 3ith the parietal pleura all the 3ay around the lungs atta0hed to the outside of them, in0luding running into ,oth opposed surfa0es of the fissures. "uperiorly the pleural 0a*ity pro2e0ts !<'0m a,o*e the first 0ostal 0artilage. Anteriorly the pleural 0a*ities approa0h one another in the upper part of the sternum. 6n the lo3er part the right side is 0loser to the midline than the left side ,e0ause of the spa0e made ,y the peri0ardium et0. 6nferiorly the pleura refle0ts onto the diaphragm. o (n the left side the diaphragm separates the left lo,e of the li*er, the spleen and the stoma0h. o (n the right side the diaphragm separates the right lo,e of the li*er. During Cuiet ,reathingD o The inferior margin of the lungs 0omes do3n to as far as a,out ri, %6 in the midclavicular line 4middle of 0la*i0le5 ri, %666 in the midaxillary line 4runs do3n side of ,ody5 and rea0hes the vertebral column at TE. o The inferior margin of the pleural cavity 0omes do3n as far as ri, %666 on the midclavicular line, ri, E on the midaxillary line, and rea0hes the vertebral column at TE66. o The spa0e ,et3een the t3o margins is the 0ostodiaphragmati0 re0ess. &. "tate ho3 the right and left lungs are normally distinguisha,le. The right lung7 o :as ! lo,es, the inferior lo,e, the superior lo,e and the middle lo,e. o :as 2 fissures, the oblique fissure, separating the inferior lo,e from the superior and middle lo,esF and the horizontal fissure separating the superior lo,e from the middle lo,e. o (n its mediastinal surfa0e in 0onta0t 3ith the heart, inferior *ena 0a*a, superior *ena 0a*a, aGygos *ein oesophagus. o 6s larger than the left lung. The left lung7 o :as only 2 lo,es, the inferior lo,e and the superior lo,e. o :as 1 fissure, the oblique fissure, that separates the superior and inferior lo,es. o (n its mediastinal surfa0e is in 0onta0t 3ith the heart, aorti0 ar0h, thora0i0 aorta, and oesophagus. 6t 0ontains a not0h 3here the heart pro2e0ts into the pleural 0a*ity from the middle mediastinum.


.. 6dentify the stru0tures present at the :ilum of the lung. All the stru0tures at the :ilum are enveloped in the pleura: o Prin0ipal ,ron0hus o Pulmonary artery 40arry deoxygenated ,lood from =ight *entri0le5 o 2 Pulmonary *eins 40arry oxygenated ,lood to left atrium5 o 1ron0hial arteries and *eins 40arry oxygenated ,lood from aorta to lung tissue5 o Pulmonary plexus of ner*es 4mainly autonomi05 o Lymph *essels.

>. 8xplain the term @pulmonary 0ir0ulationA. o =ight atrium Pulmonary Artery Lung 0apillaries Pulmonary %ein Left Atrium. o 1lood is oxygenated in the lungs. o =esistan0e is an eighth of the systemi0 0ir0ulation and ,lood pressure is only 2/H1-mm:g. 12

. Demonstrate the landmar;s of the 0hest 3all on a li*ing 0hest.

o 1et3een the medial ends of the 0la*i0les is the 2ugular not0h. o 6f you feel do3n from the 2ugular not0h 3here the sternum 0hanges dire0tion slightly, this is the sternal angle. 4this mar;s the top of the aorti0 ar0h, the tra0heal ,ifur0ation and the le*el of the 2nd 0ostal 0artilage. o 6n men the nipple lies in the 'th inter0ostal spa0e 4,et3een 'th and /th ri,s5 o 6n 3omen, ,eneath the ,reast is the &th ri,. 1-. Demonstrate the positions of the pleural 0a*ities, lungs and lo,es of the lungs in a li*ing 0hest. o Apex of pleura is 2<!0m a,o*e 0la*i0le. o Anterior of pleura runs parallel 3ith the sternum on the right, on the left, there is a not0h ,et3een 0ostal 0artilages ' and .. o 6nferior end runs 2ust a,o*e 0ostal margin. o Posterior ,order runs either side of *erte,ral 0olumn.


11. Demonstrate the positions of the fissures on a li*ing 0hest.

12. Des0ri,e and s;et0h the lungs, using 0orre0tly the follo3ing terms7 apex, 0ostal surfa0e, mediastinal surfa0e, diaphragmati0 surfa0e, upper middle and lo3er lo,es, o,liCue and horiGontal fissures.

Mediastinal Surface

Costal Surface

Diaphragmatic Surface

1!. 8xplain the stru0tural ,asis for ,reathing, in0luding the differen0es ,et3een light, deep and for0ed ,reathing. 1reathing is 0ontrolled ,y the ner*ous system and produ0ed ,y the s;eletal mus0le. Lungs *entilate the air sa0s the site of gas ex0hange. #o*ements of ,oth the diaphragm and the ri,s 0ause an in0rease of the thora0i0 0a*ity 0apa0ity o The mus0les in the 3all 0ause expansion of the pleural 0a*ity. o The elasti0 lungs expand 3ith the pleural 0a*ity. o Air is su0;ed do3n the tra0hea and ,ron0hi into the lungs.


The Ribs mo*e up for3ard and up3ard 3ith a ,u0;et<handle li;e a0tion. This in0reases the anteroposterior, as 3ell as the trans*erse dimensions of the thora0i0 0a*ity. The Diaphragm is the main inspiratory mus0le. When it 0ontra0ts the *erti0al dimension of the thora0i0 0a*ity is greatly in0reased. This also pushes the 0ontents of the a,dominal 0a*ity do3n and out. nspiration is 0aused ,y the in0rease in thora0i0 0a*ity 0apa0ity 3hi0h results in a redu0tion in the intrapleural pressure. This 0auses expansion of the lung and therefore entry of the air through the respiratory passages. Iuiet inspiration uses only the diaphragm. +or0ed inspiration uses ,oth the diaphragm and inter0ostal mus0les. !xpiration is 0aused ,y the elasti0 re0oil in the tissue around the lungs and ri, 0age. Iuiet expiration uses only the diaphragm. +or0ed expiration uses ,oth the diaphragm and a,dominal mus0les.

1'. 8xplain the rationale for insertion of 0hest drains in the pleural 0a*ity. 6nflammation of the pleural mem,rane, 0alled pleurisy or pleuritis, may in its early stages 0ause pain due to fri0tion ,et3een the parietal and *is0eral layers of the pleura. +luid may ,uild up in the pleural spa0e, a 0ondition ;no3n as pleural effusion. :en0e 3hy a 0hest drain may ,e inserted into the pleural 0a*ity. Any site ,et3een the fourth and se*enth inter0ostal spa0es, and ,et3een the mid< axillary and anterior axillary lines may ,e used. This a*oids the ris; of traumatising the great *essels or the heart. A 0ommon lo0ation is in the fifth inter0ostal spa0e in the mid<axillary line.


Thorax 3 uperior !ediastinum and "reat #essels

Anil Chopra The mediastinum is the partition that separates the t3o pleural 0a*ities. 6t extends from the superior thora0i0 aperture to the diaphragm *erti0ally and from the sternum to the *erte,ral 0olumn laterally. At the le*el of T%, it splits into7 "uperior mediastinum nferior mediastinum 3hi0h itself is split into anterior, middle and posterior mediastinum


Ant #iddle Post 6nferior

1. Des0ri,e the position and relations of the aorti0 ar0h and des0ending aorta. The as0ending aorta lea*es the left *entri0le and is 0ontinuous 3ith the aorti0 ar0h. T3o ,ran0hes 0ome off the as0ending aorta gi*ing rise to the left # right coronary arteries$ Aorti0 ar0h is ,ehind sternal angle. 6t ar0hes posteriorly and to the left o*er the left ,ron0hi of the tra0heal ,ifur0ation. 4%erte,ral le*el T6%HT%. 6t then goes do3n ,ehind the left main ,ron0hus to ,e0ome the des0ending aorta. 2. 6dentify the origin of the ,ra0hio0ephali0 artery, the su,0la*ian arteries and the 0arotid system of arteries. At top of the aorti0 ar0h ! ,ran0hes 0ome out7 %rachiocephalic trun& ' this goes off to the right side of the ,ody and almost immediately splits into the right subclavian artery 3hi0h goes to the right arm, and the right common carotid artery 3hi0h goes up to the head. (eft common carotid artery this goes up to supply the left side of the fa0e and head. 6t arises slightly posterior 4,ehind5 the ,ra0hio0ephali0 trun; and extends along the left side of the tra0hea. (eft subclavian artery this goes on to supply the left arm. 6t arises slightly posterior and 2ust left of the left 0ommon 0arotid artery. The ligamentum arteriosum is important in em,ryoni0 de*elopment. 6n adult life it is a ligament that passes from the pulmonary trun; to the ar0h of the aorta. 6n foetal life it 0ontains the du0tus arteriosum 3hi0h allo3s ,lood to ,ypass the lungs during de*elopment.


!. 8xplain ho3 ,lood lea*ing the heart rea0hes 4a5 head and ne0;, 4,5 lungs, 405 thora0i0 and a,dominal 0a*ities. 4a5 1lood rea0hes head and ne0; *ia the left and right common carotid arteries. These then split into external and internal 0ommon 0arotid high in the ne0;. 4,5 1lood rea0hes lungs *ia the pulmonary arteries. These arise from the pulmonary trun& 4still 0ontained 3ithin the peri0ardial sa05 3hi0h arises from the right *entri0le. 9ust inferior and to the left of the sternal angle, the pulmonary trun; splits into left # right pulmonary arteries. (n0e ,lood has ,een oxygenised, it passes into the pulmonary veins 3hi0h drain dire0tly into the left atrium. 405 1lood rea0hes the a,dominal and thora0i0 0a*ities from a num,er of different arteries.


Anterior Wall: The left and right subclavian arteries gi*e rise to the internal thoracic arteries$ These then tra*el inferiorly either side of the sternum and ,ran0h off into the anterior intercostal arteries 3hi0h supply the anterior half of the thora0i0 0age. At around the &th inter0ostal spa0e the internal thora0i0 arteries di*ide into the7 ) superior epigastric arteries 4supplies a,dominal 3all5 and the ) musculophrenic arteries 4pass along the 0ostal margin to supply the diaphragm


Posterior Wall: the top 2 posterior intercostal arteries arise from the supreme intercostal artery 3hi0h is a ,ran0h of the costocervical trun&. The rest arise from the aorta. ).1 #ost inter0ostal arteries and *eins split into a 0ollateral ,ran0h.

1lood is drained from the thora0i0 0a*ity in a num,er of different 3ays. Anterior Wall: The anterior inter0ostal *eins drain into the internal thoracic veins 3hi0h themsel*es drain into the brachiocephalic vein. Posterior Wall: The superior part of the posterior 3all is drained ,y the left and right upper posterior inter0ostal *eins 3hi0h drain into the aGygous *ein. The rest of the posterior 3all is drained ,y the intercostal veins draining into the azygous vein on the right side and the hemiaGygous and a00essory hemiaGygous *eins on the left side. The hemiaGygous and a00essory hemiaGygous drain into the aGygous 3hi0h drains dire0tly into the inferior vena cava$

'. 6dentify the superior *ena 0a*a. The superior *ena 0a*a ,egins 2ust posterior to 4,ehind5 the first 0ostal 0artilage 3here the left and right ,ra0hio0ephali0 *eins meet. 6t terminates 3here it enters the right atrium 2ust posterior to the right third 0ostal 0artilage.

/. 8xplain ho3 ,lood returns from the head and ne0; to the heart. The left internal *ugular vein 4from the ne0;5 and the left subclavian vein 4from the upper lim,5 drain into the left brachiocephalic vein 3hi0h ,egins 2ust posterior to 4,ehind5 the medial 4middle5 end of the left 0la*i0le. 6t passes right and slightly inferiorly ending up in the superior *ena 0a*a. The right internal *ugular vein 4from the ne0;5 and the right subclavian vein 4from the upper lim,5 drain into the right brachiocephalic vein 3hi0h ,egins 2ust posterior to 4,ehind5 the medial 4middle5 end of the right 0la*i0le. 6t passes *erti0ally do3n3ard ending up in the superior *ena 0a*a. &. (utline the prin0iples and main appli0ations of 0on*entional E<ray and CT imaging. +)Ray7 o =adiation in the form of E<rays are passed posterior to anterior. o :igh density e.g. ,oneHflo3ing ,lood stops all x<ray 4,lood has hea*y metal ions in it therefore a,sor, the x<rays5 and sho3s up 3hiteF lo3 density e.g. lung fields are trans<radiant and sho3 up ,la0;. 4hea*y atomi0 nu0lei are needed to stop E<rays5 o 6mage is @,a0;3ardsA i.e. al3ays refer to things from patients point of *ie3 4left and right5 ,- imaging7 o "ho3s an image as if loo;ing through the feet at a se0tion o E<ray ,eam tra0es a se0tion at multiple angles around the ,ody *isualises soft tissue in mu0h more detail than 0on*entional E<ray.


.. 6dentify thora0i0 s;eletal features, diaphragm, lungs, lung roots, pulmonary *essels and mediastinum in normal 0hest E<rays.

>. Bsing CT s0an images, identify features listed in . and in addition lung lo,es and fissures.


? .=elate appearan0es seen in CT se0tions of the 0hest to those in the li*ing or disse0ted ,odyF re0ognise the approximate *erte,ral le*el of any 0hest CT image.

15 =ight Cla*i0le 25 "ternum !5 Pe0toralis #a2or #us0le '5 Pe0toralis #inor #us0le /5 Axillary %ein &5 =i, .5 "u,0la*ian %ein >5 Tra0hea 5 Left 1ra0hio0ephali0 %ein 1-5 Left Common Carotid Artery 115 Left "u,0la*ian Artery 125 %erte,ral 1ody 1!5 "0apula 1'5 Le*el of "li0e


15 Left 1ra0hio0ephali0 %ein 25 1ra0hio0ephali0 Artery !5 "uperior %ena Ca*a '5 Left "u,0la*ian Artery /5 Tra0hea &5 8sophagus .5 Le*el of "li0e


15 "uperior %ena Ca*a 25 Aorti0 Ar0h !5 AGygous Ar0h '5 Tra0hea /5 8sophagus &5 Le*el of "li0e


15 6nternal Thora0i0 Artery and %ein 25 As0ending Aorta !5 Pulmonary Trun; '5 =ight Pulmonary Artery /5 Left Pulmonary Artery &5 =ight and Left #ain 1ron0hi At Le*el of Carina .5 Des0ending Aorta >5 Le*el of "li0e


15 =ight %entri0le 25 6nter*entri0ular "eptum !5 Left %entri0le '5 =ight :emidiaphragm /5 Area of =ight Atrium &5 Area of Left Atrium .5 Des0ending Aorta >5 A% $roo*e 5 Le*el of "li0e

1-. Define pneumothorax and pleural effusion, explain ho3 they may arise, re0ognise them in appropriate radiographs, explain the ;ey physi0al signs asso0iated 3ith them, explain ho3 they 0an lead to death and explain the anatomi0al ,asis of the emergen0y pro0edures used to regain 0ontrol in su0h patients. .neumothorax also ;no3n as a @0ollapsed lungA is 3here gas a00umulates in the pleural 0a*ity. This air in0reases pleural pressure 4due to lung paren0hymal or ,ron0hial in2ury5. 6t 0an o00ur for *arious reasons in0luding7 A penetrating 0hest 3ound 1arotrauma to the lungs "pontaneously 4most 0ommonly in tall slim young males and in #arfan syndrome5 Chroni0 and a0ute lung pathologies in0luding emphysema, asthma, tu,er0ulosis Can0er 2&

Catamenial pneumothorax <due to endometriosis in the 0hest 0a*ity 4i.e. 3here the endometrium in0orre0tly gro3s in parts of the ,ody other than the uterus5 This 0auses the 0hest 3all to spring out, and the lung to 0ollapse. As pressure in the pleura in0reases, the mediastinal stru0tures are pushed to the opposite side and 0ompresses the opposite lung. This 0an lead to hypoxia, and *enous return de0reases due to the pressure on the *ena 0a*a and the right atrium. This 0auses a de0rease in 0ardia0 output and hypotension. 6f left untreated, death. This sho3s up on radiographs as transparent lung fieldsF Physi0al signs are7 ta0hypnoea 4hyper*entilation5 ta0hy0ardia 4in0reased heart rate5 0yanosis 4,luish 0oloration of the s;in due to the presen0e of deoxygenated haemoglo,in in ,lood *essels5 dyspnoea 4la,oured ,reathing5 0hest pain 8mergen0y pro0edure is the The trachea is needle displaced to the Pneumothorax thora0ostomy right side has occurred on the left hand pun0ture usually side 2nd inter0ostal (characterised by transparent spa0e, along the lung field) Heart is on the mid<0la*i0ular line. wrong .leural effusion ex0ess fluid that The diaphragm is a00umulates in the much lower due pleural 0a*ity, the to pressure from the pleural cavity fluid<filled spa0e that surrounds the lungs. +our types of fluids 0an a00umulate in the pleural spa0e7 "erous fluid 4hydrothorax5 1lood 4hemothorax5 Chyle 40hylothorax5 Pus 4pyothorax or empyema5 This fluid is normally remo*ed ,y lymphati0s in the *is0eral pleura, 3hi0h ha*e the 0apa0ity to a,sor, 2- times more fluid than is normally formed. When this 0apa0ity is o*er3helmed, either through ex0ess formation or de0reased lymphati0 a,sorption, a pleural effusion de*elops. 6t 0an result from the disruption of the eCuili,rium a0ross the pleural mem,ranes 0aused ,y some pathologi0 pro0ess that may originate in the lungs or ,e another organ system or systemi0 disease.
side of the body, due to the pressure from the left pleural cavity


Physi0al signs are dyspnoea 4,reathlessness5 0hest pain dull per0ussion de0reased *o0al fremitus 4*i,ration felt on the patientJs 0hest during lo3 freCuen0y *o0aliGation @nintey niteA5 diminished or inaudi,le ,reath sounds 6n radiographs lung fields appear haGy 8mergen0y pro0edure is thora0entesis. 4draining of pleural 0a*ity 3ith needle or 0annula5

11. Define 0onsolidation of the lungF re0ognise it and identify the lo,e4s5 in*ol*ed in suita,le E<rays and CT s0ans. ,onsolidation the pro0ess ,y 3hi0h an aerated lung solidifies 3ith de,ris from ,lood *essels usually as a result of inflammation of the tissue.

12. Bsing 0on*entional E<rays and CT images demonstrate the landmar;s of the normal heart and re0ognise enlargement or displa0ement of the heart.


vertebra e Lung

!ight border of mediastinum

"bli#ue border of the mediastinum

!ight diaphragm Left diaphragm

iagrammatic border of mediastinum


1!. 6dentify other ma2or stru0tures of the mediastinum in suita,le radiologi0al images. 1ro0hogram 4air3ays5 Angiogram 4,lood *essels5

Thorax $ %rganisation of &er'es in the Thorax !on 2(th )e* 2++,

Anil Chopra 1. 6dentify the peri0ardium in the 0ada*er and des0ri,e its organisation. The peri0ardium is a fi,rous sa0 that surrounds the heart and the roots of the great *essels. 6t 0onsists of t3o parts7 /ibrous pericardium ) This is a 0one<shaped ,ag 0ontaining the serous peri0ardium, heart and entran0e of asso0iated *essels and phrenic nerves from spinal 0ord le*els ,0, ,1 and C/. 4The phreni0 ner*e also inner*ates this layer5. 6ts ,ase rests on the diaphragm, and its apex is 0ontinuous 3ith the ad*entitia of the great *essels.

"erous pericardium ' this itself is split up into 2 layers7 o .arietal layer ' 3hi0h lines the inner surfa0e of the fi,rous peri0ardium, i.e. the outermost layer. Around the roots of the great *essels it is 0ontinuous 3ith the *is0eral layer. o Visceral layer ' this is also ;no3n as the epi0ardium. 6t forms the outer 0o*ering of the heart.


o o

2. Demonstrate the four 0ham,ers of the heart. !. )ame the *essels that enter or lea*e ea0h of the 0ham,ers of the heart. '. )ame the four *al*es of the heart and indi0ate 3here they are situated The general orientation of the heart is that of a pyramid on its side7 The Right atrium is on the right ,order of the heart on the anterior surfa0e. 1lood enters the right atrium from7 superior *ena 0a*a inferior *ena 0a*a 0oronary sinus 6ts 3alls are 0o*ered in pe0tinate mus0les 3hi0h fan out li;e the teeth of a 0om,. 9ust posterior to it is the interatrial septum 4the left atrium lies posterior to the right5. There is a depression in the interatrial septum ;no3n as the fossa ovalis and around it the limbus fossa ovalis. This is *ery important during foetal life as it 3as the foramen ovale, a hole ,et3een the left and right atria so ,lood 0an ,ypass the non<fun0tioning lungs ,efore ,irth.


The right ventricle is on the diaphragmati0 ,order of the heart and also fa0es anteriorly, ,lood mo*ing from right atrium to right *entri0le therefore mo*es in a horiGontal dire0tion. 6ts outflo3 is the pulmonary trun&$ There are ! papillary mus0les in the right *entri0le7 Anterior papillary muscle is the largest. .osterior papillary muscle arises from posterior 3all "eptal papillary muscle 3hi0h arises from the septum. 6ts entry point is the tricuspid valve. This is the right atrio*entri0ular *al*e 0onsisting of ! 0uspsF anterior, posterior and septal$ The atta0hment of the 0usps to the papillary mus0les ,y the 0hordae tendinae stops the 0usps from mo*ing ,a0; into the right atrium.

6ts exit point is the pulmonary valve through 3hi0h it enters the pulmonary trun&$ The pulmonary *al*e 0onsists of three semilunar 0usps 4left, anterior and right5 ea0h 3ith a thi0;ened portion at the end ;no3n as the nodule. They pre*ent ,lood from flo3ing ,a0; into the right *entri0le.


The left atrium re0ei*es oxygenated ,lood from the ' pulmonary *eins. 6t forms most of the posterior 4,a0;5 surfa0e and is not seen at all anteriorly. The *al*e of the foramen ovale is also seen in the interatrial septum. 6ts exit point is the mitral valve.

The (eft ventricle lies slightly anterior and superior to the left atrium. 6t is 0oni0al in shape and is the longest and most mus0ular of the 0ham,ers of the heart. 46.e. it has the thi0;est layer of myocardium5. 6t, li;e the right *entri0le has traberculae


carneae and papillary muscles 3ith atta0hed chordae tendinae. There are only 2 papillary mus0lesF posterior and anterior. This is mainly due to the fa0t that the mitral valve is only bicuspid. 46t has only 2 0usps, posterior and anterior5 6t 3or;s in the same 3ay as the tri0uspid *al*e. 6ts exit point is the aortic valve through 3hi0h it flo3s into the aorta. This also has 0 semilunar cusps 4right, posterior and left5, ,ut in 2 of them, there are openings for the 0oronary arteries. 6t has a similar fun0tion to the pulmonary *al*e in that it stops the ,a0;flo3 of ,lood into the left *entri0le. /. Des0ri,e the 0ommonest patterns of distri,ution of the 0oronary arteries and explain the fun0tion and importan0e of these *essels. There are 2 main coronary arteries ea0h arising from one of the aorti0 sinuses 4left and right5 ea0h gi*ing rise to its 0orresponding 0oronary artery7 The right coronary artery emerges from the right aorti0 sinus and des0ends do3n the right atrium round to the apex of the heart ,ran0hing as it does so. 6t supplies the right atrium, right *entri0le, sino<atrial node and atrio*entri0ular node. The left coronary artery emerges from the left aorti0 sinus and passes do3n posterior 4,ehind5 to the pulmonary trun;. As it emerges it splits into t3o7 o Anterior descending branch 3hi0h des0ends anteriorly round to3ard the apex of the heart. o ,ircumflex branch 3hi0h tra*els round the left side of the heart and des0ends on the posterior left side of the heart. The left 0oronary artery supplies the left atrium, left *entri0le and most of the inter*entri0ular septum. There are 2 *ariations in the distri,ution patterns of the 0oronary arteries7 < Right coronary dominance7 is the most 0ommon and it is 3here the right 0oronary artery supplies most of the posterior 3all and the left 0oronary arteries are relati*ely small. < (eft coronary dominance7 is less 0ommon and is 3here the 0ir0umflex ,ran0h supplies the ma2ority of the posterior 3all and left *entri0le.



There are ' main cardiac veins that drain into the coronary sinus 3hi0h itself drains into the right atrium. $reat 0ardia0 *ein7 ,egins at the apex of the heart and runs up the anterior 4front5 3all along the atrio*entri0ular sul0us, 3hen it rea0hes the top it goes round the end follo3ing the path of the 0ir0umflex artery and enlarges at the posterior end to form 0oronary sinus. #iddle 0ardia0 *ein7 also ,egins at the apex ,ut runs up the posterior side in the atrio*entri0ular sul0us. "mall 0ardia0 *ein7 ,egins in the lo3er anterior 4front5 se0tor of the anterior sul0us. 6t tra*els round the ,a0; of the right atrium 3here it finishes in the 0oronary sinus. Posterior 0ardia0 *ein7 runs up the posterior surfa0e of the left atrium.


&. 8xplain the effe0ts of 0oronary insuffi0ien0y and o,stru0tion, in0luding the path3ays and lo0alisation of pain asso0iated 3ith these 0onditions. Angina pectoris is the 0ondition 3here 0hest pain is 0aused ,y is0hemia 4restri0tion or ,lo0;age of ,lood *essels 0ausing tissue damage5 of the myo0ardium due to 0oronary artery narro3ing, usually ,y atheros0lerosis. This 0an result in a myocardial infarction$ .. Demonstrate the relationship of the peri0ardium to the heart and great *essels and to surrounding stru0tures.

>. 8xplain the signs asso0iated 3ith tamponade and demonstrate the anatomi0al ,asis for relie*ing this 0ondition. ,ardiac tamponade is a 0ondition 0aused ,y fluid in the peri0ardial sa0 @0rushingA the heart. The fluid 0auses an in0rease in pressure and so the *entri0les arenKt a,le to 0ontra0t properly. The in0reased peri0ardial pressure, 0auses a de0rease in 0ardia0 output and su,seCuent hypotension. "ymptoms in0lude dyspnoea 4shortness of ,reathe5 anxiety, fatigue and 0yanosis 4a ,lueHdar; purple dis0oloration seen in the nail ,eds and mu0ous mem,ranes, that result from an in0reased 0on0entration of deoxygenated haemoglo,in5. Treatment is pericardiocentesis< to remo*e fluid and redu0e pressure. . Bse 0hest 3all landmar;s to define the 0ardia0 outline. The right vertical border of the heart runs from 2ust to the right of the sternum on the !rd 0ostal 0artilage do3n to the &th. The horizontal border is formed from here 4&th 0ostal 0artilage 2ust right of sternum5 to left /th inter0ostal spa0e on the mid<0la*i0ular line.


The oblique border is formed ,y the left *entri0le formed from here 4left /th inter0ostal spa0e on mid<0la*i0ular line5 to the medial end of the !rd inter0ostal spa0e, 2ust left of the sternum.

1-. Lo0ate the apex ,eat. The apex beat is 3here the horiGontal and o,liCue ,orders of the heart meet. 6t is on the left /th inter0ostal spa0e on the mid<0la*i0ular line. 6n men it is 2ust inferior and medial to the nipple, in 3omen it is on the lo3er ,order of the ,reast. 11. Lo0ate suita,le sites for aus0ultation of ea0h heart *al*e and demonstrate 0orre0t stethos0ope te0hniCue. -ricuspid valve < lo3er end of sternum 2itral valve < left /th inter0ostal spa0e in mid<0la*i0ular line 4apex ,eat5 .ulmonary valve < left !rd inter0ostal spa0e near sternum Aortic valve < right 2nd inter0ostal spa0e near sternum.


12. (utline the ele0tri0al and me0hani0al 0y0les of the heart and relate these to heart sounds and to features of the 8C$ tra0e. The 0ondu0tion system in the heart is di*ided into four ,asi0 main 0omponents7 "ino<atrial node 4"A)5 Atrio<*entri0ular node 4A%)5 1undle 1ran0hes "u,endo0ardial plexus of 0ondu0tion 0ells

15 The impulse ,egins at the sino<atrial node 4the 0ardia0 pa0ema;er5 in the right atrium. 8x0itation spreads a0ross atria 0ausing them to 0ontra0t.

25 8x0itation is then delayed for around 12-ms 3hen it rea0hes the Atrio< *entri0ular node.

!5 The A%) then spreads the ex0itation do3n the Pur;in2e fi,res of the ,undle ,ran0hes. This in turn 0auses the *entri0les to 0ontra0t from the ,ase up3ard. '5 This is follo3ed ,y ,oth the atria and the *entri0les relaxing in diastole.

1!. 8xplain the path3ays ,y 3hi0h the heart, lungs and the 0hest 3all re0ei*e their motor and sensory ner*e supplies. Vagus The *agus ner*e is the 1-th 0ranial ner*e 4Cranial ner*e E5. < Arises from the medulla and < "plits into the left 4runs anterior to aorti0 ar0h ,ut posterior to left ling root5 and right 4runs posterior to right lung root5. < :as parasympathetic path3ays to the heart, glands, and lungs. < Also has sensory 0ontent from entero0eptors in gut and lungs. < 1oth left and right *agus ner*es form a plexus round the oesophagus. < "plits into the re0urrent laryngeal ner*e that runs ,a0; up to supply s;eletal mus0les in the larynx "ympathetic -run& < All sympatheti0 ner*es run from spinal le*els T1 to L2. < "upply all parts of the ,ody. < T3o 0hains of sympatheti0 ganglia run either side of the spinal 0ord. < $i*e stimulatory effe0t to the heart and lungs. Recurrent (aryngeal < A ,ran0h of the *agus ner*e that supplies the s;eletal mus0les in the larynx. -horacic "omatic < These usually arise from the main ,ran0hes of thora0i0 spinal ner*es 1< 11. < 8a0h segment supplies a dermatome and group of mus0les. < The spinal root emerging splits into a dorsal and ventral root. The dorsal root 0ontains sensory fi,res and the *entral root 0ontains motor fi,res. < 8a0h then splits into 2 rami one of 3hi0h supplies posterior mus0les and one of 3hi0h supplies its parti0ular dermatome !nteric Nervous "ystem < 6ntrinsi0 ner*es of the oesophagus. < This plexus of ganglia and axons is lo0ated in the oesophageal 3all 3here it 0o<ordinates the a0ti*ity of the oesophagus.


< inhi,its it.

The parasympatheti0 supply stimulates it, sympatheti0 supply


Thorax - Lymphati. ystem, /reasts and /reast

Anil Chopra 1. "ummarise the main fun0tions and anatomi0al organisation of the lymphati0 system. Lymphati0 drain tissue fluid from thorax *is0era that has not returned to the *enous end of the ,lood in 0apillaries. Bn0ompensated fluid 3ould result in the ,uild up of fluid in tissues 4oedema5 and loss of ,lood *olume. %arious for0es a0t a0ross 0apillary 3alls affe0ting the fluid 0ontent of the ,lood. Lymph 0ontains fluid from tissues, parti0ulate matter, fat, fe3 0ells and fe3 proteins. The lymph then flo3s into the ,lind ended lymph *essels. They are thin<3alled and lined ,y endothelial 0ells. At *arious points they pass through lymph nodes$ At these lymph nodes they pass fixed reti0ular ma0rophages that remo*e ,a0teria. 4it 0annot ho3e*er remo*e 0an0erous 0ells5 The lymph system is split into deep and superfi0ial lymphati0s. Lymph from lo3er lim,s drains into cisterna chyli and then into the thoracic duct 3hi0h itself drains into the brachiocephalic vein$ Lymph from the lo3er lim,s drains into the cervical lymph nodes in the ne0;.


Lymph from the upper lim,s drains into the axillary lymph nodes.

2. Des0ri,e the lymphati0 drainage of the 0hest *is0era 4parti0ularly the lungs and ,ron0hi5 and outline the impli0ations of this pattern for the spread of lung 0an0er. Lymphati0 drainage from the lungs, ,ron0hi and mediastinum drain into the left and right ,ron0homediastinal trun;s. The parasternal nodes run up anteriorly either side of the sternum draining the front of the thorax, intercostal nodes run up posteriorly either side of the spinal 0ord and the tracheobronchial nodes run around the tra0hea and ,ron0hi. These all drain into the left brachiocephalic vein$


Can0er 0ells may tra*el in the ,lood or lymph and esta,lish ne3 tumours 3here they lodge .When metastasis o00urs *ia lymphati0 *essels, se0ondary tumour sites 0an ,e predi0ted a00ording to the dire0tion of lymph flo3, from the primary tumour site. Can0erous lymph nodes feel enlarged, firm, non<tender, and fixed to underlying stru0tures. 1y 0ontrast, most lymph nodes that are enlarged due to an infe0tion, are not firm, are mo*ea,le and are *ery tender.

!. Define the roles of ,reast examination and imaging 3ithin the epidemiologi0al 0ontext of ,reast 0an0er in0iden0e. 1reast 0an0er affe0ts one 3oman in eight. 6t usually de*elops from the du0ts of the epithelium. )ot all lumps are 0an0ers. They are some3hat dependent on oestrogen. Tumours may put tension on suspensory ligaments. This may 0ause s;in pu0;ering 4indentations5 or in*erted nipples. They may atta0h to mus0les and are *ery prone to spreading in the lymph or *enous drainage of the ,reast. '. Describe the lymphati0 and *enous drainage of the ,reast and relate these to the path3ays of metastasis of ,reast 0an0er.


1reasts de*elop in ,oth genders, in males ho3e*er they are rudimentary and 0onsist of small du0ts, 0omposed of 0ords of 0ells 3hi0h do not extend ,eyond the areola. They o*erlie the anterior mus0les of the 0hest 3all and lie ,et3een ri,s 2 and &. They ha*e an axillary tailHpro0ess leading to the axilla. This must al3ays ,e 0he0;ed on examination for lumps. They are raised stru0tures in the thora0i0 3all that 0ontain mammary glands. 8a0h ,reast 0ontains around 12<1& lobes 3hi0h 0ontain stru0tures ;no3n as alveoli. 8a0h has a small du0t 3hi0h opens out into the nipple surrounded ,y pigmented s;in the areola$ Bnderneath the areola are the lactiferous sinuses 3hi0h are mil;<filled spa0es that the ,a,y su0;s on. 1reasts 0ontain internal suspensory ligaments 3hi0h are used in supporting the ,reast. Tensing the pe0toral mus0les 4push do3n on hips5 0auses suspensory ligaments to lift ,reast. The ,ul; of it is adipose tissue ,ut 3hen pregnant, this turns to glandular tissue. Lymph drainage of ,reast parallels arterial supply. Arterial supply to lymph nodes mainly from the thoracic arteries and axillary artery$ Can0ers 0an tra*el in the internal thora0i0 4parasternal5 and axillary lymph nodes. Can0ers 0an also ,lo0; lymph drainage and therefore in0rease pressure 0ause lymph to ta;e alternati*e routes.


/. List the imaging te0hniCues used in the diagnosis of ,reast 0an0er and outline their *alue and limitations. 2ammogram this is a ,reast x<ray. ,- scans 0omputerised tomography. %one scan ' this uses radioa0ti*e isotopes. "elf examination is in0reasingly popular ma;ing sure 3omen 0he0; their ,reasts and the axillary pro0ess. 4ltrasound is also used.


Thorax ( The Posterior !ediastinum

Anil Chopra 1. Define the posterior mediastinum 8*erything in the thorax that is ,elo3 the plain of the sternal angle and posterior to 4,ehind5 the peri0ardium is the posterior mediastinum.

2. Des0ri,e the relati*e positions of the des0ending aorta, the oesophagus, the *agus ner*es and the thora0i0 du0t as they des0end through the posterior mediastinum. Descending aorta: this ,egins at *erte,ral le*el T 6% 4'5 and it is 0ontinuous 3it the ar0h of the aorta. 6t 0ontinues anteriorly do3n to T E66 4125 there it passes through the aortic hiatus of the diaphragm$ 5esophagus: this is a mus0ular tu,e running do3n from the pharynx in the ne0; to the stoma0h in the a,domen. Throughout the top part of the thorax it is situated to the right of the aorta until around *erte,ral le*el - V 4.5 3here it ,ends slightly anterior and left. 6t then pro0eeds inferiorly 4do3n5 anterior to 4in front of5 the aorta. Vagus nerves: 0ranial ner*e E 41-5 passes posterior to the lung roots and forms the oesophageal plexus. They run do3n the length of the oesophagus to the stoma0h 3here they e*entually ,e0ome the posterior and anterior vagal trun&s$ -horacic Duct: is a lymph du0t that returns lymph from the lo3er lim,s, a,domen and pel*is to the ,lood. 6t ,egins ,elo3 the diaphragm at the cisterna chyli, 0omes up ,et3een the oesophagus and the aorta and then 0rosses ,ehind the oesophagus at around *erte,ral le*el T %6 4&5.


.hrenic Nerves: pass from 0er*i0al *erte,ra C 666, 6% and % to the diaphragm anterior to the lung roots. !. Des0ri,e the ner*e supply, arterial supply, *enous drainage and lymphati0 drainage of the oesophagus Nerve "upply: the oesophagus is supplied ,y the enteric nervous system$ There are oesophageal ,ran0hes arising from the *agus ner*e and the sympatheti0 0hain. The smooth mus0le fi,res surrounding the oesophagus are stimulated ,y the parasympatheti0 ,ran0hes of the autonomi0 ner*ous system. The left and right *agus ner*es form the oesophageal plexus. This net3or; of ner*es runs do3n the oesophagus until it e*entually ,e0omes the anterior and posterior vagal trun&s 3hi0h 0ontinue on to the stoma0h. Arterial "upply: the oesophagus is mainly supplied ,y ,ran0hes of the descending 4or thoracic5 aorta$ Venous Drainage: the oesophagus is drained entirely ,y the azygous system of *eins. (n the left side of the ,ody, the inferior and superior 4a00essory5 hemiazygous *eins drain into the large azygous *ein running do3n the right side of the ,ody. This drains into the superior *ena 0a*a. (ymph Drainage: lymph from 0ells in the oesophagus is drained ,y the thoracic duct.


' .8xplain ho3 and at 3hi0h *erte,ral le*els the inferior *ena 0a*a, the oesophagus and the des0ending aorta pass through the diaphragm.


Crosses Diaphragm at *ena 0a*al foramen oesophageal hiatus Aorti0 hiatus

%erte,ral Le*el

Inferior Vena Cava: Oesophagus: Descending Aorta:



- + 6-9:8 -+ 6-9;8