Thorax

Intercostal space

Rib articulates with the body of thoracic vertebrae: costovertebral joint

With the transverse process of the vertebrae: costotransverse joint

With the costal cartilage: costochondral joint

Bucket handle movement changes the transverse diameter of the thorax

Pump handle movement changes the antero posterior diameter

Contraction of diaphragm changes the vertical diameter of the thorax

The neuro vascular plane of the thorax

Lies between the internal and the innermost intercostal ms in the costal
groove along the inferior border of the rib

Sequence is vein, artery and nerve

This sequence is reversed in the first rib

looking at the anterior wall of thorax from behind

Scalenus anterior divides the subclavian

Internal thoracic artery

Branch of 1st part of subclavian artery

Runs on either side of the sternum

At the 6th intercostal space, divides into

Superior epigastric

Musculophrenic artery

The superior epigastric artery enters the rectus sheath through Foramen
of morgagni/ Space of Larrey and anastomoses with Inferior epigastric
artery which is a branch of external Iliac artery

Anterior intercostal arteries

In the upper 6 spaces, they are branches of internal thoracic artery

In the lower spaces, branches of musculophrenic artery

Posterior intercostal arteries

In the lower spaces, are the branches of the descending thoracic aorta

In the upper two spaces, branches of

Superior intercostal artery -----> branch of costocervical trunk ------->

Branch of second part of subclavian artery

Anterior and posterior intercostals anastamose at costochondral junction

Anterior intercostal veins

In the upper 6 spaces, drain into internal thoracic vein

In the lower spaces, drain into the musculophrenic vein

Posterior intercostal veins

The anterior and posterior ICV at costochondral junction

Q. Internal thoracic vein drains into brachiocephalic vein

Obstruction in the SVC above the opening of azygous vein

Intrnal thoracic vein -----> anterior ICV-------> posterior ICV------->

Azygous-------> SVC-------> right atrium

Internal thoracic vein ------> Superior epigastric vein------> inferior

epigastric----> external iliac-----> common iliacs------> IVC ------->
right atrium

If obstruction in SVC is below the opening of azygous

The second pathway will still work

Brachiocephalic vein----> subclavian vein----> axillary vein---->

lateral thoracic -----> thoracoepigastric vein-------> superficial
epigastric ---------> great saphenous --------> femoral -------->
external iliac-------> common iliac-------> IVC

Thoracoepigastric vein gets dilated in this

Intercostal nerves

They are the ventral ramus of the thoracic spinal nerves

Branches are
1. Anterior cutaneous branch: pierces the pectoralis major
2. Lateral cutaneous branch: pierces the serratus anterior
3. Muscular branches

The above forms the typical intercostal nerve: T3 to T6

T1 joins the brachial plexus and supplies the upper limb

Intercostobrachial nerve: it is the undivided lateral cutaneous branch

of T2
It joins with medial cutaneous nerve of arm

The lower intercostal nerves supply the muscles of the anterior

abdominal wall
Lungs and pleura

Apex of the lung projects 5 cm above the first rib and 2.5 cm above the
clavicle

It is covered by cervical pleura which is further covered by

Sibson's fascia/ suprapleural membrane/ cervicothoracic diaphragm/

Scalenus minimus

Attachment of suprapleural membrane

Inner border of first rib laterally

Transverse process of C7 Medially

Oral diaphragm: mylohyoid

Pelvic: levator Ani

Urogenital: sphincter urethrae and deep transverse perineii

Extent of lung
6,8,10 : mid clavicular, mid axillary, mid scapular

Extent of pleura
8,10,12

Pleura

Visceral

Aka pulmonary pleura

Sympathetic: T2-6 segment of spinal cord

Parasympathetic : vagus

Parietal pleura
Costal and cervical are supplied by intercostal nerves

Mediastinal and diaphragmatic by phrenic nerves

Bronchopulmonary segments

Pulmonary veins are inter segmental and run between these

Foreign body

In supine position

The lowest part of the lung

Apical segment of the lower lobe/ superior segment

Aspiration pneumonia common in this lobe

Structures arching over the Hilum of right lung

Azygous vein

Left lung
Arch of aorta

Nerve in the front of the Hilum

Phrenic

Behind
Vagus

Structures in the Hilum

Anterior to posterior

Vein

Artery

bronchus

Superior to inferior

Artery

Bronchus

Vein

In right lung, superior to inferior

Eparterial Bronchus

Artery

Hyparterial Bronchus

Vein

Heart
Sternocostal surface

Base of the heart

Formed by both the atria

Groove which separates the base from the diaphragmatic surface is

Posterior atrioventricular groove

Diaphragmatic surface
Formed by both the ventricles
right coronary artery

Supplies
Right atrium

Right ventricle

SAN

AVN

Left bundle of His

Posterior 1/3 of inter ventricular septum

Apex of the heart

Left coronary artery

Supplies
Left atrium

Left ventricle

Left and right bundle of His

Anterior 2/3 of the interventricular septum

Apex of the heart

Posterior interventricular artery

Is a branch of right coronary in 85% of the cases: right coronary
predominance

If it is a branch of circumflex: left coronary predominance

If both the arteries give this branch: Codominance

Veins of the heart

Coronary sulcus is the posterior atrioventricular groove and coronary

sinus lies in it

Great cardiac vein lies in the anterior interventricular groove

All the veins drain into the coronary sinus except anterior cardiac veins
and Vene Cordae minimi/ Thebesian veins

These drain directly into the right atrium

Coronary sinus also drains into the right atrium

Pulmonary veins open into left atrium

There is a space behind the left atrium for its expansion: Oblique sinus of
the pericardium

Similarily lesser sac for stomach

Transverse sinus lies between SVC on the right side and aorta and the
pulmonary trunk on the left side

Development of heart

veins draining into sinus venosus

1. Umbilical vein: from the placenta

2. Vitelleline vein: from yolk sac

3. Common cardinal vein: from body wall

Fate of sinus venosus

The left and right horns of the sinus venosus opens in the atria through
the Sinoatrial orifice

The left horn becomes small in size

Gets detached from the atrium

Forms coronary sinus and opens into the right atrium

The right horn is absorbed into the atrium: septum Spurium

Interatrial septum

Q. Final closure of foramen ovale occurs due to fusion of septum primum

and septum secendum

Interventricular septum

Muscular part
Grows in the floor of the ventricular cavity
Membranous part
Derived from

1. Bulbar septum: formed in the Conus

2. Proliferation of AV cushion

TGA

Occurs due to improper spiraling of the Spiral septum

arch of aorta

Left horn of aortic sac

Left 4th arch artery

Subclavian artery
Left subclavian artery
Left 7th cervical inter segmental artery

Right subclavian
Right 4th arch

Right 7th cervical inter segmental artery

Brachiocephalic trunk
Right horn of aortic sac

Pulmonary arteries
6th arch artery

Ductus arteriosus
Left 6th arch artery between the lung bud and the dorsal aorta

Common carotids
Third arch artery

It gives a bud for external carotid and itself continues as internal carotid

Anterior cardinal veins proximal to the attachment of subclavian veins

Right Brachiocephalic vein

Right anterior cardinal vein between the attachment of subclavian vein
and the anastamosis

Left brachiocephalic vein

1. Left anterior cardinal vein between the attachments of the subclavian
vein and the anastamosis

2. Anastamosis itself

SVC
1. Right anterior cardinal vein below the attachment of anastamosis

2. Right common cardinal vein

Coronary sinus
Derived from

1. Left horn of sinus venosus

2. Left common cardinal vein

Constrictions of esophagus

1st constriction: C6

Pharyngo esophageal junction

2nd

T4: crossing of the Aortic arch

3rd

T6: crossing of the left bronchus

4th

T10: pierces the diaphragm

Cervical part: inferior thyroid artery, same vein

Thoracic part: descending thoracic aorta and bronchial arteries, azygous
vein
Abdominal part: inferior phrenic and left gastric, same veins

Diaphragm
Formed from

Septum transversum

Dorsal and ventral mesentry of the esophagus

Body wall

Pleuroperitoneal membranes

Muscles are derived from cervical myotomes

Thats the reason loyal nerve : Phrenic supplies it

Bochdalec's hernia

Postero lateral defect in the development of the diaphragm due to non

fusion of pleuroperitoneal membranes