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
