Anatomy of thorax

1. Anatomy of thorax

2. Landmarks – anterior view • Supresternal notch • Angle of Louis – cartilage of the 2nd rib • Xifoid apendix • Subcostal angle • Thoracic lateral wall • Ribs 7, 8, 9, 10 • Free ending 11, 12 • Collar bone – acromion • Projection of diaphragm (top ~ 5th rib) • Breast • Anterior axilary line

3. Bony structure

4. Muscles of anterior thoracic wallsignificance in respiration

5. LandmarksPosterior view • Processus sipnosum • Scapula: • Superior angle – C2 • Inferior angle – C7 • Ridge • Muscular prominences • Latissimus dorsi • Trapesius • Erectori spinae

6. Lines used for orientatiom • Median • Midd-clavicular line • Axillary line • Anterior • Middle • Posterior • Scapulary line (through the inferior angle) – armes being close to the trunk

7. Superficial projections of respiratory aparatus • Tracheea: • Cricoid – angle of Louis • Lungs • C6-C8-C10 • Pleura • C8-C10-C12

8. Aortic arch, brchiocephalic trunk, inferior vena cava, brahiocephalic veins are projected behind the manubrium Internal thoracic vein – 1-3 cm lateral to the manubrium Intercostal vessels Heart projection Pericardium Superficial projection of the heart and great vessels

10. Mediastinum

11. Communications of the thoracic cavity • Superior opening – base of the neck • T1 – C1 – manubrium • Tracheea, esofagus, great vessels from the neck • Inferior opening • T12 – costal margin xifoid apendix • Diafragm with openings ofering passage for • Esofagus, nerves vagus nerves • Aorta, inferior vena cava

12. The breast

13. Anatomy of the breast

14. Lymphatics of the breast

15. Autoexamination of the breast • Begin after onset of hormonal sexual activity • Monthly – preferable after menstruation • Inspection • Volume, position, profile • Palpation

16. Medical examination of the breast • History taking • Borths • Breast feeding + duration • Menstrual activity + changes in the breast • Other lesions • Hormonal therapy • Palpation • Breast + breast tissue outside “gland” • Nipple • Axillary lymph nodes • Skin • COMPULSURY BOTH SIDES

17. Axillary lymphnodes • External thoracic (under the pectoralis major) • Main collector • Brahial group • Inferior scapullary group - dorsal • Subclavicular – top of axxila • Central • Internal thoracic – not accesible

18. Imagistics • Ultrasound scan • Doppler effect for vessels diposition • Mamography • Galactograpy

19. THORACIC TRAUMA

20. Pain Relatively minor element that triggers changes in ventilation Significant presence in any thoracic trauma Immobilization – not applicable Suppresses cough reflex Finally generates airway obstruction and hypoxia Pneumotorax Major deficit – loss of functional pulmonary tissue Complex mechanism Airway obstruction Acute respiratory failure fearful complication Tahipnea Acute dispneea Use of accessory respiratory muscles Cyanosis Anxiety Common manifestations in thoracic trauma

21. Manifestations of thoracic contusions

22. Non-characterisctic symptoms Ecchymosed Hematoma Subcutaneous fluid collections Muscle tears As a single lesion – children (soft thorax) Clinically – same as any other locations Contusions of soft tissue

23. Sternal fractures • Mechanism • Direct impact • Acute flexion • Type: • transversal w/o movement of fragments • Particular situation – manubrio-sternal disjunction • Clinically • Pain • Deformity • Short sternumt with dimished intercostal spaces

24. Costal fractures • Very frequent in adulthood – 10% • More frequently in ribs situated in the middle unprotected area • Direct or indirect mechanism • Direct – sharp bone projected inside • Indirect – sharp bone projected outside

25. Clinically Benign lesions Pain Diminished amplitude of respiratory movements Palpation – in the arrea of fracture Deformity Osseous creptiations during deep inspiration or cough MAJOR risk Lesion of pleura or lung Direct lesions Parietal pleura Visceral pleura Lungs Intercostal vessels Indirect lesion Intercostal vessels Costal fractures

27. Common complications of thoracic contusions and wounds

28. Blood acumulation in the pleural space Vascular lesions in the intercostal space (intercostal artery – very important hemprrhage) Pulmonary lesions Mediastinal lesions Clasification Small: 300-500 ml occupies the costo-diafragmatic angle and has limited symptoms. Medium: <1500ml reaches the middle of the scapula Large: >3000 ml Hypoxia lung is compressed Circulatory changes – mediastinal shift Hypovolemia Hemothorax

29. Hemothorax

30. Hemothorax • Clinical examination • Dull on percution • Respiratory sounds not audible on the affected side • Diminished amplitude of respiratory movements • Chest X-Ray • Pleural puncture – will show the nature of the fluid (blood)

31. Typical hemothorax – secondary to rib fractures Massiv hemothorax Small – in decubit the fluid extends and shadows all the lung

32. Tension Hemothorax

33. Pneumothorax • Continuity between the lung and pleural space – during breathing in air gets in the pleural space • Aer tends to migrate: • Through the fracture area • Through pleural ruptures • Through natural communications of the chest (mediastinum, neck, etc)

34. Subcutaneous emphysema

35. Subcutaneous emphysema

36. Mechanism Pleural and pulmonary lesion Wound – aer coming from outside Calsification Small / medium /massiv Exmanition: Thoraci pain Acute sensation of thoracic constriction Diminished amplitude of respiratory movements. Tympanic sound on percution Diminished amplitude of transmitted respiratory sounds!!!! IT MAY BE TRANSMITTED FROM THE OTHER SIDE Enclose pneumothorax

37. Enclosed pneumothorax

38. Open pneumothorax • Open wound in the thoracic wall • Air freely enters and exits during expiration • Air does not accumulate and does not increase pressure inside pleural space

39. Tension pneumothorax • Wound in the parietal or visceral pleura • Air enters the cavity REPEATIDLY with each inspiratory movement • The wound spontaneously closes during expiratiosn • Accumulation of air in the pleural space • Internal or external one-way mechanism

40. Tension pneumothorax – physiologic repercussions

41. Acute onset Hypoxia, Respiratory distress, Cyanosis Agitation Sensation of imminent death Mediastinal compression (in advanced stages) Diminishes the functionality of the “normal lung” Decreases heart diastolic filling (angulation of SVC and IVC) End point – Acute Respiratory Failure and Acute Circulatory Failure Urgent decompression Tension pneumothorax - symptoms

42. Tension penumothorax

43. Complex thoracic fractures –at least 3 ribs each with 2 fractures Typical mechanism is by compression of thorax Associates complex iternal organ trauma = Multiple trauma patient Classification Ventral (including the sternum) – frequent in car accidents impact on the steering wheel Anterior and lateral Lateral Dorsal (unlikely – big muscular structures) Flail chest

44. Flail chest • According to mobility • Fix – at least temporarily • Mobil • Similar to fluid effusion • Part of thorax escapes the action of respiratory muscles • Thorax no longer rigid • PARDOXICAL MOVEMENT

45. Flail chest • Complex respiratory disfunction • Decreased pulmonary capacity • Swinging air • Mediastinal shift • ARF and ACF • Surgical emergency

46. Flail chest

47. “Posttraumatic Soft Thorax”

48. Flail chest – internal stabilisation

49. Contusions of the rachis • Fracture-dislocation • Mechanism: rotation or hyperflexion • Pathology : dislocation of vertebra and spinal cord compression • Clinically: neurologic defect, hematoma, subcutaneous hemorrhage + unequal intervertebral spaces • Fracture of vertebral body • Mechanism: compression + flexion = vertebral surfaces not parallel • Clinically: pain, musculare contraction, dorsal deformity of the spine, usual without neurological signs

50. Other contusions • Pulmonary contusions • Diaphragmatic contusions with diaphragmatic hernia • Contusions of the heart and pericardium • Trachea and bronchi contusions • Esophageal contusions