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Questions and Answers
What are the two endings of the veins in the upper six intercostal spaces?
What are the two endings of the veins in the upper six intercostal spaces?
They end in the internal thoracic vein.
In which veins do the seventh, eighth, and ninth intercostal spaces terminate?
In which veins do the seventh, eighth, and ninth intercostal spaces terminate?
They terminate in the musculophrenic vein.
How many posterior intercostal veins are present in each space?
How many posterior intercostal veins are present in each space?
There is one posterior intercostal vein in each space.
Name the three parts of the diaphragm's origin.
Name the three parts of the diaphragm's origin.
From where does the right crus of the diaphragm originate?
From where does the right crus of the diaphragm originate?
What structure forms an arch across the front of the aorta?
What structure forms an arch across the front of the aorta?
What does the medial lumbocostal arch cover?
What does the medial lumbocostal arch cover?
What are the three types of ligaments associated with the vertebral part of the diaphragm?
What are the three types of ligaments associated with the vertebral part of the diaphragm?
What is the principal muscle of respiration?
What is the principal muscle of respiration?
What are the boundaries of the thoracic outlet?
What are the boundaries of the thoracic outlet?
What causes the gap leading to congenital diaphragmatic hernia, and which side is it most commonly observed?
What causes the gap leading to congenital diaphragmatic hernia, and which side is it most commonly observed?
What are the components covering the thoracic wall?
What are the components covering the thoracic wall?
Explain the anatomical location and common characteristics of a retrosternal hernia.
Explain the anatomical location and common characteristics of a retrosternal hernia.
How many intercostal spaces are present in the thoracic wall?
How many intercostal spaces are present in the thoracic wall?
What distinguishes typical intercostal spaces from atypical intercostal spaces?
What distinguishes typical intercostal spaces from atypical intercostal spaces?
Describe the mechanism by which a paraesophageal hernia allows the stomach to move into the thoracic cavity.
Describe the mechanism by which a paraesophageal hernia allows the stomach to move into the thoracic cavity.
What distinguishes a hiatal (sliding) hernia from other types of hernias?
What distinguishes a hiatal (sliding) hernia from other types of hernias?
What is the functional role of the external intercostal muscles?
What is the functional role of the external intercostal muscles?
How is unilateral diaphragmatic paralysis clinically diagnosed?
How is unilateral diaphragmatic paralysis clinically diagnosed?
Describe the origin and insertion of the internal intercostal muscles.
Describe the origin and insertion of the internal intercostal muscles.
What are the potential consequences of bilateral phrenic nerve damage?
What are the potential consequences of bilateral phrenic nerve damage?
Identify the muscle that is replaced by the anterior intercostal membrane.
Identify the muscle that is replaced by the anterior intercostal membrane.
What is the function of the transversus thoracis muscle?
What is the function of the transversus thoracis muscle?
Which muscles are supplied by the intercostal nerves of the same space?
Which muscles are supplied by the intercostal nerves of the same space?
How do the fiber orientations differ between the external and internal intercostal muscles?
How do the fiber orientations differ between the external and internal intercostal muscles?
What is the anatomical relationship of the sympathetic trunk in relation to the lateral lumbocostal arch?
What is the anatomical relationship of the sympathetic trunk in relation to the lateral lumbocostal arch?
Describe the attachment points of the lateral lumbocostal arch.
Describe the attachment points of the lateral lumbocostal arch.
Identify the main structures that pass through the vena caval opening of the diaphragm.
Identify the main structures that pass through the vena caval opening of the diaphragm.
What is the shape of the central tendon of the diaphragm and its components?
What is the shape of the central tendon of the diaphragm and its components?
What major structures are transmitted through the esophageal opening at T10?
What major structures are transmitted through the esophageal opening at T10?
Which vessel passes through the gap known as the space of Larry in the diaphragm?
Which vessel passes through the gap known as the space of Larry in the diaphragm?
Name the sole motor and sensory nerve supply to the diaphragm.
Name the sole motor and sensory nerve supply to the diaphragm.
What passes through the aortic opening at T12?
What passes through the aortic opening at T12?
What minor openings exist in the diaphragm, and what passes through them?
What minor openings exist in the diaphragm, and what passes through them?
How are the sympathetic chain and hemiazygos vein related to the diaphragm?
How are the sympathetic chain and hemiazygos vein related to the diaphragm?
What structures contribute to the development of the diaphragm?
What structures contribute to the development of the diaphragm?
Describe the main arterial supply to the diaphragm.
Describe the main arterial supply to the diaphragm.
How does the diaphragm function during respiration?
How does the diaphragm function during respiration?
What is the mechanism of the pump-handle movement in respiration?
What is the mechanism of the pump-handle movement in respiration?
Explain the significance of diaphragmatic hernias.
Explain the significance of diaphragmatic hernias.
What happens to the transverse diameter of the thoracic cavity during respiration?
What happens to the transverse diameter of the thoracic cavity during respiration?
Identify the primary source of sympathetic supply to the diaphragm.
Identify the primary source of sympathetic supply to the diaphragm.
What is the central tendon of the diaphragm developed from?
What is the central tendon of the diaphragm developed from?
How does the diaphragm contribute to increasing the vertical diameter of the thoracic cavity?
How does the diaphragm contribute to increasing the vertical diameter of the thoracic cavity?
What can result from a posterolateral hernia of the diaphragm?
What can result from a posterolateral hernia of the diaphragm?
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Study Notes
Thoracic Wall Anatomy
- Covered by skin, superficial fascia, and deep fascia.
- Contains extrinsic muscles (upper limb, abdomen, back).
- Intercostal spaces house intercostal muscles, nerves, vessels, and lymphatics.
- Eleven intercostal spaces; typical (3rd-6th) and atypical (1st, 2nd, 7th-11th).
Intercostal Muscles
- External intercostal: Eleven pairs; originates from the rib above, inserts into the rib below; elevates ribs during inspiration.
- Internal intercostal: Eleven pairs; originates from the costal groove of the rib above, inserts into the rib below; depresses ribs during expiration.
- Transversus thoracis: Includes intercostalis intimi, subcostalis, and sternocostalis.
Intercostal Vessels
- Anterior intercostal veins: Two in each space (upper six drain into internal thoracic vein; seventh, eighth, and ninth into musculophrenic vein).
- Posterior intercostal veins: One in each space; accompany posterior intercostal arteries.
Thoracic Outlet
- Boundaries: Anteriorly – xiphoid process; Posteriorly – 12th thoracic vertebra; Laterally – costal margin, 11th and 12th ribs.
Diaphragm
- Principal muscle of respiration; peripheral muscular part and central fibrous tendon.
- Origin: Sternal (xiphoid process), costal (lower six ribs), vertebral (crura and arcuate ligaments).
- Crura: Right (upper three lumbar vertebrae); Left (upper two lumbar vertebrae).
- Arcuate ligaments: Medial, lateral (both right and left), and median arcuate ligament (Aorta passes deep to it).
- Insertion: Muscle fibers converge to central tendon.
- Central tendon: Trifoliate (anterior and two posterior leaflets); fused with fibrous pericardium; closer to sternum than vertebral column.
Diaphragmatic Openings
- Vena caval opening (T8): Inferior vena cava, right phrenic nerve.
- Oesophageal opening (T10): Esophagus, right and left vagal trunks, esophageal branches of left gastric artery (located in right crus).
- Aortic opening (T12): Aorta, azygos vein, thoracic duct (osseo-aponeurotic opening).
- Minor openings: Superior epigastric vessels, musculophrenic artery, lower five intercostal nerves and vessels, subcostal nerves and vessels, sympathetic chain, splanchnic nerves, hemiazygos vein.
Diaphragm Nerve Supply and Arterial Supply
- Nerve supply: Phrenic nerves (motor and sensory to central part); lower five intercostal and subcostal nerves (sensory to peripheral part); sympathetic supply from celiac plexus.
- Arterial supply: Superior and inferior phrenic arteries; pericardiophrenic arteries; musculophrenic arteries; superior epigastric arteries; lower five posterior intercostal and subcostal arteries.
Diaphragm Development
- Septum transversum (ventrally); pleuroperitoneal membranes (laterally); dorsal mesentery of esophagus (dorsally); body wall (peripherally).
- Central tendon from septum transversum; domes from pleuroperitoneal membrane; esophageal area from dorsal mesentery; peripheral part from body wall.
Respiratory Movements
- Anteroposterior diameter: Increased by elevation of vertebrosternal ribs (pump-handle movement) and vertebrochondral ribs.
- Transverse diameter: Increased by movements of vertebrochondral ribs (bucket-handle movement) and vertebrosternal ribs.
- Vertical diameter: Increased by diaphragm descent.
Clinical Correlations
- Diaphragmatic hernias: Congenital (posterolateral, retrosternal, paraesophageal) and acquired (traumatic, hiatal).
- Diaphragmatic paralysis: Unilateral (elevated hemidiaphragm); bilateral (respiratory failure).
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