Thoracic wall, breast and diaphragm.pdf

WELCOME TO ANAT3121 [email protected] @orientatewithjoyce Contact Information Course Convenor: Joyce El-Haddad Email: [email protected] Consultation hour: by appointment only Course Co Convenor: Patrick Chau Email: [email protected] Consultation hour: by appointment only 2 Email e...

WELCOME TO ANAT3121 [email protected] @orientatewithjoyce Contact Information Course Convenor: Joyce El-Haddad Email: [email protected] Consultation hour: by appointment only Course Co Convenor: Patrick Chau Email: [email protected] Consultation hour: by appointment only 2 Email etiquette [from your UNSW email ONLY] An example of what to do: ‘ Hi Joyce, My name is Lilly, and I am from ANAT2241 I was wondering if…..” Thank you, Lilly’ An example of what NOT to do: ‘ can u check my grade From [email protected]’ What do I do if I feel overwhelmed with the course? We are here for you. Contact the course convenors at any point in the term if you are feeling overwhelmed. We can help you and work through solutions and/or point you to the right direction for help. Moodle and Teams tour Thoracic Wall, Breast, and Diaphragm JOYCE EL-HADDAD VISCERAL ANATOMY ANAT3121 [email protected] @orientatewithjoyce Lecture Outline Learning Outcomes 1. To review the main features of the bones and joints of the thoracic region 2. To identify and discuss the anatomy of the intercostal muscles and spaces (layers, relations, neurovascular supply and actions) 3. To identify and discuss the anatomy of the diaphragm (muscles, surfaces, relations/openings, neurovascular supply and actions) 4. Discuss the position and relations of the breast with regards to the chest wall and axilla. 5. Describe the architecture, blood supply, lymphatic drainage and innervation of the breast. 6. Relate the gross anatomy of the breast to changes that may occur in breast cancer, including metastasis via lymphatic and venous routes. Thoracic Cage Overview The thoracic cage acts to protect all its internal contents. It is also involved in respiration. Health professionals are able to examine the heart and lungs through the chest wall, by way of percussion and auscultation. Procedures include ECGs, thoracocentesis or insertion of chest drains and life-saving CPR LO1.To review the main features of the bones and joints of the thoracic region Superior thoracic aperture Inlet Thoracic Wall structure and contents 1 sternum 12 ribs and costal cartilages 12 vertebrae Outlet Inferior thoracic aperture Elliptical Truncated cone Clinically orientated anatomy 7 th edition 2014. LO1. Articulation at joints allows movement for respiration Thoracic Wall structure and contents The thoracic wall consists of 1 sternum, 12 ribs and costal cartilages, and the 12 thoracic vertebrae. The proximal end of the thoracic cage = the inlet or the superior thoracic aperture The distal end of the thoracic cage = the outlet or the inferior thoracic aperture Articulation at joints allows movement for respiration LO1.To review the main features of the bones and joints of the thoracic region Thoracic Vertebrae – Typical (T2-T8) LO1.To review the main features of the bones and joints of the thoracic region Thoracic Vertebrae – Typical (T2-T8) Superior costocapitular demifacet Costotubercular facet Inferior costocapitular demifacet LO1.To review the main features of the bones and joints of the thoracic region Netter’s Atlas of Human anatomy. 6th Ed. Thoracic Vertebrae – Atypical (T1, T9, T10, T11, and T12) R1 articulates only with T1 Superior costal facet = whole facet T11 & T12 | single pair of costal facets on its pedicle T9 and 10 | one bilateral pair of costal facets on its body + pedicle LO1.To review the main features of the bones and joints of the thoracic region Gray’s Anatomy for Students 3rd Edition Thoracic vertebrae terminology and summary Terminology: Costal = relating to ribs Costocapitular = articulation between vertebral body + head of rib Costotubercular = articulation between vertebral body + tubercle of rib Demifacet = half a facet or a shallow facet Summary: - T2-T8 are classified as typical thoracic vertebrae - T1, T9, T10, T11, T12 are classified as atypical thoracic vertebrae - Atypical features occur as the morphology of the vertebral column is transitioning - T9 and 10 only have one bilateral pair of costal facets on its body and pedicle - T11 & T12 have a single pair of costal facets on its pedicle - T1 = R1 articulates only with T1 Superior costal facet = whole facet LO1.To review the main features of the bones and joints of the thoracic region RIBS - Ribs can be grouped as true, false, or floating. True Ribs: Ribs 1-7 - Articulates directly with sternum (vertebrosternal) False Ribs: Ribs 8, 9 +/- 10 - Articulates indirectly through adjacent ribs (vertebrochondral) Floating Ribs: 11, 12 - Free, not attached to sternum (vertebral) LO1.To review the main features of the bones and joints of the thoracic region RIBS – Typical (3-9, and sometimes 10) LO1.To review the main features of the bones and joints of the thoracic region Tn = thoracic number (same as rib number) RIBS – Atypical (1, 2, ~10, 11, 12) Rib 2 LO1.To review the main features of the bones and joints of the thoracic region Tn = thoracic number (same as rib number) Features of atypical ribs summary Atypical rib Rib 1 Rib 2 Rib 10 Features Shortest and broadest of all the ribs. Flattened and curved shape, which helps to protect the superior mediastinum. Two grooves on its superior surface that accommodate the subclavian artery and vein. Scalene tubercle = attachment point for the anterior scalene muscle. Articulates with only one thoracic vertebra (T1) Longer and narrower than the first rib, but still shorter and wider than the remaining ribs. Its superior surface is smooth, without the grooves found on the first rib. Head has only one facet for articulation with the corresponding thoracic vertebra, instead of two like the upper ribs. Ribs 11 and Head has only one facet for articulation with the corresponding thoracic vertebra 12 LO1.To review the main features of the bones and joints of the thoracic region Don’t memorise, but use as a guide to identify the atypical ribs Clinical Case: Bilateral cervical ribs Congenital abnormality where an extra rib forms above the first rib. This can lead to compression of vital structures passing through the thoracic inlet such as arteries, veins and nerves. (Covered in week 2) LO1.To review the main features of the bones and joints of the thoracic region Radiologypics.com Joints of thoracic cage 1. Costovertebral (costocorporeal) joint (typical vertebra): heads of ribs & superior and inferior articular facets and intervening intervertebral disc 2. Costotransverse joint: facet on transverse process & articular facet of the rib tubercle 3. Costochondral joint: (Primary cartilaginous joint): Rib perichondrium & the periosteum 4. Sternochondral joint: costal cartilage perichondrium & sternum, lateral surface LO1.To review the main features of the bones and joints of the thoracic region Developed by Nalini Pather Supporting structures for the joints Superior costotransverse ligament: btw neck of rib (w extensions to superior costal facet) and TVP of vert above. Costotransverse ligament: btw neck of rib and TVP Radiate ligament Lateral Costotransverse ligament: tubercle of rib to TVP LO1.To review the main features of the bones and joints of the thoracic region Clinically orientated anatomy 7 th Edition 2014. Costal cartilage and sternum t LO1.To review the main features of the bones and joints of the thoracic region Intercostal Muscles Thoracocentesis: There is a neurovascular plane between nerves & vessels lying between the internal & innermost muscles. Needles with local anesthetic can be safely inserted in the middle of the intercostal space (to avoid damage to vital structures) LO2. To identify and discuss the anatomy of the intercostal muscles and spaces (layers, relations, neurovascular supply and actions) LO2. To identify and discuss the anatomy of the intercostal muscles and spaces (layers, relations, neurovascular supply and actions) Interosseous part Internal Intercostal muscle replaced by a membrane posteriorly. You do not need to memorise, this is just a guide to identify these muscles in the lab Thoracic Surgery Clinics Clinically orientated anatomy 7 th Edition 2014. There are two types of intercostal arteries: anterior and posterior. The anterior intercostal arteries originate from the internal thoracic artery, while the posterior intercostal arteries arise from the thoracic aorta. There are also collateral branches that connect adjacent intercostal arteries, forming an intercostal arterial network. The collaterals run along the superior border of the rib below. (more detail as we move through the course) The DIAPHRAGM: ThoracoAbdominal Diaphragm Netter’s Atlas of Human anatomy. 6th Ed. LO3. To identify and discuss the anatomy of the diaphragm (muscles, surfaces, relations/openings, neurovascular supply and actions) Diaphragm: Attachments STERNAL ORIGIN: xiphoid COSTAL ORIGIN: Lower 6 costal cartilages Median arcuate ligament VERTEBRAL ORIGIN: Medial arcuate ligament Right crus (L1-L3) Lateral arcuate ligament Left crus (L1,L2) Clinically Oriented Anatomy 7th Edition, 2014 LO3. To identify and discuss the anatomy of the diaphragm (muscles, surfaces, relations/openings, neurovascular supply and actions) Developed by Nalini Pather Diaphragm: Major Openings Inferior vena cava (T8 vertebral level) Oesophagus (T10) Aorta (T12) Case courtesy of Joyce El-Haddad, Radiopaedia.org, rID: 172409 Netter, F. H. (2003), Interactive Atlas of Anatomy Version 3.0, Icon Learning Systems LO3. To identify and discuss the anatomy of the diaphragm (muscles, surfaces, relations/openings, neurovascular supply and actions) Diaphragm: minor openings Superficial epigastric vessels YouTube Video of diaphragm drawing: Sternocostalis opening https://youtu.be/z8WHYBvgcg?si=pcXgO1IXnarNqUpF Central tendon Right phrenic nerve Lateral arcuate Median arcuate Oes Left phrenic nerve Medial arcuate Splanchnic nerves Quadratus Lumborum Vagal trunk IVC Aorta Left crus Subcostal vessels Psoas Major Sympathetic chain hemiazygos Right crus azygos Thoracic duct LO3. To identify and discuss the anatomy of the diaphragm (muscles, surfaces, relations/openings, neurovascular supply and actions) Diaphragm: Blood supply Pericardiophrenic (From: Internal thoracic artery) Musculophrenic (Terminal branch int. thoracic) Superior phrenic (Directly off thoracic aorta) Inferior phrenic (Directly off abdominal aorta or Coeliac trunk) Superior phrenic Superior epigastric artery LO3.. Diaphragm: Innervation Phrenic nerve (C3,4,5) Intercostal nerves LO3. Clinically Oriented Anatomy 7th Edition, 2014 Clinically Oriented Anatomy 7th Edition, 2014 Normal Unilateral Paralysis of the diaphragm (right side) Due to nerve or muscle problem. Results in paradoxical breathing. With inspiration the diaphragm moves up instead of down on the affected side. Naz S et al. Heart on the left, diaphragm on right: congenital diaphragmatic eventration. Clin Case Rep. 2021. 9(11) Chest wall movements Clinically Oriented Anatomy 7th Edition, 2014 Summary of muscles involved in respiration Orthopneic (Tripod) position A patient with dyspnoea will often find relief on sitting up and resting their upper limbs on a table in front of them. What is the anatomical basis for this? Anatomy of the breast Note: Breast will be emphasized in the tutorials Mammary glands – what are they? What is their function? Modified sweat glands Secondary sexual characteristics of females Source of nutrition and immune support for the neonate Breast shape and size vary - may be hemispherical, conical, variably pendulous, piriform or thin and flattened Depends on genetic, racial, and dietary factors, age, parity, and menopausal status of the individual. Though it is present in both sexes, it is well developed in females and rudimentary in males. LO4-6 https://www.sheknows.com/wp-content/uploads/2020/08/facts-about-boobs-1.jpg?w=1024 Anatomy Let down/milk ejection reflex Nipple Areola Lobules Lactiferous sinus Connective tissue septum You don’t need to know this reflex for anatomy Australian Breastfeeding Association Lactiferous duct Clinically Oriented Anatomy, 6th edition LO4-6 © 2010 Wolters Kluwer Health/ Lippincott Williams & Wilkins Anatomy Nipple and areola are cutaneous features Fibrous tissue divides the breast into lobules (16-20) Each lobule contains glands draining into lactiferous ductsdrain towards nipple Each duct has a lactiferous sinus close to its termination (milk reservoir) Glandular tissue embedded in a fibrofatty stroma LO4-6 Location o 2nd / 3 r d to 6th costal cartilages o Lateral margin of sternum to mid-axillary line o Axillary tail/process – supralateral quadrant of breast lies in the inferolateral edge of pectoralis major and rarely enters the deep fascia of axilla o Location correlates blood supply to nerve supply to similar numbers LO4-6 Retro-mammary space The breast lies in the superficial facia of the pectoral region Separated from the deep fascia by the retromammary space Superficial fascia Pectoralis major Retromammary space Restriction of mobility implies involvement at this plane The axillary tail pierces the deep fascia and can lie deep to the deep fascia of the axilla Implications with cyclical breast changes Can be mistaken for axillary lymph nodes Support and cushioning, mobility, implant placement, and pathological significance LO4-6 Clinically Oriented Anatomy, 7th edition © 2014 Wolters Kluwer Health/ Lippincott Williams & Wilkins Suspensory ligaments (of Cooper) Run from the skin into the substance of the gland Infiltration by cancer cells can cause dimpling of the skin Suspensory ligaments https://medical-dictionary.thefreedictionary.com/Breast+neoplasms Netter, F. H. (2003), Interactive Atlas of Anatomy Version 3.0, Icon Learning Systems LO4-6 Arterial blood supply 2. Branches of internal thoracic (mammary) artery 1. Branches of axillary artery 2nd – 6th spaces 3. Branches of posterior intercostal arteries LO4-6 Clinically Oriented Anatomy, 6th edition Clinically Oriented Anatomy, 7th edition © 2014 Wolters Kluwer Health/ Lippincott Williams & Wilkins © 2010 Wolters Kluwer Health/ Lippincott Williams & Wilkins Medial blood supply LO4-6 Lateral blood supply LO4-6 Venous Drainage LO4-6 Internal Vertebral Venous Plexus Posterior intercostal veins drain into the azygos system A valveless system of interconnected veins In the thorax this plexus has connections to the azygos venous system LO4-6 It allows movement of tumour as far rostrally as the skull base and as far caudally as the lumbar vertebrae Clinically Oriented Anatomy, 7th edition © 2014 Wolters Kluwer Health/ Lippincott Williams & Wilkins Distant sites of metastasis include the following: Lungs and pleura Liver Bones Brain Vertebral plexus LO4-6 Nerve supply https://www.google.com/url?sa=i&url=https%3A%2F%2Fanatomyqa.com%2Fth oracicwall%2F&psig=AOvVaw2LUjlwXx6BG7DWp9QLzLyL&ust=1695959699488000&s ource=images&cd=vfe&opi=89978449&ved=0CBAQjRxqFwoTCPi3qq60zIEDFQA AAAAdAAAAABAE 2nd to 6th intercostal nerves supply the skin of the breast Netter, F. H. (2003), Interactive Atlas of Anatomy Version 3.0, Icon Learning Systems – Subareolar lymphatic plexus – 75% axillary – 20% internal mammary/thoracic (bilateral) – 5% posterior intercostal Subdiaphragmatic nodes (only drain skin) Breast surgery 1. Lumpectomy 2. Partial mastectomy (quadrantectomy) 3. Simple mastectomy entire breast removed 4. Radical mastectomy Rarely called for Extensive LN dissection Removal of pectoralis major LO4-6 4. Modified radical mastectomy entire breast LN dissection (sentinel or levels I and II) 5. Breast reconstruction/ augmentation/ reduction surgeries/top surgery Livingston EH. Breast Cancer and Axillary Lymph Nodes. JAMA. 2013;310(14):1518. doi:10.1001/jama.2013.280313 Screening for breast cancer Breast self examination Mammography for all over 40 Targetted screening for high risk individuals LO4-6 Normal Mammogram Not as effective for screening in younger women because of the fibrous nature of breast tissue Radiopaedia.org; rID: 25751