Join renowned medical professional, James Cartlidge, on 20/11/24 for an in-depth anatomy lecture on the thoracic wall. Familiarize yourself with the sternum, ribs, and their association with clinical applications such as rib fractures and flail chest conditions. Expand your knowledge on the anatomy of thoracic muscles, blood vessels, and nerves, as well as their clinical relevance. Understand key procedures such as needle decompression, chest drain insertion, and intercostal nerve block through a clinical perspective. This session includes multiple-choice questions for self-assessment and provides a thorough understanding of the vasculature and venous drainage systems. Perfect for medical professionals seeking to advance their skills and knowledge in thoracic anatomy.
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TheThoracicWall ClinicalRelevance Lecture1 20/11/24 JamesCartlidge Overview Anatomy Clinical Application • Sternum • RibFractures • Ribs • FlailChest • Muscles • Needle Decompression • TensionPneumothorax • BloodVessels • Nerves • Chest Drain Insertion • Thoracostomy • IntercostalNerve Block Sternum • Three parts • Manubrium • Manubriosternaljoint • Body • Costalnotches • Xiphoid Process • Xiphisternal joint • Articulates with: • Clavicles • Sternoclavicularjoints • Costal cartilages (ribs 1-7) • Sternochondral jointsSternum Ribs • 12pairs • 1-7:true • Directly articulate with sternum • 8-10: false • Indirectly articulatewith sternum • 11-12: floating • Don’t articulate with sternum • Typicalrib (3-9) • Headwith 2 articular facets • Neck • Tubercle • Body • Costalgroove • CostovertebraljointRibs Muscles Extrinsic • Oneattachment to thoracic wall • Functionally related elsewhere • Pectoralis major • Pectoralis minor • Serratusanterior • Subclavius Intrinsic • Originate andinsert on thoracic cage • Accessory respiratory muscles • Intercostal • Subcostal • Transversusthoracis • Levatores costarum • SerratusposteriorMuscles IntercostalMuscles External • Most superficial • Inferomedial course • Inferior →superior rib border Internal • Middlelayer • Inferolateral course • Lateral edge costal groove →superior border Innermost • Deepest layer • Inferolateral course • Medial edge costal border →superiorIntercostalMuscles Vasculature Arterial supply • Subclaviana. → internal thoracica. • Internal thoracica. → anterior intercostalaa.(Up6/9) • Internal thoracica. → Musculophrenic a.→ anterior intercostalaa. (Lw3/9) • Supreme intercostal a. → posteriorintercostal aa. (Up2/11) • Thoracicaorta→ posterior intercostalaa. (Lw10/11) • Thoracicaorta→ subcostal a.Vasculature Vasculature Venous drainage • Anteriorintercostal vv. (9)→ internal thoracic+ musculophrenic vv. • Posteriorintercostal vv. (11)+ subcostal v. → azygosvenous system • Right4 -11 → azygos v. • Left4 -7 → accessoryazygos v. th th • Left8 -11 → hemiazygos v. • 1 posteriorintercostal v.→ supreme intercostalv.→ brachiocephalicv. nd rd • 2 +3 posteriorintercostal vv. → superiorintercostal v →(L) brachiocephalicv. + (R) azygosv.Vasculature Nerves Thoracic nerves • Anteriorramiofspinal nn. T1-T11 Subcostalnerve • Anteriorramus of spinal n. T12 Pectoral nn. • Medial +lateral • Arisefromrespective plexusof brachialNerves NeurovascularBundle • Costalgroove • Inferior border of rib • Between inner& innermost intercostal muscles • Bundleorder(superior→ inferior) • Vein • Artery • Nerve • Collateralbranches • Superior border of lower ribNeurovascularBundle RibFractures • Commonly occurs in ribs5-10 • Tend to break atweakest part – justanterior to angle • Due to: • Crushing Injuries • Directtrauma • Soft tissue injury risk: • Lungs - pneumothorax • Diaphragm • Severe localised painRibFractures FlailChest • Multiple rib fractures • ≥2 fractures in≥2 adjacent ribs • Segment of thoracic wall disconnected • Moves freely • Paradoxicalmovement • Inspiration: inward • Expiration: outward • Impairedribcage expansion • Affects blood O2 NeedleDecompression • Pneumothorax • Collectionof airin pleural space • Tension • Mediastinal displacement • Haemodynamiccompromise • Emergencydecompression • Large-borecannula nd • 2thCthCL • 4 /5 ICSanteriortomidaxillary line • Insertatsuperior border of rib • Bevel facing upwardsNeedleDecompression ChestDrainInsertion • Triangle ofsafety • Pectoralismajor • Lthissimus dorsi • 5 ICS(~level ofnipple) • Drain positioning • Air– upwards • Fluid–downwards • Type • Surgical • Medical – SeldingerChestDrainInsertion IntercostalNerveBlock • Analgesia of: • Anterolateralthoracic& • Abdominal walls • Blockbefore lateral cutaneousbrancharises • At midaxillary line • Needledirectedtowardrib near subcostalgroove at lowerborder • Localanaesthetic infiltrated around nerve • Complications • Pneumothorax • Haemorrhage MCQ1 What isribribebelclafefiasas? A. False B. True C. Floating D. Atypical MCQ2 Which muscle of the thoracic walloriginatesfrom the lateral edge of the costal groove and inserts onto the superior border of the rib below? A. Innermost intercostal B. Externalintercostal C. Internalli trroosttal D. Transversus thoracis MCQ3 Which vesselis the 8 anterior intercostalarterydirectly derived from? A. Supreme intercostala. B. Subcostala. C. Subclavian a. D. Muscul ophreniiaa.. MCQ4 What is the order ofthe neurovascular bundle foundin the subcostalgroove, fromsuperior to inferior? A. Artery → vein → nerve B. Nerve → artery → vein C. Vein → arteryy→→nerree D. Nerve → vein → artery MCQ5 You percuss over the right chestwalland hear hyperresonance. You suspecta tension pneumothorax.Where on the chest wall would you perform an anterior emergencyneedle decompression,usinga large-bore cannula? A. L 2 ICSMCL th B. R 4 ICSMCL C. R 2 ICSMCL D. R 4th ICS MAL References • KenHub • Gray’sAnatomy for Students, 4 th Edition • Teach Me Anatomy • Snell’s ClinicalAnatomy By • USMLE First AidStep 1 Regions,10 Edition • Radiopaedia • Moore’sClinicallyOriented • Teach Me Surgery Anatomy, 9 Edition • GeekyMedics th • Thieme Atlas of Anatomy,4 • Zero To Finals Edition
