In this comprehensive on-demand medical course, participants will dive into the intricacies of the thoracic wall anatomy. Led by James Cartlidge, the course delves into the sternum, ribs, muscles, blood vessels and nerves, relating each to potential clinical applications. Learn about the three parts of the sternum, the 12 pairs of ribs and the key structures of both intrinsic and extrinsic muscles. Discover thoracic nerves and the arterial supplies and venous drainage of the thoracic wall. Medical professionals will learn crucial, practical applications like understanding rib fractures, managing flail chests, performing needle decompressions and chest drain insertions and safely conducting intercostal nerve blocks. Put your knowledge to the test with multiple-choice quizzes, enhancing your understanding and preparing you for real-world medical situations. Add this session to your professional development plan to bolster your knowledge of the thoracic wall.
By the end of this session, participants should be able to accurately explain the structure and function of the thoracic wall, specifically the sternum, ribs, and muscles of the chest.
Attendees will demonstrate a comprehensive understanding of different medical conditions and injuries that can affect the thoracic wall, including rib fractures, flail chest, and tension pneumothorax.
Participants will learn how to effectively perform a needle decompression and chest drain insertion for a patient with a pneumothorax, and know when each procedure is clinically indicated.
Attendees shall be able to describe the anatomy and clinical relevance of the blood vessels and nerves in the thoracic wall, and how they relate to medical procedures or pathologies.
By the end of the session, participants shall have knowledge about the clinical application of an intercostal nerve block, potential complications, and methods for prevention.
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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
