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Hi, and everyone here and see me, my laptop decided to have a and at the Yeah, good thanks. Um Give me two seconds and I will share my screen. We will get started. Um So, um yeah, so, hi, I'm James. Um I, I'm one of the committee members of the Clinical anatomy side at Queens. Uh We started kind of up this year and it was basically a group of masters students who did the Clinical anatomy master's program who were quite interested in kind of getting a bit more teaching experience and um potentially just create a society off the back of that. So what we're kind of hoping to do over this kind of academic year will be to um basically give online teaching sessions through metal to do short form yet hopefully high in teaching sessions on kind of street areas of anatomy that are clinically relevant for exams. So instead of doing the here's a whole body system where we're hopefully going to try and choose specific areas, talk a bit about the anatomy and then thereafter, um have a chat about the clinical applications of that, hopefully trying to help people. So I'm just going to um sta my uh spin hopefully. Um OK. So can people see these sides? OK. Yeah, yeah, thank you. So, uh this is hopefully the first lecture of Money and um it's going to be on the Thoracic wall and specifically looking at its clinical relevance. This is the QR code um for our Instagram and it'll kind of be the main platform that we'll be sharing our teaching sessions on. So, um hopefully, um you can scan that and be uh up to date with what we're um hopefully gonna be carrying out over the next year, um specifically for this session. Then um and in each session, we'll first consider the anatomy and what is normal and then we'll have a look at the clinical application of that anatomy. So for the, so the exam, we're gonna get the sternum, the ribs, muscles, blood vessels and then the nerves and then regarding the clinical application, we'll be having a brief like rib fractures, then looking at flail chest specifically, uh If someone developed a tension pneumothorax, we'd be looking at what sites would you be using to insert a needle for decompression? And thereafter, how, where would you insert a chest room? And then lastly, we have to look at um how to do an intercostal nerve block where specifically we place the needle. So the session will hopefully be short enough and then there's five NC KS at the end just to kind of go through to see um if people have kind of understood what we went through. So for each kind of area, we'll have a bit of text on the left and then a few images to talk through things and reinforce it. So we're first gonna consider the sternum and for the sternum, then we have 3.3 parts. We have the manubrium at the superior aspect in the middle, we have the body and these two are connected by the manubrial sternal joint, which is kind of a landmark um specifically um at kind of T four. And it allows you to then um look and see and allow you to then auscultate the chest. So for your aortic and your pulmonary valve and whenever we move down the body, here, we have our hy process and the joint between the body and hy process is called a zephyr joint. Essentially the sternum, it will articulate with different bones and superiorly then appear at the articular fossa, it will articulate with the clavicles. And this is at the sternoclavicular joint and then down along kind of the lateral aspects here of the minium and the body of the sternum. We have our costal cartilages where ribs won the seven ball attacks and these are the sternochondral joints, the sterno for sternum chondral for the cartilage of the joints. So this is just a labeled diagram to hopefully um kind of reinforce what we just talked to there. So you have your articular site, the clavicles, then on lateral aspects, have your articular facets with ribs. And yeah, this next diagram is just to allow you to appreciate that there's different types of joints. Um So if we just start up here, you can see that at the sternal or the sterno clavicular joint up here. It's a fibrocartilaginous joint or the man of sternal joint, it's a sepsis. Then whenever you reach kind of for the second rib here where it's the junction kind of between the body of the sternum and the manubrium. We have the synovial joint bout compartments there. Uh hy sternal joint is a synthesis. And then we have our uh at interchondral joints, you have another synovial joint. So just this cavity with a bit of fluid. Next time we're going to consider the ribs and we have 12 of them. So as you can see here, we have our 12 ribs, but they can be classified into kind of different categories. And for ribs, 137, which is labeled here. So from here until there, we have these, what you call true ribs. And what that essentially means is that they directly articulate with the sternum. As we can see here, you have the rib coming around, you have your uh costal condo joint and then you have your sternal chondral joint and that will join onto the sternum there, we then have our false ribs. So down here, so ribs eight through 12, but we're just gonna consider ribs eight through 10. And these are considered false ribs as they do not, uh, directly articulate with the sternum. So they indirectly articulate with it. What that means is that their costal cartridges don't reach the sternum. So they will join onto the, um, costal cartilage of rib seven. And that means that they're false ribs. And then down here we have these two floating ribs, they do not articulate with the sternum at all and they're quite truncated. So that means that they're not articulating with the sternum. So next time we're going to consider what a typical rib is and for ribs 3 to 9, that can be classified as typical. And it means that they have to have certain features then that allow them to be called down. So if you look at the top diagram here, um you can see the head of the rib and that has these two articular facets and the head of the rib is kind of located at the posterior aspect and it's right beside the thoracic vertebrae. And these facets allow for articulation with the vertebral bodies as we move. Then on here, more kind of an interlateral, we have our neck of the rib and after that, we have the typical. So as you can see here in this bottom diagram, this is allowing a uh a kind of an outer aspect appreciation note. So we have our head here with our articular facets with your crest, you can see the neck there and this diagram allows you to kind of appreciate the ta lot more. So as you can see, it's just a kind of a funny prominence there. As we then follow the rib around, we will reach the angle where it kind of twists and the angle will then follow around to the body of it around this way. And as you can see kind of an inferior aspect of that rib, there's a thing called a costal grave. And it's just kind of this indentation where the neurovascular bone will run, but we'll kind of cover that uh a bit later. And lastly, there, you can see the costovertebral joint to costo for rib vertebral, for vertebrae. And that's where the head will articulate. So as we can see in this diagram, if we look here, this is just the rib uh articulating round and this is where you have your costo vertebral joint here and you then have your costal transverse joint uh along there. So that will kind of articulate with the uh transverse aspect of the vertebrae. So for ribs, then this is just reinforcing that kind of ribs, one through seven are true. So they articulate with the sternum ribs, eight through 10 are pulse, the art with the rib above specifically, it's costal cartilage and then 11 and 12 are floating. So now we've considered the bones of the thoracic cage, we're gonna have a brief talk about the muscles, but we're really gonna kinda focus on the intercostal muscles. So you can have auto turned extrinsic muscles of the thoracic cage. And what this means is that there is one attachment to the thoracic wall. However, really, they're kind of functionally related elsewhere. And whenever we look at that, we can see pectoralis major, if you want extrinsic muscles, we then have pectoralis minor here, you can see it there. We then have subclavius, which is kind of hidden there and then stratus anterior, which you can see down along there. But what for this session we're kind of really interested in is the intrinsic muscles of the thoracic cage. And these are muscles which kind of they originate from and they then insert into the thoracic cage. And these can really be considered accessory muscles of respiration um because they will help with um kind of forced uh inspiration or aspiration because obviously the diaphragm does a lot of the work with breathing. So we have our intercostals, we have our subcostal that meaning below the rib have transverse thoracis, which is kind of located on the posterior aspect of the sternum and the vs costarum and SPS posterior. So this is just allowing us to have a look our intrinsic muscles that could the intercostal. So as you can see, you have your external intercostal, internal um innermost, um we're gonna kind of go on to talk about them a bit more. Next. So we're gonna specifically look at our intercostal muscles and there's three types. So most superficially then, which is here, we can see our external intercostal muscle and it really goes kind of in an inferomedial course to infer meaning going down and medial, going towards the midline. And really, you can kind of consider that as putting your hands in your pockets and that's kind of the direction that the muscle is going. And it will run from the um inferior border of the superior to the superior uh border of the inferior rib. Then whenever we move in one, we'll be looking at the internal intercostal and it can be considered the middle layer and it goes in an inferolateral course. So while it's going down, it's going laterally. So it's going away from the midline and it's going from the lateral edge of the costal groove to the superior border of the red balloon. So that costal groove here, you can see along there laterally just means come outside. So it's going to that outer aspect of the costal groove to the superior border there between the internal and the innermost ST we have our neurovascular bundles. But the next one in is the innermost intercostal muscle. And it's kind of the deepest layer here and it goes in an infer lateral course as well, just like the internal intercostals. And it's instead this time going from the medial edge of this costal groove, it's going to the inner aspect here and you can see it just there going to the superior border of the inferior rib. This is just a slightly more close up diagram. So as you can see before you get to your muscles, you're gonna go through the skin, superficial fascia, then you got your externals, your internals and then your innermost and you'll also have to straight this anterior present. But whenever you get uh past that innermost stem, you'll then be reaching your kind of endo thoracic fascia, which is kind of this yellow there and then your paal pleura. So next time we're gonna have a look, the vasculature on and from this diagram that can look quite complicated. But hopefully with this explanation here on the left and the few diagrams that I'll show you it, hopefully make things slightly more easy to understand. So we're gonna consider first one of the main uh kind of are days. It runs kind of parasternally. And one of the ones that you'd be interested in and say surgery is your internal thoracic artery here. You can see it's bilateral. So it's going down either side there and it's coming from, then the subclavian artery here that's coming off from that vessel there. It'll run down the side there. What's important about this internal thoracic artery then is that it gives these anterior intercostal arteries. And what that means is if you can appreciate their internal going down. And you can see these anterior intercostal arteries coming off, giving kind of your medial and lateral aspects. And this is for the upper six uh ribs. So for the upper six, so there's nine anterior intercostal art, the upper six, they'll be derived from the internal thoracic artery. So then for the lower three that are left out of those nine anterior intercostal arteries, they will then come from the uh well of a course along from your internal thoracic artery first. And then kind of whenever you reach the border of nearly the seven trips there, you have it spinning off, the internal thoracic will go into your superior epigastric, which will kind of go down the anterior abdominal wall and then kind of following along the costal margin will be this musculophrenic artery which is following along here. If you can follow up there. And then from this muscular phrenic artery, we will then have our anterior intercostal arteries, the lower three out of the nine vessels. And I were kind of me back up. We have this pre intercostal artery which you can see up here and this supreme intercostal artery will kind of supply our first two. So our upper two posterior intercostal arteries and really, you can see these posterior intercostal arteries will be kind of running along the after they're observed, then going in the intercostal grove. So you can see them all coming along here. And the supremacist, the upper two of those 11. But really the main constituent that will kind of derive these posterior intercostal art, which you can see slightly easier here is the thoracic aorta. So as you can see, you have your uh a aorta arch and then going down to your thoracic aorta and then from each side of that, you will get your posterior intercostal art and these are for the um kind of lower 10. And lastly, then um you're having it like at rib 12 and you have your thoracic aorta, but it's looking at the subcostal artery and this is kind of just at the bottom which you can't really see in this diagram, but essentially um might be there actually. But um from the thoracic aorta, you will have the subcostal artery and because there's no rib below the 12th, it's just subcostal cause the last one. So it can no longer be turned to intercostal cause there's no intercostal space for it. Dr So this diagram will hopefully just um kind of show you slightly better from a different view uh how the arterial supply kind of occurs. So we have our internal thoracic arteries which are derived from our subclavian. And from that, then you have your anterior intercostal artery here, as you can see, running longer and from this anterior intercostal artery, you're gonna have an anterior perforating parts which will have kind of your medial and lateral aspects. And then whenever we go around to your thoracic aorta, which is located here. You can see these posterior um intercostal arteries. So kind of coming off the back and following on a vasal angle of a lateral cutaneous punch there. Whenever you look at this from a different gene, you can see your internal thoracic vessels there. You have your arter intercostal artery going along here and then from our posterior intercostal artery coming from the thoracic aorta, it's going around the bark anterior laterally along the intercostal curve and running along from that. Then you can also get these um kind of these collateral branches. So these vessels are coming along and that's the intercostal uh the costal grave there. So we've seen how the blood gets supplied through the thoracic tube. How does the blood then drain from it? And really most of the uh venous drainage where the thoracic wall will kind of mimic what the arterial vessels do. So it'll kind of follow along to a point. So we have our anterior intercostal veins and hopefully, this will be familiar, these will then drain into our internal thoracic and are musculophrenic veins. So you can see the internal thoracic vein here. So it will receive the venous drainage from these anterior intercostal veins of which there is nine and then from your musculophrenic, it will receive the in a strand from the lower ribs. And then whenever we look at the posterior intercostal veins of which there are 11 plus our subcostal vein, it will drain into the azygous venous system and depending upon where it is on the kind of posterior aspect of the uh thoracic cage, it will drain into specific um, vessels that are part of the az venous system. So, on our right, for our fourth to 11th along here, we'll drain into the Zygus vein which is located here on the left end. Our left fourth three sevens will drain into our, our accessory hemizygous vein, which is located along here. And then for left eighth to 11th, posterior intercostal veins, they will drain into the hemi azygous vein which is located along here. And this will all feed back into the azygous azygos vein that will kind of drain back in when we consider kind of more superiorly. Then we have our first posterior intercostal vein which will then kind of form our supreme intercostal vein and then we'll feed into our um brachial brachial veins. So our big veins up here and that's where that will jump back into. We then have our second and the third uh posterior intercostal veins, we'll go into our superior intercostal vein on both sides, but they will then drain into different areas. So on the left side, it will drain back into the superior or the brachiocephalic Dion located here, they're left. So that's it getting back in there. And then for righter intercostal vein, it will jump back into the Zygus sir. And this is just a slightly more simplified diagram to show you that the venous vessels will kind of follow with our arterial parts um going back along until uh internal so pain and then back into the system. And again, this is just another diagram to allow you to kind of appreciate the venous and it to be slightly easier to see, see this vein there. And the posterior costal vessels fitting in our left and right Blix fit back into the inner sphere, Vena cava muscle, the blood will return to. So you had like a, the, the sternum, we can look at the ribs, we then had to look at the muscles, considering mainly the intercostals. And then we've had a look at the vasculature. Next, we're gonna have a look at the nerves which supply the um kind of thoracic cage of the chest wall. And for that, then our thoracic nerves are derived from the anterior remi of the spinal nerves from T one to T 11. So essentially, you get these spinal nerves given off and you have your posterior MS which will then supply the back. But then we have the anterior M I which will follow along uh around the kind of curvature of the rib within the costal groove. And these will supply the chest wall. So from T one through T 11, we have our thoracic nerves and these will supply kind of the anti lateral chest wall, but then also into the abdomen also, and then we have our subcostal nerve, as I said before because there's no rib below the 12th, it's just considered subcostal cause there's no longer an intercostal space there. So that's just the anterior MS of the spinal nerve T 12. But then we also have our pectoral nerves which will kind of spine, the muscles also, we'll have our medial and lateral and these will arise from their kind of the medial and lateral cords on the brachial paxis plexus respectively. You can see this um anterior ramus, the spinal area falling around, it will give off a collateral branch and these collateral branches, the same with the vessels will kind of go from the um inferior aspect of the superior rib down to the superior aspect of the inferior rib. And you can see them running along there. Most people kind of forget about them what they are there. And you can see as it goes around, it will give off a lateral cutaneous branch which has both posterior and anterior aspects to kind of supply this chest wall. And whenever it reaches around to this anterior cutaneous branch, it will also give off another medial branch can move the sternum and a lateral branch there. No. And this diagram will hopefully allow you to kind of appreciate a bit better. The RE I from T one to T 12, not only supply the thoracic cage over the internodal chest wall, it will also supply kind of aspects of the anterior abdominal wall also. So this is kind of bringing everything together here in this one bit. So what's quite important to consider with your thoracic wall is your neurovascular bundle. And you want to consider this because whenever you're doing any interventions, normal, it may be through an intercostal space. And what we don't want to hit or affect will be this neurovascular bundle. The neurovascular bundle then is located in this costal grove which hopefully you can kind of see it just this not in the inferior aspect and inner aspect of the rib. And I said the inferior border of the rib then and it's between the inner intercostal and then the innermost intercostal. So that's where you'll find these uh neurovascular bundles. So you can see these neovascular bundle are along within your collateral branches. And it's very important to understand the order of this neurovascular bundle. It'll go from superiorly to inferior and you can remember it through the pneumonic vein. So, or I'm sorry. So va n so it's your vein in the middle, we have our artery and we then have our nerve at the inferiormost aspect of the costal groove. So it's important to know the order of that and where it's located because if you're doing any intervention, you need to know what can potentially be affected. And like I said previously, we have our collateral branches and these are located along the superior border of the lower or the um inferior rib. So that's just that taking out from the test while I'm just kind of zooming along. And you've seen this diagram before, it's just allowing you to appreciate the different layers. So you're having to do any uh interventions that what you'd be going through. So you going through the skin fascia and then through your intercostals, avoiding the neurovascular bundle, then going through your endo thoracic fascia and then your anterior ple and then lung which you touch it. But this is just showing you a different diagram with your neurovascular bundle there in the costal groove and the Great Cats. So we've covered the kind of anatomy. Then now we're gonna move on to more of the clinical aspect as to how maybe that can be applied and how we can maybe uh uh have a look at it in conditions. So some quite common injuries can be rib fractures and these will commonly occur in ribs five through 10, these because they're quite exposed. The R isn't the big muscles like it is up here for the kind of upper ribs and they will tend to break them at its weakest part. And if you can see here, this is considered the angle of the rib just anterior to that part. This is where the ribs can be more susceptible to break. And rib fractures can occur due to other crushing injuries or then direct trauma or direct blow to the ribs. And if you fracture this rib, then you, it's understandable that there may be kind of sharp fragments or parts that may be able to penetrate tissue. And you're quite worried then about any soft tissue uh injuries. And there is a risk then for your lungs which are located in here and in that part, you would be interested in potentially if there was a hemothorax, whereby the blood vessel may be broken and then it will cause blood to go into the chest cavity or a pneumothorax, whereby you damage the pleura and then you get an infiltration or into the pleural cavity. And that's called a pneumothorax as well. And kind of the um left aspect down by the costal margin, you get hit there, you'd be worried about the spleen, you'd be worried about, about a lot of bleeding there. And as well, your diaphragm, which kind of comes right up into your chest cavity, um You'd be worried about that potential damage also. And really, whenever you get a rib fracture, it's a really severe and localized pain. And this is due to your intercostal nerves being affected there. So they will let you know exactly how much pain you're in. So this is a radiograph taken from radio P and hopefully, you can see it, but as I say, it's just allow you to uh appreciate. So if you look at this, uh this uh radiograph, you can see on the right aspect of the patient here. I follow along, hopefully be able to see that there is breaks in the ribs there. You can see it's kind of just nearly angle. You can see there this is bricks and the ribs and this is what you would do. If you did suspect any uh rib fractures, you would do a radiograph and try and see what's going on. So if you have a very severe injury, then um which is in the case would be multiple rib fractures. If you have m two or more fractures and two or more adjacent ribs, you will then end up with a segment of the thoracic wall which is disconnected from the rest. So you then have this kind of freely moving aspect of thoracic wall that isn't no longer attached to the cage. So it's no longer under the influence of that. And it's gonna be subject to the forces of the pressures located within the thoracic cavity. And if that occurs, if you have two or more fractures and two or more adjacent ribs, and you'd have this freely moving aspect of the thoracic wall, which is disconnected from the cage, you're gonna have a condition that's called flail chest. A failed chest is quite an interesting thing to see and hopefully this video will work. Um But essentially, you will have what is called paradoxical moving or paradoxical movement with breathing. Um Normally, whenever you breathe in your chest wall will expound outwards using your kind of pocket handle and pump handle accents. However, because this aspect of the chess ball is kind of broken off from the thro cage. Whenever you inspire or uh take a deep breath in, you're creating this negative pressure within the thoracic cavity to draw or into the lungs. And with that, then you will have the and well, the thoracic cavity moving outwards or thoracic cage moving outwards, creating this negative pressure in the thoracic cavity will be in fitting your lungs. But because of this um kind of free um moving element of thoracic wall, this paradoxical movement will occur. So as the rest of the chest cage moves out, it will then move in this freely moving part of bone. So in inspiration, it will move inwards and then whenever you breathe out. So whenever you expire, your thoracic cage is moving in again. So it's moving back down and in, you will then be increasing the pressure within your thoracic cavity to then draw or out of your lungs to kind of push it out again. So in that case, you're creating this kind of increased pressure or sorry, less negative pressure within thoracic cavity. And that will cause that segment of the chest to then move on. So an inspiration, the flail chest aspect of me moving inwards and on aspiration, it will then go out. So this will really impair the expansion of your rib cage and you can only imagine how painful it probably is. And due to this kind of aspect, which is affected, it will then affect the oxygenation of blood. So, if I can, hopefully playing the video, you'll hopefully be able to appreciate what flail chest looks like. And so this is a gentleman who's probably had a blow to the side. So he's had two or more fractures and two adjacent rib, one and two adjacent ribs. So hopefully you can see whenever he's breathing in the flail chest segment is moving inwards. But whenever he's breathing out, it is moving outwards. So it's really quite, it's not a nice thing to see, but it's quite cool to see cos it's right there. Hopefully that's worked. I'll play that one last time. So this is failed test. Ok. So that done. So next time, um we're considering needle decompression. And as I said before, with rib fractures, then you can potentially get what is called a pneumothorax. What this is is really just a collection of error in the pleural space. And you can get a type of pneumothorax which results in in the pneumothorax can get into the chest cavity. If it's a simple one, you can also go out. But in attention to pneumothorax, the will go in every time you breathe in, but then it can't get out and because it can escape the air will just keep building up and up and up and up and up. So you get more in the chest, whenever you get more in the chest and the side that has intension, Myra, it will then cause a shifting or what's called a mediastinal dysplasia or a mediastinal shift of your heart and great vessels over to the other side where the air isn't building up. And whenever you get to a certain stage and that when there's so much air built up in the chest and your organs are pushed all over to the other side, it will then have a really bad effect on your heart where it will cause hemodynamic compromise. So what that essentially means is that with this tension, you must ar with the air getting into the chest, not being allowed to escape, pressure will build up to a point whereby it will push all of your organs across. But then because it's a closed cavity, it can't go anywhere else. So then that means your heart will basically be crushed and that will stop, then your cardiac output from being what it should be and then that will be you and hematic compromise. So this is really an emergency situation that needs dealt with immediately and to kind of deal with this in the immediate, let's say the field setting, you will have an emergency decompression. What happens here is you will insert a large bar cannula like a 16 to 18 gauge uh into the chest cavity to then allow that air to come out and what people have described it as, as you put it in and just hear this has a bar coming out and this is just all the air escaping uh when it could previously. So in the anterior aspect, then it can go in the second intercostal space in the midclavicular line. And this is on the side that has a pneumothorax. So say you hear hyperresonance on percussion, that means that there's are in there and you would expect the pneumothorax, you would do it on that side. And whenever you do it anteriorly, you would do it in the second intercostal space in the midclavicular line. So hopefully you can appreciate here, it's almost midway along the clavicle, nearly in line with the nipple. You can see along the mid clinic line in the second intercostal space. So at our mandibular sternal joint going down from the second rib, you're in your second intercostal space going on there and you would then put the needle into there to second intercostal space vector line. This is what's been recommended. However, another guidance document as considered the fourth or the fifth intercostal space on terrier to the mid auxiliary line. While this is the anterior axillary line, if you just imagine posterior to this and along the fifth intercostal space about there, it says that you can also insert a cannula in there also to do your decompression. And the reason they consider this to maybe be more appropriate is because uh there might be less muscle and tissue there to lay the needle to go through a lot easier. It's up here. If people have done a lot of, um, chest exercises, they might have a lot of uh pack musculature that might be more difficult to get through. And whenever you're inserting this cannular needle in, you want to insert it at the superior border of the rib. And specifically for a pneumothorax, you want the bevel of that needle by facing upwards and you're inserting it at the superior border of the rib because as we well know at the inferior part of the rib, at the costal groove, we have our neurovascular bundle. And what we don't want to do there is to either hit the nerve or hit in the blood vessels there. So we don't want to cause a hemothorax. So we want to decompress it. We don't want to cause any uh genic harm. So hopefully, there'll be another few pictures here. So on this one, this is the left side of the patient in radiograph and this is the right side. Hopefully you'll see along here, we have some fractures, but more importantly, and hopefully, you've seen this with all of this kind of black space or black air. This is the pneumothorax. So this is the area that is built up in this pleural cavity. And what you can see along here is our, this would be the lungs, which is clamps and then this is just act image then to allow you to appreciate it slightly differently. You can see there's air in the pleural space and you have your partially clops lung. So it should look like that. Sports looks like this. And then here we have a tension pneumothorax. So this is the right side of the patient and this is the left, as you can see here, it doesn't look like that side. So you see all this kind of clear black, darker area and you can see the lung is clops down there and, and attached to pneumothorax. What you'll get is this mediastinal displacement. So you'll get a shifting of the tea and the mediastinal organs across to the other side, which doesn't have the pneumothorax. Whenever that reaches a certain stage, then you get your uh hemodynamic compromise. So if you have any Mirax, in that case, while you might put the cannula in and decompress it, the definitive Barish is a test and for a chest and then which you can kinda see here. What you're really considering is what is termed the triangle of safety. The triangle of safety is really located up near axilla and there's a few anatomical borders that allow you to safely put in a chest. So whenever we think about a chest strain on the triangle of safety, we're really considering um an you have the lateral border of pack major posteriorly, we will have the lateral border of the timis dorsi and kind of the lower edge of it, you have the fifth intercostal space which would be approximate to the level of the nipple. So as you can see here, we have the mid axillary line and we have our lateral edge of peck major, we have our lateral edge of the tus dorsi kind of in line with the nipple. There, you can see that it's forming a triangle and that's where you'll be putting your chest drain in if you're putting in a drain to kind of deal with aho. So deal with a air collection and pleural cavity, you'll then direct the tube upwards. Whereas if you're dealing with a, an effusion or hemothorax, so that's blood. So gin downwards, you will then put the gin down and there's two different types of din. Then there's one which is surgical where you'll kind of be um making the incision in the chest wall and putting the gin in that way. Whereas the other would be medical done by respiratory physicians and it's cell DGER. So it's using a technique whereby you insert um different kind of cars and feed it in that way using a guide wire. So hopefully, this will allow you to kind of appreciate a dream going into the chest cavity. So as you can see you kind of wanting to make your incision, kind of superior part of the rib. This is kind of pling it through, but it's just going through the different layers over the superior aspect of the rib, avoiding this neurovascular bundle here at the costal groove. And then that will hopefully drain. Um in this case, it's draining on a fusion in this diagram. And on this diagram, then hopefully, we can see um this is the right side of the patient, this is the left. Um Hopefully you can see a drain passing up along here into the chest. You know, we're on our last topic there. It's considering an intercostal nerve block. And really, this is fundamentally different from doing a needle decompression or, or during insertion. So why would you do a nerve block? Essentially, you want to provide pain relief or analgesia to either the anterolateral thoracic wall or the anterolateral abdominal wall. If you can remember last time from T one to T 12, these anterior M I of the spinal nerves will be innervating the thoracic wall and the anterior abdominal wall. So, if there's any pain there, you can block it through this. And really, you want to block before the lateral cutaneous branch arises and this will be around uh kind of the mid axillary line. So what this is meaning is the intercostal nerve will give off a a lateral cutaneous branch which will innervate the skin of that aspect of the anterolateral thoracic wall. And what is fundamentally different here is that this time you're gonna be uh directing the needle towards the rib at the subcostal groove. So at the lower border. So, whereas last time we were wanting to really avoid this lower border, this time, we're wanting to get closer to or kind of target it. And the reason we're wanting to get at the lower border, the sub uh the costal groove, this at the inferior aspect of the rib is we want to get the needle as close as possible to this intercostal nerve. What this will allow the um person to do is to infiltrate local anesthetic around the nerve. And this will then hopefully block it to prevent any pain from occurring within that kind of dermatomal area. And that will then allow you to do your intercostal nerve block, provide that one's easier. And the complications of this that can arise um can be a pneumothorax. So say someone inserts a needle, but too far, you can then go through the different uh intercostal muscles through the endo uh fascia and then into the parietal pleura. And then you can then create a new muscle arx that way, because the needle is so close to this neurovascular bundle. Um You can also result uh damage the vessels that are located here. So your intercostal nerve and vein, if you damage those, then they're gonna get hemorrhage, that's just mean bleeding. So I have five MC Qs after this. Um and hopefully I can get them sorted. So the way this will work will be um I will read it the question, uh, put up a pool, a metal and then ask you to fill it out and then hopefully people who have understood kind of a few of the topics that I've covered. So for the first M CQ, then what may rib seven be classified as false, sorry, floating or atypical? So I'll probably give you a minute for that. Ok. 12 responses. I'll get another few seconds. 18. Ok, that's good. So yeah, group 7 may be classified as true. The reason it is classified as true is because it's directly articulating with the sternum through its costal cartilage. OK. Will do so. That was 85% good stuff. So on to the next question, then this is considering our musculature of the thoracic wall. So which muscle of the thoracic wall originates from the lateral edge of the costal groove and inserts onto the superior border of the rib below. Is it the innermost intercostal, the external intercostal, the internal intercostal or CHS versus thus? But again, I'll just start the pull and I right, just give it a bit more time to hopefully get a few more responses. OK. So this question then um may be slightly more challenging, but hopefully we can have a brief chat about it. So for this one, then it's the lateral edge of the costal groove to the lateral edge of the costal groove, to the superior board of the rib. What gives it away here? Is the lateral edge of the costal groove. And for that, then it is the internal intercostal muscle and it isn't the external because the axonal is more at the inferior border of the ribs. So it's kind of more lateral whereas um the internal intercostal is kind of the best metal there and it is the lateral edge of the costal groove and then at the kind of medial edge put up the pool for that. And after this question, there's only two more. So which vessel is the eighth anterior intercostal artery directly derived from? So directly derived from again, just give me a few more seconds. Which vessel is the eighth anterior intercostal artery directly derived from it? Ok. Good. So we have 75% of people who are right. It is the musculophrenic artery, the kind of the level of the um seventh rib or seven cost cartilage. You will have the splitting of the um internal thoracic artery into the spe epigastric. And then following along the uh costal margin will be your musculophrenic artery and that will give them um the arterial supply for the kind of the lower aspects of the um intercostal anterior intercostal arteries. It won't be the cl because I asked directly what is derived from. So which vessel does it follow on from what it might be derived from the subclavian? Isn't it subcostal? No, because that's the to and sub. No, because that's the um anterior intercostals So two more questions to go. Um So what is the order of the neurovascular bundle found in the subcostal grave going from superior too inferior. So think of that acronym that I told you a while ago. So what is the order? It's a neurovascular bundle find in the subcostal grave? From superior to inferior. Is it artery vein, nerve, nerve, artery, vein or vein, artery, nerve or nerve vein artery, right? Probably not. Ok. Good get seven members bomb. So yeah, from super to fair good stuff. Um clinical spin question. So you because of the right chest wall and hear hyper rem. So I did mention earlier. So you may suspect a tension pneumo were on the chest wall which perform an anterior emergency needle decompression using a large bore cannula, the left side of intercostal space. Medal line, right. Fourth intercostal space me correct line, right. Second intercostal space, mid line or the right fourth intercostal space uh mid auxiliary line. So as this question, um read care soon, that's the last pull up. So because with the right chest wall and he had hyperresonance, so he's back to times. So were on the chest wall, you perform an anterior emergency needle decompression, just give it one more time, I guess a bit last question. OK. Good stuff. So 66% of people with the right answer, which is our right second intercostal space in the mid collicular line. And if you suspect someone that tension in muscle ar you want to insert a large part cannula into the right segment, costal space mid line. This is just what the guidelines tell us and because you're not kind of damaging any structure structures there. And I've said it's an anterior needle decompression. If I just said lateral, then you could potentially consider using the 4th and 5th endo and kind of between the me axillary and the uh anterior axillary line. And that can be another place, but that's for anterior. So these are the references for the resources that I used to kind of put this together. So kind of quite good. Um The uh anatomy textbooks are very good. Um grays and themes are very good for our uh kind of uh diagrams and then a few of the clinical resources. So teach me um and zero to finals. So that's it. Um Thank you very much for um attending the talk. I really appreciate you taking the time. Uh I appreciate if you take a second to uh provide a bit of feedback to let us know how I can do better and how the society can do better with regards to teaching. Um This is our first event, so we're still kind of finding our feet. Um But thank you very much for taking the time and signing up really uh happy to say that you're interested. Um This is the uh QR code for Instagram where we will post our um kind of messages for king sessions on different events that we've got coming up throughout the year. Um So, yeah, thank you very much. Um I appreciate it if anyone has any questions right away. Um If not, I hope it wasn't too painful and you have a nice night, but um next week will be uh Chris Archer. He um has done the inter uh masters in Clinical Anatomy. Um He's 1/4 year medical student and he will be taking the session on the anterior or the abdominal wall along with hernia, hernias. Um So it's a be quite a high li session um especially for exams because they do like to ask that. But thank you guys. Um have a nice night express.