Mid

Axi

al li

ne

Mid

Cla

vicu

lar L

ine

Ribs12 Ribs o of thoracic vertebraeT1 is where Rib 1 originates1-6 Ribs articulare with individual COATAL CARTILLAGE (Hyaline)7-10 are variable: articulate with catallagenous mass11-12: oating ribs

Manubrium Sternal Notch

Sternal AngleAngle of Louie

Intercostal musclesFunction: -ll in ribcage -keep from popping -involved in forced inspi/expiration

2 or 3 muscles depending on who you askNamed for the Rib ABOVE 11 pairsControl size of thoracic cavity, elevate and depress ribs, forced breathingExternal: run Antero-medially (downward) Anteriorly near sternum turns into transparent membrane allowing the internal intercostal to be visibleInternal: run Posterolaterally (perpendicular) (upward)Innermost: inner layer of internal separated by VAN Becomes membranous posteriorly near vertebral column

Intercostal neurovascular bundle Organized: Superior-Vein-Artery-Nerve-Inferior Run in COSTAL GROOVE on INFERIOR part of ribPosteriorly Intercostal artery fed by AORTA Intercostal vein drains into the AZECA veinAnterior Intercostal artery fed by ANTERIOR INTERNAL THORACIC A. Intercostal vein brains into ANTERIOR INTERNAL THORACIC V ANTERIOR INTERNAL THORACIC aka Internal mammary, Branch o subclavian held in place by ANTERIOR THORASUS TRANSVERSUS MUSCLE This muscle make removing the chest wall with anterior internal thoracic artery intact very dicult

External

Internal

Costal Cartillage

Costal CartillageVeinArteryNerve

Costal Groove

Anterior Intercostal

Neurovascular bundle

Ant

erio

r Int

erna

l Tho

raci

cA

rter

y an

d Ve

in

ThoracocentesisCC: for accessing the plural space Drain uid or Pus or Blood -Important to go above a rib to avoid injuring the intercostal VANStructurs passed through1) External intercostal2) Internal intercostal3) Innermost intercostal4) ENDOTHORACIC FASCIA: fused with parietal pleura but distinct5) Parietal Plura: somatic mesoderm5) Enter plural cavity = potential spaceDO NOT ENTER visceral plura (somatic mesoderm fused to lung)DO NOT PUNCTURE LUNG

Phrenic Nerve from C4-Septum Transversarium originally pulled phrenic nerve down then...-It got caught up in PLEUR-PERICARDIAL FOLDS/MEMBRANE when it grew out from the lateral wall to separate the ANTERIOR HEART from the POSTERIOR LUNGS

-Musculophrenic ARTERY travels all they way to diaphram-It literally sits in FIBROUS PERICARDIUM-Pericardial-phrenic VESSELS travels with phrenic nerve to the pericardium. -Pericardium is still living tissue and needs a blood supply-Locate Phrenic nerve as a ridge in FIBROUS PERICARDIUM, it is exaggerated by the PERICARDIAL-PHRENIC vein that runs with it PERICARDIAL PHRENIC IS A SLENDER BRANCH OFF OF THE INTERNAL THORACIC

-Phrenic nerve + Pericardial-phrenic vessels NAV travels the entire length of the MEDIA STEINUM

PERICARDIUMHeart was formed in its OWN SPLANCNIC MESODERMVISCERAL PERICARDIUM that is tightly adhered to heart-Originated from hearts OWN splancnic mesoderm-Underneath the VISCERAL PERICARDIUM is where hearts blood supply runs

FIBROUS PERICARDIUM is covered in an amount of fat proportional to body fat-It originated from PLEURO-PERICARDIAL FOLDS-Outer FIBROUS LAYER-Inner SEROUS LAYER: continuous, slimy.-Extends to proximal portion of great vessels

SuperiorVenaCava

Internal Thoracic A

Aortic Arch

Pulmonary Trunk: ligamentum art.

Left Atrium

Brachiocephalic Vein = Int Jug + subclavian

1) Brachiocephalic2) Left Common Carotid

3) Left Subclavian

Vagus Nerve CNX

Phrenic Nerve C4

Spinal Nerve (anterior/vental ramus)

Second Intercostal

Inferior Thyroid

Thyrocervical TrunkTransvers cervical

Suprascapular

Vertebral

Supercial cervical (dorsal scapular)

Scalene anterior (Phrenic n pierces)

External Jugular

Internal Jugular

CNX

Phrenic n.

Right Common Carotid

Inferior Thyroid

Aorta Loops over Pulmonary ArteryLeft Pulmonary artery infront of aortaRight Pulmonary artery behind AortaVagus nerve generally lies at the bifurcation of the carotid and the subclavian (on the right side) -CNX dives BEHIND HEART -Supplies heart then goes into the abdomen -Gives o a branch called the RECURRENT LARYNGEALRECURRENT LARYNGEAL -On left side CNX passes anterioly to Aortic arch -Left CNX gives recurrecnt laryngeal that goes UNDER LIGAMENTUM ARTERIOUSUS and then goes UNDER the AORTIC ARCH and travels back up to larynx

-Right CNX can be located anteriorly to the bifurcation of THE COMMON CAROTID AND SUBCLAVIAN -The Right Recurrent Laryngeal passes posteriorly UNDER THE SUBCLAVIAN and travels up to larynx

Left Pulmonary artery IN FRONT of aortaRight Pulmonary artery BEHIND

Sternoclavicular Ligament

Liga

men

tum

Art

erio

sus

Aortic

Tricuspid

Pulmonary

BicuspidMitral

2 Spaces (pericardial reections)1) Oblique pericardial sinus: between 5 pulmonary veins -Reminance of straight tubular heart folding over -Posterior to heart 2) Transverse pericardial space: space between two outow tracts -Surgeons use this space for bypasses -Posterior to ASCENDING AORTA + Pulmonary Trunk

CC: tamponadeCC: Pericarditis

Ductus arterioususIn fetal circulation blood in the RV travels into the pulmonary arterywith no place to go. The Ductus arteriousus creates a shunt fromthe pulmonary artery to the Aorta-However the ductus arteriosus joins the aorta posteriorly to the great vessels as to not dilute the blood traveling to the brain.-Within the rst 24hrs BRADYKININ causes ductus areteriousus toclose o and eventually become a brous vestigial connection calledthe LIGAMETUM ARTERIOUSUS = reminents of ductus arteriousum-LEFT RECURRENT LARYNGEAL loops under Ligamentum Arteriousus-If Ductus arteriousus does not close it may need to be stapled.

Rib

Exte

rnal

Inte

rcos

tal

Inte

rnal

Inte

rcos

tal

Inne

rmos

t Int

erco

stal

En

do

th

ora

cic

Fa

sia

Pa

rie

ta

l P

lura

Vis

ce

ra

l P

lura

Lung

s

Pleu

ral S

pace

Rib

VAN

MEDIA STEINUM: saggital plane through heartSuperior from inferior: Line through 1) Manubrio-sternal joint 2) top of heart 3) 5th thoracic vertabraeAbove this line is Superior Media-SteinumBelow this area is Inferior Media-SteinumInferior Media-Steinum is subdivided 1) Posterior: behind heart: Lots of stu in this space 2) Middle: Heart is in the middle 3) Anterior: nothing but fat and lymphnodes

Thymus:Right beneathManubriumImmunological origin

CHEST WALL IS REMOVEDLungs wrap around heartThe Pleura of the lungs do NOT communicate (this is a good thing, otherwise pneumothorax would be worse)

Accessory Hemiazygos left posterior intercostal vein drainage, Right Post Intercostal into Azygos