T H O R A XT H O R A X

Selfi HandayaniSelfi Handayani

MK. ANATOMI

GAMBARAN UMUMGAMBARAN UMUM

Thorax– struktur bentuk silinder tidak Thorax– struktur bentuk silinder tidak teratur, superior sempit (apertura thoracis teratur, superior sempit (apertura thoracis superior) dan inferior lebih luas (apertura superior) dan inferior lebih luas (apertura thoracis inferior)thoracis inferior)

Musculoskeletal dinding fleksibel--- Musculoskeletal dinding fleksibel--- vertebrae, costae, otot dan sternumvertebrae, costae, otot dan sternum

Cavitas thoracis– dinding thorax dan Cavitas thoracis– dinding thorax dan diaphragma; 3 komparteme: cavum diaphragma; 3 komparteme: cavum pleurae dexter dn sinister, mediastinumpleurae dexter dn sinister, mediastinum

FUNGSIFUNGSI

Pernafasan: pulmo + (diaphragma, dinding Pernafasan: pulmo + (diaphragma, dinding thorax, costa)thorax, costa)

Proteksi organ: pulmo, cor dan vasa besar Proteksi organ: pulmo, cor dan vasa besar . Hepar, lien dan gaster o/ diaphragma. . Hepar, lien dan gaster o/ diaphragma. Ren (posterior, o/ diaphragma– costa 12 Ren (posterior, o/ diaphragma– costa 12 (kiri), costa 11,12 (kanan))(kiri), costa 11,12 (kanan))

Conduit; mediastinumConduit; mediastinum

DINDING THORAXDINDING THORAX

SKELETONSKELETON

OTOTOTOT

SKELETON THORACISSKELETON THORACIS

STERNUMSTERNUM COSTAE et CARTILAGINES COSTAE et CARTILAGINES

COSTAECOSTAE VERTEBRAE THORACICAEVERTEBRAE THORACICAE DISCI INTERVERTEBRALISDISCI INTERVERTEBRALIS

Otot dinding thoraxOtot dinding thorax

M intercostalis eksternusM intercostalis eksternus M intercostalis internusM intercostalis internus M intercostalis immusM intercostalis immus M subcostalisM subcostalis M transversus thoracisM transversus thoracis

Anterior Thoracic Wall Anterior Thoracic Wall (Superficial Dissection)(Superficial Dissection)

Pectoralis major

Pectoralis minor

Clavipectoral fascia

Thoracoacromial artery

Lateral pectoral nerve

Cephalic vein

Medial pectoral nerve

Modified from Netter (2006), Plate 188

Anterior Thoracic Wall Anterior Thoracic Wall (Deep Dissection)(Deep Dissection)

External intercostals

Internal intercostals

Pectoralis minor

Serratus anterior

Long thoracic nerve and lateral thoracic artery

Modified from Netter (2006), Plate 189

Anterior Thoracic Wall Anterior Thoracic Wall (Internal View)(Internal View)

Diaphragm

Internal intercostals

Transversus thoracis

Anterior intercostal arteries and veins

Innermost intercostals

Internal thoracic artery and vein

Modified from Netter (2006), Plate 191

APERTURA THORACIS APERTURA THORACIS SUPERIORSUPERIOR

Skeleton: corpus VT1, tepi medial costa Skeleton: corpus VT1, tepi medial costa 1,manubrium sterni1,manubrium sterni

Ke superior berhub dg collumKe superior berhub dg collum Bbrp struktur berjalan melewati pintu iniBbrp struktur berjalan melewati pintu ini

APERTURA THORACIS APERTURA THORACIS INFERIORINFERIOR

- tulang, cartilago, ligamenta

- corpus VT 12, costa 11, 12, proc xipoideus

- tertutup o/ diaphragma & struktur yg berjalan di dalamnya

DIAPHRAGMADIAPHRAGMA

Struktur musculotendinosusStruktur musculotendinosus Otot--- tepi menuju ke pusat centrum Otot--- tepi menuju ke pusat centrum

tendineumtendineum Bentuk domeBentuk dome Kontraksi--- puncak turun; vol c thoracis Kontraksi--- puncak turun; vol c thoracis

meningkatmeningkat Esophagus, v cava inferior menembus Esophagus, v cava inferior menembus

diaphragma, aorta di belakangdiaphragma, aorta di belakang

diaphragmadiaphragma

Side view to see curvature of diaphragm…

Here’s a hint for what to look for…

Visceral Pleura – on lungs

Parietal Pleura – on inside of body wall and diaphragm.•Costal, Diaphragmatic, Mediastinal, Cupola•Costodiaphragmatic Recess

CAVITAS PLEURAECAVITAS PLEURAE

Root of Lung

Note!Because heart is displaced to left, left lung smaller (only two lobes).

Right lung has three lobes.

(Smaller sections are called:BRONCIOPULMONARY SEGMENTS)

Right lung (3 lobes) Left lung (2 lobes)

pulmopulmo

Ribs move like bucket handles.

CORCOR

HeartHeart ChambersChambers ValvesValves VesselsVessels External VesselsExternal Vessels

• Coronary ArteriesCoronary Arteries

Contraction CycleContraction Cycle SystoleSystole DiastoleDiastole

• Filling of the coronary arteries occurFilling of the coronary arteries occur

CORCOR

HeartHeart General StructureGeneral Structure

• PericardiumPericardium Surrounds heartSurrounds heart VisceralVisceral ParietalParietal SerousSerous

• 35-50 ml fluid35-50 ml fluid

• EpicardiumEpicardium Outer LayerOuter Layer

• MyocardiumMyocardium Muscular layerMuscular layer

• EndocardiumEndocardium Innermost layerInnermost layer

Nervous StructureNervous Structure• SA NodeSA Node

Right AtriumRight Atrium

• Intra-atrial PathwaysIntra-atrial Pathways• AV NodeAV Node

AV JunctionAV Junction

• Bundle of HisBundle of His• Left & Right Bundle Left & Right Bundle

BranchesBranches• Purkinje FibersPurkinje Fibers

CORCOR Approximately the size of your fistApproximately the size of your fist

Wt. = 250-300 gramsWt. = 250-300 grams LocationLocation

In the mediastinum between the lungsIn the mediastinum between the lungs Superior surface of diaphragmSuperior surface of diaphragm ⅔’⅔’s of it lies to the left of the midsternal lines of it lies to the left of the midsternal line Anterior to the vertebral column, posterior to the Anterior to the vertebral column, posterior to the

sternumsternum

CORCOR

Figure 18.1

Pembungkus CorPembungkus Cor Pericardium – a double-walled sac around the Pericardium – a double-walled sac around the

heart heart Composed of:Composed of:

• A superficial A superficial fibrous pericardiumfibrous pericardium• A deep two-layer A deep two-layer serous pericardiumserous pericardium

The The parietal layerparietal layer lines the internal surface of the fibrous lines the internal surface of the fibrous pericardiumpericardium

The The visceral layervisceral layer or or epicardium epicardium lines the surface of the heartlines the surface of the heart They are separated by the fluid-filled pericardial cavity called They are separated by the fluid-filled pericardial cavity called

the pericardial cavitythe pericardial cavity

Protects and anchors the heartProtects and anchors the heart Prevents overfilling of the heart with bloodPrevents overfilling of the heart with blood Allows for the heart to work in a relatively friction-free Allows for the heart to work in a relatively friction-free

environmentenvironment

Pericardial Layers of the HeartPericardial Layers of the Heart

Figure 18.2

Dinding corDinding cor Epicardium – visceral Epicardium – visceral

pericardiumpericardium Myocardium – cardiac Myocardium – cardiac

muscle layer forming the muscle layer forming the bulk of the heartbulk of the heart

Endocardium – endothelial Endocardium – endothelial layer of the inner layer of the inner myocardial surfacemyocardial surface

Anatomi corAnatomi cor

External markings External markings Apex - pointed inferior regionApex - pointed inferior region Base - upper regionBase - upper region Coronary sulcusCoronary sulcus

• Indentation that separates atria from ventriclesIndentation that separates atria from ventricles Anterior and posterior interventricular sulcusAnterior and posterior interventricular sulcus

• Separates right and left ventricles Separates right and left ventricles

Internal divisionsInternal divisions Atria (superior) and ventricles (inferior)Atria (superior) and ventricles (inferior) Interventricular and interatrial septa Interventricular and interatrial septa

Atria CordisAtria Cordis

Atria - receiving chambers of the heartAtria - receiving chambers of the heart Receive venous blood returning to heartReceive venous blood returning to heart Separated by an interatrial septum (wall)Separated by an interatrial septum (wall)

• Foramen ovale - opening in interatrial septum in fetusForamen ovale - opening in interatrial septum in fetus• Fossa ovalis - remnant of foramen ovaleFossa ovalis - remnant of foramen ovale

Each atrium has a protruding auricleEach atrium has a protruding auricle Pectinate muscles mark atrial wallsPectinate muscles mark atrial walls Pump blood into ventricles Pump blood into ventricles Blood enters right atria from superior and inferior Blood enters right atria from superior and inferior

venae cavae and coronary sinusvenae cavae and coronary sinus Blood enters left atria from pulmonary veinsBlood enters left atria from pulmonary veins

Cor potongan frontalCor potongan frontal

Figure 18.4e

Ventriculi cordisVentriculi cordis

Ventricles are the discharging chambers of the Ventricles are the discharging chambers of the heartheart

Papillary muscles and trabeculae carneae Papillary muscles and trabeculae carneae muscles mark ventricular wallsmuscles mark ventricular walls

Separated by an interventricular septumSeparated by an interventricular septum Contains components of the Contains components of the conduction systemconduction system

Right ventricle pumps blood into the pulmonary Right ventricle pumps blood into the pulmonary trunktrunk

Left ventricle pumps blood into the aortaLeft ventricle pumps blood into the aorta Thicker myocardium due to greater work loadThicker myocardium due to greater work load

• Pulmonary circulation supplied by right ventricle is a much low Pulmonary circulation supplied by right ventricle is a much low pressure system requiring less energy output by ventriclepressure system requiring less energy output by ventricle

• Systemic circulation supplied by left ventricle is a higher Systemic circulation supplied by left ventricle is a higher pressure system and thus requires more forceful contractionspressure system and thus requires more forceful contractions

Struktur luar; aspek Anterior Struktur luar; aspek Anterior

Figure 18.4b

Struktur dinding corStruktur dinding cor

Left ventricle – Left ventricle – three times three times thicker than rightthicker than right Exerts more Exerts more

pumping forcepumping force Flattens right Flattens right

ventricle into a ventricle into a crescent shapecrescent shape

Figure 18.7

Valvula cordisValvula cordis Heart valves ensure unidirectional blood flow through the Heart valves ensure unidirectional blood flow through the

heartheart Composed of an endocardium with a connective tissue coreComposed of an endocardium with a connective tissue core

Two major typesTwo major types Atrioventricular valvesAtrioventricular valves Semilunar valvesSemilunar valves

Atrioventricular (AV) valves lie between the atria and the Atrioventricular (AV) valves lie between the atria and the ventriclesventricles R-AV valve = tricuspid valveR-AV valve = tricuspid valve L-AV valve = bicuspid or mitral valveL-AV valve = bicuspid or mitral valve

AV valves prevent backflow of blood into the atria when AV valves prevent backflow of blood into the atria when ventricles contractventricles contract

Chordae tendineae anchor AV valves to papillary muscles of Chordae tendineae anchor AV valves to papillary muscles of ventricle wallventricle wall Prevent Prevent prolapse prolapse of valve back into atriumof valve back into atrium

Valvula semilunarisValvula semilunaris Semilunar valves prevent backflow of blood into Semilunar valves prevent backflow of blood into

the ventriclesthe ventricles Have no chordae tendinae attachmentsHave no chordae tendinae attachments Aortic semilunar valve lies between the left Aortic semilunar valve lies between the left

ventricle and the aorta ventricle and the aorta Pulmonary semilunar valve lies between the Pulmonary semilunar valve lies between the

right ventricle and pulmonary trunkright ventricle and pulmonary trunk Heart sounds (“lub-dup”) due to valves closingHeart sounds (“lub-dup”) due to valves closing

““Lub” - closing of atrioventricular valvesLub” - closing of atrioventricular valves ““Dub”- closing of semilunar valvesDub”- closing of semilunar valves

Fibrous SkeletonFibrous Skeleton

Surrounds all four valvesSurrounds all four valves Composed of dense connective tissueComposed of dense connective tissue

FunctionsFunctions Anchors valve cuspsAnchors valve cusps Prevents overdilation of valve openingsPrevents overdilation of valve openings Main point of insertion for cardiac muscleMain point of insertion for cardiac muscle Blocks direct spread of electrical impulsesBlocks direct spread of electrical impulses

Heart ValvesHeart Valves

Conducting SystemConducting System

Cardiac muscle tissue has intrinsic ability Cardiac muscle tissue has intrinsic ability to:to: Generate and conduct impulsesGenerate and conduct impulses Signal these cells to contract rhythmicallySignal these cells to contract rhythmically

Conducting system Conducting system A series of specialized cardiac muscle cellsA series of specialized cardiac muscle cells Sinoatrial (SA) node sets the inherent rate of Sinoatrial (SA) node sets the inherent rate of

contractioncontraction

Conducting SystemConducting System

InnervationInnervation Heart rate is altered by Heart rate is altered by

external controlsexternal controls Nerves to the heart Nerves to the heart

include:include: Visceral sensory fibersVisceral sensory fibers Parasympathetic Parasympathetic

branches of the vagus branches of the vagus nervenerve

Sympathetic fibers – Sympathetic fibers – from cervical and upper from cervical and upper thoracic chain gangliathoracic chain ganglia

External Heart: Posterior ViewExternal Heart: Posterior View

Figure 18.4d

Vessels returning blood Vessels returning blood to to the heart include:the heart include: Superior and inferior venae cavaeSuperior and inferior venae cavae

• Open into the right atriumOpen into the right atrium• Return Return deoxygenateddeoxygenated blood from body cells blood from body cells

Coronary sinusCoronary sinus• Opens into the right atriumOpens into the right atrium• Returns Returns deoxygenated deoxygenated blood from heart muscle (coronary veins)blood from heart muscle (coronary veins)

Right and left pulmonary veinsRight and left pulmonary veins• Open into the left atriumOpen into the left atrium• Return Return oxygenatedoxygenated blood from lungs blood from lungs

Major Vessels of the HeartMajor Vessels of the Heart

Vessels conveying blood Vessels conveying blood away fromaway from the heart the heart include:include: Pulmonary trunkPulmonary trunk

• Carries deoxygenated blood from right ventricle to lungsCarries deoxygenated blood from right ventricle to lungs• Splits into right and left pulmonary arteriesSplits into right and left pulmonary arteries

Ascending aortaAscending aorta• Carries oxygenated blood away from left atrium to body organsCarries oxygenated blood away from left atrium to body organs• Three major branchesThree major branches

BrachiocephalicBrachiocephalic Left common carotid, Left common carotid, Left subclavian arteryLeft subclavian artery

Major Vessels of the Heart Major Vessels of the Heart

Blood Flow Through the HeartBlood Flow Through the Heart

Figure 18.6

VASCULARISASIVASCULARISASI

SIRKULASI SIRKULASI PULMONER:PULMONER:

- Truncus pulmonaris– Truncus pulmonaris– a. pulmonaris dexter a. pulmonaris dexter dan a. pulmonaris dan a. pulmonaris sinistersinister

- Vena pulmonaris--- Vena pulmonaris--- vv. pulmonaris dari vv. pulmonaris dari lobilobi

SIRKULASI SIRKULASI SISTEMIK:SISTEMIK:

- Aorta Aorta - Vena cava superior, Vena cava superior,

vena cava inferiorvena cava inferior

TRUNCUS PULMONALISTRUNCUS PULMONALIS

Membawa darah venosa; arteria: tekanan tinggi Membawa darah venosa; arteria: tekanan tinggi (20-30 mmHg), pulsasi +, struktur elastik sama (20-30 mmHg), pulsasi +, struktur elastik sama dengan aortadengan aorta

Membentang dari conus arteriosus ventrcl Membentang dari conus arteriosus ventrcl dexter sampai concavitas arcus aorta kiri dari dexter sampai concavitas arcus aorta kiri dari aorta ascendensaorta ascendens

Menembus pericardium fibrosa bersama2 dg Menembus pericardium fibrosa bersama2 dg aortaaorta

Stl berjalan sktr 5 cm--- terbagi dexter dg sinsterStl berjalan sktr 5 cm--- terbagi dexter dg sinster

TRUNCUS PULMONALISTRUNCUS PULMONALIS

Dexter: lebih panjang dan lebar, berjalan Dexter: lebih panjang dan lebar, berjalan di bawah arcus aortae di depan bronchus di bawah arcus aortae di depan bronchus primarius dexter sampai hilus pulmonis primarius dexter sampai hilus pulmonis dexter, sblum masuk ke hilus bercabang-2dexter, sblum masuk ke hilus bercabang-2

Sinister: lebih pendek, sempit, Sinister: lebih pendek, sempit, membentang ke lateral menuju radix membentang ke lateral menuju radix pulmonis sinster di depan bronchus prims. pulmonis sinster di depan bronchus prims. Berhub arcus aortae mll lig arteriosumBerhub arcus aortae mll lig arteriosum

VENA PULMONALISVENA PULMONALIS

Bsn tdp 5 dari setiap lobus, atas dan Bsn tdp 5 dari setiap lobus, atas dan tengah (kanan) bsn bergabung--- tdp 4 tengah (kanan) bsn bergabung--- tdp 4 masing2 ada 2 yang masuk ke atrium masing2 ada 2 yang masuk ke atrium sinsitrumsinsitrum

V yg dari bawah kanan berjalan di V yg dari bawah kanan berjalan di belakang atrium dxter dian/ pintu v cava belakang atrium dxter dian/ pintu v cava sup dan inf, dr`atas kanan menyilang di sup dan inf, dr`atas kanan menyilang di belkg v cava sup.belkg v cava sup.

AORTAAORTA

Vasa darah utamaVasa darah utama Aorta ascenden, arcus aortae, aorta Aorta ascenden, arcus aortae, aorta

descendens ( aorta thoracalis)descendens ( aorta thoracalis) Arteria elastika, tunica media tebalArteria elastika, tunica media tebal Aorta ascendens dan arcus aortae--- Aorta ascendens dan arcus aortae---

baroreseptorbaroreseptor

AORTA ASCENDENSAORTA ASCENDENS

Di mediastinum medium, radix aortae– angulus Di mediastinum medium, radix aortae– angulus sternisterni

Tertanam dlm lamina fibrosa pericardium Tertanam dlm lamina fibrosa pericardium bersama dg tr pulmonalisbersama dg tr pulmonalis

D. 3cm, p. 5cmD. 3cm, p. 5cm Pangkal menonjol– sinus aortaePangkal menonjol– sinus aortae Tr pulmonalis, conus aorticus– aorta—atrium Tr pulmonalis, conus aorticus– aorta—atrium

sinistrum, sinus transversussinistrum, sinus transversus Cab: a. coronaria dextra dan sinistraCab: a. coronaria dextra dan sinistra

ARCUS AORTAEARCUS AORTAE

Lanjt aorta ascendens, ke kiri dpan Lanjt aorta ascendens, ke kiri dpan trachea, ke dorsocaudal sbl cranial trachea, ke dorsocaudal sbl cranial bronchus sinster mnj kiri trachea dan bronchus sinster mnj kiri trachea dan esophagusesophagus

Bid sagittal di mediastinum supr– aortic Bid sagittal di mediastinum supr– aortic knuckleknuckle

NERVINERVI

N. THORACICUSN. THORACICUS N. PHRENICUSN. PHRENICUS N. VAGUSN. VAGUS TRUNCUS SYMPATHICUSTRUNCUS SYMPATHICUS PLEXUS OTONOMICUSPLEXUS OTONOMICUS

N. PHRENICUSN. PHRENICUS

Asal .n. cervicalis IV dan VAsal .n. cervicalis IV dan V Setiap n masuk ke thorax stlh berjalan di depan Setiap n masuk ke thorax stlh berjalan di depan

m scalenus anteriorm scalenus anterior Berdampingan dg pericardiacophrenica– Berdampingan dg pericardiacophrenica–

pericardium, pleura mediastinalis, bag tengah pericardium, pleura mediastinalis, bag tengah pleura diaphragmatica, angulus pleura diaphragmatica, angulus pericardiophrenicapericardiophrenica

N. PHRENICUSN. PHRENICUS

Komponen fungsional: motoris, sensoris Komponen fungsional: motoris, sensoris dan sympathisdan sympathis

Motoris: diaphragmaMotoris: diaphragma Sensoris: peritoneum, pleura Sensoris: peritoneum, pleura

diaphragmatica, pleura mediastinalis, diaphragmatica, pleura mediastinalis, pericardiumpericardium

Nyeri menjalar m trapezius, bag bawah Nyeri menjalar m trapezius, bag bawah leher sampai ujung bahuleher sampai ujung bahu

N. VAGUSN. VAGUS

c. thoracis– plx pulmonalis, plx esophageus, tr c. thoracis– plx pulmonalis, plx esophageus, tr vagalis anterior dan posterior– hiatus esophageivagalis anterior dan posterior– hiatus esophagei

Cab. N laryngeus recurrent (trachea, esophagus Cab. N laryngeus recurrent (trachea, esophagus dan larynx)dan larynx)

Cab. R cardiacus superior (cervicalis)– hub dg Cab. R cardiacus superior (cervicalis)– hub dg gln sympathicus cervicalisgln sympathicus cervicalis

Cab. R cardiacus inferior (cervicothoracicus)– Cab. R cardiacus inferior (cervicothoracicus)– gab. N cervicothoracicus tr sympathicusgab. N cervicothoracicus tr sympathicus

Komponen n XKomponen n X

Motoris– otot2 pharynx dan larynx--- pars Motoris– otot2 pharynx dan larynx--- pars cranialis n accecoriuscranialis n accecorius

Sensoris– rflx pulmonal dan Sensoris– rflx pulmonal dan kardiovasculer, m mucosa trachea, bronci kardiovasculer, m mucosa trachea, bronci dan bronchiolidan bronchioli

Parasympathis– cor u regulasi denyut Parasympathis– cor u regulasi denyut jantung, otot polos dan gld di trachea, jantung, otot polos dan gld di trachea, bronchi, bronchioli, esophagus dan viscera bronchi, bronchioli, esophagus dan viscera abdominisabdominis

TRUNCUS SYMPATHICUS & TRUNCUS SYMPATHICUS & GANGLIAGANGLIA

Tdump 10 – 11 ps gangliaTdump 10 – 11 ps ganglia Gln paravertebrale 1 bersatu dg gln cervicalis Gln paravertebrale 1 bersatu dg gln cervicalis

inferior--- gln stellatuminferior--- gln stellatum Gln ke 2--- kdg gab dg 1Gln ke 2--- kdg gab dg 1 Gln lain--- segmen intervertebralis sesuaiGln lain--- segmen intervertebralis sesuai Tr masuk ke abdomen nembs crura Tr masuk ke abdomen nembs crura

diaphragmaticadiaphragmatica R communicantesR communicantes ---- n splanchnicus---- n splanchnicus