HumanAnatomy08

TelAvivUniversity
SacklerFacultyofMedicine
DepartmentofAnatomy&Anthropology

HumanAnatomy
Thorax

2008

Dr.Y.Atkin

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Unit1ThoracicWall

Topics
a.SkinandFascia
b.OsteologyandJointsoftheThoracicCage
c.MusclesoftheThorax
d.IntercostalSpaces
e. TheBreast
f. Nerves

Reading

Required:Moore,ClinicallyOrientedAnatomy,pp.75109or
Snell,ClinicalAnatomyforMedicalStudents,pp.4655;383385

Fascia:SuperficialFascia;DeepFascia;ClavipectoralFascia

Osteology:ThoracicInlet/Outlet;Rib(CostalGroove;CostalCartilage;AngleofRib;
Tubercle);Sternum(Manubrium;Body;XiphoidProcess;SternalAngle;JugularNotch);
ThoracicVertebrae(IntervertebralDisc;VertebralForamen;SpinousProcess;Transverse
Process;Superior/InferiorArticularProcesses;Tubercle;Pedicle/Lamina;Body;
IntervertebralForamen);Clavicle(ScaleneTubercle);

Muscles:SerratusPosteriorMuscles;SerratusAnterior;Intercostals(External,Internal,
Innermost,Subcostal,TransversusThoracis);RectusAbdominus;PectoralisMajor/Minor;
Subclavius

NervousSystem:Sympathetic/Parasympathetic;SpinalNerve;Intercostalnerve;
Neuron/Glia;Afferent/Efferent;Ganglion;WhiteRamus/GreyRamus;Intermediolateral
Horn;Preglanglionic/Postganglionic;LymphNode

Arteries:Aorta;Subclavian;Axillary;InternalThoracic;LateralThoracic;Thoracoacromial;
SuperiorEpigastric;Musculophrenic

Veins:Brachiocephalic;InternalThoracic;Intercostal;Axillary

Lymphatics:AxillaryNodes(Pectoral,Subscapular,Infraclavicular;Apical);Parasternal
Nodes

Breast:MammaryGland;Nipple;Areola;AxillaryTail;LactiferousDuctandSinus;
SuspensoryLigaments

Clinical:MetastaticBreastCancer;Neoplasia;Carcinoma,CervicalRib

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Questions

Anatomy

1. Listallofthebonesandmusclesformingthethoraciccage.

2. Describetheprocessoftwotypesofbonedevelopment.

3. Describeindetailthestructureofathoracicvertebra.Describethedifferencesbetween
thoracicandcervicalvertebrae.

4 Whattypesofjointsoccurbetweenaribandavertebra?Betweenaribandthe
sternum?

5. Definethetermsfloatingribs.

6. Describethemovementsoftheribcagewhichoccurduringbreathing.

7. Whenaretheexternalintercostalmusclesnormallyused?

8. Describetheoriginandcourseofanintercostalnerve.

9. Describethebloodsupplytothethoracicwall.

10. Describethelymphaticdrainageofthebreastindetail.

11. Describetheanatomicalboundriesofthethoracicinletandoutlet.

Clinical

1. InanAPradiographofthesternum,3separatesternebraeareobserved.Estimate
theageofthepatient.

Thesternumbeginstoossifyfromthebottomupandcompletelybytheageof25(the
body).Theageofthepatientisaround715yearsold.

2. Whydoesthe1stribusuallyappearinradiographsasthoughitendsintheair?
Itiscoveredbythesternoclavicularjoint.Itisbroader,wider,andflatterthanotherribs.

3. Whydoesacervicalribcausepaininthemedialaspectofthearm?
Acervicalribwillintereferewiththebrachialplexus.ThecervicalribcomesoffC7,which
hasanelongatedtransverseprocess.Ifitisreallylongitcaninterferewiththebrachial
plexus.T1isthenervethatcomesdowntothemedialaspectofthearm.Thatissometimes
beingpressed.

Thecervicalribisanabnormalelongationofavcervicalvertebraethatresemblesarib.

4. Whydoesapatientwithtuberculosisofthethoracicvertebraepresentwithabdominal
pain?
T10T9area.
Theintercostalnervesarebeingaffectedintheribareawhichradiatesasabdominalpain.
referredpainisreferredallalongthedermatomeupuntiltheabdominalwall.

5. AphysicianperformsanerveblockatT5.Whydoesntthepatientlosefeelingover
theanteriorchestwall?
Contiguousoverlappingofdermatomes.Youhavetodotwoadjacentsegmentsinorderto
getnervebloc(ie:T4andT6aswell).

6. Howcancarcinomaofthebreastrecurfollowingcompletemastectomy?

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Willflowthroughtheparasternallymphnodestotheothersideandendupintheother
breast.

7. Whatistheanatomicalbasisforpittingoftheskinoverthebreastinbreastcancer?
Thecooperligamentsbecomeshortenedandtightened.Thisiscontiguousspreading(as
opposedtolymphaticandhematogenous).Thecooperligamentsrunfromthedermis
oftheskintothedeepfasciaandpectoralismajormuscle.

8. Inaviolentautomobileaccident,amanandhisgrandsonbothreceivesevereblowsto
thechest.Radiographsshowthatthe5yearoldhasnofractures,butthegrandfather
sufferedafracturedsternumandseveralbrokenribs.Why?

Becausethegrandfatherssternumisossifiedandlesselastic.Thechildhasmore
cartilaginousconnectionandismoreflexibleandpliable.

Schemeforthesympatheticnervoussystem

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Unit2PleuralCavity

Topics
a.Mediastinum
b.Pleura
c.Lungs
d.Diaphragm

Reading

Required:Moore,ClinicallyOrientedAnatomy,pp.112134or
Snell,ClinicalAnatomyforMedicalStudents,pp.7790;106110;124

KeyWords
Pleura: Parietal/VisceralLayer,CostodiaphragmaticRecess;Dome;Suprapleural
Membrane;CardiacNotch;PulmonaryLigaments;PleuralCavity;PleuralFluid

Muscles: Diaphragm;Crura;CentralTendon;ArcuateLigaments;Hiatus(Opening)of
Diaphragm

Blood: Pulmonary;Bronchial;SuperiorEpigastric;Musculophrenic

Nerves: Phrenic,Vagus;PulmonaryAutonomicPlexus;

Organs: Trachea;Carina;Lung;Lobes;Fissures(Oblique,Horizontal);Apex;Lingula;
Root/HilusofLung;Bronchi;Eparterial/HyparterialBronchi;
BronchopulmonarySegment;Lobar;SegmentalBronchi

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Clinical:Diaphragmatichernia,Pleurisy,PleuralEffusion,LungCancer,Pneumothorax;
CollapsedLung(Atelectasis)Dyspnea,Embolus

Questions

Anatomy

1. Whichpartofthelunghasnocoveringofpleura?WhatisthePulmonaryligament?

2. Compareanddifferentiatebetweenthenervesupplyoftheparietalandvisceralpleura.

3. Whatisthepleuralcavity?

4. Definethecostomediastinalrecess;thecostodiaphragmaticrecess.

5. Describethelocationofthemiddlelobeoftherightlung.Whatisthehomologous
structureintheleftlung?Why?

6. Whatstructuresarecloselyrelatedtotheapexoftherightandleftlungs?

7. Namethestructuresfoundinthehilusofthelung.

8. Describethebloodsupplyandvenusdrainageofamainbronchus.

9. Nametheopeningsinthediaphragm,whatpassesthruthem,andthelevelofthe
vertebralcolumnatwhichtheylie.

10. Describethelymphaticdrainageofthelungs.

Clinical

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1. Howdoesonedrainthepleuralcavityofexcessfluidwithoutdamagingthelung
coveredbyit?
Thoracocentesistogetintothediaphragmaticrecess.

2. Whydoesaninflammationofthediaphragmcausepainovertheshoulder?

BecausethePhrenicnervegoesfromC3C5,itinnervatesthediaphragm.Thepainis
refferedtotherootofitinthecervicalplexus.C4goestothesuperclaviculararea
andthereforepainisreferredtotheshoulderarea.

3. Whydoesntairenteringintothepleuralcavityduringinhalationexitduring
exhalationincasesoftensionpneumothorax?

Thereisaonewayvalveformedthatpreventsairfromcomingout.Itneedstobereleavied
byaneedleaspirationathemidclavicualrlineatthe2ndintercostalspace.

3. Apeanutthatachildwastryingtocatchinhismouthafterthrowingitupintothe
air,landsinsteadinhisrightlung.Whydoesistherightlungtypicallyinvolvedin
suchaccidents?Whatistheprobableresultofthisparticularincident.

Therightmainbronchusiswiderandmorevertical(thebronchialbranch).The
inferiorrightlungwillbemostaffected.Theprobableresultislikelyapneumonic
infection.Theepiglottisisnotdevelopedenoughinsmallchildrensoitdoesntcover
thetracheaaswell.

4. Whatisapulmonaryembolus?
ItiswhenusuallytheDeepVeinthrobosgetsthrownandlodgesinthepulmonary
trunkandcirculation,blockingbloodflowintothelungsandcauseshypoxiaand
hypoxyemia.Causesrighthearthypertrophy.

5. Apatientwithcarcinomalocalizedtotheapexofthelungcomplainsofpaininhis
littlefingerandpartialdroopingofhisuppereyelidonthesameside.Whatisthe
anatomicalexplanationforthesesymptoms?
*******HornersSyndrome
Abovetheapexofthelungisthesuperpleuralmembrane.Anythingbeingpushedup
bytheapexofthelungwillcauseproblems.IncontactstheT1nerveandthestellate
ganglion(starshaped).Thisissympatheticinnervationsoyouwillgetablockof
feelingononeside.Yourpupilwillbeconstrictedaswellinthateye.

6. Whydopatientswithchronicasthmadevelopbarrelchest?
Theirintercostalmusclesworkharder,growbiggerandcauseribstospreadapartmore.

7. Whydoesparalysisofthediaphragmononesideresultinparadoxicalmovementof
thediaphragmontheaffectedside?
Paradoxicalmovementmeansthatwhenyouinhaleitgoesupinsteadofdown.
Astheworkingsideincreasesinpressure(inhale)thediaphragmcannotcontract
andthepressureincreasestherefromtheintraabdominalcavitysothereisakindof
seasaweffect.

8. Whydoeslungcancerhavesuchalowrateofcure?
Metastasizeseasily,verydifficulttogetallthelymphnodes.

9. Howdoescarcinomaofthelungappearinaradiograph?Pneumonia?
Pneumothorax?

Lungcarcinomawhitemass
PneumoniaCloudyoverwherethereshouldbeblack.

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PneumothoraxgreyareawherelunghascollapsedYouarelookingatavisceral
pleuraline.

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 HumanAnatomy08
Unit3 Heart

Topics
a.Pericardium
b.Heart
c.FetalCirculation

Reading

Required:Moore,ClinicallyOrientedAnatomy,pp.137168or
Snell,ClinicalAnatomyforMedicalStudents,pp.90105;123

KeyWords

Organs: PercardialSac;FibrousPericardium;SerousPericardium(Parietal/Visceral);
Myocardium;Endocardium;Heart(Base/Apex);Sinuses(Oblique/Transverse);
Atrium(Right/Left);Ventricle(Right/Left);CoronarySulcus;Crista/Sulcus
Terminalis;InteratrialSeptm;InterventricularSeptum;FossaOvalis;Limbus;
ValveofCoronarySinus;MusculiPectinati;SeptomarginalBand;
Infundibulum;ChordaeTendinae;PapillaryMuscle;Valves(Mitral/Bicuspid,
Tricuspid,Pulmonary,Aortic);TrabeculaeCarnae;Auricle;SemilunarFold
(Cusp)

Arteries: RightCoronary;AnteriorSinusofAorta;RightMarginal;Posterior
Interventricular;LeftCoronary;LeftPosteriorSinus;Circumflex;LeftMarginal;
LeftInterventricular(LAD);AV/SANodalArteries

Veins: CoronarySinus;Great/Middle/SmallCardiac;RightMarginal;ObliqueVeinof
LeftAtrium;VenaeCordaeMinimus

Nerves: Vagus;VasomotorCenter;UpperSympatheticGanglia;CardiacPlexus;
ConductingSystem;SANode;AVNode;BundleofHis;PurkinjeFibers

Embryo: HeartTubes;BulbisCordis;PrimativeAtrium/Ventricle;SinusVenosus;
TruncusArteriosus;SeptumPrimun;OstiumPrimun;Ostium(Foramen)
Secundum;SeptumSecundum;ForamenOvale;AtrioventricularEndocardial
Cushions;DistalBulbarSeptum;MuscularInterventricularSeptum;Aortic
Arches;DoralAortae;DuctusArteriosus

Clinical: TetrologyofFallot;PatentDuctusArteriosus;PericardialTamponade;ASD
(AtrialSeptalDefect);CoronaryArteryOcclusion;MyocardialInfarct;
PulmonaryStenosis;Murmer;ReversaloftheGreatVessels;Hypertrophy;
Pericarditis;Angina;CoronaryBypass

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Frontalsectionthroughtheheartexposingall4chambers.

Questions

Anatomy

1.Howmanylayersdoesthepericardiumhave?

2.Nameanddescribethebordersoftheheart.

3.Definethetwopericardialsinuses.

4.Describetheoriginsofthecoronaryarteriesfromtheaorta.

5.Describethevenousdrainageoftheheart.

6.Doestheheartreceivesomatosensoryinnervation?

7.Howdothepapillarymusclesandchordaetendinaework?

8.Whatstructureintheadultisderivedfromthe6thaorticarch?

9.Describethefetalcirculation.

10.Describethepathwayofanelectricalimpulsebeginninginthecardiacpacemakerand
endingwithventricularcontraction.

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Clinical

1. Amanisstabbedwithaknifeintheleft5thintercostalspaceneartheedgeofthe
sternum.Whichchamberoftheheartwouldbeexpectedtobeinjured?Why?
Rightventricle

2. Followingaheartattack,whichdiagnosticprocedurewouldbeusedtotestfor
disturbanceinthefunctionoftheAVnode?
EKG

3. Whywouldaphysicianrequestabarriumswallowfilminapaitientwithmitralvalve
disease?
Theleftatriumwillbeabnormallyenlargedandwillpressupontheesophagusandthiswill
thenbeseenasakindofobstructionoftheesophagus.

4. Whatstructureswouldacannulapassthruindrainingfluidfromthepericardiumwhen
usingacostoxiphoidapproach?

5. Inapatientwithsuspectedpulmonaryhypertension,thebloodpressureinthe
pulmonaryarteryischecked.Howisthisdone?

6. Howisitpossibleforapersontofunctionnormallywithapatentforamenovale?
ItusuallyonlyopenswhenthereishighRApressure,likewhencoughing.Itisaoneway
valve.Thepressureisusuallylowerintherightside,whichmeansitisclosed.Butonly
whenpressurerisesdoesitmix.

7. WhyisthereacuteriskatthetimeofsurgicalrepairofaV.S.D.involvingthe
membranouspartoftheinterventricularseptum?
Thiswouldonlybedoneinababy.Thisisbecausealongthemembranouspartisthebundle
ofHis(rightsideofmembranousseptum)youwanttomakesureyoudonotdamage
this.Tatwouldcausearrhythmiainthebaby.

8. WhataretheabnormalitiesthatmakeuptheTetrologyofFallot?Whatisthe
embryologicalexplanationforthissyndrome?
Itisasyndromedisplacedaorticopening,overridingaorta,pulmonarystenosis,VSD,
hypertrophyoftheRV.Ithastodowiththefoldingoftheheart.
10. Whatistheanatomicalexplanationforcardiactamponade?
Becauseofthefibrouspericardialsac,nonealstictopreventoverfillingoftheheart.

g. Whatismeantbytheexpressionmitralvalveprolapse?
Bloodgoesbackintotheleftatriumandthencausesoverfillingandpressure.

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Unit4 Mediastinum

Topics
a.GreatVessels
b.Trachea,ThymusandEsophagus

Reading

Required: Moore,ClinicallyOrientedAnatomy,pp.169190or
Snell,ClinicalAnatomyforMedicalStudents,pp.106110;124125

KeyWords

Arteries: Aorta(Ascending/Arch/Descending);Brachiocephalic;LeftCommonCarotid;
LeftSubclavian;LigamentumArteriosum;PosteriorIntercostal;Subcostal;
PulmonaryTrunk;PulmonaryArteries

Veins: Superior/InferiorVenaCava;Brachiocephalic(Right/Left);Azygos;
Hemiazygos;AccessoryHemiazygos

Lymph: ThoracicDuct;RightLymphaticDuct;CysternaChyli

Nerves: Phrenic;Vagus;RecurrentLaryngea(Right/Left);SympatheticTrunk;
SplanchnicNerves

Organs: Thymus;Trachea;Esophagus

Clinical: DissectingAneurysm

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Questions

Anatomy

1. Describethebordersofthemediastinumanditsparts.Whatarethecontentsofthe
anteriormediastinum?

2. Whatstructuresoccupyorpassthruthesuperiormediastinum?

3. Atwhatvertebralleveldoesthetracheaendandwhatisitsanatomicalrelationshipto
theaorta?

4. Describetherelationshipbetweenthearchoftheaortaandthepulmonarytrunk.

5. Whatarethedifferencesinthepositionsofthevagusandphrenicnervesontheleft
andrightsides?

6. Whatistheoriginofthegreater,lesserandlowestsplanchnicnerves?Whattypeof
nervefibersaretheymostlycomposedof?

7. Whatandwhereisthestellateganglion?

8. Describethestructureandbloodsupplytotheesophagus?

9. Atseveralpoints,theesophagusexhibitsnarrowingofitslumen.Wherearethose
constrictions?

10. Describetheorigin,courseandendofthethoracicduct.

Clinical

1. Whatlymphaticorgancanpresentasalumpintheanteriormediastinum?Whatarethe
physicalsymptomsthatthiscancause?
Thymus.

2. Whydoesapatientsufferingfromcarcinomaoftheapexofthelungsometimes
presentwithhoarseness?
Compressestherecurrentlaryngealnervecausinghorasnessonthatside.

3. Wouldcarcinomaoftheloweresophagusbeexpectedtometastisizetotheabdomen?
Yes.

4. Whatistheresultofbilateralsectionoftherecurrentlaryngealnervesattherootofthe
neck?
Paralysisoflarynx

5. Whatisthesensorylosscausedbysectionofthephrenicnerveinthethoraxonone
side?
Pericardiumandserousparietallayerareinnervatedsensory.Thediaphragmismotor.

6. Whatistheprinciplereasonthatatranspositionofthegreatvesselshasamuchshorter
lifeexpectancythananormalindividual?
Aortaandpulmonarytrunkarereversed.Thiscausestheheart(right)toworkmuch
harderandgetbigger.

7. WhatisthemostlikelyexplanationofadisplacementoftheleftlunginanAP
radiograph?

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8. Whatismeantbythetermdissectinganeurysm?
Thedescendingaortahasthetunicasandinbrtweenthelayersarebeingseparated
fromtheinsideoutandtheyballoonout,

9. Whatisthemostcommonsiteofanaorticaneurysminthethorax?
Attheascendingaortawherethefibrouspericardiumreinforcestheopeningofthe
arota.Sometimesthatwallballoonsout.

10. Whatiscoarctationoftheaorta?Whyisthisconditionoftencompatiblewithlong
life?

TheVANarteriesgethuge,whichmeansthattheycauseetchingoftheribsandthe
ribsbecomesmaller.Buttheribsbecomepronetofracture.

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Unit5SurfaceAnatomy

Topics
a.OrientationoftheChest
b.LineofPleuralReflection
c.LungsandTrachea
d.HeartandExamination

KeyWords

Inspection;Palpation;Percussion;Ascultation

Lines: Midsternal;Midclavicular;AnteriorAxillary;Midaxillary;PosteriorAxillary;
Scapular

ApexBeat;ApexofLung;VertebraProminens;AngleofLouis;Suprasternal(Juggular)
Notch;

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Questions

Anatomy

1. Identifyallofthekeywordsonthemodel.

2. Whyisthelevelofthe4ththoracicvertebraanimporatantanatomicallandmark?

3. WhyisthesternalangleofLouisanimportantlandmark?

4. Withrespecttosurfacelandmarks,howhighdoestherightdomeofthediaphragm
reachduringexpiration?

5. Howhighdoestheleftdomereach?

6. Describethesurfacemarkingsofthetrachea?

7. Describethebordersofthelungsandpleuraduringinspiration.

8. Whataretherespectivelevelsofthesuperiorandinferioranglesofthescapulaatrest?

9. Whatmusclescreatetheanteriorandposterioraxillaryfolds?

10. Whatistheleveloftherootofthelungwithrespecttothesternum?

Clinical

1. Whyisitimportanttoknowthesurfaceanatomyofthepleurabeforeperforming
catheterizationofaveinintheneck?
Youcancauseapneumothoraxifyoupuncturetheworngarea.

2. Findthe6thintercostalspace.

2. Whileexaminingapatient,youhavedifficultylocatingtheapexbeat.Whatdoesthe
apexbeatrepresentandwhatcanyoudotolocateit?
Itrepresentspointofmaximalimpulseandifyoudonothearitputthepatientonhis
side.

4. Howcanonefindtheapexbeatinapatientwhosuffersfromchroniclowblood
pressureandhassustainedastabwoundintherightsideofthethorax?

4. Wheredoesonepalpatethetrachea?Istheresignificancetofindingitinthecenterof
themediastinumasopposedtoonesideortheother?
Inthesuprasternalnotch.Significantbecauseifnotinthemidlinethereisachance
forpneumothorax.

6. Apatientissufferingfrompneumoniainthelowerlobeoftherightlung.Describethe
properplacementofthestethescopeinordertohearthepathomemonicsoundsmost
clearly.

7. Whatarethesurfacemarkersoftheheartvalves?Arethesethebestlocationstolisten
inordertoassesstheirfunction?
No,youlistentowhrrebloodisflowinginandout.
Tricuspidrightbetween2and4.
Youwanttoheardistaltothemnotwheretheyare.

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Esophagus,Vagus,Azigus,Hemiazigous,Thoracicductbirdsofthechest.

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