SURFACE ANATOMY OF ANTERIOR THORACIC WALL LUNG SURFACE

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SURFACE ANATOMY OF ANTERIOR THORACIC WALL, LUNG SURFACE MARKING, PLEURAL REFLECTIONS BY AMANDA TATAR

SURFACE ANATOMY OF ANTERIOR THORACIC WALL, LUNG SURFACE MARKING, PLEURAL REFLECTIONS BY AMANDA TATAR

OBJECTIVES • Explain lymphatic drainage of the breast and its importance in the spread

OBJECTIVES • Explain lymphatic drainage of the breast and its importance in the spread of cancer • Describe the surface markings of the lungs and pleural reflections • Identify important surface landmarks on the anterior thoracic wall • Use the sternal angle (of Louis) to accurately number the ribs on a living subject

ANATOMY OF THE BREAST • Both sexes • Mammary glands • Suspensory ligaments: attach

ANATOMY OF THE BREAST • Both sexes • Mammary glands • Suspensory ligaments: attach glands to dermis • 15 -20 lobules → parenchyma of mammary glands • 1 lobule → lactiferous duct → nipple • Lactiferous sinuses – dilated area

SURFACE ANATOMY OF THE BREAST Midaxillary line • Ribs 2 → 6 • Lateral

SURFACE ANATOMY OF THE BREAST Midaxillary line • Ribs 2 → 6 • Lateral border of sternum to midaxillary line • Axillary process • 2/3 over pectoralis major • 1/3 over serratus anterior • Nipple over 4 ics = MEN Axillary proces s Clinical relevance: pathological breast quadrants

SURFACE ANATOMY OF BREAST Axillary tail Intermammary cleft. Body of sternum Anterior axillary fold

SURFACE ANATOMY OF BREAST Axillary tail Intermammary cleft. Body of sternum Anterior axillary fold Areola Nipple Supernumerary nipple Xiphoid process

VASCULATURE OF BREAST • Arterial supply: • Medial mammary branches of anterior intercostals from

VASCULATURE OF BREAST • Arterial supply: • Medial mammary branches of anterior intercostals from internal thoracic arteries • Lateral thoracic from axillary arteries • Thoraco-acromial from axillary arteries • Posterior intercostals from thoracic aorta

ARTERIAL SUPPLY CONTINUED RSC Tho. Acr Lat. Tho AIC Med Mam A In Th

ARTERIAL SUPPLY CONTINUED RSC Tho. Acr Lat. Tho AIC Med Mam A In Th L C C BC AXILLA RY R C C ARCH PIC HEA RT LSC

LYMPHATIC DRAINAGE OF BREAST • Lymphatics – drainage • All from breast → sub-areolar

LYMPHATIC DRAINAGE OF BREAST • Lymphatics – drainage • All from breast → sub-areolar plexus then: • • • Axillary: 75 % Parasternal Abdominal

LYMPH CONTINUED • Axillary Nodes: • Pectoral • Humeral • Subscapular • Central •

LYMPH CONTINUED • Axillary Nodes: • Pectoral • Humeral • Subscapular • Central • Apical • Axillary nodes → supra/infra clavicular → subclavian trunk • Parasternal → bronchomediastinal

IMPORTANCE OF LYMPH • Breast carcinoma → metastasis • ↑ communication of lymph •

IMPORTANCE OF LYMPH • Breast carcinoma → metastasis • ↑ communication of lymph • Metastasis can be extensive

LUNG PLEURAE • Visceral – adherent to lungs • Parietal – lines pulmonary cavities

LUNG PLEURAE • Visceral – adherent to lungs • Parietal – lines pulmonary cavities • Between = pleural space = serous fluid: • • Reduces friction – respiration Surface tension - cohesion

LUNGS IN PROSECTION Sternu m Right lung VISCERAL PLEURA Left lung External intercostal muscles

LUNGS IN PROSECTION Sternu m Right lung VISCERAL PLEURA Left lung External intercostal muscles Rib s Costal margin

THORACIC CAVITY IN PROSECTION Sternum VISCERAL PLEURA ON RIGHT LUNG PARIETAL PLEURA (costal) Costal

THORACIC CAVITY IN PROSECTION Sternum VISCERAL PLEURA ON RIGHT LUNG PARIETAL PLEURA (costal) Costal margin

PARIETAL PLEURA PARTS • Costal: • • • Mediastinal: • • Lateral mediastinum Diaphragmatic:

PARIETAL PLEURA PARTS • Costal: • • • Mediastinal: • • Lateral mediastinum Diaphragmatic: • • Internal thoracic wall surfaces Endothoracic fascia separates Diaphragm Cervical: • • Thorough superior thoracic aperture 2 -3 cm above clavivles

PLEURAL REFLECTIONS – PARIETAL PLEURA • Sternal - Anteriorly • • Sharp Costal →

PLEURAL REFLECTIONS – PARIETAL PLEURA • Sternal - Anteriorly • • Sharp Costal → mediastinal • Costal - Inferiorly • • Sharp Costal → diaphragmatic • Vertebral - Posteriorly • • Rounder Costal → mediastinal

PARIETAL AND VISCERAL PLEURAL MARKINGS VISCERAL: • • • 2 cc → 4 cc

PARIETAL AND VISCERAL PLEURAL MARKINGS VISCERAL: • • • 2 cc → 4 cc → 6 cc inferiorly (R) 4 cc → 6 cc curved (L) 6 cc → 8 cc midaxillary 10 rib posteriorly PARIETAL: • • • 2 cc → 4 cc → 6 cc inferiorly (R) 4 cc → 6 cc curved (L) 6 cc → 8 cc midclavicular 8 cc → 10 rib midaxillary 12 rib posteriorly

RECESSES • Pleural cavities not full in expiration → recesses • Costodiaphragmatic • Costomediastinal

RECESSES • Pleural cavities not full in expiration → recesses • Costodiaphragmatic • Costomediastinal

SURFACE ANATOMY – ANTERIOR PLANES Jugular notch Sternal angle • Median (midsternal) • Midclavicular

SURFACE ANATOMY – ANTERIOR PLANES Jugular notch Sternal angle • Median (midsternal) • Midclavicular - two MEDIAN LINE MIDCLAVICULAR LINES

SURFACE ANATOMY – ANTEROLATERAL PLANES Axillary fossa • Anterior axillary – along ant. fold

SURFACE ANATOMY – ANTEROLATERAL PLANES Axillary fossa • Anterior axillary – along ant. fold (pectoralis major) • Midaxillary – axillary apex ↓ • Posterior axillary – along post. fold (latissimus dorsi, teres major) Anterior axillary Midaxillary Posterior axillary

IMPORTANT FEATURES TO IDENTIFY

IMPORTANT FEATURES TO IDENTIFY

IMPORTANT LEVELS • Jugular notch = T 2 • Sternal angle • • T

IMPORTANT LEVELS • Jugular notch = T 2 • Sternal angle • • T 4/T 5 2 cc Bifurcation of bronchi Counting ribs from here • Xiphoid process = T 9

COUNTING THE RIBS *

COUNTING THE RIBS *

CORRESPONDENCE! T 2 T 4/T 5 T 9

CORRESPONDENCE! T 2 T 4/T 5 T 9

CLINICAL RELEVANCE – _? _ THORAX! • Accumulation of ‘stuff’ into pleural cavity •

CLINICAL RELEVANCE – _? _ THORAX! • Accumulation of ‘stuff’ into pleural cavity • Something is broken or torn open • Pneumothorax – air • Hydrothorax – fluid (from effusion) • Hemothorax – blood • Chylothorax - lymph

QUIZ Q. Most of the lymphatic drainage of the breast goes to the other

QUIZ Q. Most of the lymphatic drainage of the breast goes to the other breast? False – most drains to the axillary nodes Q. The parietal pleura crosses the midaxillary line at 8 cc? False – crosses the midclavicular line at 8 cc, midaxillary at 10 cc. Visceral pleura crosses the midaxillary line at 8 cc Q. Sternal angle is at the level of T 3/T 4? False – T 4/T 5 A B

THANK YOU! • mzyart@nottingham. ac. uk Please email me any questions or come ask

THANK YOU! • mzyart@nottingham. ac. uk Please email me any questions or come ask me at the end! • In this powerpoint I used: • • Moore and Agur Teach me anatomy Acland Anatomy Videos Google images Point of interest: Pleural effusion – fluid on the lungs