Kaan Yücel M.D., Ph.D. 01. 10. 2013

The Two Fridas 1939 by Frida Kahlo

the part between the neck and the abdomen

Chest X-ray

1.1. REGIONS/T ERMS

Thoracic cavity cavity between neck and abdomen protected by the thoracic wall.

Thoracic wall bounds the thoracic cavity. formed by the skin, bones, fasciae, and muscles.

Thoracic cage bony portion of the thoracic wall

thoracic skeleton

1.2. SURFACES OF THE THORAX

Posterior surface 12 thoracic vertebræ & posterior parts of the ribs

Anterior surface sternum & costal cartilages

Lateral surfaces ribs, separated by the intercostal spaces

STERNUM & COSTAL CARTILAGES anteriorly 12 THORACIC VERTEBRAE & POST. RIBS posteriorly RIBS & INTERCOSTAL SPACES laterally

1.3. BOUNDARIES OF THE THORAX

Superior • Jugular notch • Sternoclavicular joint • Superior border of clavicle • Acromion • Spinous processes of C7

Inferior • Xiphoid process • Costal arch • 12th and 11th ribs • Vertebra T12

1.4. CONTENTS OF THE THORAX

Organs of the cardiovascular, respiratory, digestive, reproductive, immune, and nervous systems

• thoracic cage (skeleton) • muscles between the ribs • skin • subcutaneous tissue • muscles, and fascia covering its anterolateral aspect.

The mammary glands of the breasts lie within the subcutaneous tissue of the thoracic wall.

2.1. FUNCTIONS OF THE THORACIC WALL

1) Protects vital thoracic and abdominal organs 2) Resists the negative (sub-atmospheric) internal pressures

generated by the elastic recoil of the lungs and inspiratory movements.

3) Provides attachment for and support the weight of the upper limbs.

4) Provides the origins of many of the muscles that move and maintain the position of the upper limbs relative to the trunk.

5) Provides attachments for muscles of the abdomen, neck, back, and respiration.

3. SKELETON OF THE THORACIC WALL 1) 12 pairs of ribs and associated costal cartilages 2) 12 thoracic vertebrae and the intervertebral (IV) discs

interposed between them 3) Sternum

4. THORACIC APERTURES

‘Thoracic inlet’

‘Thoracic outlet’

4.1. Superior thoracic aperture

“doorway” between the thoracic cavity and the neck and upper limb bounded: Posteriorly vertebra T1 Laterally 1st pair of ribs and their costal cartilages Anteriorly superior border of the manubrium

Trachea Esophagus nerves, and vessels that supply and drain the head, neck, and upper limbs.

4.2. Inferior thoracic aperture

By closing the inferior thoracic aperture, the diaphragm separates the thoracic and

abdominal cavities almost completely.

bounded: Posteriorly 12th thoracic vertebra Posterolaterally 11th and 12th pairs of ribs Anterolaterally joined costal cartilages of ribs 7-10 costal margins Anteriorly xiphisternal joint

5. MOVEMENTS OF THE THORACIC WALL

One of the principal functions of the thoracic wall and the diaphragm is to alter the

volume of the thorax and thereby move air in and out of the lungs.

During breathing, the dimensions of the thorax change in vertical, lateral, and A-P directions.

Diaphragm contracts Depression Diaphragm relaxes Elevation (during passive expiration)

Elevation &depression of the ribs

DERMATOMES

Through its posterior ramus and the lateral and anterior cutaneous branches of its anterior ramus, most thoracic spinal nerves (T2-T12) supply a strip-like dermatome of the trunk extending from the posterior median line to the anterior median line.

Skin area supplied by a segment of the spinal cord

T2- Sternal angle

T4- Nipple

T6- Xiphoid process

T8- Costal arch

T10-Umbliculus

T12-Midpoint between umbilicus and symphysis pubis

2. BREASTS

Mammary glands & associated skin -connective tissues. modified sweat glands in the superficial fascia anterior to the pectoral muscles and the anterior thoracic wall.

Reproduction, back pain

Aesthetics, and breast cancer

2. BREASTS

Mammary glands: Series of ducts and associated secretory lobules. Form 15 to 20 lactiferous ducts open nipple.

Nipple is surrounded by a circular pigmented area of skin areola (L. small area).

FEMALE BREASTS

NON-LACTING WOMEN – PREDOMINANT COMPONENT: FAT

LACTING WOMEN- PREDOMINANT COMPONENT: GLANDULAR TISSUE

The breast rests on a bed extends transversely from lateral border of the sternum mid-axillary line vertically from the 2nd through 6th ribs

75% (lateral breast quadrants) Axillary lymph nodes Most of the remaining (medial breast quadrants) parasternal lymph nodes or to the opposite breast

Lymph from inferior quadrants may pass deeply to abdominal lymph nodes.

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Trapezoidal in A-P dimensions Tipped-over pyramid in 3-D

crucial organ of the human body

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Right heart (Suction) poorly- oxygenated(venous) blood

from the body

superior vena cava & inferior vena cava right atrium right ventricle

pulmonary arteries lungs

Left heart (Pumping) well- oxygenated (arterial) blood

from the lungs

pulmonary veins left atrium left ventricle

aorta the body

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right and left atria & right and left ventricles

Atrium – plural atria

Receiving chambers

Ventricles

Discharging chambers

cardiac cycle

1. Ventricular filling (diastole) 2. Ventricular emptying (systole)

Blood pressure

120-80 mm/Hg

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The fibrous skeleton of the heart

Keeps the orifices of the AV & semilunar valves patent prevents them from being overly distended by an increased volume of blood.

Provides attachments for the valves & myocardium.

Forms an electrical «insulator» separating impulses of the atria & ventricles they contract independently

surrounding and providing passage for the initial part of the AV bundle

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coronary sulcus (atrioventricular groove) between atrium & ventricles

anterior & posterior interventricular (IV) sulci (grooves)

between right and left ventricles

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apex located inferiorly & base located superiorly

Apex projects forward, downward and to the left Base faces in a posterior direction

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Anterior (sternocostal) surface o mostly of right ventricle o some of the right atrium on the right o some of the left ventricle on the left

Diaphragmatic (inferior) surface o formed mainly by the left ventricle o partly by the right ventricle o related to central tendon of diaphragm.

Right pulmonary surface o formed by the right atrium.

Left pulmonary surface o left ventricle & a portion of left atrium.

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RIGHT ATRIUM

forms the right border of the heart

Receives venous blood from the SVC, IVC, and coronary sinus.

Through the right atrioventricular orifice, discharges the poorly oxygenated blood it has received

into the right ventricle.

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RIGHT VENTRICLE

forms largest part of the anterior surface of the heart a small part of the diaphragmatic surface almost the entire inferior border of the heart.

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Bulges into the cavity of the right ventricle. Superiorly and posteriorly, a thin membrane, forms the much smaller membranous part of the IVS.

interventricular septum (IVS)

muscular and membranous parts

obliquely placed partition between the right and left ventricles, forming part of the walls of each

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LEFT ATRIUM

right and left pulmonary veins enter here. Tubular, muscular left auricle, Its wall trabeculated with pectinate muscles.

forms most of the base of the heart

A semilunar depression in the interatrial septum Floor of the oval fossa

surrounding ridge Valve of the oval fossa

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LEFT VENTRICLE

forms the apex of the heart, left (pulmonary) surface & border, most of the diaphragmatic surface.

Compared to the right ventricle

Walls 2-3 times thicker Trabeculae carneae finer and more numerous Cavity longer Anterior & posterior papillary muscles larger

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aortic valve semilunar valve between the left ventricle & ascending aorta obliquely placed.

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Guards the left AV orifice. Has two cusps, anterior and posterior.

mitral valve double-leaflet mitral valve

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6. SEMILUNAR VALVES

Semilunar cusps of the pulmonary valve anterior-right-left

Seminular cusps of the aortic valve posterior-right-left

concave when viewed superiorly

no tendinous cords to support

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VASCULATURE OF THE HEART

embedded in fat course across the surface of the heart just deep to the epicardium.

coronary arteries & cardiac veins

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first branches of the aorta

supply the myocardium and epicardium

Anastomoses between the branches of the

coronary arteries exist, which enables the

development of the collateral circulation.

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STIMULATING, CONDUCTING, &

REGULATING SYSTEMS OF HEART

1. sinuatrial (SA) node

initiates the heartbeat & coordinates contractions of the four heart chambers

2.atrioventricular (AV) node

3.bundles highly specialized conducting fibers for conducting impulses rapidly to different areas of the heart

o Propagation of the impluse

o Simultaneous contraction of the cardiac striated muscle cells

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pacemaker of the heart

@junction of the SVC & right atrium near to the superior end of the sulcus terminalis

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stimulated by sympathetic division of the autonomic nervous system to

accelerate the heart rate

inhibited by parasympathetic division

to return to or approach its basal rate.

pacemaker of the heart

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a smaller collection of nodal tissue than the SA node

in the posteroinferior region of the interatrial septum near the opening of the coronary sinus

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JOURNEY OF THE SIGNAL

Generated @ SA node

Passed through the walls of the right atrium

Propageted by the cardiac muscle

Signal passed from SA node to AV node

Distributed to the ventricles through the AV bundle

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passes from the AV node through the fibrous skeleton of the heart and along the membranous part of the IVS.

@ junction of membranous & muscular parts of the IVS

divides into : right bundle & left bundle.

AV bundle

the only bridge between the atrial and ventricular myocardium

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right and left bundles

proceed on each side of the muscular IVS deep to the endocardium

then ramify into subendocardial branches (Purkinje fibers)

extend into the walls of the respective ventricles.

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autonomic nervous system, cardiac plexus

Cardiac plexus

posterior to the ascending aorta and bifurcation of the pulmonary trunk

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Parasympathetic supply

presynaptic fibers of the vagus nerves

Slows the heart rate Reduces the force of the contraction Constricts the coronary arteries saving energy

autonomic nervous system, cardiac plexus

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sympathetic supply presynaptic fibers cell bodies in the intermediolateral cell columns

(IMLs) of the superior 5 or 6 thoracic segments

postsynaptic sympathetic fibers cell bodies in the cervical and superior thoracic

paravertebral ganglia of the sympathetic trunks.

causes increased heart rate increased impulse conduction, increased force of contraction, increased blood flow through the coronary vessels increased activity.

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9. SEPTAL DEFECTS

Atrial Septal Defects (ASD)

congenital anomaly of the interatrial septum

a hole between the two atria

What happens?

Oxygenated blood from the lungs

Left atrium Right atrium

Results in

enlargement of

right atrium & ventricle

dilation of the pulmonary trunk More blood in the right heart

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Ventricular Septal Defects (VSD)

What happens? Results in

membranous part of the IVS common site of VSDs

rank first on all lists of cardiac defects

Oxygenated blood from the ventricles Left ventricle Right ventricle

in pulmonary blood flow severe pulmonary disease

(hypertension) cardiac failure

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10. VALVULAR

HEART DISEASES

Disturb pumping efficiency of the heart.

Stenosis (narrowing) or insufficiency

Both result in an increased workload for the heart.

Valvuloplasty repairing the heart valves

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Scarring and shortening of the cusps results in insufficiency Restricts the outflow of the left ventricle Leads to the hypertrophy of the myocardium During ventricular systole, blood regurgitates back to the left atrium A hurt murmur will be heard.

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Narrowing of the mitral orifice. Restricts the outflow of the left atrium. A murmur will be heard during atrial contraction.

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Narrowing of the pulmonary valve due to the fused cusps. Restricts the outflow of the right ventricle. Leads to the hypertrophy of the myocardium.

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Incomplete closure of the cusps due to thickening of their free margins due to a disease. During diastole, blood regurgitates back to the right ventricle from the pulmonary trunk. Heart murmur could be heard.

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Blood is unable to flow freely from left ventricle to aorta. A result of degenerative calcification, fusion of the aortic cups as a result. Causes extra work for the heart, resulting in left ventricular hypertrophy.

most frequent valve abnormality

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During diastole blood regurgitates from aorta back to the left ventricle. A hurt murmur will be heard during diastole.

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could be heard by stethoscope. produced due to the turbulence caused by the blood passing from a narrow opening into a larger vessel or chamber.

a pathologic sound

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tricuspid valve

behind the right half of the sternum opposite

4th intercostal space

mitral valve

behind the left half of the sternum opposite

4th costal cartilage

pulmonary valve

behind the medial end of the 3rd left costal

cartilage and adjoining part of the sternum aortic valve

behind the left half of the sternum opposite

3rd intercostal space.

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S1

produced by contraction of the ventricles

closure of the tricuspid & mitral valves (AV valves)

S2

produced by the sharp closure of the aortic & pulmonary valves

hear sounds produced at each valve with the minimum of distraction or interference

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tricuspid valve

right half of lower end of the body of the sternum

pulmonary valve

medial end of the second left intercostal space

aortic valve

medial end of the second right intercostal space

mitral valve apex beat

fifth left intercostal space,

9 cm from the midline

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PERICARDIUM

a closed sac with two layers

fibrous pericardium

serous pericardium

parietal layer

visceral layer –heart & great vessels .

fibroserous membrane, covers the heart & beginning of its great vessels

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Continuous inferiorly w/ central tendon of the diaphragm Attached anteriorly to the sternum by sternopericardial ligaments Site of continuity pericardiacophrenic ligament Inner surface lined by parietal layer of the serous pericardium Protects the heart against sudden overfilling.

fibrous pericardium

continuous superiorly w/ tunica adventitia of the great vessels & w/pretracheal layer of deep cervical fascia

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contains a thin film of fluid : pericardial fluid enables the heart to move and beat in a frictionless environment.

pericardial cavity

potential space between opposing layers of the

parietal & visceral layers of serous pericardium

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GREAT VESSELS

posterior to the sternoclavicular (SC) joints.

brachiocephalic veins unite

to form the SVC. @ inferior border of the 1st right costal

cartilage

shunt blood from the head, neck, & upper limbs right atrium.

formed by the union of internal jugular & subclavian veins

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Returns blood from all structures superior to the diaphragm except the lungs & heart.

Passes inferiorly and ends by entering right atrium of the heart.

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begins at the aortic orifice. only branches coronary arteries, arising from the aortic sinuses.

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begins posterior to the 2nd right sternocostal (SC) joint at the level of the sternal angle. ligamentum arteriosum remnant of the fetal ductus arteriosus

root of the left pulmonary artery inferior surface of the arch of the aorta

The usual branches of the arch

1) brachiocephalic trunk

2) left common carotid artery

3) left subclavian artery.

curved continuation of the ascending aorta

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arises posterior to the manubrium. ascends superolaterally divides into right common carotid & right subclavian arteries.

first and largest branch of the arch of the aorta

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arises o posterior to the manubrium, o slightly posterior and to the left of the brachiocephalic trunk.

second branch of the arch of the aorta

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arises from the posterior part of the arch

posterior to left common carotid artery.

ascends lateral to trachea & left

common carotid artery.

Leaves the thorax and enters the

root of the neck.

third branch of the arch of the aorta

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monitor changes in blood pressure

responsible for detecting changes in blood chemistry, primarily oxygen content

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Abdominal aorta

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