Anatomy of thoraxAnatomy of thorax

Landmarks – anterior viewLandmarks – anterior view Supresternal notchSupresternal notch Angle of Louis – cartilage Angle of Louis – cartilage

of the 2of the 2ndnd rib rib Xifoid apendixXifoid apendix Subcostal angleSubcostal angle Thoracic lateral wallThoracic lateral wall

Ribs 7, 8, 9, 10Ribs 7, 8, 9, 10 Free ending 11, 12Free ending 11, 12

Collar bone – acromionCollar bone – acromion Projection of diaphragm Projection of diaphragm

(top ~ 5(top ~ 5thth rib) rib) BreastBreast Anterior axilary lineAnterior axilary line

Bony structureBony structure

Muscles of anterior thoracic wallMuscles of anterior thoracic wallsignificance in respirationsignificance in respiration

LandmarksLandmarksPosterior viewPosterior view

Processus sipnosumProcessus sipnosum Scapula:Scapula:

Superior angle – C2Superior angle – C2 Inferior angle – C7Inferior angle – C7 RidgeRidge

Muscular prominences Muscular prominences Latissimus dorsiLatissimus dorsi TrapesiusTrapesius Erectori spinaeErectori spinae

Lines used for orientatiomLines used for orientatiom

MedianMedian Midd-clavicular lineMidd-clavicular line Axillary lineAxillary line

AnteriorAnterior MiddleMiddle PosteriorPosterior

Scapulary line Scapulary line (through the inferior (through the inferior angle) – armes being angle) – armes being close to the trunkclose to the trunk

Superficial projections of Superficial projections of respiratory aparatusrespiratory aparatus

Tracheea:Tracheea: Cricoid – angle of LouisCricoid – angle of Louis

LungsLungs C6-C8-C10 C6-C8-C10

PleuraPleura C8-C10-C12C8-C10-C12

Superficial projection of the heart Superficial projection of the heart and great vesselsand great vessels Aortic arch, brchiocephalic Aortic arch, brchiocephalic

trunk, inferior vena cava, trunk, inferior vena cava, brahiocephalic veins are brahiocephalic veins are projected behind the projected behind the manubriummanubrium

Internal thoracic vein – 1-3 Internal thoracic vein – 1-3 cm lateral to the manubriumcm lateral to the manubrium

Intercostal vesselsIntercostal vessels Heart projectionHeart projection PericardiumPericardium

MediastinumMediastinum

Communications of the thoracic Communications of the thoracic cavitycavity

Superior opening – base of the neckSuperior opening – base of the neck T1 – C1 – manubriumT1 – C1 – manubrium Tracheea, esofagus, great vessels from the neckTracheea, esofagus, great vessels from the neck

Inferior openingInferior opening T12 – costal margin xifoid apendixT12 – costal margin xifoid apendix Diafragm with openings ofering passage forDiafragm with openings ofering passage for

Esofagus, nerves vagus nervesEsofagus, nerves vagus nerves Aorta, inferior vena cavaAorta, inferior vena cava

The breastThe breast

Anatomy of the breastAnatomy of the breast

Lymphatics of the breastLymphatics of the breast

Autoexamination of the breastAutoexamination of the breast

Begin after onset of Begin after onset of hormonal sexual hormonal sexual activityactivity

Monthly – preferable Monthly – preferable after menstruationafter menstruation

InspectionInspection Volume, position, profileVolume, position, profile

PalpationPalpation

Medical examination of the breastMedical examination of the breast

History takingHistory taking BorthsBorths Breast feeding + durationBreast feeding + duration Menstrual activity + changes Menstrual activity + changes

in the breastin the breast Other lesionsOther lesions Hormonal therapyHormonal therapy

Palpation Palpation Breast + breast tissue outside Breast + breast tissue outside

“gland”“gland” NippleNipple Axillary lymph nodesAxillary lymph nodes SkinSkin COMPULSURY BOTH COMPULSURY BOTH

SIDESSIDES

Axillary lymphnodesAxillary lymphnodes

External thoracic (under the pectoralis External thoracic (under the pectoralis major)major) Main collector Main collector

Brahial groupBrahial group Inferior scapullary group - dorsalInferior scapullary group - dorsal Subclavicular – top of axxilaSubclavicular – top of axxila CentralCentral Internal thoracic – not accesible Internal thoracic – not accesible

ImagisticsImagistics

Ultrasound scanUltrasound scan Doppler effect for Doppler effect for

vessels dipositionvessels diposition MamographyMamography GalactograpyGalactograpy

THORACIC TRAUMATHORACIC TRAUMA

Common manifestations in thoracic Common manifestations in thoracic traumatrauma

Pain Relatively minor element Relatively minor element

that triggers changes in that triggers changes in ventilationventilation

Significant presence in any Significant presence in any thoracic traumathoracic trauma

Immobilization – not Immobilization – not applicableapplicable

Suppresses cough reflexSuppresses cough reflex Finally generates airway Finally generates airway

obstruction and hypoxia obstruction and hypoxia

PneumotoraxPneumotorax Major deficit – loss of functional Major deficit – loss of functional

pulmonary tissuepulmonary tissue Complex mechanismComplex mechanism

Airway obstructionAirway obstruction Acute respiratory failureAcute respiratory failure

fearful complicationfearful complication TahipneaTahipnea Acute dispneea Acute dispneea Use of accessory respiratory Use of accessory respiratory

musclesmuscles CyanosisCyanosis Anxiety Anxiety

Manifestations of Manifestations of thoracic contusionsthoracic contusions

Contusions of soft tissueContusions of soft tissue

Non-characterisctic Non-characterisctic symptomssymptoms EcchymosedEcchymosed HematomaHematoma Subcutaneous fluid Subcutaneous fluid

collectionscollections Muscle tearsMuscle tears

As a single lesion – As a single lesion – children (soft thorax)children (soft thorax)

Clinically – same as any Clinically – same as any other locationsother locations

Sternal fracturesSternal fractures

MechanismMechanism Direct impactDirect impact Acute flexionAcute flexion

Type: Type: transversal w/o movement of transversal w/o movement of

fragmentsfragments Particular situation – Particular situation –

manubrio-sternal disjunctionmanubrio-sternal disjunction

ClinicallyClinically PainPain DeformityDeformity Short sternumt with dimished Short sternumt with dimished

intercostal spaces intercostal spaces

Costal fracturesCostal fractures

Very frequent in Very frequent in adulthood – 10%adulthood – 10%

More frequently in ribs More frequently in ribs situated in the middle situated in the middle unprotected area unprotected area

Direct or indirect Direct or indirect mechanismmechanism Direct – sharp bone Direct – sharp bone

projected insideprojected inside Indirect – sharp bone Indirect – sharp bone

projected outsideprojected outside

Costal fracturesCostal fractures ClinicallyClinically

Benign lesionsBenign lesions PainPain Diminished amplitude of Diminished amplitude of

respiratory movementsrespiratory movements Palpation – in the arrea of Palpation – in the arrea of

fracture fracture DeformityDeformity Osseous creptiations during Osseous creptiations during

deep inspiration or cough deep inspiration or cough

MAJOR riskMAJOR risk Lesion of pleura or lungLesion of pleura or lung

Direct lesionsDirect lesions Parietal pleuraParietal pleura Visceral pleuraVisceral pleura Lungs Lungs Intercostal vesselsIntercostal vessels

Indirect lesionIndirect lesion Intercostal vessels Intercostal vessels

Common complications of Common complications of thoracic contusions and thoracic contusions and

woundswounds

HemothoraxHemothorax

Blood acumulation in Blood acumulation in the pleural spacethe pleural space Vascular lesions in the Vascular lesions in the

intercostal space intercostal space (intercostal artery – very (intercostal artery – very important hemprrhage)important hemprrhage)

Pulmonary lesionsPulmonary lesions Mediastinal lesionsMediastinal lesions

ClasificationClasification Small: 300-500 ml occupies Small: 300-500 ml occupies

the costo-diafragmatic angle the costo-diafragmatic angle and has limited symptoms. and has limited symptoms.

Medium: <1500ml reaches Medium: <1500ml reaches the middle of the scapulathe middle of the scapula

Large: >3000 ml Large: >3000 ml Hypoxia lung is compressedHypoxia lung is compressed Circulatory changes – Circulatory changes –

mediastinal shiftmediastinal shift HypovolemiaHypovolemia

HemothoraxHemothorax

HemothoraxHemothorax

Clinical examinationClinical examination Dull on percutionDull on percution Respiratory sounds not Respiratory sounds not

audible on the affected audible on the affected sideside

Diminished amplitude of Diminished amplitude of respiratory movementsrespiratory movements

Chest X-RayChest X-Ray Pleural puncture – will Pleural puncture – will

show the nature of the show the nature of the fluid (blood)fluid (blood)

Typical hemothorax – secondary to Typical hemothorax – secondary to rib fracturesrib fractures

Small – in decubit the fluid extends and shadows all the lung

Massiv hemothorax

Tension HemothoraxTension Hemothorax

PneumothoraxPneumothorax

Continuity between the Continuity between the lung and pleural space – lung and pleural space – during breathing in air during breathing in air gets in the pleural spacegets in the pleural space

Aer tends to migrate:Aer tends to migrate: Through the fracture areaThrough the fracture area Through pleural rupturesThrough pleural ruptures Through natural Through natural

communications of the communications of the chest (mediastinum, chest (mediastinum, neck, etc)neck, etc)

Subcutaneous emphysemaSubcutaneous emphysema

Subcutaneous emphysemaSubcutaneous emphysema

Enclose pneumothoraxEnclose pneumothorax

MechanismMechanism Pleural and pulmonary lesionPleural and pulmonary lesion Wound – aer coming from Wound – aer coming from

outsideoutside

CalsificationCalsification Small / medium /massivSmall / medium /massiv

Exmanition:Exmanition: Thoraci painThoraci pain Acute sensation of thoracic Acute sensation of thoracic

constrictionconstriction Diminished amplitude of Diminished amplitude of

respiratory movements.respiratory movements. Tympanic sound on percutionTympanic sound on percution Diminished amplitude of Diminished amplitude of

transmitted respiratory transmitted respiratory sounds!!!!sounds!!!!

IT MAY BE IT MAY BE TRANSMITTED FROM TRANSMITTED FROM THE OTHER SIDETHE OTHER SIDE

Enclosed pneumothoraxEnclosed pneumothorax

Open pneumothoraxOpen pneumothorax

Open wound in the Open wound in the thoracic wallthoracic wall

Air freely enters and Air freely enters and exits during expirationexits during expiration

Air does not accumulate Air does not accumulate and does not increase and does not increase pressure inside pleural pressure inside pleural spacespace

Tension pneumothoraxTension pneumothorax

Wound in the parietal or Wound in the parietal or visceral pleuravisceral pleura

Air enters the cavity Air enters the cavity REPEATIDLY with each REPEATIDLY with each inspiratory movementinspiratory movement

The wound spontaneously The wound spontaneously closes during expiratiosncloses during expiratiosn

Accumulation of air in the Accumulation of air in the pleural spacepleural space Internal or external one-way Internal or external one-way

mechanismmechanism

Tension pneumothorax – physiologic Tension pneumothorax – physiologic repercussionsrepercussions

Tension pneumothorax - symptomsTension pneumothorax - symptoms

Acute onsetAcute onset Hypoxia, Hypoxia, Respiratory distress, Respiratory distress, CyanosisCyanosis AgitationAgitation Sensation of imminent death Sensation of imminent death

Mediastinal compression (in Mediastinal compression (in advanced stages)advanced stages)

Diminishes the functionality Diminishes the functionality of the “normal lung”of the “normal lung”

Decreases heart diastolic Decreases heart diastolic filling (angulation of SVC and filling (angulation of SVC and IVC) IVC)

End point – Acute Respiratory End point – Acute Respiratory Failure and Acute Circulatory Failure and Acute Circulatory Failure Failure

Urgent decompression Urgent decompression

Tension penumothoraxTension penumothorax

Flail chestFlail chest

Complex thoracic Complex thoracic fractures –at least 3 ribs fractures –at least 3 ribs each with 2 fractures each with 2 fractures

Typical mechanism is Typical mechanism is by compression of by compression of thoraxthorax

Associates complex Associates complex iternal organ trauma = iternal organ trauma = Multiple trauma patientMultiple trauma patient

ClassificationClassification Ventral (including the Ventral (including the

sternum) – frequent in sternum) – frequent in car accidents impact on car accidents impact on the steering wheelthe steering wheel

Anterior and lateralAnterior and lateral LateralLateral Dorsal (unlikely – big Dorsal (unlikely – big

muscular structures) muscular structures)

Flail chestFlail chest

According to mobilityAccording to mobility Fix – at least temporarilyFix – at least temporarily MobilMobil

Similar to fluid effusionSimilar to fluid effusion Part of thorax escapes the action of Part of thorax escapes the action of

respiratory muscles respiratory muscles Thorax no longer rigidThorax no longer rigid PARDOXICAL MOVEMENTPARDOXICAL MOVEMENT

Flail chest Flail chest

Complex respiratory Complex respiratory disfunctiondisfunction Decreased pulmonary Decreased pulmonary

capacitycapacity Swinging air Swinging air Mediastinal shiftMediastinal shift

ARF and ACFARF and ACF Surgical emergency Surgical emergency

Flail chestFlail chest

““Posttraumatic Soft Thorax”Posttraumatic Soft Thorax”

Flail chest – internal stabilisationFlail chest – internal stabilisation

Contusions of the rachis Contusions of the rachis

Fracture-dislocationFracture-dislocation Mechanism: rotation or hyperflexionMechanism: rotation or hyperflexion Pathology : dislocation of vertebra and spinal cord Pathology : dislocation of vertebra and spinal cord

compression compression Clinically: neurologic defect, hematoma, subcutaneous Clinically: neurologic defect, hematoma, subcutaneous

hemorrhage + unequal intervertebral spaceshemorrhage + unequal intervertebral spaces Fracture of vertebral bodyFracture of vertebral body

Mechanism: compression + flexion = vertebral surfaces not Mechanism: compression + flexion = vertebral surfaces not parallel parallel

Clinically: pain, musculare contraction, dorsal deformity of Clinically: pain, musculare contraction, dorsal deformity of the spine, usual without neurological signs the spine, usual without neurological signs

Other contusionsOther contusions

Pulmonary contusionsPulmonary contusions Diaphragmatic Diaphragmatic

contusions with contusions with diaphragmatic herniadiaphragmatic hernia

Contusions of the heart Contusions of the heart and pericardiumand pericardium

Trachea and bronchi Trachea and bronchi contusions contusions

Esophageal contusionsEsophageal contusions

Thoracic woundsThoracic wounds

1.Non-penetrated 1.Non-penetrated

2. Penetrated2. Penetrated

3. Perforant3. Perforant

Non-penetrating thoracic woundsNon-penetrating thoracic wounds

Sharp objects or low velocity Sharp objects or low velocity bullets bullets

Bonny structures oppose Bonny structures oppose penetrating injuriespenetrating injuries

Ribs can change direction – Ribs can change direction – important when reconstructing important when reconstructing the trajectorythe trajectory

SymptomsSymptoms WoundWound Hemorrhages from the intercostal Hemorrhages from the intercostal

branchbranch

Penetrating thoracic woundsPenetrating thoracic wounds Lesion of the parietal pleuraLesion of the parietal pleura Significant respiratory repercussionsSignificant respiratory repercussions

Tension pneumothorax (external one-way vent)Tension pneumothorax (external one-way vent) Open pneumothoraxOpen pneumothorax TRAUMATOPNEEATRAUMATOPNEEA

Perforated Perforated thoracic woundsthoracic wounds

Lesion concerning Lesion concerning organs in the thoracic organs in the thoracic cavity cavity

Thoracic-abdominal Thoracic-abdominal wounds – trajectory wounds – trajectory should be definedshould be defined

Symptoms and gravity Symptoms and gravity depend on individual depend on individual lesionlesion

Trajectory reconstructionTrajectory reconstruction

Trajectory reconstructionTrajectory reconstruction

Thoracic-abdominal woundsThoracic-abdominal wounds

Diseases of the pleuraDiseases of the pleura

Pleural cavityPleural cavity

Virtual cavityVirtual cavity Parietal pleuraParietal pleura Visceral pleuraVisceral pleura Minimal quantity of Minimal quantity of

liquid – very important liquid – very important in respiratory movementin respiratory movement

Pleural effusionPleural effusion

Spontaneous pneumothoraxSpontaneous pneumothorax Rupture of a emphysematous bullaRupture of a emphysematous bulla

Common symptomsCommon symptoms Pain: “stabbing” variable in intensityPain: “stabbing” variable in intensity Respiratory symproms accordin to respiratory disfunctionRespiratory symproms accordin to respiratory disfunction

Dispnoea – from insignificant to severe sensation of lack of air Dispnoea – from insignificant to severe sensation of lack of air ClinicallyClinically

Immobile hemithoraxImmobile hemithorax Hyper sonority on percussion, diminished amplitude of Hyper sonority on percussion, diminished amplitude of

transmitted vocal sounds and respiratory sounds transmitted vocal sounds and respiratory sounds Chest X-Ray: collapsed lung Chest X-Ray: collapsed lung

Pleural effusion Pleural effusion HemothoraxHemothorax

Spontaneous bleedingSpontaneous bleeding Tumors of the pleuraTumors of the pleura Hemothorax combined with pneumothoraxHemothorax combined with pneumothorax Idiopathic pleural hemorrhageIdiopathic pleural hemorrhage

Clinical findings ~ any pleural effusionsClinical findings ~ any pleural effusions ChylothoraxulChylothoraxul

Lymph due to obstruction of major thoracic lymph Lymph due to obstruction of major thoracic lymph channel channel

Symptoms: fade clinic: pain, sensation of chest Symptoms: fade clinic: pain, sensation of chest compression, weight loss with quick recovery after compression, weight loss with quick recovery after evacuationevacuation

Pleural effusionsPleural effusions Pleuritis Pleuritis

Acute or chronic infalmmation of pleura, w/o effusion Acute or chronic infalmmation of pleura, w/o effusion PURULENT PLEURITISPURULENT PLEURITIS

Rare primitiveRare primitive Secondary to septic pathology affecting the lungSecondary to septic pathology affecting the lung

Faza 1: diffuse pleuritisFaza 1: diffuse pleuritis Clinical signs of sepsisClinical signs of sepsis Stabbing pain, cough, respiratory disfunctionStabbing pain, cough, respiratory disfunction Chest X-Ray non-concludingChest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)Faza 2: localized pleuritis (according to gravity) General signs fade awayGeneral signs fade away Fluid collection on X-Ray + pleural effusionFluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)Faza 3: chronic purulent pleuritis (inefficient treatment) Clinical signs – minor or inexistentClinical signs – minor or inexistent Cough and low feverCough and low fever CXR – empyema (fluid-air level - collection)CXR – empyema (fluid-air level - collection)

Pleural tumorsPleural tumors

PrimitivePrimitive = MEZOTELIOMA = MEZOTELIOMA RareRare Involve parietal / visceral pleuraInvolve parietal / visceral pleura Frequent without symptoms or fant mediastinal Frequent without symptoms or fant mediastinal

compressioncompression CXR – abnormal opacity prompting thoracoscopic CXR – abnormal opacity prompting thoracoscopic

examination + biopsyexamination + biopsy SecondarySecondary

Metastatic pleural effusionMetastatic pleural effusion

Surgical manifestation of Surgical manifestation of pulmonary diseasespulmonary diseases

Congenital lesionsCongenital lesions

Pulmonary agenesisPulmonary agenesis Pulmonary hypoplasiaPulmonary hypoplasia Policystic hypoplasiaPolicystic hypoplasia Giant lobar emphysema – largely inflated Giant lobar emphysema – largely inflated

hemothoraxhemothorax Pulmonary sequestrum – area of the lung not Pulmonary sequestrum – area of the lung not

used in respiration – will transform cystic and used in respiration – will transform cystic and may be infected may be infected

Traumatic lesionsTraumatic lesionsPulmonary contusionPulmonary contusion Pathology – bleeding inside the parenchyma, Pathology – bleeding inside the parenchyma,

formation of hematoma, alveolar exudates= formation of hematoma, alveolar exudates= TRAUMATIC PNEUMONIA TRAUMATIC PNEUMONIA

Common signsCommon signs Non-productive coughNon-productive cough Expectoration with mucus or blood. Expectoration with mucus or blood. Associates frequent pleural effusion – aggravates Associates frequent pleural effusion – aggravates

patients’ statuspatients’ status

Pulmonary contusionsPulmonary contusions

Mostly through aggressive trauma producing Mostly through aggressive trauma producing compression of thorax with closed larynxcompression of thorax with closed larynx

Gravity increased if in personal history are Gravity increased if in personal history are diseases that decrese lung elasticity diseases that decrese lung elasticity

SymptomsSymptoms Haemoptysis sometimes massive – may be lethalHaemoptysis sometimes massive – may be lethal Cough, stabbing pain, respiratory disfunction Cough, stabbing pain, respiratory disfunction

Pulmoray contusion Pulmoray contusion blast syndrome blast syndrome

Particular formParticular form Usual patients with multiple traumaUsual patients with multiple trauma Shoch wave from a blastShoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is Pathology: alveolar and capillary ruptures – lung is transformed in a spongy non-functional tissue transformed in a spongy non-functional tissue

Clinically: Clinically: ShockShock Nasal and ear hemorrhagesNasal and ear hemorrhages Nonspecific respiratory changes + haemoptysis and Nonspecific respiratory changes + haemoptysis and

limitation of respiratory movements on the affected sidelimitation of respiratory movements on the affected side

Blast syndromeBlast syndrome

Wounds of the lungs and bronchiWounds of the lungs and bronchi

Perforant wounds and Perforant wounds and explosion (there should be explosion (there should be communication)communication)

Common clinical signsCommon clinical signs CoughCough DyspnoeaDyspnoea Respiratory failure Respiratory failure

HaemoptysiaHaemoptysia Subcutaneous emphysemaSubcutaneous emphysema Pulmonary herniation in the Pulmonary herniation in the

woundwound

Inflammatory lesionsInflammatory lesions

Chronic obstructive Chronic obstructive diseasedisease

Pulmonary abscessPulmonary abscess TuberculosisTuberculosis

In certain stages may In certain stages may benefit from surgical benefit from surgical gesturesgestures

Parasitic lesionsParasitic lesionsHydatid cystHydatid cyst

Second most frequent localizationSecond most frequent localization Primary lesionPrimary lesion Secondary : hematogenous dissemination (exceptional) or Secondary : hematogenous dissemination (exceptional) or

through the bronchial tractthrough the bronchial tract Symptoms: number, localization, compresion, stage Symptoms: number, localization, compresion, stage

pf development, complicationspf development, complications Mostly asymptomatic or nonspecificMostly asymptomatic or nonspecific Sign appear if large lesions develop Sign appear if large lesions develop

Proximity with pleuraProximity with pleura Erosion in a bronchusErosion in a bronchus

Pulmoary hydatid cystPulmoary hydatid cyst

UncomplicatedUncomplicated SymptomsSymptoms

Non-productive coughNon-productive cough Stabbing painStabbing pain Intercostal neuralgic painIntercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds Auscultation =non-significant. Diminishes sounds may be perceivedmay be perceived

Hydatid cystHydatid cyst

ComplicatedComplicated Progressive opening in a Progressive opening in a

brinchus: mucus expectorate brinchus: mucus expectorate = air-liquid level= air-liquid level

Sudden openingSudden opening Dramatic – “like vomiting”Dramatic – “like vomiting” Risk of asphyxiaRisk of asphyxia Major haemoptysisMajor haemoptysis Anaphylactic accidentsAnaphylactic accidents

Opening in the pleura= Opening in the pleura= hidro- or hidro-hidro- or hidro-pneumothoraxpneumothorax

Lung cancerLung cancer Originates in the bronchi epitheliumOriginates in the bronchi epithelium Asymptomatic onsetAsymptomatic onset

No significant signs, mostly in elderly and smokersNo significant signs, mostly in elderly and smokers Early stage:Early stage:

Cough rezistent to any treatmentCough rezistent to any treatment Thoracic pain + haemoptysis ~ pneumonia at onsetThoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:Advanced stages: Cough and dyspnoeaCough and dyspnoea Blody expectorate or mucus +bloodBlody expectorate or mucus +blood Pulmonary abscessPulmonary abscess

Diagnostic: CXR, CT, BronchoscopyDiagnostic: CXR, CT, Bronchoscopy

Lung cancerLung cancer

Lung cancerLung cancer