Anatomy of thorax

Landmarks anterior viewSupresternal notchAngle of Louis cartilage of the 2nd rib Xifoid apendixSubcostal angleThoracic lateral wallRibs 7, 8, 9, 10Free ending 11, 12Collar bone acromionProjection of diaphragm (top ~ 5th rib)BreastAnterior axilary line

Bony structure

Muscles of anterior thoracic wallsignificance in respiration

LandmarksPosterior viewProcessus sipnosumScapula:Superior angle C2Inferior angle C7RidgeMuscular prominences Latissimus dorsiTrapesiusErectori spinae

Lines used for orientatiomMedianMidd-clavicular lineAxillary lineAnteriorMiddlePosteriorScapulary line (through the inferior angle) armes being close to the trunk

Superficial projections of respiratory aparatusTracheea:Cricoid angle of LouisLungsC6-C8-C10 PleuraC8-C10-C12

Superficial projection of the heart and great vesselsAortic arch, brchiocephalic trunk, inferior vena cava, brahiocephalic veins are projected behind the manubriumInternal thoracic vein 1-3 cm lateral to the manubriumIntercostal vesselsHeart projectionPericardium

Mediastinum

Communications of the thoracic cavitySuperior opening base of the neckT1 C1 manubriumTracheea, esofagus, great vessels from the neckInferior openingT12 costal margin xifoid apendixDiafragm with openings ofering passage forEsofagus, nerves vagus nervesAorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breastBegin after onset of hormonal sexual activityMonthly preferable after menstruationInspectionVolume, position, profilePalpation

Medical examination of the breastHistory takingBorthsBreast feeding + durationMenstrual activity + changes in the breastOther lesionsHormonal therapyPalpation Breast + breast tissue outside glandNippleAxillary lymph nodesSkinCOMPULSURY BOTH SIDES

Axillary lymphnodesExternal thoracic (under the pectoralis major)Main collector Brahial groupInferior scapullary group - dorsalSubclavicular top of axxilaCentralInternal thoracic not accesible

ImagisticsUltrasound scanDoppler effect for vessels dipositionMamographyGalactograpy

THORACIC TRAUMA

Common manifestations in thoracic traumaPainRelatively minor element that triggers changes in ventilationSignificant presence in any thoracic traumaImmobilization not applicableSuppresses cough reflexFinally generates airway obstruction and hypoxia PneumotoraxMajor deficit loss of functional pulmonary tissueComplex mechanismAirway obstructionAcute respiratory failure fearful complicationTahipneaAcute dispneea Use of accessory respiratory musclesCyanosisAnxiety

Manifestations of thoracic contusions

Contusions of soft tissueNon-characterisctic symptomsEcchymosedHematomaSubcutaneous fluid collectionsMuscle tearsAs a single lesion children (soft thorax)

Clinically same as any other locations

Sternal fracturesMechanismDirect impactAcute flexionType: transversal w/o movement of fragmentsParticular situation manubrio-sternal disjunctionClinicallyPainDeformityShort sternumt with dimished intercostal spaces

Costal fracturesVery frequent in adulthood 10%More frequently in ribs situated in the middle unprotected area Direct or indirect mechanismDirect sharp bone projected insideIndirect sharp bone projected outside

Costal fracturesClinicallyBenign lesionsPainDiminished amplitude of respiratory movementsPalpation in the arrea of fracture DeformityOsseous creptiations during deep inspiration or cough MAJOR riskLesion of pleura or lungDirect lesionsParietal pleuraVisceral pleuraLungs Intercostal vesselsIndirect lesionIntercostal vessels

Common complications of thoracic contusions and wounds

HemothoraxBlood acumulation in the pleural spaceVascular lesions in the intercostal space (intercostal artery very important hemprrhage)Pulmonary lesionsMediastinal lesions

ClasificationSmall: 300-500 ml occupies the costo-diafragmatic angle and has limited symptoms. Medium: 3000 ml Hypoxia lung is compressedCirculatory changes mediastinal shiftHypovolemia

Hemothorax

HemothoraxClinical examinationDull on percutionRespiratory sounds not audible on the affected sideDiminished amplitude of respiratory movementsChest X-RayPleural puncture will show the nature of the fluid (blood)

Typical hemothorax secondary to rib fracturesSmall in decubit the fluid extends and shadows all the lungMassiv hemothorax

Tension Hemothorax

PneumothoraxContinuity between the lung and pleural space during breathing in air gets in the pleural spaceAer tends to migrate:Through the fracture areaThrough pleural rupturesThrough natural communications of the chest (mediastinum, neck, etc)

Subcutaneous emphysema

Enclose pneumothoraxMechanismPleural and pulmonary lesionWound aer coming from outsideCalsificationSmall / medium /massivExmanition:Thoraci painAcute sensation of thoracic constrictionDiminished amplitude of respiratory movements.Tympanic sound on percutionDiminished amplitude of transmitted respiratory sounds!!!!IT MAY BE TRANSMITTED FROM THE OTHER SIDE

Enclosed pneumothorax

Open pneumothoraxOpen wound in the thoracic wallAir freely enters and exits during expirationAir does not accumulate and does not increase pressure inside pleural space

Tension pneumothoraxWound in the parietal or visceral pleuraAir enters the cavity REPEATIDLY with each inspiratory movementThe wound spontaneously closes during expiratiosnAccumulation of air in the pleural spaceInternal or external one-way mechanism

Tension pneumothorax physiologic repercussions

Tension pneumothorax - symptomsAcute onsetHypoxia, Respiratory distress, CyanosisAgitationSensation of imminent death Mediastinal compression (in advanced stages)Diminishes the functionality of the normal lungDecreases heart diastolic filling (angulation of SVC and IVC) End point Acute Respiratory Failure and Acute Circulatory Failure Urgent decompression

Tension penumothorax

Flail chestComplex thoracic fractures at least 3 ribs each with 2 fractures Typical mechanism is by compression of thoraxAssociates complex iternal organ trauma = Multiple trauma patientClassificationVentral (including the sternum) frequent in car accidents impact on the steering wheelAnterior and lateralLateralDorsal (unlikely big muscular structures)

Flail chestAccording to mobilityFix at least temporarilyMobilSimilar to fluid effusionPart of thorax escapes the action of respiratory muscles Thorax no longer rigidPARDOXICAL MOVEMENT

Flail chest Complex respiratory disfunctionDecreased pulmonary capacitySwinging air Mediastinal shiftARF and ACFSurgical emergency

Flail chest

Posttraumatic Soft Thorax

Flail chest internal stabilisation

Contusions of the rachis Fracture-dislocationMechanism: rotation or hyperflexionPathology : dislocation of vertebra and spinal cord compression Clinically: neurologic defect, hematoma, subcutaneous hemorrhage + unequal intervertebral spacesFracture of vertebral bodyMechanism: compression + flexion = vertebral surfaces not parallel Clinically: pain, musculare contraction, dorsal deformity of the spine, usual without neurological signs

Other contusionsPulmonary contusionsDiaphragmatic contusions with diaphragmatic herniaContusions of the heart and pericardiumTrachea and bronchi contusions Esophageal contusions

Thoracic wounds1.Non-penetrated 2. Penetrated3. Perforant

Non-penetrating thoracic woundsSharp objects or low velocity bullets Bonny structures oppose penetrating injuriesRibs can change direction important when reconstructing the trajectorySymptomsWoundHemorrhages from the intercostal branch

Penetrating thoracic woundsLesion of the parietal pleuraSignificant respiratory repercussionsTension pneumothorax (external one-way vent)Open pneumothoraxTRAUMATOPNEEA

Perforated thoracic woundsLesion concerning organs in the thoracic cavity Thoracic-abdominal wounds trajectory should be definedSymptoms and gravity depend on individual lesion

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavityVirtual cavityParietal pleuraVisceral pleuraMinimal quantity of liquid very important in respiratory movement

Pleural effusionSpontaneous pneumothoraxRupture of a emphysematous bullaCommon symptomsPain: stabbing variable in intensityRespiratory symproms accordin to respiratory disfunctionDispnoea from insignificant to severe sensation of lack of air ClinicallyImmobile hemithoraxHyper sonority on percussion, diminished amplitude of transmitted vocal sounds and respiratory sounds Chest X-Ray: collapsed lung

Pleural effusion HemothoraxSpontaneous bleedingTumors of the pleuraHemothorax combined with pneumothoraxIdiopathic pleural hemorrhageClinical findings ~ any pleural effusionsChylothoraxulLymph due to obstruction of major thoracic lymph channel Symptoms: fade clinic: pain, sensation of chest compression, weight loss with quick recovery after evacuation

Pleural effusionsPleuritis Acute or chronic infalmmation of pleura, w/o effusion PURULENT PLEURITISRare primitiveSecondary to septic pathology affecting the lungFaza 1: diffuse pleuritisClinical signs of sepsisStabbing pain, cough, respiratory disfunctionChest X-Ray non-concludingFaza 2: localized pleuritis (according to gravity)General signs fade awayFluid collection on X-Ray + pleural effusionFaza 3: chronic purulent pleuritis (inefficient treatment)Clinical signs minor or inexistentCough and low feverCXR empyema (fluid-air level - collection)

Pleural tumorsPrimitive = MEZOTELIOMARareInvolve parietal / visceral pleuraFrequent without symptoms or fant mediastinal compressionCXR abnormal opacity prompting thoracoscopic examination + biopsySecondaryMetastatic pleural effusion

Surgical manifestation of pulmonary diseases

Congenital lesionsPulmonary agenesisPulmonary hypoplasiaPolicystic hypoplasiaGiant lobar emphysema largely inflated hemothoraxPulmonary sequestrum area of the lung not used in respiration will transform cystic and may be infected

Traumatic lesionsPulmonary contusionPathology bleeding inside the parenchyma, formation of hematoma, alveolar exudates= TRAUMATIC PNEUMONIA Common signsNon-productive coughExpectoration with mucus or blood. Associates frequent pleural effusion aggravates patients status

Pulmonary contusionsMostly through aggressive trauma producing compression of thorax with closed larynxGravity increased if in personal history are diseases that decrese lung elasticity SymptomsHaemoptysis sometimes massive may be lethalCough, stabbing pain, respiratory disfunction

Pulmoray contusion blast syndromeParticular formUsual patients with multiple traumaShoch wave from a blastPathology: alveolar and capillary ruptures lung is transformed in a spongy non-functional tissue Clinically: ShockNasal and ear hemorrhagesNonspecific respiratory changes + haemoptysis and limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchiPerforant wounds and explosion (there should be communication)Common clinical signsCoughDyspnoeaRespiratory failure HaemoptysiaSubcutaneous emphysemaPulmonary herniation in the wound

Inflammatory lesionsChronic obstructive diseasePulmonary abscessTuberculosis

In certain stages may benefit from surgical gestures

Parasitic lesionsHydatid cystSecond most frequent localizationPrimary lesionSecondary : hematogenous dissemination (exceptional) or through the bronchial tractSymptoms: number, localization, compresion, stage pf development, complicationsMostly asymptomatic or nonspecificSign appear if large lesions develop Proximity with pleuraErosion in a bronchus

Pulmoary hydatid cystUncomplicatedSymptomsNon-productive coughStabbing painIntercostal neuralgic painAuscultation =non-significant. Diminishes sounds may be perceived

Hydatid cystComplicatedProgressive opening in a brinchus: mucus expectorate = air-liquid levelSudden openingDramatic like vomitingRisk of asphyxiaMajor haemoptysisAnaphylactic accidentsOpening in the pleura= hidro- or hidro-pneumothorax

Lung cancerOriginates in the bronchi epitheliumAsymptomatic onsetNo significant signs, mostly in elderly and smokersEarly stage:Cough rezistent to any treatmentThoracic pain + haemoptysis ~ pneumonia at onsetAdvanced stages:Cough and dyspnoeaBlody expectorate or mucus +bloodPulmonary abscessDiagnostic: CXR, CT, Bronchoscopy

Lung cancer

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Anatomy of thorax