1、Section 1 Introduction,I. Boundaries and divisions,Chapter 3 The thorax,Boundaries Superior-jugular notch, sternoclavicular joint, superior border of clavicle, acromion, spinous process of C7,Inferior-xiphoid process, costal archs, 11th and 12th ribs, spinous process of T12 Lateral- anterior and pos
2、terior margins of the deltoid,Divisions Thoracic wall anterior thoracic region lateral thoracic region thoracodorsal region Thoracic cavity,anterior axillary line,posterior axillary line,Chapter 5 The thorax,II. Surface anatomy,jugular notch 颈静脉切迹 sternal angle (of Louis) 胸骨角 xiphoid process 剑突 clav
3、icle锁骨 infraclavicular fossa 锁骨下窝 costal margin (costal arch) 肋弓 infrasternal angle 胸骨下角 ribs and intercostal space 肋和肋间隙 nipple 乳头,(1) The anterior median line (2) The sternal line (3) The midclavicular line (4) The parasternal line (5) The anterior axillary line (6) The midaxillary line (7) The po
4、sterior axillary line (8) The scapular line (9) The posterior median line,The orientational lines on the thoracic wall,Section 2 The Thoracic Wall,Layers of anterior thoracic wall 1. Skin 皮肤 2. Superficial fascia 浅筋膜 3. Deep fascia 深筋膜 4. Extrinsic muscles 胸廓外肌 5. Thoracic cage and intrinsic muscles
5、 肋间肌 6. Endothoracic fascia 胸内筋膜 7. Parietal pleura 壁胸膜,(1) The superficial blood vessels perforating branches of the internal thoracic a.& v. 胸廓内A、V穿支 laterla cutaneous branches of the posterior intercostal a.& v. 肋间后A、V外侧皮支 thoracoacromial a. & v., 胸肩峰A、V lateral thoracic a. & v. 胸外侧A,V thoracoepi
6、gastric v. 胸腹壁V,The skin The superficial fascia,Section 2 The Thoracic Wall,(2) The cutaneous nerves： Supraclavicular n. 锁骨上N Anterior and lateral cutaneous branches of intercostal n. 肋间N外侧皮支和前皮支,The nerves Anterior cutaneous branches of the 2th-4th intercostal n. lateral cutaneous branches of the 4
7、th-6th intercostal n.,The blood vessels of the female breast,(1) the posterior intercostal a. ( the 3th7th lateral cutaneous branches) (2) the internal thoracic a. ( the 3th6th perforating branches, the 2th4th more large) (3) lateral thoracic a. (4) thoracoacromial a.,1. Position: Lie in superficial
8、 fascia over the pectorals major and pectoral fascia 2. shape: it is hemispherical shape, the nipple is located at the center surrounding by the areola that is lubricated by the areolar glands,(3) mamma / breast,Structures,the breast is composed of 15-20 gland lobes, that radiate around and open at
9、the nipple. The lobes are padded and separated from each other by fibrous connective tissue and fat.,Each gland lobe has a lactiferous duct which opens separately on the nipple and possesses a dilated lactiferous sinuses just prior to its termination,乳房悬韧带 suspensory ligament of breast or Cooper lig
10、ament,纤维组织小束，起自锁骨、锁胸筋膜和乳腺深面的胸筋膜，从深部向前穿过乳腺周围并与之相连，最后连于乳房皮肤。对乳房起固定作用。 乳癌早期，乳房悬韧带可受侵犯而缩短，牵拉皮肤产生凹陷称“酒窝征”，这是乳癌早期的常见体征。,乳房悬韧带,乳房后隙,为浅筋膜深层与胸肌筋膜间的间隙，内有疏松结缔组织、脂肪、淋巴管。,隆胸手术,胸大肌,胸大肌,胸肌间隙,乳房后间隙,植入假体,3.乳房的淋巴引流,乳房外侧部和中央部的淋巴胸肌淋巴结。乳房淋巴回流的主要途径。 乳房上部的淋巴尖淋巴结和锁骨上淋巴结。 乳房内侧部的淋巴胸骨旁淋巴结。 乳房内侧部的浅淋巴管与对侧乳房淋巴管相交通。 乳房深部的淋巴管穿胸大肌胸
11、肌间淋巴结或尖淋巴结。 乳房内下部的淋巴管通过腹壁和膈下淋巴管与肝的淋巴管相交通。,临床要点：乳房手术切口的选择放射状切口,orange-peel texture 桔皮样外观,dimpling酒窝征,乳腺癌,Regular self examination of breasts,More than 80% of breast cancer cases can be find at the early time. Notes: lump, changes in breast size or shape, skin dimpling, nipple inversion, or spontaneou
12、s single-nipple discharge are danger sign of cancer.,3. The Deep Structures,(1) deep fascia,Clavipectoral fascia 锁胸筋膜： extends between subclavius, coracoid process and pectoralis minor., Cephalic v. 头静脉 Thoracoacromial a. and v. 胸肩峰动、静脉 Lateral pectoral n. 胸外侧神经 lymphatic vessels 淋巴管,It is pierced b
13、y:,Pectoralis major,Pectoralis minor,Serratus anterior,(2) The extrinsic muscles,Serratus anterior,Winged scapula,(3) Intercostal space,Intercostales externi,Intercostales interni,Intercostales intimi,Before reaching to the costal angle, the intercostal nerve and vessels run in the middle of the int
14、ercostal space and their arrangement is inconstant; Then they lie between the innermost and internal intercostal muscles.,2) The intercostal vessels,位于肋角内侧的肋间淋巴结输出管注入胸导管。,3) The intercostal nerves,In the costal groove of the rib, the arrangement from up downwards is the: vein, artery nerve.,Internal
15、 thoracic artery 胸廓内动脉,1. musculophrenic a. 肌膈动脉 2. superior epigastric a. 腹壁上动脉 3. Pericardiacophrenic a. 心包膈动脉 4. anterior intercostal branches 肋间前支 5. Perforating branches 前穿支,胸骨旁淋巴结,引流腹前壁和乳房内侧部的淋巴，并收纳膈上淋巴结的淋巴，其输出管参与合成支气管纵隔干。,在近肋角处应稍靠下位肋骨上缘进针。 在肋角外侧应在肋间隙中部进针，以免伤及肋间血管神经。 临床上常在肩胛线或腋后线第78肋间隙进行。,Thor
16、acentesis 胸膜腔穿刺：,6.胸内筋膜 7.壁胸膜,施行胸膜腔穿刺术需经过哪些层次？, Skin 皮肤 superficial fascia 浅筋膜 deep fascia 深筋膜 superficial muscles of the thoracic wall胸壁肌 rib and intercostal muscles 肋间肌 endothoracic fascia 胸内筋膜 parietal pleura. 壁胸膜,气胸 pneumothorax 水胸 hydrothorax 血胸 hemothorax 乳糜胸 chylothorax,Section 3 Diaphragm,1.
17、 Position and division,It is a dome-shaped between thorax and abdomen, consists of a peripheral muscular part and a central tendon,Origin: Sternal part: xiphoid process Costal part: lower six and costal cartilages Lumbar part: arises by two crura from upper 2-3 lumbar vertebrae Insertion: central te
18、ndon,Division,Weak areas: triangular spaces without muscular tissue Lumbocostal triangle: between costal and lumbar parts. Sternocostal triangle: between costal and sternal parts.,Aortic hiatus- lies anterior to the 12th thoracic vertebra between the crura. It transmits the aorta, thoracic duct. Eso
19、phageal hiatus -for esophagus and vagus nerves at level of T10. Vena cava foramen -for inferior vena cava, through central tendon at T8 level.,Openings in the diaphragm,Action: Contraction: the dome moving downward, increases the volume of thoracic cavity which results in inspiration, at the same ti
20、me the intra-abdominal pressure is increased assists in defecation, vomiting or child birth. Relaxation: the dome returns to the former position, reduces the volume to the thoracic cavity, resulting in expiration.,吸气,呼气,The blood vessels, lymphatic drainage and nerves of the diaphragm,1.blood vessel
21、s：pericardiophrenic a., musculophrenic a., superior phrenic a., inferior phrenic a., intercostal a. 2.lymphatic drainage ：superior phrenic ln. drains into parasternal and posterior mediastinal ln. inferior phrenic ln. drains into lumbar ln. 3.nerves ：lower six pairs of intercostaln, phrenic n., acce
22、ssory phrenic n.,三、膈的血管、淋巴和神经,1.血管：心包膈动脉、肌膈动脉、膈上动脉、下位肋间后动脉、膈下动脉 2.淋巴：注入膈上、下淋巴结。膈上淋巴结注入胸骨旁淋巴结和纵隔前后淋巴结。膈下淋巴结注入腰淋巴结。 3.神经：下6对肋间神经、膈神经、副膈神经,Axillary fossa,Section 2 the axillary region,Position: inferior to the shoulder joint，between the upper part of the chest wall and the medial side of the arm. When
23、abducts the shoulder joint the skin is convex upward, called axillary fossa.,The boundaries of the axilla,1. Apex: the first ribs, the superior border of the scapula and middle 1/3 of clavicle. 2. Base axillary fascia，skin 3. Anterior wall pectoralis major, pectoralis minor clavipectoral fascia 4. M
24、edial wall 1-4 ribs, Intercostal muscles Serratus anterior 5. Posterior wall Subscapularis, Teres major Latissimus dorsi 6. Lateral wall Intertubercular sulcus of the humerus, biceps and coracobrachialis,Trilateral and quadrilateral foramina,Quadrilateral foramen四边孔: The posterior humeral circumflex
25、 a. and axillary n. pass through.,Trilateral foramen 三边孔: The circumflex scapular a. pass through.,1. Axillary a. and its branches 2. Axillary v. and its tributaries 3. Brachial plexus and its branches 4. Axillary lymph nodes 5. Loose connective tissue,2. Contents,Axillary sheath,Extension of deep c
26、ervical fascia of the neck, forming a tubular sheath that surrounds axillary a. and brachial plexus,A brachial plexus nerve block can be achieved by injecting anaesthetic into this area.,臂丛从颈部斜角肌间隙经锁骨中点后方到腋窝，临床上作臂丛阻滞麻醉可在斜角肌间隙、锁骨中点上方和腋窝进行。,Dissection,From the jugular notch to the xiphisternal junctio
27、n in the midline Continue the incision along the costal margin to the posterior axillary line Incise the skin along the full length of the clavicle to the acromion,Dissection,Make an oblique incision from the xiphisternal junction up wards and laterary, around the nipple to the anterior axillary fol
28、d, then, around the medial side of the arm to the point between the upper and middle thirds Make a transverse incision on the anterior surface of the arm at that level,Procedures,Peel of the skin Split the superficial fascia and remove it Dissect the pectoralis major and the anterior part of the del
29、toid Dissect the pectoralis minior,Procedures,Peel of the skin Split the superficial fascia and remove it Dissect the pectoralis major and the anterior part of the deltoid Dissect the pectoralis minior,Procedures,Expose the contents of the axillary cavity Remove the axillary fascia Clean the axillary vessels Identify the position of the lymph nodes,
