Transcript 凌树才_局解Thorax

Regional anatomy
Thorax
Ling Shucai
Contents
Ⅰ. Summarization 概述
Ⅱ. Thoracic wall 胸壁
Ⅲ. Blood vessels and nerves in
thoracic cavity 胸腔内的血管和神经
Ⅳ. Lungs 肺
Ⅴ. Mediastinum 纵隔
Ⅰ. Summarization
Summarization
1. Boundary 境界
2. Surface landmark 表面标志
3. Lines of orientation on the thorax 胸部标
志线
1. Boundary
2. Surface Landmarks
 Jugular notch 颈静脉切迹
 Sternal angle (of Louis) 胸骨角
 Xiphoid process剑突
 Costal margin (costal arch) 肋弓
 Infrasternal angle 胸骨下角
 Clavicle 锁骨
 Inferior angle of scapula
 Nipple 乳头
肩胛骨下角
Surface Anatomy of the Anterior Thoracic Wall
Jugular Notch
(T2 Vertebral Level)
Clavicle
Sternal Angle
(T4 Vertebral Level)
Surface Anatomy of the Posterior Thoracic Wall
C7 Spinous Process
(Veterbra Prominens)
Vertebral Border
of Scapula
Inferior Angle
of Scapula
12th Rib
3. The Lines of Orientation on the Thorax
 Anterior median line
前正中线
 Sternal line
胸骨线
 Midclavicular line
锁骨中线
 Parasternal line
胸骨旁线
 Anterior axillary line
腋前线
 Midaxillary line
腋中线
 Posterior axiltary line
腋后线
 Scapular line
肩胛线
 Posterior median line
后正中线
Ⅱ. Thoracic wall
Thoracic wall
1. Superficial structures 浅层结构
2. Deep structures 深层结构
3. Clinical notes
1. Superficial structures
∆ Skin
∆ Superficial fascia
– Thoracoepigastric v.
– Supraclavicular n.
– Anterior and lateral
cutaneous branches
of intercostal n.
The segmental innervation of anterior surface of trunk
• T2－sternal angle
• T4－ nipple
• T6－xiphoid process
• T8－costal arch
• T10－umbilicus
• T12－midpoint between
umbilicus and symphysis
pubis
C4
T2
Lymphatic drainage of breast
• Into pectoral ln. from lateral
and central parts of breast
• Into apical and
supraclavicular ln. from
superior part of breast
• Into parasternal ln. from
medial part of breast
• Into interpectoral ln. from
deep part of breast
• The lymphatic capillaries of
breast form an anastomosing
network which is continuous
across the midline with that
of the opposite side and with
that of the abdominal wall
2. Deep structures
△ Muscles of thoracic wall 胸壁的肌肉
△ Deep fascia and fascial space
深筋膜及筋膜间隙 （见胸前外侧壁章节）
△ Blood vessels and nerves of thoracic wall
胸壁的血管和神经
The muscles of thoracic wall
Extrinsic muscles
• Pectoralis major
• Pectoralis minor
• Serratus anterior
Intrinsic muscles
•
•
•
•
Intercostales externi 肋间外肌
Intercostales interni 肋间内肌
Intercostales intimi 肋间最内肌
Transverses thoracis 胸横肌
transverses thoracis
Intercostales externi
• Origin: lower border of rib)
• Insertion: upper border of rib
below origin
• Action: elevate ribs adding in
forced inspiration
• Replaced anteriorly by external
intercostals membrane.
Intercostales interni
• Origin: upper border of rib
• Insertion: lower border of rib
above origin
• Action: depress ribs for forced
expiration
• Replaced posteriorly by internal
intercostals membrane.
internal
intercostals
membrane
external intercostals membrane
Diaphragm 膈
Shape and position:
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 tendon
Weak areas:
•
•
triangular spaces without muscular
tissue
Lumbocostal triangle:
between costal and lumbar parts.
Sternocostal triangle:
between costal and sternal parts.
Openings in the diaphragm
•
•
•
Aortic hiatus 主动脉裂孔－lies anterior to the body of the 12th
thoracic vertebra between the crura. It transmits the aorta,
thoracic duct
Esophageal hiatus 食管裂孔－for esophagus and vagus nerves at
level of T10.
Vena cava foramen 腔静脉孔－for inferior vena cava, through
central tendon at T8 level
T8
T10
T12
Action:
•
Contraction: the dome
•
Relaxation: the dome
moving downward, increases
the volume of thoracic
cavity which results in
inspiration, at the same
time the intra-abdominal
pressure is increased
assists in defecation,
vomiting or child birth.
returns to the former
position, reduces the
volume to the thoracic
cavity, resulting in
expiration.
The blood vessels and nerves of thoracic wall
Anatomy of Intercostal space
Posterior intercostal v.
Posterior intercostal a.
Intercostal n.
The innervation of thoracic wall
Anterior branches of
thoracic nerves
• Intercostal nerves 肋间神经
(anterior rami of T1- T11):
• Subcostal nerve 肋下神经 (anterior
ramus of T12): follows inferior
border of T12 rib and passes into
abdominal wall
• Distribution: distributed to
intercostales and anterolateral
abdominal muscles, skin of thoracic
and abdominal wall, parietal pleura
and peritoneum
Internal thoracic
vessels
• Internal thoracic a.&v.
胸廓内动脉和静脉
• Parasternal ln.
胸骨旁淋巴结
Endothoracic fascia
胸内筋膜
Internal thoracic
artery 胸廓内动脉
－descends into thorax
1.2cm lateral to edge of
sternum, and ends at the
sixth costal cartilage by
dividing musculophrenic
（肌膈动脉 ）and superior
epigastric arteries （腹壁
上动脉）
心包膈动脉
胸廓内动脉
腹壁上动脉
Azygos vein 奇静脉
• Begins as continuation of right
ascending lumbar vein
• Ascending along the right side of
vertebral column
• Joins superior vena cava by aching
above right lung root at level of T4
to T5
• Receives right posterior
intercostals and subcostal veins plus
some of bronchial, esophageal and
pericardial veins, and hemiazygos
vein
• Tributaries－hemiazygosv.半奇静脉
and accessory hemiazygos v. 副半奇
静脉, which receive most left
posterior intercostals vein and left
bronchial veins
Veins of vertebral column
Vertebral venous plexus 椎静脉丛
• External vertebral venous
plexus
• Internal vertebral venous
plexus
Ⅲ. Blood vessels and nerves in
thoracic cavity
Arteries of thorax
Pulmonary trunk
•
•
•
Arises from right ventricle
Runs up, back ,and to the left
Bifurcates inferior to aortic
arch into right and left
pulmonary arteries, one for
each lung
Pulmonary arteries
•
•
Right pulmonary artery－passes
posterior to ascending aorta
and superior vena cava to hilum
of right lung
Left pulmonary artery－passes
anterior to descending aorta
and left main bronchus to
hilum of left lung
Ascending aorta 升主动脉
•
Runs upward, forward and
to the right,
•
Extends to level of second
right sternocostal joint
•
Branches: right and left
coronary arteries
Aortic arch 主动脉弓
•
Curves upward, to the left and
posteriorly, then downward,
arching over left principal
bronchus and pulmonary trunk to
lower border of T4 level, to
become descending aorta
•
Branches (from right to left )
–
Brachiocephalic trunk
–
Left common carotid artery
–
Left subclavian artery
•
Aortic isthmus－baroreceptor
•
Aortic glomera－chemoreceptor
Arterial ligament 动脉韧带－ remnant of ductus arteriosus,
connects bifurcation of pulmonary trunk to inferior
border of aortic arch
Triangule of ductus arteriosus 动脉导管三角
•
•
Bounded by phrenic n., left vagus n. and left pulmonary a.
Contents－ arterial ligament , left recurrent n. and
superficial cardiac plexuses
Thoracic aorta 胸主动脉
Main branches
Parietal branches
• Nine pairs posterior intercostals
arteries
• One pair subcostal artery
• For lower nine intercostals spaces
and upper part of abdominal wall;
superior phrenic arteries supply the
superior surface of the diaphragm.
Visceral branches
• Bronchial branches: one or two for
each lung
• Esophageal branches
• Pericardial branches
Veins of thorax
Brachiocephalic veins
•
Formed by union of internal jugular
and subclavian veins posterior to
the sternoclavicular joint
•
Angle of union is termed venous
angle
Superior vena cava
•
Formed by union of right and left
brachiocephalic veins behind the
right sternocostal synchorndrosis
of first rib
•
Runs vertically down on right of
ascending aorta
•
Joined by azygos vein at level of
sternal angle
•
Enters right atrium at lever of
lower border of third right
sternocostal joint
•
Collects blood from veins of upper
half of body
Lymph nodes of the thoracic contents
• Pulmonary lymph nodes 肺淋巴结
lie in the angles of bifurcation of
branching lobar bronchi
• Bronchopulmonary hilar lymph
nodes 支气管肺门淋巴结
lie in the hilus of the lung
• Tracheobronchial lymph nodes
气管支气管淋巴结
situated above or below the
bifurcation of trachea
• Paratracheal lymph nodes
气管旁淋巴结
along each side of the trachea
• Anterior mediastinal lymph
node 纵隔前淋巴结
lies anterior to the large
blood vessels of thoracic
cavity and pericardium; the
efferents unite with those of
paratracheal lymph nodes, to
form the right and left
bronchomediastinal trunks 支
气管纵隔干. The left
bronchomediastinal trunk
terminates in thoracic duct,
and right in the right
lymphtic duct
• Posterior mediastinal lymph
nodes 纵隔后淋巴结
lie along the esophagus and
thoracic aorta
Thoracic duct 胸导管
• Begins in front of L1 as a dilated sac, the
cisterna chyli 乳糜池, which formed by
joining of left and right lumbar trunks and
intestinal trunk
• Enter thoracic cavity by passing through
the aortic hiatus of the diaphragm and
ascends along on the front of the vertebral
column, between thoracic aorta and azygos
vein
• Travels upward, veering to the left at the
level of T5
• At the roof of the neck, it turns laterally
and arches forwards and descends to enter
the left venous angle
• Just before termination, it receives the
left jugular, subclavian and
bronchomediastinal trunks
• Drains lymph from lower limbs, pelvic
cavity, abdominal cavity, left side of
thorax, and left side of the head, neck
and left upper limb
Right lymphatic duct 右淋巴导管
• Formed by union of right jugular,
subclavian, and bronchomediastinal
trunks
• Ends by entering the right venous angle
• Receives lymph from right half of head,
neck, thorax and right upper limb
Innervation of thorax
Phrenic nerve 膈神经
• Accompanied by
pericardiophrenic vessels and
passes anterior to lung roots
between mediastinal pleura and
pericardium to supply motor
and sensory innervation to
diaphragm
• Sensory fibers supply to
pleurae, pericardium and
peritoneum of diaphragm;
usually right phrenic nerve may
be distributed on live,
gallbladder and biliary system.
Left vagus nerve 左迷走神经
• Enter thoracic inlet between left
common carotid and left subclavian
arteries, posterior to left
brachiocephalic vein
• Crosses aortic arch where left
recurrent laryngeal nerve branches
off
• Passes posterior to left lung root
• Forms anterior esophageal plexus
• Forms anterior vagal trunk at
esophageal hiatus（食管裂孔） where
it leaves thorax and passes into
abdominal cavity , then divides into
anterior gastric and hepatic branches
Right vagus nerve 右迷走神经
• Enter thoracic inlet on right side of
trachea
• Travels downward posterior to right
brachiocephalic vein and superior vena
cava
• Passes posterior to right lung root
• Forms posterior esophageal plexus
• Forms posterior vagal trunk at
esophageal hiatus where it leaves
thorax and passes into abdominal
cavity, then divides into posterior
gastric and celiac branches
Recurrent laryngeal nerves
喉返神经
• Right one hooks around right
subclavian artery, left one hooks
aortic arch
• Both ascend in tracheo-esophageal
groove
• Nerves enter larynx posterior to
cricothyroid joint, the nerve is now
called inferior laryngeal nerve
• Innervations: laryngeal mucosa below
fissure of glottis , all laryngeal
laryngeal muscles except
cricothyroid
Bronchial and esophageal
branches
Thoracic sympathetic trunk
胸交感干
• Branches of sympathetic trunk to
thoracic plexuses
• Greater splanchnic nerve 内脏大神经
formed by preganglionic fibers from
T5~T9 ganglia, and relay in celiac
ganglion.
• Lesser splanchnic nerve 内脏小神经
formed by preganglionic fibers from
T10~T12 ganglia, and relay in
aorticorenal ganglion.
• The postganglionic fibers supply the
liver, spleen, kidney and alimentary
tract as far as the left colic flexure.
Ⅳ. Lungs
The hilum and root of the Lungs
②
①
③
右肺（前→后 ） ： V. A. B
②
③ ①
左肺（前→后 ） : V. A. B
The hilum and root of the Lungs
②
①
③
右肺（上→下 ） ： B.A.V.
②
③ ①
左肺（上→下 ） : A. B. V
Ⅴ. Mediastinum 纵隔
Mediastinum
1. Position and bounderies 位置及界限
2. Subdivisions and contents of mediastinum 分区及内容
3. Relationships 毗邻
4. Mediastinal spaces 纵隔间隙
1. The position and bounderies
－all of organs between
the left and right
mediastinal pleurae is
called mediastinum. It
extends from the
sternum in front to the
vertebral column behind,
and from the thoracic
inlet above to the
diaphragm below.
Left side of mediastnum
Right side of mediastnum
2. Subdivisions and contents of mediastinum
•
Superior mediastinum
上纵隔
•
Inferior mediastinum
下纵隔
– Anterior mediastinum
前纵隔
– Middle mediastinum
中纵隔
– Posterior mediastinum
后纵隔
Superior mediastinum 上纵隔
Location－from inlet of thorax to
plane extending from level of
sternal angle anteriorly to
lower border of T4 vertebra
posterioly
Contents
• Superficial layer
– Thymus
– Three veins
• Left brachiocephelic v.
• Right brachiocephelic v.
• Superior vena cava
• Middle layer
– Aotic arch and its
three branches
– Phrenic n.
– Vagus n.
• Posterior layer
– Trachea
– Esophagus
– Thoracic duct
Relations of aortic arch
• Anteriorly and to the left －
pleura, lung，phrenic n.,
pericardiacophrenic vessels and
vagus n.
• Posteriorly and to the right－
trachea, esophagus, left recurrent
n., thoracic duct, deep cardiac
plexus
• Superiorly－its three branches,
left brachiocephalic v. and thymus
• Inferiorly－pulmonary a., arterial
ligament, left recurrent n., left
principal bronchus and superficial
cardiac plexus
Inferior mediastinum 下纵隔
•
•
Anterior mediastinum
前纵隔
Location－posterior to
body of sternum and
attached costal cartilages,
anterior to heart and
pericardium
Contents－fat, remnants
of thymus gland, anterior
mediastinal lymph nodes
•
•
Middle mediastinum
中纵隔
Location－between
anterior mediastinum
and posterior
mediastinum
Contents: heart and
pericardium, beginning
or termination of great
vessels, phrenic nerves,
pericardiacophrenic
vessels and lymph
nodes
•
•
Posterior mediastinum
后纵隔
Location－posterior to
heart and pericardium,
anterior to vertebrae T5－
T12
Contents: esophagus, vagus
n., thoracic aorta, azygos
system of veins, thoracic
duct, thoracic sympathetic
trunk, posterior mediastinal
lymph nodes
3. Relationships
Left subclavian a.
Thoracic duct
Left vagus n.
Left recurrent n.
Phrenic n. &
pericardiacophrenic a.
Aortic arch
Thoracic aorta
Sympathetic trunk
Root of lung
Pericardium
Esophagus
Greater splanchnic n
Relationships of the root of left lungs
Trachea
Left vagus n.
Arch of azygos v.
Azygos v.
Sympathetic trunk
Esophagus
Superior vena cava
Phrenic n. &
pericardiacophrenic a.
Root of lung
Pericardium
Inferior vena cava
Relationships of the root of right lungs
以肺根为标志观察纵隔的毗邻
左
肺
根
右
肺
根
上方
主动脉弓(自前→后)
奇静脉弓(自后→前)
下方
肺韧带
肺韧带
后方 左迷走神经，胸主动脉
右迷走神经，奇静脉
右膈神经
前方
左膈神经
心包膈血管
心包膈血管
上腔静脉
右心房
部分心包
Relations of esophagus
• Anteriorly－trachea,
bifurcation of trachea, left
principal branchus, left
recurrent n., right pulmonary a.,
anterior esophageal plexus,
pericardium, left atrium,
diaphragm
• Posteriorly－posterior
esophageal plexus,
thoracic aorta, thoracic
duct, azygos v.,
hemiazygos v.,accessory
hemiazygos v., right
posterior intercostal v.
• Left－left common carotid a., left subclavian a., aortic
arch, thoracic aorta, superior part of thoracic duct
• Right－arch of azygos v.
Relations of thoracic aorta
• Anteriorly－left root of lung,
pericardium and esophagus
• Posterior－ hemiazygos v.,
accessory hemiazygos v.,
• Right－azygos v. and thoracic
duct
• Left－mediastinal pleura
4. Mediastinal spaces 纵隔间隙
• Retrosternal space 胸骨后间隙
－lies beween sternum and
endothoracic fascia
• Pretracheal space 气管前间隙
－lies within superior mediastinum,
between trachea, bifurcation of
trachea and aortic arch
• Retroesophagus space 食管后间隙
－ lies within superior
mediastinum, beween esophagus
and endothoracic fascia
思考题

试述肺根内结构由上而下，从前向后的排列。

上纵隔内由前向后有哪些结构？

分别试述左右肺根的毗邻。

试述纵隔境界与分区。、

试述食管前方的毗邻结构。

试述后纵隔内走行的结构。

试述膈肌中的裂孔与走行结构。

试述胸导管在上纵隔内经过的毗邻结构。

试述锁胸筋膜的构成及经过结构。