Transcript - Nottingham SCRUBS

Surface anatomy,
lung markings and
pleural reflections
BY ALEX
Learning outcomes
Explain lymphatic drainage of the breast and its
importance in the spread of cancer.
Describe the surface markings of the lungs and
pleural reflections.
Identify important surface landmarks on the anterior
thoracic wall and use the sternal angle (of Louis) to
accurately number the ribs on a living subject
1: Surface anatomy of the
breast
The breast overlies the 2nd-6th Ribs
Overlying pectoralis major and serratus anterior
It contains ~20 lactiferous ducts opening into nipple
Nipple is located at the 4th ICS – In males and varies in females
Areola = Pigmented area around nipple
Deep cervical nodes
Supraclavicular nodes
Infraclavicular nodes
Lymph drainage of
the breast
Major sites of drainage:
Central axillary nodes
1. Axillary nodes - 75% (lateral esp)
2. Parasternal nodes - 20% (medial)
Subscapular
axillary
nodes
Anterior axillary
nodes
3. Abdominal nodes - 5% (inferior)
Lymph from axillary nodes drains to
infra/supraclavicular nodes
Lymph drainage
continued…
7 main Lymph drainage sites :
1.
Apical Axillary LN*
2.
Central Axillary LN*
3.
Lateral Axillary LN*
4.
Pectoral Axillary LN *
5.
Supra/infra Clavicular LN
6.
Parasternal Nodes LN
7.
Abdominal LN
Breast vasculature
Medial mammary branches of anterior
intercostal branches of the internal thoracic
artery
Lateral thoracic branches of axillary artery
Thoraco-acromial branches of axillary artery
Posterior intercostal arteries from the thoracic
aorta
Clinical
WHY
DO relevance:
I HAVE TO breast
LEARNcancer
ABOUT LYMPH?
Cancer of the breast can undergo
metastasis
Usually start in the lacteriferous
ducts*
First site of metastasis is auxiliary
nodes (most common drainage)
Palpation used for early detection
of metastasis
2: The pleura
 Parietal Pleura = Adheres to the Internal thoracic wall
 Visceral Pleura = Attached to the lungs
In between is the pleural space filled with serous fluid, this:
Reduces friction
Gives surface tension to push parietal pleura against thoracic
wall
Parts of the Pleura
4 Parts:
1.
Cervical pleura - extends superior to thoracic inlet
into the root of the neck
2.
Costal part - covers the internal surface of thoracic
wall and is separated from wall by endothoracic
fascia
3.
Mediastinal part - lateral aspects of mediastinum
4.
Diaphragmatic part - superior surface of diaphragm
The 3 Pleural reflections
Pleural Reflections = Pleural folds / change in direction of pleura – 1 Anterior, 1
Posterior and 1 Inferior
◦
Sternal line – Costal Pleura continuous with mediastinal pleura Anteriorly
◦
Costal line – Costal pleura continuous with diaphragmatic pleura Inferiorly
◦
Vertebral line – Costal pleura becomes continuous with mediastinal pleura
Posteriorly
Parietal and visceral pleura
markings
Visceral pleura:
Parietal pleura:
2, 4, 6, 8, 10
2, 4, 6, 8, 10, 12
Together cc2-4
Together cc2-4
Cardiac notch to cc6
Cardiac notch to cc6
Midaxillary cc8
Midclavicular cc8
Rib 10 posteriorly
Midaxillary cc10
Rib 12 posteriorly
3: Surface markings, planes
3 Anterior Planes
• Median Plane
• 2x Midclavicular Plane
3 Anterolateral Planes
• Anterior Axillary Plane
• Midaxillary Plane
• Posterior Axillary Plane
Other key surface lines
T2
T4/5
T9
Surface markings
Thoracic Dermatomes
Nipple - T4
Xiphoid - T7
Umbilical – T10
Suprapubic – L1
Clinical relevance: pleural
effusion
’Water on the lungs’
Excess fluid that accumulates in the pleural cavity
Can impair breathing by limiting the expansion of the lungs
Key types are:
 Hydrothorax (serous fluid)
 Hemothorax (blood)
 Chylothorax (chyle)
Quiz Time!
1) The lymph of the breast drains mainly to the abdomen
False – Mainly axillary nodes!
2) The visceral pleura attaches firmly to the internal thoracic wall
False – Its attachment is the surface of the lungs!
3) The Sternal angle lies at the level T4/5 vertebrae
True – This is a core fact to remember!
4) The visceral pleura crosses midaxillary line at T8
True – Remember that all the levels for this are even numbers!
Summary
The breast is lies over the 2nd to 6th ribs
Breast lymph drainage is Axillary (75%), Parasternal and
abdominal
There are 2 layers to the pleura- parietal and visceral
The reflections of the pleura are: Costal, Vertebral and Sternal
lines
There are 4 parts to the pleura which are named after
anatomically related structures
Thanks for listening
If you have any questions…
Email me: [email protected]
Otherwise Good Luck this week!
Sources:
Moore and Agur- Essential Clinical Anatomy 5th edition
Grays Anatomy for Students 3rd edition
teachmeanatomy.info