- Thoracic Surgery
- STRUCTURE AND FUNCTION OF THE CHEST WALL AND LUNGS
- Anatomy of the Thorax: Because of the special functions of the heart and lungs, the chest cage provides two basic functions: 1. It protects the heart, great vessels, and lungs from damage. 2. Takes part in respiration with the diaphragm and the extrathoracic muscles.
- The sternum is a flat bone with three major parts: •Manubrium. •Body. •Xiphoid process.
- The manubrium located superiorly is the thickest component articulating with: •Clavicles •First and second ribs. A palpable suprasternal notch is found at the superior border of the manubrium.
- Body f the sternum, articulating laterally with ribs three to seven. •The sternal angle is the anterior angle formed by the junction of the manubrium and the body of the sternum. This easily palpated structure is in level with the second costal cartilage anteriorly and thoracic vertebrae T4 and T5 posteriorly.
- The most caudal aspect of the sternum is the xiphoid process, a plate of hyaline cartilage that ossifies later in life. •The sternal angle marks the level of bifurcation of the trachea into the right and left main stem bronchi and provides for the pump-handle action of the sternal body during inspiration.
- PE is a common congenital deformity of the anterior wall of the chest in which several ribs and the sternum grow abnormally resulting in the sunken appearance of the chest.
- It is present at birth but rapidly progresses during the years of bone growth in the early teenage years. •These patients have several pulmonary complications, including shortness of breath and often have cardiac complications caused by the restriction of the heart.
- To gain access to the thoracic cavity for surgery, including CABG, Valvular Cardiac Surgery, and Pediatric Surgery, the sternum is split in the median plane and retracted. This procedure is known as a median sternotomy. •The flexibility of the ribs and cartilage allows for the separation of the two ends of the sternum to expose the thoracic cavity.
- The ribs, although considered “flat” bones, curve forward and downward from their posterior vertebral attachments toward their costal cartilages. •Types of Ribs: •True ribs 1st to 7th ribs. •False ribs 8th, 9th, 10th ribs. •Floating ribs 11th, and 12th ribs.
- Each rib typically has a vertebral end separated from a sternal end by the body or shaft of the rib. •The head of the rib (at its vertebral end) is distinguished by a twin-faceted surface for articulation with the facets on the bodies of two adjacent thoracic vertebrae.
- The cranial facet is smaller than the caudal, and a crest between these permits attachment of the interarticular ligament. •Typical ribs three to nine, each with common characteristics, including a head, neck, tubercle, and body.
- The neck is the 1-inch long portion of the rib extending laterally from the head; it provides attachment for the anterior costotransverse ligament along its cranial border. •The tubercle at the junction of the neck and the body of the rib consists of an articular and a nonarticular portion. ØThe articular part of the tubercle (the more medial and inferior of the two) has a facet for articulation with the transverse process of the inferior-most vertebra to which the head is connected. ØThe nonarticular part of the tubercle provides attachment for the ligament of the tubercle.
- The shaft, or body, of the rib, is bent in two directions and twisted, presenting two surfaces (internal and external) and two borders (superior and inferior). •A costal groove for the intercostal vessels and nerve extends along the inferior border dorsally but changes to the internal surface at the angle of the rib. •The sternal end of the rib terminates in an oval depression into which the costal cartilage makes its attachment.
- Although rib fractures may occur in various locations, they are more common in the weakest area where the shaft of the ribs bends—the area just anterior to its angle. •The first rib does not usually fracture, as it is protected posteroinferiorly by the clavicle.
- When 1st rib is injured, the brachial plexus of nerves and subclavian vessel injury may occur.4 •Lower rib fractures may cause trauma to the diaphragm resulting in a diaphragmatic hernia.
- Rib fractures are extremely painful because of their profound nerve supply. It is important for all therapists to recommend breathing, analgesia, and coughing strategies for patients with rib fractures. •Paradoxical breathing patterns and a flail chest may also need to be evaluated in light of multiple rib fractures in adjacent ribs.
- Chest tubes are inserted above the ribs to avoid trauma to vessels and nerves found within the costal groove.
- A chest tube insertion involves the surgical placement of a hollow, flexible drainage tube into the chest. This tube is used to drain blood, air, or fluid around the lungs and effectively allow the lung to expand. The tube is placed between the ribs and into the space between the inner lining and the outer lining of the lung (pleural space).
- Tube Placement
- The 1st, 2nd, 10th, 11th, and 12th ribs are atypical ribs. •The 1st rib is the shortest and most curved of all the ribs. Its head is small and rounded and has only one facet for articulation with the body of the first thoracic vertebra. The sternal end of the first rib is larger and thicker than it is in any of the other ribs.
- The 2nd rib, although longer than the 1st, is similarly curved. The body is not twisted. There is a short costal groove on its internal surface posteriorly. •The 10th through 12th ribs each have only one articular facet on their heads. • The eleventh and twelfth ribs (floating ribs) have no necks or tubercles and are narrowed at their free anterior ends. •The twelfth rib sometimes is shorter than the first rib.
- Thank You
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