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  <head>
    <title>077-01 Thoracic wall, diaphragm, pleura, and surface anatomy</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Thoracic wall, diaphragm, and pleura">
      <outline text="Deformable protective cage">
        <outline text="Changes volume with every breath"/>
        <outline text="Wall, diaphragm, pleura as one mechanical system"/>
        <outline text="Landmarks shift with respiration, posture, age, disease"/>
      </outline>
      <outline text="Boundaries and apertures">
        <outline text="Vertebrae, ribs, cartilages, sternum, joints"/>
        <outline text="Superior aperture: T1, first ribs, manubrium">
          <outline text="Slopes down anteriorly"/>
          <outline text="Transmits trachea, oesophagus, vessels, nerves"/>
        </outline>
        <outline text="Crowded root of neck">
          <outline text="Artery and plexus pass between scalenes"/>
          <outline text="Vein anterior to anterior scalene"/>
          <outline text="Cervical rib or band can compress"/>
          <outline text="Narrowing alone is not outlet syndrome"/>
        </outline>
        <outline text="Inferior aperture closed by diaphragm"/>
        <outline text="Sternal angle at second costal cartilage">
          <outline text="Permits rib counting"/>
          <outline text="T4-T5 disc and mediastinal plane"/>
        </outline>
      </outline>
      <outline text="Ribs and articulations">
        <outline text="Head, neck, tubercle, angle, shaft, groove"/>
        <outline text="Head meets own and upper vertebra"/>
        <outline text="True ribs attach directly to sternum"/>
        <outline text="False ribs join cartilage above">
          <outline text="Form the costal margin"/>
        </outline>
        <outline text="Floating ribs lack anterior attachment"/>
        <outline text="Rib one grooved by subclavian vessels"/>
        <outline text="Movement patterns">
          <outline text="Pump handle raises anteroposterior diameter"/>
          <outline text="Bucket handle raises transverse diameter"/>
        </outline>
      </outline>
      <outline text="Intercostal spaces">
        <outline text="External, internal, innermost layers">
          <outline text="External inferoanterior, membrane anteriorly"/>
          <outline text="Internal inferoposterior, membrane posteriorly"/>
        </outline>
        <outline text="Bundle in costal groove: vein, artery, nerve">
          <outline text="Collaterals near upper border of rib below"/>
          <outline text="Procedures aim just above a rib"/>
        </outline>
        <outline text="Posterior arteries mostly from aorta"/>
        <outline text="Anterior arteries from internal thoracic"/>
        <outline text="Intercostal nerves T1 to T11, T12 subcostal">
          <outline text="Supply muscle, skin, parietal pleura"/>
          <outline text="T2 intercostobrachial explains referred pain"/>
        </outline>
      </outline>
      <outline text="Diaphragm as muscle and partition">
        <outline text="Sternal, costal, lumbar origins to central tendon"/>
        <outline text="Right dome higher because of liver"/>
        <outline text="Contraction lowers domes, raises abdominal pressure"/>
        <outline text="Breathing mechanics">
          <outline text="Quiet inspiration: more negative pleural pressure"/>
          <outline text="Forced inspiration: scalenes, sternocleidomastoid"/>
          <outline text="Quiet expiration is elastic recoil"/>
          <outline text="Forced expiration pushes diaphragm up"/>
        </outline>
        <outline text="Openings">
          <outline text="Caval opening T8 in central tendon"/>
          <outline text="Oesophageal hiatus T10 in right crus"/>
          <outline text="Aortic hiatus T12 with thoracic duct"/>
        </outline>
        <outline text="Phrenic C3 to C5 motor and central sensation">
          <outline text="Central irritation refers to shoulder"/>
          <outline text="Periphery via lower intercostal nerves"/>
        </outline>
        <outline text="Paralysis: paradoxical rise, less ventilation"/>
      </outline>
      <outline text="Pleura and recesses">
        <outline text="Visceral pleura reflects to parietal"/>
        <outline text="Potential space with lubricating film">
          <outline text="Negative pressure couples lung to wall"/>
        </outline>
        <outline text="Cervical pleura rises above first rib">
          <outline text="Neck injury or subclavian procedures enter"/>
        </outline>
        <outline text="Lung border ribs six, eight, ten">
          <outline text="Pleura about two ribs lower"/>
        </outline>
        <outline text="Costodiaphragmatic recess collects fluid"/>
        <outline text="Pain sensitivity">
          <outline text="Visceral pleura relatively insensitive"/>
          <outline text="Parietal pleura painful via intercostal, phrenic"/>
        </outline>
      </outline>
      <outline text="Breast and anterior wall">
        <outline text="Suspensory ligaments, retromammary plane"/>
        <outline text="Internal thoracic and lateral thoracic supply"/>
        <outline text="Lymph mainly to axillary nodes">
          <outline text="Oedema, retraction, fixation nonspecific alone"/>
        </outline>
        <outline text="Axillary nerves at surgical risk">
          <outline text="Long thoracic on serratus anterior"/>
          <outline text="Intercostobrachial numbness and pain"/>
        </outline>
      </outline>
      <outline text="Procedures and trauma">
        <outline text="Drains need pleural and organ limits"/>
        <outline text="Safe triangle for tube thoracostomy"/>
        <outline text="Rib fractures impair ventilation">
          <outline text="Upper ribs signal high energy"/>
          <outline text="Lower ribs: liver, spleen, kidney"/>
          <outline text="Flail failure reflects contusion and pain"/>
        </outline>
        <outline text="Pneumothorax separates pleural layers">
          <outline text="Tension impairs venous return, decompress now"/>
        </outline>
        <outline text="Blood, chyle, pus, effusion share the space"/>
        <outline text="Landmarks are a map, not certainty"/>
      </outline>
    </outline>
  </body>
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