MPAS 504 Anatomy 2019 Thoracic Case Studies

Case 1:
A boy fell off his bicycle and hit the handlebars. He began complaining of right chest wall pain,
then suddenly developed trouble breathing. His condition quickly worsened, and he was taken to
the emergency department, where the diagnosis of flail chest was made, and arrangements were
made to send him to the OR for surgery. Prior to surgery, though, he developed respiratory
arrest, and needed an emergent needle decompression to release free air and allow his right lung
to reinflate.
Questions:
1. Where was the free air accumulating and why was it accumulating in that location? Please
answer based on the anatomy of the area.
Traumatic events such as a fall from a bicycle can cause multiple rib fractures. When this
happens, the stability of the anterior and possibly the lateral thoracic wall is compromised
causing paradoxical breathing.2 Fractured ribs can cause penetration through the thoracic wall or
surface of the lungs, disrupting the surface tension that exist between the visceral and parietal
pleura, resulting in a collapsed lung.2 The ribs and supporting internal and external intercostal
muscles make up the framework of the thoracic wall.2 Deep to these muscles, the thoracic wall is
lined with endothoracic fascia followed by an outer parietal layer, pleural cavity, and visceral
pleura of the lungs.2
Free air most likely accumulated in right pleural cavity due to the multiple rib fractures that are
responsible for causing a flail chest. Subcutaneous emphysema can also be present from trauma
in the chest wall due to a change in pressure gradient of the intra-alveolar and perivascular
interstitial space.18 In some cases, you can palpate the affected areas and may hear a crackling
sound of air in the tissue.
2. What caused the pneumothorax (air in the chest) and why did the trauma result in a
pneumothorax?
The thoracic cavity is lined with two kinds of pleura, the visceral (which adheres to the lungs)
and the parietal (which adheres to the chest wall).2 Between the layers is a pleural space which
has a negative pressure of -5 mm Hg.2 This pressure allows the visceral pleura to “adhere” to the
parietal pleura.16,17 When one of the pleural layers is disrupted, there is a loss of the normal
negative pressure in the pleural space and the affected lung collapses.16,17
Flail chest can progress to a life-threatening tension pneumothorax and because the patient had
an emergent needle decompression procedure performed it is possible that a fractured rib
punctured the pleura. A tension pneumothorax develops when a one-way valve air leak occurs
from either the lung or chest wall.19 Air enters but does not exit the pleural space, causing
increased intrapleural pressure, collapse of the lung, and shift of the mediastinal contents to the
contralateral side.19 If untreated, the patient will die.
MPAS 504 Anatomy 2019 Thoracic Case Studies

3. If a thoracostomy (chest) tube needs to be inserted to keep the lung inflated, should it be
placed over or under a rib, and at what level would it be placed to avoid trauma to the lung?
Why?
When a chest tube is emergently placed to keep the lung inflated and restore negative pressure in
the pleural space, it is vital that the practitioner places the tube over the rib.11 Typically, a small
incision is made with a scalpel in the 4th or 5th intercostal space at the midaxillary line.2 The
practitioner aims to place the tube in the “safe triangle” region consisting of the anterior border
of the latissimus dorsi, lateral border of pectoralis major, and the line superior to the nipple and
apex below the axilla.9,11
The chest tube is then placed over the superior aspect of the rib to avoid injuring the
neurovascular bundle which contains veins, arteries, and nerves in their respective order.2,14 This
neurovascular bundle runs inferior to the rib.2 Blunt dissection technique is preferred over the
trochar technique of chest tube insertion, as this method increases the risk of traumatizing the
lung.15 To avoid trauma to the lung, the chest tube should be inserted laterally at the 5th or 6th
intercostal space and enter the chest near the oblique fissure.15 If the chest tube is directed
centrally, it could possibly enter the fissure, traumatize the visceral pleura of the lung or cause a
pulmonary contusion.15

4. What are the thoracic wall muscle layers a surgeon would need to cut through to access the
right lower lobe of the lung in the midaxillary line? Would those layers differ if the incision was
anterior, in the midclavicular line, and if so, why?
To access the right lower lobe of the lung in the midaxillary line, a thoracic surgeon would need
to precisely cut through many layers of muscle. The midaxillary line is situated at the middle of
the axilla along the lateral border of the thoracic wall.10 A standard posterolateral midaxillary
thoracotomy transects the latissimus dorsi. The serratus anterior is in a deeper plane, and it is
divided as low as possible to minimize denervation. Some surgeons try to spare this muscle.12
In this same plane, posteriorly, is a small portion of the trapezius or superiorly, the rhomboid
muscles may have to be divided for additional exposure. The pleural cavity is entered after
dividing the intercostal muscles.12 An anterolateral or midclavicular thoracotomy transects the
pectoralis major, pectoralis minor, external and internal intercostal muscles, and the medial edge
of the serratus anterior.13 One reason for choosing to make an incision at the midclavicular line is
if the surgeon is performing a video-assisted thoracic surgery (VATS).20
Case 2:
A middle-aged patient presented to the provider’s office complaining of squeezing pain in the
mid-chest, radiating to the left shoulder, and shortness of breath. The provider immediately
obtained an ECG (electrical tracing of the heart), gave the patient nitroglycerin and aspirin, and
arranged for transport to the emergency room. The provider informed the emergency personnel
that the patient was most likely experiencing an “anterior” myocardial infarction (heart attack)
based on the ECG and classic presentation.
MPAS 504 Anatomy 2019 Thoracic Case Studies

Questions:
1. Based on your knowledge of anatomy, what branch of what coronary artery is most likely
affected by blockage in an “anterior” myocardial infarction?
A myocardial infarction can occur if one or more of the three coronary arteries supplying the
heart with oxygen blood becomes occluded.1 The provider most likely came to the conclusion of
an “anterior” MI due to classic ECG findings of elevation in anterior leads V3 and V4, creating a
tombstone appearance.1 The most common site of coronary artery occlusion in myocardial
infarctions occurs 40-50% of the time at the anterior interventricular branch (LAD) of the left
coronary artery (LCA).2 The anterior interventricular branch of LCA passes along the anterior IV
groove to apex of the heart and in some cases can give rise to a lateral branch(diagonal artery).2
An occlusion in the LAD is significant since it supplies oxygen rich blood to the anterior region
of the left ventricle.3 Additionally, the LAD supplies the anterolateral portion of the
myocardium, apex, anterior interventricular septum, and the anterolateral papillary muscles.3
Another significant outcome of LAD occlusion is damage to the conducting system of the heart
since the LAD contains septal branches that supply the AV bundle.2 This could lead to a massive
heart block if the patient survives the initial stages of an MI, leading to a slowed heart rate of 25-
30 times a minute.2

2. What part of the heart would be affected by a major blockage of this artery? Why?
The anterior interventricular branch (LAD) artery and the lateral branch (diagonal artery) supply
most of the interventricular (IV) septum; the anterior, lateral, and apical wall of the left ventricle,
the anterior papillary muscle of the bicuspid valve (left ventricle), and most of the left and right
bundle branches.2,8 The LAD also provides collateral circulation to the posterior descending
artery, the anterior right ventricle, and the posterior part of the IV septum.8
Since the LAD is a major blood supply to the IV septum and thus bundle branches of the
conducting system, a blockage can lead to impairment or infarction of the conducting system.8
The result would be a block of the impulse conduction between the atria and ventricles, known
as left and right bundle branch block.8 A reduction in blood supply can lead to death of
myocardial tissue and subsequent death to a patient suffering from a blocked LAD.2

3. What type of study could be performed to determine exactly where the blockage was located?
What information does such a study provide and how is it performed? Why is it considered the
“best” study to determine the location of an arterial blockage in the heart?
Since the coronary arteries supply the heart with oxygen rich blood, it is imperative for
cardiologist to quickly find out where a blockage is located so that appropriate therapy can be
instituted. With use of conventional coronary angiography, there is a special test called a
coronary angiogram which uses fluoroscopy to find the extent of blockage and precise location
of blockage in the coronary artery.2,5 Generally, coronary angiogram studies are used in
MPAS 504 Anatomy 2019 Thoracic Case Studies

conjunction with cardiac catheterization to help diagnose coronary blockage and unclog arteries
by way of angioplasty.6
A coronary angiogram is performed by insertion of a long, narrow catheter inserted into the
femoral artery in the inguinal area and is then guided to the ascending aorta.2 The cardiologist
then guides the tip of the catheter using fluoroscopy so that the catheter can be placed in the
opening of the coronary artery.2 Once the catheter is in the precise location radiopaque contrast is
injected and various pictures are taken to show the inside of the artery, branches, narrowed or
blocked areas.2 Coronary angiogram is currently considered best-practice because of it’s ability
to provide detailed anatomy of the artery to pinpoint the precise location of an arterial blockage
in the heart.7

4. What anatomic reason might cause the chest pain to radiate to the patient’s left shoulder?
Why?
Chest pain that radiates to a patient’s left shoulder can be referred to as cardiac referred pain.2
Cardiac referred pain while not fully understood, proposes that noxious stimuli arising from the
heart are perceived as pain from external parts of the body such as the shoulder and limbs.2
When chest pain radiates from substernal and left pectoral area of the left shoulder and medial
aspect of left upper limb it is called anginal pain.2 The left shoulder is innervated by the medial
cutaneous nerve which can sometimes overlap in distribution with the 2nd and 3rd intercostal
nerves.2 Because spinal cord segments of the cutaneous nerves (T1-T3) are common to visceral
afferent termination of the coronary arteries, cardiac pain can be referred to the upper limb.2
Visceral pain is most often considered referred pain since it occurs in remote cutaneous areas.4
Since the heart is supplied by sympathetic fibers, visceral pain can be felt in the shoulder region
by a person experiencing an MI.4 Dermatomes of the somatic sensory fibers in the shoulder
region are situated at the same spinal cord segments as the fibers coming from the heart.4
MPAS 504 Anatomy 2019 Thoracic Case Studies

References
1) Moore KL, Agur AMR, Dalley AF. Clinically Oriented Anatomy. 8th ed. Philadelphia,
PA: Wolters Kluwer; 2018.
2) McCaslin L, Stearley S. Chest Trauma. In: Stone C, Humphries RL. eds. CURRENT
Diagnosis & Treatment: Emergency Medicine, 8e New York, NY: McGraw-Hill;.
http://accessmedicine.mhmedical.com.ezproxy.gardner-
webb.edu/content.aspx?bookid=2172&sectionid=165061181.
3) Nicks BA, Manthey D. Pneumothorax. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM,
Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study
Guide, 8e New York, NY: McGraw-Hill; 2016.
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webb.edu/content.aspx?bookid=1658&sectionid=109429615
4) Porhomayon J, Doerr R. Pneumothorax and subcutaneous emphysema secondary to blunt
chest injury. Int J Emerg Med. 2011;4:10. Published 2011 Mar 21. doi:10.1186/1865-
1380-4-10
5) Cai K, Yan Y, Feng S, et al. Unidirectionally progressive resection of lower left lung
carcinoma under video-associated thoracoscopy. J Thorac Dis. 2015;7(12):2371-5.
6) Chapter 2. Anterior Thoracic Wall. In: Morton DA, Foreman K, Albertine KH. eds. The
Big Picture: Gross Anatomy New York, NY: McGraw-Hill; 2011.
http://accessmedicine.mhmedical.com/content.aspx?bookid=381&sectionid=40140008.
Accessed January 31, 2019.
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thoracotomy without muscle division: a new approach to complex procedures. Interact
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Gross Anatomy, 2e New York, NY: McGraw-Hill; .
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12) Ravi C, McKnight CL. Chest Tube. [Updated 2018 Nov 11]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK459199/
MPAS 504 Anatomy 2019 Thoracic Case Studies

13) Topic Reviews. Healio. https://www.healio.com/cardiology/learn-the-heart/cardiology-

review/topic-reviews/anterior-myocardial-infarction. Accessed January 26, 2019.
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2e New York, NY: McGraw-Hill; .
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webb.edu/content.aspx?bookid=2478&sectionid=202020274. Accessed January 26,
2019.
15) Kern MJ, Seto AH. CARDIAC CATHETERIZATION, CARDIAC ANGIOGRAPHY,
AND CORONARY BLOOD FLOW AND PRESSURE MEASUREMENTS. In: Fuster
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16) What Is a Coronary Angiogram? ANSWERS by heart. https://www.heart.org/-
/media/data-import/downloadables/pe-abh-what-is-a-coronary-angiogram-
ucm_300436.pdf. Published 2015. Accessed January 28, 2019.
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procedures/coronary-angiogram/about/pac-20384904. Published March 24, 2018.
Accessed January 29, 2019.
18) Leopold JA, Faxon DP. Diagnostic Cardiac Catheterization and Coronary Angiography.
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Principles of Internal Medicine, 20e New York, NY: McGraw-Hill; .
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webb.edu/content.aspx?bookid=2129&sectionid=188731162. Accessed January 29,
2019.
19) Jaffar A. Anatomical Structure of the Heart. In: Elmoselhi A. eds. Cardiology: An
Integrated Approach New York, NY: McGraw-Hill; .
http://accessmedicine.mhmedical.com.ezproxy.gardner-
webb.edu/content.aspx?bookid=2224&sectionid=171659604. Accessed January 26,
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