HUMAN ANATOMY

First Year MBBS

Note: Underlined and bold

words are important and
often asked by teachers in
vivas. Some frequently
asked questions are also
mentioned here.

These are maximum clinicals

of Thorax put together from
different books and internet
by Umer Shehroz Khan
(Kemcolian)

Cell no: 0312 7924934

Thorax:
Bones and Joints:
 Cervical rib:
A cervical rib is an extra rib that forms above the first rib, growing from the base of the neck just
above the collarbone. A cervical rib occurs in 0.5% people. It's not usually a problem, but if it
presses on nearby nerves and blood vessels, it can cause neck pain, numbness in the
arm and other symptoms. This is known as thoracic outlet syndrome.
 Rib fractures:
 The most common ribs fractured are the 7th to 10th ribs.

 The commonest site of fracture is just anterior to the angle of ribs.

 Fracture of the first rib may injure the brachial plexus and subclavian vessels.

 The middle ribs are most commonly fractured and usually result from direct blows or crushing
injuries. The broken ends of ribs may cause pneumothorax and lung or spleen injury.

 Lower rib fractures may tear the diaphragm, resulting in a diaphragmatic hernia.

Sternum:
 The sternum is a common site for bone marrow biopsy because it possesses
hematopoietic marrow throughout life. Needle pierce thin cortical bone, & enters
spongy bone. It is done in its upper half to avoid the injury to the arch of aorta which
lies behind its lower half.

 Fracture of sternum is usually comminuted fracture (a break resulting in several pieces).

 Pectus carinatum (pigeon chest):

Pectus carinatum is a condition in which the sternum (breastbone) protrudes, or sticks out, more
than usual with flattening of the chest wall. It is believed to be a disorder of the cartilage that
joins the ribs to the breastbone.

 Pectus excavatum (funnel chest):

Pectus excavatum is a condition in which a person's breastbone is depressed or sunken into his
chest. This condition can interfere with the function of the heart and lungs.

Funnel chest Pigeon chest

 Median sternotomy:
Sternum is split in the median plane & retracted (because of flexibility of ribs & cartilages) to
allow the surgeon to gain easy access for coronary artery bypass grafting & removal of tumors
from lungs.

 Ectopia cordis:
It is an extremely rare condition in which babies are born with their hearts partially or fully
outside their chests. It is because halves of sternum may not fuse together which results in
complete sternal cleft through which heart may protrude.

 Incomplete fusion of sternal halves leads to formation of sternal foramen (perforation) and
bifid xiphoid process.

Vertebral column:
 Scoliosis is abnormal lateral curvature of vertebral column.

 Kyphosis is abnormal humped back appearance of vertebral column.

 Spina bifida:
It is a birth defect that occurs when the spine and spinal cord doesn't form properly. It's a type
of neural tube defect. The two halves of neural arch may fail to fuse leaving a gap in the midline
of the vertebral column. This is called spina bifida. Meninges and spinal cord may herniate out
through the gap.
 Hemivertebra:
It is a rare congenital spinal malformation, where only one side of the vertebral body develops,
resulting in deformation of the spine, such as scoliosis, lordosis, or kyphosis.

 Disc prolapse:
When an intervertebral disc is subjected to strain, the annulus fibrosus may rupture leading to
prolapse of the nucleus pulposus. This is commonly referred to as disc prolapse. It may occur
even after a minor strain. In addition to prolapse of the nucleus pulposus, internal derangements
of the disc may also take place.
Site: Disc prolapse is usually posterolateral.
Disc prolapse occurs most frequently in the
lower lumbar region. It is also common in the
lower cervical region from fifth to seventh
cervical vertebrae.
Effects: The prolapsed nucleus pulposus
presses upon adjacent nerve roots and gives
rise to pain that radiates along the distribution
of the nerve. Such pain along the course of the
sciatic nerve is called sciatica. Motor effects,
with loss of power and reflexes, may follow.

Thoracic wall:
 The chest wall of the child is highly elastic, and fractures of the ribs are rare. In adults, the
ribs may be fractured by direct or indirect violence. In indirect violence, like crush injury, the
rib fractures at its weakest point located at the angle. The upper two ribs which are protected
by the clavicle, and the lower two ribs which are free to swing are least commonly injured.

 Intercostal spaces are 11 on the back and only 9 in front of chest.

 Intercostal muscles are in 3 layers, external, internal and transversus. These correspond to
the muscle layers of anterior abdominal wall.

 Neurovascular bundle lies in the upper part of the intercostal space in between internal and
inner most intercostal muscles.

 Right posterior intercostal arteries are longer than the left ones.
 Thoracic outlet Syndrome:
Two structures pass through thoracic outlet (space between clavicle & 1st rib): the subclavian
artery and first thoracic nerve (lower trunk of brachial plexus i.e. C8 & T1). These structures
may be pulled or pressed by

1) cervical rib which is abnormal rib.

2) variations in the insertion of the scalenus anterior & middle.

Compression of lower trunk

causes sensory loss across medial
border of forearm & wasting of
intrinsic muscles of hand.
Whereas, compression of
subclavian artery causes ischemic
muscle pain in upper limb.

 Notching of ribs:

In coarctation or narrowing of aorta, posterior intercostal arteries get enlarged greatly to

provide a collateral circulation. Pressure of enlarged arteries produce characteristic
notching on ribs especially in their posterior parts.
 Hiccups:
These are spasmodic involuntary sharp contraction of diaphragm accompanied by closed
glottis. It is common in normal individuals and occurs after eating or drinking as a result of
gastric irritation of the vagus nerve endings. Its causes are:

1. gastric irritation

2. phrenic nerve irritation

3. uraemia

4. peritonitis.

It can be stopped by sectioning phrenic nerve.

 2nd costal cartilage at the manubriosternal angle is extremely important landmark. The 2 nd
intercostal space lies below this cartilage and is used for counting the intercostal spaces for
the position of heart, lungs and liver.

 1-7 ribs with costal cartilages reach the sternum, costal cartilages of 8-10 ribs form the costal
margin, while 11th and 12th ribs do not reach the front at all.

 Apex beat lies below and to the normally placed left nipple

 Chest pain results from:

1)cardiac disease. 2)pulmonary disease. 3)intestinal, gallbladder & musculoskeletal disorders.

 Irritation of the intercostal nerves causes severe pain which is referred to the front of the
chest or abdomen, i.e. at the peripheral termination of the nerve. This is known as root pain
or girdle pain.

 Herpes virus may cause infection of intercostal nerves. If herpes infection is in 2nd thoracic
nerve, there is referred pain via intercostobrachial nerve to the medial side of arm.

 Pus from the vertebral column tends to track around the thorax along the course of the
neurovascular bundle, and may point at any of the three sites of exit of the branches of a
thoracic nerve; one dorsal primary ramus and two cutaneous branches.

 superior vena caval obstruction

 When the superior vena cava is obstructed before the opening of the azygos vein, the venous
blood of the upper half of the body is returned through the azygos vein; and the superficial
veins are dilated on the chest up to the costal margin. The pathway of blood is shown below
 oveaz
Ria l

Site of
clot
Vena
azygos

Superior Vena
cava
Superior vena cava blockage before the opening of azygos vein

 When the superior vena cava is obstructed after the opening of the azygos veins, the blood
is returned through the inferior vena cava via the femoral vein; The superficial vein
connecting the lateral thoracic vein with the superficial epigastric vein is known as the
thoracoepigastric vein.

Superior vena cava blockage after the opening of vena azygos

Q. To which area cardiac pain is referred and why?
A. Cardiac pain is an ischemic pain caused by incomplete obstruction of a coronary artery. Axons
of pain fibers conveyed by the sensory sympathetic cardiac nerves reach thoracic one to thoracic
five segments of spinal cord mostly through the dorsal root ganglia of the left side. Since these
dorsal root ganglia also receive sensory impulses from the medial side of arm, forearm and upper
part of front of chest, the pain gets referred to these areas. Though the pain is usually referred
to the left side, it may even be referred to right arm, jaw, epigastrium or back.

 Paradoxical respiration:
In paradoxical breathing, the diaphragm moves upward rather than downward when you inhale,
and the lungs can't expand as much. This prevents you from inhaling enough oxygen, which is
important for many bodily functions. It also makes it difficult to exhale carbon dioxide. It results
from 2 cases.
1. Flail chest is a loss of stability of
the thoracic cage that occurs because
of multiple rib fractures which allows
segment of anterior & lateral thoracic
wall to move freely, allowing the
loose segment to move inward on
inspiration and outward on
expiration. Flail chest is an extremely
painful injury and impairs ventilation,
thereby affecting oxygenation of the
blood and causing respiratory failure.
2. Injury of the phrenic nerve produce complete paralysis of the corresponding half of the
diaphragm. It results in paradoxical movements i.e. paralyzed half ascends during inspiration
& descends during expiration.

 Intercostal Nerve Block:

Anesthesia of intercostal space is produced by injecting anaesthetic agent around intercostal
nerve between paravertebral line & area of required anaesthesia (anterior and lateral thoracic
and abdominal walls,). The intercostal nerve should be blocked before the lateral cutaneous
branch arises at the midaxillary line. Intercostal nerve block is indicated for repair of lacerations
of the thoracic and abdominal walls, for relief of pain in rib fractures, and to allow pain-free
respiratory movements. Nerve endings & impulses carrying information of pain from required
area are blocked. Pneumothorax & hemorrhage are complications after this procedure.
 Thoracotomy:
Surgical creation of opening in thoracic cavity to enter pleural cavity is called Thoracotomy. 5th-
7th intercostal spaces are important sites for posterior thoracotomy. A lateral approach is made
with patient lying on contralateral side, upper limb is abducted placing forearm beside patient's
head. The following tissues will be incised:
(a) skin, (b) subcutaneous tissue, (c) serratus anterior and pectoral muscles, (d) external
intercostal muscle and anterior intercostal membrane, (e) internal intercostal muscle, (f)
innermost intercostal muscle, (g) endothoracic fascia, and (h) parietal pleura.

Diaphragm:

 In dyspnoea or difficulty in breathing, the patients are most comfortable on sitting up, leaning
forwards and fixing the arms. In the sitting posture, the position of diaphragm is lowest
allowing maximum ventilation. Fixation of the arms fixes the scapulae, so that the serratus
anterior and pectoralis minor may act on the ribs to good advantage.

 The height of the diaphragm in the thorax is variable according to the position of the body
and tone of the abdominal muscles. It is highest on lying supine, so the patient is extremely
uncomfortable, as he/she needs to exert immensely for inspiration. The diaphragm is lowest
while sitting. The patient is quite comfortable as the effort required for inspiration is the least.

 The diaphragm is midway in position while standing, but the patient is too ill or exhausted to
stand. So dyspnoeic patients feel comfortable while sitting

 Most prominent role in respiration is played by diaphragm.

 Thoracic Cavity, Pleura and Lungs:

 Pleura is most commonly injured at following places due to unprotected location

1. Cervical pleura & apex which causes pneumothorax.

2. Right part of infrasternal angle.

3. Right & left costovertebral angles.

 Pleurisy:
It is a condition in which the pleura gets inflamed. It is also called pleuritis, it causes sharp chest
pain (pleuritic pain) that worsens during breathing. Symptoms of pleurisy might include: Chest
pain, cough or sneeze, Shortness of breath and fever. It may be dry, but often it is accompanied
by collection of fluid in the pleural cavity. The condition is called the pleural effusion. Dry pleurisy
is more painful because during inspiration both layers come in contact and there is friction.

 Pleurectomy:
It is a type of surgery in which part of the pleura is removed. This procedure helps to prevent
fluid from collecting in the affected area and is used for the treatment of mesothelioma, a
pleural mesothelial cancer.

 Pleurodesis:
Pleurodesis is a procedure which involves putting a mildly irritant drug into the space between
lung and chest wall (the pleural space), on one side of your chest. This is done to try to 'stick' lung
to the wall of your chest and prevent a further collection of fluid or air in this space.
 Thoracoscopy:
It is a diagnostic & therapeutic procedure in which pleural cavity is examined with a thoracoscope.

 Hemoptysis:
It is the spitting of blood that originated in the lungs or bronchial tubes. Its causes include: Blood
clot in the lung, Pulmonary aspiration (breathing blood into the lungs), Lung cancer, Excessive,
Pneumonia, Tuberculosis, Pulmonary embolism (blockage of an artery in your lungs).

 Respiration occurs in two phases

Inspiration-active phase of 1 second.
Expiration-passive phase of 3 second.

 In young children (up to 2yr of age), the thoracic cavity is almost circular in cross-section so
the scope for anteroposterior or side to side expansion is limited. The type of respiration in
children is abdominal.

 In women of advanced stage of pregnancy, descent of diaphragm is limited, so the type of

respiration in them is mainly thoracic.

 Pleural effusion:
It is an abnormal accumulation of excess fluid in the pleural space.
There are two types of pleural effusion:

1. Transudate (clear watery fluid):

A transudate is caused by congestive heart failure or, less commonly, liver or kidney disease.
2. Exudate (cloudy viscous fluid):
An exudate is caused by inflammation, pneumonia, lung cancer, TB, asbestosis, or pulmonary
embolism. Symptoms include shortness of breath, chest pain, and cough. It can be treated by
removing fluid by thoracentesis.
 Paracentesis thoracis:
Aspiration of any fluid from the pleural cavity is called paracentesis thoracis. It is usually done in
the eighth intercostal space in the midaxillary line. The needle is passed through the lower part
of the space to avoid injury to the principal neurovascular bundle, i.e. vein, artery and nerve
(VAN).

 Pneumothorax: Presence of air in the pleural cavity. Its causes are

1) wound of parietal pleura from bullet. 2)Rupture of pulmonary lesion into pleural cavity.
3) Fractured ribs.

 Haemothorax: Presence of blood in the pleural cavity. It results from

1) injury to intercostal or internal thoracic vessel. 2)lung laceration.

 Hydrothorax: Fluid accumulation in pleural cavity resulting from pleural effusion.

 Hydropneumothorax: Presence of both fluid and air in the pleural cavity.

 Empyema: Presence of pus in pleural cavity.

 Referred pain:
Costal and peripheral parts of diaphragmatic pleurae are innervated by intercostal nerves. Hence
irritation of these regions cause referred pain along intercostal nerves to thoracic or abdominal
wall. Mediastinal and central part of diaphragmatic pleurae are innervated by phrenic nerve (C4).
Hence irritation here causes referred pain on tip of shoulders.

 Pain on right shoulder occurs due to inflammation of gallbladder, while on left shoulder is
due to splenic rupture.

 Bronchopulmonary segments are independent functional units of lung.

 Bronchoscopy:
Visualizing the interior of the bronchi through an instrument passed through the mouth and
trachea. The instrument is called a bronchoscope and the procedure is called bronchoscopy.

 Carina is the area where trachea divides into two primary bronchi. Right bronchus makes an
angle of 25', while left one makes an angle of 45'. Foreign bodies mostly descend into right
bronchus as it is wider and more vertical than the left bronchus.

 Postural drainage:
Carina (Latin keel) of the trachea is a sensitive area. When patient is made to lie on her/his left
side, secretions from right bronchial tree flow towards the carina due to effect of gravity. This
stimulates the cough reflex and sputum is brought out. This is called postural drainage.

 Atelectasis:
It is the term for a collapse of one or more areas in the lung. It may be caused by surgery, chest
pressure, blocked airways, and other lung conditions like lung cancer, pneumonia, pleural
effusions and respiratory distress syndrome (RDS).

 Tuberculosis:
Tuberculosis (TB) is caused by a bacterium called Mycobacterium tuberculosis and is
characterized by the formation of tubercles that can undergo caseous necrosis.

 Bronchial asthma is a common disease of respiratory system. It occurs due to bronchospasm

of smooth muscles in the wall of bronchioles. Patient has difficulty especially during
expiration. It is accompanied by wheezing. Epinephrine, a sympathomimetic drug, relieves
the symptoms.
 Chronic bronchitis:
It is a long-term inflammation of the bronchi. It is common among smokers. People with chronic
bronchitis tend to get lung infections more easily. It results in excessive mucus production that
plugs up the airways, causing a cough and breathing difficulty.

 Emphysema:
It is a condition that involves damage to the walls of the air sacs (alveoli) of the lung as a result
of which the total surface area of lungs for gaseous exchange decreases.

 Pneumonia (pneumonitis):
It is an inflammation of the lungs, which is of bacterial and viral origin. Symptoms are usually
cough, fever, sputum production, chest pain, and dyspnea.

 Pulmonary embolism (pulmonary thromboembolism):

It is an obstruction of the pulmonary artery by an embolus, which arises in the deep veins of the
lower limbs or in the pelvic veins. Symptoms may be sudden onset of dyspnea, anxiety, and
substernal chest pain

 Auscultation of lung:
 Upper lobe is auscultated above 4th rib on both sides

 lower lobes are best heard on the back.

 Middle lobe is auscultated between 4th and 6th ribs on right side.

 Percussion:
It is tapping on fingers pressed firmly on thoracic wall over lungs to detect sounds in lungs
which establishes whether underlying fissures are air filled (resonant sound), fluid filled (dull
sound) or solid (flat sound).

Q. Which bronchopulmonary segment of lungs is most dependent one?

A. Apical segment of lower lobe is the most dependent bronchopulmonary segment in supine
position. Foreign bodies are likely to be lodged here.
 Mediastinum:

 Mediastinitis:
Mediastinitis is swelling and irritation (inflammation) of the mediastinum i.e. chest area between
the lungs. This area contains the heart, large blood vessels, windpipe (trachea), food tube
(esophagus), thymus gland, lymph nodes, and connective tissue. Due to mediastinitis, these
structures get compressed.

 The prevertebral layer of the deep cervical fascia extends to the superior mediastinum, and
is attached to the fourth thoracic vertebra. An infection present in the neck behind this fascia
can pass down into the superior mediastinum but not lower down.

 The pretracheal fascia of the neck also extends to the superior mediastinum, where it blends
with the arch of the aorta. Neck infections between the pretracheal and prevertebral fasciae
can spread into the superior mediastinum, and through it into the posterior mediastinum.
Thus mediastinitis can result from infections in the neck.

 In the superior mediastinum, all large veins are on the right side and the arteries on the left
side. During increased blood flow veins expand enormously, while the large arteries do not
expand at all. Thus there is much 'dead space' on the right side and it is into this space that
tumor or fluids of the mediastinum tend to project.

 Mediastinum is widened in
1)hemorrhage. 2)malignant lymphoma. 3) Heart hypertrophy due to heart failure.

 Mediastinal syndrome:
Compression of mediastinal structures by any tumor gives rise to a group of symptoms known as
mediastinal syndrome. The common causes of mediastinal syndrome are bronchogenic
carcinoma, Hodgkin's disease causing enlarg5ement of the mediastinal lymph nodes, aneurysm
or dilatation of the aorta, etc.
The common symptoms are as follows.
a. Obstruction of superior vena cava gives rise to engorgement of veins in the upper half of the
body.
b. Pressure over the trachea causes dyspnoea, and cough.
c. Pressure on esophagus causes dysphagia.
d. Pressure or the left recurrent laryngeal nerve gives rise to hoarseness of voice (dysphonia).
e. Pressure on the phrenic nerve causes paralysis of the diaphragm on that side.
f. Pressure on the intercostal nerves gives rise to pain in the area supplied by them. It is called
intercostal neuralgia.
g. Pressure on the vertebral column may cause erosion of the vertebral bodies.

Pericardium and Heart:

 Pericarditis:
It is an inflammation of the pericardium, which may result in cardiac tamponade, pericardial
effusion, and precordial, epigastric pain and pericardial murmur. It has symptoms of dysphagia,
dyspnea and cough, inspiratory chest pain, and paradoxic pulse.

 Pericardial effusion:
Collection of fluid in the pericardial cavity is referred to as pericardial effusion or cardiac
tamponade. The fluid compresses the heart and restricts venous filling during diastole. It also
reduces cardiac output.
 Pericardiocentesis:
Drainage of fluid from pericardial cavity is called pericardiocentesis. A needle is inserted in the
left fifth or sixth intercostal space just lateral to the sternum (bare area of pericardium is
present here) or in the angle between the xiphoid process and left costal margin, with the needle
directed upwards, backwards and to the left.

 Dextrocardia:
It is a condition in which the heart is pointed toward the right side of the chest. Normally, the
heart points toward the left. The condition is present at birth (congenital).

 Situs inversus:
It is a condition in which the arrangement of the internal organs is a mirror image of normal
anatomy. Dextrocardia may be a part of situs inversus. It can occur alone (isolated, with no other
abnormalities or conditions) or it can occur as part of a syndrome with various other defects.

 The area of the chest wall overlying the heart is called as precordium

 Rapid pulse or increased heart rate is called tachycardia.

 Slow pulse or decreased heart rate is called bradycardia.

 Irregular pulse or irregular heart rate is called arrhythmia.

 Consciousness of one's heartbeat is called palpitation.

 Inflammation of the heart can involve more than one layer of the heart. Inflammation of the
pericardium is called pericarditis, of the myocardium is myocarditis; and of the endocardium is
endocarditis.

 Coronary arteries are functional end arteries.

 Pain of heart due to myocardial infarction is referred to left side of chest between 3rd and
6th intercostal spaces. It also gets extended to medial side of left upper limb in the area of
distribution of C8 and T1 spinal segments.
 Cardiac failure:
Normally the diastolic pressure in ventricles is zero. A positive diastolic pressure in the ventricle
is evidence of its failure. Any one of the four chambers of the heart can fail separately, but
ultimately the rising back pressure causes right sided failure (congestive cardiac failure or CCF)
which is associated with increased venous pressure, edema on feet, and breathlessness on
exertion. Heart failure (right sided) due to lung disease is known as cor pulmonale.
Q. To which area cardiac pain is referred and why?
A. Cardiac pain is an ischemic pain caused by incomplete obstruction of a coronary artery. Axons
of pain fibers conveyed by the sensory sympathetic cardiac nerves reach thoracic one to five
segments of spinal cord mostly through the dorsal root ganglia of the left side. Since these dorsal
root ganglia also receive sensory impulses from the medial side of arm, forearm and upper part
of front of chest, the pain gets referred to these areas. Though the pain is usually referred to the
left side, it may even be referred to right arm, jaw, epigastrium or back.

 Auscultation of heart:
1) The tricuspid valve is best heard over the right half of the lower end of the body of the
sternum.

2)The mitral valve is best heard over the apex beat, that is, at the level of the fifth left intercostal
space, 3.5 in. (9 cm) from the midline.

3) The pulmonary valve is heard with least interference over the medial end of the second left
intercostal space.

4) The aortic valve is best heard over the medial end of the second right intercostal space

 Percussion defines density & size of heart. Cardiac percussion is performed at 3rd,4th
and 5th intercostal space from left to right anterior axillary line.

 The first heart sound is produced by closure of the atrioventricular valves. The second heart
sound is produced by closure of the semilunar valves.

 Narrowing of the valve orifice due to fusion of the cusps is known as 'stenosis', e.g. mitral
stenosis, aortic stenosis, etc.

 Dilatation of the valve orifice, or stiffening of the cusps causes imperfect closure of the valve
leading to back flow of blood. This is known as incompetence or regurgitation, e.g. aortic
incompetence or aortic regurgitation.
Q. What is blood supply of conducting system of heart?
A. Except for a part of the left branch of the AV bundle supplied by the left coronary artery, the
whole of the conducting system is usually supplied by the right coronary artery. Vascular lesions
of the heart can cause a variety of arrhythmias.
Q. What is cardiac dominance?
A. In about 10% of hearts, the right coronary is rather small and is not able to give the posterior
interventricular branch. In these cases, the circumflex artery, the continuation of left coronary
provides the posterior interventricular branch as well as to the AV node. Such cases are called
left dominant. Mostly the right coronary gives interventricular artery. Such hearts are right
dominant. Thus the artery giving the posterior interventricular branch is the dominant artery.

 Angina pectoris:
Incomplete obstruction, usually due to spasm of the coronary artery causes angina pectoris,
which is associated with agonizing pain in the precordial region and down the medial side of the
left arm and forearm. Pain gets relieved by putting appropriate tablets below the tongue.

 Three most common sites of

coronary artery occlusion are
Pain of angina pectoris felt
In precordium along medial 1) Anterior IV branch of Left coronary
Border of left arm artery (40-50%).

2) Right coronary artery (30-40%).

3) Circumflex branch of Left coronary

artery (15-20%).

 Coronary angiography:
It is a procedure that uses X-ray imaging to see your heart's blood vessels. It determines the site
of narrowing or occlusion of the coronary arteries or their branches.

 Angioplasty:
Angioplasty is a procedure used to open blocked coronary arteries caused by coronary artery
disease. It restores blood flow to the heart muscle without open-heart surgery. Angioplasty can
be done in an emergency setting such as a heart attack. It is done using small stent or small
inflated balloon through a catheter passed upwards through femoral artery, aorta, into the
coronary artery.

 If there are large segments or multiple

sites of blockage, coronary bypass is
done using either great saphenous vein
or internal thoracic artery as grafts.
 Coronary bypass:
I t involves a connection of a section of vessel (the saphenous vein or of the internal thoracic
artery or radial artery) between the aorta and a coronary artery distal to an obstruction in the
coronary artery, shunting blood from the aorta to the coronary arteries.

Q. Why great saphenous vein is preferred for

coronary bypass?
A. Great saphenous vein is preferred because it
has
1) It has diameter almost equal to that of coronary
artery.
2) It can be easily dissected.
3) It offers lengthy portion with minimum walls.

 Atrial septal defect:

It is a birth defect of the heart in which there is a hole in atrial septum. It results from incomplete
closure of oval foramen. It causes hypertrophy of right atrium, ventricle &pulmonary arteries. It
causes cyanosis (blueness of skin) in new born babies (blue babies)

 Ventricle septal defect:

It is a birth defect of the heart in which there is a hole in ventricular septum. It occurs when
membranous part of interventricular septum develops separately from muscular part or defects
in muscular part.

 Patent ductus arteriosus / ligamentum arteriosum:

It results from failure of the ductus arteriosus (which connects aorta to pulmonary artery
bypassing pulmonary circulation during fetal life) to close after birth, and it is common in
premature infants. A persistent patent ductus arteriosus results in high-pressure aortic blood
passing into the pulmonary artery, which raises the pressure in the pulmonary circulation. A
patent ductus arteriosus is life threatening and should be ligated and divided surgically.

 Myocardial infarction:
It is a necrosis of the myocardium because of local ischemia resulting from vasospasm or
obstruction of the blood supply, most commonly by a thrombus or embolus in the coronary
arteries. Symptoms are severe chest pain, pressure for a prolonged period, congestive heart
failure, and murmur of mitral regurgitation.
 Atrial or ventricular fibrillation:
It is a cardiac arrhythmia that causes an irregular and often abnormally fast heart rate, resulting
from rapid irregular uncoordinated contractions of the atrial or ventricular muscle due to fast
repetitive excitation of myocardial fibers, causing palpitations, shortness of breath, angina, fatigue,
congestive heart failure, and sudden cardiac death.

 Damage to one of the bundle branches results in bundle branch block in which systole occurs
normally but impulse spreads to other ventricle via myogenic conduction producing
asynchronous contraction.

 Heart block:
Heart block, also called AV block, occurs when the electrical signal that controls heartbeat is
partially or completely blocked and is unable to reach the ventricles from atria. This makes heart
beat slow or skip beats and heart can’t pump blood effectively.
Symptoms include dizziness, fainting, tiredness and shortness of breath. Pacemaker implantation
is a common treatment.

Superior vena cava, Aorta and Pulmonary trunk:

 Superior vena cava is the second largest vein of the body.

 Pulmonary trunk and ascending aorta develop from a common source, the truncus
arteriosus.

 Obstruction of superior vena cava:

 When the superior vena cava is obstructed above the opening of the azygos vein, the venous
blood of the upper half of the body is returned through the azygos vein; and the superficial
veins are dilated on the chest up to the costal margin. Blood from upper limb is returned
through the communicating veins joining the veins around the scapula with the intercostal
veins. The latter veins of both sides drain into vena azygos.

 When the superior vena cava is obstructed below the opening of the azygos veins, the blood
is returned through the inferior vena cava via the femoral vein; and the superior veins are
dilated on both the chest and abdomen up to the saphenous opening in the thigh. The
superficial vein connecting the lateral thoracic vein with the superficial epigastric vein is
known as the thoracoepigastric vein.
 oveaz
Ria l

Site of
clot
Vena
azygos

Superior Vena
cava
Obstruction of superior vena cava Obstruction of superior vena cava
above the opening of vena azygos. below the opening of vena azygos.

Obstruction of superior vena cava above Obstruction of superior vena cava

the opening of vena azygos. below the opening of vena azygos.

 Aortic knuckle:
In posteroanterior view of radiographs of the chest, the arch of the aorta is seen as a projection
beyond the left margin of the mediastinal shadow. The projection is called the aortic knuckle. It
becomes prominent in old age.

 Aneurysm of arch of aorta may exert pressure on trachea, esophagus & recurrent
laryngeal nerve causing dyspnea, dysphagia & dysphonia.
 Coarctation of the aorta:
It is a localized narrowing of the aorta opposite to or just beyond the attachment of the ductus
arteriosus. An extensive collateral circulation develops between the branches of the subclavian
arteries and those of the descending aorta. These include the anastomoses between the anterior
and posterior intercostal arteries. These arteries enlarge greatly and produce a characteristic
notching on the ribs. It causes
(a) a characteristic rib notching and a high risk of cerebral hemorrhage
(b) tortuous and enlarged blood vessels, especially the internal thoracic, intercostal, epigastric,
and scapular arteries
(c) an elevated blood pressure in the radial artery and decreased pressure in the femoral artery
(d) the femoral pulse to occur after the radial pulse (normally, the femoral pulse occurs slightly
before the radial pulse).

 Ductus arteriosus, ligamentum arteriosum and patent ductus arteriosus:

During fetal life, the ductus arteriosus is a short wide channel connecting the beginning of the
left pulmonary artery with the arch of the aorta immediately distal to the origin of the left
subclavian artery. It conducts most of the blood from the right ventricle into the aorta, thus short
circuiting the lungs. After birth it is closed functionally within about a week and anatomically
within about eight weeks. The remnants of the ductus form a fibrous band called the ligamentum
arteriosum. The left recurrent laryngeal nerve hooks around the ligamentum arteriosum. The
ductus may remain patent after birth. The condition is called patent ductus arteriosus and may
cause serious problems.

 Aortic arch aneurysm:

It is a localized dilatation of the aorta which may press upon the left recurrent laryngeal nerve
leading to paralysis of left vocal cord and hoarseness. It may also press upon the surrounding
structures and cause the mediastinal syndrome, i.e. dyspnoea, dysphagia, dysphonia, etc.
 Trachea, Oesophagus and thoracic duct:
 Dyspnoea is the medical term used for breathing difficulties

 Dysphagia is the medical term used for swallowing difficulties.

 Trachea contains C-shaped hyaline cartilaginous rings which are deficient posteriorly, so that
the oesophagus situated behind the trachea is not compressed by trachea.

 Trachea begins at 6th cervical vertebra and ends at thoracic 4 (in expiration) by dividing into
two principal bronchi. Trachea is always patent.

 Clinically the trachea is palpated in the suprasternal notch. Normally it is median in position.
Shift of the trachea to any side indicates a mediastinal shift.

 Oesophagus is 25 cm long, like duodenum and ureter. Its maximum part about 20 cm/8" lie
in thoracic cavity.

 Lower part of oesophagus is a site of portocaval anastomoses.

 Thoracic duct drains lymph from both lower limbs, abdominal cavity, left side of thorax, left
upper limb and left side of head and neck.

 Tracheostomy:
It is a surgical procedure which allows air to enter directly into trachea. It is done in cases of
blockage of air pathway in nose or larynx.

 Tracheal tug:
During swallowing when the larynx is elevated, the trachea elongates by stretching because the
tracheal bifurcation is not permitted to move by the aortic arch. Any downward pull due to
sudden and forced inspiration, or aortic aneurysm will produce the physical sign known as
'tracheal tug'.

 Injury to the recurrent laryngeal nerve

Q. What is the function of trachealis muscle? may be caused by:

A. As the tracheal rings are incomplete 1) a bronchogenic or esophageal carcinoma

posteriorly the oesophagus can dilate during (because recurrent laryngeal nerve winds
swallowing. This also allows the diameter of the around arch of aorta & ascends between
trachea to be controlled by the trachealis trachea & esophagus).
muscle. This muscle narrows the caliber of the
tube, compressing the contained air if the vocal 2) enlargement of mediastinal lymph nodes.
cords are closed. This increases the explosive
force of the blast of compressed air, as occurs in 3) an aneurysm of the aortic arch.
coughing and sneezing.
4) thyroid and parathyroid surgeries, causing
respiratory obstruction, hoarseness, and an
inability to speak because of paralysis of the
vocal cord.
  Oesophageal varices:
In portal hypertension, the communications
between the portal and systemic veins draining the
lower end of the oesophagus dilate. These
dilatations are called oesophageal varices. Rupture
of these varices can cause serious haematemesis or
vomiting of blood. The oesophageal varices can be
visualized radiographically by barium swallow; they
produce worm-like shadows.

 Achalasia cardia:
The lower end of the oesophagus is normally kept
closed. It is opened by the stimulus of a food bolus.
In case of neuromuscular incoordination, the lower
end of the oesophagus fails to dilate with the arrival
of food which, therefore, accumulates in the
oesophagus. This condition of neuromuscular
incoordination (caused by degeneration of
myenteric (Auerbach’s) plexus) characterized by
inability of the oesophagus to dilate is known as
'achalasia cardia'. It may be due to congenital
absence of nerve cells in wall of oesophagus.

Q. How many constrictions are present in oesophagus?

A. Normally the oesophagus shows 4 constrictions at the following levels.

1. At its beginning, 15 cm./5 inch from the incisor teeth, where it is crossed by cricopharyngeus
muscle.

2. Where it is crossed by the aortic arch, 22.5 cm/9-inch from the incisor teeth.

3. Where it is crossed by the left bronchus, 27 .5 cm / 17- inch from the incisor teeth.

4. Where it pierces the diaphragm 37 .5 cml 15-inch from the incisor teeth.

 Improper separation of the

trachea from the oesophagus
during development gives rise to
tracheo-oesophageal fistula.
 Atresia means absence or
abnormal narrowing of an opening
or passage in the body.