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Radiological Anatomy of Chest Including Lungs Mediastinum and Thoracic Cage PowerPoint Presentation

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Dr. Pankaj Kaira JR – I Radiodiagnosis SRMSIMS Bareilly,India
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Chest  The chest consists of bony skeleton of the spine and ribs, chest wall and diaphragm, the mediastinum and great vessels, the airways, lung parenchyma and pulmonary vessels.
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COMPONENTS OF THORACIC CAGE: Sternum Manubrium, Body (Gladiolus), Xiphoid process Ribs 7 True Ribs 5 False Ribs (including 2 floating ribs) Clavicle Scapula Pectoral girdle  12 Thoracic Vertebrae (T1 - T12)
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Thoracic Cage It forms a conical enclosure for the lungs and heart and provides attachment for the pectoral girdle and upper limb. It has a broad base and a narrower superior apex; it is rhythmically expanded by the respiratory muscles to create a vacuum that draws air into the lungs. The inferior border of the thoracic cage is formed by a downward arc of the ribs called the costal margin. The ribs protect the thoracic organs and spleen, most of the liver, and to some extent the kidneys.
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Sternum/Breast bone  Flat bone, with 3 parts: Manubrium sterni Body/Gladiolus Xiphoid process
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PARTS OF STERNUM: Manubrium sterni Jugular/suprasternal notch Articulates with Clavicles and Ribs 1 and 2 Lies opposite to T3 and T4 vertebrae Manubriosternal joint inferiorly – called Sternal Angle/Angle of Louis – opposite articulation with 2nd rib – at the level of intervertbral disc between T4 and T5 vertebrae (imp. for counting the ribs)
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PARTS OF STERNUM: Body/Gladiolus Articulates with Ribs 2-7 Xiphisternal joint inferiorly- opposite to T9 vertebra Xiphoid process Cartilaginous - calcifies through time Allows attachment of muscles Tip of xiphoid – at level of T10
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Ribs Typical Ribs 2-7 Head Neck Tubercle Angle Shaft Subcostal groove Atypical Ribs 1, 8 -10 Rib 1 - short, flat and supports Subclavian vessels Ribs 1, 10-12 - articulate with only 1 vertebra Ribs 11 and 12 – “floating ribs” – do not articulate with Transverse processes of Vertebrae or Sternum
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Typical ribs: 1 – 7 pairs of ribs are attached anteriorly to the sternum by their costal cartilages. Atypical ribs: 8th, 9th and 10th pairs of ribs are attached anteriorly to each other and to the 7th rib by means of their costal cartilages and small synovial joints. Floating ribs :The 11th and 12th pairs have no anterior attachment. They are embedded in the abdominal muscles.
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Typical Ribs (2 -7) Long, twisted, flat bone The anterior end of each rib is attached to the corresponding costal cartilage A rib has a head, neck, tubercle, shaft, and angle Head – located posteriorly - has 2 facets for articulation – one for the numerically corresponding vertebral body and the other for the vertebral body immediately above it. Neck is a constricted portion - between the head and the tubercle. The Tubercle is a prominence on outer surface of the rib - at the junction of the neck with the shaft. It has a facet for articulation with the transverse process of the numerically corresponding vertebra. The Shaft is thin, flat and twisted on its long axis. It has a rounded, smooth superior border and a sharp, thin inferior border which has costal groove (it accommodates the intercostal vessels and nerve (VAN ) The angle is where the shaft of the rib bends sharply forward.
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Atypical Rib (1st Rib) The first rib has a close relationship to the lower nerves of the Brachial plexus, Subclavian artery and vein. This rib is shortest with a prominent tubercle for the attachment of Scalenus anterior muscle. Anterior to the attachment of Scalenus anterior, the Subclavian vein crosses the rib. Posterior to the attachment of Scalenus anterior, the Subclavian artery and the lower trunk of the Brachial plexus cross the rib and lie in contact with the bone.
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JOINTS OF STERNUM 1. MANUBRIOSTERNAL JOINT: cartilaginous joint, symphysis between Manubrium and body of Sternum 2. XIPHISTERNAL JOINT cartilaginous joint between Xiphoid process and body of Sternum The Xiphoid process usually fuses with the body of the Sternum during middle age
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JOINTS OF RIBS 1. COSTOVERTEBRAL JOINTS: 2 joints between heads of the Ribs and bodies of Vertebrae (corresponding and upper)- Synovial joints 1st, 10th, 11th and 12th rib has 1 synovial joint with the corresponding vertebra, the rest have 2 each; one for the corresponding vertebra and the other for the vertebra above it 1 joint between tubercle of Ribs and transverse process of Vertebra (corresponding) - Synovial joint (1st- 10th Rib) Intra articular ligament connects head of Rib to the intervertebral disc
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Cervical Rib (Accessory Rib) Occurs in 0.5% population There is an extra pair of ribs just above the 1st rib They arise from the transverse process of C7 vertebrae Anteriorly, they may be attached to 1st Rib or may be free Clinical Anatomy: Cervical Rib may compress Brachial plexus/Subclavian artery; causing Klumpke’s paralysis/Ischemia
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Intercostal Muscles External intercostals Internal intercostals Innermost intercostal muscles which is separated from the internal intercostal muscles by neurovascular bundle with the vein lying in a groove on the under surface of the corresponding rib and the artery and nurve lying more inferiorly (VAN).
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Blood Supply Anterior intercostal arteries arise from internal thoracic artery. The posterior intercostal arteries of first two space arise from the costo-cervical trunk (branch of subclavian artery) and posterior intercostal arteries of lower nine spaces arise from the descending thoracic artery. Intercostal veins drain into azygous and hemiaygous veins, except 1st on right drains into vertebral or brachiocephalic vein and 2nd and 3rd on left form the superior intercostal vein to drain into left brachiocephalic vein.
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Intercostal Veins
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DIAPHRAGM Seperates the thorax from the abdomen.It consists of 1)A peripeheral muscular part arising from margins of thoracic outlet. 2)Right crus arises from the front of vertebral bodies of L1- 3. 3)Left crus from the lateral aspect of vertebral bodies of L1- 2. 4)Arcuate ligament from the fascia of the psoas and guadratus lumborum. 5)Central tendon which is partly fused with the fibrous layer of pericardium.
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Main openings in Diaphragm Aortic opening (T12) – transmitting the aorta, thoracic duct and the azygous vein. Oesophageal opening (T10) – Oesophagus,oesophageal branches of left gastric artery, vein and B/L Vagus nerve. Vena caval opening (T8) – Inferior vena cava and right phrenic nerve.
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TRACHEA The trachea connects the upper respiratory tract to the lungs via the bronchial tree, enabling gas exchange. The trachea extends from the larynx at the level of the cricoid cartilage (C6) and branches into the right and left main bronchus at the carina (T4/5) There are 12-16 incomplete cartilaginous rings.The posterior wall is fibrous tissue.Rings may calcify in older people.
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Usually situated in a midline position and is slightly deviated to the right . length : 9 – 12 cms . intrathoracic portion about 6-9 cm. Trachea bifurcates into right & left main bronchus . Normal Carina Angle : 60 to 70 Degrees.
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BRONCHOPULMONARY SEGMENTS Bronchopulmonary segments are anatomic, functional and surgical units of lung. Well defined areas of lungs, each of which is aerated by a segmental/ tertiary bronchus These segments are pyramidal in shape with apex towards the root of lung Each segment is an independent respiratory unit. In each bronchopulmonary segment the segmental bronchus is accompanied by a branch of pulmonary artey, lymphatics and autonomic nerve supply. Pulmonary veins run in intersegmental planes between adjoining segments
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Broncho-Pulmonary Segments of the Right Lung (6) Superior Lobe – Apical (1) Anterior (2) Posterior (3) Middle Lobe – Lateral (4) Medial (5) Inferior Lobe –  Superior     Medial basal (7) Anterior basal (8) Lateral basal (9) Posterior basal (10)
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Broncho-Pulmonary Segments Of The Left Lung Upper Lobe : Apico -posterior (1-3) Anterior (2) Superior lingular (4) Inferior lingular (5) Lower Lobe :
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Right Main Bronchus (Eparterial) Wider, Shorter, and more Vertical 25 degrees to the median plane 2.5 cms long Enters the right lung nearly opposite the T5 vertebra It lies inferolateral and posterior to pulmonary artery.
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Left Main Bronchus (Hyparterial) 40 degrees to the median plane 5 cms long 1.2 cms wide Courses below the arch of aorta entering the hilum at T6 then courses inferolaterally to the pulmonary artery. Nearly 5 cm long Enters root of left lung at level of T6 vertebrae
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HILUM It is a large depressed area that lies near the centre of the medial surface of lung. Various structures enter and leave the lung via its root. Each hilum contains major bronchi, pulmonary vessels and lymph nodes. The left hilum is higher than the right in 97% of people and equal in 3%. Both have clearly defined concave lateral borders Lymph nodes are also present on each side but are not visible unless abnormal
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LUNGS Lungs are a pair of respiratory organs situated in thoracic cavity Right lung is larger than the left Right lung has 3 lobes Left lung has 2 lobes
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PULMONARY FISSURES & LOBES
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FISSURES ACCESSORY FISSURES : Azygous fissure Superior Accessory fissure Inferior Accessory fissure Left transverse Fissure MAIN FISSURES : RIGHT LUNG :- Horizontal fissure Oblique fissure LEFT LUNG :- i. Oblique fissure
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Oblique ( Major ) Fissure : Right oblique fissure separates the lower lobe from the middle and upper lobes where as left oblique fissure separates lower lobe from upper lobe. Extends from T4/T5 posteriorly to the diaphragm anteroinferiorly. The left oblique fissure is more vertically oriented than the right. ends just behind the anterior costophrenic angle, passing through the hilum. is usually visible on a lateral radiograph and on a high resolution CT scan as a curvilinear band from the lateral aspect to the hilum.
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Horizontal ( Minor ) Fissure : Separates upper lobe from the middle lobe of the right lung. Is short as compared to oblique fissure Runs horizontally from the hilum to the anterior and lateral surface of the right lung at the level of the 4th costal cartilage. The posterior limit is the right oblique fissure which it meets at the level of 6th rib in midaxillary line. Anatomically complete on in 1/3rd of the subjects.
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FISSURES AND LOBES OF THE RIGHT LUNG
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FISSURE OF LEFT LUNG
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Accessory fissures of the lung Accessory fissures of the lung usually occur at the borders of bronchopulmonary segments. Azygous fissure Inferior accessory fissure Superior accessory fissure Left minor fissure
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Azygous fissure On the right side. Occurs due to anomalous development of azygous vein and terminates in tear drop opacity. Consists of 4 layers of pleura and supplied by right apical bronchus or its branches. Seen in 0.5% of CXR with male:female ratio of 2:1.
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SUPERIOR ACCESORY FISSURE Separates the apical from the basal segments of the lower lobe. It is commoner on right side. It is seen in 5% of the PA chest radiograph.
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INFERIOR ACCESSORY FISSURE It seperates the medial basal broncho pulmonary segment from the rest of the lower lobe. Common on the right than left This fissure may also be referred to as Twining's lines . It is seen in 8% of PA chest radiographs.
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LUNG ZONES Lungs are assessed by dividing them into 3 zones: Upper zone : upto 2nd rib Middle zone: 2nd to 4th rib Lower zone: 4th and below
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LOBES OF THE LUNGS Right lung has three lobes : upper lobe middle lobe lower lobe
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ARTERIAL SUPPLY :  Dual supply i.e Bronchial artery and Pulmonary artery. Systemic circulation : Bronchial arteries (oxygenated blood from left ventricle) and originates directly from descending thoracic aorta between T5 and T6 vertebrae. Supply blood to the bronchi, the visceral pleura and connective tissue of the bronchial tree The most common pattern is two on the left and one on the right that arises as an intercostobronchial trunk (ICBT) (41%).
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Pulmonary circulation : Pulmonary arteries (deoxygenated blood from right ventricle) They supply only the alveoli. These gives of a branch to each bronchopulmonary segment of lung The main pulmonary trunk arises from right ventricle and divides into a short left pulmonary artery and longer right pulmonary artery. The right pulmonary artery runs between the superior vena cava and right main bronchus and divides into : (a) upper truncus arteriosus which supplies the RUL and lies medial to the bronchus. (b) descending interlobar artey supplying the RML and RLL and lies lateral to the bronchus. The left pulmonary artery arches over the left main bronchus and divides into : (a) an ascending branch which supplies the LUL and lies medial to the bronchus. (b) descending interlobar artey supplying the lingula and LLL and lies lateral to the bronchus.
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VENOUS DRAINAGE : Pulmonary veins : (oxygenated blood to left atrium) Two superior and two inferior Rt and lt superior veins drain superior , middle lobes Rt lung , superior lobe Lt lung respectively Rt and Lt inferior pulmonary veins drain inferior lobe of their respective lungs Bronchial veins : Only drain the part of blood delivered by bronchial arteries to the bronchial tree Two bronchial veins : right and left bronchial vein
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Lymphatic drainage of lungs : superficial, or subpleural and deep lymphatics of the lung drain into lymph nodes called the tracheo-bronchial nodes around the roots of the lobar and main bronchi and along the sides of the trachea Nerve supply of lungs :  parasympathetic nerves are derived from the vagus and sympathetic from 2nd to 5th spinal segments.
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PLEURA Delicate serous membrane Which forms a closed invaginated sac enclosing the lungs and lines the thoracic cavity. The pleura divides into: visceral pleura which covers the surface of the lung and dips into the fissures between its lobes parietal pleura which lines the non pulmonary surface and named according to the site it lines: costal pleura diaphragmatic pleura mediastinal pleura Apical pleura
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The Intrapleural Space is a true space between the visceral pleura and the parietal pleura. The periphery of the base of each pleural cavity forms a deep gutter around the dome of the corresponding diaphragm called as costophrenic sulcus or angle The posterior costophrenic angle being the deepest and is visualized on a lateral chest radiograph. Blood supply : Parietal by systemic circulation Visceral by both bronchial and pulmonary circulation.
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MEDIASTINUM  The mediastinum contains a group of non-deliniated organs and their surroundingconnective tissue. It lies in the midline of the chest between the pleural surfaces of each lung and extends from the sternum to the vertebral column. Anatomic Relations : Superiorly – Thoracic outlet and the root of the neck. Inferiorly – Diaphragm Anteriorly - chest wall Laterally - lungs and pleura posteriorly - Thoracic spine
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The mediastinum is divided into superior and inferior medistina by an imaginary plane passing from the sternal angle anteriorly to the lower border of the body of the 4th thoracic vertebra posteriorly. Inferior mediastinum is further subdivided into Anterior, middle and posterior medistinum.
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Radiologically the mediastinum can be divided into : Anterior - Lying anterior to pericardium ,ascending aorta and superior vena cava. Middle mediastinum - Contains heart , great vessels, hilum and carina. Posterior mediastinum – retrocardiac and paravertebral spaces.
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The superior mediastinum contains the: Aortic arch and branches; B rachiocephalic veins and superior vena cava Trachea; Oesophagus; Thoracic duct; Lymph nodes; and Nerves. The anterior mediastinum contains the: Thymus; Mammary vessels; and Lymph nodes.
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The posterior mediastinum contains the: Descending aorta; Oesophagus; Azygos venous system; Thoracic duct; and Para-aortic, oesophageal and paraspinal nodes. The middle mediastinum contains the: Heart and pericardium: Nerves; Lymph nodes; and Great vessels.
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Mediastinal Lines Anterior Junction line Contact of anterior lungs Lies posterior to the sternum Consists of 4 layers of pleura. Runs obliquely from the lower mediastinum inferiorly to the left. Posterior Junction line Contact of posterior lungs behind the oesophagus and anterior to the spine Consists of 4 layers of pleura
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Thymus It is the site for the development of T (thymic) lymphocytes. It is related to the great vessels and pericardium and is present between sternum and pericardium in the anterior mediastinum. In newborn it shows maximum size,then shows regression after puberty and fatty replacement in adults. CXR – it may be seen as a “sail sign” in children.In adults it is not visualized.
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