Pleura, pleura, which is the serous membrane of the lung, is divided into visceral (pulmonary) and parietal (parietal). Each lung is covered with pleura (pulmonary), which along the surface of the root passes into the parietal pleura.
Visceral (pulmonary) pleura, pleura visceralis (pulmonalls). Forms downward from the root of the lung pulmonary ligament, lig. pulmonary
Parietal (parietal) pleura, pleura parietalis, in each half of the chest cavity forms a closed sac containing the right or left lung, covered with visceral pleura. Based on the position of the parts of the parietal pleura, it is divided into the costal, mediastinal and diaphragmatic pleura. Costal pleura, pleura costalis, covers the inner surface of the ribs and intercostal spaces and lies directly on the intrathoracic fascia. Mediastinal pleura, pleura mediastindlis, adjacent to the mediastinal organs on the lateral side, fused with the pericardium on the right and left; on the right it also borders with the superior vena cava and azygos vein, with the esophagus, on the left with the thoracic aorta.
Above, at the level of the superior aperture of the chest, the costal and mediastinal pleura pass into each other and form dome of pleura, cupula pleurae, limited on the lateral side by the scalene muscles. The subclavian artery and vein are adjacent to the dome of the pleura anteriorly and medially. Above the dome of the pleura is the brachial plexus. Diaphragmatic pleura, pleura diaphragmatica, covers the muscular and tendon parts of the diaphragm, with the exception of its central sections. Between the parietal and visceral pleura there is pleural cavity, cavitas pleuralis.
Sinuses of the pleura. In the places where the costal pleura transitions into the diaphragmatic and mediastinal pleura, pleural sinuses, recessus pleurdles. These sinuses are the reserve spaces of the right and left pleural cavities.
Between the costal and diaphragmatic pleura there is costophrenic sinus, recessus costodiaphragmaticus. At the junction of the mediastinal pleura and the diaphragmatic pleura there is diaphragmomediastinal sinus, recessus phrenicomediastinalis. A less pronounced sinus (depression) is present at the place where the costal pleura (in its anterior section) transitions into the mediastinal pleura. Here it is formed costomedial sinus, recessus costomediastinalis.
Boundaries of the pleura. On the right is the anterior border of the right and left costal pleura from the dome of the pleura it descends behind the right sternoclavicular joint, then goes behind the manubrium to the middle of its connection with the body and from here descends behind the body of the sternum, located to the left of the midline, to the VI rib, where it goes to the right and passes into the lower border of the pleura. Bottom line The pleura on the right corresponds to the line of transition of the costal pleura into the diaphragmatic pleura.
Left anterior border of the parietal pleura from the dome it goes, just like on the right, behind the sternoclavicular joint (left). Then it is directed behind the manubrium and the body of the sternum down to the level of the cartilage of the IV rib, located closer to the left edge of the sternum; here, deviating laterally and downwards, it crosses the left edge of the sternum and descends near it to the cartilage of the VI rib, where it passes into the lower border of the pleura. Lower border of the costal pleura on the left is located slightly lower than on the right side. In the back, as well as on the right, at the level of the 12th rib it becomes the posterior border. Posterior pleural border corresponds to the posterior line of transition of the costal pleura into the mediastinal pleura.
Visceral pleura (pleura visceralis):
Sources of blood supply: rr. bronchiales aortae, rr. bronchiales art; thoracicae internae;
Venous outflow: vv. bronchiales (in w. azygos, hemiazygos).
Parietal pleura (pleura parietalis):
Sources of blood supply: aa. intercostales posteriores (posterior intercostal arteries) from the aorta, aa. intercostales anteriores (anterior intercostal arteries) from art. thoracica interna;
Venous outflow: in vv. intercostales posteriores (posterior intercostal veins drain) into vv. arygos, hemiazygos, v. thoracica interna.
Pleura visceral:
Sympathetic innervation: rr. pulmonales (from tr. sympathicus);
Parasympathetic innervation: rr. bronchiales n. Vagi.
Pleura parietal:
Innervated by nn. intercostales, nn. Phrenici
Pleura visceral: nodi lymphatici tracheobronchiales superiores, interiores, bronchopulmonales, mediastinales anteriores, posteriores.
Pleura parietal: nodi lymphatici intercostales, mediastinales anteriores, posteriores.
3.Arteries of the leg and foot.
Posterior tibial artery, a. tibialis posterior, serves as a continuation of the popliteal artery, passes in the ankle-popliteal canal.
Branches of the posterior tibial artery : 1. Muscular branches rr. musculares, - to the muscles of the lower leg; 2. Branch circumflexing the fibula g. circumflexus fibularis, supplies blood to adjacent muscles. 3. peroneal artery, A. regopea, supplies blood to the triceps surae muscle, the long and short peroneus muscles, is divided into its terminal branches: lateral malleolar branches, rr. malleolares laterales, and calcaneal branches, rr. calcanei, involved in the formation of the calcaneal network, rete calcaneum. A perforating branch, the perforans, and a connecting branch, the communicans, also depart from the peroneal artery.
4. Medial plantar artery, a. plantaris medialis, divided into superficial and deep branches, rr. superficidlis et profundus. The superficial branch feeds the abductor hallucis muscle, and the deep branch supplies the same muscle and the flexor digitorum brevis.
5. Lateral plantar artery, a. plantaris lateralis. forms a plantar arch, arcus plantaris, at the level of the base of the metatarsal bones, giving off branches to the muscles, bones and ligaments of the foot.
The plantar metatarsal arteries, aa, depart from the plantar arch. metatarsales plantares I-IV. The plantar metatarsal arteries, in turn, give off piercing branches, rr. perforantes, to the dorsal metatarsal arteries.
Each plantar metatarsal artery passes into the common plantar digital artery, a. digitalis plantaris communis. At the level of the main phalanges of the fingers, each common plantar digital artery (except the first) is divided into two own plantar digital arteries, aa. digitales plantares propriae. The first common plantar digital artery branches into three proper plantar digital arteries: to the two sides of the big toe and to the medial side of the second finger, and the second, third and fourth arteries supply blood to the sides of the second, third, fourth and fifth fingers facing each other. At the level of the heads of the metatarsal bones, perforating branches are separated from the common plantar digital arteries to the dorsal digital arteries.
Anterior tibial artery, a. tibidlis anterior, arises from the popliteal artery in the popliteal.
Branches of the anterior tibial artery:
1. Muscular branches rr. musculares, to the muscles of the lower leg.
2. Posterior tibial recurrent artery, A. hesi-rens tibialis posterior, departs within the popliteal fossa, participates in the formation of the knee articular network, supplies blood to the knee joint and popliteal muscle.
3. Anterior tibial recurrent artery, A. recurrens tibialis anterior, takes part in the blood supply to the knee and tibiofibular joints, as well as the tibialis anterior muscle and extensor digitorum longus.
4. Lateral anterior malleolar artery, a. malleold-ris anterior lateralis, begins above the lateral malleolus, supplies blood to the lateral malleolus, ankle joint and tarsal bones, takes part in the formation of the lateral malleolar network, rete malleoldre laterale.
5. Medial anterior malleolar artery, a. malleold-ris anterior medialis, sends branches to the capsule of the ankle joint, participates in the formation of the medial malleolar network.
6. Dorsal artery of the foot, a. dorsdlis pedis, is divided into terminal branches: 1) the first dorsal metatarsal artery, a. metatarsdlis dorsdlis I, from which three dorsal digital arteries arise, aa. digitdles dorsdles, to both sides of the dorsum of the thumb and the medial side of the second finger; 2) deep plantar branch, a. plantdris profunda, which passes through the first intermetatarsal space onto the sole.
The dorsal artery of the foot also gives off the tarsal arteries - lateral and medial, aa. tarsales lateralis et medialis, to the lateral and medial edges of the foot and the arcuate artery, a. ag-cuata, located at the level of the metatarsophalangeal joints. The I-IV dorsal metatarsal arteries, aa, extend from the arcuate artery towards the fingers. metatarsales dorsales I-IV, each of which at the beginning of the interdigital space is divided into two dorsal digital arteries, aa. digitales dorsales, heading towards the backs of adjacent fingers. From each of the dorsal digital arteries, perforating branches extend through the intermetatarsal spaces to the plantar metatarsal arteries.
On the plantar surface of the foot As a result of the anastomosis of the arteries, there are two arterial arches. One of them - the plantar arch - lies in the horizontal plane. It is formed by the terminal section of the lateral plantar artery and the medial plantar artery (both from the posterior tibial artery). The second arc is located in the vertical plane; it is formed by an anastomosis between the deep plantar arch and the deep plantar artery - a branch of the dorsal artery of the foot.
4.Anatomy and topography of the midbrain; its parts, their internal structure. Position of nuclei and pathways in the midbrain.
Midbrain, mesencephalon, less complicated. It has a roof and legs. The cavity of the midbrain is the cerebral aqueduct. The upper (anterior) border of the midbrain on its ventral surface is the optic tracts and mammillary bodies, and on the rear - the anterior edge of the pons. On the dorsal surface, the upper (anterior) border of the midbrain corresponds to the posterior edges (surfaces) of the thalamus, the posterior (lower) border corresponds to the level of exit of the trochlear nerve roots.
Roof of the midbrain tectum mesencephalicum, located above the cerebral aqueduct. The roof of the midbrain consists of four elevations - mounds. The latter are separated from each other by grooves. The longitudinal groove is located to form a bed for the pineal gland. A transverse groove separates the superior colliculi, colliculi superiores, from the inferior colliculi, colliculi inferiores. From each of the mounds, thickenings in the form of a roller extend in the lateral direction - the handle of the mound. The superior colliculus of the roof of the midbrain (quadrigeminal) and the lateral geniculate body perform the function of subcortical visual centers. The inferior colliculus and medial geniculate body are subcortical auditory centers.
legs of the brain, pedunculi cerebri, emerge from the bridge. The depression between the right and left cerebral peduncles is called the interpeduncular fossa, fossa interpeduncularis. The bottom of this fossa serves as a place where blood vessels penetrate the brain tissue. On the medial surface of each of the cerebral peduncles there is a longitudinal oculomotor groove, sulcus oculomotorus (medial groove of the cerebral peduncle), from which the roots of the oculomotor nerve, n. oculomotorius (III pair), emerge.
In the cerebral peduncle it is secreted black substance, substantia nigra. The substantia nigra divides the cerebral peduncle into two sections: the posterior (dorsal) tegmentum of the midbrain, tegmentum mesencephali, and the anterior (ventral) section - the base of the cerebral peduncle, basis pedunculi cerebri. The midbrain nuclei lie in the tegmentum and ascending pathways pass through. The base of the cerebral peduncle consists entirely of white matter; descending pathways pass here.
Midbrain plumbing(aqueduct of Sylvius), aqueductus mesencephali (cerebri), connects the cavity of the third ventricle with the fourth and contains cerebrospinal fluid. In its origin, the cerebral aqueduct is a derivative of the cavity of the middle cerebral bladder.
Around the midbrain aqueduct there is a central gray matter, substantia grisea centrdlis, in which the nuclei of two pairs of cranial nerves are located in the area of the bottom of the aqueduct. At the level of the superior colliculi there is a paired nucleus of the oculomotor nerve, nucleus nervi oculomotorii. It takes part in the innervation of the eye muscles. More ventral to this is the parasympathetic nucleus of the autonomic nervous system - the accessory nucleus of the oculomotor nerve, nucleus oculomotorius accessorius. Anterior and slightly above the nucleus of the third pair is the intermediate nucleus, nucleus interstitialis. The processes of the cells of this nucleus participate in the formation of the reticulospinal tract and the posterior longitudinal fasciculus.
At the level of the inferior colliculi in the ventral sections of the central gray matter lies the nucleus of the trochlear nerve, nucleus n. trochlearis. In the lateral parts of the central gray matter throughout the entire midbrain there is the nucleus of the midbrain tract of the trigeminal nerve (V pair).
In the tegmentum, the largest and most noticeable in a cross section of the midbrain is the red nucleus, nucleus ruber. The base of the cerebral peduncle is formed by descending pathways. The internal and external sections of the base of the cerebral peduncles form the fibers of the cortical-pontine tract, namely the medial part of the base is occupied by the frontal-pontine tract, the lateral part is occupied by the temporo-parietal-occipital-pontine tract. The middle part of the base of the cerebral peduncle is occupied by the pyramidal tracts.
The corticonuclear fibers pass medially, and the corticospinal tracts pass laterally.
In the midbrain there are subcortical centers of hearing and vision, which provide innervation to the voluntary and involuntary muscles of the eyeball, as well as the midbrain nucleus of the V pair.
Ascending (sensory) and descending (motor) pathways pass through the midbrain.
Ticket 33
1. Anatomy of the abdominal cavity. Linea alba, rectus sheath.
2.Lungs, pleura: development, structure, external signs. Boundaries.
3. Development of the superior vena cava. Outflow of blood from the organs of the head. sinuses of the dura mater.
4.Mandibular nerve
1.Anatomy of the abdominal muscles, their topography, functions, blood supply and innervation. Sheath of the rectus abdominis muscle. White line.
External oblique muscle, m. obliquus abdominis externa. Start: 5-12 ribs. Attachment: iliac crest, rectus sheath, linea alba. Function: exhale, rotate the torso, bend and tilt the spine to the side. Innervation Blood supply:aa. intercostals posteriors, a. thoracica lateralis, a. circumflexa iliaca superfacialis.
Internal oblique muscle, m. obliquus abdominis interna. Start: thoracolumbar fascia, crista iliaca, inguinal ligament. Attachment: 10-12 ribs, sheath of the rectus abdominis muscle. Function: exhale, tilts the torso forward and to the side. Innervation:nn. intercostales, n. iliohypogastricus, n. ilioinguinalis. Blood supply
Transverse abdominis muscle, m. transversus abdominis. Start: inner surface of 7-12 ribs, thoracolumbar fascia, crista illiaca, inguinal ligament. Attachment: rectus sheath. Function: Reduces the size of the abdominal cavity, pulls the ribs forward and towards the midline. Innervation:nn. intercostales, n. iliohypogastricus, n. ilioinguinalis. Blood supply:aa. intercostals posteriors, aa. epigastricae inferior et superior, a. musculophrenica.
Rectus abdominis muscle m. rectus abdominis. Start: pubic ridge, fibrous fascicles of the pubic symphysis. Attachment: anterior surface of the xiphoid process, outer surface of the cartilages of the V-VII ribs. Function: bends the torso, exhales, raises the pelvis. Innervation:nn. intercostales, n. iliohypogastricus. Blood supply:aa. intercostals posteriors, aa. epigastricae inferior et superior.
pyramidalis muscle, m. pyramidalis. Start: pubic bone, symphysis. Attachment: linea alba. Function: tightens the linea alba.
Quadratus lumborum muscle, m. quadratus lumborum. Start: iliac crest. Attachment: 12th rib transverse processes of 1-4 lumbar vertebrae. Function: tilts the spine to the side, exhale. Innervation: plexus lumbalis. Blood supply: a. subcostalis, aa. Lumbales, a. iliolumbalis.
Rectus sheath, vagina t. recti abdominis, is formed by the aponeuroses of the three broad abdominal muscles.
The aponeurosis of the internal oblique muscle of the abdomen splits into two plates - anterior and posterior. The anterior plate of the aponeurosis, together with the aponeurosis of the external oblique muscle, forms the anterior wall of the rectus abdominis sheath. The posterior plate, fused with the aponeurosis of the transverse abdominis muscle, forms the posterior wall of the rectus abdominis sheath.
Below this level, the aponeuroses of all three vastus abdominal muscles pass to the anterior surface of the rectus abdominis muscle and form the anterior wall of its vagina.
The lower edge of the tendinous posterior wall of the rectus abdominis sheath is called the arcuate line, linea arcuata (linea semi-circularis - BNA).
White line, linea alba, is a fibrous plate extending along the anterior midline from the xiphoid process to the pubic symphysis. It is formed by intersecting fibers of the aponeuroses of the broad abdominal muscles of the right and left sides.
2. Lungs: development, topography. Segmental structure of the lungs, acinus. X-ray image of the lungs.
lung, pulmo. Highlight: lower diaphragmatic surface lung, faces diaphragmdtica (base of the lung), apex of the lung, apex pulmonis, costal surface faces costalis (the vertebral part, pars vertebrdlis, of the costal surface borders the spinal column), medial surface faces medlis. The surfaces of the lung are separated by edges: anterior, posterior and inferior. On the leading edge margo anterior of the left lung there is a cardiac notch, incisura cardiaca. This notch is limited from below uvula of the left lung, lingula pulmonis sinistri.
Each lung is divided into shares, lobi pulmones, of which the right one has three (upper, middle and lower), the left has two (upper and lower).
oblique slit, fissura obliqua, begins at the posterior edge of the lung. It divides the lung into two parts: upper lobe lobus superior, which includes the apex of the lung, and lower lobe, lobus inferior, including the base and most of the posterior edge of the lung. In the right lung, in addition to the oblique, there is horizontal slot, fissura horizontalis. It begins on the costal surface of the lung and reaches the hilum of the lung. A horizontal slit cuts off from the upper lobe middle lobe (right lung), lobus medius. The surfaces of the lung lobes facing each other are called "interlobar surfaces" fades interlobares.
On the medial surface of each lung there are gate of the lung, hilum pulmonis, through which the main bronchus, pulmonary artery, and nerves enter the lung, and the pulmonary veins and lymphatic vessels exit. These formations constitute lung root, radix pulmonis.
At the gate of the lung, the main bronchus breaks up into lobar bronchi, bronchi lobares, of which there are three in the right lung and two in the left. The lobar bronchi enter the gate of the lobe and are divided into segmental bronchi, bronchi segmentales.
Right upper lobar bronchus, bronchus lobdris superior dexter, divided into apical, posterior and anterior segmental bronchi. Right middle lobe bronchus, bronchus lobaris medius dexter, is divided into lateral and medial segmental bronchi. Right lower lobar bronchus, bronchus lobdris inferior dexter, is divided into superior, medial basal, anterior basal, lateral basal and posterior basal segmental bronchi. Left superior lobar bronchus, bronchus lobaris superior sinister, is divided into apical-posterior, anterior, superior lingular and inferior lingular segmental bronchi. Left lower lobar bronchus, bronchus lobaris inferior sinister, is divided into the superior, medial (cardiac) basal, anterior basal, lateral basal and posterior basal segmental bronchi. The pulmonary segment consists of pulmonary lobules.
The bronchus enters a lobe of the lung called the lobular bronchus, bronchus lobularis. Inside the pulmonary lobule, this bronchus is divided into terminal bronchioles, bronchioli terminates. The walls of the terminal bronchioles do not contain cartilage. Each terminal bronchiole is divided into respiratory bronchioles, bronchioli respiratorii, which have pulmonary alveoli on their walls. From each respiratory bronchiole depart alveolar ducts, ductuli alveoldres, which carry alveoli and end in alveolar sacs, sacculi alveolares. The walls of these sacs consist of pulmonary alveoli, alveoli pulmonis. The bronchi make up bronchial tree, arbor bronchiatis. The respiratory bronchioles extending from the terminal bronchiole, as well as the alveolar ducts, alveolar sacs and alveoli of the lung form alveolar tree (pulmonary acinus), arbor alveoldris. The alveolar tree is the structural and functional unit of the lung.
Lungs: nodi lymphatici tracheobronchiales superiores, interiores, bronchopulmonales, mediastinales anteriores, posteriores (lymph nodes: lower, upper tracheobronchial, bronchopulmonary, posterior and anterior mediastinal).
Lungs:
Sympathetic innervation: pl. Pulmonalis, branches of the vagus nerve (pulmonary plexus) rr. pulmonate - pulmonary branches (from tr. sympathicus), sympathetic trunk;
Parasympathetic innervation: rr. bronchiales n. vagi (bronchial branches of the vagus nerve).
lung, pulmo:
Sources of blood supply, cities bronchiales aortae (bronchial branches of the aorta), gg. bronchiales art. thoracicae interna (bronchial branches of the internal mammary artery);
Venous outflow: vv. bronchiales (in w. azygos, hemiazygos, pulmonales).
3.The superior vena cava, sources of its formation and topography. Azygos and semi-gypsy veins, their tributaries and anastomoses.
superior vena cava, v. cava superior, formed as a result of the fusion of the moral and left brachiocephalic veins behind the junction of the cartilage of the first right rib with the sternum, flows into the right atrium. The azygos vein flows into the superior vena cava on the right, and small mediastinal and pericardial veins flow into the left. The superior vena cava collects blood from three groups of veins: the veins of the walls of the thoracic and partially abdominal cavities, the veins of the head and neck, and the veins of both upper extremities, i.e., from those areas that are supplied with blood by the branches of the arch and thoracic part of the aorta.
azygos vein, v. azygos, is a continuation of the right ascending lumbar vein, v. lumbalis ascendens dextra. The right ascending lumbar vein along its path anastomoses with the right lumbar veins flowing into the inferior vena cava. The azygos vein drains into the superior vena cava. At the mouth of the azygos vein there are two valves. On its way to the superior vena cava, the semi-gypsy vein and veins of the posterior wall of the chest cavity flow into the azygos vein: the right superior intercostal vein; posterior intercostal veins IV-XI, as well as veins of the thoracic cavity: esophageal veins, bronchial veins, pericardial veins and mediastinal veins.
Hemizygos vein, v. hemiazygos, is a continuation of the left ascending lumbar vein, v. lumbalis ascendens sinistra. To the right of the hemizygos vein is the thoracic part of the aorta, behind is the left posterior intercostal artery. The hemizygos vein drains into the azygos vein. The accessory hemizygos vein, which runs from top to bottom, flows into the hemizygos vein, and. hemiazygos accessoria, receiving 6-7 superior intercostal veins, as well as esophageal and mediastinal veins. The most significant tributaries of the azygos and semi-gypsy veins are the posterior intercostal veins, each of which is connected at its anterior end to the anterior intercostal vein, a tributary of the internal mammary vein.
Posterior intercostal veins, vv. inlercostales posteridres, are located in the intercostal spaces next to the arteries of the same name and collect blood from the tissues of the walls of the chest cavity. The dorsal vein, v., flows into each of the posterior intercostal veins. dorsalis, and intervertebral vein, v. intervertebralis. A spinal branch, M. spinalis, flows into each intervertebral vein, which is involved in the outflow of venous blood from the spinal cord.
Internal vertebral venous plexuses (anterior and posterior), plexus venosi vertebrates interni (anterior et posterior), are located inside the spinal canal and are represented by veins anastomosing each other. The spinal veins and veins of the spongy substance of the vertebrae flow into the internal vertebral plexuses. From these plexuses, blood flows through the intervertebral veins into the azygos, semi-unpaired and accessory semi-gyzygos veins and external venous vertebral plexuses (anterior and posterior), plexus venosi vertebrates externi (anterior et posterior), which are located on the anterior surface of the vertebrae. From the external vertebral plexuses, blood flows into the posterior intercostal, lumbar and sacral veins, vv. intercostdles posteriores, lumbales et sacrales, as well as into the azygos, semi-gyzygos and accessory semi-gyzygos veins. At the level of the upper spinal column, the plexus veins flow into the vertebral and occipital veins, vv. vertebrates et occipitales.
Pleura ,
pleura, being the serous membrane of the lung, it is divided into visceral (pulmonary) and parietal (parietal). Each lung is covered with pleura (pulmonary), which along the surface of the root passes into the parietal pleura.
^ Visceral (pulmonary) pleura,pleura visceralis (pulmonalls). Forms downward from the root of the lung pulmonary ligament,lig. pulmonary
Parietal (parietal) pleura,pleura parietalis, in each half of the chest cavity it forms a closed sac containing the right or left lung, covered with visceral pleura. Based on the position of the parts of the parietal pleura, it is divided into the costal, mediastinal and diaphragmatic pleura. Costal pleura, pleura costalis, covers the inner surface of the ribs and intercostal spaces and lies directly on the intrathoracic fascia. Mediastinal pleura, pleura mediastindlis, adjacent to the mediastinal organs on the lateral side, fused with the pericardium on the right and left; on the right it also borders with the superior vena cava and azygos vein, with the esophagus, on the left with the thoracic aorta.
Above, at the level of the superior aperture of the chest, the costal and mediastinal pleura pass into each other and form dome of pleura,cupula pleurae bounded on the lateral side by the scalene muscles. The subclavian artery and vein are adjacent to the dome of the pleura anteriorly and medially. Above the dome of the pleura is the brachial plexus. Diaphragmatic pleura, pleura diaphragmatica, covers the muscular and tendon parts of the diaphragm, with the exception of its central sections.
^ Sinuses of the pleura. In the places where the costal pleura transitions into the diaphragmatic and mediastinal pleura, pleural sinuses,recessus pleurdles. These sinuses are the reserve spaces of the right and left pleural cavities.
Between the costal and diaphragmatic pleura there is costophrenic sinus , recessus costodiaphragmaticus. At the junction of the mediastinal pleura and the diaphragmatic pleura there is diaphragmomediastinal sinus , recessus phrenicomediastinalis. A less pronounced sinus (depression) is present at the place where the costal pleura (in its anterior section) transitions into the mediastinal pleura. Here it is formed costomedial sinus , recessus costomediastinalis.
Boundaries of the pleura. On the right is the anterior border of the right and left costal pleura from the dome of the pleura it descends behind the right sternoclavicular joint, then goes behind the manubrium to the middle of its connection with the body and from here descends behind the body of the sternum, located to the left of the midline, to the VI rib, where it goes to the right and passes into the lower border of the pleura. Bottom line The pleura on the right corresponds to the line of transition of the costal pleura into the diaphragmatic pleura.
Left anterior border of the parietal pleura from the dome it goes, just like on the right, behind the sternoclavicular joint (left). Then it is directed behind the manubrium and the body of the sternum down to the level of the cartilage of the IV rib, located closer to the left edge of the sternum; here, deviating laterally and downwards, it crosses the left edge of the sternum and descends near it to the cartilage of the VI rib, where it passes into the lower border of the pleura. Lower border of the costal pleura on the left is located slightly lower than on the right side. In the back, as well as on the right, at the level of the 12th rib it becomes the posterior border. Posterior pleural border corresponds to the posterior line of transition of the costal pleura into the mediastinal pleura.
PLEURAL SINES
Of the four sinuses (costophrenic, anterior costomediastinal, posterior costomediastinal, phrenic-mediastinal), only two are actually determined radiologically - costophrenic and phrenic-mediastinal.
Normally, in most cases, the diaphragm forms an acute angle with the ribs (chest wall) (Fig. 50); when inhaling, the diaphragm moves downwards and the sinus opens (Fig. 51, 52).
The rounding of the costophrenic angle does not necessarily have an inflammatory origin (effusion, moorings). This also happens with pulmonary emphysema without pleurisy and adhesions and is caused by the fact that the lung, due to loss of elasticity, no longer has a lower sharp edge (Zawadowski). Anterior and posterior sections of the costophrenic
The sinuses are edge-forming in the lateral projection, and the posterior part of the osteophrenic sinus is much deeper than the anterior one.
The anterior and posterior costomediastinal sinuses are not entirely visible on radiographs; The cardiophrenic sinuses are clearly visible in front (Fig. 53).
The topography of the right phrenic-cardiac sinus was studied by A.E. Prozorov. He believed that the shadow crossing and occupying the sinus does not belong to the inferior vena cava, as was interpreted in most manuals on x-ray diagnostics (Schinz et al., etc.), not to an abnormally developed area of the pericardium (KbPeg) or the hepatic vein (Assmann), but to the right pulmonary ligament.
The pulmonary ligament, being a duplicate of the pleura, goes from the lower part of the root of the lung to the basal areas of the pulmonary parenchyma. Located in the frontal plane and having a triangular shape, it divides the lower part of the paramediastinal pleura into posterior and anterior sections. At the base of the lung it passes to the diaphragm. Length
Rice. 51. Diagram of the costophrenic sinuses in various phases of diaphragmatic breathing.
a-direct projection; b-lateral projection;
solid line - breathing pause; the lower dotted line is the inhalation phase, the upper dotted line is the exhalation phase (according to Hitzenberger).
Rice. 52. Diagram of the costophrenic sinuses in various phases of costal breathing.
o - direct projection; b - lateral projection;
solid line - inhalation phase; the upper dotted line is the expiratory phase; the lower dotted line is the respiratory pause (according to Ho1-zknecht, Hofbauer and Hitzenberger).
pulmonary ligament on a corpse in an adult reaches 6-8 cm. On the left it is located almost the same as on the right, with the only difference being that its downward direction follows a more vertical line (Fig. 54, 55). It is developed unevenly and in some it is weakly expressed. On the left in direct projection it is covered by the shadow of the heart. On the right is most clearly visible
its shadow at the moment of deep inspiration, when the flattening diaphragm strains the pulmonary ligament; it disappears when the patient turns
The shadow adjacent to the shadow of the heart in direct projection on the right belongs to the inferior vena cava (K. V. Pomeltsov). On the left there are the "following" relationships:
When inhaling, the sternum moves anteriorly and slightly upward. The anteromedial edge of the lung penetrates between the heart and the chest. This sinus, like the right costomediastinal one, is not visible. Instead, the space between the heart and the diaphragm is designated as the sinus. However, this is not a true sinus, since it does not represent any spare space for the lung (Schinz).
It often contains fat. "
Clearly visible on hard radiographs and direct tomograms
the angle formed by the paravertebral part of the diaphragm and the pos-
night light Barsony and Koppenstein called this angle “sinus phrenico-para-vertebralis” or “sinus paravertebralis”. In their opinion, it is not actually a special pleural sinus, but only a posterior continuation of the costophrenic sinus. Schinz calls it "sinus phrenico-vertebralis". Both sinuses converge anteriorly. Their extent is clearly visible on tomograms made after the introduction of air into the perinephric tissue. This reveals the inner part of the shadow of the diaphragm, extending to the lumbar vertebrae (F. Kovacs and Z. Žebök).
On hard direct radiographs under normal conditions during inspiration, the acute paravertebral sinus is clearly visible (Fig. 56). Its medial, vertical side is formed by the accompanying line of the spine, the lateral side, convex upward, is formed by the diaphragm. The position of the sinus varies from person to person.
Consequently, three sinuses are visible on radiographs: costophrenic, cardiac diaphragmatic and pair
vertebral. The costophrenic and cardiophrenic sinuses are also visible during fluoroscopy, including when using
rays of normal hardness.
In our opinion, for practical purposes the costo-diaphragm
The sinus should be divided into three sections and designated: external, posterior and anterior costophrenic sinuses. This division is followed by Yu. N. Sokolov and L. S. Rozenshtrauch, Barsony and Koppenstein. With this division, an X-ray examination should distinguish five sinuses on each side:
anterior costophrenic; posterior costophrenic;
external costophrenic; cardiophrenic; paravertebral.
Tuberculosis kills thousands of people around the world every day. In our country, they do not pay much attention to this disease, and mandatory fluorography has not changed this sad trend for the better, but it is still better than it was before. Today, the poor and hungry are not the group that suffers from tuberculosis; an increasing number of wealthy people are diagnosed with this diagnosis.
Yes, those who are malnourished have a greater predisposition to this disease, but the saturated lives of the rich and successful also make them vulnerable to this infection. Social status does not protect you from tuberculosis, and you don’t have to be homeless or a former prisoner to get it.
To somehow protect yourself from this, you need to undergo fluorography annually. Having the radiologist's findings in hand, we see mysterious inscriptions on the map and cannot decipher what it means. Individual words can still be read somehow, but their meaning is still beyond the understanding of the average person. Next we will talk about how to understand the fluorograph’s conclusion and not panic.
Fluorography. general information
X-ray radiation is the basis of any fluorograph. They pass through the entire person and stop at the pulmonary film. To date, this is the cheapest way to detect disease in the chest.
What do the fluorography results say?
Changes in the density of organs in the chest speaks volumes. The connective tissue in the lungs develops and depending on how it happens and where it is localized, all this is classified and has its own name. Connective tissue is very strong. If a person suffers from asthma or asthma, then thickened walls of blood vessels or bronchi will be noticeable in the pictures. The cavities in the lungs have their own characteristic appearance, especially if they contain fluid. Round shadows with liquid have different positions. The pleural cavity and pleural sinuses are quite often affected by fluid as well. Local lung compactions are also very quickly detected by an experienced specialist.
- Inflammation in the final stages.
- Various types of tumors.
- Pathological compactions.
- Sclerosis and fibrosis.
- Presence of foreign bodies, air or liquid.
Fluorography reveals changes of the following type:
So, what are the most common diagnoses of domestic fluorographs?
They stamped your medical card and released you without further ado, which means we can say with confidence that you are healthy. If suddenly something is wrong, then according to the law, a health worker must notify you that additional examination is needed.
Expanded/densified roots
The collection of structures located at the hilum of the lungs is usually called the roots of the lungs. From the root, bronchial arteries, lymph nodes, blood vessels, etc. are formed. In most cases, the phenomenon of compaction and expansion of the roots of the lungs occurs in pairs and occurs very often. Of course, there is an isolated compaction without expansion, but in this case, this diagnosis indicates a chronic process and a large amount of connective tissue is observed in the structures of the roots of the lungs.
Compaction and expansion of the roots occurs due to swelling of large vessels and bronchi or when the lymph nodes become enlarged. These processes can be either isolated or simultaneous and are the result of pneumonia or acute bronchitis. This diagnosis is also present in other diseases, but they are accompanied by lesions, decay cavities, etc. In this case, the roots of the lungs become denser due to the increase in local groups of lymph nodes. In the overview image (1:1), it is quite difficult to distinguish the lymph nodes from other structural elements of the lungs.
The roots are heavy
If you read a conclusion in your medical record that “the roots are enlarged, thickened,” but there are no health problems, then this indicates inflammation or bronchitis. This symptom is stable for smokers, because smoke particles constantly irritate the walls of the bronchi and contribute to the compaction of the lymph nodes. The lymph nodes are responsible for cleansing the lungs, and the smoker does not feel any discomfort.
If a person has any complaints, then it is best to consult a therapist. Despite the fact that chronic diseases allow you to lead a normal life, this does not mean that you need to forget about this unpleasant nuance. Chronic diseases may not lead to quick death, but they become the cause of predicted and already fatal diseases in the future.
Pulmonary/vascular pattern increased
Not a single fluorography can do without a pulmonary pattern. The pulmonary pattern consists of the shadows of blood vessels, arteries and veins, so it is not surprising that many people use the term vascular instead of the term pulmonary pattern. A fairly common diagnosis that indicates an increase in the pulmonary pattern; it is formed due to the fact that some areas in the lungs are more intensively supplied with blood. Acute inflammation of any origin leads to an increase in the pulmonary pattern and this can indicate both ordinary bronchitis and pneumonitis, and this already indicates cancer. In case of pneumonia, a repeat X-ray is very often prescribed to find out whether it is pneumonitis, because in the images these two diseases are very similar. An increased pulmonary pattern also indicates problems with the heart, but such a disease usually does not go away without symptoms. In general, we can say that an increase in the pulmonary pattern indicates bronchitis, pneumonia, etc., but it disappears within a few weeks after the disease has been defeated.
Fibrosis
Fibrous tissue on a fluorogram is a consequence of past pulmonary diseases. It replaces free space in the body. For example, a person has had a penetrating wound to the chest or has undergone surgery, this tissue plays the role of connective tissue and, in general, fibrosis is a more positive than negative diagnosis and is the result of the fact that some part of the lung tissue has been lost.
Focal tissues
Darkening of the pulmonary field is one of the types of foci. Lesions are very common and not uncommon in medical practice. They have their own symptoms, localized in certain places, and are also quite often combined with other diseases. A shadow up to 1 cm in size is usually called a focus. A sign of focal pneumonia is the location of focal tissues in such sections of the lungs as the lower and middle. An active inflammatory process is indicated by such words in the medical card as “increased pulmonary pattern”, “merging of shadows” and “uneven edges”. Foci that are dense and even in nature eventually subside on their own. If lesions are found in the upper sections of the lungs, then this diagnosis is typical for tuberculosis and in this case additional examination is prescribed.
Calcifications
Calcifications appear as round shadows on a fluorogram and their density resembles bones. Rib callus is very often similar to calcitis, but regardless of the nature of this formation, it is harmless, because the body “isolates” the infection from the rest of the body with calcitis.
Pleuroapical layers, adhesions
Adhesions usually do not require any treatment or intervention. They occur after inflammation and isolate the site of inflammation from healthy tissue. In some cases, adhesions can cause pain and in this case, medical help cannot be avoided. If the pleura of the apex of the lungs thickens, this should alert you, because very often this occurs as a result of a tuberculosis infection, but only a doctor can judge this.
Sealed/free sinus
Sinuses form in the folds of the pleura and when everything is fine, they are free. The liquid in these formations should definitely alert you. A sealed sinus indicates adhesions. A sealed sinus indicates former injuries, past pleurisy, etc. If there are no other symptoms in general, then it is not dangerous.
Aperture anomaly
There are a large number of reasons that lead to a change in the diaphragm, and this is a very common finding of a fluorograph. Only if this anomaly combines several other changes, then we can talk about some kind of disease, so the doctor prescribes additional examinations. An accurate diagnosis based on diaphragm abnormality is not possible.
Displacement or expansion of the mediastinal shadow
The space between the lungs is called the mediastinum. Typically, widening of the mediastinum indicates an enlarged heart. It is unilateral and increases in the right or left side of the heart. Fluorography cannot judge the condition of the heart. The normal position of the heart depends on the physique of a particular person. For a short and plump person, a heart slightly shifted to the left is not bad. If a person is tall, then his heart can be in a vertical or teardrop-shaped position. For hypertensive patients, what is written in the chart is: “expansion of the mediastinum to the left,” “expansion of the heart to the left,” or simply “expansion.” The mediastinum can expand evenly, but this already indicates myocarditis, cardiac failure, etc. For cardiologists, the results of a fluorogram are not sufficient to make a specific diagnosis.
If the pressure increases on one side, then the fluorogram indicates a mixed mediastinum. This diagnosis means the asymmetric presence of fluid or air in the pleural cavity or large tumors in the lung tissue. This diagnosis is already serious, because it can cause a gross displacement of the heart and the intervention of specialists is very important in this case.
P. S. Despite the fact that fluorography in our ordinary hospitals is not without its drawbacks, it is still capable of detecting tuberculosis or lung cancer. It's worth going through it anyway. In our country, the epidemiological conditions for tuberculosis are simply excellent. The risk group is our normal state. By undergoing annual fluorography, we thereby protect ourselves from fatal diseases, because a disease detected in time significantly increases a person’s chances of survival.
In the chest cavity there are three completely separate serous sacs - one for each lung and one, middle, for the heart. The serous membrane of the lung is called the pleura. It consists of two layers: the visceral pleura, pleura-visceralis, and the parietal pleura, parietal, pleura parietalis.
The visceral or pulmonary pleura, pleura pulmonalis, covers the lung itself and fuses so tightly with the substance of the lung that it cannot be removed without damaging the integrity of the tissue; it enters the grooves of the lung and thus separates the lobes of the lung from each other. Villous protrusions of the pleura are found on the sharp edges of the lungs. Covering the lung on all sides, the pulmonary pleura at the root of the lung directly continues into the parietal pleura. Along the lower edge of the root of the lung, the serous leaves of the anterior and posterior surfaces of the root are connected into one fold, lig. pulmonale, which descends vertically down the inner surface of the lung and attaches to the diaphragm.
The parietal pleura, pleura parietalis, is the outer layer of the serous sac of the lungs. With its outer surface, the parietal pleura fuses with the walls of the chest cavity, and with its inner surface it faces directly to the visceral pleura. The inner surface of the pleura is covered with mesothelium and, when moistened with a small amount of serous fluid, appears shiny, thereby reducing friction between the two pleural layers, visceral and parietal, during respiratory movements.
The pleura plays a vital role in the processes of extravasation (excretion) and resorption (absorption), the normal relationships between which are sharply disrupted during disease processes of the thoracic cavity organs.
With macroscopic homogeneity and a similar histological structure, the parietal and visceral pleura perform different functions, which is obviously due to their different embryological origin. The visceral pleura, in which blood vessels predominate over lymphatic vessels, primarily performs the function of excretion. The parietal pleura, which has in its costal region specific suction devices from the serous cavities and a predominance of lymphatic vessels over blood vessels, carries out the function of resorption. The slit-like space between the adjacent parietal and visceral layers is called the pleural cavity, cavitas pleuralis. In a healthy person, the pleural cavity is macroscopically invisible.
At rest, it contains 1-2 ml of liquid, which, with a capillary layer, separates the contacting surfaces of the pleural layers. Thanks to this fluid, adhesion occurs between two surfaces that are under the influence of opposing forces: inspiratory stretch of the chest and elastic traction of the lung tissue. The presence of these two opposing forces: on the one hand, the elastic tension of the lung tissue, on the other, the stretching of the chest wall, creates negative pressure in the pleural cavity, which is thus not the pressure of some gas, but arises due to the action of the mentioned forces. When the chest is opened, the pleural cavity artificially increases, since the lungs collapse due to the balancing of atmospheric pressure both on the outer surface and from the inside, from the bronchi.
The parietal pleura is one continuous sac surrounding the lung, but for purposes of description it is divided into sections: pleura costaiis, diaphragmatica and mediastinalis. In addition, the upper part of each pleural sac is called the dome of the pleura, cupula pleurae. The dome of the pleura covers the apex of the corresponding lung and stands out from the chest in the neck area 3–4 cm above the anterior end of the first rib. On the lateral side, the dome of the pleura is limited by mm. scaleni anterior et medius, medially and in front lie a. and v. subclaviae, medially and posteriorly - the trachea and esophagus. Pleura costaiis is the most extensive section of the parietal pleura, covering the ribs and intercostal spaces from the inside. Under the costal pleura, between it and the chest wall, there is a thin fibrous membrane, fascia endothoracica, which is especially pronounced in the area of the pleural dome.
Pleura diaphragmatica covers the upper surface of the diaphragm, with the exception of the middle part, where the pericardium is directly adjacent to the diaphragm. Pleura mediastinalis is located in the anteroposterior direction, extends from the posterior surface of the sternum and the lateral surface of the spinal column to the root of the lung and limits the mediastinal organs laterally. Posteriorly on the spine and anteriorly on the sternum, the mediastinal pleura passes directly into the costal pleura, below at the base of the pericardium into the diaphragmatic pleura, and at the root of the lung into the visceral layer.
Borders of the pleural sacs and lungs.
The right and left pleural sacs are not entirely symmetrical. The right pleural sac is somewhat shorter and wider than the left. Asymmetry is also observed in the outlines of the anterior edges of the bags. The tops of the pleural sacs, as indicated, protrude from the upper opening of the chest and reach the head of the 1st rib (this point corresponds approximately to the spinous process of the 7th cervical vertebra, palpable on a living person) or 3-4 cm above the anterior end of the 1st rib.
The posterior border of the pleural sacs, corresponding to the line of transition of the costal pleura into the mediastinal one, is quite constant; it stretches along the spinal column and ends at the heads of the XII ribs.
The anterior border of the pleural sacs on both sides runs from the apex of the lung to the sternoclavicular joint. Further on the right side, the edge of the pleural sac goes from the sternoclavicular joint to the midline near the junction of the manubrium with the body of the sternum, from here it descends in a straight line and at the level of the VI-VII ribs or processus xiphoideus bends to the right, passing into the lower border of the pleural sac. On the left side, the anterior edge of the pleural sac from the sternoclavicular joint also goes obliquely and down to the midline, but over a shorter distance than on the right. At the level of the IV rib, it deviates laterally, leaving the triangular area of the pericardium located here not covered by the pleura. Then the anterior border of the left pleural sac descends parallel to the edge of the sternum to the cartilage of the VI rib, where it deviates laterally downwards, passing into the lower border.
The lower border of the pleural sacs represents the line of transition of the costal pleura to the diaphragmatic pleura. On the right side, it crosses the VII rib along the linea mammillaris, the IX rib along the linea axillaris media and then goes horizontally, crossing the X and XI ribs, to the meeting point of the lower and posterior edges on the head of the XII rib. On the left side the lower border of the pleura is slightly lower than on the right. The boundaries of the lungs do not coincide with the boundaries of the pleural sacs in all places. The position of the apices of the lungs and their posterior edges fully corresponds to the boundaries of both pleurae. The anterior edge of the right lung also coincides with the pleural border. This correspondence of the anterior edge of the left lung with the pleura is observed only up to the level of the fourth intercostal space. Here, the edge of the left lung, forming a cardiac notch, retreats to the left from the pleural border. The lower borders of the lungs extend significantly above the lower borders of both pleurae. The lower border of the right lung goes in front behind the VI rib, along the linea mammillaris it approaches the lower edge of the VI rib, along the linea axillaris media it crosses the VIII rib, along the linea scapularis it crosses the X rib and at the spine it approaches the upper edge of the XI rib. The border of the left lung is slightly lower. In those places where the pulmonary edges do not coincide with the pleural boundaries, between them there remain spare spaces limited by two parietal layers of the pleura, called pleural sinuses, recessus pleurales. The lung enters them only at the moment of the deepest breath. The largest spare space, recessus costodiaphragmaticus, is located on both sides along the lower border of the pleura between the diaphragm and the chest - here the lower edges of the lungs do not reach the border of the pleura. Another, smaller, spare space is located at the anterior edge of the left lung along the cardiac notch between the pleura costais and pleura mediastinalis. It is called hecessus costomediastinalis. The fluid (inflammatory effusion) formed during inflammation of the pleura (pleurisy) accumulates primarily in the pleural sinuses. The pleural sinuses, being part of the pleural cavity, at the same time differ from it. The pleural cavity is the space between the visceral and parietal layers of the pleura. Pleural sinuses are spare spaces of the pleural cavity located between the two parietal layers of the pleura.