Along which edge of the rib do the intercostal vessels pass? Examination of the chest. The concept of plastic surgery on the mammary gland

Topography of intercostal spaces:

In the intervals between the ribs are the external and internal intercostal muscles, mm. intercostales externi et interni, fiber and neurovascular bundles.

External intercostal muscles go from the lower edge of the ribs obliquely from top to bottom and anteriorly to the upper edge of the underlying rib. At the level of the costal cartilages, the external intercostal muscles are absent and replaced by the external intercostal membrane, membrana intercostalis externa, which preserves the direction of the connective tissue bundles corresponding to the course of the muscles.

Deeper located internal intercostal muscles, whose beams go in the opposite direction: from bottom to top and back. Behind the costal angles, the internal intercostal muscles are no longer there, they are replaced by the boggy bundles of the internal intercostal membrane, membrana intercostalis interna.

The space between adjacent ribs, bounded from the outside and from the inside by the corresponding intercostal muscles, is called intercostal space spatium intercostal. It contains intercostal vessels and a nerve: a vein, below it is an artery, and even lower is a nerve (VAN). The intercostal bundle in the area between the paravertebral and middle axillary lines lies in the groove, sulcus costalis, of the lower edge of the overlying rib.

Anterior to the midaxillary line, the intercostal vessels and nerves are located in the intermuscular tissue and are not protected by the ribs, so it is preferable to make any chest punctures posterior to the midaxillary line along the upper edge of the underlying rib.

Posterior intercostal arteries depart from the aorta front from the internal mammary artery. Due to numerous anastomoses, they form a single arterial ring, the rupture of which can lead to severe bleeding from both ends of the damaged vessel. Difficulties in stopping bleeding are also explained by the fact that the intercostal vessels are closely connected with the periosteum of the ribs and the fascial sheaths of the intercostal muscles, which is why their walls do not collapse when injured.

intercostal nerves upon exiting the intervertebral foramina, giving back branches, they go outward. From the side of the chest cavity to the angle of the rib, they are not covered with muscles and are separated from the parietal pleura by bundles of the internal intercostal membrane and a thin sheet of intrathoracic fascia and subpleural tissue. This explains the possibility of involvement of the intercostal nerves in the inflammatory process in diseases of the pleura. The lower 6 intercostal nerves innervate the anterolateral abdominal wall.

The next layer of the chest wall is intrathoracic fascia, fascia endothoracica, lining the inside of the intercostal muscles, ribs and costal cartilages, the sternum, as well as the anterior surface of the thoracic vertebrae and the diaphragm. The fascia over each of these formations has the corresponding name: fascia costalis, fascia diaphragmatica, etc. In front, in close connection with the intrathoracic fascia, there is a. thoracica interna.

Primary surgical treatment of penetrating wounds of the chest wall.

Indications: stab, stab-cut, cut, gunshot wounds with open or intense pneumothorax, intrapleural bleeding.

Anesthesia: the operation is performed under endotracheal anesthesia, if possible with separate bronchial intubation. The skin and muscle wound is excised with a fringing incision within healthy tissues. Excised damaged intercostal muscles and parietal pleura.

Revision of the pleural cavity. The parietal pleura is opened wide enough and the pleural cavity is examined. Foreign bodies, blood clots and liquid blood are removed from it. In some cases, mainly in stab and stab wounds, liquid blood is filtered and used for back transfusion into a vein. The sources of bleeding and air leakage are determined, after which hemostasis and aerostasis are performed. They carry out an audit of the adjacent organs, mediastinum and diaphragm, taking special measures in cases of damage.

One or two drains are introduced into the pleural cavity above the diaphragm - anterior and posterior. The main one is the posterior drainage, which is inserted into the seventh-eighth intercostal space along the posterior axillary line and laid along the posterior chest wall to the dome of the pleural cavity. Anterior drainage is introduced in the fourth-fifth intercostal space with insufficient or doubtful aerostasis and is placed between the lung and the mediastinum. The end of the drain must also reach the dome of the pleural cavity.

Suturing the wound of the chest wall. The main principle of suturing the wound of the chest wall is the imposition of layered sutures in order to create complete tightness. If possible, which happens, as a rule, only in cases of small wounds, the first row of interrupted sutures is applied to the pleura, intrathoracic fascia and intercostal muscles. The main interrupted sutures are applied in layers to the more superficial muscles of the chest wall. Further

sutured own and superficial fascia with subcutaneous tissue, and then the skin. The diverged ribs are brought together with one, two or three polyspast sutures, and defects in the pleura and muscles are closed with the help of muscle flaps, which are cut out from the pectoralis major, latissimus dorsi, and trapezius muscles, thus achieving complete tightness.

Breast

a complex area of ​​the human body that contains vital organs: the heart and lungs.

The upper border of the chest is determined by a line drawn along the upper edge of the jugular notch, collarbones, humeral processes of the scapulae and the spinous process of the VII cervical vertebra.

The lower border is represented by a line passing from the xiphoid process of the sternum, along the costal arches, along the free edges of the X-XII ribs and the spinous process of the XII thoracic vertebra. The chest is separated from the upper extremities along the deltoid grooves in front, and along the medial edge of the deltoid muscle in the back.

The boundaries of the chest cavity do not correspond to the boundaries of the chest, since the dome of the pleura of the right and left lungs protrudes 2-3 cm above the clavicles, and 2 domes of the diaphragm are located at the level of the IV and V thoracic vertebrae.

The jugular notch is projected onto the lower edge of the second thoracic vertebra. The lower angle of the scapula is projected onto the upper edge of the VIII rib.

To determine the projection of the organs of the chest cavity on the chest wall, lines are used:

anterior midline,

sternal line,

parasternal line,

midclavicular line,

anterior axillary line,

middle axillary line,

Posterior axillary line

scapular line,

circumvertebral line,

spinal line,

Posterior median line

Layers of the chest wall:

skin, subcutaneous fat,

The superficial fascia, which forms the fascial sheath for the mammary gland, also extends the septa from the posterior leaf to the anterior, forming 15-20 lobules.

Own fascia of the chest, which forms fascial cases for the pectoralis major and minor muscles on the anterior surface of the chest. On the back surface of the chest, the own fascia is divided into two sheets and forms fascial cases for the latissimus dorsi and the lower part of the trapezius muscle. A deep sheet of its own fascia limits the bone-fibrous beds of the scapula with the muscles, vessels and nerves lying in them, and also forms cases for the large and small rhomboid muscles of the back and the muscle that lifts the scapula.

pectoralis major muscle

Superficial subpectoral cellular space,

pectoralis minor,

Deep subpectoral cellular space,

Serratus anterior.

Ribs with external and internal intercostal muscles,

Intrathoracic fascia

Prepleural adipose tissue

Parietal pleura.

Limited to:

ribs top and bottom

external intercostal muscle

internal intercostal muscle

At the same time, the relative position of the muscles is not the same throughout the entire interval from the vertebral lines to the sternal lines. On the back surface, the internal pectoral muscles do not reach the vertebral line, and thus a gap remains between the muscles. And in front, at the level of the costal cartilages, the muscles are represented by an aponeurotic plate tightly fixed to the sternum.



In the intercostal spaces are located intercostal neurovascular bundles, represented by intercostal arteries, intercostal veins and intercostal nerves.

There are anterior and posterior intercostal arteries. The anterior intercostal arteries originate from the internal thoracic arteries, which in turn are branches of the subclavian arteries. The posterior intercostal arteries are branches of the thoracic aorta.

Thus, it is formed arterial ring, the presence of which carries both benefits and dangers.

The “+” of such anatomy is the presence of anastomoses between the two main sources of blood circulation, which ensures adequate blood supply to the intercostal muscles responsible for our breathing even in the event of occlusion of one of the main sources.

"-" is that when the intercostal arteries are injured, the volume of blood loss doubles !!!

Intercostal veins, respectively, arteries are superior, inferior, anterior and posterior. Again, the main will be the front and rear. From the anterior intercostal arteries, blood flows into the anterior thoracic veins. And from the posterior intercostal veins, blood flows to the left into the semi-unpaired vein, and to the right into the unpaired vein.

The intercostal nerves are branches of the sympathetic trunk.

The intercostal neurovascular bundle is located in the groove of the rib, and if viewed from top to bottom, then the vein lies above all, the artery lies below it, and the nerve lies below the artery.

However, the SNP is located in the sulcus not throughout the intercostal space, but only up to the mid-axillary line, medial to which the neurovascular bundle exits the sulcus.

Thus, these topographic and anatomical features of the location of the SNP determined certain rules for performing puncture of the pleural cavity.

Intercostal neuralgia is a lesion of the intercostal nerves, accompanied by an intense pain syndrome. The pathology itself does not pose a threat to life, however, serious diseases can be masked under the symptoms of intercostal neuralgia, which include, first of all, cardiovascular pathologies, in particular myocardial infarction. In some cases, intercostal neuralgia indicates the presence of other diseases, for example, neoplasms of the spinal cord or chest organs, pleurisy.

Intercostal neuralgia is one of the most common diseases of the human nervous system.

The intercostal nerves contain both sensory and motor and sympathetic fibers. In the human body, there are 12 pairs of nerves in the intercostal region, each of which passes below the edge of the corresponding rib in the intercostal space as part of the neurovascular bundle. The intercostal nerves innervate the skin and muscles of the peritoneum, the costal and diaphragmatic parts of the pleura, the anterior abdominal wall, the mammary gland, and the chest. Neuralgia occurs when the roots of the intercostal nerves are compressed at the point of their exit from the spine, as a rule, as a result of muscle spasm.

Intercostal neuralgia occurs equally often in men and women. Susceptibility to the disease increases with age.

Synonyms: neuralgia of intercostal nerves, thoracic sciatica.

Causes of intercostal neuralgia and risk factors

The most common causes of intercostal neuralgia are:

  • osteochondrosis, spondylitis, ankylosing spondylitis and other diseases of the thoracic spine;
  • tumors of the thoracic spinal cord;
  • abrupt unsuccessful movement;
  • chest trauma;
  • forced uncomfortable position of the body;
  • general hypothermia of the body, hypothermia of the chest and back;
  • pathology of the upper gastrointestinal tract;

In women, intercostal neuralgia can be caused by wearing tight underwear, as well as being underweight. In children and adolescents, intercostal neuralgia may occur during the period of intensive growth of the bone skeleton.

The contributing factors are:

  • metabolic disorders (diabetes mellitus);
  • age-related changes in blood vessels;
  • diseases of the nervous system;
  • infectious and inflammatory diseases;
  • uncomfortable workplace.

Forms of the disease

There are two main forms of intercostal neuralgia:

  • radicular - due to irritation of the roots of the spinal cord and is accompanied by pain in the thoracic region, can be disguised as cardiac pathology;
  • reflex - occurs due to muscle tension in the intercostal spaces.
Intercostal neuralgia occurs equally often in men and women. Susceptibility to the disease increases with age.

Depending on the localization, intercostal neuralgia is classified into unilateral and bilateral. The latter often occurs against the background of immunodeficiency, radiation sickness, with herpes infection and a number of other diseases.

Symptoms of intercostal neuralgia

The main symptom of intercostal neuralgia is paroxysmal piercing pain, which can be shooting, burning, stabbing, resembling an electric shock. The pain is aggravated by laughing, coughing, deep breathing, turning the torso, lifting the upper limbs. In addition, pain increases with palpation of the affected area, and can become unbearable for the patient. The patient takes a forced position of the body (antalgic postures) to reduce or stop pain. The pain is prolonged, often persisting day and night, although its intensity may vary.

Pain can have different localization. In women, against the background of hormonal changes in menopause and / or postmenopausal period, pain is often noted in the area of ​​the projection of the heart, pain can radiate to the mammary gland. In men, pain is more often localized at the level of the lower ribs, on the left side of the chest. Depending on the location of the lesion, pain can radiate to the region of the heart, scapula, epigastrium. With the localization of pain along one or two intercostal nerves, it can acquire a girdle character.

A characteristic sign of intercostal neuralgia is that pain does not decrease at night. In the early stages of the disease, pain in the chest may be less intense, manifest as a tingling sensation, but increase with the progression of the pathology. Pain in intercostal neuralgia can be either unilateral or bilateral. During the first few days from the onset of the pathological condition, attacks of intercostal neuralgia can lead to sleep disturbances (up to insomnia) and worsening of the patient's general condition.

In children, intercostal neuralgia is manifested by severe pain in the affected area and is accompanied by convulsions, sleep disturbance, increased excitability, speech disorder.

The clinical picture of the disease may include:

  • muscle spasms in the affected area;
  • numbness of the affected area;
  • increased sweating (hyperhidrosis);
  • pallor or redness of the skin;
  • feeling of crawling goosebumps;
  • shortness of breath (due to incomplete breathing during attacks of pain); etc.

Signs of intercostal neuralgia, which is caused by a herpetic viral infection, are a rash on the skin and itching that occurs even before the rash appears. Skin rashes are pink spots that transform into vesicles and dry up. The rash is localized on the skin of the intercostal space. In place of the elements of the rash during the period of convalescence, temporary hyperpigmentation of the skin is observed.

Diagnosis of intercostal neuralgia

Primary diagnosis of intercostal neuralgia is carried out on the basis of complaints and history taking, as well as an objective examination of the patient. Often, the data obtained is sufficient to diagnose the disease. In complex diagnostic cases, as well as for the purpose of differential diagnosis with other pathologies that have similar manifestations, an additional examination is carried out, which, depending on the indications, includes:

  • magnetic resonance and computed tomography (to exclude neoplasms, hernia);
  • x-ray examination of the chest and spine in direct, lateral and oblique projections;
  • electroneurography (with suspicion of the consequences of injuries);
  • electrocardiography (to exclude diseases of the cardiovascular system);
  • ultrasound procedure;
  • contrast discography;
  • gastroscopy (to exclude pathologies of the gastrointestinal tract);
  • general and biochemical blood test;
  • serological blood test; etc.

The information content of computed tomography increases when combined with X-ray contrast examination of the CSF pathways of the spinal cord (myelography).

In some cases, intercostal neuralgia indicates the presence of other diseases, for example, neoplasms of the spinal cord or chest organs, pleurisy.

It is possible to detect pathology at an early stage, as well as to monitor the effectiveness of treatment using electrospondylography. The method allows you to assess the condition of the spine and determine the degree of damage.

Differential diagnosis of intercostal neuralgia with other diseases is necessary:

  • cardiovascular pathologies (angina pectoris, coronary heart disease, myocardial infarction);
  • intervertebral hernia;
  • chest sciatica;
  • lung cancer and other neoplasms of the chest;
  • diseases of the gastrointestinal tract (gastritis, acute pancreatitis, peptic ulcer);
  • renal colic ; and etc.

Treatment of intercostal neuralgia

Patients with intercostal neuralgia are shown bed rest lasting from several days to several weeks.

Acute pain syndrome accompanying intercostal neuralgia is stopped by parenteral administration of analgesics. If this is not enough, they resort to novocaine blockade of the intercostal nerves. After the intensity of the pain decreases, the patient is transferred to the parenteral administration of painkillers.

Treatment of intercostal neuralgia is complex. With increased muscle tone, centrally acting muscle relaxants are used. Edema in the affected area is eliminated with the help of diuretic drugs, as well as venotonics. In order to improve the functions of the nerve involved in the pathological process, parenteral use of ascorbic acid and vitamins of group B is indicated. According to indications, non-steroidal anti-inflammatory drugs are used (for patients with heartburn, gastritis or peptic ulcer, their appointment is supplemented with drugs from the group of organotropic gastrointestinal drugs), sedatives, antidepressants, vitamin complexes.

In the case of the development of intercostal neuralgia against the background of a herpes infection, antiviral drugs, antihistamines are prescribed. Treatment is supplemented by topical application of antiherpetic drugs in the form of an ointment.

In women, intercostal neuralgia can be caused by wearing tight underwear, as well as being underweight. In children and adolescents, intercostal neuralgia may occur during the period of intensive growth of the bone skeleton.

As an addition to the main treatment of intercostal neuralgia in the area of ​​pain localization, physiotherapy and manual therapy can be used after relief of acute symptoms of intercostal neuralgia

In the event of intercostal neuralgia due to displacement of the vertebrae or osteochondrosis, gentle manual therapy or traction of the spinal column can be performed. With intercostal neuralgia that has developed against the background of spinal pathologies, it is recommended to supplement the main treatment with physiotherapy exercises, including a set of restorative exercises.

With intercostal neuralgia caused by a neoplasm, treatment is carried out in the oncology department.

Possible complications and consequences

In the absence of adequate treatment, intercostal neuralgia can have complications:

  • circulatory disorders with subsequent development of pathologies of muscles and internal organs;
  • chronic pain syndrome;
  • exacerbation of chronic diseases of the digestive system;
  • increased blood pressure, hypertensive crisis;
  • transient ischemic attack, stroke;
  • an attack of angina on the background of intense pain; and etc.

Forecast

With timely therapy, the prognosis of the disease is favorable. In the case of intercostal neuralgia caused by a herpes infection, relapses are not uncommon.

Prevention

Specific prevention of neuralgia of the intercostal nerves has not been developed; general strengthening measures will help prevent the development of pathology. Recommended:

  • a healthy lifestyle, including regular moderate physical activity and a rational balanced diet;
  • timely treatment of diseases of the spine, chest injuries, pathologies of internal organs;
  • measures to help prevent curvature of the spine or treat an existing curvature;
  • avoiding hypothermia;
  • work in comfortable conditions, with a long forced position of the body, take breaks for a short warm-up.

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1. Shape and type of chest

The purpose of the examination is to determine the static and dynamic characteristics of the chest, as well as external respiratory parameters. To do this, determine the shape of the chest (correct or incorrect); chest type (normosthenic, hypersthenic, asthenic, emphysematous, paralytic, rachitic, funnel-shaped, navicular); symmetry of both halves of the chest; symmetry of respiratory excursions of both halves of the chest; curvature of the spine (kyphosis, lordosis, scoliosis, kyphoscoliosis); respiratory excursion of the chest at the level of the IV rib. The shape of the chest can be correct and incorrect (for diseases of the lungs, pleura, as well as for rickets, trauma of the chest and spine, bone tuberculosis).

The following types of chest are distinguished:

    normosthenic type is observed in persons of normosthenic physique. The anteroposterior dimensions of the chest are in the correct ratio with the lateral dimensions, the supraclavicular and subclavian fossae are moderately pronounced, the ribs in the lateral sections are moderately oblique, the shoulder blades do not fit snugly against the chest, the epigastric angle is straight;

    asthenic type is observed in persons with asthenic physique. The chest is elongated due to a decrease in the anteroposterior and lateral dimensions, sometimes flat, supraclavicular and subclavian spaces sink, the ribs in the lateral sections acquire a more vertical position, the shoulder blades lag behind the chest, the muscles of the shoulder girdle are poorly developed, the edge of the X rib is free and easily determined when palpation, the epigastric angle is acute;

    the hypersthenic type is observed in persons with a hypersthenic physique. The chest is shortened, the anteroposterior dimensions approach the lateral ones, the supraclavicular fossae are smoothed, the ribs in the lateral sections become horizontal, the intercostal spaces are narrowed, the shoulder blades fit snugly against the chest, the epigastric angle is obtuse;

    emphysematous (barrel-shaped) chest, in which the dimensions of the anteroposterior and lateral diameters approach each other, as a result of which the shape of the chest resembles a barrel (wide and short); the ribs are located horizontally, the supraclavicular and subclavian fossae are not distinguished, the shoulder blades are very closely adjacent to the chest and are almost not contoured, the epigastric angle is obtuse. Observed with emphysema and during an attack of bronchial asthma;

    paralytic chest resembles asthenic (elongated and flattened). The anteroposterior dimensions are much smaller than the transverse ones, the clavicles are sharply outlined, the supraclavicular and subclavian spaces recede. The shoulder blades sharply lag behind the chest, the epigastric angle is sharp. Paralytic chest is observed in patients with tuberculosis, chronic diseases of the lungs and pleura, with Marfan's syndrome, in malnourished people;

    rachitic chest (keeled) - the so-called chicken breast, in which the anteroposterior size is sharply increased due to the sternum protruding forward in the form of a keel, and there are also distinct thickenings at the junction of the costal cartilages into the bone ("rachitic beads");

    funnel-shaped chest has a funnel-shaped depression or depression in the lower third of the sternum and the xiphoid process. This form of the chest is observed in shoemakers due to the constant pressure of the shoe resting against the lower part of the still pliable sternum ("shoemaker's chest");

    the navicular chest has a navicular oblong depression in the middle and upper parts of the sternum (with syringomyelia). In addition, breathing parameters are evaluated: how the patient breathes - through the nose or mouth; type of breathing: chest (costal), abdominal (diaphragmatic or mixed); breathing rhythm (rhythmic or arrhythmic); depth of breathing (superficial, medium depth, deep); respiratory rate (number of breaths per minute).

Symmetry of respiratory excursions of the chest. Notice the movement of the angles of the scapula during deep inhalation and exhalation. Asymmetry of respiratory excursions may be the result of pleurisy, surgical interventions, wrinkling of the lung. Asymmetry of the chest may be associated with an increase in lung volume (due to the accumulation of fluid or air in the pleural cavity) and with its decrease (due to the development of pleural adhesions, atelectasis (collapse) of the lung or its lobe). Measurement of the maximum circumference and assessment of respiratory excursions of the chest is carried out by measuring the circumference of the chest with a centimeter tape at the height of maximum inspiration, while the tape is located behind the corners of the shoulder blades. Respiratory excursion of the chest is determined by measuring the circumference of the chest at the height of inhalation and exhalation. It decreases in the presence of pleural complications (after suffering pleurisy, pneumonia), emphysema, obesity. Deformation of the chest can be manifested by its retraction or protrusion in any area, developing as a result of diseases of the lungs and pleura. Retraction may result from shrinkage (fibrosis) or collapse (atelectasis) of the lung. Unilateral protrusion or expansion of the chest may be due to the accumulation of fluid in the pleural cavity (hydrothorax) or air (pneumothorax). On examination, attention is drawn to the symmetry of the respiratory movements of the chest. The doctor should put his hands on the posterior surface of the chest on the left and right and ask the patient to take a few deep breaths and exhalations. The lag of any half of the chest may be the result of damage to the pleura (dry and effusion pleurisy) and lungs (pneumonia, atelectasis). A uniform decrease and even the absence of respiratory excursions on both sides is characteristic of pulmonary emphysema.

Assessment of breathing parameters: Breathing through the nose is usually seen in a healthy person. Breathing through the mouth is observed in pathological conditions in the nasal cavity (rhinitis, ethmoiditis, polyposis, curvature of the nasal septum). Thoracic type of breathing is usually observed in women, abdominal (diaphragmatic) - in men.

Breathing rhythm: in a healthy person, uniform respiratory movements are observed, uneven respiratory movements occur in coma, agony, and cerebrovascular accident.

Breathing depth: superficial breathing occurs with intercostal neuralgia, pulmonary diseases with involvement of the pleura in the process, breathing of medium depth occurs in a healthy person, deep in athletes.

The measurement of the respiratory rate is carried out by counting the number of respiratory movements in 1 min, imperceptibly for the patient, for which the hand is placed on the surface of the chest. In a healthy person, the number of respiratory movements in 1 minute is 12-20. A decrease in the number of respiratory movements to 12 or less (bradypnea) is observed with cerebral edema and coma. Increased breathing (over 20) is observed in violation of the function of external respiration, as well as in the presence of obstacles to normal breathing (ascites, flatulence, broken ribs, diseases of the diaphragm).

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The space between the ribs is filled with intercostal muscles, ligaments, vessels and nerves (see Fig. 9).

The external intercostal muscles have a direction of fibers from top to bottom and from back to front. The muscle bundles are covered with a thin fascia, which is easily separated from the muscles, but is fused with the periosteum of the ribs. Throughout the cartilaginous part of the ribs, to the outer edge of the sternum, the bundles of the external intercostal muscle are replaced by shiny tendon bundles, which are called the external intercostal membrane. The direction of the muscle bundles of the internal intercostal muscle is opposite to those of the external intercostal muscle. Between the costal angle and the spine, on the path of the continuation of the internal intercostal muscles, there are internal intercostal membranes.

Between the external and internal intercostal muscles there is a gap filled with loose fiber, in which the intercostal neurovascular bundle is located: artery, vein and nerve. The posterior intercostal arteries arise from the thoracic aorta, with the exception of the first two, originating from the costocervical trunk. The right posterior intercostal arteries cross the spinal column in front, passing behind the esophagus, thoracic duct and unpaired vein, and then behind the thoracic sympathetic trunk.

The left posterior intercostal arteries run directly into the intercostal spaces, crossing the semi-azygous vein and the thoracic sympathetic trunk from the dorsal surface. The posterior intercostal arteries have well-defined anastomoses with the anterior ones, which are branches of the internal thoracic artery (see Fig. 6). In the posterolateral parts of the chest wall, the intercostal neurovascular bundle is adjacent to the costal groove. Here it is covered by the lower edges of the ribs. Behind the scapular and in front of the anterior axillary line, the neurovascular bundle occupies a median position in the intercostal space.

The intercostal muscles, ribs and costal cartilages are lined from the inside with intrathoracic fascia. Deeper than the intrathoracic fascia is a layer of loose fiber, which separates this fascia from the parietal fascia at the pleura.
The parietal pleura is divided into costal, diaphragmatic and mediastinal pleura.

The costal pleura is the largest part of the parietal pleura. It extends from the lateral surface of the vertebrae to the heads of the ribs and further forward to the sternum. It covers the posterior surface of the sternum for a short distance and passes into the mediastinal pleura. The costal pleura is adjacent to the intrathoracic fascia.

Between them, in areas from the 1st rib to the upper edge of the 4th rib, the dome of the pleura and its posterior section, there is loose fiber, due to which the pleura can be easily peeled off in this area. In zone IV-VII of the ribs and from them to the diaphragm, the pleura is more or less firmly connected to the fascia.

The mediastinal pleura is located in the sagittal plane from the sternum to the spine. At the root of the lung, it passes into the visceral pleura, and below the root of the lung forms a fold, the so-called pulmonary ligament. Below, the mediastinal pleura passes into the diaphragmatic, and in front and behind - into the costal pleura. The mediastinal pleura forms the upper and lower interpleural fields. In the upper field are the thymus, brachiocephalic veins, aortic arch and its branches, trachea, esophagus, in the lower - pericardium, heart and esophagus. On the left, the mediastinal pleura covers the phrenic nerve, the left lobe of the thymus, the upper left surface of the left brachiocephalic vein, the left subclavian artery, the esophagus, and the thoracic aorta.

In the lower sections, it approaches the pericardium and, quite near the diaphragm, to the esophagus. On the right, the mediastinal pleura is adjacent to the phrenic nerve, the right lobe of the thymus gland, the right surface of the right brachiocephalic vein and the superior vena cava, the right subclavian artery and vein, the arch of the unpaired vein, the right surface of the trachea and the right bronchus, the esophagus and a narrow strip to the thoracic aorta. Pronounced paraorgan loose fiber prevents the fixation of the mediastinal pleura to the organs and during surgical interventions it can easily be exfoliated. The exception is the pericardium, with which it is firmly connected.

The diaphragmatic pleura lines the diaphragm, except for the area covered by the pericardium. The pleura here is closely fused with the diaphragmatic fascia and the diaphragm, therefore it exfoliates from them with great difficulty.

The arterial blood supply of the costal pleura is carried out from the posterior intercostal and partially internal thoracic arteries, and the diaphragmatic - from the upper diaphragmatic and muscular-diaphragmatic, posterior intercostal arteries and anterior intercostal branches of the thoracic aorta.

The costal pleura is mainly innervated by the intercostal nerves, the diaphragmatic pleura by the phrenic and lower intercostal nerves, the mediastinal pleura by the phrenic nerves and the autonomic plexus of the mediastinum.

The dome of the pleura, rising above the upper opening of the chest, closes the pleural cavity from the side of the neck.

It is fixed to the surrounding bone formations by means of connective tissue strands of the prevertebral fascia. The height of the dome of the pleura above the clavicle is determined by constitutional features and may change during pathological processes of the apex of the lung. The dome of the pleura is adjacent to the head and neck of the 1st rib, the long muscles of the neck, the lower cervical node of the sympathetic nerve, outside and in front - to the scalene muscles, the brachial plexus, from the inside - to the brachiocephalic trunk (right) and the left common carotid artery (left), in front - to the vertebral artery and vein.

The projection on the chest wall of the lines of transition of one section of the pleura to another is defined as the boundaries of the pleura. So, the anterior border of the pleura is the line of transition of the costal pleura to the mediastinal one. Right and left it is not the same. The anterior border of the right pleura goes behind the sternum, reaches the midline, and then, at the level of the sixth intercostal space, passes into the lower border. The anterior border of the left pleura, descending from top to bottom, reaches the cartilage of the IV rib, then deviates to the left, crossing the cartilage, reaches the VI rib, passing into the lower border. Thus, the right and left mediastinal pleurae at the level of III-IV costal cartilages come close to each other, in some places close. Above and below this level, free triangular interpleural spaces remain, the upper one is filled with fatty tissue and remnants of the thymus gland, and the lower one is filled with the pericardium.

The position of the anterior border of the pleura and its other parameters vary and depend on the shape of the chest. With a narrow chest, the interpleural fields are long and narrow, and with a wide chest, they are short and wide. In pathological conditions, the position of the pleura compared to the norm can also change.

The lower borders of the pleura from the cartilage of the VI rib turn down and outward and cross the VII rib along the midclavicular middle axillary, scapular and paravertebral lines. In a wide chest, the lower borders of the pleura occupy a high position, and in a narrow one - low.

The posterior border of the pleura on the right lies closer to the vertebral bodies, and its projection line corresponds to the spinous processes. On the left, it remains on the paravertebral line and can sometimes pass 1 cm lateral to it, which corresponds to the position of the aorta.

In the place of transition of one department of the parietal pleura to another, pleural sinuses are formed. Under normal conditions, the sheets of the parietal pleura are in close contact, but when pathological fluid accumulates, they diverge.

The deepest of the sinuses is the costophrenic. It is located in the angle formed by the diaphragm and costal pleura. The sinus goes in the form of a semicircle from the VI costal cartilage to the spine. Its depth at the midaxillary line is 6 cm. Costal-mediastinal sinuses can only be spoken of below the level of the IV rib and, first of all, on the left side, where the pleura and lung follow the bulge of the heart. The fold of the fold of the pleura extends further between the heart and the chest wall. This area at the level of the IV-V ribs is considered a sinus, which, when inhaled, serves as an additional space for the anterior edge of the left lung. Its value depends on the size of the heart.

The diaphragmatic-mediastinal sinus is formed between the mediastinal and diaphragmatic pleura. The shape and size of this sinus change and depend solely on the shape and topography of neighboring organs. The sinus passes sagittally along the arches of the diaphragm and from behind passes into the costophrenic sinus. Anteriorly, this sinus follows the lateral bulge of the heart. Under the heart, the phrenic-mediastinal sinus has a sharper angle.

A.A. Vishnevsky, S.S. Rudakov, N.O. Milanov

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