局部解剖学课件：第三章 胸前外侧壁双语

Section1IntroductionI.Boundariesanddivisions

Chapter3ThethoraxBoundaries

Superior--jugularnotch,sternoclavicularjoint,superiorborderofclavicle,acromion,spinousprocessofC7Inferior--xiphoidprocess,costalarchs,11thand12thribs,spinousprocessof

T12Lateral--anteriorandposteriormarginsofthedeltoidDivisionsThoracicwall

anteriorthoracicregionlateralthoracicregionthoracodorsalregionThoraciccavityanterioraxillarylineposterioraxillarylineChapter3ThethoraxII.Surfaceanatomyjugularnotch颈静脉切迹sternalangle(ofLouis)胸骨角xiphoidprocess剑突clavicle锁骨infraclavicularfossa锁骨下窝costalmargin(costalarch)肋弓infrasternalangle胸骨下角ribsandintercostalspace肋和肋间隙nipple乳头(1)Theanteriormedianline(2)Thesternalline(3)Themidclavicularline(4)Theparasternalline(5)Theanterioraxillaryline(6)Themidaxillaryline(7)Theposterioraxillaryline(8)Thescapularline(9)TheposteriormedianlineTheorientationallinesonthethoracicwallSection2ThethoracicwallLayersofanteriorthoracicwall1.Skin皮肤2.Superficialfascia浅筋膜3.Deepfascia深筋膜4.Extrinsicmuscles胸廓外肌

5.Thoraciccageandintrinsicmuscles肋间肌

6.Endothoracicfascia胸内筋膜

7.Parietalpleura壁胸膜

1.Thesuperficialbloodvesselsperforatingbranchesoftheinternalthoracica.&v.胸廓内A、V穿支laterlacutaneousbranchesoftheposteriorintercostala.&v.肋间后A、V外侧皮支thoracoacromiala.&v.,胸肩峰A.V

lateralthoracica.&v.胸外侧A,V

thoracoepigastricv.胸腹壁V

TheskinThesuperficialfascia2.Thecutaneousnerves：

①Supraclavicularn.

锁骨上N

②Anteriorandlateralcutaneousbranchesofintercostaln.

肋间N外侧皮支和前皮支

Thebloodvesselsofthefemalebreast(1)theposteriorintercostala.(the3th～7thlateralcutaneousbranches)(2)theinternalthoracica.(the3th～6thperforatingbranches,the2th～4thmorelarge)(3)lateralthoracica.(4)thoracoacromiala.ThenervesAnteriorcutaneousbranchesofthe2th-4thintercostaln.lateralcutaneousbranchesofthe4th-6thintercostaln.(1)Position:

Lieinsuperficialfasciaoverthepectoralsmajorandpectoralfascia(2)Shape:

itishemisphericalshape,thenippleislocatedatthecentersurroundingbytheareolathatislubricatedbytheareolarglands3.mamma/breast(3)Structuresthebreastiscomposedof15-20glandlobes,thatradiatearoundandopenatthenipple.Thelobesarepaddedandseparatedfromeachotherbyfibrousconnectivetissueandfat.Eachglandlobehasalactiferousduct

whichopensseparatelyonthenippleandpossessesadilatedlactiferoussinuses

justpriortoitstermination乳房悬韧带

suspensoryligamentofbreast

/Cooperligament

纤维组织小束，起自锁骨、锁胸筋膜和乳腺深面的胸筋膜，从深部向前穿过乳腺周围并与之相连，最后连于乳房皮肤。对乳房起固定作用。乳癌早期，乳房悬韧带可受侵犯而缩短，牵拉皮肤产生凹陷称“酒窝征”，这是乳癌早期的常见体征。乳房悬韧带乳房后隙

为浅筋膜深层与胸肌筋膜间的间隙，内有疏松结缔组织、脂肪、淋巴管。隆胸手术胸大肌胸大肌胸肌间隙乳房后间隙植入假体(4)乳房的淋巴引流①乳房外侧部和中央部的淋巴→胸肌淋巴结。乳房淋巴回流的主要途径。

②乳房上部的淋巴→尖淋巴结和锁骨上淋巴结。③乳房内侧部的淋巴→胸骨旁淋巴结。④乳房内侧部的浅淋巴管与对侧乳房淋巴管相交通。⑤乳房深部的淋巴管穿胸大肌→胸肌间淋巴结或尖淋巴结。⑥乳房内下部的淋巴管通过腹壁和膈下淋巴管与肝的淋巴管相交通。临床要点：乳房手术切口的选择－－放射状切口放射状切口乳晕边缘弧形切口乳房下缘弧形切口orange-peeltexture桔皮样外观dimpling酒窝征乳腺癌RegularselfexaminationofbreastsMorethan80%ofbreastcancercasescanbefindattheearlytime.

Notes:lump,changesinbreastsizeorshape,skindimpling,nippleinversion,orspontaneoussingle-nippledischargearedangersignofcancer.III.TheDeepStructures1.deepfasciaClavipectoralfascia锁胸筋膜：extendsbetweensubclavius,coracoidprocessandpectoralisminor.①Cephalicv.头静脉②Thoracoacromiala.andv.

胸肩峰动、静脉③Lateralpectoraln.胸外侧神经④lymphaticvessels淋巴管Itispiercedby:PectoralismajorPectoralisminorSerratusanterior2.TheextrinsicmusclesSerratusanterior

3.IntercostalspaceIntercostalesexterniIntercostalesinterniIntercostalesintimi(1)IntercostalmuscleBeforereachingtothecostalangle,theintercostalnerveandvesselsruninthemiddleoftheintercostalspaceandtheirarrangementisinconstant;Thentheyliebetweentheinnermostandinternalintercostalmuscles.(2)Theintercostalvessels位于肋角内侧的肋间淋巴结输出管注入胸导管。(3)TheintercostalnervesInthecostalgrooveoftherib,thearrangementfromupdownwardsisthe:vein,arterynerve.Internalthoracicartery胸廓内动脉1.musculophrenica.

肌膈动脉2.superiorepigastrica.

腹壁上动脉3.Pericardiacophrenica.

心包膈动脉4.anteriorintercostalbranches肋间前支5.Perforatingbranches

前穿支胸骨旁淋巴结引流腹前壁和乳房内侧部的淋巴，并收纳膈上淋巴结的淋巴，其输出管参与合成支气管纵隔干。

在近肋角处应稍靠下位肋骨上缘进针。在肋角外侧应在肋间隙中部进针，以免伤及肋间血管神经。临床上常在肩胛线或腋后线第7～8肋间隙进行。Thoracentesis胸膜腔穿刺：6.胸内筋膜

7.壁胸膜施行胸膜腔穿刺术需经过哪些层次？①Skin皮肤②superficialfascia浅筋膜③deepfascia深筋膜④superficialmusclesofthethoracicwall胸壁肌⑤ribandintercostalmuscles肋间肌⑥endothoracicfascia胸内筋膜⑦parietalpleura.壁胸膜气胸pneumothorax水胸hydrothorax血胸hemothorax乳糜胸chylothoraxSection3Diaphragm1.PositionanddivisionItisadome-shapedbetweenthoraxandabdomen,consistsofaperipheralmuscularpartandacentraltendon

Origin:Sternalpart:xiphoidprocess

Costalpart:lowersixandcostalcartilagesLumbarpart:arisesbytwocrurafromupper2-3lumbarvertebraeInsertion:

centraltendonDivisionWeakareas:triangularspaceswithoutmusculartissueLumbocostaltriangle:betweencostalandlumbarparts.Sternocostaltriangle:betweencostalandsternalparts.Aortichiatus--liesanteriortothe12ththoracicvertebrabetweenthecrura.Ittransmitstheaorta,thoracicduct.Esophagealhiatus

--foresophagusandvagusnervesatlevelofT10.Venacavaforamen--forinferiorvenacava,throughcentraltendonatT8level.OpeningsinthediaphragmopeninglevelstructurescavalopeningT8inferiorvenacava,andsomebranchesoftherightphrenicnerveesophagealhiatusT10esophagus,vagaltrunks,andsomesmallesophagealarteriesaortichiatusT12theaorta,theazygosvein,andthoracicducttwolesserapertureofrightcrusgreaterandlesserrightsplanchnicnervesthreelesserapertureofleftcrusgreaterandlesserleftsplanchnicnervesandthehemiazygosveinbehindthediaphragm,underthemediallumbocostalarchessympathetictrunkareolartissuebetweenthesternalandcostalparts(seealsoforaminaofMorgagni)thesuperiorepigastricbranchoftheinternalmammaryarteryandsomelymphaticsfromtheabdominalwallandconvexsurfaceoftheliverareolartissuebetweenthefibersspringingfromthemedialandlaterallumbocostalarchesThisintervalislessconstant;whenthisintervalexists,theupperandbackpartofthekidneyisseparatedfromthepleurabyareolartissueonly.Action:Contraction:thedomemovingdownward,increasesthevolumeofthoraciccavitywhichresultsininspiration,atthesametimetheintra-abdominalpressureisincreasedassistsindefecation,vomitingorchildbirth.Relaxation:thedomereturnstotheformerposition,reducesthevolumetothethoraciccavity,resultinginexpiration.吸气呼气Thebloodvessels,lymphaticdrainageandnerves

ofthediaphragm1.bloodvessels：pericardiophrenica.,musculophrenica.,superiorphrenica.,

inferiorphrenica.,

intercostala.2.lymphaticdrainage

：superiorphrenicln.—drainsintoparasternalandposteriormediastinalln.inferiorphrenicln.—drainsintolumbarln.3.nerves

：lowersixpairsofintercostaln,phrenicn.,accessoryphrenicn.,

三、膈的血管、淋巴和神经1.血管：心包膈动脉、肌膈动脉、膈上动脉、下位肋间后动脉、膈下动脉2.淋巴：注入膈上、下淋巴结。膈上淋巴结注入胸骨旁淋巴结和纵隔前后淋巴结。膈下淋巴结注入腰淋巴结。3.神经：下6对肋间神经、膈神经、副膈神经AxillaryfossaSection2theaxillaryregionPosition:

inferiortotheshoulderjoint，betweentheupperpartofthechestwallandthemedialsideofthearm.Whenabductstheshoulderjointtheskinisconvexupward,calledaxillaryfossa.

I.Theboundariesoftheaxilla1.Apex:

thefirstribs,thesuperiorborderofthescapulaandmiddle1/3ofclavicle.

2.Base

axillaryfascia，skin3.Anteriorwall

pectoralismajor,pectoralisminorclavipectoralfascia4.Medialwall

1-4ribs,IntercostalmusclesSerratusanterior5.Posteriorwall

Subscapularis,TeresmajorLatissimusdorsi6.LateralwallIntertubercularsulcusofthehumerus,bicepsandcoracobrachialis

TrilateralandquadrilateralforaminaQuadrilateralforamen四边孔:

Theposteriorhumeralcircumflexa.andaxillaryn.passthrough.Trilateralforamen三边孔:

Thecircumflexscapulara.passthrough.1.Axillarya.anditsbranches2.Axillaryv.anditstributaries3.Brachialplexusanditsbranches4.Axillarylymphnodes5.LooseconnectivetissueII.ContentsAxillarysheathExtensionofdeepcervicalfasciaoftheneck,formingatubularsheaththatsurroundsaxillarya.andbrachialplexusAbrachialplexusnerveblockcanbeachievedbyinjectinganaestheticintothisarea.

臂丛从颈部斜角肌间隙经锁骨中点后方到腋窝，临床上作臂丛阻滞麻醉可在斜角肌间隙、锁骨中点上方和腋窝进行。DissectionFromthejugularnotchtothexip