胸壁课件_2

局部解剖学,胸壁的局部解剖与操作（2）,Summarization 概述 Thoracic wall 胸壁 Breast 乳房 Axillary Region 腋区,主要内容 Main Contents,一、概述 Summarization,境界 The boundary 分部 The regions 表面标志 The surface landmark 胸部标志线 The Lines of orientation on the Thorax,胸部是躯干的上部，位于颈部与腹部之间。 The thorax (chest) is the upper part of the trunk between the neck and the abdomen,1. Boundary,其上界是从颈静脉切迹沿锁骨上缘至肩峰，然后至第七颈椎棘突的连线。,1. Boundary,Its upper boundary is formed by a line drawing from the suprasternal notch，along the superior margins of the clavicles to the acromions，and then to the spinous process of the 7th cervical vertebra,下界为剑突、肋弓、第11肋前端、第12肋下缘和第12胸椎棘突的连线。,1. Boundary,The lower boundary is formed by a line drawing from the xiphoid process, costal archs, anterior extremity of 11th ribs, inferior margin of 12th ribs to spinous process of 12th thoracic vertebra.,两外侧界为三角肌的前、后缘。,1. Boundary,The lateral boundaries of the thorax separating from the upper limb are the anterior and posterior margins of the deltoid,Thoracic wall and cavity,2.Region,The thoracic wall consists of skin, fascia, nerves, vessels, muscles, and bones.,The thoracic cavity, surrounded by the thoracic wall, contains the lungs, pleura and pleural cavity and mediastinum,颈静脉切迹 The jugular notch 胸骨角The sternal angle (of Louis) 剑突The xiphoid process 肋弓The costal margin (costal arch) 胸骨下角The infrasternal angle 锁骨 The clavicle 肩胛骨下角The inferior angle of scapula 乳头The nipple,3.表面标志 Surface Landmarks,The jugular notch,颈静脉切迹,Xiphoid process,剑 突,Costal arch,肋 弓,costal arch,The infrasternal ( subcostal) angle,胸 骨 下 角,肩胛骨下角 The inferior angle of scapula,剑 肋 角,经剑肋角的心包（液）穿刺术,Inferior fossa of clavicle,Clavicle,Greater supraclavicular fossa,Lesser supraclavicular fossa,Nipple,Sternal angle (of Louis),胸 骨 角,胸 骨 角 The sternal Angle (of Louis),The sternal angle marks the following items,The lower border of the 4th thoracic vertebra,向后平对第4胸椎下缘；,The level where the trachea divides into the right and left principal (main) bronchi.,气管分为左、右主支气管的水平，即气管杈水平；, The second constriction of the esophagus,平左主支气管与食管交叉处，即食管的第2狭窄处；, The origin and end of the aortic arch,平主动脉弓的起、止处；,The ligamentum arteriosum joins the left pulmonary artery to the aortic arch,动脉韧带连与左肺动脉与主动脉弓之处；,The azygos vein enters the superior vena cava,奇静脉汇入上腔静脉处；, The boundary line between the superior and inferior mediastina, 上、下纵隔的分界线；,4.The Lines of Orientation on the Thorax,(1) The anterior median line 前正中线 (2) The sternal line 胸骨线 (3) The midclavicular line 锁骨中线 (4) The parasternal line 胸骨旁线 (5) The anterior axillary line腋前线 (6) The midaxillary line 腋中线 (7) The posterior axiltary line腋后线 (8) The scapular line 肩胛线 (9) The posterior median line后正中线,胸 部 标 志 线,The Lines of Orientation on the Thorax,The Lines of Orientation on the Thorax,parasternal line,sternal line,The Lines of Orientation on the Thorax,The Lines of Orientation on the Thorax,The thoracic wall may be divided into The superficial structures The deep structures 胸壁可分为浅层结构和深层结构。,二、胸 壁 The Thoracic Wall,（一）The Superficial Structures,The skin 皮肤 The superficial fascia 浅筋膜 The superficial blood vessels 浅血管 The cutaneous nerves皮神经 The superficial lymphatic vessels浅淋巴管 The breast 乳房,深筋膜 deep fascia 胸壁浅层肌 superior muscles of thoracic wall 肋及肋间隙 ribs and intercostal space 胸内筋膜 internal thoracic fascia,（二）The Deep Structures,1. 深 筋 膜 deep fascia,Clavipectoral fascia,Suspensory ligament of axilla,锁胸筋膜及其穿行结构,Clavipectoral fascia,cephalic vein头静脉, lymphatic vessels淋巴管,thoracoacromial artery and vein胸肩峰动、静脉, lateral pectoral nerve胸外侧神经. “二进二出”,The pectoralis major 胸大肌 The subclavius 锁骨下肌 The pectoralis minor 胸小肌 The serratus anterior 前锯肌 The obliquus externus abdominis 腹外斜肌 The trapezius 斜方肌 The rhomboids 菱形肌 The latissimus dorsi 背阔肌 The transversus thoracis 胸横肌 The rectus abdominis 腹直肌 The intercostal muscles 肋间肌,2. The muscles,The intercostal muscles 肋间肌 Nerves 神经 Vessels 血管(the intercostal vessels 肋间血管, the internal thoracic vessels 胸廓内血管),3. The intercostal Spaces,（1）The intercostal muscles, The external intercostal muscle and membrane The internal intercostal muscle and membrane The innermost intercostal muscle,肋间外膜,肋间外肌,肋间内肌,肋间最内肌,肋间内膜,（2）The course and Relationship of the intercostal Nerve and Vessels,Anterior and posterior intercostal artery,胸廓内动脉,胸主动脉,肋间后动脉,肋间前动脉,在达肋角之前，肋间血管和神经位于肋间隙中部，彼此排列关系不恒定；然后行于肋沟内、肋间内肌与肋间最内肌之间。,Before reaching to the costal angle, the intercostal nerve and vessels run in the middle of the intercostal space and their arrangement is inconstant; Then they lie between the innermost and internal intercostal muscles.,In the costal groove of the rib, the arrangement from up downwards is the vein, artery and nerve.,肋间血管和神经循肋沟前行，在肋角前方，三者排列顺序自上而下为静脉、动脉、神经。,胸廓内动脉: 腹壁上动脉、肌膈动脉、肋间前动脉,4. 胸内筋膜,Intenal thoracic fascia,气胸 pneumothorax 水胸 hydrothorax 血胸 hemothorax 乳糜胸 chylothorax,在肋角内侧： 在肋角之前：,行胸膜腔穿刺术（抽液）在何部位进行？,不宜穿刺；,可在肋间隙的中部或肋上缘稍上方进针。,临床行胸膜腔穿刺术（抽液）常选在肩胛线或腋后线、第7或8肋间隙中部或肋上缘稍上方进针。,施行胸膜腔穿刺术需经过哪些层次？,Skin 皮肤,superficial fascia 浅筋膜,deep fascia 深筋膜,superficial muscles of the thoracic wall胸壁肌,rib and intercostal muscles 肋间肌, endothoracic fascia 胸内筋膜, parietal pleura.壁胸膜,三、乳房,女性乳房的位置、形态、结构、临床意义 形态结构：乳腺叶、乳腺小叶、输乳管、输乳窦、乳房悬韧带,乳房的血管,乳房的淋巴引流,四、腋 区 Axillary Region,腋区的位置 腋窝的概念,腋窝的一顶、一底、四壁,腋窝的底：由皮肤、浅筋膜和腋筋膜构成。 Base of the axilla is formed by the skin, subcutaneous tissue and axillary fascia. 腋窝的前璧：由胸大肌、胸小肌锁骨下肌和锁胸筋膜构成。 Anterior wall of the axilla is formed by the pectoralis major, subclavius, clavipectoral fascia, pectoralis minor and suspensory ligament of axilla. 腋窝的后璧：由大圆肌、背阔肌、肩胛下肌和肩胛骨构成。 Posterior wall of the axilla is formed by the scapula , the subscapularis, the teres major and latissimus dorsi.,腋窝的后璧： 由大圆肌、背阔肌、肩胛下肌和肩胛骨构成。 Posterior wall of the axilla is formed by the scapula , the subscapularis, the teres major and latissimus dorsi.,腋窝的外侧璧： 由肱骨结节间沟、肱二头肌长头、短头和喙肱肌构成。 Lateral wall of the axilla is the narrow bony wall formed by the intertubercular groove of the humerus，the two heads of biceps and the coracobrachialis.,腋窝的内侧壁：由前锯肌、上4为肋骨及肋间肌构成。 Medial wall of the axilla is formed by the thoracic wall(1st to 4th ribs and intercostal muscles)and the overlying serratus anterior.,腋窝的四壁 Four Walls of the Axilla,腋窝的顶：是腋窝的上口，向上内通颈根部，由锁骨中1/3、第1肋外缘和肩胛骨上缘围成。 Apex of the axilla, the entrance from neck to axilla, lies between the 1st rib, the middle one-third of clavicle, and superior border of the scapula.,腋动脉 Axillary artery 腋静脉 Axllary vein 臂丛锁骨下部及其分支 Infraclavicular part of brachial plexus and its branches 腋淋巴结 Axillary nodes 脂肪和疏松结缔组织 Fat and loose areolar tissue,腋窝的内容 Contents of axillary fossa,腋动脉的分段及其分支,肩胛动脉网,位于肩胛骨周围，由肩胛上动脉、肩胛背动脉、旋肩胛动脉等的分支彼此吻合成的动脉网，是肩部的重要侧支循环途径。 腋动脉血流受阻或结扎时，可借此网维持上肢的血供。,臂丛锁骨下部及其毗邻,臂丛及其分支,臂丛后束的分支与分布 三边孔、四边孔的构成及其穿行的结构,旋肱前动脉、旋肱后动脉、腋神经,肋间臂神经Intercostobrachial nerve 腋静脉 Axillary vein 胸外侧动脉和静脉 Lateral thoracic artery and vein 胸腹璧静脉 Thoracoepigastric vein,腋淋巴结 axillary lymph node: 位于腋窝疏松结缔组织内，沿血管排列，分5群。,1.胸肌淋巴结pectoral lymph node 2.外侧淋巴结 lateral lymph node,3.肩胛下淋巴结 subscapular lymph node 4.中央淋巴结 central lymph node,5.尖淋巴结 apical lymph node:收集上述4群淋巴结和锁骨下淋巴结的输出淋巴管，其输出淋巴管合成锁骨下干，分别注入胸导管和右淋巴导管。,腋 鞘 Axillary Sheath,腋鞘为包裹包绕腋动脉、腋静脉和臂丛周围的结缔组织膜，向上与颈部椎前筋膜相延续，亦称颈腋管。,又称肩袖，为冈上肌、冈下肌、小圆肌和肩胛下肌的肌腱，在肩关节囊周围连成腱板，围绕肩关节的上、后、前方，对肩关节起稳定作用。 当肩关节脱位或扭伤时，可伴有肌腱袖的撕裂。,肌腱袖Myotendinous Cuff,解剖与观察 Dissection and Observation,皮肤切口,胸前区和腋窝,浅层结构 解剖乳房 解剖肋间神经外侧皮支、前皮支及伴行的血管 解剖胸腹壁静脉 去除浅筋膜，保留已解剖的浅血