Along which edge of the rib do the intercostal vessels pass? Topography of intercostal spaces
The bony basis of the segment is represented by the ribs, and the muscular basis is represented by the external and internal intercostal muscles, the neurovascular part consists of the intercostal nerve and intercostal vessels: from top to bottom - vein, artery. nerve. The chest segments are covered with soft tissue both inside and outside.
Topography: skin, subcutaneous fat, superficial fascia, pectoral fascia, muscles (pectoralis major or serratus anterior or latissimus dorsi), pectoral fascia, chest segment, intrathoracic fascia, tissue (prepleural, parapleural, pleural), costal pleura.
Treatment of purulent pleurisy:
Puncture of the pleural cavity.
Passive drainage according to Bulau.
Active aspiration.
Radical operations.
Puncture of the pleural cavity: in the 7-8 intercostal space. along the scapular or posterior axillary line along the upper edge of the rib, a puncture is made in the chest wall with a thick needle connected to a short rubber tube, which is clamped after removing each portion of pus.
Passive drainage, according to Bulau: a drainage tube connected to a jar from the Bobrov apparatus is inserted into the pleural cavity or a puncture in the 6-7 intercostal space (in adults with resection of the rib, but with preservation of the periosteum) along the midaxillary line using a thoracary, pus flows into the jar according to the law of communicating vessels.
Active aspiration: i.e., but a water jet pump is connected to a short tube, the pus flows out under the influence of negative pressure in the system, equal to 10-40 cm of water column.
46 Topography of the diaphragm
Along the right middle line, the dome of the diaphragm is located at the level of the 4th rib, and along the left middle line - at the 5th rib. The diaphragm is covered with serous membranes. On the side of the cavity, it is covered with the diaphragmatic pleura and partially with the pericardium. On the abdominal side, the diaphragm is covered by the parietal peritoneum. The central part of the diaphragm is represented by the tendon center. The muscular section of the diaphragm consists of 3 parts: sternal, costal, lumbar. The sternal part begins from the posterior part of the xiphoid process. To the left of the xiphoid process between the sternum and costal parts there is a gap (described by Larrey) - the left sternocostal triangulation. To the right of the xiphoid process, between the sternum and costal parts of the diaphragm, there is a similar gap (described by Morgagni) - the right costosternal triangle. The internal mammary artery passes through each of the slits. The lumbar part of the diaphragm is represented by powerful muscle bundles, forming 3 pairs of legs: internal, intermediate, lateral. Inner legs starting from the anterolateral surface of the bodies of 1-4 lumbar vertebrae. Going up, the inner legs converge, forming 2 holes. The first is at the level of the 7th-1st vertebrae and is called the aortic. The second is at the level of 11 degrees pos. and is called esophageal. Intermediate legs shorter and starting from the lateral part of the body of the 2nd vertebral belt. Lateral crura even shorter, they can start from the lateral surface of the body of the first or second vertebral belt. The descending aorta passes through the aortic opening, and the thoracic duct passes posteriorly and to the right. Through the esophageal opening, the cavity leaves the esophagus with the vagus nerves. On the left, between the internal and intermediate legs, the hemizygos vein and splanchnic nerves pass. On the right, between similar legs, there is the azygos vein and celiac nerves. The sympathetic trunk passes between the intermediate and lateral crura on the left and right. Between the costal and waist sections of the diaphragm there are 2 triangles (described by Bokhdalik) - lumbocostal triangles. To the right of the midline in the tendon center of the diaphragm there is an opening through which the inferior vena cava passes. To the right of this opening, the branches of the right phrenic nerve pass through the tendinous center.
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 indicators of breathing. To do this, determine the shape of the chest (correct or irregular); type of chest (normosthenic, hypersthenic, asthenic, emphysematous, paralytic, rachitic, funnel-shaped, scaphoid); 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 regular or irregular (in diseases of the lungs, pleura, as well as rickets, trauma to the chest and spine, bone tuberculosis).
The following types of chest are distinguished:
the normosthenic type is observed in persons of normosthenic physique. The anteroposterior dimensions of the chest are in the correct relationship with the lateral dimensions, the supra- and subclavian fossae are moderately pronounced, the ribs in the lateral sections have a moderately oblique direction, the shoulder blades do not fit tightly to the chest, the epigastric angle is straight;
the asthenic type is observed in persons of asthenic physique. The chest is elongated due to a decrease in the anteroposterior and lateral dimensions, sometimes flat, the supra- and subclavian spaces recede, 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 is easily identified when palpation, epigastric angle is acute;
The hypersthenic type is observed in individuals 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 acquire a horizontal direction, the intercostal spaces are narrowed, the shoulder blades fit tightly to the chest, the epigastric angle is obtuse;
emphysematous (barrel-shaped) chest, in which the dimensions of the anteroposterior and lateral diameters approach each other, resulting in the shape of the chest resembling a barrel (wide and short); the ribs are located horizontally, the supraclavicular and subclavian fossae are not prominent, the shoulder blades are very close 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 are sharply behind the chest, the epigastric angle is acute. 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 chest has a funnel-shaped depression or depression in the lower third of the sternum and the area of the xiphoid process. This shape of the chest is observed in shoemakers due to the constant pressure of the block resting on the lower part of the still pliable sternum (“shoemaker’s chest”);
The scaphoid chest has a scaphoid oblong depression in the middle and upper parts of the sternum (with syringomyelia). In addition, breathing indicators are assessed: how the patient breathes - through the nose or mouth; type of breathing: thoracic (costal), abdominal (diaphragmatic or mixed); breathing rhythm (rhythmic or arrhythmic); depth of breathing (superficial, medium depth, deep); respiratory rate (number of respiratory movements per 1 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 can be a consequence of pleurisy, surgical interventions, and shrinkage of the lung. Asymmetry of the chest can 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). Measuring the maximum circumference and assessing 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, with the tape at the back located at the corners of the shoulder blades. The 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 pleurisy, pneumonia), emphysema, and obesity. Deformation of the chest can be manifested by retraction or protrusion in any area, developing as a result of diseases of the lungs and pleura. Retraction may be the result of shrinkage (fibrosis) or collapse (atelectasis) of the lung. Unilateral protrusion or expansion of the chest may be caused by the accumulation of fluid (hydrothorax) or air (pneumothorax) in the pleural cavity. During examination, attention is paid to the symmetry of the respiratory movements of the chest. The doctor should place his hands on the posterior inferior surface of the chest on the left and right and ask the patient to take several deep breaths. The lag of any half of the chest may be a consequence of damage to the pleura (dry and effusion pleurisy) and lungs (pneumonia, atelectasis). A uniform decrease and even absence of respiratory excursions on both sides is characteristic of pulmonary emphysema.
Assessment of breathing indicators: Breathing through the nose is usually observed in a healthy person. Breathing through the mouth is observed in pathological conditions in the nasal cavity (rhinitis, ethmoiditis, polyposis, deviated nasal septum). The chest 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 comatose states, agony, and cerebrovascular accident.
Breathing depth: shallow breathing occurs with intercostal neuralgia, pulmonary diseases involving the pleura; breathing of medium depth occurs in a healthy person, deep breathing occurs in athletes.
The respiratory rate is measured by counting the number of respiratory movements in 1 minute, unnoticed by the patient, for which a 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 respiration rate (over 20) is observed when the function of external respiration is impaired, as well as in the presence of obstacles to normal breathing (ascites, flatulence, rib fractures, diseases of the diaphragm).
In the discussion of one of the posts, the following off-topic question arose: “How to debunk the urban legend that men have one less rib than women?” This problem seemed quite interesting to me, especially since I wrote about urban medical legends at one time.
There are two options.
First: take an anatomy textbook and find the corresponding drawing, count the ribs.
On the other hand, it remained unclear - whose ribs were considered male or female? You never know that the textbook says that the number of ribs is 12 pairs, that sometimes there is even a 13th additional pair, that the first 10 pairs are attached to the vertebrae and sternum, and the lower ribs are attached only to the vertebrae...
In this case we will need second option: X-ray. It is done to living people. Basically... Moreover, on the Internet you can find both women's pictures (with boobs) and men's (without them).
Female radiograph, arrows pointing to the posterior arches of the corresponding ribs:
Male radiograph, arrows indicate the posterior and anterior arches of ribs 1-3, numbers 4 to 12 are placed on the posterior arches of the corresponding ribs:
Explanatory back view of the skeleton:
Edges are always counted from above, that is, you first need to find the first edge, and then count up to it to the place of interest to us. At least that's what we were taught.
But finding the first rib is the biggest ambush. Most often, it is mistaken for the collarbone, and before my eyes this mistake was made not only by students, but also by doctors. On the second radiograph, to avoid confusion, the collarbone is designated by the letter “C” - clavicula, lat.
The posterior arch of the ribs is visible better than the anterior one, which can be explained quite simply - the posterior arch is entirely bone, while the anterior arch is largely cartilage. Pay attention to another ambush - a crowd in the area of 1, 2 and 3 ribs. This is due to different angles of inclination and features of projecting all this volumetric disgrace onto a plane.
The counting of the ribs leaves no doubt that both in the first image and in the second there are exactly 24 of them. And, as I already mentioned, there may be more.
However, it may be less. But only for women. And only after a special surgical intervention to remove the 12th pair (and some especially gifted ones even remove the 11th). For what? And for a wasp waist... I would venture to suggest that it is from the removed ribs that those same blondes from jokes are made, who have only bone marrow. It's in the ribs.
Z.Y. If I missed or missed anything, radiologists, correct me.
Damage to the intercostal nerves, accompanied by acute pain. It is characterized by paroxysmal shooting or burning pain in one or more intercostal spaces, extending from the spinal column to the sternum. Diagnosis is based on complaints and an objective examination of the patient; to exclude/detect pathology of the spine and internal organs, additional examination is carried out using radiography, CT, and endoscopy of the gastrointestinal tract. The main directions of therapy are etiotropic, anti-inflammatory, neuroprotective and physiotherapeutic treatment.
General information
Intercostal neuralgia is a pain syndrome associated with damage to the intercostal nerves of any etiology (due to pinching, irritation, infection, intoxication, hypothermia, etc.). Intercostal neuralgia can occur in people of all ages, including children. Most often it is observed in adults. The most common is intercostal neuralgia, caused by osteochondrosis of the spine with radicular syndrome or intervertebral hernia of the thoracic region, and also caused by herpes zoster. In some cases, intercostal neuralgia acts as a “signaler” of serious diseases of the structures that form the chest, or organs located inside it (for example, pleurisy, tumors of the spinal cord, chest and mediastinum). In addition, left-sided intercostal neuralgia can mimic cardiac pathology. Due to the variety of etiologies of neuralgia of the intercostal nerves, patient management is not limited to clinical neurology, but often requires the participation of related specialists - vertebrologists, cardiologists, oncologists, pulmonologists.
Anatomy of intercostal nerves
Intercostal nerves are mixed, containing motor, sensory (sensitive) and sympathetic fibers. They originate from the anterior branches of the spinal roots of the thoracic segments of the spinal cord. There are a total of 12 pairs of intercostal nerves. Each nerve passes in the intercostal space below the edge of its corresponding rib. The nerves of the last pair (Th12) pass under the 12th ribs and are called subcostal. In the area from the exit from the spinal canal to the costal angles, the intercostal nerves are covered by the parietal pleura.
The intercostal nerves innervate the muscles and skin of the chest, the anterior wall of the abdomen, the mammary gland, the costophrenic part of the pleura, and the peritoneum lining the anterolateral surface of the abdominal cavity. The sensory branches of adjacent intercostal nerves branch and connect with each other, providing cross-innervation, in which an area of skin is innervated by one main intercostal nerve and partially by the superior and inferior lying nerve.
Causes of intercostal neuralgia
Damage to the intercostal nerves may be inflammatory in nature and be associated with previous hypothermia or an infectious disease. The most common neuralgia of infectious etiology is intercostal neuralgia due to herpetic infection, the so-called. herpes zoster. In some cases, damage to the nerves is associated with their injury due to bruises and fractures of the ribs, other injuries to the chest, and spinal injuries. Neuralgia can occur due to compression of nerves by intercostal muscles or back muscles with the development of muscular-tonic syndromes associated with excessive physical activity, working in an uncomfortable position, reflex impulses in the presence of pleurisy, chronic vertebrogenic pain syndrome.
Various diseases of the spine (thoracic spondylosis, osteochondrosis, intervertebral hernia) often cause irritation or compression of the intercostal nerves at the point of their exit from the spinal canal. In addition, the pathology of the intercostal nerves is associated with dysfunction of the costovertebral joints due to arthrosis or post-traumatic changes in the latter. Factors predisposing to the development of neuralgia of the intercostal nerves are deformations of the chest and curvature of the spine.
In some cases, intercostal neuralgia occurs as a result of compression of the nerves by a growing benign tumor of the pleura, a neoplasm of the chest wall (chondroma, osteoma, rhabdomyoma, lipoma, chondrosarcoma), aneurysm of the descending thoracic aorta. Like other nerve trunks, intercostal nerves can be affected when the body is exposed to toxic substances, hypovitaminosis with B vitamin deficiency.
Symptoms of intercostal neuralgia
The main symptom is a sudden unilateral penetrating acute pain in the chest (thoracalgia), which runs along the intercostal space and encircles the patient's torso. Patients often describe it as "lumbago" or "passage of electric current." At the same time, they clearly indicate the spread of pain along the intercostal space from the spine to the sternum. At the beginning of the disease, thoracalgia may be less intense in the form of tingling, then the pain usually intensifies, becomes unbearable. Depending on the location of the affected nerve, pain can radiate to the scapula, heart, epigastric region. The pain syndrome is often accompanied by other symptoms (hyperemia or pallor of the skin, local hyperhidrosis) due to damage to the sympathetic fibers that make up the intercostal nerve.
Repetitive painful paroxysms are characteristic, lasting from a few seconds to 2-3 minutes. During an attack, the patient freezes and holds his breath while inhaling, since any movements, including the respiratory excursion of the chest, cause increased pain. Fearing to provoke a new painful paroxysm, in the interictal period, patients try to avoid sharp turns of the body, deep breaths, laughter, coughing, etc. During the period between painful paroxysms along the intercostal space, paresthesias can be noted - subjective sensitive sensations in the form of tickling, crawling.
With a herpetic infection, intercostal neuralgia is accompanied by skin rashes that appear on the 2-4th day of thoracalgia. The rash is localized on the skin of the intercostal space. It appears as small pink spots, which then transform into vesicles that dry out to form crusts. Itching is typical, occurring even before the first elements of the rash appear. After the disease resolves, temporary hyperpigmentation remains at the site of the rash.
Diagnosis of intercostal neuralgia
A neurologist can determine the presence of neuralgia of the intercostal nerves based on characteristic complaints and examination data. The patient's antalgic posture is noteworthy: in an effort to reduce pressure on the affected intercostal nerve, he tilts his torso to the healthy side. Palpation in the affected intercostal space provokes the appearance of a typical painful paroxysm; trigger points are identified at the lower edge of the corresponding rib. If several intercostal nerves are affected, during a neurological examination an area of decreased or loss of sensitivity in the corresponding area of the skin of the body can be determined.
The clinical differentiation of the pain syndrome is important. Thus, when pain is localized in the cardiac region, it is necessary to differentiate it from the pain syndrome associated with cardiovascular diseases, primarily from angina pectoris. Unlike the latter, intercostal neuralgia is not relieved by taking nitroglycerin, but is provoked by movements in the chest and palpation of the intercostal spaces. With angina, a painful attack is of a compressive nature, provoked by physical activity and is not associated with turning the body, sneezing, etc. In order to clearly exclude coronary heart disease, the patient is given an ECG, and if necessary, a consultation with a cardiologist is indicated.
When the lower intercostal nerves are damaged, the pain syndrome can mimic diseases of the stomach (gastritis, gastric ulcer) and pancreas (acute pancreatitis). Stomach pathology is characterized by a longer and less intense pain paroxysm, usually associated with food intake. With pancreatitis, girdle pain is also observed, but they are usually bilateral in nature and associated with food. In order to exclude pathology of the gastrointestinal tract, additional examinations may be prescribed: determination of pancreatic enzymes in the blood, gastroscopy, etc. If intercostal neuralgia occurs as a symptom of thoracic radiculitis, then painful paroxysms occur against the background of constant dull pain in the back, which decreases when the spine is unloaded in a horizontal position. To analyze the condition of the spine, an X-ray of the thoracic region is performed, and if an intervertebral hernia is suspected, an MRI of the spine is performed.
Intercostal neuralgia can be observed in some lung diseases (atypical pneumonia, pleurisy, lung cancer). To exclude/detect such a pathology, a chest x-ray is performed, and if indicated, a computed tomography is performed.
Treatment of intercostal neuralgia
Complex therapy is carried out aimed at eliminating the causative pathology, relieving thoracalgia, and restoring the affected nerve. One of the main components is anti-inflammatory therapy (piroxicam, ibuprofen, diclofenac, nimesulide). In case of severe pain, drugs are administered intramuscularly, therapy is supplemented by therapeutic intercostal blockades with the administration of local anesthetics and glucocorticosteroids. An auxiliary means in relieving pain is the prescription of sedatives, which reduce pain by increasing the threshold of excitability of the nervous system.
Etiotropic therapy depends on the genesis of neuralgia. Thus, for herpes zoster, antiviral agents (famciclovir, acyclovir, etc.), antihistamine pharmaceuticals and local use of antiherpetic ointments are indicated. In the presence of muscular-tonic syndrome, muscle relaxants (tizanidine, tolperisone hydrochloride) are recommended. If there is compression of the intercostal nerve at the exit of the spinal canal due to osteochondrosis and displacement of the vertebrae, gentle manual therapy or spinal traction can be performed to relieve the compression. If nerve compression is caused by a tumor, surgical treatment is considered.
In parallel with etiotropic and anti-inflammatory therapy, neurotropic treatment is carried out. To improve the functioning of the affected nerve, intramuscular administration of B vitamins and ascorbic acid is prescribed. Drug therapy is successfully complemented by physiotherapeutic procedures: ultraphonophoresis, magnetotherapy, UHF, reflexology. For herpes zoster, local UV irradiation on the area of the rash is effective.
Forecast and prevention of intercostal neuralgia
In general, with adequate treatment, intercostal neuralgia has a favorable prognosis. Most patients experience complete recovery. In the case of herpetic etiology of neuralgia, relapses are possible. If intercostal neuralgia is persistent and cannot be treated, you should carefully reconsider its etiology and examine the patient for the presence of a herniated disc or tumor process.
Prevention measures include timely treatment of spinal diseases, prevention of spinal curvature, and adequate treatment of chest injuries. The best protection against herpes infection is a high level of immunity, which is achieved by a healthy lifestyle, hardening, moderate physical activity, and active recreation in nature.
Pulmonary lesions or decay cavities during fluoroscopy or on a radiograph, they are projected anteriorly and posteriorly onto completely different segments of the ribs. For example, if the cavity is located at the level of the II rib in front, then in relation to the posterior segments of the ribs this will correspond to the V or VI rib.
Ribs They don't have the same shape everywhere. In front and partly from the side they are wider and flatter; towards the back they become somewhat narrower and their shape changes, approaching triangular. At the back of the chest wall is the scapula, the position of which is not the same in all cases and depends on the shape of the chest wall. Most authors believe that normally the upper edge of the scapula lies at the level of the II rib, and the lower angle - at the level of the VIII rib.
Apparently this position varies. According to Brezika, the lower angle of the scapula reaches the VII-VIII rib. This is partly confirmed by the fact that after upper thoracoplasty with resection of the 7th ribs, the lower part of the scapula in some cases fits well behind the VIII rib and does not cause the patient any unpleasant sensations. In other cases, the lower angle of the scapula rests on the VIII rib and patients complain of constant pain, which is why it is ultimately necessary to additionally resect the VIII rib or the lower part of the scapula.
The blade is very makes it difficult production of upper thoracoplasty, especially when, according to the operation plan, it is necessary to resect large sections of ribs. Difficulties also lie in the fact that the most severe suppurative processes after thoracoplasty occur precisely under the scapula, and the fight against these suppurations can sometimes be extremely difficult.
Intercostal spaces the back is narrower than the front, and is made of external and internal intercostal muscles. The external ones begin at the junction of the ribs with the transverse processes of the vertebrae and end at the junction of the ribs into the costal cartilages; then they are replaced by interosseous ligaments (lig. intercostalia externi), which are shiny tendon bundles. The external intercostal muscles originate from the lower edge of the overlying rib and are attached to the upper edge of the underlying rib, having a direction from top to bottom and from back to front.
Internal intercostal muscles begin near the angle of the rib and reach the lateral edge of the sternum. They originate from the inner edge of the overlying rib and are attached to the upper edge of the underlying rib, having a direction from top to bottom and from front to back. This arrangement of the internal intercostal muscles is of practical importance: in the posterior sections, starting from the spine to the angle of the ribs, the intercostal vessels and nerves are covered only by the endothoracic fascia and parietal pleura and can easily be damaged when the adhesions are burned directly at the chest wall.
IN between between the external and internal intercostal muscles along the lower edge of each rib there is a groove (sulcus costalis), in which the intercostal vessels and nerve are located. Blood flow in the intercostal arteries comes from three sources: 1) truncus costo-cervicalis, which gives a branch (a. intercostalis suprema) for the two upper intercostal spaces; 2) the thoracic aorta, from which 9 pairs of posterior intercostal arteries emerge (aa. intercostales posteriores); 3) a. mammaria interna, from which the anterior intercostal arteries (aa. intercostales anteriores) depart - two for each intercostal space.
Posterior and anterior intercostal arteries widely anastomose with each other. The posterior intercostal arteries, starting from the spine, are located on the inner surface of the ribs in the sulcus costalis. Anterior to the axillary line, the intercostal arteries enter the intercostal spaces. Thus, dorsal to the axillary line, the intercostal arteries are protected by ribs, but ventral to the axillary line, they are not protected by ribs, since they lie at the lower edge of the rib. The practical significance of this position of the intercostal arteries is that, if necessary, to puncture ventrally from the axillary line, the trocar should be directed obliquely to the upper edge of the underlying rib.
