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a) Describe the role of the ribs in respiration

a. Respiration involves both contraction and relaxation of breathing


muscles, mainly diaphragm as well as the movement of the ribs.
b. The synovial joints that are present in the ribs allow the movements
of the ribs during respiration. The expansion of the ribs during
inspiration causes a drop in intrapulmonary pressure allowing air to
rush in while the contraction of the ribs during expiration causes an
increase in intrapulmonary pressure and forces air out.
c. The main joints that are involved in the movement of the ribs are
the sternocostal (articulation between the costal cartilages of the
rib and the sternum) joints, the costovertebral (articulation between
the head of the ribs and the vertebral) joints and the
sternocalvicular joint (articulation between the sternum and
clavicle)
d. The joints aid in both the pump handle movement of the thoracic
cage, which increases the anterior posterior dimension of the
thorax, and the bucket handle movement of the rubs which
increases the transverse diameter of the thorax. Both movements
bring about an increase in volume of the thoracic cage which allows
air uptake. The other joints such as the costalchondral joints are
equally important in maintaining the integrity of the thoracic cage
to ensure uniform expansion.
e. The movement of the ribs is aided by the contraction and relaxation
of the diaphragm as well as the other inspiratory and expiratory
muscles
f. With respect to the presenting patient, he had difficulty
breathing as his multiple rib fractures destroyed the
integrity of his thoracic cage which prevented its adequate

expansion and contraction to draw air in and also to expel


air.
b) Based on your knowledge of pleural reflections, surface mark the
costodiaphragmatic recess. If the needle used for removal of fluid were to
be inserted too deep, what organs could be potentially injured
a. There are two components to the pleural of the lungs. The parietal
pleura and the visceral pleura. The visceral pleura is attached to the
lungs.
b. The costodiaphragmatic recess is formed between the parietal
pleura and the visceral pleura at the costodiaphragmatic reflection.
This is at the base of the lungs. The lower border of the left lung
follows a curved line, it crosses the 6th rib at the mid-clavicular line,
the 8th rib in the mid axilla line and the 10th rib adjacent to the
vertebral column. The parietal pleura crosses the MCL at the 8 th rib,
10th rib in the mid axilla line and 12th rib at the vertebral column.
The space in between the parietal pleura and the visceral pleura of
the left lung forms the costodiaphragmatic recess
c. In the case of the patient, blood filled fluid was removed as blood
had leaked into the costodiaphragmatic recess due to trauma to
nearby organs during the crash. (hemothorax) The needle is to be
inserted at the mid axilla line at the 8th or 9th intercostal space and
at the superior border of the corresponding rib. At this region, the
thoracic cage covers a portion of the spleen and stomach. These
organs together with the lungs can be damaged if the needle was
inserted too deep. To avoid damage to these internal organs,
the needle is always aimed 45 degree upwards as it is
inserted into the 9th intercostal space and inserted in slowly.
(If right side, potential damage would be to the liver)
c) Which components of the chest wall are sensitive to pain. Outline the
neural pathway for pain from the chest wall to the cerebral cortex
a. The thoracic wall is the boundary of the thoracic cavity. It includes
the thoracic cage, the skin and fascia overlying the thoracic cage,
as well as the muscles (external, internal and innermost intercostal
muscles, transverse thoracic, subcostal muscle and the diaphragm)
b. The thoracic cage, the muscles and the skin and fascia all have
sensory innervations and will all be sensitive to pain.
c. 12 pairs of thoracic spinal nerves supply the thoracic wall. The
thoracic spinal nerves divide into anterior and posterior primary
rami. The anterior rami form the 11 intercostal nerves that run
along the extent of the 11 intercostal spaces as well as the
subcostal nerve which courses inferior to the 12 th rib. The posterior
rami of the thoracic spinal nerve pass posteriorly to innervate the
muscles and skin of the back. The intercostal nerves carry both
motor and sensory innervation to the relevant structures in the
thoracic wall.
d. Tissues have special pain receptors called nociceptors which fire off
responses when there has been an injury or a potential injury. Pain
impulses are transmitted via sensory afferent fibres in the
intercostal nerves to the vertebral foramina. Nerve fibres enter the
dorsal horn of the grey matter of the spinal cord where it synapses

before the impulse is transmitted upwards to the brain. The pain


signal reaches the thalamus in the brain where the impulses is
distributed to different areas for interpretation.
e. Lacerations to the chest wall in the case of this patient, damaging
skin and superficial fascia, tearing muscles as well as fracturing
ribs, all would have caused increase in pain impulses being sent to
the cerebral cortex in the brain.