L5 Surface Anatomy of pleura ,lungs

&Anatomy of diaphragm
CLO No L. LO No Lecture Intended Learning Outcomes

1.1 L 5.1 Describe the types, parts and nerve supply of

the pleura

1.2 L5.2 Describe surface anatomy of the lung

1.3 L5.3 Describe surface anatomy of pleura

2.1 L4.4 Describe the attachments, openings and nerve

supply of the diaphragm.
PLEURA AND SURFACE
ANATOMY
 Pleura
@It is a completely closed
sac invaginated by the
lung from its medial
aspect.
@Part of pleura covering
the lung visceral
pleura.
@Part of pleura lining
thoracic wall parietal
pleura.
Lung is like the hand pushing into the balloon

Pleural
cavity
Pleural cavity
@ Subdivisions of
parietal pleura:
1. Cervical pleura.
2. Costal pleura.
3. Mediastinal
pleura.
4. Diaphragmatic
pleura.
 Subdivisions of Parietal Pleura
1.Cervical
Pleura part
of parietal
pleura
bulging up
through the
thoracic inlet
into root of
neck.
 Suprapleural membrane

Cervical pleura is covered by the suprapleural

membrane which is fan shaped fibrous membrane
which spreads from transverse process of C7 to inner
border of 1st rib.
2. Costal pleura part of
parietal pleura which
lines ribs & intercostal
spaces.
3. Mediastinal pleura
part of parietal pleura
covering the side of the
mediastinum.
4. Diaphragmatic pleura
part of the parietal
pleura which covers
upper surface of
diaphragm.
 Pulmonary ligament
@ Parietal pleura covering
mediastinum is
continuous with visceral
pleura by a sheath or
sleeve of pleura.
@ Its upper part contains
structures forming root of
lung.
@ Its lower part is collapsed
& forms the pulmonary
ligament.
 Significance of pulmonary ligament

@Allows free up & down movements of the

root of lung during respiration.
@Gives space to allow dilatation of lower
pulmonary vein during increased venous
return from the lung.
 Pleural Recesses
@ These are narrow
spaces inside the
pleural cavity which
are not occupied by
the lung except in full
inspiration.
@ There are two Recesses
:
1. Costodiaphragmatic
recess.
2. Costomediastinal
recess.
 Pleural Recesses (contd.)

@Costodiaphragmatic
recess lies between
thoracic wall &
diaphragm, along the
lower border of pleura.
In full inspiration, the
inferior border of lung
extends into this
recess.
 Pleural Recesses (contd.)

@Costomediastinal
recess lies
between front of
thoracic wall &
mediastinum, along
the anterior border of
pleura. In full
inspiration, the
anterior border of
lung extends into this
recess.
 Nerve supply of pleura

@Parietal pleura is highly

sensitive to pain.
@Visceral pleura is not
sensitive to pain.
@Visceral pleura is
supplied by autonomic
nerve plexuses.
 Nerve supply of pleura

@Costal pleura &

peripheral part of
diaphragmatic pleura
are supplied by
intercostal nerves.

@Mediastinal pleura &

central part of
diaphragmatic pleura
are supplied by phrenic
nerve.
 Applied Anatomy
Pain resulting from
irritation of costal &
peripheral diaphragmatic
pleura may be referred to
thoracic & abdominal wall .
WHY?
Pain resulting from
irritation of mediastinal &
central diaphragmatic
pleura may be referred to
the root of neck & shoulder.
WHY? Group Discussion
@ Mediastinal & central
diaphragmatic pleura are
supplied by phrenic nerve which
arises from segments C3,4,5 of
spinal cord. Root of neck &
shoulder are also supplied by the
same segments of spinal cord.
Thats why pain from one place
could be referred to the other.
 Blood Supply of Pleura

@Parietal pleura
supplied by
intercostal &
internal mammary
( thoracic )
vessels.
 Blood Supply of Pleura

@Visceral
Pleura
supplied by
bronchial
vessels.
 Surface Anatomy of Lungs
@ Apex of lung same as
summit of pleura 1above
medial 1/3 of clavicle.
@ Anterior border like
anterior margin of pleura,
a point behind
sternoclavicular joint
opposite 2nd cc close to
midline opposite 4th cc
close to midline.
Then differs on right and
left sides.
 Surface Anatomy of Lungs (contd.)
@ On right side:
from a point on 4th
cc vertically down
to 6th cc.

@ On left side: from a

point on 4th cc, it
deviates laterally to
form the cardiac
notch to a point on
6th cc, 4cms from
median plane.
 Inferior border of lung

@Same on right &

left sides.
@When followed
laterally &
backwards, it
reaches 6th rib in
midclavicular line,
then 8th rib in
midaxillary line.
 Inferior & posterior borders of lung

@ Then, backwards &

medially to a point
1lateral to spine of
T10.
@ Posterior border is a
line vertically upwards
from previous point to
point of apex which
corresponds on the
back of neck, 1 lateral
to spine of C7.
 oblique fissure in either lung can be shown by
a line drawn from the spinous process of the
T3 around the thorax to the sixth rib in the
mid-clavicular line; this line corresponds
roughly to the line of the medial border of the
scapula when the hand is placed on the top of
the head.
The horizontal fissure in the right lung is indicated by
a line drawn from the anterior border of the lung
along the fourth costal cartilage to meet the oblique
fissure in the midaxillary line.
The root of the lung lies opposite 5th.,6th.&7th.
Thoracic vertebrae
 Surface anatomy of pleura
@ Point of summit of cervical pleura 1above medial 1/3 of
clavicle.
@ Point behind sternal angle close to midline opp 2nd costal
cartilage.
@ Point behind sternum close to midline opp 4th costal cartilage.
@ On right side point behind sternum close to midline opp 6th
cc.
@ On left side point behind 6th cc 2 cm from sternum.
@ Point on 8th rib midclavicular line.
@ Point on 10th rib midaxillary line.
@ Point just below medial end of 12th rib opp T12 spine.
@ Up by a vertical line to the point of summit.
 Surface anatomy of pleura

clavicle
Surface anatomy of pleura
It is a double domed,
musculotendinous
partition separating
the thoracic &
abdominal cavities.
It is a chief muscle of
inspiration
It is formed of a
peripheral muscular
part & centrally placed
(tendon)
 Origin:

Vertebral origin:
Sternal origin: By means of
By 2 slips (right & left) (crura) & (ligaments)
1 3
from the inner surface
of the xiphoid process

Costal origin:
From lower six ribs &
2 their costal cartilages
 Vertebral Origin
Crura:
Right crus:
From the bodies of upper
3 lumbar vertebrae (L1,L2
& L3) & their
intervertebral discs.
Left crus:
From the bodies of the
upper 2 lumbar vertebrae
(L1 & L2 ) & their
intervertebral discs.
 Vertebral origin
Lateral to crura the
diaphragm arises from the
medial & lateral arcuate
ligaments

Medial arcuate Lateral arcuate

ligaments: ligaments:
is the thickened upper is the thickened upper
margin of the fascia margin of the fascia
covering the anterior covering the anterior
surface of psoas surface of quadratus
major muscle lumborum muscle
 Medial borders of the two crura connected by a
median arcuate ligaments which crosses over
the anterior surface of the aorta (T12)

Median
arcuate
ligament
 INSERTION

It is inserted into
a central tendon
which is shaped
like 3 leaves
(Trifle)
 X-RAY

38
Shape of the diaphragm

The diaphragm has

right & left domes.
The right dome:
reaches as the upper
border of 5th rib,
The left dome:
may reach the lower
border of 5th rib,
NB: The central
tendon lies at the
xiphsternal junction,
 MAJOR OPENINGS
It has 3 main openings (Voice Of Arabs)
Caval opening T8
Esophageal openingT10 Transmits:
Transmits: IVC,
Esophagus, right phrenic nerve
Vagi,
Esophageal branches of
left gastric vessels &
Lymph vessels

Aortic opening T12

Transmits:
Aorta,
Thoracic duct &
Azygos vein
 Other openings
Splanchnic nerves, superior epigastric vessels,
left phrenic nerve,

Blood Supply of the diaphragm :

Superior surface:
Pericardiacophrenic & Musculophrenic arteries
(internal thoracic)

Inferior surface:
Inferior phrenic arteries (abdominal aorta)
Nerve Supply of the diaphragm
Motor through phrenic nerve (C3, 4 & 5)

Sensory supply to the central tendon (phrenic nerve)

But the periphery is from the lower five intercostal

nerves & subcostal nerve.
 Function
Muscle of Inspiration
It is the chief muscle of respiration:
In order to draw air into the lungs, the diaphragm
contracts, thus enlarging the thoracic cavity and
reducing intra-thoracic pressure.
When the diaphragm relaxes, air is exhaled by elastic
recoil of the lung.
Muscle of abdominal straining
Micturation, defecation, parturition

Weight-lifting muscle
Thoracoabdominal pump
Caval lymphatic force increase by increase in intra-
abdominal pressure
Clinical Notes
Hiccup
Involuntary spasmodic contraction of the diaphragm

Paralysis of the diaphragm

Done to give rest to lower lobe of the lung

Penetrating injury to the diaphragm

Any penetrating wound below the level of nipples
should be suspected of causing damage to the
diaphragm

Diaphragmatic hernia
May occur in middle age person due to week
musculature
THANKS