Thoracic Outlet

Question 1

Boundaries of thoracic outlet?

Answer 1

• Manubrium
• First rib
• First thoracic vertebrae

Question 2

Prevertebral muscles?

Answer 2

Lateral:

• Scalenes (anterior, middle, posterior)
• Splenius Capitus
• Levator Scapulae

Question 3

Anterior and Middle scalenes attachments?

Answer 3

• Transverse process

- 1st rib

Question 4

Posterior scalene attachments?

Answer 4

• Transverse process

- 2nd rib

Question 5

Scalenes innervation?

Answer 5

ventral rami

Question 6

Scalenes function?

Answer 6

• flex neck laterally
• flex head
• raise ribs

Question 7

Branches of Aortic arch?

Answer 7

1. Brachiocephalic trunk off right side
   - Right Common Carotid
   - Right Subclavian
2. Left Common Carotid
3. Left Subclavian

Question 8

Branches of Subclavian Artery?

Answer 8

1. Vertebral Artery (1st branch)
2. Internal Thoracic
3. Thyrocervical Trunk
   - Inferior Thyroid
   - Transverse Cervical (Trapezius)
   - Suprascapular (level of clavicle)
4. Costocervical Trunk
   - Superior Intercostal
   - Deep Cervical
5. Dorsal Scapular

Question 9

Clinical significance of Internal Thoracic Artery?

Answer 9

-used for bypass surgery to maintain blood flow to ventricles

Question 10

Where does Dorsal Scapular Artery run?

Answer 10

• runs in between trunks of brachial plexus

- supplies Rhomboids

Question 11

Where does Subclavian Vein run?

Answer 11

• anterior to anterior scalene

- not compromised by scalene interval syndrome

Question 12

What drains into the Subclavian vein?

Answer 12

• External jugular vein runs superficial to sternocleidomastoid muscle
• Subclavian combines with Internal Jugular

Question 13

What drains into the Brachiocephalic vein?

Answer 13

-Internal Jugular and Subclavian form it

Question 14

Where does the brachiocephalic vein drain?

Answer 14

• 2 brachiocephalic veins join to form the Superior Vena Cava
• Left vein crosses the midline

Question 15

T/F

Thymus is always active.

Answer 15

T

-does regress in size but stays active

Question 16

Path of Vagus nerve?

Answer 16

• starts as Cranial Nerve 10 off of the brainstem
• goes down the neck along with Internal Carotid Artery and Internal Jugular Vein
• Left side sends a branch that loops under the Aortic arch at the Ligamentum Arteriosum called the Left Recurrent Laryngeal Nerve
• Right Side sends the Right Recurrent Laryngeal Nerve back up and loops under Right Subclavian Artery

Question 17

Phrenic Nerve?

Answer 17

• C3, 4, 5
• innervates diaphragm
• anterior to anterior scalene

Question 18

Ligamentum Arteriosum?

Answer 18

• ligament that is remnant of ductus arteriosum

- connects Aorta to Pulmonary Artery

Question 19

Sympathetic trunk path?

Answer 19

• starts anterior then lateral to vertebral bodies
• ganglia along chain (1 per level)
• Cervical ganglion
• stellate ganglion
• ganglion impar
• ends anterior to sacrum

Question 20

Where do superficial lymph nodes drain?

Answer 20

• external jugular vein

- anterior jugular veins

Question 21

Where do deep cervical lymph nodes drain?

Answer 21

-internal jugular vein

Question 22

Lymphatics in neck?

Answer 22

• Superficial cervical
• deep cervical
• pharyngeal
• pretracheal
• paratracheal
• retropharyngeal

Question 23

What does the Thoracic duct drain?

Answer 23

• lymph from everything below diaphragm

- everything except right side of head and neck, right upper limb and right side of thorax (right lymphatic duct)

Question 24

Where does the Thoracic duct drain into?

Answer 24

junction between left Internal Jugular Vein and Subclavian Vein

Question 25

Cervical viscera?

Answer 25

1. Respiratory layer - larynx - trachea 2. Alimentary layer - pharynx - esophagus

Question 26

Cartilage in larynx?

Answer 26

- thyroid - cricoid (inferior C6) - arytenoids

Question 27

Where does the trachea begin?

Answer 27

- after cricoid cartilage | - this marks the end of larynx

Question 28

What is the trachea?

Answer 28

- conduit from larynx to main bronchi | - 16-20 C shaped rings of cartilage

Question 29

Location of C shaped rings in trachea?

Answer 29

- anterior side | - posterior side is smooth muscle to allow movement of bolus down esophagus without pain sensation

Question 30

Where is the pharynx and esophagus located?

Answer 30

-posterior to larynx and trachea

Question 31

Divisions of the pharynx?

Answer 31

- Nasopharynx - Oropharynx - Laryngopharynx

Question 32

Muscles of the pharynx?

Answer 32

Pharyngeal Constrictors: - superior - middle - inferior

Question 33

Where is the landmark for the end of the pharynx and larynx?

Answer 33

- Cricoid cartilage | - beginning of esophagus and trachea

Question 34

What is the esophagus?

Answer 34

- continuation of pharynx inferior to cricoid cartilage (C6 vertebral level) - conduit from pharynx to stomach

Question 35

Where do the brachial plexus and Axillary Artery run in relation to scalene muscles?

Answer 35

-in between anterior and middle scalenes

Question 36

Where does the Axillary vein run in relation to Scalene muscles?

Answer 36

-anterior to anterior scalene

Question 37

Prefixed brachial plexus?

Answer 37

-C4-C8

Question 38

Postfixed brachial plexus?

Answer 38

- C6-T2 - lower syndrome - ulnar nerve problems

Question 39

Cervical rib?

Answer 39

- bilateral or unilateral - fuses with 1st rib - restricts space of Subclavian Artery

Question 40

Thoracic Outlet syndrome?

Answer 40

Injury to structures between anterior and middle scalene: 1. Brachial Plexus and Subclavian Artery 2. Scalenus Anticus Syndrome 3. Cervical Rib syndrome 4. Costoclavicular syndrome - surgery as intervention, maybe OMM

Question 41

Superior Brachial Plexus Injury?

Answer 41

- C5-C6 - limb hangs by side - medial rotation - Erb-Duchenne Palsy (waiters tip) - could be from trauma or pulling baby out

Question 42

Inferior Brachial Plexus injury?

Answer 42

- C8-T1 - see more often in thoracic outlet syndrome - hyperflexion - claw hand - could be from pulling on baby's arm at birth, climbing