Ovid: Clinically Oriented Anatomy Page 40 of 158. Sternum. Axillary process of breast Axilla Lobules of fat Nipple Serratus anterior Anterior view FIGURE 1.22. Sagtal section of female breast and anterior thorate wall, The superior two thirds ofthe rigure demonstrates the suspensory laments and alveal af the breast with resting labules of mammary gland: {he Infertor part shows lactating abules af marvnary sland. ‘The mammary sand i irmly attaches tothe dermis ofthe overtying sin, especially by substantia skin ligaments (. retinacula cutis), the suspensory ligaments (of Cooper. These condensations of fibrous connective tse, particularly well developed inthe superior part ofthe gland, help support the lobes and abules of the mammary ‘lon During puberty (ages 8-5 years}, the breasts normaly enlarge, owing in pat to glandular development Sut primarily ‘rom increased fat deposition. The areola and nipples als enlarge. Breast size and shape are determined in pat by genetic, ethnic, ané ietary factors. The latiferous ducts give rise to buds that doveop into 15-20 lbules of the ‘mammary slang, which constitute the parenchyma (functional substance) ofthe mammary gland. Thus each lobule s rained bya lactierous duct, al of which converge to open independenty. Each duct has a diated portion deep to the areola, the latiferous sinus, in which a smal roplt of mi accumulates or remains in the nursing mater. As the infant begins to suckle, compression ofthe areola (and actifrous snus beneath it) expresses the accumulated Aroplets and encourages the infant continue nursing asthe hormarally meciated letdown reflex ensues. The mothers miki secreted into—not sucked frm the gland by-the babys moth oa ‘The areolae contaln numerous sebaceous glands, which enlarge during pregnancy and secrete an aly substance that rovdes a protective lubricant forthe areola and nipple. The areola and nipple are particulary subject to chafing and intation as mother and baby begin the nursing experience. The nipples are conical or clinical prominences in the centers of the areola. The nipples have no fat, hal, or sweat gland. The tps af te nlpples are issued with the lactiferous ducts epening into them. The nipples are composed mostly of circulartyaranged smooth muscle ibers that compres the laciferous ducts during lactation ane erst the nipples in respans t stimulation, as when a baby begins to suckle ‘Tae mammary sland are moéitied sweat slands; therefore, they have ne capsule or sheath. The rounded contour and most of the volume ofthe Breasts are procuced by subcutaneous fa, except during pregnancy when the mammary mk:@MSITStore:D:\FITRI\dr.%20Fitri\e%20bo0k20tugas%20baca%20respi\Moor... 27-Aug-19Ovid: Clinically Oriented Anatomy Page 41 of 158 lands enlarge and new glanduar tissue forms, The milksecretng alveot(L.smal hollow spaces) are arranged in rape: tke clusters. n most women, the breasts enlarge slightly during the menstrual pried trom increase release of gonadetropichermenesfolcle-stimulating hormone (FSH) and utenizing hormone (Li) on the glandular tissue. VASCULATURE OF BREAST ‘The arterial suppy of the breast (Fig. 1.238 6 8) derives from the: ‘+ Medial mammary branches of perforating branches anc anterior intercostal branches ofthe internal thoracic ‘artery, originating from the subclavian artery. + Lateral thoracic and thoracoacromial arteries, branches af the allay artery 1 Posterior intercostal arteries, branches of the thoracic aorta in the 2nd, 3, and th intercostal spaces. The venous drainage of the breast Is mainly to the ailary veln, but there f some drainage tothe internal thoracic vein Fig. 1.23 Tre lymphatic crainage of the breast is important because of its role nthe metastasis of cancer cll. Lymph pases from the nipple, areola, and lobules ofthe sand to the subareolar Iymphatc plexus (Fig. 1.244 6 8). From this plous ‘+ Most lymph (75%), especialy from the lateral breast quadrants, drains othe axilary lymph nodes, initial to the anterior ar pectoral nodes forthe most pat, However, some iemph may drain eirecty to other axa nodes ‘oreven to interpectoral,deltopectoral, supraclavicular, o inferior deep cervical nodes. (The axlary lymph nodes are covered in detail in Chapter 6.) ‘+ Most of the remaining yp, particularly fom the medal breast quadrats, drains to the parasternal lymph hades orto the opposite bresst, wnereas mph fom the inferior quadrants may past deeply to abdominal lymph sades(sebdaphragmatic inferior phrenic lymph nodes} Lymph fom the skin af the Breast, except the ripple and arela, drains inte the ipsilateral axlary, inferor deep cervical, and ifraclavicularIymph nodes and nt the parasternal mph nodes of both sides, Lympn fom the ailary nodes dain int clavculr(ifracavcular and supraclavicular) lymph nodes an from thers into the subclavian lymphatic trunk, which also drains lymph from the upper limb. Lymph fom the parasteral nodes enters the Bronchamediasinl mphatc trunks, which also érain mph from the thoracic viscera. Te termination of these iymphatic trunks varies; adtionaly, these trunks are described as merging with each other an withthe Jusular lymphatic trunk, dining the head ane neck to forma short ght lymphatic duct onthe right sde or entering the termination atthe thraci duct on the ef ic. However, n many (perhaps mast) cases, the trunks open indepencenty into te junction ofthe Internal jugular and subclavian veins, the right or left venous angle, that ferm the right and left brachiocephalic veins (ig 1.240). n sore cases, they open into both ofthese veins. NERVES OF BREAST ‘Te nerves ofthe Breast derive frm anterior and ateral cutaneous branches ofthe th-6th intercostal nerves (Fis. 1.15) The brancres ofthe intercostal nerves passthrough the pectoral fascia covering the pectorais major to reach coverying subcutaneous tissue and skin ofthe breast, The branches ofthe intercostal nerves convey sensory fibers from te sin ofthe breast and sympathetic fibers tothe blood vessels in the breasts and smooth muscle in the overying skin and nipple Surface Anatomy of Thoracic Wall The claviles (oar bones) le subcutaneeusl, forming bony ridges a the junction of the thorax and neck (Fig. 1.25). They can be palpated easily throughout ther length, especially where their medial ends articulate withthe rmanubrium ofthe sternum. The clavicles demarcate the superior division Between zones of lymphatic drainage: above the clavicles, lymph fows ultimately t inferior jugular iynph nodes; below them, parietal lymph (that from the body wall ane uoper limbs lows tothe axillary lymph nodes. ‘The sternum (oreastbone) les subcutaneowsy inthe anterior mean ine andi palpable throughout its length Between the prominences of the medal ends ofthe cavicles a the steroclavciar joints, the Jugular natch in the ‘manubrium can be palpated between the preminent medial ends of the clavicle, The notch lesa the eve of the inferior border ofthe body of T2 vertebra ané the space between the ft and 2nd thorace spinous processes. The manubrium, approximately 4 cm long, ies atthe level ofthe bodies of 13 and Td vertebrae (Fg 1.26). The mk:@MSiTStore:D:\FITRI\dr.%20Fitri\e%20book%20tugas%20baca%20respi\Moor... 27-Aug-19Ovid: Clinically Oriented Anatomy Page 42 of 158. sternal angle is palpable and often visible n young people because of the light movernent that occurs at the ofthe T4T5 IV lc and the space between the 3rd and 4th thoracic spinous processes. The sternal angle mark the level ofthe 2nd alr of costal cartilages. The left side ofthe manuoriu Is anterior Ce the atch af the aorta, and ts Fight side directly overlies the merging of the brachiocephalic vers to form the superter vena cava (SVC). Because It ‘scommen clinical practice to insert catheters int the SVC for intravenous feeding of extremely il patients and for other purposes, i essential to know the surface anatomy ofthis large vein, The SVC pases inferorly deep to the ‘manubrium and manubriestemal Junction bu projects as much 36a fngerbreadt to the right of the margin ofthe ‘manubrium. The SVC enters the right atrium of the heart opposite the right 3 costal cartilage. nny $$ Intemal thoracic Pr Fotorare bones a W o- comma Dt asst (9) Aner of mammary ‘mero fae igh te) ow roma: ity (6) Treva section ot morn ove (©) Ys of mana gland ‘Antero (nd igi bye] ew FIGURE 1.23. Vasculature of breast. A. The mammary sland s supplied from ts medial aspect mainy by perforating branches ofthe internal thoracic artery and by several branches of the axillary artery (principally ‘he lateral thoracic artery) superiorty ang laterally. B. The breast i supplied deeply by branches arising from ‘he Intrcoetal arteries. C. Venous drainage fst the slay vein (mainy) and te intemal tharacte veins ‘The body ofthe sternum, approximately 10 cm long, les anterior tothe right border af the heart ang vertebrae T5- 13. The intermammary cleft (misline depression or cleavage between the mature female Breasts) overlies the sternal body. The xiphold process Ve na sight depression, the epigastric fossa, This fossa uses a8 a guide in caréiopulmonary resuscitation (CPR) to propery pesition the Rand onthe inferior par of the sternum. The iphsternl joint i palpable ands often seen as a ridge, at the evel ofthe inferior border of T9 vertebra, ‘Toe costal margins, formed by the joined costal cartilages of the 7eh10th ribs, are easily palpable because they extend infroiaterally tram the xiphisteraljolnt. The converging right and left costa margins form the infrasternal mk:@MSITStore:D:\FITRI\dr.%20Fitri\e%20bo0k20tugas%20baca%20respi\Moor... 27-Aug-19Ovid: Clinically Oriented Anatomy Page 43 of 158. wee at wate a oes recess sat ‘hee ‘aca — oe a ia se pcan caiivoer oo eae reer roma pn fant een earpectocnl nodes x ‘ Yo orem Peconatls mejor’ = = J ? mesial St he 0 esto mo sie ton kn tt re et cope Tomcat, | Ladera Reptigaie ator ceae A nenvin Rooted Renee aM aon "yooh Si (© Let eos arte tern soror (ars ear ose van FIGURE 1.24, Lymphate drainage of breast. A. The lymph nodes receiving sranage from the breast. B. The ‘arrows neeate In flow trom the righ breast. Most iymph, especially that fom the supersr lateral ‘quadrant and center of the breast, ain othe allay lymph nodes, which, in ten, ae drained by the Subelavian lymphatic trunk. On the right sie, 1 enters the venous sytem via the right ymphatie duct. C, Most "lymph from the left beast retuns to the venous system va the thorace dct mk:@MSITStore:D:\FITRI\dr.%20Fitri\e%20bo0k20tugas%20baca%20respi\Moor... 27-Aug-19Ovid: Clinically Oriented Anatomy Page 44 of 158 ntact beeen FIGURE 1.25. Surface features of anterior thoracic wall The ribs and intercostal spaces provide a basis fr locating or describing the poston of structures or sites of trauma or pathology on or deep tothe theracte wall. Because the ist rib ot palpable, rb counting n physical examinations starts with the 2nd nib adjacent te the subcutaneous and easly palpated steral ange, To count the rte and Intercostal spaces anterol, sie the fingers (ts) laterally from the sternal angle onto the 2nd costal cartilage and begin counting the ribs and spaces by moving the fingers from here. The {st intercostal space is that superior to the 2d costal cartiiage-that is, intercostal spaces are numbered according tothe rib forming ther superior bouncary. Generally, i's morerlible to count intercastal spaces, since the fingertip tends t rest n (lip into) the {g2ps between the ribs. One finger should remain in pace while anether is used to locate the next space. Using all the fingers, ts posibie to locate four spaces at a time. The spaces are widest anteroateraly (approximately inthe rmiclavcular Une), If the fingers are removed fom the thoracic wall while counting spaces, the finger may easly be retuned to the same space, mistaking it for the one below. Pesterorly, the mesial end of the spine ofthe scapula cverties the 4th eb, mk:@MSITStore:D:\FITRI\dr.%20Fitri\e%20bo0k20tugas%20baca%20respi\Moor... 27-Aug-19Ovid: Clinically Oriented Anatomy Page 45 of 158. ‘Sternal angle at manubriosternal joint Body of sternum Xiphisternal joint Epigastric fossa Xiphold process Diaphram Heart * Transverse thoracic plane FIGURE 1.26. Vertebral levels f sternum and transverse theracle plane. Wie the ribs andar intercostal spaces provide the “attude” for navigation ané localization onthe thorace wall, several imaginary lines faciitate anatomical and clinical descriptions by providing “Longitude.” The following lines are extrapolated over the thoracic wall based on visible or palpable supertcia features: ‘+The anterior median (midsternal line (AML) indicates the intersection af the median plane withthe anterior ‘thoracic wall Fig. 1.27). ‘+The midelavicuar tine (MCL) passes through the midpoint ofthe clavicle, parallel to the AML, ‘+ The anterior axilary tine (AAL] runs vertically along the anterior slay fle that f formed bythe inferalaters border ofthe pectoris major a spans fram the tharaic cage to he humerus nthe am (Figs. 1.278) ‘The midaxillary tne (MAL) runs from the apex (deepest part of the allay fssa (armpit), parallel tothe AA “+The posterior axillary tne (PAL), also parallel to the AL, i drawn vertically along the posterior aia fld formes by te atsimus drs and tees major muscies a5 they span from the back to the humerus or) ‘+ The posterior median (midvertebral) ine (PAL) {8 vertical line along the tips of the spines processes ofthe vertedrae (ig, 1.270), ‘+The scapular ines (Ls) are paralelto the posterior median ine and intersect the inferir angles of the scapula mk:@MSITStore:D:\FITRI\dr.%20Fitri\e%20bo0k20tugas%20baca%20respi\Moor... 27-Aug-19