Wednesday, March 25, 2009

Anatomy

A very broad topic, so I thought it would be best to concentrate on what is most relevant to this case:

The Original Penetrative Wound
The patient was stabbed with a kitchen knife, causing a penetrative wound 15x1.5cm deep, entering in the right chest, in the mid-clavicular line at the level of the right nipple.
As it was entering, the knife would have passed through many layers and structures before entering the thoracic cage, including:
 Skin (dermis)
 Mammary tissue + associated glands
 Subcutaneous tissue
 Pectoral fascia
 Pectoralis major
 Pectoralis minor
The knife is likely to then have passed through an intercostal space, likely the fourth or fifth, damaging the following structures
 The external, inner and innermost intercostal muscles
 The neurovascular bundle, consisting of a vein, an artery and a nerve which runs between the inner and innermost intercostal muscles.
From here, the knife would have pierced the parietal, then the visceral pleural membranes before puncturing the lung.

The Drainage Tube
A correctly placed drainage tube is inserted in an intercostal space (usually the 2nd-6th) “just above the rib below” in order to avoid the neurovascular bundle at the top of the space. Its purpose is to drain fluid or air from the pleural cavity, and hence the chest tube is inserted into this space. The layers the chest tube is passed through before reaching the pleural cavity are:
 Skin (dermis)
 Subcutaneous tissue
 Fascia
 Muscles of the upper limb eg. Pectoralis major and minor/Serratus anterior (which ones depend on the where the tube is being inserted)
 The external, inner and innermost intercostal muscles
 The parietal pleural membrane

In our case however, the drainage tube was placed at an intercostal space too low, so that instead of being inserted into the pleural cavity, it was put into the liver, at the level of about the 8th intercostal space. The layers the chest tube passed through in this case are likely to be:
 Skin (dermis)
 Subcutaneous tissue
 Fascia
 Latissimus dorsi
 The external, inner and innermost intercostal muscles
 The diaphragm
 The liver

References: Moore's, Last's, Netter's
By Steph

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