Clinical anatomy of the intercostal spaces and pleura. Topography of the chest wall

Topography of intercostal spaces:

In the intervals between the ribs are the external and internal intercostal muscles, mm. intercostales externi et interni, fiber and neurovascular bundles.

External intercostal muscles go from the lower edge of the ribs obliquely from top to bottom and anteriorly to the upper edge of the underlying rib. At the level of the costal cartilages, the external intercostal muscles are absent and replaced by the external intercostal membrane, membrana intercostalis externa, which preserves the direction of the connective tissue bundles corresponding to the course of the muscles.

Deeper located internal intercostal muscles, whose beams go in the opposite direction: from bottom to top and back. Behind the costal angles, the internal intercostal muscles are no longer there, they are replaced by the boggy bundles of the internal intercostal membrane, membrana intercostalis interna.

The space between adjacent ribs, bounded from the outside and from the inside by the corresponding intercostal muscles, is called intercostal space spatium intercostal. It contains intercostal vessels and a nerve: a vein, below it is an artery, and even lower is a nerve (VAN). The intercostal bundle in the area between the paravertebral and middle axillary lines lies in the groove, sulcus costalis, of the lower edge of the overlying rib.

Anterior to the midaxillary line, the intercostal vessels and nerves are located in the intermuscular tissue and are not protected by the ribs, so any punctures chest it is preferable to produce posterior to the midaxillary line along the upper edge of the underlying rib.

Posterior intercostal arteries depart from the aorta front from the internal mammary artery. Due to numerous anastomoses, they form a single arterial ring, the rupture of which can lead to heavy bleeding from both ends of the damaged vessel. Difficulties in stopping bleeding are also explained by the fact that the intercostal vessels are closely connected with the periosteum of the ribs and the fascial sheaths of the intercostal muscles, which is why their walls do not collapse when injured.

intercostal nerves upon exiting the intervertebral foramina, giving back branches, they go outward. From the side of the chest cavity to the angle of the rib, they are not covered with muscles and are separated from the parietal pleura by bundles of the internal intercostal membrane and a thin sheet of intrathoracic fascia and subpleural tissue. This explains the possibility of involvement of the intercostal nerves in the inflammatory process in diseases of the pleura. The lower 6 intercostal nerves innervate the anterolateral abdominal wall.

next layer chest wall -- intrathoracic fascia, fascia endothoracica, lining the inside of the intercostal muscles, ribs and costal cartilages, the sternum, as well as the anterior surface of the thoracic vertebrae and the diaphragm. The fascia over each of these formations has the corresponding name: fascia costalis, fascia diaphragmatica, etc. In front, in close connection with the intrathoracic fascia, there is a. thoracica interna.

Primary surgical treatment of penetrating wounds of the chest wall.

Indications: stab, stab-cut, cut, gunshot wounds with open or intense pneumothorax, intrapleural bleeding.

Anesthesia: the operation is performed under endotracheal anesthesia, if possible with separate bronchial intubation. The skin and muscle wound is excised with a fringing incision within healthy tissues. Excised damaged intercostal muscles and parietal pleura.

Revision of the pleural cavity. The parietal pleura is opened wide enough and the pleural cavity is examined. Foreign bodies, blood clots and liquid blood are removed from it. In some cases, mainly with stab and stab wounds, liquid blood is filtered and used for back transfusion into a vein. The sources of bleeding and air leakage are determined, after which hemostasis and aerostasis are performed. They carry out an audit of the adjacent organs, mediastinum and diaphragm, taking special measures in cases of damage.

One or two drains are introduced into the pleural cavity above the diaphragm - anterior and posterior. The main one is the posterior drainage, which is inserted into the seventh-eighth intercostal space along the posterior axillary line and laid along the posterior chest wall to the dome of the pleural cavity. Anterior drainage is introduced in the fourth-fifth intercostal space with insufficient or doubtful aerostasis and is placed between the lung and the mediastinum. The end of the drain must also reach the dome of the pleural cavity.

Suturing the wound of the chest wall. The main principle of suturing the wound of the chest wall is the imposition of layered sutures in order to create complete tightness. If possible, which happens, as a rule, only in cases of small wounds, the first row of interrupted sutures is applied to the pleura, intrathoracic fascia and intercostal muscles. The main interrupted sutures are applied in layers to the more superficial muscles of the chest wall. Further

sutured own and superficial fascia with subcutaneous tissue and then skin. The diverged ribs are brought together with one, two or three polyspast sutures, and defects in the pleura and muscles are closed with the help of muscle flaps, which are cut out from the pectoralis major, latissimus dorsi, and trapezius muscles, thus achieving complete tightness.

The skin of the anteromedial surface of the shoulder is innervated by the medial cutaneous nerve of the shoulder, extending from: 2. Medial bundle of the brachial plexus

Skin incisions with panaritiums of the fingers should not cross the line of interphalangeal joints in order to: 2. The periarticular ligaments were not damaged

The knee joint has synovial torsion in the amount of: d) 9;

The number of segments in the left lung is often equal to: 3. 10

The number of segments in the right lung is: 3 . 10

The number of synovial torsion of the knee joint is equal to: 5. 13th

Collateral circulation is: 2. Blood flow through the lateral branches after the cessation of blood flow through the main vessel

The ends of the nerves are truncated during amputation: D to prevent the development of phantom pains

The root of the mesentery of the small intestine passes: 3. Obliquely from top to bottom, left to right

The root of the right lung goes around from above: 4. Unpaired vein

The crown of death is a variant of the outlet of an artery: 4. Obturator

The crown of death in the region of the inner ring of the femoral canal usually passes through its border: d) medial;

The bone base of the small pelvis is supplemented by the following ligaments: 1. Sacrotuberous 2. Sacrospinous

Anterior to the gluteus maximus in the gluteal region are located directly d) deep sheet of own fascia;

Anterior to which line is the intercostal neurovascular bundle not covered by the lower edge of the overlying rib? WITHmiddle axillary

Anterior to the neurovascular bundle of the posterior bed of the upper third of the lower leg is: e) posterior tibial muscle;

The sacral plexus forms all nerves except: b) obturator;

The sacro-uterine ligaments are: 2. Fixing device

The blood supply to the scrotum is carried out from the pool of the artery: c) internal iliac;

The blood supply to the descending colon is carried out by the artery: a) left colon;

The blood supply to the ileum is carried out by the branches of the arteries : 2. Superior mesenteric

The blood supply to the pancreas is carried out by arteries extending from the following three of the listed vessels: 1. Superior mesenteric artery 2. Gastroduodenal artery 6. Splenic artery

The blood supply of the sigmoid colon is carried out from the pool of the artery: 4. Inferior mesenteric

The blood supply of the caecum is carried out from the pool of the artery: 1. Superior mesenteric

The blood supply of the jejunum of the small intestine is carried out due to the branches of the arteries: b) superior mesenteric;

The blood supply to the jejunum is carried out by the branches of the arteries : 2. Superior mesenteric

The blood flow in the lower limb after blockage or ligation of the femoral artery in the middle third of the thigh is restored: 3. Through the deep artery of the thigh

The round foramen at the base of the skull contains: maxillary branch of the fifth pair of cranial nerves;

Round ligaments of the uterus refer to: 1. Hanging device

The circular muscle lies in the anterior wall of the vestibule of the mouth between: mucous membrane and muscle that raises the corner of the mouth;

Circular amputations are: 1 . Single-stage 2. Two-moment 3. Three-moment 5. Guillotine

A circular incision in the first moment of the cone-circular amputation of the thigh according to N.I. Pirogov is dissected: Skin, subcutaneous tissue and superficial fascia

Where does the genital neurovascular bundle go after exiting the subpiriform foramen? 3. Into the ischiorectal fossa through the lesser sciatic foramen

The dome of the diaphragm on the left midclavicular line is located at level: 3. V ribs

The dome of the diaphragm on the right midclavicular line is located at level: 2. IV ribs

The lateral umbilical fold of the peritoneum contains: 1. Lower epigastric artery and vein

Laterally, pararectal parietal tissue is limited to: a) sheath of the internal iliac artery;

The lateral border of the femoral triangle is: 2. Tailor muscle

The lateral border of the right mesenteric sinus is : 3. Medial margin of the ascending colon

The lateral border of the carotid triangle of the neck is: sternocleidomastoid muscle;

The lateral wall of the armpit is: 4. Humerus with coracobrachialis and biceps brachii

The lateral border of the lumbar space of Lesgaft-Grunfeld is:

The lateral border of the lumbar Petit triangle is represented by: d) external oblique abdominal muscle;

The lateral border of the lumbar region is the line: 3. Posterior axillary

The lateral wall of the femoral canal is: 5. Fascialvagina femoral vein

The lateral wall of the canal of the adductor muscles is the muscle: a) medial wide;

The left gastric artery originates from: 2. Celiac trunk

The left gastroepiploic artery originates from: 4. Splenic artery

The left lung consists of shares in the amount of: b) two;

Left-sided chylous pleurisy occurs when the thoracic duct is damaged at the level of the vertebrae: e) Th5 and above;

The left vagus nerve enters the chest cavity between: b) left common carotid and subclavian arteries;

The left vagus nerve is located in relation to the wall of the esophagus: c) in front;

The left lateral abdominal canal communicates with: 3. Pelvic cavity

The left lateral canal is delimited from the left subdiaphragmatic space: 3. Bundle

The left mesenteric sinus has a message : 1. With small pelvis 2. With right sinus

The left mesenteric sinus is separated from the small pelvis : 1. Not delimited

The left recurrent laryngeal nerve usually arises from the left vagus nerve: 3. At the lower edge of the aortic arch

The left recurrent laryngeal nerve arises from the vagus nerve at the level of: Inferior edge of the aortic arch

The pulmonary artery in the hilum of the left lung in relation to the bronchus is located: c) from above;

Ligatures on the axillary artery should be applied: 2. Slightly above the level of discharge of a.subscapularis

Lymphatic drainage from the vagina occurs in the lymph nodes: a) inguinal; b) sacral; c) internal iliac; d) para-aortic;

Lymphatic drainage from the uterus is carried out to the lymph nodes: a) sacral; b) internal iliac; c) common iliac; d) inguinal;

Lymphatic outflow from the bladder is carried out to the lymph nodes: a) anterior sacral; b) internal iliac; c) external iliac; d) deep inguinal;

Lymph outflow from the anal rectum is carried out to the lymph nodes: e) inguinal;

Lymph outflow from the lateral region of the face is carried out to the lymph nodes: parotid deep

Lymph outflow from the lower ampulla of the rectum is carried out to the lymph nodes: c) sacral and internal iliac;

Lymph outflow from the descending colon is carried out into the system: d) portal vein;

Lymph outflow from the transverse colon is carried out to all lymph nodes, except: e) upper rectal;

Lymph outflow from the recto-sigmoid rectum is carried out primarily to the lymph nodes: b) lower mesenteric;

Lymph outflow from the sigmoid colon is carried out to the lymph nodes along the course: d) inferior mesenteric vein;

Ken's line is a projection :d) femoral artery;

The line connecting the middle of the inguinal ligament with the medial epicondyle of the thigh serves to determine the projection: c) femoral artery;

The facial nerve enters the thickness of the parotid. glands and is divided into: Temporal, Cheekbones, Buccal, Regional vet.lower. pers., Neck.

The facial nerve exits the skull at its outer base through: Stylomastoid foramen

The facial nerve provides innervation to all formations, with the exception of: chewing muscles;

The facial artery and vein lie on the face between: thin fascial plate and zygomatic muscles;

False insertion of a Luer cannula into the trachea during tracheostomy is likely to result in increased asphyxia;

The scapular-tracheal triangle is limited: Medial-median line of the neck, Above and laterally - Sternocleidomastoid muscle,Inferior and laterally-Superior belly of the scapular-hyoid muscle

The scapular circle of blood circulation is made up of all arteries, with the exception of: ascending artery of the neck;

d) longitudinal arrangement of blood vessels;

The macroscopic difference between the rectum and other parts of the colon is: a) the absence of shadows;

The lesser sciatic foramen of the small pelvis forms a ligament: a) sacrotuberous;

The small splanchnic nerve is formed by the roots of the thoracic nodes of the sympathetic border trunk: d) Th10 - Th11;

The uterine artery is a branch of: 1. Internal iliac artery

The fallopian tube is located: 1. Along the upper edge of the broad ligament of the uterus

The fallopian tube is located: e) at the upper edge of the broad ligament of the uterus;

The medial inguinal fossa is limited: 2. Medialumbilicalcrease3. Lateralumbilicalcrease

The medial umbilical fold of the peritoneum contains: 2. Obliterated umbilical artery

Medially, the pararectal parietal tissue of the pelvis is limited: b) visceral sheet of the pelvic fascia of the ampulla of the rectum;

Medially from the femoral vein in the femoral canal lies d) adipose tissue and lymph nodes;

The medial border of the stair-vertebral triangle of the neck is. long muscle of the neck;

The medial wall of the armpit is: 2. Chest wall with serratus anterior

The medial border of the inner ring of the femoral canal is: d) lacunar ligament;

The medial border of the parotid the masticatory region consists of: the styloid process of the temporal bone with outgoing muscles;

The medial border of the lumbar space of Lesgaft-Grunfeld is: e) back extensor muscle;

The medial border of the lumbar Petit triangle is: a) the latissimus dorsi;

The medial wall of the femoral ring is: 4. Lacunar ligament

The medial wall of the internal femoral ring is: c) lacunar ligament (Zhimbernatov);

The medial wall of the canal of the adductor muscles is the muscle: b) large adductor;

The medial wall of the hepatic sac is: 4. Falciform ligament

The medial wall of the axillary fossa is made up of muscles: d) anterior gear; bagIfinger in the synovial sacYfinger; b) in the cellular spaces of elevationsIAndYfingers; c) into the middle cellular space of the palm; d) into the Pirogov-Paron space;

The medial wall of the right hepatic sac is: e) falciform ligament of the liver;

The medial ankle canal of the foot communicates proximally with: a) posterior deep bed of the lower leg;

The medial ankle canal passes all the elements of the lower leg to the foot, except: 4. Tendons of the long peroneal muscle

The medial ankle canal of the foot communicates proximally with: 1. Back bed of the lower leg

Between what anatomical layers is the retromammary cellular space located?3. Psuperficial fascia4. Gore fascia

Interpterygoid tissue of the deep region of the face communicates with all spaces, except: temporal interaponeurotic;

Interpterygoid cellular space deep. region faces sod..: mandibular nerve with branches; lingual nerve;

The interpterygoid cellular space of the deep region of the face contains all of the following except: deep temporal artery;

The interstitial space is limited from below: First edge

The interstitial space is located between: Anterior and middle scalene muscles

Intercostal-lateral access to the lungs is carried out along the ribs: c) IV-V;

The intercostal vascular-nerve bundle is located: g ) along the lower edge of the rib;

The intercostal neurovascular bundle most of all protrudes from under the edge of the rib: 1. On the anterior wall of the chest

The intercostal neurovascular bundle is located between: d) external and internal intercostal muscles;

The exit point of the sensitive branches of the cervical plexus is projected: Along the posterior edge of the middle thirdm. sternocleidomastoideus

The place of insertion of the needle in pararenal blockade is: 3. The apex of the angle between the 12th rib and the outer edge of the erector spinae muscle

Metastasis in breast cancer can occur in various groups of regional lymph nodes under the influence of a number of specific conditions, including the localization of the tumor. Determine the most probable group of lymph nodes where metastasis can occur, if the tumor is localized in the upper part of the mammary gland: 2. Subclavian lymph nodes

The urogenital diaphragm is enclosed bilaterally between the edges of the muscles: b) pubic-coccygeal;

The ureter is supplied by arteries: c) ovarian (testicular);

The ureter along its course has: 3. Three restrictions

The ureters are located in relation to the peritoneum: a) extraperitoneally;

The muscle gap is limited: 1. FrontV.inguinal ligament-2. Behind and laterallyA.Ilium-3. Mediallyb.iliopectineal arch

The muscular and vascular lacunae of the thigh are separated by: 4. Iliopectineal arch

The muscular lacuna behind and laterally forms: c) ilium;

The muscle gap in front forms: b) inguinal ligament;

Muscles of the lateral fascial bed 3. Adductor muscle thumb 4. Interosseous muscles 6. Two lateral worm-like muscles

The muscles of the anterolateral wall of the abdomen are innervated by: 2. Lateral and anterior branches of the intercostal nerves from 7 to 12, 3. Branches of the lumbar plexus

The fleshy membrane of the scrotum is a derivative of the layer of the anterior abdominal wall :b) subcutaneous tissue;

At 5 cm. below the navel, the anterior wall of the fascial sheath of the rectus abdominis is formed by: 1. Aponeurosis of the external oblique muscle of the abdomen2. Aponeurosis of the internal oblique muscle of the abdomen 3. Aponeurosis of the transverse abdominal muscle

On the posterior surface of the uterus, the peritoneum covers: 4. The body of the uterus, the supravaginal part of the cervix and the posterior fornix of the vagina

What branches does the radial nerve divide into in the anterior lateral groove of the cubital fossa? 1. On superficial and deep

What departments divides the space under the inguinal ligament?4 . On muscle and vascular lacunae

On what surface of the esophagus are the branches of the left vagus nerve located? Hand the front

On the skin of the subclavian region at the level of the thoracic triangle are projected: b) medial and posterior bundles brachial plexus;

On the skin of the subclavian region at the level of the thoracic triangle are projected: a) posterior bundle of the brachial plexus;

primary bundles of the brachial plexus;

On the skin of the subclavian region at the level of the clavicular-thoracic triangle are projected: a) suprascapular artery;

On the skin armpit at the level of the pectoral triangle is projected: d) median nerve;

The duodenum is projected onto the anterolateral abdominal wall in the following areas: 2. Umbilical and epigastric

The stomach is projected onto the anterolateral abdominal wall in the following areas: 2. In the left hypochondrium and proper epigastric

On the anterior surface of the uterus, the peritoneum covers: 1. Only the body of the uterus

On the anterior surface of the aortic arch are: 2. Left vagus nerve 3. Left phrenic nerve

The following three fascial beds are located on the forearm: 1. Anterior, posterior, lateral

At the level of the elbow joint, the ulnar nerve is located: 4. Behind between the medial epicondyle and the olecranon

At the level of the elbow joint, the radial nerve is located: 1. Anteriorly in the lateral ulnar groove

At the level of the border line, the left ureter crosses: 1. Common iliac artery

At the level of the border line, the right ureter crosses: 3. External iliac artery

At the level of the cervical triangle of Pirogov, between the posterior wall of the pharynx and the prevertebral fascia is: pharyngeal tissue;

The supraampullary part of the rectum is covered by the peritoneum: 1. From all sides

The supravaginal part of the cervix in relation to the peritoneum is located: c) intraperitoneally;

Supraorbital and frontal nerves of the cranial vault yavl. final branch nerve: orbital;

The suprasternal interaponeurotic cellular space of the neck contains: venous jugular arch;

The suprasternal interaponeurotic cellular space of the neck communicates with: blind sac of the sternocleidomastoid muscle;

The suprascapular artery is one of the main arteries involved in the formation of the collateral circulation of the upper limb. The suprascapular artery is a branch of which artery? 5. Thyroid trunk

The supravesical fossa (fossa supravesicalis) is limited: 1. Median umbilical fold 2. Medial umbilical fold

Name the anatomical formation passing through the tendon center of the diaphragm.3. inferior vena cava

Name the arteries supplying the uterus: 1. Uterine arteries 3. Arteries of the round uterine ligament 4. Ovarian arteries

Name the arteries that supply blood to the rectum: 1. Superior rectal artery 2. Middle rectal arteries 4. Inferior rectal arteries

Name the arteries that supply blood to the ovaries: 1. Uterine arteries 4. Ovarian arteries

Name the venous plexuses in the tissue of the prevesical space of the small pelvis: 2. Vesicoprostatic (in men) 3. Vesical (in women)

Name the probable ways of spreading the infected exudate from the parotid-masticatory area: 1. Temporal pterygoid tissue 2. Interpterygoid tissue 3. Peripharyngeal tissue 5. External auditory meatus

Name all anatomical structures passing through the suprapiriform foramen: 1. Superior gluteal nerve 4. Superior gluteal artery and vein

Name all anatomical formations passing through the subpiriform opening: 1. Sciatic nerve 2. Inferior gluteal neurovascular bundle 4. Posterior femoral cutaneous nerve 5. Genital neurovascular bundle

Name the suspensory apparatus of the uterus: 1. Broad ligaments of the uterus 2. Round ligaments of the uterus

Name the supporting apparatus of the uterus: 1. Pelvic diaphragm 4. Urogenital diaphragm

Name the ligaments between which the dorsal vein of the penis or clitoris passes into the prevesical cellular space: 1. Arcuate ligament of the pubis 2. Transverse ligament of the perineum

Name the walls of the prevesical cellular space of the pelvis: 1. Transverse fascia 2. Prevesical fascia 4. Fascial lateral valves of the bladder 5. Pelvic diaphragm 6. Urogenital diaphragm

Name the fixing apparatus of the uterus: 1. Vesicouterine ligaments 2. Sacrouterine ligaments 4. Cardinal ligaments

The most likely route for the spread of purulent peritonitis from the left lateral canal is: 5. Peritoneal floor of the small pelvis

The most likely route for the spread of purulent peritonitis from the right mesenteric sinus is: 2. Left mesenteric sinus

The most likely route for the spread of purulent peritonitis from the right lateral canal is: 1. Liver bag

The most likely ways of spreading purulent peritonitis from the left mesenteric sinus are two of the following: 3. Right mesenteric sinus 5. Peritoneal floor of the small pelvis

The most pronounced arterial and venous plexuses of the hollow organs of the abdominal cavity are located in: 3. Submucosal

The largest sinus of the pericardium is: b) anterior-lower;

The most dangerous is tissue damage in the proximal thenar (“forbidden zone”): 3. Damage to the motor branch of the median nerve with a violation of the opposition of the thumb

The most typical location of thrombi in vascular embolism is: e) place of vessel bifurcation.

The most severe violations are observed with pneumothorax: 3. valve

The most physiological anastomosis to the small intestine is: 4. End to end

The most common is the position of the appendix in relation to the caecum: 3. Medial 5. Descending

The most effective method for preventing scarring after tendon suture is: c) early movement;

The external oblique muscle of the abdomen has a course of fibers: 3. From top to bottom and outside inside

The external seminal fascia of the scrotum is a derivative of the layer of the anterior abdominal wall: e) none of the options;

The external carotid artery in the neck gives off all branches except: lower thyroid;

The outer quarter of the neck of the hip joint is not covered by the capsule: b) behind;

The outer ring of the femoral canal is formed by: c) superficial leaf of the wide fascia of the thigh;

External pudendal vessels and nerves in the urogenital diaphragm are enclosed in a) subcutaneous tissue;

The external (derivative) sphincter of the bladder covers the urethra: c) membranous (membranous);

The external sphincter of the rectum is located at a distance from the anus: b) 1-2 cm;

Being in the prevertebral tissue, the thoracic duct in the posterior mediastinum is located between: 2 . Thoracic aorta and unpaired vein

The beginning of the trunk of the left gastric artery contains the ligament of the stomach: 4. Gastro-pancreas

The beginning of the formation of the internal iliac artery occurs at the level of: b) sacroiliac joint;

Neurolysis - release of nerve from scar tissue

Neurolysis" or "neurolysis" is: Release of the nerve from cicatricial adhesions

The neuroma of the nerve segment is excised: in ) with a razor blade;

The disadvantage of using the femoral method of femoral hernia surgery is: 2. In the possibility of increasing the inguinal gap with a downward displacement of the inguinal ligament

The need for urgent surgical intervention for purulent tendovaginitis of the flexor tendons of the fingers is explained by: 3. The possibility of necrosis of the tendons due to compression of their mesentery

The unpaired vein of the posterior mediastinum flows into the vein: b) upper hollow;

The azygous vein receives venous blood from all veins except: e) transverse lumbar;

The unpaired vein often flows into the wall of the superior vena cava: 2. Into the back

Unpaired and semi-unpaired veins pass through the diaphragm from the retroperitoneal space to the mediastinum: 1. Between the medial and middle crura of the diaphragm

The unpaired splanchnic nerve is formed by the roots of the thoracic nodes of the sympathetic border trunk: e) Th12;

Directly behind the collarbone is: subclavian vein

A non-permanent element of the pedicle of the lung segment is: a) segmental vein;

The Keys-Flyak nerve ganglion is located in the wall of the right atrium under: c) epicardium;

The lower border of the scapular-trapezoid triangle of the neck is the muscle: lower abdomen scapular-hyoid;

The lower border of the pelvic region of the rectum is: b) pelvic diaphragm;

The lower-lateral border of the scapular-tracheal triangle of the neck is the muscle: sternocleidomastoid;

Mandibular branch trigeminal nerve provides innervation of all anatomical formations, except: muscles that lift the upper lip; large zygomatic muscle;

Lower 2/3 of the chest lymphatic duct to VII-VI thoracic vertebra are located in relation to the spine: a) front and right;

The lower edges of the internal oblique and transverse muscles are the wall of the inguinal canal: 1. Top

The lower edge of the liver in the midline is: 3. In the middle of the distance between the base of the xiphoid process and the navel

The lower interpleural space is located below the costal cartilages: c) III-IV;

The inferior nasal passage communicates with: nasolacrimal canal;

The lower border of the outer femoral ring is: d) lower sickle of the broad fascia of the thigh;

The lower border of the subperitoneal floor of the pelvic cavity is: c) the inner sheet of the pelvic fascia;

The lower border of the subcutaneous floor of the pelvic cavity is: d) skin of the perineum;

The lower border of the lumbar Petit triangle is: d) crest of the iliac wing;

The lower border of the lumbar region is: 2. Combs ilium and sacrum

The lower border of the neck is made up of all formations, except: top vynyy line;

The lower border of the cervical triangle of Pirogov is: digastric tendon;

The lower wall of the inguinal gap is: b) inguinal ligament;

The bottom wall of the stuffing bag is: c) mesentery of the transverse colon;

The lower wall of the stuffing box is made up of : 3. Transverse colon and her mesentery

The lower 1/3 of the vagina is supplied with blood from the pool of arteries: a) internal shameful;

The lower ampullar part of the rectum in relation to the peritoneum is located extraperitoneally;

The inferior orbital fissure connects the orbit to: pterygopalatine, infratemporal and temporal fossae;

The lower horizontal line of the Krenlein cranial topography diagram passes through: the lower edge of the orbit and the upper edge of the external auditory canal;

The inferior and superior epigastric arteries of the anterior abdominal wall are: d) behind the rectus abdominis;

The lower limb takes the pathological position of the "horse foot" in case of damage: b) common peroneal nerve;

The lower limb takes the pathological position of the "heel foot" in case of damage: a) tibial nerve;

The inferior adrenal artery originates from the artery: d) renal;

The inferior vena cava in relation to the peritoneum is located: extraperitoneally;

The lower wall of the inguinal canal is formed by: 2. Inguinal ligament

The lower part of the rectum is covered by the peritoneum: 3. Not covered by the peritoneum at all

The inferior thyroid artery is a branch of the artery: subclavian;

The nasolacrimal canal connects the eye socket with: lower nasal passage;

The projection area of ​​the gallbladder on the anterior abdominal wall is: 4. Epigastric region

The olfactory nerve provides sensitive specific innervation of the mucosa: upper nasal passage;

The formation, located immediately anterior to the soleus muscle in the upper third of the lower leg, is: b) a deep sheet of its own fascia;

Education constituting back wall vagina m. rectus above the umbilical ring is: d) aponeurosis of the internal oblique muscle of the abdomen;

Education, constituting the posterior wall of the vagina m. rectus below the umbilical ring, is: a) transverse fascia;

Right lung: right parasternal line - 6th intercostal space, midclavicular - 7th rib, anterior axillary - 8th rib, middle axillary - 8th intercostal space, posterior axillary - 9th rib, scapular - 10th rib.

Left lung: anterior axillary - 7th rib, middle axillary - 7th intercostal space, posterior axillary - 8th rib, scapular - 9th rib.

The mobility of the pulmonary edge is 6 cm.

The chest is painless on palpation.

Auscultation of the lungs: vesicular breathing over the entire surface of the lungs, side breath sounds are not heard.

Bronchophony is not defined.

The cardiovascular system:

The chest over the region of the heart is not deformed. The apex beat is determined in the 5th intercostal space, 1 cm outward from the midclavicular line. Pathological pulsation of vessels in the neck and epigastrium is not observed. The pulsation of the vessels of the feet is distinct.

Pulse - 74 beats per minute, rhythmic, satisfactory filling and tension, the same on both hands. There is no pulse deficit.

The apex beat is palpated in the 5th intercostal space 1 cm outward from the mid-clavicular line, diffuse, of medium strength, with an area of ​​about 2 cm.

The upper limit of the relative dullness of the heart passes in the second intercostal space.

The border of the heart on the right is along the right edge of the sternum. The border of the heart on the left is 2 cm outward from the mid-clavicular line.

The tones are rhythmic. The first tone is muted. An accent of the second tone is heard on the aorta. At the apex, a systolic murmur is heard, which is not conducted anywhere.

The pulsation of the peripheral arteries is preserved.

Blood pressure is the same on both hands and amounted to 140/75.

Digestive organs:

The oral cavity is sanitized.

The oral mucosa is moist, pale pink in color, shiny.

The tongue is pale pink, moist, without plaque, no ulcers or cracks.

The gums are pale pink, without pathological changes.

Zev is calm, there are no dyspeptic disorders at the time of curation.

The abdomen is symmetrical, rounded, participates in the act of breathing. The skin of the abdominal wall is of normal color, there is no visible peristalsis.

Percussion sound over the entire surface of the abdomen is the same. There is no free gas in the abdominal cavity. On superficial palpation: the abdomen is soft, painless.

Deep palpation of the caecum and transverse colon revealed no pain. Palpation of the sigmoid colon moderate pain. Symptoms of peritoneal irritation are negative.

The lower edge of the liver is palpated along the edge of the costal arch, smooth, elastic, painless. Ortner-Grekov's symptom is negative, Mussi-Georgievsky's symptom is negative.

The size of the liver according to Kurlov: right - 9 cm, median - 8 cm,

oblique - 7 cm.

The spleen is not palpable. The size of the spleen. revealed during percussion: longitudinal - 6 cm, transverse - 4 cm.

Inspection of the area anus external hemorrhoids, inflammation, neoplasms were not revealed. Examination of the rectum revealed: sphincter tone is normal, palpation is painful. There is a small amount of scarlet blood and feces on the glove.

The stool is frequent, liquid, which the patient associates with taking a laxative.

Urinary system:

Skin in the area of ​​the anatomical projection of the kidneys normal temperature and colors.

Urination regular, painless.

The kidneys are not palpable on both sides.

The symptom of tapping (Pasternatsky) is negative on both sides.

The bladder is not percussed.

The ureteral points are painless.

Neurological status:

Intelligence and emotions correspond to age. Pathology of the cranial nerves according to the examination was not revealed.

Physiological reflexes:

abdominal reflexes - present;

tendon reflexes from the arms and legs are present.

Endocrine system:

The proportions of the trunk and limbs correspond to age.

Sexual organs correspond to age. Exophthalmos and other eye symptoms are absent.

Provisional diagnosis:

Regarding complaints about:

Frequent, painful, bloody stools

Weakness

Medical history:

Examination in hospital No. 30 and exclusion of acute dysentery

Data from an objective study:

Rectal examination showed traces of feces mixed with red blood on the glove.

Cr of the rectosigmoid region

Accompanying illnesses:

Angina pectoris 2 f.cl.

Hypertension stage 2

Pairs of intercostal spaces.

The greatest width is in III, then II and I intercostal spaces, but this is a non-permanent phenomenon. The width and direction of the intercostal spaces vary considerably. The intercostal spaces are filled with external and internal intercostal membranes and muscles.

Elderly and sometimes middle-aged people often have pain in the ribs. It is difficult to immediately determine the exact cause of their occurrence, since intercostal neuralgia has symptoms similar to heart attacks, sciatica, pneumonia, hepatic colic and other diseases. Thoracalgia is more often observed in men, which is caused by the peculiarities of their work and lifestyle.

Intercostal neuralgia, symptoms

Intercostal neuralgia is manifested by severe pain in the ribs and chest. When you try to take a deep breath and change the position of the body, the pain intensifies. This happens when coughing, sneezing and even talking loudly. The pain may be:

• on right;
• left;
• encircling.

On palpation, you can feel the direction of the spasm that passes from the spine between the ribs. This may cause numbness and blanching of the skin in the affected area. When pressed, the pain intensifies.

It can be impossible to make an accurate diagnosis right away, since the pain often radiates (radiates) to the shoulder and arm, to the navel and below, along the edge of the sternum and to the lower back. In addition, there may be burning, numbness and tingling in the chest area.

Causes of pain

By its nature, neuralgia is a pinched nerve, which can be in two zones:

• spinal column, infringement of the spinal nerves of the thoracic region;
• in the intercostal space inflammation or infringement of nerve endings.

In both cases, the pain is very strong, prolonged and does not go away without taking painkillers. The cause of a pinched nerve are various diseases of the body. Therefore, it is important to eliminate the cause, otherwise the pain syndrome will remain.

Infringement of the spinal nerves

The roots of the thoracic spinal nerves are pinched at the exit of the nerve from spinal canal. It's caused by a disease musculoskeletal system. With the deposition of salts, inflammation of the joints and deformation as a result of osteoporosis and trauma, the vertebral bones change their shape and size and begin to put pressure on the nerves extending from the spinal cord into the intercostal space. The nerve ceases to receive nutrition and signals a violation of pain along its entire length.

When the spinal nerve is infringed, girdle pain often occurs, since the deformed bones of the spinal column pinch both nerves. Unilateral neuralgia in this case is more often the result of trauma. With inflammation in the spine, the temperature may rise.

Infringement of nerve endings

More frequent cases of thoracolgia are caused by compression of nerve endings in the intercostal space. The reason for this may be nervous disorders, stress, disease of internal organs, viral infections, hypothermia and overload. Muscles increase in size or shrink from spasm and compress nerve endings. In such cases, the pain spreads on one side.

Pain on the left

Often the pain on the left is mistaken for a heart pain, since numerous roots have a branch and pass in the region of the heart and under the scapula. There is a difference in symptoms. Angina pectoris is characterized by throbbing pain, which is relieved by nitroglycerin. In this case, the pulse is disturbed, the pressure reading changes.

With intercostal neuralgia on the left, the pulse and pressure remain the same, but when you try to take a deep breath and change your position, the pain will increase. The temperature may rise slightly in any case. Taking heart medications will help prevent a heart attack and more accurately determine the diagnosis.

Pain on the right

Often, left-sided neuralgia is mistaken for attacks of pain in the liver and renal colic. Pain from the intercostal region can radiate to the lumbar region and kidneys. The main signs of intercostal neuralgia, severe constant pain, aggravated by movement, coughing, sneezing and inhalation, with finger pressure at the place where the nerve passes from the spine to the sides and forward between the ribs.

With a disease of the internal organs, the body temperature rises significantly, the pain is aching and spasmodic in nature. In any case, it is necessary to consult a doctor and undergo an examination for correct definition diagnosis. A disease of the internal organs can also provoke intercostal neuralgia.

Causes of thoracolgia

The nerve can be pinched by the body of the spine, enlarged muscles, as well as their spasm. This is provoked by diseases of the supporting system, osteochondrosis and microtrauma. When lifting weights, muscle spasm occurs. Such a reaction can also be caused by working in a room where the temperature is low, or on the street.

Pain occurs due to malnutrition nerve cells oxygen, which can cause diabetes, anemia, body toxicity due to alcohol consumption, smoking, poisoning with chemical and biological substances, spoiled and low-quality products.

Violates the metabolism and nutrition of body cells with oxygen and increased cholecystitis, obesity and prolonged stay in one position without movement. Elevated cholecystitis and obesity interfere with normal blood flow, as do diseases gastrointestinal organs, especially ulcers, colitis, gastritis, hemorrhoids. Metabolism is disturbed with a lack of B vitamins in the body, diabetes mellitus.

In men, an attack of intercostal neuralgia most often begins when lifting weights, especially in the cold, since muscle contraction from low temperature is added to the stress from excessive physical exertion. This is especially possible if the body is constantly exposed to nicotine and alcohol poisoning and there are toxins in the blood that reduce the oxygen content and increase the number of oxidants.

Treatment of intercostal neuralgia

You need to start with a visit to the doctor and examination. Then, after determining the cause of neuralgia, a course of treatment follows in three stages.

1. Removal of acute pain and bed rest. A blockade is made and dry heat is applied, bypassing the heart zone.
2. Treatment of muscle and nerve inflammation with a course of anti-inflammatory drugs and B vitamins.
3. Treatment of the disease that caused intercostal neuralgia.

It is necessary to determine and eliminate the cause of a pinched nerve in the intercostal zone and the spine in order to avoid recurrence of pain attacks. In addition, it is necessary to treat the disease in itself, and not only because of its ability to provoke neuralgia.

Prevention

Since the pain is caused by a malnutrition of the cells of the body, including nerve cells, with oxygen, the measures to prevent the disease are standard. It's a healthy lifestyle proper nutrition and playing sports, especially if you have to be in the same position a lot, standing or sitting.

Of great importance is the annual medical examination in order to identify abnormalities in the work of organs on initial stage the development of the disease. This is especially important for older men and those who have harmful conditions labor in production, including cold, fumes, dampness and gas pollution.

For the purpose of prevention, it is necessary to periodically take a course of vitamins and minerals. Once a year, cleanse the blood with antioxidants, especially for residents of large cities. Watch your weight and do not wear tight clothing that interferes with the natural blood circulation. Dress for the weather and don't get cold.

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Intercostal neuralgia: symptoms and causes. Treatment of intercostal neuralgia: new drugs

Intercostal neuralgia is one of the most common causes pain in the chest. In most cases, intercostal neuralgia is observed in elderly and middle-aged people. In children, this disease practically does not occur.

Symptoms of intercostal neuralgia

By its nature, intercostal neuralgia is:

Basically, pain in intercostal neuralgia is localized in the intercostal space, but irradiation of pain along the strangulated nerve is possible - in the lower back, in the back, under the shoulder blade. There may be spastic muscle contractions, redness or blanching of the skin, loss of skin sensitivity in the area of ​​the affected nerve. Pain with intercostal neuralgia is very strong, burning, constant, without attacks

Intercostal neuralgia - clarify the diagnosis

Intercostal neuralgia is sometimes confused with heart pain. It's not that hard to tell them apart though.

With intercostal neuralgia, the pain increases with a deep breath or exhalation, or any other movement of the body, including coughing or sneezing, during physical exertion. Sometimes it hurts not even to take a deep breath - attacks of burning pain appear along the intercostal spaces (pain can be felt only on one side of the chest).

Heart pain in angina pectoris does not change with a deep breath or exhalation, from a change in position or movement in the chest; usually relieved with nitroglycerin; may be accompanied by a violation of the rhythm of the pulse, a drop or increase in blood pressure.

With intercostal neuralgia, the pain may increase with palpation - you can feel the direction of pain along the nerve. Aching or paroxysmal pain, spreading along the nerve trunk or its branches, may be accompanied by other unpleasant sensations - burning, tingling, numbness. By the way, therefore, intercostal neuralgia can respond with pain not only in the region of the heart, but also under the scapula, in the back, lower back (they can sometimes be confused with kidney pain).

It is important to differentiate between an attack of intercostal neuralgia and myocardial infarction, which can also cause severe pain that is not relieved by nitroglycerin. Therefore, when sudden attack pain in the heart area must be caused ambulance and make an electrocardiogram, since a heart attack needs urgent medical attention.

Causes of intercostal neuralgia

There are many reasons that can cause intercostal neuralgia, but, in fact, the pain is caused either by pinching of the spinal nerve root in the thoracic spine, or by pinching or irritation of the intercostal nerves in the intercostal space.

Pinched roots are most often caused by various manifestations of osteochondrosis, but other causes are possible (spondylitis, Bechterew's disease, and others).

However, more often attacks occur as a result of irritation of the nerve due to infringement of its intercostal muscles due to inflammation or muscle spasm.

The cause of spasm and, accordingly, an attack of neuralgia, may be mental stress, traumatic effects, excessive physical activity without necessary training. Spasm and inflammation of the intercostal muscles can be caused by hypothermia, past infection. Sometimes intercostal neuralgia occurs with lung diseases.

An attack of intercostal neuralgia can occur with poisoning, with changes in the spine due to hormonal disorders in women in menopause. The cause of neuralgia may be allergic diseases, disease nervous system (multiple sclerosis, polyradiculoneuritis). It is possible to develop intercostal neuralgia with aortic aneurysm, diseases of internal organs, after a herpes infection.

Also, the cause of neuralgia can be microtrauma with constant physical stress (for example, when lifting weights), especially in combination with hypothermia.

Alcohol abuse (due to the toxic effect of alcohol on the nervous system), as well as diabetes mellitus and a lack of B vitamins in the body (observed with gastric and duodenal ulcers, gastritis, hepatitis, colitis) can lead to the development of the disease - due to a violation metabolism in nervous tissue.

It should be noted that symptoms resembling intercostal neuralgia are possible due to excessive tone (spasm) of one or more back muscles. In this case, there is an increase pain when stretching the affected muscle (leaning forward, moving the shoulder or shoulder blade).

What is intercostal neuralgia? What are its reasons? How to treat intercostal neuralgia?

The causes and symptoms of intercostal neuralgia and new methods of treatment are described by Ph.D. E.L. Shakhramanova, doctor of the consultative polyclinic department of the Research Institute of Rheumatology.

Treatment of intercostal neuralgia

Treatment of intercostal neuralgia usually consists of two stages. First, it is necessary to remove the pain that accompanies intercostal neuralgia, then it is necessary to treat the disease that caused the nerve injury.

In the first week of the disease, it is better to stay in bed for 1-3 days, and it is advisable to lie on a hard surface, it is best to put a shield under the mattress. To relieve pain, painkillers are prescribed, usually from the NSAID group, which not only relieve pain, but also have an anti-inflammatory effect. In addition, muscle relaxants are prescribed - to relieve muscle spasms, sedatives. Vitamins of group B (B1, B6, B12) are recommended - they help to restore damaged nerve structures. During attacks, light, dry heat helps.

After the removal of acute symptoms, it is necessary to diagnose and determine the cause that caused the attack of intercostal neuralgia. If this is any common disease(infectious, catarrhal, allergic, diabetes mellitus, nervous system disease, depression) - it is necessary to treat it.

If intercostal neuralgia is caused by a disease of the spine, that is, it has a vertebrogenic nature, complex treatment of the spine is recommended. To restore the correct physiological position of the chest and cervical of the spinal column in case of intercostal neuralgia, courses are conducted therapeutic massage, manual therapy, exercise therapy.

A good effect in vertebrogenic intercostal neuralgia is given by physiotherapy, acupuncture, laser therapy. So that the disease does not pass into chronic form With frequent attacks, you need to reduce physical activity, do not abuse alcohol, avoid stressful situations if possible.

In the first week of the disease, it is better to stay in bed for 1-3 days, and it is advisable to lie on a hard surface, it is best to put a shield under the mattress. During attacks, light, dry heat helps.

To relieve pain, take painkillers and sedatives. A good effect with intercostal neuralgia is given by physiotherapy, acupuncture, laser therapy. It is advisable to take B vitamins (B1, B6, B12). To prevent the disease from becoming chronic with frequent attacks, you need to reduce physical activity, do not abuse alcohol, and avoid stressful situations if possible.

To restore the correct physiological position of the thoracic and cervical spine in case of intercostal neuralgia, courses of therapeutic massage, manual therapy, and physiotherapy exercises are carried out.

If conservative treatment fails, then surgery(for example, osteochondrosis or disc herniation, which cause bouts of intercostal neuralgia).

Treatment of intercostal neuralgia with a new drug - NANOPLAST forte medical plaster

At therapeutic treatment intercostal neuralgia, various drugs are used, such as NSAIDs, analgesics, etc. All these drugs are effective, but with prolonged use they can harm the body. Therefore, it is very important to minimize side effects and improve the effectiveness of treatment of intercostal neuralgia. This can be helped by a new generation drug - an analgesic anti-inflammatory medical plaster NANOPLAST forte.

In the treatment of intercostal neuralgia, the NANOPLAST forte therapeutic patch is highly effective, it allows you to relieve pain and inflammation, improve blood circulation in the affected area, and reduce the dose of painkillers and anti-inflammatory drugs.

In case of intercostal neuralgia, the NANOPLAST forte therapeutic patch is applied to the intercostal region (avoiding the region of the heart) or to the projection of the exit of the spinal nerves, which are usually restrained against the background of osteochondrosis to the right or left of the spine in the thoracic region - depending on the location of the pain. Maybe simultaneous use patch in the intercostal region (where the pain is localized) and at the site of the projection of the corresponding nerve in the thoracic spine. It is usually recommended to use the patch in the morning at 12 o'clock, but it is possible to apply it at night. The duration of the course treatment of intercostal neuralgia medical plaster- from 9 days.

High efficiency, unique composition, long-term (up to 12 hours!) therapeutic effect, ease of use and affordable price make NANOPLAST forte the drug of choice in the treatment of intercostal neuralgia.

intercostal space

In the intervals between the ribs are the external and internal intercostal muscles, mm. intercostales externi et interni, fiber and neurovascular bundles.

The external intercostal muscles run from the lower edge of the ribs obliquely from top to bottom and anteriorly to the upper edge of the underlying rib. At the level of the costal cartilages, the external intercostal muscles are absent and replaced by the external intercostal membrane, membrana intercostalis externa, which preserves the direction of the connective tissue bundles corresponding to the course of the muscles.

Figure 7.4. Topography of the intercostal neurovascular bundle on the posterior and anterior surfaces of the chest (scheme). I - between the middle axillary and paravertebral lines; II - between the middle axillary and midclavicular lines. 1 - fascia m. latissimus dorsi; 2 - m. latissimus dorsi; 3 - fascia thoracica; 4-v. intercostalis; 5-a. intercostalis; 6 - n. intercostalis; 7 - m. intercostalis externus; 8 - m. intercostalis internus; 9 - fascia endothoracica; 10 - prepleural tissue; 11 - pleura parietalis; 12 - fascia pectoralis; 13 - m. pectoralis major.

Deeper are the internal intercostal muscles, the bundles of which run in the opposite direction: from bottom to top and back. Behind the costal angles, the internal intercostal muscles are no longer there, they are replaced by the boggy bundles of the internal intercostal membrane, membrana intercostalis interna.

The space between adjacent ribs, bounded from the outside and from the inside by the corresponding intercostal muscles, is called the intercostal space, spatium intercostale. It contains intercostal vessels and a nerve: a vein, below it is an artery, and even lower is a nerve (for ease of remembering: Vienna, Artery, Nerve - VANya). The intercostal bundle in the area between the paravertebral and middle axillary lines lies in the groove, sulcus costalis, of the lower edge of the overlying rib.

Anterior to the midaxillary line, the intercostal vessels and nerves are located in the intermuscular tissue and are not protected by the ribs, so it is preferable to make any chest punctures posterior to the midaxillary line along the upper edge of the underlying rib.

Topographic anatomy of the chest. Topography of intercostal spaces.

The thorax is the bone base of the chest walls. Consists of XII thoracic vertebrae, XII pairs of ribs and sternum.

Chest wall:

The back wall is formed by the thoracic part of the spinal column, as well as the posterior parts of the ribs from the head to their corners.

The anterior wall is formed by the sternum and cartilaginous ends of the ribs.

The side walls are formed by the bony part of the ribs.

The upper thoracic inlet is limited by the posterior surface of the manubrium of the sternum, the inner edges of the first ribs and the anterior surface of the first thoracic vertebra.

The lower aperture of the chest is limited by the posterior surface of the xiphoid process of the sternum, the lower edge of the costal arch, the anterior surface of the X thoracic vertebra. The lower aperture is closed by a diaphragm.

Skeleton of the chest, a - front view. 1 - top thoracic aperture; 2 - jugular

tenderloin; 3 - handle of the sternum; 4 - body of the sternum; 5 - xiphoid process of the sternum; 6 - oscillating ribs (XI-XII); 7 - infrasternal angle; 8 - lower thoracic aperture; 9 - false ribs (VIII-X); 10 - costal cartilages; true ribs (I-VII); 12 - clavicle.

Topography of intercostal spaces.

Topography of the intercostal neurovascular bundle on the posterior and anterior surfaces of the chest:

I - between the middle axillary and paravertebral lines;

II - between the middle axillary and midclavicular lines.

1 - fascia m. latissimus dorsi; 2 - m. latissimus dorsi; 3 - fascia thoracica; 4-v. intercostalis;

5 – a. intercostalis; 6-n. intercostalis; 7 - m. Intercostalisexternus; 8 - m. intercostalis internus;

9 - fascia endothoracica; 10 - prepleural fiber; 11 - pleura parietalis;

12 - fasciapectoralis; 13 - m. pectoralis major.

In the spaces between the ribs are the external and internal intercostal muscles, fiber and neurovascular bundles.

External intercostal muscles (mm. intercostalisexterni) run from the lower edge of the ribs obliquely from top to bottom and anteriorly to the upper edge of the underlying rib. At the level of the costal cartilages, the muscles are absent and are replaced by an external intercostal membrane.

Internal intercostal muscles (mm. intercostales interni) go obliquely from the bottom up and back. Posterior to the costal angles, the muscle bundles are absent and are replaced by an internal intercostal membrane.

The space between adjacent ribs, bounded from the outside and from the inside by the corresponding intercostal muscles, is called the intercostal space. It contains a vein, below her artery, even lower - the nerve.

The posterior intercostal arteries (IX-X pairs) depart from the aorta, are located in the intervals from III to XI ribs, the twelfth artery, lying under the XII rib, is called the hypochondrium artery (a. subcostalis). Branches:

Dorsal branch (r. dorsalis) goes to the muscles and skin of the back

Lateral and medial skin branches (r. cutaneus lateraliset medialis) go to the skin of the chest and abdomen

Lateral and medial branches of the mammary gland (rr. mammariilateralisetmedialis)

The anterior intercostal arteries arise from the internal mammary artery.

Venous outflow occurs through the veins of the same name.

Intercostal nerves (n. intercostalis) first go directly adjacent to the parietal pleura, and then lies in the intercostal groove. Branches:

Anterior and lateral skin branches (r. cutaneianterioreset laterales)

Muscular branches innervating the intercostal muscles

Intercostal space;

complex area of ​​the human body, containing the vital important organs: heart and lungs.

The upper border of the chest is determined by a line drawn along the upper edge of the jugular notch, collarbones, humeral processes of the scapulae and the spinous process of the VII cervical vertebra.

The lower border is represented by a line passing from the xiphoid process of the sternum, along the costal arches, along the free edges of the X-XII ribs and the spinous process of the XII thoracic vertebra. The chest is separated from the upper extremities along the deltoid grooves in front, and along the medial edge of the deltoid muscle in the back.

The boundaries of the chest cavity do not correspond to the boundaries of the chest, since the dome of the pleura of the right and left lungs protrudes 2-3 cm above the clavicles, and 2 domes of the diaphragm are located at the level of the IV and V thoracic vertebrae.

The jugular notch is projected onto the lower edge of the second thoracic vertebra. The lower angle of the scapula is projected onto the upper edge of the VIII rib.

To determine the projection of the organs of the chest cavity on the chest wall, lines are used:

anterior midline,

anterior axillary line,

middle axillary line,

Posterior axillary line

Posterior median line

skin, subcutaneous fat,

The superficial fascia, which forms the fascial sheath for the mammary gland, also extends the septa from the posterior leaf to the anterior, forming a lobule.

Own fascia of the chest, which forms fascial cases for the pectoralis major and minor muscles on the anterior surface of the chest. On the back of the chest, its own fascia is divided into two sheets and forms fascial cases for the latissimus dorsi and the lower part of the trapezius muscle. A deep sheet of its own fascia limits the bone-fibrous beds of the scapula with the muscles, vessels and nerves lying in them, and also forms cases for the large and small rhomboid muscles of the back and the muscle that lifts the scapula.

pectoralis major muscle

Superficial subpectoral cellular space,

pectoralis minor,

Deep subpectoral cellular space,

Serratus anterior.

Ribs with external and internal intercostal muscles,

Prepleural adipose tissue

ribs top and bottom

external intercostal muscle

internal intercostal muscle

At the same time, the relative position of the muscles is not the same throughout the entire interval from the vertebral lines to the sternal lines. On the back surface, the internal pectoral muscles do not reach the vertebral line, and thus a gap remains between the muscles. And in front, at the level of the costal cartilages, the muscles are represented by an aponeurotic plate tightly fixed to the sternum.

In the intercostal spaces are located intercostal neurovascular bundles, represented by intercostal arteries, intercostal veins and intercostal nerves.

There are anterior and posterior intercostal arteries. The anterior intercostal arteries originate from the internal thoracic arteries, which in turn are branches of the subclavian arteries. The posterior intercostal arteries are branches of the thoracic aorta.

Thus, an arterial ring is formed, the presence of which carries both benefits and dangers.

The “+” of such anatomy is the presence of anastomoses between the two main sources of blood circulation, which ensures adequate blood supply to the intercostal muscles responsible for our breathing even in the event of occlusion of one of the main sources.

"-" is that when the intercostal arteries are injured, the volume of blood loss doubles.

Intercostal veins, respectively, arteries are superior, inferior, anterior and posterior. Again, the main will be the front and rear. From the anterior intercostal arteries, blood flows into the anterior thoracic veins. And from the posterior intercostal veins, blood flows to the left into the semi-unpaired vein, and to the right into the unpaired vein.

The intercostal nerves are branches of the sympathetic trunk.

The intercostal neurovascular bundle is located in the groove of the rib, and if viewed from top to bottom, then the vein lies above all, the artery lies below it, and the nerve lies below the artery.

However, the SNP is located in the sulcus not throughout the intercostal space, but only up to the mid-axillary line, medial to which the neurovascular bundle exits the sulcus.

Thus, these topographic and anatomical features of the location of the SNP determined certain rules for performing puncture of the pleural cavity.

Massage for intercostal neuralgia: technique for performing acupressure and classical methods

Intercostal neuralgia is the cause of acute, severe pain in the ribs.

It may be stinging or dull in character.

Although this pathology does not pose a particular danger, treatment still cannot be postponed until later.

In the treatment of this disease, special attention is paid to massage.

After all, the main cause of pain is muscle spasm.

Properly performed massage can reduce muscle stiffness. As a result, the intensity of pain decreases.

What is intercostal neuralgia?

Intercostal neuralgia is a syndrome characterized by the appearance severe pain in the space between the ribs. Pain occurs due to compression of the nerve endings that pass between the ribs.

Nerves passing between the ribs and cause intercostal neuralgia when they are squeezed and inflamed

• radicular, in which the nerve fibers passing in the spine are pinched;
• reflex, it is caused by muscle spasm in the space between the ribs.

The disease is not life-threatening, but noticeably worsens its quality. After all, because of pain syndrome the patient does not sleep well, his irritability increases, hypertensive crises may occur.

What are the main methods of treatment of intercostal neuralgia

With the appearance of pain in the intercostal space, it is necessary to contact a neurologist as soon as possible. The doctor will assess the condition and select the most appropriate therapy tactics. Most often, medication is prescribed.

Doctors prescribe injections, tablets, ointments that help relieve inflammation and relieve pain. At the same time, B vitamins are prescribed, which have a positive effect on the state of nerve endings.

In addition, neurologists prescribe:

• physiotherapy;
• wearing belts, corsets that limit mobility;
• massage;
• manual therapy;
• reflexology.

The use of massage for intercostal neuralgia

Massage is independent therapeutic agent, which can help reduce the severity of pain. But often it is used as one of the components of complex treatment. It is combined with medication, physiotherapy, manual therapy, LFC.

Before prescribing a massage, the patient must be examined. If the cause of the pain is a tumor, then massage procedures are contraindicated. Due to the increased blood flow, the tumor may begin to grow faster.

What are the benefits and how massage can help with intercostal neuralgia

• strengthen the muscular corset;
• eliminate muscle tightness;
• improve blood flow in tissues;
• stimulate local metabolic processes.

The main benefit of massage is the elimination of muscle spasm, which contributes to nerve compression.

The main cause of severe pain is muscle spasm, because of which the pain passes from acute form into chronic. Massage allows you to remove the spasm, due to this, the severity of pain decreases.

When can you get a massage?

Massage procedures are prescribed only after the acute stage of the disease has passed. The patient should not complain of severe pain that interferes with speaking, inhaling deeply, emptying the intestines.

With a timely visit to the doctor and the appointment of adequate treatment, 4-5 days pass from the moment the onset of severe pain until the acute stage subsides. After that, the doctor can give a referral to a massage therapist to consolidate the effect obtained from drug therapy. Often, drug treatment continues, it can be combined with medication.

Contraindications to the use of massage for intercostal neuralgia

Before the appointment of treatment and massage, the patient is sent for a comprehensive diagnosis. The doctor needs to find out the reason why they were clamped nerve roots. With some pathologies, massage is prohibited.

Do not prescribe massage in such cases:

• acute infectious and inflammatory processes, due to increased blood flow, the infection spreads throughout the body;
• purulent skin lesions, dermatological diseases;
• pronounced depletion of the body;
• elevated arterial pressure, hypertension;
• oncological diseases;
• mental illness;
• epilepsy;
• hereditary blood diseases, in which there is an increased tendency to thrombosis and bleeding (thrombophlebitis, severe atherosclerosis, hemophilia, hemorrhagic vasculitis);
• disruption of the intestines (dysbacteriosis, diarrhea).

In such situations, massage can worsen the patient's condition.

Video: "How to treat intercostal neuralgia at home?"

Types of massage used for intercostal neuralgia

After the severe pain subsides, the patient can recover to the massage therapist. To alleviate the condition, reduce pain, the specialist will knead the back and chest. Patients are prescribed therapeutic or acupressure massage.

Classic therapeutic massage procedures allow you to:

• stimulate blood flow in small arteries, capillaries;
• warm up the skin and tissues that are under it;
• enhance metabolic processes;
• improve the functioning of the nervous system, the conduction of nerve impulses;
• accelerate the process of removing toxins, other substances that are involved in the inflammatory process.

When performing acupressure, the specialist affects biologically active points. Finger sticking, pressure, kneading, nail prick are used. To reduce the severity of pain, a strong and medium-duration effect is used from 2 to 5 minutes.

Points affected by thoracalgia

Technique and performance features for intercostal neuralgia

A selection of interesting facts:

Massage is done in the back and chest area. Before it begins, the masseur must clarify from which side and at what level the painful sensations are concentrated.

Massage is started on the opposite side from the place where the pain is concentrated. From healthy areas, the specialist gradually moves to problem areas. The massage therapist begins to work on the affected area after 3 sessions.

If intercostal neuralgia provokes the appearance of pain on both sides, then the impact begins from those places where discomfort less pronounced. Massage is done for the first time as carefully as possible. Over time, the intensity and strength of the impact can be increased.

For massage, the patient is first placed on the massage table on the stomach. A special pillow is placed under the chest. After complete treatment of the back, the patient turns over, the specialist continues to massage, acting on the muscles of the chest.

With intercostal neuralgia, massage sessions are usually prescribed. Most people who experience intercostal neuralgia are prescribed sessions. The duration of the first of them should not be more than 15 minutes. It increases over time.

In the absence of contraindications, warming ointments are used. Anesthetic ointments, gels can be applied to problem areas after the massage is completed.

For massage, the patient is placed on the stomach, hands are asked to stretch along the body. First, the back is stroked with both hands on both sides. The movement is repeated 7–9 times.

Then, on a healthy part of the back, they begin to squeeze. Make it with the edge of the palm. The movement is made in the direction from the long dorsal muscle down towards the couch.

Having completed such a combined stroking, the massage therapist can proceed to kneading. Begin the procedure with the long muscles of the back.

• kneading with 4 fingertips (repeat 3-4 times);
• stroking with 2 hands (2-3 times);
• exposure to the finger phalanges, while the palms are clenched into a fist (3-4 times).

Kneading ends with stroking to soothe mashed muscles.

After processing the long muscle of the back, they move to the latissimus dorsi.

To warm up and warm up, use the following techniques:

• ordinary kneading (3-4 times);
• shaking, carried out in the direction from the iliac crests to armpits(2-3 repetitions);
• double ring kneading (3-4 times);
• shaking (2-3 times);
• stroking (3 times).

The complex on the healthy side is repeated 2-3 times, then the massage therapist can switch to the diseased side. The impact on it should be less intense. The focus should be on the well-being of the patient.

The described techniques are the preparatory stage of the massage. After it is carried out, they proceed to rubbing the spaces between the ribs, in which pain is felt. It should be carried out in the direction from the spinous vertebral processes along the spaces between the ribs, through the long back muscle. With the fingertips, the massage therapist should get into the grooves between the ribs to the maximum depth. Processing starts from the bottom of the waist.

After completion, the patient is asked to roll over on his back. The development of the pectoral muscles begins with stroking and squeezing movements (3-4 repetitions each).

Then the following complex is performed:

• shaking (2-3 repetitions);
• kneading (4-6 times);
• alternating stroking and shaking (3 times).

After completing the warm-up of the pectoral muscles, they proceed to the intercostal ones. The masseur conducts a circular, zigzag, rectilinear rubbing in the direction from the sternum to the pectoralis major muscle (up to the mammary gland in women), then he moves down to the back. Each technique is repeated 3-4 times.

Familiarize yourself with the technique and sequence of performing massage procedures for thoracalgia. After that, the massage therapist should rub the hypochondrium. During the massage, the fingers are positioned so that 4 of them go deep under the hypochondrium, and the big one remains on top. Rub them from the center of the sternum down to the couch. After 3-4 repetitions, stroking, squeezing, rubbing, kneading movements are performed on the treated area. Repeat them 2-3 times.

Separately massage the anterior and lateral parts of the chest. The specialist should work out the pectoralis major muscles by stroking and squeezing, the movements are repeated 3-4 times. Then he rubs the intercostal spaces in the direction from the sternum to the back. Move your hands as far as possible.

Rectilinear, spiral, circular, zigzag rubbing is repeated 3-4 times, which is done with the pads of 4 fingers. After rubbing, they begin to squeeze the base of the palm along the ribs. Then alternate stroking and squeezing movements.

After completion, ordinary kneading is carried out (4 times), kneading with the finger phalanges, while the palms are clenched into a fist (3 times). These movements alternate with stroking and shaking (2 times each).

After the completion of this complex, they begin to rub the spaces between the ribs. To do this, the hand from the treated side is wound behind the head, and the massage therapist performs the following movements:

• zigzag stroking along the ribs towards the iliac cavity, along the body (3-4 repetitions);
• squeezing the bases of the palms (5 repetitions), movements are directed along the ribs;
• rectilinear, zigzag rubbing (each 3-4 repetitions);
• squeezing (3 times).

After that, the patient should take a deep breath several times, deviating to the healthy side, close the hands in the lock, raise the arms up and lower them to the hips. To complete the procedure, the patient turns on his stomach, and the massage therapist strokes, squeezes, shakes, kneads the latissimus dorsi muscle.

During the massage or after it, you can use warming ointments, creams.

Video: "Massage for intercostal neuralgia: execution technique"

45 Topography of intercostal spaces

The bone base of the segment is represented by ribs, and the muscular base is represented by external and internal intercostal muscles, the neurovascular part consists of the intercostal nerve and intercostal vessels: from top to bottom - vein, artery,. nerve. The segments of the chest are covered with soft tissues both inside and out.

Topography: skin, subcutaneous fat, superficial fascia, thoracic fascia, muscles (pectoralis major or serratus anterior or latissimus dorsi muscle), pectoral fascia, chest segment, intrathoracic fascia, tissue (prepleural, parapleural, pleural), costal pleura.

Treatment of purulent pleurisy:.

Puncture of the pleural cavity.

Passive drainage according to Bulau.

Puncture of the pleural cavity: in 7-8 intercostal space. along the scapular or posterior axillary line along the upper edge of the rib, a puncture of the chest wall is made with a thick needle connected to a short rubber tube, which is clamped after each portion of pus is removed.

Passive drainage, according to Bulau: in the pleural cavity or a puncture in the 6-7th intercostal space (in adults with resection of the rib, but with preservation of the periosteum), a drainage tube is inserted along the midaxillary line using a thoracar, connected to the jar from the Bobrov apparatus, pus flows into the jar according to the law of communicating vessels.

Active suction: i.e., but a water jet pump is attached to a short tube, pus flows out under the influence of negative pressure in the system, equal to 10-40 cm of water column.

46 Diaphragm topography

On the right midline line, the dome of the diaphragm is located at the level of the 4th rib, and on the left midline line, along the 5th rib. The diaphragm is covered with serous membranes. From the side of the gr cavity, it is covered by the diaphragmatic pleura and partially by the pericardium. From the side of the abdominal cavity, the diaphragm is covered by the parietal peritoneum. The central part of the diaphragm is represented by the tendon center. The muscular part of the diaphragm consists of 3 parts: sternum, costal, lumbar. The sternal part starts from the back of the xiphoid process. To the left of the xiphoid process between the sternum and costal parts there is a gap (described by Larrey) - the left sternocostal cuff. To the right of the xiphoid process, between the sternum and costal parts of the diaphragm, there is a similar gap (described by Morgagni) - the right costosternal triangle. Through each of the slots passes the internal thoracic artery. The lumbar part of the diaphragm is represented by powerful muscle bundles, forming 3 pairs of legs: internal, intermediate, lateral. Inner legs beginning from the anterior-lateral line of the bodies of 1-4 lumbar vertebrae. Heading up, the inner legs converge, forming 2 holes. The first one is at the level of the 7th-1st vertebrae and behind the aortic. The second one is at the level of 11gr and called the esophagus. Intermediate legs shorter and beginning from the lateral line of the body 2nd vertebral belt. Lateral legs even shorter, they can start from the lateral surface of the body of the first or second vertebral girdle. The descending aorta passes through the aortic opening, and the thoracic duct passes posteriorly and to the right. Through esophageal opening gr cavity leaves the esophagus with vagus nerves. On the left between the internal and intermediate legs are a semi-unpaired vein, celiac nerves. On the right, between similar legs, there is an unpaired vein and splanchnic nerves. The sympathetic trunk passes between the intermediate and lateral legs on the left and on the right. Between the costal and girdle sections of the diaphragm, there are 2 cocked hats (described by Bohdalik) - lumbar-rib cuffs. To the right of the midline, in the tendon center of the diaphragm, there is an opening through which the inferior vena cava passes. To the right of this opening, branches of the right phrenic nerve pass through the tendon center.

We find out the symptoms of intercostal neuralgia on the right

With the development of intercostal neuralgia, the localization of the site of the pain focus can differ significantly. This is due to the peculiarity of the anatomical location of the intercostal nerves, which make up 12 pairs in the body. Depending on the affected nerve, pain can be felt in the lower back, back, chest, under the shoulder blade. In addition, the appearance of characteristic pain for intercostal neuralgia may indicate other diseases.

Symptoms on the right

This disease is characterized by the development of acute pain syndrome, which occurs unexpectedly. The location of the source of pain can be easily palpated: as a rule, painful sensations spread along the affected area of ​​the nerve and intensify when pressed. At rest, the pain is slightly disturbing, has a aching character, abruptly changing to paroxysmal contractions when changing position, turning the body, inhaling and exhaling. In our section you will find all the necessary information about intercostal neuralgia.

In addition to the pain syndrome, there may be a burning sensation, tingling, numbness in certain areas of the body, thereby making it difficult to make a correct diagnosis. Pain in intercostal neuralgia can manifest itself both in the region of the heart, and under the scapula, in the back, lower back.

In addition, the symptomatology directly depends on which part of the nerve is affected and the degree of its damage, since they consist of sensory, motor and autonomic fibers.

Important! When squeezing a sensitive nerve, it is expressed in the appearance of acute pain. In addition to pain, sweating in the chest area increases, with motor exercises - additional symptom serves as increased shortness of breath.

Causes

In the vast majority of cases, the manifestation of intercostal neuralgia is a consequence of any pathological changes in the body, or a negative impact on health.

The very occurrence of pain is associated mainly with pinching of the spinal nerves in the thoracic spine. In the intercostal space, the appearance of pain occurs due to the infringement of the intercostal nerves. The reasons for this may be developing osteochondrosis, inflammatory processes that provoke muscle spasm and seizures. Such processes can be the result of stress, injury, excessive physical exertion on an unprepared body and muscle fatigue.

Important! Also, factors contributing to the appearance of the disease can be hypothermia of the body, early infectious diseases.

Other destructive processes in the region of the chest and back can also cause intercostal neuralgia: scoliosis, osteochondrosis of the thoracic region, intervertebral hernia, joint dysfunctions, tumors, protrusion. Only a full examination by a specialist will help identify the source and begin adequate treatment.

Important! Intercostal neuralgia is not so much an independent disease, but a consequence of the presence of certain health problems. Therefore, it is important to establish and solve these problems in order to exclude relapses in the future, and also to determine correct diagnosis, so as not to miss diseases that threaten life and health, such as myocardial infarction.

Neuralgia right front

Symptoms that manifest with intercostal neuralgia, depending on the location of the pain, may indicate the development of other diseases. As a rule, in such cases, if the diagnosis is not clear, then additional studies are prescribed.

In case of pain in the chest area in front, fluorography, examination thyroid gland and consultation of a mammologist in women, examination by a cardiologist and appointment of an ECG.

Regardless of the center of pain, a course of treatment is carried out aimed at reducing and removing it, identifying the causes and eliminating them.

The course of treatment consists of anti-inflammatory and analgesic drugs, muscle relaxants. With the passage of the stage of exacerbation, it is possible to conduct a course of massage, physiotherapy and acupuncture.

Neuralgia right back

The development of intercostal neuralgia, radiating pain mainly from the back on the right, indicates the infringement of the lower sections of the intercostal nerves.

It may also indicate the presence of problems with the kidneys, therefore, in order to exclude the possibility of development renal pathology held additional examination by a urologist or nephrologist.

Otherwise, treatment and examinations are carried out as part of therapy for ordinary intercostal neuralgia.

Neuralgia on the right under the scapula

If pain occurs under the shoulder blade, it is necessary to exclude diseases associated with the lungs. For this, fluorography can be additionally prescribed.

The spine is also diagnosed, and if the vertebrogenic nature of intercostal neuralgia is established, it is prescribed complex treatment spine. It includes not only drug treatment, but also the use of massage, physiotherapy, classes are recommended by a specialist in kinesitherapy.

Neuralgia right under the ribs

One of the most common forms of manifestation of intercostal neuralgia is its development in the intercostal space on the right and below.

Symptoms of intercostal neuralgia in the case of pain concentration mainly under the ribs, may indicate problems with internal organs. It can be diseases of the stomach, liver, pancreas and other digestive organs. Therefore, consultations with a gastroenterologist are often additionally prescribed, ultrasound studies are carried out.

Treatment of the disease

A full course of treatment can be prescribed by a doctor after examination and examination of the patient. Self-treatment, including taking medication, in this case can be not only useless, but also harmful to health if another disease is hidden under the symptoms of intercostal neuralgia.

Surveys may include:

• ultrasound diagnostics;
• magnetic resonance imaging or MRI;
• radiography;
• computed tomography or CT;
• additional studies - electrospondylography, myelography, contrast discography.

Treatment includes complex measures depending on the causes and source of intercostal neuralgia. Priority measures are aimed at relieving acute pain syndrome with medications.

First of all, the main task is to relieve acute pain syndrome, which causes extreme inconvenience, causes physical anxiety and can even lead to immobilization of the patient due to acute attacks when trying to move. Read also about methods for relieving pain in the coccyx.

At home

Treatment at home is possible only if there is a slight manifestation of the disease and it is impossible for any reason to consult a doctor.

1. During the acute stage of the disease, it is strongly recommended to maintain bed rest for several days. The mattress should be hard enough, it is better to put some hard surface under it during this period.
2. Dry warm compresses can be used to relieve pain.
3. It is important to exclude or limit physical activity during the acute period.

Taking medications is allowed at home by agreement with the doctor. Self-administration is not recommended, since the presence of other diseases that give similar symptoms, such as angina pectoris, should first be excluded.

Important! After the acute stage has passed, a trip to the doctor should not be postponed.

Medical treatment

In the treatment of intercostal neuralgia on the right, a course of non-steroidal anti-inflammatory drugs is prescribed first of all to relieve pain. It is possible to use painkillers to alleviate the patient's condition.

Ointments and creams are used as a local anesthetic:

• anti-inflammatory and analgesic ointments based on diclofenac;
• anesthetic ointments and gels with active substance- Ketaprofen.

Ointments based on bee and snake venom, which not only relieve pain, but also accelerate the excretion of substances that contribute to the development of the inflammatory process and increase blood flow. Turpentine ointment, camphor, menthol, which can be added to finished preparations or purchased creams containing these substances, have a local irritant effect that reduces pain.

1. To reduce muscle spasm, muscle relaxants are taken, which reduces pain and increases mobility.
2. For a restorative effect, a course of B vitamins and calcium is additionally prescribed.
3. As part of a general set of measures and in case of excessively acute pain, novocaine blockade can be placed to alleviate the condition.

Treatment with folk remedies

Non-drug treatments can help relieve the condition and reduce pain.

Flax seeds

Steamed flax seeds can be used as a source of dry heat. To do this, they are brewed in boiling water, taken out, dried with a towel and then poured into a cotton bag and applied to the sore spot.

Baths with sage

Also, to relax and reduce muscle spasm, it is useful to take warm baths with sage and sea salt before bed. Sage must first be poured with warm water and let it brew. Sage is taken - 4-5 tbsp. l. to a glass of water. The infusion is poured into the bathroom, a couple of spoons are added sea ​​salt. Take a bath should be no more than 15 minutes.

Herbs

Well helps with pain infusion of herb rue. For its preparation 2 tbsp. l. herbs are poured with 1 glass of alcohol, closed tightly with a lid, cleaned in a dark place and infused for a week.

1. As an ointment, steamed and ground aspen buds are used, which are mixed with petroleum jelly at the rate of 1:4.
2. Additionally, for a warming effect, you can wear woolen clothes in the form of a vest and make bandages around the sore spot.

Compress

As a warming compress, use a mixture of spices: red chili pepper - 1 tsp, ground ginger - 2 tsp, turmeric - 1 tsp. Add some water to the mixture vegetable oil. Apply the mixture to a clean cloth and apply to the sore spot and wrap with a clean bandage. The bandage is worn until it starts to burn.

For use as a warm dry compress, you can use boiled eggs, they can be applied both in the sensed form and in the shell, after wrapping it with a clean cloth and keeping it until it cools down.

The intercostal spaces are filled with intercostal muscles, blood and lymphatic vessels, nerves, and lymph nodes (Fig. 4). Vessels and nerves pass through intermuscular spaces, sometimes called intercostal canals. The intercostal gap is formed due to the fact that the external intercostal muscle is connected with the lower edge of the rib, and the internal intercostal muscle is connected with that part of the rib that faces the chest cavity and is located above the costal groove (sulcus costalis).

Thus, the intercostal fissure is delimited from above by the costal groove, and from the outside and inside by the intercostal muscles.

External intercostal muscles (mm.intercostales externi) do not perform the entire intercostal space: they do not reach the sternum. Throughout the costal cartilages, they are replaced by dense, shiny aponeurotic plates containing tendon fibers (ligg. intercostalia externa). The direction of the fibers of the external intercostal muscles and ligaments is from top to bottom and from back to front.

Deeper than the external intercostal muscles are the neurovascular bundles: usually v.intercostalis is located above everything, n.intercostalis is below the artery.

An arterial ring is formed in each intercostal space due to anastomosis between the anterior and posterior intercostal arteries. According to the segmental structure of the walls of the chest cavity, there are segmental intercostal posterior arteries (10 pairs) extending from thoracic aorta. The two upper pairs depart from the costal-cervical trunk. At the beginning of the intercostal spaces, each intercostal posterior artery gives off a posterior branch, ramus dorsalis, to spinal cord and to the muscles and skin of the back. The continuation of the initial trunk of the posterior intercostal artery, making up the actual intercostal artery, is directed along the costal groove. To the angle of the rib, it is adjacent directly to the pleura, then it is located between the external and internal intercostal muscles and anastomoses with its endings with the anterior intercostal branches extending from the internal thoracic artery. The three lower intercostal arteries anastomose with the superior epigastric artery. Along the way, the intercostal arteries give branches to the parietal pleura and to the parietal peritoneum, to the muscles, to the ribs, to the skin, and in women to the mammary gland.

In the posterior part of the chest wall, up to the midaxillary line, the vessels pass in the costal groove, located near the lower edge of the rib, along its deep surface. Further anteriorly, the vessels are no longer protected by the rib. Therefore, it is preferable to make any punctures of the chest posterior to the middle axillary line, or if the puncture is made along this line, then always along the upper edge of the rib.

The intercostal nerves usually pass outside the costal groove, as a result of which they are more susceptible to damage than the vessels. Upon exiting the intervertebral (holes), the intercostal nerves are connected by means of rami communicantes with the trunk of the sympathetic nerve, then, having given up the back branches, they go outwards, adjoining for a short distance directly to the intrathoracic fascia and pleura (hence the possibility of their involvement in the process in diseases of the pleura). paths from the intercostal nerves are separated perforating skin branches.The lower 6 intercostal nerves innervate the pre-lateral abdominal wall, as a result of which inflammation of the pleura and lungs often causes radiating pain in the abdomen.

Rice. 4. Topography of the intercostal space

1 - rib, 2 - the innermost intercostal muscle, 3 - intercostal nerve, 4 - intercostal artery, 5 - intercostal vein, 6 - internal intercostal muscle, 7 - external intercostal muscle, 8 - collateral branch of the intercostal artery. (From: Ernest W. April. Clinical Anatomy, 1997.)

Deeper than the intercostal vessels and nerves are the internal intercostal muscles (mm. intercostales interni). They also do not completely fill the entire intercostal space: in front they reach the sternum, and in the back they end at the costal angles. The direction of the fibers of the internal intercostal muscles is the opposite to the direction of the external intercostal muscles, i.e. bottom to top and back to front.

The intercostal muscles, ribs and costal cartilages are lined from the inside with intrathoracic fascia (fascia endothoracica). It also covers the anterior surface of the thoracic vertebrae and the diaphragm.

Deeper than the intrathoracic fascia is a layer of loose fiber, which separates it from the parietal pleura throughout the latter. The subpleural tissue is most developed near the spine, from the sides of it. This makes it possible to easily exfoliate the pleura here and gain access to the organs of the posterior mediastinum without opening the pleural cavity.

In the clinic, the tissue between the fascia endothoracica and the pleura is often called parapleural, and the inflammatory process in it is called parapleurisy. Most often, this disease is associated with tuberculosis of the lungs and pleura and is caused by inflammation of the lymph nodes embedded in the parapleural tissue. In the anterior nodes (nodi lymphatici sternales), located along the vasa thoracica interna, flow lymphatic vessels mammary gland and intercostal spaces of the anterior chest wall, into the posterior nodes (n.intercostales posteriores), located at the heads of the ribs, are the vessels of the intercostal spaces of the posterior chest wall.