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Practice Quiz - Thoracic Wall, Pleura, & Pericardium

Below are written questions from previous quizzes and exams.

The second costal cartilage can be located by palpating the:

costal margin

sternal angle

sternal notch

sternoclavicular joint

xiphoid process

1. The thoracic wall is innervated by:

Dorsal primary rami

Intercostal nerves

Lateral pectoral nerves

Medial pectoral nerves

Thoracodorsal nerves
2. The sternocostal surface of the heart is formed primarily by the anterior wall of which heart
chamber?

Left atrium

Left ventricle

Right atrium

Right ventricle
3. A patient involved in an automobile accident presents with a sharp object puncture of the
middle of the sternum at about the level of the 4th or 5th costal cartilage. If the object also
penetrated pericardium and heart wall, which heart chamber would most likely be damaged?

Left atrium

Left ventricle

Right atrium

Right ventricle
4. You are caring for a 68-year-old male who has copious amounts of fluid in the left pleural
cavity due to acute pleurisy. When you examine him as he sits up in bed (trunk upright), where
would the fluid tend to accumulate?

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costodiaphragmatic recess

costomediastinal recess

cupola

hilar reflection

middle mediastinum
5. A 23-year-old male injured in an industrial explosion was found to have multiple small metal
fragments in his thoracic cavity. Since the pericardium was torn inferiorly, the surgeon began to
explore for fragments in the pericardial sac. Slipping her hand under the heart apex, she slid her
fingers upward and to the right within the sac until they were stopped by the cul-de-sac formed
by the pericardial reflection near the base of the heart. Her fingertips were then in the:

coronary sinus

coronary sulcus

costomediastinal recess

oblique sinus

transverse sinus
6. When inserting a chest tube, intercostal vessels and nerves are avoided by placing the tube
immediately:

above the margin of a rib

below the margin of a rib


7. A hand slipped behind the heart at its apex can be extended upwards until stopped by a line of
pericardial reflection that forms the:

Cardiac notch

Costomediastinal recess

Hilar reflection

Oblique pericardial sinus

Transverse pericardial sinus


8. The first rib articulates with the sternum in close proximity to the:

Nipple

Root of the lung

Sternal angle

Sternoclavicular joint

Xiphoid process

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9. The portion of the parietal pleura that extends above the first rib is called the :

costodiaphragmatic recess

costomediastinal recess

costocervical recess

cupola

endothoracic fascia
10. You are attending an operation to remove a thymic tumor from the superior mediastinum. The
surgeon asks, "What important nerve lying on and partly curving posteriorly around the arch of
the aorta should we be careful of as we remove this mass?" You quickly answer, "The--

left phrenic

left sympathetic trunk

left vagus

right phrenic

right sympathetic trunk


11. In cardiac surgery it is sometimes necessary to clamp off all arterial flow out of the heart. This
could be done within the pericardial sac by inserting the index finger immediately behind the
two great arteries and compressing them with the thumb of the same hand. The index finger
would have to be inserted into which space?

Cardiac notch

Coronary sinus

Oblique pericardial sinus

Coronary sulcus

Transverse pericardial sinus


12. A needle inserted into the 9th intercostal space along the midaxillary line would enter which
space?

Cardiac notch

Costodiaphragmatic recess

Costomediastinal recess

Cupola

Oblique pericardial sinus


13. During a heart transplant procedure, the surgeon inserted his left index finger through the
transverse pericardial sinus, and then pulled forward on the two large vessels lying ventral to
his finger. Which vessels were these?

Pulmonary trunk and brachiocephalic trunk


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Pulmonary trunk and aorta

Pulmonary trunk and superior vena cava

Superior vena cava and aorta

Superior vena cava and right pulmonary artery


14. While observing in the OR, you see the resident insert a needle through the body wall just
above the ninth rib in the mid-axillary line. She was obviously trying to enter the:

Costodiaphragmatic recess

Costomediastinal recess

Cupola

Hilar reflection

Pulmonary ligament
15. The pleural cavity near the cardiac notch is known as the:

Costodiaphragmatic recess

Costomediastinal recess

Cupola

Hilum

Pulmonary ligament
16. The tubercle of the 7th rib articulates with which structure?

Body of vertebra T6

Body of vertebra T7

Body of vertebra T8

Transverse process of vertebra T6

Transverse process of vertebra T7


17. The ductus arteriosus sometimes remains open after birth requiring surgical closure. When
placing a clamp on the ductus, care must be taken to avoid injury to what important structure
immediately dorsal to it?

Accessory hemiazygos vein

Left internal thoracic artery

Left phrenic nerve

Left recurrent laryngeal nerve

Thoracic duct
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18. A 16-year-old male suffered a stab wound in which a knife blade entered immediately superior
to the upper edge of the right clavicle near its head. He was in extreme pain, which was
interpreted by the ER physician as a likely indicator of a collapsed lung following disruption of
the pleura. If that was true, what portion of the pleura was most likely cut or torn?

costal pleura

cupola

hilar reflection

mediastinal pleura

pulmonary ligament
19. During a lung transplant procedure, an observing 4th year attempted to pass his index finger
posteriorly inferior to the root of the left lung, but he found passage of the finger blocked.
Which structure would most likely be responsible for this?

Costodiaphragmatic recess

Cupola

Inferior vena cava

Left pulmonary vein

Pulmonary ligament
20. Which of the following layers provides a natural cleavage plane for surgical separation of the
costal pleura from the thoracic wall?

Deep fascia

Endothoracic fascia

Parietal pleura

Visceral pleura

Transversus thoracis muscle fascia


21. The lowest extent of the pleural cavity, into which lung tissue does not extend, is known as the:

costodiaphragmatic recess

costomediastinal recess

cupola

inferior mediastinum

pulmonary ligament
22. The sternal angle is a landmark for locating the level of the:

Costal margin

Jugular notch
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Second costal cartilage

Sternoclavicular joint

Xiphoid process
23. A 3rd-year medical student was doing her first physical exam. In order to properly place her
stethoscope to listen to heart sounds, she palpated bony landmarks. She began at the jugular
notch, then slid her fingers down to the sternal angle. At which rib (costal cartilage) level were
her fingers?

Can't be determined

Answers & Explanations:

1. The correct answer is: sternal angle

The sternal angle is the point where the costal cartilage attaches the second rib to the sternum. This is
an important anatomical landmark to remember--it is used to find the valves when auscultating the
heart! The costal margins are formed by the medial borders of the 7th through 10th costal cartilages.
They are easily palpable and extend inferolaterally from the xiphisternal joint. The sternal
notch/jugular notch is the notch located at the superior border of the manubrium, between the sternal
ends of the clavicles. The sternoclavicular joints are simply the joints connecting the sternum with the
clavicles. Finally, the xiphoid process is the bone that makes the inferior part of the sternum.

2. The correct answer is: intercostal nerves

Intercostal nerves are the ventral primary rami of spinal nerves T1-T11. They provide motor
innervation to intercostal muscles, abdominal wall muscles (via T7-T11) and muscles of the forearm
and hand (via T1). They provide sensory innervation to the skin of the chest and abdomen on the
anterior and lateral sides. The other nerves listed do not innervate the chest wall. Dorsal primary rami
provide motor innervation to true back muscles and sensory innervation to the skin on the back. The
lateral pectoral nerve provides motor innervation to pectoralis major only, while the medial pectoral
nerve provides motor innervation to pectoralis major and minor. The thoracodorsal nerve provides
motor innervation to latissimus dorsi.

3. The correct answer is: right ventricle

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The heart has three important surfaces: an anterior surface, a diaphragmatic surface, and a pulmonary
surface. The anterior surface, or sternocostal surface, is mostly made up of the right ventricle. The
diaphragmatic surface is mostly the left ventricle, but a little bit of the right ventricle sits on the
diaphragm as well. Finally, the pulmonary surface, which is on the left, is mostly made up of the left
ventricle.

4. The correct answer is: right ventricle

Remember, the anterior surface, or sternocostal surface, of the heart is mostly made up of the right
ventricle. So, if an object punctured the sternum,it would be likely to pierce the right ventricle.

5. The correct answer is: costodiaphragmatic recess

The costodiaphragmatic recess is the lowest extent of the pleural cavity or sac. It is the part of the
pleural sac where the costal pleura changes into the diaphragmatic pleura. Because this is the most
inferior part of the pleural sac, fluid in the pleural sac will fall to this region when a patient sits up. The
costodiaphragmatic recess is also the area into which a needle is inserted for thoracocentesis, and it is
found at different levels at different areas of the thorax. At the mid clavicular line, the
costodiaphragmatic recess is between ribs 6 and 8; at the midaxillary line it is between 8 and 10; and at
the paravertebral line it is between 10 and 12.

The costomediastinal recess is found where the costal pleura becomes the mediastinal pleura. The
cupola is the part of the pleural cavity which extends above the level of the 1st rib into the root of the
neck. The hilar reflection is the point at the root of the lung where the mediastinal pleura is reflected
and becomes continuous with the visceral pleura. Finally, the middle mediastinum is the space in the
mediastinum which contains the heart, pericardium, great vessels, and bronchi (at the roots of the
lung).

6. The correct answer is: oblique sinus

The oblique sinus is an area of the pericardial cavity located behind the left atrium of the heart where
the serous pericardium reflects onto the inferior vena cava and pulmonary veins. If you slide your
fingers under the heart, they will be in the oblique sinus. The other pericardial sinus that you should be
familiar with is the transverse sinus. The transverse sinus is an area of the pericardial cavity located
behind the aorta and pulmonary trunk and anterior to the superior vena cava. It separates the outflow
vessels from inflow vessels.

The coronary sinus is a large vein on the heart which drains into the right atrium. The coronary sulcus
is a groove on the heart which separates the atria from the ventricles. The costomediastinal recess is an
area in the pleural sac where the costal pleura changes to the mediastinal pleura.

7. The correct answer is: above the margin of a rib

The VAN triad of an intercostal vein, artery, and nerve run along the bottom of a rib, in the costal
groove. To avoid hitting any of these important structures, it is important to remember to always place
a tube or needle above the margin of a rib (or,if you prefer to think about it this way, at the bottom of
an intercostal space).

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8. The correct answer is: oblique pericardial sinus

The oblique pericardial sinus is an area of the pericardial cavity located behind the left atrium of heart
where the serous pericardium reflects onto the inferior vena cava and pulmonary veins. If you slide
your fingers under the heart, they will be in this space. The other pericardial sinus that you should be
familiar with is the transverse sinus. The transverse sinus is an area of the pericardial cavity located
behind the aorta and pulmonary trunk and anterior to the superior vena cava. It separates the outflow
vessels from inflow vessels.

The cardiac notch is an indentation in the superior lobe of the left lung which creates the lingula. The
costomediastinal recess is an area in the pleural sac where the costal pleura changes to the mediastinal
pleura. Finally, the hilar reflection is the reflection of pleura on the root of the lung, where visceral
pleura on the lung becomes continuous with the mediastinal pleura.

9. The correct answer is: sternoclavicular joint

The first rib articulates with the sternum directly below the sternoclavicular joint. The nipple is found
in the fourth intercostal space, between the 4th and 5th ribs. The sternal angle is connected to the costal
cartilage of rib 2. Finally, the xiphoid process is located just below the point where the costal cartilage
of rib 7 articulates with the sternum. The root of the lung consists of the main bronchus, pulmonary
and bronchial vessels, lymphatic vessels, and nerves entering and leaving the lung.

10. The correct answer is: cupola

The cupola is the cervical parietal pleura which extends slightly above the level of the 1st rib into the
root of the neck. The costodiaphragmatic recess is the part of the pleural sac where the costal pleura
changes into the diaphragmatic pleura. It is the lowest extent of the pleural sac. The costomediastinal
recess is found where the costal pleura becomes the mediastinal pleura. Endothoracic fascia is
connective tissue between the inner chest wall and costal parietal pleura. The costocervical recess is a
made up term.

11. The correct answer is: left vagus

The left vagus nerve lies against the lateral surface of the arch of the aorta. The left recurrent laryngeal
nerve is an especially important nerve from the vagus which loops around the aortic arch. This nerve
innervates the muscles of the left larynx. If it is damaged, a patient may experience hoarseness after
surgery. Care must be taken to preserve this nerve, especially during thyroid surgery.

The left and right phrenic nerves, which innervate the diaphragm, are lateral to the vagus nerves and
are not looping near the aortic arch. The left and right sympathetic trunks lie on the posterior chest wall
and are not involved with the aortic arch.

12. The correct answer is: Transverse pericardial sinus

The transverse pericardial sinus is an area of the pericardial cavity located behind the aorta and
pulmonary trunk and anterior to the superior vena cava. When entering the transverse pericardial sinus,

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a surgeon will insert an index finger between the aorta and pulmonary trunk on the ventral side and the
superior vena cava on the dorsal side. The oblique pericardial sinus is an area of the pericardial cavity
located behind the left atrium of the heart. If a surgeon places fingers under the apex of the heart, then
moves the fingers until they are stopped by a pericardial reflection, then the fingers are in the oblique
sinus. You should understand what these two sinuses are and how they can be entered!

13. The correct answer is: Costodiaphragmatic recess

The costodiaphragmatic recess is the lowest extent of the pleural cavity or sac. It is the part of the
pleural sac where the costal pleura changes into the diaphragmatic pleura. It is also the area into which
a needle is inserted for thoracocentesis, and it is found at different levels at different areas of the
thorax. At the mid clavicular line, the costodiaphragmatic recess is between ribs 6 and 8; at the
midaxillary line it is between 8 and 10; and at the paravertebral line it is between 10 and 12. So,
inserting the needle just above the 9th rib at the midaxillary line should put you in the
costodiaphragmatic recess.

The cardiac notch is a structure on the left lung which separates the lingula below from the upper
portion of the superior lobe of left lung. The costomediastinal recess is found where the costal pleura
becomes the mediastinal pleura. The cupola is the part of the pleural cavity which extends above the
level of the 1st rib into the root of the neck. The oblique pericardial sinus is an area of the pericardial
cavity located behind the left atrium of the heart.

14. The correct answer is: Pulmonary trunk and aorta

The transverse pericardial sinus is an area of the pericardial cavity located behind the aorta and
pulmonary trunk and anterior to the superior vena cava. So, the two large vessels lying ventral to his
finger are the pulmonary trunk and aorta; the large vessel lying dorsal to his finger is the superior vena
cava.

15. The correct answer is: Costodiaphragmatic recess

The costodiaphragmatic recess is the lowest extent of the pleural cavity or sac. It is the part of the
pleural sac where the costal pleura changes into the diaphragmatic pleura. It is also the area into which
a needle is inserted for thoracocentesis, and it is found at different levels at different areas of the
thorax. At the mid clavicular line, the costodiaphragmatic recess is between ribs 6 and 8; at the
midaxillary line it is between 8 and 10; and at the paravertebral line it is between 10 and 12. So,
inserting the needle just above the 9th rib at the midaxillary line should put the resident's needle in the
costodiaphragmatic recess. Make sure you know where to enter the costodiaphragmatic recess at the
midclavicular line, the mid axillary line, and the paravertebral line!

The costomediastinal recess is found where the costal pleura becomes the mediastinal pleura. The
cupola is the part of the pleural cavity which extends above the level of the 1st rib into the root of the
neck. The hilar reflection is the point at the root of the lung where the mediastinal pleura is reflected
and becomes continuous with the visceral pleura. The pulmonary ligament is a fold of pleura located
below the root of the lung, where the visceral pleura and the mediastinal parietal pleura are continuous
with each other.

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16. The correct answer is: Costomediastinal recess

The costomediastinal recess is an area right next to the cardiac notch, which is an indentation in the
superior lobe of the left lung. If you take a very deep breath, the lingula of the left lung, which is
formed by the cardiac notch, will tend to expand into the costomediastinal recess.

The costodiaphragmatic recess is the lowest extent of the pleural cavity or sac. It is the part of the
pleural sac where the costal pleura changes into the diaphragmatic pleura. The cupola is the part of the
pleural cavity which extends above the level of the 1st rib into the root of the neck. The hilum is found
on the medial surface of the lung--it is the point at which the structures forming the root enter and
leave the lung. The pulmonary ligament is a fold of pleura located below the root of the lung, where
the visceral pleura and the mediastinal parietal pleura are continuous with each other.

17. The correct answer is: Transverse process of vertebra T7

The tubercle of a rib is a projection located posteroinferior and lateral to the neck of the rib. It
articulates with the transverse process of the vertebra of the same number. So, the tubercle of rib 7
should articulate with the transverse process of the T7 vertebra. The head of the rib is the part of the rib
that articulates with the demifacets of two adjacent vertebral bodies. So, the head of rib 7 should
articulate with the 6th vertebra superiorly and the 7th vertebra inferiorly.

18. The correct answer is: Left recurrent laryngeal nerve

The left recurrent laryngeal nerve is a branch of the vagus that wraps around the aorta, posterior to the
ductus arteriosus or ligamentum arteriosum. It then travels superiorly to innervate muscles of the
larynx. It's important to protect this nerve during surgery! If the left recurrent laryngeal nerve becomes
paralyzed, a patient might experience a hoarse voice or even have difficulty breathing due to a
laryngeal spasm. You should make sure that you understand what this nerve does, what types of
procedures might injure this nerve, and the effects of a damaged left recurrent laryngeal!

The accessory hemiazygos vein is a vein on the left side of the body. It drains the posterolateral chest
wall and empties blood into the azygos vein. The left internal thoracic artery is a branch of the left
subclavian artery that supplies blood to the anterior thoracic wall. The left phrenic nerve runs lateral to
the vagus nerve and its branches in the thorax; it is not close enough to be damaged by the surgery.
The thoracic duct is deep in the chest - it travels between the azygos vein and the aorta, posterior to the
esophagus.

19. The correct answer is: cupola

The cupola is the part of the plural cavity which extends above the level of the 1st rib into the root of
the neck. So, if a patient was stabbed above the clavicle, it would be very likely that the cupola was
damaged. The costal pleura is the layer of parietal pleura that covers the costal surface. The hilar
reflection is the point where the visceral pleura of the lung reflects to become continuous with the
parietal pleura. The mediastinal pleura is the parietal pleura on the mediastinal surface, found medial to
the lung. Finally, the pulmonary ligament is a double layer of pleura extending from the inferior end of
the hilar reflection downward to the diaphragm below.

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20. The correct answer is: pulmonary ligament

The pulmonary ligament is a double layer of pleura extending from the inferior end of the hilar
reflection downward to the diaphragm. So, it is a structure that would block you from moving your
finger posteriorly at the root of a lung. The costodiaphragmatic recess is the space at the inferior border
of the lung where the costal pleura touches the diaphragmatic pleura. The cupola is the part of the
pleura that extends superiorly above the first rib--it's not associated with the root of the lung in any
way. The inferior vena cava is found in the mediastinum and would not be near the root of the lung.
The left pulmonary veins are part of the root of the lung and would not block someone from reaching
behind the lung.

21. The correct answer is: endothoracic fascia

The endothoracic fascia is the connective tissue between the inner aspect of chest wall and the costal
parietal pleura. By clearing the endothoracic fascia, it is easy to separate the costal pleura from the
thoracic wall. Deep fascia is a fascial layer that invests a muscle or muscle group - it is not present
around the lungs. The parietal pleura is made up of the cupula or cervical pleura, costal pleura,
diaphragmatic pleura, and mediastinal pleura. It lines the inner surfaces of the walls of the pleural
cavity. The visceral pleura is the serous membrane that covers the lungs. Finally, the transversus
thoracis muscle fascia is only associated with the transversus thoracis - it would not provide a natural
cleavage plane for separating the costal pleura from the thoracic wall

22. The correct answer is: costodiaphragmatic recess

The costodiaphragmatic recess is the area inferior to the lung where the costal and diaphragmatic
pleura are continuous. This is the lowest extent of the pleural cavity. The costomediastinal recess is a
small anterior recess where the costal and mediastinal pleura are continuous. The cupola is the pleural
space that extends above the first rib. The inferior mediastinum is a term sometimes used to refer to the
anterior, middle, and posterior subdivisons of the mediastinum all together. The pulmonary ligament is
a fold of pleura located beneath the root of the lung.

23. The correct answer is: Second costal cartilage

The sternal angle is a very important anatomical landmark which is used when placing the stethoscope
and listening for heart sounds. The sternal angle is the location of the attachment of the costal cartilage
of the second rib to the sternum. So, once you locate the sternal angle on a patient, you know the
location of the second rib, and you can use that landmark to find the right spots to auscultate each
valve of the heart. Also remember that a horizontal plane through the sternal angle passes through the
T4/T5 intervertebral disc and marks the inferior boundary of the superior mediastinum.

24. The correct answer is: 2

Remember, the sternal angle is where the costal cartilage of the second rib attaches to the sternum.
This is a significant landmark!

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