THORACIC DIAPHRAGM

OLUWOLE AKINOLA
 • Is a dome-
The Diaphragm shaped,
musculotendino
us partition
• between the
thoracic and
abdominal
cavities
• Surfaces:
• Has a concave
inferior surface
and
• a convex
superior surface
The Diaphragm
• Anatomic
relations:
• Superior
relations: heart,
lungs
• Inferior
relations: liver,
stomach, spleen,
etc.
 • 2 domes (right and left)
Domes of the Diaphragm • Separated by an
aponeurotic central
tendon
• Fibrous pericardium is
apposed to, and partly
fused with this tendon
• The right dome is higher
up than the left
• owing to the presence of
the liver beneath this
dome.
Domes of the Diaphragm
• During expiration,
• right dome reaches as high
up as the 5th rib
• left dome reaches the 5th
intercostal space (in the
midclavicular line)
• The position of the dome
varies with respiration,
posture and the state of
abdominal organs
Importance of the Diaphragm
• Is the chief muscle of
inspiration
• During inspiration, the
domes of the diaphragm
descend
• towards the abdominal
cavity
• thereby increasing
intrathoracic volume
 Based on peripheral attachment of
its fibres, the diaphragm may be
Parts of the Diaphragm divided into the following parts:
• Sternal part,
• consists of two muscular slips
attached to the xiphoid
process
• Costal part,
• consists of slips that arise from
the lower six costal cartilages
and their ribs
• Its fibres form the domes of
the diaphragm
• Lumbar part
• consists of fibres that arise
from the arcuate ligaments
and crura of the diaphragm
Diaphragm is attached Peripheral Attachment of
peripherally to the ff: the Diaphragm
1. Posterior surface of the
xiphoid process
• This gives rise to fibres of the
sternal part of the diaphragm
2. Lower six costal cartilage and
their ribs
• These give rise to the costal part
3. Median, medial and lateral
arcuate ligaments.
• These give rise to some posterior
fibres of the diaphragm
4. Right and left crura,
• give rise to some posterior fibres
of the diaphragm
• Right crus of the diaphragm
• attached to the upper 3 lumbar vertebrae
Peripheral Attachment of
• Left crus the Diaphragm
• attached to the upper 2 lumbar vertebrae • Medial and lateral arcuate
• Median arcuate ligament ligaments
• a fibrous arc that links the right and left crura across the
midline • fibrous thickening of the
• It lies anterior to aortic hiatus, and thus, to the fascia of psoas major and
descending aorta quadratus lumborum,
• Medial and lateral arcuate ligaments respectively
• fibrous thickening of the fascia of psoas major and
quadratus lumborum, respectively
 Central Attachment of the Diaphragm
• From the peripheral sites of
attachment, fibres of the diaphragm
converge on the central tendon
• Central tendon
• is trifoliate,
• lies near the centre of the diaphragm
• is connected to the fibrous
pericardium by pericardiacophrenic
ligaments; but
• has no bony attachment
Innervation of the Diaphragm
• Motor fibres: Phrenic
nerve (C3–C5)
• Sensory fibres (central
part): Phrenic nerve (C3–
C5)
• Sensory fibres (peripheral
part):
• Lower intercostal nerves
(T5–T11), and
• subcostal nerves (T12)
Arterial Supply of the Diaphragm
• Superior phrenic arteries
• from the thoracic aorta
• Musculophrenic and
pericardiacophrenic
arteries
• from internal thoracic
arteries
• Inferior phrenic arteries
• from abdominal aorta
Venous Drainage of the Diaphragm
• Musculophrenic veins
• tributaries of internal thoracic veins
• Pericardiacophrenic veins
• tributaries of internal thoracic veins
• Superior phrenic vein (right side only)
• tributary in inferior vena cava [IVC]
• Inferior phrenic veins
• right vein drains into the IVC, while
• left one drains into the IVC and left
suprarenal vein
 Lymphatic Drainage
of the Diaphragm
Lymph vessels from the
diaphragm drain into the
following nodes:
• Diaphragmatic nodes
• From these nodes, lymph
drains into phrenic,
parasternal and posterior
mediastinal nodes
• Upper lumbar nodes
 Apertures of the Diaphragm
• Diaphragm has openings via which
neurovascular structures and
oesophagus pass
• The major apertures of the
diaphragm include:
• Aortic hiatus
• Oesophageal hiatus
• Vena caval foramen (caval opening)
 • a median opening
The Aortic Hiatus • lies btw right and left crura and
behind the median arcuate
ligament
• at the level of T12 vertebra
• Transmits descending aorta
• Because the aorta does not pierce
the fibres of the diaphragm, blood
flow through this vessel is not
disturbed by the contraction of the
diaphragm
• Also transmits the thoracic duct
and, occasionally, azygos vein
Oesophageal Aperture • an opening in the muscle of the right crus
of the diaphragm
• at the level of T10
• Lies above and to the left of aortic hiatus
• Transmits oesophagus
• as this enters the abdomen from the thorax
• fibres of the right crus of the diaphragm
surround the oesophagus here
• these fibres form a sphincter for the
oesophagus, and thus constricts it when the
diaphragm contracts
• Also transits:
• right and left vagal trunks and
• oesophageal branches of left gastric vessels
 • An aperture in the central tendon of the
Caval Opening diaphragm
• to the right of the median plane,
• at the level of the disc btw T8 and T9
vertebrae
• This opening is at the junction of the right and
middle leaves of the central tendon
• Transmits IVC
• Also transmits
• terminal part of the right phrenic nerve,
• some lymph vessels, and
• Vagal trunks
• Caval opening is adherent to the wall of
the IVC
• Thus, when the diaphragm contracts, IVC
widens,
• and this enhances venous return to the heart
• The diaphragm has a small sternocostal foramen (or triangle)
• This lies (on each side) between the sternal and costal attachments of the diaphragm
• It transmits superior epigastric vessels and lymph vessels

• Each sympathetic
chain descends
into the abdomen
behind the medial
arcuate ligament
• Greater and lesser
splanchnic nerves
pierce the crus of
the diaphragm on
each side
Applied Anatomy of the Diaphragm
• Paralysis of a hemidiaphragm
• Due to injury to phrenic nerve of that side
• Thus, muscle fibres of half of the diaphragm
atrophy
• Such paralysed hemidiaphragm does not
descend during inspiration;
• rather, it is forced upwards by increased
abdominal pressure
• In certain subjects, accessory phrenic
nerve is present.
• Thus, injury to the main phrenic nerve does
not result in paralysis of a hemidiaphragm
• Pain arising from irritation of the diaphragmatic pleura or
diaphragmatic peritoneum is referred to the shoulder region,
• which is innerved by C3–C5 segments of the spinal cord
• same nerve roots as the phrenic nerve
• Pain from the irritation of the peripheral part of the diaphragm is
referred to the skin over the costal margin
• Hiccups are associated with involuntary spasmodic contractions of
the diaphragm.
• It may be caused by cerebral lesions, irritation of the diaphragm,
indigestion, alcoholism or abdominal/thoracic lesions.
• the phrenic nerve is involved
• Herniation of abdominal organs
(e.g stomach, intestine, spleen,
etc) into the thoracic cavity is
possible:
• may be congenital or
• could occur following the rupture of
the diaphragm
• as may occur in auto accident, when
there is a sudden increase in
intrabdominal pressure
• Hiatal hernia
• characterised by protrusion of part
of the stomach into the thorax
through the oesophageal hiatus
• Sliding hiatal hernia; or
• Para-esophageal hiatal hernia
• The diaphragm may also be
congenitally defective
• In most cases,
posterolateral defect of
the diaphragm occurs
• Thus, abdominal organs are
prone to herniation into the
thorax (through this defect)
• Frequency: 1:2200 births
ASSIGNMENT
• STUDTY THE DEVELOPMENTAL ANATOMY AND CONGENITAL
ANOMALIES OF THE DIAPHRAGM