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THORAX

REYNALDO V. LOPEZ, M.D. Head

Department of Anatomy

Learning Objectives

At the end of the lecture, the student should be able to:

1.

Enumerate the bony components of the thoracic cage

2.

Describe the intercostal space & the musculature of

the thorax

3.

Discuss the cavities of the thorax & pleura

4.

Describe the vessels supplying the thorax

5.

Discuss the nerves of the thorax

6.

Describe the surface landmarks of the thorax

Overview of the Thorax
Overview of the
Thorax

Region of the body between the neck & abdomen

Overview of the Thorax  Region of the body between the neck & abdomen
Overview of the Thorax
Overview of the
Thorax

Female thorax: Anterior & posterior views

Overview of the Thorax  Female thorax: Anterior & posterior views
Overview of the Thorax  Female thorax: Anterior & posterior views
Overview of the Thorax
Overview of the
Thorax

Male thorax: Anterior & posterior views

Overview of the Thorax  Male thorax: Anterior & posterior views
Overview of the Thorax  Male thorax: Anterior & posterior views
Overview of the Thorax
Overview of the
Thorax

Flattened in front & behind

but rounded at the sides

Superiorly communicates

with the neck & inferiorly

separated from the

abdomen by the diaphragm

at the sides  Superiorly communicates with the neck & inferiorly separated from the abdomen by
Overview of the Components Thorax
Overview of the
Components
Thorax

Framework of the walls of

the thorax (thoracic cage):

is formed by the vertebral column behind

ribs & intercostal spaces on either side

the sternum & costal cartilages in front

column behind  ribs & intercostal spaces on either side  the sternum & costal cartilages
Overview of the Thorax Thoracic Inlet & Outlet
Overview of the
Thorax
Thoracic Inlet &
Outlet

Structure/

Description/

Significance

Space

Boundaries

Thoracic inlet

Opening at the superior end of the rib cage through which cervical

Marks the boundary between the neck and the

structures enter the thorax;

superior mediastinum;

Bounded by the T1 vertebral body,

Also known as: superior

both of the 1st ribs and their costal

thoracic aperture

cartilages, and the manubrium of the sternum

Thoracic outlet

Opening at the inferior end of the rib cage through which thoracic

Closed by the respiratory diaphragm which is

structures exit the thorax;

attached at its boundary;

Bounded by the T12 vertebral body,

Also known as: inferior

both 12th ribs, the costal cartilages

thoracic aperture

of ribs 7-12, and the xiphisternal joint

Overview of the Thoracic Inlet & Thorax Outlet INLET
Overview of the
Thoracic Inlet &
Thorax
Outlet
INLET
Overview of the Thoracic Inlet & Thorax Outlet INLET OUTLET
OUTLET
OUTLET
Overview of the Thoracic Inlet Thorax
Overview of the
Thoracic Inlet
Thorax
Overview of the Thoracic Inlet Thorax
Overview of the Thoracic Outlet Thorax
Overview of the
Thoracic Outlet
Thorax
Overview of the Thoracic Outlet Thorax
Overview of the Functions Thorax
Overview of the
Functions
Thorax

Functions of the thorax:

for breathing

protection of vital organs passageway of vessels & nerves

affords attachment for the muscles of the thorax,

upper extremity, abdomen & back

of vessels & nerves  affords attachment for the muscles of the thorax, upper extremity, abdomen

Bony Components of the Thoracic Cage

Bony Components of the Thoracic Cage
Bony Thoracic Cage Components
Bony Thoracic Cage
Components

1. Sternum in front of the thoracic cage

manubrium sternum

body of sternum

xiphoid process 2. Ribs 12 pairs

upper 7 articulates with sternum

8,9 & 10 articulates with rib

above

11 & 12 are rudimentary & called

with rib above  11 & 12 are rudimentary & called floating ribs 3. Thoracic vertebrae

floating ribs 3.Thoracic vertebrae at the back, 12 in number

Bony Thoracic Cage Sternum
Bony Thoracic Cage
Sternum

Parts:

1.

Manubrium

upper part that articulates with the clavicles and the 1 st & upper part of the 2 nd costal cartilages on each side

lies opposite the 3 rd & 4 th thoracic vertebrae

of the 2 n d costal cartilages on each side  lies opposite the 3 r
Bony Thoracic Cage Sternum
Bony Thoracic Cage
Sternum

Parts:

2.

Body

articulates with the:

manubrium - manubriosternal joint

xiphoid process - xiphisternal joint

with notches for articulation with the 2 nd costal cartilage and the 3 rd - 7 th costal cartilages

 with notches for articulation with the 2 n d costal cartilage and the 3 r
Bony Thoracic Cage Sternum
Bony Thoracic Cage
Sternum

Parts:

3. Xiphoid process

lowest & smallest part

no ribs or costal cartilages are attached

to it

Sternum Parts: 3. Xiphoid process  lowest & smallest part  no ribs or costal cartilages
Bony Thoracic Cage Ribs
Bony Thoracic Cage
Ribs

12 pairs of ribs, all attached posteriorly to the thoracic vertebrae Upper 7 ribs attached anteriorly to the sternum by

their costal cartilages (true

ribs)

to the thoracic vertebrae  Upper 7 ribs attached anteriorly to the sternum by their costal
Bony Thoracic Cage Ribs
Bony Thoracic Cage
Ribs

8 th , 9 th & 10 th pairs of ribs attached anteriorly to each other & to the 7 th rib by means of their costal cartilages &

small synovial joints (false ribs)

11 th & 12 th pairs have no anterior attachment & are

referred to as floating ribs

(false ribs)  11 t h & 12 t h pairs have no anterior attachment &
Bony Thoracic Cage Ribs
Bony Thoracic Cage
Ribs

Typical rib is:

a long, twisted, flat bone

with a rounded, smooth, superior border sharp, thin inferior border which forms the costal groove that contains the intercostal vessels & nerves

 sharp, thin inferior border which forms the costal groove that contains the intercostal vessels &
Bony Thoracic Cage Ribs Parts:
Bony Thoracic Cage
Ribs
Parts:

1. Head

has 2 facets for articulation with the numerically corresponding

vertebral body & that of the vertebra immediately above

2. Neck

a constricted portion situated between the head & the tubercle

that of the vertebra immediately above 2. Neck  a constricted portion situated between the head
Bony Thoracic Cage Ribs 3. Tubercle
Bony Thoracic Cage
Ribs
3.
Tubercle

prominence on the outer surface of the rib at the junction of the neck with the shaft

has a facet for articulation with the transverse process of the

numerically corresponding vertebra

with the shaft  has a facet for articulation with the transverse process of the numerically
Bony Thoracic Cage Ribs
Bony Thoracic Cage
Ribs

4.

Shaft or Body

thin & flattened & twisted on its long axis

inferior border has the costal groove

5.

Angle

where the shaft bends sharply forward

on its long axis  inferior border has the costal groove 5. Angle  where the
Bony Thoracic Cage Costal Cartilages
Bony Thoracic Cage
Costal Cartilages

Bars of hyaline cartilage connect the upper 7 ribs to the lateral edge of the sternum & the 8 th , 9 th & 10 th ribs to the cartilage immediately above

Cartilages of the 11 th & 12 th ribs end in the abdominal

musculature

cartilage immediately above  Cartilages of the 11 t h & 12 t h ribs end
Bony Thoracic Cage Costal Cartilages
Bony Thoracic Cage
Costal Cartilages

Contribute significantly to the elasticity & mobility of the

thoracic walls In old age, they tend to lose

some of their flexibility as a result

of superficial calcification

the thoracic walls  In old age, they tend to lose some of their flexibility as
Bony Thoracic Cage Thoracic Vertebrae
Bony Thoracic Cage
Thoracic Vertebrae

Characteristics:

Body is medium size & heart- shaped Vertebral foramen is small & circular Costal facets are present on the sides of the bodies for

& circular  Costal facets are present on the sides of the bodies for articulation with

articulation with the heads of

the ribs

Bony Thoracic Cage Thoracic Vertebrae
Bony Thoracic Cage
Thoracic Vertebrae

Characteristics:

Superior articular processes bear facets that face

backward & laterally

Facets on the inferior articular processes face

forward & medially

Spines are long & inclined downward

 Facets on the inferior articular processes face forward & medially  Spines are long &
Bony Thoracic Cage Thoracic Vertebra
Bony Thoracic Cage
Thoracic Vertebra
Bony Thoracic Cage Thoracic Vertebra
Bony Thoracic Cage Thoracic Vertebra
Bony Thoracic Cage
Thoracic Vertebra
Bony Thoracic Cage Thoracic Vertebra

Intercostal Space

Intercostal Space
Intercostal Space Components
Intercostal Space
Components

Space between the ribs Each space contains 3 muscles of respiration:

External intercostal Internal intercostal

Innermost intercostal

space contains 3 muscles of respiration:  External intercostal  Internal intercostal  Innermost intercostal
Intercostal Space Components
Intercostal Space
Components

Innermost intercostal is lined internally by the endothoracic

fascia Intercostal vessels & nerves run between the intermediate & deepest layers of muscles Arranged from above downward as: V A N

& nerves run between the intermediate & deepest layers of muscles  Arranged from above downward
Intercostal Intercostal Space Muscles
Intercostal
Intercostal Space
Muscles

Muscle

Direction of fibers

Extent

External Intercostal

fibers are directed

extends forward from the

Muscle

downward & forward from

rib tubercle behind to the

- most superficial layer

the inferior border of the

costochondral junction in

rib above to the superior border of the rib below

front, where the muscle is replaced by the

anterior(external) intercostal membrane

Intercostal Intercostal Space Muscles
Intercostal
Intercostal Space
Muscles
 

Muscle

Direction of fibers

Extent

Internal Intercostal Muscle

fibers are directed

extends backward from

-

forms intermediate layer

downward & backward

the sternum in front to the

 

from the subcostal groove

angles of the rib behind,

of the rib above to the upper border of the rib below

where the muscle is replaced by the posterior

(internal) intercostal membrane

Intercostal Intercostal Space Muscles
Intercostal
Intercostal Space
Muscles

Muscle

Direction of fibers

Extent

Innermost Intercostal

Layer

- forms the deepest layer

corresponds to the

transversus abdominis

muscle in the anterior

abdominal wall

an incomplete muscle

layer that crosses more

than one intercostal space

within the ribs

a. Transversus thoracis

(anterior)

b. Innermost intercostal

(lateral)

c. Subcostal

(posterior)

within the ribs a. Transversus thoracis (anterior) b. Innermost intercostal (lateral) c. Subcostal (posterior)
within the ribs a. Transversus thoracis (anterior) b. Innermost intercostal (lateral) c. Subcostal (posterior)
within the ribs a. Transversus thoracis (anterior) b. Innermost intercostal (lateral) c. Subcostal (posterior)
Intercostal Intercostal Space Muscles
Intercostal
Intercostal Space
Muscles

Action of these muscles:

when they contract, they all

tend to pull the ribs nearer to

one another

if the 1 st rib is fixed by the contraction of the muscles in

the root of the neck, namely

the scaleni muscles, the intercostal muscles raise the 2 nd - 12 th ribs toward the 1 st rib, as in inspiration

muscles, the intercostal muscles raise the 2 n d - 12 t h ribs toward the
Intercostal Intercostal Space Muscles
Intercostal
Intercostal Space
Muscles

Action of these muscles:

if the 12 th rib is fixed by the quadratus lumborum & the oblique muscles of the abdomen, the 1 st - 11 th ribs will be lowered by the contraction

of the intercostal muscles, as

in expiration

the 1 s t - 11 t h ribs will be lowered by the contraction of
Intercostal Arteries Intercostal Space & Veins
Intercostal Arteries
Intercostal Space
& Veins

Each intercostal space contains 2 small anterior

intercostal & a large posterior intercostal arteries:

1. Anterior intercostal arteries

1 st 6 spaces are branches of the internal thoracic artery lower 5 spaces are branches of the musculophrenic artery

6 spaces are branches of the internal thoracic artery  lower 5 spaces are branches of
Intercostal Arteries Intercostal Space & Veins
Intercostal Arteries
Intercostal Space
& Veins

2. Posterior intercostal arteries:

1 st 2 spaces are branches of the superior intercostal artery

lower 9 spaces are branches of the descending thoracic aorta

spaces are branches of the superior intercostal artery  lower 9 spaces are branches of the
Intercostal Arteries Intercostal Space & Veins
Intercostal Arteries
Intercostal Space
& Veins

Corresponding Veins:

1.

2.

Anterior intercostal veins > internal thoracic & musculophrenic veins

Posterior intercostal veins > azygos or hemiazygos veins

veins > internal thoracic & musculophrenic veins Posterior intercostal veins > azygos or hemiazygos veins
Intercostal Space Intercostal Nerves
Intercostal Space
Intercostal Nerves

Anterior rami of the 1 st 11 thoracic spinal nerves

Enters an intercostal space between the parietal pleura &

the posterior intercostal

membrane

spinal nerves  Enters an intercostal space between the parietal pleura & the posterior intercostal membrane
Intercostal Space Intercostal Nerves
Intercostal Space
Intercostal Nerves

Runs forward inferiorly to the intercostal vessels in the subcostal groove of the corresponding rib, between

the innermost intercostal & internal intercostal muscle

in the subcostal groove of the corresponding rib, between the innermost intercostal & internal intercostal muscle
Intercostal Space Intercostal Nerves
Intercostal Space
Intercostal Nerves

Distribution:

1 st 6 th nerves within their intercostal space

7 th to 9 th nerves - enter the anterior abdominal wall after

leaving their intercostal space

10 th & 11 th nerves pass directly into the abdominal wall

leaving their intercostal space  10 t h & 11 t h nerves – pass directly
Intercostal Arteries, Intercostal Space Veins & Nerves
Intercostal Arteries,
Intercostal Space
Veins & Nerves

Intercostal nerves and associated major arteries and veins lie in the costal groove along the

inferior margin of the superior

rib and pass in the plane

between the inner two layers of

muscles.

If you are to drain fluid or air from

the thoracic cavity, be sure to do

the puncture in the middle of the

intercostal space to prevent

hitting an intercostal nerve or

vessel.

be sure to do the puncture in the middle of the intercostal space to prevent hitting
Suprapleural Intercostal Space Membrane
Suprapleural
Intercostal Space
Membrane

Dense fascial layer that closes

the thoracic inlet

Also known as Sibson’s fascia

Attached laterally to the medial border of the 1 st rib & costal cartilage

known as Sibson’s fascia  Attached laterally to the medial border of the 1 s t
Suprapleural Intercostal Space Membrane
Suprapleural
Intercostal Space
Membrane

Attachment:

at its apex to the tip of the transverse process of the 7 th cervical vertebra & medially to the fascia investing the structures

passing from the thorax into

the neck

h cervical vertebra &  medially to the fascia investing the structures passing from the thorax
Suprapleural Intercostal Space Membrane
Suprapleural
Intercostal Space
Membrane

Functions:

Protects the underlying cervical pleura

Resists the changes in intrathoracic pressure

occurring during respiratory

movement

the underlying cervical pleura  Resists the changes in intrathoracic pressure occurring during respiratory movement
Endothoracic Intercostal Space Fascia
Endothoracic
Intercostal Space
Fascia

Thin layer of loose connective tissue that separates the

parietal pleura from the thoracic wall

Suprapleural membrane is a thickening of this fascia

Muscles of the Thorax

Muscles of the Thorax
Muscles of the Diaphragm Thorax
Muscles of the
Diaphragm
Thorax

Primary muscle of respiration

Dome shaped

Consists of:

Peripheral muscular part 3 parts of

origin

Centrally placed tendon shaped

like 3 leaves

Consists of:  Peripheral muscular part – 3 parts of origin  Centrally placed tendon –
Muscles of the Diaphragm Thorax
Muscles of the
Diaphragm
Thorax

Origin can be divided into 3 parts:

Sternal part (R) & (L) slips from posterior surface of xiphoid

process

Costal part 6 slips from the deep surfaces of the lower 6 ribs & their costal cartilages

Vertebral part arising by means

of vertical columns or crura & from

the arcuate ligaments

Sternal origin
Sternal
origin
Costal origin
Costal
origin
Vertebral origin
Vertebral
origin
Muscles of the Diaphragm Thorax
Muscles of the
Diaphragm
Thorax

Vertebral Part:

1.

Right crus from the sides

of the bodies of the 1 st 3 lumbar vertebrae & the

intervertebral discs

2.

Left crus from the sides

of the bodies of the 1 st 2 lumbar vertebrae & the

intervertebral discs

2. Left crus – from the sides of the bodies of the 1 s t 2
2. Left crus – from the sides of the bodies of the 1 s t 2
Muscles of the Diaphragm Thorax
Muscles of the
Diaphragm
Thorax

Vertebral Part:

3. Medial arcuate ligament thickened upper margin of

the fascia covering the

anterior surface of the

psoas muscle

4. Lateral arcuate ligament thickened upper margin of the fascia covering the anterior surface of the

arcuate ligament – thickened upper margin of the fascia covering the anterior surface of the quadratus
arcuate ligament – thickened upper margin of the fascia covering the anterior surface of the quadratus

quadratus lumborum

muscle

Muscles of the Diaphragm Thorax
Muscles of the
Diaphragm
Thorax
Muscles of the Diaphragm Thorax
Muscles of the Diaphragm Thorax
Muscles of the
Diaphragm
Thorax

Shape of the diaphragm:

As seen from front, curves up into (R) & (L) domes or cupolate

(R) dome reaches as high as the upper border of the 5 th rib

(L) dome may reach the lower border of the 5 th rib

reaches as high as the upper border of the 5 t h rib  (L) dome
Muscles of the Diaphragm Thorax
Muscles of the
Diaphragm
Thorax

Shape of the diaphragm:

Central tendon lies at the

level of the xiphisternal joint

& supports the heart

The domes support the (R) & (L) lungs

Lower when person is

sitting or standing & higher

in the supine position &

after a large meal

& (L) lungs  Lower when person is sitting or standing & higher in the supine
Muscles of the Diaphragm Thorax Openings
Muscles of the
Diaphragm
Thorax
Openings
T8 T10 T12 Aortic
T8
T10
T12
Aortic

3 openings:

1.

Aortic opening

Lies anterior to the body of the 12 th thoracic vertebra between the crura

Transmits the:

aorta

thoracic duct

azygos vein

Muscles of the Diaphragm Thorax Openings
Muscles of the
Diaphragm
Thorax
Openings

3 openings:

2. Esophageal opening

Lies at the level of the 10 th thoracic vertebra in a sling of

muscle fibers from the (R)

crus

Transmits the:

esophagus

(R) & (L) vagus nerves

esophageal branches of the (L) gastric vessels

lymphatics from the lower 3 rd of the esophagus

T8 T10 Esophageal T12
T8
T10
Esophageal
T12
Muscles of the Diaphragm Thorax Openings
Muscles of the
Diaphragm
Thorax
Openings

3 openings:

3. Caval opening

Lies at the level of the 8 th thoracic vertebra in the central

tendon

Transmits the:

inferior vena cava

terminal branches of the (R) phrenic nerve

T8 T10 Caval T12
T8
T10
Caval
T12

Action

Contraction: the dome moving downward,

increases the volume of thoracic cavity which results in inspiration,

at the same time the intra- abdominal pressure is

increased;

assists in defecation,

vomiting or child birth.

 at the same time the intra- abdominal pressure is increased;  assists in defecation, vomiting

Action

Relaxation: the dome returns to the former position, reduces the volume to the thoracic cavity, resulting in expiration.

: the dome returns to the former position,  reduces the volume to the thoracic cavity,
Muscles of the Diaphragm Thorax
Muscles of the
Diaphragm
Thorax
Muscles of the Diaphragm Thorax
Muscles of the Composite Diagram Thorax of Diaphragm
Muscles of the
Composite Diagram
Thorax
of Diaphragm
Muscles of the Composite Diagram Thorax of Diaphragm
Muscles of the Other Muscles Thorax
Muscles of the
Other Muscles
Thorax

Levatores costarum:

12 pairs

Each muscle is triangular in shape & arises by its apex

from the tip of the transverse

process & inserted into the

rib below

is triangular in shape & arises by its apex from the tip of the transverse process
Muscles of the Other Muscles Thorax
Muscles of the
Other Muscles
Thorax

Levatores costarum:

Action: each raises the rib below & is therefore an

inspiratory muscle

Nerve supply: posterior rami

of thoracic spinal nerves

raises the rib below & is therefore an inspiratory muscle  Nerve supply: posterior rami of
Muscles of the Other Muscles Thorax
Muscles of the
Other Muscles
Thorax

Serratus posterior superior

muscle:

Thin, flat muscle that arises

from the lower cervical &

upper thoracic spines

Its fibers pass downward &

laterally & are inserted into the

upper ribs

cervical & upper thoracic spines  Its fibers pass downward & laterally & are inserted into
Muscles of the Other Muscles Thorax
Muscles of the
Other Muscles
Thorax

Serratus posterior superior

muscle:

Action: elevates the ribs is therefore an inspiratory muscle

Nerve supply: intercostal nerves

superior muscle :  Action: elevates the ribs is therefore an inspiratory muscle  Nerve supply:
Muscles of the Other Muscles Thorax
Muscles of the
Other Muscles
Thorax

Serratus posterior inferior

muscle:

Thin, flat muscle that arises

from the upper lumbar lower

cervical & lower thoracic spines

Its fibers pass upward &

laterally & are inserted into the

lower ribs

cervical & lower thoracic spines  Its fibers pass upward & laterally & are inserted into
Muscles of the Other Muscles Thorax
Muscles of the
Other Muscles
Thorax

Serratus posterior inferior

muscle:

Action: depresses the ribs is therefore an expiratory muscle

Nerve supply: intercostal nerves

inferior muscle :  Action: depresses the ribs is therefore an expiratory muscle  Nerve supply:

PART 2

PART 2

Thoracic Cavity & Pleura

Thoracic Cavity & Pleura
Thoracic Cavity Divisions
Thoracic Cavity
Divisions

Divided into 3 parts:

Mediastinum contains the heart surrounded by the pericardial sac; median partition Pleurae & lungs laterally placed

contains the heart surrounded by the pericardial sac; median partition  Pleurae & lungs – laterally
Thoracic Cavity Mediastinum
Thoracic Cavity
Mediastinum
Thoracic Cavity Divisions
Thoracic Cavity
Divisions

The mediastinum is subdivided

into several smaller regions.

A transverse plane extending

from the sternal angle to the

intervertebral disc between vertebrae T4 and T5

separates the mediastinum

into:

superior mediastinum

inferior mediastinum

disc between vertebrae T4 and T5 separates the mediastinum into:  superior mediastinum  inferior mediastinum
Thoracic Cavity Divisions
Thoracic Cavity
Divisions

The inferior mediastinum is

further partitioned into the:

anterior mediastinum

middle mediastinum

posterior mediastinum

by the pericardial sac.

partitioned into the:  anterior mediastinum  middle mediastinum  posterior mediastinum by the pericardial sac.
Thoracic Cavity Pleural Cavities
Thoracic Cavity
Pleural Cavities

Pleurae & lungs lie on either side of the mediastinum

within the chest cavity.

Thoracic Cavity Pleural Cavities Pleurae & lungs lie on either side of the mediastinum within the
Thoracic Cavity Pleural Cavities
Thoracic Cavity
Pleural Cavities

The pleural cavities are completely separated from each other by the

mediastinum.

Therefore, abnormal events

in one pleural cavity do not

necessarily affect the other

cavity.

This also means that the mediastinum can be entered

surgically without opening

the pleural cavities.

other cavity.  This also means that the mediastinum can be entered surgically without opening the
Thoracic Cavity Pleurae
Thoracic Cavity
Pleurae

Each pleura has 2 parts:

1. Parietal layer

Lines the thoracic wall

Covers the thoracic surface of the diaphragm & lateral aspect

of the mediastinum

Extends into the root of the neck to line the undersurface of

the suprapleural membrane at the thoracic inlet

2. Visceral layer

Completely covers the outer surfaces of the lungs

Extends into the depths of the interlobar fissures

Thoracic Cavity Pleura
Thoracic Cavity
Pleura
Thoracic Cavity Pleura
Thoracic Cavity Pleura
Thoracic Cavity Parietal Pleura
Thoracic Cavity
Parietal Pleura

The names given to the parietal

pleura correspond to the parts

of the wall with which they are

associated.

pleura related to the ribs and intercostal spaces is termed

the costal part;

pleura covering the diaphragm is the

diaphragmatic part;

ribs and intercostal spaces is termed the costal part ;  pleura covering the diaphragm is
Thoracic Cavity Parietal Pleura
Thoracic Cavity
Parietal Pleura

pleura covering the

mediastinum is the

mediastinal part;

the dome-shaped layer of

parietal pleura lining the

cervical extension of the

pleural cavity is cervical pleura

(dome of pleura or pleural

cupola).

pleura lining the cervical extension of the pleural cavity is cervical pleura (dome of pleura or
Thoracic Cavity Parietal Pleura
Thoracic Cavity
Parietal Pleura

Divisions:

1. Cervical pleura

extends up into the neck

lines the undersurface of the suprapleural membrane

reaches a level 1-1.5 (2.5-4 cm) above the medial 3 rd of the clavicle

of the suprapleural membrane  reaches a level 1-1.5 (2.5-4 cm) above the medial 3 r
Thoracic Cavity Parietal Pleura
Thoracic Cavity
Parietal Pleura

Divisions:

2. Costal pleura lines the inner surfaces of the:

ribs

intercostal spaces

sides of the vertebral bodies

back of the sternum

the inner surfaces of the:  ribs  intercostal spaces  sides of the vertebral bodies
Thoracic Cavity Parietal Pleura
Thoracic Cavity
Parietal Pleura

Divisions:

3.

4.

Diaphragmatic pleura

covers the thoracic surface of

the diaphragm

Mediastinal pleura

covers & forms the lateral

boundary of the mediastinum

thoracic surface of the diaphragm Mediastinal pleura –  covers & forms the lateral boundary of
Thoracic Cavity Recesses
Thoracic Cavity
Recesses

The lung does not completely

fill the potential space of the

pleural cavity, resulting in

recesses, which do not

contain lung and are

important for accommodating

changes in lung volume during breathing. These recesses are the:

Costodiaphragmatic recess

Costomediastinal recess

lung volume during breathing.  These recesses are the:  Costodiaphragmatic recess  Costomediastinal recess
Thoracic Cavity Recesses
Thoracic Cavity
Recesses

Costodiaphragmatic recess

a potential space at the posteriormost tips of the cavity,

located at the junction of the

costal pleura and diaphragmatic pleura during inspiration, the lower margins of the lungs descend into this recess

costal pleura and diaphragmatic pleura  during inspiration, the lower margins of the lungs descend into
Thoracic Cavity Recesses
Thoracic Cavity
Recesses

Costodiaphragmatic recess

pleural effusions collect in the costodiaphragmatic recess

when in standing position

Costodiaphragmatic recess  pleural effusions collect in the costodiaphragmatic recess when in standing position
Costodiaphragmatic recess  pleural effusions collect in the costodiaphragmatic recess when in standing position
Thoracic Cavity Recesses
Thoracic Cavity
Recesses

Costomediastinal recess

potential space at the border of the mediastinal pleura and

the costal pleura

during inspiration & expiration, the anterior borders of the

lungs slide in & out of the

recesses

pleura  during inspiration & expiration, the anterior borders of the lungs slide in & out
Thoracic Cavity Recesses
Thoracic Cavity
Recesses

Costomediastinal recess most obvious in the cardiac notch of the left lung

–  most obvious in the cardiac notch of the left lung 1. Costodiaphragmatic recess 2.

1. Costodiaphragmatic recess

2. Costomediastinal recess

Thoracic Cavity Nerve Supply
Thoracic Cavity
Nerve Supply

Parietal pleura is sensitive to

pain, temperature, touch and

pressure & is supplied as

follows:

Costal pleura - intercostal nerves

Mediastinal pleura phrenic nerve

Diaphragmatic pleura around

the domes by the phrenic nerve

& around the periphery by the

lower 6 intercostal nerves

pleura – around the domes by the phrenic nerve & around the periphery by the lower
Thoracic Cavity Nerve Supply
Thoracic Cavity
Nerve Supply

Visceral pleura receives an autonomic supply from the

pulmonary plexus; it is

sensitive to stretch but is

insensitive to common

sensations such as pain &

touch

from the pulmonary plexus; it is sensitive to stretch but is insensitive to common sensations such

Vessels of the Thorax

Vessels of the Thorax
Vessels of the Thorax Arteries
Vessels of the Thorax
Arteries

The thoracic wall is supplied by three sources of blood supply:

1. axillary

supreme thoracic (2)

lateral thoracic (3)

2. subclavian

internal thoracic (or

mammary) artery (1)

anterior intercostal branches

3. aorta

intercostal arteries (4)

 internal thoracic (or mammary) artery (1) • anterior intercostal branches 3. aorta  intercostal arteries
Vessels of the Thorax Arteries
Vessels of the Thorax
Arteries
Vessels of the Thorax Arteries
Internal Thoracic Vessels of the Thorax Artery
Internal Thoracic
Vessels of the Thorax
Artery

Internal Thoracic Artery

Supplies the anterior wall of the body from the clavicle to the umbilicus

Branch of the 1 st part of the subclavian artery in the neck

of the body from the clavicle to the umbilicus  Branch of the 1 s t
Internal Thoracic Vessels of the Thorax Artery
Internal Thoracic
Vessels of the Thorax
Artery

Internal Thoracic Artery

Descends vertically on the pleura behind the costal cartilages, a

fingerbreadth lateral to the sternum

Ends in the 6 th intercostal space by dividing into:

Superior epigastric artery Musculophrenic artery

Ends in the 6 t h intercostal space by dividing into:  Superior epigastric artery 
Internal Thoracic Vessels of the Thorax Artery
Internal Thoracic
Vessels of the Thorax
Artery

Branches:

1.

Anterior intercostal arteries for the upper 6

intercostal spaces

2.

Perforating arteries accompany the terminal branches of the corresponding intercostal nerves

3.

Pericardiophrenic artery accompanies the phrenic

nerve & supplies the pericardium

Internal Thoracic Vessels of the Thorax Artery
Internal Thoracic
Vessels of the Thorax
Artery

Branches:

4.

Mediastinal arteries to the contents of the anterior

mediastinum ( e.g

thymus)

5.

Superior epigastric artery enters the rectus sheath of the anterior abdominal wall & supplies the rectus

muscle as far as the umbilicus

6.

Musculophrenic artery runs around the costal

margin of the diaphragm & supplies the lower intercostal spaces & the diaphragm

Vessels of the Thorax Veins
Vessels of the Thorax
Veins

Internal Thoracic Vein Begins as small veins accompanying the internal thoracic artery

Small veins eventually join to form a single vessel, which drains into the brachiocephalic vein on each side

artery  Small veins eventually join to form a single vessel, which drains into the brachiocephalic
Vessels of the Thorax Veins
Vessels of the Thorax
Veins

Brachiocephalic Veins

Formed by union of internal jugular and subclavian

veins posterior to the

sternoclavicular joint

jugular and subclavian veins posterior to the sternoclavicular joint • Angle of union is termed venous

Angle of union is termed venous angle

Vessels of the Thorax Veins
Vessels of the Thorax
Veins

Superior Vena Cava

Formed by union of right and left brachiocephalic

veins behind the right

sternocostal synchondrosis

of first rib

veins behind the right sternocostal synchondrosis of first rib • Runs vertically down on right of

Runs vertically down on right of ascending aorta

Vessels of the Thorax Veins
Vessels of the Thorax
Veins

Superior Vena Cava

Joined by azygos vein at level of sternal angle

Enters right atrium at level of lower border of 3 rd right sternocostal joint

Collects blood from veins

of upper half of body

at level of lower border of 3 r d right sternocostal joint • Collects blood from
Vessels of the Thorax Veins
Vessels of the Thorax
Veins

Azygos vein

Begins as continuation of (R) ascending lumbar vein

Ascending along the right

side of vertebral column

Joins superior vena cava by arching above right lung root

at level of T4 to T5

the right side of vertebral column • Joins superior vena cava by arching above right lung
Vessels of the Thorax Veins
Vessels of the Thorax
Veins

Azygos vein

Receives:

(R) posterior intercostals and

subcostal veins

bronchial

esophageal

pericardial veins

hemiazygos vein

(R) posterior intercostals and subcostal veins • bronchial • esophageal • pericardial veins • hemiazygos vein
Vessels of the Thorax Veins
Vessels of the Thorax
Veins
Vessels of the Thorax Veins Azygos vein • Tributaries - hemiazygos v . and accessory hemiazygos

Azygos vein

Tributarieshemiazygos v. and accessory hemiazygos v.

which receive most (L)

posterior intercostals vein

and (L) bronchial veins

Vessels of the Thorax Veins
Vessels of the Thorax
Veins
Vessels of the Thorax Veins Veins of vertebral column Consists of • External vertebral venous plexus

Veins of vertebral column

Consists of

External vertebral

venous plexus

Internal vertebral

venous plexus

The lymphatic drainage Vessels of the Thorax of thoracic wall
The lymphatic drainage
Vessels of the Thorax
of thoracic wall
lymphatic drainage Vessels of the Thorax of thoracic wall  To axillary lymph nodes  To

To axillary lymph nodes

To parasternal lymph nodes (along internal thoracic

vessels)

To intercostals lymph nodes from deeper structures

Vessels of the Thorax Lymph nodes
Vessels of the Thorax
Lymph nodes

Lymph nodes of trachea,

bronchi and lungs

Pulmonary lymph nodes -

lie in the angles of

bifurcation of branching

lobar bronchi

Bronchopulmonary hilar

lymph nodes - lie in the

hilus of the lung

angles of bifurcation of branching lobar bronchi  Bronchopulmonary hilar lymph nodes - lie in the
Vessels of the Thorax Lymph nodes
Vessels of the Thorax
Lymph nodes

Lymph nodes of trachea,

bronchi and lungs

Tracheobronchial lymph

nodes -situated above or

below the bifurcation of

trachea

Paratracheal lymph nodes - along each side of the

trachea

nodes -situated above or below the bifurcation of trachea  Paratracheal lymph nodes - along each
Vessels of the Thorax Thoracic Duct
Vessels of the Thorax
Thoracic Duct
Vessels of the Thorax Thoracic Duct Thoracic duct  Begins in front of L1 as a

Thoracic duct

Begins in front of L1 as a dilated sac, the cisterna chyli, formed

by the joining of left and right

lumbar trunks and intestinal

trunk

of L1 as a dilated sac, the cisterna chyli , formed by the joining of left
Vessels of the Thorax Thoracic Duct
Vessels of the Thorax
Thoracic Duct
Vessels of the Thorax Thoracic Duct Thoracic duct  Enters thoracic cavity by passing through the

Thoracic duct

Enters thoracic cavity by passing through the aortic hiatus

of the diaphragm and ascends

along on the front of the

vertebral column, between

thoracic aorta and azygos vein

Vessels of the Thorax Thoracic Duct
Vessels of the Thorax
Thoracic Duct

Travels upward, veering

to the left at the level of

T5

At the roof of the neck, it

turns laterally and arches

forwards and descends

to enter the left venous

angle

Just before termination, it

receives the left jugular,

subclavian and

bronchomediastinal

trunks

the left venous angle  Just before termination, it receives the left jugular, subclavian and bronchomediastinal
Vessels of the Thorax Thoracic Duct
Vessels of the Thorax
Thoracic Duct
Vessels of the Thorax Thoracic Duct  Drains lymph from  lower limbs  pelvic cavity

Drains lymph from

lower limbs

pelvic cavity

abdominal cavity

left side of thorax

left side of the head,

neck & left upper limb

Vessels of the Thorax Thoracic Duct
Vessels of the Thorax
Thoracic Duct

Right lymphatic duct

Formed by union of right jugular, subclavian, and

bronchomediastinal trunks

Ends by entering the right venous angle

Receives lymph from right

half of head, neck, thorax

and right upper limb

Ends by entering the right venous angle  Receives lymph from right half of head, neck,

Nerves of the Thorax

Nerves of the Thorax
Nerves of the Thorax Thoracic Nerves
Nerves of the Thorax
Thoracic Nerves

Intercostal nerves (anterior rami of T1- T11):

runs forward inferiorly to

intercostal vessels in costal

groove of corresponding rib,

between intercostals externi

and intercostals interni

rib, between intercostals externi and intercostals interni  first 6 nerves are distributed within their

first 6 nerves are distributed within their intercostal spaces

lower 5 intercostal nerves

leave anterior ends of their

intercostal spaces to enter

abdominal wall

intercostal spaces  lower 5 intercostal nerves leave anterior ends of their intercostal spaces to enter
Nerves of the Thorax Thoracic Nerves
Nerves of the Thorax
Thoracic Nerves
Nerves of the Thorax Thoracic Nerves Subcostal nerve (anterior ramus of T12):  follows inferior border
Nerves of the Thorax Thoracic Nerves Subcostal nerve (anterior ramus of T12):  follows inferior border

Subcostal nerve (anterior ramus of T12):

follows inferior border of T12

rib and passes into abdominal

wall

distributed to intercostales and anterolateral abdominal

muscles, skin of thoracic and

abdominal wall, parietal

pleura and peritoneum

The segmental innervation of anterior surface of trunk

T2sternal angle

T4nipple

T6xiphoid process

T8costal arch

T10umbilicus

T12midpoint between

umbilicus and symphysis

pubis

xiphoid process  T8 - costal arch  T10 - umbilicus  T12 - midpoint between
Nerves of the Thorax Phrenic Nerve
Nerves of the Thorax
Phrenic Nerve
Nerves of the Thorax Phrenic Nerve Phrenic nerve  Descends over scalenus anterior to enter thorax

Phrenic nerve

Descends over scalenus anterior to enter thorax

Nerves of the Thorax Phrenic Nerve
Nerves of the Thorax
Phrenic Nerve

Phrenic nerve Accompanied by pericardiophrenic vessels &

passes anterior to lung roots

between mediastinal pleura

and pericardium to supply

motor and sensory innervation

to diaphragm

sensory fibers supply to

pleurae, pericardium and

peritoneum of diaphragm

usually (R) phrenic nerve may

be distributed on liver,

gallbladder and biliary system.

and peritoneum of diaphragm • usually (R) phrenic nerve may be distributed on liver, gallbladder and
Nerves of the Thorax Vagus Nerve
Nerves of the Thorax
Vagus Nerve
Nerves of the Thorax Vagus Nerve Left vagus nerve  Enters thoracic inlet between (L) common

Left vagus nerve

Enters thoracic inlet between (L) common carotid and (L)

Enters thoracic inlet between (L) common carotid and (L) subclavian arteries posterior to (L) brachiocephalic vein
Enters thoracic inlet between (L) common carotid and (L) subclavian arteries posterior to (L) brachiocephalic vein

subclavian arteries posterior to (L)

brachiocephalic vein

Crosses aortic arch where (L)

recurrent laryngeal nerve branches off

Passes posterior to left lung root

Nerves of the Thorax Vagus Nerve
Nerves of the Thorax
Vagus Nerve
Nerves of the Thorax Vagus Nerve Left vagus nerve  Forms anterior esophageal plexus  Forms

Left vagus nerve

Forms anterior esophageal plexus

Forms anterior vagal trunk at esophageal hiatus where it

leaves thorax and passes

into abdominal cavity , then

divides into anterior gastric

and hepatic branches

hiatus where it leaves thorax and passes into abdominal cavity , then divides into anterior gastric
hiatus where it leaves thorax and passes into abdominal cavity , then divides into anterior gastric
Nerves of the Thorax Vagus Nerve
Nerves of the Thorax
Vagus Nerve
Nerves of the Thorax Vagus Nerve Right vagus nerve  Enter thoracic inlet on (R) side
Nerves of the Thorax Vagus Nerve Right vagus nerve  Enter thoracic inlet on (R) side

Right vagus nerve

Enter thoracic inlet on (R) side

of trachea Travels downward posterior to (R) brachiocephalic vein and superior vena cava

Passes posterior to (R) lung root

 Travels downward posterior to (R) brachiocephalic vein and superior vena cava  Passes posterior to
 Travels downward posterior to (R) brachiocephalic vein and superior vena cava  Passes posterior to
Nerves of the Thorax Vagus Nerve
Nerves of the Thorax
Vagus Nerve
Nerves of the Thorax Vagus Nerve Right vagus nerve  Forms posterior esophageal plexus  Forms

Right vagus nerve

Forms posterior esophageal plexus Forms posterior vagal trunk at esophageal hiatus where it leaves thorax and passes into abdominal cavity, then divides

hiatus where it leaves thorax and passes into abdominal cavity, then divides into posterior gastric and

into posterior gastric and celiac

branches

Recurrent Nerves of the Thorax Laryngeal Nerves
Recurrent
Nerves of the Thorax
Laryngeal Nerves
Recurrent Nerves of the Thorax Laryngeal Nerves Recurrent laryngeal nerves  Right one hooks around (R)
Recurrent Nerves of the Thorax Laryngeal Nerves Recurrent laryngeal nerves  Right one hooks around (R)

Recurrent laryngeal nerves

Right one hooks around (R)

subclavian artery, left one hooks

aortic arch

Both ascend in tracheo-

esophageal groove

Recurrent Nerves of the Thorax Laryngeal Nerves
Recurrent
Nerves of the Thorax
Laryngeal Nerves
Recurrent Nerves of the Thorax Laryngeal Nerves Recurrent laryngeal nerves  Nerves enter larynx posterior to

Recurrent laryngeal nerves

Nerves enter larynx posterior to cricothyroid joint, the nerve is now

called inferior laryngeal nerve

Innervations:

laryngeal mucosa below fissure of

glottis

all laryngeal muscles except

cricothyroid

Thoracic Nerves of the Thorax Sympathetic Trunk
Thoracic
Nerves of the Thorax
Sympathetic Trunk
Thoracic Nerves of the Thorax Sympathetic Trunk Branches of sympathetic trunk to thoracic plexuses  Greater

Branches of sympathetic trunk to

thoracic plexuses Greater splanchnic nerve

formed by preganglionic fibers from

T5~T9 ganglia, and relay in celiac

ganglion.

.

Thoracic Nerves of the Thorax Sympathetic Trunk
Thoracic
Nerves of the Thorax
Sympathetic Trunk
Thoracic Nerves of the Thorax Sympathetic Trunk Branches of sympathetic trunk to thoracic plexuses  Lesser

Branches of sympathetic trunk to

thoracic plexuses Lesser splanchnic nerve

formed by preganglionic fibers from T10~T12 ganglia, and relay in

aorticorenal ganglion.

The postganglionic fibers supply the liver, spleen, kidney and

alimentary tract as far as the left

colic flexure.

Surface Landmarks

Surface Landmarks
Surface Landmarks
Surface Landmarks

Structure/Space

Description/

Significance

Boundaries

Midaxillary line

Imaginary vertical line

Used as a surface

passing through the

landmark for descriptive

middle of the axilla

purposes

Midclavicular line

Imaginary vertical line passing through the

Used as a surface landmark for descriptive

midshaft of the clavicle

purposes

Nipple

Located superficial to the

1) left nipple - apex of the

4th intercostal space in

heart, 8 cm from the

the male and prepuberal female

midline (L) 5th ICS 2) surface landmark - for

auscultation of the

bicuspid valve

Surface Landmarks
Surface Landmarks
Surface Landmarks
Surface Landmarks
Surface Landmarks

Structure/Space

Description/

Significance

Boundaries

Sternal angle

A protrusion on the

1) location of the

anterior thoracic wall at

attachment of the

the junction of the manubrium and body of

costal cartilage of the 2nd rib to the sternum;

the sternum

2) T4/T5 intervertebral

(manubriosternal

disc

symphysis)

3) marks the inferior

boundary of the superior mediastinum

Suprasternal notch

Notch located at the superior border of the

Also known as: jugular notch

manubrium of the

sternum, between the

sternal ends of the

 

clavicles

 
Surface Landmarks
Surface Landmarks
Surface Landmarks
Surface Landmarks Counting ribs
Surface Landmarks
Counting ribs

Knowing how to count ribs is

important because different ribs

provide palpable landmarks for

the positions of deeper

structures.

To determine the location of specific ribs, palpate the

jugular notch at the superior extent of the manubrium of

the sternum.

the location of specific ribs, palpate the jugular notch at the superior extent of the manubrium
Surface Landmarks Counting ribs
Surface Landmarks
Counting ribs

Move down the sternum until

a ridge is felt. This ridge is the

sternal angle.

The costal cartilage of rib 2

articulates with the sternum at

this location.

Identify rib 2.

Then continue counting the ribs, moving in a downward

and lateral direction.

at this location.  Identify rib 2.  Then continue counting the ribs, moving in a
Surface Landmarks T4-T5 Level
Surface Landmarks
T4-T5 Level

The T4/5 vertebral level is a transverse plane that passes

through the sternal angle on the anterior chest wall and

the intervertebral disc between T4 and T5 vertebrae

posteriorly.

through the sternal angle on the anterior chest wall and the intervertebral disc between T4 and
Surface Landmarks T4-T5 Level
Surface Landmarks
T4-T5 Level

At the T4/5 level):

costal cartilage of rib 2

articulates with the sternum

superior mediastinum is

separated from the inferior

mediastinum

ascending aorta ends and the arch of aorta begins

arch of aorta ends and the

thoracic aorta begins

trachea bifurcates.

aorta ends and the arch of aorta begins  arch of aorta ends and the thoracic
Surface Landmarks Heart
Surface Landmarks
Heart

Surface landmarks can be palpated to visualize the outline

of the heart:

The upper limit of the heart reaches as high as the 3rd costal cartilage on the (R) side of the sternum and the

2nd ICS on the (L) side of the sternum.

Surface Landmarks Heart
Surface Landmarks
Heart

The lower margin of the heart extends from the sternal

end of the (R) 6th costal cartilage to the apex in the 5th

ICS near the midclavicular line.

heart extends from the sternal end of the (R) 6th costal cartilage to the apex in
Surface Landmarks Heart
Surface Landmarks
Heart

The right margin of the heart extends from the (R) 3rd

costal cartilage to near the (R) 6th costal cartilage.

The left margin of the heart descends laterally from the 2nd ICS to the apex located near the midclavicular line

in the 5th ICS.

margin of the heart descends laterally from the 2nd ICS to the apex located near the
Surface Landmarks Heart Sounds
Surface Landmarks
Heart Sounds

To listen for valve sounds, position the stethoscope downstream from the flow of blood through the valves. The tricuspid valve is heard just to the left of the lower part of the sternum near the 5 th ICS.

Surface Landmarks Heart Sounds
Surface Landmarks
Heart Sounds

The mitral valve is heard over the apex of the heart in the (L) 5th ICS at the midclavicular line.

Heart Sounds  The mitral valve is heard over the apex of the heart in the
Surface Landmarks Heart Sounds
Surface Landmarks
Heart Sounds

The pulmonary valve is heard over the medial end of the (L) 2nd ICS.

Surface Landmarks Heart Sounds  The pulmonary valve is heard over the medial end of the
Surface Landmarks Heart Sounds
Surface Landmarks
Heart Sounds

The aortic valve is heard over the medial end of the (R) 2 nd ICS.

Surface Landmarks Pleura & Lungs
Surface Landmarks
Pleura & Lungs

Palpable surface landmarks can be used to visualize the normal outlines of the pleural cavities

and the lungs and to determine the positions of the

pulmonary lobes and fissures.

normal outlines of the pleural cavities and the lungs and to determine the positions of the
Surface Landmarks Pleura & Lungs
Surface Landmarks
Pleura & Lungs

Superiorly, the parietal pleura projects above the

first costal cartilage.

Anteriorly, the costal pleura approaches the midline posterior to the upper portion of the sternum.

costal cartilage.  Anteriorly, the costal pleura approaches the midline posterior to the upper portion of
Surface Landmarks Pleura & Lungs
Surface Landmarks
Pleura & Lungs

Posterior to the lower portion of the sternum, the left parietal pleura does not come as close to the

midline as it does on the right side. This is because the heart bulges onto the left side.

Surface Landmarks Pleura & Lungs
Surface Landmarks
Pleura & Lungs

Inferiorly, the pleura reflects onto the diaphragm above the costal margin and courses around the

thoracic wall following an VIII, X, XII contour (i.e. rib

VIII in the midclavicular line, rib X in the midaxillary

line, and vertebra TXII posteriorly).

Surface Landmarks Pleura & Lungs
Surface Landmarks
Pleura & Lungs

In the posterior view, the oblique fissure on both

sides is located in the midline near the spine of

vertebra T4.

It moves laterally in a downward direction, crossing

the 4th and 5th ICS and reaches rib 6 laterally.

Surface Landmarks Pleura & Lungs
Surface Landmarks
Pleura & Lungs

In the anterior view, the horizontal fissure on the right side follows the contour of rib 4 and costal

cartilage and the oblique fissures on both sides follow the contour of rib 6 and its costal cartilage.

of rib 4 and costal cartilage and the oblique fissures on both sides follow the contour
Surface Landmarks Lung Sounds
Surface Landmarks
Lung Sounds

The stethoscope placements for listening for lung sounds anteriorly are shown below.

Surface Landmarks Lung Sounds
Surface Landmarks
Lung Sounds

The stethoscope placements for listening for lung sounds posteriorly are shown below.

Thank you for listening

AUF School of Medicine

Department of Anatomy