The Thoracic

The thoracic wall is wall

formed of:
1.The thoracic cage
which is
formed of:
A. Sternum & costal cartilages
anteriorly
B. Ribs on either
side

C. Vertebral column
posteriorly
 The Thoracic
The thoracic wall is wall
formed of:
1.The thoracic cage
2. Intercostal
muscles
3. Intercostal vessels
&nerves
 The Thoracic
The thoracic wall is wall
formed of:
1. The thoracic cage which is formed of:
A. Sternum & costal cartilages
anteriorly
B. Ribs on either side
C. Vertebral column posteriorly

2. Intercostal muscles
3. Intercostal vessels and nerves
 Vertebral column
The vertebral column is situated in the posterior part
of the trunk, its
average length is 70 cm in males and 60 cm in females.
Parts:
A. Separate
vertebrae
7 cervical vertebrae
12 thoracic vertebrae
5 lumbar vertebrae
B. Fused vertebrae
Sacrum: 5 sacral pieces fused together
Coccyx: 3-4 pieces fused together
Curves of vertebral
column
Primary curves
A. Thoracic & sacral forward
concavity
They are present in the fetus and
persist after birth.They are caused
by the flexure attitude of the
fetus in the uterus
Secondary curves
1. Forward cervical
convexity
It appears at the third
month after birth when the
child raises his head
 Curves of vertebral
column
Secondary curves (cont)
2. Forward lumbar
convexity
It starts to appear when the baby
starts to sit, stand and walk.

Significance of secondary
curves:
1. They give resilience to the
vertebral
column
2. They act as shock absorbing
mechanisms
Curves of vertebral
column
Primary curves

Primary curve
(thoracic and sacral forward concavities
Thoracic and sacral kyphosis
 Curves of vertebral
column
secondary curves

1. Forward cervical convexity (Cervical

lordosis)

Cervical curve
(when supporting his neck)
(3rd month)
 Curves of vertebral
column
secondary curves

1. Forward lumbar convexity (Lumbar

lordosis)

(Lumbar curve)
(on sitting & standing)
(15 months)
Features of a typical
vertebra
 Features of a typical
Any
vertebra
vertebra has:
1. Body:
- It transmits the body weight.
- Its upper & lower surfaces are flattened for intervertebral discs.

Body
 Features of a typical
Any
vertebra
vertebra has:
2. Vertebral foramen:
Contains
- Spinal cord & its meninges.

- Arteries and veins of the spinal cord

- Roots and ganglia of spinal nerves.

- Loose fatty tissue.

 Features of a typical
Any
vertebra
vertebra has:
3. Vertebral arch: formed
of: A- Two pedicles
Their upper and lower borders are notched (vertebral
notch). The articulation between many vertebrae
converts the notches into intervertebral foramina
for transmission of spinal nerves.
 3- A: Two pedicles

Their upper and lower borders are

notched (vertebral notch). The
articulation between many vertebrae
converts the notches into inter-
vertebral foramina for transmission
of spinal nerves.
 Features of a typical
Any
vertebra
vertebra has:
3. Vertebral arch: formed
of:
A- Two pedicles

B- Two laminae: They fuse posteriorly to

form the spine
 Features of a typical
Any
vertebra
vertebra has:
3. Vertebral arch: formed
S.A.P.
of:
A- Two pedicles

B- Two laminae:

C- Seven bony processes

T.P
.
i. 2 sup. Articular: with
post.facets
ii. 2 inf. Articular: with
anterior facets I.A.P.
iii. 2 transverse processes
Spine
iv. Spine
 Articulations between
vertebrae
Fibrous :
1-Anterior longitudinal ligament.
2-Posterior longitudinal ligament.
3-Interspinous ligament.
4-Supraspinous ligament.
5-Intertransverse ligament.
5 1 6-Ligamentum flavum.
Cartilagenous:
2 I.V. Intervertebral discs.
I.V. Synovial :
Plane joint between superior
and inferior articular processes.

3
4
 Articulations between
Synovial plane vertebrae
joints: Between superior and
inferior articular processes of succeeding vertebrae

Cartilagenous joints: (intervertebral discs):

Between bodies of vertebrae. They measure ¼ the length of
the vertebral column
Fibrous ligaments:
A. Anterior longitudinal
ligament
B. Posterior longitudinal
ligament
C. Ligamenta flava: Between
laminae
D. Intertransverse ligaments
E. Interspinous ligaments
F. Supraspinous ligaments
 Articulations between
vertebrae

Supraspinou
s
Anterior
longitudinal ligaments
Interspinou
ligament s

ligaments
 Articulations between
vertebrae

Posterior longitudinal Ligamenta

ligament flava
 Movements between
thoracic vertebrae
Flexion and extension
Lateral flexion
Features of a typical
thoracic vertebrae
 Features of a typical
thoracic vertebrae
Body:
Heart-shaped with upper & lower demifacets on sides of
the body
Vertebral foramen: Rounded

Vertebral arch:
- Transverse processes with facets on it

- Spine, directed downwards and backwards

Features of a typical
cervical vertebra

- Oval body

- Large, triangular v.
foramen
- Foramina transversaria
- Short, bifid spine
 Features of a typical
cervical vertebra
Body: Oval body, with no facets

Vertebral foramen: large,triangular

Vertebral arch:
- Transverse processes having foramina transversaria

- Spine, short and bifid

 Features of a typical
lumbar vertebra

Kidney -
shaped
Long , narrow
body transverse
process

Small
triangula
r
Horizontal
spine
 Features of a typical
lumbar vertebra
Body: Large, kidney-shaped with no facets

Vertebral foramen: Small ,triangular

Vertebral arch:
- Transverse processes: Narrow with mamillary processes.

- Spine, Horizontal and quadrangular

How to know a given vertebra
1. Look to transverse
processes

Foramen No
transversarium foramen

(Cervical) 2. Look to side of

body
Facet (s) No
facets

•No body. Dens Long spine

•No spine. horizontal
not bifid

(Lumbar)
(1st) (2nd) (7th) (Thoracic)
(Atlas) (Axis)
 Cervical vertebrae
First cervical vertebra (Atlas)
No body
Kidney-shaped
No spine occipital facets
 Cervical vertebrae
second cervical vertebra (Axis)
Has odontoid
process
Odontoid
process
 Typical cervical vertebrae
(3-6)
Has the features of a typical cervical
vertebra
- Oval body

- Large, triangular v.
foramen
- Foramina transversaria

- Short, bifid spine

 Seventh cervical vertebrae
(7)
Has long horizontal spine and not
bifid.

Long
horizontal
spine , not
bifid
 Thoracic vertebrae

Firs 2-8
t 9

10 11 12
 Lumbar vertebrae

Typical ( 1
-4)
5

Short, broad transverse

process

Long, narrow transverse

process
 Ribs
True ribs (1-7):
Connected
with sternum
through
False costal
ribs (8-cartilages
10): their
costal
cartilages join
costal
cartilages
Floating ribs (11-of
12):ribs
aboveno
Have
connection with
sternum
 Features of a
typical rib
Outer Tubercle Demi facet
surface Neck Ridge
Demi facet
Head
posterior
end

Inner Upper
surface border

Anterior
Lower end
border
Costal
groove
 Features of a
typical rib
1. Anterior end: Cup-shaped, articulates with costal
cartilages
2. posterior end: with head ,neck, and tubercle

Head: Has 2 demifacets and a ridge inbetween

A- Lower facet articulates with body of corresponding vertebra

Upper facet articulates with body of vertebra above

Ridge articulates with I.V.D. between the two vertebrae

Head articulates with I.V.D. & both vertebrae by triradiate ligaments

Triradiate
ligaments
 Features of a
2. posterior
typical rib
end: with head ,neck, and tubercle
Head:

Neck: Next to head, connected to

- Transverse process of corresponding vertebra by inf. costotransverse lig.

- Transverse process of vertebra above by sup. costotransverse lig.

 Ligaments of neck of
ribs

Transverse
process

2a Triradiate
ligament
2b Neck of the rib
2c Tubercle of the rib

2a Superior costo-transverse ligament

Rib 2b Inferior costo-transverse ligament
2c Lateral costo- transverse ligament
 Ligaments of neck of
ribs
-Connected to Transverse
process of vertebra above
by sup. costotransverse lig.
 Features of a
2. posterior
typical rib
end: with head ,neck, and tubercle
Head:

Neck: Next to head

Tubercle: has:
-Medial smooth articular facet for articulation of transverse process of
corresponding vertebra

-Lateral rough non articular part connected to tip of transverse process of

corresponding vertebra by lateral costotransverse ligament
 Features of a
1. Anterior end:
typical rib
2. posterior end: with head ,neck, and tubercle
3. Shaft: With

Upper border: Rounded and thick

Lower border: Sharp
Outer surface: Convex
Inner surface: Concave,grooved along its lower border by
the costal
groove containing VAN from above
downwards
Angle of the rib: About 5-6 cm anterior to the tubercle
 Atypical ribs
First rib
The shortest and most curved and flattened rib

Subclavius
muscle
Scalenus Head
anterior
Neck

V.
tuberc
le
A.
Scalenus
Serratus medius
anterior ( 1st
digit )
 Atypical ribs
First rib
Anterior end: Larger than any other rib
Posterior end: Has head(with only one facet), neck,
tubercle
(coincides with the angle)
Shaft:With

-Upper surface with 2 grooves (subclavian vein anteriorly and subclavian

artery & lower trunk of brachial plexus posteriorly)

-Lower surface: Smooth lying on the pleura.

-Inner border with scalene tubercle between the 2 grooves

-Outer border
 Atypical ribs
First rib
Particular features of the first rib
-2 insertions : Scalenus anterior and scalenus medius

-2 origins : Subclavius and first digit of serratus anterior

-2 grooves : Subclavian vein anteriorly and subclavian artery &

lower trunk of brachial plexus posteriorly

-2 membranes :Pleura related to lower surface and suprapleural

membrane attached to inner border

N . B .: First rib is rarely

fractured ( why ? )
 Atypical ribs
Second rib

Serratus
anterior
( 1st
digit ) Scalenus
posterior

Serratus
anterior
(2 nd
digit )
 Atypical ribs
Second rib
Its surfaces and borders are midway between first and other ribs
At middle of outer surface is the scalene tuberosity(insertion of
scalenus posterior)

Anterior to scalene tuberosity origin of 1st & 2nd digits of serratus

anterior muscle.
Costal groove is poorly developed.
 Atypical ribs
Tenth , eleventh and twelfth
ribs

10

11

12
 Atypical ribs
Tenth , eleventh and twelfth
ribs
10 11 12

Head One facet only One facet only One facet only

No neck No neck No neck

Faint tubercle No tubercle No tubercle

Costal groove is Faint costal No costal groove

present groove
 Ribs
The longest rib : 7
The most laterally
projected rib : 8
The most oblique rib : 9
The lowest rib anteriorly :
10
 Rib fractures
Ribs liable to fractures are middle ribs
(Why)
Weakest point of the rib is just anterior
to its angle
Direct trauma may fracture the rib anywhere
A fractured rib may injure lung, spleen or
liver
Lower rib fractures may injure the
diaphragm
Rib fractures are very painful (why ?)
 Abnormal ribs
Cervical rib
Bony or fibrous band attached to 7th cervical transverse process

It may have no symptoms

It may compress structures on upper
surface of first rib:

-Compression of subclavian
artery--- Ischaemia of upper limb

-Compression of subclavian vein

---- Oedema of upper limb
-Compression of lower trunk-----
numbiness on medial side of upper
limb
 The sternum
Suprasternal
notch
Clavicular
notch

Manubrium Sternal angle

sterni 2nd costal

cartilage

3rd costal cartilage

4th costal cartilage

Body
5th costal cartilage

6th costal cartilage

7th costal cartilage

Xiphoid
process
Lateral
Anterior view view
 The sternum
Dagger like bone in middle of front of thoracic cage.

Convex in front,concave behind

Has manubrium, body and xiphoid process

Manubrium lies opposite 3-4 thoracic vertebrae

Body lies opposite 5-8 thoracic vertebrae, formed of 4 pieces,

(sternebrae) which fuse together between puberty and 25 years
Xiphoid process lies opposite 9th thoracic vertebra, cartilagenous
in youth but more or less ossified in adults
 The sternum
Particular
features
Sternomastoid Sternohyoid
Sternothyroid

Pectoralis
major
Sternocostalis

Rectus Diaphragm
abdominis

Anterior Posterior
surface surface
 The sternum
Important
relations
Left common carotid artery
Brachiocephalic artery
Left subclavian artery
Left brachiocephalic
vein Aortic arch
Right lung Left lung

Right pleura Left pleura

Pericardium

Liver
 Intercostal
muscles
External intercostal
muscles
Eleven in number on each side.

Origin: From lower border of rib above

Direction: Downwards,forwards

Insertion: : Upper border of rib below

Continues : As anterior intercostal

membrane which is attached to side of
the sternum
 Intercostal
muscles
Ext . intercostal
muscles
Sternum

External
intercostal
membrane

External
intercostal
 Intercostal
muscles
internal intercostal
muscles
Inner view

Internal intercostal
 Intercostal
muscles
internal
intercostal
Eleven in number on each side.
muscles
Origin: From floor of costal groove of rib above
Direction: Downwards,backwards

Insertion: : Upper border of rib below

Continues: At angles of ribs it continues as posterior intercostal
membrane
 Intercostal
muscles
Inner most
intercostal
muscles
Sternocostalis

Sternocostalis(transversus
thoracis), formed of 5 slips
arising from back of body of
sternum to be inserted into
costal cartilages from 2-6 ribs
 Intercostal
muscles
Inner most intercostal
muscles
Posterior intercostal
membrane

Subcostalis

Pleura
E
Intercostalis intimus
I

Sternocostalis

Anterior
Sternum intercostal
membrane
 Intercostal
muscles
Inner most intercostal
muscles
A. Sternocostalis

B. Intercostalis intimus: Attached to inner surfaces of 2

succeeding ribs, present in middle intercostal spaces, separates
intercostal vessels and nerves from pleura.

C. Subcostalis: Well developed only in lower part of the

thorax, it arises from inner surfaces of ribs above to inner
surfaces of ribs below.
 Intercostal
muscles
Nerve supply of intercostal muscles :
By collateral branches from corresponding
intercostal nerves
Actions of intercostal muscles :
Elevation of ribs but the inner most
intercostal depresses the ribs
Neurovascular bundle ( VAN ): Lies
between internal intercostals and inner
most intercostals.
 Typical intercostal
nerves ( 3 - 6 ) Intercostal nerve

Posterior
intercostal
membrane
.

In.
1: Lateral cutaneous branch
1a Posterior division Intercostal I.
1b Anterior division nerve 1a
2: Anterior cutaneous branch
2a Lateral branch
2b Medial branch 1
Pleura
E.
1b
2

2a

Sternum Anterior
2b intercostal
membrane
 Typical intercostal
Branches : nerves ( 3 - 6 )
1. White rami communicans to sympathetic ganglia near them
2. Receive grey rami communicans from sympathetic ganglia
3. Collateral muscular branches to intercostal muscles.
4. Lateral cutaneous branches, arise before angles of ribs. Divide
into anterior & posterior branches to supply side of thorax.
5. Anterior cutaneous branches, divide into medial & lateral
branches to supply front of thorax.
6. Articular to joints of ribs.

The lower intercostals : Supply as well

7. Muscular branches to anterior abdominal muscle
8. Sensory branches to parietal pleura & costal part of diaphragm
 Atypical intercostal
nerves
The first : It joins the brachial plexus
The second : Its lateral cutaneous branch does not
divide, it forms the intercostobrachial nerve which
supplies the floor of the axilla
The lower 5 intercostals : they supply
muscles of anterior abdominal wall
 Anterior intercostal
arteries
Subclavian artery

Subclavian
artery
1
2

Internal
3
mammary
artery
Anterior
4
intercostal
arteries
5

7
Superior
epigastric

Musculophrenic
 posterior intercostal
arteries
Superior intercostal artery
Subclavian artery
1 2
Arch of aorta 3

6
Descending
thoracic aorta 7

10

11

12
Anastomosis between intercostal
arteries
1
Descending
aorta

2 1a
2

Internal
mammary artery
Sternum

1 Posterior intercostal artery

1a collateral branch
2 Pair of anterior intercostal
arteries
 Intercostal arteries
Anterior intercostal arteries Posterior intercostal arteries
1. Pair in every space. 1. Single, but gives collateral branch.

A. Upper one anastomoses with the

posterior intercostal artery.
B. Lower one anastomoses with the
collateral branch of posterior
intercostal artery.

2. 9 in number (10 ribs anteriorly) from:

A. Upper 6, from internal mammary. 2. 11+ subcostal
A. Upper (12superior
2 from ribs behind).
intercostal.
B. Lower 3, from musculophrenic. B. 3-12 from descending aorta.
Intercostal arteries
Internal mammary
artery
Subclavian artery

Subclavian
artery
1
2

Internal
mammary 3
artery Anterior
4
intercostal
arteries
5

Superior 7
epigastric

Musculophrenic
 Internal mammary
Branches
artery
1. 6 pairs of anterior intercostal arteries to upper 6 spaces
2. Perforating branches, pierce pectoralismajor supplying it &
overlying skin, 2-4th in females supply the breast
3. Sternal branches to transversus thoracis and back of sternum
4. Pericardial branches to upper part of pericardium.
5. Mediastinal branches to ant. mediastinum & thymus
6. Pericardiophrenic: accompanies phrenic nerve to supply
diaphragm as well as the pericardium.
Branches of musculophrenic artery

1. 3 pairs of anterior intercostal arteries to lower 3 spaces

2.Pericardial branches
To anterior abdominal wall muscles.
 Intercostal veins
Anterior intercostal veins

Follow anterior intercostal arteries:

A .7-9 anterior intercostal veins end in

musculophrenic
vein
B. 1-6 anterior intercostal veins end in
internal mammary
vein
 Intercostal veins
posterior intercostal veins

I.J I.J R.B.: Right brachiocephalic vein

L.B.: Left brachiocephalic vein
S.C L.B I.J.: Internal jugular vein
R.B S.C.: Subclavian vein
1 S.C
S. A. S 1 S.V.C.: Superior vena cava
2 S.: Superior intercostal vein
3 2
A.: Arch of azygos vein
4 3 AZ.: Azygos vein
S.V.C.
5 5 4 A.H.: Accessory hemiazygos vein
H.: Hemiazygos vein
6 6 I.V.C.: inferior vena cava
AZ A.L.: Ascending lumbar vein
7 7
A.H.
8 8
Right H. Left
9 9
10 10
11 11

12 12
I.V.C. A.L
A.L.
 Intercostal veins
posterior intercostal veins

Posterior intercostal veins

Right side Left side
1st: Ends in right brachiocephalic. 1st: Ends in left brachiocephalic.
2,3,4 end in superior intercostal vein 2,3,4 end in superior intercostal vein
 arch of azygos.  left brachiocephalic vein.

5-12 end separately into azygos vein. 5-8 end in accessory hemiazygos vein
9-12 end in hemiazygos vein
 Azygos vein

Origin :

1. Back of I.V.C. opposite L2 vertebra

2. As continuation of right subcostal vein

3. Union of right subcostal & righr ascending lumbar veins

Azygos vein Azygos vein

Azygos vein Heart

I.V.C. Diaphragm
Subcostal Ascending lumbar Subcostal vein
vein vein
 Azygos vein

S.V.C
.
Posterior
intercostal veins
Azygos
vein

I.V.C
.
 Azygos vein

Course :

Trache
a

Right Left
bronchus bronchus

Esophagus
Azygos vein
Thoracic
duct
Diaphragm
Azygos vein

S.V.C
.
Arch of azygos
vein

Root of right
lung

Azygos vein
 Azygos vein

Course :
Hilum of
- It enters the thorax through lung
aortic opening of diaphragm.

- It ascends in
Arch of
the posterior mediastinum azygos
on the right side of
descending aorta and veinEsophagu
thoracic duct and behind s
the right border of the Azygos vein
esophagus and behind the
hilum of the right lung.
Diaphragm
At the level of T4 vertebra,
it arches forwards above
the hilum of the right lung
to join the back of S.V.C.
 Azygos vein

Tributaries :
1. Right ascending lumbar
2.Right subcostal
3.Right posterior intercostal veins from 5-11
4.Right superior intercostal
5. Mediastinal veins
N.B.: The left bronchial vein joins the left
superior intercostal or hemiazygos vein
6. Esophageal veins
7. Pericardial veins
8. Right bronchial veins
9. Hemiazygos vein
10. Accessory hemiazygos vein
 Hemiazygos ( Inferior hemiazygos) vein

Origin : It arises either

from
Left renal
I.J I.J

Union of left ascending lumbar & S.C L.B

R.B
left subcostal veins 1
S 1
S.C
2 S. A.
2
Course : 3
4
S.V.C.
3
5 5 4

6 6
It ascends through the left crus AZ
7 7
of the diaphragm till the level of 8
A.H.
8
lower border of T8 vertebra Right H. Left
9
where it curves to the right 9
10 10
behind the aorta, esophagus 11 11
and thoracic duct to end in the
azygos vein. 12 12
I.V.C. A.L
A.L.
 Hemiazygos ( Inferior hemiazygos) vein

Tributaries :
1. Left ascending lumbar
I.J I.J

2. Left subcostal S.C L.B

R.B
1 S.C
1
3. Posterior intercostal veins 9-11 2 S. A. S
3 2
4 3
4. Esophageal veins S.V.C.
4
5 5

5. Mediastinal veins 6
AZ
6
7 7
A.H.
8 8
Right H. Left
9 9
10 10
11 11

12 12
I.V.C. A.L
A.L.
 Accessory hemiazygos vein

Origin , course and

end :
It receives posterior intercostal veins from I.J I.J
5-8 spaces. It descends on the left side of S.C L.B
the vertebral column till the level of upper R.B
1 S.C
border of T8 vertebra. It curves to the 2 S. A. S 1
right behind the aorta, esophagus and 3 2
thoracic duct to end in the azygos vein. 4
S.V.C.
3
5 5 4

Tributaries : 6
7
AZ
6
7
A.H.
8 8
5-8 left posterior intercostal veins Right H. Left
9 9
Sometimes left bronchial vein 10 10
11 11

12 12
I.V.C. A.L
A.L.
 Thoracic cavity
Boundaries

Anteriorly: Sternum & costal

cartilages

Posteriorly: Thoracic vertebrae

On either side: Ribs
Above: Thoracic inlet
Below: Diaphragm( thoracic outlet
 Thoracic inlet
Boundaries:
T1 1s
Anteriorly: Upper border of t
manubrium sterni 1s
t M
Posteriorly: Upper border of 1st
thoracic vertebra
On either side: Inner borders of
both first ribs
and
their costal
cartilages
 Thoracic 4b
inlet
Structures passing:
3
1. Trachea 1
4a
2. Esophagus. 4c
3. Thoracic duct.
4. Arteries:

4a.Brachiocephalic
4b.Lt. C. carotid
4c.Lt. subclavian
4d: Int. mammary
4e: Thyr. Ima if present
 Thoracic
inlet
Structures passing:
6a
6b 6b
6a

5. Veins

5..Brachiocephalic 5 5

6. Nerves
6c
6a : Phrenic nerves
6b..Vagi
6C..lt. rec. laryngeal.
6d..Sym. chain
 Thoracic inlet
Structures passing in the thoracic inlet:

1. Trachea.
2. Esophagus.
3. Thoracic duct.
Apex of both lungs and their cervical pleurae.
4. Arteries:
A. brachiocephalic,
B. left common carotid
C. left subclavian arteries).
D. Thyroida ima artery (if present).
E. Internal mammary artery.
F. Superior intercostal artery.
 Thoracic inlet
Structures passing in the thoracic inlet:

5. Veins: A. brachiocephalic vein.

B. Inferior thyroid veins.
6. Nerves:
A.Phrenic nerves
B. Vagi
C. Left recurrent laryngeal nerve
D. Sympathetic chain of both sides.
7. Muscles:
A. Lower parts of sternohyoid and sternothyroid muscles.
B. Longus coli muscle.
8. Remains of thymus gland.
9. Suprapleural membrane (closes the lateral part of the inlet).
Suprapleural membrane
Transverse process
C7

Suprapleural
T1 membrane

1st rib
 Suprapleural
membrane ( Sibson ’ s fascia
Tent-shaped strong membrane which closes the lateral part of
the thoracic inlet

Attachments

Medially: Attached to fascia investing structures passing in thoracic inlet.

Laterally: Attached to inner borders of 1st ribs and their costal cartilages.
Posteriorly: The apex of the membrane is attached to the 7th cervical
transverse processes.

Importance of the membrane

1. It protects the cervical pleura.
2. Resists changes in intrathoracic pressure during respiration.
Thoracic outlet ( Diaphragm )
Sternal
origin
Central
tendon costal
Median origin
arcuate
lig .

Right
crus left
crus

Med . arcuate
Lat . arcuate lig .
lig .
 Thoracic outlet ( Diaphragm )
Is a thin muscle which separates the abdominal cavity
from the thoracic cavity. It forms a concave roof for the
abdomen and convex floor for the thorax. This floor is
elevated on the right side (due to the presence of the
liver) to form the right cupula of the diaphragm.
Origin:

Sternal origin: 2 slips from back of xiphoid process

Costal origin: Inner surfaces of lower 6 ribs interdigitating with ..
vertebral origin:
1. Right crus: from anterolateral surfaces of upper 3 lumbar vertebrae
2. Left crus: from anterolateral surfaces of upper 2 lumbar vertebrae
 Thoracic outlet ( Diaphragm )
Origin:

vertebral origin:
1. Right crus: From anterolateral surfaces of upper 3 lumbar vertebrae
2. Left crus: From anterolateral surfaces of upper 2 lumbar vertebrae
3. Median arcuate ligament: Arches over aorta between the 2 crura
4. Medial arcuate ligaments: Arch over psoas major from tendineous
part of the corresponding crus and 1st lumbar transverse process

5. lateral arcuate ligaments: Arch over quadratus lumborum from 1st

lumbar transverse process to last rib

Insertion: Into the central tendon

 Thoracic outlet ( Diaphragm )
N.B:

Between the vertebral and costal origins, there is a

triangular gap (vertebro-costal triangle). Through
this gap abdominal contents may herniate into the
thorax.

Nerve supply

Phrenic nerve (motor)

Lower 6-7 intercostal nerves (sensory) to peripheral

parts of the diaphragm
 Thoracic outlet ( Diaphragm )
Arterial supply:

1. Inferior phrenic (From abdominal aorta)

2. Superior phrenic (From lower part of thoracic aorta)
3. Pericardiophrenic (From internal mammary)
4. musculophrenic (From internal mammary)
5. Superior epigastric (From internal mammary)
6. Lower 3 posterior intercostal arteries
7. Upper 2 lumbar arteries
Movements of respiration
Vertebra
Vertebral
column

Rib

Sternum Rib
Sternum
Combination of movements in
inspiration

Inspiration Expiration
 Movements of respiration
Quiet inspiration:

The first rib remains relatively fixed

Ribs from 2-7 are elevated and everted by intercostals leading to
increase of the anteroposterior diameter of thoracic cavity.

Movements of lower ribs result in increase of the transverse diameter of

the thoracic cavity.

Descent of diaphragm by its contraction increases the vertical diameter

Deep forced inspiration: accessory muscles of respiration work

Contraction of scalene muscles, sternomastoid, & pectoralis major

increase the vertical diameter of the thoracic cavity.

Contraction of serratus anterior increases the transverse diameter of

the thoracic cavity
 Movements of respiration
Quiet expiration:

Is a passive process resulting from elastic recoil of the lung

Forced expiration

Contraction of abdominal muscles increase the intra-abdominal

pressure and push the diaphragm upwards thus decreasing the vertical
diameter of the thoracic cavity
 Movements of
respiration
Sternomastoi
d
Scalene
muscles
Deep forced inspiration:
accessory muscles of
respiration work

Forced expiration

Abdominal
muscles
 Major openings of the
diaphragm

I.V.C. esophage
opening alopenin
g

Aortic
openin
g
 Major openings of the
diaphragm
I.V.C. opening Esophageal opening Aortic opening

One inch to right of One inch to left of middle Exactly in middle line
middle line line
At lower border of At lower border of
T8 At lower border of T10 T12

In central tendon In right crus of diaphragm Behind median

arcuate lig.
Transmits Transmits
I.V.C. Esophagus Transmits
Right phrenic nerve Ant. & post. Gastric Aorta
Lymph vessels nerves. Thoracic duct
Esophageal vessels Vena azygos
Lymph vessels
 Minor openings of the
diaphragm
X Superior epigastric artery
7 7 Musculophrenic artery
8 8
C.T Intercostal nerves
9 9
Right phrenic
I.V.C. 10
1 Esophagus
0
S 11
1
Right crus 1 S
Left crus
1 12
First lumbar transverse process
Quadratus 2 H
lumborum X.: Xiphoid process
Sy S. 7-12.: 7-12 ribs
S. Sy m
A C. S.C.: Subcostal nerve
C. m
Sym.:Sympathetic chain
V.
Psoas H.: Hemiazygosvein
Th
major
S.: Splanchnicnerves

Th: Thoracic duct.

V.: Vena azygos
A.: Aorta
C.T.: Central tendon
 Minor openings of the
diaphragm
1. Between sternal and costal origins: For superior epigastric artery.
2. Between 7th and 8th slips of costal origins: For musculophrenic artery.
3. Between all slips of costal origin: For lower 5 intercostal nerves.
4. Behind lateral arcuate ligament: For subcostal nerve and vessels.
5. Behind medial arcuate ligament: For sympathetic chain.
6. The greater and lesser splanchnic nerves pass through the corresponding
crus of the diaphragm.
7. The inferior hemiazygos vein passes through the left crus to enter the thorax.
 Diaphragmatic hernias
1. Congenital hernia:
A. Parasternal hernia.
B. Hiatus hernia (congenitally large esophageal opening).

2. Acquired hernia.
A. Sliding esophageal hernia: The esophageal opening is large, the stomach &
lower part of the esophagus slide upwards into the thorax  acid reflux 
severe esophageal ulcerations.
B. Rolling para-esophageal hernia: The fundus herniates through
esophageal opening  no acid reflux.

Paralysis of the
diaphragm
Each dome of the diaphragm has a separate nerve supply.
- Paralysis of half of the diaphragm because of injury of its phrenic nerve does not
affect the other half.
- The paralyzed dome is pushed superiorly on inspiration by the abdominal viscera
(instead of descending).this occurs because the abdominal viscera are compressed
by the active side . During expiration,it falls down in response to the positive
pressure in the lungs !.
 Division of thoracic
cavity
The thoracic cavity is divided into:
1, Right and left parts, containing
M.
both pleurae and lungs.
2. Median part (mediastinum).

Pleurae
& lungs