THORAX

Crisle Dychingco, MD, DPBS

Department of Anatomy
AUFSOM
THORACIC WALL
 Thoracic Wall

Bones
Joints
Muscles
Blood Vessels
Lymphatic Drainage
 Bones of the Thoracic Wall

Click to edit Master text styles Sternum

Second level
● Third level Ribs
● Fourth level

● Fifth level
Costal cartilages
 Sternum

Click to edit Master text styles 1. Manubrium

Second level Body, clavicle, 1st costal and
● Third level
upper part of 2nd costal
● Fourth level cartilage
● Fifth level
Sternal angle of Louis
2nd costal cartilage
Intervertebral disc T4-T5
Jxns of asc aorta and aortic arch,
aortic arch and desc aorta
Tracheal bifurcation
Jxn of sup and inf mediastnum
 Sternum

Click to edit Master text styles 2. Body of Sternum

Second level Manubriosternal jt
● Third level
Xiphisternal jt
● Fourth level
2nd-7th costal cartilages
● Fifth level
Site for marrow biopsy

3. Xiphoid Process
Thin cartilage plate
Ossified at proximal end
No rib or costal cartilage attachments
 Ribs

12 pairs
All attached to thoracic vertebrae
True
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1st 7 pairs
Second level
●

● Attached to sternum via costal

cartilages ● Third level

False ● Fourth level

● 8th-10th pairs ● Fifth level
● Attached to each other and to 7th rib
above
Floating
● 11th-12th ribs
● No anterior attachment
 Typical Rib
Long twisted flat bone
Click to edit Master text styles Rounded superior
Second level Grooved inferior
● Third level
Costal groove
● Fourth level
Intercostal vessels and nerve
● Fifth level
Head, neck, tubercle, shaft and
angle
Click to edit Master textHead
styles
with 2 facets for articulation with
corresponding vertebra and vertebra
Second level above
● Third level
Tubercle has facet with corresponding
● Fourth level transverse process
● Fifth level
 First Rib

ck to edit Master
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text
to styles
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Brachial plexus,
ond level Second level subclavian a and v
Third level ● Third level
● Fourth level ● Fourth level Small and flattened
● Fifth level ● Fifth level
Scalenus anterior to upper
and inner surface
Subclavian v crosses rib ant to
scalenus
Subclavian a and brachial
plexus in contact with bone
posterior to scalenus
 Costal Cartilages

Bars of cartilage Click to edit Master text styles

Second level
Connect upper 7 ribs ● Third level

to sternum ● Fourth level

● Fifth level
Connect 8-10 ribs to
cartilage of 7
Cartilage of 11 and 12
in the abd’l
musculature
 Joints of the Thoracic Wall
Manubriosternal
Cartilaginous jt
Small mov’t possible during resp
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Xiphisternal Second level
Cartilaginous jt ● Third level

Costovertebral jts ● Fourth level

Synovial jts ● Fifth level

Costochondral jts
Cartilaginous
No mov’t possible
Jts of costal cartilage with sternum
 Muscles of the Thoracic Wall

Muscle Origin Insertion Nerve Supply Action

Diaphragm Xihpoid Central Phrenic n Inspiration; inc

process; lowertendon vertical
6 costal diameter of
cartilages; L1- thorax by
L3 by crura; pulling down
medial and central
lateral arcuate tendon;
ligaments assists in
raising lower
ribs
 Diaphragm

Click to edit Master text styles

Second level
● Third level

● Fourth level

● Fifth level
 Diaphragm

Dome-shaped
Peripheral muscular, central tendon
Origins
Sternal part
● Post surface of xiphoid process
Costal part
● Deep surfaces of lower 6 ribs and costal cartilages
Vertebral part
● Vertical columns or crura and arcuate ligaments
– Right crus
● From bodies of L1-L3 and intervertebral discs
● Splits to enclose esophagus
– Left crus
● L2-L3 and intervertebral discs
Click to edit Master text styles
Second level
● Third level

● Fourth level

● Fifth level
 Diaphragm
Openings
Aortic
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Second level
Ant to body of T12
● Third level
Aorta, thoracic duct and azygos vein
● Fourth level
Esophageal ● Fifth level

Level of T10
Esophagus, R and L vagus n, esophageal
branches of L gastric vessels, lymphatics
from lower 3rd of esoph
Caval
T8 level in central tendon
IVC and terminal branches of phrenic n
 Diaphragm

Phrenic n
Actions
Muscle of respiration
Muscle of abdominal
straining
● Micturition, defecation,
parturition
Weight-lifting
Thoracoabdominal pump
 Muscles of the Thoracic Wall
Muscle Origin Insertion Nerve Supply Action
Raise ribs on
inspiration; inc
External AP and
Intercostal Inferior border Superior border transverse
Intercostal n
(down and of rib above of rib below diameter of
forward) thorax; lower
ribs on
expiration
Internal
Intercostal Inferior border Superior border Assist ext
Intercostal n
(down and of rib above of rib below intercostals
back)
Innermost
Assist ext and
intercostal Adjacent ribs Adjacent ribs Intercostal n
int intercostals
(transverse)
Intercostal Muscles

Click to edit Master text styles

Second level
● Third level

● Fourth level

● Fifth level
 Muscles of the Thoracic Wall

Muscle Origin Insertion Nerve Supply Action

Levatores Transverse Superior Post rami of Elevate ribs

costarum (12) processes C7- border of ribs thoracic spinal
T11 n
Serratus Ligamentun Upper ribs Intercostal n Elevates ribs
posterior nuchae and
superior upper thoracic
vertebra

Serratus Lower thoracic Lower ribs Intercostal n Lowers ribs

posterior and upper
inferior lumbar spines
Levatores Costarum and
Serratus Posterior
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Second level
● Third level

● Fourth level

● Fifth level
 Intercostal Spaces
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Click to edit Master text styles
Second level Second level
● Third level
● Third level
● Fourth level
● Fourth level
● Fifth level
● Fifth level

Intercostal muscles
Endothoracic fascia and parietal pleura
Intercostal n and blood vessels bet internal and innermost
muscles
VAN
 Blood Vessels of Thoracic Wall

Click to edit Master textIntercostal

styles arteries
Second level 1 post intercostal a
● Third level
1st 2 fr sup intercostal a from costocervical
● Fourth level trunk of subclavian
● Fifth level Lower 9 from thoracic aorta
2 ant intercostal aa
1st 6 fr int thoracic a
Click to edit Master text styles Lower fr musculophrenic a fr int thoracic a
econd level Intercostal veins
● Third level

● Fourth level
Post intercostal vv to azygos or
hemiazygos
● Fifth level
Ant intercostal vv into int thoracic and
musculophrenic vv
 Blood Vessels of Thoracic Wall

Click to edit Master text styles Internal Thoracic A

Second level Fr 1st part of subclavian a
● Third level Descends behind 1st 6 costal
● Fourth level
cartilages

● Fifth level Terminates at 6th ICS

Superior epig a
Musculophrenic a

Internal Thoracic V
Begins as venae comitantes of int
thoracic a
Drains to brachiocephalic v on each
side
 Blood Vessels of Thoracic Wall

Branches of Internal
Click to edit Master text styles Thoracic Artery
Second level
● Third level Anterior intercostal aa
● Fourth level
Perforating aa
● Fifth level

Pericardiophrenic a
Mediastinal aa
Superior epig a
Musculophrenic a
 Lymphatic Drainage of
Thoracic Wall
Skin of ant chest wall
Click to edit Master text styles to ant axillary LN
Second level Skin of post chest wall
● Third level
Fourth level
●
to post axillary LN
● Fifth level ICS to internal thoracic
nodes and post
intercostal nodes
THORACIC CAVITY
 Thoracic Cavity
Divided into the mediastinum
and the lateral pleurae and
lungs Click to edit Master text styles
Superiorly, communicates with
Second level
● Third level
neck through thoracic outlet
● Fourth level
Bounded by T1, 1st ribs and costal
cartilages, manubrium sterni ● Fifth level

Esophagus, trachea, vessels and

nerves
Inferiorly, closed by diaphragm
 Mediastinum

Extends fr thoracic outlet toClick to edit Master text styles

diaphragm Second level
● Third level
Sternum to vertebral column
● Fourth level
Divided into superior and ● Fifth level
inferior mediastina Inferior
mediastinum further
subdivided
Middle (heart, pericardium)
Anterior
Posterior
 Superior Mediastinum
Thymus
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Brachiocephalic vv
Second level
Upper part of SVC ● Third level
Brachiocephalic a
● Fourth level
Left CCA
● Fifth level
L subclavian a
Arch of aorta
Phrenic and vagus n
L recurrent laryngeal and cardiac n
Trachea and LNs
Esophagus and thoracic duct
Sympathetic trunks
Anterior
Sternopericardial ligaments
LNs
Inferior
Remains of thymus
Middle
Mediastinum
Pericardium
Heart
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Roots of great blood vessels
Second level
● Third level
Phrenic n
● Fourth level
Tracheal bifurcation
LNs ● Fifth level

Posterior
Descending thoracic aorta
Esophagus
Thoracic duct
Azygos and hemiazygos veins
Vagus n
Splanchnic n
Sympathetic trunks
LNs
 Trachea

Mobile cartilaginous and Click to edit Master text styles

membranous tube Second level
● Third level
fr lower border of cricoid ● Fourth level
(C6) as continuation of
● Fifth level
larynx
to sternal angle (T4-T5) by
dividing into R and L
bronchi
Approx 5 cm in length
2.5 cm diameter (adults)
 Tracheal Relations
Anterior
sternum, thymus, L brachiocephalic v, Click to edit Master text styles
origins of brachiocephalic and L CCA, Second level
arch of aorta ● Third level

Posterior ● Fourth level

Esophagus, L recurrent laryngeal n ● Fifth level

Right
Azygos v, R vagus n, pleura
Left
Aortic arch, L CCA, L subclavian a, L
vagus n, pleura
 Bronchi

Right main bronchus

Wider, shorter, vertical Click to edit Master text styles
Gives off superior lobar bronchus Second level
before entering hilum ● Third level

In hilum, divides into middle and ● Fourth level

inferior lobar bronchi ● Fifth level

Left main bronchus

Narrower, longer, horizontal
Passes to left below aortic arch in
front of esophagus
Divides into superior and inferior
lobar bronchi
 Pleurae
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Serous sacs covering lungs Second level
● Third level
Parietal and visceral pleurae
● Fourth level
Pleural cavity (space) ● Fifth level

Separates parietal fr visceral pleura

Pleural fluid lubricates surfaces
Costodiaphragmatic recess - lowest
Nerve Supply
area
Parietal
• Pain, temp, touch, pressure
• Intercostal and phrenic n
Endothoracic fascia Visceral
• Stretching
Separates parietal pleura fr thoracic • Pulm plexus (autonomic)
wall
 Lungs

Blunt apex 2.5 cm above clavicle

Concave base sitting on diaphragm Click to edit Master text styles
Convex costal surface Second level
● Third level
Concave mediastinal surface
● Fourth level
Hilum
● Fifth level
Middle of mediastinal surface
Bronchi, vessels and nerves enter lung
Thin anterior border overlap the heart
Cardiac notch
Thick posterior border
 Lobes and Fissures

Right
Upper, middle and lower
lobes Click to edit Master text styles
Oblique and horizontal Second level
● Third level
fissures
● Fourth level

● Fifth level

Left
Upper and lower lobes
Oblique fissure
 Bronchopulmonary
Segments
Click to edit Master text styles
Anatomic, functional and surgical
units Second level
● Third level
Bronchopulmonary segment ● Fourth level

Subdivision of a lung lobe ● Fifth level

Pyramidal shape, apex toward root

Surrounded by connective tissue
Segmental bronchus, artery, lymph
vessel and autonomic n
Segmental vein in connective tissue
between segments
Diseased segment removed
surgically (structural unit)
 Blood Supply to the Lungs

Bronchial arteries Click to edit Master text styles

Second level
Br of descending thoracic ● Third level

aorta ● Fourth level

● Fifth level
Bronchi, connective tissue,
visceral pleura
Bronchial veins
Azygos and hemiazygos
vv
 Lymph Drainage of Lungs

Superficial plexus
Beneath visceral pleura Click to edit Master text styles
Second level
Drains surface of lung toward ● Third level
bronchopulm nodes (hilum)
● Fourth level
Deep plexus ● Fifth level

Bronchi and pulm vessels toward

hilum to pulmonary nodes (lung)
to bronchopulm nodes (hilum)
Tracheobronchial nodes
Bronchomediastinal
lymphatic trunks
 Nerve Supply of Lungs

Each lung supplied by pulmonary plexus

Formed by branches of sympathetic trunk
Receives parasympathetic fibers from
vagus n
 Pericardium

Click to edit Master text styles Fibroserous sac enclosing heart and
roots of great BVs
Second level
Fibrous pericardium
● Third level

● Fourth level
Strong and limits unnecessary mov’t

● Fifth level
Fuses with walls of great BVs
Attached firmly to central tendon
Attached to sternum (sternopericardial
ligaments)
Serous pericardium
Parietal and visceral layer
Paricardial cavity with pericardial fluid
(lubricant)
 Pericardium
Click to edit Master text styles
Pericardial sinuses
Second level
● Third level Transverse sinus
● Fourth level ●Reflection around ascending
● Fifth level aorta, pulm trunk and great veins
Oblique sinus
● Reflection around vena cavae and
Click to edit Master text styles 4 pulm veins
Second level
● Third level
Nerve supply
● Fourth level

● Fifth level Phrenic n

 Heart

Hollow muscular organ

somewhat pyramidal
Click to edit Master text styles
3 surfaces: Second level
sternocostal, ● Third level

diaphargmatic, base ● Fourth level

● Fifth level
Apex: downward,
forward, left
5th left ICS 9 cm from
midline
 Heart
4 chambers
R atrium and ventricle anterior
Walls Click to edit Master text styles
Epicardium Second level
● Visceral serous outer layer ● Third level

Myocardium ● Fourth level

● Middle, thick, muscle layer ● Fifth level

Endocardium
● Inner thin layer
Skeleton
Fibrous rings around AV, pulmonary and
aortic openings
Continuous with upper part of ventricular
septum
 Heart
Chambers
Right Atrium
Main cavity and auricle
Sulcus terminalis (external)
Sinus venosus and RA proper
Crista terminalis (internal)
Interior of auricle roughened by
bundles of muscle fibers
Musculi pectinati
Openings
SVC (no valve), IVC (rudimentary valve)
Coronary sinus bet IVC and AV orifice
R AV orifice with tricuspid valve
 Fetal Remnants

Rudimentary valve of Click to edit Master text styles

IVC Second level
● Third level

Fossa ovalis ● Fourth level

● Fifth level
Shallow depression on atrial
septum
Foramen ovale
Annulus ovalis
Upper margin of fossa
ovalis
 Right Ventricle
Greater part of anterior heart surface
Connects with RA via AV orifice, pulmonary trunk
via pulmonary orifice (infundibulum) Click to edit Master text styles
Thicker walls than RA Second level
Trabeculae carneae (internal surface ridges) ● Third level

Papillary muscles ● Fourth level

Base attached to ventricular wall ● Fifth level

●

● Apices attached to tricuspid valve through chordae

tendinae
Moderate band
● Attached to septal and anteriro ventricular wall
● Conveys R branch of AV bundle
Simple prominent projections
 Right Ventricle

Tricuspid Valve
Guards AV orifice
Click to edit Master text styles
Second level
3 cusps attached with chordae
● Third level
tendinae
● Fourth level
● Anterior, septal and inferior
● Fifth level
Pulmonary Valve
Guards pulmonary orifice
3 semilunar cusps attached to arterial
wall
● 1 posterior, 2 anterior
Pulmonary sinuses
● 3 dilatations at root of pulmonary
trunk
 Left Atrium

Posterior to RA
Click to edit Master text styles
Main cavity and auricle Second level
● Third level
Muscle ridges in auricle ● Fourth level

● Fifth level
Openings
Pulmonary veins (2 from each
lung) on posterior wall (no
valves)
L AV orifice guarded by mitral
valve
 Left Ventricle
Behind RV
Small portion projects to L, forms Click to edit Master text styles
L margin of heart and apex
Second level
Communicates with LA via AV ● Third level
orifice, Aorta via aortic orifice
● Fourth level
3x thicker walls than RV ● Fifth level

Trabeculae carneae and 2

papillary muscles
No moderator band
Aortic vestibule below aortic
orifice
 Left Ventricle
Click to edit Master text styles
Mitral Valve Second level
Guards AV orifice ● Third level

2 cusps (anterior and posterior) ● Fourth level

Chordae tendinae and papillary ● Fifth level

muscles
Aortic Valve
Guards aortic orifice Click to edit Master text styles
3 semilunar cusps (1 anterior, 2 Second level
posterior) ● Third level
Aortic sinus behind each cusp ● Fourth level
● Ant - R coronary a ● Fifth level
● L post - L coronary a
 Heart Sounds

Tricuspid valve Click to edit Master text styles

R half of lower end of sternal Second level
body ● Third level

Mitral valve ● Fourth level

● Fifth level
L 5th ICS 9 cm from midline
Pulmonary valve
2nd left ICS parasternal
Aortic valve
2nd right ICS parasternal
 Conducting System of the Heart

Sinoatrial node
Initiates heartbeat

Upper part of sulcus terminalis (SVC opening)

Click to edit Master text styles
Supplied by R coronary a (sometimes L)
Second level
● Third level
Atrioventricular node
● Fourth level
Lower part of atrial septum

Above attachment of septal cusp of tricuspid ● Fifth level

R coronary a

Atrioventricular bundle
Continuous with AV node and fibers of Purkinje

Descends behind septal cusp of tricuspid

Divides into R and L bundles

Continuous with Purkinje plexus

R coronary a
 Blood Supply of the Heart

Click to edit Master text styles Arterial Supply

Second level
● Third level
R Coronary A
● Fourth level Arises fr anterior aortic sinus of
● Fifth level ascending aorta
Descends in R AV groove
Click to edit Master text styles Send branches to RA and RV
Second level
● Third level
Anastomose with L coronary a
in posterior interventricular
● Fourth level
groove
● Fifth level
 Blood Supply of the Heart

L Coronary A
Click to edit Master text styles Arises fr L post aortic
Second level sinus of ascending aorta
● Third level

● Fourth level Larger than R

● Fifth level
Divides into anterior
interventricular br and a
circumflex branch
 Venous Drainage

Most fr heart walls drains into

Click to edit Master text styles RA through coronary sinus
Second level Remainder drains thru
● Third level anterior cadiac vein and small
● Fourth level veins (venae cordis minimae)
● Fifth level Coronary sinus
Great cardiac vein
Middle cardiac vein
Small cardiac vein
Anterior cardiac vein
 Nerve Supply of the Heart

Cardiac plexuses
Click to edit Master text styles Postganglionic sympathetic
Second level and parasympathetic fibers
● Third level
on SA and AV nodes,
● Fourth level
cardiac muscle fibers and
● Fifth level coronary aa
HR
Force of contraction
Coronary dilatation/constriction
PS fibers reach cardiac
plexuses via vagus n
 Large Veins of the Thorax
ck to edit Master text styles
ond level Brachiocephalic veins
Third level SVC
● Fourth level

● Fifth level Azygos v

Inferior hemiazygos v
Superior hemiazygos v
IVC
Pulmonary veins
 Large Arteries of the Thorax

Click to edit Master text styles Aorta

Second level Ascending
● Third level ● R and L coronaries

● Fourth level
Arch
Brachiocephalic a
● Fifth level
●

● L CCA
● L subclavian a
Descending
● Post intercostal aa
● Subcostal aa
● Pericardial aa
● Esophageal aa
● Bronchial aa
Abdominal
Large Arteries of the Thorax

Pulmonary Trunk
Click to edit Master text styles
Second level De-O2 from RV to lungs
● Third level
R and L pulmonary
● Fourth level
arteries
● Fifth level

Ligamentum arteriosum
 Lymph Nodes and Vessels
of the Thorax
LNs
Click to edit Master text styles Internal thoracic nodes
Second level Intercostal nodes
● Third level
Diaphragmatic nodes
● Fourth level

● Fifth level
Brachiocephalic nodes
Posterior mediastinal nodes
Tracheobronchial nodes
Lymph Vessels
Thoracic duct
● Cysterna chyli
Right lymphatic duct
 Large Nerves of the Thorax
Vagus nerves Click to edit Master text styles
R vagus
Ant to subclavian a
Second level
● Third level
Lateral to trachea
Medial to azygos v ● Fourth level
Posterior esophagus
● Fifth level
L vagus
Bet L CCA and L subclavian a
Anterior esophagus
Branches
Recurrent laryngeal n
● R - subclavian
● L - arch
Cardiac br
Pulmonary br
Esophageal br
 Large Nerves of the Thorax
Click to edit Master text styles
Phrenic nerve Second level
● Third level
Anterior rami of 3-4th ● Fourth level
cervical nerves ● Fifth level

R - R of SVC
L - L of subclavian a

Sympathetic Trunk
Thoracic part
 Esophagus
25 cm muscular tube
Continuous with pharynx (C6) Click to edit Master text styles
Passes diaphragm (T10) to join stomach Second level
3 constrictions ● Third level
Beginning
● Fourth level
Crossed by left bronchus
● Fifth level
Diaphragm

Behind trachea, left bronchus and LA

Blood supply: inferior thyroid a, descending aorta, L
gastric a
Venous drainage: inf thyroid v, azygos v, L gastric v
Lymph: deep cervical LN, sup and post mediastinal
LN, L gastric and celiac LN
Nerve supply: symp and parasymp from RLN, vagus,
symp trunk, splanchnic n
 Thymus

Flattened bilobed Click to edit Master text styles

structure Second level
● Third level

Bet sternum and ● Fourth level

● Fifth level
pericardium
Source of T-
lymphocytes
THANK YOU!