bismillahirrahmanirraheem

In the previous lecture, someone claimed that they heard me say that the central nervous
system contains a skeletal vault. I never said it contains a skeletal vault. I said the central
nervous system contained within a skeletal vault which is the skull. So, please pay attention
to what I say. I mean,some mistake change the meaning to a 180 degree.

In the last lecture we talked about the skeletal parts of the thoracic region of the human
body. And since we said that its a cage made by the articulation of different skeletal
components it’s gonna be plenty of joints. So in this lecture, I’m going to review the joints
that make up the thoracic cage.

Let’s start from posterior to anterior. We have the joints that connects the 2 adjacent
vertebral body together, we called it the intervertebral joints which is considered to be a
pivot cartilaginous joint. We have the joint to be the head of the rib and the adjacent
vertebral body, we called it costovertebral joint which is synovial. Other joints between the
tubercle of the rib and the transverse process of the respected vertebrae. It’s also synovial.
The ribs have some degree of movement ( refer slide pg 20) which is based on movement in
these blue joints which is no 2 and no 3 and the movement is location around the axis. It will
allow us to move out or down. We’ll talk about the significance of this movement in a bit.

As we move anteriorly, the first joint is that between the costal cartilage and the rib called
costochondral joint. It’s the primary cartilaginous joint that can afford no movement. Then,
we have the joints between each costal cartilage and the sternum. It’s all synovial joint
except the first costal cartilage because the joint here is primary cartilaginous and no
movement is allowed. The joints within the sternum itself, we have the manubriosternal
joint. It’s a fibrocartilagenous joint and we have the xiphisternal joint that connect the
sternum body and the xiphoid process. It’s a primary cartilaginous joint.

Now we start our second lecture about the thoracic region of the human body. We had
talked about the skeletal part, now we’ll talk about the rest of the component which are
muscle, nerves, vasculature and we will mention the surface markers, if I have the time for
that.

As I mention, more than one layer make up the thoracic wall. We talked about the skeletal
component. Now we’ll talk about the muscles and also the blood vessel and nerves that go
between these muscles.

The major muscle making the thoracic wall are the intercostal muscles and they have the
accessory muscle of respiration. The space between two ribs is called an intercostal space.
Intercostal muscles fill this space. The first layer or the most superficial layer is the external
intercostal muscle. This muscle transends in the downward direction and forward toward
the sternum. Notice it does not go all the way until the sternum,it dissapears. Instead of it,
they will be replaced by a thin layer of connective tissue called external interthoracic
membrane. (refer slide pg 4). It is a fascia indeed. If we remove the membrane we will find a
deeper muscle called internal intercostal muscle. It is opposite to the external intercostal
muscle. It is backward toward vertebral column (not completely opposite to external
intercostal muscle) and goes downward. Note that muscle fibre of both muscle does not
cross ribs, it just extend from one rib to another one rib below. This is an important feature
to distinguish this muscle with the third muscle I’m gonna talk about later. The external
intercostal muscle orientation is like putting your hand in the anterior pocket (downward
and medially) whereas the internal intercostal muscle is like putting your hand in the back
posterior pockets. Likewise, the internal intercostal muscle does not go all the away until it
reaches the vertebral column. It dissapears and is replaced by a thin fascia layer called the
internal intercostal membrane.

Now the third layer or the deepest muscular layer in the thoracic wall is called the innermost
intercostal and transversus thoracic muscles. Note that the transverse thoracic muscle is
discrete band and not continuous layer. It form discrete band and it cross rib, does not
extend from one rib to another. Sometime it goes over one rib and does not make an
articulation here. It just overpassed one rib and went to another part. That’s the way we
distinguish the transversus thoracic muscle. The innermost intercostal muscle in the text
book is considered as part of the transversus thoracic muscle. But stop! We can see it in this
view (we should be looking in the posterior thoracic wall on either side of the vertebral
column). By doing that, we be able to see the innermost intercostal muscle.

Blood vessel is mentioned as intercostal arteries and veins. Nerves is called the intercostal
nerves. They run in between the deepest layer which is the innermost intercostal
membrane and the internal intercostal membrane.

This is the cross section through the thoracic wall (refer slide pg 6).Note that, as I had
mentioned that the external intercostal muscle run from the vertebral column toward the
sternum,but it does not reach the sternum. It get dissapear and get replaced by external
intercostal membrane. This membrane will be covering the internal intercostal muscle.
When we remove it,we will see the fibre of internal intercostal muscle. It does not go all the
way to the vertebral column, you notice here it get replaced by a membrane which is the
internal intercostal membrane. The deepest layer is made anteriorly by the transversus
thoracic muscle and then we have a membrane that is not continuous muscle layer. Thats
what i meant,we will have a membrane in between. Posteriorly is called the innermost
intercostal muscle. Then, we have neurovascular bundle (vein,artery,nerve). It run between
the innermost muscle and internal intercostal membrane.

Slide page 7 is to emphasize what I had told. The both external and internal intercostal
muscle run in between adjacent rib,they do not cross ribs. But the transversus thoracic
muscle,it crosses rib. It’s not a complete muscle layer and formed of discrete slip or band.

Now we talk about the neurovascular bundle. If you remember when I talked about spinal
nerves. There are two roots,posterior and anterior that join together to form spinal nerve.
Then,it splits into to rami which are anterior and posterior. In the thoracic region,we will
calling the anterior rami as intercostal nerves. The posterior rami will supply some muscle at
the back. Also we have venous drainage to drain the thoracic region back to the venous
circulation. The neurovascular bundle start in the intercostal space. At some point they got
protected by the costal group. So, the costal group provide partial protection to these
structures but it won’t covering them entirely all the way. That is why we can see it here in
the intercostal space (slide pg 9) eventhough I mentioned before the costal groove houses
this structure. The orientation is vein-artery-nerve. Sometimes it is hard to distinguish each
one. This arrangement will help to distinguish which is which. Just to review the lecture
before,this is how a parasympathetic trunk looks like (refer slide pg 10). The
parasympathetic fibre will swipe back up forth in the gray ramus and the white ramus and
the fibres that do not synapse,they’ll escape somewhere else as long fibre.

Each intercostal space have a large posterior intercostal artery and 2 small anterior
intercostal arteries. The posterior come from the aorta and anterior come from internal
thoracic artery. In the first six intercostal spaces,the anterior from internal thoracic. After
that,it give branch called musculophrenic artery that will give rise to the anterior intercostal
artery ( not in the picture) in the lower six intercostal spaces. The intercostal nerve will give
rise to the branches of sympathetic branch named rami communicas. It will give a lateral
cutaneous branch and then the terminal branch will be called the anterior cutaneous
branch for supplying the skin anteriorly. Also it will give muscular branches which means
motor fibre for the muscle. It will also give sensory branches to the pleural. We said the
pleural will be elevated by the sensory fibre which are coming from intercostal nerves.

Each intercostal space had one large posterior and two small interior intercostal artery. The
posterior are derived from the descended aorta with one exception. The first intercostal
artery is not directly from the aorta instead it is derived from the costocervical trunk( a
branch of subclavian artery. Anteriorly, the anterior intercostal artery are derived from the
internal thoracic artery (first 6 intercostal spaces) and from musculophrenic artery (lower 6
intercostal space).On the other hand,the same terminology goes to vein. One large posterior
intercostal vein and two small anterior intercostal vein. Azygos vein and hemiazygos vein
are large veins in the side of vertebral column that drain into superior vena cava. Anterior
vein are derived from internal thoracic vein and musculophrenic vein. Most of the time,the
terminology of vein and artery correspond with each other but sometimes is different.

diaphragm

Now we talk about the major muscle in the thoracic wall and the major respiration muscle
which is the diaphragm. It is a thin muscle,it makes the partition with the thorax and the
abdomen. It has more than one origin. Origin means where the muscle fibres are attached.

 The sternal origin is fibre inserted in the xiphoid process.

 The costal origin are inserted in the lower six ribs

 The vertebral origin take the shape of the ligaments and columns called crura.
(singular ; crus)

The muscle is inserted in the central tendon. The central fibres of this muscle is not made of
muscular tissue but it was made of connective tissue . The innervation from the phrenic
nerve. What type of phrenic nerve? Cranial nerve or spinal nerve? It is derived from the
spinal root C3 until C5. So that level of spinal cord is important. If injury is on top of the
level ,that mean brain cannot send messages to the lower part to contract. So if a patient for
example injured on C2,the patient no longer can breathe anymore. If the injury occur below
for example T1,the patient will be able to retain breathing ability. That is why its important
to determine the outcome of injury,whether it devourable or not devourable. And of course
there are sensory fibre going from the diaphragm to the central nervous system. The central
portion is from the phrenic nerve. The diaphragm,the sensation is carried by the sensory
nerve.

And what the action of the diaphragm?

Breathing. Contraction itself is called expiration. Energy is spentto do expiration. When the
diaphragm relaxes,it helps expiration. So, it’s a breathing muscle. It helps expiration when
relaxes and inspiration when contract.

It just summary for the origin of diaphragm.(refer slide pg 15) The right crus make a sling
around the esophagus. On the left side we have the left crus and this is not the only part for
the vertebral origin,we have something we call arcuate ligaments. Arcuate refer to the shape
of arch. In the abdomen we have muscle called the psoas major and quadratus lumborum
muscle. They will be covered by fascia like any other muscle in the body. Whenever this
situation,the fascia of the psoas major will reaches the level of diaphragm and it will
thickened,will get duplicate and we start calling the structure the medial arcuate ligament.
The fascia of the quadratus lumborum muscle again it will get thickened and we start calling
the structure the lateral arcuate ligament. Do we still have another arcuate ligament?.. yes,
the one in between the two crura.We have fibrous tissue joining both crura, we called it the
medial arcuate ligament. It form part of aortic opening of diaphragm.

The shape of the diaphragm eventhough it is a flat muscle,it takes the shape of two domes
on each side. The right is higher than the left. Why is that? The heart is in the middle,has
nothing to do with diaphragm. It is because the large liver pushes the diaphragm up in the
right side.

Note that the central tendon looks like 3 leaves. (refer slide pg 16). This is actually the
fibrous pericardium that surrounds the heart. It is fused with the central leaf of the central
tendon.The structure passing from the thorax to the abdomen is called an opening. The
major opening are :

 The aortic opening which occur at the same level with thoracic vertebrae number 12
in between the crura. It allows the aorta to pass along with the azygos vein and
thoracic duct.

 The esophageal opening is at the T10 and the opening is nearly at the right crus. It
allows the esophagus and the vagus nerves to pass into abdomen.

 The caval opening at the level T8 in the central tendon. It allows the inferior vein
cava and the right phrenic nerve to pass.

These are the major opening. You don’t have to know the minor opening and the blood
vessel that pierce through the structure to the abdomen.
Like any other structure in body,we have clinical problems related to it. The first is the
diaphragmatic hernia. Hernia when certain object get displaced across a boundary.
Sometimes the diaphragm will rupture leading to herniation of the lumbar viscera into the
thorax. What’s does that mean?. It’s the part tissue between the thorax and the abdomen .
So, the stomach is in the abdomen. It won’t go to the thorax unless we have a problem with
the diaphragm called hernia. A part of the stomach will be displace into the thorax. There
are 2 types. (refer to book text because the there are pictures).

 Sliding : like we pull the esophagus and pull the stomach with it into the thorax.

 Paraesophangeal : If esophagus stays in its place but part of the stomach goes up
along with the esophagus so the opening will have both,part of the stomach and part
of esophagus.

Another common situation related to diaphragm is hiccup. Hiccup due to the irritation of the
vagus nerve. It leads to spasmodic contraction.

The last muscle we cover would be the accessory muscle. (Please see grants atlas for clearer
images). The levator costarum are available in triangular shape. The apex originate from the
spinous process of the lower cervical and upper thoracic vertebrae and get inserted in
adjacent ribs. It is inspiratory muscle which help raises the ribs when the muscle contract.
This action increases the anterior-posterior dimension of the thorax so the pressure inside
will decrease and allow the air to flow inside. It supplied by the posterior rami of the spinal
nerve. Serratus posterior are two types muscle,superior and inferior. Both are flat and
innervated by intercostal nerves. There is one major distinction in between them. The
superior aids in inspiratory. It’s action raises the ribs,so it’s an upward rotation of the ribs.
Meanwhile the inferior aids in the expiratory. It push the rib downward. It decrease the
pressure and force the air flow out.

The surface markings are easy and I will live it to you to study by your own. The study
anatomy means the deeper structure in the body that can be seen through the skin. For
example,the clavicle. It is not covered by any fat,normally just subcutenous layer. No matter
how fat or slim he or she is,usually he or she can feel their own clavicle.

p/s : please stick to your station in the lab. No swaping between station is allowed.

Done by : sharina