CHAPTER 21

The Musculature of
the Thoracic Wall
THE EXTRINSIC MUSCLES The scalene muscles elevate first and second
ribs during deep inspiration.
These muscles are attached to the external surface
of thoracic cage. They help in the movements of
THE INTRINSIC MUSCLES
shoulder girdle, upper extremity and the neck.
Some of these muscles also help to a great The intrinsic muscles consist of three layers of
extent in the respiratory movements of thoracic intercostal muscles, that fill up the intercostal
cage. spaces.
I. The pectoralis major connects medial half of a. The outer layer has external intercostal muscles
clavicle, upper six costal cartilages and front (Fig. 21.1).
of sternum to the lateral lip of bicipital groove b. The intermediate layer has internal intercostal
of humerus. muscles
The muscle elevates upper six ribs during c. The inner layer is incomplete and consists of
forced inspiration. i. Sternocostals (transversus thoracic)
II. The pectoralis minor connects third, fourth, and anteriorly
fifth ribs to coracoid process of scapula. ii. Innermost intercostal (intercostalis intimus)
It helps to elevate third, fourth, and fifth located in middle two-fourth part of inter-
ribs during deep inspiration. costal space
III.The sterno-cleidomastoid muscle passes from iii. Subcostalisposteriorly.
manubrium sterni and medial one-third of
clavicle to mastoid process and superior nuchal The External Intercostal Muscles
line of skull.
There are eleven pairs of external intercostals filling
It elevates manubrium sterni
up all eleven intercostal spaces.
IV. The scalene muscles
a. The scalenus anterior connects anterior
tubercles of transverse processes of third
to sixth cervical vertebrae to scalene
tubercle of first rib
b. The scalenus medius connects posterior
tubercles of transverse processes of second
to sixth cervical vertebrae to first rib
c. The scalenus posterior (when present)
connects posterior tubercles of transverse
processes of fifth and sixth cervical verte- Fig. 21.1: Part of thoracic wall showing
brae to second rib. three layers of muscles
 The Musculature of the Thoracic Wall
Attachments
UpperSharp inferior border of the rib
above
LowerOuter edge of thick superior border
of the rib below
Extent
AnteriorlyThe external intercostal extends
up to costo-chondral junction. It is replaced
in between the costal cartilages by anterior
(external) intercostal membrane
PosteriorlyThe muscle extends up to the
posterior end of the intercostal space.
Direction of fibersis downwards forwards
and medially in front of chest wall.
Nerve supplyis by the corresponding inter-
costal nerve (i.e. ventral ramus of thoracic
nerve)
ActionsElevation of the rib during inspiration.
The Internal Intercostal Muscles
There are eleven pairs of internal intercostal
muscles, that fill up all eleven intercostal spaces.
Fig. 21.2: TS thoracic wall showing intercostal muscles and intercostal arteries
195
Attachments
Upperthe floor of the costal groove of
the rib above
Lowermiddle part of thick superior border
of rib below
Extent
AnteriorlyThe muscle extends up to the
side of sternum
PosteriorlyIt extents up to the angle of
the rib, beyond that it is replaced by internal
(posterior) intercostal membrane
Direction of fibers is upwards, forwards and
medially in anterior part of chest wall, nearly at
right angles to the fibers of external intercostal
muscle.
Nerve supplyis by the corresponding inter-
costal nerve (ventral ramus of thoracic nerve).
Actions
i. The intra-cartilaginous part helps to elevate
the anterior ends of the rib.
ii. The rest of the muscle helps in depression
of the rib (Fig. 21.2).
196 Essentials of Human Anatomy

The Innermost Intercostal

(Intercostalis Intimus)
This muscle of the inner layer of thoracic wall
covers only middle two-fourth part of the intercostal
space.
Attachments
UpperInner surface of the upper rib
above costal groove
LowerInner edge of the thick upper border
of the rib below
ExtentThe muscle covers only middle two-
fourth part of the intercostal space
Direction of fiberssame as internal intercostal
Nerve supplyis by the corresponding inter-
costal nerve (ventral ramus of thoracic nerve)
Fig. 21.3: The sternocostalis muscle
Actions
i. Functionally the muscle is part of internal
intercostal. The innermost intercostal is The Subcostalis
separated from the internal intercostal by
The subcostalis is a part of inner layer of intercostal
intercostal vessels and nerve (neuro-vascular
plane) muscles, that is attached to posterior part of ribs
ii. The three intercostal muscles also help to as digitations. The subcostalis is better developed
prevent bulging in and bulging out of in lower part of thoracic cage.
intercostal spaces during inspiration. Thus Attachments
they maintain the integrity of intercostal UpperInternal surface of one rib near its
spaces. angle
LowerInternal surface of second or third
The Sternocostalis rib below
(Transversus Thoracis) Direction of fibersSame as internal intercostal
The sternocostalis is a part of inner layer of Nerve supplyis by corresponding intercostal
intercostal muscles, that is attached to sternum (Fig. nerves
21.3). ActionsThe subcostalis depresses posterior
OriginPosterior surface of lower third of parts of ribs during expiration.
body sternum
Muscle bellyconsists of digitations that pass MUSCLES CONNECTING THORACIC
upwards and a little laterally towards costal CAGE TO VERTEBRAL COLUMN
cartilages I. The Serratus Posterior Superior
InsertionInner surface second to sixth costal
cartilages It is a thin quadrilateral muscle covering upper
Nerve supplyThird to sixth intercostal nerves posterior part of thoracic cage.
(ventral rami of thoracic nerves) Origin
ActionsIt depresses anterior ends of second Lower part of ligamentum nuchae
to sixth ribs. Spine of seventh cervical vertebrae
 The Musculature of the Thoracic Wall
Spines of upper two or three thoracic
vertebrae
InsertionUpper border and external surfaces
of second to fifth ribs
Nerve supplySecond and third intercostal
nerves (Ventral rami of second and third thoracic
nerves)
ActionsThe muscles elevates second to fifth
ribs during inspiration.
II. The Serratus Posterior Inferior
It is also a thin quadrilateral muscle covering lower
posterior part of thoracic cage.
Origin
Spines of lower two or three thoracic
vertebrae
Spines of upper two or three lumbar
vertebrae through lumbar fascia
InsertionInferior border and outer surfaces
of lower four ribs
Nerve supplyVentral rami of ninth to twelfth
thoracic spinal nerves
ActionsIt depresses lower four ribs.
Fig. 21.4: The thoracic diaphragm
197
III. The Levatores Costarum
These are twelve pairs of strong bundles of muscles
fibers connecting vertebrae with the posterior parts
of the ribs.
Origin: Seventh cervical to eleventh thoracic
transverse processes at their tips.
Insertion: Upper edge and external surface of
neck of the rib below.
Nerve supply: Lateral branches of dorsal rami
of corresponding thoracic spinal nerves.
Actions: The levatores costarum elevate
posterior parts of the ribs.
THE THORACIC DIAPHRAGM
The thoracic diaphragm is a musculo-tendinous
bidomed structure, that separates thoracic cavity
from the abdominal cavity.
The diaphragm completely fills up the thoracic
outlet.
Origin (Fig. 21.4)
a. Sternal is by two slips from inner surface
of xiphisternum.
b. Costal is by slips from inner surface of
lower six costal cartilages of both sides.
198 Essentials of Human Anatomy
c. Lumbar is by means of two cruramus-
culo-tendinous structuresand two paired
ligaments.
i. The right crus is larger and is attached
to front of bodies of upper three lumbar
vertebrae and intervertebral discs.
ii. The left crus is smaller and is attached
to front of bodies of upper two lumbar
vertebrae and intervertebral disc.
The two ligaments are:
i. Lateral arcuate ligament (lateral lumbo-
costal arch) is attached from tip of first
lumbar transverse process to lower border
of twelfth rib.
ii. Medial arcuate ligament (Medial lumbo-
costal arch) is attached from the side of
crus to transverse process of first lumbar
vertebra.
Muscle belly
The muscular fibers from the three origins
ascend upwards and converge medially
towards the central tendon.
The diaphragm forms two domes or
cupolae. The right dome is a little higher
due to liver below it.
The fibers of right crus cross towards left
of the median plane and form a sling-like
elliptical opening for giving passage to the
esophagus.
Table 21.1: Major openings of diaphragm
Inferior vena caval opening Esophageal opening
1. Position In central tendon, between
2. Vertebral level
3. Shape
right and central leaflet
8th thoracic vertebra
Quadrangular
4. Structures Inferior vena cava
passing
through { Branches of right phrenic
nerve
{ Anterior and posterior gastric nerves
Some lymphatics
5. Effect of con- The inferior vena caval
traction of opening is dilated (venous
diaphragm return takes place)
Insertion
The muscular fibers from all sidesi.e. from
sternum, costal cartilages and the two crura,
ascend upwards and medially and are inserted
on Central tendona fibrous aponeurosis in
the center, from all sides.
Nerve supply
Motor fibers are supplied by two phrenic
nerves (C3, C4, C5)
Sensory (proprioceptive fibers)
For central portion by the phrenic nerves
For peripheral part of the lower five
intercostals and subcostals (T7 to T12
ventral rami)
Actions
i. The thoracic diaphragm is the main muscle
of inspiration. When it contracts, it descends
and increases the vertical diameter of
thoracic cavity.
ii. The diaphragm helps in all voluntary expul-
sive efforts, e.g. micturition, defecation,
coughing, sneezing, vomiting and parturition
(in females).
iii. The diaphragm helps to maintain and control
the intra-abdominal pressure.
iv. The fibers of right crus of diaphragm exer-
cise a sphincteric control over esophageal
opening (Table 21.1).
Aortic opening
Muscular part of diaphragm Behind median arcuate ligament
surrounded by fibre of right crus
10th thoracic vertebra
Elliptical
{ of diaphragm
12th thoracic vertebra (lower
border)
Oval
Esophagus Descending aorta
Branches of left gastric artery
{ Thoracic duct
Azygos vein
Esophageal opening is closed No effect on aortic opening
 The Musculature of the Thoracic Wall
Other Structures Passing
Through Diaphragm
I. The superior epigastric artery passes between
sternal and costal slips.
II. The musculo phrenic artery passes between
slips of seventh and eighth costal cartilages.
III. The lower five intercostal nerves (T7 to T11)
pass between costal slips.
IV. The subcostal vessels and nerve pass out deep
to lateral arcuate ligament.
V. The sympathetic trunk passes out deep to
medial arcuate ligament.
VI. The three splanchnic nervesgreater, lesser
and lowerpierce the crus of diaphragm.
VII. The hemiazygos vein pierces left crus of
diaphragm.
Development
The thoracic diaphragm develops from the
following embryonic structures
1. Septum transversum-(median part of
secondary mesoderm) that forms the central
tendon of diaphragm.
2. Two pleuro-peritoneal membranes.
3. Muscular components from lateral and
dorsal body walls.
4. Mesentery of esophagus in which the
crura of diaphragm develop.
Anomalies
Incomplete fusion of developmental parts may
result in congenital defects or anomalies in
diaphragm.
a. Incomplete closure of pleuro-peritoneal canal
results in diaphragmatic hernia. It is more
common on left side.
b. Foramen of Morgagni is result of incomplete
closure of sterno-costal triangle, between
sternal and costal origins. This is also a site for
rare type of diaphragmatic hernia.
Applied Anatomy
I. The phrenic nerve lesion paralyses half the
diaphragm. It may lead to paradoxical
199
movements of paralyzed hemidiaphragm,
resulting in poor oxygenation of blood.
II. Hiccups are recurrent spasms of diaphragm,
phrenicotomy is done sometimes to relieve
chronic case of hiccups.
III. Diaphragmatic hernia is a rare type of hernia
that occurs due to a defect in development
of diaphragm.
THE MOVEMENTS OF RESPIRATION
The respiratory movements can be divided into:
The costsal movements
The diaphragmatic movements
The Costal Movements
a. Normal Costal Inspiration
The external intercostals and intra-chondral
parts of internal intercostals contract and move
the ribs upwards and outwards (bucket-handle
movements).
The concave inner surface of ribs is also turned
outwards. By these movements the transverse
diameter of thoracic cavity is increased.
Simultaneously with movements of ribs, the
sternum moves forwards and upwards, thereby
increasing the anteroposterior diameter of thora-
cic cavity (pump-handle type of movements).
By increasing transverse and anteroposterior
diameter of thorax, the intrathoracic pressure
becomes lower and lungs expand, thus bringing
more air by inspiration.
b. Forced Costal Inspiration
Apart from the intercostal, pectoral muscles assist
in maximal elevation of ribs. The sterno-mastoid
and the scalene muscles further elevate the first rib
and manubrium sterni. These muscles, therefore,
help in further increasing the transverse and
anteroposterior diameters of thoracic cavity.
Forced inspiration is required for ventilating a
larger part of lung for greater oxygenation of
blood.
200 Essentials of Human Anatomy
c. Normal Costal Expiration
No muscular effort is needed to expel the air from
the lungs.
Quiet (normal) expiration is done mainly by the
elastic recoil of the costal cartilages and the
lungs.
External elastic recoilis provided by the costal
cartilages, that are deformed during normal quiet
inspiration. They, now, turn back to their normal
shape. Gravity also helps in this process. This
elastic recoil of costal cartilages decreases as
age advances.
Internal elastic recoilis provided by the lungs.
The elastic fibers of interstitial tissue between
the alveoli of lungs, tend to cause shrinkage of
lung tissue.
The tension between two surfacesvisceral and
parietal pleuraseparated by a thin film of fluid
produces a very high degree of adhesive effect
(surface tension). This force called intratho-
racic pressure tends to pull the chest wall
inwards.
Diseases like emphysema, that reduce the
elasticity of lung tissue, affects this type of
movements.
d. Forced Costal Expiration
Forced costal expiration is caused by additional
muscular effort.
The internal intercostal muscles contract and
decrease the transverse and anteroposterior
diameters of thoracic cavity.
Quadratus lumborum muscle lowers and fixes
the twlfth rib so that thoracic cage can be
depressed effectively.
The Diaphragmatic Movements
a. The Diaphragmatic Inspiration
The contraction of diaphragm lowers the level of
its two domes, thereby increasing the vertical
diameter of thoracic cavity. This decreases the intra-
thoracic pressure.
Active diaphragmatic movements lower the
dome of diaphragm as much as 10.0 cm.
During diaphragmatic contraction, the
abdominal contents are displaced.
This movement is helped by slight relaxation of
abdominal wall muscles.
b. The Diaphragmatic Expiration
The abdominal wall muscles act as antagonists
to diaphragm. When they contract, they push
the abdominal viscera upwards, thus they stretch
the diaphragm in thoracic cavity and reduce
the vertical diameter and volume of thoracic
cavity.
The abdominal musculature comes into effect
when respiratory requirements are more than
normal.
In erect posture, gravity tends to lower the
diaphragm.
But when one is in supine position, the gravity
tends to push up the abdominal viscera and
stretch the diaphragm. So when a person has
respiratory difficulty, he has to be propped up
for proper ventilation of lungs.
The normal balance between the costal and
diaphragmatic movements depends upon many
factors like sex, body type, profession, state of
health and clothing.
The children and elderly people breathe more
by the abdominal type of respiration.
Fat persons and women in advanced pregnancy
cannot have abdominal type of respiration, so
they respire mainly due to the movements of
ribs (costal respiration).
Applied Anatomy
1. Pneumothorax: A penetrating wound or rupture
of pulmonary tissue or tear of pleura allows the
entry of air into pleural cavity, thereby abolishing
the negative intra-thoracic pressure and results
in collapse of lung.
 The Musculature of the Thoracic Wall 201

[A negative intrathoracic pressure (as compared withstand the decrease in intra-thoracic

to the atmospheric pressure) and surface tension pressure and during expiration the flat
normally holds the lungs against thoracic wall.] portion moves outwards (paradoxical respi-
a. A sucking pneumothorax is accompanied by ratory movements). This results in reduced
hyper-expansion of chest wall on normal ventilation of lungs.
side. This causes mediastinal flutter, a slight 4. The respirators
shift of mediastinal contents towards normal Negative pressure devices of iron lung or
side during inspiration and injured side respiratory lower the extra thoracic and
during expiration. intra-pulmonary pressure below the
atmospheric pressure thereby simulating
b. A tension penumothorax is created when
natural negative pressure breathing.
due to nature of wound air is sucked in
Positive pressure devices elevate the
during each thoracic expansion, without atmospheric pressure above normal, so that
expelling out the air. The resultant air is forced inside the lung.
pneumothorax pushes mediastinal contents
significantly towards the normal side, The Blood Vessels of the Thoracic Wall
thereby interfering with vital capacity of
The Arteries
normal lungs.
2. Pleural effusion: Fluid may collect in the pleural a. The internal thoracic artery supplies anterior
cavity due to part of the thoracic wall (Fig. 21.5)
a. Inflammation of pleura (pleurisy with OriginThe internal thoracic artery arises
effusion) from inferior surface of first part of sub-
clavian artery.
b. Secondary to congestive heart failure, as a
part of generalized edema of body.
Such collections reduce the vital capacity
of lung and thus reducing the
oxygenation taking place in the lung.
As little as 500 ml of fluid may be seen
in X-ray of the chest as it obscures the
costo-diaphragmatic angle.
The fluid in the pleural cavity can be
aspirated out if it causes embarrassment
to function of the lung.
3. Fracture of rib may penetrate thoracic wall,
tear visceral pleura and cause pneumothorax
Tearing of associated blood vessels (inter-
costal vessels) may cause hemothorax
(collection of blood in the pleural cavity).
Fracture of several ribs in two locations
(anterior and posterior) diminishes the
structural integrity of thoracic cage. It leads
to flat chest. The thoracic wall cannot Fig. 21.5: The internal thoracic artery
202 Essentials of Human Anatomy
Course
The artery descends behind internal
jugular and right brachio-cephalic vein
to enter thoracic inlet behind first costal
cartilage.
As it enters thorax, the phrenic crosses
in front of the artery from lateral to
medial side.
The internal thoracic artery descends
deep to the upper six costal cartilages
and intercostal spaces, lying about
1.2 cm from side of sternum.
TerminationThe artery divides into its two
terminal branchessuperior epigastric and
musculophrenicin the sixth intercostal
space.
Branches
i. The pericardio-phrenic branch: A slender
artery that accompanies phrenic nerve
and after supplying pericardium supplies
the diaphgram.
ii. The mediastinal branches supply lymph
nodes and other structures in media-
stinum
iii. The pericardial branches supply the
fibrous pericardium.
iv. The sternal branches supply the sternum
v. The paired anterior intercostal bran-
chessuperior and inferiorfor upper
six intercostal spaces supply anterior part
of thoracic wall
vi. The perforating branches accompany
second to sixth intercostal nerves
In second, third and fourth spaces in
females the perforating branches are large
and supply the mammary gland.
vii. The superior epigastric artery enters the
rectus sheath in anterior abdominal wall,
between sternal and costal slips of orign
of diaphragm.
viii. The musculo-phrenic artery passes
between seventh and eighth costal slips
of diaphrarm and runs along costal
margin, supplying inter-costal muscles
and diaphragm.
b. The intercostal arteries: The intercostal arteries
supply the thoracic wall
The upper nine intercostal spaces have two
anterior and one posterior intercostal arteries.
The lower two intercostal spaces are small
and have only one posterior intercostal
artery.
I. The anterior intercostal arteries are two
superior and inferior-in each space
Origin
The anterior intercostal arteries in upper
six spaces are branches of internal
thoracic artery
In seventh, eighth and ninth space they
are branches from musculophrenic
artery.
Course
The anterior, superior intercostal artery
runs in the costal groove between inter-
costal vein above the intercostal nerve
below. The anterior inferior intercostal
artey runs along the upper border of the
rib below. The intercostal vessels and
nerve lie in the neuro-vascular plane of
thoracic wall between internal intercostal
and innermost intercostal.
The anterior intercostal arteries are
smaller and supply only anteior one third
part of intercostal space.
The anterior superior intercostal artery
anastomoses with the posterior inter-
costal artery.
The anterior inferior intercostal artery
anastomoses with the collateral branch
of posterior intercostal artery.
II. The posterior intercostal arteries are larger and
supply nearly two-third part of the intercostal
space.
Origin (Fig. 21.6)
In upper two spaces, the posterior inter-
costal arteries are branches of superior
 The Musculature of the Thoracic Wall
Fig. 21.6: The intercostal arteries
intercostal branch of costo-cervical
trunk for first part of subclavian artery.
In lower nine intercostal spaces, the
posterior intercostal arteries are branches
of descending thoracic aorta.
Course
The posterior intercostal artery runs in
the costal groove with intercostal vein
above and intercostal nerve below, in the
neuro-vascular plane of thoracic wall.
It gives a collateral branch, near the
angle of rib, that runs along the upper
border of rib below and anastomoses
with anterior inferior intercostal artery.
The posterior intercostal artery anasto-
moses with anterior superior intercostal
artery
Branches
i. The dorsal branch supplies the muscles
of the back and gives a spinal branch
that enters vertebral canal to supply
203
meninges and also give radicular branch
of spinal cord.
ii. The collateral branch supplies the inter-
costal muscles
iii. The small muscular branches are also
given
iv. The lateral cutaneous branch accom-
panies the lateral cutaneous nerve. In
females, the lateral cutaneous branch in
second, third and fourth spaces supply
mammary gland.
v. The right bronchial artery arises from
the first right aortic intercostal artery.
The Veins
a. The internal thoracic artery is accompanied by
a pair of venae comitantes up to the lower
border of third costal cartilage
Above that, there is only one internal
thoracic vein, that ascends, medial to internal
thoracic artery.
The internal thoracic vein ends in brachio-
cephalic vein.
The internal thoracic veins receive tribu-
taries corresponding to the branches of
internal thoracic artery.
b. The intercostal veins
I. The anterior intercostal veins are two in each
upper nine intercostal spaces.
These veins accompany the corres-
ponding arteries, lying in the neuro-
vascular plane of thoracic wall.
They drain venous blood from anterior
part of thoracic wall.
In upper six intercostal spaces, the
anterior intercostal veins end in internal
thoracic veins.
In lower three intercostal spaces, the
anterior intercostal veins end in venae
comitantes of musculophrenic artery.
II. The posterior intercostal veins are one in
each eleven intercostal spaces, accom-
panying posterior intercostal artery (Fig.
21.7).
204 Essentials of Human Anatomy
Fig. 21.7: The posterior intercostal veins
The posterior intercostal veins, run in
the costal grooves of the ribs above the
intercostal artery, lying in the neuro-
vascular plane of the thoracic wall.
They drain venous blood from most part
of intercostal space and receives
tributaries corresponding to the branches
of posterior intercostal arteries.
On right side
The first posterior intercostal vein ends
in the right brachiocephalic vein.
The second, third, and fourth posterior
intercostal veins join to form right
superior intercostal vein that ends in
azygos veins.
The fifth to eleventh posterior intercostal
veins join the azygos vein.
On left side
The first posterior intercostal vein ends
in left brachiocephalic vein.
The second, third, and fourth posterior
intercostal veins join to form left
superior intercostal vein that crosses
anterior to arch of aorta and ends in left
brachiocephalic vein.
The fifth, sixth, seventh, and eighth
posterior intercostal veins join to form
accessory hemiazygos vein that ends
in azygos vein.
The ninth, tenth, and eleventh posterior
intercostal veins join the hemiazygos
vein that also ends in the azygos vein.
The Nerve Supply of the Thoracic Wall
The muscles and the skin of the thoracic wall
are supplied by the intercostal nerves (ventral
rami of first to eleventh thoracic spinal nerves).
A typical intercostal nerve is one that supplies
the skin and muscles of the thoracic wall only.
Third to sixth intercostal nerves are typical.
The first intercostal nerve mainly joins the
branchial plexus.
The second intercostal nerve gives an inter-
costo-brachial nerve that supplies the skin of
upper part medial side of arm.
The seventh to eleventh intercostal nerves after
supplying thoracic wall, enter anterior abdominal
wall to supply muscles and skin.
The Typical intercostal Nerve (Fig. 21.8)
BeginningThe typical intercostal nerve begins
near the inter-vertebral foramen, where the spinal
nerve divides into a ventral ramus and a dorsal
ramus.
CourseThe typical intercostal nerve enters
posterior part of intercostal space by passing
behind the intercostal vessels
The nerve runs forwards in the costal groove
below the intercostal artery and vein lying
in the neuro-vascular plane of the thoracic
wall between internal intercostal and
innermost intercostal.
In anterior part of intercostal space, the
intercostal nerve passes in front of internal
thoracic vessels, pierces internal intercostal
muscle, anterior intercostal membrane,
 The Musculature of the Thoracic Wall 205

Fig. 21.8: TS thoracic wall showing a typical intercostal nerve

pectoralis major and its fascia and comes
out as the anterior cutaneous nerve.
Branches
I. The communicating branches are two and
connect the intercostal nerve to the corres-
ponding sympathetic ganglion.
III.The cutaneous branches are twolateral
a. The white ramus communicans (WRC)
lies laterally and contains preganglionic
sympathetic fibers from the nerve to the
ganglion.
b. The grey ramus communicans (GRC)
lies medially and contains postganglionic
sympathetic fibers from the ganglion to
the intercostal nerve.
II. The muscular branches are twocollateral
and smaller muscular branches
a. The collateral branch is given near the
angle of the rib, and runs along the upper
border of rib below. It may rejoin the
parent stem.
b. Small muscular branches supply the
three layers of intercostal muscles, sub-
costalis and sterno-costalis.
cutaneous and anterior cutaneous.
a. The lateral cutaneous branches pierces
the muscles along mid-axillary line and
divides into anterior and posterior
branches to supply skin of lateral part
of thoracic wall.
b. The anterior cutaneous branch pierces
the muscles, about 1.2 cm lateral to the
sternum. It divides into a medial and a
lateral branch to supply skin of anterior
part of thoracic wall.