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 Second level ● Third level ● Fourth level ● Fifth level

Sternum Ribs Costal cartilages

Sternum
Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level
1. Manubrium Body, clavicle, 1st costal and upper part of 2nd costal cartilage 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 Second level ● Third level ● Fourth level ● Fifth level
2. Body of Sternum Manubriosternal jt Xiphisternal jt 2nd-7th costal cartilages 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

1st 7 pairs Attached to sternum via costal cartilages 8th-10th pairs Attached to each other and to 7th rib above 11th-12th ribs No anterior attachment

False
● ●

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

Floating
● ●

Typical Rib
Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level
Long twisted flat bone Rounded superior Grooved inferior
Costal groove Intercostal vessels and nerve

Head, neck, tubercle, shaft and angle

Head with Click to edit Master text styles 2 facets for articulation with corresponding vertebra and vertebra Second level above ● Third level Tubercle has facet with corresponding transverse process ● Fourth level ● Fifth level

First Rib

ck to edit Master text styles Click to edit Master text styles Brachial plexus, ond level Second level subclavian a and v ● Third level Third level Small and flattened ● Fourth level ● Fourth level ● 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 Connect upper 7 ribs to sternum Connect 8-10 ribs to cartilage of 7 Cartilage of 11 and 12 in the abd’l musculature
Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level

Joints of the Thoracic Wall
Manubriosternal
Cartilaginous jt Small mov’t possible during resp

Xiphisternal
Cartilaginous jt

Costovertebral jts
Synovial jts

Costochondral jts
Cartilaginous No mov’t possible

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

Jts of costal cartilage with sternum

Muscles of the Thoracic Wall
Muscle Diaphragm Origin Insertion Nerve Supply Action Phrenic n Inspiration; inc vertical diameter of thorax by pulling down central tendon; assists in raising lower ribs

Xihpoid Central process; lowertendon 6 costal cartilages; L1L3 by crura; medial and lateral arcuate ligaments

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 Deep surfaces of lower 6 ribs and costal cartilages Vertical columns or crura and arcuate ligaments

Costal part

Vertebral part

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
Ant to body of T12 Aorta, thoracic duct and azygos vein

Esophageal
Level of T10 Esophagus, R and L vagus n, esophageal branches of L gastric vessels, lymphatics from lower 3rd of esoph

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

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 AP and transverse diameter of thorax; lower ribs on expiration Assist ext intercostals Assist ext and int intercostals

External Intercostal (down and forward)

Inferior border of rib above

Superior border Intercostal n of rib below

Internal Intercostal (down and back) Innermost intercostal (transverse)

Inferior border of rib above

Superior border Intercostal n of rib below

Adjacent ribs

Adjacent ribs

Intercostal n

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 posterior superior Ligamentun Upper ribs nuchae and upper thoracic vertebra Lower thoracic Lower ribs and upper lumbar spines Intercostal n Elevates ribs

Serratus posterior inferior

Intercostal n

Lowers ribs

Levatores Costarum and Serratus Posterior

Click to edit Master text style Second level ● Third level ● Fourth level ● Fifth level

Intercostal Spaces
Click to edit Master text styles to edit Master text styles Click 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 arteries styles 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 Lower fr musculophrenic a fr int thoracic a

Click to edit Master text styles econd level ● Third level ● Fourth level ● Fifth level

Intercostal veins Post intercostal vv to azygos or hemiazygos Ant intercostal vv into int thoracic and musculophrenic vv

Blood Vessels of Thoracic Wall
Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level
Internal Thoracic A Fr 1st part of subclavian a Descends behind 1st 6 costal cartilages 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
Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level

Branches of Internal Thoracic Artery Anterior intercostal aa Perforating aa 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 to post axillary LN Fourth level
● ● ●

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 Superiorly, communicates with neck through thoracic outlet
Bounded by T1, 1st ribs and costal cartilages, manubrium sterni Esophagus, trachea, vessels and nerves

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

Inferiorly, closed by diaphragm

Mediastinum
Extends fr thoracic outlet to diaphragm

Click to edit Master text styles Second level ● Third level Sternum to vertebral column ● Fourth level Divided into superior and ● Fifth level inferior mediastina Inferior
mediastinum further subdivided
Anterior Posterior Middle (heart, pericardium)

Superior Mediastinum
Thymus Brachiocephalic vv Upper part of SVC Brachiocephalic a Left CCA 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

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

Anterior
Sternopericardial ligaments LNs Remains of thymus

Middle
Pericardium Heart Roots of great blood vessels Phrenic n Tracheal bifurcation LNs

Inferior Mediastinum
Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level

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

Trachea
Mobile cartilaginous and membranous tube fr lower border of cricoid (C6) as continuation of larynx to sternal angle (T4-T5) by dividing into R and L bronchi Approx 5 cm in length 2.5 cm diameter (adults) Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level

Tracheal Relations
Anterior
sternum, thymus, L brachiocephalic v, origins of brachiocephalic and L CCA, arch of aorta

Posterior
Esophagus, L recurrent laryngeal n

Click to edit Master text styles Second level ● Third level ● Fourth level ● 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 Gives off superior lobar bronchus before entering hilum In hilum, divides into middle and inferior lobar bronchi

Click to edit Master text styles Second level ● Third level ● Fourth level ● 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
Serous sacs covering lungs Parietal and visceral pleurae Pleural cavity (space)
Separates parietal fr visceral pleura Pleural fluid lubricates surfaces Costodiaphragmatic recess - lowest area

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

Endothoracic fascia
Separates parietal pleura fr thoracic wall

Nerve Supply Parietal • Pain, temp, touch, pressure • Intercostal and phrenic n Visceral • Stretching • Pulm plexus (autonomic)

Lungs
Blunt apex 2.5 cm above clavicle Concave base sitting on diaphragm Convex costal surface Concave mediastinal surface Hilum
Middle of mediastinal surface Bronchi, vessels and nerves enter lung

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

Thin anterior border overlap the heart
Cardiac notch

Thick posterior border

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

Left
Upper and lower lobes Oblique fissure

Bronchopulmonary Segments
Anatomic, functional and surgical units Bronchopulmonary segment
Subdivision of a lung lobe 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)

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

Blood Supply to the Lungs
Bronchial arteries
Br of descending thoracic aorta Bronchi, connective tissue, visceral pleura Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level

Bronchial veins
Azygos and hemiazygos vv

Lymph Drainage of Lungs
Superficial plexus
Beneath visceral pleura Drains surface of lung toward bronchopulm nodes (hilum)

Deep plexus
Bronchi and pulm vessels toward hilum to pulmonary nodes (lung) to bronchopulm nodes (hilum)

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

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 Second level ● Third level ● Fourth level ● Fifth level
Fibroserous sac enclosing heart and roots of great BVs Fibrous pericardium
Strong and limits unnecessary mov’t 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 Transverse sinus ● Third level ● Fourth level Reflection around ascending aorta, pulm trunk and great veins ● Fifth level

Oblique sinus

Click to edit Master text styles Second level ● Third level Nerve supply ● Fourth level Phrenic n ● Fifth level

Reflection around vena cavae and 4 pulm veins

Heart
Hollow muscular organ somewhat pyramidal 3 surfaces: sternocostal, diaphargmatic, base Apex: downward, forward, left
5th left ICS 9 cm from midline Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level

Heart
4 chambers
R atrium and ventricle anterior

Walls
Epicardium

Visceral serous outer layer

Myocardium

Middle, thick, muscle layer

Endocardium

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

Inner thin layer

Skeleton
Fibrous rings around AV, pulmonary and aortic openings Continuous with upper part of ventricular septum

Right Atrium

Heart Chambers

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 IVC Fossa ovalis
Shallow depression on atrial septum Foramen ovale

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

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) Thicker walls than RA Trabeculae carneae (internal surface ridges)
Papillary muscles

Base attached to ventricular wall Apices attached to tricuspid valve through chordae tendinae

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

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 3 cusps attached with chordae tendinae

Anterior, septal and inferior

Pulmonary Valve
Guards pulmonary orifice 3 semilunar cusps attached to arterial wall

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

1 posterior, 2 anterior 3 dilatations at root of pulmonary trunk

Pulmonary sinuses

Left Atrium
Posterior to RA Main cavity and auricle Muscle ridges in auricle Openings
Pulmonary veins (2 from each lung) on posterior wall (no valves) L AV orifice guarded by mitral valve

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

Left Ventricle
Behind RV Small portion projects to L, forms L margin of heart and apex Communicates with LA via AV orifice, Aorta via aortic orifice 3x thicker walls than RV Trabeculae carneae and 2 papillary muscles
No moderator band

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

Aortic vestibule below aortic orifice

Left Ventricle
Mitral Valve
Guards AV orifice 2 cusps (anterior and posterior) Chordae tendinae and papillary muscles

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

Aortic Valve
Guards aortic orifice 3 semilunar cusps (1 anterior, 2 posterior) Aortic sinus behind each cusp

Ant - R coronary a L post - L coronary a

Heart Sounds
Tricuspid valve
R half of lower end of sternal body

Mitral valve
L 5th ICS 9 cm from midline

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

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) Supplied by R coronary a (sometimes L)

Atrioventricular node
Lower part of atrial septum Above attachment of septal cusp of tricuspid R coronary a

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

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

Blood Supply of the Heart
L Coronary A Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level Arises fr L post aortic sinus of ascending aorta Larger than R Divides into anterior interventricular br and a circumflex branch

Venous Drainage
Click to edit Master text styles Second level Remainder drains thru ● Third level anterior cadiac vein and small veins (venae cordis minimae) ● Fourth level Coronary sinus ● Fifth level
Great cardiac vein Middle cardiac vein Small cardiac vein Anterior cardiac vein

Most fr heart walls drains into RA through coronary sinus

Nerve Supply of the Heart
Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level
Cardiac plexuses Postganglionic sympathetic and parasympathetic fibers on SA and AV nodes, cardiac muscle fibers and coronary aa
HR Force of contraction Coronary dilatation/constriction

PS fibers reach cardiac plexuses via vagus n

Large Veins of the Thorax
Brachiocephalic veins SVC Azygos v Inferior hemiazygos v Superior hemiazygos v IVC Pulmonary veins

ck to edit Master text styles ond level Third level ● Fourth level ● Fifth level

Large Arteries of the Thorax
Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level
Aorta
Ascending

R and L coronaries Brachiocephalic a L CCA L subclavian a Post intercostal aa Subcostal aa Pericardial aa Esophageal aa Bronchial aa

Arch
● ●

Descending
● ●

Abdominal

Large Arteries of the Thorax
Click to edit Master text styles De-O2 from RV to lungs Second level ● Third level R and L pulmonary ● Fourth level arteries ● Fifth level Ligamentum arteriosum

Pulmonary Trunk

Lymph Nodes and Vessels of the Thorax
Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level
LNs
Internal thoracic nodes Intercostal nodes Diaphragmatic nodes Brachiocephalic nodes Posterior mediastinal nodes Tracheobronchial nodes

Lymph Vessels
Thoracic duct

Cysterna chyli

Right lymphatic duct

Large Nerves of the Thorax
Vagus nerves R vagus
Ant to subclavian a Lateral to trachea Medial to azygos v Posterior esophagus

L vagus
Bet L CCA and L subclavian a Anterior esophagus

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

Branches
Recurrent laryngeal n

R - subclavian L - arch

Cardiac br Pulmonary br Esophageal br

Large Nerves of the Thorax
Phrenic nerve Anterior rami of 3-4th cervical nerves R - R of SVC L - L of subclavian a Sympathetic Trunk Thoracic part
Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level

Esophagus
25 cm muscular tube Continuous with pharynx (C6) Passes diaphragm (T10) to join stomach 3 constrictions
Beginning Crossed by left bronchus Diaphragm

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

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 structure Bet sternum and pericardium Source of Tlymphocytes
Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level

THANK YOU!

Sign up to vote on this title
UsefulNot useful