Thoracic Wall

At the end of your study, you should be able to:

▪ Identify the major features of the surface anatomy of the
chest wall
▪ Know the types of joints of the thoracic cage
▪ Identify muscles of the anterior chest wall and know their
attachments, actions, and innervation
▪ Identify the intercostal muscles, ribs and their parts
▪ Understand the organization of a typical intercostal space
and clinical significance of its contents
▪ Understand the mammary gland – location, blood supply,
innervation and lymphatic drainage of the breast
Thoracic Wall
Thoracic Wall
▪ The thorax lies between the neck and the abdomen
▪ Consists of skin, fat, muscles, bones and cartilage.
▪ Above, it communicates through the ‘thoracic inlet’ with
the root of the neck; below, it is separated from the
abdominal cavity by the diaphragm
▪ Components of the thoracic wall
✓Thoracic outlet – superiorly
✓12 Thoracic vertebrae and intervening intervertebral discs –
posteriorly
✓ribs and intercostal spaces – laterally
✓Sternum and costal cartilages of ribs– anteriorly
✓Diaphragm - inferiorly
Thoracic inlet or superior thoracic aperture
▪ Slopes anterior-inferiorily
st
due to
obliquity of the 1 rib
▪ Clinically called the thoracic outlet
▪ bounded by the
▪ body of T1 vertebra
▪ medial borders of the 1st ribs
and their costal cartilages
▪ superior border of the
manubrium sterni
▪ transmits structures that pass
between the thorax and the neck
(esophagus, trachea, blood vessels,
etc.)
▪ the outlet is closed by a dense
fascial layer called the suprapleural
membrane, a thickening of the
endothoracic fascia.
Sternum

▪ Has 3 parts:
▪ Manubrium – superior part
✓Articulates with clavicles and 1st
two pairs of ribs
▪ Body – bulk of sternum
✓Sides are notched at articulations
for costal cartilage of ribs 2–7
▪ Xiphoid process – inferior end
of sternum, may be bifid or
perforated
✓Hyaline cartilage in youth
✓Ossifies around age 40
Sternum
▪ Anatomical landmarks
▪ Jugular notch/suprasternal notch
▪ Central indentation at superior border
of the manubrium
▪ Sternal angle (of Louis)
▪ A horizontal ridge where the
manubrium joins the body
▪ Landmark for counting ribs
▪ Infrasternal notch/subcostal
angle
▪ The costal cartilages of 7th, 8th,
9th, and 10th ribs form a sloping
costal margin

Sternal puncture (for bone marrow), sternal

fracture, midsternotomy, sternal foramen
and cleft sternum
Clinical Correlation

Pectus Carinatum/ Pigeon

Pectus excavatum/Funnel chest
or sunken chest
Ribs
▪ 12 pairs. All ribs articulate with thoracic vertebrae posteriorly
▪ Spaces between the ribs are the intercostal spaces
▪ Space is greater in upper ribs than lower ribs. Also, height of space is greater
anteriorly than posteriorly
▪ 2nd intercostal space at the midclavicular line: Insertion of tube for an
apical pneumothorax (thoracostomy)
▪ 4th to 6th intercostal space at the midaxillary line: Insertion of chest drains
for a hemothorax (thoracostomy)
▪ True ribs (vertebrosternal ribs) – upper 7 pairs of ribs
▪ Articulate directly with sternum via costal cartilages
▪ False ribs – lower 5 pairs of ribs. Consists of
▪ vertebrochondral ribs: ribs 8-10
▪ articulate each with the cartilage of the rib above which in turn is attached
to the sternum
▪ vertebral/floating ribs: ribs 11–12.
▪ do not attach to the sternum
Structure of a typical rib

▪ Costal groove at inferior border of inner surface

▪ contain intercostal vein, arteries and nerve – VAN
Structure of a typical rib
▪ Head
▪ Articulates with 2 successive thoracic vertebrae
▪ Exceptions: ribs 1, 10, 11 and 12
▪ Neck
▪ Ribs 11 and 12 have short neck

▪ Angle
▪ No angle in ribs 12

▪ Tubercle
▪ Articulates with the transverse process of associated vertebra
▪ Exceptions: ribs 11 and 12 have no transverse process
articulation

▪ Costal groove
▪ No costal groove in ribs 1, 12
Rib 1
▪ Strongest, shortest, broadest, flattest and most curved.
▪ Small rounded head with a single circular articular facet;
angle and tubercle coincide; no costal groove on its inner
surface; medial and lateral borders
▪ Round and elongated neck. Larger and thicker anterior end
▪ Rib belongs to the side on which its both ends touch the surface
of a table.

Rib 2
▪ Not twisted; hence both the ends of rib touch the table-top when
placed on it
▪ Head has two facets for articulation with T1 and T2
▪ Rough area on its upper surface, the tuberosity for serratus
anterior
▪ Short costal groove
First and second ribs
Ribs
Ribs

T4

T5

Rib 5
Ribs

Normal Lumbar rib (Gorilla rib)

Flail chest (stove-in-chest) Cervical rib and thoracic

outlet syndrome
Thoracic Outlet Syndrome
▪ Caused by compression of the brachial plexus and the subclavian artery and
vein
▪ Most of the symptoms are caused by pressure on the lower trunk of the
plexus producing pain down the medial side of the forearm and hand and
wasting of the small muscles of the hand. Pressure on the blood vessels may
compromise the circulation of the upper limb
Tube thoracostomy

A. The site for insertion of the tube at the anterior axillary line. The skin incision is usually made over the
intercostal space one below the space to be pierced. Triangle of safety?
B. The various layers of tissue penetrated by the scalpel and later the tube as they pass through the chest wall
to enter the pleural cavity (space). The incision through the intercostal space is kept close to the upper border
of the rib to avoid injuring the intercostal vessels and nerve.
C. The tube advancing superiorly and posteriorly in the pleural space.
Thoracic Vertebrae (T1 – T12)
▪ All articulate with ribs.
✓Presence of costal facets
✓Body - Facet for heads of ribs
✓Transverse Process - Facet for tubercle of ribs
✓Heart-shaped bodies
✓Vertebral foramen is circular
✓Spinous processes are long and point inferiorly
▪ 2-8 are typical
▪ T1 –resemble C7
▪ T9 – T12 only a single facet on the body
▪ T11 – T12 no articular facet on transverse process
▪ T12 resembles T1
Thoracic Vertebrae
Joints of the thoracic cage
▪ Intervertebral joint
▪ Interchondral joint – Plane
▪ Costovertebral joint – Plane
▪ Costotransverse joint – Plane
▪ Costochondral joint – Primary cartilaginous joint
▪ Sternoclavicular joint – Saddle
▪ Sternocostal joint or Sternochondral joint
▪ 1st sternocostal joint - Primary cartilaginous joint
▪ 2- 7th sternocostal joints - Plane jt.
▪ Manubriosternal joint – Secondary cartilaginous joint
▪ Xiphisternal joint – Primary cartilaginous joint
Joints of the thoracic cage
Muscles of the thoracic region
Muscles of the thoracic region
Muscles of the thoracic region
Muscles of the thoracic region
Neurovascular bundle course
between the internal and innermost
intercostal muscles
Muscles of the thoracic region
Muscles of the thoracic region
Vasculature of thoracic wall

• Anterior intercostal arteries from the internal thoracic

• The corresponding posterior intercostal veins
and its branch the musculophrenic arteries
• Posterior intercostal arteries of the lower 9 intercostal drain backward into the azygos or hemiazygos
spaces from the thoracic aorta veins, and the anterior intercostal veins drain
• The first and second posterior intercostal arteries forward into the internal thoracic and the
arise from the superior (supreme) intercostal musculophrenic veins.
arteries, a branch of the costocervical trunk of the
subclavian artery
Innervation of thoracic wall
 Diaphragm
• Musculoaponeurotic sheet with right and left domes; the right dome is
higher (reaches as high as the upper border of the 5 th rib) than the left dome (may
reach the lower border of the 5th rib) owing to the liver.
• Completely formed by 10 weeks of gestation
• Separates the abdominal cavity from the thoracic cavity
• Major muscle is respiration,

• Arises from
• post surface of xiphoid process (sternal part, not always present)
• inner surfaces of lower 6 costal cartilages (costal part)
• medial and lateral lumbocostal arches; vertebrae L1-L3 for the right crus, and
vertebrae L1-L2 for the left crus (lumbar part),
• Inserts on trifoliate central aponeurotic part, the central tendon
Nerves: Motor – Phrenic nerve (C3-C5)
Sensory: 102

central part – phrenic nerve,

peripheral part –intercostal nerves.
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 Diaphragm

Medial arcuate ligament (medial Lateral arcuate ligament (lateral103

lumbocostal arch) lumbocostal arch)
•thickening of the fascia covering the
•thickening of the fascia covering the
psoas major quadratus lumborum muscles
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 Diaphragm
Apertures through and behind the diaphragm

Caval hiatus
• lies in the central tendon of the diaphragm at the level of T8
• transmits the IVC and, occasionally, the right phrenic nerve.

Esophageal hiatus
• lies in the muscular part of the diaphragm (right crus) at the level of T10
• transmits the esophagus, anterior and posterior trunks of the vagus
nerves, oesophageal branches of left gastric vessels, left inferior
phrenic vessels

Aortic hiatus
• lies behind diaphragm or between the crura posterior to the median
arcuate ligament at the level of TI2 105
• transmits the aorta, thoracic duct, azygos vein, and, occasionally,
greater splanchnic nerve.
 Diaphragm
Apertures through and behind the diaphragm
Small Openings in Diaphragm
•Lymphatic vessels from the diaphragmatic surface of the liver
and the superior epigastric vessels pass the Sternocostal triangle
(foramen)

•Sympathetic trunks and least splanchnic nerves pass deep to the

medial arcuate ligament

•two small apertures in each crus of the diaphragm; one transmits

the greater splanchnic nerve and the other the lesser splanchnic
nerve.

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 or celiac trunk

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Respiratory Movements

Forced inhalation

Forced
exhalation

Eupnea?
Hyperpnea?
Respiratory Movements
Inspiration
▪ Volume of thoracic cavity increases
▪ Decreases internal gas pressure
▪ Diaphragm contracts and flattens to increase the
vertical diameter
▪ External intercostal muscles contract and elevates the
ribs and sternum up and out
▪ the transverse diameter increases - Bucket-handle
movement.
▪ the anteroposterior diameter of the thorax increases as
ribs 2-6 move up and out - Pump-handle movement
Inspiration
Congenital diaphragmatic hernias, eg Morgagni’s and Bochdalek’s hernias?
Congenital diaphragmatic hernias
• Bochdalek hernia- most common type of congenital diaphragmatic hernia,
represents an absence of a pleuroperitoneal membrane, usually on the left
side of the diaphragm, adjacent abdominal organs can enter the thorax, where they
may compress the lungs and move the heart anteriorly.

• Morgagni hernia – rare, may be asymptomatic, most often occurs on the right side
of the diaphragm, is due to muscular deficits in the sternocostal triangles (foramina
of Morgagni),
 Hiatal hernia
▪ Found in patients usually of middle age due to weakening and widening of the
oesophageal hiatus
▪ Sliding hernia
▪ upper stomach and lower oesophagus slide upwards into the chest through the lax hiatus
when the patient lies down or bends over. The competence of the cardia is often disturbed
and peptic juice can therefore regurgitate into the oesophagus in lying down or bending
over. It may be followed by oesophagitis with consequent heartburn, bleeding and,
eventually, stricture formation.

▪ Rolling hernia/para-oesophageal hernia

(which is far less common)
▪ the cardia remains in its normal position
and the cardio-oesophageal junction is
intact. The fundus of the stomach rolls up
through the hiatus in front of the
oesophagus.
▪ there may be epigastric discomfort,
flatulence and even dysphagia, but no
regurgitation because the cardiac
mechanism is undisturbed.
 Diaphragm
▪ Referred pain from the diaphragm to the shoulder due to C4 phrenic
innervation
▪ Hiccups
▪ involuntary, spasmodic contractions of the diaphragm, leading to quick
inhalations that are interrupted by the involuntary closure of the glottis
▪ result from irritation of nerve endings or of medullary centers (which control
respiration).
▪ causes are indigestion, diaphragm irritation, alcoholism, cerebral lesions, and
thoracic and abdominal lesions, all of which disturb the phrenic nerves.

▪ Valsalva maneuver
▪ An action that forcibly exhales, with the glottis, nostrils and mouth closed
▪ When this occurs, the diaphragm contracts, thereby increasing intra-abdominal
pressure. The increased intra-abdominal pressure equalizes
pressure in the middle ear, and expels vomit, feces, and urine
from the body.
Mammary (mamma = breast) glands
▪ Modified apocrine sweat gland that secrete milk to nourish an infant
(lactation).
▪ Size of female breast is determined by the amount of fat surrounding
the glandular tissue.

▪ Rudimentary and functionless in males and immature females. Reach

mature state of development during pregnancy.
▪ Located in the subcutaneous tissue (superficial fascia) and overlies the
pectoralis major and serratus anterior muscles.
▪ Extends from the 2nd to 6th ribs and from the sternal edge to the
midaxillary line.

▪ Is separated from the deep fascia covering the underlying muscles

(Pectoralis major) by an area of loose areolar tissue known as the
retromammary space, which allows the breast some degree of
movement over the pectoralis major muscle.
Mammary (mamma = breast) gland
▪ Divided into 15 to 20 radially arranged lobes of glandular tissue
by the septa of the suspensory ligaments. Each lobe opens by a
lactiferous duct onto the tip of the nipple, and each duct enlarges
to form a lactiferous sinus, which serves as a reservoir for milk
during lactation

▪ Divided into the upper and lower lateral and medial quadrants. A
small part of the upper lateral quadrant (axillary tail of Spencer)
may be prolonged towards the axilla. 50% breast cancer cases
occur in the upper lateral quadrant.

▪ Nipple
▪ projection on anterior surface of breast that contains lactiferous
ducts, and orifice for delivery of milk
50
Mammary Glands
▪ Areola
▪ dark patch of skin around each nipple.
▪ pigmentation increases during pregnancy
▪ contains areolar glands or glands of Montgomery. These
sebaceous glands make oily secretions to keep the areola and the
nipple lubricated to minimize cracking of the skin of the nipple
during breast feeding. The areolar glands form small elevations
(tubercles of Montgomery), particularly when they enlarge
during pregnancy.
Mammary Glands
▪ Suspensory ligaments (Cooper’s ligament)
▪ Strands of fibrous tissues that connect the dermis of the skin to the
deep layer of the superficial fascia.
▪ help to maintain the protuberance of the young breast; with the
atrophy of age they allow the breast to become pendulous,
▪ they cause pitting of the oedematous skin that results from
malignant involvement of dermal lymphatics (an appearance often
referred to as peau d’orange).
 First rib

Skin (cut)
Pectoralis major muscle

Suspensory ligament

Adipose tissue
Lobe
Areola
Nipple
Opening of lactiferous duct
Lactiferous sinus
Lactiferous duct
Lobule containing alveoli
Hypodermis
(superficial fascia)
Intercostal muscles
Blood supply, Lymphatic and Innervation
▪ Arteries: Mainly from lateral thoracic (from axillary artery). And also
anterior intercostal branches of internal thoracic or internal
mammary), posterior intercostal and thoracoacromial arteries
▪ Veins: Tributaries from the internal thoracic, lateral thoracic, and
posterior intercostal veins.
▪ Lymphatics
▪ Mostly to the axillary lymph nodes. Some lymph from the medial region
drain into the parasternal and supraclavicular lymph nodes, and may cross
the midline or reach inguinal lymph nodes
▪ Cancerous infiltration of the axillary lymph nodes may produce arm
swelling (lymphoedema). Symptoms include persistent accumulation
of a protein-rich fluid in the interstitial tissues and swelling of
the upper limb on the affected side

▪ Innervations: anterior and lateral cutaneous branches of the T2-T6

nerves, supraclavicular nerves from cervical plexus
Prominent lymph nodes in the axillary region

Breast examination
The breast is palpated in a circular fashion, beginning with the nipple and moving
outward. The palpation should extend into the axilla to palpate the axillary tails
Mammogram procedure

Malignancy

Film of normal Film of breast

breast with tumor
 Supernumerary breasts or
Gynecomastia: enlargement of the breasts
nipples may be formed
in males
anywhere along the ‘milk
Polymastia - more than one pair of breasts,
line’, which extends from
Polythelia - more than one pair of nipples,
axilla to groin.
Amastia - absence of breasts
Athelia - absence of nipples.