You are on page 1of 111

Thoracic Cage and Wall

Nur Afrainin Syah

Functions



Protects vital organs within the thorax
Supports thorax during respiration,
Supports shoulder girdles and upper limbs
Provides attachment points for back, chest
and shoulder muscles.

Thoracic
cage

Thoracic inlet .

Triangular in shape Apex: attached to transverse process of C7 Base: Attached to medial border of the first rib Superiorly: Related to subclavian vessels Inferiorly: Apex of lung & cervical pleura .       Suprapleural membrane Dense fascia closes the lateral part of the thoracic inlet.

.

.

Mediastinum .

.

.

.

.

.

.

.

.

.

.

.

and the thoracic vertebrae. Anterior -------------. Thoracic inlet: (the upper opening of the thoracic cage) Boundaries: a. c.First rib. . I.First thoracic vertebra. Posterior -------------. the ribs. b.Thoracic Cage .The thoracic cage consists of the sternum.Supra-sternal notch of the manubrium sterni.It has a narrow inlet and a wide outlet. On each side --------. .

Lower six costal cartilages + Last two ribs. b. On each side --------. . Boundaries: a. Posterior -------------.Xiphoid process.Last thoracic vertebra. . c. Thoracic outlet It is the lower opening of the thoracic cage. Anterior -------------.II.It is closed by the diaphragm which separates it from the abdominal cavity.

Parts    Composed of thoracic vertebrae (dorsal) Ribs (laterally) Sternum with costal cartilages (anteriorly). .

.

manubrium.Sternum     Divided into three parts. body and xiphoid process. Manubrium (superior) is shaped like a knot in a necktie. Articulates with clavicle at clavicular notches. A flat bone approximately 6 inches long. .

Sternum .

triangular shape  Articulates with clavicles (collarbones)  Articulates with cartilages of first rib pair  Has a jugular notch.Manubrium  The superior portion of sternum  Broad. a shallow indentation between clavicular articulations .

.Body   Forms the bulk of the sternum (tongue shapes) Sides are notched where it articulates with cartilages of the second to seventh ribs.

Body .

but ossifies in adults. Articulates only with sternal body and serves as attachment point for diaphragm and some abdominal muscles (m. . rectus abdominis).Xiphoid process    Forms inferior end of sternum. Is hyaline cartilage in youth.

Sternal landmarks    Jugular notch Sternal angle Xiphisternal joint .

.Jugular notch    Visible as a central indentation in the upper border of manubrium. Is also in line with the point where the left common carotid artery issues from the aorta. Is generally in line with the disc between T-2 and T-3.

Sternum is slightly angled at this point. Can be felt as a horizontal ridge across across front of sternum.Sternal angle     Found where the manubrium joins the sternal body. Landmark position for 2nd rib and the disc between T-4 and T-5. .

Xiphisternal angle   Where sternal body and xiphoid process fuse. Lies opposite ninth thoracic vertebrae. .

. Inc. Development of the Sternum   The developing sternal body  Consists of four unfused bones  Completes fusion about age 25  Leaving transverse lines The xiphoid process  Is the last part of sternum to fuse  Can easily be broken away Copyright © 2009 Pearson Education. publishing as Pearson Benjamin Cummings .

.Rib Cage  Ribs  Are mobile  Can absorb shock  Functions of ribs  Rib movements (breathing):  affect width and depth of thoracic cage  changing its volume Copyright © 2009 Pearson Education. publishing as Pearson Benjamin Cummings . Inc.

Rib Cage .

The Rib Cage Copyright © 2009 Pearson Education. Inc.. publishing as Pearson Benjamin Cummings .

The Rib Cage  Ribs (costae)  Are 12 pairs of long. Inc.. curved. flat bones  Extending from the thoracic vertebrae  Ribs are divided into two types  True ribs  False ribs Copyright © 2009 Pearson Education. publishing as Pearson Benjamin Cummings .

Inc.. Ribs 1–7 (true ribs)    Vertebrosternal ribs Connected to the sternum by costal cartilages Ribs 8–12 (false ribs)   Do not attach directly to the sternum Vertebrochondral ribs (ribs 8–10)    Fuse together Merge with cartilage before reaching the sternum Floating or vertebral ribs (ribs 11–12)   Connect only to the vertebrae and back muscles Have no connection with the sternum Copyright © 2009 Pearson Education. publishing as Pearson Benjamin Cummings .

Copyright © 2009 Pearson Education. Inc.. publishing as Pearson Benjamin Cummings .

Inc.Copyright © 2009 Pearson Education.. publishing as Pearson Benjamin Cummings .

Typical rib .

Atypical ribs First rib (general features) .

Second rib .

.

Single articular facet on the head. .Tenth rib a.

Single articular facet on the head. No tubercle.Eleventh rib a. . b.

No neck. Large head. d. c.Twelveth rib a. No tubercle. No costal groove. Single articular facet on the head. Tapering anterior end. . f. e. b.

and 12th vertebrae (first one and last 4 vertebrae). B: Atypical ----.2nd – 8th vertebrae. . 10th.There are twelve thoracic vertebrae classified as: A: Typical -----. 11th.Thoracic vertebrae Classification of thoracic vertebrae: . 9th.1st.

while the inferior articular . 4. and directed downwards and backwards. tapering. b. Large upper demifacet for articulation with the head of the rib of the corresponding number.Characteristics of a typical thoracic vertebra 1. .Small in size and heart shaped.  3.  5. The vertebral foramen is circular and small. The superior articular process faces backwards. Small lower demifacet for articulation with the head of the rib below it. The body is characterized by: .Its side contains two demifacets: a.  2. The spine is long. The tip of the transverse process contains circular facet for articulation with the tubercle of the rib of the corresponding number.

Typical thoracic vertebra Lateral surface Superior surface .

2. The body carries complete circular articular facet for articulation with the head of the first rib.First thoracic vertebra 1. The vertebral foramen is wide and triangular. The body is small . 3. .

The ninth& tenth thoracic vertebrae Ninth vertebra Tenth vertebra .

The eleventh & twelveth thoracic vertebrae Eleventh vertebra Twelveth vertebra .

.

Articulation between Thoracic vertebrae and the ribs .

The muscles of the thorax      They are all concerned in the movements of the ribs and hence with respiration The intercostales Transversus thoracis Levatores costarum Pectorales .

Pectoralis major Origo : Clavicula. sternum Vagina m. pectorales Sulcus deltoideopectoralis Clavipectoral triangle Trigonum clavipectorale Anterior wall of the axilla M. rectorum Insertio : crista tuberculi majoris .Mm.

Clavipectoral fascia .

.

.

Relations of the pectoralis minor to axillary vessels and brachial plexus .

.

CLAVIPECTORAL FASCIA .

N. – 9.M. serratus ant. Rib Insertio : medial margin of the scapula. Origo : 1. Thoracicus longus .

3.Intercostal muscles: (External.        Intercostal Spaces There are 9 anterior and 11 posterior Each space contains: 1.Intercostal vessels: a. Internal and transversus thoracicus) 2. Intercostal arteries (Anterior & Posterior) b.An Intercostal nerve. . Intercostal veins (Anterior & Posterior).

end of Intercostal space close to the tubercle of the rib. Ends at the costochondral junction where it is replaced by external or anterior Intercostal membrane. It elevates the rib during inspiration .       EXTERNAL INTERCOSTAL Origin: From the lower border of the rib above Insertion: Into outer lip of upper border of rib below Fibers are directed from above downward and forwards Begins from post.

Or internal Intercostal membrane. where it is replaced by post. Action: Depresses the rib downwards during expiration . Ends at the angle of the rib.       INTERNAL INTERCOSTAL Origin: Floor of costal groove Insertion: Inner lip of upper border of rib below Fibers are directed from above downwards & backward Begins from anterior end of space close to the sternum.

3.Sternocostalis. 2. which splits each muscle into 2 parts: Outer: Internal Intercostal (proper) Inner: Innermost Intercostal (In the middle of the space)  Transversus thoracicus The most inner layer of thoracic wall It is formed of 3 muscles 1.Innermost Intercostal.          Internal Intercostal is partly traversed by the nerve & vessels.Subcostalis .

.

. Only in post.        Sternocostalis 4 to 5 slips which arise from inner surface of lower part of body of sternum and costal cartilages Inserted into inner surface of costal cartilages from 2 to 6. Origin: Inner surface & lower border of rib above. Mainly in lower 6 spaces. Insertion: Upper border of 2nd or 3rd rib below. part of spaces.  Subcostalis muscle Thin bands of muscle fibers.

Anterior Intercostal arteries 2 small arteries in each of the 9 spaces. Internal mammary or internal thoracic artery is a branch from1st part of subclavian artery      . The upper 6 from internal mammary artery The lower 3 from musculo-phrenic artery NB.

.    Posterior Intercostal arteries One in each of the 11 spaces 1st & 2nd arise from superior Intercostal artery of costocervical trunk of 2nd part of subclavian artery The lower 9 arteries & subcostal artery arise from descending thoracic aorta.

 In each space the posterior Intercostal artery and its collateral branch anastomose with the 2 anterior Intercostal arteries .

     Anterior Intercostal veins 2 in each space.5th & 4th join venae commitantes of internal mammary artery 3rd.2nd &1st join internal mammary vein Internal mammary vein drains into innominate (Brachiocephalic vein) .8th & 7th join the venae commitantes of musculophrenic artery 6th. 9th.

6th. On the Left: 1st drains into Lt.          Posterior Intercostal veins One in each of the 11 spaces.3rd & sometimes the 4th unite to form Rt. 5th.11th &Subcostal form inferior hemiazygos vein to azygos vein. innominate V. Innominate v.10th. Superior Intercostal vein (B) which drains into azygos vein. 2nd. From 5th to 11th & subcostal veins drain into azygos vein ©. Superior Intercostal vein which drains into Lt innominate vein. On the right: 1st drains into Rt. 2nd.3rd& sometimes the 4th join to form Lt. . & 8th form superior hemiazygos vein to azygos vein 9th.7th.

.

     Intercostal Nerves They are the anterior primary rami of spinal thoracic nerves fromT1 to T11 T3 toT6 are Typical T12 is called Subcostal The remaining nerves are called atypical (non-typical) Each nerve runs in the Intercostal space inferior to the Intercostal vessels .

and deep fascia to become anterior cutaenous nerve . Intercostal membrane Pierces Internal Intercostal muscle splitting it into Internal Intercostal (proper) and innermost Intercostal. pectoralis major.Typical Intercostal nerve       From T3 to T6 Leaves the intervertebral foramen to reach the Intercostal space. Runs between Internal Intercostal muscle & Pleura. anterior Intercostal membrane. Pierces Internal Intercostal muscle. Runs between pleura & post.

Branches:  White & grey rami (I) communicans with sympathetic ganglion  Collateral branch to Intercostals (2)  Lateral cutaenous branch to skin (3)  Anterior cutaenous (4)  Muscular branches  Pleural sensory branches  peritoneal branches (5)  Articular branches. .

with previous exception the upper 6 Intercostal nerves supply skin & parietal pleura and Intercostal muscles in each space .     1st Intercostal nerve: Joined to Brachial plexus. by a branch that is equivalent to lateral cutaenous branch. So. by a branch called Intercostobrachial nerve ( corresponds to lateral cutaenous branch) In Angina pectoris & myocardial infarction pain referred to medial side of arm along this nerve.  2nd Intercostal nerve: Joined to the medial cutaenous nerve of the arm.

side of thoracic duct & aorta. S V C I V C . Lung In sup. Border of esophagus & root of rt. lung Enters the middle of the back of the SVC. Mediastinum (L4) it crosses above the root of rt. Mediastinum it passes behind Rt.     Azygos Vein Connects IVC with SVC Begins in abdomen from back of IVC at level of L2 Enters thorax through Aortic opening of diaphragm on Rt. In post.

.

Mm. Intercostales interni (11) Internal intercostal membrane (depression of the ribs) Exspiratory muscles From posterior costal angles to the sternum Mm.intercostales externi (11) Inspiratory muscles (elevation of ribs) From the tubercles of the ribs to the cartilage of the ribs in front .

function unclear .Intercostal Muscles  External Intercostals     Internal Intercostals     O: Inferior border of rib above I: Superior border of rib below Fibers run OBLIQUE (down and forward) Aid in Inspiration (lift ribcage. Subcostals. increase dimensions) O: Superior border of rib below I: Inferior border of rib above Fibers run at RIGHT ANGLES to external intercostals Aid in forced expiration (depress ribcage. variable. Transversus thoracis   Attachments similar to Internal Intercostals. Attach ribs Small. decrease dimensions) Innermost Intercostals.

Neurovascular Bundle of Intercostal Muscles  VAN (vein. nerve)      Intercostal vein Intercostal artery Intercostal nerve Sit in Subcostal Groove Between Internal Intercostal and Innermost intercostal layer Pg 128 . artery.

Mm. Intercostales externi External intercostal membrane .

Spatium intercostale
Intercostal space and layers of thoracic wall

The intercostales intimi
Poorly developed in upper spaces,
More extensive in lower spaces
Separate intyercostal vessels and
nerve from the pleura

Action : like the intercostales interni

Spatium
intercostale

Puncture of the pleural cavity
Punkce cavum pleurae

.

LUMBAR PART COSTAL PART STERNAL PART The diaphragmatic aperturtes : Aortic Oesophageal Vena caval Main inspiratory muscle .shaped muscle which separates the thoracic from the abdominal cavity.DIAPHRAGMA THE DIAPHRAGM A dome. Its periphery consists of muscular fibres attached to the central tendon (aponeurotic).

DIAPHRAGMA  Hranice mezi dutinou hrudní a břišní .

Diaphragma Crus mediale L1 – L3 Crus laterale L 1 – L2 .

.

.

Lumbocostal arches Medial and lateral .

N. Phrenicus (C 4) .

Inferior phrenic artery Phrenic nerve .

Diaphragmatic part of the pericard .

Relations of the diaphragm  The upper surface is in relation with the pleura (right and left diaphragmatic pleura) and with the pericardium  Lower surface is covered by peritoneum .

Right dome Left dome 4th intercostal space 5th intercostal space .

Upper surface and diaphragmatic apertures .

.

Diaphragma .actions   Principal muscle of inspiration During inspiration muscular fibres contract and the central tendon and domes move downwards (volume of the thoracic cavity increases) .

Inspiration     Elevation of ribs (external intercostal muscles) Depression of the diaphragm In quiet inspiration the principal muscle is the diaphragm In forced inspiration additional muscles are called into action (pectoral. scalenic) .

Expiration   Relaxation of the diaphragm Contraction of the intercostales interni .

Surface Anatomy Use the next 3 slides and follow the book to palpate (feel) the features listed .

Anterior Surface of Thorax  Palpate the following         Sternum (3 parts) Jugular notch Sternal Angle (= 2nd rib) Clavicle Costal margin Xiphosternal joint Midclavicular Line Midaxillary Line Page 201 .

Posterior Surface of Thorax  Palpate the following   Spinous Process of C7 Scapula (ribs 2-7) Scapular spine  Acromion Process  Inferior Angle of Spine  Inferior Border  Page 90 .

Locating Internal Structures  Pleural Cavities       Inferior margin = adjacent to T12 in Posterior Midline To Rib 10 at Midaxillary line To Rib 8 at Midclavicular line To Xiphosternal joint medially Lungs posterior border is 2 ribs superior to pleural cavity (rib 8) Heart  Deep to xiphisternal angle Page 206 .