SURFACE ANATOMY &

MARKINGS OF THE
THORAX

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 Bony Landmarks of the thorax
• The thorax (or chest) is the region of the body between the
neck and the abdomen. The jugular notch is in the same
horizontal plane as the lower border of the body of the
second thoracic vertebra (T2)

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 Bony Landmarks…
• The sternal angle corresponding to the second costal
cartilage, is at the level opposite the intervertebral disc
between the fourth and fifth thoracic vertebrae is so readily
found that it is used as a starting-point from which to count
the ribs.

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 The sternal angle (angle of Louis)
• The angle is formed by the articulation of the manubrium with the body of
the sternum, can be recognized by the presence of a transverse ridge on the
anterior aspect of the sternum. The transverse ridge lies at the level of the
second costal cartilage, the point from which all costal cartilages and ribs
are counted. The sternal angle lies opposite the intervertebral disc between
the fourth and fifth thoracic vertebrae

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 Landmarks…
• Lungs
• The apex of the lung is situated in the neck above the medial
third of the clavicle. The height to which it rises above the
clavicle varies very considerably, but is generally about 2.5
cm.

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Landmarks…

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 Landmarks…
• Trachea. This may be marked out on the back by a line from the
spinous process of the sixth cervical to that of the fourth
thoracic vertebra (C6-T4). In front, the point of bifurcation
corresponds to the sternal angle. It’s a point where trachea
bifurcates.

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 Landmarks…
• Esophagus.—The extent of the esophagus may be
indicated on the back by a line from the sixth cervical
to the level of the ninth thoracic spinous process (C6-
T9), 2.5 cm. to the left of the middle line.

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 Landmarks…
• Heart:-The apex of the heart is first determined,
either by its pulsation or as a point in the fifth
interspace, 9 cm.
• The position of the various orifices is as follows:
The pulmonary orifice is situated in the upper angle
of the third left sternocostal articulation; the aortic
orifice is a little below and medial to this, close to the
articulation. The left atrioventricular opening is
opposite the fourth costal cartilage, and rather to
the left of the midsternal line; the right
atrioventricular opening is a little lower,
opposite the fourth interspace of the right side.
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 Structure of the Thoracic Wall

• The thoracic wall is covered

on the outside by skin and by
muscles attaching the shoulder
girdle to the trunk. It is lined
with parietal pleura.

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Thoracic vertebra:
 They are 12 in number

Classification:
Typical thoracic vertebra:
Second to Eight
Atypical thoracic vertebra:
First, Nine to Twelve

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Features of typical thoracic vertebra:
Body: It is heart shaped; Presence of two costal demifacets
The transverse process: Tips bear oval costal facets
Spinous process: Long and slopes downward

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Features of typical thoracic vertebra…

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Features of typical thoracic vertebra…

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Atypical thoracic
vertebra:
First, Nine to Twelve

have only a
single pair of
costal facets

Atypical

typical

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 Thorax…
• The framework of the walls of the thorax, which is referred to
as the thoracic cage, is formed posteriory by the vertebral
column, the ribs and intercostal spaces on either side, and
the sternum and costal cartilages in front

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 Structure of the Thoracic Wall
• The thoracic wall is formed posteriorly by the thoracic part of the
vertebral column; anteriorly by the sternum and costal cartilages;
laterally by the ribs and intercostal spaces; superiorly by the
suprapleural membrane; and inferiorly by the diaphragm, which
separates the thoracic cavity from the abdominal cavity

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 Skeleton of the Thoracic Wall

• The thoracic skeleton

includes 12 pairs of ribs and
associated costal cartilages,
12 thoracic vertebrae and
the intervertebral discs
interposed between them, and
the sternum.

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 Sternum
• The sternum lies in the
midline of the anterior chest
wall. It is a flat bone that can
be divided into three parts:
manubrium sterni, body of
the sternum, and xiphoid
process.

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 The manubrium
• The manubrium is the upper part of the sternum. It articulates with the
body of the sternum at the manubriosternal joint, and it also
articulates with the clavicles and with the first costal cartilage and
the upper part of the second costal cartilages on each side. It lies
opposite the third and fourth thoracic vertebrae

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 Applied anatomy
• Sternum and Marrow Biopsy
• Since the sternum possesses red hematopoietic marrow
throughout life, it is a common site for marrow biopsy. Under a
local anesthetic, a wide-bore needle is introduced into the marrow
cavity through the anterior surface of the bone.
• The sternum may also be split at operation to allow the surgeon to
gain easy access to the heart, great vessels, and thymus.

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 Ribs
• Ribs (L. costae) are the long curved, flat bones that form most of
the thoracic cage

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 Ribs…
• There are three types of rib:
• True (vertebrocostal) ribs (1st to 7th ribs): They attach directly to
the sternum through their own costal cartilages.
• False (vertebrochondral) ribs (8th, 9th, and usually 10th ribs):
Their cartilages are connected to the cartilage of the rib above
them; thus their connection with the sternum is indirect.
• Floating (vertebral, free) ribs (11th, 12th, and sometimes 10th
ribs): The rudimentary cartilages of these ribs do not connect even
indirectly with the sternum; instead they end in the posterior
abdominal musculature.

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Ribs…

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 Ribs…
• Typical ribs (3rd to 9th) have the following components:
• Head: wedge-shaped and has two facets
• Neck: connects the head with the body at the level of the tubercle
• Tubercle: at the junction of the neck and body and has a smooth
articular part, for articulating with the corresponding transverse process
of the vertebra
• Body (shaft): thin, flat, and curved, most markedly at the costal angle
where the rib turns anterolaterally, the concave internal surface of the
body has a costal groove paralleling the inferior border of the rib

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Typical ribs (3rd to 9th)

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 Intercostal spaces
• Intercostal spaces separate the ribs and their costal cartilages
from one another.
• There are 11 intercostal spaces and 11 intercostal nerves.
Intercostal spaces are occupied by intercostal muscles and
membranes, and two sets (main and collateral) of intercostal
blood vessels and nerves, identified by the same number
assigned to the space.
• The space below the 12th rib does not lie between ribs and thus
is referred to as the subcostal space, and the anterior ramus of
spinal nerve T12 is the subcostal nerve.

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 Intercostal spaces
• The spaces between the ribs contain three muscles of respiration: the external
intercostal, the internal intercostal, and the innermost intercostal muscle.
The innermost intercostal muscle is lined internally by the endothoracic
fascia, which is lined internally by the parietal pleura. The intercostal nerves
and blood vessels run between the intermediate and deepest layers of muscles

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Applied anatomy:
Pleural effusion is excess fluid that accumulates between the two
pleural layers, the fluid-filled space that surrounds the lungs.
Excessive amounts of such fluid can impair breathing by limiting
the expansion of the lungs during ventilation.

Pleural tap

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Applied Anatomy: Thoracentesis
Sometimes it is necessary to insert a hypodermic needle through an intercostal
space into the pleural cavity (thoracentesis) to obtain a sample of fluid or to
remove blood or pus
Inserting the needle into the 9th intercostal space in the midaxillary line
during expiration will avoid the inferior border of the lung.

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 Intercostal muscles
• Action
• When the intercostal muscles contract, they all tend to pull the ribs
nearer to one another. If the 1st rib is fixed by the contraction of the
muscles in the root of the neck, namely, the scaleni muscles, the
intercostal muscles raise the 2nd to the 12th ribs toward the first rib, as
in inspiration. If, conversely, the 12th rib is fixed by the quadratus
lumborum muscle and the oblique muscles of the abdomen, the 1st to
the 11th ribs will be lowered by the contraction of the intercostal
muscles, as in expiration.
• Nerve Supply
• The intercostal muscles are supplied by the corresponding intercostal
nerves.

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 Vasculature of the Thoracic Wall
• Arteries of the Thoracic Wall
• The arterial supply to the thoracic wall derives from the: Thoracic
aorta, through the posterior intercostal and subcostal arteries. The
internal thoracic arteries. Axillary artery, through the superior and
lateral thoracic arteries

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Applied anatomy:
Referred Pain
• An intercostal nerve not only supplies areas of skin, but also
supplies the ribs, costal cartilages, intercostal muscles, and
parietal pleura lining the intercostal space. Furthermore, the 7th
to 11th intercostal nerves leave the thoracic wall and enter the
anterior abdominal wall so that they, in addition, supply
dermatomes on the anterior abdominal wall, muscles of the
anterior abdominal wall, and parietal peritoneum.
• This latter fact is of great clinical importance because it means
that disease in the thoracic wall may be revealed as pain in a
dermatome that extends across the costal margin into the anterior
abdominal wall.

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Applied anatomy:
Referred Pain
For example, a pulmonary thromboembolism or a pneumonia
with pleurisy involving the costal parietal pleura could give rise
to abdominal pain and tenderness and rigidity of the abdominal
musculature. The abdominal pain in these instances is called
referred pain.

Irritation of the mediastinal and central diaphragmatic areas

of the parietal pleura results in pain that is referred to the root
of the neck and over the shoulder

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Lymph Drainage of the Thoracic
Wall

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