Abdela Hayato, Cardiothoracic

ANATOMY OF THORACIC WALL Surgery Fellow

Oct 2, 2023
 CONTENTS
• Introduction
• Anatomy of the thoracic wall
• surface anatomy
• clinically important landmarks
• bony structure
• muscle of thorax
• Neuro-Vasculature of the thoracic wall
• Anatomy of the diaphragm

2
 INTRODUCTION

• Thorax is the superior part of trunk between neck

and abdomen
• Contains heart, great vessels, lungs, thymus,
trachea and oesophagus
• Has narrow inlet and wide outlet

• It is divided into three major spaces:

• central compartment or mediastinum
• The right and left pulmonary cavities housing
the lungs 3
Functions
 Protect vital thoracic and abdominal organs from external forces.

 Resist the negative (subatmospheric) internal pressures generated by the elastic

recoil of the lungs and inspiratory movements.

 Provide attachment for and supports the weight of the upper limbs, muscles of the
abdomen, neck, and back.

4
SURFACE ANATOMY

11/30/2023 5
 THE THORACIC WALL

• consists of

• skin
• fascia
• muscles
• neurovascular structures
• skeleton

• Superiorly by Superior Thoracic aperture and inferiorly by Diaphragm.

6
 BONY STUCTURE OF THE THORAX
•12 pairs of ribs and associated costal cartilage
•12 thoracic vertebrae and IV disks
• sternum
Boundaries of the thoracic wall

Anterior wall
 sternum ,costal cartilages and anterior parts of the ribs

Posterior wall
 thoracic vertebra
 posterior parts of the ribs

Lateral wall
 ribs 7
 STERNUM
• It is a 17cm long, Sword shaped Flat bone
• It is formed by the union of 3 bones
Manubrium, Body and Xiphoid process

Manubrium
• Located at level of T3-T4, 4cm long
• Wide superiorly and narrow inferiorly
• Superior surface is indented by jugular notch
• Articulates with the body at manubriosternal joint (at T4 )
• Clavicular notch articulate with clavicle
• First rib articulate with lateral margin 8
Body
• Located at level of T5-T9
• it articulates with costal cartilages from the 2nd to 7th ribs
• composed of four parts or ‘sternebrae’ which fuse between
puberty and 25 years.

Xiphoid process
• Sword-shaped Cartilaginous at birth fuses at around 25yrs
• Landmark: inferior limit of thoracic cavity, inferior border of heart

• Sternal Fractures and displacement are not common

• its usually comminuted fracture
• heart injury and lung injury are fatal

9
10
• The sternal plane
• separates the superior mediastinum from the inferior mediastinum
• marks the positions of the superior limits of the pericardium
• the bifurcation of the pulmonary trunk
• the origin of the arch of the aorta
• the level at which the trachea bifurcates into right and left principal bronchi
• the site where the superior vena cava penetrates the pericardium to enter the right
atrium.
 RIBS

• Ribs are long curved bones which form the rib cage

• Can be divided into:

• True (vertebrocostal) ribs (1st–7th ribs)

directly attach to Sternum by costal cartilage

• False (vertebrochondral) ribs (8th, 9th, and usually 10th ribs):

share a common cartilaginous connection to the sternum

• Floating (vertebral, free) ribs (11th and 12th ribs);

no attachement to stenum
12
• They can also be divided into typical and
atypical

typical ribs(3rd-9th)
• Has four parts:
1. Head
2. Neck
3. Tubercle
4. Body (shaft) –
-costal groove
-angle
13
 Atypical ribs (1st, 2nd, & 10th–12th)are dissimilar:
1st rib
• It is the flattest, shortest and most curvaceous of all
the ribs.
• It has a prominent tubercle-for insertion of scalenus
anterior and middle scalenus.
• subclavian groove – subclavian artery and brachial
plexus
(place for Brachial Block)

2nd rib
more atypical, thinner and less curved, has tuberosity
for serratus anterior

10th–12th ribs
Short, have single facet on their head
no neck or tubercle
14
Costal cartilages
 prolong the ribs anteriorly
 contribute to the elasticity of the thoracic wall
 The first 7 costal cartilages attach directly
 the 8th, 9th, and 10th articulate with the costal
cartilages just superior to them

15
 CLINICAL CORRELATION
Rib Fractures
 Rare in children- elastic chest wall
1st rib is rarely fractured
When it is broken, the brachial plexus nerves and subclavian vessels are injured.
 The middle ribs are most commonly fractured.
 The weakest part of a rib is just anterior to its angle
 Fractures of the lower ribs may results in
 Injury to the diaphragm, abdominal organs like Spleen and Liver

16
 MUSCLES OF THE THORACIC WALL
• There are 17 muscles on the thoracic wall.
• which can be Divided in to two:

 Superficial muscles-  Deep muscles- aka true muscles of the

Pectoralis major thorax
Pectoralis minor External intercostal
Serratus anterior Internal intercostal
Trapezius
Innermost intercostal
Rhomboid major
Rhomboid minor subcostal
Latissimus dorsi Transversus thoracis
Levator Scapulae Levator costarum
Subscapularis Seratus posterior superior
Scalene muscles(all)
Seratus posterion inferior 17
18
19
20
 INTERCOSTAL SPACE
• There are 11 IC spaces
• Named after the rib above each space
• consists of
• External intercostal muscles
• Internal intercostal muscles
• Innermost intercostal muscles
• neurovascular bundle

21
External intercostal muscle
• There are 11 pair of EIM
• Runs from the tubercles to the costochondral
junctions.
• run infero-anteriorly
• after reaching the costal cartilage it forms
external intercostal membrane
• continuous inferiorly with abdominal wall as
external oblique muscle.
• Most active during inspiration
Internal intercostal muscle
Their fibers run infero-posteriorly at right angles to
the external intercostals
• replaced posteriorly, medial to the angles by the
internal intercostal membranes .
• inferiorly continuous with the internal oblique
muscles
• Most active during expiration.
 Innermost intercostal muscles
•The innermost intercostals are separated from the
internal intercostals by intercostal nerves and vessels
• Incomplete, variable
 VASCULATURE OF THORACIC WALL
Intercostal arteries
1-Posterior ICA –
 the 1st and 2nd PICAs arise from Superior ICA
3rd-11th PICAs arose from Thoracic aorta.
2-Anterior ICA-
 is from Internal thoracic
1st-5th from ITA
6-11th from musculophrenic artery
• run in the costal groove
• both arteries anastomose in the intercostal spaces
around the midclavicular line
24
25
 Intercostal veins
• Venous drainage of ICS generally follows the
arterial distribution.
Posterior ICV
• 1st and 2nd ICV on the Lt form Lt superior ICV
and directly drain to Lt BCV.
• 1st and 2nd ICV on the Rt forms Rt superior
ICV and drains to Azygous Vein.
• The rest Posterior ICV drains to Azygous Vein
(directly or indirectly through hemi azygous/
accessory hemi azygous vein)

Anterior ICV drains to Internal thoracic

vein which finally drains to BCV

26
 NERVES OF THORACIC WALL
• 12 pairs of thoracic spinal nerves.
• Leave spinal cord through corresponding intervertebral foramina and divide into 2 branches

1. Posterior (dorsal) rami: innervate muscles, bones, joints and skin of the back
2. Anterior (ventral) rami: innervate intercostal musculature, periosteum of the ribs and skin
of the thorax (dermatome)

• Supply successive segments of thoracoabdominal wall (dermatome and myotome)

T1–T2 : also supply upper limb
T3 -T6: only intercostal region, typical
T7-T11: intercostal region + abdominal wall
27
28
Clinical Correlates
Needle thoracentesis
• Done for tension pneumothorax
• 2nd intercostal in the midclavicular line
Insertion of a Chest Tube
• at the safe triangle
• 5th or 6th intercostal space in the mid-axillary line
Intercostal nerve block
• Infiltration of local anesthesia in the intercostal space i.e. around the intercostal
nerve trunk and its collateral branch

29
FASCIA OF THORACIC WALL
• There are multiple layers of fasciae that covers the thoracic wall.
• pectoral fascia overlying the anterior thoracic wall
• Clavipectoral fascia: Deep to the pectoralis major suspended from the clavicle and
investing the pectoralis minor muscle
• Endothoracic fascia: line thoracic cage internally.
attaches costal parietal pleura to the thoracic wall.
It becomes more fibrous over the apices of the lungs
(suprapleural membrane)
 DIAPHRAGM
• The diaphragm is a double-domed, musculotendinous partition separating the
thoracic and abdominal cavities.

• It is the chief muscle of inspiration.

• Composed of two portions:

• muscular (peripheral part)
• fascial fibers (central part)

31
• The crura of the diaphragm are musculotendinous bands that arise from the anterior
surfaces of L1-L3 Vertebrae.
• The right crus, larger and longer than the left crus.
• The left crus arises from the first two lumbar vertebrae.
• esophageal hiatus is a formed by the right crus

• Its domelike shape allows important abdominal structures, such as the liver and the
spleen, to have the protection of the lower ribs and the chest wall.

32
 The Rt dome of diaphragm is slightly higher
than the left one usually by 1cm.

33
 DIAPHRAGMATIC APERTURES

• There are Four large apertures on the diaphragm.

• Vena caval - T8 right of the median plane

• Esophageal - T10 left of the median plane
• Aortic - T12 median plane,
• Parasternal foramina (i.e., the foramina of Morgagni) through which the internal
mammary arteries pass into the abdomen to become the superior epigastric arteries.

• A variable number of pores are present or are potentially, so in either hemidiaphragmatic

leaf.

34
35
36
 NEUROVASCULATUR
E

Arteries

• The arteries supplying the superior surface of the

diaphragm
• Pericardiacophrenic
• musculophrenic arteries
• superior phrenic arteries

• The arteries supplying the inferior surface of the

diaphragm are the inferior phrenic arteries, which
typically are the first branches of the abdominal aorta.
37
 Veins
• Veins draining the superior surface of the diaphragm
• pericardiacophrenic
• musculophrenic veins, which empty into the internal
thoracic veins
• a superior phrenic vein, which drains into the IVC

• The veins draining the inferior surface of the diaphragm

are the inferior phrenic veins.

• The right inferior phrenic vein usually opens into the

IVC, whereas the
• left inferior phrenic vein is usually joining the left
suprarenal vein to drain in to Lt renal vein
38
Nerve Distribution
• The entire motor supply is from the right and left phrenic nerves (C3–C5)

• Sensory innervation (pain and proprioception) to the diaphragm is

• mostly from the phrenic nerves
• Peripheral parts from the intercostal nerves (lower six or seven) and the subcostal nerves.

39
40
Lymphatic drainage
• Lymph nodes of the diaphragm are divided into three
groups

• first anterior (prepericardiac) group located behind the

xiphoid

• The second group located in proximity to the phrenic

nerves bilaterally

• The third group is the posterior or retrocrural lymph

nodes, which lie behind the left and right crura.
41
 CLINICAL CORRELATION
Congenital Diaphragmatic Hernia
• Part of the stomach and intestine herniate through a large posterolateral defect (foramen of
Bochdalek) in the region of the lumbocostal trigone of the diaphragm.
• Herniation almost always occurs on the left owing to the presence of the liver on the right.
• occurring approximately once in 2,200 newborn infants
• Because of the consequent pulmonary hypoplasia, the mortality rate in these infants is high
(approximately 76%).

Hiccups
• Hiccups are involuntary, spasmodic contractions of the diaphragm.
• Hiccups result from irritation of afferent/efferent nerve endings, or of medullary centers in
the brainstem that control the muscles of respiration, particularly the diaphragm.
42
43
 THE MEDIASTINUM AND STRUCTURES

• The mediastinum is defined as the thoracic space located between the two pleural cavities.

• Boundaries:
Ant- sternum
Post - Thoracic Vertebrae and IVD
Lat - by the two pleural cavities
Sup- Thoracic inlet and
Inf - Diaphragm
• Several organs and structures, such as heart and great vessels, trachea and main bronchi,
esophagus, thymus, and lymphatic vessels, are contained in the mediastinum.
44
• There are different ways of dividing the
mediastinum

• by imaginary plane passing through sternal angle

anteriorly to lower border of T4
I. Superior mediastinum
II. Inferior mediastinum
• anterior, middle and posterior

45
• The superior mediastinum Contents
• the aorta and great vessels,
• trachea,
• upper third of the esophagus,
• upper thymus,
• vagus and phrenic nerves,
• lymphatic tissues, and upper
thoracic duct.
• The anterior mediastinum Contents
• mediastinal fat,
• lymph nodes, and
• the thymus.
• The middle mediastinum Contents
• The pericardium and its contents,
• carina,
• lymphatic tissues, and
• proximal portions of the main
bronchi.
• The posterior mediastinum Contents
• esophagus,
• descending thoracic aorta,
• azygos vein,
• sympathetic trunk,
• lymphatic tissues, and
• thoracic duct.
46
 THYMUS
• It is an asymmetrical, bi-lobed primary lymphoid organ,
• lies posterior to the manubrium and extends into the
anterior mediastinum, anterior to the fibrous
pericardium.
• After puberty undergoes gradual involution and
replaced by fat.

• Arterial supply derived from the anterior intercostal

and internal thoracic arteries.

• The veins end in the left brachiocephalic, internal

thoracic, and inferior thyroid veins.

• The lymphatic vessels end in the parasternal,

brachiocephalic, and tracheobronchial lymph nodes. 47
 GREAT VESSELS
• The right and left brachiocephalic veins are
formed posterior to the sternoclavicular joints by
the union of the internal jugular and subclavian
veins.

• The left brachiocephalic vein is more than twice as

long as the right brachiocephalic vein

• Located anterior to the roots of the three major

branches of the arch of the aorta.
 The ascending aorta
• 5 cm long and 2.5 cm in diameter.

• Its only branches are the coronary arteries

• it lies inferior to the transverse thoracic plane.

 Nerves of the thorax
Vagus nerve (CN-X)
 The 10th cranial nerve originating from medulla
oblongata
 On the arch of aorta the left CNX gives off left
recurrent laryngeal nerve that hooks around
the ligamentum arteriosum.
 The right recurrent laryngeal nerve is given off
in the root of the neck and hooks around the
right subclavian artery

 Fibers from the left and right vagi form the

anterior and posterior vagal trunks, which enter
the abdomen through the esophageal hiatus.

11/30/2023 50
 phrenic nerve
• Arises from C3-5

• At the thoracic inlet, the nerve is on the medial

border of the scalenus anterior muscle, just 3-4
cm from the sternoclavicular joint

• The right and left nerves enter the thoracic cage

between the subclavian artery and the origin of
the brachiocephalic vein.

• pass anterior to the roots of the lungs

• Innervates the pericardium and diaphragm

11/30/2023 51
Clinical importance
• Thoracic incisions
REFERENCES

53
Thank you!

54