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Functional Anatomy: Thoracic Wall and Cavity

Dr. Gregorio Anastacio Rufon, Jr.


A.) GENERAL OVERVIEW OF THE THORAX
- region between the neck and abdomen
- irregularly shaped cylinder
- framework (referred to as thoracic cage) is made up of
skeletal, muscular and articulating tissues
narrow opening superiorly (superior thoracic
aperture)
Kidney-shaped
Slopes from behind downward and forward
Boundaries:
o Body of the T1 vertebra (posteriorly)
o First ribs and their cartilages (laterally)
o Upper border of the manubrium sterni
(anteriorly)
o Suprapleural membrane/ Sibsons fascia
(Superiorly)
relatively large opening inferiorly (inferior thoracic
aperture)
Boundaries:
o T12 vertebra (posteriorly)
o Curving costal margin (laterally)
o Xiphisternal joint (anteriorly)
Boundaries (Thoracic cage)
Posterior: thoracic vertebrae and ribs as far as
their angles
Lateral: ribs, intercostal spaces (ICS)
Anterior: sternum, costal cartilages
Thoracic cavity
- Divided into 3 major compartments:
Mediastinum
Right pleural cavity
Left pleural cavity
General functions:
1.) Respiration
2.) Skeletal support
3.) Protection of vital organs (heart, lungs and the
great vessels)

Block 6 Module 1
Lecturette #2

Date: November 23, 2015


4.) Conduit for structures that pass completely
through the thorax from one body region to
another (Head, neck and abdominal cavity)

B.) LINES OF ORIENTATION/ CONVENTIONAL


LONGITUDINAL LINES
a.) Midsternal line
Bisects the sternum; corresponds to the
midline of the back
b.) Midclavicular/mammary line
Passes through the nipple
c.) Parasternal line
Midway between the midsternal and
mammary lines
d.) Anterior axillary line
Runs through the anterior axillary fold
e.) Posterior axillary line
Runs through the posterior axillary fold
f.) Midaxillary line
From the middle of the axillary space
downward.
g.) Scapular line
Bisects the apex of the scapular inferior
angle
h.) Paravertebral line
Along the tips of the vertebral transverse
processes.
A.) REGIONAL ANATOMY

1.) Pectoral region


- Two compartments:
a.) Superficial compartment
Skin
Superficial fascia (continuous with the
superficial fascia of the abdomen
Campers fascia)
Breasts

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Copyright 2015 Bobares 1nc.

Functional Anatomy: Thoracic Wall and Cavity


Dr. Gregorio Anastacio Rufon, Jr.
b.) Deep compartment
Muscles (pectoralis major, pectoralis
minor, serratus anterior and subclavius)

2.) Thoracic wall


A.) Skeletal framework
Thoracic vertebrae
Ribs and costal cartilages
Sternum

THORACIC VERTEBRAE
QUESTIONS AS POINTERS (from Doc Rufon):
What are the peculiarities of the thoracic
vertebrae?
Characteristics of a typical thoracic vertebra
o Vertebral body: medium size and heart shaped;
with superior and inferior demifacets for
articulation with the heads of the ribs
o Vertebral canal/foramen: small and circular
o Spines: long and inclined upward
o Transverse process: with costal facets for
articulation with the tubercles of the ribs except
for rib 11 and 12
o Has a lamina, pedicle and superior and inferior
notches.

Intervertebral discs:
- Main structures that bind vertebral bodies
together.

Block 6 Module 1
Lecturette #2

Date: November 23, 2015


- Extends from C2 to sacrum
- Has two distinct parts:
a.) Annulus fibrosus peripheral part; made
up of fibrocartilage
b.) Nucleus pulposus ovoid inner mass;
slightly nearer to the posterior disc margin
than to the anterior; gelatinous material
with high water content that diminishes
with aging.

RIBS AND COSTAL CARTILAGES


- 12 pairs of elastic arches constituting the greater
part of the thoracic skeleton; flat bones
- Separated by intercostal spaces (with 11 ICS)
- With highly vascularized trabecular bone within a
thin layer of compact bone; contains large
amount of red marrow
- They increase in length from the 1st to 7th but
from the 8th to the 12th, they progressively
become shorter.
Longest: 7th or 8th
Shortest: 1st or 12th
- all 12 pairs articulate posteriorly with the
vertebrae
- anterior rib extremities continue forward to the
sternum through their costal cartilages (bars of
hyaline cartilage)
- Classified as to:
1.) True ribs
with costal cartilages that articulates
anteriorly to the sternum
First 7 pairs
2.) False ribs
Remaining 5 pairs
with costal cartilages that turn upward
and join the cartilage of the superjacent
rib (8th, 9th and 10th ribs) or with anterior
extremities that are free at their ends
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Functional Anatomy: Thoracic Wall and Cavity


Dr. Gregorio Anastacio Rufon, Jr.
(11th and 12th ; sometimes termed as
floating ribs)
Further classified as to:
1.) Typical ribs
- Head: articulates posteriorly with the costal facets
on the lateral body of 2 adjacent thoracic
vertebrae (Superior facet: vertebra a number
lower than that of the rib; Inferior facet: vertebra
with the same number as the rib)
- Neck: constricted portion and about 1 inch long
- Tubercle: junction of the neck and the shaft;
articulates with the transverse costal facet (in the
transverse process) of the vertebra having the
same number as the rib
- Shaft: compressed laterally giving it an internal
(smooth; covered with pleura) and external
surfaces (smooth; covered with muscles) with
superior (rounded) and inferior borders (grooved;
the costal groove)
The rib shaft curved greatest posteriorly
(angle)
- Costal groove: contains intercostal vessels and
nerves top to bottom: Vein, Artery and Nerve
- includes 2nd to 9th ribs

2.) Special ribs


- possesses
special
structural
characteristics/features
- includes the 1st, 2nd, 10th, 11th and 12th ribs

Block 6 Module 1
Lecturette #2

Date: November 23, 2015


a.) 1st rib/ Superlative rib
It is the highest, broadest, strongest,
flattest, most curved and, with the
occasional exception of the 12th, the
shortest of all the ribs - Thorek.
Head: small; one facet that articulates
with one vertebra (T1)
Neck: Long
Tubercle: large and coincides with the
location of the angle
Shaft: surfaces face upward (superior
surface are muscular attachments of
scalenus medius [insertion] and the first
digitation of serratus anterior [origin])
and downward (inferior surface)
Costal groove: not present because it is a
flat surface, instead it is covered with
pleura
b.) 2nd rib
Shaft: sharply curved with
surfaces
Costal groove: poorly marked

oblique

c.) 10th rib/ Uncertain rib


Resembles typical ribs, only shorter.
Head: one facet that articulates with T10
vertebra
Uncertain since it may articulate with
the 9th costal cartilage or may remain free
as a floating rib Thorek.
d.) 11th rib
A short rib
Head: one facet that articulates with the
T11 vertebra
Neck: absent
Tubercle: absent
Costal groove: difficult to see
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Functional Anatomy: Thoracic Wall and Cavity


Dr. Gregorio Anastacio Rufon, Jr.
e.) 2th rib
Very short
Head: one facet
Lacks tubercle, angle and costal groove

Block 6 Module 1
Lecturette #2

Date: November 23, 2015

- broadest at the junction between the 1st cartilage

Arterial supply and innervation (Ribs):


- receives blood vessels anteriorly and posteriorly
- located within the costal groove
- also supplies the muscles, pleura and the skin
Anterior:
Internal thoracic artery (1st 6 ICS)
Musculophrenic artery (subsequent ICS)
Posterior:
Superior intercostal artery from the subclavian
artery (1st two ICS)
Posterior intercostal arteries from the descending
aorta (lower 9 spaces)
Venous drainage:
Posterior intercostal veins drains to the azygos
or hemiazygos veins
Anterior intercostal veins drains to the internal
thoracic and musculophrenic veins
QUESTIONS AS POINTERS (from Doc Rufon):
1.) How many ribs are attached directly to the
sternum through their respective costal
cartilage?
2.) How many of the ribs are vertebral ribs?
3.) What specific type are the costal cartilages
histologically?
4.) What type of bones are the ribs?

STERNUM
- a flat bone with 3 parts: (1) manubrium sterni, (2)
body and; (3) xiphoid (ensiform) process
- slopes down; slightly forward
- convex in front; concave behind

Joints:
Manubriosternal joint corresponds to sternal
angle/angle of Louis where the costal angle of 2nd
rib attaches to sternum; landmark for locating ICS
Xiphisternal joint
Muscle attachments:
pectoralis major
sternocleidomastoid
sternohyoid
sternothyroid
transversus thoracis
diaphragm
aponeurosis of external
internal oblique and transversus abdominis
rectus abdominis
Vascular supply:
Internal mammary/thoracic artery

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Copyright 2015 Bobares 1nc.

Functional Anatomy: Thoracic Wall and Cavity


Dr. Gregorio Anastacio Rufon, Jr.
B.) Muscles of the thorax
QUESTIONS AS POINTERS (from Doc Rufon):
Muscles involved in the thoracic cage?

Block 6 Module 1
Lecturette #2

Date: November 23, 2015


2.)
3.)
4.)
5.)

SUBCOSTALES
TRANSVERSUS THORACIS
LEVATORES COSTARUM
SERRATUS POSTERIOR

Intrinsic muscles:

VASCULAR SUPPLY (THORACIC WALL AND CAVITY)

1.) INTERCOSTAL MUSCLES


- Thin, multiple layers of muscular and tendinous
fibers in the ICS

A.) Arteries
Internal thoracic/mammary artery
- from the undersurface of subclavian artery (first
part) opposite to the thyrocervical trunk
- descends behind the 1st six costal cartilages 1
cm from lateral sternal border
- divides
into
superior
epigastric
and
th
musculophrenic arteries at 6 ICS

a.) External intercostal muscle (thicker than internal


intercostals)
Most superficial; fibers are directed obliquely
downward laterally at the back and downward
forward in front
from inferior border of the rib above to superior
border of the rib below
continues anteriorly to sternum as the anterior
(external) intercostal membrane
b.) Internal intercostal muscles
Intermediate layer; fibers are directed
downward and backward from the above
subcostal groove to the upper border of the rib
below
begin anteriorly at sternum
at the posterior costal angles, they continue as
the posterior (internal) intercostal membrane
c.) Innermost intercostal muscle
Deepest layer; incomplete muscle layer
Crosses more than one ICS within the ribs
Insignificant and absent at highest thoracic
levels
Progressively substantial in the lower
interspaces
Lined internally by the endothoracic fascia that
separates it from the parietal pleura; and
externally, to the intercostal neurovascular
bundle

Superior/highest intercostal artery


- from the costocervical trunk
- descends between the pleura and necks of the
1st and 2nd ribs and anastomose with 3rd
posterior intercostal arteries
- supplies the 1st two ICS (not constant; if absent,
replaced by a direct branch from the aorta)
Posterior intercostal arteries
- 9 pairs
- From the posterior aspect of descending
thoracic aorta
- Distributed to lower 9 ICS; crosses ICS obliquely
towards the angle of the rib above and course
within its costal groove
- Branches: (1) dorsal, (2) collateral, (3) muscular;
and (4) cutaneous
Subcostal artery
- Same as any intercostal artery
- Since there is no 12th ICS, artery assumed a
different name
Superior thoracic artery
- 1st branch of axillary artery
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Functional Anatomy: Thoracic Wall and Cavity


Dr. Gregorio Anastacio Rufon, Jr.
- Supplies 1st ICS
B.) Veins
Internal thoracic veins
- vena comitantes of inferior half of internal
thoracic artery; has many valves
- unite near the 3rd costal cartilage or a bit lower
to form a single trunk which ascends medial to
the artery and drain in the brachiocephalic
(innominate) vein
- Tributaries: (1) anterior intercostal veins from
upper 6 ICS, (2) perforating branches, (3)
muscular branches, (4) mediastinal, (5)
pericardial; and (6) thymic veins
Left superior intercostal vein
- drains 2nd and 3rd or sometimes 4th left posterior
intercostal veins
- drains into left brachiocephalic vein
- Tributaries: left bronchial veins and left
pericardiacophrenic vein
Posterior intercostal veins
- Accompanies corresponding arteries (11 pairs)
- On both sides: 1st posterior intercostal vein
ascends and end in the ipsilateral
brachiocephalic or vertebral vein
- Right side: 2nd, 3rd and 4th veins form a right
superior intercostal vein that joins the azygos
vein
- Left side: 2nd, 3rd and 4th veins form a left
superior intercostal vein
- 4th/5th to 8th drain into the accessory
hemiazygos veins
- 9th to 11th drain into the hemiazygos vein
Hemiazygos vein
a.) Superior hemizygos vein formed by union
of 4th to 8th intercostal veins; joins azygos at
T7 vertebra

Block 6 Module 1
Lecturette #2

Date: November 23, 2015


b.) Inferior hemiazygos formed by union of
left ascending lumbar vein and left
subcostal vein; joins azygos at T8 vertebra;
tributaries: lower left intercostal and
mediastinal veins
Azygos vein
- origin varies; union of right ascending lumbar
and right subcostal veins
- drain into posterior SVC at T5 vertebra
- Tributaries: (1) lower 8 right intercostal veins,
(2) right superior intercostal vein, (3) superior
and inferior hemiazygos veins; and (4) many
mediastinal veins
Brachiocephalic veins
a.) Right brachiocephalic vein union of right
subclavian and right internal jugular veins at
the neck root
b.) Left brachiocephalic vein same origin;
passes behind the manubrium and in front
of aortic arch branches; joins the right BCV
forming the SVC
LYMPHATIC DRAINANGE
Superficial lymphatic vessels converge on the
axillary nodes
Lymph vessels from deeper tissues drain mainly
to:
a.) Parasternal (internal thoracic) nodes
b.) Intercostal nodes
c.) Diaphragmatic nodes (Anterior, lateral and
posterior groups)
INNERVATION
Thoracic ventral spinal rami 12 pairs (upper 11
lie between the ribs as intercostal nerves; 12 th
pair is the subcostal nerve)
Thoracic dorsal spinal rami
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Functional Anatomy: Thoracic Wall and Cavity


Dr. Gregorio Anastacio Rufon, Jr.
3.) Diaphragm
- dome-shaped musculoaponeurotic/tendinous
partition separating the thoracic cavity from
abdominal cavity; fills the inferior thoracic
apperture
- Superiorly: Pleura and Pericardium
- Inferiorly: Peritoneal cavity
- It has 2 distinct regions:
fleshy
(muscular)
periphery

originated at 4 points in the thoracic


outlet circumference: (1) sternal, (2)
costal, (3) right and left crura and; (4)
the medial and lateral arcuate
ligaments
central tendinous region site of
insertion.
Arterial supply: (1) Pericardiophrenic, (2) inferior
phrenic largest arterial supply of diaphragm, (3)
musculophrenic; and (4) the intercostal arteries
Venous drainage: (1) brachiocephalic vein, (2) azygos
vein, (3) abdominal vein, (4) left suprarenal vein; and (5)
IVC
Innervation: Right and left phrenic nerves (C3,4 and 5)
Action: chief muscle of respiration with the greatest
role in abdominal breathing (normal breathing during
1st 2 years of life); adult: thoracic breathing
During normal breathing, diaphragm contributes
to changes in shape of the thorax.
Depression
(contraction)
and
elevation
(relaxation) alters vertical dimension of thorax
- Its continuity is interrupted by 3 large
openings and several smaller ones.
3 Large diaphragmatic openings/ hiatus:
1.) Aortic opening
- median plane; anterior to T12 vertebra (lower
border)

Block 6 Module 1
Lecturette #2

Date: November 23, 2015


- Transmits: (1) aorta, (2) thoracic duct; and (3)
the azygos vein
2.) Esophageal opening
- oval-shaped; at the level of T10 and lies to the
left of the aortic opening behind the central
tendon
- Transmits: (1) esophagus, (2) right and left
vagus nerves; and (3) esophageal branches of
left gastric artery and vein
3.) Inferior vena cava opening
- wide; at the level of T8 about 1 inch to the
right from median plane
- Transmits: (1) inferior vena cava (IVC), (2)
branches from the right phrenic nerve; and
(3) few hepatic lymph vessels

Smaller diaphragmatic openings:


- Are numerous in the diaphragmatic surfaces and
generally transmits vessels and nerves.
QUESTIONS AS POINTERS (from Doc Rufon):
What levels in the thoracic vertebrae do
structures pierces the diaphragm?

4.) Mediastinum
- Broad central partition between 2 laterally
placed pleural cavities
- Regions:
Superior mediastinum
Inferior mediastinum divided by the
pericardium into: anterior, middle and
posterior inferior mediastina

5.) Pleura
- Single layer of flat cells, mesothelium and
supporting connective tissue that lines the
pleural cavity
- Types:
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Functional Anatomy: Thoracic Wall and Cavity


Dr. Gregorio Anastacio Rufon, Jr.
Parietal pleura
Surfaces:
Costal,
diaphragmatic,
mediastinal and cervical
Visceral pleura firmly attached to lung
surfaces including both opposed surfaces
of fissures that divide lungs into lobes

SURGICAL APPLICATIONS
POINTERS (from Doc Rufon):
1.) Thoracostomy VS Thoracentecis (Why is the
tube inserted on the posterior aspect?)
2.) On which part of the chest should the needle
be inserted?
3.) On which part of the chest should the chest
tube be inserted?
A.) Thoracentesis/thoracocentesis/pleural aspiration
- Both diagnostic and therapeutic (goal: lung
reexpansion) procedure
Indications: assessment of pleural effusions (fluid)
and life threatening pneumothorax (air)
Site of election:
a.) a little posterior to posterior axillary line in the
6th, 7th or 8th ICS; others prefer midaxillary line
b.) 2nd ICS MCL on the affected side; patient in
upright position (air e.g. pneumothorax)
Parts of chest wall traversed by needle: (1) skin, (2)
superficial fascia; (3) pectoral muscles if anterior site,
(4) serratus anterior, (5) external intercostal, (6) internal
intercostal, (7) innermost intercostal, (8) endothoracic
fascia; and (9) parietal pleura

Block 6 Module 1
Lecturette #2

Date: November 23, 2015

B.) Thoracostomy
- Opening is made through the chest wall
- Purpose: drainage
Insertion site (tube thoracostomy): 4th or 5th ICS at
anterior axillary line; though insertion in lower ICS is
possible provided the presence of the domes of
diaphragm must be considered
Parts of chest wall traversed by needle: (1) skin, (2)
superficial fascia; (3) serratus anterior, (4) external
intercostal, (5) internal intercostal, (6) innermost
intercostal, (7) endothoracic fascia, (8) parietal pleura;
and (9) pleural cavity
Surg consideration: same with thoracentesis
C.) Thoracotomy
- with incision and removal of a small rib segment
Incision site: 4th or 5th ICS from the lateral margin of
sternum to the anterior axillary line; whether left or
right will be determined by the site of injury
QUESTIONS AS POINTERS (from Doc Rufon):
1.) If you wanted to open the thoracic cage, how
will you go about it?
2.) Which particular parts of the cage will you
approach and why?

References:
1.) Clinical Anatomy by Regions Snell, R.
2.) Grays Anatomy Standring, S.
3.) Anatomy in Surgery Thorek, P.
4.) Upclass notes

Surg consideration: needle should be passed near the


superior surface of lower rib so as not to injure
intercostal neurovascular bundle

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