Thorax – the upper conical part of the trunk where the heart, great vessels & lungs are

found.  Transversus thoracis

Thoracic Cage External Oblique Ms

 Posteriorly: 12 thoracic vertebrae w/ ribs up to the angles  Origin: External surfaces and inferior borders of 5-12 ribs with serratus anterior and
 Laterally: Body of the ribs latissimus dorsi
 Anteriorly: Sternum & Anterior portions of the 1st 10 ribs and their costal cartilages  Insertion: Iliac crest, Linea alba, forms inguinal ligament
 Direction: Inferiorly and anteriorly
Peculiarities  Nerve Supply: T7 – L1 ICN
1. Anterior wall (only until xiphoid process) is shorter than posterior wall (until T12).
2. Antero-posterior diameter is shorter than median place at the sides. (Due to Rectus Abdominis Ms
backward sweep of the posterior portions of the ribs)  Where 6-packs forms
3. Vertical diameter is increased or decreased by the contraction or relaxation of the  Longitudinal ms along anterior border of abdominal wall on either side of linea alba
respiratory diaphragm.  Origin: Sides of the 5th to 12th ribs interdigitating with serratus anterior ms fibers

Communications External Intercostal Ms

 Thoracic Inlet (Superior Thoracic Aperture)  Most superior
- Kidney shaped opening  Origin: Lower border of the rib
- Apex of the conical thoracic cage
 Insertion: Upper border of the rib below, fibers running downwards & forward or
- Communicates with neck
medially
- Clinically referred to in cases of Thoracic Outlet Syndrome
 Fibers run infero-anteriorly from rib above to rib below
 Thoracic Outlet (Inferior Thoracic Aperture)
 A: Rib elevation (inspiration)
- Respiratory diaphragm – its large irregular inferior boundary
 Nerve Supply: Intercostal nerve
MUSCLES OF THE THORAX
Internal Intercostal Ms
 Axio-appendicular ms: from thoracic cage (axial skeleton) to bones of upper limb
 Origin: Upper border of rib
(appendicular skeleton)
 Insertion: Lower border of rib above
 Accessory ms of respiration – help elevate ribs to expand thoracic cavity when
inspiration is deep and forceful  Fibers run inferoposteriorly from floors of costal grooves to superior borders of ribs
 Pectoralis major inferior to them
 Pectoralis minor  A: Rib depression (expiration)
 Inferior part of Serratus anterior  Nerve Supply: Intercostal nerve
 Scalene ms of neck
 Descend from vertebrae of neck to 1st and 2nd ribs Transversus Thoracis Ms
 Act primarily on vertebral column 1. Sternocostalis ms
 Also serve as accessory respiratory ms by fixing these ribs and enabling ms 2. Innermost intercostal ms
connecting the ribs below to be more effective in elevating the lower ribs during 3. Subcostal ms
forced inspiration
 True ms of thoracic wall Sternocostalis Ms (Triangularis Sterni)
 Serratus posterior  The most constant & better developed
o Inspiratory ms  Origin: Xiphoid Process & Lower portion of the corpus sterni, posterior surface
o Superior: elevate superior 4 ribs = increase AP diameter of thorax and  Insertion: Costo-chondral junctions of the 2nd to the 6th ribs
raising sternum  A: depress ribs (expiration)
o Inferior: depress inferior ribs = preventing them from being pulled  Nerve Supply: Intercostal Nerve
superiorly by diaphragm
o May have proprioceptive fxn Innermost Intercostal Ms
 Levatores costarum  Closely adherent to the parietal pleura
 Intercostal  Incomplete & inconstant ms lying inside of the internal intercostal ms
 Origin: Lower border of the rib
APN2017 – edited by G. M. B. ‘17
  Insertion: Upper border of the lower one or two ribs - Runs obliquely downwards and medially beneath the 12th rib to supply the
 A: depressor of the rib lower part of the intercostal spaces
 Nerve Supply: Intercostal Nerve
Posterior Intercostal Arteries
Subcostal Ms  Origin:
 Small triangular muscular slips lying on the internal surface of the posterior thoracic - 1st & 2nd: Highest intercostal branch of the costo-cervical trunk of the subclavian
wall artery; costo-cervical trunk  supreme/superior intercostal A  1st and 2nd
posterior intercostal A
Levatores Costarum Ms - Lower 9: Thoracic descending aorta
 Also found in the posterior part of thoracic cage
 Origin: Transverse process of the C7 and upper 11 thoracic vertebrae Anterior Intercostal Arteries
 Insertion: External surface of the rib below, medial to the angle  Origin:
 A: Rib elevation (inspiration) - Upper 6: Internal mammary/thoracic artery of the subclavian artery
 Nerve Supply: 1st slip by 8th cervical spinal nerve; rest by corresponding intercostal - 7th, 8th, 9th: Musculo-phrenic A (terminal branch of the internal mammary
nerve artery)

Anterior Intercostal Membrane (External Intercostal Membrane) Posterior Intercostal Veins

 Membranous sheet covering the interchondral spaces from the costo-chondral  Right Side:
junction to the sternal border - 1st Posterior Intercostal Vein  Right innominate vein (Brachiocephalic V)
 Continuation of the external intercostal ms - 2nd + 3rd Posterior Intercostal Veins unite to form the right superior intercostal
vein  Azygos Vein
Posterior Intercostal Membrane - 4th – 11th Posterior Intercostal Veins  Azygos Vein
- Subcostal vein  Azygos Vein
 Membranous sheet covering the interchondral spaces from the angle of the rib to
 Left Side:
the costo-vertebral junction
- 1st Posterior intercostal Vein  Left innominate vein
 Continuation of the internal intercostal ms
- 2nd + 3rd Posterior intercostal Veins unite to form the superior intercostal vein
 Left Innominate vein
Intercostal Nerves
- 4th – 8th Posterior intercostal veins  Superior Hemiazygos vein
 Anterior rami of the upper 11 thoracic spinal nerves
- 9th – 11th Posterior Intercostal veins  Inferior Hemiazygos vein
 At the lateral side of the chest, it gives the lateral cutaneous branch
- Subcostal Vein  Inferior Hemiazygos Vein
 At the border of the sternum, it pierces the wall to become the anterior cutaneous *Azygos V – larger and more visible compared to Hemiazygos V
nerve
Peculiarities: Internal Thoracic (Mammary) Artery
 1st ICN
 Origin: From the first part of the subclavian artery
- Short & Stout
 Termination: opposite the sixth intercostal space by dividing into superior epigastric
- Most of its branches are contributed to the formation of the BP (Brachial Plexus)
and musculo-phrenic arteries
- Usually no lateral or anterior cutaneous branches are given off
 Collateral Branches
 2nd ICN
- Perforating branches: to upper 6 ICS close to sternal border, accompany the
- Lateral Cutaneous Branch
anterior cutaneous nerve to the superficial fascia & skin, from internal
- Does not divide nor supply the lateral chest wall but crosses the axilla to supply
mammary A
the skin on the medial aspect of the upper 3rd of the arm
- Anterior intercostal branch: 7th-9th ICS, from musculo-phrenic A
- Intercostobrachial Nerve
- Pericardio-phrenic branch
 7th, 8th, 9th ICN
- Mediastinal branch
- Its terminal branches go to the epigastric region of the abdomen
 10th, 11th ICN
Internal Thoracic (Mammary) Vein
- Supplies the region around and below the umbilicus of the abdomen
 It is formed by the union of the two venae comitantes of the internal thoracic artery
 Subcostal Nerve
behind the third costal cartilage
- The anterior ramus of the 12th thoracic spinal nerve
APN2017 – edited by G. M. B. ‘17
  It ascends close to the artery to terminate in the corresponding innominate vein - Vagus, Phrenic & Left recurrent laryngeal nerve
- Esophagus, Trachea & Thoracic duct
Reference Lines in the Thorax - Thymus & Lymph glands
1. Midsternal Line – imaginary line in bet sternum
2. Lateral Sternal Line – lateral borders of sternum Anterior Mediastinum
3. Mid-clavicular Line – from midpoint of clavicle, passes through the nipples  Superior: Imaginary Plane
4. Parasternal Line – line drawn midway bet midsternal or mammary lines or bet lateral  Inferior: Diaphragm
sternal and midclavicular lines  Anterior: Corpus sterni
5. Anterior Axillary Line – corresponds to anterior axillary fold  Posterior: Anterior surface of the pericardium
6. Posterior Axillary Line – corresponds to posterior axillary fold  Lateral: Mediastinal pleura
7. Midaxillary Line – bet anterior and posterior axillary lines Contents:
8. Scapular Line – line drawn from back passing through inferior angle of scapula - Thymus or its remnants
9. Paravertebral Line – line drawn along the tips of transverse processes of thoracic - Anterior mediastinal LG
vertebrae - Fat and areolar tissue

Thoracic Cavity Middle Mediastinum

 The space enclosed by the thoracic cage  Superior: Imaginary Line
 Above: Thoracic Inlet  Inferior: Diaphragm
 Below: Respiratory diaphragm  Anterior: Anterior part of the pericardium
 2 lateral parts occupied by the lungs & pleurae  Posterior: Posterior part of the pericardium
 Intermediate area: rest of the thoracic organs  Lateral: Pericardium & Mediastinal pleurae
Contents:
Mediastinum (Interpleural space) - Heart with its pericardium
 Boundaries - Ascending aorta, pulmonary trunk & its right and left branches
- Above: Thoracic inlet - Lower half of the Superior Vena Cavae, Left and Right pulmonary veins,
- Below: Respiratory diaphragm termination of the Azygos Vein
- Lateral: Mediastinal pleurae - Bifurcation of the trachea, phrenic nerves & bronchial lymph glands
- Anterior: Sternum
- Posterior: 12 thoracic vertebrae Posterior Mediastinum
 Superior: Imaginary Plane
Division of the Mediastinum  Inferior: Diaphragm
 Superior & Inferior Mediastinum  Anterior: Posterior pericardium
- Imaginary horizontal plane extending from the sternal angle of Lewis (A) to the  Posterior: Lower 8 thoracic vertebral bodies (T5-T12)
IV disc between the T4 & T5 (P)  Lateral: Posterior part of the mediastinal pleurae
 Inferior Mediastinum further divided into: Contents:
 Anterior, Middle & Posterior Mediastinum - Descending thoracic aorta
- Divide the heart and its pericardial covering - Azygos, Hemiazygos & accessory
- Esophagus, thoracic duct & vagi nerves
Superior Mediastinum
 Superior: Thoracic Inlet Pleural Cavities
 Inferior: Imaginary plane drawn from the sternal angle to the T4 IV disc  Parts of the thoracic cavity, lying on either side of the mediastinum
 Anterior: Manubrium sterni  Occupied by the lungs & corresponding pleurae
 Posterior: Bodies of the upper 4 thoracic vertebrae
 Lateral: Upper parts of the mediastinal pleurae Pleura
Contents:  Closed serious sac invaginated completely by the lung and has 2 layers
- Aortic arch and its branches
- Innominate vein & Upper half of the Superior Vena Cavae
APN2017 – edited by G. M. B. ‘17
 - Parietal pleurae – lines pulmonary cavities  adhering to thoracic wall, Lines of Pleural Reflection
mediastinum, and diaphragm; may be separated from surfaces it covers; thicker  Sternal line
than visceral  Anterior costo-mediastinal
- Visceral pleurae – pulmonary pleura; closely covers the lung and adheres to all  R side = continues pass inferiorly in AML to posterior aspect of xiphoid process
its surfaces; provide lung w/ smooth slippery surface, enabling it to move freely  L side = descends in AML only to lvl of 4th costal cartilage
on parietal pleura; continuous w/ hilum of the lung  Shallow notch in pleural sac and “bare area” of pericardial contact w/ anterior
wall  impt for pericardiocentesis
Parietal Pleura  Diaphragmatic line
1. Costal Part (Costovertebral) – thickest; covers internal surfaces of thoracic wall;  Costo-diaphragmatic
separated from internal surface of thoracic wall by endothoracic fascia  Vertebral line
2. Cervical or Cupola Pleura – covers the lung apex  Posterior costo-mediastinal
3. Diaphragmatic – in contact w/ the diaphragm; covers superior (thoracic) surface of  Much rounder, gradual reflections and occur where costal pleura becomes
diaphragm on each side of mediastinum, except along its costal attachments continuous w/ mediastinal pleura posteriorly
(origins) and where diaphragm is fused to pericardium  Parallel the vertebral column, running in the paravertebral planes from T1
4. Mediastinal – enveloping the heart; covers lateral aspects of mediastinum, partition through T12, become continuous w/ costal lines
of tss and organs separating pulmonary cavities and their pleural sacs
5. Pericardial *Costal line
- sharp continuations of sternal lines, occurring where costal pleura becomes
Visceral Pleura continuous w/ diaphragmatic pleura inferiorly
 Inner layer of the pleural sac - R = proceeds laterally from AML
 Completely investing the lungs and firmly adherent to it - L = bc of bare area of pericardium  begins at MCL
- Otherwise, R and L are symmetrical as they proceed laterally, posteriorly, and
Sibson’s Fascia/Suprapleural Membrane medially, passing obliquely across 8th rib in MCL and 10th rib in MAL, becoming
 Small fan shaped aponeurotic expansion extending from the inner surface of the continuous posteriorly w/ vertebral lines at necks of 12th rib inferior to them
scalene ms to the transverse process of the C7 and the inner border of the 1st rib
 Forms a covering for the cupola pleura (apex), separating it from the subclavian
artery (anteriorly)

Phrenico-pleural fascia
 Thin narrow slip of fibrous connective tissue found along the inferior border of the
pleura & anchoring it to the diaphragm and adjoining ribs and costal cartilages

Pulmonary ligament
 Empty, lower part of the double layered pleura whose lower end may reach the
diaphragm
 The transition of the mediastinal parietal pleura to the visceral part along the medial
aspect of the lung, produces a longitudinal vertical fold of serous membrane,
occupied at its upper portion by the structures forming the root of the lung

Pleural Recesses – formed bc it is where the lungs will descend

 Costo-mediastinal recess
- Space along the anterior margin of the pleura between the costal & mediastinal
portions of the parietal layers
 Costo-diaphragmatic recess
- Space along the inferior or lower margin of the pleura between the costal and
diaphragmatic portions of the parietal layer

APN2017 – edited by G. M. B. ‘17