Anatomy of thoracic wall

&
Pleural Cavity

Dr. Mega Sari Sitorus, M.Kes, Sp.PA/

Dr. Dwi Rita Anggraini M.Kes, Sp.PA

Dep. Anatomi FK USU-2020

 Regional anatomy Thoracic
Wall
The cylindrical
thorax consists of:
 a wall;
 two pleural
cavities;
 the lungs; and
 the mediastinum.
 Thorax
 houses the heart and lungs,
 A conduit for structures passing
between the neck and the abdomen,
 Plays a principal role in breathing.
 Thoracic wall protects the heart and
lungs and provides support for the
upper limbs.
 Muscles anchored to the anterior
thoracic wall, together with their
associated connective tissues,
nerves, and vessels, and the overlying
skin and superficial fascia, define the
pectoral region.
Topographic Anatomy of the Thorax
Bones of Thoracic wall
 Thoracic vertebrae
 There are twelve thoracic vertebrae, each of
which is characterized by articulations with ribs.
typical thoracic vertebra :
 heart-shaped vertebral body,
 The vertebral foramen is generally circular.
 The superior articular processes are flat,
 The transverse processes are club shaped
and project posterolaterally.
 has three sites on each side for articulation with
ribs. Two demifacets (i.e., partial facets) are
located on the superior and inferior aspects of
the body and An oval facet (transverse costal
facet) at the end of the transverse process
RIBS
• ribs 1-7 "true" ribs - those
which attach directly to the
sternum true ribs actually
attach to the sternum by
means of a costal cartilage
and a true synovial joint.
• rib 8-10 "false" ribs they
articulate via costal cartilages
with the costal cartilage of rib
7.
• rib 11-12 "floating" ribs the
anterior ends of these ribs do
not articulate with the
sternum or the costal
cartilage of the rib above;
their costal cartilages are
short and end in the muscle
of the posterolateral
abdominal wall.
 Rib
• ribs have many features in
common:
– Head, posteromedial end of
the rib, it articulates with
demifacets of two adjacent
vertebral bodies.
– Neck, the constricted
region lateral to the head of
the rib, the neck of the rib
is located between the head
and the tubercle.
– Tubercle, a projection
located posteroinferior and
lateral to the neck of the
rib, it articulates with the
transverse process of a
vertebra.
– body., the shaft of the rib,
the body is the longest
part of a typical rib.
– Angle, the marked
angulation of the body
located just lateral to the
tubercle ,the angle of the
rib is its most posterior
part.
– costal groove, the groove
on the inner surface of the
inferior border of the
body of the rib, it
accommodates the
intercostal neurovascular
bundle
Sternum
• the broad flat bone is
formed by three parts:
Manubrium, body and
xiphoid process.
Manubrium is the superior
part of the sternum,
manubrium means
"handle", as in the handle
of a sword.
– jugular (suprasternal)
notch.
– clavicular notch a notch
on the superolateral
border of the
manubrium.
• sternal angle the junction
of the manubrium and
body of the sternum.

Body the middle part of

the sternum, it articulates
with the manubrium
superiorly and the xiphoid
process inferiorly; laterally
it articulates with the
costal

Xiphoid process the

inferior part of the
sternum, xiphoid means
"sword shaped"
 Intercostal spaces
 lie between adjacent
ribs and are filled by
intercostal muscles
 Intercostal nerves
and associated major
arteries and veins lie
in the costal groove
along the inferior
margin of the
superior rib and pass
in the plane between
the inner two layers
of muscles.
 In each space, the vein is the most
superior structure,The artery is
inferior to the vein, and the nerve is
inferior to the artery and often not
protected by the groove.
 Deep to the intercostal spaces and
ribs, and separating these structures
from the underlying pleura,is a layer
of loose connective tissue, called
endothoracic fascia, which
contains variable amounts of fat.
 Superficial to the spaces are deep
fascia, superficial fascia, and skin.
Muscles of the Thoracic Wall
• The muscles of the thoracic and
abdominal walls are in general arranged in
external, middle, and internal layers.
• In the thorax , these are the
– (1) external intercostal muscles,
– (2) internal intercostal muscles, and
– (3) innermost intercostal muscles, subcostal
muscles, and transversus thoracis.
The intercostal muscles.
The diaphragm.
• the most important
muscle of respiration.
• It separates the
thoracic and
abdominal viscera.
• Three of its parts
(sternal, costal, and
lumbar) are inserted
into the central
tendon.
• The sternal part
consists of slips from
the xiphoid process.
• the sternocostal
triangle transmits the
superior epigastric
vessels and some
lymphatics, and it
may be the site of a
diaphragmatic hernia.
• The costal parts, which form the right and left
"domes," arise from the inner surfaces of the
lower costal cartilages and ribs and
interdigitate with the transversus abdominis.
• They are inserted into the central tendon
anterolaterally.
• Each lumbar (or vertebral) part arises from (1) a lateral
arcuate ligament over the quadratus lumborum, (2) a
medial arcuate ligament over the psoas major, and (3) a
crus from the upper lumbar vertebrae .
– The crura are united anterior to the aorta by the
median arcuate ligament, a fibrous arch that forms the
aortic opening.
– The right crus splits around the esophagus, and part
of it continues into the suspensory ligament of the
duodenum.
– The left crus is smaller and more variable.
Structures traveling
through the
diaphragm :
• the inferior vena cava
passes through the central
tendon at approximately
vertebral level TVIII;
• the esophagus passes
through the muscular part
of the diaphragm, just to
the left of midline,
approximately at vertebral
level TX;
• the vagus nerves pass
through the diaphragm with
the esophagus;
• the aorta passes behind
the posterior attachment
of the diaphragm at
vertebral level TXII;
• the thoracic duct passes
behind the diaphragm with
the aorta;
• the azygos and
hemiazygos veins may
also pass through the
aortic hiatus or through
the crura of the
diaphragm.
• The arterial supply to the diaphragm is from
pericardiacophrenic and musculophrenic arteries.
• Superior phrenic arteries, which arise directly from
lower parts of the thoracic aorta, and small branches
from intercostal arteries contribute to the supply.
• The largest arteries supplying the diaphragm arise
from inferior phrenic arteries, which branch directly
from the abdominal aorta.
Venous drainage
Venous drainage of the diaphragm is by veins that
generally parallel the arteries.
The veins drain into:
• the brachiocephalic veins in the neck;
• the azygos system of veins; or
• abdominal veins (left suprarenal vein and inferior
vena cava).

Innervation by the phrenic nerves (C3 to C5), which

penetrate the diaphragm and innervate it from its
abdominal surface.

Contraction of the domes of the diaphragm flattens

the diaphragm, so increasing thoracic
volume. Movements of the diaphragm are essential
for normal breathing.
 Arterial supply
 Vessels that supply the
thoracic wall consist
mainly of posterior
and anterior
intercostal arteries,
 These arteries
originate from the
aorta and internal
thoracic arteries,
which in turn arise
from the subclavian
arteries.
The internal thoracic.
• The internal thoracic artery (previously called the internal
mammary) artery arises from the first part of the subclavian
artery.
• It descends posterior to the sternomastoid muscle, clavicle,
and subclavian and internal jugular veins
• It then descends posterior to the upper six costal cartilages,
immediately lateral to the sternum, and anterior to the pleura.
• It gives branches to the intercostal spaces, pleura,
pericardium, and breast.
• At the sixth intercostal space, it divides into the superior
epigastric and musculophrenic arteries.
 Venous Drainage
 Intercostal veins drain into the
azygos system of veins or into
internal thoracic veins, which
connect with the
brachiocephalic
 the upper posterior intercostal
veins on the left side form the
left superior intercostal vein,
which empties into the left
brachiocephalic vein.
 the upper posterior intercostal
veins on the right side form the
right superior intercostal
vein, which empties into the
azygos vein.
 Innervation Thoracic Wall

 Innervation mainly by the

intercostal nerves,
which are the anterior
rami ofspinal nerves T1
to T11
 The anterior ramus
 of spinal nerve T12 (the
subcostal nerve) is
inferior to rib XII
 Intercostal nerves.
 Intercostal nerves 4 to 6 are "typical” in that they supply only the thoracic
wall and its associated muscles (intercostal, subcostal, serratus posterior
superior, and transversus thoracis).
 Each passes inferior to the neck of the corresponding rib and enters the
costal groove.
 At the anterior end of the intercostal space, it passes through the internal
intercostal muscle, external intercostal membrane, and pectoralis major, to
be distributed as the anterior cutaneous branch to the anterior chest.
 Each intercostal nerve gives off a collateral branch to the inferior part of
the intercostal space and a lateral cutaneous branch to the side of the
chest.
 In addition to being distributed to muscle and skin, branches are given to
the parietal pleura, mammary gland, and periosteum of the ribs.
 The first thoracic nerve divides into a superior part, which joins the
brachial plexus, and an inferior part, which becomes the first
intercostal nerve .
 The lateral cutaneous branches of intercostal nerves 1 to 3
contribute to the upper limb, that of the second being known as
the intercostobrachial nerve.
 Intercostal nerves 7 to 11 supply the abdominal as well as the
thoracic wall; hence they may be termed thoraco-abdominal.
 The ventral ramus of thoracic nerve 12 is known as the subcostal
nerve. It enters the abdomen posterior to the lateral arcuate
ligament, crosses posterior to the kidney, penetrates the muscles of
the abdominal wall, enters the rectus sheath, and becomes
cutaneous
Anatomy Of Pleura
 Location
➢ The pleurae and lungs lie on either side
of the mediastinum within the chest
cavity

▪ Each pleura has two parts:

➢ Parietallayer
➢ Visceral layer
 Parietal Layer
➢ It lines the thoracic wall

➢ Covers the thoracic surface of the diaphragm

and the lateral aspect of the mediastinum

➢ Extends into the root of the neck to line the

undersurface of the suprapleural membrane at
the thoracic outlet
the parts of parietal pleura:
 costal part;
 diaphragmatic part;
 mediastinal part;
 the dome-shaped layer of parietal pleura lining the
cervical extension of the pleural cavity is cervical
pleura (dome of pleura or pleural cupola).
 Cervical Pleura

➢ Parietalpleura is divided into the region in

which it lies or the surface that it covers

➢ The cervical pleura extends up into the neck

➢ It
lines the undersurface of the suprapleural
membrane

➢ It reaches a level 1 to 1.5 in. (2.5 to 4 cm)

 Costal Pleura

▪ It lines the inner surfaces of:

➢ The ribs
➢ The costal cartilages
➢ The intercostal spaces
➢ The sides of the vertebral bodies
➢ The back of the sternum
 Diaphragmatic Pleura

➢ Itcovers the thoracic surface of the

diaphragm

➢ In quiet respiration, the costal and

diaphragmatic pleurae are in apposition to
each other below the lower border of the
lung

➢ Costal and diaphragmatic pleurae separate in

 Mediastinal Pleura
➢ It covers and forms the lateral boundary of the mediastinum

➢ It is reflected as a cuff around the vessels and bronchi at the

hilum of the lung

➢ Then continuous with the visceral pleura

➢ Each lung lies free except at the hilum

➢ it is attached to the blood vessels and bronchi that constitute

the lung root
 Mediastinal Pleura
➢ During full inspiration the
lungs expand and fill the
pleural cavities

➢ During quiet inspiration

the lungs do not fully
occupy the pleural cavities
at four sites

➢ The right and left

costodiaphragmatic
recesses

➢ The right and left

costomediastinal recesses
The lungs do not completely fill the anterior or
posterior inferior regions of the pleural cavities.

This results in recesses in which two layers of parietal

pleura become opposed.

Expansion of the lungs into these spaces usually

occurs only during forced inspiration;

the recesses also provide potential spaces in which

fluids can collect and from which fluids can be
aspirated.
 Costodiaphragmatic recesses

➢ Are slitlike spaces between the costal and diaphragmatic

parietal pleurae

➢ Separated only by a capillary layer of pleural fluid

➢ During inspiration, the lower margins of the lungs descend

into the recesses

➢ During expiration, the lower margins of the lungs ascend so

that the costal and diaphragmatic pleurae come together
again
 Costomediastinal Recesses
➢ Aresituated along the anterior margins of the
pleura

➢ Theyare slitlike spaces between the costal

and the mediastinal parietal pleurae

➢ Separated by a capillary layer of pleural fluid

➢ Duringinspiration and expiration, the anterior

borders of the lungs slide in and out of the
recesses
Costodiaphragmatic recesses
Costomediastinal recesses
 Visceral Layer
➢ Itcompletely covers the outer surfaces of the
lungs

➢ Extends into the depths of the interlobar

fissures
 visceral pleura is innervated by visceral
afferent nerves that accompany bronchial
vessels, pain is generally not elicited from this
tissue.
 Nerve Supply
➢ The parietal pleura is sensitive to pain, temperature, touch
and pressure, and is supplied as follows:

➢ The costal pleura is segmentally supplied by the intercostal

nerves

➢ The mediastinal pleura is supplied by the phrenic nerve

➢ The diaphragmatic pleura is supplied over the domes by the

phrenic nerve and around the periphery by the lower six
intercostal nerves
 Pleural Cuff

➢ Thetwo layers continuous with one another

by means of a cuff of pleura

➢ Thiscuff surrounds the structures entering

and leaving the lung at the hilum of each lung

➢ Pleural
cuff hangs down as a loose fold called
the pulmonary ligament
 Pleural Cavity
➢ The parietal and visceral layers are
separated from one another by a
slitlike space called pleural cavity

➢ Pleural cavity contains thin film of

tissue fluid called pleural fluid

➢ Fluid permits the two layers to

move on each other with the
minimum of friction
 Pleural Fluid
➢ Any condition that increases the production of the fluid
or impairs the drainage of the fluid results in the
abnormal accumulation of fluid, called pleural effusion

➢ The presence of 300 ml of fluid in the

costodiaphragmatic recess in an adult is sufficient to
enable its clinical detection

➢ The clinical signs include decreased lung expansion on

the side of the effusion, with decreased breath sounds
and dullness on percussion over the effusion
 Pleuricy
➢ Inflammation of the pleura secondary to
inflammation of the lung called pneumonia

➢ Pleuralsurfaces become coated with inflammatory

exudate, causing the surfaces to be roughened

➢ Produces friction, and a pleural rub

➢ Itcan be heard with the stethoscope on inspiration

and expiration
 Pleuricy

➢ Often the exudate becomes invaded by

fibroblasts

➢ Thatlay down collagen and bind the visceral

pleura to the parietal pleura

➢ Forms pleural adhesions