DR.

OLATUNJI SUNDAY YINKA

 Give your
worries/challenges to
Jesus

Let Him worry about

your challenges, don’t
forget everyone has
his/her challenge(s)
 LEARNING OBJECTIVES
 At the end of this lecture, you should be able
to describe the :

 thoracic apertures and boundaries

 osteology of the thorax
 muscles of the thorax
 applied anatomy of the areas taught
Introduction
 The thorax is the part of the
trunk that is situated between
the neck and the abdomen. It
contains some vital organs such
as the lungs, the heart and the
great vessels

 It is continuous with the neck

above and separated from the
abdomen by the diaphragm
The ribs
 The ribs are a set of twelve paired bones
which form the protective ‘cage’ of
the thorax.

 They articulate with the vertebral column

posteriorly, and terminate anteriorly as
cartilage (known as costal cartilage).
The Ribs
 Usually, 12 pairs
 7 true ribs- direct attachment to the sternum
 5 false ribs- indirect or no attachment to the
sternum

 Floating ribs – make up 2 of the 5 false ribs, no

ventral attachment

 Typical ribs-- Ribs 3-9

 Atypical ribs --Ribs 1, 2, 10, 11, 12
Types of ribs
Applied anatomy
Thoracic vertebrae
 Characteristic Features
 The thoracic vertebrae have four features which
distinguish them from other vertebrae:

 Vertebral body is heart shaped.

 Presence of demi-facets on the sides of each vertebral
body – these articulate with the heads of the ribs.
 Presence of costal facets on the transverse processes –
these articulate with the tubercles of the ribs. They are
present on T1-T10 only.
 The spinous processes are long and slant inferiorly. This
offers increased protection to the spinal cord, preventing
an object such as a knife entering the spinal canal.
Applied anatomy
 Thoracic Kyphosis is an
excessive curvature of the
thoracic spine, causing the
back to appear “hunched”. It
may occur for a number of
reasons early in life. These
include poor posture,
abnormally wedge-shaped
vertebrae, and fusing of
vertebrae during
development.
 Various diseases can also lead to kyphosis in
adults. The most common cause is osteoporosis
– a condition whereby bone mass is lost (mostly
in older people). This leaves the spine less able to
support the weight of the body, thus resulting in
characteristic kyphosis.
Applied anatomy
 Pectus carinatum is a genetic disorder
of the chest wall. It makes the chest jut
out.
 This happens because of an unusual
growth of rib and breastbone (sternum)
cartilage . The bulging gives the chest a
birdlike appearance. That's why the
condition is sometimes called pigeon
breast or pigeon chest.
 Pectus excavatum is a structural
deformity of the anterior thoracic wall in
which the sternum and rib cage are
shaped abnormally. This produces a caved-
in or sunken appearance of the chest. It
can either be present at birth or develop
after puberty.
 Assignment
 List the events that occur at the sternal
angle
 Draw a well label structure of the following
bones of the upper limb
 Sternum
 Rib 1, 5 and 12
 6 thoracic vertebra

 Submit next week Tuesday by 9AM

THORACIC WALL
Muscles of thoracic wall
 Muscles follow the pattern of abdominal
arrangement.
 Neurovascular plane between the 2nd and
3rd layers. Muscles broken into segments
by intervening ribs.
 They lift and depress the thoracic cage
changing the volume of the cage in
changing phases of respiration.
 3 layers are clearly demarcated.
 External layer; consist of 3 muscles.
 Serratus posterior superior; from spinous
process of C7, T1, 2 and intervening supraspinous
ligament.
 Inserted just lateral to the angles of ribs 2-5.
 It lies on the surface of splenius muscle.
 Dorsal scapular nerve and vessel lie on it.
 Serratus posterior inferior; from T11, 12, L1, 2
and intervening supraspinous ligament.
 Inserted just lateral to the angles of ribs 9, 10, 11,
12.
 They are weak respiratory muscles.
 Levator costae; from the transverse process
of C7 to T11 to the upper border of the rib
below it lateral to the tubercle.
 They are fan shaped and only thoracic muscle
supplied by posterior rami.
 External intercostal muscle; from the
sharp lower border of the ribs above to the
smooth upper border of the rib below.
 It extends from the superior costotransverse
ligament to the costochondral junction.
 Anterior intercostal membrane completes it.
The fibers run anterio-inferiorly.
 Intermediate layer; consist of 1 muscle, the
intermediate intercostal muscle.
 Fibers run posterio-inferiorly from the costal
groove of the rib above to the upper border
of the ribs below.
 Extends as far as the sternal border, but
completed posteriorly by the posterior
intercostal membrane.
 Membrane extends from the rib angle to the
superior costotransverse ligaments.
 Innermost layer; consists of 3 muscles, they
span more than 1 intercostal space.
 Innermost intercostal; fibers are wider
below than above, lie at the lateral side of the
thoracic wall.
 Subcostalis; fibers run in the paravertebral
gutter, better developed below than above
 Transversus thoracis; from the lower part
of the sternum to the costal cartilages of 2nd
to 6th ribs.
INTERCOSTAL SPACE
 Between the sharp lower border of the rib
below and the smooth upper border of the rib
above.
 Filled by the intercostal muscles,
neurovascular plane runs between the
intermediate and the innermost layers.
 Neurovascular bundle arranged as VAN from
above downward in the concavity of the
costal groove.
 Important for pleural drainage and thoracotomy.
Intercostal nerves
 Intercostal nerves; emerge from the
intervertebral foramen, gives collateral
branch that supply muscle of the space.
Collateral branch runs above the lower rib of
the space.
 Other branches are the lateral and anterior
cutaneous branches. Superficial to the artery
in front and behind. Lower 5 nerves and
collateral branches run in neurovascular plane
of the abdominal wall.
 1st nerve is small with no cutaneous branch,
Subcostal passes behind lateral arcuate
ligament into abdomen.
 Intercostal artery
 Intercostal artery; it has 2 components
 posterior and anterior components.
 Posterior intercostal arteries: The
posterior intercostal arteries are branches
of the superior intercostal artery (upper
two spaces) and the descending
thoracic aorta (lower nine spaces).

 Anterior intercostal arteries consist of

branches of the internal thoracic artery
(1-6) and musculophrenic artery (7-9).
 2 branches of anterior anastomose with 1
branch of posterior.
 Intercostal veins; 2 anterior intercostal
veins per space, drain into the internal
thoracic and musculophrenic veins.
 Posterior drain into the azygos system of
veins
 Lower 8 right intercostal veins drain into the
azygos vein while left drain into the
hemiazygos and accessory hemiazygos.
 1st space drain by the Supreme intercostal
vein, 2nd to 3rd drain into the Superior
intercostal vein which drains into the azygos
on the right and brachiocephalic on the left.
 INTERNAL THORACIC
ARTERY
 From the 1st part of subclavian
 Runs a finger breath lateral to sternum on both
sides.
 Gives 2 anterior intercostal arteries per space.
 Divides to superior epigastric and
musculophrenic arteries at the costal margin.
 Musculophrenic gives 2 branches to the lower
spaces. Pierce diaphragm to supply its abdominal
surface.
The Diaphragm
 The diaphragm is a double-domed
musculotendinous sheet, located at the
inferior-most aspect of the rib cage. It serves two
main functions:
 Separates the thoracic cavity from the
abdominal cavity (the word diaphragm is derived
from the Greek ‘diáphragma’, meaning partition).
 Undergoes contraction and relaxation, altering
the volume of the thoracic cavity and the
lungs, producing inspiration and expiration.
Anatomical Position and
Attachments

 The diaphragm is located at the inferior-

most aspect of the ribcage, filling
the inferior thoracic aperture.
 It acts as the floor of the thoracic
cavity and the roof of the abdominal
cavity.
 The attachments of diaphragm can be
divided into peripheral and central
attachments.
 It has three peripheral attachments:
 Lumbar vertebrae and arcuate
ligaments.
 Costal cartilages of ribs 7-10 (attach
directly to ribs 11-12).
 Xiphoid process of the sternum.
 The parts of the diaphragm that arise from
the vertebrae are tendinous in structure, and
are known as the right and left crura:
 Right crus – Arises from L1-L3 and their
intervertebral discs. Some fibres from the
right crus surround the oesophageal
opening, acting as a physiological sphincter
to prevent reflux of gastric contents into
the oesophagus.
 Left crus – Arises from L1-L2 and their
intervertebral discs.
 The muscle fibres of the diaphragm
combine to form a central tendon. This
tendon ascends to fuse with the inferior
surface of the fibrous pericardium.
 Either side of the pericardium, the
diaphragm ascends to form left and
right domes.
 At rest, the right dome lies slightly higher
than the left – this is thought to be due to
the presence of the liver
Openings through the diaphragm
 The diaphragm divides the thoracic and
abdominal cavities.
 Thus, any structure that pass between the
two cavities will pierce the diaphragm.
 There are three openings that act as
conduit for these structures
 VOA
 Diaphragmatic openings;
 Aortic (midline) T12, transmit aorta, azygos
vein and thoracic duct in between.
 Esophageal; left) T10, transmits vagal trunk
and left gastric artery branch.
 Vena caval; (right) T8, transmits IVC and
right phrenic nerve.
 Actions
 The diaphragm is the primary muscle of
respiration.
 During inspiration, it contracts and flattens,
increasing the vertical diameter of the
thoracic cavity.
 This produces lung expansion, and air is
drawn in.
 During expiration, the diaphragm passively
relaxes and returns to its original dome shape.
This reduces the volume of the thoracic
cavity.
Innervation
 The halves of the diaphragm receive
motor innervation from the phrenic
nerve. The left half of the diaphragm
(known as a hemidiaphragm) is innervated
by the left phrenic nerve, and vice versa.
Each phrenic nerve is formed in the neck
within the cervical plexus and contains
fibres from spinal roots C3-C5.
Blood supply
 The majority of the arterial supply to the
diaphragm is delivered via the inferior
phrenic arteries, which arise directly
from the abdominal aorta.
 The remaining supply is from the
superior phrenic,
pericardiacophrenic, and
musculophrenic arteries.
 The draining veins follow the accompany
arteries
Clinical Relevance: Paralysis of the
Diaphragm
 Diaphragmatic paralysis is due to an
interruption in its nervous supply. This can occur
in the phrenic nerve, cervical spinal cord, or the
brainstem. It is most often due to a lesion of
the phrenic nerve:

 Mechanical trauma: ligation or damage to the

nerve during surgery.
 Compression: due to a tumour within the chest
cavity.
 Myopathies: such as myasthenia gravis.
 Neuropathies: such diabetic neuropathy.
Elevated right hemidiaphragm
THORACIC CAVITY AND PLEURA
 NERVE SUPPLY
 PP- Intercostal nerve and phrenic nerve
 VP- sympathetic: 2-5 spinal segment of nerve
 parasympathetic: vagus nerve
 BLOOD SUPPLY TO THE PLEURA
 PP- Intercosta, internal thoracic,
musculophrenic arteries
 VP: Bronchial arteries
Applied Anatomy
 Pleurisy(pleuritis): inflammation of the
pleura

 Pneumothorax
 Haemothorax
 Hydropneumothorax
The Lungs
Introduction
Structure of the lung
Fissures and lobes
Root of the Lungs
R&L Lung Differences
Blood supply
Innervation
Lymphatic
Applied Anatomy
Introduction
 The lungs are a pair of
respiratory organs that are
situated in the thoracic
cavity.

 The two right and left lung

are separated by the
mediastinum
 The function of the
lungs is
to oxygenate blood.
They achieve this by
bringing inspired air
into close contact
with oxygen-poor
blood in the
pulmonary capillaries.
 The lungs are
spongy(texture) and
brown/ grey in colour
which gradually becomes
mottled black because of
deposition of inhaled
carbon particles.
 Each weighs about 700g
Structure of the lungs
 Each lung is conical in shape, with
 an apex,
 A base,
 3surfaces &
 3 borders.
 (The left lung is slightly smaller
than the right – this is due to the
presence of the heart).
 Each lung consists of:
 Apex – located superiorly and covered by
suprapleural membrane
 Base – inferiorly located and sits/rest on the
diaphragm.
 3 Surfaces – costal surface,
mediastinal surface &
diaphragmatic surface
 3 Borders – anterior border,
inferior border and
posterior border
 Fissures and Lobes of the lungs
 The right and left lungs do not have an identical
lobular structure.

 The right lung has 3 lobes; superior, middle

and inferior. The lobes are divided from each
other by two fissures: Oblique fissure
 Horizontal fissure
 The left lung contains superior and inferior
lobes, which are separated by a similar oblique
fissure.
Differences between right and left lungs
 Root and Hilum

 The lung root of the lung is the media surface of

the lungs where structures leave and enters the
lung from the mediastinum.
 Each root contains a bronchus, pulmonary
artery, two pulmonary veins, bronchial vessels,
pulmonary plexus of nerves and lymphatic
vessels.

 All these structures enter or leave the lung via

the hilum – a wedge shaped area on its
mediastinal surface.
 NB
 The eparterial bronchus (right superior lobar
bronchus) is a branch of the right main bronchus given
off about 2.5 cm from the bifurcation of the trachea.
This branch supplies the superior lobe of the right
lung and is the most superior of all secondary bronchi.
It arises above the level of the right pulmonary artery,
and for this reason is named the eparterial
bronchus.[1] All other distributions falling below the
pulmonary artery are termed hyparterial.

 The eparterial bronchus is the only secondary

bronchus with a specific name apart from the name of
its corresponding lobe.
 Blood Supply
 The lungs are supplied with deoxygenated blood by the
paired pulmonary arteries. Once the blood has received
oxygenation, it leaves the lungs via four pulmonary veins
(two for each lung).

 The bronchi, lung roots, visceral pleura and supporting lung

tissues require an extra nutritive blood supply. This is
delivered by the bronchial arteries, which arise from the
descending aorta.

 The bronchial veins provide venous drainage. The right

bronchial vein drains into the azygos vein, whilst the left
drains into the accessory hemiazygos vein.
 Nerve Supply
 The nerves of the lungs are derived from
the pulmonary plexuses. They feature
sympathetic, parasympathetic and visceral
afferent fibres:

 sympathetic: 2-5 spinal segment of nerve

 parasympathetic: vagus nerve
 Lymphatic Drainage
 The lymphatic vessels of the lung arise from
two lymphatic plexuses:

 Superficial (subpleural) – drains the lung

parenchyma.
 Deep – drains the structures of the lung root.
 Both these plexuses empty into the
trachebronchial nodes – located around the
bifurcation of the trachea and the main bronchi.
Applied Anatomy
- Pulmonary Embolism
 A pulmonary embolism refers to the obstruction of a
pulmonary artery by a substance that has travelled from
elsewhere in the body. The most common emboli are:

 Thrombus – responsible for the majority of cases and

usually arises in a distant vein.
 Fat – following a bone fracture or orthopaedic surgery.
 Air – following cannulation in the neck.
 The effect of a pulmonary embolism is a reduction in
lung perfusion. This results in decreased blood
oxygenation, and the accumulation of blood in the right
ventricle of the heart.
 Tuberculosis: a bacterial infection of the lungs

 The lungs are pink in healthy in children and

young people who live in a clean environment
(e.g people in Himalayans mountain) it is mottle
dark in most adults in urban and agricultural
area because of accumulation of carbon and
dust particle
 Cancer of the lungs is also a major disease of
the lungs common in smokers
Assignment
1. Write extensively on the tracheobroncial tree
and comments of its applied anatomy

2. Write extensively on Bronchopulmonary

segment and comments of its applied anatomy
3. Write on the azygous system of veins with the
aid of well labeled diagram
Tracheobronchial tree
• The trachea extends from the neck as a
continuation of the larynx (C6) to the
level of upper border of T5
• Caudally it bifurcates into the main
bronchi.
• It measures about 10cm in length but can
stretch as much as 15cm in full
inspiration.
• It has a diameter of about 2cm
• It is made up of about 15 -20 C-shaped hyaline
cartilage rings.
• The cartilaginous ring is completed
posteriorly by longitudinal and transverse
(trachealis) muscle fibres.
• It is lined by a pseudostratified columnar
ciliated epithelium with numerous goblet cells
and mucous gland.
• The oesophagus is the main posterior
relation.
• Half of its length resides in the neck region
from the cricoid cartilage to the jugular notch.
• It lies in the midline anterior to the
oesophagus.
• The recurrent laryngeal nerve runs in the
groove between them.
• The carotid sheath is a lateral relation.
• The thyroid gland is an anterio-lateral relation,
the isthmus been attached to the 2nd-4th rings.
 Thymus, thyroidea ima artery, inferior thyroid
vein and anterior jugular venous arch are
other anterior relations in the neck
 The upper part is more anterior than the
lower part following the curvature of the
cervico-thoracic vertebra
 The thoracic part runs in the superior
mediastinum.
 The sternohyoid, sternothyroid, manubrium,
left brachiocephalic vein, left common carotid
artery and brachiocephalic artery are anterior
relations.
 The arch of azygos, pleura and right vagus
intervene between the right side and the right
lung.
 The left common carotid and subclavian
arteries separate the left side from the pleura
and left vagus.
 The aorta arch arches over the left bronchus
while the arch of azygos arches over the right
bronchus
 The left recurrent laryngeal nerve runs in the
groove between the trachea and the
oesophagus
 THE LEFT BRONCHUS
 It measures about 5cm in length; diameter is smaller
than the right. Enters the left lung at the level of the
6th thoracic vertebra.
 The arch of the aorta arches over it
 The oesophagus, thoracic duct and descending aorta
are posterior relations.
 The left pulmonary artery is above and later anterior
to it.
 The right bronchus appears a more direct
continuation of the trachea than the left
 Objects tend to follow the right path than the left.
STRUCTURE
• The trachea and the extrapulmonary
bronchus consist of C-shaped cartilages
• The trachea has about 15-20 cartilages
• The right bronchus has between 6-8 cartilages
while the left has between 9-12 cartilages.
• The cartilages are flat externally but convex
internally.
• Cartilages could be ossified later in life.
• The cartilaginous rings are invested in a
double layered fibrous membrane that fuses
into a single layer in between and behind the
cartilages.
• The outer membrane is thicker than the inner
layer
• The muscular layer consist of the external
longitudinal and inner transverse fibres
(trachealis)
• Trachealis connects the 2 posterior ends of
the cartilage.
 BRONCHIAL SEGMENTATION
 The hyparterial branches of the right
bronchus supply the middle and lower lobes
 There are 10 branches corresponding to the
bronchopulmonary segments on both sides.
 Some branches in the left superior and
inferior lobes can be fused.
 The left superior lobe branch is given off
about 5cm post bifurcation.
 Branches to the lingular region of the superior
lobe of the left lung correspond with those of
the middle lobe of the right.
 Each bronchopulmonary segment is cone
shaped region supplied by a branch of the
lobar bronchus.
 Each segment is also supplied by its own
artery, it is anatomically independent.
 Branches of the pulmonary vein and
lymphatics run in the plane between segments.
 Lobular bronchi do not have cartilages with
diameters of about 0.2mm
 Respiratory bronchioles divide into alveolar
duct, alveoli are attached around them.
 The alveoli are lined by simple squamous
epithelium
 Bronchial Tree
 The bronchial tree is a series of passages that supplies air to
the alveoli of the lungs. It begins with the trachea, which
divides into a left and right bronchus.

 Note: The right bronchus has a higher incidence of foreign

body inhalation due to its wider shape and more vertical
course.

 Each bronchus enters the root of the lung, passing through

the hilum. Inside the lung, they divide to form lobar bronchi –
one supplying each lobe.

 Each lobar bronchus then further divides into several tertiary

segmental bronchi. Each segmental bronchus provides air to a
bronchopulmonary segment – these are the functional units
of the lungs.
 Neurovascular supply
 Arterial supply is from the bronchial artery (2
on the left, 1 on the right).
 Venous drainage; right to azygos, left to
hemiazygos.
 Also to bronchial and pulmonary veins.
 Nerve supply; pulmonary plexus, sympathetic
and parasympathetic
Mediastinum

 Introduction
 Boundaries
 Divisions
 Introduction

 The mediastinum
is the space
between the two
lungs in the
thoracic cavity
 Boundaries
 It is bounded
 anteriorly by the sternum
 Posteriorly by the Vertebrae
column
 Superiorly by the thoracic
inlet
 Inferiorly by the diaphragm
 Laterally by the mediastinal
pleura
 Divisions

 For descriptive purpose,

the mediastinum is divided
into superior and
inferior mediastinum by
an imaginary line plane
passing through the
sternal angle anteriorly
and the lower border of
the T4 posteriorly
 The inferior
mediastinum is further
subdivided into 3 by the
pericardium as
 Anterior mediastinum-
b4 the pericardium
 Middle mediastinum-
pericardium and its
contents
 Posterior
mediastinum- behind
the pericardium
 Superior Mediastinum
 Contents:
 phrenic nerve,
 Vagus nerve,
 thoracic duct,
 left recurrent laryngeal nerve,
 brachiocephalic vein(R&L),
 aortic arch(RBCt, LCC, LSA)
 thymus,
 trachea,
 lymphatics,
 Esophagus
 Mnemonic: PVT Left battle
 Middle mediastinum
 Superiorly – imaginary plane
 Posteriorly- esophagus, descending thoracic
aorta
 Anteriorly- sterno pericardia ligament
 Inferiorly- the diaphragm
 On each side- mediastinal pleura
Applied Anatomy
 Mediastinitis (inflammation of the
structures within the mediastinum)
Summary
References
 Chaurasia BD (2010) Human Anatomy
Regional and Applied Dissection And
Clinical 5th Edition volume1 CSB
Publishers New Delhi India.
 Keith Moore and Arthur Dalley (2010)
Clinical Oriented Anatomy 6th Edition
Lippincott Williams and Wilkins
Philadelphia, Pennsylvania.
 and some other internet sources