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- 1. By DARE SAMUEL SUNDAY Departmentof Human Anatomy, KABSOM
- 2. The chestis Region between the neck and abdomen. Flattened in front & behind but rounded at the sides Framework is called thoracic cage 2
- 3. Covered onthe outside by skin and muscles attaching the shoulder girdle to the trunk. Lined with parietal pleural on the inside. Walls Anteriorly: Sternum & costal cartilages Posteriorly: Thoracic part of vertebral column Laterally: Ribs & intercostal spaces Superiorly: Suprapleural membrane Inferiorly: Diaphragm 3
- 4. A flatbone in the midline of the anterior chest wall Divided into: manubrium sterni, body & xiphoid process Relatively shorter and thinner in the female Sternal angle (Angle of Louis): formed by articulation of the manubrium with the body of the sternum Joints: ◦ Manubriosternal – level of disc btw T4 & T5 ◦ Xiphisternal – opposite the body of T9 ◦ Manubrium articulates with clavicle and 1st rib ◦ Body of sternum articulates with 2nd to 7th costal cartilages. 4
- 5. Sternum andMarrow Biopsy Since the sternum possesses red hematopoietic marrow throughout life, it is a common site for marrow biopsy. Under a local anesthetic, a wide-bore needle is introduced into the marrow cavity through the anterior surface of the bone. The sternum may also be split at operation to allow the surgeon to gain easy access to the heart, great vessels, and thymus. 5
- 6. Consist of 12pairs of bones that form the main part of the thoracic cage Structure: Typical rib: long twisted flatbone and has head, neck, tubercule angle & body (e.g 3rd to 9th ribs) Atypical rib: are dissimilar (1st, 2nd, 10th, 11th & 12th ribs) Classification: True ribs: are ribs attached to their costal cartilages False ribs: ribs 8th, 9th, 10th attached to costal cartilage of the 7th rib. Floating ribs: 11th & 12th, has no attachment anteriorly. 6
- 7. First Rib Isthe broadest and shortest of the true ribs. Has a single articular facet on its head, which articulates with the first thoracic vertebra. Has a scalene tubercle for the insertion of the anterior scalene muscle and two grooves for the subclavian artery and vein. Second Rib Has two articular facets on its head, which articulate with the bodies of the first and second thoracic vertebrae. Is about twice as long as the first rib. 7
- 8. Tenth Rib Hasa single articular facet on its head, which articulates with the 10th thoracic vertebra. Eleventh and Twelfth Ribs Have a single articular facet on their heads. Have no neck or tubercle. 8
- 9.
- 10. Joints ofthe Sternum Joints of the ribs ◦ Head ◦ Tubercules ◦ Costal cartilages ◦ Sternum 10
- 11. Sternoclavicular Joint Saddle-typesynovial joint with two separate synovial cavities Provides the only bony attachment between the appendicular and axial skeletons. Sternocostal (Sternochondral) Joints Articulates the sternum with the first seven cartilages. Articulation of manubrium with first costal cartilage is synchondrosis (cartilaginous) Second to seventh costal cartilages form synovial plane joints with the sternum. 11
- 12. Costochondral Joints Articulationof ribs with their respective costal cartilages Are synchondroses. Manubriosternal Joint Between manubrium and body of the sternum. Is symphysis (secondary cartilaginous joint) Xiphisternal Joint Articulation between xiphoid process and body of the sternum is synchondrosis 12
- 13. Costovertebral Joints Synovialplane joints of heads of ribs with corresponding and supraadjacent vertebral bodies. Costotransverse Joint Synovial plane joint of tubercle of rib with transverse process of corresponding vertebra. Interchondral Joints Synovial plane joints between 6th and 10th costal cartilages of ribs. 13
- 14. Boundaries Anteriorly: Superiorborder of manubrium sterni Posteriorly: First thoracic verterbra Laterally: Medial border of first ribs and their costal cartilages 14
- 15. The ThoracicOutlet Syndrome The brachial plexus of nerves (C5, 6, 7, and 8 and T1) and the subclavian artery and vein are closely related to the upper surface of the first rib and the clavicle as they enter the upper limb. It is here that the nerves or blood vessels may be compressed between the bones. Most of the symptoms are caused by pressure on the lower trunk of the plexus producing pain down the medial side of the forearm and hand and wasting of the small muscles of the hand. Pressure on the blood vessels may compromise the circulation of the upper limb. 15
- 16. Muscle Origin InsertionNerve Action External intercostals Lower border of ribs Upper border of rib below Intercostal Elevate ribs in inspiration Internal intercostals Lower border of ribs Upper border of rib below Intercostal Depress ribs (costal part); elevate ribs (interchondral part) Innermost intercostals Lower border of ribs Upper border of rib below Intercostal Elevate ribs Transversus thoracis Posterior surface of lower sternum and xiphoid Inner surface of costal cartilages 2–6 Intercostal Depresses ribs Subcostalis Inner surface of lower ribs near their angles Upper borders of ribs 2 or 3 below Intercostal Elevates ribs Levator costarum Transverse processes of T7–T11 Subjacent ribs between tubercle and angle Dorsal primary rami of C8–T11 Elevates ribs 16
- 17. Spaces betweenthe ribs contaning: ◦ External intercostal muscle ◦ Internal intercostal muscle ◦ Innermost intercostal muscle (*endothoracic fascia and pleural) ◦ Neurovascular bundles: Intercostal nerves and blood vessels (VAN) 17
- 18. Structures penetratedby a needle when it passes from skin surface to pleural cavity. Depending on the site of penetration, the pectoral muscles will be pierced in addition to the serratus anterior muscle. 18
- 19. Skin Subcutaneoustissue Pectoral muscles Serratus anterior muscle External Intercostal muscle Anterior Intercostal membrane Internal Intercostal muscle Innermost Intercostal muscle Endothoracic fascia Parietal pleura 19
- 20. Intercostal arteriesand Veins Each intercostal space contains a large single posterior intercostal artery (PIA) and two small anterior intercostal arteries (AIA). ◦ PIAs of intercostal space 1 & 2 are branches from superior intercostal artery, a branch of the costocervical trunk of the subclavian artery. ◦ PIAs arteries of the lower nine spaces are branches of the descending thoracic aorta. ◦ AIAs of the first six spaces are branches of the internal thoracic artery, which arises from the first part of the subclavian artery. 20
- 21. AIAs oflower spaces are branches of the musculophrenic artery, one of the terminal branches of the internal thoracic artery Posterior intercostal veins drain backward into the azygos or hemiazygos veins, and the anterior intercostal veins drain forward into the internal thoracic and musculophrenic veins. 21
- 22. Intercostal nerves Anteriorrami of the first 11 thoracic spinal nerves. Anterior ramus of the 12th thoracic nerve lies in the abdomen and runs forward in the abdominal wall as the subcostal nerve. Note: The first six nerves are distributed within their intercostal spaces. o 7th to 9th intercostal nerves leave the anterior ends of their intercostal spaces by passing deep to the costal cartilages, to enter the anterior abdominal wall. o The 10th and 11th nerves, since the corresponding ribs are floating, pass directly into the abdominal wall 22
- 23. 23 Branches • Rami communicates •Collateral branch • Anterior cutaneous branch • Muscular branch • Pleural sensory branches • Peritoneal sensory branches
- 24. First intercostalnerve ◦ Joined to the brachial plexus by a large branch that is equivalent to the lateral cutaneous branch of typical intercostal nerves. ◦ The remainder of the first intercostal nerve is small, and there is no anterior cutaneous branch. Second intercostal nerve ◦ Is joined to the medial cutaneous nerve of the arm by a branch called the intercostobrachial nerve ◦ supplies the skin of the armpit and the upper medial side of the arm. In coronary artery disease, pain is referred along this nerve to the medial side of the arm 24
- 25. A thinmuscular and tendinous septum that separates the chest cavity above from the abdominal cavity below. It is pierced by the structures that pass between the chest and the abdomen Parts of the origin ◦ Sternal part: from the posterior surface of the xiphoid process. ◦ Costal part: from the deep surfaces of the lower six ribs and their costal cartilages. ◦ Vertebral part: by vertical columns or crura and from the arcuate ligaments. 25
- 26.
- 27. Branch of thefirst part of subclavian artery supplying the anterior wall of the body from the clavicle to the umbilicus. Branches 2 anterior intercostal arteries (supply upper 6 ICS) Perforating arteries Pericardiacophrenic artery Superior epigastric artery Musculophrenic artery 27
- 28.
- 29. Internal Thoracic Vein Formed by the confluence of the superior epigastric and musculophrenic veins, Ascends on the medial side of the artery Receives the upper six anterior intercostal and pericardiacophrenic veins Ends in the brachiocephalic vein. Thoracoepigastric Vein Is a venous connection between the lateral thoracic vein and the superficial epigastric vein. 29
- 30.
- 31. Sternal or Parasternal(Internal Thoracic) Nodes Are placed along the internal thoracic artery. Receive lymph from the medial portion of the breast, intercostal spaces, diaphragm, and supraumbilical region of the abdominal wall. Drain into the junction of the internal jugular and subclavian veins. Intercostal Nodes Lie near the heads of the ribs. Receive lymph from the intercostal spaces and the pleura. Drain into the cisterna chyli or the thoracic duct. Phrenic Nodes Lie on the thoracic surface of the diaphragm. Receive lymph from the pericardium, diaphragm, and liver. Drain into the sternal and posterior mediastinal nodes. 31
- 32. Suprasternal notch: Isthe superior margin of the manubrium sterni and is easily felt between the prominent medial ends of the clavicles in the midline. It lies opposite the lower border of the body of the second thoracic vertebra. The sternal angle (angle of Louis): Angle made between the manubrium and body of the sternum. It lies opposite the intervertebral disc between the fourth and fifth thoracic vertebrae. 32
- 33. Xiphisternal Joint: isthe joint between the xiphoid process of the sternum and the body of the sternum. It lies opposite the body of the ninth thoracic vertebra. The subcostal angle: is situated at the inferior end of the sternum, between the sternal attachments of the seventh costal cartilages. 33
- 34. Costal Margin Lower boundary of the thorax and is formed by the cartilages of the 7th, 8th, 9th, and 10th ribs and the ends of the 11th and 12th cartilages. Lowest part of the costal margin is formed by the 10th rib and lies at the level of the third lumbar vertebra (L3). 34
- 35. 1. Clavicle 2. Suprasternalnotch 3. Manubrium 4. Sternoclavicular joint 5. Body of sternum 6. Xiphisternum 7. Coracoid process 8. True ribs (1–7) 9. False ribs (8–10) 10. Costal cartilages 11. Costal margin 35 Doctorlib © 2015-2019
- 36. 1. Clavicle 2. Ribs 3.Left dome of diaphragm 4. Right costophrenic angle 5 Right border of heart 6 Left border of heart 7 Pulmonary conus 8 Aortic knuckle 36 Doctorlib © 2015-2019
- 37. 1. Midline sternotomyapproach to the mediastinum 2. Left anterolateral thoracotomy through bed of fifth rib 3. Posterolateral thoracotomy through bed of fourth rib 4. Thoraco-abdominal incision 5. Point for insertion of a needle into ventricles 6. Point for insertion of a needle into pericardial cavity for emergency pericardiocentesis 37 Doctorlib © 2015-2019
- 38. Anatomic and PhysiologicChanges in the Thorax with Aging The rib cage becomes more rigid and loses its elasticity as the result of calcification and even ossification of the costal cartilages. The stooped posture (kyphosis), so often seen in the old because of degeneration of the intervertebral discs, decreases the chest capacity. Disuse atrophy of the thoracic and abdominal muscles can result in poor respiratory movements. Degeneration of the elastic tissue in the lungs and bronchi results in impairment of the movement of expiration. These changes, when severe, diminish the efficiency of respiratory movements and impair the ability of the individual to withstand respiratory disease. 38
- 39. Read up thefollowings: Surface markings of the lungs and heart The pleural 39
- 40.