Thoracic wall l4 dr kandil

‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
THORACIC WALL
Dr Mostafa Kandil
2/19/2020 1

Bony Thorax
• The thoracic wall (thoracic cage) is
conical in shape consists of :
• Anteriorly: sternum &
costal cartilage
• Posteriorly: twelve thoracic vertebrae
and their intervertebral discs and
posterior of ribs
• Laterally:
ribs(twelve on each side) and three
layers of flat muscles
2/19/2020 Thoracic wall Dr Mostafa 2

• THE thoracic cage Has 2
apertures (openings):
• Superior (thoracic inlet):
narrow, open, continuous
with neck
• Inferior (thoracic outlet):
wide, closed by diaphragm
•Thoracic inlet
• Boundaries:
• a. Anterior: Supra-sternal
notch of the manubrium
sterni.
• b. On each side: First rib.
• c. Posterior: First
thoracic vertebra.

d
Structures passing through inlet
Viscera- trachea,oesophagus,apices of
lungs with pleura
Vessels-
1.brachiocephalic artery rt)
2.left common carotid artery
3.left subclavian artery
4.rt. & Lt. brachiocephalic veins
5.rt. & Lt. internal thoracic artery
Muscles- Sternothyroid& sternohyoi
Nerves-1.rt. & Lt. phrenic nerves
2.rt. & Lt. vagus nerve
3.rt. & Lt. sympathetic nerve.
4.rt. & Lt. first thoracic nerve2/19/2020 Thoracic wall Dr Mostafa 5

Thoracic outlet
Boundaries:
a. Anterior: Xiphoid process.
b. On each side: Lower six
costal cartilages & Last two
ribs.
c. Posterior: Last thoracic
vertebra.
It is closed by the diaphragm
which separates it from the
abdominal cavity.

Bones of thoracic cage
1-Sternum: Flat bone, 6 inches in
length, supports clavicles and
provides attachment to 1st seven
costal cartilages of ribs.
The sternum consists of three major
elements:
1-Manubrium of sternum, the broad
upper part, lies opposite T3,4
2-The Body of sternum; narrow and
longitudinally oriented, T5 toT8
3- Xiphoid process T9

•Manubrium of sternum
• The superior surface represent
palpable notch, the Jugular Notch
(Suprasternal Notch), in
the midline.
• On either side articulation with the
clavicle; clavicular notch.
• on each lateral surface: notch for
the attachment of the first costal
cartilage. At the lower end of the
lateral border is a demifacet for
articulation with the upper half of
the anterior end of the second
costal cartilage.
• Inferiorly: articulate with body of
sternum to form manubrio-sternal
junction or sternal angleLouis
Angle

Body of the sternum
• The lateral margins of the body; have articular
facets for costal cartilages from 2nd to 7th .
• Superiorly, each lateral margin has a demifacet for
articulation with the second costal cartilage.
• Inferior to this demifacet are four facets for
articulation with the costal cartilages of ribs IIIto VI.
• At the inferior end of the body of the sternum is a
demifacet for articulation with the upper demifacet
on the seventh costal cartilage.
• The inferior end of the body of the sternum is
attached to the xiphoid process to form xiphosternal
joint
• Xiphoid process
• Its shape is variable: it may be wide, thin, pointed,
bifid, curved, or perforated. On each side of its upper
lateral margin is a demifacet for articulation with the
inferior end of the seventh costal cartilage

Thoracic vertebrae
• They are 12 vertebra.
• From 2 to 8 they are
called Typical.
• Character of typical
thoracic vertebrae:
• Body: Heart shape &
carries 2 demi-facet at
its side.
• Transverse process:
has a facet for rib
tubercle of the same
number.
• Spine: Long, pointed &
directed downward
and backward.
• Vertebral foramen:
Small & circular.
•The superior articular processes are
flat, with their articular surfaces facing
almost directly posteriorly.
•The inferior articular processes project
from the laminae and their articular
facets face anteriorly

Articulations of vertebrae together
• Adjacent vertebrae are connected
together through
intervertebral articulations.
• Synovial joints are formed between
the inferior articular facets of
one vertebrae and the superior
articular facets of the vertebrae below.
• The bodies of adjacent vertebrae are
connected by specialized cartilaginous
joints known as intervertebral discs
(secondary cartilaginous joint).
• Each disc is composed of a central
core of gelatinous material, known as
the nucleus pulposus, and a
surrounding series of fibrous rings
known as the annulus fibrosis

Ribs
:
Classification according to their attachments to
the sternum:
Total number of Ribs: 12 pairs
A: True ribs: Upper seven ribs (Directly attached to
the sternum).
B: False ribs: Lower five ribs (Indirectly attached to
the sternum).
The lower two ribs (11th & 12th) are called the
Floating ribs because they are free anteriorly.
Classification of ribs according to their structure
A: Typical: 3rd - 9th ribs.
B: Atypical:1st, 2nd, 10th, 11th, and 12th ribs. (first
two and last 3) ribs.

• A typical rib consists of :
• a curved shaft with anterior and posterior
ends.
• The anterior end is continuous with its costal
cartilage.
• The posterior end articulates with the
vertebral column and is characterized by a
head, neck, and tubercle.
• The head: presents two articular surfaces separated by a
crest. The smaller superior surface articulates with the
inferior costal facet on the body of the vertebra above,
whereas the larger inferior facet articulates with the superior
costal facet of its own vertebra.

• The neck is a short flat region of bone that separates the
head from the tubercle.
• The tubercle projects posterior from the junction of the neck
with the shaft and consists of two regions, an articular part
and a non-articular part:
• the articular part is medial and has an oval facet for
articulation with a corresponding facet on the transverse
process of the associated vertebra;
• the non-articular part is roughened by ligament
attachments.

•The shaft:
•thin and flat with internal and external
surfaces.
•The superior margin is smooth and
rounded, whereas the inferior margin is
sharp.
•The shaft bends forward just laterally to
the tubercle at a site termed The Angle.
•It also has outer rough surface and
smooth inner surface.
•The inferior margin of the internal
surface is marked by a distinct costal
groove.

Atypical ribs
• First rib
• Shortest C- Shaped
• Ant end: cup shape & wide.
• Post end: It has Head, neck and
tubercle.
• Head: One facet
• Surfaces: Sup. & Inferior
• Borders: Outer (lateral) & Inner
(medial).
• Second rib
• Twice the length of 1st
• - Head has 2 facets
Surfaces of shaft are in between that of
1st & typical

• 10th rib:
• Single articular facet on the head.
• 11t h rib: Single articular facet on the
head.
• b. No tubercle
• 12th rib:. Single articular facet on the
head.
• b. No tubercle.
• c. No neck.
• d. No costal groove.
• e. Large head.
• f. Tapering anterior end.

Articulation between Thoracic vertebrae and the ribs
A typical thoracic vertebra has three
sites on each side for articulation with
ribs.
•Two demifacet on the superior and
inferior aspects of the body for
articulation with corresponding sites
on the heads of adjacent ribs.
•The superior costal facet articulates
with part of the head of its own rib, and
the inferior costal facet articulates with
part of the head of the rib below.
•An oval facet (transverse costal facet)
at the end of the transverse process
articulates with the tubercle of its own
rib.

Articulations
Sternocostal
(synovial), mobile
EXCEPTfirst, which
iscartilagenous &
fixed
Costochondral
(cartilagenousJ.)
nomovements
possible
Costovertebral
(Synovial joint)
Xiphisternal
(fibrocartilagenous J.)
nosignificant
movements
Manubriosternal
(fibrocartilagenous J.)
Smallangular
Movement possible

Intercostal spaces or chest wall
• There are 9 anterior and 1 1 posterior
• Each space contains:
• 1- Intercostal muscles: (External,
Internal and transversus thoracicus)
• 2- An Intercostal nerve.
• 3- Intercostal vessels:
• a. Intercostal arteries
(Anterior & Posterior)
• b. Intercostal veins
(Anterior & Posterior).

EXTERNAL INTERCOSTAL
• Origin: From the lower border of the rib above
• Insertion: Into outer lip of upper border of rib
below
• Fibers are directed from above
downward, forwards and medially
• Begins from post. end of
Intercostal space close to the tubercle of
the rib.
• Ends at the costochondral
junction where it is replaced by
external or anterior Intercostal
membrane.
▪ Nerve supply: intercostal nerves
▪ Action: rib elevators (inspiratory)

•INTERNAL INTERCOSTAL
• Origin: Floor of costal groove
• Insertion: Inner lip of upper border of rib
below
• Fibers are directed from above downwards &
backward
• Begins from anterior end of space close to
the sternum.
• Ends at the angle of the rib, where it is replaced
by post. Or internal Intercostal membrane.
•Action: Depresses the rib
downwards during expiration

• Transversus thoracicus
• The most inner layer of thoracic wall
• It is formed of 3 muscles
• 1- Innermost Intercostal. From upper lip of
costal groove above to upper lip of rib below
and directed : upward & medially
• 2- Sternocostalis.
• 4 to 5 slips which arise from inner surface
of lower part of body of sternum and costal
cartilages
• Inserted into inner surface of costal
cartilages from 2 to 6.
• 3- Subcostalis
• Mainly in lower 6 spaces.
• Only in post. part of spaces.
• Origin: Inner surface & lower border of rib
above.
• Insertion: Upper border of 2nd or 3rd rib
below.

•The neuromuscular bundles
•Are found between the middle and innermost layers,
protected by the costal groove of the superior rib of
each intercostal space. They are ordered vein, artery, nerve
from superior to inferior (mnemonic VAN).

Intercostal Arteries
1- Anterior Intercostal
Arteries.
•2 small arteries in each
of the 9 spaces.
•The upper 6 from
internal mammary
artery from 1st part of
subclavian
•The lower 3 from
musculo-phrenic artery
from internal mammary
artery

Internal thoracic (Mammary)artery
• Origin : from 1st part of subclavian
artery opposite the thyrocervical
trunk, one finger width lateral to
the sternoclavicular joint.
• Course : it descend lateral to the
sternum posterior to the costal cartilages.
• on either side,give off several
branches on the way, including
the 1 2 anterior intercostal
branches which anastomose with
their counterpart posterior intercostal
arteries.
• Termination: Posterior to the sixth
rib, it divided into terminal
branches; musculopherenic and
superior epigastric arteries

• Branches:
• 1. Pericardial branches
• 2-Pericardiaco-phrenic
artery.
• 3. Mediastinal branches
• 4-Sternal branches.
• 5. Perforating branches for
the mammary gland
• 6- Anterior intercostal
arteries (upper 6 spaces)
• 7-Superior epigastric artery
8-Musculo-phrenic artery.

• 2- Posterior Intercostal
Arteries.
• One in each of the 1 1 spaces
• 1st & 2nd arise from superior
Intercostal artery of
costocervical trunk of 2nd part
of subclavian artery
• The lower 9 arteries &
subcostal artery arise from
descending thoracic aorta.
• In each space the posterior
Intercostal artery and its
collateral branch anastomose
with the 2 anterior Intercostal
arteries

Intercostal veins
Anterior Intercostal veins
• 2 in each space.
• 9th,8th & 7th join the venae
commitantes of
musculo-phrenic artery
• 6th,5th & 4th join venae
commitantes of internal
mammary artery
• 3rd,2nd &1st join internal
mammary vein
• Internal mammary vein
drains into innominate
(Brachiocephalic vein)

Posterior Intercostal veins
• One in each of the 1 1 spaces.
• On the right:
• 1st drains into Rt. Innominate v.
• 2nd,3rd & sometimes the 4th unite to form
Rt. Superior Intercostal vein which
drains into azygos vein.
• From 5th to 11t h & subcostal veins drain
into azygos vein.
• On the Left:
• 1st drains into Lt. innominate V.
• 2nd,3rd& sometimes the 4th join to form
Lt. Superior Intercostal vein which
drains into Lt innominate vein.
• 5th,6th,7th, & 8th form superior
hemiazygos vein to azygos vein
• 9th,10th.11th &Subcostal form inferior
hemiazygos vein to azygos vein.

Azygos Vein
• Connects IVC with SVC
• Begins in abdomen from
back of IVC at level of L2
• Enters thorax through Aortic
opening of diaphragm on Rt. side
of thoracic duct & aorta.
• In post. Mediastinum it passes
behind Rt. Border of esophagus &
root of rt. Lung
• In sup. Mediastinum it crosses
above the root of rt. lung
Enters the middle of the back of
the SVC.

Intercostal Nerves
•They are the anterior primary rami
of spinal thoracic nerves fromT1 to
T11
•T3 toT6 are Typical
•T12 is called Subcostal
•The remaining nerves are called
atypical (non-typical)
•Each nerve runs in the Intercostal
space inferior to the Intercostal
vessels (VAN)

Typical Intercostal nerve
• From T3 to T6
• Leaves the intervertebral
foramen to reach the
Intercostal space.
• Runs between pleura &
post. Intercostal
membrane
• Pierces Internal Intercostal
muscle splitting it into
Internal Intercostal (proper)
and innermost Intercostal.
• Runs between Internal
Intercostal muscle & Pleura.
• Pierces Internal Intercostal
muscle, anterior Intercostal
membrane, pectoralis major,
and deep fascia to become
anterior cutaenous nerve2/19/2020 Thoracic wall Dr Mostafa 35

Branches:
1. Collateral branch to
Intercostals
2. Lateral cutaenous branch
to skin
3. Anterior cutaneous
4. Muscular branches
5. Pleural sensory branches
6. peritoneal branches
7. Articular branches.
8. White & grey rami
communicans with
sympathetic ganglion

Applied anatomy:
1. Stab wounds in the posterior part of the
intercostal spaces lead to injury of the posterior
intercostal nerve and vessels because they run
midway between the ribs.
-But in the lateral part of the intercostal
spaces, they do not injury the posterior
intercostal nerve and vessels because these
structures are protected by the costal groove.

Applied anatomy:
2. Needles introduced into the intercostal
spaces (to remove collection in the pleura)
Site: They are done in the lateral part of the
chest wall to avoid injury of the posterior
intercostal nerve and vessels.
(It is also better to be introduced near the rib
below).

2/19/2020Thoracic wall Dr Mostafa Kandil
40
Superior thoracic aperture
Completely surrounded by skeletal elements, the superior thoracic aperture
consists of the body of vertebra TI posteriorly, the medial margin of rib I on each
side, and the manubrium anteriorly.
Superior thoracic aperture and axillary inlet

41
Inferior thoracic aperture
Skeletal elements of the inferior thoracic aperture are:
• the body of vertebra TXII posteriorly;
• rib XII and the distal end of rib XI posterolaterally;
• the distal cartilaginous ends of ribs VII to X, which unite to form the costal margin anterolaterally; and
• the xiphoid process anteriorly.
 The joint between the costal margin and sternum lies roughly in the same horizontal plane as the
intervertebral disc between vertebrae TIX and TX.
A. Inferior thoracic aperture. B. Diaphragm

42
The horizontal plane passing through the disc that
separates thoracic vertebrae TIV and TV is one of
the most significant planes in the body because it:
• passes through the sternal angle anteriorly.
• separates the superior mediastinum from the
inferior mediastinum and marks the position of the
superior limit of the pericardium;
• marks where the arch of the aorta begins and ends;
• passes through the site where the superior vena
cava penetrates the pericardium to enter the heart;
• is the level at which the trachea bifurcates into right
and left main bronchi; and
• marks the superior limit of the pulmonary trunk.
Disc between TIV and TV

43
B. Anterior view of thoracic dermatomes associated with thoracic spinal nerves.
C. Lateral view of dermatomes associated with thoracic spinal nerves.
Dermatomes of the thoracic wall

Intercostal spaces
44
Details of an intercostal space and relationships
The neurovascular bundle is located between the
internal & the inner most layers of the muscles.Anterolateral view
The nerve is the structure most at risk when objects
perforate the upper aspect of an intercostal space.
In the thorax, the intercostal nerves carry:
• somatic motor innervation to the muscles of
the thoracic wall (intercostal, subcostal, and
transversus thoracis muscles);
• somatic sensory innervation from the skin
and parietal pleura; and
• postganglionic sympathetic fibers to the
periphery.
Intercostal artery

45
Intercostal muscles
A.Subcostal
muscles
B.Transversus
thoracis muscles

Movement of thoracic wall during breathing
46
• .
• When the ribs are depressed, the sternum moves
downward and backward. This "pump handle"
movement changes the dimensions of the thorax in
the anteroposterior direction.
A. Pump handle movement of ribs and sternum

47
• When the shafts are elevated, the middles of the shafts
move laterally. This "bucket handle" movement increases
the lateral dimensions of the thorax
B. Bucket handle movement of ribs
Movement of thoracic wall during breathing (Cont’d)

48
The weakest area of
the rib is just anterior
to its angle, where it
is commonly
fractured.

49
Flail chest
After severe trauma, ribs may be broken in two
or more places. If enough ribs are broken, a
loose segment of chest wall, a flail segment (flail
chest), is produced.
A, Inspiration:
As intrapleural pressure becomes increasingly
negative, the flail segment and its underlying
lung tissue are sucked inward, collapsing the
lung on the affected side and shifting the
mediastinum toward the unaffected side.
B, Expiration:
As intrapleural pressure becomes less negative,
the flail segment and underlying tissue are
pushed outward, and the mediastinum shifts to
the affected side. Some air moves between the
lungs instead of passing through the upper
airways.
• Large arrows indicate structural movement;
• Dashed arrows indicate abnormal air movement;
• Small arrows indicate normal air movement;
• Open arrows indicate flail segment movement.
From Kitt et al., 1995.

Basic
Interpretation of
Chest
Radiography

Five Radiographic Opacities
Air Fat Soft tissue Bone Metal
least opaque to most
opaque
most lucent to least
lucent
Black to White

Penetration
With correct exposure you should barely see
the intervertebral disc through the heart
• If you see them very clearly
the film is overpenetrated
• If you do not see them it is
underpenetrated

• Left upper lobe with Lingula:

• Left upper lobe - upper division:

Abnormal Chest X-ray
• Radiopacity (whiteness) = increased density
• Radiotranslucency (blackness) = decreased density

Radiopacity
AlveolarPattern InterstitialPattern Vascularpattern
• Fluffy, soft, poorly demarcated opacifications < 1cm in
diameter
• Possible causes:
1. Pulmonary edema
2. Viral pneumonia
3. Pneumocystis
4. Alveolarcell carcinoma
• Consolidation of interstitial
tissue
• Looks like branching lines radiating
toward the periphery of the lung
• Possible causes:
1. Interstitial
pneumonitis
2. Pulmonary
fibrosis
• If there is an increase in size
of thepulmonary arteries as
they
extend out into lung
–pulmonary
hypertension
• If there is a decrease in size,
truncation, or obliteration of
a pulmonaryartery
• Lack ofvascular marking
in the periphery
– pneumothorax
– embolus

• No ventilation to
lobe beyond the
obstruction
• Trapped air
absorbed by
pulmonary
circulation
• Segmental/lobar
density
• Compensatory
hyper-inflation of
normal lungs.
Atelectasis

Thoracic wall Dr Mostafa2/19/2020 70
HYDROPNEUMOTHORAX
• It is the concurrent presence of
a pneumothorax as well as a
hydrothorax in the pleural
space.
• On an erect chest radiograph,
classically seen as an air-fluid
level.

Thoracic wall l4 dr kandil

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