Chapter I

Bones of the thorax

Bones Of The Thorax

Thoracic Cage
Definition:
The thoracic cage is an osteocartilaginous framework

Shape:
-It is conical in shape with its upper end (inlet) narrow and its lower end (outlet) wide. -Its posterior wall is longer than its anterior wall.

Function:
It encloses and protects the heart and its great vessels together with the lungs on both sides.

Formation:
The skeleton of the thorax is formed of Anteriorly: -The sternum -The costal cartilage and -The anterior parts of the ribs Laterally: The ribs. Posteriorly -The thoracic vertebrae -The posterior parts of the ribs. Fig. (1) Bony framework of thorax Inlet of the thorax: Definition: It is the narrow upper end, which is continuous above with the root of the neck. Direction: - Its plane is oblique and slopes downwards and forwards. Boundaries: - In front: the upper border of the manubrium sterni. - Behind: the upper border of the body of the first thoracic vertebra. - On each side: first rib and its costal cartilage. Outlet of the thorax: Definition: It is the broad lower end of the thorax and is separated from the upper part of the abdominal cavity by the diaphragm. 1

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Direction: - Its plane is oblique and slopes downwards and backwards. Boundaries:

Bones of the thorax

- In front: the cartilages of the seventh, eighth, ninth and tenth ribs,(costal margin) which join each other on each side. - Behind: the lower border of the twelfth thoracic vertebra. - On each side: eleventh and twelfth ribs.

Sternum
The sternum is a flat bone forming the median part of the anterior wall of the chest. It is composed of 3 parts (from above downwards): 1. Manubrium sterni. 2. Body. 3. Xiphoid process. Measurements of the sternum: -Xiphoid process = 2.5 crn long. -Manubrium sterni = 5 cm long. -Body of the sternum = 10 cm long.

General features:
1. Manubrium sterni - Is the upper quadrilateral part of the sternum. - Lies opposite the third and fourth thoracic vertebrae. - Broad above and narrow below where it articulates with the body of the sternum. - Has two surfaces (anterior and posterior) and four borders (superior, inferior and two lateral) The surfaces of the manubrium sterni: a. The anterior surface: is slightly convex from side to side. b. The posterior surface: is slightly concave. Fig. (2) Anterior surface of the sternum

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The borders of the manubrium sterni: a. The superior border: - Is thick and rounded. It presents: 1. Jugular (suprasternal) notch: a median notch.

Bones of the thorax

2. Clavicular notch: the notch on each side of the suprasternal notch for articulation with the medial end of the clavicle to form the sternoclavicular joint (synovial, saddle variety). b. The inferior border: - Articulates with the upper border of the body of the sternum at manubrio-sternal joint (secondary cartilaginous joint). Sternal angle (angle of Louis): - Angle between manubrium sterni and body of the sternum, can be felt on the surface and lies opposite the second costal cartilage. c. The lateral borders: - Articulate with: 1. The first costal cartilage, just below the clavicular notch (primary cartilaginous joint). 2. The second costal cartilage, close to the inferior border (synovial plane). Fig. (3) Sternocostal articulations 2. Body of the sternum - Long with its widest part present opposite the fifth costal cartilage. - Lies opposite the fifth, sixth, seventh, eighth and ninth thoracic vertebrae. - The body of the sternum has: I. Two surfaces: The anterior surface: is flat and is marked by three ill-defined transverse ridges, which indicate the lines of fusion of the four primitive segments of the sternum. The posterior surface: is smooth and slightly concave backwards. II. Two ends: The upper end: articulates with the lower border of the manubrium sterni at the sternal angle. The lower end: articulates with the xiphoid process. III. Two lateral borders Each lateral border shows: costal notches for the costal cartilages from second to seventh (synovial plane). 3

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Bones of the thorax

The notch for the second costal cartilage: at the upper border of the body with a similar one on the manubrium forms a complete notch for the second costal cartilage. The notch for the seventh costal cartilage: lies at the junction of the body with the xiphoid process.

3. Xiphoid process - Is the smallest part of the sternum - Shape: It may be pointed, bifid or perforated. - Articulation: -with the lower border of body of sternum to form xiphisternal joint (secondary cartilaginous joint). -With the seventh costal cartilage at its junction with the body of the sternum. - Ossification: ossified after 40 years.

Particular features

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1. Manubrium sterni Muscles attached: a) To the anterior surface:

Bones of the thorax

1- Sternal head of the sternomastoid muscle (origin): from the upper part of the anterior surface. 2- Pectoralis major muscle (origin): from the sides of the anterior surface. b) To the posterior surface: 1- Sternohyoid muscle (origin): from posterior surface opposite the clavicular notch. 2- Sternothyroid muscle (origin): from posterior surface opposite the notch of the first rib. Ligaments attached to the manubrium sterni: 1. The interclavicular ligament: is attached to the jugular notch. 2. The costoclavicular ligament: is attached to the side of the manubrium sterni below the clavicular notch. Vessels related to the posterior surface of the manibrum: 1. The lower half of the surface is related to the arch of the aorta. 2. The upper half of the surface is related to the left brachiocephalic vein, brachiocephalic artery, left common carotid artery and left subclavian artery N. B. The posterior relation of the manubrium sterni = the content of the superior mediastinum.

2. Body of the sternum: Muscles attached to the anterior surface: Sternal head of pectoralis major muscle (origin): from the lateral half of the anterior surface. Muscles attached to the posterior surface: - Sternocostalis muscle (origin): from the lower part of the posterior surface of the body. Ligaments attached to the posterior surface of the body: 1. The superior sternopericardial ligament: is attached to the upper part of the posterior surface of the body. 2. The inferior sternopericardial ligament: is attached to the lower part of the posterior surface of the body. The lateral border of the body gives attachment to the followings: 1. Anterior intercostal membranes. 2. Anterior ends of the internal intercostal muscles.

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3. Xiphoid process: Muscles attached to the xiphoid process: 1. Rectus abdominis muscle (origin): from the anterior surface.

Bones of the thorax

2. Aponeurosis of external oblique, internal oblique and transversus abdominis through the linea alba (insertion): to the lateral borders. 3. Diaphragm (origin): the sternal origin from the posterior surface. 4. Sternocostalis muscle (origin): from the posterior surface. The posterior surface of the xiphoid process is related to the anterior surface of the liver. Ossification: From 6 centers; one for the manubrium, four for the body and one for the xiphoid process.

The relation between the sternal and vertebral levels:

1. The suprasternal notch: lies opposite the disc between the second and third thoracic vertebrae. 2. The sternal angle (angle of Louis): lies opposite the disc between the fourth and fifth thoracic vertebrae. 3. The xiphisternal joint: at the level of the lower 'border of the 9th thoracic vertebra.

Ribs
General characters of the ribs: 1. The ribs are 12 pairs, forming the greater part of the thoracic cage. 2. They are separated from each other by the intercostal spaces. These spaces are wider in front than behind and wider between the upper ribs than lower ribs. 3. The ribs increase in length from the first to the seventh rib (the longest), then gradually diminish to the twelfth rib. 4. Each rib articulates posteriorly with the vertebral column and in front, it is continued with the costal cartilage. 5. The upper ribs are less oblique than the lower ribs. The tenth rib is the most oblique. Classification of the ribs: A. According to the structure of the rib: 1. Typical: which include the ribs from third to ninth. 6

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Bones of the thorax

2. Atypical: which include the first two ribs and the last three ribs (have special features). B. According to the extent (true and false): 1. True ribs (vertebrocostal): - Represented by the first seven ribs, which known as the true ribs. -They articulate behind with the vertebra and in front, through the costal cartilages, with the sternum. 2. False ribs: a. Vertebrochondral ribs: - Include the eighth, ninth and tenth ribs. -They join the vertebrae behind, but ventrally join the costal cartilages of the ribs above. b. Floating ribs: -Include the eleventh and twelfth ribs. The ventral ends of the ribs are free.

Typical ribs
How to identify the side of the rib, right or left ? Posteriorly: the posterior end consists of head, neck and tubercle. Anteriorly: the anterior end is cup-shaped. Superiorly: the superior border is thick and rounded. Inferiorly: the inferior border is thin and sharp. Outer surface: convex. Inner surface: concave and has the costal groove near the inferior border. General features Each rib has two ends (anterior and posterior) and a shaft: I-The posterior (vertebral) end: The posterior end includes the head, neck and tubercle. I-The head: -It presents two articular facets divided by a transverse ridge known as the crest. Fig.(5) Typical rib
crest

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Bones of the thorax

-The larger lower facet articulates with the side of the body of the thoracic vertebra having the same number as the rib. -The smaller upper facet articulates with the side of the body of the thoracic vertebra just above. -The crest lies opposite the intervertebral disc. -The head lies above the level of the anterior end. 2.The neck: - About one inch in length. - Lies lateral to the head and in front of the transverse process of the vertebra of the same number. - The upper border is sharp and is called the crest of the neck. - The lower border is rounded and is continuous with the upper border of the costal groove. - The posterior surface is rough. - The anterior surface is smooth and is related to the pleura. 3. The tubercle: -Lies on the outer surface of the ribs at the junction of the neck and the body. - It is divided into: a) Articular part: articulates with the oval facet on the tip of the transverse process of the corresponding vertebra. b) Non-articular part: is rough and lies lateral to the articular part. II-The shaft: It has two surfaces (outer and inner) and two borders (superior and inferior). 1. The surfaces: a) The outer (external) surface: Is convex and rough. b) The inner (internal) surface: It is concave and smooth. It is marked along its lower border by the costal groove. 2. The borders: a) The upper (superior) border: It is thick and rounded. b) The lower (inferior) border: It is thin and sharp. -Angle of the ribs: lies about 5 cm from the tubercle and it is marked on the external surface of the rib by an oblique ridge. III. The anterior end: It is distinguished by the presence of small cup-shaped depression, which receives the lateral end of the costal cartilage.

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Bones of the thorax

Particular Features
A. Ligaments attached to the typical rib: 1. To the head: it gives attachment to: a. Radiate ligament: is attached to the anterior aspect of the head. b. Intra-articular ligament: is attached to crest of the head. 2. To the tubercle: it gives attachment to: Lateral costotransverse ligament 3. To the neck: it gives attachment to: a. Superior costotransverse ligament. b. Inferior costotransverse ligament. B. Muscles attached to the typical rib: 1. Muscles attached to the outer surface: a. Serratus anterior muscle (origin): from the upper 8 ribs. b. External oblique muscle (origin): from the lower 8 ribs. c. Latissimus dorsi muscle (origin): from the lower 4 ribs. 2. Muscles attached to the inner surface: a. Internal intercostal muscle: from the floor of the costal groove of the rib. b. Intercostalis intimus muscle: from the middle two-fourth of the ridge above the costal groove. c. Diaphragm (origin): from the lower 6 ribs. d. Subcostalis muscle: from the inner surface of the rib near the angle to the inner surface of the 2nd or 3rd rib below. 3. Muscles attached to the superior border: a. External intercostal muscle (insertion): to the outer lip of the superior border. b. Internal intercostal muscle (insertion): to the inner lip of the superior border. 4. Muscles attached to the inferior border: External intercostal muscle (origin): the outer lip of the inferior border.

C. Contents of the costal groove (from above downwards): 1. Posterior intercostal vein (V). 11. Posterior intercostal artery (A). 111. Intercostal nerve (N).

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Bones of the thorax

Atypical Ribs
1) First rib:
How to identify the side of first rib, right or left? - The anterior end: is much expanded than that of the other ribs. - The posterior end: consists of head, neck and tubercle. - Outer border: convex. - Inner border: concave. - The superior surface: is rough and is characterized by the presence of the scalene ridge and impressions for the attached structures.

General features:
A. The posterior end: 1. The head: - It is small and carries, only, one articular facet. - Articulates with the facet on the body of the first thoracic vertebra. - Lies below the level of the anterior end. 2. The neck: -It is rounded. 3. The tubercle: -Is directed upwards. - Coincides with the angle of the rib. - It has an oval facet on its medial part for articulation with the transverse process of the first thoracic vertebra. B. The shaft: - It has two surfaces (superior and inferior) and two borders (outer and inner). 1. The surfaces: a) The superior surface: I t is crossed by two shallow grooves. The two grooves are separated from each other by a ridge, which ends at the inner border of the rib by a small projection known as the scalene tubercle. b) The inferior surface: Smooth and has no costal groove. 2. The borders: a) The outer border: Is convex. 10 Fig. (6) First rib

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b) The inner border: Is concave. C. The anterior end: - Is expanded and cup shaped.

Bones of the thorax

Particular Features
A. Structures attached and related to the superior surface of the 1st rib: a. Scalenus anterior muscle (insertion): to the ridge between the two grooves on the superior surface and to the scalene tubercle. b. Subclavius muscle (insertion): to the most anterior part of the superior surface. c. Scalenus medius (insertion): to the rough area on the superior surface near the tubercle of the rib. d. Costoclavicular ligament: to the most anterior part of the superior surface. e. Subclavian artery: is related to the posterior groove on the superior surface behind the scalene tubercle. f. Subclavian vein: is related to anterior groove on the superior surface in front of the scalene tubercle.

Fig. (7) First rib (structures attached & related)

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Structures related to the inferior surface of the 1st rib: a. 1st intercostal nerve. b. Parietal pleura. Structures attached to the outer border of the 1st rib:

Bones of the thorax

a. 1st digitation of the serratus anterior (origin): to the outer border opposite the groove for the subclavian artery. b. External intercostal muscle. Structure attached to the inner border of the 1st rib: It gives attachment to the suprapleural membrane. Structures in front of the neck of the 1st rib: (from medial to lateral side) a. Sympathetic chain (stellate ganglion). b. Superior intercostal artery and vein. c. Ventral primary ramus of the 1st thoracic nerve.

2) Second rib:
Identification: 1. The second rib twice the length of the first rib. 2. The external surface is marked near its middle by a large rough impression. 3. The superior border in its posterior part has distinct outer and inner lips. 4. The anterior and posterior ends lie at the same horizontal level. General features: A. The posterior end: i. The head: Shows two small facets, which articulate with the adjacent facets of the bodies of the first and second thoracic vertebrae. ii. The non-articular area of the tubercle is small. iii. The angle: is ill defined and is close to the tubercle. B. The shaft: The surfaces are oblique and intermediate in direction between the first rib (superior and inferior) and the typical rib (medial and lateral). Fig. (8) Left 1st & 2nd ribs 12

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-The external surface faces superolaterally. -The internal surface faces inferomedially. Particular features: Muscles attached to the second rib:

Bones of the thorax

a. The first and second digitations of serratus anterior muscle (origin): it is attached to the rough impression near the middle of the external surface. b. The scalenus posterior muscle (insertion): is attached to the rough outer lip in front of the angle. c. The serratus posterior superior (insertion): to the external surface below the scalenus posterior.

3) Tenth rib:
Its head presents only a single facet for the articulation with the body of the tenth thoracic vertebra.

4) Eleventh and twelfth ribs:

General features: The anterior end: is pointed. The posterior end: has a single large facet on the head. The inner surface: near the posterior end is directed upwards and inwards.

Particular features:
Muscles attached to the last rib: a. The quadratus lumborum (insertion): into the lower part of the medial half of the outer surface. b. The internal intercostal muscle (insertion): is attached near the upper border. c. The diaphragm (origin): takes origin from the lateral part of the inner surface close to the upper border.

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Bones of the thorax

10th rib Facet on the head The neck The tubercle The anterior end The costal groove The length Large & single. Present, but short. Present Cup-shaped. Present. Shorter than the typical rib

11 th rib Large & single. Absent. Absent. Pointed Shallow. Shorter than the 10th rib

12 th rib Large & single. Absent Absent. Pointed. Absent Shorter than the 11th rib

Table (1): Differences between 10th , 11th &12th ribs

Fig. (10) Ribs (different views) 14

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Bones of the thorax

The vertebral column

Definition: The vertebral column is a part of the axial skeleton that lies in the central axis of the body. Length: It is about 70 cm in the male Structure: The unit of the structure of the vertebral column is the vertebra. The vertebrae are arranged in 5 regions: 1) Cervical region: consists of 7 vertebrae. 2) Thoracic region: consists of 12 vertebrae. 3) Lumbar region: consists of 5 vertebrae. 4) Sacral region: consists of 5 vertebrae, which are fused together to form the sacrum. 5) Coccygeal region: consists of 4 small vertebrae which are fused together to form the coccyx. Each region has its own specific features. Function of the vertebral column: 1) Provides the central axis of the body. 2) Protects the spinal cord against trauma. 3) Transmits the body weight to the lower limbs. Curves of the vertebral column: The vertebral column has four curves: cervical, thoracic, lumbar and pelvic. 1) The thoracic and pelvic curves: are concave forward and are called primary curves because they are the same original concave vertebral column in the fetus. 2) The cervical and lumbar curves: are convex forward and are called the secondary curves because they are acquired after birth. Fig.(11) Vertebral column (different views)

Thoracic vertebrae
Number: They are 12 in number Classification: 1) Typical: from the 2nd to the 8th. 2) Atypical: they are the 1 st , 9th , 10th , 11th and 12th . 15

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Identification:

Bones of the thorax

i. The body: is medium sized and is characterized by the presence of costal facets on the side of the vertebral bodies. ii. The transverse process: is characterized by the presence of costal facet for articulation with the tubercle of the ribs. iii. The spine: is long and pointed. iv. The vertebral foramen: is small and circular in shape.

General features of the typical thoracic vertebra:

1.The body: -Heart-shaped. Its transverse and antero-posterior diameters are nearly equal. -On each side of the body, there are two incomplete articular facets for the articulation with the heads of the ribs. They are called the costal demifacets. a) Superior costal facet: is larger and is placed on the upper border near the pedicle. It articulates with the head of the same numbered rib. b) Inferior costal facet: is smaller and is placed on the lower border in front of the inferior vertebral notch. It articulates with the head of the rib below. 2. The vertebral foramen: Small and circular in outline.
Fig. (12) Typical thoracic vertebra (side view)

3. The lamina: Thick and broad. 4. The spine: Long with a pointed tip and directed backwards and downwards. 5. The articular processes: a) The superior articular process: Faces backwards and slightly upwards and laterally. b) The inferior articular process: Faces forwards and slightly downwards and medially. 6. The transverse process: - Large and directed posterolaterally -Bears on its anterior surface near the tip a costal facet for articulation with the facet on the tubercle of the rib of the same number.

Atypical thoracic vertebrae: 1. The first thoracic vertebra: It is distinguished by:

Fig. (13) Typical thoracic vertebra (superior view)

a) The upper costal facet on the body: is a complete circular facet, which articulates with the single facet on the head of the first rib.

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b) The inferior costal facet on the body: is a demifacet, which articulates with the upper facet on the head of the second rib. c) The spine is thick, long and horizontal. c) The other features of typical thoracic vertebra are present. 2. The ninth thoracic vertebra: Is distinguished by: a) Has a small demifacet at the upper border of its body for the head of the ninth rib. b) The inferior costal facets on the lower border of the body are absent. c) The other features of the typical thoracic vertebra are present. 3. The tenth thoracic vertebra: a) Has a large oval facet on the side of the body close to the upper border. b) The inferior costal facet on the lower border of the body is absent.

Bones of the thorax

Fig. (14) Thoracic vertebrae Fig.(12) Thoracic vertebrae

c) The other features of the typical thoracic vertebra are present.

4. The eleventh thoracic vertebra: a) Has a single circular facet close to the upper border of the body for the head of the eleventh rib. b) The transverse process is small with no costal facet. c) The spine is triangular with a blunt tip.

5. The twelfth thoracic vertebra: a) Has a single circular facet for the head of the twelfth rib. This facet lies at some distance below the upper border and encroaches on the pedicle. b) The body is large and lumbar in type. c) The spine is triangular with a blunt tip. d) The transverse process is very small and carries no costal facet. e) The inferior articular process is slightly convex and is directed forwards and laterally.

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1st Body & articular facet 1 single facet near the upper border 9th Only 1 demifacet near the upper border Transverse process & costal facets Spines Long , thick &horizontal Articular processes Directed backward & forward Long & tapering Directed backward & forward Long & tapering Directed backward & forward Present Present Present 10th One complete facet 11th

Bones of the thorax

12th One complete facet

One complete facet

Small with no facet Triangular with blunt tip Directed backward & forward

Small with no facet

Triangular with blunt tip The inferior facet is directed forward and laterally

Table (2A) Differences between thoracic vertebrae

Table (2B) Differences between thoracic vertebrae

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