1

The Thorax
 The thorax (chest) is the
superior part of the trunk
between the neck and
abdomen.
 The thoracic cavity,
surrounded by the thoracic
wall ,contains the heart, lungs,
thymus, distal part of the
trachea, and most of the
esophagus.
 To perform a physical
examination of the thorax, a
working knowledge of its
structure and vital organs is
 Thoracic Wall
2

 The thoracic wall consists of

 skin, fascia, nerves, vessels,
muscles, and bones.
 The functions of the thoracic wall
include
 protecting of the thoracic and
abdominal internal organs;
 resisting the negative internal
pressures generated by the elastic
recoil of the lungs and inspiratory
movements;
 providing attachment for and
supporting the weight of the upper
limbs;
 and providing attachment for
many of the muscles of the upper
limbs, neck, abdomen and back,
and the muscles of respiration.
 The mammary glands of the
 Skin of the Thorax
3

 The thoracic skin is relatively thin

and contains a variable amount of
hair, which depends on age, sex and
race; i.e. its amount is genetically
determined.
 Thoracic hair is abundant in males
than in females.
 It is found in a higher density at the
median plane and extends to the
anterior abdominal wall for a
variable distance.
 In male the amount of hair on the
chest and on the head are inversely
4

 Blood Vessels of the Skin of the Thorax

 Arteries - cutaneous branches of lateral
thoracic and intercostal arteries
 Veins - drain into lateral thoracic,
thoracoepigastric and intercostal veins
 Innervation of the Skin of the Thorax
 Thethoracic wall is innervated by the
cutaneous branches of the segmental
ventral rami spinal nerves and by
supraclavicular nerves
 Fascia of the Thorax
5

 The fascia of the thorax can be divided

into two:
 The outer thoracic fascia
 on the outside of the thoracic wall having its
own two layers
 Superficial layer
 a part of the superficial fascia of the body
containing the breast, which is fibrous and
tough
 Deep layer
 a thin layer inseparable from the epimysium of
the underlying muscles, except dorsally where
it forms the thick thoracolumbar fascia
 The inner endothoracic fascia
 found on the inner surface of the thoracic
wall covering the thoracic surface of the
ribs, muscles and diaphragm.
 Internally it is related to the parietal pleura.
 Its part covering the cervical pleura (cupola)
is known as suprapleural membrane
 Skeleton of Thoracic Wall
6

 The thoracic skeleton

forms the
osteocartilaginous thoracic
cage
 The thoracic skeleton
(bony thorax) includes
 12 pairs of ribs and costal
cartilages,
 12 thoracic vertebrae and
intervertebral (IV) discs,
and
 the sternum.
 Costal cartilages form the
anterior continuation of the
ribs, providing a flexible
attachment at their
articulation with the
sternum
 Ribs and their cartilages
are separated by
 Skeleton of Thoracic Wall
7
 The Bony
8
Thorax
 Sternum
 Manubrium, Body
(Gladiolus), Xiphoid
Process
 Ribs
7 True Ribs
 5 False Ribs

 Clavicle
 Scapula
 Vertebrae
 Cervical,Thoracic,
Lumbar, Sacral
(Sacrum), Coccygeal
 Projections and Depressions
9

 Site of muscle and

ligament
attachments
 Spine
 Process
 Help form joints
 Head
 Facet
 Allow BV, nerves,
and muscles to pass
 Notch
 Fossa
 Thoracic Cage
10
 Borders:
 Thoracic
vertebrae
posteriorly
 Ribs laterally
 Sternum and
costal cartilages
anteriorly
 Forms protective
cage around
heart, lungs, and
other organs
 Composed of:
 Sternum
11
The Sternum
(Composed of fused sternebrae)
 Manubrium

 Jugular (sternal) notch

 Articulation with rib #1 &
2
 Clavicular Articular
facets
 Sternal Angle – 2nd rib

 Body (Gladiolus)
 Articulates
w/ribs 2-7
 Xiphosternal joint

 Xiphoid process
 Cartilage-calcifies thru
 The Ribs
12
 Usually, 12 pairs
7 True ribs-direct
attachment to
sternum
 5 False ribs-indirect
or no attachment to
sternum
 Floating ribs-make
up 2 of 5 False ribs,
no ventral
attachment
 Typical Ribs
 Ribs Typical rib. The features (A) and midbody cross
# 2-9 section (B) of a typical rib are demonstrated
 Atypical Ribs
 Rib Anatomy
13

 Typical Ribs
 Head

 Neck

 Tubercle

 Angle

 Shaft

 Subcostal
Groove

Typical rib. The features (A) and midbody cross

section (B) of a typical rib are demonstrated
14
Rib Anatomy

 Atypical Ribs
 #1-short, flat (S-I),
wide, Supports
Subclavian vessels
 #1, 10-12 articulate
with only = #
vertebra
 #11, 12 don’t
articulate with
transverse
processes, or Atypical ribs. The 1st (A) and 12th (B) ribs are
anteriorly at all shown.
 Joints of Thoracic Wall
15

 Although movements of the joints of the

thoracic wall are frequent e.g., during
respiration, the range of movement at the
individual joints is small.
 Any disturbance that reduces the mobility of
these joints interferes with respiration.
 Joints of the thoracic wall occur between the:
 Vertebrae (intervertebral joints).
 Ribs and vertebrae (costovertebral joints: joints of
the heads of ribs and the costotransverse joints).
 Sternum and costal cartilages (sternocostal
joints).
 Sternum and clavicle (sternoclavicular joints).
 Ribs and costal cartilages (costochondral joints).
 Costal cartilages (interchondral joints).
 Parts of the sternum (manubriosternal and
xiphisternal joints) in young people; usually the
manubriosternal joint and sometimes the
Typical Rib
Articulation
 Dorsal (P) Attachment Thoracic
Vertebrae
 Head of Rib  2 costal facets
 Superior costal facet
 Inferior costal facet of vertebra
above it
 Intervertebral disc
 Tubercle
of Rib  Transverse
Costal Facet
 e.g. Rib #4 articulates with
Superior Costal Facet and
Transverse Costal Facet of T4
& Inferior Costal Facet of T3
16
 Ventral (A) Attachment to
 Typical Rib Articulation
17

Costovertebral joints. The elements of the joint of the head

of the rib and the costotransverse joint are identified.
 Muscles of the Thoracic
18
Wall
 Except a small area posteriorly, the thorax is entirely
covered by muscle.
 These muscles can be grouped into two groups.
 Muscles on the Outside of the Thorax,
 most of which are inserted to the upper limb and include:
 Pectoralis major
 Serratus anterior
 Pectoralis minor
 Trapezius
 Rectus abdominis
 Latissimus dorsi
 External oblique
 Rhomboids
 Internal oblique
 Serrati posterior
 Muscles of the Thoracic Wall Proper –
 that are attached to the vertebrae (muscles of the back), the
ribs and the sternum (intercostal muscles).
 The Intercostal Muscles
19

 The intercostal muscles fill the

intercostal spaces together with the
intercostal vessels, nerves and
membranes.
 Their fibers attach the ribs above
and below each space and assist in
respiration.
 They appear in the following three
layers.
 External layer - formed by the
external intercostal muscle
 Middle layer - formed by the internal
intercostal muscle
 Internal layer - formed by
intercostalis intimi (inner most
intercostal),subcostalis and transverse
 Intercostal Muscles
20

 External Intercostals
 O: Inferior border of rib above I: Superior border
of rib below
 Fibers run OBLIQUE (down and forward)

 Aid in Inspiration (lift ribcage, increase dimensions)

 Internal Intercostals
 O: Superior border of rib below I: Inferior border
of rib above
 Fibers run at RIGHT ANGLES to external intercostals

 Aid in forced expiration (depress ribcage, decrease

dimensions)

 Intercostal Muscles
21

 All the intercostal muscles are

innervated by the ventral rami of
the spinal nerves that form the
intercostal nerves.
 The intercostal spaces near the
sternum and the vertebrae are
not completely filled by muscles,
vessels or nerves.
 The filling of the spaces near the
sternum is completed by
external (anterior) intercostal
membrane, while the internal
(posterior) intercostal membrane
completes that of those near the
 Intercostal Muscles
22
Diaphragm

23 Origin:
1. Sternal head: from xiphoid process.
2. Costal head: lower six ribs and costal
cartilage.
3. Vertebral head: right and left crura from
the first, second and third lumbar
vertebrae and arcuate ligaments.
 Insertion:
Central tendon of the diaphragm.
 Nerve Supply:
Motor: phrenic nerve.
Sensory: phrenic and Intercostal nerves.
 Action:
Increase the vertebral diameter of the
24
25
Muscles of Thorax
Muscle Origin Insertion Action Innervation

Pectoralis Sternum, Greater Adduct, M&L

major Ribs 2-6 tubercle of Flex, Med pectorals
humerus Rotate
Arm
Pectoralis Ribs 3-5 Coracoid Depress, M&L
minor process of Rotate pectorals
scapula scapula
Serratus Ribs 1-9 Scapula Protract, Long
anterior Rotate Thoracic
(ventralis) scapula
26
Muscles of Thorax

Muscle Origin Insertion Action Innervation

Trapezius Ligamentum Clavicle, Elevate, Accessory
nuchae, Spine of Adduct,
C7-T12 scapula Rotate,
Depress
Levator C1-C4 Medial Elevate D. Scapular
Scapulae border of scapula
scapula
Rhomboids C7-T5 Medial Adduct, D. Scapular
border of Elevate,
 Muscles of Thorax
27

Muscle Origin Insertion Action Innervation

Deltoids Clavicle, Deltoid Flex, Abduct, Axillary
Scapula tuberosity Extend, Lat
of & med.
humerus rotate arm
Latissimus Iliac Inter- Extend, Thoraco-
dorsi crest, tubercular Adduct, dorsal
T7-12, groove of Med. rotate
Lumbar humerus arm
fascia
28 Rotator Cuff Muscles
Muscle Origin Insertion Action Innervatio
n
Supraspinatu Supraspinous Greater Abduction of Suprascapul
s fossa of tubercle of arm ar
scapula humerus
Infraspinatus Infraspinous Greater Lat rotation Suprascapul
fossa of tubercle of of arm ar
scapula humerus
Teres Minor Lateral border Greater Lat rotation Axillary
of scapula tubercle of of arm
humerus
Subscapularis Subscapular Lesser Med rotation Subscapular
fossa of tubercle of of arm
scapula humerus
Nerves and Vessels
(Neurovascular bundle) of the
thoracic wall
29

 The main nerve and vascular

supplies to the thoracic wall run in
the intercostal spaces in bundles
that form the neurovascular bundle
of the thoracic wall.
 Each bundle consists of vein, artery
and nerve, which are related to the
lower borders of the ribs, where they
lie In the costal grooves and
protected by their sharp lower
edges.
 The components of the bundle are
arranqed from cranial to caudal in
the order of VAN, i.e. Vein, Artery,
and Nerve.
 To avoid the injury of this
 Neurovascular bundle of the
30
thoracic wall
 The Intercostal Nerves
31

 There are 12 pairs of intercostal nerves.

 Each intercostal nerve is divided into
 anterior (ventral) and
 posterior (dorsal) branches or rami.
 The posterior branches
 supply the muscles, bones, joints and skin of
the back.
 The anterior branches
 run segmentally in the intercostal spaces as
intercostal nerves.
 At the level of the midaxillary line, they give
lateral cutaneous branches to the skin of the
lateral thoracic wall.
 Near the edge of the sternum, anterior
cutaneous branches are given off to the
anterior thoracic wall
 The Intercostal Nerves
32

 The intercostal nerves

 innervate all the muscles along
their way.
 carry sensory fibers not only from
the skin of thorax but also from
the abdominal wall, breast,
parietal pleura and parietal
peritoneum.
 They also carry postganglionic
sympathetic fibers to blood
vessels, sweat glands, arrectores
pillorum muscle.
 The anterior branch of the 12th
spinal nerve runs below the costal
margin, and hence called
subcostal nerve.
 The Intercostal Nerves
33

Dermatomes and myotomes of the trunk. Note the relationship between the area of skin (dermatome) and
skeletal muscle (myotome) innervated by a spinal nerve or segment of the spinal cord.The dermatomes of the
thorax (T1 to12) are shown at the right.
 Intercostal Arteries
34
 
 There are two sets of intercostal arteries:
 anterior and posterior intercostal arteries.
 the posterior intercostal arteries
 Allarise from the thoracic aorta, except the first
two,
 the first two arise from the intercostalis
suprema (supreme intercostal) artery, a branch
of branch of costocervical trunk originating from
the subclavian artery.
 anterior intercostal arteries
 The upper six are branches of the internal
thoracic,
 while the lower five are branches of the
musculophrenic artery, a branch of the internal
thoracic artery running along the lower border
of the thorax.
 The thoracic wall gets additional arterial
supply by some branches of the axillary
artery.
 Intercostal Arteries
35
 Intercostal Veins & Lymphatic
Drainage
36

 Intercostal Veins
 Similar to the arteries there are posterior and
anterior intercostal veins.
 The posterior intercostal veins drain into the
brachiocephalic, azygos (right side), hemiazygos
and accessory hemiazygos (left side) that
ultimately drain into the superior vena cava.
 The anterior intercostal veins drain into
musculophrenic and internal thoracic veins that
finally end in the brachiocephalic vein.
 Lymphatic Drainage of the Thoracic Wall
 Superficial and deep lymphatic vessels drain the
lymph from the thoracic wall.
 Anterior thoracic wall
 Superficial vessels - drain into anterior axillary
lymph nodes
 Deep vessels - drain into internal thoracic
(parasternal) lymph nodes
 Posterior thoracic wall
 Superficial vessels - drain into the posterior
axillary lymph nodes
 Deep vessels - drain into the intercostal lymph
nodes
 Intercostal Veins
37
 Thoracic Apertures
38

 The thoracic cavity communicates with

the neck and upper limb through
 the superior thoracic aperture, the
anatomical thoracic inlet
 Structures entering and leaving the thoracic
cavity through this aperture include the
trachea, esophagus, vessels, and nerves.
 The adult superior thoracic aperture
measures approximately 6.5 cm
anteroposteriorly and 11 cm transversely.
 Because of the obliquity of the 1st pair of
ribs, the superior thoracic aperture slopes
anteroinferiorly.
 The superior thoracic aperture is bounded:
 Posteriorly by the T1 vertebra.
 Laterally by the 1st pair of ribs and their
costal cartilages.
 Thoracic Apertures
39

 The thoracic cavity communicates with the

abdomen
 through the inferior thoracic aperture, the
anatomical thoracic outlet
 In closing the inferior thoracic aperture, the
diaphragm separates the thoracic and
abdominal cavities almost completely.
 The inferior thoracic aperture is more spacious
than the superior thoracic aperture.
 Structures passing to or from the thorax to the
abdomen pass through openings in the
diaphragm (e.g., the inferior vena cava and
esophagus) or posterior to it (e.g., aorta).
 The inferior thoracic aperture is bounded:
 Posteriorly, by the T12 vertebra.
 Posterolaterally, by the 11th and 12th pairs of
ribs.
 Anterolaterally, by the joined costal cartilages of
ribs 7 to10, forming the costal margin.
 The
Breast
40

 Location: (female breast)

 Superior border: 2nd rib
 Inferior border: 6th rib
 Medial border: Sternum
 Lateral border: Midaxillary line
 Location: (male nipple)
 Fourth Intercostal Space, Midclavicular line
 Underlying muscle
 Pectoralis major and minor
 Part of serratus anterior, external obliques
 Lateral Thoracic Artery, branches of Internal
Thoracic A., Post. Intercostals
 Intercostal, Internal Thoracic, Axillary Veins
 Branches of Intercostal Nerve
41
Mammary Glands

 Lactiferous (modified sweat) Glands

 Breast made of 15-25 lobes (each a compound
alveolar gland)
 Lobes made of lobules (= clusters of
acini/alveoli)
 Acini/Alveoli lined w/milk-secreting simple
epithelial cells
 Lactiferous Ducts of lobes open at nipple
 Areola-ring of pigmented skin around nipple
 Sebaceous gland produce sebum during nursing
 Surface Anatomy
42

Use the next 3 slides and follow the book to

palpate (feel) the features listed
 Anterior Surface of
43
Thorax
 Palpate the following
 Sternum (3 parts)
 Jugular notch

 Sternal Angle (= 2nd

rib)
 Clavicle

 Costal margin

 Xiphosternal joint

 Midclavicular Line
 Midaxillary Line
44
 Anterior Surface of Thorax
45
 Anterior Surface of Thorax
46
 Posterior Surface of
47 Thorax
 Palpate the following
 Spinous Process of C7
 Scapula (ribs 2-7)
 Scapular spine
 Acromion Process
 Inferior Angle of Spine
 Inferior Border
 Readabout breast &
diaphragm
 Locating Internal
48 Structures
 Pleural Cavities
 Inferiormargin = adjacent to
T12 in Posterior Midline
 To Rib 10 at Midaxillary line

 To Rib 8 at Midclavicular line

 To Xiphosternal joint medially

 Lungs posterior border is 2 ribs

superior to pleural cavity (rib 8)
 Heart
 Deep to xiphisternal angle
 Vertebral

Column
Humans’ made of 26 bones
49
 Cervical7
 Thoracic 12
 Lumbar 5
 Sacrum (5 fused sacral vertebrae)
 Coccyx (4 fused coccygeal
vertebrae)
 Extends from skull to pelvis
 Supports body, muscle
attachment
 Vertebral Canal
 Created by vertebral foramen
 Contains + protects spinal cord

Pg 45, 18
 Intervertebral foramina
 Cervical Vertebrae
(7)
50  **Transverse Foramen **
 Superior Articular Facets face
superoposteriorly
 Inferior Articular Facets face inferoanteriorly
 Allows wide range of motion
 Spinous process fairly short, bifid (except for
C7)
 Vertebral Foramen is Triangular
 Body is wider laterally than in A-P direction

Page 31
 Atypical Cervical
Vertebrae
51

 C1 – Atlas
 No body
 No Spinous Process

 Superior Articular
facets are kidney
shaped
 C2 – Axis
 Odontoid Process =
Dens
 Other features typical
Page 32
 Thoracic Vertebrae
52 (12) **Transverse Costal


Facets **
 *S/I Costal facets on
vertebral body*
 Spinous Processes long,
point inferiorly
 Superior Articular Facets
face Dorsally/Posteriorly
 Inferior Articular Facets
Pg 119
face Ventrally/Anteriorly
 Vertebral Foramen is
Circular

 Lumbar Vertebrae
53
(5)
 Spinous process is short, rectangular, projects
dorsally
 Superior Articular Facets face Medially
 Inferior Articular Facets face Laterally
 Vertebral Foramen is Triangular
 Body is large and Kidney-shaped

Page 30
 Sacrum & Coccyx
54

Sacrum Coccyx
 5 fused Sacral  3-4 fused Coccygeal vertebrae
Vertebrae
 Articulations
 Articulates with
 #1 articulates with 5th Sacral
 5th Lumbar vertebra
 Coccyx Vertebra
 Ilia of coxal bones  Some muscle + ligament
 Functions in weight attachment
transfer  Slightly different orientation in
 Has a body, sacral males vs. females
canal, sacral foramina
 Remnants of other  No canal
typical vertebrae
features visible
 Intervertebral Discs
Absent between
55


 C1 and C2
 Sacrum and coccyx

 Annulus Fibrosus
 Outer collar of concentric rings
 Outer rings = ligaments

 Inner rings = fibrocartilage

 Supportive/Structural

 Nucleus Pulposus
 Innerdisc, cushiony pad
 Remnants of notocord
Pg 41
 Shock Absorber
 Vertebral
56
Column

IN
 Lateral Curvature
(Following Dorsal Side)
OUT  Cervical Region = Concave
curve
 Thoracic Region = Convex

IN curve
 Lumbar Region = Concave
curve
Page 45 OUT  Sacrum = Convex curve
 Abnormal
Curves
57

 Scoliosis-abnormal
lateral curve of more
than 10°
 “twisted disease”
 Kyphosis-
www.nlm.nih.gov
exaggerated thoracic
curve
 “humped disease”
 Lordosis-accentuated
www.nlm.nih.gov lumbar curve
 Ligaments of Vertebral
Column
58

 Anterior Longitudinal Ligaments (neck –

sacrum)
 Run vertically on anterior surface of vertebral bodies +
intervertebral discs
 Wide,strong
 Prevents hyperextension
 Posterior Longitudinal Ligaments (neck –
sacrum)
 Run vertically on posterior surface of intervertebral discs
only
 Narrow, weak
 Prevents hyperflexion
Page 44
 Ligamentum Flavum (contains elastic connective