Lecture I

Introduction to Thorax.
Thoracic CAGE (Skeleton of
Thorax).
Inlet of THORAX.
Outlet of THORAX.
Bony Landmarks of Thorax.
Intercostal Spaces.
Intercostal Muscles.
Intercostal Nerves.

Introduction to Thorax
@ Trunk of body is divided by diaphragm
into: an upper part: Thorax and
lower part: Abdomen.
@ Thorax is supported by a skeletal
framework (Thoracic Cage) and contains
principal(main) organs of respiration
(lungs) and circulation (heart).
@ Thoracic cage is an osseocartilagenous,
elastic cage which is primarily designed
for increasing and decreasing intrathoracic pressure, so that air is alternately
sucked into lungs during inspiration and
expelled out during expiration

THORACIC CAGE (Skeleton of Thorax)

Formation:

* Anteriorly Sternum.
* Posteriorly 12 Thoracic vertebrae and intervening intervertebral discs.
* On each side 12 Ribs with their cartilages.

Shape:

@ Thorax resembles a truncated cone; which is narrow above and broad below.
@ Narrow upper end is continuous with root of neck; from which it is partly
separated by suprapleural membrane.
@ Broad lower end is almost completely separated from abdomen by diaphragm.
@ Thoracic cavity is actually much smaller than what it appears; because:
# Upper narrow part appears broad due to shoulders.
# Lower part is greatly encroached by abdominal cavity.
@ In transverse section, thorax is reniform (Kidney- shaped); with a greater
transverse diameter than anteroposterior.

SUPERIOR APERTURE(opening, hole)

(Inlet) of THORAX

@ It is narrow upper end of thorax; which is continuous with neck.

Boundaries:
* Anterior Upper border of manubrium sterni.
* Posterior Superior surface of body of first thoracic vertebra.
* On each side First rib with its cartilage.
Shape: Reni-forrm.(kidnet shape)
Dimentions: # Transverse diameter ( 4 - 5 inches).
# Anteroposterior diameter ( 2 - 2 inches).

Suprapleural Membrane
(Diaphragm of inlet of thorax)
@ It partly separates thorax from neck.
@ It is triangular in shape:
# Apex: is attached to tip of transverse
process of C7 vertebra.
# Base: is attached to inner border of
first rib and its cartilage.
# Function: it provides rigidity to
thoracic inlet so that root of neck is
not puffed up and down during
respiration.
@ Its inferior surface is fused to cervical
pleura, and its superior surface is
related to subclavian vessels and
other structures at root of neck.

INFERIOR APERTURE(opening, hole)

(Outlet) of THORAX

@ It is broad lower end of thorax, which surrounds upper part of abdominal cavity,
but it is separated from it by diaphragm.

Boundaries:

Anterior infrasternal angle between two costal margins.

Posterior inferior surface of body of 12th thoracic vertebra.
On each side:
1) Costal margin, formed by cartilages of 7th, 8th, 9th and 10th ribs.
2) 11th and 12th ribs.
Shape: it is wider transversely than from before backwards, and slopes obliquely
downwards and backwards.
Diaphragm (diaphragm of outlet of thorax):
@ A musculotendinous partition which, separates thorax from abdomen and forms
floor of thorax.
*
*
*

Bony Landmarks of Thorax

@ Suprasternal (jugular) notch: It lies at level of lower border of body of second
thoracic vertebra.
@ Sternal angle (angle of Louis): It is felt as a transverse ridge below suprasternal
notch. It marks manubrio-sternal joint, and lies at level of second costal cartilage
anteriorly, and disc between fourth and fifth thoracic vertebrae posteriorly.
@ Infrasternal (subcostal) angle: It lies between two costal margins, at level of
upper border of 9th thoracic vertebra.
@ Costal margin: On each side is formed by 7th to 10th costal cartilages.
@ Ribs: Scapula overlies form 2nd to 7th ribs on posterolateral aspect of chest wall.
10th Rib is lowest rib at thoracic outlet. 11th and 12th Ribs are confined to back
and are not seen from front.
@ Thoracic vertebral spines: First prominent spine felt at lower part of back of
neck is that of C7 vertebra (vertebra prominens). Below this spine, all thoracic
spines can be palpated along posterior median line. T3 spine lies at level of roots
of spines of scapulae, while T7 spine lies at level of its inferior angles.

Importance of sternal angle:

@ Ribs are counted from this level down.
@ Marks plane, which separates superior from inferior mediastinum.
@ Ascending aorta ends at this level.
@ Arch of aorta begins and also ends at this level.
@ Descending aorta begins at this level.
@ Trachea divides into two principal(main) bronchi.
@ Azygos vein arches over root of right lung and opens into superior vena cava.
@ Pulmonary trunk divides into two pulmonary arteries just below this level.
@ Thoracic duct crosses from right to left side at level of T5 vertebra and
reaches left side at level of sternal angle.
@ Marks upper limit of base of heart.
@ Cardiac plexuses are situated at same level.

Intercostal Spaces
@ Ribs are separated by intercostal spaces, which are 11 on each side.
@ Typically, each intercostal space contains:
# 3 Intercostal muscles:
External intercostal, Internal intercostal & Transversus thoracis.
# 3 Other intercostal sturctures:An artery, a vein & a nerve.

Intercostal
Muscles
@ Arranged in 3 layers, like 3 layers of
muscles of anterior abdominal wall.
@ In both thorax and anterior abdominal
wall, nerves and vessels lie between
internal and innermost layers.

External intercostal:

Origin: from lower border of upper rib.

Insertion: into outer lip of upper border of
lower rib.
Fibers: directed downwards and medially.
Extent:
* from costochondral junction to tubercle
of rib.
* Anteriorly, it is continuous as exrternal
(anterior) intercostal membrane to
reach sternum.

Internal
intercostal:

Origin: from floor of costal groove of

upper rib.
Insertion: into inner lip of upper
border of lower rib.
Fibers: directed upwards and medially.
Extent:
* from lateral border of sternum to
angle of rib.
* Posteriorly, it continuous as
internal (posterior) intercostal
membrane.

Transversus thoracis:
Transversus thoracis
@ Formed of 3 parts:

1) Subcostalis: confined (enclosed) to

posterior parts of lower spaces only.

Origin: from inner surfaces of rib near
angle.
Insertion: into inner surface of 2nd or 3rd
rib below.

2) Intercostalis intimi(innermost):
@ in middle 2/4 of space.
Origin: from inner surface of upper rib.
Insertion: into inner surface of lower rib.

3) Sternocostalis:

@ In anterior part of upper spaces, except

first space.
Origin from:
* Lower of posterior surface of body of
sternum.
* Posterior surface of xiphoid process.
* Posterior surfaces of costal cartilages of
lower 3 or 4 true ribs.
Insertion: into costal cartilages of 2nd to
6th ribs.

Nerve Supply:
Intercostal nerve or nerves.
Actions:
1) Elevators of ribs.
2) Main action of intercostal muscles is to prevent retraction during
inspiration and bulging during expiration of intercostal spaces.
@ Such movements are indicative of paralysis of intercostal
muscles.

Intercostal Nerves
@ Anterior (ventral) primary rami of: T1 - T11 nerves are called
intercostal
nerves.
@ T12 is subcostal nerve, because it runs below last rib.
@
@

Upper intercostal nerves (T1 - T3) supply upper limb.

Lower intercostal nerves (T7 - T11) are thoracoabdominal nerves, supply
abdominal wall; in addition to thoracic wall.
@ Rest (T4 - T6) nerves are called typical intercostal nerves.
@ Subcostal nerve (T12) is distributed to abdominal wall and skin of buttock.

Typical Intercostal Nerve:

@ Each nerve passes below neck of
rib of same number, and enters
costal groove.
@ In costal groove, it lies below
intercostal vessels, relation being
VAN (Vein-Artery-Nerve) from
above downwards.
@ In posterior part of groove, nerve
lies between pleura and internal
intercostal membrane.
@ In greater part of space, it lies
between intercostalis
intimi(innermost) and internal
intercostal muscles.
@ Near sternum, it crosses in front of
internal thoracic vessels and
sternocostalis.
@ It then pierces internal intercostal
muscle, external intercostal
membrane and pectoralis major
muscle to terminate as anterior
cutaneous nerve of thorax.

Branches:
Muscular:
* Numerous branches, supply intercostal muscles and transversus thoracis.
* Collateral branch arises near angle of rib, runs in lower part of space, to supply
muscles of space, parietal pleura and periosteum of ribs.

Cutaneous:

* Lateral cutaneous branch: Pierces intercostal muscles and body wall along
midaxillary line, distributed to skin after dividing into anterior & posterior branches.
* Anterior cutaneous branch: Emerges on side of sternum to supply overlying skin
after dividing into medial and lateral branches.
Communicating:
# Each nerve is connected to thoracic sympathetic ganglion by:
* A white preganglionic ramus to corresponding ganglion.
* A grey postganglionic ramus from corresponding ganglion.
# Nerve is also connected to adjoining intercostal nerves, chiefly in posterior part of
space.