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Thoracic cage

  • - Ant: Sternum and costal cartilages

  • - Post: vertebral column

  • - Lat and med: Ribs and intercostal spaces

Thoracic cavity/

  • - Bounded by chest wall and inferiorly by diaphragm

chest cavity

  • - Extends upward into root of the neck about 1 fingerbreadth above the clavicles

  • - Mediastinum (median partition)

  • - Pleura and lungs (laterally placed)


  • - Movable partition

  • - Sup extension: thoracic outlet and the root of the neck

  • - Inf extension: diaphragm

  • - Ant extension: sternum

  • - Post extension: vertebral column

  • - Contents: thymus, heart and large blood vessels, trachea and esophagus, thoracic duct and lymph nodes, vagus and phrenic nerves, sympathetic trunks

  • - Sup mediastinum separated from inf mediastinum by an imaginary place passing from the sternal angle ant to the lower border of the body of T4 vertebra post.

  • - Sup mediastinum:

  • - Ant border is manubrium, post border is T1-T4 vertebra

  • - (contents from ant to post) Thymus, large veins, large arteries, trachea, esophagus and thoracic duct, sympathetic trunk

  • - Inf mediastinum:

  • - Ant border is body of sternum, post border is T5-T12 vertebrae

  • - Ant mediastinum is a space between sternum and pericardium, contains thymus

  • - Middle mediastinum contains heart within the pericardium with the phrenic nerves on each side

  • - Post mediastinum lies between pericardium and vertebral column, contains esophagus and thoracic duct, descending aorta and sympathetic trunks


  • - Manubrium: articulates with body of sternum at cartilaginous manubriosternal joint and articulates with the clavicles, 1 st costal cartilage and upper part of 2 nd costal cartilage. Lies opposite T3 and T4. Arch of aorta, roots of brachiocephalic and left common carotid arteries, sup vena cava and terminal parts of left, right brachiocephalic veins lie behind the manubrium

  • - Sternal angle: recognized by transverse ridge on body of sternum. Lies opposite intervertebral disc between T4 and T5, lies at the level of the 2 nd costal cartilage, the point from which all costal cartilages and ribs are counted

  • - Body: articulates with manubrium at manubriosternal joint and with xiphoid process at cartilaginous xiphisternal joint opposite body of T9. Articulates with 2 nd to 7 th costal cartilages at the side

  • - Xiphoid process: thin cartilage plate which becomes


ossified during adult life


  • - 12 pairs, all ribs attached posteriorly to thoracic vertebrae

  • - True ribs (1-7): attached anteriorly to sternum by costal cartilages ie cartilaginous joints

  • - False ribs (8-10): attached anteriorly to each other and to the 7 th rib by their costal cartilages and small synovial joints

  • - Floating ribs (11-12): no anterior attachment

  • - Typical rib: head with 2 facets for synovial articulation with corresponding vertebral body and that of vertebra above, intraarticular ligament connects head to intervertebral disc, neck, tubercle with articular part for transverse process of corresponding vertebra and nonarticular part, shaft, angle, costal groove on inf border

  • - Atypical rib:

  • - 1 st rib small and flattened, scalenus anterior attached to upper surface and internal border, rib closely related to the subclavian artery and vein (ant and post to scalenus ant attachment) and lower trunk of brachial plexus (when brachial plexus compressed, called thoracic outlet syndrome).

Thoracic outlet

  • - Post: T1 vertebra


  • - Lat: medial border of 1 st ribs and their costal cartilages

  • - Ant: Sup border of manubrium

  • - Opening is obliquely placed facing upward and forward, so apices of lung and pleurae project upward into the neck

  • - Esophagus, trachea, blood vessels passes through the outlet between the neck and the thorax

  • - On either side, the outlet is closed by a dense fascial layer called the suprapleural membrane which protects the underlying cervical pleura and resists changes in intrathoracic pressure during resp movements. Suprapleural membrane is a thickening of the endothoracic fascia which is a thin connective tissue layer separating the parietal pleura from the thoracic wall.


  • - Post: T12 vertebra

opening (lower)

  • - Lat: curving costal margin

  • - Ant: Xiphisternal joint

  • - Opening is closed by diaphragm

  • - Esophagus and many large vessels and nerves pass through the opening and pierce the diaphragm


  • - External intercostal muscle, most superficial, fibres

  • - Internal intercostal muscle, intermediate layer, fibres


directed downward and forward from inf border of rib

above to sup border of rib below. Extends forward to costal cartilage where it is replaced by the external intercostal membrane, an aponeurosis

directed downward and backward from the subcostal groove of rib above to sup border of rib below. Extends


backwards from sternum to angles of ribs behind, where it is replaced by the internal intercostal membrane, an apon.

  • - Innermost intercostal muscle, deepest layer, corresponds to transversus abdominis muscle in ant abd wall. Crosses more than 1 intercostal space within the ribs, is an incomplete muscle layer. Related internally to endothoracic fascia and parietal pleura, externally to intercostal nerves and vessels

  • - Inspiration: 1 st rib fixed by contraction of scaleni, intercostals raise 2 nd to 12 th ribs

  • - Expiration: 12 th rib fixed by quadratus lumborum and oblique muscles of abd, intercostals contract to lower 1 st to


th ribs

  • - Intercostal blood vessels and nerves run between the internal and innermost intercostal muscles. Arranged from sup to inf: intercostal VAN


  • - Post intercostal arteries of 1 st 2 spaces are branches from

blood vessels

the sup intercostal artery

  • - Post intercostal arteries of lower 9 spaces are branches of the descending thoracic aorta

  • - Ant intercostal arteries of 1 st 6 spaces are branches of the internal thoracic artery, which arises from 1 st part of subclavian artery

  • - Ant intercostal arteries of the lower 6 spaces are branches of the musculophrenic artery, which is a terminal branch of the internal thoracic artery

  • - Each intercostal artery gives off branches to the muscles, skin and parietal pleura, & branches to superficial structures of breast

  • - Post intercostal veins drain backward into the azygos or hemiazygos veins

  • - Ant intercostal veins drain forwards into the internal thoracic and musculophrenic veins


  • - Intercostal muscles supplied by corresp intercostal nerves


  • - Intercostal nerves are ant rami of first 11 thoracic spinal nerves

  • - Ant ramus of 12 th thoracic spinal nerve lies in abd, runs forward in abd wall as subcostal nerve



  • - Each intercostal nerve enters an intercostal space between the parietal pleura and the post intercostal membrane, runs forward inf to intercostal vessels in subcostal groove between the internal and innermost intercostal muscles.

  • - 1-6 nerves distributed within their intercostal spaces, supply skin and parietal pleura, intercostals, levatores costarum and serratus posterior of each intercostal space



7-9 nerves leave the ant ends of intercostal spaces deep to the costal cartilages to enter the ant abd wall


10-11th nerves pass directly into abd wall since their corresp ribs are floating


7-11 th nerves supply the skin and parietal peritoneum and the ant abd muscles which include the external oblique, internal oblique, transversus abdominis and rectus abdominus



Rami communicantes: connect the intercostal nerve to a ganglion of the sympathetic trunk. Gray ramus joins the nerve medial to whre the white ramus leaves the nerve


Collateral branch: inf to main nerve, runs on upper border of rib below


Ant and lat cut branch: skin on midline and lat side of chest resp. Ant cut branch gives med and lat branches, lat cut branch gives ant and post branches


Muscular branch: to intercostal muscles


Pleural sensory branches: to parietal pleura


Peritoneal sensory branches of 7-11 th intercostal nerves: to parietal peritoneum


  • 1 st intercostal nerve joined to brachial plexus by lat cut

branch. 1 st intercost nerve does not have ant cut branch


  • 2 nd intercostal nerve joined to med cut nerve of arm by intercostobrachial nerve, does not have lat cut branch. Supplies skin of armpit and upper med side of arm. Referred pain to med side of arm in coronary artery disease

Sensory innerv


Supraclavicular nerves (C3-4) to ant chest wall


Post rami of spinal nerves to post chest wall


Ant and lat cut branches of intercostal nerves to oblique bands of skin in regular sequence arranged in dermatomes


Pain in the thoracic wall may be revealed as pain in a dermatome that extends across the costal margin into the ant abd wall referred pain

Internal thoracic


Internal thoracic artery supplies the ant wall of the body


from the clavicle to the umbilicus


Is a branch of the 1 st part of the subclavian artery


Descends vertically on the pleura behind the costal cartilages, a fingerbreadth lateral to the sternum, ends in the

  • 6 th intercostal space by dividing into sup epigastric and musculophrenic arteries



Ant intercostal arteries to the upper 6 intercostal spaces


Perforating arteries which accompany the terminal branches of the corresp intercostal nerves

  • - Pericardiacophrenic artery which accompanies the phrenic nerve and supplies the pericardium

  • - Mediastinal arteries to the ant mediastinal contents eg thymus

  • - Sup epigastric artery which enters the rectus sheath of the ant abd wall and supplies the rectus muscle as far as the umbilicus

  • - Musculophrenic artery which runs around the costal margin of the diaphragm and supplies the lower intercostal spaces and the diaphragm

  • - Internal thoracic nerve accompanies the internal thoracic artery and drains into the right,left brachiocephalic veins


  • - Levatores costarum: 12 pairs of levator costa, triangular


  • - Origin & insertion: Arises by its apex from the tip of the transverse process, inserts into the rib below

  • - Action: Elevates the rib below inspiratory muscle

  • - Innerv: Post rami of thoracic spinal nerves

  • - Serratus posterior superior

  • - Origin: from the lower cervical and upper thoracic spines, fibers pass downward and laterally

  • - Insertion: upper ribs

  • - Action: Elevates the ribs inspiratory muscle

  • - Innerv: Intercostal nerves

  • - Serratus posterior inferior

  • - Origin: from the upper lumbar and lower thoracic spines, fibers pass upward and laterally

  • - Insertion: lower ribs

  • - Action: Depresses the ribs expiratory muscle

  • - Innerv: Intercostal nerves


  • - Thin muscular and tendinous septum. Is the only structure separating the chest wall from the abd viscera in the abd cavity below

  • - When seen from the side, has the appearance of an inverted

J, ie

J, ie ,the long limb extending up from the vertebral

,the long limb extending up from the vertebral

column and the short limb extending forward to the xiphoid process


  • - Dome shaped. Curves into right and left domes or cupulae. Right dome reaches as high as upper border of 5 th rib, left dome may reach lower border of 5 th rib. Right dome lies at a higher level because of the large size of the right lobe of the liver. The domes support the right and left lungs

  • - Has a central tendon, shaped like 3 leaves. Sup surface of tendon is partially fused with the inf surface of the fibrous pericardium. Central tendon lies at the level of the xiphisternal joint and supports the heart.

  • - Has 3 parts: (peripheral musculature)

  • - Sternal part arising from post surface of xiphoid process

  • - Costal part arising from deep surfaces of lower 6 ribs and their costal cartilages

  • - Vertebral part arising from crura and arcuate ligaments Right crus arises from sides of bodies of L1-L3 vertebrae and intervertebral discs, left crus arises from sides of bodies of L1-L2 vertebrae and intervertebral discs.

  • - Some muscle fibres from right crus pass up to the left and surround the esophageal orifice in a slinglike loop, fibres act as a sphincter and assist in preventing regurgitation of stomach contents into the thoracic part of the esophagus

  • - Medial arcuate ligament extends from side of body of L2 to tip of transverse process of L1, lateral arcuate ligament extends from tip of transverse process of L1 to lower border of 12 th rib, median arcuate ligament crosses over the ant surface of the aorta and connects the medial borders of the two crura

  • - Pierced by the structures that pass between the chest and the abd

  • - Has 3 openings:

  • - Aortic opening lies ant to body of T12 between the crura, transmits the aorta, thoracic duct and azygos vein

  • - Esophageal opening lies at level of T10 in a sling of muscles derived from right crus, transmits the esophagus, right and left vagus nerves, esophageal branches of the left gastric vessels, lymphatics from the lower 1/3 of the esophagus

  • - Caval opening lies at level of T8 in the central tendon, transmits the inf vena cava and terminal branches of the right phrenic nerve

  • - 2 sympathetic splanchic nerves pierce the crura

  • - Sympathetic trunks pass post to the medial arcuate ligament on each side

  • - Sup epigastric vessels pass between the sternal and costal origins of the diaphragm on each side


  • - 1. Muscle of inspiration Diaphragm is the most impt muscle of respiration. On contraction, diaphragm pulls down the central tendon and increases the vertical diameter of the thorax

  • - 2. Muscle of abd straining contraction of diaphragm assists contraction of the ant abd wall muscles in raising intraabdominal pressure for micturition (urination), defecation and parturition (childbirth). Mechanism is aided by person taking deep breath and closing the glottis of the larynx, to trap air in the resp tract so diaphragm is unable to rise

  • - 3. Weight lifting muscle person takes deep breath and holds it, fixing the diaphragm. Diaphragm assists ant abd wall muscles in raising the intraabdominal pressure to support vertebral column and prevent flexion, assisting postvertebral muscles in lifting heavy weights

  • - 4. Thoracoabdominal pump Descent of diaphragm decreases intrathoracic pressure and increases intraabdominal pressure, compressing the blood in the inf vena cava and forcing it upward into the right atrium of the heart. Lymph in the abd lymph vessels is also compressed and the negative intrathoracic pressure aids its passage upward within the thoracic duct. Presence of valves prevents backflow

Motor innerv

  • - Right and left phrenic nerves Sensory innerv

  • - Parietal pleura and peritoneum covering the central surfaces of the diaphragm are innerv by the phrenic nerve

  • - Periphery of the diaphragm innerv by the lower 6 intercostal nerves


  • - Mobile cartilaginous and membranous tube

  • - Fibroelastic tube is kept patent by U shaped rings of hyaline cartilage embedded in its wall. The post free ends of the cartilage are connected by smooth muscle, the trachealis

  • - Extends from the lower border of the cricoid cartilage (opp body of C6 vertebra) in the neck to the level of the sternal angle on the thorax (opp intervertebral disc between T4 and


  • - Begins in the midline, ends to the right of the midline by bifurcating into right and left principal bronchi

  • - During expiration, the bifurcation rises about 1 vertebral level, during deep inspiration, the bifurcation may be lowered as far as T6

  • - Can be palpated in the root of the neck in the midline in the suprasternal notch Relations

  • - Ant: sternum, thymus, left brachiocephalic vein, origins of the brachiocephalic and left common carotid arteries, arch of aorta

  • - Post: esophagus, left recurrent laryngeal nerve

  • - Right side: azygos vein, right vagus nerve, pleura

  • - Left side: arch of aorta, left common carotid and left subclavian arteries, left vagus and left phrenic nerves, pleura

Blood supply

  • - Upper 2/3 by inferior thyroid arteries

  • - Lower 1/3 by bronchial arteries


Lymph drainage

  • - Pretracheal and paratracheal and deep cervical nodes


  • - Sensory innerv by vagi and recurrent laryngeal nerves

  • - Sympathetic innerv to trachealis nuscle


  • - Trachea bifurcates behind the arch of the aorta into the right and left principal/primary/main bronchi.

  • - Right main bronchus:

  • - wider, shorter and more vertical than the left, it is a more direct continuation of the trachea where things tend to get stuck

  • - before entering the hilum, the right main bronchus gives rise to superior lobar bronchus

  • - on entering hilum, the bronchus divides into middle and inferior lobar bronchi

  • - Left main bronchus:

  • - Narrower, 2X longer and more horizontal than the right

  • - Passes to the left below the arch of the aorta and in front of the esophagus

  • - On entering hilum, the bronchus divides into superior and inferior lobar bronchi

  • - Bronchi divide dichotomously into terminal bronchioles,

  • - Terminal bronchioles terminate in one or more respiratory bronchioles

  • - Each respiratory bronchiole divides into alveolar ducts that enter alveolar sacs

  • - Alveoli arise from the walls of the sacs as diverticula


  • - Parietal pleura lines thoracic wall, covers thoracic surface of diaphragm and lat aspect of mediastinum, extends into root of neck to line undersurface of suprapleural membrane at thoracic outlet

  • - Visceral pleura completely covers outer surface of lungs, extends into the depths of the interlobar fissures

  • - 2 layers of pleura become continuous with one another by a cuff of pleura that surrounds the structures entering and leaving the lung at the hilum. Pleural cuff hangs down as a loose fold called the pulmonary ligament to allow for movement of the pulmonary vessels and large bronchi during respiration

  • - 2 layers of pleura separated from one another by a potential space called the pleural space containing a small amount of pleural fluid that permits the layers to move on each other with minimum friction

  • - 4 divisions of parietal pleura:

  • - Cervical pleura - projects upwards into the neck

  • - Costal pleura - lines the inner surfaces of the ribs, costal


cartilages, intercostal spaces, sides of vertebral bodies and back of sternum

  • - Diaphragmatic pleura covers thoracic surface of diaphragm

  • - Mediastinal pleura covers and froms the lateral boundary of the mediastinum


  • - Apex of lung and cervical dome of pleura project upwards into the neck

Lines of pleural reflection

  • - Cervical pleura bulges upward into the neck

  • - Ant border of right pleura begins behind the sternoclavicular joint, runs downward in midline to the xiphisternal joint. Ant border of left pleura has a similar course, but deviates laterally at the level of the 4 th costal cartilage and extends to form the cardiac notch, then turns sharply downward to the xiphisternal joint

  • - Lower border of the pleura crosses the 6,8, 12 th ribs in the

midclavicular, midaxillary and paravertebral lines respectively. Lower limit of the pleural reflection crosses the 12 th rib adj to the vertebral column at the lat border of the erector spinae

  • - Lower border of the lung in midinspiration crosses the 6, 8,


th ribs in the midclavicular, midaxillary and paravertebral

lines respectively

  • - Distance between the lower borders of the lungs and pleura corresponds to the costodiaphragmatic recess

  • - Post border of the lung extends downwards from the spinous processes of C7 to the level of T10 vertebra

  • - Oblique fissure of the lung can be indicated by a line drawn from the root of spine of scapula obliquely downward, laterally and anteriorly, following the course of the 6 th rib to the costochondral junction.

  • - Horizontal fissure of right lung can be indicated by a horizontal line along the 4 th costal cartilage to meet the oblique fissure in the midaxillary line.

  • - Left lung: upper lobe sup and ant to oblique fissure, lower lobe inf and post to oblique fissure

  • - Right lung: upper lobe sup to horizontal fissure, middle

lobe inf to horizontal fissure, lower lobe inf and post to oblique fissure