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Anatomy
The chest
Al-Zu'bi Ahmad

Ziad Bataineh

Sunday, 12/3/2011
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Sunday, 12-march-2011
Anatomy lec.(5)
Dr.Zeyad Al-Batayneh
Al-Zu'bi Ahmad

Last time we talked about the thoracic cavity and its content of. Today we will
describe the thoracic cage or the boundaries of the thoracic cavity mainly the
thoracic wall. Simply the thoracic wall includes the thoracic cage.
The thoracic cage: the bony compartment and other structures related to the thorax
from outside like the muscles. general speaking, the main function of the bony skeleton or
the skeleton -in general- is to give support and to protection, so the main function of the
thoracic cage is to protect all the viscera inside the thoracic cavity, and that's why it's
rigid, elastic and tough, but there is some flexibility via the joints that articulates with the
bones of the thoracic cage.
The skeleton of the thoracic cage consists of: sternum, 12 pairs of ribs, costal
cartilages, 12 thoracic vertebrae and the inter-vertebral discs.

12 pairs in number and we can divide them - according to their shape- into typical ribs and
atypical ribs as following:
The typical rib consists of a head (small head) with 1 or 2 articulating facets (I am talking
about the edge of the rib) and next to the head - as other long bones - we have the neck, then after
the neck of the rib we have a small protrusion we call it the tubercle, an angle then the body (or
the shaft) of the rib. All of these terms are applied to what we call typical rib, because some ribs
do not have this structures exactly as described like the 11th and the 12th ribs, they don't
considered as typical ribs.
Head Tubercle

Typical Rib Neck

Body

** The typical ribs: 3rd – 9th // The atypical ribs: 1st, 2nd, 10th – 12th**
Why are the (1st, 2nd, 10th – 12th) ribs considered atypical ribs??? Because they do not fulfill
all the descriptions of the typical ribs that were mentioned earlier (head, neck, tubercle, angle,
body, subcostal groove).
To make it clear:
The 1st rib: all ribs are flattened from upward downward (vertically), but the 1st rib is
flattened horizontally, another thing it has certain tubercles on the top surface that we call
scalene tubercles for the attachment of the scalene muscles, that is why we consider it atypical.
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The 2nd rib: It

is atypical
because it has a wide
flattened area, which
is wider than the
rest of the ribs,
and it has an
attachment
for the scalene
muscles.
The 10th rib:
its atypical
because it is
attached
indirectly to
the
sternum
through the
7th rib, in
addition you
will find that
it has one
articular facet for
attaching to the body
of only one
vertebra, later on we
will discuss
how the head is attached to the body of the vertebrae -most of them have two facets to be
attached to two vertebrae, but in the case of the 10th rib it has one facet for the attachment to one
vertebra.
The 11th and the 12th ribs: They are atypical because they do not have an angle, they are
straight, they are floating; don't attach to the sternum at all.
So the1st and the 2nd ribs are the only ribs have scalene tubercles for the attachment of the
scalene muscles.

Scalene tubercles and scalene muscles

of the 1st and 2nd ribs
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Another classification of ribs: true ribs and false ribs. The first seven ribs are true ribs,
because all of them have two same attachments; one end attaches to the vertebrae and the other
end attaches to sternum directly.
The remaining five ribs (8th, 9th, 10th, 11th, 12th) we call them false ribs, because they either
articulate with the sternum indirectly or do not articulate with the sternum at all (those ribs do
not articulate with sternum directly or indirectly).
You know that the 11th and the 12th ribs are not attached to the sternum at all so we call
them floating ribs, sometimes we include the floating ribs to the false ribs; because the true
ones are attached to the sternum so the non sternum-attached ribs we call them false ribs.
Again false ribs are those ribs that attach indirectly to the sternum and those that have free
anterior end (the floating ribs).

"True ribs: 1st -7th …. False ribs: 8th – 10th ….

Floating ribs: 11th, 12th; also they can be considered as false ribs"
Don't forget that as we move from the 1st rib downward, the length of the ribs increases
- The 1st rib is the shortest, the 2nd rib is little bit longer until we reach the 7th one which is
the longest. Now we suppose that the 8th, 9th, 11th and the 12th ribs are longer, but actually
they are shorter, because their anterior ends of are not attached directly to the sternum, they
are continued by their cartilages which are attached to the ribs above. So the 8th rib is
attached by a cartilage to the 7th rib, and the 9th rib is attached to the 8th rib and so on. and
that's why they are shorter than the 7th one .

Now the space between the ribs is called the intercostal space. They are 11 intercostal
spaces in number, and the last one is called subcostal space. Don't forget when we name
these intercostal spaces we do that according to the rib above it (the 1st space is below the
1st rib, the 2nd one is below the 2nd rib and so on).

What do we find in these intercostal spaces???

We have the intercostal muscles filling the gap between the upper border and the lower
border of the adjacent ribs, and we have nerves, arteries and veins of the same name
(((intercostal nerves, intercostal arteries, intercostal veins))).

The costal cartilages (hyaline cartilage) connect the anterior end of the ribs to the sternum,
and you know that the hyaline cartilage is more or less elastic or resilient, so they can provide
some movement, and that is why they connect the anterior end of the ribs to the sternum (to give
some elasticity or some movement to the continuously moving chest or thoracic cavity), What is
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their function??!!! they prolong the ribs anteriorly in addition they provide some flexibility to
the distal end and they increase the length of the ribs.

One of the structures in any vertebra is the transverse process. *sometimes the transverse
process of 7th cervical vertebra may elongate much more than normal so it looks like a rib, and
you know that the brachial plexus or the nerve that leave the spinal cord in the cervical region,
they cross the 1st rib to reach the upper limb to supply it. So if there is a rib -something like a
rib- above them it will press on them, so the spinal nerves that leave the spinal cord in this area
will be pressed or constricted by what we call the cervical rib, and this causes many symptoms
that affect the upper limb and we are not discussing them.*
The condition is cervical rib, the problem is pressing on the nerve that leave the neck to the
upper limb and causing some symptoms (sensory or motor symptom). So this is a congenital
anomaly.
The thoracic vertebra as usual , it consists of a body , small projections ( pedicles ) , arch
shape structure (lamina) and between the pedicle and the lamina we have transverse process from
both sides , and from the lamina –attached to it – we have the spine (superior view ).

Now if we look to the vertebra from this side ((( lateral view ))) , in addition to the body ,
pedicles , lamina , transverse process and the spine , there are two facets , these facets are for the
attachment of the ribs -as you can see in the picture- these facets are for the attachment of two
ribs. And the transverse process is for the attachment of the tubercle of the rib. You can notice
here the spine; it is narrow, thin and somehow vertical in direction, compared to the spine of the
lumbar vertebra which is short, wide, more or less horizontal in direction.

Superior view )A(

lateral view )B(

v
A B

You notice that almost each two adjacent vertebrae –either in the cervical region or the
thoracic region or the lumbar region- they are more or less identical in size , and here we have
an IMPORTANT QUESTION : what is the difference between the 12th thoracic vertebra
and the 1st lumbar vertebra ???? By size they are almost the same , so HOW ??? some
students answered we can differentiate between them by the spine, but the spines of both of
them are almost the same, here is the ANSWER: the body of the 12th thoracic vertebra has
two facets for the attachment of the ribs as we said before, while the 1st lumbar vertebra
has only one facet, so we can differentiate between them from the body.
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NOTES
* The characteristics of the spine: narrow, thin, vertical in direction, but these
characteristics change (length, thickness, direction) as we move down, and that is why
we cannot differentiate between the 12th thoracic vertebra and the 1st lumbar vertebra
from the spine.
* Each vertebra has two facets in the body for attachment of two halves of two ribs –
not the whole two ribs- , each rib has two facets for the attachment, one for the upper
vertebra and the other one for the lower vertebra, but there is an exception which is
the 1st lumbar vertebra, it has only one facet for attachment of one rib.
* The 1st , 2nd , 10th , 11th , 12th are atypical ribs , because their characteristics do
not fit with the typical rib , the 1st rib has one facet for attachment to one vertebra ,
the 11th and 12th ribs are atypical for the same reason , they have one facet.

The sternum is a flat bone, consists of three parts: manubrium sterni, body, Xiphoid
process, going up there is a notch called jugular notch, and we have clavicular notch for the
attachment of the clavicle , and there is a joint between the manubrium sterni and the body
(sternal angle) at the level of the 4th and 5th vertebrae , in the body we have transverse
ridges on the anterior surface of the sternum .

Anterior view of the

sternum
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Embryologically, these (the ridges) represent that is the sternum consists of many
Pons (I am not sure , the word is not clear) on its bones , so when they merge they
form line of fusion between the different parts (pons) during development .

Xiphoid process is at the level of the 10th thoracic vertebra (T10). Abnormally
the xiphoid process maybe perforated, that there is a hole in the xiphoid process or the
body itself, so don't be surprised if you see an X-ray with a hole in the body of the
sternum or in the xiphoid process, and more the xiphoid process maybe biped (two
xiphoid processes), so these are congenital abnormalities associated with the
development of the sternum and the xiphoid process.

As I mentioned before the thoracic cavity has two openings (upper opening ,
lower opening) or (superior aperture , inferior aperture), the superior one is narrower
than the inferior one, it is bounded by the upper border of the sternum , the upper
border of the 1st thoracic vertebra, and the medial border of the 1st rib from both
sides. Now the inferior border, we have the last ribs, costal cartilages, the 12th
thoracic vertebra and the xiphoid process of the sternum.

There are many joints joining the different bones of the thoracic cage mainly:
ribs, vertebrae and the sternum. The movement in a single joint is very minimal or
cannot be noticed, but any defect in one of these joints will affect the movement of
the thoracic cage.

Firstly, we have joints between the clavicle and the manubrium, and the costal
cartilages of the (1st, 2nd, 3rd, 4th, until we reach the 7th rib) with the sternum as well
as the costal cartilages of the (8th, 9th, 10th ribs) with the upper ribs, these joints are
synovial joints, as we know the synovial joint has cavity, cartilage, capsule and so on
with free movement.

This is a cross-section of one rib and one vertebra, there are the joints: a joint
between the head of the rib and the body of the vertebra, and a joint between the
transverse process of the vertebra and the tubercle of the rib, all these joints are
synovial joints.
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The joint between the head of the rib and the body of
the vertebra

The joint between the transverse process of the vertebra

and the tubercle of the rib

There are joints between the ribs and the costal-cartilages called cartilaginous
joints; there is a fibro cartilage with hyaline cartilage at this joint, so there will be
very minimal movement.

We have joints between the vertebrae, others between the Manubrium and the
body of the sternum, again these joints are cartilaginous joints or fibro cartilage
joints, and these are very strong joints with minimal movement.

What are the Muscles that attach to the thoracic cage? We have muscles
attach to the outside of the thoracic cage, and they are concerned with the movement
of the thoracic cage itself or the movement of the upper limbs, these muscles are:
(check the picture next page)

1- We have two muscles at the posterior aspect of the thoracic cage: Serratus
posterior superior (SPS) and Serratus posterior inferior (SPI).

Muscle: Serratus posterior superior Serratus posterior inferior

Origin The spine process of C7-T2 The spine process of T11-L2

Insertion The 2nd - 4th Ribs The 8th - 12th Ribs

when they contract they pull the ribs

when they contract they pull the ribs downward,
Function upward,
so they are muscles of EXPIRATION
so they are muscles of INSPIRATION

2- Levatores costarum (LC) : From their name

they elevate the ribs, so they are muscles of
INSPIRATION.
LC
3- Transversus thoracis: You can see these
muscles from inside - behind the sternum.
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All these muscles are supplied by the spinal nerves (upper, middle and lower
spinal nerves).

What are the muscles that fill the gaps between the ribs? These muscles found within the
intercostal spaces. We have three sheaths of muscles: (refer to slide no. 13)
1. From the outside, we call it Internal Intercostal Muscles.
2. From the inside, we call it Innermost Intercostal Muscles.
 Origin: from the Ribs bellow.
 Insertion: the Ribs above. (So the ribs above are the one which will move).
 The Direction of these muscles: Perpendicular to the external intercostal muscles
(which we will discuss in the following point), so they direct upward and
laterally.
 Function: when they contract they will move the ribs above so they will depress
the ribs, that is why we consider these muscles as muscles of EXPIRATION.

The intercostal artery and the intercostal nerve are set between them. These two muscles
are considered as one muscle because they have the same direction, the same origin and the
same insertion.
The difference between them is only they are separated by the intercostal nerves and
arteries.

3. External Intercostal Muscles:

 The direction of these muscles' fibers is: Downward and
Medially.
 Origin: the Ribs from above.
 Insertion: the Ribs from below.
 Function: As we know the insertion is the one which will move, so
these muscles will elevate the ribs below during INSPIRATION.
The nerve supply of these muscles is the intercostal nerves corresponding to the
number of the space that they are found in.

Because the ribs are slanting (they direct slightly forward and downward), when the
muscle of inspiration contract they pull the ribs upward from all directions.
So in the anterioposterior direction: when the ribs are pulled upward they will be pushed
forward, that will increase the anterioposterior diameter of the thoracic cavity.
lateral view: when I pull the ribs upward I move them to the lateral side, that will
increase the distance between the ribs on the lateral side, so the transverse diameter will
increase.

Conclusion: when the inspiratory muscle contract >>> they pull the ribs upward
>>> that will increase the anterioposterior and transverse diameters >>> this will increase
the space of the chest cavity >>> that will allow the air to enter by the negative pressure
that will present in the pleura.
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There are three main sources for the blood coming to the chest:
 The first one coming directly from the thoracic aorta via the posterior intercostal.
 Subcostal arteries where the origin is the subclavian artery which gives the
internal thoracic artery anteriorly which gives most of the anterior intercostal
arteries.
 Finally from the axillary artery which is a continuation of the subclavian artery
and the upper limb. In the first part it gives me something called superior and
lateral thoracic arteries supplying the upper two spaces of the intercostal spaces.

The posterior intercostal arteries as I mentioned, they come directly from the descending
aorta, but the upper two has a cephalic origin, they come from the costocervical trunk (costo
ribs cervical trunk), so they supply the ribs and the trunk, so the first pair doesn’t come from
the descending aorta, but the other ten pairs come from the descending aorta.

Atypical posterior intercostal artery presented at the intercostal spaces, at its origin it will
give a posterior branch that supplies the posterior muscles, at the middle axiallry line it will
give me a lateral branch and while in the intercostal space it gives me another branch runs with
it.

So in the intercostal space we have the posterior intercostal artery and its branch
(like we have two posterior intercostal arteries but the name of the branch is co-
lateral branch). So now we have posterior branch supplying the posterior
muscles, lateral and co-lateral branch runs with it in the intercostal space.

The internal thoracic artery as I mentioned before (comes from the subclavian) it will give
me the upper six pairs of anterior intercostal artery. Each intercostal space is fed by two anterio-
intercostal arteries they will anastomose with the posterior intercostal and its co-lateral.

The upper anterior intercostal arteries come from the terminal branch of the internal thoracic
artery: superior megastric artery and the other one is called epicardium musclophrenic artery it
gives the other three. (I'm not sure about the names of the last two arteries , but that is what the
Doctor said )
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Summary for the blood supply of intercostal spaces:

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the blood supply of the intercostal spaces

one large posterior two small anterior

intercostal artery intercostal artery

intercostal )1,2( intercostal )3-11( intercostal )1-6( intercostal )7-11(

spaces spaces spaces spaces

1st part of
subclavian artery
subclavian artery 1st part of
subclavian artery
descending thoracic internal thoracic
costocervical trunk aorta artery
internal thoracic
superior(supereme) artery
musculophernic(
intercostal artery
)artery

This table is done by: Odai Ma’aiah .. Thank you My friend

THE END
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I wanna thank my dear friends el-Dakatra:

Muhammad Al-Smadi >>> bdros m3na 6eb.

Ahmad Al-Khatib>>> our CR , rabbak yassar el-tafree3'.

Hisham Al-Qadi>>> aaammm aaaaaammm aaaaammmm, alla ys3edak ;)

Odia Ma’aiah>>> Big thanks to you man.

‫ متأملني مبجيء اليوم اذلي نتفوه فيه‬، ‫جيري اليوم اذلي نتأوه فيه من عقبات احلياة‬
‫ و لنرِس إىل مستقبل) يشع‬، ‫ فلنصنع تكل احلروف من تكل اآلهات‬، ‫حبروف الفرح‬
‫ابألمل‬.