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Thorax Region of the body between
the neck and abdomen Flattened in front and behind,
but rounded on the sides The bony framework of the
walls is called the thoracic thoracic cagecage, which is formed of: Vertebral column
posteriorly Ribs & intercostal spaces
on the sides Sternum and costal
cartilages anteriorly
• Superiorly: It communicates with the neck through an opening bounded: Posteriorly by 1st thoracic
vertebra Laterally by medial border of
the 1st ribs and their costal cartilages
Anteriorly by superior border of manubrium sterni
• This opening is occupied: In the midline, by the structures
that pass between the neck and the thorax
On either sides, it is closed by a dense suprapleural membrane
1
1st rib
Suprapleural membrane
Suprapleural Membrane Tent shaped dense fascial sheet that
covers the apex of each lung. An extension of the endothoracic
fascia Extends approximately an inch
superior to the superior thoracic aperture
It is attached:Laterally to the internal border of
the first rib & costal cartilageAt its apex to the transverse
process of C7 vertebra. Medially to the fascia covering the
structures passing through the superior thoracic aperture
• Inferiorly: It communictes with the abdomen through a large opening bounded: Posteriorly by the 12th
thoracic vertebra Laterally by curving
costal margin Anteriorly by xiphisternal
joint• This opening is closed
by the diaphragm
Costal margin
2th rib
12
• The thoracic cage: Protects the lungs, heart
and large vessels Provides attachment to
the muscles of thorax, upper limb, abdomen & back
• The cavity of thorax is divided into:• A median partition, the
mediastinum• Laterally placed pleurae &
lungs
Cutaneous Nerves• Anterior wall:
Above the level of sternal angle: Supraclavicular nerves
Below the level of sternal angle: Segmental innervation by anterior and lateral cutaneous branches of the intercostal nerves
• Posterior wall: Segmental innervation by
posterior rami of the thoracic spinal nerves nerves
Thoracic Dermatomes
The Intercostal Space
Intercostal Space
• It is the space between two ribs• Since there are 12 ribs on each side,
there are 11 intercostal spaces. • Each space contains:
Intercostal muscles Intercostal neurovascular bundle Lymphatics
Intercostal muscles• Each intercostal space
has three muscles:• External Intercostal• Internal Intercostal• Innermost Intercostal
• Supplied by corresponding intercostal nerves
• Action: • Tend to pull the ribs
nearer to each other Strengthen the tissue
of the space
External Intercostal Muscle• Most superficial• Fibers directed downward &
forward• OriginOrigin: from lower border of the
rib above• InsertionInsertion: upper border of rib
below• Extends from the rib tubercle
behind to the costo-chondral junction in front
• Deficient anteriorly & replaced by external (anterior) intercostal external (anterior) intercostal membranemembrane
Costo-chondral junction
Internal Intercostal Muscle• Intermediate layer• Fibers directed downward &
backward• OriginOrigin: from subcostal groove
of the rib above• InsertionInsertion: upper border of rib
below• Extends from the sternum in
front to the angle of the rib behind
• Deficient posteriorly & replaced by internal (posterior) internal (posterior) intercostal membraneintercostal membrane
S
costochondral junction
CC
V
anterior intercostal membrane &
external intercostal muscle
posterior intercostal membrane &
internal intercostal muscle
Angle of the rib
Innermost Intercostal Muscle• Deepest layer• Incomplete layer,
divided into three portions
• Fibers cross more than one intercostal space
• Related externally to intercostal nerve and vessels, and internally to endothoracic fasciaendothoracic fascia
Endothoracic Fascia• It is the extrapleural fascia
that lines the wall of the chest • It is located between the
muscles and bones of the thoracic wall and the parietal pleura, extends over the apex (cupola) of the pleura as the suprapleural membrane, and forms a thin layer between the diaphragm and the pleura.
Intercostal Neurovascular Bundle• Lies between the innermost and
the internal intercostal muscles• Runs high in the intercostal
space, related to subcostal groove of the rib above
• Has a strict order in arrangement: Vein-Artery-Nerve (VANVAN)), from top to bottom
• As the innermost intercostal muscle is not forming a complete layer, the bundle is generally covered on the inside by the endothoracic fascia
Intercostal Nerves• Twelve pairs• Are the anterior primary anterior primary
rami rami of the thoracic spinal thoracic spinal nerves.nerves.
• 1-6 distributed in the intercostal spaces, 7-11th supply the anterior abdominal wall
• Anterior ramus of 1212thth nerve runs forward in the abdomen as the subcostal nervesubcostal nerve
Intercostal Nerves cont’d• These are mixedmixed nerves & supply the:
• The skin• Muscles of the intercostal space & abdomen • The parietal pleura & parietal peritoneum
• Branches:
• Rami communicantes• Collateral branches Lateral cutaneous Anterior cutaneous Muscular branches Pleural Peritoneal (7th-11th)
Atypical Intercostal Nerves• First thoracic nerve:
• Has no anterior cutaneous branch
• Is joined to the brachial plexus by a large branch that corresponds to the lateral cutaneous branch
• Second thoracic nerve : • Is joined to the medial
cutaneous nerve of the arm by brachial plexus by a branch called the intercostobrachial nerve that corresponds to the lateral cutaneous branch
Intercostal Arteries
• Each intercostal space contains: A single posterior & Two anterior intercostal arteries
• Each artery gives off branches to the muscles, skin, parietal pleura (& breast)
Posterior Intercostal Arteries• In the upper two two spaces,
arise from the superior superior intercostal arteryintercostal artery (a branch of costocervical trunk of the subclavian artery)
• In the lower nine nine spaces, arise from the branches of thoracic aortathoracic aorta
• The course and The course and branching of the branching of the intercostal arteries intercostal arteries follow the intercostal follow the intercostal nervesnerves
Anterior Intercostal Arteries• In the upper sixsix
spaces, arise from the internal thoracic internal thoracic artery artery
• In the lower fivefive spaces arise from the musculophrenicmusculophrenic artery (one of the terminal branch of internal thoracic)
• Form anastomosis with the posterior intercostal arteries
Intercostal Veins• Accompany intercostal
arteries and nerves• Each space has posterior &
anterior intercostal veins• Eleven posterior intercostal
and one subcostal vein• Lie deepest in the costal
grooves• Contain valves which direct
the blood posteriorly
Posterior Intercostal Veins• On right side:On right side:
• The firstfirst space drains into the right brachiocephalic vein
• Rest of the intercostal spaces drain into the azygos vein
• On left side:On left side:• The upper three upper three spaces
drain into the left brachiocephalic vein.
• Rest of the intercostal spaces drain into the hemiazygos and accessory hemiazygos veins, which drain into the azygos vein
Anterior Intercostal Veins
• The lower fivefive spaces drain into the musculophrenicmusculophrenic vein (one of the tributary of internal thoracic vein)
• The upper sixsix spaces drain into the internal internal thoracic veinthoracic vein
• The internal thoracic internal thoracic
vein drains into the subclavian vein.
Lymphatics
• Lymph vessels of the intercostal space conform to the general rule, that deep lymphatics follow arteries• Anteriorly drain into anterior intercostal anterior intercostal
nodesnodes that lie along the internal thoracic artery
• Posterioly drain into posterior intercostal posterior intercostal nodesnodes that lie in the posterior mediastinum
Applied Anatomy Sternum:
used for marrow biopsy May be split to make surgical access to heart, great
vessels and thymus Sternal angle as an important landmark for counting
ribs, costal cartilages and intercostal spaces Thoracic outlet syndrome: Compression of nerves
/vessels at the superior aperture of thorax Cervical rib Referred pain: Disease in the thorax may reveal pain in
the anterior abdominal wall… Why?
Applied Anatomy cont’d
Traumatic injuries to the thorax: Fracture of rib is extremely painful condition as
periosteum of the rib is supplied by the intercostal nerves above & below the rib
Fractured rib may penetrate the lung (and produce pneumothorax) or may damage the upper abdominal organs
Injuries involving multiple ribs result in flail chest. The flail segment is sucked in during inspiration and pushed out during expiration
Applied Anatomy cont’d The intercostal spaces are
important access points for: Surgical procedures, e.g.
resection of (part of) the lung Percussion and auscultation of
underlying structures e.g. heart & lung
To obtain a sample of pleural fluid or drain pus/blood from the pleural cavity. The needle/drain is passed through the intercostal space just above the upper border of the rib to avoid the neurovascular bundle .