Thoracic Wall

• Boundries of thorax
• Landmarks of thorax
• Muscles of thorax
• Extrinsinc
• Intrinsinc
• Vessels of thorax
Copyright © 2005 Pearson Education, Inc., publishing as Benjamin Cummings
Parts and regions of the thorax
• Boundaries
• Superior: jugular notch,
sternoclavicular joint, superior border
of clavicle, acromion, spinous
processes of C7

• Inferior: xiphoid process, costal arch,

11th and 12th ribs, vertebra T12

• Regions
• Thoracic wall

• Thoracic cavity
Parts and Regions of the Thorax
• Thoracic cage is an osteo-
cartilagenous conical cage
which has a narrow inlet &
a wide outlet.

• Boundaries of thoracic
cage:
• Ant: Sternum, costal
cartilages and ribs

• Post: Thoracic vertebrae

and ribs

• Lat: Ribs
Parts and Regions of the Thorax
• Thoracic inlet:
• Ant: Upper border of
manubrium sterni

• Post: 1st thoracic

vertebra

• On each side: 1st rib &

1st costal cartilage

• It is sloping downwards
& forward
Parts and Regions of the Thorax
Landmarks
• Jugular notch

• Corresponds with the 2th thoracic

vertebra in male, the 3th thoracic
vertebra in female.
Landmarks
• Sternal angle connects 2nd
costal cartilage laterally ，
corresponds with
• The lower border of 4th thoracic
vertebra

• The bifurcation of trachea in the

adult

• The beginning of aortic arch which

ends posteriorly at the same level

• The esophagus is crossed by the

left main bronchus
Landmarks
• Xiphoid process
• Xiphisternal junction lies
opposite the body of the 9th
thoracic vertebra.

• Clavicle
• Inferior fossa of clavicle
• Coracoid process

• Ribs and intercostal spaces

• Costal arch
• Infrasternal angle
• Xiphocostal angle
Landmarks
Landmarks
Landmarks
Thoracic wall
• Skin

• Superficial fascia
• Thoracoepigastric v.

• Supraclavicular n.

• Anterior and lateral

cutaneous branches of
intercostal n.

• Deep fascia
Thoracic Cage
Thoracic Cage
Sternum
• Has 3 parts:
• Manubrium:
• Lies opposite T3 and 4.
• Body:
• Lies opposite T5 toT8.
• Xiphoid:
• Lies opposite T9
• Sternal angle:
• Formed between the
manubrium and body of
the sternum.
Sternum
• Has 3 parts:
• Manubrium:
• Lies opposite T3 and
4.
• Body:
• Lies opposite T5 toT8.
• Xiphoid:
• Lies opposite T9
• Sternal angle:
• Formed between the
manubrium and body
of the sternum.
Intercostal Spaces
• There are 9 anterior and
11 posterior.
• Each space contains:
• 1. Intercostal muscles:
• External
• Internal
• Transversus thoracicus

• 2. An Intercostal nerve.
• 3. Intercostal vessels:
• a. Intercostal arteries
• (Anterior & posterior)
• b. Intercostal veins
• (Anterior & posterior).
The muscles of thorax
Extrinsic muscles
• Pectoralis major
• Pectoralis minor
• Serratus anterior

Intrinsic muscles
• Intercostales externi
• Intercostales interni
• Intercostales intimi
• Transverses thoracis
Pectoralis Major Muscle
Pectoralis Major Muscle
Pectoralis Major Muscle

• The pectoralis major (Latin: pectus

= breast) is a thick, fan-shaped
muscle.

• Situated at the chest (anterior) of

the human body.

• It makes up the bulk of the chest

muscles in the male and lies under
the breast in the female.
Pectoralis Minor Muscle
Located deep to pectoralis major.

Origin: Ribs 3-6.

Insertion: Coracoid process of

scapula

Innervation:

Function: Stabilization of scapula

Positionally important for

understanding location of other
structures.
Serratus Anterior Muscle
The muscles of thorax

Muscle Origin Insertion Action Innervation

Pectoralis Sternum, Inter- Adduct, M&L
major Ribs 2-6 tubercular Flex, Med pectorals
groove of Rotate
humerus 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
Latissimus Dorsi Muscle
Origin:
Spines of T7-T12
Thoracolumbar fascia

Insertion:
Humerus: inertubecular groove
and lesser tubecular crest

Innervation:
Thoracodorsal nerve
Pectoralis and Latissimus Dorsi Muscles
Latissiumus: extends, adducts and medially rotates humerus.

Pectoralis: is large, fan-shaped muscle opposing it ventrally.

Pectoralis Minor Muscle
Pectoralis Minor Muscle
Pectoralis Minor Muscle
External Intercostal Muscles
• Origin:
above
From the lower border of the rib

• Insertion:
rib below
Into outer lip of upper border of

• Fibers are directed from above downward

and forwards.

• Begins from post. end of Intercostal space

close to the tubercle of the rib.

• Ends at the costochondral junction where it

is replaced by external or anterior Intercostal
membrane.

• It elevates the rib during inspiration.

Internal Intercostal Muscles
• Origin: Floor of costal groove
• Insertion: Inner lip of upper border
of rib below

• Fibers are directed from above

downwards & backward

• Begins from anterior end of intercostal

space close to the sternum.

• Ends at the angle of the rib, where it is

replaced by posterior or internal
Intercostal membrane.

• Action: Depresses the rib

downwards during expiration.
The muscles of thorax
Intercostales externi
• Origin: lower border of rib above
• Insertion: upper border of rib below
• Action: elevate ribs adding in forced
inspiration
• Replaced anteriorly by external
intercostals membrane.

Intercostales interni
• Origin: upper border of rib above
• Insertion: lower border of rib above
below
• Action: depress ribs for forced
expiration
• Replaced posteriorly by internal
intercostals membrane.
Internal Intercostal Muscles
• is partly traversed by the nerve &
vessels, which splits each muscle into 2
parts:

• Outer: Internal intercostal (proper)

• Inner: Innermost intercostal (in the middle

of the space)
Internal Intercostal Muscles
Transversus Thoracicus Muscles
• The most inner layer of thoracic wall.
• It is formed of 3 muscles:
• 1- Innermost intercostal.
• 2- Sternocostalis.
• 3- Subcostalis
Sternocostalis Muscles
• 4 to 5 slips which arise from inner surface of lower part of body of
sternum and costal cartilages
• Inserted into inner surface of costal cartilages from 2 to 6.
Subcostalis Muscles
• Thin bands of muscle fibers.
• Mainly in lower 6 spaces.
• Only in post. part of
spaces.
• Origin: Inner surface &
lower border of rib above.
• Insertion: Upper border of
2nd or 3rd rib below.
Origin of the Anterior Intercostal Arteries
• 2 small arteries in each of the 9
spaces.

• The upper 6 from internal

mammary artery.

• The lower 3 from musculo-phrenic

artery.

• Note: Internal mammary or

internal thoracic artery is a branch
from1st part of subclavian artery
Origin of the Anterior Intercostal Arteries

• Internal thoracic artery

Descends into thorax 1.2cm
lateral to edge of sternum, and
ends at the sixth costal cartilage
by dividing musculophrenic and
superior epigastric arteries
Origin of the Anterior
Intercostal Arteries
• 2 small arteries in each of the 9 spaces.

• The upper 6 from internal mammary artery.

• The lower 3 from musculo-phrenic artery.

• Note: Internal mammary or internal thoracic artery

is a branch from1st part of subclavian artery.
Origin of the Posterior Intercostal Arteries
• One in each of the 11 spaces.

• 1st & 2nd arise from superior

Intercostal artery of costocervical
trunk of 2nd part of subclavian
artery.

• The lower 9 arteries & subcostal

artery arise from descending
thoracic aorta.
Anastomosis between the Intercostal Arteries
• In each space the posterior intercostal artery and its collateral branch
anastomose with the 2 anterior intercostal arteries
Anterior Intercostal Veins
• 2 in each space.

• 9th,8th & 7th join the venae commitantes

of musculo-phrenic artery.

• 6th,5th & 4th join venae commitantes of

internal mammary artery.

• 3rd,2nd &1st join internal mammary vein.

• Internal mammary vein drains into

innominate (Brachiocephalic vein).
Posterior Intercostal Veins
• One in each of the 11 spaces.

• On the right:
• 1st drains into right innominate v.

• 2nd,3rd & sometimes the 4th unite

to form right superior intercostal
vein (B) which drains into azygos
vein.

• From 5th to 11th & subcostal veins

drain into azygos vein.
Posterior Intercostal Veins
• One in each of the 11 spaces.
• On the Left:
• 1st drains into left. innominate v.

• 2nd,3rd& sometimes the 4th join to

form left superior intercostal vein
which drains into left innominate
vein.

• 5th,6th,7th, & 8th form superior

hemiazygos vein to azygos vein.

• 9th,10th.11th & subcostal form

inferior hemiazygos vein to
azygos vein.
Azygos Vein
• Begins as continuation of right
ascending lumbar vein.

• Ascending along the right side of

vertebral column.

• Joins superior vena cava by aching

above right lung root at level of T4 to T5.

• Receives right posterior intercostals and

subcostal veins plus some of bronchial,
esophageal and pericardial veins, and
hemiazygos vein.

• Tributaries: hemiazygos v. and

accessory hemiazygos v. which
receive most left posterior intercostals
vein and left bronchial veins.
Azygos Vein
• Connects IVC with SVC. SVC
• Begins in abdomen from back
of IVC at level of L2.

• Enters thorax through aortic

opening of diaphragm on right
side of thoracic duct & aorta.

• In post. mediastinum it passes

behind right border of
esophagus & root of right
IVC
lung.

• In sup. mediastinum (L4) it

crosses above the root of right
lung and enters the middle of
the back of the SVC.
Veins of thorax
Brachiocephalic veins
• Formed by union of internal jugular and
subclavian veins posterior to the sternoclavicular
joint.

• Angle of union is termed venous angle.

Superior vena cava

• Formed by union of right and left
brachiocephalic veins behind the right
sternocostal synchorndrosis of first rib.

• Runs vertically down on right of ascending aorta.

•
• Joined by azygos vein at level of sternal angle.

• Enters right atrium at lever of lower border of

third right sternocostal joint.

• Collects blood from veins of upper half of body.

Posterior Intercostal Veins
Veins of Vertebral Column

Consists of
• External vertebral
venous plexus
• Internal vertebral
venous plexus
The lymphatic drainage of thorax
• To axillary lymph nodes

• To parasternal lymph nodes (along

internal thoracic vessels)

• To intercostals lymph nodes from

deeper structures
Anterior branches of thoracic nerves
• Intercostal nerves
• They are anterior rami of T1- T11.

• They run forward inferiorly to

intercostals vessels in costal groove of
corresponding rib, between intercostals
externi and intercostals interni

• First six nerves are distributed within

their intercostals space.

• Lower five intercostals nerves leave

anterior ends of their intercostals
spaces to enter abdominal wall.
Anterior branches of thoracic nerves
• Subcostal nerve
• It is anterior ramus of T12.

• It follows inferior border of T12 rib and

passes into abdominal wall.

• Distribution: distributed to
intercostales and anterolateral
abdominal muscles, skin of thoracic
and abdominal wall, parietal pleura
and peritoneum
Intercostal Nerves
• They are the anterior primary rami of
spinal thoracic nerves fromT1 to T11.
• T3 toT6 are Typical.

• T12 is called subcostal n.

• The remaining nerves are called

atypical (non-typical).

• Each nerve runs in the intercostal space

inferior to the intercostal vessels.
Typical Intercostal
Nerves
• From T3 to T6.

• Leaves the intervertebral foramen

to reach the Intercostal space.

• Runs between pleura & post.

Intercostal membrane.

• Pierces internal intercostal muscle

splitting it into Internal Intercostal
(proper) and innermost intercostal.

• Runs between Internal intercostal

muscle & pleura.

• Pierces internal intercostal

muscle, anterior intercostal
membrane, pectoralis major, and
deep fascia to become anterior
cutaenous nerve.
Branches of Intercostal
Nerves
• White & grey rami (I) communicans
with sympathetic ganglion
collateral branch to intercostals (2)

• Lateral cutaenous branch to skin (3)

• Anterior cutaenous (4)

• Muscular branches

• Pleural sensory branches

• peritoneal branches (5)

• Articular branches.
Intercostal Nerves
1st Intercostal nerve:
• Joined to brachial plexus, by a branch that is equivalent to lateral
cutaenous branch.

2nd Intercostal nerve:

• Joined to the medial cutaenous nerve of the arm, by a branch called
Intercostobrachial nerve (corresponds to lateral cutaenous branch).

• In Angina pectoris & myocardial infarction pain referred to medial

side of arm along this nerve.

• So, with previous exception the upper 6 intercostal nerves supply

skin & parietal pleura and intercostal muscles in each space
Intercostal Space
Overview of the Thoracic Wall
Intercostal Space
Intercostal Space
Intercostal Space
External and Internal Intercostal Muscles
Neurovascular Bundle of Intercostal Muscles

VAN (vein, artery, nerve)

◦ Intercostal vein
◦ Intercostal artery
◦ Intercostal nerve
Sit in subcostal groove

Between internal intercostal and

innermost intercostal layer
Intercostal space

Posterior intercostal v.
Posterior intercostal a.
Intercostal n.
The Segmental Innervation of Anterior
Surface of Trunk
• T2 － sternal angle
• T4 － nipple
• T6 － xiphoid process
• T8 － costal arch
• T10 － umbilicus
• T12 － midpoint between
umbilicus and symphysis
pubis
The Segmental Innervation of Anterior
Surface of Trunk
• T2 － sternal angle
• T4 － nipple
• T6 － xiphoid process
• T8 － costal arch
• T10 － umbilicus
• T12 － midpoint between
umbilicus and symphysis
pubis
The Segmental Innervation of Anterior
Surface of Trunk
Intercostal Nerve