Thoracic Wall
Sylvia Santos
Learning Objectives
• Skeleton of thoracic wall
• Thoracic apertures
• Joints of thoracic wall
• Muscles, blood vessels and nerves of thoracic wall
Thorax (Chest)
• Part of the body between the
neck and the abdomen.
• Thoracic (/ Rib) cage
• Thoracic cavity – 3 major spaces –
mediastinum in center and on
each side right and left
pulmonary /pleural cavities
• Organs of respiratory and
cardiovascular systems
Thoracic cavity has
an appearance of
truncated cone
Thoracic Wall
Skeleton of Thoracic Wall
• Thoracic cage is an osseocartilaginous
structure
• Anteriorly by the sternum
• Posteriorly by the 12 thoracic vertebrae
and the intervening intervertebral discs
• On each side by 12 ribs with their
cartilages
Ribs / Costae
• 12 pairs
• There are 3 types of ribs that can be classified as typical and atypical
Types of ribs
Typical Ribs
Typical Ribs
Typical Ribs
Atypical Ribs – 1st
Atypical Ribs – 2nd
Atypical Ribs – 10-12
11 - 12
Vertebral Column/Spine
Kyphosis – Hunch-back - Exaggerated thoracic curvature
Parts of a vertebra
Thoracic Vertebrae
Thoracic Vertebrae
• Characteristic features:
✓Heart-shaped and medium size body
✓Presence of demi-facets on the sides of the body
✓Presence of costal facets on transverse process
✓Spinous process long and incline downwards
Thoracic Vertebrae
Atypical Thoracic Vertebrae
Sternum
Sternum
Sternum (G. sternon, chest)
(L. Handle)
Sternum
Sternum
Sternal Angle of Louis
• It is felt 5 cm below the suprasternal notch as a transverse prominence.
• It marks the joint between manubrium and sternum- manubriosternal
joint.
• It lies at the level of 2nd costal cartilage anteriorly and between T4-T5
posteriorly.
• Is used to find the position of 2nd rib as a reference for counting ribs (The
1st rib in not palpable due to overlying clavicle)
Sternal Angle of Louis
• Events occurring at sternal angle:
✓Rib – counting ribs - second downwards
✓Aorta – beginning and ending of arch of aortya
✓Trachea – bifurcation
✓Pulmonary trunk – bifurcation
✓Left recurrent laryngeal nerve arches around arch of aorta, ligamentum
arteriosum location
✓Azygous vein drains into SVC
✓Nerves – cardiac plexus situation
✓Thoracic duct – crosses from right to left
✓Plane of separation of superior and inferior mediastinum
✓Upper limit of the base of the heart
Sternum
Sternum
Sternum
Sternum
Xiphoid process
ossifies at 40 – felt as
hard lump (“tumor”)
in the ‘pit of the
stomach’
Joints of Thoracic Wall
Joints of Thoracic Wall
Anteriorly Posteriorly
1. Costochondral Joints – 1. Intervertebral joints - 2º
1º cartilaginous cartilaginous
2. Sternochondral/Sternocostal 2. Costovertebral joints – Plane
joint – Plane synovial EXCEPT 1st synovial
sternocostal is 1º cartilaginous 3. Costotransverse joints - Plane
3. Manubriosternal joint – synovial
2º cartilaginous
4. Xiphisternal joint - 1º
cartilaginous
Joints of Thoracic Wall
/Sternochondral
Joints of Thoracic Wall
Joints of Thoracic Wall
Superior and Inferior Thoracic Apertures
Superior Thoracic Apertures
Inferior Thoracic Aperture
Movements of Thoracic Wall
Movements of Thoracic Wall
Movements of Thoracic Wall
BUCKET- HANDLE MOVEMENT
Intercostal spaces
11 intercostal spaces
Intercostal Space
Intercostal Space
Intercostal Space
• Typical intercostal spaces – 3rd, 4th, 5th, 6th (as supplied by blood
vessels and nerves confined to thoracic wall)
• Atypical intercostal spaces – 1st, 2nd, 7th -12th
Muscles of the Thoracic Wall
Muscles of the Thoracic Wall
Muscles of the Thoracic Wall
Serratus Posterior Superior & Inferior
Serratus Posterior Superior & Inferior
Levatores Costarum
Intercostal Muscles
Intercostal Muscles
External Intercostal Muscles
Internal Intercostal Muscles
Internal Intercostal Muscles
Innermost Intercostal Muscles
Intercostal Muscles and Breathing
Subcostal Muscles
Transversus Thoracis Muscle
Transversus Thoracis Muscle
Suprapleural Membrane/ Sibson’s Fascia
Intercostal Vessels and Nerves
Intercostal Nerves
Intercostal Nerves
Intercostal Nerves
COMMUNICATING RAMI
Intercostal Nerves
Intercostal Nerves
Intercostal Nerves
Intercostal Nerves
Intercostal Arteries
Intercostal Arteries
Intercostal Arteries
Intercostal Arteries
• Posterior intercostal arteries
✓Each space contains one
✓Gives rise to collateral branch
✓For upper two spaces - arise from superior
intercostal artery (from costo-cervical trunk – 2nd
part of subclavian artery)
✓3- 11 spaces and subcostal arteries – arise from
descending thoracic aorta
Intercostal Arteries
Intercostal Arteries
• Anterior intercostal arteries
✓Each space has two (except the
lower two spaces)
✓Upper 6 pairs are by internal
thoracic a.
✓7th, 8th, 9th pairs arise from
musculophrenic a.
Intercostal Arteries
Intercostal Arteries
Intercostal Arteries
Intercostal Arteries
Subcostal Artery
Intercostal Veins
Intercostal Veins
Intercostal Veins
LEFT BRACHIOCEPHALIC VEIN
Clinical Anatomy
Rib Fractures
Weakest part of a rib is just anterior to its angle
Rib Fractures
Rib Fractures
Since ribs move during
respiration
Lower rib fractures may tear the diaphragm, resulting in a diaphragmatic hernia.
Flail Chest
• Flail chest is a loss of stability of the thoracic cage that occurs when a
segment of the anterior or lateral thoracic wall moves freely because
of multiple rib fractures, allowing the loose segment to move inward
on inspiration and outward on expiration (paradox movement)
Flail Chest
Flail Chest
Median Sternotomy
Thoracotomy
• The surgical creation of an opening through the thoracic wall to enter
a pleural cavity is a thoracotomy
• Posterolateral incision is a gold standard for access to thorax (5th – 7th
intercostal space); optimal access to pulmonary hilum
Arm fully
abducted ,
beside the
head
Thoracotomy
Thoracotomy
Supernumerary Ribs
• Presence of cervical and/or lumbar ribs or decreased by failure of the 12th pair to form.
• Cervical ribs are relatively common (0.5–2%) and may interfere with neurovascular structures
exiting the superior thoracic aperture.
• Most are asymptomatic
• Less than 10% of those with cervical ribs will be symptomatic
• Their clinical importance is their association with thoracic outlet syndrome
• Caused by compression of the lower portion of the brachial plexus
• Clinical manifestations may include pain in the neck and shoulder which
radiates into the upper extremity affecting course of the ulnar nerve-hand
and inner forearm; Paresthesias; Hand weakness, numbness, and clumsiness.
• Supernumerary (extra) ribs also have clinical significance in that they may
confuse the identification of vertebral levels in radiographs and other
diagnostic images.
Supernumerary Ribs
Supernumerary Ribs
There are bilateral accessory
ribs arising from the 7th
cervical vertebral body
(white arrows). The check
marks show the normal, first
ribs.
Sternal Biopsy , Bone Marrow Aspiration
Pectus Excavatum / Funnel Chest
Pectus Excavatum
Pectus Carinatum / Pigeon Chest
Pectus Carinatum
Ectopia Cordis
Christopher Wall
TOS – Thoracic Outlet Syndrome
• TOS is a group of neurovascular symptoms due to compression of
brachial plexus, T1 nerve, subclavian artery or vein
Thoracic Outlet Syndrome
Thoracic Outlet Syndrome
Thoracic Outlet Syndrome
Thoracic Outlet Syndrome
Safety
• Needle inserted at the upper border of the rib to protect intercostal
vessels and nerves
