THORACIC WALL, TRACHEA & LUNG

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OBJECTIVES:

- THORACIC WALL - boundary: thoracic inlet & outlet - ribs - intercostal space: intercostal a., v. & n. - blood vessels & nerve of thoracic wall - lymphatic drainage
- THORACIC CAVITY - bronchus - lung - pleura - blood vessels & nerves - bronchopulmonary segment - lymphatic drainage

REFERENCES:
-Moore KL, Dalley AF. Clinical oriented anatomy. 4th ed. Baltimore : Lippincott William & Wilkins, 1999. -Snell RS. Clinical anatomy for medical students. 4th ed. Boston : Little, Brown, 1992. -Hall-Craggs ECB. Anatomy as a basis for clinical medicine. 3rd ed. London : Waverly Europe, 1995.

Bony Thorax (Thoracic Cage)

THORACIC INLET

THORACIC OUTLET

Ribs
There are twelve pair of ribs forming the flaring sides of the thoracic cage All ribs attach posteriorly to the thoracic vertebrae The superior 7 pair (true, or vertebrosternal ribs) attach directly to the sternum via costal cartilages Ribs 8-10 (false, or vertebrocondral ribs) attach indirectly to the sternum via costal cartilage Ribs 11-12 (floating, or vertebral ribs) have no anterior attachment

Typical Ribs
Ribs 3-9 (7) Head Neck Tubercle Angle Shaft Subcostal Groove
Intercostal vein Intercostal artery Intercostal nerve

Dorsal (vertebral) extremity

Ventral (sternal) extremity

Atypical Ribs
Rib 1
articulates only with T1 (remember there is a full facet on the body of T1) Flattened and broad Supports the subclavian vein and artery which supply the arm No angle

Atypical Ribs
Rib 2 - Flattened, angle , 2 articular facet Rib 10 - 1 articular facet Ribs 11 and 12
Articulate with only one vertebral body Do not articulate with a vertebral transverse process Do not have a ventral attachment floating ribs

Atypical Ribs

The Sternum
Lies in anterior midline Formed from multiple fused sternebrae 3 Sections
Manubrium
Articulates with ribs 1 and 2 Articulates with clavicle at clavicular notches Has jugular notch Joins body at sternal angle which is a fibrocartilage joint

Body (Gladiolus)
4 separate bones that fuse after puberty Articulates with costal cartilages of ribs 2-7

Xiphoid Process

Joints of Thorax
Sternoclavicular joint
Synovial joint (saddle) Anterior sternoclavicular ligament Posterior sternoclavicular ligament Interclavicular ligament Costoclavicular ligament Articular disk

Sternocostal joint
1. Costal cartilage & 1st rib
synchondrosis

Sternocostal joint
2. Sternum & 2-7 ribs
Synovial joint (plane or gliding) Radiate sternocostal ligament Intra-articular sternocostal ligament Costoxiphoid ligament

Sternocostal joint
3. Interchondral joint
6-10, 6 & 7, 7 & 8, 8 & 9 costal cartilages; plane synovial jt. 9 & 10 costal cartilages; fibrous joint Inter chondral ligament

Sternocostal joint
4. Costochondral joint
Medial end of ribs & lateral end of costal cartilage Primary cartilaginous joint; periosteum & perichondrium

Intrasternal joint
1. Manubriosternal joint
Symphysis joint symphysis are articular surfaces separated by thin layers of hyaline cartilage attached to a band of fibrocartilage, which makes them amphiarthrotic or slightly movable

Intrasternal joint
2. Xiphisternal joint
Synchodrosis

Costovertebral joint
Symphysis or secondary cartilaginous

Radiate ligament Intraarticular ligament

Costotransverse joint

Synovial joint; tubercle & transverse process Superior costotransverse ligament

Neck to transverse process

Posterior costotransverse ligament

Neck to transverse process & inferior articular process

Ligament of neck of rib (costotransverse ligament)

Neck to transverse process

Ligament of tubercle of rib (lateral costotransverse ligament)

Tubercle to apex of transverse process

THE INTERCOSTAL SPACE

Muscles
Origin
The attachment of a muscle that remains relatively fixed during contraction

Insertion
The attachment of a muscle that is more moveable during contraction

The Intercostal Muscles

External Intercostals
Superficial 11 pairs lie between ribs Fibers run obliquely downward and anteriorly Origin is inferior border of rib above Insertion is superior border of rib below Lift ribcage, aiding in inspiration External intercostal membrane

The Intercostal Muscles (cont.)

Internal Intercostal muscles
Lie deep to external intercostals 11 pairs lie between ribs Fibers run downward and posteriorly Origin is superior border of rib below Insertion is inferior border of rib above (subcostal groove) Draw ribs together, aiding in forced expiration Internal intercostal membrane

 Innermost Intercostals
Attach to innermost surfaces of ribs

Fibers run anteroposteriorly (i.e. horizontally)

Thought to function like internal intercostals

SUBCOSTALS
-Angle of ribs -More than 1 space -Fibers run downward -and posteriorly

TRANSVERSUS THORACIS
- ATTACH FROM BODY, XIPHOID PROCESS AND STERNAL END OF COSTAL CARTILAGE 4-6 TO LOWER END OF COSTAL CARTILAGE 2-6

Abdominal type of respiration: Thoracic type of respiration: 2

ENDOTHORACIC FASCIA (THE PARIETAL PLEURA)

- parietal pleura
- SUPRAPLEURAL MEMBRANE (SIBSONS FASCIA)

diaphragm, prevertebral, transversalis, scalene and fascia of infrahyoid muscle

INTERCOSTAL NERVES
-Rami communicant -Collateral branch -Lateral cutaneous branch - anterior & posterior branches -Anterior cutaneous branch -Muscular branch -Peritoneal sensory branch (7-11)

RAMI COMMUNICANT

Collateral branch

Lateral cutaneous branch

Anterior cutaneous branch

1st intercostal nerve: brachial plexus

2nd intercostal nerve: intercostobrachial nerves (medial cutaneous nerve of arm) 7th -11th intercostal nerve: thoraco-abdominal intercostal nerves

12th intercostal nerve: subcostal nerve

INTERCOSTAL ARTERY
-Anterior intercostal arteries
internal thoracic & musculophrenic artery

-Posterior intercostal arteries

1-2 post. Intercostal aa.: superior (supreme) intercostal artery aorta

POSTERIOR INTERCOSTAL ARTERIES

1-2 post. Intercostal aa.: superior (supreme) intercostal artery

Internal Thoracic Artery

-Pericardiophrenic arteries -Anterior intercostal arteries -Musculophrenic arteries (7-11) -Superior epigastric arteries

POSTERIOR INTERCOSTAL ARTERY

SUPREME INTERCOSTAL ARTERY

INTERNAL THORACIC ARTERY

MUSCULOPHRENIC ARTERY

SUPERIOR EPIGASTRIC ARTERY

INTERNAL THORACIC VEIN

INTERCOSTAL VEIN
ANTERIOR INTERCOSTAL VEINS - internal thoracic vein - musculophrenic vein

INTERCOSTAL VEIN
POSTERIOR INTERCOSTAL VEINS 1st brachiocephalic v. or vertebral v. 2, 3, 4 superior intercostal v.

accessory azygos v. hemiazygos v.

Lt. brachiocephalic v.

Rt. arch of azygos v.

Accessory hemiazygos & hemiazygos veins

Azygos

VAN the intercostal neurovascular bundle runs between the internal intercostals and the innermost interior intercostals

THE PARIETAL LYMPHATICS OF THE CHEST

Anterior thoracic wall

Parasternal node
(internal thoracic a., intercostal spaces 3-4)

Junction of internal jugular and subclavian veins or Lymphatic duct (Rt.) and thoracic duct (Lt.)

Posterior & lateral thoracic wall Intercostal spaces 1-2

Intercostal node
(head of rib) Intercostal spaces 3-6 Intercostal spaces 7-11

Junction of Int. jugular & Subclavian vv.

Thoracic duct

Cisterna chyli or Thoracic duct

TRACHEA
Hyaline cartilage U shape 16-20 tracheal rings Cervical and thoracic parts Sternal angle or T4 Carina

 Anterior: sternum, brachiocephalic v., arch of aorta, brachiocephalic trunk, common carotid a. Posterior: esophagus, recurrent laryngeal n. Left: arch of aorta, common carotid a., subclavian a., vagus n., phrenic n., pleura Right: brachiocephalic trunk, azygos v., vagus n., pleura

CERVICAL PLEURA

COSTOMEDIASTINAL RECESSES

COSTODIAPHRAGMATIC RECESSES

NERVE SUPPLY OF THE PLEURA

INTERCOSTAL N.

COSTAL PLEURA

PHRENIC NERVE

MEDIASTINAL PLEURA

PHRENIC & INTERCOSTAL NERVE

DIAPHRAGMATIC PLEURA

PULMONARY PLEXUS

VISCERAL PLEURA

HORIZONTAL FISSURE
COSTAL CARTILAGE 4

PULMONARY LIGAMENTS

bronchial a. & v., pulmonary plexus, bronchopulmonary node

THORACIC ARTERY

3RD POSTERIOR INTERCOSTAL ARTERY

LEFT BRONCHIAL A.

RIGHT BRONCHIAL A.

BRONCHIAL VEIN

PULMONARY OR AZYGOS VEINS

Bronchopulmonary segment

Right lung upper lobe: apical anterior posterior middle lobe: lateral medial lower lobe: superior (apex) anterior basal medial basal lateral basal posterior basal

Left lung upper lobe: apical-posterior anterior superior inferior lower lobe: superior (apex) anterior basal medial basal lateral basal posterior basal

Pulmonary artery and vein

Superior pulmonary vein
Right: upper and middle lobes Left: upper lobe

Inferior pulmonary vein

Lower lobe

THE NERVE SUPPLY OF LUNGS

SYMPATHETIC TRUNK & PARASYMPATHETIC FIFER OF VAGUS NERVE

ANTERIOR AND POSTERIOR PULMONARY PLEXUS SYMPATHETIC: PARASYMPATHETIC:

THE LYMPHATIC DRAINAGE OF THE LUNGS

PLEURA & ALVEOLAR DUCT SUPERFICIAL LYMPHATIC PLEXUS

TRACHEOBRONCHIAL & PARASTERNAL NODE BRONCHOMEDIASTINAL TRUNK BRONCHOPULMONARY NODE

(ROOT OF LUNG)

JUNCTION OF INTERNAL JUGULAR & SUBCLAVIAN

THORACIC DUCT (LT.)

DEEP LYMPHATIC PLEXUS

(SUBMUCOSA & TISSUE OF BRONCHUS but not alveoli) (BRONCHIAL TREE & PULMONARY VESSEL)

PULMONARY NODE
(MAIN BRONCHUS)

Parietal pleura parasternal or intercostal lymph node

OBLIQUE FISSURE (3RD THORACIC SPINE)

HORIZONTAL FISSURE 4TH RIB

HORIZONTAL FISSURE

INFERIOR BORDER

Diaphragmatic pleura

Inferior border

Diaphragmatic pleura Scapular line