f.x.t.

hudyono

The thoracic wall

Skeleton of the thorax:

a.sternum
b.ribs/costa
c.articulations
d.breast /mammary gld
e.nerves and blood vessel
f.lymphatic drainage
g.thymus

Sternum
Is a flat bone and consist of the manubrium

sterni, corpus sterni and proc.xyphoideus.

Is shorter in female and thinner and its body
is more than twice as lond as the
manubriumin the male but ussually less in the
female.

Sternum
Manubrium sterni
Has a superior margin the Incisura Jugularis
Has a incisura clavicularis os each side for

articulation with the clavicle

Also articulates with costa 1 and corpus
sternalis at angulus sternalis./manubrium
sternal joint

Sternum
Angulus sternalis/Angulus Ludovici /Angle of Louis
Is the junction between manubrium and corpus

sternum
Is located at the level :
-the second ribs articulate with sternum
-the aortic arch begins and ends
-the trachea bifurcatio in the right and left bronchi at
the carina
The inferior border of the superior mediastinum
A transverse plane can pass through the
intervertebral disk between T4-T5

Sternum
Corpus sterni
Articulates with the second until seventh

costal cartilages
Articulates with procesus xyphoideus with is
at level with vertebra thoracalis number 9.

Sternum
Processus Xyphoideus
o Is a flat cartilaginous proses at birth that

ossifies slowly from central core qnd unites

with the body of the sternum after middle age
o Lies at the level vertebra thoracalis no 10
o Can be palpated in the epigastrium and is
attached via its pointed caudal end to the
linea alba

Sternum
Costa
- Consists 12 pairs of bone that form the main

of caum thorax extending from the vertebrae

to or toward the sternum.
- Inrease the anteroposterior and transverse
diameters of the thorax by movements

Sternum
- Structure:
Typical costa 3 through 9,of which has a caput,

collum,tuberculum and corpus/shaft

Caput articulates with the corresponding vertebral
bodies and intervertebral disk
Corpus /shaft is thin and flat and turns sharply anteriorly
at the angle/angulus costae and has a sulcus costae that
follow the inferior and lodges the intercostal vessel and
nerve
The tuberculum articulates with the processus
transversus of the corresponding vertebra with
exception costa no 11 and 12

Sternum
Classification of ribs
True ribs are the first seven ribs (costa vera)
False ribs are number 8-12
Costa 8-10 (costa spuriae)are connected to

the costal cartilages above and thus costa 710form the arcus costalis (costal arch/costal
margin)
Costa 11-12 is the floating ribs(costa
arquariae)

Sternum
Costa 1: is the broadest and shortest of the

true ribs.
Has a single articular facet on its head which
articulates with the first thoracic vertebrae.
has a scalenen tubercle for insertions
m.scalenus anterior. And two sulcus for the
subclavian artery and vein.

Sternum
Costa 2:has two facet for articulate with

vertebra thoracic no 2.Its twice long then the

first rib.
Costa 10:has a single facet for articulates with
the thoracic vertebra 10
Costa 11&12: has a single facet and have no
neck and tubercle.

Clinnical feature
Common site for bone marrow biopsy and

allow the surgeon to gain easy access to the

lungs,heart and great vessel.
Thoracic outlet syndrom is the compression of
neurovascular structures in the thoracic outlet
(space between rib 1 and clavicule) causing of
pain,tingling,weakness and fatique in the
upper limb.
Flail chest..

Articulations of the
thorax
Articulations of the thorax:
Sternoclavicular joint
Sternocostal joint
Costchondral joint
Manubriosternal joint
Xiphosternal joint
Costovertebral joint
Costotransversal joint
Interchondral joint

Breasts and Mammary

glands
Breasts.
Consist mammary gld tissue,fibrous and fatty

tissue,blood and lymph vessel and nerves.

Extend from the second to sixth rib from the
sternum to the mid axillary line and divided
into 4 quadrantupper,lower,medial and lateral.
Has mammary gld lie in the superficial fascia
Is supported by lig.suspensory of Cooper

Breasts and Mammary

Nipple ussualy lies at the level ICS 4 and
glands
midaxillary line and contains smooth muscle
for firmness and prominence.
Areola is a ring of pigmented skin around
the nipple.
Receives blood from a.mammria medialis
branches from a.thoracica interna,
a.mammaria lateralis branches fro,
a.thoracica lateralis,and ramus pectoralis
branches from a .thoracoacromialis and
a.intercostalis posterior.

Breasts and Mammary

glands
Innervated by n.intercostalis anterior and
lateral branches no 2 6.
May have more than one pair of breasts
(polymastia),more than one nipple (polythelia)
absence of breasts (amastia) and absence of
nipples (athelia)

Breasts and Mammary

glands
Mammary gld a is a modified sweat gld(gld

sudorifera) located at the fatty superficial

fascia.
Has the axillary tail a small part of mammary
gld that extends through the deep fascia lie
in the axilla.
Has 15-20 lobes of gld.tissue,each lobes
open by a duct.lactiferus onto the nipple and
each duct enlarges to form sinus
lactiferus,which serves as a reservoir for milk
during lactation.

Nerves and blood vessel of

the thoracic wall

A.Intercostal nerves
From the twelth nerve thoracalis the first
nerves spinalis thoracalis is nerve sub costalis
and the other will be nerves thoracalis spinalis
Runs between internal and intima layers of
muscle,with the vena and artery intercostalis.
Are logde in sulcus intercostalison the inferior
surface of the costa.
Give rise to posterior,lateral and anterior
branches

Nerves and blood vessel of

the thoracic wall

B.Artery thoracalis interna

Usually arise from the first part of a.subclavia
and descends directly behind the first six
cartilago costa,just lateral the sternum.
Gives rise to two artery intercostalis in each of
the 6 upper intercostal spaces and terminates
at the intercostal space 6 by dividing to artery
musculophrenic and epigastrica superior.

Nerves and blood vessel of

the thoracic wall
1) Arteria pericardiophrenica.

Supplies to pleura,pericardium and

diaphragma.
2) Art.intercostalis anterior .
supplies to m.intercostalis,m.serratus
anterior, m.pectoralis.
3) A.perforantes anterior
supplies m.intercostalis,m.pectoralis,
provide the a.mammaria medialis

Nerves and blood vessel of the thoracic

wall
4).a.musculophrenicafollow the arcus
costalis on the inner surface. Anastomose
with a.cyrcumflexa iliaca profundus.
supplies : pericardium, diaphragma,
musc.at the abdominal wall
5). A.epigastrica superior.
descends on the deep surface of the
m.rectus abdominis within the rectus
sheath and anastomose with a.epigastrica
inferior.
supplies : diaphragma, peritoneum and
m.abdominal wall

Nerves and blood vessel of

the thoracic wall

C. Vena thoracica interna

Is formed by v.epigastrica superior and
v.musculophrenica ascends on the medial
side of the artery receive the six anterior
intercostal and pericardiophrenica and ends in
the vena brachiocephalica.

Nerves and blood vessel of

the thoracic wall
D.Vena thoracoepigastrica
is a veinous connection between vena
thoracica lateralis with vena epigastrica
superficialis.

Lymphatic drainage
B.Lnn.intercostalis.
- Lie near caput costa
- Receives lymph from intercostal space and
pleura
- Drain to cysterna chyli and duct thoracicus.

Lymphatic drainage
A.Lnn.sternalis/parasternalis/thoracica interna
- are placed along the a.thoracica interna
- Received lymph from breast,intercostal space,
diaphragma,and regio supra umbilical of the
abdominal wall.
- Drain into the junction of the vena jugularis
interna and vena subclavia.

Lymphatic drainage
C.Lnn.phrenicus
- Lie on the thoracic surface of the diaphragma
- Receives lymph from pericardium,diaphragma
and pericard
- Drain to lnn.sternalis and lnn mediastinum
post

Thorax
Is divided :

1.trachea and bronchus

2.pleurae and pleural cavities
3.lungs
4.lymphatic vessel
5.blood vessel of the lung
6.nerve supply to the lung

Trachea and bronchus

A.Trachea.

Begins at the inferior borderof the cricoid

cartilage (C6) as a continuation of larynx

and ends by bifurcating into the right and
left main stem bronchial the level of
angulus sternalis. (disk between T4-T5).
Is approximately 12 cm at the length and
has 16-20 incomplete cartilago hyaline
rings that open towards the esophagus
and prevent trachea from collapsing

Trachea
May be compressed by an arcus Ao aneurysm, a

goiter, thyroid tumor, causing dyspnea.

Has the carina at the last of tracheal
cartilage,which lies at the level of angulus
sternalis and form a keel like ridge separating
the openings of the right and left main bronchus.
Carina may be distorted,widened post,and
immobile in the presence of bronchocarcinogenic.Its a most sensitive areas of the
bronchial treeand associated with the cough
reflex

Bronchi
B.Right main bronchi

Is shorter ,wider and more vertical than

the left main bronchus.

Runs under the arcus vena azygos and
divides into 3 lobar as secondary
(sup.med.inf) and finnaly into 10
segmental bronchi,the right superior
bronchus is eparterial (above the
artery)bronchus because it passabove
the pulmonary artery. All others are the
hyparterial bronchi

Bronchi
C.Left main bronchi.

Runs inferior lateral to the arcus Ao,

crosses anterior esophagus and Ao

thoracalis.
Divided into 2 lobus secondair sup and inf.
And finnaly into 8-10 segmental bronchi.
Crosse superiorly by the Arcus Aoand
distal part of the artery pulmonalis
Delates by sympathetic and constricti by
para sympathetic

Pleura and cavum pleura

A.Pleura
Is a thin serous membran that consist of a parietal

and visceral pleura.

1.Parietal pleura:
o Lines the inner surface of the thoracic wall and the
mediastinum and has a costal, diaphragmatica,
mediastinal and cervical parts The cervical is the
dome of pleura.It is reinforced by Sibsons
fascia(supra pleural membrane) which is
thickening the endothoracic fascia and attached at
the costa 1 and the proc.transversus cervical 7

Pleura
Is separated with the thoracic wall by the

endothoracic fascia which is an extrapleural

fascia sheet lining the thoracic wall.
Costal pleura and peripheal portion of the
diaphragma innervated by nerve intercostalis
Central portion of the diaphragmatic and
mediastinal pleura innervated by n.phrenicus
Parietal pleura is very sensitive to pain

Pleura
Pleura parietal is supplied blood from

a.intercostalis superior,a.thoracica interna,

a.phrenica superior, and a.intercostalis
posterior.
Forms a pulmonary ligament a two layered
vertical fold of mediastinal pleura which extends
along the mediastinal surface of each lung from
the hilus to the base and ends in a free falciform
border. It support the lungs in the pleural sac by
retaining the lower parts of the lung in position.

Pleura

2.Visceral pleura
Intimately invest the lungs and dips into all
the fissure.
Is supplied by a.bronchialis but its venous
blood is drained by pulmonary vein
Sensitive to pain,but is sensitive to stretch
and contains vasomotor fibers and sensory
endings from n.vagus which may involved in
respiratory reflex

Pleura
B.Pleural cavity
i. Is a potential space between parietal and
visceral pleura.
ii.Represents a clossure sac with no
communication between right and left.
iii.Contains a film of fluid that lubricates the
surface of pleurae and facilitate the
movement of the lungs.

Clinnicaly features
Pleurisy/pleuritis
Pneumothorax
Tension pneumothorax
Pleural effusion
Transudate and exudate
Thoracocentesis
Hydrothorax
Hemothorax
Chylothorax
Pyothorax

Lungs

Are the essentials organ of respiration and are

attached to the heart and trachea by their

roots and the pulmonary ligaments.
Contain no respiration tissues,which are
nourish by the a.bronchialis and drained by
v.bronchialis
Receive parasympathetic fibers that innervate
smooth muscle, glds of the brochial tree,
Have some sensory endings in the vagal nerve
which are stimulated by the strecthing of the
lung during inspiration and are concerned in
the reflex control of respiration

Lungs
A.Right lung
Has an apex that projects into the neck and
concave base sits on the diaphragma
Is larger and heavier than left lung but shorter
and wider.
Divided inti sup,med,and inf by fissura obliqua
and horizontalis. Obliqua ussualy begins at
costa 5 and ends at costa 6 Horizontal begins
at costa 6 and ends at costa 4
Has 3 lobus and 10 segmen

Lungs
B.Left lung
Is divided inti upper and lower lobus by an
fissura obliqua and 9-10 segmen.
Contains Lingula that correspondence to the
lobus medialis at right lung.
Contains cardian impression,incisura cardiaca,
sulcus for various structure.

Lungs
C.Bronchopulmonary segment.
Is the anatomic and surgical unit of the lungs
Consists segmental or tertiary or lobular
bronchus.Lung supplied by each segmental
bronchus and segmental artery and vein. The
pulmonary vein are said to be intersegmental.

Lungs
D.Conducting portion
I.Inspiration
occurs when the ribs and sternum/cavum
thorax are elevated by the following
muscle,the diaphragma, external, internal,
innermost intercostal muscle, seratus anterior
scalenus , sternocleidomastoideus,
pectoralismajor and minor,seratus posterior
muscle

Lungs
Involves the following process:
1.Contractions of the diaphragma, pulls the dome

inferiorly to the abdomen thereby increasing the

diameter of the vertical of the thorax.
2.Enlargement of the pleural cavity and the lungs.
Reduces
the intrapulmonary pressure (create a negative
pressure) thus allowing air to rush into the lung
passively because of atmospheric prressure.

Lungs
3.Forced inspiration.
involves of the contraction of the intercostal
muscle and elevation of the ribs (superolateral
movement) with the sternum moving
anteriorly like a bucket handle.

Lungs
B.Expiration
Involves the following muscles : anterior wall
muscles, internal intercostal,and seratus
posterior muscle.
Involves the following process:
1. Overall process
involves relaxation of the diaphragma and the
other muscles, decrease the thoracic volume
and increase the intra thoracic pressure The
abdominal pressure is decreased and the ribs
are depressed

Lungs
2.Elastic recoil of the lungs produce
subatmospheric pressure of the pleural
cavities. thus much of the air is expelled.
(Quiet expiration is a passive process caused
by elastic coil of the lungs,whereas quiet
inspiration results from the contraction of the
diaphragma)

Lungs
3.Forced expiration
Requires contraction of the anterior
abdominal muscle and internal intercostal
(costal part).

Lymphatic vessels
Drain the bronchial tree,pulmonary vessel

and the connective tissue septa.

Run along the bronchioles,bronchi toward
the hilus where they drain to the pulmonary
(intrapulmonary). And then
brochopulmonary nodes, which in drain to
the inferior and superior tracheoa bronchial
nodes to the thoracic
duct,,bronchomediastinal nodes and trunks
Are not presents in the walls of the
pulmonary alveoli

Blood vessel of the lung

A.Pulmonary trunk
Extends upward from the conus arteriosus
of the right ventricle of the heart and carries
poorly oxygenated blood to the lungs for
oxygenation.
Passes superiorly and posteriorly from the
front of the ascend Ao to its left side 5 cm
and bifurcates into the right and left
pulmonary artery within the concavity of the
Ao arch at the level of the sternal angle

Blood vessel of the lung

Has much lower the blood pressure than that

in the Ao and is contains within the fibrous

pericardium.
1.Left pulmonary artery
Carries deoxygenated blood to the left lung is
shorter and narrower than the right
pulmonary artery arch over the left pulmonary
bronchus
Is connected to the arch of the Ao by the
ligamentum arteriosum,the fibrous is remain
of the ductus arteriosus

Blood vessel of the lung

2.Right pulmonary artery
Runs horizontallytoward to the hilus lung
under the arch of the aorta behind the
ascending Ao and SVC and anterior to the
right bronchus.

Blood vessel of the lung

B.Pulmonary veins
Are intersegmental in drainage
Leave the lung as 5 pulmonary vein one
from each lobe of the lungs however the
sup and med veins ussualy join so that
only 4 veins enter the left atrium.
Carry oxygenated blood from the lung
and deoxygenated blood from the
visceral pleural and from a part of the
bronchioles to the left atrium of the heart

Blood vessel of the lung

C.Bronchial artery
Arise from thoracic Ao ;usually there is 1
artery for the right lung and 2 for the left lung
Supply oxygenated blood to the non
respiratory conducting tissues of the lungs
and the visceral pleura. Anastomose occur
between the cappilaries of the bronchial and
pulmonary systims

Blood vessel of the lung

D.Bronchial veins
Receive blood from the bronchi and empty
into the azygos vein on the right and into the
accesory hemiazygos vein or the superior
intercostal on the vein on the left.
May receives twigs (small vessel) from the
tracheobronchial lymph nodes.

Nerve supply to the lung

A.Pulmonary plexus
Receives aff and eff parasympathetic pre
ganglionic fibers from n.vagus and joined by
branches sympathetic postganglionic fibers
from truncus sympathicus and cardiac plexus
Is divided inti the anterior pulmonary plexus
which lies in the anterior root of the lung and
posterior pulmonary plexus which lies at the
posterior root of the lung.
Has branches that accompany the blood
vessels and bronchi into the lung

Nerve supply to the lung

B.Nerve phrenicus
Arises from the C3-C5 cervical nerves and lies in front of
the m.scalenus anterior
Enters the thorax by passing deep to the vena subclavia
and superficial to the a.subclavia
Runs to the root of the lung where as n.vagus runs
posterior to the root of the lung.
Is accompanied by the pericardiophrenic vessel and
descends between mediastinal and pericardium.
Innervates motoric for fibrous pericardium, mediastinal
and diaphragmatic pleura and sensoric for central
tendineae

Clinnical features
Pneumonia..
TB..
Pancoasts /superior pulmonary sulcus tumor
Pancoasts syndrome
Lower trunk brachio

plexopathy..
Horners syndrom ,ptosis,enophthalmus,
miosis, anhidrosis,vasodilatation..
Pulmonary edema

Clinnical features
Asbestosis
Mesothelioma..
Atelectasis
Collapsed of the lung
Small sell carcinoma..
Non small sel Ca
Pulmonary emboli.
Embolectomy
Hiccup