Chapter 2 The Thorax: Part IThe Thoracic Wall

A 20-year-old woman was the innocent victim of a street shoot-out involving drugs. On examination, the patient showed signs of severe hemorrhage and was in a state of shock. Her pulse was rapid and her blood pressure was dangerously low. T here was a small entrance wound about 1 cm across in the fourth left intercostal space about 3 cm from the lateral margin of the sternum. T here was no exit wound. T he left side of her chest was dull on percussion, and breath sounds were absent on that side of the chest. A chest tube was immediately introduced through the chest wall. Because of the massive amounts of blood pouring out of the tube, it was decided to enter the chest (thoracotomy). T he physician carefully counted the ribs to find the fourth intercostal space and cut the layers of tissue to enter the pleural space (cavity). She was particularly careful to avoid important anatomic structures. T he incision was made in the fourth left intercostal space along a line that extended from the lateral margin of the sternum to the anterior axillary line. T he following structures were incised: skin, subcutaneous tissue, pectoral muscles and serratus anterior muscle, external intercostal muscle and anterior intercostal membrane, internal intercostal muscle, innermost intercostal muscle, endothoracic fascia, and parietal pleura. T he internal thoracic artery, which descends just lateral to the sternum and the intercostal vessels and nerve, must be avoided as the knife cuts through the layers of tissue to enter the chest. T he cause of the hemorrhage was perforation of the left atrium of the heart by the bullet. A physician must have a knowledge of chest wall anatomy to make a reasoned diagnosis and institute treatment.

Cha pte r Obje c tive s

An understanding of the structure of the chest wall and the diaphragm is essential if one is to understand the normal movements of the chest wall in the process of aeration of the lungs. Contained within the protective thoracic cage are the important life-sustaining organs lungs, heart, and major blood vessels. In addition, the lower part of the cage overlaps the upper abdominal organs, such as the liver, stomach, and spleen, and offers them considerable protection. Although the chest wall is strong, blunt or penetrating wounds can injure the soft organs beneath it. T his is especially so in an era in which automobile accidents, stab wounds, and gunshot wounds are commonplace. Because of the clinical importance of the chest wall, examiners tend to focus on this area. Questions concerning the ribs and their movements; the diaphragm, its attachments, and its function; and the contents of an intercostal space have been asked many times.

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Basic Anatom y
T he thorax (or chest) is the region of the body between the neck and the abdomen. It is flattened in front and behind but rounded at the sides. T he framework of the walls of the thorax, which is referred to as the thoracic cage , is formed by the vertebral column behind, the ribs and intercostal spaces on either side, and the sternum and costal cartilages in front. Superiorly the thorax communicates with the neck, and inferiorly it is separated from the abdomen by the diaphragm. T he thoracic cage protects the lungs and heart and affords attachment for the muscles of the thorax, upper extremity, abdomen, and back. T he cavity of the thorax can be divided into a median partition, called the m e diastinum , and the laterally placed pleurae and lungs. T he lungs are covered by a thin membrane called the v isce ral ple ura, which passes from each lung at its root (i.e., where the main air passages and blood vessels enter) to the inner surface of the chest wall, where it is called the parie tal ple ura. In this manner, two membranous sacs called the ple ural cav itie s are formed, one on each side of the thorax, between the lungs and the thoracic walls.

Structure of the T horacic Wall

T he thoracic wall is covered on the outside by skin and by muscles attaching the shoulder girdle to the trunk. It is lined with parietal pleura. T he thoracic wall is formed posteriorly by the thoracic part of the vertebral column; anteriorly by the sternum and costal cartilages (Fig. 2-1); laterally by the ribs and intercostal spaces; superiorly by the suprapleural membrane; and inferiorly by the diaphragm, which separates the thoracic cavity from the abdominal cavity.

Sternum
T he sternum lies in the midline of the anterior chest wall. It is a flat bone that can be divided into three parts: manubrium sterni, body of the sternum, and xiphoid process. P.47 T he m anubrium is the upper part of the sternum. It articulates with the body of the sternum at the manubriosternal joint, and it also articulates with the clavicles and with the first costal cartilage and the upper part of the second costal cartilages on each side (Fig. 2-1). It lies opposite the third and fourth thoracic vertebrae. T he body of the ste rnum articulates above with the manubrium at the m anubrioste rnal joint and below with the xiphoid process at the x iphiste rnal joint. On each side it articulates with the second to the seventh costal cartilages (Fig. 2-1). T he x iphoid proce ss (Fig. 2-1) is a thin plate of cartilage that becomes ossified at its proximal end during adult life. No ribs or costal cartilages are attached to it. T he ste rnal angle (angle of Louis), formed by the articulation of the manubrium with the body of the sternum, can be recognized by the presence of a transverse ridge on the anterior aspect of the sternum (Fig. 2-2). T he transverse ridge lies at the level of the second costal cartilage, the point from which all costal cartilages and ribs are counted. T he sternal angle lies opposite the

intervertebral disc between the fourth and fifth thoracic vertebrae. T he x iphiste rnal joint lies opposite the body of the ninth thoracic vertebra (Fig. 2-2).

Figure 2-1 A. Anterior view of the sternum. B. Sternum, ribs, and costal cartilages forming the thoracic skeleton.

Clinical Notes Sternum and Marrow Biopsy

Since the ste rnum p o s se s s es re d he matop o ie tic marro w thro ugho ut lif e , it is a c ommo n s ite f o r ma r r ow biops y . Und e r a lo c al ane sthe tic , a wid e -b o re ne e d le is intro d uc e d into the marro w c avity throug h the ante rio r surf ac e o f the b o ne . T he s ternum may also b e s plit at op e ration to allo w the s urge o n to g ain e as y acc e s s to the he art, g re at ve s se ls , and thymus.

Ribs
T here are 12 pairs of ribs, all of which are attached posteriorly to the thoracic vertebrae (Figs. 2-1, 2-3, 2-4, and 2-5). T he ribs are divided into three categories: True ribs: T he upper seven pairs are attached anteriorly to the sternum by their costal cartilages. False ribs: T he 8th, 9th, and 10th pairs of ribs are attached anteriorly to each other and to the 7th rib by means of their costal cartilages and small synovial joints. Floating ribs: T he 11th and 12th pairs have no anterior attachment. P.48

Figure 2-2 Lateral view of the thorax showing the relationship of the surface markings to the vertebral levels.

Figure 2-3 Thoracic vertebra. A. Superior surface. B. Lateral surface.

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Figure 2-4 Fifth right rib as it articulates with the vertebral column posteriorly and the sternum anteriorly. Note that the rib head articulates with the vertebral body of its own number and that of the vertebra immediately above. Note also the presence of the costal groove along the inferior border of the rib.

Typical Rib
A typical rib is a long, twisted, flat bone having a rounded, smooth superior border and a sharp, thin inferior border (Figs. 2-4 and 2-5). T he inferior border overhangs and forms the costal groov e , which accommodates the intercostal vessels and nerve. T he anterior end of each rib is attached to the corresponding costal cartilage (Fig. 2-4).

Figure 2-5 Fifth right rib, as seen from the posterior aspect.

A rib has a he ad, ne ck, tube rcle , shaft, and angle (Figs. 2-4 and 2-5). T he he ad has two facets for articulation with the numerically corresponding vertebral body and that of the vertebra immediately above (Fig. 2-4). T he ne ck is a constricted portion situated between the head and the P.50 tubercle. T he tube rcle is a prominence on the outer surface of the rib at the junction of the neck with the shaft. It has a facet for articulation with the transverse process of the numerically corresponding vertebra (Fig. 2-4). T he shaft is thin and flattened and twisted on its long axis. Its inferior border has the costal groove. T he angle is where the shaft of the rib bends sharply forward.

Figure 2-6 Thoracic outlet showing the cervical dome of pleura on the left side of the body and its relationship to the inner border of the first rib. Note also the presence of brachial plexus and subclavian vessels. (Anatomists often refer to the thoracic outlet as the thoracic inlet.)

Atypical Rib
T he first rib is important clinically because of its close relationship to the lower nerves of the brachial plexus and the main vessels to the arm, namely, the subclavian artery and vein (Fig. 2-6). T his rib is small and flattened from above downward. T he scalenus anterior muscle is attached to its upper surface and inner border. Anterior to the scalenus anterior, the subclavian vein crosses the rib; posterior to the muscle attachment, the subclavian artery and the lower trunk of the brachial plexus cross the rib and lie in contact with the bone.

Clinical Notes Cerv ical Rib

A c e rvic al rib (i.e ., a rib aris ing f ro m the ante rio r tub e rc le o f the transve rs e p ro c e ss o f the s e venth ce rvical ve rte b ra) o c c urs in ab o ut 0 .5 % o f humans (Fig . 2 -7 ). I t may have a f re e ante rio r end , may be c o nne c te d to the f irs t rib b y a f ib rous b and , o r may articulate with the f irst rib . T he imp o rtanc e o f a c e rvic al rib is that it c an c ause p re s sure o n the lo we r trunk o f the brac hial p le xus in s o me p atie nts , p ro d ucing pain d o wn the me d ial s id e o f the f o re arm and hand and wasting o f the s mall mus c le s o f the hand . I t can als o e xe rt p re s sure o n the o ve rlying s ub clavian arte ry and inte rf e re with the c irculatio n o f the up p e r limb .

Rib Excision
R ib e xc is io n is c o mmo nly p erf orme d b y tho rac ic s urg eo ns wishing to g ain e ntrance to the tho rac ic c avity. A lo ngitud inal incis ion is mad e thro ugh the p e rio ste um o n the o ute r s urf ac e o f the rib and a s e g me nt o f the rib is re mo ve d. A s e c ond long itud inal inc isio n is the n made thro ug h the b e d o f the rib, whic h is the inne r co ve ring o f p erio s te um. Af te r the o p e ratio n, the rib re g e ne rate s f ro m the o s te o g ene tic laye r o f the p e rios te um.

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Costal Cartilages
Costal cartilages are bars of cartilage connecting the upper seven ribs to the lateral edge of the sternum and the 8th, 9th, and 10th ribs to the cartilage immediately above. T he cartilages of the 11th and 12th ribs end in the abdominal musculature (Fig. 2-1). T he costal cartilages contribute significantly to the elasticity and mobility of the thoracic walls. In old age, the costal cartilages tend to lose some of their flexibility as the result of superficial calcification.

Joints of the Chest Wall

Joints of th e Sternu m
T he m anubrioste rnal joint is a cartilaginous joint between the manubrium and the body of the sternum. A small amount of angular movement is possible during respiration. T he x iphiste rnal joint is a cartilaginous joint between the xiphoid process (cartilage) and the body of the sternum. T he xiphoid process usually fuses with the body of the sternum during middle age.

Joints of the Ribs

Joints of th e Heads of th e Ribs
T he first rib and the three lowest ribs have a single synovial joint with their corresponding vertebral body. For the second to the ninth ribs, the head articulates by means of a synovial joint with the corresponding vertebral body and that of the vertebra above it (Fig. 2-4). T here is a strong intraarticular ligam e nt that connects the head to the intervertebral disc.

Joints of th e Tu bercles of th e Ribs

T he tubercle of a rib articulates by means of a synovial joint with the transverse process of the

corresponding vertebra (Fig. 2-4). (T his joint is absent on the 11th and 12th ribs.)

Joints of th e Ribs and Costal Cartilages

T hese joints are cartilaginous joints. No movement is possible.

Figure 2-7 Thoracic outlet as seen from above. Note the presence of the cervical ribs ( black ) on both sides. On the right side of the thorax, the rib is almost complete and articulates anteriorly with the first rib. On the left side of the thorax, the rib is rudimentary but is continued forward as a fibrous band that is attached to the first costal cartilage. Note that the cervical rib may exert pressure on the lower trunk of the brachial plexus and may kink the subclavian artery.

Joints of th e Costal Cartilages w ith th e Sternu m

T he first costal cartilages articulate with the manubrium, by cartilaginous joints that permit no movement (Fig. 2-1). T he 2nd to the 7th costal cartilages articulate with the lateral border of the sternum by synovial joints. In addition, the 6th, 7th, 8th, 9th, and 10th costal cartilages articulate with one another along their borders by small synovial joints. T he cartilages of the 11th and 12th ribs are embedded in the abdominal musculature.

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Mov ements of the Ribs and Costal Cartilages

T he 1st ribs and their costal cartilages are fixed to the manubrium and are immobile. T he raising and lowering of the ribs during respiration are accompanied by movements in both the joints of the head and the tubercle, permitting the neck of each rib to rotate around its own axis.

Openin gs of the T h orax

T he chest cavity communicates with the root of the neck through an opening called the thoracic outle t. It is called an outlet because important vessels and nerves emerge from the thorax here to enter the neck and upper limbs. T he opening is bounded posteriorly by the first thoracic vertebra, laterally by the medial borders of the first ribs and their costal cartilages, and anteriorly by the superior border of the manubrium sterni. T he opening is obliquely placed facing upward and forward. T hrough this small opening pass the esophagus and trachea and many vessels and nerves. Because of the obliquity of the opening, the apices of the lung and pleurae project upward into the neck. T he thoracic cavity communicates with the abdomen through a large opening. T he opening is bounded posteriorly by the 12th thoracic vertebra, laterally by the curving costal margin, and anteriorly by the xiphisternal joint. T hrough this large opening, which is closed by the diaphragm, pass the esophagus and many large vessels and nerves, all of which pierce the diaphragm.

Clinical Notes The Thoracic Outlet Syndrome

The b rac hial p le xus o f ne rve s (C 5 , 6 , 7 , and 8 and T1 ) and the s ubc lavian arte ry and ve in are clo s e ly re late d to the up p e r surf ac e o f the f irs t rib and the clavic le as the y e nte r the up p er limb (s e e Fig . 2 -6 ). I t is he re that the ne rves o r b lo o d ve s s e ls may b e c o mp res s e d b e twe e n the b one s . Mo s t o f the s ymp to ms are c aus e d b y pre s s ure o n the lo we r trunk o f the p le xus p ro duc ing p ain d o wn the me d ial s id e o f the f o re arm and hand and wasting o f the s mall mus c le s o f the hand . Pre s sure o n the blo o d ve s s els may co mp ro mis e the c irculatio n o f the up p e r limb .

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Intercostal Spaces
T he spaces between the ribs contain three muscles of respiration: the external intercostal, the internal intercostal, and the innermost intercostal muscle. T he innermost intercostal muscle is lined internally by the e ndothoracic fascia, which is lined internally by the parietal pleura. T he intercostal nerves and blood vessels run between the intermediate and deepest layers of muscles (Fig. 2-8). T hey are arranged in the following order from above downward: intercostal vein, intercostal artery, and intercostal nerve (i.e., VAN).

Intercostal Muscles
T he e x te rnal inte rcostal m uscle forms the most superficial layer. Its fibers are directed downward and forward from the inferior border of the rib above to the superior P.53

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border of the rib below (Fig. 2-8). T he muscle extends forward to the costal cartilage where it is replaced by an aponeurosis, the ante rior (e x te rnal) inte rcostal m e m brane (Fig. 2-9).

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Figure 2-8 A. Section through an intercostal space. B. Structures penetrated by a needle when it passes from skin surface to pleural cavity. Depending on the site of penetration, the pectoral muscles will be pierced in addition to the serratus anterior muscle.

Figure 2-9 Cross section of the thorax showing distribution of a typical intercostal nerve and a posterior and an anterior intercostal artery.

T he inte rnal inte rcostal m uscle forms the intermediate layer. Its fibers are directed downward and backward from the subcostal groove of the rib above to the upper border of the rib below (Fig. 2-8). T he muscle extends backward from the sternum in front to the angles of the ribs behind, where the muscle is replaced by an aponeurosis, the poste rior (inte rnal) inte rcostal m e m brane (Fig. 2-9). T he inne rm ost inte rcostal m uscle forms the deepest layer and corresponds to the transversus abdominis muscle in the anterior abdominal wall. It is an incomplete muscle layer and crosses more than one intercostal space within the ribs. It is related internally to fascia (endothoracic fascia) and parietal pleura and externally to the intercostal nerves and vessels. T he innermost intercostal muscle can be divided into three portions (Fig. 2-9), which are more or less separate from one another.

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Action
When the intercostal muscles contract, they all tend to pull the ribs nearer to one another. If the 1st rib is fixed by the contraction of the muscles in the root of the neck, namely, the scaleni muscles, the intercostal muscles raise the 2nd to the 12th ribs toward the first rib, as in inspiration. If, conversely, the 12th rib is fixed by the quadratus lumborum muscle and the oblique muscles of the abdomen, the 1st to the 11th ribs will be lowered by the contraction of the intercostal muscles, as in expiration. In addition, the tone of the intercostal muscles during the different phases of respiration serves to strengthen the tissues of the intercostal spaces, thus preventing the sucking in or the blowing out of the tissues with changes in intrathoracic pressure. For further details concerning the action of these muscles, see mechanics of respiration on page 100.

Nerv e Supply
T he intercostal muscles are supplied by the corresponding intercostal nerves. T he intercostal nerves and blood vessels (the neurovascular bundle), as in the abdominal wall, run between the middle and innermost layers of muscles (Figs. 2-8 and 2-9). T hey are arranged in the following order from above downward: intercostal vein, intercostal artery, and intercostal nerve (i.e., VAN).

Intercostal Arteries and Veins

Each intercostal space contains a large single posterior intercostal artery and two small anterior intercostal arteries. T he poste rior inte rcostal arte rie s of the first two spaces are branches from the superior intercostal artery, a branch of the costocervical trunk of the subclavian artery. T he posterior intercostal arteries of the lower nine spaces are branches of the descending thoracic aorta (Figs. 2-9 and 2-10). T he ante rior inte rcostal arte rie s of the first six spaces are branches of the internal thoracic artery (Figs. 2-9 and 2-10), which arises from the first part of the subclavian artery. T he anterior intercostal arteries of the lower spaces are branches of the musculophrenic artery, one of the terminal branches of the internal thoracic artery. Each intercostal artery gives off branches to the muscles, skin, and parietal pleura. In the region of the breast in the female, the branches to the superficial structures are particularly large. T he corresponding poste rior inte rcostal v e ins drain backward into the azygos or hemiazygos veins (Figs. 2-10 and 2-11), and the ante rior inte rcostal v e ins drain forward into the internal thoracic and musculophrenic veins. P.54

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Figure 2-10 A. Internal view of the posterior end of two typical intercostal spaces; the posterior intercostal membrane has been removed for clarity. B. Anterior view of the chest showing the courses of the internal thoracic vessels. These vessels descend about one fingerbreadth from the lateral margin of the sternum.

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Figure 2-11 The common arrangement of the azygos vein, the superior hemiazygos (accessory hemiazygos) vein, and the inferior hemiazygos

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(hemiazygos) vein.

Intercostal Nerves
T he intercostal nerves are the anterior rami of the first 11 thoracic spinal nerves (Fig. 2-12). T he anterior ramus of the 12th thoracic nerve lies in the abdomen and runs forward in the abdominal wall as the subcostal ne rv e . Each intercostal nerve enters an intercostal space between the parietal pleura and the posterior intercostal membrane (Figs. 2-8 and 2-9). It then runs forward inferiorly to the intercostal vessels in the subcostal groove of the corresponding rib, between the innermost intercostal and internal intercostal muscle. T he first six nerves are distributed within their intercostal spaces. T he seventh to ninth intercostal nerves leave the anterior ends of their intercostal spaces by passing deep to the costal cartilages, to enter the anterior abdominal wall. T he 10th and 11th nerves, since the corresponding ribs are floating, pass directly into the abdominal wall.

Branches
See Figures 2-9 and 2-12. Ram i com m unicante s connect the intercostal nerve to a ganglion of the sympathetic trunk (see Fig. 1-26). T he gray ramus joins the nerve medial at the point at which the white ramus leaves it. T he collate ral branch runs forward inferiorly to the main nerve on the upper border of the rib below. T he late ral cutane ous branch reaches the skin on the side of the chest. It divides into an anterior and a posterior branch. T he ante rior cutane ous branch, which is the terminal portion of the main trunk, reaches the skin near the midline. It divides into a medial and a lateral branch. Muscular branche s run to the intercostal muscles. Ple ural se nsory branche s go to the parietal pleura. Pe ritone al se nsory branche s (7th to 11th intercostal nerves only) run to the parietal peritoneum.

Clinical Notes Skin Innerv ation of the Chest W all and Referred Pain
Ab o ve the le ve l o f the s te rnal ang le , the c utaneo us inne rvation o f the ante rio r c he s t wall is d e rive d f ro m the s upr a c la v icula r n er v e s (C 3 and 4). Be lo w this leve l, the ante rior and lateral c utaneo us branc he s o f the inte rc o stal ne rve s s upp ly o b liq ue b and s o f skin in re g ular s e que nce . The skin o n the p o ste rio r surf ac e o f the c he st wall is sup p lie d b y the

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p o s te rio r rami o f the s p inal ne rves . The arrange me nt o f the d e rmatome s is s ho wn in Fig ures 1 -2 3 and 1 -24 . An inte rc o stal ne rve no t o nly sup p lie s are as of s kin, b ut als o s up p lies the rib s , c o s tal c artilage s , inte rc o stal mus cle s , and parie tal p le ura lining the interco s tal s p ac e . Furthermo re , the 7 th to 1 1 th inte rc o s tal nerve s le ave the tho racic wall and e nte r the ante rio r abd o minal wall s o that the y, in ad d itio n, s up p ly d ermato me s o n the ante rior ab d ominal wall, mus c les o f the ante rio r abd o minal wall, and p arie tal p e ritone um. This latte r f ac t is of g re at clinic al impo rtance b e c aus e it me ans that dis e as e in the tho racic wall may b e re ve aled as p ain in a d e rmato me that e xte nds acro s s the c o stal marg in into the ante rio r ab d o minal wall. Fo r e xamp le , a p ulmo nary thro mb o e mb o lis m o r a pne umo nia with ple uris y involving the c o stal parie tal p leura co uld give ris e to ab d o minal p ain and te nde rne s s and rig id ity o f the ab d o minal mus culature . The ab d o minal p ain in the se instance s is c alle d r e fe r r e d pa in.

Herpes Zoster
He rp e s zo s ter, o r s hing le s , is a re lative ly c o mmo n co nd itio n cause d b y the re ac tivatio n o f the late nt varic e lla-zo s te r virus in a p atie nt who has p re vio us ly had c hic ke np o x. The le sio n is s ee n as an inf lammatio n and d eg e ne ratio n of the se ns o ry ne uro n in a cranial o r s p inal ne rve with the f o rmatio n o f ve sic les with inf lammatio n o f the skin. I n the tho rax the f irs t s ymp to m is a b and o f d e rmato mal p ain in the d is trib utio n o f the s e nso ry ne uro n in a tho rac ic s p inal ne rve , f o llo we d in a f e w d ays b y a s kin e rup tion. The c o nd itio n o c c urs mo st f re q ue ntly in patie nts o ld e r than 5 0 ye ars.

T he first inte rcostal ne rv e is joined to the brachial plexus by a large branch that is equivalent to the lateral cutaneous branch of typical intercostal nerves. T he remainder of the first intercostal nerve is small, and there is no anterior cutaneous branch. T he se cond inte rcostal ne rv e is joined to the medial cutaneous nerve of the arm by a branch called the inte rcostobrachial ne rv e , which is equivalent to the P.56 lateral cutaneous branch of other nerves. T he second intercostal nerve therefore supplies the skin of the armpit and the upper medial side of the arm. In coronary arte ry dise ase , pain is re fe rre d along this ne rv e to the m e dial side of the arm .

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Figure 2-12 The distribution of two intercostal nerves relative to the rib cage.

Clinical Notes Intercostal Nerv e Block Area of Anesthesia

The skin and the p arie tal p le ura c ove r the o uter and inne r s urf ace s o f eac h inte rco s tal s p ac e , re sp e c tive ly; the 7 th to 1 1 th inte rco s tal ne rve s sup p ly the s kin and the p arie tal p e ritone um c o ve ring the o ute r and inne r s urf ac e s of the ab d o minal wall, res p e c tive ly. The re f o re , an inte rco s tal ne rve b lo ck will als o ane s the tize the se are as . I n ad d itio n, the p e rio ste um o f the ad jac e nt rib s is ane s thetized .

Indications

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I nte rco s tal ne rve b lo ck is ind ic ate d f o r re pair o f lac e ratio ns o f the tho rac ic and ab d o minal walls , f o r re lie f o f p ain in rib f rac ture s , and to allo w p ain-f re e re s p irato ry mo ve me nts.

Procedure
To p ro d uc e analge s ia o f the ante rio r and late ral tho rac ic and ab d o minal walls , the inte rc o s tal nerve sho uld b e b lo c ked b e f o re the late ral c utane o us b ranch aris e s at the midaxillary line . The rib s may b e ide ntif ie d b y c o unting d o wn f ro m the 2 nd (o p p o site s te rnal ang le ) o r up f ro m the 12 th. The ne e dle is d ire cte d to ward the rib ne ar the lo wer b o rd e r (Fig . 2 -8 ), and the tip c o me s to re st ne ar the sub c o stal g ro o ve , whe re the lo c al anes the tic is inf iltrate d aro und the ne rve . Re me mbe r that the ord e r o f s truc tures lying in the ne uro vas cular b und le f ro m ab o ve d o wnward is inte rc o stal ve in, arte ry, and ne rve and that the se s truc ture s are situate d b e twe e n the p o s te rio r inte rc o s tal memb rane o f the inte rnal inte rco s tal mus c le and the p arie tal p le ura. Furthe rmo re , late rally the ne rve lie s b e twe e n the inte rnal inte rc o stal mus cle and the inne rmo s t inte rco s tal mus c le.

Anatomy of Complications
C omp lic atio ns inc lud e p ne umotho rax and he morrhag e . Pne umothor a x c an o c c ur if the ne e d le p o int mis s e s the sub c os tal g ro o ve and p e netrate s to o d e e ply thro ug h the parie tal p leura. He mor r ha ge is c aus e d b y the p unc ture o f the inte rco s tal b lo od ve ss e ls. This is a c o mmo n co mp lic atio n, so asp iratio n sho uld always b e p e rf o rme d b e f o re inje c ting the anes the tic . A small he mato ma may re s ult.

P.57 With the exceptions noted, the first six intercostal nerves therefore supply the skin and the parietal pleura covering the outer and inner surfaces of each intercostal space, respectively, and the intercostal muscles of each intercostal space and the levatores costarum and serratus posterior muscles. In addition, the 7th to the 11th intercostal nerves supply the skin and the parietal peritoneum covering the outer and inner surfaces of the abdominal wall, respectively, and the anterior abdominal muscles, which include the external oblique, internal oblique, transversus abdominis, and rectus abdominis muscles.

Suprapleural Membrane
Superiorly, the thorax opens into the root of the neck by a narrow aperture, the thoracic outle t (see page 51). T he outlet transmits structures that pass between the thorax and the neck (esophagus, trachea, blood vessels, etc.) and for the most part lie close to the midline. On either side of these structures the outlet is closed by a dense fascial layer called the supraple ural m e m brane (Fig. 2-13). T his tent-shaped fibrous sheet is attached laterally to the medial border of the first rib and costal cartilage. It is attached at its apex to the tip of the transverse process of the seventh cervical vertebra and medially to the fascia investing the structures passing from the thorax into the neck. It protects the underlying cervical pleura and resists the changes in intrathoracic pressure occurring during respiratory movements.

Endothoracic Fascia
T he endothoracic fascia is a thin layer of loose connective tissue that separates the parietal

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pleura from the thoracic wall. T he suprapleural membrane is a thickening of this fascia.

Diaphragm
T he diaphragm is a thin muscular and tendinous septum that separates the chest cavity above from the abdominal cavity below (Fig. 2-16). It is pierced by the structures that pass between the chest and the abdomen. T he diaphragm is the most important muscle of respiration. It is dome shaped and consists of a peripheral muscular part, which arises from the margins of the thoracic opening, and a centrally placed tendon (Fig. 2-16). T he origin of the diaphragm can be divided into three parts: A ste rnal part arising from the posterior surface of the xiphoid process (Fig. 2-2) A costal part arising from the deep surfaces of the lower six ribs and their costal cartilages (Fig. 2-16) A v e rte bral part arising by vertical columns or crura and from the arcuate ligaments T he right crus arises from the sides of the bodies of the first three lumbar vertebrae and the intervertebral discs; the le ft crus arises from the sides of the bodies of the first two lumbar vertebrae and the intervertebral disc (Fig. 2-16). Lateral to the crura the diaphragm arises from the m e dial and late ral arcuate ligam e nts (Fig. 2-16). T he medial arcuate ligament extends from the side of the body of the second lumbar vertebra to the tip of the transverse process of the first lumbar vertebra. T he lateral arcuate ligament extends from the tip of the transverse process of the first lumbar vertebra to the lower border of the 12th rib. T he medial borders of the two crura are connected by a m e dian arcuate ligam e nt, which crosses over the anterior surface of the aorta (Fig. 2-16).

22

Figure 2-13 Lateral view of the upper opening of the thoracic cage showing how the apex of the lung projects superiorly into the root of the neck. The apex of the lung is covered with visceral and parietal

23

layers of pleura and is protected by the suprapleural membrane, which is a thickening of the endothoracic fascia.

Clinical Notes Thoracic Cage Distortion

The shap e o f the tho rax c an b e d is to rte d b y co ng e nital ano malie s o f the verte b ral c o lumn o r b y the rib s . De s truc tive d is e ase o f the ve rteb ral co lumn that p ro d uc e s late ral f le xio n o r s c olio sis re sults in marked d isto rtio n o f the tho racic cag e .

Clinical Notes Traumatic Injury to the Thorax

Traumatic injury to the tho rax is c o mmo n, e sp e c ially as a re s ult o f auto mo b ile ac cid e nts .

Fractured Sternum
The ste rnum is a re s ilie nt s truc ture that is held in p o s itio n b y re lative ly p liab le c o s tal c artilage s and b e ndab le rib s . For the s e re as o ns , f rac ture of the ste rnum is no t c ommo n; ho we ve r, it d o e s o cc ur in hig h-s p ee d mo to r ve hic le ac cid e nts . Re me mb e r that the he art lies p o ste rio r to the ste rnum and may b e s eve re ly c ontuse d b y the ste rnum o n imp act.

Rib Contusion
Bruis ing o f a rib , s e c o nd ary to trauma, is the mo st c o mmo n rib injury. I n this p ainf ul c o nd ition, a small he mo rrhage o c c urs b e ne ath the p erio s te um.

Rib Fractures
Frac ture s o f the ribs are co mmon c he s t injurie s . I n c hild re n, the rib s are hig hly elas tic , and f rac ture s in this ag e g ro up are the re f ore rare . Unf ortunate ly, the pliable c he s t wall in the yo ung c an b e e as ily c omp re s se d s o that the und e rlying lungs and he art may b e injure d . W ith inc re asing ag e , the rib cag e be c o me s mo re rig id , o wing to the d ep o s it o f c alc ium in the co s tal c artilage s , and the rib s b e c o me b rittle . The rib s the n tend to bre ak at the ir we ake s t p art, the ir ang le s. The rib s p ro ne to f racture are tho se that are exp o se d o r re lative ly f ixed . Rib s 5 thro ugh 1 0 are the mo s t co mmo nly f rac ture d rib s. The f irs t f o ur rib s are p ro te cte d b y the clavic le and p e c to ral mus c le s ante rio rly and b y the sc ap ula and its ass o c iate d mus cle s p o s te rio rly. The 11 th and 1 2 th rib s f lo at and mo ve with the f o rc e of imp ac t. Be c aus e the rib is s and wic he d b e twe en the s kin e xte rnally and the d e lic ate p le ura inte rnally, it is no t surp rising that the jag g e d e nd s o f a f rac ture d rib may p e ne trate the lung s and p re se nt as a pne umo thor a x . Se ve re lo c alize d p ain is us ually the mo st imp ortant s ymp to m o f a f rac ture d rib. The p e rio ste um o f e ach rib is inne rvate d by the inte rc o s tal nerve s ab o ve and b e lo w the rib . To e nco urage the patie nt to b reathe ad e q uate ly, it may b e nec e s sary to re lieve the p ain b y p e rf o rming an inte rco s tal ne rve b loc k.

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Flail Chest
I n se ve re crus h injurie s, a numb e r of rib s may b re ak. I f limite d to o ne s id e , the f racture s may o c cur near the rib ang le s and ante rio rly ne ar the c o sto c hond ral junc tio ns . This c aus e s f lail c hes t, in which a se c tio n o f the c he s t wall is d is co nnec te d to the re st o f the tho rac ic wall. I f the f racture s o c c ur o n e ithe r sid e o f the s te rnum, the ste rnum may b e f lail. I n e ither c ase , the s tab ility o f the c hes t wall is lo s t, and the f lail se g me nt is s ucke d in d uring insp iratio n and d rive n out d uring e xp iratio n, p ro d ucing parad o xic al and inef f ec tive re s pirato ry mo ve me nts .

Traumatic Injury to the Back of the Chest

The p os te rior wall of the che s t in the midline is f orme d b y the ve rte b ral c olumn. I n se ve re p o s te rio r c he s t injurie s the p o ss ib ility o f a ve rte b ral f racture with as so c iate d injury to the s p inal c o rd s ho uld b e c ons ide re d . Re me mb e r also the p re s e nc e o f the s cap ula, whic h o verlie s the up p e r s e ve n rib s . This b one is c o ve re d with musc le s and is f rac ture d o nly in c ase s o f se ve re trauma.

Traumatic Injury to the Abdominal Viscera and the Chest

W he n the anato my o f the thorax is re vie we d , it is imp o rtant to re me mb e r that the up p e r ab d ominal o rg ans name ly, the live r, s tomac h, and s p le e nmay b e injure d b y trauma to the rib c ag e . I n f ac t, any injury to the che s t b e lo w the le ve l o f the nip p le line may invo lve ab d ominal o rg ans as we ll as che s t o rg ans.

P.58 T he diaphragm is inserted into a ce ntral te ndon, which is shaped like three leaves. T he superior surface of the tendon is partially fused with the inferior surface of the fibrous pericardium. Some of the muscle fibers of the right crus pass up to the left and surround the esophageal orifice in a slinglike loop. T hese fibers appear to act as a sphincter and possibly assist in the prevention of regurgitation of the stomach contents into the thoracic part of the esophagus (Fig. 2-16).

Shape of the Diaphragm

As seen from in front, the diaphragm curves up into right and le ft dom e s, or cupulae. T he right dome reaches as high as the upper border of the fifth rib, and the left dome may reach the lower border of the fifth rib. (T he right dome lies at a higher level, because of the large size of the right lobe of the liver.) T he central tendon lies at the level of the xiphisternal joint. T he domes support the right and left lungs, whereas the central tendon supports the heart. T he levels of the diaphragm vary with the phase of respiration, the posture, and the degree of distention of the abdominal viscera. T he diaphragm is lower when a person is sitting or standing; it is higher in the supine position and after a large meal. When seen from the side, the diaphragm has the appearance of an inverted J, the long limb extending up from the vertebral column and the short limb extending forward to the xiphoid process (Fig. 2-2).

Nerv e Supply of the Diaphragm

Motor ne rv e supply : T he right and left phrenic nerves (C3, 4, 5) Se nsory ne rv e supply : T he parietal pleura and peritoneum covering the central surfaces

25

of the diaphragm are from the phrenic nerve and the periphery of the diaphragm is from the lower six intercostal nerves. P.59

Figure 2-14 Tube thoracostomy. A. The site for insertion of the tube at the anterior axillary line. The skin incision is usually made over the intercostal space one below the space to be pierced. B. The various layers of tissue penetrated by the scalpel and later the tube as they pass through the chest wall to enter the pleural cavity (space). The incision through the intercostal space is kept close to the upper border of the rib

26

to avoid injuring the intercostal vessels and nerve. C. The tube advancing superiorly and posteriorly in the pleural space.

Action of the Diaphragm

On contraction, the diaphragm pulls down its central tendon and increases the vertical diameter of the thorax.

Functions of the Diaphragm

Muscle of inspiration: On contraction, the diaphragm pulls its central tendon down and increases the vertical diameter of the thorax. T he diaphragm is the most important muscle used in inspiration. Muscle of abdom inal straining: T he contraction of the diaphragm assists the contraction of the muscles of the anterior abdominal wall in raising the intra-abdominal pressure for micturition, defecation, and parturition. T his mechanism is further aided by the person taking a deep breath and closing the glottis of the larynx. T he diaphragm is unable to rise because of the air trapped in the respiratory tract. Now and again, air is allowed to escape, producing a grunting sound. We ight-lifting m uscle : In a person taking a deep breath and holding it (fixing the diaphragm), the diaphragm assists the muscles of the anterior abdominal wall in raising the intra-abdominal pressure to such an extent that it helps support the vertebral column and prevent flexion. T his greatly assists the postvertebral muscles in the lifting of heavy weights. Needless to say, it is important to have adequate sphincteric control of the bladder and anal canal under these circumstances. Thoracoabdom inal pum p: T he descent of the diaphragm decreases the intrathoracic pressure and at the same time increases the intra-abdominal pressure. T his pressure change compresses the blood in the inferior vena cava and forces it upward into the right atrium of the heart. Lymph P.60 within the abdominal lymph vessels is also compressed, and its passage upward within the thoracic duct is aided by the negative intrathoracic pressure. T he presence of valves within the thoracic duct prevents backflow.

Clinical Notes Needle Thoracostomy

A ne e d le thorac o s to my is ne c e s sary in p atie nts with te nsio n p ne umotho rax (air in the p le ural cavity und e r p res s ure ) o r to d rain f luid (b lo o d o r pus ) away f ro m the p le ural c avity to allo w the lung to re -e xp and . I t may als o b e ne ce s s ary to withd raw a s amp le o f ple ural f luid f o r mic ro b iolo g ic e xaminatio n.

27

Anterior Approach
Fo r the anterio r ap proac h, the patie nt is in the s up ine p o s itio n. The s te rnal ang le is id e ntif ie d, and the n the se c o nd c o s tal cartilag e , the s e co nd rib , and the se c o nd inte rc o s tal s pac e are f o und in the mid c lavic ular line .

Lateral Approach
Fo r the lateral app ro ac h, the p atient is lying on the late ral s id e . The s e c ond inte rc o stal s p ac e is id e ntif ie d as ab o ve, b ut the ante rio r axillary line is us e d. The skin is p re p are d in the us ual way, and a lo c al anes the tic is intro d uc ed along the c o urs e o f the ne e dle abo ve the up pe r b o rd e r o f the third rib. The tho rac o sto my ne e dle will p ie rc e the f o llo wing s tructure s as it p ass e s thro ug h the che s t wall (Fig . 2 -8 ): (a) s kin, (b ) s up e rf ic ial f as c ia (in the ante rio r ap p ro ach the p e c toral mus c le s are the n p e ne trate d ), (c ) s erratus ante rio r mus c le, (d ) e xte rnal interc o s tal mus c le , (e ) inte rnal inte rc o s tal musc le , (f ) inne rmo s t inte rco s tal mus c le, (g ) e nd otho racic f as c ia, and (h) p arie tal p le ura. The ne e d le s ho uld b e ke p t clo s e to the up p e r bo rd e r o f the third rib to avoid injuring the inte rc o s tal ve s s e ls and ne rve in the sub c os tal g ro o ve .

Tube Thoracostomy
The p ref e rre d ins e rtio n s ite f o r a tub e tho rac o sto my is the f o urth o r f if th inte rc o stal s p ac e at the ante rior axillary line (Fig. 2 -1 4 ). The tub e is intro d uc e d thro ug h a s mall incis io n. The ne urovasc ular b und le change s its re latio nship to the rib s as it p as se s f o rward in the inte rco s tal s p ac e . I n the mo s t p os te rio r p art o f the s p ac e , the b und le lie s in the mid d le o f the inte rco s tal s p ac e . As the b und le pas s es f o rward to the rib angle , it b e c ome s clo s e ly re late d to the lo we r b o rd e r o f the rib ab o ve and maintains that p o s itio n as it c ours e s f o rward . The intro d uc tio n o f a tho raco s to my tube o r ne ed le thro ug h the lo wer interco s tal s p ac e s is p o s sib le p ro vid e d that the p re s e nc e o f the d o me s o f the d iap hragm is re me mbe re d as the y c urve up ward into the rib c ag e as f ar as the f if th rib (hig he r o n the rig ht). Avo id d amag ing the diap hrag m and e nte ring the p erito neal cavity and injuring the live r, s ple e n, o r s tomac h.

Thoracotomy
I n p atie nts with p e ne trating c he st wo unds with unc ontro lle d intrathorac ic he morrhag e , tho rac o to my may b e a lif e -s aving p ro c e d ure . Af te r p re p aring the s kin in the usual way, the p hys ician make s an incis io n o ve r the f o urth o r f if th inte rco s tal s p ac e , e xte nd ing f ro m the late ral marg in o f the s te rnum to the ante rio r axillary line (Fig . 2 -1 5 ). W he the r to make a rig ht o r le f t inc is io n d e p e nd s o n the site of the injury. Fo r ac c e ss to the he art and ao rta, the c he st s ho uld b e e nte re d f ro m the le f t sid e . T he f o llo wing tis s ue s will b e inc is e d (Fig. 2 -1 4 ): (a) s kin, (b ) sub c utaneo us tis s ue , (c ) se rratus ante rio r and p e cto ral mus cle s , (d ) e xte rnal inte rco s tal mus c le and ante rio r inte rc o s tal memb rane , (e ) inte rnal inte rc o s tal musc le , (f ) inne rmo s t inte rco s tal mus c le, (g ) e nd otho racic f as c ia, and (h) p arie tal p le ura. Avo id the inter na l th or a c ic a r ter y , whic h runs ve rtic ally d ownward b e hind the c o stal c artilage s ab out a f ing e rb read th late ral to the marg in of the ste rnum, and the in ter c os ta l v e s s e ls and ne r ve , which e xte nd f o rward in the s ub c o s tal g roo ve in the up p e r part o f the inte rc o s tal s pac e (Fig . 2 -1 4 ).

Hiccup
Hic cup is the involuntary sp as mo d ic c o ntrac tion o f the d iap hrag m ac co mp anie d by the

28

ap p ro ximatio n o f the vo cal f o ld s and c lo s ure of the g lo ttis o f the larynx. I t is a c o mmo n c o nd ition in no rmal ind ivid uals and o c curs af te r e ating o r d rinking as a re s ult o f g astric irritatio n o f the vag us nerve e nd ings . I t may, ho we ve r, b e a symp to m o f d is e as e s uc h as p le uris y, p e rito nitis , p e ric ard itis , o r ure mia.

Paralysis of the Diaphragm

A s ing le d ome o f the d iap hrag m may b e paralyze d b y crus hing o r s e c tio ning o f the p hre nic ne rve in the ne ck. This may b e ne c es s ary in the treatme nt o f c ertain f o rms of lung tube rc ulos is , whe n the p hys ician wis hes to re st the lo we r lo be o f the lung o n one s ide . Occ asio nally, the c o ntrib ution f ro m the f if th c e rvic al s p inal ne rve jo ins the p hre nic ne rve late as a b ranc h f ro m the ne rve to the s ub clavius musc le . T his is kno wn as the a c c e s sor y phr e nic ner v e . To o b tain co mp le te p aralysis und e r the s e circ ums tanc e s , the ne rve to the s ub c lavius mus c le must also b e se c tione d .

Penetrating Injuries of the Diaphragm

Pe ne trating injurie s can res ult f ro m s tab o r b ulle t wound s to the c he st o r ab d o me n. Any p e netrating wo und to the c he st b e low the leve l o f the nip p le s s ho uld b e s us p e c te d o f c aus ing d amag e to the d iap hrag m until p ro ve d o the rwise . The arc hing d o me s o f the d iap hrag m c an re ac h the le vel o f the f if th rib (the rig ht d o me can re ac h a highe r leve l).

Openin gs in the Diaph ragm

T he diaphragm has three main openings: T he aortic ope ning lies anterior to the body of the 12th thoracic vertebra between the crura (Fig. 2-16). It transmits the aorta, the thoracic duct, and the azygos vein. T he e sophage al ope ning lies at the level of the 10th thoracic vertebra in a sling of muscle fibers derived from the right crus (Fig. 2-16). It transmits the esophagus, the right and left vagus nerves, the esophageal branches of the left gastric vessels, and the lymphatics from the lower third of the esophagus. T he cav al ope ning lies at the level of the eighth thoracic vertebra in the central tendon (Fig. 2-16). It transmits the inferior vena cava and terminal branches of the right phrenic nerve. In addition to these openings, the sympathetic splanchnic nerves pierce the crura; the sympathetic trunks pass posterior to the medial arcuate ligament on each side; and the superior epigastric vessels pass between the sternal and costal origins of the diaphragm on each side (Fig. 2-16). P.61

29

30

Figure 2-15 Left thoracotomy. A. Site of skin incision over fourth or fifth intercostal space. B. The exposed ribs and associated muscles. The line of incision through the intercostal space should be placed close to the upper border of the rib to avoid injuring the intercostal vessels and nerve. C. The pleural space opened and the left side of the mediastinum exposed. The left phrenic nerve descends over the pericardium beneath the mediastinal pleura. The collapsed left lung must be pushed out of the way to visualize the mediastinum.

P.62

Figure 2-16 Diaphragm as seen from below. The anterior portion of the right side has been removed. Note the sternal, costal, and vertebral origins of the muscle and the important structures that pass through it.

Embryologic Notes

31

Dev elopment of the Diaphragm

The d iap hrag m is f o rme d f ro m the f o llowing struc ture s : (a) the s e ptum tr a ns ve r s um, which f o rms the mus cle and c e ntral te nd o n; (b ) the two ple ur o per itone a l me mbr a ne s , which are larg e ly re s po ns ib le f o r the p e rip he ral are as o f the d iaphrag matic p le ura and p e ritone um that c o ve r its up p e r and lower s urf ace s , re sp e c tive ly; and (c ) the d o rsal me se nte ry o f the e s o p hag us, in whic h the crura d e ve lo p. The se p tum transve rsum is a mas s o f me so d e rm that is f o rme d in the ne ck b y the f us io n o f the myoto me s o f the third , f o urth, and f if th c ervical se g me nts . W ith the d e s c e nt o f the he art f ro m the ne ck to the tho rax, the se p tum is pus hed c aud ally, pulling its nerve s up p ly with it; thus , its mo to r ne rve s up p ly is de rived f ro m the third , f o urth, and f if th c e rvic al ne rve s , whic h are c o ntaine d within the p hre nic ne rve . The p le uro p erito ne al memb rane s g ro w med ially f rom the b o d y wall o n e ach s id e until the y f us e with the s e p tum trans ve rs um ante rio r to the e so p hagus and with the d ors al me se nte ry p o s terio r to the e s op hag us . During the p ro c e ss o f f usio n, the me s o d e rm o f the s e p tum trans ve rsum exte nd s into the o the r parts , f orming all the mus c le s o f the d iap hrag m. The mo to r nerve s up p ly to the e ntire mus c le o f the d iap hrag m is the p hre nic ne rve . The c e ntral p le ura o n the up p e r s urf ace o f the d iaphrag m and the p e rito ne um o n the lo wer s urf ac e are also f o rme d f rom the s e p tum trans vers um, whic h e xp lains their s e ns o ry inne rvatio n f rom the p hre nic nerve . The s e ns o ry innervatio n o f the p e rip he ral p arts o f the p le ura and p e rito ne um c o ve ring the p e rip he ral are as o f the up p er and lo we r s urf ac e s o f the d iap hrag m is f ro m the lo wer s ix tho rac ic ne rves . This is unde rs tand ab le, s inc e the p e rip he ral p le ura and p e rito ne um f rom the p le urop e rito ne al me mb rane s are d e rive d f ro m the b o d y wall.

Diaphragmatic Herniae
C onge nita l he r nia e o c cur as the res ult o f inc o mp le te f usio n o f the se p tum transve rsum, the d o rs al me s ente ry, and the p le uro p e rito ne al me mb ranes f ro m the b o d y wall. The he rniae o cc ur at the f o llo wing s ite s : (a) the ple uro p erito neal canal (mo re co mmon o n the le f t sid e ; c ause d b y f ailure o f f us io n o f the s e p tum trans versum with the p le uro p e rito ne al me mb rane ), (b ) the op e ning b e twe e n the xip ho id and c o stal o rig ins o f the d iap hrag m, and (c ) the e s o phag e al hiatus. Ac quir ed he r niae may o c cur in mid dle -ag ed p e o p le with we ak mus c ulature aro und the e s o phag e al o p e ning in the d iap hrag m. The se he rniae may b e e ithe r s lid ing o r p arae s o p hag e al (Fig . 2 -17 ).

P.63

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Figure 2-17 A. Sliding esophageal hernia. B. Paraesophageal hernia.

Internal Thoracic Artery

T he internal thoracic artery supplies the anterior wall of the body from the clavicle to the umbilicus. It is a branch of the first part of the subclavian artery in the neck. It descends vertically on the pleura behind the costal cartilages, a fingerbreadth lateral to the sternum, and ends in the sixth intercostal space by dividing into the superior epigastric and musculophrenic arteries (Figs. 2-9 and 2-10).

Branches
T wo ante rior inte rcostal arte rie s for the upper six intercostal spaces Pe rforating arte rie s, which accompany the terminal branches of the corresponding intercostal nerves T he pe ricardiacophre nic arte ry , which accompanies the phrenic nerve and supplies the pericardium Me diastinal arte rie s to the contents of the anterior mediastinum (e.g., the thymus) T he supe rior e pigastric arte ry , which enters the rectus sheath of the anterior abdominal wall and supplies the rectus muscle as far as the umbilicus T he m usculophre nic arte ry , which runs around the costal margin of the diaphragm and

33

supplies the lower intercostal spaces and the diaphragm

Internal Thoracic Vein

T he internal thoracic vein accompanies the internal thoracic artery and drains into the brachiocephalic vein on each side.

Levatores Costarum
T here are 12 pairs of muscles. Each levator costa is triangular in shape and arises by its apex from the tip of the transverse process and is inserted into the rib below. Action: Each raises the rib below and is therefore an inspiratory muscle. Ne rv e supply : Posterior rami of thoracic spinal nerves

Serratus Posterior Superior Muscle

T he serratus posterior superior is a thin, flat muscle that arises from the lower cervical and upper thoracic spines. Its fibers pass downward and laterally and are inserted into the upper ribs. Action: It elevates the ribs and is therefore an inspiratory muscle. Ne rv e supply : Intercostal nerves

Serratus Posterior Inferior Muscle

T he serratus posterior inferior is a thin, flat muscle that arises from the upper lumbar and lower thoracic spines. Its fibers pass upward and laterally and are inserted into the lower ribs. Action: It depresses the ribs and is therefore an expiratory muscle. Ne rv e supply : Intercostal nerves A summary of the muscles of the thorax, their nerve supply, and their actions is given in T able 2-1.

Radiographic Anatom y
T his is fully described on page 131.

Clinical Notes Internal Thoracic Artery in the Treatment of Coronary Artery Disease
I n p atie nts with o c c lus ive co ro nary d ise as e c ause d b y athero s c le ro s is, the d is e as e d arte rial se g me nt c an b e b yp as se d b y inse rting a g raf t. The graf t mo st c o mmo nly us e d is

34

the g re at sap he no us ve in o f the le g (se e p age 5 7 2 ). I n s o me p atie nts , the myo c ard ium c an b e re vas cularize d b y surg ically mo bilizing o ne of the inte rnal thorac ic arte rie s and jo ining its d is tal c ut e nd to a co ro nary arte ry.

Lymph Drainage of the Thoracic W all

The lymph dr a ina ge o f the s kin o f the ante rio r che s t wall pas s es to the ante rio r axillary lymp h no d e s ; that f ro m the p o s terio r c he s t wall p ass e s to the p o s te rio r axillary no d e s (Fig . 2-1 8 ). The lymp h d rainag e o f the inte rco s tal s p ac e s pas s es f o rward to the inte rnal tho rac ic no d e s, s ituate d alo ng the inte rnal tho rac ic arte ry, and p o ste rio rly to the p o ste rio r inte rc o s tal nod e s and the p ara-ao rtic no d e s in the p o ste rio r me d iastinum. The lymp hatic d rainag e of the b reas t is d e sc rib e d o n p ag e 4 2 7 .

P.64

Surface Anatom y

Anterior Chest Wall

T he supraste rnal notch is the superior margin of the manubrium sterni and is easily felt between the prominent medial ends of the clavicles in the midline (Figs. 2-19 and 2-20). It lies opposite the lower border of the body of the second thoracic vertebra (Fig. 2-2). T he ste rnal angle (angle of Louis) is the angle made between the manubrium and body of the sternum (Figs. 2-19 and 2-20). It lies opposite the intervertebral disc between the fourth and fifth thoracic vertebrae (Fig. 2-2). T he position of the sternal angle can easily be felt and is often seen as a transverse ridge. T he finger moved to the right or to the left will pass directly onto the second costal cartilage and then the second rib. All ribs may be counted from this point. Occasionally in a very muscular male, the ribs and intercostal spaces are often obscured by large pectoral muscles. In these cases, it may be easier to count up from the 12th rib.

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Figure 2-18 Lymph drainage of the skin of the thorax and abdomen. Note that levels of the umbilicus anteriorly and iliac crests posteriorly may be regarded as watersheds for lymph flow.

T he x iphiste rnal joint is the joint between the xiphoid process of the sternum and the body of the sternum (Fig. 2-21). It lies opposite the body of the ninth thoracic vertebra (Fig. 2-2). T he subcostal angle is situated at the inferior end of the sternum, between the sternal attachments of the seventh costal cartilages (Fig. 2-21). T he costal m argin is the lower boundary of the thorax and is formed by the cartilages of the 7th, 8th, 9th, and 10th ribs and the ends of the 11th and 12th cartilages (Figs. 2-19 and 2-20). T he lowest part of the costal margin is formed by the 10th rib and lies at the level of the third lumbar vertebra. P.65

Table 2-1 M uscles of the Thorax Name of M uscle

Origin

Insertion

Nerve Supply Action

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External intercostal muscle (11) (fibers pass downward and forward)

Inferior border of rib

Superior border of rib below

Intercostal nerves

With first rib fixed, they raise ribs during inspiration and thus increase anteroposterior and transverse diameters of thorax With last rib fixed by abdominal muscles, they lower ribs during expiration

Internal intercostal muscle (11) (fibers pass downward and backward) Innermost intercostal muscle (incomplete layer) Diaphragm (most important muscle of respiration)

Inferior border of rib

Superior border of rib below

Intercostal nerves

Adjacent ribs

Adjacent ribs

Intercostal nerves

Assists external and internal intercostal muscles Very important muscle of inspiration; increases vertical diameter of thorax by pulling central tendon downward; assists in raising lower ribs Also used in

Xiphoid process; lower six costal cartilages, first three lumbar vertebrae

Central tendon

Phrenic nerve

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abdominal straining and weight lifting Levatores costarum (12) Tip of transverse process of C7 and T111 vertebrae Lower cervical and upper thoracic spines Upper lumbar and lower thoracic spines Rib below Posterior rami of thoracic spinal nerves Raises ribs and therefore inspiratory muscles

Serratus posterior superior

Upper ribs

Intercostal nerves

Raises ribs and therefore inspiratory muscles

Serratus posterior inferior

Lower ribs

Intercostal nerves

Depresses ribs and therefore expiratory muscles

Clinical Notes Anatomic and Physiologic Changes in the Thorax with Aging
C ertain anato mic and p hys io lo g ic chang e s take plac e in the thorax with ad vanc ing ye ars: The r ib c a ge b e c o me s more rig id and lo s e s its e lastic ity as the re s ult o f c alc if ic atio n and e ve n o s sif icatio n o f the c o s tal cartilag e s ; this also alte rs their us ual rad io g rap hic ap p e arance . The sto o p e d p o s ture (k y phos is ), so o f te n s e e n in the o ld b e c aus e o f d e g e ne ration o f the inte rve rte bral d is c s, d e c re as e s the c he s t cap acity. D is us e a tr ophy o f the tho rac ic and ab d o minal musc le s c an re s ult in p o o r re s p irato ry mo ve me nts . D ege ne r ation of the e la s tic tis s ue in the lungs and b ro nchi re sults in imp airme nt o f the mo ve me nt o f e xpiratio n. The se c hang e s , whe n se ve re , d iminish the e f f ic ie nc y o f re s pirato ry mo ve me nts and impair the ab ility o f the ind ivid ual to withs tand re s p irato ry d is e as e .

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T he clav icle is subcutaneous throughout its entire length and can be easily palpated (Figs. 2-19 and 2-20). It articulates at its lateral extremity with the acromion process of the scapula.

Ribs
T he first rib lies deep to the clavicle and cannot be palpated. T he lateral surfaces of the remaining ribs can be felt by pressing the fingers upward into the axilla and drawing them downward over the lateral surface of the chest wall. T he 12th rib can be used to identify a particular rib by counting from below. However, in some individuals, the 12th rib is very short and difficult to feel. For this reason, an alternative method may be used to identify ribs by first palpating the sternal angle and the second costal cartilage.

Diaphragm
T he central tendon of the diaphragm lies directly behind the xiphisternal joint. In the midrespiratory position the summit of the right dome of the diaphragm arches upward as far as the upper border of the fifth rib in the midclavicular line, but the left dome only reaches as far as the lower border of the fifth rib. P.66

39

Figure 2-19 Anterior view of the thorax of a 27-year-old man.

Nipple
In the male, the nipple usually lies in the fourth intercostal space about 4 in. (10 cm) from the midline. In the female, its position is not constant.

Apex Beat of the Heart

T he apex of the heart is formed by the lower portion of the left ventricle. T he apex beat is caused by the apex of the heart being thrust forward against the thoracic wall as the heart contracts. (T he heart is thrust forward with each ventricular contraction because of the ejection of blood from the left ventricle into the aorta; the force of the blood in the aorta tends to cause the curved aorta to straighten slightly, thus pushing the heart forward.) T he apex beat can usually be felt by placing the flat of the hand on the chest wall over the heart. After the area of cardiac pulsation has been determined, the apex beat is accurately localized by placing two fingers over the intercostal spaces and moving them until the point of maximum pulsation is found. T he apex beat is normally found in the fifth left intercostal space 3.5 in. (9 cm) from the midline. Should you have difficulty in finding the apex beat, have the patient lean forward in the sitting position. In a female with pendulous breasts, the examining fingers should gently raise the left breast from below as the intercostal spaces are palpated.

Axillary Folds
T he ante rior fold is formed by the lower border of the pectoralis major muscle (Figs. 2-19 and 2-20). T his can be made to stand out by asking the patient to press a hand hard against the hip. T he poste rior fold is formed by the tendon of the latissimus dorsi muscle as it passes around the lower border of the teres major muscle.

Posterior Chest Wall

T he spinous proce sse s of the thoracic v e rte brae can be palpated in the midline posteriorly (Fig. 2-22). T he index finger should be placed on the skin in the midline on the posterior surface of the neck and drawn downward in the nuchal groove. T he first spinous process to be felt is that of the seventh cervical vertebrae (v e rte bra prom ine ns). Below this level are the overlapping spines of the thoracic vertebrae. T he spines of C1 to 6 vertebrae are covered by a large ligament, the ligamentum nuchae. It should be noted that the tip of a spinous process of a thoracic vertebra lies posterior to the body of the next vertebra below. T he scapula (shoulder blade) is flat and triangular in shape and is located on the upper part of the posterior surface of the thorax. T he supe rior angle lies opposite the spine of the second thoracic vertebra (Figs. 2-20 and 2-22). T he spine of the scapula is subcutaneous, and the root of the spine lies on a level with the spine of the third thoracic vertebra (Figs. 2-21 and 2-22). T he infe rior angle lies on a level with the spine of the seventh thoracic vertebra (Figs. 2-20 and 2-22). P.67

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41

42

Figure 2-20 A. Anterior view of the thorax and abdomen of a 29-year-old woman. B. Posterior view of the thorax of a 29-year-old woman.

Clinical Notes Clinical Examination of the Chest

As me dic al p e rs onne l, yo u will b e e xamining the c he s t to d e te ct e vid e nce o f d ise as e. Yo ur e xaminatio n co ns is ts of insp e c tion, p alp atio n, p erc us sio n, and aus cultatio n. Ins pe c tion sho ws the c o nf ig uratio n o f the che s t, the rang e of re s p irato ry mo ve me nt, and any ine q ualities o n the two sid e s . The typ e and rate o f re s p iratio n are als o no te d . Pa lpa tion e nab le s the physic ian to c o nf irm the imp re ss io ns g aine d by ins p e ctio n, e s p ec ially o f the res p irato ry mo ve me nts o f the che s t wall. A b no rmal p ro tube rance s o r re c e ss io n o f p art o f the che s t wall is no te d . Ab normal p ulsatio ns are f e lt and te nd e r are as d e te cte d . Pe r cu ss ion is a s harp tap p ing o f the che s t wall with the f ing ers . This p ro d uc e s vib rations that e xte nd thro ug h the tis sue s of the tho rax. Air-c o ntaining o rgans s uc h as the lung s p ro duc e a re s o nant no te ; co nve rs e ly, a mo re s olid vis cus suc h as the he art p ro d uce s a d ull no te. W ith prac tice , it is po s s ib le to d is ting uis h the lung s f rom the he art o r live r b y p e rcus s io n. Aus c ulta tion e nab le s the physic ian to lis te n to the b re ath so und s as the air e nte rs and le ave s the re sp iratory p ass ag es . Sho uld the alve o li o r b ro nc hi b e d ise as e d and f illed with f luid , the nature o f the b re ath s o und s will b e alte re d. The rate and rhythm o f the he art c an b e co nf irmed b y aus cultatio n, and the vario us s ound s p ro d uce d b y the he art and its valve s d uring the d if f e re nt p has e s of the card iac c yc le c an b e he ard . I t may b e p o s sib le to d e te c t f rictio n s o und s p ro duc e d b y the rub b ing tog e the r of d is e as e d layers o f p le ura o r p e ric ard ium. To make the s e examinatio ns, the p hysic ian mus t be f amiliar with the no rmal struc ture o f the tho rax and must have a me ntal imag e o f the no rmal p o s itio n of the lung s and he art in re latio n to id e ntif iab le surf ac e land marks . Furthe rmo re , it is e s se ntial that the p hys ician b e ab le to re late any ab normal f ind ing s to e as ily id e ntif iable b o ny land marks s o that he o r s he c an ac curate ly re co rd and c o mmunic ate the m to c o lle ag ue s . Since the tho racic wall actively particip ates in the mo ve me nts o f re s p iratio n, many b ony land marks change the ir le ve ls with e ach p has e of re s p iratio n. I n p rac tice , to simp lif y matte rs , the le ve ls g ive n are tho s e us ually f o und at ab o ut mid way b e twe e n f ull insp iratio n and f ull e xp iratio n.

P.68

Lines of Orientation
Several imaginary lines are sometimes used to describe surface locations on the anterior and posterior chest walls.

43

Midste rnal line : Lies in the median plane over the sternum (Fig. 2-21) Midclav icular line : Runs vertically downward from the midpoint of the clavicle (Fig. 2-21) Ante rior ax illary line : Runs vertically downward from the anterior axillary fold (Fig. 2-21) Poste rior ax illary line : Runs vertically downward from the posterior axillary fold Midax illary line : Runs vertically downward from a point situated midway between the anterior and posterior axillary folds Scapular line : Runs vertically downward on the posterior wall of the thorax (Fig. 2-22), passing through the inferior angle of the scapula (arms at the sides)

Clinical Notes Rib and Costal Cartilage Identification

W he n one is e xamining the c he s t f ro m in f ront, the s te r na l a ngle is an impo rtant land mark. I ts p o s itio n can eas ily b e f e lt and o f te n b e se e n b y the p re s e nce o f a trans ve rse rid g e. The f ing e r move d to the rig ht o r to the le f t p as s e s d ire ctly o nto the s e co nd co s tal c artilag e and the n the s ec o nd rib . All o the r rib s c an b e c o unte d f ro m this p o int. The 1 2 th rib c an us ually b e f e lt f ro m b e hind , b ut in s o me ob e s e pe rs o ns this may p ro ve d if f icult.

T rachea
T he trachea extends from the lower border of the cricoid cartilage (opposite the body of the sixth cervical vertebra) in the neck to the level of the sternal angle in the thorax (Fig. 2-23). It commences in the midline and ends just to the right of the midline by dividing into the right and left principal bronchi. At the root of the neck it may be palpated in the midline in the suprasternal notch.

Lungs
T he ape x of the lung projects into the neck. It can be mapped out on the anterior surface of the body by drawing a curved line, convex upward, from the sternoclavicular joint to a point 1 in. (2.5 cm) above the junction of the medial and intermediate thirds of the clavicle (Fig. 2-23). T he ante rior borde r of the right lung begins behind the sternoclavicular joint and runs downward, almost reaching the midline behind the sternal angle. It then continues downward until it reaches the xiphisternal joint (Fig. 2-23). T he ante rior borde r of the le ft lung has a similar course, but at the level of the fourth costal cartilage it deviates laterally and extends for a variable distance beyond the lateral margin of the sternum to form the cardiac notch (Fig. 2-23). T his notch is produced by the heart displacing the lung to the left. T he anterior border then turns sharply downward to the level of the xiphisternal joint. T he low e r borde r of the lung in midinspiration follows a curving line, which crosses the 6th rib in the midclavicular line and the 8th rib in the midaxillary line, and reaches the 10th rib adjacent to the vertebral column posteriorly (Figs. 2-23, 2-24, and 2-25). It is important to understand that

44

the level of the inferior border of the lung changes during inspiration and expiration. T he poste rior borde r of the lung extends downward from the spinous process of the 7th cervical vertebra to the level of the 10th thoracic vertebra and lies about 1.5 in. (4 cm) from the midline (Fig. 2-24). T he oblique fissure of the lung can be indicated on the surface by a line drawn from the root of the spine of the scapula obliquely downward, laterally and anteriorly, following the course of the sixth rib to the sixth costochondral junction. In the left lung the upper lobe lies above and anterior to this line; the lower lobe lies below and posterior to it (Figs. 2-23 and 2-24). In the right lung is an additional fissure, the horizontal fissure , which may be represented by a line drawn P.69 horizontally along the fourth costal cartilage to meet the oblique fissure in the midaxillary line (Figs. 2-23 and 2-25). Above the horizontal fissure lies the upper lobe and below it lies the middle lobe; below and posterior to the oblique fissure lies the lower lobe.

45

46

Figure 2-21 Surface landmarks of anterior (A) and posterior (B) thoracic walls.

P.70

Figure 2-22 Surface landmarks of the posterior thoracic wall.

47

Figure 2-23 Surface markings of lungs and parietal pleura on the anterior thoracic wall.

P.71

48

Figure 2-24 Surface markings of the lungs and parietal pleura on the posterior thoracic wall.

49

Figure 2-25 Surface markings of the lungs and parietal pleura on the lateral thoracic walls.

P.72

Pleura
T he boundaries of the pleural sac can be marked out as lines on the surface of the body. T he lines, which indicate the limits of the parietal pleura where it lies close to the body surface, are referred to as the line s of ple ural re fle ction. T he ce rv ical ple ura bulges upward into the neck and has a surface marking identical to that of the apex of the lung. A curved line may be drawn, convex upward, from the sternoclavicular joint to a point 1 in. (2.5 cm) above the junction of the medial and intermediate thirds of the clavicle (Fig. 2-23). T he ante rior borde r of the right ple ura runs down behind the sternoclavicular joint, almost reaching the midline behind the sternal angle. It then continues downward until it reaches the xiphisternal joint. T he ante rior borde r of the le ft ple ura has a similar course, but at the level of the fourth costal cartilage it deviates laterally and extends to the lateral margin of the sternum to form the cardiac notch. (Note that the pleural cardiac notch is not as large as the cardiac notch of the lung.) It then turns sharply downward to the xiphisternal joint (Fig. 2-23). T he low e r borde r of the ple ura on both sides follows a curved line, which crosses the 8th rib in

50

the midclavicular line and the 10th rib in the midaxillary line, and reaches the 12th rib adjacent to the vertebral columnthat is, at the lateral border of the erector spinae muscle (Figs. 2-23, 2-24, and 2-25). Note that the lower margins of the lungs cross the 6th, 8th, and 10th ribs at the midclavicular lines, the midaxillary lines, and the sides of the vertebral column, respectively; the lower margins of the pleura cross, at the same points, the 8th, 10th, and 12th ribs, respectively. T he distance between the two borders corresponds to the costodiaphragm atic re ce ss. (See page 84.)

Clinical Notes Pleural Reflections

I t is hard ly ne c e s sary to e mp has ize the imp o rtanc e o f kno wing the surf ace marking s o f the p le ural re f le ctio ns and the lo b e s o f the lung s. W he n liste ning to the b re ath s o und s o f the res p irato ry trac t, it s ho uld be p o s sib le to have a me ntal imag e o f the struc ture s that lie b e ne ath the s te tho s co p e . The c er v ica l dome of the ple ur a and the a pe x of the lungs e xte nd up into the ne c k s o that at the ir hig he st p o int they lie ab out 1 in. (2 .5 c m) ab o ve the c lavic le (Fig s . 2 -6 , 2 -1 3 , and 2 -2 3 ). Co nse q ue ntly, the y are vulne rab le to s tab wo unds in the ro ot o f the ne c k o r to d amag e b y an ane sthe tis t' s ne e d le whe n a ne rve b loc k of the lo we r trunk o f the b rachial p le xus is b eing p erf o rme d . R eme mb er also that the lo we r limit of the ple ur al r efle c tion, as s e e n f ro m the b ack, may b e damage d d uring a ne p hre cto my. The ple ura c ro s se s the 1 2 th rib and may b e d amag e d d uring re mo val o f the kid ne y thro ug h an inc is io n in the lo in.

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Figure 2-26 Surface markings of the heart.

Heart
For practical purposes, the heart may be considered to have both an apex and four borders. T he ape x , formed by the left ventricle, corresponds to the apex beat and is found in the fifth left intercostal space 3.5 in. (9 cm) from the midline (Fig. 2-26). T he supe rior borde r, formed by the roots of the great blood vessels, extends from a point on the second left costal cartilage (remember sternal angle) 0.5 in. (1.3 cm) from the edge of the sternum to a point on the third right costal cartilage 0.5 in. (1.3 cm) from the edge of the sternum (Fig. 2-26). T he right borde r, formed by the right atrium, extends from a point on the third right costal cartilage 0.5 in. (1.3 cm) from the edge of the sternum downward to a point on the sixth right costal cartilage 0.5 in. (1.3 cm) from the edge of the sternum (Fig. 2-26). T he le ft borde r, formed by the left ventricle, extends from a point on the second left costal cartilage 0.5 in. (1.3 cm) from the edge of the sternum to the apex beat of the heart (Fig. 2-26). T he infe rior borde r, formed by the right ventricle and the apical part of the left ventricle, extends from the sixth P.73 right costal cartilage 0.5 in. (1.3 cm) from the sternum to the apex beat (Fig. 2-26).

Clinical Notes Position and Enlargement of the Heart

The surf ac e marking s o f the he art and the p o sitio n o f the ap e x b e at may e nab le a p hys ician to d e te rmine whe the r the he art has s hif te d its p o sition in re latio n to the che s t wall o r whe ther the he art is e nlarg e d by d is e ase . T he ap e x b e at can o f te n b e se e n and almo s t always c an b e f e lt. The p o s itio n o f the marg ins o f the he art c an b e d e termined b y p e rc us s io n.

T horacic Blood Vessels

T he arch of the aorta and the roots of the brachioce phalic and le ft com m on carotid arte rie s lie behind the manubrium sterni (Fig. 2-2). T he supe rior v e na cav a and the terminal parts of the right and le ft brachioce phalic v e ins also lie behind the manubrium sterni. T he inte rnal thoracic v e sse ls run vertically downward, posterior to the costal cartilages, 0.5 in. (1.3 cm) lateral to the edge of the sternum (Figs. 2-9 and 2-10), as far as the sixth intercostal space.

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T he intercostal vessels and nerve ( vein, artery, nerve VANis the order from above downward) are situated immediately below their corresponding ribs (Fig. 2-8).

Mam m ary Gland

T he mammary gland lies in the superficial fascia covering the anterior chest wall (Fig. 2-20). In the child and in men, it is rudimentary. In the female after puberty, it enlarges and assumes its hemispherical shape. In the young adult female, it overlies the second to the sixth ribs and their costal cartilages and extends from the lateral margin of the sternum to the midaxillary line. Its upper lateral edge extends around the lower border of the pectoralis major and enters the axilla. In middle-aged multiparous women, the breasts may be large and pendulous. In older women past menopause, the adipose tissue of the breast may become reduced in amount and the hemispherical shape lost; the breasts then become smaller, and the overlying skin is wrinkled. T he structure of the mammary gland is described fully on page 427.

Clinical Problem Solv ing

Study the following c a s e histor ie s a nd s e le c t the be s t a ns we r to the que s tions following the m. On p e rc us s ing the ante rio r c hes t wall o f a p atient, yo u f ind the rig ht marg in o f the he art to lie 2 in. (5 c m) to the rig ht o f the ed g e o f the s ternum. 1 . W hic h chambe r o f the he art is like ly to b e e nlarg e d ? (a) The le f t ve ntricle (b ) The le f t atrium (c ) The rig ht ve ntric le (d ) The rig ht atrium Vie w Ans we r A 3 1 -year-o ld so ld ie r re c e ive d a s hrap ne l wound in the ne c k d uring the Pe rs ian Gulf W ar. R ec e ntly, during a p hys ic al e xaminatio n, it was no tic e d that whe n he b le w his no s e o r s nee ze d , the skin ab o ve the rig ht c lavicle b ulg e d up ward . 2 . The up ward bulg ing o f the s kin co uld b e e xp laine d b y (a) injury to the c e rvic al p le ura. (b ) d amag e to the sup rap le ural me mbrane . (c ) d amag e to the de e p f asc ia in the ro o t of the ne c k. (d ) ununited f rac ture o f the f irs t rib . Vie w Ans we r A 5 2 -year-o ld wo man was ad mitte d to the ho s p ital with a d iag no s is o f rig ht-s id ed p le uris y with pne umo nia. I t was d e c ide d to re mo ve a s amp le of p le ural f luid f ro m he r p le ural c avity. The res id e nt ins e rte d the nee d le clo s e to the lo we r b o rd e r o f the eig hth rib in the ante rio r axillary line. The ne xt mo rning he was s urp ris e d to he ar that the patie nt had c o mp laine d o f alte re d s kin s e ns atio n e xte nding f ro m the p o int whe re the ne e d le was inse rte d d ownward and f o rward to the mid line o f the ab d ominal wall ab o ve the umbilicus .

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3 . The altere d s kin se ns atio n in this patie nt af te r the nee d le tho rac os to my c o uld b e e xplaine d b y whic h o f the f o llowing ? (a) The ne e d le was ins e rte d to o lo w d o wn in the inte rc os tal s p ace . (b ) The ne e d le was ins e rte d to o c lo s e to the lo we r b o rd e r o f the e ig hth rib and d amag e d the e ig hth inte rc o stal ne rve. (c ) The ne e d le had imp ale d the e ig hth rib . (d ) The ne e d le had pe ne trate d to o de e p ly and p ie rc ed the lung. Vie w Ans we r A 6 8 -year-o ld man co mp lained o f a swe lling in the skin o n the b ac k of the che s t. He had no tic e d it f o r the last 3 ye ars and was c o nce rne d be c aus e it was rapid ly e nlarg ing. On e xaminatio n, a hard lump was f o und in the s kin in the rig ht s c ap ula line o p p o site the s e ve nth tho racic ve rte b ra. A b io p sy re ve ale d that the lump was malignant. 4 . Be c aus e o f the rap id inc re as e in s ize o f the tumo r, which o f the f o llo wing lymph no de s we re e xamine d f o r me tas tas e s? (a) Sup e rf ic ial inguinal nod e s (b ) Ante rior axillary nod e s (c ) Po s terio r axillary no d e s (d ) Exte rnal iliac no d es (e ) De e p c e rvic al nod e s Vie w Ans we r A 6 5 -year-o ld man and a 1 0 -ye ar-o ld b oy we re invo lve d in a s e ve re auto mo b ile acc id ent. I n b o th p atie nts the tho rax had b e e n bad ly c rushe d . R adio g rap hic examinatio n reve ale d that the man had f ive f racture d rib s b ut the b o y had no f rac ture s . 5 . W hat is the mo s t like ly e xp lanatio n f o r this d if f e re nc e in me d ical f ind ing s ? (a) The p atients we re in d if f e re nt se ats in the ve hic le . (b ) The bo y was we aring his s e at b e lt and the man was no t. (c ) The c he st wall o f a child is ve ry elas tic , and f racture s o f rib s in child re n are rare . (d ) The man anticip ate d the imp ac t and te nse d his mus c le s , inc lud ing tho se o f the s ho uld e r g ird le and ab d o me n. Vie w Ans we r On e xaminatio n o f a p os te ro ante rio r c he st rad iog rap h of an 18 -ye ar-old wo man, it was s e e n that the le f t d o me o f the d iaphrag m was hig he r than the right d o me and re ac he d to the up p e r b orde r o f the f o urth rib . 6 . The p o s itio n o f the le f t d o me o f the d iaphrag m c o uld b e e xp laine d by o ne o f the f o llo wing co nd itio ns e xce p t which? (a) The le f t lung co uld b e c o llap se d . (b ) The re is a c o lle c tion o f b lo o d und e r the d iaphrag m o n the le f t sid e .

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(c ) The re is an ame b ic ab s ce s s in the le f t lo b e o f the live r. (d ) The le f t d o me o f the d iaphrag m is no rmally hig her than the rig ht d ome . (e ) The re is a p e rito ne al ab s c es s b ene ath the diap hrag m on the le f t sid e . Vie w Ans we r A 4 3 -year-o ld man was invo lve d in a vio le nt q uarre l with his wif e o ve r ano the r wo man. I n a f it o f rag e , the wif e p ic ked up a c arving knif e and lung e d f o rward at he r hus b and , striking his ante rio r nec k ove r the le f t c lavic le . The hus band co llap s e d o n the kitc he n f lo o r, b le ed ing pro f us e ly f ro m the wo und . The d is traug ht wif e c alle d an amb ulanc e. 7 . On e xaminatio n in the eme rg e nc y de p artment o f the ho sp ital, the f o llowing c ond itio ns we re f o und e xce p t whic h? (a) A wo und was se e n abo ut 1 in. (2 .5 c m) wid e o ve r the le f t c lavic le . (b ) Aus cultatio n reve ale d d iminis he d b re ath s o und s o ve r the le f t he mitho rax. (c ) The trac he a was d e f le c te d to the le f t. (d ) The le f t up pe r limb was lying s tatio nary o n the tab le, and ac tive mo ve me nt o f the small mus c les o f the le f t hand was abs e nt. (e ) The patie nt was ins e ns itive to p in p ric k along the lateral sid e o f the lef t arm, f o re arm, and hand. Vie w Ans we r A 7 2 -year-o ld man co mp laining o f burning p ain o n the rig ht sid e o f his che s t was s ee n b y his p hys ician. On e xaminatio n the p atie nt ind ic ated that the pain p as se d f o rward o ve r the rig ht s ixth inte rc os tal s p ace f ro m the p o ste rio r axillary line f o rward as f ar as the mid line o ver the ste rnum. The physic ian note d that there we re s e ve ral wate ry ble b s o n the s kin in the p ainf ul area. 8 . The f o llowing s tate ments are c o rre ct e xce p t whic h? (a) This p atie nt has he rp e s zo s te r. (b ) A virus d e sc e nds alo ng the c utane o us nerve s , c aus ing d e rmato mal p ain and the e rup tio n o f ve s ic le s. (c ) The s ixth right inte rc o stal ne rve was invo lve d . (d ) The co nd itio n was c o nf ine d to the ante rio r c utane o us b ranc h o f the sixth interc o s tal ne rve . Vie w Ans we r An 1 8 -ye ar-o ld wo man was thro wn f ro m a ho rs e while atte mp ting to jump a f enc e . S he land e d he avily o n the g ro und , s triking the lo we r p art o f he r che s t o n the le f t sid e . On e xaminatio n in the e me rg e ncy d e partme nt s he was c ons c io us b ut b re athles s . The lo we r le f t sid e of he r c he s t was b ad ly b ruis e d, and the 9 th and 1 0 th rib s we re extre me ly te nd e r to to uc h. S he had s e ve re tachycard ia, and he r sys tolic b lo o d pre s s ure was lo w. 9 . The f o llowing s tate ments are p o s sib ly c o rre ct e xc e p t whic h? (a) The re was e vid e nc e o f tend e rne ss and mus c le s p asm in the le f t upp e r q uad rant o f the ante rio r ab d ominal wall. (b ) A p o s tero anterio r rad io g rap h o f the c he st re ve ale d f rac ture s o f the le f t 9 th and

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1 0 th rib s ne ar the ir ang le s . (c ) The b lunt trauma to the ribs had re s ulte d in a te ar o f the und e rlying sp le e n. (d ) The pres e nce o f b loo d in the p erito neal cavity had irritate d the p arie tal p e rito ne um, p ro d ucing ref le x s p asm o f the up p e r ab d o minal musc le s. (e ) The mus cle s of the ante rio r ab d o minal wall are not s up plie d b y tho rac ic s p inal ne rve s . Vie w Ans we r

Rev iew Questions

M ultiple -Choic e Que s tions Se le c t the be st a ns we r for e a c h que stion. 1 . The f o llowing s tate ments co nc e rning s tructure s in the inte rc o s tal s pac e are c o rre ct e xce p t whic h? (a) The ante rio r inte rc o s tal arte rie s of the up p e r s ix inte rc o stal s p ace s are b ranche s o f the inte rnal tho rac ic arte ry. (b ) The inte rc os tal ne rve s trave l f orward in an inte rc o stal s p ace b e twe e n the internal inte rco s tal and inne rmo s t inte rco s tal mus c les . (c ) The inte rco s tal b lo od ve ss e ls and ne rves are p o s itio ne d in the o rd e r o f ve in, ne rve , and arte ry f ro m sup e rio r to inf erio r in a s ub c o stal gro o ve . (d ) The lo we r f ive interc o s tal nerve s sup p ly s ens o ry inne rvatio n to the s kin o f the lateral tho rac ic and ante rio r abd o minal walls . (e ) The po s te rior inte rco s tal veins d rain b ac kward into the azyg o s and he miazyg o s ve ins . Vie w Ans we r 2 . The f o llowing s tate ments co nc e rning the d iap hrag m are c o rre c t e xce p t which? (a) The rig ht crus pro vide s a mus cular s ling aro und the e s o phag us and p o s sib ly p re vents re gurg itatio n o f s to mac h c o ntents into the e s op hag us . (b ) On c o ntrac tio n, the d iap hrag m raise s the intra- ab d ominal p re ss ure and as s ists in the re turn o f the ve no us b lo o d to the rig ht atrium o f the he art. (c ) The le vel o f the d iap hrag m is hig her in the re c umb e nt p o s itio n than in the s tand ing p o s itio n. (d ) On c o ntrac tio n, the c e ntral te nd o n d e s c end s , red uc ing the intratho rac ic p re s sure . (e ) The es o p hag us pas s es throug h the d iap hragm at the leve l o f the eig hth tho rac ic ve rteb ra. Vie w Ans we r 3 . The f o llowing s tate ments co nc e rning the inte rc o stal ne rves are co rre c t exc e pt whic h? (a) The y p ro vid e mo to r inne rvatio n to the p e rip he ral p arts of the d iap hrag m.

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(b ) The y p ro vid e moto r inne rvatio n to the inte rco s tal mus c les . (c ) The y p ro vid e se ns o ry inne rvatio n to the c o s tal p arie tal p le ura. (d ) The y c o ntain s ymp athe tic f ib e rs to inne rvate the vasc ular s moo th mus c le . (e ) The 7th to the 1 1 th inte rc o s tal ne rve s p ro vid e s e ns o ry innervatio n to the p arie tal p e rito ne um. Vie w Ans we r 4 . To pas s a ne ed le into the p le ural sp ac e (c avity) in the midaxillary line , the f o llo wing s truc ture s will have to b e p ie rc e d e xce p t which? (a) I nternal inte rco s tal musc le (b ) L e vato re s c o s tarum (c ) External inte rco s tal musc le (d ) Parie tal p le ura (e ) I nnermo s t inte rco s tal musc le Vie w Ans we r 5 . The f o llowing s tate ments co nc e rning the tho rac ic o utle t (anato mic inle t) are true e xce p t whic h? (a) The manub rium s te rni f o rm the ante rio r bo rd e r. (b ) On e ac h s ide , the lo we r trunk o f the b rac hial p le xus and the sub c lavian arte ry e me rg e thro ugh the o utlet and p as s laterally o ve r the surf ace o f the f irs t rib . (c ) The b o d y o f the se ve nth ce rvical ve rte b ra f o rms the p o ste rio r b ound ary. (d ) The f irs t ribs f o rm the late ral b o undarie s . (e ) The es o p hag us and trac he a p ass thro ug h the o utle t. Vie w Ans we r 6 . The f o llowing s tate ments co nc e rning the tho rac ic wall are co rre c t e xc e p t whic h? (a) The trac he a b if urc ates o p p o site the manub rio s te rnal jo int (ang le o f L o uis ) in the mid res p irato ry p os itio n. (b ) The arc h o f the ao rta lie s b ehind the b od y o f the s te rnum. (c ) The ap e x b e at of the he art can no rmally be f e lt in the le f t inte rc os tal s p ace ab o ut 3 .5 in. (9 cm) f ro m the mid line . (d ) The lo we r marg in o f the rig ht lung o n f ull ins piratio n c ould e xte nd d o wn in the mid clavic ular line to the eig hth c o stal cartilag e . (e ) All inte rc os tal ne rve s are d e rive d f ro m the ante rio r rami o f tho racic sp inal ne rve s . Vie w Ans we r C omple tion Que stions Se le c t the phr a s e tha t be s t c omple te s e a c h s ta te ment. 7 . Clinic ians d e f ine the tho rac ic o utle t as

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(a) the lo we r o p ening in the thorac ic c age . (b ) the g ap b e twee n the c rura o f the d iap hrag m. (c ) the e s o p hag e al o p e ning in the d iap hrag m. (d ) the up p e r o pe ning in the tho rac ic c ag e . (e ) the g ap b e twee n the s te rnal and c o stal o rig ins o f the d iap hrag m. Vie w Ans we r 8 . The c o s tal marg in is f o rme d b y (a) the 6 th, 8 th, and 1 0 th rib s. (b ) the inner marg ins o f the 1 st rib s. (c ) the e d g e o f the xip hoid p ro ce s s . (d ) the c o s tal c artilag e s o f the 7 th, 8 th, 9 th, and 10 th ribs . (e ) the c o s tal c artilag e s o f the 7 th to the 1 0 th rib s and the e nds o f the c artilag es o f the 11 th and 1 2 th rib s . Vie w Ans we r 9 . The lo we r marg in o f the le f t lung in midre s p iratio n c ro s se s (a) the 6 th, 8 th, and 1 0 th rib s. (b ) the 7 th, 8 th, and 9 th rib s . (c ) the 1 0 th, 1 1 th, and 12 th ribs . (d ) the 8 th rib o nly. (e ) the 6 th, 1 1th, and 1 2 th rib s. Vie w Ans we r 1 0 . The s uprap le ural me mb rane is attache d late rally to the marg ins of (a) the 1 s t rib . (b ) the 6 th, 8 th, and 1 0 th rib s . (c ) the manub rio ste rnal junc tion. (d ) the 2 nd rib. (e ) the xip ho id cartilag e . Vie w Ans we r 1 1 . The mammary g land in the yo ung ad ult f e male o ve rlie s (a) the 1 s t to the 5th rib s. (b ) the 2 nd to the 6 th rib s. (c ) the 1 s t and 2 nd rib s. (d ) the 2 nd and 3 rd rib s . (e ) the 4 th to the 6 th rib s. Vie w Ans we r

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1 2 . The p arie tal ple ura (a) is s e nsitive o nly to the s e nsatio n o f s tre tc h. (b ) is s e p arate d f ro m the p le ural s p ac e b y e nd o tho racic f asc ia. (c ) is s e nsitive to the se ns atio ns o f p ain and to uch. (d ) re c e ive s its s e nso ry inne rvatio n f ro m the auto no mic ne rvo us s ys te m. (e ) is f o rme d f ro m s p lanc hno p leuric me s o de rm. Vie w Ans we r Fill-in-the -Bla nk Que s tions Fill in the bla nk with the be s t a ns we r . 1 3 . The tho rac ic d uc t p as se s thro ug h the _ _ __ _ _ _ _ o pe ning in the d iap hrag m. 1 4 . The s upe rio r e p ig as tric arte ry p as s e s thro ug h the _ _ _ _ _ __ _ o p e ning in the d iap hrag m. 1 5 . The rig ht p hre nic ne rve p as s e s thro ug h the _ _ _ _ __ _ _ o p e ning in the d iap hrag m. 1 6 . The le f t vag us ne rve p as s e s thro ugh the _ _ _ _ _ _ __ o p e ning in the d iaphrag m. (a) ao rtic (b ) e s o phag e al (c ) c aval (d ) no ne o f the ab o ve Vie w Ans we r 1 7 . The ao rtic o p e ning in the d iap hrag m lies at the leve l o f the __ _ _ _ _ _ _ tho racic ve rte b ra. 1 8 . The xip histe rnal jo int lie s at the le ve l o f the _ _ _ _ _ _ __ tho rac ic ve rte bra. 1 9 . The c aval o p e ning in the diap hrag m lie s at the le ve l o f the _ _ _ __ _ _ _ tho rac ic ve rte b ra. (a) 1 0 th (b ) 1 2 th (c ) 8 th (d ) 9 th (e ) 7 th Vie w Ans we r M ultiple -Choic e Que s tions Re a d the c a se his tor y a nd s e le ct the be s t a ns we r to the que s tion following it. A 3 5 -year-o ld man co mp laining o f se ve re p ain in the lower p art o f his le f t c he s t was s e e n b y his p hysic ian. The p atie nt had b ee n c o ug hing f o r the last 4 d ays and was p ro d ucing b lo od -s taine d sp utum. He had an inc re as e d res p irato ry rate and had a p yre xia o f 1 0 4 F. On e xaminatio n, the p atie nt was f ound to have f luid in the le f t p le ural s p ace . 2 0 . W ith the p atient in the s tand ing po s itio n, the p leural f luid would mo s t likely gravitate

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d o wn to the (a) o b liq ue f is s ure . (b ) c ardiac no tc h. (c ) c o sto me dias tinal re c e ss . (d ) ho rizo ntal f is s ure . (e ) c o sto d iap hrag matic re c e ss . Vie w Ans we r

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