TOPOGRAPHICAL ANATOMY OF THE

THORAX

Dr. Andrea D. Székely

Semmelweis University
Faculty of Medicine
Department of Anatomy, Histology and Embryology
Budapest
 BONY FRAMEWORK OF THE THORAX
auscultation
percussion
palpation

THORACIC CAVITY:
- superior thoracic aperture (Th2)
Borders: Th1, 1st ribs, sternum, pleura

- inferior thoracic aperture (Th10)

Borders: Th12, 11-12th ribs, costal arch, Costal arch
xiphoid process

SUPERIOR – „open” (inflammations!)

INFERIOR - diaphragma Infrasternal angle

Prof. Á.Szél
BORDERS AND CONTENTS OF THE THORAX
BORDERS AND CONTENT OF THE THORAX
LANDMARKS ON THE VENTRAL
SURFACE OF THE THORAX

Jugular notch– Th2

Sternal angle – 2. rib (Th4/5)

Nipple - 4. IC space (Th8)

Subcostal plane – L3
LANDMARKS ON THE VENTRAL
SURFACE OF THE THORAX

Jugular notch– Th2

Sternal angle – 2. rib (Th4/5)

Nipple - 4. IC space (Th8)

Inframammary sulcus
5.(-6.) IC space (Th10)

Subcostal plane – L3
 TOPOGRAPHICALLY RELEVANT
PLANES OF THE THORAX
Anterior
Paravertebral
axillary Anterior
line line Scapular
Midline line
Sternal Posterior
line Midline
Parasternal
line Anterior
Middle axillary lines
Posterior

Midclavicular
line
 COMPONENTS OF THE THORAX
BONES: Muscles

- thoracic vertebrae
- ribs 1-12.
- sternum
Plus Scapula and Clavicula
MUSCLES
 COMPONENTS OF THE THORAX
skin CT Serratus ant.

Sulcus costae

Intercostalis
externus

Intercostalis
internus Prof. Á.Szél
 COMPONENTS OF THE THORAX
skin CT Serratus ant.

v. intercostalis

a. intercostalis

n. intercostalis

Intercostalis
externus

Intercostalis
internus Transversus
Prof. Á.Szél
thoracis
 MM. INTERCOSTALES

V columna vertebralis V membrana

intercostalis posterior

RIB

intercostalis
internus

intercostalis
externus

intercostalis
RIB cartilage externus

(v)
membrana intercostalis
anterior (v)
Prof. Á.Szél +
CHEST DRAIN (INTERCOSTAL DRAIN)
THORACOCENTESIS
(Pleura-punctio)
1. Cutis
2. Subcutaneous fat,
Fascia thoracica ext.
3. M. serratus ant.
4. M. intercostalis ext.
NEEDLE AND
5. M. intercostalis int.
SYRINGE 1 2 3 4 5 67 8 910 M. intercostalis intimus
6. M. transversus thoracis,
Fascia thoracica int.
7. Pleura parietalis
8. Cavum pleurae
9. Pleura visceralis
10. Pulmo

Prof. Á.Szél
 INNERVATION - DERMATOMES

Cutivisceral reflexes !!!

 BLOOD SUPPLY OF THE THORACIC WALL
SUBCLAVIAN A.
INTERNAL THORACIC A.
ANT. INTERCOSTAL RAMI
Perforator branches (!!)
AXILLARY A.
SUPREME THORACIC A. (2)
THORACOACROMIAL
LATERAL THORACIC A. (3)
DESCENDING AORTA
INTERCOSTAL AA

SIMILAR VENOUS DRAINAGE

TOWARDS THE
SUPERIOR V CAVA
MAJOR VEINS:
AXILLARY V.
SUBCLAVIAN V.
AZYGOS & HEMIAZYGOS V.
TOPOGRAPHICAL REGIONS
 VENTRAL SURFACE OF THE THORAX

Regio infraclavicularis
Regio parasternalis
Regio axillaris Regio mammalis
(Regio pectoralis)

THORACIC CAVITY:
- superior thoracic aperture (Th2)
Borders: Th1, 1st ribs, sternum, pleura,
- inferior thoracic aperture (Th10)
Borders: Th12, 11-12th ribs, costal arch, xiphoid process
SUPERIOR – „open” (inflammations!)
INFERIOR - diaphragma
 DORSAL SURFACE OF THE THORAX
REGIO DORSALIS SCAPULAE
Borders:
- acromion and line of Th1 spinous proc
- medial margin of scapula
- inferior angle, post axillary fold
- vertical line from the acromion
STRUCTURES
- C6-7 és Th1-6 nerves
- muscles and fasciae
- axillarisok hiati
- suprascapular a. & n.
- circumflex scapular a.
- posterior circumflex humeral a. & v.
- axillary n.
- dorsal scapular n.
TRIGONUM AUSCULTATIONIS - deep branch of the transverse cervical a.
(dorsal scapular a. )
thoracodorsal fascia
 REGIO (FOSSA) AXILLARIS
Borders:
- anterior axillary fold
(m. pectoralis major et minor)
- posterior axillary fold
(m. latissimus dorsi, m. teres major,
m. subscapularis)
- m. serratus anterior (body wall)
- m. biceps (short head) & m.
coracobrachialis, neck of the humerus
- superficial axillary fascia

Structures:
- medial brachial cutaneous n., intercostobrachial nn.
- content of the axillary hiatus
- branches of the axillary a. et v. (superior thoracic a., thoracoacromial a., lateral thoracic a.,
subscapular a., anterior & posterior circumflex humeral aa., cicumflex scapular a.,
thoracodorsal a.)
- Branches of the brachial plexus
- axillary & pectoral (Sorgius) lymph nodes

Never remove the long thorcic nerve! Effects the serratus anterior.
 REGIO (FOSSA) AXILLARIS

Parasagittal section through the pectoral region.

1. Trapezius. 7. Vagina Axillaris

2. Fascia Cervicalis 8. n. pectoralis lateralis
3. Clavicula 9. n. pectoralis medialis + pectoralis minor
4. Subclavius 10. ligamentum suspensoryium axillae
5. Fascia Pectoralis 11. m. latissimus dorsi
6. Pectoralis major 12. scapula
(Modified from Colborn GL, Skandalakis JE. Clinical Gross Anatomy. Pearl River NY: Parthenon 1993; with permission.)
„THORACIC
Scalenus
OUTLET” medius

Brachial plexus

Scalenus medius
cupula
Scalenus
Scalenus anterior
anterior

1. rib

Prof. Á.Szél
 THORACIC OUTLET SYNDROME
A condition at the superior thoracic
outlet involving compression of a
neurovascular bundle passing between
the anterior scalene and middle scalene.
It can affect the brachial plexus and/or
the subclavian artery or rarely the vein
which does not normally pass through
the scalene hiatus.
(Pancoast tumour in the apex of the lung)
The compression may be positional
(caused by movement of the clavicle and
shoulder girdle on arm movement) or
static (caused by abnormalities or
enlargement or spasm of the various
muscles surrounding the arteries, veins,
and brachial plexus), a first rib fixation
and a cervical rib.
 SPATIUM INTERCOSTALE / REGIO PARASTERNALIS
The upper 5 IC spaces reach to the sternum
Below: arcus costalis

Borders:
- Ribs
- mm. intercostales et
ligg. intercostalia (ANT)

Content:
Posteriorly mm. intercostales externi
ant: ligg. intercostalia

-a mm. intercostales interni

Between angulus costae and sternum
2 parts (m. ic. intimus)

- VAN : v., a. et n. intercostalis (in : canalis

intercostalis, formed by mm.
intercostales interni et intimi as well as
sulcus costae)

Fasciae:
fascia thoracica externa & fascia endothoracica (m.transversus thoracis and the pleura parietalis)
 REGIO INFRACLAVICULARIS

Borders:
- clavicle
- anterior axillary forld
- deltoideus
(deltoideopectoral groove)
- vertical line from the sternoclavicular
joint

Structures/content
- platysma
- m. pectoralis major, fascia pectoralis
- nn. supraclaviculares (cutaneous nerves)
- borders of the axillary hiatus
- cephalic v., thoracoacromial a. (+branches)
- subclavius m., pectoralis minor, clavipectoral fascia
- axillary vessels, brachial plexus
- lateral pectoral n.
- axillary and infraclavicular lymph nodes
 REGIO MAMMALIS
Borders: Lymphatic drainage
- linea parasternalis plexus areolaris
- plica axillaris anterior et subareolaris
- between 3-7. ribs nodi lymphatici
- mamilla: 4. IC space - axillares
- pectorales
- parasternales
- interpectorales
Content/structures:
- 12-15 lobes (biggest : lobus axillaris)
- corpus adiposum and lig. suspensorium
- fascia pectoralis superficialis
- m. pectoralis major et minor
- fascia pectoralis profunda et f. clavipectoralis
- Body wall
Arteries: rr. mammariae (a. thoracica interna, aa.
intercostales, a. thoracica lateralis, a. thoracoacromialis
Veins: towards the v. axillaris and the vv. intercostales
Nerves: supraclavicular nn, 2-6 intercostal nn (skin)
4-6 intercostal nn (gland)
INFRAMAMMARY SULCUS
 MAMMA
Excretory ducts:
ductus lactifer
sinus lactifer ???
(open on the nipple)
 MAMMA

Muscular basis
m. pectoralis major
m. latissimus dorsi
m. rectus abdominis
m. obliquus abd. Externus

4 Quadrants

It could be moved together

with the fascial layers
THE INFRAMAMMARY FOLD IS CONSISTENT
RETINACULA MAMMAE
Cooper - ligaments

Corpus adiposum mammae

LAYERS OF THE REGIO MAMMALIS
Skin
Subcutis
Fascia superficialis (lamina ext)
Glandula mammaria
and the Cooper - ligaments
(retinacula mamme)
Fascia superficialis (lam. Int.)
(continuous with the fascia cervicalis)
Submammary space
Fascia pectoralis (f. profunda = deep)
M. pectoralis major
Fascia clavipectoralis
(contains the lig. susp. axillae)
M. pectoralis minor
IMPLANT IN THE RETROMAMMARY SPACE
VASCULAR AND NERVOUS SUPPLY OF
THE BREAST
MAMMARY REGION
LYMPHATIC DRAINAGE
areolar and subareolar plexus
nodi lymphatici
- axillary
- pectoral
- parasternal
- interpectoral
 MAMMARY CARCINOME
MORBIDITY AND MORTALITY

Dr. Molnár Béla Ákos

Egyetemi adjunktus
Semmelweis Egyetem I. Sebészeti Klinika c
 MASTECTOMY
http://www.youtube.com/watch?v=yEehBwapj1c

Dr. Béla Ákos Molnár

Adjunct Professor
Semmelweis University 1st Surgery Clinic
SUBCUTANEOUS MASTECTOMY FOLLOWED BY
SUBPECTORAL EXPANDER IMPLANT

Dr. Béla Ákos Molnár

Adjunct Professor
Semmelweis University 1st Surgery Clinic
IMPLANTS
BRCA 1 PATIENT SUBCUTANEOUS MASTECTOMY
EXPANDER IMPLANT

Dr. Béla Ákos Molnár

Adjunct Professor
Semmelweis University 1st Surgery Clinic
BREAST RECONSTRUCTION AND
SYMMETRIZATION

Dr. Béla Ákos Molnár

Adjunct Professor
Semmelweis University 1st Surgery Clinic
LATISSIMUS DORSI FLAP RECONSTRUCTION

Dr. Béla Ákos Molnár

Adjunct Professor
Semmelweis University 1st Surgery Clinic
 m. Latissimus dorsi

a., v., n. thoracodorsalis

a. axillaris

Dr.
Dr. Béla
Béla Ákos
Ákos Molnár
Molnár
Adjunct Professor
Adjunct Professor
Semmelweis University 1st Surgery Clinic
Semmelweis University 1st Surgery Clinic
Dr. Béla Ákos Molnár
Adjunct Professor
Semmelweis University 1st Surgery Clinic
a., v., n. thoracodorsalis

Dr. Béla Ákos Molnár

Adjunct Professor
Semmelweis University 1st Surgery Clinic
Dr. Béla Ákos Molnár
Adjunct Professor
Semmelweis University 1st Surgery Clinic
Dr. Béla Ákos Molnár
Adjunct Professor
Semmelweis University 1st Surgery Clinic
LATISSIMUS DORSI FLAP RECONSTRUCTIOJN
1 year later

Dr. Béla Ákos Molnár

Adjunct Professor
Semmelweis University 1st Surgery Clinic
LATISSIMUS DORSI FLAP RECONSTRUCTION
6 years later

Dr. Béla Ákos Molnár

Adjunct Professor
Semmelweis University 1st Surgery Clinic
THANK YOU FOR YOUR ATTENTION!