THORACIC WALL

I. SKELETON OF THE THORAX (Figure 4-1)

A. Sternum
■ Is a flat bone and consists of the manubrium, the body, and the xiphoid process.
■ Is relatively shorter and thinner in the female, and its body is more than twice as long as the
manubrium in the male but is usually less in the female.
1. Manubrium
■ Has a superior margin, the jugular notch, which can be readily palpated at the root
of the neck.
■ Has a clavicular notch on each side for articulation with the clavicle.
■ Also articulates with the cartilage of the first rib, the upper half of the second rib, and
the body of the sternum at the manubriosternal joint, or sternal angle.
2. Sternal Angle (Angle of Louis)
■ Is the junction between the manubrium and the body of the sternum.
■ Is located at the level where:
■ The second ribs articulate with the sternum.
■ The aortic arch begins and ends.
■ The trachea bifurcates into the right and left bronchi at the carina.

Superior costal facet

Superior articular process
Inferior articular
process T4
Manubrium of sternum
T5
Transverse Sternal angle
process
Inferior costal
facet Vertebral body Body of sternum
Rib IV

Rib V

Costal cartilage
Xiphoid process
of sternum
FIGURE 4-1. Articulations of the ribs with the vertebrae and the sternum.

132

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 ■ The inferior border of the superior mediastinum is demarcated.
■ A transverse plane can pass through the intervertebral disk between T4 and T5.
3. Body of the Sternum
■ Articulates with the second to seventh costal cartilages.
■ Also articulates with the xiphoid process at the xiphisternal joint, which is at level
with the ninth thoracic vertebra.
4. Xiphoid Process
■ Is a flat, cartilaginous process at birth that ossifies slowly from the central core and
unites with the body of the sternum after middle age.
■ Lies at the level of T10 vertebra, and the xiphisternal joint lies at the level of the T9
vertebral body, which marks the lower limit of the thoracic cavity in front, the upper
surface of the liver, diaphragm, and lower border of the heart.
■ Can be palpated in the epigastrium and is attached via its pointed caudal end to the
linea alba.

CLINICAL The sternum is a common site for bone marrow biopsy because it possesses
CORRELATES hematopoietic marrow throughout life and because of its breadth and subcuta-
neous position. It may be split in the median plane (median sternotomy) to allow the surgeon to gain
easy access to the lungs, heart, and great vessels.

B. Ribs
■ Consist of 12 pairs of bones that form the main part of the thoracic cage, extending from
the vertebrae to or toward the sternum.
■ Increase the anteroposterior and transverse diameters of the thorax by their movements.
1. Structure
■ Typical ribs are ribs 3 through 9, each of which has a head, neck, tubercle, and body
(shaft).
■ The head articulates with the corresponding vertebral bodies and intervertebral disks
and supra-adjacent vertebral bodies.
■ The body (shaft) is thin and flat and turns sharply anteriorly at the angle and has a
costal groove that follows the inferior and internal surface of a rib and lodges the
intercostal vessels and nerves.
■ The tubercle articulates with the transverse processes of the corresponding verte-
brae, with the exception of ribs 11 and 12.
2. Classification
a. True Ribs
■ Are the first seven ribs (ribs 1 to 7), which are attached to the sternum by their
costal cartilages.
b. False Ribs
■ Are the lower five ribs (ribs 8 to 12); ribs 8 to 10 are connected to the costal carti-
lages immediately above, and thus the 7th to 10th costal cartilages form the ante-
rior costal arch or costal margin.
c. Floating Ribs
■ Are the last two ribs (ribs 11 and 12), which are connected only to the vertebrae.

CLINICAL Thoracic outlet syndrome is the compression of neurovascular structures in the

CORRELATES thoracic outlet (a space between the clavicle and the first rib), causing a combi-
nation of pain, numbness, tingling, or weakness and fatigue in the upper limb caused by pressure on
the brachial plexus (lower trunk or C8 and T1 nerve roots) by a cervical rib (mesenchymal or carti-
laginous elongation of the transverse process of the seventh cervical vertebra). A cervical rib may
also compress the subclavian artery in the thoracic outlet, resulting in ischemic muscle pain in the
upper limb. Compression on the neurovascular bundle occurs as a result of cervical ribs or abnormal
insertions of the anterior and middle scalene muscles.

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 134 BRS Gross Anatomy

CLINICAL Flail chest is a loss of stability of the thoracic cage that occurs when a seg-
CORRELATES ment of the anterior or lateral thoracic wall moves freely because of multiple
rib fractures, allowing the loose segment to move inward on inspiration and outward on expiration.
Flail chest is an extremely painful injury and impairs ventilation, thereby affecting oxygenation of the
blood and causing respiratory failure.
Rib fractures: Fracture of the first rib may injure the brachial plexus and subclavian vessels.
The middle ribs are most commonly fractured and usually result from direct blows or crushing
injuries. The broken ends of ribs may cause pneumothorax and lung or spleen injury. Lower rib
fractures may tear the diaphragm, resulting in a diaphragmatic hernia.

3. First Rib
■ Is the broadest and shortest of the true ribs.
■ Has a single articular facet on its head, which articulates with the first thoracic ver-
tebra.
■ Has a scalene tubercle for the insertion of the anterior scalene muscle and two grooves
for the subclavian artery and vein.
4. Second Rib
■ Has two articular facets on its head, which articulate with the bodies of the first and
second thoracic vertebrae.
■ Is about twice as long as the first rib.
5. Tenth Rib
■ Has a single articular facet on its head, which articulates with the 10th thoracic vertebra.
6. Eleventh and Twelfth Ribs
■ Have a single articular facet on their heads.
■ Have no neck or tubercle.

II. ARTICULATIONS OF THE THORAX (See Figure 4-1)

A. Sternoclavicular Joint
■ Is a saddle-type synovial joint with two separate synovial cavities and provides the only
bony attachment between the appendicular and axial skeletons.

B. Sternocostal (Sternochondral) Joints

■ Are the articulation of the sternum with the first seven cartilages. The sternum (manu-
brium) forms synchondrosis with the first costal cartilage, whereas the second to seventh
costal cartilages form synovial plane joints with the sternum.

C. Costochondral Joints
■ Are synchondroses in which the ribs articulate with their respective costal cartilages.

D. Manubriosternal Joint
■ Is symphysis (secondary cartilaginous joint) between manubrium and body of the sternum.

E. Xiphisternal Joint
■ Is synchondrosis articulation between xiphoid process and body of the sternum.

F. Costovertebral Joints
■ Are synovial plane joints of heads of ribs with corresponding and supraadjacent vertebral
bodies.

G. Costotransverse Joint
■ Is synovial plane joint of tubercle of rib with transverse process of corresponding vertebra.

H. Interchondral Joints
■ Are synovial plane joints between 6th and 10th costal cartilages of ribs.

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 III. BREASTS AND MAMMARY GLANDS (See page 34 and
Figure 2-10, Chapter 2)

IV. MUSCLES OF THE THORACIC WALL (Table 4-1)

t a b l e 4-1 Muscles of the Thoracic Wall

Muscle Origin Insertion Nerve Action

External intercostals Lower border of ribs Upper border of rib below Intercostal Elevate ribs in inspiration
Internal intercostals Lower border of ribs Upper border of rib below Intercostal Depress ribs (costal part);
elevate ribs (interchon-
dral part)
Innermost intercostals Lower border of ribs Upper border of rib below Intercostal Elevate ribs
Transversus thoracis Posterior surface of Inner surface of costal Intercostal Depresses ribs
lower sternum and cartilages 2–6
xiphoid
Subcostalis Inner surface of lower Upper borders of ribs 2 or Intercostal Elevates ribs
ribs near their angles 3 below
Levator costarum Transverse processes Subjacent ribs between Dorsal pri- Elevates ribs
of T7–T11 tubercle and angle mary rami
of C8–T11

V. NERVES AND BLOOD VESSELS OF THE THORACIC WALL

A. Intercostal Nerves
■ Are the anterior primary rami of the fi rst 11 thoracic spinal nerves. The anterior primary
ramus of the 12th thoracic spinal nerve is the subcostal nerve, which runs beneath the 12th
rib.
■ Run between the internal and innermost layers of muscles, with the intercostal veins and
arteries above (veins, arteries, nerves [VAN]).
■ Are lodged in the costal grooves on the inferior surface of the ribs.
■ Give rise to lateral and anterior cutaneous branches and muscular branches.

B. Internal Thoracic Artery

■ Usually arises from the first part of the subclavian arteryand descends directly behind the first six
costal cartilages, just lateral to the sternum.
■ Gives rise to two anterior intercostal arteries in each of the upper six intercostal spaces and
terminates at the sixth intercostal space by dividing into the musculophrenic and superior epigastric
arteries.

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 4. Musculophrenic Artery
■ Follows the costal arch on the inner surface of the costal cartilages.
■ Gives rise to two anterior arteries in the 7th, 8th, and 9th spaces; perforates the dia-
phragm; and ends in the 10th intercostal space, where it anastomoses with the deep
circumflex iliac artery.
■ Supplies the pericardium, diaphragm, and muscles of the abdominal wall.
5. Superior Epigastric Artery
■ Descends on the deep surface of the rectus abdominis muscle within the rectus
sheath; supplies this muscle and anastomoses with the inferior epigastric artery.
■ Supplies the diaphragm, peritoneum, and anterior abdominal wall.

C. Internal Thoracic Vein

■ Is formed by the confluence of the superior epigastric and musculophrenic veins, ascends
on the medial side of the artery, receives the upper six anterior intercostal and pericardi-
acophrenic veins, and ends in the brachiocephalic vein.

D. Thoracoepigastric Vein
■ Is a venous connection between the lateral thoracic vein and the superficial epigastric
vein.

VI. LYMPHATIC DRAINAGE OF THE THORAX

A. Sternal or Parasternal (Internal Thoracic) Nodes
■ Are placed along the internal thoracic artery.
■ Receive lymph from the medial portion of the breast, intercostal spaces, diaphragm, and
supraumbilical region of the abdominal wall.
■ Drain into the junction of the internal jugular and subclavian veins.

B. Intercostal Nodes
■ Lie near the heads of the ribs.
■ Receive lymph from the intercostal spaces and the pleura.
■ Drain into the cisterna chyli or the thoracic duct.

C. Phrenic Nodes
■ Lie on the thoracic surface of the diaphragm.
■ Receive lymph from the pericardium, diaphragm, and liver.
■ Drain into the sternal and posterior mediastinal nodes.

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