THE THORAX

The thorax is the upper part of the trunk. It consists of an external musculoskeletal
cage, the thoracic wall, and an internal cavity that contains the heart, lungs, oesophagus,
trachea, thymus, the vagus and phrenic nerves and the right and left sympathetic trunks, the
thoracic duct and major systemic and pulmonary blood vessels. Inferiorly the thorax is
separated from the abdominal cavity by the diaphragm, which is a curved musculotendinous
sheet attached to the circumference of the inferior thoracic aperture and to the upper lumbar
vertebrae; superiorly the thorax communicates with the neck and the upper limbs. The
thoracic wall also offers protection to some of the abdominal viscera: the greater part of the
liver lies under the right dome of the diaphragm; the stomach and spleen lie under the left
dome of the diaphragm; the posterior aspects of the superior poles of the kidneys lie on the
diaphragm.
The thoracic skeleton consists of 12 thoracic vertebrae and their intervertebral discs
(median, posterior), 12 pairs of ribs and their costal cartilages (predominantly lateral) and
the sternum (median, anterior). Laterally the thoracic cage is convex and is formed by the
ribs, and anteriorly it is slightly convex and is formed by the sternum and the distal parts of
the ribs and their costal cartilages. The first 7 pairs of ribs are connected to the sternum by
costal cartilages, the costal cartilages of the 8th to 10th ribs usually join the superjacent
cartilage, and the 11th and 12th ribs are free (floating) at their anterior ends.
The superior thoracic aperture is formed by the first thoracic vertebral body
posteriorly, the medial border of the first ribs on each side, and the superior border of the
sternal manubrium anteriorly.
The inferior thoracic aperture consists of the twelfth thoracic vertebral body,
posterolaterally by 11th and 12th ribs, anterolaterally by the distal cartilaginous ends of the 7th
to 10th ribs (which unite and ascend to form the costal arch), and anteriorly by the xiphoid
process.

RIBS

The ribs are 12 pairs of elastic arches. They articulate posteriorly with the vertebral column
and form the greater part of the thoracic skeleton. The ribs are separated by the intercostal
spaces.
The first 7 pairs are connected to the sternum by costal cartilages, and are referred to
as the true ribs. The remaining five are the so-called false ribs: the cartilages of the 8th to 10th
usually join the superjacent costal cartilage, whereas the 11th and 12th ribs, which are free at
their anterior ends, are sometimes termed the ‘floating' ribs.

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The typical rib :
A typical rib has a shaft with anterior and posterior ends. The anterior end (costal) has
a small concave depression for the lateral end of its cartilage. The shaft is thin and flat and
has external and internal surfaces, and superior and inferior borders. It is curved, bent at the
posterior angle and twisted about its long axis. The external surface is convex and smooth,
and the inner surface (medial) has an inferior groove for intercostal nerves and vessels.
The posterior end (vertebral) has a head, neck and tubercle. The head presents two
articular facets, separated by a transverse crest, for articulation with the vertebral body of
two adjacent thoracic vertebrae – costo-vertebral joint. The tubercle is situated at the junction
of the neck and shaft and articulates with the transverse process of the corresponding
vertebra: costo-transverse joint.
The first rib :
- small, its costal cartilage articulates with the sternal manubrium;
- is flat, its surfaces are superior and inferior, and its borders are
internal and external. It slopes obliquely down and forwards to its sternal end;
- at the internal border is a small pointed projection, the scalene tubercle, to which
scalenus anterior is attached. The subclavian artery and (usually) the lower trunk of
the brachial plexus pass into a groove behind the tubercle. The groove anterior to the
scalene tubercle is crossed by the subclavian vein.

STERNUM

Sternum it’s a flat bone, median, located in the anterior part of the thorax, convex in
front, concave behind. It consists of three parts: manubrium, body and xiphoid process. On
each lateral sides of the sternum are 7 pairs of costal notches (depressions) for articulation of
costal cartilages with the sternum. The manubrium and sternal body are unit by a
cartilaginous joint, that determine a sternal angle (angle of Louis) which can be palpated. The
sternum contains highly vascular trabecular bone enclosed by a compact layer, and the
medulla contains haemopoietic bone marrow.
The manubrium: the superior border contains a central jugular (suprasternal) notch
between two oval fossae, the clavicular notches for articulation with the sternal ends of the
clavicles.
The body bears three variable transverse ridges, which mark the levels of fusion of its
four sternebrae. The lower end of the body is narrow and continuous with the xiphoid
process.
The xiphoid process is in the epigastrium, it is small, cartilaginous in youth, but more
or less ossified in adults.

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 THE UPPER EXTREMITY
1. THE SHOULDER REGION
The bones that connect the upper extremity with the trunk are: clavicle (the collar bone),
scapula (shoulder blade).
THE CLAVICLE
Is “S” shaped : a forwards curve (convex forwards) in its medial two-thirds, and a
backward curve (concave forwards) in its lateral third;
The medial end of clavicle is enlarged and articulates with the clavicular notch of the sternal
manubrium forming the sterno-clavicular joint, and
The lateral third: is flattened and has a superior and an inferior surface, limited by an
anterior and a posterior border; the superior surface can be felt through the skin, on this
surface being attached deltoid (anterior) and trapezius (posterior). The inferior surface of the
lateral extremity presents a prominent conoid tubercle which gives attachment to the
coracoclavicular ligament (unites the clavicula with the coracoid process of scapula).
A narrow, roughened strip, the trapezoid line, runs forwards and laterally from this tubercle.
The lateral end articulates with medial side of acromion – acromio-clavicular joint.
The medial two-thirds of the clavicle: its margins give attachment to the
costoclavicular ligament, which connects the clavicle to the upper surface of the first rib and
its cartilage. Also, the medial end provide attachment, anteriorly, for the pectoralis major, and
on the superior surface for the clavicular head of sternocleidomastoid. The inferior surface
gives insertion to subclavius in the subclavian groove.

THE SCAPULA:
The scapula is a large, flat, triangular bone which lies on the posterolateral aspect of the
chest wall. It has costal and dorsal surfaces, superior, lateral and medial borders, inferior,
superior and lateral angles, and three processes, the spine, its continuation the acromion and
the coracoid process.
The costal surface: is directed medially and forwards and represents an attachment for
subscapularis and for serratus anterior near the inferior angle.
Dorsal surface: is divided by the spine of the scapula, a prominent bony ridge, into a
small upper and a large lower area - supraspinous fossa and infraspinous fossa.
Supraspinatus, Teres minor are attached to supraspinous fossa surface, and the infraspinatus
and latissimus dorsi are attached to the infraspinous fossa . The spine of scapula is triangular
in shape, it has a dorsal border named the crest of the spine that is subcutaneous, an anterior
border that joins the dorsal surface of the scapula, and a lateral border between the
supraglenoid notch and the neck of the bone. Supra- and infraspinatus are attached to the
upper and lower surfaces of the spine of the scapula, respectively. The posterior fibres of
deltoid are attached to the lower border of the crest. The middle fibres of trapezius are
attached to the upper border of the crest.

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 Superior border: its anterolateral end is separated from the root of the coracoid process by
the suprascapular notch that transmits the suprascapular nerve to the supraspinous fossa and
whereas the suprascapular vessels pass backwards.
Lateral border runs from the inferior angle to the glenoid cavity.
The medial border of the scapula extends from the inferior to the superior angle. On this
border are attached three muscles: levator scapulae, rhomboid minor and rhomboid major.
The inferior angle lies over the seventh rib, or over the seventh intercostal space. It is
covered by a part of latissimus dorsi.
The superior angle is placed at the junction of the superior and medial borders, is covered
by trapezius.
The lateral angle : it bears the glenoid cavity, a smooth concave articular surface that
articulates with the head of the humerus in the shoulder joint (scapulo-humeral joint). Above
the glenoid cavity is supraglenoid tubercle (the long head of biceps brachii is attached to the
supraglenoid tubercle), and below is the infraglenoid tubercle (the long head of triceps is
attached to the infraglenoid tubercle). The neck of the scapula is the constriction immediately
adjoining the head. Acromion: a flattened angulated projection forwards on the lateral angle
of scapula, with which continue the lateral end of the spine, for articulation with the lateral
end of clavicle. Coracoid process: trapezoid and conoid ligaments fix the clavicle on
coracoid process; Pectoralis minor, coracobrachialis, and the short head of biceps are attached
to the superior aspect of the coracoid process.