THORACIC WALL

BONES OF THE THORACIC WALL

STERNUM
Flat bone divided into 3 parts :
manubrium
Body
xiphoid process
Sternal angle of Louis is formed by the articulation of the manubrium
with the body of the sternum
It is important surface landmark and it lies at the level of
2nd costal cartilage
Intervertebral disc between the 4 th and 5th thoracic vertebra
Junction between the aorta and aortic arch and the junction of the
aortic arch and descending thoracic aorta
Bifurcation of the trachea
Junction of the superoir mediastinum and inferior mediastinum

o RIBS
12 pairs of ribs, all of which are attach posteriorly to the thoracic
vertebrae
3 categories:
True ribs: upper 7 ribs attached to the sternum by their costal cartilage
False ribs: 8th-9th ribs attached anteriorly to each other
Floating ribs 11th-12th
Typical rib is a long ,twisted flat bone with a rounded superior border
and a grooved inferior border(costal groove) which accomodates
intercostal vessels and nerves
Atypical rib
First rib w/c is important clinically because of its close relationship to
the nerves of the brachial plexus and the subclavian artery and vein
Cervical rib occurs in approximately 0.5% of individual. It may cause
pressure n the lower trunk of brachial plexus or subclavian arery
leading to symptoms and signs that are referred as the thoracic outlet
syndrome

 Diaphragm
Most important muscle of respiration
Dome shape and consist of a peripheral muscular part and a
centrally placed tendon
o Origin of diaphragm is divided into 3 parts:
Sternal part arise from posterior surface of the xiphoid process
Costal part arise from deep surfaces of the lower 6 th ribs and
their costal cartilage
Vertebral part arise from vertical columns or crura and form the
arcuate ligaments
Nerve supply: phrenic nerve
o Action:
Muscle of inspiration
Weight lifting muscle
Thoracoabdominal pump

o Openings:
Aortic opening :
lies anterior to the body of the 12th thoracic vertebra and
transmits the aorta, thoracic duct, azygous vein
Esophageal opening:
lies at the level of 10th thoracic vertebra and transmits the
esophagus, right and left vagus nerves, esophageal branch
of the left gatric vessel and the lymphatic vessels
Caval opening:
lies at the level of the 8th thoracic vertebra in the central
tendon. It transmits the inferior vena cava and the terminal
branches of the phrenic nerve

 Surgical considerations:
o Diaphragmatic hernias
A. Esophageal hiatal hernia: most common type
a. Congenitally short esophagus with thoracic stomach
b. Esophageal hiatal hernia with shortened esophagus
c. Esophageal hiatal hernia without shortening of the
esophagus
d. Paraesophageal hiatal hernia through the hiatus
B. hernia through the parasternal opening( foramen of
mrgagni)
C. pleuroperitoneal hiatal hernia ( bochdaleck hernia) :
most common
congenital abnormality
D. hernia from the congenital absence of hemidaphragm
E. Trumatic diaphragmatic hernia

 The thoracic cavity is divided into right and left pleural cavities and the
region situated between this is called the mediastinum
Visceral pleura invest the lung, dips into its fissure and adheres firmly
Parietal pleura:
divided into 4 parts according to location
A. Costal pleura lines the ribs and their cartilages, the side of the
vertebral
bodies and the back of the sternum.
Thickest of all parietal pleura
B. Cervical pleura extends upward into the root of the neck . The upper
aspect
is covered by a layer of connective tissue called sibsons fascia
C. Diaphragmatic pleura cover the part of diaphragm,thin and very
adherent
D. Mediastinal pleura
Pleural cavity is a slit like space that separates the parietal and visceral
pleura and normally contains small amount of pleural fluid
Costodiaphragmatic recess is the lowest area opf the pleural cavity into
which the lungs expand during deep inspiration

 Mediastimum
An interpleural partition that extends superiorly to the thoracic outlet and the
root of the neck and inferiorly to the diaphragm
A. Superior mediastinum contains the remains of the thymus,
brachiocephalic artery and vein, upper part of superior vena cava, left
common carotid artery, left subclavian artery, arch of aorta, phrenic
and vagus nerves, left recurrent laryngeal and cardiac nerves, trachea
and lymph nodes, thoracic duct and symphatetic trunk
B. Anterior mediastinum: contains strenopericardial ligaments, lymph
nodes and remains of the thymus
C. Middle mediastinum contains pericardium, heart and roots of great
vessels, phrenic nerves, bifurcation of trachea, lymph nodes
D. Posterior mediastinum: contains descending thoracic aorta, esophagus,
thoracic duct, azygous and hemiazygous veins, splanchnic nerves,
symphatetic trunks and lymph nodes

 Thoracic truma
o Immediate life threatening injuries are those that can cause
death in a matter of minutes
A. airway obstruction
B. tension pneumthorax
C. Open pneumothorax
D. Massive hemothorax
E. Cardiac tamponade
F. Flail chest

 Potentially life threatening injuries

o Tracheobronchial disruption occurs w/n 2 cm of the carina
Dx:
collapsed lung fails to expand following placement of CTT
Massive air leaks
Massive subcutaneous empyhsema
o Aortic disruption result of decelaration injury in w/c mobile ascending aorta and
arch move forward while the descending thoracic remains fix w/c causes tear
at the aortic isthmus just distal to the takeoff of the left subclavian artery
Chest radiograph finding:
Widened mediastinum
Indistinct aortic knob
Depressed left mainstem bronchus
Apical cap]
Deviation of trachea to the right
Left pleural effusion
o Diaphragmatic disruption
o Esophageal disruption
o Cardiac contusion
o Pulmonary contusion