Thoracic Wall

IQRA KANWAL
M.PHIL. FOTRENSIC SCIENCE
 Thoracic wall
• The 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.
• The framework of the walls of the thorax, which is referred to as the
thoracic cage, is formed by the:
• Posteriorly: vertebral column
• Laterally: the ribs and intercostal spaces
• Anteriorly: the sternum and costal cartilages
• Superiorly: the thorax communicates with the neck
• Inferiorly: it is separated from the abdomen by the diaphragm.
• The thoracic cage protects the lungs and heart and affords attachment
for the muscles of the thorax, upper extremity, abdomen, and back.
 Thoracic wall
• The cavity of the thorax can be divided into a median
partition, called the mediastinum
• laterally placed pleurae and lungs
• The lungs are covered by a thin membrane called the
visceral pleura, 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 parietal pleura.
• In this manner, two membranous sacs called the pleural
cavities are formed, one on each side of the thorax,
between the lungs and the thoracic walls.
 Sternum

• The 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.
• The manubrium 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 the1st costal cartilage and the upper
part of the 2nd costal cartilages on each side. It lies
opposite the 3rd and 4th thoracic vertebrae.
 Sternum

• The body of the sternum articulates above with the

manubrium at the manubriosternal joint and below
with the xiphoid process at the xiphisternal joint.
The xiphisternal joint lies opposite the body of the
ninth thoracic vertebra
• On each side, it articulates with the 2nd to the 7th
costal cartilages.
• The xiphoid process 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.
 Sternum

• The sternal angle (angle of Louis), formed by the

articulation of the manubrium with the body of the
sternum,
• It can be recognized by the presence of a transverse
ridge on the anterior aspect of the sternum.
• The transverse ridge lies at the level of the 2nd costal
cartilage, the point from which all costal cartilages
and ribs are counted.
• The sternal angle lies opposite the intervertebral disc
between the 4th and 5th thoracic vertebrae.
 Nerve Supply & Actions of the Diaphragm

• Motor nerve supply: The right and left phrenic nerves

(C3, 4, 5).
• Sensory nerve supply: The parietal pleura and
peritoneum covering the central surfaces of the
diaphragm are from the phrenic nerve and the periphery
of the diaphragm is from the lower six intercostal nerves.
• Action of the Diaphragm
• On contraction, the diaphragm pulls down its central
tendon and increases the vertical diameter of the thorax.
 Levatores Costarum Muscle

• There 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.
• ■■ Nerve supply: Posterior rami of thoracic
spinal nerves
 Serratus Posterior Superior Muscle

• The 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.
• ■■ Nerve supply: Intercostal nerves
 Serratus Posterior Inferior Muscle

• The 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.
• ■■ Nerve supply: Intercostal nerves
SURFACE ANATOMY
 Anterior Chest Wall
• The suprasternal notch is the superior margin of the manubrium sterni and is
easily felt between the prominent medial ends of the clavicles in the midline.
It lies opposite the lower border of the body of the 2nd thoracic vertebra
• The sternal angle (angle of Louis) is the angle made between the manubrium
and the body of the sternum .It lies opposite the intervertebral disc between
the 4th and 5th thoracic vertebrae .The position of the sternal angle can
easily be felt and is often seen as a transverse ridge. The finger moved to the
right or to the left will pass directly onto the 2nd costal cartilage and then
the 2nd 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.
• The xiphisternal joint is the joint between the xiphoid process of the
sternum and the body of the sternum . It lies opposite the body of the ninth
thoracic vertebra.
• The subcostal angle is situated at the inferior end of the sternum, between
the sternal attachments of the 7th costal cartilages.
 Anterior Chest Wall
• The costal margin 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. The lowest part of the costal
margin is formed by the 10th rib and lies at the
level of the third lumbar vertebra.
• The clavicle is subcutaneous throughout its entire
length and can be easily palpated. It articulates at
its lateral extremity with the acromion process of
the scapula.
 RIBS
• The 1st rib lies deep to the clavicle and cannot be
palpated. The 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.
• The 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
• The 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 5th rib in the
midclavicular line, but the left dome only
reaches as far as the lower border of the 5th
rib.
 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
• The apex of the heart is formed by the lower portion of
the left ventricle. The apex beat is caused by the apex of
the heart being thrust forward against the thoracic wall as
the heart contracts.
• The 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
• The anterior fold is formed by the lower
border of the pectoralis major muscle. This
can be made to stand out by asking the
patient to press a hand hard against the hip.
The posterior 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
• The spinous processes of the thoracic vertebrae can be palpated in the
midline posteriorly. The 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. The first spinous process to be felt is that of the
seventh cervical vertebrae (vertebra prominens). The spines of C1 to 6
vertebrae are covered by a large ligament, the ligamentum nuchae.
• The scapula (shoulder blade) is flat and triangular in shape and is
located on the upper part of the posterior surface of the thorax. The
superior angle lies opposite the spine of the second thoracic vertebra .
The spine of the scapula is subcutaneous, and the root of the spine lies
on a level with the spine of the third thoracic vertebra. The inferior
angle lies on a level with the spine of the seventh thoracic vertebra.
 Lines of Orientation
• Several imaginary lines are sometimes used to describe surface locations
on the anterior and posterior chest walls. ■ Midsternal line: Lies in the
median plane over the sternum
• ■ Midclavicular line: Runs vertically downward from the midpoint of the
clavicle
• ■ Anterior axillary line: Runs vertically downward from the anterior
axillary fold
• ■ Posterior axillary line: Runs vertically downward from the posterior
axillary fold
• ■ Midaxillary 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 , passing through the inferior angle of the scapula (arms at the
sides)
 Trachea
• The trachea extends from the lower border of
the cricoid cartilage (opposite the body of the
6th cervical vertebra) in the neck to the level
of the sternal angle in the thorax .
• It commences in the midline and ends just to
the right of the midline by dividing into the
right and the left principal bronchi. At the root
of the neck, it may be palpated in the midline
in the suprasternal notch.
 Lungs
• The apex 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 .
• The anterior border 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 . The anterior border of
the left 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 . This notch is produced by the heart
displacing the lung to the left. The anterior border then turns sharply downward to
the level of the xiphisternal joint.
• The lower border 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. It is important to
understand that the level of the inferior border of the lung changes during
inspiration and expiration.
 Lungs
• The posterior border 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.
• The 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 6th 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.
• In the right lung is an additional fissure, the horizontal fissure, which
may be represented by a line drawn horizontally along the fourth costal
cartilage to meet the oblique fissure in the midaxillary line. 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.
 pleura

• The boundaries of the pleural sac can be marked out as lines

on the surface of the body. The lines, which indicate the
limits of the parietal pleura where it lies close to the body
surface, are referred to as the lines of pleural reflection.
• The cervical pleura 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.
 pleura
• The anterior border of the right pleura runs down
behind the sternoclavicular joint, almost reaching the
midline behind the sternal angle. It then continues
downward until it reaches the xiphisternal joint. The
anterior border of the left pleura 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.
 pleura
• The lower border of the pleura on both sides follows a
curved line, which crosses the 8th rib in the midclavicular
line and the 10th rib in the midaxillary line, and reaches the
12th rib adjacent to the vertebral column—that is, at the
lateral border of the erector spinae muscle. 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. The distance between the
two borders corresponds to the costodiaphragmatic recess.
 pleura
• The lower border of the pleura on both sides follows a
curved line, which crosses the 8th rib in the midclavicular
line and the 10th rib in the midaxillary line, and reaches the
12th rib adjacent to the vertebral column—that is, at the
lateral border of the erector spinae muscle. 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. The distance between the
two borders corresponds to the costodiaphragmatic recess.
 Heart
• For practical purposes, the heart may be considered to
have both an apex and four borders.
• The apex, 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.
• The superior border, 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.
 Heart
• The right border, 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
6th right costal cartilage 0.5 in. (1.3 cm) from the edge of
the sternum.
• The left border, formed by the left ventricle, extends from
a point on the 2nd left costal cartilage 0.5 in. (1.3 cm) from
the edge of the sternum to the apex beat of the heart.
• The inferior border, formed by the right ventricle and the
apical part of the left ventricle, extends from the sixth
right costal cartilage 0.5 in. (1.3 cm) from the sternum to
the apex beat.
 Thoracic Blood Vessels
• The arch of the aorta and the roots of the brachiocephalic and
left common carotid arteries lie behind the manubrium sterni.
• The superior vena cava and the terminal parts of the right and
left brachiocephalic veins also lie behind the manubrium sterni.
• The internal thoracic vessels run vertically downward, posterior
to the costal cartilages, 0.5 in. (1.3 cm) lateral to the edge of the
sternum, as far as the sixth intercostal space.
• The intercostal vessels and nerve (“vein, artery, nerve”— VAN—
is the order from above downward) are situated immediately
below their corresponding ribs
 Mammary Gland
• The mammary gland is clinically a very
important structure. Because it is closely
related to the pectoral muscles and its main
lymph drainage is into the axillary lymph
nodes. To summarize briefly, the mammary
gland lies in the superficial fascia covering the
anterior chest wall. In the child and in men, it is
rudimentary. In the female after puberty, it
enlarges and assumes its hemi spherical shape.
 Mammary Gland
• . In the young adult female, it overlies the 2nd to 6th
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.