Thorax

PROFESSOR. DR. FAUZIAH OTHMAN DEPARTMENT OF HUMAN ANATOMY, FACULTY OF MEDICINE AND HEAALTH SCIENCE, UPM

Regional anatomy of thorax

Parts and regions of the thorax

Boundaries Superiorjugular notch, sternoclavicular joint, superior border of clavicle, acromion, spinous processes of C7 Inferiorxiphoid process, costal arch, 12th and 11th ribs, vertebra T12 Regions Thoracic wall Thoracic cavity

Xiphoid processphisternal junction lies opposite the body of the 9th thoracic vertebra Clavicle

Inferior fossa of clavicle Coracoid process

Ribs and intercostal spaces Costal arch

Infrasternal angle Xiphocostal angle

Landmarks

Jugular notch corresponds with

2th to 3th thoracic vertebra.

Sternal angle connects 2nd costal cartilage laterally corresponds with

The lower border of 4th thoracic vertebra The bifurcation of trachea in the adult The beginning of aortic arch which ends posteriorly at the same level The esophagus is crossed by the left main bronchus

Thoracic wall

Skin Superficial fascia

Thoracoepigastric v. Supraclavicular n. Anterior and lateral cutaneous branches of intercostal n.

Deep fascia

The muscles of thorax

Extrinsic muscles

Pectoralis major Pectoralis minor Serratus anterior

Intrinsic muscles

Intercostales externi Intercostales interni Intercostales intimi Transverses thoracis

Intercostales externi

Origin: lower border of ri) Insertion: upper border of rib below origin Action: elevate ribs adding in forced inspiration Replaced anteriorly by external intercostals membrane. Origin: upper border of rib Insertion: lower border of rib above origin Action: depress ribs for forced expiration Replaced posteriorly by internal intercostals membrane.

Intercostales interni

Diaphragm
Shape and position:
dome-shaped between thorax and abdomen, consists of a peripheral muscular part and a central tendon

Origin

Sternal part: xiphoid process Costal part: lower six and costal cartilages Lumbar part: arises by two crura from upper 2-3 lumbar vertebrae Insertion: central tendon
muscular tissue Lumbocostal triangle: between costal and lumbar parts. Sternocostal triangle: between costal and sternal parts.

Weak areas: triangular spaces without

Openings in the diaphragm

Aortic hiatuslies anterior to the body of the 12th thoracic vertebra between the crura. It transmits the aorta, thoracic duct Esophageal hiatus for esophagus and vagus nerves at level of T10. Vena cava foramen for inferior vena cava, through central tendon at T8 level

T8

T10

T12

Action:

Contraction: the dome moving downward, increases the volume of thoracic cavity which results in inspiration, at the same time the intraabdominal pressure is increased assists in defecation, vomiting or child birth. Relaxation: the dome returns to the former position, reduces the volume to the thoracic cavity, resulting in expiration.

Arteries of thorax
Pulmonary trunk

Arises from right ventricle Runs up, back ,and to the left Bifurcates inferior to aortic arch into right and left pulmonary arteries, one for each lung Right pulmonary arterypasses posterior to ascending aorta and superior vena cava to hilum of right lung Left pulmonary arterypasses anterior to descending aorta and left main bronchus to hilum of left lung

Pulmonary arteries

Arterial ligament remnant of ductus arteriosus, connects

bifurcation of pulmonary trunk to inferior border of aortic arch

Triangule of ductus arteriosus Bounded by phrenic n., left vagus

n. and left pulmonary a. Contents arterial ligament , left recurrent n. and superficial cardiac plexuses

Ascending aorta

Runs upward, forward and to the right, Extends to level of second right sternocostal joint Branches: right and left coronary arteries

Aortic arch Continuation of

ascending aorta Curves upward, to the left and posteriorly, then downward, arching over left principal bronchus and pulmonary trunk to lower border of T4 level, to become descending aorta Branches (from right to left )
Brachiocephalic trunkextends to right sternoclavicular joint, bifurcates into right subclavian and right common carotid arteries Left common carotid artery Left subclavian artery

Aortic isthmusbaroreceptor Aortic glomerachemoreceptor

Thoracic aorta

Continuation of aortic arch at lower border of T4 Courses downward on left side of, then in front of vertebral column Passes through aortic hiatus of diaphragm at level of T12 vertebra to enter abdominal cavity Main branches Parietal branches Nine pairs posterior intercostals arteries One pair subcostal artery For lower nine intercostals spaces and upper part of abdominal wall; superior phrenic arteries supply the superior surface of the diaphragm. Visceral branches Bronchial branches: one or two for each lung Esophageal branches Pericardial branches

Internal thoracic artery descends into thorax 1.2cm lateral to edge of sternum, and ends at the sixth costal cartilage by dividing musculophrenic and superior epigastric arteries

Veins of thorax
Brachiocephalic veins

Formed by union of internal jugular and subclavian veins posterior to the sternoclavicular joint Angle of union is termed venous angle

Superior vena cava

Formed by union of right and left brachiocephalic veins behind the right sternocostal synchorndrosis of first rib Runs vertically down on right of ascending aorta Joined by azygos vein at level of sternal angle Enters right atrium at lever of lower border of third right sternocostal joint Collects blood from veins of upper half of body

Azygos vein

Begins as continuation of right ascending lumbar vein Ascending along the right side of vertebral column Joins superior vena cava by aching above right lung root at level of T4 to T5 Receives right posterior intercostals and subcostal veins plus some of bronchial, esophageal and pericardial veins, and hemiazygos vein Tributarieshemiazygosv. and accessory hemiazygos v. which receive most left posterior intercostals vein and left bronchial veins

Veins of vertebral column

Consists of External vertebral venous plexus Internal vertebral venous plexus

The lymphatic drainage of thorax

The lymphatic drainage of thoracic wall

To axillary lymph nodes To parasternal lymph nodes (along internal thoracic vessels) To intercostals lymph nodes from deeper structures

lymph nodes of the thoracic contents

lymph nodes of trachea, bronchi and lungs

Pulmonary lymph nodes lie in the angles of bifurcation of branching lobar bronchi Bronchopulmonary hilar lymph nodeslie in the hilus of the lung Tracheobronchial lymph nodes situated above or below the bifurcation of trachea Paratracheal lymph nodes along each side of the trachea

Anterior mediastinal lymph node

lies anterior to the large blood vessels of thoracic cavity and pericardium; the efferents unite with those of paratracheal lymph nodes, to form the right and left bronchomediastinal trunks The left bronchomediastinal trunk terminates in thoracic duct, and right in the right lymphtic duct

Posterior mediastinal lymph nodes

lie along the esophagus and thoracic aorta

Thoracic duct
Begins in front of L1 as a dilated sac, the cisterna chyli which formed by joining of left and right lumbar trunks and intestinal trunk Enter thoracic cavity by passing through the aortic hiatus of the diaphragm and ascends along on the front of the vertebral column, between thoracic aorta and azygos vein Travels upward, veering to the left at the level of T5 At the roof of the neck, it turns laterally and arches forwards and descends to enter the left venous angle

Just before termination, it receives the left jugular, subclavian and bronchomediastinal trunks Drains lymph from lower limbs, pelvic cavity, abdominal cavity, left side of thorax, and left side of the head, neck and left upper limb Formed by union of right jugular, subclavian, and bronchomediastinal trunks Ends by entering the right venous angle Receives lymph from right half of head, neck, thorax and right upper limb

Right lymphatic duct

Anterior branches of thoracic nerves

Intercostal nerves (anterior rami of T1- T11): runs forward inferiorly to intercostals vessels in costal groove of corresponding rib, between intercostals externi and intercostals interni; first six nerves are distributed within their intercostals space, lower five intercostals nerves leave anterior ends of their intercostals spaces to enter abdominal wall Subcostal nerve (anterior ramus of T12): follows inferior border of T12 rib and passes into abdominal wall Distribution: distributed to intercostales and anterolateral abdominal muscles, skin of thoracic and abdominal wall, parietal pleura and peritoneum

The segmental innervation of anterior surface of trunk

T2sternal angle T4 nipple T6xiphoid process T8costal arch T10umbilicus T12midpoint between umbilicus and symphysis pubis

Phrenic nerve
Descends over scalenus anterior to enter thorax Accompanied by pericardiophrenic vessels and passes anterior to lung roots between mediastinal pleura and pericardium to supply motor and sensory innervation to diaphragm Sensory fibers supply to pleurae, pericardium and peritoneum of diaphragm; usually right phrenic nerve may be distributed on live, gallbladder and biliary system.

Left vagus nerve

Enter thoracic inlet between left common carotid and left subclavian arteries, posterior to left brachiocephalic vein Crosses aortic arch where left recurrent laryngeal nerve branches off Passes posterior to left lung root Forms anterior esophageal plexus Forms anterior vagal trunk at esophageal hiatus where it leaves thorax and passes into abdominal cavity , then divides into anterior gastric and hepatic branches

Right vagus nerve

Enter thoracic inlet on right side of trachea Travels downward posterior to right brachiocephalic vein and superior vena cava Passes posterior to right lung root Forms posterior esophageal plexus Forms posterior vagal trunk at esophageal hiatus where it leaves thorax and passes into abdominal cavity, then divides into posterior gastric and celiac branches

Recurrent laryngeal nerves

Right one hooks around right subclavian artery, left one hooks aortic arch Both ascend in tracheo-esophageal groove Nerves enter larynx posterior to cricothyroid joint, the nerve is now called inferior laryngeal nerve Innervations: laryngeal mucosa below fissure of glottis , all laryngeal laryngeal muscles except cricothyroid

Bronchial and esophageal branches

Thoracic sympathetic trunk

Branches of sympathetic trunk to thoracic plexuses Greater splanchnic nerve formed by preganglionic fibers from T5~T9 ganglia, and relay in celiac ganglion. Lesser splanchnic nerve formed by preganglionic fibers from T10~T12 ganglia, and relay in aorticorenal ganglion. The postganglionic fibers supply the liver, spleen, kidney and alimentary tract as far as the left colic flexure.

Intercostal space
Posterior intercostal v. Posterior intercostal a. Intercostal n.

Lymphatic drainage of breast

Into pectoral ln. from lateral and central parts of breast Into apical and supraclavicular ln. from superior part of breast Into parasternal ln. from medial part of breast Into interpectoral ln. from deep part of breast The lymphatic capillaries of breast form an anastomosing network which is continuous across the midline with that of the opposite side and with that of the abdominal wall

Internal thoracic vessels Internal thoracic a.&v. Parasternal ln. Endothoracic fascia

The Mediastinum
Conceptall of organs between the left and right mediastinal pleurae is called mediastinum. It extends from the sternum in front to the vertebral column behind, and from the thoracic inlet above to the diaphragm below.

Subdivisions of mediastinum

Superior mediastinum Inferior mediastinum

Anterior mediastinum

Middle mediastinum Posterior mediastinum

Left side of mediastnum

Left subclavian a. Thoracic duct

Left vagus n. Left recurrent n. Phrenic n. & pericardiacophrenic a.

Root of lung Pericardium Esophagus

Aortic arch Thoracic aorta

Sympathetic trunk

Greater splanchnic n

Right side of mediastnum

Trachea Left vagus n. Arch of azygos v. Azygos v. Superior vena cava Phrenic n. & pericardiacophrenic a. Root of lung Pericardium

Sympathetic trunk
Esophagus Inferior vena cava

Superior mediastinum
Locatingfrom inlet of
thorax to plane extending from level of sternal angle anteriorly to lower border of T4 vertebra posterioly

Contents

Superficial layer

Thymus Three veins

Left brachiocephelic v. Right brachiocephelic v. Superior vena cava

Middle layer

Aotic arch and its three branches Phrenic n. Vagus n.

Posterior layer

Trachea Esophagus Thoracic duct

Relations of aortic arch

Anteriorly and to the left pleura, lungphrenic n., pericardiacophrenic vessels and vagus n. Posteriorly and to the right trachea, esophagus, left recurrent n., thoracic duct, deep cardiac plexus Superiorlyits three branches, left brachiocephalic v. and thymus Inferiorlypulmonary a., arterial ligament, left recurrent n., left principal bronchus and superficial cardiac plexus

Triangule of ductus arteriosus

Bounded by phrenic n., left vagus n. and left pulmonary a. Contents arterial ligament , left recurrent n. and superficial cardiac plexuses

Inferior mediastinum
Anterior mediastinum
Locationposterior to body of sternum and attached costal cartilages, anterior to heart and pericardium Contentsfat, remnants of thymus gland, anterior mediastinal lymph nodes

Middle mediastinum

Locationbetween anterior mediastinum and posterior mediastinum Contents: hart and pericardium, beginning or termination of great vessels, phrenic nerves, pericardiacophrenic vessels , lymph nodes,

Posterior mediastinum
Locationposterior to heart and pericardium, anterior to vertebrae T5T12 Contents: esophagus, vagus n., thoracic aorta, azygos system of veins, thoracic duct, thoracic sympathetic trunk, posterior mediastinal lymph nodes

Relations of esophagus

Anteriorlytrachea, bifurcation of trachea, left principal branchus, left recurrent n., right pulmonary a., anterior esophageal plexus, pericardium, left atrium, diaphragm

Posteriorlyposterior esophageal plexus, thoracic aorta, thoracic duct, azygos v., hemiazygos v.,accessory hemiazygos v., right posterior intercostal v.

Leftleft common carotid a., left subclavian a., aortic arch, thoracic aorta, superior part of thoracic duct Rightarch of azygos v.

Relations of thoracic aorta

Anteriorlyleft root of lung, pericardium and esophagus Posterior hemiazygos v., accessory hemiazygos v., Rightazygos v. and thoracic duct Leftmediastinal pleura

Mediastinal spaces

Retrosternal space lies beween sternum and endothoracic fascia Pretracheal space lies within superior mediastinum, between trachea, bifurcation of trachea and aortic arch Retroesophagus space lies within superior mediastinum, beween esophagus and endothoracic fascia