1 Structure of the Thoracic Wall A. Sternum 1. Location: midline of the anterior chest wall 2.

Divided into three parts a. Manubrium i. Location: opposite T3, T4 vertebrae ii. Articulates with: A. Body of the sternum (see 3.a.) B. Clavicles C. 1st costal cartilage and the superior part of the 2nd costal cartilage b. Body of the sternum i. Articulates with: A. Manubrium (see 3.a.) B. 2nd to 7th costal cartilages C. Xiphoid process (see 3.b.) c. Xiphoid process i. Location: opposite T9 vertebral body ii. Articulates with: A. Body of the sternum (see 3.a.) iii. Thin plate of cartilage iv. Proximal end becomes ossified during adult life 3. Joints of the sternum a. Manubriosternal joint i. Location: opposite the T4-T5 intervertebral disc ii. Sternal angle describes the palpable traverse ridge marking the joint, lying in between the two facets for the second costal cartilages iii. Cartilaginous joint iv. Movement: small amount during respiration b. Xiphisternal joint i. Location: opposite the body of the T9 vertebrae ii. Cartilaginous joint iii. Fuses with the body of the sternum during middle age 4. Clinical correlations a. Marrow biopsy i. Marrow cavity of sternum rich in red hematopoietic marrow throughout life b. Median sternotomy i. Vertical incision along the sternum to gain access to the heart, lungs, and great vessels

B. Ribs 1. Anterior attachment a. True ribs (superior 7 pairs): via costal cartilages to sternum b. False ribs (8th-10th pairs): to each other, and via costal cartilages to the 7th rib c. Floating ribs (11th-12th pairs): no anterior attachment 2. Components of a typical rib a. Head i. Two facets articulate with the numerically corresponding, and the immediately superior, vertebral body b. Neck i. Constricted portion between the head and the tubercle c. Tubercle i. Prominence on the outer surface of the rib at the junction of the rib and shaft ii. Facet for articulation with the numerically corresponding transverse process d. Shaft i. Thin and flatted and twisted on its long axis ii. Inferior border has a costal groove e. Angle i. Where the shaft of the rib bends sharply forward 3. Atypical rib-1st rib a. Small and flattened superiorly b. Muscular attachements i. Scalenus anterior: attached to the superior surface and inner border c. Relations i. Subclavian v. crosses the rib anterior to the scalenus anterior m. ii. Subclavian a. and lower trunk of the brachial plexus cross the rib posterior to the scalenus anterior m. 4. Costal Cartilages a. Contribute to the elasticity and the mobility of the thoracic wall i. Flexibility is lost during old age as a result of superficial calcification b. 11th and 12th ribs end in the abdominal musculature 5. Joints of the ribs a. Joints of the head of the ribs i. 1st rib and the inferior 3 ribs have a single synovial joint with their corresponding vertebral body ii. 2nd to 9th ribs have synovial joint with the numerically corresponding, and the immediately superior, vertebral body 1. Intra-articular lig. connects the head to the intervertebral disc b. Joints of the tubercles of the ribs i. Articulate by means of synovial joints with the numerically corresponding transverse process (absent in the 11th-12th ribs) c. Joints of the ribs and costal cartilages i. Cartilaginous joint with no movement possible d. Joints of the costal cartilages with the sternum i. 1st costal cartilage-manubrium joint is cartilaginous, hence no movement possible ii. 2nd-7th costal cartilage-lateral border of sternum joints are synovial iii. 6th-10th costal cartilage articulate with each other along their borders via small synovial joints iv. 11th-12th costal cartilages are embedded in the abdominal musculature C. Thoracic Cavity 1. D. Intercostal Spaces 1. Musculature a. External intercostal muscle i. Most superficial layer, fibers directed downward and forward ii. Attachments: inferior border of the superior rib -> superior border of the inferior rib iii. Muscle extends forward to the costal cartilage, where it is replaced by the anterior (external) intercostal membrane b. Internal intercostal muscle

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3.

i. Intermediate layer, fibers directed downward and backward ii. Attachments: subcostal groove of the superior rib -> superior border of the inferior rib iii. Muscle extends backward from the sternum to the angles of the ribs, where it is replaced by the posterior (internal ) intercostal membrane c. Innermost intercostal muscle i. Deepest layer ii. Relations 1. Internally: endothoracic fascia and the parietal pleura 2. Externally: intercostal neurovasculature d. Action of the intercostal muscles e. Innervation of the intercostal muscles i. Corresponding intercostal nerves Vasculature a. Intercostal arteries and veins i. Posterior intercostal arteries 1. 1st-2nd spaces: subclavian a. -> costocervical trunk -> superior intercostal a. -> post. intercostal arteries 2. 3rd-11th spaces: descending thoracic aorta -> post. intercostal arteries ii. Anterior intercostal arteries 1. 1st-6th spaces: subclavian a. (1st part) -> intercostal thoracic artery -> anterior intercostal arteries 2. 7th-11th spaces: internal thoracic artery -> musculophrenic artery -> anterior intercostal arteries b. Intercostal arteries supply branches to the muscles, skin, and parietal pleura i. Branches are particularly large to the superficial structures in the breast region in females c. Posterior intercostal veins -> azygos or hemiazygous veins d. Anterior intercostal veins -> internal thoracic and musculophrenic veins Nerves a. Intercostal nerves i. Anterior rami of the 1st-11th thoracic spinal nerves ii. Anterior ramus of the 12th thoracic spinal nerves runs forward in the abdominal wall as the subcostal nerve iii. Path 1. Enters space between parietal pleura and the posterior intercostal membrane 2. Runs inferior to intercostal vessels in the subcostal groove between the innermost intercostal and internal intercostal muscle a. 1st-6th nerves distribute within the intercostal spaces b. 7th-9th nerves pass deep to the costal cartilages to enter the anterior abdominal wall c. 10th-11th nerves pass directly into the abdominal wall (as ribs are floating) iv. Branches 1. Rami communicantes a. Connect the intercostal nerve to a ganglion of the sympathetic trunk 2. Collateral branch a. Runs forward inferiorly to the main nerve, superior to the upper border of the rib below 3. Lateral cutaneous branch a. Cutaneous supply of the side of the chest b. Divides into anterior and posterior branch c. Exceptions i. 1st lat. cut. branch: contributes to the brachial plexus ii. 2nd lat. cut. branch (intercostobrachial nerve): contributes to the medial cutaneous nerve of the arm 4. Anterior cutaneous branch a. Terminal portion of the main trunk b. Cutaneous supply near the midline

c. Divides into medial and lateral branch Muscular branches a. Supplies the intercostal muscles 6. Pleural sensory branches a. Runs to the parietal pleura 7. Peritoneal sensory branches (7th-11th intercostal nerves) a. Runs to the parietal peritoneum v. 1st-6th intercostal nerves supply the skin and parietal pleura covering the outer and inner surfaces of the intercostal space, intercostal muscles, and levatores costarum and serratus posterior muscle vi. 7th-11th intercostal nerves supply the skin and the parietal peritoneum covering the outer and inner surfaces of the abdominal wall, and the anterior abdominal muscles E. Endothoracic fascia 1. Separates the parietal pleura from the thoracic wall 2. Suprapleural membrane is thickening of the endothoracic fascia a. Located lateral to the structures passing through the thoracic outlet b. Membrane closes the thoracic outlet on either side of these structures c. Attachments i. Lateral: medial border of the 1st rib and costal cartilage ii. Superior: transverse process of the 7th cervical vertebra iii. Medial: fascia investing the structures passing from the thorax into the neck d. Functions i. Protects underlying cervical pleura ii. Resists changes to the intrathoracic pressure during respiration F. Diaphragm 1. Muscular, tendinous septum separating the chest cavity from the abdominal cavity 2. Three parts a. Sternal part b. Costal part c. Vertebral part 3. 5.