THORACIC

WALL
DANTE JOSE D. MERCADO, MD
CHIEF OF SECTION GROSS ANATOMY

OBJECTIVES
1. Analyze the articular surfaces on these bones with regards
their possible movements: - ribs, sternum and thoracic
vertebrae.
2. Determine the boundaries of the thoracic inlet and discuss
its functional and clinical significance.
3. Identify the following landmarks on the chest of a live
subject: sternoclavicular junctions; jugular notch; sternal
angle of Louis; ribs composing the costal arch; level of the
nipple; anterior and posterior axillary folds; and at the back,
the vertebra prominens, crest of the scapular spine,
vertebral border and inferior angle of the scapula.
4. Indicate these reference lines on an illustration of the chest
or on a live subject: midsternal, midclavicular; anterior,
posterior, mid-axillary and scapular lines.
5. Discuss the significance of the origin, course and position of
the intercostal neurovascular structures.
6. Differentiate these deformities: pectus excavatus; pigeon
breast; barrel chest; scoliosis and kyphosis.

Soft Tissue Landmarks

Muscular and membranous components

inherent to the thoracic wall:
External and Internal Intercostal Muscles and membranes: - attached to the
superior and inferior borders of each rib; and occupying each intercostal
space (ICS)
fibers of these 2 muscles cross each other obliquely in each ICS.
(To verify, cut the attachments of a few external intercostal muscles along
the inferior border of the rib and carefully cut the fibers from those of the
underlying internal intercostal muscle.)
fibers of each external muscle fill each ICS from the vertebral border to
the costo-chondral junction;
those of the internal muscle range from the sternal border to the angles
of the ribs dorsally.
the unoccupied areas are filled with the corresponding anterior and
posterior intercostal membranes.
innervated by corresponding intercostal nerves
The traditional view: the external intercostals elevate each rib, while the
internal intercostals depress the ribs
others recently support the view that both muscles elevate each rib,
allegedly supported by electro-myographic studies. Whichever concept
is considered, the muscles are respiratory muscles in the sense that
they help to expand and contract the thoracic wall thus affecting the
diameters of the thoracic cavity.

Pedicle

Lamina

Superior articular process

Inferior articular process

Articular process fro head of the rib

The common middle rib

consists of the neck that
is closest to the thoracic
spine with an articular
tubercle, the angle of
which is a curved portion
of the rib, and the distal
body.
The subcostal groove is
best seen when viewed
from the back. The costal
artery and nerve follow
the subcostal groove.

1st Rib

The first rib is one of the

upper, specialized ribs.
Important features include
the attachment of the
scalenus medius muscle
and the serratus anterior
muscle. A groove for the
subclavian artery and vein
represent important
potential areas of serious
injury in fractures of the
first rib.

10th Rib

Drawing of the 10th rib.

Note that the 10th rib has
a single articular facet. No
direct anterior connection
to the sternum is present.
The forms of the 10th,
11th, and 12th ribs are
similar.

Typical Ribs

Typical upper thoracic rib.

Each of the upper 9
thoracic ribs has 2
posterior articulations
with a thoracic vertebral
body above and below
(CVJ) and an anterior
articulation with the
sternum (CCJ).

INTERCOSTAL NERVE BLOCK

Intercostal nerve block is

intended to anesthetize the
intercostal nerves in anticipation
of performing minor surgery on
some part of the thoracic wall
(e.g. removal of a skin tag, sewing
a laceration,) and to relieve pain
in a rib fracture.
The posterior angle of the rib is
palpated and the anesthetic
introduced along the lower edge
of the rib selected. The aim is to
bathe the intercostal nerve with
the local anesthetic and eliminate
sensation in the intercostal space
anterior to this point. Remember
that several intercostal nerves
must be blocked to achieve real
anesthesia in just one segment
because of the presence of
collateral branches.

External Intercostal Muscle

& Anterior Intercostal Membrane

Internal Intercostal Muscle

& Posterior Intercostal Membrane

At the inner surface of the chest wall:

Sterno-costalis (or transversus thoracis or triangularis sterni)

- has narrow origins from the deep surface of the xyphoid
process and adjoining 6th and 7th costal cartilages. The fibers
expand laterally and superiorly to the costal cartilages of the
2nd to the 4th ribs.
The muscle pulls down to a certain extent the corresponding
ribs to which the fibers are attached during forced expiration.
It also maintains the position of the internal thoracic vessels
alongside the lateral sternal border.
Along the internal surface, among the lower ICS, many of the
deeper fibers of the internal intercostal muscles are separated
by the passage of the intercostal neurovascular structures.
These separated fibers are often referred to as the innermost
intercostal muscles.
More posteriorly, some of these muscle slips bridge through
one or more ribs to be attached to higher ribs, to be
distinguished as subcostal muscles.

Movements of the Thoracic Wall

Costo-vertebral synovial joints allow upward, outward and

limited backward movements of the ribs.
The elastic cartilages allow forward expansion, thrusting the
sternum forwards and upwards, thus increasing the anteroposterior (AP) diameter of the thoracic cavity.
Ribs 7 to 10 are pulled upwards and backwards (bucket-handlecaliper movements, by Grant) which increase the diameters of
the lower part of the thoracic cavity.
Demonstrate.
The last two pairs of ribs are held fixed by the attached
abdominal muscles and the serratus posterior.
Furthermore, the tone of the intercostal muscles maintain the
tension of each ICS to counteract the inward pull of the
contracting respiratory diaphragm and intra-thoracic pressure.
For very deep, forced inspirations, the action of other extrinsic
muscles attached to other parts of thoracic cage help in
the
expansion of the thoracic cavity.
What are those muscles?

Respiratory Diaphragm

Expiration results from

the elastic recoil of the
lungs, ribs and costal
cartilages upon relaxation
of the above-named
muscles.
In forced expiration, the
abdominal muscles are
called into play, including
other muscles in other
regions for increased
support and fixation
purposes.

Accessory Muscles

Intercostal Nerves

Intercostal nerves - extensions of the anterior rami of the 12

pairs of thoracic spinal nerves.
These nerves initially occupy the middle of each ICS with the
accompanying blood vessels situated above each nerve, thus
arranged as V.A.N.
At the costal angles, these N.V.S. fit in the costal groove of
the upper rib, held and protected by strips of fascia and
occasional fasciculi of the innermost intercostal muscles.

Each intercostal nerve is composed of 3 kinds of fibers:

a. Motor fibers
b. Sensory fibers from the cutaneous areas and some from the
parietal pleura.
c. Sympathetic fibers (GVE) for smooth muscles around blood
vessels; and secretory fibers to the glands in
the skin.

The lower 6 intercostal nerves extend their fibers to

corresponding structures at the antero-lateral aspect of the
abdominal wall.

The Intercostal Arteries

Anterior set - consists of a pair of slender arteries for
each ICS, coursing along the upper and lower
borders of each rib.
Branches of the internal thoracic artery which
courses downwards after arising from the parent
trunk which is the subclavian artery.
Upon reaching the 6th ICS level, the internal thoracic
divides into its 2 terminal branches:
lateral musculo-phrenic artery coursing along the
inner border of the costal margin giving intercostal
branches for the 7th,8th and 9th ICS
the superior epigastric artery which continues
descending vertically on the inner surface of the
anterior abdominal wall to supply its tissues.

Posterior set - 9 single arteries for each ICS arising from

the thoracic aorta starting with the 3rd ICS down to the
12th, which is called subcostal artery since it is below
the 12th rib.
The first two posterior intercostal arteries arise from the
superior intercostal artery, which is a branch of the
costo-cervical trunk of the subclavian.
At the angle of the ribs, each artery divides into an
upper and a lower branch to anastomose with the
anterior arteries in each ICS.
The 10th and 11th ICS are supplied by the posterior
arteries only. The subcostal artery supplies the posterolateral abdominal wall.

The intercostal veins are positioned above the arteries.

Anterior set, from the 1st to the 3rd ICS drain into the internal
thoracic vein.
The veins in the lower 4th-9th ICS drain into the musculophrenic vein. This vein joins with the ascending superior
epigastric vein to form the single internal thoracic vein at the
level of the 3rd ICS.
The posterior set:
The lower 4th-11th intercostal veins at the right side drain into
the azygos vein that ascends from the abdominal cavity
alongside the lumbar vertebrae.
The left veins drain into an inferior hemi-azygos vein (if
present) also from the abdominal cavity.
The first intercostal veins drain into the vertebral or brachiocephalic vein.
The 2nd and 3rd veins unite to form a superior intercostal vein
which drains into the azygos at the right and into a superior
hemiazygos at the left.

Intercostal NVS

Surgeons must be
very careful
When they take the
knife!
Underneath their fine
incisions stirs the
culpritLIFE!
DJDMERCADO, MD