3. Thorax  Region of the body between the neck and abdomen  Flattened in front and behind, but rounded on the sides thoracic cage  The bony framework of the walls is called the thoracic cage, which is formed of:  Vertebral column posteriorly  Ribs & intercostal spaces on the sides  Sternum and costal cartilages anteriorly

4. Superiorly: It communicates with the neck through an opening bounded:  Posteriorly by 1 st thoracic vertebra  Laterally by medial border of the 1 st ribs and their costal cartilages  Anteriorly by superior border of manubrium sterni This opening is occupied:  In the midline, by the structures that pass between the neck and the thorax  On either sides, it is closed by a dense suprapleural membrane 1 1 st rib Suprapleural membrane

5. Suprapleural Mem brane  Tent shaped dense fascial sheet that covers the apex of each lung.  An extension of the endothoracic fascia  Extends approximately an inch superior to the superior thoracic aperture  It is attached:  Laterally to the internal border of the first rib & costal cartilage  At its apex to the transverse process of C7 vertebra.  Medially to the fascia covering the structures passing through the superior thoracic aperture

6. Inferiorly: It communictes with the abdomen through a large opening bounded:  Posteriorly by the 12 th thoracic vertebra  Laterally by curving costal margin  Anteriorly by xiphisternal joint This opening is closed by the diaphragm Costal margin 2th rib 12

7. The thoracic cage:  Protects the lungs, heart and large vessels  Provides attachment to the muscles of thorax, upper limb, abdomen & back The cavity of thorax is divided into: A median partition, the mediastinum Laterally placed pleurae & lungs

8. Cutaneous Nerves Anterior wall:  Above the level of sternal angle: Supraclavicular nerves  Below the level of sternal angle: Segmental innervation by anterior and lateral cutaneous branches of the intercostal nerves Posterior wall:  Segmental innervation by posterior rami of the thoracic spinal nerves nerves

9. Thoracic Dermatomes

10. The Intercostal Space

11. Intercostal Space It is the space between two ribs Since there are 12 ribs on each side, there are 11 intercostal spaces. Each space contains:  Intercostal muscles  Intercostal neurovascular bundle  Lymphatics

12. Intercostal muscles Each intercostal space has three muscles: External Intercostal Internal Intercostal Innermost Intercostal Supplied by corresponding intercostal nerves Action: Tend to pull the ribs nearer to each other  Strengthen the tissue of the space

13. External Intercostal Muscle Most superficial Fibers directed downward & forward Origin Origin: from lower border of the rib above Insertion Insertion: upper border of rib below Extends from the rib tubercle behind to the costo-chondral junction in front external (anterior) intercostal membrane Deficient anteriorly & replaced by external (anterior) intercostal membrane Costo-chondral junction

14. Internal Intercostal Muscle Intermediate layer Fibers directed downward & backward Origin Origin: from subcostal groove of the rib above Insertion Insertion: upper border of rib below Extends from the sternum in front to the angle of the rib behind internal (posterior) intercostal membrane Deficient posteriorly & replaced by internal (posterior) intercostal membrane

15. S costochondral junction CC V anterior intercostal membrane & external intercostal muscle posterior intercostal membrane & internal intercostal muscle Angle of the rib

16. Innermost Intercostal Muscle Deepest layer Incomplete layer, divided into three portions Fibers cross more than one intercostal space endothoracic fascia Related externally to intercostal nerve and vessels, and internally to endothoracic fascia

17. Endothoracic Fascia It is the extrapleural fascia that lines the wall of the chest It is located between the muscles and bones of the thoracic wall and the parietal pleura, extends over the apex (cupola) of the pleura as the suprapleural membrane, and forms a thin layer between the diaphragm and the pleura.

18. Intercostal Neurovascular Bundle Lies between the innermost and the internal intercostal muscles Runs high in the intercostal space, related to subcostal groove of the rib above VAN) Has a strict order in arrangement: Vein-Artery-Nerve (VAN), from top to bottom As the innermost intercostal muscle is not forming a complete layer, the bundle is generally covered on the inside by the endothoracic fascia

19. Intercostal Nerves Twelve pairs anterior primary rami thoracic spinal nerves. Are the anterior primary rami of the thoracic spinal nerves. 1-6 distributed in the intercostal spaces, 7-11 th supply the anterior abdominal wall 12 th subcostal nerve Anterior ramus of 12 th nerve runs forward in the abdomen as the subcostal nerve

20. Intercostal Nerves cont’d mixed These are mixed nerves & supply the: The skin Muscles of the intercostal space & abdomen The parietal pleura & parietal peritoneum Branches: Rami communicantes Collateral branches  Lateral cutaneous  Anterior cutaneous  Muscular branches  Pleural  Peritoneal (7 th -11 th )

22. Atypical Intercostal Nerves First thoracic nerve : Has no anterior cutaneous branch Is joined to the brachial plexus by a large branch that corresponds to the lateral cutaneous branch Second thoracic nerve : Is joined to the medial cutaneous nerve of the arm by brachial plexus by a branch called the intercostobrachial nerve that corresponds to the lateral cutaneous branch

23. Intercostal Arteries Each intercostal space contains:  A single posterior &  Two anterior intercostal arteries Each artery gives off branches to the muscles, skin, parietal pleura (& breast)

24. Posterior Intercostal Arteries two superior intercostal artery In the upper two spaces, arise from the superior intercostal artery (a branch of costocervical trunk of the subclavian artery) nine thoracic aorta In the lower nine spaces, arise from the branches of thoracic aorta The course and branching of the intercostal arteries follow the intercostal nerves The course and branching of the intercostal arteries follow the intercostal nerves

25. Anterior Intercostal Arteries six internal thoracic artery In the upper six spaces, arise from the internal thoracic artery five musculophrenic In the lower five spaces arise from the musculophrenic artery (one of the terminal branch of internal thoracic) Form anastomosis with the posterior intercostal arteries

26. Intercostal Veins Accompany intercostal arteries and nerves Each space has posterior & anterior intercostal veins Eleven posterior intercostal and one subcostal vein Lie deepest in the costal grooves Contain valves which direct the blood posteriorly

27. Posterior Intercostal Veins On right side: On right side: first The first space drains into the right brachiocephalic vein Rest of the intercostal spaces drain into the azygos vein On left side: On left side: upper three The upper three spaces drain into the left brachiocephalic vein. Rest of the intercostal spaces drain into the hemiazygos and accessory hemiazygos veins, which drain into the azygos vein

28. Anterior Intercostal Veins five musculophrenic The lower five spaces drain into the musculophrenic vein (one of the tributary of internal thoracic vein) six internal thoracic vein The upper six spaces drain into the internal thoracic vein internal thoracic The internal thoracic vein drains into the subclavian vein.

29. Lymphatics Lymph vessels of the intercostal space conform to the general rule, that deep lymphatics follow arteries anterior intercostal nodes Anteriorly drain into anterior intercostal nodes that lie along the internal thoracic artery posterior intercostal nodes Posterioly drain into posterior intercostal nodes that lie in the posterior mediastinum

30. Applied Anatomy  Sternum:  used for marrow biopsy  May be split to make surgical access to heart, great vessels and thymus  Sternal angle as an important landmark for counting ribs, costal cartilages and intercostal spaces  Thoracic outlet syndrome: Compression of nerves /vessels at the superior aperture of thorax  Cervical rib  Referred pain: Disease in the thorax may reveal pain in the anterior abdominal wall… Why?

31. Applied Anatomy cont’d  Traumatic injuries to the thorax:  Fracture of rib is extremely painful condition as periosteum of the rib is supplied by the intercostal nerves above & below the rib  Fractured rib may penetrate the lung (and produce pneumothorax) or may damage the upper abdominal organs  Injuries involving multiple ribs result in flail chest. The flail segment is sucked in during inspiration and pushed out during expiration

32. Applied Anatomy cont’d  The intercostal spaces are important access points for:  Surgical procedures, e.g. resection of (part of) the lung  Percussion and auscultation of underlying structures e.g. heart & lung  To obtain a sample of pleural fluid or drain pus/blood from the pleural cavity. The needle/drain is passed through the intercostal space just above the upper border of the rib to avoid the neurovascular bundle.