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Anatomy of the thorax

Thoracic cavity is simply an area within the thoracic cage and is divided into
3 spaces.
What are the 3 spaces?
o Right pulmonary cavity
o Left pulmonary cavity
o mediastinum
The first 2 spaces are occupied by the lungs (left and right pulmonary cavity).
The middle space is called the mediastinum (one of the main contents of the
mediastinum is the heart).
It is divided into three major spaces: the central compartment (mediastinum)
that houses the thoracic viscera except for the lungs and, on each side, the
right and left pulmonary cavities houses the lungs.
So the thoracic cavity and its wall have a shape of truncated cone, superiorly
is smaller than inferiorly (being narrowest superiorly, with the circumference
increasing inferiorly, and reaching its maximum size at the junction with the
abdominal portion of the trunk).
The thoracic cavity is basically located in between the neck and abdomen;
however, it is an open space with the neck but it is seperated inferiorly from
the abdomen.
we were talking about the space now we are talking about the wall
so the bony thing by itself is called the thoracic cage however when I add the
muscle into the bone I am talking about the thoracic wall
the thoracic cage is basically composed of what ?
1- ribs
2- sternum
3- vertebrae (12 thoracic vertebrae are involved in the thoracic cage)
from the name how many types of vertebrae do we have?
1- Cervical
2- Thoracic
3- Lumbar
4- Sacrum
so the cage is formed by sternum at the middle, the ribs found laterally and
anteriolaterally and posteriorly we have the 12 vertebrae.
When I add into the thoracic cage the muscles then I call it the thoracic wall
The thoracic wall includes the thoracic cage and the muscles that extended
between the ribs as well as the skin, subcutaneous tissue, muscles, and
fascia covering its anterolateral aspect. The same structures covering its
posterior aspect are considered to belong to the back. (from note)
The skeletal elements of the thoracic wall consist of 12 thoracic vertebrae
posteriorly, 12 pairs of ribs laterally and the sternum anteriorly.(from note)
Three (3) types of muscles are available in between the ribs it basically closes
the area in between the ribs what are the names of the muscles?
1- the external intercostal (because it is in between the costals) muscle
2- the internal intercostal muscle which is the inner one

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3- the innermost intercostal muscle

as u can see here the waves of both muscles are in different directions and
thats basically to give strength to that wall (if u have a material or anything
that you put in a different direction the stength of that material will be much
more) so we have 3 layers closing the area and giving stength and protecting
what ever is inside
The floor of the thoracic cavity is deeply invaginated inferiorly by viscera of
the abdominal cavity.(from note)
so the name in anatomy always apply a position and connection between 2
structures or the function.
What is the function of the thoracic cage ?
1- Protection (protect all the thoracic organs within it)
2- Take part in breathing (with the muscles that are available contraction
of the muscle will allow the cage to get bigger and increase in
capacity)
3- Provide attachments for muscles (without the thoracic cage the
muscles wouldnt be able to attach)
4- Support the pectoral girdle (this is the name we give to the shoulder so
in order for me to have my upper limb conncted to my central axis the
cage helps in the attachment of the muscle so we have the pectoral
girdle or upper limb or the shoulders connected to the entire body)
5- Considered as a conduit for structures that passes to or out of the
thorax (as we know within the thorax we have the heart and the heart
provides blood to the entire body for that to happen we need to
conduct blood through vessels so vessels will either go up to the head
and neck or descend to go to the abdomen not only that we also need
nerves to go from the spinal cord all the way either to supply the head
ad neck or descend to the lower limbs abdomen and all other structure
so the thoracic cage provide a passage superiorly and inferiorly)
Slide 6

The first passage is the superior thoracic aperture, which is a

passageway that allows communication with the neck and upper limb.
(appears in red in the picture)
What are the boundries of superior aperture?
1- Anteriorly the sternum
2- laterally rib (which rib? the first rib)
3- posteriorly the verterbra (which thoracic vertebra the first
thoracic vertebra)
What passes through the superior aperture?
1- Blood vessels (both arteries and veins)
2- Nerves
3- Esophagus
4- Trachea
Arteries include:

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1- Subclavian artery: which is an artery that go all the way to

supply the upper limb (so we need to bring the artery from the
heart all the way above here through the Superior thoracic
appereture and then send it to the upper limb)
2- Common carotid artery: which go all the way to the head and
neck and this divided into 2 ( just remember that she wont
mention them in details )
At the same time you have equivelant veins that are responsiible for
collecting blood these veins include:
1- the subclavian vein: collecting blood from the upper limb
2- the internal jugular vein: which collects blood from the head and
neck and send it back to the heart.
all these arties and veins need to pass through the supperior Thoracic
Aperture to get to their places
not only that we also have the esophagus and we have the trachea in
this space
we have 2 important nerves which are
1- the vagus
2- and phrenic nerve ( remember the names now but they descend
from the head and neck all the way through this aperture
interiorly (inferiorly) to do their job )
Why we need to know that ? How would it help ?
o Superior thoracic aperture is a small area within it as u can see
even the apex of the lung is located and sometimes with
breathing it extend all the way up to here so any injury within
that area or any hemorrage or lump whether internal lump or
external lump will affect any of these structures (an example
which u dont need to know is if u have a thyroid enlargement
whether it is hyperatrophy or cancer any increase in that thyroid
will pressure everything behind it so the patient will come and
probably complain of diffuculty breathing or swallowing all these
things can compromise the blood supply (force pressure) either
to the head and neck or to the upper limb)
o Remember that it is a close space within it passes a load of
important and critical structures even if u have an injury in that
area u need to know what u have so u work on this area
another clinical example is thoracic outlet syndrome in thoracic outlet
syndrome it is either a lump or an extra rib here (extra cervical rib)
which is not normal but can happen normally we have 12 pairs but u
can have an extra pair which is connected to the 8 th cervical vertebrae
and that will compromise the area because we said it is a small area it
has loads of things and it doesnt need anything extra if that happen
this will either compromise the nerves which passes from the spinal
cord to supply the upper limb and we call them the brachial plexus or it
can simply pressure the subclavian artery which supply the hand and
arm and in that case the patient will be complain about pain either due

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to the fact that u compromised or forced pressure on the blood supply

or because ur forcing pressure on the nerve supply to the upper limb.
The axillary inlet to the upper limb lies on each side of the superior
thoracic aperture.(from note)
Cervical rib syndrome results from compression of the inferior trunk of
brachial plexus.(from note)
The costoclavicular syndrome results from compression of the
subclavian artery between the clavicle and 1st rib. (from note)

Inferior thoracic aperture

The difference between the two apertures ( superior and inferior)

1- The inferior thoracic aperture is a bigger aperature
2- The inferior thoracic aperture is closed completely
Superiorly (in the superior thoracic aperture) there was no closure
to this area (direct communication between the thorax and the
neck)
when it comes to the lower or inferior aperture it is closed by the
diaphragm
Simply the diaphragm is a muscular structure it attaches all the
way to the borders of the inferior apperture and it helps separate
the sturctures in the thorax from the abdomen.
The diaphragm basically attaches to
1- posteriorly to the 12th rib and the tip of the 11th
2- the costal margin (cartilage) of the ribs 7/8/9/10.
The diaphragm has a muscular sturcture and a central tendon
structure that attaches into it because of the function of the
diaphragm
what is the function of the diaphragm? for breathing
1- separates the thorax from the abdomen
2- it contracts to help in breathing as it increases the space of the
thorax.
The larger inferior aperture provides the ring-like origin of the
diaphragm, which completely occludes the opening.(from note)
Generally muscle fibers of the diaphragm arise radially from the
margins of the inferior thoracic aperture, and converge into a large
central tendon.(from note)
Attachment of the diaphragm: xiphoid process, distal cartilaginous
ends of ribs VII to X, ribs XI and XII, vertebrae of lumber region.
(from note)
What are the borders of the inferior thoracic aperture ?
1- Ribs (the costal cartilage of the ribs 7-8-9-10)
2- 12th rib and the tip of the 11th rib
3- anteriory the xiphoid process which is a part (inferior part) of the
sternum.
4- The 12th vertebra

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How many thoracic vertbrae do we have?

12
How many ribs do we have ?
12 pairs
So the attachement of the muscle here goes in a radial way and
then all of it attaches to the central tendon.

Slide 9
The domes of the diaphragm rise to the level of the 4th intercostal
space, and abdominal viscera (liver, spleen, stomach) lies superior
to the plane of the inferior thoracic aperture.(from the note)
The esophagus pass through the muscular part of the diaphragm
and the inferior vena pass through the central tendon of the
diaphragm whereas the aorta passes posterior to the diaphragm.
(from the note)
The aorta pass posterior to the diaphragm. (from the note)
The diaphragm closes the area between the thorax and the
abdomen Within that diaphragm we have things passing from the
thorax all the way to the abdomen, what are these important
things?
1- Artries
2- Veins
3- Nerves
4- Esophagus
so we need to find a passage by looking at the diaphragm from the
top (superior view) so u have a patient with the head lying towards
you and you have a section in it looking from top to the diaphragm
Another section where u have a patient standing and u took a
sagital section so within it u have
1- the inferior vena cava (having an opening within the
tendinous part of the diaphragm to pass all the way
inferiorly)
2- you have the esophagus which has an opening with the
muscular structure to pass all the way to the abdomen .
3- the aorta (the aorta basically takes advantage and passes
posteriorly due to the way the muscle is located it just goes
at the very end at the posteior and pass down all the way to
the abdomen without actually piercing it doesnt actually has
a pierce.
as u can see the caval opening is related to the inferior vena cava
as the name implies then u have the esophgeal hiatus here which is

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basically the opening of the esophegus and u have the aorta going
posterirly.
each one of them passes from the thorax to the abdomen at a
certain level these levels are:
1- Inferior vena cava passes at the 8th thoracic vertebra
2- Esophagus passes at the tenth
3- the aorta passes at the 12th verebra

Mediastinum

The sternal angle is used to find the position of the rib II as

reference for counting ribs.(from note)
Anterior mediastinum contains a portion of thymus and fat.(from
note)
Middle mediastinum contains the pericardium and heart.(from
note)
We said we have 3 spaces within the thoracic cavity 2 of them
are easy and have the lungs the 3rd is the mediastinum which is
the name of the space (it isnt a structure) so the name of the
middle space is callecd the mediastinum.
This mediastinum is subdivided into 4 areas
1- superior mediastinum: located at the vertebral disc 4 (We
have a line here just with a sternal angle) (picture)
2- middle mediastinum: The middle bluish part (in picture)
which simply contains the heart
3- anterior mediastinum: which is located to the anterior of
the heart (in between the heart and the sternum).
4- posterior mediastinum: which is located posterior to the
heart with vertebrae behind it.
Each area is subdivided because it contains different stuff
On the second picture of slide 10 you can see thats basically
the heart within the middle, the 2 lungs on the sides, the
posteior mediastinum, and simply the anterior mediastinum, and
u cant see here in this section the superior mediastinum
because it is above that.

Slide 11 CONTENT OF THE MEDIASTINUM

Superior mediastinum contains the thymus, Superior vena cava,

brachiocephalic veins, arch of aorta and roots of its major
branches.(from note)
Posterior mediastinum contains the esophagus, descending
aorta, azygos vein, thoracic duct, sympathetic trunk and
thoracic splanchnic nerves.(from note)
Within the middle mediastinum what do we have?
o the middle mediastinum is the simplest all it has is the
heart

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Superiorly what do we have?

o All of the blood vessels that leave the heart are located in
the superior mediastinum so u have the superior vena
cava u have the brachiocephalic trunck ( is simply the
beginning of the blood veseel that will eventually divide
into 2) one of them will go to the common carotid and the
other one will give u the subclavian brachiocephalic.
o Brachio= upper limb | Cephalic = head
o So the brachiocephalic trunk basically divide into the
common carotid artery and the subclavian artery and it
leaves there
o and of course u will have the esophagus passing from the
mouth all the way down and u will have the trachea as
well so all of those are located within the superior
mediastinum
anterior mediastinum what do we have? simply this area which
is anterior to the heart (in between the heart and sternum) has a
part of the thymus
Remaining part of the thymus as u can see it is located in the
superior mediastinum
The middle mediastinum we talked about it so if u take it and
now looking posteriorly What does the posterior mediastinum
contain?
1- the aorta going down
2- the vein (which vein) eventually will descend u will find
here inferior vena cava
Esophagus going down as well u will have the nerve supply
which is the sympthatic nervous supply part of the autonomic u
will take it later
All of these vessels remember the aorta descend howerver the
esophagus start in the superior mediastinumm and it descends
within the posterior mediastinum so it is locatted in 2 areas
where as the upper vessels which are simply going superiorly
are just located in the superior mediastinum

Pericardium

The pericardium is a fibroserous sac surrounding the heart and

the roots of the great vessels.(from the note)
Consists of two components: 1- fibrous pericardium is a tough
connective tissue outer layer that defines the boundaries of the
middle mediastinum, 2- the serous pericardium is thin and
consist of the parietal layer lines the inner surface of the fibrous
and visceral layer adheres to the heart and forms its outer
covering. (from the note)

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Pericardium is simply a cover

Because we have many structures within the thoracic cavity and
they are all moving u need to protect each organ within a cover
(something to cover it) so when it moves it doesnt have any
friction with another structure
the pericardium is simply composed of 1 layer which is the very
white in color in picture (the fibrous part of the pericardium is
the thick protective coverage) and basically allow the
attachment of the heart to the sternum so it is attatched slightly
to the sternum and inferiorly it is attachted to the tendon
process of the diaphragm and posteriorly it has a loose
connection and thats keep the heart while it is moving in
position
to protect from friction u have other layer can (see the red line
in the picture and reflects so u have another red line) and in
between u have a black space the first red line is called parietal
layer (outside) second one is the visceral layer (inside) and in
between them there is a space and all of this is simply to reduce
friction within the space u have a serous fluid in that area it
basically reduces the firction and protect the heart.
This space in between them is called the pericardial space so
the pericardial space has nothing to do with the spaces in the
heart it is simply the space in between the 2 layers of the
pericardium the parietal and the visceral the parietal is
connected to the fibrous layer and the visceral layer is the layer
which is connected to the heart itself and thats how it get this
name since it is connected to the viscera.

Pleural cavity

Each pleural cavity is lined by the pleura which is divided in to

two types:
1- Parietal pleura associated with the walls of the pleural
cavity.
2- Visceral pleura which reflects from the medial wall and
onto the surface of the lung to cover the lung. (from note)
The same concept goes to the lung, to protect the lung u have
something called the pleura which consist of a double layer.
Think of both the pericardium and the pleura as a ballon during
development thats what happen u have ur structure (heart or
lungs). ur structure invaginate within that balllon and then that
ballon has a double structure a layer that covers the viscera
itself and another layer that reflects at some stage there isnt a
complete closure of that ballon as u have all the vessels going
out of the heart or u have all the vessels going out of the lungs

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and then within the ballon there is a cavity but in this case it is a
cavity and it has a fluid to lubricate the 2 surfaces so that they
dont rub against each other.
So u have the pleural membrane it has also the parietal which is
the other one and a visceral, within those 2 layers u have the
pleural caivity dont confuse the pleural cavity with the thoracic
cavity (the thoracic cavity is the cavity were u find the lungs in)
(the pleural cavity is simply the cavity in between the parietal
and visceral layer of the pleura)
The internal part is the thoracic cavity where u have the lungs
surronded by this layer which is the pleura which is divided into
2 and within it u have the pleura cavity

Slide 14

Vessels that supply the thoracic wall consist of posterior

intercostal which originate from the aorta and anterior
intercostal arteries which originate from the internal thoracic
(branch of subclavian). (from the note)
To supply the cage u need blood veseels going posteriorly and
another coming anteriorly the name of the vessels that supply
the thoracic wall are called the intercostal vessels
so u have posterior intercostal coming all the way from the aorta
and u have anterior intercostal which are simply a branch of this
blood vessel which is the internal thoracic artery
So the internal thoracic artery is simply a branch that comes out
of the subclavian (in the pictures of the note) that supply the
upper limb it descends anteriorly to give the anterior intercostal
artety.
the posterior one come all the way from the aorta from the
thoracic aorta we have all these branches

Slide 15 veins

Most intercostal veins ends in the azygos venous system of

veins which ultimately drains into the SVC.(from the note)
The 1st -3rd superior intercostal veins drain into brachiocephalic
vein.(from the note)
All the intercostal veins will eventually or most of them will
eventually drain in to this vein here which is called the azygous
vein (and the azygous eventually will drain into the superior

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vena cava) except for the upper 2 intercostal as u can see here
they will go directly into the brachiocephalic vein but most of the
intercostal will drain into the azygous vein and eventually drain
into superior vena cava
Slide 16 Lymphatic drainage

The right lymphatic duct drains lymph from the bodys right
upper quadrant (right side of head, neck, and thorax plus the
right upper limb).(from the note)
The thoracic duct drains lymph from the remainder of the body.
(from the note)
We know that the lymphatic system is a system that
complements the venous system so what ever is left by the
venous system and not collected will be collected within the
lymphatic system it also has an immunity function
in general only this quarter (right side) of the body will drain into
the right lymphatic duct and the entire remanent will
eventually drain into the thoracic duct the same happen with the
thoracic wall the right side will drain to the right lymphatic duct
and the left side will drain into the thoracic duct.

Slide 17

Why do we need to know all this info here?

o As a clinician u will eventually see these pictures
wheather CT or MRI Every single dot has a meaning and
we should know what is located at that level
so if I gave u the level for example (T III) 3rd thoracic vertebra so
we are cutting through which mediastinum?
o superior mediastinum from the forth and above is the
superior and thats the line we have drawn if u dont know
the level approximately and cant think about it u wont
know what we have here
o in this case u know u are around the 3rd vertebra so u can
imagine ur at the level of superior mediasinum and within
the superior mediastinum u have ur main blood vessels,
veins, some nerves u know which vertebrae is there
according u can know the relation and u know what is
anteriorly and what is posteriorly
o So in here (superior mediastinum) u have the left
brachiocephalic vein (anteriorly) behind it the smaller one
is the left common carotid artery which will supply the
head and neck and after that u have the left subclavian
artery (supply upper limb) posteriorly

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o

u have the esophagus in here (it is less translucent but u

will learn about the color later on) then bcoz u have air
within the trachea it will look black so u will know this is ur
trachea
on the right side u have the right subclavian u have the
right branchiocephalic vein and then u have the right
common coratid

slide 18

How does this differ?

o I lowered down my cut to the 5th vertebra
o passed the superior mediastinum and I am going a little
bit lower now
o I am seeing this part here which is the plumonary trunck
and is dividing into 2 right and left plumonary and behind
it here u can see the treachea then the esophagus is more
squeezed down here and thats it
o now at this level I am seeing the thoracic aorta which I
couldnt see previously here this black area is simply the
right bronchus and u have the right pulmonary artery and
the superior vena cava and again part of the ascending
aorta coz u know the aorta has an arch into it.
o So u can see both parts here at a different section it is
clinically important to know the location of every single
thing coz as a clincian u need to know where is is the
heart and what is it related to

I am not going to go in details with this coz u will take it in the

cardiovascular to know exactly every single valve and where to
look for it and simply use
Looking at the sternal angle coz it is an important landmark
becoz from sternal angle u can always locate the second costal
cartilage which is related to the second rib and u can always
count ur way from their so ur sternal angel is an important
landmark for u to know the location of the 2nd rib or 2nd costal
cartilage and thats why clinically u need to know that area and
the content of it and imagine it as a clinician when a patient is
complaining and what organ ur basically looking for.

(note: please check each and every pictures in the

lecture note coz they are important)