Thorax: overview and surface anatomy

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CHAPTER 53 Thorax: overview and surface anatomy

The thorax is the upper part of the trunk. It consists of an external musculoskeletal cage, the thoracic wall, and an internal cavity that contains the heart, lungs, oesophagus, trachea, thymus, the vagus and phrenic nerves and the right and left sympathetic trunks, the thoracic duct and major systemic and pulmonary blood vessels. Inferiorly the thorax is separated from the abdominal cavity by the diaphragm, superiorly it communicates with the neck and the upper limbs. The thoracic wall also offers protection to some of the abdominal viscera: the greater part of the liver lies under the right dome of the diaphragm; the stomach and spleen lie under the left dome of the diaphragm; the posterior aspects of the superior poles of the kidneys lie on the diaphragm and are anterior to the twelfth rib on the right, and to the eleventh and twelfth ribs on the left (Fig. 53.1).

image

Fig. 53.1 Thoracic wall and cavity.

(From Drake, Vogl and Mitchell 2005.)

Variations in thoracic dimensions and proportions are partly individual and also linked to age, sex and race. At birth, the transverse diameter is relatively less than it is in the adult, but adult proportions develop as walking begins. Thoracic capacity is less in females than it is in males, both absolutely and proportionately: the female sternum is shorter, the thoracic inlet more oblique, and the suprasternal notch is level with the third thoracic vertebra (whereas it is level with the second in males). In all individuals, the size of the thoracic cavity changes continuously, according to the movements of the ribs and diaphragm during respiration (see Ch. 58), and the degree of distension of the abdominal viscera.

MUSCULOSKELETAL FRAMEWORK

BONES AND JOINTS

The thoracic skeleton consists of twelve thoracic vertebrae and their intervening intervertebral discs (midline, posterior), twelve pairs of ribs and their costal cartilages (predominantly lateral) and the sternum (midline, anterior). When articulated, they form an irregularly shaped osteocartilaginous cylinder, reniform in horizontal section, which is narrow above, broad below, flattened anteroposteriorly and longer behind (see Fig. 54.7). Laterally the thoracic cage is convex and is formed by the ribs, and anteriorly it is slightly convex and is formed by the sternum and the distal parts of the ribs and their costal cartilages. The first seven pairs of ribs are connected to the sternum by costal cartilages, the costal cartilages of the eighth to tenth ribs usually join the superjacent cartilage, and the eleventh and twelfth ribs are free (floating) at their anterior ends. The posterolateral curvature of the ribs, from their vertebral ends to their angles, produces a deep internal groove, the paravertebral gutter, on either side of the vertebral column. The ribs and costal cartilages are separated by intercostal spaces, which are deeper anteriorly and between the upper ribs. Each space is occupied by three layers of flat muscles and their aponeuroses, neurovascular bundles and lymphatic channels.

The narrow thoracic inlet (superior thoracic aperture) typically measures 5 cm anteroposteriorly and 10 cm transversely. It is bounded by the first thoracic vertebral body posteriorly, the medial border of the first ribs on each side, and the superior border of the manubrium sterni anteriorly. It slopes down and forwards, so that the apex of the lung extends upwards into the neck behind the anterior end of the first rib: structures that pass between the thorax and the upper limb therefore pass over the first rib and the apices of the lungs and the apical pleurae.

The broad thoracic outlet (inferior thoracic aperture) is limited posteriorly by the twelfth thoracic vertebral body, posterolaterally by the twelfth rib and the distal end of the eleventh rib, anterolaterally by the distal cartilaginous ends of the seventh to tenth ribs (which unite and ascend to form the costal margin), and anteriorly by the xiphoid process. It is wider in the transverse plane than in the sagittal plane and slopes obliquely downward and backward, so that the thoracic cavity is deeper posteriorly than anteriorly.

The horizontal plane that passes through the intervertebral disc between the fourth and fifth thoracic vertebrae posteriorly and the manubriosternal joint (sternal angle or angle of Louis) at the level of the second costal cartilage anteriorly is a useful aid to orientation in the thorax. It separates the superior mediastinum from the inferior mediastinum and also marks the positions of the superior limits of the pericardium and of the pulmonary trunk, the origin of the arch of the aorta, the level at which the trachea bifurcates into right and left main bronchi, and the site where the superior vena cava penetrates the pericardium to enter the right atrium.

MUSCLES

Intrinsic and extrinsic muscles

The intrinsic muscles of the chest wall are the intercostal muscles, subcostalis, transversus thoracis, levatores costarum, serratus posterior superior and serratus posterior inferior. The intercostal muscles occupy each of the intercostal spaces and are named according to their surface relations, i.e. external, internal and innermost. All except levatores costarum are innervated by the adjacent intercostal nerves derived from the ventral rami of the thoracic spinal nerves; levatores costarum are innervated by the dorsal rami of the thoracic spinal nerves. The intrinsic muscles can elevate or depress the ribs, and are active during respiration, particularly forced respiration: their primary action is believed to be to stiffen the chest wall, preventing paradoxical movement during inspiration (see Ch. 58).

The skeletal framework of the thoracic wall provides extensive attachment sites for muscles associated functionally with the neck, abdomen, back, and upper limbs. Some of them (scalenes, infrahyoid strap muscles, sternocleidomastoid, serratus anterior, pectoralis major and minor, external and internal obliques, and rectus abdominis) function as accessory muscles of respiration and are usually active only during forced respiration; scalenus medius is active in quiet inspiration. Scalenus anterior, medius and posterior are described in Chapter 28. Trapezius, latissimus dorsi, rhomboid major, rhomboid minor, levator scapulae, pectoralis major, pectoralis minor, subclavius, serratus anterior, deltoid, subscapularis, supraspinatus, infraspinatus, teres minor and teres major are described in Chapter 46. Rectus abdominis, external oblique and internal oblique are described in Chapter 61.

Diaphragm

The diaphragm is a curved musculotendinous sheet attached to the circumference of the thoracic outlet and to the upper lumbar vertebrae. It forms the floor of the thoracic cavity, and separates it from the abdominal cavity (see Ch. 58). The diaphragm is relatively flat centrally and domed peripherally, rising higher on the right side than on the left, an asymmetry that reflects the relative densities of the underlying liver and gastric fundus respectively. From its highest point on each side the diaphragm slopes downward to its costal and vertebral attachments: this slope is most marked posteriorly, where the space between the diaphragm and the posterior wall of the thorax is very narrow.

THORACIC CAVITY

PLEURAL CAVITIES

The right and left pleural cavities are separate compartments on either side of the mediastinum. Each encloses a lung and its associated bronchial tree and vessels, nerves and lymphatics (see Ch. 57). The walls are formed by a serous membrane, the pleura, arranged as a closed sac. The outer layer of the sac, the parietal pleura, lines the corresponding half of the thoracic wall and covers much of the diaphragm and structures occupying the middle region of the thorax. The inner or visceral layer is more delicate and adheres closely to the pulmonary surface, following the interlobar fissures. The two layers are continuous with each other around the structures at the hila of the lungs. They remain in close, though sliding, contact at all phases of respiration. The potential space between them is the pleural cavity, which is maintained at a negative pressure by the inward elastic recoil of the lung and the outward pull of the chest wall. The lungs do not fill this space in quiet respiration, but move into recesses such as the costodiaphragmatic recess, which separates the costal and diaphragmatic pleura, in deep breathing.

The left pleural cavity is the smaller of the two pleural cavities because the heart extends further to the left.

MEDIASTINUM

The mediastinum lies between the right and left pleural sacs in and near the median sagittal plane of the chest (see Ch. 55). It extends from the sternum anteriorly to the vertebral column behind. A horizontal plane passing through the manubriosternal joint and the intervertebral disc between the fourth and fifth thoracic vertebrae separates the mediastinum into superior and inferior portions.

Inferior mediastinum

The inferior mediastinum may be divided into three parts: anterior, in front of the pericardium; middle, containing the pericardium and its contents (see Ch. 56); posterior, behind the pericardium.

VASCULAR SUPPLY AND LYMPHATIC DRAINAGE

VENOUS DRAINAGE

The intercostal veins accompany the similarly named arteries in the intercostal spaces (Fig. 53.3). The small anterior intercostal veins are tributaries of the internal thoracic and musculophrenic veins: the internal thoracic veins drain into the appropriate brachiocephalic vein. The posterior intercostal veins drain backwards and most drain directly or indirectly into the azygos vein on the right and the hemiazygos or hemiazygos veins on the left. The azygos veins exhibit great variation in their origin, course, tributaries, anastomoses and termination.

image

Fig. 53.3 Veins of the thoracic wall and azygos system.

(From Drake, Vogl, Mitchell, Tibbitts and Richardson 2008.)

LYMPHATIC DRAINAGE

Superficial lymphatic vessels of the thoracic wall ramify subcutaneously and converge on the axillary nodes (see Fig. 54.19). Lymph vessels from deeper tissues of the thoracic walls drain mainly to the parasternal, intercostal and diaphragmatic lymphatic nodes.

INNERVATION

THORACIC SPINAL NERVES

There are twelve pairs of thoracic spinal nerves. The ventral rami, unlike their cervical and lumbar counterparts, have retained a largely segmental distribution to the body wall (see Figs 15.12, 54.3, 54.20). The upper eleven lie between the ribs (intercostal nerves), and the twelfth lies below the last rib (subcostal nerve). Each is connected with the adjoining ganglion of the sympathetic trunk by pre- and postganglionic branches (white and grey rami communicantes respectively). Intercostal nerves are distributed primarily to the thoracic and abdominal walls. The greater part of the first thoracic ventral ramus passes into the brachial plexus, together with a variable proportion of the second. The next four ventral supply only the thoracic wall, and the lower five supply both thoracic and abdominal walls. The subcostal nerve is distributed to the abdominal wall and the gluteal skin. Communicating branches link the intercostal nerves posteriorly in the intercostal spaces, and the lower five nerves communicate freely in the abdominal wall. Thoracic dorsal rami divide into medial and lateral branches that supply the intrinsic muscles of the back and the overlying postvertebral skin on a segmental basis (see Ch. 42).

The supraclavicular branches of C4 from the cervical plexus innervate the skin over the clavicle and may communicate with the anterior cutaneous branches of the second thoracic ventral ramus (see Ch. 28).

AUTONOMIC INNERVATION

The autonomic nervous system in the thorax consists of right and left sympathetic trunks and vagus nerves and the cardiac, oesophageal and pulmonary plexuses.

Sympathetic trunks

The ganglionated sympathetic trunks lie anterior to the heads of the ribs; the ganglia are arranged segmentally (see Fig. 55.7). Preganglionic sympathetic axons originate from neurones in the lateral grey column of the spinal cord from T1 to L2, and leave the spinal cord with the corresponding ventral roots as white rami communicantes. Their targets vary. Some enter the sympathetic trunk, where they either synapse in their segmental ganglion or ascend or descend in the trunk to synapse in cervical or lumbar ganglia. Many of the preganglionic axons which originate in the lower thoracic spinal segments (T5–12) do not synapse locally but enter the abdominal cavity as the thoracic splanchnic nerves and synapse either in prevertebral ganglia, especially the coeliac ganglion, or around the medullary chromaffin cells of the suprarenal gland (see Ch. 72). Axons destined for the cervical ganglia are derived from preganglionic neurones in T1.

Autonomic plexuses in the thorax

Cardiac plexus

The cardiac plexus has a superficial component inferior to the aortic arch, lying between it and the pulmonary trunk, and a deep part between the aortic arch and tracheal bifurcation (see Ch. 56). The superficial part is formed by the cardiac branch of the left superior cervical sympathetic ganglion and the lower of the two cervical cardiac branches of the left vagus. The deep part is formed by the cardiac branches of the cervical and upper thoracic sympathetic ganglia and of the vagus and recurrent laryngeal nerves. The only cardiac nerves which do not join it are those that join the superficial part of the plexus. Branches from the cardiac plexuses also form the left and right coronary plexuses and the atrial plexuses.

Pulmonary plexus

The pulmonary plexuses are anterior and posterior to the other structures at the hila of the lungs (see Ch. 57). They are formed by cardiac branches from the second to fifth (or sixth) thoracic sympathetic ganglia and from the vagus, and from cervical sympathetic cardiac nerves. The left plexus also receives branches from the left recurrent laryngeal nerve.

Oesophageal plexus

The oesophageal plexus surrounds the oesophagus below the level of the lung roots (see Ch. 55). Vagal fibres either pass through the plexus or are given off directly by the vagus in the thorax. All fibres relay in the oesophageal wall and are motor to the smooth muscle in the lower oesophagus and secretomotor to mucous glands in the oesophageal mucosa. Vasomotor sympathetic fibres arise from the upper six thoracic spinal cord segments. Those from the upper segments synapse in cervical ganglia; postganglionic axons innervate the vessels of the cervical and upper thoracic oesophagus. Fibres from the lower segments pass directly to the oesophageal plexus or to the coeliac ganglion, where they synapse; postganglionic axons innervate the vessels of the distal oesophagus.

SURFACE ANATOMY

SKELETAL LANDMARKS

Anteriorly, the clavicle and sternoclavicular joint are not only palpable, but also visible in all but the most obese individuals (Fig. 53.4). The sternum can be felt throughout its length in the midline, but laterally it may be obscured by pectoralis major. The jugular notch (suprasternal notch) at the superior end of the sternum is easily found, and the trachea may be felt deep to it. The cartilaginous rings are usually palpable: by rolling one’s finger over the trachea, or by using two fingers within the notch, it is possible to assess whether the trachea is in the midline or deviated to one side. The jugular notch lies at the level of the junction between the second and third thoracic vertebrae. The manubriosternal angle is more pronounced in the male than in the female, and is felt at the junction of the manubrium with the body of the sternum. It is a particularly useful landmark because it indicates the medial ends of the second costal cartilages, and is level with the junction of the fourth and fifth thoracic vertebrae. The xiphisternal joint and xiphoid process may be felt at the inferior end of the sternum. The joint usually lies at the level of the ninth thoracic vertebra. Lateral to this, may be felt the costal margin, formed here by the anterior ends of the seventh costal cartilages. The rest of the costal margin is formed by the fused anterior ends of the eighth, ninth and tenth costal cartilages, whereas posteriorly the free ends of the eleventh and twelfth ribs may be palpable. In thin individuals, it is possible to palpate all the ribs from the first down to the costal margin. However, well-developed musculature or the female breast will obscure the ribs anteriorly and the shaft of the first rib (which lies predominantly behind the clavicle).

Posteriorly (Fig. 53.5), the spinous processes of the thoracic vertebrae are easily palpable; the posterior angles of the ribs can be felt lateral to the spinous processes. The surface anatomy of the back and skeletal surface landmarks are described in Chapters 42 and 43.

INTRATHORACIC VISCERA

Anteriorly, the manubriosternal joint overlies the concavity of the aortic arch and marks the level at which the trachea bifurcates and the azygos vein enters the superior vena cava. The costal cartilages of the second ribs meet the sternum here, and so the joint offers an accurate point at which to start counting ribs. The transverse thoracic plane, which includes the sternal angle, demarcates the lower border of the superior mediastinum and the point at which the aortic arch receives the ascending aorta (anteriorly) and becomes the descending aorta (posteriorly). At this point, the right and left pleurae are in contact with each other; it is therefore a useful starting point when delineating the surface markings of the parietal pleura (Fig. 53.6A,B).

Heart

The surface projections to be described below apply to an average adult. It must be appreciated that they are considerably modified by age, sex, stature and proportions, ventilation and posture. The projections of the position of the valves on the surface are not the best sites for their auscultation. The cardiac apex almost corresponds to the apex beat, which is usually visible and always palpable in the fifth intercostal space, slightly medial to the midclavicular line, 9 cm from the midline in average adult males. The apex beat is the most inferolateral point at which a pulsation can be felt; however, the true cardiac apex is a short distance further inferolaterally and does not contact the thoracic wall in systole.

The cardiac sternocostal surface, projected onto the anterior thoracic wall, is a trapezoid. The area of superficial cardiac dullness as mapped out by light percussion is roughly triangular and corresponds to the area of the heart not covered by lung. The borders of the heart, although frequently given as being fixed, are in fact variable and depend largely on the position of the diaphragm and the obesity and build of the patient.

The following borders are usually recognized. The upper border forms a gently sloping line from the second left costal cartilage to the third right costal cartilage. The right border is a gently curved line, convex to the right from the third right to the sixth right costal cartilage, usually 1–2 cm lateral to the sternal edge. The inferior or acute border runs from the sixth right costal cartilage to the apex of the heart, which lies in the fifth left intercostal space approximately in the midclavicular line. The left (‘obtuse’) border extends superomedially, convex laterally, from the apex to meet the second left costal cartilage 1 cm from the left sternal edge. An oblique line joining the sternal end of the third left and sixth right costal cartilages represents the anterior part of the coronary sulcus, which separates the right atrium from the right ventricle (the left atrium lies behind the heart). The left and right borders can be identified by heavy percussion.

The surface projection of the anterior part of the atrioventricular groove is an oblique line that joins the sternal ends of the third left and sixth right costal cartilages and separates the atrial and ventricular areas. Although in different planes, the projections of the cardiac valves are also sited along or close to this line (see Fig. 56.6).

The pulmonary orifice lies partly behind the superior border of the third left costal cartilage, and partly behind the left third of the sternum. It is represented by a horizontal line, 2.5 cm long, which crosses cartilage and sternum. Parallel lines from the ends of this line, up to the second left costal cartilage, indicate the site of the pulmonary trunk.

The aortic orifice is below and a little right of the pulmonary, and is marked by a line, 2.5 cm long, running from the medial end of the third left intercostal space downward to the right. Two parallel lines from the ends of this line, slanting up to the right half of the manubrio-sternal joint, outline the location of the ascending aorta.

The tricuspid valvar orifice is represented by a line, 4 cm long, starting near the midline just below the level of the fourth right costal cartilage, and passing down and slightly to the right. The centre of this line should be level with the middle of the fourth right intercostal space.

The mitral orifice is behind the left half of the sternum opposite the fourth left costal cartilage, and is represented by a line, 3 cm long, descending to the right.

The sites of auscultation for the cardiac valves do not correspond directly to the surface anatomy of the valves, because the intensity of the sounds is influenced by direction of blood flow, which carries the sound with it. Thus, convenient sites at which to apply the stethoscope bell or diaphragm are: the sternal end of the second left intercostal space (pulmonary area); the sternal end of the second right intercostal space (aortic area); near the cardiac apex (mitral area); and over the left lower sternal border, at the level of the fifth intercostal spaces (tricuspid area) (see Fig. 56.6).

Lungs and pleurae

Anteriorly, the apex of the lung is approximately 2.5 cm above the centre of the medial one-third of the clavicle; posteriorly, it lies at the level of the seventh cervical vertebra. The surface markings of the apical dome and costovertebral border of the lung correspond to those of the parietal pleura. The anterolateral surface projection of the lung may be represented by a curved line that crosses the midclavicular line at the level of the sixth rib, and the midaxillary line at the level of the eighth rib. On inspiration, the lower border of the lung moves downwards, from the level of the tenth thoracic vertebra to the level of the twelfth thoracic vertebra (these levels are approximate). In full expiration, the lower border of the lung retreats anteriorly a short distance from the retrosternal costomediastinal recess; laterally, the lower margin of the lung may rise 5 cm above the parietal pleural reflection (the costodiaphragmatic recess).

Pleural reflections

Starting in the midline at the manubriosternal joint, the anterior reflections of the parietal pleura may be traced superiorly along a line that diverges from the midline and extends up and outwards to the apex of the pleural cavity. This point lies 3–4 cm above the anterior end of the first rib, on a level with the posterior end of the rib; its surface marking is usually 2.5 cm above the centre of the medial one-third of the clavicle. The parietal pleura is intimately fused with the inner aspect of the thoracic cavity, and it can be followed laterally and inferiorly down the inner aspect of the chest wall to the level of the tenth rib in the midaxillary line. Followed medially, the pleura covers the diaphragm; its position will therefore vary according to the phase of ventilation.

The costodiaphragmatic reflections of the pleurae can be followed anteriorly from the midaxillary line towards the midline. On the right, the pleura crosses the eighth rib in the midclavicular line, passes to the xiphisternum and then ascends to the manubriosternal joint. On the left, the pleura does not reach the midline, but turns superiorly at the anterior end of the sixth rib, 3–5 cm from the midline, and passes up to the level of the fourth costal cartilage. This deviation produces an area between the heart and the sternum that is free of pleura; a needle puncture of the heart may be performed at this site without risk of damaging the pleura. The right and left pleurae meet at the level of the fourth costal cartilage and maintain contact up to the level of the second costal cartilage.

Viewed from the back, the medial edge of the pleura may be followed along a line joining the transverse processes of the second to the twelfth thoracic vertebrae. It extends horizontally laterally, and crosses the twelfth and eleventh ribs to meet the tenth rib in the midaxillary line (Fig. 53.6A,B).

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