The chest is generally conceived as being broadest superiorly owing to the presence of the pectoral, or shoulder, girdle (clavicles

and scapulae), with much of its girth accounted for by the associated pectoral and scapular (upper limb) musculature. They have the shape of a truncated cone, being narrowest superiorly, with the circumference increasing inferiorly, and reaching its maximum at the junction with the abdominal portion of the trunk The thoracic skeleton takes the form of a domed birdcage, the thoracic cage (rib cage), with the horizontal bars formed by ribs and costal cartilages supported by the vertical sternum (breastbone) and thoracic vertebrae (Fig. 1.1). Furthermore, the floor of the thoracic cavity (the diaphragm) is deeply invaginated inferiorly (i.e., is pushed upward) by viscera of the abdominal cavity. Although chest pain can result from pulmonary disease, it is probably the most important symptom of cardiac disease (Swartz, 2002). However, chest pain may also occur in intestinal, gallbladder, and musculoskeletal disorders. People who have had a heart attack usually describe the associated pain as a crushing substernal pain (deep to the sternum) that does not disappear with rest. The true thoracic wall includes the thoracic cage and the muscles that extend between its elements 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. The mammary glands of the breasts lie within the subcutaneous tissue of the thoracic wall. Although the shape of the thoracic cage provides rigidity, its joints and the thinness and flexibility of the ribs allow remarkable flexibility, permitting it to absorb many external blows and compressions without fracture and to change its shape repetitively and sufficiently as required for respiration. The thoracic skeleton includes 12 pairs of ribs and associated costal cartilages, 12 thoracic vertebrae and the intervertebral (IV) discs interposed between them, and the sternum. The ribs and costal cartilages form the largest part of the thoracic cage. Ribs (L. costae) are curved, flat bones that form most of the thoracic cage (Figs. 1.1 and 1.2). They are remarkably light in weight yet highly resilient. Each rib has a spongy interior containing bone marrow (hematopoietic tissue), which forms blood cells.

True (vertebrocostal) ribs (1st7th ribs): They attach directly to the sternum through their own costal cartilages. False (vertebrochondral) ribs (8th, 9th, and usually 10th ribs): Their cartilages are connected to the cartilage of the rib above them; thus their connection with the sternum is indirect.

Floating (vertebral, free) ribs (11th, 12th, and sometimes 10th ribs): The rudimentary cartilages of these ribs do not connect even indirectly with the sternum; instead they end in the posterior abdominal musculature.

Typical ribs (3rd9th)

Head: wedge-shaped and has two facets, separated by the crest of the head (Figs. 1.2 and 1.3); one facet for articulation with the numerically corresponding vertebra and one facet for the vertebra superior to it. Neck: connects the head with the body at the level of the tubercle. Tubercle: at the junction of the neck and body and has a smooth articular part, for articulating with the corresponding transverse process of the vertebra, and a rough nonarticular part, for attachment of the costotransverse ligament. Body (shaft): thin, flat, and curved, most markedly at the costal angle where the rib turns anterolaterally (also the point of the lateral limit of attachment of the erector spinae muscles to the ribs; see Chapter 4); the concave internal surface of the body has a costal groove paralleling the inferior border of the rib, which provides some protection for the intercostal nerve and vessels.

Atypical rib: 1,2 10-12

The 1st rib is the broadest (i.e., its body is widest and nearly horizontal), shortest, and most sharply curved of the seven true ribs. It has a single facet on its head for articulation with the T1 vertebra only and two transversely directed grooves crossing its superior surface for the subclavian vessels; the grooves are separated by a scalene tubercle and ridge, to which the anterior scalene muscle is attached. The 2nd rib is more typical; its body is thinner, less curved, and substantially longer than the 1st rib, and its head has two facets for articulation with the bodies of the T1 and T2 vertebrae; its main atypical feature is a rough area on its upper surface, the tuberosity for serratus anterior, from which part of that muscle originates. The 10th12th ribs, like the 1st rib, have only one facet on their heads and articulate with a single vertebra. The 11th and 12th ribs are short and have no neck or tubercle.

Costal cartilages prolong the ribs anteriorly and contribute to the elasticity of the thoracic wall, providing a flexible attachment for their anterior or distal ends (tips). The cartilages increase in length through the first 7 and then gradually decrease. The first 7 cartilages (and sometimes the 8th; Fig. 1.16) attach directly and independently to the sternum; the 8th, 9th, and 10th articulate with the costal cartilages just superior to them, forming a continuous, articulated, cartilaginous costal margin The 11th and 12th cartilages form caps on the anterior ends of these ribs and do not reach or attach to any other bone or cartilage.

Intercostal spaces separate the ribs and their costal cartilages from one another (Fig. 1.1A). The spaces are named according to the rib forming the superior border of the spacefor example, the 4th intercostal space lies between rib 4 and rib 5. There are 11 intercostal spaces and 11 intercostal nerves The space below the 12th rib does not lie between ribs and thus is referred to as the subcostal space, and the anterior ramus of spinal nerve T12 is the subcostal nerve. The intercostal spaces are widest anterolaterally, and they widen with inspiration. The short, broad 1st rib, posteroinferior to the clavicle, is rarely fractured because of its protected position (it cannot be palpated). When it is broken, however, injury to the brachial plexus of nerves and subclavian vessels may occur. The middle ribs are most commonly fractured. Rib fractures usually result from blows or from crushing injuries. The weakest part of a rib is just anterior to its angle; however, direct violence may fracture a rib anywhere, and its broken end may injure internal organs such as a lung and/or the spleen. Lower rib fractures may tear the diaphragm and result in a diaphragmatic hernia (see Chapter 2). Rib fractures are painful because the broken parts move during respiration, coughing, laughing, and sneezing.

Flail chest (stove-in chest) is an extremely painful injury and impairs ventilation, thereby affecting oxygenation of the blood. During treatment, the loose segment is often fixed by hooks and/or wires so that it cannot move.
The surgical creation of an opening through the thoracic wall to enter a pleural cavity is a thoracotomy. The posterolateral aspects of the 5th7th intercostal spaces are important sites for posterior thoracotomy incisions. In general, a lateral approach is most satisfactory for entry into the thoracic cage. People usually have 12 ribs on each side, but the number is increased by the presence of cervical and/or lumbar ribs, or decreased by failure of the 12th pair to form Cervical ribs may interfere with neurovascular structures exiting the superior thoracic aperture (See Thoracic Outlet Syndromes, in Chapter 6.) Supernumerary (extra) ribs also have clinical significance in that they may confuse the identification of vertebral levels in radiographs and other diagnostic images. In elderly people, the costal cartilages lose some of their elasticity and become brittle; they may undergo calcification, making them radiopaque (e.g., in radiographs).

Because of the remarkable elasticity of the ribs and costal cartilages in children, chest compression may produce injury within the thorax even in the absence of a rib fracture.

Bilateral costal facets (demifacets) on their bodies, usually occurring in inferior and superior pairs, for articulation with the heads of ribs. Costal facets on their transverse processes for articulation with the tubercles of ribs, except for the inferior two or three thoracic vertebrae. Long, inferiorly slanting spinous processes.

They occur as bilaterally paired, planar surfaces on the superior and inferior posterolateral margins of typical (T2T9) thoracic vertebrae.

The superior costal facets of vertebra T1 are not demifacets because there are no demifacets on the C7 vertebra above, and rib 1 articulates only with vertebra T1. T1 has a typical inferior costal (demi)facet. T10 has only one bilateral pair of (whole) costal facets, located partly on its body and partly on its pedicle. T11 and T12 also have only a single pair of (whole) costal facets, located on their pedicles.

The sternum (G. sternon, chest) is the flat, elongated bone that forms the middle of the anterior part of the thoracic cage (Fig. 1.6). The sternum consists of three parts: manubrium, body, and xiphoid process.
The manubrium (L. handle, as in the handle of a sword, the sternal body forming the blade) is a roughly trapezoidal bone. The manubrium is the widest and thickest of the three parts of the sternum. The easily palpated concave center of the superior border of the manubrium is the jugular notch (suprasternal notch). The manubrium and body of the sternum lie in slightly different planes superior and inferior to their junction, the manubriosternal joint (Fig. 1.6A & B); hence, their junction forms a projecting sternal angle (of Louis). The body of the sternum, which is longer, narrower, and thinner than the manubrium, is located at the level of the T5T9 vertebrae Its width varies because of the scalloping of its lateral borders by the costal notches. Its width varies because of the scalloping of its lateral borders by the costal notches. In young people, four sternebrae (primordial segments of the sternum) are obvious. The sternebrae articulate with each other at primary cartilaginous joints (sternal synchondroses). These joints begin to fuse from the inferior end between puberty (sexual maturity) and age 25.

The nearly flat anterior surface of the body of the sternum is marked in adults by three variable transverse ridges (Fig. 1.6A), which represent the lines of fusion (synostosis) of its four originally separate sternebrae. The xiphoid process, the smallest and most variable part of the sternum, is thin and elongated. It lies at the level of T10 vertebra. It is cartilaginous in young people but more or less ossified in adults older than age 40. In elderly people, the xiphoid process may fuse with the sternal body. Its junction with the sternal body at the xiphisternal joint indicates the inferior limit of the central part of the thoracic cavity projected onto the anterior body wall; this joint is also the site of the infrasternal angle (subcostal angle) of the inferior thoracic aperture (Fig. 1.1).

It is a midline marker for the superior limit of the liver, the central tendon of the diaphragm, and the inferior border of the heart.

The installation and use of air bags in vehicles has reduced the number of sternal fractures. A fracture of the sternal body is usually a comminuted fracture (the sternum is broken into several pieces). The most common site of sternal fracture is at the sternal angle, after the manubriosternal joint has fused in elderly people, resulting in dislocation of the (re-established) manubriosternal joint. In sternal injuries, the concern is not primarily for the fracture itself but for the likelihood of heart injury (myocardial contusion, cardiac rupture, tamponade) or pulmonary injury. Sternal splitting also gives good exposure for removal of tumors in the superior lobes of the lungs. Sternal biopsy is commonly used to obtain specimens of marrow for transplantation and for detection of metastatic cancer and blood dyscrasias (abnormalities). Complete sternal cleft is uncommon. Sternal clefts involving the manubrium and superior half of the body are V- or U-shaped and can be repaired during infancy by direct apposition and fixation of the cartilaginous sternal halves. Sometimes there is a perforation (sternal foramen) in the sternal body because of incomplete fusion of the fetal sternal plates. Although the xiphoid process is commonly perforated in elderly persons because of age-related changes, this perforation is not clinically significant. Similarly, a protruding xiphoid process in infants is not unusual; when it occurs, it usually does not require correction.

Superior Thoracic Aperture The superior thoracic aperture, the anatomical thoracic inlet, is bounded as follows (Fig. 1.7):

Posteriorly, by vertebra T1 (protruding or convex posterior boundary/landmark). Laterally, by the 1st pair of ribs and their costal cartilages.

Anteriorly, by the superior border of the manubrium (anterior landmark).

Structures that pass between the thoracic cavity and the neck through the oblique, kidney-shaped superior thoracic aperture include the trachea, esophagus, nerves, and vessels that supply and drain the head, neck, and upper limbs.

Inferior Thoracic Aperture The inferior thoracic aperture, the anatomical thoracic outlet, is bounded as follows:

Posteriorly, by the 12th thoracic vertebra (posterior landmark). Posterolaterally, by the 11th and 12th pairs of ribs.

The inferior thoracic aperture (thoracic outlet) provides attachment for the diaphragm, which protrudes upward so that upper abdominal viscera receive protection from the thoracic cage.

Anterolaterally, by the joined costal cartilages of ribs 710, forming the costal margins. Anteriorly, by the xiphisternal joint (anterior landmark).

Structures passing from or to the thorax from the abdomen pass through openings that traverse the diaphragm (e.g., esophagus and inferior vena cava), or pass posterior to it (e.g., aorta). Although the diaphragm takes origin from the structures that make up the inferior thoracic aperture, the domes of the diaphragm rise to the level of the 4th intercostal space, and abdominal visceral, including the large liver, spleen, and stomach, lie superior to the plane of the inferior thoracic aperture, within the thoracic wall (Fig. 1.1A & B). When clinicians refer to the superior thoracic aperture as the thoracic outlet, they are emphasizing the arteries and T1 spinal nerves that emerge from the thorax through this aperture to enter the lower neck and upper limbs. Hence, various types of thoracic outlet syndrome (TOS) exist in which emerging structures are affected by obstructions of the superior thoracic aperture (Rowland, 2000). Although TOS implies a thoracic location, the obstruction actually occurs outside the aperture in the root of the neck (see Chapter 8), and the manifestations of the syndromes involve the upper limb The intervertebral joints between the bodies of adjacent vertebrae are joined together by longitudinal ligaments and intervertebral discs.

Costovertebral Joints A typical rib articulates with the vertebral column at two joints: the joints of heads of ribs and the costotransverse joints (Fig. 1.8).
For example, the head of the 6th rib articulates with the superior part of the body of the T6 vertebra, the inferior part of T5, and the IV disc between these vertebrae (Fig. 1.8). The crest of the head of the rib attaches to the IV disc by an intra-articular ligament within the joint, dividing the enclosed space into two synovial cavities.

Exceptions to this general arrangement of articulation occur with the heads of the 1st, sometimes the 10th, and usually the 11th and 12th ribs; they articulate only with their own vertebral bodies (bodies of the same number as the rib). A joint capsule surrounds each joint and connects the head of the rib with the circumference of the joint cavity. The fibrous layer of the capsule is strongest anteriorly, where it forms a radiate sternocostal ligament that fans out from the anterior margin of the head of the rib to the sides of the bodies of two vertebrae and the IV disc between them. A costotransverse ligament passing from the neck of the rib to the transverse process and a lateral costotransverse ligament passing from the tubercle of the rib to the tip of the transverse process strengthen the anterior and posterior aspects of the joint A superior costotransverse ligament is a broad band that joins the crest of the neck of the rib to the transverse process superior to it. The superior costotransverse ligament may be divided into a strong anterior costotransverse ligament and a weak posterior costotransverse ligament. The strong costotransverse ligaments binding these joints limit their movements to slight gliding. However, the articular surfaces on the tubercles of the superior 6 ribs are convex and fit into concavities on the transverse processes (Fig. 1.8C). As a result, rotation occurs around a mostly transverse axis that traverses the intra-articular ligament and the head and neck of the rib (Fig. 1.8A & B). This results in elevation and depression movements of the distal (sternal) ends of the ribs (and the sternum to which they attach) in the sagittal plane (pump-handle movement) (Fig. 1.9A & C). Flat articular surfaces of tubercles and transverse processes of the 7th10th ribs allow gliding here (Fig. 1.8C), resulting in elevation and depression of the lateral-most portions of these ribs in the transverse plane (buckethandle movement) (Fig. 1.9B & C).

The floating 11th and 12th ribs do not articulate with transverse processes and have even freer movements as a result.
The costochondral articulations are hyaline cartilaginous joints. Each rib has a cup-shaped depression in its sternal end into which the costal cartilage fits. No movement normally occurs at these joints.

The interchondral jointsarticulations between the adjacent borders of the 6th and 7th, 7th and 8th, and 8th and 9th costal cartilagesare plane synovial joints (Table 1.1). Each of P.87

P.88

these joints usually has a synovial cavity that is enclosed by a joint capsule. The joints are strengthened by interchondral ligaments.
The articulation between the 9th and the 10th costal cartilages is a fibrous joint.

Sternocostal Joints The 1st7th ribs articulate through their costal cartilages with the lateral borders of the sternum; in mature adults, the articulations are (Fig. 1.1; Table 1.1):

The 1st pair of cartilages with the manubrium only. The 2nd pair of cartilages with the manubrium and body of the sternum (i.e., with components of manubriosternal joint). The 3rd6th pairs of cartilages with the body of the sternum. The 7th pair of cartilages with the body of the sternum and the xiphoid process (i.e., with the components of the xiphisternal joint).