Thorax [ 101 - 154 ]

SKELETON OF THE THORAX

The skeleton of the thorax forms an osteo-cartilagenous cage which is conical
in shape with a narrow inlet and a broad outlet.
BOUNDARIES OF THORACIC CAGE:
 Anterior wall : formed by :
 Sternum.
 Anterior parts of the ribs and costal cartilages.
 Posterior wall : formed by :
 All thoracic vertebrae.
 Posterior parts of the ribs.
 Lateral wall :
 Formed by the ribs [only].
 Thoracic inlet :
 Slopes downwards and forwards, and is bounded by :
o Behind : 1st thoracic vertebra.
o In front: upper border of manubrium sterni.
o On each side : 1st rib.
 Thoracic outlet :
 Slopes downwards and backwards, and is bounded by :
o Behind: 12th thoracic vertebra.
o In front: cartilages of the 10th, 9th, 8th, and 7th ribs which
form the infrasternal angle.
o On each side: 12th and 11th ribs.

VERTEBRAL COLUMN
GENERAL COSNIDERATIONS
 Regions :
The column is about 75cm long in length [in the adult] and consists of
several regions :
 Cervical : 7 vertebrae.
 Thoracic : 12 vertebrae.
 Lumbar : 5 vertebrae.
 Sacrum : 5 fused vertebrae.
 Coccyx : 4 vertebrae.
 Curves of the vertebral column :
 The curves of the thoracic and pelvic regions are concave forwards.
They retain the same concavity present during foetal life and are called
primary curves.
 The curves of the cervical and lumbar regions are on the other hand,
convex forwards. As they develop after birth, they are called secondary
curves.
 Size of bodies of vertebrae :
The bodies show a general increase in width from above downwards, to
the level of lumbo-sacral junction where a rapid diminution occurs [as
the weight of the body is transmitted through the hip bones to the
femur].
 Direction of the spines :
 Horizontal : in the cervical and lumbar regions.
 Oblique : in the upper thoracic region.
 Vertical : in the mid-thoracic region.
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 Intervertebral foramina :
 They are placed in between the pedicles.
 They are small in size in the cervical and upper thoracic regions, but
gradually increase till the last lumbar vertebra.
 They transmit the spinal nerves and spinal vessels.
 Vertebral canal :
It is large and triangular in the cervical and lumbar regions [where the
movements are free], but it is small and circular in the thoracic region
[where the movement is limited].
 Functions of the column :
 Supports the body weight and transmits it to the lower limbs.
 Protects the spinal cord.
APPLIED ANATOMY :
Injury of the vertebral column below the level of 2nd lumbar vertebra is not so
dangerous as the spinal cord does not extend below the level of the disc
between L.1 and L.2.
The ligaments are so tightly attached that it is more common for the vertebrae
to be fractured than the ligaments to be torn.

COMMON FEATURES OF A VERTEBRA

A vertebra consists of : body, arch and processes.
1. Body :
Forms the anterior part of the vertebra
Covered behind by the posterior longitudinal ligament and in front by
the anterior longitudinal ligament.
2. Vertebral arch :
Consists of a pedicle and a lamina on each side.
 Pedicles: Attached to the back of the body [near its sides]. Between
the pedicles of contiguous vertebrae are enclosed the intervertebral
foramina.
 Laminae: Are continuous in front with the pedicles but join each
other behind, in the median plane, to form the spine.
 Vertebral foramen: Enclosed between the arch and the body.
3. Processes :
At the junction of the pedicle with the lamina there are 3 processes on
each side :
a. A transverse process.
b. A superior articular process : carrying a superior articular facet.
c. An inferior articular process : carrying an inferior articular facet.

CONNECTIONS BETWEEN INDIVIDUAL VERTEBRAE

The vertebrae are connected together by both joints and ligaments.
A. JOINTS :
1. INTERVERTEBRAL JOINTS :
 These are secondary cartilaginous joints.
 They constitute 1/4 the length of the vertebral column.
 They vary in thickness from one region to the other.
 Each disc is composed of :
a. Anulus fibrosus :
Peripheral fibrous part, at the circumference of the disc. Its fibres
are gathered in laminae which are arranged in a concentric
manner.
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b. Nuclues pulposus :
Soft jelly-like part, enclosed within the centre of the annulus
fibrosus. Its structure changes by age where it becomes firm and
inelastic and may calcify in old age.
c. Plates of cartilage :
A plate on each surface of the disc. Separating it from the
vertebral body.
2. SYNOVIAL JOINTS :
Between the superior and inferior articular processes of
contiguous vertebrae.
They are synovial joints of the plane type.
B. LIGAMENTS :
1. Between the bodies of vertebrae :
a. Anterior longitudinal ligament :
It extends from the basilar part of occipital bone downwards in
front of the vertebral bodies to the upper part of the sacrum.
b. Posterior longitudinal ligament t:
It lies within the vertebral canal and is attached to the posterior
surface of the vertebral bodies and intervetebral discs. Its
continuation to the skull above the axis vertebra is called
membrana tectoria.
2. Between the spines :
a. Interspinous ligament : between the spines.
b. Supraspinuous ligament : between tips of the spines [extends
in the neck as the ligamentum nuchae].
3. Between the transverse processes :
Inter-transverse ligaments.
4. Between the laminae :
Ligamenta flava [yellow elastic fibres].

CERVICAL VERTEBRAE
TYPICAL CERVICAL VERTEBRAE
These are the 3rd, 4th, 5th and 6th C.V., and are characterized by:
1. Vertebral body :
Small and broad from side to side. It has 2 raised lips one on each
side of its upper surface.
2. Vertebral foramen :
Triangular in shape and large in proportion to the body of the
vertebra.
3. Spine :
Short and bifid.
4. Articular facets :
Are directed either backwards and upwards [superior facet] or
forwards and downwards [inferior facets].
5. Transverse process :
Has the foramen transversarium [for the vertebral vessels] and ends
in 2 tubercles [anterior and posterior].
N.B.: The anterior tubercle of the transverse process of 6th C.V is more
prominent and called carotid tubercle as the common carotid artery can
be compressed against it.

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ATLAS VERTEBRA [1st cervical]
It is ring-like and characterized by having :
1. No body, [its body has fused during development with the body of
the axis vertebra to form the dens].
2. No spine.
3. 2 lateral masses connected together by 2 arches [anterior and
posterior].
LATERAL MASS :
a. Upper surface :
Carries the superior articular facet which is elongated and concave for
articulation with the occipital condyle of the skull.
This atlanto-occipital joint [ellipsoid in type] permits :
1. Flexion and extension [forward and backward nodding].
2. Slight lateral flexion.
b. Lower surface :
Carries the inferior articular facet for articulation with the axis. This
atlanto-axial joint [plane] permits rotation of the atlas [with the skull on
it] over the axis.
ANTERIOR ARCH :
Carries on its posterior surface a facet for articulation with the dens of
the axis to form the median atlanto-axial joint [pivot type].
POSTERIOR ARCH :
 Longer than the anterior arch, and have a posterior tubercle in place
of the spine.
 Its upper surface has a groove behind the lateral mass for :
a. 3rd part of vertebral artery.
b. 1st cervical nerve.
LIGAMENTS OF THE ATLAS :
1. Transverse ligament of atlas :
Attached on each side to the inner surface of the lateral mass of atlas
and extends behind the dens of the axis vertebra.
2. Cruciate ligament of atlas :
It is formed of 2 bands which cross each other at right angle :
a. Transverse band : is the transverse ligament of the atlas.
b. Vertical band : extends from the transverse ligament of atlas, both
upwards to the upper surface of the basilar part of the occipital
bone and downwards to the back of the body of axis.
APPLIED ANATOMY :
Dislocation of the dens with rupture of the transverse ligament of atlas, as in
hanging, leads to sudden death due to injury of the spinal cord and stoppage
of respiration.
AXIS VERTEBRA [2nd cervical]
It is characterized by :
1. Presence of the dens [odontoid process] : it gives attachment to
ligaments :
a. Apical ligament [from its apex].
b. 2 alar ligaments [one from each side].
2. Strong spine [provides attachment for muscles which extend the neck
and rotate the head].
3. Very small transverse process.

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LIGAMENTS ATTACHED TO THE AXIS :
1. Apical ligament :
From the apex of dens to the anterior margin of foramen magnum. [It
represents a rudimentary intervertebral disc and may contain remnants
of the notochord].
2. Alar ligaments : [very strong] :
One on each side of the dens. They extend to the inner aspect of the
occipital condyles and limit free rotation of the head.
3. Membrana tectoria :
It extends from the posterior surface of the body of the axis to the upper
surface of the basilar part of occipital bone. It is the continuation of the
posterior longitudinal ligament extending upwards behind the cruciate
ligaments.
N.B.: The ligaments which gain attachment to the basilar part of occipital
bone are arranged as follows, from before backwards.
a. Apical ligament : from the tip of the dens.
b. Vertical band of cruciate ligament : from the transverse ligament
of atlas.
c. Membrana tectoria : from the body of axis.
7TH CERVICAL VERTEBRA [Vertebra prominens]
It is characterized by :
 Spine: not bifid, but long and projected directly backwards [a surface
landmark].
 Foramen transversarium : transmits an accessory vertebral vein [the
foramina transversaria of the other cervical vertebrae transmit the
vertebral artery and vein].

THORACIC VERTEBRAE
TYPICAL THORACIC VERTEBRAE
These are from the 2nd to 8th T.V., and are characterized by:
1. Vertebral body :
Heart-shaped and has costal facets on each side :
a. A superior demi-facet : [1/2 of a circle] on the upper border of the
body for the head of the rib corresponding in number to that of
the vertebra.
b. An inferior demi-facet: On the lower border of the body, for
articulation with the head of the rib below.
2. Vertebral foramen :
Circular and small in relation to the vertebral body.
3. Transverse process :
Has a facet on its anterior surface for articulation with the tubercle of
the rib having the same number as the vertebra. The facets in shape
and position.
a. Upper 6 T.V. carry concave facets that lie on the anterior
surface of the process.
b. 7, 8, 9, 10 T.V.: carry flat facets that encroach more on the
upper surface of the process.
4. Spine :
Long, Pointed and directed obliquely downwards and backwards.

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NON-TYPICAL THORACIC VERTEBRAE
These are the 1st, 9th, 10th, 11th and 12th T.V.
1. 1st THORACIC VERTEBRA :
a. There is a complete facet on the side of the body near its upper
border for the head of the 1st rib.
b. A demi-facet at the lower border of the body for the 2nd rib.
2. 9th THORACIC VERTEBRA :
a. There is a demi-facet at the upper border of the body for head of
the 9th rib.
b. No facet at its lower border.
3. 10th THORACIC VERTEBRA :
a. There is one complete facet on the side of the body for the head of
the 10th rib.
b. The transverse process shows a facet as the other thoracic
vertebrae above.
4. 11th THORACIC VERTEBRA :
a. It has one complete facet close to the upper border of the body
and encroaching on the pedicle.
b. The transverse process is very small and has no facet.
5. 12th THORACIC VERTEBRA :
a. There is one complete facet encroaching on the pedicle [as the
11th].
b. The transverse process is very small and has no facet.
c. Its inferior articular facets are convex and directed laterally [as the
lumbar].
d. The spine is lumbar in type.

LUMBAR VERTEBRAE
CHARACTERS OF A LUMBAR VERTEBRA :
1. Vertebral body :
It is markedly larger in size in relation to the vertebral foramen.
2. Spine :
Broad and short [quadrangular] and directed backwards.
3. Transverse process :
Thin and elongated [no articular facet].
However, the transverse process of the 5th lumbar vertebra is thick,
strong and is connected to the whole pedicle and extends more on to
the side of the body.
4. Articular facets :
a. Superior facets : concave and directed medially.
b. Inferior facets : convex and directed laterally.
N.B.: The shape of the facets allow some rotation, in addition to flexion
and extension.
5. Mamillary process :
A tubercle projecting from the posterior border of the superior articular
process.
IMPORTANT RELATIONS OF LUMBAR VERTEBRAE :
 The right crus of diaphragm extends along the side of the upper 3
lumbar vertebrae, while the left crus extends along the upper 2 only.
 Psoas major: arises from the front of transverse processes of all lumbar
vertebrae as well as the sides of their bodies.

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Aorta, I.V.C. and sympathetic chain : are related to the bodies [the aorta
ends at lower border of 4th L.V., while I.V.C. begins at 5th L.V].
 The spinal cord ends at the disc between L.1 and L.2, while the caudal
part of the vertebral canal is filled with the cauda equina and the filum
terminale.
 The spines : give attachment mainly to :
o Posterior layer of the lumbar fascia.
o Sacrospinalis muscle, and the group of short muscles deeper to it
[transversospinalis].
STRUCTURES ATTACHED TO LUMBAR TRANSVERSE PROCESSES :
 Psoas major : to the anterior surface of processes of all L.V.
 Quadratus lumborum : inserted into the tips of processes of upper 4 L.V.
 Anterior layer of lumbar fascia : attached near the tips [anterior to
quadratus lumborum].
 Middle layer of lumbar fascia : attached near the tips [posterior to
quadratus lumborum].
 Medial and lateral arcuate ligaments : to the tip of transverse process of
L. 1 [one passes medially while the other passes laterally].
 Ilio-lumbar ligament : to the tip of transverse process of L.5.
HOW TO DIFFERENTIATE BETWEEN VERTEBRAE FROM DIFFERENT
REGIONS :
1. If the vertebra has a foramen transversarium, it is definitely cervical
vertebra.
2. If it has no foramen transversarium , but has articular costal facets on
the sides of the body [ for the ribs], it is thoracic vertebra.
3. If it has neither a foramen transversarium nor a costal facet, it is lumbar
vertebra.
N.B :Sacrum and coccyx [described in the volume of “Abdomen”]

RIBS
 There are 12 pairs of ribs which articulate behind with the thoracic
vertebrae but in front they vary in their relation to the sternum and
accordingly they are divided into true and false ribs :
1. True ribs : (upper 7 ribs)
Articulate in front ( through their costal cartilages) with the sternum.
2. False ribs : (lower 5 ribs)
3. Fail to reach the sternum but their costal cartilages curve upwards to
fuse with each other as in case of 8,9,10 ribs. The ends of 11 and 12 ribs
remain free and are called floating ribs.
 The ribs may be also divided into typical and atypical ribs depending on
their features.
 A rib that possesses all the features common to most ribs is called typical.
While a rib that differs in one or more of these features is called atypical
(non-typical ).
TYPICAL RIBS
These are from the 3rd to 9th ribs. A typical rib has posterior end, shaft and
anterior end.
A. POSTERIOR END :
It possesses a head, neck and tubercle.

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1. HEAD of the rib :
Articulates with the side of 2 contiguous thoracic vertebrae and
the intervetebral disc in between. Accordingly, it has 2 facets and
a ridge in between :
a. The lower facet: for the vertebra of the corresponding
number.
b. The upper facet : for the vertebra above.
c. The ridge: for the intervertebral disc.
N.B. The costovertebral joint is synovial [plane] and the head of
`the rib is connected to the 2 adjacent vertebrae and the
disc in between by a radiate ligament. There is also an intra-
articular ligament extending inside the joint between the
crest on the head and the intervertebral disc.
2. NECK of the rib :
 It is the constricted part following the head .
 It lies in front of the transverse process of the vertebra with
the same number. It is attached to it by the costotransverse
ligament.
 It is attached to the transverse process of the vertebra
above by the superior costotransverse ligament.
3. TUBERCLE of the rib :
Lies at the junction of the neck with the shaft, it is composed of 2
parts :
a. Medial articular part :
 Articulates with the transverse process of the
corresponding vertebra to form the
costotransverse joint (synovial).
 The surfaces of the upper 6 joints are curved
(convex on the tubercle and concave on the
transverse process). But those of the lower joint
are flat.
b. Lateral non-articular part :
Attached to the tip of the corresponding transverse
process by the lateral costotransverse ligament.
B SHAFT :
 It is curved, and shows the angle of rib at its posterior part(5 cm
from the tubercle).
 It is also twisted in its long axis (if the rib is placed on a horizontal
surface only one end comes in contact with the surface)
 It has 2 borders and 2 surfaces :
1. Upper border : Rounded and blunt
2. Lower borde r: Thin and sharp
3. Internal surface : Concave and related to the pleura and lung.
It has the costal groove at its lower part which lodges :
 Posterior intercostals vein : above [V]
 Posterior intercostals artery : in the middle [A]
 Intercostal nerve : below [N]
4. External surface: Convex and gives attachment to :
 Pectoralis minor : [3 – 5 ribs].
 Serratus anterior : [upper 8 ribs].
 External oblique of abdomen : [lower 8 ribs].
 Latissimus dorsi : [lower 4 ribs].
N.B.: The pectoralis major is attached to the upper 6 costal cartilages.
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A. ANTERIOR END :
Cup-shaped and is attached to the costal cartilage at the
costochondral junction].
N.B.:
7th rib : the longest.
8th rib : the most convex [most projected laterally].
9th rib : the most oblique.
ATYPICAL [NON-TYPICAL] RIBS
These are the 1st, 2nd, 10th, 11th, and 12th ribs
1. FIRST RIB :
It differs from the typical ribs in the following :
 It is the shortest and most curved.
 It has one facet only on the head.
 The shaft is broad.
 The tubercle and angle coincide.
 It has an upper and lower surfaces [instead of outer and inner].
The upper surface is rough while the lower is smooth.
 It has an inner and outer borders [instead of upper and lower].
FEATURES OF FIRST RIB :
1. Upper surface : rough and shows the followings :
 Scalene tubercle : gives insertion to scalenus anterior muscle.
 Groove in front of scalene tubercle : for subclavian vein.
 Groove behind scalene tubercle : for subclavian artery [3rd
part] and lower trunk of brachial plexus.
 Posterior rough area: [behind the groove for the artery], for
insertion of scalenus medius.
 Anterior rough area : [in front of the groove for the vein] for
origin of subclavius muscle and attachment of the
costoclavicular ligament.
2. Lower surface : Smooth and is related to the pleura and lung [the
reverse of the clavicle: where the upper surface is smooth, but the
lower surface is rough].
3. Inner border : Gives attachment to the suprapleural membrane [from
the tip of the transverse process of 7th C.V].
4. Outer border : Gives origin to
a. 1st digitations of serratus anterior [very thick digitations].
b. Intercostals muscles of the 1st space.
STRUCTURES PASSING IN FRONT OF NECK OF FIRST RIB :
a. Medially :
Sympathetic chain where the 1st thoracic ganglion may fuse with
the inferior cervical ganglion to form the cervicothoracic [stellate]
ganglion.
b. Laterally :
1st thoracic nerve ascending to join other roots of the brachial
plexus.
c. In between :
Superior intercostal artery descending from the costocervical
trunk in between the 2 nerves [supplies the 1st 2 spaces].
N.B.: The deep cervical artery passes backwards above the neck
of 1st rib.

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2. SECOND RIB :
It is identified by the fact that its shaft is not twisted [when put on a
horizontal surface both of its posterior and anterior ends touch the
surface].
3. 10th RIB :
it has one facet on the head [for the 10th T.V.].
4. 11th and 12th RIBS
They are characterized by having :
 One facet on the head.
 Pointed anterior end [free end].
 No neck, no tubercle and no costal groove.
IMPORTANT RELATIONS OF THE 12TH RIB
 Pleural sac [costodiaphragmatic recess] :
Its lower border crosses in front of the medial part of the 12th rib.
Laterally, the rib is not covered by pleura.This relation is of surgical
importance in operations on the kidney.
 Muscles attached to the 12th rib :
a. To internal surface :
 Quadratus lumborum.
b. To external surface :
 Sacrospinalis.
 Latissimus dorsi.
 External oblique muscle of abdomen.
 Serratus posterior inferior.
 Ligaments and fascia related to 12th rib :
a. Lateral arcuate ligament.
b Lumbar fascia.
JOINTS RELATED TO A TYPICAL RIB
1. Costovertebral joint : between the head of the rib and the sides of 2
vertebral bodes [synovial].
2. Costotransverse joint : between the tubercle of the rib and transverse
process of the vertebra [synovial].
3. Sternocostal joint : between the costal cartilage and side of sternum
[that of the 1st rib is cartilaginous while the others are synovial].

STERNUM
It is a flat bone formed of 3 parts : manubrium, body and xiphoid
process.
I. MANUBRIUM STERNI :
It is the upper part and joins the body of sternum at the sternal angle
[opposite the level of 2nd costal cartilage or 4th thoracic vertebra].
It has 4 borders and 2 surfaces :
Upper border :
 Has a clavicular notch on each side for articulation with the
medial end of the clavicle [sternociavicular joint].
 In between these notches, the upper border is concave and forms
the suprasternal notch [jugular notch].
Lower border :
 Meets the sternal body at the manubriosternal joint which may
ossify in old age [sternal angle].
 This angle is an important landmark for counting the ribs [the 2nd
rib joins the sternum at this angle.

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Lateral border :
 The 1st costal cartilage articulates close to its upper end
[cartilogenous joint].
 The 2nd costal cartilage articulates close to its lower end
[synovial joint].
Anterior surface :
Rough and gives origin to :
 Sternomastoid muscle : close to the clavicular notch.
 Pectoralis major : close to the lateral border.
Posterior surface :
Smooth and has the following features :
1. Gives origin to muscles :
 Sternohyoid : opposite the clavicular notch.
 Sternothyroid : opposite the 1st costal cartilage [below
sternohyoid].
2. Related to superior mediastinum :
 Arch of aorta : behind the lower 1/2.
 Branches of aortic arch [brachiocephalic, left common
carotid, left subclavian arteries] : behind the upper 1/2.
 Left innominate vein : along the upepr border of the aortic
arch.
 Thymus gland.
 Anterior borders of pleura and lungs [most superficial].
JOINTS RELATED TO MANUBRIUM STERNI :
a. 1st costal cartilage [on each side].
b. 2nd costal cartilage [on each side].
c. Manubriosternal joint.
LEVELS OF MANUBRIUM STERNI :
a. Upper border : opposite lower border of 2nd T.V.
b. Lower border: opposite lower border of 4th T.V.
II. BODY OF STERNUM :
It is formed of 4 segments [sternebrae] that are fused together. It has
the following borders and surfaces :
1. Upper border :
Articulates with the manubrium at the manubriosternal joint
[cartilaginous, but may be synovial in 30%].
2. Lower border :
Joins the xiphoid process to form the xiphi-sternal joint
[cartilaginous].
The joint is at the level of 9th thoracic vertebra and usually ossifies in
old age.
3. Anterior surface :
Rough and gives origin to the pectoralis major muscle.
4. Posterior surface :
Smooth and has the following relations :
 Gives origin to transversus thoracis [sternocostalis] muscle.
 Gives attachment to upper and lower sternopericardial
ligaments [in its middle line].
 It comes in contact with :
a. Pericardium [direct contact at the bare area].
b. Thymus gland.
c. Anterior borders of the 2 pleurae and lungs.

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5. On each side :
It articulates with costal cartilages from the 2nd to 7th [synovial
joints].
Applied Anatomy :
It is a common place for sternal puncture to get a sample of bone
marrow [has thin compact bone and is subcutaneous].
III. XIPHOID PROCESS :
It lies at the apex of the infrasternal angle and gives attachment to :
 Linea alba : from its tip.
 Sternal origin of diaphragm : from its posterior surface.
 External oblique muscle of the abdomen : from its anterior surface.
 Internal oblique and transversus abdominis : from its borders.

MUSCLES OF THE BACK

There are 2 main groups of muscles in the back : superficial and deep.
A. SUPERFICIAL MUSCLES OF THE BACK :
 These are muscles of the upper limb connecting it to the vertebral
column [trapezius, latissimus dorsi, rhomboideus major and minor,
levator scapulae] in addition to the serratus posterior [superior and
inferior].
 These muscles are supplied by the anterior primary rami of spinal
nerves.
B. DEEP MUSCLES OF THE BACK :
 These are the true or intrinsic muscles of the back [sacrospinalis and
transversospinalis].
 They extend from the back of the pelvis upwards to the skull and are
all supplied by the posterior primary rami of the spinal nerves.
 They are covered by a layer of thick deep fascia termed thoraco-
lumbar fascia.
SACROSPINALIS [erector spinae]
 It forms a large mass on each side of the vertebral column.
 It is narrow and tendinous at its origin from the back of the sacrum
but it is thick and fleshy in the lumbar region where it can be easily
felt in the living body.
Common origin of sacrospinalis : from
1. Back of the sacrum.
2. Dorsal segment of the iliac crest.
3. Spines of all lumbar and also 2 thoracic vertebrae.
The muscular mass splits at the lower limit of the chest into 3
Columns of muscular slips:
a. Lateral column [ilio-costocervicalis].
b. Intermediate column [longissimus]
c. Medial column [spinalis]
Insertions of the 3 columns of sacrospinalis :
1. Lateral column :
Into the angles of the ribs.
2. Intermediate column : [the largest of the 3 columns]
Into the transverse processes of the lumbar and thoracic
vertebrae.
3. Medial column:
Into the spines of the upper thoracic vertebrae.

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SOME DETAILS ABOUT THE 3 COLUMNS OF SACROSPINALIS:
1. LATERAL COLUMN:
Consists of 3 parts [one higher than the other].
a. Illo-costalis : [lower part] attached to the lower ribs.
b. Costalis : [middle part] extends from the lower ribs to the
upper ribs.
c. Costo-cervicalis : [upper part] extends from the upper ribs to
the cervical vertebrae.
2. INTERMEDIATE COLUMN :
Consists of 3 parts [one higher than the other].
a. Longissimus thoracis : [lower part] related to the thoracic
vertebrae.
b. Longissimus cervicis : [middle part] extends from the upper
thoracic vertebrae to the cervical vertebrae.
c. Longissimus capitis : [upper part] extends from the upper
thoracic and lower cervical vertebrae to the mastoid process of
the skull.
3. MEDIAL COLUMN :
Consists of 3 parts [one higher than the other]
a. Spinalis thoracis : [lower part] extends from the spines of
lower thoracic vertebrae to those of the upper thoracic
vertebrae.
b. Spinalis cervicis : [middle part] extends from the upper
thoracic vertebrae to the upper cervical vertebrae.
c. Spinalis capitis : [upper part] extends upwards to the back of
the skull [it is blended with the semispinalis capitis].
TRANSVERSO-SPINALIS
 This group of short muscles lies deep to the sacrospinalis muscle. It
consists of muscles extending from the transverse processes to the
spines of the vertebrae.
 These muscles are the semispinalis, multifidus and rotatores
[arranged one superficial to the other].
1. SEMISPINALIS : [superficial]:
a. Semispinalis thoracis :
Extends from the transverse processes of the lower thoracic
vertebrae to spines of the upper thoracic vertebrae.
b. Semispinalis cervicis :
Extends from the upper thoracic to the cervical vertebrae.
c. Semispinalis capitis :
Extends from the upper thoracic and lower cervical vertebrae to
the back of the skull [between the superior and inferior nuchal
lines].
2. MULTIFIDUS :
 These are short muscles that lie deep to the semispinalis, in the
groove between the spines and transverse processes of all
vertebrae from the axis to the sacrum.
 Each muscle arises from the transverse process of a vertebra and
ascend upwards and medially to get insertion into the whole
length of the spine of the vertebra above.
3. ROTATORES :
 They lie deep to the multifidus, and are present only in the
thoracic region.

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 The muscle fibres arise from the transverse process of a vertebra
and are inserted into the lamina of the vertebra just above.
ACTIONS OF DEEP MUSCLES OF THE BACK :
1. The sacrospinalis is the main extensor of the vertebral column.
2. The multifidus and rotatores help in rotation of the vertebrae.
3. The multifidus can produce lateral flexion of the column.
4. In general, the short muscles of the back are postural muscles, as
they steady the adjoining vertebrae and control their movements
during contraction of the long muscles [sacrospinalis].
NERVE SUPPLY OF DEEP MUSCLES OF THE BACK :
They are supplied by the posterior primary rami of the spinal nerves.
These nerves remain separate from each other [do not form plexuses]
and enter the muscles to supply them as well as the covering skin
[motor and sensory].

THORACIC WALL
The thoracic wall is formed of series of intercostal spaces, each of which is
occupied by :
A. 3 intercostal muscles : external, internal and innermost.
B. An intercostals nerve.
C. Intercostal arteries : [anterior and posterior].
D. Intercostal veins : [anterior and posterior]

MUSCLES OF THORACIC WALL

A. MUSCLES IN THE INTERCOSTAL SPACE :
1. External intercostal : outer
2. Internal intercostal : inner
3. Innermost intercostal : innermost
B. MUSCLES ON THE INNER SURFACE OF THORACIC WALL :
[towards the pleura]
1. Transversus thoracis : [anteriorly] behind sternocostal junctions.
2. Subcostales : [posteriorly] in front of the angles of ribs.
C. MUSCLES OF THE BACK OF THORACIC WALL : [from outside]
1. Levatores costarum : to all ribs [medial to the angles].
2. Serratus posterior superior : to upper 4 ribs [lateral to the angles].
3. Serratus posterior inferior : to lower 4 ribs [lateral to the angles].
N.B.: The thoracic wall is covered externally by skin and fascia, and internally
by parietal pleura.
EXTERNAL INTERCOSTAL :
 It extends from the tubercle of the rib [posteriorly] to the costochondral
junction [anteriorly].
 It is continued to the side of the sternum as the anterior intercostal
membrane.
 Its fibres pass downwards and forwards [as these of the external oblique
of abdomen], from the lower border of the rib above to the upper border
of the rib below.
INTERNAL INTERCOSTAL :
 It extends from the side of the sternum to the angle of the rib.
 It is continued to the posterior end of the space as the posterior
intercostal membrane.

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 Its fibres pass downwards and backwards from the inner surface of the
rib above [close to the upper margin of the costal groove] to the upper
border of the rib below [deep to the external muscle].
INNERMOST INTERCOSTAL : [intercostalis intimus]
 It is the deepest of the intercostal muscles.
 It is actually the inner part of the internal intercostal muscle splitted by
the intercostal vessels and nerve.
 Its fibres have the same direction as the internal intercostal.
 It extends only along the middle 2/4 of the internal intercostal.
TRANSVERSUS THORACIS [sternocostalis] :
 Lines the inner surface of the anterior wall of thorax.
 Arises from the back of lower part [1/3] of sternum and adjoining costal
cartilages.
 It is inserted by oblique slips into 2, 3, 4, 5, 6 costal cartilages.
 It separates the intercostal nerves from the pleura.
N.B.: Its attachment is comparable to the origin of the sternocostal head of
pectoralis major. [The bone is in between].
SUBCOSTALES :
 Several muscle slips situated at the angles of ribs.
 Each slip arises from the inner surface of one rib and inserted into the
2nd or 3rd rib below.
 It intervenes between the pleura [on one hand] and the intercostal nerve
and vessels [on the other hand].
N.B.: The innermost intercostal, sternocostalis and subcostales form the
innermost layer of muscles of the thoracic wall and are separated from
the internal intercostal by the neurovascular plane lodging the
intercostal nerve and vessels [as the case with the transversus
abdominis].
LEVATORES COSTARUM :
 These are 12 slips each of which arises from the tip of transverse
process of a thoracic vertebra and is inserted into the outer surface of
the rib below, medial to its angle.
 They may be regarded as muscles of the back as they are supplied by
the posterior primary rami of the corresponding nerves.
SERRATUS POSTERIOR SUPERIOR :
 Lies deep to the rhomboid muscles.
 Arises from the lower part of the ligamentum nuchae and upper 2
thoracic spines.
 Inserted into the upper 4 ribs, lateral to their angles.
SERRATUS POSTERIOR INFERIOR :
 Lies deep to the latissimus dorsi.
 Arises from the lower 2 thoracic and upper 2 lumbar spines.
 Inserted into the lower 4 ribs, lateral to their angles.
N.B.: Both serrati muscles are supplied by the anterior primary rami of the
related spinal nerves.

THORACIC NERVES
[INTERCOSTAL AND SUBCOSTAL NERVES]
 These are the anterior [ventral] primary rami of the 12 thoracic spinal
nerves. The 12th [last] nerve is called the subcostal nerve, while the
others are the intercostal nerves.
 The upper 6 nerves : are distributed to the thoracic wall and upper limb.
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 The lower 6 nerves : are distributed to the thoracic and abdominal walls
as well as to the diaphragm.
I. UPPER 6 THORACIC NERVES
The 3rd, 4th, 5th, and 6th nerves have the same course and branches
and therefore described as typical.
The 1st and 2nd nerves differ in some respects.
TYPICAL INTERCOSTAL NERVE:
COURSE :
The nerve passes forwards in the intercostal space where it lies at
1st directly behind the parietal pleura [till the angle of the rib].
It then enters the costal groove separated from the pleura by the
innermost intercostal muscle. In the groove, it passes in the
neurovascular plane accompanied by the posterior intercostal
vessels.
Near the sternum : it pierces the structures in the anterior part of
the intercostal space and appears on the surface as the anterior
cutaneous nerve.
RELATIONS :
1. At the posterior part of intercostal space [till the angle of rib]:
 It lies between the parietal pleura and the posterior
intercostal membrane.
 The posterior intercostal artery crosses obliquely in front of
the nerve.
2. In the costal groove : It lies :
 Between the internal and innermost intercostals.
 Below the posterior intercostal vessels.
3. At the anterior part of intercostal space :
 It lies in front of :
a. Transversus thoracis [sternocostalis].
b. Internal thoracic artery.
 It pierces the following structures to reach the surface :
a. Internal intercostal muscle.
b. Anterior intercostal membrane
c. Pectoralis major muscle.
BRANCHES :
1. Ganglionic branches :
 It gives off a white ramus communicans [myelinated] to
the corresponding thoracic ganglion, and receives a
grey ramus communicans [non-myelinated] from the
ganglion.
 These are sympathetic [preganglionic and
postganglionic] fibres and accompany the thoracic
nerves to supply blood vessels, hairs and sweat glands
of the skin.
N.B.: The pregnanglionic fibres [white ramus] arise from the
sympathetic cells in the lateral horn of the spinal cord and
pass along the ventral root of the spinal nerve.
2. Collateral branch :
Runs along the upper border of the rib below. It ends on the
surface as an additional anterior cutaneous nerve.

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3. Lateral cutaneous nerve :
Pierces the intercsotal muscles to appear on the surface at the
mid-axillary line. It divides into anterior and posterior branches
to supply the skin of the side of chest.
4. Anterior cutaneous nerve :
It is the terminal part of the intercostal nerve which pierces the
anterior part of the intercostal space and appears on the
surface close to the sternum. It supplies the skin of the front
of the chest.
5. Muscular branches :
Mainly to the intercostal muscles [in addition to other muscles
of the thoracic wall].
1st INTERCOSTAL NERVE :
 The greater part of it ascends on the front of the neck of the 1st
rib to join the brachial plexus.
 The remaining smaller part of the nerve passes on the under
surface of the 1st rib as a fine branch [does not pierce the
intercostal space and has no lateral cutaneous branch].
2nd INTERCOSTAL NERVE :
It differs from a typical nerve only in that its lateral cutaneous
branch does not divide into anterior and posterior branches and is
called intercosto-brachial nerve which supplies the skin of the
axilla.
II. LOWER 6 THORACIC NERVES
 They extend into the anterior abdominal wall [among its muscles],
 Near the anterior ends of the intercostal spaces :
 7th and 8th nerves: curve upwards and medially across the
costal margin.
 9th nerve : runs horizontally.
 10th, 11th, 12th nerves : pass downwards and medially.
 They have the same branches and relations as the upper typical
nerves, except that they enter the abodominal wall and pierce the
rectus sheath to appear on the surface as the anterior cutaneous
nerves [close to the linea alba].
 Subcostal nerve [12th].
1. It passes behind the kidney and in front of the upper part of the
quadratus lumborum, then pierces the trasnversus abdominis
to run between it and the internal oblique [as the lower thoracic
nerves].
2. Its lateral cutaneous branch descend over the iliac crest. 5 cm
behind the anterior superior iliac spine to supply the skin of
the front of the buttock.
N.B.:
The dermatomes of the chest extend around its circumference as
contiguous bands from the midline posteriorly, to the midline anteriorly.
At the sternal angle the 4th cervical nerve [through supraclavicular
nerves] comes in contact with the 2nd thoracic nerve.

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VESSELS OF THORACIC WALL

I. ARTERIES OF THORACIC WALL

The arteries of the thoracic wall are :
 Posterior intercostal arteries : from thoracic aorta [except the upper 2
arteries].
 Anterior intercostal arteries : from internal thoracic artery.
 Internal thoracic artery : from 1st part of subclavian artery.
1. POSTERIOR INTERCOSTAL ARTERIES :
ORIGIN :
a. The arteries of the 1st and 2nd spaces arise from the superior
intercostal artery which is a branch of the costocervical trunk
[from 2nd part of subclavian artery].
The superior intercostal artery passes downwards in front of the
neck of 1st rib between the sympathetic chain and 1st intecostal
nerve. It divides into 2 posterior intercostal arteries for the upper
2 spaces.
b. The arteries of the remaining spaces and the subcostal artery
arise from the back of descending thoracic aorta.
COURSE AND RELATIONS :
 As the artery enters the posterior end of the space it ascends
obliquely till it reaches the angle of the rib, where it continues
forwards in the costal groove.
 Before it reaches the angle it lies between the pleura and the
posterior intercostal membrane.
 In the costal groove it runs between the internal and innermost
intercostal muscles [below its vein and above the nerve,
V.A.N].
 The artery and its collateral branch anastomose with the 3
anterior intercostal arteries coming from the internal thoracic
artery.
N.B.:
As the thoracic aorta lies to the left of the median plane, the right
intercostal arteries are longer than the left and cross the
median plane behind the oesophagus and pericardium.
BRANCHES:
1. Posterior branch:
Arises at the posterior end of the intercostal space and passes to the
back. It gives off a spinal branch that enters the vertebral canal
through the intervertebral foramen.
2. Collateral branch:
Arises at the angle of the rib and runs along the upper border of the
rib below [the intercostal artery itself runs along the lower border of
the rib above].
3. Lateral cutaneous branch:
Accompanies the lateral cutaneous nerve.
4. Mammary branches :
From the vessels in the [2nd, 3rd, and 4th] spaces to the mammary
gland.

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1. ANTERIOR INTERCOSTAL ARTERIES :
ORIGIN :
 In upper 6 spaces : the arteries arise from the internal thoracic
artery.
 In 7th, 8th and 9th spaces : they arise from the musculophrenic [a
terminal branch of internal thoracic artery].
COURSE AND RELATIONS :
There are 2 anterior intercostal arteries passing along the upper and
lower boundaries of each intercostal space to anastomose with the
posterior intercostal artery and its collateral branch.
APPLIED ANATOMY :
The position of the posterior intercostal artery is of surgical
importance, in case of aspiration of fluid from the pleural cavity.
At the lateral side of chest the artery lies close to the upper boundary
of the space while its collateral branch lies close to its lower
boundary. So, the needle should be inserted midway between the
ribs bordering the space.
2. INTERNAL THORACIC ARTERY :
COURSE AND RELATIONS :
a. In the root of neck :
 It arises from the 1st part of subclavian artery [1 inch
above the medial end of clavicle].
 It passes downwards and medially through the thoracic
inlet behind the medial end of the clavicle and 1st costal
cartilage.
b. In the chest:
 It descends vertically behind the costal cartilage about 1
cm from the lateral margin of sternum where it is crossed
[anteriorly] by the intercostal nerves.
 It ends opposite the 6th intercostal space by dividing into
2 terminal divisions: superior epigastric and
musculophrenic arteries.
 It is accompanied by a pair of veins and a chain of lymph
nodes [parasternal nodes].
 Its upper part lies directly in front of the pleura, but its
lower part is separated from it by the transversus thoracis
muscle.
BRANCHES :
1. Pericardiaco-phrenic artery :
Arises from its upper part and descends in company with the
phrenic nerve on the surface of the pericardium till the diaphragm.
2. Anterior intercostal arteries :
A pair for each of the upper 6 intercostal spaces.
3. Perforating arteries :
Pierce the intercostal space together with the anterior cutaneous
nerve. Those of the 2nd, 3rd, 4th spaces are important in the
female for supply of the mammary gland.
4. Superior epigastric artery :
Enters the rectus sheath between the sternal and costal origins of
the diaphragm. In the sheath, it anastomoses with the inferior
epigastric branch of the external iliac artery.

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5. Musculophrenic artery :
 Descends downwards and laterally along the costal margin
close to the origin of the diaphragm.
 It gives a pair of anterior intercostal arteries to each of the
7th, 8th and 9th spaces.
 It anastomoses with arteries of the anterior abdominal wall
and the diaphragm.

II. VEINS OF THORACIC WALL

The chest wall is drained by :
a. Posterior intercostals veins : most of them join the hemiazygos veins
on the left and the azygos being on the right.
b. Anterior intercostal veins : join the internal thoracic vein.
c. Internal thoracic vein : ends in the brachiocephalic vein.
d. Azygos vein : ends in the superior vena cava.
e. Hemiazygos veins : end in the superior vena cava.
f. Hemiazygos veins : ends in the azygos vein.
1. POSTERIOR INTERCOSTAL VEINS :
a. ON THE RIGHT SIDE :
 The 1st posterior intercostal vein : ends in the right
brachiocephalic vein.
 The 2nd and 3rd veins: join each other to form the right
superior intercostal vein that ends in the arch of the azygos
vein.
 The remaining posterior intercostal and subcostal veins: join
the azygos vein.
b. ON THE LEFT SIDE :
 The 1st vein : ends in the left brachiocephalic vein.
 The 2nd and 3rd veins: join each other to form the left superior
intercostal vein that ascends on the left side of the arch of
aorta to end in the left brachiocephalic vein.
 From the 4th to 8th veins : join the superior hemiazygos vein
which crosses to the right side opposite the 7th thoracic
vertebra behind the aorta to join the azygos vein.
 The remaining posterior intercostal vein and the subcostal vein
: join the inferior [accessory] hemiazygos vein which crosses
to the right opposite the 8th thoracic vertebra to end in the
azygos vein.
2. ANTERIOR INTERCOSTAL VEINS :
They join the internal thoracic vein :
3. INTERNAL THORACIC VEIN :
 Arises at the 3rd costal cartilage by union of the venae comitantes
of the internal thoracic artery.
 Ascends close to its artery to end in the brachiocephalic vein.
 Receives the anterior intercostal veins and the
pericardiacophrenic vein.
4. AZYGOS VEIN :
ORIGIN :
 It arises from the back of the inferior vena cava at the level of the
renal vein [2nd L.V].
 Sometimes it arises from union of the right ascending lumbar vein
with the right subcostal vein.
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 Thorax [ 101 - 154 ]
N.B.:The ascending lumbar vein run in front of the transverse
processes of lumbar vertebrae down to the psoas major and links
the common iliac, ilio-lumbar and lumbar veins together.
COURSE AND RELATIONS :
a. In the abdomen :
 It runs on the upper 2 lumbar vertebrae behind the right
crus of diaphragm where it is separated from the aorta by
the cisterna chylli.
 It ascends through the aortic opening of the diaphragm. On
the right side of the aorta and separated from it by the
thoracic duct.
b. In the chest :
 It ascends on the bodies of thoracic vertebrae to the right of
the aorta and behind the right border of oesophagus.
 It passes behind the root of right lung, then arches above it
at the level of 4th thoracic vertebra to form the arch of
azygos vein.
 The arch of azygos vein crosses the right side of
oesophagus and trachea as well as the vagus nerve on the
side of the trachea.
 It ends into the superior vena cava opposite the 2nd costal
cartilage [4th thoracic vertebra].
 It connects the superior vena cava with the inferior vena
cava and is of importance for collateral circulation in
obstruction of either vein.
TRIBUTARIES :
 Right superior intercostal vein [union of 2nd and 3rd veins].
 Right posterior intercostal veins from 4 to 11, and the right
subcostal vein [draining right side of chest].
 Superior and inferior hemiazygos veins [draining left side of
chest].
 Bronchial veins from the right lung.
 Some veins from oesophagus and pericardium.
5. HEMIAZYGOS VEINS :
 These 2 veins lie on the left side of the vertebral column and drain
the left side of the chest.
 They are the hemiazygos and accessory hemiazygos veins.
1. Hemiazygos [superior hemizygos] :
 It is the upper one and receives the posterior intercostal
veins from the 4th to 8th spaces.
 It crosses to the right at the 7th thoracic vertebra behind the
aorta, oesophagus and thoracic duct to join the azygos
vein.
2. Accessory hemiazygos [inferior hemiazygos] :
 It arises either from the back of left renal vein or from union
of the ascending lumbar and subcostal veins on the left
side.
 It receives the remaining lower posterior intercostal and
subcostal veins.
 It crosses to the right at the 8th thoracic vertebra to join the
azygos vein.

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CAVITY OF THE THORAX
The cavity of the thorax is composed of :
 Right and left cavities : contains both the right and the left lungs
covered by the pleurae.
 A median partition between the 2 lungs called mediastinum is composed
of the heart and its pericardium as well as other related structures.

PLEURA
It is a closed serous sac [on each side], which has been invaginated in the
foetus from its medial aspect by the lung bud. As a result, each sac becomes
formed of 2 layers:
1. Parietal layer: lining the thoracic wall.
2. Pulmonary [visceral] layer: covering the lung.
N.B.: The pleural cavity lies between the 2 layers.
I. PARIETAL PLEURA :
For the purpose of description, it is divided into several parts : cervical,
costal, diaphragmatic and mediastinal.
1. Cervical pleura :
 It is the part projecting into the root of the neck up to the neck
of the 1st rib [covers the apex of lung].
 It is covered by the suprapleural membrane [extending from tip
of transverse process of 7th cervical vertebra to inner border of
1st rib].
 It is related to :
a. Subclavian artery : in front.
b. Costocervical trunk : ascends to its apex [where it
divides].
c. Superior intercostal artery : descends behind the apex
[the apex of lung is related to arteries with the
suprapleural membrane intervening].
2. Costal pleura :
Lines the inner surface of the ribs and intercostal spaces.
3. Diaphragmatic pleura :
Covers the upper surface of diaphragm.
4. Mediastinal pleura :
Covers the side of mediastinum.
SURFACE ANATOMY OF THE PLEURA :
This description deals with the parietal pleura [the surface anatomy of
the visceral pleura is that of the lung itself].
1. Apex of cervical pleura :
At the neck of the 1st rib, 1 inch above the medial 1/3 of the
clavicle.
2. Anterior border:
Corresponds to an oblique line drawn from the apex, to the middle
of sternal angle passing by the sternoclavicular joint. Below the
sternal angle, the right side differs from the left sides
a. On the right :
It descends vertically to the level of 6th costal cartilage to
become continuous with the inferior border of pleura.

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b. On the left :
It descends vertically to the level of 4th costal cartilage,
then deviates to the left and descends close to the margin
of sternum down to the level of 6th costal cartilage.
3. Inferior border:
From the lower point of the anterior border [6th costal cartilage] a
line is drawn backwards around the chest wall and so It crosses:
a. 8th rib in mid-clavicular plane.
b. 10th rib in mid-axillary plane.
Ends at 12th thoracic spine close to the vertebral column.
N.B.: It crosses the medial part of 12th rib [at the point where it is
crossed by lateral border of sacrospinalis] to end below it.
4. Posterior border:
A vertical line drawn on the back parallel to the vertebral column
from the posterior end of the inferior border to the apex of the
pleura[ at the neck of 1st rib].
II. PULMONARY PLEURA :
It covers the surfaces of the lung and lines the fissures between it lobes
PLEURAL RECESSES :
These are angular spaces in the pleural cavity into which the lungs
expand during deep inspiration.
These recesses are mainly :
A. Costo - diaphragmatic recess:
At the junction of the parietal pleura lining the ribs (costal pleura)
with that covering the upper surface of diaphragm (diaphragmatic
pleura].
N.B.: In case of pleural effusion, fluid fills this recess and prevents
the lung from complete expansion.
B. Costo-mediastinal recess:
Lies behind the sternum, at the junction of the costal pleura with the
mediastinal pleura.
NERVE SUPPLY OF THE PLEURA:
a. Parietal pleura: supplied by the thoracic [somatic] nerves of the chest
wall [sensitive to pain].
b. Pulmonary pleura: supplied by autonomic nerves [insensitive].

LUNGS
SURFACES AND BORDERS:
Each lung has 2 surfaces, 3 borders, apex and base.
 Apex:
Directed upwards and projects into the root of the neck.
 Base:
Concave and is related to the diaphragm.
 Anterior border:
Sharp, thin and extends medially into the costo-mediastinal recess.
 Posterior border:
Thick, rounded and lies by the side of the vertebral column.
 Lateral [costal] surface:
Convex and is related to the ribs and intercostal spaces.
 Medial surface:
Contains the hilus [hilum] and is divided into mediastinal and
vertebral parts:

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 Thorax [ 101 - 154 ]
a. Mediastinal part:
Related to the side of the mediastinum and has the hilus in its
posterior part.
b. Vertebral part:
Lies behind the hilus and is related to the side of the vertebral
column.
DIFFERENCES BETWEEN RIGHT AND LEFT LUNGS
a. The right lung has 3 lobes, but the left lung has only 2 lobes.
b. The right lung is shorter and broader [presence of the liver pushes the
diaphragm upwards on the right side].
c. The left lung is longer and narrower [the heart lies on the left side].
d. The left lung has a cardiac notch on its anterior border and lingula below
the notch.
To know a lung, right or left:
 Put it in the anatomical position [on yourself].
The apex: above, and the base: below
 The thin anterior border : in front, and the thick posterior border:
behind.
 The medial surface : contains the hilus.
 Don’t rely much on the fissures as they may be obliterated by
disease.
LOBES AND FISSURES OF THE LUNG :
 Right lung : is divided into 3 lobes [upper, middle and lower] by 2
fissures [oblique and horizontal].
 Left lung : is divided into 2 lobes only [upper and lower] by the oblique
fissure which is similar to that of the right lung.
OBLIQUE FISSURE:
 It is a long oblique fissure separating the upper lobe from the lower lobe
[on the left] of the upper and middle lobes from the lower one [on the
right].
 Course:
 It begins at the posterior border of the lung opposite the tip of the 3rd
thoracic spine [spine of scapula].
 It passes downwards and forwards along the line of the 6th rib.
 It ends at the inferior border of the lung at the 6th costo-chondral
junction.
 It corresponds to the medial border of the scapula in the position of
abduction of the arm above the head [the scapula is rotated upwards].
HORIZONTAL FISSURE : [only on the right side]
 It separates the upper lobe from the middle lobe
 It begins at the anterior border of the lung at the 4th costal cartilage and
extends horizontally to meet the oblique fissure at the midaxillary line [at
6th rib].
N.B.:
The upper and middle lobes lie in front of most of the lower lobe. So
clinical examination of the upper lobe is mainly from the front, while
examination of the lower lobe is mainly from the back. The middle lobe
is examined only from the front.
BRONCHOPULMONARY SEGMENTS ;
 Each lung is composed of 10 bronchopulmonary segments which are
separated from each other by connective tissue septa.

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 Each segment has its own branches [3rd order bronchus] and a branch
of pulmonary artery. The pulmonary veins run in these septa between
the segments and are a guide to the intersegmental planes [the arteries
are segmental].
 A segment can be removed surgically without affecting other segments.
 Each segment extends to the surface of the lung, and the position of the
segment is constant.
A. SEGMENTS OF RIGHT LUNG : ]10 segments].
 Upper lobe : [3 segments]
 Apical : Its bronchus runs upwards.
 Posterior : Its bronchus runs backwards and laterally.
 Anterior : Its bronchus runs forwards and downwards
 Middle lobe : [2 segments]
 Medial
 Lateral
The middle lobe bronchus passes downwards and forwards then gives
off a medial branch and a lateral branch.
 Lower lobe : [5 segments]
 Apical segment : its bronchus runs backwards
 Anterior basal : Its bronchus runs downwards and forwards.
 Posterior basal : Its bronchus runs downwards and laterally.
 Medial basal : Its bronchus runs downwards.
 Medial basal : Its bronchus runs downwards and medially.
B. SEGMENTS OF LEFT LUNG : [10 segments]
 Upper lobe : (5 segments]
 Apical : Its bronchus runs upwards
 Posterior : Its bronchus runs backwards and laterally.
The apical and posterior bronchial branches come from common
apico posterior bronchus.
 Anterior : Its bronchus runs forwards and downwards.
 Superior lingular : Its bronchus runs downwards and forwards.
 Inferior lingular : Its bronchus runs downwards and forwards.
The lingular bronchi arise from the lower part of the upper lobe
bronchus, one above the other.
 Lower lobe: [5 segments]
 Apical
 Anterior basal
 Posterior basal
 Lateral basal
 Medial basal [sometimes absent]
The direction of their bronchi is the same as in the right lung.
N.B.:
Both lungs have essentially the same distribution of the segments
except for the middle lobe on the right [medial and lateral segments] and
the corresponding part on the left side [superior and inferior lingular
segments]. This difference appears to be due to the fact that the right
lung is shorter and broader, while the left lung is narrower and longer.
APPLIED ANATOMY:
a. The direction of the segmental bronchi is of importance in postural
drainage of fluid inside the lung.
b. The bronchi of the middle lobe are comparatively narrow and are
liable to occlusion by enlarged lymph nodes.

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ROOT OF THE LUNG :
 It lies opposite the 5th, 6th and 7th thoracic vertebrae.
 It is surrounded by a covering of pleura which is prolonged below
forming the pulmonary ligament.
 It includes all the structures passing through the hilus of the lung:
1. Principal bronchus:
It is the most posterior structure of the root and is characterized by
the presence of firm plates of cartilage in its walls. It carries on its
posterior surface the bronchial vessels which supply the tissues of
the lung.
2. Pulmonary artery:
Lies anterior to the bronchus and carries non-oxygenated blood to
the lung [in the left lung it is higher in position so comes above the
bronchus].
3. Pulmonary veins:
These are superior and inferior veins:
a. The superior vein : lies in the most anterior part of the root.
b. The inferior vein : lies in the most inferior part of the root.
They carry oxygenated blood from the lungs.
4. Broncho pulmonary lymph nodes and the lymph vessels.
5. Pulmonary nerve plexuses:
These are anterior and posterior autonomic plexuses that lie on the
anterior and posterior aspects of the root respectively.
6. Bronchial vessels:
 There are 2 bronchial arteries on the left side and only one on the
right side. The left ones arises from the aorta while the right one
arises from either the aorta of the upper left bronchial artery.
 The bronchial veins end in the azygos system.
RELATIONS OF THE MEDIASTINAL SURFACE OF THE LUNG
A. RIGHT LUNG:
 Above the hilus : There are impressions for :
1. Arch of azygos vein.
2. Vertical impressions above the azygos vein for the following
structures : [from before backwards]:
a. Right brachiocephalic vein, which descend downward to
continue as the superior vena cava.
b. The right-phrenic nerve lies the lateral surface of these
veins.
c. Trachea [the right vagus nerve lies on its surface].
d. Oesophagus
 Behind the hilus:
1. Oesophagus
2. Azygos bein [behind the oesophagus]
 In front of the hilus:
1. Cardiac impression : for the right atrium and its pericardium.
2. Impression for ascending aorta and thymus gland [above the
cardiac area and in front of the groove for superior vena cava.
 Below the hilus
Impression for inferior vena cava : very short groove below and
posterior to the cardiac area.

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B. LEFT LUNG
 Above the hilus : there are impressions for:
1. Arch of aorta
2. Vertical impression above the aortic arch for the following
structures[ from before backwards]:
a. Left common carotid artery.
b. Left subclavian artery.
[The vagus and phrenic nerves lie on the surface of these 2
arteries which separate the nerves from the trachea].
c. Oesophagus, with the thoracic duct on its let side.
 Behind the hilus:
Descending aorta [a large groove]
 In front of the hilus:
1. Cardiac impression for :
a. Left ventricle and left auricle [deep fossa, below]
b. Infundibulum of right ventricle [above]
2. Thymus gland : above the impression for the infundibulum.
 Below the hilus:
1. A short impression for the oesophagus in front of the lower end of
the pulmonary ligament.
2. At this point the oesophagus crosses in front of the descending
aorta from right to left.
N.B.:
Both lungs have nearly similar impressions but for different structures
SURFACE ANATOMY OF THE LUNG AND ITS FISSURES:
I. LATERAL SURFACE OF THE LUNG:
a. Apex
A point 1 inch above the medial 1/3 of the clavicle [at the neck of 1st
rib].
b. Anterior border :
An oblique line drawn from the apex to a point at the middle of the
sternal angle passing by the stemoclavicular joint.
 On the right side : it descends vertically down to the 6th costal
cartilage.
 On the left side: descends to the 4th costal cartilage where it
deviates to the left for a greater distance, the deviation of the
pleura [cardiac notch] and continue downwards 1 inch from the
margin of the sternum to the 6th costal cartilage [the pleural
descends very close to the left margin of the sternum below the
4th costal cartilage].
N.B.:
At the lateral part of the cardiac notch, the pericardium is covered
only with pleura but not lung tissue. This area [1 inch lateral to the
sternum below the left 4th costal cartilage] is called clinically area
of the superficial cardiac dullness [dull by light percussion].
c. Inferior border : crosses:
 6th rib in the midclavicular plane
 8th rib in the midaxillary plane
 Ends opposite the 10th thoracic spine close to the vertebral
column.
N.B.
The lung lies higher than the pleura by 2 ribs : this area is the
costo-diaphragmatic recess.
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 Thorax [ 101 - 154 ]
d. Posterior border :
A vertical line drawn from the inferior border along the side of the
vertebral column up to the apex.
II. FISSURES:
1. Oblique fissure:
A line is drawn from the 3rd thoracic spine [medial end of the spine of
scapula] and extends obliquely downwards and forwards along the
course of the 6th rib to end at the junction of the 6th rib with its
cartilage.
2. Horizontal [transverse] fissure:
A horizontal line drawn from the margin of sternum opposite the 4th
costal cartilage and extends laterally to meet the 6th rib at the
midaxillary line.

MEDIASTINUM
 It is the median space of the chest cavity extending from its inlet to its
outlet, and is bounded on each side by pleura and lung.
 For the purpose of description, it is divided into:
1. Superior mediastinum:
It is the area above a line extending from the sternal angle to the
lower border of 4th thoracic vertebra. It extends from the
manubrium sterni [anteriorly] to the vertebral column
[posteriorly].
2. The part below the superior mediastinum [inferior mediastinum] is
divided into 3 parts].
a. Anterior mediastinum : anterior to the heart.
b. Middle mediastinum : occupied by the heart and
pericardium.
c. Posterior mediastinum : posterior to the heart.

SUPERIOR MEDIASTINUM
BOUNDARIES:
 Anteriorly : manubrium sterni
 Posteriorly : upper 4 thoracic vertebrae
 Superiorly : an oblique line from the upper border of manubrium sterni
to the upper border of 1st thoracic vertebra [inlet of thorax].
 Inferiorly : a horizontal line from the lower border of the manubrium to
the lower border of 4th thoracic vertebra.
CONTENTS
The structures in the superior mediastinum can be described to be arranged
into 2 main groups:
a. Superficial structures : These are mainly vessels and nerves related to
the arch of aorta.
b. Deeper structures : These are mainly 2 tubes [trachea and oesophagus]
related to nerves and lymph nodes.
I. SUPERFICIAL STRUCTURES:
1. Arch of aorta:
Related to the lower ½ of the manubrium sterni.
2. 3 branches of the arch.
a. Brachiocephalic artery : passes upwards and to the right.
b. Left common carotid artery : passes upwards and to the left.

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c. Left subclavian artery : passes upwards behind the left
common carotid.
3. Left brachiocephalic vein:
Passes from the left to the right along the upper border of the arch of
the aorta and in front of its 3 branches
4. Right brachiocephalic vein:
Descends on the right of the brachiocephalic artery to join the left
vein behind the 1st costal cartilage to form the superior vena cava.
5. Superior vena cava:
Only its upper ½ lies in the superior mediastinum [its lower ½ is
inside the pericardium].
6. Phrenic nerves:
 The right nerve : descends on the right side of the right
brachiocephalic vein and superior vena cava.
 The left nerve : descends between the left common carotid and
left subclavan arteries.
7. Left vagus nerve:
Descends on the left side of the arch of aorta.
8. Cardiac branches [autonomic fibres]
Descend on the left side of the arch to join the superficial and deep
cardiac plexuses.
9. Left superior intercostal vein:
Ascends on the left side of the arch to end in the left brachiocephalic
vein.
10. Remains of thymus gland:
Superficial to all these vessels.
II. DEEPER STRUCTURES
1. Trachea:
Descends behind the arch of the aorta and its 3 branches.
2. Oesophagus:
Descends behind the trachea, with the thoracic duct on its left side.
3. Left recurrent laryngeal nerve:
Ascends between the left border of the oesophagus and trachea.
4. Right vagus
Descends on the right side of trachea.
5. Lymph nodes : [tracheobronchial nodes]
Lie around the lower end of the trachea.
ANTERIOR MEDIASTINUM
BOUNDARIES :
 Anteriorly : body of sternum
 Posteriorly : pericardium
 Above : a horizontal line from the lower border of manubrium to the
lower border of 4th thoracic vertebra.
 Below : diaphragm.
CONTENTS :
1. Thymus gland
2. Superior and inferior sternopericardial ligaments : fine fibrous strands
extending from the back of sternum to the anterior surface of
pericardium.

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POSTERIOR MEDIASTINUM
BOUNDARIES:
 Anteriorly : back of pericardium
 Posteriorly : vertebral column.
 Above and below : as the anterior mediastinum.
CONTENTS :
1. Oesophagus
2. Oesophageal nerve plexus [mainly from both vagi]
3. Descending thoracic aorta
4. Azygos vein
5. Hemiazygos veins [as they cross to the right side]
6. Thoracic duct
MIDDLE MEDIASTINUM
It lies in between the anterior mediastinum and posterior mediastinum.
CONTENTS
1. Heart and its pericardium
2. Great vessels to and from the heart.
 Ascending aorta
 Pulmonary trunk
 Lower 1/2 of superior vena cava.
 Terminal part of inferior vena cava.
 4 pulmonary veins.
3. Phrenic nerves and pericardiaco-phrenic arteries : on each side of the
pericardium.
PERICARDIUM
It surrounds the heart and proximal parts of its great vessels. It is made of 2
parts.
1. Fibrous pericardium
2. Serous pericardium
[the serous part lines the fibrous part]
FIBROUS PERICARDIUM:
 It is conical in shape with its apex directed upwards and its base
downwards [reverse of the heart].
 Its apex is fused with the coats of the ascending aorta, Pulmonary
trunk, pulmonary veins and superior vena cava.
 Its base is attached to the central tendon of diaphragm [both are
developed from the septum transversum of the embryo].
RELATIONS:
Anteriorly:
 Pleura and lung : from each side
 Upper and lower sternopericardial ligaments : in the median
plane.
 Anterior chest wall, left 1/2 of the lower part of the body of the
sternum. This is opposite the medial part of the cardiac notch of
the left lung where the pericardium is not covered by both pleura
and lung. It is called bare area of pericardium.
Posteriorly:
 Descending aorta
 Oesophagus
On each side:
 Phrenic nerve and pericardiaco-phrenic artery
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 Pleura and lung [mediastinal surface]
SEROUS PERICARDIUM:
It is a serous sac that has been invaginated in foetal life by the developing
heart, so it becomes formed of 2 layers:
1. Visceral layer : [epicardium] adherent to the walls of the heart.
2. Parietal layer : lines the fibrous pericardium.
The pericardial cavity lies between the visceral and parietal layers.
Fluid accumulating inside the pericardial cavity is called
pericardial effusion. It may constrict the veins entering the heart or
may prevent diastole of the heart.
SINUSES OF PERICARDIUM:
These are 2 sinuses related to the serous pericardium : transverse and
oblique.
1. TRANSVERSE SINUS:
It is a transverse space lined by serous pericardium : extending from
one side of the heart to the other [inside the fibrous pericardium]. It lies
between the arterial and venous ends of the heart.
Boundaries:
 Anteriorly : pulmonary trunk and ascending aorta.
 Posteriorly :
a. Left and right atria [their upper part].
b. Superior vena cava [its lower part].
 Above : right pulmonary artery.
 Below : reflection of visceral pericardium [from the posterior to
the anterior boundaries].
N.B:
To find the sinus pass the finger from the right side between the
S.V.C. [behind] and ascending aorta and pulmonary trunk [in front].
2. OBLIQUE SINUS :
 The visceral pericardium ascends on the diaphragmatic surface of the
heart to cover the back of the left atrium. It is then reflected downwards
on the fibrous pericardium to form the parietal layer of the serous
pericardium.
 The part of the pericardial cavity behind the left atrium is the oblique
sinus of pericardium.
Boundaries :
 Anteriorly : back of left atrium.
 Posteriorly : fibrous pericardium separating the sinus from the
descending aorta and oesophagus.
 On each side : 2 right and 2 left pulmonary veins.
 Above : reflection of visceral pericardium from the back of the left atrium
on to the fibrous pericardium.
 Below : it is continuous with the pericardial cavity where its entrance is
guarded by :
a. Inferior vena cava : below and to the right.
b. Lower left pulmonary vein : above and to the left.
N.B:
To find it, open the fibrous pericardium and pass the finger upwards
along the diaphragmatic surface of the heart [behind it], up to the back
of the left atrium.

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HEART
SIZE AND POSITION
 The heart size is better measured in radiograms [X-ray films].
 About 2/3 of the breadth of the heart is to the left of the median plane.
 In the living, determination of the size of the heart can be made
approximately by percussion.
 Palpating the apex beat is a better guide to position of the left border of
the heart.
 The long axis of the heart extends from its base to its apex. It is directed
downwards, forwards and laterally. According to whether the long axis
is more vertical or horizontal, the heart is described to be:
a. Vertical : common in tall slender persons.
b. Transverse : common in obese persons, in pregnancy and in
infants.
SURFACES AND BORDERS OF THE HEART
BASE:
 It is formed by both atria [mainly the left atrium].
 It is directed backwards, behind the ventricles opposite the middle 4
thoracic vertebrae [5, 6, 7, 8].
 It is separated from the vertebral column mainly by:
a. Pericardium
b. Oesophagus
c. Descending aorta
APEX:
 It is formed by the left ventricle only and so, It is directed downwards,
forwards and to the left.
 It is opposite the 5th intercostal space 3.5 inches to the left of the
median plane. It is very close to the anterior wall of the chest Just
medial to the midclavicular line.
STERNOCOSTAL SURFACE
It is directed mainly forwards and is divided by the atrioventricular
[coronary] groove into atrial and ventricular parts:
1. Atrial part:
 It is the smaller part above the groove and is formed by part
of the right atrium and its auricle.
 The left atrium is concealed by the ascending aorta and
pulmonary trunk but only the left auricle appears on the left
side of he root of the pulmonary trunk.
2. Ventricular part:
It is the larger part below the groove, and is divided by the
anterior interventricular groove into:
a. Right 2/3 : formed by the right ventricle.
b. Left 1/3 : formed by the left ventricle.
N.B.:
 In general the sternocostal surface of the heart is formed
mainly by the right ventricle.
 The atrioventricular [coronary] groove on the sternocostal
surface lodges the right coronary artery.
 The anterior interventricular groove is filled with fat and
lodges:
a. Anterior interventricular artery of the left coronary.
b. Great cardiac vein.
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DIAPHRAGMATIC SURFACE
 It is directed downwards and is related to the diaphragm.
 It is divided by the posterior interventricular groove into:
a. Right 1/3 : formed by the right ventricle.
b. Left 2/3 : formed by the left ventricle.
N.B.: [the reverse of the sternocostal surface].
 The posterior interventricular groove lodges:
a. Posterior interventricular artery of the right coronary.
b. Middle cardiac vein.
BORDERS OF THE HEART:
 Upper border : formed by both atria.
 Right border : formed by the right atrium [only]
 Lower border : formed by:
a. Right ventricle [mainly]
b. Left ventricle [a small part forming the apex].
 Left border: formed by:
a. Left ventricle
b. Left auricle
CHAMBERS OF THE HEART
RIGHT ATRIUM:
 It forms the whole of the right side of the heart.
 It lies anterior and to the right of the left atrium.
RELATIONS : It is related to:
 Lung and pleura : laterally and anteriorly.
 Right phrenic nerve and pericardiaco-phrenic artery : on its right side.
 Beginning of ascending aorta : medial.
 Left atrium: posterior and to the left from which it is separated by the
interatrial septum.
CAVITY OF RIGHT ATRIUM:
 Shows vertical ridge on its lateral wall called crista terminalis which
extends from the opening of the S.V.C. to the opening of the I.V.C. Its
position is marked on the surface by a groove called salcus terminalis.
 The crista terminalis divides the cavity of the right atrium into 2 parts:
1. Posterior smooth part : derived from the sinus venosus, and is
called sinus venarum.
2. Anterior rough part : derived from the foetal right atrium and is
roughened by the presence of the musculi pectinati. This part
forms the auricle of right atrium.
INTERATRIAL SEPTUM:
 Forms the posterior and left wall of the right atrium.
 It has an oval depression called the fossa ovalis surrounded [above, in
front and behind] by an arched margin called the limbus fossae ovalis
[annulus ovalis].
 A patient foramen ovale may persist at the upper part of the fossa.
N.B.: Embryological origin.
a. Fossa ovalis : septum primum.
b. Limbus fossae ovalis [annulus ovalis] : free lower margin of the septum
secundum.
c. Foramen ovale : a slit between the septum primum and septum
secundum.

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OPENINGS INTO RIGHT ATRIUM:
a. S.V.C. : in the upper posterior part, opposite the right 3rd stenocostal
junction.
b. I.V.C. : in the lower posterior part, opposite the right 6th sternocostal
junction.
c. Coronary sinus: to the left of the opening of the I.V.C between it and the
right A-V opening. It is guarded by a valve.
d. Right atrio-ventricular opening : in the lower anterior part of the cavity, it
is guarded by the tricuspid valve.
e. Foramina venarum minimarum : these are small openings of the Venae
cordis minimi [they are more numerous on the septum].
f. Openings of the anterior cardiac veins.
LEFT ATRIUM:
 It is posterior and to the left of the right atrium.
 Its walls are smooth and receive the 4 pulmonary veins carrying
oxygenated blood from both lungs.
 Its auricle projects forwards at the upper part of the left border of the
heart to reach the root of the pulmonary trunk. It is rough from inside
due to the presence of musculi pectinati.
 It opens into the left ventricle through the left atrio-ventricular orifice
which is guarded by the mitral [bicuspid] valve.
RIGHT VENTRICLE:
SURFACES AND RELATIONS
It has 3 surfaces : anterior, inferior and left [septal].
1. Anterior surface :
 Forms the main part of the sternocostal surface of the heart.
 Related to the anterior chest wall but separated from it by :
pericardium and anterior margin of the left pleura and lung.
2. Inferior surface:
Is also known as the diaphragmatic surface and it is related to the dome
convex superior surface of the diaphragm.
3. Left surface:
 It is formed by the interventricular septum [septal wall].
 It is convex towards the cavity of the right ventricle so on cross
section its cavity is crescentic.
CAVITY OF RIGHT VENTRICLE:
a. Smooth part:
It is the part of the cavity below the pulmonary orifice [derived from the
bulbus cordis] and is called infundibulum [funnel-shaped]. It has an
important role, in support of the pulmonary cusps in diastole.
b. Rough part:
The rest of the cavity is rough due to the presence of :
1. Trabeculae carneae:
Muscular ridges
2. Septomarginal trabecula [moderator band] :
 It is a muscular band extending from the interventricular
septum to the anterior wall of the right ventricle at the base of
the anterior papillary muscle.
 It transmits the right branch of the atrio-ventricular bundle
[may prevent over-distension of the ventricle].

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3. Papillary muscles:
 These are muscular projections arising from the walls of the
ventricle and are attached by chordae tendineae to the cusps
of the tricuspid valve.
 They are arranged according to the walls of the ventricle:
a. Anterior papillary muscle : to the anterior wall
b. Inferior papillary muscle : to the inferior wall
c. Septal papillary muscles : some small muscles attached
to the L.V. septum [left wall].
OPENINGS INTO RIGHT VENTRICLE:
1. Right atrio ventricular [A.V] orifice :
 Lies at the lower and posterior part of the cavity and admits the
tips of 3 fingers.
 It is guarded by the tricuspid valve whose cusps are arranged as
follows:
a. Anterior cusp :[largest] related to the anterior wall of the
ventricle.
b. Inferior cusp : related to the inferior wall of the ventricle.
c. Septal cusp : related to the septum.
 The bases of the cusps are fixed to a fibrous ring surrounding the
A-V orifice.
 The adjacent margins of the cusps give attachment from their
ventricular surface to the chordae tendineae which are fixed
below to the papillary muscles.
 The ventricular surface of each cusp is rough, while the atrial
surface is smooth.
2. Pulmonary orifice:
 Lies at the upper and posterior part of the cavity of right ventricle.
 It is guarded by a valve, having 3 semilunar cusps :
a. One posterior cusp.
b. 2 anterior cusps.
 Each cusp is concave towards the pulmonary trunk and convex
towards the ventricle.
 The middle of the free margin of each cusp is thickened by the
nodule.
LEFT VENTRICLE:
SURFACES AND RELATIONS
 It has 3 surfaces : anterior, inferior and right [septal].
 It is more conical in shape and forms the apex of the heart. On cross
section, it is more circular in outline and the walls are 3 times as thick as
those of the right ventricle.
 It is related to :
1. Left phrenic nerve and pericardiaco-phrenic artery [comparable to
the right atrium].
2. it forms most of the diaphragmatic surface [in relation to the
diaphragm].
3. It lies posterior and to the left of the right ventricle.
CAVITY OF LEFT VENTRICLE:
It has 2 parts, smooth part and rough part:
a. Smooth part:
Lies just below the aortic orifice, it is fibrous and called the aortic
vestibule [developed from the bulbus cordis as the infundibulum of right

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ventricle]. It allows free closure of the aortic valve at early diastole by
giving a room for the cusps to move in.
b. Rough part: due to the presence of :
 Trabeculae carneae : more numerous
 2 papillary muscles :
I. Anterior papillary muscle : attached to the anterior wall.
II. Inferior [posterior] papillary muscle : attached to form the
inferior wall.
N.B.: They are attached by chordae tendineae to the cusps of the mitral valve.
INTERVENTRICULAR SEPTUM:
 It is composed of two parts :
1. Muscular part : forms its larger lower part [close to the apex]
2. Membranous part : forms its upper posterior part [close to the
aortic orifice].
 It lies obliquely so that its right side looks more anteriorly [the right
ventricle is partly anterior to the left ventricle].
 It separates the left ventricle from both the right ventricle and right
atrium.
 It is convex towards the right ventricle, but concave towards the left
ventricle.
OPENINGS INTO LEFT VENTRICLE
1. Left atrioventricular orifice:
 In the lower and posterior part of the ventricle and admits the tips of
2 fingers.
 It is guarded by the mitral valve which has only 2 cusps.
a. Anterior cusp : larger, and lies in front and to the right
[towards aortic orifice]. Both of its surfaces are smooth.
b. Posterior cusp : smaller, and lies behind and to the left
[towards inferior wall].
2. Aortic orifice:
 In the upper and posterior part of the cavity.
 It is guarded by the aortic valve which is formed of 3 semilunar
cusps:
a. One anterior cusp.
b. Posterior cusps
[the reverse of the pulmonary valve].
SURFACE ANATOMY OF THE HEART
I. STERNOCOSTAL SURFACE:
 Upper Border:
A line drawn in the 2nd intercostal space between :
a. Left point : at the lower border of 2nd left costal cartilage about
15 cm from the margin of the sternum.
b. Right point: at the upper border of 3rd right costal cartilage
1.5cm from the sternal margin.
 Right Border:
A vertical line slightly convex to the right especially at the 4th
space between:
a. Upper point : is the right end of the upper border
b. Lower point : at the right 6th costal cartilage, 1.5cm from the
sternal margin.
 Lower border:
A horizontal line between :

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a. Right point: at the lower end of the right border
b. Left point [apex of the heart] : at the 5th left intercostal space,
3.5 inches [9 cm from the median plane].
 Left border
An oblique vertical line :
a. Lower point : is the point of the apex.
b. Upper point : is the left end of the upper border:
II. ORIFICES OF THE HEART:
 Pulmonary orifice : 3rd costal cartilage, just to the left side of the
sternum.
 Aortic orifice : at 3rd space, behind the left margin of the sternum.
 Mitral orifice : at 4th costal cartilage, immediately below the aortic
orifice.
 Tricuspid orifice : at 4th space, at the middle of the sternum.
III. Atrioventricular [coronary] groove :
It extends from the sternal end of 3rd left costal cartilage to the sternal
end of the 6th right costal cartilage.
VESSELS OF THE HEART
I. ARTERIES OF THE HEART
A. LEFT CORONARY ARTERY
COURSE
 It arises from the left posterior aortic sinus of the ascending aorta.
 It passes forwards for a short distance between the pulmonary trunk
and the auricle or left atrium where it gives off its anterior
interventricular branch then turns to the left in the coronary groove.
 In the posterior part of the coronary groove it is accompanied by the
coronary sinus, and ends by anastomosing with the right coronary
artery.
N.B.: Its continuation to the left, after giving off its anterior I.V.
branch, may be termed the circumflex artery.
BRANCHES:
1. Anterior interventricular branch:
 Arises very close to the pulmonary trunk at the point where the
left coronary turns to the left.
 It descends in the anterior interventricular groove to the apex of
the heart, where it anastomoses with the posterior interventricular
branch of the right coronary.
It supplies
Both ventricles.
It is the chief supply of the interventricular septum.
2. Branches to the left atrium and base of the left ventricle.
3. A branch to the sino-atorial (SA) node.
B. RIGHT CORONARY ARTERY
COURSE;
 It arises from anterior aortic sinus of the ascending aorta.
 It passes forwards between the root of the pulmonary trunk and the
auricle of the right atrium.
 It runs downwards and to the right in the coronary (A-V) groove then
curves the left on the back of the heart to anatomose with the left
coronary artery.

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BRANCHES;
1. Posterior interventricular branch,
 Arises near the termination of the right coronary and runs in the
posterior interventricular groove where it anatomoses with the
anterior I.V. branch.
 It supplies:
a. a. Both ventricles
b. part of I.V. septum.
c. Gives off a branch that supply the A.V. node
2. Branches to the right atrium.
3. Marginal branch;
Runs along the lower margin to the apex of the heart. It supplies
both surfaces of the right ventricle.
APPLIED ANATOMY
 The anastomoses between both coronaries is poorly developed at birth
but progressively increases by age (they are not typical end arteries).
 Sudden obstruction of a coronary artery leads to sudden death (poor
collateral circulation].
 Gradual obstruction leads only to ischemia of the heart thereby causing
angina pectoris.
II – VEINS OF THE HEART:
Most of the venous blood of the heart is drained by way of the coronary
sinus.
In addition, there are some veins which open directly into the chambers
of the heart, viz., anterior cardiac veins and venae cordis minimi.
A. CORONARY SINUS :
 It is a wide short channel 3cm long present in the posterior part of
the coronary groove between the lower border of the left atrium
and upper border of left ventricle.
 It opens into the right atrium to the left side of the opening of I.V.C
and its opening is guarded by a valve [allows blood to flow only
towards right atrium].
 Its tributaries are :
1. Great cardiac vein:
Ascend in the anterior interventricular groove then curves
to the left in the A-V groove to join the left end of coronary
sinus. It receives the left marginal vein [on the left margin
of the heart].
2. Middle cardiac vein:
Passes in the inferior interventricular groove to join the
middle of the coronary sinus.
3. Small cardiac vein :
Runs along the lower border of the heart towards the right
then curves to the left in the A.V. groove to join the
coronary sinus just before its right end. It receives the right
marginal vein [accompanies the marginal artery on lower
margin of the heart].
4. Posterior vein of left ventricle :
Runs on the left side of the middle cardiac vein and ends by
joining the coronary sinus [may open into the great cardiac
vein].

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5. Oblique vein of left atrium:
Descends on the back of left atrium to join the coronary
sinus near its middle. It is a vestige of the left common
cardinal vein of the foetus [the coronary sinus represents
the left horn of the sinus venosus].
B. ANTERIOR CARDIAC VEINS :
These are 3-4 small veins draining the anterior surface of the right
ventricle and open into the cavity of the right atrium.
C. VENAE CORDIS MINIMI:
These are minute veins present within the myocardium and open into
all chambers of the heart especially the 2 atria.

NERVES OF THE HEART

 There are 2 cardiac plexuses [superficial and deep] each of which is
formed of sympathetic and parasympathetic fibres.
 These plexuses send secondary plexuses around the right and left
coronary arteries to supply the substance of the heart.
A. Superficial cardiac plexus:
 It is present in front of the ligamentum arteriosum and on the
bifurcation of the pulmonary trunk.
 It is formed by 2 branches from the left side :
1. Superior cervical cardiac branch of left sympathetic chain.
2. Inferior cervical cardiac branch of left vagus.
B. Deep cardiac plexus :
 It lies on the bifurcation of trachea deep to the aorta.
 It is formed by branches from both sides :
1. Sympathetic fibres :
 Cardiac branches of the cervical sympathetic vegal of both
sides [except the part from the superior cervical ganglion].
 From 2, 3, 4, and 5 thoracic sympathetic ganglia of both
sides.
2. Parasympathetic fibres:
a. All cardiac branches of both vagi : (except the inferior
cervical cardiac branch of the left vagus].
b. Cardiac branches from both recurrent laryngeal nerves.

CONDUCTING SYSTEM OF THE HEART

The conducting system consists of specialize muscle fibres. i.e. concerned
with conduction of impulses:
1. Sino-atrial node [S-A node] :
 It is found in the upper part of the sulcus terminalis to the right of the
opening of S.V..C
 It is the “pacemaker” of the heart and the sinus node artery is a guide
to it.
2. Atrio-ventricular node [A-V node]:
 It lies in the lower part of the interatrial septum above the orifice of
the coronary sinus.
 It gives the A-V bundle which reaches the posterior margin of the
membranous part of the interventricular septum.
 It passes forwards and divides into 2 branches [crura], one on each
side of the muscular part of the I.V septum.

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 Thorax [ 101 - 154 ]
a. The right branch [crus]:
Enters the septo-marginal band to reach the base of the
anterior papillary muscle and ends as Purkinje fibres.
b. The left branch [crus]:
Descends on the left side of the I.V. septum to end, as Purkinje
fibres.
N.B:
The right coronary artery is the principal artery supplying the
conducting tissue.
THORACIC AORTA
The aorta is divided into 3 parts : ascending aorta, arch of aorta and
descending aorta.
I. ASCENDING AORTA
COURSE:
 It begins at the aortic orifice of the left ventricle opposite the
sternal end of the left 3rd costal cartilage.
 It ascends upwards and to the right behind the upper piece of the
body of sternum [opposite the 2nd intercostal space].
 It ends at the sternal end of the right 2nd costal cartilage, where it
continues as the arch of aorta.
 It has 3 small dilatations in its wall opposite the cusps of the
aortic valve called aortic sinuses [one anterior and 2 posterior].
 A longer dilatation is also present in its right wall called the bulb
of aorta.
RELATIONS:
 Anteriorly : [from below upwards]
 Upper part of the infundibulum of right ventricle
 Beginning of pulmonary trunk
 Pericardium separating it from right pleura and lung.
 Posteriorly :
 Left atrium from which it is separated by the transverse
sinus of pericardium
 Right pulmonary artery
 Right principal bronchus
 On right side :
 Right atrium [below]
 S.V.C. [above]
 On left side :
 Left atrium [below]
 Pulmonary trunk [above]
Branches:
1. Right coronary artery : from the anterior aortic sinus.
2. Left coronary artery : from the left posterior aortic sinus.
II. ARCH OF AORTA
COURSE:
 It begins at the sternal end of the right 2nd costal cartilage as a
continuation of the ascending aorta.
 It passes to the left behind the lower 1/2 of manubrium sterni, then
turns to the back to reach the side of 4th thoracic vertebra.
 Its course has 2 directions and 2 curvatures : includes:
1. 1st part of the arch:
 Runs upwards and to the left [in front of trachea].

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 Its convexity is upwards [reach up to the centre of the
manubrium sterni].
2. 2nd part of the arch :
 Runs directly backwards [on left side of trachea]
 Its convexity is forwards and to the left [called aortic
knuckle in X-ray films].
 It ends at the lower border of the 4th thoracic vertebra [on
its left side].
RELATIONS:
 Above:
 The branches of the arch [from before backwards and to the
left]:
a. Brachiocephalic artery : behind the centre of the
manubrium.
b. Left common carotid artery.
c. Left subclavian artery
 Left innominate vein : in front of the lower part of the 3
mentioned branches and close to the upper border of the
arch.
 Below:
 Bifurcation of pulmonary trunk
 Ligamentum arteriosum : between the left pulmonary artery
and lower surface of aortic arch
 Left recurrent laryngeal nerve : hooks round the
ligamentum arteriosum.
 Superficial cardiac plexus : in front of the ligamentum
arteriosum.
 Left principal bronchus.
 On left side : [superficial relations]
 Left phrenic nerve
 Left vagus nerve
 Left superior intercostal vein
 2 cardiac branches to the superficial cardiac plexus
All these structures are covered by the left pleura and lung.
 On right side : [deep relations]
 Trachea
 Oesophagus (behind the trachea)
 Thoracic duct (on the left side of oesophagus)
 Left recurrent laryngeal nerve : in the groove between the
trachea and oesophagus
BRANCHES:
1. Brachiocephalic artery.
2. Left common carotid artery
3. Left subclavian artery
1. BRACHIOCEPHALIC (INNOMINATE) ARTERY:
COURSE:
Begins behind the centre of manubrium sterni and passes
upwards to the right to end at the right sternoclavicular joint by
dividing into right subclavian and right common carotid arteries.
RELATIONS:
 Right brachiocephalic vein : on its right side
 Left brachiocephalic vein : in front of its origin.
 Trachea : at 1st it is behind, then comes on its left side (above).
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2. LEFT COMMON CAROTID ARTERY:
COURSE:
Begins on the left side of the brachiocephalic artery and passes
upwards and to the left to enter the neck behind the left sterno-
clavicular joint.
RELATIONS:
 Left lung and pleura: lateral with the phrenic and vagus nerves
in between.
 Trachea : at 1st it is behind, then comes to lie right side
(above).
 Left brachiocephalic vein : in front of it.
3. LEFT SUBCLAVIAN ARTERY:
COURSE:
 It lies behind the left common carotid artery from its origin till
the left sterno-clavicualr joint.
 It then makes an arch in the root of the neck behind the
scalenus anterior muscle.
RELATIONS:
 Left common carotid and both phrenic and vagus nerves: in
front.
 Trachea : medial to its lower part.
 Oesophagus and thoracic duct : medial to its upper part.
 Left lung and pleura : lateral
III. DESCENDING THORACIC AORTA
COURSE:
 It begins at the left side of the lower border of the 4th thoracic
vertebra as a continuation of the arch of aorta.
 It descends with an inclination to the right till the lower border of
12th thoracic vertebra.
 It enters the abdomen by passing through the aortic opening of
diaphragm and becomes the abdominal aorta.
RELATIONS:
 Anteriorly: (from above downwards)
 Root of left lung
 Pericardium : separating it from the oblique sinus of
pericardium and back of left atrium.
 Oesophagus : where it crosses to the left at the 7th thoracic
vertebra.
 Diaphragm
 Posteriorly :
 Vertebral column.
 2 hemiazygous veins crossing to the right side at the levels
of 7th and 8th thoracic vertebrae.
 On the right side:
 Oesophagus: at its upper part (before it crosses superficial
to the aorta).
 Vena azygos : at its lower part (before the vein deviates to
the right to arch above the root of lung). It is separated
from the aorta by the thoracic duct.
 On left side:
 Left pleura and lung (the aorta makes a long deep groove).

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BRANHCES:
1. Posterior intercostal arteries (3 to 11) and subcostal artery :
(those of the upper 2 spaces arise from the superior intercostal
artery).
2. 2 left bronchial arteries : pass on the posterior surface of the left
bronchus to enter the lung and supply its tissue. (The right
bronchus has only one bronchial artery which arises from the 3rd
right intercostal artery or from the upper left bronchial artery).
3. Oesophageal branches : form a longitudinal vascular chain along
the esophagus.
4. Pericardial branches : to the back of pericardium.
5. Superior phrenic branches : to the upper surface of diaphragm.
N.B:
The posterior intercostal branches (parietal) arise from the back of
the aorta, while its other branches (visceral) arise from its anterior
surface.
SURFACE ANATOMY OF THE AORTA:
1. Ascending aorta:
An oblique line from the sternal end of 3rd left costal cartilage to
the sternal end of 2nd right costal cartilage (opposite the 2nd
space).
2. Arch of aorta:
From the sternal end of 2nd right costal cartilage to the sternal
end of 2nd left costal cartilage. The upper point of the arch is at
the centre of the manubrium (opposite the 1st space).
3. Descending aorta:
From the sternal end of 2nd left costal cartilage (4th T.V) to a point
in the median plane 2cm above the Transpyloric plane.

PULMONARY TRUNK
COURSE:
 It arises from the right ventricle at the pulmonary orifice opposite the
sternal end of 3rd left costal cartilage.
 It is at 1st in front of the ascending aorta enclosed together within a
single sheath of serous pericardium (both develop from the truncus
arteriosus).
 It then passes upwards to gain the left side of the ascending aorta and
ends below the arch of aorta (opposite the 2nd left costal cartilage) by
dividing into right and left pulmonary arteries.
 The point of division is to the left of the median plane (bifurcation of
trachea is to the right of the median plane).
 It runs in the 2nd left space close to the sterna margin.
RELATIONS:
 In front:
 Left pleura and lung : separate it from the sternal end of 2nd left
intercostal space.
 Behind:
 Ascending aorta and left coronary artery : at its origin.
 Left atrium separated from it by the transverse sinus of
pericardium : above.
 On each side:
 The auricle of each atrium

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 Thorax [ 101 - 154 ]
 A coronary artery : in between the auricle and the pulmonary
trunk.
BRANCHES: (only 2 terminal branches)
1. RIGHT PULMONARY ARTERY:
 It is longer than the left one
 It passes to the right in the roof of the transverse sinus of
pericardium to join the root of the right lung.
Relations:
a. Anterior relations:
 Ascending aorta.
 S.V.C.
b. Posterior relations:
 Oesophagus
 Right bronchus
2. LEFT PULMONARUY ARTERY:
 It is shorter and passes to the left to join the root of left lung.
 It is joined to lower surface of the arch of aorta by the ligamentum
arteriosum (fibrosed ductus arteriosus of the foetus).
 Posterior relations:
 Descending aorta
 Left bronchus

SUPERIOR VENA CAVA

COURSE:
 It begins by union of the right and left brachiocephalic veins, opposite
the sternal end of 1st right costal cartilage.
 It descends on the right of the ascending aorta to open into the upper
and posterior part of the right atrium at the sternal end of 3rd right
costal cartilage.
 Its lower 1/2 lies within the fibrous pericardium, but it is joined by the
azygos vein at its middle (opposite 2nd right costal cartilage) just before
it enters the fibrous pericardium.
RELATIONS:
A. UPPER 1/2 OF THE SUEPRIOR VENA CAVA:
It lies in the superior mediastinum (outside pericardium) and is related
to :
 Antero-medially : ascending aorta
 Postero-medially : trachea and right vague nerve.
 Laterally : right phrenic nerve covered by the right pleura and
lung.
B. LOWER 1/2 OF SUPERIOR VENA CAVA:
It lies in the middle mediastinum (inside the pericardium) and is related
to:
 Antero-medially :ascending aorta.
 Posteriorly : root of right lung (separated by pericardium)
 Laterally : right phrenic nerve separated from it by the
pericardium.
TRIBUTARIES:
1. Right and left brachiocephalic veins.
2. Azygos vein: enters the back of S.V.C at the middle just before it
enters the pericardium (opposite the sternal end of 2nd right costal
cartilage).
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 Thorax [ 101 - 154 ]
N.B: Levels of some veins:
 Origin of brachiocephalic veins : sternal end of the clavicle (on both
sides)
 Origin of S.V.C: sternal end of 1st right costal cartilage.
 End of azygos vein : sternal end of 2nd right costal cartilage.
 End of S.V.C: sternal end of 3rd right costal cartilage.
RIGHT BRACHIOCEPHALIC VEIN:
COURSE AND RELATIONS:
 It begins by union of the right subclavian and internal jugular veins
opposite the sternoclavicular joint.
 It is short and ends at the sternal end of the 1st right costal cartilage by
forming the superior vena cava.
 It related to
1. Medially : brachiocephalic artery
2. Laterally: phrenic nerve covered by the right pleura and lung.
TRIBUTARIES:
1. Right vertebral vein
2. Right internal thoracic vein
3. 1st right posterior intercostal vein.
4. Right lymphatic duct (draining the upper limb and right side of the
head and neck).
LEFT BRACHIOCEPHALIC VEIN:
COURSE AND RELATIONS:
 It begins behind the left sternoclavicular joint by union of the left
subclavian and internal jugular veins.
 It is longer than the right vein and has a more horizontal course.
 It runs to the right and slightly downwards behind the upper 1/2 of the
manubrium sternal where it joins the right brachiocephalic vein to form
S.V.C.
 It passes immediately above the aortic arch and in front of its 3
branches.
TRIBUTARIES:
1. Left vertebral vein.
2. Left internal thoracic vein.
3. 1st left posterior intercostal vein
4. Left superior intercostal vein (from 2nd and 3rd spaces)
5. Thoracic duct : joins the point of union of left subclavian and internal
jugular veins.

PHRENIC NERVES
COURSE AND RELATIONS:
 It is formed in the neck from the anterior primary rami of the (3rd, 4th
and 5th) cervical nerves (mainly 4th).
 It descends on the anterior surface of the scalenus anterior muscle
(between the muscle and its fascia) crossing the muscle from lateral to
medial, deep to the sternomastoid muscle.
 The phrenic nerve carry motor and sensory fibres.
a. Motor: to diaphragm
b. Sensory : to pericardium and parietal pleura.
RELATIONS OF RIGHT PHRENIC NERVE : (related to veins)
a. It descends on right side of:
 Right brachiocephalic vein.
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 Thorax [ 101 - 154 ]
 S.V.C.
 Pericardium covering right atrium
 I.V.C.
b. It passes through the opening of I.V.C. in the diaphragm to supply the
latter from its abdominal surface.
c. It is accompanied by the pericardiaco-phrenic artery.
d. It is covered laterally by right pleura and lung.
RELATIONS OF LEFT PHRENIC NERVE: (related to arteries)
a. It descends on left side of:
 Left subclavian and left common carotid arteries.
 Arch of aorta.
 Left ventricle separated from it by pericardium.
b. It pierces the substance of the diaphragm to supply it from its abdominal
surface.
c. It is accompanied by the pericardiaco-phrenic artery.
d. It is covered laterally by left pleura and lung.
APPLIED ANATOMY:
A irritation of the diaphragm (e.g by inflammation) referred pain is felt at
the Cutaneous areas supplied by the same spinal segments of the
phrenic nerve. This is found at the tip of the shoulder (supplied by C.4,
from the lateral supraclavicular nerve).

TRACHEA
COURSE:
a. It is 10 cm long.
b. It begins at the lower border of he cricoid cartilage opposite 6th cervical
vertebra.
c. It ends at the lower border of 4th thoracic vertebra (sternal angle) where
it divides into right and left principal bronchi, just to the right of median
plane.
d. It descends exactly in the median plane, its upper 1/2 (5 cm) lies in the
neck while its lower 1/2 lies in the superior mediastinum.
e. Its lumen is kept open by incomplete C-shaped rings of cartilage which
are open posteriorly and completed by a muscle sheet (unstraited).
f. In the living, the diameter of its lumen is about 1.5cm in the adult, but is
much smaller in the child (important in introducing a tube).
g. The last (lower most) tracheal ring gives off a ridge which projects
backwards inside the trachea between the 2 bronchi, called the carina.
The carina is seen only from the inside and is a useful landmark in
bronchoscopy as it separates the openings of the right and left principal
bronchi.
RELATIONS:
A. RELATIONS IN THE NECK:
 Anteriorly: (from above downwards)
 Anastomoses between superior thyroid arteries : above the
isthmus of thyroid gland.
 Isthmus of thyroid gland : opposite 2, 3, 4 tracheal rings (covered
by pretracheal fascia).
 Inferior thyroid veins.
 Jugular arch: connecting the anterior jugular veins of both sides
(just above the manubrium).

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 Thorax [ 101 - 154 ]
 Posteriorly:
 Oesophagus : separates it from the vertebral column.
 Recurrent laryngeal nerve : in the groove between trachea and
oesophagus (one on each side).
 On each side:
 Lobe of thyroid gland : extends down to the 6th tracheal ring.
 Common carotid artery : (within the carotid sheath).
B. RELATIONS IN THE CHEST:
It lies in the superior mediastinum and is related to:
 Anteriorly : (from before backwards)
 Manubrium sternai.
 Remains of thymus gland
 Left brachiocephalic vein
 Arch of aorta together with the origin of the brachiocephalic and
left common carotid arteries.
 Posteriorly:
 Oesophagus
 Left recurrent laryngeal nerve (not the right): in the left groove
between the trachea and oesophagus.
 On right side:
 Right vague nerve (not the left)
 Upper part of brachiocephalic artery : (only above)
 Arch of vena azygos: (at its lower end)
 Right pleura and lung : (most lateral)
 On left side :
 Left subclavian and upper part of left common carotid arteries
(separate it from the left vagus and left phrenic nerves.
 Arch of aorta : (at its lower end, similar to the arch of azygos vein)
 Left pleura and lung : (most lateral).
RIGHT PRINCIPAL BRONCHUS:
COURSE AND RELATIONS:
 It passes to the right behind the right pulmonary artery, having only one
bronchial artery on its posterior surface.
 The azygos vein arches above its origin to enter the S.V.C.
 It differs from the left bronchus in being:
a. Wider and shorter
b. More in line with the trachea (i.e. more vertical). A foreign body in
the trachea usually passes into the right lung.
DIVISIONS:
 It divides before reaching the hilus of the right lung (2½ cm from the
trachea) into 2 divisions:
1. Eparterial bronchus : (above the pulmonary artery), it passes to the
upper lobe.
2. Hyparterial bronchus : (below the pulmonary artery), it continues
downwards, backwards and laterally to the middle and lower lobes.
 Inside the lung the 2nd order bronchi divide into smaller 3rd order
branches for the bronchopulmonary segments.
LEFT PRINCIPAL BRONCHUS
COURSE AND RELATIONS:
 It is longer, narrower and more horizontal.
 It has 2 bronchial arteries on its posterior surface.
 The aortic arch curves above its origin.
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 Thorax [ 101 - 154 ]
 It crosses in front of:
 Oesophagus
 Descending aorta
 The left pulmonary artery runs at 1st in front then above the
bronchus (the bronchus is horizontal while the artery ascends
obliquely in front of it).
DIVISIONS:
 Inside the lung (5cm from the trachea): It gives off an upper division
(2nd order bronchus) to the upper lobe and then continues downwards,
backwards and laterally to the lower lobe (no eparterial bronchus as in
the right).
 These divisions give off their 3rd order branches to the
bronchopulmonary segments.
N.B.:
The walls of the bronchi contain plates of cartilage as well as circular
muscle fibres (unstriated). However, the terminal bronchioles (1/4 cm in
diameter) are devoid of cartilage and are called respiratory bronchioles.

OESOPHAGUS
COURSE:
 It is 25 cm long (about double the length of the trachea).
 It begins at the level of the cricoid cartilage (6th cervical vertebra) as a
continuation of the lower end of the pharynx.
 It descends in the median plane in front of the vertebral column then
deviates to the left at the level of 7th thoracic vertebra, where it crosses
in front of the descending aorta (here it make an impression on the left
lung).
 It enters the abdomen by piercing the right crus of diaphragm (opposite
the 10th thoracic vertebra) then rapidly ends at the cardiac orifice of the
stomach (1 inch to the left of the median plane).
 In the lower part of the chest, it is surrounded by the oesophagael
plexus of nerves
CONSTRICTIONS:
1. At its beginning : 6 inches from the incisors.
2. Where it is crossed by the aortic arch : 9 inches from the incisors.
3. Where it is crossed by the left bronchus : 12 inches from the incisors.
4. Where it pierces the diaphragm : 15 inches from the incisors.
N.B.:
These constrictions are of clinical importance in introducing surgical
instruments inside the oesophagus.
RELATIONS:
The oeosphagus has 3 parts : cervical, thoracic and abdominal.
A. RELATIONS IN THE NECK:
 Anteriorly:
 Trachea
 Recurrent laryngeal nerves : in the groove between the trachea
and oesophagus (one on each side).
 Posteriorly:
 Vertebral column
 On each side:
 Common carotid artery (in the carotid sheath)
 Lobe of thyroid gland
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B. RELATIONS IN THE CHEST:

 Anteriorly : (from above downwards).
 Trachea (down to sternal angle).
 Left principal bronchus : (in concavity of aortic arch).
 Right pulmonary artery (not the left)
 Pericardium (covering the left atrium)
 Diaphragm
 Posteriorly:
It is separated from the vertebral column by:
 Right posterior intercostal arteries (not the left)
 Thoracic duct : crosses to the left at 5th thoracic vertebra (then
ascends on left side of oesophagus)
 Azygos vein.
 Terminal parts of the 2 hemiazygos veins : cross to the right at 7th
and 8th thoracic vertebrae
 Descending aorta : The oesophagus crosses in front of it at 7th
thoracic vertebra.
 On left side:
Separated from the left lung and pleura :
 Thoracic duct
 Left subclavian artery
 Terminal part of the aortic arch.
 Descending aorta : before the crossing at 7th thoracic vertebra.
 On right side:
 Arch of azygos vein
 Right pleura and lung
C. RELATIONS IN THE ABDOMEN : (1 inch long)
 Anteriorly:
 Left lobe of liver
 Anterior vagal trunk
 Posteriorly:
 Diaphragm
 Posterior vagal trunk
ARTERIAL SUPLY:
The oesophageal arteries arise from :
1. Inferior thyroid artery : to the cervical part
2. Descending thoracic aorta : to the thoracic part
3. Left gastric artery : to the abdominal part
4. Inferior phrenic artery : to the abdominal part.
These arteries join each other to form a longitudinal anastomosis on the
surface of oesophagus.
VENOUS DRAINAGE:
1. Cervical part : to the inferior thyroid veins, then to the left
brachiocephalic vein.
2. Thoracic part : to the azygos vein, then to S.V.C.
3. Abdominal part : venous blood is drained through 2 routes:
i. Through azygos vein : to S.V.C.
ii. Through left gastric vein : to portal vein
N.B.:
At the abdominal part there is porto-systemic anastomosis.

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NERVE SUPPLY:
By sympathetic and parasympathetic fibres coming from both
sympathetic trunks and both vagi.
APPLIED ANATOMY:
 The oesophagus is seen in X-ray films (oblique lateral view) after a barium
meal, where it lies in the retrocardiac space behind the heart.
 Its anterior wall is indented by ; (from above downwards)
a. Arch of aorta
b. Left main bronchus

VAGUS NERVE
(in the chest)
COURSE AND RELATIONS:
 It descends downwards and backwards on the side of the trachea
(separated from it on the left side by the left subclavian artery, and the arch
of aorta).
 It passes behind the root of the lung, where it breaks up into several
branches that join sympathetic branches from the 2nd , 3rd and 4th
ganglion to form the posterior pulmonary plexus and sends twigs to the
anterior pulmonary plexus (in front of the root of the lungs).
 From each posterior pulmonary plexus 2-3 branches descend around the
oesophagus to form the oesophageal plexus (from both vagi).
 From the lower end of the oesophageal plexus the anterior vagal trunk
(anterior gastric nerve) and posterior vagal trunk (posterior gastric nerve)
descend on the corresponding surfaces of the abdominal part of
oesophagus. (They represent the left and right vagi respectively due to
rotation of the stomach to the right).
BRANCHES IN THE CHEST:
1. Cardiac branches :
From the right vagus as it lies on the side of the trachea, and from the left
recurrent laryngeal nerve on the left side.
2. Left recurrent laryngeal nerve:
 Arises from the vagus nerve on the left side of the aortic arch and winds
round the arch just below the ligamentum arteriosum.
 It then ascends in a groove between the trachea and oesophagus to
enter the larynx behind the inferior cornu of thyroid cartilage.
 Close to the larynx it is related to the medial surface of thyroid gland.
Branches: (to the heart, oesophagus and trachea)
a. As it hooks round the arch of aorta, it gives off its cardiac branches.
b. As it ascends it gives off branches to the oesophagus and trachea.
3. pulmonary plexuses : [posterior and anterior]
a. Posterior pulmonary plexus : (main one)
Lies behind the root of the lung and is larger than the anterior plexus.
It is formed by branches from:
I. The vagus nerve itself :as it breaks up into many branches.
II. The 2nd, 3rd and 4th thoracic sympathetic ganglia.
b. Anterior pulmonary plexus:
Lies in front of the root of the lung and is formed by fine vagal
filaments as well as sympathetic branches (from the posterior
plexus).

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4. Oesophageal plexus:
Surrounds the oesophagus (below the root of the lung) and is formed of
branches from both sides :
a. Vagal branches : from the posterior pulmonary plexus.
b. Sympathetic fibres: from upper thoracic ganglia.
THORACIC PART OF SYMPATHETIC CHAIN
COURSE AND RELATIONS
 It is a chain of nerve fibres and ganglia that enters the chest in front of
the neck of 1st rib (one on each side).
 As the bodies of the vertebrae are smaller in the upper part of vertebral
column, the 2 parallel sympathetic chains are related to:
a. Transverse process : of the cervical vertebrae
b. Heads of ribs : in the upper thoracic region
c. Sides of bodies : of the lower thoracic and all lumbar vertebrae.
 The thoracic sympathetic chain carries 11 ganglia, which are suspended
from the corresponding intercostal nerves by white and grey rami
communicantes.
 The 1st thoracic ganglion is usually fused with the inferior cervical
ganglion to form the cervico-thoracic (stellate) ganglion which is related
to the neck of the 1st rib.
BRANCHES:
1. RAMI COMMUNCIANTES TO INTERCOSTAL NERVES:
Each intercostal nerve is connected to the corresponding sympathetic
ganglion by 2 rami (white and grey):
A. White ramus :
 It is formed of preganglionic (medullated) fibres that arises from
the lateral horn of spinal cord and leave the cord through the
ventral root of the spinal nerve.
 It leaves the intercostal nerve to enter the corresponding
sympathetic ganglion.
B. Grey ramus:
 It is formed of postganglionic (non-medullated) fibres emerging
from the cells of the ganglion.
 They rejoin the intercostal nerve and are distributed through it to
the blood vessels, hairs and sweat glands of the skin.
2. BRANCHES FROM THE UPPER 5 GANGLIA : to
 Surround the aorta
 Posterior pulmonary plexus (from 2, 3, 4 ganglia)
 Deep cardiac plexus : (from 2,3,4,5 ganglia)
 Oesophageal plexus
3. SPLANCHNIC NERVES
a. Greater splanchnic nerve:
Arises from (5,6,7,8) thoracic ganglia and pierces the crus of diagphram
on each side, to reach the coeliac ganglion of the coeliac plexus (in the
abdomen).
b. Lesser spanchnic nerve:
Arises from 9, 10 thoracic ganglia, and also pierces the crus of
diaphragm to end in the aorticorenal ganglion (it is the lower part of the
coeliac ganglion).
c. Lowest splanchnic nerve:
Arises from the 11th ganglion and pierces the diaphragm to end in the
renal plexus around the renal artery.

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N.B.:
The greater, lesser and lowest splanchnic nerves are preganglionic
(white and medullated) fibres that pass through the sympathetic trunk
without relay.

THORACIC DUCT
It is the main lymph trunk (45 cm long) which carries lymph from most of the
body to pour it into the venous blood.
COURSE AND RELATIONS
A. In the abdomen:
 Begins from the upper end of the cisterna chyli that lies deep to the
right crus of diaphragm (in front of 1st and 2nd L.V.)
 It ascends between the aorta (on its left side) and azygos vein (on its
right side) and leaves the abdomen through the aortic opening of
diaphragm.
B. In the posterior mediastinum:
 It ascends on the vertebral column behind the right border of the
oesophagus till the level o the 5th thoracic vertebra, where it crosses
to the left behind the oesophagus.
C. In the superior mediastinum:
 It continues upwards on the left side of the oesophagus to enter the
root of the neck.
D. In the root of the neck
 It arches to the left behind the carotid sheath to join the junction of
the subclavian and internal jugular veins.
TRIBUTARIES:
It receives tributaries from:
1. Both lower limbs and abdomen:
Through the lumbar and intestinal lymph trunks which join the cisterna
chyli.
2. Left 1/2 of the chest:
Through the left broncho-mediastinal lymph trunk
3. Left 1/2 of head and neck:
Through the left jugular lymph trunk
4. Left upper limb :
Through the left subclavian lymph trunk.
N.B.:
Therefore, the thoracic duct receives the lymph from the whole body
except :
 Right side of the head and neck : (to right jugular trunk).
 Right upper limb (to right subclavian trunk).
 Right lung and part of the upper surface of the liver (to right
bronchomediastinal trunk).
 These trunks end in the right lymphatic duct, which joins the junction
of the subclavian and internal jugular veins of the right side.

LYMPH DRAINAGE OF THE THORAX

The lymph nodes of the chest drain its walls (parietal nodes) as well as its
contents (visceral nodes)
I. LYMPH NODES OF THE THORACIC WALL :
1. PARASTERNAL (INTERNAL THORACIC) NODES:
That lie along the internal thoracic vessels.

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 They drain:
a. Deep parts of the anterior wall of chest and abdomen
above the umbilicus (related skin into axillary nodes).
b. Medial part of the mammary gland.
 It efferents : join the bronchomediastinal trunk.
2. INTERCOSTAL NODES:
 Lie at the posterior ends of the intercostal spaces close to the
vertebral column.
 They drain: the deeper parts of the lateral and posterior
thoracic wall.
 Its efferents : end in the thoracic duct.
3. PHRENIC (DIAPHRAGMATIC) NODES :
 Lie on the upper surface of the diaphragm
 They drain :
a. Diaphragm
b. Upper surface of the liver
 Its efferents : end in the parasternal nodes (mainly).
II. LYMPH NODES OF THORACIC CONTENTS:
1. MEDIASTINAL NODES :
 They lie in :
a. Superior mediastinum (close to left brachiocephalic
vein)
b. Posterior mediastinum (in relation to oesophagus)
 They drain:
a. Diaphragm
b. Pericardium
c. Heart
d. Oesophagus
 Their efferents : end in the thoracic duct.
2. NODES RELATED TO LUNGS, BRONCHI AND TRACHEA:
 These nodes can be divided into the following groups:
a. Pulmonary nodes:
Inside the tissue of the lungs, near the hilus and along
the side of the bronchi.
b. Broncho-pulmonary nodes :
In the root of the lung especially at the hilus.
c. Tracheo-bronchial nodes:
Lie just below and above the bifurcation of the trachea.
They are superior and inferior groups.
d. Paratracheal nodes:
On each side of lower part of the trachea.
 These nodes drain:
a. Lung tissue and bronchi
b. Lower part of the trachea
c. Heart
 Their efferents : end in the broncho-mediastinal trunk (one
each side).
III. LYMPH VESSELS:
1. Efferent lymphatic vessels (from the lung tissue) pass from the
pulmonary nodes to the broncho-pulmonary, then to the tracheo-
bronchial and finally to the paratracheal nodes.

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2. Efferents from the paratracheal nodes join the efferents from the
mediastinal and parasternal nodes to form a broncho-mediastinal
lymph trunk (one on each side).
3. This trunk joins either the thoracic duct (on the left side), or the
right lymphatic duct on the right side.

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