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Anatomy_Gray_300 | Anatomy_Gray | the wall, mainly along the inferior margin of each rib (Fig. 3.12A). Running with these vessels are intercostal nerves (the anterior rami of thoracic spinal nerves), which innervate the wall, related parietal pleura, and associated skin. The position of these nerves and vessels relative to the ribs must be considered when passing objects, such as chest tubes, through the thoracic wall. Dermatomes of the thorax generally reflect the segmental organization of the thoracic spinal nerves (Fig. 3.12B). The exception occurs, anteriorly and superiorly, with the first thoracic dermatome, which is located mostly in the upper limb, and not on the trunk. The anterosuperior region of the trunk receives branches from the anterior ramus of C4 via supraclavicular branches of the cervical plexus. The highest thoracic dermatome on the anterior chest wall is T2, which also extends into the upper limb. In the midline, skin over the xiphoid process is innervated by T6. | Anatomy_Gray. the wall, mainly along the inferior margin of each rib (Fig. 3.12A). Running with these vessels are intercostal nerves (the anterior rami of thoracic spinal nerves), which innervate the wall, related parietal pleura, and associated skin. The position of these nerves and vessels relative to the ribs must be considered when passing objects, such as chest tubes, through the thoracic wall. Dermatomes of the thorax generally reflect the segmental organization of the thoracic spinal nerves (Fig. 3.12B). The exception occurs, anteriorly and superiorly, with the first thoracic dermatome, which is located mostly in the upper limb, and not on the trunk. The anterosuperior region of the trunk receives branches from the anterior ramus of C4 via supraclavicular branches of the cervical plexus. The highest thoracic dermatome on the anterior chest wall is T2, which also extends into the upper limb. In the midline, skin over the xiphoid process is innervated by T6. | [
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Anatomy_Gray_301 | Anatomy_Gray | The highest thoracic dermatome on the anterior chest wall is T2, which also extends into the upper limb. In the midline, skin over the xiphoid process is innervated by T6. Dermatomes of T7 to T12 follow the contour of the ribs onto the anterior abdominal wall (Fig. 3.12C). All preganglionic nerve fibers of the sympathetic system are carried out of the spinal cord in spinal nerves T1 to L2 (Fig. 3.13). This means that sympathetic fibers found anywhere in the body ultimately emerge from the spinal cord as components of these spinal nerves. Preganglionic sympathetic fibers destined for the head are carried out of the spinal cord in spinal nerve T1. The thoracic wall is expandable because most ribs articulate with other components of the wall by true joints that allow movement, and because of the shape and orientation of the ribs (Fig. 3.14). | Anatomy_Gray. The highest thoracic dermatome on the anterior chest wall is T2, which also extends into the upper limb. In the midline, skin over the xiphoid process is innervated by T6. Dermatomes of T7 to T12 follow the contour of the ribs onto the anterior abdominal wall (Fig. 3.12C). All preganglionic nerve fibers of the sympathetic system are carried out of the spinal cord in spinal nerves T1 to L2 (Fig. 3.13). This means that sympathetic fibers found anywhere in the body ultimately emerge from the spinal cord as components of these spinal nerves. Preganglionic sympathetic fibers destined for the head are carried out of the spinal cord in spinal nerve T1. The thoracic wall is expandable because most ribs articulate with other components of the wall by true joints that allow movement, and because of the shape and orientation of the ribs (Fig. 3.14). | [
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Anatomy_Gray_302 | Anatomy_Gray | The thoracic wall is expandable because most ribs articulate with other components of the wall by true joints that allow movement, and because of the shape and orientation of the ribs (Fig. 3.14). A rib’s posterior attachment is superior to its anterior attachment. Therefore, when a rib is elevated, it moves the anterior thoracic wall forward relative to the posterior wall, which is fixed. In addition, the middle part of each rib is inferior to its two ends, so that when this region of the rib is elevated, it expands the thoracic wall laterally. Finally, because the diaphragm is muscular, it changes the volume of the thorax in the vertical direction. Changes in the anterior, lateral, and vertical dimensions of the thoracic cavity are important for breathing. Innervation of the diaphragm | Anatomy_Gray. The thoracic wall is expandable because most ribs articulate with other components of the wall by true joints that allow movement, and because of the shape and orientation of the ribs (Fig. 3.14). A rib’s posterior attachment is superior to its anterior attachment. Therefore, when a rib is elevated, it moves the anterior thoracic wall forward relative to the posterior wall, which is fixed. In addition, the middle part of each rib is inferior to its two ends, so that when this region of the rib is elevated, it expands the thoracic wall laterally. Finally, because the diaphragm is muscular, it changes the volume of the thorax in the vertical direction. Changes in the anterior, lateral, and vertical dimensions of the thoracic cavity are important for breathing. Innervation of the diaphragm | [
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Anatomy_Gray_303 | Anatomy_Gray | Changes in the anterior, lateral, and vertical dimensions of the thoracic cavity are important for breathing. Innervation of the diaphragm The diaphragm is innervated by two phrenic nerves that originate, one on each side, as branches of the cervical plexus in the neck (Fig. 3.15). They arise from the anterior rami of cervical nerves C3, C4, and C5, with the major contribution coming from C4. The phrenic nerves pass vertically through the neck, the superior thoracic aperture, and the mediastinum to supply motor innervation to the entire diaphragm, including the crura (muscular extensions that attach the diaphragm to the upper lumbar vertebrae). In the mediastinum, the phrenic nerves pass anteriorly to the roots of the lungs. | Anatomy_Gray. Changes in the anterior, lateral, and vertical dimensions of the thoracic cavity are important for breathing. Innervation of the diaphragm The diaphragm is innervated by two phrenic nerves that originate, one on each side, as branches of the cervical plexus in the neck (Fig. 3.15). They arise from the anterior rami of cervical nerves C3, C4, and C5, with the major contribution coming from C4. The phrenic nerves pass vertically through the neck, the superior thoracic aperture, and the mediastinum to supply motor innervation to the entire diaphragm, including the crura (muscular extensions that attach the diaphragm to the upper lumbar vertebrae). In the mediastinum, the phrenic nerves pass anteriorly to the roots of the lungs. | [
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Anatomy_Gray_304 | Anatomy_Gray | The tissues that initially give rise to the diaphragm are in an anterior position on the embryological disc before the head fold develops, which explains the cervical origin of the nerves that innervate the diaphragm. In other words, the tissue that gives rise to the diaphragm originates superior to the ultimate location of the diaphragm. Spinal cord injuries below the level of the origin of the phrenic nerve do not affect movement of the diaphragm. The cylindrical thorax consists of: a wall, two pleural cavities, the lungs, and the mediastinum. | Anatomy_Gray. The tissues that initially give rise to the diaphragm are in an anterior position on the embryological disc before the head fold develops, which explains the cervical origin of the nerves that innervate the diaphragm. In other words, the tissue that gives rise to the diaphragm originates superior to the ultimate location of the diaphragm. Spinal cord injuries below the level of the origin of the phrenic nerve do not affect movement of the diaphragm. The cylindrical thorax consists of: a wall, two pleural cavities, the lungs, and the mediastinum. | [
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Anatomy_Gray_305 | Anatomy_Gray | The cylindrical thorax consists of: a wall, two pleural cavities, the lungs, and the mediastinum. The thorax houses the heart and lungs, acts as a conduit for structures passing between the neck and the abdomen, and plays a principal role in breathing. In addition, the thoracic wall protects the heart and lungs and provides support for the upper limbs. Muscles anchored to the anterior thoracic wall provide some of this support, and together with their associated connective tissues, nerves, and vessels, and the overlying skin and superficial fascia, define the pectoral region. The pectoral region is external to the anterior thoracic wall and helps anchor the upper limb to the trunk. It consists of: a superficial compartment containing skin, superficial fascia, and breasts; and a deep compartment containing muscles and associated structures. Nerves, vessels, and lymphatics in the superficial compartment emerge from the thoracic wall, the axilla, and the neck. | Anatomy_Gray. The cylindrical thorax consists of: a wall, two pleural cavities, the lungs, and the mediastinum. The thorax houses the heart and lungs, acts as a conduit for structures passing between the neck and the abdomen, and plays a principal role in breathing. In addition, the thoracic wall protects the heart and lungs and provides support for the upper limbs. Muscles anchored to the anterior thoracic wall provide some of this support, and together with their associated connective tissues, nerves, and vessels, and the overlying skin and superficial fascia, define the pectoral region. The pectoral region is external to the anterior thoracic wall and helps anchor the upper limb to the trunk. It consists of: a superficial compartment containing skin, superficial fascia, and breasts; and a deep compartment containing muscles and associated structures. Nerves, vessels, and lymphatics in the superficial compartment emerge from the thoracic wall, the axilla, and the neck. | [
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Anatomy_Gray_306 | Anatomy_Gray | Nerves, vessels, and lymphatics in the superficial compartment emerge from the thoracic wall, the axilla, and the neck. The breasts consist of mammary glands and associated skin and connective tissues. The mammary glands are modified sweat glands in the superficial fascia anterior to the pectoral muscles and the anterior thoracic wall (Fig. 3.16). The mammary glands consist of a series of ducts and associated secretory lobules. These converge to form 15 to 20 lactiferous ducts, which open independently onto the nipple. The nipple is surrounded by a circular pigmented area of skin termed the areola. A well-developed, connective tissue stroma surrounds the ducts and lobules of the mammary gland. In certain regions, this condenses to form well-defined ligaments, the suspensory ligaments of breast, which are continuous with the dermis of the skin and support the breast. Carcinoma of the breast creates tension on these ligaments, causing pitting of the skin. | Anatomy_Gray. Nerves, vessels, and lymphatics in the superficial compartment emerge from the thoracic wall, the axilla, and the neck. The breasts consist of mammary glands and associated skin and connective tissues. The mammary glands are modified sweat glands in the superficial fascia anterior to the pectoral muscles and the anterior thoracic wall (Fig. 3.16). The mammary glands consist of a series of ducts and associated secretory lobules. These converge to form 15 to 20 lactiferous ducts, which open independently onto the nipple. The nipple is surrounded by a circular pigmented area of skin termed the areola. A well-developed, connective tissue stroma surrounds the ducts and lobules of the mammary gland. In certain regions, this condenses to form well-defined ligaments, the suspensory ligaments of breast, which are continuous with the dermis of the skin and support the breast. Carcinoma of the breast creates tension on these ligaments, causing pitting of the skin. | [
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Anatomy_Gray_307 | Anatomy_Gray | In nonlactating women, the predominant component of the breasts is fat, while glandular tissue is more abundant in lactating women. The breast lies on deep fascia related to the pectoralis major muscle and other surrounding muscles. A layer of loose connective tissue (the retromammary space) separates the breast from the deep fascia and provides some degree of movement over underlying structures. The base, or attached surface, of each breast extends vertically from ribs II to VI, and transversely from the sternum to as far laterally as the midaxillary line. | Anatomy_Gray. In nonlactating women, the predominant component of the breasts is fat, while glandular tissue is more abundant in lactating women. The breast lies on deep fascia related to the pectoralis major muscle and other surrounding muscles. A layer of loose connective tissue (the retromammary space) separates the breast from the deep fascia and provides some degree of movement over underlying structures. The base, or attached surface, of each breast extends vertically from ribs II to VI, and transversely from the sternum to as far laterally as the midaxillary line. | [
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Anatomy_Gray_308 | Anatomy_Gray | The base, or attached surface, of each breast extends vertically from ribs II to VI, and transversely from the sternum to as far laterally as the midaxillary line. The breast is related to the thoracic wall and to structures associated with the upper limb; therefore, vascular supply and drainage can occur by multiple routes (Fig. 3.16): laterally, vessels from the axillary artery—superior thoracic, thoraco-acromial, lateral thoracic, and subscapular arteries; medially, branches from the internal thoracic artery; the second to fourth intercostal arteries via branches that perforate the thoracic wall and overlying muscle. Veins draining the breast parallel the arteries and ultimately drain into the axillary, internal thoracic, and intercostal veins. Innervation of the breast is via anterior and lateral cutaneous branches of the second to sixth intercostal nerves. The nipple is innervated by the fourth intercostal nerve. Lymphatic drainage of the breast is as follows: | Anatomy_Gray. The base, or attached surface, of each breast extends vertically from ribs II to VI, and transversely from the sternum to as far laterally as the midaxillary line. The breast is related to the thoracic wall and to structures associated with the upper limb; therefore, vascular supply and drainage can occur by multiple routes (Fig. 3.16): laterally, vessels from the axillary artery—superior thoracic, thoraco-acromial, lateral thoracic, and subscapular arteries; medially, branches from the internal thoracic artery; the second to fourth intercostal arteries via branches that perforate the thoracic wall and overlying muscle. Veins draining the breast parallel the arteries and ultimately drain into the axillary, internal thoracic, and intercostal veins. Innervation of the breast is via anterior and lateral cutaneous branches of the second to sixth intercostal nerves. The nipple is innervated by the fourth intercostal nerve. Lymphatic drainage of the breast is as follows: | [
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Anatomy_Gray_309 | Anatomy_Gray | Lymphatic drainage of the breast is as follows: Approximately 75% is via lymphatic vessels that drain laterally and superiorly into axillary nodes (Fig. 3.16). Most of the remaining drainage is into parasternal nodes deep to the anterior thoracic wall and associated with the internal thoracic artery. Some drainage may occur via lymphatic vessels that follow the lateral branches of posterior intercostal arteries and connect with intercostal nodes situated near the heads and necks of ribs. Axillary nodes drain into the subclavian trunks, parasternal nodes drain into the bronchomediastinal trunks, and intercostal nodes drain either into the thoracic duct or into the bronchomediastinal trunks. The breast in men is rudimentary and consists only of small ducts, often composed of cords of cells, that normally do not extend beyond the areola. Breast cancer can occur in men. Muscles of the pectoral region | Anatomy_Gray. Lymphatic drainage of the breast is as follows: Approximately 75% is via lymphatic vessels that drain laterally and superiorly into axillary nodes (Fig. 3.16). Most of the remaining drainage is into parasternal nodes deep to the anterior thoracic wall and associated with the internal thoracic artery. Some drainage may occur via lymphatic vessels that follow the lateral branches of posterior intercostal arteries and connect with intercostal nodes situated near the heads and necks of ribs. Axillary nodes drain into the subclavian trunks, parasternal nodes drain into the bronchomediastinal trunks, and intercostal nodes drain either into the thoracic duct or into the bronchomediastinal trunks. The breast in men is rudimentary and consists only of small ducts, often composed of cords of cells, that normally do not extend beyond the areola. Breast cancer can occur in men. Muscles of the pectoral region | [
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Anatomy_Gray_310 | Anatomy_Gray | Muscles of the pectoral region Each pectoral region contains the pectoralis major, pectoralis minor, and subclavius muscles (Fig. 3.17 and Table 3.1). All originate from the anterior thoracic wall and insert into bones of the upper limb. The pectoralis major muscle is the largest and most superficial of the pectoral region muscles. It directly underlies the breast and is separated from it by deep fascia and the loose connective tissue of the retromammary space. The pectoralis major has a broad origin that includes the anterior surfaces of the medial half of the clavicle, the sternum, and related costal cartilages. The muscle fibers converge to form a flat tendon, which inserts into the lateral lip of the intertubercular sulcus of the humerus. The pectoralis major adducts, flexes, and medially rotates the arm. The subclavius and pectoralis minor muscles underlie the pectoralis major: | Anatomy_Gray. Muscles of the pectoral region Each pectoral region contains the pectoralis major, pectoralis minor, and subclavius muscles (Fig. 3.17 and Table 3.1). All originate from the anterior thoracic wall and insert into bones of the upper limb. The pectoralis major muscle is the largest and most superficial of the pectoral region muscles. It directly underlies the breast and is separated from it by deep fascia and the loose connective tissue of the retromammary space. The pectoralis major has a broad origin that includes the anterior surfaces of the medial half of the clavicle, the sternum, and related costal cartilages. The muscle fibers converge to form a flat tendon, which inserts into the lateral lip of the intertubercular sulcus of the humerus. The pectoralis major adducts, flexes, and medially rotates the arm. The subclavius and pectoralis minor muscles underlie the pectoralis major: | [
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Anatomy_Gray_311 | Anatomy_Gray | The pectoralis major adducts, flexes, and medially rotates the arm. The subclavius and pectoralis minor muscles underlie the pectoralis major: The subclavius is small and passes laterally from the anterior and medial part of rib I to the inferior surface of the clavicle. The pectoralis minor passes from the anterior surfaces of ribs III to V to the coracoid process of the scapula. Both the subclavius and pectoralis minor pull the tip of the shoulder inferiorly. A continuous layer of deep fascia, the clavipectoral fascia, encloses the subclavius and pectoralis minor and attaches to the clavicle above and to the floor of the axilla below. | Anatomy_Gray. The pectoralis major adducts, flexes, and medially rotates the arm. The subclavius and pectoralis minor muscles underlie the pectoralis major: The subclavius is small and passes laterally from the anterior and medial part of rib I to the inferior surface of the clavicle. The pectoralis minor passes from the anterior surfaces of ribs III to V to the coracoid process of the scapula. Both the subclavius and pectoralis minor pull the tip of the shoulder inferiorly. A continuous layer of deep fascia, the clavipectoral fascia, encloses the subclavius and pectoralis minor and attaches to the clavicle above and to the floor of the axilla below. | [
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Anatomy_Gray_312 | Anatomy_Gray | A continuous layer of deep fascia, the clavipectoral fascia, encloses the subclavius and pectoralis minor and attaches to the clavicle above and to the floor of the axilla below. The muscles of the pectoral region form the anterior wall of the axilla, a region between the upper limb and the neck through which all major structures pass. Nerves, vessels, and lymphatics that pass between the pectoral region and the axilla pass through the clavipectoral fascia between the subclavius and pectoralis minor or pass under the inferior margins of the pectoralis major and minor. The thoracic wall is segmental in design and composed of skeletal elements and muscles. It extends between: the superior thoracic aperture, bordered by vertebra TI, rib I, and the manubrium of the sternum; and the inferior thoracic aperture, bordered by vertebra TXII, rib XII, the end of rib XI, the costal margin, and the xiphoid process of the sternum. | Anatomy_Gray. A continuous layer of deep fascia, the clavipectoral fascia, encloses the subclavius and pectoralis minor and attaches to the clavicle above and to the floor of the axilla below. The muscles of the pectoral region form the anterior wall of the axilla, a region between the upper limb and the neck through which all major structures pass. Nerves, vessels, and lymphatics that pass between the pectoral region and the axilla pass through the clavipectoral fascia between the subclavius and pectoralis minor or pass under the inferior margins of the pectoralis major and minor. The thoracic wall is segmental in design and composed of skeletal elements and muscles. It extends between: the superior thoracic aperture, bordered by vertebra TI, rib I, and the manubrium of the sternum; and the inferior thoracic aperture, bordered by vertebra TXII, rib XII, the end of rib XI, the costal margin, and the xiphoid process of the sternum. | [
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Anatomy_Gray_313 | Anatomy_Gray | The skeletal elements of the thoracic wall consist of the thoracic vertebrae, intervertebral discs, ribs, and sternum. There are twelve thoracic vertebrae, each of which is characterized by articulations with ribs. A typical thoracic vertebra has a heart-shaped vertebral body, with roughly equal dimensions in the transverse and anteroposterior directions, and a long spinous process (Fig. 3.18). The vertebral foramen is generally circular and the laminae are broad and overlap with those of the vertebra below. The superior articular processes are flat, with their articular surfaces facing almost directly posteriorly, while the inferior articular processes project from the laminae and their articular facets face anteriorly. The transverse processes are club shaped and project posterolaterally. Articulation with ribs A typical thoracic vertebra has three sites on each side for articulation with ribs. | Anatomy_Gray. The skeletal elements of the thoracic wall consist of the thoracic vertebrae, intervertebral discs, ribs, and sternum. There are twelve thoracic vertebrae, each of which is characterized by articulations with ribs. A typical thoracic vertebra has a heart-shaped vertebral body, with roughly equal dimensions in the transverse and anteroposterior directions, and a long spinous process (Fig. 3.18). The vertebral foramen is generally circular and the laminae are broad and overlap with those of the vertebra below. The superior articular processes are flat, with their articular surfaces facing almost directly posteriorly, while the inferior articular processes project from the laminae and their articular facets face anteriorly. The transverse processes are club shaped and project posterolaterally. Articulation with ribs A typical thoracic vertebra has three sites on each side for articulation with ribs. | [
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Anatomy_Gray_314 | Anatomy_Gray | Articulation with ribs A typical thoracic vertebra has three sites on each side for articulation with ribs. Two demifacets (i.e., partial facets) are located on the superior and inferior aspects of the body for articulation with corresponding sites on the heads of adjacent ribs. The superior costal facet articulates with part of the head of its own rib, and the inferior costal facet articulates with part of the head of the rib below. An oval facet (transverse costal facet) at the end of the transverse process articulates with the tubercle of its own rib. Not all vertebrae articulate with ribs in the same fashion (Fig. 3.19): The superior costal facets on the body of vertebra TI are complete and articulate with a single facet on the head of its own rib—in other words, the head of rib I does not articulate with vertebra CVII. Similarly, vertebra TX (and often TIX) articulates only with its own ribs and therefore lacks inferior demifacets on the body. | Anatomy_Gray. Articulation with ribs A typical thoracic vertebra has three sites on each side for articulation with ribs. Two demifacets (i.e., partial facets) are located on the superior and inferior aspects of the body for articulation with corresponding sites on the heads of adjacent ribs. The superior costal facet articulates with part of the head of its own rib, and the inferior costal facet articulates with part of the head of the rib below. An oval facet (transverse costal facet) at the end of the transverse process articulates with the tubercle of its own rib. Not all vertebrae articulate with ribs in the same fashion (Fig. 3.19): The superior costal facets on the body of vertebra TI are complete and articulate with a single facet on the head of its own rib—in other words, the head of rib I does not articulate with vertebra CVII. Similarly, vertebra TX (and often TIX) articulates only with its own ribs and therefore lacks inferior demifacets on the body. | [
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Anatomy_Gray_315 | Anatomy_Gray | Similarly, vertebra TX (and often TIX) articulates only with its own ribs and therefore lacks inferior demifacets on the body. Vertebrae TXI and TXII articulate only with the heads of their own ribs—they lack transverse costal facets and have only a single complete facet on each side of their bodies. There are twelve pairs of ribs, each terminating anteriorly in a costal cartilage (Fig. 3.20). Although all ribs articulate with the vertebral column, only the costal cartilages of the upper seven ribs, known as true ribs, articulate directly with the sternum. The remaining five pairs of ribs are false ribs: The costal cartilages of ribs VIII to X articulate anteriorly with the costal cartilages of the ribs above. Ribs XI and XII have no anterior connection with other ribs or with the sternum and are often called floating ribs. | Anatomy_Gray. Similarly, vertebra TX (and often TIX) articulates only with its own ribs and therefore lacks inferior demifacets on the body. Vertebrae TXI and TXII articulate only with the heads of their own ribs—they lack transverse costal facets and have only a single complete facet on each side of their bodies. There are twelve pairs of ribs, each terminating anteriorly in a costal cartilage (Fig. 3.20). Although all ribs articulate with the vertebral column, only the costal cartilages of the upper seven ribs, known as true ribs, articulate directly with the sternum. The remaining five pairs of ribs are false ribs: The costal cartilages of ribs VIII to X articulate anteriorly with the costal cartilages of the ribs above. Ribs XI and XII have no anterior connection with other ribs or with the sternum and are often called floating ribs. | [
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Anatomy_Gray_316 | Anatomy_Gray | Ribs XI and XII have no anterior connection with other ribs or with the sternum and are often called floating ribs. A typical rib consists of a curved shaft with anterior and posterior ends (Fig. 3.21). The anterior end is continuous with its costal cartilage. The posterior end articulates with the vertebral column and is characterized by a head, neck, and tubercle. The head is somewhat expanded and typically presents two articular surfaces separated by a crest. The smaller superior surface articulates with the inferior costal facet on the body of the vertebra above, whereas the larger inferior facet articulates with the superior costal facet of its own vertebra. The neck is a short flat region of bone that separates the head from the tubercle. The tubercle projects posteriorly from the junction of the neck with the shaft and consists of two regions, an articular part and a nonarticular part: | Anatomy_Gray. Ribs XI and XII have no anterior connection with other ribs or with the sternum and are often called floating ribs. A typical rib consists of a curved shaft with anterior and posterior ends (Fig. 3.21). The anterior end is continuous with its costal cartilage. The posterior end articulates with the vertebral column and is characterized by a head, neck, and tubercle. The head is somewhat expanded and typically presents two articular surfaces separated by a crest. The smaller superior surface articulates with the inferior costal facet on the body of the vertebra above, whereas the larger inferior facet articulates with the superior costal facet of its own vertebra. The neck is a short flat region of bone that separates the head from the tubercle. The tubercle projects posteriorly from the junction of the neck with the shaft and consists of two regions, an articular part and a nonarticular part: | [
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Anatomy_Gray_317 | Anatomy_Gray | The tubercle projects posteriorly from the junction of the neck with the shaft and consists of two regions, an articular part and a nonarticular part: The articular part is medial and has an oval facet for articulation with a corresponding facet on the transverse process of the associated vertebra. The raised nonarticular part is roughened by ligament attachments. The shaft is generally thin and flat with internal and external surfaces. The superior margin is smooth and rounded, whereas the inferior margin is sharp. The shaft bends forward just laterally to the tubercle at a site termed the angle. It also has a gentle twist around its longitudinal axis so that the external surface of the anterior part of the shaft faces somewhat superiorly relative to the posterior part. The inferior margin of the internal surface is marked by a distinct costal groove. Distinct features of upper and lower ribs The upper and lower ribs have distinct features (Fig. 3.22). | Anatomy_Gray. The tubercle projects posteriorly from the junction of the neck with the shaft and consists of two regions, an articular part and a nonarticular part: The articular part is medial and has an oval facet for articulation with a corresponding facet on the transverse process of the associated vertebra. The raised nonarticular part is roughened by ligament attachments. The shaft is generally thin and flat with internal and external surfaces. The superior margin is smooth and rounded, whereas the inferior margin is sharp. The shaft bends forward just laterally to the tubercle at a site termed the angle. It also has a gentle twist around its longitudinal axis so that the external surface of the anterior part of the shaft faces somewhat superiorly relative to the posterior part. The inferior margin of the internal surface is marked by a distinct costal groove. Distinct features of upper and lower ribs The upper and lower ribs have distinct features (Fig. 3.22). | [
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Anatomy_Gray_318 | Anatomy_Gray | Distinct features of upper and lower ribs The upper and lower ribs have distinct features (Fig. 3.22). Rib I is flat in the horizontal plane and has broad superior and inferior surfaces. From its articulation with vertebra TI, it slopes inferiorly to its attachment to the manubrium of the sternum. The head articulates only with the body of vertebra TI and therefore has only one articular surface. Like other ribs, the tubercle has a facet for articulation with the transverse process. The superior surface of the rib is characterized by a distinct tubercle, the scalene tubercle, which separates two smooth grooves that cross the rib approximately midway along the shaft. The anterior groove is caused by the subclavian vein, and the posterior groove is caused by the subclavian artery. Anterior and posterior to these grooves, the shaft is roughened by muscle and ligament attachments. | Anatomy_Gray. Distinct features of upper and lower ribs The upper and lower ribs have distinct features (Fig. 3.22). Rib I is flat in the horizontal plane and has broad superior and inferior surfaces. From its articulation with vertebra TI, it slopes inferiorly to its attachment to the manubrium of the sternum. The head articulates only with the body of vertebra TI and therefore has only one articular surface. Like other ribs, the tubercle has a facet for articulation with the transverse process. The superior surface of the rib is characterized by a distinct tubercle, the scalene tubercle, which separates two smooth grooves that cross the rib approximately midway along the shaft. The anterior groove is caused by the subclavian vein, and the posterior groove is caused by the subclavian artery. Anterior and posterior to these grooves, the shaft is roughened by muscle and ligament attachments. | [
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Anatomy_Gray_319 | Anatomy_Gray | Rib II, like rib I, is flat but twice as long. It articulates with the vertebral column in a way typical of most ribs. The head of rib X has a single facet for articulation with its own vertebra. Ribs XI and XII articulate only with the bodies of their own vertebrae and have no tubercles or necks. Both ribs are short, have little curve, and are pointed anteriorly. The adult sternum consists of three major elements: the broad and superiorly positioned manubrium of the sternum, the narrow and longitudinally oriented body of the sternum, and the small and inferiorly positioned xiphoid process (Fig. 3.23). Manubrium of the sternum The manubrium of the sternum forms part of the bony framework of the neck and the thorax. The superior surface of the manubrium is expanded laterally and bears a distinct and palpable notch, the jugular notch (suprasternal notch), in the midline. | Anatomy_Gray. Rib II, like rib I, is flat but twice as long. It articulates with the vertebral column in a way typical of most ribs. The head of rib X has a single facet for articulation with its own vertebra. Ribs XI and XII articulate only with the bodies of their own vertebrae and have no tubercles or necks. Both ribs are short, have little curve, and are pointed anteriorly. The adult sternum consists of three major elements: the broad and superiorly positioned manubrium of the sternum, the narrow and longitudinally oriented body of the sternum, and the small and inferiorly positioned xiphoid process (Fig. 3.23). Manubrium of the sternum The manubrium of the sternum forms part of the bony framework of the neck and the thorax. The superior surface of the manubrium is expanded laterally and bears a distinct and palpable notch, the jugular notch (suprasternal notch), in the midline. | [
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Anatomy_Gray_320 | Anatomy_Gray | The superior surface of the manubrium is expanded laterally and bears a distinct and palpable notch, the jugular notch (suprasternal notch), in the midline. On either side of this notch is a large oval fossa for articulation with the clavicle. Immediately inferior to this fossa, on each lateral surface of the manubrium, is a facet for the attachment of the first costal cartilage. At the lower end of the lateral border is a demifacet for articulation with the upper half of the anterior end of the second costal cartilage. Body of the sternum The body of the sternum is flat. The anterior surface of the body of the sternum is often marked by transverse ridges that represent lines of fusion between the segmental elements called sternebrae, from which this part of the sternum arises embryologically. | Anatomy_Gray. The superior surface of the manubrium is expanded laterally and bears a distinct and palpable notch, the jugular notch (suprasternal notch), in the midline. On either side of this notch is a large oval fossa for articulation with the clavicle. Immediately inferior to this fossa, on each lateral surface of the manubrium, is a facet for the attachment of the first costal cartilage. At the lower end of the lateral border is a demifacet for articulation with the upper half of the anterior end of the second costal cartilage. Body of the sternum The body of the sternum is flat. The anterior surface of the body of the sternum is often marked by transverse ridges that represent lines of fusion between the segmental elements called sternebrae, from which this part of the sternum arises embryologically. | [
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Anatomy_Gray_321 | Anatomy_Gray | The lateral margins of the body of the sternum have articular facets for costal cartilages. Superiorly, each lateral margin has a demifacet for articulation with the inferior aspect of the second costal cartilage. Inferior to this demifacet are four facets for articulation with the costal cartilages of ribs III to VI. At the inferior end of the body of the sternum is a demifacet for articulation with the upper demifacet on the seventh costal cartilage. The inferior end of the body of the sternum is attached to the xiphoid process. The xiphoid process is the smallest part of the sternum. Its shape is variable: it may be wide, thin, pointed, bifid, curved, or perforated. It begins as a cartilaginous structure, which becomes ossified in the adult. On each side of its upper lateral margin is a demifacet for articulation with the inferior end of the seventh costal cartilage. | Anatomy_Gray. The lateral margins of the body of the sternum have articular facets for costal cartilages. Superiorly, each lateral margin has a demifacet for articulation with the inferior aspect of the second costal cartilage. Inferior to this demifacet are four facets for articulation with the costal cartilages of ribs III to VI. At the inferior end of the body of the sternum is a demifacet for articulation with the upper demifacet on the seventh costal cartilage. The inferior end of the body of the sternum is attached to the xiphoid process. The xiphoid process is the smallest part of the sternum. Its shape is variable: it may be wide, thin, pointed, bifid, curved, or perforated. It begins as a cartilaginous structure, which becomes ossified in the adult. On each side of its upper lateral margin is a demifacet for articulation with the inferior end of the seventh costal cartilage. | [
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Anatomy_Gray_322 | Anatomy_Gray | A typical rib articulates with: the bodies of adjacent vertebrae, forming a joint with the head of the rib; and the transverse process of its related vertebra, forming a costotransverse joint (Fig. 3.24). Together, the costovertebral joints and related ligaments allow the necks of the ribs either to rotate around their longitudinal axes, which occurs mainly in the upper ribs, or to ascend and descend relative to the vertebral column, which occurs mainly in the lower ribs. The combined movements of all of the ribs on the vertebral column are essential for altering the volume of the thoracic cavity during breathing. Joint with head of rib | Anatomy_Gray. A typical rib articulates with: the bodies of adjacent vertebrae, forming a joint with the head of the rib; and the transverse process of its related vertebra, forming a costotransverse joint (Fig. 3.24). Together, the costovertebral joints and related ligaments allow the necks of the ribs either to rotate around their longitudinal axes, which occurs mainly in the upper ribs, or to ascend and descend relative to the vertebral column, which occurs mainly in the lower ribs. The combined movements of all of the ribs on the vertebral column are essential for altering the volume of the thoracic cavity during breathing. Joint with head of rib | [
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Anatomy_Gray_323 | Anatomy_Gray | Joint with head of rib The two facets on the head of the rib articulate with the superior facet on the body of its own vertebra and with the inferior facet on the body of the vertebra above. This joint is divided into two synovial compartments by an intra-articular ligament, which attaches the crest to the adjacent intervertebral disc and separates the two articular surfaces on the head of the rib. The two synovial compartments and the intervening ligament are surrounded by a single joint capsule attached to the outer margins of the combined articular surfaces of the head and vertebral column. Costotransverse joints are synovial joints between the tubercle of a rib and the transverse process of the related vertebra (Fig. 3.24). The capsule surrounding each joint is thin. The joint is stabilized by two strong extracapsular ligaments that span the space between the transverse process and the rib on the medial and lateral sides of the joint: | Anatomy_Gray. Joint with head of rib The two facets on the head of the rib articulate with the superior facet on the body of its own vertebra and with the inferior facet on the body of the vertebra above. This joint is divided into two synovial compartments by an intra-articular ligament, which attaches the crest to the adjacent intervertebral disc and separates the two articular surfaces on the head of the rib. The two synovial compartments and the intervening ligament are surrounded by a single joint capsule attached to the outer margins of the combined articular surfaces of the head and vertebral column. Costotransverse joints are synovial joints between the tubercle of a rib and the transverse process of the related vertebra (Fig. 3.24). The capsule surrounding each joint is thin. The joint is stabilized by two strong extracapsular ligaments that span the space between the transverse process and the rib on the medial and lateral sides of the joint: | [
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Anatomy_Gray_324 | Anatomy_Gray | The costotransverse ligament is medial to the joint and attaches the neck of the rib to the transverse process. The lateral costotransverse ligament is lateral to the joint and attaches the tip of the transverse process to the roughened nonarticular part of the tubercle of the rib. A third ligament, the superior costotransverse ligament, attaches the superior surface of the neck of the rib to the transverse process of the vertebra above. Slight gliding movements occur at the costotransverse joints. The sternocostal joints are joints between the upper seven costal cartilages and the sternum (Fig. 3.25). The joint between rib I and the manubrium is not synovial and consists of a fibrocartilaginous connection between the manubrium and the costal cartilage. The second to seventh joints are synovial and have thin capsules reinforced by surrounding sternocostal ligaments. | Anatomy_Gray. The costotransverse ligament is medial to the joint and attaches the neck of the rib to the transverse process. The lateral costotransverse ligament is lateral to the joint and attaches the tip of the transverse process to the roughened nonarticular part of the tubercle of the rib. A third ligament, the superior costotransverse ligament, attaches the superior surface of the neck of the rib to the transverse process of the vertebra above. Slight gliding movements occur at the costotransverse joints. The sternocostal joints are joints between the upper seven costal cartilages and the sternum (Fig. 3.25). The joint between rib I and the manubrium is not synovial and consists of a fibrocartilaginous connection between the manubrium and the costal cartilage. The second to seventh joints are synovial and have thin capsules reinforced by surrounding sternocostal ligaments. | [
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Anatomy_Gray_325 | Anatomy_Gray | The joint between the second costal cartilage and the sternum is divided into two compartments by an intraarticular ligament. This ligament attaches the second costal cartilage to the junction of the manubrium and the body of the sternum. Interchondral joints occur between the costal cartilages of adjacent ribs (Fig. 3.25), mainly between the costal cartilages of ribs VII to X, but may also involve the costal cartilages of ribs V and VI. Interchondral joints provide indirect anchorage to the sternum and contribute to the formation of a smooth inferior costal margin. They are usually synovial, and the thin fibrous capsules are reinforced by interchondral ligaments. | Anatomy_Gray. The joint between the second costal cartilage and the sternum is divided into two compartments by an intraarticular ligament. This ligament attaches the second costal cartilage to the junction of the manubrium and the body of the sternum. Interchondral joints occur between the costal cartilages of adjacent ribs (Fig. 3.25), mainly between the costal cartilages of ribs VII to X, but may also involve the costal cartilages of ribs V and VI. Interchondral joints provide indirect anchorage to the sternum and contribute to the formation of a smooth inferior costal margin. They are usually synovial, and the thin fibrous capsules are reinforced by interchondral ligaments. | [
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Anatomy_Gray_326 | Anatomy_Gray | The joints between the manubrium and the body of the sternum and between the body of the sternum and the xiphoid process are usually symphyses (Fig. 3.25). Only slight angular movements occur between the manubrium and the body of the sternum during respiration. The joint between the body of the sternum and the xiphoid process often becomes ossified with age. A clinically useful feature of the manubriosternal joint is that it can be palpated easily. This is because the manubrium normally angles posteriorly on the body of the sternum, forming a raised feature referred to as the sternal angle. This elevation marks the site of articulation of rib II with the sternum. Rib I is not palpable, because it lies inferior to the clavicle and is embedded in tissues at the base of the neck. Therefore, rib II is used as a reference for counting ribs and can be felt immediately lateral to the sternal angle. | Anatomy_Gray. The joints between the manubrium and the body of the sternum and between the body of the sternum and the xiphoid process are usually symphyses (Fig. 3.25). Only slight angular movements occur between the manubrium and the body of the sternum during respiration. The joint between the body of the sternum and the xiphoid process often becomes ossified with age. A clinically useful feature of the manubriosternal joint is that it can be palpated easily. This is because the manubrium normally angles posteriorly on the body of the sternum, forming a raised feature referred to as the sternal angle. This elevation marks the site of articulation of rib II with the sternum. Rib I is not palpable, because it lies inferior to the clavicle and is embedded in tissues at the base of the neck. Therefore, rib II is used as a reference for counting ribs and can be felt immediately lateral to the sternal angle. | [
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Anatomy_Gray_327 | Anatomy_Gray | In addition, the sternal angle lies on a horizontal plane that passes through the intervertebral disc between vertebrae TIV and TV (see Fig. 3.10). This plane separates the superior mediastinum from the inferior mediastinum and marks the superior border of the pericardium. The plane also passes through the end of the ascending aorta and the beginning of the arch of the aorta, the end of the arch of the aorta and the beginning of the thoracic aorta, and the bifurcation of the trachea, and just superior to the pulmonary trunk (see Fig. 3.79 and 3.86). Intercostal spaces lie between adjacent ribs and are filled by intercostal muscles (Fig. 3.26). Intercostal nerves and associated major arteries and veins lie in the costal groove along the inferior margin of the superior rib and pass in the plane between the inner two layers of muscles. | Anatomy_Gray. In addition, the sternal angle lies on a horizontal plane that passes through the intervertebral disc between vertebrae TIV and TV (see Fig. 3.10). This plane separates the superior mediastinum from the inferior mediastinum and marks the superior border of the pericardium. The plane also passes through the end of the ascending aorta and the beginning of the arch of the aorta, the end of the arch of the aorta and the beginning of the thoracic aorta, and the bifurcation of the trachea, and just superior to the pulmonary trunk (see Fig. 3.79 and 3.86). Intercostal spaces lie between adjacent ribs and are filled by intercostal muscles (Fig. 3.26). Intercostal nerves and associated major arteries and veins lie in the costal groove along the inferior margin of the superior rib and pass in the plane between the inner two layers of muscles. | [
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Anatomy_Gray_328 | Anatomy_Gray | Intercostal nerves and associated major arteries and veins lie in the costal groove along the inferior margin of the superior rib and pass in the plane between the inner two layers of muscles. In each space, the vein is the most superior structure and is therefore highest in the costal groove. The artery is inferior to the vein, and the nerve is inferior to the artery and often not protected by the groove. Therefore, the nerve is the structure most at risk when objects perforate the upper aspect of an intercostal space. Small collateral branches of the major intercostal nerves and vessels are often present superior to the inferior rib below. Deep to the intercostal spaces and ribs, and separating these structures from the underlying pleura, is a layer of loose connective tissue, called endothoracic fascia, which contains variable amounts of fat. | Anatomy_Gray. Intercostal nerves and associated major arteries and veins lie in the costal groove along the inferior margin of the superior rib and pass in the plane between the inner two layers of muscles. In each space, the vein is the most superior structure and is therefore highest in the costal groove. The artery is inferior to the vein, and the nerve is inferior to the artery and often not protected by the groove. Therefore, the nerve is the structure most at risk when objects perforate the upper aspect of an intercostal space. Small collateral branches of the major intercostal nerves and vessels are often present superior to the inferior rib below. Deep to the intercostal spaces and ribs, and separating these structures from the underlying pleura, is a layer of loose connective tissue, called endothoracic fascia, which contains variable amounts of fat. | [
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Anatomy_Gray_329 | Anatomy_Gray | Superficial to the spaces are deep fascia, superficial fascia, and skin. Muscles associated with the upper limbs and back overlie the spaces. Muscles of the thoracic wall include those that fill and support the intercostal spaces, those that pass between the sternum and the ribs, and those that cross several ribs between costal attachments (Table 3.2). The muscles of the thoracic wall, together with muscles between the vertebrae and ribs posteriorly (i.e., the levatores costarum and serratus posterior superior and serratus posterior inferior muscles) alter the position of the ribs and sternum and so change the thoracic volume during breathing. They also reinforce the thoracic wall. The intercostal muscles are three flat muscles found in each intercostal space that pass between adjacent ribs (Fig. 3.27). Individual muscles in this group are named according to their positions: The external intercostal muscles are the most superficial. | Anatomy_Gray. Superficial to the spaces are deep fascia, superficial fascia, and skin. Muscles associated with the upper limbs and back overlie the spaces. Muscles of the thoracic wall include those that fill and support the intercostal spaces, those that pass between the sternum and the ribs, and those that cross several ribs between costal attachments (Table 3.2). The muscles of the thoracic wall, together with muscles between the vertebrae and ribs posteriorly (i.e., the levatores costarum and serratus posterior superior and serratus posterior inferior muscles) alter the position of the ribs and sternum and so change the thoracic volume during breathing. They also reinforce the thoracic wall. The intercostal muscles are three flat muscles found in each intercostal space that pass between adjacent ribs (Fig. 3.27). Individual muscles in this group are named according to their positions: The external intercostal muscles are the most superficial. | [
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Anatomy_Gray_330 | Anatomy_Gray | The external intercostal muscles are the most superficial. The internal intercostal muscles are sandwiched between the external and innermost muscles. The innermost intercostal muscles are the deepest of the three muscles. The intercostal muscles are innervated by the related intercostal nerves. As a group, the intercostal muscles provide structural support for the intercostal spaces during breathing. They can also move the ribs. | Anatomy_Gray. The external intercostal muscles are the most superficial. The internal intercostal muscles are sandwiched between the external and innermost muscles. The innermost intercostal muscles are the deepest of the three muscles. The intercostal muscles are innervated by the related intercostal nerves. As a group, the intercostal muscles provide structural support for the intercostal spaces during breathing. They can also move the ribs. | [
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Anatomy_Gray_331 | Anatomy_Gray | The eleven pairs of external intercostal muscles extend from the inferior margins (lateral edges of costal grooves) of the ribs above to the superior margins of the ribs below. When the thoracic wall is viewed from a lateral position, the muscle fibers pass obliquely anteroinferiorly (Fig. 3.27). The muscles extend around the thoracic wall from the regions of the tubercles of the ribs to the costal cartilages, where each layer continues as a thin connective tissue aponeurosis termed the external intercostal membrane. The external intercostal muscles are most active in inspiration. | Anatomy_Gray. The eleven pairs of external intercostal muscles extend from the inferior margins (lateral edges of costal grooves) of the ribs above to the superior margins of the ribs below. When the thoracic wall is viewed from a lateral position, the muscle fibers pass obliquely anteroinferiorly (Fig. 3.27). The muscles extend around the thoracic wall from the regions of the tubercles of the ribs to the costal cartilages, where each layer continues as a thin connective tissue aponeurosis termed the external intercostal membrane. The external intercostal muscles are most active in inspiration. | [
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Anatomy_Gray_332 | Anatomy_Gray | The eleven pairs of internal intercostal muscles pass between the most inferior lateral edge of the costal grooves of the ribs above, to the superior margins of the ribs below. They extend from parasternal regions, where the muscles course between adjacent costal cartilages, to the angle of the ribs posteriorly (Fig. 3.27). This layer continues medially toward the vertebral column, in each intercostal space, as the internal intercostal membrane. The muscle fibers pass in the opposite direction to those of the external intercostal muscles. When the thoracic wall is viewed from a lateral position, the muscle fibers pass obliquely posteroinferiorly. The internal intercostal muscles are most active during expiration. | Anatomy_Gray. The eleven pairs of internal intercostal muscles pass between the most inferior lateral edge of the costal grooves of the ribs above, to the superior margins of the ribs below. They extend from parasternal regions, where the muscles course between adjacent costal cartilages, to the angle of the ribs posteriorly (Fig. 3.27). This layer continues medially toward the vertebral column, in each intercostal space, as the internal intercostal membrane. The muscle fibers pass in the opposite direction to those of the external intercostal muscles. When the thoracic wall is viewed from a lateral position, the muscle fibers pass obliquely posteroinferiorly. The internal intercostal muscles are most active during expiration. | [
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Anatomy_Gray_333 | Anatomy_Gray | The innermost intercostal muscles are the least distinct of the intercostal muscles, and the fibers have the same orientation as the internal intercostals (Fig. 3.27). These muscles are most evident in the lateral thoracic wall. They extend between the inner surfaces of adjacent ribs from the medial edge of the costal groove to the deep surface of the rib below. Importantly, the neurovascular bundles associated with the intercostal spaces pass around the thoracic wall in the costal grooves in a plane between the innermost and internal intercostal muscles. | Anatomy_Gray. The innermost intercostal muscles are the least distinct of the intercostal muscles, and the fibers have the same orientation as the internal intercostals (Fig. 3.27). These muscles are most evident in the lateral thoracic wall. They extend between the inner surfaces of adjacent ribs from the medial edge of the costal groove to the deep surface of the rib below. Importantly, the neurovascular bundles associated with the intercostal spaces pass around the thoracic wall in the costal grooves in a plane between the innermost and internal intercostal muscles. | [
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Anatomy_Gray_334 | Anatomy_Gray | The subcostales are in the same plane as the innermost intercostals, span multiple ribs, and are more numerous in lower regions of the posterior thoracic wall (Fig. 3.28A). They extend from the internal surfaces of one rib to the internal surface of the second (next) or third rib below. Their fibers parallel the course of the internal intercostal muscles and extend from the angle of the ribs to more medial positions on the ribs below. The transversus thoracis muscles are found on the deep surface of the anterior thoracic wall (Fig. 3.28B) and in the same plane as the innermost intercostals. The transversus thoracis muscles originate from the posterior aspect of the xiphoid process, the inferior part of the body of the sternum, and the adjacent costal cartilages of the lower true ribs. They pass superiorly and laterally to insert into the lower borders of the costal cartilages of ribs III to VI. They most likely pull these latter elements inferiorly. | Anatomy_Gray. The subcostales are in the same plane as the innermost intercostals, span multiple ribs, and are more numerous in lower regions of the posterior thoracic wall (Fig. 3.28A). They extend from the internal surfaces of one rib to the internal surface of the second (next) or third rib below. Their fibers parallel the course of the internal intercostal muscles and extend from the angle of the ribs to more medial positions on the ribs below. The transversus thoracis muscles are found on the deep surface of the anterior thoracic wall (Fig. 3.28B) and in the same plane as the innermost intercostals. The transversus thoracis muscles originate from the posterior aspect of the xiphoid process, the inferior part of the body of the sternum, and the adjacent costal cartilages of the lower true ribs. They pass superiorly and laterally to insert into the lower borders of the costal cartilages of ribs III to VI. They most likely pull these latter elements inferiorly. | [
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Anatomy_Gray_335 | Anatomy_Gray | The transversus thoracis muscles lie deep to the internal thoracic vessels and secure these vessels to the wall. Vessels that supply the thoracic wall consist mainly of posterior and anterior intercostal arteries, which pass around the wall between adjacent ribs in intercostal spaces (Fig. 3.29). These arteries originate from the aorta and internal thoracic arteries, which in turn arise from the subclavian arteries in the root of the neck. Together, the intercostal arteries form a basket-like pattern of vascular supply around the thoracic wall. Posterior intercostal arteries originate from vessels associated with the posterior thoracic wall. The upper two posterior intercostal arteries on each side are derived from the supreme intercostal artery, which descends into the thorax as a branch of the costocervical trunk in the neck. The costocervical trunk is a posterior branch of the subclavian artery (Fig. 3.29). | Anatomy_Gray. The transversus thoracis muscles lie deep to the internal thoracic vessels and secure these vessels to the wall. Vessels that supply the thoracic wall consist mainly of posterior and anterior intercostal arteries, which pass around the wall between adjacent ribs in intercostal spaces (Fig. 3.29). These arteries originate from the aorta and internal thoracic arteries, which in turn arise from the subclavian arteries in the root of the neck. Together, the intercostal arteries form a basket-like pattern of vascular supply around the thoracic wall. Posterior intercostal arteries originate from vessels associated with the posterior thoracic wall. The upper two posterior intercostal arteries on each side are derived from the supreme intercostal artery, which descends into the thorax as a branch of the costocervical trunk in the neck. The costocervical trunk is a posterior branch of the subclavian artery (Fig. 3.29). | [
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Anatomy_Gray_336 | Anatomy_Gray | The remaining nine pairs of posterior intercostal arteries arise from the posterior surface of the thoracic aorta. Because the aorta is on the left side of the vertebral column, those posterior intercostal vessels passing to the right side of the thoracic wall cross the midline anterior to the bodies of the vertebrae and therefore are longer than the corresponding vessels on the left. In addition to having numerous branches that supply various components of the wall, the posterior intercostal arteries have branches that accompany lateral cutaneous branches of the intercostal nerves to superficial regions. The anterior intercostal arteries originate directly or indirectly as lateral branches from the internal thoracic arteries (Fig. 3.29). | Anatomy_Gray. The remaining nine pairs of posterior intercostal arteries arise from the posterior surface of the thoracic aorta. Because the aorta is on the left side of the vertebral column, those posterior intercostal vessels passing to the right side of the thoracic wall cross the midline anterior to the bodies of the vertebrae and therefore are longer than the corresponding vessels on the left. In addition to having numerous branches that supply various components of the wall, the posterior intercostal arteries have branches that accompany lateral cutaneous branches of the intercostal nerves to superficial regions. The anterior intercostal arteries originate directly or indirectly as lateral branches from the internal thoracic arteries (Fig. 3.29). | [
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Anatomy_Gray_337 | Anatomy_Gray | The anterior intercostal arteries originate directly or indirectly as lateral branches from the internal thoracic arteries (Fig. 3.29). Each internal thoracic artery arises as a major branch of the subclavian artery in the neck. It passes anteriorly over the cervical dome of the pleura and descends vertically through the superior thoracic aperture and along the deep aspect of the anterior thoracic wall. On each side, the internal thoracic artery lies posterior to the costal cartilages of the upper six ribs and about 1 cm lateral to the sternum. At approximately the level of the sixth intercostal space, it divides into two terminal branches: the superior epigastric artery, which continues inferiorly into the anterior abdominal wall (Fig. 3.29); and the musculophrenic artery, which passes along the costal margin, goes through the diaphragm, and ends near the last intercostal space. | Anatomy_Gray. The anterior intercostal arteries originate directly or indirectly as lateral branches from the internal thoracic arteries (Fig. 3.29). Each internal thoracic artery arises as a major branch of the subclavian artery in the neck. It passes anteriorly over the cervical dome of the pleura and descends vertically through the superior thoracic aperture and along the deep aspect of the anterior thoracic wall. On each side, the internal thoracic artery lies posterior to the costal cartilages of the upper six ribs and about 1 cm lateral to the sternum. At approximately the level of the sixth intercostal space, it divides into two terminal branches: the superior epigastric artery, which continues inferiorly into the anterior abdominal wall (Fig. 3.29); and the musculophrenic artery, which passes along the costal margin, goes through the diaphragm, and ends near the last intercostal space. | [
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Anatomy_Gray_338 | Anatomy_Gray | Anterior intercostal arteries that supply the upper six intercostal spaces arise as lateral branches from the internal thoracic artery, whereas those supplying the lower spaces arise from the musculophrenic artery. In each intercostal space, the anterior intercostal arteries usually have two branches: One passes below the margin of the upper rib. The other passes above the margin of the lower rib and meets a collateral branch of the posterior intercostal artery. The distributions of the anterior and posterior intercostal vessels overlap and can develop anastomotic connections. The anterior intercostal arteries are generally smaller than the posterior vessels. | Anatomy_Gray. Anterior intercostal arteries that supply the upper six intercostal spaces arise as lateral branches from the internal thoracic artery, whereas those supplying the lower spaces arise from the musculophrenic artery. In each intercostal space, the anterior intercostal arteries usually have two branches: One passes below the margin of the upper rib. The other passes above the margin of the lower rib and meets a collateral branch of the posterior intercostal artery. The distributions of the anterior and posterior intercostal vessels overlap and can develop anastomotic connections. The anterior intercostal arteries are generally smaller than the posterior vessels. | [
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] |
Anatomy_Gray_339 | Anatomy_Gray | In addition to anterior intercostal arteries and a number of other branches, the internal thoracic arteries give rise to perforating branches that pass directly forward between the costal cartilages to supply structures external to the thoracic wall. These vessels travel with the anterior cutaneous branches of the intercostal nerves. Venous drainage from the thoracic wall generally parallels the pattern of arterial supply (Fig. 3.30). Centrally, the intercostal veins ultimately drain into the azygos system of veins or into internal thoracic veins, which connect with the brachiocephalic veins in the neck. Often the upper posterior intercostal veins on the left side come together and form the left superior intercostal vein, which empties into the left brachiocephalic vein. Similarly, the upper posterior intercostal veins on the right side may come together and form the right superior intercostal vein, which empties into the azygos vein. | Anatomy_Gray. In addition to anterior intercostal arteries and a number of other branches, the internal thoracic arteries give rise to perforating branches that pass directly forward between the costal cartilages to supply structures external to the thoracic wall. These vessels travel with the anterior cutaneous branches of the intercostal nerves. Venous drainage from the thoracic wall generally parallels the pattern of arterial supply (Fig. 3.30). Centrally, the intercostal veins ultimately drain into the azygos system of veins or into internal thoracic veins, which connect with the brachiocephalic veins in the neck. Often the upper posterior intercostal veins on the left side come together and form the left superior intercostal vein, which empties into the left brachiocephalic vein. Similarly, the upper posterior intercostal veins on the right side may come together and form the right superior intercostal vein, which empties into the azygos vein. | [
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Anatomy_Gray_340 | Anatomy_Gray | Similarly, the upper posterior intercostal veins on the right side may come together and form the right superior intercostal vein, which empties into the azygos vein. Lymphatic vessels of the thoracic wall drain mainly into lymph nodes associated with the internal thoracic arteries (parasternal nodes), with the heads and necks of ribs (intercostal nodes), and with the diaphragm (diaphragmatic nodes) (Fig. 3.31). Diaphragmatic nodes are posterior to the xiphoid and at sites where the phrenic nerves penetrate the diaphragm. They also occur in regions where the diaphragm is attached to the vertebral column. Parasternal nodes drain into bronchomediastinal trunks. Intercostal nodes in the upper thorax also drain into bronchomediastinal trunks, whereas intercostal nodes in the lower thorax drain into the thoracic duct. | Anatomy_Gray. Similarly, the upper posterior intercostal veins on the right side may come together and form the right superior intercostal vein, which empties into the azygos vein. Lymphatic vessels of the thoracic wall drain mainly into lymph nodes associated with the internal thoracic arteries (parasternal nodes), with the heads and necks of ribs (intercostal nodes), and with the diaphragm (diaphragmatic nodes) (Fig. 3.31). Diaphragmatic nodes are posterior to the xiphoid and at sites where the phrenic nerves penetrate the diaphragm. They also occur in regions where the diaphragm is attached to the vertebral column. Parasternal nodes drain into bronchomediastinal trunks. Intercostal nodes in the upper thorax also drain into bronchomediastinal trunks, whereas intercostal nodes in the lower thorax drain into the thoracic duct. | [
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Anatomy_Gray_341 | Anatomy_Gray | Nodes associated with the diaphragm interconnect with parasternal, prevertebral, and juxta-esophageal nodes, brachiocephalic nodes (anterior to the brachiocephalic veins in the superior mediastinum), and lateral aortic/lumbar nodes (in the abdomen). Superficial regions of the thoracic wall drain mainly into axillary lymph nodes in the axilla or parasternal nodes. Innervation of the thoracic wall is mainly by the intercostal nerves, which are the anterior rami of spinal nerves T1 to T11 and lie in the intercostal spaces between adjacent ribs. The anterior ramus of spinal nerve T12 (the subcostal nerve) is inferior to rib XII (Fig. 3.32). A typical intercostal nerve passes laterally around the thoracic wall in an intercostal space. The largest of the branches is the lateral cutaneous branch, which pierces the lateral thoracic wall and divides into an anterior branch and a posterior branch that innervate the overlying skin. | Anatomy_Gray. Nodes associated with the diaphragm interconnect with parasternal, prevertebral, and juxta-esophageal nodes, brachiocephalic nodes (anterior to the brachiocephalic veins in the superior mediastinum), and lateral aortic/lumbar nodes (in the abdomen). Superficial regions of the thoracic wall drain mainly into axillary lymph nodes in the axilla or parasternal nodes. Innervation of the thoracic wall is mainly by the intercostal nerves, which are the anterior rami of spinal nerves T1 to T11 and lie in the intercostal spaces between adjacent ribs. The anterior ramus of spinal nerve T12 (the subcostal nerve) is inferior to rib XII (Fig. 3.32). A typical intercostal nerve passes laterally around the thoracic wall in an intercostal space. The largest of the branches is the lateral cutaneous branch, which pierces the lateral thoracic wall and divides into an anterior branch and a posterior branch that innervate the overlying skin. | [
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Anatomy_Gray_342 | Anatomy_Gray | The intercostal nerves end as anterior cutaneous branches, which emerge either parasternally, between adjacent costal cartilages, or laterally to the midline, on the anterior abdominal wall, to supply the skin. In addition to these major branches, small collateral branches can be found in the intercostal space running along the superior border of the lower rib. In the thorax, the intercostal nerves carry: somatic motor innervation to the muscles of the thoracic wall (intercostal, subcostal, and transversus thoracis muscles), somatic sensory innervation from the skin and parietal pleura, and postganglionic sympathetic fibers to the periphery. Sensory innervation of the skin overlying the upper thoracic wall is supplied by cutaneous branches (supraclavicular nerves), which descend from the cervical plexus in the neck. In addition to innervating the thoracic wall, intercostal nerves innervate other regions: The anterior ramus of T1 contributes to the brachial plexus. | Anatomy_Gray. The intercostal nerves end as anterior cutaneous branches, which emerge either parasternally, between adjacent costal cartilages, or laterally to the midline, on the anterior abdominal wall, to supply the skin. In addition to these major branches, small collateral branches can be found in the intercostal space running along the superior border of the lower rib. In the thorax, the intercostal nerves carry: somatic motor innervation to the muscles of the thoracic wall (intercostal, subcostal, and transversus thoracis muscles), somatic sensory innervation from the skin and parietal pleura, and postganglionic sympathetic fibers to the periphery. Sensory innervation of the skin overlying the upper thoracic wall is supplied by cutaneous branches (supraclavicular nerves), which descend from the cervical plexus in the neck. In addition to innervating the thoracic wall, intercostal nerves innervate other regions: The anterior ramus of T1 contributes to the brachial plexus. | [
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Anatomy_Gray_343 | Anatomy_Gray | In addition to innervating the thoracic wall, intercostal nerves innervate other regions: The anterior ramus of T1 contributes to the brachial plexus. The lateral cutaneous branch of the second intercostal nerve (the intercostobrachial nerve) contributes to cutaneous innervation of the medial surface of the upper arm. The lower intercostal nerves supply the muscles, skin, and peritoneum of the abdominal wall. The diaphragm is a thin musculotendinous structure that fills the inferior thoracic aperture and separates the thoracic cavity from the abdominal cavity (Fig. 3.34 and see Chapter 4). It is attached peripherally to the: xiphoid process of the sternum, costal margin of the thoracic wall, ends of ribs XI and XII, ligaments that span across structures of the posterior abdominal wall, and vertebrae of the lumbar region. From these peripheral attachments, muscle fibers converge to join the central tendon. The pericardium is attached to the middle part of the central tendon. | Anatomy_Gray. In addition to innervating the thoracic wall, intercostal nerves innervate other regions: The anterior ramus of T1 contributes to the brachial plexus. The lateral cutaneous branch of the second intercostal nerve (the intercostobrachial nerve) contributes to cutaneous innervation of the medial surface of the upper arm. The lower intercostal nerves supply the muscles, skin, and peritoneum of the abdominal wall. The diaphragm is a thin musculotendinous structure that fills the inferior thoracic aperture and separates the thoracic cavity from the abdominal cavity (Fig. 3.34 and see Chapter 4). It is attached peripherally to the: xiphoid process of the sternum, costal margin of the thoracic wall, ends of ribs XI and XII, ligaments that span across structures of the posterior abdominal wall, and vertebrae of the lumbar region. From these peripheral attachments, muscle fibers converge to join the central tendon. The pericardium is attached to the middle part of the central tendon. | [
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Anatomy_Gray_344 | Anatomy_Gray | From these peripheral attachments, muscle fibers converge to join the central tendon. The pericardium is attached to the middle part of the central tendon. In the median sagittal plane, the diaphragm slopes inferiorly from its anterior attachment to the xiphoid, approximately at vertebral level TVIII/IX, to its posterior attachment to the median arcuate ligament, crossing anteriorly to the aorta at approximately vertebral level TXII. Structures traveling between the thorax and abdomen pass through the diaphragm or between the diaphragm and its peripheral attachments: The inferior vena cava passes through the central tendon at approximately vertebral level TVIII. The esophagus passes through the muscular part of the diaphragm, just to the left of midline, approximately at vertebral level TX. The vagus nerves pass through the diaphragm with the esophagus. The aorta passes behind the posterior attachment of the diaphragm at vertebral level TXII. | Anatomy_Gray. From these peripheral attachments, muscle fibers converge to join the central tendon. The pericardium is attached to the middle part of the central tendon. In the median sagittal plane, the diaphragm slopes inferiorly from its anterior attachment to the xiphoid, approximately at vertebral level TVIII/IX, to its posterior attachment to the median arcuate ligament, crossing anteriorly to the aorta at approximately vertebral level TXII. Structures traveling between the thorax and abdomen pass through the diaphragm or between the diaphragm and its peripheral attachments: The inferior vena cava passes through the central tendon at approximately vertebral level TVIII. The esophagus passes through the muscular part of the diaphragm, just to the left of midline, approximately at vertebral level TX. The vagus nerves pass through the diaphragm with the esophagus. The aorta passes behind the posterior attachment of the diaphragm at vertebral level TXII. | [
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Anatomy_Gray_345 | Anatomy_Gray | The vagus nerves pass through the diaphragm with the esophagus. The aorta passes behind the posterior attachment of the diaphragm at vertebral level TXII. The thoracic duct passes behind the diaphragm with the aorta. The azygos and hemiazygos veins may also pass through the aortic hiatus or through the crura of the diaphragm. Other structures outside the posterior attachments of the diaphragm lateral to the aortic hiatus include the sympathetic trunks. The greater, lesser, and least splanchnic nerves penetrate the crura. | Anatomy_Gray. The vagus nerves pass through the diaphragm with the esophagus. The aorta passes behind the posterior attachment of the diaphragm at vertebral level TXII. The thoracic duct passes behind the diaphragm with the aorta. The azygos and hemiazygos veins may also pass through the aortic hiatus or through the crura of the diaphragm. Other structures outside the posterior attachments of the diaphragm lateral to the aortic hiatus include the sympathetic trunks. The greater, lesser, and least splanchnic nerves penetrate the crura. | [
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Anatomy_Gray_346 | Anatomy_Gray | Other structures outside the posterior attachments of the diaphragm lateral to the aortic hiatus include the sympathetic trunks. The greater, lesser, and least splanchnic nerves penetrate the crura. The arterial supply to the diaphragm is from vessels that arise superiorly and inferiorly to it (see Fig. 3.34). From above, pericardiacophrenic and musculophrenic arteries supply the diaphragm. These vessels are branches of the internal thoracic arteries. Superior phrenic arteries, which arise directly from lower parts of the thoracic aorta, and small branches from intercostal arteries contribute to the supply. The largest arteries supplying the diaphragm arise from below it. These arteries are the inferior phrenic arteries, which branch directly from the abdominal aorta. | Anatomy_Gray. Other structures outside the posterior attachments of the diaphragm lateral to the aortic hiatus include the sympathetic trunks. The greater, lesser, and least splanchnic nerves penetrate the crura. The arterial supply to the diaphragm is from vessels that arise superiorly and inferiorly to it (see Fig. 3.34). From above, pericardiacophrenic and musculophrenic arteries supply the diaphragm. These vessels are branches of the internal thoracic arteries. Superior phrenic arteries, which arise directly from lower parts of the thoracic aorta, and small branches from intercostal arteries contribute to the supply. The largest arteries supplying the diaphragm arise from below it. These arteries are the inferior phrenic arteries, which branch directly from the abdominal aorta. | [
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Anatomy_Gray_347 | Anatomy_Gray | Venous drainage of the diaphragm is by veins that generally parallel the arteries. The veins drain into: the brachiocephalic veins in the neck, the azygos system of veins, or abdominal veins (left suprarenal vein and inferior vena cava). The diaphragm is innervated by the phrenic nerves (C3, C4, and C5), which penetrate the diaphragm and innervate it from its abdominal surface. Contraction of the domes of the diaphragm flattens the diaphragm, thereby increasing thoracic volume. Movements of the diaphragm are essential for normal breathing. One of the principal functions of the thoracic wall and the diaphragm is to alter the volume of the thorax and thereby move air in and out of the lungs. During breathing, the dimensions of the thorax change in the vertical, lateral, and anteroposterior directions. | Anatomy_Gray. Venous drainage of the diaphragm is by veins that generally parallel the arteries. The veins drain into: the brachiocephalic veins in the neck, the azygos system of veins, or abdominal veins (left suprarenal vein and inferior vena cava). The diaphragm is innervated by the phrenic nerves (C3, C4, and C5), which penetrate the diaphragm and innervate it from its abdominal surface. Contraction of the domes of the diaphragm flattens the diaphragm, thereby increasing thoracic volume. Movements of the diaphragm are essential for normal breathing. One of the principal functions of the thoracic wall and the diaphragm is to alter the volume of the thorax and thereby move air in and out of the lungs. During breathing, the dimensions of the thorax change in the vertical, lateral, and anteroposterior directions. | [
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Anatomy_Gray_348 | Anatomy_Gray | During breathing, the dimensions of the thorax change in the vertical, lateral, and anteroposterior directions. Elevation and depression of the diaphragm significantly alter the vertical dimensions of the thorax. Depression results when the muscle fibers of the diaphragm contract. Elevation occurs when the diaphragm relaxes. Changes in the anteroposterior and lateral dimensions result from elevation and depression of the ribs (Fig. 3.35). The posterior ends of the ribs articulate with the vertebral column, whereas the anterior ends of most ribs articulate with the sternum or adjacent ribs. | Anatomy_Gray. During breathing, the dimensions of the thorax change in the vertical, lateral, and anteroposterior directions. Elevation and depression of the diaphragm significantly alter the vertical dimensions of the thorax. Depression results when the muscle fibers of the diaphragm contract. Elevation occurs when the diaphragm relaxes. Changes in the anteroposterior and lateral dimensions result from elevation and depression of the ribs (Fig. 3.35). The posterior ends of the ribs articulate with the vertebral column, whereas the anterior ends of most ribs articulate with the sternum or adjacent ribs. | [
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Anatomy_Gray_349 | Anatomy_Gray | Because the anterior ends of the ribs are inferior to the posterior ends, when the ribs are elevated, they move the sternum upward and forward. Also, the angle between the body of the sternum and the manubrium may become slightly less acute. When the ribs are depressed, the sternum moves downward and backward. This “pump handle” movement changes the dimensions of the thorax in the anteroposterior direction (Fig. 3.35A). As well as the anterior ends of the ribs being lower than the posterior ends, the middles of the shafts tend to be lower than the two ends. When the shafts are elevated, the middles of the shafts move laterally. This “bucket handle” movement increases the lateral dimensions of the thorax (Fig. 3.35B). Any muscles attaching to the ribs can potentially move one rib relative to another and therefore act as accessory respiratory muscles. Muscles in the neck and the abdomen can fix or alter the positions of upper and lower ribs. | Anatomy_Gray. Because the anterior ends of the ribs are inferior to the posterior ends, when the ribs are elevated, they move the sternum upward and forward. Also, the angle between the body of the sternum and the manubrium may become slightly less acute. When the ribs are depressed, the sternum moves downward and backward. This “pump handle” movement changes the dimensions of the thorax in the anteroposterior direction (Fig. 3.35A). As well as the anterior ends of the ribs being lower than the posterior ends, the middles of the shafts tend to be lower than the two ends. When the shafts are elevated, the middles of the shafts move laterally. This “bucket handle” movement increases the lateral dimensions of the thorax (Fig. 3.35B). Any muscles attaching to the ribs can potentially move one rib relative to another and therefore act as accessory respiratory muscles. Muscles in the neck and the abdomen can fix or alter the positions of upper and lower ribs. | [
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Anatomy_Gray_350 | Anatomy_Gray | Two pleural cavities, one on either side of the mediastinum, surround the lungs (Fig. 3.37): Superiorly, they extend above rib I into the root of the neck. Inferiorly, they extend to a level just above the costal margin. The medial wall of each pleural cavity is the mediastinum. Each pleural cavity is lined by a single layer of flat cells, mesothelium, and an associated layer of supporting connective tissue; together, they form the pleura. The pleura is divided into two major types, based on location: Pleura associated with the walls of a pleural cavity is parietal pleura (Fig. 3.37). Pleura that reflects from the medial wall and onto the surface of the lung is visceral pleura (Fig. 3.37), which adheres to and covers the lung. | Anatomy_Gray. Two pleural cavities, one on either side of the mediastinum, surround the lungs (Fig. 3.37): Superiorly, they extend above rib I into the root of the neck. Inferiorly, they extend to a level just above the costal margin. The medial wall of each pleural cavity is the mediastinum. Each pleural cavity is lined by a single layer of flat cells, mesothelium, and an associated layer of supporting connective tissue; together, they form the pleura. The pleura is divided into two major types, based on location: Pleura associated with the walls of a pleural cavity is parietal pleura (Fig. 3.37). Pleura that reflects from the medial wall and onto the surface of the lung is visceral pleura (Fig. 3.37), which adheres to and covers the lung. | [
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Anatomy_Gray_351 | Anatomy_Gray | Pleura that reflects from the medial wall and onto the surface of the lung is visceral pleura (Fig. 3.37), which adheres to and covers the lung. Each pleural cavity is the potential space enclosed between the visceral and parietal pleurae. They normally contain only a very thin layer of serous fluid. As a result, the surface of the lung, which is covered by visceral pleura, directly opposes and freely slides over the parietal pleura attached to the wall. The names given to the parietal pleura correspond to the parts of the wall with which they are associated (Fig. 3.38): Pleura related to the ribs and intercostal spaces is termed the costal part. Pleura covering the diaphragm is the diaphragmatic part. Pleura covering the mediastinum is the mediastinal part. The dome-shaped layer of parietal pleura lining the cervical extension of the pleural cavity is cervical pleura (dome of pleura or pleural cupola). | Anatomy_Gray. Pleura that reflects from the medial wall and onto the surface of the lung is visceral pleura (Fig. 3.37), which adheres to and covers the lung. Each pleural cavity is the potential space enclosed between the visceral and parietal pleurae. They normally contain only a very thin layer of serous fluid. As a result, the surface of the lung, which is covered by visceral pleura, directly opposes and freely slides over the parietal pleura attached to the wall. The names given to the parietal pleura correspond to the parts of the wall with which they are associated (Fig. 3.38): Pleura related to the ribs and intercostal spaces is termed the costal part. Pleura covering the diaphragm is the diaphragmatic part. Pleura covering the mediastinum is the mediastinal part. The dome-shaped layer of parietal pleura lining the cervical extension of the pleural cavity is cervical pleura (dome of pleura or pleural cupola). | [
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Anatomy_Gray_352 | Anatomy_Gray | The dome-shaped layer of parietal pleura lining the cervical extension of the pleural cavity is cervical pleura (dome of pleura or pleural cupola). Covering the superior surface of the cervical pleura is a distinct dome-like layer of fascia, the suprapleural membrane (Fig. 3.38). This connective tissue membrane is attached laterally to the medial margin of the first rib and behind to the transverse process of vertebra CVII. Superiorly, the membrane receives muscle fibers from some of the deep muscles in the neck (scalene muscles) that function to keep the membrane taut. The suprapleural membrane provides apical support for the pleural cavity in the root of the neck. | Anatomy_Gray. The dome-shaped layer of parietal pleura lining the cervical extension of the pleural cavity is cervical pleura (dome of pleura or pleural cupola). Covering the superior surface of the cervical pleura is a distinct dome-like layer of fascia, the suprapleural membrane (Fig. 3.38). This connective tissue membrane is attached laterally to the medial margin of the first rib and behind to the transverse process of vertebra CVII. Superiorly, the membrane receives muscle fibers from some of the deep muscles in the neck (scalene muscles) that function to keep the membrane taut. The suprapleural membrane provides apical support for the pleural cavity in the root of the neck. | [
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Anatomy_Gray_353 | Anatomy_Gray | In the region of vertebrae TV to TVII, the mediastinal pleura reflects off the mediastinum as a tubular, sleeve-like covering for structures (i.e., airway, vessels, nerves, lymphatics) that pass between the lung and mediastinum. This sleeve-like covering and the structures it contains forms the root of the lung. The root joins the medial surface of the lung at an area referred to as the hilum of the lung. Here, the mediastinal pleura is continuous with the visceral pleura. The parietal pleural is innervated by somatic afferent fibers. The costal pleura is innervated by branches from the intercostal nerves, and pain would be felt in relation to the thoracic wall. The diaphragmatic pleura and the mediastinal pleura are innervated mainly by the phrenic nerves (originating at spinal cord levels C3, C4, and C5). Pain from these areas would refer to the C3, C4, and C5 dermatomes (lateral neck and the supraclavicular region of the shoulder). | Anatomy_Gray. In the region of vertebrae TV to TVII, the mediastinal pleura reflects off the mediastinum as a tubular, sleeve-like covering for structures (i.e., airway, vessels, nerves, lymphatics) that pass between the lung and mediastinum. This sleeve-like covering and the structures it contains forms the root of the lung. The root joins the medial surface of the lung at an area referred to as the hilum of the lung. Here, the mediastinal pleura is continuous with the visceral pleura. The parietal pleural is innervated by somatic afferent fibers. The costal pleura is innervated by branches from the intercostal nerves, and pain would be felt in relation to the thoracic wall. The diaphragmatic pleura and the mediastinal pleura are innervated mainly by the phrenic nerves (originating at spinal cord levels C3, C4, and C5). Pain from these areas would refer to the C3, C4, and C5 dermatomes (lateral neck and the supraclavicular region of the shoulder). | [
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Anatomy_Gray_354 | Anatomy_Gray | The peripheral reflections of parietal pleura mark the extent of the pleural cavities (Fig. 3.39). Superiorly, the pleural cavity can project as much as 3 to 4 cm above the first costal cartilage but does not extend above the neck of rib I. This limitation is caused by the inferior slope of rib I to its articulation with the manubrium. Anteriorly, the pleural cavities approach each other posterior to the upper part of the sternum. However, posterior to the lower part of the sternum, the parietal pleura does not come as close to the midline on the left side as it does on the right because the middle mediastinum, containing the pericardium and heart, bulges to the left. | Anatomy_Gray. The peripheral reflections of parietal pleura mark the extent of the pleural cavities (Fig. 3.39). Superiorly, the pleural cavity can project as much as 3 to 4 cm above the first costal cartilage but does not extend above the neck of rib I. This limitation is caused by the inferior slope of rib I to its articulation with the manubrium. Anteriorly, the pleural cavities approach each other posterior to the upper part of the sternum. However, posterior to the lower part of the sternum, the parietal pleura does not come as close to the midline on the left side as it does on the right because the middle mediastinum, containing the pericardium and heart, bulges to the left. | [
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Anatomy_Gray_355 | Anatomy_Gray | Inferiorly, the costal pleura reflects onto the diaphragm above the costal margin. In the midclavicular line, the pleural cavity extends inferiorly to approximately rib VIII. In the midaxillary line, it extends to rib X. From this point, the inferior margin courses somewhat horizontally, crossing ribs XI and XII to reach vertebra TXII. From the midclavicular line to the vertebral column, the inferior boundary of the pleura can be approximated by a line that runs between rib VIII, rib X, and vertebra TXII. The visceral pleura is continuous with the parietal pleura at the hilum of each lung, where structures enter and leave the organ. The visceral pleura is firmly attached to the surface of the lung, including both opposed surfaces of the fissures that divide the lungs into lobes. Although the visceral pleura is innervated by visceral afferent nerves that accompany bronchial vessels, pain is generally not elicited from this tissue. | Anatomy_Gray. Inferiorly, the costal pleura reflects onto the diaphragm above the costal margin. In the midclavicular line, the pleural cavity extends inferiorly to approximately rib VIII. In the midaxillary line, it extends to rib X. From this point, the inferior margin courses somewhat horizontally, crossing ribs XI and XII to reach vertebra TXII. From the midclavicular line to the vertebral column, the inferior boundary of the pleura can be approximated by a line that runs between rib VIII, rib X, and vertebra TXII. The visceral pleura is continuous with the parietal pleura at the hilum of each lung, where structures enter and leave the organ. The visceral pleura is firmly attached to the surface of the lung, including both opposed surfaces of the fissures that divide the lungs into lobes. Although the visceral pleura is innervated by visceral afferent nerves that accompany bronchial vessels, pain is generally not elicited from this tissue. | [
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Anatomy_Gray_356 | Anatomy_Gray | Although the visceral pleura is innervated by visceral afferent nerves that accompany bronchial vessels, pain is generally not elicited from this tissue. The lungs do not completely fill the anterior or posterior inferior regions of the pleural cavities (Fig. 3.40). This results in recesses in which two layers of parietal pleura become opposed. Expansion of the lungs into these spaces usually occurs only during forced inspiration; the recesses also provide potential spaces in which fluids can collect and from which fluids can be aspirated. Anteriorly, a costomediastinal recess occurs on each side where costal pleura is opposed to mediastinal pleura. The largest is on the left side in the region overlying the heart (Fig. 3.40). | Anatomy_Gray. Although the visceral pleura is innervated by visceral afferent nerves that accompany bronchial vessels, pain is generally not elicited from this tissue. The lungs do not completely fill the anterior or posterior inferior regions of the pleural cavities (Fig. 3.40). This results in recesses in which two layers of parietal pleura become opposed. Expansion of the lungs into these spaces usually occurs only during forced inspiration; the recesses also provide potential spaces in which fluids can collect and from which fluids can be aspirated. Anteriorly, a costomediastinal recess occurs on each side where costal pleura is opposed to mediastinal pleura. The largest is on the left side in the region overlying the heart (Fig. 3.40). | [
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Anatomy_Gray_357 | Anatomy_Gray | Anteriorly, a costomediastinal recess occurs on each side where costal pleura is opposed to mediastinal pleura. The largest is on the left side in the region overlying the heart (Fig. 3.40). The largest and clinically most important recesses are the costodiaphragmatic recesses, which occur in each pleural cavity between the costal pleura and diaphragmatic pleura (Fig. 3.40). The costodiaphragmatic recesses are the regions between the inferior margin of the lungs and inferior margin of the pleural cavities. They are deepest after forced expiration and shallowest after forced inspiration. | Anatomy_Gray. Anteriorly, a costomediastinal recess occurs on each side where costal pleura is opposed to mediastinal pleura. The largest is on the left side in the region overlying the heart (Fig. 3.40). The largest and clinically most important recesses are the costodiaphragmatic recesses, which occur in each pleural cavity between the costal pleura and diaphragmatic pleura (Fig. 3.40). The costodiaphragmatic recesses are the regions between the inferior margin of the lungs and inferior margin of the pleural cavities. They are deepest after forced expiration and shallowest after forced inspiration. | [
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Anatomy_Gray_358 | Anatomy_Gray | During quiet respiration, the inferior margin of the lung crosses rib VI in the midclavicular line and rib VIII in the midaxillary line, and then courses somewhat horizontally to reach the vertebral column at vertebral level TX. Thus, from the midclavicular line and around the thoracic wall to the vertebral column, the inferior margin of the lung can be approximated by a line running between rib VI, rib VIII, and vertebra TX. The inferior margin of the pleural cavity at the same points is rib VIII, rib X, and vertebra TXII. The costodiaphragmatic recess is the region between the two margins. During expiration, the inferior margin of the lung rises and the costodiaphragmatic recess becomes larger. The two lungs are organs of respiration and lie on either side of the mediastinum surrounded by the right and left pleural cavities. Air enters and leaves the lungs via main bronchi, which are branches of the trachea. | Anatomy_Gray. During quiet respiration, the inferior margin of the lung crosses rib VI in the midclavicular line and rib VIII in the midaxillary line, and then courses somewhat horizontally to reach the vertebral column at vertebral level TX. Thus, from the midclavicular line and around the thoracic wall to the vertebral column, the inferior margin of the lung can be approximated by a line running between rib VI, rib VIII, and vertebra TX. The inferior margin of the pleural cavity at the same points is rib VIII, rib X, and vertebra TXII. The costodiaphragmatic recess is the region between the two margins. During expiration, the inferior margin of the lung rises and the costodiaphragmatic recess becomes larger. The two lungs are organs of respiration and lie on either side of the mediastinum surrounded by the right and left pleural cavities. Air enters and leaves the lungs via main bronchi, which are branches of the trachea. | [
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Anatomy_Gray_359 | Anatomy_Gray | The pulmonary arteries deliver deoxygenated blood to the lungs from the right ventricle of the heart. Oxygenated blood returns to the left atrium via the pulmonary veins. The right lung is normally a little larger than the left lung because the middle mediastinum, containing the heart, bulges more to the left than to the right. Each lung has a half-cone shape, with a base, apex, two surfaces, and three borders (Fig. 3.43). The base sits on the diaphragm. The apex projects above rib I and into the root of the neck. The two surfaces—the costal surface lies immediately adjacent to the ribs and intercostal spaces of the thoracic wall. The mediastinal surface lies against the mediastinum anteriorly and the vertebral column posteriorly and contains the comma-shaped hilum of the lung, through which structures enter and leave. | Anatomy_Gray. The pulmonary arteries deliver deoxygenated blood to the lungs from the right ventricle of the heart. Oxygenated blood returns to the left atrium via the pulmonary veins. The right lung is normally a little larger than the left lung because the middle mediastinum, containing the heart, bulges more to the left than to the right. Each lung has a half-cone shape, with a base, apex, two surfaces, and three borders (Fig. 3.43). The base sits on the diaphragm. The apex projects above rib I and into the root of the neck. The two surfaces—the costal surface lies immediately adjacent to the ribs and intercostal spaces of the thoracic wall. The mediastinal surface lies against the mediastinum anteriorly and the vertebral column posteriorly and contains the comma-shaped hilum of the lung, through which structures enter and leave. | [
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Anatomy_Gray_360 | Anatomy_Gray | The three borders—the inferior border of the lung is sharp and separates the base from the costal surface. The anterior and posterior borders separate the costal surface from the medial surface. Unlike the anterior and inferior borders, which are sharp, the posterior border is smooth and rounded. The lungs lie directly adjacent to, and are indented by, structures contained in the overlying area. The heart and major vessels form bulges in the mediastinum that indent the medial surfaces of the lung; the ribs indent the costal surfaces. Pathology, such as tumors, or abnormalities in one structure can affect the related structure. | Anatomy_Gray. The three borders—the inferior border of the lung is sharp and separates the base from the costal surface. The anterior and posterior borders separate the costal surface from the medial surface. Unlike the anterior and inferior borders, which are sharp, the posterior border is smooth and rounded. The lungs lie directly adjacent to, and are indented by, structures contained in the overlying area. The heart and major vessels form bulges in the mediastinum that indent the medial surfaces of the lung; the ribs indent the costal surfaces. Pathology, such as tumors, or abnormalities in one structure can affect the related structure. | [
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Anatomy_Gray_361 | Anatomy_Gray | The root of each lung is a short tubular collection of structures that together attach the lung to structures in the mediastinum (Fig. 3.44). It is covered by a sleeve of mediastinal pleura that reflects onto the surface of the lung as visceral pleura. The region outlined by this pleural reflection on the medial surface of the lung is the hilum, where structures enter and leave. A thin blade-like fold of pleura projects inferiorly from the root of the lung and extends from the hilum to the mediastinum. This structure is the pulmonary ligament. It may stabilize the position of the inferior lobe and may also accommodate the down-and-up translocation of structures in the root during breathing. In the mediastinum, the vagus nerves pass immediately posterior to the roots of the lungs, while the phrenic nerves pass immediately anterior to them. | Anatomy_Gray. The root of each lung is a short tubular collection of structures that together attach the lung to structures in the mediastinum (Fig. 3.44). It is covered by a sleeve of mediastinal pleura that reflects onto the surface of the lung as visceral pleura. The region outlined by this pleural reflection on the medial surface of the lung is the hilum, where structures enter and leave. A thin blade-like fold of pleura projects inferiorly from the root of the lung and extends from the hilum to the mediastinum. This structure is the pulmonary ligament. It may stabilize the position of the inferior lobe and may also accommodate the down-and-up translocation of structures in the root during breathing. In the mediastinum, the vagus nerves pass immediately posterior to the roots of the lungs, while the phrenic nerves pass immediately anterior to them. | [
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Anatomy_Gray_362 | Anatomy_Gray | In the mediastinum, the vagus nerves pass immediately posterior to the roots of the lungs, while the phrenic nerves pass immediately anterior to them. Within each root and located in the hilum are: a pulmonary artery, two pulmonary veins, a main bronchus, bronchial vessels, nerves, and lymphatics. Generally, the pulmonary artery is superior at the hilum, the pulmonary veins are inferior, and the bronchi are somewhat posterior in position. On the right side, the lobar bronchus to the superior lobe branches from the main bronchus in the root, unlike on the left where it branches within the lung itself, and is superior to the pulmonary artery. The right lung has three lobes and two fissures (Fig. 3.45A). Normally, the lobes are freely movable against each other because they are separated, almost to the hilum, by invaginations of visceral pleura. These invaginations form the fissures: | Anatomy_Gray. In the mediastinum, the vagus nerves pass immediately posterior to the roots of the lungs, while the phrenic nerves pass immediately anterior to them. Within each root and located in the hilum are: a pulmonary artery, two pulmonary veins, a main bronchus, bronchial vessels, nerves, and lymphatics. Generally, the pulmonary artery is superior at the hilum, the pulmonary veins are inferior, and the bronchi are somewhat posterior in position. On the right side, the lobar bronchus to the superior lobe branches from the main bronchus in the root, unlike on the left where it branches within the lung itself, and is superior to the pulmonary artery. The right lung has three lobes and two fissures (Fig. 3.45A). Normally, the lobes are freely movable against each other because they are separated, almost to the hilum, by invaginations of visceral pleura. These invaginations form the fissures: | [
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Anatomy_Gray_363 | Anatomy_Gray | The oblique fissure separates the inferior lobe (lower lobe) from the superior lobe and the middle lobe of the right lung. The horizontal fissure separates the superior lobe (upper lobe) from the middle lobe. The approximate position of the oblique fissure on a patient, in quiet respiration, can be marked by a curved line on the thoracic wall that begins roughly at the spinous process of the vertebra TIV level of the spine, crosses the fifth interspace laterally, and then follows the contour of rib VI anteriorly (see pp. 241–242). The horizontal fissure follows the fourth intercostal space from the sternum until it meets the oblique fissure as it crosses rib V. The orientations of the oblique and horizontal fissures determine where clinicians should listen for lung sounds from each lobe. | Anatomy_Gray. The oblique fissure separates the inferior lobe (lower lobe) from the superior lobe and the middle lobe of the right lung. The horizontal fissure separates the superior lobe (upper lobe) from the middle lobe. The approximate position of the oblique fissure on a patient, in quiet respiration, can be marked by a curved line on the thoracic wall that begins roughly at the spinous process of the vertebra TIV level of the spine, crosses the fifth interspace laterally, and then follows the contour of rib VI anteriorly (see pp. 241–242). The horizontal fissure follows the fourth intercostal space from the sternum until it meets the oblique fissure as it crosses rib V. The orientations of the oblique and horizontal fissures determine where clinicians should listen for lung sounds from each lobe. | [
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Anatomy_Gray_364 | Anatomy_Gray | The orientations of the oblique and horizontal fissures determine where clinicians should listen for lung sounds from each lobe. The largest surface of the superior lobe is in contact with the upper part of the anterolateral wall and the apex of this lobe projects into the root of the neck. The surface of the middle lobe lies mainly adjacent to the lower anterior and lateral wall. The costal surface of the inferior lobe is in contact with the posterior and inferior walls. When listening to lung sounds from each of the lobes, it is important to position the stethoscope on those areas of the thoracic wall related to the underlying positions of the lobes (see p. 243). The medial surface of the right lung lies adjacent to a number of important structures in the mediastinum and the root of the neck (Fig. 3.45B). These include the: heart, inferior vena cava, superior vena cava, azygos vein, and esophagus. | Anatomy_Gray. The orientations of the oblique and horizontal fissures determine where clinicians should listen for lung sounds from each lobe. The largest surface of the superior lobe is in contact with the upper part of the anterolateral wall and the apex of this lobe projects into the root of the neck. The surface of the middle lobe lies mainly adjacent to the lower anterior and lateral wall. The costal surface of the inferior lobe is in contact with the posterior and inferior walls. When listening to lung sounds from each of the lobes, it is important to position the stethoscope on those areas of the thoracic wall related to the underlying positions of the lobes (see p. 243). The medial surface of the right lung lies adjacent to a number of important structures in the mediastinum and the root of the neck (Fig. 3.45B). These include the: heart, inferior vena cava, superior vena cava, azygos vein, and esophagus. | [
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Anatomy_Gray_365 | Anatomy_Gray | The right subclavian artery and vein arch over and are related to the superior lobe of the right lung as they pass over the dome of the cervical pleura and into the axilla. The left lung is smaller than the right lung and has two lobes separated by an oblique fissure (Fig. 3.46A). The oblique fissure of the left lung is slightly more oblique than the corresponding fissure of the right lung. During quiet respiration, the approximate position of the left oblique fissure can be marked by a curved line on the thoracic wall that begins between the spinous processes of vertebrae TIII and TIV, crosses the fifth interspace laterally, and follows the contour of rib VI anteriorly (see pp. 241–242). As with the right lung, the orientation of the oblique fissure determines where to listen for lung sounds from each lobe. | Anatomy_Gray. The right subclavian artery and vein arch over and are related to the superior lobe of the right lung as they pass over the dome of the cervical pleura and into the axilla. The left lung is smaller than the right lung and has two lobes separated by an oblique fissure (Fig. 3.46A). The oblique fissure of the left lung is slightly more oblique than the corresponding fissure of the right lung. During quiet respiration, the approximate position of the left oblique fissure can be marked by a curved line on the thoracic wall that begins between the spinous processes of vertebrae TIII and TIV, crosses the fifth interspace laterally, and follows the contour of rib VI anteriorly (see pp. 241–242). As with the right lung, the orientation of the oblique fissure determines where to listen for lung sounds from each lobe. | [
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Anatomy_Gray_366 | Anatomy_Gray | As with the right lung, the orientation of the oblique fissure determines where to listen for lung sounds from each lobe. The largest surface of the superior lobe is in contact with the upper part of the anterolateral wall, and the apex of this lobe projects into the root of the neck. The costal surface of the inferior lobe is in contact with the posterior and inferior walls. When listening to lung sounds from each of the lobes, the stethoscope should be placed on those areas of the thoracic wall related to the underlying positions of the lobes (see p. 243). The inferior portion of the medial surface of the left lung, unlike the right lung, is notched because of the heart’s projection into the left pleural cavity from the middle mediastinum. From the anterior border of the lower part of the superior lobe a tongue-like extension (the lingula of the left lung) projects over the heart bulge. | Anatomy_Gray. As with the right lung, the orientation of the oblique fissure determines where to listen for lung sounds from each lobe. The largest surface of the superior lobe is in contact with the upper part of the anterolateral wall, and the apex of this lobe projects into the root of the neck. The costal surface of the inferior lobe is in contact with the posterior and inferior walls. When listening to lung sounds from each of the lobes, the stethoscope should be placed on those areas of the thoracic wall related to the underlying positions of the lobes (see p. 243). The inferior portion of the medial surface of the left lung, unlike the right lung, is notched because of the heart’s projection into the left pleural cavity from the middle mediastinum. From the anterior border of the lower part of the superior lobe a tongue-like extension (the lingula of the left lung) projects over the heart bulge. | [
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Anatomy_Gray_367 | Anatomy_Gray | From the anterior border of the lower part of the superior lobe a tongue-like extension (the lingula of the left lung) projects over the heart bulge. The medial surface of the left lung lies adjacent to a number of important structures in the mediastinum and root of the neck (Fig. 3.46B). These include the: heart, aortic arch, thoracic aorta, and esophagus. The left subclavian artery and vein arch over and are related to the superior lobe of the left lung as they pass over the dome of the cervical pleura and into the axilla. | Anatomy_Gray. From the anterior border of the lower part of the superior lobe a tongue-like extension (the lingula of the left lung) projects over the heart bulge. The medial surface of the left lung lies adjacent to a number of important structures in the mediastinum and root of the neck (Fig. 3.46B). These include the: heart, aortic arch, thoracic aorta, and esophagus. The left subclavian artery and vein arch over and are related to the superior lobe of the left lung as they pass over the dome of the cervical pleura and into the axilla. | [
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Anatomy_Gray_368 | Anatomy_Gray | The left subclavian artery and vein arch over and are related to the superior lobe of the left lung as they pass over the dome of the cervical pleura and into the axilla. The trachea is a flexible tube that extends from vertebral level CVI in the lower neck to vertebral level TIV/V in the mediastinum where it bifurcates into a right and a left main bronchus (Fig. 3.47). The trachea is held open by C-shaped transverse cartilage rings embedded in its wall—the open part of the C facing posteriorly. The lowest tracheal ring has a hook-shaped structure, the carina, that projects backward in the midline between the origins of the two main bronchi. The posterior wall of the trachea is composed mainly of smooth muscle. | Anatomy_Gray. The left subclavian artery and vein arch over and are related to the superior lobe of the left lung as they pass over the dome of the cervical pleura and into the axilla. The trachea is a flexible tube that extends from vertebral level CVI in the lower neck to vertebral level TIV/V in the mediastinum where it bifurcates into a right and a left main bronchus (Fig. 3.47). The trachea is held open by C-shaped transverse cartilage rings embedded in its wall—the open part of the C facing posteriorly. The lowest tracheal ring has a hook-shaped structure, the carina, that projects backward in the midline between the origins of the two main bronchi. The posterior wall of the trachea is composed mainly of smooth muscle. | [
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Anatomy_Gray_369 | Anatomy_Gray | Each main bronchus enters the root of a lung and passes through the hilum into the lung itself. The right main bronchus is wider and takes a more vertical course through the root and hilum than the left main bronchus (Fig. 3.47A). Therefore, inhaled foreign bodies tend to lodge more frequently on the right side than on the left. The main bronchus divides within the lung into lobar bronchi (secondary bronchi), each of which supplies a lobe. On the right side, the lobar bronchus to the superior lobe originates within the root of the lung. The lobar bronchi further divide into segmental bronchi (tertiary bronchi), which supply bronchopulmonary segments (Fig. 3.47B). | Anatomy_Gray. Each main bronchus enters the root of a lung and passes through the hilum into the lung itself. The right main bronchus is wider and takes a more vertical course through the root and hilum than the left main bronchus (Fig. 3.47A). Therefore, inhaled foreign bodies tend to lodge more frequently on the right side than on the left. The main bronchus divides within the lung into lobar bronchi (secondary bronchi), each of which supplies a lobe. On the right side, the lobar bronchus to the superior lobe originates within the root of the lung. The lobar bronchi further divide into segmental bronchi (tertiary bronchi), which supply bronchopulmonary segments (Fig. 3.47B). | [
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Anatomy_Gray_370 | Anatomy_Gray | The lobar bronchi further divide into segmental bronchi (tertiary bronchi), which supply bronchopulmonary segments (Fig. 3.47B). Within each bronchopulmonary segment, the segmental bronchi give rise to multiple generations of divisions and, ultimately, to bronchioles, which further subdivide and supply the respiratory surfaces. The walls of the bronchi are held open by discontinuous elongated plates of cartilage, but these are not present in bronchioles. A bronchopulmonary segment is the area of lung supplied by a segmental bronchus and its accompanying pulmonary artery branch. Tributaries of the pulmonary vein tend to pass intersegmentally between and around the margins of segments. Each bronchopulmonary segment is shaped like an irregular cone, with the apex at the origin of the segmental bronchus and the base projected peripherally onto the surface of the lung. | Anatomy_Gray. The lobar bronchi further divide into segmental bronchi (tertiary bronchi), which supply bronchopulmonary segments (Fig. 3.47B). Within each bronchopulmonary segment, the segmental bronchi give rise to multiple generations of divisions and, ultimately, to bronchioles, which further subdivide and supply the respiratory surfaces. The walls of the bronchi are held open by discontinuous elongated plates of cartilage, but these are not present in bronchioles. A bronchopulmonary segment is the area of lung supplied by a segmental bronchus and its accompanying pulmonary artery branch. Tributaries of the pulmonary vein tend to pass intersegmentally between and around the margins of segments. Each bronchopulmonary segment is shaped like an irregular cone, with the apex at the origin of the segmental bronchus and the base projected peripherally onto the surface of the lung. | [
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Anatomy_Gray_371 | Anatomy_Gray | Each bronchopulmonary segment is shaped like an irregular cone, with the apex at the origin of the segmental bronchus and the base projected peripherally onto the surface of the lung. A bronchopulmonary segment is the smallest functionally independent region of a lung and the smallest area of lung that can be isolated and removed without affecting adjacent regions. There are ten bronchopulmonary segments in each lung (Fig. 3.48); some of them fuse in the left lung. The right and left pulmonary arteries originate from the pulmonary trunk and carry deoxygenated blood to the lungs from the right ventricle of the heart (Fig. 3.49). The bifurcation of the pulmonary trunk occurs to the left of the midline just inferior to vertebral level TIV/V, and anteroinferiorly to the left of the bifurcation of the trachea. The right pulmonary artery is longer than the left and passes horizontally across the mediastinum (Fig. 3.49). | Anatomy_Gray. Each bronchopulmonary segment is shaped like an irregular cone, with the apex at the origin of the segmental bronchus and the base projected peripherally onto the surface of the lung. A bronchopulmonary segment is the smallest functionally independent region of a lung and the smallest area of lung that can be isolated and removed without affecting adjacent regions. There are ten bronchopulmonary segments in each lung (Fig. 3.48); some of them fuse in the left lung. The right and left pulmonary arteries originate from the pulmonary trunk and carry deoxygenated blood to the lungs from the right ventricle of the heart (Fig. 3.49). The bifurcation of the pulmonary trunk occurs to the left of the midline just inferior to vertebral level TIV/V, and anteroinferiorly to the left of the bifurcation of the trachea. The right pulmonary artery is longer than the left and passes horizontally across the mediastinum (Fig. 3.49). | [
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Anatomy_Gray_372 | Anatomy_Gray | The right pulmonary artery is longer than the left and passes horizontally across the mediastinum (Fig. 3.49). It passes: anteriorly and slightly inferiorly to the tracheal bifurcation and anteriorly to the right main bronchus, and posteriorly to the ascending aorta, superior vena cava, and upper right pulmonary vein. The right pulmonary artery enters the root of the lung and gives off a large branch to the superior lobe of the lung. The main vessel continues through the hilum of the lung, gives off a second (recurrent) branch to the superior lobe, and then divides to supply the middle and inferior lobes. The left pulmonary artery is shorter than the right and lies anterior to the descending aorta and posterior to the superior pulmonary vein (Fig. 3.49). It passes through the root and hilum and branches within the lung. | Anatomy_Gray. The right pulmonary artery is longer than the left and passes horizontally across the mediastinum (Fig. 3.49). It passes: anteriorly and slightly inferiorly to the tracheal bifurcation and anteriorly to the right main bronchus, and posteriorly to the ascending aorta, superior vena cava, and upper right pulmonary vein. The right pulmonary artery enters the root of the lung and gives off a large branch to the superior lobe of the lung. The main vessel continues through the hilum of the lung, gives off a second (recurrent) branch to the superior lobe, and then divides to supply the middle and inferior lobes. The left pulmonary artery is shorter than the right and lies anterior to the descending aorta and posterior to the superior pulmonary vein (Fig. 3.49). It passes through the root and hilum and branches within the lung. | [
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Anatomy_Gray_373 | Anatomy_Gray | On each side a superior pulmonary vein and an inferior pulmonary vein carry oxygenated blood from the lungs back to the heart (Fig. 3.49). The veins begin at the hilum of the lung, pass through the root of the lung, and immediately drain into the left atrium. The bronchial arteries (Fig. 3.49) and veins constitute the “nutritive” vascular system of the pulmonary tissues (bronchial walls and glands, walls of large vessels, and visceral pleura). They interconnect within the lung with branches of the pulmonary arteries and veins. The bronchial arteries originate from the thoracic aorta or one of its branches: A single right bronchial artery normally arises from the third posterior intercostal artery (but occasionally, it originates from the upper left bronchial artery). Two left bronchial arteries arise directly from the anterior surface of the thoracic aorta—the superior left bronchial artery arises at vertebral level TV, and the inferior one inferior to the left bronchus. | Anatomy_Gray. On each side a superior pulmonary vein and an inferior pulmonary vein carry oxygenated blood from the lungs back to the heart (Fig. 3.49). The veins begin at the hilum of the lung, pass through the root of the lung, and immediately drain into the left atrium. The bronchial arteries (Fig. 3.49) and veins constitute the “nutritive” vascular system of the pulmonary tissues (bronchial walls and glands, walls of large vessels, and visceral pleura). They interconnect within the lung with branches of the pulmonary arteries and veins. The bronchial arteries originate from the thoracic aorta or one of its branches: A single right bronchial artery normally arises from the third posterior intercostal artery (but occasionally, it originates from the upper left bronchial artery). Two left bronchial arteries arise directly from the anterior surface of the thoracic aorta—the superior left bronchial artery arises at vertebral level TV, and the inferior one inferior to the left bronchus. | [
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Anatomy_Gray_374 | Anatomy_Gray | The bronchial arteries run on the posterior surfaces of the bronchi and ramify in the lungs to supply pulmonary tissues. The bronchial veins drain into: either the pulmonary veins or the left atrium, and into the azygos vein on the right or into the superior intercostal vein or hemiazygos vein on the left. Structures of the lung and the visceral pleura are supplied by visceral afferents and efferents distributed through the anterior pulmonary plexus and posterior pulmonary plexus (Fig. 3.50). These interconnected plexuses lie anteriorly and posteriorly to the tracheal bifurcation and main bronchi. The anterior plexus is much smaller than the posterior plexus. Branches of these plexuses, which ultimately originate from the sympathetic trunks and vagus nerves, are distributed along branches of the airway and vessels. Visceral efferents from: the vagus nerves constrict the bronchioles; the sympathetic system dilates the bronchioles. | Anatomy_Gray. The bronchial arteries run on the posterior surfaces of the bronchi and ramify in the lungs to supply pulmonary tissues. The bronchial veins drain into: either the pulmonary veins or the left atrium, and into the azygos vein on the right or into the superior intercostal vein or hemiazygos vein on the left. Structures of the lung and the visceral pleura are supplied by visceral afferents and efferents distributed through the anterior pulmonary plexus and posterior pulmonary plexus (Fig. 3.50). These interconnected plexuses lie anteriorly and posteriorly to the tracheal bifurcation and main bronchi. The anterior plexus is much smaller than the posterior plexus. Branches of these plexuses, which ultimately originate from the sympathetic trunks and vagus nerves, are distributed along branches of the airway and vessels. Visceral efferents from: the vagus nerves constrict the bronchioles; the sympathetic system dilates the bronchioles. | [
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Anatomy_Gray_375 | Anatomy_Gray | Visceral efferents from: the vagus nerves constrict the bronchioles; the sympathetic system dilates the bronchioles. Superficial, or subpleural, and deep lymphatics of the lung drain into lymph nodes called tracheobronchial nodes around the roots of lobar and main bronchi and along the sides of the trachea (Fig. 3.51). As a group, these lymph nodes extend from within the lung, through the hilum and root, and into the posterior mediastinum. Efferent vessels from these nodes pass superiorly along the trachea to unite with similar vessels from parasternal nodes and brachiocephalic nodes, which are anterior to brachiocephalic veins in the superior mediastinum, to form the right and left bronchomediastinal trunks. These trunks drain directly into deep veins at the base of the neck, or may drain into the right lymphatic trunk or thoracic duct. | Anatomy_Gray. Visceral efferents from: the vagus nerves constrict the bronchioles; the sympathetic system dilates the bronchioles. Superficial, or subpleural, and deep lymphatics of the lung drain into lymph nodes called tracheobronchial nodes around the roots of lobar and main bronchi and along the sides of the trachea (Fig. 3.51). As a group, these lymph nodes extend from within the lung, through the hilum and root, and into the posterior mediastinum. Efferent vessels from these nodes pass superiorly along the trachea to unite with similar vessels from parasternal nodes and brachiocephalic nodes, which are anterior to brachiocephalic veins in the superior mediastinum, to form the right and left bronchomediastinal trunks. These trunks drain directly into deep veins at the base of the neck, or may drain into the right lymphatic trunk or thoracic duct. | [
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Anatomy_Gray_376 | Anatomy_Gray | The mediastinum is a broad central partition that separates the two laterally placed pleural cavities (Fig. 3.55). It extends: from the sternum to the bodies of the vertebrae, and from the superior thoracic aperture to the diaphragm (Fig. 3.56). The mediastinum contains the thymus gland, the pericardial sac, the heart, the trachea, and the major arteries and veins. Additionally, the mediastinum serves as a passageway for structures such as the esophagus, thoracic duct, and various components of the nervous system as they traverse the thorax on their way to the abdomen. | Anatomy_Gray. The mediastinum is a broad central partition that separates the two laterally placed pleural cavities (Fig. 3.55). It extends: from the sternum to the bodies of the vertebrae, and from the superior thoracic aperture to the diaphragm (Fig. 3.56). The mediastinum contains the thymus gland, the pericardial sac, the heart, the trachea, and the major arteries and veins. Additionally, the mediastinum serves as a passageway for structures such as the esophagus, thoracic duct, and various components of the nervous system as they traverse the thorax on their way to the abdomen. | [
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Anatomy_Gray_377 | Anatomy_Gray | For organizational purposes, the mediastinum is subdivided into several smaller regions. A transverse plane extending from the sternal angle (the junction between the manubrium and the body of the sternum) to the intervertebral disc between vertebrae TIV and TV separates the mediastinum into the: superior mediastinum, and inferior mediastinum, which is further partitioned into the anterior, middle, and posterior mediastinum by the pericardial sac. The area anterior to the pericardial sac and posterior to the body of the sternum is the anterior mediastinum. The region posterior to the pericardial sac and the diaphragm and anterior to the bodies of the vertebrae is the posterior mediastinum. The area in the middle, which includes the pericardial sac and its contents, is the middle mediastinum (Fig. 3.57). The anterior mediastinum is posterior to the body of the sternum and anterior to the pericardial sac (see Fig. 3.57). | Anatomy_Gray. For organizational purposes, the mediastinum is subdivided into several smaller regions. A transverse plane extending from the sternal angle (the junction between the manubrium and the body of the sternum) to the intervertebral disc between vertebrae TIV and TV separates the mediastinum into the: superior mediastinum, and inferior mediastinum, which is further partitioned into the anterior, middle, and posterior mediastinum by the pericardial sac. The area anterior to the pericardial sac and posterior to the body of the sternum is the anterior mediastinum. The region posterior to the pericardial sac and the diaphragm and anterior to the bodies of the vertebrae is the posterior mediastinum. The area in the middle, which includes the pericardial sac and its contents, is the middle mediastinum (Fig. 3.57). The anterior mediastinum is posterior to the body of the sternum and anterior to the pericardial sac (see Fig. 3.57). | [
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Anatomy_Gray_378 | Anatomy_Gray | The anterior mediastinum is posterior to the body of the sternum and anterior to the pericardial sac (see Fig. 3.57). Its superior boundary is a transverse plane passing from the sternal angle to the intervertebral disc between vertebra TIV and TV, separating it from the superior mediastinum. Its inferior boundary is the diaphragm. Laterally, it is bordered by the mediastinal part of parietal pleura on either side. The major structure in the anterior mediastinum is an inferior extension of the thymus gland (Fig. 3.58). Also present are fat, connective tissue, lymph nodes, mediastinal branches of the internal thoracic vessels, and sternopericardial ligaments, which pass from the posterior surface of the body of the sternum to the fibrous pericardium. The middle mediastinum is centrally located in the thoracic cavity. It contains the pericardium, heart, origins of the great vessels, various nerves, and smaller vessels. | Anatomy_Gray. The anterior mediastinum is posterior to the body of the sternum and anterior to the pericardial sac (see Fig. 3.57). Its superior boundary is a transverse plane passing from the sternal angle to the intervertebral disc between vertebra TIV and TV, separating it from the superior mediastinum. Its inferior boundary is the diaphragm. Laterally, it is bordered by the mediastinal part of parietal pleura on either side. The major structure in the anterior mediastinum is an inferior extension of the thymus gland (Fig. 3.58). Also present are fat, connective tissue, lymph nodes, mediastinal branches of the internal thoracic vessels, and sternopericardial ligaments, which pass from the posterior surface of the body of the sternum to the fibrous pericardium. The middle mediastinum is centrally located in the thoracic cavity. It contains the pericardium, heart, origins of the great vessels, various nerves, and smaller vessels. | [
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Anatomy_Gray_379 | Anatomy_Gray | The middle mediastinum is centrally located in the thoracic cavity. It contains the pericardium, heart, origins of the great vessels, various nerves, and smaller vessels. The pericardium is a fibroserous sac surrounding the heart and the roots of the great vessels. It consists of two components, the fibrous pericardium and the serous pericardium (Fig. 3.59). The fibrous pericardium is a tough connective tissue outer layer that defines the boundaries of the middle mediastinum. The serous pericardium is thin and consists of two parts: The parietal layer of serous pericardium lines the inner surface of the fibrous pericardium. The visceral layer (epicardium) of serous pericardium adheres to the heart and forms its outer covering. | Anatomy_Gray. The middle mediastinum is centrally located in the thoracic cavity. It contains the pericardium, heart, origins of the great vessels, various nerves, and smaller vessels. The pericardium is a fibroserous sac surrounding the heart and the roots of the great vessels. It consists of two components, the fibrous pericardium and the serous pericardium (Fig. 3.59). The fibrous pericardium is a tough connective tissue outer layer that defines the boundaries of the middle mediastinum. The serous pericardium is thin and consists of two parts: The parietal layer of serous pericardium lines the inner surface of the fibrous pericardium. The visceral layer (epicardium) of serous pericardium adheres to the heart and forms its outer covering. | [
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Anatomy_Gray_380 | Anatomy_Gray | The parietal layer of serous pericardium lines the inner surface of the fibrous pericardium. The visceral layer (epicardium) of serous pericardium adheres to the heart and forms its outer covering. The parietal and visceral layers of serous pericardium are continuous at the roots of the great vessels. The narrow space created between the two layers of serous pericardium, containing a small amount of fluid, is the pericardial cavity. This potential space allows for the relatively uninhibited movement of the heart. | Anatomy_Gray. The parietal layer of serous pericardium lines the inner surface of the fibrous pericardium. The visceral layer (epicardium) of serous pericardium adheres to the heart and forms its outer covering. The parietal and visceral layers of serous pericardium are continuous at the roots of the great vessels. The narrow space created between the two layers of serous pericardium, containing a small amount of fluid, is the pericardial cavity. This potential space allows for the relatively uninhibited movement of the heart. | [
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Anatomy_Gray_381 | Anatomy_Gray | The fibrous pericardium is a cone-shaped bag with its base on the diaphragm and its apex continuous with the adventitia of the great vessels (Fig. 3.59). The base is attached to the central tendon of the diaphragm and to a small muscular area of the diaphragm on the left side. Anteriorly, it is attached to the posterior surface of the sternum by sternopericardial ligaments. These attachments help to retain the heart in its position in the thoracic cavity. The sac also limits cardiac distention. | Anatomy_Gray. The fibrous pericardium is a cone-shaped bag with its base on the diaphragm and its apex continuous with the adventitia of the great vessels (Fig. 3.59). The base is attached to the central tendon of the diaphragm and to a small muscular area of the diaphragm on the left side. Anteriorly, it is attached to the posterior surface of the sternum by sternopericardial ligaments. These attachments help to retain the heart in its position in the thoracic cavity. The sac also limits cardiac distention. | [
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Anatomy_Gray_382 | Anatomy_Gray | The phrenic nerves, which innervate the diaphragm and originate from spinal cord levels C3 to C5, pass through the fibrous pericardium and innervate the fibrous pericardium as they travel from their point of origin to their final destination (Fig. 3.60). Their location, within the fibrous pericardium, is directly related to the embryological origin of the diaphragm and the changes that occur during the formation of the pericardial cavity. Similarly, the pericardiacophrenic vessels are also located within and supply the fibrous pericardium as they pass through the thoracic cavity. The parietal layer of serous pericardium is continuous with the visceral layer of serous pericardium around the roots of the great vessels. These reflections of serous pericardium (Fig. 3.61) occur in two locations: one superiorly, surrounding the arteries—the aorta and the pulmonary trunk; the second more posteriorly, surrounding the veins—the superior and inferior vena cava and the pulmonary veins. | Anatomy_Gray. The phrenic nerves, which innervate the diaphragm and originate from spinal cord levels C3 to C5, pass through the fibrous pericardium and innervate the fibrous pericardium as they travel from their point of origin to their final destination (Fig. 3.60). Their location, within the fibrous pericardium, is directly related to the embryological origin of the diaphragm and the changes that occur during the formation of the pericardial cavity. Similarly, the pericardiacophrenic vessels are also located within and supply the fibrous pericardium as they pass through the thoracic cavity. The parietal layer of serous pericardium is continuous with the visceral layer of serous pericardium around the roots of the great vessels. These reflections of serous pericardium (Fig. 3.61) occur in two locations: one superiorly, surrounding the arteries—the aorta and the pulmonary trunk; the second more posteriorly, surrounding the veins—the superior and inferior vena cava and the pulmonary veins. | [
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Anatomy_Gray_383 | Anatomy_Gray | The zone of reflection surrounding the veins is J-shaped, and the cul-de-sac formed within the J, posterior to the left atrium, is the oblique pericardial sinus. A passage between the two sites of reflected serous pericardium is the transverse pericardial sinus. This sinus lies posterior to the ascending aorta and the pulmonary trunk, anterior to the superior vena cava, and superior to the left atrium. When the pericardium is opened anteriorly during surgery, a finger placed in the transverse sinus separates arteries from veins. A hand placed under the apex of the heart and moved superiorly slips into the oblique sinus. The pericardium is supplied by branches from the internal thoracic, pericardiacophrenic, musculophrenic, and inferior phrenic arteries, and the thoracic aorta. Veins from the pericardium enter the azygos system of veins and the internal thoracic and superior phrenic veins. | Anatomy_Gray. The zone of reflection surrounding the veins is J-shaped, and the cul-de-sac formed within the J, posterior to the left atrium, is the oblique pericardial sinus. A passage between the two sites of reflected serous pericardium is the transverse pericardial sinus. This sinus lies posterior to the ascending aorta and the pulmonary trunk, anterior to the superior vena cava, and superior to the left atrium. When the pericardium is opened anteriorly during surgery, a finger placed in the transverse sinus separates arteries from veins. A hand placed under the apex of the heart and moved superiorly slips into the oblique sinus. The pericardium is supplied by branches from the internal thoracic, pericardiacophrenic, musculophrenic, and inferior phrenic arteries, and the thoracic aorta. Veins from the pericardium enter the azygos system of veins and the internal thoracic and superior phrenic veins. | [
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Anatomy_Gray_384 | Anatomy_Gray | Veins from the pericardium enter the azygos system of veins and the internal thoracic and superior phrenic veins. Nerves supplying the pericardium arise from the vagus nerve [X], the sympathetic trunks, and the phrenic nerves. It is important to note that the source of somatic sensation (pain) from the parietal pericardium is carried by somatic afferent fibers in the phrenic nerves. For this reason, “pain” related to a pericardial problem may be referred to the supraclavicular region of the shoulder or lateral neck area dermatomes for spinal cord segments C3, C4, and C5. | Anatomy_Gray. Veins from the pericardium enter the azygos system of veins and the internal thoracic and superior phrenic veins. Nerves supplying the pericardium arise from the vagus nerve [X], the sympathetic trunks, and the phrenic nerves. It is important to note that the source of somatic sensation (pain) from the parietal pericardium is carried by somatic afferent fibers in the phrenic nerves. For this reason, “pain” related to a pericardial problem may be referred to the supraclavicular region of the shoulder or lateral neck area dermatomes for spinal cord segments C3, C4, and C5. | [
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Anatomy_Gray_385 | Anatomy_Gray | C3, C4, and C5. The general shape and orientation of the heart are that of a pyramid that has fallen over and is resting on one of its sides. Placed in the thoracic cavity, the apex of this pyramid projects forward, downward, and to the left, whereas the base is opposite the apex and faces in a posterior direction (Fig. 3.63). The sides of the pyramid consist of: a diaphragmatic (inferior) surface on which the pyramid rests, an anterior (sternocostal) surface oriented anteriorly, a right pulmonary surface, and a left pulmonary surface. The base of the heart is quadrilateral and directed posteriorly. It consists of: the left atrium, a small portion of the right atrium, and the proximal parts of the great veins (superior and inferior venae cavae and the pulmonary veins) (Fig. 3.64). | Anatomy_Gray. C3, C4, and C5. The general shape and orientation of the heart are that of a pyramid that has fallen over and is resting on one of its sides. Placed in the thoracic cavity, the apex of this pyramid projects forward, downward, and to the left, whereas the base is opposite the apex and faces in a posterior direction (Fig. 3.63). The sides of the pyramid consist of: a diaphragmatic (inferior) surface on which the pyramid rests, an anterior (sternocostal) surface oriented anteriorly, a right pulmonary surface, and a left pulmonary surface. The base of the heart is quadrilateral and directed posteriorly. It consists of: the left atrium, a small portion of the right atrium, and the proximal parts of the great veins (superior and inferior venae cavae and the pulmonary veins) (Fig. 3.64). | [
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Anatomy_Gray_386 | Anatomy_Gray | Because the great veins enter the base of the heart, with the pulmonary veins entering the right and left sides of the left atrium and the superior and inferior venae cavae at the upper and lower ends of the right atrium, the base of the heart is fixed posteriorly to the pericardial wall, opposite the bodies of vertebrae TV to TVIII (TVI to TIX when standing). The esophagus lies immediately posterior to the base. From the base the heart projects forward, downward, and to the left, ending in the apex. The apex of the heart is formed by the inferolateral part of the left ventricle (Fig. 3.65) and is positioned deep to the left fifth intercostal space, 8 to 9 cm from the midsternal line. Surfaces of the heart The anterior surface faces anteriorly and consists mostly of the right ventricle, with some of the right atrium on the right and some of the left ventricle on the left (Fig. 3.65). | Anatomy_Gray. Because the great veins enter the base of the heart, with the pulmonary veins entering the right and left sides of the left atrium and the superior and inferior venae cavae at the upper and lower ends of the right atrium, the base of the heart is fixed posteriorly to the pericardial wall, opposite the bodies of vertebrae TV to TVIII (TVI to TIX when standing). The esophagus lies immediately posterior to the base. From the base the heart projects forward, downward, and to the left, ending in the apex. The apex of the heart is formed by the inferolateral part of the left ventricle (Fig. 3.65) and is positioned deep to the left fifth intercostal space, 8 to 9 cm from the midsternal line. Surfaces of the heart The anterior surface faces anteriorly and consists mostly of the right ventricle, with some of the right atrium on the right and some of the left ventricle on the left (Fig. 3.65). | [
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Anatomy_Gray_387 | Anatomy_Gray | The anterior surface faces anteriorly and consists mostly of the right ventricle, with some of the right atrium on the right and some of the left ventricle on the left (Fig. 3.65). The heart in the anatomical position rests on the diaphragmatic surface, which consists of the left ventricle and a small portion of the right ventricle separated by the posterior interventricular groove (Fig. 3.66). This surface faces inferiorly, rests on the diaphragm, is separated from the base of the heart by the coronary sinus, and extends from the base to the apex of the heart. The left pulmonary surface faces the left lung, is broad and convex, and consists of the left ventricle and a portion of the left atrium (Fig. 3.66). The right pulmonary surface faces the right lung, is broad and convex, and consists of the right atrium (Fig. 3.66). Some general descriptions of cardiac orientation refer to right, left, inferior (acute), and obtuse margins: | Anatomy_Gray. The anterior surface faces anteriorly and consists mostly of the right ventricle, with some of the right atrium on the right and some of the left ventricle on the left (Fig. 3.65). The heart in the anatomical position rests on the diaphragmatic surface, which consists of the left ventricle and a small portion of the right ventricle separated by the posterior interventricular groove (Fig. 3.66). This surface faces inferiorly, rests on the diaphragm, is separated from the base of the heart by the coronary sinus, and extends from the base to the apex of the heart. The left pulmonary surface faces the left lung, is broad and convex, and consists of the left ventricle and a portion of the left atrium (Fig. 3.66). The right pulmonary surface faces the right lung, is broad and convex, and consists of the right atrium (Fig. 3.66). Some general descriptions of cardiac orientation refer to right, left, inferior (acute), and obtuse margins: | [
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Anatomy_Gray_388 | Anatomy_Gray | Some general descriptions of cardiac orientation refer to right, left, inferior (acute), and obtuse margins: The right and left margins are the same as the right and left pulmonary surfaces of the heart. The inferior margin is defined as the sharp edge between the anterior and diaphragmatic surfaces of the heart (Figs 3.63 and 3.65)—it is formed mostly by the right ventricle and a small portion of the left ventricle near the apex. The obtuse margin separates the anterior and left pulmonary surfaces (Fig. 3.63)—it is round and extends from the left auricle to the cardiac apex (Fig. 3.65), and is formed mostly by the left ventricle and superiorly by a small portion of the left auricle. | Anatomy_Gray. Some general descriptions of cardiac orientation refer to right, left, inferior (acute), and obtuse margins: The right and left margins are the same as the right and left pulmonary surfaces of the heart. The inferior margin is defined as the sharp edge between the anterior and diaphragmatic surfaces of the heart (Figs 3.63 and 3.65)—it is formed mostly by the right ventricle and a small portion of the left ventricle near the apex. The obtuse margin separates the anterior and left pulmonary surfaces (Fig. 3.63)—it is round and extends from the left auricle to the cardiac apex (Fig. 3.65), and is formed mostly by the left ventricle and superiorly by a small portion of the left auricle. | [
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Anatomy_Gray_389 | Anatomy_Gray | For radiological evaluations, a thorough understanding of the structures defining the cardiac borders is critical. The right border in a standard posteroanterior view consists of the superior vena cava, the right atrium, and the inferior vena cava (Fig. 3.67A). The left border in a similar view consists of the arch of the aorta, the pulmonary trunk, left auricle, and the left ventricle. The inferior border in this radiological study consists of the right ventricle and the left ventricle at the apex. In lateral views, the right ventricle is seen anteriorly, and the left atrium is visualized posteriorly (Fig. 3.67B). Internal partitions divide the heart into four chambers (i.e., two atria and two ventricles) and produce surface or external grooves referred to as sulci. | Anatomy_Gray. For radiological evaluations, a thorough understanding of the structures defining the cardiac borders is critical. The right border in a standard posteroanterior view consists of the superior vena cava, the right atrium, and the inferior vena cava (Fig. 3.67A). The left border in a similar view consists of the arch of the aorta, the pulmonary trunk, left auricle, and the left ventricle. The inferior border in this radiological study consists of the right ventricle and the left ventricle at the apex. In lateral views, the right ventricle is seen anteriorly, and the left atrium is visualized posteriorly (Fig. 3.67B). Internal partitions divide the heart into four chambers (i.e., two atria and two ventricles) and produce surface or external grooves referred to as sulci. | [
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Anatomy_Gray_390 | Anatomy_Gray | Internal partitions divide the heart into four chambers (i.e., two atria and two ventricles) and produce surface or external grooves referred to as sulci. The coronary sulcus circles the heart, separating the atria from the ventricles (Fig. 3.68). As it circles the heart, it contains the right coronary artery, the small cardiac vein, the coronary sinus, and the circumflex branch of the left coronary artery. The anterior and posterior interventricular sulci separate the two ventricles—the anterior interventricular sulcus is on the anterior surface of the heart and contains the anterior interventricular artery and the great cardiac vein, and the posterior interventricular sulcus is on the diaphragmatic surface of the heart and contains the posterior interventricular artery and the middle cardiac vein. These sulci are continuous inferiorly, just to the right of the apex of the heart. | Anatomy_Gray. Internal partitions divide the heart into four chambers (i.e., two atria and two ventricles) and produce surface or external grooves referred to as sulci. The coronary sulcus circles the heart, separating the atria from the ventricles (Fig. 3.68). As it circles the heart, it contains the right coronary artery, the small cardiac vein, the coronary sinus, and the circumflex branch of the left coronary artery. The anterior and posterior interventricular sulci separate the two ventricles—the anterior interventricular sulcus is on the anterior surface of the heart and contains the anterior interventricular artery and the great cardiac vein, and the posterior interventricular sulcus is on the diaphragmatic surface of the heart and contains the posterior interventricular artery and the middle cardiac vein. These sulci are continuous inferiorly, just to the right of the apex of the heart. | [
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Anatomy_Gray_391 | Anatomy_Gray | These sulci are continuous inferiorly, just to the right of the apex of the heart. The heart functionally consists of two pumps separated by a partition (Fig. 3.69A). The right pump receives deoxygenated blood from the body and sends it to the lungs. The left pump receives oxygenated blood from the lungs and sends it to the body. Each pump consists of an atrium and a ventricle separated by a valve. The thin-walled atria receive blood coming into the heart, whereas the relatively thick-walled ventricles pump blood out of the heart. More force is required to pump blood through the body than through the lungs, so the muscular wall of the left ventricle is thicker than the right. Interatrial, interventricular, and atrioventricular septa separate the four chambers of the heart (Fig. 3.69B). The internal anatomy of each chamber is critical to its function. | Anatomy_Gray. These sulci are continuous inferiorly, just to the right of the apex of the heart. The heart functionally consists of two pumps separated by a partition (Fig. 3.69A). The right pump receives deoxygenated blood from the body and sends it to the lungs. The left pump receives oxygenated blood from the lungs and sends it to the body. Each pump consists of an atrium and a ventricle separated by a valve. The thin-walled atria receive blood coming into the heart, whereas the relatively thick-walled ventricles pump blood out of the heart. More force is required to pump blood through the body than through the lungs, so the muscular wall of the left ventricle is thicker than the right. Interatrial, interventricular, and atrioventricular septa separate the four chambers of the heart (Fig. 3.69B). The internal anatomy of each chamber is critical to its function. | [
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Anatomy_Gray_392 | Anatomy_Gray | Interatrial, interventricular, and atrioventricular septa separate the four chambers of the heart (Fig. 3.69B). The internal anatomy of each chamber is critical to its function. In the anatomical position, the right border of the heart is formed by the right atrium. This chamber also contributes to the right portion of the heart’s anterior surface. Blood returning to the right atrium enters through one of three vessels. These are: the superior and inferior venae cavae, which together deliver blood to the heart from the body; and the coronary sinus, which returns blood from the walls of the heart itself. The superior vena cava enters the upper posterior portion of the right atrium, and the inferior vena cava and coronary sinus enter the lower posterior portion of the right atrium. | Anatomy_Gray. Interatrial, interventricular, and atrioventricular septa separate the four chambers of the heart (Fig. 3.69B). The internal anatomy of each chamber is critical to its function. In the anatomical position, the right border of the heart is formed by the right atrium. This chamber also contributes to the right portion of the heart’s anterior surface. Blood returning to the right atrium enters through one of three vessels. These are: the superior and inferior venae cavae, which together deliver blood to the heart from the body; and the coronary sinus, which returns blood from the walls of the heart itself. The superior vena cava enters the upper posterior portion of the right atrium, and the inferior vena cava and coronary sinus enter the lower posterior portion of the right atrium. | [
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Anatomy_Gray_393 | Anatomy_Gray | The superior vena cava enters the upper posterior portion of the right atrium, and the inferior vena cava and coronary sinus enter the lower posterior portion of the right atrium. From the right atrium, blood passes into the right ventricle through the right atrioventricular orifice. This opening faces forward and medially and is closed during ventricular contraction by the tricuspid valve. The interior of the right atrium is divided into two continuous spaces. Externally, this separation is indicated by a shallow, vertical groove (the sulcus terminalis cordis), which extends from the right side of the opening of the superior vena cava to the right side of the opening of the inferior vena cava. Internally, this division is indicated by the crista terminalis (Fig. 3.70), which is a smooth, muscular ridge that begins on the roof of the atrium just in front of the opening of the superior vena cava and extends down the lateral wall to the anterior lip of the inferior vena cava. | Anatomy_Gray. The superior vena cava enters the upper posterior portion of the right atrium, and the inferior vena cava and coronary sinus enter the lower posterior portion of the right atrium. From the right atrium, blood passes into the right ventricle through the right atrioventricular orifice. This opening faces forward and medially and is closed during ventricular contraction by the tricuspid valve. The interior of the right atrium is divided into two continuous spaces. Externally, this separation is indicated by a shallow, vertical groove (the sulcus terminalis cordis), which extends from the right side of the opening of the superior vena cava to the right side of the opening of the inferior vena cava. Internally, this division is indicated by the crista terminalis (Fig. 3.70), which is a smooth, muscular ridge that begins on the roof of the atrium just in front of the opening of the superior vena cava and extends down the lateral wall to the anterior lip of the inferior vena cava. | [
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Anatomy_Gray_394 | Anatomy_Gray | The space posterior to the crista is the sinus of venae cavae and is derived embryologically from the right horn of the sinus venosus. This component of the right atrium has smooth, thin walls, and both venae cavae empty into this space. The space anterior to the crista, including the right auricle, is sometimes referred to as the atrium proper. This terminology is based on its origin from the embryonic primitive atrium. Its walls are covered by ridges called the musculi pectinati (pectinate muscles), which fan out from the crista like the “teeth of a comb.” These ridges are also found in the right auricle, which is an ear-like, conical, muscular pouch that externally overlaps the ascending aorta. | Anatomy_Gray. The space posterior to the crista is the sinus of venae cavae and is derived embryologically from the right horn of the sinus venosus. This component of the right atrium has smooth, thin walls, and both venae cavae empty into this space. The space anterior to the crista, including the right auricle, is sometimes referred to as the atrium proper. This terminology is based on its origin from the embryonic primitive atrium. Its walls are covered by ridges called the musculi pectinati (pectinate muscles), which fan out from the crista like the “teeth of a comb.” These ridges are also found in the right auricle, which is an ear-like, conical, muscular pouch that externally overlaps the ascending aorta. | [
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Anatomy_Gray_395 | Anatomy_Gray | An additional structure in the right atrium is the opening of the coronary sinus, which receives blood from most of the cardiac veins and opens medially to the opening of the inferior vena cava. Associated with these openings are small folds of tissue derived from the valve of the embryonic sinus venosus (the valve of the coronary sinus and the valve of inferior vena cava, respectively). During development, the valve of the inferior vena cava helps direct incoming oxygenated blood through the foramen ovale and into the left atrium. Separating the right atrium from the left atrium is the interatrial septum, which faces forward and to the right because the left atrium lies posteriorly and to the left of the right atrium. A depression is clearly visible in the septum just above the orifice of the inferior vena cava. This is the fossa ovalis (oval fossa), with its prominent margin, the limbus fossa ovalis (border of the oval fossa). | Anatomy_Gray. An additional structure in the right atrium is the opening of the coronary sinus, which receives blood from most of the cardiac veins and opens medially to the opening of the inferior vena cava. Associated with these openings are small folds of tissue derived from the valve of the embryonic sinus venosus (the valve of the coronary sinus and the valve of inferior vena cava, respectively). During development, the valve of the inferior vena cava helps direct incoming oxygenated blood through the foramen ovale and into the left atrium. Separating the right atrium from the left atrium is the interatrial septum, which faces forward and to the right because the left atrium lies posteriorly and to the left of the right atrium. A depression is clearly visible in the septum just above the orifice of the inferior vena cava. This is the fossa ovalis (oval fossa), with its prominent margin, the limbus fossa ovalis (border of the oval fossa). | [
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Anatomy_Gray_396 | Anatomy_Gray | The fossa ovalis marks the location of the embryonic foramen ovale, which is an important part of fetal circulation. The foramen ovale allows oxygenated blood entering the right atrium through the inferior vena cava to pass directly to the left atrium and so bypass the lungs, which are nonfunctional before birth. Finally, numerous small openings—the openings of the smallest cardiac veins (the foramina of the venae cordis minimae)—are scattered along the walls of the right atrium. These are small veins that drain the myocardium directly into the right atrium. In the anatomical position, the right ventricle forms most of the anterior surface of the heart and a portion of the diaphragmatic surface. The right atrium is to the right of the right ventricle and the right ventricle is located in front of and to the left of the right atrioventricular orifice. Blood entering the right ventricle from the right atrium therefore moves in a horizontal and forward direction. | Anatomy_Gray. The fossa ovalis marks the location of the embryonic foramen ovale, which is an important part of fetal circulation. The foramen ovale allows oxygenated blood entering the right atrium through the inferior vena cava to pass directly to the left atrium and so bypass the lungs, which are nonfunctional before birth. Finally, numerous small openings—the openings of the smallest cardiac veins (the foramina of the venae cordis minimae)—are scattered along the walls of the right atrium. These are small veins that drain the myocardium directly into the right atrium. In the anatomical position, the right ventricle forms most of the anterior surface of the heart and a portion of the diaphragmatic surface. The right atrium is to the right of the right ventricle and the right ventricle is located in front of and to the left of the right atrioventricular orifice. Blood entering the right ventricle from the right atrium therefore moves in a horizontal and forward direction. | [
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Anatomy_Gray_397 | Anatomy_Gray | The outflow tract of the right ventricle, which leads to the pulmonary trunk, is the conus arteriosus (infundibulum). This area has smooth walls and derives from the embryonic bulbus cordis. The walls of the inflow portion of the right ventricle have numerous muscular, irregular structures called trabeculae carneae (Fig. 3.71). Most of these are either attached to the ventricular walls throughout their length, forming ridges, or attached at both ends, forming bridges. A few trabeculae carneae (papillary muscles) have only one end attached to the ventricular surface, while the other end serves as the point of attachment for tendon-like fibrous cords (the chordae tendineae), which connect to the free edges of the cusps of the tricuspid valve. There are three papillary muscles in the right ventricle. Named relative to their point of origin on the ventricular surface, they are the anterior, posterior, and septal papillary muscles: | Anatomy_Gray. The outflow tract of the right ventricle, which leads to the pulmonary trunk, is the conus arteriosus (infundibulum). This area has smooth walls and derives from the embryonic bulbus cordis. The walls of the inflow portion of the right ventricle have numerous muscular, irregular structures called trabeculae carneae (Fig. 3.71). Most of these are either attached to the ventricular walls throughout their length, forming ridges, or attached at both ends, forming bridges. A few trabeculae carneae (papillary muscles) have only one end attached to the ventricular surface, while the other end serves as the point of attachment for tendon-like fibrous cords (the chordae tendineae), which connect to the free edges of the cusps of the tricuspid valve. There are three papillary muscles in the right ventricle. Named relative to their point of origin on the ventricular surface, they are the anterior, posterior, and septal papillary muscles: | [
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Anatomy_Gray_398 | Anatomy_Gray | There are three papillary muscles in the right ventricle. Named relative to their point of origin on the ventricular surface, they are the anterior, posterior, and septal papillary muscles: The anterior papillary muscle is the largest and most constant papillary muscle, and arises from the anterior wall of the ventricle. The posterior papillary muscle may consist of one, two, or three structures, with some chordae tendineae arising directly from the ventricular wall. The septal papillary muscle is the most inconsistent papillary muscle, being either small or absent, with chordae tendineae emerging directly from the septal wall. | Anatomy_Gray. There are three papillary muscles in the right ventricle. Named relative to their point of origin on the ventricular surface, they are the anterior, posterior, and septal papillary muscles: The anterior papillary muscle is the largest and most constant papillary muscle, and arises from the anterior wall of the ventricle. The posterior papillary muscle may consist of one, two, or three structures, with some chordae tendineae arising directly from the ventricular wall. The septal papillary muscle is the most inconsistent papillary muscle, being either small or absent, with chordae tendineae emerging directly from the septal wall. | [
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Anatomy_Gray_399 | Anatomy_Gray | The septal papillary muscle is the most inconsistent papillary muscle, being either small or absent, with chordae tendineae emerging directly from the septal wall. A single specialized trabeculum, the septomarginal trabecula (moderator band), forms a bridge between the lower portion of the interventricular septum and the base of the anterior papillary muscle. The septomarginal trabecula carries a portion of the cardiac conduction system, the right bundle of the atrioventricular bundle, to the anterior wall of the right ventricle. The right atrioventricular orifice is closed during ventricular contraction by the tricuspid valve (right atrioventricular valve), so named because it usually consists of three cusps or leaflets (Fig. 3.71). The base of each cusp is secured to the fibrous ring that surrounds the atrioventricular orifice. This fibrous ring helps to maintain the shape of the opening. The cusps are continuous with each other near their bases at sites termed commissures. | Anatomy_Gray. The septal papillary muscle is the most inconsistent papillary muscle, being either small or absent, with chordae tendineae emerging directly from the septal wall. A single specialized trabeculum, the septomarginal trabecula (moderator band), forms a bridge between the lower portion of the interventricular septum and the base of the anterior papillary muscle. The septomarginal trabecula carries a portion of the cardiac conduction system, the right bundle of the atrioventricular bundle, to the anterior wall of the right ventricle. The right atrioventricular orifice is closed during ventricular contraction by the tricuspid valve (right atrioventricular valve), so named because it usually consists of three cusps or leaflets (Fig. 3.71). The base of each cusp is secured to the fibrous ring that surrounds the atrioventricular orifice. This fibrous ring helps to maintain the shape of the opening. The cusps are continuous with each other near their bases at sites termed commissures. | [
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