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Learning Objiective
1. Know the vertebral levels of the jugular notch, sternal angle, and xiphoid process.
2. Master the formation and function of intercostals nerves and the dermatomes of the thoracic wall.
3. Master the structure and contents of an intercostal space.
4. Know the layers of thoracic wall.
5. Master the arteries, veins, and nerves supplying thoracic wall.
Keystone
1. The concept of dermatomes.
2. The structure and contents of an intercostal space.
3. The arteries, veins, and nerves supplying thoracic wall.
Questions Requiring Short Answer
1. Describe the structure and contents of an intercostal space.
2. Where and how to insert a chest drain?
Reading and Comprehension
Section 1 Introduction of the Thorax
Ⅰ. Boundaries
Ⅰ) Superiorly－jugular notch, sternoclavicular joint, superior border of clavicle, acromion, spinous processes of C7
Ⅱ) Inferiorly－xiphoid process, costal arch, 12th and 11th ribs, vertebra T12
Ⅱ. Regions
Ⅰ) Thoracic wall
Ⅱ) Thoracic cavity
Ⅲ. Landmarks of thorax
Ⅰ) Jugular notch corresponds with
1. The 2th thoracic vertebra in male
2. The 3th thoracic vertebra in female
Ⅱ) Sternal angle corresponds with
1. Connects 2nd costal cartilage laterally
2. The lower border of 4th thoracic vertebra
3. The bifurcation of trachea in the adult
4. The beginning of aortic arch which ends posteriorly at the same level
5. The esophagus is crossed by the left main bronchus
Ⅲ) Xiphoid process－xiphisternal synchondrosis lies opposite the body of the 9th thoracic vertebra
Ⅳ) Clavicle
1. Inferior fossa of clavicle
2. Coracoid process
Ⅴ) Ribs and intercostal spaces
Ⅵ) Costal arch
1. Infrasternal angle
2. Xiphocostal angle
Ⅶ) Papillae
Section 2 Thoracic wall
Ⅰ. Superficial structures
Ⅰ) Skin
Ⅱ) Superficial fascia
1. Superficial vv.
(1) Thoracoepigastric v.
(2) Lateral thoracic v.
2. Superficial nn.
(1) Supraclavicular n.
(2) Anterior and lateral cutaneous branches of intercostal n.
Ⅱ. Deep structures
Ⅰ) Deep fascia
1. Superficial layer
2. Deep layer—clavipectoral fascia
Ⅱ) Muscles of thorax
1. Pectoralis major
2. Subclavius
3. Pectoralis minor
4. Serratus anterior
5. Intercostales externi
6. Intercostales interni
7. Intercostales intimi
8. Transverses thoracis
Ⅲ) Intercostal spaces
1. Eleven spaces between ribs
2. Filled by intercostal muscules
3. Neurovascular bundle
(1) Lie between intercostalses interni and intimi
(2) Consists, from above downwards, of vein, artery and nerve, the vein lying in a costal groove of the corresponding rib (remember －VAN)
1) Posterior intercostal veins
2) Posterior intercostal arteries
3) Intercostal nerves (anterior rami T1－T11)
Ⅳ) Endothoracic fascia

Mediastinum
Learning Objiective
1. Know the subdivisions and contents of the mediastinum.
2. Know the visible structures of the right and left side of mediastinum.
3. Master the order of main structures of the root of lung. Master the relations of the root of lung.
4. Master the composition of pericardium. Know the position of pericardial sinuses.
5. Master the relations of the aortic arch.
6. Master the boundaries and contents of the triangle of ductus arteriosus.
7. Master the relations of thoracic part of esophagus.
8. Know the relations of thoracic aorta.
9. Master the course of the thoracic part of thoracic duct.
10. Know the disposition of the azygos vein and sympathetic trunk.
Keystone
1. The subdivisions and contents of the mediastinum.
2. The relations of the root of lung, aortic arch, and thoracic part of esophagus.
3. The boundaries and contents of the triangle of ductus arteriosus.
Questions Requiring Short Answer
1. List the order of main structures of the root of lung.
2. Briefly describe the relations of aortic arch and esophagus.
3. Describe boundaries and contents of the triangle of ductus arteriosus.
Reading and Comprehension
Section 3 The Mediastinum
The thoracic cavity is divided into a central area, the mediastinum, which contains the heart in its pericardial sac and other structures, and lateral areas containing the lungs in their pleural sacs.
Ⅰ. Concept of mediastinum
Ⅰ) All of organs between the left and right mediastinal pleurae is called mediastinum.
Ⅱ) It extends from the sternum in front to the vertebral column behind, and from the thoracic inlet above to the diaphragm below.
Ⅱ. Subdivisions of mediastinum
For purposes of description, the mediastinum is divided into superior and inferior mediastina by an imaginary plane passing from the sternal angle anteriorly to the lower border of T4 posteriorly. The inferior mediastinum is further subdivided into the middle mediastinum, which consists of the pericardium, and heart; the anterior mediastinum, which is a space between the pericardium and the sternum; and the posterior mediastinum, which lies between the pericardium and the vertebral column.
Ⅰ) Superior mediastinum
1. Locating－from inlet of thorax to plane extending from level of sternal angle anteriorly to lower border of T4 vertebra posterioly
2. Contents
(1) Superficial layer
1) Thymus
2) Three veins
3) Left brachiocephelic v.
4) Right brachiocephelic v.
5) Superior vena cava
(2) Middle layer
1) Aotic arch and its three branches
2) Phrenic n.
3) Vagus n.
(3) Posterior layer
1) Trachea
2) Esophagus
3) Thoracic duct
3. Relations of aortic arch
(1) Anteriorly and to the left
1) Pleura
2) Lung
3) Phrenic n.
4) Pericardiacophrenic vessels
5) Vagus n.
(2) Posteriorly and to the right
1) Trachea
2) Esophagus
3) Left recurrent n.
4) Thoracic duct
5) Deep cardiac plexus
(3) Superiorly
1) Its three branches
2) Left brachiocephalic v.
3) Thymus
(4) Inferiorly
1) Pulmonary a.
2) Arterial ligament
3) Left recurrent n.
4) Left principal bronchus
5) Superficial cardiac plexus
4. Triangle of ductus arteriosus
(1) Bounded by
1) Phrenic n.
2) Left vagus n.
3) Left pulmonary a.
(2) Contents
1) Arterial ligament
2) Left recurrent n.
3) Superficial cardiac plexuses
Ⅱ) Inferior mediastinum－has three subdivisions that extend downward from lower border of superior mediastinum to diaphragm
1. Anterior mediastinum
(1) Location－posterior to body of sternum and attached costal cartilages, anterior to heart and pericardium
(2) Contents
1) Fat
2) Remnants of thymus gland
3) Anterior mediastinal lymph nodes
2. Middle mediastinum
(1) Location－between anterior mediastinum and posterior mediastinum
(2) Contents
1) Heart and pericardium
2) Beginning or termination of great vessels
3) Phrenic nerves
4) Pericardiacophrenic vessels
5) Lymph nodes
3. Posterior mediastinum
(1) Location－posterior to heart and pericardium, anterior to vertebrae T5－T12
(2) Contents:
1) Esophagus
2) Vagus n.
3) Thoracic aorta
4) Azygos system of veins
5) Thoracic duct
6) Thoracic sympathetic trunk
7) Posterior mediastinal lymph nodes
(3) Relations of esophagus
1) Anteriorly
① Trachea
② Bifurcation of trachea
③ Left principal branchus
④ Left recurrent n.
⑤ Right pulmonary a.
2) Anterior esophageal plexus
① Pericardium
② Left atrium
③ Diaphragm
3) Posteriorly
① Posterior esophageal plexus
② Thoracic aorta
③ Thoracic duct
④ Azygos v.
⑤ Hemiazygos v.
⑥ Accessory hemiazygos v.
⑦ Right posterior intercostal v.
4) Left
① Left common carotid a.
② Left subclavian a.
③ Aortic arch
④ Thoracic aorta
⑤ Superior part of thoracic duct
5) Right－Arch of azygos v.
(4) Relations of thoracic aorta
1) Anteriorly
① Left root of lung
② Pericardium
③ Esophagus
2) Posterior
①Hemiazygos v.
②Accessory hemiazygos v.
3) Right
① Azygos v.
② Thoracic duct
4) Left－mediastinal pleura
Ⅲ. Mediastinal spaces
Ⅰ) Retrosternal space －lies beween sternum and endothoracic fascia
Ⅱ) Pretracheal space －lies within superior mediastinum, between trachea, bifurcation of trachea and aortic arch
Ⅲ) Retroesophagus space－lies within superior mediastinum, beween esophagus and endothoracic fascia