The ribs are arc-shaped, flat bones that protect thoracic organs such as the heart and lungs,

and provide attachment points to muscles of the back, chest and proximal upper limb. They are
12 pairs of ribs, attached posteriorly to the thoracic vertebrae.

The ribs can be divided into groups based on their distal attachment points. The first seven pairs
of ribs articulate directly with the sternum through their costal cartilages and are known as the
true ribs or vertebrosternal ribs. The 8th-10th ribs unite anteriorly via their costal cartilages and
articulate indirectly with the sternum via the 7th rib; they are known as false ribs or
vertebrocostal ribs. The 11th and 12th ribs are known as floating ribs as they do not attach to
the sternum in any manner and are particularly short and have no necks nor tubercles.

Watch the following video to learn more about the various bony landmarks found on each rib
and how they relate with nearby surrounding structures.

Hello everyone! This is Joao from Kenhub, and on this anatomy tutorial, we are going to be
looking at the ribs and costal cartilages. We will cover the structure and major landmarks of ribs.
We will start by looking at the overall anatomy of the ribs – that is, their location and
organization in the body and the two different types of ribs, including true ribs, and false ribs.
Next, we will look at the bony landmarks found on all ribs and then examine the landmarks that
can be found on only a few specific ribs. We'll then look at the joints of the ribs and then the
floating ribs which are a subtype of the false ribs. Once we know our way around the ribs in the
thorax, we'll look at what happens when something goes wrong with the ribs.

Now, ribs are part of the axial skeletal which is made up of the skull, spine, ribs, sternum, and
sacrum. Ribs are long. They are thin bones that make up the thoracic cage. The rib cage
protects vital organs found in the thorax like your heart and lungs. It also provides attachments
for some of the muscles that move your arms and help you breathe.

Now, let's look at the types of ribs that we can find in the human body including true ribs, false
ribs and floating ribs. We'll start by looking at the rib cage from the front to see the costal
cartilages. Now, this is an image of the rib cage from the front. The sternum is highlighted in
green and ribs are classified into two groups by how they attach to the sternum. The first seven
pairs of ribs are what we call true ribs, and true ribs attach directly to the sternum through costal
cartilage. Ribs eight through twelve are called false ribs. They also attach to the sternum but not
directly. Instead, they attach to the costal cartilage of the true ribs. Note that the true and false
ribs have a flat sternal end to accommodate the costal cartilage. The cartilage forms the joint
between the rib and the sternum. Finally, the last two false ribs, ribs eleven and twelve do not
attach to the sternum at all. These are called floating ribs and are considered a subsection of
the false ribs. You can only see small part of them from this perspective because the floating
ribs do not pass all the way around the body.

Before we move on to talk about the bony landmarks of the ribs, let's talk about costal
cartilages, which we mentioned briefly earlier. As we mentioned, the ribs are connected medially
to costal cartilages, which are cartilages that extend the ribs and make the thoracic wall more
elastic for respiration. The first seven cartilages, and occasionally the eighth, are connected to
the sternum as you can see in this image. The eighth to tenth cartilages on the other hand are
connected to the cartilages immediately superior to them, which you can see in this image. The
costal cartilages on ribs eleven and twelve are not visible on this image but form caps on the
ends of the ribs.

Let's now have a look at some bony landmarks that are found on most ribs. To show you the
landmarks, we have isolated here a rib for you. These landmarks include the head of the rib, the
neck of the rib, the articular facet of the rib tubercle, the articulation between the rib and
vertebra, the crest of the neck of the rib, the angle, and shaft of the rib.

Now this is an image of four ribs from different levels of the thoracic cage. This is the first rib,
this is the second one, this is a true rib, and this is the eleventh rib. Although there are some
exceptions, most ribs have the same bony landmarks. Let's go over some of the landmarks you
would see on a typical rib and then we'll look at some special features seen only on a couple of
ribs.

To start, the head of the rib is the part closes to the spine. All ribs have a head with a surface to
articulate or form a joint with the vertebral body next to it. If we move a little further out, we reach
this part here which is the neck of the rib. It is a slightly longer region between the head and
angle of the rib. In this image, we have highlighted it in green. The neck has more surfaces for
attaching the vertebrae to the ribs which we call articular tubercles.

The tubercles of the ribs are small, rough bumps that attach the neck of the rib to the thoracic
vertebra. If you look closely at the tubercles, you will notice a smooth surface in the middle of
the articular tubercle called the articular facet. This is where the tubercle of the rib articulates
with the transverse process of a thoracic vertebra. Let's take a closer look at how the surfaces fit
together.

This is what the joint between the ribs and spinal column looks like from above. This is the body
and transverse process of the vertebra. You can see here that there are two articulations
involved. This is the joint between the head of the rib and the vertebral body and here is the joint
between the articular facet of the tubercle and the transverse process of the vertebra.

To reorient ourselves, these are four ribs from different levels of the thoracic cage. This is the
first rib, this one here is the second one, this is a typical rib near the middle of the thoracic cage,
and this is the eleventh rib. The uppermost part of the neck of the rib is referred to as the crest
of the rib. In this image, it is the green line between the head of the rib and the tubercle of the
neck.

We just looked at the head and neck of the ribs, and if we move a little further away from the
spine, the bone curves. This is the angle of the rib. At this point, the rib begins to course around
the lung towards the sternum. The rest of the rib from the angle to the joint with the sternum is
called the body or shaft of the rib. The body of the rib has a small groove at the bottom on the
inside of the rib cage. This is the costal groove. Nerves and arteries that supply the ribs and
muscles follow this groove.

Now that we know the basic structure of the ribs, let's look at some of the features of atypical
ribs. Remember, atypical ribs include ribs one, two, and ten through twelve. In this section, we
will look at the scalene tubercle, the attachment for the subclavius, the groove for the subclavian
vein, and also the groove for the subclavian artery. And lastly, we will look at the serratus
anterior tuberosity.

Now, this is the first rib. Like a typical rib, it has a head, neck, shaft and articular tubercles but it
is much shorter than other ribs and has a few extra bony landmarks made by muscle
attachments and blood vessels passing across it. The landmark highlighted in this picture is
called the scalene tubercle, and it is the attachment point for the anterior and middle scalene
muscles.

This is another bony landmark created by a muscle attachment. The subclavius muscle
attaches to the clavicle and first rib. When this muscle is tensed, it pulls the clavicle closer to the
first rib. Now, the subclavian vein is a large vein draining blood from the upper limb and it
passes over the first rib on its way to the heart. The subclavian vein is large enough to create a
small depression on the rib. This is what we call the groove for the subclavian vein and it is
highlighted in green on the image right now.

The subclavian artery passes over the first rib next to the subclavian vein and also creates a
groove. Blood pressure is higher in arteries than veins so the groove created by the subclavian
artery is larger than the groove from the subclavian vein. The groove for the subclavian artery is
highlighted in green here next to the groove for the subclavian vein.

Like the scalene muscles, the serratus anterior muscle also creates a unique bony landmark
where it attaches to the ribs. The first eight or nine ribs feature a serratus anterior tuberosity.
This is the serratus anterior tuberosity of the second rib.

Let's have a look now at some important joints associated with the ribs.

Sternochondral or sternocostal joints as they're sometimes called are joints that connect the
medial aspect of the second to seventh costal cartilages to the lateral surface of the sternum.
These joints are synovial plane joints moving with respiration. The sternochondral joints of the
first pair of costal cartilages on the other hand articulate with the manubrium of the sternum as
you can see in this image here. These joints are known as synchondroses which are strong and
stable joints with little movement.

Moving laterally along the costal cartilages, costochondral joints are those found between the
lateral end of the costal cartilage and the sternal or medial end of the ribs. The sternal ends of
the ribs each have a small cup shaped depression into which the lateral end of the costal
cartilage inserts. These joints are hyaline cartilaginous joints and are connected by the
periosteum of both ribs and the cartilage so there is usually no movement in these joints.

And moving down the rib cage towards the lower ribs we have the interchondral joints which are
articulations between the contiguous borders of costal cartilages six to ten. Do note however
that while the articulations between the costal cartilages six to nine are synovial plane joints, the
articulation between ninth and tenth costal cartilages is a fibrous joint. These joints are
reinforced by interchondral ligaments and you can see them here.

Let's look at some features of floating ribs. Ribs three through ten show typical structure and
landmarks, even though ribs eight to twelve are false ribs. Remember that false ribs do
articulate with the sternum, but only through the costal cartilages of true ribs. Floating ribs are
also very similar to a typical rib. Note here that on this image, we are looking at the floating ribs
from the back. This is the eleventh rib. You can see here that it has a head, neck, angle, and
shaft but the sternal end of this rib is tapered rather than flat.

Now that we are familiar with features of our thoracic ribs, let's take a look at the implications of
having a cervical rib. This is a radiograph of the neck and upper part of the thorax. The spine
and ribs are visible in a light gray color. The first four ribs are here. In some rare cases, an
individual may present with another rib above it. This is called a cervical rib because it arises
from a cervical vertebra. In this radiograph, the cervical rib is indicated with the red arrow.
Usually, there is a cervical rib on only one side. Cervical ribs do not usually cause a person
major distress but can sometimes alter the position of a major nerve plexus that runs from the
cervical and thoracic spine to the arm. Supraclavicular nerve blocks used for shoulder surgery
can still be performed with a cervical rib although a physician has to take extra care to work
around it.

Now that we're finished looking at the features of the ribs and clinical correlations, let's take a
quick moment to summarize what we have learned about the ribs. In this video, we looked at
the classification and structure of ribs. Ribs are classified into two groups. True ribs connect
directly to the sternum through their own costal cartilage. Ribs one through seven are true ribs.
We also looked at false ribs which connect to the sternum through the costal cartilages of true
ribs. Ribs eight to twelve are false ribs, and floating ribs do not connect to the sternum at all.
Ribs eleven and twelve are floating ribs.

The costal cartilages are cartilage that attach to the medial end of the ribs and help make the
thoracic wall more elastic for respiration. Costal cartilages one to seven attach to the sternum,
while costal cartilages eight to ten attach to the cartilages above.

Then we looked at some common features seen on all ribs. The head of the rib is closest to the
vertebral body. The neck of the rib is just distal to the head. The neck of the rib features an
articular facet for attaching to the transverse process of a vertebra, and a crest, which is the
highest point of the neck. Just distal to the neck is the angle of the rib. This is the point where
the rib begins to curve around the front of the body. The long part of the rib that travels around
the thorax is called the shaft of the rib.

Some of the ribs feature unique bony landmarks. The serratus anterior tuberosity is created by
the origins of the serratus anterior muscle on the first eight or nine ribs. The scalene tubercle is
created by the attachment of the scalene muscles on the first and second ribs. The subclavius
muscle creates a small bony landmark where it attaches to the first rib. Finally, the subclavian
artery and vein both create grooves on the first rib where they pass over it. The groove for the
subclavian vein and subclavian artery are next to each other on the rib.

We also looked at joints of the rib, including the sternochondral joints, which connect the medial
aspect of the second to seventh costal cartilages to the lateral surface of the sternum and the
sternochondral joints of the first pair of costal cartilages which articulate with the manubrium.
We looked at the costochondral joints which are found between the lateral end of the costal
cartilage and the sternal end of the ribs. And we also looked at the interchondral joints, which
are the articulations between the contiguous borders of costal cartilages six through ten.

And, finally, finally, we looked at a radiograph of a very unusual rib. Ribs articulate with the
thoracic spine, however, they can also sometimes arise from a vertebra in the neck. This is then
called a cervical rib. Although it is not usually a major cause for concern, cervical ribs can affect
the location of nerves controlling the arms.

And that's it, we've reached the end of this tutorial. Thank you for watching and I hope to see
you on the next one.

Classifications True ribs: Vertebrosternal ribs: 1st-7th

False ribs: Vertebrocostal ribs: 8th to 12th
(Floating ribs: 11th/12th)

Typical ribs: 3rd- 9th

Atypical ribs: 1st, 2nd, 10th-12th

Bony landmarks Head: Facet divided into two by crest of head of rib
Neck: Crest of neck of rib
Body: Tubercle, costal groove, angle

External and internal surfaces

Round superior border, sharp inferior border
Proximal (vertebral) and distal (sternal) ends
Atypical ribs Rib 1: Shortest true rib, single facet on head; lacks angle and costal groove, has
two grooves for subclavian vessels, scalene tubercle
Rib 2: Tuberosity for serratus anterior muscle
Rib 10: Single facet on head
Rib 11: Single facet on head; short neck, lacks tubercle, has a slight costal
groove
Rib 12: Single facet on head; lacks tubercle, angle, costal groove

Function Provide attachment points to muscles of the back, thorax and proximal upper
limb
Protect thoracic organs such as heart and lungs
Sternum
There is a bone in the center of our chest right in front of the rib cage which has a shape of a
sword. Can you guess what bone that is? Well, yes, it's the sternum. So, today, my friends, we
are going to then dedicate this tutorial to this very important bone of the human body and learn
everything about its anatomy. We will cover the overall anatomy and major features of the
sternum.

So, first, we will look at the three parts of the sternum which are the manubrium, the sternal
body, and the xiphoid process. Then we'll look at articulations that join these parts together
which are then the sternal angle and the xiphisternal junction. Then we will look at the bony
landmarks unique to the manubrium and the sternal body.

On the manubrium, we will look at the suprasternal notch. We're going to be seeing these
structures called clavicular notches, also the first costal notch, the second costal notch, and the
sternal body features many notches for the ribs to then connect to the sternum. Each notch is
named after the number of the rib so there is a third costal notch, a fourth costal notch, a fifth, a
sixth, and a seventh costal notch. And at the end of this tutorial, we will also include some
clinical notes connected to the sternum. Now before we explore all those elements in great
detail, let's start by looking at the sternum as a whole.

So, this is the skeleton as if we were standing in front of a person. You can see the sternum
here highlighted in green which is this long, flat bone in the front part of the rib cage. These are
the ribs and this is the spine. Note here that the sternum joins the right and left ribs to then
complete the rib cage and provides a base for the pectoral girdle. Like I mentioned before, the
sternum is made up of three parts – so there is the manubrium, the sternal body and the xiphoid
process, and each of these structures have their own set of unique characteristics. Let's look at
each part individually. We'll start with the most superior portion of the sternum – the manubrium.

We are now looking at an isolated sternum both from the right side which is the image on the far
right, and from the front which is the image on the left. Keep in mind that manubrium is Latin for
"handle or hilt". If you look at it, it somewhat resembles a triangle when viewed from the front.
The tip of the triangle points down and its base is in line with the two clavicles. At the center of
the base, there is a small depression and this is then the suprasternal or jugular notch. On
either side of the suprasternal notch, there are two smaller notches called the clavicular
notches. The clavicular notches are then the contribution of the sternum to then the
sternoclavicular joints. Here, each clavicle articulates with the sternum to then support and
stabilize the shoulder joint.

We've backed away to look at the sternoclavicular joint along with the thorax. The clavicle
attaches to the scapula at the acromioclavicular joint but the scapula itself has no bony
attachments to any other part of the axial skeleton and besides the clavicle, it is only attached
by some of the muscles in your back. This means the only joint holding your arm to the rest of
your body is the sternoclavicular joint. Don't worry, though, this joint is reinforced with several
ligaments and a strong joint capsule to hold it together.

Now, let's isolate the sternum again to look at costal notches. Costal notches are depressions
marking articulations with the ribs. This first costal notch is on the manubrium directly below the
clavicular notches and it articulates with the first rib. The second costal notch is below the first
costal notch near the tip of the manubrium. The second rib articulates with the sternum at the
junction between the manubrium and sternal body so there is a depression on each part of the
sternum to then accommodate the rib.

Now, the junction between the sternal body and manubrium has a special name. It is called the
sternal angle and is sometimes also known as the manubriosternal junction or angle of Louis.
Here, we can see it both from the front and from the side. The sternal angle can be palpated in
the center of your chest. It feels like a small horizontal ridge usually about one or two inches
long or two point five to five centimeters.

The sternal angle, if you're in the Health Sciences, is an important medical landmark. It marks
an imaginary transverse line between the second sternocostal joint and the intervertebral disc
between T4 and T5 vertebrae. This plane separates the superior mediastinum from the inferior
mediastinum.

Now, let's move on to another part of the sternum. We're going to be talking about the body. The
sternal body highlighted in green now on the image is the middle part of the sternum. It is
relatively flat and rectangular in shape and is formed by the fusion of two fetal cartilage models.
The majority of the true ribs articulate with the sternal body through individual costal notches –
and there is lots of them. The third costal notch is the most superior notch that is completely on
the sternal body. The costal cartilage of the third rib articulates here.

The costal cartilage of the fourth rib articulates with then the fourth costal notch then we're going
to see that the costal cartilage of the fifth rib articulates with the fifth costal notch. A bit further
down, we find that the costal cartilage of the sixth rib articulates with the sixth costal notch. And,
lastly, the costal cartilage of the seventh rib articulates with the seventh costal notch.

Now that we've looked at all the notches, let's take a closer look at the sternocostal joint. Now,
this is a close-up view of the joints between the ribs and sternum. The sternum does not
articulate directly with the ribs. Rather, they are attached by a square or rectangle-shaped costal
cartilage. This feature gives the sternocostal joints the ability to stretch slightly as the rib cage
expands during breathing.

We're going to move a bit further down. It is time for us to talk about the xiphoid process of the
sternum. Below the sternal body, you can see that the sternum features a small bony projection.
This is then the xiphoid process. And the xiphoid process is very thin and projects inferiorly and
it typically ossifies in late childhood. The junction between the sternal body and the xiphoid
process is then called the xiphisternal junction. This is a delicate connection and is frequently
broken during CPR.

Now that we covered the anatomy of the sternum, it is time for us to look at two conditions that
make this bone significant in a clinical setting. The sternal body is formed by the fusion of
multiple smaller pieces of cartilage. The pieces of cartilage join in fetal development but do not
completely fuse until after birth. Sometimes, parts of the cartilage do not fuse at all and will
leave a small hole in the sternum. This is what we call sternal foramen. The sternal foramen is
most frequently seen in a sternal body but can sometimes be located in the manubrium.
Although it usually asymptomatic, a sternal foramen can cause complications in medical
procedures if the variation has not been noted beforehand.

Now that we're done with clinical notes as well, we are going to summarize what we just learned
before we finish this tutorial. In this tutorial, we looked at the sternum, and the sternum is a flat,
sword-shaped bone in front of the rib cage. It is made up of three parts. The manubrium is the
most superior portion of the sternum, the sternal body is the middle part where most of the ribs
attach, and the xiphoid process which is a small piece of bone projecting off the bottom of the
sternal body.

The three parts of the sternum are then connected by special junctions. The sternal angle joins
the manubrium and the sternal body. The xiphisternal junction joins the sternal body and the
xiphoid process. We also saw that each part of the sternum has a unique set of bony landmarks.
The manubrium features a small depression at the middle of the top margin of the manubrium
called the suprasternal notch.

The clavicular notches on either side of the suprasternal notch form a joint with the clavicles.
The first costal notch is the attachment site of the first rib and the second costal notch is the
attachment site for then the second rib. The sternal body features many notches for the rest of
the true ribs, so there is a third costal notch, fourth costal notch, a fifth one, a sixth, and, finally,
a seventh costal notch.

Now we have reached the end of our tutorial on the sternum. Thank you very much for watching
and I hope to see you on the next video.

Anterior and lateral perspectives of the sternum

The manubrium articulates with the body of the sternum through the manubriosternal joint, and
the body of the sternum with the xiphoid process through the xiphisternal joint. On the
manubrium, the jugular/suprasternal notch is located centrally along its superior border and is
flanked either side by the clavicular notches which accommodate the sternal end of each
clavicle. Directly below the clavicular notch and along the length of the manubrium and body of
the sternum are seven paired costal notches which receive the cartilages of the true ribs. It’s
important to note that the sternum articulates with the costal cartilages and not directly with the
ribs, through the sternochondral joints. These joints allow slight movement of the thoracic cavity
and expansion when breathing.
 Parts Manubrium, body of sternum, xiphoid process

Bony landmarks Manubrium: Jugular notch, clavicular notch, 1st costal notch, 2nd costal notch
Body of Sternum: 2nd-7th costal notches
Xiphoid process

Joints Sternoclavicular joint: Articulation between manubrium and clavicle

Sternochondral joints: Articulation between sternum and costal cartilages of
1st-7th ribs
Manubriosternal joint: Articulation between manubrium and body of sternum
Xiphisternal joint: Articulation between body of sternum and xiphoid process)

Function Provides an anchoring point for the costal cartilages

Protection of heart and lungs from mechanical damage

The muscles of the thoracic wall are defined as muscles attached to the bony framework of the
thoracic cage. They maintain the stability of the thoracic wall, and play a role in respiration. The
muscles of the thoracic wall include the following muscle groups:

Serratus posterior muscles

Levatores costarum muscles
Intercostal muscles
Subcostal muscles
Transversus thoracis muscles
Note that some of the muscles of the pectoral girdle and neck, such as the pectoralis major and
minor or the scalene muscles, also aid in respiration. However, from an anatomical point of view,
the true muscles of the thoracic wall are those listed above.

The following video will introduce you to the anterior trunk muscles in general, with an emphasis
on a few specific muscle groups of the thoracic wall.

Hello, everyone! This is Joao from Kenhub, and welcome to another anatomy tutorial where,
this time, we're going to be talking about the muscles of the ventral trunk. So, what we are going
to be doing here on this tutorial is looking at this image and describing the different muscles that
define the ventral trunk… so, the anterior part or front part of your trunk. So, basically, we are
going to be describing the different thoracic muscles and also some of the abdominal muscles
that define the anterior portion of the thorax and also the abdomen.

So, as you would probably expect, right now, we’re looking at the anterior view of the thorax and
abdomen so the anterior view of the trunk where we can see the different muscles that we’re
going to be talking about on this tutorial. But, before I do so, I would like to list the different
muscles of the ventral trunk and these include the abdominal muscles, the intercostal and
subcostal muscles, the transversus thoracis, the serratus anterior, the pectoralis major and
minor, the subclavius, and the cremaster.

We’re going to start off by talking about the first list of muscles which are the abdominal muscles
which you can see now on the image on the right side and the list includes the rectus abdominis
muscle, the pyramidalis muscle, the external oblique, the internal oblique, the transversus
abdominis muscle. So, these are the abdominal muscles that define the ventral trunk.

We’re going to start off with this one that you see here highlighted in green which is known as
the rectus abdominis. The muscle is passing through what is known as the rectus sheath which
is a tendinous muscle envelope built by the aponeurosis of the lateral abdominal muscles. This
muscle has between 3-4 horizontal tendinous intersections which you can clearly see here on
this image, and they are adhered to the anterior layer of the rectus sheath giving it its
multi-bellied appearance. And, thanks to this muscle, and when you work hard on it, this is when
you get then the well-known washboard abs or the well-known 6-pack.

Now, we’re going to be talking about the different origin points for this muscle. It originates from
the 5th to 7th costal cartilages and also the xiphoid process of the sternum, as you can see here
on this image. So, these are the origin points for the rectus abdominis. It goes all the way to
then insert at the pubic bone, to be more precise between the pubic tubercle and the symphysis,
which you can also see here on the image. And as a very good muscle out there, we’ll have to
talk about the innervation of the rectus abdominis, and the innervation will come from the
intercostal nerves… to be more specific, the lower intercostal nerves.

Now, in terms of the different functions associated to the rectus abdominis, one of the main
things is that this muscle is able to tense the anterior abdominal wall. As I mentioned before, the
rectus abdominis muscle is responsible for the 6-pack abs because of its tendinous
intersections which gives the muscle the multi-belly appearance. When the muscle contracts, it’s
also able to perform flexion of the lumbar spine. It is also an important muscle for respiration as
it helps perform a strong exhalation and creates then intra-abdominal pressure during
defecation and/or childbirth. The rectus abdominis muscle is an antagonist to the intrinsic back
musculature.

Next muscle that we’re going to be talking about is a tiny, tiny muscle known as the pyramidalis
which is poorly developed in humans. Now, the origin, the muscle will come from the pubic bone
as you can see here on the image and then will be running within the rectus sheath to the linea
alba where it’s going to be inserting, and this is the linea alba as you can see here on the image.
As for the innervation of the pyramidalis, the muscle is going to be innervated by this nerve or
these nerves seen here highlighted in green, the subcostal nerves, also known as the 12th
intercostal nerves. When it comes to the different functions associated to the pyramidalis, while
this muscle almost has no functions we’re talking about, but it’s important to mention that it’s
able to tense the linea alba in this section.

We’re going to move on and talk about the next muscle in our list. This one that you see here
highlighted in green which is known as the external oblique. This muscle is going to be
originating from the 5th to 12th ribs and at its origin point, it is highly connected with other 2
muscles, the serratus anterior and the latissimus dorsi. The muscle runs caudomedially to then
insert on the half of the iliac crest, the pubic tubercle, the linea alba, and also the inguinal
ligament will serve as an insertion point for the external oblique. Now, the innervation of the
external oblique is going to come from the intercostal nerves, the lower intercostal nerves, to be
more specifically between T7 to T12.

We’re going to move on and talk about the different functions associated to the external oblique.
When the muscle produces a unilateral contraction, it’s going to be able to contralaterally rotate
the torso while a bilateral contraction will be able to flex the lumbar spine. This happens
together with the other abdominal muscles. It also supports forced exhalation and increases the
intra-abdominal pressure.

If there is an external oblique, there should be the next muscles that we’re going to be talking
about, the internal oblique. Now, the internal oblique is going to be originating from the
thoracolumbar fascia, the iliac crest, and also the inguinal ligament. The muscle will be then
inserting cranially at the lower costal cartilages and ventrally at the linea alba. So, first insertion,
linea alba which you can also see here on this image. And as I mentioned, it’s going to be
inserting on the lower borders of ribs 10 to 12. In men, the caudal fibers will be extending to the
spermatic cord merging to form another muscle that we’re going to talk about, the cremaster.

Now, we’re going to talk about the innervation of the internal oblique. Now, there is a list of
nerves that you need to know. The intercostal nerves T7 to T12 are going to be responsible for
the innervation of this muscle as well as the iliohypogastric nerve and the ilioinguinal nerve
which are branches of the lumbar plexus.
Next in line will be then the functions of the internal oblique. And, unilateral contraction will be
producing ipsilateral rotation and ipsilateral flexion. Now, bilateral contraction will be producing
flexion of the lumbar spine together with the other abdominal muscles, and the internal oblique
also supports forced exhalation and increases the intra-abdominal pressure.

Next muscle that we’re going to be talking about that you see here highlighted in green is known
as the transversus abdominis. This muscle arises from the inner surface of the lower costal
cartilages no. 7 to 12. Also the thoracolumbar fascia will serve as an origin point as well as the
iliac crest and the lateral 3rd of the inguinal ligament.

Now, when it comes to the insertion point and, as the name suggests, the fibers are running
horizontally to the linea alba as you can see here which is now removed but you can see how
the muscle is running or the fibers of the muscle are running towards the linea alba with the
aponeurosis of the internal oblique. Now, the muscle also inserts at the pubic crest and the
pecten pubis. Also, caudal fibers of the transversus abdominis are involved in the formation of
another muscle, the cremaster.

And as we’ve seen on the internal oblique muscle, the innervation of the transversus abdominis
is going to come from the intercostal nerves T7 to T12 as well as branches of the lumbar plexus,
the iliohypogastric nerve and the ilioinguinal nerve. Keep in mind these 2 images. The first one
on the left is showing the different intercostal nerves while the image on the right side is showing
the intercostal nerve no. 12 which is also known as subcostal nerve.

Now, it is time for us to talk about the different functions associated to this muscle. Now, a
unilateral contraction will be causing ipsilateral rotation and ipsilateral flexion. Bilateral
contraction will be causing flexion of the lumbar spine together with the other abdominal
muscles.

We’re going to go a bit further up to talk about the different muscles that define the anterior
portion of the thorax, as you can see here on this image.

We’re going to start off with this one that you see here or these that you see highlighted in green
which are known as the external intercostal muscles. They originate from the lower border of the
rib and then run ventrocaudally to the upper border of the rib below. Ventrally, these muscles are
bordered by the external thoracic fascia. The innervation of the external intercostal muscles
come from these nerves that you see here highlighted in green which are the intercostal nerves
which arise from the thoracic nerves T1 to T11.

The next group of muscles that we’re going to be talking about that you see here highlighted in
green are known as the internal intercostal muscles. As for their origin points, these muscles
originate from the upper border of the rib and then they go to insert ventrocranially at the lower
border of the rib above. The internal intercostal muscles are going to be innervated by the
intercostal nerves, same thing that we saw previously, which arise from the thoracic nerves T1
to T11.

As for the different functions associated to these muscles, the task of the intercostal muscles is
to then tense the intercostal spaces during deep inspiration and they also support the breathing
mechanism. Keep in mind that the contraction of the external intercostal muscles will cause
elevation of the ribs whereas the internal intercostal muscles will be lowering the ribs. So, they
are also known as expiratory breathing muscles.

Moving on to the next muscle that you see, or next set of muscles that you see here highlighted
in green, the transversus thoracis. This muscle is a thin muscle on the inner surface of the
anterior thoracic wall. As for its origin points, it lies on the dorsal surface of the xiphoid process
which you can also see here on the image, the xiphoid process, and the body of the sternum as
you can see here is going to serve as an origin point for this muscle as well.

Now, from there, there are 5 insertion tendons which run craniolaterally to the cartilages of ribs 2
to 6 giving it a serrated appearance as you can see on the image. Now, the exact number of
tendons and the places of insertion vary greatly making the transversus thoracis one of the most
variable muscles in your body. Caudally, its fibers course almost parallel to those of the
transversus abdominis which is where it got its name from. In rare cases, these 2 muscles can
even be found merged together.

Now, the innervation of the transversus thoracis will come from these nerves that you see here
highlighted in green. You probably have guessed, you’ve seen several times throughout this
tutorial, these are the intercostal nerves specifically 2 to 6. So, the intercostal nerves arising
from the thoracic nerves T2 to T6.

Now, the next topic will be the functions associated to the transversus thoracis. The contraction
of this muscle will be pulling the ribs’ cartilages caudally and that way supporting expiration, so,
when you breathe out. However, it is not considered to be among the primary respiratory
muscles such as the intercostal muscles or even the diaphragm because many people have a
poorly developed transversus thoracis and show no breathing difficulties. For those reasons, it is
only regarded as an accessory muscle of expiration.

Next muscles in line that we’re going to see here also a collection of muscles known as the
subcostal muscles. As you can see here, they’re also connecting the ribs, and they will be
originating from the inner surface of one rib and then they are inserted into the inner surface of
the 2nd or 3rd rib below near its angle, to be more specific, the angle of the rib.

Now, the innervation of the subcostal muscles is carried out by the lower intercostal nerves. As
for the different functions associated to these muscles, the subcostal muscles have a similar
function to that of the internal intercostal muscles and they depress the ribs which makes them
accessory muscles of expiration.
Moving onto the next muscle on our list that you see here highlighted in green, one on each
side, is known as the serratus anterior. The serratus anterior is a fan-shaped muscle at the
lateral wall of your thorax. It is originating from the ribs specifically rib 1 to 9. And as for the
insertion point, the muscle will be inserting at the ventral surface of the medial border of the
scapula and, due to its course as you can see here, the muscle has a serrated appearance.

Now, the serratus anterior can be divided into different parts. The superior part which goes from
the 1st to 2nd ribs and then all the way to the superior angle of the scapula. There is also an
intermediate part which runs from the 2nd to the 3rd ribs and will go all the way to the medial
border of the scapula. Another part which is known as the inferior part which runs from the 4th
to 9th ribs and then goes to insert on the medial border and also the inferior angle of the
scapula.

Now, keep in mind that on the previous slide, I was mentioning that the insertion point for this
muscle is the medial border of the scapula. I also mentioned here the superior angle of the
scapula and the inferior angle of the scapula as insertion points for the superior and inferior
parts which is important to highlight here. So, you can also mention for more detail that the
superior and inferior angles of the scapula serve as insertion points for the superior and inferior
parts respectively.

Moving onto the innervation of the serratus anterior, the muscle is going to be innervated by this
nerve that you see here highlighted in green, the long thoracic nerve. What you see here on this
image, this is an anterior view of the shoulder where you see then the humerus, the scapula and
the long thoracic nerve, which as you can also see here is a branch of this plexus here, the very
famous brachial plexus.

We’re going to move on and talk about the different functions associated to the serratus anterior.
Now, the contraction of the entire serratus anterior leads to ventrolateral movement of the
scapula along the ribs. Due to this pull, the inferior part at the lower scapula, the shoulder joint is
then shifted superiorly. And this shift, will now enable you to lift your arm up to 90 degrees which
is then elevation. In contrast, the superior part will be depressing the scapula and does act
antagonistically. Another function of this muscle is to then stabilize the scapula within the
shoulder. And finally, with a fixed scapula, the muscle lifts the ribs, is able to act as an accessory
muscle of inspiration.

We’re going to move on and talk about one of the major muscles that defines your chest. This is
the pectoralis major, definitely shapes the surface anatomy of the chest and participates in
forming the anterior wall of the axilla. It has a broad origin point so it goes from the medial part
of the clavicle; also, the sternum serves as an origin point, and this is a bit of variable
information but most sources indicate the costal cartilages 2nd to 6th. The anterior layer of the
rectus sheath will be serving as an origin point as well for the pectoralis major.

When it comes to the insertion point for the pectoralis major, this is an easier one. The muscle is
going to then or all of the fibers of this muscle will insert together at the crest of the greater
tubercle as you can see here. So this is the greater tubercle of the humerus and the crest is
found just below it and will be serving as an insertion point for the pectoralis major. The
innervation of the pectoralis major will be provided by 2 nerves; the medial pectoral nerve which
you see here highlighted in green and the lateral pectoral nerves.

Moving onto the different functions associated to the pectoralis major, this is the most important
muscle for adduction and anteversion of the shoulder joint which you see here indicated by this
arrow. Adduction when you bring your arm closer to your torso, and also anteversion when you
extend your arm forward. This also involved in internal rotation which you see here indicated by
this arrow. So if the arms are fixed, the muscle is also able to lift the trunk which can be helpful
in climbing or during inspiration.

The next muscle is the smaller one where the very similar name, the pectoralis minor. The
pectoralis minor is located under the pectoralis major and both form the anterior wall of the
axilla. The contracted muscle can be easily felt or palpated there. The pectoralis minor is going
to be originating from 3 ribs specifically; so, from rib 3 all the way to the 5th rib. Then it inserts
on the coracoid process of the scapula as you can see here, this projection, of the scapula. And
as its big brother, the pectoralis minor is going to be innervated by 2 nerves, the medial pectoral
nerve which you see highlighted in green and the lateral pectoral nerves too.

As for the different functions associated to the pectoralis minor, this muscle is able to pull the
scapula anteriorly and inferiorly towards the ribs to what we call then depression of the scapula.
This movement is both helpful when retracting the elevated arm as well as moving the arm
posteriorly behind the back. It’s also involved in elevation of the 3rd to 5th ribs given a fixed
scapula then expands the rib cage. By those means, it can also serve as an accessory muscle
during respiration.

Next muscle that we’re going to talk about a very small muscle that you see here highlighted in
green is known as the subclavius muscle. It’s also known as a muscle, a short muscle of the
shoulder girdle. It’s going to be originating, as you can see on the image, from the first rib. So
this is the first rib and will serve as an origin for the muscle, just on the border between the bone
and the cartilage. As for the insertion point of the subclavius, it inserts at the lower surface of the
lateral clavicle, as you can see here, this is the clavicle, thereby, it lies behind the pectoralis
major. The brachial plexus and both the subclavian artery and vein pass under the subclavius
muscle and, due to its location and relatively small size, it is really hard to palpate this muscle.

As for the innervation associated to the subclavius muscle, we’re looking now at the brachial
plexus here and you see this nerve here highlighted in green which is named after the muscle,
the subclavian nerve, which is then a branch of the brachial plexus. And just for clarification on
this image, you’re seeing the brachial plexus as well as the cervical plexus.

We’re going to talk about the different functions associated to the subclavius. The main task of
the subclavius is the active stabilization of the clavicle and the sternoclavicular joint during
movements of the shoulder and arm, and in addition its contraction leads to depression of the
clavicle and elevation of the 1st rib respectively. And these movements, however, play a rather
subordinate role.

Last muscle on our list that you see here highlighted in green, this is known as the cremaster.
The cremaster is formed by fibers from the abdominal musculature and covers the spermatic
cord and testes. Now, the origin point can be known as the inguinal ligament. And as for the
insertion point of this muscle, this is a bit more complicated but it forms a thin network of muscle
fascicles around the spermatic cord and testes or around the distal portion of the round ligament
of uterus in women.

When it comes to the innervation of the cremaster muscle, this muscle is innervated by the
genital branch of the genitofemoral nerve. Now when it comes to the different functions
associated to the cremaster, contraction of this muscle is initiated by several stimuli. It lifts the
testicles towards the torso known as the cremaster reflex. This mechanism adjusts the
temperature of the testicles for an adequate sperm production, one point that the cremaster is
not well-developed in females.

Muscles Serratus posterior muscles (superior, inferior)

Levatores costarum muscles
Intercostal muscles (external, internal, innermost)
Subcostal muscles
Transversus thoracis muscles

Innervation Thoracic nerves, intercostal nerves

Function Accessory respiratory muscles, support and stabilize thoracic cage

Hello, everyone. This is Joao from Kenhub, and welcome to another anatomy tutorial where,
this time, we’re going to be talking about the neurovasculature of the ventral trunk.

And what we’re going to be doing is looking at what you see now on your screen, the anterior
view of your trunk and describing all these colorful structures here that are, then, your… the
different arteries, different veins, and also nerves that we find in this part of your body, the
ventral trunk.

And the first we’re going to start covering are then the arteries that I’m going to list now before
we talk about them in a little bit more detail.

So we’re going to be talking about the internal thoracic, the lateral thoracic, the anterior
intercostal, superior epigastric, and inferior epigastric arteries. So all of these arteries are going
to be discussed on the following slides.

We’re going to start off with the very first one here on the list that you now see here highlighted
in green on this image.

And keep in mind that we’re still looking at the anterior view of your chest now or the trunk, but
we stripped all of those muscles, and veins, and nerves to just be left with bones and the
different arteries that we’re going to be talking about.

Now, these highlighted structures are, if you remember from that list, yes, we’re looking at the
internal thoracic arteries.

These structures are going to be supplying the anterior chest wall and the breasts, and they
arise from the subclavian arteries, as you can also see here on the image, the subclavian
arteries. And notice how the internal thoracic arteries are coming out of these structures.

Now, the internal thoracic artery will be dividing into other branches, including the
musculophrenic artery and also the superior epigastric artery around the sixth intercostal space.

We’re moving on to another set of structures or arteries, and here, we just see one on one side.
This highlighted artery is known as the lateral thoracic artery.

Now, this one will be arising from the axillary artery, which you can see here on this image. It will
be forming different connections, what we call then—a fancy word for it—anastomosis.

And this structure, this lateral thoracic artery is going to be anastomosing with the internal
thoracic artery, also the subscapular artery, the intercostal arteries, and with the pectoral branch
of the thoracoacromial artery.

Now, as every good artery, this one will be supplying different structures with oxygenated blood,
including the serratus anterior muscle, the pectoralis major muscle.
It also sends branches across the axilla to the axillary lymph nodes and also the subscapularis
muscle.

Now, in females, it supplies an external mammary branch which turns around the free edge the
pectoralis major, then supplies the breasts.

The next structure that we’re going to be talking about, the next artery that you now see here or
a set of arteries that you see here, they are known as the anterior intercostal arteries.

Now, they arise from the internal thoracic artery in the upper five or six interspaces and from the
musculophrenic artery.

Now, these arteries will also be forming connections with other arteries, which we call
anastomosis, with the first interspace with the different branches of the costal cervical trunk and
in the other interspaces with the aortic intercostal arteries.

Now, the anterior intercostal arteries will be supplying the external and internal intercostal
muscles and also the ribs.

The next one on the list that you see here, this is a paired artery known as the superior
epigastric artery. You have two as you can see here on the highlighted image.

Right now, what we did, we just moved a bit further down. We’re still looking at the anterior view
of this image, but now, a little bit more focused on the abdominal region.

Now, the superior epigastric artery arises from the internal thoracic artery and will be forming
anastomosis with the inferior epigastric artery as you can clearly see here on this image, these
are the inferior epigastric arteries.

And you notice how they form some connections here, anastomosis, with the superior epigastric
arteries.

Now, the superior epigastric artery will be supplying the anterior part of the abdominal wall and
some of the diaphragm.

We’re going to be talking about the next set of arteries, two arteries that we just talked about. If
you guess, yes, these are the inferior epigastric arteries.

And these will be arising from these arteries here. I don’t know if you remember from the
tutorials where we went over these structures here.

Yes, these are the external iliac arteries, and these are branches… the inferior epigastric
arteries are branches of the external iliac arteries.
And as I mentioned on the previous slide, these arteries will be forming connections to,
anastomosis with the superior epigastric artery, which you can also see here.

And we form these connections specifically at your navel or also known as a more technical
term, the umbilicus.

The inferior epigastric arteries are going to be supplying the anterior and caudal parts of the
abdominal wall.

We have now covered the different arteries. We’re moving on to these structures in blue that are
known as the veins of the ventral trunk, and I’m going to list them before we go into more detail
throughout this tutorial.

We’re going to be seeing the internal thoracic, the anterior intercostal, the thoracoepigastric, the
superficial epigastric, the superior epigastric, and then the inferior epigastric.

Let’s start with the very first one here on the list that you see here highlighted in green. These
are the internal thoracic vein. Similar to the internal thoracic arteries that we saw.

Arising from the superior epigastric vein, they accompany the internal thoracic artery along its
course and drain into the brachiocephalic vein.

The next structures that we’re going to be seeing here now in green, these, as you probably
guessed, anterior intercostal veins, like we also saw with the arteries.

The anterior intercostal veins are the veins which drain the anterior intercostal spaces into the
internal thoracic vein.

The next structure, next veins that you see here highlighted in green, these are known as the
thoracoepigastric veins.

And these are important veins because when your inferior vena cava becomes obstructed, they
actually provide a collateral venous return. It creates what is called as a cavocaval anastomosis
with the superficial epigastric veins.

Now, the thoracoepigastric vein will be draining into the lateral thoracic vein and also the
femoral vein.

The next veins that we’re going to be talking about that you see here highlighted in green, these
are known as the superficial epigastric veins.
Now, the superficial epigastric veins are veins which travel with the superficial epigastric
arteries. It collects blood from the lower and medial parts of the anterior abdominal wall and
drains it into the accessory saphenous vein near the fossa ovalis.

There are these structures that we’re going to be talking about, these veins that you see now
highlighted in green which are known as, now, the superior epigastric veins.

Now, the superior epigastric veins refer to a blood vessel that carries deoxygenated blood of
course, blood from the anterior part of the abdominal wall and some of your diaphragm and then
will drain it into the internal thoracic vein.

The superior epigastric vein will be forming an anastomosis or a connection with the inferior
epigastric vein, as you can also see here on this image.

And just as we talked about then, it is time to then talk about these structures that you see here
highlighted in green. These veins are known as the inferior epigastric veins.

Now, the inferior epigastric veins, they arise from the superior epigastric vein and drain into the
external iliac vein, which you can see here on this image. These are the external iliac veins.

We have completed the different veins, the main veins that you find on the ventral trunk. It is
time for us to move on and talk about the different nerves that we find in this region of your
body.

Now, this will include then the brachial plexus, the medial pectoral nerve, the lateral pectoral
nerve, the subcostal, the genitofemoral nerve, and the iliohypogastric nerve, and as well as the
ilioinguinal nerve.

We’re going to start off by briefly talking about this structure here, which is known as the
brachial plexus, a very important structure that you need to learn in anatomy.

It is quite complex to learn, but we’re going to just briefly mention a few points that you need to
know for this particular tutorial.

Now, the motoric and branches of the brachial plexus are irrelevant for this tutorial as they go
into or most of them go into your arm.

However, there are other branches directly from the brachial plexus that are worth mentioning,
including the subclavian nerve, which runs together with the brachial plexus through the
interscalene triangle towards the subclavius muscles, which it innervates.

So, another important branch is the long thoracic nerve, which runs caudally towards the
serratus anterior muscle, which is going to then be innervated by the long thoracic nerve.
Additionally, the medial and pectoral nerves arise from the brachial plexus cords, but we’re
going to be talking about, right about next, as you can see here on this image, this is the medial
pectoral nerve highlighted in green.

And as I mentioned, this one will be arising from this cord here, the medial cord of the brachial
plexus.

The medial pectoral nerve will be innervating the pectoral minor and the pectoralis major
muscles.

A good way to remember how to differentiate the medial pectoral nerve which pierces both
pectorals from the lateral pectoral nerve which pierces only the pectoralis major is this
pneumonic here that I use.

The lateral less, medial more. So L-L, M-M. Don’t forget this.

We’re moving on to the next set of nerves that you see here. This is then the lateral pectoral
nerves. The lateral pectoral nerves arise from the lateral cord of the brachial plexus.

As you can also here on this image, this is the lateral cord of the brachial plexus and the medial
cord here where we also see here the medial pectoral nerve.

The lateral pectoral nerve will be then innervating the deep surface of the pectoralis major
muscle.

Although this nerve is described as mostly motor, it also has been considered to transport
proprioceptive and nociceptive fibers.

We’re ready to move on to the next ones that you see here highlighted in green. These are
known as subcostal nerves. And the subcostal nerves are the anterior division of the twelfth
thoracic nerve.

Now, they will be innervating a few structures including the transversus abdominis, the
abdominal internal oblique, and also the pyramidalis muscle.

It also gives off a lateral cutaneous branch that supplies the sensory innervation of the skin over
the hip.

The next ones that we’re going to also see here, this pair is known as the genitofemoral nerves,
and these nerves are found of course on the abdominal region and the genitofemoral nerve
originates from the upper L1 to L2 segments of the lumbar plexus.

Will be giving off two branches, the genital branch and of course a femoral branch.
Now, the genital branch passes through the deep inguinal ring and enters the inguinal canal.

In men, the genital branch continues down and supplies the scrotal skin, and in women, the
genital branch accompanies the long—the round ligament of the uterus and terminating in the
skin of the mons pubis and also the labia majora.

The femoral branch passes underneath the inguinal ligament, traveling adjacent to the external
iliac artery and then supplies the skin of the upper and anterior thigh.

We’re going to continue on to the next set of nerves that you see here highlighted in green.
These are known as the iliohypogastric nerves. And these are the superior branches of the
interior ramus of the spinal nerve, L1.

Will be giving off two branches, and these are the lateral cutaneous branch and the anterior
cutaneous branch.

The lateral cutaneous branch will be innervating the abdominal internal oblique muscle and the
skin of the gluteal region, while the anterior cutaneous branch will be, then, supplying or
innervating the abdominal internal oblique muscle as well, the abdominal external oblique, and
the skin of the hypogastric region.

The next pair of nerves that you see here highlighted in green, these are known—and we have
now here a few more structures so you can see how these nerves connect to some of the
structures that you see here, a few blood vessels as well as some muscles.

These highlighted are then the ilioinguinal nerves.

They are branches of the first lumbar nerve, L1. They separate from the first lumbar nerve along
with the larger iliohypogastric nerve, the one we just talked about before.

The ilioinguinal nerve will be, then, innervating the abdominal internal oblique muscle, also the
skin of the upper and medial parts of the thigh. And also in males, they will be innervating the
skin over the root of the penis and part of the scrotum. And in females, to the skin covering the
mons pubis and the labium majus.
Arteries Internal thoracic artery:
Origin: Subclavian artery
Branches: Musculophrenic artery, superior epigastric artery, upper 6 anterior
intercostal arteries
Superior thoracic artery:
Origin: Axillary artery
Lateral thoracic artery:
Origin: Axillary artery
Anterior intercostal arteries:
Origin: Internal thoracic artery (upper 6), musculophrenic artery (lower 3)
Posterior intercostal arteries:
Origin: Supreme intercostal artery (upper 2), thoracic aorta (lower 10)
Subcostal artery:
Origin: Thoracic aorta

Veins Anterior intercostal veins:

Drain into: Internal thoracic vein
Posterior intercostal veins:
Supreme intercostal vein drains into: Brachiocephalic vein
Superior intercostal vein drains into: Azygos/left brachiocephalic vein
Right 4th-11th drain into: Azygos vein
Left 4th-7th drain into: Accessory intercostal vein
Left 8th-11th drain into: Hemiazygos vein
Superior intercostal vein:
Drains into: Left brachiocephalic vein (left), azygos vein (right)
Subcostal vein:
Drains into: Azygos vein

Nerves Thoracic nerves:

Anterior rami of spinal nerves T1-T11: Intercostal nerves
Anterior ramus of spinal nerve T12: Subcostal nerve
Brachial plexus:
Long thoracic nerve (C5, C6, C7)
Lateral pectoral nerve (C5, C6, C7)
Medial pectoral nerve (C8, T1)
If there’s one thing we can say with certainty about our bodies is that they’re both organized and
efficient in their layout. Almost every structure in our body, big or small, is compartmentalized in
one way or another to ensure that everything stays where it needs to be. One way which our
body achieves this is by the presence of defined spaces or cavities. For instance, our cranial
cavity keeps our brain safely tucked in our head and our abdominal cavity packs in over seven
meters of gut to absorb anything worth taking from that burg you had for lunch.

Our thoracic cavity is also an interesting space with its bony cage protecting your heart and
lungs, but between our lungs is a special yet somewhat anatomically complex region whose
name alone often brings horror to anatomy students all over. But don’t fear, that’s why we’re
here. I assure you, it’s safe to come out because today, we’re going to master the anatomy of
the mediastinum.

So let’s get down to business and see what the fuss is all about.

So we’ve established that the mediastinum is located roughly on the midline of our body
between the pleural cavities of the thorax. In our tutorial today, we’re going to be looking at the
anatomy of this space with these two illustrations with both right and left lateral views of the
thorax. So, let’s take a moment to define some of the anatomical boundaries of the mediastinum
as a whole.

Anteriorly, the mediastinum is limited by the anterior thoracic wall which is comprised of the
sternum as well as the costal cartilages of the first to fifth ribs which you can see here
highlighted in green. The posterior boundary of the mediastinum is marked by the vertebral
bodies of the superior thoracic vertebrae. Knowing the anterior and the posterior borders of the
mediastinum, we can now define the superior most border of the mediastinum as the superior
thoracic aperture delineated by the manubrium of the sternum following around the superior
border of the first rib to the T1 vertebral body.

Of course, laterally, since the mediastinum is located between the pleural sacs, the parietal
pleura of each lung provides the lateral border for each side of the mediastinum. And, finally, the
inferior boundary of the mediastinum is formed by the respiratory diaphragm which you can see
just over here.

So, to give our borders a little bit more context, let’s take an alternative look at the mediastinum
by looking at the diaphragm from a superior perspective. So here you can get a better idea of
the space occupied by the mediastinum.

Okay, now, let’s get into the nitty-gritty of what the mediastinum is all about.
So as typical anatomists, we like to divide things up into smaller divisions to make it easier for
us to explore and, of course, the mediastinum is no different. So, the mediastinum as a whole
can be subdivided into two major divisions. And, firstly, we have the superior mediastinum which
is found superior to an imaginary line known as the thoracic plane intersecting the sternal angle
anteriorly and the T4 to T5 intervertebral discs posteriorly. And, of course, if we have a superior,
there must also be an inferior mediastinum, and as you can see, this is the space inferior to the
thoracic plane we just mentioned – and guess what? – we can divide this one up even more.

So, the inferior mediastinum is actually further subdivided into three smaller subsections mainly
in relation to the pericardial sac around the heart. And anterior to the pericardial sac is the
anterior mediastinum which is more of a potential space limited by the anterior thoracic cage.
The pericardial sac, its contents, and adjacent parts of the great vessels are located in the
middle mediastinum which means that everything else posterior to or behind the pericardial sac
is unsurprisingly considered to reside in the posterior mediastinum.

So, in this tutorial, we’re going to explore each region of the mediastinum one by one,
examining the organs and the major neurovasculature located within each division. So let’s get
to it and begin first with the superior mediastinum.

So just to remind ourselves of where the superior mediastinum begins and ends, remember that
it is the space superior to the thoracic plane running from the sternal angle and the T4 to T5
intervertebral disc. And we’re going to work anterior to posterior and quickly identify the major
structures found here.

First up is this somewhat fatty glandular-looking organ here which is the thymus, which is one of
our primary lymphoid organs. And this means that it’s where our body produces our
lymphocytes which work hard to kill off those pesky bacteria and viruses attacking our bodies.

When we’re younger, the thymus is a flat, bilobar gland, however, after puberty, it undergoes a
gradual involution – meaning that it shrivels up – and is largely replaced by fat tissue instead.

Our next structure of interest in the superior mediastinum is this one here, which you might be
able to identify by its characteristic cartilaginous ring seen here. And that’s right. It’s indeed the
trachea, commonly known as the windpipe. And the trachea, of course, descends from the
larynx into the neck deviating just a little to the right of the midline. It passes inferiorly to around
the level of the T5 vertebra where it bifurcates into the right and left main bronchi which enter
the hilum of the lung.

Just posterior to the trachea is the esophagus, which is this fibromuscular tube which carries our
swallowed food from the pharynx along the length of the superior and posterior mediastina
before continuing into the abdomen via the diaphragm.

Posterior to the thymus are several major arteries and veins, and we’re going to begin with this
one here highlighted in green for you which is the superior vena cava. The superior vena cava is
formed by the union of the left and right brachiocephalic veins and carries deoxygenated blood
received from the head, the neck, the upper limbs, and the thoracic wall. And we can tell from
this illustration that the superior vena cava is situated in the right side of the superior
mediastinum and empties its contents directly into the right atrium of the heart which is over
here.

The superior vena cava also receives the contents of the azygos vein, which runs along the
right-hand side of the vertebral bodies before arching over the right main bronchus. And as it
courses through the mediastinum, the azygos vein receives several of the right posterior
intercostal veins which drain the right intercostal spaces.

So we’re going to turn our focus over to the left view of the mediastinum now so we can get a
better view of some of the other vasculature of the superior mediastinum. So again to begin of
course with this structure here which is the aortic arch which is a continuation of the ascending
aorta beginning at about the level of the second sternocostal joint. And as it courses through the
superior mediastinum, it arches posteriorly and to the left before then turning inferiorly as the
descending thoracic aorta just to the left of the T4 vertebral body.

The aortic arch gives off three large branches which are the brachiocephalic trunk which is not
visible in this illustration, the left common carotid artery which supplies much of the left side of
the head and neck, and the left subclavian artery which provides arterial supply of the upper
limb as well as the upper spinal cord, the brainstem, the cerebellum, and the posterior
cerebrum.

So before we move on from the superior mediastinum, let’s just check out some of the major
nerves that are present here. So beginning first with the left vagus nerve which enters the
superior mediastinum between the left common carotid and the subclavian arteries. So when
the left vagus nerve reaches the aortic arch, it turns posteriorly before coursing medially at the
inferior border of the aortic arch where it gives off the left recurrent laryngeal nerve which goes
on to ascend back up into the neck running in a groove formed by the trachea and the
esophagus.

The left vagus nerve then descends posterior to the root of the left lung giving several branches
to the left pulmonary plexus before continuing on to join its right counterpart to form the
esophageal plexus.

The phrenic nerve provides both sensory and motor innervation to the respiratory diaphragm as
well as sensory innervation to the pericardium of the heart. As you can see in the illustration, the
phrenic nerve descends into the superior mediastinum between the subclavian artery and the
brachiocephalic vein. The phrenic nerve then passes anterior to the root of the lungs which will
help you distinguish it from the vagus nerve in your dissection class.

And with that, we’ve touched on the main structures of the superior mediastinum. So let’s drop
down into the inferior mediastinum now and get a hold on the anatomy there.
So you’ll remember from the beginning of our tutorial that the inferior mediastinum is subdivided
into three parts which are the anterior, middle, and posterior mediastina. In reality, the anterior
mediastinum is extremely limited in volume and is defined as the space between both the
pleural sacs anterior to the pericardial sac. And if we look at the anterior mediastinum from a
superior view, we can get an even better understanding of its proportions.

So given the fact that it’s almost only a potential space, it will come as no surprise to hear that
there’s very little anatomy for us to examine here. In fact, the only structures that you’ll find here
are some remnants of the thymus as well as some anterior mediastinal lymph nodes such as
the prepericardial lymph nodes.

Moving posteriorly, we’re now entering the middle mediastinum which is the largest portion of
the inferior mediastinum. And it’s dominated by the pericardial sac which means that the middle
mediastinum is where our heart takes residence in addition to the great vessels such as the
inferior part of the superior vena cava, the inferior vena cava, the pulmonary veins, the
pulmonary trunk and arteries, and of course the ascending aorta.

Other major vasculature in this region includes the pericardiophrenic arteries as well as its
venous counterpart, the pericardiophrenic veins. The main bronchi are also considered to be
part of the middle mediastinum.

And that brings us back to the posterior mediastinum which is interposed between the
pericardial sac and the T5 to T12 vertebral bodies. And although the posterior mediastinum is
smaller than the middle mediastinum, it contains quite a lot of anatomical structures which we’re
going to find a little bit more about right now.

So, we’re going to begin with what is arguably the most important structure of the posterior
mediastinum which is the descending thoracic aorta. So continuing on from the aortic arch, the
descending thoracic aorta runs along the left side of the lower thoracic vertebral bodies before
passing through the aortic hiatus of the respiratory diaphragm, and once it’s there, it becomes
the abdominal aorta.

As it descends through the posterior mediastinum, the descending thoracic aorta gives off
paired lateral branches which supply the intercostal spaces between the third through to the
twelfth ribs. And these are known as the posterior intercostal arteries.

Along its anterior aspect, the descending thoracic aorta gives off between two and five unpaired
esophageal branches as well as a number of bronchial and pericardial branches. It also gives
off a pair of superior phrenic arteries which supply the diaphragm. Running laterally to the
descending thoracic aorta are the hemiazygos and accessory hemiazygos veins which receive
the contents drainage by the left posterior intercostal veins. And in this illustration, you can also
see this vein here which is the left superior intercostal vein which drains the uppermost
intercostal spaces.
And finally before we complete our study of the posterior mediastinum, let’s just take a moment
to look at the major nerves found in this region.

So many of the nerves which we saw in the superior mediastinum naturally continue their
course down into the posterior mediastinum, for example, the vagus and the phrenic nerves as
well as their respective branches. And though technically not part of the posterior mediastinum, I
want to take a quick look at this collection of nervous structures situated here along the
posterior thoracic wall.

So running inferior to each rib alongside the posterior intercostal arteries and veins are the
intercostal nerves which are the anterior rami of the thoracic spinal nerves. All of the intercostal
nerves supply innervation to the parietal pleura and structures of the thoracic wall.

You also see this chain of nerves and ganglia descending here along the posterolateral border
of the vertebral bodies and this is known as the sympathetic trunk and the sympathetic ganglia
which, as its name suggests, is one of the major pathways of the sympathetic division of the
autonomic nervous system. You can also see several branches coming off the sympathetic
trunk which also descend inferiorly into the abdomen and these form what’s known as the
greater thoracic splanchnic nerve which provides sympathetic innervation to several parts of the
gastrointestinal tract as well as to other abdominal organs.

And with that we’ve reached the end of our tour of the mediastinum. So now that we’ve explored
the anatomy of the mediastinum, let’s finish up our tutorial today with some clinical correlates of
the mediastinum.

Mediastinitis is an extremely serious condition which involves inflammation of the mediastinal

tissues due to chronic or acute infection, and it can be a life-threatening condition and like many
infections, needs immediate treatment. Acute mediastinitis may occur as a result of infection
originating from one of the structures within the mediastinum or it may migrate from another
region of the body altogether.

For example, infections originating from within the mediastinum could arise due to rupture or
perforation of the esophageal wall which can occur after foreign body ingestion, cancer or due
to iatrogenic causes, which means conditions resulting from medical procedures such as
intubation, gastrointestinal endoscopy or cardiothoracic surgery. An infection can also spread
from the lungs or even from the bones of the thoracic wall.

Infections originating from outside of the mediastinum most often involve the spread of
retropharyngeal and odontogenic infections.

Clinical features of acute mediastinitis are similar to those seen with other major infections such
as chills, fever, tachycardia, tachypnea, and general restlessness. Of course, in cases of
mediastinitis, the patient will also experience chest pain which may be referred to the neck or to
the interscapular region of the back. Chronic mediastinitis is caused by fibrosis of the soft tissue
of the mediastina resulting from immune-related diseases such as histoplasmosis and
tuberculosis, and this can cause constriction or obstruction of airways or vessels of the
mediastinum – for example, superior vena cava syndrome which causes swelling of the upper
limbs, the head and the neck region as well as breathing distress and lightheadedness.

And with that, we’ve reached the end of our tutorial on the mediastinum. Before I leave you, let
me quickly summarize what we’ve learned today.

So, it began first by defining the main regions of the mediastinum which were the superior
mediastinum located between the thoracic inlet and the thoracic plane and the inferior
mediastinum which is found between the thoracic plane and the respiratory diaphragm. We then
subdivided the inferior mediastinum into three smaller divisions which were the anterior
mediastinum, a small restricted space anterior to the pericardial sac; the middle mediastinum,
which contains the pericardial sac and much of the great vessels; and finally, the posterior
mediastinum, which comprises the space posterior to the pericardial sac.

In the superior mediastinum, we identified several major organs such as the thymus, the
trachea, and the esophagus. We then looked at some of the major vessels in this region which
included the superior vena cava, the arch of the azygos vein, the aortic arch, the
pericardiophrenic artery and vein, the vagus nerve, and the phrenic nerve.

Moving on to the anterior mediastinum, we discovered that this was more of a potential space
only and it contained very few structures; for example, the remnants of the thymus, as well as
the anterior mediastinal lymph nodes. The middle mediastinum, of course, gave us lots of
anatomical structures to consider, none more important than the heart and the pericardium, of
course. And we managed to identify several of the great vessels including the ascending aorta,
the pulmonary trunk and arteries as well as their venous counterparts, the pulmonary veins, and
we also made note of the phrenic nerve descending towards the diaphragm.

Last but not least, we reached the posterior mediastinum, and here we looked at the
descending thoracic aorta as well as a number of its branches including the posterior intercostal
arteries. We also saw the continuation of the esophagus as it descended towards the abdomen
and lateral to the vertebral bodies we looked at the sympathetic trunk and ganglia as well as the
greatest splanchnic nerve which provides sympathetic innervation to parts of the gastrointestinal
tract and to other abdominal organs.

And that wraps up our tutorial for today. I hope you’ve enjoyed exploring the mediastinum. It’s
not so complicated after all. So we’re looking for a few to having you join us for another Kenhub
tutorial soon, but until then, happy studying!
Borders Superior: Superior thoracic aperture (delineated by the manubrium of the
sternum, superior border of the first rib and T1 vertebral body)
Inferior: Diaphragm
Anterior: Sternum and costal cartilages of 1st-5th ribs
Posterior: Vertebral bodies of superior thoracic vertebrae
Lateral: Parietal pleura of each lung

Divisions Thoracic plane: Extends from sternal angle to vertebrae T4/5 intervertebral
space
Superior mediastinum: Above thoracic plane
Inferior mediastinum: Below thoracic plane, further subdivided into anterior,
middle and posterior compartments, according to relations with pericardial sac

Contents Superior mediastinum: Thymus, trachea, superior part of superior vena cava,
aortic arch and its branches (brachiocephalic trunk, left common carotid artery
and left subclavian artery, esophagus
Anterior mediastinum: Some remnants of the thymus
Middle mediastinum: Pericardial sac and heart; roots of superior and inferior
vena cava; pulmonary trunk, arteries and veins; root of aorta; main bronchi;
pericardiacophrenic arteries and veins
Posterior mediastinum: Descending thoracic aorta and its branches; azygos
veins, esophagus

Definition Esophagus is a muscular, tubular part of the gastrointestinal tract, connecting

the pharynx to the stomach

Parts Cervical part: Between pharyngoesophageal junction and upper thoracic

aperture
Thoracic part: Between upper thoracic aperture and esophageal hiatus
Abdominal part: Between esophageal hiatus and gastroesophageal junction

Function Propel food from pharynx to stomach through peristaltic movements

Neurovascular supply Arterial supply: Esophageal branches of inferior thyroid artery, esophageal
branches of aorta, right intercostal arteries, esophageal branches of left gastric
artery
Venous drainage: Esophageal veins drain into inferior thyroid vein, azygos
venous system, left gastric vein
Innervation via esophageal plexus: Parasympathetic innervation from vagus
nerve (CN X), recurrent laryngeal nerve; sympathetic supply from cervical and
thoracic sympathetic trunk and thoracic spinal nerves T5-T12
Myenteric plexus (of Auerbach) and submucosal plexus (of Meissner) embedded
in esophageal wall play role in regulating peristalsis
Lymphatics: Deep cervical lymph nodes, regional lymph nodes
(juxtaoesophageal lymph nodes), paratracheal, superior and inferior
tracheobronchial lymph nodes, left gastric and coeliac lymph nodes

Relations Posterior: Vertebral column, distal part of descending thoracic aorta

Anterior: Trachea, left main bronchus, left atrium of heart
Lateral: Proximal part of descending thoracic aorta

Definition The trachea is a fibrocartilaginous tube that transports air from the upper
respiratory tract to the lungs and vice versa

Structure Anterolateral wall: 16-20 tracheal cartilages connected by anular ligaments

Posterior wall: Fibromuscular wall (trachealis muscle)

Function Air conduction, immune and mechanical protection

Lateral view Right lung: Apex, costal impressions, oblique fissure, horizontal fissure, superior
lobe, medial lobe, inferior lobe
Left lung: Apex, cardiac notch, lingula, superior lobe, inferior lobe
Medial view Right lung: Horizontal and oblique fissures, smaller cardiac impression, grooves
for trachea, esophagus, brachiocephalic vein, azygos vein, superior vena cava,
inferior vena cava
Left lung: Oblique fissure, cardiac impression, grooves for aorta, subclavian
artery, 1st rib, trachea, esophagus

Hilum contents Principal bronchus, lobar bronchi (superior, intermediate, inferior), one
pulmonary artery, two pulmonary veins, bronchial arteries and veins, pulmonary
nervous plexus, lymphatics, bronchopulmonary lymph nodes, areolar tissue

Right lung Consists of three lobes: Superior, middle and inferior, separated from each other
by the horizontal and oblique fissures, respectively

Left lung Left inferior lobe separated by the oblique fissure from the superior lobe
Noticeable cardiac notch, which exposes the pericardium over the apex of heart

Surface projections Apex of lung: ~2.5 cm above the clavicle

Inferior border of lung: 6th rib, 8th rib, and 10th rib
Inferior border of pleura: 8th rib, 10th rib, and 12th rib

Superficial (subpleural) Drains visceral pleura and superficial lung parenchyma (tissue) → drains initially
pathway into the bronchopulmonary nodes

Deep (central) pathway Drains bronchi and peribronchial parenchyma → drains initially into the
intrapulmonary nodes

Right lung Intrapulmonary nodes → bronchopulmonary nodes → right inferior

tracheobronchial nodes → right superior tracheobronchial nodes → right
paratracheal nodes → right bronchomediastinal lymph trunk → right venous
angle → venous circulation
 Left lung Upper lobe: Intrapulmonary nodes → bronchopulmonary nodes → left inferior
tracheobronchial nodes → left superior tracheobronchial nodes → left
paratracheal nodes → left bronchomediastinal lymph trunk → left venous angle
(or thoracic duct) venous circulation
Lower lobe: Intrapulmonary nodes → bronchopulmonary nodes → left inferior
tracheobronchial nodes → right superior tracheobronchial nodes → right
paratracheal nodes → right bronchomediastinal lymph trunk → right venous
angle → venous circulation

Location/Orientation Location: Middle mediastinum, mostly to the left of the midsagittal plane
Orientation: Positioned in a direction extending from the right shoulder to left
hypochondrium, with the apex biased towards the left

Visceral relationships Pericardium (sac surrounding the heart)

Thymus (anterior)
Lungs (lateral)
Diaphragm (inferior)
Esophagus (posterior)

Surrounding Arteries: Aortic arch, brachiocephalic trunk, right and left common carotid
neurovasculature arteries, right and left subclavian arteries, internal thoracic artery,
pericardiacophrenic artery, pulmonary trunk

Veins: Left and right internal jugular veins, left and right subclavian veins, left
and right brachiocephalic veins, superior vena cava, pericardiacophrenic

Nerves: Left and right vagus nerves (CN X), left and right phrenic nerves

The heart is a muscular organ that pumps blood around the body by circulating it through the
vascular system. It sits in the middle mediastinum between the left and right lungs, anterior to
the esophagus and posterior to the sternum. It presents five surfaces:

Anterior (sternocostal) surface, which lies adjacent to the body of sternum, sternocostal muscles
and the third to sixth costal cartilages.
Inferior (diaphragmatic) surface, which sits mainly on the central tendon of the diaphragm.
Left and right (pulmonary) surfaces, which face the left and right lungs, respectively. The left
surface involves the lateral portion of the left ventricle as well as a small part of the left
atrium/auricle, while the right surface is found between the superior vena cava and the
intrathoracic part of the inferior vena cava.
Posterior surface (base), which lies anterior to the principal bronchi and esophagus.
The heart also presents four borders:

The right border is a line that runs mainly over the right atrium, extending between the superior
and inferior vena cava, and over a small portion of the right ventricle.
The left (obtuse) border separates the left and anterior surfaces, mainly formed by the left
ventricle and part of the left auricle.
The superior border is a line that goes over the roots of the aorta and pulmonary trunk and a
small portion of the left and right auricle.
The inferior (acute) border extends along the right ventricle and part of the left ventricle at its
apex.

Anterior (sternocostal) Components: Right atrium, ⅔ right ventricle, ⅓ left ventricle

surface Landmarks: Right auricle of heart, coronary sulcus, anterior interventricular
sulcus, cardiac apex
Vessels: Right coronary artery, anterior interventricular artery/vein, anterior veins
of right ventricle
Relations: Sternum, sternocostal muscles, third to sixth costal cartilages

Inferior (diaphragmatic) Components: Left ventricle, right ventricle

surface Landmarks: Inferior (posterior) interventricular groove, atrioventricular groove,
cardiac apex
Vessels: Inferior (posterior) interventricular artery, middle cardiac vein, coronary
sinus, inferior vein of right ventricle
Relations: Sits mainly the central tendon of diaphragm, and a small portion of left
muscular part of diaphragm

Left (pulmonary) surface Components: Left ventricle, small part of left atrium and left auricle of heart
Landmarks: Atrioventricular groove
Vessels: Circumflex artery, great cardiac vein, left marginal vein
Relations: Left pericardiacophrenic neurovascular bundle, left pleura/lung
Right (pulmonary) Components: Right atrium
surface Landmarks: Sulcus terminalis
Relations: Intrathoracic part of inferior vena cava, superior vena cava, right
pleura/lung

Posterior surface (base) Components: Right atrium, left atrium

Vessels: Coronary sinus, left and right pulmonary veins, vena cavae
Relations: Principal bronchi, esophagus

Features Receives deoxygenated blood from the systemic circulation via the superior
vena cava, inferior vena cava and coronary sinus

Characteristics: Thin wall; contains the sinoatrial and atrioventricular nodes;

three internal surfaces (venous, vestibular, auricular)

Landmarks: Right auricle

Function: Reservoir for blood and an active pump that helps fill the ventricle

Right auricle of heart Cone-shaped pouch which extends from the superoanterior part of right atrium

Pectinate muscles Array of parallel muscular columns on the internal anterior wall of right atrium

Crista terminalis Crescent-shaped muscular ridge on the internal aspect of right atrium that
externally corresponds with the terminal sulcus

Sinus of venae cavae Portion of right atrium that receives the superior and inferior venae cavae

Vestibule of right Fibrous rings that support the leaflets of the right atrioventricular valve
atrioventricular valve
Fossa ovalis Oval depression on the interatrial septum (remnant of foramen ovale)

Sinoatrial (SA) node Collection of specialized nodal tissue that produces electrical impulses that
travel through the electrical conduction system
(natural pacemaker)

Atrioventricular (AV) Part of electrical conduction system found near coronary sinus on the interatrial
node septum

Features Receives deoxygenated blood from the right atrium and pumps it to the lungs for
oxygenation
Characteristics: Septomarginal trabecula (moderator band)
Landmarks: Three prominent papillary muscles
Function: Pumps blood into the pulmonary circulation

Supraventricular crest Round accentuation of the internal muscular wall that separates the conus
arteriosus from the rest of the ventricular cavity

Conus arteriosus Conical pouch where the pulmonary trunk arises

Trabeculae carneae Muscular elevations that course along mainly apical parts of ventricular wall

Papillary muscles Muscular projections attached to cusps of right atrioventricular valve via
(anterior, inferior, septal), tendinous cords (chordae tendineae) preventing prolapse
chordae tendineae

Septomarginal trabecula A muscular tissue that transmits the right branch of atrioventricular bundle from
the interventricular septum to the anterior papillary muscle

Features Receives oxygenated blood from the lungs via the pulmonary veins (4 ostia)

Characteristics: Cuboidal chamber, thicker walls (compared to right atrium); has

a small muscular pouch → left auricle of heart (contains pectinate muscles)
 Landmarks: T5 - T8 (supine), T6 - T9 (erect)

Function: Reservoir for blood and active pumps that help fill the ventricles

Sinus of pulmonary veins Portion of posterior wall of left atrium that receives pulmonary veins

Vestibule of left Contains fibrous ring that supports the leaflets of left AV valve
atrioventricular valve

Features Receives oxygenated blood from left atrium

Characteristics: Long conical shape, thicker walls (compared to right ventricle),
smooth inflow/outflow tracts
Function: Pumps blood into systemic circulation

Aortic vestibule Area immediately below aortic orifice, has fibrous walls that support leaflets of
aortic valve

Trabeculae carneae Muscular elevations that course along mainly apical parts of ventricular wall

Papillary muscles Muscular projections attached to cusps of left atrioventricular valve via tendinous
(superior/anterior, cords (chordae tendineae) preventing prolapse
inferior/posterior),
chordae tendineae

Apex of heart Rounded anteroinferior extremity of heart formed by left ventricle;

Located at left 5th intercostal space approximately 9 cm from median plane
where apex beat (sounds of left AV valve closure) is maximal

Right atrioventricular Leaflets (cusps): 3 - superior (anterior), inferior (posterior) and septal
valve (tricuspid) Papillary muscles: Anterior, septal (medial) and inferior (posterior)
Position: Between right atrium and right ventricle
Function: Prevents backflow from right ventricle into right atrium
Left atrioventricular valve Leaflets (cusps): 2 - anterior (aortic) and posterior (mural)
(mitral) Papillary muscles: Inferior (posterior) and superior (anterolateral)
Position: Between left atrium and left ventricle
Function: Prevents backflow from left ventricle into left atrium

Pulmonary valve Leaflets (cusps): 3 - anterior (non-adjacent), right (right adjacent), and left (left
adjacent)
(No associated papillary muscles)
Position: Between right ventricle and root of pulmonary trunk
Function: Prevents backflow from pulmonary circulation into right ventricle

Aortic valve Leaflets (cusps): 3 - right coronary (right semilunar), left coronary (left
semilunar), and non-coronary (posterior semilunar)
(No associated papillary muscles)
Position: Between left ventricle and root of aorta
Function: Prevents backflow from systemic circulation into left ventricle

Parasympathetic efferent Cervical and thoracic cardiac branches of vagus nerves

fibers Function: Reduce heart rate, reduce force of contraction of myocardium,
vasoconstriction of coronary arteries

Sympathetic efferent Cardiac nerves from superior, middle and inferiorcervical and upper thoracic
fibers ganglia
Function: Increase heart rate, increasing force of contraction of myocardium,
increasing blood flow in coronary vessels

Afferent parasympathetic Cervical and thoracic cardiac branches of vagus nerves

Function: Feedback on blood pressure

Afferent sympathetic Afferents to middle and inferior cervical and upper thoracic ganglia
fibers Function: Feedback on blood pressure, pain sensation
 Lymphatic plexuses of Subendocardiac plexus: Drains into subepicardial plexus
the heart Myocardiac plexus: Drains into subepicardial plexus
Subepicardiac plexus: Efferents form the right and left coronary trunks

Right coronary trunk Drains: Right atrium, right border of heart and inferior (diaphragmatic) surface of
right ventricle
Empties into: Brachiocephalic lymph nodes (usually on the left) → thoracic duct

Left coronary trunk Drains: Regions of right and left ventricles around anterior interventricular
groove, as well as inferior (diaphragmatic) surface of left ventricle
Empties into: Inferior tracheobronchial lymph nodes → right lymphatic duct

Heart
This patient is in critical condition. We need to perform an emergency thoracotomy to repair her
wounds. We’ll start with incisions up the mid-axillary lines bilaterally, across the clavicles, over
the manubrium, and across the costal margin. Now, cut the ribs and clavicles. Now, let’s remove
the chest wall and save this patient. Wow, that sounds intense. The surgeon has performed an
advanced surgical procedure called the thoracotomy. Let’s step aside and let the healthcare
team treat this patient. We’ll check in with them later.

Meanwhile, we can explore the anatomy we see in this view. Here we are looking at the thorax
with the front part of the chest wall removed, and since none of the structures have been
removed or disturbed, we can say that everything is in situ, which translates to “in its original
place.” In this video, we’ll focus particularly on the heart as it sits in its normal anatomical
position a.k.a. in situ.

Before we delve into the nitty-gritty of our tutorial, let’s briefly go over what we’ll be looking at
today. So, first, we’ll go over the anatomy of the heart that can be seen in the normal anatomical
position, and this will include looking at some of the heart’s chambers, atrial appendages, and
external features. Then, we’ll look at some important neighboring structures including different
tissues and organs. Next, we’ll look at important neurovasculature including arteries, veins and
nerves. And we’ll wrap things up by looking at a clinical scenario related to the heart in situ. But
first let’s start by looking at the belle of this video’s ball – the heart.

In order to see this muscular organ in all its glory, we have to first remove this structure which is
the pericardium. This layer of tissue surrounds and protects the heart. Although it’s very
important, don’t worry too much about it now, we’ll get to it later. With the pericardium out of the
way, we can identify several key anatomical structures of the heart. We’ll be going through the
chambers, the appendages, as well as some of the heart’s external features.

And we’re going to start by identifying its chambers. And from this perspective, we can clearly
see three of the four chambers – these being the right atrium, the smaller right ventricle, and the
larger left ventricle. The fourth chamber – the left atrium – is actually best seen from the back or
the posterior view. We’d had to lift the heart out of the pericardial sac in order to see it, but then
the heart wouldn’t be in situ anymore. But as a quick refresher, here’s what the left atrium looks
like from a posterior view.

Okay, let’s take a second to look at these chambers in a little bit more detail, starting with the
right atrium.

So, blood enters this chamber through two large veins called the superior and inferior vena
cavae although we can only see the superior with the heart in situ. The inferior cava is hiding
behind the heart. And we’ll look at the superior vena cava in more detail a little bit later. The
blood within these veins has just travelled all throughout the body delivering its oxygen to
various muscles and organs, and now it’s returning to the heart to be rejuvenated.

Next, the blood enters the right ventricle by traveling through the tricuspid valve, also known as
the right atrioventricular valve – and we can’t see that valve with the heart in situ as we’d have
to cut open the heart and have a look inside. From the right ventricle, the blood travels to the
lungs to pick up oxygen via the pulmonary trunk which we’ll get to in just a bit.

The largest of the four chambers seen here is the left ventricle, and this sits just inferior and
anterior to the left atrium which, remember, we can’t see since it’s on the posterior side of the
heart, and the blood within this chamber was just revitalized or oxygenated at the lungs, has
traveled through the left atrium, and is ready to be pumped out to the rest of the body to deliver
its delicious oxygen.

Next, we’re going to be looking at two mini-chambers of the heart, and these include the left
atrial appendage and the right atrial appendage. And this little ear-like projections act as
reservoirs for when the larger four chambers become overfilled, and you may hear these
structures also being called auricles which actually means little ear, referring to their shape.

If we look at the left atrial appendage a little more closely, we can see that it is perched just on
top of the left ventricle. Meanwhile, the right atrial appendage sits just on top of the right
ventricle and you can probably see how prominent it is. With the heart in situ, it actually covers a
lot of the right atrium.

Okay, so now that we’ve covered the chambers and appendages seen with the heart in situ,
we’ll check out three of the heart’s external features as seen from this view. So, first stop is the
conus arteriosus and then we have the anterior interventricular sulcus, and finally, we have the
apex of the heart.
The conus arteriosus is this cone-shaped pouch that we can see highlighted now and notice
that it is at the upper most part of the right ventricle and it actually gives rise to the pulmonary
trunk that we saw earlier. It might help to think of it as a small piece of plumbing that connects
the right ventricle and the pulmonary trunk.

Just to the left of the conus arteriosus, we have a shallow groove called the anterior
interventricular sulcus. Now, don’t let this big name scare you. Anterior just means that’s on the
front of the heart, and thinking about the chambers that we looked at earlier will help you figure
out the next word. So, interventricular just refers to the fact that it is located between the right
and the left ventricles. The last word, sulcus, is another term for groove or depression. And it’s
long and narrow and that’s where you’d find the interventricular branch of the left coronary artery
– one of the arteries that we’ll look at later.

So, normally, when you hear apex you may think of top as the top of a mountain. However, this
word really just means the pointy end. In the case of the heart, the apex isn’t’ pointing up, it’s
actually pointing downwards and to the left, and we can see here how the apex of the heart is
part of the left ventricle which we saw earlier.

So now that we covered the heart, we can start investigating some important things that are
close by. We’ll start by looking at relevant lung tissue layers located near the heart that we can
see with the heart in situ including the pericardium and the mediastinal part of the parietal pleura
and there are also some key organs that we can see from this view, too, like the thymus, the
lungs, and the diaphragm. And lastly, we’re going to be looking at the neurovascular structures
we can see with the heart in situ.

So we’re going to start with a structure that we saw at the beginning of the video, and that’s the
pericardium. And this layer of tissue forms a sac around the heart and actually has two layers –
the fibrous pericardium and the serous pericardium – and what we see highlighted now is the
fibrous pericardium which is the most superficial of the two layers.

Next, we have the serous pericardium, which can actually be divided into two parts. On the
inner surface of the fibrous pericardium, we have the parietal layer of the serous pericardium
and adhered directly onto the heart is the visceral layer of the serous pericardium or more
simply known as the epicardium. Between the parietal and visceral layers of the pericardium is a
fluid, and this is simply called the pericardial fluid. The pericardium helps to protect the heart
from infection while fixing it to the mediastinum and also provides some lubrication from the
heart as it vigorously pumps blood throughout the body.

The mediastinal part of the parietal pleura is just one section of a continuous layer of tissue that
lines the inside of the thorax which collectively is called the parietal pleura. The mediastinal part
of this tissue is the part that is contact with the mediastinum and if it helps, you can think of the
thorax as being like a room with the pleura being the wallpaper that’s stuck to the inside walls of
the room. The mediastinal part of the parietal pleura is just one part of the wallpaper that faces
the space found between the two lungs.

Okay, looking at the upper part of the mediastinum, we can see the lymphoid organ known as
the thymus, and if we zoom in, we can see how close the thymus lies to the great vessels of the
heart, which we’ll go over in more detail when we discuss the neurovascular structures.

When we look at the sagittal view, we can see how the thymus sits right at the front of the
mediastinum directly behind the sternum, and this organ would be one of the first thing the
doctor at the beginning of the video would have seen when performing the thoracotomy.
However, normally, as we age, this organ slowly undergoes involution or regresses into fatty
tissue.

On either side of the heart, we can see the right and left lungs and if we take a closer look, we
can actually identify some of the lobes and fissures associated with each lung.

So let’s start with the right lung, which we can see highlighted now and this lung has three lobes
– the superior, middle, and inferior. And these lobes are separated from each other by fissures.
And since we have three lobes, we know that there must be two separate fissures, so let’s have
a look. So, first separating the superior and middle lobes is the horizontal fissure and separating
the middle and inferior lobes is the oblique fissure.

Let’s quickly jump over to the left lung now, and on this side, we only have two lobes as three
lobes would just make it a bit too crowded with the heart in the way. So over here we can see
the superior lobe, and just inferior to that, we can see the inferior lobe. So, just like we saw on
the right side, these lobes are going to be separated by a fissure and in this instance, we only
have one fissure that is separating our two lobes, and this fissure is called the oblique fissure
since it is in an oblique or diagonal orientation.

If we keep our focus near the left lung, we can see one important structure traveling towards it
and that’s the left main bronchus. And here, you can see that it’s kind of hidden behind some of
the great vessels, so if we move these out of the way, we can see the whole left main bronchus
and its counterpart on the other side, the right main bronchus, and you can see that the left
main bronchus comes off the trachea at a little bit more of an angle compared to the right main
bronchus which appears more continuous with the trachea. And this is why if you were to
accidentally inhale a piece of candy down the wrong pipe, it would most likely fall into the right
main bronchus.

So if we go back to our image with the heart in situ, we can see the last neighboring structure
before we get to the neurovasculature and that’s the thoracic diaphragm. Sometimes, it’s also
referred to as the respiratory diaphragm or even more simply just the diaphragm. And this thin
sheet of skeletal muscle extends across the bottom of the ribcage and serves as a boundary
between the upper thoracic cavity and the lower abdominal cavity. And this muscle is very
important as it plays a crucial role in breathing. As it contracts and pulls down on the thorax, the
thoracic cavity gets bigger and air is drawn into the lungs, and when it relaxes, the thoracic
cavity shrinks and air is forced out of the lungs.

Okay, so now that we’ve looked at the heart and some of the surrounding organs and structures,
we’re ready to move on to the arteries, veins and nerves that can be seen with the heart in situ.
And get your notepad ready, there’s quite a few to get through.

So, we’re going to start by looking at the arteries, and we know that normally arteries are
responsible for carrying oxygenated blood, however, we’re going to be looking at one very
unique artery that actually carries blood that is deoxygenated. Then we’ll move on to the veins
and some of the veins that’re close by and have similar names to the arteries so hopefully that
part will be a breeze. And finally, we’ll wrap up this section by looking at some major nerves, and
this will be a nice way to end since the structures we’ve looked at prior will be either good
landmarks of finding these nerves or actually innervated by these nerves.

Okay, so we’ve got a lot to get through so let’s just jump right into it.

So the first artery that we’re going to be looking at is this big one here, and that’s the aortic arch.
The blood that’s being pumped through the aortic arch is highly oxygenated and just came out
of the left ventricle – one of the four chambers that we looked at previously via the ascending
aorta. And it’s easy to remember the name of this one, since this vessel is actually in the shape
of an arch, which can be seen a little bit better if we remove some of the surrounding structures.
And you can also see there are three big branches that come off the arch and ascend upwards,
and these three branches are what we’ll look at next.

With the heart in situ, you can only see a sliver of the first branch of the aortic arch known as the
brachiocephalic trunk and it’s kind of hidden by some of the veins that we’ll get to in a little bit
and usually hides behind the thymus, but that’s already been removed. So, let’s remove a few
more structures so that we can see it a little bit more clearly, and here we go, that’s a lot better.

So now we can see that this artery is actually pretty short before it splits into the right common
carotid artery and the right subclavian artery, and we’ll look at those next. So coming off the
brachiocephalic trunk and going up the neck is the right common carotid artery, and we can see
it pretty well here, but it’s important to see it while the heart is in situ since that’s the whole point
of the video.

Alright, so let’s add all our structures back in. It’s going to hide this artery a little bit, but it’s
important to see where it’s at in relation to everything else. And there we go. So now we can see
that it sits behind the vein and nerve that we’ll talk about in just a minute.

The second branch of the brachiocephalic trunk is the subclavian artery, and this branch heads
a little bit more lateral towards the right arm where it will supply blood. It also gives off some
branches which supply the neck and parts of the brain.
Up next is the left common carotid artery which is the second branch of the aortic arch and this
is different than what we saw on the right side. Rather than coming off a common trunk, the left
common carotid and the left subclavian arteries come directly off the aortic arch, and like its
right-sided counterpart, the left common carotid goes up to supply the head and the neck.

Just nearby, we can see the third and final branch of the aortic arch which is the left subclavian
artery, and like on the right side, this vessel is responsible for supplying the left upper limb, the
neck, and parts of brain with oxygenated blood.

Coming off the left and right subclavian arteries are the internal thoracic arteries and here we’re
only seeing a small stub of this vessel but actually it’s quite long. So if we add the chest plate
back on, we can see that the internal thoracic artery actually travels down the whole length of
the front of the thorax on either side of the breast bone or the sternum.

So if we head back to our heart in situ image, we can see the next artery on our list, and this is
the pericardiacophrenic arteries. It’s a little bit of a mouthful, but don’t let that intimidate you as
these guys are just named based of what they supply. So the first part of the word ‘pericardiaco’
means that it supplies the pericardium – the layer of tissue that we looked at previously – and
the last part of the word ‘phrenic’ refers to the fact that it supplies the diaphragm, which is the
thin muscle at the bottom of the thorax that we already discussed. And not only are these little
guys sort of hard to pronounce, they’re also a little bit hard to identify, and zooming in definitely
helps us see them a little bit better.

The next artery we’re going to be looking at is a little bit tricky since it’s not a true artery, but it
used to be. So, in the developing embryo, there is a small arterial shunt between the aortic arch
and the pulmonary trunk, and this shunt is called the ductus arteriosus, and it allows the blood
to bypass the lungs since our lungs aren’t functional in utero. However, after we’re born and our
lungs start working, this shunt closes off, and what’s left behind is this little guy, the ligamentum
arteriosum.

Okay, so we’ve got three more arteries to go, and the next ones are a little bit more closely
associated with the actual heart, so they might be a little bit easy to remember.

So, first, we’re going to look at one vessel that supplies the actual heart muscle tissue and it’s
called the right coronary artery, and you can see that it’s located just below the right atrium and
just above the right ventricle, and it travels around the right part of the heart and sits sort of like
a crown.

The next artery that we’ll look at also supplies the heart muscle tissue and it’s called the
interventricular branch of the left coronary artery. It’s a branch of the left coronary artery which
we can’t see from this view but it would be located around about here. And we mentioned the
interventricular branch of the left coronary artery earlier when we talked about the anterior
interventricular sulcus which is where you would find this artery snugly fitting right between the
two ventricles.
And, finally, here we have the pulmonary trunk. We briefly saw this structure earlier when we
talked about the conus arteriosus which sits just inferior to the pulmonary trunk, and this artery
is unique because it actually carries blood that is deoxygenated. Remember that the blood
leaving the right ventricle is heading for the lungs to pick up oxygen and it gets to the lungs by
traveling through the conus arteriosus and then the pulmonary trunk. And it might be easy to
remember that arteries are traveling away from the heart and aren’t necessary always carrying
oxygenated blood.

Okay, so the next set of neurovascular structures we’re going to be looking at are the veins, and
we’re going to start off more distally and follow the drainage pattern towards the heart.

So the first veins that we’re going to be looking at are these guys which are the left and right
internal jugular veins and they’re responsible for draining the head and the neck of
deoxygenated blood. And you’ll find them just anterior to the common carotid arteries that we
looked at previously.

So now we know that the blood from the head is traveling downwards in the internal jugular
veins. The blood from the upper limbs meanwhile is traveling back to the heart in the veins that
you see highlighted now called the left and the right subclavian veins. And as the name
suggests, you would find these just beneath the clavicle or the collarbone. The blood from the
internal jugular veins and the subclavian veins then merge together to form the left and the right
brachiocephalic veins.

And I known this is kind of a lot to take in right now, so it might help if we break down the word
parts of brachiocephalic. So, ‘brachio’ refers to arm which is where the subclavian vein is
receiving blood from and ‘cephalic’ refers to head which is where the internal jugular vein is
receiving blood from. And if we put these two together, we get brachiocephalic meaning arm
and head which is where all the blood in this vein is coming from.

The left and the right brachiocephalic veins then drain into this vein which is the superior vena
cava and from there, the blood finally reaches the heart by entering into a chamber we looked at
previously which is the right atrium.

Just one vein to go and it’s a mouthful, but hopefully it sounds familiar – the pericardiacophrenic
veins travel right along with the aforementioned pericardiacophrenic arteries. And similar to their
arterial counterparts, the pericardiacophrenic veins are associated with the pericardium and the
diaphragm, however, unlike the arteries that supply these structures with blood, these veins are
responsible for draining these structures of deoxygenated blood.

Okay, so now that we’ve looked at the arteries and veins seen with the heart in situ, we’re ready
to move on to the nerves, and the first nerves that we’re going to be looking at are the vagus
nerve. We might also hear them referred to as cranial nerve ten. Seen over here is the left
vagus nerve and it can be kind of tricky to find during dissection, so let’s have a look at some
key landmarks for this nerve.

In the neck, you can see that it is situated between the common carotid artery and the internal
jugular vein and you’ll notice that it then travels just in front of the aortic arch before it dives
behind the left main bronchus. Finally, it travels through the diaphragm before reappearing in the
abdomen. What a journey! And it might be interesting to know that vagus in Latin actually
means ‘wanderer’ which makes perfect sense when you consider its crazy course through the
body.

On the right side of the body, we’ll find the other vagus nerve and with the heart in situ, you can’t
quite see as much of the right vagus nerve, but you can see how it is also situated between the
common carotid artery and the internal jugular vein on the right side. It will also dive behind the
right primary bronchus and will pierce the diaphragm to enter the abdomen. We just can’t see
this relationships on the right side because the heart is in the way.

Next, we’re going to talk about the left recurrent laryngeal nerve which is actually a branch of
the left vagus nerve. And you can kind of see it here but let’s remove some structures and zoom
in a little to make things a little bit clearer. There we go. Hopefully that clears things up a little bit,
and you can see that this nerve actually loops underneath the aortic arch before climbing up the
neck next to the trachea, and this nerve is very important as it helps control small muscles in
your larynx or voice box. After all, without it, I wouldn’t be able to narrate this video.

The last nerves that we’re going to be looking at are the phrenic nerves which are responsible
for innervating the large flat muscle that we looked at earlier, the diaphragm. So these guys
travel in the same direction as the vagus nerve, so it can be sometimes confusing to correctly
identify them in the lab. There are a few key differences that we’ll look at to help you
differentiate between the two.

So you can see here that the phrenic nerve is smaller in diameter than the larger vagus nerve,
and also as it travels down the thorax, it lays anterior or in front of the two primary bronchi,
whereas the left and right vagus nerves traveled behind these structures. Also, since the
phrenic nerve actually innervates the diaphragm, it will stop at this muscle whereas the vagus
nerves just kept on going right into the abdomen. Keeping these things in mind will hopefully
help avoid any confusion.

Okay, so now that we’ve looked at all the relevant anatomy in this image, let’s check back in
with the patient from the beginning of the video.

So, earlier, we saw the trauma surgeon successfully removing the chest plate in a procedure
called a thoracotomy, and with the chest plate removed, the healthcare team then performed
what’s called a cardiac massage. This doesn’t quite mean the same thing as getting a good old
fashion foot rub at the end of a long day, although it is kind of a similar idea. Essentially, it’s a
resuscitative procedure which involves the application of rhythmic pressure to the patient’s heart
in order to restore and maintain a sufficient blood flow after cardiac arrest or ventricular
fibrillation, and this keeps the patient alive while the doctor could repair a serious internal injury
that the patient suffered. But, fortunately, the team knew their anatomy, avoided damaging
important structures, and save the patient.

And there you have it, the heart in situ.

Before I let you go, let’s quickly recap what we went through today.

So, first we went through the heart and the anatomy that can be seen in its normal anatomical
position and this included three of the four chambers, being the right atrium, the right ventricle,
and the left ventricle. We also looked at the left atrial appendage and the right atrial appendage.
Finally, we looked at some external features of the heart and these included the conus
arteriosus, the anterior interventricular sulcus, and the apex of the heart.

We then moved on to neighboring structures which included the lungs, their lobes and their
fissures that separate the lobes. We also looked at parts of the airway with particular focus on
the left main bronchus since this can be seen with the heart in situ. We checked out the
pericardium and talked about its various layers, and then we looked at the lymphoid organ
known as the thymus and the flat muscular diaphragm.

We then delved into a lot of neurovasculature and we started by looking at some major arteries,
and these included the aortic arch, the brachiocephalic trunk, the right and left common carotid,
the right and left subclavian, the internal thoracic, the pericardiacophrenic, the ligamentum
arteriosum, the right coronary, the interventricular branch of the left coronary, and the pulmonary
trunk. And then we moved on to the veins which included the left and right internal jugular, the
left and right subclavian, the left and right brachiocephalic, the superior vena cava, and the
pericardiacophrenic.

We finished our neurovasculature section by identifying some major nerves – the left and the
right vagus nerve, the left and the right phrenic, and the left recurrent laryngeal. And we then
wrapped things up by investigating some clinical notes on the thoracotomy and cardiac
massage procedures.
Main cavities of the body Dorsal cavity: Cranial cavity, vertebral canal
Ventral cavity: Thoracic cavity, abdominopelvic cavity

Main contents of body Cranial cavity: Brain

cavities Vertebral canal: Spinal cord
Thoracic cavity:
Mediastinum contents: Heart, trachea, esophagus
Mediastinum divisions: Superior, inferior (subdivisions: anterior, middle posterior)
Pleural cavity: Lungs
Abdominopelvic cavity:
Abdominal cavity: Gastrointestinal system, kidneys and suprarenal glands
Pelvic cavity: Reproductive organs, urinary bladder, sigmoid colon and rectum