4
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Suprasternal Notch – U shaped depression
Sternum – “breastbone” = 3 parts
1.
2.
3.
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Manubrium
Body
Xiphoid process
Angle of Louis – manubriosternal angle
continuous with the 2nd Rib
 Costal angle- usually 900 or <. (increases
when rib cage is chronically overinflated)
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Vertebra Prominence – Flex head, feel most
prominent bony projection at base of neck =
C7 next lower one is T1
Spinous Processes – spinal columnScapula – symmetrical , lower tip at the 7 -8th
Rib
12th Rib = midway b/t spine & side
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12 pairs of ribs
• 7 true ribs
• 5 false ribs (including 2 floating ribs)
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Head of rib articulates with vertebra
Ribs move as a unit to accommodate breathing
Intercostal spaces =
(spaces between ribs)
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All 12 pairs of ribs attach to the building blocks of the
spine (vertebrae) in the back. The 12 pairs of ribs consist
of:
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True ribs: The first seven ribs attach to the sternum
(the breast bone) in the front and are known as true (or
sternal) ribs.
False ribs: The lower five ribs do not directly
connect to the sternum and are known as false ribs.
The upper three false ribs connect to the costal
cartilages of the ribs just above them. The last two
(#11 and 12) are false ribs. They have no ventral
attachment (no anchor at all in front) and are called
floating ribs.
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Supernumerary (Extra) Rib present above the
1st rib
Arises from 7th cervical vertebra
Present in 1 in 500 peoples
Can cause thoracic outlet syndrome due to
compression on the brachial plexus and
subclavian artery.
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Trauma is the most important cause of rib
fractures
First Rib : Rare , associated with cranial,
maxillofacial ,cervical spinal injuries ,
multiple rib fractures and life threatening
vascular injuries.
Second, Third and fourth : Associated with
major vascular injuries and injury to brachial
plexus.
Fifth to Ninth ribs : can be single or multiple.
Multiple fractures can present as flail chest,
which is present when paradoxical respiratory
movement occurs in a segment of the chest
wall.
This type of fracture requires at least 2
segmental fractures in each of 3 adjacent ribs,
the costal cartilages, or the sternum
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Tenth to twelfth ribs : Associated with thoracic
and lumber vertebral injuries
Injuries to spleen , kidneys, adrenals , liver
may occur.
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Pathological Rib Fractures: occurs
spontaneously without trauma due to
weakness of the bone by the underlying
disease.
- Metastasis
- Multiple myeloma
- Hyperparathyroidism
◦ Pulmonary contusion (almost always)
 Airspace disease representing hemorrhage into the alveoli
usually subjacent to the point of impact
◦ Pulmonary laceration
 Lacerations in the lung may be blood-containing, air-containing,
or both
 Frequently masked by the surrounding pulmonary contusion
◦ Pneumothorax (very common)
 Since the severity of the injury means a supine radiograph will
be performed, pneumothoraces may only be seen on chest CT
◦ Hemothorax (common)
◦ Pneumomediastinum
◦ Subcutaneous emphysema
◦ Mediastinal hemorrhage
◦ Aortic injuries
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Flail chest is traditionally described as the
paradoxical movement of a segment of chest
wall caused by fractures of 3 or more ribs
anteriorly and posteriorly within each rib.
Variations include posterior flail segments,
anterior flail segments, and flail including the
sternum with ribs on both sides of the
thoracic cage fractured.
Severe blunt trauma
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breastbone
Lies in anterior midline
of thorax
Three parts:
◦ Manubrium
◦ Body
◦ Xiphoid process
Surface landmarks
◦ Jugular notch
◦ Sternal angle
( angle of Louis)
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Broad, upper part
of the sternum
Quadrangular
shape, wider
superiorly and
narrower
inferiorly
Articulates with
the clavicles and
the first two ribs.
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A ridge where the
manubrium and
the body of the
sternum meet
Raised horizontal
ridge located at
the second rib
joint
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Xiphoid means
“sword-shaped”
May be bone or
cartilage
Apex of thoracic
arch
“Pit” of stomach,
where heartburn
often occurs
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Blunt trauma to chest
Rarely may occur during CPR
Stress fractures weight lifters , golfers
Long term steroids, severe kyphosis
Fractures usually occurs at body or manubrium
X-Rays Chest PA & Lateral Views , USG Chest
CT chest.
Normal chest
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Most common congenital deformity of
anterior chest wall.
Also called funnel chest , sunken chest,
cobblers chest.
Lower end of sternum is depressed alongwith
costal cartilages.
Treatment is surgical repair.
Pectus Excavatum (Funnel)
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AP diameter is equal or more than transverse
diameter.
COPD
Barrel Chest
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Also called pigeon chest.
Characterized by protrusion of sternum and
ribs
Congenital, Obstructive airway disease,
Marfan syndrome, turner syndrome, Ehlers
danlos syndrome.
Treatment is external braces or surgical.
Pectus Carinatum
(Pigeon)
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Very rare
Sternal defects can be categorized into 4
types,:
thoracic ectopia cordis
cervical ectopia cordis
thoracoabdominal ectopia cordis
cleft sternum.
Sternal foramina – perforation in sternal body
clinically insignificant.
Perforation of xiphoid process in elderly.
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Often used for bone marrow needle biopsy
because of its breadth and subcutaneous
position
Commonly used for specimen for bone
marrow transplant and for the detection of
metastatic cancers and blood dyscrasias .
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Anterior Chest
◦ Midsternal line
◦ Midclavicular line
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Posterior Chest
◦ Vertebral line – midspinal
◦ Scapular line
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Lateral Chest
◦ Anterior Axillary line
◦ Posterior Axillary line
◦ Mid–axillary line
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Surgical creation of an opening through the
thoracic wall
Types :
- Anterior thoracotomy
- Posterolateral thoracotomy
- Anterolateral thoracotomy
Posterolateral thoracotomy is the most
commonly used site.
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Sternal splitting for the mediastinal
operations
For upper lobe lung tumours
CABAG
After surgery the halves of sternum are joined
using wire sutures.
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Atelectasis, the permanent collapse of lung tissue
Benign (non-cancerous) tumors or cysts
Confirmation of a diagnosis, such as for lung disease
Diaphragm disorders
Diseased or damaged blood vessels of the heart or lungs
Empyema, or infection in the chest cavity
Heart disease
Hemothorax, or blood in the lungs
Lung damage caused by emphysema or bronchietasis
Pleurodesis, a procedure to treat a buildup of fluid in the chest cavity
Pneumothorax, or injuries that cause the collapse of lung tissue
Pulmonary embolism, or a blood clot in the lungs or pulmonary artery
Severe and very specific types of chest injury or trauma, such as certain
types of stabbings or gunshot wounds
Some types of cancer including lung cancer
Trachea (windpipe) or esophageal (swallowing tube) conditions
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A bone graft is surgery to place new bone or
bone substitutes into spaces around a broken
bone or bone defects.
If the transplanted bone comes from another
person, it is called an allograft.
If the transplanted bone comes from another
part of your own body, it is called an
autograft.
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