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anterior chest wall (manibrium+sternum+xiphoid process)

• 
• sternal angle (angle of louis) bw 4th,5th thoracic verteb. counter ribs + intercostal spaces.
• xiphoid process = 9th vertb (4+5).
• sternum= sternotomy + bone marrow biopsy.
• atypical rib (1st) = relationship to lower nerves of brachial plexus.

cervical rib

• 
• arise from the anterior tubercle of the transverse process of 7th vertb.
• connect to 1st rib by fibrous band.
• pressure on lower trunk of brachial plexus= pain down the medial side of forearm and hand and wasting of small muscles of the hand.
• exert pressure on the subclavian artery and interfering of the circulation of the UL.
• rib exicision by 2 longitudinal incision to regenerate from the osteogenitic layer of the periostium.
• on the left side is rudmentary and complete as afibrous band.

thoracic outlet syndrome.

• 
• brachial plexus of(Cervical 5th,6th,7th,8th,T1) and subclavian artery and vein closely related to the upper surface of the 1st rib and the clavicle so nerves and ves copmressed bw the bones causing weakness down the medial side of the forearm and hand and the small muscles of the hand. and comprmise the circulation of the arm.

intercostal spaces

• 
• intercosatal Vs and nerves bw the intermediate and deepest layer of intercostal ms from above downward(VAN).
• Vein.
• artery.
• nerve.
• intercostal ms supplied by corresponding intercostal nerves.
• ant intercostal art(2 small ant) from internal thoracic art.
• post intercostal art(large single post one) from thoracic aorta.
• post intercostal art of the 1st 2 spaces is branche from sup intercostal art ,abranch from costocervical trunk of the subclavian art. and the following 9th spaces from descending thoracic aorta.
• the ant intercostal art of the 1st 6 spaces from internal thoracic art that abranch of 1st part of subclavian art. the next lower spaces from musculophrenic art that aterminal br from internal thoracic art.
• the corresponding ant intercostal vein drain of azygos and hemiazygos.
• post intercostal vein drain of internal thoracic and musculophrenic veins.
• the 1st 11 intercostal nerves from ant rami of spinal cord and the 12th inter n run in the abdomen as subcostal n.

Referred pain (Branches of intercostal n.)

• above sternal angle = supraclavicular n
• below sternal angle = ant and lat brs of intercostal ns.
• post chest wall = post rami of spinal n.
• intercostal n = supply skin , ribs , cartilages.
• referred pain from chest to abd(thromboembolism, pneumonia)= 7th ,11th intercostal ns supply dermatomes in abd as skin of ant abd wall and parietal peritonium.
• Rami commiunicants connects the intercostal ns to the ganglion sympathetic trunk.
• collateral br.
• ant cutanious br
• lat cutanious br
• muscular br.
• pleural sensory br.
• peritoneal sensory br.

commiunications of intercostal ns

• 1st intercostal br commiunicate to brachial plexus by large br of lat cutanious intercostal n and ant cutanious n.
• 2nd intercostal n join the medial cutanious n of the arm by abr called intercostobrachial n that supply the armbit and medial side of arm so referred pain during coronary dis.
• the 1st 6 intercostal ns supply the skin and parietal pleura and intercostal ms and levator costarum and serratus posterior.
• from 7th to 11th intercostal ns supply the parietal peritonium covering the the outer and the inner surface of abd. and abd ms (ext oblique , inter obliqe , transversus abd and rectus abdominis.

intercostal n block