On the front of the thorax the most important vertical lines are the midsternal, the middle line of the sternum; and the mammary, or, better midclavicular, which runs vertically downward from a point midway between the center of the jugular notch and the tip of the acromion

1. Thorax
Surface Markings
Dr Mathew Joseph
MBBS, MD(AIIMS), BCC(Palliative Medicine)
Assistant Professor
Department of Anatomy
Amala Institute of Medical Sciences, Thrissur

2. Surface Landmarks

3. Suprasternal notch: This is felt at the superior border of
the sternum.
Sternal angle: This is the joint between the manubrium
sterni and the body of the sternum. This can be felt as a
prominent ridge as we move from the suprasternal
notch below over the manubrium sternum at the
junction between manubrium and body of sternum. This
joint also corresponds to the articulation of the 2nd
costal cartilage to the sternum.
Counting of ribs: This can be initiated by identifying the
manubriosternal angle as this corresponds to the 2nd
rib. Then continue counting ribs downwards and
laterally.
Costal margin: This is a continuous bony margin formed
by the joining of the sternal end of the 7th to 10th ribs
to one another via the costal cartilages.
Subcostal angle: This is the angulation between the two
costal margins (right and left).

4. Midsternal line: Line drawn through the middle
of the sternum.
Midclavicular line: Drawn through the
midpoint of the medial and lateral ends of
the clavicle. This usually passes through the
nipple.

5. Anterior axillary line: This line is drawn
vertically at the plane of anterior axillary fold.
Posterior axillary line: This line is drawn at the
plane of the posterior axillary fold.
Midaxillary line: This line passes from the apex
of the axilla between the anterior and the
posterior axillary folds.

6. HEART
SURFACE ANATOMY

7. • The heart anatomically can be shown in four borders. They
are the right, left, upper and lower margins. They can be
drawn by identifying the following points:
• Point A: Marked on the right 3rd costal cartilage by the
side of the right sternal margin.
• Point B: Marked on the left 2nd intercostal space by the
side of the left sternal margin.
• Point C: Right 6th costal cartilage joining the sternum.
• Point D: Left 5th intercostal space just medial to the
midclavicular line.
• Upper border is formed by the joining of the points A and
B. Lower border is formed by the joining of the points C
and D.
• Right border is formed by the joining of the points A and C
by a curved line. Convexity is maximum in the 4th
intercostal space, about 3.7 cm to 4 cm from the midline.
Left border is formed by the joining of the points B and D.
BORDERS OF THE HEART

8. APPLIED ANATOMY
• By drawing/identifying the borders of the heart, it is possible to
percuss the borders and be able to identify the enlargement of the
heart. This also helps in putting the leads of the electrocardiogram
(ECG) and continuous cardiac monitoring.
• The area bounded by the borders of the heart is called as the
precordial area.

9. Apex Beat
1) This is the farthest point of the
heart. This is positioned at the left
5th intercostal space, just medial
to the midclavicular line.
2) This is approximately 9 cm from
the midsternal line.

10. APPLIED ANATOMY
• This is the most commonly accessed part of the heart during clinical
examination. The heart beat is felt in this position. The apex beat
which can be palpated and auscultated by using a stethoscope is due
to the vortex like motion of the left ventricle.

11. Orifices of the Heart
These are mainly the valvular openings of the heart. They are
the tricuspid, mitral, pulmonic and the aortic valvular areas.
1) The tricuspid valve is situated behind the sternum in a
vertical plane extending from the 4th to the 5th intercostal
space. It is 4 cm long and vertically placed (T).
2) The mitral valve is situated behind the left margin of the
sternum at the level of the 4th costal cartilage (M).
3) The pulmonary valve orifice is situated at the level of the
left 3rd costal cartilage and partly behind the sternum. It is
horizontally placed and is 2.5 cm long (P).
4) The aortic valve is very close to the pulmonary valve. It is
situated in the 3rd intercostal space behind the left half of
the sternum with an inclination downwards and medially
(A).

12. Auscultatory Areas of the Heart
There are mainly four valves of the heart. They are the mitral,
tricuspid, aortic and the pulmonary valve.
1. The tricuspid valve can be heard at the left lower part of
the sternum in the 5th intercostal space (T).
2. The mitral valve can be heard in the left 5th intercostal
space near the apex beat (M).
3. The pulmonary valve is in the left 2nd intercostal space
near the lateral end of the sternum (P).
4. The aortic valve is in the right 2nd intercostal space near
lateral end of the sternum (A).
5. The left 3rd intercostal space near the lateral border of the
sternum is also called the neo aortic or 2nd aortic (A2)
area as, some aortic valvular pathologies such as the
murmur of aortic valve incompetence is better heard here.

13. APPLIED ANATOMY
• Learning to identify the auscultatory areas is important as we regularly
auscultate these areas to confirm the normal heart sounds and be able
to diagnose the different murmurs created due to the valvular
abnormalities such as mitral valve regurgitation, aortic stenosis, etc.
• The auscultatory areas might differ in their position in rare cases as
dextrocardia and lung diseases which push the heart toward the
opposite side.
• The best position to auscultate the heart is in the sitting position. This is
because the heart is closer to the anterior thoracic wall and the sounds
will be heard clearly than in supine position as the heart falls away from
the thoracic wall.

14. PLEURA & LUNGS
SURFACE ANATOMY

15. Cervical Pleura
Cervical pleura are drawn as an
inverted V shape about 1 inch above
the medial third of the clavicle in the
neck (A).

16. Costal Pleura
Right side:
1) The anterior margin extends as a
vertical line over the midsternal line
from the suprasternal margin up to the
xiphisternal joint (BC).
2) The inferior margin is drawn from the
xiphisternal joint to cross the 8th rib in
the midclavicular line, 10th rib in the
midaxillary line (CDE) and the 12th rib in
the paravertebral line (2 cm lateral to
the spinous process of the 12th thoracic
vertebra) (IJ)].

17. Costal Pleura
Left side:
1) The anterior margin extends as a vertical line
over the midsternal line from the
suprasternal margin up to the 4th costal
cartilage (BF).
2) Then it deviates to the left along the
left lateral sternal border up to the
6th costal cartilage (FG).
3) The inferior margin is drawn from
the 6th costal cartilage to meet the
8th rib in the midclavicular line,
10th rib in the midaxillary line (GHI)
and the 12th rib in the
paravertebral line (IJ).

18. Both Sides
The posterior margin is drawn as a vertical line from the
spinous process of the 7th cervical vertebra to the 12th
thoracic vertebra. The line is 2 cm lateral to the spinous
processes of the vertebrae. (KJ)
Costal Pleura

19. APPLIED ANATOMY
• Pleurocentesis is an invasive procedure done in order to draw pleural fluid in cases of
pleural effusion for evaluation of the effusion also as treatment if the effusion is large.
• This is usually done in the intercostal space along the superior surface of the lower rib.
The level of intercostal space is determined by the level of the fluid by X-ray.
• The level of the effusion should be confirmed on the basis of diminished or absent
sounds on auscultation, dullness to percussion, and decreased or absent fremitus.
• The needle should be inserted one or two intercostal spaces below the level of the
effusion, 5–10 cm lateral to the spine (in the space between the scapular line and
midline (posteriorly). To avoid intra-abdominal injury, the needle should not be
inserted below the 9th rib.

20. Lungs
Apex of the lungs: is drawn in the neck about 2.5
cm above the medial 3rd of the clavicle along the
pleural reflection (A)

21. Right lung:
▪ The anterior margin extends as a vertical line
over the midsternal line from the suprasternal
margin up to the xiphisternal joint (BC).
▪ The inferior margin is drawn from the
xiphisternal joint to cross the 6th rib in the
midclavicular line, 8th rib in the midaxillary line
(CDE) and the 10th rib in theparavertebral line
(IJ).

22. Left lung:
1) The anterior margin extends as a vertical line
over the midsternal line from the suprasternal
margin up to the 4th costal cartilage (BF). Then
it deviates to the left along the left lateral
sternal border. From here the line curves 3.5 cm
lateral to the lateral sternal border and then
reach the 6th costal cartilage (FG).
2) The inferior margin is drawn from the
xiphisternal joint to cross the 6th rib in the
midclavicular line, 8th rib in the midaxillary line
(GHI) and the 10th rib in the
paravertebral line (IJ).

23. Lungs:
Both sides
The posterior margin is drawn as a vertical line from
the spinous process of the 7th cervical vertebra to the
10th thoracic vertebra. The line is 2 cm lateral to the
spinous processes of the vertebrae (KJ).

24. Root of Lungs
1) These are marked in prone position.
2) Mark the spines of 4th, 5th and 6th thoracic
vertebrae.
3) Mark a vertical oval area about 2.5 cm lateral
to the spines mentioned above (midway
between the spines and medial border of the
scapula).

25. Fissures of the lung
These fissures cut through the lung till the hilum
into three lobes on the right lung and two lobes on the left
lung.
Oblique fissure: This can be drawn as an oblique line starting
from the 2nd thoracic vertebra posteriorly to meet the 6th rib
in the midclavicular line anteriorly. This fissure
is present in both the lungs. (OF)
Horizontal fissure: Drawn as a horizontal line from the point
where the oblique fissure meets the midaxillary line to the
midsternal line along the 4th costal cartilage. This is
present in the right lung. (HF)
Hence the right lung is divided into three lobes by the oblique
and the horizontal fissures.
The left lung is divided into two lobes by the oblique fissure
only

26. APPLIED ANATOMY
Orientation of the lobes of the lung to the thoracic surface:
• The oblique fissure because of its obliquity projects the upper lobe to
the anterior thoracic wall and the lower lobe to the posterior thoracic
wall.
• Hence when the anterior thoracic wall is palpated and auscultated for
respiratory sounds, the student should have the upper lobe in mind
and similarly the lower lobe when examining the posterior thoracic
wall.

27. ARTERIES OF THORAX

28. Ascending Aorta
The aorta is the outlet of the left ventricle. It is
marked by:
1) A point on the left of the midsternal line at the
3rd costal cartilage (A).
2) A point to the 2nd costal cartilage on the right
side at the border of the sternum (B).
3) The direction of the ascending aorta is from the
left to the right and upwards.

29. Arch of the Aorta
The arch of the aorta is the continuation of the
ascending aorta. It is marked by:
1) A point on the right 2nd costal cartilage at the
lateral border of the sternum (B).
2) A point on the midsternal line 2.5 cm below the
jugular notch (C).
3) A point of the left 2nd costal cartilage on the
lateral border of the sternum (D).
4) Join B, C and D by a double line of 2 cm width.

30. Descending Thoracic Aorta
1) The descending aorta is the continuation of
the arch of the aorta. It is marked by:
2) A point on the left 2nd costal cartilage at the
lateral border of the sternum (D).
3) A point in the midline, 2 cm above the
transpyloric plane(E).
4) Join D and E by double lines 2 cm apart.

31. Innominate Artery, Left Common
Carotid Artery and Left Subclavian
Artery
1) The innominate artery (brachiocephalic artery) arises
in the midline from the arch of the aorta (A) and
extends to the right sternoclavicular joint (B).
2) To the left of this is the origin of the left common
carotid artery (C) which extends to the left
sternoclavicular joint.
3) Then mark a point to the left of left common carotid
artery. Mark the left sternoclavicular joint (D).
4) Join the points. This marks the left subclavian artery.

32. Internal Thoracic Artery
1) This is the only branch of the subclavian artery
which descends downwards. It is marked by:
2) A point 2 cm above the sternal end of the
clavicle (A).
3) A line from the above point, 1 cm lateral to the
lateral sternal margin (B).
4) A point at the sternal end of the 6th costal
cartilage (C).

33. APPLIED ANATOMY
• The ascending aorta and arch of the aorta are some of the common
sites of aneurysmal dilatation (disproportionate/abrupt dilatation of a
part/segment of a blood vessel). This can cause compression of the
adjacent veins, nerves, trachea/bronchi, esophagus and patient will
present with corresponding symptoms. Clinically, this can be
suspected when we find superior mediastinal widening on
percussion, i.e., dullness extending more than half an inch lateral to
the sternal border on either side in the 2nd and 3rd intercostal
spaces.
• Differential diagnoses: Thymoma, ectopic thyroid, pulmonary arterial
dilatation on the left side, lymph nodes.

34. APPLIED ANATOMY
• The internal thoracic artery needs ligation in cases of cardiac bypass
and breast procedures. The best areas to access are in the 2nd and
3rd intercostal spaces as these are the widest and the artery can be
accessed at 1 cm lateral to the sternal margin.

35. VEINS OF THORAX

36. Right Brachiocephalic Vein
1) A point on the right sternoclavicular joint.
2) A point on the right 1st costal cartilage, 1 cm
lateral to the lateral sternal margin.

37. Left Brachiocephalic Vein
1) A point on the left sternoclavicular joint.
2) A point on the right 1st costal cartilage, 1 cm
lateral to the lateral sternal margin.
3) The direction is from the left to the right and
downwards.

38. Superior Vena Cava
1) A point on the right 1st costal cartilage, 1 cm
lateral to the lateral sternal margin (A).
2) A point on the upper border of the 3rd costal
cartilage, 1 cm parallel to the lateral sternal
margin (B).
3) Join the points A and B by two parallel lines 2 cm
apart.

39. TRACHEA AND
OESOPHAGUS

40. Trachea
Anteriorly, the trachea can be marked as follows:
1) Mark a point below the cricoid cartilage (A).
2) Mark a point 1 cm to the right of the midpoint
of the sternal angle (B).
3) Join these two points by two parallel lines 2 cm
apart.

41. Trachea
Posteriorly, the trachea can be marked as follows:
1) A point on the spinous process of the 6th cervical
vertebra (A).
2) A point on the 4th thoracic spine (B).
3) This corresponds to the sternal angle on the
front.
4) Join the above two points by two parallel lines 2 cm
apart.

42. Esophagus
The surface marking is done on the back of the trunk.
1) A point on the 7th cervical spine. The spine of
the 7th cervical vertebra is the most prominent
spine on the back of the neck (A).
2) A point 2.5 cm lateral to the 9th thoracicvertebral
spine. Both the points are marked on the left side
(B).
3) Join both the points with two parallel lines around
2 cm apart.

43. Thoracic Duct
1) Mark a point 2 cm above and 2 cm right lateral
to the transpyloric plane from the midline (A).
2) Mark a point at the 3rd right lateral
chondrosternal margin (B).
3) Mark a point at the midpoint of the sternal
angle (C).
4) Mark a point to the 2nd left chondrosternal
margin (D).
5) Mark a point 2 cm from the midline and 2.5 cm
above the left clavicle (E).
6) Mark a point at the left sternoclavicular joint
(F).
7) Join A through F.

44. THANK YOU