Chest deformity in children and adolescents

Congenital chest deformities in children

Congenital deformity of the chest in children may be associated with genetic characteristics and changes in the formation of the sternocostal complex, which can lead to a gradual increase in deformity until the growth of the child’s or adolescent’s skeleton is completed.

Congenital pathology is associated with improper development of the skeleton (vertebral column, ribs) due to an imbalance of mineral and endocrine metabolism. The consequence may be a specific development of the body:

painful thinness;
narrow shoulders;
high growth;
protrusion of the shoulder blades and collarbone;
sunken chest when inhaling;
long limbs;
curvature of the spine (scoliosis or kyphosis).

Hereditary deformity is determined in 20-65% of cases of chest deformity. There are diseases and specific syndromes where this type of deformation is one of the symptoms. For example, pathology often develops against the background of Marfan syndrome.

Marfan syndrome

This disease is characterized by funnel-shaped and keeled deformities of the chest.

Marfan syndrome has the following symptoms:

asthenic physique;
arachnodactyly;
dissecting aortic aneurysm;
dislocation or subluxation of the lenses of the eyes (or other vision pathology);
biochemical changes in the metabolism of collagen and glycosaminoglycans.

The development of chest deformity can be facilitated by dysplasia of connective and cartilaginous tissues, which is caused by enzymatic disorders.

Sporadic (non-hereditary) forms of deformity

Non-hereditary deformity of the chest develops due to teratogenic factors that affect the fetus during its development. Most often, abnormal development is caused by asynchronous, inharmonious growth of the sternum and costal cartilages.

Formation

Each thoracic vertebra articulates with a pair of ribs

It is not difficult to guess that how many vertebrae there are in the human thoracic spine, so many pairs of ribs are attached to it. It should be noted that contrary to biblical beliefs, men and women have the same number of pairs of ribs. The ribs of the first seven pairs are attached to the thoracic spine at the back and directly to the sternum at the front. The next three pairs arise from the “spines” of the thoracic region, and are fastened in front by costal cartilages, which form false ribs. And finally, the last two pairs (11th and 12th ribs) are attached at only one point - to the corresponding thoracic vertebrae, and in front their cartilaginous ends end in the abdominal muscles and are therefore called free.

Some people, as an exception, have a 13th pair of ribs, which are considered rudimentary features. Moreover, their formation most often occurs at the last (seventh) cervical vertebra, which has hyperplastic transverse processes. In this case, rudimentary ribs can be felt as bone formations through the supraclavicular fossa.

The presence of fastening of the thoracic spine through the ribs with the sternum makes this area much tougher than the cervical and lumbar spine, and also gives some structural features to the thoracic vertebrae. The spinous processes of the thoracic vertebrae partially overlap each other, which further stiffens the thoracic region and makes it more limited in movement. However, this part of the spine is also characterized by flexibility and springiness, since the vertebrae are separated by the intervertebral disc. Its structure is typical for the entire spine: the internal nucleus pulposus is surrounded by a dense ring of cartilage tissue, which has elasticity and elasticity. This structure allows for anterior flexion, lateral flexion of the thoracic region and its rotation, while protecting the vertebrae from friction against each other.

Types of movement that can be performed in the thoracic region: bending, rotation and excursion of the chest

Acquired chest deformities

Acquired chest deformity in a child develops against the background of diseases of the lungs and ribs (including tumor-like formations). This pathology can lead to other disorders of the body, for example, improper functioning of the respiratory system or psychological problems.

The acquired deformity is characterized by weakened immunity; the child often suffers from acute respiratory viral infections.

Physiological development is inhibited, fatigue appears after weak physical exertion. There are sharp changes in blood pressure.

Acquired curvature of the chest in a child can develop after suffering musculoskeletal diseases:

Tuberculosis;
Rickets;
Scoliosis (Taking into account the fact that the spine and the sternocostal complex are an interconnected system, with severe deformities of the spine, a pronounced deformation of the chest is sometimes observed. More often, the posterior chest wall is deformed in the form of a rib hump, but there are also accompanying deformities of the anterior chest wall);
Costal osteomyelitis;
Rib tumors.

Pathology can be provoked by purulent-inflammatory processes in the soft tissues of the chest walls and pleura, injuries and burns of the chest. In some cases, the deformity is a consequence of cardiac surgery after median sternotomy, which can change the growth of the sternum in a child.

Surgical anatomy of the chest wall

Common data. Borders of the chest: above and in front - a line drawn from the notch of the manubrium of the sternum along the collarbone to the acromioclavicular joint; behind - straight lines connecting the acromioclavicular joints with the spinous process of the VII cervical vertebra; below - a line drawn from the xiphoid process along the edge of the costal arch to the X rib, then through the ends of the XI and XII ribs to the spinous process of the XII thoracic vertebra.

The indicated lines, however, do not reflect the true boundaries of the chest cavity, since at the top the dome of the pleura protrudes above the collarbone. Below, the dome of the diaphragm rises into the chest cavity, which naturally leads to a decrease in its volume.

There are: anterolateral, posterolateral and lower chest wall. The entrance to the thoracic cavity (apertura thoracis superior) is limited: from behind - by the spine, from the sides - by the first rib and in front - by the manubrium of the sternum.

The lower opening of the chest cavity (apertura thoracis inferior) is limited: behind by the body of the XII thoracic vertebra, by the XII and partially by the XI rib, on the sides by the costal arch and in front by the xiphoid process.

The tissues involved in the formation of the walls of the chest cavity can be divided into three layers: 1) the superficial layer, which includes tissues involved in the formation of the integument of the entire body, 2) the middle layer, which includes tissues common to both the shoulder girdle and neck, and for neighboring areas (abdomen, lumbar region), and, finally, 3) a deep layer, which includes tissues related directly to the wall of the chest cavity itself.

Anatomical structures that form the walls of the chest cavity

In the deep layers of the chest wall, the segmentation of the structure is most clearly expressed, which is manifested in the location of the ribs, muscles, nerves and blood vessels.

In the middle layers, segmentation is disrupted due to the complexity of the formation of the upper limbs. The skin of the armpit area is very thin and mobile; on the back it is significantly thickened and difficult to fold. The sweat and sebaceous glands are located deep in the skin. Arteries and veins in the thickness of the skin form a multilayer network - superficial and deep. The first, finely looped, is located in the subpapillary layer, the second, broadly looped, is in the lower layers of the skin itself.

From the skin of the posterior surface of the chest, lymph flows both into the nodes of the axillary cavity and into the nodes located in the intermuscular spaces of the posterior wall of the chest.

Innervation of the skin in front, in the region of the subclavian fossae, is carried out by branches of the cervical plexus arising from CIII, CIV - nn. supraclavicularis, nn. cutanei colli, in front and on the sides - by the branches of seven paired intercostal nerves. The skin of the back is innervated by the posterior branches of the thoracic nerves from ThI to ThIX.

The degree of development of subcutaneous tissue varies individually. In the anterior sections of the chest, the subcutaneous tissue is loose, large-lobed, but on the back it is small-lobed and contains many connective tissue elements that sharply limit skin mobility.

The fatty tissue contains arteries that supply the skin (branches of a. thoracica interna, intercostal and lateral thoracic). The veins form an individually differently expressed venous network.

The veins of the subcutaneous tissue in the area of the anterior surface of the chest are connected by anastomoses with both the inferior vena cava system and the superior vena cava system, as a result of which, with tumors of the mediastinum that cause difficulties in the outflow of blood in the trunk, one can see the expansion of the saphenous veins, and sometimes, with pronounced stagnation , swelling of the tissue is noted.

If there are difficulties in the outflow of blood into the inferior vena cava system, dilatation of the saphenous veins is noted in the anteroinferior and inferolateral sections of the anterior chest wall.

The subcutaneous tissue contains lymphatic pathways and nerve branches that supply the skin, and the mammary glands are located in the thickness of the subcutaneous tissue.

Middle layer. Due to the fact that the middle layer of the chest wall includes formations common to the chest and neighboring areas (shoulder girdle, neck, abdomen, lower back), the structure and topography of the chest wall in different parts of it are not the same. Based on practical considerations, it is advisable to consider the middle layer of the wall by region.

They are distinguished: anterosuperior region of the chest, anterioinferior, posterosuperior and posteroinferior regions.

The boundaries of the anterior superior region of the chest (regio thoracis anterior superior) are: upper - the clavicle, lower - the edge of the pectoralis major muscle, external - the middle axillary line, which at the top turns into a line corresponding to the sulcus deltoideo-pectoralis, internal - lin. sternalis.

The fascial layer of this area is formed by the fascia of the chest (fascia pectoralis propria), in which two plates are distinguished - superficial and deep.

The superficial plate (lamina superficialis fasciae pectoralis propriae) forms the sheath of the pectoralis major muscle and in the upper part connects with the periosteum of the clavicle and the fascia of the neck; Laterally this leaf passes into the axillary fascia and the fascia of the deltoid muscle, medially into the aponeurotic plate of the sternum - membrana sterni anterior.

The pectoralis major muscle (m. pectoralis major) consists of three parts: pars clavicularis, pars sternalis and pars abdominalis. All three parts of the muscle form one flat tendon, which is attached to the crista tuberculi majoris humeri. The degree of muscle development varies individually. Sometimes you can see a partial or complete congenital absence of this muscle.

Between m. deltoideus and the clavicular part of the pectoralis major muscle in the sulcus deltoideo-pectoralis passes v. cephalica, which in the trigonum deltoideo-pectorale (Morenheim's fossa) plunges into the depths and flows into v. subclavia.

Vascularization of the pectoralis major muscle is carried out by the branches of a. thoracoacromialis, a. axillaris. The main arteries enter the muscle in its upper outer section.

The veins of the muscle are tributaries of the veins accompanying the above arteries.

The lymphatic vessels of the clavicular part of the muscle flow into the supraclavicular nodes, the medial part - into the retrosternal (lnn. sternalis), the outer part - into the subclavian and the lower - into the lnn. subpectorales, located along the lower edge of the muscle.

Innervation is provided by the branches of the anterior thoracic nerves (nn. thoracalis anteriores), arising from CV - CVIII. The deep plate of the chest's own fascia (lamina profunda fasciae pectorales propriae) is a rather dense formation. The fascia is fixed to the coracoid process of the scapula, clavicle and ribs, and therefore is called fascia coracoclavicostalis.

It forms the vagina, which contains the pectoralis minor muscle. In the upper part, the fascia is pierced by the branches of the truncus thoracoacromialis and nn. thoracales anteriores. Between the posterior surface of the pectoralis major muscle and the coracocleidocostal fascia there is a layer of fiber - the first deep fiber space.

Pectoralis minor muscle - m. pectoralis minor starts from the III, IV and V ribs and is attached to the processus coracoideus scapulae. The vessels of the muscle are the branches of a. thoracoacromialis, a. axillaris. The veins of the same name accompany the arteries. Together with the vessels, nn penetrate into the muscle. thoracales anteriores. Lymph flows into the substernal nodes. The subclavian muscle (m. subclavius) is located between the clavicle and the first rib and is surrounded by a dense sheath formed by the coracoclavicular-costal fascia. The muscle is innervated by the nerve of the same name, arising from the brachial plexus.

The serratus anterior muscle (m. serratus anterior) within this area is located with 4-5 upper teeth.

The clavipectoral triangle (trigonum clavipectorale) is bounded above by the lower edge of the clavicle with the subclavian muscle, below by the upper edge of the pectoralis minor muscle, and from the inside by the chest wall.

After removing the fiber and fasciae coracoclavicostales within the triangle, a second deep fiber space opens, in which the neurovascular bundle of the upper limb is located.

Here in the tissue there are subclavian lymph nodes lnn. infraclaviculares, from which the vessels forming the subclavian lymphatic duct are formed.

The fiber that performs the trigonum clavipectorale communicates with the fiber space of the neck and posterior wall of the chest, which should be kept in mind during suppurative processes. In addition to the described triangle, in this area there are also thoracic and inframammary triangles, the practical significance of which is relatively small.

The boundaries of the anterior inferior region of the chest (regio thoracis anterior inferior) are: above - the lower edge of the pectoralis major muscle, below - the costal arch, outside - the middle axillary line, inside - lin. sternalis. The main layers of the region are formed by the fascia of the chest itself, which continues downwards into the fascia of the abdomen, and medially participates in the formation of the anterior wall of the vagina of the rectus abdominis muscle, and the serratus anterior muscle (m. serratus anterior). The latter begins with 8-9 teeth from the same number of upper ribs and forms a muscular plate that covers the anterolateral and partially posterior walls of the chest and is attached to the vertebral edge of the scapula. Throughout its entire length, the muscle is enclosed in a fascial sheath formed by its own fascia of the chest.

The arterial supply to the muscle occurs through branches arising from a fairly large number of sources (a. thoracalis lateralis is the main source, aa. intercostales and a. thoracodorsalis).

The outflow of blood occurs through the veins of the same name. Lymphatic vessels flow into lymph nodes, which are 2-5 located on the outer surface of the muscle along the course of a. thoracalis lateralis along the length from the II to VI ribs (D.A. Zhdanov). N is involved in the innervation of the muscle. thoracalis longus, located next to a. thoracalis lateralis. The external oblique muscle of the abdomen (m. obliquus abdominis externus) occupies the lower section of the described area. The teeth of this muscle alternate with the teeth of the anterior scalene muscle, and downward and posteriorly with the teeth of m. latissimus dorsi. The most medial tooth of the external oblique abdominal muscle is located at the anterior end of the 5th and 6th ribs, from here the broken line of contact of this muscle with the serratus anterior stretches downwards and outwards.

The rectus abdominis muscle occupies only the inferomedial part of this area and is located under the initial part of the external oblique abdominal muscle.

Between the chest wall and the serratus anterior muscle there is a thin layer of loose tissue, which posteriorly passes into the tissue of the prescapular fissure. In this layer, purulent-inflammatory processes can spread.

The boundaries of the anteromedian region of the chest (regio thoracis mediana anterior) are the outlines of the sternum, and therefore they are as different as the shape of the sternum is variable.

The proper fascia of the chest is reinforced here with tendon fibers and fused with the periosteum of the sternum. As a result, a thick plate is formed - membrana sterni anterior. There is no muscle layer, except for the initial bundles of the pectoralis major muscles.

Borders of the posterior superior region of the chest (regio thoracis posterior superior): at the top - the line connecting the acromion with the spinous process of the VII cervical vertebra; below - a horizontal line drawn along the lower corner of the scapula; outside - the posterior edge of the deltoid muscle and inside - the vertebral line.

The proper fascia of the chest has a very complex structure in this area, as it takes part in the formation of the fascial sheaths of numerous muscles. In it one can conditionally distinguish between superficial and deep plates.

The superficial plate forms the vagina m. trapezius and m. latissimus dorsi. The trapezius muscle, starting from the occipital bone and the spinous processes of the cervical and thoracic vertebrae, is attached to the spina scapulae, acromion and the outer part of the clavicle. The muscle is only partially located within this area. Muscle arteries arise from a. transversa colli, a. transversa scapulae from the posterior branches of aa. intercostales. Veins accompany arteries of the same name. Lymphatic vessels accompany the arteries and flow into the lower cervical nodes.

N. participates in the innervation of muscles. accessorius and rr. musculares pl. cervicale (CIII - CIV). The deep plate of the fascia propria participates in the formation of the supraspinatus and infraspinatus osteofibrous space of the posterior surface of the scapula.

Within the region are the following muscles attached to the scapula: m. levator scapulae, attached to the inner corner of the scapula, mm. rhomboidei major et minor, attached to the vertebral edge of the scapula, and m. teres major, starting from the outer edge of the lower angle of the scapula. The first three muscles are supplied with blood from a. transversa colli. The outflow of blood occurs into the veins of the same name. Innervation is carried out by branches n. dorsalis scapulae. The arteries of the teres major muscle are branches of aa. circumflexa scapulae, thoracodorsalis and circumflexa humeri posterior. Innervation is carried out by nn. subscapulares (CV - CVII). The supraspinatus osteo-fibrous space of the scapula is formed by the edges of the supraspinatus fossa and the deep plate of the fascia proper, thickened by fibrous fibers.

This space is filled with the muscle of the same name, fiber, vessels and nerves.

The loose fiber of this space communicates with the fiber of the infraspinatus space and the paraarticular fiber of the shoulder joint.

The infraspinatus osteo-fibrous space of the scapula is filled with the infraspinatus muscle starting here and the teres minor muscle separated from it by a thin fascial layer. Both of these muscles are attached to the greater tubercle of the humerus.

The main part of the blood supply to the supraspinatus and infraspinatus muscles is a. transversa scapulae, which is located directly on the bone. In addition, the muscles of the infraspinatus space receive blood from a. circumflexa scapulae, which anastomoses with the above-mentioned artery. The outflow of blood occurs through the veins of the same name. Lymphatic vessels flow into the node located at the notch of the scapula, and then into the supraclavicular nodes. The innervation of the muscles of both spaces is carried out by the branches of the nn. suprascapulares, formed from the brachial plexus (CIV - CVI), which is located next to a. transversa scapulae.

The subscapular fibrous space (spatium subscapulare) is formed by the concave anterior surface of the scapula - fossa subscapularis and a fairly strong fascial layer - fascia subscapularis, which is attached to the edges of the bone.

This space contains the subscapularis muscle, which, starting from the anterior surface of the scapula, is attached by a flat short tendon to the lesser tubercle of the humerus. The tendon is adjacent to the capsule of the shoulder joint. There is also a mucous bursa (bursa mucosa subscapularis), which usually communicates with the cavity of the shoulder joint.

Muscle arteries arise from a. subscapularis and sometimes branches extend to it directly from a. axillaris. Blood flows into veins, which are the same as arteries. Lymphatic vessels drain into the lnn. subscapulares, located in the area of the foramen trilaterum, as well as in the supra- and subclavian nodes.

Several short branches extend from the brachial plexus to the muscle - nn. subscapulares. Between the chest wall itself and the anterior surface of the scapula with its muscles there is a gap, which is divided into two gaps by the serratus anterior muscle passing here, attached to the inner edge of the scapula, into two gaps - the posterior and anterior prescapular gaps.

The posterior prescapular fissure is located between the anterior surface of m. subscapularis with the covering fascia in the back and the serratus anterior muscle in the front. This gap is filled with fiber, which is part of the fiber of the axillary cavity. Branches of a. are located in the fiber. axillaris and veins flowing into the axillary vein or its tributaries; in addition, the lymph nodes are located here and pass nn. subscapulares and n. thoracodorsalis.

The anterior prescapular fissure is formed by the serratus anterior muscle and its covering fascia posteriorly and the fascia covering the ribs and intercostal muscles anteriorly. The gap is completely closed, it contains loose connective tissue, sometimes there are mucous bags. During purulent-inflammatory processes, pus can accumulate in this gap without spreading to neighboring areas.

The boundaries of the posterior inferior region of the chest (regio thoracis posterior inferior) are: at the top - a horizontal line passing through the lower corner of the scapula; below - a line drawn along the XII rib through the anterior ends of the XI and X ribs; outside - the middle axillary line; inside - the vertebral line.

The proper fascia of the chest forms two plates here: superficial and deep.

The superficial plate forms the vagina m. latissimus dorsi. Due to the fact that m. latissimus dorsi starts from several points, it distinguishes: vertebral, iliac and costal parts. A powerful flat tendon is attached to the scallop tuberculi minoris humeri. The arteries of the muscle are multiple and arise from the branches of the intercostal arteries. Veins accompany arteries. Lymphatic vessels carry lymph to the nearest lymph nodes - at the top in the lnn. subscapulares, below in lnn. intercostales and lnn. lumbales. The main nerve is n. thoracodorsalis. The deep plate of the fascia propria is located under the m. latissimus dorsi and forms vaginas for m. serratus posterior and m. serratus anterior, which is only partially included in the region. Between the superficial plate of the fascia with the muscle enclosed in it and the deep one there is a layer of fatty tissue, which spreads to adjacent areas of the chest, which must be kept in mind during purulent-inflammatory processes.

The posteromedian region of the chest (regio thoracis mediana posterior) corresponds to the projection of the spine and organs of the posterior mediastinum. The boundaries of the region are: from above - a horizontal line drawn through the spinous process of the VII cervical vertebra; below - a horizontal line drawn through the spinous process of the XII thoracic vertebra; on the right and left - vertical lines drawn along the ends of the transverse processes.

After removing the superficial plate of the fascia propria of the chest in this area along with the initial part of m. trapezius, as well as the deeper rhomboid muscle and the initial part of m. latissimus dorsi, you can see the deep plate of the fascia of the chest (lamina profunda fasciae pectoralis propriae). The latter in this area is particularly strong and fuses along the midline with the spinous processes of the vertebrae, and on the sides with the angles of the ribs and forms paravertebral osteo-fibrous canals. These channels are made of a complex system of muscles of different sizes and lengths that ensure mobility of the spine. Arteries rr. posteriores aa. intercostalis are distributed strictly segmentally in the muscles and are interconnected by numerous anastomoses. The veins form a plexus here (plexus venosus vertebralis exterior posterior), which is part of the system of venous plexuses located in the spinal canal and associated with the azygos and semi-gypsy veins and, therefore, with v. cava superior. Lymphatic vessels are formed segmentally and carry lymph to the intercostal nodes located in each intercostal space at the heads of the ribs.

The innervation of the muscles contained in the osteofibrous canals is carried out by segmentally running posterior branches of the thoracic nerves nn. thoracales. In addition to the listed formations, this area contains well-developed fiber that fills numerous intermuscular spaces.

Deep layer (the chest itself). The formation of the chest itself involves the sternum, ribs, thoracic spine, intercostal muscles and fascia, in particular the fascia endothoracica, which lines the chest cavity. The listed elements are interconnected both anatomically and functionally. The chest is a very stable elastic formation, the shape of which changes relatively easily depending on the condition of the organs contained in it. The topography of the layers of the wall of the chest cavity is different. First, we should consider the structural features of the individual elements participating in the structure of the wall.

The sternum (sternum) is a flat bone consisting of three parts: the manubrium, the body and the xiphoid process. The shape of it as a whole and its constituent parts is individually different. The length varies widely - from 16 to 23 cm. The thickness of the bone is variable and depends on the degree of development of the spongy layer, the thickness of which ranges from 4 to 13 mm, more often, however, it is within 8 mm. In some cases, one can encounter a sharp thinning of the body of the sternum, up to the formation of holes, which must be kept in mind during sternal punctures. Often the xiphoid process can also be expanded or deformed. Arterial supply and outflow of blood are carried out by vasa mammariae internae.

Articulations of the sternum. The sternoclavicular joint (art. sternoclavicularis) is formed by the clavicular notch of the manubrium of the sternum and the sternal end of the clavicle. The sternocostal joints (art. sternocostales) are not identical in structure. Thus, there is no joint between the first rib and the sternum. The articulation of the sternum with the II, III, and sometimes IV ribs is a flat joint, and with the V, VII and XII ribs - syndesmoses.

The ribs (costae) are long, flat, arched bones, twisted along an axis. The first rib has a number of features. While all ribs have an outer convex and an inner concave surface, the first rib has an upper and lower surface, a convex outer edge and a concave inner edge. In addition, three sections, or segments, are distinguished in the first rib. The vertebral segment is equipped with a head, which has one articular platform, since it articulates only with the first vertebra, a short round neck and a pronounced tubercle that articulates with the transverse process. At this point the rib is sharply curved anteriorly. The middle segment of the first rib, called the muscular segment, has a tuberosity where the middle scalene muscle is attached. The anterior segment is vascular, the longest and widest; you can see grooves on it corresponding to the location of the subclavian artery and vein.

The costal cartilages consist of hyaline cartilage, in which lime begins to be deposited with age, which can cause them to completely ossify.

The cartilages of the first seven ribs are directly connected to the sternum, and the lower the rib, the greater the angle formed between the cartilage and the rib. The cartilages of the VIII, IX and X ribs, sequentially connecting with each other, form a costal arch, which connects to the cartilage of the VII rib. The cartilages of the 11th and 12th ribs are short and lie freely in the soft tissues. Sometimes intercartilaginous joints form between the cartilages of adjacent ribs.

The thoracic spine, consisting of 12 vertebrae, has a sharp posterior bend, reaching a maximum in the region of the VI, VII and VIII vertebrae.

The mobility of the thoracic spine is sharply limited along almost its entire length, but mobility is noted within the 1st and 12th vertebrae.

The external intercostal muscles fill the intercostal space from the junction of the tubercle with the transverse process of the vertebra to the junction of the rib and cartilage. Further, anteriorly to the sternum, the muscle is replaced by tendon fibers, which form the external intercostal ligament. The direction of the muscle fibers is oblique - from top to bottom and from back to front. The internal intercostal muscles have the opposite direction of fibers. They fill the intercostal space from the corners of the ribs to the outer edge of the sternum.

Vascularization and innervation of both muscles is carried out by the intercostal neurovascular bundle.

Due to the fact that in the most medial part of the intercostal space, from the angle of the rib to the spine, there are no internal intercostal muscles, the neurovascular bundle is covered here only by the intrathoracic fascia, loose tissue and pleura. The transverse muscle of the chest (m. transversus thoracis) is located on the inner surface of the sternum and is like a continuation of the transverse abdominal muscle. It starts from the lower half of the sternum with 4-3 teeth on each side and is attached at the junction of the bony part with the cartilaginous part of the II - XII ribs. The innervation of the muscle occurs through the branches of the intercostal nerves. The largest artery of the chest - the paired internal thoracic artery (a. thoracica interna) - arises on each side from the subclavian artery.

At the level of the second rib, the artery approaches the anterior wall of the chest and is further located on the costal cartilages and internal intercostal muscle parallel to the edge of the sternum at a distance of 1.5 - 2 cm from it.

Along its length, the internal thoracic artery gives off a number of branches: Rr thymici, Rr mediastinales, a. pericardiacophrenica, etc. In each intercostal space, branches depart from the artery - anastomoses with the intercostal arteries. In addition, both aa. thoracicae internae are interconnected by anastomoses through the vessels of the sternum. Below, at the level of the VII costal cartilage, the artery divides into its terminal branches - a. musculophrenica and a. epigastrica superior, which is connected by anastomosis with the inferior artery of the same name.

The intercostal arteries arise from two sources: the truncus costocervicalis and the thoracic aorta.

From the truncus costocervicalis comes a. intercostalis suprema, the trunk of which passes in front of the first six ribs, and the intercostal arteries of the first and second intercostal spaces, and sometimes the third and even the fourth, depart from it. Intercostal arteries depart segmentally from the posterior semicircle of the thoracic aorta, the number of which corresponds to the number of intercostal spaces. In cases where the intercostal arteries of the third and fourth intercostal spaces are branches of the truncus costocervicalis, the number of arteries branching from the aorta decreases accordingly. However, it must be borne in mind that in some cases, the 2nd and 3rd intercostal arteries can depart from the aorta with one trunk, the common trunk of which can be located vertically in the region of the necks of the ribs. The intercostal arteries in the region of the rib heads are divided into two main branches - anterior and posterior.

From the posterior branch, which branches in the soft tissues, small branches also extend to the vertebrae and ramus spinalis, which passes into the intervertebral foramen and supplies the membranes of the spinal cord with blood.

In the initial section, the left intercostal arteries lie on the anterior outer surface of the vertebral bodies, then are located posterior to the border trunk and hemizygos vein. The right ones pass along the anterior surface of the vertebral bodies and are also located behind the sympathetic nerve and v. azygos. In the posterior sections, in the region of the costal angle, the artery lies below the rib, the vein of the same name is located slightly higher, and the intercostal nerve can be located differently. Further, anteriorly, the artery is located in the sulcus costae and passes between the intercostal muscles. The veins of the chest accompany the arteries of the same name and can be single or double.

In the chest cavity, one can distinguish visceral lymphatic vessels and nodes, parietal and those located in the mediastinum. Here we will consider the parietal ones, which are divided into two main groups - anterior intercostal and posterior.

The anterior intercostal nodes are located on the inner surface of the anterior chest wall along the edges of the sternum in the intercostal spaces. Their number is not constant. Usually they are well expressed in the first five intervals. The anterior intercostal nodes receive lymph from the tissues of the anterior chest wall. The outflow of lymph from the anterior intercostal nodes on the right and left occurs in different ways. So, according to D.A. Zhdanov, on the left, the efferent vessels flow into the arch of the thoracic duct or into the axillary trunk. On the right, the lymphatic trunks usually flow into the right subclavian duct, sometimes into the jugular duct. Often (in 10% of cases) lymphatic vessels extending from the chain of right nodes connect with the vessels of the left nodes.

The posterior intercostal nodes are located near the spine and receive lymph from the intercostal lymphatic vessels. They are connected with the vessels of the pleura and mediastinal organs. The vessels draining lymph from the posterior intercostal nodes flow into the right and left lymphatic ducts, respectively.

The intercostal nerves upon exiting the intervertebral foramen are divided into three branches: ramus meningeus, ramus posterior, ramus anterior. The latter is the intercostal nerve itself. In addition to the listed branches, at the site of division there is the ramus communicans, which connects the pectoral nerve with the borderline trunk of the sympathetic nerve.

The intercostal nerves are located strictly segmentally, corresponding to the intercostal spaces.

The territory of their distribution does not correspond only to the chest area, in the innervation of which the first six to seven intercostal nerves take part. The rest innervate the muscles of the anterior abdominal wall.

Throughout the intercostal space, the nerve lies between the oblique muscles or between the bundles of the internal oblique. As a rule, the nerve is located slightly below the vessels.

The nodes of the border trunk are located on the heads of the ribs, corresponding to the intervertebral foramina. The number of nodes does not always correspond to the number of edges; it is not uncommon to see an increase in nodes to 16 or a decrease to six or seven. Changing the number of nodes affects their shape, size and topography.

The first thoracic node, as a rule, is united with the VIII cervical node, resulting in the formation of a stellate node. There is almost always a II thoracic node. Each node is vertically connected to each other through rami interganglionares, the length and number of which are related to the number of nodes of the border trunk.

Visceral branches, which take part in the innervation of the mediastinal and abdominal organs, and parietal branches depart from the sympathetic nerve. The latter include rami communicantes, consisting of white preganglionic and gray postganglionic fibers that connect the border trunk and intercostal nerves.

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Types of chest deformation

Ryzhikov Dmitry Vladimirovich
Ryzhikov Dmitry Vladimirovich (Head of the Department of General Bone Pathology of the Federal State Budgetary Institution "National Medical Research Center for Pediatric Traumatology and Orthopedics named after G.I. Turner, Candidate of Medical Sciences, doctor of the highest qualification category, traumatologist-orthopedist)
By type, we most often see the corpo-costal type, this is a deformation of the sternum in the lower part with the involvement of the ribs.
The manubrial type (manubrio-costal) is much less common, this type includes deformation of the manubrium of the sternum (this is the upper part of this bone).
Orthopedists also differentiate between asymmetric forms of deformation and its elasticity.
At what age and by what symptoms can chest deformation be detected in a child?
Among the patients of our Center there are children of any age. Most patients are admitted with a congenital form of the pathology. Sometimes a child is born with an already noticeable chest deformity, but most often we see situations where the deformation becomes noticeable for the first time at the age of 6-8 years and progresses significantly at 10-13 years. Chest deformities can increase while there is potential for skeletal growth, that is, on average until 15-17 years of age. And the higher the height of the parents and the more active the growth of the children, the higher the risk of developing a very pronounced deformity. In contrast to limb deformities, chest deformities often include in their list of symptoms and disturbances in the functioning of the chest organs.

Unique treatment methods at the G.I. Turner National Medical Research Center

Vissarionov Sergey Valentinovich
Vissarionov Sergey Valentinovich (Director of the G.I. Turner National Medical Research Center for Pediatric Traumatology and Orthopedics of the Ministry of Health of Russia, Doctor of Medical Sciences, Professor, Corresponding Member of the Russian Academy of Sciences, laureate of the Government of the Russian Federation)
Today, our Center is one of the few that performs unique operations to eliminate pectus excavatum deformity in children (PCD) through the use of low-traumatic methods of surgical correction. In some situations, we can treat keeled chest deformities in children conservatively by using special braces developed in our Center to correct this pathological condition.
The treatment of chest deformities in children and adolescents is carried out by the General Bone Pathology Clinic of our center.

Conservative methods and surgical treatment of chest pathology

How to get treatment at the Turner Center for Pediatric Traumatology and Orthopedics (formerly the G.I. Turner Research Children's Orthopedic Institute)

The decision on the possibility and necessity of hospitalization at the National Medical Research Center clinic is made after consultation with a specialist from the specialized department and consideration by the Subcommittee of the Medical Commission of the Center for Patient Selection.

For those patients who cannot come for an in-person consultation, there are 2 options:

Contact a doctor at your place of residence and request a telemedicine consultation in the doctor/doctor mode.
Send a request for an absentee consultation, attaching all necessary documents. Including a scan of the attending physician's report. It is important for the doctor to obtain information on the form of the deformity (photos of the chest on the right and left are required), it is also important to send data on the FUNCTION OF THE HEART AND LUNG (ECG, echo-kg, spirography)