Thoracic anatomy

Anatomical knowledge requires rote learning.

.
The more points of reference one has for knowledge, the
better the retention.
.
Learning relative anatomy enhances anatomical
knowledge.

A thorough understanding of anatomy is essential for radiologic interpretation and is examined in the first part of the
Royal College of Radiologists Fellowship examination. Conventional anatomical texts tend to represent anatomy in
terms of a three-dimensional (3D) model. Radiological interpretation is primarily performed on two-dimensional (2D)
images: either the mapping of a 3D body to a 2D image (i.e. plain radiography) or display of a 3D structure as a
series of 2D slices (CT/MRI tomography). An understanding of radiological anatomy can be gleaned from
conventional anatomic texts, but is more easily assimilated from texts presenting the anatomy in the form in which it
is encountered in radiological practice. This review presents plain radiographic and axial CT images accompanied by
explanatory text. The image labels are anonymised, and a key to the answers is to be found at the end of the paper.
As a learning experience we would recommend that you attempt to identify any structures you do not immediately
recognise by referring to the text and then test your assertion through the key at the end.
This review has been written with the Royal College of Radiologists Fellowship anatomy examination revision in
mind. All the images have anonymised labels; the key to these labels is given in Table 1 and the answers are at the
end of the review (Tables 24). The anatomy has been described in terms of the relative position of anatomical
features with respect to readily identified anatomy, enabling the reader to work out the anatomical label. We would
recommend the reader uses the text to identify any anatomical labels they are unable to identify, and in so doing will
be able to apply that knowledge to non-axial sections that may be used in the exam.

Table 1. Key to labels

Table 1.Key to labels

La
Structure
bel
A Airways
B Bones
H Heart
L Lines
M Muscles

La
Structure
bel
V Vessels
Other
O
structures
Ta
ble
2.
An
sw
ers
for
lun
g
(L),
bon
es
(B)
and
oth
ers
(O)
Table 2.Answers for lung (L), bones (B) and others (O)

No
Bones
Lines (L)
.
(B)
Rt.
Rt.
transvers
1 paratrache
e
al stripe
process T
AzygoLt.
2 oesophage
clavicle
al line
Posterior Lt.
3 junctional humeral
line
head
Anterior
Lt.
4 junctional
glenoid
line
Retrostern
5
Scapula
al line
6

Others (O)
Oesophagus
1

Carina
Rt. oblique
fissure
Lt. oblique
fissure

Horizontal
fissure
Gastric
Sternum
fundus

No
Bones
Lines (L)
.
(B)
7
8

Others (O)

Rt.
Manubriu
hemidiaphra
m
gm
Lt.
hemidiaphra
gm
Rt. hila point

Lt, left; Rt, right.

Table 3. Answers for vessels (V) and heart (H)

Table 3.Answers for vessels (V) and heart (H)

No
Vessels (V)
.

Heart (H)

Lt. atrial
Superior vena appendag
1
cava
e
(auricle)
Interlobular
2
Rt. atrium
artery
Lt. subclavian
3
Lt. atrium
artery
Aortic
Rt.
4
knuckle
ventricle
Descending Lt.
5
thoracic aorta ventricle
Lt. lower lobe
Mitral
6 pulmonary
valve
artery
Non
Lt. common
7
coronary
carotid artery
sinus
Innominate Lt
8 (brachiocepha coronary
lic) vein
sinus
Rt.
Brachiocephal
9
coronary
ic artery
sinus

No
Vessels (V) Heart (H)
.
Rt. subclavian pericardiu
10
vein
m
LUL ant.
11 segmental
artery
Ascending
12
aorta
Rt. main
13 pulmonary
artery
Lt. main
14 pulmonary
artery
15 Azygos vein
Lt. coronary
16
artery
17 Aortic root
18 LAD
Lt circumflex
19
artery
Intercostal
20
artery
Hemi-azygos
21
vein
Rt superior
22 pulmonary
vein
LUL apicoposterior
23
segmental
artery
Lt superior
24 pulmonary
vein
LLL
25 pulmonary
artery
RUL ant.
26 segmental
artery
27 Lingula artery
28 RLL ant.

No
Vessels (V) Heart (H)
.
segmental
artery
RLL medial
29 segmental
artery
LLL medial
30 segmental
artery
LLL ant.
31 segmental
artery
LLL lateral
32 segmental
artery
Rt. inferior
33 pulmonary
vein
RLL lateral
34 segmental
artery
RLL posterior
35 segmental
artery
Pulmonary
36
outflow tract
Diagonal
37 branch of
LAD
Rt. coronary
38
artery
Lt. inferior
39 pulmonary
vein
LLL apical
40 segmental
artery
Axillary
41
artery
RLL
42 pulmonary
artery
Rt. common
43
carotid artery

No
Vessels (V) Heart (H)
.
Rt. subclavian
44
artery
LLL post.
45 segmental
artery
RUL ant.
46 segmental
artery
RML
47 pulmonary
vein
Ant, anterior; LAD, left anterior descending artery; LCA, left coronary artery; LLL, left lower lobe; Lt, left; LUL, left
upper lobe; Post, posterior; RCA, right coronary artery; RLL, right lower lobe; RML, right middle lobe; Rt, right; RUL,
right upper lobe.

Table 4. Answers for airways (A) and muscles (M)

Table 4.Answers for airways (A) and muscles (M)

No Airways
. (A)
1 Trachea
RUL
apical
2 segmenta
l
bronchus
RUL
post.
3 segmenta
l
bronchus
Rt. main
4
bronchus
Lt. main
5
bronchus
6 LUL
apicopost.

Muscles (M)
Subscapularis
Pectoralis minor

Pectoralis minor

Subclavius
Sternocleidomast
oid
Sternohyoid

No Airways
. (A)
segmenta
l
bronchus
LUL
anterior
7 segmenta
l
bronchus
LUL
8
bronchus
Lingula
9
bronchus
RLL
anterior
10 segmenta
l
bronchus
RLL
medial
11 segmenta
l
bronchus
LLL
medial
12 segmenta
l
bronchus
LLL
lateral
13 segmenta
l
bronchus
RLL
lateral
14 segmenta
l
bronchus
RLL
posterior
15 segmenta
l
bronchus
16 LLL

Muscles (M)

Sternothyroid

Longus colli
Scalenus anterior

Scalenus medius

Scalenus
posterior

Supraspinatus

Levator scapulae

Erector spinae

Trasversus
spinalis
Trapezius

No Airways
Muscles (M)
. (A)
apical
segmenta
l
bronchus
Bronchus
17 intermedi Deltoid
us
RLL
apical
18 segmenta Teres major
l
bronchus
LLL
19
Latissimus dorsi
bronchus
RML
20
Intercostal
bronchus
LLL
anterior
21 segmenta Rhomboid minor
l
bronchus
RML
lateral
22 segmenta Serratus anterior
l
bronchus
RML
medial
23 segmenta Infraspinatus
l
bronchus
RLL
24
Rhomboid major
bronchus
LLL
posterior
25 segmenta
l
bronchus
RUL
26
bronchus
27 RUL
anterior
segmenta

No Airways
Muscles (M)
. (A)
l
bronchus
LUL
apical
28 segmenta
l
bronchus
LUL
posterior
29 segmenta
l
bronchus
Ant, anterior; LAD, left anterior descending artery; LCA, left coronary artery; LLL, left lower lobe; Lt, left; LUL, left
upper lobe; Post, posterior; RCA, right coronary artery; RLL, right lower lobe; RML, right middle lobe; Rt, right; RUL,
right upper lobe.

Plain film anatomy

Section:
Choose

There is a limit to the range of anatomy discernible on plain film imaging. The structures one should be aware of are
outlined below (Figure 1).

Figure 1. Posteroanterior chest radiograph.

Frontal chest X-ray

The superior aspect of the right mediastinal contour is formed by the lateral aspect of the superior vena cava. This
margin becomes confluent with the right atrial wall, which forms the right heart border. An overlapping convex margin
representing the ascending aorta may alter the upper right heart border, particularly if the patient is rotated to the
right. The inferior aspect of the right heart border may be obscured by fat in the cardiophrenic angle, and the lateral
margin of the inferior vena cava may be visible as it drains into the inferior aspect of the right atrium.
The superior aspect of the left mediastinal contour is formed by the lateral margin of the left subclavian artery, but the
clarity of this margin is variable. The first consistent part of the left mediastinal contour is formed by the aortic arch
and called the aortic knuckle. Inferior to the arch of the aorta there is a relative scarcity of tissue, giving rise to a
concavity termed the aorto-pulmonary window, which is limited inferiorly buy a bulge formed by the pulmonary outflow
tract as it divides with the left main pulmonary artery coursing posteriorly. A further more subtle concavity is then

encountered in the mediastinal silhouette, corresponding to the left atrial appendage. The remainder of the contour is
formed by the left ventricle, although this margin is made indistinct inferiorly by pericardial fat, as on the right.
At the right hilum the right main pulmonary artery can be seen dividing into upper and interlobar arteries; the latter
divides into the right lower lobe and middle lobe arteries. In addition there are upper lobe pulmonary veins, which
drain into the left atrium just inferior to the hilum, and therefore have a similar orientation to the arteries from which
they are difficult to separate. The lower lobe pulmonary veins take a more horizontal course to drain more inferiorly
into the left atrium, and are therefore more readily distinguished from the more vertical arteries. The right main
bronchus is seen to divide into the upper lobe bronchus, which has a relatively horizontal course, and the bronchus
intermedius, just off the vertical. The anterior segmental bronchus of the upper lobe may take an anterior course at its
origin, such that it is visible as a ring seen end-on arising from the upper lobe bronchus.
At the left hilum the main pulmonary artery is seen to divide into the left upper and lower lobe arteries; the
configuration of the venous anatomy is the same as on the right. The left main bronchus is seen to divide into the
upper and lower lobe bronchi.
The hilar points are defined by the concavity formed by the lateral margin of the basal artery overlapping the lateral
margin of the upper lobe pulmonary veins. On the right the hilar point should be level with the lateralmost aspect of
the right sixth rib; on the left the main pulmonary artery arches over the left main bronchus such that the left lower
lobe artery originates at a higher point, and the hilar point is therefore approximately 1.5cm higher than that on the
right.
There is little in the way of specific anatomy to identify in the lungs; on the right the horizontal (or lesser) fissure may
be visible arising medially at the right hilar point. A not infrequent anatomical variant is the presence of an azygos
fissure; this is formed by two layers of parietal and two layers of visceral pleura, and variably contains the azygos vein
as it drains into the superior vena cava. An accessory fissure may be seen diagonally to connect the right heart
border with the right hemidiaphragm.
Lateral chest X-ray
The lateral chest X-ray (Figure 2) has become relatively uncommon in recent years, but an understanding of the
anatomy is still required. The sternum is seen side-on anteriorly, and just posterior to this is the retrosternal line
formed by the soft tissue plane attached to the posterior aspect of the sternum. Posterior to this is the retrosternal
space, effectively the anterior mediastinum, a variably sized triangular area of lucency demarcated by the retrosternal
line, the anterosuperior border of the heart and the ascending aorta. The anterosuperior border of the heart, formed
by the right ventricle, and the anterior border of the ascending aorta may be indistinct due to adjacent mediastinal fat.

Figure 2. Lateral chest radiograph.

In the lungs the oblique (major) fissures are seen extending diagonally from the upper posterior pleural surface, at
about the level of the upper margin of the aortic arch, to the anterior surface of the hemidiaphragm; the right oblique
fissure is met in its middle third by the horizontal (minor) fissure, which may be used to distinguish it from the left
oblique fissure; in addition the major fissures may be differentiated by the hemidiaphragm at which they stop (see
below).

The hemidiaphragms are convex, doming superiorly, and are superimposed on one another, but will usually be at
different heights: the right hemidiaphragm is seen up to the anterior pleural surface, is met by the right oblique fissure
and tends to dome more anteriorly; the left is met by the left oblique fissure, tends to dome more posteriorly and is
obscured in its anterior aspect by the heart.
The trachea can be seen demarcated by its anterior and posterior borders down to the carina. Just inferior to the
carina the horizontal orientation of the right upper lobe bronchus can be seen as a ring and the bronchus intermedius
may be discernible as a tube side-on extending inferiorly from that point.
The arch of the aorta is opened out on the lateral chest X-ray and gives rise to the descending aorta, which follows a
vertical course just anterior to or overlapping the thoracic spine. The upper quarter of the film includes both shoulders
and arms superimposed; the inferior contour of the soft tissues of the arm may be seen and will extend anteriorly
beyond the margins of the thorax. The blades of the scapulae are seen side-on, and therefore appear as two thin
strips of bone projected over the posterior aspect of the film.

Axial anatomy
Section:
Choose

Bronchial tree
When deciphering the bronchial tree anatomy it helps to consider the orientation of the various lobar segments in
relation to the origin of the bronchial tree, effectively the hila. The apical and posterior segments of the upper lobes lie
superior to the hilum therefore the respective segmental bronchi will follow a cranial course; in the lower lobes all but
the apical segments at the base of the lungs and the respective segmental airways follow a caudal course. On axial
imaging airways following a cranial or caudal course are seen in cross-section. By comparison the upper lobe anterior
segmental bronchi, the lower lobe apical segmental bronchi, the right middle lobe bronchi and lingula bronchi course
at least partially within the axial plane. In addition it is worth bearing in mind that the various divisions of the right
bronchial tree occur on more cranial sections than the equivalent divisions of the left bronchial tree, which explains
the discrepancy in the segmental airways evident on any particular axial slice.
The trachea divides into the right and left main bronchi at approximately the level of T4. The right upper lobe
bronchus is the first branch of the right main bronchus and comes off horizontally, rapidly dividing into the anterior,
posterior and apical branches. The apical segmental bronchus of the right upper lobe is seen end-on, and the anterior
and posterior segmental bronchi can be seen anterior and posterior, respectively, to a coronal plane through the
apical segmental bronchus (Figures 3 and 4).

Figure 3. Axial CT image with lung windows.

Figure 4. Axial CT image with lung windows.

The right middle lobe bronchus courses anterolaterally from the anterior aspect of the bronchus intermedius, the
stretch of bronchus between the origins of the upper and middle lobe bronchi. The right middle lobe bronchus rapidly
divides into medial and lateral segmental branches, the relative position of which matches their designation. At about
the same level the right lower lobe apical (superior) segmental bronchus courses posteriorly in the axial plane from
the posterior aspect of the bronchus intermedius (Figures 5 and 6).

Figure 5. Axial CT image with lung windows.

Figure 6. Axial CT image with lung windows.

The bronchus intermedius becomes the right lower lobe bronchus after the origin of the right middle lobe bronchus.
This airway gives rise to four segmental bronchi in a variable order, but usually the medial and anterior segmental
bronchi arise first followed by the posterior and lateral segmental bronchi. The medial segmental bronchus arises
anteriorly coursing medially and inferiorly, the anterior bronchus courses antero-laterally, the posterior segmental
bronchus courses postero-inferiorly and the lateral segmental bronchus courses postero-infero-laterally. At the level
where all the segmental bronchi are visible, they are from the most antero-medial bronchus in a clockwise direction
the medial, anterior, lateral and posterior segmental bronchi (Figures 7 and 8).

Figure 7. Axial CT image with lung windows.

Figure 8. Axial CT image with lung windows.

The left main bronchus divides into the left upper and lower lobe bronchi at the hilum. The first branch of the left
upper lobe bronchus is the lingular bronchus, which courses anterolaterally in the axial plane; the lingular bronchus
then divides into the superior and inferior segmental branches, the former initially in the axial plane, the latter seen
end-on taking a caudal course. The upper lobe bronchus then divides into the anterior segmental bronchus, coursing
anteriorly in the axial plane, and the apicoposterior bronchus; the latter then divides into the apical and posterior
segmental bronchi. The apical segmental bronchus takes a cranial course and is therefore seen end-on; a coronal
plane through this bronchus separates the anterior and posterior segmental bronchi. Note the posterior segment of
the left upper lobe, as on the right, is superior to its segmental bronchus, which therefore takes a cranial course and
is also seen end-on (Figures 9 and 10).

Figure 9. Axial CT image with lung windows.

Figure 10. Axial CT image with lung windows.

The left lower lobe bronchus is created at the division of the left main bronchus and courses inferolaterally almost
immediately, giving rise to the apical segmental bronchus, which courses posteriorly in the axial plane. There is then
a short segment of left main bronchus, equivalent to the bronchus intermedius on the right, before the bronchus
divides, in a variable order, into the anterior segmental bronchus coursing anterolaterally, the posterior segmental
bronchus coursing posteroinferiorly and the lateral segmental bronchus coursing posterolaterally. The medial
segmental bronchus arises from the medial aspect of the anterior segmental bronchus. All these segmental bronchi
course inferiorly, and are therefore seen end-on. Once all the segmental bronchi have been formed they are, from the
most anteromedial bronchus in a clockwise direction, the medial, anterior, lateral and posterior segmental bronchi
(Figures 11 and 12).

Figure 11. Axial CT image with lung windows.

Figure 12. Axial CT image with lung windows.

The pulmonary arterial tree follows the same branching structure as the bronchial tree, but the anatomy has to
account for the fact that where the main bronchi arise from the carina, which is central, and course caudally, the origin
of the main pulmonary arteries from the division of the pulmonary outflow tract is inferior to the main bronchi, and
eccentrically placed on the left. As a result the right main pulmonary artery takes a horizontal course, reaching the
gap between the right main bronchus and the superior vena cava, where it divides into its lobar branches, whereas
the left main pulmonary artery takes a posterocranial course, dividing into its lobar branches superior to the left main
bronchus (Figures 10 and 13).

Figure 13. Axial CT image with mediastinal windows.

The right upper lobe pulmonary artery arises between the superior vena cava and the right main bronchus just before
the origin of the right upper lobe bronchus and gives rise to the anterior segmental artery, which courses anteriorly in
the axial plane medial to the anterior segmental bronchus. The apical segmental artery courses superiorly and is
seen end-on medial to the apical segmental bronchus, and the posterior segmental artery courses posterolaterally in
the axial plane behind the apical segmental bronchus to lie posteromedial to the posterior segmental bronchus
(Figures 9 and 10).
The pulmonary artery segment between the origin of the right upper lobe artery and origin of the right middle lobe
artery is the arterial equivalent of the bronchus intermedius and is called the interlobar artery (Figure 11).
The right middle lobe artery arises just cranial and anterior to the right middle lobe bronchus; it immediately divides
into medial and lateral segmental arteries, which then course anterolaterally to their equivalent segmental bronchi.
The right lower lobe artery courses around the front of the bronchus intermedius, at which point the apical segmental
artery courses posteriorly, lying above the right lower lobe apical segmental bronchus. The medial, anterior, lateral
and posterior segmental arteries arise just above the equivalent divisions of the right lower lobe bronchus and course
laterally to their respective segmental bronchi (Figures 7, 8 and 12).
The first branch of the left upper lobe artery, very close to its origin, is the lingula artery, which courses laterally and
lies anterosuperior to the lingula bronchus; the inferior and superior segmental branches lie anterior to their
respective bronchi. The anterior segmental artery is the next branch, coursing anterolaterally to lie medial to the
anterior segmental bronchus. The remaining left upper lobe artery then divides into the apical and posterior
segmental arteries that lie posteromedial to their respective segmental bronchi (Figures 3 and 4).
The left lower lobe artery arches over the left main bronchus, and as it starts its caudal course it gives off the apical
segmental branch, which courses posteriorly in the axial plane lateral to the equivalent segmental bronchus. The left
lower lobe artery first gives off an anterior branch, which is the anterior segmental artery coursing anterolaterally; the
remaining lower lobe artery then divides into the lateral and posterior segmental arteries, which course laterally and
posteriorly, respectively, with both also taking a caudal course. At around this level the medial segmental artery arises
medially from the anterior segmental artery. Due to the posterolateral position of the left lower lobe artery in relation to
the left lower lobe bronchus, the segmental arteries tend to lie lateral to their respective segmental bronchi (Figures
10 and 11).
The right upper lobe pulmonary vein is formed from the confluence of the segmental draining veins from the right
upper lobe and lies anterior to the right main pulmonary artery at about the level of the origin of the right middle lobe
artery. The vein then continues an inferomedial course and is joined by the right middle lobe pulmonary vein just
before entering the left atrium. The right lower lobe pulmonary vein enters the posterolateral aspect of the left atrium
at a more caudal level (Figures 4, 5, 7 and 10).
The left upper lobe pulmonary vein is formed by the confluence of the venous drainage of the upper lobe segments
anterior to the lingula artery and then continues inferomedially towards the left atrium, being joined by the lingula vein
anterior to the left upper lobe bronchus. The left lower lobe pulmonary vein enters the left atrium at its posterolateral
aspect (Figure 10).
Mediastinum and lower neck
Down to the carina the mediastinal anatomy will be described in relation to the trachea. The oesophagus lies
posterior to the trachea, slightly to the left, down to the carina.
The most usual anatomy of the aortic arch comprises three arch vessels. The most anterior is the brachiocephalic
artery, which courses to the right and superiorly, dividing into the right common carotid artery (anterior) and right
subclavian artery (posterior) at around the level of the sternal notch. The next arch vessel, arising posteriorly and to

the left of the brachiocephalic artery, is the left common carotid artery, which courses superiorly and to the left to lie at
the anterolateral aspect of the trachea at the level of the sternal notch in a position that mirrors that of the right
common carotid artery. The last arch vessel is the left subclavian artery, which courses superiorly to lie adjacent to
the trachea on the left mirroring the right subclavian artery at the level of the sternal notch. There are therefore four
vessels seen end-on in axial section, surrounding the trachea at the sternal notch; the anterior vessels are the
common carotid arteries and the posterior vessels are the subclavian arteries. Higher up at the level of the thyroid
gland the subclavian arteries course laterally, but the common carotid arteries keep a superior course and the internal
jugular veins can be seen anterolateral to them. Also at this level the vertebral arteries arise from the subclavian
arteries and can be seen coursing superiorly just posterior to the subclavian arteries (Figures 14 and15).

Figure 14. Axial CT image with mediastinal windows.

Figure 15. Axial CT image with mediastinal windows.

Just above the level of the aortic arch the internal jugular veins on each side join the subclavian veins. On the left this
forms the brachiocephalic (innominate) vein, which courses anterior to the arch vessel and joins the confluence of the
equivalent veins on the right to form the superior vena cava. At the level where the brachiocephalic vein is seen
anterior to the arch vessels the brachiocephalic artery is yet to divide, and the three arch vessels are seen: anteriorly,
the brachiocephalic artery; posteriorly, the left subclavian artery; and between them the left common carotid artery.
At the level of the aortic arch the superior vena cava is seen to the right of the anterior aspect of the arch and lower
down comes to lie posterolateral to the ascending aorta. Just above the level of the carina is the azygos vein coursing
anteriorly alongside the right tracheal wall and draining into the superior vena cava.
At the carina the trachea divides into the right and left main bronchi. The oesophagus is found slightly anteriorly to the
right and medial to the descending aorta, which in turn is on the left adjacent to the spine. The ascending aorta is the
most anterior vessel, and the superior vena cava lies posterior and to the right of this.
Cardiac anatomy is described in a subsequent section. In the posterior mediastinum, below the level of the carina,
the azygos vein is seen anterolateral to the spine on the right, and on the left the hemiazygos vein is to be found
adjacent to the spine posterior to the aorta; at a variable level this vein crosses behind the aorta and oesophagus,
and joins the azygos vein. Numerous small vessels originate from the lateral aspect of the descending aorta. These
are the intercostal arteries, which find their way to the intercostal space, where they run a tortuous course before
arriving at the flange of the rib; there they accompany the intercostal nerves (Figure 16).

Figure 16. Axial CT image with mediastinal windows.

The diaphragmatic hiatus that admits the oesophagus and aorta into the abdomen is demarcated by the spine
posteriorly and the crura of the diaphragms anterolaterally.
Muscles of the thorax
Figure 17 represents the usual most superior slice on a thoracic CT, and it can be very difficult at this level to
distinguish muscles, vessels and lymph nodes. The patient has their arms abducted fully for this image, causing
rotation of the scapula, which explains the orientation of the structures around the shoulders when compared with an
axial anatomy text based on a cadaver (arms down).The bones visible are the T1 vertebra and proximal first rib, the
middle third of the clavicles anteriorly, the glenoid (anterior) and acromion (posterior) of the scapula, and the humeral
head. The anterior muscle is the pectoralis major. Deep to this muscle are subclavius medially (connecting to the
clavicle) and pectoralis minor laterally (as it passes superiorly to the coracoid process of the scapula). The muscle
directly posterior to the humeral head and glenoid is the supraspinatus muscle. The only other rotator cuff muscle
visible is the subscapularis muscle anterior to the glenoid. Superficial to these muscles over the humeral head is
deltoid muscle. Passing medial to the clavicles, the first muscle is sternocleidomastoid, lying anterior to the
sternohyoid and sternothyroid, the latter two lying anterolateral to the trachea, with sternohyoid being most superficial
and lateral. Posterior to the clavicle are the scalene muscles, with scalenus anterior separated from scalenus medius
and posterior by the costocervical trunk superiorally, and the subclavian artery inferior to this slice, immediately
superior to the first rib. Lying on the anterolateral aspect of the vertebral body is the longus colli muscle. The large
superficial posterior muscle is the trapezius muscle. Passing laterally from the spinous process of the vertebra are
two groups of muscles that each contain three muscles; however, they are not individually easily visible on CT. They
are transversospinales muscles medially attaching to both the spinous and transverse processes, and the erector
spinae muscles more laterally, originating from and extending slightly beyond the tip of the transverse process.
Immediately posterolateral to the erector spinae is the levator scapula muscle. The transversospinales and erector
spinae muscles exist at cervical, thoracic and lumbar vertebral levels, and are seen in the same places on the more
caudal axial images (Figure 17).

Figure 17. Axial CT image with mediastinal windows.

Figure 14 is at the level of the sternal notch, superior to the sternum and medial to the medial ends of the clavicle.
Anteromedial to the clavicle is sternocleidomastoid. Posterior to the medial tips of the clavicle are the sternohyoid and
then sternothyroid muscles lying anterior to the thyroid gland. On the anterior thoracic wall the pectoralis major and
minor muscles can be seen, with the latter being the smaller and lying deeper. The scapula at this angle appears as a
Y shape. The sagittally aligned spine of the scapula separates the infraspinatus muscle laterally from the
supraspinatus muscle in the supraspinous fossa. Anterior to the coronally aligned blade of the scapula is the
subscapularis muscle, accounting for the lateral two-thirds of the subscapular fossa. Anterolateral to the lateral aspect
of subscapularis is the teres major muscle. The serratus anterior muscle can be found at the medial aspect of the
subscapular fossa, as well as being immediately superficial to the thoracic cage from the medial aspect of the
scapula to the anterolateral thoracic wall. Between the ribs are the intercostal muscles (external, internal and
innermost intercostal muscles). Posteriorly, and most superficial, is trapezius muscle with rhomboid minor muscle
immediately deep between the tip of the spinous process and the medial border of the scapula. At the point where the
Y of the scapula becomes a flat blade inferiorly is the point where the rhomboid minor muscle becomes the major,
just deep to trapezius (Figure 14).
At the level depicted by Figure 18 the scapula appears as a flat blade-like structure. On the posterior surface lies
infraspinatus, and on the anterior surface is subscapularis. Over the lateral border is teres major, with latissimus dorsi
more superficial. Deep to subscapularis is serratus anterior. Again, pectoralis major is the large muscle on the
anterior thoracic wall, with the minor barely discernible as a small muscle deep to the major at its lateral edge.

Trapezius remains the large muscle of the posterior thoracic wall, with rhomboid major now lying immediately deep to
it (Figure 18).

Figure 18. Axial CT image with mediastinal windows.

In Figure 19 the left and right trapezius muscles, lying posteriorly, are narrowing and do not now extend past the
angle of the rib laterally. Latissimus dorsi is the large muscle of the posterolateral thoracic wall, and the muscle bulk
at the most lateral aspect of the thorax is serratus anterior, with pectoralis major muscle existing only as a small
structure extending from the lateral margin of the sternum (Figure 19).

Figure 19. Axial CT image with mediastinal windows.

Cardiac anatomy
For completeness, a description of basic cardiac anatomy is included here with some accompanying imaging;
however, a detailed account of cardiac/coronary anatomy is beyond the scope of this review.
The heart is a pyramid-shaped structure, with a base just right of the midline that faces posterolaterally and an apex
that directs anteroinferiorally towards the left. It has four chambers: a right atrium that is found at the most right
aspect of the heart; a right ventricle that makes up most of the anterior surface of the heart; a left atrium that is found
at the heart's most posterior aspect; and a left ventricle that is posterior to the right ventricle but passes
anterolaterally to the left, where it accounts for the apex. The right atrium receives blood from the vertical superior
and inferior venae cavae. Two pulmonary veins enter the left atrium obliquely on both the right and left aspects. The
great vessels, ascending thoracic aorta and pulmonary trunk exit the superior aspect of the heart on the right and left,
respectively. The tricuspid valve is a sagittally placed structure at the right sternal edge and the mitral valve lies level
with the left sternal edge coronally. On axial imaging the pulmonary valve is situated in line with the left sternal edge,
lying more anterior to the aortic valve, which lies in line with the right sternal edge; both consist of three cusps. The
pulmonary valve normally has two anterior cusps (one right and one left) and one posterior cusp. The aortic valve has
one anterior cusp related to the osteum of the right coronary artery and two posterior cusps (one right and the other
left); the left posterior cusp is usually related to the osteum of the left coronary artery (Figures 19 and 20).

Figure 20. ECG-gated axial CT image of the heart.

The coronary circulation consists of a right and left coronary artery, with each supplying a typical territory; however,
the arteries have a relatively large number of anatomical variants, some of which are described.

The right coronary artery (RCA) arises from the right aortic sinus and passes anterolaterally just posterior to the right
ventricle, and then inferiorly in the right atrioventricular groove, demarcating the boundary between the right atrium
and right ventricle. It continues inferiorly until it reaches the most inferior aspect of the right side of the heart. At this
point the right marginal artery branches off and continues along the inferior aspect of the right ventricle, towards (but
not reaching) the apex. The RCA then ascends medially, still in the atrioventricular groove, until it reaches the
interventricular septum posteriorly, where it then provides a posterior interventricular artery that passes in the
posterior interventricular sulcus inferiorly towards the apex.
The left coronary artery (LCA) arises from the left posterior coronary sinus, passing left horizontally behind the
pulmonary trunk and medial to the auricle of the left atrium. The auricle is an appendage that extends from the left
border of the left atrium around the root of the pulmonary trunk. Between the auricle and pulmonary trunk the LCA
divides into the anterior interventricular artery (also referred to as the left anterior descending, or LAD) and circumflex
arteries close to its origin. The LAD passes around the pulmonary trunk before it meets the anterior interventricular
sulcus, in which it then travels inferiorly, giving off diagonal branches. The circumflex travels laterally below the auricle
of the left atrium until it meets the left coronary groove, in which it sits. The artery passes posteriorly in the groove,
where the left marginal artery branches off and descends inferolaterally at the most lateral aspect of the left side of
the heart. As the circumflex turns medially it gives off a posterior left ventricular branch that travels inferiorly at the
most posterior aspect of the left ventricle. The circumflex continues medially in the left atrioventricular groove towards
the interventricular septum; however, in most patients it terminates before the septum (Figures 19and 20).
Typically, the RCA supplies the right atrium, most of the right ventricle, the diaphragmatic surface of the left ventricle,
the posterior third of the interventricular septum, and in most cases the sinoatrial and atrioventricular nodes. The left
coronary artery therefore supplies the left atrium, most of the left ventricle, a small part of the right ventricle, the
anterior two-thirds of the interventricular septum (including the atrioventricular bundle of connecting tissue) and in a
minority both or one of the nodes.