A reappraisal of pediatric thoracic surface anatomy

Abstract

Accurate knowledge of surface anatomy is fundamental to safe clinical practice. A paucity of evidence in the literature regarding thoracic surface anatomy in children was identified. The associations between surface landmarks and internal structures were meticulously analyzed by reviewing high quality computed tomography (CT) images of 77 children aged from four days to 12 years. The results confirmed that the sternal angle is an accurate surface landmark for the azygos-superior vena cava junction in a plane through to the level of upper T4 from birth to age four, and to lower T4 in older children. The concavity of the aortic arch was slightly below this plane and the tracheal and pulmonary artery bifurcations were even lower. The cardiac apex was typically at the 5 intercostal space (ICS) from birth to age four, at the 4 ICS and 5 rib in 4-12 year olds, and close to the midclavicular line at all ages. The lower border of the diaphragm was at the level of the 6 or 7 rib at the midclavicular line, the 7 ICS and 8 rib at the midaxillary line, and the 11 thoracic vertebra posteriorly. The domes of the diaphragm were generally flatter and lower in children, typically only one rib level higher than its anterior level at the midclavicular line. Diaphragm apertures were most commonly around the level of T9, T10, and T11 for the IVC, esophagus and aorta, respectively. This is the first study to provide an evidence-base for thoracic surface anatomy in children. Clin. Anat. 30:788-794, 2017. © 2017Wiley Periodicals, Inc.

Apprasial of the surface anatomy of the Thorax in an adolescent population

“…In children younger than 7 years old, it is reported that the cardiac apex lies in relation to the fourth ICS, and at the 5, sixth ICS in older children (Tasker et al ; Park ). This is similar to what was reported in the current study and in recent adult population studies (Mirjalili et al ; Pak et al ; Shen et al ; Keough et al ), as well as in children younger than 4 years old (Fischer et al ) where the cardiac apex was reported at the fifth ICS on the left. Fischer et al () had found that the cardiac apex children older than 4 years old were in relation to the fourth ICS and fifth rib.…”

“…This is similar to what was reported in the current study and in recent adult population studies (Mirjalili et al ; Pak et al ; Shen et al ; Keough et al ), as well as in children younger than 4 years old (Fischer et al ) where the cardiac apex was reported at the fifth ICS on the left. Fischer et al () had found that the cardiac apex children older than 4 years old were in relation to the fourth ICS and fifth rib. This is slightly higher than what was found in the current study, or the range reported in pediatric anatomical textbooks (Tasker et al ; Park ).…”

“…Although the authors do not necessarily disagree with this definition, it is important to note that 53.3% of the samples in this study were reported to lie inferior to upper half of T5 and that this disparity is a possible range of variation that should be discussed. Compared to other studies that use pediatric and adult populations, this level is slightly lower as these studies had concluded the sternal angle plane to lie mostly at T4 with few of their cases found inferior to this level (Mirjalili et al, & ; Shen et al ; Uzun et al ; Keough et al ; Fischer et al ). Chukwuemeka et al () reported the sternal angle to lie at the lower half of the fifth thoracic vertebra, similar to the current study, with a slightly different method.…”

“…Of the studies mentioned above, Subramaniam et al (), Tarr et al (), and Fischer et al () are the only studies to the authors' knowledge that focus on the surface anatomy of a pediatric population. Their studies show the similarities and differences between an adult and pediatric population, thereby highlighting the need for further comparative studies.…”

A Comparison of the external anatomical landmark and the radiological landmark for obtaining the optimal depth of a right internal jugular venous catheter in pediatric cardiac patients

“…Various thoracic surface landmarks corresponding to intrathoracic structures have been described . The midpoint of a perpendicular line from the sternal head of the right clavicle to a line connecting the nipples (point C) was the relative site of the distal SVC .…”