An understanding of thoracic landmarks is integral to the systematic examination of the thorax.

The
bony thorax encases the heart and lungs and partially covers the stomach, liver, kidneys, and spleen.

The thorax consists of 12 pairs of ribs which attach anteriorly to the sternum via their costal cartilages
and posteriorly to the thoracic vertebrae. Inferiorly the anterior cartilage and ribs form the right and left
costal margins. To locate and describe your findings when examining the thorax and lungs, you must be
able to number the 12 ribs and their interspaces accurately as well. Anteriorly, begin by identifying the
sternal angle.

To find the sternal angle, place your finger in the hollow curve of the suprasternal notch...

...and slide your fingers downward about 5 centimeters until you feel the bony ridge that joins the
manubrium to the body of the sternum. This is the sternal angle.

Move your fingers laterally and find the adjacent second rib and costal cartilage. Using two fingers, walk
down the interspaces, one space at a time, on an oblique line.

Do not try to count interspaces along the lower edge of the sternum as the ribs there are too close
together.

Posteriorly, the 12th rib is another starting point for counting ribs and interspaces.

Find T12 and the adjacent 12th rib by pressing your fingers in and up from below the rib cage. Then
“walk up” the interspaces above.

The inferior tip of the scapula is another useful bony landmark; it usually lies at the level of the 7th rib or
interspace.

An alternate method of numbering the ribs posteriorly is to count down from C7.

Lower your chin to your chest, please.

With the patient’s neck flexed forward, find the most prominent spinous process, which is usually at C7.

Then feel and count from C7 to T12. You can often palpate and count the processes below them,
especially when the spine is flexed.

To further locate and describe your findings, use these imaginary vertical lines: the midsternal,
midclavicular, anterior axillary...

...midaxillary, anterior and posterior axillary...

...scapular, and vertebral.

When examining the chest, it’s helpful to visualize the underlying lungs and their fissures and lobes on
the chest wall.

Anteriorly, the apex of each lung usually rises 2 to 4 centimeters above the inner third of the clavicle.
The lower border of the lung crosses the 6th rib at the midclavicular line and the 8th rib at the
midaxillary line.
Posteriorly, the border of the lung lies at about the level of the T10 spinous process. On inspiration it
normally descends 3 to 5 cm further down.

Each lung is divided roughly in half by an oblique or major fissure. The right lung is divided into the
upper, middle, and lower lobes. Note that the right middle lobe underlies the axilla. The left lung has
only two lobes, the upper and lower.

Make a point to learn the general anatomical terms used to locate chest findings. Supraclavicular means
above the clavicles. Infraclavicular means below the clavicles. Interscapular means between the
scapulae. Infrascapular means below the scapulae.

The bases of the lungs are the lowermost portions and the upper, middle, and lower lung fields are self‐
explanatory.

The trachea bifurcates into its mainstream bronchi at the levels of the sternal angle anteriorly and the
T4 spinous process posteriorly. Breath sounds over the trachea and bronchi usually have a different
quality than breath sounds over the lung parenchyma.