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Plate AT-B

Bones

Landmarks, fracture patterns, pressure points, and the cord levels that decide function.

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TEXT ONLY — NOT A SEPARATE PART OF THIS MODEL: Bone as tissue · Coccyx

Thorax

3 structures

Thorax

Clavicle

The collarbone: an S-shaped bone just under the skin at the top of the chest, running from the top of the breastbone out to the tip of the shoulder, with the subclavian vein and the top of the lung close beneath its inner half.

Why the exam cares

It is the bone most often broken during birth and one of the most commonly broken bones at any age, usually from a fall onto the shoulder or an outstretched hand. The nurse checks a newborn's arm movement and Moro reflex after a hard delivery, checks circulation and feeling in the hand after an adult's fracture, and runs nothing through a new subclavian line until the chest X-ray is read.

How to find it

  • Run a finger from the notch at the top of the breastbone out to the shoulder; the whole clavicle is right under the skin.
  • The subclavian vein passes behind the clavicle where its inner and middle thirds meet, which is where a subclavian central line goes in.
  • The top of the lung rises just above the level of the inner third of the clavicle, close to that needle path.
  • At the top of the shoulder the outer end of the clavicle meets the acromion, the bony tip of the shoulder blade; the deltoid injection site is measured down from the acromion.

Fracture

Newborn clavicle fracture

A large baby or a hard shoulder delivery can break the clavicle. The nurse looks for a baby who does not move one arm, a Moro reflex missing on that side, crying when the arm is moved, or crepitus and swelling over the bone, and reports it. The bone heals on its own; the nurse handles the arm gently, pins the sleeve to the shirt if ordered, and teaches parents that a small firm bump will form over the bone as it heals.

Fracture

Adult clavicle fracture

After a fall onto the shoulder, the patient usually holds the injured arm against the body, and a displaced break makes the shoulder sag down and forward. The nurse checks pulse, color, warmth, and sensation in that hand, because the vessels and nerves to the arm run just beneath the bone, and applies a sling as ordered.

Procedure

Subclavian central line

Critical

The needle for a subclavian line passes close to the top of the lung, so pneumothorax is a known risk of this site. The nurse infuses nothing through the new line until a chest X-ray confirms the tip position and shows no pneumothorax, because fluid run into a misplaced catheter can go into the chest. After insertion the nurse watches for sudden shortness of breath, chest pain, diminished breath sounds on that side, or a falling oxygen saturation and reports them at once.

Reduction of Risk PotentialHealth Promotion and Maintenance
ThoraxHigh yield

Ribs

Twelve pairs of curved bones that run from the spine toward the front of the chest, and each gap between them is named for the rib above it.

Why the exam cares

The nurse counts intercostal spaces to find the apical pulse before digoxin and to place the stethoscope over each heart valve. Rib injuries test priorities: keep a patient with a broken rib breathing deeply instead of binding the chest, and treat paradoxical chest movement or the signs of tension pneumothorax as emergencies to report at once, not after an x-ray.

How to find it

  • Feel the ridge of the sternal angle, slide sideways onto the second rib, and the space just below it is the second intercostal space. Count down from there.
  • In an adult man the nipple usually sits at about the fourth intercostal space; the fifth space at the left midclavicular line is the mitral area.
  • A vein, artery, and nerve run in a groove along the underside of each rib, so a needle or chest tube goes in over the top edge of the rib below.
  • Ribs 1 to 7 reach the sternum by their own cartilage, ribs 8 to 10 join the cartilage above, and ribs 11 and 12 float free. The kidneys sit partly behind the lowest ribs, so the nurse checks for kidney tenderness where the twelfth rib meets the spine.

Auscultation

Heart sounds and the apical pulse

Watch

Aortic is the second space at the right sternal border, pulmonic the second space at the left sternal border, Erb's point the third space at the left sternal border, tricuspid the fourth space at the left sternal border, and mitral the fifth space at the left midclavicular line. The nurse counts the apical pulse at the mitral site for a full minute before digoxin and holds the dose and notifies the provider if an adult's rate is under 60, because digoxin slows conduction through the AV node. The nurse also asks about loss of appetite, nausea, vomiting, and visual changes, which are early signs of digoxin toxicity.

Fracture

Rib fracture and shallow breathing

Watch

A broken rib hurts with every breath, so the patient breathes shallowly and avoids coughing, which leads to atelectasis and pneumonia. The nurse gives ordered pain medicine on time, coaches deep breathing, coughing, and incentive spirometry, and does not bind or tape the chest, because that limits lung expansion further.

Emergency

Flail chest

Critical

Two or more adjacent ribs broken in two or more places leave a loose segment that sinks in on inspiration and bulges out on expiration, opposite to the rest of the chest. The nurse gives oxygen, watches for falling oxygen saturation and signs of a bruised lung or pneumothorax, and prepares for intubation and mechanical ventilation if breathing fails.

Emergency

Tension pneumothorax

Critical

Absent breath sounds on one side, a trachea pushed toward the other side, distended neck veins, and a falling blood pressure mean trapped air is compressing the lung and heart. The nurse calls the provider at once, gives high-flow oxygen, and prepares for needle decompression at the second intercostal space in the midclavicular line or a lateral site per protocol, followed by a chest tube. The nurse does not wait for a chest x-ray, because the patient can go into cardiac arrest in that time.

Physiological AdaptationReduction of Risk PotentialPharmacological and Parenteral Therapiesheart failure →
ThoraxHigh yield

Sternum

The sternum is the breastbone, a flat bone in the midline of the front of the chest made of three parts: the manubrium at the top, the body, and the small xiphoid process at the bottom.

Why the exam cares

The nurse puts compressions on the lower half of the sternum and keeps both compressions and abdominal thrusts off the xiphoid. The xiphoid is also the end point for measuring an NG tube, and a wired sternum after open-heart surgery needs precautions the nurse teaches.

How to find it

  • The jugular (suprasternal) notch is the dip at the top of the manubrium, between the inner ends of the two collarbones.
  • The sternal angle (angle of Louis) is a horizontal ridge about 2 inches (5 cm) below the notch, where the manubrium meets the body. The second rib attaches here, so the nurse counts ribs and intercostal spaces down from it.
  • The xiphoid process is the narrow tip at the bottom of the sternum, in the midline where the lower rib margins meet. The nurse keeps compressions and thrusts off it.
  • The adult CPR hand position is the lower half of the sternum in the center of the chest, found by the bone itself rather than by the nipples.

Emergency

CPR hand position

Critical

For an adult, the nurse places the heel of one hand on the lower half of the sternum, the other hand on top, and pushes straight down at least 2 inches but no more than 2.4 inches at 100 to 120 per minute, letting the chest fully recoil each time. Hands stay above the xiphoid, because pressure there can injure the liver beneath.

Emergency

Abdominal thrusts for a choking adult

Watch

The nurse stands behind the patient and places the thumb side of a fist just above the navel and well below the xiphoid, then gives quick inward and upward thrusts. Thrusts placed too high, over the xiphoid or ribs, can cause internal injury. A patient who is visibly pregnant or too large to reach around gets chest thrusts instead.

Procedure

Measuring an NG tube

Critical

Before inserting a nasogastric tube, the nurse measures from the tip of the nose to the earlobe and then down to the xiphoid process, and marks that length on the tube. This length only estimates the distance to the stomach, so placement is confirmed by x-ray before the first feeding or medication. The nurse documents the external length at the nostril and checks it before each use per facility policy, because a tube that has moved can deliver feeding or medication into the esophagus or airway.

Procedure

Sternal precautions after cardiac surgery

Watch

After a median sternotomy, the sternum is wired closed and takes about 6 to 8 weeks to heal. The nurse teaches the patient to hug a pillow when coughing, not to push up from a bed or chair with the arms, not to lift more than the prescribed limit (commonly about 5 to 10 pounds), and to follow any arm-movement limits the surgeon orders. The patient reports clicking or shifting in the chest, or redness or drainage at the incision, because these can signal the sternum separating or an infection.

Physiological AdaptationReduction of Risk Potential

Sources

SourceLicense
BodyParts3D, © The Database Center for Life Science licensed under CC Attribution 4.0 InternationalThe 3D plates. Modified: element meshes merged per structure, simplified, compressed, and recoloured for the web.CC-BY-4.0
OpenStax Anatomy and Physiology 2e (CC BY 4.0)Informed the anatomical facts. The prose is original to this portal.CC-BY-4.0
MedlinePlus / NIHPublic Domain (US Gov)
Nursing Nerds editorialEvery sentence in the atlas entries, each passed through independent clinical review.Original