Anatomy Super Supplement

Head and Neck Loubomir E. Antonio, M.D. Bones of Skull Cranium Eight (8) Bones Frontal Parietal (2) Occipital Temporal (2) Sphenoid Ethmoid Facial Bones Fourteen (14) bones • Zygomatic(2) • Maxillae (2) • Nasal bones(2) • Lacrimal (2) • Vomer (1) • Palatine (2) • Inferior concha (2) • Mandible (1) New Born Skull Fontanelles Anterior fontanelle “Bregma” Diamond-shaped Between Two halves of frontal bone Two parietal bones Closed by 18 months Posterior fontanelle “Lambda” Triangular Between Two parietal bones Occipital bone Closed by first year of life CLINICAL SIGNIFICANCE Depressed – Dehydration Bulging – Increased ICP

Excessive molding Tears anterior attachments of falx cerebri to tentorium cerebelli Bleeding comes from; Great Cerebral vein Straight sinus Inferior Sagittal sinus SKULL FRACTURE Adult - likened to an eggshell - splintering of bone Young child - likened to a table tennis ball - “pond fracture” FRACTURES OF CRANIAL FOSSAE Anterior Cranial Fossa - Epistaxis - Rhinorrhea -Racoon’s eye - Exophthalmos Middle Cranial Fossa (WEAKEST) - Otorrhea/Rhinorrhea - Damage to CN 3,4,6 - Damage to CN 7,8 Posterio Cranial Fossa - Battle’s sign - Damage to CN 9,10,11 Nasal fractures - most common - considered open fractures - damage to mucoperiosteum - septal hematoma Maxillofacial fractures - facial swelling - diplopia - malocclussion/ open bite deformities - anesthesia/paresthesia in the cheek or upper gum (infraorbital nerve) Le Fort Classification of Maxillofacial Fractures

Mastoid Process Not present at birth Develops during first 2 years of life CLINICAL SIGNIFICANCE Forceps delivery may result to Facial nerve injury Adult Skull Sutures - fibrous type ( synarthroses ) - Wormian or Inca bones in between sutures Coronal Suture • Frontal bone • Parietal bone Sagittal Suture • Parietal bones Lambdoid Suture • Parietal bone • Occipital bone Adult Skull Pterion Thinnest part of lateral wall Between Anteroinferior corner of the parietal bone Greater wing of sphenoid INTRACRANIAL HEMORRHAGES Epidural – Ant. division middle meningeal artery Subdural – Cerebral veins Subarachnoid – Aneurysm/Angioma IntraParenchymal – Lenticulostriate artery INTRACRANIAL HEMORRHAGE (INFANT)

ARTERIAL SUPPLY Anterior Circulation- ICA Posterior Circulation- VA VENOUS DRAINAGE Superior sagittal sinus Inferior sagittal sinus Great vein of Galen Straight sinus Transverse sinus Sigmoid sinus CLINICAL SIGNIFICANCE Queckenstedt’s Test (+) FAILURE of the cerebral venous pressure to rise as measured by a lumbar tap in the sub arachnoid space upon compression of the IJV signifies obstruction at the vertebral canal or meninges (tumor)

Between pons/medulla -> Cavernous Sinus w/ICA -> SOF -> Lateral Rectus Type: Motor Function: Abducts eyeball (lateral rectus) Lesion: diplopia, medial/internal strabismus, loss of parallel gaze Foramen: Superior orbital fissure Innervated Region: Orbit

Cavernous Sinus Contents CNs III, IV, V1,V2 and VI ICA CLINICAL SIGNIFICANCE Cavernous Sinus Thrombosis V infections in the dangerous area of the face V thrombosis of the facial vein V organisms ascend through inf. ophthalmic vein

Cranial Nerve V - Trigeminal Nerve Anterior pons - small motor root -large sensory root Trigeminal Ganglion Trigeminal Ganglion ( anterior border ) - arises the 3 divisions Cranial nerve V1-Ophthalmic Nerve Passes in the lateral wall of Cavernous Sinus -> SOF Nasociliary Post. Ethmoidal Infratrochlear Long ciliary nerve Anterior ethmoidal -> External nasal nerve ( tip of nose ) Sensory br. To ciliary ganglion

CSF PATHWAY Choroid plexus Lateral ventricles foramen of Monroe 3rd ventricle aqueduct of Sylvius/iter 4th ventricle foramen of Luschka and Magendie Subarachnoid space Arachnoid granulations Cranial Nerve I – Olfactory Nerve Olfactory nerve cells -> Olfactory bulb -> Olfactory area Type: Sensory Function: Smells Lesion: Anosmia Foramen: Cribiform plate Innervated Region:Nasal Cavity Cranial nerve II – Optic Nerve Retina -> Optic chiasm -> Optic tract -> radiation -> Visual cortex Type: Sensory Function: Vision Lesion: Visual field deficits (Anopsia) Foramen: Optic canal Innervated Region: Orbit

Olfactory tract ->

LGB -> Optic

Cranial nerve III – Oculomotor Nerve Anterior midbrain -> Lateral wall Cavernous Sinus -> SOF -> EOM’s except SO and LR sphincter pupillae Ciliary muscles Type: Motor Functions: • EOMs *adduction most important action (medial rectus) • Constricts pupil (spincter pupillae) • Accomodation (ciliary muscle) • Raises upper eyelid (levator papillae) Lesion: Diplopia, lateral/external strabismus Foramen: Superior oribital fissure Innervated Region: Orbit Cranial nerve IV - Trochlear Nerve Posterior midbrain -> Lateral wall cavernous Sinus -> Superior Oblique Type: Motor Function: Depresses and abducts eyeball (Superior oblique) Intorts Lesion: Weakness looking down with adducted eye Difficulty going down stairs Head tilts away from lesioned side Foramen: Superior orbital fissure Innervated Region: Orbit Cranial nerve VI – Abducent Nerve

SOF ->

Frontal – divides into supraorbital/trochlear nerves Lacrimal + zygomaticotemporal branch of V2 gland Type: Sensory Function: General sensation of forehead/scalp/cornea Lesion: • Loss of sensation in skin of forehead/scalp • Loss of blink reflex w/ CN VII Innervated Region: Orbit and scalp

lacrimal

Cranial nerve V2 – Maxillary Nerve Foramen rotundum -> pterygopalatine fossa IOF Meningeal branch Zygomaticotemporal lacrimal gland ( w/ lacrimal nerve of V1 ) Zygomaticofacial Ganglionic branches – TWO nerves going to pterygopalatine ganglion Posterior Superior Alveolar Middle Superior Alveolar Anterior Superior Alveolar Type: Sensory Function: General sensation of palatae, nasal cavity, maxillary face, maxillary teeth Lesion: Loss of general sensation in skin over maxilla, maxillary teeth Foramen: Foramen rotundum Innervated Region: Pterygopalatine fossa (leave by openings to face, oral, and nasal cavity) Cranial nerve V3 – Mandibular Nerve Foramen ovale -> Infratemporal fossa Type: Mixed Motor: MNEMONIC: My Ass Meets The Toilet Mylohyoid Anterior digastric Muscles of mastication Tensor veli palatini Tensor tympani Sensory: MNEMONIC: LIBAG Lingual nerve Inferior Alveolar Buccal nerve Auriculotemporal nerve Ganglion ( otic ganglion ) Lesion: Loss of general sensation in skin over mandible, mandibular teeth, tongue Weakness in chewing Jaw deviation toward weak side Trigeminal neuralgia (intractable pain in V2, V3 territory)

Foramen: Foramen Ovale Innervated Region: Infratemporal fossa INJURY TO THE LINGUAL NERVE COURSE: infratemporal fossa V inferior to superior constrictor V (closely related to last molar tooth) v submandibular triangle In cases of clumsy extraction of impacted 3rd molar tooth Cranial Nerve VII - Facial Nerve

Brainstem - 2roots ( Motor and Sensory- Nervus intermedius )

Brainstem Jugular foramen Neck – POSTERIOR to STLOPHARYNGEUS IMPORTANT BRANCHES Tympanic branch lesser petrosal nerve Otic ganglion w/ Parotid gland Brainstem Jugular foramen Neckwithin the carotid Auriculotemporal sheath nerve

Type: Mixed Function: Senses pharynx, carotid sinus/body Salivates (parotid gland) Tastes (posterior one third of tongue) Motor to one muscle - stylopharyngeus Lesion: Loss of gag reflex with CN X Foramen: Jugular foramen Innervated Region: Neck/pharynx/tongue Cranial Nerve X – Vagus Nerve

Internal acoustic meatus Type: Mixed Function: Motor: muscles of facial expression, posterior belly of digastric, stylohyoid, stapedius Sensory Taste to anterior two-thirds of tongue/palate Autonomics Salivates (submandibular, sublingual glands) Tears (lacrimal gland) Makes mucus (nasal and palatine glands) Lesion: • Corner of mouth droops, can’t close eye, can’t wrinkle forehead, loss of blink reflex, hyperacusis • Alteration or loss of taste (ageusia) • Eye dry and red Foramen: Internal auditory meatus Innervated Region: Face, nasal and oral cavity, branches leave skill in stylomastoid foramen, petrotympnic fissure, or hiatus of facial canal

Facial canal Chorda tympani petrotympanic fissure Infratemporal

Cranial nerve VIII – Vestibulocochlear Nerve Vestibule AND semicircular canal > Vestibular ganglion > Int. acoustic meatus > Brainstem/Cerebellum

fossa Inner Ear/Middle ear Nerve to stapedius

Cochlea -> Spiral ganglion -> Auditory Center

Internal acoustic meatus ->

Type: Sensory Function: Hears Linear acceleration (gravity) Angular acceleration (head turning) Lesion: Loss of balance, nystagmus Foramen: Internal auditory meatus Innervated Region: Inner ear

Cranial Nerve IX – Glossopharyngeal Nerve

joins lingual nerve Geniculate ganglion

IMPORTANT Carotid branch BRANCHES Carotid ( neck ): body/sinus Cardiac branches Cardiac branch plexus Pharyngeal Recurrent laryngeal Pharyngeal plexus nerve ALL ( w/ CN Xmuscles and SNSof) Intrinsic larynx EXCEPT CRICOTHYROID Lingual branch Auricular branches Posterior 1/3 of Tympanic tongue membrane/Pinna Meningeal Nerve to branches

Type: Mixed Function: Muscles of palate and phaynx for swallowing except tensor veli palatini (CN V) and stylopharyngeus (CN IX) To all muscles of larynx (phonates) Sensation to larynx and laryngopharynx Sensation to larynx and GI tract To GI tract smooth muscle and glands in foregut and midgut Lesion: Nasal speech. Nasal regurgitation (due to palate weakness) Dysphagia, palate droop Uvula pointing CONTRALATERAL from affected side Hoarseness/fixed vocal cord Loss of gag reflex with IX Loss of cough reflex Foramen: Jugular foramen Innervated Region: Neck/ Pharynx/ Larynx/ Thorax/ Abdomen

Cranial Nerve XI – Spinal Accessory Nerve

Greater petrosal nerve 2 roots Pterygopalatine Cranial root – from ganglion brainstem Submandibular/ Jugular foramen Neck Type: Motor Function: Turn head to opposite side (Sterocleidomastoid) Elevates and rotates scapula (Trapezius) Lesion: Weakness turning head to opposite side Shoulder droop Foramen: Jugular foramen Innervated Region: Neck

Sublingual gland Stylomastoid - SCM foramen Foramen Lacrimal/Nasal/Palat magnum al glands Ant. 2/3- tongue Trapezius

Cranial Nerve XII – Hypoglossal Nerve Brainstem > Hypoglossal canal > Neck down to lower border of POST.BELLY DIGASTRIC > crosses ext/int. Carotid arteries > deep to mylohyoid > below lingual nerve and submandibular duct IMPORTANT BRANCHES: Meningeal branch Descending branch ( C1 ) - joins descending cervical nerve ( C2C3 ) to form ANSA CERVICALIS to supply STERNOHYOID, OMOHYOID, STERNOTHYROID Nerve to THYROHYOID Nerve to GENIOHYOID ALL muscles of the tongue EXCEPT: PALATOGLOSSUS

Posterior auricular Spinal root – C1 Stylohyoid to C5 Posterior belly of digastric

Type: Motor Function: Moves tongue (styloglossus, hyoglossus, genioglossus, and intrinsics. *palatoglossus by pharyngeal plexus) Lesion: Tongue pointing IPSILATERAL side of protrusion Foramen: Hypoglossal canal Innervated Region: Tongue MEMORIZE All muscles of the tongue are supplied by CN12 EXCEPT: PALATOGLOSSUS ( pharyngeal plexus CN9,10) All muscles of the palate are supplied by the pharyngeal plexus EXCEPT: TENSOR VELLI PALLATINI (CNV – 3division) MEMORIZE All muscles of the pharynx are supplied by the pharyngeal plexus EXCEPT: STYLOPHARYNGEUS ( CN IX ) All intrinsic muscles of the larynx are supplied by the recurrent laryngeal nerve EXCEPT: CRICOTHYROID (External branch – Superior laryngeal nerve ) Summary of Tongue Innervation Sensation Anterior 2/3rds Sensation CN V3 (Trigeminal mandibular) Taste CN VII (Facial) Posterior 1/3rd Sensation and Taste Mainly CN IX (Glossopharyngeal), Extreme posterior CN X (Vagus) Motor

Pharyngeal plexus - supply ALL muscles of Pharynx EXCEPT STYLOPHARYNGEUS - muscles of soft palate EXCEPT TENSOR VELI PALATINI Superior laryngeal nerve Internal laryngeal nerve – SENSORY to larynx External laryngeal nerve – ONLY MOTOR to CRICOTHYROID

CN XII (Hypoglossal)

Scalp 5 layers “SCALP” Skin Connective tissue of superficial fascia Aponeurosis Loose Connective Tissue ( dangerous layer ) Periosteum of skull and bones ORBIT Pyramidal in shape Orbital Margin Superior-frontal bone Lateral- frontal and zygomatic Inferior- zygomatic and maxilla Medial-maxilla and frontal

EYE TRAUMA - Least protected from the LATERAL side Blowout Fractures - explodes INFERIORLY into the Maxillary sinus resulting to diplopia, injury to infraorbital nerve and entrapment of inferior rectus muscle LACRIMAL APPARATUS Lacrimal gland Lacrimal punctum Lacrimal canaliculi Lacrimal sac Nasolacrimal duct Inferior nasal concha

MIDDLE EAR Superior wall tegmen tympani (petrous bone) Anterior wall thin bone plate /// ICA 2 openings Tensor tympani Eustachian tube Posterior wall aditus to mastoid antrum pyramid – stapedius tendon Medial wall lateral wall/promontory of inner ear 2 windows oval round Lateral wall tympanic membrane(dflat) epitympanic recess Inferior wall Thin bone plate /// IJV INFECTIONS AND OTITIS MEDIA Pathogenic organisms ascending through the pharyngotympanic tube from the nasopharynx COMPLICATIONS Acute Mastoiditis/Sigmoid sinus Thrombosis - thru the mastoid antrum Meningitis/cerebral abscess - superiorly Facial nerve palsy/Labyrinthitis/Vertigo - medially Osseus membranous labyrinth Sensory organ Vestibule Semicircular Canal Cochlea Utricle and Saccule Macula Semicircular Ducts Crista ampullaris Cochlear Duct organ of Corti COCHLEA Scala Vestibuli Scala Media/cochlear duct

Scala Tympani Membranes Reissner’s Basilar NASAL CAVITY Lateral nasal wall superior turbinate middle turbinate Inferior turbinate Medial nasal wall septal cartilage perpendicular plate of ethmoid vomer MNEMONIC Kiss Little Girls ASS Kiesselbach’s plexus Little’s Area Greater Palatine artery Anterior Ethmoidal artery Sphenopalatine artery Superior labial artery PARANASAL SINUSES Sphenoidal sinus Ethmoidal sinus Anterior Middle Posterior Frontal sinus Maxillary sinus DRAINAGE Sphenoethmoidal recess Sphenoidal sinus Superior meatus Posterior ethmoidal sinus Middle meatus Frontal sinus Anterior ethmoidal sinus Middle ethmoidal sinus Maxillary sinus Inferior meatus Nasolacrimal duct Muscles of Facial Expression Innervated by terminal branches of facial nerve Temporal Zygomatic Buccal Mandibular Cervical “Ten Zebras Bit My Cheek” FREY SYNDROME Post-gustatory sweating due to damage to auriculotemporal and great auricular nerve ( trauma/surgery) Both fibers may innervate a sweat gland A stimulus intended for saliva production results to sweat secretion instead TROUBLESOME BLEEDING AFTER A TOSILLECTOMY Damage to external palatine vein located just lateral to the tonsills at the tonsillar fossa ORAL CAVITY LESIONS QUINCKE’S DISEASE VS QUINSY Quincke’s disease – angioedema of uvula Quinsy – peritonsillar abscess Muscles of Mastication • Masseter • Temporalis M – Munching • Medial Pterygoid • Lateral Pterygoid L - Lowers

Triangles of the Neck Posterior Triangle • Occipital triangle • Supraclavicular triangle Anterior Triangle • Carotid triangle • Digastric triangle • Submental triangle • Muscular triangle Posterior Triangle Boundaries • Trapezius (posterior) • Sternocleidomastoid (anterior) • Clavicle (inferior) Divided by Omohyoid into • Occipital triangle • Supraclavicular triangle Floor • Anterior scalene • Middle Scalene • Posterior Scalene • Levator scapulae • Splenius Capitis Posterior Triangle Contents In scalene interval (between anterior & middle scalene) • Three (3) trunks of brachial plexus • Subclavian artery Spinal accessory nerve (CN XI) to • Sternocleidomastoid • Trapezius Phrenic nerve (anterior surface of anterior scalene) Cutaneous branches of cervical plexus • greater auricular, • lesser occipital, • transverse cervical, • supraclavicular nerves Anterior Triangle Boundaries Anterior border of sternocleidomastoid Anterior midline Body of mandible Subtriangles Digastric triangle Submental triangle Muscular triangle Carotid triangle Digastric Triangle Boundaries • Lower border of mandible • Posterior belly of digastric • Anterior belly of digastric Contents • Submandibular gland • Submandibular duct • Submandibular lymph node • CN XII • Cervical mandibular branch of CN VII • Submental branch of facial vessels Submental Triangle Boundaries Mentum of mandible Anterior bellies of digastric muscles Hyoid bone Floor: Mylohyoid Apex: Mandibular symphysis Contents Submental lymph nodes Muscular Triangle Boundaries • Midline of neck • Superior belly of omohyoid • Anterior border of sternocleidomastoid Roof: Strap muscles

Contents Viscera of neck • Thyroid gland • Superior laryngeal nerve • Recurrent laryngeal nerve • Trachea • Esophagus Carotid Triangle Boundaries Sternocleidomastoid Posterior belly of digastric Superior belly of omohyoid Contents Carotid sheath MNEMONIC CAROTID SHEATH CONTENTS I See – Internal Carotid Artery 10 – Vagus Nerve cc – Common Carotid Artery IV – Internal Jugular Vein Fascial Layers Superficial cervical fascia Thin layer enclosing platysma muscle Cutaneous nerves Superifical veins Superficial lymph nodes Fascial Layers Deep cervical fascia Supports muscles, vessels, viscera of neck Condenses to form: 1. Investing layer Trapezius Sternocleidomastoid 2. Pretracheal layer Laryngeal cartilages Thyroid Parathyroid Infrahyoid muscles Fascial Layers Deep cervical fascia 3. Prevertebral layer Over prevertebral muscles, vertebral column Forms Axillary Sheath 4. Carotid Sheath Common carotid artery Internal carotid artery Internal jugular vein Vagus nerve Retropharyngeal space “Danger space” Retropharyngeal abscess à airway compression Tracking to thorax and mediastinum External Carotid Artery Branches: SAL FOP SM Superior thyroid Ascending pharyngeal Lingual Facial Occipital Posterior auricular Superficial temporal Maxillary Thyroid Gland Isthmus is at level of 2nd 3rd 4th tracheal ring Blood Supply: Superior thyroid artery Inferior thyroid artery Thyroidea ima Venous drainage Superior thyroid vein Middle thyroid vein Inferior thyroid vein PARATHYROID GLAND

Four (4) separate glands Secretes Parathyroid Hormone Blood Supply: • Superior thyroid artery. • Inferior thyroid artery Larynx Cartilages 3 unpaired: Thyroid Cricoid Epiglottis 3 paired: Arytenoid Corniculate Cuneiform

Intrinsic Laryngeal Muscles TENSES – CRICOTHYROID RELAXES – THYROHYOID (VOCALIS ) ABDUCTOR – POSTERIOR CRICOARYTENOID ADDUCTORS – TRANSVERSE ARYTENOID OBLIQUE ARYTENOID Lateral cricoarytenoid Pharynx Parts Nasopharynx Oropharynx Laryngopharynx (hypopharynx ) Circular Muscles Superior constrictor Middle constrictor Inferior constrictor Longitudinal muscles Stylopharyngeus Salphingopharyngeus FOREIGN BODY INGESTION PYRIFORM SINUS most common site for the lodging of ingested sharp foreign bodies ( fishbones ) CERVICAL PLEXUS Anterior rami C1-C4 spinal nerves Cutaneous Lesser occipital Greater auricular Transverse cutaneous Supraclavicular CERVICAL LYMPHNODES Level 1 Submental/ Submandibular Level 2 Upper jugular Level 3 Mid jugular Level 4 Lower jugular Level 5 Suboccipital Level 6 Central THE END

Back and Spine Loubomir E. Antonio, MD Vertebral Column Central pillar of the body Protects the spinal cord Supports weight of the head and trunk Transmits to hip bones and lower limbs Flexible, Segmented • Vertebrae • Intervertebral discs Vertebral Column Curvatures (4)

Cervical: Posterior concavity (Lordosis) Thoracic: Posterior convexity (Kyphosis) Lumbar: Posterior concavity (Lordosis) Sacral: Posterior convexity (Kyphosis) Vertebral Column Parts Body Vertebral arch Pedicles Laminae 7 processes Spinous (1) Transverse (2) Articular (4) Vertebral Column • Spinous process – Directed posteriorly • Junction of two laminae • Transverse process – Directed laterally • Junction of laminae and pedicles Function – levers – attachment for muscles, ligaments Vertebral Column  Articular Process  Vertically arranged ▪ Two superior ▪ Two inferior  Pedicles are notched on upper and lower borders ▪ Superior vertebral notch ▪ Inferior vertebral notch Forming Intervertebral foramen ▪ Transmit spinal nerves ▪ And blood vessels Cervical Vertebra  Characteristics  Vertebral foramen ▪ Large ▪ Triangular  Superior articular processes ▪ Small ▪ Flat ▪ Face backward, & upward  Inferior articular processes ▪ Face downward & forward Cervical Vertebra  Characteristics  Foramen transversarium ▪ Transverse process ▪ Passage of the vertebral artery and veins  Spines ▪ Small ▪ Bifid Atypical Cervical Vertebrae First cervical vertebra (Atlas) No body, No spinous process Anterior arch Posterior arch Lateral mass (each side) Articular surfaces Upper aspect (Occipital condyles of skull) Lower aspect (Axis) Atypical Cervical Vertebrae Second cervical vertebra (Axis) Odontoid process peg-like Projects upward from superior surface of body Represents body of atlas that has fused with the axis Atypical Cervical Vertebra

Seventh cervical vertebra Longest spinous process NOT bifid Large transverse process Small foramen transversarium DOES NOT transmit vertebral artery Cervical Vertebral Fracture Jefferson’s fracture – disruption of the ring of atlas w/ displacement of lateral masses Hangman’s fracture – fracture of the odontoid and pedicles of axis Thoracic Vertebra Characteristics Body Medium sized, heart-shaped Vertebral Foramen Small, circular Spines Long, inclined downward  Characteristics  Costal facets ▪ Present on sides, and on transverse process ▪ T11, T12 ~ no facets on transverse process  Superior articular process ▪ Facets face backward, laterally  Inferior articular process ▪ Facets face forward, medially Lumbar Vertebrae • Characteristics – Body • Massive, kidney shaped – Pedicles • Strong – Laminae • Thick – Vertebral foramina • Triangular – Transverse processes • Long, slender Lumbar Vertebrae  Characteristics  Spinous processes ▪ Short, flat, quadrangular, project backward  Superior articular processes ▪ Facets face medially  Inferior articular processes ▪ Factes face laterally No rib facets, no foramina in the transverse processes Sacral Vertebrae Sacrum Five rudimentary vertebrae fused together Single wedge shaped bone Sacral Vertebrae Characteristics Sacral promontory Anterior upper margin of 1st sacral vertebrae Bulges forward into pelvic cavity Important obstetric landmark Sacral Vertebrae Characteristics Sacral canal Formed from sacral foramina Contains: Part of cauda equina Meninges (up to lower border S2) Lower sacral nerve roots Coccygeal nerve roots Filum terminale Sacral Vertebrae Characteristics Sacral Hiatus

Failure of the 5th and sometimes 4th sacral vertebra to meet in the midline Anterior & Posterior sacral foramina Passage of anterior and posterior rami of the upper four spinal nerves Sacral Vertebrae Articulations Upper border (base) 5th lumbar vertebrae Narrow inferior end Coccyx Laterally Two hip bones Sacroiliac joints Coccygeal Vertebrae Coccyx Four (4) fused together* Single Small Triangular * first coccygeal vertebra commonly not fused with 2nd Atlanto-occipital Joints between Occipital condyles Lateral masses of the atlas Ligaments  Anterior Atlanto-occipital membrane  Posterior Atlanto-occipital membrane Movements ( YES Joint )  Flexion  Extension  Lateral flexion NO rotation Atlantoaxial Joints between Odontoid process and anterior arch of atlas (1) Lateral masses of bones (2) Movement ( No Joint )  Rotation if atlas w/ head on axis Ligaments Apical – from dens to anterior margin foramen magnum Alar – lateral to apical ligament Cruciate – dens to atlas and foramen magnum Membrana tectoria – upward extension of posterior longitudinal ligament Joints Between Two Vertebral Bodies Covered by thin plate of hyaline cartilage Intervertebral disc of fibrocartilage in between Ligaments Anterior longitudinal ligaments Posterior longitudinal ligaments Continuous bands down the anterior and posterior surface of the vertebral column from the skull to the sacrum Intervertebral Discs Characteristics 1/4th of length of vertebral column Thicker in cervical and lumbar regions Annulus fibrosus forms periphery of the disc Fibrocartilage Collagen fibers arranged in alternating concentric layers Intervertebral Discs  Characteristics  Nucleus pulposus forms central part of disc ▪ Ovoid mass of gelatinous material ▪ Normally under pressure ▪ With advancing age, ▪ decrease in water content ▪ Replaced by fibrocartilage  No discs ▪ between first two cervical vertebrae ▪ In sacrum ▪ In coccyx Intervertebral Discs  Herniation of the nucleus pulposus  Frequently occurs in the

Lower lumbar region (Most common) Due to sudden increase in compression load on vertebral column Rupture of annulus fibrosus Nucleus pulposus herniates posteriorly into vertebral canal Compression of spinal nerve roots, spinal nerve, or spinal cord Two Vertebral Arches ▪

    Joints Between Synovial joints 

Between adjacent superior and inferior articular processes

Ligaments Supraspinous ligament ▪ Connect adjacent spines  Interspinous ligament ▪ Connect adjacent spines  Ligamentum flavum ▪ Connect adjacent laminae Ligamentum Nuchae ▪ Cervical region ▪ Thickening of supraspinous and infraspinous ligaments Movements of Vertebral Column  Type and range in regions depend on  Thickness of intervertebral discs  Shape and direction of the articular processes Cervical region: most movable Muscles of the Back Groupings Superficial Connected with shoulder girdle Intermediate Involved with movements of the thoracic cage Deep or Postvertebral Vertebral column Postvertebral Muscles Classification Superficially running muscles Erector spinae Iliocostalis Longissimus Spinalis Postvertebral Muscles Classification Intermediate oblique running muscles Transversospinalis Semispinalis Rotatores Multifidus Postvertebral Muscles Classification Deepest Muscles Interspinales Intertransversari Postvertebral Muscles Muscles of longest length lie superficially  From sacrum to rib angles, transverse processes, upper vertebral spines Intermediate length run obliquely  From transverse processes to the spines Shortest and deepest muscles  From spines and transverse processes of adjacent vertebrae Muscular Triangles Auscultatory triangle Site on back where breath sounds most easily hear via stethoscope Boundaries Latissimus dorsi Trapezius Medial border of Scapula Rhomboid major (floor) Muscular Triangles Lumbar Triangle Site where pus may emerge from the abdominal wall 

Boundaries Latissiumus dorsi Posterior border of the external oblique Iliac crest Spinal Cord Cylindrical in shape From Medulla Oblongata (of brain) Begins superiorly at Foramen magnum End inferiorly at Lower border 1st lumbar vertebrae (Adults) Occupies upper 2/3rds of the vertebral canal Spinal Cord Surrounded by three (3) meninges Dura mater Arachnoid mater Pia mater Additonal protection by Cerebrospinal fluid Subarachnoid space Spinal Cord • Enlargements – Cervical • Origin of brachial plexus – Lumbar • Origin of lumbar plexus • Lower end – Conus medularis – Filum terminale • pia mater prolongation • From conus medullaris to back of coccyx Spinal Cord Fissures Anterior median fissure Midline on the anterior surface of the cord Posterior median fissure Midline on the posterior surface of the cord Spinal Cord  Roots (31 pairs)  Anterior ▪ Motor  Posterior ▪ Sensory ▪ w/ posterior root ganglion  Roots in regions  Upper cervical region ▪ Short, run almost horizontally  Lumbar, Sacral below level of termination of cord ▪ Vertical leash of nerves around filum terminale ▪ Cauda equina Spinal Cord Roots Pass though intervertebral foramina Unite to form spinal nerves which divides into Anterior ramus (large) Posterior ramus (smaller) Both contain motor and sensory fibers Blood Supply of Spinal Cord Arteries Posterior spinal arteries Arise directly or indirectly from the vertebral arteries Supply posterior 1/3rd of spinal cord Blood Supply of Spinal Cord Arteries Anterior spinal arteries Arise from vertebral arteries Unite to form a single artery Supply anterior 2/3rds of spinal cord Posterior spinal arteries Arise directly or indirectly from the vertebral arteries Supply posterior 1/3rd of spinal cord Radicular arteries Branches of regional arteries Reinforce anterior and posterior spinal arteries

Veins Drain into internal vertebral venous plexus Meninges of Spinal Cord  Dura Mater  External membrane,  Dense fibrous tissue  Encloses spinal cord and cauda equina  Above, continuous with dura covering brain  Below, dura ends on filum terminale ▪ at level of lower border of the 2nd sacral vertebra  Gives sheaths to all spinal nerve roots Meninges of the Spinal Cord Arachnoid Mater Delicate, impermeable membrane Lies within the dura, outside the pia Separated from pia mater by subarachnoid space (filled with cerebrospinal fluid) Meninges of the Spinal Cord  Arachnoid Mater  Above, continuous with arachnoid covering the brain  Below, end on the filum terminale ▪ At the level of lower border of the 2nd sacral vertebra  Continues along spinal nerve roots forming small lateral extensions of subsrachnoid space Meninges of the Spinal Cord  Pia Mater  Vascular membrane  Closely covers spinal cord  Thickened on either side between nerve roots (ligamentum denticulatum)  Extends along each nerve root as far as the spinal nerve  Inferiorly prolonged off the lower end of the spinal cord as the filum terminale Lumbar puncture (Spinal Tap) Patient on the side with vertebral column well flexed Above or Below 4th lumbar spine Lies within imaginary line between highest points on iliac crests Lumbar puncture (Spinal Tap)  Needle passes through the following structures to subarachnoid space  Skin  Fascia  Supraspinous ligament  Interspinous ligament  Ligamentum flavum  Fatty tissue (internal vertebral venous plexus)  Dura mater  Arachnoid mater THE END Thorax Loubomir E. Antonio,M.D. Bones of the Thoracic Wall Sternum Manubrium Body of the Sternum Xiphoid Process Ribs Typical Rib Atypical Rib Cervical Rib Costal Cartilages BONE MARROW BIOPSY STERNUM Site of red hematopoiesis throughout life STERNAL ANGLE OF LOUIS

Articulation of manubrium with the body Landmark 2nd costal cartilage Intervertebral disc between 4th and 5th thoracic vertebrae Junction of Ascending aorta and aortic arch Junction of aortic arch and descending thoracic aorta Bifurcation of the trachea Junction of the superior mediastinum and inferior mediastinum Ribs 12 pairs Attached posteriorly to thoracic vertebrae (3) categories True ribs ( ribs 1 to 7 ) False ribs ( ribs 8 to 10 ) Floating ribs ( ribs 11 and 12 ) TYPICAL RIBS – ribs 3 to 9 ATYPICAL RIBS – ribs 1,2,10,11,12 PARTS OF A TYPICAL RIB Head – attached to vertebral body Neck Tubercle – attached to transverse process Shaft Angle Cervical rib Congenital variation 0.5% of people From transverse process of 7th cervical vertebra Thoracic outlet syndrome Pressure on the lower trunk of the brachial plexus or subclavian artery RIB FRACTURES Ribs 5 to 10 Most commonly fractured ribs Severe localized pain - most important symptom Flail Chest - section of chest wall disconnected to the thoracic wall - paradoxic breathing - underlyinf lung contusion Muscles of the Thoracic Wall Diaphragm Intercostal Muscles External Intercostal Fibers ~ downward, forward Internal Intercostal Fibers ~ downward, backward Innermost Intercostal Fibers ~ transverse, incomplete layer Levatores costarum (12) Serratus posterior Superior Inferior Diaphragm Origin Xiphoid process, lower 6 costal cartilages 1-3 lumbar vertebrae by crura and medial and lateral arcuate ligaments Insertion Central tendon Embryonic Origin MNEMONIC: Several Parts Build Diaphragm Septum transversum Pleuriperitoneal fold Body wall Dorsal mesentery Diaphragmatic Hernias Congenital Incomplete fusion of the septum transversum, pleuroperitoneal fold, and dorsal mesentery from the body wall 3 sites 1. at the back, usually left – Bochdalek’s hernia 2. in front – Morgagni’s hernia 3. thru esophageal hiatus Acquired - weakness in the musculature 1. Sliding 2. Para esophageal

Diaphragm Action MOST IMPORTANT muscle of INSPIRATION Increases vertical diameter of the thorax by pulling down central tendon Assists in raising the lower ribs Innervation Phrenic nerve (C3-C5) Needle Thoracentesis Lifesaving for tension pneumothorax Drain fluid, blood or pus May be done ANTERIOR and LATERAL at 2nd ICS, ABOVE the 3rd rib Tube Thoracostomy 4th or 5th ICS preferred site at anterior axillary line May be done at a lower ICS but NOT LOWER than 5th rib on either side ( dome of diaphragm ) Intercostal Spaces Spaces between ribs contain External intercostal Internal intercostal Intercostal vein Intercostal artery Intercostal nerve “VAN” à downward Innermost intercostal Lined internally by endothoracic fascia, & parietal pleura Diaphragm Actions Weight lifting muscle Abdominal straining Inspiration Thoraco-abdominal pump REMEMBER! “I ate (8), ten (10) EGGs AAT twelve (12)” IVC , right phrenic(T8) Esophagus, vaGus nerves (T10) Aorta, Azygous vein, Thoracic duct (T12) C8 E 10 A 12 Paralysis of the Diaphragm Traumatic/Thrapeutic sectioning of the phrenic nerve May have to include the accessory phrenic nerve from C5 ( nerve to subclavius ) SNIFF TEST Penetrating Injuries to the Diaphragm Any penetrating injury BELOW the NIPPLE anteriorly and the Inferior angle of the SCAPULA Associated intra abdominal injuries Intercostal Vessels Each intercostal space (1) large Posterior intercostal artery (2) small Anterior intercostal arteries Posterior intercostal vein Drain azygous or hemiazygous veins Anterior intercostal veins Drain into the internal thoracic and musculophrenic veins Posterior Intercostal Arteries First 2 - branches of superior intercostal artery, branch of costocervical trunk of subclavian artery Last 9 - branches of the thoracic aorta Anterior Intercostal Arteries First 6 - branches of the internal thoracic artery Last 5 - branches are from the musculophrnic artery, a terminal branch of internal thoracic artery Internal Thoracic Artery From first part of subclavian artery Descends directly behind the first six costal cartilages In front of the parietal pleura

Lies a finger breath lateral to sternum Terminates in 6th intercostal space, dividing to Superior espigastric artery Musculophrenic arteries Lymphatic Drainage of the thorax Nerves of Thoracic wall Intercostal nerves Anterior rami of first eleven (11) thoracic spinal nerves Enters intercostal space Runs inferiorly to intercostal vessels (VAN) In intercostal groove Between innermost and internal intercostal muscles Intercostal nerves First six (6) nerves distributed within their intercostal spaces 7th, 8th, 9th intercostal nerves Leave anterior ends of the intercostal spaces Passing deep to costal cartilages Enter abdominal wall 10th, 11th intercostal nerves Pass forward directly into abdominal wall Intercostal nerves First intercostal nerve Large branch Joins anterior ramus of the 8th cervical nerve Forms lower trunk of brachial plexus Remainder is small Intercostal nerves Second intercostal nerve Joined by medial cutaneous nerve of the arm by intercostobrachial nerve Supplies skin of armpit, and upper medial side of arm *area of pain referred to by coronary arterial disease REFERRED PAIN Pneumonia/Pulmonary thromboembolism - abdominal pain, tenderness and rigidity Thoracic cavity Divided into mediastinum medially, and pleurae and lungs laterally Above ~ Thoracic outlet Anteriorly: superior border of the manubrium sterni Posteriorly: first thoracic vertebra Laterally: medial borders of the first ribs and costal cartilages Allows passage: Esophagus Trachea Many vessels, nerves Widening of the Mediatinum > 50% or > 8cms Normally LESS THAN 50% of the transverse diameter of the chest Seen in cardiomegaly, pericardial effusion, pericardial tamponade Shifting of the Mediastinum IPSILATERAL - side of atelectasis CONTRALATERAL - Side of tension pneumothorax Mediastinal Infections From a deep infection in the neck From an esophageal perforation Mediastinits Mediastinoscopy Chamberlain procedure - obtain samples of tracheobronchial lympnodes through the substernal space Trachea Mobile, cartilaginous membranous, fibroelastic tube U-shaped rings Approx 5in. (13cm) in length, 1in (2.5cm) in diameter Continuation of larynx at lower border of cricoid cartilage (6th cervical vertebra) Descends in midline of neck Ends in thorax level of sternal angle (between T4-T5) dividing into Right principal (main) bronchi Left principal (main) bronchi Compression of the Trachea Enlarged thyroid Aortic arch aneurysm Bronchi

Right principal (main) bronchus Wider, shorter, more vertical Before entering hilum, gives off Superior lobar bronchus On entering the hilum, divides to Middle lobar bronchus Inferior lobar bronchus Bronchi Left principal (main) bronchus Narrower, longer, more horizontal Passes below arch of the aorta In front of esophagus On entering hilum, divides to Superior lobar bronchus Inferior lobar bronchus Inhaled Foreign Body Common on children Pins, screws, nuts, bolts, peanuts, chicken bones, toys, tooth Usually enters the RIGHT primary bronchus Pleurae Two serous sacs surrounding and covering the lungs Parts Parietal pleura Lines thoracic wall Thoracic surface of diaphragm Lateral surface of mediastinum Sensitive to pain, temperature, touch, pressure Visceral pleura Outer surfaces of lungs Interlobar fissures Sensitive to stretch Pleurae Pleural cavity (pleural space) Slitlike space that separates parietal and visceral pleurae Contains small amount of pleural fluid Lubricates apposing pleural surfaces Costodiaphragmatic recess Lowest area of pleural cavity into which the lungs expand during deep inspiration LUNG HILUM Right most superior structure Primary bronchus “eparterial” Left most superior structure Pulmonary artery primary bronchus below the artery hence; “hyparterial” Cervical Dome of the Pleura and Apex of Lungs Vulnerable to stab wounds at the root of the neck Damage by anesthetist needle in brachial plexus nerve block Lung and Pleural Reflections Lungs Pleura Midclavicular rib 6 8 Midaxillary 8 10 Paravertebral 10 12 Lungs, lobes and fissures Right lung Slightly larger Oblique fissure Horizontal fissure Divides right lung into Upper lobe Middle lobe Lower lobe Lungs, lobes and fissures Left lung Only one fissure (oblique fissure) Two lobes Upper lobe Lower lobe Bronchopulmonary segments Characteristics Subdivision of a lung lobe Pyramidal in shape, apex toward lung root Surrounded by connective tissue

Has own segmental bronchus, segmental artery, lymph vessels, autonomic nerves Segmental vein NOT included in connective tissue between adjacent segments Diseased segment can be removed surgically Blood Supply of the Lungs Pulmonary arteries Deoxygenated blood to alveoli Bronchial arteries - oxygenated blood Pericardium Middle mediastinum Fibroserous sac enclosing Heart Roots of great vessels Parts Fibrous pericardium Serous pericardium Pericardial sinuses Nerve supply Phrenic nerves Pericardial Lesions Pericarditis inflammation of the serous pericardium Hamman’s sign ( pericardial friction rub ) Pericardial tamponade accumulation of fluid or blood in the pericardial space Beck’s triad ( hypotension, neck vein distention, distant heart sounds ) Pericardiocentesis Needle is introduced to the left of the xiphoid process in an upward and backward direction in an angle 45 degrees to the skin Prevents damage to the pleura and lungs due to the presence of cardiac notch Heart • Hollow muscular organ • Middle mediastinum • Pyramidal • Three (3) surfaces – Sternocostal (anterior) – Diaphragmatic (inferior) – Base (posterior) • Apex – Directed downward, forward, to the left – 5th left intercostal space – Approx 3.5in (9cm) from midline Heart Structure Divided by vertical septa into four (4) chambers Right atria (anterior) Left atria (posterior) Right ventricle (anterior) Left ventricle (posterior) Walls w/ three (3) layers Epicardium: outer visceral layer of serous pericardium Myocardium: thick layer of cardiac muscle Endocardium: thin inner layer Right Atrium Consists of Cavity and Auricle Junction is external vertical groove (sulcus terminalis), which On the inside forms a ridge (crista terminalis) junction between sinus venosus and right atrium proper Part posterior to ridge ~ smooth walled Interior of auricle ~ roughened by bundles of muscle fibers (musculi pectinati) Right atrium Openings Superior vena cava Upper part of the right atrium Valveless Inferior vena cava Larger

Lower part of right atrium Rudimentary valve Coronary sinus Between inferior vena cava and atrioventricular orifice Rudimentary valve Right atrioventricular orifice Anterior to inferior vena cava Tricuspid valve Right atrium Fetal remnants Fossa ovalis Shallow depression Site of foramen ovale (fetus) Annulus ovalis Upper margin of fossa ovalis lie on atrial septum, separating right from left atrium Right ventricle, papillary muscles • Trabeculae carneae – Papillary muscles • Attached by bases to ventricular wall • Apex to fibrous cords (chordae tendineae) to cusps of tricuspid valve – Moderate band • Large ridge attached to – Septal wall – Atrioventricular wall • Conveys part of right bundle branch of conducting system – Simple prominent projections Left atrium Main cavity and Auricle Interior contains muscular ridges (similar to right) Openings Pulmonary veins (4) 2 from each lung Posterior wall Valveless Atrioventricular orifice Mitral valve Left ventricle Largely behind right ventricle, w/ small portion projecting on the left forms left heart margin and apex Openings Atrioventricular orifice Aortic Orifice Aortic vestible, below Walls 3x thicker than right ventricle Trabecular carneae 2 papillary muscles NO moderator band Heart sounds • First sound – Contraction of ventricles – Closure of tricuspid and mitral valves • Second sound – Sharp closure of aortic and pulmonary valves • Best heard – Tricuspid valve ~ right half of lower end of body of sternum – Mitral valve ~ apex beat – Pulmonary valve ~ medial end of 2nd left intercostal space – Aortic valve ~ medial end of 2nd right intercostal space Conducting system Modified Cardiac Muscle Blood Supply Sinoatrial node (pacemaker) both Atrioventricular node RCA Atrioventricular bundle RCA Right branch LCA Left branch both Blood supply of the heart Arterial supply Right coronary artery Left coronary artery

Venous drainage Coronary sinus Great cardiac vein Small cardiac vein Middle cardiac vein Anterior cardiac vein Venae cordae minimae Right vs Left Dominance “Right dominance” Posterior interventricular artery Large branch of right coronary artery “Left dominance” Posterior interventricular artery Branch of left coronary artery Coronary Artery Disease Functional end arteries Acute thrombosis on top of chronic atherosclerosis STEMI vs NSTEMI Venous drainage Right Atrium Main venous drainage: CORONARY SINUS ONLY 2 drains directly to right atrium anterior cardiac vein venae cordis minimae “Thebesian veins” Nerve supply of the heart Autonomic nervous system via cardiac plexuses Sympathetic fibers Sinoatrial node, atrioventricular node, cardiac muscles, coronary arteries Cardiac acceleration Increase force of contraction Dilation of coronary arteries Nerve supply of the heart Autonomic nervous system via cardiac plexuses Parasympathetic fibers Vagus nerves Sinoatrial node, atrioventricular node, coronary arteries Reduced rate Reduced force of contraction Constriction of coronary vessels Gross anatomic changes in fetal circulation at birth Closure of foramen ovale due to decreased pressure in inferior vena cava Increased pulmonary blood flow Constriction of ductus arteriosus à ligamentum arteriosus Dimished pulmonary vascular resistance Shift flow across from right to left (fetus) to left to right (neonate) Constriction of ductus venosus à ligamentum venosum Large veins of the thorax Barchiocephalic veins Superior vena cava Azygous vein Inferior hemiazygous vein Superior hemiazygous vein Inferior vena cava Pulmonary veins Azygous vein Has variable origin Commonly formed by union of right ascending lumbar vein and right subcostal vein Ascends through aortic opening in the diaphragm at the level of the 5th thoracic vertebra Arches forward to join superior vena cava Inferior hemiazygous vein Formed by union of Left ascending lumbar vein Left subcostal vein Ascends through left crus of the diaphragm to join the azygous vein Superior hemiazygous vein Formed by union of Fourth intercostal vein Eighth intercostal vein Joins azygous vein Large arteries of the thorax Aorta

Ascending aorta Arch of the aorta Descending aorta Pulmonary trunk Aorta • Divided into four parts 1. Ascending aorta 2. Arch of ascending aorta 3. Descending aorta 4. Abdominal aorta First 3 parts, are in the thorax Ascending aorta Arises from left ventricle Ascends behind sternum to level of sternal angle Continuous with the arch of the aorta Three (3) bulges behind each aortic cusp sinuses of the aorta “sinuses of Valsalva” Branches Right coronary artery (anterior aortic sinus) Left coronary artery (posterior aortic sinus) Arch of the Aorta Continuation of ascending aorta Arches upward, backward, and to the left Behind the manubrium sterni and In front of the trachea Level of the sternal angle Continous with descending aorta Related inferiorly to root of the left lung Ligamentum arteriosum Left recurrent laryngeal nerve Bifurcation of the pulmonary trunk Arch of the Aorta Three (3) Branches from convex surface Brachiocephalic artery Left common carotid artery Left subclavian artery Descending Aorta Continuation of the arch of the aorta Left side of lower border of the body of the 4th thoracic vertebra (sternal angle) Descends through posterior mediastinum until anterior surface of 12th thoracic vertebra Enters the abdomen behind the diaphragm Becomes continous with abdominal aorta Descending aorta Branches Posterior intercostal arteries Pass to the lower nine intercostal spaces Subcostal arteries Along lower border of 12th rub to enter abdominal wall Pericardial arteries Esophageal arteries Bronchial arteries Lymph vessels Thoracic duct Root of the left side of neck Lymph from Lower limbs Pelvic cavity Abdominal cavity Left side of thorax Left side of head, neck Left upper limb At termination, receives left jugular, subclavian, mediastinal lymph trunks But these vessels may drain independently into neighboring great veins Lymph vessels Thoracic duct Begins in abdomen as Cisterna chyli (a dilated sac) Ascends through aortic opening in diaphragm right side of the descending aorta Reaches left border of esophagus Follows esophagus to root of neck

Turns laterally behind carotid sheath Enters beginning of left brachiocephalic vein Lymph vessels Right lymphatic duct Root of right side of neck, beginning of right brachiocephalic vein Drains lymph from Right side head, neck Right upper limb Right side of thorax Sometimes absent Large nerves of the thorax Vagus nerve Phrenic nerve Thoracic part of sympathetic trunk Vagus nerves Right vagus nerve Crosses anterior to subclavian artery Descends laterally to the trachea Medial to azygous vein Runs behind root of right lung Contributes to the pulmonary plexus Posterior to esophagus Contributes to esophageal plexus Leaves thorax and enters abdomen through esophageal opening Vagus nerves Left vagus nerve Descends into thorax between Left common carotid Left subclavian arteries Descends behind root of left lung Contributes to pulmonary plexus Anterior to esophagus Contributes to esophageal plexus Enters abdomen through esophageal opening Phrenic nerves From anterior rami of 3rd, 4th, 5th cervical nerves Right phrenic nerve Descends in thorax along right side of vena cava In front of root of right lung Passes over pericardium into the diaphragm Phrenic nerves Left phrenic nerve descends along left side of left subclavian artery Crosses left side of the aortic arch and left vagus nerve Passes in front of root of left lung Descends on pericardium into diaphragm Phrenic nerves The ONLY motor supply to the diaphragm Sensory branches to Pericardium Mediastinal parietal pleura Pleura covering upper and lower surfaces of diaphragm Thoracic part of sympathetic trunk Most lateral structure in the mediastinum 11-12 segmentally arranged ganglia stellate ganglion First ganglion often fused with inferior cervical ganglion Downward on heads of the ribs Leaves thorax passing behind medial arcuate ligament Continuous with lumbar part of sympathetic trunk Thoracic part of sympathetic trunk Branches Cardiac, Aortic,Pulmonary, Esophageal branches From first five ganglia Splanchnic nerves Supply abdominal viscera Greater splanchnic Ganglia 5-9 Lesser splanchnic Ganglia 10-11 Lowest splanchnic Last thoracic ganglion Esophagus Muscular tube Approx 10in (25cm) Continuous w/ pharnyx

Opposite 6th cervical vertebrae Passes through diaphragm Level of 10th thoracic vertebra Three (3) constrictions Beginning Crossing of left bronchus Piercing the diaphragm Esophagus Blood supply Upper 3rd: inferior thyroid artery Inferior thyroid vein Middle 3rd: branches from descending thoracic aorta Azygous vein Lower 3rd: Left gastric artery Left gastric vein à tributary to portal vein à portosystemic anastomosis Thymus Flattened Bilobed structure Between sternum and pericardium Continues to grow until puberty Imporant source of T-lymphocytes The End

Abdomen Loubomir E. Antonio, M.D. Surface Markings 2 Vertical lines - mid point of ASIS and symphysis pubis 2 Horizontal lines Subcostal plane: L3 Intertubercular plane: L5 9 Regions Epigastrium R and L Hypochondriac Umbilical R and L Lumbar Hypogastric R and L Iliac Transpyloris Plane Addison’s plane Level of L1 ( 9th costal cartilage ) Structures fundus of GB termination of adult spinal cord pylorus of stomach neck of pancreas hilum of kidney ANTERIOR ABDOMINAL WALL Skin Superficial fascia superficial fatty “Camper’s fascia” deep membranous “Scarpa’s fascia” - fades laterally and above - inferiorly fuses with deep fascia of the thigh - forms a tubular sheath for the penis/clitoris - attached to the sides of pubic arch ( Colle’s fascia ) - fuses with perineal body and perineal membrane Deep fascia Muscles Nerves Skin Nerve Supply From Anterior Rami of • lower six (6) thoracic – Lower 5 intercostal nerves – Subcostal nerves

•

First lumbar nerves – Iliohypogastirc – Ilioinguinal nerves

•

Midline – – Flanks – – –

Skin Blood Supply Arteries

•

Superior epigastric artery Inferior epigastric artery Intercostal Lumbar Deep circumflex iliac arteries

Skin Blood Supply Veins •

•

Above – – Below –

Axillary vein via Lateral thoracic vein Femoral vein

Via – –

Superficial epigastric vein Great saphenous veins

Skin Blood Supply Veins Connection between superior and inferior vena cavae Small paraumbilical veins Along ligamentus teres to portal vein “Caput Medusae” Skin Lymph Drainage Superficial/ Cutaneous Above umbilicus Anterior axillary lymph nodes Below umbilicus Superificial inguinal lymph nodes Rectus Sheath Long fibrous sheath aponeuroses Contents: Rectus abdominis Anterior rami of lower 6 thoracic nerves Lymph vessels Superior and inferior epigastric vessels Pyramidalis Rectus Sheath Between Costal margin and ASIS Internal oblique splits to cover rectus abdominis Below ASIS and Above pubis All aponeuroses pass anteriorly Deficient posteriorly Arcuate line of Douglas - lower crescent shaped edge of the posterior wall Rectus Sheath Linea alba Fibrous band Fusion of aponeurosis at midline from xiphoid process to pubic symphysis Transverse Tendinous intersections (1) Level of xiphoid (1) in between (1) Level of umbilius Linea Semilunaris “Spiegelian Line” Lateral edge of the rectus abdominis Crosses margin of tip of the ninth costal cartilage Conjoint Tendon Internal oblique Lower free border Lowest tendinous fibers joined by transversus abdominis

Strengthens medial half of posterior wall of inguinal canal Inguinal Ligament Poupart’s ligament Lower border of External oblique aponeurosis Connects Anterior Superior Iliac Spine (ASIS) to pubic tubercle Medial end: lacunar ligament (Gimbernat’s ligament) Continuous with pectineal ligament (Cooper’s ligament) ~ thickening of periosteum Lower border, Attached to fascia lata Fascia Transveralis Thin layer of fascia lining transveralis muscle Continuous with fascia iliaca (of ilacus muscle) Together forms femoral sheath Femoral sheath = FT + FI Inguinal Canal Length Approx 1.5in (4cm) Parallel and above inguinal ligament Deep inguinal ring Oval opening in Transveralis fascia Above inguinal ligament Margins attachment for internal spermatic fascia Superficial inguinal ring Triangular shaped defect on External oblique aponeurosis Above and medial to pubic tubercle Margins give attachment to external spermatic fascia Inguinal Canal Walls Anterior • External oblique aponeurosis • Internal oblique Posterior • Conjoint tendon, medially • Fascia transveralis, laterally Superior • Arching fibers of the internal oblique and transversus Inferior • Inguinal and lacunar ligaments Inguinal Canal Function Allows structures to pass from Testes to Abdomen: Spermatic cord Uterus to labium majus: Round ligament of uterus Both sexes transmit Ilioinguinal nerve Hesselbach’s Triangle Medially: Rectus abdominis Inferiorly: Inguinal ligament Laterally: Inferior epigastric vessels Inguinal Hernia Site of potential weakness in both sexes Above inguinal ligament - lateral to inferior epigastric vessels Indirect Inguinal Hernia - medial to inferior epigastric vessels Direct Inguinal Hernia Below inguinal ligament Femoral hernia Spermatic Cord Contents MNEMONIC: Protruding Piles Don’t Contribute To A Good Sex Life Pampiniform plexus Processus vaginalis remnants Deferens, vas Cremasteric artery Testicular artery Artery to vas Genital branch, genitofemoral nerve Sympathetics Lymphatics Processus vaginalis Peritoneal diverticulum formed in fetus Passes through lower part of anterior abdominal wall to form inguinal canal Spermatic cord

Coverings External spermatic fascia From external oblique Attached to margins of superficial inguinal ring Cremasteric fascia From internal oblique Internal spermatic fascia From fascia transversalis Attached to margins of deep inguinal ring Gubernaculum testis Musculoligamentous cord Connects fetal testis w/ floor of scrotum Important role in descent of testis Homolog: Round ligament of ovary and uterus Scrotum Outpouching of lower part of anterior abdominal wall Contains: Testes Epididymis Lower ends of spermatic cord Scrotum Layers 1. Skin 2. Superifical fascia “Dartos muscle” 3. External spermatic fascia 4. Cremasteric fascia 5. Internal spermatic fascia 6. Tunica vaginalis NOTE: Transversus abdominis has NO contribution to the formation of scrotal wall Testes Paired ovoid organs Produce Spermatozoa Testosterone Tunica albuginea Outer fibrous capsule of testis Epididymis Lies posterior to testis Coiled tube approx 20ft (6m) long Parts Head Body Tail Vas deferens emerges from tail Epididymis Blood Supply Testicular artery • From abdominal aorta Testicular vein • From testis and epididymis (pampiniform plexus) • Reduced to single vein though inguinal canal RIGHT: • IVC LEFT: • Left Renal Vein Peritoneum • Serous membrane • Lubricates surfaces ~ free movement Parietal layer • Lines walls Visceral layer • Covers organs Peritoneal cavity • Potential space in between – Males: Closed – Females: Communicates through uterus, vagina Peritoneum Greater sac • Main compartment • From diaphragm to pelvis Lesser Sac • Smaller • Lies behind stomach Epiploic foramen • Allows free communication between both Peritoneal Derivatives

2 layered folds Ligaments Omentum Mesentery Lesser Sac Behind stomach and lesser omentum Left margin Spleen Gastrosplenic omentum Splenicorenal ligament Right margin Greater sac (main part of peritoneal cavity) Through epiploic foramen Epiploic Foramen Boundaries Anterior • Free border of lesser omentum Bile duct: Anterior Hepatic artery: Posterior to the L Portal vein: Posterior to the R Posterior • Inferior vena cava Superior • Caudate lobe of the liver Inferior • First part of the duodenum Peritoneal Spaces Subphrenic spaces Between diaphragm and liver Right anterior Left anterior Posterior subphrenic space * Clinically: provide sites for the accumulation of pus Peritoneal Gutters Paracolic gutters Lie on lateral and medial sides of ascending and descending colons Provide channels for movement of infected fluid in the peritoneal cavity Nerve Supply of the Peritoneum Parietal peritoneum Lower 6 thoracic, first lumbar nerves Pain, temperature, touch, pressure Visceral peritoneum Autonomic nerves on mesenteries Stretch Stomach Parts Fundus • dome-shaped Body • from cardiac orifice to incisura angularis Pyloric Antrum • incisura angularis to pylorus Pylorus • Most tubuluar part of stomach • Thick muscular wall (pyloric sphincter) • Cavity (pyloric canal) Stomach Parts Lesser curvature • Right border of stomach • Connected to liver by lesser omentum Greater curvature • Longer • From left cardiac orifice along left border of stomach • Gastrosplenic omentum/ ligament extends from upper part to spleen • Greater omentum extends from lower part to transverse colon Stomach Parts Cardiac orifice NO anatomic sphincter Physiologic sphincter Pyloric orifice Anatomic and physiologic pyloric sphincter formed Stomach, Blood Supply Arteries

Lesser curvature • Right gastric • Left gastric Greater curvature • Right gastroepiploic • Left gastroepiploic Fundus • Short gastric arteries ß splenic artery Stomach, Blood Supply Veins Drain into Portal Circulation Right gastric vein Left gastric vein Splenic vein Short gastric vein Left gastroepiploic vein Superior mesenteric vein Right gastroepiploic Duodenum C-shaped tube Approx 10in (25cm) Curves around head of pancreas Begins at pyloric sphincter Ends by becoming the jejunum 2nd 3rd and 4th portion: retroperitoneal Duodenum First part • Transpyloric plane • Level of L1! Second part • Main pancreatic ducts pierce medial wall à unite to form ampulla (of Vater) opening into major duodenal papilla (of Wirsung) • Accessory pancreatic duct, opens to Minor duodenal papilla (of Santorini) Duodenum Third part • Horizontal in front of the vertebral column • Anteriorly crossed by – Root of mesentery of small intestine – Superior mesenteric vessels Fourth part • Upward and left to duodenojejunal flexure • held in postion by Ligament of Treitz Jejunum & Ileum Jejunum • approx 8ft (2.5m) • Upper left • Wider • Thicker • Redder in color Meckel’s Diverticulum Congenital anomaly Persistent portion of the vitellointestinal duct antimesenteric border of ileum Rule of 2s 2 ft from iliocecal junction 2 in. in length 2% of individuals Bleeding may occur from adjacent ileal mucosa NOT the diverticulum Cecum Blind-ended pouch within right iliac fossa Completely covered w/ peritoneum Joined on left side by terminal ilieum at junction of cecum and ascending colon Appendix at posteromedial surface Ileocecal Valve Two horizontal folds of mucous membrane Around orifice of ileum Ileocecal sphincter Sphincter that controls flow of contents from ileum into colon Appendix Narrow muscular tube Large amount of lymphoid tissue in its wall Approx 1in (2.5cm) Complete peritoneal covering

Own Mesoappendix w/ • Appendicular vesels and nerves Taniae coli of cecum converge to form its continuous muscular coat Ascending colon Approx. 5in (13cm) long Cecum to inferior surface of right lobe of liver (Right colic flexure) Continuous with transverse colon Peritoneum covers front and sides Transverse Colon • Approx 15in (38cm) long • Umbilical, and hypogastric regions Left colic flexure • higher than the right • Held up by Phrenocolic ligament Transverse mesocolon • Attached to superior border of transverse colon • Suspends it from pancreas *posterior layers of greater omentum, attached to inferior border Transverse mesocolon Arteries Proximal 2/3rds • Middle colic artery ß superior mesenteric artery Distal 1/3rd • Left colic artery ß inferior mesenteric artery Veins • Superior mesenteric vein • Inferior mesenteric vein Transverse Colon Lymph drainage Proximal 2/3rds Colic nodes à superior mesenteric nodes Distal 1/3rd Inferior mesenteric node Transverse Colon Nerve supply Proximal 2/3rds • Superior mesenteric plexus – Sympathetic – Vagal Distal 1/3rd • Inferior mesenteric plexus • pelvic splanchnic nerves – Sympathetic – Parasympathetic Descending Colon Approx 10in (25cm) long From left colic flexure to pelvic brim Peritoneum covers front and sides Sigmoid Colon Approx 10-15in (25-38cm) long From descending colon in front of pelvic brim To rectum in front of 3rd sacral vertebra Attached to posterior pelvic wall by fan-shaped sigmoid mesocolon Liver Largest organ of body Divided by falciform ligament into Small left lobe Large right lobe Right lobe further divided by gall bladder, fissure of ligamentum teres, IVC, fissure of ligamentum venosum into Quadrate lobe Caudate lobe Liver Porta Hepatis (hilus) • Posteroinfeior surface of liver • Upper part lesser omentum attached to margins Contains • Right and left hepatic ducts • Right and left branches of hepatic artery • Portal vein • Nerves • Lymph vessels Liver Fissure for the ligamentum teres Between left lobe and quadrate lobe Ligamentum teres = fibrous remains of umbilical vein

Fissure for the ligamentum venosum Between left lobe and caudate lobe Ligamentum venosum = Fibrous remains of the ductus venosus Liver Groove for the inferior vena cava Between right lobe and caudate lobe Hepatic veins join inferior vena cava Fossa for the Gallbladder Between right lobe and quadrate lobe NO peritoneum between the gallbladder and right lobe of liver Peritoneal Ligaments Falciform ligament Attaches liver to diaphragm above To anterior abdominal wall below Sickle-shaped free margin contains ligamentum teres Peritoneal Ligaments Coronary ligament Attaches liver to diaphragm Layers widely separated forming “bare area” of liver devoid of covering Right triangular ligament V-shaped fold right extremity of the coronary ligament Connects posterior surface of the right lobe of liver to diaphragm Left triangular ligament reflection from upper surface of the left lobe of the liver to the diaphragm Lesser Omentum Attached above to the margins of the porta hepatis Fissure for the ligamentum venosum Attached below to lesser curvature of stomach Gallbladder Pear-shaped sac Lies in undersurface of liver Approx 30ml Parts • Fundus • Body • Neck – Continuous w/ cystic duct Bile Ducts Hepatic Duct Right and left hepatic ducts (from each lobe bile canaliculi via porta hepatis) à form common hepatic duct Joined by cytic duct à common bile duct Cystic duct S-shaped Connects neck of gallbladder w/ Common hepatic duct Forming Common bile duct “Spiral valve of Heister” Common Bile Duct Union of cytic duct with common hepatic duct Joins main pancreatic duct à ampulla of vater à major duodenal papilla (of Wirsung) “Spinchter of Oddi” Circular smooth muscle Surrounds both ducts and ampulla Pancreas Parts Head Disc shaped within concavity of C-shaped duodenum Uncinate process Projection to left from lower part to head behind superior mesenteric arteries Neck Narrow Connects head to body In front of beginning of portal vein Pancreatic duct Main pancreatic duct (Wirsung) • Opens to second part of duodenum • With bile duct • Via ampulla of vater Accessory duct (Santorini)

• Often absent • Drains upper half of head • Open into duodenum on the minor duodenal papilla Spleen Largest single mass of lymphoid tissue Lies beneath diaphragm, 9th, 10th, 11th rib Ovoid w/ notched anterior border Surrounded by peritoneum Gastrosplenic ligament • From hilus to stomach • Contains short gastric, left gastroepiploic vessels Splenicorenal ligament • To left kidney • Contains splenic vessels, tail of pancreas Blood Supply Celiac artery (foregut) • Lower third of esophagus to • Middle second of duodenum Superior mesenteric artery (midgut) • Middle second part of duodenum to • Distal third of transverse colon Inferior mesenteric (hindgut) • Distal third of transverse colon to • Half way down anal canal Celiac artery (Trunk) From front of abdominal aorta, through diaphragm Terminal Branches Left gastric Splenic Hepatic Left gastric artery Runs to cardiac end of stomach Gives off a few esophageal branches Turns right along lesser curvature Anastomoses with right gastric artery Splenic artery Largest branch of celiac trunk Runs along upper border of pancreas Behind stomach Enters splenicorenal ligament to hilum of spleen Splenic artery, branches 1. Pancreatic branches 2. Left gastroepiploic artery • From Near hilum of spleen • To greater curvature of stomach • Within gastrosplenic omentum, Greater omentum • Anastomoses with right gastroepiploic Splenic artery, branches 3. Short gastric arteries • 5-6 in no. • To fundus of stomach • Run within gastrosplenic omentum • Anastomose with left gastric artery • Left gastroepiploic artery Hepatic artery Ascends within lesser omentum In front of opening of lesser sac Left of the bile duct Front of portal vein At porta hepatis Divides into right hepatic artery left hepatic artery Hepatic Artery, branches Right gastric artery To left in lesser omentum, along lesser curvature Anastomoses with left gastric artery Gastroduodenal artery Descends behind first part of duodenum Divides into Right gastroepiploic artery à greater curvature Superior pancreaticoduodenal artery à 2nd part duodenum, head of pancreas Right hepatic artery Gives off cystic artery Left hepatic artery Superior Mesenteric Artery

Relations From front of abdominal aorta Behind neck of pancreas Front of 3rd part of duodenum Downward to right in root of mesentery of small intestine Superior Mesenteric Artery, Branches Inferior pancreaticoduodenal artery Upper border of the 3rd part of duodenum below the head of pancreas Middle colic artery In transverse mesocolon à transverse colon Right branch anastomoses with right colic Left branch anastomoses with left colic Superior Mesenteric Artery, Branches Right colic artery • Branch of ileocolic • Supplies ascending colon Ileocolic artery • Give off Superior branch à anatomoses with right colic Inferior branch à anastomoses with end of superior mesenteric artery • Gives rise to – Anterior cecal artery – Posterior cecal artery à Appendicular artery Superior Mesenteric Artery Jejunal and Ileal branches 12-15 in number Arise from left side of superior mesenteric artery Arteries divide and unite to form arcades Small, straight branches supply intestine Inferior Mesenteric Artery Arises from abdominal aorta Approx 1.5in (3.8cm) above aortic bifurcation Artery runs downard and to the left Crosses left common iliac artery Becomes superior iliac artery Inferior Mesenteric Artery, Branches Left colic artery • Divides into ascending and descending branches • Supply – distal 3rd of transverse colon – Left colic flexure – Upper part of descending colon Sigmoid arteries • 2-3 in number • Supplies descending sigmoid colon Inferior Mesenteric Artery, Branches Superior rectal artery • Continuation of inferior mesenteric artery • Descends into pelvis behind rectum • Supplies – Rectum – Upper half of anal canal • Anastomoses with – Middle Rectal Artery ß Intenal Iliac Artery) and – Inferior Rectal Artery (ß Internal Pudendal) Marginal artery Anastomosis of colonic arteries Along concave margin of large intestine Begins at ileocolic junction End at junction of sigmoid colon and rectum Portal venous system Portal vein Approx. 2in (5cm) long Union of • Superior mesenteric vein • Splenic veins Ascends to porta hepatis • Behind first part of duodenum • In free margin of lesser omentum • Divides to right and left terminal branches Portal venous system Portal vein Drains blood form Gastrointestinal tract • Lower end of esophagus • To halfway down anal canal

As well as from – Pancreas – Gallbladder – Bile ducts – Spleen Portal Venous System Tributaries 1. Splenic vein Receives • Short gastric • Left gastroepiploic • Inferior mesenteric • Pancreatic 2. Inferior mesenteric vein Receives • Superior rectal • Sigmoid • Left colic Portal Venous System Tributaries 3. Superior mesenteric vein Receives • Jejunal • Ileal • Ileocolic • Right colic • Middle colic • Inferior pancreaticoduodenal • Right gastroepiploic 4. Left gastric vein Drains left portion of lesser curvature Distal part of esophagus 5. Right gastric vein Drains right portion of lesser curvature 6. Cystic vein Drains gallbladder Portal-Systemic Anastomosis IMPORTANT! 1. Distal 3rd, Esophageal branches of left gastric vein (Portal) à Middle 3rd, esophageal branches of azygous veins (Systemic) “Esophageal varices” 2. Superior rectal veins (Portal) à Middle and Inferior rectal veins (Systemic) “Hemorrhoids” Portal-Systemic Anastomosis IMPORTANT! 3. Paraumbilical veins (in falciform ligament w/ ligamentum teres) from left branch of portal vein (portal)  Superficial veins of anterior abdominal wall (Systemic) “Caput medusae” 4. Veins of ascending and descending colon, duodenum, pancreas liver (portal) à renal, lumbar, phrnenic veins (systemic) Kidneys • Paired organs • Retroperitoneal Right kidney lower than left due to liver! Hilus • Concave border of kidney • Extends to cavity of renal sinus Transmits • Renal vein • Renal artery • Ureter • Sympathetic nerve fibers “V.A.U.A.” Kidneys Coverings: from within to without Fibrous capsule • True capsule/renal capsule • Closely applied to outer surface Perirenal fat • Fat covering fibrous capsule Renal Fascia • “Gerotas fascia” • Encloses kidney and suprarenal glands Pararenal fat • External to renal fascia •

Kidneys, Structure Outer cortex • Extends into medulla between adjacent pyramids (Renal columns) Inner medulla • 12 renal pyramids (base toward cortex; apex - renal papilla oriented medially) • Medullary rays Striations from bases of pyramids to cortex Kidneys, Structure Renal Pelvis Upper expanded end of ureter Divided into Two major calyces Subsequently divided into 2-3 minor calyces Each minor calyx indented by apex of renal pyramid (renal papilla) Kidneys, Blood Supply Artery • Renal artery Vein • Renal vein Lymph drainage • Lateral aortic lymph nodes – Around renal artery origin Nerve supply • Renal sympathetic plexus Ureters Muscular tubes extend from kidneys to posterior surface of urinary bladder Approx 10in (25cm) long Renal pelvis Lies within renal hilus Upper expanded end of ureter receives major calyces Ureteric Constrictions 1. Junction of pelvis and ureter 2. Crossing of pelvic brim 3. Piercing of bladder wall Ureter Arteries Upper end: • Renal artery Middle: • Testicular/ ovarian artery Inferior end: • Superior vesicular artery Veins Veins correspond to arteries Suprarenal (Adrenal) Glands Located to upper poles of kidneys Retroperitoneal Surrounded by renal fascia Separated from kidneys by perirenal fat Has Cortex (yellow colored) Medulla (brown colored) Suprarenal (Adrenal) Glands Arteries Inferior phrenic artery Aorta Renal arteries Veins Right suprarenal vein à inferior vena cava Left suprarenal vein à left renal vein Aorta Abdominal aorta Enters through aortic opening in diaphragm (T12) Divides into common iliac (L4) Aorta Branches 1. Three (3) anterior visceral • Celiac artery • Superior mesenteric • Inferior mesenteric 2. Three (3) lateral visceral • Suprarenal artery • Renal artery • Testicular of ovarian artery

Aorta Branches 3. Five (5) lateral abdominal • Inferior phrenic artery (1) • Four lumbar arteries (4) 4. Three (3) terminal • Two common iliac arteries (2) • Median sacral artery (1) Common Iliac Arteries Terminal branches of abdominal aorta Run downward and laterally Divide into external and internal iliac arteries Crossed anteriorly by ureter on each side Inferior vena cava Formed by union of common iliac veins (L5) Pierces central tendon of diaphragm at (T8) To right atrium Inferior vena cava, tributaries Tributaries 1 Two (2) anterior visceral • Hepatic veins 2. Three (3)lateral visceral • Right suprarenal vein* • Renal veins • Right testicular/ovarian vein* * Left drains to left renal Inferior vena cava, tributaries Tributaries 3. Five (5) lateral abdominal wall tributaries Inferior phrenic vein (1) Four lumbar veins (4) 4. Three (3) veins of origin Two common iliac veins (2) Median sacral vein (1) Lymphatics on posterior abdominal wall Cysterna Chyli (thoracic duct) Elongated sac in abdomen Lies on right side of aorta (L1-L2) Receives Intestinal trunk Right and Left lumbar trunks Lymph vessels from lower part of thorax Lumbar Plexus Branches( L1L2L3L4 ) MNEMONIC: I 2x Get Laid On Friday Ilioinguinal (L1) Iliolumbar (L1) Genital branch, genitofemoral nerve (L1L2) Lateral cutaneous nerve of the thigh (L2L3) Obturator (L2L3L4) Femoral (L2L3L4) All arise lateral to psoas EXCEPT: Genital branch, genitofemoral nerve ( anterior ) Obturator nerve ( medial ) Sympathetic trunk Enters abdomen behind medial arcuate ligament Runs downward along medial border of psoas muscle On bodies of lumbar vertebrae Enter pelvis behind common iliac vessels Possess 4-5 segmentally arranged ganglia Muscles of Posterior Abdominal Wall Psoas Quadratus lumborum Iliacus Nerve supply: Lumbar plexus EXCEPT: Iliacus ( femoral nerve ) THE END • Pelvis and Perineum • Loubomir E. Antonio, M.D. • Bony Pelvis Four (4) bones • Two (2) hips bones • Sacrum • Coccyx Pelvic brim composed of: • Sacral promontory (posteriorly) • Iliopectineal lines (laterally)

• Symphysis pubis (anteriorly) Divides pelvis into: • False pelvis (greater pelvis) - ABOVE • True pelvis (lesser pelvis) - BELOW • True Pelvis Pelvic Inlet • Sacral promontory (posteriorly) • Iliopectineal lines (laterally) • Symphysis pubis (anteriorly) Outlet • Coccyx (posteriorly) • Ischial tuberosities (laterally) • Pubic arch (anteriorly) Cavity • Between inlet and outlet • Short curved canal • Shallow anterior wall • Deeper posterior wall • True pelvis Ligaments • Sacrotuberous ligament • Sacrospinous ligament Divide sciatic notches to Greater sciatic foramen Lesser sciatic foramen • Sacroiliac joint • Strong synovial joint Between • Sacrum • Iliac bones Supported by • Posterior sacroiliac ligament • Interosseous sacroiliac ligament • Anterior sacroiliac ligament (thin) *Transmit weight of body from vertebral column to bony pelvis Nerve Supply • Sacral plexus • Symphysis pubis Cartilagenous joint Between two pubic bones • Articular surface covered by hyaline cartilage • Connected by fibrocartilagenous disc • Joint surrounded by ligaments • No movement permitted • Sacrococcygeal joint Cartilagenous joint Between sacrum and coccyx Cornua of sacrum and coccyx joined by ligaments Great deal of movement possible Ligaments relaxed during pregnancy • Sex differences of pelvis • Walls of the pelvis Anterior wall • Bodies of pubic bone • Pubic rami • Symphysis pubis • Sacrotuberous ligament • Strong From • Lateral part of Sacrum and Coccyx and • Posteroinferior Iliac spine To à • Ischial tuberosity *prevent lower end of sacrum from being rotated by the body • Sacrospinous ligament Strong Triangluar shaped Base: lateral part of sacrum and coccyx Apex: spine of ischium *Prevent lower end of sacrum from being rotated by the body • Inferior pelvic wall (Pelvic Floor) • Support pelvic viscera Formed by pelvic diaphragm • Levator ani muscle • Small coccygeal muscles • Pelvic fasciae

Incomplete anteriorly • Allows passage of urethra (and vagina) • PELVIC FRACTURE • Muscles of the Pelvic Walls and Floor • Piriformis • Obturator internus • Levator ani – Puborectalis – Pubococcygeus – Iliococcygeus • Coccygeus • Pelvic Fasciae Parietal pelvic fascia • Line pelvic walls • Continuous with fascia lining abdominal walls • Pelvic Fasciae Visceral pelvic fascia • Covers all pelvic viscera • Parametrium – fascia around cervix • Pelvic peritoneum • Lines pelvic walls • Reflected onto pelvic viscera • Continuous with visceral peritoneum • Nerves of the Pelvis • Sacral Plexus • Branches of lumbar plexus • Autonomic nerves • Sacral plexus On posterior pelvic wall In front of piriformis Formed by anterior rami of L4-L5, S1-S4 nerves Lumbosacral trunk (Lumbar plexus) • Combination of L4 and L5 • Passes into pelvis • Joins sacral nerves • Sacral Plexus Branches MNEMONIC: NO Priests Sleeps Soundly Inside Nuns Quarters Nerve to Obturator internus Posterior cutaneous nerve of the thigh Sciatic nerve Superior gluteal nerve Inferior gluteal nerve Nerve to Quadratus femoris Branches that leave the pelvis through Greater sciatic foramen • Sacral Plexus Branches Branches to the pelvic muscles, viscera and peritoneum Pudendal nerve Nerve to piriformis muscle Pelvic splanchnic nerves ( S2S3S4 ) • Lumbar Plexus MNEMONIC: I 2x Get Laid On Friday Ilioinguinal Iliolumbar Genital branch, genitofemoral nerve Lateral cutaneous nerve of the thigh Obturator Femoral • Autonomic nerves Pelvic part of sympathetic trunk Continuous with lumbar part Two trunks come together in from of coccyx Sympathetic trunk has 4-5 segmental ganglia Branches • Gray rami communicantes – Sacral nerves – Coccygeal nerves • Fibers to hypogastric plexuses • Autonomic nerves Pelvic splanchnic nerves • Parasympathetic part of autonomic nervous system • From S2,3,4 • Preganglionic fibers à ganglia of hypogastric plexuses • Autonomic Nerves Superior Hypogastric Plexus In front of promontory Divides to

• Right hypogastric nerve • Left hypogastric nerve Continuation of • Aortic plexus and • Branches of 3rd, 4th lumbar sympathetic ganglia • Contains – Sympathetic – Sacral parasympathetic – Visceral afferent • Autonomic Nerves Inferior Hypogastric Plexus From • hypogastric nerve (of superior hypogastric plexus) • Pelvic splanchnic nerve Contains • Postganglionic sympathetic • Pre-and-post ganglionic parasympathetic • Visceral afferent Supply • Large bowel from left colic flexure to upper half of anal canal • Arteries of Pelvis False Pelvis • Common Iliac artery • External Iliac artery True Pelvis • Internal Iliac artery – Anterior division – Posterior division • Superior Rectal artery • Ovarian artery • Median sacral artery • Common Iliac Artery Ends at pelvic inlet in front of the sacroiliac joint Divides into • External iliac • Internal iliac • External Iliac Medial border of psoas Follows pelvic brim Branches • Inferior epigastric • Deep circumflex iliac Leaves false pelvis as femoral artery • Internal Iliac Leaves pelvis thorugh greater sciatic foramen Divides into • Anterior division • Posterior division Supply • Pelvic viscera • Perineum • Pelvic walls • Buttocks • Internal Iliac Artery Branches MNEMONIC: I Milked Our Insatiable Interns Udders Under the Desk Inferior gluteal Middle rectal Obturator Inferior vesical Internal pudendal Umbilical Superior vesical Uterine Vaginal the Deferential • Posterior Division of Internal Iliac Iliolumbar artery Lateral sacral arteries Superior gluteal arteries • Superior Rectal Artery Direct continuation of inferior mesenteric artery Supplies • mucous membrane of rectum • Upper half of anal canal • Ovarian Artery From abdominal aorta (L1 level)

Passes downward behind the peritoneum Enters suspensory ligament of ovary Passes into broad ligament Enters ovary through mesovarium • Median Sacral Artery • Bifurcation of the aorta (L4L5 ) • Descends over anterior surface of the sacrum and coccyx • Veins of the Pelvis False Pelvis • External Iliac vein True Pelvis • Internal Iliac vein • Superior rectal vein • Ovarian vein • Median Sacral vein • External Iliac Vein • Begins behind inguinal ligament • Continuation of femoral vein • Runs medially to artery • Joins internal iliac vein à common iliac vein • Receives – Inferior epigastric – Deep circumflex iliac • Internal Iliac Vein • Union of tributaries corresponding to branches of internal iliac artery • ascends in front of sacroiliac joint • Joins external iliac à common iliac vein • Superior Rectal Vein Drains • Rectal mucous membrane • Mucous membrane of upper half of anal canal Important! portal-systemic anastomosis as it unites with inferior mesenteric vein • Ovarian Vein Right ovarian vein drains into inferior vena cava • Median Sacral Vein • Small Drains into • Inferior vena cava or • Left common iliac vein • Sigmoid Colon • 10-15in (25-38cm) long • From pelvic brim to S3 • Attached to posterior pelvic wall by sigmoid mesocolon • Rectum Approx. 5in (13cm) long From S3 to tip of coccyx Pierces pelvic floor à anal canal Peritoneum only covers upper 2/3rds • Rectum Rectal ampulla • Dilated lower portion Transverse folds ( Houston’s valves) • Three (3) semicircular folds superior - L middle - R inferior - L • Rectum Arteries • Superior rectal artery ß inferior mesenteric artery • Middle rectal artery ß internal iliac artery • Inferior rectal artery ß internal pudendal artery • Rectum Veins • Superior rectal vein à portal system • Middle rectal vein à systemic system • Inferior rectal vein à systemic system • Rectum Lymph drainage • Pararectal nodes • à inferior mesenteric nodes • à internal iliac nodes • Rectum Nerve Supply

Inferior hypogastric plexuses – Sympathetic – Parasympathetic • Ureters Muscular tube from kidney to posterior surface of bladder Enter pelvis crossing bifurcation of common iliac arteries • Runs down lateral wall of pelvis Enters lateral angle of bladder • In males, crossed by vas deferens • In females, turns forward medially beneath broad ligament • crossed by uterine artery • Ureteric Constrictions Three (3) constrictions 1. Where renal pelvis joins ureter 2. Where it is kinked as it crosses the pelvic brim 3. Where it pierces the bladder wall • Urinary Bladder Max capacity approx 500ml Pyramidal Apex: • connected to umbilical ligament (remains of urachus) Base: • faces posteriorly • triangular Neck: • points inferiorly Supralateral angles: • entry of ureters Inferior angle: • exit of urethra Superior surface: • covered w/ peritoneum • Urinary Bladder, Interior Trigone • Internal surface Smooth mucous membrane adheres to underlying muscle Ureteral Openings Small slit like opening at lateral angles Interureteric ridge runs in between • forms upper limit of trigone • Urinary Bladder, Interior Opening of urethra below In males, median lobe of prostate bulges slightly upward Uvula vesicae • Swelling behind urethral orifice • Urinary Bladder, muscular coat Detrusor muscle • Three (3) interlacing layers of smooth muscle fibers Sphincter vesicae • Circular muscle at neck of bladder • Urinary bladder, ligaments Ligaments from pelvic fascia Hold bladder neck in place Puboprostatic ligament • males Pubovesical ligament • females • Urinary Bladder Arteries Internal Iliac artery à • Superior vesical artery • Inferior vesical artery Veins Internal Iliac vein • Urinary Bladder Lymph drainage • Internal Iliac nodes • External Iliac nodes Nerve Supply Inferior Hypogastric plexus • Sympathetic • Parasympathetic • Vas Deferens • Thick-walled tube • Approx 18in (45cm) long •

• From lower end/tail of epididymis • Through inguinal canal • Crosses ureter to reach posterior bladder • Expands forming ampulla • Joins seminal vesicle • à ejaculatory duct • Ejaculatory duct • Two (2) From union of • Vas deferens • Duct of seminal vesicle • Open into protastic urethra • Seminal Vesicles Much coiled tube embedded in connective tissue Located on • Posterior surface of bladder • Lateral part of vas deferens Contribute • Fluid • Fructose • Ascorbic acid • Amino acids • Prostaglandins • Prostate Glandular Surrounds prostatic urethra • Below neck of bladder • Above urogenital diaphragm Fibrous capsule • And fibrous sheath = visceral layer of pelvic fascia Base: • lies superiorly against bladder neck Apex: • lies inferiorly against urogenital diaphragm • Prostate • Ejaculatory ducts open into prostatic urethra at lateral margins of Prostatic utricle Lobes • Anterior • Middle/median – Behind urethra, above ejaculatory ducts • Right lateral • Left lateral • Prostate Arteries • Inferior vesical • Middle rectal • Prostate Lymph drainage • Internal Iliac nodes Nerve Supply • Inferior hypogastric plexus • Ovaries Found in Ovarian fossa • Depression near lateral wall of pelvis • Bounded by external and internal iliac arteries Mesovarium • Attaches ovary to back of broad ligament Hilum • Entry of ovarian vessels and nerves • Ovaries Germinal epithelium • Modified area of peritoneum covering ovary • Thin fibrous capsule (Tunica albugina) beneath Outer Cortex • Contains ovarian follicles Inner Medulla • Ligaments of Ovaries Suspensory Ligament • Lateral part of broad ligament • Connects mesovarium to lateral pelvic wall • Contains – Blood – Lymphatic vessels – Nerves Round Ligament

• Remains of upper part of gubernaculum • (Round ligament of uterus ~ lower part) • Medial margin of ovary to lateral wall of uterus • Ovaries Arteries • Ovarian artery ß abdominal aorta • Veins Ovarian vein à (right) inferior vena cava à (left) left renal vein • Uterine tubes Upper border of broad ligament Connects peritoneal cavity in region of ovary with cavity of uterus Provides • Conduit for spermatozoa to reach ovum • Site for fertilization of the ovum (usually the ampulla) • Nourishment for fertilized ovum • Transports ovum to cavity of uterus • Uterine Tubes Four (4) parts 1. Infundibulum • Funnel-shaped • w/ fimbrae draped over ovary 2. Ampulla • Widest part 3. Isthmus • Narrowest portion of tube • Just lateral to uterus 4. Intramural • Pierces uterine wall • Uterine tubes Arteries • Uterine and ovarian arteries Veins • Uterine and ovarian veins Lymph drainage • Internal iliac • Para-aortic nodes Nerve supply • Superior hypogastric plexus • Inferior hypogastric plexus Sympathetic, Parasympathetic • Uterus Fundus • Above entrance of uterine tubes Body • Beneath entrance of uterine tubes Cervix • Pierces anterior wall of vagina • Internal os – Uterine opening • External os – Vaginal opening • Uterus Positions Anteversion • Forward bending of uterus on long axis of vagina Anteflexion • Forward bending of uterus along long axis of body of uterus on cervix • Uterine Support Pelvic diaphragm - Most Important Perineal body Transverse cervical ( cardinal ) ligaments Pubocervical ligament Sacrocervical ligament • Broad ligaments Two-layered folds of peritoneum Lateral margins of uterus àLateral pelvic walls Contains • Uterine tube (in upper free border) • Round ligaments of ovary and of the uterus • Uterine and ovarian – Blood vessels – Lymph vessels

– Nerves * Little support for the uterus • Round ligament of uterus Superolateral angle of uterus  inguinal canal  subcutaneous tissue of labium majus Assists in uterine • Anteversion • Anteflexion • Uterus Arteries • Uterine artery ß internal iliac • Ovarian artery Veins • Uterine vein • Ovarian vein • Uterus Lymph drainage Fundus Ovarian artery à • Para-aortic nodes (level L1) Body and Cervix • Internal and external iliac nodes Nerve Supply • Inferior hypogastric plexus Sympathetic, Parasympathetic • Vagina Female genital canal • Excretory duct for menstrual flow • Birth canal Muscular tube between vulva and uterus Cervix pierces anterior wall Hymen • Mucosal fold found in virgins • Perforated at center • Vagina Area surrounding cervix Four fornices • Anterior • Posterior • Right lateral • Left lateral Relations Upper half: between • pelvis (anteriorly) and • rectum (posteriorly) Lower half: within peritoneum • Urethra (anteriorly) • Anal canal (posteriorly) • Vagina, Support Upper third • Levatores ani muscles • Transcervical ligament • Pubocervical ligament • Sacrocervical ligament Middle third • Urogenital diaphragm Lower third • Perineal body • Vagina Arteries • Vaginal artery ß internal iliac artery • Vaginal branch of uterine artery Veins • Internal iliac veins • Vagina Lymph drainage Upper 3rd à internal & external iliac nodes Middle 3rd à internal iliac nodes Lower 3rd à superificial inguinal nodes Nerve Supply

• Inferior hypogastric plexus • Visceral pelvic fascia Covers supports pelvic viscera Condensed to form • Pubocervical ligament • Transverse cervical ligament • Sacrocervical ligament Parametrium • Pelvic fascia in region of uterine cervix • Peritoneum in the Female Pelvis Passes over • Urinary bladder • Uterus • Vagina • Front of rectum Rectouterine pouch (of douglas) • Peritoneal pouch between vagina and rectum • Most inferior part of peritoneal cavity • Perineum Below pelvic diaphragm Diamond-shaped Boundaries Anteriorly: • symphysis pubis Posteriorly: • ischial tuberosities Divided into two by: • imaginary line between tuberosities Anterior triangle ~ urogenital triangle Posterior triangle ~ anal triangle • Urogenital Triangle Urogenital diaphragm Musculofascial diaphragm Fills gap between pubic arch Formed by • Sphincter urethrae • Deep transverse perineal muscles (between superior and inferior fascial layers) Inferior perineal fascia = perineal membrane • Urogenital Triangle Perineal body Small mass of fibrous tissue • Attached to center of the posterior margin of the urogenital diaphragm Larger in females • Provides support to posterior vaginal wall • Provides attachment to muscles in the perineum • Perineal Pouches • Superficial perineal pouch • Deep perineal pouch • Superificial Perineal Pouch Closed posteriorly and laterally Anteriorly: Space communicates freely with potential space between • superficial fascia of anterior abdominal wall (Scarpa’s fascia) and • anterior abdominal muscles • SUPERFICIAL PERINEAL POUCH (contents) “B I G S S” Bulbospongiosus Ischiocavernosus Great vestibular glands (Bartholin’s) Superficial transverse perinei Scrotal nerves • DEEP PERINEAL POUCH (contents) Dorsal nerve of penis (men) Sphicter urethrae Bulbourethral glands (Cowper’s) (men) Membranous part of urethra Pudendal vessels and nerves Deep transverse perinei “Dont Stop Banging My Perineum Dear” • Male External Genitalia Interior Three (3) cylinders of erectile tissue

Within tubular sheath of fascia Corpora cavernosa • Two (2) • Dorsal Corpus spongiosum • One (1) • Ventral • Forms Glans Penis • Contains penile part of urethra • Male External Genitalia Root of penis In superificial perineal pouch 3 masses of erectile tissue • Bulb à Corpus spongiosum • Midline • Traversed by urethra • Covered by bulbospongiosus muscle • Right and Left crura à corpora cavernosa • Attached to side of pubic arch • Covered by Ischiocarvernosus muscle • Male external genitalia Arteries • Deep arteries of penis • Branches of dorsal artery Veins • Deep dorsal vein • Lymph Drainage Glans • Deep inguinal • External iliac Skin • Supeficial inguinal nodes Erectile tissue • Internal iliac Nerve Supply • Pudendal nerve • Bulbourethral (Cowper’s Glands) • Two (2) small glands • Deep perineal pouch • Fibers of sphincter urethrae muscle • Open into penile urethra • Prostatic Urethra Widest, Most dilatable Urethral crest • Longitudinal ridge on posterior wall Prostatic sinus • on sides of crest • Opening of prostatic glands Prostatic utricle • Analogue of uterus and vagina • Edge of mouth: (2) ejaculatory ducts • Membranous Urethra • Through urogenital diaphragm • Surrounded by sphincter urethrae • Shortest, Least dilatable • Penile Urethra External meatus • Narrowest part of entire urethra Fossa terminalis (navicular fossa) • Urethra within bulb of penis • Bulbourethral glands • Open to penile urethra below urogential diaphragm • Female External Genitalia (Vulva) • Mons pubis • Labia majora • Labila minora • Clitoris • Greater vestibular glands • Vestibule of the Vagina • Space between labia minora Apex • Clitoris Floor • Openings of the urethra • Vagina

• Ducts of greater vestibule glands • Greater Vestibular Glands Two (2) • Mucus- secreting glands Duct of each gland à groove between hymen and posterior part of labium minus • Female Urethra From bladder neck à external meatus • 1.5in (3.8cm) long Through • Urogenital diaphragm • Sphincter urethrae Opens into surface below clitoris In front of vagina • Muscles of Urogenital Triangle • Superficial transverse perineal muscle • Bulbospongiosus • Ischiocavernosus • Deep transverse perineal muscle • Sphincter urethrae All suplied by perineal branch of pudendal nerve • Anal Canal • 1.5in (4cm) long • Below pelvic diaphragm • Rectal ampulla à anus Anal Columns • Vertical folds on mucous membrane • On Upper half of anal canal (Lower half is smooth) Anal Valves • Small semilunar folds • Connect anal columns together • Anal Canal Muscle coat • Outer longitudinal layers • Inner circular layer of smooth muscle Involuntary Internal sphincter • Thickening of circular layer at upper end Voluntary External sphincter • Surround internal sphincter with collar of striped muscle Parts • Subcutaneous • Superficial • Deep • Anal Canal Puborectalis • Sling formed from fibers of levator ani muscle • Attached anteriorly to pubic bone • Around junction of rectum and anal canal • Pulls forward to make angle more acute Anorectal ring Distinct ring at anorectal junction, from: • Internal sphincter • Deep part of external sphincter • Puborectalis • Anal Canal Arteries Upper half • Superior rectal artery Lower half • Inferior rectal artery Veins Upper half • Superior rectal vein à inferior mesenteric vein Lower half • Inferior rectal vein à internal pudendal vein • Anal Canal Lymph drainage Upper half • Pararectal nodes à inferior mesenteric nodes Lower half • Medial group of superficial inguinal nodes • Anal Canal Nerve Supply Upper half (and internal anal sphincter) • sensitive to stretch

à hypogastric plexus Lower half (and external anal sphincter) • Pain Temperature Touch Pressure • à inferior rectal nerves • Ischiorectal Fossa Wedge- shaped space on each side of anal canal Base: • Superficial; skin Edge: • junction of medial and lateral walls Medial Wall: • levator ani muscle • Anal canal Lateral wall: • Lower part of obturator internus muscle and pelvic fascia • Ischiorectal Fossa Fat-filled, Allows distention during defecation Pudendal canal • Fascial canal • Medial side of ischial tuberosity • Passage – Pudendal nerve – Internal pudendal vessels • Muscles of Anal Triangle External Anal sphincter • Subcutaneous part • Superficial part • Deep part Nerve Supply: perineal branch of S4 Puborectalis muscle Nerve Supply: Perineal branch of S4 Perineal branch of pudendal nerve Upper Extremity Loubomir E. Antonio, M.D. Bones of the Shoulder Girdle Clavicle Scapula Fractures Clavicular fracture Most commonly fractured bone in the body Fall on the shoulder or outstretched hand Junction of m/3rd and distal 3rd Distal fragment goes downward, medial and forward by pectoralis major Medial end pulled upward by SCM Fractures Scapular fracture Result of severe trauma Run-over accident victims, vehicular crashes Require little treatment Bone of the Arm Humerus Head Anatomical neck Greater tuberosity Lesser tuberosity Bicipital groove (biceps tendon) Surgical neck Deltoid tuberosity Bone of the Arm  Humerus  Spiral groove (radial nerve and deep artery of arm)  Medial epicondyle  Lateral epicondyle  Capitulum (head of radius)  Trochlea (trochlear notch of ulna)  Radial fossa  Coronoid fossa (coronoid process of ulna)  Olecranon fossa Fractures

Humeral head Greater tuberosity – pulled by S,I,T Lesser tuberosity – pulled by S Surgical neck - most common site Humeral shaft proximal to deltoid insertion proximal fragment adducted by PM,LD,TM distal fragment pulled by D,BB,TB distal to deltoid insertion proximal fragment abducted by D distal fragment pulled by BB, TB - radial nerve at risk Volkmann’s Ischemic Contracture Contracture of muscles of the forearm following fractures of the distal end of the humerus - brachial artery spasm leading to ischemic necrosis Bones of the Forearm • Radius Lateral bone of forearm (scaphoid and lunate) – Head (circular) – Neck – Bicipetal tuberosity (biceps brachii) – Shaft • Interosseous border • Interosseous membrane – Styloid process – Ulnar notch – Dorsal tubercle Bones of the Forearm Ulna Medial bone of forearm Olecranon Trochlear notch Coronoid process Shaft Interosseous border Head Styloid process Fractures of the Forearm Colle’s fracture fracture of the distal end of the radius with the distal fragment displaced dorsally “ dinner fork deformity “ Smith’s fracture fracture of the distal end of the radius with the distal fragment displaced volarly Galeazzi’s fracture fracture of the proximal end of the radius with dislocation of DRUJ Monteggia’s fracture fracture in the shaft of ulna with anterior dislocation of the radial head and rupture of annular ligament Bones of the Wrist Carpal bones “Scared Lovers Try Positions That They Cannot Handle” 1. Scaphoid (navicular) 2. Lunate 3. Triquetral 4. Pisiform 5. Trapezium 6. Trapezoid 7. Capitate 8. Hamate Bones of the Hand • Metacarpal Bones – Base – Shaft – Head • Phalanges – 3 for each Digit • Proximal • Middle • Distal – Except Thumb (2) • Proximal • Distal Shoulder Joint

• Shoulder joint (Glenohumeral joint) – Glenoid cavity • Shallow • Glenoid labrum (fibrocartilagenous) – Synovial Ball-and-socket joint – Capsule • Glenoid labrum • Anatomical neck • Strengthened by tendons of Rotator cuff muscles Shoulder Joint • Ligaments – Glenohumeral • 3 bands that strengthen anterior part of capsule • Superior band and Inferior band – primary ligamentous support • Middle – strongest stabilizing ligament – Transverse humeral Ligament • Gap between grater and lesser tuberosities • Holds tendon of the biceps muscle in place Shoulder Joint • Ligaments – Coracohumeral Ligament • Extends from the root of the coracoid process to the greater tuberosity of the humerus • Strengthens capsule above – Accessory Ligament • Coracoacromial ligament • Protects superior aspect of joint Shoulder Lesions Shoulder Dislocation - most commonly dislocated large joint - Anterior more common than posterior - impingement of axillary nerve Shoulder Separation - acromioclavicular dislocation due to tearing of the coracoclavicular ligament - cases of severe blow to the point of the shoulder Shoulder movements 3-2-1 ASS rule Every 3 degree abduction of arm = 2 degree abductiion of shoulder joint 1 degree by rotation of scapula At 120degree abduction Greater tuberosity of humerus hits lateral edge of acromion Elbow Joint Elbow joint Trochlea and capitulum of humerus Trochlear notch and head of the radius Synovial hinge joint Enclosed by capsule Elbow Joint Movements Flexion Extension Carrying Angle When extended 170 degrees in males 167 degrees in females Disappears on flexion Elbow Joint Important Relations Anteriorly Median Nerve Brachial Artery Medially Ulnar nerve as it passes behind the medial epicondyle of humerus! Superior Radioulnar Joint Superior Radiounlar joint Head of radius and annular ligament Radial notch of ulna Synovial pivot joint (trochoid)

Synovial membrane Lines capsule Continuous with that of elbow joint Superior Radioulnar Joint Movements Pronation Supination More powerful than pronation Inferior Radioulnar Joint Inferior Radioulnar Joint Head of ulna Ulnar notch of radius Synovial pivot joint Capsule Encloses joint Strengthened by anterior and posterior ligaments Inferior Radioulnar Joint Movements Pronation Supination Wrist Joint  Wrist joint (Radiocarpal joint)  Distal end of radius (triangular cartilaginous articular disc)  Scaphoid, Lunate, Triquetral  Synovial condyloid Joint  Biaxial  Ball and socket but w/ no rotation Wrist Joint  Nerve Supply  Anterior interosseous nerve (from Median nerve)  Deep branches of Radial and Ulnar nerves  Movements  Flexion  Extension  Abduction  Adduction  NO Rotation (done by radioulnar joint pronationsupination) Wrist Joint Important Relations Anterior Median nerve Ulnar nerve Laterally Radial artery Carpometacarpal Joints Carpometacarpal Joints Carpal bones Metacarpal bones Synovial gliding joints Ligaments Anterior Posterior Interosseous Carpometacarpal Joint of Thumb  Thumb carpometacarpal joint  Trapezium  Saddle shaped base of first metacarpal bone  Synovial saddle joint (biaxial)  Movement  Flexion  Extension  Abduction  Adduction  Rotation (Opposition) Metacarpophalangeal Joints Metacarpophalangeal joints Convex heads of metacarpals Concave bases of proximal phalanges Synovial condyloid joint Interphalangeal Joint  Interphalangeal joint  Proximal  Middle

 Distal Synovial hinge joints Similar structure as metacarpophalangeal joint Movements  Flexion  Extension Muscles of the Shoulder Region Connect upper limb to vertebral column MNEMONIC: The Lone Ranger Likes Riding Trapezius Latissimus Dorsi Rhomboid minor Levator Scapulae Rhomboid major Nerve Supply Trapezius CN11, C3C4 Latissimus dorsi Thoracodorsal nerve Rhomboid minor Levator scapula Dorsal scapular nerve Rhomboid major Muscles of the Shoulder Region Connecting upper limb to thoracic wall Pectoralis major Pectoralis minor Subclavius Serratus anterior Nerve Supply Pectoralis minor Medial pectoral nerve Pectoralis major Medial and Lateral pectoral nerve MNEMONIC: The Major has 2, The minor only 1 Medial – more ( both ) Lateral – less ( Major only ) Subclavius nerve to subclavius Serratus anterior long thoracic nerve The Lady Between Two Majors INSERTION Teres major – at medial lip bicipital groove Latissimus dorsi – floor of bicipital groove Pectoralis major – lateral lip bicipital groove Muscle of the Shoulder Region Connecting scapula to humerus Deltoid Rotator cuff Supraspinatus Infraspinatus Teres minor Subscapularis Teres major Nerve Supply Deltoid Axillary nerve Supraspinatus Suprascapular nerve Infraspinatus Teres minor Axillary nerve Subscapularis Upper and lower subscapular nerve Teres major Lower subscapular nerve Rotator Cuff Muscles All inserts into the greater tuberosity EXCEPT Subscapularis ( lesser tuberosity ) Supraspinatus Abducts Infraspinatus and Teres minor Laterally rotates Subscapularis Medially rotates Rotator Cuff Tendinitis Subacromial bursitis Excessive overhead activity of the upper limb Degeneration of subacromial bursa exposes the supraspinatus to friction at the acromion - pain on mid abduction of the arm ( 50 to 130 degrees ) Supraspinatus Tendon Rupture - inability to initiate abduction of the arm - if assisted in the first 15 degrees of abduction, the deltoids can complete the abduction to right angle Imporant Landmark Quadrangular space Located immediately below shoulder joint   

Superior: Subscapularis Inferior: Teres major Lateral: Surgical neck of humerus Medial: Long head of triceps Transmits Axillary nerve and Posterior humeral circumflex artery Triangular Spaces Upper Triangular Space - Superior: Teres minor - Inferior: Teres major - Lateral: Long head triceps Transmits circumflex scapular vessels Lower Triangular Space - Superior: Teres major - Medial: Longhead triceps - Lateral: Medial head triceps Transmits Radial nerve and Profunda brachii Muscles of the Upper arm  Anterior Fascial compartment  Biceps brachii  Coracobrachialis  Brachialis  Posterior Fascial compartment  Triceps Cubital fossa • Skin depression – Triangular shaped – In front of elbow • Boundaries: – Laterally: Brachioradialis – Medially: Pronator teres – Base: imaginary line between epicondyles of humerus Contents: from medial to lateral Median nerve Brachial artery Tendon of biceps brachii Radial nerve Anterior Fascial Compartement of Forearm 1. Pronator teres 2. Flexor carpi radialis 3. Palmaris longus 4. Flexor carpi ulnaris 5. Flexor digitorum superficialis 6. Flexor pollicis longus 7. Flexor digitorum profundus 8. Pronator quadratus Forearm anterior compartment Innervated by Median nerve EXCEPT: Flexor carpi ulnaris Flexor digitorum profundus (medial half/ ulnar half) - ULNAR NERVE Lateral fascial compartment of forearm 1. Brachioradialis 2. Extensor carpi radialis longus Both supplied by radial nerve Posterior Fascial Compartment of the Forearm 1. Extensor carpi radialis brevis 2. Extensor digitorum 3. Extensor digiti minimi 4. Extensor carpi ulnaris 5. Anconeus 6. Supinator 7. Abductor pollicis longus 8. Extensor pollicis brevis 9. Extensor pollicis longus 10. Extensor indicis All supplied by the Radial nerve Radial Nerve Abductor pollicis longus Brachioradialis Anconeus Triceps Extensors Supinator ANATOMICAL SNUFFBOX Boundaries

Anterior/Lateral Posterior/Medial EPOL

APOL + EPB

Carpal Tunnel Contains Medial nerve Flexor digitorum superficialis tendons (4) Flexor digitorum profundus tendons (4) Flexor pollicis longus tendon Small muscles of hand Lumbricals (4) Flexes MCP, Extends IPJ ( Z ) Interossei (8) Palmar (4) Dorsal (4) ACTION: PAD DAB Palmar – Adducts Dorsal - Abducts Palmaris brevis Improves grip Nerve Supply Intrinsic Muscles of the Hand All Ulnar nerve EXCEPT: Lateral two Lumbricals Thenar Hypothenar Muscles MNEMONIC: One For All And - All For One Thenar Muscles Hypothenar Muscles - Opponens pollicis - Abductor digiti minimi - Flexor pollicis brevis - Flexor digiti minimi - Abductor pollicis brevis - Opponens digiti minimi - Adductor pollicis Median nerve EXCEPT: All Ulnar nerve Adductor pollicis ( Ulnar nerve ) Thumb Muscles Innervation Snuffbox group All Radial nerve APOL + EPB + EPOL Thenar Muscles All Median EXCEPT Adductor pollicis ( ulnar ) Opponens pollicis Flexor pollicis brevis Abductor pollicis brevis Adductor pollicis Flexor pollicis longus Median nerve Axillary artery  Continuation of subclavian artery  Begins at lateral border of first rib, until  Lower border of teres major muscle (brachial artery)  Related to the cords of the brachial plexus  Enclosed with them in the axillary sheath Axillary artery Divided into 3 parts by the pectoralis minor MNEMONIC: Screw The Lawyer Save A Patient 1st part - Supreme or Highest Thoracic Artery 2nd part - Thoracoacromial Artery - Lateral Thoracic Artery 3rd part - Subscapular Artery - Anterior Humeral Circumflex Artery - Posterior Humeral Circumflex Artery Shoulder Joint Arterial Anastomosis  1st part of subclavian artery  Superficial cervical artery  Thyrocervical trunk Anastomose with  3rd part of axillary artery  Subscapular artery  Anterior circumflex  Posterior circumflex Brachial artery

Begins at lower border of teres major (from axillary artery)  Descends through anterior compartment of arm on brachialis muscle  Enters cubital fossa  Ends at level of neck of radius, divides into  Radial artery  Ulnar artery Brachial artery  Branches  Muscular branches  Nutrient artery (to humerus)  Profunda brachii artery ▪ Large branch ▪ Follows radial nerve in spiral groove ▪ Posterior compartment of arm  Superior ulnar collateral artery ▪ Follows ulnar nerve  Inferior ulnar collateral artery ▪ Part of anastomosis around elbow joint

Subscapular or Posterior External mammary or Anterior Axillary vein or Lateral



Radial artery Smaller than ulnar artery Begins at cubital fossa, neck of radius Radial pulse! Laterally: tendon of brachioradialis Medially: tendon of flexor carpi radialis Radial artery  Wrist ~ winds around lateral side of the carpus to the proximal space bertween 1st and 2nd metacarpal bones  Passes anteriorly into palm between two heads of first dorsal interosseous muscle  Joins deep branch of the ulnar artery à deep palmar arch Ulnar artery  Larger than radial artery  Begins at cubital fossa, neck of radius  Descends through  Anterior compartment  Enters palm in front of flexor retinaculum  With ulnar nerve  Ends by forming superficial palmar arch à superficial palmar branch of radial artery Veins of upper limb Superficial veins Dorsal venous network Cephalic vein Basilic vein Median cubital vein Median vein of the forearm Deep veins Venae comitantes Axillary vein Vein Catheterization Basilic vein Vein of choice for central vein catheterization Increases in diameter as it ascends the arm and is in direct line with the axillary vein Axillary vein  Formed by union of venae comitantes of brachial artery w/ basilic vein  Ascends along medial border to first rib  Receives tributaries corresponding to branches of the axillary artery  Also receives cephalic vein Axillary lymph nodes  Drain lymph from  Upper limb  Lateral part of breast  Superficial lymph vessels from throacoabdominal wall above level of umbilicus  20-30 lymph nodes Axillary Lymphnode Levels Level I

Level II Central Interpectoral “ Rotter’s nodes” Level III Infra or subclavicular Supratrochlear (Cubital) lymph nodes In superficial fascia of cubital fossa Close to trochlea Lymph from medial fingers, medial hand, forearm Ascend to the lateral axillary lymph nodes Upper limb lymphatic drainage summary Brachial plexus “RoTonDa CuBao” Roots (5) Trunks (3) Divisions (3 anterior, 3 posterior) Cords (3) Branches (5 terminal branches) Brachial Plexus  Roots  Enter base of the neck between ▪ Scalenius anterior ▪ Scalenius medius  Trunks and divisions  Cross posterior triangle of neck  Cords  Arranged around axillary artery in the axilla  Enclosed in axillary sheath with axillary artery and vein Roots (5) 5 roots (anterior rami of C5,C6,C7,C8,T1) Branches Dorsal Scapular (C5) Rhomboid minor Rhomboid major Levator scapulae Long thoracic (C5-C6-C7) Serratus anterior Trunks (3) Superior Supscapular nerve (C5-C6) Supraspinatus Infraspinatus Nerve to Subclavius (C5-C6) Subclavius Middle Inferior Cords (3) Medial cord Medial pectoral nerve Pectoralis major + minor Medial cutaneous nerve of the arm Medial cutaneous nerve of the forearm Lateral cord Musculocutaneous nerve Anterior arm compartment muscles Lateral pectoral nerve Pectoralis major Posterior cord Subscapular nerve Upper Subscapularis Lower Subscapularis + Teres major Thoracodoral nerve Latissimus dorsi Axillary nerve Deltoid and Teres minor Radial nerve ABATES Branches From lateral to medial

MNEMONIC: My Aunt Raped My Uncle Musculocutaneous nerve Axillary nerve Radial nerve Median nerve Ulnar nerve Brachial plexus injuries  Upper trunk lesions  Erb-Duchenne Palsy  Displacement of head to the opposite side and depression of the shoulder on same side  Falls on shoulder  Infants during difficult delivery  “waiter’s tip” ▪ Hangs by side ▪ Medially rotated ▪ Forearm pronated Brachial plexus injuries Lower trunk lesions Klumpke’s palsy Traction injury Excessive abduction of the arm First thoracic nerve usually torn Small muscles of hand paralyzed “Claw hand” Brachial plexus injuries Long thoracic nerve (C5-C6-C7) lesion Blows or surgical injury to nerve Paralysis of serratus anterior “Winged scapula” Difficulty raising the arm above the head Brachial plexus injuries  Axillary nerve (C5-C6) lesion  Inferior dislocation of the shoulder joint  Fracture of the surgical neck of the humerus  Quadrangular space  Deltoid paralysis and atrophy  Loss of cutaneous sensation over lower half of deltoid Brachial plexus injuries Radial nerve (C5-C6-C7-C8-T1) lesion Midshaft humeral fracture Nerve in spiral groove “Wrist drop” Unable to extend wrist Unable to extend fingers Brachial plexus injuries  Median nerve (C5-C6-C7-C8-T1) Lesions  Supracondylar fractures of the humerus  Wounds proximal to flexor retinaculum  “Apelike hand” ▪ Thumb rotated ▪ Thumb adducted ▪ Thenar eminence ▪ Paralysis ▪ Atrophy ▪ Flattening Brachial plexus injuries  Ulnar nerve (C8-T1) Lesions  Behind medial epicondyle of humerus  In front of flexor retinaculum of wrist  Hand small muscle paralyis ▪ except for (median nerve) ▪ thenar eminence muscles ▪ first two lumbricals  Thumb cannot be adducted!  Metacarpophalangeal hyperextension  3rd and 4th lumbrical paralysis  Interosseous paralysis  Interphalangeal joint flexion  “Claw hand” THE END

Lower Extremity

Loubomir Hip   

E. Antonio, M.D.

Ilium Ischium Pubis meets at the acetabulum Bones of the thigh Femur Patella Femur  Head  Hemispheric (2/3)  Fovea capitis  Ligament of the head ▪ Obturator artery  Neck  Greater trochanter  Lesser trochanter  Intertrochanteric line ▪ Iliofemoral ligament  Intertrochanteric crest ▪ Quadrate tubercle Femur  Shaft  Linea aspera  Medial supracondylar ridge  Adductor tubercle  Lateral supracondylar ridge  Gluteal tuberosity  Popliteal surface  Condyles  Medial condyle  Lateral condyle  Intercondylar notch  Medial epicondyle  Lateral epicondyle Avascular Necrosis of the Femoral Head Common in ADULTS with femoral neck fractures The small branch of the obturator artery within the ligamentum teres femoris is insufficient to supply the femoral head Uncommon in a child due to free anastomoses between medial femoral circumflex artery and the obturator artery Coxa valga vs.Coxa vara Normal angle between femoral neck and shaft Adults: 125 degrees Children: 160 degrees Coxa valga: INCREASED Congenital dislocation of the hip Adduction is limited Coxa vara: Decreased Femoral neck fractures and Slipped capital femoral epiphyses Abduction is limited Femoral Neck Fracture Patella  Largest sesamoid bone (develops within a tendon)  Tendon of the quadriceps femoris  Triangular shaped  Ligamentum patellae  connects to tibial tuberosity  Posterior surface  Articulates with condyles of femur Tibia  Large, weight bearing, medial bone of leg  Lateral condyle  Oval articular facet for head of fibula  Medial condyle  Lateral meniscus  Medial meniscus  Intercondylar eminence  Tibial tuberosity  Medial malleolus Fibula Muscle attachment

No articulation with knee Head Styloid process Articular surface Shaft Interosseous membrane Lateral malleolus Bones of the foot Tarsal bones Calcaneum Talus Navicular Cuboid Cuneiform bones Metatasal bones and phalanges Calcaneum  Largest bone of the foot  Articulations  Above: talus  Front: cuboid  Posterior surface  Prominence of the heel  Medial surface  Large shelflike ridge “Sustentaculum tali” ▪ Assists in supporting the talus Cuboid Articulation Anterior end of calcaneum Deep groove on inferior aspect Peroneus longus tendon Cuneiform bones Three (3) Small Wedge-shaped Maintenance of transverse arch of foot Articulations Proximally: navicular Distally: first 3 metatarsals Metatarsal bones  Five (5)  Numbered medial to lateral  Head  Shaft  Base  5th metatarsal  Tubercle  Peroneus brevis tendon attachment Hip joint Articulation Head of femur Acetabulum Synovial ball-and-socket joint Hip joint Iliofemoral ligament of Bigelow Strongest! Most important! Inverted Y Base: anteroinferior iliac spine Limbs: upper and lower part of intertrochanteric line of femur Resists: Hyperextension of hip Lateral rotation of hip Hip joint Nerve supply Femoral Obturator Sciatic Nerve to quadratus femoris Movements Flexion Extension Abduction Adduction Lateral rotation Medial rotation Cirumduction

Hip Joint Important relations Anteriorly femoral vessels Femoral nerve Posteriorly Sciatic nerve Knee joint  Synovial hinge joint  Between femur and tibia  Synovial gliding joint  Between patella and femur Knee Joint Capsule Encloses the knee joint Except anteriorly (capsule deficient) Synovial membrane pouches upward beneath quadricepts tendon “Suprapatellar bursa” Knee joint  Extra capsular Ligaments  Ligamentum patellae  Lateral collateral ligament  Medial collateral ligament  Oblique poplititeal ligament  Intracapsular ligaments  Cruciate ligaments ▪ Anterior cruciate ligament ▪ Posterior cruciate ligament Knee joint Lateral collateral ligament Separated from the lateral meniscus by the popliteus muscle Knee joint  Medial Collateral Ligament  Strongly attached to medial meniscus! Cruciate MNEMONIC: PAM’s APPLES Posterio cruciate passes Anterior and Medial Anterior cruciate passes Posterior and Lateral Unhappy Triad of O’Donoghue Medial collateral ligament Anterior cruciate Medial meniscus Bursae  Suprapatellar Bursa ▪ Largest ▪ Always communicates with knee joint  Prepatellar Bursa ▪ Housemaid’s knee/Prostitute’s knee  Infrapatellar Bursa ▪ Clergyman’s knee/Vicar’s knee Ankle joint  Inferior transverse tibiofibular ligament deepens socked into which talus fits  Synovial hinge joint  Enclosed by capsule Ankle joint ligaments  Medial (Deltoid) ligament ▪ Stronger than lateral! ▪ Attachments ▪ Apex: tip of medial malleolus ▪ Below: deep fibers to medial surface of the body of the talus ▪ Superficial fibers medial side of talus sustentaculum tali Plantar calcaneonavicular ligament Tuberosity of navicular bone Ankle joint Synovial membrane lines capsule Nerve supply

Deep peroneal Tibial Movements Dorsiflexion (toes point upward) Plantar flexion (toes point downward) Intertarsal joint  Talocalcaneonavicular joint  Articulation ▪ Rounded head of the talus ▪ Upper surface of sustentaculum tali of calcaneum ▪ Posterior concave surface of navicular bone  Synovial joint  Plantar calcaneonavicular (spring) ligament ▪ Anterior border of sustentaculum tali to ▪ Inferior surface and tuberosity of the navicular bone ▪ Supports head of talus Intertarsal joints  Subtalar, Talocalcaneonavicular,calcaneocuboid)  Inversion ▪ Movement of foot so that sole faces medially  Eversion ▪ Movement of foot so that sole faces laterally *inversion more extensive than eversion Gluteal Region  Bounded  Superiorly: iliac crest  Inferiorly: fold of the buttock  Gluteal muscles  Fascia  Superficial fascia ▪ Thick ▪ esp in women, and impregnated with large quantities of fat.)  Deep fascia ▪ Continous below with fascia lata of thigh ▪ Splits to enclose gluteus maximus muscle Important ligaments Stabilize the sacrum Prevent its rotation by weight of the vertebral column  Sacrotuberous ligament  Posteroinferior iliac spine, lateral part of sacrum, coccyx to  ischial tuberosity  Sacrospinous ligament  Lateral part of the sacrum, coccyx to  Spine of the ischium Important foramina  Greater sciatic foramen  Piriformis muscle  Sciatic nerve  Posterior cutaneous nerve of thigh  Superior gluteal nerve  Inferior gluteal nerve  Nerve to obturator internus  Nerve to quadratus femoris  Pudendal nerve  Superior gluteal artery and vein  Infereior gluteal artery and vein  Internal pudendal artery and vein Important foramina Lesser sciatic foramen Pudendal nerve Internal pudendal vessels Nerve to obturator internus Tendon of obturator internus Gluteal Muscles MNEMONIC: Gods Greatest Gift To People iS Outstanding I Q Gluteus maximus Gluteus medius

Gluteus minimus Tensor fascia latae Piriformis Superior gemellus Obturator internus Inferior gemellus Quadratus femoris Trendelenburg’s Test Factors that determine hip stability when standing in one leg Gluteus medius/minimus Head of the femur located inside acetabulum Intact femoral neck and angle Gluteal Muscles  Inferior gluteal nerve Gluteus maximus Extends and laterally rotates thigh + Extends knee joint  Superior gluteal nerve Gluteus medius Abducts thigh, tilts pelvis Gluteus minimus Tensor fascia latae Assists G. maximus in extending thigh  Sacral Plexus Small lateral rotators of the thigh Piriformis Superior gemellus Obturator internus Inferior gemellus Quadratus femoris Thigh  Saphenous opening Passage ▪ Great saphenous vein ▪ Small branches of femoral artery ▪ Lymph vessels ▪ Cribiform fascia (loose connective tissue) Femoral Triangle  Boundaries  Superiorly: inguinal ligament  Laterally: sartorious muscle  Medially: the adductor longus muscle  Contains NAVEL from lateral to medial  Femoral nerve  Femoral artery  Femoral vein  Empty space  Inguinal lymph nodes ( Rosenmuller’s/Cloquet’s node) Femoral nerve is outside the femoral sheath Floor of Femoral Triangle Ilio-psoas Pectineus Adductor longus Femoral Canal Small medial compartment of the femoral sheath occupied by lymphatics Approx length: 0.5inches(1.3cm) in Potentially weak area in wall of abdomen Femoral hernia Femoral Ring  Upper opening of the femoral canal  Filled by extraperitoneal fat  “femoral septum”  Important relations  Anteriorly: ▪ inguinal ligament ( Poupart’s ligament )  Posteriorly: ▪ pectineal ligament ( Cooper’s ligament )  Laterally:

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▪ femoral vein Medially: ▪ lacunar ligament ( Gimbernat’s ligament)

Thigh Muscles Anterior Compartment Sartorius Iliopsoas Pectineus Quadriceps femoris Medial Compartment Gracilis Adductor longus Adductor brevis Adductor magnus Obturator externus Posterior Compartment Biceps femoris Semitendinosus Semimembranosus Adductor magnus Generalities of thigh muscles Anterior compartment Femoral nerve EXCEPT Psoas (lumbar plexus) Thigh flexors EXCEPT Vastus muscles (leg extensors) Two muscles that crosses both hip joint and knee joint Sartorius “Tailor’s muscle” Rectus femoris Generalities of thigh muscles Medial compartment Obturator nerve Thigh adductors EXCEPT obturator externus (laterally rotates thigh at hip joint) Adductor magnus also receives innervation from sciatic Generalities of thigh muscles Posterior compartment Sciatic nerve tibial portion EXCEPT short head biceps femoris (common peroneal nerve) Leg flexors EXCEPT adductor magnus (extends thigh at hip) Knee region  Popliteal fossa  Boundaries: ▪ Laterally ▪ Above: biceps femoris ▪ Below: Lateral head of gastronemius Lateral head of plantaris ▪ Medially ▪ Above: Semimembranosus Semitendinosus ▪ Below: Medial head of the gastrocnemius Anterior Compartment of the Leg Peroneus tertius Extensor digitorum longus Tibialis anterior Extensor hallucis longus Nerve Supply: Deep peroneal nerve Lateral Compartment of the Leg Peroneus longus Peroneus brevis Nerve Supply: Superficial peroneal nerve Posterior Compartment of the Leg Superficial group Gastrocnemius Plantaris Soleus Deep group Popliteus Flexor digitorum longus Flexor hallucis longus

Tibialis posterior Nerve Supply: Tibial nerve Generalities of Leg Compartments Anterior Deep peroneal nerve Dorsiflexors of the foot Lateral Superficial peroneal nerve Plantar flexors Posterior Tibial nerve Plantar flexors Peroneus vs Tibialis Muscle 2nd letter rule Peroneus muscles Everts foot Plantar flex Tibialis muscles Inverts foot Plantar flex Muscle on the Dorsum of the Foot  Extensor digitorum brevis  Origin ▪ Calcaneum  Insertion ▪ Four tendons into the proximal phalanx of the big toe (sometimes called extensor hallucis brevis) ▪ Long extensor tendons into 2nd,3rd, 4th toes  Action ▪ Extends 1st, 2nd,3rd, 4th toes  Innervation ▪ Deep peroneal nerve Sole of foot Deep fascia Plantar aponeurosis Foot arches (3) Medial longitudinal arch Calcaneonavicular (spring) ligament Lateral longitudinal arch Transverse arch Muscles of the Sole First layer Abductor hallucis MPN Flexor digitorum brevis MPN Abductor digiti minimi LPN Second layer Lumbricals 1MPN, 234LPN Quadratus plantae LPN Muscles of the Sole  Third layer  Flexor hallucis brevis MPN  Adductor hallucis LPN  Flexor digiti minimi brevis LPN  Fourth layer  Tibialis posterior TN  Interossei LPN 4 dorsal 3 plantar  Peroneus longus SPN Arches of the Foot Median longitudinal - largest - most important Lateral longitudinal Transverse Mechanism of Arch Support Shape of the stone Inferior edges tied together Tie beam Suspension bridge Femoral Artery  Continuation of the external iliac artery

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Begins:  

behind inguinal ligament Midway between anterosuperior iliac spine and symphisis pubis (“femoral pulse”)  Descends through femoral triangle and adductor canal,  Enters popliteal space as popliteal artery Femoral Artery Branches MNEMONIC: Six Sweet Sexy Ladies Put My Pants Down Daily Superficial circumflex iliac Superficial epigastric Superficial external pudendal Lateral femoral circumflex Profunda femoris Medial femoral circumflex Perforators Deep external pudendal Descending genicular Arterial Anastomoses Trochanteric Anastomosis Superior gluteal Lateral femoral circumflex Inferior gluteal Medial femoral circumflex Cruciate Anastomosis Medial femoral circumflex Inferior gluteal Lateral femoral circumflex First perforating branch of profunda brachii Popliteal artery Continuation of femoral artery Opening of adductor magnus to lower border of popliteus muscle Divides into anterior and posterior tibial arteries Anastomosis around the knee  Descending genicular artery  Lateral femoral circumflex artery  Popliteal artery  Anterior tibial artery  Posterior tibial artery Anterior tibial artery  From bifurcation of tibial artery  Passes forward between tibia and fibula through the upper part of the interosseous membrane  Enters anterior compartment of leg  Descends with deep peroneal nerve  front of ankle, becomes dorsalis pedis artery Anterior tibial artery “Anterior tibial pulse”  Ankle, midway between malleoli,  Medially: Tendon of extensor hallucis longus  Laterally: Tendons of extensor digitorum longus Dorsalis pedis artery  Begins front of ankle, continuation of anterior tibial artery  Ends entering sole through proximal part of space between 1st and 2nd metatarsal bones  Joins lateral plantar artery, completes plantar arch Dorsalis pedis arteries Branches Lateral tarsal artery Dorsum of foot Arcuate artery Laterally across bases of metatarsal bones, gives off branches to the toes First dorsal metatarsal artery Both sides of big toe Dorsalis pedis artery “dorsalis pedis pulse” Laterally: tendons of extensor digitorum longus Medially: tendon of extensor hallucis longus Posterior tibial artery  From bifurcation of popliteal artery in politeal fossa  Descends in posterior compartment of the leg  Accompanied by tibial nerve  Artery terminates behind medial malleolus

Medial and lateral plantar arteries “posterior tibial pulse” ▪ Between medial malleolus and heel Posterior tibial artery Branches Peroneal artery - Largest branch Muscular branches Nutrient artery Anastomotic branches Posterior tibial artery Terminal branches Medial plantar artery Smaller than lateral plantar artery Forward along medial border of foot with medial plantar nerve Posterior tibial artery Terminal branches Lateral plantar artery Larger Forward, deep to abductor hallucis and flexor digitorum brevis With lateral plantar nerve End curving medially to form lateral plantar arch Perforating arteries Metatarsal artereis Digital arteries Dorsal venous network Dorsum of foot Drained Medially: great saphenous vein Laterally: small saphenous vein Great saphenous vein  Ascends in front of medial malleolus  Accompanied by saphenous nerve  Ascends in leg in superficial fascia  Passes behind knee  Curves around medial side of thigh passes through saphenous opening in deep fascia  Joins femoral vein Great saphenous vein  Posseses numerous valves  Connected to  Small saphenous vein ▪ by branches passing behind the knee  Deep veins ▪ Via perforating veins, medial side of calf  Tributaries  Superficial circumflex iliac vein  Superficial epigastric vein  Superficial external pudendal vein Small saphenous vein  From lateral side of dorsal venous network of foot  Ascends behind lateral malleolus  Accompanies sural nerve  Passes up back of leg, pierces deep fascia entering popliteal fossa  Drains into popliteal vein Venae commitantes Deep veins accompanying respective arteries Deep veins of anterior and posterior tibial arteries unite to for popliteal vein Popliteal vein  Formed by union of anterior and posterior tibial arteries venae comitantes  End by passing through opening of adductor magnus to become femoral vein  Receives many tributaries including from small saphenous vein Femoral vein  Continuation of popliteal vein through opening of adductor magnus  Ascends through adductor canal and femoral triangle  Accompanied by femoral artery  Ascends behind inguinal ligament  Continous with external iliac vein  

 Receives great saphenous vein Superficial inguinal nodes In superficial fascia below inguinal ligament Drain into deep inguinal nodes  Horizontal group  Superficial lymph vessels ▪ anterior abdominal wall below umbilicus ▪ Perineum ▪ External genitalia (not testes) ▪ Lower half of anal canal ▪ Skin of buttocks Superficial inguinal nodes Vertical group Lies along terminal part of great saphenous vein Receives most of the superficial lymph vessels of lower limb EXCEPT back and lateral side of calf Lateral side of foot (Popliteal nodes) Deep inguinal nodes  Usually three (3) in number  Along medial side of femoral vein  In femoral canal  Receive all lymph from  superficial inguinal nodes and  deep structures of lower limb  Drain into external iliac nodes Popliteal lymph nodes  Situated in the popliteal fossa  Receive superficial lymph vessels accompanying small saphenous vein  Drain lateral side of foot  Back and lateral side of calf  Drain into deep inguinal nodes Nerves of the lower limb Femoral nerve Obturator nerve Sciatic nerve Tibial nerve Common peroneal nerve Femoral nerve Lumbar plexus L2-L3-L4 Enters thigh behind inguinal ligament Lies lateral to femoral vessels Terminates into anterior and posterior divisions Femoral nerve, branches  Cutaneous branches  Medial cutaneous nerve of thigh ▪ Skin on medial side of thigh  Intermediate cutaneous nerve of thigh ▪ Skin on anterior side of thigh  Saphenous nerve ▪ Infrapatellar branch to skin ▪ Skin on medial side of leg ▪ Skin on medial side of foot as far as ball of big toe Obturator nerve Lumbar plexus L2-L3-L4 Lateral side of pelvis to reach obturator canal Upper part of obturator foramen Divides into anterior and posterior divisions Sciatic nerve  From sacral plexus  L4-L5-S1-S2-S3  Passes through greater sciatic foramen  Below piriformis  Covered by gluteus maximus  Posterior compartment of thigh  Divides into  Tibial nerve and  Common peroneal nerve Tibial nerve Descends through popliteal fossa

Posterior compartment of leg Deep to gastrocnemius and soleus Divides into medial and lateral plantar nerves Tibial nerve, branches Cutaneous branches Sural nerve Skin on calf Skin on back of leg Lateral border of foot Lateral side of little toe Medial calcaneal nerve Skin over medial side of heel Tibial nerve, branches  Medial plantar nerve (deep to hallucis muscle w/ medial plantar artery)  Cutaneous branch ▪ Medial part of sole ▪ Medial 3.5 toes and nail beds  Muscular branch ▪ Abductor hallucis ▪ Flexor digitorum brevis ▪ Flexor hallucis brevis ▪ First lumbrical Tibial nerve, branches  Lateral plantar nerve (deep to abductor hallucis, flexor digitorum brevis, w/ lateral plantar artery)  Cutaneous branch ▪ Lateral part of sole ▪ Laterl 1.5 toes and nail beds  Muscular branch  Flexor digitorum accessorius  Abductor digiti minimi  Flexor digiti minimi brevis  Adductor hallucis  Interosseous muscles  2nd, 3rd, 4th lumbricals Common peroneal nerve Through popliteal fossa Laterally around neck of fibula Piercing peroneus longus Divides into Superficial peroneal nerve Deep peroneal nerve Lower Limb Nerve Injuries Femoral nerve lesions Stab Gunshot wounds Pentrating injuries Quadriceps paralyzed No knee extension Sensory loss Medial side of lower part of leg Medial border of foot at far as ball of the big toes Obturator Nerve Rarely injured in penetrating injuries Behing the floor of femoral triangle Compressed in: Anterior hip dislocations Parturition Obturator hernia Howship’s Romberg Sign - paresthesia of medial aspect of the thigh - paralysis of adductor muscles except adductor magnus portion Sciatic Nerve Sciatic nerve lesion  Badly placed intramuscular injections in gluteal region  Fracture dislocations of hip  Hamstring muscle paralysis  Weakend knee flexion  All muscles below knee, paralyzed  “FOOT DROP”

Weight of foot causes it to assume a plantar flexed position Loss of skin sensation below the knee, Except for ▪ narrow part of leg ▪ Medial border of the foot as far as the ball of the big toe 

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Sciatica Pain along the distribution of sciatic nerve posterior thigh posterior and lateral sides of leg lateral side of foot Compressed by herniated nucleus pulposus intrapelvic tumor/inflammation Common Peroneal Nerve Exposed at the area of the neck of fibula Fractures, casts, splints

Anterior and lateral compartment muscles paralyzed Talipes Equinovarus deformity Foot is Plantar flexed and Inverted Tibial Nerve Rarely injured in penetrating injuries Deep to gastrocnemius and soleus Talipes Calcaneovalgus deformity “clubfoot” Foot is Dorsiflexed - Everted Tendon Reflexes MNEMONIC: 1-2 buckle my shoe S1S2 3-4 kick the door L3L4 5-6 pick-up sticks C5C6 7-8 shut the gate C7C8 THE END