Anatomy, 1

Long bones

Anatomy, 2

-longer than they are wide

-clavicle, humerus, radius, ulna, femur, tibia, fibula, metacarpals
and phalanges
-develop by replacement of hyaline cartilage plate
-have a shaft (diaphysis) and two ends (epiphyses):
-Diaphysis = central region, thick collar of compact bone
surrounded by periosteum, contains marrow cavity
-Epiphyses = made of trabecular bony meshwork surrounded by
a thin layer of compact bone; have articular surfaces covered by
hyaline cartilage

Anatomy, 3

1. Short bones

2. Flat bones

Anatomy, 4

1.
-found only in wrist and ankle, ~cuboidal-shaped
-composed of spongy bone and marrow surrounded by thin outer
layer of dense compact bone
2.
-include ribs, sternum, scapulae and bones in vault of skull
-consist of 2 layers of compact bone separated by spongy bone
and marrow space (diploe)

Anatomy, 5

-grow by replacement of connective tissue

1. Irregular bones

2. Sesamoid bones

Anatomy, 6

1.
-bones of mixed shapes (skull, vertebrae, coxal bones)
-contain mostly spongy bone enveloped by a thin outer layer of
dense compact bone
2.
-develop in certain tendons

Anatomy, 7

-reduce friction on tendon (protect it from excessvie wear)

-found where tendons cross ends of long bones in limbs and
wrist

1. Hiltons Law

Anatomy, 8

2. Joints

1.
-the nerve supplying a joint also supplies the muscles that move
the joint and the skin covering the insertion of such muscles
2.

Anatomy, 9

-classifed on the basis of the structural features into a)fibrous, b)

cartilagionus, and c) synovial types

Fibrous joints

Anatomy, 10

-also called synarthroses

-Two types:

Anatomy, 11

a) Sutures connected by fibrous conn tissue, found

between flat bones of skull
b) Syndesmoses connected by fibrous conn tissue,
occur as inferior tibiofibular and tympanostapedial
syndesmoses

Anatomy, 12

Cartilagionous joints (two types)

Anatomy, 13

a) Synchondroses (Primary Cartilaginous Joints)

a. United by hyaline cartilage
b. Permit NO movement, only growth in bone length
c. Include epiphyseal cartilage plates (union between
epiphysis and diaphysis) and spheno-occipital and
manubriaosternal joints
b) Symphyses (Secondary Cartilaginous joints)
a. Joined by plate of fibrocartilage, slightly movable
b. Include pubic symphysis, intervertebral discs

Anatomy, 14

Synovial joints

Anatomy, 15

-also called Diarthrodial joints

-permit great degree of free movement
-characterized by 4 features:
a) joint cavity
b) articular cartilage
c) synovial membrane (produces synovial fluid)
d) articular capsule
-classified according to axes of movement in to 1. plane, 2.
hinge, 3. pivot, 4. ellipsoidal, 5. saddle, 6. ball-and-socket

Anatomy, 16

1.Plane joints

2. Hinge (ginglymus) joints

Anatomy, 17

1.
-allow gliding or sliding movement between 2 flat surfaces
-occur in proximal tibiofibular,intercarpal, intermetacarpal,
carpometacarpal, and acromioclavicular joints
2.
-1O of freedom
-allow flexion and extension only

Anatomy, 18

-occur in elbow, knee, ankle, and interphalangeal joints

3. Pivot (trochoid) joints

Anatomy, 19

4.Elliposidal (condyloid joints)

3.
- central bony pivot rotates w/in a bony ring
-allow rotation only (1O of freedom)
-occur in sup and inf radioulnar joints, joint between 1st and 2nd
cervical vertebrae (atlanto-axial)

Anatomy, 20

4.
-2O of freedom
-allow flexion/extenstion and abduction/adduction
-occur in wrist (radiocarpal) and metacarpophalangeal joints

5. Saddle (sellar) joints

Anatomy, 21

6. Ball-and-Socket (spheroidal) joints

5.
-have 2O of freedom
-allow movement in several directions but less movements of
flex/ext, abd/add, and rotation than ball-and-socket

Anatomy, 22

-occur in carpometacarpal joint of thumb

6.
-multiaxial, have 3O of freedom, greateset freedom of motion
-allow flex/ext, abd/add, med & lat rotation, and circumduc.
-occur in shoulder and hip joints

Skeletal muscle: insertion vs. origin

Anatomy, 23

-origion is usually the more fixed and proximal attachment

-insertion is the more movable and distal attachment

Anatomy, 24

Anatomy, 25

1. Bursa
2. Synovial tendon sheaths

Anatomy, 26

1.
-flattened sac of synovial membrane containing viscid fluid to
moisten its wall in order to help movement by friction
-found where tendon rubs against bone, ligament or tendon
-prone to fill w/fluid when infected or injured
2.
-sacs wrapped around tendons, similar to bursae
-occur where tendons pass under ligaments, retinacula
-responds to infection by fluid and cells, causing adhesions
and thus restriction of movement of the tendon

Anatomy, 27

Spinal Cord

Anatomy, 28

-occupies ~ 2/3 of vertebral canal

-has cervical and lumbar enlargements for limbs
-has conical end known as conus medularris
-grows more slowly than vertebral column during fetal
development
-ends at level of L2 (or betwee L1 and L2) in adult and at level
of L3 in newborn

Anatomy, 29

Spinal nerves

Anatomy, 30

-have 31 pairs: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1

coccygeal
-formed from dorsal and ventral roots
-each dorsal root has ganglion within intervertebral foramen
-connected w/sympathetic chain ganglia by rami communica
-divided into ventral and dorsal primary rami

Anatomy, 31

-ventral primary rami enter into formatio of plexuses (cervical,

brachial, and lumbosacral)
-dorsal primary rami innervate skin and deep muscles of back

Vertebral column

Anatomy, 32

-consists of 33 vertebrae: C1-7, T1-12, L1-5, S1-5, Co1-4

-primary curves: thoracic and sacral curvatures that form during
the featal period
-secondary curves: cervical and lumbar curvatures that form
after birth as result of lifting the head and walking, respectively

Anatomy, 33

1. Epidural space

Anatomy, 34

2. Cauda equina
3. Filum terminale
4. Filum of dura mater

1.Lies between the vertebrae and dura; contains fat, connective

tissue, and the internal vertebral venous plexus

Anatomy, 35

2.Bundle of nerve roots of lumbar and sacral spinal nerves

below the termination of the spinal cord
3.Fibrous strand covered by pia mater, extends to end of dural
sac at S2; blends into the filum of dura mater
4.Passes thru sacral canal,exits thru sacral hiatus, and inserts
onto dorsum of coccyx

1. Kyphosis

Anatomy, 36

2.Lordosis
3.Scoliosis

Anatomy, 37

1. Exaggeration of thoracic curvature; can occur in aged due

to osteoporosis or disc degeneration
2. Exaggeration of lumbar curvature; can occur as result of
pregnancy, spondylolisthesis, or potbelly
3. Complex lateral deviation/torsion; can be caused by
poliomyelitis, a short leg, or hip disease

Anatomy, 38

1.Atlanto-occipital joints

2.Atlantoaxial joints

Anatomy, 39

1. Between C1 (atlas) and occipital condyles

-nods head
-synovial, have NO intervertebral disc
-anterior and posterior atlanto-occipital membranes limit
excessive movement at this joint
2. Between C1 (atlas) and C2 (axis)
-turns head side to side
-synovial, have NO intervertebral disc
-alar ligaments limit excessive movement at this joint

Anatomy, 40

1.Dens

2.Atlantoaxial dislocation

Anatomy, 41

1.
-secured in position by the cruciform, alar, and apical ligamentes
and by the tectorial membrane (continuation of posterior
longitudinal ligament)
2.
-rupture of the cruciform (transverse) ligament due to trauma or
rheumatoid arthritis

Anatomy, 42

-allows mobility of the dens (part of axis) w/in vertebral canal

-places cervical spinal cord and medulla at risk

1.Facet joints

Anatomy, 43

2.Denervation of facet joints

1.
-synovial joints between inf and sup articular facets
-located near the intervertebral foramen

Anatomy, 44

2.
-trauma or disease (rheumatoid arth.) of facet joints may result
in impinging of spinal n., causing severe pain
-to relieve pain: medial branches of dorsal primary ramus are
severed (thus denervation of facet joints)

Intervertebral disc

Anatomy, 45

-consists of annulus fibrosus (fibrocartilage) and nucleus

pulposus (remnant of embryonic notochord)

Anatomy, 46

-nuc pulposus generally herniates in a posterior-lateral direction

and compresses a nerve root
-ex. herniated disc between C4 and C5 C5 nerve root is
compressed affecting dermatome of shoulder and lateral
aspect of arm, deltoid m. abduction of arm is weak, biceps
jerk reflex affected
(pg. 4, High Yield Gross, chart on herniated discs)

1.Dislocations without fracture

Anatomy, 47

2.Dislocations with fracture

Anatomy, 48

1. Occur ONLY in cervical region b/c articular surfaces are

inclined horizontally
-cervical dislocations stretch posterior long. Ligament

2. Occur in thoracic and lumbar region b/c articular surfaces

are inclined vertically

Anatomy, 49

1. What does hyperextension of the neck (whiplash) stretch?

2. Hemivertebrae

Anatomy, 50

1. the anterior longitudinal ligament

2. Occurs when a portion fo the vertebral body fails to

develop, can lead to scoliosis

Anatomy, 51

1. Where does a route of metastasis for breast, lung, and

prostate cancer to the brain exists?

2. Spina bifida occulta

Anatomy, 52

1. At the internal and external vertebral venous plexuses

since they communicate with the cranial dural sinuses and
veins of thorax, abdomen, and pelvis
2. Common congenital malformation where vertebral arch is
absent
-the defect is covered by skin and usually is marked by a
tuft of hair
-is NOT associated with any neurological deficit

Anatomy, 53

1. What characteristic of vertebrae is associated with sickle

cell anemia?

2. Osteomyelitis

Anatomy, 54

1. H-type vertebra (as observed radiographically) in which

central depressions occur in the vertebral body

2. Bacterial infection that may occur within vertebrae

Anatomy, 55

-causative agents: tuberculosis and Staph. Aureus

1. Spondylolisthesis
2. Spondylolysis

Anatomy, 56

3. Ankylosing spondylitis

1. When pedicles of lumbar vertebra fail to develop properly

body of vertebra thus moves anteriorly, causing a lordosis
2. Fracture of lamina between inf and sup articular processes
w/in a lumbar vertebra

Anatomy, 57

3. Inflam arthritis affecting lumbar vertebrae,sacroiliac joint

-annulus fibrosus may become ossified this ossification
bridges discs at various levels forming a bamboo spine
-majority of these pts are positive for histocompatibility antigen
HLA-B27

Reference points (w/respect to vertebral levels):

1. Sacral promontory
2. Hyoid bone, bifurcation of common carotid artery
3. Thyroid cartilage

Anatomy, 58

4. Sternal notch
5. Sternal angle, bifurcation of trachea
6. IVC hiatus
7. Esophageal hiatus
8. Aortic hiatus
9. Umbilicus
10.Bifurcation of aorta, iliac crest
1. The anterior edge of S1; imp obstetrical landmark
2. C4
3. C5

Anatomy, 59

4. T2
5. T4
6. T8
7. T10
8. T12
9. L3
10.L4
(for others, see pg. 5, Table 1-2 in High Yield Gross)

Denticulate ligaments

Anatomy, 60

-lateral extensions of pia mater

Anatomy, 61

-attach to the dura mater, thereby suspend spinal cord within the
dural sac

Anatomy, 62

Vascular Supply of Spinal Cord

Anatomy, 63

a). Anterior spinal artery arises from vertebral arteries and

supplies ventral 2/3 of spinal cord; majorly contributed to by the
great radicular artery
b). Posterior spinal arteries arise from vertebral arteries or
PICAs and supply dorsal 1/3 of spina lcord
c). Radicular arteries arise from vertebral, deep cervical,
ascending cervical, posterior intercostal, lumbar and lateral
sacral aa.; enter the vertebral canal thru intervertebral foramina
and branch into ant and post radicular arteries

Anatomy, 64

Great radicular artery

Anatomy, 65

-generally arises on the LEFT side from a posterior intercostal

artery or lumbar artery
-clinically imp b/c a) it makes a major contribution to the
anterior spinal artery and b) is the main blood supply to the
lower part of the spinal cord
-if it is ligated during resection of an aortic aneurysm, pt may
become paraplegic, impotent, and lose voluntary control of the
bladder and bowel

Anatomy, 66

Epidural (caudal) anesthesia

Anatomy, 67

-used to relieve pain during childbirth labor

-anesthetic is injected into sacral canal via the sacral hiatus,
which is marked by the sacral cornua
-anesthetic diffuses thru dura mater and arachnoid to enter CSF
where it bathes the cauda equina

Anatomy, 68

Lumbar puncture

Anatomy, 69

-done to withdraw CSF OR inject anesthetic (spinal block)

-a needle is inserted above or below the spinous process of L4
-needle passes thru the:
1. skin
2. superficial fascia
3. supraspinous ligament

Anatomy, 70

4. interspinous ligament
5. ligamentum flavum
6. epidural space (containing int vert ven plexus)
7. dura mater
8. subdural space
9. arachnoid (Pia is NOT pierced)
10.Subarachnoid space CSF

Transection of the spinal cord

Anatomy, 71

-results in loss of sensation and motor function below the lesion

-Paraplegia occurs if transection occurs anywhere between the
cervical and lumbar enlargements of cord
-Quadriplegia occurs if transection occurs above C3

Anatomy, 72

-may die quickly due to respiratory failure if phrenic

nerve is compromised

Vertebral levels of a herniated disc:

Anatomy, 73

Compressed nerve root, dermatome and muscles affected,

movement weakness, and reflex involved

Herniated
between

Cmp
root

Dermatome
affected

Muscles
affected

Movement
weakness

Reflex
involved

Anatomy, 74

C4 and C5

C5

C5 shoulder &
lateral arm

Deltoid
Biceps

C5 and C6

C6

C6 and C7

C7

L4 and L5

L5

L5 and S1

S1

C6 lateral arm,
forearm, thumb
C7 posterior arm,
forearm, middle
finger
L5 lateral thigh,
leg, dorsum of foot

S1 post thigh,
leg, lateral foot

Extensor carpi
radialis longus
Flexor carpi
radialis
Triceps
Tibialis anter
Ext hallucis
longus
Ext digitorum
longus
Gastrocnemius
Soleus

Abduction of
arm
Flexion of
forearm
Extension of
wrist
Flex of wrist
Ext of elbow
Dorsiflexion
of ankle
Extension of
toes
Plantar flex
of ankle

Biceps
jerk
Biceps
jerk
Triceps
jerk
None

Ankle jerk

Anatomy, 75

Dermatomes

-strips of skin extending from posterior midline to the anterior

midline that are supplied by cutaneous branches of dorsal and
ventral rami of spinal nerves

Anatomy, 76

-clinical finding of sensory deficit in a dermatome is imp in

order to assess which spinal nerve, nerve root, or spinal cord
segment may be damaged
-see Table 1-3, pg. 11 of High Yield Gross

Anatomy, 77

Breast

-located in the superficial fascia of anterior chest wall overlying

pectoralis major and serratus anterior muscles

Anatomy, 78

-extends into axilla, where high % of tumors occur

-in women extends: vertically from rib 2 to rib 6, laterally from
sternum to midaxillary line
-adipose tissue w/in it contributes largely to its contour & size
-glandular tissue (mammary gland) modified sweat gland
consisting of acini, which are drained by 15-20 lactiferous ducts
that open onto nipple
-just deep to nipple, each lactiferous duct expands into
lactiferous sinus (reservoir for milk during lactation)

Anatomy, 79

1.Retromammary space

2.Suspensory (Coopers) ligaments

Anatomy, 80

1
-lies between breast and pectoral (deep) fascia, allows free
movement of breast
-if it and pectoral fascia are invaded by breast carcinoma,
contraction of pectoralis major may cause whole breast to move
superiorly
2.
-extend from dermis to pectoral fascia, provide support
-if invaded by breast carcinoma, ligaments may shorten and
cause dimpling of skin or inversion of nipple

Anatomy, 81

Breast:
1. Arterial supply
2. Venous drainage
3. Lymphatic drainage
4. Innervation

Anatomy, 82

1. Internal thoracic, lateral thoracic, and intercostal aa.

2. Chief: axillary vein
-also drained by internal thoracic, lateral thoracic, and
intercostal veins
3. Chief: axillary nodes
-also by parasternal, clavicular and inguinal nodes
4. Intercostal nerves 2-6 (T2 T6 dermatomes)

Anatomy, 83

1. How may metastasis of breast carcinoma to the brain

occur?
2. How does breast carcinoma cause a thick leathery skin?

Anatomy, 84

3. What nerve must be preserved during a mastectomy?

1. Cancer cells enter an intercostal vein vertebral venous
plexuses cranial dural sinuses
2. By blocking lymph flow

Anatomy, 85

3. long thoracic nerve; damage to it paralyzes serratus

anterior muscle, causing winged scapula

Insertion of a right subclavian venous catheter

Anatomy, 86

-needle is inserted at inferior border of clavicle just lateral to

midclavicular line
-needle angled toward sternoclavic. joint (T2) and penetrates:
-skin
-superficial fascia
-subclavius muscle

Anatomy, 87

-Clavipectoral fascia
-anteiror scalene m. and right subclavian a. are located posterior
to right subclavian vein in this area
-improper insertion of catheter may tear subclavian v. and/or
subclavian a. hemothorax (blood in right pleural space)

Thoracostomy

Anatomy, 88

-may be necessary to drain fluid out of pleural cavity by

inserting a needle thru intercostal space 4 in midaxillary line
-needle penetrates:
-skin, superficial fascia

Anatomy, 89

-serratus anterior m., external intercostal m., internal

intercostal m.
-innermost intercostal m.
-parietal pleura
-needle should be inserted close to upper border of rib to avoid
intercostal vein, artery and nerve (VAN) which run in costal
groove between internal and innermost intercostal mm.
Intercostal nerve block and intercostal nerve innervation

Anatomy, 90

-relieves pain associated w/rib fracture, herpes zoster

Anatomy, 91

-needle is inserted at posterior angle of rib along lower border of

rib in order to bathe nerve in anesthetic
-several intercostal nn. must be blocked for pain relief b/c of
presence of nerve collaterals (i.e.overlapping of dermatomes)
-Supraclav nn. (C4, C5 derm) chest wall above sternal angle
-Intercost nn 1,2 (T1, T2 derm) chest wall and upper limb
-Intercost nn 3-6 (T3-6 derm) chest wall
-Intercost nn 7-11 (T7-11 derm) chest wall, abdominal wall
-Subcostal n (T12 derm) follows lower border of rib 12,
supplies abdominal wall and upper inguinal region
-Level of nipple T4 dermatome
-Level of umbilicus T10 dermatome

Anatomy, 92

Where may an aneurysm of the aorta appear in the thorax?

Anatomy, 93

1. In the sternal notch (T2) b/c the arch of the aorta lies behind
the manubrium

Anatomy, 94

Coarctation (constriction) of the aorta

Anatomy, 95

1. Congenital malformation associated w/:

blood pressure to the upper extremities
Lack of femoral artery pulse
High risk of cerebral hemorrhage
High risk of bacterial endocarditis
2. Generally located distal to the left subclavian artery and inferior to the
ligamentum arteriosum
3. Arteries involved in collateral circulation to bypass constriction and
thus become dilated:
Internal thoracic

Anatomy, 96

Intercostal erosion of lower border of the ribs (rib notching)

Superior epigastric
Inferior epigastric
External iliac arteries

Boundaries of parietal pleura (pleural reflections)

Anatomy, 97

1. Right-side reflection extends:

From the sternoclavicular joint to anterior midline at sternal angle

(T4), where the 2 pleural sacs come into contact and may overlap
Inferiorly to the xiphoid process, where pleura extends beyond the
rib cage at the infrasternal notch
Laterally across rib 8 at the MCL and rib 10 at the midaxillary line
Posteriorly across rib 12 at its neck

2. Left-side reflection extends:

Anatomy, 98

From the sternoclavicular joint to the anterior midline at the sternal

angle (T4)
Inferiorly to costal cartilage 4 and lateraly to costal cartilage 6
(cardiac notch)
Laterally across rib 8 at the MCL and rib 10 at the midaxillary line
Posteriorly across rib 12 at its neck
(picture: pg. 22, High Yield)
Pleural recesses

Anatomy, 99

1. Right and left costodiaphragmatic recesses

Slit-like spaces between costal and diaphragmatic parietal pleura

During inspiration
o Lungs descend into recesses radiolucent (dark) on x-ray film
During expiration
o Lungs ascend so that parietal pleura come together radiolucency
disappears on x-ray

Anatomy, 100

Excess fluid within pleural cavity accumulates here w/pt standing

2. Right and left costomediastinal recesses

Slit-like spaces bewteen costal and mediastinal parietal pleura

During inspiration
o Anterior borders of both lungs expand and enter recceses
o Lingula of left lung expands and enters a portion of left recess
portion of recess radiolucent (dark) on x-ray
During expiration
o Anterior borders of both lungs recede and exit recesses

Pleuritis

Anatomy, 101

1. Inflammation of the pleura

2. If involves only the visceral pleura
NO pain b/c visceral pleura receives no nerve fibers of general
sensation
3. If involves parietal pleura

Anatomy, 102

Sharp local PAIN

Referred PAIN to thoracic and abdominal wall b/c parietal pleura is
innervated by intercostal nerves
Referred PAIN may also be felt at root of neck and shoulder b/c
mediastinal and central part of diaphgramatic parietal pleura are
innervated by the phrenic nerve (C3, C4, C5)

Pneumothorax

Anatomy, 103

1. Spontaneous pneumothorax
Occurs when air enters pleural cavity usually due to a ruptured bleb
(bullus) of a diseased lung

Anatomy, 104

2. Open pneumothorax
Occurs when parietal pleura is pierced (e.g. knife wound) and
pleural cavity is opened to outside atmosphere
Upon inspiration air is sucked into pleural cavity
3. Tension pneumothorax
May occur as a sequela to an open pneumothorax if inspirated air
cannot leave the pleural cavity thru the wound upon expiration
Result collapsed lung on wounded side and a compressed luing
on opposite side due to a deflected mediastinum

Anatomy, 105

The Right and Left Lungs: Components

1. Right lung

Anatomy, 106

Consists of 3 lobes (upper, middle, lower) separated by a

horizontal fissure and an oblique fissure
Diaphragmatic surface consists of middle and lower lobes
2. Left lung
Consists of 2 lobes (upper, lower) separated by an oblique fissure
Upper lobe
o Contains the cardiac notch (where L ventricle abut lung)
o Just beneath notch lies the lingula (embryological counterpart
to the right middle lobe)
Diaphragmatic surface consists of the lower lobe

Anatomy, 107

Bronchopumonary segments

Anatomy, 108

1. Correspond to the branching of segmental bronchi (main bronchi

lobar bronchi segmental bronchi bronchopulmonary segments)
2. Particularly variable within the lower lobes of both lungs
3. Contains:
A segmental bronchus
A branch of the pulmonary artery
A branch of the bronchial artery
4. Tributaries of the pulmonary vein are found at the periphery between 2
adjacent segments
Form surgical landmarks during resection of the lung

Anatomy, 109

What lung diseases cause destruction of lung elasticity? Of lung

distensibility?

Anatomy, 110

1. Emphysema and Pulmonary fibrosis destruction of lung elasticity

Lungs thus are unable to recoil adequately, causing incomplete expiration

Consequently, the following must assist in expiration:
-Rectus abdominis
-Transversus abdominis
-Serratus posterior inferior

-Ext and int obliques

-Internal intercostal

Chronic emphysema may be associated w/an retrosternal air space,

anterior-posterior diameter of chest wall, and flattening of diaphragm

2. Silicosis, cancer, pneumonia destruction of lung distensibility

Lungs thus unable to expand fully upon inspiration

Conseqeuntly, the following must work harder to inspire:

Anatomy, 111

-Diaphragm
-SCM
-Serratus anterior and posterior
-Pec major and minor

Metastasis of bronchogenic carcinoma

-Ext intercostal
-Levator scapulae
-Scalenes
-Erector spinae

Anatomy, 112

1. Lymphatic metastasis via tracheobronchial (mediastinal),

parasternal and supraclavicular nodes
Enlargement of mediastinal nodes may indent the esophagus
observed during a barium swallow
Enlargement of supraclavicular nodes indicates possibility of
malignancy in thoracic OR abdominal organs
2. Arterial blood metastasis to the brain may occur by following route:
Cancer cells enter a lung capillary pulmonary vein left atrium
and ventricle aorta internal carotid and vertebral arteries
3. Venous blood metastasis to the brain may occur by following route:

Anatomy, 113

Cancer cells enter bronchial vein azygous vein vertebral

venous plexuses cranial dural sinuses

Transverse sinus
Oblique sinus

Anatomy, 114

1. Transverse sinus
Recess of the pericardial cavity
After sac is opened, surgeon can pass a finger or ligature thru it
between the great arteries and pulmonary veins
2. Oblique sinus
Recess of pericardial cavity
Ends in a cul-de-sac surrounded by pulmonary veins

Anatomy, 115

Pericardiocentesis

Anatomy, 116

1. Removal of fluid from the pericardial cavity

2. Can be approached in 2 ways:
Sternal approach
o Needle is inserted at intercostal space 5 or 6 on the left near sternum.
(cardiac notch leaves the fibrous pericardium exposed at this site)
o The needle penetrates the following layers:

Anatomy, 117

Skin Superficial fascia Pec major muscle Ext intercostal

Int intercostal Transverse thoracic muscle Fibrous pericardium
Parietal layer of serous pericardium

o Risk: Internal thoracic artery, coronary arteries, pleura

Subxiphoid approach
o Needle is inserted at L infrasternal angle in a sup & post position
o The needle penetrates the following layers
Skin & Superficial fascia Anterior rectus sheath Rectus
abdominis muscle Transverse abdominis muscle Fibrous
pericardium Parietal layer of serous pericardium

Risk: diaphragm and liver (if needle isnt angled properly)

Blood supply and venous drainage of the heart

Anatomy, 118

1. Blood supply to the heart

Left coronary
artery

Circumflex artery
Anterior descending
(interventricular)

Left atrium
Left ventricle
Interventricular septum

Anatomy, 119

Right coronary
artery

Marginal artery
Posterior interventricular*
AV nodal artery
SA nodal artery

Right atrium & ventricle

Interventricular septum
AV node
SA node

2. Venous drainage of the heart

Vein
Travels with

Drains into

Great cardiac vein

Middle cardiac vein
Small cardiac vein
Anterior cardiac veins
Least cardiac veins

Coronary sinus
Coronary sinus
Coronary sinus
Right atrium
Nearest heart chamber

LAD
Posterior interventricular
Marginal artery

*Heart blood supply is right-side dominant if post interventric arises from right coronary
artery. Its lef-side dominant if post interventric arises from left coronary artery.

Paracentesis

Anatomy, 120

1. Uses a needle inserted thru abdominal wall to w/draw excess peritoneal fluid
2. Two approaches:
Midline approach - Kneedle or knife passes through:

Anatomy, 121

o
o
o
o
o
o

Skin
Superficial fascia (Campers and Scarpas)
Linea alba
Transversalis fascia
Extraperitoneal fat
Parietal peritoneum

Flank approach - Kneedle or knife passes through:

o
o
o
o
o
o
o
o

Skin
Superficial fascia (Campers and Scarpas)
External oblique muscle
Internal oblique muscle
Transverse abdominus muscle
Transversalis fascia
Extraperitoneal fat
Parietal peritoneum

Inguinal region

Knife wounds
to the
abdomen
penetrate these
same layers

Anatomy, 122

1.

Area of weakness from penetration of testes and spermatic cord (males) or round
ligament of uterus (females) during embryological development

Anatomy, 123

2.

Contents:
Inguinal ligament (lower border of aponeurosis of external oblique muscle)
o
Extends from anterior-superior iliac spine to pubic tubercle
Deep inguinal ring (oval opening in transversalis fascia)
o
Lateral to the inferior epigastric artery
Superficial inguinal ring (triangular defect in aponeurosis of ext oblique)
o
Lateral to the pubic tubercle
o
Transmits spermatic cord (males) or round ligament (females)
Inguinal canal
o
Begins at deep inguinal ring and ends at superficial ring
o
Transmits spermatic cord (males) or round lig (females) & ilioinguinal n.
o
Main components of canal walls:
Anterior aponeurosis of external and internal obliques
Posterior transversalis fascia, conjoint tendon
Roof internal oblique and transversus abdominus muscles
Floor inguinal ligament and lacunar ligament

Anatomy, 124

What are the following derived from?

1. Inguinal ligament
2. Conjoint tendon
3. Lacunar ligament
What is Hesselbachs (inguinal) triangle?

Anatomy, 125

1. Inguinal ligament aponeurosis of external oblique muscle

2. Conjoint tendon aponeuroses of internal oblique and transverse
abdominus muscles)
3. Lacunar ligament medial expansion of inguinal ligament
1. Hesselbachs triangle
Area of potential weakness and hence often the site of direct
inguinal hernia
Boundaries
o Lateral: inferior epigastric artery and vein
o Medial: rectus abdominus muscle
o Inferior: inguinal ligament

Anatomy, 126

Hernia characteristics

Anatomy, 127

Direct inguinal
hernia
Indirect
inguinal hernia

Femoral hernia

Protrudes directly thru the anterior abdominal wall

w/in Hesselbachs triangle
Protrudes medial to inf epigastric artery and vein
Common in older men; rare in women
Protrudes thru deep inguinal ring to enter the inguinal
canal and may exit thru superficial inguinal ring
Protrudes lateral to inf epigastric artery and vein
Protrudes above and medial to the pubic tubercle
Common in males, young adults, children
Most common
Protrudes thru femoral canal below inguinal ligament
Protrudes below and lateral to pubic tubercle
More common in females

Anatomy, 128

Scrotum: What is it and what will cancer of the scrotum vs. the testes
metastasize to?

Anatomy, 129

1. Scrotum is an outpouching in the lower abdominal wall whereby layers

of the abdominal wall continue into the scrotal area to cover the
spermatic cord and testes
2. Cancer of the scrotum metastasizes to superficial inguinal nodes
3. Cancer of the testes metastasizes to deep lumbar nodes

Anatomy, 130

The peritoneal cavity is divided into what? What connects these

compartments?

Anatomy, 131

1. Lesser peritoneal sac (omental bursa)

Forms due to 90O clockwise rotation of stomach during embryology

Boundaries:
o Anterior liver, stomach, lesser omentum
o Posterior diaphragm
o Right side liver
o Left side gastrosplenic and lienorenal (splenorenal) ligaments

2. Greater peritoneal sac

Remainder of peritoneal cavity

Extends from diaphragm to the pelvis
Contains pouches, recesses, paracolic gutters thru which fluid circulates
o Normally, peritoneal fluid flows upward thru gutters to the
subphrenic recess, where it enters the lymphatics with the diaphragm

Anatomy, 132

3. Epiploic (Winslows) foramen

Opening/connection between the 2 sacs

If you place finger in it, IVC lies posterior and portal vein lies anterior

Where will excess peritoneal fluid due to peritonitis or ascites flow?

Anatomy, 133

1. When the pt is sitting or standing:

Downward thru the paracolic gutters to the rectovesical pouch (in
males) or the rectouterine pouch (females)
2. When the pt is supine:
Upward thru the paracolic gutters to the subphrenic recess and the
hepatorenal recess
Pt may complain of shoulder pain (referred) b/c supraclavicular
nerves and phrenic nerves have same nerve root origins (C3-5)
The hepatorenal recess is the lowest part of the peritoneal cavity
when the pt is in the supine position

Anatomy, 134

Omentum

Anatomy, 135

1. Lesser omentum
Extends from porta hepatis of liver to the lesser curvature of the
stomach
Consists of the:
o Hepatoduodenal ligament
o Hepatogastric ligament
Portal triad lies in the free margin of the hepatoduodenal ligament
and consists of the:
o Portal vein posterior
o Common bile duct anterior and to the right

Anatomy, 136

o Hepatic artery anterior and to the left

2. Greater omentum
Hangs down from the greater curvature of the stomach

Intraperitoneal and extraperitoneal viscera

Anatomy, 137

Intraperitoneal
Stomach
Part 1 of duodenum
Jejunum
Ileum
Cecum
Appendix
Transverse colon

Extraperitoneal
Part 2, 3, 4 of duodenum
Ascending colon
Descending colon
Rectum
Head, neck, body of pancreas
Kidneys
Ureters

Anatomy, 138

Sigmoid colon
Liver
Gallbladder
Tail of pancreas
Spleen

Branches of the abdominal aorta

Suprarenal gland
Abdominal aorta
IVC

Anatomy, 139

dSuprarenal arteries
Renal arteries
Gonadal arteries
Celiac trunk (CT)
Left gastric artery
Splenic artery
Common hepatic artery

Visceral, paired
Visceral, paired
Visceral, paired
Visceral, unpaired

Suprarenal gland
Kidney
Testes, ovaries
Foregut derivatives:
Esophagus
Stomach
Duodenum
Liver
Gallbladder
Pancreas
Spleen*

Anatomy, 140
Superior mesenteric artery

Visceral, unpaired

Inferior mesenteric artery

Visceral, unpaired

Inferior phrenic arteries

Lumbar arteries**
Common iliac arteries
Median sacral artery

Parietal, paired
Parietal, paired
Parietal, paired
Parietal, unpaired

Midgut derivatives:
Small intestine
Cecum
Appendix
Ascending colon
Prox 2/3 of transverse colon
Hindgut derivates:
Distal 1/3 of transverse colon
Descending and sigmoid colon
Upper portion of rectum
Diaphragm
Body wall
Pelvis, perineum, leg
Body wall

What are the routes of collateral circulation in case the abdominal aorta is
blocked?

Anatomy, 141

1. Internal thoracic a. superior epigastric a. inferior epigastric a.

2. Superior pancreaticoduodenal a. (from celiac trunk) inferior
pancreaticoduodenal artery (from sup mesenteric artery)
3. Middle colic artery (from SMA) left colic artery (from IMA)

Anatomy, 142

4. Marginal artery (from SMA and IMA)

5. Superior rectal artery (from IMA) middle rectal artery (from internal
iliac artery)

Venous drainage of abdomen

Anatomy, 143

1. Azygos venous system

Azygos vein: ascends on R side of verteb column, drains blood from IVC to SVC
Hemiazygos vein: ascends on L side of the vertebral column, drains blood from
the L renal vein to the azygous vein

Anatomy, 144

2. IVC

Formed by union of the R and L common iliac veins at vertebral level L5

Drains all the blood from below the diaphragm to the right atrium
Drains the R gonadal and R suprarenal veins directly, whereas the L gonadal and
L suprarenal veins drain into the L renal vein

3. Hepatic portal system

Consists specifically of the following:

o
Capillary bed of the GI tract
o
Portal vein
o
Capillary bed of the liver (hepatic sinusoids)
Portal vein is formed posterior to neck of the pancreas by union of the splenic v.
& sup mesenteric vein (inf mesenteric vein usually ends by joining the splenic v)
Carries high levels of nutrients from the GI tract & products of RBC destruction
from the spleen

1. What may the appearance of a left testicular varicocele indicate?

Anatomy, 145

2. Routes of collateral circulation in case the IVC is blocked (e.g.,

malignant retroperitoneal tumors, large thrombi).
3. What, generally, does the term portal refer to?

1. What may the appearance of a left testicular varicocele indicate?

Anatomy, 146

Occlusion of the left testicular vein and/or left renal vein (caused by
a malignant tumor of the kidney, for example)
2. Routes of collateral circulation in case the IVC is blocked (e.g.,
malignant retroperitoneal tumors, large thrombi).
Femoral vein superficial epigastric vein lateral thoracic vein
axillary vein right atrium
Hemiazygos vein azygos vein SVC right atrium
Lumbar veins vertebral venous plexuses cranial dural sinsues
internal jugular vein right atrium
External iliac vein superior epigastric vein internal thoracic
vein brachiocephalic vein right atrium
3. What, generally, does the term portal refer to?

Anatomy, 147

A vein interposed between 2 capillary beds (e.g., capillary bed

vein capillary bed)

Portal-IVC (caval) anastomosis

Anatomy, 148

1. Becomes clinically relevant when portal HTN occurs

Portal HTN causes blood w/in portal vein to reverse its flow and
enter the IVC in order to return to the heart
2. Three main sites of portal-IVC anastomosis:
Site of
Veins involved in Portal-IVC
Anastomosis Clinical Sign
Anastomosis
Esophagus
Umbilicus

Esophageal
varices
Caput medusa

Rectum

Hemorrhoids

Left gastric vein esophageal vein

Paraumbilical vein superficial & inf
epigastric veins
Sup rectal vein middle & inf rectal veins

Anatomy, 149

1.
2.
3.
4.

What do G cells of the stomach secrete?

Describe the parasympathetic innervation of the stomach.
How may gastric ulcers be treated surgically?
Dumping syndrome

Anatomy, 150

1. What do G cells of the stomach secrete?

Gastrin stimulates HCl secretion from parietal cells

Found predominantly in the pyloric antrum

2. Describe the parasympathetic innervation of the stomach.

Parasymp innervation is via branches of the vagus (CN X), notably the
anterior and posterior nerves of Latarget, which run along the lesser
curvature of the stomach
Stimulates HCl secretion from parietal cells

3. How may gastric ulcers be treated surgically?

Surgical removal of pyloric antrum, which eliminates the hormonal

stimulation of HCl secretion

Anatomy, 151

Selective vagotomy of the nerves of Latarget, which eliminates the neural

stimulation of HCl secretion

4. Dumping syndrome

An abnormally rapid emtyping of the stomach contents

Usually follows partial gastrectomy or vagotomy

Describe the parts of the duodenum

Anatomy, 152

1. First (superior) part

Begins at pylorus (gastroduodenal junction), which is marked by prepyloric vein

Has a mesentery is mobile
Posterior relations: common bile duct, gastroduodenal artery
Radiologists refer to it as the duodenal cap or bulb
Common site of duodenal ulcers
o
May perforate posteriorly erode gastroduodenal a. hemorrhage

2. Second (descending) part

Retroperitoneal

Anatomy, 153

Receives the common bile duct and main pancreatic duct on its posterior/medial
wall at the hepatopanacreatic ampulla (Vaters ampulla)

3. Third (horizontal) part

Retroperitoneal
Runs across L3 between sup mesenteric a. anteriorly & aorta and IVC posteriorly
May be crushed against L3 in severe abdominal injuries

4. Fourth (ascending) part

Meets jejunum at the duodenojejunal flexure, which is supported by the

suspensory ligament of Treitz

Features of jejunum, ileum, and large intestine

Anatomy, 154

Jejunum
Villi
Intestinal glands (crypts)
Resides in umbilical region

Ileum
Villi
Crypts
Resides in
hypogastric and
inguinal regions

Large intestine
NO Villi
Crypts
Tenia coli (3
longitudinal bands of
smooth muscle)

Anatomy, 155

Larger diameter than ileum

Smaller diameter then

jejunum

Vasa recta are longer than

those to ileum
Large plica circularis (folds
of mucosa & submucosa)
Often empty
Thicker, more vascular, and
redder than ileum

Vasa recta are shorter

than those to jejunum
Small plica circularis

Appendices epiploicae
(fatty tags)
Haustra (sacculations
of wall)
NO plica circularis

Describe the cystic duct.

Where are the 3 clinically important sites of gallstone obstruction?

Anatomy, 156

1. Describe the cystic duct.

Drains bile from the gallbladder

Mucosa is arranged in a spiral fold w/core of smooth mm. = spiral valve
Spiral valve keeps the cystic duct constantly open so that bile can freely
flow in either direction

Anatomy, 157

2. Where are the 3 clinically important sites of gallstone obstruction?

Within the cystic duct

o If transiently lodged pain (biliary colic) w/in epigastric region
o If entrapped bile flow obstructed acute cholecystitis pain
shifts to right hypochondriac region
Within the common bile duct
o If stone is entrapped bile flow from both gallbladder and liver is
obstructed inflammation of gallbaldder and liver jaundice
At the hepatoduodenal ampulla
o If entrapped bile flow from both gallbladder & liver is obstructed,
bile may pass into pancreatic duct jaundice and pancreatitis

1. What does the falciform ligament divide the liver into?

2. Structures within the portal triad enter and leave the liver between
what two lobes?

Anatomy, 158

3. How is the liver secured within the abdominal cavity?

4. Describe a liver biopsy procedure.

1. What does the falciform ligament divide the liver into?

Into the right lobe and left lobe
2. Structures w/in portal triad enter & leave the liver between what 2 lobes?
Between the caudate and quadrate lobes

Anatomy, 159

3. How is the liver secured within the abdominal cavity?

By the attachment of the hepatic veins to the IVC, which allows for very
little rotation of the liver during surgery
4. Describe a liver biopsy procedure.
Performed by needle puncture thru the right intercostal space 8, 9, or 10
The needle passes thru:
o
o
o
o
o
o
o
o

Skin and Superficial fascia

External oblique muscle
Intercostal muscles
Costal parietal pleura
Costodiaphragmatic recess
Diaphragmatic parietal pleura
Diaphragm
Peritoneum

Describe the bony pelvis and associated ligaments.

Anatomy, 160

1. Two coxal (hip) bones, sacrum, and coccyx form the bony pelvis

Each coxal bone consists of 3 parts:

o Ischium

Anatomy, 161

o Ilium
o Pubis
These 3 parts joint at the acetabulum of the hip joint

2. Ligaments

Sacrotuberous ligament runs from sacrum ischial tuberosity

The sacrospinous ligament runs from the sacrum ischial spine
These ligaments form the borders of the greater sciatic foramen and the
lesser sciatic foramen, thru which important structures pass:

Structures traversing GSF

Piriformis muscle
Inf gluteal vein, artery, nerve
Sciatic nerve
Posterior femoral cutaneous nerv
Sup gluteal vein, art, nerv
Nerve to quadratus femoris msc
Internal pudendal vein, artery
Pudendal nerve
Nerve to obturator internus muscle

Pelvic inlet

Structures traversing LSF

Internal pudendal vein, artery

Pudendal nerve
Nerve & tendon of obturator internus muscl

Anatomy, 162

1. Is defined by sacral promontory (S1 vertebral body) and & linea terminalis

Linea terminalis: includes pubic crest, iliopectineal line, and arcuate line of ilium

Anatomy, 163

2. Divides the pelvis into two parts:

The major (false) pelvis
o Lies above the pelvic inlet between the iliac crests
o Actually part of the abdominal cavity
The minor (true) pelvis
o Lies below the pelvic inlet
o Extends to the pelvic outlet
3. Measurements of the pelvic inlet

Transverse diameter: widest distance across inlet

Oblique diameter: from sacroiliac joint to the contralateral iliopectineal eminence
True conjugate diameter: sacral promontory to sup margin of pubic symphisis
Diagonal conjugate diameter: sacral promontory to inf margin of pubic
symphysis
o
Measured during an obstetrical examination

Anatomy, 164

Pelvic outlet

What does the birth canal consist of?

Anatomy, 165

1. Pelvic outlet
Defined by the coccyx, ischial tuberosities, inf pubic ramus, and
pubic symphysis
Closed by the pelvic diaphragm and urogenital diaphragm
Measurements:
o Transverse diameter: distance between ischial tuberosities
o Interspinous diameter: distance between ischial spines
Ischial spines may present a barrier to fetus during
childbirth if the interspinous distance is <9.5 cm
2. What does the birth canal consist of?
Pelvic inlet
Minor pelvis
Cervix
Vagina

Anatomy, 166

Pelvic outlet

What muscles comprise the pelvic diaphragm? The urogenital diaphragm?

Anatomy, 167

1. Pelvic diaphragm comprised of:

Coccygeus muscle
Levator ani muscles
o Iliococcygeus muscle
o Pubococcygeus muscle
o Puborectalis muscle
Forms a U-shaped sling around anorectal junction at the
90-degree anorectal flexure
Important factor in maintaining fecal continence
2. Urogenital diaphragm comprised of:
Deep transverse perineal muscle
Sphincter urethra muscle

Anatomy, 168

Ureter: Course in abdominal cavity and Kidney stones

Anatomy, 169

1. Ureters course:
Courses along the lateral wall of the pelvis retroperitoneally and
anterior to the internal iliac arteries and psoas major muscle
In the male: passes posterior to the ductus deferens
In the female: passes posterior to the uterine artery (which lies in
the transverse cervical ligament/cardinal ligament of Mackenrodt)
o Ureter may be damaged if it is clamped or ligated along with
the uterine artery during a hysterectomy
2. Kidney stones obstruct ureters most commonly where the ureter:
Crosses the pelvic inlet

Anatomy, 170

Runs obliquely thru the wall of the urinary bladder (intramural

portion)

Urinary bladder: Position and Related ligaments

Anatomy, 171

1. Bladder: position

In the adult: empty bladder lies w/in the pelvis minor; as it fills, it rises
out of pelvis minor above the pelvic inlet and may extend as high as the
umbilicus
In the infant: empty bladder lies w/in the abdominal cavity
Its anterior surface is related to pubic symphysis & retropubic space
o Retropubic space can be used as a surgical approach to the prostate
Its posterior surface is related to the:

Anatomy, 172

Rectovesical pouch, seminal vesicles, and ampulla of ductus

deferens in males
o Vesicouterine pouch and anterior wall of vagina in females
Its base is related to the prostate gland in the male

2. Related ligaments

Median umbilical ligament (1): remnant of urachus (allantois) in embryo

Medial umbilical ligaments (2): remnants of umbilical arteries in embryo
Lateral umbilical ligaments (2): defined by inf epigastric artery and vein

Urinary bladder: Acute retention of Urine and Bladder rupture

Anatomy, 173

1. In acute retention of urine, a needle may be passed thru the anterior

abdominal wall without entering peritoneal cavity to drain off urine
The needle passes thru the following structures
o Skin
o Superficial fascia (Campers and Scarpas)
o Linea alba

Anatomy, 174

o Transversalis fascia
o Extraperitoneal fat
o Wall of urinary bladder
2. Bladder rupture
If the superior wall is ruptured b/c of an injury to abdominal wall:
o Peritoneum reflected over bladders surface frequently is torn,
causing urine to leak into peritoneal cavity (intraperitoneal)
If the anterior wall is ruptured b/c of a fractured pelvis:
o Urine will leak into the retropubic space (extraperitoneal)
Rectum

Anatomy, 175

1.
2.
3.

Joins anal canal at a 90-degree angle, forming the anorectal flexure

Angle is maintained by the U-shaped puborectalis muscle

Receives parasympathetic fibers via pelvic splanchnic nerve
Ampulla of the rectum

Lies just above the pelvic diaphragm

Anatomy, 176

4.

Generates the urge to defecate when feces move into it

Three transverse rectal folds (Houstons valves)

Formed by mucosa, submucosa, and inner circular layer of smooth muscle

Permanently extend into lumen of rectum

Need to be negotiated during a proctoscopy or sigmoidoscopy

Rectum
Arterial supply
Venous drainage
Upper portion
Sup rectal artery (IMA)
Sup rectal inf mesenteric portal
Middle portion
Middle rectal artery (int iliac)
Mid rectal internal iliac IVC
Lower portion
Inf rectal artery (int pudendal a.)
Inf rectal int pudendal int iliac IVC

5.

Carcinoma of the rectum may metastasize:

To the liver (superior rectal vein drains into hepatic portal system)
Posteriorly to sacral nerve plexus sciatica
Laterally to ureter
Anteriorly: males prostate, seminal vesicles, bladder; females uterus, vagina

Prostate

Anatomy, 177

1. Located between the base of the bladder and pelvic diaphragm

2. Its anterior surface is related to the retropubic space

Anatomy, 178

3. Its posterior surface is related to the seminal vesicles and rectum

4. Consists of 5 lobes:

Right and left lateral lobes

Right and left posterior lobes
o
Predisposed to malignant transformation (cancer)
Median lobe
o
Predisposed to BPH
o
If hypertrophied encroaches on sphincter vesicae (located at bladder
neck) leakage of urine into prostatic urethra reflex desire to micturate

5. Prostatic fluid

Contains citric acid, acid phosphatase, prostaglandins, fibrinogen, and prostatespecific antigen (PSA)
o
Serum levels of acid phosphatase & PSA used as dx tools for prostatic CA

6. Prostatic venous plexus drains into the:

Internal iliac veins IVC (metastasis of prostatic CA to heart and lungs)

Vertebral venous plexus (metastasis of CA to vertebral column & brain)

Anatomy, 179

Uterus

Anatomy, 180

1. Divided into 4 regions:

Fundus: superior to cornua

o
Contributes largely to upper segment of uterus during pregnancy
o
At term, may extend as high as the xiphoid process (T9)
Cornu: defines the entry of the uterine tube
Body: located between cornu and cervix
Isthmus: part of the body
o
Dividing line between the body of the uterus and the cervix
o
Corresponds to the internal os and is preferred site for C-section

2. Uterus is supported by the:

Pelvic diaphragm, urogenital diaphragm, and urinary bladder

Round ligament (remnant of gubernaculum in embryo)
Transverse cervical lig (cardinal lig) contains uterine artery and vein
Uterosacral ligament
Pubocervical ligament

Anatomy, 181

3. Uterus is normally in an anteflexed and anteverted position

Flexion refers to angle between the cervix and body of uterus

Version refers to angle between the vagina and cervix

Broad ligament

Anatomy, 182

1. Consists of the:

Mesosalpinx (supports uterine tube)

Mesovarium (supports ovary)
Mesometrium (supports uterus)
Suspensory ligament of the ovary (lateral extension of the broad
ligament) contains the ovarian artery, vein, and nerves

2. Contains the following structures:

Ovarian artery, vein, and nerves

Uterine tubes
Ovarian ligament (remnant of gubernaculum in embryo)
Round ligament of the uterus (remnant of gubernaculum)

Anatomy, 183

Epoophoron (remanant of mesonephric tubules in embryo)

Paroophoron (remnant of mesonephric tubules)
Gartners duct (remnant of mesonephric duct)
Ureter (lies at base of broad ligament)
Uterine artery, vein, and nerves (lie at base of broad ligament)

Perineum and The Anal Canal

Anatomy, 184

1.
2.

Is a diamond-shaped region inferior to the pelvic diaphragm

Can be divided by a line passing thru the ischial tuberosities into the:
Urogenital (UG) triangle
o
Contains the outlets of the urinary and genital systems
Anal triangle
o
Contains the anal canal, which is divided into the upper and lower anal
canal by the pectinate line
o
Distinctions between the upper and lower anal canal:
Feature
Upper Anal Canal
Lower Anal Canal

Anatomy, 185

Arterial supply

Sup rectal artery (<-- IMA)

Venous drainage

Sup rectal --> inf mesenteric -->

portal
Deep nodes
Motor: internal anal sphincter
(smooth muscle); autonomic
Sensory: stretch sensation
Endoderm (hindgut)
Simple columnar
Internal (varicosities of sup rectal)

Lymphatic drainage
Innervation
Embryo. derivation
Epithelium
Hemorrhoids

Superficial and Deep Perineal Spaces

Inf rectal a. (<--int pudendal a.)

Inf rectal --> int pudendal --> int
iliac vein --> IVC
Superficial inguinal nodes
Motor: external anal sphincter
(striated m.); pudendal nerve
Sensory: pain, temp, touch
Ectoderm (proctodeum)
Stratified squamous
External (varicosities of inf rectal)

Anatomy, 186

1.

Superficial perineal space

Boundaries: superficial perineal fascia (continuous w/Colles fascia), inferior fascia of UG

diaphragm (also called the perineal membrane)

Rupture of male urethra (straddle injuries) --> urine escapes into sup perineal space -->
connective tissue around scrotum, penis, anterior abdominal wall (urine will NOT pass
into thigh region or anal triangle)
Male Structures
Female Structures
Bulb of penis, crura of penis

Vestibular bulbs, crura of clitoris

Anatomy, 187
Urethra
Urethra, Vagina
Greater vestibular (Bartholins) glands
Bulbospongiosus, ischiocavernosus, superficial transverse perineal mm.
Perineal body
Perineal nerve

2.

Deep perineal space

Boundaries: inferior and superior fasciae of the UG diaphragm

Male Structures
Female Structures
Urethra
Urethra, Vagina
Bulbourethral (Cowpers) glands
Deep transverse perineal and sphincter urethrae muscles
Perineal nerve
Dorsal nerve of penis/clitoris (branch of pudendal)

Male and Female Genitalia

Anatomy, 188

1. Male Genitalia

Penis: 3 columns of erectile tissue bound together by the tunica albuginea

o
Corpus spongiosum (1 column) transmits the urethra
Proximally enlarges to form the bulb of the penis
Distally enlarges to form the glans of the penis

Anatomy, 189

o
Corpus cavernosa (2 columns)
Scrotum: consists of 3 parts Skin, Colles fascia, and Dartos muscle
Testes

2. Female genitalia

Clitoris: consists of 3 parts similar to those in penis except clitoris has no corpus
spongiosum and does not transmit the urethra
o
Crura of the clitoris
o
Corpus cavernosa
o
Glans of the clitoris
Labia majora
Labia minora
Vestibule (the space between the labia minora into which the vagina, urethra,
paraurethral glands, and greater vestibular glands open)

Episiotomy

Anatomy, 190

1. Incision made to enlarge the vaginal orifice when it appears inevitable

that the perineum or perineal body will tear during childbirth
2. Median episiotomy

Anatomy, 191

Incision starts at the frenulum of the labia minora and extends thru
the following structures:
o Skin
o Vaginal wall
o Perineal body
o Superficial transverse perineal muscle
3. Mediolateral episiotomy
Incision starts at the frenulum of the labia minora and extends thru
the following structures:
o Skin
o Vaginal wall
o Bulbospongiosus muscle
Pudendal nerve block

Anatomy, 192

1. Performed in order to relieve pain associated w/childbirth

Anatomy, 193

2. Pudendal nerve may be blocked via the perineal route by using the
ischial tuberosity as the chief bony landmark
3. When complete perineal anesthesia is required, the following must also
be blocked by making injections along the lateral margin of the labia
majora:
Genitofemoral nerve
Ilioinguinal nerve
Perineal branch of the posterior cutaneous nerve of the thigh

Anatomy, 194

Subclavian artery

Anatomy, 195

1. Extends from the arch of the aorta to the lateral border of the first rib
2. Branches off into the following arteries:
Internal thoracic artery
o Continuous w/superior epigastric artery, which anastomoses
w/the inferior epigastric artery (a branch of the external iliac
artery) this may provide a route of collateral circulation if the
abdominal aorta is blocked
Vertebral artery
Thyrocervical trunk has 3 branches:
o Suprascapular artery
Aids in collateral circulation around the shoulder
o Transverse cervical artery
Aids in collateral circulation around the shoulder
o Inferior thyroid artery

Anatomy, 196

Costocervical trunk

Axillary artery

Anatomy, 197

1. Continuation of the subclavian artery

2. Extends from the lateral border of the 1st rib to the inferior border of the
teres major muscle
3. Tendon of the pectoralis minor muscle crosses the axillary artery
anteriorly
4. Branches into the following arteries:
Supreme thoracic artery
Thoracicoacromial artery
Lateral thoracic artery
Posterior humeral circumflex artery
Anterior humeral circumflex artery
Subscapular artery

Anatomy, 198

Brachial artery

Anatomy, 199

1. Continuation of the axillary artery

2. Extends from lateral border of teres major muscle to the cubital fossa
3. Branches off into the following arteries:

Profunda brachii artery

o
Fracture of the humerus at midshaft may damage the deep brachial artery
and radial nerve as they travel together on the posterior aspect of the
humerus in the radial groove
Superior ulnar collateral artery
Inferior ulnar collateral artery

4. Terminally branches off into the:

Radial artery (travels down lateral side of arm)

Ulnar artery (travels down medial side of arm)

5. The radial and ulnar arteries anastomose in the:

Anatomy, 200

Deep palmar arch lies posterior to the tendons of the flexor digitorum
superficialis and flexor digitorum profundus muscles
o
A deep laceration at the metacarpal-carpal joint that cuts the deep palmar
arch compromises flexion of the fingers
Superficial palmar arch

Collateral circulation:
1). Around the shoulder
2). Around the elbow
3). In the hand

Anatomy, 201

1. Collateral circulation around the shoulder:

Transverse cervical artery

Suprascapular artery
Subscapular artery

2. Collateral circulation around the elbow:

Superior ulnar collateral artery

o Anastomoses w/the posterior ulnar recurrent artery
Inferior ulnar collateral artery
o Anastomoses w/the anterior ulnar recurrent artery
Middle collateral artery

Anatomy, 202

o Anastomoses w/the interosseous recurrent artery

Radial collateral artery
o Anastomoses w/the radial recurrent artery

3. Collateral circulation in the hand:

Superificial palmar arch

Deep palmar arch

Placement of ligatures to arteries of the upper limb

Anatomy, 203

1. Ligatures may be placed in the following locations:

On the subclavian artery or axillary artery between the
thyrocervical trunk and subscapular artery
On the brachial artery distal to the inf ulnar collateral artery
2. A surgical ligature may NOT be placed on the axillary artery just
distal to the subscapular artery

Anatomy, 204

Compartment syndrome

Anatomy, 205

1. Both the upper and lower limbs are separated into compartments by
various fascial sheets
2. A traumatic injury to the limb may cause progressive hemorrhage into
one of these compartments, which compresses uninjured blood vessels
and/or nerves, producing ischemia and atrophy of the musculature
3. Muscle movements are painful and weakened when performed against
resistance

Anatomy, 206

Subdivisions of the Brachial plexus

Anatomy, 207

1.
2.

3.

Rami (C5-T1 ventral primary rami)

Located between the anterior and middle scalene muscles
Trunks (upper, middle, lower)
Randy Travis
Formed by the joining of rami
Drinks Cold Beer
Located in the posterior triangle of the neck
Divisions (3 anterior, 3 posterior)
Formed by trunks dividing to ant and post divisions
Located deep to the clavicle

Anatomy, 208

4.

5.

Cords (lateral, medial, posterior)

Formed by joining of the ant and post divisions
Located in the axilla deep to the pectoralis minor muscle
Named according to their relationship to the axillary artery
Branches. The 5 major terminal branches are:
Musculocutaneous nerve
Axillary nerve
Radial nerve
Median nerve
Ulnar nerve

Injuries to the brachial plexus:

1). Erb-Duchenne injury
2). Klumpkes injury

Anatomy, 209

Injury
ErbDuchenne
(upper

Cervical
Level
C5 & C6
(follows
fall to

Injury
Description
Violent
stretch
between

Nerves Damaged
Musculocutaneous

Muscles
affected
Biceps brachii
Brachialis
Infraspinatus

Clinical Sign
Arm is medially
rotated &
pronated

Anatomy, 210
trunk)

Klumpkes
(lower
trunk)

shoulder
or tauma
during
delivery)
C8 & T1

head and
shoulder

Suprascapular
Teres minor

(Waiters tip)*

Muscles of
the hand and
wrist

Loss of function
of the hand and
wrist

Axillary
Sudden pull
upward of
arm

Median
Ulnar

*The infraspinatus muscle, innervated by the suprascapular nerve, is a lateral

rotator of the arm. If its weakened, the medial rotators of the arm dominate. The
biceps brachii muscle, innervated by the musculocutaneous nerve, assists in
supination. If its weakened, the pronators of the arm dominate

Axillary nerve injury

Anatomy, 211

1. May be caused by:

A fracture of the surgical neck of the humerus

Anatomy, 212

Dislocation of the shoulder joint

2. Effects:
Paralysis of the deltoid muscle abduction of the arm to the
horizontal position is compromised
Paralysis of the teres minor muscle lateral rotation of the arm
is weakened
Sensory loss on the lateral side of the upper arm
3. To test the deltoid muscle clinically:
Pts arm is abducted to horizontal and then pt holds that position
against a downward pull

Anatomy, 213

Long thoracic nerve injury

1. May be caused by:

Anatomy, 214

A stab wound
Removal of lymph nodes during a mastectomy
2. Effects:
Paralysis of serratus anterior muscle abduction of arm past
the horizontal position is compromised, arm cannot be used to push
3. To test: pt is asked to face a wall and push against it w/both arms if
injured, the medial border and inferior angle of the scapula on in the
injured side become prominent (winging of the scapula)

Anatomy, 215

Radial nerve injury

Anatomy, 216

1. May be caused by:

A fracture of the humerus at midshaft
A badly fitted crutch
2. Effects:
Paralysis of the muscles in the extensor compartment of
forearm extension of the wrist and digits is lost, supination is
compromised (extention of forearm is preserved b/c innervation to
the triceps is generally intact)
Sensory loss on the posterior arm, posterior forearm, and
lateral aspect of the dorsum of the hand
3. Clinically:
Hand is flexed at the wrist and lies flaccid (wrist-drop)

Anatomy, 217

Median nerve injury at the elbow or axilla

Anatomy, 218

1. May be caused by a supracondylar fracture of the humerus

2. Effects:
Paralysis of the muscles in the flexor compartment flexion of
wrist is weakened, flexion of digits is lost, pronation is lost
Paralysis of abductor pollicis brevis, opponens pollicis, and
flexor pollicis brevis muscles thumb movements are lost
Sensory loss on palmar and dorsal aspects of the index, middle,
and half of the ring fingers and the palmar aspect of the thumb
3. Clinically:
Flattening of the thenar eminence occurs (ape hand)

Anatomy, 219

Median nerve injury at the wrist

Anatomy, 220

1. May be caused by :
A slashing of the wrist
Carpal tunnel syndrome
2. Effects:
ALL the same effects as median nerve injury at the elbow or axilla
EXCEPT THERE IS NO PARALYSIS OF THE MUSCLES IN
THE FLEXOR COMPARTMENT OF THE ARM
3. Clinically:
Ape hand

Anatomy, 221

Ulnar nerve injury at the elbow or axilla

Anatomy, 222

1. May be caused by a fracture of the medial epicondyle of the humerus

2. Effects:

Paralysis of flexor carpi ulnaris muscle deviation of the hand to the radial
side upon flexion at the wrist joint
Paralysis of the medial part of flexor digitorum profundus muscle flexion
of the ring and little fingers at the distal phalangeal joint is lost
Paralysis of lumbricales 3 and 4 flexion of ring & little fingers at metacarpophalangeal joint is lost (note: extensors are intact hyperextension)
Paralysis of palmar and dorsal interosseous muscle abduction and
adduction of the fingers are lost
Paralysis of the adductor pollicis muscle adduction of the thumb is lost
Paralysis of the abductor digiti minimi, flexor digiti minimi, and opponens
digiti minimi muscles abduction, flexion, opposition of little finger are lost

Anatomy, 223

Sensory loss on palmar and dorsal aspects of the little finger and of the
ring finger

3. Clinically:

Clawhand (due to paralysis of muscles in blue)

Ulnar nerve injury at the wrist

Anatomy, 224

1. May be caused by a slashing of the wrist

2. Effects:
ALL the same effects as produced by an ulnar injury at the elbow or
axilla EXCEPT THERE IS:
o NO PARALYSIS OF FLEXOR CARPI ULNARIS M.
o NO PARALYSIS OF MEDIAL PART OF FLEXOR
DIGITORUM PROFUNDUS MUSCLE
3. Clinically:
Clawhand BUT NOT AS SEVERE as w/a lesion at the elbow or
axilla

Anatomy, 225

Rotator cuff

Anatomy, 226

1. Contributes to the stability of the glenohumeral joint (along w/the

tendon of the long head of the biceps brachii muscle) by holding the
head of the humerus against the glenoid surface of the scapula
2. Formed by the tendons of the following muscles:
Muscle
Innervation
Subscapularis
Subscapularis nerve
Supraspinatus
Suprascapular nerve
Infraspinatus
Teres minor
Axillary nerve

Anatomy, 227

Shoulder region injuries:

1). Dislocation of the humerus (shoulder dislocation)
2). Acromioclavicular subluxation (shoulder separation)
3). Fracture of the clavicle
4). Subacromial bursitis and supraspinatus tendinitis

Anatomy, 228

1. Dislocation of the humerus (shoulder dislocation)

Frequently occurs b/c of the shallowness of the glenoid fossa

Anterior dislocation: head of humerus lies inferior to the coracoid
process of the scapula and may damage the axillary nerve
Posterior dislocation: head of humerus is displaced posteriorly

2. Acromioclavicular subluxation (shoulder separation)

Results in a upward displacement of clavicle

Common despite acromioclavicular & coracoclavicular ligaments

3. Fracture of the clavicle

Anatomy, 229

Most commonly occurs at the middle 1/3 of the clavicle

Results in:
o displacement of proximal fragment (due to pull of SCM)
o displacement of distal fragment (due to pull of deltoid and gravity)

4. Subacromial bursitis and supraspinatus tendinitis

Involves inflammation of the subacromial bursa, which separates the

acromion from the supraspinatus muscle

Cubital fossa contents

Anatomy, 230

1.
2.
3.
4.
5.

Median nerve
Brachial artery
Biceps tendon
Median cubital vein (superficial to bicipital aponeurosis)
Radial nerve (lyding deep to brachioradial muscle)

Anatomy, 231

Elbow joint: associated ligaments and injuries

Anatomy, 232

1. Consists of 3 articulations amond the humerus, ulna, and radius:

Humeroulnar joint is reinforced by ulnar (medial) collateral ligament
o Sprain of this ligament abnormal abduction of forearm
Humeroradial joint is reinforced by radial (lateral) collateral ligament
o Sprain of this ligament abnormal adduction of forearm
o Inflammation of this ligament tennis elbow
Radioulnar joint is reinforced by the anular ligament
o Pronation and supination occur at this joint

Anatomy, 233

2. Pulled elbow
Subluxation of the head of the radius from its articulations w/the humerus
and ulna and tearing of the annular ligament
Caused by severe distal traction of radius (ex. parant yanking childs arm)
Effects:
o Pronation and supination restricted
To reduce: apply pressure posterioly on head of radius, while supinating
& extending forearm (this screws head of the radius into annular lig)

Carpal tunnel:
1). Is formed by?
2). Contents
3). Syndrome

Anatomy, 234

1. Carpal tunnel is formed by the flexor retinaculum attaching to the

palmar surface of the carpal bones
2. The following pass thru the tunnel:

Flexor digitorum superficialis tendons

Flexor digitorum profundus tendons
Flexor pollicis longus tendon

Anatomy, 235

Median nerve

3. Carpal tunnel syndrome:

Compression of the median nerve w/in the carpal tunnel

Symptoms:
o Flexion and abduction of thumb are weakened
o Opposition of thumb is lost
o Extension of index and middle fingers is lost
o Sensory loss on palmar and dorsal aspects of index, middle and of
ring fingers and palmar aspect of thumb

1. What may a deep laceration on the radial side of the wrist cut?
2. What may a deep lacerationon the ulnar side of the wrist (as in a
suicide attempt) cut?

Anatomy, 236

1. What may a deep laceration on the radial side of the wrist cut?
Radial artery
Median nerve
Flexor carpi radialis tendon

Anatomy, 237

Palmaris longus tendon

2. What may a deep lacerationon the ulnar side of the wrist (as in a
suicide attempt) cut?
Ulnar artery
Ulnar nerve
Flexor carpi ulnaris tendon

Obturator artery

Anatomy, 238

1. Is a continuation of the internal iliac artery and passes through the

obturator foramen
2. Branches off into the following structures:

Anatomy, 239

Muscular branches to the adductor muscles

Artery to the head of the femur

Anatomy, 240

Femoral artery

1. Is a continuation of the external iliac artery

Anatomy, 241

2. Enters the thigh posterior to the inguinal ligament and midway between
the anterior-superior iliac spine and symphysis pubis where it can be
palpated
3. Branches off into:
Superficial epigastric artery
Superficial circumflex iliac artery
External pudendal artery
Profunda femoris artery, which branches into:
o 4 perforating arteries
o Medial circumflex artery
o Lateral circumflex artery

Anatomy, 242

Popliteal artery

Anatomy, 243

1. Continuation of femoral artery at the adductor hiatus in adductor magnus m.

2. Extends thru the popliteal fossa where it can be palpated
3. Branches into:
Genicular arteries
Anterior tibial artery
o
o

Descends on anterior surface of interossesous membrane w/the deep

peroneal nerve
Terminates as dorsalis pedis artery, which lies between extensor hallucis
longus & extensor digitorum longus tendons midway between the medial &
lateral malleolus where it can be palpated

Posterior tibial artery

o
o

Passes behind med malleolus w/the tibial nerve where it can be felt
Branches into:
Peroneal artery (passes behind the lateral malleolus)
Medial plantar artery

Anatomy, 244

Lateral plantar artery (forms plantar arch, which connects to the

dorsalis pedis artery)

Collateral circulation in the lower limb

Anatomy, 245

1. Collateral circulation around the hip joint (cruciate anastomosis):

Inferior gluteal artery (branch of internal iliac artery)

Medial femoral circumflex artery
Lateral femoral circumflex artery
First perforating branch of profundis femoris artery

2. Collateral circulation around the head of the femur (trochanteric

anastomosis):

Superior gluteal artery

Inferior gluteal artery
Medial femoral circumflex a. (major supply to head & neck of femur)
Lateral femoral circumflex artery
Artery to the head of the femur

Anatomy, 246

o
o

Not considered part of trochanteric anastomosis, though important in

children b/c it supplies head of femur proximal to epiphyseal plate
After epiphyseal growth plate closes in the adult, this artery plays an
insignificant role in supplying blood to the head of the femur

Atherosclerotic occlusive disease of the leg

Anatomy, 247

1. Often causes intermittent claudication (muscular pain or fatigue that

occurs w/exercise but subsides w/rest)
2. May occur in the following arteries:
External iliac artery blood supply to almost all of muscles of
the lower limb pain in gluteal region, thigh, and leg
Femoral artery proximal to profunda femoris artery blood
supply to thigh and leg muscles pain in thigh and leg
Femoral artery distal to profunda femoris artery blood
supply to leg muscles pain in leg
Popliteal artery blood supply to leg muscles pain in leg

Anatomy, 248

Anterior or posterior tibial artery does NOT diminish blood

supply to leg muscle and, therefore, NO intermittent claudication

Lumbosacral plexus

Anatomy, 249

1. Subdivisions include:
Rami (L1-L4 & S1-S4 ventral primary rami)
Divisions (anterior & posterior)
o Formed by rami dividing into anterior and posterior divisions
Branches the 6 major terminal branches are:
o Superior gluteal nerve
o Inferior gluteal nerve
o Obturator nerve
Sciatic nerve

Anatomy, 250

o
o
o

Femoral nerve
Tibial nerve
Common peroneal nerve, which divides into the:
Superficial peroneal nerve
Deep peroneal nerve

Superior gluteal nerve injury

Anatomy, 251

1. May be caused:

During surgery
As a result of poliomyelitis

2. Effects:

Paralysis of gluteus medius and minimus muscles ability to pull

pelvis down and abduction of thigh is lost

3. Clinically:

Condition is called gluteus medius limp or waddling gait

Anatomy, 252

Pt demonstrates a + Trendelenburgs sign, which is tested as follows:

o Pt stands w/back to examiner and alternatively raises each foot off
the ground
o If sup gluteal nerve on left is injured right pelvis will fall
downward when pt raises his right foot off the ground
o This sign can also be seen in a pt w/hip dislocation or fracture of the
neck of the femur

1. Inferior gluteal nerve injury

2. Obturator nerve injury
3. Femoral nerve injury

Anatomy, 253

1.

Inferior gluteal nerve injury - may be caused during surgery

Effects:
o

Paralysis of gluteus maximus muscle ability to rise from seated

position, climb stairs, or jump is lost

Clinically:

Anatomy, 254

2.

Pt will be able to walk, but will lean the body trunk backward at heel
strike to compensate
Obturator nerve injury - rare

Effects:
o

3.

Paralysis of portion of adductor magnus, longus, and brevis

adduction of thigh is lost
o
Sensory loss on medial aspect of thigh
Femoral nerve injury - may be caused by a trauma of femoral triangle

Effects:
o
o
o

Paralysis of iliacus & sartorius muscles flexion of thigh is weak

Paralysis of quadriceps femoris muscles extension of leg is lost
Sensory loss on anterior thigh & medial aspect of leg & foot

1. Tibial nerve injury

2. Common peroneal nerve injury

Anatomy, 255

1.

Tibial nerve injury (at the popliteal fossa) - may be caused by trauma of pop fossa
Effects:

Anatomy, 256
o
o
o
o

Clinically:
o

2.

Paralysis of gastrocnemius, soleus, plantaris muscles plantar flexion of foot is

lost (pt cannot stand on toes)
Paralysis of flexor digitorum and hallucis longus flexion of toes is lost
Paralysis of tibialis posterior muscle inversion of foot is weak
Sensory loss on sole of foot
Pt will present with calcaneovalgocavus dorsiflexion and eversion of the foot

Common peroneal nerve injury common injury

May be caused by: a) blow to lateral aspect of leg, or b) fracture of neck of the fibula
Effects:

o
o
o
o

Paralysis of peroneus longus and brevis eversion of foot is lost

Paralysis of tibialis anterior dorsiflexion of foot is lost (pt cant stand on heels)
Paralysis of extensor digitorum and hallucis longus extension of toes is lost
Sensory loss on anterolateral aspect of leg and dorsum of foot

Clinically:
o
o

Pt presents w/equinovarus plantar flexion (footdrop) and inversion of the foot

Pt has high stepping gait & foot is brought down suddenly (clopping sound)

Anatomy, 257

Hip Joint: Ligamentous support and Posterior Dislocation of

Anatomy, 258

1. Ligamentous support of hip joint:

Iliofemoral ligament (Y ligament of Bigelow)

Pubofemoral ligament
Ischiofemoral ligament
Ligamentum teres (plays only a minor role in stability but does carry the
artery to the head of the femur)

2. Posterior dislocation of the hip joint

Usually caused by severe trauma (e.g. car crash) that fractures acetabulum
Head of femur comes to lie posterior to iliofemoral ligament
If articular capsule is damaged blood to head of femur is in jeopardy
Sciatic nerve may be damaged
Clinically, pt will present w/lower limb that is
o
o
o

Flexed at hip joint

Adducted
Medially rotated

Anatomy, 259

o
Shorter than opposite limb
(Contrast this w/fracture of the neck of the femur)

What structures does the femoral triangle contain? What are its boundaries?

Anatomy, 260

1. Femoral triangle contains the following structures (medial lateral):

Femoral canal
o Contains lymphatics and lymph nodes
Femoral vein
o Great saphenous vein joins the femoral vein w/in the femoral
triangle just below and lateral to the pubic tubercle
Imp site where a great saphenous vein cutdown can be
performed
Femoral artery
Femoral nerve
2. Boundaries of the triangle:
Superior: Inguinal ligament

Anatomy, 261

Lateral: Sartorius muscle

Medial: Adductor longus muscle

What structures does the popliteal fossa contain?

Anatomy, 262

1.
2.
3.
4.
5.

Tibial nerve
Common peroneal nerve
Popliteal artery
Popliteal vein
Small saphenous vein

Anatomy, 263

Knee joint: Menisci and Ligaments

Anatomy, 264

1.
2.
3.
4.

5.

Medial meniscus: C-shaped fibrocartilage attached to tibial collateral ligam

Lateral meniscus: O-shaped fibrocartilage
Patellar ligament: struck to elicit knee-jerk reflex, which is blocked by
Damage to femoral nerve (supplies quadriceps), OR damage to L2, 3, 4
Tibial (medial) collateral ligament

Extends from medial epicondyle of femur to shaft of tibia

Prevents abduction of knee joint

If torn abnormal passive abduction of extended leg

Fibular (lateral) collateral ligament

Extends from lateral epicondyle of femur to head of fibula

Prevents adduction of knee joint

If torn abnormal passive adduction of extended leg

Anatomy, 265
6.

7.

Anterior cruciate ligament

Extends from anterior aspect of tibia to lateral condyle of femur

Prevents anterior movement of tibia in reference to the femur

If torn abnormal passive anterior displacement of tibia (anterior drawer sign)

Posterior cruciate ligament

Extends from posterior aspect of tibia to medial condyle of femur

Prevents posterior movement of tibia in reference to femur

If torn abnormal passive posterior dispacement of tibia (posterior drawer sign)

Combined knee injury

Anatomy, 266

1. AKA terrible triad

2. The following structures are torn:
Tibial collateral ligament
o Torn due to excessive abduction of knee joing
Medial meniscus
o Torn as a result of its attachment to tibial collateral ligament
Anterior cruciage ligament

Anatomy, 267

Ankle (talocrural) joint:

1. Ligaments
2. Injuries to (Potts fracture, Inversion sprain)

Anatomy, 268

1.

Ligaments (both limit dorsiflexion and plantaflexion)

Medial (deltoid) ligament

o
Extends from medial malleolus to tarsal bones
o
Prevents abduction of ankle joint
Lateral ligaments (anterior talofibular, posterior talofibular, calcaneofibular)
o
Extend from lateral malleolus to talus and calcaneus
o
Prevents adduction of ankle joint

Anatomy, 269

2.

Ankle injuries

Potts fracture
o
Occurs when foot is forcibly everted pulls medial ligament
o
Medial ligament is so strong that, instead of tearing, it causes an avulsion (a
tearing away or forcible separation) of the medial malleolus
o
Result: talus moves laterally fracture of the fibula
Inversion sprain
o
Most common ankle injury
o
Occurs when foot is forcibly inverted stretches or tears lateral ligaments
o
Avulsion of lateral malleolus OR of tuberosity of the 5th metatarsal (where
peroneus brevis attaches) may occur, depending on severity of injury

Important anterior and posterior relationships of the medial malleolus

Anatomy, 270

Tom, Dick, and Harry

1. Anterior relationships
anterior posterior as
Saphenous nerve
they run down and
Great saphenous vein (excellent location for cutdown)
under the flexor
2. Posterior relationships
retinaculum

Anatomy, 271

Posterior tibial tendon

Flexor digitorum longus tendon
Posterior tibial artery
Tibial nerve
Flexor hallucis longus tendon

Result of a fracture of the:

1). Neck of the femur
2). Tibia and fibula

Anatomy, 272

1. Fracture to the neck of the femur:

Gluteus maximus, piriformis, obturator internus, gemelli, and
quadratus femoris muscles rotate the distal fragment laterally

Anatomy, 273

Rectus femoris, adductor, and hamstring muscle draw distal

fragment proximally
Result: lower limb presents as laterally rotated and shortened
2. Fracture to the tibia and fibula:
If only one bone is broken, the other bone acts as a splint so that
there is little displacement

Anatomy, 274

Branches of the arch of the aorta

1. Brachiocephalic artery

Anatomy, 275

Right subclavian artery

Right common carotid artery
2. Left common carotid artery
3. Left subclavian artery

Anatomy, 276

Branches of the common carotid artery

Anatomy, 277

1. Internal carotid artery (no branches in the neck)

Ophthalmic artery
Anterior cerebral artery
Middle cerebral artery
2. External carotid artery (8 branches in the neck)
Superior thyroid artery
Lingual artery
Facial artery
Ascending pharyngeal artery
Occipital artery
Posterior auricular artery
Superifical temporal artery
Maxillary artery

Anatomy, 278

Maxillary artery

Anatomy, 279

1. Enters the infratemporal fossa by passing posterior to the neck of the

mandible
2. Branches:
Middle menineal artery
o Supplies periosteal dura in cranium
o May be severed in fractures in the area of the pterion (junction
of parietal, frontal, temporal, and sphenoid bones) epidural
hemorrhage
Inferior alveolar artery
Posterior superior alveolar artery
Descending palatine artery
Sphenopalatine artery

Anatomy, 280

Venous drainage of the head and neck

Anatomy, 281

1. Facial vein (no valves)

Drains into internal jugular vein
Major venous drainage of face
Clinically important connection with the cavernous sinus via:
o Inferior ophthalmic vein
o Superior ophthalmic vein
o Pterygoid plexus of veins
Connection w/cavernous sinus provides potential route of
infection from superficial face to the dural sinuses within the
cranium

Anatomy, 282

Cervical plexus

Anatomy, 283

1. Formed by C1-C4 ventral primary rami

2. Motor branches
Superior ramus of ansa cervicalis (C1)
o Innervates geniohyoid and thyrohyoid muscles
Inferior ramus of ansa cervicalis (C2, C3)
o Innervates sternohyoid, omohyoid, and sternothyroid muscles
Phrenic nerve (C3-C5)
o Innervates the diaphragm
3. Sensory branches
Lesser occipital nerve

Anatomy, 284

Greater auricular nerve

Transverse cervical nerve
Supraclavicular nerves
An unnamed sensory branch that passes thru the foramen
magnum to innervate the meninges

Cervical triangles of the neck

Anatomy, 285

1. SCM divides neck into anterior & posterior s, which are further subdivided

Triangle
Anterior
Digastric
Submental
Muscular
Carotid

Boundaries

Contents

SCM
Base of mandible
Ventral midline

Common carotid, internal jugular, CNX, ansa

cervicalis, sympathetic trunk, CN XI, CN XII

Anatomy, 286

Posterior
Supraclav
Occipital

SCM
Trapezius
Clavicle
Transverse cervical a., suprascapular a., subclavian a.,
external jugular v., brachial plexus, phrenic n., lesser
occipital n., greater auricular n., transverse cervical n.,
supraclavicular nerves, CN XI

Clinical aspects of the anterior triangle

Anatomy, 287

1. Platysma muscle lies in the superficial fascia above the anterior triangle
Inervated by the facial nerve
Accidental damage during surgery of facial nerve distortion of the
shape of the mouth
2. Carotid pulse is palpated at anterior border of SCM at level of superior
border of the thyroid cartilage (C5)
3. Bifurcation of common carotid artery occurs in anterior at the level of C4
At the bifurcation, the carotid body and carotid sinus can be found
Carotid body: oxygen chemoreceptor, CN X (and CN IX)

Anatomy, 288

Carotid sinus: pressure receptor, CN IX (and CN X)

4. Atherosclerosis of internal carotid artery w/in anterior can result in:
Insufficient blood flow to retinal artery ipsilateral visual impairment
Insufficient blood flow to middle cerebral artery motor and sensory
impairment of the body on the contralateral side
5. Internal jugular vein catheter inserted in an area bounded by the sternal &
clavicular heads of the SCM & medial end of clavicle

Clinical aspects of the posterior

Anatomy, 289

1. Injury to CN XI within the posterior due to surgery or penetrating

wound paralysis of trapezius muscle abduction of arm past
horizontal position is compromised
2. Injuries to the trunks of the brachial plexus that lie in posterior
Erb-Duchenne or Klumpkes syndromes

Anatomy, 290

3. Severe upper limb hemorrhage may be stopped by compressing the

subclavian artery against the 1st rib, applying downard and posterior
pressure

Intrinsic muscles of the larynx

Anatomy, 291

1. Posterior cricoarytenoid muscle

Blue = innervated by inf laryngeal

Abducts vocal folds (only muscle that abducts folds)
nerve of CN X (continuation of
Opens airway during respiration
recurrent laryngeal nerve)

2. Lateral cricoarytenoid muscle

Adducts vocal folds

Green = innervated by ext branch

of the superior laryngeal nerve of
CN X

Anatomy, 292

3. Arytenoid muscle

Adducts vocal folds

4. Thyroarytenoid muscle

Relaxes vocal folds

5. Vocal muscle

Alters vocal folds for speaking and singing

6. Cricothyroid muscle

Stretches and tenses vocal folds

7. Transverse & Oblique arytenoid muscles

Close laryngeal aditus (sphincter function)

Damage to the recurrent laryngeal nerve

Anatomy, 293

1. May be damaged during thyroidectomy surgery

Anatomy, 294

2. Results in much more profound effects on the abduction of the vocal

folds (i.e., posterior cricoarytenoid muscle) than on adduction of the
vocal folds
3. Unilateral damage to the recurrent laryngeal nerve results in:
Hoarse voice
Inability to speak for long periods
Movement of vocal fold on affected side moves toward midline
4. Bilateral damage to the recurrent laryngeal nerve results in:
Acute breathlessness (dyspnea) b/c both vocal folds move toward
the midline and close off the air passage

Anatomy, 295

Cricothyroidectomy

Anatomy, 296

1. Requires that a tube be inserted between the cricoid and thyroid

cartilages
2. Incision made for this procedure passes thru:
Skin
Superficial fascia (avoiding the anterior jugular veins)
Investing layer of deep cervical fascia
Pretracheal fascia (avoiding the sternohyoid muscle)
Cricothyroid ligament (avoiding cricothyroid muscle)

Anatomy, 297

Skull and foramina

Anatomy, 298

Anterior fossa
Cribiform plate
Middle fossa
Sup orbital fissure
Optic canal
Inf orbital fissure
Carotid canal
Foramen rotundum
Foramen ovale
Foramen spinosum
Foramen lacerum
Posterior fossa
Int acoustic meatus
Jugular foramen

Ethmoid

CN I (fracture will cause blood

and CSF to run from the nose)

Between lesser and greater

wings of sphenoid
Lesser wing of sphenoid
Between zygomatic & greater wing
Between petrous part of temporal
& greater wing of sphenoid
Greater wing of sphenoid
Greater wing of sphenoid
Greater wing of sphenoid
Between petrous part of temporal
and sphenoid

CN III, IV, V1, VI

Petrous part of temporal

Betweeen petrous part of temporal

CN VII, CN VIII
CN IX, X, XI, sigmoid sinus

CN II
Infraorbital vein, artery, nerve
Internal carotid artery
CN V2
CN V3, lesser petrosal nerve
Middle meningeal artery
None

Anatomy, 299
Hypoglossal canal
Foramen magnum

and occipital
Occipital
Occipital

1. Epidural hemorrhage
2. Subdural hemorrhage

CN XII
Medulla, CN XI, vertebral aa.

Anatomy, 300

1. Epidural hemorrhage (arterial blood)

Usually results from a skull fracture of one of the following:

o
Temporal bone
o
Parietal bone
o
Near the pterion
Fracture tears the middle meningeal artery
o
Blood rapidly accumulates between periosteum of skull & outer dura
o
Requires emergency surgery
Transtentorial/uncal herniation compresses CN III dilated, fixed pupil
Blood will not appear in the CSF

2. Subdural hemorrhage (venous blood)

May result from:

o
A blow to the head

Anatomy, 301

o
Violent movement of the brain w/in a fixed space of the skull
Most commonly tears superior cerebral veins (bridging veins)
o
Blood accumulates between the dura and outer surface of arachnoid
Bleeding may be relatively rapid (acute) or gradual (chronic)
Blood will not appear in CSF if arachnoid is intact

1. Subarachnoid hemorrhage
2. Intracerebral hemorrhage

Anatomy, 302

1. Subarachnoid hemorrhage
2. Intracerebral hemorrhage

Anatomy, 303

1. Subarachnoid hemorrhage

Results from either a:

o
Contusion/laceration injury of the brian
o
Aneurysm of a cerebral artery (e.g., Berry aneurysm)
Injury tears a cerebral artery
Blood accumulates w/in subarachnoid sapce
Blood will appear in the CSF
o
Note: major arteries to brain travel w/in subarachnoid space and thus are
surrounded by CSF

Anatomy, 304

Blood w/in subarachnoid space irritates the meninges and causes a severe
headache, stiff neck, and loss of consciousness

2. Intracerebral hemorrhage

Results from either:

o
Contusion/laceration injury of the brain
o
Penetrating injury to the brain
Injury tears a cerebral artery, and blood accumulates w/brain parenchyma
Commonly arteries from circle of Wilis to basal gang&int capparalytic stroke
Blood may appear in the CSF