HI-YIELD FACTS IN ANATOMY [from MOORE & USMLE-ANATOMY roadmap] veins and L atrium veins [except of pulmonary circulation]

ARTERIES carry blood from heart to all areas of the body

CHAPTER 1 BASIC STRUCTURES AND CONCEPTS Type Functions Examples
SKELETAL SYSTEM Elastic Conducting arteries Aorta, pulmonary trunk, common carotid & subclavian A
Composed of 206 individual bones [80 - axial, 126 appendicular] Muscular Distributing arteries All other arteries
Functions: support, attachment, protection, storage [calcium, phosphorus], hemopoiesis Arterioles w/ precapillary sphincter Anywhere in the body
Axial skeleton Appendicular skeleton
Skull, vertebral column, rib cage, hyoid, Pectoral girdle and pelvic girdle, bones of CAPILLARIES smallest of the blood vessels, site of exchange between tissues and blood
auditory ossicles the upper and lower extremities VEINS carry blood back to heart from peripheral tissues
Type Characteristics
BONES consists of cancellous [spongy] and compact bone Venules w/ valves, smallest type, from confluence of several capillaries
Classification Examples Small veins w/ valves and smooth muscle in their walls
Long bones Clavicle, bones of extremities [except carpals, tarsals] Medium veins w/ valves and connective tissue + smooth muscle
Short bones Carpal bones [hand], tarsal bones [foot] Large veins No valves, w/ abundant elastic fibers and smooth muscle
Flat bones Ribs, sternum, scapula, calvaria Other components:
Irregular bones Vertebrae, hip bones, skull bones SINUSOIDS discontinuous capillaries larger than ordinary capillaries, found in adrenal &
Sesamoid bones Patella pituitary glands, liver, spleen, and bone marrow
PORTAL SYSTEM system of vessels interposed between 2 capillary beds, includes hepatic-
Clinical notes portal system and hypophyseal-portal system
Fracture
Due to trauma or atrophy from either osteoporosis [loss of bone mass] or disuse. LYMPHOID SYSTEM
Leads to avascular necrosis [loss of bone tissue caused by disruption of arterial supply] Functions: returns tissue fluids to venous system, provides immunologic defense & route for
lymphocytes + absorbed fats, important route for spread of malignant tumor.
JOINTS where 2 or more skeletal elements meet [either bone or cartilage] All lymph enters the venous system at the junction of internal jugular V. and subclavian V. in the
Innervated according to HILTONs law [nerves that supply muscles that move a joint also neck via R lymphatic duct on R side and thoracic duct on the L.
supply the joint and skin] Tissues that lack blood vessels also lack lymphatic vessels w/c include: epidermis, cartilage,
Classification Types Examples CNS and thymus.
Fibrous Sutures Skull Type Example Functions
Syndesmoses Tibiofibular, tympanostapedial joints Lymph Right Receives lymph from R side of head and neck through R jugular lymph
Cartilaginous synchondroses Epiphyseal plates, sphenooccipital synchondroses vessels lymphatic trunk, R upper extremity thru R subclavian trunk, R thoracic cavity thru R
symphysis Pubic symphysis, vertebral joints duct bronchomediatinal trunk
Synovial Plane/gliding Intercarpal, sternoclavicular, acromioclavicular Lymph Thoracic Receives lymph from most of the body below diaphragm, L and lower R
Hinge/ginglymus Elbow, knee, ankle joints nodes duct posterior intercostals spaces, L side of neck thru L internal jugular trunk, L
Pivot / trochoid Atlantoaxial, superior and inferior radioulnar upper extremity thru L subclavian trunk, and L side of thoracic cavity thru
Condyloid Metacarpo/metatarsophalangeal,atlantooccipital L bronchomediastinal trunk
Ellipsoid Radiocarpal/wrist joint
Saddle Carpometacarpal joint of thumb NERVOUS SYSTEM
Ball + socket Shoulder and hip joints [aka enarthroidal joint] Classificatio Features
n
Clinical notes Central NS Brain + spinal cord composed of gray matter [myelinated axons and neuroglia],
Bursitis inflammation of bursa results in bursitis w/c may limit movement of a joint.
Peripheral NS
and white matter [neuronal bodies and dendrites + neuroglia]
Afferent [conduct impulses from sensory receptors towards CNS], and efferent /
motor neurons [impulses away from CNS to periph. end organ]
MUSCULAR SYSTEM Somatic NS Control voluntary activities
Smooth Cardiac Skeletal Visceral NS Control visceral activities
Involuntary, nonstriated Involuntary, striated Voluntary, striated Other components:
In viscera, blood vessels In myocardium of heart Anywhere in the body Astrocytes physical support, repair, K+ metabolism, help maintain BBB. Its marker is GFAP.
Modulated by autonomic Does not receive direct
Microglia for phagocytosis
nerves, hormones, or innervations [contraction is
mechanical stimulation innervated by autonomic n. Neuron/nerve cell functional unit of nervous system, for communication.
Ganglion collection of neuronal cell bodies outside CNS.
Other structures: Oligodendrocytes glial cells that form central myelin for parts of multiple axons in the CNS.
Tendon Connects muscle to bone or cartilage Schwann cells are glial cells that form peripheral myelin for axons or processes in the PNS.
Ligament CT band that crosses a joint binding the articulating bones Ependymal cells lines inner lining of ventricles
CNS axons do not regenerate if cut while myelinated axons in PNS does regenerate down.
Clinical notes
Myasthenia gravis Clinical notes
Antibodies attack acetylcholine receptors resulting in defective neuromuscular transmission. Multiple sclerosis
S/Sx: bilateral ptosis, horizontal diplopia, dysphagia, dysarthria, and weakness in chewing and Both sensory and motor systems containing axons w/ myelin formed by oligodendrocytes
in musles of facial expression. Proximal limb muscles may be affected. Cardiac and smooth undergo an inflammatory reaction that impairs or blocks impulse transmission.
muscle are spared. Sensory and motor deficits can be seen in all areas of the body.
Most of them have thymic hyperplasia or thymoma. CN 2/optic nerve is affected because all of the myelin sheaths of its axons are formed by
Tx: Acetylcholinesterase inhibitors allowing acetylcholine to remain in synaptic cleft longer. oligodendrocytes. Optic neuritis is the presenting sign.
Lambert-Eaton syndrome Corticosteroid administration promotes remission.
An immunologic disorder of Ca+ channels in nerves at the end plate Guillain-Barre syndrome
Proximal muscles in limbs are primarliy affected; muscles innervated by CN are spared. Myelin formed by Schwann cells in PNS undergoes acute inflammatory reaction after a respiratory
Repetitive contractions of affected muscles temporarily increase in strength. or gastrointestinal illness. This also impairs or blocks impulse transmission.
Associated w/ small cell CA of the lung Motor axons are always affected producing weakness in limbs. Weakness of CN 6 and 7 or
respiratory muscles may be seen. Sensory deficits are mild or absent.
VASCULAR SYSTEM Antibodies to peripheral myelin are removed by plasmapheresis or autoimmune attack is blocked
A. Blood vascular system by administration of gamma globulin. Patients often completely recover.
Functions: carries oxygen, absorbed nutrients and waste products, promotes healing Schwannomas
Pulmonary circulation Systemic circulation Benign encapsulated schwannomas of vestibular nerve [CN 8] may develop affecting hearing and
Transports blood from R side of heart to lungs Transports blood from L side of heart to the balance. Large acoustic schwannomas may compress facial nerve [CN 7] or trigeminal nerve
and back to L side of heart body [except lungs] and back to R side of heart [CN V].
Facilitates exchange of O2 & CO2 in LUNGS Facilitates exchange of O2 & CO2 in TISSUES Bilateral acoustic schwannomas are seen in pxs w neurofibromatosis type 2.
R ventricle, pulmonary arteries, capillaries, L ventricle, R atrium, all arteries, capillaries,

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CRANIAL NERVES - 12 pairs w/c arise from brainstem: sensory = CN 1, 2, 8; motor = CN 3, 4, 6, Facial N. reflexes
11, 12; mixed = CN 5, 7, 9, 10. [Refer to Netter p. 112] Blink reflex uses sensory fibers of the ophthalmic division of CN 5 and skeletal motor fibers of
Some Say Marry Money But My Bride Says Big Brains Matter Most facial N. [CN 8]. Causes direct and consensual blink that results from bilateral contraction of
Name Lesions result in Functions orbicularis oculi muscles.
CN 1 olfactory [S] Anosmia Smell Lacrimal reflex also uses sensory fiber of CN V1 and results in an increase in lacrimal secretions
CN 2 optic [S] Anopsia, loss of light reflex w/ Vision, Only nerve affected by multiple in response to touching the cornea or in response to chemical stimulants.
CN 3 sclerosis Taste salivary reflex, stimulation of taste receptors on the anterior 2/3 of tongue may cause an
CN 3 oculomotor [M] Diplopia, external strabismus, EOM: SR, IR, MR, IO, LPS [except LR increase in salivary gland secretions.
loss of parallel gaze, ptosis, and SO] Facial N. lesions
loss of near response Accommodation of near vision Occur in facial canal and result in Bells palsy. Pxs manifest w/ weakness of muscles of facial
CN 4 trochlear [M] Diplopia, difficulty reading, EOM: superior oblique expression on side of injured nerve. There is weakness in the ability to shut the eye, nasal flaring,
going down stairs, head tilting and wrinkle the forehead. There is also drooping of corner of the mouth. They may have pain
CN 5 trigeminal Loss of sensation in skin of Sensation to scalp, face, jaw, oral behind the external auditory meatus resulting from involvement of the general sensory fibers of the
[mixed] forehead, scalp, cornea, Movements of masticators, facial posterior auricular nerve.
maxilla, mandible, tongue, loss Lesions of facial N. at genicuate ganglion may have alterations in taste sensations [from anterior
of blinking reflex, chewing loss 2/3 of tongue and palate], a reduction in salivary gland secretions [from submandibular and
CN 6 abducens [M] Diplopia, internal strabismus, EOM: lateral rectus adducts eyeball sublingual glands] and a dry eye [from a reduction of lacrimal secretions].
loss of parallel gaze Hyperacusis [hypersensitivity to loud sounds] may result if nerve to stapedius is affected.
CN 7 facial [mixed] Mouth drooping, cannot close Facial expression muscles As pxs recover from a facial nerve lesion, they may experience synkinesis, w/c results from
the eye, wrinkle forehead, loss Secretomotor [salivary glands] misdirected regenerating motor axons.
of blink reflex, hyperacusis, Taste: anterior 2/3 of tongue Distal to stylomastoid foramen, a tumor of the parotid gland may compress muscular branches of
altered taste, reduction of Visceral sensation: body
facial N. as they traverse the gland and may result in a weakness of muscles of facial expression
saliva and other secretions Somatic sensation: ear
but no sensory deficits, hyperacusis or alteration of glandular secretions.
CN 8 cochlear Sensorineural hearing loss, Equilibrium [linear & angular
Vestibulocochlear [S] loss of balance, nystagmus acceleration], balance, hearing SPINAL NERVES
CN 9- Loss of sensory limb of GAG Stylopharyngeus muscle Consists of 31 pairs [8 cervical, 12 thoracic, 5 lumbar, 1 coccygeal]
glossopharyngeal reflex w/ CN 10 Secretomotor: parotid gland
Formed by union of dorsal root and ventral root at intervertebral foramen
[mixed] Reduction of saliva Taste: posterior 1/3 of tongue
Visceral: pharynx, 1/3 of tongue Other components:
Somatic: tympanic membrane At T1-L2, trunk of spinal nerve contains preganglioninc symphathetic fibers from cell bodies in the
CN 10 vagus Nasal speech, nasal Pharynx, larynx, soft palate intermediolateral cell column of spinal cord
[mixed] regurgitation, palate droop, Cardiac, smooth, glands At S2-4, trunk and proximal ventral rami contain preganglioninc parasymphathetic fibers from cell
deviation of uvula away from Taste over epiglottis bodies in sacral parasymphathetic nucleus of spinal cord. They leave the ventral rami as pelvic
lesioned nerve, dysphagia, Visceral sensation and reflexes splanchnic nerves [nervi erigentes]
loss of GAG reflex w/ CN 9, Somatic: ear and dura
loss of cough reflex, miosis, AUTONOMIC NERVOUS SYSTEM
anhydrosis, & ptosis [Horners] Innervates visceral organs [vascular, glandular], motor to cardiac, smooth muscles and glands, it
CN 11 accessory Weakness in turning head to Joins vagus to larynx distribution also maintains homeostasis
Spinal portion opposite side, shoulder droop, Sternocleidomastoid, trapezius Above and below T1 to L2-3 levels of spinal cord, there are no more white rami.
difficulty in combing the hair Divisions Features
CN 12 - hypoglossal Tongue deviation on protrusion Intrinsic/extrinsic tongue m. [except Symphathetic NS Activates bodys response to stress [fight or flight reponse]
toward leisioned nerve palatoglossus] Parasymphathetic NS Also called craniosacral flow [from S2-4 spinal cord], part of
CN 3,7,9,10, supplies cardiac, smooth and glands but does not
Clinical notes [rest or digest] innervate blood vessels [except erectile tissue of ext. genitalia]
Olfactory N. lesions
May cause hyposmia, dysosmia or anosmia. Autonomic nerve functions:
Olfactory deficits may be caused by a fracture of cribriform plate; w/c damages the primary Features Sympathetic Parasympathetic
olfactory neurons. SA node Increases HR Decreases HR
Fracture of cribriform plate may also tear the meninges [of the olfactory bulb and result in AV node conduction delay conduction delay
CSF rhinorrheadischarge of CSF from the nostrils]. Cardiac output contractility and velocity of contractility and velocity of
Oculomotor N. lesions conduction conduction
Caused by compression by a herniated part of hemisphere or by a berry aneurysm tend to Blood vessels Generally constricts Generally dilates
affect the parasympathetic fibers 1st resulting in a dilated pupil [mydriasis] and suppression of Skin, mucosa, salivary glands Generally constricts Little effect
papillary light reflex. Radial muscle of iris Dilates pupil; mydriasis -
Complete lesion results most dramatically in an inability to adduct eyeball. Sphincter muscle of iris - Constricts pupil; miosis
Pxs may have external strabismus [laterally deviated eyeball] that results from unopposed Ciliary muscle Relaxes for far vision Contracts
contractions of lateral rectus and superior oblique. Trachea, bronchi, lungs Relaxes, allows dilation Constricts
It may also result in ptosis; w/c is due to weakness of skeletal motor part of levator palpebrae Gastrointestinal structures Inhibits Stimulates peristalsis
superioris muscle. Internal anal sphincter Contributes to contraction Contributes to relaxation
Trochlear N. lesions Urinary bladder Inhibits Contracts
Results in diplopia, when a px attempts to depress the adducted eye. Uterus Variable Variable
Pxs may experience difficulty in reading or difficulty in going down the stairs. Arrector pili muscles Contracts No effect
They may tilt their head away from side of the leioned nerve w/c resuts from weakness in the Salivary glands viscosity of secretion Stimulates secretion
ability to rotate the affected eyeball inward [intorsion]. The head tilt is an attempt to counteract Lacrimal gland, nasal glands No direct effect Stimulates secretion
the extorsion by the unopposed inferior oblique and inferior rectus muscles. Gastrointestinal glands Inhibits Stimulates
A head tilt observed in pxs w/ trochear nerve lesion might be mistaken for torticollis caused by Sweat glands Stimulates secretion -
abnormal contractions of sternocleidomastoid muscle. Adrenal medulla Simulates secretion -
Abducens N. lesions Pineal gland Increases synhesis and -
Result in weakness in the ability to fully abduct the eye. The superior and inferior oblique release of melatonin
muscles act to partially abduct the eye. Pxs may have internal strabismus [medially deviated Erection - Facilitates
eyeball] because of the unopposed contractions of medial rectus muscle and other adductors Secretion No direct effect Facilitates
innervated by CN 3. Emission Facilitates No direct effect
Abducens nerve is MC the 1st nerve to be affected in a thrombosis of cavernous sinus.
Hypoglossal N. lesions Clinical notes
Result in deviation of tongue towards side of the injured nerve on protrusion. They may Horners syndrome
experience dysarthria and difficulty moving a bolus of food from the oral cavity into the
oropharynx.

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 Lesion in either preganglionic or postganglionic sympathetic neurons that innervate sweat Skeleton at Distal humerus Accounts for carrying angle in the elbow
glands and blood vessels in face and scalp or 2 smooth muscles in the orbit. The smooth elbow Proximal radius Where biceps brachii tendon attaches
muscle elevates the upper eyelid and dilates the pupil. Proximal ulna Where triceps brachii tendon attaches
S/Sx: anhydrosis [inability to sweat on corresponding side of the face], ptosis [drooping of Skeleton of Distal radius w/ dorsal tubercle of LISTER for ext. pollicis longus
upper eyelid], miosis [pupil constriction] wrist and Distal ulna For articulation w/ articular disc
hand Phalanges 2 for thumb, 3 for fingers, forms the knucles
Metacarpals [5] 2nd metacarpal is the longest
Shy-Drager syndrome Carpal bones [8] Pisiform last to ossify [10-12 yrs], capitate 1st to ossify [2-3
Degeneration of preganglionic sympathetic and parasympathetic neurons in brainstem and mos.] Some Lovers Try Position That They Cant Handle
spinal cord and degeneration of neurons in most ganglia. This may be combined w/ loss of Proximal [lat-medial] scaphoid, lunate, triquetrum, pisiform
other non-autonomic CNS neurons. Distal [lat-medial] trapezium, trapezoid, capitate, hamate
S/Sx: impotence, urine retention, dizziness on standing, blurred vision, and inability to sweat.
Hirschprungs disease [aganglionic megacolon] Clinical notes
Clavicular fracture
Failure of neural crest cells either to migrate into the wall of descending colon, sigmoid colon,
Commonly fractured at its weakest point between middle third and lateral third.
or rectum or to differentiate into terminal parasympathetic ganglia in these areas.
It results in absence of perisalsis in the affected segment and a distended bowel proximal to Middle 2/3 may be elevated by sternocleidomastoid and lateral 3rd may be depressed by weight
that segment. of the limb or adducted by petoralis major.
The ventral rami of C8-T1 in medial cord of brachial plexus may be lacerated due to fracture.
Reflexes autonomic motor response to a sensory stimulus, examples include: Shoulder trauma to acromioclavicular joint
Muscle stretch Muscle spindles in skeletal muscles are stimulated by stretch causing a May be caused by subluxation of aromion at the acromioclavicular joint. The coracocavicular
reflexes reflex contraction of that same muscle ligament w/c extends from the acromion, prevents dislocation at acromioclavicular joint.
Autonomic Sensory stimuli cause reflex contraction of smooth muscle, the secretion of Colles fracture
reflexes a gland, or a change in rate and force of contraction of cardiac muscle Fracture at distal radius may result in avulsion of styloid process from shaft of radius. May exhibit
Cranial nerve Use sensory and motor fibers in 1 or more cranial nerves and include dinner-fork deformity as a result of the posterior displacement of the distal radius.
reflex papillary light reflex, blink reflex, gag reflex, and cough reflex. Lunate dislocation
MC disLocated carpal bone. Typically dislocated anteriorly into the carpal tunnel. This may
Clinical notes cause carpal tunnel syndrome.
Reduced sensation [hypesthesia] and altered sensation [paresthesia] are sensory signs. Scaphoid fracture
Weakness [paresis] of skeletal muscles is a motor sign. MC fractured carpal bone
Nerve lesions are destructive when nerves are severely compressed or severed, resulting in a S/Sx: pain and tenderness localized over anatomic snuffbox. The proximal part of scaphoid may
loss of abiity of nerves to conduct impulses. undergo vascular necrosis because blood supply to bone supplies distal part first then proximal.
Lesions to sensory fibers result in loss of sensory modality or modalities carried by fibers in
that nerve [anesthesia]. Joints of upper extremity
Lesions to motor fibers result in paralysis of denervated skeletal muscles. Denervated skeletal Name of joint Type Features
muscle fibers exhibit fasciculations [random twitches seen beneath skin] and may atrophy. Sternoclavicular Ball and socket Only joint btw trunk and upper limb
Acromioclavicular Atypical synovial Dislocated w/ fall on outstretched hand
CHAPTER 2 UPPER EXTREMITY Shoulder Ball and socket Supplied by axillary, suprascapular, lat. Pectoral nerves,
[glenohumeral] joins upper extremity to pectoral girdle
AXILLA, PECTORAL REGION AND SHOULDER [refer to Neter p. 400] Elbow Synovial hinge Strengthened by medial and lateral collateral ligament
Boundaries of the axilla Proxl radioulnar Synovial pivot Annular lig. - Chief ligament of proximal radioulnar jt.
Base: axillary fascia and skin of armpit Distal radioulnar types of joint Distal radioulnar jt - provide the strongest attachment
Apex: clavicle anteriorly, 1st rib medially, superior border of scapula posteriorly
Medial wall: upper rib cage Joints of wrist and hand
Name of joint Type Features
Lateral wall: intertubercular groove
Radiocarpal Condyloid Does not includes the ulna or pisiform bones
Anterior wall: pectoralis major and minor muscle
Midcarpal Plane / ellipsoid Allows flexion, extension, abduction and adduction
Posterior wall: subscapularis, teres major and latissimus dorsi muscles
Carpometacarpal Saddle type [1st] Flexion, extension, abduction, adduction, opposition
Boundarie Quadrangular space Triangular space Metacarpophalangeal Condyloid Flexion, extension, abduction, adduction, rotation
s
Interphalangeal Hinge Allows only flexion and extension
Lateral Surgical neck of humerus Shaft of humerus
Medial Long head of triceps brachii Long head of triceps brachii Veins of upper extremity [refer to Netter p. 400]
Superior Teres minor, subscapularis Teres major Location Name of vein Distribution Drainage
Inferior Teres major None Superficial Dorsal venous arch Back of hand Cephalic [lateral] and basilic [medial]
veins Cephalic veins Lateral forearm Axillary vein
Quadralateral space
Basilic veins Medial forearm Axillary vein
Above: subscapularis [front], teres minor behind]
Median cubital Cubital fossa Connects cephalic to basilica vein
Below: teres major Median antebrachial Middle forearm
Lateral: surgical neck of humerus Deep veins Axillary vein Main venous structure draining the upper extremity, it
Medial: long head of triceps [brachial + basilic] becomes the subclavian vein at outer border of 1 st rib
Contents: passage for axillary joint
Arteries of upper extremity [refer to Neter p. 398, 435]
Name of artery Features
Axillary lymph nodes Subclavian A. Branch: thyrocervical trunk w/c divides into:
Name Distribution Suprascapular A.
Lateral/ brachial nodes Upper extremity except vessels following cephalic vein Transverse cervical A. deep branch gives rise to dorsal scapular A.
Posterior/ subscapular nodes Shoulder, trunk, lower neck
Axillary A. 1st part gives rise to superior or highest thoracic A.
Pectoral/ anterior nodes Breast and anterior chest wall [shoulder] 2nd part gives rise to thoracoacromial and lateral thoracic A.
Central nodes Receives lateral, posterior and pectoral nodes 3rd part gives rise to subscapular [largest branch], anterior and posterior
Apical nodes Receives lymph from all other groups humeral circumflex
Brachial A. [arm] Branches: profunda brachii, superior and inferior ulnar collateral arteries,
Bones of upper extremities [refer to Netter p. 391-392, 407, and 426] muscular, nutrient A. to humerus
Division Type Features Radial A. [forearm] Branches: radial recurrent A., muscular and superficial palmar branch, 1 st
Pectoral Clavicle or MC fractured at middle and lateral third. Only bone to dorsal metacarpal branch, arteria princes pollicis, arteria radialis indicis
girdle and collar bone undergo intramembranous ossification, 1st to ossify 5-6 wks Ulnar A. [forearm] Branches: anterior and posterior ulnar recurrent, the common, anterior and
proximal Scapula or Overlies 2nd-7th ribs posterior interosseous, deep palmar arch [palmar, metacarpal, perforating br.]
humerus shoulder blade Articulates w/ clavicle and humerus Scapular anast. Joins axillary system w/ subclavian system
Elbow joint ansas. Joins branches of brachial A. w/ radial & ulnar A.

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Wrist & arm anast. Joins branches of radial & ulnar A. Head of humerus is commonly displaced inferiorly then anteriorly and becomes positioned just
inferior to coracoid process. This may stretch the axillary or radial nerve.
Lymphatic drainage of upper limb Humeral fracture
Name of nodes Features In a fracture of the surgical neck of humerus, axillary neve may be lesioned, and posterior
Axillary LN Drains from entire upper limb , located as follows: anterior pectoral, posterior circumflex artery may be lacerated.
subscapular, lateral, infraclavicular/deltopectoral and apical LN Fracture on the greater tubercle of humerus may result in avulsion of greater tubercle and
Supratrochlear LN Aka cubital LN which drains from medial fingers, medial arm and forearm detachment of the rotator cuff muscles from humerus.
A transverse fracture of humerus distal to deltoid tuberosity may result in abduction of proximal
Clinical notes fragment by deltoid muscle.
Volkmanns ischemic contracture In a midshaft spinal fracture of humerus, the radial nerve may be lesioned and the profunda
Caused by supracondylar fracture of humerus w/c compress brachial A. resulting in brachii artery may be lacerated.
In supracondylar fracture of humerus, contraction of triceps and brachialis may shorten the arm.
ischemia of forearm &hand. The hand is flexed at wrist & fingers are flexed at the
Median nerve may be lesioned as a result of an intercondylar or supracondylar fracture of the
interphalangeal joints.
distal end of humerus.
Dupuytrens contracture
In fracture of medial epicondyle of humerus, the ulnar nerve may be lesioned.
Caused by fibrosis and shortening of palmar aponeurosis. Thickening and shortening of the
bands of aponeurosis over the flexor tendons results in flexion of ring and little fingers.
Epicondylitis
Brachial plexus [from ventral rami of spinal nerves C5-T1] LaTEral epicondyitis [TEnnis elbow] infammation of common extensor tendon that results from
Branch Name Distribution forced extension and flexion of the forearm at the elbow. Pxs exhibit pain over the lateral
Lateral cord Lateral pectoral [C5-7] Pectoralis major and minor muscles epicondyle w/c may radiate down the posterior aspect of forearm.
Medial cord Medial pectoral [C8, T1] Pectoralis major and minor muscles Medial epicondylitis [golfers elbow] inflammation of common flexor tendon that results from
Medial brachial cutaneous [C8-T1] Skin on medial aspect of arm repetitive flexion and pronation of forearm at elbow.
Medial antebranchial cutaneous Skin of forearm
Posterior Upper subscapular [C5-6] Subscapularis, upper part ARM AND FOREARM
Thoracodorsal [C6-8] Latissimus dorsi Cubital fossa [refer to Netter p. 402]
Lower subscapular [C5-6] Subscapularis, lower part bounded by: brachioradialis [lateral], pronator teres [medial], brachialis and supinator [floor], skin,
fascia and bicipital aponeurosis [roof]
Terminal branches of brachial plexus Medial to lateral contents: median N., fats, brachial A. bifurcation, biceps tendon, radial and
Name Features Origin ulnar A, radial N.
Musculocutaneous [C5-7] Supplies coracobrachialis, brachialis, biceps brachii Lateral crossed superficially by median cubital V. [for phlebotomy]
Axillary [C5-6] Supplies deltoid, teres minor and major muscles Posterior
Radial [C5-8, T1] Largest branch of brachial plexus and is the Posterior Muscles of the Upper Arm [refer to Netter p. 403]
sole innervation of extensor compartments of Name Innervation Actions
arm and forearm, supplies most of the cutaneous Coracobrachialis Musculocutaneous N. Flex and adduct arm
innervations to back opf arm, forearm and hand Brachialis Musculocutaneous N. Flex elbow joint
Ulnar [C8, T1] Main nerve to small muscles of the hand Medial Biceps brachii Musculocutaneous N. Flex elbow joint, supinates forearm
Median [C5-8, T1] Supplies all muscles in anterior forearm [except Triceps brachii Radial N. Extends elbow joint
flexor carpi ulnaris and ulnar half of flexor Anconeus Radial N. Extends elbow joint
digitorum longus ulnar N., brachioradialis
Branch: radial N.], also supplies thenar muscles and lateral 2 Muscles of flexor compartment of forearm [refer to Netter p. 402 & 416]
Anterior interosseous nerve lumbricals Name Innervation Actions
Supplies flexor pollicis longus, lateral half of flexor Superficial group
digitorum profundus and pronator quadratus Pronator teres Median nerve Pronates forearm
Flexor carpi radialis Median Flex and adducts hand
Muscles of pectoral girdle and shoulder Palmaris longus Median Flex hand
Muscles that move shoulder girdle Flexor digitorum superficialis Median Flexes PIP
Name Innervation Flexor carpi ulnaris Ulnar nerve Flex and adducts hand
Trapezius Accessory N. [motor], C3-4 [sensory] Deep group
Latissimus dorsi Thoracodorsal N. Pronator quadratus Median Pronates forearm
Rhomboid major and minor Dorsal scapular N. Flexor pollicis longus Median Flex interphlangeal joint of thumb
Levator scapulae Dorsal scapular N. [motor], C3-4 [sensory] Flexor digitorum profundus Ulnar nerve Flexes DIP
Serratus anterior Long thoracic N.
Pectoralis minor Medial pectoral N. Muscles of extensor compartment of forearm [refer to Netter p. 403 & 414]
Subclavius Nerve to subclavius [upper trunk of brachial] Name Innervation Actions
Superficial group
Rotator [musculotendinous] cuff muscles major stabilizing factor for shoulder joint Brachioradialis Radial Flex elbow
Name [from top SITS] Innervation Extensor carpi radialis longus Radial Extends and abducts hand
Supraspinatus Suprascapular N. Ext. carpi radialis brevis Radial Extends and abducts hand
infraspinatus Suprascapular N. Extensor digitorum Radial Extends phalanges and wrist
Teres minor Axillary N. Extensor digiti minimi Radial Extends 5th finger
Subscapularis Upper and lower subscapular N. Extensor carpi ulnaris Radial Extends and abducts hand
Deep group
Other muscles that move the humerus Supinator Radial Supinates forearm
Name Innervation Abductor pollicis longus Radial Abducts thumb
Pectoralis major Lateral pectoral N. Extensor pollicis brevis Radial Extend thumb
Deltoid Axillary N. Extensor pollicis longus Radial Extends thumb
Latissimus dorsi Thoracodorsal N. Extensor indicis Radial Extend index finger
Teres major Lower subscapular N.
WRIST AND HAND
Clinical notes Carpal tunnel
Inflammation of Rotator cuff Formed poseriorly by 8 carpal bones.
Tendon of supraspinatus is most commonly affected. Contents: median nerve, flexor digitorum superficialis & profondus, flexor pollicis longus.
Pxs w/ rotator cuff tears experience pain anterior to glenohumeral joint during abduction. Phalens test dorsal surface of both hands pressed together w/ wrist flexion produces
Humeral dislocation pain
Tinels test tapping the median nerve produces pain

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 Canal of Guyon musculocutaneous n. main branch of the lateral cord
Located btw pisiform and hook of hamate superficial to carpal tunnel. The ulnar nerve, ulnar radial n. biggest branch of brachial plexus
artery, and ulnar vein cross the wrist and pass into the hand after traversing the canal. hearT-shaped vertebra = Thoracic
Anatomic snuffbox [refer to Netter p. 434] kidney-shaped vertebra = lumbar
Lateral: tendons of abductor pollicis longus and extensor pollicis brevis Brachioradialis
Medial: extensor pollicis longus Function: beer raising muscle, flexes the elbow
Floor: scaphoid and trapezium Strongest when writ is oriented like holding a beer
Contents: radial artery Innervation: its a flexor muscle but innervated by radial nerve
Its skin is innervated by superficial branch of radial nerve The only flexor muscle supplied by radial nerve
Thenar muscles [radial nerve usually supplies the extensors]
Name Innervation Actions
Abductor pollicis brevis Median N. Abducts thumb CHAPTER 3 LOWER EXTREMITY
Flexor pollicis brevis Median N. Flex metacarpophalangeal jt. Thumb
Opponens pollicis Median N. Opposes thumb to other digits Bones of lower extremities
Adductor pollicis Ulnar N. Adducts thumb Division Type Features
Pelvic Pubis Forms the anterior and medial part of hipbone
Hypothenar muscles girdle Ilium Forms the lateral part of hipbone
Name Innervation Actions
Ischium Posterior and inferior part of hipbone
Abductor digiti minimi Ulnar N. Abducts little finger
Acetabulum Formed by ilium, ischium and pubis
Flexor digiti minimi brevis Ulnar N. Flexes metacarpophalangeal jt [LF]
Femur w/ fovea capitis [ligament of head], quadrate tubercle [quadratus femoris]
Opponens digiti minimi Ulnar N. Opposes little finger to thumb, helps in
cupping the palm Patella Largest bone to develop w/in tendon of a muscle , a sesamoid bone
Palmaris brevis Ulnar N. Tenses skin on medial palm Tibia Weight-bearing bone of the leg, w/tibial tubrosity [patellar ligament]
Fibula Non-weight bearing bone of the leg, w/ interosseous border
Interosseus and lumbrical muscles
Name Innervation Actions Joints of the lower extremities
Palmar interossei [3] Ulnar N. Adduct fingers, flex metacarpal jts Sacroiliac joint Synovial Only joint btw pelvic girdle and axial skeleton
Dorsal interossei [4] Ulnar N. Abduct fingers, flex metacarpal jts Hip joint Ball and socket Strengthened by 3 ligaments: iliofemoral [strongest],
pubofemoral, and ischiofemoral lig.
Lumbricals [4] Medial [1,2] - ulnar Flexes metacarpophalangeal jts., extend
Lateral [3,4] median interphalangeal jts Knee joint Modified hinge jt Located btw patella and femur, formed by lateral and
medial condyles of femur and tibial plateus
NOTE: C6 dermatome thumb, C8 little finger
Ankle joint Synovial hinge jt Include the talocrural, subtalar, and transverse tarsal joints
Arteries of hand
Name Branches Ligaments of the lower extremity
Radial A. Dorsal digital A., princeps pollicis A., radialis indicis A. Name Features
Ulnar A. Deep palmar and superficial palmar arch Iliofemoral Strongest and most important ligament of the hip joint
Dorsal carpal arch 3 dorsal metacarpal A., dorsal digital A. Ischiofemoral Thinnest of the ligaments of hip joint
Pubofemoral Resists excessive abduction of hip joint
Thenar & midplamar spaces Patellar ligament Anterior ligament of knee joint
Thenar space Contents: 1st lumbrical, long flexor tendon [thumb and index finger] Tibial collateral Important stabilizer of knee joint
Midpalmar space Contents: lumbricals, long flexor tendons of medial 3 fingers Fibular collateral Is taut and stabilizes the joint best when knee if fully extended
Anterior cruciate Maximally taut and stabilizes the joint best w/ fully extended knee
Nerve injuries of upper extremities [refer to Netter p. 441] Posterior cruciate Maximally taut and stabilizes the joint best w/ fully extended knee
Injury Affected Causes Manifestations Menisci of knee joint Shock absorbers, lateral meniscus is more movable
Erb-duchenne C5-6 spinal n. Violent fall on shoulder [ex. Waiters tip hand
palsy upper [superior trunk] motorcycle], birth injury Clinical notes
Klumpkes C8-T1 spinal n. All from a height, birth injury Clawhand or ape-hand Fracture of Femoral neck
paralysis - lower [inferior trunk] deformity [cannot fist] The head of femur may undergo avascular necrosis as a result of disruption of the branches of
Thoracodorsal N. Latissimus dorsi Improper use of crutch, [+] Crutch palsy or Saturday medial circumflex femoral artery [main source of arterial supply to head & neck of femur]
difficulty in elevating trunk night palsy In pxs w/ fractures of the femoral neck, the thigh is laterally rotated by the short lateral rotators of
Long thoracic N. Serratus anterior Paralysis of serratus Winged scapula the thigh at the hip and the gluteus maximus.
anterior, cant abduct above Dislocation of femoral head
the horizontal This most commonly occur in posterior direction. The thigh is shortened and medially rotated by
Musculocutaneous Biceps and Waiters tip hand gluteus medius and minimus muscles.
nerve brachialis The sciatic nerve may be compressed, resulting in weakness of muscles in the posterior thigh,
Axillary nerve Deltoids Fracture of surgical neck of Crutch pressure injury leg, and foot, and paresthesia over the posterior and lateral parts of the leg and the dorsal and
humerus or inferior plantar surfaces.
dislocation of shoulder jt. Knee injuries
Radial nerve Extensors of Improper deltoid injection or Wristdrop The 3 most commonly injured structures at the knee are the tibial collateral ligament, medial
wrist and fingers tight cast, meniscus and ACL [the terrible triad].
Median nerve Thenar nuscles, Numb palm and finger, Papal benediction & A blow to lateral apect of knee when foot is on the ground may sprain the tibial collateral
[recurrent lateral 2 fingers, inability to flex fingers, in forearm ape-like hand ligaments; the medial meniscus may also be torn.
branch] lumbricals typist, as in Dupuytrens Carpal tunnel syndrome ACL tears may occur when tibial collateral ligament and medial meniscus are injured; a blow to the
Ulnar nerve Medial 2 Inability to adduct/abduct Ulnar Clawhand anterior aspect of the flexed knee may tear only ACL.
lumbricals fingers, interosseous atropy Pxs w/ a torn ACL exhibit an anterior drawer sign, in w/c tibia may be displaced anteriorly from
Suprascapular N. Waiters tip position the femur in the flexed knee.
Spinal accessory Drooping of shoulder Ankle sprains
Inversion ankle joints are more common than eversion sprains at the talocrural joint. The anterior
RAPID REVIEW talofibular part of the lateral ligament is commonly torn in inversion ankle sprains.
Muscles of the flexor forearm compartment NOT supplied by median nerve are the:
flexor carpi ulnaris and ulnar half of flexor digitorum longus [w/c are supplied by ulnar nerve] Veins of lower extremity
The only THENAR muscle NOT supplied by median nerve is the adductor polis [w/c Location Name of vein Distribution Drainage
is supplied by ulnar nerve] Superficial Dorsal venous arch Dorsum of foot Small + great saphenous V.
Not strictly a thenar muscle adductor pollicis muscle Small saphenous Posterior leg Popliteal vein
All interosseus and lumbrical muscles are supplied by ulnar nerve EXCEPT the lateral Great saphenous Anterior leg Popiteal
2 lumbricals [w/c are supplied by median nerve] Deep veins Venae comitantes Paired, runs alongside of arteries

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 Femoral vein Main venous structure draining the lower extremity Tibial N. Principal nerve to posterior thigh and leg, sole of foot, divides into medial
plantar N. [w/c innervates flexor digitorum brevis, flexor hallucis brevis,
Arteries of lower extremity abductor hallucis and 1st lumbrical] and lateral plantar N. [w/c innervates skin
Name Origin Branches of lateral side of the sole of foot and lateral digits.
Femoral A. External iliac A. Superficial circumflex iliac, superficial epigastric, Common fibular / Innervates the short head of biceps femoris, divides into superficial and deep
superficial and deep external pudendal, profunda peroneal nerve fibular N. as it enters he fibularis longus muscle.
femoris and descending genicular arteries Superficial fibular Innervates the fibularis longus and brevis muscles
Popiteal A. Femoral A. Muscular br., articular br. to knee joint, terminal Deep fibular N. Innervates tibialis anterior, extensor hallucis longus, extensor digitorum
branches [anterior and posterior tibial arteries] longus, and peroneus tertius muscle
Anterior tibial A Popliteal A. Muscular and anastomotic branches
Dorsalis pedis Anterior tibial A. Lateral tarsal, arcuate & 1st dorsal metatarsal A. Clinical notes
Posterior tibial Popliteal A. Peroneal, nutrient A. to tibia, medial & lateral Superficial gluteal N. lesions
plantar, muscular branches & anastomotic branches This pxs have weakness in the ability to abduct the thigh at the hip. They experience a waddling
Internal iliac A. Common iliac A. Superior & inferior gluteal, and obturator artery or trendelenburg gait, in w/c the pelvis sags on side of the unsupported limb.
Inferior gluteal N. lesions
Clinical notes This pxs have a weakness in the ability to laterally rotate and extend the thigh at the hip.
Cruciate anastomosis in posterior thigh is formed by medial and lateral circumflex They have difficulty extending the thigh at the hip from a flexed position as in climbing the stairs or
femoral A., inferior gluteal A. and 1st perforating A. This may contribute to collateral rising from a chair.
circulation of lower limb if femoral artery becomes occluded. Pxs may have a gluteus maximus gait in w/c they thrust their torso posteriorly in an attempt to
Anastomosis around knee joint is formed by descending genicular A. [from femoral A.], counteract the weakness of the gluteus maximus.
lateral femoral circumflex A. [from profunda femoris], articular branch [from popliteal A.],
and branches from anterior and posterior tibial A. Sciatic N. lesions
Dorsalis pedis pulse may be evaluated by compressing the dorsal artery of foot against tarsal Susceptible to damage from an IM injection in the lower medial quadrant of gluteus maximus
bones lateral to tendon of extensor hallucis longus. muscle, or it may be compressed as a result of posterior dislocation of the femur.
Foot drop all muscles of the knee are paralyzed due to sciatic nerve lesion.
Nerves of lower extremity Common fibular N. lesions
Name of nerve Features It is the most frequently lesioned nerve in lower limb. This usually occurs as it passes around neck
Lumbosacral Formed by ventral rami of L4 thru S3. The posterior and anterior division of fibula.
plexus form 2 terminal nerves: common peroneal/fibular N., and tibial N. Pxs experience foodrop w/c results from a loss of dorsifexion at the ankle and loss of eversion.
Lumbosacral trunk Formed by fibers of L4 and L5 They also have pain and paresthesia in the lateral leg and dorsum of the foot.
Pxs w/ foodrop may have steppage gait in w/c they raise their affected leg high off the ground
Terminal nerves of the lumbar plexus and their foot slaps the ground when walking.
Name Component Features In piriformis syndrome, the common fibular nerve may be compressed by fibers of the piriformis
s muscle when the nerve passes thru the piriformis rather than anterior to it w/ tibial N.
Femoral N. L2-4 Largest branch of lumbar plexus, w/ cutaneous br. [gives Superficial fibular N. lesions
rise to saphenous N., medial and intermediate cutaneous The nerve may be lesioned as he nnerve emerges from lateral compartment of the leg. Pxs
N. of thigh] , muscular br. & articular branches., susceptible experience pain and paresthesia in the dorsal aspect of the foot.
to injury Deep fibular N. lesions
Saphenous Femoral N. Only branch of femoral N. to extend below the knee The nerve may be compressed in the anterior compartment of the leg. This pxs may have footdrop
Obturator N. L2-4 Branches: anterior, posterior, and articular branches and parethesia in skin of the webbed space btw the great toe and 2nd toe.
Clinical notes Lymphatics of lower extremity
Femoral N. lesions Name Distribution
The femoral nerve may be damaged in the abdomen by an abscess of the psoas major. Superficial inguinal nodes Receive lymph from thigh, foot, leg, buttock, perineum
Pxs experience weakness in the ability to flex thigh at the hip, weakness in the abiity to extend Deep inguinal nodes Receive lymph from deep structure of thigh and leg
the leg at the knee, and a diminished patellar tendon reflex.
Popliteal LN Receive lymph from deep structures of leg below the knee
Saphenous N. lesions
Saphenous nerve may be lesioned during a surgical procedure of the leg to remove part
GLUTEAL REGION
of the great saphenous vein, or it may be lacerated as it pierces the wall of adductor canal. Pxs Important features of gluteal region
experience pain and paresthesia in the skin of the medial aspect of leg and foot.
Sacrotuberous lig. Connects posterior iliac spines, sacrum, coccyx to ischial tuberosity
Obturator N. lesions
Sacrospinous lig. Connects posterior surface of sacrum and coccyx w/ ischial spine
Obturator nerve is commonly lesioned in the pelvis. Pxs are unable to adduct the thigh
Greater sciatic Transmits: piriformis M., sciatic N., superior and inferior gluteal N. and
at he hip and may have paresthesia in skin of the medial thigh.
foramen vessels, pudendal N., internal pudendal A and V, posterior femoral
cutaneous N, nerve to quadratus femoris and obturator internus
5 collateral nerves of lumbar plexus
Lesser sciatic Transmits: tendon of obturator internus, nerve to obturator internus,
Name of nerve Features
foramen pudendal nerve, internal pudendal artery and vein
Subcostal nerve Innervates abdominal musculature & skin of lateral & anterior abdominal wall
iliohypogastric N. Innervates abdominal musculature and skin of inguinal and hypogastric Muscles of gluteal region [refer to Netter p. 461]
regions of the lateral and anterior abdominal wall
Name Innervation Actions
iIioiguinal N. Innervates the skin of the medial thigh, labium majus, and anterior scrotum
Gluteus maximus Inferior gluteal N. Extends, laterally rotates thigh
Genitofemoral N. Innervates skin on medial thigh [femoral br.], & cremasteric M. [genital br.]
Gluteus medius Superior gluteal N Abducts and medially rotates thigh
Lateral femoral Inervates the skin of the lateral thigh
Gluteus minimus Superior gluteal N Abducts and medially rotates thigh
cuaneous N.
Tensor fasciae latae Superior gluteal N Flex, abducts,medially rotates thigh
Piriformis S1-2 lumbar plexus Laterally rotates thigh
Clinical notes
Lateral femoral cutaneous nerve lesions Obturator internus N. to obturator internus Laterally rotates thigh
Superior gemelli N. to obturator internus Laterally rotates thigh
The lateral femoral cutaneous nerve may be compressed as it passes posterior to lateral part of
Inferior gemelli N. to quadratus femoris Laterally rotates thigh
inguinal ligament just medial to anterosuperior iliac spine. Pxs w/ compression of the lateral
femoral cutaneous nerve [meralgia paresthetica] present w/ pain and paresthesia in the Quadratus femoris N. to quadratus fwmoris Laterally rotates thigh
anterolateral thigh.
Vessels of gluteal region
Terminal branches of lumbosacral plexus Name Features
Name of nerve Features Superior gluteal A. Largest branch of internal iliac A., w/ superior and inferior branches
Sciatic nerve Largest branch of lumbosacral plexus, largest nerve of the body, Inferior gluteal A. Gives rise to companion artery to sciatic nerve
branches: tibial and common peroneal N. Internal pudendal A. Distributed to perineum, no branches to gluteal region
Superior gluteal N Innervates gluteus medius and minimus, tensor fasciae latae Gluteal Veins Provide alternative pathway for return of blood to lower extremities
Inferior guteal N. Innervates gluteus maximus muscle

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THIGH Popliteus Tibial Laterally rotates femur
Important features of thigh Tibialis posterior Tibial Plantar flex, inverts foot
Fascia lata Deep investing fascia of lata, acts like a tight stocking Flexor hallucis longus Tibial Flex big toe, plantar flex foot
Iliotibial tract Important in maintaining posture and in locomotion Flexor digitorum longus Tibial Flex toes, plantar flex foot
Saphenous opening Aka fossa ovalis, transmits great saphenous V. & superficial femoral A
Femoral sheath Derived from transversalis fascia. Lateral-medial: invests the femoral A, Popliteal fossa
femoral V, and femoral canal Superiorly and medially: semimebranosus, semitendinosus
Femoral canal Most medial compartment of femoral sheath, a potential weak area Superiorly and laterally: biceps femoris
Femoral ring Lacunar ligament [medial], femoral V [lateral], inguinal ligament [anterior], Inferiorly and medially: medial head of gastrocnemius
superior ramus of pubis and pectineal ligament [posterior] Inferiorly and laterally: lateral head of gastrocnemius
Femoral triangle Sartorius [lateral], Adductor longus [medial], iliopsoas and pectineus [floor]
Floor [anteriorly]: popliteal surface of distal femur
& Inguinal Ligament [base] - SAIL
Contents: femoral N, A, V., inguinal LN, femoral sheath Roof [posteriorly]: deep popliteal fossa
Adductor canal of Lies btw vastus medialis, adductor brevis and magnus, covered by Contents: [superficial to deep] tibial N., popliteal V, popliteal A., popliteal LN, small
Hunter or subartorial sartorius muscle [thus called subsartorial canal] saphenous V., common peroneal and tibial N., posterior cutaneous N. of the thigh
canal Contents: femoral A + V, saphenous N., nerve. to vastus medialis, LN Nerves found: sciatic [tibial+peroneal N] and posterior femoral cutaneous N.
Cruciate anastomosis Provides an important potential collateral pathway to bypass an obstruction
of external iliac or femoral artery Nerves of the leg [refer to Netter p. 483-484]
Profunda femoris A Largest branch of femoral artery Name Origin Features
Perforating arteries Major supply to posterior thigh Tibial N. Formed by L4-5, Supplies all muscles of posterior leg compartment
S1-3 Branches: medial sural cutanous, medial calcaneal
Common peroneal Sciatic Branches: lateral sural cutaneous N., sural
Muscles of posterior thigh [refer to Netter p. 461] communicating N., recurrent articular branch
Name Innervation Actions Deep peroneal Common peroneal Supplies all muscles of anterior leg compartment
Semitendinosus Tibial division of sciatic Extends thigh, flex knee, rotates leg medially Superficial peroneal Common peroneal Supplies on lateral leg and foot
Semimembranosus Tibial division of sciatic Extends thigh, flex knee, rotates leg medially
Biceps femoris Long head: sciatic N. Extends thigh, flex knee, rotates leg laterally Arteries of leg and popliteal region [refer to Netter p. 483]
Short: common peroneal Name Branches
Popliteal A. Medial and lateral superior genicular A., medial and lateral inferior
Muscles of anterior thigh [refer to Netter p. 458] genicuar A., middle genicular A., sural arteries [largest branch]
Name Innervation Actions Genicular anastomosis Receives: popliteal A, femoral A, profunda femoris A. ant. + post. tibial A.
Iliacus Femoral N. Flex thigh Posterior tibial A. Nutrient A. to tibia, circumflex fibular A, medial posterior malleolar branch
Psoas major Ventral rami [L2-3] Flex thigh and medial calcaneal branches, peroneal A.
Sartorius Femoral N. Flex and laterally rotates thigh, flex knee joint Peroneal A. Muscular branches, nutrient A. to fibula, communicating banch to
Rectus femoris Femoral N. Flex thigh, extend knee joint posterior tibial A., perforating branch, lateral posterior malleolar A.
Vastus medialis Femoral N. Extends knee joint Anterior tibial A. Muscular branches, posterior and anterior tibial recurrent, A, medial and
Vastus lateralis Femoral N. Extends knee joint lateral anterior malleolar branches, dorsalis pedis
Vastus Femoral N. Extends knee joint
intermedius FOOT
Articularis genus Femoral N. Retracts synovial membrane on extended knee Bones of foot
1. tarsal bones [7]
Muscles of medial thigh [refer to Netter p. 459] begin ossification before birth except for cuneiform and navicular, w/c begin at 3-4 years of age
Name Innervation Actions Components: talus, calcaneus [largest tarsal bone, forms the heel of the foot, ossification at 6
Pectineus Femoral and obturator Flex and adducts thigh mos.], navicular, cuboid, medial cuneiform [largest of the cuneiform bones], intermediate
Obturator externus Obturator N. Laterally rotates thigh cuneiform, lateral cuneiform
2. metatarsal bones [5]
Gracilis Obturator N. Adducts thigh, flex and medially rotates knee
begin ossification at shaft in 2nd-3rd mos. in utero
Adductor longus Obturator N. Adducts and laterally rotates thigh
Adductor brevis Obturator N. Adducts and laterally rotates thigh 2nd metatarsal [longest metatarsal]
Adductor magnus Adductor part: obturator Adductor part: adducts and lat rotates thigh 5th metatarsal has prominent tubercle on its base
Hamstring: sciatic N. Hamstring: extends thigh 3. phalanges [14]
2 for the great toe and 3 for the remaining toes
Vessels of thigh Begin ossification at the shaft in 3rd month in utero
Name Branches
Femoral artery Superficial epigastric, superficial circumflex iliac, superficial + deep Composition of foot
external pudendal, profunda femoris [largest branch], medial + lateral Hindfoot Talus, calcaneus
femoral circumflex, perforating arteries, descending genicular arteries Midfoot Navicular, cuboid, cuneiform
Obturator artery Anterior and posterior branches Forefoot Metatarsals and phalanges

LEG AND POPLITEAL REGION Intrinsic muscles on plantar surface [sole] of foot [refer to Netter p. 497-500]
Muscles of the anterior and lateral compartments of the leg [refer to Netter p. 484] Name Innervation Actions
Name Innervation Actions st
1 layer
Anterior group Abductor hallucis Medial plantar N Abducts great toe
Tibialis anterior Deep peroneal Dorsiflex ankle, inverts foot Flexor digitorum brevis Medial plantar N Flex lateral 4 toes
Extensor digitorum longus Deep peroneal Extends toes, dorsiflex foot Abductor digiti minimi Lateral plantar N Abducts little toe
Extensor hallucis longus Deep peroneal Extends great toe, dorsiflex foot 2nd layer
Peroneus tertius Deep peroneal Dorsiflex ankle and everts foot Quadratus plantae Lateral plantar Flex toes when foot is plantar flexed
Deep group Flexor digitorum Lateral plantar Flex lateral 4 toes
Peroneus longus Superficial peroneal Everts foot accesorius
Peroneus brevis Superficial peroneal Everts foot Flexor digiorum longus Tibial N. Flex distal phalanges, plantar flex foot
Flexor hallucis longus Tibial N. Flex distal phalanx of big toe, plantar flex foot
Muscles of the posterior compartment of the leg [refer to Netter p. 482] Lumbricals [4] st:
1 medial plantar Flexes metatarsophalangeal and extend
Name Innervation Actions 2-4: lat. plantar interphalangeal joints
rd
Superficial group 3 layer
Soleus Tibial N. Plantar flex foot Flexor hallucis brevis Medial plantar Flexes matatarsophalangeal joint of great toe
Gastrocnemius [medial ,lateral] Tibial Plantar flex foot, flex ankle joint Adductor hallucis Lateral plantar Adducts great toe
Plantaris Tibial Insignificant plantar flexor Flexor digiti minimi Lateral plantar Flexes metatarsophalangeal joint of little toe
Deep group Unlocks knee in flexion and also 4th layer

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 Plantar interossei [3] Lateral plantar Adduct toes, flexes metatarsophalangeal jts Popliteal cyst/bakers cyst Fluid-filled herniations of synovial membrane of
Dorsal interossei [4] Lateral plantar Abduct toes, flexes metatarsophalangeal jts knee joint
Genu varum Tibia diverted medially
Intrinsic muscles on dorsum of foot Genu vaLgum Tibia diverted Laterally
Name Innervation Actions ACL injury anterior drawer sign Pushed tibialis posterior
Extensor digitorum brevis Deep peroneal N. Extends toes PCL injury posterior drawer sign Lands on tibial tuberosity w/ flexed knee
Extensor hallucis brevis Deep peroneal N. Extends great toe
RAPID REVIEW
Posterior tibial pulse Largest synovial joint of the body: knee joint
Palpated btw posterior surface of medial malleolus & medial border of calcaneal tendon Tailors muscle and also the longest muscle of the body: sartorius
Essential in occlusive peripheral arterial disease Most superficial muscle in the POSTERIOR leg compartment: gastrocnemius
Intermittent claudication characterized by leg cramps during walking and disappears after rest Deepest muscle in POSTERIOR leg compartment: tibialis posterior
[due to ischemia] Strongest dorsiflexor and invertor of foot: tibialis anterior
Most lateral of the ANTERIOR leg compartment muscles: extensor digitorum longus
Arteries of foot [refer to Netter p. 495] Most important stabilizer at knee joint: quadriceps femoris
Name Branches
Powerful push-off muscle during walking, running and jumping: flexor hallucis longus
Medial plantar A Plantar digital A. to medial side of great toe, anastomotic branches
m.
Lateral plantar A Plantar metatarsal A, , anastomosis w/ deep plantar A.
Largest nutrient artery: Nutrient artery to tibia
Dorsalis pedis A Medial and lateral tarsal A, 1st dorsal metatarsal A, arcuate A, deep plantar A
Major blood supply to toes: dorsalis pedis A. or dorsal artery of foot
Nerves of foot Do not act on knee joint: soleus M.
Name Origin Distribution Triceps surae muscle: gastrocnemius [medial and lateral heads] and soleus muscles
Deep peroneal N Common peroneal Extensor digitorm brevis, extensor hallucis brevis Hamstring muscles: biceps femoris, semitendinosus & semimembranosus
Medial plantar N Tibial N [terminal] Abductor hallucis, flexor hallucis brevis, flexor Quadriceps femoris muscles: rectus femoris, vastus medialis, lateralis and
digitorum brevis, 1st lumbrical muscles intermedius
Lateral plantar N Tibial N [terminal] Flexor digiti minimi brevis, plantar and dorsal Most superficial of the 3 components of popliteal fossa: tibial N.
interossei, lateral 3 lumbricals, adductor hallucis Only branch of lumbosacral plexus that contains both anterior [S2-3] and posterior [S1-2]
Saphenous N Femoral Largest branch of femoral nerve, to foot [medial] division fibers: posterior femoral cutaneous nerve
Fibular nerves Common fibular Dorsum of foot, skin on sides of 1st and 2nd toes Largest and longest branch of femoral nerve: saphenous nerve [the only branch of lumbar
Sural nerve Tibial+peroneal Accompanies small saphenous vein plexus to cross the knee joint]
Main stabilizer of femur: POSTERIOR cruciate ligament
Lymphatic drainage of foot Buttock quadrant safest for needle: Sciatic nerve [upper outer quadrant of buttock]
Name Distribution
Medial superficial lymph vessels Drains dorsum of foot and sole Inversion vs. Invertion [2ND letter rule]
Lateral superficial lymph vessels Drains lateral side of foot and sole Inversion of foot Eversion of foot
Deep lymph vessels Follow the main blood vessels, goes to popliteal LN tIbialis anterior and posterior pErineus longus, brevis, terius

Nerve injuries of lower extremities [refer to Netter p. 502-506] CHAPTER 4 THORAX

Injury Affected Causes Manifestations
Femoral nerve Quadriceps Cathetherization of Loss sensation over anterior THORACIC WALL AND SKELETON [refer to Netter p. 470]
femoris M. femoral artery thigh, medial leg and foot Ribs 12 pairs, attached posteriorly to thoracic vertebrae
Obturator Obstetric procedures Decreased sensation over True ribs [1st 7 ribs] Typical ribs [3-9] w/ neck, head, tubercle and body
nerve and pelvic diseases upper medial thigh False ribs [8-12 ribs] Atypical [1st, 2nd, 10th, 11th, 12th ribs]
Sciatic nerve Misplaced Footdrop and lost of sensation Sternum Until puberty, consists of 6 sternebrae
intramuscular injection over the leg Manubrium Widest and thickest of the 3 parts
Common Extensors of Direct trauma to head Footdrop Body Articulates w/ manubriosternal joint
peroneal N. foot and toes of fibula, compression Xiphoid Increases w/ age and may eventually fuse w/ the body
by leg cast Sternal angle of Lewis Aka as manubriosternal jt, marks the level of 2nd costal cartilage
Tibial nerve Puncture wound in [-] standing on tiptoes
popliteal fossa Clinical notes
Rib fracture
Other Injuries of lower extremities Fractures of a rib commonly occur just ANTERIOR to the angle of the rib [weakest point] and may
Ischial bursitis Weavers buttom cause pneumothorax.
Trochanteric bursitis Pain to iliotibial tract
Gluteus medius limp Gluteal gait Sternal angle of LOUIS indicates the boundary of:
Piriformis syndrome Compression of sural N. by piriformis 1. between superior and inferior mediastinum
Anterior tibilais strain/shin splints Edema and pain on distal 2/3 of tibia 2. beginning and ending of aortic arch
Deep fibular nerve entrapment/ski-boot synd. Compression by boots 3. tracheal bifurcation
Gastrocnemius strain/tennis leg Tearing of medial belly of gastrocnemius 4. lower border of 4th thoracic vertebrae
Calcaneal bursitis Retroachilles bursitis 5. convenient starting place for counting the ribs
6. the azygos vein drains into the superior vena cava
Calcaneal spur Heel-spur syndrome
Medial plantar nerve compression Joggers foot
Muscles of the thoracic wall
Polagra Sever pain on metatarsal joint
Name Innervation Actions
Clubfoot/talipes Foot twisted out of position
Diaphragm Phrenic nerve Main muscle of inspiration, elevates the ribs
Pes planus Fallen arches
External intercostals Intercostals N. Assists in inspire/expiration [down & forward]
Claw toes Flexion of metatarsophalangeal joints and
Internal intecostals Intercostals N. Assists in inspire/expiration [down & backward]
distal interphalangeal joint
Innermost intercostals Intercostals N. Assists in inspiration & expiration [transversely]
Hammertoe Permanent flexion of proximal phalanx at
Subcostals Intercostals N. Assists in inspiration and expiration
metatarsophalangeal joint
Transversus thoracis Intercostals N. Assists in inspiration and expiration
Hallux valgus Lateral dislocation of great toe
Levator costarum C8-T1 spinal N Elevates rib
Tarsal tunnel syndrome Tibial nerve entrapment
Serratus posterior sup. Intercostals N. Assists inspiration by elevating ribs
Patellofemoral syndrome/runners knee Direct blow to patella
Serratus posterior inf. Intercostals N. Assists expiration by depressing ribs
Prepatellar bursitis/housemaids knee Friction between skin and patella
Subcutaneous infrapatellar bursitis or Friction between skin and tibial tuberosity
Clinical notes
clergymans knee
Phrenic N. lesions
Deep infrapatellar bursitis Friction between patellar ligament and tibia
An irritative lesion causes involuntary contractions of diaphragm and may result in hiccups.

8
 A destructive lesion may result in paralysis and paradoxical movement of one half of
diaphragm. The paralyzed dome of diaphragm fails to descend upon inspiration, and is forced
superiorly by an increase in intraabdominal pressure
Intercostal space
contains the intercostals muscles, and neurovascular bundle [VAN]
a needle to be placed into pleural cavity should be inserted midway between the ribs to avoid
the neurovascular bundle and its collateral bundle
Intercostal arteries
Anterior intercostal A. [anterior thoracic wall], from internal thoracic A. or musculophrenic A.
Posterior intercostal A. [posterior and lateral thoracic walls], from descending aorta.
Intercostal veins
Anterior intercostal V. drain anterior chest wall & empty into internal thoracic V. then to
brachiocephalic veins
Posterior intercostal V. drains posterior and lateral thoracic walls and empty into hemiazygos
veins to the L and azygos veins to the R.
Azygos veins drains into SVC while hemiazygos vein drains into azygos vein.
Intercostals nerves [refer to Netter p. 176]
from ventral rami of 1st 11 spinal nerves
lies between internal and innermost intercostals muscles
branches: collateral, lateral cutaneous, anterior cutaneous branches
the 7-11 intercostal nerves are aka as thoracoabdominal nerves
BREAST or MAMMARY GLAND
w/ 15-20 lobes drained by a single lactiferous duct that opens to nipple
extend into axilla as axillary tail of SPENCE
supported by suspensory ligament of COOPER
nipple is at level of 4th ICS, its base extends from 2nd-6th ri
Supplied by: internal [from 2nd -4th ICS] and lateral thoracic [from 2nd -4th IC arteries], anterior
intercostals, thoracoacromial A. [from axillary A. and perforating branch of internal thoracic and
intercostals A.]
Drained by anterior axillary or pectoral nodes [75%] and parasternal nodes [20%], mediastinal
nodes [clavicle], medial quadrants drain into internal thoracic nodes, & subareolar plexus of
Sappey & circumareolar plexus as cutaneous drainage of thorax
Clinical notes
Adenocarcinoma of Breast
Most breast adenocarcinoma are lactiferous duct CA that begin as painless masses in the
upper lateral quadrant [most common]
Late-stage adenoCA may cause retraction and fixation of the nipple and skin dimpling, w/c
results from invasion of suspensory ligaments.
Adenocarcinomas metastasize mainly to axillary LN, but also to parasternal nodes to the
opposite breast and to nodes of anterior abdominal wall.
In radical mastectomy, the breast is removed along w/ pectoralis major and minor muscles,
axillary LN and vessels, and tributaries of axillary vein.
The long thoracic nerve or thoracodorsal nerve may be damaged in a mastectomy
procedure w/c results in winged scapula, causing weakness in extension, adduction, and
medial rotation of the humerus.
MEDIASTINUM [refer to Netter p. 218-219]
space between paired pleural sacs, contains all thoracic organs [except the lung]
Divisions Contents [from anterior to posterior]
Superior mediastinum Thymic remnants, R and L brachiocephalic V, SVC [upper], L common
carotid A., L subclavian A., aortic arch and branches, phrenic and
vagus N, trachea, esophagus, thoracic duct, cardiac plexus of nerves,
L recurrent laryngeal, prevertebral M., sympathetic trunks
Inferior mediastinum
Anterior division Thymic remnants and lymph nodes, sternopericardial ligaments
Middle division Pericardium, heart, roots of great vessels, phrenic N, tracheal
bifurcation and primary bronchi, arch of azygos vein, lymph nodes
Posterior division Descending thoracic aorta, esophagus & esophageal plexus, vagus
N., thoracic duct [cystera chili], azygos/hemiazygos V, lumbar &
thoracic N., LN, sympathetic trunk & ganglia
Clinical notes
Thymoma
This may develop in superior and anterior mediastinum. Most pxs also have myashenia
gravis. S/Sx includes an obstructed L brachiocephalic vein and chest pain.
Superior Vena cava syndrome
SVC may be compressed by enlarged LN because of metastasis from bronchogenic CA
S/Sx: headache, edema of head and neck, prominent superficial veins and cyanosis. The veins
of the upper limb fail to empty when the limb is elevated above the heart.
In complete SVC occlusion, venous return itself from head, neck and upper limbs is shunted
into tributaries of the IVC.
Anastomoses of the SVC to IVC may occur btw lateral thoracic veins and superficial epigstric
veins, and btw superior epigastric veins and inferior epigastric veins.
Coactation of aorta
A constriction of aorta that occur in proximal [INfantile type] or Distal [aDult type] to ligamentum
arteriosum.
BP of these pxs is reduced in lower limb and elevated in head, neck and upper limbs.
Anasomoses in interostal spaces btw anterior intercosal A. [from internal thoracic A.], and posterior
intercostals A. [from descending aorta] provide collateral circulation that bypasses the coarctation.
Blod flows in the retrograde direction thru posterior intercostal A. into descending aorta.
Dilation of the anterior and posterior intercostals A. may result in resorption of ribs and
notching observed on x-ray.
Esophageal carcinoma
This commonly develops at 1 of the 3 sites of constriction in mediastinum.
Aortic Arch aneurysm
This may compress trachea, esophagus, and L recurrent laryngeal N. Patients may experience
difficulty in breathing, difficulty in swallowing and hoarseness.
Cardiac tamponade
Results from fluid accumulation in pericardial cavity that compresses chambers of the heart.
Pericardial effusion may result in kausmaull respiration [distention of veins of neckon inspiration]
A penetrating wound of heart chamber or weakening of wall of the heart from MI may cause an
acute tamponade as a result of accumulation of blood in pericardial cavity [hemopericardium].
Pxs w/ tamponade have decreased venous return and reduced cardiac output.
In pericardiocentesis to relieve tamponade, a needle is passed thru parietal pericardium to
aspirate blood from pericardial sac [site: L xiphocostal angle]
The needle enters pericardial sac after passing thru skin, fascia, rectus sheath, rectus abdominis
muscle, fibrous layer, and serous layer of parietal pericardium.
Pericarditis
Causes stiffening & reduced compliancy of serous pericardium. The ventricles may not fill
completely and cardiac output may be reduced because of pericardial effusion.
PLEURA
Divisions and contents:
Parietal pleura Highly sensitive to pain, temperature, touh and pressure
Costal pleura Lines thoracic wall, supplied by intercostals N.
Diaphragmatic pleura Forms floor of pleural cavity, supplied by phrenic N.
Mediastinal pleura Forms lateral boundary of mediastinum, phrenic N.
Cervical pleura Aka as cupula of pleura
Visceral pleura Sensitive to stretching, suplied. by pulmonary plexus
Endothoracic fascia Binds parietal pleura to thoracic wall
Suprapleural membrane Reinforces cervical pleura
Pleural recesses Include costodiaphragmatic and costomediastinal recess
Clinical notes
Pleuritis or pleurisy
The visceral or parietal pleura are inflamed and become rough, causing adhesions.
During respiration, friction created by adhesions may be audible as pleural rub.
Pxs w/ costal pleurisy may experience sharp pain localized over the adhesion site that
increases w/ respiration.
Pxs w/ mediastinal or diaphragmatic pleurisy may have pain that is referred over C3
thru C5 dermatomes in supraclavicular region.
Thoracentesis
A needle is used to sample or withdraw fluid from costodiaphagmatic recess, introduced
into pleural cavity in the midaxillary line in 9th intercostals space after passing thru skin,
superficial fascia, the 3 layers of intercostals muscles and parietal pleura.
To avoid intercostal nerves, the needle is inserted into the inferior part of the
interspace. To anesthesize the intercosal nerves for relief of pain assoiated w/ rib fracture, the
needle is inserted into superior part of interspace.
Pneumothorax & Pleural effusion
In open pneumothorax, a penetrating wound of the chest wall pierces the costal
pleura, or a penetrating wound in the root of the neck pierces the cervical pleura. Pleuritic pain
results from stimulation of the intercostals nerves.
o Air enters the affected pleural cavity during inspiration, but the negative intrapleural pressure is
lost and the lung on the affected side collapses. The heart and the other mediastinal structures
shift AWAY from the affected side and compress the opposite lung.
o During expiration, air is expelled from the affected pleural cavity thru the wound, and the heart
and other mediastinal structures shift back to affected side. Shifting of mediastinal structures
reduces venous return to the heart.
In tension pneumothorax, a penetrating wound of parietal pleura creates a valve-like
effect in pleura during respiration.
o Air enters the pleural cavity during inspiration and the lung on affected side collapses, the heart
and other mediastinal structures shift AWAY from affected side & compress the opposite lung.
o During expiration, a flap of pleural tissue that closes the wound prevents expulsion of air. w/
each breath, intrapleural pressure is increased and the shift of heart and mediastinal structures
to the opposite side is augmented. Cardiac output, venous return, and respiratory function are
compromised.
o A pleural effusion is an accumulation of fuid in pleural cavity and may be caused by
obstruction of veins or lymphatic vessels that drain the thorax or by an inflammation of
structures near the pleura.
9
 In a hemothorax, blood accumulates in pleural cavity from hemorrhage of anterior Paresthesia in forearm and hand, and weakness and atrophy of hand musles as a result of
or posterior intercostals vessels or internal thoracic vessels. compression of C8 and T1 ventral rami in the inferior trunk of brachial plexus.
In chylothorax, lymph accumulates in a pleural cavity as a complication of
mediastinal surgery or trauma that injures the thoracic duct. Blood vessels of the lungs
Pulmonary A. Carry deoxygenated blood to alveolar capillary plexuses, w/ L and R branches
TRACHEA, BRONCHI AND LUNGS [refer to Netter p. 186-190] Pulmonary V. Carry oxygenated fom lungs to L atrium, 5 in number
Trachea Begins at lower border of cricoid [C6 vertebra], w/ 16-20 hyaline cartilage Bronchial A. Supply oxygenated blood to bronchial tree and visceral pleura
10-12 cm long, 2.5 cm diameter in male, slightly smaller in females L side 2 bronchial A. arising from descending thoracic aorta
Ends at level of sternal angle to divide into the 2 main bronchi R side - bronchial A. arising from 3rd R posterior intercostals A.
Bronchi Bronchial V. Drain deoxygenated blood from bronchial tree and visceral pleura [2 per side
R main bronchus Shorter, wider, more vertical than L main bronchus, gives rise to R upper lobe R side empty into azygos vein, L side empty into hemiazygos vein
bronchus [epiarterial bronchus], crossed by azygos veins
More likely to contain inhaled objects because it is closer to trachea Lymphatic drainage of lungs
L main bronchus Longer, narrower, more horizontal than R main bronchus Superficial lymphatic plexus Drains beyond hilus
Epiarterial bronchi Is the most superior of the lobar bronchi, aka hyparterial bronchus Deep lymphatic plexus Follows along bronchial tree to the hilus
Lungs W/ a main bronchus, 1 pulmonary A., and 2 pulmonary V. Peribronchial pulmonary nodes Course along w/ deep plexus
R lung Shorter than left because of dome of diaphragm, divided into upper, middle Bronchopulmonary nodes Located at root of the lung
and lower lobes by oblique and horizontal fissures Tracheobronchial nodes Empties into R and L subclavian veins
It has 3 lobar and 10 segmental bronchi
L lung Divided into upper and lower lobes by the oblique fissure, w/ cardiac notch Nerve supply of the lungs [refer to Netter p. 195]
where heart and pericardium lies, lowest part is called lingula Name Origin Features
It has 2 lobar and 8 segmental bronchi
Parasympathetic fibers Vagus N. Bronchial constriction + mucus secretions
Sympathetic fibers Upper 5 symph. ganglia Produce bronchial relaxation
Clinical notes
Visceral afferent fibers Vagus N. Sensitive to stretch and participate in reflex
Breath sounds
control of respiration, also for cough reflex
Breath sounds from superior lobe of each lung may be auscultated on the anterior and superior
aspects of thoracic wall.
Muscles involved in respiration
Breath sounds from inferior lobe of each lung may be auscultated on posterior and inferior
Muscles of respiration External, internal and innermost intercostals muscles, subcostal muscles
aspects of the back. and transverses thoracis muscles
Breath sounds ffom middle lobe of R lung, may be auscultated on anterior chest wall ner the Accessory muscles of Sternocleidomastoid, scalenus anterior and medius, serratus anterior,
sternum, inferior to R 4th costal cartilage. respiration pectoralis major and minor
Foreign body aspiration Respiratory Most important muscle of respiration [quiet respiration]
An aspirated foreign body is more likely to enter the R main bronchus because it is shorter, diaphragm Receives motor [phrenic N], sensory [phrenic and intercostals nerves]
wider and more vertical than the L main bronchus. Muscular diaphragm w/ sternal part, costal part, and lumbar part
In a px who is standing or sitting, the foreign body tends to become lodged in the
posterobasal segment of the inferior lobe of the R lung. Ligaments of the lungs
Emphysema Medial arcuate lig. Fascial thickening over upper part of psoas major muscle
The respiratory tissue is destroyed resulting in permanent abnormal enlargement and increased Lateral arcuate lig. Fascial thickening over upper part of quadratus lumborum M.
radiolucency of the affected air spaces, and formation of blebs or bullae. R crus Longer and larger than left, from upper 3 lumbar ertebrae
In spontaneous pneumothorax, an emphysematous bleb spontaneously ruptures, air is L crus From bodies of upper 2 lumbar vertebrae
introduced into pleural cavity thru the visceral pleura, and conditions similar to an open or a
tension pneumothorax result. Openings in the diaphragm
MC site of a spontaneous pneumothorax: visceral pleura of superior lung lobe Esophageal T10 Transmits esophagus, vagus N, esophageal branches of L
hiatus gastric vessels, lymphatics from lower 3 rd of esophagus
Surfaces of the lungs Aortic hiatus T12 Transmits aorta, thoracic duct, sometimes azygos veins
Diaphragmatic surface Inferiorly to fit the diaphragm Vena caval hiatus T8 Transmits inferior vena cava and branches of R phrenic N.
Costal surface Convex to fit against thoracic wall
Mediastinal surface Concave to fit against pericardium Clinical notes
Diaphragmatic hernia
Bronchopulmonary segments of the lung [refer to Netter p. 188-189] Occur at 1 of 4 locations:
part of lung lobe supplied by segmental [tertiary] bronchus and its accompanying branch of 1. Congenital diaphragmatic hernia may occur in the L posterolateral part of diaphragm just
pulmonary artery anterior to quadratus lumborum.
Segments R lung L lung 2. Hiatal hernia may occur at esophageal hiatus. In a sliding hiatal hernia [MC type], the
Upper lobe Apica, posterior, anterior [3] Apicoposterior, anterior, abdominal part of esophagus and part of stomach herniated thru esophageal hiatus into
superior & inferior lingular [4] mediastinum. Gastroesophageal reflux or heartburn may result from sliding hiatal hernia.
Middle lobe Medial & lateral [2] None [corresponds to lingular] 3. Paraesophageal hernia may also occur at esophageal hiatus where fundus or body of
Lower lobe Superior, basal medial, anterior Superior, basal anteromedial, stomach herniates into the mediastinum adjacent to esophagus.
lateral & posterior [5] lateral & posterior [4] 4. Retrosternal diaphragmatic hernia may occur in the anterior part of diaphragm adjacent to
Total lobes 10 8 xiphisernal joint

Clinical notes PERICARDIUM

Bronchogenic CA Fibrous Tough fibrous sac surrounding the heart
May metastasize thru lymph channels but may also penetrate the wall of a tributary of a Serous Covers heart [visceral], and inner surface of fibrous pericardium [parietal]
pulmonary vein and metastasize thru pulmonary and systemic circulations. Pericardial sinus w/ oblique and transverse pericardial sinus
Supraclavicular LN may act as sentinel nodes indicating presence of a malignancy.
Enlarged supraclavicular LN on R may indicate malignancy in thorax. HEART
Enlarged supraclavicular LN on L may indicate a malignancy in thorax, abdomen, or pelvis Layers: epicardium [outer], myocardium and endocardium [inner]
because all lymph below diaphragm is returned to venous system on L by way of thoracic duct. Skeleton of heart is consists of annuli fibrosi
A pancoast tumor that develops in apical part of superior lobe of either lung and may cause Surfaces of the heart [refer to Netter p. 202]
thoracic outlet syndrome. Diaphragmatic surface Formed by L ventricle and narrowed part of R ventricle
Thoracic outlet syndrome results from compression of sympathetic trunk, subclavian vessels, Sternocostal surface Composed of R atrium and R ventricle
recurrent laryngeal nerve or inferior trunk of brachial plexus in root of the neck. This pxs may Obtuse margin Formed entirely by L ventricle
have: Horners syndrome [anhydrosis, loss of sweating, ptosis, drooping of upper eyelid, and Acuate margin Formed largely by R ventricle
miosis]. Right margin Formed by superior vena cava and right atrium
Decreased radial pulse in upper limb caused by compression of subclavian artery and vein. Left margin Formed by left ventricle and L atrium
Hoarseness and dysphagia resuling from compression of a recurrent laryngeal nerve.
Chambers and valves

10
R atrium Receives blood from SVC & IVC, coronary sinus, anterior cardiac V., larger and
thinner walled than L atrium, w/ pectinate muscles Fetal circulation
w/ valve of coronary sinus [thebesian], and valve of IVC [Eustachian] Oxygenated blood from placenta enters fetus thru umbilical V. and passes to liver
the fossa ovalis marks the site of foramen ovale in embryonic heart thru w/c shunted to IVC via ductus venosus RA foramen ovale LA RV pulmonary
blood passes from R and L atrium before birth trunk [deoxygenated] bypass lung ductus arteriosus aortic arch
L atrium Receives blood from 4 pulmonary veins, left interatrial septum [anterior wall] Deoxygenated blood then returns to placenta via umbilical arteries
R ventricle w/ papillary M., chordae tendinae, moderator band/septomarginal trabecula Changes after birth
L ventricle w/ trabeculae carnae, no moderator band, 2 papillary M. [ant erior, posterior] Contraction of umbilical A. stops flow of blood to placenta, its remnant then forms the medial
Pulmonary valve w/ 3 semilunar cusps, has associated pulmonary sinuses umbilical ligament
Aoric valve w/ 3 semilunar cusps and sinuses named according to their fetal position The umbilical V. closes and obliterates to form ligamentum teres hepatis
tRicuspid valve Guards the R atrioventricular orifice, w/ anterior, posterior and septal cusps The ductus venosus closes and obliterates to form ligamentum venosum establishing normal
MitraL valve Guards the L atrioventricular orifice circulation to the liver
w/ expansion of the lungs and rise in the left atrial pressure, foramen ovale closes and its
Heart sounds [refer to Netter p. 210] flaplike valve eventually fuses w/ interatrial septum giving rise to fossa ovalis
1st sound [lub] Closure of atrioventricular orifice [MV & TV] at start of systole ductus arteriosus closes and obliterates to form ligamentum arteriosum
2nd sound [dub] Closure of AV & PV at end of systole
Tricuspid valve At lower end of sternum opposite 4-6th ICS Clinical notes
Mitral valve At apex in L 5th ICS Atrial septal defect
Pulmonary valve At medial end of L 2nd ICS A small patency in upper part of fossa ovalis of interatrial septum may be present but is not
Aortic valve At medial end of R 2nd ICS symptomatic a large patency in fossa ovalis may form a symptomatic ASD.
Normally, BP is higher in L side of heart than in R side of heart in postnatal life.
Clinical notes In this pxs, blood from L atrium will be shunted thru defect into R atrium.
Valvular stenosis Ventricular septal defect
Diseases such as rheumatic fever may cause stenosis of aortic or mitral valve A large postnatal defect in interventricular sepum [often membranous part], results in too much
Mitral valve stenosis impedes flow of blood from LA to LV. pulmonary blood flow caused by a shunt of blood from L ventricle into R ventricle. In pxs w/ VSD,
Aortic valve stenosis slows the rate at w/c blood empties from LV. A defect in leaflet or a cusp pulmonary HPN may result causing CHF.
of any of the 4 valves may result in a prolapse of that valve component and regurgitation of
blood back into chamber behind the valve. Prolapse is commonly seen in leaflets of mitral AV block
valve. In an atrioventricular heart block, conduction is slowed thru AV node, some impulses are not
Heart murmur transmitted thru the node, or in a complete block, no impulses are conducted thru AV node.
Sound that result from vibrations produced by turbulent blood flow [from stenotic or incompetent In a complete AV block, the cotractions of atria and ventricles become dissociated, and these
valve, from increased flow thru a valve, or from a dilated heart chamber adjacent to valve] chambers beat independently.
Can occur during diastole [mitral valve stenosis], systole [aortic valve stenosis] and may have a The atria may continue to contract about 70 times/min; a pacemaker may develop in AV bundle
longer duration than normal heart valve sounds. distal to the site of the block, initiating contraction of the ventricles at a rate of 30-40 times/min.
ESOPHAGUS [refer to Netter p. 220]
Conducting system of the heart [refer to Netter p. 213] Passes thru diaphragm at level of T10
Sinoatrial node Pacemaker of the heart, initiates stimulus that causes contraction Constrictions on barium swallow: Relationships:
Atrioventricular Receives impulse generated in sinoatrial node 1. begins at level of 6th cervical vertebra Anterior: trachea to its bifurcation
AV bundle of HIS Begins from AV node and ends as plexus of subendocardial Purkinje fibers 2. where it is crossed by L main bronchus Posterior: upper 4 thoracic vertebrae
3. where it lies behind L atrium where L To the left: aortic arch, thoracic duct, L
Blood supply of the heart [refer to Netter p. 204] atrium is enlarged recurrent laryngeal nerve
Name Origin Distribution 4. where it passes thru diaphragm To the right: mediatinal pleura
R coronary A. R aortic R ventricle, posterior half of interventricular septum
sinus Branches: A. to sinoatrial node and atrioventricular Clinical notes
node, R marginal A, posterior interventricular A. Esophageal disorders
L coronary A. L aortic sinus L atrium, L ventricle, anterior half of IV septum GERD/heartburn may result from incompetent LES. Pxs complain of substernal burning that is
Branches: anterior interventricular A., circumflex A., L worst w/ lying down.
marginal A. diagonal A., posterior ventricular A. In Achalasia, the smooth muscle sphincter of esophagus fails to relax. Pxs have difficullty
swallowing liquids and solids.
Venous drainage of the heart Hirschprungs disease is caused by absence of terminal sympathetic ganglia.
Cardiac veins Largest of which is the coronary sinus btw tricuspid valve & valve of IVC
Epinephric diverticulum may develop just superior to LES. These diverticula are false or
Great cardiac V. Drains into L end of coronary sinus, courses w/ anterior interventricular A.
pulsion diverticula not consist of all of the layers of esophagus. MC it occurs in sgmoid colon.
Middle cardiac V Empty along midpoint fo coronary sinus,alongside posterior interventricular A
Small cardiac V. Accompanies R marginal A., aka as venae cordis minimae Blood vessels & lymphatics of esophagus
Location Venous supply Arterial supply Lymphatics
Clinical notes Upper 3rd Inferior thyroid V. Inferior thyroid A. Deep cervical LN
Angina pectoris rd
Middle 3 Azygos veins Esophageal br. of descending Superior & posterior
Refers to chest pain that resuls from transient ischemia brought by exertion. thoracic aorta mediastinal LN
This ischemia results from reduced blood flow to cardiac muscle because of narrowing of a Lower 3 rd
L gastric vein L gastric & inferior phrenic A. L gartic nodes & celiac LN
coronary artery, but there is no loss of cardiac muscle cells. Pxs have substernal pain
referred over T1-5 dermatomes of thoracic wall corresponding to same segments of spinal Nerve supply of esophagus
cord that provide sympathetic innervation to the heart. Sympathetic fibers Producing vasoConstriction when stimulated
Referred pain may be felt in T1 dermatome in the medial aspect of L arm and forearm and Parasympathetic fibers Affects peristalsis and act on enteric nervous system
may be felt over cervical dermatomes in neck, up to level of angle of mandible. Vagal visceral afferent Concerned w/ reflex activity of esophagus
Myocardial infarction
Results from localized avascular necrosis of cardiac muscle cells caused by ischemia. THYMUS
The anterior interventricular artery is a common site of an occlusion that results in an acute Lymphoid organ lying behind the sternum in superior mediastinum
MI. less frequently occluded are the R coronary A. and circumflex branch of L coronary artery. Important source of T lymphocytes & crucial to establishment of immune competence after birth
In pxs, the onset of an MI is usually marked by sudden, severe pain beneath the sternum.
Begins involution after puberty
Supplied by branches of internal thoracic and inferior thyroid arteries
Nerve supply of the heart
Name Origin Features Drains largely to L brachiocephalic vein
Sympathetic fibers ANS heart rate, contraction, dilatation of arteries
Arteries of the thorax
Parasympathetic fibers ANS heart rate, ventricular contraction
Name Branches
Visceral symph. fibers Thoracic spinal N. Cardiac reflexes, sole pain conductors [heart]
Ascending aorta R and L coronary arteries
Visceral parasymp. Inf.vagal ganglion Sensory input for cardiac reflexes
Aortic arch 3 brachiocephalic, L common carotid, L subclavian, thyroidea ima

11
Descending [T4] Posterior intercostals A., subcostal A., bronchial A., esophageal A., Muscles of the anterior abdominal wall [refer to Netter p. 232-234]
thoracic aorta superior phrenic A., pericardial A., mediastinal A. Name Innervation Actions
Supreme intercostals From costocervical trunk and supplies the 1 st 2 ICS External abdominal Iliohypogastric, and Flexes and rotates trunk, depreses ribs in forced
Internal thoracic Anterior intercostals, musculophrenic, superior epigastric, oblique ilioinguinal N. expiration [fibers runs medially and inferiorly]
pericardiophrenic, perforating branches to the intercostals spaces Internal abdominal Iliohypogastric and Flexes and rotates trunk, depreses ribs in forced
Pulmonary trunk R and L pulmonary arteries oblique ilioinguinal N. expiration [fibers run superiorly and medially]
Transverses Iliohypogastric and Compresses abdominal contents, depresses ribs
Great systemic veins of the thorax [refer to Netter p. 195] abdominis ilioinguinal N. in forced expiration [fibers run horizonally]
Name Features Rectus abdominis Lower 6 thoracic N. Flexes trunk, depresses ribs in forced expiration
R brachiocephlic V. Receives R internal thoracic V. [its only thoracic tributary] Pyramidalis T12 spinal N. Tenses linea alba
L brachiocephlic V. Receives L internal thoracic v, L superior intercostals V, inf. thyroid V. Cremaster Genital br. of Retracts testis
Superior vena cava Receives the azygos veins genitofemoral N.
Inferior vena cava Passes at level of 8th thoracic vertebrae
Azygos V. Drains R posterior intercostals V. except the first, important tributaries Clinical notes
include bronchial, esophageal, hemiazygos, accessory hemiazygos V. Ascites
Hemiazygos V. Receives lower 4 L posterior intercostals veins Accumulationof fluid in peritoneal cavity and may be caused by peritonitis or result from congestion
Access. hemiazygos Drains the 4th-7th or 8th intercostals spaces of venous drainage of the abdomen.

Other nerves of the thorax Important features of the abdominal wall

Name Origin Features Name Features
Phrenic N. Ventral rami [C3, 4, Sole motor innervation to respiratory diaphragm, pain Linea alba Fusion of aponeurosis of transverses abdominis, internal & external oblique
5] its major from areas supplied by phrenic N. is usually referred to Linea semilunaris Crosses costal margin near tip of 9th costal cartilage
contribution - C4 base of neck and tip of shoulder Arcuate line Lies midway between umbilicus and pubis
Vagus N. Brainstem Supplies parasympathetic and general visceral afferent Inguinal ligament Aka Poupars ligament, it fuses inferiorly w/ fascia lata of thigh
innervation to thoracic viscera, important branches: cardiac, Lacunar ligament Aka Gimbernats ligament, continuous w/ pectineal line w/ pectineal
pulmonary, esophageal, L+R recurrent laryngeal N ligament [coopers ligament]
Conjoint tendon Fusion of transverses abdominis and internal oblique aponeurosis, it also
Nerve supply of thorax strengthens abdominal wall behind the superficial inguinal ring
Autonomic plexus of thorax Rectus sheath Contains the superior and inferior epigastric arteries and distal portions of
Sympathetic and parasymphathetic fibers Function below level of consciousness thoracoabdominal,subcostal and iliohypogastric nerves, formed by fusion of
General visceral afferent fibers Sensory limb of autonomic reflex arc poneurosis of transverses abdominis, internal / external abdominal oblique
Visceral nerves Control function of the heart Arcuate line Marks the point where all aponeurosis pass anterior to rectus abdominis M,
Superficial cardiac plexus Lies below the level of aortic arch located btw umbilicus and pubic symphysis.
Deep cardiac plexus Btw aortic arch and tracheal bifurcation
Coronary plexuses Extensions of cardiac plexus along coronary A. Topography of the anterior abdominal wall
Pulmonary plexus Nerve supply to lungs Plane Dividions Notes & contents
Esophageal plexus Formed by stand of vagus N. Vertical planes Transpyloric and R and L Approximate the midclavicular lines of thorax and
Thoracic sympathetic trunk W/ 11-12 segmentally arranged ganglia lateral planes extend caudally to midpoint of inguinal ligament
Thoracic sympathetic nerves Include gray and white ramus communicans Horizontal Transpyloric plane Midway between jugular notch and pubic symphysis
planes Intertubercular plane Passes thru the tubercles of iliac creast
Lymphatic drainage of thorax Lateral planes R hypochondriac Containing the liver
Name Drainage L hypochondriac Containing the fundus of stomach and spleen
Parasternal nodes From thoracic wall, upper anterior abdominal wall, diaphragm R lateral lumbar region Containing the descending colon
Posterior intercostals nodes From thoracic wall and paravertebral region R inguinal iliac region Containing ileocecal junction and appendix
Diaphragmatic nodes From diaphragm, pericardium, and upper liver surface L inguinal iliac region Conaining the sigmoid colon
Posterior mediastinal nodes From pericardium and esophagus Midline planes Epigastric region Containing the liver stomach and pancreas,
Brachiocephalic nodes From heart, pericardium, thymus, and thyroid Umbilical region Containing the small intestine, transverse colon and
Tracheobronchial nodes Receive lymphatic drainage from bronchopulmonary nodes greater omentum
Bronchomediastinal trunk Post medistinal, brachiocephalic, tracheobronchial parasternal Hypogastric/pubic region Containing the small intestine, full urinary bladder, or
Thoracic duct L side of head and neck [L internal jugular lymph trunk], L upper pregnant uterus.
extremity [L subclavian lymph trunk], L side of thoracic cavity [L
bronchomediastinal lymph trunk] Blood vessels of the anterior abdominal wall
Right lymphatic duct R side of the head, neck, thorax, R upper limb A. Arteries
Name Features
RAPID REVIEW Superior epigastric A. From terminal branch of internal thoracic A.
Inferior epigastric A. From external iliac A., Branches: cremasteric A., pubic branch
Batsons plexus Deep circumflex iliac A. From external iliac A., supplies lower part of abdominal wall
Communication w/ vertebral veins Superficial epigastric A. Supplies inferior + medial parts of the superficial abdominal wall
Route for hematogenous spread to vertebral column and hips Superf circumflex iliac A Supplies inferior + lateral part of the superficial abdominal wall
Serratus anterior innervation and action Superf external pudendal A Supplies the lower abdominal wall over the mons pubis
C5-6-7 raise your wings up to heaven
Inability to raise arm past 90 degrees B. Veins [refer to Netter p. 239]
Winging of the scapula Name Drains
Long thoracic nerve innervates serratus anterior External iliac V. Inferior epigastric and deep circumflex iliac V.
Femoral V. Superf circumplex iliac, superf epigastric and superf ext pudendal V.
CHAPTER 5 ABDOMEN Superior epigastric Brachiocephalic V.
Thoracoepigastric Important anastomotic connection btw superior and IVC
ANTERIOR ABDOMINAL WALL Superficial epigastric Femoral vein and communicate w/ small paraumbilical V.
Fasciae of the abdominal wall Superf circumflex iliac Femoral veins
Superficial layer of superficial Fatty layer Deep circumflex iliac Internal thoracic and external iliac veins
fascia/Campers fascia
Deep layer of superficial fascia/ Membranous layer, most apparent on the abdominal wall, it Clinical notes
Scarpas fascia continues as superficial perineal fascia/Colles fascia [perineum], Varocosity of the superficial epigastric veins
Dartos fascia [scrotum] and superficial penile fascia
Deep fascia Thin layer covering external surface of abdominal M. Obstruction of either the IVC or hepatic portal vein, both of w/c drain structures below the
Transversalis fascia Gives rise to internal spermatic fascia [testis and spinal cord] diaphragm may result in varicosities of superficial epigasric veins.

12
 C. Nerves [from ventral rami of T7-L1 spinal nerves] Lymphatics: Area 1 = aortic nodes [2/3], Area 2 = subpyloric nodes & Area 3 = greater curvature
Name Origin Nerve supply: celiac plexus [sympathetic] and vagus N. [parasympathetic]
Thoracoabdominal N. Ventral rami of T7-T11
Iliohypogastric and ilioinguinal N. Ventral ramus of L1 Clinical notes
Surgical access to omental bursa
D. Lymphatic drainage of anterior abdominal wall This may be obtained by incising lesser omentum, gastrocolic or gastrosplenic ligament.
Anterior axillary LN Cutaneous vessels Above level of umbilicus The middle colic A. w/c courses in gastrocolic ligament would have to be avoided in surgery
Superficial inguinal LN Cutaneous vessels below evel of umbilicus Short gastric A. and L gastroepiploic A. w/c course in gastrosplenic ligament would have to be
avoided in surgery.
PERITONEUM Gastric carcinoma
Serous membrane that lines the abdominal and pelvic cavities Commonly develop in pyloric part and metastasize to cisterna chylli and thru thoracic duct to L
Parietal peritoneum lines the walls, for pain, temperature, touch and pressure, innervated by brachiocephalic vein.
lower 6 thoracic and 1st lumbar nerves, and obturator nerve in pelvis. An enlarged L supraclavicular node of Virchow may act as a sentinel node for gastric CA.
Visceral peritoneum covers abdominal organs, for strength only, innervated by autonomic N. CA of stomach that metastasizes to ovaries is known Krukenberg tumors.

Clinical notes DUODENUM [refer to Netter p. 261]

Inflammation of parietal peritoneum
This results in sharp, localized pain over the affected area.
Pxs may exhibit rebound tenderness [pain elicited after pressure of palpation over affected area
is moved] and guarding [reflex spasms of abdominal musces in response o palpation] over site
of inflammation.
Peritoneal irritation
Irritation of peritoneum covering the diaphragm may result in pain being referred to C3, 4, 5
dermatomes in region of neck and shoulder.
Peritoneal ligaments and mesenteries
Greater omentum Is the dorsal mesentery of the stomach, it prevents spread of infection by
adhering to and localizing aeas of inflammation [abdominal policeman]
Gastrocolic lig. Attached to greater curvature of stomach and 1st part of duodenum,
contains the gastroepiploic arteries
Gastrolienal lig. Aka gastrolienal lig., from greater curvature of stomach to hilus of spleen
Gastrosplenic From greater curvature to spleen, separates L greater & lesser sacs
Lienorenal lig. From hilus of spleen to L kidney, contains the splenic A. & V.
Gastrophrenic lig. Connect esophagus and fundus of stomach to undersurface of diaphragm
Lesser omentum Ventral mesentery of stomach, from septum transversum
Hepatogatric lig. Between lesser curvature of stomach and liver, contains the R and L
gastric arteries and veins near the stomach
Hepatoduodenal lig. Between 1st part of duodenum and anterior border of epiploic foramen,
contains the CBD, proper hepatic A., and portal V. [portal triad]
Other structures
Phrenicocolic lig. Connects L colic flexure to diaphragm, limits the paracolic gutter
Falciform lig. Connects liver to anterior abdominal wall above umbilicus, contains the
ligamentum teres hepatis [remnant of L umbilical V. of the fetus]
Mesentery proper Attaches small intestine from duodenojejunal flexure to ileocecal junction
Transverse Attaches to transverse colon from L to R colic flexures and to anterior
mesocolon surface of pancreas, it normally fuses w/ gastrocolic ligament to form the
definitive transverse mesocolon, it contains the middle colic A. and V.
Sigmoid mesocolon Attaches sigmoid colon from L iliac fossa to pelvis, contains sigmoidal V
Mesoappendix Suspends vermiform appendix and transmits the appendicular A. and V.
Ligament of Treitz Aka suspensory ligament of duodenojejunal junction
PERITONEAL CAVITY [refer to Netter p. 258]
A completely closed cavity in males, but open in females thru the uterine tube, uterus & vagina
Greater sac Extends from diaphragm to pelvis, communicates w/ lesser sac thru
foramen of WINSLOW or epiploic foramen
Hepatorenal recess Aka MORISONS POUCH, lies btw R lobe of liver and R kidney
Paracolic gutters Provide potential pathway for spread of infection
Lesser sac Aka as omental bursa, develops as evagination of dorsal mes.
Inferior recess Extends beyond stomach into the layers of greater omentum
Splenic recess Extends behind stomach, btw gastrosplenic lienorenal lig.
Superior recess From diaphragm behind L lobe of liver,btw IVC and esophagus
Epiploic foramen of WINSLOW
Communication between greater and lesser peritoneal sacs
Anterior: hepatoduodenal ligament [contains CBD, proper hepatic A., and portal V.]
Posterior: inferior vena cava
Superior: caudate lobe of liver
Inferior: 1st part of duodenum
STOMACH [refer to Netter p. 258]
Anchored by esophagus proximally and duodenum posteriorly
Located in epigastric and L hypochondriac regions of the abdomen
Blood supply: L gastric [from celiac] & R gastric A [from hepatic], L gastroepiploic [from
splenic] & R gastroepiploic A. [from hepatic], short gastric A.
w/ accompanying veins that drain to the portal vein or its tributaries
Is the shortest [25 cm] but widest part of small intestine
Duodenum From pylorus to jejunum, retroperitoneal [except for its most proximal and
st
1 part [sup]
most distal parts], lies at level of L1-2, surrounds the head of pancreas
W/ duodenal cap or bulb, joined to liver by free edge of hepatoduodenal lig.
nd
2 [descend] Descends vertically to the R of the bodies of L1,2,3
rd
3 [transverse Crosses anterior to body of L3
th
4 [ascend] To L side of the body of L2 and end at duodenojejunal flexure
Blood supply of duodenum: [refer to Netter p. 283]
Name Origin
Anterior and posterior superior pancreaticoduodenal A. Gatric A.
Anterior and posterior inferior pancreaticoduodenal A. Superior mesenteric A.
Supraduodenal and retroduodenal A. Gastroduodenal A.
Lymphatics: pancreaticoduodenal nodes gastroduodenal nodes celiac nodes superior
mesenteric nodes
Nerve supply: vagus N. [via celiac and superior mesenteric plexuses]
Clinical notes
Duodenal compression
The superior mesenteric vessels may compress the horizontal part of duodenum. Pxs experience
epigastric or umbilical pain, nausea after a meal, and billous vomiting.
Gastrointesinal bleeding
Hematemesis [vomiting of blood], results from bleeding into esophageal lumen, stomach, or
duodenum proximal to ligament of Treitz. It is commonly caused by duodenal or gastric ulcer
and esophageal varices.
Hematochezia [blood in stool] usually results from bleeding into lumen of jejunum, ileum, colon or
rectum distal to ligament of Treitz.
Melena [black, tarry stools] that contain blood altered by gastric secretions. In melenamesis, there
is coffee-ground vomitus.
Celiac A. occlusion & collateral circulation & effects of ulcers
In occlusion of celiac A. at its origin from abdominal aorta, collateral circulation ay develop in
pancreatic head by way of anastomoses btw pancreaticoduodenal branches of both superior
mesenteric and gastroduodenal arteries. 3 branches of celiac circulation may be subject to erosion
if an ulcer penetrates posterior wall of duodenum.
The splenic A. may be subject to erosion by contents of a penetrating ulcer of posterior wall of
stomach.
The L gastric A. may be subject to erosion by contents of a penetrating ulcer of the lesser
curvature of stomach.
The gastroduodenal A. may be subject to erosion by contents of a penetrating ulcer of the
posterior wall of 1st part of duodenum.
Pxs w/ penetrating ulcer may have pain referred to shoulder w/c occurs when air escapes thru the
ulcer and stmulates the peritoneum covering the inferior aspect of diaphragm.
The contents of a penetrating ulcer of posterior wall of stomach or duodenum may enter omental
bursa. The fluid contents from an ulcer may pass thru epiploic foramen into subhepatic recess
[MORRISONS POUCH], the part of greater peritoneal cavity situated btw posterior aspect of
liver and R kidney.
JEJUNUM AND ILEUM
Jejunum Larger and thicker than ileum, w/ abundant plicae circulares and diffuse
[2 m] lymphoid tissue, less fat, deep red color, greater vasculature, fewer arterial
arcades
Ileum Smaller and thinner than jejunum, paler pink color, less vvascularity, short vasa
[3 m] recta, fewer plicae circulres, numerous peyers patches and arcades, more fat
Both are approximately 20 ft in length [8ft jejunum, 12 ft ileum]
Blood supply: anastomosing branches of superior mesenteric A. & by superior mesenterc V. w/c
joins the portal V.
Lymphatics of jejunum: superior and inferior mesenteric nodes
Nerve supply: vagus nerve fibers [from superior mesenteric plexus]

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Clinical notes Diverticulitis refers to inflammed diverticula. If a diverticulum ruptures, the ruptured contents may
Meckels diverticulum irritate the parietal peritoneum resulting in pain that is localized to LLQ.
Fingerlike true diverticulum from antimesenteric side of ileum about 2-3 ft. from ileocecal Ischemic bowel infarction
junction Common sites: transverse colon near splenic flexure, and rectum
Represents persistence of fetal vitelline duct /omphalomesenteric duct, in 2% of population, Infarction of transverse colon occurs btw middle colic branches of SMA & L colic branches of
2 inches long, and may contain ectopic gastric or pancreatic cells. IMA.
It may also retain a connection w/ umbilicus of newborn allowing feces to leak from the Infarction of rectum occurs btw superior rectal branches of IMA and middle rectal branches of
umbilcus [meckels fistula] internal iliac A.
A diverticulum is an outpocketing of a tubuar or saccular organ such as GIT or bladder. True Hirschprungs disease
diverticula are protrusions that include all layers of affected structure; while false or pulsion Caused by failure of neural crest cells either to migrate into hindgut or to differentiate into terminal
diverticula are protrusions that do not contain all tissue layers. parasympathetic ganglia in walls of hindgut.
Pxs may have bleeding associated w/ ulceration of ectopic cells, obstruction and pain that is Pxs experience constriction in the affected segment [often rectum], an absence of peristalsis and
referred over the area of umbilical region in T10 dermatome. a dilated large bowel proximal to affected segment.
This is common in pxs w/ Downs syndrome.
LARGE INTESTINE [refer to Netter p. 254]
4-5 ft long, characterized by tenia coli [3 narrow bands of longitudinal muscle], haustra coli Differences btw small and large intestine
[sacculations], and appendices epiploicae [small sacs of peritoneum] Small intestine Large intestine
Cecum [6 cm] Blind pouch, covered by peritoneum and lies free in peritoneal cavity, has an More mobile [except duodenum] Less mobile
ileocecal valve [rudimentary valve] and ileocecal orifice, attached posteriorly w/ mesentery [except duodenum] w/o mesentery
to vermiform appendix Intraperitoneal Retroperitoneal [except transverse & sigmoid]
Blood supply: anterior & posterior cecal A. [from ileocecal A.] & SMA & is Smaller diameter Larger
drained by superior mesenteric vein to portal vein
Continuous layer of longitudinal muscle Longitudinal uscles forms 3 bands [taenia coli]
Lymphatics: superior mesenteric nodes
No fatty tags in its wall w/ fatty tags [appendices epiploicae]
Nerve supply: vagus N. via superior mesenteric plexus
Smooth wall Sacculated wall [haustrae]
Vermiform Usually 10-12 cm, completely covered by peritoneum, suspended from
appendix [9 terminal ileum by mesoappendix, completely infiltrated by lymphoid tissue w/ w/ permanent folds [plicae circulares] Absent
cm] complete layer of longitudinal muscle derived from convergence of tenia coli, w/ peyers patches Solitary lymph follicles
supplied by appendicular A. & V. [from post. cecal branch of ileocolic A.] w/ villi Absent villi
Colon
Ascending From ilocecal valve to R colic [hepatic] flexure below liver, its posterior side is LIVER
[12-20 cm] fused to posterior abdominal wall, is related to R paracolic gutter Largest visceral organ, weighing about 1.5 kg
Is supplied by ileocolic A. and R colic A. [from superior mesenteric A.] Enclosed by fibrous capsule and covered by visceral peritoneum [except where it directly contacts
Transverse From R colic [hepatic] flexure to L colic [splenic] flexure, suspended from the underside of the diaphragm]
[50 cm] posterior wall by transverse mesocolon, is also suspended at L colic flexure Surfaces of liver
by phrenicocolic ligament, related to R of liver and L of spleen Diaphragmatic surface Consists of anterior, superior and posterior surfaces, it has a bare area
Supplied by middle colic A. [from superior mesenteric A.] w/c directly contacts the diaphragm
Descending From L colic flexure to pelvic brim, its posterior side is fused to the posterior Visceral surface In the inferior surface and is contact w/ abdominal organs
[25 cm] abdominal wall; it is supplied by L colic A. [from inferior mesenteric A.] Inferior border Is where the visceral and diaphragmatic surfaces meet
Sigmoid Begins in iliac fossa at pelvic brim as continuation of the descending colon, Bare area Is in direct contact w/ the: diaphragm, IVC, R suprarenal gland & superior
[40 cm] continuous w/ rectum at level of S3, suspended by sigmoid meocolon, is pole of R kidney
supplied by sigmoidal A. [from inferior mesenteric A.] drained by sigmoidal V. Space of Disse Separates sinusoidal wall from liver cell plates where exchange of
Rectum At S3 level, no haustra or appendices epiploicae, w/ valves of HOUSTON nutrients & waste products takes place
[12-15 cm] Supplied by superior rectal A. [from inferior mesenteric A.], middle [from
inferior vesical A.] and inferior rectal A. [from internal pudendal A.] Lobes of liver [refer to Netter p. 270]
Drained by superior rectal V. and anastomoses w/ middle and inferior rectal V. R lobe Largest lobe, lies to the R of gallbladder and the IVC
Innervated by pelvic splanchnic N. and inferior hypogastric plexus L lobe Lies to the L of the falciform ligament, and the fissures of ligamentum venosum
Lymphatics: pararectal nodes [superior], internal iliac nodes [inferior] and ligamentum teres on its visceral surface
Caudate lobe Functionally part of the L lobe, lies posterior to porta hepatic btw groove for
Clinical notes IVC and fissure for ligamentum venosum
Appendicitis Quadrate Functionally part of L lobe, lies anterior to porta hepatis btw fossa for
The vermiform appendix may become inflammed as a result of either an obstrucion by fecalith lobe gallbladder and fissure for ligamentum venosum
[adults] or lymphoid hyperplasia [children].
An inflamed appendix may stimulate visceral pain fibers w/c course back in lower splanchnic Features of the visceral surface of the liver
N. and result in colicky pain referred over umbilical region. Porta hepatis Is the hilus of the liver, a transverse fissure that separates caudate and
Irritation of parietal peritoneum may result in pain localized over the base of appendix quadrate lobes, it transmits the R and L hepatic ducts, R and L hepatic A., R
[McBurneys point btw ASIS and umbilicus in RLQ]. and L branches of portal vein, autonomic plexus, and LN
S/Sx: [+] psoas sign on R, where pain from irritated parietal peritoneum is accentuated when Fissure for lig. Contains ligamentum venosum [remnant of ductus venosus] w/c
the R thigh is extended at hip against resistance. Venosum bypasses liver by shunting blood from portal and umbilical V.
A [+] obturator sign on R, where pain from irritated parietal peritoneum is accentuated when R Fissure for lig. Contains the ligamentum teres hepatis [remnant of L umbilical V.] w/c
thigh is flexed and then internally rotated. teres carries blood returning to the fetus from the placenta
The iliohypogastric nerve may be lesioned in an appendectomy procedure; a weakenng of
anterior abdominal wall & a direct inguinal hernia may result. Clinical notes
Intestinal intussusception Cirrhosis
Part of the small intestine invaginates or telescopes into adjacent distal segment Obstruction of portal vein and HPN in portal system is caused by destruction of hepatocytes and its
[intussuscipiens] replacement by fibrous tissue.
May be jejunoileal, ileoileal, or MC an ileocecal where distal part of ileum telescopes into Pxs may develop portal HPN, in w/c venous blood from GIT w/c normally enters the liver via portal
ascending colon. vein is forced to flow in the opposite or retrograde direction in tributaries of portal vein.
It is more commn in children than in adults and may be caused by hyperplasia of lymphatic Esophageal varices are dilated and tortous veins that develop in submucosal venous plexus in
tissue in Peyers patches in ileal wall. esophageal wall. This may burst and result in hematemesis.
Pxs may have an obstructed bowel, R sided colicky pain, abdominal distention and Internal hemorrhoids are painless protrusions of anal canal covered by mucosa. It contains
hematochezia because blood supply to intussuscepted ileum may be compromised. dilated veins of internal rectal venous plexus.
Sigmoid volvulus, diverticulosis, & diverticulitis Caput medusae is a pattern of varicose superficial epigastric veins that radiate away from
Sigmoid volvulus, the sigmoid colon twists around sigmoid mesocolon and may become umbilicus.
obstructed. Splenomegaly is also a common sign associated w/ pxs having portal HPN.
This pxs may experience L sided colicky pain, abdominal distention, and hemaochezia as a
resut of compromise of he sigmoid arteries. Peritoneal ligaments of the liver
Diverticulosis refers to diverticula that are not inflamed. Falciform ligament Double layer of peritoneum, attaches to anterior abdominal wall to the

14
 undersurface of the diaphragm, derived from septum transversum KIDNEY [refer to Netter p. 311]
Coronary ligament Reflection of visceral peritoneum of liver onto undersurface of diaphragm Retroperitoneal organ lying adjacent to upper 3 lumbar vertebrae
R triangular lig. Joins the R lobe to undersurface of diaphragm On right side, extends superiorly to level of 12th rib and on left side to the level of 11th rib
L triangular lig. Joins L lobe to undersurface of the diaphragm, lies anterior to esophagus R kidney is lower than L because of R lobe of liver
Hilum transmits from front to backward: renal V., 2 branches of renal A., ureter and 3 rd branch of
Blood supply of liver [refer to Netter p. 284] = study portal vein tributaries p. 297 renal A.
Name Origin Branches Coverings: fibrous capsule [outer], preirenal fat, and renal fascia, pararenal fat [outer] & has a
Proper hepatic A Common hepatic Divides into R and L hepatic arteries, 20% of blood parenchyma divided into cortex and medulla
R hepatic A. Proper hepatic A. To R lobe, Cystic A. [to GB] in the angle btw cystic duct Supplied by renal arteries [from abdominal aorta] and veins [drains to IVC at L2 level]
& CBD called hepatocystic triangle of CALOT Lymphatic drainage: lateral aortic nodes
L hepatic A. Proper hepatic A. Supplies the L lobe, quadrate and caudate lobes
Nerve supply: renal sympathetic plexus [T101-12]
Portal vein SMV + splenic V. w/ R and L branches, carries 80% of blood to liver
Hepatic veins [3] Drain the hepatic sinusoids, empty directly into IVC URETER
Muscular tube that transports urine from renal pelvis to urinary bladder
Lymphatic drainage of liver: celiac nodes and posterior mediastinal nodes
Is most likely to become obstructed [ureteral constrictions] where it joins the renal pelvis,
Nerve supply of liver: Sympathetic and parasympathetic [vagal] fibers from celiac plexus & L vagus to
large hepatic branches w/c travels directly to liver. crosses the pelvic brim or enters the bladder wall
Function: propels urine from renal pelvis to urinary bladder
BILIARY SYSTEM [refer to Netter p. 276] In female, lies in the base of the broad ligament where it is crossed anteriorly and superiorly by
Gallbladder Stores and concentrates bile, w/ 30 ml volume, divided into fundus, body uterine A. In male, it is crossed superiorly by ductus deferens near the bladder
and neck, lies btw R lobe and quadrate lobe of liver. Has a Hartmanns pouch The prostatic urethra is the widest and most dilatable part, while the membranous urethra is
[infundibulum]. Lymphatic drainage: cystic LN, hepatic LN and celiac LN. the shortest and least dilatable part. External urethral meaus is the narrowest part.
Nerve supply: celiac nodes Receives blood supply from renal A. [upper 3rd] common iliac A. [middle 3rd] and superior vesical A.
Bile ducts [distal 3rd], drained by similar veins
Common hepatic Union of R & L hepatic ducts, accompanied by portal V. & proper hepatic A. Lymphatic drainage: lateral aortic and iliac nodes
Cystic duct Connects neck of GB to common hepatic duct, it is lined by spiral folds Nerve supply: ureteric plexus [from aortic plexus]
[spiral valve of REISTER] w/c keeps lumen always open Associated w/ pain referred to cutaneous distribution of T11-12, particularly to lower abdominal
Union of common hepatic duct and cystic duct, pierces head of pancreas and wall, external genitalia, and medial thigh
Common bile duct joins w/ main pancreatic duct to form hepatopancreatic ampulla of VATER,
it opens into 2nd part of duodenum at the major duodenal papilla Clinical notes
PANCREAS [p. 279] Both an exocrine [w/ ducts, producing enzyme] and endocrine organ Kidney transplantation
[ductless, producing hormones], it lies at the level of L1, supplied by splenic In kidney transplants, only the upper part of ureter supplied by renal A. is transplanted w/
A. and superior + inferior pancreaticoduocenal arteries and pancreatic vein to renal vessels and the kidney. The kidneys are placed in the pelvis, where the upper part of ureter is
portal V. attached to the bladder and the renal A. is joined to external iliac A.
Lymphatic drainage to pancreas. Lymphatics: celiac & superior mesenteric Ureteral calculi
LN. Nerve supply to pancreas: Sympathetic & parasympathetic innervation A calculus may become lodged at 1 of 3 narrow points in the ureter and results in a
from vagus N. thru celiac plexus
Head hydronephrosis proximal to the site of the blockage.
w/ hook-like uncinate process behind superior mesenteric vessels
Neck Renal colic
constricted where it is crossed by superior mesenteric vessels
Body A severe type of colicky pain that results from distention of ureter by a calculus referred over
lies above and to the left of duodenojejunal flexure
Tail lies in the lienorenal ligament [peritoneal] and ends a hilus of the spleen T11 thru L2 dermatomes. The pain may radiate from back above iliac crest thru the inguinal
region and into scrotum or labium majus.
Main pancreatic duct Opens into the 2nd part of duodenum at MAJOR duodenal papilla, it
of WIRSUNG traverses the CBD to form thehepatopancreatic ampulla of VATER
Accessory duct of Drains the uncinate process, and lower part of head of pancreas, opens into
RENAL FAT AND FASCIA [refer to Netter p. 313]
SANTORINI 2nd part of duodenum at the MINOR duodenal papilla
Support and cushion the kidney & provides compliance for movement occurring during respiration
SPLEEN [p. 281] Largest lymphatic organ, lies through the diaphragm along axis of ribs 9-
12. Functions: graveyard of RBC, w/ Hassals corpuscles & part of RES. It is Renal fascia Surrounds the kidney and suprarenal gland
supplied by splenic A. [from the celiac trunk]. Perirenal fat Lies between capsule of kidney and renal fascia
Lienorenal ligament Contains tail of pancreas and splenic A. + V. Pararenal fat Lies outside renal fascia
Gastrosplenic lig. Contains L gastroepiploic A.+ V. and short gastric A. + V.
NOTE: sphincter of Oddi closes w/ morphine sulfate thus C/I in acute cholecystitis & inferior wall MI Blood vessels of kidney [refer to Netter p. 314]
Renal arteries From abdominal aorta, 1 to each kidney
Clinical notes Anterior branch Divides into upper, middle and lower segmental A.
Fractured ribs & spleen Posterior branch Divides into posterior segmental A.
A fractured 9th, 10th, or 11th rib on the L may lacerate the spleen. The spleen bleeds Apical segmental A. From upper segmental A.
profusely when lacerated and is usually removed. Segmental A. Are end arteries, will result to death if occluded
Gallstones R renal A. Passes posterior to Inferior vena cava
May become lodged in biliary ducts or in gallbladder. Accessory renal A. Are segmental A. that do not reach the kidney thru renal hilus
The hepatopancreatic ampulla, a narrow point in biliary duct system, is a common site
of impacted gallstones. Pxs exhibit referred pain in epigastric area. Renal veins From IVC, 1 from each kidney
Stone blocking cystic duct may cause enlargement of gallbladder. Pxs may exhibit L renal V. Longer than the R, receives terminations of L suprarenal V. and L gonadal V.
biliary colic [severe colicky pain that begins in epigastric area but moves to a point where 9th R renal V. Shorter, passes posterior to 2nd part of duodenum and head of pancreas
costal cartilage intersects the lateral border of rectus sheath.
An inflammed gallbladder may adhere to duodenum and develop a fistula, permitting a URINARY BLADDER
gallstone to pass into duodenum. The gallstone may become lodged at ileocecal junction Highly distensible muscular organ
forming a gallstone ileus. Parts: apex, base, superior surface and neck
Pancreatic adenocarcinoma Muscles of bladder wall: detrusor muscles composed of inner and outer longitudinal layer and a
MC at pancreatic head and may result in compression of bile ducts & main pancreatic middle circular layer, it surrounds the uretra as the circularly-arranged sphincter vesicae
duct. Space of Retzius: btw pubic bones & bladder, limited below by pubovescial ligament [F] &
S/Sx: epigastric pain that frequently radiates to the back, obstructive jaundice puboprostatic ligament [M]
If the main pancreatic duct is obstructed, the pancreas may become inflamed; pxs w/ Supplied by superior & inferior vesical A. [from internal iliac] & drained by same veins
acute pancreatitis may experience localized ileus in duodenum adjacent to area of Lymphatics: external iliac LN [anterior] & internal iliac LN [posterior]
inflammation. Innervated by hypogastric plexus [filling nerves] & pelvic splanchnic N. [emptying nerves]
TOC: Whipples [TOC] Relations Female Male
Pringles maneuver poke your finger in pancreas Infero-laterally Prevesical space of Retzius Prevesical space of Retzius
5 year survival rate = 3-5% [lowest rate] Posteriorly Vagina & cervix, separated by Recum, separated by 2 seminal vesicles &
vesicovaginal septum ductus deferens & by Denonvilliers fascia

15
Inferiorly Ress directly on pelvic floor Rest directly on pelvic floor Renal V.
Superiorly Covered by peritoneum Covered by peritoneum Lumbar segmental V.
Hepatic V.
SUPRARENAL GLAND R gonadal V. L ends in L renal V.
Paired retroperitoneal organ on upper pole of kidney, surrounded by perirenal fat & fibrous R suprarenal V. L ends in L renal V.
capsule R inferior phrenic V. L ends in L suprarenal V.
R suprarenal is pyramidal-shaped, L suprarenal is cresentic
Lymphatics: lateral aortic nodes Clinical notes
Innervated by splanchnic nerves Compression of L renal vein
Blood supply: L renal vein may be compressed by aneurysm of the superior meenteric A. as the vein crosses
Superior suprarenal A. From inferior phrenic A. anterior to aorta. Pxs w/ compression of L renal vein may have renal and adrenal HPN on L and a
Middle suprarenal A. From abdominal aorta varicocele on the R [in males].
Inferior suprarenal A. From renal A.
HEPATIC PORTAL VENOUS SYSTEM [refer to Netter p. 297]
Single suprarenal V. Terminates on the R into the IVC, and on the L into L renal V.
Main vein Terminations Notes
Portal vein Splenic V., Superior and inferior Superior mesenteric + splenic
1 regulatory control Anatomy Secretory products
mesenteric V., R and L gastric V., Cystic veins
Renin-angiotensin Zona Glomerulosa of cortex Aldosterone V., Superior pancreaticoduodenal V. &
ACTH, hypothalamic CRH Zona Fasciculata of cortex Cortisol, sex hormones Paraumbilical V.
ACTH, hypothalamic CRH Zona Reticularis of cortex Sex hormones, androgens Splenic vein Inferior mesenteric V., Short gastric V., L Forms at hilus of spleen and
Preganglionic symph. fibers Adrenal medulla [chromaffin cells] Catecholamines [NEp, Ep] gastroepiploic or gastroomental V. & enters the lienorenal
Pancreatic V. ligament
Clinical notes Superior Tributaries corresponding to branches of
Aortic aneurysm Mesenteric Vein superior mesenteric A., R gastroepiploic
MC site: proximal to bifurcation of aorta at L4 level. Pxs may have pulsating painless mass or gastroomental V., & Inferior
in the midline. pancreaticoduodenal V.
Inferior Superior rectal V., Sigmoidal V. & L colic Superior rectal + sigmoidal V.
Muscles of the posterior abdominal wall [refer to Netter p. 246] Mesenteric Vein V.
Name Innervation Actions Left Gastric Vein Drains the L side of lesser curvature of stomach and lower esophagus
Psoas major Ventral rami of L1-2 Flexes and medially rotates thigh Right gastric Vein Drains R side of lesser curvature of stomach
Psoas minor Ventral ramus of L1 Flexes trunk Paraumbilical vein Accompany the ligamentum teres hepatis in the free edge of falciform
Iliacus Femoral N. Flexes and medially rotates thigh ligament & connects the L branch of portal V. to superficial V. in umbilicus
Quadratus lumborum Ventral rami of T12, L1-3 Depresses the 12th rib Portocaval Occurs at lower end of esophagus, anal canal, umbilicus & bare areas
anastomoses
Nerve supply on posterior abdominal wall
Iliohypogastric N. [L1] With anterior and lateral cutaneous branches Arteries of the Gastrointestinal tract [refer to Netter p. 282]
Ilioinguinal N. [L1] Gives cutaneous branches to upper medial thigh, scrotal, or labial branches Name Features
Genitofemoral [L1,2] Divides into genital [scrotum/labia majora + cremaster M.] & femoral br. [skin] Celiac A. Lies anterior to body of T12, said to be the artery of foregut
Femoral N. [L2-4] Largest branch of lumbar plexus, divides into its terminal branches just Splenic A. Largest branch of the celiac trunk, branches include: dorsal, great,
below the inguinal ligament and caudal pancreatic A., short gastric A., L gastroepiploic A.
L gastric A. Smallest branch of celiac trunk; anastomoses w/ R gastric A.
Clinical notes Common hepatic A. Give rise to gastroduodenal, R gastric, R and L hepatic A. &
Compression of ureter continues as proper hepatic A.
The proximal part of ureter may be compressed by an aberrant renal artery; w/c commonly Superior mesenteric A. Arise anterior to body of L1, said to be the artery of midgut
arises from inferior to renal artery and passes anterior to origin of ureter causing Inferior mesenteric A. Arise anterior to body of L3, said to be the artery of hindgut
hydronephrosis. Thoracoabdominal A. Branches: Clavicular, Acromial, Pectoral, Deltoid [At California Police
A male px w/ varicocele [often on L], resulting from compression of L renal vein by an Department]
aneurysm of superior mesenteric artery near origin of the artery from the abdominal aorta.
Branches of Common hepatic Artery
Lymphatics on posterior abdominal wall Name Branches
Preaortic node Divided into celiac, superior & inferior mesenteric nodes Gastroduodenal A. Supraduodenal, retroduodenal, post. superior pancreaticoduodenal A.
Lateral aortic nodes From R and L lumbar trunks Proper hepatic A. Cystic A. to gallbladder [usually from theR hepatic A.]
Cisterna chili From intestinal trunk, R and L lumbar trunks Superior Arise as independent anterior and posterior superior pancreaticoduodenal
pancreaticoduodenal A. branches from the gastroduodenal A.
ABDOMINAL AORTA [refer to Netter p. 247] R gastroepiploic A. Aka as gastroomental A.,arise as terminal branch of gastroduodenal
Enters abdomen thru aortic hiatus in diaphragm at level of T12 and descends on body of L4
3 unpaired anterior visceral branches: celiac [T12], superior [L1] & inferior [L3] mesenteric A. Branches of Superior Mesenteric Artery [refer to Netter p. 286]
3 paired lateral visceral branches Name Branches
Middle suprarenal A. At level of L1 to supply the suprarenal gland Inferior pancreaticoduodenal A. Anterior and posterior inferior pancreaticoduodenal A.
Renal arteries At level of L1-2, gives rise to inferior suprarenal A. Middle colic A. Right and left branches
Testicular/ovarian A. At level of L2-3, supplies testis [M], and ovaries [F] R colic A. Ascending and descending branches
Ileocolic A. Ascending colic branch, ileal branch, anterior and posterior cecal
5 paired lateral somatic branches to abdominal wall A. and appendicular A.
Inferior phrenic A. Gives rise to superior suprarenal A. Intestinal A. Distributed to jejunum and ileum
Lumbar segmental A. [4 pairs] Supplies crura of diaphragm & muscles of the posterior
abdominal wall, it gives rise to dorsal & spinal branches Branches of the Inferior Mesenteric Artery [refer to Netter p. 287]
Inferior phrenic A. Name Branches
Other branches L colic A. Ascending and descending branches w/c join marginal A.
Median sacral A. May give rise to 5th pair of small lumbar segmental A. Sigmoidal A. Form series of anstomosing arcades to sigmoid colon
Common iliac A. [2] Terminal branches of aorta, lies in the body of L4 Superior rectal A. Anastomoses w/ middle rectal and inferior rectal A.
Marginal A. of DRUMMOND Formed by ileocolic, R colic, middle colic, L colic and sigmoidal A.
INFERIOR VENA CAVA [refer to Netter p. 248] Nerves of the abdomen
Union of common iliac veins and ends in R atrium Name Origin Branches
Pierces central tendon of diaphragm at T8 level. Vagus N. Aortic, celiac, superior mesenteric plexuses
Receives terminations of: Thoracic splanchnic N T5-12 ganglia Greater, lesser and least splanchnic N.
Common iliac V. Lumbar splanchnic N. Upper lumbar Joins the celiac, sup. and inf. mesenteric plexuses
Pelvic splanchnic N. S2-4 spinal N. Aka as nervi ergentes

16
Autonomic plexus Aortic plexus Celiac, superior and inferior mesenteric plexus Sacrogenital [M] or uterosacral [F] lig. Stabilize and support pelvic organs
Lumbar symph. Trunk w/ 4 segmentally arranged ganglia [grey and white]
Clinical notes
Clinical notes Penile urethral laceration
Referred pain
Stimulation of visceral pain fibers that innervate a gastrointestinal structure results in dull, This may result in extravasation of urine into superficial perineal pouch that may spread into
aching, poorly localized pain referred over T5-L1 dermatomes. regions covered by extensions of Colles fascia. The extravasated urine may be found around
Sites of referred pain generally correspond to spinal cord segments that provide sympathetic penis, scrotum, and deep to Scarpas fascia on anterior abdominal wall. The only difference btw
innervation to affected gastrointestinal structure. male perineal pouches and female perineal pouches is the location of bulbourethral glands and
Colicky pain greater vestibular glands.
A rhythmic, recurring pain symptomatic of ileus [obstruction of GIT] Bulbourethral glands are situated in deep perineal pouch in males while greater vestibular
It resuls from recurrent smooth muscle contractions against the obstruction. glands are located in superficial pouch in females.
Biliary or renal colic results from recurring smooth muscle contractions against a gallstone
lodged in biliary system or calculous lodged in ureter. INGUINAL REGION
Superficial Triangular defect in the aponeurosis of ext. abdominal oblique. Larger in male &
CHAPTER 6 PELVIS AND PERINEUM inguinal ring transmits spermatic cord. In female it transmits the round ligament of the uterus
Deep inguinal Tubular evagination of transversalis fascia
PELVIS [refer to Netter p. 332] Inguinal canal Transmits the spermatic cord in male and round ligament of uterus in female, it also
Components of the bony pelvis: paired hip bones, sacrum, coccyx allows passage of ilioinguinal nerve in both sexes
Pelvic brim Aka as superior pelvic aperture or pelvic inlet, bounded by promontory of Femoral ring Is medial to femoral vein and lateral to lacunar ligament [w/c is an extension of
sacrum, arcuate line of ilium, and iliopectineal line of pubis inguinal ligament]
Pelvic outlet Bounded by coccyx, sacrotuberous ligaments, ischial tuberosities, ischiopubic
rami, & pubic symphysis, bounded by coccyx, ischial tuberosities, & pubic arch Inguinal canal
Greater pelvis Aka as false or major pelvis, forms the lowest part of abdominal cavity Roof: transversus abdominis and internal abdominal oblique muscles
Lesser pelvis Aka as true or minor pelvis Floor: inguinal and lacunar ligament
Anterior wall: external oblique aponeurosis [medial], internal abdominal oblique m. [lateral]
Sex differences in bony pelvis
Posterior wall: conjoint tendon [medial], transversalis fascia [lateral]
Feature Male Female
True pelvis/minor/lesser Narrow and deep Wide and shallow It is a site of potential weakness in lower abdomen
False pelvis/major/greater Deep Shallow On coughing or straining as in micurition, defecation or parturition, the arching lowest fibers of
Pelvic inlet Narrow, heart-shaped Wide, oval or rounded internal oblique and transversus abdominis muscle contracts.
Pelvic cavity Longer, tapered, cone-shaped Short, cylindrical, roomier
Pelvic outlet Smaller Larger Inguinal or HESSELBACHS triangle
Pelvic brim Android Ovoid Medial: rectus abdominis m.
Pubic arch Narrow Wide Lateral: inferior epigastric vessels
Greater sciatic notch Narrower Wider Inferiorly: inguinal ligament
Ilium Tall, deep, narrow Short, shallow, wide Floor: transversalis fascia
Shape of sacrum Longer, narrower, more curved Shorter, wider, flatter Lies in the abdominal wall behind the superficial inguinal ring
Coccyx Fixed, pointed inwards Not fixed, attached loosely Site of potential weakness for hernia
Ischial spines Inverted, closer More widely separated Type of hernia Features
Direct inguinal hernia M>F, lies passes medial to inferior epigastric vessels
Measurements of pelvic inlet and outlet Indirect inguinal Passes lateral to inferior epigastric vessels, said to be congenital if
Conjugate diameter Aka obstetric conjugate diameter or true conjugate diameter, lies hernia [MC type] associated w/ persisting processus vaginalis, female pxs may develop
between pubic symphysis and sacral promontory this at the canal of NUCK
Oblique diameter Maximum distance between opposing arcuate lines [pelvic inlet] or the Femoral hernia F>M, enter anterior thigh after passing femoral ring deep to inguinal
distance between ischial spines [pelvic outlet] ligament, has the highest bowel incarceration rate of any hernia type
Diagonal conjugate Between lower border of pubic symphysis and sacral promontory
AP diameter of outlet Between lower border of pubic symphysis and tip of coccyx Inner aspect of the lower abdominal wall
Median umbilical fold Contains the median umbilical ligament [remnant of urachus]
The smallest diameter of pelvic outlet: transverse diameter between the ischial spines Medial umbilical folds Contains the mediaL umbilical ligament [remnant of umbiLical A.]
Maximum measurement of pelvic inlet: transverse diameter Lateral umbilical folds
Median inguinal fossa
Contains the inferior epigastric vessels
Area thru w/c direct inguinal hernia occurs
Maximum diameter of pelvic outlet: anteroposterior diameter Lateral inguinal fossa
Supravesical fossa
Depression that lies lateral to lateral umbilical fold
Depression lying above the bladder on sides of median umbilical fold
Pelvic diaphragm [refer to Netter p. 333]
SPERMATIC CORD
Coccygeus muscle Aka ischiococcygeus, innervated by S4-5 spinal N.
Contents: ductus/vas deferens and its artery, testicular A. and V. [pampiniform plexus], testicular
Levator ani muscle Maintains integrity of pelvic floor, important in maintaining urinary
lymph vessels, cremasteric A., genital branch of the genitofemoral N. , periarterial autonomic [renal
continence and preventing uterine prolapse, innervated by S4 spinal N.
aortic] plexus, processus vaginalis remnants & loose areolar tissues
Pubococcygeus w/ levator prostatae, puborectalis and pubovaginalis muscle
Coverings:
Puborectalis Functions as sphincter to maintain anal continence
Layers Origin
Clinical notes Internal spermatic fascia Transversalis fascia [deep inguinal ring]
Weakness in pelvic diaphragm Cremasteric muscle and fascia Internal abdominal oblique muscle
May result in prolapse of uterus into vagina or herniation of bladder or rectum into vagina. External spermatic fascia External oblique aponeurosis [superficial inguinal ring]
In pxs w/ uterine prolapse, the cervix, isthmus, and body of uterus protrude into the superior Femoral sheath Transversalis fascia and fascia iliaca
aspect of vagina. Px may experience bleeding and discharge into the vagina. Blood supply: Testicular [aorta], Cremasteric [inferior epigastric], Vas [inferior vesicle]
In pxs w/ cystocele, the bladder herniates into upper part of anterior vaginal wall. Px may
experience urinary problems. Clinical notes
Cremasteric reflex
In pxs w/ rectocele, the rectum herniates into lower part of posterior vaginal wall. Px may have
Utilizes sensory and motor fibers in ventral ramus of L1 spinal nerve.
difficulty in defecation.
Kegel exercises strengthen pelvic diaphragm, in particular pubococcygeus muscles to prevent Stroking the skin of superior and medial thigh stimulates sensory fibers of ilioinguinal nerve
prolapse or herniation of pelvic viscera. Motor fibers from genital branch of genitofemoral nerve cause the cremasteric muscle to
contract elevating the testis.
Pelvic fascia Testicular torsion
Puboprostic [M] or pubovesical [F] lig. Fills the anterior gap in levator ani [genital hiatus] Results in sudden onset of testicular pain and a loss of cremasteric reflex.
Transverse cervical/cardinal ligament Stabilize and support uterus and vagina Abnormal cysts in spermatic cord

17
 A hydrocele is accumulation of serous fluid in tunica vaginalis or in a persistent part of EPIDIDYMIS [refer to Netter p. 238]
processus vaginalis in a cord. Formed by duct of epididymis and continuous at the tail w/ ductus deferens
A hematocele is an accumulation of blood in tunic vaginalis and results from rupture of w/ coiled tubules about 20 ft long [6 meters]
testicular blood vessels after trauma to spermatic cord or testis.
A spermatocele is a cyst containing sperm that develops in epididymis just above the testis. Blood supply of testis and epididymis
A varicocele results from dilatations of tributaries of testicular vein in pampiniform plexus. It Testicular A. From abdominal aorta
may be caused by defective valves in pampiniform plexus or by compression of a testicular Testicular V. Emerges as pampiniform plexus
vein [often on the L] in the abdomen. This is observed when the px is standing and R testicular Vein Drains to IVC
disappear upon lying down. Palpation of plexus feels like a bag of worms. L testicular Vein Drains to L renal vein
Testicular spasm Lymphatic drainage Para-aortic nodes
A malignant neoplasm of testis [MC a SEMINOMA] metastasizes directly to lumbar nodes,
distinguishing it from a malignancy in scrotum, w/c metastasizes initially to superficial Clinical notes
inguinal nodes. A malignancy is the MC cause of painless testicular mass. Fibromatosis of Bucks fscia
Cryptorchidism May cause Peyronies disease, w/c results in an abnormal curvature of the penis and painful
Refers to faiure of 1 or both testes to descend completely in scrotum. The MC location is in erections.
the inguinal canal. If cryptorchidism is bilateral, the px may be sterile.
SEMINAL VESICLE [refer to Netter p. 338]
Other structures of spermatic cord Unites w/ ductus deferens near base of prostate to form ejaculatory duct
Pampiniform plexus of Merges in inguinal canal to form a single testicular vein at deep Do not store spermatozoa but it produces seminal fluid w/c imparts alkalinity to the ejaculate, it also
veins [10-12] inguinal ring contains fructose that is nutritive to spermatozoa
Cremasteric artery From inferior epigastric A. to enter deep inguinal ring Supplied by inferior vesical and middle rectal A., drained by similar veins
Artery of ductus From superior vesical artery to enter deep inguinal ring, it supplies Lymphatics: internal iliac nodes
deferens ductus deferens and epididymis Innervated by superior lumbar, hypogastric and pelvic splanchnic N.
Testicular artery From abdominal aorta
Processus vaginalis Evagination of parietal peritoneum into the inguinal canal and scrotum DUCTUS OR VAS DEFERENS
in fetus, promotes hernial occurrence, if persisent it forms the canal Dilated part [ampulla], ends by joining the duct of seminal vesicle to form ejaculatory duct
of NUCK in females Supplied by deferential A. [from inferior vesical A.], drained by similar veins
Gubernaculums testis From inguinal ligament of mesonephros, is homologous to round
Lymphatics: external iliac nodes
ligament of uterus and ovarian ligament proper of Female
Innervated by inferior hypogastric plexus
Male external & internal genitalia [refer to Netter p. 361]
PENIS EJACULATORY DUCT
Male organ of copulation Union of ductus deferens and duct of seminal vesicle
Opens into prostatic urethra on colliculus seminalis lateral to prostatic utricle
Surrounded by superficial and deep penile fascia [bucks] Supplied by deferential A. [from inferior vesical A.], drained by similar veins
Lymphatics: external iliac nodes
Suspended by suspensory ligament of penis to pubic symphysis and fundiform ligament to Innervated by inferior hypogastric plexus
anterior body walldivisions: body and root
Crus of penis is an erectile tissue covered by ischiocavernus muscle PROSTATE GLAND
Opens into prostatic sinus, a recess in prostatic urethra along colliculus seminalis
Bulb of penis is covered by bulbospongiosus muscle and contains the spongy uethra and Divided into anterior, middle and posterior lobes [easily palpated during DRE]
ducts of bulbouretral glands Prostatic utricle [remnant of fused paramesonephric ducts]
Supplied by prostatic A. [from internal iliac A.], drained by prostatic venous plexus
Clinical notes Lymphatics: internal iliac and sacral nodes
Hypospadias Innervated by pelvic splanchnic N. [S2-4] and inferior hypogastric plexus
Abnormal penile urethra opening on inferior [ventral] side due to failure of urethral folds to Clinical notes
close. Benign prostatic hyperplasia
Epispadias It commonly occurs in periurethral zone of prostate and will result in obstruction of prostate
Abnormal penile urethral opening on superior [dorsal] side due to faulty positioning of genital urethra w/c may impede urinary flow and result in incomplete emptying of the bladder.
Pxs may have difficulty initiating urination and an increased need to urinate.
tubercle.
SCROTUM Prostate adenocarcinoma
Derived from continuation of of skin and fascia of lower abdominal wall into peritoneum It commonly develops in peripheral part of prostate [MC in posterior part]. Urine flow may be
altered and pxs may pass blood in urine.
Contents on each side: testis, epididymis, spermatic cord and coverings
It frequently metastasizes to bones of the pelvis and to bodies of vertebrae.
Layers:
They also have elevated blood levels of prostatic acid phosphatase and PSA.
o Skin
o Superficial fascia or dartos layer [functions to elevate scrotum to conserve heat] Female internal & external genitalia [refer to Netter p. 367]
CLITORIS
o External spermatic fascia [from external oblique] Homologue of penis and consists of erectile tissue, highly sensitive like the glans penis
o Cremasteric fascia [from internal obique] Attached to symphysis by suspensory ligament of clitoris

o Internal spermatic fascia [from transversalis fascia] LABIA MAJORA

o Tunica vaginalis Homologous to scrotum in males, unite at the anterior labial commissure
Blood supply: superficial and deep external pudendal A. [from femoral A.] and posterior scrotal Contain the terminations of the round ligament of the uterus
A. [from internal pudendal A.] LABIA MINORA
Innervation: anterior scrotal branch of ilioinguinal N., genital branch of genitofemoral N., Hairless and contain no fat unlike majora, join posteriorly to form the fourchette
posterior scrotal branches of the perineal branch of pudendal N., perineal branch of posterior Divides anteriorly into prepuce and frenulum of the clitoris
femoral cutaneous N.
TESTIS VESTIBULE OF VAGINA
Measures 4 x 3 x 2.5 cm and lies in floor of the scrotal sac, covered by tunica albuginea and Contains the openings of urethra, vagina, ducts of greater vestibular glands
tunica vaginalis testis [may accumulate serous fluid [hydrocele] or blood [hematocele]
Responsible for spermatozoa and testosterone production BULB OF VESTIBULE
Tubular structure, 4-5 m in length Homologue of the bulb of penis and is divided into an erectile tissue that lie on either side of
Promotes sperm maturation & motility the vaginal opening

18
GREATER VESTIBULAR GLAND OR BARTHOLINS GLANDS Name Branches
Mucus secreting glands homologous to bulbourethral glands in males Internal iliac A. Anterior division: umbilical, obturator, inferior gluteal, internal
Lies in the superficial perineal pouch and provides lubrication for coitus pudendal, inferior vesical, middle rectal, uterine and vaginal arteries
Posterior division: superior gluteal, lateral sacral, iliolumbar A.
OVARY [refer to Netter p. 345] Umbilical A. Superior vesical A. [3], Artery to ductus deferens
w/ fibrous capsule called tunica albuginea, covered by germinal epithelium Common iliac A. Divides into internal and external iliac A.
attached to posterior aspect of broad ligament by mesovarium External iliac A. Inferior epigastric A., deep circumflex iliac, and femoral A.
suspended from lateral pelvic wall by suspensory ligament of ovary Veins of the pelvis accompanies similar branches w/ the arteries
round ligament/cardinal ligament represents the remains of gubernaculums that connects Lymphatic drainage of pelvis: Internal iliac nodes [Where most vessels drains], Aortic nodes [from ovary
lateral margin of uterus to ovary & contains the ovarian vessels and testis], Inferior mesenteric nodes [From rectum]
Supplied by ovarian A. [from abdominal aorta], uterine A.
Nerves of pelvis: Sacral plexus
Drained by ovarian V. w/c ends in IVC on R, and L renal V. on L
Name Features
Lymphatics drain to paraortic nodes at L1 level. Sciatic N. Largest branch, consists of common peroneal and tibial nerves
Nerve supply from aortic plexus w/c accompanies ovarian A. Superior gluteal Supplies gluteus medius + minimus, tensor fascia lata, and hip joint
Inferior gluteal Supplies gluteus maximus
UTERINE TUBE / FALLOPIAN TUBE/ OVIDUCT Posterior femoral cutaneous Supplies buttocks, posterior thigh, popliteal fosa, external genitalia
Connects uterine cavity to peritoneal cavity N. to obturator internus Supplies superior gemellus and obturator internus muscles
Functions: to convey ovum to uterine cavity, serve as conduit for spermatozoa, provide the N. to quadratus femoris Supplies inferior gemellus and quadratus femoris
appropriate environment for fertilization to occur Pudendal N. Has no branches in the gluteal region
Divisions: infundibulum, ampulla [widest], isthmus [narrowest], intramural part
Supplied by uterine and ovarian A., drained by uterine venous plexus
Lymphatics: lumbar nodes PERINEUM [refer to Netter p. 350-354]
Innervated by ovarian and uterine plexus Diamond-shaped area below pelvic diaphragm
Bounded by pubic symphysis [anterior], ischial tuberosities [lateral], and coccyx [posterior], pelvic
UTERUS diaphragm [roof], skin and fascia of perineum [floor]
Organ in w/c the embryo or fetus develops and is nourished until birth
Divisions: fundus, body, cervix Anal triangle & urogenital triangle
Boundaries Urogenital triangle Anal triangle
Can be anteverted [angled forward at the junction of cervix and vagina], and anteflexed
Front Pubic arch Imaginary line
[angled forward at junction of body and cervix]
Lateral Ischial tuberosities, rami of ischium & pubis Ischial tuberosities, sacrotuberous lig.
Supplied by uterine and ovarian A., drained by uterine venous plexus
Posterior Imaginary line Tip of coccyx
Lymphatics: lumbar [fundus], external iliac [body], internal iliac and sacral [cervix]
Innervated by uterovaginal plexus Contents of perineum
Supported by: Anal canal Continues w/ rectum at pelvic diaphragm
1. transverse cervical or cardial ligament [Mackenrodts] from cervix to laeral fornix of vagina Internal anal sphincter Controlled reflexly and involuntarily
2. uterosacral ligament from lower end of sacrum to cervix & upper end of vagina External anal sphincter Controlled voluntarily
3. pubocervical ligament from posterior surface of pubis to cervix Ischiorectal / ischioanal Contains the ischioretal fat pad, pudendal N. and internal
4. round ligament of uterus btw angle of uterus, thru inguinal ring & labia majora fossa pudendal vessels, inferior rectal N. and vessels, and the perineal
5. broad ligament formed by 2 layers of peritoneum and contains the uterine tube, round branch of posterior femoral cutaneous nerve
ligament of uterus, ovarian ligament, nerves, lymphatics, ovarian and uterine vessels Pudendal / ALCOCKS A tunnel in the fascia of obturator internus M. and contains
canal pudendal N. and internal pudendal vessels to the perinum
Clinical notes
Hysterectomy procedure Clinical notes
In hysterectomy, the ureter may be injured or inadvertently ligated because of the proximity of Internal hemorrhoids
the ureter to the cervix and to uterine artery. Are painless protrusions of anal canal covered by mucosa. They contain dilated veins of the
Metastasis & the Round ligament internal rectal venous plexus.
CA of the fundus of the uterus may metastasize to superficial inguinal nodes along lymphatic External hemorrhoids
vessels that course w/ the round ligament. Are painful enlargements covered by skin that contains dilated veins of the external rectal venous
plexus.
VAGINA
Female organ for copulation receiving penis during coitus Differences between internal and external anal sphincter
Serve as excretory duct for products of menstruation Characteristic Internal anal sphincter External anal sphincter
Highly distensible fibromuscular tube Epithelium Simple columnar Stratified squamous
Supplied by uterine A. [superior], middle rectal and internal pudendal A. [middle and inferior], Pain Insensitive Sensitive
drained by vaginal venous plexus Hemorrhoids Internal External
lymphatics: internal and external [superior], internal iliac [middle], sacral and common iliac Lymphatics Pelvic nodes Superior inguinal nodes
[inferior] Anal columns Present Absent
innervated by uterovaginal plexus [superior] and pudendal N. [lower] Innervation Inferior hypogastric plexus Inferior rectal N.
Supported by:
1. levator ani muscle Clinical notes
2. urogenital diaphragm Disorders of micturition
3. perineal body A spinal, automatic or spastic bladder may result from lesions to spinal cord above sacral
4. transverse, cervical, uterosacral, and pubocervical ligaments levels. In these pxs, parasympathetic neurons that innervate detrusor muscle are not inhibited
effectively when bladder is stretched during filling. The detrusor contracts in response to a
Homologues minimum amount of stretch causing frequent emptying.
Embryologic remnant Male Female An atonic bladder may result from lesions to sacral spinal cord or to the roots of sacral
Developing gonad Testis Ovary spinal nerves in cauda equina. These lesions disrupt the neural components of vesical reflex.
Genital tubercle Glans of penis Glans of clitoris Bladder fills to capacity but urine dribbles thru urethra continuously because detrusor fails to
Genital urethral folds Penile urethra Labia minora contract and empy the bladder, and the voluntary urethral sphincter may be wekened. Pxs tend to
Genital swellings Scrotum Labia majora retain a considerabe volume of urine w/ high infection risk and pass urine only as a result of
Gubernculum Gubernaculums testis Round ligament of ovary overflow incontinence.
Urogenital sinus Bulbourethral/Cowpers Bartholinsl glands Injury to cavernous sinus
Prostate gland Skenes gland [paraurethral] In surgical procedures involving prostate, the cavernous nerves may be lesioned. This
Corpus spongiosum Vestibular bulbs nerves course lateral to prostate before passing thru urogenital hiatus to enter the perineum.
This pxs may have impotence [inability to obtain erection].
Arteries of the pelvis [refer to Netter p. 371]

19
UROGENITAL TRIANGLE [refer to Netter p. 355, 367] Boundaries of urogenital triangle:
Urogenital diaphragm Penetrated by membranous urethra in M, and by membranous o Anterior: pubic arch
urethra and vagina in F o Lateral: ischial tuberosity
Deep perineal pouch Marks lower end of GIT: anocutaneous line
Deep transverse perineal M. Supports the pelvic viscera, innervated by deep perineal N. Line between upper and lower anal: dentate line
Sphincter urethrae muscle Compresses membranous urethra, supplied by deep perieal N.
Non-muscular segment of anal canal between internal and external anal sphincter: Hiltons
Superficial perineal pouch
white line
Superf transverse perineal M. Stabilize perineal body, iinervated by deep perineal N.
Ischiocavernous muscle Help maintain erection, supplied by deep perineal N. Area of infection during habitual constipation: Crypts of morgagni
Bulbospongiousus muscle Maintain erection, supplied by deep perineal N. Fibrous tissue w/c separates posterior surface of urinary bladder and prostate gland from
Perineal body Aka as central tendon of perineum, it support s pelvic organs anterior rectal wall: Denonvilliers fascia
secretes mucus that maintains acidity of penis: Gland of Tysons
Nerve supply of perineum: Pudendal nerve [branches: inferior rectal N., perineal N., dorsal nerve of
penis or clitoris] RECTAL EXAM: screening procedure of choice in:
Prostate CA
Clinical notes Colorectal CA
Pudendal nerve block
This may be performed to suppress labor pain by anesthesizing pudendal nerve as it crosses CHAPTER 7 BACK
the iliac spine.
VERTEBRAL COLUMN
Blood vessels to perineum Consists of 32-34 individual vertebrae and their intervertebral disks
Internal pudendal A. principal blood supply to perineum; branches: inferior rectal A., It protects he spinal cord and supports the weight of the head and trunk
perineal A., artery to bulb of penis or clitoris, deep artery of penis or Type Features
clitoris, and dorsal artery of penis or clitoris
Cervical vertebrae [7] Atlas [atypical C1], axis [atypical C2], C7 w/ vertebral prominens
Perineal A. Enters superficial perineal pouch and gives rise to tansverse perineal A.
Thoracic vertebrae [12] Atypical are the T1, T10, 11, and 12
and the posterior scrotal or labial A.
Lumbar vertebrae [5] Massive, w/ kidney-shaped body
External pudendal V. Receives the superficial dorsal vein of penis or clitoris and ends in great
Sacrum Fusion of 5 sacral vertebrae
saphenous V.
Coccyx Triangular bone from 4 rudimentary coccygeal vertebrae
Deep dorsal vein of Drains into prostatic venous plexus [M], or vesical venous plexus [F]
penis or clitoris
Clinical notes
Spina bifida
Lymphatic drainage of perineum
Results when laminae fail to fuse to form a spinous process and is most commonly seen at lower
Superficial inguinal nodes Drains lower part of anal canal
lumbar or sacral vertebral levels.
Internal iliac nodes Drains deep perineal space, membranous urethra, vagina
In spina bifida occulta, 1 or more spinous processe fail to form at lumbar or sacral levels. This is
.
RAPID REVIEW asymptomatic and may be marked by a tuff of hair in skin over the defect.
Divisions of pelvis: In spina bifida cystica, a cyst protrudes thru the defect in vertebral arch. These conditions can be
o Greater/major/false pelvis diagnosed in utero based on elevated levels of AFP after amniocentesis and by UTZ. This may
result in hydrocephalus and neurological deficits.
Behind: lumbar vertebra
In spina bifida cystica w/ meningocele, the cyst is lined by meninges and contains CSF.
Lateral: iliac fossa and iliacus mucle
Front: lower part of abdominal wall In spina bifida cystica w/ meningomyelocele, the lumbosacral spinal cord is also in the cyst.
o Lesser/minor/true pelvis Displacement of the cord stretches the lumbosacral spinal nerves and results in bladder, bowel, or
limb weakness.
Boundaries Pelvic inlet Pelvic outlet
In spina bifida w/ myeloschisis or rachischisis, the caudal end of neural tube fails to close in
Lateral Ileopectineal line Ischial tuberosiities
the dorsal midline and is exposed on back surface.
Posterior Sacral promontory Coccyx
Anterior Pubic symphysis Pubic arch Joints between vertebrae
Name Features
Bladder usually enter the greater pelvis by 6 years Intervertebral disks Fibrocartilaginous joint between adjacent vertebrae, functions as
Holds kidney in position: fibrous capsule, perirenal fat and renal fascia shock absorber when distorted by compression, consists of
70 million sperms is required to impregnate a female annulus fibrosus and nucleus pulposus [remnant of notochord]
Conveys sperm from epididymis to urethra: ductus deferens Facet /zygapophyseal joints Synovial joints between superior and inferior articular facets
Largest accessory gland in males: prostate, in females: paraurethral glands
MC site of obstruction to urethra: middle prostate lobe Curvatures of the vertebral column
Usually lacerated during sex: fornix of the vagina A. Normal curvatures
Skeenes gland secretes mucuc for acidity of vagina Primary curvatures Exits before birth, C-shaped and is concave anteriorly,
retained in the thoracic and sacral regions of the adult
Bartholins gland secretes lubricant during sexual act for penis to slide thru
Secondary Develops after birth, concave posteriorly, and is retained
Not supplied by internal iliac artery in females: ovary curvatures in cervical and lumbar vertebra
Main nerve in the perineum and chief sensory nerve of external genitalia: pudendal
nerve B. Abnormal curvatures
Boundaries of anal triangle: Lordosis Convex anteriorly, seen in pregnant women
o Behind: tip of coccyx KyPOSis Convex POSteriorly [MC due to postural], seen in old age
o Side: ischial tuberosity, sacrotuberous ligament, ischiorectal fossa Scoliosis Lateral curvature of the spine
o Midline: anus Deep muscles of the back [refer to Netter p. 160]
Boundaries of anal canal: Name Innervation
o Posterior: anococygeal body Splenius cervicis & capitis Dorsal primary rami of spinal nerves
o Lateral: ischiorectal fossa Erector spinae
o Anterior: perineal body, urogenital diaphragm, membranous urethra, bulb of penis, lower Iliocosalis Dorsal primary rami of spinal nerves
vagina Spinalis Dorsal primary rami of spinal nerves
Boundaries of ischiorectal/ischioanal canal or fossa Longissimus Dorsal primary rami of spinal nerves
o Lateral: ischium, obturator internus Transversospinal muscles
o Medial: anal canal Semispinalis Dorsal primary rami of spinal nerves
o Posterior: sacrotuberous ligament, gluteus maximus Mutifidus Dorsal primary rami of spinal nerves
o Anterior: external urethra sphincter, deep transverse perineal muscle Roatores Dorsal primary rami of spinal nerves
o Superior: pelvic diaphragm
o Inferior: skin SUBOCCIPITAL REGION

20
 Lies deep to semispinalis capitis muscle in the upper part of neck Herniated nucleus pulposus
Include the suboccipital muscles, suboccipital N., greater occipital N., 3rd occipital N., and the This MC occurs btw C6 and 7, w/c compresses C7 spinal nerve or less commonly btw C7-
vertebral A. T1 w/c compresses C8 spinal nerve.
Muscles of the suboccipital region [refer to Netter p. 162] C7 compression may result in referred pain in neck and shoulder w/ pain and paresthesia
Name Innervation Action in index and middle fingers.
Rectus capitis posterior major Suboccipital N Extends head and rotates to same side C8 compression may result in pain in the neck and shoulder and pain and paresthesia in
Rectus capitis posterior minor Suboccipital N Extension of head the ring and little fingers.
Obliquus capitis inferior Suboccipital N Rotation of head to same side A cervical rib may emerge from costal process of C7. The T1 spinal nerve and subclavian
Obliquus capitis superior Suboccipital N Extension and lateral flexion of head A. may be compressed as they course superior to cervical rib instead of superior to the 1 st thoracic
rib. Pxs may present w/ diminished radial pulse and pain and paresthesia in medial forearm.
Vessels and nerves in suboccipital region Horners syndrome may also be present.
Spondylosis & spondylolisthesis
Suboccipital N. Supplies the suboccipital muscles
In spondylolysis, there is a defect or fracture of the isthmus, w/ no anterior displacement
Vertebral A. From subclavian A. to supply post. atlantooccipital membrane
Greater occipital N Supplies cutaneous innervation to scalp of vertebral body.
3rd occipital N. Supplies cutaneous innervation to scalp In spondylolisthesis, a uni/bilateral defect or fracture of the isthmus is accompanied by
anterior displacement of vertebral body. MC site is btw L5 and sacrum and may stretch roots of
lumbosacral spinal nerves in cauda equina. Pxs may have bilateral lower back pain that radiates
Boundaries of suboccipital triangle:
into both lower limbs and weakness in leg muscles.
o Medially: rectus capitis posterior major
Spinal stenosis or narrowing of vertebral canal can be caused by spondylosis [in w/c
o Laterally: obliquus capitis superior
degenerative changes occur in L4 or L5 interverebral disks or osteoarthritis [at facet joints of the
o Inferiorly: obliquus capitis inferior
vessels].
o Contents: Vertebral artery and suboccpital nerve L5 compression may result in sciatica, characterized by pain that radiates from the back
thru posterior thigh into leg and foot, combined w/ pain and paresthesia in anterolateral leg and
Other features of the back dorsum of foot. There may be weakness in extension of great toe [extensor hallucis longus] and
Boundaries Triangle of auscultation in the back Lumbar triangle: weakness in dorsiflexion [tibialis anterior].
Medial Trapezius, lateral border Latissimus dorsi, medial border S1 compression may also result in sciatica, combined w/ pain and paresthesia in
Lateral Scapula, medial border External abdominal oblique, posterolateral leg, heel, and lateral side of foot. There may be wekness in flexion of the leg at knee
posterior border [hamstrings], weakness in plantar flexion [gastrocnemius and soleus] and a diminished Achilles
Inferiorly Latissimus dorsi, upper border iliac crest, upper border tendon reflex.
Epidural or caudal block
Innervation of the back Is performed by administering anesthetic thru sacral hiatus w/c diffuses thru meninges and
Both the intrinsic muscles of the back and the overlying skin ae supplied in a segmental anesthesizes the roots of sacral and coccygeal spinal nerves in cauda equina.
pattern by dorsal primary rami of spinal nerves [w/ medial and lateral branches]
SPINAL CORD
MENINGES Begins at foramen magnum where it is continuous w/ medulla of brain stem
Dura mater Fuses w/ inside of the skull at foramen magnum, surrounded by epidural space Ends at level of lower border of L1 in adult
Arachnoid Intermediate layer, ends inferiorly at the level of 2nd sacral vertebra
Receives blood from single anterior spinal A. and paired posterior spinal A., and radicular A.
Pia mater Extends from lower end of spinal cord as the filum terminale
Veins drain into internal vertebral venous plexus.
Other features of the meninges
Spinal nerves
Epidural space Contains fat and internal vertebral venous plexus
31 pairs of segmentally aanged nerves: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1
Subdural space Only a potential space, may collect leaking blood
coccygeal
Subarachnoid space Contains CSF, and cauda equine below the end of spinal cord
Union of dorsal and ventral root at intervertebral foramen
Denticulate ligament Extension of pia mater on lateral sides of spinal cord
Filum terminale Extension of pia mater from conus medullaris Are mixed nerves containing all of the general functional components
Batsons venous Provides pathway for dispersion of malignant tumor cells from the Arterial supply of the back
plexus pelvic, abdominal and thoracic vertebrae, spinal cord and brain Level Arterial supply
Cervical ganglion Occipital, vertebral, deep and ascending cervical arteries
Clinical notes Thoracic Posterior intercostal A.
Lumbar puncture Lumbar Subcostal and lumbar A.
Allows removal of CSF from lumbar cistern of the subarachnoid space Sacral Iliolumbar and lateral sacral A.
Involves insertion of a needle in midline between 3rd and 4th or 4th and 5th lumbar Venous drainage of the back: external and internal vertebral venous plexus and basivertebral veins
vertebrae
Lymphatic drainage of the back:
Penetrates: skin, fascia, supraspinous ligament, interspinous ligament, ligamentum
Name Drainage
flavum, epidural space, dura, arachnoid, subarachnoid
Superficial LN Above iliac crest: axillary nodes; Below iliac crest: superficial inguinal nodes
In a lumbar puncture off the midline, needle will traverse a ligamentum flavum instead
Deep LN Deep cervical, posterior mediastinal, lateral aortic, and sacral nodes
of supraspinous and interspinous ligaments and intralaminar space.
Radiculopathies Nerve supply of the back: frm posterior rami of C1, 6, 7 and 8, also of L4-5 spinal nerves.
Results from compression of roots of spinal nerves in intervertebral foramina or in
CHAPTER 8 HEAD & NECK
vertebral canal.
S/Sx: pain and paresthesia in the form of numbness or tingling in dermatomes supplied Muscles of the anterior neck
by the compressed sensory roots. Pain may radiate over dermatomal distribution of the affected Name Innervation Action
sensory roots. Pxs may also have weakness of skeletal muscles in myotomes supplied by
Trapezius Spinal accessory Elevates and rotates scapula
compressed motor roots.
Sternocleidomastoid Spinal accessory Flex head + neck, rotates face opposite sd\ide
Osteoarthritis is an inflammation resulting in additional bone growth by osteophytes at
Infrahyoid muscles
facet joints Sternohyoid Ansa cervicalis Depresses hyoid bone and larynx
Spondylitis is an inflammation that results in additional bone growth by osteophytes at Sternothyroid Ansa cervicalis Depresses hyoid bone and larynx
margins of vertebral bodies. Pxs may exhibit ankylosis [joint stiffening] and a bamboo spine. Thyrohyoid Hypoglossal N. Depresses hyoid bone and elevates larynx
Spondylosis involves degenerative changes in intervertebral disks w/c are usually Omohyoid Ansa cervicalis Depresses hyoid bone
combined w/ additional bone growth by osteophytes at margins of vertebral bodies. Suprahyoid muscles
A herniated disk exists when nucleus pulposus protrudes at posterolteral part of an Stylohyoid Facial N. Eleates hyoid bone
annulus fibrosus resulting in compression of roots of lower cervical or lower lumbar spinal Digastric Ant: Mylohyoid Elevates hyoid bone and tongue, depresses
nerves. The compressed roots are those of the more inferior spinal nerve [ex. Herniations at Post: facial N. mandible
C5-6 disk compress C6 roots, herniations at L4-5 disk compress L5 roots]. Mylohyoid Mylohyoid N. Elevates floor of mouth and hyoid bone
Whiplash
Geniohyoid Hypoglossal N. Elevates hyoid bone and tongue
Causes cervical vertebrae to be strongly extended and then strongly flexed and may
result in anterior dislocation of facet joints.

21
Muscles of the posterior neck o Contents: internal jugular vein, common carotid artery, internal and external carotid artery,
Name Innervation Action superior thyroid, lingual and facial artery, vagus and hypoglossal nerves, caroitid sheath,
Lateral group larynx, pharynx, deep cervical lymph node, and cervical plexus
Scalenus anterior Cervical spinal N. Laterally flex the neck, elevates 1st rib
Scalenus medius Cervical spinal N. Laterally flex neck, elevates 1st rib Clinical notes
Scalenus posterior Cervical spinal N. Laterally flex neck elevates 2nd rib Baroreceptor & chemoreceptor reflexes
Scalenus minimus Cervical spinal N. Laterally flex neck, elevates 1st rib Baroreceptor reflex maintains BP in response to changes in posture. Disrupted barorereceptor
Levator scapulae Dorsal scapular N. Elevates scapula reflex results in orthostatic hypotension, a decrease in BP when px assumes an upright position.
Prevertebral/Anterior Chemoreceptor reflex maintains blood gases by adjusting respiration, cardiac output, and
Longus capitis Cervical nerves Flexes head peripheral BP. A decrease in oxygen tension [PO2] and increase in CO2 tension [PCO2], result in
Longus colli Cervical nerves Flexes and rotates head and neck an increase respiration, HR, and peripheral BP.
Rectus capitis anterior Cervical plexus Flexes head
Rectus capitis lateralis Cervical plexus Laterally flex head
Arteries of the Neck
Boundaries of the anterior triangle of the neck: Name Branches
o Base: mandible Subclavian A. Vertebral, A. internal thoracic A., thyrocervical trunk, costocervical trunk,
o Apex: jugular notch and dorsal scapular A.
Vertebral A. Radicular arteries and muscular branches
o Lateral: sternocleidomastoid
Thyrocervical trunk Inferior thyroid A., transverse cervical A., suprascapular A.
o Anterior: median line of neck
Inferior thyroid A. Ascending cervical A. and inferior laryngeal A.
o Posterior: anterior border of sternocleidomastoid
Transverse cervical A. W/ superficial and deep branches
o Roof: subcutaneous tissue, platysma Suprascapular A. None joins the suprascapular N.
Boundaries of submandibular trangle: Internal thoracic A. Superior epigastric and musculophrenic A.
o Roof: mandible and digastric Costocervical trunk Deep cervical, and superior intercostals A.
o Floor: mylohyoid, hyoglossus Dorsal scapular A. Accompanies dorsal scapular N. on deep surface of rhomboids
o Contents: submandibular gland, facial vein and artery, submandibular LN Common carotid A. Internal and external carotid A.
Boundaries of the submental triangle: Internal carotid A. None in neck [ophthalmic, posterior communicating, middle cerebral A.]
o Inferior: hyoid bone External carotid A. Superior thyroid, lingual, facial, occipital, posterior auricular, ascending
o Lateral: digastric pharyngeal, maxillary, and superficial temporal A.
o Roof: hyoid bone, digastric, mandibular symphysis Superior thyroid A. Superior laryngeal A.
o Florr: mylohyoid Lingual A. Suprahyoid branch, dorsal lingual, deep lingual , and sublingual A.
o Contents: submental LN, beginning of anterior jugular veins Facial A. Neck: ascending palatine, tonsllar, glandular, and submental A.
Boundaries of the thyroid triangle: Face: inferior and superior labial, lateral nasal and angular A.
o Superior: superior omohyoid Occipital A. Sternomastoid, meningeal, descending and occipital branches
o Middle: median raphe Posterior auricular A. Auricular, occipital and stylomasoid branches
o Inferior: Ascending pharyngeal A. Pharyngeal, meningeal, palatine branches, inferior tympanic A.
Boundaries of the muscular triangle: Maxillary A. Deep auricular, anterior tympanic, middle meningeal, inferior alveolar,
o Roof: sternocleidomastoid [anterior border], omohyoid, anterior midline of neck posterior superior alveolar, infraorbital, sphenopalatine, descending
o Floor: sternothyroid, sternohyoid palatine, pharyngeal A. and A. to pterygoid canal
Superficial temporal A. Transverse fascial A.
o Contents: anterior juguylar vein, sternohyoid, sternothyroid, thyroid and parathyroid
glands
Veins of the head face and neck
Boundaries of digastric triangle:
Name Features
o Lateral: mandibular margin
Fascial vein Provides a danger area of face due to potential spread of infection
o Middle: digastric, superior belly
Retromandibular v. Union of maxillary and superficial temporal veins
o Inferior: digastric, inferior belly
External jugular V. Union of posterior auricular V. and post. div. of retromandibular V.
Boundaries of the posterior triangle of the neck: Anterior jugular V. Connected to jugular venous arch
o Lateral: trapezius Internal jugular V. Continuation of sigmoid venous sinus, receives facial, lingual,
o Medial: sternocleidomastoid pharyngeal, and middle thyroid veins
o Apex: mastoid bone Subclavian V. Continuation of axillary V.
o Base: clavicle
o Anterior: sternocleidomastoid, posterior border Lymphatic drainage of head and neck
o Posterior: trapezius, anterior border Name of lymph node Drainage
o Contents: accessory N., roots of brachial plexus, subclavian A., suprascapular N., Occipital nodes Back of scalp
supraclavicular N., dorsal scapular and long thoracic N., nerves to levator scapulae, Mastoid / post. auricular Back of scalp, auricle of ear, external auditory meatus
transverse cervical and suprascapular arteries Parotid nodes Anterior scalp, external and middle ear, paotid gland
Boundaries of occipital triangle: Buccal / facial nodes Eyelids, conjunctiva, nose, cheek
o Lateral: trapezius Submandibular nodes Nose, lips, gums, cheeks, tongue
o Medial: sternocleidomastoid, upper part Submental nodes Tip of tongue, floor of mouth, lower lip and chin
o Posterior: omohyoid, inferior border Superficial cervical nodes Lower parotid region, ngle of jaw, auricle of ear
o Contents: occipital nerve, cervical plexus, splenius Anterior cervical nodes Skin and subcutaneous tissue on anterior neck
Boundaries of supraclavicular or subclavian triangle: Retropharyngeal nodes Nasopharyx and auditory tube
o Anterior: sternocleidomastoid Tracheal nodes Trachea and thyroid gland
o Superior: omohyoid Jugulodigastric node Posterior 3rd of tongue and palatine tonsil
o Inferior: clavicle Juguloomohyoid node Anterior 2/3 of tongue
o Contents: subclavian artery and vein, suprascapular artery, supraclavicular LN
Nerves of the neck
Carotid sheath Name of nerve Features
Formed by pretracheal, prevertebral and investing layers of deep cervical fascia Cervical plexus Lesser occipital. great auricular, transverse cervical, supraclavicular N.
Contents: common, external & internal carotid A., internal jugular vein and vagus N. Lesser occipital N.
Great auricular N.
Supplies skin of neck and scalp behind the ear
To auricle, parotid gland, and angle of the jaw
Boundaries of the carotid triangle: Transverse cervical N. To skin of anterior neck
o Superior: digastric, posterior belly Supraclavicular N. To skin over clavicle and shoulder
o Posterior: sternocleidomastoid Phrenic N. To pericardium, pleura, and peritoneal coverings
o Inferior: superior omohyoid Ansa cervicalis To infrahyoid muscles, EXCEPT for THYROHYOID muscle
o Roof: sternocleidomastoid, omohyoid, digastric Brachial plexus
o Floor: middle and inferior pharyngeal constrictor muscles, thyrohyoid Dorsal scapular N. To rhomboid major and minor

22
 Long thoracic N. To serratus anterior
Suprascapular N. To supraspinatus and infraspinatus PARATHYROID GLAND
N. to subclavius To subclavius muscle Small endocrine glands [4] w/c lie on or embedded in posterior aspect of thyroid gland
Cranial nerves in neck Secretes PTH essential for regulation of calcium metabolism in body tissues
Hypoglossal N. Gives superior root of ansa cervicalis and N. to thyrohyoid M. Arise as diverticulae of the 3rd and 4th branchial pouches
Accessory N. Gives a cranial and spinal portion Blood supply of parathyroid gland
Vagus N. Gives a cardiac, meningeal, auricular, pharyngeal brnches and superior Inferior thyroid A. Main supply
laryngeal and recurrent laryngeal N., Others Superior thyroid, thyroidea ima, laryngeal, tracheal and
Superior cervical ganglion Gives rami communicantes, superior cervical sympathetic cardiac N. esophageal arteries
internal and external carotid N., communicating
Middle cervical ganglion Gives rise to gray rami comunicantes, middle cervical sympathetic Veinous drainage to parathyroid V. [from anterior thyroid venous plexus]
cardiac N.and branches to perivascular plexus
Lymphatics: deep cervical LN and paratracheal LN
Inferior cervical ganglion Gves rise to gray rami communicantes, inferior cervical sympathetic
Innervated by thyroid branch of cervical sympathetic ganglia
cardiac N. and branches to priarterial plexus
Ansa subclavia Connects inferior cervical ganglion to vertebral ganglion or the middle
TRACHEA
cervical ganglion
Begins in the neck at the lower border of cricoid cartilage as the inferior continuation of larynx and
Clinical notes terminates by bifurcating at level of the sternal angle
Excessive vasoconstriction 10-12 cm long and 1.5-2 cm in diameter
A stellate ganglion block may be performed in pxs who exhibit excessive vasoconstriction or w/ series of tracheal rings completed posteriorly by trachealis muscle
sweating in upper limb.
Horners syndrome ESOPHAGUS
Caused by a lesion on cervical part of sympathetic trunk or superior cervical ganglion. Pxs have begins at the level of cricoid cartilage as continuation of the pharynx
anhydrosis, ptosis and miosis. Innervated by SVE fibers from recurrent laryngeal N.
Accesory nerve lesions Supplied by branches of the inferior thyoid A.
Lesion at posterior triangle may result in weakness of trapezius muscles. Px may have difficulty
elevating scapula [shrugging of shoulder] and difficulty in laterally rotating scapula during CHAPTER 9 - HEAD
abduction of the arm.
Lesions inferior to jugular foramen may also result in weakness of sternocleidomastoid. Pxs BONES OF THE SKULL
may have decreased ability to turn chin to side opposite the lesioned nerve. Cranial bones
Vagus nerve lesions Name Features
Complete lesions of vagus N. commonly result in weakness of palate, pharyngeal, and Parietal Paired bones that articulate w/ each other at midline sagittal suture
aryngeal muscles. Frontal Unpaired bone that forms the forehead and roof of orbit, it has squamous, orbital
Weakness of levator veli palatini may result in drooping of palate on side of the injured nerve bone and nasal portions, it contains the supraorbital foramen [for orbital A. and N.],
and a deviation of uvula to side opposite the lesioned nerve. Pxs may also experience nasal supratrochlear notch [for supratrochlear A. and N.]
speech and nasal regurgitation of liquids during swallowing. Occipital Unpaired bone that forms base of the skull
Weakness of pharyngeal constrictors may result in dysphagia [difficulty in swallowing]. Temporal Paired bones
Lesions of vagus nerve that includes the laryngeal nerves may result in weakness of all Sphenoid Unpaired bone
laryngeal muscles on the affected side. Vocal cord may assume a fixed position midway btw Ethmoid Unpaired cube-shaped bone
abduction and adduction, resulting in speech that is hoarse and weak. Lesions of the
pharyngeal branches & laryngeal N. may also result in loss of motor limb of GAG reflex and Sutures and landmarks of cranium [refer to Netter atlas p. 4]
cough reflex respectively. Name Features
Coronal suture Articulation btw frontal and paired parietal bones
VISCERA OF THE NECK Sagittal suture Articulation btw paired parietal bones
3 layers of cervical viscera [superior and deep] Lambdoid suture Articulation btw paired parietal bones and occipital bones
Endocrine layer Thyroid and parathyroid Squamous suture Articulation btw parietal bone and squamous part of temporal bone
Respiratory layer Larynx and trachea Bregma Point at w/c sagittal and coronal sutures meet
Alimentary layer Pharynx and esophagus Lambda Point at w/c sagittal and lambdoid sutures meet
Vertex Highest point of the skull near midpoint of sagittal suture
Lymph drainage: pratracheal nodes and inferior cervical nodes Nasion Point at w/c frontal and nasal bones meet
Pterion Temporal region where frontal and parietal bones meet the greater
THYROID GLAND wing of sphenoid bone and the squamous part of temporal bone
An endocrine gland that secretes T3 and T4 w/c regulates the metabolic rate of body tissues, Inion Highest point of external occipital protuberance
and thyrocalcitonin w/c is concerned w/ regulation of calcium catabolism in body tissues Glabella Region above nasion btw paired superciliary arches
Consists of R and L lobes joined by isthmus Anterior fontanelle At area of bregma, closes a 18 mos,
Surrounded by fibrous capsule derived from pretracheal fascia Posterior fontanelle At area of lambda, closes by end of 1st year
Lobes Extend inferiorly to level of 5th or 6th tracheal ring, covered by
sternothyroid and sternocleidomastoid muscles Clinical notes
Isthmus Lies over the 2nd and 3rd tracheal rings, vulnerable to injury SKULL FRACTURE AT PTERION
Pyramidal lobe May be attached to hyoid bone by levator glandulae thyroideae, A lateral skull fracture at pterion [thinnest part of calvaria], may lacerate the middle meningeal A.
drained by superior, middle and inferior thyroid veins, supplied by and cause epidural hematoma.
superior and inferior thyroid A. and sometimes thyrpidea ima A. The epidural hemorrhage forms a biconvex lens-shaped hematoma btw skull and periosteal
dura, w/c does not pass sutures.
Veins of thyroid gland An epidural hematoma may compress lateral part of a cerebral hemisphere and result in herniation
Superior thyroid V. Drains into internal jugular V. of medial temporal lobe thru tentorial notch of dura. The herniated temporal lobe may compress the
Middle thyroid V. Drains into internal jugular V. brainstem.
Inferior thyroid V. Drains into L brachiocephalic V. Px may have an initial lucid asymptomatic interval followed by weakness of limb muscles, a dilated
pupil resulting from compression of occulomotor nerve [CN 3], and deterioration of
Blood supply of thyroid gland cardiorespiratory functions.
Superior thyroid From 1st branch of external carotid A., w/ ant and post branches
A. Facial bones
Inferior thyroid A. From thyrocervical trunk, it is intimately related to recurrent Name Features
laryngeal N. w/c is vulnerable in surgery of thyroid gland Maxillae Pair of bones that fuse to form upper jaw
Thyroid ima A. Inconstant branch of the brachiocephalic trunk or aortic arch, it Zygomatic bone Paired bones that forms the prominence of cheek
lies anterior to trachea thus is vulnerable to injury during thyroid Nasal bones Paired bones that fuse to form the central portion of zygomatic arch
surgery or surgical tracheostomy Lacrimal bone Paired bone that contributes to anterior part of medial wall of orbit
Palatine bones L-shaped bones consists of horizontal and perpendicular plates

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Vomer Unpaired midline bone that forms the posterior & inferior nasal septum Orbicularis oris Sphincter of the mouth Facial N.
Inferior nasal cioncha Attached to lateral wall of nasal cavity Depressor anguli oris Frowning Facial N.
Mandible Bone of the lower jaw, consists of a body and paired rami Depressor labii inferioris Impatience Facial N.
Leavtor labii superioris Pulls upper lip superiorly Facial N.
CRANIAL CAVITY Levator labii superioris alaque nasi Above action + dilates nostrils Facial N.
Circle of Willis Mentalis Doubt Facial N.
Completed by an anterior communicating A. w/c connects anterior cerebral A. and a pair of Risorius Grinning or sardonic grim Facial N.
posterior communicating A. w/c connects the internal carotid A. w/ posterior cerebral A. Zygomaticus major Smiling or laughing Facial N.
MC site of aneurysm anterior communicating artery Zygomaticus minor Sadness, lonely Facial N.
Left and right artery basilar artery [brainstem] Buccinator Compress cheeks, aids in mastication, Facial N.
sucking, whistling, trumpeters muscle
Clinical notes Auricularis Auricular movement Facial N.
Berry aneurysms Occipitofrontalis Scalp movement, wrinkles scalp Facial N.
Are saccular dilatations of walls of arteries w/c MC occur in anterior part of the circle of Willis at Platysma Grimace, tension, stress Facial N.
branch points of anterior and posterior communicating A., or middle cerebral A. Blood from
ruptured aneurysm may accumulate in subarachnoid space and causes subarachnoid Nerves of face and scalp
hematoma. Name Origin Branches
Pxs may experience an acute explosive worst headache of my life caused by blood leaking Facial N. Stylomastoid Temporal, Zygomatic, Buccal, Mandibular, and Cervical N.
from aneurysm, w/c irritates the meninges. Pxs may also have stiff nek resulting from irritation foramen [Ten Zebras Bought My Car]. It also gives rise to posterior
of spinal dura. auricular N. and Neves to stylohyoid and posterior digastric
Occulomotor N. [CN 3] may be compressed by an aneurysm at junction of posterior Trigeminal N. Cavenous Ophthalmic, maxillary, mandibular N.
communicating A. and internal carotid A. or posterior cerebral A. pxs may initially have a dilated Ophthalmic N. sinus Supraorbital, supra/infratrochlear, lacrimal, ext. nasal
or a blown pupil. Maxillary N. F rotondum Infraorbital, zygomaticofacial, zygomaticotemporal N.
Mandibiular N. F ovale Auriculotemporal, buccal, mental nerves
Major apertures of the skull Cervical spinal N. Great auricular, lesser and greater occipital nerves
Aperture Bone Traversed by
Cribriform plate Ethmoid Olfactory N. [filia] Clinical notes
Optic canal Sphenoid Optic N., ophthalmic A. Bells palsy
Superior orbital fissure Sphenoid Occulomotor, trochlear, ophthalmic and abducens Idiopathic unilateral paralysis of facial muscles due to facial N. lesion
Nerves, opthalmic V. Sudden onset [w/in 24 H], and transient w/ recovery in few months
Foramen rotundum Sphenoid Maxillary N. Characterized by: drooping corner of mouth, inability to smile, whistle or blow, drooping upper
Foramen OVALE Sphenoid Mandibular nerve, Accessory meningeal nerve, Lesser eyelid and an everted lower lid, inability to blink or close the eyes
petrosal nerve, Emissary veins [MALE]
Foramen spinosum Sphenoid middle meningeal A., meningeal br. of mandibular N. Blood vessels of face and scalp
Innominate foramen Sphenoid Lesser petrosal N. Name Branches
Foramen lacerum Btw sphenoid Internal carotid A., deep petrosal and greater petrosal Superficial temporal A. Transverse facial A.,
and temporal N., origin of thenerve of the pterygoid canal Maxillary A. Mental, buccal, and infraorbital A.
Lacrimal foramen Sphenoid Communicating br. btw middle meningeal + lacrimal A. Facial A. Inferior labial and superior labial A., lateral nasal, and angular A.
Carotid canal Temporal Internal carotid A., periarterial sympathetic plexus Occipital A. None, distributed w/ greater occipital N. to posterior scalp
Internal auditory Temporal Facial N., nervus intermedius, vestibulocochlear N., Posterior auricular A. Auricular and occipital branches
meatus labyrinthine A. Ophthalmic A. Supraorbital, supratrochlear, lacrimal and dorsal nasal A.
Stylomastoid foramen Temporal Facial N., stylomastoid A.
Jugular foramen Btw occipital and Glossopharyngeal, vagus, and accessory N., internal BRAIN
temporal jugular V., inferior petrosal sinus, posterior meningeal
Arteries and nerves Development of brain & spinal cord
Foramen magnum Occipital Brainstem, vertebral Arteies and veins, spinal part of 1 brain vesicles 2 brain vesicles Mature brain
accessory N., spinal A. Prosencephalon Telencephalon [lateral ventricles] Cerebral hemispheres
Hypoglossal canal Occipital Hypoglossal N., meningeal br. of cervical spinal Nerves Diencephalons [3rd ventricle] Thalamus, hypo/epi/subthalamus,
Mesencephalon Mesencephalon [cerebral Midbrain
Clinical notes aqueduct or ITER]
Jugular foramen sndrome Rhombencephalon Metencephalon Pons & cerebellum
Lesions of glossopharyngeal N. may occur in conjunction w/ vagus N. and accessory N. in Myelencephalon Medulla oblongata
jugular foramen syndrome. Sx: loss of GAG reflex
PAROTID GLAND
Lingual branch of CN IX [glossopharyngeal N.] may be lesioned as it traverses the floor of Largest, lies below zygomatic arch and external auditory meatus
tonsilar fossa during tonsillectomy procedures. This results in loss of sensation from posterior Overlies massetr M. and ramus of mandible anteriorly, sternocleidomastoid posteriorly
1/3 of the tongue. Separated from submndibular gland by stylomandibulr ligament
Structures w/in parotid gland: Facial N., Retromandibular V., External carotid A. & parotd LN
SCALP Parotid duct / STENSENS duct passes over masseter muscle and opens into oral cavity
Skin Relatively thick w/ abundant hairs opposite the upper 2nd molar
Connective tissue Between skin and galea aponeurotica, w/ nerves and vessels Supplied by superficial temporal and external carotid A., drained by retromandibular V.
Aponeurosis Is the membranous galea aponeurotica w/c connects frontalis and Innervated by: parasympathetic N. [secretomotor] and sympathetic [vasomotor] nerves
occipitalis components of occipitofrontalis M., in gaping wounds Lymphatics: parotid nodes [to superficial and deep cervical LN]
Loose connective Is the plane of separation for subdural hematoma & scalping
tse injuries, allows spread of infection to galea aponeurotica. Most Clinical notes
dangerous area [emissary vessels are located] Parotid gland tumor
Pericranium Periosteum covering the outer surface of skull May compress muscular branches of facial N. and cause weakness of muscles of facial expression
on side of the tumor.
Muscles of the Face and Scalp / Muscles of Facial expression
Name Features Innervatio SUBMANDIBULAR GLAND
n Found in submandibular and digastric triangle
Orbicularis oculi Sphincter of the eye Facial N.
Submandibular / WHARTONS duct related closely to lingual N.
Corugator supercilli Concern Facial N.
Lies between mandible and mylohyoid muscle
Procerus Protects against bright sunlight, wrinkles Facial N.
Supplied by submental A. and veins
Nasalis Depresses skin btw eyebrows Facial N.
Depressor septi Depresses nasal septum Facil N. Innervated by submandibular ganglion

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 Lymphatics: deep cervical LN [part of jugulo-omohyoid node]
Clinical notes
Boundaries of the temporal and infratemporal fossae Headache
Features Temporal fossa Infratemporal fossa Meningeal dura is sensitive to pain. Irritation or stretching is a common cause of headache; pain is
Superiorly Inferior temporal line Greater wing of sphenoid commonly referred to regions supplied by branches of trigeminal nerve.
Anteriorly Frontal part of zygomatic bone Maxilla Subdural hematoma
Inferiorly Zygomatic arch Continuous to neck Skull trauma may cause shearing of bridging veins at points where they enter dural venous
Posteriorly Inferior temporal line Temporomndibulr jt, styloid process sinuses; venous blood may accumulate in subdural space forming a crescent-shaped
Contents Temporalis M., deep temporal N. Mandibular N., maxillary A., pterygoid hematoma not bound by sutures of the skull.
and A., zygomaticotemporal N. M., temporalis, chorda tympani N., and Pxs w/ chronic subdural hematoma experience headache, impairment of cognitive skills, and gait
the otic ganglion instability.
Cavernous sinus hrombosis
Muscles of mastication May result from infection that is transported from face to cavernous sinus by superior ophthalmic
Name Innervation Action vein.
Temporalis Deep temporal N. Elevates and retracts mandible Pxs may initially experience an internal strabismus resuting from a lesion of abducens nerve.
Masseter Masseteric N. Elevates mandible, biting, chewing Pxs may later exhibit loss of all ocular movements because of occulomotor and trochlear nerve
Lateral pterygoid N. to lat. pterygoid Protracts and depresses th mandible involvement and pain & numbness in face and scalp due to involvement of ophthalmic and
Medial pterygoid N. to medial pterygoid Protracts and elevates mandible maxillary divisions of trigeminal nerve.
An infection in cavernous sinus may spread to other cavernous sinus thru intercavernous sinuses.
Temporomandibular joint
Synovial joint between head of mandible and mandibualr fossa + tubercle of temporal bone Folds of dural mater
W/ articular disc, reinforced by lateral temporomandibular ligament Falx cerebri Btw cerebral hemispheres, encloses superior + inferior sagittal sinus
Functions both as hinge joint and gliding joint Tentorium cerebelli Supports occipital lobes, encloses transverse sinus
Innervated by auriculotemporal and masseteric N. [from mandibular division of trigeminal N.] Falx cerebelli Btw cerebellar hemisphere, encloses occipital sinus
Diaphragma sellae Horizontal projection that forms the roof of hypophyseal fossa
Other arteries of the mandibular region
Name Distribution Innervation of cranial dura
Maxillary A. 1st [mandibular part], 2nd [pterygoid part], 3rd [pterygopalatine part] Anterior cranial fossa
[First part] Meningeal br. of anterior and posterior ethmoidal N.
Deep auricular A. Temporomandibular jt, ext. auditory meatus, tympanic membrane Middle cranial fossa
Anterior tympanic A. Tympanic cavity and tympanic membrane Meningeal br. of mandibular N. Enters thru foramen spinosum
Middle meningeal Skull and dur mater, often damaged in fractures of temporal bone Meningeal br. of maxillary N. Enters thru foramen rotundum
A. Posterior cranial fossa
Accessory meningeal Semilunar [trigeminal] ganglion and dura mater Meningeal br. of vagus N. Enters thru jugular foramen
A. Meningeal br. of upper cervical Enters thru hypoglossal canal
Inferior alveolar A. Lower teeth, gums, chin and lower lip, mucous membrane of neck
[Third part] Posterior Upper molars and premolars Blood supply of cranial dural mater
superior alveolar Name Origin Distribution
Infraorbital A. Lower eyelid, side of nose, upper lip, mucosa of mouth Anterior meningeal A, Ant + post ethmoidal A. Anterior cranial fossa
Pharyngel A. Roof of nasal cavity, nasopharynx and sphenoid sinus Middle meningeal A. Maxillary A. Middle cranial fossa
Artery of pterygoid canal Pharynx and auditory tube Accessory meningel A. Maxillary or middle Middle cranial fossa including
Sphenopalatine A. Major supply to nasal cavity and paranasal sinuses Meningeal A. trigeminal ganglion
Descending palatine A. Soft and hard palates Posterior meningeal A. Ascending pharyngeal A. Posterior cranial fossa
and occipital A.
Clinical notes
Mandibular N. lesions Obstruction of central retinal A. or one of its branches will result in partial or complete blindness
Trigeminal neuralgia [tic douloureux] is characterized by episodes of sharp, stabbing pain because there are no functional anastomoses between internal carotid and external carotid A.
that radiates over the areas innervated by sensory branches of maxillary or mandibular
divisions of the trigeminal nerve. Exttraocular muscles
Pain radiates over the mandible extending around the TMJ and deep to external ear. In others, Name Innervation Action
pain radiate up to nostril and around the inferior aspect of the orbit. Superior rectus Occulomotor N. Elevates and adducts pupil
Pain may be associated w/ the neuralgia is frequently triggered by moving the mandible, Inferior rectus Occulomotor N. Depreses and adducts pupil
smiling or yawning or by cutaneous or mucosal stimulation. It may be caused by pressure or Medial rectus Oculomotor N. Adducts pupil
interruption of the blood supply to trigeminal ganglion. Lateral rectus Abducens N. Abducts pupil
A lesion of the motor root of mandibular nerve may result in weakness of muscles of Superior oblique Trochlear N. Depresses and abducts pupil
mastication and a deviation of the jaw on protrusion toward the side of the injured nerve. Inferior oblique Occulomotor N. Elevates and abducts pupil
Levator palpebrae superioris Occulomotor N. Elevates upper eyelid
Other structures of mandibular region
Mandibular N. The only division of trigeminal N. to innervate skeletal muscle Testing the function of extraocular muscles
Trunk Gives rise to meningeal branch and N. to medial pterygoid Lateral rectus Px is directed to look far laterally
Anterior division Deep temporal, masseteric, N. to lateral pterygoid, buccal N. Medial rectus Px is directed to look far medially
Posterior division Auriculotemporal, lingual, inferior alveolar N. Superior rectus Px is directed to look far laterally and then downward
Meningeal branch Supplies dura and middle cranial fossa Superior oblique Px is directed to look far medially and then downward
Inferior oblique Px is directed to look far medially and then upward
MENINGES
Name Features EYEBALL
Pia mater [vascular] Closely applied to brain surface, dips into fissures and sulci Receives blood supply from branches of ophthalmic A.
Arachnoid mater Delicate intermediate meningeal layer, w/ numerous arachnoid villi, Receives innervation from nasociliary N. [from ophthalmic nreve]
[avascular] separated from pia mater by subarachnoid space w/c contains CSF Walls of eyeball
Dura mater or Tough CT layer that forms a sac around the brain, has no associated Fibrous tunic / outer fibrous layer Comprises the sclera and cornea
pachymeninx epidural space, consists of a meningeal and periosteal layer, encloses Vascular tunic / middle pigmented Comprises the choroids, ciliary body, iris
the dural venous sinuses Inner tunic / inner vascular layer Formed by retina [optic, ciliary, iridial parts]
Epidural space Only a potential space because the dura fuses w/ periosteum lining
inside of the skull, separates meningeal and periosteal layer of dura Chambers of the eyeball
Subdural space A real space, allows blood to collect [as in subdural hemorrhage]
Anterior chamber Contains aqueous humor
Subarachnoid space Space between arachnoid and pia mater, containd CSF
Posterior chamber Contains aqueous humor

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 Vitreous chamber Contains gelatinous vitreous body Inf. Pharyngeal constrictor Vagus N. Constricts pharynx
Cricopharyngeus muscle Recurrent Prevents entry of air into esophagus
Other important features of eyeball laryngeal N. during swallowing
Optic disc Referred to as blindspot because it has no visual receptors Longitudinal muscles
[rods/cones], pierced by central artery of retina Salpingopharyngeus Vagus N. Elevates pharynx in swallowing
Macula lutea Yellow spot, has a central depression called fovea centralis Palatopharyngeus Vagus N. Elevates pharynx in swallowing
Fovea centralis Area of maximum visual acuity, has cones and no rods Stylopharyngeus Glossopharyngea Elevates larynx and pharynx
Pupil Acted upon by sphincter pupillae and dilator muscles l
Cornea Transparent and vascular membrane of fibrous tunic
Lens Transparent biconvex disc, exerted by ciliary body and susp. Lig. Innervation of pharynx
Pharyngeal plexus Provides most of the innervation of pharynx, receives contribution
Accommodation reflex / Near response from the pharyngeal branch of vagus N, glossopharyngeal N, and
Characterized by convergence of pupils to maintain binocular vision superior cervical ganglion
Constriction of pupil by sphincter pupillae muscles Accessory N. Provides motor nerve supply to all pharyngeal M. except
stylopharyngeus
Rounding of lens by ciliary muscle w/c reduces tension exerted on lens
Maxillary N. Provides sensory to mucous membrane of nasopharynx
A parasympathetic response mediated by oculomotor nerve via ciliary ganglion
Glosspharyngeal N. Provides sensory to mucous membrane of nasopharynx
Vagus N. Provides sensory to mucous membrane around entrance of larynx
Clinical notes
Pupillary light deficits
Blood supply and lymphatics of pharynx
Deficits in response of 1 or both pupils to light may be caused by lesion of either afferent or
Name Branches
efferent components of light reflex.
Ascending pharyngeal A. From medial surface of external carotid A.
Afferent papillary defect [Marcus Gunn pupil] may result from optic N. lesions confirmed by
Other arteries Ascending palatine, superior thyroid, and inferior thyroid A.
swinging flashlight test. When normal eye is exposed to light, both pupils constrict; however
Pharyngeal venous plexus Drains pharynx, goes to IVC
when the flashlight is swung to affected eye, both pupils paradoxically dilate.
Lymphatic supply Deep cervical LN, retropharyngeal and pretracheal nodes
Lesions to occulomotor N. may result in an efferent papillary defect. In these pxs, the pupil is
dilated on affected side and does not constrict in response to light shown in the other eye. If the
lesion is complete, px may have a blown pupil.
Papilledema
PTERYGOPALATINE FOSSA
Due to an increase in intracranial CSF pressure, a swelling nerve at optic disk caused by
Anteriorly Posterior surface of maxilla
reduced venous return from the retina.
Posteriorly Pterygoid process and greater wing of sphenoid
Visual field defects
Medially Perpendicular plate of palatine bone
Complete nasal and temporal visual field deficits are anopsias. Deficits in nasal or temporal
Laterally Pterygomaxillary fissure
half of a visual field are hemianopsias. Deficits in a quadrant of temporal or nasal visual field
Superiorly Body of sphenoid and orbital process of palatine bone
are quadrantanopsias.
Inferiorly Greater palatine canal
Lesions in retina produce scotomas [small spot-like deficits in a part of a temporal or nasal
visual field of the eye.
contents: 3rd part of maxillary A., maxillary N. , pterygoplatine ganglion
Complete optic nerve lesion results in monocular anopsia.
Complete optic chiasmal lesion produces bitemporal heteronymous hemianopsias [because ORAL CAVITY
of L and R temporal hemifields]. Anterior Teeth and gums
Lesions in visual pathway past the chiasm produce contralateral and binocular Lateral Teeth and gums
homonymous deficits, in the same part of the L or R nasal and temporal hemifield. Therefore a Superiorly Hard and soft palate
complete lesion of R optic tract will resut in a L homonymous hemianopsia.
Inferiorly Anterior 2/3 of tongue and guuter of the floor
NASOPHARYNX
Vestibule
Opens to the nose via posterior choanae
lies between lips and cheeks externally and teeth and gums internally
Boundaries:
receives opening of parotid duct opposite the upper and 2nd molar tooth
o Superior: adenoid in the roof
Teeth
o Lateral: Eustachian tube opening
Functions of the teeth
Fossa of Rosenmuller
Incisors 8 [4 in upper, 4 in lower jaw] For cutting food
Tensor veli palatine Canines 4 [2 in upper, 2 in lower jaw] For cutting and tearing food
Waldeyers ring: imaginary ring composed of tonsils namely: Premolars 8 [4 in upper, 4 in lower jaw] For crushing food
Nasophartynx Oropharynx Molars 8 [deciduous], 12 [permanent] For chewing and grinding food
Nasopharyngeal/adenoids unpaired Palatine/faucial tonsils paired [prominent cryps NOTE: Koplik spots are found in 2nd upper molar
Tubal/tonsils of Gerlach - paired where food particles may lodged]
Differences between deciduous and permanent teeth
Clinical notes Deciduous teeth/milk teeth/baby teeth Permanent teeth
radiosensitive tumor: nasopharyngeal CA 20 [2 incisors, 1 canine, 2 molars in each half 32 [2 incisors, 1 canine, 2 premolars, 3 molars in
nasopharyngeal CA starts at fossa of Rosenmuller caused by EBV jaw] each half jaw]
elastic cartilage are seen in: epiglottis, ear pinna, Eustachian tube Erupt at 6 mos. and is finished at 2 yrs Erupts at age 6 and alre all present at age 12
hyaline cartilage are seen in: bronchi, larynx, trachea [except the last mola]
Shed and replaced by permanent teeth at 6 yrs Last molar [wisdom tooth] erupts until 18-20 yrs
Palatine tonsil
an accumulation of lymphoid tissue that lies in the tosillar fossa btw palatoglossal fold [ant] and Blood supply & innervaion of teeth
palatopharyngeal fold [post] of the oropharynx Vessel Origin Features
lies in muscular bed formed by superior pharyngeal constrictor muscles Sup. & inf. alveolar A. Branch of maxillary A., Supplies both maxillary & mandibular teeth
Receives most of its blood supply from tonsillar branch of facial A. and ascending + descending Sup. & inf. alveolar N Dental plexuses Supply maxillary & mandibular teeth
palatine A, ascending pharyngeal A. and lingual A.
Innervated by tonsillar branches of glossopharyngeal N. PALATE
drained by lymph vessels in jugulogastric node Consists of bony plate and soft palate, separates oral cavity from nasal cavity
Bony palate Anterior 2/3 of soft palate, contains the openings of incisive canal
Muscles of pharynx and greater and lesser palatine canals
Name Innervation Action Soft palate Posterior 1/3 of palate, strengthened by palatine aponeurosis
Circular muscles
Sup. Pharyngeal constrictor Vagus N. Constricts the pharynx Muscles of palate
Middle pharyngeal constrictor Vagus N. Constricts the pharynx Name Innervation Action

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Levator veli palatini Vagus N. Elevates soft palate Medial Nasal septum
Tensor veli palatini N. to tnsor vli palatine Tenses soft palate
Musculus uvulae Vagus N. Elevates the uvulae Formed by nasal bones, frontal process of maxillae, nasal part of frontal bones
Palatoglossus Vagus N. Depresses the palate Cartilaginous skeleton formed by septal cartilage, lateral nasal cartilages, alar cartilages
Palatopharyngeus Vagus N. Elevates pharynx during swallowing NASAL CAVITY
NOTE: Muscles for mastication Extends from naris [nostril] anteriorly and choanae posteriorlly
Lateral pterygoids opens mouth Vestibule Functions to filter incoming air
Medial pterygoids closes mouth Olfactory ganglion Conveys sense of smell
Respiratory ganglion Covered by vascular and glandular resp. mucosa
Blood supply of palate Nasal conchae Increases surface area of respiratory epithelium to facilitate
Name Branches Distribution warming & humidifying of the inhaled air
Descending palatine A. Greater and lesser palatne A. Soft and hard palate Nasal meatuses
Ascending palatine A. None Btw tensor and levator veli palatini Superior nasal Receives opening of posterior ethmoidal air cells
meatus
Nerves of palate Middle nasal meatus Receives opening of frontal and maxillary, anterior and
Name Canal Distribution middle ethmoid air cells
Greater palatine N. Palatine canal Hard palate and gums Inferior nasal meatus Receives opening of nasolacrimal duct
Lessere palatine N. Palatine canal Soft palate
Nasopalatine N. Incisive canal Largest, Hard palate Lymph drainage of nasal cavity
Vestibule Submandibular nodes
TONGUE Remainder of nasal cavity Upper deep cervical nodes
Name Features
Filiform papillae Numerous, covers the ant. 2/3 of tongue on its upper surface Innervation of nasal cavity
Fungiform papillae Scattered on apex of tongue Name Origin
Valate papillae In its walls lie the taste buds General somatic afferent Branches of ophthalmic and maxillary nerves
Parasymphathetic fibers Facial N. via pterygopalatine ganglion
Other features of the tongue Sympathetic fibers Superior cervical ganglion
Foramen cecum Blind pouch lying at apex of sulcus terminalis, marks the origin of thyroid Olfactory nerve Convey sense of smell [olfaction]
diverticulum [thyroglossal duct] Maxillary nerve Supplies lateral wall of nasal cavity; its branch Nasopalatine N.
Frenulum Midline mucosal fold w/c connects inferior surface of tongue to floor of mouth [largest] supplies nasal septum and hard palate
Sublingual gland Lies on upper surface of mylohyoid beneath the mucosa of the floor of Ophthalmic nerve Supplies both septum & lateral wall of nasal cavity & dorsum of nose
mouth, supplied by sublingual A., innervated by submandibular ganglion Blood supply of nasal cavity
Name Branches
Movements of the tongue Sphenopalatine A. Lateral and posterior nasal A. , it is the most common source of
Protrusion Genioglossus bleeding in the posterior nasal cavity
Retraction Styloglossus, hyaloglossus Anterior ethmoidal A. Medial and lateral branches
Refraction and elevation Styloglossus, palatoglossus Other arteries Greater palatine, superior labil, posterior ethmoidal A.
Depression Hyoglossus, genioglossus
Clinical notes
Muscles of the tongue Epistaxis
Extrinsic muscles Innervation Action Notes Occurs often in the anterior part of nasal septum anterior to inferior concha. This is the area
Palatoglossus Vagus N. Depresses palate, elevates tongue Pretty where the distribuition of the septal branches of the sphenopalatine and labial arteries meet and is
Styloglossus Hypoglossal N. Elevates and retracts tongue Sexy referred to as Kiesselbachs area [maxillary A., ophthalmic & facial A.]
Genioglossus Hypoglossal N. Depresses and protrudes tongue Girl
Hyoglossus Hypoglossal N. Depresses tongue Hiding PARANASAL SINUSES
Intrinsic muscles Innervation Action Lined by mucoperiosteum covered respiratory epithelium
Sup. and inf. longitudinal Hypoglossal N. Alters shape of tongue Innervated by maxillary and ophthalmic N.
Transverse and ertical Hypoglossal N. Alters shape of tongue Functions: reduce weight of the skull, serve as resonators for sound production, warm and humidify
NOTE: All extrinsic and intrinsic muscles of the tongue are innervated by hypoglossal nerve [except the inspired air
the palatoglossus, innervated by vagus via pharyngeal plexus] 1. Maxillary sinus
Largest of paranasal sinuses and is present at birth
Innervation of tongue Drains into middle meatus of the nasal cavity thru semilunar hiatus
Mucosa of the anterior 2/3 General somatic fibers: lingual N. [from mandibular N.] Supplied by superior alveolar and infraorbital nerves
Taste fibers: facial N. [from chorda tympani and lingual N.] Roof Floor of orbit, contains infraorbital groove and canal
Mucosa of posterior 1/3 General visceral afferent: glossopharyngeal N. Floor Contains elevations produced by roots of number of teeth
Taste fibers: glossopharyngeal N. Posterior Forms infratemporal surface of maxilla
Glosopharyngeal N. Gives rise to pharyngeal branches to pharyngeal plexus, motor br. to Anterior Contains roots of premolar and canine teeth
stylophryngeus M., lingual branche to posterior 1/3 of tongue
Medial Contains opening of sinus into nasal cavity
Hypoglossal N. Supplies all extrinsic and intrinsic M. [except palatoglossus w/c is
Lateral Lies in zygomatic process of the maxilla
supplied by vagus N.]
2. Sphenoid sinus
Blood supply to tongue
Drains into nasal cavity thru sphenoethmoidal recess
Name Origin Branches
Divided into L and R sinuses by deviated bony septum
Lingual A. External carotid A. Suprahyoid br., dorsal lingual A., deep lingual A., sublingual A.
Supplied by lateral posterior superior nasal N. [from maxillary N.], lateral posterior nasal A., and
Lymph drainage of tongue posterior ethmoidal nerve and artery [from ophthalmic A.]
Tip of tongue Submental nodes
Anterior 2/3 Submandibular and deep cervical nodes 3. Ethmoid sinus
Name Opening Innervation
Posterior 1/3 Deep cervical nodes
Anterior ethmoid cells Infundibulum [middle] Anterior ethmoidal N. and A.
EXTERNAL NOSE Middle ethmoid cells Ethmoid bulla [middle] Anterior ethmoidal N. and A.
Consists of ala, dosum and bridge. Covered by ciliated pseudostratified-columnar epithelium Posterior ethmoidal Superior meatus Anterior ethmoidal N. and A.
[like epididymis]
4. Frontal sinus
Floor Palatine process of maxilla, horizontal plate of palatine bone
Opens by way of frontonasal duct into the ethmoidal infundbulum of the middle meatus
Roof Body of sphenoid, cribriform plate of ethmoid, frontal, nasal bone
Lateral Superior, middle and inferior nasal conchae Supplied by supratrochlear and supraorbital N. and A.

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Clinical notes External ear
Sinusitis Auricle Collects sound waves and directs them to external auditory meatus,
Maxillary sinus is a common site of sinusitis [inflammation of mucosa] that may result from innervated by great auricular, auriculoyemporal and lesser occipital N.
infection or obstruction of ostium that drains the maxillary sinus. It has a poor gravitational External acoustic Consists of cartilaginous part [outer 1/3], bony part [inner 2/3], innervated by
drainage because the ostium of the sinus is situated on superior part of medial wall of the sinus. meatus auriculotemporal N, auriculotemporal br. Of vagus N., supplied by superficial
temporal, deep auricular and post. Auricular A.
Lymph drainage of the paranasal sinuses Middle ear [Or tympanic cavity]
Name Drainage Tympanic Separates external acoustic meatus from tympanic cavity, conducts sound
Maxillary sinus Middle meatus [hiatus semilunaris] membrane vibrations to ossicles of the middle ear, innervated by auriculotemporal N.
Frontal sinus Middle meatus [infundibulum] and auricular br. Of vagus N. on outer surface and tympanic br. of
Sphenoid sinuses Sphenoethmoidal recess glossopharyngeal N. on its inner surface
Ethmoidal sinus Tympanic cavity Air-filled cavity w/in petrous temporal bone, contains the auditory ossicles,
Anterior group Infundibulum and middle meatus communicates w/ nasopharynx [via auditory tube], and mastoid air cells [via
Middle group Middle meatus above bulla ethmoidalis aditus ad anthrum]
Posterior group Superior meatus Lateral wall [membranous] Formed by tympanic membrane + epitympanic recess
Medial wall [labyrinthine] Separates tympanic cavity from inner ear
LARYNX Oval window/fenestra vestibule closed by footplate of stapes
Provides a protective sphincter at the inlet of air passages; also for voice production Round/fenestra cochlea closed by secondary tympanic membrane
Regulates the passage of air during: phoation [speech], and inspiration or expiration Cochleariform process serves as pulley for tendon of tensor tympani
Anterior wall Aka carotid wall, pierced by caroticotympanic canalliculus
Laryngeal skeleton Posterior wall Aka mastoid wall, contains facial canal and pyramidal eminence
Roof Aka tegmental wall, formed by tegmen tympani
Thyroid cartilage Largest of the laryngeal cartilage
Floor Aka jugular wall, formed by jugular fossa of temporal bone
Cricoid cartilage Unpaired hyaline cartilage, lies at C6 level, ring-shaped
Auditory ossicles Transmits the sound waves received at tympanic membrane to perilymph of
Arytenoids cartilage Paired hyaline cartilage, pyramidal shaped
ear, covered by mucous membrane
Epiglottic cartilage Leaf-shaped cartilaginous plate
Malleus [hammer] Attaches to tympanic membrane
Incus [anvil] Its body articulates w/ head of malleus
Laryngeal cavity and folds
Stapes [stirrup] Its neck receives th attachment of stapedius tendon
Vestibule Btw aditus [entrance from phaynx to laryx] and vestibular folds
Inner ear
Vestibular fold Aka as false vocal cords, contains vestibular ligament and upper part of
thyroarytenoid muscles. Rima vestibule space btw paired vestibular fold Bony labyrinth Contains the membranous labyrinth suspended in peilymph [K, Na like
ECF]. It includes cochlea, vestibule, and semicircular canals
Ventricle Btw vestibular fold and vocal cord. Saccule evagination of the ventricle
o Vestibular portion [pars superior] balance
Ventricular Aka vocal fold or true vocal cord, contains the vocal ligament and vocalis part
o Cochlear portion [pars inferior] - hearing
fold of thyroarytenoid muscles, produce thes sound of speech, controls air flow
Rimma glottidis Interval btw paired vocal cords, narrowest part of laryngeal cavity, it opens and Membranous Contains the endolymph [K, Na, like ICF]. It includes cochlear duct, utricle
closes to regulate the passage of air labyrinth and semicircular ducts
Infraglottic Btw vocal fold and lower border of cricoid cartilage, continuous inferiorly w/ Otolith organs [Saccule, Utricle - respond to Linear acceleration]
cavity trachea, related anteriorly to cricothyroid membrane Semicircular canal [respond to Angular acceleration]
NOTE: organ of corti sensory organ of the ear; Gasserian ganglion largest ganglion
Intrinsic & extrinsic muscles of larynx
Name Innervation Action Muscles related to middle ear
Cricothyroid Vagus N. Tenses and legthens vocal ligament Stapedius muscle Contracts reflexly in response to loud sounds, innervated by facial N.
Posterior cricoarythenoid Vagus N. Abducts the vocal cord Tensortympani M. Contracts reflexly in response to loud sounds, innervated by N. to tensor
Lateral cricoarythenoid Vagus N. Adducts vocal cord tympani [from N. of medial ptrygoid, br. of mandibular N.]
Transverse arythenoid Vagus N. Adducts the vocal cords
Oblique arythenoid Vagus N. Adducts the vocal cords Clinical notes
Hyperacusis
Thyroarythenoid Vagus N. Decreases tension and length of vocal lig.
The stapedius contracts reflexively to protect inner ear from high intensiy vibrations. A lesion of
Vocalis Vagus N. Varies the length and tension of vocal cord
Thyroepiglotticus Vagus N. Depresses the epiglottis facial nerve, if it includes the nerve to stapedius, results in hyperacusis [increased sensitivity to
loud sounds].
Aryepiglotticus Vagus N. Depresses the epiglottis
Types of hearing loss
NOTE: All extrinsic muscles of larynx = recurrent laryngeal nerve except cricothyroid
Conductive hearing loss result from interference of sound transmission thru external or middle
Cricothyoid emergency airway for cervical injury
ear. Middle ear infections in children and otosclerosis in adults are the common causes.
Innervation of larynx Sensorineural hearing loss may result from loss of hair cells in cochlea or lesion to cochlear part
Name Origin Branches of CN VIII or to CNS auditory pathways.
Superior laryngeal N. Vagus N. Internal and external laryngeal N. Test to determine hearing loss type
Inferior laryngeal N. Recurrent laryngeal N. None Webers test used to determine whether a px has a hearing loss but does not determine whether
it is conductive or sensorineural. A vibrating tuning fork is placed in midline of the skull or on the
Clinical notes bridge of nose; normally vibrations reach the normal ear by both bone and air conduction, but they
Superior laryngeal nerve lesions interfere w/ each other making the normal ear less sensitive. Pxs w/ sensorineural hearing loss will
hear the vibrations better in normal ear.
Are largely asymptomatic because its fibers are mainly sensory. If motor fibers to cricothyroid
Rinnes test used to determine whether a px has a conductive hearing loss. The base of the
are affected in a lesion of the external branch, a px may experience mild hoarseness and slight
decrease in vocal strength w/ tendency to produce monotonous speech. vibrating tuning fork is placed on mastoid process. When the px no longer hears the vibrations, the
Recurrent laryngeal nerve lesions tuning fork is then placed next to the external ear. Normally, airborne vibrations are heard better
than those conducted thru skull bones because of the efficiency of middle ear, so the px should
Both recurrent laryngeal nerves are susceptible to injury in surgical procedures involving thyroid
again hear the vibrations. If the px has condutive hearing loss, the tuning fork cannot be heard
gland. Lesions of recurrent laryngeal N. result in fixed vocal cord and transient hoarsness.
when placed next to external ear.
L recurrent laryngeal N. is injured more frequently than R because of its couse thru superior
mediastinum. Nerves related to middle ear
In the mediastinum, the L recurrent laryngeal N. hooks around the arch of aorta and might be Name Origin Distribution
compressed by aortic aneurysm. Tympanic N. Glossopharyngeal N. Tympanic cavity, mastoid air cells, auditory tube
R recurrent laryngeal N. is found only in the neck, where it hooks around R subclavian A. Lesser petrosal N. Tympanic N. Middle cranial fossa structures
Caroticotympanic N. Internal carotid plexus Anterior wall
Blood supply of larynx Facial N. Petrous temporal bone area
Name Origin Distribution Chorda tympani Facial N. Infratemporal fossa
Superior laryngeal A. Superior thyroid A. Upper part of larynx
Inferior laryngeal A. Inferior thyroid A. Lower part of larynx Nerves related to inner ear
Name Origin Distribution
EAR

28
Vestibulocochlear N. Vestibular ganglion Internal auditory meatus Arcus seniles Benign peripheral corneal degeneration
Vestibular N. Vestibulocochlear N. Macule and cristae ampullares Diabetic retinopathy Uncontrolled sugar In blood causes fat deposition in retina
Cochlear N. Vestibulocochlear N. Spiral organ of corti Horners syndrome Constricted pupil w/ sinking, redness and dryness of the eyes
Glaucoma Blockage of drainage of aqueous humor
RAPID REVIEW Papilledema Edema of retina due to increased ICP
Largest and most important interfascial space: retropharyngeal space Hyphema Hemorrhage of the anterior chamber of eye
Congenital torticollis [wry neck] flexion deformity of neck due to a fibrous tissue
tumor Clinical notes on eyelids
Spasmodic torticollis [cervical dystonia] abnormal tonicity of neck involving Ablepharon Absent eyelid
trapezius and sternocleidomastoid muscles Ankyloblepharon Fused eyelids
MC iatrogenically injured nerve: Accessory N. Cryptholthalmos Overlying skin hiding the eye
Serves as internal barometer when venous pressure rises: external jugular vein Coloboma 1 or both upper eyelid has vertical fissure
Largest endocrine gland of the body: thyroid gland [C5-T1] Ectropion Eversion of eyelid
Largest branch of thyroid artery: inferior thyroid artery Entropion Inversion of eyelid
Largest branch of vertebral A: posterior inferior cerebellar A. Distichiasis Accessory row of eyelashes
Blespharitis Inflammation of lid margin affecting Meibonian gland
An artifact found only in dried skull: foramen lacerum [in life it is filled w/ cartilage]
Hordeolum / stye Acute, solitary, circumscribed glands of Beis [ciliary glands]
Principal muscle of cheeks: buccinator
Chalazion Chronic granulosa/cysts of Meibonian glands
Main nerve for secretomotor fibers of submandibular and sublingual glands: facial N. Ptosis Drooping of eyelid involving CN 3 [occulomotor nerve]
Largest of the paired salivary glands: parotid gland
Stensens duct [parotid], whartons duct [submandibular] MISCELLANEOUS
Major retractor of the lower jaw: temporalis
Indirect trauma to orbital walls produces: blowout fracture Summary of important landmarks
Common in boxers and basketball players: periorbital echymosis Linea semilunaris Crosses costal margin near tip of 9th costal cartilage
Skeleton of eyelids: tarsal plates Spleen Axis of ribs 9-12,
Sensory nerve to eyeball: Nasociliary N. Kidney Upper 3 lumbar vertebrae
Largest part of the vascular layer of eyeball, lines the sclera: Choroids Tracheal bifurcation Sternal angle
Ciliary processes: secretes aqueous humor w/c fills posterior eye chamber Oropharynx C2-3 vertebrae
Laryngopharynx C4, 5, 6 vertebrae
Vitreous chamber: comprises the bulk of the eyeball
Thyroid gland C5-T1
Fovea centralis: area of most acute vision [maximum visual acuity] contains only
Cricoid cartilage, trachea starts C6 vertebrae
cones, no rods
Superior angle of scapula T2
Prevents air entry into esophagus between swallowing: cricopharyngeus muscle
Suprasternal or jugular notch T2/3
Entrance from pharynx into larynx: aditus Spine of scapula T3
1st bones to be fully ossified: auditory ossicles Sternal angle of Louis, trachea ends 2nd costal cartilage & lower border of T4/T5
Smallest striated muscle of the body: stapedius Tracheal bifurcation T6
Skin is thin in eyelids and genitals Inferior angle of scapula, IVC passes T8
Skin is the largest organ Xiphisternal joint T9
Facial nerve branches: Temporal, zygomatic, maxillary, mandibular, cervical Abdominal aorta, celiac A. T12 & divides at L4 into R and L common iliac A.
Lesions in primary visual pathways Duodenum L1-L2 [2nd part is at bodies of L1,2,3
Sorbitol sugar accumulation in lens in DM cataract Pancreas, SMA, spinal cord in adults end Level of L1
Glaucoma diuretic of choice: acetazolamide Spinal dura L2
Central retinal artery lesion blindness Lowest costal margin [10th rib], IMA L3
Ophthalmologic emergencies chemical burns and central retinal artery occlusion Common iliac artery L4
Amaurosis fugax TIA of eyes Sacral promontory S2-3
Temporal, parietal, occipital Recto-Sigmoid colon S3
Optic nerve blindness in ipsilateral area
Dermatomes
Optic chiasm bilateral hemianopsia
C2 Back
Meyors loop optic radiation
C5 Tip of shoulder, perianal region

C6 Thumb
Optic pathway: C7 Middle finger
o Cornea lens retina optic nerve optic chiasm optic tract lateral C8 Small finger
geniculate body optic radiation visual field T4 Nipple
Flow of aqueous humor: T7 Xiphoid process
o Choroids plexus posterior chamber iris anterior chamber canal of schelm T10 Umbilicus
iricorneal junction sclera L1 Inguinal ligament
Flow of tears: L4-5 Big toe, kneecaps
o Excretory duct fornix cornea conjunctiva lacus lacrimalis lacrimal S1 Small toe
puncta lacrimal canaliculi lacrimal sac nasolacrimal duct inferior meatus of S2, 3, 4 Erection & sensation of penile zones
nose
Most common
Clinical notes on the eyes
Most mobile segment of omentum R lower segment
Nystagmus Rapid eyeball movement
MC bone injury invoving the face Nasal bone trauma
Astigmatism Defective curvature of refractive surface of the eye
MC nerve involved in TOS Ulnar nerve
Emetropia Norman vision
Most posterior cavity w/in peritoneal cavity Morrisons pouch
Myopia Nearsigtedness [needs concave lens]
Most posterior extension of lateral thyroid lobule Tubercle of Zuckerkandl
Hyperopia Farsightedness [needs convex lens]
MC carpal bone dislocation Lunate
Presbyopia Impaired vision due to old age
MC carpal bone fracture Scaphoid
Diplopia Double vision due to paralysis of extraocular eye muscles
MC tarsal bone fracture Calcaneus
Exopthalmus Protrusion of eyeball seen in hyperthyroidism
MC fractured bone Clavicle
Pink eye / conjunctivitis Palpebral conjunctival inflammation [mucus bacteria, red viral]
MC damaged nerve in px w/ shoulder dislocation Axillary nerve
Pterygium White scar tissue in the eye
Firs carpal bone to ossify [at 1st year of life] Capitate
Keratitis Corneal inflammation
Photophobia Morbid fear of light as seen in rabies IMPORTANT MNEUMONICS
Kayser-fleisher rings Rings around limbus as seen in 29ilsons disease

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Aoric branches
Aortic arch gives off the Bracheiocephalic trunk, the left Common Carotid, and the left Tarsal bones [superior to inferior, medial to laeral]
Subclavian artery [ABC'S] In order (right foot, superior to inferior, medial to lateral): Talus Calcanous Navicular Medial
cuneiform Intermediate cuneiform Lateral cuneifrom Cuboid [Tall Californian Navy Medcial Interns
Axillary artery branches [from proximal to distal] Lay Cuties]
Superior thoracic, Thoracoacromial, Lateral thoracic, Subscapular, Anterior circumflex humeral,
Posterior circumflex humeral [Screw The Lawyer, Save A Patient] Elbow
Muscles that bend/flex it: 3Bs - Brachialis, Biceps, Brachioradialis
Thoracoacromial artery branches
Clavicular Acromial Pectoral Deltoid [CAlifornia Police Department] Ureter to ovarian/ testicular artery
Ureters [water] is posterior to it
Subclavian artery branches [Very Tired Individuals Sip Strong Coffee Served Daily]
Vertebral artery Kidney hilums at transpyloric plane L1
Thyrocervical trunk L1 goes thru hilum of only 1 kidney and its the left
---Inferior thyroid
---Superficial cervical Erector spinae muscles
---Suprascapular Iliocostalis, Longissimus, Spinalis [I Love Sex lateral to medial]
Costocervical
---Superior intercostal Scrotum layers
---Deep cervical From superficial to deep: Skin Dartos External spermatic fascia Cremaster Internal spermatic
fascia Tunica vaginalis Testis [Some Damn Englishman Called It The Testis]
Coeliac trunk branches
Left gastric artery, Hepatic artery, Splenic artery [Left Hand Side] Collagen types [memorize]
Type 1 bone = 90% of tendon and fascia
Internal iliac artery branches Type 2 = car Two lage, caritilage, vitreous body, nucleous pulposus
ileolumbar, Lateral sacral, Gluteal [superior and inferior], Pudendal [internal], Inferior vesical Type 4 under the floor, bone marrow, basal ganglia
[uterine in females], Middle rectal, Vaginal, Obturator, Umbilical [I Love Going Places In My K+ epidermal plates
Very Own Underwear]
Internal jugular vein: tributaries
Superior thyroid A. branches: From inferior to superior: Middle thyroid Superior thyroid Lingual Common facial Pharyngeal
Muscular, Infrahyoid, Superior laryngeal, Sternomastoid, Cricothyroid, Glandular [May I Softy Inferior petrosal sinus [Medical Schools Let Confident People In]
Squeeze Charlies Glans]
Inferior vena cava tributaries [I Like To Rise So High]
External carotid A. branches Illiacs, Lumbar, Testicular, Renal, Suprarenal, Hepatic vein.
Superior thyroid, Lingual, Facial, Ascending pharyngeal, Occipital, Posterior auricular,
Superficial temporal, Maxillary [Shiela Lies Flat As Oscars Penis Stops Masturbating]
Carotid sheath contents [I See 10 CC's in the IV]
Femoral artery deep branches [Put My Leg Down Please] I See (I.C.) = Internal Carotid artery
Profundus femoris (deep femoral artery) 10 = CN 10 (Vagus nerve)
Medial circumflex femoral artery CC = Common Carotid artery
Lateral circumflex femoral artery IV = Internal Jugular Vein
Descending genicular arteries
Perforating arteries Retroperitoneal structures list [SAD PUCKER]
Suprarenal glands, Aorta & IVC, Duodenum (half), Pancreas, Ureters, Colon (ascending &
descending), Kidneys, Esophagus (anterior & left covered), Rectum
Lumbar plexus branches
Iliohypogastric, Ilioinguinal, Genitofemoral, Lateral femoral cutaneous, Obturator, Femoral [I Superior mediastinum: contents [PVT Left BATTLE]
Get Laid On Fridays] Phrenic nerve, Vagus nerve, Thoracic duct, Left recurrent laryngeal nerve (not the right),
Brachiocephalic veins, Aortic arch (and its 3 branches), Thymus, Trachea, Lymph nodes,
Trigeminal Nerve: where branches exit the skull Esophagus
Superior obital fissure [V1], foramen Rotundum [V2], foramen Ovale [V3] [Standing Room
Only] Diaphram aperatures: spinal levels [Come Enter the Abdomen]
Vena Cava [8], Esophagus [10], Aorta [12]
Vagus Nerve: pathway into thorax
Left Vagus nerve goes to Anterior descending into the thorax [I Left my Aunt in Vegas] Superior orbital fissure
Lacrimal nerve, Frontal nerve, Trochlear nerve, Superior branch of occulomotor nerve, Abducent
Facial nerve branches nerve, Nasociliary nerve, Inferior branch of occulomotor nerve [Live Free To See Absolutely No
Temporal branch, Zygomatic, Buccal mandibular [Two Zombies Bugging] Insult]

Deep tendon reflexes: root supply "1, 2, 3, 4, 5, 6, 7, 8": Cubital fossa contents [My Bottoms Turned Red]
S1-2: ankle From medial to lateral: Median nerve, Brachial artery, Tendon of biceps, Radial nerve
L3-4: knee
C5-6: biceps, supinator Posterior mediastinum structures
C7-8: triceps There are 4 birds:
The esophaGOOSE (esophagus)
Bronchopulmonary segments of right lung The vaGOOSE nerve
In order from superior to inferior: Apical Posterior Anterior Lateral Medial Superior Medial basal The azyGOOSE vein
The thoracic DUCK (duct)
Anterior basal Lateral basal Posterior basal [A PALM Seed Makes Another Little Palm]
Tarsal tunnel: contents
Wrist bones [prone to avascular necrosis]
From superior to inferior: Tibialis posterior, flexor Digitorum longus, posterior tibial Artery, tibial
Scaphoid, Lunar, Triquetrum, Pisiform, Trapezoid, Trapezium, Capitate, Hammate [Some
Nerve, flexor Hallucis longus [Tiny Dogs Are Not Hunters]
Lovers Try Position That They Cant Handle]
Spermatic cord contents [Piles Don't Contribute To A Good Sex Life]
Carpal bones [multangular names]
Pampiniform plexus, Ductus deferens, Cremasteric artery, Testicular artery, Artery of the ductus
Navicular, Lunate, Triquetrum, Pisiform, Greater Multangular [trapezium], Lesser Multangular
deferens, Genital branch of the genitofemoral nerve, Sympathetic nerve fibers, Lymphatic vessels
[trapezoid], Capitate, Hamate

30
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