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Firecracker

ANATOMY
2016
Table of Contents
Introduction 5
Abdomen 8
Abdominal Vasculature-Anterior Abdominal Wall 8
Abdominal Vasculature-The Abdominal Aorta 13
Abdominal Vasculature-The Celiac Trunk 23
Abdominal Vasculature-The Inferior Mesenteric Artery 34
Abdominal Vasculature-The Superior Mesenteric Artery 35
Inguinal Canal 42
Muscles of the Anterior Abdominal Wall 45
Muscles of the Posterior Abdominal Wall 51
Spaces & Gutters of the Abdominal Cavity 58
The Lumbar Plexus 61
The Mesenteric Plexus 68
The Spermatic Cord 70
Back & Thorax 74
Back: Muscles-Deep 74
Back: Muscles-Superficial 76
Back: Vertebral Column - Cervical 85
Back: Vertebral Column-Lumbar & Sacral 88
Back: Vertebral Column-Overview 97
Back: Vertebral Column-Thoracic 103
Back: Vertebral Column-Vertebral Ligaments 110
Spinal Meninges 112
Thorax: Anterior Wall 115
Thorax: Heart-Coronary Arteries & Cardiac Veins 128
Thorax: Heart-External Anatomy 137
Thorax: Heart-Internal Anatomy 146

Thorax: Pericardial Sac 155


Thorax: The Mediastinum 164
Thorax: Vasculature 174

1
Head & Neck 178
Cranial Meninges & Dural Sinuses 178
Face-Deep Layer 192
Face-Superficial Layer 201
Neck: Anterior & Posterior Triangles 211
Neck: Muscles 217
Neck: Nerves 232
Neck: Vasculature 243
Parotid Gland 260
The Ear 263
The Oral Cavity & Tongue 273
The Orbit 286
The Palate 294
Thyroid & Parathyroid Glands 296
Lower Limb 302
Foot: Dorsal Muscles 302
Foot: Nerves 307
Foot: Plantar Muscles-1st Layer 310
Foot: Plantar Muscles-2nd Layer 314
Foot: Plantar Muscles-3rd Layer 316
Foot: Plantar Muscles-4th Layer 317
Foot: Vasculature 318
Gluteal Region: Muscles 320
Gluteal Region: Nerves 326
Gluteal Region: Vasculature 334
Leg: Muscles-Anterior Compartment 338
Leg: Muscles-Lateral Compartment 340
Leg: Muscles-Posterior Compartment 341
Leg: Nerves 346
Leg: Vasculature 350
Lumbosacral Plexus 352
The Ankle (Talocrural) Joint 362
The Hip Joint 367
The Knee Joint 381

2
The Popliteal Fossa 388
Thigh: Muscles-Anterior Compartment 390
Thigh: Muscles-Medial Compartment 395
Thigh: Muscles-Posterior Compartment 399
Thigh: Nerves 409
Thigh: The Femoral Triangle 423
Thigh: Vasculature 425
Pelvis 442
Anal Triangle 427
Nerves of the Pelvis 442
Pelvic Viscera-Female 448
Pelvic Viscera-Male 457
The Pelvic Floor 463
Urogenital Triangle-Female 473
Urogenital Triangle-Male 475
Vasculature of the Pelvis 487
Upper Limb 494
Arm: Muscles 494
Arm: Nerves 508
Arm: Vessels 512
Brachial Plexus-Axillary Nerve 523
Brachial Plexus-Median Nerve 528
Brachial Plexus-Musculocutaneous Nerve 540
Brachial Plexus-Radial Nerve 547
Brachial Plexus-Ulnar Nerve 552
Brachial Plexus 562
Forearm: Muscles-Deep Extensors 572
Forearm: Muscles-Deep Flexors 576
Forearm: Muscles-Superficial Extensors 578
Forearm: Muscles-Superficial Flexors 580
Forearm: Nerves 584
Forearm: Vessels 593
Hand: Innervation of Intrinsic Muscles 611

3
Hand: Muscles-Deep 613
Hand: Muscles-Superficial 637
Hand: Nerves 644
Hand: Vasculature 654
Rotator Cuff Muscles 665
The Cubital Fossa 677
The Elbow Joint 683
The Shoulder (Glenohumeral Joint) 688
The Wrist Joint 701

4
Introduction

About this book.


Over the past few years, we've heard many requests from Firecracker members asking if it
was possible to download all of our topic summaries as a single PDF. We've even had
students ask if they could buy a complete printed edition. And while we didn't have the
bandwidth to handle these requests at the time, we knew that we would eventually return to
the idea and deliver our topic summaries in a more standalone way. The question was,
"How?"

Our answer: Give them away to everyone Firecracker member or not for free.

While we certainly view content as a necessary and important asset, we don't view it as our
unique or even primary source of value. There are dozens of content resources out there,
from textbooks to flashcards to review books like First Aid or Pathoma (both of which are
great). What there isn't a lot of is what Firecracker has spent the last six years building, i.e. a
data-driven recommendation engine that is capable of creating a personalized study plan for
every student, presenting the appropriate content and question difficulty at the appropriate
time, ensuring long-term retention of all foundational knowledge learned in school,
progressively assessing a student's ability to apply this foundational knowledge to
increasingly complex clinical scenarios, accurately modeling mastery across all testable
subject areas, and automatically providing remediation of weak areas, all while being proven
to improve student outcomes on board exams by roughly one standard deviation.

Given this, we wouldn't feel right charging students for content that 1) they can get
elsewhere, 2) doesn't include our extensive library of questions, and 3) doesn't provide the
full value that Firecracker offers. So, from now on, we're offering all of our topic summaries
for free (via these downloabable subject books) to any student who wants to use them. We
hope they come in handy.

One last important note: While the content in our online platform is updated and improved
daily, we are viewing these subject books as annual editions which we won't actively
update. If you want access to our most up to date content, I recommend using the
Firecracker web and mobile platform.

Thanks again, and best of luck with your studies!

Keith Frankel
Chief Product Officer, Firecracker

All images license from and provided by our friends at Lippincott Williams &Wilkins

5
Abdominal Vasculature-Anterior Abdominal Wall

USMLE Step 1 > Basic Sciences > Anatomy > Abdomen

Abdominal VasculatureAnterior
Abdominal Wall
https://med.firecracker.me/app#/tree/1/1-20-41-74-3497

The superior epigastric a. is a branch of the internal thoracic a. It is found posterior to the
rectus abdominis muscle anterior to the the rectus sheath, where it forms an anastomosis
with the inferior epigastric a.

The inferior epigastric a. is a branch of the external iliac a.

Clinical Correlate: The inguinal triangle ( Hesselbachs triangle ) is an area of natural


weakness in the anterior abdominal wall. It is bounded by the lateral edge of the rectus
abdominis, the inferior epigastric vessels, and the inguinal ligament. This region is prone to
direct hernias.

The posterior intercostal aa. from ribs 7-11 and the subcostal a. course anteriorly in the
plane between the internal abdominal oblique and the transversus abdominis to anastomose
with the superior and inferior epigastric arteries.

Recall that the posterior intercostal aa are branches of the thoracic aorta.

8
Abdominal Vasculature-Anterior Abdominal Wall

Intercostal arteries.

9
Abdominal Vasculature-Anterior Abdominal Wall

Inguinal triangle.

10
Abdominal Vasculature-Anterior Abdominal Wall

Superior and inferior epigastric arteries.

The thoracoepigastric v. drains to both the SVC and IVC and thus provides a crucial
anastomotic link between the two vessels in situations of portal or caval obstruction.

Clinical Correlate: The portal v. is connected to the thoracoepigastric v. via the paraumbilical
vv. Dilation of the thoracoepigastric and paraumbilical vv as a result of portal hypertension is
what causes the characteristic finding of caput medusae (superficially dilated veins
surrounding the umbilicus).

11
Abdominal Vasculature-The Abdominal Aorta

USMLE Step 1 > Basic Sciences > Anatomy > Abdomen

Abdominal VasculatureThe Abdominal


Aorta
https://med.firecracker.me/app#/tree/1/1-20-41-74-3499

The abdominal aorta is a continuation of the thoracic aorta inferior to the diaphragm.

The abdominal aorta is retroperitoneal and supplies the abdominal viscera. At the level of
vertebra L4 , it bifurcates into right and left common iliac arteries, which supply the lower
limbs.

Arteries supplying gastrointestinal structures branch anteriorly from the abdominal aorta,
while arteries supplying non-gastrointestinal structures branch posteriorly and laterally.

For details on branching and blood supply, review The Celiac Trunk, The SMA, and The
IMA.

The celiac trunk , SMA (superior mesenteric a.), and IMA (inferior mesenteric a.) are
unpaired branches of the abdominal aorta and supply, respectively, derivatives of the
embryonic foregut, midgut, and hindgut. These three are considered the three major
unpaired arteries of the abdominal aorta.

Note: The median sacral a. is also unpaired but descends along the sacrum into the pelvis
to supply the rectum.

13
Abdominal Vasculature-The Abdominal Aorta

Arteries of the posterior abdominal wall. Quiz yourself!

14
Abdominal Vasculature-The Abdominal Aorta

The superior mesenteric artery serves the midgut derivatives. This tube is longer than the
celiac trunk and typically includes primary branches for the pancreas duodenum ileocecal
junction ascending colon and transverse colon. The long jejunum and ileum receive a
battery of primary branches from the left side of the superior mesenteric. (Modified from
LifeART image copyright 2007 Lippincott Williams & Wilkins. All rights reserved.)

15
Abdominal Vasculature-The Abdominal Aorta

Arteries of the posterior abdominal wall.

Paired branches of the abdominal aorta are:

Inferior phrenic aa. : The inferior phrenic arteries supply the diaphragm, as well as give
off branches to the abdominal portion of the esophagus and superior suprarenal aa. to
the adrenal glands.
Middle suprarenal aa. : The middle suprarenal arteries supply the adrenal glands.
Renal aa. : The renal arteries arise at the level of L1-L2 and supply the kidneys, as well
as give off inferior suprarenal arteries to the adrenal glands.

Note: There is some variability between sources on the level of the renal arteries
with authors stating L1, L2, or in between L1-L2.
Gonadal aa. : The gonadal arteries arise at the level of L2 and supply the ovaries (
ovarian arteries ) in women. In men, the testicular arteries pass through the inguinal
canal within the spermatic cord to supply the testicles.
Lumbar aa. : The lumbar arteries supply the muscles of the posterior abdominal wall.

16
Abdominal Vasculature-The Abdominal Aorta

Arteries of the posterior abdominal wall. Quiz yourself!

17
Abdominal Vasculature-The Abdominal Aorta

Arteries of the posterior abdominal wall.

18
Abdominal Vasculature-The Abdominal Aorta

The abdominal aorta.

19
Abdominal Vasculature-The Abdominal Aorta

The upper abdominal aorta.

20
Abdominal Vasculature-The Abdominal Aorta

The abdominal aorta

21
Abdominal Vasculature-The Abdominal Aorta

The abdominal aorta

Image Credit: Adapted from Gray's Anatomy

22
Abdominal Vasculature-The Celiac Trunk

USMLE Step 1 > Basic Sciences > Anatomy > Abdomen

Abdominal VasculatureThe Celiac Trunk


https://med.firecracker.me/app#/tree/1/1-20-41-74-2921

Celiac trunk :

The celiac trunk is the first large unpaired branch of the abdominal aorta. It arises at the
level of T12 and travels anteriorly for ~1cm before branching into 3 arteries:

Left gastric a.
Splenic a.
Common hepatic a.

23
Abdominal Vasculature-The Celiac Trunk

The abdominal aorta and supply of the foregut organs. The aorta below the diaphragm
serves the gut tube through three midline arteries. The first which runs to the derivatives of
the foregut is the celiac trunk. It divides almost immediately into a small branch for part of
the stomach a large branch for the spleen and a large branch for the liver gallbladder
duodenum and rest of the stomach.

24
Abdominal Vasculature-The Celiac Trunk

Branches of the celiac trunk

Image Credit: Adapted from Gray's Anatomy

Common hepatic artery : The common hepatic a. travels right along the duodenum and
gives rise to the proper hepatic a. and the gastroduodenal a.. Proper hepatic a. : The
proper hepatic a. is an ascending branch which travels with the common bile duct and
hepatic portal vein within the hepatoduodenal ligament.

The proper hepatic a. gives has 3 main branches:

Right hepatic a. Gives rise to the cystic a.


Left hepatic a.
Right gastric a. Travels within the lesser curvature of the stomach and
anastomoses with the left gastric a.

Note: The right gastric artery has variable origins and can arise from the common hepatic
artery or the proper hepatic artery. Origin of the artery varies person to person and by
source. Gastroduodenal a. : The gastroduodenal a. is a descending branch of the
common hepatic a. and splits to form two arteries:

Superior pancreaticoduodenal a. : Further divides into anterior-superior and posterior-

25
Abdominal Vasculature-The Celiac Trunk

superior branches that descend to supply the head of the pancreas and the proximal
duodenum
Right gastroepiploic a. (gastroomental): Courses along the greater curvature of the
stomach within the greater omentum and anastomoses with the left gastroepiploic a.
(branch of the splenic a.)

Gastroduodenal artery.

26
Abdominal Vasculature-The Celiac Trunk

Common hepatic and proper hepatic arteries.

27
Abdominal Vasculature-The Celiac Trunk

Common hepatic and proper hepatic arteries.

28
Abdominal Vasculature-The Celiac Trunk

Hepatic and gastric arteries. Note the gastroduodenal artery.

Splenic a. : The splenic a. travels a tortuous path to the left along the superior border of the
pancreas. The artery then passes within the splenorenal ligament to enter the hilum of the
spleen. The splenic a. gives rise to the following major named branches:

Left gastroepiploic a. : Courses to the right along the greater curvature of the stomach
within the greater omentum and anastomoses with the right gastroepiploic a.
Short gastric aa. : Supply the fundus of the stomach
Greater pancreatic a.: Largest artery supplying the pancreas
Dorsal pancreatic a.: Forms an anastamosis with the superior pancreaticoduodenal
artery Note: The splenic artery gives off many small branches that supply the pancreas.

29
Abdominal Vasculature-The Celiac Trunk

Short gastric and left gastro-epiploic arteries. The splenic artery is depicted here as the
lienal artery, an older term for the structure.

30
Abdominal Vasculature-The Celiac Trunk

Note the splenic artery, a branch of the celiac trunk.

Left gastric a. : The left gastric a. runs along the lesser curvature of the stomach and gives
off the esophageal branches.

The hepatic portal vein carries nutrients and drugs absorbed from the GI tract.

The hepatic artery carries oxygen rich blood from the heart to supply the metabolic needs
of the hepatocytes.

These two blood supplies branch into the portal triads where they are taken to the hepatic
sinusoids.

Blood supply of liver : The liver has a dual blood supply which includes the hepatic portal
v. and the hepatic a.

31
Abdominal Vasculature-The Celiac Trunk

Celiac trunk. Note that the lienal artery is an older term for the splenic artery.

32
Abdominal Vasculature-The Celiac Trunk

Left and right gastric arteries.

33
Abdominal Vasculature-The Inferior Mesenteric Artery

USMLE Step 1 > Basic Sciences > Anatomy > Abdomen

Abdominal VasculatureThe Inferior


Mesenteric Artery
https://med.firecracker.me/app#/tree/1/1-20-41-74-902

Inferior mesenteric artery :

The inferior mesenteric artery (IMA) arises from the abdominal aorta at the level of
vertebral body L3. It supplies the hindgut derivatives, consisting of the distal 1/3 of the
transverse colon to the rectum. The same distribution receives parasympathetic innervation
from the pelvic splanchnic nerves (S2-S4).

The venous blood from the IMA region , along with the rest of the gut, travels to the liver
via the portal circulation. There are paired veins for all of the arteries from the gut.

Clinical Correlate: The inferior mesenteric artery (IMA) is one of three major abdominal blood
vessels that can be implicated in mesenteric ischemia , which occurs when blood flow to
the bowel is decreased due to disruption of blood flow. Mesenteric ischemia can be caused
by atherosclerosis, thromboembolisms, or aneurysms.

34
Abdominal Vasculature-The Superior Mesenteric Artery

USMLE Step 1 > Basic Sciences > Anatomy > Abdomen

Abdominal VasculatureThe Superior


Mesenteric Artery
https://med.firecracker.me/app#/tree/1/1-20-41-74-144

Superior mesenteric artery (SMA):

The superior mesenteric artery (SMA) arises at the level of L1. It supplies the portion of
the GI tract derived from the midgut (the portion of the duodenum distal to the major
duodenal papilla through the proximal two-thirds of the transverse colon ).

The same distribution receives parasympathetic supply from the vagus nerve (CN X).

Note: The distal 1/3 of the transverse colon is supplied by the IMA and pelvic splanchnic
nerves. The SMA, as well as its associated veins, lymphatics, and nerves travel through the
mesentery of the small intestine.

Branches of the SMA :

Inferior pancreaticoduodenal a. : The inferior pancreaticoduodenal a. travels


superiorly to anastomose with the superior pancreaticoduodenal a. (branch of
gastroduodenal a. from the celiac trunk); supplies the head of the pancreas as well as
the distal half of the duodenum.
Middle colic a. : The middle colic a. supplies the proximal half of the transverse colon.
Right colic a. : The right colic a. supplies the ascending colon.
Ileocolic a. : The ileocolic a. supplies the ileum, cecum, and appendix (via its
appendicular branch).

35
Abdominal Vasculature-The Superior Mesenteric Artery

The superior mesenteric artery serves the midgut derivatives. This tube is longer than the
celiac trunk and typically includes primary branches for the pancreas duodenum ileocecal
junction ascending colon and transverse colon. The long jejunum and ileum receive a
battery of primary branches from the left side of the superior mesenteric. (Modified from
LifeART image copyright 2007 Lippincott Williams & Wilkins. All rights reserved.)

36
Abdominal Vasculature-The Superior Mesenteric Artery

Main branches of the SMA

Image Credit: Adapted from Gray's Anatomy

SMA collateral circulation : The arteries to the small intestine all anastomose within the
mesentery to form several arcades. The straight arteries (vasa recta) arise from the distal
arcades, the anastamoses of the ileal and jejunal arteries, to supply the jejunum and ileum.
The marginal artery of Drummond courses along the inner border of the colon from the
ileocecal junction to the rectosigmoid junction. It is the anastomotic link between all of the
branches that supply the colon.

37
Abdominal Vasculature-The Superior Mesenteric Artery

Intestinal arcades.

38
Abdominal Vasculature-The Superior Mesenteric Artery

Note the straight arteries (vasa recta) branching off the distal arcades to supply the jejunum
(11) and ileum (12). SMA (8); ileocolic artery (10). The other structures include the:
transverse colon (1), ascending colon (2), cecum (3), right colic artery (4), appendix (5),
middle colic artery (6), transition sight between the SMA/IMA (7), and marginal artery (9).

Clinical Correlates :

Acute mesenteric ischemia most commonly occurs due to embolic occlusion of


the superior mesenteric artery (SMA). It presents with pain disproportionate to physical
findings and red "currant jelly" stools.
Nutcracker syndrome can result when the left renal vein becomes compressed
between the SMA and the aorta. This causes venous congestion in the left renal v.
resulting in left flank pain, testicular pain, lower limb varicosities, and varicocele of the
left testicle. Classically, this occurs when patients rapidly lose weight resulting in a
decrease in mesenteric fat precipitating the syndrome.

39
Abdominal Vasculature-The Superior Mesenteric Artery

Superior mesenteric artery syndrome results when the 3rd portion of the
duodenum is compressed between the SMA and abdominal aorta.

This extremely rare condition often manifests with vomiting, malnutrition,


postprandial pain, and subsequent anorexia.

Superior Mesenteric Artery Syndrome: Lateral view noting duodenal compression between
the abdominal aorta and SMA.

Superior Mesenteric Artery Syndrome: Note the duodenum (arrow) being compressed
between the SMA and abdominal aorta.

40
Abdominal Vasculature-The Superior Mesenteric Artery

Nutcracker Syndrome: Note the left renal vein (arrow) being compressed between the
abdominal aorta and SMA.

41
Inguinal Canal

USMLE Step 1 > Basic Sciences > Anatomy > Abdomen

Inguinal Canal
https://med.firecracker.me/app#/tree/1/1-20-41-74-3307

Inguinal canal :

The inguinal canal is a fascial tunnel at the inferior border of the anterior abdominal wall
mainly formed by the aponeurosis of the external oblique. The external oblique
aponeurosis forms its anterior wall of the inguinal canal. The inguinal canal contains the:

Spermatic cord (in males) or round ligament of the uterus (females)


Ilio-Inguinal nerve (both sexes) The path of the inguinal canal can be approximated by
the inguinal ligament , which forms its floor.

The inguinal canal is comprised of a superficial and a deep ring.

The superficial ring marks the end of the inguinal canal at the anterior abdomen. It is
formed by the aponeurosis of the external oblique muscle and resides lateral to the pubic
tubercle and superior to the pubic crest.

The deep ring is the entrance to the inguinal canal and is formed by the evagination of
the transversalis fascia. It is found lateral to the inferior epigastric a. at the midpoint along
the inguinal ligament, which is midway between the anterior superior iliac spine (ASIS) and
pubic tubercle.

An indirect hernia is a hernia that goes through the deep ring and is the most common type
of inguinal hernia.

Boundaries of the inguinal canal:

Anterior wall : Aponeurosis of internal and external oblique


Posterior wall : Aponeurosis of transverse abdominal muscle and fascia
Superior wall : Muscle fibers from the transverse abdominal and internal oblique
muscles
Inferior wall : Lacunar and inguinal lacunar ligaments Note: Some sources may refer
to the superior wall as the roof and inferior wall as the floor. These terms are
interchangeable.

42
Inguinal Canal

Note the relationship between the deep inguinal ring (internal ring) and superficial inguinal
ring (external ring) and the inferior epigastric arteries.

Note the spermatic cord exiting the superficial inguinal ring, which marks the exit of the
inguinal canal.

43
Inguinal Canal

Clinical Correlate: The inguinal (Hesselbachs) triangle is the site of direct inguinal
hernias. The borders of the inguinal triangle are:

Lateral : Inferior epigastric a.


Medial : Lateral portion of rectus abdominis m. (linea semilunaris)
Inferior : Inguinal ligament Direct inguinal hernias emerge through inguinal triangle
and may exit through the superficial inguinal ring. However, unlike indirect hernias,
direct hernias rarely enter the scrotum or labium majus. Indirect inguinal hernias pass
through the deep inguinal ring and are transmitted by the inguinal canal into the
scrotum or labium majus following the path of the spermatic cord.
It is the most common type of inguinal hernias and travels lateral to the inferior
epigastric artery and vein.

44
Muscles of the Anterior Abdominal Wall

USMLE Step 1 > Basic Sciences > Anatomy > Abdomen

Muscles of the Anterior Abdominal Wall


https://med.firecracker.me/app#/tree/1/1-20-41-74-869

There are 4 main muscles of the anterior abdominal wall which help support the contents of
the abdominal cavity. These muscles are also involved in forceful expiration.

External abdominal oblique : The external abdominal oblique is the most superficial layer
of muscular tissue.

The following structures are derivatives of its fascia:

Inguinal ligament : The thickened inferior margin of the aponeurosis of the external
abdominal oblique
Lacunar ligament : The medial portion of the inguinal ligament which attaches to the
pecten pubis
Pectineal ligament : A fibrous band which communicates with the lacunar ligament and
goes posteriorly along the pecten pubis (pectineal line of the pubis) Internal
abdominal oblique : The internal abdominal oblique is the intermediate layer of
muscular tissue. Transversus abdominis : The transversus abdominis is the deepest
layer of muscle tissue. Its aponeurosis fuses with that of the internal abdominal oblique
to form the conjoint tendon. Rectus abdominis : The rectus abdominis is a vertically
oriented muscles that spans the distance between the pubic crest and the costal
cartilage of ribs 5-7. It is covered by the rectus sheath.

45
Muscles of the Anterior Abdominal Wall

Pectoral region and anterior abdominal wall - pec major, serratus anterior, external
intercostals, rectus abdominis

Rectus abdominis muscles

46
Muscles of the Anterior Abdominal Wall

Image License: CC by-SA 3.0

Transversus abdominis muscle

Image Credit: Gray's Anatomy

47
Muscles of the Anterior Abdominal Wall

Muscles of the anterior abdominal wall.

The muscles of the anterior abdominal wall are under the superficial and deep fascial layers
of the abdominal wall.

The superficial fascia is composed of:

48
Muscles of the Anterior Abdominal Wall

Campers fascia Superficial fatty layer


Scarpas fascia Deep membranous layer which attaches to the deep fascia of the
thigh The deep fascia invests the muscles of the anterior abdominal wall.

The transversalis fascia is the deepest layer of the abdominal wall and is adjacent to the
extraperitoneal tissue , which is superficial to the peritoneum.

The constituents of the rectus sheath are different above and below the arcuate line (see
below). This point is found approximately halfway between the umbilicus and the pubic
symphysis and is the point where the inferior epigastric vessels enter the rectus
sheath.

The rectus sheath contains the superior and inferior epigastric vessels, the ventral primary
rami of T7-T12, and houses the rectus abdominis muscle.

Note: The arcuate line is also known as the linea semicircularis.

Superior to the arcuate line :

Anterior layer of the rectus sheath : Aponeuroses of the external abdominal oblique
and internal abdominal oblique muscles
Posterior layer of the rectus sheath : Aponeuroses of the internal abdominal oblique
and transversus abdominis muscles Inferior to the arcuate line :
Anterior layer of the rectus sheath : Aponeuroses of the external abdominal oblique,
internal abdominal oblique and transversus abdominis muscles
Posterior layer of the rectus sheath : Absent the rectus abdominis muscle is in
contact with the transversalis fascia.

49
Muscles of the Anterior Abdominal Wall

Rectus sheath superior to the arcuate line. Note that the aponeurosis of the internal
abdominal oblique contributes to both anterior and posterior layers.

Image Credit: Adapted from Gray's Anatomy

Rectus sheath.

50
Muscles of the Posterior Abdominal Wall

USMLE Step 1 > Basic Sciences > Anatomy > Abdomen

Muscles of the Posterior Abdominal Wall


https://med.firecracker.me/app#/tree/1/1-20-41-74-882

The muscles of the posterior abdominal wall are:

Quadratus lumborum
Psoas major
Psoas minor
Iliacus

The quadratus lumborum is responsible for lateral flexion of lumbar spine. It also
assists in inspiration by anchoring rib 12 during diaphragmatic contraction.

The quadratus lumborum is innervated by the subcostal n. and ventral rami of L1-L4

The psoas major flexes the lumbar spine and flexes the thigh at the hip joint.

It is innervated by the ventral rami of L1-L3

The psoas major fuses with the iliacus within the pelvis to form the iliopsoas, which
attaches to the femur.

51
Muscles of the Posterior Abdominal Wall

Psoas Major Image Credit: Anatomography via CC BY-SA 2.1 JP

52
Muscles of the Posterior Abdominal Wall

Psoas major and minor muscles

Image Credit: Gray's Anatomy

Psoas minor flexes** the lumbar spine. **It is also a weak flexor of the thigh at the hip
joint.

Psoas minor is innervated by the ventral rami of L1-2.

The psoas minor is immediately anterior to the psoas major.

The iliacus muscle contributes to flexion of the thigh.

The iliacus muscle is innervated by the femoral nerve (L2-L4).

The iliacus combines with the psoas major to form the iliopsoas.

53
Muscles of the Posterior Abdominal Wall

Iliacus Image Credit: Anatomography via CC BY-SA 2.1 JP

54
Muscles of the Posterior Abdominal Wall

Iliacus Image Credit: Anatomography via CC BY-SA 2.1 JP

55
Muscles of the Posterior Abdominal Wall

Muscles of the hip and gluteal region. The iliacus is seen adjacent to the iliac, and with the
psoas major is a powerful hip flexor. Image Citation: Beth ohara CC BY-SA 3.0

The inferior aspect of the diaphragm forms part of the musculature of the posterior
abdominal wall. Superiorly, the diaphragm also forms the boundary of the posterior
abdominal region, and separates the abdominal cavity from the thoracic cavity.

The left and right crura of the diaphragm are musculotendinous extensions of the diaphragm
inferiorly that attach to lumbar vertebrae.

Various structures pass through the diaphragm at the levels of T8, T10 and T12. At the level
of T8, the inferior vena cava and branches of the right phrenic nerve pass through the
vena caval hiatus.

56
Muscles of the Posterior Abdominal Wall

At the level of T10, the esophagus and vagus nerve pass through the esophageal
hiatus.

At the level of T12, the aorta, azygous vein and thoracic duct pass through the aortic
hiatus.

To help remember these structures, use the mnemonic: I ate 10 eggs at noon:

"I ate" IVC at level of T8


"10 eggs" esophagus at level of T10
"at noon" aorta at level of T12

57
Spaces & Gutters of the Abdominal Cavity

USMLE Step 1 > Basic Sciences > Anatomy > Abdomen

Spaces & Gutters of the Abdominal Cavity


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The peritoneal cavity is divided into the greater and lesser sacs.

The greater sac is the largest portion of the peritoneal cavity. It extends from the diaphragm
to the floor of the pelvis.

The hepatorenal recess (aka Morrison's pouch) is located between the right lobe of the
liver and the right kidney. It is the most dependent portion in the peritoneal cavity when
supine, which allows fluid in the peritoneum to accumulate there.

Clinical Correlate: Morrison's pouch is the most dependent portion of the body when
supine and for this reason, it is commonly checked for fluid (i.e. blood) during assessment of
a trauma patient. Dependent positioning refers to "gravity-dependent positioning" and is the
lowest part of the body in a given position where fluid would naturally collect.

The greater sac is further divided into the supracolic and infracolic compartments by the
transverse mesocolon (suspends the transverse colon).

The supracolic compartment refers to the region of the peritoneal cavity superior to the
transverse mesocolon and includes the stomach, liver, and spleen.

The infracolic compartment lies inferior to the transverse mesocolon and contains the
vertical portions of the colon and the small intestines. The subphrenic recess
separates the liver from the diaphragm (split by the falciform ligament).

Clinical Correlate: Subphrenic recess is a common site for abscess formation due
to peritonitis. Right-sided abscesses are more common due to the incidence of perforation
from acute appendicitis. Pus usually tracks into the hepatorenal recess in the supine position
th
and is best drained inferior to the 12 rib.

58
Spaces & Gutters of the Abdominal Cavity

Lesser omentum :

The lesser omentum is a bilayered peritoneal sheet that extends from the lesser curvature of
the stomach and superior part of the duodenum up to the visceral surface of the liver. It is
composed of the hepatogastric and hepatoduodenal ligaments.

The hepatoduodenal ligament carries the portal triad and as the name suggests, it travels
from the porta hepatis to the first part of the duodenum.

The hepatogastric ligament connects the lesser curvature of the stomach to the liver. The
opening into omental bursa (lesser sac) is called the epiploic foramen of Winslow.

Boundaries :

Superiorly: The caudate lobe of the liver


Anteriorly: The free edge of the lesser omentum (hepatoduodenal ligament)
Posteriorly: The inferior vena cava (IVC)
Inferiorly: The first part of the duodenum The lesser sac is the region posterior to the
stomach and lesser omentum.

Lesser omentum.

59
Spaces & Gutters of the Abdominal Cavity

The arrow indicates entrance to omental bursa via the omental foramen ( foramen of
Winslow ). The hepatoduodenal ligament carries the portal triad and the structure labeled
lesser omentum in the image is actually the hepatogastric ligament. Together, the
hepatogastric and hepatoduodenal ligaments form the lesser omentum.

The right paracolic gutter communicates superiorly with Morrisons pouch.


The left paracolic gutter is limited superiorly by the phrenicocolic ligament. The
paracolic gutters run lateral to the ascending and descending colon, allowing
communication of the ~50ml of peritoneal fluid between the supracolic and infracolic
subspaces.

60
The Lumbar Plexus

USMLE Step 1 > Basic Sciences > Anatomy > Abdomen

The Lumbar Plexus


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The lumbar plexus is formed by the anterior rami of nerves L1-L4 (with possible T12
contribution). Together with the sacral plexus, it forms the lumbosacral plexus. Though it also
innervates the skin and muscle of the inguinal and pubic region, it mainly supplies structures
of the lower limb.

Note: Due to the diagonal descending course of spinal nerve roots, the anterior abdominal
muscles are supplied by thoracic spinal nerves, despite their closer proximity to the lumbar
spine.

61
The Lumbar Plexus

Branches of the lumbar plexus on the posterior abdominal wall.

62
The Lumbar Plexus

Roots of the lumbar plexus.

Iliohypogastric n. (L1): The iliohypogastric n. courses in the plane between the


transversus abdominis m. and internal abdominal oblique m.

The iliohypogastric n. then enters the rectus sheath and emerges to give cutaneous
innervation to the anterior abdominal wall.

Ilioinguinal n. (L1): Off of L1, the ilioinguinal n. travels anterior to the quadratus lumborum
and then continues in between the internal and external oblique aponeurosis after
piercing through both the transversalis fascia and internal oblique muscle.

The nerve continues to travel between the internal and external abdominal oblique
aponeurosis and then enters the inguinal canal alongside the spermatic cord.

63
The Lumbar Plexus

It exits the superficial inguinal ring and supplies the skin of the upper medial thigh
(femoral cutaneous branch) and anterior scrotum or labium majus (anterior scrotal and
labial branches).

Lateral femoral cutaneous n. (L2-3): The lateral femoral cutaneous n. emerges along the
lateral border of the psoas major m. and crosses the iliacus m.

The lateral femoral cutaneous n. supplies skin of the lateral thigh (see image below).

Clinical Correlate: Meralgia paresthetica is a condition characterized by pain,


numbness, or burning in the anterior lateral thigh corresponding to the distribution of the
lateral femoral cutaneous nerve. It is not caused by a neurological disorder, but is due to
increased pressure placed on the nerve due to obesity or pregnancy. The nerve can
become compressed against anatomical structures, clothing such as belts or underwear, or
against seat-belts.

64
The Lumbar Plexus

Cutaneous supply of the thigh. Note the lateral femoral cutaneous innervation pattern.

65
The Lumbar Plexus

Cutaneous supply of the thigh. Note the lateral femoral cutaneous innervation pattern.

Genitofemoral n. (L1-2): The genitofemoral n. descends along the surface of the psoas
major m.

The genital branch descends in the spermatic cord to innervate the cremaster muscle. It
also provides sensory innervation to the anterior scrotum or labium majus.

66
The Lumbar Plexus

The femoral branch accompanies the femoral a. and supplies the skin of the upper medial
thigh.

The femoral n. crosses under the inguinal ligament to supply the anterior compartment of
the thigh.

Femoral n. (L2-4):

Obturator n. (L2-4): The obturator n. leaves the pelvis through the obturator canal to supply
the medial compartment of the thigh.

67
The Mesenteric Plexus

USMLE Step 1 > Basic Sciences > Anatomy > Abdomen

The Mesenteric Plexus


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Abdominal autonomic plexuses are nerve networks that provide sympathetic and
parasympathetic autonomic function to the intestines:

Sympathetic : Sympathetic innervation decreases motility and secretions


and constrict sphincters.
Parasympathetic : Parasympathetic innervation is the opposite of sympathetic and acts
to increase motility and secretions and relaxation of sphincters.

There are 3 main anatomic divisions surrounding their corresponding arterial roots:

Celiac plexus
Superior mesenteric plexus
Inferior mesenteric plexus

The myenteric plexus , also known as Auerbachs plexus , lies between the longitudinal
and circular layers of the muscularis externa. The myenteric plexus provides sympathetic
innervation (decrease motility, decrease secretions, constrict sphincters) and
parasympathetic innervation (increase motility, increase secretions, relax sphincters) to
both the circular and longitudinal layers.

Meissners plexus is a submucosal plexus that provides ONLY parasympathetic


innervation to neighboring epithelium, glands, vessels, and smooth muscle of the
muscularis mucosa.

Clinical correlate: Hirschsprung disease is a form of congenital megacolon due to the


absence of Auerbach and Meissner plexuses in the distal colon.

Superior mesenteric plexus : Preganglionic parasympathetic efferent fibers are derived


from the vagal trunks and are distributed along the vascular supply of the superior
mesenteric a. Inferior mesenteric plexus : Preganglionic parasympathetic efferent fibers

68
The Mesenteric Plexus

are derived from the pelvic splanchnic nerves (S2-S4) and are distributed along the
vascular supply of the inferior mesenteric a.

69
The Spermatic Cord

USMLE Step 1 > Basic Sciences > Anatomy > Abdomen

The Spermatic Cord


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The spermatic cord carries male reproductive structures via the inguinal canal to the testis.

The ductus deferens (vas deferens) is the largest structure of the spermatic cord and
conducts sperm from the testis.

The ductus deferens begins at the inferior pole of the testis and is continuous with the
epididymis.

Clinical Correlate: Vasectomy is a surgical procedure designed to result in male infertility.


The ductus deferens is cut and ligated to prevent sperm from entering the seminal
fluid.

The spermatic cord is sheathed by four layers. Superficial to deep these layers are:

External spermatic fascia


Cremaster muscle
Cremasteric fascia
Internal spermatic fascia The external spermatic fascia is the outermost fascial layer.
It is a continuation of the aponeurosis of the external abdominal oblique muscle.

The cremaster muscle is derived from muscle fibers of the internal abdominal oblique
muscle, and is responsible for drawing the testis toward the abdominal wall to reduce
heat loss. The cremaster muscle is innervated by the genital branch of the genitofemoral n.

The cremasteric fascia is the intermediate fascial layer of the spermatic cord and testis.
The cremasteric fascia is a continuation of the aponeurosis of the internal oblique muscle.

The internal spermatic fascia is the innermost layer of the spermatic cord. It is continuous
with the transversalis fascia.

The vessels of the spermatic cord include:

Testicular artery

70
The Spermatic Cord

Pampiniform plexus
Cremasteric artery
Artery to ductus deferens

Other components of the spermatic cord include small lymphatic vessels and various
nerves. The testicular artery is a branch of the abdominal aorta , and is responsible for
supplying the testicles.

The pampiniform plexus is an anastomotic venous network draining the testicles. A


varicocele develops when the veins of the plexus become swollen, commonly caused by a
valvular defect within the plexus , but also by Nutcracker syndrome or a renal cell
carcinoma.

The cremasteric artery is a branch of inferior epigastric artery , and is responsible


for supplying the cremaster muscle.

The artery to the ductus deferens is of variable origin. It may be either a branch of the
inferior vesical artery or the patent portion of the umbilical artery.

Multiple small lymphatic vessels travel in the spermatic cord. The testicular lymphatics drain
to the para-aortic nodes and the scrotal lymphatics drain to the superficial inguinal
nodes.

The genital branch of the genitofemoral nerve (aka external spermatic n.) descends
with the spermatic cord deep to the internal spermatic fascia. It provides sensation to the
skin of the anterior scrotum.

The femoral branch of the genitofemoral nerve (aka lumboingunial n.) provides sensory to
the more lateral portion of the upper medial thigh anterior to the femoral triangle.

The Ilioinguinal nerve travels adjacent to the spermatic cord (is NOT within the cord) to
provide sensation to the skin of the anterior scrotum and the more medial portion of
the upper medial thigh.

Structures within the spermatic cord can be remembered with the mnemonic " A ll D octors
L ove T aking C are of P atients' G enitals":

A rtery to the ductus


D uctus deferens
L ymphatics
T esticular artery
C remaster muscle and artery
P ampiniform plexus

71
The Spermatic Cord

G enital branch of the genitofemoral n.

72
Back: Muscles-Deep

USMLE Step 1 > Basic Sciences > Anatomy > Back & Thorax

Back: MusclesDeep
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The deep muscles of the back are involved in movements of the vertebral column, head, and
neck.

From lateral to medial, the erector spinae muscles are the:

Iliocostalis
Longissimus
Spinalis
Action: Extension and lateral flexion of the vertebral column ; helps maintain
posture
Innervation: Local dorsal rami The erector spinae muscles are often referred to by
region (e.g. spinalis thoracis attaches to the thoracic vertebrae, iliocostalis lumborum to
lumbar vertebrae).

The serratus posterior muscles are accessory muscles of respiration.

Serratus posterior superior:

Action: Elevates ribs 2-5 ; involved with inspiration


Innervation: Upper intercostal nerves
Serratus posterior inferior:

Action: Depresses ribs 9-12 ; involved with expiration


Innervation: Lower intercostal nerves

Deep muscles :

Semispinalis The semispinalis muscles include three groups: the capitis, cervicis,
and thoracis.
Multifidus The multifidus muscle can be implicated in lower back pain and
originates on the sacrum/ilium and inserts onto the vertebrae of the lumbar region.
Rotators Small muscles running from the transverse processes of the spine to the
spinous process of vertebrae 1-2 segments above.

74
Back: Muscles-Deep

Interspinales These muscles form connections between neighboring spinous


processes and shortening of the fibers causes extension of the spine.
Intertransversari These muscles form connections between neighboring transverse
processes and shortening of the fibers causes lateral flexion (side-bending).
Levatores costarum These muscles includes the levator longus and brevis.
Splenius capitis The muscle runs from the nuchal line to the spinous processes of
C7 and upper thoracic spine; actions include extension, rotation, and side-bending of
the head.

Note: These muscles are involved in minor movements of the vertebral column and are less
high yield muscles for board examinations.

75
Back: Muscles-Superficial

USMLE Step 1 > Basic Sciences > Anatomy > Back & Thorax

Back: MusclesSuperficial
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The superficial back consists of 5 muscles: 2 superficial and 3 deep muscles.

The two superficial back muscles are the trapezius and latissimus dorsi.

The three deep back muscles are the levator scapula, rhomboid major, and rhomboid
minor.

All of the deep group muscles are located on the dorsum by the scapula so they are
dorsal scapular in location. Conveniently, the neurovascular supply of these three
muscles is the dorsal scapular nerve, artery, and vein.

Trapezius :

The trapezius is innervated by the spinal accessory nerve (CN XI) and perfused by the
transverse cervical artery and vein.

Action: Most of the scapular movements, including elevation, retraction, and rotation
; the exceptions are protraction and internal rotation. The trapezius muscle originates
on the medial plane of the vertebrae and inserts on the lateral 1/3 of the clavicle and
spine of the scapula.

Clinical Correlate: Damage to CN XI can be tested by asking the patient to shrug their
shoulders against resistance.

76
Back: Muscles-Superficial

Back and neck muscles - SCM, splenius capitus and cervicis, levator scapulae, rhomboids,
trapezius

77
Back: Muscles-Superficial

Trapezius muscle (red)

Image Credit: Gray's Anatomy

Latissimus dorsi :

The latissimus dorsi muscle attaches to the thoracodorsal fascia proximally and the
intertubercular groove distally.

Innervation and blood supply: Thoracodorsal nerve, artery, and vein


Action: Extension, adduction, and medial rotation of the arm Clinical Correlate: The
thoracodorsal nerve travels with parts of the axillary lymph nodes and is at risk during
partial or complete removal of the breast (mastectomy) for cancer treatment. Patients

78
Back: Muscles-Superficial

complain of being unable to pull doors open when this nerve is damaged, as it
innervates the latissimus dorsi.

back, supf and deep back mm - trap, lat, rhomboids, levator scapulae

79
Back: Muscles-Superficial

Latissimus dorsi muscle (red)

Image Credit: CC by-SA 3.0

Levator scapulae :

The levator scapulae attaches to the spine of the cervical vertebrae proximally and the
superior angle of the scapula distally.

Innervation and blood supply: Like the rhomboids, the levator scapulae receives its
innervation and blood supply from the dorsal scapular nerve, artery and vein.
Action: Elevate the scapula

Note: The trapezius is more important for elevation of the scapula.

80
Back: Muscles-Superficial

Back and neck muscles - SCM, splenius capitus and cervicis, levator scapulae, rhomboids,
trapezius

81
Back: Muscles-Superficial

Levator scapulae muscle (red)

Image Credit: Gray's Anatomy

Rhomboids :

The rhomboid major and minor attach to the spines of the thoracic vertebrae proximally and
the medial scapula. The minor is superior to the major, so major holds up minor.

Innervation and blood supply: Dorsal scapular nerve, artery, and vein
Action: Both the major and the minor retract the scapula (along with the trapezius).

82
Back: Muscles-Superficial

Note: The rhomboids are referred to as the military muscles because with the scapula
retracted, you are standing at attention.

Back and neck muscles - SCM, splenius capitus and cervicis, levator scapulae, rhomboids,
trapezius

83
Back: Muscles-Superficial

Rhomboid major and minor muscles (red)

Image Credit: Gray's Anatomy

84
Back: Vertebral Column - Cervical

USMLE Step 1 > Basic Sciences > Anatomy > Back & Thorax

Back: Vertebral Column - Cervical


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The 7 cervical vertebrae are the smallest and have the greatest motion of any vertebrae in
the body.

The cervical vertebrae are distinguished by bilateral transverse foramina and sometimes
by a bifid spinous processes (at the C2-C6 level). The transverse foramina allow for the
passage of the vertebral artery.

Out of the 7 cervical vertebrae, 2 are atypical and dont have an intervertebral disk. These
vertebrae are atlas (C1) and axis (C2).

Atlas (C1) doesnt have a vertebral body or a spinous process and it is helpful to think of it
as a ring. Its vertebral canal transmits veins and fatty tissue, the spinal cord, and the dens
(odontoid process) of axis (C2). This dens or odontoid process of axis (C2) goes in and
above atlas (C1) to rotate. Think of the dens as a finger going through the ring, which is atlas
(C1).

Although atlas (C1) is technically the first vertebrae, the most cranial process on a
midsaggital CT scan is usually the dens (odontoid process) of the axis (C2) anterior to the
cord itself.

The dens is a common site of axis (C2) fractures but does not displace against cord
because it is restricted by the transverse ligament of atlas (C1).

The spinous process of C7 is the largest and is called the vertebra prominens. It forms
the visible protrusion at the posterior surface of the neck.

85
Back: Vertebral Column - Cervical

The second cervical vertebra, or axis.

The first cervical vertebra, or atlas.

The skull, atlas, and axis make up two joints:

Atlanto-occipital joint
Atlanto-dental (atlanto-axial) joint The atlanto-occipital joint is what allows you to
nod your head and give the OK. It is formed by the articulation between atlas and the
occipital condyles. The atlanto-occipital membranes limit excessive movements at this
joint.

The atlanto-dental joint is when you turn your head side to side to say no or deny. It is
formed by the articulation between the atlas and the axis. The alar ligaments limit
excessive movement at this joint.

86
Back: Vertebral Column - Cervical

Mnemonic: You O K with the O ccipital and D eny with the D ental joints. Atlantoaxial
dislocation is a rupture of the transverse (sometimes called cruciform) ligament due to
trauma, rheumatoid arthritis, or Down syndrome, placing the cervical spinal cord and
medulla at risk. Other than the space between C1 and C2 (atlas and axis), the rest of the
cervical vertebrae have an intervertebral disk between them.

Cervical spinal nerves exit via the intervertebral foramina. Cervical spinal nerves for
each cervical spine travel ABOVE the vertebrae with the same number. For example, C3
spinal nerve travels between C2 and C3. The only exception to this rule is C8 spinal nerve,
which actually travels between C7 and T1. This is because there are only 7 cervical
vertebrae.

Clinical Correlate: A herniated disc/herniated nucleus pulposus (HNP) or an osteophyte


between C5 and C6 compresses C6 spinal nerve.

Clinical Correlates:

Cervical osteophytes are bone spurs that grow on any of the 7 vertebrae in the
cervical spine and can put nerve roots at risk. They typically occur when ligaments and
tendons around the bones are inflamed and other instances such as cervical
osteoarthritis where the joints of the neck degrade. Cervical osteophytes tend to occur
in the elderly.
Hyperextension of the neck (whiplash) commonly occurs in motor vehicle accidents. It
stretches the anterior longitudinal ligament and injures the cervical vertebrae (most
commonly C4-C5 or C5-C6 ).
Cervical fractures can occur with anything involving heavy collisions, including falls
and sports. Fractures at the cranial junction, atlas or axis are the most fatal while
fractures at the C6 or C7 level are the most common due to cervical lordosis.

Rheumatoid arthritis can cause C1 and C2 instability and can be seen on a cervical
spine radiograph.

87
Back: Vertebral Column-Lumbar & Sacral

USMLE Step 1 > Basic Sciences > Anatomy > Back & Thorax

Back: Vertebral ColumnLumbar & Sacral


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There are 5 lumbar vertebrae :

The lumbar vertebrae have larger bodies but smaller spinous processes than those of
thoracic vertebrae.

The superior and inferior articular processes of the lumbar vertebrae lie in a sagittal plane
and thus the lumbar vertebrae can flex and extend, laterally flex, but have limited
rotation.

The inferior articular process of L5 and the superior articular process of S1 are placed
coronally to prevent spondylolisthesis of L5 (see below).

Due to the large weight bearing load, the lumbar region is the most common region for
spondylosis and spondylolisthesis.

Spondylosis : Spondylosis is a degenerative osteoarthritis of the vertebrae with nodular


bone formation. It frequently causes narrowing of the intervertebral foramen and
compression of exiting spinal nerves.

Spondylolisthesis : Spondylolisthesis is anterior (forward) displacement of the vertebrae in


relation to adjacent vertebrae. L4-L5 and L5-S1 are very commonly involved.

For additional information on vertebral ligaments please see: Back: Vertebral Column
Vertebral Ligaments

For additional information on lumbar puncture and the spinal meninges please see: Spinal
Meninges

88
Back: Vertebral Column-Lumbar & Sacral

Lumbar vertebra.

Lumbar vertebra.

89
Back: Vertebral Column-Lumbar & Sacral

Vertebral articulations.

Lateral X-Ray showing severe spondylolisthesis.

90
Back: Vertebral Column-Lumbar & Sacral

Lateral X-Ray showing spondylosis.

The sacrum is a triangular bone formed by 5 fused sacral vertebrae :

Promontory : The promontory of the sacrum is the superior anterior lip of S1.
Alae : The alae of the sacrum are broad flat anterolateral surfaces on either side of S1.
Auricular surface : The auricular surfaces of the sacrum are lateral "ear-shaped"
articulating regions of the sacrum that form the sacroiliac joint.
Sacral canal : The sacral canal is a central canal that carries the dorsal and ventral
spinal roots of S1-S5 and C1 (coccygeal 1).
Sacral foramina : The sacral foraminae are 4 pairs of ventral and dorsal foramina that
allow the ventral and dorsal rami of S1-S4 to exit.

91
Back: Vertebral Column-Lumbar & Sacral

Sacrum.

92
Back: Vertebral Column-Lumbar & Sacral

Posterior sacrum.

Sacroiliac articulations.

93
Back: Vertebral Column-Lumbar & Sacral

Sacroiliac joint - anterior view.

94
Back: Vertebral Column-Lumbar & Sacral

Sacroiliac joint - posterior view.

95
Back: Vertebral Column-Lumbar & Sacral

Sacroiliac joint - anterior view.

96
Back: Vertebral Column-Overview

USMLE Step 1 > Basic Sciences > Anatomy > Back & Thorax

Back: Vertebral ColumnOverview


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The vertebral column consists of 33 vertebrae:

7 cervical
12 thoracic
5 lumbar
5 sacral (fused)
4 coccygeal (fused)
Scoliosis is an abnormal lateral sidebending and rotation of the spine. The posterior
surface of the vertebral body, together with the two lateral pedicles and connecting
lamina forming the U shaped vertebral arch, make up the boundaries of the vertebral
foramen. Collectively, the vertebral foramina form the vertebral canal that contains the
spinal cord and meninges.

Spinous process : A spinous process is a prominent posterior projection that arises


from the midpoint of the two laminae. Cervical and lumbar vertebrae curve with
convexity anteriorly and concavity posteriorly, which is called lordosis. Thoracic and
saccrococcygeal vertebrae curve with concavity anteriorly and convexity posteriorly, or
kyphosis.

Obesity, pregnancy, or a congenital anomaly can lead to excessive L umbar L ordosis.

Superior articular process : The superior articular processes are two articulating
process that project from the superior part of the junction of each pedicle and lamina;
these articulate with the inferior articulating processes of the vertebra above.
Inferior articular process : The inferior articular processes are two articulating
processes that project from the inferior part of the junction of each pedicle and lamina;
these articulate with the superior articulating processes of the vertebra below.

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Back: Vertebral Column-Overview

Typical thoracic vertebra.

Typical thoracic vertebra

98
Back: Vertebral Column-Overview

Vertebral Column.

Generally a vertebra contains:

Body : The body is the anterior cylindrical weight bearing part. Loss of bone density,
which can occur with osteoporosis, causes vertebral body compression fractures.
Vertebral arch : The left and right pedicles extend posteriorly from the body and
continue as L/R laminae past the L/R transverse processes to join medially at the
spinous process forming the U shape.

99
Back: Vertebral Column-Overview

100
Back: Vertebral Column-Overview

Posterolateral view of vertebrae.

There are 7 vertebral processes that come off of the vertebral arch:

2 transverse processes (left and right)


4 articular processes (left and right superior/inferior)
1 spinous process

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Back: Vertebral Column-Overview

These articular processes interconnect adjacent vertebral arches, making zygapophyseal or


Z joints. Inside the vertebral foramina is the vertebral canal, which contains the spinal cord
and meninges.

Spinous process : The spinous process is a prominent posterior projection that arises
from the midpoint of the two laminae.
Transverse process : The transverse processes are two laterally projecting processes
that arise at the junction of each pedicle and lamina.
Superior articular process : The superior articular processes are two articulating
process that project from the superior part of the junction of each pedicle and lamina.
These articulate with the inferior articulating processes of the vertebra above.
Inferior articular process : The inferior articular processes are two articulating
processes that project from the inferior part of the junction of each pedicle and lamina.
These articulate with the superior articulating processes of the vertebra below.
Intervertebral foramen : The intervertebral foramina are lateral openings between two
adjacent vertebrae where spinal nerves exit. Note: Intervertebral foramina increases
in size from cervical to lumbar.

Intervertebral discs are formed by an outer fibrocartilaginous part called the annulus
fibrosus and an inner aqueous portion called the nucleus pulposus. The nucleus
pulposus is the only embryological remnant of the notocord.

In a herniated disc or herniated nucleus pulposus (HNP), the annulus fibrosus


undergoes degeneration and tears, allowing the nucleus pulposus to herniate out and
impinge adjacent structures.

The intervertebral discs account for nearly 25% of the vertebral column length. In
older patients, dehydration and degeneration of the nucleus pulposus accounts for a
significant loss in height as a part of aging. Herniated nucleus pulposus (HNP) is usually
on the posterolateral side because the posterior longitudinal ligament is incomplete laterally.
The most common HNP sites are in the lower lumbar area, most commonly at L4-L5 and
L5-S1. Sciatica, or irritation of the sciatic nerve, results from a L5-S1 disk herniation.

102
Back: Vertebral Column-Thoracic

USMLE Step 1 > Basic Sciences > Anatomy > Back & Thorax

Back: Vertebral ColumnThoracic


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There are 12 thoracic vertebrae with ribs classified as typical or atypical.

Typical Ribs: Ribs 3-9

There are costal facets on the posterolateral borders of thoracic vertebral bodies where the
heads of ribs articulate. Vertebrae have superior and inferior costal facets, also called demi-
facets.

Ribs articulate with both the vertebral bodies of their segmental origin and the
adjacent superior vertebrae.

Articulation is with the superior costal facet of the same number and the inferior costal facet
of the vertebra one level superior. The transverse costal facet at the end of the transverse
process articulates with the tubercle of its own rib. Thoracic vertebrae have large, downward
pointing spinous processes, a feature that helps in differentiating thoracic vertebrae from
cervical and lumbar vertebrae.

The transverse processes have costal facets that articulate with ribs of the same segmental
origin.

The thoracic vertebrae do NOT have a large range of motion due to restriction by the ribs.

A herniated disc in the thoracic vertebrae is the least likely of the 3 possible anatomic
locations (cervical, thoracic, lumbar) due to the restricted mobility.

Atypical Ribs: 1, 2, 10-12

Rib 1 : The shortest and most flat rib, rib 1 forms the bony structure of the thoracic inlet
(superior thoracic aperture). It has a single articular facet that articulates solely with T1.
There are two eminences for the attachment of the anterior and middle scalene
muscles. A groove runs between the attachments sites for the subclavian artery and
vein.

Rib 2 : Similar to the typical ribs, rib 2 has two articular facets that connect with T1 and
T2. However, the shape and curvature of the rib is more analogous to rib 1 but longer.
There are two eminences for the attachment of the posterior scalene and serratus

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Back: Vertebral Column-Thoracic

anterior muscles.

Rib 10 : Has a single articular facet that articulates only with T10.

Rib 11 and 12 : Do not have a neck or tubercle and articulate only with their single
corresponding vertebra (T11 or T12). True ribs : Anteriorly attach directly to the
sternum ribs 1-7

False ribs : Anteriorly attach to the costal cartilage of the vertebrae one level above (NOT
the sternum) ribs 8-10

Floating ribs : Have NO anterior attachment to the sternum or costal cartilage ribs 11
and 12

Thoracic vertebra.

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Back: Vertebral Column-Thoracic

Radiograph with labeled rib number.

105
Back: Vertebral Column-Thoracic

Articulation of thoracic vertebrae.

Thoracic vertebra, superior view.

106
Back: Vertebral Column-Thoracic

Rib articulations.

Vertebral articulations.

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Back: Vertebral Column-Thoracic

Thoracic cage with numerically labeled ribs.

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Back: Vertebral Column-Thoracic

Thoracic cage. Note the attachment of ribs 8-10 to the costal cartilage of the rib above.

109
Back: Vertebral Column-Vertebral Ligaments

USMLE Step 1 > Basic Sciences > Anatomy > Back & Thorax

Back: Vertebral ColumnVertebral


Ligaments
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There are several important vertebral ligaments that protect the vertebral column against
improper movement and dislocation (see specific ligaments below).

Supraspinous ligament : The supraspinous ligament runs the entire length of the vertebral
column on the tips of the spinous processes. Superiorly, it becomes the nuchal ligament
which extends from C7 to the external occipital protuberance on the skull and separates the
posterior neck muscles on either side. Interspinous ligament : The interspinous ligament
runs longitudinally between adjacent spinous processes. Ligamentum flavum : The
ligamentum flavum is a paired yellowish ligament on either side of each vertebra that
connects the adjacent vertebral lamina from top to bottom. Superiorly, the ligamentum
flavum forms the posterior atlanto-occipital membrane.

Piercing of the ligamentum flavum corresponds to the first "pop" heard when
performing a lumbar puncture. Anterior longitudinal ligament : The anterior longitudinal
ligament runs the entire length of the vertebral column along the anterior surface of the
vertebral bodies and prevents dislocation of the vertebral bodies and hyperextension of
the spine. Posterior longitudinal ligament : The posterior longitudinal ligament runs the
entire length of the vertebral column on the posterior surface of the vertebral bodies (inside
the vertebral canal). It prevents dislocation/herniation of the vertebral bodies and
intervertebral discs and hyperflexion of the spine .

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Back: Vertebral Column-Vertebral Ligaments

Orientation of ligamentum flavum between the vertebral laminae.

Ligaments of the vertebral column.

111
Spinal Meninges

USMLE Step 1 > Basic Sciences > Anatomy > Back & Thorax

Spinal Meninges
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The meninges wrap the brain and spinal cord. From deep to superficial they PAD the brain
and spine:

P ia mater
A rachnoid membrane
D ura mater

Dura mater is the most superficial layer of the meninges. It is composed of tough connective
tissue and is continuous from the cranium to the spinal cord blindly ending at S2.

The epidural space lies between the wall of the vertebral canal and dura mater.

The epidural space contains fat and the internal vertebral venous plexus. The internal
venous plexus serves as a potential route for hematogenous metastasis of cancer to the
brain.

Additionally, it is the site of delivery of epidural anesthesia.

Vertebral venous plexus.

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Spinal Meninges

Vertebral venous plexus.

In living humans, because of CSF flow, the arachnoid membrane sits flush against the dura.

The arachnoid membrane is a thin, translucent membrane deep to and continuous with the
dura.

The subarachnoid space lies between the arachnoid membrane and pia mater and houses
cerebral spinal fluid (CSF).

Lumbar puncture is the withdrawal of CSF from the subarachnoid space. A quick review the
pops felt on an LP:

1st pop Ligamentum flavum


2nd pop Dura mater and arachnoid

Note: The pia mater is not pierced and there is no separate 3rd pop when the arachnoid is
pierced.

The pia mater is a microscopic layer of connective tissue which shrink-wraps the spinal
cord and brain.

In the spinal cord, the pia mater has denticulate ligaments , small thickened extensions of
pia mater extending bilaterally from the spinal cord, piercing the arachnoid and attaching to
the dura.

113
Thorax: Anterior Wall

USMLE Step 1 > Basic Sciences > Anatomy > Back & Thorax

Thorax: Anterior Wall


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The ribs are classified as true or false ribs based on their articulations.

True ribs: Ribs 1-7 are true ribs because their costal cartilage articulates directly with
the sternum or manubrium.
False ribs: Ribs 8-12 are false ribs as they do NOT articulate with the sternum or
manubrium.
Floating ribs : Ribs 11-12 are called floating ribs because they have no anterior
articulation. Posteriorly, all ribs articulate with thoracic vertebra.

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Thorax: Anterior Wall

Anatomy of the posterior rib cage

Image Credit: Gray's Anatomy

116
Thorax: Anterior Wall

Anatomy of the anterior rib cage

Image Credit: Gray's Anatomy

The pectoral muscles attach to the thorax and act on the upper limb.

Pectoralis major :

Action: Adduction, medial rotation, flexion of the humerus at the shoulder joint
Innervation: Medial and lateral pectoral nerves , which are branches of the brachial
plexus Pectoralis minor :

The pectoralis minor is one of the three muscles that attach to the coracoid process
(coracobrachialis and short head of biceps brachii are the other two).

Action: Depress the tip of the shoulder and protraction (punching forward) of the
scapula

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Thorax: Anterior Wall

Innervation: Medial pectoral nerve (C8-T1)

Pectoralis major muscle (red)

Image Credit: Gray's Anatomy

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Thorax: Anterior Wall

Pectoralis minor muscle

Image Credit: CC by-SA 3.0

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Thorax: Anterior Wall

Serratus anterior muscle

Image Credit: CC by-SA 3.0

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Thorax: Anterior Wall

Pectoral region and axilla. A. Thoracoappendicular muscles. Anterior view. B. Pectoralis


minor and subclavius. Anterior view. C. Serratus anterior and subscapularis. Lateral view.
Inset, scapular attachments of the subscapularis (red) and serratus anterior (blue).

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Thorax: Anterior Wall

Pectoral region and anterior abdominal wall - pec major, serratus anterior, external
intercostals, rectus abdominis

The breasts are glandular tissues that lie within the fat of the superficial pectoral fascia.

Superficial anatomy : The nipple is surrounded by an area of darker skin called the areola.
Internal anatomy : Suspensory ligaments aka Coopers ligaments radiate outwards
from nipple and separate the breast into lobes , each of which drains into a lactiferous duct.
Breast lymphatics :

Outer (lateral) half of the breast axillary lymph nodes


Inner (medial) half of the breast parasternal lymph nodes

Clinical Correlate: The blockage of lymph channels as a result of inflammatory breast


cancer can cause " peau d'orange." The skin appears pitted and dimpled, like the skin
of an orange peel, due to invasion of local lymph channels resulting in lymph
edema. Cooper's ligaments and sweat ducts tether to the skin and provide the inwards
pull that allows the dimpling in concert with the lymph edema, which is responsible for
the swelling. Clinical Correlate: The majority of breast cancers occur in the upper
outer (superior lateral) quadrant and metastasize to axillary lymph nodes.

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Thorax: Anterior Wall

Anatomy of the breast

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Thorax: Anterior Wall

Anatomy of the female breast

Image Credit: Adapted from P. Lynch, medical illustrator CC by-SA 3.0

The intercostal muscles contract to pull adjacent ribs together and assist in active
respiration.

External intercostals : The external intercostals are involved in active inspiration, such as
during exercise. Internal and innermost intercostals : The internal and innermost
intercostals are involved in active expiration. All intercostal muscles are innervated by
intercostal nerves.

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Thorax: Anterior Wall

Intercostal muscles.

Pectoral region and anterior abdominal wall - pec major, serratus anterior, external
intercostals, rectus abdominis

125
Thorax: Anterior Wall

Pectoral region and axilla. A. Thoracoappendicular muscles. Anterior view. B. Pectoralis


minor and subclavius. Anterior view. C. Serratus anterior and subscapularis. Lateral view.
Inset, scapular attachments of the subscapularis (red) and serratus anterior (blue).

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Thorax: Anterior Wall

Intercostal muscles and innervation.

The thoracic cage is supplied by intercostal arteries.

Anterior intercostal arteries : The first 6 anterior intercostal arteries are direct branches of
the internal thoracic artery , which is a branch of the subclavian artery.

Around the 6th rib, the internal thoracic artery divides into the superior epigastric and
musculophrenic arteries.

The musculophrenic artery gives rise to the lower 3 anterior intercostal arteries then
proceeds inferiorly. Posterior intercostal arteries : The first two posterior intercostal
arteries are branches of the supreme intercostal artery and the remaining 9 arise directly
from the thoracic aorta.

127
Thorax: Heart-Coronary Arteries & Cardiac Veins

USMLE Step 1 > Basic Sciences > Anatomy > Back & Thorax

Thorax: HeartCoronary Arteries &


Cardiac Veins
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Left coronary artery (LCA): The left coronary artery (LCA) originates within the sinus of the
left aortic cusp and is supplied by the ascending aorta.

The LCA travels anteriorly between the left auricle and the pulmonary trunk; it gives rise to
both the left anterior descending artery (LAD), also known as the anterior
interventricular artery, and the circumflex arteries.

Left anterior descending (LAD) (anterior interventricular artery) The LAD passes
within the anterior interventricular sulcus toward the apex.
Circumflex artery The circumflex artery wraps around the left border of the heart
within the coronary sulcus.

Veins of the heart primarily drain to the coronary sinus , which empties directly into the right
atrium

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Thorax: Heart-Coronary Arteries & Cardiac Veins

Coronary veins, posterior view

129
Thorax: Heart-Coronary Arteries & Cardiac Veins

Coronary blood supply, posterior view

Great cardiac vein: The great cardiac vein originates in the anterior interventricular sulcus;
travels first with the left anterior descending artery (LAD) and then alongside the left
circumflex artery (LCX).

Middle cardiac vein: The middle cardiac vein ascends in the posterior interventricular
sulcus with the posterior interventricular artery.

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Thorax: Heart-Coronary Arteries & Cardiac Veins

Coronary veins, posterior view.

131
Thorax: Heart-Coronary Arteries & Cardiac Veins

Coronary blood supply, posterior view.

Small cardiac vein: The small cardiac vein runs alongside the right marginal artery before
traveling posteriorly in the right coronary sulcus with the right coronary artery ; drains into
the coronary sinus near its junction with the right atrium.

Anterior cardiac veins: The anterior cardiac veins originate on the anterior wall of the
right ventricle , cross the coronary sulcus, and drain into the right atrium.

Smallest (thebesian) veins:

The smallest (thebesian) veins are found in the walls of myocardium of the 4 chambers of
the heart; drain directly into the chambers.

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Thorax: Heart-Coronary Arteries & Cardiac Veins

Note: The small veins are also referred to as venae cordis minimae.

Atrioventricular nodal artery The atrioventricular nodal artery supplies the AV


node (90% of patients AV nodal artery, 10% LCX). The artery that supplies the PDA is
the structure that determines coronary dominance :

Right dominant PDA is supplied by the RCA (85% of population)

Left dominant PDA is supplied by the LCX (8% of population)


Co-dominant PDA is supplied by both the RCA and LCX (7% of population) The
RCA travels in the coronary sulcus between RA and RV and passes around right border
of heart between the posterior and diaphragmatic surfaces.

The RCA gives rise to the 4 branches below :

Right marginal branch The right marginal branch arises from the RCA before it
crosses the right border of the heart and travels along the acute margin just superior to
the inferior border (see image); supplies the right ventricle.
Sinoatrial nodal artery (60% from proximal RCA, 40% from left circumflex artery
(LCX)) The sinoatrial nodal artery has a variable course of travel and can encircle the
SVC either posteriorly or anteriorly; during posterior circling, the artery travels left of the
SVC, circles around the posterior aspect of the vessel, and emerges anteriorly on the
right side of the SVC to supply the SA node.
Posterior descending artery (PDA) The posterior descending artery is also known
as the posterior interventricular artery (PIV), emerges from the RCA after leaving the
coronary sulcus and descends toward the apex of the heart (70% of population). Right
coronary artery (RCA): The right coronary artery (RCA) originates within the sinus of
the right aortic cusp and is supplied by the ascending aorta.

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Thorax: Heart-Coronary Arteries & Cardiac Veins

Coronary arteries and cardiac veins.

134
Thorax: Heart-Coronary Arteries & Cardiac Veins

Coronary blood supply, posterior view.

135
Thorax: Heart-Coronary Arteries & Cardiac Veins

Coronary arteries.

136
Thorax: Heart-External Anatomy

USMLE Step 1 > Basic Sciences > Anatomy > Back & Thorax

Thorax: HeartExternal Anatomy


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Diaphragmatic (inferior) surface: The diaphragmatic (inferior) surface of the heart is


comprised by 2/3 of the left ventricle and 1/3 of the right ventricle.

On the external surface of the heart, the ventricles and atria are separated circumferentially
by the coronary sulcus. The structure is also known as the coronary or atrioventricular
groove.

Borders and landmarks:

Apex of the heart : The apex of the heart is approximately 8 cm left of the median
plane in the 5th intercostal space ; formed by the left ventricle.
Base of the heart: The base of the heart is a region where the aorta, pulmonary trunk,
and SVC emerge from the heart; found immediately deep to the sternal angle and the
left and right portions of the 2nd intercostal spaces.
Right border : The right border of the heart is formed by the right atrium.
Left border: The left border of the heart is formed mainly by the left ventricle.
Inferior border : The inferior border of the heart is formed by the right ventricle and a
small portion of the left ventricle near the apex of the heart. The inferior border of
the heart is defined on the external surface of the body by a line that slopes caudally
and to the left through the xiphosternal junction.

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Thorax: Heart-External Anatomy

External anatomy of the heart and relationships with great vessels.

138
Thorax: Heart-External Anatomy

External anatomy of the heart.

Posterior surface :

The posterior surface of the heart is defined by the left atrium and a portion of the right
atrium.

139
Thorax: Heart-External Anatomy

The left atrium and a portion of the right atrium comprise the posterior surface of the heart

140
Thorax: Heart-External Anatomy

The left atrium and a portion of the right atrium comprise the posterior surface of the heart.

141
Thorax: Heart-External Anatomy

Posterior surface of the heart. Comprised of the left atrium and a portion of the right atrium.

Sternocostal (anterior) surface: The sternocostal (anterior) surface is comprised of 2/3


right heart and 1/3 left heart centrally by the RV and by the RA and LV on their
corresponding sides.

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Thorax: Heart-External Anatomy

The sternocostal surface is comprised 2/3 by the right heart and 1/3 by the left ventricle

143
Thorax: Heart-External Anatomy

The sternocostal surface is comprised 2/3 by the right heart and 1/3 by the left ventricle.

144
Thorax: Heart-External Anatomy

The sternocostal surface is comprised 2/3 by the right heart and 1/3 by the left ventricle

145
Thorax: Heart-Internal Anatomy

USMLE Step 1 > Basic Sciences > Anatomy > Back & Thorax

Thorax: HeartInternal Anatomy


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The human heart has four chambers and is composed of two collecting chambers, the
atria, and two pumping chambers, the ventricles.

Right atrium : The right atrium receives deoxygenated blood from the venous circulation.
Sinus venarum : The sinus venarum is the smooth internal portion of the posterior right
atrium in between the two vena cavae and includes the interatrial septum. It is the
incorporated adult remnant of the embryonic sinus venosus. Crista terminalis : The crista
terminalis is the internal muscular ridge that divides the right atrium into the atrium
proper and the vena caval area. Atrium proper: The atria are lined with pectinate
muscles , which are bundle muscle fibers found predominately within the auricle, an ear-
shaped appendage.

Note: Pectinate muscles are also present in the left atrium but are less prominent. Fossa
ovalis: The fossa ovalis is a depression in the interatrial septum and the remnant of
the foramen ovale ; lateral and superior borders form the limbus of the fossa ovalis.

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Thorax: Heart-Internal Anatomy

Internal ventricular anatomy. Note the papillary muscles providing strong support for the
chordae tendinae, which attach to the AV valves.

Right side of the heart.

147
Thorax: Heart-Internal Anatomy

Internal anatomy of the heart. Note the pectinate muscles appearing here using a common
alternative name musculi pectinati.

148
Thorax: Heart-Internal Anatomy

Right side of the heart. Note the pectinate muscles of the right atrium appearing as a
roughened muscular surface.

Right ventricle : The right ventricle pumps blood received from the right atrium to the lungs
via the pulmonary artery. Trabeculae carneae : The trabeculae carneae are thick bundles of
muscle that give the right ventricle its rough texture; thicker than the pectinate muscles of
the atria. Papillary muscle : The papillary muscles are projections of ventricular muscle that
are attached to the cusps of atrioventricular valves via the chordae tendineae preventing
valvular prolapse during systole.

Note: Please see associated image for the relationship of the three structures.
Septomarginal trabeculae (moderator band): The septomarginal trabeculae form the
connecting bridge between the IV septum and the root of the anterior papillary muscle.
Chordae tendinae: The chordae tendinae are fibrous cords that attach the papillary
muscles to the valve cusps; the tension created by contracting papillary muscles and taut

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Thorax: Heart-Internal Anatomy

chordae tendinae prevent the cusps of the AV valve from prolapsing into the atrium as
the ventricle contracts and the pressure on the valve increases. Right atrioventricular
(tricuspid) valve: The right atrioventricular valve is formed by the anterior, posterior, and
septal cusps.

Internal anatomy of the right ventricle. Quiz yourself!

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Thorax: Heart-Internal Anatomy

Internal anatomy of the right ventricle.

151
Thorax: Heart-Internal Anatomy

Internal anatomy of the right side of the heart.

Internal anatomy of the heart.

152
Thorax: Heart-Internal Anatomy

Left atrium : The left atrium receives oxygenated blood from the lungs via the pulmonary
veins. The posterior, smooth-walled portion of the left atrium receives oxygenated blood from
the 4 pulmonary veins.

The left atrium has an auricle with pectinate muscles.

The valve of the foramen ovale is found in the left atrium.

Left ventricle : The left ventricle receives oxygenated blood from the left atrium to pump out
of the heart into the systemic circulation via the aorta. The wall of the left ventricle is
approximately 3x as thick as that of the right ventricle under non-pathological
conditions.

Aortic vestibule (outflow tract): The aortic vestibule is the smooth portion of the left ventricle
immediately proximal to the aortic valve.

The anterior cusp of the mitral valve separates the outflow tract from the inflow tract
(trabeculated tract).

Aortic orifice : The aortic orifice includes the aortic valve and lies posteriorly and to the right
of the pulmonary orifice. Left atrioventricular orifice : The left atrioventricular orifice is
defined by the bicuspid (mitral) valve; located posteriorly and to the left of the aortic orifice
and to the left of the right atrioventricular orifice. Left atrioventricular (bicuspid/mitral)
valve: The mitral valve is composed of anterior and posterior cusps; the anterior and
posterior papillary muscles attach to the cusps via chordae tendinae. Interventricular
septum : The interventricular septum is a thick muscular and thin membranous component;
the muscular septum makes up the inferior portion of the IV septum whereas the
membranous portion makes up the superior portion of the IV septum and is immediately
inferior to the attached margins of the right and non-coronary cusps of the aortic valve.

Skeleton of the heart : Anuli fibrosis: The anuli fibrosis are fibrous rings of connective
tissue that encompass each of the 4 valvular orifices; provide stable attachment sites and
support for the cusps of the valves. Fibrous trigones : The fibrous trigones
are triangular-shaped fibrous connective tissue structures. The left fibrous trigone is between
the annuli fibrosis of the aortic and mitral orifices; the right fibrous trigone is situated
between the annuli fibrosis of the tricuspid, mitral, and aortic orifices.

Note: The fibrous trigones provide structural support for the valves of the heart and are
components of the fibrous skeleton of the heart.

153
Thorax: Pericardial Sac

USMLE Step 1 > Basic Sciences > Anatomy > Back & Thorax

Thorax: Pericardial Sac


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Spaces or sinuses caused by reflections of pericardium:

Transverse pericardial sinus : The transverse pericardial sinus is an anatomical space


within the pericardial cavity posterior to the pulmonary trunk and ascending aorta
but anterior to the superior vena cava.
Oblique pericardial sinus : The oblique pericardial sinus is a space on the posterior
aspect of the left atrium ; it is formed by reflections of pericardium from where the IVC,
SVC, and pulmonary veins enter into the heart. The right border is formed by the IVC
and right pulmonary veins and the left border is formed by the left pulmonary veins.

Pericardium : The pericardium is double-walled sac that encloses the heart and great
vessel roots.

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Thorax: Pericardial Sac

156
Thorax: Pericardial Sac

There are two layers of the pericardium:

Outer fibrous pericardium


Inner serous pericardium

Note: See below for detailed description.

157
Thorax: Pericardial Sac

The Heart Wall. The parietal and visceral layers comprise the serous pericardium. The
parietal layer resides in between the fibrous pericardium and visceral layer of the serous
pericardium. The visceral layer forms the epicardium on the external surface of the heart and
is the innermost layer of the pericardium.

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Thorax: Pericardial Sac

Pericardium. Note the fibrous pericardium, the outermost layer of the pericardium. It blends
with the adventitia of the the vessels entering and exiting the heart and attaches to the
diaphragm.

159
Thorax: Pericardial Sac

160
Thorax: Pericardial Sac

161
Thorax: Pericardial Sac

Fibrous pericardium :

The fibrous pericardium is a strong external layer that limits the expansion of the
pericardial cavity ; it is continuous with the adventitia that surrounds the great vessels
entering and exiting the heart.

It is fused to the diaphragm on its inferior surface and is anchored to the sternum by
connective tissue called the sternopericardial ligaments.

Serous pericardium :

Parietal layer : The parietal layer forms the inner layer of the fibrous pericardium and is
the most external layer of the serous pericardum; it is fused to the fibrous pericardium,
which is external to the parietal layer.

162
Thorax: Pericardial Sac

Visceral layer (epicardium): The visceral layer covers the external surface of the heart
itself and is the innermost layer of the pericardium deep to the parietal layer and fibrous
pericardium.

163
Thorax: The Mediastinum

USMLE Step 1 > Basic Sciences > Anatomy > Back & Thorax

Thorax: The Mediastinum


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The superior mediastinum :

The superior mediastinum is bounded inferiorly by the invisible plane from sternal angle to
T4-T5 bodies. Its contents can be remembered with the mnemonic:

The VAST TET on mountains of Wyoming.

V agus
A ortic arch
S VC
T rachea
T horacic duct
E sophagus
T hymus

The phrenic nerve and left recurrent laryngeal nerve also resides in the superior
mediastinum. Branches of the aorta: ABCS :

A orta
B rachiocephalic trunk Gives rise to the right common carotid and right subclavian
C ommon carotid (left)
S ubclavian artery (left) Important relationships:

The aorta curves over the left bronchus and pulmonary artery like an arm over a
shoulder.

The azygos does the same to the right pulmonary artery. Clinical Correlate: The
ligamentum arteriosum connects the left pulmonary artery to the aorta, and a car
accident can cause transection of the aorta at this attachment.

Clinical Correlate: The left recurrent laryngeal nerve is a branch off the left vagus and
hooks under the aorta. Mediastinal pathology or trauma to the region can cause
hoarseness due to its action of supplying the intrinsic muscles of the larynx.

The posterior mediastinum :

164
Thorax: The Mediastinum

The posterior mediastinum, a division of the inferior mediastinum, is found behind the heart
and in front of the vertebrae, down to diaphragm. It contains the esophagus, thoracic
aorta, and the thoracic duct.

Other (less important) structures include the azygos and hemiazygos veins and the vagus
nerves.

Clinical Correlate: Changes to the mediastinum seen on imaging may indicate a pathological
process.

A shifted mediastinum Abnormal change pleural cavity pressure, commonly due to


space occupying lesions or a tension pneumothorax
A widened mediastinum can be due to:

Aortic dissection
_Bacillus anthracis _infection
Retropharyngeal abscess in the danger space
Thoracic surgery
Esophageal perforation
A mediastinoscopy is used to determine etiology of lymphadenopathy Hodgkins
lymphoma, lung cancer, TB, or sarcoidosis (bilateral hilar lymphadenopathy)

The mediastinum is the central cavity of the thorax between the two pleural cavities. It
contains the heart and associated vessels, as well as vessels that pass from the neck down
through the diaphragm.

Note: Knowing the divisions of the mediastinum is clinically important as certain tumors
reside only in specific divisions of the mediastinum. Compartmentalizing the mediastinum is
also important for radiological imaging.

165
Thorax: The Mediastinum

Axial view of the mediastinum

Image Credit: Gray's Anatomy

166
Thorax: The Mediastinum

X-ray (PA chest) - anatomy of thoracic radiographic structures purposefully unlabeled -- test
yourself!

167
Thorax: The Mediastinum

X-ray (lateral chest) - anatomy - thoracic radiographic structures labeled:

1, trachea; 2, r. upper lobe bronchus; 3, l. upper lobe bronchus; 4, r. pulmonary artery; 5, l.


pulmonary artery; 6, inferior vena cava; 7, ascending aorta

168
Thorax: The Mediastinum

X-ray (lateral chest) - anatomy of thoracic radiographic structures purposefully unlabeled --


test yourself!

169
Thorax: The Mediastinum

The mediastinum.

170
Thorax: The Mediastinum

X-ray (PA chest) - anatomy - thoracic radiographic structures labeled:

1, first rib; 2, upper portion of manubrium; 3, trachea; 4, r. main bronchus; 5, l. main


bronchus; 6, main pulmonary a.; 7, l. pulmonary a.; 8, r. interlobar pulmonary a.; 9, r.
pulmonary v.; 10, aortic arch

The mediastinum has 2 major divisions, which include superior and inferior.

The inferior mediastinum is sub-divided into:

Anterior mediastinum
Middle mediastinum
Posterior mediastinum

The anterior mediastinum :

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Thorax: The Mediastinum

The anterior mediastinum, a division of the inferior mediastinum, is located between the
pericardium and the sternum. It contains parasternal lymph nodes, sternopericardial
ligaments, remnants of the thymus gland, and the internal thoracic vessels.

Divisions of the mediastinum.

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Thorax: The Mediastinum

Divisions of the mediastinum.

The middle mediastinum :

The middle mediastinum, a division of the inferior mediastinum, contains the heart and
pericardium. It also contains the ascending aorta, the bifurcation of the trachea and 2
bronchi, the pulmonary arteries and veins, and the phrenic nerves.

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Thorax: Vasculature

USMLE Step 1 > Basic Sciences > Anatomy > Back & Thorax

Thorax: Vasculature
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Aortic arch :

The branches of the aortic arch provide blood supply to the head, neck and upper limbs. The
first branch is the brachiocephalic artery , which immediately branches into the right
common carotid and right subclavian arteries to supply the right arm, neck and head.

The second branch is the left common carotid artery , which supplies the left side of the
neck and head.

The third branch is the left subclavian artery which primarily supplies the left arm.

Both the right and left subclavian arteries give off multiple branches that enter and supply
the neck region.

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Thorax: Vasculature

Anterior view of the vasculature of the thoracic cavity.

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Thorax: Vasculature

Branches of the aortic arch

Image Credit: Adapted from Gray's Anatomy

Pulmonary arteries :

The pulmonary arteries are branches of the pulmonary trunk and carry deoxygenated blood
to the lungs. The right pulmonary artery is longer than the left and enters the hilum of the
right lung between the right pulmonary vein and intermediate bronchus.

The shorter left pulmonary artery enters the hilum of the left lung posterior to the left
pulmonary vein and superior to the left primary bronchus.

The left pulmonary artery is attached to the aortic arch by the ligamentum arteriosum a
fibrous remnant of the ductus arteriosus.

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Thorax: Vasculature

The relationship of the pulmonary artery to the bronchus can be remembered with the
mnemonic: RALS

R ight A nterior (right pulmonary artery is anterior to right intermediate bronchus )


L eft S uperior (left pulmonary artery is superior to the left principal bronchus )

Pulmonary veins :

The pulmonary veins carry oxygenated blood and enter the left atrium. There are two right
and two left pulmonary veins.

Similar to the arteries, the right pulmonary veins are longer than the left.

The internal thoracic (mammary) artery:

The internal thoracic (mammary) artery is the first caudal branch of the subclavian artery and
runs inferiorly along the internal surface of the anterior thoracic wall. At the level of the
6th intercostal space the internal thoracic artery branches into the musculophrenic and
superior epigastric arteries.

The descending thoracic aorta is the distal continuation of the aortic arch.

The thoracic aorta courses inferiorly along the thoracic vertebral bodies.

At the level of T12, it penetrates the diaphragm via the aortic hiatus and becomes the
abdominal aorta.

In addition to the posterior intercostal arteries , the thoracic aorta also gives rise to
bronchial, esophageal, and tracheal arteries which supply their respective structures.

177
Cranial Meninges & Dural Sinuses

USMLE Step 1 > Basic Sciences > Anatomy > Head & Neck

Cranial Meninges & Dural Sinuses


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The meninges are composed of 3 superimposed layers making up the 3 mothers:

The Tough Mother


The Spider Mother
The Tender Mother The tough mother is the dura mater.

The dura mater is the superficial dense tissue made up of 2 layers:

Periosteal layer Attaches to the intracranial surface of the skull


Deep meningeal layer Forms the dural partitions The falx cerebri is a partition
between the cerebral hemispheres and is formed by the continuation of the deep
meningeal layers of the dura.

Other examples of partitions include the:

Tentorium cerebelli : separates the cerebellum from the cerebrum


Falx cerebelli : separates the cerebellar hemispheres Unlike in the spinal cord,
epidural space is a potential space in the cranium. It is a potential space because it
houses the middle meningeal arteries and rupture of these arteries in, for example
epidural hematoma, would make it a real space. The subdural space is also a potential
space.

The spider mother is the arachnoid mater which is a membranous tissue (spider webs) that
is deep to the dura.

Arachnoid granulations are sites where CSF is reabsorbed into the venous system.
The subarachnoid space is the only real space in the meninges of the cranium and it
contains cerebrospinal fluid.

The tender mother is the one closest to the brain, the pia mater. It is a thin membrane that
covers the surface of the brain.

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Cranial Meninges & Dural Sinuses

Cranial meninges showing the arachnoid granulation, site of CSF resorption

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Cranial Meninges & Dural Sinuses

Anatomy of the dural venous sinuses and meninges

The cranial meninges.

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Cranial Meninges & Dural Sinuses

Diagram of the cranial meninges

Image Credit: NIH

The middle meningeal artery (a branch of the maxillary artery) supplies the majority of
the supratentorial cranial dura. It is important to note than many other arteries supply the
dura, but the middle meningeal provides significant supply and it's relationship to the dura is
clinically relevant (see below).

Rupture of the middle meningeal artery from head trauma produces an epidural
hematoma , which appears as "lens" shaped (biconvex) on imaging. Epidural hematomas
do not cross suture lines, the locations where the dura attaches to the skull, and explains the
classic biconvex shape.

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Cranial Meninges & Dural Sinuses

Epidural hematoma. Note the biconvex (lens) shape.

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Cranial Meninges & Dural Sinuses

Development of an epidural hematoma.

A. Transection of a branch of the middle meningeal artery by the sharp fracture initiates
bleeding under arterial pressure that dissects the dura from the calvaria and produces an
expanding hematoma. After an asymptomatic interval of several hours, transtentorial
herniation becomes life-threatening.

B. A discoid mass of fresh hemorrhage overlies the frontal-parietal cortex.

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Cranial Meninges & Dural Sinuses

Arteries of brain (lateral view of right side). Note the following arteries:

MCA (middle cerebral artery)

Posterior communicating artery

Basilar artery

Vertebral artery

The dural venous sinuses receive cerebral veins and drain into the internal jugular vein.

Superior sagittal sinus (SSS): The SSS is a large sinus between the two
hemispheres. It is embedded within the falx cerebri and drains to the confluence of
sinuses (which also receives blood from the straight sinus). In turn, the confluence
empties laterally into the 2 transverse sinuses.

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Cranial Meninges & Dural Sinuses

Note: A subdural hematoma forms when the cerebral veins draining to the SSS
are ruptured during head trauma and appears as "crescent" shaped on imaging.
Transverse sinus: The transverse sinus is the lateral continuation of the confluence
of sinuses. It curves inferiorly to become the sigmoid sinus.
Sigmoid sinus: The sigmoid sinus drains to the internal jugular vein.
Cavernous sinus : The cavernous sinus is located just lateral to the body of the
sphenoid.

Note: Cranial nerves III, IV, V1, V2, VI , as well as the internal carotid artery, must
pass through the cavernous sinus en route to their destinations.

Dural Venous Sinuses.

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Cranial Meninges & Dural Sinuses

Dural venous sinuses. Note the cavernous sinus (red) and the transverse sinus (blue)

Image Credit: Gray's Anatomy

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Cranial Meninges & Dural Sinuses

Dural venous sinuses.

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Cranial Meninges & Dural Sinuses

CSF (cerebrospinal fluid) is produced by the choroid plexus lining the lateral, 3rd and 4th
cerebral ventricles. CSF circulates through the ventricles and foramina of the brain to reach
the SAS (subarachnoid space) surrounding the brain and spinal cord CSF drains through
arachnoid granulations in the dura mater along the superior aspect of the brain to enter the
dural venous sinuses, which drain into the venous blood.

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Cranial Meninges & Dural Sinuses

Venous drainage of the brain. Blood from the brain drains differently than blood elsewhere in
the body. Vein networks in the sub-arachnoid space drain directly into sleeves of the dura
mater called dural sinuses (e.g. sagittal sinus top). The dural sinuses act like a peripheral

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Cranial Meninges & Dural Sinuses

plumbing system by routing blood back toward the confluence of sinuses and then around
the bowl the braincase until it all pours through the jugular foramen much like the drain in
the bottom of a sink (bottom). CSF = cerebrospinal fluid.

Subdural hematoma. Note the crescent shape.

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Cranial Meninges & Dural Sinuses

In venous sinus thrombosis , occlusion of the dural sinus leads to increased venous
pressure and elevated intracranial pressure. Patients most commonly present with:

Headache
Focal neurologic deficits
Altered mental status
Seizure Prothrombotic states are the major risk factors for venous sinus thrombosis.
These include: factor V Leiden, oral contraceptive use, pregnancy, and malignancy.

191
Face-Deep Layer

USMLE Step 1 > Basic Sciences > Anatomy > Head & Neck

FaceDeep Layer
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The deep regions of the face are primarily innervated by the maxillary (V2) and mandibular
(V3) branches of the trigeminal nerve (CN V).

This includes the muscles of mastication ( V3 innervation ):

Masseter
Temporalis
Medial pterygoid
Lateral pterygoid

Muscles of mastication. Oblique view.

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Face-Deep Layer

Muscles of mastication. Posterior view.

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Face-Deep Layer

Superficial dissection of the infratemporal region. Note the branches of V2, V3 and the
maxillary artery which overlie the lateral pterygoid muscle.

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Face-Deep Layer

Temporalis muscle

Image Credit: Gray's Anatomy

Medial pterygoid (arrow) and lateral pterygoid muscles.

Image Credit: Gray's Anatomy

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Face-Deep Layer

The maxillary branch serves to relay sensory information from the maxillary teeth, gums,
and palate.

The mandibular branch has five sensory branches:

Meningeal nerve
Auriculotemporal nerve
Inferior alveolar nerve
Lingual nerve
Buccal nerve (not to be confused with the buccal branch of the facial nerve) The
lingual nerve provides general sensation to the anterior two thirds of the tongue. It is
joined by the chorda tympani branch of CN VII, which carries special taste sensation
from the same region.

The inferior alveolar nerve relays sensation from the mandibular teeth and gums.

In addition, it branches to form the nerve to mylohyoid, which provides motor innervation to
the anterior belly of the digastric and mylohyoid muscles.

The meningeal branch of the mandibular nerve supplies the meninges of the middle
cranial fossa via the foramen spinosum.

Additionally, the mandibular nerve provides supplemental motor innervation to the muscles
of mastication.

Note: Please see Trigeminal System for additional information.

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Face-Deep Layer

Deep dissection of the infratemporal region. Note the branches of V3.

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Face-Deep Layer

Branches of the mandibular nerve (V3)

Image Credit: Gray's Anatomy

Circulation to the deep regions of the face is provided by branches of the maxillary artery ,
which is one of the terminal branches of the external carotid artery.

The middle meningeal artery is a branch of the maxillary artery. It enters the skull via the
foramen spinosum and supplies circulation to the dura.

Clinical Correlate: Laceration of the middle meningeal artery may result in an epidural
hematoma. The sphenopalatine artery is a terminal branch of the maxillary artery. It enters
the sphenopalatine foramen to supply the nasal septum and is one of the main arteries of
Kiesselbachs Plexus.

Clinical Correlate: Branches of the sphenopalatine artery are often implicated in


nosebleeds.

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Face-Deep Layer

Sphenopalatine artery.

Maxillary artery and its branches.

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Face-Deep Layer

The branches of the first (mandibular) part supply the external acoustic meatus (auditory
canal) and tympanic membrane (eardrum). The middle meningeal artery sends branches to
the pharyngotympanic tube before entering the skull through the foramen spinosum.

Branches of the maxillary artery

Image Credit: Gray's Anatomy

200
Face-Superficial Layer

USMLE Step 1 > Basic Sciences > Anatomy > Head & Neck

FaceSuperficial Layer
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The major motor nerve of the face is the facial nerve (CN VII). It innervates the muscles of
facial expression , the stapedius , the stylohyoid muscles , and the posterior belly of
the digastric muscle.

The facial nerve exits the cranial cavity and enters the skull via the internal acoustic
meatus (contained within the petrous part of the temporal bone) before exiting the skull via
the stylomastoid foramen after which the posterior auricular nerve , the nerve to the
posterior belly of the digastric , and the nerve to the stylohyoid muscle branch off.

The facial nerve then enters the parotid gland and divides into five terminal motor branches;
the temporal branch , the zygomatic branch , the buccal branch , the marginal
mandibular branch , and the cervical branch.

Mnemonic: T o Z anzibar B y M otor C ar

T emporal branch
Z ygomatic branch
B uccal branch
M arginal mandibular branch
C ervical branch

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Face-Superficial Layer

The branches of the facial nerve can be remembered with the mnemonic:
To Temporal
Zanzibar Zygomatic
By Buccal
Motor Marginal mandibular
Car Cervical

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Face-Superficial Layer

Branches of the facial nerve

Image Credit: PJ Lynch, medical illustrator and C. Carl Jaffe, MD CC by-SA 2.5

The ophthalmic nerve (V1) is the superior division of the trigeminal nerve and is the
smallest of the three divisions.

It is all sensory and supplies the skin of the forehead , the dorsum of the nose and the
upper eyelid.

The maxillary nerve (V2) is the intermediate division of the trigeminal nerve.

It is also all sensory and supplies the lower eyelid , the side of the nose , the upper lip ,
the anterior temple and the skin overlying the maxilla and zygoma.

Cutaneous innervation to the face is provided by branches of the ophthalmic (V1),


maxillary (V2) and mandibular (V3) nerves.

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Face-Superficial Layer

The mandibular nerve (V3) is the inferior and largest division of the trigeminal nerve. It is a
mix of motor and sensory and the sensory portion supplies the skin of the cheek , chin ,
lower lip and the posterior temple region.

Cutaneous innervation of mandibular nerve (V3)

Adapted from P Lynch, CC BY 2.5.

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Face-Superficial Layer

Cutaneous innervation of maxillary nerve (V2)

Adapted from P Lynch, CC BY 2.5

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Face-Superficial Layer

Cutaneous innervation by the ophthalmic nerve (V1)

Adapted from P Lynch, CC BY 2.5

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Face-Superficial Layer

Cutaneous innervation of the face by the divisions of the trigeminal nerve (V1-V3)

Adapted from P Lynch, CC BY 2.5

The superficial muscles of the face provide facial expression and all have motor
innervation from branches of the facial nerve.

The orbicularis oris muscle encircles the mouth.

Action: Close the mouth and protrude the lips (like kissing)
Innervation: Buccal branch of CN VII The levator labii superioris originates from the
maxilla and inserts on the skin of the upper lip.

Action: Raise the upper lip

Innervation: Buccal branch of CN VII The depressor labii inferioris originates from
the base of the mandible and inserts on the lower lip.

Action: Depression of lower lips

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Face-Superficial Layer

Innervation: Marginal mandibular branch of CN VII The levator labii superioris


alaeque nasi along with the nasalis originates from the frontal process of the maxilla
and insert into the major alar cartilage.

Action: Raise the upper lip and open the nostrils

Innervation: Zygomatic and superior buccal branches of CN VII The depressor


anguli oris muscle originates from the mandible and inserts on the inferior angle of the
mouth.

Action: Frown the mouth

Innervation: Marginal mandibular branch of CN VII The buccinator or the "cheek


muscle" inserts on the medial angle of the mouth and orbicularis oris.

Action: Flattens the cheeks against the teeth and keep food between teeth out of the
oral vestibule (the space between the cheeks and teeth)

Innervation: Buccal branch of CN VII

Note: the buccal branch of CN V provides cutaneous innervation to the same area. The
zygomaticus major/minor muscles originate from the zygomatic bone and inserts on
to the superior angle of the mouth.

Action: Smile

Innervation: Buccal and zygomatic branches of CN VII The orbicularis oculi muscle
circles around the orbit and eyelids and consists of 3 parts : Orbital, lacrimal and
palpebral.

Action: Close the eyes

Innervation: Temporal and zygomatic branches of CN VII The frontalis belly is the
anterior portion of the occipitofrontalis muscle connected by the epricranial aponeurosis.

Action: Elevate the eyebrows and wrinkle skin of the forehead (indicating surprise)

Innervation: Temporal branch of CN VII

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Face-Superficial Layer

Muscles of facial expression

Adapted from P. Lynch, CC BY 2.5

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Face-Superficial Layer

Muscles of facial expression. Oblique view.

210
Neck: Anterior & Posterior Triangles

USMLE Step 1 > Basic Sciences > Anatomy > Head & Neck

Neck: Anterior & Posterior Triangles


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The neck is divided into 2 anatomic triangles: anterior and posterior.

Anterior triangle :

The boundaries of the anterior triangle are the following:

Anterior boundary Midline (of the body)


Superior boundary Inferior border of the mandible
Lateral boundary Sternocleidomastoid (SCM) muscle

It is subdivided into:

Submandibular triangle : The submandibular triangle is formed by the anterior and


posterior bellies of the digastric muscle and the inferior border of the mandible.

It contains the submandibular gland, as well as the facial artery and vein. The
hypoglossal nerve passes deep to the submandibular gland.
Submental triangle : The submental triangle is bordered by the anterior bellies of the
digastric bilaterally and the hyoid bone.

It contains submental lymph nodes.


Carotid triangle : The carotid triangle borders are formed by the posterior belly of the
digastric, superior belly of the omohyoid, and upper part of the SCM.

It contains the external carotid artery, as well as its first 5 branches (superior
thyroid, ascending pharyngeal, lingual, occipital, facial arteries). Muscular triangle
: The muscular triangle is bounded by the:
Superior belly of the omohyoid
Anterior border of the SCM
Midline

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Neck: Anterior & Posterior Triangles

Submandibular Triangle, highlighted in red

Image Credit: O. Remesz, CC-A

212
Neck: Anterior & Posterior Triangles

Muscular Triangle, highlighted in red.

Image Credit: O. Remesz, CC-A

Carotid Triangle (7).

Posterior belly of digastric (3), superior belly omohyoid (10), SCM (8).

213
Neck: Anterior & Posterior Triangles

Submental Triangle, highlighted in red.

Carotid Triangle.

Posterior triangle :

The posterior triangle boundaries are:

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Neck: Anterior & Posterior Triangles

Anterior SCM
Inferior Clavicle
Posterior Anterior border of the trapezius muscle

It is divided into:

Occipital triangle : The occipital triangle is formed by the upper part of the SCM, the
inferior belly of the omohyoid, and the anterior border of the trapezius.

It contains the occipital artery and transverse cervical artery, as well as CN XI


(accessory nerve,) which course posteriorly.
Subclavian (supraclavicular) triangle: The subclavian triangle is formed by the lower
part of the SCM, the inferior belly of the omohyoid, and the clavicle.

It contains the subclavian artery and the brachial plexus.

Subclavian Triangle, highlighted in red.

Image Credit: O. Remesz, CC-A

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Neck: Anterior & Posterior Triangles

Occipital Triangle, highlighted in red.

Image Credit: O. Remesz, CC-A

216
Neck: Muscles

USMLE Step 1 > Basic Sciences > Anatomy > Head & Neck

Neck: Muscles
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The superficial muscles of the neck , which are extrinsic muscles of the larynx, are
generally organized based on their relationship to the hyoid bone.

There are 4 suprahyoid muscles and are all involved in swallowing and vocalization.

Digastric :

The digastric muscle, as its name suggests, has two bellies: the anterior and posterior
bellies, which work to depress the mandible or elevate the hyoid bone during swallowing
and speaking.

The anterior belly originates from the digastric fossa of the mandible and attaches to
the hyoid bone via the intermediate tendon.

Innervation: Nerve to mylohyoid , branch of CN V3


The posterior belly originates from the mastoid notch of the temporal bone and
attaches to the hyoid bone via the intermediate tendon.

Innervation: Digastric branch of CN VII Mylohyoid :


The mylohyoid is the fan shaped muscle that originates from the mandible and attaches
to the hyoid bone.

Innervation: Nerve to mylohyoid , which is a branch off of the inferior alveolar nerve
of V3 Geniohyoid :
The geniohyoid originates from the inferior mental spine of the mandible and attaches to
the body of the hyoid. It lies immediately deep to the mylohyoid.

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Neck: Muscles

Innervation: C1 via hypoglossal nerve Stylohyoid :


The stylohyoid muscle originates from the styloid process of the temporal bone and
attaches to the hyoid bone adjacent to the intermediate tendon of the digastric.

Innervation: Stylohyoid branch of CN VII

The muscles of the anterior neck.

218
Neck: Muscles

Anterior and posterior bellies of the digastric muscle, highlighted in magenta.

Image Credit: Gray's Anatomy

219
Neck: Muscles

Mylohyoid muscle, found just deep to the anterior belly of the digastric, highlighted in red.

Image Credit: Gray's Anatomy

220
Neck: Muscles

Geniohyoid muscle, deep to the mylohyoid (cut away), highlighted in magenta.

Image Credit: Gray's Anatomy

221
Neck: Muscles

Pointer on stylohyoid muscle, highlighted in pink.

Image Credit: O. Remesz CC-A

There are also 4 infrahyoid muscles , which act to depress the hyoid and larynx during
swallowing. Most are named to describe their locations. They are also known as the strap
muscles.

Sternohyoid :

The sternohyoid originates from the manubrium of the sternum and attaches to the body
of the hyoid.

Innervation: Ansa cervicalis , a branch of the C1-C3 cervical plexus Sternothyroid :


The sternothyroid originates from the posterior aspect of the manubrium of the sternum
and attaches to the thyroid cartilage.

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Neck: Muscles

Innervation: Ansa cervicalis , a branch of the C2-C3 cervical plexus Thyrohyoid :


The thyrohyoid muscle originates from the oblique line of the thyroid cartilage and
attaches to the hyoid.

Innervation: C1 via hypoglossal nerve

Note: You can use the mnemonic C1 = GT to remember which two muscles this nerve
innervates (G is Geniohyoid, and T is Thyrohyoid). Omohyoid :

The omohyoid muscle is similar to the digastric in that it has 2 bellies: superior and
inferior belly.

The superior belly attaches to the hyoid bone and the inferior belly originates from
the superior border of the scapula. The intermediate tendon which connects these two
bellies passes through a fascial sling thats attached to the medial end of the clavicle.

Innervation: Ansa cervicalis All of the infrahyoid muscles are innervated by the ansa
cervicalis except for the thyrohyoid, which is innervated by C1 via hypoglossal nerve.

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Neck: Muscles

The infrahyoid muscles

224
Neck: Muscles

The infrahyoid muscles.

The infrahyoid muscles consist of the sternohyoid, sternothyroid, thyrohyoid and the
omohyoid muscles.

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Neck: Muscles

Sternohyoid muscle, highlighted in pink.

Image Credit: O. Remesz CC by SA

226
Neck: Muscles

Sternothyroid muscle, highlighted in red.

Image Credit: Gray's Anatomy

227
Neck: Muscles

Thyrohyoid muscle, highlighted in magenta.

Image Credit: Gray's Anatomy

228
Neck: Muscles

Omohyoid muscle. Pointers to superior and inferior bellies, highlighted in pink.

Image Credit: O. Remesz CC by SA

229
Neck: Muscles

Muscles of the hyoid assembly.

A number of small muscles overlie the respiratory and alimentary tubes. The superficial
muscles are the long ones. The omohyoid runs from the shoulder blade to the hyoid. The
sternohyoid runs from the sternum to the hyoid. Deep to them lay two muscles of half the
length. The sternothyroid runs from the sternum to the thyroid cartilage. The thyrohyoid runs
from the thyroid cartilage to the hyoid bone. The strap-like design continues from the hyoid
bone to the mandible in the form of the geniohyoid (not shown). These muscles are
innervated by a loop of cervical plexus nerves called the ansa cervicalis indicating that they
are not directly or primarily involved in swallowing.

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Neck: Muscles

Sternocleidomastoid:

The sternocleidomastoid (SCM) muscle originates from the sternum ("sterno") and the
clavicle ("cleido") and inserts on the mastoid process ("mastoid").
Action: The SCM laterally flexes the head to the ipsilateral side and rotates the
head to the contralateral side. When acting together, both SCM muscles flex the
cervical spine.

Innervation: CN XI (spinal accessory nerve)

231
Neck: Nerves

USMLE Step 1 > Basic Sciences > Anatomy > Head & Neck

Neck: Nerves
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Several major nerves pass through the musculature of the neck on their way to the body.
The most important are summarized below.

Structures of the neck.

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Neck: Nerves

Major nerves of the neck

Image Credit: Gray's Anatomy

Mnemonic: C3, 4 and 5 keep the diaphragm alive! Phrenic nerve : The phrenic nerve is
a motor nerve derived from C3, C4 and C5. It descends from the neck into the thorax and
provides motor innervation to the diaphragm.

Vagus nerve (CN X): The vagus nerve exits the skull via the jugular foramen and
descends in the neck in the carotid sheath adjacent to the carotid artery and the internal
jugular vein. It gives off several branches, the most important are:

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Neck: Nerves

Superior laryngeal nerve : Divides into the internal and external laryngeal nerves
Recurrent laryngeal nerve : Innervates muscles of the larynx
Auricular branch : Provides general sensory innervation to the auricle, the external
auditory canal, and the tympanic membrane
Pharyngeal branch : Provides motor innervation to the pharyngeal constrictors

Jugular foramen.

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Neck: Nerves

Jugular foramen.

235
Neck: Nerves

Vagus nerve.

Accessory nerve (CN XI): The accessory nerve arises from the upper spinal cord and
medulla, enters the skull via the foramen magnum, and exits the skull along side the vagus
nerve via the jugular foramen. It passes posteriorly through the occipital triangle of the
neck.

Innervates: SCM and trapezius muscles

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Neck: Nerves

Jugular foramen.

237
Neck: Nerves

Jugular foramen.

238
Neck: Nerves

Jugular foramen.

Hypoglossal nerve (CN XII): The hypoglossal nerve exits the skull via the hypoglossal
canal. It can be seen just inferior to the posterior belly of the digastric muscle.

Innervates: Extrinsic and intrinsic muscles of the tongue (except palatoglossus,


innervated by CN X)

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Neck: Nerves

Hypoglossal canal.

240
Neck: Nerves

Hypoglossal canal.

Diagram of the relationships of nerves and vessels to the suprahyoid muscles and cervical
triangles.

241
Neck: Nerves

Hypoglossal canal.

242
Neck: Vasculature

USMLE Step 1 > Basic Sciences > Anatomy > Head & Neck

Neck: Vasculature
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Common carotid artery :

The common carotid artery arises from the brachiocephalic trunk on the right and directly
from the aortic arch on the left. It ascends the neck adjacent to the internal jugular vein.
The carotid sinus , a blood pressure sensor , is found at its bifurcation. The carotid sinus
is innervated by a branch of the glossopharyngeal nerve, CN IX (also known as Herings
nerve).

The carotid body , an oxygen sensor , is also found here and is innervated by the
glossopharyngeal nerve ( CN IX ).

Note: The aortic body is innervated by the vagus nerve (CN X).

Having trouble remembering the difference between carotid sinus and carotid body?

Think: Sinus pressure for the carotid sinus, a pressure sensor.

External carotid artery : The external carotid artery has 8 major branches (Mnemonic: S
ome A ttendings L ike F reaking O ut P otential M edical S tudents):

S uperior thyroid artery: The superior thyroid artery supplies the thyroid gland.
A scending pharyngeal artery
L ingual artery
F acial artery: The facial artery has several small branches which go to the palate, the
tonsils, and pharynx.
O ccipital artery: The occipital artery arises adjacent to the lingual artery and ascends
posteriorly.
P osterior auricular artery
M axillary artery: The maxillary artery is a terminal branch of the external carotid artery
and enters the deep face.
S uperficial temporal artery: The superficial temporal artery is a terminal branch of the
external carotid artery.

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Neck: Vasculature

Branching pattern of the external carotid artery

244
Neck: Vasculature

Branches of the external carotid artery shown in situ. Note the relationship with the
surrounding structures.

245
Neck: Vasculature

Branches of the external carotid artery. Make sure you can identify them all!

246
Neck: Vasculature

Carotid circulation. Blood supply to the head and neck travels mostly in the carotid system
first through a common carotid artery and then through an internal carotid artery to the brain
and an external carotid artery to everything else.

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Neck: Vasculature

Ascending pharyngeal artery

Image Credit: Gray's Anatomy

248
Neck: Vasculature

Lingual artery

Image Credit: Gray's Anatomy

249
Neck: Vasculature

Facial artery

Image Credit: Gray's Anatomy

250
Neck: Vasculature

Occipital artery

Image Credit: Gray's Anatomy

251
Neck: Vasculature

Posterior auricular artery

Image Credit: Gray's Anatomy

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Neck: Vasculature

Maxillary artery: terminal branch of external carotid

Image Credit: Gray's Anatomy

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Neck: Vasculature

Superficial temporal artery: terminal branch of external carotid

Image Credit: Gray's Anatomy

Internal carotid artery : The internal carotid artery supplies the brain; there are
no branches in the neck.

Subclavian artery :

The subclavian artery arises from the brachiocephalic trunk on the right and from the aortic
arch directly on the left.

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Neck: Vasculature

The subclavian artery is typically divided into three parts by its relation to the anterior
scalene muscle:

First part The first part comprises the region from the origin on the vessel up until
the medial border of the anterior scalene.
Second part The second part resides posterior to (behind) the anterior scalene.
Third part The third part consists of the region lateral to the lateral border of the
anterior scalene and medial to the border of the 1st rib.

The branches can be remembered with the mnemonic VIT C & D:

Note: Please see associated notes in each section for variable anatomy. First Part :

V ertebral artery: The vertebral artery passes through the transverse foramina C1-C6.

I nternal thoracic artery (also called the internal mammary artery)

T hyrocervical trunk: The thyrocervical trunk gives off the inferior thyroid, suprascapular,
and transverse cervical arteries.

Note: The ascending cervical artery can arise from the thyrocervical trunk and is a common
anatomical variant. Second Part :

C ostocervical trunk: The costocervical trunk gives off the deep cervical artery and
superior intercostal artery. Third Part :
D orsal scapular artery

Note: The dorsal scapular artery has variable origin and can originate from the
transverse cervical artery in a subset of the population.

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Neck: Vasculature

Subclavian and carotid arteries in the anterior neck

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Neck: Vasculature

3D angiogram of course of the vertebral arteries

Image Credit: Dr. Frank Gaillard, CC by-SA

257
Neck: Vasculature

Branches of the Thyrocervical trunk

Image Credit: Gray's Anatomy

258
Neck: Vasculature

Costocervical trunk

Image Credit: Gray's Anatomy

Internal thoracic artery - a branch off the subclavian artery than travels inferiorly along the
posterior surface of the sternum.

259
Parotid Gland

USMLE Step 1 > Basic Sciences > Anatomy > Head & Neck

Parotid Gland
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The parotid gland spans between the zygomatic arch and the angle of the mandible and
extends anteriorly to the masseter.

It is composed of a superficial lobe and a deep lobe which extends toward the mastoid
process.

The parotid gland receives parasympathetic supply from the glossopharyngeal nerve (CN
IX).

The parotid gland is covered by the parotid fascia , which thickens on the deep side of the
gland to form the stylomandibular ligament.

The parotid duct (Stensens duct) originates at the parotid gland and courses anteriorly
along the masseter muscle.

The duct then pierces the buccinator muscle and emerges on the buccal mucosa at the level
of the 2nd upper molar.

The facial nerve takes an intricate course through the parotid gland.

Clinical Correlate: The facial nerve must be closely monitored and protected during
parotidectomy.

Parotid gland tumors :

Parotid gland tumors are the most common salivary gland tumors:

Pleomorphic adenoma (aka mixed tumor) is the most common benign tumor of the
parotid. It presents as a slow growing, painless, mobile mass.

Pleomorphic adenomas are histologically diverse and are composed of stromal

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Parotid Gland

and epithelial tissue , hence the name pleomorphic adenoma.


Warthin tumor (papillary cystadenoma lymphomatosum) is the second most common
benign parotid tumor. Histologically, it appears as a cystic tumor with a lymphocytic
infiltrate that can form germinal centers.
Mucoepidermoid carcinoma is the most common malignant tumor.

Composed of varying amounts of squamous cells and mucous secreting cells


Commonly involves the facial nerve

Mucoepidermoid carcinoma. Note the nests of squamous cells and the atypical appearing
nuclei.

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Parotid Gland

Warthin tumor. Note the epithelial and lymphoid cellular components.

CC by SA

262
The Ear

USMLE Step 1 > Basic Sciences > Anatomy > Head & Neck

The Ear
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The external ear is the region external to the tympanic membrane. It helps focus sound
waves into the ear canal and is derived from the first branchial cleft.

The auricle is a cartilaginous structure which collects sound waves and directs them
towards the external auditory meatus.

It receives sensory information from the auriculotemporal branch of the trigeminal nerve
(CN V), facial nerve (CN VII), auricular branch of the vagus nerve (CN X), lesser
occipital nerve (C2, C3), and the great auricular nerve (C2, C3).

The external auditory meatus is a canal lined by stratified squamous epithelium and ends
at the tympanic membrane. It receives sensory innervation from the auriculotemporal
branch of the trigeminal nerve (CN V3) and the auricular branch of the ** vagus nerve
(CN X)**.

The skin of the external auditory meatus contains modified sweat glands known as
ceruminous glands which secrete cerumen (ear wax).

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The Ear

Overview of the ear

Image Credit: M. Komorniczak, CC by-SA 2.5

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The Ear

Outer, middle and inner ear

The middle ear is the cavity bounded by the tympanic membrane laterally and the
cochlea and oval window medially. Endoderm of the middle ear is derived from the first
pharyngeal pouch.

The tympanic cavity is an air filled space of the middle ear.

It is boundaries include:

Superior Tegmentum tympani


Inferior Jugular fossa
Anterior Carotid canal
Posterior Mastoid antrum

The mastoid antrum communicates with the mastoid air cells. Clinical Correlate:
Incompletely treated middle ear infections can spread to the mastoid air cells, resulting in
mastoiditis. The inner surface of the tympanic membrane and mucosa of the tympanic

265
The Ear

cavity are innervated by the tympanic nerve and the tympanic plexus both of which are
branches of the glossopharyngeal nerve (CN IX).

The tympanic membrane is a thin derivative of the first pharyngeal membrane which
attaches the manubrium of the malleus, drawing it medially to form the umbo. It functions to
transmit sound waves from the external acoustic meatus to the ossicles of the middle ear.

The external surface of the tympanic membrane is innervated anteriorly by the


auriculotemporal branch of the mandibular nerve (CN V3), b** ranches of the facial
nerve (CN V**II), and posteriorly by the auricular branch of the vagus nerve (CN X).

Right tympanic membrane

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The Ear

Internal and external cross-sectional anatomy of the ear

267
The Ear

Structures of the ear

The ossicles of the middle ear are three small bones which transmit and amplify sound as it
moves from the tympanic membrane to the cochlea. They include the malleus (hammer),
the incus (anvil), and the stapes (stirrup).

The malleus contains anterior and lateral processes which contact and receive vibrations
from the tympanic membrane and transmit them to the incus. It is derived from the first
pharyngeal arch.

The incus articulates with and receives vibrations from the malleus and transmits them
to the stapes. It is derived from the first pharyngeal arch.

The head of the stapes articulates with and receives vibrations from the incus and
transmits them to the oval window of the cochlea through its base. It is derived from the
second pharyngeal arch.

268
The Ear

Stapes

Image Credit: Gray's Anatomy

Incus

Image Credit: Gray's Anatomy

Malleus

Image Credit: Gray's Anatomy

269
The Ear

Ossicle chain in the middle ear

There are two muscles found within the middle ear cavity: the stapedius and tensor
tympani.

The stapedius inserts into the neck of the stapes. It acts to contract in response to loud
noises in order to dampen the effect of the stapes transmitting sound at the inner ear and is
innervated by the nerve to the stapedius , a branch of the facial nerve (CN VII).

The tensor tympani inserts on the manubrium of the malleus. It acts to contract in response
to loud noises in order to tense the tympanic membrane to properly transmit sound and is
innervated by the nerve to tensor tympani , a branch of the mandibular nerve (CN V3).

Clinical Correlate: Mandibular nerve (CN V3) paralysis can result in the loss of function the
tensor tympani muscle, which functions to dampen sound and protect the ear from loud
noises by tightening the tympanic membrane. Loss of this function can lead to hypoacusis
to low-pitch sounds.

The facial nerve (CN VII) enters the petrous part of the temporal bone of the skull via the
internal acoustic meatus adjacent to the inner ear before entering the facial canal.

270
The Ear

The geniculate ganglion of the facial nerve contains the cell bodies for the chorda
tympani branch which enters the tympanic cavity and courses across the mandible in order
to bring taste sensation from the anterior two thirds of the tongues to sensory nuclei of the
brain stem.

The facial nerve gives off the greater petrosal nerve at the geniculate ganglion , which
leaves the middle ear to ultimately synapse on the pterygopalatine ganglion.

The facial nerve ultimately exits the skull distally via the stylomastoid foramen.

Geniculate ganglion.

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The Ear

Nerves of the inner ear

Image Credit: PJ Lynch, medical illustrator, C. Carl Jaffe, MD CC by-SA 2.5

Middle ear cavity showing the course of the chorda tympani nerve across the manubrium of
the malleus.

The ear is the primary organ involved in the transmission of sound and position into
sensation.

It is divided into three distinct parts:

External ear
Middle ear
Inner ear

Note: Please refer to the link for greater detail on the Inner Ear.

272
The Oral Cavity & Tongue

USMLE Step 1 > Basic Sciences > Anatomy > Head & Neck

The Oral Cavity & Tongue


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The oral cavity is bounded by the teeth, palate and floor of the mouth. It communicates
posteriorly with the faucial isthmus.

The tongue is a large group of skeletal muscles and associated epithelium located within
the oral cavity that functions to manipulate food and aid in speech.

The tongue has three major parts:

Root
Superior surface
Inferior surface The root of the tongue refers to posterior region of the tongue ,
which joins the epiglottis at the back of the oropharynx and forms the anterior wall of the
laryngopharynx.

The superior surface of the tongue is covered by specialized epithelial structures called
taste buds. These include the fungiform papillae anteriorly, vallate papillae posteriorly, and
foliate papillae laterally.

Only fungiform, vallate, and foliate papillae are actually involved in taste sensation. Filiform
papillae exist as mechanical ridges, designed to aid in scraping or shearing food (ie they
are analogous to the roughness of a cats tongue).

Fungiform papillae mushroom shaped and reside on the dorsal and lateral
surfaces; distinguish all 5 tastes
Vallate papillae reside on the posterior region of the tongue and are few in number
Foliate papillae distinguish taste and resides on the posterior and lateral tongue
Filiform papillae cannot taste and are the most numerous of the papillae The
foramen cecum is a depression found posteriorly on the dorsal surface of the
tongue. It is the origin of the thyroid gland and the obliterated opening of the
thyroglossal duct.

Clinical Correlate: The foramen cecum is the most common site of ectopic thyroid tissue
due to a failed descent of the developing thyroid gland into the thyroglossal duct. The inferior
surface of the tongue is connected to the floor of the mouth by a mid-line fold called the

273
The Oral Cavity & Tongue

lingual frenulum.

Dorsum of the tongue and taste buds.

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The Oral Cavity & Tongue

Taste buds of the tongue.

The genioglossus originates from the mandible and inserts into the entire dorsum of the
tongue. When acting alone, it acts to deviate the tongue to the contralateral side. When
acting in unison, they act to protrude the tongue. It is innervated by the hypoglossal
nerve (CN XII).

The hyoglossus muscle originates from the hyoid bone and inserts into the side of the
tongue. It acts to depress the tongue and is innervated by the hypoglossal nerve (CN XII).

The styloglossus muscle originates from the distal styloid process and inserts into the side of
the tongue. It acts to elevate and retract the tongue and is innervated by the hypoglossal
nerve (CN XII).

The palatoglossus muscle originates from the soft palate and inserts into the side of the
tongue. It acts to elevate the tongue and is innervated by the vagus nerve (CN X). It is the
only extrinsic muscle of the tongue not innervated by the hypoglossal nerve (CN XII).

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The Oral Cavity & Tongue

The extrinsic muscles of the tongue are a set of four skeletal muscles that originate
outside of the tongue and attach to it. They function to move the tongue and include the:

Genioglossus
Hyoglossus
Styloglossus
Palatoglossus

The extrinsic muscles of the tongue

The extrinsic muscles of the tongue include the genioglossus, hyoglossus, styloglossus,and
palatoglossus.

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The Oral Cavity & Tongue

The extrinsic muscles of the tongue

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The Oral Cavity & Tongue

Muscles, nerves, and arteries of the tongue. Muscles and nerves. Right lateral view. The
ansa cervicalis is a loop in the cervical plexus.

278
The Oral Cavity & Tongue

Genioglossus, highlighted in red

Image Credit: Gray's Anatomy

279
The Oral Cavity & Tongue

Hyoglossus, highlighted in red

Image Credit: Gray's Anatomy

280
The Oral Cavity & Tongue

Styloglossus, highlighted in red

Image Credit: Gray's Anatomy

The intrinsic muscles of the tongue are a set of skeletal muscles which attach and insert
within the tongue. They are composed of the superior longitudinal, inferior longitudinal,
transverse and vertical muscles. Innervation is supplied by the hypoglossal nerve (CN
XII).

Sensory innervation to the tongue is provided by four nerves:

Lingual nerve
Chorda tympani
Glossopharyngeal nerve (CN IX)
Internal laryngeal nerve The lingual nerve is a branch of the mandibular nerve (CN
V3). It relays general somatic afferent (GSA) sensory information from the anterior

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The Oral Cavity & Tongue

two thirds of the tongue.

The chorda tympani is branch of the facial nerve (CN VII) and carries parasympathetic
fibers to the submandibular ganglion , as well as relays special visceral afferent (SVA)
sensation (taste) from the anterior two thirds of the tongue.

Note: The preganglionic fibers traveling via the chorda typani that synapse at the
submandibular ganglion arise from the superior salivary nucleus in the pons.

Postganglionic parasympathetic fibers from the submandibular ganglion ultimately


innervate the submandibular and sublingual salivary glands.

The glossopharyngeal nerve (CN IX) provides general sensation and taste sensation to
the posterior 1/3 of the tongue.

The internal laryngeal nerve is a branch of the vagus nerve (CN X). It relays general
somatic afferent (general sensation) information and special visceral afferent (taste)
sensation from the epiglottis and epiglottic region of the tongue.

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The Oral Cavity & Tongue

Cranial nerve XII (hypoglossal nerve). The nerve provides motor innervation to the major
muscle of the tongue genioglossus most of the other muscles that connect to the tongue
and all the intrinsic muscles that are embedded in the tongue surface. CN = cranial nerve.

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The Oral Cavity & Tongue

The tongue is a raised surface of the mouth that is embedded with muscles.

A. The ventral midline of pharynx swells along all of the pharyngeal arches.

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The Oral Cavity & Tongue

B. Aggressive swelling of the first arch and migration of the third arch result in the elevated
surface of a tongue. The back of the tongue also is elaborated from the floor of the pharynx
as an epiglottis which passively closes off the larynx during swallowing.

C. General innervation of the tongue surface comes from the cranial nerves dedicated to the
arches from which it derives ; the special sense cells of the second arch migrate into the
anterior two-thirds of the tongue which explains why taste from there is carried back to the
brain by cranial nerve (CN) VII.

The floor of the mouth contains duct openings from two major groups of salivary glands, the
sublingual glands and the submandibular glands.

The sublingual glands are the smallest and most deeply situated salivary glands. They are
mixed serous and mucinous glands (with a mucinous predomination) and are innervated
by parasympathetic fibers of the chorda tympani branch of the facial nerve (CN VII).

The submandibular glands are mixed serous and mucinous glands (with a serous
predomination) which empty their secretions into the oral cavity via Whartons duct , opens
lateral to the base of the lingual frenulum. They are innervated by parasympathetic fibers of
the chorda tympani branch of the facial nerve (CN VII).

285
The Orbit

USMLE Step 1 > Basic Sciences > Anatomy > Head & Neck

The Orbit
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The outside of the orbit contains dense connective tissue and muscles that comprise the
eyelids, the tarsus and the orbital septum.

Orbital septum : The orbital septum protects the orbit within the ocular cavity; it is
continuous with the pericranium. Tarsus : The tarsus is formed by dense connective tissue
plates that forms the walls of the eyelids. Superior tarsal muscle : The superior tarsal
muscle attaches to the tarsus of the upper eyelid.

Action: Elevation of the eyelid


Innervation: Sympathetic nerves (superior cervical ganglion)

Clinical Correlate: Sympathetic innervation of the superior tarsal muscle explains the
ptosis seen in Horners Syndrome.

The lacrimal punctum a tiny opening which drains lacrimal fluid via the lacrimal
canaliculus.

The lacrimal canaliculus drains to the lacrimal sac , which communicates inferiorly with the
nasal cavity via the nasolacrimal duct.

Note: This is why you sniffle when you cry!

The lacrimal gland is located laterally within the orbit and functions to secrete tears which
lubricate the eye.

The nerves of the orbit enter the orbit via the superior orbital fissure.

The oculomotor nerve (CN III) also gives off the preganglionic oculomotor root of the
ciliary ganglion , which synapses with the ciliary ganglion.

The short ciliary nerves carry postganglionic parasympathetic fibers to the ciliary muscle
and the pupillary sphincter muscle, which act on the lens and pupil. The ciliary muscle is
responsible for accommodation and the pupillary muscle is responsible for miosis
(constriction of the pupils).

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The Orbit

The arteries of the orbit are mainly derived from the ophthalmic artery , a branch of the
internal carotid artery.

Central retinal artery : The central retinal artery is found at the center of the optic nerve and
supplies the retina.

Clinical Correlate: Cholesterol emboli from the internal carotid artery can occlude the central
retinal artery and cause central retinal artery occlusion (CRAO). CRAO often presents
with amaurosis fugax, the sudden loss of vision in one eye lasting up to a few hours.
"Cherry-red" spots are classically seen on physical exam.

CRAO is also a consequence of giant cell (temporal) arteritis. For this reason, it is very
important to ask about symptoms of jaw claudication and temporal headaches in elderly
patients presenting with symptoms of CRAO. Ophthalmic veins :

Superior ophthalmic vein drains into the cavernous sinus


Inferior ophthalmic vein drains into the pterygoid venous plexus

The muscles of extraocular movement (EOM) function to move the eyeball within the
bony orbital cavity.

Innervation: CN III, IV and VI

The common annular tendon is the attachment for the 4 rectus muscles. Superior oblique :

The superior oblique muscle originates on the medial side of the orbit and passes through
the trochlea to insert onto the sclera.

Action: Depresses, abducts, and medially rotates (intorts) the eye


Innervation: CN IV Inferior oblique :

The inferior oblique muscle is located inferiorly at the floor of the orbit.

Action: Elevates, abducts, and externally rotates (extorts) the eye


Innervation: CN III Superior rectus :

The superior rectus muscle originates from the superior part of the common annular
tendon.

Action: Elevates and medially rotates (intorts) the eye


Innervation: CN III Inferior rectus :
Action: Depresses and externally rotates (extorts) the eye
Innervation: CN III Medial rectus :
Action: Adducts the eye

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The Orbit

Innervation: CN III Lateral rectus :


Action: Abducts the eye
Innervation: CN VI Levator palpebrae superioris :
Action: Elevates the upper eyelid
Innervation: CN III Mnemonic: Remember the innervation of the muscles of EOM:

SO4 LR6, and all the rest by 3

SO4: Superior oblique CN IV (trochlear nerve)


LR6: Lateral rectus CN VI (abducens nerve)

Superior view of the orbit

288
The Orbit

Dissections of the right orbit. Similar view of a deep dissection.

289
The Orbit

Anterior view of the orbit

A: lateral rectus muscle

B: superior rectus muscle

C: medial rectus muscle

D: Inferior rectus muscle

E: oculomotor nerve (superior branch)

F: optic nerve

G: abducens nerve innervating the lateral rectus

H: tendon of the superior oblique passing through trochlea

I: inferior oblique

J: superior orbital fissure

Image Credit: Adapted from PJ Lynch, medical illustrator and C. Carl Jaffe, MD CC by-SA
2.5

290
The Orbit

Lateral view of left eye

A: lateral rectus (cut)

B: inferior oblique

C: superior oblique

D: ciliary ganglion, receiving preganglionic parasympathetic fibers from the oculomotor nerve

E: optic nerve

F: levator palpebrae superioris

Image Credit: PJ Lynch, medical illustrator and C. Carl Jaffe, MDCC by-SA 2.5

291
The Orbit

Superior view of the orbit

A: superior rectus

B: lateral rectus

C: superior oblique passing through trochlea

D: trigeminal nerve giving rise to the opthalmic nerve (V1)

E: ethmoid air cells

Image Credit: PJ Lynch, medical illustrator and C. Carl Jaffe, MDCC by-SA 2.5

292
The Palate

USMLE Step 1 > Basic Sciences > Anatomy > Head & Neck

The Palate
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The palate is a mass of tissue which separates the oral and nasal cavities.

The hard palate makes up the anterior two thirds of the palate. It is composed of bone
and derived from the palatine processes of the maxillae and the horizontal plates of the
palatine bones.

Clinical Correlate: Failed fusion of the palatine processes of the maxillae results in cleft
palate.

The soft palate makes up the posterior one third of the palate. It contains the uvula
posteriorly and is manipulated by three major muscles:

Levator veli palatini


Tensor veli palatini
Musculus uvulae The levator veli palatini originates from the cartilage of the auditory
tube and inserts on the soft palate, forming the bulge in the lateral wall of the
nasopharynx known as the torus levatorius.

The levator veli palatini acts to elevate the soft palate , effectively closing the oropharynx
from the nasopharynx. It is innervated by the vagus nerve (CN X).

The tensor veli palatini originates from the cartilage of the auditory tube and descends to
form an aponeurosis within the soft palate. It acts to tense the palate and thus facilitate the
action of the levator veli palatini.

The tensor veli palatini is innervated by the nerve to the tensor veli palatini , which is a
branch of the mandibular nerve (CN V3).

The musculus uvulae inserts into the uvula and acts to elevates and laterally deviate the
uvula. It is innervated by the vagus nerve (CN X).

The palate receives sensory innervation from the greater and lesser palatine nerves , both
of which are branches of the maxillary nerve (CN V2). The nasopalatine nerve (long
sphenopalatine nerve), another branch of CN V2 , enters the mouth via the incisive canal

294
The Palate

and provides sensation to the incisive gum of the hard palate.

The greater palatine nerve descends in through the greater palatine canal and provides
sensory innervation to the hard palate.

The lesser palatine nerves also descends in the greater palatine canal and provides sensory
innervation to the soft palate.

295
Thyroid & Parathyroid Glands

USMLE Step 1 > Basic Sciences > Anatomy > Head & Neck

Thyroid & Parathyroid Glands


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The thyroid gland consists of 2 lobes located anterolaterally, which span the area between
the oblique line of the thyroid cartilage and the 5th tracheal ring.

Anterior view of the thyroid gland.

296
Thyroid & Parathyroid Glands

Posterior view of the thyroid gland.

297
Thyroid & Parathyroid Glands

Anterior view of the thyroid gland.

298
Thyroid & Parathyroid Glands

Cartilages and structures of the airway.

The thyroid receives arterial supply from the superior (via external carotid) and inferior
thyroid (via thyrocervical trunk) arteries.

Note: For more information on where these arteries arise, please review Neck: Vasculature.

299
Thyroid & Parathyroid Glands

Blood supply of the thyroid gland.

300
Thyroid & Parathyroid Glands

Superior thyroid artery.

Three separate veins provide drainage of the thyroid gland:

Superior thyroid vein Drains to internal jugular vein


Middle thyroid vein Drains to internal jugular vein
Inferior thyroid vein Drains to the brachiocephalic vein

The parathyroid glands are 4 small circular glands found on the posterior surface of the
thyroid gland.

Clinical Correlate: Thyroid surgery is a common cause of removal or damage to the


parathyroid glands.

301
Foot: Dorsal Muscles

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

Foot: Dorsal Muscles


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Extensor digitorum brevis : The extensor digitorum brevis originates on the dorsal surface
of the calcaneus and inserts onto the tendons of the extensor digitorum longus.

Action: Aids in extension of the MTP and IP joints of digits 2-4


Innervation: Deep fibular (peroneal) n.

Extensor hallucis brevis : The extensor hallucis brevis originates on the dorsal surface of
the calcaneus where it attaches to the extensor digitorum brevis. It inserts onto the dorsal
surface of the proximal phalanx of the hallux.

Action: Extension of MTP joint of hallux


Innervation: Deep fibular (peroneal) n.

The dorsum of the foot contains 2 intrinsic muscles: extensor digitorum brevis and
extensor hallucis brevis.

302
Foot: Dorsal Muscles

Foot and lower leg, anterior/frontal view w/ mm and tendons labeled

303
Foot: Dorsal Muscles

Muscles of the dorsum of the foot.

304
Foot: Dorsal Muscles

Muscles of the dorsum of the foot.

305
Foot: Dorsal Muscles

Muscles of the dorsum of the foot.

Muscles of the dorsum of the foot.

306
Foot: Nerves

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

Foot: Nerves
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The dorsum of the foot is supplied by the:

Deep** peroneal(fibular)nerve**
Superficial peroneal (fibular) nerve
Sural nerve Superficial peroneal nerve : The superficial peroneal n. supplies
cutaneous innervation to the dorsum of the foot and skin of the digits.

Note: The superficial peroneal n. gives sensory innervation to the skin of the dorsal foot
except for the web between digits 1 and 2 , which is innervated by the deep peroneal n.

Deep peroneal nerve : The deep peroneal nerve courses between the tendons of the
extensor hallucis longus and extensor digitorum longus. It provides cutaneous innervation
for the space in between digit 1 and 2 on the dorsum of the foot.

Innervation: Extensor digitorum brevis and extensor hallucis brevis

The plantar aspect of the foot is supplied by the tibial nerve, which divides into the medial
and lateral plantar nerves.

Medial plantar n. : The medial plantar n. courses deep to abductor hallucis.

Innervates:

Muscles Abductor hallucis, flexor hallucis brevis, flexor digitorum brevis and
lumbrical 1
Skin Medial plantar side of foot and medial 3 and 1/2 digits Lateral plantar n. :
The lateral plantar n. courses laterally between the flexor digitorum brevis and
quadratus plantae.
Innervation:

Muscles Quadratus plantae, abductor digiti minimi, flexor digiti minimi brevis,
lumbricals 2-4, adductor hallucis, and dorsal and plantar interossei
Skin Lateral foot and lateral 1 and 1/2 digits

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Foot: Nerves

Cutaneous innervation of the plantar aspect of the foot.

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Foot: Nerves

The medial and lateral plantar nn. supply the plantar aspect of the foot.

Other dermatomal innervation:

Medial border of foot Saphenous n.


Lateral border of foot Sural n.

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Foot: Plantar Muscles-1st Layer

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

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Foot: Plantar Muscles1 Layer
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The plantar aspect of the foot is divided into four layers (1-4) listed from superficial to
deep.

The intrinsic plantar muscles serve the important function of stabilizing the bones when
walking and preventing flattening of the arch. The effect of these muscles reinforcing the
arch provides essential cushioning to the foot strike in walking.

The 1st layer contains the superficial and deep fascial layers:

Superficial fascia : The superficial fascia forms thick fibrous padding that anchors skin
to the deep fascia. It contains the sensory nerves that supply the plantar foot.
Heel and forefoot fat pads help cushion the foot and protect deep tendons and vessels
traveling within the foot.
Deep fascia : The deep fascia ensheaths the muscles of the 1st layer. It also contains
the following structures:

Plantar aponeurosis : Thick connective tissue layer found in the sole of the foot
Fibrous tendon sheaths : Fibrous tunnels that attach the tendons of the flexor
muscles

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Foot: Plantar Muscles-1st Layer

Foot, 1st layer of the plantar mm w/ med and lat plantar aa and nn

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Foot: Plantar Muscles-1st Layer

Foot, supf and deep layers of plantar mm

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There are 3 muscles in the 1 layer:

Abductor hallucis
Flexor digitorum brevis

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Foot: Plantar Muscles-1st Layer

Abductor digiti minimi In general, the deeper layer muscles become smaller and span
less of the foot.

Abductor Hallucis :

Action: Abduction and flexion of the MTP (metatarsophalangeal) joint of the hallux.
Note: Abduction is defined as movement of the toe away from the longitudinal axis.
Innervation: Medial plantar n.

Action: Flexion of the PIP and MTP joints of digits 2-5


Innervation: Medial plantar n. Flexor digitorum brevis :

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Action: Abduction and flexion of the MTP joint of the 5 digit
Innervation: Lateral plantar n. Abductor digiti minimi :

Clinical Correlation: Plantar fasciitis is a common running injury. Overuse and strain of the
plantar fascia results in inflammation.

Signs : Signs of plantar fasciitis include pain when pressing distal to the calcaneus
tuberosity and during passive extension of big toe.
Symptoms : Symptoms of plantar fasciitis include pain on waking usually
while taking the first steps of the day and after resting. Pain often dissipates during
exercise.
Plantar fasciitis can sometimes result in bone spurs on anteroinferior surface of
calcaneus.

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Foot: Plantar Muscles-2nd Layer

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

nd Layer
Foot: Plantar Muscles2
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Contents of the 2nd layer of the foot:

2 muscle groups: Quadratus plantae and lumbricals


2 tendon groups: Tendon of flexor digitorum longus and tendon of flexor hallucis
longus

Quadratus plantae :

The quadratus plantae is anchored to the tendons of the flexor digitorum longus.

Action: Laterally corrects the pull of the flexor digitorum longus tendon on digits 2-
5, allowing them to be more in line with the longitudinal axis of the foot

Innervation: Lateral plantar n.

Lumbricals (4):

Action: Extension of IP (interphalangeal) joints and flexion of MTP joints 2-5

Innervation:

1st lumbrical Medial plantar n.


2nd-4th lumbrical Lateral plantar n.

Tendon of flexor digitorum longus :

The tendon courses laterally, superficial to the tendon of the flexor hallucis longus, and
inserts into digits 2-5.

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Foot: Plantar Muscles-2nd Layer

The muscle originates in the posterior compartment of the leg.

Tendon of flexor hallucis longus :

The tendon of the flexor hallucis longus inserts into the base of the distal phalanx of the
hallux.
The muscle originates in the posterior compartment of the leg.

The contents passing deep to the flexor retinaculum can be remembered with the
mnemonic, T om D ick AN d H arry (ant post):

T ibialis posterior m.
Flexor D igitorum longus m.
Posterior tibial A rtery
Tibial N erve
Flexor H allucis longus m.

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Foot: Plantar Muscles-3rd Layer

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

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Foot: Plantar Muscles3 Layer
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There are three muscles that are found in the 3rd layer of the foot:

Flexor hallucis brevis


Adductor hallucis (with an oblique and transverse head)
Flexor digiti minimi brevis

Flexor hallucis brevis : The flexor hallucis brevis has a medial and lateral head.

Action: Flexion of the MTP joint of the hallux


Innervation: Medial plantar n.

Adductor hallucis : The adductor hallucis has an oblique head and a transverse head.

Action: Adduction and flexion of the MTP joint of the hallux


Innervation: Lateral plantar n.

Action: Flexion of the MTP joint of the little toe


Innervation: Lateral plantar n. Flexor digiti minimi brevis :

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Foot: Plantar Muscles-4th Layer

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

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Foot: Plantar Muscles4 Layer
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The 4th layer of the plantar foot contains 2 muscle groups: plantar interossei and the
dorsal interossei.

Plantar interossei (3):

Action: The plantar interossei act on digits 3-5 to adduct toes at the MTP joints.

Also flex toes at the MTP joints and extend toes at the IP joints (adduction is most
important action)
Innervation: Lateral plantar n.

Dorsal interossei (4):

Action: The dorsal interossei act on digits 2-4 to abduct toes at MTP joints.
Innervation: Lateral plantar n.

A way to remember their action is by remembering PAD-DAB :

P lantar AD duct
D orsal AB duct

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Foot: Vasculature

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

Foot: Vasculature
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The anterior tibial artery supplies the dorsum of the foot.

This is easy to remember since the anterior tibial a. supplies the anterior compartment of the
leg. As it enters the foot, the artery is called the dorsalis pedis a..

The dorsalis pedis a. runs subcutaneously with the deep peroneal nerve towards the big
toe. It penetrates the first dorsal interosseous muscle to complete the plantar arch medially.

The posterior tibial artery supplies the plantar surface of the foot via its terminal branches,
the medial and lateral plantar arteries.

The medial plantar a. courses with the medial plantar nerve.

The lateral plantar a. courses with the lateral plantar nerve and forms the plantar arch ,
which is met by the dorsalis pedis a. medially.

The plantar arch is the origin of the plantar digital arteries.

Pulses of the feet : The dorsalis pedis and posterior tibial arteries are easily palpated
because of their subcutaneous course.

The dorsalis pedis pulse can be felt on the dorsum running towards the big toe lateral to
the extensor hallucis longus tendon. The pulse can be accentuated by asking the patient to
dorsiflex the big toe.

The posterior tibial pulse can be felt posterior and inferior to the medial malleolus.

Absence of a pulse can be indicative of vascular insufficiency though an absent dorsalis


pedis pulse can sometimes be a normal anatomic finding.

Recall that there are four compartments of the leg: anterior, lateral, posterior deep and
superficial. Each compartment has a distinct neurovascular supply.

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Foot: Vasculature

The major arteries in the leg are the anterior and posterior tibial arteries and the fibular
a. , which is a branch of the posterior tibial a.

Of these, only the anterior and posterior tibial arteries continue into the foot.

Venous return of the foot is subcutaneous, draining into the great and small saphenous
veins.

The small saphenous v. courses posterior to the lateral malleolus and ascends the
posterior leg with the sural nerve.

The great saphenous v. originates on the dorsum of the foot near the MTP of the great toe
and courses anterior to the medial malleolus and ascends the leg with the saphenous
nerve.

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Gluteal Region: Muscles

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

Gluteal Region: Muscles


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The muscles of the gluteal region act on the femur to either flex, extend, adduct, abduct or
laterally rotate the thigh at the hip.

There are 4 gluteal muscles:

Gluteus maximus
Gluteus medius
Gluteus minimus
Tensor fasciae latae Gluteus maximus :

Attaches to the iliotibial tract (IT band) and the gluteal tuberosity of the femur.

Action: Extension, lateral rotation and abduction of the femur at the hip.
Innervation: Inferior gluteal n. Gluteus medius :
Action: Abduction and medial rotation of the femur at the hip.
Innervation: Superior gluteal n. Gluteus minimus :
Action: Medial rotation and abduction of the femur at the hip
Innervation: Superior gluteal n. Clinical Correlate: The gluteus medius and minimus
play an important role in walking. Their ability to abduct the hip prevents the opposite
side of the pelvis from sagging while standing on one leg. Weakness of either of these
muscles produces the Trendelenburg sign. Tensor fasciae latae :

The tensor fasciae latae originates around the ASIS and inserts into the iliotibial tract.

Action: Flexion, medial rotation and abduction of the hip ; lateral rotation and
extension of the knee; through its insertion on the IT tract, it helps keep the knee in a
locked position.
Innervation: Superior gluteal n.

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Gluteal Region: Muscles

Tensor fasciae latae muscle (red)

Image Credit: Adapted from Gray's Anatomy

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Gluteal Region: Muscles

Gluteus minimus (red)

Image Credit: Adapted from Gray's Anatomy

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Gluteal Region: Muscles

Gluteus medius (red). Note that the muscle has been cut to expose the underlying gluteus
minimus muscle.

Image Credit: Adapted from Gray's Anatomy

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Gluteal Region: Muscles

Gluteus maximus muscle (red)

Image Credit: CC by-SA 3.0

There are 7 lateral rotators of the thigh at the hip joint:

Piriformis
Obturator internus
Superior gemellus
Inferior gemellus
Quadratus femoris
Obturator externus
Gluteus maximus Piriformis :

The piriformis originates on the ant. surface of the sacrum, exits the pelvis via the greater
sciatic foramen , and inserts on the superior surface of the greater trochanter.

Action: Externally rotate thigh at hip ; assists in abduction when hip is flexed
Innervation: Nerve to the piriformis (S1-S2) Obturator internus :

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Gluteal Region: Muscles

The obturator internus originates from the internal surface of the obturator membrane (which
overlies the obturator foramen), exits the pelvis via the lesser sciatic foramen , and inserts
on the medial surface of the greater trochanter.

Action: Externally rotates the thigh at hip ; abduct thigh


Innervation: Nerve to obturator internus (L5, S1-2) Superior gemellus :

The superior gemellus originates from the ischial spine and insert onto the medial surface
of the greater trochanter.

Action: Externally rotate thigh at hip


Innervation: Nerve to obturator internus (L5, S1-2) Inferior gemellus :

The inferior gemellus originates from the ischial tuberosity and inserts onto the medial
surface of the greater trochanter.

Action: Externally rotate thigh at hip


Innervation: Nerve to quadratus femoris (L4-5, S1) Quadratus femoris :

The quadratus femoris originates on the tuberosity of the ischium and inserts on the
intertrochanteric crest.

Action: Externally rotate thigh at hip


Innervation: Nerve to quadratus femoris (L4-5, S1) Obturator externus :

The obturator externus originates on ischiopubic ramus and lateral boarder of obturator
membrane and inserts on the trochanteric fossa.

Action: Externally rotate thigh at hip


Innervation: Post. branch of obturator n. Note: The gluteus maximus is also an
external (lateral) rotator of the thigh. Additional information can be found above in the
section discussing the gluteal muscles.

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Gluteal Region: Nerves

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

Gluteal Region: Nerves


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Some nerves of the gluteal region supply the gluteal muscles and skin. Others pass through
the gluteal region to supply the lower limb.

The perforating cutaneous (S2-S3) nerve is the only nerve of the gluteal region that does
not traverse the greater sciatic foramen. It pierces the sacrotuberous ligament and supplies
the skin over the medial portion of the gluteus maximus.

Sacral nerves.

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Gluteal Region: Nerves

Lumbosacral plexus.

Sacrotuberous ligament and sciatic foramina.

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Gluteal Region: Nerves

Clinical Correlate: The gluteal region is commonly used as a site for the placement of
intramuscular injections.

Lower quadrants : Injections can injure the sciatic n. and the remainder of the nerves
and vessels emerging inferior to the piriformis muscle.
Upper medial quadrant : Injections can injure the superior gluteal n. and vessels as
they arise superior to the piriformis muscle.
Upper lateral quadrant : It is generally considered to be the ideal location for
placement of an injection as there are very few nerves and vessels traveling here.

The remaining nerves enter the gluteal region through the greater sciatic foramen. All but
one nerve, the superior gluteal nerve , enter inferior to the piriformis muscle.

Superior gluteal n. (L4-S1): The superior gluteal n. is the only nerve passing through the
greater sciatic foramen that travels superior to the piriformis muscle.

It supplies the gluteus medius, gluteus minimus, and tensor fascia latae muscles.
Sciatic n. : The sciatic n. is the largest nerve of the body and is formed by the
combination of the tibial (anterior part of L4-S3) and common peroneal (also known
as the fibular nerve; posterior part of L4-S2) nerves.
The sciatic nerve emerges from the greater sciatic foramen inferior to the piriformis
muscle. It travels inferiorly between the deep and superior muscles of the gluteal region
and supplies the lower limb. It has no branches in the gluteal region. Inferior gluteal n.
(L5-S2): The inferior gluteal n. travels posterior to the sciatic nerve and supplies the
gluteus maximus.
Remember the innervation of the gluteus maximus muscle with the mnemonic:
Gluteus maximus has an inferior ity complex. Nerve to the quadratus femoris (L4-
S1): The nerve to the quadratus femoris runs anterior to the deep gluteal muscles and
innervates the quadratus femoris and the inferior gemellus muscles. Nerve to the
obturator internus (L5-S2): The nerve to the obturator internus supplies the obturator
internus and superior gemellus muscles. Pudendal n. (S2-S4): The pudendal n. is the
primary nerve of the perineum. It enters the gluteal region through the greater sciatic
foramen then immediately exits through the lesser sciatic foramen. Posterior femoral
cutaneous n. (S1-S3): The posterior femoral cutaneous n. innervates skin over the
gluteal fold, scrotum (in men) or labia majora (in women), and posterior thigh.

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Gluteal Region: Nerves

Greater sciatic foramen (denoted in red).

Lumbosacral plexus. Note the origin of supply for the nerves that innervate the gluteal
musculature.

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Gluteal Region: Nerves

Nerves of the gluteal region and posterior thigh and leg.

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Gluteal Region: Nerves

Muscles of the gluteal region and posterior thigh.

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Gluteal Region: Nerves

Sciatic nerve traversing the gluteal region.

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Gluteal Region: Nerves

Muscles of the posterior hip region.

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Gluteal Region: Vasculature

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

Gluteal Region: Vasculature


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Superior gluteal artery :

The superior gluteal artery is a branch of the posterior trunk of the internal iliac artery. It
emerges superior to the piriformis muscle and immediately divides into superficial and
deep branches.

The deep branch courses between the gluteus medius and gluteus minimus muscles. It
travels with the superior gluteal nerve.

The superficial branch courses between the gluteus maximus and gluteus medius
muscles. It does NOT travel with a nerve.

The artery supplies blood to the gluteus maximus, medius, and minimus, as well as the
hip joint.

Note: The inferior gluteal artery provides the major blood supply to the gluteus maximus
muscle. The superficial branch of the superior gluteal artery forms anastomoses with the
inferior gluteal artery.

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Gluteal Region: Vasculature

Note the superior gluteal artery.

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Gluteal Region: Vasculature

Superior gluteal artery.

Inferior gluteal artery :

The inferior gluteal artery is a branch of the anterior trunk of the internal iliac artery. It
emerges inferior to the piriformis muscle.

It courses with the inferior gluteal nerve deep to the gluteus maximus muscle.

The artery anastomoses with branches of the femoral artery and with the superior gluteal
artery.

The two primary arteries of the gluteal region enter through the greater sciatic foramen.

The superior gluteal and inferior gluteal veins follow their respective arteries from the
gluteal region into the pelvic region.

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Leg: Muscles-Anterior Compartment

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

Leg: MusclesAnterior Compartment


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Tibialis anterior :

The tibialis anterior is the most anterior of the anterior compartment leg muscles. As the
name implies, the tibialis anterior originates from the anterior surface of the tibia.

Action: Dorsiflexion of the ankle and inversion of the foot ; provides support to the
medial arch of the foot
Innervation: Deep fibular n. Clinical Correlate: Injury to the deep fibular nerve (as with
fracture of the fibular head) can cause paralysis or weakness of the tibialis anterior and
other muscles in the anterior compartment of the leg resulting in foot drop.

The four muscles of the anterior compartment of the leg are innervated by the deep
branch of the peroneal (fibular) nerve, a branch of the common peroneal n.

Extensor hallucis longus :

The extensor hallucis longus originates from the distal fibula and inserts on the distal
phalanx of the hallux.

Action: Dorsiflexion of the ankle; extension of the IP and MTP joints of the hallux
Innervation: Deep fibular n.

Extensor digitorum longus :

The extensor digitorum longus originates from the surfaces of both the tibia and fibula. It
inserts via a tendon onto each of digits 2-5.

Action: Extension of MTP and IP joints of digits 2-5; dorsiflexion of the ankle
Innervation: Deep fibular n.

Peroneus (fibularis) tertius:

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Leg: Muscles-Anterior Compartment

The peroneus (fibularis) tertius is sometimes considered part of the extensor digitorum
longus. It originates from the medial surface of the fibula and inserts on the base of the 5th
metatarsal.

Action: Dorsiflexion of the ankle and eversion (weak) of the foot


Innervation: Deep fibular n.

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Leg: Muscles-Lateral Compartment

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

Leg: MusclesLateral Compartment


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There are two muscles in the lateral compartment of the leg: the fibularis (peroneus)
longus and the fibularis (peroneus) brevis.

Fibularis (peroneus) longus:

The fibularis (peroneus) longus originates from the superior, lateral surface of the fibula.
After passing posterior to the lateral malleolus, its tendon passes under the arch of the foot
and inserts on the base of the 1st metatarsal and the medial cuneiform.

Action: Eversion of the foot and plantar flexion of the ankle ; also provides support
to the arch of the foot
Innervation: Superficial fibular (peroneal) n.

Fibularis (peroneus) brevis:

The fibularis (peroneus) brevis is deep to the fibularis longus. It originates from the distal,
lateral surface of the fibula. Like the fibularis longus, its tendon hooks around the lateral
malleolus and inserts on the tuberosity of the 5th metatarsal.

Action: Eversion of the foot; plantar flexion of the ankle


Innervation: Superficial fibular (peroneal) n.

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Leg: Muscles-Posterior Compartment

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

Leg: MusclesPosterior Compartment


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The superficial and deep muscles of the posterior compartment of the leg are anatomically
separated by a layer of fascia.

The tendons of the three superficial muscles all fuse to form the calcaneal (achilles)
tendon. The calcaneal tendon inserts on the posterior surface of the calcaneous.

Gastrocnemius :

The gastrocnemius has two heads, medial and lateral, which originate from the medial
condyle and lateral condyle of the femur.

Action: Plantar flexion of the ankle and flexion of the knee


Innervation: Tibial n. Soleus :

The soleus resides deep to the gastrocnemius.

Action: Plantar flexion of the ankle


Innervation: Tibial n. Plantaris :

The plantaris is a small muscle with a long, thin tendon.

Action: Plantar flexion of the foot (extremely weak and often considered an
unimportant muscle)
Innervation: Tibial n.

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Leg: Muscles-Posterior Compartment

Gastrocnemius muscle (red)

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Leg: Muscles-Posterior Compartment

Superficial muscles of the posterior leg

There are four deep muscles of the posterior compartment of the leg: popliteus, flexor
hallucis longus, tibialis posterior and flexor digitorum longus.

Popliteus :

The popliteus forms part of the floor of the popliteal fossa.

Action: Medial rotation of the knee; "unlocking" the knee prior to knee flexion
Innervation: Tibial n. Tibialis posterior :

The tendon of the tibialis posterior muscle hooks around the medial malleolus and
passes forward to insert on the plantar surface of the foot.

Action: Inversion of the foot and plantar flexion of the ankle ; also supports the
medial arch of the foot during walking
Innervation: Tibial n. Flexor digitorum longus (FDL):

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Leg: Muscles-Posterior Compartment

The tendon of FDL hooks around the posterior aspect of the medial malleolus, posterior
to the tendon of the tibialis posterior. On the plantar surface of the foot it divides into
small tendons which insert onto digits 2-5.

Action: Flexion of DIP, PIP and MTP joints of digits 2-5; plantar flexion of the ankle
Innervation: Tibial n. Flexor hallucis longus (FHL):

The FHL originates on the posterior surface of the fibula.

Action: Flexion of the IP and MTP joints of the hallux; plantar flexion of the ankle
Innervation: Tibial n.

Tibialis posterior muscle (red)

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Leg: Muscles-Posterior Compartment

Deep muscles of the posterior compartment of the leg.

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Leg: Nerves

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Leg: Nerves
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Just superior to the knee, the sciatic nerve divides into the tibial n. and the common
fibular n. These two nerves continue inferiorly to supply muscles and skin of the leg and
foot.

Tibial nerve :

The tibial n. (L4-5, S1-3) primarily supplies the posterior compartment of the leg.

Note: The posterior compartment can be subdivided into superficial and deep
compartments. Both are supplied by the tibial nerve. Muscles in the leg innervated by the
tibial n. are the:

Gastrocnemius
Soleus
Plantaris
Popliteus
Flexor digitorum longus
Flexor hallucis longus
Tibialis posterior The terminal branches of the tibial n. are the medial and lateral
plantar nn., which supply the plantar surface of the foot.

The sural n. is a branch of the tibial n. originating between the two heads of the
gastrocnemius. It provides cutaneous innervation to the skin of the lower posterolateral leg
and lateral side of the foot and little toe.

Note: For information regarding the terminal branches of the tibial nerve in the foot, please
see Foot: Nerves.

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Leg: Nerves

Tibial nerve exiting the popliteal fossa to innervate the posterior compartment of the leg.

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Leg: Nerves

Innervation of the posterior thigh and leg. Note the path of the tibial nerve.

Common fibular (peroneal) nerve:

The common fibular (peroneal) n. (L4-5, S1-2) primarily supplies the anterior and lateral
compartments of the leg. It runs superficial to the neck of the fibula. Just distal to the knee
on the lateral aspect of the leg, the common fibular n. divides into the deep fibular n. and
the superficial fibular n.

Superficial fibular n. The superficial fibular n. descends in the lateral compartment

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Leg: Nerves

of the leg and supplies the fibularis longus and the fibularis brevis muscles. It also
supplies the skin of the distal, lateral leg.
Deep fibular n. The deep fibular n. travels to the deep anterior area of the leg and
supplies the muscles of the anterior compartment: the tibialis anterior, extensor
digitorum longus, extensor hallucis longus, and fibularis tertius. The common
fibular n. also gives off two cutaneous nerves:

Sural communicating n. joins the sural n. to supply skin of the lower posterolateral
leg

Lateral sural n. supplies skin of the upper lateral leg Clinical Correlate: The deep
fibular n. can become injured in fractures of the neck of the fibula. This causes loss
of dorsiflexion due to weakness of tibialis anterior, extensor hallucis longus, extensor
digitorum longus and peroneus tertius. This condition is called foot drop.

Note: Fracture of the proximal fibula or fibular head can damage the common fibular nerve.
In this case, deep fibular n. and superficial fibular n. deficits would be present, including foot
drop.

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Leg: Vasculature

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Leg: Vasculature
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Popliteal artery :

The popliteal artery is the distal continuation of the femoral artery and its branches and
continuations supply all of the compartments of the leg and foot. The popliteal a. enters the
posterior compartment of the leg between the two heads of the gastrocnemius. It courses
with the tibial nerve but soon divides into the posterior and anterior tibial aa.

Anterior tibial artery :

After branching off the popliteal artery, the anterior tibial a. courses around the lateral aspect
of the leg between the tibia and fibula, and descends in the anterior compartment of the
leg giving off multiple branches. It travels with the deep fibular n. The recurrent branch of
the anterior tibial a. anastomoses with vasculature of the knee area.

When it crosses the ankle joint, it is known as the dorsalis pedis a.

Posterior tibial artery :

The posterior tibial a . supplies the posterior compartment of the leg. A major branch of
the posterior tibial a., the fibular a. (the other branch is the circumflex fibular artery),
supplies the lateral compartment of the leg. The fibular a. arises proximally from the
posterior tibial a. It parallels the course of the posterior tibial a. but descends on the lateral
side of the posterior compartment.

It gives off perforating branches that supply the lateral compartment of the leg. These
perforating branches pass through the interosseous membrane and eventually anastomose
with the anterior tibial artery.

The terminal branches of the posterior tibial a. are the medial and lateral plantar aa., which
supply the plantar surface of the foot.

350
Lumbosacral Plexus

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

Lumbosacral Plexus
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The lumbosacral plexus is made up of the anterior rami of L1-S4, with the lower
extremities being innervated by L2-S3.

Lumbosacral plexus - sacral plexus

352
Lumbosacral Plexus

Lumbosacral plexus - lumbar plexus

Nerves of the lower extremity and their spinal roots:

Femoral n.
Obturator n.
Tibial n.
Common fibular (peroneal) n. Femoral n. Posterior divisions of L2-L4 Obturator n.
Anterior divisions of L2-L4 (Note: Do not confuse with the nerve to the obturator.)
Tibial n. Anterior divisions of L4-S3 (from sciatic nerve) Common fibular (peroneal)
n. Posterior divisions of L4-S2 (from sciatic nerve)
Note: The tibial and common fibular nerve comprise the sciatic nerve.

Sciatic nerve:

The sciatic n . is the largest nerve in the body. Splits to form the following 2 nerves:

Tibial n. (anterior branches of L4-S3)


Common fibular n. (peroneal n.) (posterior branches of L4-S2) The common fibular
(peroneal) n. divides at the level of the proximal fibula into the superficial and deep
fibular (peroneal) nerves.

353
Lumbosacral Plexus

Common fibular (peroneal) nerve. Note the splitting of the nerve into the superficial deep
fibular (peroneal) nerves.

354
Lumbosacral Plexus

Sciatic, tibial, and common fibular nerves.

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Lumbosacral Plexus

Tibial and common fibular nerves.

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Lumbosacral Plexus

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Lumbosacral Plexus

Sciatic, tibial, and common fibular nerves.

Femoral nerve :

The femoral n. innervates muscles of the anterior osteofascial compartment of the thigh
: sartorius and quadriceps femoris, as well as the pectineus (in the medial osteofascial
compartment)

The femoral n. also innervates the iliacus.

Note: The pectineus can be considered a component of the medial compartment when
considering muscle function and the anterior compartment when considering innervation.
Classification varies by source.

Actions: Flexion of hip, extension of leg at knee joint (all quadriceps extend the knee
joint), lateral rotation of the thigh, and hip adduction (pectineus)

Obturator nerve :

The obturator n . innervates muscles of the medial osteofascial compartment of the thigh
(with the exception of the pectineus):

Adductor longus
Gracilis
Adductor brevis
Obturator externus
Adductor magnus
Actions: Adduction, medial and lateral rotation of the thigh, and flexion of the
thigh at the hip joint (adductor portion of adductor magnus)

Note: The obturator externus is involved with external rotation and extension at the hip
joint.

Tibial nerve :

The tibial n. innervates muscles of the posterior osteofascial compartment of the thigh.

The hamstring muscles include:

Semimembranosus
Semitendinosus

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Lumbosacral Plexus

Long head of biceps femoris

The tibial nerve also innervates the posterior compartment of the leg :

Gastrocnemius
Soleus
Plantaris
Popliteus
Tibialis posterior
Flexor digitorum longus
Flexor hallucis longus

Note: The sciatic nerve is often considered to supply innervation to the hamstring muscles,
but more specifically, it is the tibial portion supplying the innervation. The hamstring portion
of the adductor magnus is also innervated by the tibial nerve.

Actions: Extension of thigh at the hip, flexion of the leg at the knee, plantarflexion
of the foot at the ankle, inversion and adduction of the foot, and flexion of the
toes

Common fibular (peroneal) nerve:

The common fibular n. (peroneal n.) innervates the short head of biceps femoris. The
superficial fibular n. innervates the fibularis longus and fibularis brevis.

The deep fibular n. innervates leg muscles : tibialis anterior, extensor hallucis longus,
extensor digitorum longus and peroneus tertius.

The deep fibular n. also innervates foot muscles : extensor digitorum brevis and extensor
hallucis brevis.

Actions:

Common fibular n. Flexion of the knee


Superficial fibular n. Eversion and plantar flexion
Deep fibular n. Dorsiflexion, inversion, and adduction of the foot, extension of great
toe, extension of lateral 4 toes, weak foot eversion (peroneus tertius)

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Lumbosacral Plexus

Lumbosacral plexus - common peroneal nerve palsy, foot drop

360
Lumbosacral Plexus

Lumbosacral plexus - common peroneal (fibular) nerve (peroneal division of sciatic nerve),
distribution

361
The Ankle (Talocrural) Joint

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

The Ankle (Talocrural) Joint


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The ankle (talocrural) joint is formed by the articulation of the tibia, talus, medial and lateral
malleoli.

It is surrounded by a fibrous capsule and reinforced by the deltoid ligament on the medial
side and anterior talofibular, posterior talofibular, and calcaneofibular ligaments on the
lateral side.

362
The Ankle (Talocrural) Joint

Foot and ankle, plantar view w/ tendons labeled (FDL, FHL, peroneus longus, peroneus
brevis)

363
The Ankle (Talocrural) Joint

Foot, lateral view w/ 3 ligaments labeled (post talofibular, calcaneofibular, ant talofibular)

364
The Ankle (Talocrural) Joint

Foot, frontal view w/ bones labeled + 2 ligaments labeled (ant talofibular, deltoid)

The medial (deltoid) ligament attaches superiorly at the medial malleolus.

It has 4 parts which attach to the tuberosity of the navicular, medial talus, sustentaculum tali
of the calcaneus and tibia.

It resists eversion of the ankle.

Clinical Correlate: The deltoid ligament is so strong that extreme eversion injuries often
result in fracture of the medial malleolus instead of ligamentous injury.

365
The Ankle (Talocrural) Joint

The lateral ligament is actually composed of 3 separate ligaments that resist extreme
inversion of the foot :

Anterior talofibular ligament (ATFL) The ATFL can be torn during extreme
inversion of the foot and is the most commonly torn ankle ligament.
Calcaneofibular ligament
Posterior talofibular ligament

Ankle fractures are common among young athletes.

The mechanism of injury can be discerned from X-ray:

Twisting force spiral fracture


Compressive force talus impact breaks posterior malleolus of tibia
Inversion/Eversion collateral ligament will pull off piece of malleolus causing
transverse fracture Since ankle fractures are intra-articular, restoration of the joint is
essential to preserve integrity. Approximately 1mm of dislocation can result in 40% loss
in surface contact.

366
The Hip Joint

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

The Hip Joint


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The hip joint is a ball and socket joint formed by the articulation between the head of the
femur and the acetabulum of the pelvis.

The pelvic bone is composed of 3 separate bones that fuse together during puberty:

Ilium
Ischium
Pubis

These three components of the hip bone contribute to forming the "socket" portion of the
hip joint called the acetabulum. The acetabular labrum forms a fibrocartilaginous rim
surrounding the bony acetabulum. It is analogous to the glenoid labrum in the shoulder.

The transverse acetabular ligament is the part of the acetabular labrum that spans the
acetabular notch.

The head of the femur is encapsulated in articular cartilage everywhere except for at the
fovea , the central pit found on the head.

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The Hip Joint

Cross sectional view of the hip joint capsule

Image Credit: Gray's Anatomy

368
The Hip Joint

Internal view of the hip joint. Note the fovea and the ligament of the head of the femur, which
emerges from it.

Image Credit: Gray's Anatomy

369
The Hip Joint

Hip -- note the surrounding mm + nn + aa + vv

370
The Hip Joint

The hip joint

Image Credit: Smith & Nephew, FAL

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The Hip Joint

The hip joint and surrounding ligaments.

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The Hip Joint

Lateral view of the hip joint (source).

The hip joint is surrounded by a fibrous capsule that provides stability against excessive
motion of the joint.

Note: Please see the individual ligaments below for the specific restrictions of motion.

Iliofemoral ligament : The iliofemoral ligament attaches to the AIIS (anterior inferior iliac
spine) of the hip bone and the intertrochanteric line on the femur.

It resists against excessive extension and medial rotation of the hip. Ischiofemoral
ligament : The ischiofemoral ligament attaches the anterior and posterior aspects of the
acetabulum to the greater trochanter of the femur.
Similar to the iliofemoral ligament, it resists excessive extension and medial rotation of
the hip. Pubofemoral ligament : The pubofemoral ligament extends from the obturator
crest to the medial aspect of the base of the neck of the femur.
It resists against excessive extension, medial rotation, and abduction of the hip joint.
Ligament of head of femur : The ligament of the head of the femur extends from the
fovea of the head of the femur to the transverse acetabular ligament.
It resists against excessive adduction of the hip.

373
The Hip Joint

Note: Some authors consider the ligament to contribute limited influence on hip mechanics
and stability.

Ischiofemoral ligament

Image Credit: Gray's Anatomy

374
The Hip Joint

Iliofemoral ligament

Image Credit: Gray's Anatomy

375
The Hip Joint

hip joint, posterior view

376
The Hip Joint

Hip joint, anterior view

377
The Hip Joint

The hip joint and surrounding ligaments.

Movements of the hip joint:

Extension : Posterior movement of the thigh in a sagittal plane


Flexion : Anterior movement of the thigh in a sagittal plane
Abduction : Movement of the thigh away from the body in a coronal plane
Adduction : Movement of the thigh towards the body in a coronal plane
Lateral Rotation : Rotation of the thigh so the anterior surface now faces laterally
Medial Rotation : Rotation of the thigh so the anterior surface now faces more medially
Circumduction : A combination of the above movements, wherein the knee traces a
circular path

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The Hip Joint

Movements of the hip joint

379
The Hip Joint

Anatomical motions. Note medial and lateral rotation of the thigh.

Clinical Correlates:

Congenital hip dislocation results from failure of the superior portion of the acetabular
labrum to properly form, with resultant superior dislocation of the head of the femur.
Developmental dysplasia of the hip occurs with ligamentous laxity of the hip joint
and/or a shallow acetabulum.
The most frequent traumatic hip dislocation is a posterior dislocation , which can
classically cause damage to the sciatic nerve.
Instability of the hip joint results in a positive Trendelenburgs sign.

380
The Knee Joint

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

The Knee Joint


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The knee joint is a complex joint that includes:

Hinge joint between the femur and tibia


Plane gliding joint between the patella and femur

The pathologic conditions of the knee are reviewed here: Knee conditions The patella
is a large sesamoid bone held completely within the patellar ligament and quadriceps
femoris tendon.

A fibrous capsule surrounds the knee joint to add stability.

Medially, the capsule attaches to the medial meniscus.


Laterally, the capsule does NOT attach to the lateral meniscus.

Anterior cruciate ligament (ACL): The ACL originates on the lateral femoral condyle
(medial surface) and inserts on the anterior intercondylar region of the tibia. It inserts
anterior to the PCL on the tibia.

The ACL prevents excessive anterior movement of the tibia in relation to the
femur.
Posterior cruciate ligament (PCL): The PCL attachments are opposite that of the ACL;
it attaches to the lateral aspect of the superior surface of the tibia and the medial aspect
of the inferior surface of the femur. It inserts posterior to the ACL on the tibia.

The PCL prevents excessive posterior movement of the tibia in relation to the
femur.
Medial collateral ligament (MCL): The MCL attaches to the medial epicondyle of the
femur and the medial surface of the tibia. It also attaches to the medial meniscus.

The MCL resists excessive abduction of the leg at the knee (valgus stress).
Lateral collateral ligament (LCL): The LCL attaches to the lateral epicondyle of the
femur and lateral surface of the head of the fibula. It does not attach to the lateral
meniscus.

381
The Knee Joint

The LCL resists excessive adduction of the leg at the knee (varus stress).
Note: The LCL is also known as the fibular collateral ligament.
Patellar tendon: The patellar tendon is a continuation of the quadriceps femoris
tendon inferior to the patella.

Tension from the quadriceps femoris muscles is transferred to the tibia through the
patellar tendon to extend the leg at the knee.

Knee joint, movements of knee

382
The Knee Joint

Anterior and posterior cruciate ligaments.

383
The Knee Joint

Posterior view of the left knee. Note the PCL and the relationship of the collateral ligaments
to their respective menisci. The LCL is depicted as the fibular collateral ligament on this
image.

384
The Knee Joint

Anterior view of the knee joint.

385
The Knee Joint

Knee joint, anterior view (patella removed)

386
The Knee Joint

Knee joint, posterior view

The menisci are fibrocartilaginous structures that provide padding to the articulating
surfaces of the tibia and femur. They are malleable enough to accommodate the change
in shape of the knee joint during flexion and extension.

The medial and lateral menisci are connected anteriorly by a small transverse ligament.

Due to the medial meniscuss attachment to the fibrous capsule of the knee and MCL,
damage to either will often damage the medial meniscus as well.

387
The Popliteal Fossa

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

The Popliteal Fossa


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The popliteal fossa is a diamond shaped space behind the knee.

The borders of the popliteal fossa are:

Superior Semimembranosus and semitendinosus (medially) and the biceps femoris


m. laterally
Inferior The medial and lateral heads of the gastrocnemius m.
Deep The popliteal surface of the femur

Major contents include important neurovascular structures: From superficial to deep:

Tibial n.
popliteal v.
popliteal a. The common fibular n. runs laterally between the tendon of the biceps
femoris and lateral head of the gastrocnemius.

The popliteal a. has several branches within the popliteal fossa:

Medial & lateral superior genicular aa.


Middle genicular a.
Medial & lateral inferior genicular aa.

Anastomoses between the genicular arteries allow blood to flow during compression
of the popliteal a. (as in flexion of the knee.)

Clinical Correlates:

A Bakers cyst , or popliteal cyst, is a common benign swelling of the synovial bursa
in the popliteal fossa. This outpouching of the synovial membrane can occur as a
result of any inflammatory or traumatic injury.
A popliteal artery aneurysm (PAA) is the most common peripheral aneurysm (1% men
65-80). It usually presents with claudication and discomfort. While rupture is rare ,

388
The Popliteal Fossa

thrombi or embolisms can cause distal ischemia necessitating amputation.


The large caliber of the popliteal vein can lead to blood stasis and thus is a common site
of origin for deep vein thromboses (DVT).

Embryology Correlate: Recall that the legs rotate 180 degrees inward during
embryogenesis, meaning the popliteal fossa is analogous to the cubital fossa. Both are
bordered by their respective biceps muscles.

389
Thigh: Muscles-Anterior Compartment

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

Thigh: MusclesAnterior Compartment


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The muscles of the anterior compartment of the thigh act on both the hip and knee joints.

Sartorius :

The sartorius muscle descends from the anterior superior iliac spine (ASIS) and inserts
distally on the medial surface of the proximal tibia at the pes anserinus, along with the
tendons of the gracilis and semitendinosus muscles.

Action: Flexion of the thigh at the hip joint and flexion of the leg at the knee joint, as well
as abduction and lateral rotation of the hip
Innervation: Femoral n.

Mnemonic: Remember the muscles that contribute tendons to the pes anserinus (latin for
"goose foot") and the nerves that innervate them: "Sergeant FOT"

S S artorius
G G racilis
T semi T endinosus (from anterior to posterior)
F F emoral nerve
O O bturator nerve
T T ibial nerve Iliopsoas :

The Iliopsoas is made up of the iliacus (from the iliac fossa) and the psoas major (from the
posterior abdominal wall).

Action: Flexion of the hip and lumbar spine


Innervation: The Iliopsoas muscle is a fusion of two muscles and has 2 innervations.

Iliacus Femoral n.
Psoas major Ventral rami L1-3 Articularis genus :

The articularis genus is a tiny muscle that originates on the lower part of the femur and
attaches to the suprapatellar bursa. It is usually part of the much bigger vastus intermedius
muscle.

Action: Draw the suprapatellar bursa proximally during extension of the knee and
preventing injury to the suprapatellar bursa
Innervation: Femoral n.

390
Thigh: Muscles-Anterior Compartment

Quadriceps femoris :

The quadriceps femoris is composed of 4 different muscles:

Rectus femoris
Vastus medialis
Vastus intermedius
Vastus lateralis

Action: Extension of leg at the knee joint


Innervation: Femoral n.
Blood supply: Femoral a. The rectus femoris originates from the AIIS (anterior
inferior iliac spine) and the superior acetabular rim. It crosses both the hip joint and
the knee joint. In addition to extending the leg at the knee, it also flexes the thigh at
the hip joint.

The vastus lateralis originates from the lateral part of the femur.

The vastus medialis originates medially from the femur.

Innervation: Nerve to the vastus medialis , a branch of femoral n. The vastus


intermedius originates from the anterior surface of the femur.

The quadriceps muscles converge to insert on the patella via the quadriceps tendon ,
which attaches distally to the tibial tuberosity, where it is known as the patellar ligament.

Some fibers of the quadriceps tendons insert into the capsule of the knee joint and help
strengthen it.

Some fibers of the vastus medialis tendon are horizontal at the knee and help prevent lateral
displacement of the patella during contraction of the quadriceps femoris.

391
Thigh: Muscles-Anterior Compartment

Vastus medialis muscle (red)

Image Credit: Adapted from Gray's Anatomy

392
Thigh: Muscles-Anterior Compartment

Vastus lateralis muscle (red)

Image Credit: Adapted from Gray's Anatomy

393
Thigh: Muscles-Anterior Compartment

Rectus femoris muscle (red)

Image Credit: Adapted from Gray's Anatomy

394
Thigh: Muscles-Medial Compartment

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

Thigh: MusclesMedial Compartment


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The muscles of the medial compartment of the thigh are primarily involved with adduction
of the thigh at the hip joint.

Gracilis :

The gracilis originates from the pubis and inserts on the medial proximal tibia at the pes
anserinus.

Action: Adduction of the thigh at the hip joint and flexion and medial rotation of
the leg at knee joint
Innervation: Obturator n. (anterior branch) Pectineus :

The pectineus muscle originates from the pectineal line of the pelvic bone and attaches to
the base of the lesser trochanter to the linea aspera.

Action: Flexion and adduction of the thigh at the hip joint


Innervation: Femoral n. with variable innervated by the obturator n. Obturator
externus :

The obturator externus muscle originates from the external surface of the obturator
membrane and inserts on the trochanteric fossa of the femur.

Action: Lateral rotation of the the thigh at the hip joint


Innervation: Obturator n. (posterior branch)

Note: The obturator externus is included as a member of the medial compartment of the
thigh by some sources. It is included because of location but functions as a lateral
rotator of the thigh.

395
Thigh: Muscles-Medial Compartment

Obturator externus muscle originating from the external surface of the obturator membrane

Image Credit: Gray's Anatomy

396
Thigh: Muscles-Medial Compartment

Pectineus muscle (red)

Image Credit: Gray's Anatomy

The muscles with adductor in their name, from anterior to posterior, are the: adductor
longus, adductor brevis , and adductor magnus. All three originate from the pubis portion
of the pelvic bone and insert on the posterior femur.

All three act to adduct and flex the thigh at the hip and are innervated by the obturator
nerve.

Note: The adductor magnus also originates on the ischial tuberosity (see more detail below).

Adductor longus :

397
Thigh: Muscles-Medial Compartment

The adductor longus muscle originates on the pubis and inserts on the linea aspera on the
femur. This muscle makes up the medial border of the femoral triangle

Action: Adduction and flexion of the thigh at the hip joint

Innervation: Obturator n. (anterior branch) Adductor brevis :

The adductor brevis originates from the pubis and inserts on the posterior surface of the
femur on the linea aspera.

Action: Adduction and flexion of the thigh at the hip joint

Innervation: Obturator n. (anterior and posterior branches) Adductor magnus :

The adductor magnus is the largest muscle of the medial compartment of the thigh. It is
divided into 2 segments which have different functions: the superior (adductor) part and the
inferior (hamstring) part.

Action: Adduct and flex thigh at the hip joint adductor function
Innervation: Obturator nerve

Action: Extend thigh at the hip joint hamstring function


Innervation: Tibial division of sciatic n.

Note: The adductor magnus has both vertical and horizontal fibers. The vertical fibers are
innervated by the tibial branch of the sciatic nerve and have hamstring function. The superior
horizontal fibers are innervated by the obturator nerve and have adductor and flexion
function.

398
Thigh: Muscles-Posterior Compartment

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

Thigh: MusclesPosterior Compartment


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The muscles of the posterior compartment of the thigh are often collectively referred to as
the hamstrings.

All muscles of the posterior compartment of the thigh, except for the short head of the biceps
femoris, cross the hip and knee joint. The short head of the biceps femoris only crosses the
knee joint.

Biceps femoris : The biceps femoris is comprised of long and short heads.

The long head originates from the ischial tuberosity and the short head originates from the
linea aspera of the femur. Both heads insert on to the head of the fibula.

Action: Flexion and lateral rotation of the knee; the long head also extends the hip
Innervation: Long head by the tibial division of sciatic nerve ; short head by the
fibular (common peroneal) division of the sciatic nerve Semitendinosus : The
semitendinosus originates from the ischial tuberosity and inserts on the medial surface
of the tibia into the pes anserinus.
Action: Flexion and medial rotation of the knee; extension of the hip
Innervation: Tibial division of the sciatic nerve Semimembranosus : The
semimembranosus originates from the ischial tuberosity and inserts on medial surface
of the tibia.
Action: Flexion and medial rotation of the knee; extension of the hip
Innervation: Tibial division of the sciatic nerve

399
Thigh: Muscles-Posterior Compartment

Biceps femoris muscle short head (red)

400
Thigh: Muscles-Posterior Compartment

Biceps femoris long head (red)

401
Thigh: Muscles-Posterior Compartment

Semitendinosus (red)

402
Thigh: Muscles-Posterior Compartment

Semimembranosus muscle (red)

403
Thigh: Muscles-Posterior Compartment

Proximal end of the femur.

404
Thigh: Muscles-Posterior Compartment

405
Thigh: Muscles-Posterior Compartment

Anterior femur.

406
Thigh: Muscles-Posterior Compartment

407
Thigh: Muscles-Posterior Compartment

Posterior femur.

Superior epiphysis of the femur.

The pes anserinus attaches inferior to the medial tibial condyle and is the site of insertion of
1 muscle from each compartment of the thigh:

Semitendinosus Posterior compartment


Sartorius Anterior compartment
Gracilis Medial compartment Mnemonic: SGT - S artorius, G racilis, semi T
endinosis

408
Thigh: Nerves

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

Thigh: Nerves
https://med.firecracker.me/app#/tree/1/1-20-41-77-457

Femoral nerve :

The femoral nerve (posterior division of L2-L4) and its branches supply the anterior fascial
compartment of the thigh.

Note: The femoral nerve also supplies the pectineus in the medial compartment, as well as
the iliopsoas that is often considered a member of the anterior compartment. The femoral n.
enters the anterior compartment of the thigh by passing under the inguinal ligament.

Sensory branches: The sensory branches supply the skin of the distal medial and distal
anterior thigh. Distally, the femoral n. continues as the saphenous nerve , which
supplies the medial leg and foot.
Motor branches: The motor branches innervate the sartorius, quadriceps (vastus
medialis, vastus intermedius, rectus femoris, and vastus lateralis), pectineus, iliacus,
and articularis genus.

Femoral sheath.

409
Thigh: Nerves

Femoral nerve: The nerve of the anterior compartment of the thigh. Note that distally it
becomes the saphenous nerve.

410
Thigh: Nerves

Cadaveric image of anterior thigh. Note femoral nerve.

411
Thigh: Nerves

Cadaveric image of anterior thigh. Note femoral nerve.

412
Thigh: Nerves

Anterior and posterior cutaneous innervation of the thigh and leg.

413
Thigh: Nerves

414
Thigh: Nerves

Muscles of the anterior thigh.

Obturator nerve :

The obturator nerve (anterior division of L2-L4) supplies the medial compartment of the
thigh. The obturator n. divides into the anterior and posterior branches within the obturator
canal.

Posterior branch : The posterior branch pierces the obturator externus and descends
between the adductor brevis and adductor magnus muscles.

Innervation: Obturator externus , part of the adductor brevis , and superior fibers
of the adductor magnus
Anterior branch : The anterior branch runs between the adductor longus and adductor
brevis muscles.

Innervation: Adductor longus , gracilis , part of the adductor brevis , as well as


cutaneous innervation of the medial thigh

Note: The pectineus is innervated by the femoral nerve but can receive variable partial
innervation by the obturator nerve.

415
Thigh: Nerves

Transverse (axial) plane of the thigh. Note the obturator nerve.

Obturator nerve piercing the obturator externus muscle.

416
Thigh: Nerves

Obturator nerve.

417
Thigh: Nerves

Cadaveric image highlighting the obturator nerve.

Sciatic nerve :

The sciatic nerve (L4-S3) supplies the posterior compartment of the thigh. The sciatic
nerve is composed of a tibial (anterior division of L4-S3) portion and a common fibular
portion (posterior division of L4-S2). The common fibular nerve is often called the common
peroneal nerve.

The sciatic n. descends deep to the long head of the biceps femoris.

With the exception of the short head of the biceps femoris, the tibial portion of the sciatic
nerve innervates all muscles of the posterior compartment of the thigh: long head of biceps
femoris , semimembranosus , and semitendinosus. Also supplies the inferior fibers of the
adductor magnus.

The short head of the biceps femoris is innervated by the fibular division of the sciatic
nerve.

Just proximal to the knee, the divisions of the sciatic nerve bifurcate and take separate paths
to innervate the leg and foot.

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Thigh: Nerves

Skin of the posterior thigh is innervated by the posterior cutaneous nerve of the thigh
(aka posterior femoral nerve), a nerve originating in the gluteal region. The skin of the
posterior thigh is not innervated by the tibial or common fibular nn.

Cadaveric image of the posterior thigh. Note the sciatic nerve.

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Thigh: Nerves

Cadaveric image of the sciatic nerve emerging deep to the piriformis.

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Thigh: Nerves

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Thigh: Nerves

Nerves of the posterior thigh.

There is one primary nerve each for the anterior, medial and posterior compartments of the
thigh.

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Thigh: The Femoral Triangle

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

Thigh: The Femoral Triangle


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Femoral triangle :

The femoral triangle is an anatomical space inferior to the inguinal ligament which spans
between the iliac crest and pubic tubercle, and is bounded laterally by the sartorius m. and
medially by the adductor longus m. From lateral to medial, the contents of the femoral
triangle are the:

Femoral N erve
Femoral A rtery
Femoral V ein
E mpty space filled by the femoral canal
L ymphatics Mnemonic: NAVEL

Note: The lymphatics are found within the femoral canal. The "E" of the mnemonic stands as
a reminder that the femoral canal is medial to the femoral nerve, artery, and vein.

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Thigh: The Femoral Triangle

Contents of the femoral triangle: femoral nerve, artery and vein.

The femoral triangle is bounded laterally by the superior portion of the sartorius m. and
medially by the lateral border of the adductor longus m. Note the contents: femoral n.
(yellow), femoral a. (red) and femoral v. (blue).

The femoral sheath contains the femoral a., femoral v., and femoral canal.

The femoral canal contains some inguinal lymphatics and nodes, and is a potential site for
hernias.

Femoral hernias occur when a loop of intestine passes through the femoral ring and into
the femoral canal. It occurs more commonly in females.

The vessels in the femoral triangle are superficial. The femoral vein can be used for venous
access (for lab draws, drugs, nutrition) and is a route used for right coronary angiography.

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Thigh: Vasculature

USMLE Step 1 > Basic Sciences > Anatomy > Lower Limb

Thigh: Vasculature
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Femoral artery :

The femoral artery is a continuation of the external iliac artery inferior to the inguinal
ligament. It is the primary source of blood supply to the lower limb. The femoral artery
descends and enters the adductor hiatus , then exits the adductor hiatus into the popliteal
fossa on the posterior surface of the knee as the popliteal artery.

Four small branches arise from the femoral artery within the femoral triangle :

The superficial epigastric a. ascends to supply the superficial abdomen.


The superficial circumflex iliac a. supplies the groin region.
The superficial external pudendal and deep external pudendal aa. supply the
superficial perineal region. Profunda femoris artery :

The only major branch of the femoral a. is the profunda femoris a. (deep artery of the thigh).

It descends between the adductor longus and adductor brevis muscles proximally, then
between the adductor longus and adductor magnus muscles distally. Its branches are:

Lateral circumflex femoral a.


Medial circumflex femoral a.
Four perforating arteries that penetrate the adductor magnus and supply the
posterior compartment of the thigh

Three major arteries supply the thigh:

Femoral a.
Profunda femoris a.
Obturator a.

Obturator artery :

The obturator artery is a branch of the internal iliac artery that supplies structures of the
superior medial thigh.

425
Anal Triangle

USMLE Step 1 > Basic Sciences > Anatomy > Pelvis

Anal Triangle
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The perineum is the area between the thighs and the gluteal clefts below the pelvic
diaphragm.

It is divided by an imaginary line between the ischial tuberosities into the urogenital triangle
anteriorly and the anal triangle posteriorly.

Male perineum.

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Anal Triangle

Female perineum.

The anal triangle is defined anteriorly by the horizontal line between the two ischial
tuberosities (imaginary line) and posteriorly by the coccyx.

It contains the ischioanal fossa , the anal orifice and the external anal sphincter.

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Anal Triangle

Anal Triangle.

429
Anal Triangle

Anal Triangle - Male.

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Anal Triangle

Anal Triangle - Female.

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Anal Triangle

External anal sphincter.

External anal sphincter.

The ischioanal fossae on each side of the anal canal are wedge shaped spaces between
the skin (superficial) and the pelvic diaphragm (deep). It is normally covered with fat for
support and expansion of the anal canal during passage of feces.

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Anal Triangle

It is medially and laterally bound by the levator ani and the obturator internus muscles
respectively.

Male perineum.

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Anal Triangle

Female perineum.

The anal canal is the terminal portion of the colon and lies between the rectum and the anal
opening.

The pectinate line :

The pectinate line forms the junction between hindgut and embryonic ectoderm
derivative. The innervation, arterial blood supply, venous drainage and mucosal lining are
different superior and inferior to the line.

Superior to the pectinate line the anal canal has a simple columnar epithelium. It is
supplied by the superior rectal artery off of the inferior mesenteric artery (IMA) and
drained via the superior rectal vein (which drains via the portal system).

It is innervated by the sympathetic and parasympathetic branches of the inferior


hypogastric plexus (pelvic plexus).
Inferior to the pectinate line , the anal canal is characterized by non-keratinized
stratified squamous epithelium and receives blood supply from the inferior rectal
vein/artery/nerve (VAN) off of the pudendal VAN. Clinical Correlate: The venous

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Anal Triangle

drainage and innervation of the anal canal helps explain internal vs. external
hemorrhoids.
Internal hemorrhoids (superior to the pectinate line) can form as a result of portal
hypertension, constipation, increased intra-abdominal pressure, prolonged straining,
and pregnancy. They are relatively painless because of its visceral innervation from the
inferior hypogastric plexus. Structures proximal to the pectinate line drain into the
inferior mesenteric vein (IMV) providing the connection to the portal system.

External hemorrhoids (inferior to the pectinate line) can form as a result of varicosities
in the systemic venous system. They are relatively painful because the nerve supply
inferior to the pectinate line is somatic branches of the pudendal nerve. Structures
distal to the pectinate line drain into the internal iliac veins and do not directly enter the
portal system.

Note: Portal hypertension is a major cause of anorectal varices.

Pectinate line and internal vs external hemorrhoids.

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Anal Triangle

The anal canal. Note that the venous plexuses may give rise to hemorrhoids.

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Anal Triangle

Anal Canal

Image Credit: Gray's Anatomy

The sphincteric musculature forms a series of rings encircling the anal canal and helps
maintain continence.

The internal anal sphincter is found at the superior part of the anal canal. It is composed of
involuntary smooth muscle.

The external anal sphincter is composed of 3 rings of voluntary skeletal muscle which
span the entire anal canal.

Subcutaneous part Located just deep to the skin, surrounding the anal opening
Superficial part Deep to the subcutaneous part
Deep part Deep to the superficial part and merges with the puborectalis portion of
the levator ani muscle

Innervation: Inferior rectal branches of the pudendal nerve

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Anal Triangle

External anal sphincter.

Internal anal sphincter.

The ischioanal fossae are triangular spaces adjacent to the anal canal.

The lateral and medial walls are formed by the obturator fascia and the external anal
sphincter, respectively.

The ischioanal fossae contains the:

Inferior rectal nerve : Branch of the pudendal n.


Inferior rectal artery : Branch of the internal pudendal a.
Inferior rectal vein : Drains the anal canal below the pectinate line

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Anal Triangle

Pudendal nerve.

Pudendal nerve.

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Anal Triangle

Ischioanal fossae.

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Anal Triangle

Ischioanal fossae.

441
Nerves of the Pelvis

USMLE Step 1 > Basic Sciences > Anatomy > Pelvis

Nerves of the Pelvis


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The major somatic nerves of the pelvic region come from the sacral plexus , which is
formed by ventral rami of spinal nerves L4-S4. Additionally, the coccygeal plexus is
formed by ventral rami of spinal nerves S4-S5.

The somatic branches are:

The sciatic n. (L4-S3), which is the largest nerve in the body supplying the posterior
thigh and the entire leg and foot
The superior gluteal n. (L4-S1), which passes superior to the piriformis and supply
muscles of the gluteal region
The inferior gluteal n. (L5-S2), which passes inferior to the piriformis and supply the
gluteus maximus
The posterior femoral cutaneous n. (S1-3), which supply the skin of the posterior
surface of the thigh and leg
The pudendal n. (S2-4), which supply structures in the perineum
The nerve to piriformis (S1-2)
Nerves to levator ani and coccygeus (S4)
Nerve to obturator internus (L5-S2)
Nerve to quadratus femoris (L4-S1)

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Nerves of the Pelvis

Formation and branching of the sacral plexus

Image Credit: Gray's Anatomy

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Nerves of the Pelvis

Nerves on the posterior abdominal wall. Note formation of the sacral plexus inferiorly.

Image Credit: Gray's Anatomy

The pelvic splanchnic nerves contain preganglionic parasympathetic nerves and enter
the hypogastric plexus where the sympathetic fibers are conveyed to the pelvic viscera.
From here, they travel with branches of the internal iliac artery to postganglionic
parasympathetic cell bodies within pelvic and perineal structures.

In both males and females, the pelvic splanchnic nerves are responsible for
engorgement of the erectile tissue , while the sympathetic nerve is mainly responsible for
emission.

Mnemonic: " Point and Shoot" Point (erection) is P arasymapthetic and Shoot
(emission) is S ympathetic.

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Nerves of the Pelvis

Note: Ejaculation is due to somatic innervation via the pudendal nerve.

There are three pelvic foramina with structures traversing them:

Obturator foramen
Greater sciatic foramen
Lesser sciatic foramen

Structures traversing the obturator foramen :

Obturator nerve, artery and vein (NAV) The obturator internus muscle covers the
obturator foramen and its tendon exits the pelvis via the lesser sciatic foramen.

Structures traversing the greater sciatic foramen :

Superior gluteal NAV


Inferior gluteal NAV
Pudendal NAV (exiting the pelvis)
Sciatic nerve
Piriformis muscle

Structures traversing the lesser sciatic foramen :

Obturator internus tendon and nerve


The pudendal NAV , which exits the pelvis via the greater sciatic foramen , hooks
around the sacrospinous ligament and the ischial spine before entering the perineum
via the lesser sciatic foramen.

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Nerves of the Pelvis

Path of the pudendal NAV.

Path of the pudendal NAV.

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Nerves of the Pelvis

Clinical Correlate: Pelvic inflammatory disease (PID) caused by Chlamydia or Gonorrhea


can present with shoulder pain. Bacteria migrates from: vagina cervix uterine tubes,
out the abdominal osteum surrounded by the fimbria intraperitoneal infection irritates
diaphragm C3,4,5 innervation causes referred pain to shoulder.

447
Pelvic Viscera-Female

USMLE Step 1 > Basic Sciences > Anatomy > Pelvis

Pelvic VisceraFemale
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The true pelvis of the female contains three main structures residing anterior to posterior:

Bladder
Uterus
Rectum These structures create two intraperitoneal pouches with the uterus in the
center:

Rectouterine pouch (pouch of Douglas) between the rectum and the uterus

Uterovesical pouch between the uterus and the bladder Clinical Correlate: The
posterior wall near the fornix of the vagina is unique from the rest of the vagina because
it is separated from the rectouterine pouch only by a thin membrane of peritoneum.

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Pelvic Viscera-Female

Sagittal view of the female pelvis. The peritoneal sac drapes over the ovary reproductive
organs and rectum. The thick body of the uterus transitions to the vagina through a cervix.
An archway or fornix at the upper end of the vaginal canal surrounds the cervix and
brushes into contact with the peritoneum posteriorly.

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Pelvic Viscera-Female

Sagittal view of the female pelvis.

Image Credit: CC by-SA 3.0

Uterus :

The uterus is a pear-shaped hollow muscular organ. Its position in the pelvis is anteflexed
and anteverted relative to the vagina , meaning it is curved forward and leaning forward,
respectively, like a wave crashing over the bladder.

The uterus is divided into 3 parts:

The body of the uterus forms the superior 2/3 of the organ. The fundus of the
uterus , the most superior portion of the body, is palpated externally during a bimanual
exam.
The cervix forms the inferior 1/3 of the uterus with supravaginal and vaginal divisions.
The isthmus of the uterus is a narrowed section between the cervical canal and body
of the uterus. Remember the associated ligaments with the mnemonic: R oot B eer, S
oda O f U.S. ** C**hampions:

R ound Connects the uterus to the deep skin of labia majora through round inguinal
canal; it is the embryonic derivative of gubernaculum and can stretch in pregnancy
causing pain.

B road Connects the uterus to the lateral walls


S uspensory Connects the ovary to the lateral wall (carries ovarian vessels)

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Pelvic Viscera-Female

O varian Connects the ovary to uterus


U tero S acral Connects the posterior cervix to the anterior surface of the sacrum.
C ardinal Connects the cervix to the lateral wall; it is located in inferior margin of
broad ligament (carries uterine vessels; also known as Mackenrodts or transverse
cervical ligament) The broad ligament is formed by a double layer of peritoneum (or
mesentery) that connects the lateral uterus to the lateral pelvic wall. It is further divided
(from superior to inferior) into the mesosalpinx, mesovarium, and mesometrium.

Mesosalpinx Supports the uterine tube

Mesovarium Connects the ovary and the broad ligament


Mesometrium Lies inferior to the attachment of the mesovarium Blood supply : The
cardinal ligament contains uterine vessels which supply the uterus. Clinical Correlate:
Damage to these ligaments or muscular pelvic diaphragm during childbirth may lead to
vaginal prolapse of uterus, rectum and bladder.

Clinical Correlate: The round ligament of the uterus is supplied by Sampson's artery, which
runs beneath the ligament and is often a source of student quizzing during general anatomy
or surgical procedures. Innervation : Sympathetic, parasympathetic and visceral afferents
pass through the inferior hypogastric plexus to innervate the uterus and send information
back to the brain. Nociception (pain) from the body and fundus of uterus follow lumbar
splanchnic nerves. All other afferent information from the entire uterus and nociception of the
cervix follow parasympathetic pelvic splanchnic nerves (S2,3,4). Clinical Correlate : Different
modes of spinal anesthesia will affect different parts of the uterus: an epidural at T8-10,
often used to reduce pain in childbirth, usually provides analgesia (pain relief) to the uterus
in the first stage of labor while allowing the mother to feel the contractions of the uterus, feel
pressure, and be able to bear down and push.

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Pelvic Viscera-Female

Blood supply to the uterus and ovary.

Ligaments of the uterus and ovary.

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Pelvic Viscera-Female

Ligaments of the uterus and ovary.

Image Credit: Gray's Anatomy

Blood supply to the uterus and ovary.

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Pelvic Viscera-Female

Ovaries :

The ovaries , which are the size and shape of an almond, are attached to the uterus via
ovarian ligaments (utero-ovarian ligaments) and to the lateral walls via suspensory
ligaments (infundibulopelvic ligament) of ovaries. The ovaries are composed of a
cortex (follicles and connective tissue), and medulla (neurovascular). The ova develop from
follicles in the cortex.

Ovarian blood supply : The suspensory ligaments (infundibulopelvic ligaments) carry


the ovarian vessels, lymphatics, and nerves to ovaries.

Ligaments of the uterus and ovary.

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Pelvic Viscera-Female

Blood supply to the uterus and ovary.

Path of Ovum : When a Graafian follicle ruptures, the ovum is momentarily intraperitoneal
before entering the Fallopian tube (also known as the uterine tube or oviduct) and is carried
from the ovary to the uterine cavity.

The ovum is first swept by the distal fallopian tube, the infundibulum , then passes into the
ampulla , and finally the isthmus of the fallopian tube before entering the uterus for
implantation. Fertilization usually occurs in the ampulla. Implantation can sometimes occur
here, making the ampulla of the oviduct the most common site of ectopic pregnancies ,
specifically a tubal pregnancy .

Clinical Correlation : An ectopic pregnancy that implants in the ampulla of the uterine
tube is called a tubal pregnancy. There are dangerous risks for the mother, such as tubal
rupture or bleeding into the peritoneal cavity.

Due to the proximity of the lumina of the urethra, vagina, and rectum, fistulous
communication can occur between them.

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Pelvic Viscera-Female

For information on the urinary bladder , please see Pelvic Viscera - Male.

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Pelvic Viscera-Male

USMLE Step 1 > Basic Sciences > Anatomy > Pelvis

Pelvic VisceraMale
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The key structures of the male pelvis are the bladder and rectum.

In contrast to females who have both rectouterine and uterovesicle pouches, males only
have the rectovesical pouch.

Sagittal view of the male pelvis

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Pelvic Viscera-Male

Sagittal section of the male pelvis. The peritoneum drapes over the relatively simple
topology of the bladder and rectum. The prostate gland which is subject to hyperplasia with
advancing age can be palpated via the rectum.

Urinary bladder :

Urination requires the coordination of 3 muscles: the detrusor, the internal sphincter, and the
external urethral sphincter.

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Pelvic Viscera-Male

The detrusor muscle is the smooth muscle for most of the bladder wall, and extends into the
internal sphincter. Both are smooth muscle and thus involuntarily controlled.

Parasympathetic nerve stimulation leads to contraction of the detrusor muscle and


inhibition of the internal sphincter resulting in micturition. The external urethral sphincter
, while technically not part of the bladder, is a voluntary striated muscle that can delay
urination. Loss of sphincter tone may lead to incontinence.

Associated with the bladder are 4 tubes: Urachus, 2 ureters, and urethra.

The urachus is the embryological remnant of the allantois that usually regresses from a
tube into a connection attached to the anterior abdominal wall called the median umbilical
ligament. It lies beneath the median umbilical fold and functions to drain the fetal bladder.
The median umbilical ligament/urachus is a landmark for the apex of the bladder (see
images).

Mnemonic: 4 U tubes: U rachus, 2 U reters, and U rethra

Clinical Correlate: The bladder is located deep to the pubis and inferior to the peritoneum.
An empty bladder lies in the true pelvis while a full bladder extends into the abdomen,
superior to the pubis. Thus, in emergency a needle can be introduced into the full bladder
from a suprapubic approach without incising the peritoneum and risking abdominal
infection. Parasympathetic fibers innervate the bladder via pelvic splanchnic nerves from
S2-S4 levels. These nerves supply motor innervation to the detrusor muscle, which
contracts the bladder and allows urine to flow (micturition). Additionally, the pelvic
splanchnics inhibit the internal urethral sphincter in males.

The external urethral sphincter must relax in order for micturition to occur but it is under
voluntary control, not autonomic control. The sympathetic fibers innervate the bladder via
the hypogastric plexuses and cause contraction of the internal urethral sphincter (in males)
during ejaculation to prevent reflux of semen into the bladder.

Blood supply : The bladder is supplied and drained by the superior and inferior vesical
branches of the internal iliac arteries and veins.

Note: The inferior vesical branch is analogous to the vaginal artery in females.

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Pelvic Viscera-Male

Structure of the bladder. (1) Urachus, (2) Posterior wall, (3) Ureteral orifice, (4) Bladder neck,
(5) Prostate, (6) Trigone, (7) Anterior wall, (8) Lateral wall, (9) Dome.

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Pelvic Viscera-Male

Structure and orientation of the bladder. Note the urachus, which serves as a landmark for
the apex of the bladder.

Prostate :

The prostate is a walnut shaped organ found inferior to the neck of the bladder. It is flanked
by the pubococcygeus muscles laterally. The puboprostatic ligament attaches the prostate
to the pubic symphysis.

Sperm enters the urethra via the ductus deferens which merges with the duct of the seminal
vesicle within the prostate to form the ejaculatory duct.

Digital palpation is possible through the anterior wall of the rectum.

Note: Due to the anatomy of the prostate, benign prostatic hyperplasia (BPH) presents
with urinary symptoms due to obstruction of urinary outflow. BPH is extremely common ,
with prevalence increasing with age (~90% by age 80).

Clinical Correlate: The prostate can be divided into zones related to the incidence of cancer
or lobes related to hypertrophy of the prostate.

Four Zones:

Fibromuscular (very unlikely for cancer)


Transitional (1/3 of cancer)
Central (unlikely for cancer)
Peripheral (2/3 of cancer)

Five lobes:

Anterior
Middle
Lateral R/L
Posterior

Note: The middle lobe is the most common location for BPH.

Seminal vesicle :

The seminal vesicles are elongated sacculated tubes located on the posterior surface of the
bladder. They do not store sperm, but rather secrete fluid rich in fructose, prostaglandins and
fibrinogen, which increases viability of ejaculate by providing energy for the sperm.

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Pelvic Viscera-Male

The seminal vesicles can be palpated during rectal exam only when pathology is present.
They connect to the vas deferens via the ejaculatory ducts.

Vas deferens :

As the continuation of the tail of the epididymis, the vas deferens runs to the join seminal
vesicle in the ejaculatory duct. It is thick, muscular, and can be easily palpated in scrotum.
The vas deferens ascends through the inguinal canal to penetrate the anterior abdominal
wall, arcs over the external iliac vessels and crosses superior to the ureter to enter the
pelvis and merge with the duct of the seminal vesicle to make the ejaculatory duct.

Male reproductive anatomy.

Path of the ureters.

462
The Pelvic Floor

USMLE Step 1 > Basic Sciences > Anatomy > Pelvis

The Pelvic Floor


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Pelvic diaphragm :

The pelvic diaphragm is a bowl-shaped structure that forms the pelvic floor, made up of two
layers of fascia with a middle layer of skeletal muscle.

There are 2 muscles that form the middle layer: the levator ani and the coccygeus. The
pelvic diaphragm is a contractile structure. Therefore, only structures that can safely
withstand compression are able to pass through, such as the urethra, vagina, and
rectum. Anterior structures (urethra and vagina) are aided by a gap between the anterior
parts of levator ani (puborectalis part), the urogenital hiatus.

The pelvic diaphragm lies within the lesser (true) pelvic cavity and separates the peritoneum
from the more inferior perineum. The perineum contains the ischioanal fossa.

In contrast, nerves and vessels circumvent this compression by passing anteriorly or


posteriorly to the pelvic diaphragm (the deep dorsal vein of the penis and the pudendal
vessels, respectively ).

Clinical correlation : The ability for the pelvic floor to relax is important in defecation and
parturition (childbirth).

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The Pelvic Floor

Note the pudendal neurovasculature and deep dorsal vein of the penis. These structures
avoid compression via the pelvic diaphragm.

Pelvic walls. Floor of the female pelvis.

464
The Pelvic Floor

Note the pudendal neurovasculature and deep dorsal vein of the penis. These structures
avoid compression via the pelvic diaphragm.

Levator ani :

The levator ani is a funnel-shaped broad muscle that acts as a muscular sling for the
rectum and marks the boundary between the rectum and anal canal.

It is made up of 3 muscles: the puborectalis, pubococcygeus, and iliococcygeus.


Clinical correlate : Rupture of the levator ani may cause incontinence and rectal or vaginal
prolapse. The 3 muscles of levator ani are all innervated by the ventral rami of S3-S4
spinal nerves, as well as the inferior rectal nerve , a branch of the pudendal nerve ,
which consists of ventral rami of S2-S4 nerves.

The puborectalis is the medial part of the levator ani and forms a sling around the
distal end of the anorectal junction that helps to maintain fecal continence.
The pubococcygeus attaches from the posterior surface of the pubis to the coccyx .
The "PC" muscle is often targeted in Kegel exercises to strengthen the pelvic floor, and
is considered an important muscle for urinary continence and core strengthening.

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The Pelvic Floor

The iliococcygeus is the posterolateral part of levator ani, and is often mostly
aponeurotic.

Levator ani muscles (red)

Image Credit: Gray's Anatomy

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The Pelvic Floor

Sagittal view of pelvic musculature

Image Credit: Gray's Anatomy

The coccygeus muscle is located posterior to levator ani and together they form the pelvic
diaphragm.

Innervation: Anterior rami of S4 and S5

Piriformis :

The piriformis forms the posterosuperior portion of the pelvic wall. It attaches proximally in
the pelvis on the sacrum and distally to the greater trochanter of the femur after passing
through the greater sciatic foramen. Clinical correlate : Piriformis strain is a common injury
among runners, cyclists and rowers. In some individuals, the sciatic nerve can pierce the

467
The Pelvic Floor

piriformis instead of traveling inferior to it. If the piriformis becomes tight or is overused, it
can lead to piriformis syndrome , with similar symptoms to sciatic nerve compression
such as buttock pain with sitting .

Innervation: Nerve to the piriformis (S1-2)


Action: Lateral rotation of the hip

Obturator internus :

The obturator internus forms the lateral wall of pelvic cavity. It covers the internal surface
of the anterior pelvis and obturator foramen. The obturator internus exits the pelvis via
the lesser sciatic foramen and attaches to the greater trochanter of the femur.

Innervation: Nerve to the obturator internus , from roots L5, S1, S2.
Action: Lateral rotation and abduction of the thigh

Note: This nerve is from the sacral plexus of nerves it shouldn't be confused with the
obturator nerve which is a branch of the lumbar plexus.

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The Pelvic Floor

Note the obturator internus muscle.

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The Pelvic Floor

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The Pelvic Floor

Note the obturator internus muscle.

Note the obturator internus muscle.

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The Pelvic Floor

Obturator internus.

Iliacus :

The Iliacus lines the iliac fossa and fuses with the psoas major to form the iliopsoas , a
powerful flexor of the hip. The iliopsoas travels between the pubic bone and the inguinal
ligament.

The perineal membrane is a triangular shaped structure attaching to the ischiopubic rami. It
is both the inferior border of the deep perineal pouch and superior border of the
superficial perineal pouch , which divides the two pouches.

472
Urogenital Triangle-Female

USMLE Step 1 > Basic Sciences > Anatomy > Pelvis

Urogenital TriangleFemale
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The female urogenital (UG) triangle is homologous in location and organization to the
male UG triangle.

It is located anterior to the ischial tuberosities and inferior to the pubic symphysis.

Composed of three fascial layers from superficial to deep:

Colles fascia
Perineal membrane
Superior fascia of the UG diaphragm

These structures form the superficial and deep perineal pouches.

There are also five muscles in common between male and female:

Ischiocavernosus : Paired muscles which insert onto the crura of the clitoris
Bulbospongiosus : Paired muscles which originate at the perineal body and insert
onto the bulbs of the vestibule
Sphincter urethrae : Voluntary muscle surrounding the membranous urethra
Superficial transverse perineal muscle
Deep transverse perineal muscle Note: Please see Urogenital Triangle - Male for
additional description of the male musculature. Clinical correlate: All of these muscles
can be intentionally strengthened during Kegel exercises to prevent postpartum
incontinence and prolapse.

There are some notable differences between male and female UG triangles:

Female superficial pouch : The female superficial pouch contains erectile tissues of
the vestibular bulbs and crura of the clitoris , as well as the greater vestibular
(Bartholins) glands. In contrast, males do not have Bartholin's glands and the crura
and bulbs are of the penis.
Female deep pouch : The female deep pouch contains the sphincter urethrae (same in
men), but the urethra itself is short (4cm) and descends vertically from the bladder

473
Urogenital Triangle-Female

located directly superior.

In addition to ovaries and testicles, there are some homologous structures between
females and males:

Greater vestibular (Bartholins) glands and bulbourethral (Cowpers) glands


Lesser vestibular (Skenes) glands and prostate Note: The seminal vesicles , which
flank the prostate above the UG triangle, have no female homologue.

474
Urogenital Triangle-Male

USMLE Step 1 > Basic Sciences > Anatomy > Pelvis

Urogenital TriangleMale
https://med.firecracker.me/app#/tree/1/1-20-41-168-867

The bony pelvis is shaped like a diamond. The boundaries are formed by the pubis,
coccyx, and ischial tuberosities laterally.

A line between the tuberosities divides the space into the urogenital and anal triangles.

The area inferior to the pelvic diaphragm within this space is called the perineum.

Male urogenital and anal triangles.

475
Urogenital Triangle-Male

Female urogenital and anal triangles.

The urogenital triangle :

The perineal membrane is a thin sheet of deep fascia that runs between the two
ischiopubic rami superficial to the pelvic diaphragm. It is the inferior fascia of the
urogenital diaphragm.

It does not continue to the anal triangle and forms the space for superficial pouch
(superficial to the perineal membrane) and deep pouch (space between the superior and
inferior fascial layers of the urogential diaphragm).

Note: Older texts and board review sources may refer to the existence of a urogenital
diaphragm. It is likely that a physical diaphragm does not exist, but the term is often used to
delineate anatomical boundaries. There continues to be conflicting views amongst
anatomists and researchers. Colles fascia, also known as the superficial perineal fascia, is
continuous with Scarpas fascia from the anterior abdominal wall. It forms the inferior
boundary of the superficial perineal pouch. The perineal membrane is the inferior
fascia of the urogenital diaphragm.

476
Urogenital Triangle-Male

These layers create the superficial and deep perineal pouches.

Colle's fascia, labeled on this image as the deep layer of superficial fascia.

477
Urogenital Triangle-Male

Perineal membrane.

The deep pouch :

The deep pouch is the space between the perineal membrane (inferior fascia of the
urogenital diaphragm) and the superior ** fascia of the urogenital diaphragm**.

Note: Older texts and board review sources may refer to the existence of a urogenital
diaphragm. It is likely that a physical diaphragm does not exist, but the term is often used to
delineate anatomical boundaries. There continues to be conflicting views amongst
anatomists and researchers.

Muscles of the deep pouch:

External urethral sphincter a voluntary muscle which surrounds the


membranous urethra
Deep transverse perineal muscle (DTPM) attaches to the perineal body and
provides support for the prostate or vagina Glands of the deep pouch:
The bulbourethral (Cowpers) glands lie adjacent to the sphincter urethrae.

Note: The Bartholins gland, the female analog of Cowpers, is in the superficial pouch. Note:
The prostate and bladder sit superior to the levator ani and thus outside the urogenital
triangle and inside the true pelvis

478
Urogenital Triangle-Male

Cowper's gland.

Cowper's gland.

479
Urogenital Triangle-Male

Deep transverse perineal muscle.

480
Urogenital Triangle-Male

The external sphincter muscle of male urethra surrounds the membranous portion of the
urethra.

481
Urogenital Triangle-Male

Deep transverse perineal muscle.

The superficial pouch is essentially everything inferior to the perineal membrane. Precisely,
it represents the area between the perineal membrane (superior border) and superficial
perineal fascia or Colles fascia (inferior border).

Muscles of the superficial pouch:

Superficial transverse perineal muscle (STPM) originates from ischial rami and
tuberosities and inserts into the perineal body
Ischiocavernosus muscles originates from ischial rami and tuberosities
and inserts into the corpus cavernosum
Bulbospongiosus muscles originates from the perineal body and inserts into the
corpus spongiosum

482
Urogenital Triangle-Male

Innervation: Perineal nerves, branches of the pudendal nerve All erectile tissue and muscles
are located in the superficial pouch.

Clinical Correlate : Since Colles fascia extends anteriorly as the penile fascia, trauma to the
urethra in the urogenital triangle can cause urine extravasation along superficial perineal
pouch into scrotum, neck of penis, and anterior abdominal wall.

Note: The fascia surrounding the scrotum is called Dartos fascia, which is still a continuation
of Colles fascia and Scarpas fascia.

Coronal section of the male pelvis showing the prostate, the urogenital diaphragm, and the
contents of the superficial perineal pouch.

483
Urogenital Triangle-Male

Muscles, arteries and nerves of the male superficial pouch

Bulbospongiosus muscle.

484
Urogenital Triangle-Male

Ischiocavernosus muscle.

485
Urogenital Triangle-Male

Superficial transverse perineal muscle.

486
Vasculature of the Pelvis

USMLE Step 1 > Basic Sciences > Anatomy > Pelvis

Vasculature of the Pelvis


https://med.firecracker.me/app#/tree/1/1-20-41-168-3173

The abdominal aorta branches to form the common iliac arteries, which in turn branch to
form the internal and external iliac arteries.

The internal iliac artery has anterior and posterior divisions.

All branches of these arteries have paired veins which are part of the systemic circuit,
except for the venous drainage of the rectum and upper anal canal, which drains through
the portal system via the inferior mesenteric vein.

The common iliac arteries arise at the level of L4.

The ureters pass anterior to the common iliac arteries.

The external iliac artery gives off the inferior epigastric and deep circumflex arteries
before continuing on to become the femoral artery.

The external iliac artery forms the femoral artery after passing under the inguinal
ligament.

The femoral artery becomes the popliteal artery after passing through the adductor
hiatus.

487
Vasculature of the Pelvis

External and internal iliac arteries.

488
Vasculature of the Pelvis

Branches of the iliac arteries.

Deep circumflex artery, a branch off the external iliac artery.

489
Vasculature of the Pelvis

Inferior epigastric artery, a branch off the external iliac artery.

The exact branching pattern of the internal iliac artery varies by individual, however, the
branches should be learned for the anterior and posterior divisions: III O UU Rectal PILS :

Anterior division: III O UU Rectal :

I nferior gluteal
I nferior vesical (vaginal)
I nternal pudendal
O bturator
U terine (vaginal)
U mbilical (superior vesical)
(Middle) R ectal Posterior division: PILS :

P osterior:

490
Vasculature of the Pelvis

I liolumbar
L ateral sacral
S uperior gluteal Females : The vaginal a. supplies the anterior and posterior walls
of the vagina and base of bladder. It arises from the uterine artery or anterior
division of the internal illiac artery (differences between sources).

Males :

The inferior vesical a. supplies the:

Fundus of bladder
Prostate
Seminal vesicles
Ductus deferens
Lower portion of the ureters

It arises from the internal iliac artery (anterior division). The vas deferens and testicular
artery (branch of the abdominal aorta) run anterior to the ureters.

Mnemonic: Water under the bridge.

Main branches of the iliac artery.

491
Vasculature of the Pelvis

Image Credit: Gray's Anatomy

Uterine and vaginal arteries.

492
Vasculature of the Pelvis

Branches of the iliac artery.

493
Arm: Muscles

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Arm: Muscles
https://med.firecracker.me/app#/tree/1/1-20-41-72-140

There are 3 flexors in the arm that are all innervated by the musculocutaneous nerve:

Coracobrachialis Flexes the arm


Brachialis Flexes the forearm
Biceps brachii Flexes the forearm

Coracobrachialis :

Action: Adduct and flex arm at the shoulder joint


Innervation: M** usculocutaneous nerve** Clinical Correlate: The coracobrachialis is
pierced by the musculocutaneous nerve and is location of potential nerve compression.
It attaches to the coracoid process.

494
Arm: Muscles

Muscles of the arm. (A) Anterior view superficial layer featuring the deltoid and biceps
brachii. (B) Anterior view deep layer featuring the coracobrachialis and brachialis.

495
Arm: Muscles

Coracobrachialis (highlighed in blue) extends from the coracoid process to the medial
surface of the humeral midshaft.

Attribution: Gray's Anatomy PD-US

Brachialis :

Action: Flex forearm at elbow


Innervation: M** usculocutaneous nerve** Note: In some patients, the lateral portion of
brachialis is innervated by the radial nerve while the medial portion is innervated by the
musculocutaneous nerve.

496
Arm: Muscles

Muscles that abduct and flex the arm and forearm. (A) Anterior view superficial layer
featuring the deltoid and biceps brachii. (B) Anterior view deep layer featuring the
coracobrachialis and brachialis.

497
Arm: Muscles

Brachialis (highlighed in blue) extends from the distal half of the anterior humeral surface to
the ulnar tuberosity.

Attribution: Gray's Anatomy PD-US

Biceps brachii :

Action:

Supinate forearm The biceps brachii is the strongest supinator muscle in the
body!
Flex forearm at elbow
Innervation: M** usculocutaneous nerve**
Origin and insertion:

Long head : Originates on the supraglenoid tubercle of scapula and inserts on


the radial tuberosity (proximal radius)
Short head : Originates on the coracoid process of scapula and inserts on
the radial tuberosity (proximal radius) Note:

498
Arm: Muscles

Supination of the forearm Lateral rotation of the radius such that the palm of the
hand faces anteriorly. For example, stand upright with your hands relaxed at your side
keeping your hands at your side, supination of your forearms would consist of lateral
rotation such that your palms face anteriorly and your thumbs point away from the
midline.
Pronation of the forearm The opposite of supination of the forearm; medial rotation
of the radius such that the palm of the hand faces posteriorly.

One way to remember this is to hold one hand out in front of you if someone asked you to
hold a cup of soup in your outstretched hand, you would sup inate your forearm to turn
your palm face up. If you wanted to p our the soup on the ground, you would p ronate your
forearm to turn your outstretched palm face down.

Muscles that abduct and flex the arm and forearm. (A) Anterior view superficial layer
featuring the deltoid and biceps brachii. (B) Anterior view deep layer featuring the
coracobrachialis and brachialis.

499
Arm: Muscles

Muscles of the arm and forearm. Note the muscles of the flexor compartment.

500
Arm: Muscles

Biceps brachii (highlighted in red): strongest supinator; also flexes the elbow and shoulder.
Innervated by the musculocutaneous nerve.

Attribution: Chrizz CC BY-SA 3.0

501
Arm: Muscles

Normal anatomy of the shoulder, anterior view.

There are 2 extensors in the arm, both of which are innervated by the radial nerve :

Anconeus
Triceps brachii

502
Arm: Muscles

Anconeus :

Action: Extends the forearm at the elbow joint


Innervation: Radial nerve

Anconeus (arrow).

Attribution: Gray's Anatomy PD-US

503
Arm: Muscles

Anconeus. Extends the forearm at the elbow joint.

Triceps brachii :

Action:

Extend the forearm at the elbow


Adduct and extend shoulder (long head only)
Innervation: Radial nerve

504
Arm: Muscles

Muscles that abduct and flex the arm and forearm. (A) Anterior view superficial layer
featuring the deltoid and biceps brachii. (B) Anterior view deep layer featuring the
coracobrachialis and brachialis.

505
Arm: Muscles

Triceps brachii (highlighted in red).

Attribution: Chrizz CC BY-SA 3.0

506
Arm: Muscles

Triceps brachii: major extensor of the elbow, innervated by radial nerve.

Attribution: Gray's Anatomy PD-US

507
Arm: Nerves

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Arm: Nerves
https://med.firecracker.me/app#/tree/1/1-20-41-72-2869

The medial brachial cutaneous nerve (aka the medial cutaneous nerve of the arm)
(C8, T1) provides cutaneous innervation to the medial upper limb. This nerve is the smallest
branch of the medial cord and communicates with the intercostobrachial nerve (T2).

The lateral upper limb cutaneous innervation is provided by the following 3 nerves:

Axillary nerve (via superior lateral cutaneous nerve)


Radial nerve (via inferior lateral cutaneous nerve)
Musculocutenous nerve (via lateral antebrachial cutaneous nerve)

Mnemonic: ARM the A xillary, R adial, and M usculocutaneous nerves The


superior lateral cutaneous nerve of the arm is derived from the axillary nerve.

The inferior lateral cutaneous nerve of the arm is derived from the radial nerve.

The lateral antebrachial cutaneous nerve is derived from the musculocutaneous nerve.

The posterior (dorsal) upper limb cutaneous innervation is provided by the following nerves:

Posterior cutaneous nerve of the arm (from radial nerve)


I** nferior lateral cutaneous nerve of the arm **(from radial nerve)
Posterior cutaneous nerve of forearm (from radial nerve)
Superior lateral cutaneous nerve of arm (from axillary nerve)

Suprascapular nerve is derived from C5 and C6. It travels deep to the superior transverse
ligament through the scapular notch.

The suprascapular nerve arises from the upper trunk of brachial plexus.

The suprascapular nerve innervates the supraspinatus and infraspinatus muscles of the
rotator cuff .

508
Arm: Nerves

Axillary nerve is derived from C5 and C6.

The axillary nerve arises from the posterior cord of the brachial plexus.

The axillary nerve travels with the posterior humeral circumflex vessels and passes
through the quadrangular space.

The axillary nerve provides motor innervation to the t** eres minor and deltoid and sensory
innveration to the upper lateral arm via the superior lateral cutaneous nerve of the arm**.

The radial nerve is derived from C5-T1. It travels along with the deep brachial vessels and
descends laterally in the radial groove on the humerus posteriorly.

The radial nerve arises from the posterior cord and is the largest branch of brachial
plexus.

The radial nerve innervates the m** uscles on the dorsal side of the arm (and forearm).
**For reference only, the muscles include:

Triceps brachii
Brachioradialis
Anconeus
Extensor carpi radialis longus
Extensor carpi radialis brevis
Extensor digitorum
Extensor carpi ulnaris
Extensor digiti minimi
Supinator
Abductor pollicis longus
Extensor pollicis brevis
Extensor pollicis longus
Extensor indicis proprius

The musculocutaneous nerve is derived from C5, C6, and C7. It pierces through the
coracobrachialis, supplying its innervation, then travels between the biceps brachii and the
brachialis. The musculocutaneous n. then becomes the lateral antebrachial cutaneous nerve
to supply cutaneous innervation (mentioned above).

The musculocutaneous nerve arises from the lateral cord of the brachial plexus.

509
Arm: Nerves

The musculocutaenous nerve provides sensory innervation to the lateral side of the forearm
and innervates the following muscles:

C** oracobrachialis**
B** iceps brachii**
B** rachialis**

The median nerve is derived from C5, C6, C7, C8, and T1 ; sources vary on whether C5 is
included . It travels through the arm, but does NOT supply any motor innervation in the
arm. The median nerve supplies structures within the forearm and hand.

The median nerve arises from both the medial and lateral cords of the brachial plexus.

It accompanies the brachial artery to the cubital fossa.

The ulnar nerve is derived from C8 and T1. It descends medially to the brachial artery in the
anterior compartment of the arm. The ulnar nerve then enters the posterior compartment
after penetrating the medial intermuscular septum.

The ulnar nerve arises from the medial cord of the brachial plexus.

The ulnar nerve provides sensory innervation to skin over the palmar and dorsal surface
of the medial hand and digits and innervation s** elect forearm muscles(flexor carpi
ulnaris and the medial half of flexor digitorum profundus) and themuscles of the hand
excluding the thenar eminence . For reference only, the muscles include : **

Flexor carpi ulnaris


Flexor digitorum profundus (medial half)
Deep head flexor pollicis brevis
Adductor pollicis
Palmaris brevis
Abductor digiti minimi
Flexor digiti minimi brevis
Opponens digiti minimi
Lumbricals 3 & 4
Palmar and dorsal interossei

510
Arm: Vessels

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Arm: Vessels
https://med.firecracker.me/app#/tree/1/1-20-41-72-3525

There are 3 branches of the brachial artery:

Profunda brachii artery


Superior ulnar collateral artery
Inferior ulnar collateral artery

Profunda brachii artery (deep brachial artery) divides into the r** adial collateral artery and
middle collateral artery**.

The profunda brachii artery travels with the radial nerve passing through the triangular
interval, which is bordered by the inferior margin of the teres major, lateral margin of the long
head of the triceps, and the shaft of the humerus.

Radial collateral artery runs with the radial nerve and forms an anastomosis with the
radial recurrent artery anterior to the lateral epicondyle.

Middle collateral artery runs with nerve to the anconeous muscle within the medial head of
the triceps brachii and forms an anastomosis with the interosseous recurrent artery
posterior to the elbow joint.

512
Arm: Vessels

Arteries near the elbow joint. Note the radial collateral artery.

513
Arm: Vessels

Arteries of the arm.

The paired brachial veins arise at the elbow by the joining together of the radial and ulnar
veins. They travel with the brachial artery and form numerous anastomoses.

514
Arm: Vessels

Note ulnar and radial veins in the forearm.

515
Arm: Vessels

Veins of the forearm and brachium.

516
Arm: Vessels

Brachial vein.

517
Arm: Vessels

Veins of the forearm and brachium.

The axillary vein begins at the inferior border of the teres major muscle.

The axillary vein is formed by the joining of the brachial vein and the basilic vein.

518
Arm: Vessels

Arm - venous drainage of upper limb (cephalic v, brachial v, basilic v, axillary v)

519
Arm: Vessels

Brachial, basilic, and axillary veins.

The brachial artery is the major artery of the arm. It is a continuation of the axillary artery ,
beginning at the inferior border of the teres major muscle.

The brachial artery terminates by dividing into the radial and ulnar arteries in the forearm.

520
Arm: Vessels

Brachial artery and branches.

521
Arm: Vessels

Brachial artery, a distal continuation of the axillary artery.

522
Brachial Plexus-Axillary Nerve

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Brachial PlexusAxillary Nerve


https://med.firecracker.me/app#/tree/1/1-20-41-72-2802

Axillary nerve (C5, C6):

The axillary nerve is formed from the terminal branch of the posterior cord of the brachial
plexus.

Sensory innervation: Upper lateral arm (ie, skin over the deltoid)
Motor innervation:

Deltoid : Shoulder abduction; anterior muscle fibers contribute to flexion and


medial rotation of the shoulder and posterior muscle fibers contribute to extension
and lateral rotation of the shoulder
Teres minor : Lateral rotation and adduction of the shoulder Axillary nerve injury
causes both sensory and motor deficits, including a reduction in arm abduction
from 15 to 90 degrees (supraspinatus is responsible for first 10-15 degrees of arm
abduction at the shoulder joint). Additionally, the loss of abduction can be coupled
with visible flattening of the deltoid.

523
Brachial Plexus-Axillary Nerve

Sensory innervation of brachial plexus.

524
Brachial Plexus-Axillary Nerve

Brachial plexus - axillary nerve, relation to subscapularis and quadrangular space

Dermatomes vs. cutaneous areas of sensory nn, anterior view

525
Brachial Plexus-Axillary Nerve

Dermatomes vs. cutaneous areas of sensory nn, posterior view

526
Brachial Plexus-Axillary Nerve

Brachial plexus.

Axillary nerve injury can be caused by:

Anterior dislocation of the humeral head , the most common type of shoulder
dislocation, can place a stretching pressure on the axillary nerve as the humeral head
moves in the anterior-inferior direction. However, damage to the axillary nerve is rare.
Fracture of the surgical neck of the humerus can damage the axillary nerve due to
its course around the posterior aspect of the surgical neck of the humerus. The axillary
nerve is accompanied by the posterior humeral circumflex artery which can also be
injured.

527
Brachial Plexus-Median Nerve

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Brachial PlexusMedian Nerve


https://med.firecracker.me/app#/tree/1/1-20-41-72-890

Median nerve (C5, 6, 7, 8, T1):

The median nerve is formed by the medial and lateral cords of the brachial plexus.

Note: The median nerve receives variable C5 innervation; C5 supply varies by person and
by source. Sensory innervation :

Midpalm and thenar eminence (palmar branch of the median nerve)


Palmar aspect of the lateral 3 1/2 digits
Distal part of the dorsal aspect of the lateral 3 1/2 digits Motor innervation :
Anterior forearm musculature (except FCU (flexor carpi ulnaris) and the ulnar half of
FDP (flexor digitorum profundus), both of which are innervated by the ulnar
nerve) Flexion of the wrist and fingers, pronation of the forearm
Thenar eminence musculature Thumb opposition
1st and 2nd lumbricals Extension of interphalangeal joints and flexion of
metacarpophalangeal joints of digits 2 and 3 (index and middle fingers)

528
Brachial Plexus-Median Nerve

Brachial plexus - median nerve, distribution

529
Brachial Plexus-Median Nerve

Brachial plexus - median nerve palsy, claw hand

530
Brachial Plexus-Median Nerve

Sensory innervation of brachial plexus.

531
Brachial Plexus-Median Nerve

Brachial plexus - distribution of the musculocutaneous, median, and ulnar nerves

532
Brachial Plexus-Median Nerve

Brachial plexus - middle portion of the biceps brachii has been removed to show the
musculocuta-neous nerve lying in front of the brachialis. Also shown: median and ulnar
nerves.

533
Brachial Plexus-Median Nerve

Dermatomes vs. cutaneous areas of sensory nn, anterior view

534
Brachial Plexus-Median Nerve

Dermatomes vs. cutaneous areas of sensory nn, posterior view

535
Brachial Plexus-Median Nerve

Median nerve injury is commonly caused by:

Supracondylar fracture of the distal humerus or other fracture-dislocations around


the elbow
Dislocation of the lunate anteriorly into the carpal tunnel
Carpal tunnel syndrome

Supracondylar fracture of the distal humerus causes proximal median nerve injury:

Ape (simian) hand Thumb is in line w/ the fingers and hand in the coronal plane due
to:

Loss of abductor pollicis brevis causing unopposed adduction (movement of thumb


posteriorly in the sagittal plane)
Loss of thumb opposition (opponens pollicis)
Median claw hand loss of lumbricals 1 and 2:

Decreased flexion of corresponding MCP joints causing increased extension of


digits 2 (index) and 3 (middle) by extensor digitorum
Together with the ape hand, this forms the so-called Popes blessing or hand of
benediction, which is accentuated when the patient tries to make a fist
Loss of forearm pronation and flexion of the lateral 3 1/2 digits
Sensory deficit Note:_ _The most common neurological complication of a supracondylar
fracture of the humerus is damage to the ulnar nerve.

536
Brachial Plexus-Median Nerve

Ape hand - palmar view.

537
Brachial Plexus-Median Nerve

Ape hand - lateral view.

Carpal tunnel syndrome or dislocation of the lunate into the carpal tunnel causes distal
median nerve injury:

Ape (simian) hand Thumb is in line w/ the fingers and hand in the coronal plane due
to:

Loss of abductor pollicis brevis causing unopposed adduction (movement of thumb


posteriorly in the saggital plane)
Loss of thumb opposition (opponens pollicis)
Thenar atrophy Note: The opponens pollicis plays a role in thumb opposition, but loss
of this muscle can be compensated by other muscles. Loss of opposition in carpal
tunnel syndrome appears after the loss of thumb abduction.

Note: Sensory deficit is unlikely as the palmar branch of the median nerve, which supplies
innervation to the palm of the hand, travels superficial to the flexor retinaculum and is
unlikely to be injured during a lunate dislocation. Loss of point discrimination may be due to
increased swelling. __Clinical Correlates:

Tinel's sign : Tinel's sign is a test for carpal tunnel syndrome. It is conducted by tapping
the carpal tunnel. Elicitation of "pins and needles" in the median nerve distribution of the
hand or reproduction of pain is a positive test and indicates median nerve entrapment
within the carpal tunnel.

Phalen's sign : Phalen's sign is a test conducted by having the patient flex both wrists
and press the dorsum of their flexed wrists against each other. The patient is instructed
to hold this position for up to 1 minute. Elicitation of "pins and needles" in the median
nerve distribution of the hand or reproduction of pain is a positive test and indicates
median nerve entrapment within the carpal tunnel.

Proximal versus distal median nerve lesions :

The palmar branch of the median nerve arises proximal to the wrist and does not go through
the carpal tunnel with the rest of the median nerve, therefore sensation in the midpalm
and thenar eminence may help distinguish distal from proximal median nerve lesions.
Lesions of the median nerve distal to the palmar branch will result in preserved sensation
while proximal lesions will result in loss of palmar and thenar sensation.

538
Brachial Plexus-Median Nerve

Proximal lesion : If a median nerve lesion is proximal to the bifurcation of the palmar
branch (eg, supracondylar humeral fracture), then the sensation in the midpalm and
thenar eminence will be compromised.
Distal lesion : If a median nerve lesion is distal to the bifurcation of the palmar branch
(eg, carpal tunnel syndrome, dislocated lunate), then the sensation in the midpalm and
thenar eminence is usually intact

539
Brachial Plexus-Musculocutaneous Nerve

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Brachial PlexusMusculocutaneous
Nerve
https://med.firecracker.me/app#/tree/1/1-20-41-72-888

Musculocutaneous nerve (C5, C6, C7):

The musculocutaneous nerve is formed from the terminal branch of the lateral cord of the
brachial plexus.

Sensory innervation: Anterolateral forearm


Motor innervation:

Anterior arm musculature ( biceps brachii, coracobrachialis, brachialis


) Flexion of elbow and shoulder
Biceps brachii Forearm supination

Note: The biceps brachii is the strongest forearm supinator.

540
Brachial Plexus-Musculocutaneous Nerve

Brachial plexus - middle portion of the biceps brachii has been removed to show the
musculocuta-neous nerve lying in front of the brachialis. Also shown: median and ulnar
nerves.

541
Brachial Plexus-Musculocutaneous Nerve

Cutaneous distribution of the brachial plexus.

542
Brachial Plexus-Musculocutaneous Nerve

Brachial plexus - distribution of the musculocutaneous, median, and ulnar nerves

543
Brachial Plexus-Musculocutaneous Nerve

Dermatomes vs. cutaneous areas of sensory nn, anterior view

544
Brachial Plexus-Musculocutaneous Nerve

Dermatomes vs. cutaneous areas of sensory nn, posterior view

545
Brachial Plexus-Musculocutaneous Nerve

Brachial plexus.

Musculocutaneous nerve injury can be caused by anterior dislocation of the humeral


head due to its lateral course anterior to the shoulder joint. It pierces and innervates the
coracobrachialis before descending between and innervating the biceps brachii and
brachialis.

Note: Anterior dislocation of the humeral head, the most common type of dislocation, most
commonly damages the axillary nerve. Note: Although anterior dislocation of the humeral
head may damage the musculocutaneous nerve, neurovascular injury due to shoulder
dislocation most likely involves the axillary nerve due to its close association with the
glenohumeral joint and its course around the surgical neck of the humerus.

546
Brachial Plexus-Radial Nerve

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Brachial PlexusRadial Nerve


https://med.firecracker.me/app#/tree/1/1-20-41-72-889

Radial nerve (C5-T1):

The radial nerve is formed from the terminal branch of the posterior cord of the brachial
plexus.

Note: Radial nerve supply by T1 has an inconstant contribution.

Sensory innervation:

Posterior aspect of the arm and forearm


Lateral half of the dorsal aspect of the hand, including the proximal portions of the
lateral 3 1/2 digits
Motor innervation:

Posterior arm musculature ( triceps brachii and anconeus ) Extension of the


elbow
Posterior forearm musculature ( extensor carpi ulnaris, extensor carpi radialis
brevis, extensor carpi radialis longus, extensor digitorum, extensor digiti
minimi, abductor pollicis longus, extensor pollicis brevis, extensor pollicis
longus, extensor indicis ) Extension of the wrist
Brachioradialis Forearm flexion at elbow
Supinator Forearm supination Radial nerve injury:
Wrist drop : Wrist drop is the inability to hold the wrist in extension.

Decreased grip strength : Decreased grip strength occurs due to increased overlap of
actin and myosin fibers in flexion (wrist drop) compared to the ideal orientation in
neutral/minor extension. This is known as the force-length relationship and is analogous
to Starling's law (myocardium).
Sensory deficit along the radial nerve distribution (see sensory innervation above
and accompanying image for clarity) What accounts for the decreased grip strength in
wrist drop?

Without the ability to hold the wrist in extension, the flexors in the anterior forearm
(flexor pollicis longus, flexor digitorum profundus, flexor digitorum superficialis) are not
adequately stretched. This causes excessive overlap of actin and myosin filaments
which leads to suboptimal power generation and decreased grip strength.

547
Brachial Plexus-Radial Nerve

Brachial plexus

548
Brachial Plexus-Radial Nerve

Brachial plexus - radial nerve, distribution

549
Brachial Plexus-Radial Nerve

Sensory distribution of brachial plexus.

Radial nerve injury can be caused by:

Prolonged compression of the axilla (e.g., inappropriate/prolonged use of


crutches) due to its course inferior to the tendon of latissimus dorsi

Saturday night palsy passing out drunk with arms hanging over a
chair, balcony, etc.
Midshaft humeral fracture due to its course in the radial groove on the surface of the
midshaft humerus with profunda brachii (deep brachial artery)
Fracture of the lateral epicondyle of the distal humerus
Radial head subluxation Also known as Nursemaid's elbow, radial head

550
Brachial Plexus-Radial Nerve

subluxation occurs when a strong traction occurs on a pronated and extended forearm.
Classically, this occurs when a child's arm is pulled upwards by a taller adult holding
their hand.

551
Brachial Plexus-Ulnar Nerve

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Brachial PlexusUlnar Nerve


https://med.firecracker.me/app#/tree/1/1-20-41-72-3022

Ulnar nerve (C8, T1):

The ulnar nerve arises from the terminal branch of the medial cord of the brachial plexus.
Sensory innervation :

Palmar and dorsal aspects of the medial half of the hand (including the hypothenar
eminence) and the medial 1 1/2 digits Motor innervation :
Anterior forearm muscles (flexor carpi ulnaris, medial half of flexor digitorum profundus):
Flexion of the wrist and medial fingers
Most of the intrinsic muscles of the hand (3rd and 4th lumbricals, palmar and dorsal
interossei, adductor pollicis, and hypothenar musculature): Movement at the
carpometacarpal, metacarpophalangeal, and interphalangeal joints

552
Brachial Plexus-Ulnar Nerve

Deep nerves of the hand.

553
Brachial Plexus-Ulnar Nerve

Superficial nerves of the hand.

554
Brachial Plexus-Ulnar Nerve

Brachial plexus - ulnar nerve palsy, claw hand

Sensory innervation of brachial plexus.

555
Brachial Plexus-Ulnar Nerve

Brachial plexus - middle portion of the biceps brachii has been removed to show the
musculocuta-neous nerve lying in front of the brachialis. Also shown: median and ulnar
nerves.

556
Brachial Plexus-Ulnar Nerve

Dermatomes vs. cutaneous areas of sensory nn, anterior view

557
Brachial Plexus-Ulnar Nerve

Dermatomes vs. cutaneous areas of sensory nn, posterior view

558
Brachial Plexus-Ulnar Nerve

Ulnar nerve injury can be caused by :

Fracture of the medial epicondyle or supracondylar fracture of the distal


humerus may cause ulnar nerve injury due to its superficial location at the elbow as it
courses posterior to the medial epicondyle.
Cubital tunnel syndrome is caused either by compression or stretching of the ulnar
nerve as it crosses from the arm into the forearm posterior to the medial epicondyle of
the humerus.
Fracture of the hook of the hamate can cause ulnar nerve injury due to its superficial
location in the hand as it passes between the hook of the hamate and the pisiform bone
in a fibroosseous tunnel called Guyon's canal.
Injury during delivery can damage the ulnar nerve and is called Klumpke's
palsy. Klumpke's palsy is caused by a lesion of the lower roots of the brachial plexus
during traumatic vaginal delivery or by excessive traction of an abducted arm during
delivery.
Ulnar tunnel syndrome , also known as Guyon's canal syndrome or handlebar palsy,
results from prolonged pressure on the ulnar aspect of palmar surface of the hand. This
classically occurs to cyclists when the wrist is in extension and significant bodyweight is
placed on the region of Guyon's canal (hands on handlebars) causing entrapment of the
ulnar nerve.

Fracture of the medial epicondyle of the distal humerus or cubital tunnel syndrome
causes proximal ulnar nerve injury :

Ulnar claw hand , often readily apparent at rest (vs. median claw hand, which may
subtle at rest but becomes apparent when the patient is asked to make a fist).

Note: This presentation may be apparent but is less pronounced than what is
observed in a distal ulnar nerve injury, such as a fracture of the hook the hamate.
Sensory deficit, including loss of sensation in the hypothenar eminence
Weakness in flexion of the wrist and digits 4 and 5 due to paralysis of some (but not all)
of the anterior forearm musculature, including paralysis of flexor carpi ulnaris and
medial half of flexor digitorum profundus

Sign: "OK" gesture The patient is able to make "OK" sign with first 3 digits flexed

559
Brachial Plexus-Ulnar Nerve

and the 4th and 5th extended.

Fracture of the hook of the hamate can cause distal ulnar nerve injury :

Ulnar claw hand is often readily apparent at rest (vs. median claw hand, which may
subtle at rest but becomes apparent when the patient is asked to make a fist). The 4th
and 5th digits are extended at the MCP joint and flexed at the DIP and PIP joint due to
loss of the action of the lumbricals.
Sensory deficit, except hypothenar eminence sensation may be intact because the
palmar branch of the ulnar nerve arises proximal to the wrist and thus may not be
damaged by an ulnar nerve lesion distal to the wrist.

Ulnar claw hand :

What accounts for the "clawing" observed in ulnar claw hand (i.e., claw hand secondary to
ulnar nerve injury)?

Paralysis of lumbricals 3 & 4 :

Decreased functional flexion of MCP (metacarpophalangeal) joints of digits 4 &


5; in the face of decreased opposing flexion, extensor digitorum may pull these
MCP joints into extension, which causes the corresponding IP (interphalangeal)
joints to become more flexed. Digits 2 & 3 remain intact as lumbricals 1 & 2 are
innervated by the median nerve.
Paralysis of adductor pollicis :

Decreased adduction of the carpometacarpal joint of the thumb; in the face of


decreased opposing adduction, abductor pollicis longus and abductor pollicis brevis
may pull the thumb into abduction
Paralysis of interossei :

Inability to adduct and abduct the digits of the hand


Loss of wrist flexion and adduction :

This is possible with a proximal lesion of the ulnar nerve (medial epicondyle of
humerus fracture) causing denervation to flexor carpi ulnaris and flexor digitorum
profundus (FDP). This is known as the "ulnar paradox," as flexion at the IP joints

560
Brachial Plexus-Ulnar Nerve

is lost due to paralysis of digitorum profundus and the MCP joints appear extended.
The paradox refers to the fact that losing both the lumbricals and FDP from a
proximal injury results in a less severe claw (because the digits are paralyzed in
extension) than what is observed in a distal injuring which spares the FDP resulting
in flexion (clawing) of the digits.

561
Brachial Plexus

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Brachial Plexus
https://med.firecracker.me/app#/tree/1/1-20-41-72-887

The brachial plexus and the subclavian artery traverse the posterior triangle of the neck
and the interscalene triangle.

The interscalene triangle is formed by the 1st rib, scalenus anterior, and scalenus
medius.

Thoracic outlet syndrome (also known as scalenus anticus syndrome) is a neurologic


and/or vascular impairment of the upper limb due to narrowing of the interscalene triangle
and consequent compression of the brachial plexus and subclavian artery.

Brachial plexus emerging through anterior and middle scalenes

562
Brachial Plexus

Interscalene triangle. Formed by the the anterior scalene, medial scalene, and 1st rib.

The s** ubclavius muscle** protects the brachial plexus and the subclavian vessels from the
sharped end of a clavicle when fractured.

The clavicle is the most frequently fractured bone in the body.

The subclavius muscle is innervated by the n** erve to the subclavius , which is a branch
from the superior trunk** of the brachial plexus.

Use the mnemonic R eal T exans D rink C old B eer to remember the proximal-to-distal
organization of the brachial plexus: R oots T runks D ivisions C ords B ranches

5 R oots: ventral rami of C5, C6, C7, C8, T1

563
Brachial Plexus

3 T runks:

Superior (upper) trunk (C5, C6)


Middle trunk (C7)
Inferior (lower) trunk (C8,T1) 6 D ivisions: There is an anterior and posterior division
for each of the 3 trunks.

There are 3 C ords (named according to their anatomic relationship to the axillary artery):

Posterior cord Axillary nerve, radial nerve


Lateral cord Musculocutaneous nerve, part of median nerve
Medial cord Ulnar nerve, part of median nerve There are 5 terminal B ranches:

Musculocutaneous nerve

Axillary nerve
Radial nerve
Median nerve
Ulnar nerve

564
Brachial Plexus

Brachial plexus, relationship to structures in upper chest, shoulder, axilla

565
Brachial Plexus

Brachial plexus

566
Brachial Plexus

Brachial plexus.

567
Brachial Plexus

Normal anatomy of the shoulder, anterior view.

Erb's palsy (Waiter's tip):

Erb's palsy may result from a lesion of the upper trunk (C5-C6) of the brachial plexus. Injury
to roots C5 and C6 affects the musculocutaneous (C5-C7), axillary (C5-C6), median (C5-
T1), and radial (C5-T1) nerves.

568
Brachial Plexus

The muscles affected in Erb's palsy: the deltoid , rotator cuff , elbow flexors , wrist and
hand extensors.

Rotator cuff muscles : SItS supraspinatus, infraspinatus, teres minor, subscapularis


Arm flexor : Coracobrachialis
Elbow flexors : Biceps brachii, brachialis
Wrist extensors : Extensor carpi radialis longus, extensor carpi radialis brevis,
extensor carpi ulnaris The latissimus dorsi is innervated by the thoracodorsal
(middle subscapular) nerve, which is primarily derived from C7 and is NOT affected
in Erb's palsy.

With the deltoid and rotator cuff muscles paralyzed due to injury of C5 and C6, the action of
latissimus dorsi on the shoulder (extension, adduction, medial rotation) is unopposed
resulting in the arm hanging by the side (adduction) with internal (medial) rotation.

Klumpke's palsy :

Klumpke's palsy may result from a lesion of the lower trunk (C8-T1) of the brachial plexus.
It is an extremely rare injury and can be caused by a forceful combination of arm traction
and abduction during delivery.

Note: Although lower trunk lesions are typically presented as obstetrical complications,
adults may sustain the injury by grasping for a ledge when falling from height. Examples
include grasping for the top rung of a ladder when falling or grabbing a tree branch when
falling from above. Affects the wrist flexors and the intrinsic muscles of the hand presenting
as a claw hand :

Intrinsics: Hyperextension at MCP joint and flexion at DIP and PIP due to loss of
lumbricals and interossei
Thenar compartment: Deep head of flexor pollicis brevis
Adductor compartment: Adductor pollicis
Hypothenar compartment: Abductor digiti minimi, flexor digiti minimi brevis,
opponens digiti minimi
Flexors of hand at wrist: Flexor carpi ulnaris, flexor digitorum profundus (medial
half)

Note: Sources will vary on the precise presentation of Klumpke's palsy due to variable
degrees of median nerve damage.

Injury of C8-T1 may also involve the sympathetic trunk/ganglia and is called Horner's
syndrome :

569
Brachial Plexus

Miosis

Anhidrosis
Ptosis

Medial winging of the scapula is caused by a lesion of the long thoracic nerve.

Wall test : The patient stands facing wall with palms flat against the wall and pushes
forward; a positive test is medial winging of the scapula.

The serratus anterior is innervated by the long thoracic nerve , formed by ventral rami of
spinal nerves C5, C6, C7.

Actions of serratus anterior:

Protraction of scapula Anterior rotation of the scapula around the ribs observed
during a "punching" motion
Stabilization of scapula Holds scapula flat against posterior ribs
Upward rotation of scapula Shoulder abduction above the horizontal plane when
raising the arms above the head
Aid in inspiration during exercise Lesion of the long thoracic nerve (eg, status post
mastectomy with axillary lymph node dissection) causes paralysis of serratus
anterior:
Inability to raise the arms above the horizontal (90)
Medial winging of the scapula Inferior scapular angle is rotated medially and lifted
superiorly and away from the posterior thoracic wall, which may be accentuated by
having the patient push against a wall with flat palms (see image)

Compare:

Lesion of accessory nerve (CN XI) (eg, radical neck dissection) causes paralysis of
trapezius:

Drooping of the shoulder


Lateral scapular winging Inferior scapular angle is rotated laterally and lifted
superiorly and away from the posterior thoracic wall, which may be accentuated during
resisted abduction.

570
Brachial Plexus

Winged scapula secondary to injury of long thoracic nerve. Note the protrusion of the medial
boarder of the scapula from the posterior rib cage.

Winged scapula secondary to injury of long thoracic nerve. Note the protrusion of the medial
boarder of the scapula from the posterior rib cage.

571
Forearm: Muscles-Deep Extensors

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Forearm: MusclesDeep Extensors


https://med.firecracker.me/app#/tree/1/1-20-41-72-876

There are 5 deep extensors in the forearm , all of which are innervated by branches of the
radial nerve:

Supinator** ** Deep branch of the radial nerve


APL (abductor pollicis longus) Posterior interosseous nerve (branch of radial
nerve)
EPB (extensor pollicis brevis) Posterior interosseous nerve (branch of radial
nerve)
EPL (extensor pollicis longus) Posterior interosseous nerve (branch of radial
nerve)
Extensor indicis Posterior interosseous nerve (branch of radial nerve)

The supinator is innervated by the deep branch of the radial nerve or the posterior
interosseous nerve (PIN). Sources vary on the innervation of the supinator. The PIN is a
continuation of the deep branch of the radial nerve, which begins after the nerve pierces the
supinator. Its action is supination of the forearm. The supinator is not involved in
extension but is included in this section because of its anatomical location in the deep
extensor compartment.

572
Forearm: Muscles-Deep Extensors

1) Supinator

573
Forearm: Muscles-Deep Extensors

Abductor pollics longus (APL) is innervated by the p** osterior interosseous nerve (PIN), a
branch of radial nerve. Its action is abduction, extension, and lateral rotation of the thumb
at the carpometacarpal (CMC) joint.**

The extensor pollicis brevis (EPB) is innervated by the p** osterior interosseous nerve (PIN),
a branch of radial nerve . Its action is extension of the MCP (metacarpophalangeal) and
CMC (carpometacarpal) joints of thumb.**

The extensor pollicis longus (EPL) is innervated by the p** osterior interosseous nerve
(PIN), a branch of the radial nerve. Its action is extension of the IP (interphalangeal),
MCP (metacarpophalangeal), and CMC (carpometacarpal) joints of thumb.**

The extensor indicis is innervated by the p** osterior interosseous nerve (PIN), a branch of
the radial nerve. Its action is extension of IP (interphalangeal) and MCP
(metacarpophalangeal) joints of digit 2 (the index finger) and extension of the wrist.**

574
Forearm: Muscles-Deep Flexors

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Forearm: MusclesDeep Flexors


https://med.firecracker.me/app#/tree/1/1-20-41-72-874

There are 2 deep wrist flexors in the forearm , both of which are innervated by the anterior
interosseous nerve (branch of median nerve):

Flexor pollicis longus (FPL)


Flexor digitorum profundus (FDP) The FDP (medial aspect) is also innervated by
the ulnar nerve

Note: The pronator quadratus resides in the deep forearm compartment as well but
does not assist in flexion (pronation only).

Flexor pollicis longus (FPL) is innervated by the anterior interosseus nerve (AIN), a
branch of the median nerve. Its action is f** lexion of the IP (interphalangeal), MCP
(metacarpophalangeal), and CMC (carpometacarpal) joints of the thumb and f **lexion of
the wrist.

Flexor digitorum profundus (FDP) is innervated on the lateral half by the anterior
interosseous nerve (AIN), a branch of median nerve, and on the medial half by the ulnar
nerve. Its action is:

Flexion of the DIP (distal interphalangeal) joints of digits 2, 3, 4, 5 (primary action)


Assists with flexion of PIP (proximal interphalangeal) and MCP
(metacarpophalngeal) joints of digits 2, 3, 4, 5 (secondary action)
Flexion of the wrist

The pronator quadratus is innervated by the anterior interosseous nerve (AIN), a branch
of the median nerve. Its action is pronation of the wrist.

576
Forearm: Muscles-Superficial Extensors

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Forearm: MusclesSuperficial Extensors


https://med.firecracker.me/app#/tree/1/1-20-41-72-875

There are 5 superficial extensors in the forearm , all of which are innervated by the radial
nerve or one of its branches:

ECRL (extensor carpi radialis longus) Radial nerve


ECRB (extensor carpi radialis brevis) Deep branch of radial nerve
Extensor digitorum Posterior interosseous nerve (branch of radial nerve)
EDM (extensor digiti minimi) Posterior interosseous nerve (branch of radial nerve)
ECU (extensor carpi ulnaris) Posterior interosseous nerve (branch of radial nerve)

Extensor carpi radialis longus (ECRL) is innervated by the radial nerve. Its action is
extension and abduction of the hand at the wrist.

Extensor carpi radialis brevis (ECRB) is innervated by the deep branch of the radial nerve.
Its action is extension and abduction of the hand at the wrist.

Extensor digitorum is innervated by the posterior interosseous nerve (PIN), a branch of


the radial nerve. Its action is:

Extension of the IP (interphalangeal) and MCP (metacarpophalangeal) joints of


digits 2, 3, 4, and 5
Extension of the wrist

Extensor digiti minimi (EDM) is innervated by the posterior interosseous nerve (PIN), a
branch of the radial nerve. Its action is:

Extension of the IP (interphalangeal) and MCP (metacarpophalangeal) joints of


digit 5 (little pinky finger)
Extension of the wrist

578
Forearm: Muscles-Superficial Extensors

Extensor carpi ulnaris (ECU) is innervated by the posterior interosseous nerve (PIN), a
branch of the radial nerve. Note: Some sources may list the innervation as the deep
branch of the radial nerve. The posterior interosseous nerve is a continuation of the deep
branch of the radial nerve and sources vary for this reason. Its action is extension and
adduction of the hand at the wrist.

579
Forearm: Muscles-Superficial Flexors

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Forearm: MusclesSuperficial Flexors


https://med.firecracker.me/app#/tree/1/1-20-41-72-873

There are 6 superficial flexors in the forearm, all of which are innervated by the median
nerve or ulnar nerve except for the brachioradialis, which is innervated by the radial nerve:

Brachioradialis Radial nerve


Pronator teres Median nerve
FCR (flexor carpi radialis) Median nerve
Palmaris longus Median nerve
FCU (flexor carpi ulnaris) Ulnar nerve
FDS (flexor digitorum superficialis) Median nerve

The brachioradialis (BR) is innervated by the radial nerve. Its action is flexion at the
elbow.

The brachioradialis is the only forearm flexor innervated by the radial nerve. This
unique radial nerve innervation is due to the fact that, although functionally a flexor,
brachioradialis is embryologically derived from extensor musculature and all forearm
extensors are innervated by the radial nerve.

The pronator teres is innervated by the median nerve. Its action is forearm pronation and
flexion.

580
Forearm: Muscles-Superficial Flexors

Muscles of the forearm. Note the pronator teres.

581
Forearm: Muscles-Superficial Flexors

Pronator teres.

Flexor carpi radialis (FCR) is innervated by the median nerve. Its action is wrist flexion
and abduction.

The palmaris longus is innervated by the median nerve. Its action is wrist flexion (weak).
The palmaris longus is absent in 10-15% of people.

Flexor carpi ulnaris (FCU) is innervated by the ulnar nerve. Its action is wrist flexion and
adduction.

582
Forearm: Muscles-Superficial Flexors

Flexor digitorum superficialis (FDS) is innervated by the median nerve. Its action is flexion
of PIP (proximal interphalangeal) and MCP (metacarpophalangeal) joints of digits 2, 3,
4, and 5 and f**lexion of wrist.**

583
Forearm: Nerves

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Forearm: Nerves
https://med.firecracker.me/app#/tree/1/1-20-41-72-936

Radial nerve (C5-T1): The radial nerve descends anterior to the lateral epicondyle traveling
between the brachialis and brachioradialis.

Innervation: Lateral part of the brachialis, brachioradialis, and extensor carpi


radialis longus

After innervating those 3 muscles, the radial nerve divides into two terminal branches, the
superficial and deep branches of the radial nerve.

Superficial branch of the radial nerve : Travels deep to the brachioradialis; this nerve
does not have any branches in the forearm
Deep branch of the radial nerve : Innervates both the extensor carpi radialis brevis
and the supinator muscle; penetrates the supinator muscle lateral to the radius and
becomes the posterior interosseus nerve

Median nerve (C5, 6, 7, 8, T1): Path of median nerve :

Travels in between the humeral and ulnar heads of the pronator teres

In the mid-forearm, it continues in between flexor digitorum superficialis and flexor


digitorum profundus
Continues between flexor digitorum profundus and flexor pollicis longus before
entering the carpal tunnel

Note: There may be slight discrepancies between sources regarding the path of the median
nerve. Some sources state the median nerve enters the carpal tunnel between the flexor
digitorum profundus and flexor pollicis longus. Netter's Concise Orthopaedic Anatomy was
used for this card.

The median nerve passes through the carpal tunnel before entering the hand.
Innervation :

Most of the first and second layers of the forearm including: Pronator teres, flexor
carpi radialis, palmaris longus, flexor digitorum superficialis

584
Forearm: Nerves

Three muscles in the deep flexor layer including: Flexor digitorum profundus (radial
half only), flexor pollicis longus, and pronator quadratus via the anterior
interosseous branch A branch of the median nerve found on the interosseus
membrane, the anterior interosseus nerve , innervates the third and fourth layers
of the forearm, which includes the flexor pollicis longus, flexor digitorum profundus
(radial half), and pronator quadratus.

Median nerve entering the wrist. Note that the median nerve is found between flexor pollicis
longus and flexor digitorum superificialis (depicted here using a common alternative name
flexor digitorum sublimis) as it enters the carpal tunnel.

585
Forearm: Nerves

Nerves of the forearm. Note the course of the median nerve.

Ulnar nerve (C8, T1):

586
Forearm: Nerves

Innervation: Flexor carpi ulnaris; ulnar half of the flexor digitorum profundus Path
of the ulnar nerve :
Passes between the humeral and ulnar heads of the flexor carpi ulnaris muscle on the
posterior aspect of the medial epicondyle of the humerus

Travels on top of the flexor digitorum profundus muscle to the level of the wrist

The ulnar nerve enters the hand via Guyon's canal , which is formed by the superior
palmar carpal ligament superficially, the hook of hamate laterally, the pisiform medially,
and the flexor retinaculum deep.

The ulnar nerve then splits into the deep motor and superficial sensory branches.

The deep motor branch travels adjacent to the hook of hamate and alongside the
deep arterial arch.

587
Forearm: Nerves

Note the structure and lateral surface of the pisiform bone, the structure that provides lateral
support for the ulnar nerve as it enters the hand.

588
Forearm: Nerves

Ulnar and median nerves entering the hand.

589
Forearm: Nerves

Ulnar and median nerves entering the hand.

590
Forearm: Nerves

Nerves of the forearm. Note the course of the ulnar nerve.

591
Forearm: Vessels

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Forearm: Vessels
https://med.firecracker.me/app#/tree/1/1-20-41-72-1783

The brachial artery is found within the cubital fossa between the median nerve (most
medial structure) and the biceps tendon. The radial nerve traverses the cubital fossa and
is the most lateral structure.

From medial to lateral: Median nerve, brachial artery, biceps tendon, and radial nerve


Mnemonic (lateral to medial): R eally N eed B eer T o B e A t M y N icest

R eally N eed: R adial N erve


B eer T o: B iceps T endon
B e A t: B rachial A rtery
M y N icest: M edian N erve The brachial artery splits into the radial and ulnar arteries
at the neck of the radius.

593
Forearm: Vessels

Brachial plexus - middle portion of the biceps brachii has been removed to show the
musculocuta-neous nerve lying in front of the brachialis. Also shown: median and ulnar
nerves; brachial, radial, and ulnar arteries.

594
Forearm: Vessels

Arteries of the arm. Note the course of the brachial artery.

595
Forearm: Vessels

Cubital fossa.

596
Forearm: Vessels

Cubital fossa.

597
Forearm: Vessels

Radial artery : The radial artery crosses the forearm superficial to the pronator teres
muscle and deep to the brachioradialis.

Brachial plexus - middle portion of the biceps brachii has been removed to show the
musculocuta-neous nerve lying in front of the brachialis. Also shown: median and ulnar
nerves; brachial, radial, and ulnar arteries.

598
Forearm: Vessels

Arteries of the arm. Note the course of the radial artery.

599
Forearm: Vessels

Ulnar artery : The ulnar artery travels deep to the pronator teres (both heads), passes
under the median nerve , and then travels posteriorly to the flexor digitorum
superficialis toward the ulnar nerve on the medial aspect of the forearm.

After crossing the median nerve , the ulnar artery travels lateral to the ulnar nerve on
the surface of the flexor digitorum profundus between flexor carpi ulnaris and flexor
digitorum superficialis toward the medial side of the wrist.

The ulnar artery then enters the hand by passing through Guyon's canal , which
is formed by the flexor retinaculum (transverse carpal ligament) on the floor and the palmar
(volar) carpal ligament superficially.

The ulnar artery gives rise to the superficial palmar arch of the hand.

600
Forearm: Vessels

Brachial plexus - middle portion of the biceps brachii has been removed to show the
musculocuta-neous nerve lying in front of the brachialis. Also shown: median and ulnar
nerves; brachial, radial, and ulnar arteries.

601
Forearm: Vessels

Arteries of the forearm. Note the course of the ulnar artery.

602
Forearm: Vessels

Ulnar artery.

603
Forearm: Vessels

Ulnar artery.

604
Forearm: Vessels

Ulnar artery.

Common interosseous artery : The common interosseous artery is a branch of the ulnar
artery that arises near its origin and bifurcates almost immediately into the anterior and
posterior interosseous arteries.

Anterior interosseous artery: The anterior interosseous artery travels on the interosseous
membrane accompanied by the anterior interosseous nerve. Posterior interosseous
artery : The posterior interosseous artery passes through the anterior border of the
interosseous membrane to its posterior side where it then emerges from beneath the
supinator muscle in the posterior forearm compartment adjacent to the posterior
interosseous nerve.

605
Forearm: Vessels

Posterior interosseous artery.

606
Forearm: Vessels

Arteries of the forearm. Note the branches of the common interosseous artery.

607
Forearm: Vessels

Arteries of the forearm. Note the branches of the common interosseous artery.

608
Forearm: Vessels

Arteries of the forearm. Note the branches of the common interosseous artery.

Collateral circulations : From the brachial and deep brachial arteries:

609
Forearm: Vessels

Brachial artery collaterals superior ulnar collateral artery and the inferior ulnar
collateral artery
Deep brachial artery collaterals radial collateral artery and middle (medial)
collateral artery From the radial artery radial recurrent artery

From the ulnar artery anterior ulnar recurrent artery and posterior ulnar recurrent
artery

From the posterior interosseous artery interosseous recurrent artery

610
Hand: Innervation of Intrinsic Muscles

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Hand: Innervation of Intrinsic Muscles


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The intrinsic muscles in the hand are innervated either by branches of the median nerve or
by branches of the ulnar nerve :

Median nerve :

To remember the intrinsic muscles of the hand innervated by the median nerve, use the
mnemonic, ME at LOAF :

ME dian nerve innervates:

L umbricals 1 and 2 Digital branches of median nerve


O pponens pollicis Recurrent branch of median nerve
A PB (abductor pollicis brevis) Recurrent branch of median nerve
Superficial head of F PB (flexor pollicis brevis) Recurrent branch of median nerve
(vs. the deep head of FPB, which is innervated by the deep branch of the ulnar nerve)

All other non-meat-loaf hand intrinsics are innervated by the ulnar nerve. Ulnar nerve:

The ulnar nerve innervates the intrinsic muscles of the hand:

Superficial branch of ulnar nerve :

Palmaris brevis

Deep branch of ulnar nerve :

Deep head of FPB (flexor pollicis brevis)


ADM (abductor digiti minimi)
FDMB (flexor digiti minimi brevis)
ODM (opponens digiti minimi)
Adductor pollicis
Lumbricals 3 & 4
Palmar (volar) interossei & dorsal interossei

611
Hand: Muscles-Deep

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Hand: MusclesDeep
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Adductor pollicis :

Action:

Adduct and flex CMC (carpometacarpal) joint of thumb


Flex MCP (metacarpophalangeal) joint of thumb
Innervation: Deep branch of ulnar nerve

613
Hand: Muscles-Deep

Muscles of the Hand.

614
Hand: Muscles-Deep

Right hand, palmar view with an arrow pointing to adductor pollicis.

Attribution: Gray's Anatomy PD-US

615
Hand: Muscles-Deep

616
Hand: Muscles-Deep

Hand, dorsal and palmar views with mm and tendons labeled

Hand, deep layer of mm

617
Hand: Muscles-Deep

Hand, anterior view w/ deep palmar arch, deep br of ulnar n, interossei

There are 4 lumbricals :

From lateral (thumb-side) to medial (pinky-side), the lumbricals are numbered 1, 2, 3, 4.

Lumbricals 1 & 2 are unipennate and lumbricals 3 & 4 are bipennate.

Action:

Extend PIPJ (proximal interphalangeal joints) of digits 2, 3, 4, 5


Flex MCPJ (metacarpophalangeal joints) of digits 2, 3, 4, 5
Innervation:

Lumbricals 1 & 2: Digital branches of median nerve


Lumbricals 3 & 4: Deep branch of ulnar nerve

618
Hand: Muscles-Deep

Hand, lumbricals and interossei

619
Hand: Muscles-Deep

620
Hand: Muscles-Deep

Hand, dorsal and palmar views with mm and tendons labeled

Left hand, palmar view with the 4 lumbricals highlighted in red and numbered.

621
Hand: Muscles-Deep

Attribution: Gray's Anatomy PD-US

Muscles of the Hand.

Mnemonic: PAD DAB :

P almar interossei AD duct the MCP (metacarpophalangeal) joint of digits 2, 4, 5


D orsal interossei AB duct the MCP (metacarpophalangeal) joint of digits 2, 3, 4

There are 3 PIO (palmar interossei):

From lateral (thumb-side) to medial (pinky-side), PIO are numbered 1, 2, 3.

All 3 PIO are unipennate.

Action:

622
Hand: Muscles-Deep

Adduct MCP (metacarpophalangeal) joint of digits 2, 4, 5 (i.e., movement in the


plane of the palm toward an imaginary longitudinal axis through digit 3 (middle
finger))

Mnemonic: PAD Palmar ADduct


__Innervation: Deep branch of ulnar nerve

Muscles of the Hand.

623
Hand: Muscles-Deep

Left hand, palmar view showing palmar interossei.

Attribution: Gray's Anatomy PD-US

624
Hand: Muscles-Deep

625
Hand: Muscles-Deep

Hand, dorsal and palmar views with mm and tendons labeled

Hand, deep layer of mm

626
Hand: Muscles-Deep

Hand, anterior view w/ deep palmar arch, deep br of ulnar n, interossei

627
Hand: Muscles-Deep

Hand, lumbricals and interossei

628
Hand: Muscles-Deep

Deep palmar structures of the right hand.

There are 4 DIO (dorsal interossei): From lateral (thumb-side) to medial (pinky-side), DIO
are numbered 1, 2, 3, 4. All 4 DIO are bipennate.

Action:

Abduct MCP (metacarpophalangeal) joint of digits 2, 3, 4 (i.e., movement in the


plane of the palm away from an imaginary longitudinal axis through digit 3 (middle
finger))

Mnemonic: DAB Dorsal ABduct


Minor Action: Flex MCP (metacarpophalangeal) joints of digits 2, 3, 4
Innervation: Deep branch of ulnar nerve

629
Hand: Muscles-Deep

Muscles of the Hand.

630
Hand: Muscles-Deep

Left hand, dorsal view showing dorsal interossei.

Attribution: Gray's Anatomy PD-US

631
Hand: Muscles-Deep

Lateral view of the hand showing the first dorsal interosseous muscle as well as the first
lumbrical.

Attribution: Gray's Anatomy PD-US

632
Hand: Muscles-Deep

633
Hand: Muscles-Deep

Hand, dorsal and palmar views with mm and tendons labeled

Hand, deep layer of mm

634
Hand: Muscles-Deep

Hand, anterior view w/ deep palmar arch, deep br of ulnar n, interossei

635
Hand: Muscles-Deep

Hand, lumbricals and interossei

636
Hand: Muscles-Superficial

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Hand: MusclesSuperficial
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Palmaris brevis :

Action: Elevate and tense the hypothenar eminence , thereby increasing grip power
Innervation: Superficial branch of ulnar nerve

Thenar eminence 3 muscles:

APB (abductor pollicis brevis)


FPB (flexor pollicis brevis)
Opponens pollicis The median nerve innervates 4 muscles within the hand.

Mnemonic: M eat LOAF

M edian nerve
L umbricals (1-2)
O pponens pollicis
A bductor pollicis brevis
F lexor pollicis brevis

637
Hand: Muscles-Superficial

638
Hand: Muscles-Superficial

Hand, dorsal and palmar views with mm and tendons labeled

Left hand, palmar view showing thenar eminence and hypothenar eminence.

Attribution: Gray's Anatomy PD-US

APB (abductor pollicis brevis):

Action:

Abduct and flex CMC (carpometacarpal) joint of thumb


Flex MCP (metacarpophalangeal) joint of thumb

639
Hand: Muscles-Superficial

Innervation: Recurrent branch of median nerve

FPB (flexor pollicis brevis):

Action: Flex CMC (carpometacarpal) and MCP (metacarpophalangeal) joints of


thumb
Innervation:

Superficial head Recurrent branch of median nerve


Deep head Deep branch of ulnar nerve

Opponens pollicis :

Action: Medially rotate and flex CMC (carpometacarpal) joint of thumb

Note:

Opposition of the thumb Simultaneous medial rotation and flexion of CMC joint of
thumb, allowing contact between tip of thumb and tips of digits 2, 3, 4, or 5

Reposition of the thumb The opposite of opposition


Innervation: Recurrent branch of median nerve

Hypothenar eminence 3 muscles:

ADM (abductor digiti minimi)


FDMB (flexor digiti minimi brevis)
ODM (opponens digiti minimi)

640
Hand: Muscles-Superficial

641
Hand: Muscles-Superficial

Hand, dorsal and palmar views with mm and tendons labeled

Left hand, palmar view showing thenar eminence and hypothenar eminence.

Attribution: Gray's Anatomy PD-US

ADM (abductor digiti minimi):

Action: Flex and abduct MCP joint of digit 5 (little pinky finger)
Innervation: Deep branch of ulnar nerve

642
Hand: Muscles-Superficial

FDMB (flexor digiti minimi brevis):

Action: Flex MCP of digit 5 (little pinky finger)


Innervation: Deep branch of ulnar nerve

ODM (opponens digiti minimi):

Action: Laterally rotate and flex CMC (carpometacarpal) joint of digit 5 (little pinky
finger)

Note: Simultaneous lateral rotation and flexion of CMC (carpometacarpal) joint of digit 5
cups the hand, thereby increasing grip power.

Innervation: Deep branch of ulnar nerve

643
Hand: Nerves

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Hand: Nerves
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The ulnar nerve :

The ulnar nerve enters the hand lateral to the pisiform bone then immediately branches into
deep and superficial branches. The superficial branch of the ulnar nerve supplies the
palmaris brevis muscle.

The deep branch of the ulnar nerve provides motor innervation to most muscles of the
hand:

Hypothenar muscles
Dorsal interossei
Palmar interossei
Medial 2 lumbricals (3 and 4)
Adductor pollicis
Deep head of flexor pollicis brevis Within the hand, the ulnar nerve provides sensory
innervation to the skin over the medial palm, and palmar and dorsal aspects of the
little finger and medial half of the ring finger.

644
Hand: Nerves

Nerves of the hand

645
Hand: Nerves

Sensory innervation of upper limb: Ventral aspect

646
Hand: Nerves

Sensory innervation of upper limb: Dorsal aspect

647
Hand: Nerves

Hand, anterior view w/ deep palmar arch, deep br of ulnar n, interossei

The median nerve :

Proximal to the carpal tunnel the median nerve gives off a palmar (superficial) branch.
After passing through the carpal tunnel, the median nerve gives off a recurrent branch and
multiple digital branches. The palmar and digital branches of the median nerve provide
sensory innervation to:

Skin over the lateral palm, minus a small portion innervated by the radial nerve.
Skin over the palmar aspect of the lateral half of the ring finger and lateral 3 fingers.
Skin over the dorsal aspect of the distal phalanges of the lateral 3 fingers and lateral
half of the ring finger. Digital branches of the median nerve also innervate the lateral 2
lumbricals (1 and 2). The recurrent branch of the median nerve innervates the thenar
muscles. The thenar muscles include:

648
Hand: Nerves

Abductor pollicis brevis

Flexor pollicis brevis


Opponens pollicis

Sensory innervation of upper limb: Ventral aspect

649
Hand: Nerves

Sensory innervation of upper limb: Dorsal aspect

650
Hand: Nerves

Nerves of the hand

The radial nerve :

A superficial branch from the radial nerve enters the hand passing over the anatomical
snuff box. Provides sensory innervation to:

Dorsolateral hand
Dorsal aspect of the lateral 3.5 digits minus the distal phalanges

651
Hand: Nerves

Sensory innervation of upper limb: Ventral aspect

652
Hand: Nerves

Sensory innervation of upper limb: Dorsal aspect

653
Hand: Vasculature

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Hand: Vasculature
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Ulnar artery :

The ulnar artery enters the hand with the ulnar nerve via Guyon's canal , which is a tunnel
formed between the flexor retinaculum and the palmar carpal ligament that spans a
depression between the pisiform and hamate. Within the palm, the ulnar artery courses
laterally as the superficial palmar arch.

The superficial palmar arch anastomoses with the palmar branch of the radial artery.

The superficial palmar arch gives off 3 common digital arteries.

The common digital arteries branch into proper digital arteries that run along the sides of
the fingers.

654
Hand: Vasculature

Arteries of the hand

655
Hand: Vasculature

Arteries of the hand, isolated view

656
Hand: Vasculature

Hand, anterior view w/ deep palmar arch, deep br of ulnar n, interossei

657
Hand: Vasculature

Arteries of the forearm and hand: Superficial view

658
Hand: Vasculature

Arteries of the forearm and hand: Deep view

Radial artery :

The radial artery is initially anterior to the wrist, then courses over the floor of the
anatomical snuffbox and enters the hand dorsal to the base of the thumb. The first
branch of the radial artery within the hand is the dorsal carpal artery, which then gives off
multiple dorsal metacarpal arteries.

The dorsal metacarpal arteries become dorsal digital arteries within the fingers.

659
Hand: Vasculature

After passing over the dorsal aspect of the base of the thumb, the radial artery re-enters the
palmar hand as the deep palmar arch , which anastomoses with the deep branch of the
ulnar artery.

The deep palmar arch gives off the radialis indicis and princeps pollicis arteries, which
supply the index finger and thumb respectively.

Arteries of the hand

660
Hand: Vasculature

Arteries of the hand, isolated view

661
Hand: Vasculature

Hand, anterior view w/ deep palmar arch, deep br of ulnar n, interossei

662
Hand: Vasculature

Arteries of the forearm and hand: Superficial view

663
Hand: Vasculature

Arteries of the forearm and hand: Deep view

664
Rotator Cuff Muscles

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

Rotator Cuff Muscles


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The 4 rotator cuff muscles are:

S upraspinatus
I nfraspinatus
t eres minor
S ubscapularis

Mnemonic: SItS

The t in the mnemonic is purposefully lower case so you remember that it refers to teres
minor; teres major is NOT one of the 4 rotator cuff muscles.

665
Rotator Cuff Muscles

Socket of right shoulder joint, lateral view.

666
Rotator Cuff Muscles

Normal anatomy of the shoulder, anterior view.

The action of the supraspinatus muscle is initiation of the first 15-30 degrees of abduction
at glenohumeral joint.

The supraspinatus muscle is innervated by the suprascapular nerve (C5, with a smaller
contribution from C6).

667
Rotator Cuff Muscles

Clinical Correlate: The supraspinatus is the most commonly torn muscle of the rotator cuff
muscles. Function of the supraspinatus can be evaluated with the empty/full can test.

Socket of right shoulder joint, lateral view.

668
Rotator Cuff Muscles

Shoulder normal rotator cuff vs. rotator cuff tear

669
Rotator Cuff Muscles

Rotator cuff muscles.

The infraspinatus muscle is innervated by the suprascapular nerve (C5-C6).

The action of the infraspinatus muscle is external rotation at glenohumeral joint.

Clinical Correlate: Baseball pitchers are classically at risk for tearing the infraspinatus
muscle.

670
Rotator Cuff Muscles

Socket of right shoulder joint, lateral view.

671
Rotator Cuff Muscles

Normal anatomy of the shoulder, anterior view.

The teres minor adducts and laterally rotates the arm.

The teres minor is innervated by the axillary nerve (C5, C6).

672
Rotator Cuff Muscles

Socket of right shoulder joint, lateral view.

673
Rotator Cuff Muscles

Normal anatomy of the shoulder, anterior view.

The action of the subscapularis muscle is internal rotation at glenohumeral joint.

The subscapularis muscle is innervated by the u** pper and lower subscapular nerves**
(C5-C6).

674
Rotator Cuff Muscles

Socket of right shoulder joint, lateral view.

675
Rotator Cuff Muscles

Normal anatomy of the shoulder, anterior view.

676
The Cubital Fossa

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

The Cubital Fossa


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The cubital fossa is a triangle-shaped depression anterior to the elbow with the following
borders:

Superior border: imaginary line between the medial and lateral epicondyles of the
humerus
Medial border: pronator teres muscle
Lateral border: brachioradialis muscle

The apex is formed by the junction of the brachioradialis and pronater teres.

677
The Cubital Fossa

Arm, right cubital fossa

678
The Cubital Fossa

Note the brachial artery and median nerve running within the cubital fossa.

Right cubital fossa. Note the contents, the order of the contents, and boundaries of the
fossa.

679
The Cubital Fossa

Note the lateral (brachioradialis) and medial (pronator teres) boarders of the cubital fossa.

The major contents of the cubital fossa from medial to lateral are:

Median nerve
Brachial artery , which normally bifurcates into the radial and ulnar arteries near the
apex
Tendon of the biceps brachii muscle

Radial nerve, which is immediately deep to the brachioradialis muscle where it divides
into a superficial and deep branch, is not technically considered part of the cubital fossa.

680
The Cubital Fossa

Vasculature of forearm and cubital fossa: deeper view

681
The Cubital Fossa

Vasculature of forearm and cubital fossa: superficial view

682
The Elbow Joint

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

The Elbow Joint


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Supporting and accessory structures of the elbow joint:

The radial collateral ligament , ulnar collateral ligament , and joint capsule act together
to surround the joint space and stabilize the ulna, radius, and humerus relative to one
another.

The head of the radius articulates with the radial notch of the ulna forming the proximal
radioulnar joint. This facilitates supination and pronation of the arm.

The annular ligament encircles most of the head of the radius and stabilizes the
proximal radioulnar joint. It also serves as a point of attachment for the radial
collateral ligament

Clinical Correlate: Radial head subluxation (aka "Nursemaid's elbow" ) occurs frequently in
children. The head of the radius is pulled out of the annular ligament usually from a child
being lifted in the air by the hand. Patients present with pain and limited supination in the
affected arm.

The radial collateral ligament attaches to the lateral epicondyle of the humerus, the
radial notch of the ulna, and the annular ligament.
The ulnar collateral ligament attaches to the medial epicondyle and the coronoid
process and olecranon of the ulna.

683
The Elbow Joint

Annular ligament

684
The Elbow Joint

Ligaments of the elbow joint, posterior

685
The Elbow Joint

Ligaments of the elbow joint, anterior

Blood supply of the elbow joint comes from an anastomosis with branches of the brachial
artery and recurrent branches of radial and ulnar arteries.

Medial epicondylitis : Also known as golfer's elbow , medial epicondylitis results from
tendinosis of the muscles of the flexor compartment of the forearm at the insertion point at
the medial epicondyle of the elbow.

686
The Elbow Joint

Lateral epicondylitis : Also known as tennis elbow , lateral epicondylitis results from
tendinosis of the muscles of the extensor compartment of the forearm at the insertion point
at the lateral epicondyle of the elbow.

687
The Shoulder (Glenohumeral Joint)

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

The Shoulder (Glenohumeral Joint)


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The glenohumeral joint is a ball-and-socket joint in which the head of the humerus
(ball) articulates with the glenoid cavity of the scapula (socket).

The shoulder joint.

688
The Shoulder (Glenohumeral Joint)

The glenoid cavity.

689
The Shoulder (Glenohumeral Joint)

The glenoid cavity.

The shoulder joint.

690
The Shoulder (Glenohumeral Joint)

A fibrous capsule attaches to the circumference of the glenoid cavity (proximally) and to the
anatomical neck of the humerus (distally).

This fibrous capsule, by itself, is too thin and weak to keep the humeral head in the glenoid
cavity.

Most of the dynamic stability of the glenohumeral joint is provided by the tendons of the
rotator cuff muscles (SItS: Supraspinatus, Infraspinatus, teres minor, Subscapularis),
which insert on the greater and lesser tuberosities of the proximal humerus and keep the
humeral head seated in the glenoid during shoulder motion.

Clinical Correlate: The supraspinatus is the most commonly torn rotator cuff muscle.

The shoulder joint.

691
The Shoulder (Glenohumeral Joint)

Glenohumeral joint, anterior view: the fibrous capsule can be seen here labeled as "capsular
ligament". Also of note:

the coracoacromial and coracohumeral ligaments

the tendon of the long head of biceps brachii (which courses up and over the humeral
head to insert on the supraglenoid tubercle of the clavicle) is shown here within the
intertubercular sulcus (bicipital groove) on the anterior surface of the proximal humerus.

Attribution: Gray's Anatomy PD-US

692
The Shoulder (Glenohumeral Joint)

Normal anatomy of the shoulder, anterior view.

Several ligaments help reinforce the fibrous capsule of the glenohumeral joint and thereby
help prevent dislocation of the humeral head.

SGHL, MGHL, and IGHL (superior, middle, and inferior glenohumeral ligaments):

These ligaments extend from near the supraglenoid tubercle (glenoid rim/labrum) to the

693
The Shoulder (Glenohumeral Joint)

superior, middle, and inferior regions of the anterior aspect of the anatomical neck of the
humerus, respectively.
The ligaments reinforce the anterior aspect of the fibrous capsule and helps prevent
anterior dislocation of the humeral head. CHL (coracohumeral ligament):
The CHL extends from the base of the coracoid process of scapula to the superior
aspect of the anatomical neck of the humerus.
It reinforces the superior aspect of the fibrous capsule.

Socket of right shoulder joint, lateral view.

694
The Shoulder (Glenohumeral Joint)

Ligaments of shoulder joint.

Bursae (sacs that contain synovial fluid and are lined by synovial cells) help to decrease
friction within the glenohumeral joint during shoulder motion. Subacromial bursa is located
between the acromion of the scapula and the fibrous capsule of the glenohumeral joint.

The subacromial bursa is a common site of bursitis (inflammation of bursa), which can
result in shoulder pain. This type of injury is common in throwing athletes or tennis players
(serving) as the bursa can become inflamed during repetitive overhead motions.

Subtendinous bursa of the subscapularis is located between the neck of the scapula and
the subscapularis tendon and communicates with the synovial cavity of the
glenohumeral joint between SGHL (superior glenohumeral ligament) and MGHL
(middle glenohumeral ligament).

Intertubercular (bicipital) tendon sheath is a bursa-like synovial tendon sheath that


communicates with the synovial cavity of the glenohumeral joint proximally, and extends
distally to enclose the tendon of the long head of biceps brachii within the intertubercular
sulcus (bicipital groove) on the anterior aspect of the proximal humerus.

695
The Shoulder (Glenohumeral Joint)

Socket of right shoulder joint, lateral view.

696
The Shoulder (Glenohumeral Joint)

Anterior view of glenohumeral joint: subscapular bursa and the bursa-like intertubercular
(bicipital) synovial tendon sheath.

Attribution: Gray's Anatomy PD-US

697
The Shoulder (Glenohumeral Joint)

The shoulder joint.

The shoulder joint.

Movements of the arm at the shoulder joint (glenohumeral joint):

Flexion of the arm at the shoulder Ventral movement of the arm in a sagittal plane

Extension of the arm at the shoulder Dorsal movement of the arm in a sagittal plane
Abduction of the arm at the shoulder Movement of the arm away from the midline in
a coronal plane

Adduction of the arm at the shoulder Movement of the arm toward the midline in a
coronal plane
Lateral (external) rotation of the arm at the shoulder Rotation of the arm around its
longitudinal axis such that the anterior surface of the humerus turns laterally

Medial (internal) rotation of the arm at the shoulder Rotation of the arm around its
longitudinal axis such that the anterior surface of the humerus turns medially

698
The Shoulder (Glenohumeral Joint)

Anatomic movements.

699
The Shoulder (Glenohumeral Joint)

Abduction and adduction of the shoulder joint.

700
The Wrist Joint

USMLE Step 1 > Basic Sciences > Anatomy > Upper Limb

The Wrist Joint


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The wrist region contains multiple joints.

The radiocarpal joint is formed by the articulation between the radius, an articular disc over
the ulna, and 3 proximal carpal bones :

Scaphoid
Lunate
Triquetrum Note: The pisiform is also a proximal carpal bone like the aforementioned
structures but does not articulate with the radius. The radiocarpal joint is strengthened
by multiple ligaments:

Radial collateral ligament

Ulnar collateral ligament


Dorsal radiocarpal ligament
Palmar radiocarpal ligament Possible movements of the hand at the wrist:

Extension

Flexion
Abduction
Adduction The carpal bones do articulate with each other, but movement between them
is limited.

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The Wrist Joint

Bones of the wrist joint. Note that navicular and scaphoid are interchangeable terms; the
term navicular is often used in the wrist to signify similar function to the navicular bone in the
foot.

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The Wrist Joint

Bones of the wrist joint

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The Wrist Joint

Bones of the wrist joint

Bones of the wrist joint

The carpal tunnel is formed in the anterior wrist from the arch made by the carpal bones
and the overlying flexor retinaculum.

Structures passing through the carpal tunnel:

Median nerve

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The Wrist Joint

Tendons of the flexor pollicis longus


Tendons of the flexor digitorum superficialis
Tendons of the flexor digitorum profundus

x-ray (AP wrist + hand) - Hand, carpal bones purposefully unlabeled (ie, give it a shot on
your own, then compare with the labeled radiograph)

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The Wrist Joint

x-ray - Hand, carpal bones labeled

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The Wrist Joint

Hand, carpal bones (palmar view)

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The Wrist Joint

Hand, carpal bones (dorsal view)

708

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