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CLAVICLE: most frequently fractured bone
of body; break occurs where bone is weakest,
at junction of lateral and middle third; following
break, medial end is pulled superiorly by SCM
and lateral end is pulled inferiorly by weight of
arm and medially by pectoralis major
Fracture of clavicle usually occurs as result of
fall on shoulder or outstretched hand

Fracture at surgical neck injures axillary nerve,
which innervates deltoid resulting in loss of
abduction of arm
Fracture at midshaft (spiral groove) injures
radial nerve, resulting in wrist drop and
decreased extension at elbow
Fracture inferiorly (at medial epicondyle) affects
ulnar nerve, major nerve to intrinsic hand
muscles, resulting in ulnar claw hand

Colles fracture is fracture of distal
radius resulting from fall on outstretched hand;
common; produces "dinner fork effect whereby
distal fragment is posterior (top picture)
Smiths fracture (less common) results from fall
on back of hand with anterior displacement of
distal fragment (bottom picture)

Carpal bones: scaphoid is most commonly

fractured carpal bone; at times, avascular
necrosis of proximal portion of scaphoid occurs
when deprived of its arterial supply
Lunate is most commonly dislocated carpal
bone; usually occurs in young adults
From lateral to medial, bones of wrist are:
scaphoid, lunate, triquetrum and pisiform
(proximal row); trapezium, trapezoid, capitate
and hamate (distal row) (Some Lovers Try Positions
That They Cant Handle)

MUSCLES: Deltoid is chief abductor, chief flexor

and chief extensor of arm; deltoid is innervated by
axillary nerve; deltoid is muscle of shoulder and all
muscles of shoulder are innervated by C5 and C6.
Posterior compartment of arm: triceps is innervated
by radial nerve
Anterior compartment (3): coracobrachialis, biceps
brachii, and brachialis are innervated by
musculocutaneous nerve; biceps is major muscle
that supinates hand

Abduction of arm
Action is initiated by supraspinatus; deltoid is chief
abductor but can only abduct just beyond horizontal
plane without scapular rotation
For complete abduction of arm, scapula needs to be
rotated; upward rotators of scapula are (1) trapezius:
both upper fibers that pull acromial end of spine up,
and lower fibers that pull medial end down, and (2)
serratus anterior

SITS muscles = rotator cuff muscles

Supraspinatus: strengthens shoulder superiorly
- does not rotate, but initiates abduction
- most commonly torn tendon of rotator cuff
- innervated by suprascapular nerve (C5 and C6)
Infraspinatus: strengthens shoulder posteriorly
- lateral rotator
- innervated by suprascapular nerve (C5 and C6)
Teres minor: strengthens shoulder posteriorly
- lateral rotator; innervated by axillary nerve
Subscapularis : strengthens shoulder anteriorly
- medial rotator and is innervated by upper and
lower subscapular nerves (C5 and C6)

Forearm muscles: anterior compartment: flexor

muscles, posterior compartment: extensor muscles
Superficial muscles of anterior compartment all arise
from medial epicondyle of humerus:
1. Pronator teres
2. Flexor carpi radialis
3. Palmaris longus
4. Flexor carpi ulnaris: only muscle innervated by
ulnar nerve exclusively
5. Flexor digitorum superficialis: lies on deeper plane

Deep muscles of flexor compartment

Flexor pollicis longus
Pronator quadratus
Flexor digitorum profundus
- Has dual innervation, median and ulnar;
only muscle of forearm with two nerves
- Only muscle to go to distal phalanges on
flexor side
Median nerve innervates all muscles of anterior
compartment of forearm except flexor carpi ulnaris

All muscles on extensor side are innervated by

radial nerve
Superficial muscles arise from lateral epicondyle and
its supracondylar ridge
1. Brachioradialis
2. Extensor carpi radialis longus
3. Extensor carpi radialis brevis
4. Extensor digitorum
5. Extensor carpi ulnaris
6. Extensor digiti minimi
Brachioradialis: unique, does not act on hand;
flexes at elbow

Deep muscles of extensor side of forearm:

Extensor pollicis longus
Extensor pollicis brevis
Abductor pollicis longus
Extensor indicis

Actions of pronation and supination occur at

radio-ulnar joints
Both pronator muscles are innervated by median
Biceps brachii (stronger muscle) is innervated by
musculocutaneous nerve and supinator in innervated
by radial nerve
Supination is stronger than pronation

Three thenar muscles are innervated by motor

recurrent branch of median nerve (after median
courses through carpal tunnel); this branch of median
nerve also innervates lateral two lumbricals
Three thenar muscles are flexor pollicis brevis,
abductor pollicis brevis, and opponens pollicis
Functionally, hypothenar muscles are not nearly as
important: flexor digiti minimi brevis, abductor
digiti minimi, and opponens digiti minimi; these
muscles are innervated by ulnar nerve

Adductor pollicis (located centrally) is not classified

as thenar muscle and is innervated by ulnar nerve
Four lumbrical muscles: arise from tendon of flexor
digitorum profundus and insert into extensor hood;
these muscles serve to flex at metacarpophalangeal
joints and extend at interphalangeal joints; only
muscles to arise from tendons and insert into tendons
Lateral two lumbricals are innervated by median
nerve and medial two muscles receive ulnar nerve

Interossei: all muscles innervated by ulnar nerve

Dorsal: bipennate (arise from adjacent metacarpals)
Palmar: unipennate (arise from single metacarpal)
DAB - PAD: Dorsal ABduct fingers, Palmar Adduct
Interossei, like lumbricals, insert into extensor hoods
and, like lumbricals, flex at metacarpophalangeal
joints and extend at interphalangeal joints

Insertions of long flexor tendons: at base of

proximal phalanx, tendon of flexor digitorum
superficialis (FDS) splits to allow tendon of flexor
digitorum profundus (FDP) to pass through; FDS
inserts into base of middle phalanx and FDP inserts
into base of distal phalanx
Extensor hood: tendon of extensor digitorum is
joined by lumbrical and interossei; both lumbricals
and interossei cross flexor side of metacarpophalangeal joint and extensor sides of proximal and
distal interphalangeal joints; hence, muscles flex at
MP joints and extend at both PIP and DIP joints

Swan-neck deformity of fingers: flexion of MP,

PIP hyperextension, and slight DIP flexion; due to
contracture of intrinsic muscles (tendons) as seen
with rheumatoid arthritis (top picture)
Mallet finger (bottom picture): caused by rupture
of DIP extensor mechanism or avulsion fracture of
distal phalanx; common in baseball catchers; cannot
extend DIP
Boutonniere deformity: central portion of extensor
hood torn over PIP allowing tendon to become
flexor; DIP is hyperextended

Dupuytrens contracture
not nerve injury; localized
pathological thickening
and contracture of
palmar aponeurosis

Dupuytrens contracture
Starts at root of ring finger, drawing finger to palm;
fifth finger is affected later
More common in males
Begins as fibrous nodules which progress to dense

Brachial plexus: stages are roots (ventral rami C5

through T1), trunks (upper, middle, and lower),
divisions (anterior and posterior), cords (lateral,
medial and posterior) and terminal branches
From roots: phrenic (C3 - 5), long thoracic (C5 - 7)Serratus anterior,
dorsal scapular (C5)- Rhomboids
From trunks (upper): suprascapular (supra and
infraspinatus) and nerve to
subclavius (C5 and C6)

There are no nerves that arise from divisions

Lateral cord: lateral pectoral, C5 and 6, (to pectoralis
Medial cord (C8 and T1): medial pectoral (to both
pectoralis major and minor); medial brachial and
medial antebrachial cutaneous nerve
Posterior cord: upper subscapular (C5 and 6) to
subscapularis; lower subscapular (C5 and 6) to
both subscapularis and teres major; and
thoracodorsal (C6 - 8) to latissimus dorsi

Axillary (C5 and 6), from posterior cord, innervates

deltoid and teres minor; becomes lateral brachial
Radial (C5 - T1), from posterior cord, innervates all
muscles of posterior side of arm and forearm
Musculocutaneous (C5 - 7), from lateral cord,
innervates all muscles of anterior side of arm,
becomes lateral antebrachial cutaneous nerve
Ulnar (C8, T1), from medial cord, innervates only
flexor carpi ulnaris and flexor digitorum profundus in
forearm; innervates most muscles of hand
Median (C5 - T1), from both medial and lateral cords,
innervates most muscles of anterior forearm and, in
hand, innervates only three muscles of thenar
eminence and two lumbricals

MOTOR: all muscles are innervated by C8 and T1
SENSORY: Dermatomes
C6: thumb and index finger
C7: middle finger
C8: ring and little fingers
Cutaneous nerves
Median: 3 1/2 fingers on palmar side, related
palm, and middle and distal phalanges of
lateral 3 1/2 fingers on dorsal side
Ulnar: medial 1 1/2 fingers (both sides and
Radial: dorsolateral aspect

Axillary: courses around surgical neck of humerus
(with posterior humeral circumflex artery) to pass
through quadrangular space; axillary nerve can be
injured with fracture of surgical neck; would result
in atrophy of deltoid and functional loss at shoulder
joint: major losses of abduction, flexion, extension,
and rotation


site of injury to median nerve
Osseo-fibrous tunnel formed by carpal bones and
transverse carpal ligament (thickening of deep
fascia); ligament is attached laterally to scaphoid and
trapezium and medially to hamate and pisiform
Contents of carpal tunnel: (1) median nerve,
(2) four tendons of flexor digitorum superficialis,
(3) four tendons of flexor digitorum profundus, and
(4) tendon of flexor pollicis longus

Winged scapula: injury to long thoracic nerve

Long thoracic nerve arises from roots of brachial
plexus, C5 - C7; this nerve, which innervates
serratus anterior on its superficial surface, is very
vulnerable as it courses through axilla; potentially,
long thoracic nerve is injured with removal of lymph
nodes in axilla
Serratus anterior serves to fix scapula; when
pushing against wall, scapula will look like a wing
if long thoracic nerve is injured

Erb-Duchennes palsy: injury to upper trunk or

C5 and C6 roots; occurs with falling on head and
shoulder simultaneously or pulling head from away
from shoulder with rough birth; results in loss of
flexors and lateral rotators of arm, so medial rotators
place upper limb in waiters tip position
Klumkes palsy: lower trunk injury (roots C8 and
T1); occurs when catching ones self when falling
from tree; loss of intrinsic hand muscles resulting in
claw hand
All intrinsic hand muscles are innervated by C8
and T1

There are three types of claw hand, (1) total claw,

(2) median claw, and (3) ulnar claw
Total claw occurs with loss of all intrinsic hand
muscles (lumbricals and interossei) which serve to
balance flexor and extensor muscles of forearm
that act on fingers; seen with lower trunk injury

Median claw occurs with injury to median nerve;

there is wasting of thenar eminence, paresis upon
flexing, abducting, and opposing thumb, and
paresthesias of lateral 3 1/2 fingers; ape hand
Ulnar claw occurs with injury to ulnar nerve; there
is wasting of hypothenar eminence and interosseous
spaces; with flexion at wrist, there is radial
deviation; loss of adduction of thumb, Froments

Subclavian artery: on right side, arises from

brachiocephalic trunk; on left side, direct branch of
arch of aorta; one of branches of subclavian artery is
thyrocervical trunk that gives rise to two arteries to
upper limb: transverse cervical and suprascapular
Axillary artery: continuation of subclavian artery
distal to outer border of first rib; significant branches
include anterior and posterior humeral circumflex
and subscapular arteries
Brachial artery is continuation of axillary at inferior
border of teres major; chief branch is deep brachial
(that courses with radial nerve); ends at elbow as
radial and ulnar arteries

Scapular anastomoses: branches from first portion

of subclavian artery form anastomoses with branches
from third portion of axillary artery; arteries are:
1. Suprascapular (first part of subclavian)
2. Transverse cervical (first part of subclavian) or
descending scapular (third part of subclavian)
3. Circumflex scapular (third part of axillary)
4. Thoracodorsal (third part of axillary)
5. Anterior humeral circumflex (third part of
6. Posterior humeral circumflex (third part of

Cubital fossa: triangular area anterior to elbow joint

that is bounded superiorly by line between medial
and lateral epicondyles, medially by pronator teres,
and laterally by brachioradialis
Lateral to medial relationships are TAN,
Tendon of biceps, brachial Artery and median Nerve
Median cubital vein (communication between
cephalic and basilic veins) overlies structures of

At cubital fossa, brachial artery divides to form

radial and ulnar arteries; major branch in forearm is
common interosseous artery, branch of ulnar artery
that gives rise to anterior and posterior interosseous
arteries that supply bones and deep muscles of
Radial artery leaves flexor surface by passing
laterally deep to tendons of anatomical snuff box
Ulnar artery courses with ulnar nerve and passes
superficial to flexor retinaculum (and carpal tunnel)

Superficial palmar arterial arch is formed mainly by

ulnar artery (aided by radial artery)
Deep palmar arterial arch is formed mainly by radial
artery (aided by ulnar artery)
Raynauds disease: increased sympathetic
stimulation to distal arteries of fingers resulting in
vasoconstriction with decrease in blood flow; finger
tips are cold and limb becomes progressively warmer
proximally; origin is unknown; need cervicodorsal sympathectomy; sympathetics to upper limb
have preganglionic cells of origin at T2 - T8

Axillary lymph nodes

Drainage from thumb, index finger, and lateral side
of hand follow cephalic vein to infraclavicular or
apical nodes; lymphatic drainage from medial side of
hand goes along basilic vein to supratrochlear nodes
and then to lateral group of axillary nodes
Lymphangitis of upper limb is common (infected
thumb or finger); characterized by red streaks along
lymph vessels

Dislocation of sternoclavicular joint is not

common; when it occurs,
can be either anterior or
posterior dislocation
dislocation is known as
shoulder separation;
often occurs with blocking
or tackling in football;
coracoclavicular ligament
provides strength to joint

Sternoclavicular joint: functional saddle type of

synovial joint that contains disc; costoclavicular
ligament is very short, strong ligament that provides
great stability to this joint
Acromioclavicular joint: plane type of synovial joint
that allows gliding and rotational movements;
coracoclavicular ligament is strong extrinsic
ligament consisting of conoid and trapezoid
ligaments; acromioclavicular ligament is thickening
of articular capsule

Shoulder joint: classical ball-and-socket type of

synovial joint; little support is provided by either
bony configuration or ligaments; major support to
joint is tendons of rotator cuff
Joint is strengthened superiorly by supraspinatus,
anteriorly by subscapularis, and posteriorly by both
teres minor and infraspinatus
Dislocation is in inferior direction (weakest region);
head of humerus is then pulled anteriorly and
superiorly by strong flexors and adductors so that
head ends up in subcoracoid position

Elbow joint is hinge type of synovial joint between

trochlea of humerus and trochlear notch of ulna;
since superior radioulnar joint is part of elbow joint,
radius is also part of joint; head of radius articulates
with capitulum of humerus
Anular ligament forms about 4/5ths of fibro-osseous
ring around head of radius
Elbow dislocations are common and are posterior;
occur with falling on outstretched hand; more
common in children
Ulnar nerve is often affected with elbow injuries

Femur: head is about 2/3rds of sphere and has pit
(fovea) for attachment of round ligament of head
Neck joins shaft at angle of 1250, angle of
inclination; coxa vara: abnormally decreased angle;
coxa valga: abnormally increased angle
Neck often fractured in fall with elderly, especially
Greater trochanter: palpable landmark, site of
numerous muscular attachments (lateral rotators of
gluteal area)
Lesser trochanter: attachment site for iliopsoas, chief
flexor of thigh; not palpable

Arterial supply to head of femur: prior to puberty

when epiphyseal plate closes, no anastomoses
between branch of obturator artery (conveyed by
round ligament) and medial femoral circumflex
(chief artery of head and neck of femur) since
cartilage is avascular
Following puberty, medial femoral circumflex and
branch of obturator anastomose with each other, but
vascular necrosis may result following fracture of
neck of femur when there is tear of artery

Medial longitudinal arch: talus is summit; calcaneus

is posterior; navicular, three cuneiform bones and
first three metatarsal bones lie anterior; spring
ligament (plantar calcaneonavicular ligament) has
elastic fibers that support talus and medial arch; flat
foot when ligament is excessively stretched
Bones of lateral longitudinal arch are calcaneus,
cuboid, and fourth and fifth metatarsal bones; this
arch is supported by long and short plantar ligaments
Common accessory bones are os trigonum (talus) and
os tibialae (navicular)
Two constant sesamoid bones with flexor hallucis

Gluteus maximus: only muscle innervated by
inferior gluteal nerve; powerful lateral rotator and
chief extensor at hip when rising from chair (with
other situations, hamstring muscles, that is, long head
of biceps femoris, semitendinosus, and
semimembranosus, extend at hip)
Muscles attached to greater trochanter that laterally
rotate thigh are piriformis, superior and inferior
gemelli, obturator internus and externus, and
quadratus femoris
Intramuscular injections: given in upper, lateral
quadrant to avoid sciatic nerve

Gluteus medius and gluteus minimus, along with

tensor fasciae latae, are innervated by superior
gluteal nerve; although both gluteus medius and
minimus abduct and medially rotate thigh, major
function is to prevent tilting of pelvis when
walking; positive Trendelenburgs test: pelvis
tilts toward unsupported side - indicates injury to
superior gluteal nerve: associated with
poliomyelitis that affects ventral horn cells of
L 4 - S 1 region of spinal cord

Anterior compartment of thigh: all muscles are

innervated by femoral nerve (L2 - L4)
Sartorius: origin from ASIS; flexes at both hip and
knee: rotates thigh laterally and leg medially
Quadriceps femoris: three vasti muscles (medial,
lateral and intermediate) and rectus femoris
Rectus femoris is only portion of quadriceps to arise
from hip bone (ilium); vasti arise from femur
Inserts via patellar ligament; entire muscle extends
leg; rectus femoris also flexes at hip
Vastus medialis is first part of quadriceps to atrophy
with knee joint disease and last part to recover
Patellar reflex tests L4 spinal level

All muscles of medial compartment adduct at hip,

arise from pubis and are innervated by obturator
nerve (except pectineus, usually femoral nerve)
Gracilis is only muscle to insert on tibia (all others
attach to femur
Muscles are: gracilis, pectineus, obturator externus,
adductors longus, brevis, and magnus
Adductor magnus is also innervated by tibial part of
sciatic nerve
Patients with cerebral palsy often have marked
spasticity of adductor group of muscles

Muscles of posterior compartment are collectively

called hamstrings; they arise from ischial tuberosity,
flex leg and extend thigh, and are innervated by tibial
part of sciatic nerve
Short head of biceps femoris not part of hamstrings;
it does not act on hip and is innervated by common
fibular part of sciatic nerve
Both semitendinosus and semimembranosus insert on
tibia and medially rotate leg
Biceps femoris inserts on fibula and laterally rotates

Muscles are of anterior compartment are innervated

by deep fibular nerve and all muscles dorsiflex at
ankle; tibialis anterior inverts foot; extensor hallucis
longus extends great toe; extensor digitorum
longus extends toes 2 - 5; fibularis tertius everts
Compartment syndrome: increase in pressure due
to increased tissue fluid (often as result of soft tissue
injury associated with fracture of bone); results in
decreased venous return; very painful with need to
decrease pressure; shin splints are minor trauma to
tibialis anterior causing muscle to swell and pull
crural fascia off tibia; untrained person in walkathons

Lateral compartment contains only two muscles,

fibularis longus and fibularis brevis; both muscles
are innervated by superficial fibular nerve and
function to evert foot
Tendon of fibularis longus crosses sole of foot,
grooves cuboid bone, and inserts into first metatarsal
and medial cuneiform
Tendon of fibularis brevis inserts into base of fifth
metatarsal; at times, base of fifth metatarsal is
fractured and tendon of fibularis brevis pulls off base
of bone: avulsion fracture seen with severe sprain

All muscles of compartment are innervated by tibial

nerve; superficial muscles are gastrocnemius, soleus
and plantaris, short muscle belly with long tendon
Gastrocnemius and soleus insert into calcaneus via
tendocalcaneus (Achilles tendon); this tendon often
often ruptures in middle-aged males while playing
tennis; tear occurs about inches superior to insertion
Achilles tendon is test for spinal level S1
Deep muscles are popliteus (flexes and unlocks
knee by rotating femur laterally upon tibia), tibialis
posterior (inverts foot), flexor hallucis longus (flexes
great toe), and flexor digitorum longus (flexes toes

Extensor digitorum brevis is located on dorsum of

foot; this is intrinsic muscle of foot (arising from
calcaneus and inferior extensor retinaculum)
There is no intrinsic hand muscle on dorsal side
Tendon to great toe, called extensor hallucis brevis,
inserts into proximal phalanx; for toes 2 - 4 tendons
join lateral side of extensor digitorum longus
Extensor digitorum brevis is innervated by deep
fibular nerve

Plantar aponeurosis: deep fascia of sole of foot is

composed of tough collagen fibers; posteriorly,
attached to calcaneus; plantar fasciitis occurs with
excessive walking/running and can result in
ossification of posterior portion of aponeurosis to
form heel spur
Deep part of aponeurosis attaches to first and fifth
metatarsals to form three muscular compartments
Superficial part of aponeurosis has digital slips that
attach to skin of toes

Muscles of sole of foot are arranged in layers; first

layer, most superficial, has abductor hallucis, flexor
digitorum brevis, and abductor digiti minimi
Layer two contains quadratus plantae and four
Layer three has flexor hallucis brevis, adductor
hallucis and flexor digiti minimi brevis
Interossei are located in layer four
Medial plantar nerve innervates only four muscles:
abductor hallucis, flexor digitorum brevis, flexor
hallucis brevis, and first lumbrical; lateral plantar
nerve innervates all other muscles

Lumbar plexus
Ventral rami T12 - L4; located in abdominal cavity,
related to psoas major muscle
Iliohypogastric (T12 and L1) and ilioinguinal (L1)
nerves innervate muscles of lower anterior abdominal
wall and are cutaneous; iliohypogastric to suprapubic
area and ilioinguinal to anterosuperior aspect of thigh
Femoral (L2 - 4) innervates muscles of anterior
compartment of thigh and has major cutaneous
distribution to anterior thigh and medial side of leg
and foot; obturator has same spinal levels,
innervates muscles of adductor compartment, and has
minor cutaneous distribution: medial side of knee

Sacral plexus
Ventral rami L4 - S3; located in pelvis, related to
piriformis muscle; ventral rami divide into anterior
and posterior divisions
Anterior (preaxial) nerves: tibial, nerves to obturator
internus and quadratus femoris
Posterior (postaxial) nerves: common fibular, superior
and inferior gluteal nerves
Posterior femoral cutaneous is large nerve formed by
both anterior and posterior divisions
Sural nerve: cutaneous nerve formed from both tibial
and common fibular portions of sciatic nerve

Important cutaneous nerves

Saphenous: arises from femoral and supplies medial
side of leg and foot; only branch of lumbar plexus to
supply limb inferior to knee
Sural: supplies lateral side of leg and foot
Deep fibular: small area between web of first and
second toes on dorsal side of foot
Superficial fibular: supplies most of dorsum of foot
Tibial (and medial and lateral plantar branches)
supply plantar side of foot
Dermatomes: L4 - big toe; L5 - toes 2, 3, and 4;
S1 - little toe

Sites of arterial pulses: (1) femoral at groin, (2)

popliteal in popliteal fossa (with leg partially flexed),
(3) posterior tibial just superior to flexor retinaculum
and (4) dorsalis pedis in first intermetatarsal space,
between tendons of extensor hallucis longus and
extensor digitorum longus
To increase vascular flow to lower limb, it is
necessary to sever sympathetic fibers; lower limb is
innervated by sympathetic fibers from T10 - L2 area
of spinal cord

Femoral artery is continuation of external iliac as

vessel courses deep to inguinal ligament
Femoral artery is located in lateral compartment of
femoral sheath; site for insertion of catheter
Femoral vein is located in middle compartment of
femoral sheath; great saphenous vein enters femoral
sheath to terminate in femoral vein
Medial compartment of femoral sheath contains few
lymph nodes (deep inguinal nodes) and is site for
femoral hernia; medial compartment is known as
femoral canal; femoral ring is small potential opening
of superior end of femoral canal

Deep femoral artery is chief branch of femoral;

medial and lateral femoral circumflex arteries may
arise from either femoral or deep femoral.
Medial femoral circumflex is chief artery to head of
femur; lateral femoral circumflex participates in
collateral circulation at both hip joint and knee joint
At apex of femoral triangle, femoral artery enters
adductor (subsartorial) canal and courses around
thigh; when artery emerges through adductor hiatus,
it is renamed as popliteal artery (deepest structure in
popliteal fossa)

Collateral circulation around knee: effective only

with gradual occlusion of major artery
Arteries include descending genicular (from
femoral), lateral femoral circumflex, four branches
from popliteal (superior medial, superior lateral,
inferior medial, and inferior genicular), circumflex
fibular, and anterior and posterior tibial recurrent
arteries which arise from anterior tibial artery
Middle genicular artery, branch of popliteal, does not
participate in collateral circulation; supplies anterior
and posterior cruciate ligaments

Popliteal artery divides to form anterior and posterior

tibial arteries; anterior tibial artery gives rise to
posterior tibial recurrent artery and then passes
through interosseous membrane and gives rise to
anterior tibial recurrent artery
Anterior tibial artery courses with deep fibular nerve
and after it crosses ankle joint, anterior tibial artery
becomes dorsalis pedis artery
Posterior tibial artery gives rise to fibular artery; both
arteries descend in posterior compartment of leg;
nutrient branch of posterior tibial (to tibia) is largest
nutrient artery of any bone; posterior tibial artery
descends with tibial nerve

Deep to flexor retinaculum, posterior tibial artery

divides to form medial and lateral plantar arteries
Lateral plantar is major branch and it crosses foot
from medial to lateral sides between first and
second layers of muscles; when lateral plantar artery
reaches fifth metatarsal, it is renamed plantar arch
and it courses medially between third and fourth
layers of muscles; deep plantar branch of dorsalis pedis
artery often anastomoses with plantar arch
Medial plantar artery is smaller terminal branch of
posterior tibial and it supplies big toe

Hip joint is very stable ball-and-socket type of
synovial joint; 2/3rds of head of femur lies within
acetabulum, which is formed by union of pubis,
ilium, and ischium
Transverse acetabular ligament unites edges of
horseshoe-shaped acetabular labrum, fibrocartilage
that serves to deepen acetabular fossa
Ligament of head of femur conveys branch of
obturator artery to pit (fovea) of head of femur

Pubofemoral, iliofemoral and ischiofemoral

ligaments are thickenings of articular capsule; all
three ligaments check hyperextension at hip joint;
pubofemoral ligament additionally checks overabduction of thigh
Iliofemoral ligament (also called Y ligament) is
probably strongest ligament of body
Zona orbicularis: deep capsular fibers that encircle
neck of femur and bland with ischiofemoral ligament
Fractures of femur: subcapital occurs in elderly with
even minor fall; more common in females due to
thinning of cortical and trabecular bone after

Knee joint is most complex and least stable joint of

body; capsule is pierced by tendon of popliteus and
capsular ligaments are not strong
Deep fibers of TCL attach to medial meniscus; blow
to lateral side of fixed knee results in terrible triad,
TCL, ACL, and medial meniscus
Injury to ACL is 4 - 5 times more common in
females; ACL checks backward displacement of
femur on tibia (anterior drawer sign when injured)
PCL checks hyperflexion of knee; not commonly
injured; LCL can be injured with blow to medial side
of knee joint

Synovial membrane of knee is very extensive, and

up to 95 % can be removed (regeneration can occur
with as little as 5%); both ACL and PCL are
Bursae that communicate with knee: suprapatellar,
popliteal and medial gastrocnemial
Prepatellar: housemaids knee
Subcutaneous infrapatellar: clergymans knee

True hinge joint

1. Tibialis anterior
2. Extensor hallucis
3. Extensor digitorum
4. Fibularis tertius

Numerous muscles plantarflex at ankle: soleus,

gastrocnemius, plantaris, tibialis posterior, flexor
hallucis longus, flexor digitorum longus, fibularis
longus, and fibularis brevis
Deltoid ligament strengthens medial side of ankle;
strong ligament and usually not injured
Components of deltoid ligament:
1. Anterior tibiotalar ligament
2. Tibionavicular ligament
3. Tibiocalcaneal ligament
4. Posterior tibiotalar ligament

Ligaments on lateral side of ankle are three distinct

bands: anterior talofibular, calcaneofibular, and
posterior talofibular
Sprained ankle is usually inversion sprain, and most
commonly injured
ligament at ankle
is anterior talofibular
Calcaneofibular is
second most
injured ligament
at ankle

Two functional intertarsal joints: subtalar joint and

transverse tarsal joint; movements of inversion and
eversion occur at these two joints
Major invertors of foot are tibialis anterior and
tibialis posterior
Major evertors are
fibularis longus,
fibularis brevis

BACK: Muscles
Superficial muscles act on upper limb or on ribcage;
trapezius is innervated by CN XI, shoulder droops
with injury to CN XI; other superficial muscles are
innervated by ventral rami
Latissimus dorsi, used in climbing, is innervated by
thoracodorsal nerve and muscle acts to adduct,
extend, and medially rotate arm
Triangle of auscultation overlies sixth interspace
and is bounded by trapezius, latissimus dorsi, and
rhomboid major; lumbar triangle, site of (fat) hernia
is bounded by iliac crest, external oblique and
latissimus dorsi

True back muscles are deep back muscles; they are

confined to back and are innervated by dorsal rami
Two layers of deep muscles; more superficial layer
contains splenius and erector spinae
Splenius muscle has two parts, capitis and cervicis;
turns head and neck to ipsilateral side

Erector spinae has three parts: Iliocostalis,

Longissimus, Spinalis from lateral to medial;
(mnemonic I Like Spaghetti)
Like splenius, erector spinae is in superficial layer
of deep back muscles; innervated by regional
dorsal rami
Extends vertebral column; muscle fibers are
oriented in vertical direction

Transverospinal muscles: origin is transverse process

and insertion is spinous process
Transverospinal muscles lie deep
Orientation of muscle fibers is in oblique direction
From superficial to deep, semispinalis (spans 6 - 8
vertebrae), mutifidus (spans 3 - 4 vertebrae), and
rotators (span 1-2 vertebrae)
All muscles rotate column to contralateral side

Suboccipital triangle
Rectus capitis posterior minor does not serve as
Boundaries are rectus capitis posterior major,
obliquus capitis superior, and obliquus capitis
inferior; all muscles are innervated by dorsal ramus
of C1 (suboccipital nerve)
Roof: semispinalis capitis; floor: posterior atlantooccipital membrane
Vertebral artery: inside cranial cavity gives rise to
PICA; dizziness with turning of head

Vertebral column: 33 vertebrae and intervertebral

discs; only upper 24 vertebrae move
In newborn, column is C-shaped, concave anteriorly;
as baby ages, primary curvatures in thoracic
and sacral areas; secondary curvatures in cervical
area (child holds head upright) and lumbar area
(child stands)
Articular processes: all superior facets directed
posteriorly; in cervical area, directed superiorly;
in thoracic area, directed slightly laterally; and in
lumbar area, directed mainly medially; dislocation
without fracture only in cervical area (C4/5 or 5/6)

Abnormal curvatures of spine:

(1) Kyphosis: humpback, exaggerated over-curvature
of thoracic region
(2) Lordosis: swayback, exaggerated over-curvature
of lumbar area
(3) Scoliosis: side-bending of vertebral column;
several causes for scoliosis: compensatory due to
short lower limb or hip disease; paralysis of
muscles due to poliomyelitis or congenital

Portions of vertebra are:

(1) Body: articulates with intervertebral disc
(cartilagenous type of joint)
(2) Neural arch: surrounds spinal cord and meninges
- pedicle: attached to body
- lamina: attached to pedicle
- processes: spinous, transverse, and articular,
superior and inferior
Vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral
(fused as sacrum) and 4 coccygeal (fused as coccyx)

7 Cervical: key feature is transverse foramen for

vertebral vessels (only vein courses in CV7); except
for CV7, have short bifid spinous processes
Cervical vertebrae 1, 2, & 7 are atypical
CV1 = atlas: has no body and no spinous process
CV2 = axis: dens
CV7 has long spinous process (vertebra prominens)
CV6 has carotid tubercle; common carotid artery can
be compressed against this landmark

Thoracic vertebrae have costal facets for ribs; due

to ribs, movements of flexion, extension, and lateral
bending in thoracic region are limited
Lumbar vertebrae are large, bulky and have
mammillary processes and hatchet-shaped spines
SPONDYLOLYSIS: fracture of lamina between
superior and inferior articular processes; occurs in
lumbar area
arthritis affecting lumbar vertebrae, sacroiliac joint
OSTEOMYELITIS: bacterial infection that may
affect vertebrae

Fifth sacral vertebra has no lamina nor spinous

process, leaving a sacral hiatus, site for epidural
anesthesia; with caudal anesthesia, needle goes
through sacrococcygeal ligament; type of anesthesia
used with birth
Spondylolisthesis: body of vertebra moves anterior;
usually LV 5 moves on S 1; due to defect of
lamina; when spondylolisthesis occurs in the
cervical area, it is a defect of the pedicles

Two portions of intervertebral disc are

(1) nucleus pulposus: inner area; remnant of
notochord, high water content; shrinks with age,
(2) anulus fibrosus: collagen fibers, surrounds
nucleus pulposus
There is no disc between atlas and axis
Herniation (rupture) of intervertebral disc
occurs in posterolateral direction

Nucleus pulposus pushes anulus fibrosus and

posterior longitudinal ligament; this ligament checks
against protrusion directly posterior
Most common in lumbar region, disc between
LV4&5 compresses L5 (and nerves inferior to it);
although L4 corresponds to the disc space, it is too
far lateral to be affected; L5 and S1 are compressed
For cervical region, most common site is disc
between CV5&6, which affects spinal level C6
With herniation, scoliosis occurs with concavity on
side of lesion due to muscle spasm

Anterior longitudinal ligament: only ligament of

vertebral column that lies anterior to vertebral bodies
and therefore, only ligament to check hyperextension
- injured with whiplash
All other ligaments of column check hyperflexion.
Both posterior longitudinal ligament and ligamentum
flava lie with neural arch; ligamentum nuchae that
contains elastic fibers is found in cervical area only;
other ligaments are supraspinal, interspinal, and

Atlanto-occipital joint: plane sliding type of synovial

joint; nodding yes motion is checked by anterior
and posterior atlanto-occipital membranes
Atlanto-axial: (1) paired lateral joints: plane sliding
(2) unpaired median: pivot type, (turning head no)
Anterior surface of dens articulates with atlas and
posterior surface with transverse ligament of atlas
Transverse ligament is part of cruciate (cruciform)
ligament; tears with trauma, and dens will damage
spinal cord or cause death
Alar ligaments: attach dens to lateral sides of
foramen magnum

No valves, so blood can flow in either direction

Two major portions: (1) external plexus lies outside
vertebrae, (2) internal plexus lies within vertebral
canal (external to dura mater)
Communicates with vertebral veins in cervical area,
intercostal veins in thoracic area, lumbar veins
and lateral sacral veins (in pelvis)
Clinical significance: communicates with dural
sinuses within cranium; metastasis of cancer of
prostate or penis to brain

Lumbar punctures are done

above or below LV4
Layers (from superficial to deep)
- Skin
- Superficial fascia
- Aponeurosis of latissimus dorsi
- Aponeurosis of erector spinae
- Supraspinal ligament
- Interspinal ligament
- Ligamentum flavum
- Dura & arachnoid

Depth of needle is about 1 inch in child and up to

4 inches in obese adult
Bone most commonly encountered is spinous
Although last layer to pierce is arachnoid, last layer
that is felt is dura mater
Subarachnoid space contains cerebrospinal fluid

31 Pairs: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral,

1 coccygeal; dorsal roots = sensory roots; ventral
roots = motor roots
All spinal nerves receive gray rami; therefore they
have four functional components, GSA, GVA, GSE,
and GVE (sympathetic)
Dorsal and ventral rami, like spinal nerves, contain
four functional components

Costal groove lies on inferior border of rib; houses
posterior intercostal vein, artery, and intercostal
With thoracocentesis, the needle is inserted on the
superior surface of the rib, in order to avoid
collateral vessels and nerves
Middle ribs are ones most commonly fractured
Rib is weakest just anterior to its angle, site of
greatest curvature

Major lymphatic drainage of breast is to anterior or

pectoral group of axillary lymph nodes
Carcinoma causes shortening of suspensory
ligaments : dimpling
Long thoracic nerve is at risk during resection
Regardless of breast shape and size, base is constant:
2nd 6th ribs, lateral edge of sternum, and
midaxillary line

Plane between sternal angle (junction of manubrium

and body of sternum) and intervertebral disc between
T4 and T5 separates superior mediastinum from
inferior portions
Anterior mediastinum lies anterior to pericardium
Pericardium and related structures lie in middle
Posterior mediastinum lies posterior to pericardium

Thymus gland is structure immediately posterior to

manubrium; produces T cells and involutes with age
Thymoma is often associated with myasthenia gravis
Major contents of superior mediastinum include:
Arch of aorta: brachiocephalic, left common carotid,
and left subclavian arteries; phrenic nerve, vagus
nerve, left recurrent laryngeal nerve and thoracic duct
Left brachiocephalic vein crosses to join right
brachiocephalic vein to form the superior vena cava

Two structures can compress esophagus within

thorax: (1) Left bronchus and (2) arch of aorta;
can interfere with swallowing
Esophagus can also be constricted
(1) By cricopharyngeus where pharynx is continuous
with esophagus
(2) At diaphragm where esophagus passes (T 10)

Aneurysms of the arch of the aorta (often associated

with syphilis) commonly present with referred pain
to back, difficulty swallowing (compression of
esophagus) and a twang in voice (compression of
recurrent laryngeal nerve)
Ductus arteriosus is vessel of fetus that communicates
between left pulmonary artery and aorta, just distal
to origin of left subclavian artery; usually becomes
ligamentous, but can remain open (PDA); the left
recurrent laryngeal nerve wraps around the aorta and
the ductus arteriosus

Azygos venous system

Highly variable in formation
Communicates with veins in abdomen
Drains thoracic wall and thoracic organs exclusive of
heart and lungs
Ends in superior vena cava; important
communication between IVC and SVC

Surfaces of heart
1. The sternocostal surface is formed mainly by the
right ventricle
2. The diaphragmatic surface is formed mainly by the
inferior wall of the left ventricle
3. The posterior surface is formed mainly by the left

Auscultation of heart sounds

Tricuspid valve: near xiphisternal joint
Pulmonary valve: left second intercostal space,
lateral to sternum
Mitral valve: left fifth intercostal space, near
midclavicular line
Aortic valve: right second intercostal space, lateral
to sternum

Fibrous pericardium is attached to both sternum and

diaphragm; it is lined by parietal serous layer
Fibrous pericardium is innervated by phrenic nerve
Pericarditis: may produce friction rub which can be
Cardiac tamponade: leaking of fluid or blood into
pericardial cavity that compromises heart function

Right coronary artery (RCA) descends between right atrium

and right ventricle; usual origin of artery to SA node and artery
to AV node; often gives rise to posterior interventricular artery
Left coronary artery (LCA) is very short before it divides to
form left anterior descending (LAD) and circumflex arteries
Origin of posterior interventricular artery determines
coronary dominance; left dominant when origin is
circumflex branch (of LCA)
Myocardial infarction: impact depends on collateral circulation
(usually more serious in younger person since collateral
circulation not as well developed); may cause cardiac
arrhythmia and fibrillation

Right atrium
Forms right border of heart
Fossa ovalis is major internal feature; was foramen
ovale prior to birth that shunted blood from right to
Crista terminalis: ridge of tissue between sinus
venarum and musculi pectinati; SA node, pacemaker
of heart, is located within crista terminalis
Atrial septal defect (ASD): common defect of heart;
usually involves foramen ovale; severity depends on
amount of blood passing to left

Right ventricle
Moderator band (septomarginal trabecula) is located
in right ventricle
Pulmonary stenosis results in hypertrophy of right
ventricle due to increased resistance to right
ventricular outflow caused by a stenotic pulmonic
Ventricular septal defect (VSD) is common
defect of heart; involves membranous portion of
interventricular septum

Valvular incompetence may involves any of the

cardiac valves
Chronic aortic valvular regurgitation results in a
reduction in diastolic arterial pressure, resulting in a
wide pulse pressure (a normal or high systolic arterial
pressure and a low diastolic arterial pressure)
Aortic stenosis is a common cause of systolic
ejection murmur

SA node is pacemaker of heart; impulses travel from

SA node via interatrial fibers to AV node to
bundle of His
Right and left bundle branches carry impulses to
Purkinje fibers
Sympathetic nerves to heart: increase hearts rate and
force of contraction and (indirectly) produces dilation
of coronary arteries (by inhibiting constriction)
Parasympathetics: slow heart rate, reduce force of
contraction and constrict coronary arteries

Small aspirated food or small objects go to right

primary bronchus rather than left because, compared
to left bronchus, right bronchus is:
directed more vertical
Aspirated objects can go to right inferior lobe or to
middle lobe

Intercostal nerves innervate the costal pleura; the

phrenic nerve innervates the mediastinal pleura
Anteriorly, lungs and pleura extend above first rib
and clavicle; however, posteriorly, they extend only
to level of first rib
Inferior extent:
6th rib
8th rib
8th rib
10th rib
10th rib
12th rib

Right lung has three lobes and two fissures, oblique

(major) and horizontal (minor); left lung normally has
only two lobes that are separated by oblique fissure

The second rib is related to the oblique fissure

posteriorly; the horizontal fissure of the right lung
parallels the fourth rib
Needle location for therapeutic pleural tapping is
superior to 12th rib posteriorly

Preganglionic parasympathetic branches from vagus

Postganglionic sympathetic fibers (T 1 - 5)
Sympathetic effects on lungs: vasoconstriction and
Parasympathetic effects on lungs: vasodilatation,
bronchoconstriction, and glandular secretion

Ventral rami of spinal nerves T7 through L1 supply
skin and musculature of anterolateral abdominal wall
T10 supplies skin around umbilicus; pain from ovary
or appendix is initially perceived at umbilical level;
intervertebral disc L3/L4 lies at level of umbilicus
L1 supplies skin of suprapubic area; pain from uterus
or prostate

Inguinal canal contains round ligament of uterus in

females and spermatic cord in males; round ligament
and spermatic cord are not homologous structures
Inguinal ligament forms floor of inguinal canal; edge
of external oblique attached to ASIS and pubic
tubercle; conjoint tendon is formed by union of
internal oblique and transversus abdominis
Deep ring is formed by transversalis fascia
Superficial ring is formed by external oblique

Fascial continuities: external oblique and external

spermatic fascia; internal oblique and cremasteric
fascia and muscle; transversalis fascia and internal
spermatic fascia
Tunica vaginalis of testis: derived from the processus
vaginalis, an outpocketing of peritoneum; a
hydrocele is an accumulation of fluid within the
tunica vaginalis

Indirect inguinal hernia is more common than

direct inguinal; passes through deep ring, which lies
lateral to inferior epigastric blood vessels; hernia
follows path of spermatic cord (through both inguinal
rings) to reach scrotum; hernia on right side is more
common than on left side
Direct inguinal hernia protrudes through
Hesselbachs triangle, bounded by rectus abdominis,
inferior epigastric blood vessels, and inguinal
ligament; usually seen in elderly with weakness of
abdominal wall musculature; rarely reaches scrotum

Paracolic gutters lie lateral to ascending colon and

descending colon; on right side, ascitic fluid can
reach hepatorenal recess, while on left side,
phrenicocolic ligament limits spread of fluid
Infracolic gutters lie medial to large intestine, root
of mesentery prevents ascitic fluid from spreading to
pelvic cavity

Epiploic foramen is small space that communicates

between greater peritoneal cavity and lesser cavity
(omental bursa); bounded superiorly by caudate lobe
of liver, and inferiorly by first part of duodenum
IVC bounds epiploic foramen posteriorly, and
anteriorly, it is bounded by hepatoduodenal ligament
(portion of lesser omentum) that contains bile duct,
hepatic artery, and portal vein

ORGANS: Stomach
The celiac artery, the first unpaired visceral branch
of the abdominal aorta, has three branches: left
gastric, common hepatic and splenic
All three arteries supply the stomach: left gastric
arises directly from the celiac; right gastric and
right gastroepiploic arise from the hepatic; and
the left gastroepiploic and short gastric arteries
arise from the splenic
Venous blood from the stomach drains directly to the
portal vein

Stomach bed = posterior relations of stomach

Structures of the stomach bed include the following:
pancreas, spleen, diaphragm, left suprarenal gland,
and left kidney; transverse colon is not part of the
stomach bed since the transverse colon lies inferior
(not posterior)
First portion of duodenum is peritonealized; part two
receives the bile duct; third part courses posterior to
superior mesenteric vessels, and part four ascends
Parts two - four are retroperitoneal

Falciform ligament divides the liver into right and

left lobes; caudate lobe lies adjacent to the IVC and
quadrate lobe lies adjacent to the gallbladder
Liver is only site of bile production; it also produces
albumin (edema with poor liver function)
Porta hepatis lies between gallbladder and fossa for
IVC; structures located at the porta hepatis include
portal vein, hepatic artery and hepatic duct
Hepatic veins are not located at the porta hepatis

The gallbladder stores and concentrates bile; bile

duct is formed by union of cystic and hepatic ducts
Surface projection of the fundus of the gallbladder is
at the intersection of the right costal margin and the
linea semilunaris, lateral margin of rectus abdominis
Posterior relations are transverse colon and parts one
and two of duodenum; liver and abdominal wall are
Although the origin of the cystic artery is highly
variable, the usual origin is the right hepatic artery
Gallstones most commonly block the infundibulum
or hepatopancreatic ampulla and occur in
overweight, multigravida women in their forties

PANCREAS: classical endocrine - exocrine gland;

insulin and glucagon secretion by islets of
Langerhans and hydrolytic enzymes by exocrine
portion; retroperitonealized except at tail
Significant posterior relations: IVC, origin of portal
vein, and aorta; lesser peritoneal sac lies anterior
Extensive blood supply from splenic, gastroduodenal
and superior mesenteric arteries
Pain from the pancreas is commonly referred to the
Cancer of the head of the pancreas often causes
obstructive jaundice

SPLEEN: Lymphoid organ: immune response and

destroys old RBCs; located in upper left quadrant; lies
in relation to ribs 9, 10 and 11; related to stomach,
left kidney and transverse colon
Normally not palpable, but may become
enlarged and palpable due to lymphoid cancer,
infection (mononucleosis), or portal
Rupture of the spleen results in massive
intraperitoneal hemorrhage; because of its friable
nature, it is usually removed rather than repaired


Jejunum has more circular folds, larger diameter, and
is better vascularized
Ileum has more fat in its mesentery; contains
lymphatic nodules (Peyers patches); has more
arching of arteries
Suspended by the mesentery; root of the mesentery
is attached to the posterior body wall from the left of
LV2 to the right sacroiliac joint

Three classical identifying features are: (1) fatty
appendages; (2) haustra or sacculations; and (3)
tenia coli, three longitudinal bundles of smooth
Diverticulosis of the colon is common; herniation of
the lining mucosa through the circular muscle
between the tenia coli
Cancer of the large bowel is common; usually
spreads by lymphatics before the bloodstream is

The cecum does not contain a mesentery; the root of

the appendix attaches where the three tenia coli unite
Both cecum and appendix are supplied by the
ileocolic artery, the terminal branch of SMA
Location of appendix is variable; often retrocecal
Pain from appendix is conveyed by (GVA) T10
fibers (lesser splanchnic nerve) and is vague and
referred to umbilicus; when parietal peritoneum is
irritated, pain localized in the lower right quadrant
(McBurneys point)

KIDNEYS: Posterior relations are diaphragm,

psoas major, quadratus lumborum, and transversus
abdominis; three nerves lie posterior to the kidneys:
subcostal, ilioinguinal and iliohypogastric
Anterior to right kidney: liver, right colic flexure,
part two of duodenum and right suprarenal gland
Anterior to left kidney: stomach, spleen, splenic
flexure and left suprarenal gland
Perirenal fat lies in contact with the capsule of the
kidney; renal fascia surrounds perirenal fat;
pararenal fat lies external to the renal fascia

Unpaired arteries and their vertebral levels

Celiac - T12; SMA - L1; IMA - L3
Paired arteries and their vertebral levels
Suprarenal - L1; Ovarian or testicular - L2;
Renal - L2
Aneurysm of the abdominal aorta usually occurs just
inferior to the origin of the renal arteries; most of
these aneurysms result from atherosclerosis
Aortic bifurcation is a common site for an embolus to

Superior mesenteric artery supplies the entire small

bowel, cecum, appendix, ascending colon, right 2/3
of transverse colon and pancreas
Arises from aorta (at LV1) at a very acute angle;
structures that course between aorta and origin of
SMA are: left renal vein, part three of duodenum
and uncinate process of pancreas; an aneurysm of
SMA at its origin produces the nutcracker
syndrome whereby the duodenum is blocked as well
as flow of blood in left renal vein (includes both left
suprarenal vein and left ovarian or testicular vein)


On the right side, testicular or ovarian vein, inferior
phrenic vein and suprarenal vein all drain directly to
the IVC; on the left. testicular or ovarian vein,
inferior phrenic vein and suprarenal vein all drain
to the left renal vein
Injuries to the IVC are usually lethal; thin wall makes
it prone to extensive tears and the IVC is not readily
accessible, being located posterior to the liver,
duodenum and root of the mesentery

Portal vein is formed by union of superior

mesenteric and splenic veins; occurs posterior to
neck of pancreas; usual termination of inferior
mesenteric vein is to splenic
As the portal vein courses within the hepatoduodenal
ligament (portion of lesser omentum), it lies
posterior to the hepatic artery and bile duct
The portal vein drains the structures that receive
their arterial supply from three major arteries,
celiac, SMA, and IMA

Portacaval anastomoses: (1) left gastric vein (that

drains to portal) and esophageal veins that drain to
SVC; esophageal varices associated with alcoholics;
(2) superior rectal drains to IMV which goes to the
portal vein and middle and inferior rectal veins drain
to the internal iliac which ends in the IVC;
hemorrhoids; (3) paraumbilical veins; caput
medusae seen with late pregnancy, in newborns and
with cirrhosis; (4) veins of Retzius: venous
anastomoses of organs that are retroperitoneal

Psoas major
O = T12 - L5; I = joins iliacus to form iliopsoas
to insert on lesser trochanter of femur
Chief flexor at hip (flexes trunk with feet on
Subfascial space route for spread of infection;
spread of tuberculosis from lumbar vertebrae
to lower limb
Flexion of thigh against force: test for disorders of
posterior abdominal viscera
Psoas minor
Quadratus lumborum

DIAPHRAGM: phrenic nerve (C3 - C5) is the sole

motor nerve; phrenic is sensory to region of central
tendon and lowest intercostal nerves are sensory to
peripheral, muscular part of diaphragm
Opening for IVC (and right phrenic nerve): TV 8
Esophageal hiatus (and right and left vagus): TV 10
Aorta (and thoracic duct): TV 12

Branches of the lumbar plexus are:

Iliohypogastric L1: innervates rectus abdominis and is
cutaneous to small area of thigh
Ilioinguinal L1: courses through superficial inguinal
ring; potentially injured with hernia repair
Genitofemoral L1-L2: innervates cremaster muscle and
is cutaneous to small area of thigh
Lateral femoral cutaneous L2-L3: cutaneous to thigh
Femoral L2-L4: innervates anterior compartment of
Obturator L2-L4: innervates medial compartment of
Lumbosacral trunk L4-L5: joins the sacral plexus in the

Greater splanchnic nerve: T 5 - 9; synapses at

celiac ganglion and suprarenal medulla
Lesser splanchnic nerve: T 10 and 11; synapses at
aorticorenal and superior mesenteric ganglia
Least splanchnic nerve: T 12; synapses at renal
Pressure (distension), fullness and motion sensations
travel with parasympathetic innervation (e.g. the
vagus nerve)
Pain afferents travel with sympathetics to the level of
the preganglionic origin
Referred pain [important clinical concept]: perceived
at the level of the preganglionics that serve the area


Pelvic brim (inlet) is bounded by sacral promontory,
arcuate and pectineal lines, and pubic symphysis
Most common shape of inlet in females is gynecoid,
with the transverse diameter being slightly greater
than the AP diameter
Orientation of the pelvis: ASIS and pubic tubercle
lie on the same vertical plane

Pelvic diaphragm is primary support for all pelvic

viscera; muscle complex separates pelvis from
perineum, which lies inferior
Two major components of pelvic diaphragm are
(1) levator ani and (2) coccygeus
Levator ani consists of two major portions,
pubococcygeus and iliococcygeus; pubococcygeus is
the portion of the levator ani that serves as the
primary support of the pelvic organs

Urinary bladder
Strong muscular wall known as the detrusor muscle
Apex is located anterior and is continuous with the
urachus, the fibrous cord that is the remnant of the
allantois; the urachus forms the median umbilical
ligament; base is located posterior and is outlined by
the trigone, which is bounded by the two ureters and
the urethra; oblique course of the ureter acts as valve
Blood supply: superior and inferior vesical arteries
Micturition reflex is entirely parasympathetic; S2 - 4
(pelvic splanchnic nerves)

Chief artery to rectum and anal canal is superior

rectal, the terminal branch of inferior mesenteric;
also supplied by middle and inferior rectal arteries
Pectinate line of anal canal serves as important
divide line: for lymphatic drainage; superior to line:
inferior mesenteric and internal iliac nodes; inferior to
line, to superficial inguinal nodes
Somatic innervation below line, visceral afferents
superior to pectinate line
Site of portacaval anastomoses
Line between internal and external hemorrhoids

OVARY: several important facts appear on boards

Ovarian artery arises from aorta directly (L2)
Venous drainage: IVC on right, renal vein on left
Para-aortic group of lumbar lymph nodes
Ovarian blood vessels are conveyed by the
suspensory ligament; this ligament does not suspend

Two remnants of gubernaculum in females are

(1) round ligament of uterus, that courses from the
uterus through the deep inguinal ring, and in the
inguinal canal to end in the labium majus
(2) ovarian ligament: connects ovary to the uterus
Uterine tube: Fimbriae of infundibulum open into
peritoneal cavity; ampulla is the site of fertilization

Usual uterine position is anteverted and anteflexed;

angle between uterus and vagina is approximately
900 (anteverted) and angle between uterine body and
cervix is about 150 (anteflexed)
Uterine support: pelvic diaphragm (pubococcygeus
part of levator ani), UG diaphragm, bladder and
areolar tissue, cardinal and uterosacral ligaments
Cardinal (lateral cervical) ligament conveys uterine
blood vessels; uterine artery courses superior to
the ureter; ureter is at risk with a hysterectomy
Lymph nodes: external iliac, internal iliac, common
iliac, sacral, superficial inguinal and lumbar

Vagina: fornix is continuous recess around cervix

Relationships: lateral, levator ani and ureter
Anterior: uterus and bladder
Posterior: perineal body, pouch of Douglas and
Support is similar to that of uterus: pelvic diaphragm,
UG diaphragm, organs, areolar tissue, and ligaments
Arteries: vaginal, uterine and middle rectal
Lymphatics: superior portion to internal iliac nodes;
inferior portion to superficial inguinal nodes

Seminal vesicle is a highly coiled gland that secretes

fructose into seminal fluid; it lies lateral to vas
deferens; ducts join inside of prostate to form
ejaculatory duct
The fluid secreted by the seminal vesicle comprises
the bulk of the seminal fluid
Separated from rectum by Denonvilliers fascia

Prostate: lies on UGD; paired lateral and median

lobes; so-called posterior lobe is really part of
lateral lobe
Traversed by urethra and the ejaculatory ducts
Base of prostate lies in contact with bladder; apex of
prostate lies on UGD
Prostatic venous plexus lies between capsule of
prostate and its fibrous sheath; drains to vertebral
venous plexus (of Batson); metastasis to brain
Arteries: inferior vesical, middle rectal and internal
Prostatic ducts open into prostatic sinuses, which
lie lateral to urethral crest

Internal iliac artery

Posterior division: superior gluteal (exits superior to
piriformis), lateral sacral and iliolumbar
Anterior division: umbilical, obturator, (in females,
uterine and vaginal), inferior vesical, middle rectal;
terminal branches are internal pudendal and inferior
gluteal; (superior vesical arises from umbilical)
Although located in the pelvis, the ovary does not
gets its supply from the internal iliac; supplied by the
aorta directly

Sacral plexus supplies the lower limb

Ventral rami L4 S3
Anterior division: tibial, nerve to obturator internus
and nerve to quadratus femoris
Posterior division: common fibular, superior gluteal
and inferior gluteal
While in the pelvis, the nerves lie medial to the
piriformis, and as they exit, all pass inferior to the
piriformis except the superior gluteal nerve (which
passes superior)

Boundaries of the perineum (pelvic outlet)

Anterior: pubic symphysis
Anterolateral: ischiopubic rami
Lateral: ischial tuberosities
Posterolateral: sacrotuberous ligaments
Posterior: coccyx
Horizontal line/plane between ischial tuberosities
forms two triangles, anal and urogenital

Ischioanal fossa is a fat-filled space bounded by:

Medial: anal canal and levator ani
Lateral: fascia overlying obturator internus; pudendal
canal lies within fascia of obturator internus
Superior (apex): levator ani joins fascia of obturator
Inferior (base): skin; posterior: coccyx
Anterior: extends into UG triangle as a recess

Superficial perineal space

Ischiocavernosus: compresses venous outflow
maintaining erection; bulbospongiosus: functions to
empty urethra and compresses deep dorsal vein and
erectile tissue; superficial transverse perineus:
stabilizes other muscles
Contains the crura and bulb of the penis

Paired corpus cavernosum; each is continuous with

crus; unpaired corpus spongiosum: contains urethra,
continuous with bulb and glans
Tunica albuginea = CT capsule around penis
Deep arteries lie within corpora cavernosa to supply
erectile tissue; dorsal arteries course on dorsum of
Veins: superficial dorsal vein drains to superficial
external pudendal (tributary of great saphenous); deep
dorsal vein drains to prostatic plexus
Glans of penis drains DEEP inguinal lymph nodes

Common site of injury is in superficial space; urine

collects in penis, scrotum and passes up abdominal
wall; does not spread to anal triangle nor to thigh
due to fascial attachments
Fascial continuities of Colles fascia, dartos, and
Scarpas fascia allows for the spread of urine

Superficial space contains Bartholins gland, crus of

the clitoris, and the vestibular bulb
Perineal body: central point of perineum, important
with episiotomy
Muscles attached: bulbospongiosus, superficial
transverse perineus, deep transverse perineus,
external anal sphincter, and pubovaginalis (portion
of pubococcygeus of the pelvic diaphragm)
Fascia attached: Colles, perineal membrane,
superior fascia of UGD, inferior fascia of pelvic
diaphragm, and fascia around muscles (Gallaudets)

The urogenital diaphragm (UGD) in both sexes aids

the pelvic diaphragm in supporting the bladder and
the reproductive organs of the pelvis
The UDG is composed of two layers of fascia, the
superior fascia of the UGD and the perineal
membrane, and two muscles: deep transverse
perineus and sphincter urethrae
In males, it also contains Cowpers gland (in females,
homologue is Bartholins gland, which is in the
superficial space)

Pudendal nerve arises from sacral plexus, S2 - 4; exits

pelvis by the greater sciatic foramen and enters the
perineum by the lesser sciatic foramen
Courses in pudendal canal (fascia of obturator
internus); its branches are the inferior rectal nerve,
perineal nerve and dorsal nerve of the penis or
The pudendal nerve innervates ALL of the muscles
of the perineum

Clinically, cutaneous innervation is an important

consideration due to pudendal nerve blocks
The perineal nerve , a branch of the pudendal, has
posterior lateral and medial labial nerves that supply
much of the the skin; however, there are additional
Nerves that are NOT affected by a pudendal nerve
The ilioinguinal (L1) supplies the anterior labia and
the skin around root of clitoris, and the posterior
femoral cutaneous (S1 3) innervates the
posterior portion of the labia

1. Investing fascia: collar around entire neck, invests SCM
and trapezius
2. Infrahyoid fascia: surrounds the four strap muscles
3. Visceral fascia has two layers: (a) pretracheal fascia lies anterior
to trachea and surrounds thyroid gland; and
(b) buccopharyngeal fascia lies posterior
4. Prevertebral fascia: - surrounds muscles of vertebral column;
alar fascia is anterior layer of prevertebral fascia;
danger space lies between alar and prevertebral
5. Carotid sheath (paired) contains common and internal carotid
arteries, CN X, internal jugular vein & deep cervical lymph
nodes; sympathetic trunk lies posterior and ansa cervicalis lies

Boundaries: clavicle (middle 1/3) , SCM, trapezius
Muscles of floor (from apex inferiorly): semispinalis
capitis, splenius capitis, levator scapulae, posterior
scalene, middle scalene, anterior scalene
Platysma muscle overlies pectoralis major, deltoid,
and posterior triangle; innervated by cervical branch

Spinal accessory nerve: emerges from behind SCM,

innervates both SCM & trapezius; nerve can be
injured with removal of lymph nodes causing
shoulder to sag
Cutaneous nerves:
1. Great auricular - parallels external jugular;
prominence of external jugular is indicator of
heart failure
2. Lesser occipital
3. Anterior cutaneous nerve of neck
4. Supraclavicular

Between anterior and middle scalenes: brachial

plexus and subclavian artery
Either the plexus and/or the artery can be
compressed between the scalene muscles
Anterior to anterior scalene: subclavian vein, phrenic
nerve, branches of thyrocervical trunk:
1. Suprascapular
2. Transverse cervical
3. Ascending cervical

Anterior triangle
Boundaries: SCM, mandible and midline
Carotid triangle: omohyoid, posterior belly digastric
and SCM
Muscular triangle: omohyoid, SCM and midline
Digastric (submandibular): mandible and two bellies
of digastric muscle
Submental: hyoid bone and paired anterior bellies
of digastric

Suprahyoid muscles: ones that elevate hyoid

and larynx with swallowing
Digastric: anterior belly (CN V3) pulls hyoid
forward; posterior belly (CN VII) pulls hyoid
Stylohyoid (CN VII); geniohyoid (C1 via CN XII);
mylohyoid (CN V3)

Infrahyoid muscles: ones that depress hyoid and

larynx; thyrohyoid is innervated by C1 via CN XII;
sternohyoid, sternothyroid and omohyoid are muscles
innervated by the ansa cervicalis

Cervical plexus: ventral rami C1 - 4; communicates

with the sympathetic chain and with CN X, XI & XII
Ansa cervicalis is loop formed by C1 - 3
Cutaneous branches:great auricular, lesser occipital,
transverse cervical and supraclavicular
Muscular branches: phrenic; to prevertebral muscles

Right common carotid arises from brachiocephalic

trunk; left one arises directly from arch of aorta
Usual bifurcation at CV3; site of carotid body and
sinus (innervated by CN IX and X)
Branches of external carotid: superior thyroid,
ascending pharyngeal, lingual (goes to floor of the
mouth as well as the tongue), facial (to tonsil, face,
and submandibular gland), posterior auricular and
occipital supply the scalp
Terminal branches are maxillary, chief artery of the
head and the superficial temporal

Internal jugular vein: continuation of sigmoid

sinus at inferior aspect of jugular foramen
Courses within carotid sheath
Tributaries: pharyngeal, facial, lingual (especially
important because this is the rationale for putting
nitroglycerin under the tongue), superior thyroid,
and middle thyroid
Ends by joining subclavian to form brachiocephalic
vein (at venous angle)

Three portions of the pharynx

1. Nasopharynx: base of skull to soft palate (CV2);
communicates with paired nasal cavities & auditory
tubes and oropharynx
2. Oropharynx: CV2 to hyoid bone (CV3);
communicates with oral cavity, nasopharynx and
3. Laryngopharynx: extends to CV6; (level of cricoid
cartilage); communicates with oropharynx, larynx
and esophagus

Pharyngeal muscles: two groups

Longitudinal muscles elevate when swallowing:
1. Stylopharyngeus: arises from styloid process
(only muscle innervated by CN IX)
2. Salpingopharyngeus: arises from auditory tube
3. Palatopharyngeus: arises from palate
Circular muscles propel food
Superior, middle and inferior constrictors;
the inferior fibers of the inferior constrictor are
continuous with the esophagus to form the
cricopharyngeus, that acts as an upper esophageal
sphincter; (innervated by recurrent laryngeal nerve)

OPENINGS of the pharyngeal wall:

Above superior constrictor: auditory tube and
levator veli palatini
Between superior and middle: CN IX, stylohyoid
ligament and stylopharyngeus
Between middle and inferior, through thyrohyoid
membrane: superior laryngeal artery and internal
laryngeal nerve
Below inferior: inferior laryngeal artery and
recurrent laryngeal nerve

Major cartilages of larynx

Thyroid: unpaired; vocal cords attach to its posterior
surface; Adams apple
Cricoid: CV6; unpaired, signet ring (only complete
ring of entire respiratory system)
Epiglottis: unpaired; looks like tennis racket
Arytenoid: paired and articulate with cricoid by
synovial joints; has vocal and muscular processes
Vocal cords extend from thyroid cartilage to
arytenoid cartilage

Posterior cricoarytenoid: only muscle to abduct

vocal cords (thereby opening the rima glottidis);
antagonistic muscles: lateral cricoarytenoid and
transverse and oblique arytenoids
Cricothyroid is only muscle to increase tension;
thyroarytenoid and vocalis are antagonistic muscles
Motor: external branch of superior laryngeal is motor
to cricothyroid; recurrent laryngeal is motor all others
Sensory: internal branch is sensory to larynx superior
to vocal cords; recurrent laryngeal is sensory below
vocal cords

Piriform recess: site where a fishbone can be

lodged; can pierce mucosa and injure internal
laryngeal nerve
Rima glottidis: opening between vocal cords
Aditus: opening to larynx
Vestibular folds = false vocal cords
Vestibule: region superior to false vocal cords
Ventricle: region between false and true cords

Sagittal suture: between parietal bones

Coronal: between frontal and paired parietal bones
Lambdoidal: between occipital and parietal
Squamosal: between temporal and parietal

Paired: sphenoid and mastoid
Unpaired: sagittal and coronal sutures intersect at
bregma, site of anterior fontanelle
Lambda, where sagittal and lambdoidal sutures
meet, site of posterior fontanelle

Pterion: overlies anterior branch of middle

meningeal artery
Union of four bones: frontal, parietal, sphenoid, and
These bones are relatively thin at the pterion

Middle meningeal arises from part one of maxillary

artery passes through foramen spinosum; artery
supplies both dura mater and calvaria
Severe blow to the head tears the artery; events:
brief concussion, lucid for several hours, coma; need
to operate since blood is compressing brain
Epidural bleeding is arterial bleeding

Sphenoidal ridge: separated anterior fossa and

middle fossa; petrosal ridge separates middle fossa
and posterior fossa
Significant foramen to remember
Internal acoustic meatus for CN VII and CN VIII
For the three divisions of CN V, superior orbital
fissure, foramen rotundum and foramen ovale
Optic canal for CN II and ophthalmic artery
Foramen spinosum for middle meningeal artery
Jugular foramen for CM IX, CN X and CN XI

Emissary veins pass through calvaria,

communicating veins of scalp with dural sinuses; no
valves, so blood can flow in either direction
Diploic veins: begin within diploe; drain in or out
Arachnoid villi terminate in the superior sagittal
sinus; return of CSF to the circulatory system

Cavernous sinus: contains internal carotid artery

and CNVI; CN III, IV & V1 are located within its
lateral wall; communicates with ophthalmic veins
and pterygoid plexus and drains to superior and
inferior petrosal sinuses
Hormones from both anterior and posterior lobes of
the pituitary drain to the cavernous sinus
Enlargement of the pituitary gland can compress the
structures within the cavernous sinus as well as CN II

Numerous arteries to the scalp with extensive

anastomoses; all arteries enter peripherally
Three branches from external carotid: superficial
temporal, occipital and posterior auricular
Two branches from internal carotid: supraorbital and
Clinically, wounds to the scalp are serious
The aponeurotic layer holds lacerations open, so
extensive bleeding occurs with a wound to the scalp

All muscles of facial expression are innervated by

Orbicularis oculi: closes eye
Buccinator keeps food from collecting between
teeth and oral vestibule; buccal branch of CN VII is
motor to buccinator while buccal branch of CN V is
cutaneous to skin over cheek and it is sensory to
mucosa inside of the mouth

Parotid gland: Largest salivary gland; infected by

mumps virus
Innervation: CN IX via tympanic branch which
becomes lesser petrosal that synapses at otic
ganglion; carried by auriculotemporal nerve
Duct crosses masseter to pierce buccinator and
opens opposite 2nd upper molar
Structures that traverse: CN VII, auriculotemporal
nerve, external carotid artery and retromandibular

CN V is cutaneous to the face; all three divisions

innervate the skin of the face and scalp
CN VII is motor to muscles of facial expression
CN VII is not cutaneous to face
Courses within parotid but does not innervate
Divides into two trunks: upper trunk (temporofacial)
and lower trunk (cervicofacial) give rise to five
terminal branches: temporal, zygomatic, buccal,
mandibular and cervical

Lateral pterygoid muscle attaches to the disc of the

TMJ; this muscle pulls the disc of the TMJ forward
and is concerned with opening the mouth
Temporalis, masseter and medial pterygoid all close
the jaw
The auriculotemporal nerve is sensory to the TMJ;
important with pain associated with TMJ syndrome

Paranasal sinuses
Frontal drains to middle meatus via frontonasal duct
Maxillary: largest; drains superiorly to middle
meatus; problem clinically
Sphenoid drains to sphenoethmoid recess
Anterior: middle meatus
Middle: middle meatus
Posterior: superior meatus

CN V1 & CN V2 innervate paranasal sinuses and

nasal cavity
CN I: innervates roof, superior concha and superior
part of nasal septum
Arteries: sphenopalatine is chief artery
Anterior and posterior ethmoidal and septal
branch of superior labial
Kiesselbachs plexus is located on nasal septum

Hyoglossus depresses tongue

Styloglossus elevates & retracts tongue
Palatoglossus elevates tongue; innervated by CN X
-anterior fibers protrude
-posterior fibers retract
Except palatoglossus, innervated by CN XII
Sensory: lingual nerve (CN V3) to anterior 2/3 for
general sensation and chorda tympani (CN VII) for
taste; CN IX innervates root of the tongue, both
taste and general sensation

Palatine (major): between anterior and posterior

pillars, formed by palatoglossal and
palatopharyngeal arches
Lingual: on dorsum of tongue
Pharyngeal: in nasopharynx; adenoids when
Tubal (lateral pharyngeal band): near opening of
auditory tube
Waldeyers tonsillar ring: entire collection of
tonsillar tissue

Superior oblique (SO) and inferior oblique (IO)

attach to the posterior side of the equator of the eye
SO rotates eye medially causing it to look down and
out (abduct and depress); IO rotates eye laterally
causing it to look up and out
(SO4 LR6 )3
Elevate: SR and IO; depress: IR and SO
Abduct: LR, SO, IO; adduct: MR, SR, IR
Injury to CN VI causes eye to turn in
Injury to CN IV, diplopia when looking down
Injury to CN III: ptosis, dilated pupil, no light
reflex; eye is turned down and out

Ophthalmic veins
Superior: formed by confluence of angular,
supraorbital, and supratrochlear veins; drains to
cavernous sinus
Inferior: drains eyelids; divides and passes through
both superior and inferior orbital fissures;
communicates with pterygoid plexus

CN I: telencephalon
CN II: diencephalon
CN III & IV: midbrain
CN V - VIII: pons
CN IX - XII: medulla
Special sensation: CN I - olfaction, CN II vision;
CN VIII hearing; CN VII, IX and X taste
Motor only: CN III, IV and VI for eye muscles;
CN XI for trapezius and SCM; CN XII tongue

Facial nerve leaves the brain by passing through the

internal acoustic meatus; while in the temporal
bone, it has two important branches
1. Greater petrosal: parasympathetic fibers to
pterygopalatine ganglion; distribution to lacrimal
gland and mucous glands of nose and mouth
2. Chorda tympani: taste and parasympathetic to
submandibular and sublingual glands
CN VII exits the skull at the stylomastoid foramen and
on face, it is only motor to muscles of facial

Glossopharyngeal nerve
Tympanic branch re-enters skull, courses through the
Middle ear and exits as the lesser petrosal nerve that
goes to the otic ganglion (parasympathetics for the
parotid gland)
Very important branch to carotid sinus and body
(CN X also innervates both carotid sinus and body)
Only one muscle: stylopharyngeus
Sensation to tonsillar bed, posterior 1/3rd of tongue,
and muscles of pharynx

Branches of CN V carry postganglionic

parasympathetic fibers for CN III, VII and IX
CN III: ciliary ganglion: accommodation of lens and
constriction of pupil
CN VII: pterygopalatine ganglion: lacrimal, nasal,
palatal and pharyngeal glands
CN VII: submandibular ganglion: submandibular and
sublingual glands
CN IX: otic ganglion: parotid glands