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Head and Neck

Loubomir E. Antonio, M.D.


Bones of Skull
Cranium
Eight (8) Bones
Frontal
Parietal (2)
Occipital
Temporal (2)
Sphenoid
Ethmoid
Facial Bones
Fourteen (14) bones

Zygomatic(2)

Maxillae (2)

Nasal bones(2)

Lacrimal (2)

Vomer (1)

Palatine (2)

Inferior concha (2)

Mandible (1)
New Born Skull
Fontanelles
Anterior fontanelle Bregma
Diamond-shaped
Between
Two halves of frontal bone
Two parietal bones
Closed by 18 months
Posterior fontanelle Lambda
Triangular
Between
Two parietal bones
Occipital bone
Closed by first year of life
CLINICAL SIGNIFICANCE
Depressed Dehydration
Bulging Increased ICP

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

Mastoid Process
Not present at birth
Develops during first 2 years of life
CLINICAL SIGNIFICANCE
Forceps delivery may result to Facial nerve injury
Adult Skull
Sutures
- fibrous type ( synarthroses )
- Wormian or Inca bones in between sutures
Coronal Suture

Frontal bone

Parietal bone
Sagittal Suture

Parietal bones
Lambdoid Suture

Parietal bone

Occipital bone
Adult Skull
Pterion
Thinnest part of lateral wall
Between
Anteroinferior corner of the parietal bone
Greater wing of sphenoid
INTRACRANIAL HEMORRHAGES
Epidural Ant. division middle meningeal artery
Subdural Cerebral veins
Subarachnoid Aneurysm/Angioma
IntraParenchymal Lenticulostriate artery
INTRACRANIAL HEMORRHAGE (INFANT)

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

Between pons/medulla -> Cavernous Sinus w/ICA -> SOF ->


Lateral Rectus
Type: Motor
Function: Abducts eyeball (lateral rectus)
Lesion: diplopia, medial/internal strabismus, loss of parallel gaze
Foramen: Superior orbital fissure
Innervated Region: Orbit

Cavernous Sinus Contents


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

Cranial Nerve V - Trigeminal Nerve


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

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

Olfactory tract ->

LGB -> Optic

Cranial nerve III Oculomotor Nerve


Anterior midbrain -> Lateral wall Cavernous Sinus ->
SOF -> EOMs except SO and LR
sphincter pupillae
Ciliary muscles
Type: Motor
Functions:

EOMs
*adduction most important action (medial rectus)

Constricts pupil (spincter pupillae)

Accomodation (ciliary muscle)

Raises upper eyelid (levator papillae)


Lesion: Diplopia, lateral/external strabismus
Foramen: Superior oribital fissure
Innervated Region: Orbit
Cranial nerve IV - Trochlear Nerve
Posterior midbrain -> Lateral wall cavernous Sinus ->
Superior Oblique
Type: Motor
Function:
Depresses and abducts eyeball (Superior oblique)
Intorts
Lesion:
Weakness looking down with adducted eye
Difficulty going down stairs
Head tilts away from lesioned side
Foramen: Superior orbital fissure
Innervated Region: Orbit
Cranial nerve VI Abducent Nerve

SOF ->

Frontal divides into supraorbital/trochlear nerves


Lacrimal +
zygomaticotemporal branch of V2
gland
Type: Sensory
Function: General sensation of forehead/scalp/cornea
Lesion:

Loss of sensation in skin of forehead/scalp

Loss of blink reflex w/ CN VII


Innervated Region: Orbit and scalp

lacrimal

Cranial nerve V2 Maxillary Nerve


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

Foramen: Foramen Ovale


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

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

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

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

Internal acoustic
meatus
Type: Mixed
Function:
Motor: muscles of facial expression, posterior belly of
digastric, stylohyoid, stapedius
Sensory
Taste to anterior two-thirds of tongue/palate
Autonomics
Salivates (submandibular, sublingual glands)
Tears (lacrimal gland)
Makes mucus (nasal and palatine glands)
Lesion:

Corner of mouth droops, cant close eye, cant wrinkle


forehead, loss of blink reflex, hyperacusis

Alteration or loss of taste (ageusia)

Eye dry and red


Foramen: Internal auditory meatus
Innervated Region: Face, nasal and oral cavity, branches leave skill
in stylomastoid foramen, petrotympnic fissure, or hiatus of facial canal

Facial canal
Chorda tympani
petrotympanic
fissure
Infratemporal

Cranial nerve VIII Vestibulocochlear Nerve


Vestibule AND semicircular canal > Vestibular ganglion > Int.
acoustic meatus
> Brainstem/Cerebellum

fossa
Inner Ear/Middle ear
Nerve to
stapedius

Cochlea -> Spiral ganglion ->


Auditory Center

Internal acoustic meatus ->

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

Cranial Nerve IX Glossopharyngeal Nerve

joins lingual nerve


Geniculate ganglion

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

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

Cranial Nerve XI Spinal Accessory Nerve

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

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

Cranial Nerve XII Hypoglossal Nerve


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

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

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

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

CN XII (Hypoglossal)

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

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

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

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

Masseter

Temporalis
M Munching

Medial Pterygoid

Lateral Pterygoid
L - Lowers

Triangles of the Neck


Posterior Triangle

Occipital triangle

Supraclavicular triangle
Anterior Triangle

Carotid triangle

Digastric triangle

Submental triangle

Muscular triangle
Posterior Triangle
Boundaries

Trapezius (posterior)

Sternocleidomastoid (anterior)

Clavicle (inferior)
Divided by Omohyoid into

Occipital triangle

Supraclavicular triangle
Floor

Anterior scalene

Middle Scalene

Posterior Scalene

Levator scapulae

Splenius Capitis
Posterior Triangle
Contents
In scalene interval (between anterior & middle scalene)

Three (3) trunks of brachial plexus

Subclavian artery
Spinal accessory nerve (CN XI) to

Sternocleidomastoid

Trapezius
Phrenic nerve (anterior surface of anterior scalene)
Cutaneous branches of cervical plexus

greater auricular,

lesser occipital,

transverse cervical,

supraclavicular nerves
Anterior Triangle
Boundaries
Anterior border of sternocleidomastoid
Anterior midline
Body of mandible
Subtriangles
Digastric triangle
Submental triangle
Muscular triangle
Carotid triangle
Digastric Triangle
Boundaries

Lower border of mandible

Posterior belly of digastric

Anterior belly of digastric


Contents

Submandibular gland

Submandibular duct

Submandibular lymph node

CN XII

Cervical mandibular branch of CN VII

Submental branch of facial vessels


Submental Triangle
Boundaries
Mentum of mandible
Anterior bellies of digastric muscles
Hyoid bone
Floor: Mylohyoid
Apex: Mandibular symphysis
Contents
Submental lymph nodes
Muscular Triangle
Boundaries

Midline of neck

Superior belly of omohyoid

Anterior border of sternocleidomastoid


Roof: Strap muscles

Contents
Viscera of neck

Thyroid gland

Superior laryngeal nerve

Recurrent laryngeal nerve

Trachea

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

Four (4) separate glands


Secretes Parathyroid Hormone
Blood Supply:

Superior
thyroid artery.

Inferior
thyroid artery
Larynx
Cartilages
3 unpaired:
Thyroid
Cricoid
Epiglottis
3 paired:
Arytenoid
Corniculate
Cuneiform

Intrinsic Laryngeal Muscles


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

Back and Spine


Loubomir E. Antonio, MD
Vertebral Column
Central pillar of the body
Protects the spinal cord
Supports weight of the head and trunk
Transmits to hip bones and lower limbs
Flexible, Segmented

Vertebrae

Intervertebral discs
Vertebral Column
Curvatures (4)

Cervical: Posterior concavity (Lordosis)


Thoracic: Posterior convexity (Kyphosis)
Lumbar: Posterior concavity (Lordosis)
Sacral: Posterior convexity (Kyphosis)
Vertebral Column
Parts
Body
Vertebral arch
Pedicles
Laminae
7 processes
Spinous (1)
Transverse (2)
Articular (4)
Vertebral Column

Spinous process

Directed posteriorly

Junction of two laminae

Transverse process

Directed laterally

Junction of laminae and pedicles


Function

levers

attachment for muscles, ligaments


Vertebral Column

Articular Process

Vertically arranged

Two superior

Two inferior

Pedicles are notched on upper and lower borders

Superior vertebral notch

Inferior vertebral notch


Forming Intervertebral foramen

Transmit spinal nerves

And blood vessels


Cervical Vertebra

Characteristics

Vertebral foramen

Large

Triangular

Superior articular processes

Small

Flat

Face backward, & upward

Inferior articular processes

Face downward & forward


Cervical Vertebra

Characteristics

Foramen transversarium

Transverse process

Passage of the vertebral artery and


veins

Spines

Small

Bifid
Atypical Cervical Vertebrae
First cervical vertebra (Atlas)
No body, No spinous process
Anterior arch
Posterior arch
Lateral mass (each side)
Articular surfaces
Upper aspect (Occipital condyles of skull)
Lower aspect (Axis)
Atypical Cervical Vertebrae
Second cervical vertebra (Axis)
Odontoid process
peg-like
Projects upward from superior surface of body
Represents body of atlas that has fused with the axis
Atypical Cervical Vertebra

Seventh cervical vertebra


Longest spinous process
NOT bifid
Large transverse process
Small foramen transversarium
DOES NOT transmit vertebral artery
Cervical Vertebral Fracture
Jeffersons fracture disruption of the ring of atlas w/ displacement
of
lateral masses
Hangmans fracture fracture of the odontoid and pedicles of axis
Thoracic Vertebra
Characteristics
Body
Medium sized, heart-shaped
Vertebral Foramen
Small, circular
Spines
Long, inclined downward

Characteristics

Costal facets

Present on sides, and on transverse


process

T11, T12 ~ no facets on transverse


process

Superior articular process

Facets face backward, laterally

Inferior articular process

Facets face forward, medially


Lumbar Vertebrae

Characteristics

Body

Massive, kidney shaped

Pedicles

Strong

Laminae

Thick

Vertebral foramina

Triangular

Transverse processes

Long, slender
Lumbar Vertebrae

Characteristics

Spinous processes

Short, flat, quadrangular, project


backward

Superior articular processes

Facets face medially

Inferior articular processes

Factes face laterally


No rib facets, no foramina in the transverse processes
Sacral Vertebrae
Sacrum
Five rudimentary vertebrae fused together
Single wedge shaped bone
Sacral Vertebrae
Characteristics
Sacral promontory
Anterior upper margin of 1st sacral vertebrae
Bulges forward into pelvic cavity
Important obstetric landmark
Sacral Vertebrae
Characteristics
Sacral canal
Formed from sacral foramina
Contains:
Part of cauda equina
Meninges (up to lower border S2)
Lower sacral nerve roots
Coccygeal nerve roots
Filum terminale
Sacral Vertebrae
Characteristics
Sacral Hiatus

Failure of the 5th and sometimes 4th sacral vertebra to meet in the
midline
Anterior & Posterior sacral foramina
Passage of anterior and posterior rami of the upper four spinal nerves
Sacral Vertebrae
Articulations
Upper border (base)
5th lumbar vertebrae
Narrow inferior end
Coccyx
Laterally
Two hip bones
Sacroiliac joints
Coccygeal Vertebrae
Coccyx
Four (4) fused together*
Single
Small
Triangular
* first coccygeal vertebra commonly not fused with 2nd
Atlanto-occipital Joints
between
Occipital condyles
Lateral masses of the atlas
Ligaments

Anterior Atlanto-occipital membrane

Posterior Atlanto-occipital membrane


Movements ( YES Joint )

Flexion

Extension

Lateral flexion
NO rotation
Atlantoaxial Joints
between
Odontoid process and anterior arch of atlas (1)
Lateral masses of bones (2)
Movement ( No Joint )

Rotation if atlas w/ head on axis


Ligaments
Apical from dens to anterior margin foramen
magnum
Alar lateral to apical ligament
Cruciate dens to atlas and foramen magnum
Membrana tectoria upward extension of posterior
longitudinal ligament
Joints Between Two Vertebral Bodies
Covered by thin plate of hyaline cartilage
Intervertebral disc of fibrocartilage in between
Ligaments
Anterior longitudinal ligaments
Posterior longitudinal ligaments
Continuous bands down the anterior and posterior surface of the
vertebral column
from the skull to the sacrum
Intervertebral Discs
Characteristics
1/4th of length of vertebral column
Thicker in cervical and lumbar regions
Annulus fibrosus forms periphery of the disc
Fibrocartilage
Collagen fibers arranged in alternating concentric layers
Intervertebral Discs

Characteristics

Nucleus pulposus forms central part of disc

Ovoid mass of gelatinous material

Normally under pressure

With advancing age,

decrease in water content

Replaced by fibrocartilage

No discs

between first two cervical vertebrae

In sacrum

In coccyx
Intervertebral Discs

Herniation of the nucleus pulposus

Frequently occurs in the

Lower lumbar region (Most


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

Joints Between
Synovial joints

Between adjacent superior and inferior articular


processes

Ligaments
Supraspinous ligament

Connect adjacent spines

Interspinous ligament

Connect adjacent spines

Ligamentum flavum

Connect adjacent laminae


Ligamentum Nuchae

Cervical region

Thickening of supraspinous and


infraspinous ligaments
Movements of Vertebral Column

Type and range in regions depend on

Thickness of intervertebral discs

Shape and direction of the articular processes


Cervical region: most movable
Muscles of the Back
Groupings
Superficial
Connected with shoulder girdle
Intermediate
Involved with movements of the thoracic cage
Deep or Postvertebral
Vertebral column
Postvertebral Muscles
Classification
Superficially running muscles
Erector spinae
Iliocostalis
Longissimus
Spinalis
Postvertebral Muscles
Classification
Intermediate oblique running muscles
Transversospinalis
Semispinalis
Rotatores
Multifidus
Postvertebral Muscles
Classification
Deepest Muscles
Interspinales
Intertransversari
Postvertebral Muscles
Muscles of longest length lie superficially

From sacrum to rib angles, transverse processes,


upper vertebral spines
Intermediate length run obliquely

From transverse processes to the spines


Shortest and deepest muscles

From spines and transverse processes of adjacent


vertebrae
Muscular Triangles
Auscultatory triangle
Site on back where breath sounds most easily hear via stethoscope
Boundaries
Latissimus dorsi
Trapezius
Medial border of Scapula
Rhomboid major (floor)
Muscular Triangles
Lumbar Triangle
Site where pus may emerge from the abdominal wall

Boundaries
Latissiumus dorsi
Posterior border of the external oblique
Iliac crest
Spinal Cord
Cylindrical in shape
From Medulla Oblongata (of brain)
Begins superiorly at
Foramen magnum
End inferiorly at
Lower border 1st lumbar vertebrae (Adults)
Occupies upper 2/3rds of the vertebral canal
Spinal Cord
Surrounded by three (3) meninges
Dura mater
Arachnoid mater
Pia mater
Additonal protection by
Cerebrospinal fluid
Subarachnoid space
Spinal Cord

Enlargements

Cervical

Origin of brachial plexus

Lumbar

Origin of lumbar plexus

Lower end

Conus medularis

Filum terminale

pia mater prolongation

From conus medullaris to back of coccyx


Spinal Cord
Fissures
Anterior median fissure
Midline on the anterior surface of the cord
Posterior median fissure
Midline on the posterior surface of the cord
Spinal Cord

Roots (31 pairs)

Anterior

Motor

Posterior

Sensory

w/ posterior root ganglion

Roots in regions

Upper cervical region

Short, run almost horizontally

Lumbar, Sacral below level of termination of cord

Vertical leash of nerves around filum


terminale

Cauda equina
Spinal Cord
Roots
Pass though intervertebral foramina
Unite to form spinal nerves which divides into
Anterior ramus (large)
Posterior ramus (smaller)
Both contain motor and sensory fibers
Blood Supply of Spinal Cord
Arteries
Posterior spinal arteries
Arise directly or indirectly from the vertebral arteries
Supply posterior 1/3rd of spinal cord
Blood Supply of Spinal Cord
Arteries
Anterior spinal arteries
Arise from vertebral arteries
Unite to form a single artery
Supply anterior 2/3rds of spinal cord
Posterior spinal arteries
Arise directly or indirectly from the vertebral arteries
Supply posterior 1/3rd of spinal cord
Radicular arteries
Branches of regional arteries
Reinforce anterior and posterior spinal arteries

Veins
Drain into internal vertebral venous plexus
Meninges of Spinal Cord

Dura Mater

External membrane,

Dense fibrous tissue

Encloses spinal cord and cauda equina

Above, continuous with dura covering brain

Below, dura ends on filum terminale

at level of lower border of the 2nd


sacral vertebra

Gives sheaths to all spinal nerve roots


Meninges of the Spinal Cord
Arachnoid Mater
Delicate, impermeable membrane
Lies within the dura, outside the pia
Separated from pia mater by subarachnoid space (filled with
cerebrospinal fluid)
Meninges of the Spinal Cord

Arachnoid Mater

Above, continuous with arachnoid covering the


brain

Below, end on the filum terminale

At the level of lower border of the 2nd


sacral vertebra

Continues along spinal nerve roots forming small


lateral extensions of subsrachnoid space
Meninges of the Spinal Cord

Pia Mater

Vascular membrane

Closely covers spinal cord

Thickened on either side between nerve roots


(ligamentum denticulatum)

Extends along each nerve root as far as the spinal


nerve

Inferiorly prolonged off the lower end of the spinal


cord as the filum terminale
Lumbar puncture
(Spinal Tap)
Patient on the side with vertebral column well flexed
Above or Below 4th lumbar spine
Lies within imaginary line between highest points on iliac crests
Lumbar puncture
(Spinal Tap)

Needle passes through the following structures to


subarachnoid space

Skin

Fascia

Supraspinous ligament

Interspinous ligament

Ligamentum flavum

Fatty tissue (internal vertebral venous plexus)

Dura mater

Arachnoid mater
THE END
Thorax
Loubomir E. Antonio,M.D.
Bones of the Thoracic Wall
Sternum
Manubrium
Body of the Sternum
Xiphoid Process
Ribs
Typical Rib
Atypical Rib
Cervical Rib
Costal Cartilages
BONE MARROW BIOPSY
STERNUM
Site of red hematopoiesis throughout life
STERNAL ANGLE OF LOUIS

Articulation of manubrium with the body


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

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

Lies a finger breath lateral to sternum


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

Right principal (main) bronchus


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

Has own
segmental bronchus,
segmental artery,
lymph vessels,
autonomic nerves
Segmental vein NOT included
in connective tissue between adjacent segments
Diseased segment can be removed surgically
Blood Supply of the Lungs
Pulmonary arteries
Deoxygenated blood to alveoli
Bronchial arteries
- oxygenated blood
Pericardium
Middle mediastinum
Fibroserous sac enclosing
Heart
Roots of great vessels
Parts
Fibrous pericardium
Serous pericardium
Pericardial sinuses
Nerve supply
Phrenic nerves
Pericardial Lesions
Pericarditis
inflammation of the serous pericardium
Hammans sign ( pericardial friction rub )
Pericardial tamponade
accumulation of fluid or blood in the pericardial space
Becks triad ( hypotension, neck vein distention, distant heart
sounds )
Pericardiocentesis
Needle is introduced to the left of the xiphoid process in an upward
and backward direction in an angle 45 degrees to the skin
Prevents damage to the pleura and lungs due to the presence of
cardiac notch
Heart

Hollow muscular organ

Middle mediastinum

Pyramidal

Three (3) surfaces

Sternocostal (anterior)

Diaphragmatic (inferior)

Base (posterior)

Apex

Directed downward, forward, to the left

5th left intercostal space

Approx 3.5in (9cm) from midline


Heart
Structure
Divided by vertical septa into four (4) chambers
Right atria (anterior)
Left atria (posterior)
Right ventricle (anterior)
Left ventricle (posterior)
Walls w/ three (3) layers
Epicardium: outer visceral layer of serous pericardium
Myocardium: thick layer of cardiac muscle
Endocardium: thin inner layer
Right Atrium
Consists of
Cavity and
Auricle
Junction is external vertical groove (sulcus terminalis), which
On the inside forms a ridge (crista terminalis)
junction between sinus venosus and right atrium proper
Part posterior to ridge ~ smooth walled
Interior of auricle ~ roughened by bundles of muscle fibers (musculi
pectinati)
Right atrium
Openings
Superior vena cava
Upper part of the right atrium
Valveless
Inferior vena cava
Larger

Lower part of right atrium


Rudimentary valve
Coronary sinus
Between inferior vena cava and atrioventricular orifice
Rudimentary valve
Right atrioventricular orifice
Anterior to inferior vena cava
Tricuspid valve
Right atrium
Fetal remnants
Fossa ovalis
Shallow depression
Site of foramen ovale (fetus)
Annulus ovalis
Upper margin of fossa ovalis
lie on atrial septum, separating right from left atrium
Right ventricle, papillary muscles

Trabeculae carneae

Papillary muscles

Attached by bases to ventricular wall

Apex to fibrous cords (chordae


tendineae) to cusps of tricuspid valve

Moderate band

Large ridge attached to

Septal wall

Atrioventricular wall

Conveys part of right bundle branch


of conducting system

Simple prominent projections


Left atrium
Main cavity and
Auricle
Interior contains muscular ridges (similar to right)
Openings
Pulmonary veins (4)
2 from each lung
Posterior wall
Valveless
Atrioventricular orifice
Mitral valve
Left ventricle
Largely behind right ventricle, w/ small portion projecting on the left
forms left heart margin and apex
Openings
Atrioventricular orifice
Aortic Orifice
Aortic vestible, below
Walls
3x thicker than right ventricle
Trabecular carneae
2 papillary muscles
NO moderator band
Heart sounds

First sound

Contraction of ventricles

Closure of tricuspid and mitral valves

Second sound

Sharp closure of aortic and pulmonary valves

Best heard

Tricuspid valve ~ right half of lower end of body


of sternum

Mitral valve ~ apex beat

Pulmonary valve ~ medial end of 2nd left


intercostal space

Aortic valve ~ medial end of 2nd right intercostal


space
Conducting system
Modified Cardiac Muscle
Blood Supply
Sinoatrial node (pacemaker)
both
Atrioventricular node
RCA
Atrioventricular bundle
RCA
Right branch
LCA
Left branch
both
Blood supply of the heart
Arterial supply
Right coronary artery
Left coronary artery

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

Ascending aorta
Arch of the aorta
Descending aorta
Pulmonary trunk
Aorta

Divided into four parts


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

Turns laterally behind carotid sheath


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

Opposite 6th cervical vertebrae


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

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

lower six (6) thoracic

Lower 5 intercostal nerves

Subcostal nerves

First lumbar nerves

Iliohypogastirc

Ilioinguinal nerves

Midline

Flanks

Skin
Blood Supply
Arteries

Superior epigastric artery


Inferior epigastric artery
Intercostal
Lumbar
Deep circumflex iliac arteries

Skin
Blood Supply
Veins

Above

Below

Axillary vein
via Lateral thoracic vein
Femoral vein

Via

Superficial epigastric vein


Great saphenous veins

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

Strengthens medial half of posterior wall of inguinal canal


Inguinal Ligament
Pouparts ligament
Lower border of External oblique aponeurosis
Connects Anterior Superior Iliac Spine (ASIS) to pubic tubercle
Medial end: lacunar ligament (Gimbernats ligament)
Continuous with pectineal ligament (Coopers ligament)
~ thickening of periosteum
Lower border,
Attached to fascia lata
Fascia Transveralis
Thin layer of fascia lining transveralis muscle
Continuous with fascia iliaca (of ilacus muscle)
Together forms femoral sheath
Femoral sheath = FT + FI
Inguinal Canal
Length Approx 1.5in (4cm)
Parallel and above inguinal ligament
Deep inguinal ring
Oval opening in Transveralis fascia
Above inguinal ligament
Margins attachment for internal spermatic fascia
Superficial inguinal ring
Triangular shaped defect on External oblique aponeurosis
Above and medial to pubic tubercle
Margins give attachment to external spermatic fascia
Inguinal Canal
Walls
Anterior

External oblique aponeurosis

Internal oblique
Posterior

Conjoint tendon, medially

Fascia transveralis, laterally


Superior

Arching fibers of the internal oblique and transversus


Inferior

Inguinal and lacunar ligaments


Inguinal Canal
Function
Allows structures to pass
from Testes to Abdomen: Spermatic cord
Uterus to labium majus: Round ligament of uterus
Both sexes transmit Ilioinguinal nerve
Hesselbachs Triangle
Medially:
Rectus abdominis
Inferiorly:
Inguinal ligament
Laterally:
Inferior epigastric vessels
Inguinal Hernia
Site of potential weakness in both sexes
Above inguinal ligament
- lateral to inferior epigastric vessels
Indirect Inguinal Hernia
- medial to inferior epigastric vessels
Direct Inguinal Hernia
Below inguinal ligament
Femoral hernia
Spermatic Cord Contents
MNEMONIC: Protruding Piles Dont Contribute To A Good Sex Life
Pampiniform plexus
Processus vaginalis remnants
Deferens, vas
Cremasteric artery
Testicular artery
Artery to vas
Genital branch, genitofemoral nerve
Sympathetics
Lymphatics
Processus vaginalis
Peritoneal diverticulum formed in fetus
Passes through lower part of anterior abdominal wall to form inguinal
canal
Spermatic cord

Coverings
External spermatic fascia
From external oblique
Attached to margins of superficial inguinal ring
Cremasteric fascia
From internal oblique
Internal spermatic fascia
From fascia transversalis
Attached to margins of deep inguinal ring
Gubernaculum testis
Musculoligamentous cord
Connects fetal testis w/ floor of scrotum
Important role in descent of testis
Homolog: Round ligament of ovary and uterus
Scrotum
Outpouching of lower part of anterior abdominal wall
Contains:
Testes
Epididymis
Lower ends of spermatic cord
Scrotum
Layers
1.
Skin
2.
Superifical fascia Dartos muscle
3.
External spermatic fascia
4.
Cremasteric fascia
5.
Internal spermatic fascia
6.
Tunica vaginalis
NOTE: Transversus abdominis has NO contribution to the formation of
scrotal wall
Testes
Paired ovoid organs
Produce
Spermatozoa
Testosterone
Tunica albuginea
Outer fibrous capsule of testis
Epididymis
Lies posterior to testis
Coiled tube approx 20ft (6m) long
Parts
Head
Body
Tail
Vas deferens emerges from tail
Epididymis
Blood Supply
Testicular artery

From abdominal aorta


Testicular vein

From testis and epididymis (pampiniform plexus)

Reduced to single vein though inguinal canal


RIGHT:

IVC
LEFT:

Left Renal Vein


Peritoneum

Serous membrane

Lubricates surfaces ~ free movement


Parietal layer

Lines walls
Visceral layer

Covers organs
Peritoneal cavity

Potential space in between

Males: Closed

Females: Communicates through uterus, vagina


Peritoneum
Greater sac

Main compartment

From diaphragm to pelvis


Lesser Sac

Smaller

Lies behind stomach


Epiploic foramen

Allows free communication between both


Peritoneal Derivatives

2 layered folds
Ligaments
Omentum
Mesentery
Lesser Sac
Behind stomach and lesser omentum
Left margin
Spleen
Gastrosplenic omentum
Splenicorenal ligament
Right margin
Greater sac (main part of peritoneal cavity)
Through epiploic foramen
Epiploic Foramen
Boundaries
Anterior

Free border of lesser omentum


Bile duct: Anterior
Hepatic artery: Posterior to the L
Portal vein: Posterior to the R
Posterior

Inferior vena cava


Superior

Caudate lobe of the liver


Inferior

First part of the duodenum


Peritoneal Spaces
Subphrenic spaces
Between diaphragm and liver
Right anterior
Left anterior
Posterior subphrenic space
* Clinically: provide sites for the accumulation of pus
Peritoneal Gutters
Paracolic gutters
Lie on lateral and medial sides of ascending and descending colons
Provide channels for movement of infected fluid in the peritoneal cavity
Nerve Supply of the Peritoneum
Parietal peritoneum
Lower 6 thoracic, first lumbar nerves
Pain, temperature, touch, pressure
Visceral peritoneum
Autonomic nerves on mesenteries
Stretch
Stomach
Parts
Fundus

dome-shaped
Body

from cardiac orifice to incisura angularis


Pyloric Antrum

incisura angularis to pylorus


Pylorus

Most tubuluar part of stomach

Thick muscular wall (pyloric sphincter)

Cavity (pyloric canal)


Stomach
Parts
Lesser curvature

Right border of stomach

Connected to liver by lesser omentum


Greater curvature

Longer

From left cardiac orifice along left border of stomach

Gastrosplenic omentum/ ligament extends from upper


part to spleen

Greater omentum extends from lower part to transverse


colon
Stomach
Parts
Cardiac orifice
NO anatomic sphincter
Physiologic sphincter
Pyloric orifice
Anatomic and physiologic pyloric sphincter formed
Stomach, Blood Supply
Arteries

Lesser curvature

Right gastric

Left gastric
Greater curvature

Right gastroepiploic

Left gastroepiploic
Fundus

Short gastric arteries splenic artery


Stomach, Blood Supply
Veins
Drain into Portal Circulation
Right gastric vein
Left gastric vein
Splenic vein
Short gastric vein
Left gastroepiploic vein
Superior mesenteric vein
Right gastroepiploic
Duodenum
C-shaped tube
Approx 10in (25cm)
Curves around head of pancreas
Begins at pyloric sphincter
Ends by becoming the jejunum
2nd 3rd and 4th portion: retroperitoneal
Duodenum
First part

Transpyloric plane

Level of L1!
Second part

Main pancreatic ducts pierce medial wall unite to form


ampulla (of Vater) opening into major duodenal papilla
(of Wirsung)

Accessory pancreatic duct, opens to Minor duodenal


papilla (of Santorini)
Duodenum
Third part

Horizontal in front of the vertebral column

Anteriorly crossed by

Root of mesentery of small intestine

Superior mesenteric vessels


Fourth part

Upward and left to duodenojejunal flexure

held in postion by Ligament of Treitz


Jejunum & Ileum
Jejunum

approx 8ft (2.5m)

Upper left

Wider

Thicker

Redder in color
Meckels Diverticulum
Congenital anomaly
Persistent portion of the vitellointestinal duct
antimesenteric border of ileum
Rule of 2s
2 ft from iliocecal junction
2 in. in length
2% of individuals
Bleeding may occur from adjacent ileal mucosa
NOT the diverticulum
Cecum
Blind-ended pouch within right iliac fossa
Completely covered w/ peritoneum
Joined on left side by terminal ilieum
at junction of cecum and ascending colon
Appendix at posteromedial surface
Ileocecal Valve
Two horizontal folds of mucous membrane
Around orifice of ileum
Ileocecal sphincter
Sphincter that controls flow of contents from ileum into colon
Appendix
Narrow muscular tube
Large amount of lymphoid tissue in its wall
Approx 1in (2.5cm)
Complete peritoneal covering

Own Mesoappendix w/

Appendicular vesels and nerves


Taniae coli of cecum converge to form its continuous muscular coat
Ascending colon
Approx. 5in (13cm) long
Cecum to inferior surface of right lobe of liver (Right colic flexure)
Continuous with transverse colon
Peritoneum covers front and sides
Transverse Colon

Approx 15in (38cm) long

Umbilical, and hypogastric regions


Left colic flexure

higher than the right

Held up by Phrenocolic ligament


Transverse mesocolon

Attached to superior border of transverse colon

Suspends it from pancreas


*posterior layers of greater omentum, attached to inferior border
Transverse mesocolon
Arteries
Proximal 2/3rds

Middle colic artery superior mesenteric artery


Distal 1/3rd

Left colic artery inferior mesenteric artery


Veins

Superior mesenteric vein

Inferior mesenteric vein


Transverse Colon
Lymph drainage
Proximal 2/3rds
Colic nodes superior mesenteric nodes
Distal 1/3rd
Inferior mesenteric node
Transverse Colon
Nerve supply
Proximal 2/3rds

Superior mesenteric plexus

Sympathetic

Vagal
Distal 1/3rd

Inferior mesenteric plexus

pelvic splanchnic nerves

Sympathetic

Parasympathetic
Descending Colon
Approx 10in (25cm) long
From left colic flexure to pelvic brim
Peritoneum covers front and sides
Sigmoid Colon
Approx 10-15in (25-38cm) long
From descending colon in front of pelvic brim
To rectum in front of 3rd sacral vertebra
Attached to posterior pelvic wall by fan-shaped sigmoid mesocolon
Liver
Largest organ of body
Divided by falciform ligament into
Small left lobe
Large right lobe
Right lobe further divided by
gall bladder, fissure of ligamentum teres, IVC, fissure of
ligamentum venosum into
Quadrate lobe
Caudate lobe
Liver
Porta Hepatis (hilus)

Posteroinfeior surface of liver

Upper part lesser omentum attached to margins


Contains

Right and left hepatic ducts

Right and left branches of hepatic artery

Portal vein

Nerves

Lymph vessels
Liver
Fissure for the ligamentum teres
Between left lobe and quadrate lobe
Ligamentum teres = fibrous remains of umbilical vein

Fissure for the ligamentum venosum


Between left lobe and caudate lobe
Ligamentum venosum = Fibrous remains of the ductus venosus
Liver
Groove for the inferior vena cava
Between right lobe and caudate lobe
Hepatic veins join inferior vena cava
Fossa for the Gallbladder
Between right lobe and quadrate lobe
NO peritoneum between the gallbladder and right lobe of liver
Peritoneal Ligaments
Falciform ligament
Attaches liver
to diaphragm above
To anterior abdominal wall below
Sickle-shaped free margin
contains ligamentum teres
Peritoneal Ligaments
Coronary ligament
Attaches liver to diaphragm
Layers widely separated forming bare area of liver devoid of
covering
Right triangular ligament
V-shaped fold
right extremity of the coronary ligament
Connects posterior surface of the right lobe of liver to diaphragm
Left triangular ligament
reflection from upper surface of the left lobe of the liver to the
diaphragm
Lesser Omentum
Attached above to the margins of the
porta hepatis
Fissure for the ligamentum venosum
Attached below to lesser curvature of stomach
Gallbladder
Pear-shaped sac
Lies in undersurface of liver
Approx 30ml
Parts

Fundus

Body

Neck

Continuous w/ cystic duct


Bile Ducts
Hepatic Duct
Right and left hepatic ducts (from each lobe bile canaliculi via
porta hepatis) form common hepatic duct
Joined by cytic duct common bile duct
Cystic duct
S-shaped
Connects neck of gallbladder w/ Common hepatic duct
Forming Common bile duct
Spiral valve of Heister
Common Bile Duct
Union of cytic duct with common hepatic duct
Joins main pancreatic duct ampulla of vater major duodenal
papilla (of Wirsung)
Spinchter of Oddi
Circular smooth muscle
Surrounds both ducts and ampulla
Pancreas
Parts
Head
Disc shaped within concavity of C-shaped duodenum
Uncinate process
Projection to left from lower part to head behind superior mesenteric
arteries
Neck
Narrow
Connects head to body
In front of beginning of portal vein
Pancreatic duct
Main pancreatic duct (Wirsung)

Opens to second part of duodenum

With bile duct

Via ampulla of vater


Accessory duct (Santorini)

Often absent

Drains upper half of head

Open into duodenum on the minor duodenal papilla


Spleen
Largest single mass of lymphoid tissue
Lies beneath diaphragm, 9th, 10th, 11th rib
Ovoid w/ notched anterior border
Surrounded by peritoneum
Gastrosplenic ligament

From hilus to stomach

Contains short gastric, left gastroepiploic vessels


Splenicorenal ligament

To left kidney

Contains splenic vessels, tail of pancreas


Blood Supply
Celiac artery (foregut)

Lower third of esophagus to

Middle second of duodenum


Superior mesenteric artery (midgut)

Middle second part of duodenum to

Distal third of transverse colon


Inferior mesenteric (hindgut)

Distal third of transverse colon to

Half way down anal canal


Celiac artery (Trunk)
From front of abdominal aorta, through diaphragm
Terminal Branches
Left gastric
Splenic
Hepatic
Left gastric artery
Runs to cardiac end of stomach
Gives off a few esophageal branches
Turns right along lesser curvature
Anastomoses with right gastric artery
Splenic artery
Largest branch of celiac trunk
Runs
along upper border of pancreas
Behind stomach
Enters splenicorenal ligament to hilum of spleen
Splenic artery, branches
1. Pancreatic branches
2. Left gastroepiploic artery

From Near hilum of spleen

To greater curvature of stomach

Within gastrosplenic omentum, Greater omentum

Anastomoses with right gastroepiploic


Splenic artery, branches
3. Short gastric arteries

5-6 in no.

To fundus of stomach

Run within gastrosplenic omentum

Anastomose with left gastric artery

Left gastroepiploic artery


Hepatic artery
Ascends within lesser omentum
In front of opening of lesser sac
Left of the bile duct
Front of portal vein
At porta hepatis Divides into
right hepatic artery
left hepatic artery
Hepatic Artery, branches
Right gastric artery
To left in lesser omentum, along lesser curvature
Anastomoses with left gastric artery
Gastroduodenal artery
Descends behind first part of duodenum
Divides into
Right gastroepiploic artery greater curvature
Superior pancreaticoduodenal artery 2nd part duodenum, head
of pancreas
Right hepatic artery
Gives off cystic artery
Left hepatic artery
Superior Mesenteric Artery

Relations
From front of abdominal aorta
Behind neck of pancreas
Front of 3rd part of duodenum
Downward to right in root of mesentery of small intestine
Superior Mesenteric Artery, Branches
Inferior pancreaticoduodenal artery
Upper border of the 3rd part of duodenum below the head of pancreas
Middle colic artery
In transverse mesocolon transverse colon
Right branch anastomoses with right colic
Left branch anastomoses with left colic
Superior Mesenteric Artery, Branches
Right colic artery

Branch of ileocolic

Supplies ascending colon


Ileocolic artery

Give off
Superior branch anatomoses with right colic
Inferior branch anastomoses with end of superior mesenteric artery

Gives rise to

Anterior cecal artery

Posterior cecal artery Appendicular artery


Superior Mesenteric Artery
Jejunal and Ileal branches
12-15 in number
Arise from left side of superior mesenteric artery
Arteries divide and unite to form arcades
Small, straight branches supply intestine
Inferior Mesenteric Artery
Arises from abdominal aorta
Approx 1.5in (3.8cm) above aortic bifurcation
Artery runs downard and to the left
Crosses left common iliac artery
Becomes superior iliac artery
Inferior Mesenteric Artery, Branches
Left colic artery

Divides into ascending and descending branches

Supply

distal 3rd of transverse colon

Left colic flexure

Upper part of descending colon


Sigmoid arteries

2-3 in number

Supplies descending sigmoid colon


Inferior Mesenteric Artery, Branches
Superior rectal artery

Continuation of inferior mesenteric artery

Descends into pelvis behind rectum

Supplies

Rectum

Upper half of anal canal

Anastomoses with

Middle Rectal Artery Intenal Iliac Artery)


and

Inferior Rectal Artery ( Internal Pudendal)


Marginal artery
Anastomosis of colonic arteries
Along concave margin of large intestine
Begins at ileocolic junction
End at junction of sigmoid colon and rectum
Portal venous system
Portal vein
Approx. 2in (5cm) long
Union of

Superior mesenteric vein

Splenic veins
Ascends to porta hepatis

Behind first part of duodenum

In free margin of lesser omentum

Divides to right and left terminal branches


Portal venous system
Portal vein
Drains blood form Gastrointestinal tract

Lower end of esophagus

To halfway down anal canal

As well as from

Pancreas

Gallbladder

Bile ducts

Spleen
Portal Venous System Tributaries
1. Splenic vein
Receives

Short gastric

Left gastroepiploic

Inferior mesenteric

Pancreatic
2. Inferior mesenteric vein
Receives

Superior rectal

Sigmoid

Left colic
Portal Venous System Tributaries
3. Superior mesenteric vein
Receives

Jejunal

Ileal

Ileocolic

Right colic

Middle colic

Inferior pancreaticoduodenal

Right gastroepiploic
4. Left gastric vein
Drains left portion of lesser curvature
Distal part of esophagus
5. Right gastric vein
Drains right portion of lesser curvature
6. Cystic vein
Drains gallbladder
Portal-Systemic Anastomosis
IMPORTANT!
1. Distal 3rd, Esophageal branches of left gastric vein (Portal)
Middle 3rd, esophageal branches of azygous veins (Systemic)
Esophageal varices
2. Superior rectal veins (Portal)
Middle and Inferior rectal veins (Systemic)
Hemorrhoids
Portal-Systemic Anastomosis
IMPORTANT!
3. Paraumbilical veins (in falciform ligament w/ ligamentum
teres) from left branch of portal vein (portal)

Superficial veins of anterior abdominal wall (Systemic)


Caput medusae
4. Veins of ascending and descending colon, duodenum, pancreas liver
(portal)
renal, lumbar, phrnenic veins (systemic)
Kidneys

Paired organs

Retroperitoneal
Right kidney lower than left due to liver!
Hilus

Concave border of kidney

Extends to cavity of renal sinus


Transmits

Renal vein

Renal artery

Ureter

Sympathetic nerve fibers


V.A.U.A.
Kidneys
Coverings: from within to without
Fibrous capsule

True capsule/renal capsule

Closely applied to outer surface


Perirenal fat

Fat covering fibrous capsule


Renal Fascia

Gerotas fascia

Encloses kidney and suprarenal glands


Pararenal fat

External to renal fascia

Kidneys, Structure
Outer cortex

Extends into medulla between adjacent pyramids (Renal


columns)
Inner medulla

12 renal pyramids (base toward cortex; apex - renal papilla


oriented medially)

Medullary rays
Striations from bases of pyramids to cortex
Kidneys, Structure
Renal Pelvis
Upper expanded end of ureter
Divided into Two major calyces
Subsequently divided into 2-3 minor calyces
Each minor calyx indented by apex of renal pyramid (renal papilla)
Kidneys, Blood Supply
Artery

Renal artery
Vein

Renal vein
Lymph drainage

Lateral aortic lymph nodes

Around renal artery origin


Nerve supply

Renal sympathetic plexus


Ureters
Muscular tubes extend from kidneys to posterior surface of urinary
bladder
Approx 10in (25cm) long
Renal pelvis
Lies within renal hilus
Upper expanded end of ureter
receives major calyces
Ureteric Constrictions
1.
Junction of pelvis and ureter
2.
Crossing of pelvic brim
3.
Piercing of bladder wall
Ureter
Arteries
Upper end:

Renal artery
Middle:

Testicular/ ovarian artery


Inferior end:

Superior vesicular artery


Veins
Veins correspond to arteries
Suprarenal (Adrenal) Glands
Located to upper poles of kidneys
Retroperitoneal
Surrounded by renal fascia
Separated from kidneys by perirenal fat
Has
Cortex (yellow colored)
Medulla (brown colored)
Suprarenal (Adrenal) Glands
Arteries
Inferior phrenic artery
Aorta
Renal arteries
Veins
Right suprarenal vein inferior vena cava
Left suprarenal vein left renal vein
Aorta
Abdominal aorta
Enters through aortic opening in diaphragm (T12)
Divides into common iliac (L4)
Aorta
Branches
1. Three (3) anterior visceral

Celiac artery

Superior mesenteric

Inferior mesenteric
2. Three (3) lateral visceral

Suprarenal artery

Renal artery

Testicular of ovarian artery

Aorta
Branches
3. Five (5) lateral abdominal

Inferior phrenic artery (1)

Four lumbar arteries (4)


4. Three (3) terminal

Two common iliac arteries (2)

Median sacral artery (1)


Common Iliac Arteries
Terminal branches of abdominal aorta
Run downward and laterally
Divide into external and internal iliac arteries
Crossed anteriorly by ureter on each side
Inferior vena cava
Formed by union of common iliac veins (L5)
Pierces central tendon of diaphragm at (T8)
To right atrium
Inferior vena cava, tributaries
Tributaries
1 Two (2) anterior visceral

Hepatic veins
2. Three (3)lateral visceral

Right suprarenal vein*

Renal veins

Right testicular/ovarian vein*


* Left drains to left renal
Inferior vena cava, tributaries
Tributaries
3. Five (5) lateral abdominal wall tributaries
Inferior phrenic vein (1)
Four lumbar veins (4)
4. Three (3) veins of origin
Two common iliac veins (2)
Median sacral vein (1)
Lymphatics on posterior abdominal wall
Cysterna Chyli (thoracic duct)
Elongated sac in abdomen
Lies on right side of aorta (L1-L2)
Receives
Intestinal trunk
Right and Left lumbar trunks
Lymph vessels from lower part of thorax
Lumbar Plexus Branches( L1L2L3L4 )
MNEMONIC: I 2x Get Laid On Friday
Ilioinguinal (L1)
Iliolumbar (L1)
Genital branch, genitofemoral nerve (L1L2)
Lateral cutaneous nerve of the thigh (L2L3)
Obturator (L2L3L4)
Femoral (L2L3L4)
All arise lateral to psoas EXCEPT:
Genital branch, genitofemoral nerve ( anterior )
Obturator nerve ( medial )
Sympathetic trunk
Enters abdomen behind medial arcuate ligament
Runs downward along medial border of psoas muscle
On bodies of lumbar vertebrae
Enter pelvis behind common iliac vessels
Possess 4-5 segmentally arranged ganglia
Muscles of Posterior Abdominal Wall
Psoas
Quadratus lumborum
Iliacus
Nerve supply: Lumbar plexus EXCEPT: Iliacus ( femoral nerve )
THE END

Pelvis and Perineum

Loubomir E. Antonio, M.D.

Bony Pelvis
Four (4) bones

Two (2) hips bones

Sacrum

Coccyx
Pelvic brim composed of:

Sacral promontory (posteriorly)

Iliopectineal lines (laterally)


Symphysis pubis (anteriorly)
Divides pelvis into:

False pelvis (greater pelvis) - ABOVE

True pelvis (lesser pelvis) - BELOW

True Pelvis
Pelvic Inlet

Sacral promontory (posteriorly)

Iliopectineal lines (laterally)

Symphysis pubis (anteriorly)


Outlet

Coccyx (posteriorly)

Ischial tuberosities (laterally)

Pubic arch (anteriorly)


Cavity

Between inlet and outlet

Short curved canal

Shallow anterior wall

Deeper posterior wall

True pelvis
Ligaments

Sacrotuberous ligament

Sacrospinous ligament
Divide sciatic notches to
Greater sciatic foramen
Lesser sciatic foramen

Sacroiliac joint

Strong synovial joint


Between

Sacrum

Iliac bones
Supported by

Posterior sacroiliac ligament

Interosseous sacroiliac ligament

Anterior sacroiliac ligament (thin)


*Transmit weight of body from vertebral column to bony pelvis
Nerve Supply

Sacral plexus

Symphysis pubis
Cartilagenous joint
Between two pubic bones

Articular surface covered by hyaline cartilage

Connected by fibrocartilagenous disc

Joint surrounded by ligaments

No movement permitted

Sacrococcygeal joint
Cartilagenous joint
Between sacrum and coccyx
Cornua of sacrum and coccyx joined by ligaments
Great deal of movement possible
Ligaments relaxed during pregnancy

Sex differences of pelvis

Walls of the pelvis


Anterior wall

Bodies of pubic bone

Pubic rami

Symphysis pubis

Sacrotuberous ligament

Strong
From

Lateral part of Sacrum and Coccyx and

Posteroinferior Iliac spine


To

Ischial tuberosity
*prevent lower end of sacrum from being rotated by the body

Sacrospinous ligament
Strong
Triangluar shaped
Base: lateral part of sacrum and coccyx
Apex: spine of ischium
*Prevent lower end of sacrum from being rotated by the body

Inferior pelvic wall (Pelvic Floor)

Support pelvic viscera


Formed by pelvic diaphragm

Levator ani muscle

Small coccygeal muscles

Pelvic fasciae

Incomplete anteriorly

Allows passage of urethra (and vagina)

PELVIC FRACTURE

Muscles of the Pelvic Walls and Floor

Piriformis

Obturator internus

Levator ani

Puborectalis

Pubococcygeus

Iliococcygeus

Coccygeus

Pelvic Fasciae
Parietal pelvic fascia

Line pelvic walls

Continuous with fascia lining abdominal walls

Pelvic Fasciae
Visceral pelvic fascia

Covers all pelvic viscera

Parametrium fascia around cervix

Pelvic peritoneum

Lines pelvic walls

Reflected onto pelvic viscera

Continuous with visceral peritoneum

Nerves of the Pelvis

Sacral Plexus

Branches of lumbar plexus

Autonomic nerves

Sacral plexus
On posterior pelvic wall
In front of piriformis
Formed by anterior rami of L4-L5, S1-S4 nerves
Lumbosacral trunk (Lumbar plexus)

Combination of L4 and L5

Passes into pelvis

Joins sacral nerves

Sacral Plexus Branches


MNEMONIC: NO Priests Sleeps Soundly Inside Nuns Quarters
Nerve to Obturator internus
Posterior cutaneous nerve of the thigh
Sciatic nerve
Superior gluteal nerve
Inferior gluteal nerve
Nerve to Quadratus femoris
Branches that leave the pelvis through Greater sciatic foramen

Sacral Plexus Branches


Branches to the pelvic muscles, viscera and peritoneum
Pudendal nerve
Nerve to piriformis muscle
Pelvic splanchnic nerves ( S2S3S4 )

Lumbar Plexus
MNEMONIC: I 2x Get Laid On Friday
Ilioinguinal
Iliolumbar
Genital branch, genitofemoral nerve
Lateral cutaneous nerve of the thigh
Obturator
Femoral

Autonomic nerves
Pelvic part of sympathetic trunk
Continuous with lumbar part
Two trunks come together in from of coccyx
Sympathetic trunk has 4-5 segmental ganglia
Branches

Gray rami communicantes

Sacral nerves

Coccygeal nerves

Fibers to hypogastric plexuses

Autonomic nerves
Pelvic splanchnic nerves

Parasympathetic part of autonomic nervous system

From S2,3,4

Preganglionic fibers ganglia of hypogastric plexuses

Autonomic Nerves
Superior Hypogastric Plexus
In front of promontory
Divides to


Right hypogastric nerve

Left hypogastric nerve


Continuation of

Aortic plexus and

Branches of 3rd, 4th lumbar sympathetic ganglia

Contains

Sympathetic

Sacral parasympathetic

Visceral afferent

Autonomic Nerves
Inferior Hypogastric Plexus
From

hypogastric nerve (of superior hypogastric plexus)

Pelvic splanchnic nerve


Contains

Postganglionic sympathetic

Pre-and-post ganglionic parasympathetic

Visceral afferent
Supply

Large bowel from left colic flexure to upper half of anal


canal

Arteries of Pelvis
False Pelvis

Common Iliac artery

External Iliac artery


True Pelvis

Internal Iliac artery

Anterior division

Posterior division

Superior Rectal artery

Ovarian artery

Median sacral artery

Common Iliac Artery


Ends at pelvic inlet in front of the sacroiliac joint
Divides into

External iliac

Internal iliac

External Iliac
Medial border of psoas
Follows pelvic brim
Branches

Inferior epigastric

Deep circumflex iliac


Leaves false pelvis as femoral artery

Internal Iliac
Leaves pelvis thorugh greater sciatic foramen
Divides into

Anterior division

Posterior division
Supply

Pelvic viscera

Perineum

Pelvic walls

Buttocks

Internal Iliac Artery Branches


MNEMONIC: I Milked Our Insatiable Interns Udders Under the Desk
Inferior gluteal
Middle rectal
Obturator
Inferior vesical
Internal pudendal
Umbilical
Superior vesical
Uterine
Vaginal
the
Deferential

Posterior Division of Internal Iliac


Iliolumbar artery
Lateral sacral arteries
Superior gluteal arteries

Superior Rectal Artery


Direct continuation of inferior mesenteric artery
Supplies

mucous membrane of rectum

Upper half of anal canal

Ovarian Artery
From abdominal aorta (L1 level)

Passes downward behind the peritoneum


Enters suspensory ligament of ovary
Passes into broad ligament
Enters ovary through mesovarium

Median Sacral Artery

Bifurcation of the aorta (L4L5 )

Descends over anterior surface of the sacrum and coccyx

Veins of the Pelvis


False Pelvis

External Iliac vein


True Pelvis

Internal Iliac vein

Superior rectal vein

Ovarian vein

Median Sacral vein

External Iliac Vein

Begins behind inguinal ligament

Continuation of femoral vein

Runs medially to artery

Joins internal iliac vein common iliac vein

Receives

Inferior epigastric

Deep circumflex iliac

Internal Iliac Vein

Union of tributaries corresponding to branches of internal


iliac artery

ascends in front of sacroiliac joint

Joins external iliac common iliac vein

Superior Rectal Vein


Drains

Rectal mucous membrane

Mucous membrane of upper half of anal canal


Important! portal-systemic anastomosis
as it unites with inferior mesenteric vein

Ovarian Vein
Right ovarian vein
drains into inferior vena cava

Median Sacral Vein

Small
Drains into

Inferior vena cava or

Left common iliac vein

Sigmoid Colon

10-15in (25-38cm) long

From pelvic brim to S3

Attached to posterior pelvic wall by sigmoid mesocolon

Rectum
Approx. 5in (13cm) long
From S3 to tip of coccyx
Pierces pelvic floor anal canal
Peritoneum only covers upper 2/3rds

Rectum
Rectal ampulla

Dilated lower portion


Transverse folds ( Houstons valves)

Three (3) semicircular folds


superior - L
middle - R
inferior - L

Rectum
Arteries

Superior rectal artery inferior mesenteric artery

Middle rectal artery internal iliac artery

Inferior rectal artery internal pudendal artery

Rectum
Veins

Superior rectal vein portal system

Middle rectal vein systemic system

Inferior rectal vein systemic system

Rectum
Lymph drainage

Pararectal nodes

inferior mesenteric nodes

internal iliac nodes

Rectum
Nerve Supply

Inferior hypogastric plexuses

Sympathetic

Parasympathetic

Ureters
Muscular tube from kidney to posterior surface of bladder
Enter pelvis crossing bifurcation of common iliac arteries

Runs down lateral wall of pelvis


Enters lateral angle of bladder

In males, crossed by vas deferens

In females, turns forward medially beneath broad


ligament

crossed by uterine artery

Ureteric Constrictions
Three (3) constrictions
1.
Where renal pelvis joins ureter
2.
Where it is kinked as it crosses the pelvic brim
3.
Where it pierces the bladder wall

Urinary Bladder
Max capacity approx 500ml
Pyramidal
Apex:

connected to umbilical ligament (remains of urachus)


Base:

faces posteriorly

triangular
Neck:

points inferiorly
Supralateral angles:

entry of ureters
Inferior angle:

exit of urethra
Superior surface:

covered w/ peritoneum

Urinary Bladder, Interior


Trigone

Internal surface
Smooth mucous membrane adheres to underlying muscle
Ureteral Openings
Small slit like opening at lateral angles
Interureteric ridge runs in between

forms upper limit of trigone

Urinary Bladder, Interior


Opening of urethra below
In males, median lobe of prostate bulges slightly upward
Uvula vesicae

Swelling behind urethral orifice

Urinary Bladder, muscular coat


Detrusor muscle

Three (3) interlacing layers of smooth muscle fibers


Sphincter vesicae

Circular muscle at neck of bladder

Urinary bladder, ligaments


Ligaments from pelvic fascia
Hold bladder neck in place
Puboprostatic ligament

males
Pubovesical ligament

females

Urinary Bladder
Arteries
Internal Iliac artery

Superior vesical artery

Inferior vesical artery


Veins
Internal Iliac vein

Urinary Bladder
Lymph drainage

Internal Iliac nodes

External Iliac nodes


Nerve Supply
Inferior Hypogastric plexus

Sympathetic

Parasympathetic

Vas Deferens

Thick-walled tube

Approx 18in (45cm) long

From lower end/tail of epididymis

Through inguinal canal

Crosses ureter to reach posterior bladder

Expands forming ampulla

Joins seminal vesicle

ejaculatory duct

Ejaculatory duct

Two (2)
From union of

Vas deferens

Duct of seminal vesicle

Open into protastic urethra

Seminal Vesicles
Much coiled tube embedded in connective tissue
Located on

Posterior surface of bladder

Lateral part of vas deferens


Contribute

Fluid

Fructose

Ascorbic acid

Amino acids

Prostaglandins

Prostate
Glandular
Surrounds prostatic urethra

Below neck of bladder

Above urogenital diaphragm


Fibrous capsule

And fibrous sheath = visceral layer of pelvic fascia


Base:

lies superiorly against bladder neck


Apex:

lies inferiorly against urogenital diaphragm

Prostate

Ejaculatory ducts open into prostatic urethra at lateral


margins of Prostatic utricle
Lobes

Anterior

Middle/median

Behind urethra, above ejaculatory ducts

Right lateral

Left lateral

Prostate
Arteries

Inferior vesical

Middle rectal

Prostate
Lymph drainage

Internal Iliac nodes


Nerve Supply

Inferior hypogastric plexus

Ovaries
Found in Ovarian fossa

Depression near lateral wall of pelvis

Bounded by external and internal iliac arteries


Mesovarium

Attaches ovary to back of broad ligament


Hilum

Entry of ovarian vessels and nerves

Ovaries
Germinal epithelium

Modified area of peritoneum covering ovary

Thin fibrous capsule (Tunica albugina) beneath


Outer Cortex

Contains ovarian follicles


Inner Medulla

Ligaments of Ovaries
Suspensory Ligament

Lateral part of broad ligament

Connects mesovarium to lateral pelvic wall

Contains

Blood

Lymphatic vessels

Nerves
Round Ligament


Remains of upper part of gubernaculum

(Round ligament of uterus ~ lower part)

Medial margin of ovary to lateral wall of uterus

Ovaries
Arteries

Ovarian artery abdominal aorta

Veins
Ovarian vein
(right) inferior vena cava
(left) left renal vein

Uterine tubes
Upper border of broad ligament
Connects peritoneal cavity in region of ovary with cavity of uterus
Provides

Conduit for spermatozoa to reach ovum

Site for fertilization of the ovum (usually the ampulla)

Nourishment for fertilized ovum

Transports ovum to cavity of uterus

Uterine Tubes
Four (4) parts
1. Infundibulum

Funnel-shaped

w/ fimbrae draped over ovary


2. Ampulla

Widest part
3. Isthmus

Narrowest portion of tube

Just lateral to uterus


4. Intramural

Pierces uterine wall

Uterine tubes
Arteries

Uterine and ovarian arteries


Veins

Uterine and ovarian veins


Lymph drainage

Internal iliac

Para-aortic nodes
Nerve supply

Superior hypogastric plexus

Inferior hypogastric plexus


Sympathetic, Parasympathetic

Uterus
Fundus

Above entrance of uterine tubes


Body

Beneath entrance of uterine tubes


Cervix

Pierces anterior wall of vagina

Internal os

Uterine opening

External os

Vaginal opening

Uterus
Positions
Anteversion

Forward bending of uterus on long axis of vagina


Anteflexion

Forward bending of uterus along long axis of body of uterus


on cervix

Uterine Support
Pelvic diaphragm
- Most Important
Perineal body
Transverse cervical ( cardinal ) ligaments
Pubocervical ligament
Sacrocervical ligament

Broad ligaments
Two-layered folds of peritoneum
Lateral margins of uterus Lateral pelvic walls
Contains

Uterine tube (in upper free border)

Round ligaments of ovary and of the uterus

Uterine and ovarian

Blood vessels

Lymph vessels

Nerves
* Little support for the uterus

Round ligament of uterus


Superolateral angle of uterus

inguinal canal

subcutaneous tissue of labium majus


Assists in uterine

Anteversion

Anteflexion

Uterus
Arteries

Uterine artery internal iliac

Ovarian artery
Veins

Uterine vein

Ovarian vein

Uterus
Lymph drainage
Fundus
Ovarian artery

Para-aortic nodes (level L1)


Body and Cervix

Internal and external iliac nodes


Nerve Supply

Inferior hypogastric plexus


Sympathetic, Parasympathetic

Vagina
Female genital canal

Excretory duct for menstrual flow

Birth canal
Muscular tube between vulva and uterus
Cervix pierces anterior wall
Hymen

Mucosal fold found in virgins

Perforated at center

Vagina
Area surrounding cervix
Four fornices

Anterior

Posterior

Right lateral

Left lateral
Relations
Upper half:
between

pelvis (anteriorly) and

rectum (posteriorly)
Lower half:
within peritoneum

Urethra (anteriorly)

Anal canal (posteriorly)

Vagina, Support
Upper third

Levatores ani muscles

Transcervical ligament

Pubocervical ligament

Sacrocervical ligament
Middle third

Urogenital diaphragm
Lower third

Perineal body

Vagina
Arteries

Vaginal artery internal iliac artery

Vaginal branch of uterine artery


Veins

Internal iliac veins

Vagina
Lymph drainage
Upper 3rd
internal & external iliac nodes
Middle 3rd
internal iliac nodes
Lower 3rd
superificial inguinal nodes
Nerve Supply


Inferior hypogastric plexus

Visceral pelvic fascia


Covers supports pelvic viscera
Condensed to form

Pubocervical ligament

Transverse cervical ligament

Sacrocervical ligament
Parametrium

Pelvic fascia in region of uterine cervix

Peritoneum in the Female Pelvis


Passes over

Urinary bladder

Uterus

Vagina

Front of rectum
Rectouterine pouch (of douglas)

Peritoneal pouch between vagina and rectum

Most inferior part of peritoneal cavity

Perineum
Below pelvic diaphragm
Diamond-shaped
Boundaries
Anteriorly:

symphysis pubis
Posteriorly:

ischial tuberosities
Divided into two by:

imaginary line between tuberosities


Anterior triangle ~ urogenital triangle
Posterior triangle ~ anal triangle

Urogenital Triangle
Urogenital diaphragm
Musculofascial diaphragm
Fills gap between pubic arch
Formed by

Sphincter urethrae

Deep transverse perineal muscles


(between superior and inferior fascial layers)
Inferior perineal fascia = perineal membrane

Urogenital Triangle
Perineal body
Small mass of fibrous tissue

Attached to center of the posterior margin of the urogenital


diaphragm
Larger in females

Provides support to posterior vaginal wall

Provides attachment to muscles in the perineum

Perineal Pouches

Superficial perineal pouch

Deep perineal pouch

Superificial Perineal Pouch


Closed posteriorly and laterally
Anteriorly:
Space communicates freely with potential space between

superficial fascia of anterior abdominal wall (Scarpas


fascia) and

anterior abdominal muscles

SUPERFICIAL PERINEAL POUCH (contents)


B I G S S
Bulbospongiosus
Ischiocavernosus
Great vestibular glands (Bartholins)
Superficial transverse perinei
Scrotal nerves

DEEP PERINEAL POUCH (contents)


Dorsal nerve of penis (men)
Sphicter urethrae
Bulbourethral glands (Cowpers) (men)
Membranous part of urethra
Pudendal vessels and nerves
Deep transverse perinei
Dont Stop Banging My Perineum Dear

Male External Genitalia


Interior
Three (3) cylinders of erectile tissue

Within tubular sheath of fascia


Corpora cavernosa

Two (2)

Dorsal
Corpus spongiosum

One (1)

Ventral

Forms Glans Penis

Contains penile part of urethra

Male External Genitalia


Root of penis
In superificial perineal pouch
3 masses of erectile tissue

Bulb Corpus spongiosum

Midline

Traversed by urethra

Covered by bulbospongiosus muscle

Right and Left crura corpora cavernosa

Attached to side of pubic arch

Covered by Ischiocarvernosus muscle

Male external genitalia


Arteries

Deep arteries of penis

Branches of dorsal artery


Veins

Deep dorsal vein

Lymph Drainage
Glans

Deep inguinal

External iliac
Skin

Supeficial inguinal nodes


Erectile tissue

Internal iliac
Nerve Supply

Pudendal nerve

Bulbourethral
(Cowpers Glands)

Two (2) small glands

Deep perineal pouch

Fibers of sphincter urethrae muscle

Open into penile urethra

Prostatic Urethra
Widest, Most dilatable
Urethral crest

Longitudinal ridge on posterior wall


Prostatic sinus

on sides of crest

Opening of prostatic glands


Prostatic utricle

Analogue of uterus and vagina

Edge of mouth: (2) ejaculatory ducts

Membranous Urethra

Through urogenital diaphragm

Surrounded by sphincter urethrae

Shortest, Least dilatable

Penile Urethra
External meatus

Narrowest part of entire urethra


Fossa terminalis (navicular fossa)

Urethra within bulb of penis

Bulbourethral glands

Open to penile urethra below urogential diaphragm

Female External Genitalia (Vulva)

Mons pubis

Labia majora

Labila minora

Clitoris

Greater vestibular glands

Vestibule of the Vagina

Space between labia minora


Apex

Clitoris
Floor

Openings of the urethra

Vagina


Ducts of greater vestibule glands

Greater Vestibular Glands


Two (2)

Mucus- secreting glands


Duct of each gland groove between hymen and posterior part of
labium minus

Female Urethra
From bladder neck external meatus

1.5in (3.8cm) long


Through

Urogenital diaphragm

Sphincter urethrae
Opens into surface below clitoris
In front of vagina

Muscles of Urogenital Triangle

Superficial transverse perineal muscle

Bulbospongiosus

Ischiocavernosus

Deep transverse perineal muscle

Sphincter urethrae
All suplied by perineal branch of pudendal nerve

Anal Canal

1.5in (4cm) long

Below pelvic diaphragm

Rectal ampulla anus


Anal Columns

Vertical folds on mucous membrane

On Upper half of anal canal (Lower half is smooth)


Anal Valves

Small semilunar folds

Connect anal columns together

Anal Canal
Muscle coat

Outer longitudinal layers

Inner circular layer of smooth muscle


Involuntary Internal sphincter

Thickening of circular layer at upper end


Voluntary External sphincter

Surround internal sphincter with collar of striped muscle


Parts

Subcutaneous

Superficial

Deep

Anal Canal
Puborectalis

Sling formed from fibers of levator ani muscle

Attached anteriorly to pubic bone

Around junction of rectum and anal canal

Pulls forward to make angle more acute


Anorectal ring
Distinct ring at anorectal junction, from:

Internal sphincter

Deep part of external sphincter

Puborectalis

Anal Canal
Arteries
Upper half

Superior rectal artery


Lower half

Inferior rectal artery


Veins
Upper half

Superior rectal vein inferior mesenteric vein


Lower half

Inferior rectal vein internal pudendal vein

Anal Canal
Lymph drainage
Upper half

Pararectal nodes inferior mesenteric nodes


Lower half

Medial group of superficial inguinal nodes

Anal Canal
Nerve Supply
Upper half
(and internal anal sphincter)

sensitive to stretch

hypogastric plexus
Lower half
(and external anal sphincter)

Pain
Temperature
Touch
Pressure

inferior rectal nerves

Ischiorectal Fossa
Wedge- shaped space on each side of anal canal
Base:

Superficial; skin
Edge:

junction of medial and lateral walls


Medial Wall:

levator ani muscle

Anal canal
Lateral wall:

Lower part of obturator internus muscle and pelvic fascia

Ischiorectal Fossa
Fat-filled,
Allows distention during defecation
Pudendal canal

Fascial canal

Medial side of ischial tuberosity

Passage

Pudendal nerve

Internal pudendal vessels

Muscles of Anal Triangle


External Anal sphincter

Subcutaneous part

Superficial part

Deep part
Nerve Supply: perineal branch of S4
Puborectalis muscle
Nerve Supply: Perineal branch of S4
Perineal branch of pudendal nerve
Upper Extremity
Loubomir E. Antonio, M.D.
Bones of the Shoulder Girdle
Clavicle
Scapula
Fractures
Clavicular fracture
Most commonly fractured bone in the body
Fall on the shoulder or outstretched hand
Junction of m/3rd and distal 3rd
Distal fragment goes downward, medial and forward by pectoralis
major
Medial end pulled upward by SCM
Fractures
Scapular fracture
Result of severe trauma
Run-over accident victims, vehicular crashes
Require little treatment
Bone of the Arm
Humerus
Head
Anatomical neck
Greater tuberosity
Lesser tuberosity
Bicipital groove (biceps tendon)
Surgical neck
Deltoid tuberosity
Bone of the Arm

Humerus

Spiral groove (radial nerve and deep artery of arm)

Medial epicondyle

Lateral epicondyle

Capitulum (head of radius)

Trochlea (trochlear notch of ulna)

Radial fossa

Coronoid fossa (coronoid process of ulna)

Olecranon fossa
Fractures

Humeral head
Greater tuberosity pulled by S,I,T
Lesser tuberosity pulled by S
Surgical neck - most common site
Humeral shaft
proximal to deltoid insertion
proximal fragment adducted by
PM,LD,TM
distal fragment pulled by D,BB,TB
distal to deltoid insertion
proximal fragment abducted by D
distal fragment pulled by BB, TB
- radial nerve at risk
Volkmanns Ischemic Contracture
Contracture of muscles of the forearm following fractures of the distal
end of the humerus
- brachial artery spasm leading to ischemic
necrosis
Bones of the Forearm

Radius
Lateral bone of forearm (scaphoid and lunate)

Head (circular)

Neck

Bicipetal tuberosity (biceps brachii)

Shaft

Interosseous border

Interosseous membrane

Styloid process

Ulnar notch

Dorsal tubercle
Bones of the Forearm
Ulna
Medial bone of forearm
Olecranon
Trochlear notch
Coronoid process
Shaft
Interosseous border
Head
Styloid process
Fractures of the Forearm
Colles fracture
fracture of the distal end of the radius with the distal fragment
displaced dorsally dinner fork deformity
Smiths fracture
fracture of the distal end of the radius with the distal fragment
displaced volarly
Galeazzis fracture
fracture of the proximal end of the radius with dislocation of DRUJ
Monteggias fracture
fracture in the shaft of ulna with anterior dislocation of the radial head
and rupture of annular ligament
Bones of the Wrist
Carpal bones
Scared Lovers Try Positions That They Cannot Handle
1.
Scaphoid (navicular)
2.
Lunate
3.
Triquetral
4.
Pisiform
5.
Trapezium
6.
Trapezoid
7.
Capitate
8.
Hamate
Bones of the Hand

Metacarpal Bones

Base

Shaft

Head

Phalanges

3 for each Digit

Proximal

Middle

Distal

Except Thumb (2)

Proximal

Distal
Shoulder Joint

Shoulder joint
(Glenohumeral joint)

Glenoid cavity

Shallow

Glenoid labrum (fibrocartilagenous)

Synovial Ball-and-socket joint

Capsule

Glenoid labrum

Anatomical neck

Strengthened by tendons of Rotator cuff


muscles
Shoulder Joint

Ligaments

Glenohumeral

3 bands that strengthen anterior part of


capsule

Superior band and Inferior band


primary ligamentous support

Middle strongest stabilizing ligament

Transverse humeral Ligament

Gap between grater and lesser


tuberosities

Holds tendon of the biceps muscle in


place
Shoulder Joint

Ligaments

Coracohumeral Ligament

Extends from the root of the coracoid


process to the greater tuberosity of the
humerus

Strengthens capsule above

Accessory Ligament

Coracoacromial ligament

Protects superior aspect of joint


Shoulder Lesions
Shoulder Dislocation
- most commonly dislocated large joint
- Anterior more common than posterior
- impingement of axillary nerve
Shoulder Separation
- acromioclavicular dislocation due to tearing of the
coracoclavicular ligament
- cases of severe blow to the point of the shoulder
Shoulder movements
3-2-1 ASS rule
Every 3 degree abduction of arm = 2 degree abductiion of shoulder
joint
1 degree by rotation of scapula
At 120degree abduction
Greater tuberosity of humerus hits lateral edge of acromion
Elbow Joint
Elbow joint
Trochlea and capitulum of humerus
Trochlear notch and head of the radius
Synovial hinge joint
Enclosed by capsule
Elbow Joint
Movements
Flexion
Extension
Carrying Angle
When extended
170 degrees in males
167 degrees in females
Disappears on flexion
Elbow Joint
Important Relations
Anteriorly
Median Nerve
Brachial Artery
Medially
Ulnar nerve as it passes behind the medial epicondyle of humerus!
Superior Radioulnar Joint
Superior Radiounlar joint
Head of radius and annular ligament
Radial notch of ulna
Synovial pivot joint (trochoid)

Synovial membrane
Lines capsule
Continuous with that of elbow joint
Superior Radioulnar Joint
Movements
Pronation
Supination
More powerful than pronation
Inferior Radioulnar Joint
Inferior Radioulnar Joint
Head of ulna
Ulnar notch of radius
Synovial pivot joint
Capsule
Encloses joint
Strengthened by anterior and posterior ligaments
Inferior Radioulnar Joint
Movements
Pronation
Supination
Wrist Joint

Wrist joint (Radiocarpal joint)

Distal end of radius (triangular cartilaginous


articular disc)

Scaphoid, Lunate, Triquetral

Synovial condyloid Joint

Biaxial

Ball and socket but w/ no rotation


Wrist Joint

Nerve Supply

Anterior interosseous nerve (from Median nerve)

Deep branches of Radial and Ulnar nerves

Movements

Flexion

Extension

Abduction

Adduction

NO Rotation (done by radioulnar joint pronationsupination)


Wrist Joint
Important Relations
Anterior
Median nerve
Ulnar nerve
Laterally
Radial artery
Carpometacarpal Joints
Carpometacarpal Joints
Carpal bones
Metacarpal bones
Synovial gliding joints
Ligaments
Anterior
Posterior
Interosseous
Carpometacarpal Joint of Thumb

Thumb carpometacarpal joint

Trapezium

Saddle shaped base of first metacarpal bone

Synovial saddle joint (biaxial)

Movement

Flexion

Extension

Abduction

Adduction

Rotation (Opposition)
Metacarpophalangeal Joints
Metacarpophalangeal joints
Convex heads of metacarpals
Concave bases of proximal phalanges
Synovial condyloid joint
Interphalangeal Joint

Interphalangeal joint

Proximal

Middle

Distal
Synovial hinge joints
Similar structure as metacarpophalangeal joint
Movements

Flexion

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

Superior: Subscapularis
Inferior: Teres major
Lateral: Surgical neck of humerus
Medial: Long head of triceps
Transmits Axillary nerve and Posterior humeral circumflex artery
Triangular Spaces
Upper Triangular Space
- Superior: Teres minor
- Inferior: Teres major
- Lateral: Long head triceps
Transmits circumflex scapular vessels
Lower Triangular Space
- Superior: Teres major
- Medial: Longhead triceps
- Lateral: Medial head triceps
Transmits Radial nerve and Profunda brachii
Muscles of the Upper arm

Anterior Fascial compartment

Biceps brachii

Coracobrachialis

Brachialis

Posterior Fascial compartment

Triceps
Cubital fossa

Skin depression

Triangular shaped

In front of elbow

Boundaries:

Laterally: Brachioradialis

Medially: Pronator teres

Base: imaginary line between epicondyles of


humerus
Contents: from medial to lateral
Median nerve
Brachial artery
Tendon of biceps brachii
Radial nerve
Anterior Fascial Compartement of Forearm
1.
Pronator teres
2.
Flexor carpi radialis
3.
Palmaris longus
4.
Flexor carpi ulnaris
5.
Flexor digitorum superficialis
6.
Flexor pollicis longus
7.
Flexor digitorum profundus
8.
Pronator quadratus
Forearm anterior compartment
Innervated by Median nerve EXCEPT:
Flexor carpi ulnaris
Flexor digitorum profundus (medial half/ ulnar half)
- ULNAR NERVE
Lateral fascial compartment of forearm
1.
Brachioradialis
2.
Extensor carpi radialis longus
Both supplied by radial nerve
Posterior Fascial Compartment of the Forearm
1.
Extensor carpi radialis brevis
2.
Extensor digitorum
3.
Extensor digiti minimi
4.
Extensor carpi ulnaris
5.
Anconeus
6.
Supinator
7.
Abductor pollicis longus
8.
Extensor pollicis brevis
9.
Extensor pollicis longus
10. Extensor indicis
All supplied by the Radial nerve
Radial Nerve
Abductor pollicis longus
Brachioradialis
Anconeus
Triceps
Extensors
Supinator
ANATOMICAL SNUFFBOX
Boundaries

Anterior/Lateral
Posterior/Medial EPOL

APOL + EPB

Carpal Tunnel
Contains
Medial nerve
Flexor digitorum superficialis tendons (4)
Flexor digitorum profundus tendons (4)
Flexor pollicis longus tendon
Small muscles of hand
Lumbricals (4)
Flexes MCP, Extends IPJ ( Z )
Interossei (8)
Palmar (4)
Dorsal (4)
ACTION: PAD DAB
Palmar Adducts
Dorsal - Abducts
Palmaris brevis
Improves grip
Nerve Supply
Intrinsic Muscles of the Hand
All Ulnar nerve EXCEPT: Lateral two Lumbricals
Thenar Hypothenar Muscles
MNEMONIC: One For All And - All For One
Thenar Muscles
Hypothenar Muscles
- Opponens pollicis
- Abductor digiti minimi
- Flexor pollicis brevis
- Flexor digiti minimi
- Abductor pollicis brevis
- Opponens digiti minimi
- Adductor pollicis
Median nerve EXCEPT:
All Ulnar nerve
Adductor pollicis
( Ulnar nerve )
Thumb Muscles Innervation
Snuffbox group
All Radial nerve
APOL + EPB + EPOL
Thenar Muscles
All Median EXCEPT
Adductor pollicis ( ulnar )
Opponens pollicis
Flexor pollicis brevis
Abductor pollicis brevis
Adductor pollicis
Flexor pollicis longus
Median nerve
Axillary artery

Continuation of subclavian artery

Begins at lateral border of first rib, until

Lower border of teres major muscle (brachial artery)

Related to the cords of the brachial plexus

Enclosed with them in the axillary sheath


Axillary artery
Divided into 3 parts by the pectoralis minor
MNEMONIC: Screw The Lawyer Save A Patient
1st part
- Supreme or Highest Thoracic Artery
2nd part
- Thoracoacromial Artery
- Lateral Thoracic Artery
3rd part
- Subscapular Artery
- Anterior Humeral Circumflex Artery
- Posterior Humeral Circumflex Artery
Shoulder Joint Arterial Anastomosis

1st part of subclavian artery

Superficial cervical artery

Thyrocervical trunk
Anastomose with

3rd part of axillary artery

Subscapular artery

Anterior circumflex

Posterior circumflex
Brachial artery

Begins at lower border of teres major (from axillary


artery)

Descends through anterior compartment of arm on


brachialis muscle

Enters cubital fossa

Ends at level of neck of radius, divides into

Radial artery

Ulnar artery
Brachial artery

Branches

Muscular branches

Nutrient artery (to humerus)

Profunda brachii artery

Large branch

Follows radial nerve in spiral groove

Posterior compartment of arm

Superior ulnar collateral artery

Follows ulnar nerve

Inferior ulnar collateral artery

Part of anastomosis around elbow joint

Subscapular or Posterior
External mammary or Anterior
Axillary vein or Lateral

Radial artery
Smaller than ulnar artery
Begins at cubital fossa, neck of radius
Radial pulse!
Laterally: tendon of brachioradialis
Medially: tendon of flexor carpi radialis
Radial artery

Wrist ~ winds around lateral side of the carpus to the


proximal space bertween 1st and 2nd metacarpal bones

Passes anteriorly into palm between two heads of first dorsal


interosseous muscle

Joins deep branch of the ulnar artery


deep palmar arch
Ulnar artery

Larger than radial artery

Begins at cubital fossa, neck of radius

Descends through

Anterior compartment

Enters palm in front of flexor retinaculum

With ulnar nerve

Ends by forming superficial palmar arch superficial


palmar branch of radial artery
Veins of upper limb
Superficial veins
Dorsal venous network
Cephalic vein
Basilic vein
Median cubital vein
Median vein of the forearm
Deep veins
Venae comitantes
Axillary vein
Vein Catheterization
Basilic vein
Vein of choice for central vein catheterization
Increases in diameter as it ascends the arm and is in direct line with
the axillary vein
Axillary vein

Formed by union of venae comitantes of brachial artery w/


basilic vein

Ascends along medial border to first rib

Receives tributaries corresponding to branches of the axillary


artery

Also receives cephalic vein


Axillary lymph nodes

Drain lymph from

Upper limb

Lateral part of breast

Superficial lymph vessels from throacoabdominal


wall above level of umbilicus

20-30 lymph nodes


Axillary Lymphnode Levels
Level I

Level II
Central
Interpectoral Rotters nodes
Level III
Infra or subclavicular
Supratrochlear (Cubital) lymph nodes
In superficial fascia of cubital fossa
Close to trochlea
Lymph from medial fingers, medial hand, forearm
Ascend to the lateral axillary lymph nodes
Upper limb lymphatic drainage summary
Brachial plexus
RoTonDa CuBao
Roots (5)
Trunks (3)
Divisions
(3 anterior, 3 posterior)
Cords (3)
Branches
(5 terminal branches)
Brachial Plexus

Roots

Enter base of the neck between

Scalenius anterior

Scalenius medius

Trunks and divisions

Cross posterior triangle of neck

Cords

Arranged around axillary artery in the axilla

Enclosed in axillary sheath with axillary artery and


vein
Roots (5)
5 roots (anterior rami of C5,C6,C7,C8,T1)
Branches
Dorsal Scapular (C5)
Rhomboid minor
Rhomboid major
Levator scapulae
Long thoracic (C5-C6-C7)
Serratus anterior
Trunks (3)
Superior
Supscapular nerve (C5-C6)
Supraspinatus
Infraspinatus
Nerve to Subclavius (C5-C6)
Subclavius
Middle
Inferior
Cords (3)
Medial cord
Medial pectoral nerve
Pectoralis major +
minor
Medial cutaneous nerve of the arm
Medial cutaneous nerve of the forearm
Lateral cord
Musculocutaneous nerve
Anterior arm
compartment muscles
Lateral pectoral nerve
Pectoralis
major
Posterior cord
Subscapular nerve
Upper
Subscapularis
Lower
Subscapularis + Teres major
Thoracodoral nerve
Latissimus
dorsi
Axillary nerve
Deltoid and
Teres minor
Radial nerve
ABATES
Branches
From lateral to medial

MNEMONIC: My Aunt Raped My Uncle


Musculocutaneous nerve
Axillary nerve
Radial nerve
Median nerve
Ulnar nerve
Brachial plexus injuries

Upper trunk lesions

Erb-Duchenne Palsy

Displacement of head to the opposite side and


depression of the shoulder on same side

Falls on shoulder

Infants during difficult delivery

waiters tip

Hangs by side

Medially rotated

Forearm pronated
Brachial plexus injuries
Lower trunk lesions
Klumpkes palsy
Traction injury
Excessive abduction of the arm
First thoracic nerve usually torn
Small muscles of hand paralyzed
Claw hand
Brachial plexus injuries
Long thoracic nerve (C5-C6-C7) lesion
Blows or surgical injury to nerve
Paralysis of serratus anterior
Winged scapula
Difficulty raising the arm above the head
Brachial plexus injuries

Axillary nerve (C5-C6) lesion

Inferior dislocation of the shoulder joint

Fracture of the surgical neck of the humerus

Quadrangular space

Deltoid paralysis and atrophy

Loss of cutaneous sensation over lower half of


deltoid
Brachial plexus injuries
Radial nerve (C5-C6-C7-C8-T1) lesion
Midshaft humeral fracture
Nerve in spiral groove
Wrist drop
Unable to extend wrist
Unable to extend fingers
Brachial plexus injuries

Median nerve (C5-C6-C7-C8-T1) Lesions

Supracondylar fractures of the humerus

Wounds proximal to flexor retinaculum

Apelike hand

Thumb rotated

Thumb adducted

Thenar eminence

Paralysis

Atrophy

Flattening
Brachial plexus injuries

Ulnar nerve (C8-T1) Lesions

Behind medial epicondyle of humerus

In front of flexor retinaculum of wrist

Hand small muscle paralyis

except for (median nerve)

thenar eminence muscles

first two lumbricals

Thumb cannot be adducted!

Metacarpophalangeal hyperextension

3rd and 4th lumbrical paralysis

Interosseous paralysis

Interphalangeal joint flexion

Claw hand
THE END

Lower Extremity

Loubomir
Hip

E. Antonio, M.D.

Ilium
Ischium
Pubis
meets at the acetabulum
Bones of the thigh
Femur
Patella
Femur

Head

Hemispheric (2/3)

Fovea capitis

Ligament of the head

Obturator artery

Neck

Greater trochanter

Lesser trochanter

Intertrochanteric line

Iliofemoral ligament

Intertrochanteric crest

Quadrate tubercle
Femur

Shaft

Linea aspera

Medial supracondylar ridge

Adductor tubercle

Lateral supracondylar ridge

Gluteal tuberosity

Popliteal surface

Condyles

Medial condyle

Lateral condyle

Intercondylar notch

Medial epicondyle

Lateral epicondyle
Avascular Necrosis of the Femoral Head
Common in ADULTS with femoral neck fractures
The small branch of the obturator artery within the ligamentum teres
femoris is insufficient to supply the femoral head
Uncommon in a child due to free anastomoses between medial femoral
circumflex artery and the obturator artery
Coxa valga vs.Coxa vara
Normal angle between femoral neck and shaft
Adults: 125 degrees
Children: 160 degrees
Coxa valga: INCREASED
Congenital dislocation of the hip
Adduction is limited
Coxa vara: Decreased
Femoral neck fractures and
Slipped capital femoral epiphyses
Abduction is limited
Femoral Neck Fracture
Patella

Largest sesamoid bone (develops within a tendon)

Tendon of the quadriceps femoris

Triangular shaped

Ligamentum patellae

connects to tibial tuberosity

Posterior surface

Articulates with condyles of femur


Tibia

Large, weight bearing, medial bone of leg

Lateral condyle

Oval articular facet for head of fibula

Medial condyle

Lateral meniscus

Medial meniscus

Intercondylar eminence

Tibial tuberosity

Medial malleolus
Fibula
Muscle attachment

No articulation with knee


Head
Styloid process
Articular surface
Shaft
Interosseous membrane
Lateral malleolus
Bones of the foot
Tarsal bones
Calcaneum
Talus
Navicular
Cuboid
Cuneiform bones
Metatasal bones and phalanges
Calcaneum

Largest bone of the foot

Articulations

Above: talus

Front: cuboid

Posterior surface

Prominence of the heel

Medial surface

Large shelflike ridge


Sustentaculum tali

Assists in supporting the talus


Cuboid
Articulation
Anterior end of calcaneum
Deep groove on inferior aspect
Peroneus longus tendon
Cuneiform bones
Three (3)
Small
Wedge-shaped
Maintenance of transverse arch of foot
Articulations
Proximally: navicular
Distally: first 3 metatarsals
Metatarsal bones

Five (5)

Numbered medial to lateral

Head

Shaft

Base

5th metatarsal

Tubercle

Peroneus brevis tendon attachment


Hip joint
Articulation
Head of femur
Acetabulum
Synovial ball-and-socket joint
Hip joint
Iliofemoral ligament of Bigelow
Strongest! Most important!
Inverted Y
Base: anteroinferior iliac spine
Limbs: upper and lower part of intertrochanteric line of femur
Resists:
Hyperextension of hip
Lateral rotation of hip
Hip joint
Nerve supply
Femoral
Obturator
Sciatic
Nerve to quadratus femoris
Movements
Flexion
Extension
Abduction
Adduction
Lateral rotation
Medial rotation
Cirumduction

Hip Joint
Important relations
Anteriorly
femoral vessels
Femoral nerve
Posteriorly
Sciatic nerve
Knee joint

Synovial hinge joint

Between femur and tibia

Synovial gliding joint

Between patella and femur


Knee Joint Capsule
Encloses the knee joint
Except anteriorly (capsule deficient)
Synovial membrane pouches upward beneath quadricepts tendon
Suprapatellar bursa
Knee joint

Extra capsular Ligaments

Ligamentum patellae

Lateral collateral ligament

Medial collateral ligament

Oblique poplititeal ligament

Intracapsular ligaments

Cruciate ligaments

Anterior cruciate ligament

Posterior cruciate ligament


Knee joint
Lateral collateral ligament
Separated from the lateral meniscus by the popliteus muscle
Knee joint

Medial Collateral Ligament

Strongly attached to medial meniscus!


Cruciate
MNEMONIC: PAMs APPLES
Posterio cruciate passes Anterior and Medial
Anterior cruciate passes Posterior and Lateral
Unhappy Triad of ODonoghue
Medial collateral
ligament
Anterior cruciate
Medial meniscus
Bursae

Suprapatellar Bursa

Largest

Always communicates with knee joint

Prepatellar Bursa

Housemaids knee/Prostitutes knee

Infrapatellar Bursa

Clergymans knee/Vicars
knee
Ankle joint

Inferior transverse tibiofibular ligament deepens


socked into which talus fits

Synovial hinge joint

Enclosed by capsule
Ankle joint ligaments

Medial (Deltoid) ligament

Stronger than lateral!

Attachments

Apex: tip of medial malleolus

Below: deep fibers to medial


surface of the body of the
talus

Superficial fibers
medial side of talus
sustentaculum tali
Plantar
calcaneonavicular
ligament
Tuberosity of
navicular bone
Ankle joint
Synovial membrane lines capsule
Nerve supply

Deep peroneal
Tibial
Movements
Dorsiflexion (toes point upward)
Plantar flexion (toes point downward)
Intertarsal joint

Talocalcaneonavicular joint

Articulation

Rounded head of the talus

Upper surface of sustentaculum tali of


calcaneum

Posterior concave surface of navicular


bone

Synovial joint

Plantar calcaneonavicular (spring) ligament

Anterior border of sustentaculum tali to

Inferior surface and tuberosity of the


navicular bone

Supports head of talus


Intertarsal joints

Subtalar, Talocalcaneonavicular,calcaneocuboid)

Inversion

Movement of foot so that sole faces


medially

Eversion

Movement of foot so that sole faces


laterally
*inversion more extensive than eversion
Gluteal Region

Bounded

Superiorly: iliac crest

Inferiorly: fold of the buttock

Gluteal muscles

Fascia

Superficial fascia

Thick

esp in women, and impregnated with


large quantities of fat.)

Deep fascia

Continous below with fascia lata of thigh

Splits to enclose gluteus maximus


muscle
Important ligaments
Stabilize the sacrum
Prevent its rotation by weight of the vertebral column

Sacrotuberous ligament

Posteroinferior iliac spine, lateral part of sacrum,


coccyx to

ischial tuberosity

Sacrospinous ligament

Lateral part of the sacrum, coccyx to

Spine of the ischium


Important foramina

Greater sciatic foramen

Piriformis muscle

Sciatic nerve

Posterior cutaneous nerve of thigh

Superior gluteal nerve

Inferior gluteal nerve

Nerve to obturator internus

Nerve to quadratus femoris

Pudendal nerve

Superior gluteal artery and vein

Infereior gluteal artery and vein

Internal pudendal artery and vein


Important foramina
Lesser sciatic foramen
Pudendal nerve
Internal pudendal vessels
Nerve to obturator internus
Tendon of obturator internus
Gluteal Muscles
MNEMONIC: Gods Greatest Gift To People iS Outstanding I Q
Gluteus maximus
Gluteus medius

Gluteus minimus
Tensor fascia latae
Piriformis
Superior gemellus
Obturator internus
Inferior gemellus
Quadratus femoris
Trendelenburgs Test
Factors that determine hip stability when standing in one leg
Gluteus medius/minimus
Head of the femur located
inside acetabulum
Intact femoral neck and
angle
Gluteal Muscles

Inferior gluteal nerve


Gluteus maximus
Extends and laterally
rotates thigh +
Extends knee joint

Superior gluteal nerve


Gluteus medius
Abducts thigh, tilts pelvis
Gluteus minimus
Tensor fascia latae
Assists G. maximus in extending
thigh

Sacral Plexus
Small lateral rotators of the thigh
Piriformis
Superior gemellus
Obturator internus
Inferior gemellus
Quadratus femoris
Thigh

Saphenous opening
Passage

Great saphenous vein

Small branches of femoral artery

Lymph vessels

Cribiform fascia (loose connective


tissue)
Femoral Triangle

Boundaries

Superiorly: inguinal ligament

Laterally: sartorious muscle

Medially: the adductor longus muscle

Contains NAVEL from lateral to medial

Femoral nerve

Femoral artery

Femoral vein

Empty space

Inguinal lymph nodes ( Rosenmullers/Cloquets


node)
Femoral nerve is outside the femoral sheath
Floor of Femoral Triangle
Ilio-psoas
Pectineus
Adductor longus
Femoral Canal
Small medial compartment of the femoral sheath occupied by
lymphatics
Approx length:
0.5inches(1.3cm) in
Potentially weak area in wall of abdomen
Femoral hernia
Femoral Ring

Upper opening of the femoral canal

Filled by extraperitoneal fat

femoral septum

Important relations

Anteriorly:

inguinal ligament ( Pouparts ligament )

Posteriorly:

pectineal ligament ( Coopers ligament )

Laterally:

femoral vein
Medially:

lacunar ligament ( Gimbernats


ligament)

Thigh Muscles
Anterior Compartment
Sartorius
Iliopsoas
Pectineus
Quadriceps femoris
Medial Compartment
Gracilis
Adductor longus
Adductor brevis
Adductor magnus
Obturator externus
Posterior Compartment
Biceps femoris
Semitendinosus
Semimembranosus
Adductor magnus
Generalities of thigh muscles
Anterior compartment
Femoral nerve EXCEPT Psoas (lumbar plexus)
Thigh flexors EXCEPT Vastus muscles (leg extensors)
Two muscles that crosses both hip joint and knee joint
Sartorius Tailors muscle
Rectus femoris
Generalities of thigh muscles
Medial compartment
Obturator nerve
Thigh adductors EXCEPT obturator externus (laterally rotates thigh
at hip joint)
Adductor magnus also receives innervation from sciatic
Generalities of thigh muscles
Posterior compartment
Sciatic nerve tibial portion EXCEPT short head biceps femoris
(common peroneal nerve)
Leg flexors EXCEPT adductor magnus (extends thigh at hip)
Knee region

Popliteal fossa

Boundaries:

Laterally

Above:
biceps femoris

Below:
Lateral head of
gastronemius
Lateral head of
plantaris

Medially

Above:
Semimembranosus
Semitendinosus

Below:
Medial head of the
gastrocnemius
Anterior Compartment of the Leg
Peroneus tertius
Extensor digitorum longus
Tibialis anterior
Extensor hallucis longus
Nerve Supply: Deep peroneal nerve
Lateral Compartment of the Leg
Peroneus longus
Peroneus brevis
Nerve Supply: Superficial peroneal nerve
Posterior Compartment of the Leg
Superficial group
Gastrocnemius
Plantaris
Soleus
Deep group
Popliteus
Flexor digitorum longus
Flexor hallucis longus

Tibialis posterior
Nerve Supply: Tibial nerve
Generalities of Leg Compartments
Anterior
Deep peroneal nerve
Dorsiflexors of the foot
Lateral
Superficial peroneal nerve
Plantar flexors
Posterior
Tibial nerve
Plantar flexors
Peroneus vs Tibialis Muscle
2nd letter rule
Peroneus muscles
Everts foot
Plantar flex
Tibialis muscles
Inverts foot
Plantar flex
Muscle on the Dorsum of the Foot

Extensor digitorum brevis

Origin

Calcaneum

Insertion

Four tendons into the proximal phalanx


of the big toe (sometimes called
extensor hallucis brevis)

Long extensor tendons into 2nd,3rd, 4th


toes

Action

Extends 1st, 2nd,3rd, 4th toes

Innervation

Deep peroneal nerve


Sole of foot
Deep fascia
Plantar aponeurosis
Foot arches (3)
Medial longitudinal arch
Calcaneonavicular (spring) ligament
Lateral longitudinal arch
Transverse arch
Muscles of the Sole
First layer
Abductor hallucis
MPN
Flexor digitorum brevis
MPN
Abductor digiti minimi
LPN
Second layer
Lumbricals
1MPN, 234LPN
Quadratus plantae
LPN
Muscles of the Sole

Third layer

Flexor hallucis brevis


MPN

Adductor hallucis
LPN

Flexor digiti minimi brevis


LPN

Fourth layer

Tibialis posterior
TN

Interossei
LPN
4 dorsal
3 plantar

Peroneus longus
SPN
Arches of the Foot
Median longitudinal
- largest
- most important
Lateral longitudinal
Transverse
Mechanism of Arch Support
Shape of the stone
Inferior edges tied together
Tie beam
Suspension bridge
Femoral Artery

Continuation of the external iliac artery

Begins:

behind inguinal ligament


Midway between anterosuperior iliac spine and
symphisis pubis (femoral pulse)

Descends through femoral triangle and adductor


canal,

Enters popliteal space as popliteal artery


Femoral Artery Branches
MNEMONIC: Six Sweet Sexy Ladies Put My Pants Down Daily
Superficial circumflex iliac
Superficial epigastric
Superficial external pudendal
Lateral femoral circumflex
Profunda femoris
Medial femoral circumflex
Perforators
Deep external pudendal
Descending genicular
Arterial Anastomoses
Trochanteric Anastomosis
Superior gluteal
Lateral femoral circumflex
Inferior gluteal
Medial femoral circumflex
Cruciate Anastomosis
Medial femoral circumflex
Inferior gluteal
Lateral femoral circumflex
First perforating branch of profunda brachii
Popliteal artery
Continuation of femoral artery
Opening of adductor magnus to lower border of popliteus muscle
Divides into anterior and posterior tibial arteries
Anastomosis around the knee

Descending genicular artery

Lateral femoral circumflex artery

Popliteal artery

Anterior tibial artery

Posterior tibial artery


Anterior tibial artery

From bifurcation of tibial artery

Passes forward between tibia and fibula through the upper


part of the interosseous membrane

Enters anterior compartment of leg

Descends with deep peroneal nerve

front of ankle, becomes dorsalis pedis artery


Anterior tibial artery
Anterior tibial pulse

Ankle, midway between malleoli,

Medially: Tendon of extensor hallucis longus

Laterally: Tendons of extensor digitorum longus


Dorsalis pedis artery

Begins front of ankle, continuation of anterior tibial artery

Ends entering sole through proximal part of space between


1st and 2nd metatarsal bones

Joins lateral plantar artery, completes plantar arch


Dorsalis pedis arteries
Branches
Lateral tarsal artery
Dorsum of foot
Arcuate artery
Laterally across bases of metatarsal bones, gives off branches to the
toes
First dorsal metatarsal artery
Both sides of big toe
Dorsalis pedis artery
dorsalis pedis pulse
Laterally: tendons of extensor digitorum longus
Medially: tendon of extensor hallucis longus
Posterior tibial artery

From bifurcation of popliteal artery in politeal fossa

Descends in posterior compartment of the leg

Accompanied by tibial nerve

Artery terminates behind medial malleolus

Medial and lateral plantar arteries


posterior tibial pulse

Between medial malleolus and heel


Posterior tibial artery
Branches
Peroneal artery
- Largest branch
Muscular branches
Nutrient artery
Anastomotic branches
Posterior tibial artery
Terminal branches
Medial plantar artery
Smaller than lateral plantar artery
Forward along medial border of foot
with medial plantar nerve
Posterior tibial artery
Terminal branches
Lateral plantar artery
Larger
Forward, deep to abductor hallucis and flexor digitorum brevis
With lateral plantar nerve
End curving medially to form lateral plantar arch
Perforating arteries
Metatarsal artereis
Digital arteries
Dorsal venous network
Dorsum of foot
Drained
Medially: great saphenous vein
Laterally: small saphenous vein
Great saphenous vein

Ascends in front of medial malleolus

Accompanied by saphenous nerve

Ascends in leg in superficial fascia

Passes behind knee

Curves around medial side of thigh passes through


saphenous opening in deep fascia

Joins femoral vein


Great saphenous vein

Posseses numerous valves

Connected to

Small saphenous vein

by branches passing behind the knee

Deep veins

Via perforating veins, medial side of calf

Tributaries

Superficial circumflex iliac vein

Superficial epigastric vein

Superficial external pudendal vein


Small saphenous vein

From lateral side of dorsal venous network of foot

Ascends behind lateral malleolus

Accompanies sural nerve

Passes up back of leg, pierces deep fascia entering popliteal


fossa

Drains into popliteal vein


Venae commitantes
Deep veins accompanying respective arteries
Deep veins of anterior and posterior tibial arteries unite to for
popliteal vein
Popliteal vein

Formed by union of anterior and posterior tibial


arteries venae comitantes

End by passing through opening of adductor magnus to


become femoral vein

Receives many tributaries including from small saphenous


vein
Femoral vein

Continuation of popliteal vein through opening of adductor


magnus

Ascends through adductor canal and femoral triangle

Accompanied by femoral artery

Ascends behind inguinal ligament

Continous with external iliac vein


Receives great saphenous vein
Superficial inguinal nodes
In superficial fascia below inguinal ligament
Drain into deep inguinal nodes

Horizontal group

Superficial lymph vessels

anterior abdominal wall below umbilicus

Perineum

External genitalia (not testes)

Lower half of anal canal

Skin of buttocks
Superficial inguinal nodes
Vertical group
Lies along terminal part of great saphenous vein
Receives most of the superficial lymph vessels of lower limb
EXCEPT
back and lateral side of calf
Lateral side of foot
(Popliteal nodes)
Deep inguinal nodes

Usually three (3) in number

Along medial side of femoral vein

In femoral canal

Receive all lymph from

superficial inguinal nodes and

deep structures of lower limb

Drain into external iliac nodes


Popliteal lymph nodes

Situated in the popliteal fossa

Receive superficial lymph vessels accompanying small


saphenous vein

Drain lateral side of foot

Back and lateral side of calf

Drain into deep inguinal nodes


Nerves of the lower limb
Femoral nerve
Obturator nerve
Sciatic nerve
Tibial nerve
Common peroneal nerve
Femoral nerve
Lumbar plexus
L2-L3-L4
Enters thigh behind inguinal ligament
Lies lateral to femoral vessels
Terminates into anterior and posterior divisions
Femoral nerve, branches

Cutaneous branches

Medial cutaneous nerve of thigh

Skin on medial side of thigh

Intermediate cutaneous nerve of thigh

Skin on anterior side of thigh

Saphenous nerve

Infrapatellar branch to skin

Skin on medial side of leg

Skin on medial side of foot as far as ball


of big toe
Obturator nerve
Lumbar plexus
L2-L3-L4
Lateral side of pelvis to reach obturator canal
Upper part of obturator foramen
Divides into anterior and posterior divisions
Sciatic nerve

From sacral plexus

L4-L5-S1-S2-S3

Passes through greater sciatic foramen

Below piriformis

Covered by gluteus maximus

Posterior compartment of thigh

Divides into

Tibial nerve and

Common peroneal nerve


Tibial nerve
Descends through popliteal fossa

Posterior compartment of leg


Deep to gastrocnemius and soleus
Divides into medial and lateral plantar nerves
Tibial nerve, branches
Cutaneous branches
Sural nerve
Skin on calf
Skin on back of leg
Lateral border of foot
Lateral side of little toe
Medial calcaneal nerve
Skin over medial side of heel
Tibial nerve, branches

Medial plantar nerve


(deep to hallucis muscle w/ medial plantar artery)

Cutaneous branch

Medial part of sole

Medial 3.5 toes and nail beds

Muscular branch

Abductor hallucis

Flexor digitorum brevis

Flexor hallucis brevis

First lumbrical
Tibial nerve, branches

Lateral plantar nerve


(deep to abductor hallucis, flexor digitorum brevis, w/ lateral plantar
artery)

Cutaneous branch

Lateral part of sole

Laterl 1.5 toes and nail beds

Muscular branch

Flexor digitorum accessorius

Abductor digiti minimi

Flexor digiti minimi brevis

Adductor hallucis

Interosseous muscles

2nd, 3rd, 4th lumbricals


Common peroneal nerve
Through popliteal fossa
Laterally around neck of fibula
Piercing peroneus longus
Divides into
Superficial peroneal nerve
Deep peroneal nerve
Lower Limb Nerve Injuries
Femoral nerve lesions
Stab
Gunshot wounds
Pentrating injuries
Quadriceps paralyzed
No knee extension
Sensory loss
Medial side of lower part of leg
Medial border of foot at far as ball of the big toes
Obturator Nerve
Rarely injured in penetrating injuries
Behing the floor of femoral triangle
Compressed in:
Anterior hip dislocations
Parturition
Obturator hernia
Howships Romberg Sign
- paresthesia of medial aspect of the thigh
- paralysis of adductor muscles except adductor magnus
portion
Sciatic Nerve
Sciatic nerve lesion

Badly placed intramuscular injections in gluteal


region

Fracture dislocations of hip

Hamstring muscle paralysis

Weakend knee flexion

All muscles below knee, paralyzed

FOOT DROP

Weight of foot causes it to assume a plantar flexed


position
Loss of skin sensation below the knee, Except for

narrow part of leg

Medial border of the foot as far as the


ball of the big toe

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

Anterior and lateral compartment muscles paralyzed


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