100 Concepts Anatomy Annotatedcorrected1

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Understand first, then memorize and apply
l Dear students, you can use this presentation like a guide during your
preparing for GA exams.
l It does NOT cover all material of the Gross Anatomy course.
100 must important l To complete GA material you should work with ALL professorís
GA conceptions presentations.
l Good Luck and All the best!
Dr. Mavrych, MD, PhD, DSc
Dr. Bolgova, MD, PhD
Dr. Mavrych
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
1. Lumbar puncture (tap) and

Epidural anesthesia
l When lumbar puncture is
performed, the needle
enters the subarachnoid
space to extract
cerebrospinal fluid (CSF)
or to inject anesthetic to
epidural space. 3
l The needle is usually adults
1
inserted between L3/L4 or 4 2
5
kids L4/L5. Level of horizontal
line through upper points 6*
of iliac crests.
l Remember, the spinal cord Conus medullaris
may ends as low as L2 in Cauda Equina w/ FT
adults and does end at L3 10* dura matter 7
in children and dural sac subdural space
subd spac 8
extends caudally to level of Arachnoid matter 9
S2.
7
Spinal cord ends L2: Conus Medullaris

End Dura Sac S2: Cauda Equina w/ Filum terminale
Lamina= front smooth of arches
8 cervical SN (above) Pedicles= attachment of bodies to arches
12 thoracic SN Processes= protuberances and "attachments" (articular=restricts movement, spinous &
5 lumbar SN (below body) transverse muscle attachment & movement)
5 Sacral SNs facets= attachments of other vertebrae or bones
1 coccygeal SN Body=large part where attachment of intervertebral disc (gelatinous nucleus pulposus,
peripheral anulus fibrosus)
3. Abnormal curvatures of the
2. Herniated IV disc spine
l Patients typically have history l Kyphosis is an exaggeration of
of back pain that may radiate the thoracic curvature that may
down to the lower limb.
l Herniation of disc usually occur in elderly persons as a result
occurs in lumbar ((L4/L5 or of osteoporosis (multiply
L5/S1)) or cervical regions compression fracture of vertebral
(C5/C6 or C6/C7) of bodies) or disk degeneration.
individuals younger than age
50. l Lordosis is an exaggeration of the
l Herniated lumbar disc usually lumbar curvature that may be
compreses the nerve root one temporary and occurs as a result
number below: traversing root of pregnancy, spondylolisthesis
(e.g., the herniation L4/L5 will
PLL compress L5 root). or potbelly.
Scoliosis is a complex lateral Leg lengths:
l The pain begins soon after l
patient lifted some heavy thing. deviation, or torsion, that is short bone:
l Lower limb reflexes are caused by poliomyelitis, a leg- Coxa Vara
ALL decreased on the affected length discrepancy, or hip disease. <100deg
side Long bone:
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Coxa Valga
Anterior longitudinal ligament protects 9-3oclock around vertebral body Degenerative osteoarthritis: >130deg
Posterior longitudinal ligament protects 6oclock vertebral arch Spondylosis: immobility or fusion of vertebral joints
herniations are typically posterior laterally (4-5 or 7-8oclock) Spondylolysis: degeneration of articulating part of vertebrae
Spondylolisthesis: forward displacement of vertebrae
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4. Upper limb fractures:

Humerus fractures Fracture of distal radius:
Sites of potential injury to major l Transverse fracture within the distal 2 cm of
nerves in fractures of the humerus: the radius. Most common fracture of the
Quadrangular Space: teres major, teres
minor, long head biceps brachii, humerus 1. Axillary nerve and posterior forearm (after 50).
humeral circumflex artery at the l Smith's fracture results from a fall or a blow
surgical neck. on the dorsal aspect of the flexed wrist
deep and produces a ventral angulation of the
2. Radial nerve and profunda brachii
artery at midshaft. Midshaft wrist. The distal fragment of the radius is
fracture affect origin of brachialis ANTERIORLY displaced.
Posterior between triceps brachii
muscle. l Colles' fracture results from forced
3. Brachial artery and median nerve extension of the hand, usually as a result of
at the supracondylar region. trying to ease a fall by outstretching the
cubital fossa upper limb. Distal fragment is displaced
4. Ulnar nerve at the medial
epicondyle. DORSALLY - ìdinner fork deformityî.
Often the ulnar styloid process is avulced
ulnar epicondylar groove
(broken off)
posteriorly and medial to
olecranon
Scaphoid fracture Boxerís fracture

proximal carpal fracture
l Occurs as a result of a fall onto Necks of the metacarpal
l
the palm when the hand is bones are frequently
abducted Extension & abduction of wrist fractured during fistfights.
l Pain occurs primarily on the l Typically, fractures of 2d and
lateral side of the wrist, Boxer's Fracture d
especially during wrist extension 3 metacarpals are seen in
and abduction Brawler's Fracture professional boxers, and
l Scaphoid fracture may not show fractures of 5th and sometimes
on X-ray films for 2 to 3 weeks, 4th metacarpals are seen in
but a deep tenderness will be unskilled fighters.
present in the anatomical
snuffbox.
l The proximal fragment may
undergo avascular necrosis
because the blood supply is
interrupted.
deep radial artery could be compromised
Mallet or Baseball Finger 5. Rotator cuff muscles ñ SITS

l This deformity results from the DIP joint suddenly l Support the shoulder joint by
being forced into extreme flexion (hyperflexion) forming a musculotendinous
when, for example, a baseball is miscaught or a rotator cuff around it
finger is jammed into the base pad.
l Reinforces joint on all sides
l These actions avulse the attachment of the
except inferiorly, where
extensor digitorum tendon to the base of the dislocation is most likely
distal phalanx. As a result, the person cannot
extend the DIP joint. The resultant deformity bears Rotator cuff muscles are:
some resemblance to a mallet. l Supraspinatus Initiate Abduction, Suprasacular n
Forced Flexion of DIP l Infraspinatus Lat rotation, Suprascapcular n
l Teres minor Lat rotation, Axillary n
Right humerus l Subscapularis Med. rotation, Upper & Lower

Subscapular ns
Subacromial bursitis &

6. Abduction of the upper limb Tearing of supraspinatus tendon
l Subacromial bursitis (inflammation of
l (0_-15_) Abduction of the the subacromial bursa) is often due to
upper extremity is initiated calcific supraspinatus tendinitis,
by the supraspinatus causing a painful arc of abduction.
muscle ((suprascapular
suprascapular l The same symptoms will be in case of
nerve).
inflammation or trauma of the
l (15_-110a) Further abduction supraspinatus tendon (MRI !torn!
to the horizontal position is a
tendon)
function of the deltoid
muscle ((axillary
axillary nerve).
l (110_-180_) Raising the
extremity above the
horizontal position requires
at.seeton
triangle scapular rotation by action
ywmba of the trapezius ((accessory
accessory
nerve CNXI) and serratus
anterior ((long
long thoracic
nerve).
Supraspinatus tendon is most commonly ruptured.
7. Three Elbows: Student's elbow Tennis elbow

(Subcutaneous olecranon bursitis) (Lateral epicondylitis)
l The olecranon, to which the triceps l Lateral epicondylitis: repeated
tendon attaches distally, is easily forceful flexion and extension of the
palpated. It is separated from the wrist resulting strain attachment of
skin by only the olecranon bursa, common extensor tendon and
which allow the mobility of the inflammation of periosteum of
overlying skin. lateral epicondyle. Pain felt over
l Repeated excessive pressure and lateral epicondyle and radiates
friction may cause this bursa to down posterior aspect of forearm.
Pain often felt when opening a
become inflamed, producing a door or lifting a glass
friction subcutaneous olecranon l Origins of following muscles may
bursitis. be affected:
1. Extensor Carpi Radialis Extends and abducts
Longus & Brevis the hand
2. Extensor Digitorum Extends fingers and wrist
3. Extensor Digiti Minimi
4. Extensor Carpi Ulnaris Extends and adducts
Radial n the hand
Golferís elbow 8. Arterial anastomoses

(Medial epicondylitis) around the scapula
l Medial epicondylitis is
l Blockage of the
inflammation of the common Subclavian or Axillary
flexor tendon of the wrist artery can be bypassed
where it originates on the by anastomoses
medial epicondyle of the between branches of
humerus. the Thyrocervical and
Subscapular arteries:
l Origins of following muscles l Transverse cervical
may be affected: l Suprascapular
off thyrocervical trunk
1. Pronator Teres Pronates forearm
l Subscapular
2. Flexor Carpi Radialis Flexes and abducts wrist
3. Palmaris Longus flexes wrist (Median n) l Circumflex scapular
off subscapular
4. Flexor Carpi Ulnaris flexes and adducts Wrist
Ulnar n Suprascapular a above the Transverse Superior
Scapular Ligament anastamoses with the
Circumflex Scapular a from the triangular space
(Teres major/minor and long head biceps brachii)
9. Cubital fossa Anterior Elbow joint

10. Carpal Tunnel Syndrome
l Contents from lateral to medial:
l Results from a lesion that
1. Biceps brachii tendon reduces the size of the carpal
2. Brachial artery tunnel (fluid retention, infection,
dislocation of lunate bone)
3. Median nerve l Median nerve ñ most sensitive
LATERAL MEDIAL l Subcutaneos structures from lateral to structure in the carpal tunnel
medial: and is the most affected
l Clinical manifestations:
1. Cephalic vein
l Pins and needles or anesthesia
2. Median cubital vein:: joins cephalic of the lateral 3.5 digits
and basilic veins l palm sensation is not affected
3. Basilic vein because superficial palmar
cutaneous branch passes
superficially to carpal tunnel
l Sites of venipuncture is usually median l Apehand deformity - absent
cubital vein because: of OPPOSITION
l Overlies bicipital aponeurosis, so deep Recurrent Median n to Thenar ms are affected
Biceps Brachii m (flex and supinate forearm) structures protected
O: Longhead supraglenoid tubercle, Shorthead l Not accompanied by nerves
coracoid process)
Dr. Mavrych,
I: to Radial TuberosityMD, PhD, DSc prof.mavrych@gmail.com
Venous blood is darker/purpleish and flows passively Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
Arterial blood is cherry red and has a pulse ULNAR TUNNEL SYNDROME: Compression at the wrist between pisiform and hook of hamate
carpal bones causes hypoesthesia of medial 1.5 fingers and weakened instrinsic ms (Partial Claw
Cubital Tunnel Syndrome: Compression of ulnar epicondylar groove via tendon of Flexor hand bc flexors of forearm are unaffected)
Carpi Ulnaris, Ulnar n is compressed: Claw hand and weakened adduction of wrist
11. Test of the proximal and 12. Lesion of UL nerves

distal interphalangeal joints Upper Brachial Palsy
l Injury of upper roots and trunk
l Usually results from excessive
increase in the angle between the
l PIP ñ FDS neck and the shoulder stretching or
Proximal Interphalangeal joint tearing of the superior parts of the
Flexor Digitorum Superficialis brachial plexus (C5 and C6 roots or
Median n
superior trunk)
l May occur as birth injury from
forceful pulling on infant's head
during difficult delivery
l DID
DIP - FDP
Distal Interphalangeal Joint
DIPS- Flexor Digitorum Profundus
Birth injury or Fall causes
Ulnar and Median ns Superior Trunk Damage:
Erb's Palsy
MCPs- Lumbricals
Metacarpal phalangeal joint
Upper Brachial Palsy Lower Brachial Palsy

(Erb-Duchenne palsy) (Klumpke paralysis)
Inferior Trunk damage C8-T1
! In all cases, paralysis of the muscles of the l Injury of lower roots and
shoulder and arm supplied by C5 and C6 spinal trunk
nerves (roots) of the upper trunk. l May occur when the upper
! Combination lesions of axillary, suprascapular limb is suddenly pulled
and musculocutaneous nerves with loss of the superiorly: stretching or
shoulder mm and anterior arm. tearing of the inferior parts
! As result patient has ìwaiterís tipî hand: of the brachial plexus (C8
! adducted shoulder and T1 roots or inferior
trunk)
! medially rotated arm
l E.g., grabbing support
! extended elbow Wrist flexed
during falling from height
! loss of sensation in the lateral aspect of the or as a birth injury, or
upper limb TOS ñ thoracic outlet
Axillary C5-C6 syndrome
Musculocutaenous C5-7
Median C6-T1
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Dr. Mavrych, MD, PhD,Full
DSc hand paralysis (open extended hand), ulnar and
prof.mavrych@gmail.com
median n damage, thumb is extended bc radial n still good
Lower Brachial Palsy Injury to musculocutaneous

Ulnar and Median Nerve Lesions
(Klumpke paralysis) nerve
l All intrinsic muscles of the hand l Usually results from lesions
supplied by the C8 and T1 roots of of lateral cord
the lower trunk affected.
l Combination lesions of ulnar l Greatly weakens flexion of
nerve (ìclaw handî) î) and median elbow (biceps and brachialis
nerve (ìape handî) muscles) and supination of
l Loss of sensation in the medial forearm (biceps muscle)
aspect of the upper limb and weakened adduction (coracobrachialis m)
medial 1,5 fingers. l May be accompanied by
l May include a Horner syndrome anesthesia over lateral
aspect of forearm
Lateral musculocutaneous n of forearm
Median n lesion: Ape hand/benediction with lateral 3 digits are extended, wrist is extended
Ulnar n lesion: Claw hand with medial 2 digits extended
Radial n lesion: Drop Wrist with flexion of the wrist
Cutaneous innervation
of the hand Inradial
reality, in case of superficial branch of
nerve lesion it will be skin deficit 13. Cardiac catheterization
between 1 & 2 digits on the dorsum of the
hand ONLY because of nerve overlapping
l The femoral artery is
used for cardiac
catheterization
l It can be cannulated
for left cardiac
angiography & also
for visualizing the
coronary arteries ñ a
long, slender catheter
is inserted
percutaneously and
passed up the
external iliac artery,
common iliac artery,
aorta, to the left
ventricle of the heart
Dorsum: 1,5-U and 3,5 R Palm: 1,5-U and 3,5 M
A catheter can also be passed through a peripheral vein (femoral vein) into IVC, the
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com R atrium,
Dr. Mavrych, R ventricle,
MD, PhD, pulm trunk and pulm arteries. Intracardiac pressures, blood
DSc prof.mavrych@gmail.com
samples, and visualization of great vessels using Xray
14. Injury of the gluteal region Avascular necrosis

Fractures of Femoral Neck of femoral head
l A common fracture in
elderly women with
osteoporosis is fracture of
the femoral neck.
l Fractures of the femoral
neck cause shortness and
lateral rotation of the lower
limb. Coxa Vara <100deg l Transcervical fracture
disrupts blood supply to
l Fractures of the femoral the head of the femur via
neck often disrupt the blood retinacular arteries (from
supply to the head of the medial circumflex femoral
femur. artery) and may cause
l At present time the best way avascular necrosis of the
in case of femoral neck femoral head if blood
fracture is hip replacement. supply through the ligament
to the head is inadequate.
Fractures of neck and head of femur will disrupt the cruciate anastamosis that includes the medial circumflex
femoral a & ascending and transverse lateral circumflex femoral aa with Retinacular branches that anastamose
with the acetabular branch of obturator a within Ligamentum Teres
congenital dislocations are more common in females > males

Injury to sciatic nerve Posterior hip dislocations
l They are most common. A head-on
l Weakened hip collision that causes the knee to
extension and knee
flexion strike the dashboard may dislocate
l Footdrop (lack of the hip when the femoral head is
dorsiflexion) forced out of the acetabulum.
l Flail foot (lack of l The joint capsule ruptures inferiorly
both dorsiflexion and and posteriorly (fracture of ishium),
plantar flexion)
allowing the femoral head to pass
through the tear in the capsule
lCause of injury:
caused by (tearing of ishiofemoral lig.) and
improperly placed over the posterior margin of the
gluteal injections acetabulum onto the lateral surface
but may result from of the ilium, shortening and
posterior hip anterior
dislocation medial rotating the limb.
pubofemoral lig
Gluteal injections should be done with palm over & Piriformis syndrome: Trucker's may also tear
greater trochanter, pinky on ASIS and middle finger on who sit all day piriformis m Posterior dislocations can damage the sciatic n. bc it is weakest
Dr. Mavrych,
mid axillary MD, PhD,
line, thumb DSc prof.mavrych@gmail.com
point posteriorly, the V between compress n, numbness and tingling Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
middle and ring finger is site of injection. to the affected side.
Superior gluteal
nerve injury Injury to inferior gluteal nerve
possibly also due to Piriformis syndrome
Normal Right l The superior gluteal nerve
superior may be injured during surgery,
gluteal nerve posterior dislocation of the l Weakened hip extension
injury hip or poliomyelitis. (gluteus maximus), most
l Paralysis of the gluteus noticeable when climbing
medius and gluteus minimus stairs or standing from a
muscles occurs so that the seated position
ability to pull the pelvis up l Cause of injury: posterior
and abduction of the thigh
are lost. hip dislocation, surgery in
this region
Trendelenburg sign:
l If the superior gluteal nerve on
the right side is injured, the left Inferior gluteal n passes through inferior
pelvis falls downward when the piriformis fossa with the sciatic n,
patient raises the left foot off the posterior femorial cutaneous n, Superior
Patient stands and raises
ground.
gluteal a & v, pudendal n, and internal
l Note that side is contralateral to
L leg, if the L leg drops, it the nerve injury. pudendal a & v
is standing right leg nerve
injury
passes through superior piriformis fossa w/ inferior gluteal a & v
tearing off
Injury of obturator 15. Avulsion fractures

of the hip bone and
nerve Waddleing Gait (lateral leg swing/drag)
hamstrings muscles
l Difficulty adducting thigh
(e.g., crossing legs while l Avulsion fractures occur
sitting) where muscles are
attached - ischial
l Decreased sensation tuberosities
over upper medial thigh
Hamstrings muscles:
l Cause of injury: anterior 1. Biceps femoris (long head)
hip dislocation, radical 2. Semitendinosus
retropubic prostatectomia 3. Semimembranosus
l Action: extension of hip
passes through obturator joint and flexion of knee
canal that is covered by joint
obturator membrane in l Nerve supply ñ Tibial
obturator foramen nerve (short head of
Affects Obturator externus, Adductor longus, biceps femoris is supplied
brevis, magnus (paritally), pectineus, gracilis by the common fibular
lateral rotation weakness and poor adduction nerve)
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Dr. Pseudohamstrings:

Mavrych, MD, PhD,Adductor
Magnus (obturator & tibal ns), Biceps femoris ms (tibial &
common peroneal ns)
16. Structures under inguinal

ligament: Femoral hernia
Inguinal lig.
l From lateral to
medial side: FN A femoral hernia passes below
FA l
l Iliopsoas muscle Sartorius m FV inguinal ligament through the femoral
l Femoral nerve w/ circumflexes & ring into the femoral canal to form a
l Femoral arteryperforating br swelling in the upper thigh inferior and
lateral to the pubic tubercle
l Femoral vein & great saphenous v br
l The hernial sac may protrude through
l Femoral canal
the saphenous hiatus into the
Deep inguinal lymph nodes Adductor magnus m superficial fascia
l A femoral hernia occurs more
frequently in females and is dangerous
because the hernial sac may become
strangulated
l An aberrant obturator artery is
Femoral Triangle: Superior inguinal ligament, Medially adductor longus m, vulnerable during surgical repair
laterally sartorius m, it lies on top of pectinius m and iliopsoas ms
Inguinal lig serves as flexor retinaculum. Psoas m and Femoral n pass from pelvis Loop of bowel gets pulled downward into femoral canal, aberrant obturator a off
Dr. Mavrych,
to anterior thigh, MD, PhD,iliac
External DSc prof.mavrych@gmail.com
becomes femoral vessels Dr. Mavrych,external
MD, PhD,iliacDSc prof.mavrych@gmail.com
would cross bowel and becomes vulnerable
The inguinal canal runs perpendicular to the femoral canal
Laceration of the Femoral a can be compensated by the perforating branch of femoral a
and the lateral superior genicular a that anastamoses with the descending lateral
femoral circumflex a.
Femoral v ligation can be compensated via the great saphenous v
17. Knee joint injuries: Tibial collateral ligament

Unhappy triad (medial collateral ligament)
l Because the lateral side of the l Broad flat band
knee is struck more often extending from medial
(e.g., in a football tackle), the
tibial collateral ligament is epicondyle of femur to
the most frequently torn medial condyle and
ligament at the knee. shaft of tibia
l The unhappy triad of athletic l Blends with capsule and
knee injuries involves:
1. Tibial collateral ligament firmly attaches to
2. Medial meniscus medial meniscus
3. Anterior cruciate ligament l Limits extension and
abduction of leg at
MCL, MM, ACL tears knee
Fibular collateral ligament Rupture of the

(lateral collateral ligament) cruciate ligaments
l Rounded cord between l With rupture of the anterior

lateral epicondyle of femur cruciate ligament, the tibia
can be pulled forward
and head of fibula excessively on the femur,
l Does NOT blend with joint exhibiting anterior drawer
capsule and does NOT sign.
attach to lateral meniscus
l In the less common rupture of
l Limits extension and the posterior cruciate
adduction of leg at knee ligament, the tibia can be
pushed backward excessively
on the femur, exhibiting
posterior drawer sign.
drawer sign is movement of the leg in

opposition of the femur 5mm
Prepatellar bursa
Suprapatellar bursa Knee jerk reflex
articularis l Prepatellar bursa: between
genu m superficial surface of patella l The patellar reflex
and skin. May become is tested by tapping
the patellar Rectus femoris m
inflamed and swollen ligament with a
(prepatellar bursitis). reflex hammer to
elicit extension at
the knee joint. Both
l Suprapatellar bursa: superior afferent and
extension of synovial cavity efferent limbs of
between distal end of femur the reflex arch are
in the femoral
and quadriceps muscle and nerve (L2-L4).
tendon. Usual place for intra-
articular injections. May l Knee jerk reflex:
become inflamed and swollen tests spinal nerves
(suprapatellar bursitis). L2-L4.
Posterior to Rectus femoris m
and vastis intermedialis m
18. Ankle joint injuries:

Ankle sprains Pottís fracture
l Sprains are the most common
ankle injuries
l A sprained ankle is nearly
always an inversion injury, l It is fracture-dislocations of
involving twisting of the weight- the ankle joint
bearing plantarflexed foot. l Reason - forced eversion
l The lateral ligament (anterior (abduction) of the foot
talofibular ligament) is injured l The Deltoid ligament
because it is much weaker than avulses the medial
the medial ligament. malleolus and after that
l In severe sprains, the lateral fibula fractures at a
malleolus of the fibula may be higher level
fractured.
Pott's fracture
Eversion injury is Deltoid ligament at medial malleolus
19. Injures of the leg and foot:

Ankle jerk reflex Fracture of the fibular neck
Calcaneous Tendon Reflex l May cause an injury to the common
peroneal nerve,
nerve which winds
l Achilles tendon reflex is laterally around the neck of the
tested by tapping the fibula.
calcaneal tendon to elicit l This injury results in paralysis of all
plantar flexion at the ankle muscles in the anterior and lateral
compartments of the leg
joint. (dorsiflexors and evertors of the
l Both afferent and efferent foot) and loosing sensation on the
limbs of the reflex arc are dorsum of the foot.
carried in the tibial nerve l Causing foot drop.
(S1, S2).
l Ankle jerk reflex: tests

spinal nerves S1-S2.
Flexors take over (Plantar flexion)
Rupture of the Achilles tendon

and Triceps surae muscle Plantar Fasciitis (calcaneal spur)
l Plantar fasciitis is the
l Avulsion or rupture of the calcaneal most common hindfoot
(Achilles) tendon disables the triceps problem in runners. It
sure muscle (gastrocnemius & soleus) causes pain on the
so that the patient cannot plantar flex plantar surface of the
the foot. foot and heel.
Triceps surae muscle:
l Point tenderness is
l 2 Heads of Gastrocnemius m.
located at the proximal
l 1 Head - Soleus muscle
attachment of the plantar
l Plantaris
aponeurosis to the
l small fusiform belly with long thin
tendon; medial tubercle of the
l sometimes may become calcaneus and on the
hypertrophy medial surface of this
bone.
20. Injury of tibial nerve

SOLE OF FOOT TIBAL n BRANCHES
l In popliteal fossa: loss of On soil of the foot there are two terminal
plantar flexion of foot (mainly branches of tibial n:
gastrocnernius and soleus
l Medial plantar nerve supplies:
muscles) and weakened
inversion (tibialis posterior 1. Abductor hallucis,
muscle), causing
calcaneovalgus. 2. Flexor hallucis brevis
l Inability to stand on toes 3. Flexor digitorum brevis
4. 1st lumbrical muscles
l Loss of sensation and l skin of medial 3.5 digits
Popliteal fossa from superficial to
paralysis of intrinsic muscles
l
of the sole of the foot l Lateral plantar nerve supplies:
deep, contains:
l All intrinsic plantar muscles which
l Tibial nerve
are not innervated by medial plantar
l Popliteal vein Femoral vessels after passing through adductor haitus/ nerve
l Popliteal artery Hunter's canal, Sartorius canal, to become popliteal vessels
l skin of lateral 1.5 digits
Popliteal Fossa is bordered by Semitendinosus, Semimembranosus, Biceps Adductor hallucis (oblique & transverse
Dr. Mavrych, MD, and
femoris, PhD, DSc prof.mavrych@gmail.com
quadracepts (gastronemius, plantaris, and soleus ms) heads), Quadratus Plantae, Flexor Digiti
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
minimi, abductor digiti minimi, DABs,
PADs, lateral 3 lumbricals
Common Fibular/Common Peroneal n does not pass in popliteal
fossa, instead it goes around neck of fibula
21. Breast: Lymphatic drainage

Carcinoma of the Breast of the breast
l Carcinomas of the
breast are malignant l It is important because
of its role in the
tumors, usually metastasis of cancer
adenocarcinomas cells.
arising from the l Most lymph (> 75%),
epithelial cells of the especially from the
lactiferous ducts in the lateral breast
mammary gland quadrants, drains to
lobules the axillary lymph
l 1. It enlarges, attaches nodes, initially to the
anterior (pectoral)
to suspensory nodes for the most
(Cooperës) ligaments, part.
and produces l Most of the remaining
shortening of the lymph, particularly from
ligaments, causing the medial breast
depression or dimpling quadrants, drains to the
of the overlying skin. parasternal lymph
75% 25% nodes or to the
Suspensory/Cooper's lig sround the lobules of mammary glands. opposite breast.
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Lymph from

Dr. Mavrych, breast->Interpectoral
MD, PhD, "Rotter's" lymph nodes -> axillary lymph nodes->
clavicular nodes-> R lymphatic duct or L Thoracic duct -> subclavian vs -
$$Million dollar space: Retromammary space behind Pect Major or between >brachiocephalic vs -> SVC-> heart
fat pad and Pect Major for insertion of breast implants Rotter's nodes are a way breast cancer can metastasize by bypassing axillary nodes
Mastectomy Breast infection

l Mastitis is an infection of the tissue
l Radical mastectomy, a more extensive surgical
procedure, involves removal of the breast, pectoral of the breast that occurs most
muscles, fat, fascia, and as many lymph nodes as frequently during the time of
possible in the axilla and pectoral region. breastfeeding (1 to 3months after the
1. During a radical mastectomy, the long thoracic delivery of a baby).
nerve may be lesioned during ligation of the lateral l This infection causes pain, swelling,
thoracic artery. A few weeks after surgery, the redness, and increased temperature
female may present with a winged scapula and of the breast.
weakness in abduction of the arm above 90_ l It can occur when bacteria, often from
because serratus anterior m. paralysis. the baby's mouth, enter a milk duct
2. The intercostobrachial nerve may also be through a crack in the nipple.
damaged during mastectomy, resulting in skin l It can occur in women who have not
deficit of the medial arm. T2 intercostal n branch gives recently delivered as well as in women
sensation to skin of axilla and after menopause.
medial cutaneous arm
22. Thoracic wall & Diaphragm: Diaphragm:

Intercostal spaces Paralysis of half and ruptures
C3, 4, 5 keeps the Diaphragm alive!
Intercostal blood vessels
and nerves: l Paralysis of the half
l run between the of the Diaphragm
internal intercostal and may result from injury
innermost intercostal or operative division of
muscles in the costal the phrenic nerve of
groove same side
l arranged from superior l It can be detected
to inferior as vein, radiologically.
artery, nerve
l Paradoxical
l Most vulnerable movement: dome of
structures ñ intercostal diaphragm of injured
nerve and posterior side pushed superiorly
intercostal artery by abdominal viscera
because they are not during inspiration
covering by ribs. Flail Chest: One or more broken ribs in two separate places instead of descending
upon inspiration the broken area will sink in as chest wall moves out
Skin->Fascia->Fat->External Intercostal m \\ //->Internal Intercostals // \\ upon expiration the broken area will push out as chest wall moves in
-> Intercostal VAN-->Innermost Intercostals == -> Fascia -> Parietal Pleura--> Dangerous bc lungs can be punctured
Thoracocentesis: Ribs 9-10 (9th intercostal space), above rib avoid VAN, remove fluid in
pleural cavity
Bochdalek Hernia: common hernia on the posterolateral L side of diaphragm,
Pericardiocenetesis: Left 5-6th intercostal space near sternum, Infrasternal (xiphoid) angle up
fatal congenital hernia that causes pulmonary hypoplasia.
to left shoulder for Cardiac Tamponade due to Pleural effusion
Morgangi Hernia: rare hernia on anteromedial R side of diaphragm, not fatal bc
musculature typically creates spincter
Sliding hernia: Stomach slides up through diaphragm bc of short esophagus
Rolling/paraesophageal hernia stomach slides up next to esophagus
Diaphragmatic ruptures
Phrenic nerve
l Diaphragmatic injuries are
l Arises from the anterior relatively rare and result from
branches C3-C5 nerves and either blunt trauma or
lies in front of the anterior penetrating trauma.
scalene muscle.
l Runs anterior to the root of l Presently, 80-90% of blunt
the lung,, whereas the vagus diaphragmatic ruptures result
nerve runs posterior to the from motor vehicle crashes.
root of the lung.
l The majority (80-90%) of blunt
l Innervates the fibrous
pericardium, the diaphragmatic ruptures have
mediastinal and occurred on the left side.
side
diaphragmatic pleurae l Blunt trauma typically produces
(sensory innervation), and
the diaphragm for motor large radial tears measuring 5-15
and its central tendon for cm, most often at the
sensory. posterolateral aspect of the
diaphragm.
I ate 10 eggs at noon! Vessels entering the diaphragm

Inferior vena cava T8
Esophagus T10
Aorta T12
P-A projection
23. Cardiac hypertrophy

Left atrial enlargement
l Cardiac Shadow
(hypertrophy) secondary to
mitral valve failure may Right border is formed by:
compress on the 1. SVC,
esophagus and manifest
as dysphagia (difficulty in
2. Right atrium
swallowing).
l It may be observed as a Left border is formed by:
filling defect in the
esophagus by barium 1. Aortic arch
swallow on the lateral 2. Pulmonary trunk
thoracic X-Ray
mitral valve failure/tenting keeps 3. Left auricle
causes mitral regurgitation into L 4. Left ventricle
atrium during systole, pressure
dilates the LA as well as
decreases BP causing heart to
work harder to pump blood to
aorta resulting in hypertrophy
24. Auscultation of Heart

Auscultation sites for
Valves
mitral and aortic murmurs
Right 2 ICS Left 2 ICS
PSL PSL
Left 4 ICS Left 5 ICS

PSL MCL
A heart murmur is heard downstream from the valve:
l stenosis is orthograde direction from valve
l insufficiency is retrograde direction from valve
regurgitation
VALVE
Dr. Mavrych, ANAT.
MD, PhD,LOCATION AUSCULTATION SITE
DSc prof.mavrych@gmail.com Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
•P 3rd CC 2nd LT ICS
•A 3rd ICS 2nd RT ICS Stenosis Regurgiation
•M 4th CC cardiac apex (5th Lt ICS MCL) Aortic Systole (HOOT Dub) Aortic Diastole (Lub hoot)
•T 4th ICS Rt inferior most ST (5th RT ICS) Pulm Systole (HOOT Dub) Pulm Diastole (Lub hoot)
• (3344) (2255) Tricuspid Diastole (Lub hoot) Tricuspid Systole (hoot Dub)
Mitral Diastole (Lub hoot) Mitral Systole (hoot Dub)
25. Conducting System 26. Blood supply of the Heart:

of the Heart Sinoatrial (SA) node
l
Right coronary artery (RCA)
l site where contraction of heart muscle is
initiated (pacemaker of the heart) l It supplies major parts of the right
l situated in the upper part of the sulcus
Crista Terminalis separates atrium and the right ventricle.
terminalis just near to the opening of pectinate muscles w/ sinus l It anastomoses with the marginal
the SVC venarum branch of the left coronary artery
l Atrioventricular (AV) node posteriorly
l the AV node receives impulses from the Branches:
SA node; situated in the lower part of 1. Anterior cardiac branches ñ
the atrial septum near coronary sinus supplies the right atrium
l Atrioventricular bundle of His 2. Nodal branch ñ supplies the (1) SA
l descends from the AV node to the node, (2) AV node
membranous portion of the ventricular 3. Marginal artery ñ supplies the right
septum where it divides into the left and ventricle Small cardiac vein
right bundle branches 4. Posterior interventricular artery ñ
l Right bundle branch ñ passes down to supplies (1) diafragmatic (inferior)
reach the moderator band - right surface of both ventricles and (2)
ventricle Septomarginal trabeculae posterior 1/3 of the IV septum
l left bundle branch ñ passes down left Middle cardiac vein
side of ventricular septum
Purkinje Fibers throughout walls of ventricles
stimulate contractile cells
Dr. Mavrych,
Triangle of Koch: MD, PhD,ofDSc
Location prof.mavrych@gmail.com
AV node in R Atria Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
Valve of coronary sinus (Thebesian) & IVC (Valve of Eustice) meet
to form tendon of todaro, which joins the Septal leaflet of Tricuspid valve
Left coronary artery Blood supply of the conducting

(LCA) system
"Widow Maker"
Branches: l SA node ñ RCA
1. Anterior (descending)
interventricular artery ñ most
common place of MI descends in the l AV node ñ RCA
anterior interventricular sulcus and
provides branches to the (1) anterior
heard wall, (2) anterior 2/3 of IV l AV bundle (and
septum, (3) bundle of His, and (4)
Great cardiac vein
moderator band)- LCA
mo
apex of the heart.
2. Circumflex artery ñ winds around the
left margin of the heart in the When
l a MI occurs, a coronary bypass
atrioventricular groove to anastomose graft can be completed using the
with the right coronary artery internal thoracic artery (used to be Great
posteriorly; supplies the left atrium saphenous v)
and left ventricle
Great cardiac v, middle cardiac v, small cardiac v, L marginal v drain into Coronary Sinus which empties in Triangle of Koch at RA
27. Congenital cardiac defects: Ventricular Septal

Atrial Septal Defect (ASD) Defect (VSD)
lIt is less frequent than
VSD l Ventricular septal defect
l It results from failure to (VSD) is the most common
close of the foramen of the congenital heart defects
ovale after birth (failure of l It may be found in the
the septum primum and membranous part of the
ventricular septum and
septum secundum to results from failure to fuse of
fuse) Patent Foramen Ovale the membranous portion with
l Postnatally, ASDs result the muscular portion of the
in left-to-right shunting ventricular septum
(between right and left l In this case, present leftñto-
atrium) and are non- right shunt (right ventricular
cyanotic conditions. hypertrophy (RVH)) and
again non-cyanotic.
l If it is small, has no
l Necessary surgery for large
clinical significance & if defects
large - necessary surgical
Muscular VSD rarest when there is a hole
repair
in the trabeculated inferior ventricle wall
Ostium secundum: MOST common resorption of lower septum primum or incomplete septum secundum (fatal)
leaves open foramen ovale
Ostium primum: non fusion of septum primum with septum intermedium leaves open foramen primum
Hypoplastic L heart syndrome: premature closure of FO leaving underdeveloped L heart
Patent Ductus Arteriosus (PDA) Aneurysm of the aorta

l It results from failure of the ductus l Aneurysm of the aortic arch:
arteriosus (a connection between the compresses the left recurrent
pulmonary trunk and aorta)) to constrict and laryngeal nerve,, leading to
close after birth. coughing, hoarseness, and
paralys is of the ipsilateral vocal
l Prostaglandin E and low O2 tension sustain cord. It may cause dysphagia
patency of the ductus arteriosus in the fetal (difficulty in swallowing), resulting
period. from pressure on the esophagus,
l PDA is common in premature infants and in
and dyspnea (difficulty in
breathing), resulting from
cases of maternal rubella infection. pressure on the trachea, root of
l Left ñto-right shunt increased pressure in the lung, or phrenic nerve
pulmonary circulation (pulmonary
hypertension) and is non-cyanotic l Aneurysm of the thoracic aorta
l Treatment: surgical division and ligation may compress and tug on the
imperative. In great danger is left recurrent trachea with each cardiac systole
nerve (wrapping aorta arch). Injure of this so that the aneurysm can be felt
nerve results in hoarseness. by palpating the trachea at the
sternal notch (T2).
Ductus arteriosus (fetal lung bypass from pulmonary trunk to aorta) should immediately
close post birth by contraction of muscular wall and become lig. arteriosus, L recurrent
laryngeal
Dr. n (CNX)
Mavrych, wrapsDSc
MD, PhD, around it. Increase BP post birth creates increased BP in pulm
prof.mavrych@gmail.com Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
circulation, less blood to body slightly decreases O2 L Recurrent Laryngeal n innervates Intrinsic Laryngeal ms: Posterior
cricoarytenoid (PCA)-abducts vocal cords*, Transverse arytenoid-whisper,
Thyroarytenoid-low pitch, vocalis-opera singer
Abdominal aortic aneurysm

Coarctation of the Aorta
l It is a localized dilatation of the l It results from congenital
aorta. It is typically happened narrowing of the aorta distal to the
just above of the bifurcation at offshoot of the left subclavian
level of L4 and crossed by 3rd artery.
part of duodenum. l Cardinal clinical sign: higher blood
l Pulsations of a large aneurysm pressure in the upper limbs
compared to the lower limbs.
can be detected to the left of
l Coarctation of the aorta results in
the midline at the umbilical
the intercostal arteries providing
region. collateral circulation between the
l Acute rupture of an abdominal internal thoracic artery and the
aortic aneurysm is associated thoracic aorta to provide blood
with severe pain in the supply to the lower parts of the
abdomen or back (mortality rate body
is nearly 90%). l Coarctation of the Aorta
l Surgeons can repair an

characteristic X-ray picture:
serrated appearance of inferior
aneurysm by opening it and borders of ribs (rib
rib notching)
notching
inserting a prosthetic graft. Preductal stenosis proximal to ductus arteriosus causes deoxygenated blood w/
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com lowMD,
Dr. Mavrych, BP to the DSc
PhD, body (life threatening)
Postductal stenosis w/ obliterated ductus ateriorsus is more common
28. Aspiration of Foreign Right lung:

Bodies & Bronchopulmonary 10 bronchopulmonary segments
segments
Aspiration of Foreign Bodies:
Superior lobe:
l Inhalation of FBís (e.g. pins,
parts of teeth, screws, nuts,
1. Apical
bolts, toys) into the lower 2. Anterior
1
respiratory tract is common, 3. Posterior
especially in children Middle lobe:
3
l More likely to enter the right 4. Lateral
2
primary bronchus and pass into 5. Medial
the middle or lower lobe Inferior lobe: 6 4
bronchi 6. Superior
8 5
l If the vertical position of the 7. Anterior basal
body, the foreign body usually 8. Posterior basal 10
falls into the posterior basal 9. Lateral basal 9
segment of the right inferior 7
10. Medial basal
lobe.
Laying down on back, it will go into posterior superior lobe
Dr. Mavrych, MD, PhD,
Liquids DSc prof.mavrych@gmail.com
(Mendleson syndrome) will go to BOTH superior Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
segmental bronchus of Lower Lobes (SULL)
Left lung: 29. Lung diseases:

9 bronchopulmonary segments Pneumonia
l Pneumonia is an inflammation
Superior lobe: of the lung, caused by an
1. Apicoposterior infection or chemical injury to the
2. Anterior lungs.
1
3. Superior lingularsurrounds cardiac notch l Three common causes are
4. Inferior lingular bacteria, viruses and fungi.
2
Inferior lobe: l Symptoms: cough, chest pain,
5. Superior fever, and difficulty in breathing.
6. Anterior basal 3 5
l Chest x-rays: areas of opacity
7. Posterior basal
7 (seen as white) of the lung
8. Lateral basal 4
parenchyma and enlargement of
9. Medial basal 9 8
bronchomediastinal lymph
nodes (mediastinal widening).
6
Bronchogenic Carcinoma Bronchogenic carcinoma

may lead to:
1
1. Thoracic outlet syndrome ((TOS)TOS)
l Arises in the mucosa of the l It can cause pressure on the lower
large bronchi trunk of the brachial plexus C8-T1
l Produces as persistent, and subclavian artery by cervical
productive cough or rib or pancoast tumor. It results in
hemoptysis spitting blood pain down the medial side of the Blue arm
l Early metastasis to thoracic forearm and hand and atrophy of
(bronchomediatinal) lymph the intrinsic hand muscles)
nodes 2. Horner syndrome: compression of cervical
Hematogenous spread to the 2 sympathetic trunk
symp
l l miosis - constriction of the pupil
brain, bones, lungs,malignant cells due to paralysis of the dilator
suprarenal glands spread through blood pupillae muscle Long ciliary n of CNV1-> SNS br
l A tumor at the apex of the l ptosis - drooping of the eyelid due
lung (Pancoast
( tumor)) may to paralysis of the superior tarsal
result in thoracic outlet muscle pseudoptosis bc NOT CNIII lesion
syndrome SNS compression to smooth ms
l hemianhydrosis - loss of sweating
on one side Sweat glands are SNS
Bronchogenic carcinoma Qs about Auscultation

may lead to: and penetrated wounds
3. Superior vena cava
syndrome, which causes l To listen to breath sounds of the
dilation of the head and superior lobes of the right and left
neck veins, facial swelling, lungs, the stethoscope is placed on
and cyanosis Blue Face & arm the superior area of the anterior
4. Dysphagia as a result of chest wall (above the 4th rib for the
esophageal obstruction right lung & above 6th for the left
5. Hoarseness as a result of one).
recurrent laryngeal nerve
involvement l For breath sounds from the
6. Paralysis of the middle lobe of the right lung, the
diaphragm as a result of stethoscope is placed on the
4
phrenic nerve involvement anterior chest wall between the 4th
3 and 6th ribs
6 l For the inferior lobes of both
lungs, breath sounds are primarily
heard on the posterior chest wall.
30. Open pneumothorax &

pleura Pleura & Pleural Cavity
l It is entry of air into a pleural l 1. Cervical pleura may be affected in
cavity causing lung collapse. case of improper subclavian
l Open pneumothorax ñ due to stab venipuncture.
wounds of the thoracic wall which
pierce the parietal pleura so that l 2. Costodiaphragmatic Recess is
the pleural cavity is open to the
outside air via the lung or through deepest place in pleural cavity, around
the chest wall. the chest wall, there are two rib
l Air moves freely through the interspaces separating the inferior
wound during inspiration and limit of parietal pleural reflections from
expiration. During inspiration, air the inferior border of the lungs and
enters the chest wall and the visceral pleura:
mediastinum will shift toward other 2 1. Midclavicular line - between ribs 6-8
side and compress the opposite
lung. During expiration, air exits 2. Midaxillary line - between ribs 8-10
the wound and the mediastinum 3. Paravertebral line between ribs 10-12
moves back toward the affected
side.
Costodiaphragmatic Recess is where fluid is
Stab Wounds & Open pneumothorax: retained during pleural effusion
Straight in air can move in and out with each respiratory cycle, No air trapping (listen to ventilation of wound)
At an angle air can move in with inspiration BUT with expiration skin acts as flap and closes trapping air inside collapsing the lung
31. Mediastinum
Nerve supply of the pleura Superior
p mediastinum
Parietal Pleura ñ sensitive to general l Improperly done
sensibilities (pain, temperature, touch, sternal puncture
and pressure) - somatic sensory may affect
innervation: structures related
l costal pleura ñ intercostal nerves to the posterior
block may be used to decrease surface of the
thoracic pain manubrium
l mediastinal pleura ñ phrenic nerve sternum:
l diaphragmatic pleura ñ phrenic nerve
l In upper part ñ
over the domes and lower 6 intercostal
nerves around the periphery Left
brachiocephalic
vein
Visceral Pleura ñ sensitive to stretch but
insensitive to general sensibilities; l In lower part ñ
autonomic nerve supply from the Aortic arch
pulmonary plexus Azygous vein and ascending
aortic arches
Cervicothoracic Stellate Gangion down to T11 and Subcostal sympathetic ganglion comprise the thoracic Trachea and Pulmonary artery
sympathetic trunk Ribs 1-2 down to transverse thoracic bifurcations
Dr. muscles
Innervate Mavrych,ofMD,
the PhD, DSc prof.mavrych@gmail.com
ribs, abdominal wall, pulmonary and cardiac plexus, and esophageal plexus Dr. Mavrych, MD,plane
PhD,(T2)/Plane
of ludwig/angle of louis esophagus and thoracic duct
Vagus CNX assists plexus of thorax for vocal cords and swallowing, and gives off recurrent laryngeal and change directions (cross over)
superior external laryngeal to the larynx muscles
Pericardial sinus: behind pulm trunk and aorta place fingers to
clamp/ligate great vessels during surgical procedures
Thoracic duct A Duck between 2 Gooses

Thoracic duct between azygos v and esophagus
Constrictions of the esophagus
25cm long/10in Barium swallow allows Xray visualization
l Function ñ conveys to the 1 There are sites where ingested
blood all lymph from the foreign bodies can lodge or
lower limbs, pelvic cavity, where strictures may develop
abdominal cavity, left side following ingestion of caustic
fluids, common sites of
of the thorax, left side of esophageal carcinoma
the head & neck, and left
upper limb ((3/4
3/4 of the 2
body) 1. C6 - where the pharynx joins
the upper end (6" from the 15cm
upper incisors)
Tributaries ñ at the root of the 2. T4-T5 - where the aortic arch
neck and left main bronchus cross 22.5-27.5cm
l Left jugular lymph trunk its anterior surface (10" from the
upper incisors)
l Left subclavian lymph 3 3. T10 - where it passes through
trunk the diaphragm into the
l Left bronchomediastinal stomach (16" from the upper 40cm
lymph trunk incisors)
R lymphatic duct drains 1/4 of body from R jugular

lymph trunk, R subclavian lymph trunk, and R
bronchomediastinal lymph trunk
Referred abdominal pain

32. Anterior abdominal wall
l The liver and gallbladder
are in the right upper
quadrant; l Pain arising out of the
foregut derived structures
l The stomach and spleen is referred to the
are in the left upper epigastric region.
region
quadrant;
RH E LH l Pain arising out of the
l The cecum and appendix midgut derived structures
are in the right lower RL U LL is referred to the
quadrant; umbilical region.
l The end of the descending H

colon and sigmoid colon RI LI l Pain arising out of the
are in the left lower hindgut derived
quadrant. structures is referred to
the hypogastric region.
Dr. Layers of abdominal

Mavrych, MD, PhD, wall:
DSc Skin, Camper's Fascia, Scarpa's Fascia, Galludets Fascia (superficial
prof.mavrych@gmail.com Ext oblique),
Dr. Mavrych, MD,Ext Oblique
PhD, DSc m \\//, (deep ext oblique, superficial int oblique),
Inter Oblique m //\\, (deep int oblique, superficial transversalis ab), Transversalis abdominus m, deep TA fascia, Extraperitoneal fat, parietal peritoneum
.
Arcuate line is where lateral abdominal ms tendons merge with Rectus abdominus (linea semilunaris), Above arcuate line int oblique superficial fascia is above rectus abdominus (3 layers
of fascia), Below arcuate line ALL fascias above rectus abdominis (6 layers) typically inferior to umbilicus
Nerve supply of the Arterial supply of the anterior

anterior abdominal wall abdominal wall:
l Therefore totally 7 nerves: Important SUPERFICIAL
lower 5 intercostals, 1 ARTERIES ((supply
supply skin)
skin are:
subcostal and L1 1. Superficial epigastric
(iliphypogastric and from femoral a
2. Superficial circumflex iliac
ilioinguinal) nerves supply
ilioinguinal
the anterior abdominal wall.
l L1 can be anaesthetized by Important DEEP ARTERIES lie in
injecting 1 inch (2.5 cm) the neurovascular plane:
plane
superior to the anterior 1. Superior epigastric internal thoracic a
superior iliac spine. 2. Posterior intercostals arteries
l All nerves and deep blood 3. Lumbar arteries
vessels lie in the 4. Deep circumflex iliac artery
neurovascular plane: external iliac a
between internal oblique 5. Inferior epigastric
from femoral a just past
and transversus muscles femoral ring (inguinal lig)
T5-T11
T12
L1 PortalMD,
Caval anastamosis of paraumbilical veins off hepatic portal v with superficial
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Dr. Mavrych, PhD, DSc prof.mavrych@gmail.com
epigastric veins (Caput Medusae- swiggly veins on belly button)
33. Herniations Transversalis fascia is the FIRST

STRUCTURE which is crossed by
Hernia consist of 3 parts: any abdominal hernia
l Hernial sac is a pouch

(diverticulum) of peritoneum and
has a neck and a body
l Hernial contents may consist of
any structure found in the aponerocis of internal
abdominal cavity (more offen ñ oblique fascia and
loops of small intestine and tranversalis fascia
piece of omentum major)
l Hernial coverings are formed
from the layers of the abdominal
wall through which the hernial
sac passes
TIE ICE
Transversalis Fascia becomes Internal Spermatic Fascia
Internal Oblique m & Fascia becomes Cremasteric m & Fascia
External Oblique fascia becomes External Spermatic Fascia
Surrounds the Spermatic cord within the inguinal canal:
3 as: cremasteric (inferior epigastric), ductus deferans (internal iliac-inferior vesicle),
gonadal a (aorta)
3 ns: genital br (motor genitofemoral), ANS, ilioinguinal
3 others: Pampiniform plexus (IVC and Lrenal), Ductus Deferens, Lymphatics
Process Vaginalis/Gubernaculum
Indirect Inguinal Hernia Direct Inguinal Hernia

l Indirect inguinal hernia is the most l Direct inguinal hernia composes
common form of hernia and is believed about 15% of all inguinal hernias.
to be congenital in origin (boys 0-3 l During a direct inguinal hernia,
years). the abdominal contents will
l It passes through the deep inguinal ring protrude through the weak area of
lateral to the inferior epigastric the posterior wall of the inguinal
vessels, inguinal canal, superficial canal medial to the inferior
inguinal ring and descend into the epigastric vessels in the inguinal
scrotum. [Hesselbach's] triangle and after
l An indirect inguinal hernia is about 20 that through superficial inguinal
times more common in males than in ring. It never descends into the
females, and nearly 1/3 are bilateral. scrotum.
l It is more common on the right l It is a disease of old men with
(normally, the right processus vaginalis weak abdominal muscles. Direct
becomes obliterated after the left; the inguinal hernias are rare in women,
right testis descends later than the left). and most are bilateral.

Insertprof.mavrych@gmail.com
finger into superficial inguinal ring, if you can feel hernia at TIP Dr. Mavrych,
of finger than itMD, PhD, DSc
is indirect prof.mavrych@gmail.com
hernia at the lateral inguinal fossa.
If you can feel something lateral to finger it is direct hernia pushing towards Hesselbach's triangle (medial inguinal fossa between medial and lateral
umbilical folds. The inferior epigastric vessels reside within Lateral umbilical fold (functional), the inferior border is the inguinal lig.
34. Peritoneal structures:

Lesser omentum Epiploic (winslowís) foramen
Consist of 2 ligaments:
l hepatogastric l Anteriorly: The free
l hepatoduodenal border of the
hepatoduodenal
Contents : ligament, containing
l Right & Left gastric
portal triad (DVA).
vessels
l Connective and fatty l Posteriorly: IVC
tissue
and Portal triad:
l Superiorly: Caudate
l Bile duct
lobe of the liver.
l Portal vein
l Proper hepatic artery
l Inferiorly: The 1st
part of the
duodenum.
Site of Pringles Manuver to block blood supply to liver and investigate
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Dr. Mavrych,
Liver bleeds: block Hepatic Artery Proper, Hepatic Portal MD,
Vein,PhD, DSc prof.mavrych@gmail.com
and Common
Bile Duct. Use thumb anterior, and index posterior within Winslow foramen.
If R side bleeds: aberrant R Hepatic artery from SMA
If L side bleeds: aberrant L Heptatic artery from L Gastric
If double bleed accessory arteries come from elsewhere.
Douglas (rectouterine) pouch Culdocentesis

In women only!
l Culdocentesis is
aspiration of fluid from
l Rectouterine pouch the cul-de-sac of
(pouch of Douglas): Douglas (rectouterine
deeper point of pouch) by a needle
peritoneal space in puncture of the
vertical position of the posterior vaginal
female body between the fornix near the midline
rectum and the cervix of between the uterosacral
ligaments
uterus.
l Because the
l It is space of the pelvic rectouterine pouch is
abscess location. the lowest portion of
the female peritoneal
cavity, it can collect
Vesicouterine pouch inflammatory fluid
(pelvic abscess).
Males have a vesicorectal pouch, fluid can accumulate in these peritoneal areas if there is a pelvic abscess.
Morrison's prof.mavrych@gmail.com
pouch Dr.kidney
is where fluid accumulates if the person is lying down (between Mavrych,
and MD,
liver)PhD, DSc prof.mavrych@gmail.com
FOREGUT MIDGUT HINDGUT
35. Smart Table Artery: CA Artery: SMA Artery: IMA
Parasympathetic Parasympathetic Parasympathetic

FOREGUT MIDGUT HINDGUT innervation: vagus innervation: vagus innervation: pelvic
nerves, CNX nerves, CNX splanchnic nerves, S2-S4
Esophagus Duodenum (2nd, 3rd, Transverse colon
Sympathetic Sympathetic Sympathetic
Stomach 4th (distal 1/3)
innervation: innervation: innervation:
Duodenum (1st and parts) Descending colon ïPreganglionics: greater ïPreganglionics: lesser ïPreganglionics: lumbar
2nd parts) Jejunum Sigmoid colon splanchnic nerves, T5-T9 splanchnic nerves, T10- splanchnic nerves, L1-L2
Liver Ileum Rectum (anal canal ïPostganglionics: T11 ïPostganglionics: inferior
Pancreas Cecum (with above pectinate line) celiac ganglion ïPostganglionics: mesenteric ganglion
Biliary apparatus Appendix) IMV to splenic v to superior mesenteric
Gallbladder Ascending colon ganglion
hepatic portal v to liver
1st part duodenum is Transverse colon to IVC Sensory Innervation: Sensory Innervation: Sensory Innervation:
suspended by greater (proximal 2/3) SMV joins splenic v to DRG T5-T9 DRG T10-T11 DRG L1-L2
omentum and hepato form hepatic portal v
duodenal lig 2nd part of duodenum is Referred Pain: Referred Pain: Referred Pain:
where Spincter of Oddi/ Epigastrium Umbilical Hypogastrium
Ampula of Vader/major
papilla of the Wirsung major
Pancreatic duct empties Dr. Mavrych,
Retroperitoneal Organs: MD,
SAD PhD, DSc prof.mavrych@gmail.com
PUCKER
along with the common bile Suprarenal glands, Aorta, Duodenum (2-3rd), Pancreas, Ureters, Colon, Kidneys, Esophagus, Rectum
duct DPC are secondary retroperitoneal
37. Congenital diaphragmatic

36. Posterior gastric ulcer hernia
1. Posterior gastric ulcer may l Hernia of stomach or

erode through the posterior intestine through a
wall of the stomach into the posterolateral defect
Omental bursa (Lesser in diaphragm
peritoneal sac) and affect (foramen of
pancreas resulting in Bochadalek).
referred pain to the back.
l It is seen in infants
and the mortality rate is
2. Erosion of splenic artery is high because of left
very common in posterior lung hypoplasia.
gastric ulcers as well
because of the proximity of
the artery to this wall. Improper fusion of pleuroperitoneal
membranes with septum transversarus
Most L sided bc liver and R side closes first.
38. Sliding hiatal hernia 39. Meckel's diverticulum

Outpouch of intestines into rectum
l Meckel's diverticulum is a congenital
anomaly representing a persistent portion of
l A sliding hiatal hernia which the vitellointestinal duct.
occurs in individuals past l This condition is often asymptomatic but
middle age is caused by occasionally becomes inflamed if it contains
the hernia of cardia of the ectopic gastric, pancreatic, or endometrial
tissue, which may produce ulceration.
stomach into the thorax
l Meckel's diverticulum is located on the
through the esophageal Ileum about 2 feet (61 cm) before the
hiatus of the diaphragm. ileocecal junction and SMA supply it. It
Fundus of stomach through occurs in 2% of patients and is about 2 inches
(5 cm) long.
l This can damage the vagal l The diverticulum is clinically important
trunks as they pass through because diverticulitis, liberation, bleeding,
the hiatus and resulting in perforation, and obstruction are complications
hyposecretion of gastric requiring surgical intervention and frequently
mimicking the symptoms of acute
juice. appendicitis.
Often due to shortened esophagus
commonly presents at 2yo, 2:1 males to females
40. Features of the large

intestine Colon
l The ascending colon lies
retroperitoneally and lacks a
Features of the large intestine: mesentery.
l It is continuous with the
1. Appendices epiploic transverse colon at the right
2. Sacculations (hepatic) flexure (1) of colon. 1
(haustrations) l The transverse colon (3) has 3
3. Taeniae coli its own mesentery called the
l The taeniae coli meet transverse mesocolon
together at the base of (intraperitoneal position).
the appendix where they l It becomes continuous with the
form a complete descending colon at the left
longitudinal muscle coat (splenic) flexure (2) of colon. 4
for the appendix. l The sigmoid colon (4) is
suspended by the sigmoid
mesocolon (intraperitoneal
position).
Ascending colon (R colic a, iliocolic a w/ appendicular a-SMA)

Transverse colon (Middle colic a, marginal a-SMA)
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Dr. Mavrych, MD, PhD,
Descending DSc
colon prof.mavrych@gmail.com
(L colic a-IMA)
Sigmoid colon (Sigmoid branches of IMA)
Rectum (Superior Rectal a from IMA, Inferior and medial rectal-internal iliac a)
41. Pain of Appendicitis Mc Burney's point

l In appendicitis, first pain is l This point indicates
the surface marking
referred around the umbilicus. of the base of the
Visceral pain in the appendix is appendix.
produced by distention of its
lumen or spasm of its muscle.
l It is a point at the
l The afferent pain fibers enter junction between the
the spinal cord at the level of lateral 1/3 and
T10 segment,
segment and a vague medial 2/3 of a line
referred pain is felt in the region joining the right
of the umbilicus. anterior superior iliac
spine with the
umbilicus.
l Later if parietal peritoneum
gets involved, and then the pain
is shifted laterally to the Mc
Burneyís point. Here the pain
is precise, severe, and localized
(second pain)
McBurney's point lies 2/3 from umbilicus to ASIS OR 1/3 from ASIS to umbilicus
42. Volvulus 43. Hirschsprung's Disease

l It is a rare congenital abnormality that
results in obstruction because the
l Because of its extreme mobility, intestines do not work normally.
the Jejunum, Ileum and l It is commonly found in Down Syndrome
Sigmoid colon sometimes children. males>females
rotates around its mesentery. l The inadequate motility is a result of an
aganglionic section (congenital absents
It results in avascular necrosis of postganglionic parasympathetic
corresponding part of interstine. neurons inside of the intestinal wall) of the
l This may correct itself intestines resulting in megacolon.
spontaneously, or the rotation l In a newborn, the main signs and
symptoms are failure to pass a
may continue until the blood meconium stool within 1-2 days after
supply of the gut is cut off birth, reluctance to eat, bile-stained
completely. (green) vomiting, and abdominal
distension.
l Treatment is removal of the aganglionic
portion of the colon.
NCCs did not travel correctly to the colon resulting in lack of

innervation to the large bowel, no parastalic movements results in
megacolon
44. Branches of Abdominal aorta

and Mesenteric ischemia CELIAC ARTERY (TRUNK)
l Celiac trunk (CA) originates l Origin: T12, just below the

from the aorta at the lower aortic opening of the between crura of
border of T12 vertebra
1 diaphragm. diaphragm
l Superior mesenteric artery
originates at the lower l The CA passes above the
border of L1 vertebra superior border of the
l Renal arteries originate at pancreas and then divides
approximately L2 vertebra 3 into three retroperitoneal
l Inferior mesenteric artery branches:
originates at L3 vertebra 2
l Two terminal branches are l Left gastric artery (1)
common iliac arteries at l Common hepatic artery (2)
the level of L4 vertebra
l Splenic artery (3)
Ovarian/testicular (gonadal) as arise between L2-3
1st off Celiac Trunk 2nd off Celiac Trunk
Left gastric artery Common hepatic artery

2 l The left gastric artery (1)
l The common hepatic artery
courses upward to the left to
(1) passes to the right to
reach the lesser curvature of
reach the superior surface of
the stomach and may be 2
3 the first part of the duodenum,
subject to erosion by a
1 where it divides into its two
penetrating ulcer of the
terminal branches:
lesser curvature of the
1 stomach. l Proper hepatic artery (2)
Branches: l Gastroduodenal artery (3)
l Esophageal branches (2) - to
the abdominal part of the 3
esophagus
l Gastric branches (3) supply
the left side of the lesser
curvature of the stomach and
make anastomosis with right
gastric artery.
OFF Common Hepatic a of Celiac Trunk OFF Common Hepatic a of Celiac Trunk
Proper hepatic artery Gastroduodenal artery

l Proper hepatic artery (1) gives l Gastroduodenal artery (1)
off right gastric artery (2) and descends posterior to the first
5 then ascends within the part of the duodenum (may be
4
hepatoduodenal ligament of the subject to erosion by a
lesser omentum to reach the penetrating ulcer in this place)
3
porta hepatis, where it divides and divides into two branches:
into the right (4) and left (3) 1 l Right gastroepiploic artery (2)
hepatic arteries.
(supplies the right side of the
l The right and left arteries enter the greater curvature of the
two lobes of the liver,, right stomach where it anastomoses
1 2
2 hepatic artery gives cystic artery the left gastroepiploic)
(5) to the gallbladder.
l Superior pancreaticoduodenal
l Right gastric artery (2) supplies arteries (3) (supply the head of
the right side of the lesser the pancreas, where they
curvature of the stomach where it 3 anastomoses the inferior
anastomoses the left gastric pancreaticoduodenal arteries
artery. from the SMA).
3rd off Celiac Trunk
Ligature of the hepatic artery: Splenic artery

l The hepatic artery may be l Splenic artery (1) runs a
ligated proximal to the origin tortuous horizontal course to
of its gastroduodenal branch,
a collateral circulation to the the left along the upper border
liver is established through of the pancreas, behind the
the left and right gastric peritoneum of the posterior
arteries, left and right wall of the lesser sac, forming a
gastroepiploic and part of the stomach bed.
gastroduodenal arteries. 1 l The splenic artery may be
subject to erosion by a
l The right hepatic artery
may be mistakenly ligated penetrating ulcer of the
during holecystectomy in posterior wall of the stomach
Calot triangle together with into the lesser sac.
sac
the cystic artery, right lobe
hepatic necrosis commonly l N.B. The splenic vein runs a
occurs. more straight course below the
artery and behind of the
Anastamoses of the L gastric, L pancreas.
gastroepiploic, and Lgastroduodenal
arteries with the R side will cause Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
retrograde flow into the proper hepatic
artery to supply the liver
SUPERIOR MESENTERIC ARTERY (midgut)
Splenic artery BRANCHES 7

1
lSplenic (1) a. is retroperitoneal

5 until it reaches the tail of the 6 SMA Branches:
pancreas, where it enters the l (1) Inferior
1 2 splenorenal ligament to enter pancreaticoduodenal
the hilum of the spleen. 2 arteries
l (2)Jejunal and (3)
3 4 Branches: Ileal branches
l Branches to the spleen (2) 4
l (4) Ileocolic artery
l Branches to the neck, body, and
l Ascending branch
tail of pancreas (3)
l Anterior cecal artery
l Left gastroepiploic (4) artery that
l Posterior cecal artery
supplies the left side of the
l (5) Appendicular
greater curvature of the stomach
artery
where it anastomoses the right
l (6) Right colic artery
gastroepiploic
3 l (7) Middle colic artery
l Short gastric (5) branches that
supply fundus of the stomach
5

Marginal artery anastamoses the iliocolic a,
vasa recta-SMA, with the L colic, sigmoid a
and vasa recta of the IMA
INFERIOR MESENTERIC ARTERY
Mesenteric ischemia
l Atherosclerosis, which slows the
1 IMA Branches: amount blood flowing through arteries, is
a frequent cause of chronic mesenteric
l (1) Left colic artery ischemia.
l (2) Sigmoid arteries l Ischemia occurs when blood cannot flow
through arteries as well as it should, and
l (3) Superior rectal artery intestines do not receive the necessary
oxygen to perform normally. Mesenteric
ischemia usually involves SMA and small
intestine.
3 l Mesenteric ischemia primarily affects
organs which locate far away from
anastomoses with CA & IMA. Usually
blood supply of the Jejunum and Ileum is
most compromised.
l Mesenteric ischemia typically occurs in
2 people older than age 60 with history of
smoking and high cholesterol level.
45. Biliary system & gallstones Biliary system

l Bile is secreted by the liver cells,
stored, and concentrated in the
gallbladder and later it is
cystic a from R hepatic a
delivered to the duodenum.
l The gallbladder lies in itís fossa l The common bile duct descends in
on the visceral surface of the hepatoduo
the hepatoduodenal ligament,
ligament,
Calot's Triangle
liver right side of quadrate lobe. then passes posterior to the first
l It stores and concentrates bile, part of the duodenum
duo
which enters and leaves it l It penetrates tthe head of the
through the cystic duct. Sphincter of Oddi pancreas whewhere it joins the main
l The cystic duct joins the Ampula of Vader
Amp pancreatic d duct and they form the
common hepatic (from left hepatopancreatic ampulla
hepatopancre
and right hepatic) due to form (sphincter o of Oddi)
Oddi), which drains
the common bile duct. into posteromedial wall the
second part of the duodenum at the
major duodenal papilla
Tumor in the head of the pancreas can block the duct and cause jaundice
Blockage of the cystic or common bile duct via gall stones can cause gall bladder rupture w/ refered
pain to the shoulder (C3-5 phrenic n), and backflow of pancreatic enzymes that digest the pancreas
and the spleen via splenic artery branches
Cholelithiasis (gallstones)
Gallstones
l The distal end of the hepato- l The fundus [1] of the gallbladder is
pancreatic ampulla (Bile duct) is the in contact with the transverse colon
narrowest part of the biliary passages and thus gallstones erode through the
posterior wall of the gallbladder and
and is the common site for impaction enter the transverse colon. They are
of gallstones. passed naturally to the rectum 2
4 1 through the descending colon and
l As result of common hepatic (1), bile sigmoid colon.
duct (2), or hepatopancreatic
ampulla (3) obstruction patient will l Gallstones lodged in the body [2] of
have yellow eyes and jaundice the gallbladder may ulcerate through 1
2 the posterior wall of the body of the
l Gallstones may also lodge in the gallbladder into the duodenum
3 cystic duct. A stone lodged in the (because the gallbladder body is in
cystic duct (4) causes biliary colic contact with the duodenum) and may
be held up at the ileocecal junction,
(intense, spasmodic pain in the producing an intestinal obstruction.
gallbladder) but doesn't produce
jaundice.
Dr. Mavrych, MD,inPhD,

Gall stone DScduct
the cystic prof.mavrych@gmail.com
will cause backflow to the gall bladder (burst) Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
BUT NOT jaundice bc Common bile duct is still releasing bile properly to the stomach
46. Nerve supply of the liver 47. Portal Hypertension &

and gallbladder Portocaval shunts
l Sensory innervation of the liver: by the right l Portal hypertension is a
phrenic nerve ((C3-C5
(C3-C5).
C3-C5).
C3-C5 ). Pain may radiate to the common clinical condition, and
right shoulder.
shoulder for this reason portal-systemic
anastomoses should be
l The liver receives parasympathetic innervation remembered.
from the vagi nerves (CNX), reaching it through
the celiac plexuses around the supplying arteries. l [1] Extrahepatic portocaval
The preganglionic fibers synapse on the cells of
the uxtramural plexuses in hilum of the liver and shunt for the treatment of
shot postganglionic fibers supply organs. portal hypertension: the
splenic vein may be
anastomoses to the left renal
l Sympathetic fibers of preganglionic neurons vein after removing the
T5-T9 segments (IML) come through the
sympathetic trunk and form greater splanchnic spleen.
nerves. They contribute to the celiac plexus, l [2] Intrahepatic portocaval
where postganglionic neurons are located. shunt : between portal vein
Branches of celiac plexus reach the liver wrapping and hepatic veins
around the branches of the celiac artery.
Diverting blood from portal venous system to the systemic venous system by creating a
communication between the hepatic portal vein and the IVC.
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Dr. Mavrych, MD,
Side to side PhD,
shunts DSc prof.mavrych@gmail.com
connecting the portal system to the IVC, End to side connection with
separation and connection of end and head of portal caval system to IVC. And typical
splenorenal central shunt all allow portion of blood to IVC to decrease flow to liver.
Large intestine metastases &

Portocaval anastomosis Esophageal anastomosis
l Metastases of the Large intestine
cancer typically rich the Liver via l Anastomosis between the
portal venous system: Rectum - tributaries of the left gastric
IMV - splenic vein - portal vein - vein (portal vein) and the
Liver tributaries of the azygous
vein (SVC) in the wall of the
l If there is an obstruction to flow lower end of the esophagus.
through the portal system (portal
hypertension), blood can flow in a
retrograde direction and pass
l In portal hypertension these
veins enlarge in the wall of the
through anastomoses to reach the esophagus and later burst
caval system.. Sites for these into the lumen of the
anastomoses include: esophagus (esophageal
l (1) esophageal veins varices) resulting in
hematemesis (vomiting red
l (2) paraumbilical veins blood).
l (3) rectal veins
(4) R, L and middle colic vs anastamose with Esophageal branches of the L Gastric v will anastomose with azygous
Renal, suprarenal and gonadal vs, No clinical Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
name however represents as varicocele on the
abdomen
Umbilical anastomosis Rectal anastomosis

l Anastomosis between the l Anastomosis between the
paraumbilical veins (portal superior rectal vein
vein) and the superior and (inferior mesenteric vein
inferior epigastric veins and then portal vein)
vein and
(SVC and IVC) in anterior inferior rectal vein which
drains into the internal iliac
abdominal wall around the vein (from IVC system).
umbilicus.
l In portal hypertension
l In portal hypertension, this (chronic alcoholics) this
anastomosis gets enlarged anastomosis gets dilated
and dilated veins form ìcaput resulting in internal
Medussaeî around the hemorrhoids and bleeding
umbilicus. per anus from superior
rectal vein.
Superior Rectal vein (IMV) anastomoses with middle and inferior rectal vs (internal iliac v &
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Dr. Mavrych,
internalMD, PhD,v)DSc
pudendal duringprof.mavrych@gmail.com
portal hypertension Rectal varices (Hemorrhoids)
Internal hemorrhoids are painless superior to pectinate line at internal rectal venous plexus.
External hemorrhoids are painful due to blockage of external rectal venous plexus, where
Nociceptors (pain) are located.
48. Pancreas: Cancer of the head

Head and uncinate process of the pancreas
l The head of the pancreas ! Cancer of the head of the
rests within the C-shaped pancreas compresses the bile
1st part of Duodenum area formed by the 1st-3rd parts of duct and results in
duodenum and is duodenum OBSTRUCTIVE TYPE OF
traversed by the common JAUNDICE.
bile duct. ! Pain will be conveyed to sensory
neurons T5-T9 dorsal root
l It includes the uncinate ganglia via celiac plexus and
2nd part of greater splanchnic nerve.
duodenum
process which is crossed
by the superior
mesenteric vessels. ! This type of jaundice is NOT
usually associated with fever.
! Hepatitis also causes jaundice
4th part of duodenum
but is associated with the
fever.
3rd part of duodenum
If the cancer blocks the Wirsung duct, it can cause pancreatic enzymes to digest the
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Dr. Mavrych, MD, PhD,
pancreas and theDSc prof.mavrych@gmail.com
spleen via splenic artery.
Neck of the pancreas Body of the pancreas
l The body passes to the

left and anterior to the (1)
aorta and the (2) left
l Posterior to the 1 kidney. posterior to the stomach
3 neck of the 3
1 pancreas is the site l The (3) splenic artery
of formation of the undulates along the
PORTAL VEIN.
VEIN superior border of the
2 body of the pancreas with
2 the splenic vein coursing
l (1)Splenic vein
joins with (2) posterior to the body.
body
superior
mesenteric vein to The splenic artery is tortuous and has branches
form (3) portal vein. going down to perforate the pancreas.
Arterial supply of the

Tail of the pancreas pancreas
Head and Duodenum:
l The tail of the pancreas l (1) Superior
enters the splenorenal pancreaticoduodenal arteries - Off Common
ligament to reach the branches of gastroduodenal Hepatic a of
hilum of the spleen
spleen. artery. Celiac trunk
l It is the only part of the l (2) Inferior pancreaticoduodenal

arteries - branches of SMA
pancreas that is
intraperitoneal. l This region is important for
3 collateral circulation because
l Tail of the pancreas may there are anastomoses between
be mistakenly removed 1 these branches of the CA and
during spleenectomy SMA.
(ligation of splenic artery
2
and vein) and resulting in Neck, Body, and Tail of the
sugar diabetes because it pancreas:
contains a lot endocrine l Pancreatic branches of the (3) Off celiac trunk
cells. Splenic artery.
Endocrine pancreas contains
islet of langerhans that secretes
insulin (B cells glucose uptake) Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
and glucagon (A cells glucose
release)
49. Spleen: RUPTURE

Annular Pancreas Rapture of the Spleen
l Annular pancreas is caused by
malformation during the l Rapture of the spleen may be
result of the left 9th and 10th ribs
development of the pancreas,
fracture or blunt trauma of the
before birth. left upper abdomen.
l Occurs when the ventral and dorsal l The spleen is a peritoneal organ
pancreatic buds form a ring around in the upper left quadrant that is
the duodenum,, thereby causing an deep to the left 9th, 10th, and 11th
obstruction of the duodenum and ribs.
polyhydramnios l The spleen follows the contour of
l Symptoms: rib 10 (axis of the spleen).
l When blood collected deep to the
1. Feeding intolerance in newborns diaphragm phrenic nerve
2. Fullness after eating irritates and pain may irradiate to
left shoulder.
3. Nausea and bile-stained vomiting
(Projectile vomiting) l When spleen is ruptured, it
l Half of cases are not diagnosed cannot be sutured therefore
until symptoms occur in adulthood. removing is required.
Polyhyrdaminos (>1500mL) AF in the amnion bc the fetus is unable to
Prenatally the spleen is primary source for hematopoiesis, post birth it is site of RBC
Dr. Mavrych, drink
MD, and recycle
PhD, DScit.prof.mavrych@gmail.com
Also caused by esophageal atresis. Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
sequester, destruction, and filtration, it produces lymphoctyes and immune
surveillance, it recycles iron and globin. (Not vital organ)
The spleen has gastric, colic, renal, and costal impressions. It contains many
lymphatic nodules, red pulp (blood sinuses) and white pulp (germinal centers).
Relations of the Spleen and 50. Kidney:

Left Kidney Dimensions and position
l The spleen follows l During life, kidneys are
reddish brown and measure
the contour of 10th rib approximately 11-12 cm in
and extends from the length, 5-6 cm in width, and
superior pole of the 2.5-3 cm in thickness.
thickness
left kidney to just l They are extending from the
posterior to the level of T12 to the level of L3,
midaxillary line. the right kidney lying about
2-3 cm lower than the left
one.
l The border between
l The lateral border of the
spleen and upper kidney is convex. Its medial
pole of the left kidney border is convex at both ends
is 11th rib. but concave in the middle
where there is the hilum of
the kidney (L1).
parietal lateral plate mesoderm
Hilum of the kidney contains the renal v
(front), renal a (middle), and ureter (back).
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Kidneys are intermediate mesoderm from
mesonephric duct and metanephric cap.
Anterior relations Anterior relations

of the right kidney of the left kidney
APICAL 1. Right suprarenal gland pyramidal

Pouch of Morison 2. 2nd part of the 1. Left suprarenal gland semilunar
ANTEROSUPERIOR duodenum 2. Stomach
3. Right lobe of the liver 3. Spleen
4. Right colic flexure ascending colon to 4. Body of pancreas and
L2 splenic vessels L1
5. Small intestine transverse colon
ANTEROINFERIOR Short renal v and Long renal a 5. Descending colon
6. Small intestine
Long renal v and short renal a
INFERIOR
Suprarenal glands/adrenal glands have 3 sources of

bloody supply: Phrenic artery (superior), aorta (mid),
and renal artery (inferior)

APICAL Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
POSTERIOR
INFERIOR
segments of posterior kideny
Renal (Gerota) fascia Perinephric abscess

Pus around the kidney within the perinephric/renal fascia
l Enclosing the perinephric fat is
a membranous condensation l Most infections of the perinephric
of the extraperitoneal fascia - space occur as a result of extension
of an ascending urinary tract
the renal fascia (3). infection, commonly in association
l The suprarenal glands (4) are with nephrolithiasis or tuberculosis.
4 also enclosed in this fascial l Perinephric abscess typically
compartment, usually descends down between 2 sheets of
the renal fascia along the psoas
separated from the kidneys by major muscle.
a thin septum. l In case if abscess locates behind of
l N.B. The renal fascia must the psoas major muscle it descends
3 down and may affect hip joint.
be incised in any surgical
approach to this organ. l If abscess spreads up itíll reach the
diaphragm and irritate phrenic
nerve. As result patient will feel pain
in shoulder region.
Paranephric fat surrounds the
renal fascia and collagen bundles loosely attached renal fascia in anterior and posterior
thether the renal vessels and layers can allow extension of abscess
kidneys in a fixed position even
though supine to erect
movements (~3cm) occurs during
inspiration.
51. Nephrolithiasis 3 constrictions of ureter:

l Renal calculi are solid concretions
(crystal aggregations) formed in the 1 l Ureter located on the anterior
kidneys from dissolved urinary minerals. surface of the Psoas major
muscle and has 3 constrictions:
l There are several types of kidney l 1st constriction is at the
stones. The majority are calcium pelviureteric junction (level of L1)
oxalate stones, followed by calcium l 2d constriction lies at the level of
phosphate stones. pelvic brim (level of the sacroiliac
joint)
l Kidney stones typically leave the body
l 3d constriction appears where
by passage in the urine stream, and ureter lies obliquely in the wall of
many stones are formed and passed 2 urinary bladder (level of ischial
without causing symptoms. spine)
l If stones grow to sufficient size before
passage (at least 2-3 mm), they can
cause obstruction of the ureter (renal
colic).
Kidney stones that can form and become located in
the calices of the kidneys, ureters or bladder.
Renal colic is abdominal pain that courses down from
loin to groin as stone moves anteroinferiorly.
Staghorn calculi 52. Suprarenal glands

l Renal stone that develops in the l They are endocrine glands
renal pelvis and greater calices,
calices having cortex and medulla.
and in advanced cases has a l The adrenal cortex [1]
branching configuration which secretes aldosterone,,
resembles the antlers of a stag. corticosteroids and
l Staghorn calculi are composed of genital hormones.
magnesium ammonium l The chromaffin cells of the adrenal medulla [2]
phosphate, which forms in urine secrete two catecholamines: epinephrine and
that has an abnormally high pH 1
norepinephrine, which affect smooth muscle, cardiac
(above 7.2). muscle, and glands in the same way as sympathetic
l This high pH usually develops 2 stimulation.
because of recurrent urinary tract l Sympathetic stimulation or hypersecretion of
infection with microorganisms catecholamines ((tumor
tumor of adrenal medulla or
such as Proteus mirabilis. sympathetic chain ganglia)) resulting in: episodes of
tachycardia, sweating and high blood pressure.
Congenital Adrenal Hyperplasia (CAH):
Nephroptosis: Drop kidney >3cm when standing, suprarenal glands stay in place within perinephric fat, ureters coil/kink.
Ectopic kidneys: abnormal location and formation congenitally.
excessive androgen production bc of cortex
hyperplasia causing virilization of female genitals
Horseshoe kidney: inferior poles of kidneys fuse during embryonic development and are inhibited from ascending by IMA
Pancake kidney: inferior and superior poles of kidneys fuse into disc shape organ, also inhibited by IMA.
Pelvic kidney: failure of ascent of kidneys so they remain in pelvic region still attached to embryological renal vessels off common iliacs.
Renal agenesis (absent of kidneys) is common cause of oligohydraminos (<400mL AF) that can lead to pulmonary hyperplasia.
Hydronephrosis: extreme dilation of renal pelvis and calices due to obstruction of renal ureters, typically due to accessory renal vessels.
Unpaired tributaries of IVC

53. Varicocele
l The right renal (1) vein is
much shorter than the left. l It is enlargement of the
3 Both veins lie anterior to the pampiniform plexus that
corresponding artery in produces a wormlike scrotal
2 hilum of kidneys. mass and enlargement of the
l The long left renal vein (2) spermatic cord. Varicocele
may be reason of low sperm
1 is joined by the left count.
4 suprarenal (3) and left
l Varicocele formation is usually
gonadal (4) (testicular or on the left side and may
ovarian) veins before it disappear in supine position
reached IVC. of the body.
l Varicocele may indicate
l Right suprarenal vein and kidney disease or may signal
right gonadal vein drain a retro peritoneal malignancy
obstructing the testicular
directly to IVC (unpaired vein.
IVC tributaries).
Nutcracker Syndrome: L Renal v passed UNDER the SMA
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Dr. Mavrych, MD, and
PhD, DSc prof.mavrych@gmail.com
ABOVE Aorta. Compression will cause backflow into the
L gonadal vein to pampiniform plexus.
.
May be mistaken for Hydrocele (fluid/blood) within tunica
vaginalis of the scrotum, but when lying down Hydrocele
DOES NOT Disappear!
Pampiniform plexus
54. Hydrocele
l Each testicular or ovarian vein is
formed by coalescence of a l The tunica vaginalis testis or
pampiniform plexus:
plexus the other remnants of the processus
testicular at the deep inguinal vaginalis may form a hydrocele
ring, the ovarian at the margin of or hematocele.
the superior aperture of the l In spermatic cord it is smooth
pelvis. sausage-shaped structure that
l The veins run accompanied by persists under gentle
the corresponding arteries. The compression and isnít disappear
left pampiniform plexus enters in supine position.
the left renal vein; the right one l In the scrotum with
enters directly the IVC inferior transillumination, a hydrocele
to the renal vein. produces a reddish glow,
l That is why varicocely whereas light will not penetrate
(engorgement of the pampiniform other scrotal masses such as a
plexus that produces a scrotal hematocele, solid tumor, or
mass) is more often located on herniated bowel. spermatocele
the left.
Testicular torsion is twisting of the testis within the
scrotum, it can cause ischemia to the blood vessels
and must be corrected quickly or may lose testis.
Cryptochidism: failure of testis to descend by age 6-9mo can cause infertility

55. Hemorrhoids:
Venous drainage from rectum External hemorrhoids
l Above pectinate line: superior
rectal vein [1] into portal l Hemorrhoids are masses that
2 system [2]. typically protrude from anus
4 PAINLESS during defecation.
l Hemorrhoids are commonly
l Below pectinate line: inferior associated with constipation,
rectal vein [3] into inferior extended sitting and straining at
vena cava [4]. the toilet, pregnancy, and
disorders that hinder venous return.
PAINFUL
l 1. External hemorrhoids are
1 1 dilated tributaries of the inferior
rectal veins (IRV) BELOW THE
PECTINATE LINE and are painful
because the mucosa is supplied by
3 somatic afferent fibers of the
1 inferior rectal nerves (from
pudendal).
56. Perineal pouches:

Deep perineal pouch
Internal hemorrhoids
Bound inferiorly by perineal membrane and superiorly by pelvic diaphragm.
l 2. Internal hemorrhoids The deep perineal pouch is
are dilated tributaries of the formed by the fasciae and
superior rectal veins muscles of the urogenital
(SRV) ABOVE THE diaphragm.
PECTINATE LINE and are It contains:
not painful because the 1. Sphincter urethrae
mucosa is supplied by muscle
visceral afferent fibers.
2. Deep transverse
perineal muscle
l Internal hemorrhoids 3. Bulbourethral
2
frequently develop in (Cowper) glands (in
chronic alcoholics
the male only)) - ducts
2 because of liver cirrhosis
and portal hypertension perforate perineal
2 membrane and enters
syndrome.
bulbar urethra.
Dorsal neurovascular structures
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com of the glans penis and clitoris
Bound laterally by Ishiopubic rami
Superficial perineal pouch

1. Ischiocavernosus muscle ñ related to the Crus of the
penis (Male) & Crus of the clitoris (Female)
Urine leaks
2. Bulbospongiosus muscle ñ related to the Bulb of & deep internal pudendal vessels Straddle injury or false passage of catheter
vestibule (Female) & Bulb of the penis (Male) and pudendal n (dorsal VAN)
l After a crushing blow or a
3. Superficial transverse perineal muscle ñ related to the penetrating injury, the spongy
Perineal body (both genders) urethra commonly ruptures
1 within the bulb of the penis,, and
urine leaks into the superficial
perineal pouch.
2
l The superficial perineal fascia
keeps urine from passing into the
3
thigh or the anal triangle, but after
distending the scrotum and penis,
urine can pass over the pubis into
the anterior abdominal wall deep
to the deep layer of superficial
abdominal fascia.
Fractures of the pelvic girdle can rupture the intermediate urethra and
cause extravasation of urine and blood into deep peritoneal pouch that may
Dr. Mavrych,
Essential MD, PhD,
for integrity of theDSc prof.mavrych@gmail.com
pelvic floor, Damage leads to prolapse of uterus, rectum, and urinaryDr. Mavrych, MD, pass
bladder PhD,through
urogenital hiatus to bladder and prostate.
Males: between bulb of penis and anus, Females: between vagina and anus
Episiotamies in mediallateral incisions are made to widen pouch for labor, and to fix prolapses. Congenital persistence of allantois into urachus of the umbilicus can cause
urine to leak from belly button.
57. Ischiorectal abscess 58. Cystocele

(hernia of bladder)
l Ischiorectal abscess [1] is an important
surgical condition which usually results l Loss of bladder support in
from spread of an infection through the females by damage to the
external sphincter ani into the pelvic floor during childbirth
ischiorectal fossa [2]. (e.g., laceration of perineal
l Ischiorectal abscess is a surgical muscles or a lesion of the
2 emergency which should be nerves supply).
immediately drained by a wide cruciate l It can result in protrusion of
incision through the skin of the base of the bladder onto the
anterior vaginal wall and
the fossa to avoid fistula formation.
loss of urine when a women
l A surgeon should avoid lateral wall of strains or coughs.
3 ischiorectal fossa because here located
Pudendal (Alcock's) canal [3] with In extreme cases it can lead to
pudendal nerve and internal pudendal vaginal prolapse
1 artery.
Fistulas are abnormal connections of organs and

Dr. Mavrych, MD, PhD,Ischiorectal
tissues, DSc prof.mavrych@gmail.com
abscesses can travel to both sidess Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
and spread infection through the fat fad that raps
posteriorly around the rectum. Incisions must be made
as medial as possible. If Pudental canal is affected
there will be no arousal. Abscesses are also prone to
supralevator, internsphincteric, or perianal.
60. Prostate tumors:

59. Paracentesis of Urinary
Prostate cancer
Bladder Suprapubic cystotomy of a full bladder, as the
empty bladders lies just at height of pubis
l It usually begins in the posterior

Sup
Suprapubic aspiration: lobe of the gland, and early
stages are often asymptomatic,
l Urine can be removed from may be found during digital
the bladder without penetrating rectal examination.
the peritoneum by inserting a Full bladder during exam to
needle JUST ABOVE the keep prostate in place
pubic symphysis. l Prostatic malignancies tend to
l The needle passes
metastasize to vertebrae and
successively through skin, the brain because the prostatic
superficial and deep layers of venous plexus has numerous
superficial fascia, linea alba, connections with the vertebral
transversalis fascia, venous plexus via sacral veins.
veins
extraperitoneal connective M
tissue, and wall of the bladder. A Benign hypertrophy of prostate (BHP) is
P common after middle age in majority of males
does not transverse peritoneum distorts the prostatic urethra (middle lobe).
Malignant tumors are irregular and hard and
often found in posterior lobe due to its
proximity to seminal vesicles and lymph.
Benign hypertrophy of the

prostate (BHP) typically middle lobe Prostatectomy
l A prostatectomy may be performed
l BHP is common in men after through a suprapubic [1] or
middle age. perineal [2] incision or
l Prostate adenoma (benign transurethrally [3].
hypertrophy) usually involves l Because of damage to nerves in
1
median lobe.
lobe 2 the capsule of the prostate and
l BHP is a common cause of around the urethra (cavernosus
urethral obstruction, leading nerves) can cause impotence
to nocturia (need to void (erectaile dysfunction) and/or
during the night), dysuria urinary incontinence.
(difficulty and/or pain during l Pelvic splanchnic nerves may be
urination), and urgency 3 injured in case of intensive
(sudden desire to void). dissection of pelvic lymph nodes
l The prostate is examined for Transurethral (prostatic cancer ectomy) and as
enlargement and tumors by resection of th
the result autonomic innervation of
DIGITAL RECTAL prostate = TURP
TUR derivate of hindgut may be
examination. allows preservation of affected.
neurovasculature
Posterior lobe is mostly metastatic and spreads via Batson's plexus (male has lower back pain)
61. Male urethra

Prostatic 1st part
Membranous 2nd part
l It is the widest and the most
dilatable part. l Passes through the
l It is spindle shaped (middle part is urogenital
dilated) diaphragm to enter
the bulb of the penis
l Its posterior wall presents the
following features: l It is the shortest,
opening of seminal glandscolliculus NARROWEST and
1. Seminal the least dilatable part
2. Openings of the 2 ejaculatory l It is surrounded by the
ductus deferens ducts are seen on each side on
external sphincter
the seminal colliculus. urethra
3. Ducts of the prostate gland open l Bulbourethral
into the male urethra glands lie
posterolateral to this
part inside of
urogenital diaphragm
(deep perineal
pouch)
Seminal vesicles secrete alkaline fructose solution that nourishes and provides energy for the sperm.
Prostate gland secretes a milky fluid (20% of semen volume) and plays role in sperm activation.
Bulbourethral glands (cowper's glands) secrete mucous solution that neutralizes urine within the urethra.
Spongy 3rd part 2 sphincters of the urethra

l Longest part: average 15 1. Internal urethral
cm in length. sphincter is made of
l Passes through the bulb smooth muscles in the
and corpus spongiosum neck of the bladder
of the penis to open at the and has sympathetic
external urethral orifice on innervation
the tip of the glans penis. 1
l There are two dilatations 2. External urethral
ñ bulbar fossa (in the sphincter has skeletal
beginning) and navicular 2
muscle fibers and
fossa (in the glans penis) surrounds the
l Ducts of the membranous part of
bulbourethral glands urethra, supplied by
open into the floor of the the perineal branch of
spongy part in its the pudendal nerve
beginning
The 1st and 2nd parts of the urethra are urogenital endoderm and the external urethra meatus is ectoderm
The ductus deferens is intermediate mesoderm of the remaining mesonephric duct/tubules
Muscle of the bladder is Detrusor m, the urinary trigone is where the
entrance of the 2 ureters and exit of bladder meet. Internal urethral
sphincters are involuntary.
62. Ejaculatory duct 63. Pudendal nerve (S2-S4)

l It is PRINCIPAL SOMATIC ((motor
motor and
l It is a very narrow duct sensory) nerve to supply perineum.
2 cm long l Lies against ischial spine as it passes
l Formed by union of through lesser sciatic foramen to
ductus deferens and traverse pudendal canal on lateral
wall of ischiorectal fossa.
duct of seminal vesicle
Branches:
l It serve to passage of l 1. Inferior rectal nerve
seminal fluid from l Supplies external anal sphincter
ductus deferens to muscle and skin around anus
prostatic urethra. 3 l 2. Perineal nerve
1 l Deep branch is motor nerve to muscles
of urogenital triangle.
2 l Superficial branch gives cutaneous
posterior scrotal/labial branches.
l 3. Dorsal nerve of penis or clitoris
l Supplies body, prepuce, and glans of
penis or clitoris
Dr. Mavrych,CREMASTERIC
MD, PhD, DSc prof.mavrych@gmail.com
REFLEX: Genitofemoral Dr. Mavrych,
nerve L1-2, Genital branch: withinMD, PhD, DSc
inguinal prof.mavrych@gmail.com
canal with the cremasteric m and fascia acts as
motor division to pull testis up. Femoral branch is the sensory division of the reflex that is stimulated by touch and temperature
64. Nerve supply of pelvic

Pudendal nerve block
viscera
l To relieve pain for the mother and Parasympathetic innervation:
prepare for an episiotomy, a l Preganglionic neurons are located in sacral parasympathetic n.
pudendal nerve block may be (S2-S4) in the spinal cord.
administered during early labor. l Their processes run into pelvic splanchnic nerves and relay with
The nerve may be blocked in 2 ways postganglionic neurons located inside of pelvic organs in the
either: intramural plexus.
plexus
1. by piercing the vaginal wall Sympathetic innervation:
posterolaterally near the ischial l Sympathetic fibers of preganglionic neurons T12-L2 segments (IML)
spine or come through the sympathetic trunk and form sacral splanchnic
nerves.
2. percutaneously along the medial
l They contribute to the inferior hypogastric plexus,
plexus where
side of the ischial tuberosity. postganglionic neurons are located. Branches of inferior hypogastric
l Note: Pain from uterine contractions is plexus reach organs wrapping around the branches of the internal iliac
unaffected because pelvic visceral artery.
Sensory innervation:
pain is carried by afferent fibers
l The sensory fibers from S2-S4 dorsal root ganglia move together
accompanying autonomic nerve fibers. with parasympathetic and carry pain sensations from the organs.
Doctors hand is placed between the baby's head and the pudendal nerve.
PNS Pelvic Splanchnic nerves to intramural plexus
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Dr.SNS Sympathetic
Mavrych, Trunk
MD, PhD, DScto Sacral Splanchnic nerves to inferior hypogastric plexus
Sensory DRG ride with PNS for PAIN
Micturition reflex 65. Erection and ejaculation

l Afferent fibrous: Dorsal nerve of penis or clitoris from
Pudendal nerve (DRG S2-S4)
Facilitating emptying: l Efferent fibrous:
l Parasympathetic fibers (pelvic
1 l Erection: Parasympathetic fibers (S2-S4) from the
splanchnic nn.) stimulate
DETRUSOR MUSCLE [1] Pelvic splanchnic nerves dilate arteries supplying
contraction and involuntary relax erectile bodies of the penis, allowing them to fill with
internal sphincter [2]. blood. Somatic motor (S2-S4) fibrous from the
2 l Somatic motor fibers (pudendal pudendal nerves cause contraction of
nerve) cause voluntary ischiocavernosus and bulbospongiosus muscles to
relaxation of external [3] urethral press the root of the penis and relax external urethral
sphincter. sphincter.
3 l Ejaculation: Sympathetic fibers (L1-L2) from the
Inhibiting emptying: Inferior hypogastric plexus (Sacral splanchnic
l Sympathetic fibers (sacral nerves) cause contraction of smooth muscle of
splanchnic nn.)
.) inhibit detrusor epididymis, ductus deferens, seminal vesicles, and
muscle [1] and stimulate prostate; sympathetic nerve fibers stimulate internal
internal sphincter [2]. urethral sphincter to prevent semen from entering
bladder or urine entering prostatic urethra.
PNS & Pudendal to pee!
SNS to stop!
1. Erection: PNS S2-4 fill blood, Ischiocavernosus m keeps erect, and bulbospongiosus m
prevents venous drainage.
2. Emission: SNS move sperm from epididymis and cause gland secretions
3. Ejaculation: SNS Closure of Internal sphincter, contraction of urethral m and
bulbospongiosus m
4. Remission: blood leaves
67. Torsion of the spermatic

66. Cryptorchism cord
Main components of the spermatic cord:
l Undescended testes l Ductus deferens
(cryptorchism) when the testes l Testicular artery ñ direct branch of
fail to descend into the scrotum. Aorta
This normally occurs within 3 l Pampiniform plexus to become
months after birth. single testicular vein (right ! IVC, left
l The undescended testes may be ! Left renal vein)
found in the abdominal cavity or
in the inguinal canal. l Torsion of the spermatic cord
l If neglected, malignant produces acute pain with swelling
transformation may occur in the because of twisting of testicular
undescended testis. artery that can result in testicular
l N.B. In case of cryptorchism, avascular necrosis.
spermatogenesis is arrested l Repair requires a high scrotal incision
and the spermatogenic tissue is to untwist the cord,, and the testis is
damaged leading to permanent sutured to the scrotal septum to
sterility in bilateral cases. prevent recurrence.
68. Lymphatic drainage of the Lymphatic drainage from the

male viscera female viscera
n Testis & epididymis ñ lumbar n Ovary and uterine tubes ñ to Lumbar
lymph nodes lymph nodes
n Uterus:
n Scrotum ñ superficial inguinal n lateral angle and teres ligament ñ
nodes Superficial inguinal lymph nodes
n Penis: n fundus and upper part of the body
- Lumbar lymph nodes
n skin - superficial inguinal nodes n lower part of the body - External
n glans ñ deep inguinal nodes iliac lymph nodes
n body and roots ñ internal iliac n cervix - External & Internal iliac
nodes n Vagina:
n Superior to hymen - to External &
n Prostate gland & bladder - internal
internal iliac
iliac nodes n Inferior to hymen - to Superficial
n Anal canal: inguinal nodes
n above pectinate line - internal iliac n All external genitalia (with exception -
n below pectinate line - superficial glans clitoris) - Superficial inguinal
lymph nodes
inguinal nodes
n Glans clitoris ñ Deep inguinal
Deep inguinal nodes-> superficial inguinal nodes-> internal & external iliac nodes-> lumbar nodes-> paraaortic nodes-> thoracic duct
69. Arterial supply of the uterus

Hysterectomy
and Hysterectomy
l Hysterectomy is surgical removing of the
The uterus is almost exclusively
uterus and may include removing of the cervix
supplied by the uterine arteries
4 (total) and the vagina (radical).
[1] (from internal iliac artery):
l Blood supply to the ovaries is saved in case of
2 l Uterine a. crosses pelvic floor in
partial hysterectomy ovarian suspensory
cardinal ligament [2]
1 ligament should be left intact because contain
l Ureter passes
passessuperior
below the
andUterine ovarian artery (direct branch of abdominal
3 anterior(bridge
artery to uterine artery[3]
over water) aorta) and vein.
l Ascending branch [4] of uterine
l In case of total hysterectomy (with cervix)
artery comes along lateral wall of pelvic splanchnic nerves may be affected.
uterus within broad ligament. Thatís resulting in bladder dysfunction
Note: During hysterectomy ureter in the because of detrusor urine muscle loose
Uterine a anastamosis with
greatest risk because of close relations parasympathetic innervation.
with uterine artery and cervix of the Ovarian a from aorta on lateral
uterus. sides of the uterus. Both need to No contraction of bladder and no relaxation of
be taken out so that the pt does not internal sphincter.
bleed out.
.
The Uterine a is homologous to the
ductus deferens a in males and the
Ovarian a is the testicular a in
males
70. Parts of the uterine tube Hysterosalpingography

oviduct, fallopian tube, ovarian tube...
l Uterine part l The instillation of
Pierces uterine wall to Cornua 3
l
open into uterine cavity
of the uterus 4 viscous iodine
through the
l Isthmus
l Narrowest part of tube external os [1] of
just lateral to uterus 2 the uterine cervix
l Ampulla allows the lumen of
l Medial continuation of 1 the cervical canal
infundibulum comprising [2],, the uterine
about half of uterine tube
l Usual site of fertilization cavity [3],, and the
l Infundibulum different parts of
l Funnel-shaped expansion the uterine tubes
of lateral end, fringed with [4] to be visualized
fimbriae on X-ray.
l Overlies ovary and
receives oocyte at Can be used to detect uterine tube
ovulation
obstructions or malformations of uterus/
Ampulla is the site of ectopic pregnancy if the fertilized
vagina (bicornate uterus)
Dr. Mavrych,
ovum MD, PhD,
does notDSc prof.mavrych@gmail.com
make its way to the fundus of the uterus. Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
The Uterine Triad: Fallopian tube, Round lig of uterus (inguinal

canal), and ovarian lig come off the fundus of the uterus.
Internal iliac artery

71. Branches of the Internal
iliac artery
Anterior Division Posterior Division
goes back up
1. Obturator 1. Iliolumbar
w/ superior to medial sacral a to medial sacral a
2. Umbilical vesicle of bladder 2. Lateral sacral
between lumosacral trunk & S1 obturator canal
3 Inferior gluteal 3. Superior gluteal
alcock's canal gluteus maximus
maxi
4. Internal pudendal urachus
5. Inferior vesical (males)
bladder
or
Vaginal (females) bladder gluteus med & min
6. Middle rectal
coccygeus m
ductus deferens
7. Uterine (females)
aberrant or accessory arteries are common in obturator, inferior vesicle genitals
72. Fracture of the Craniosyntosis-FGFR2 gene mt

anterior cranial fossa 73. Cranial Malformations
l Fracture of the anterior cranial l [A] Scaphocephaly: premature
fossa (Cribriform plate of the closure of the sagittal suture, in
Ethmoid bone) is suggested by which the anterior fontanelle is small
anosmia, periorbital bruising or absent, results in a long, narrow,
(raccoon eyes), and CSF leakage wedge-shaped cranium.
from the nose (rhinorrhea). l [C] Oxycephaly: premature closure
of the coronal suture results in a
high, tower-like cranium.
l When premature closure of the
coronal or the lambdoid suture occurs
on one side only, the cranium is
twisted and asymmetrical, a condition
known as plagiocephaly [B].
76. Infection of the Cavernous

74. Epidural hematoma Bean Bleed sinus
Skull fracture near pterion often
l Structures which may be affected by
causes epidural hematoma from cavernous sinus thrombosis:
thrombosis
torn middle meningeal artery 1. Structures that pass through
sinus directly:
(foramen spinosum).
spinosum)
ÿ Internal carotid artery (in case
l Unconsciousness and death are of laceration - arteriovenous
rapid because the bleeding fistula)
dissects a wide space as it strips ÿ Abducens nerve CN VI (in case
the dura from the inner surface of of lesion - internal squint)
the skull, which puts pressure on
the brain. 2. Structures on lateral wall of
sinus:
l An epidural hematoma forms a
ÿ Oculomotor nerve (CN III)
characteristic biconvex pattern ÿ Trochlear nerve (CN IV)
on computed tomography ÿ V1
images. ÿ V2
can push uncus through foramen magnum and compress CNIII causing pupillary
dilation (SNS) bc no PNS to constrictor, eye points down and out (CNVI and IV take Medial Rectus adduction takes over (cross-eyed) initially, if bleed persists
over), ptosis bc levator palpebrae m
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Dr. Mavrych, MD, then
PhD,lateral
DSc wall structures will be affected: loss of eye movements and
Subdural Hematoma: blood spread over brain, Shaken Baby visual acuity. Loss of sensory to face
Syndrome, coup and counter coup injuries, cause bleeding from
bridging veins
77. Pituitary gland tumors and

Dangerous triangle of the face transsphenoidal operation
2 1
l The middle third of the face l Pituitary tumors [1] may extend
is a "danger areaì because superiorly through opening in the
infection there may produce diaphragma sella, producing
thrombophlebitis of the facial disturbances in endocrine system.
system
vein that can spread to the l Superior extension of a tumor may
cavernous sinus via swelling of v w/ blot cause visual deficit owing to pressure
ophthalmic veins or clot that goes to brain on the optic chiasm [2], the place
pterygoid venous plexus.
where the optic nerve fibers cross.
l The transsphenoidal operation is the
l Septicemia leads to
meningitis and cavernous most common operation for a pituitary
sinus thrombosis, both of tumor. The surgical approach for it is
which can cause neurological through the nose, nasal cavity and
damage and are life- sphenoidal sinus [3][3]. This surgical
threatening. bacterial infection response 3 approach provides the best exposure
of the tumor at the lowest risk.
Facial v (cheeks)-> angular v (lateral nose)-> opthalmic v (super& inferior eye)-> Cavernous sinus (BRAIN)
Hormones of the pituitary 78. Trigeminal nerve

gland
l Releasing and inhibiting factors
from neurosecretory cells of the l Skin of face supplied
hypothalamus reach pituitary by branches of the
gland thought special capillary three divisions of the
network ñ hypophyseal portal [1] TRIGEMINAL
system and control the production NERVE (CN V)
of adenohypophyseal hormones 1
(ACTH, FSH, LH, TSH, prolactin l Except for a small
area over the angle
and somatotropin). of the mandible
l Hormones of neurohypophysis which is supplied by
Infraorbital the [2] great
(ADH and Oxytocin) are secreted foramen auricular nerve
in hypothalamus and transported (C2-C3) ñ cervical
through axons to pituitary gland. plexus
2
ACTH-> adrenal gland-> cortisol
FSH-> follicles of ovaries
LH-> ovaries and leydig cells
Dr. Mavrych,TSH->
MD, PhD, DSc prof.mavrych@gmail.com CNV1:
Dr. Mavrych, sensory
MD, PhD, DSc to forehead, sinuses, nose, dilator pupillae (SNS) and sensory
thyroid gland for release of T4&T3 TH
blinking reflex, (VII is motor)
Prolactin-> mammary gland
CNV2: sensory to cheeks, nose, upper mouth, tears (SNS/PNS)
Somatotrophin-> GH -> bones and muscles
CNV3: sensory to chin, lower mouth, ant 2/3 tongue (taste is VII), ears, scalp,
.
muscles of mastication
ADH/Vasopressin to collecting duct and DCT of nephron-> water reabsorption
Oxy to uterus for uterine contractions and orgasm
79. Bell's palsy Can be corrected using CNXI 80. Epistaxis

spinal accessory n transplant
l It is idiopathic unilateral facial

l Epistaxis (nosebleed)
paralysis. most often occurs from
l Terminal branches of CN VII the anterior nasal septum
may be injured by parotid (Kiesselbach's area),
cancer or inflammation injury as passes where branches of the
(parotitis) by surgery to through parotid gland sphenopalatine,
remove a parotid tumorw/ retromandibular v anterior ethmoidal,
foramen).and external carotid a
(stylomastois foramen)
foramen greater palatine, and
superior labial (from
l Manifestations: facial) arteries converge.
l unable to close lips and eyelids on affected side
l eye on affected side is not lubricated (dry eye)
l unable to whistle, blow a wind instrument, or chew effectively
l facial distortion due to contractions of unopposed contralateral facial

muscles
Lesion of CNVII at internal acoustic meatus causes no saliva/tears, hyperacoustics (stapedius m),
imbalance and distorted hearing (CNVIII)
LesionDr. Mavrych,
past MD,ganglion
geniculate PhD, DSc prof.mavrych@gmail.com
causes hyperacoustics and Bell's Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
Lesion at chorda tympani causes no taste, no saliva from submandibular& sublingual glands Splenopalantine and Greater palantine as are most vulnerable bc
Lesion at stylomastoid foramen causes Bells they are in Atrium of middle meatus
81. Sinusitis
Sphenoiditis Ethmoiditis
l Relationships of the l Infection in the ethmoidal
sphenoidal sinus are clinically sinuses can erode the medial
important ; because of potential wall of the orbit, resulting in
injury during pituitary orbital cellulites that can
surgery and the possible spread to the cranial cavity.
spread of infection.
l In orbital cavity infection may
l Infection can reach the sinuses erode structures related to the
through their ostia from the medial orbital wall:
nasal cavity or through their
l Medial rectus muscle
floor from the nasopharynx.
l Superior oblique muscle
l Infection may erode the walls to
reach the cavernous sinuses, l Nasociliary nerve
pituitary gland, optic nerves,

or optic chiasma No adduction, no down and out rotation of the eye,
and constricted pupils w/ lack of corneal reflex
(sensory: touch eye and no blink)
Temporal Maxillary Junction

84. Movements at the TMJs
83. Cheeks
l Form the lateral, movable walls of
All 4 muscles of
the oral cavity and the zygomatic
mastication are
prominences of the cheeks over the
innervated by V3:
zygomatic bones.
1 1. Temporalis ñ
l Buccinator [1] ñ principal muscle elevation &
of the cheek. retraction
2 l Buccal pad of fat ñ encapsulated 2. Masseter - Strong
3 collection of fat superficial to elevation
buccinator. 3. Medial closes jaw
l Parotid duct [2] from Parotid gland pterygoid -
[3] perforate buccinator and opens in Note: In case of mandibular nerve elevation
inner surface of the cheek right damage mandible (when it is 4. Lateral Only muscle to
opposite 2nd upper molar tooth protruded) deviate toward the side of pterygoid -open jaw/mouth
lesion because of Lateral pterygoid protrusion
weakness.
Tensor veli palatini m prevents inhale of food and equalizes the air
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Dr. Mavrych, MD, PhD, DSc toprof.mavrych@gmail.com
pressure protect tympanic membrane
Tensor tympani dampens the sound from chewing
85. Innervation of the tongue 86. Gag reflex

1. Sensory anterior 2/3:: general ñ lingual n. (V3), l Touching the posterior part of the
taste ñ chorda tympani (CNVII) pharynx results in muscular
2. Sensory posterior 1/3:: general and taste ñ contraction of each side of the
glossopharyngeal (CNIX) pharynx - gag reflex:
3. Motor ñ hypoglossal (CNXII) l Afferent limb: CN IX
ÿ A lesion of the chorda tympani ñ lose of the taste l Efferent limb: CN X
sensation anterior 2/3 of the tongue l Injury to the
ÿ A lesion of the lingual nerve ñ lose of both GLOSSOPHARYNGEAL NERVE
general and taste sensation anterior 2/3 of the (CN IX) will result in a negative
tongue bc chorda tympani runs with lingual n gag reflex No longer sensed
ÿ A lesion of CN XII (hypoglossal canal) allows the
contralateral, unparalyzed genioglossus muscle to Touching the soft palate or posterior pharynx will be sensed
Lick your wounds pull the protruded tongue toward the paralyzed side via CNIX pharyngeal branch (afferent) and stimulate a
(deviation and atrophy of the tongue). response (efferent) through CNX pharyx, larynx, and palate
weaker unparalyzed genioglossus m is ms to "gag"
unable to maintain contraction of
tongue out, the opposite side takes
over and pushes tongue to the side of
lesion.
87. Palatine tonsils Tonsillitis

l During palatine tonsillectomy, the
l Receives main blood supply
peritonsillar space facilitates tonsil
from tonsillar branch of
removal, except after capsular
facial artery
adhesion to the superior constrictor.
l Drained by lymph vessels
l If the glossopharyngeal nerve
mainly to jugulodigastric
CNIX is injured, taste and general
lymph node, which is body's
sensation from the posterior 1/3 of
most frequently enlarged
the tongue are lost.
lymph node
l Hemorrhage may occur, usually
l Nerve supply: tonsillar
from the tonsillar branch of the
plexus of nerves formed by
facial artery; if the superior
branches of CN IX and CN X
constrictor is penetrated, a high
facial artery or tortuous internal
Found between Faucel Pillars and become highly inflamed during infection carotid artery may be injured.
Tonsilectomy and adenoectomy can risk the tonsilar a and v.
.
Pharyngeal, Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
Tubal, Palatine, Lingual Tonsils (Waldeyer's ring of lymph tissue)
89. Lymph drainage from face

88. Muscles of Soft Palate structures
CNV3 prevents inhalation of food & equalizes
pressure to protect tympanic membrane 1. Preauricular (parotid
(parotid ) (on front
1. Tensor veli palatini and of auricle) receive lymph from
2. Levator veli palatini ñ elevates anteriolateral part of scalp
the soft palate during swallowing (including eyelids)
to prevent food entering to the 2. Submandibular (in digastric or
nasopharynx 1
submandibular ") ñ from all air
3. Palatoglossus and sinuses, nose and adjacent
4. Palatopharyngeus ñ depress cheek, upper lip and lateral
soft palate and pulls walls of parts of lower lip.
pharynx superiorly 3 3. Submental (in submental ") ñ
5. Uvular muscle ñ shortens uvula
2 from the chin, tip of the tongue
and pulls it superiorly and central part of the lower
CNX innervation via pharyngeal branch lip.
ALLOWS EFFICIENT SWALLOWING!
Lesion to Vagus can be seen as Uvula deviation to
opposite of lesion Triangles of neck:
Carotid: post digastric, omohyoid, SCM contain internal jugular v, common
Swallowing has 3 stages: carotid a, and vagus
1. chew to create bolus (CNV3), tongue rise to hard palate (CNX, IX, VII, XII), Submandibular/submental: growth of lip can be throat cancer (CNVII, XII)
hyoid elevates, and fauceal pillars up and back Muscular: isthmus of thyroid larynx and trachea
2. Seal nasopharynx w/ soft palate and epiglottis (CNX) Posterior: Trapezius, SCM, clavical contain ext jugular v, and brachial plexus
3. constrictors contract and pull up larynx to push bolus down
91. Muscles of the orbit

90. Blow-out fracture
No look down, no sensation to upper mouth and
bleeding from branch of external carotid a
l A blow-out fracture of the
orbital floor typically is not
involve the orbital rim and is
caused by blunt trauma to the
orbital contents (e.g., by a
handball). Content of orbital
Muscle Action Innerva-
cavity blow-out in maxillary tion
sinus. Superior rectus Elevates and adducts CN III
pupil
l Blow-out fractures may damage:
Inferior rectus Depresses and adducts CN III
1. Inferior rectus muscle pupil
Medial rectus Adducts pupil CN III
2. Infraorbital nerve (from Lateral rectus Abducts pupil CN VI
maxillary V2) Superior oblique Depresses and abducts CN IV
Branches of External Carotid Artery pupil
Some = Superior Thyroid A. 3. Infraorbital artery Inferior oblique Elevates and abducts CN III
pupil
Angry = Ascending Pharyngeal A. (hemorrhaging). Levator pulpebra superior Elevates upper eyelid CN III
Lady = Lingual A.
Found = Facial A.
Dr.Out
Mavrych, MD,A.PhD, DSc prof.mavrych@gmail.com
= Occipital Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
P = Posterior Auricular A.
M = Maxillary A.
S = Superficial Temporal A.
92. Strabismus Eyes are not aligned

Oculomotor Nerve Palsy (CNIII) Trochlear Nerve Palsy (CNIV)
l Lesions of this nerve or its nucleus
l Oculomotor Nerve Palsy cause paralysis of the superior
(external squint) affects most of the oblique and impair the ability to turn
extraocular muscles the affected eyeball infero-medially
l Manifestations: (pupil look superio-laterally)
l ptosis,
levator palpebrae superioris is out
l The characteristic sign of trochlear
.
l fully dilated pupil, nerve injury is diplopia (double
constrictor pupilae (PNS) is out
l and eye is fully depressed and vision) when looking down (e.g.,
abducted (ìdown and outî) due to when going down stairs)
No cheating muscle (down and out)
unopposed actions of superior l The person can compensate for the
person will turn head to mimic contraction
oblique and lateral rectus, diplopia by inclining the head
respectively. anteriorly and laterally toward the side
Eyes are looking in opposite directions of the normal eye.
inferior oblique is
unopposed so eye looks
up and out
Abducens Nerve Palsy (CNVI) 93. Horner syndrome

Sympathetic trunk compression
l Penetrating injury to the neck,
l Abducens Nerve Palsy Pancoast tumor, or thyroid carcinoma
may cause Horner syndrome by
(internal squint). Injury to abducens
interrupting ascending preganglionic
nerve Æ paralysis of lateral rectus sympathetic fibers anywhere between
Æ inability to abduct the affected their origin in the T1 segment (IML) of
eye spinal cord and their synapse in the
l Affected eye is fully adducted by Superior cervical ganglion.
the unopposed action of the medial l It includes the following signs:
rectus that is supplied by CN III l Constriction of the pupil (miosis) PNS
l Drooping of the superior eyelid sup. tarsal m
(ptosis), paralysis
l Redness and increased temperature
of the skin (vasodilation)
l Absence of sweating (anhydrosis)
Middle ear inflammation Perforation of the

94. Otitis Media
Tympanic Membrane
l Hearing is diminished because of l May result from otitis media and is
pressure on the eardrum and CNVIII one of several causes of middle ear
reduced movement of the ossicles. (conduction) deafness
l Taste may be altered because the
l Causes: foreign bodies in external
chorda tympani is affected.CNVII
acoustic meatus, excessive pressure
l Infection spreading posteriorly
(as in diving), trauma
cause mastoiditis.
l Because chorda tympani directly
l Infection that spreads to the
middle cranial fossa can cause Pars flaccida relates to the posterior surface of the
meningitis or temporal lobe tympanic membrane it may be
abscess, and infection moving damaged and resulting in loss of
through the floor may produce taste over anterior 2/3 of the tongue
sigmoid sinus thrombosis. Umbo and secretion of the sublingual and
refracted cone of light
submandibular glands
l Minor perforation heal spontaneously;
pars tensa large ones require surgical repair
Anterior inferior incisions based on cone of light for surgery
95. Thyroid and parathyroid Anatomical relations

glands of tthe
o e tthyroid
y odg gland
a d
Hormones:
l The thyroid gland is the body's largest endocrine
l Anterolateral ñ
gland. It produces thyroid hormone (T3 & T4), infrahyoid muscles
which controls the rate of metabolism (increase
1 l Posterolateral ñ
the temperature of the body), and calcitonin, a COMMON CAROTID
hormone controlling calcium metabolism (reduce ARTERY [1]
blood calcium Ca2+). decrease osteoclasts
l Medial ñ larynx,
l After total thyroidectomy may develop lower TRACHEA [2],
temperature of the body and hypercalcemia. pharynx, esophagus,
cricothyroid muscle,
recurrent laryngeal
l The hormone produced by the parathyroid 1 nerve [3]
glands, parathormone (PTH), controls the l Posterior ñ
metabolism of phosphorus and calcium in the parathyroid glands
blood (increase Ca2+ level).increase osteoclasts 1 [4]
3
Superior thyroid a off external common carotid and inferior Recurrent laryngeal n to laryngeal ms (PCA*) abducts vocal cords
thyroid gland
Dr. Mavrych, off thyrocervical
MD, PhD, trunk of subclavian
DSc prof.mavrych@gmail.com Dr. Mavrych,
External MD, PhD, DSc
laryngeal n to prof.mavrych@gmail.com
cricothyroid for high pitch
External laryngeal n w/ superior thy a & Recurrent laryngeal n
w/ inferior thy a
CS of the neck Median cervical cyst

l Usually presents as a painless
midline mass on the anterior aspect
of the neck just below of the hyoid
Carotid Sheath bone and moves during
swallowing together with thyroid
gland because of relation with
pretracheal layer of cervical fascia
Buccopharyngeal membrane & CNX and infrahyoid muscles of the neck.
RETROPHARYNGEAL SPACE
Alar Fascia
l Remanent of the thyroglossal canal
DANGER ZONE (thyroid gland originally from
Prevertebral fascia epithelium of the tongue).
l Treatment: surgical excision
Retropharyngeal area allows infection to spread to posterior mediastinum

DANGER ZONE allows infection to spread to abdomen
Variation of parathyroid 96. Larynx

glands position 3
l The superior parathyroid 1 Cavity of the Larynx - 2 Folds:

glands, more constant in 2
l Vestibular folds [1] (false vocal
position than the inferior ones. cords) Morgangni ventricle between them
l The inferior parathyroid l Vocal folds [2] (true vocal cords)
glands are usually near the
inferior poles of the thyroid
gland, but they may lie in ÿ Rima vestibuli ñ gap between the
various positions vestibular folds
l In 1-5% of people, an inferior ÿ Rima glottidis [3] ñ gap between
parathyroid gland is deep in the vocal folds anteriorly and
the superior mediastinum vocal processes of the arytenoid
inside the thymus because of 1 cartilages posteriorly is most
common embryonic origin. narrow place in the larynx (it
2 limits size of intubation tube
This makes surgery dangerous bc parathyroid during endotrachial anaesthesia)
glands are essential for life as Ca2+ is needed
Piriform recess at hyoid-> epiglottis is where small sharp objects get stuck
for neuronal pathways, bones, muscle
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Zenker's
Dr. Mavrych, MD, PhD,Diverticulum is outpouch of pharynx at inferior constrictor where food gets caught
contractions, etc....
in killians triangle and gets infected leading to hallitosis (bad breath)
Muscles of the Larynx Cricothyrotomy

Transverse arytenoid (whisper), Thyroarytenoid (low pitch), vocalis (opera singer)- ADDUCTORS
Abductors l A cricothyrotomy is an emergency
l Posterior cricoarytenoid ñ procedure that relieves an airway
abducts vocal folds (the only obstruction (e.g. swallowed foreign
abductors of the vocal folds) bodies or abnormal tissue growths).
l It is innervated by recurrent l A hollow needle is inserted into the
laryngeal nerve (CNX midline of the neck, just below the
vagus). thyroid cartilage (needle
Most intrinsic ms of the larynx
ÿ Interruption of recurrent
cricothyrotomy).
laryngeal nerve results in l More frequently, a small incision is made
hoarseness because the in the skin over the Cricothyroid
corresponding vocal fold membrane, and another one is made
does not abduct and deviate through the membrane between the
toward the midline. cricoid and thyroid cartilage.. A tube
Superior Laryngeal n gives that enables breathing is inserted through
branches to internal (vocal cords) the incision.
and external to cricothyroid ms
(high pitch)
lesionDSc
causesprof.mavrych@gmail.com
weak low pitch voice Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
98. Retropharyngeal space 99. Axillary sheath

Between Buccopharyngeal fascia and Alar fascia of Carotid sheaths
l Derived from the prevertebral
l It is interval between pharynx
fascia
(Bucco-pharyngeal
Bucco-pharyn fascia)
fascia)
and prevertebral fascia l Encloses the subclavian artery
and brachial plexus as they
l May provide a passageway of
emerge in the interval between the
infection from pharynx
p to
scalenus anterior and medius
posterior media
mediastinum
muscles (Interscalenus
( space)
(mediastinitis !90%!mortality!
rate). l Extends into the axilla
DANGER ZONE: Alar Fascia to prevertebral fascia and

infection DSc prof.mavrych@gmail.com
spreads farther to abdomen Dr. BRACHIAL
Mavrych, MD, PLEXUS BRANCHES:
PhD, DSc prof.mavrych@gmail.com
MARMU, LT, DS, SS, SC, LP, MP, AP, USS, TD, LSS, Mca, Mcf
100. Posterior Triangle of the

Good Luck!
Neck Clavical, SCM, Trapezius
l Veins ñ external jugular vein, Carotid Triangle of the Neck:
subclavian vein. Posterior digastric, omohyoid, SCM
l Arteries ñ occipital artery.
Contains: Internal jug v, common carotid, CNX
l Nerves ñ Accessory nerve (XI),
trunks of the brachial plexus, branches
of cervical plexus, phrenic nerve.
l Lymph nodes ñ superficial cervical
CN XI nodes along external jugular vein.
CN XI (accessory nerve) supply:
l Sternocleidomastoid muscle - face
looks upward to the opposite side
l Trapezius - superior fibers elevate,
middle fibers retract, and inferior fibers
depress scapula.
External Jugular v, Brachial Plexus


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Understand first, then memorize and apply

1. Lumbar puncture (tap) and

Spinal cord ends L2: Conus Medullaris

4. Upper limb fractures:

Scaphoid fracture Boxerís fracture

Mallet or Baseball Finger 5. Rotator cuff muscles ñ SITS

Forced Flexion of DIP l Infraspinatus Lat rotation, Suprascapcular n

l Teres minor Lat rotation, Axillary n

Right humerus l Subscapularis Med. rotation, Upper & Lower

Subacromial bursitis &

7. Three Elbows: Student's elbow Tennis elbow

Golferís elbow 8. Arterial anastomoses

9. Cubital fossa Anterior Elbow joint

11. Test of the proximal and 12. Lesion of UL nerves

Upper Brachial Palsy Lower Brachial Palsy

Lower Brachial Palsy Injury to musculocutaneous

14. Injury of the gluteal region Avascular necrosis

congenital dislocations are more common in females > males

Injury of obturator 15. Avulsion fractures

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Dr. Pseudohamstrings:

16. Structures under inguinal

17. Knee joint injuries: Tibial collateral ligament

Fibular collateral ligament Rupture of the

l Rounded cord between l With rupture of the anterior

drawer sign is movement of the leg in

18. Ankle joint injuries:

19. Injures of the leg and foot:

l Ankle jerk reflex: tests

Rupture of the Achilles tendon

20. Injury of tibial nerve

21. Breast: Lymphatic drainage

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com Lymph from

Mastectomy Breast infection

22. Thoracic wall & Diaphragm: Diaphragm:

I ate 10 eggs at noon! Vessels entering the diaphragm

23. Cardiac hypertrophy

24. Auscultation of Heart

Left 4 ICS Left 5 ICS

25. Conducting System 26. Blood supply of the Heart:

Left coronary artery Blood supply of the conducting

27. Congenital cardiac defects: Ventricular Septal

Patent Ductus Arteriosus (PDA) Aneurysm of the aorta

Abdominal aortic aneurysm

l Surgeons can repair an

28. Aspiration of Foreign Right lung:

Left lung: 29. Lung diseases:

Bronchogenic Carcinoma Bronchogenic carcinoma

Bronchogenic carcinoma Qs about Auscultation

30. Open pneumothorax &

Thoracic duct A Duck between 2 Gooses

R lymphatic duct drains 1/4 of body from R jugular

Referred abdominal pain

l The end of the descending H

Dr. Layers of abdominal

Nerve supply of the Arterial supply of the anterior

33. Herniations Transversalis fascia is the FIRST

l Hernial sac is a pouch

Indirect Inguinal Hernia Direct Inguinal Hernia

Dr. Mavrych, MD, PhD, DSc

34. Peritoneal structures:

Douglas (rectouterine) pouch Culdocentesis

FOREGUT MIDGUT HINDGUT