UPPER LIMBBONESCLAVICLE: most frequently fractured bone of body; break occurs where bone is weakest, at junction of lateral and middle third; following break, medial end is pulled superiorly by SCM and lateral end is pulled inferiorly by weight of arm and medially by pectoralis major

Fracture of clavicle usually occurs as result offall on shoulder or outstretched hand

HUMERUSFracture at surgical neck injures axillary nerve,which innervates deltoid resulting in loss of abduction of armFracture at midshaft (spiral groove) injures radial nerve, resulting in wrist drop anddecreased extension at elbowFracture inferiorly (at medial epicondyle) affects ulnar nerve, major nerve to intrinsic hand muscles, resulting in ulnar claw hand

Radius: Colles fracture is fracture of distal radius resulting from fall on outstretched hand; common; produces "dinner fork effect whereby distal fragment is posterior (top picture)

Smiths fracture (less common) results from fallon back of hand with anterior displacement of distal fragment (bottom picture)

Carpal bones: scaphoid is most commonly fractured carpal bone; at times, avascularnecrosis of proximal portion of scaphoid occurswhen deprived of its arterial supply

Lunate is most commonly dislocated carpal bone; usually occurs in young adults

From lateral to medial, bones of wrist are: scaphoid, lunate, triquetrum and pisiform (proximal row); trapezium, trapezoid, capitate and hamate (distal row) (Some Lovers Try Positions That They Cant Handle)

MUSCLES: Deltoid is chief abductor, chief flexorand chief extensor of arm; deltoid is innervated byaxillary nerve; deltoid is muscle of shoulder and allmuscles of shoulder are innervated by C5 and C6.

Posterior compartment of arm: triceps is innervated by radial nerveAnterior compartment (3): coracobrachialis, bicepsbrachii, and brachialis are innervated by musculocutaneous nerve; biceps is major musclethat supinates hand

Abduction of armAction is initiated by supraspinatus; deltoid is chiefabductor but can only abduct just beyond horizontalplane without scapular rotation

For complete abduction of arm, scapula needs to berotated; upward rotators of scapula are (1) trapezius: both upper fibers that pull acromial end of spine up,and lower fibers that pull medial end down, and (2)serratus anterior

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

Forearm muscles: anterior compartment: flexormuscles, posterior compartment: extensor muscles

Superficial muscles of anterior compartment all arisefrom medial epicondyle of humerus:1.Pronator teres2.Flexor carpi radialis3.Palmaris longus4.Flexor carpi ulnaris: only muscle innervated byulnar nerve exclusively5.Flexor digitorum superficialis: lies on deeper plane

Deep muscles of flexor compartment1.Flexor pollicis longus2.Pronator quadratus3.Flexor digitorum profundus- Has dual innervation, median and ulnar; only muscle of forearm with two nerves- Only muscle to go to distal phalanges on flexor side

Median nerve innervates all muscles of anteriorcompartment of forearm except flexor carpi ulnaris

All muscles on extensor side are innervated byradial nerveSuperficial muscles arise from lateral epicondyle andits supracondylar ridge1.Brachioradialis2. Extensor carpi radialis longus3.Extensor carpi radialis brevis4. Extensor digitorum5.Extensor carpi ulnaris6. Extensor digiti minimiBrachioradialis: unique, does not act on hand;flexes at elbow

Deep muscles of extensor side of forearm:1.Supinator2.Extensor pollicis longus3.Extensor pollicis brevis4.Abductor pollicis longus5.Extensor indicis

Actions of pronation and supination occur atradio-ulnar joints

Both pronator muscles are innervated by median nerve

Biceps brachii (stronger muscle) is innervated bymusculocutaneous nerve and supinator in innervatedby radial nerve

Supination is stronger than pronation

Three thenar muscles are innervated by motorrecurrent branch of median nerve (after mediancourses through carpal tunnel); this branch of mediannerve also innervates lateral two lumbricalsThree thenar muscles are flexor pollicis brevis,abductor pollicis brevis, and opponens pollicis

Functionally, hypothenar muscles are not nearly asimportant: flexor digiti minimi brevis, abductordigiti minimi, and opponens digiti minimi; thesemuscles are innervated by ulnar nerve

Adductor pollicis (located centrally) is not classifiedas thenar muscle and is innervated by ulnar nerve

Four lumbrical muscles: arise from tendon of flexordigitorum profundus and insert into extensor hood;these muscles serve to flex at metacarpophalangealjoints and extend at interphalangeal joints; onlymuscles to arise from tendons and insert into tendons

Lateral two lumbricals are innervated by median nerve and medial two muscles receive ulnar nerve

Interossei: all muscles innervated by ulnar nerve

Dorsal: bipennate (arise from adjacent metacarpals)Palmar: unipennate (arise from single metacarpal)

DAB - PAD: Dorsal ABduct fingers, Palmar Adduct

Interossei, like lumbricals, insert into extensor hoodsand, like lumbricals, flex at metacarpophalangeal joints and extend at interphalangeal joints

Insertions of long flexor tendons: at base of proximal phalanx, tendon of flexor digitorumsuperficialis (FDS) splits to allow tendon of flexordigitorum profundus (FDP) to pass through; FDS inserts into base of middle phalanx and FDP insertsinto base of distal phalanxExtensor hood: tendon of extensor digitorum isjoined by lumbrical and interossei; both lumbricals and interossei cross flexor side of metacarpo-phalangeal joint and extensor sides of proximal anddistal interphalangeal joints; hence, muscles flex atMP joints and extend at both PIP and DIP joints

Swan-neck deformity of fingers: flexion of MP, PIP hyperextension, and slight DIP flexion; due tocontracture of intrinsic muscles (tendons) as seenwith rheumatoid arthritis (top picture)

Mallet finger (bottom picture): caused by ruptureof DIP extensor mechanism or avulsion fracture ofdistal phalanx; common in baseball catchers; cannotextend DIP

Boutonniere deformity: central portion of extensorhood torn over PIP allowing tendon to become flexor; DIP is hyperextended

Dupuytrens contracturenot nerve injury; localizedpathological thickeningand contracture of palmar aponeurosis

Dupuytrens contracture

Starts at root of ring finger, drawing finger to palm;fifth finger is affected later

More common in males

Begins as fibrous nodules which progress to densebands

Brachial plexus: stages are roots (ventral rami C5 through T1), trunks (upper, middle, and lower),divisions (anterior and posterior), cords (lateral,medial and posterior) and terminal branches

From roots: phrenic (C3 - 5), long thoracic (C5 - 7)- Serratus anterior,dorsal scapular (C5)- Rhomboids

From trunks (upper): suprascapular (supra and infraspinatus) and nerve tosubclavius (C5 and C6)

There are no nerves that arise from divisions

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

Axillary (C5 and 6), from posterior cord, innervates deltoid and teres minor; becomes lateral brachial cutaneous Radial (C5 - T1), from posterior cord, innervates all muscles of posterior side of arm and forearmMusculocutaneous (C5 - 7), from lateral cord, innervates all muscles of anterior side of arm, becomes lateral antebrachial cutaneous nerveUlnar (C8, T1), from medial cord, innervates only flexor carpi ulnaris and flexor digitorum profundus in forearm; innervates most muscles of handMedian (C5 - T1), from both medial and lateral cords, innervates most muscles of anterior forearm and, in hand, innervates only three muscles of thenar eminence and two lumbricals

HAND INNERVATIONMOTOR: all muscles are innervated by C8 and T1SENSORY: Dermatomes C6: thumb and index fingerC7: middle fingerC8: ring and little fingersCutaneous nervesMedian: 3 1/2 fingers on palmar side, related palm, and middle and distal phalanges of lateral 3 1/2 fingers on dorsal sideUlnar: medial 1 1/2 fingers (both sides and palmRadial: dorsolateral aspect

NERVE INJURIES Axillary: courses around surgical neck of humerus(with posterior humeral circumflex artery) to passthrough quadrangular space; axillary nerve can beinjured with fracture of surgical neck; would resultin atrophy of deltoid and functional loss at shoulderjoint: major losses of abduction, flexion, extension,and rotation

CARPAL TUNNEL SYNDROME: most commonsite of injury to median nerveOsseo-fibrous tunnel formed by carpal bones andtransverse carpal ligament (thickening of deep fascia); ligament is attached laterally to scaphoid andtrapezium and medially to hamate and pisiformContents of carpal tunnel: (1) median nerve,(2) four tendons of flexor digitorum superficialis,(3) four tendons of flexor digitorum profundus, and(4) tendon of flexor pollicis longus

Winged scapula: injury to long thoracic nerve

Long thoracic nerve arises from roots of brachialplexus, C5 - C7; this nerve, which innervates serratus anterior on its superficial surface, is veryvulnerable as it courses through axilla; potentially,long thoracic nerve is injured with removal of lymphnodes in axilla

Serratus anterior serves to fix scapula; when pushing against wall, scapula will look like a wing if long thoracic nerve is injured

Erb-Duchennes palsy: injury to upper trunk orC5 and C6 roots; occurs with falling on head andshoulder simultaneously or pulling head from awayfrom shoulder with rough birth; results in loss offlexors and lateral rotators of arm, so medial rotatorsplace upper limb in waiters tip positionKlumkes palsy: lower trunk injury (roots C8 and T1); occurs when catching ones self when fallingfrom tree; loss of intrinsic hand muscles resulting inclaw handAll intrinsic hand muscles are innervated by C8 and T1

There are three types of claw hand, (1) total claw,(2) median claw, and (3) ulnar clawTotal claw occurs with loss of all intrinsic handmuscles (lumbricals and interossei) which serve tobalance flexor and extensor muscles of forearmthat act on fingers; seen with lower trunk injury

Median claw occurs with injury to median nerve;there is wasting of thenar eminence, paresis uponflexing, abducting, and opposing thumb, andparesthesias of lateral 3 1/2 fingers; ape hand

Ulnar claw occurs with injury to ulnar nerve; thereis wasting of hypothenar eminence and interosseousspaces; with flexion at wrist, there is radial deviation; loss of adduction of thumb, Froments sign

Subclavian artery: on right side, arises frombrachiocephalic trunk; on left side, direct branch ofarch of aorta; one of branches of subclavian artery isthyrocervical trunk that gives rise to two arteries toupper limb: transverse cervical and suprascapularAxillary artery: continuation of subclavian arterydistal to outer border of first rib; significant branchesinclude anterior and posterior humeral circumflexand subscapular arteriesBrachial artery is continuation of axillary at inferiorborder of teres major; chief branch is deep brachial(that courses with radial nerve); ends at elbow asradial and ulnar arteries

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

Cubital fossa: triangular area anterior to elbow jointthat is bounded superiorly by line between medialand lateral epicondyles, medially by pronator teres, and laterally by brachioradialis

Lateral to medial relationships are TAN,Tendon of biceps, brachial Artery and median Nerve

Median cubital vein (communication betweencephalic and basilic veins) overlies structures ofTAN

At cubital fossa, brachial artery divides to formradial and ulnar arteries; major branch in forearm iscommon interosseous artery, branch of ulnar artery that gives rise to anterior and posterior interosseousarteries that supply bones and deep muscles offorearm

Radial artery leaves flexor surface by passinglaterally deep to tendons of anatomical snuff boxUlnar artery courses with ulnar nerve and passessuperficial to flexor retinaculum (and carpal tunnel)

Superficial palmar arterial arch is formed mainly byulnar artery (aided by radial artery)Deep palmar arterial arch is formed mainly by radialartery (aided by ulnar artery)

Raynauds disease: increased sympatheticstimulation to distal arteries of fingers resulting invasoconstriction with decrease in blood flow; fingertips are cold and limb becomes progressively warmerproximally; origin is unknown; need cervico-dorsal sympathectomy; sympathetics to upper limbhave preganglionic cells of origin at T2 - T8

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

Dislocation of sterno-clavicular joint is notcommon; when it occurs,can be either anterior orposterior dislocation

Acromioclaviculardislocation is known asshoulder separation; often occurs with blockingor tackling in football;coracoclavicular ligamentprovides strength to joint

Sternoclavicular joint: functional saddle type ofsynovial joint that contains disc; costoclavicular ligament is very short, strong ligament that providesgreat stability to this joint

Acromioclavicular joint: plane type of synovial jointthat allows gliding and rotational movements; coracoclavicular ligament is strong extrinsic ligament consisting of conoid and trapezoid ligaments; acromioclavicular ligament is thickeningof articular capsule

Shoulder joint: classical ball-and-socket type ofsynovial joint; little support is provided by eitherbony configuration or ligaments; major support tojoint is tendons of rotator cuffJoint is strengthened superiorly by supraspinatus,anteriorly by subscapularis, and posteriorly by bothteres minor and infraspinatusDislocation is in inferior direction (weakest region);head of humerus is then pulled anteriorly and superiorly by strong flexors and adductors so thathead ends up in subcoracoid position

Elbow joint is hinge type of synovial joint betweentrochlea of humerus and trochlear notch of ulna; since superior radioulnar joint is part of elbow joint,radius is also part of joint; head of radius articulateswith capitulum of humerusAnular ligament forms about 4/5ths of fibro-osseousring around head of radiusElbow dislocations are common and are posterior;occur with falling on outstretched hand; more common in childrenUlnar nerve is often affected with elbow injuries

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

Arterial supply to head of femur: prior to pubertywhen epiphyseal plate closes, no anastomoses between branch of obturator artery (conveyed byround ligament) and medial femoral circumflex(chief artery of head and neck of femur) sincecartilage is avascularFollowing puberty, medial femoral circumflex andbranch of obturator anastomose with each other, butvascular necrosis may result following fracture ofneck of femur when there is tear of artery

Medial longitudinal arch: talus is summit; calcaneusis posterior; navicular, three cuneiform bones andfirst three metatarsal bones lie anterior; spring ligament (plantar calcaneonavicular ligament) haselastic fibers that support talus and medial arch; flatfoot when ligament is excessively stretchedBones of lateral longitudinal arch are calcaneus,cuboid, and fourth and fifth metatarsal bones; thisarch is supported by long and short plantar ligamentsCommon accessory bones are os trigonum (talus) andos tibialae (navicular)Two constant sesamoid bones with flexor hallucisbrevis

MUSCLESGluteus maximus: only muscle innervated by inferior gluteal nerve; powerful lateral rotator andchief extensor at hip when rising from chair (withother situations, hamstring muscles, that is, long headof biceps femoris, semitendinosus, andsemimembranosus, extend at hip)Muscles attached to greater trochanter that laterallyrotate thigh are piriformis, superior and inferiorgemelli, obturator internus and externus, andquadratus femorisIntramuscular injections: given in upper, lateralquadrant to avoid sciatic nerve

Gluteus medius and gluteus minimus, along withtensor fasciae latae, are innervated by superiorgluteal nerve; although both gluteus medius andminimus abduct and medially rotate thigh, majorfunction is to prevent tilting of pelvis whenwalking; positive Trendelenburgs test: pelvistilts toward unsupported side - indicates injury tosuperior gluteal nerve: associated withpoliomyelitis that affects ventral horn cells ofL 4 - S 1 region of spinal cord

Anterior compartment of thigh: all muscles areinnervated by femoral nerve (L2 - L4) Sartorius: origin from ASIS; flexes at both hip andknee: rotates thigh laterally and leg mediallyQuadriceps femoris: three vasti muscles (medial, lateral and intermediate) and rectus femorisRectus femoris is only portion of quadriceps to arisefrom hip bone (ilium); vasti arise from femurInserts via patellar ligament; entire muscle extendsleg; rectus femoris also flexes at hipVastus medialis is first part of quadriceps to atrophywith knee joint disease and last part to recoverPatellar reflex tests L4 spinal level

All muscles of medial compartment adduct at hip,arise from pubis and are innervated by obturatornerve (except pectineus, usually femoral nerve)Gracilis is only muscle to insert on tibia (all others attach to femurMuscles are: gracilis, pectineus, obturator externus, adductors longus, brevis, and magnusAdductor magnus is also innervated by tibial part ofsciatic nervePatients with cerebral palsy often have markedspasticity of adductor group of muscles

Muscles of posterior compartment are collectivelycalled hamstrings; they arise from ischial tuberosity, flex leg and extend thigh, and are innervated by tibialpart of sciatic nerveShort head of biceps femoris not part of hamstrings;it does not act on hip and is innervated by commonfibular part of sciatic nerveBoth semitendinosus and semimembranosus insert on tibia and medially rotate legBiceps femoris inserts on fibula and laterally rotatesleg

Muscles are of anterior compartment are innervatedby deep fibular nerve and all muscles dorsiflex atankle; tibialis anterior inverts foot; extensor hallucislongus extends great toe; extensor digitorumlongus extends toes 2 - 5; fibularis tertius evertsfootCompartment syndrome: increase in pressure due to increased tissue fluid (often as result of soft tissueinjury associated with fracture of bone); results indecreased venous return; very painful with need todecrease pressure; shin splints are minor trauma totibialis anterior causing muscle to swell and pullcrural fascia off tibia; untrained person in walkathons

Lateral compartment contains only two muscles, fibularis longus and fibularis brevis; both musclesare innervated by superficial fibular nerve and function to evert footTendon of fibularis longus crosses sole of foot,grooves cuboid bone, and inserts into first metatarsaland medial cuneiformTendon of fibularis brevis inserts into base of fifthmetatarsal; at times, base of fifth metatarsal is fractured and tendon of fibularis brevis pulls off baseof bone: avulsion fracture seen with severe sprain

All muscles of compartment are innervated by tibialnerve; superficial muscles are gastrocnemius, soleusand plantaris, short muscle belly with long tendonGastrocnemius and soleus insert into calcaneus viatendocalcaneus (Achilles tendon); this tendon oftenoften ruptures in middle-aged males while playingtennis; tear occurs about inches superior to insertionAchilles tendon is test for spinal level S1Deep muscles are popliteus (flexes and unlocks knee by rotating femur laterally upon tibia), tibialisposterior (inverts foot), flexor hallucis longus (flexesgreat toe), and flexor digitorum longus (flexes toes2-5)

Extensor digitorum brevis is located on dorsum offoot; this is intrinsic muscle of foot (arising fromcalcaneus and inferior extensor retinaculum)There is no intrinsic hand muscle on dorsal side

Tendon to great toe, called extensor hallucis brevis,inserts into proximal phalanx; for toes 2 - 4 tendonsjoin lateral side of extensor digitorum longus

Extensor digitorum brevis is innervated by deepfibular nerve

Plantar aponeurosis: deep fascia of sole of foot iscomposed of tough collagen fibers; posteriorly,attached to calcaneus; plantar fasciitis occurs withexcessive walking/running and can result inossification of posterior portion of aponeurosis toform heel spur

Deep part of aponeurosis attaches to first and fifthmetatarsals to form three muscular compartments

Superficial part of aponeurosis has digital slips thatattach to skin of toes

Muscles of sole of foot are arranged in layers; firstlayer, most superficial, has abductor hallucis, flexordigitorum brevis, and abductor digiti minimiLayer two contains quadratus plantae and fourlumbricalsLayer three has flexor hallucis brevis, adductor hallucis and flexor digiti minimi brevisInterossei are located in layer fourMedial plantar nerve innervates only four muscles:abductor hallucis, flexor digitorum brevis, flexorhallucis brevis, and first lumbrical; lateral plantar nerve innervates all other muscles

Lumbar plexusVentral rami T12 - L4; located in abdominal cavity,related to psoas major muscleIliohypogastric (T12 and L1) and ilioinguinal (L1)nerves innervate muscles of lower anterior abdominalwall and are cutaneous; iliohypogastric to suprapubicarea and ilioinguinal to anterosuperior aspect of thighFemoral (L2 - 4) innervates muscles of anteriorcompartment of thigh and has major cutaneous distribution to anterior thigh and medial side of leg and foot; obturator has same spinal levels, innervates muscles of adductor compartment, and has minor cutaneous distribution: medial side of knee

Sacral plexusVentral rami L4 - S3; located in pelvis, related topiriformis muscle; ventral rami divide into anterior and posterior divisionsAnterior (preaxial) nerves: tibial, nerves to obturatorinternus and quadratus femorisPosterior (postaxial) nerves: common fibular, superiorand inferior gluteal nervesPosterior femoral cutaneous is large nerve formed byboth anterior and posterior divisionsSural nerve: cutaneous nerve formed from both tibialand common fibular portions of sciatic nerve

Important cutaneous nervesSaphenous: arises from femoral and supplies medialside of leg and foot; only branch of lumbar plexus tosupply limb inferior to kneeSural: supplies lateral side of leg and footDeep fibular: small area between web of first andsecond toes on dorsal side of footSuperficial fibular: supplies most of dorsum of footTibial (and medial and lateral plantar branches) supply plantar side of footDermatomes: L4 - big toe; L5 - toes 2, 3, and 4;S1 - little toe

Sites of arterial pulses: (1) femoral at groin, (2) popliteal in popliteal fossa (with leg partially flexed),(3) posterior tibial just superior to flexor retinaculumand (4) dorsalis pedis in first intermetatarsal space,between tendons of extensor hallucis longus andextensor digitorum longus

To increase vascular flow to lower limb, it is necessary to sever sympathetic fibers; lower limb isinnervated by sympathetic fibers from T10 - L2 areaof spinal cord

Femoral artery is continuation of external iliac as vessel courses deep to inguinal ligamentFemoral artery is located in lateral compartment offemoral sheath; site for insertion of catheterFemoral vein is located in middle compartment offemoral sheath; great saphenous vein enters femoralsheath to terminate in femoral veinMedial compartment of femoral sheath contains fewlymph nodes (deep inguinal nodes) and is site forfemoral hernia; medial compartment is known asfemoral canal; femoral ring is small potential openingof superior end of femoral canal

Deep femoral artery is chief branch of femoral; medial and lateral femoral circumflex arteries mayarise from either femoral or deep femoral.Medial femoral circumflex is chief artery to head offemur; lateral femoral circumflex participates incollateral circulation at both hip joint and knee joint

At apex of femoral triangle, femoral artery enters adductor (subsartorial) canal and courses aroundthigh; when artery emerges through adductor hiatus,it is renamed as popliteal artery (deepest structure inpopliteal fossa)

Collateral circulation around knee: effective onlywith gradual occlusion of major arteryArteries include descending genicular (fromfemoral), lateral femoral circumflex, four branchesfrom popliteal (superior medial, superior lateral, inferior medial, and inferior genicular), circumflexfibular, and anterior and posterior tibial recurrentarteries which arise from anterior tibial artery

Middle genicular artery, branch of popliteal, does notparticipate in collateral circulation; supplies anteriorand posterior cruciate ligaments

Popliteal artery divides to form anterior and posteriortibial arteries; anterior tibial artery gives rise to posterior tibial recurrent artery and then passes through interosseous membrane and gives rise to anterior tibial recurrent arteryAnterior tibial artery courses with deep fibular nerveand after it crosses ankle joint, anterior tibial arterybecomes dorsalis pedis arteryPosterior tibial artery gives rise to fibular artery; botharteries descend in posterior compartment of leg;nutrient branch of posterior tibial (to tibia) is largestnutrient artery of any bone; posterior tibial arterydescends with tibial nerve

Deep to flexor retinaculum, posterior tibial arterydivides to form medial and lateral plantar arteriesLateral plantar is major branch and it crosses footfrom medial to lateral sides between first andsecond layers of muscles; when lateral plantar arteryreaches fifth metatarsal, it is renamed plantar arch and it courses medially between third and fourthlayers of muscles; deep plantar branch of dorsalis pedisartery often anastomoses with plantar archMedial plantar artery is smaller terminal branch ofposterior tibial and it supplies big toe

JOINTSHip joint is very stable ball-and-socket type ofsynovial joint; 2/3rds of head of femur lies withinacetabulum, which is formed by union of pubis,ilium, and ischiumTransverse acetabular ligament unites edges ofhorseshoe-shaped acetabular labrum, fibrocartilagethat serves to deepen acetabular fossaLigament of head of femur conveys branch ofobturator artery to pit (fovea) of head of femur

Pubofemoral, iliofemoral and ischiofemoral ligaments are thickenings of articular capsule; allthree ligaments check hyperextension at hip joint;pubofemoral ligament additionally checks over-abduction of thighIliofemoral ligament (also called Y ligament) isprobably strongest ligament of bodyZona orbicularis: deep capsular fibers that encircleneck of femur and bland with ischiofemoral ligamentFractures of femur: subcapital occurs in elderly witheven minor fall; more common in females due tothinning of cortical and trabecular bone after menopause

Knee joint is most complex and least stable joint ofbody; capsule is pierced by tendon of popliteus andcapsular ligaments are not strongDeep fibers of TCL attach to medial meniscus; blowto lateral side of fixed knee results in terrible triad, TCL, ACL, and medial meniscusInjury to ACL is 4 - 5 times more common in females; ACL checks backward displacement offemur on tibia (anterior drawer sign when injured)PCL checks hyperflexion of knee; not commonlyinjured; LCL can be injured with blow to medial sideof knee joint

Synovial membrane of knee is very extensive, and up to 95 % can be removed (regeneration can occurwith as little as 5%); both ACL and PCL are extrasynovial Bursae that communicate with knee: suprapatellar,popliteal and medial gastrocnemialPrepatellar: housemaids kneeSubcutaneous infrapatellar: clergymans knee

True hinge jointDorsiflexion:1.Tibialis anterior2.Extensor hallucislongus3.Extensor digitorumlongus4.Fibularis tertius

Numerous muscles plantarflex at ankle: soleus,gastrocnemius, plantaris, tibialis posterior, flexorhallucis longus, flexor digitorum longus, fibularislongus, and fibularis brevis

Deltoid ligament strengthens medial side of ankle;strong ligament and usually not injuredComponents of deltoid ligament:1.Anterior tibiotalar ligament2.Tibionavicular ligament3.Tibiocalcaneal ligament4.Posterior tibiotalar ligament

Ligaments on lateral side of ankle are three distinctbands: anterior talofibular, calcaneofibular, andposterior talofibularSprained ankle is usually inversion sprain, and mostcommonly injured ligament at ankle is anterior talofibular

Calcaneofibular issecond most commonly injured ligamentat ankle

Two functional intertarsal joints: subtalar joint andtransverse tarsal joint; movements of inversion andeversion occur at these two jointsMajor invertors of foot are tibialis anterior andtibialis posteriorMajor evertors arefibularis longus,fibularis brevis

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

True back muscles are deep back muscles; they areconfined to back and are innervated by dorsal rami

Two layers of deep muscles; more superficial layer contains splenius and erector spinae

Splenius muscle has two parts, capitis and cervicis;turns head and neck to ipsilateral side

Erector spinae has three parts: Iliocostalis,Longissimus, Spinalis from lateral to medial;(mnemonic I Like Spaghetti)

Like splenius, erector spinae is in superficial layerof deep back muscles; innervated by regionaldorsal rami

Extends vertebral column; muscle fibers areoriented in vertical direction

Transverospinal muscles: origin is transverse process and insertion is spinous processTransverospinal muscles lie deepOrientation of muscle fibers is in oblique directionFrom superficial to deep, semispinalis (spans 6 - 8vertebrae), mutifidus (spans 3 - 4 vertebrae), androtators (span 1-2 vertebrae)

All muscles rotate column to contralateral side

Suboccipital triangleRectus capitis posterior minor does not serve asboundaryBoundaries are rectus capitis posterior major,obliquus capitis superior, and obliquus capitisinferior; all muscles are innervated by dorsal ramusof C1 (suboccipital nerve)Roof: semispinalis capitis; floor: posterior atlanto-occipital membraneVertebral artery: inside cranial cavity gives rise toPICA; dizziness with turning of head

Vertebral column: 33 vertebrae and intervertebraldiscs; only upper 24 vertebrae moveIn newborn, column is C-shaped, concave anteriorly;as baby ages, primary curvatures in thoracicand sacral areas; secondary curvatures in cervical area (child holds head upright) and lumbar area(child stands)Articular processes: all superior facets directedposteriorly; in cervical area, directed superiorly;in thoracic area, directed slightly laterally; and inlumbar area, directed mainly medially; dislocationwithout fracture only in cervical area (C4/5 or 5/6)

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

Portions of vertebra are:(1) Body: articulates with intervertebral disc (cartilagenous type of joint)(2) Neural arch: surrounds spinal cord and meninges - pedicle: attached to body - lamina: attached to pedicle - processes: spinous, transverse, and articular, superior and inferior

Vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral(fused as sacrum) and 4 coccygeal (fused as coccyx)

7 Cervical: key feature is transverse foramen forvertebral vessels (only vein courses in CV7); exceptfor CV7, have short bifid spinous processes

Cervical vertebrae 1, 2, & 7 are atypicalCV1 = atlas: has no body and no spinous processCV2 = axis: densCV7 has long spinous process (vertebra prominens)

CV6 has carotid tubercle; common carotid artery canbe compressed against this landmark

Thoracic vertebrae have costal facets for ribs; dueto ribs, movements of flexion, extension, and lateralbending in thoracic region are limitedLumbar vertebrae are large, bulky and havemammillary processes and hatchet-shaped spinesSPONDYLOLYSIS: fracture of lamina betweensuperior and inferior articular processes; occurs in lumbar area ANKYLOSING SPONDYLITIS: inflammatory arthritis affecting lumbar vertebrae, sacroiliac jointOSTEOMYELITIS: bacterial infection that may affect vertebrae

Fifth sacral vertebra has no lamina nor spinous process, leaving a sacral hiatus, site for epidural anesthesia; with caudal anesthesia, needle goes through sacrococcygeal ligament; type of anesthesiaused with birth

Spondylolisthesis: body of vertebra moves anterior;usually LV 5 moves on S 1; due to defect of lamina; when spondylolisthesis occurs in thecervical area, it is a defect of the pedicles

Two portions of intervertebral disc are(1) nucleus pulposus: inner area; remnant of notochord, high water content; shrinks with age, avascular(2) anulus fibrosus: collagen fibers, surrounds nucleus pulposus

There is no disc between atlas and axis

Herniation (rupture) of intervertebral disc occurs in posterolateral direction

Nucleus pulposus pushes anulus fibrosus andposterior longitudinal ligament; this ligament checksagainst protrusion directly posteriorMost common in lumbar region, disc betweenLV4&5 compresses L5 (and nerves inferior to it);although L4 corresponds to the disc space, it is toofar lateral to be affected; L5 and S1 are compressedFor cervical region, most common site is discbetween CV5&6, which affects spinal level C6With herniation, scoliosis occurs with concavity onside of lesion due to muscle spasm

Anterior longitudinal ligament: only ligament ofvertebral column that lies anterior to vertebral bodiesand therefore, only ligament to check hyperextension- injured with whiplash

All other ligaments of column check hyperflexion.Both posterior longitudinal ligament and ligamentumflava lie with neural arch; ligamentum nuchae thatcontains elastic fibers is found in cervical area only;other ligaments are supraspinal, interspinal, andintertransverse

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

No valves, so blood can flow in either directionTwo major portions: (1) external plexus lies outsidevertebrae, (2) internal plexus lies within vertebral canal (external to dura mater)Communicates with vertebral veins in cervical area,intercostal veins in thoracic area, lumbar veins and lateral sacral veins (in pelvis)Clinical significance: communicates with duralsinuses within cranium; metastasis of cancer ofprostate or penis to brain

Lumbar punctures are doneabove or below LV4

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

Depth of needle is about 1 inch in child and up to4 inches in obese adult

Bone most commonly encountered is spinous process

Although last layer to pierce is arachnoid, last layerthat is felt is dura mater

Subarachnoid space contains cerebrospinal fluid

31 Pairs: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral,1 coccygeal; dorsal roots = sensory roots; ventralroots = motor rootsAll spinal nerves receive gray rami; therefore theyhave four functional components, GSA, GVA, GSE,and GVE (sympathetic)

Dorsal and ventral rami, like spinal nerves, containfour functional components

THORAXCostal groove lies on inferior border of rib; housesposterior intercostal vein, artery, and intercostal nerve

With thoracocentesis, the needle is inserted on thesuperior surface of the rib, in order to avoidcollateral vessels and nerves

Middle ribs are ones most commonly fracturedRib is weakest just anterior to its angle, site ofgreatest curvature

Major lymphatic drainage of breast is to anterior orpectoral group of axillary lymph nodes

Carcinoma causes shortening of suspensory ligaments : dimpling

Long thoracic nerve is at risk during resection

Regardless of breast shape and size, base is constant:2nd 6th ribs, lateral edge of sternum, and midaxillary line

Plane between sternal angle (junction of manubrium and body of sternum) and intervertebral disc betweenT4 and T5 separates superior mediastinum frominferior portions

Anterior mediastinum lies anterior to pericardium

Pericardium and related structures lie in middlemediastinum

Posterior mediastinum lies posterior to pericardium

Thymus gland is structure immediately posterior tomanubrium; produces T cells and involutes with ageThymoma is often associated with myasthenia gravis

Major contents of superior mediastinum include:Arch of aorta: brachiocephalic, left common carotid,and left subclavian arteries; phrenic nerve, vagusnerve, left recurrent laryngeal nerve and thoracic duct

Left brachiocephalic vein crosses to join rightbrachiocephalic vein to form the superior vena cava

Two structures can compress esophagus withinthorax: (1) Left bronchus and (2) arch of aorta; can interfere with swallowing

Esophagus can also be constricted(1) By cricopharyngeus where pharynx is continuous with esophagus(2) At diaphragm where esophagus passes (T 10)

Aneurysms of the arch of the aorta (often associatedwith syphilis) commonly present with referred painto back, difficulty swallowing (compression ofesophagus) and a twang in voice (compression ofrecurrent laryngeal nerve)

Ductus arteriosus is vessel of fetus that communicatesbetween left pulmonary artery and aorta, just distalto origin of left subclavian artery; usually becomesligamentous, but can remain open (PDA); the leftrecurrent laryngeal nerve wraps around the aorta andthe ductus arteriosus

Azygos venous systemHighly variable in formationCommunicates with veins in abdomenDrains thoracic wall and thoracic organs exclusive ofheart and lungsEnds in superior vena cava; important communication between IVC and SVC

Surfaces of heart

1.The sternocostal surface is formed mainly by theright ventricle2.The diaphragmatic surface is formed mainly by theinferior wall of the left ventricle3.The posterior surface is formed mainly by the leftatrium

Auscultation of heart sounds

Tricuspid valve: near xiphisternal joint

Pulmonary valve: left second intercostal space,lateral to sternum

Mitral valve: left fifth intercostal space, near midclavicular line

Aortic valve: right second intercostal space, lateralto sternum

Fibrous pericardium is attached to both sternum anddiaphragm; it is lined by parietal serous layer

Fibrous pericardium is innervated by phrenic nerve

Pericarditis: may produce friction rub which can be auscultated

Cardiac tamponade: leaking of fluid or blood intopericardial cavity that compromises heart function

Right coronary artery (RCA) descends between right atriumand right ventricle; usual origin of artery to SA node and arteryto AV node; often gives rise to posterior interventricular arteryLeft coronary artery (LCA) is very short before it divides toform left anterior descending (LAD) and circumflex arteries

Origin of posterior interventricular artery determinescoronary dominance; left dominant when origin iscircumflex branch (of LCA)

Myocardial infarction: impact depends on collateral circulation(usually more serious in younger person since collateralcirculation not as well developed); may cause cardiacarrhythmia and fibrillation

Right atriumForms right border of heartFossa ovalis is major internal feature; was foramenovale prior to birth that shunted blood from right toleftCrista terminalis: ridge of tissue between sinusvenarum and musculi pectinati; SA node, pacemakerof heart, is located within crista terminalis Atrial septal defect (ASD): common defect of heart; usually involves foramen ovale; severity depends onamount of blood passing to left

Right ventricle Moderator band (septomarginal trabecula) is locatedin right ventricle

Pulmonary stenosis results in hypertrophy of rightventricle due to increased resistance to rightventricular outflow caused by a stenotic pulmonic valve

Ventricular septal defect (VSD) is commondefect of heart; involves membranous portion ofinterventricular septum

Valvular incompetence may involves any of thecardiac valves

Chronic aortic valvular regurgitation results in areduction in diastolic arterial pressure, resulting in awide pulse pressure (a normal or high systolic arterialpressure and a low diastolic arterial pressure)

Aortic stenosis is a common cause of systolicejection murmur

SA node is pacemaker of heart; impulses travel fromSA node via interatrial fibers to AV node tobundle of HisRight and left bundle branches carry impulses toPurkinje fibers

Sympathetic nerves to heart: increase hearts rate andforce of contraction and (indirectly) produces dilationof coronary arteries (by inhibiting constriction)Parasympathetics: slow heart rate, reduce force ofcontraction and constrict coronary arteries

Small aspirated food or small objects go to right primary bronchus rather than left because, comparedto left bronchus, right bronchus is:1.wider2.directed more vertical3.shorter

Aspirated objects can go to right inferior lobe or tomiddle lobe

Intercostal nerves innervate the costal pleura; thephrenic nerve innervates the mediastinal pleura

Anteriorly, lungs and pleura extend above first rib and clavicle; however, posteriorly, they extend onlyto level of first ribInferior extent: LocationLungPleuraAnterior6th rib8th ribLateral 8th rib10th rib Posterior 10th rib12th rib

Right lung has three lobes and two fissures, oblique(major) and horizontal (minor); left lung normally hasonly two lobes that are separated by oblique fissure

The second rib is related to the oblique fissureposteriorly; the horizontal fissure of the right lungparallels the fourth rib

Needle location for therapeutic pleural tapping is superior to 12th rib posteriorly

Preganglionic parasympathetic branches from vagusPostganglionic sympathetic fibers (T 1 - 5)

Sympathetic effects on lungs: vasoconstriction andbronchodilatation

Parasympathetic effects on lungs: vasodilatation,bronchoconstriction, and glandular secretion

ABDOMENVentral rami of spinal nerves T7 through L1 supplyskin and musculature of anterolateral abdominal wall

T10 supplies skin around umbilicus; pain from ovaryor appendix is initially perceived at umbilical level;intervertebral disc L3/L4 lies at level of umbilicus

L1 supplies skin of suprapubic area; pain from uterusor prostate

Inguinal canal contains round ligament of uterus infemales and spermatic cord in males; round ligamentand spermatic cord are not homologous structures

Inguinal ligament forms floor of inguinal canal; edgeof external oblique attached to ASIS and pubictubercle; conjoint tendon is formed by union ofinternal oblique and transversus abdominis

Deep ring is formed by transversalis fasciaSuperficial ring is formed by external oblique

Fascial continuities: external oblique and externalspermatic fascia; internal oblique and cremasteric fascia and muscle; transversalis fascia and internalspermatic fascia

Tunica vaginalis of testis: derived from the processusvaginalis, an outpocketing of peritoneum; a hydrocele is an accumulation of fluid within thetunica vaginalis

Indirect inguinal hernia is more common than direct inguinal; passes through deep ring, which lieslateral to inferior epigastric blood vessels; hernia follows path of spermatic cord (through both inguinalrings) to reach scrotum; hernia on right side is morecommon than on left side

Direct inguinal hernia protrudes throughHesselbachs triangle, bounded by rectus abdominis,inferior epigastric blood vessels, and inguinal ligament; usually seen in elderly with weakness ofabdominal wall musculature; rarely reaches scrotum

Paracolic gutters lie lateral to ascending colon anddescending colon; on right side, ascitic fluid canreach hepatorenal recess, while on left side,phrenicocolic ligament limits spread of fluidsuperiorly

Infracolic gutters lie medial to large intestine, rootof mesentery prevents ascitic fluid from spreading topelvic cavity

Epiploic foramen is small space that communicatesbetween greater peritoneal cavity and lesser cavity(omental bursa); bounded superiorly by caudate lobeof liver, and inferiorly by first part of duodenum

IVC bounds epiploic foramen posteriorly, and anteriorly, it is bounded by hepatoduodenal ligament(portion of lesser omentum) that contains bile duct,hepatic artery, and portal vein

ORGANS: StomachThe celiac artery, the first unpaired visceral branch of the abdominal aorta, has three branches: left gastric, common hepatic and splenic

All three arteries supply the stomach: left gastricarises directly from the celiac; right gastric and right gastroepiploic arise from the hepatic; andthe left gastroepiploic and short gastric arteriesarise from the splenicVenous blood from the stomach drains directly to theportal vein

Stomach bed = posterior relations of stomachStructures of the stomach bed include the following:pancreas, spleen, diaphragm, left suprarenal gland,and left kidney; transverse colon is not part of thestomach bed since the transverse colon lies inferior(not posterior)

First portion of duodenum is peritonealized; part tworeceives the bile duct; third part courses posterior tosuperior mesenteric vessels, and part four ascendsParts two - four are retroperitoneal

Falciform ligament divides the liver into right and left lobes; caudate lobe lies adjacent to the IVC andquadrate lobe lies adjacent to the gallbladder

Liver is only site of bile production; it also producesalbumin (edema with poor liver function)

Porta hepatis lies between gallbladder and fossa forIVC; structures located at the porta hepatis includeportal vein, hepatic artery and hepatic ductHepatic veins are not located at the porta hepatis

The gallbladder stores and concentrates bile; bile duct is formed by union of cystic and hepatic ductsSurface projection of the fundus of the gallbladder isat the intersection of the right costal margin and thelinea semilunaris, lateral margin of rectus abdominisPosterior relations are transverse colon and parts oneand two of duodenum; liver and abdominal wall areanteriorAlthough the origin of the cystic artery is highlyvariable, the usual origin is the right hepatic arteryGallstones most commonly block the infundibulumor hepatopancreatic ampulla and occur in overweight, multigravida women in their forties

PANCREAS: classical endocrine - exocrine gland;insulin and glucagon secretion by islets ofLangerhans and hydrolytic enzymes by exocrineportion; retroperitonealized except at tailSignificant posterior relations: IVC, origin of portalvein, and aorta; lesser peritoneal sac lies anteriorExtensive blood supply from splenic, gastroduodenaland superior mesenteric arteriesPain from the pancreas is commonly referred to thebackCancer of the head of the pancreas often causesobstructive jaundice

SPLEEN: Lymphoid organ: immune response and destroys old RBCs; located in upper left quadrant; liesin relation to ribs 9, 10 and 11; related to stomach,left kidney and transverse colonNormally not palpable, but may becomeenlarged and palpable due to lymphoid cancer,infection (mononucleosis), or portal hypertensionRupture of the spleen results in massiveintraperitoneal hemorrhage; because of its friablenature, it is usually removed rather than repaired

JEJUNUM AND ILEUM: comparisonJejunum has more circular folds, larger diameter, andis better vascularizedIleum has more fat in its mesentery; containslymphatic nodules (Peyers patches); has morearching of arteriesSuspended by the mesentery; root of the mesenteryis attached to the posterior body wall from the left ofLV2 to the right sacroiliac joint

LARGE INTESTINEThree classical identifying features are: (1) fattyappendages; (2) haustra or sacculations; and (3)tenia coli, three longitudinal bundles of smoothmuscleDiverticulosis of the colon is common; herniation ofthe lining mucosa through the circular musclebetween the tenia coliCancer of the large bowel is common; usually spreads by lymphatics before the bloodstream isinvolved

The cecum does not contain a mesentery; the root ofthe appendix attaches where the three tenia coli uniteBoth cecum and appendix are supplied by theileocolic artery, the terminal branch of SMALocation of appendix is variable; often retrocecal

Pain from appendix is conveyed by (GVA) T10 fibers (lesser splanchnic nerve) and is vague and referred to umbilicus; when parietal peritoneum isirritated, pain localized in the lower right quadrant(McBurneys point)

KIDNEYS: Posterior relations are diaphragm,psoas major, quadratus lumborum, and transversusabdominis; three nerves lie posterior to the kidneys:subcostal, ilioinguinal and iliohypogastricAnterior to right kidney: liver, right colic flexure,part two of duodenum and right suprarenal glandAnterior to left kidney: stomach, spleen, splenic flexure and left suprarenal glandPerirenal fat lies in contact with the capsule of thekidney; renal fascia surrounds perirenal fat;pararenal fat lies external to the renal fascia

Unpaired arteries and their vertebral levelsCeliac - T12; SMA - L1; IMA - L3

Paired arteries and their vertebral levelsSuprarenal - L1; Ovarian or testicular - L2;Renal - L2

Aneurysm of the abdominal aorta usually occurs just inferior to the origin of the renal arteries; most ofthese aneurysms result from atherosclerosis Aortic bifurcation is a common site for an embolus tolodge

Superior mesenteric artery supplies the entire smallbowel, cecum, appendix, ascending colon, right 2/3of transverse colon and pancreas

Arises from aorta (at LV1) at a very acute angle;structures that course between aorta and origin ofSMA are: left renal vein, part three of duodenum and uncinate process of pancreas; an aneurysm ofSMA at its origin produces the nutcrackersyndrome whereby the duodenum is blocked as wellas flow of blood in left renal vein (includes both leftsuprarenal vein and left ovarian or testicular vein)

INFERIOR VENA CAVAOn the right side, testicular or ovarian vein, inferiorphrenic vein and suprarenal vein all drain directly tothe IVC; on the left. testicular or ovarian vein,inferior phrenic vein and suprarenal vein all drain to the left renal vein

Injuries to the IVC are usually lethal; thin wall makes it prone to extensive tears and the IVC is not readilyaccessible, being located posterior to the liver,duodenum and root of the mesentery

Portal vein is formed by union of superiormesenteric and splenic veins; occurs posterior toneck of pancreas; usual termination of inferiormesenteric vein is to splenicAs the portal vein courses within the hepatoduodenalligament (portion of lesser omentum), it lies posterior to the hepatic artery and bile duct

The portal vein drains the structures that receivetheir arterial supply from three major arteries,celiac, SMA, and IMA

Portacaval anastomoses: (1) left gastric vein (that drains to portal) and esophageal veins that drain toSVC; esophageal varices associated with alcoholics;(2) superior rectal drains to IMV which goes to theportal vein and middle and inferior rectal veins drainto the internal iliac which ends in the IVC;hemorrhoids; (3) paraumbilical veins; caput medusae seen with late pregnancy, in newborns andwith cirrhosis; (4) veins of Retzius: venousanastomoses of organs that are retroperitoneal

Psoas majorO = T12 - L5; I = joins iliacus to form iliopsoas to insert on lesser trochanter of femurChief flexor at hip (flexes trunk with feet onground)Subfascial space route for spread of infection;spread of tuberculosis from lumbar vertebrae to lower limbFlexion of thigh against force: test for disorders of posterior abdominal visceraPsoas minorQuadratus lumborumIliacus

DIAPHRAGM: phrenic nerve (C3 - C5) is the solemotor nerve; phrenic is sensory to region of centraltendon and lowest intercostal nerves are sensory toperipheral, muscular part of diaphragm

Opening for IVC (and right phrenic nerve): TV 8Esophageal hiatus (and right and left vagus): TV 10Aorta (and thoracic duct): TV 12

Branches of the lumbar plexus are:Iliohypogastric L1: innervates rectus abdominis and is cutaneous to small area of thighIlioinguinal L1: courses through superficial inguinal ring; potentially injured with hernia repairGenitofemoral L1-L2: innervates cremaster muscle and is cutaneous to small area of thighLateral femoral cutaneous L2-L3: cutaneous to thighFemoral L2-L4: innervates anterior compartment ofthighObturator L2-L4: innervates medial compartment ofthighLumbosacral trunk L4-L5: joins the sacral plexus in the pelvis

Greater splanchnic nerve: T 5 - 9; synapses atceliac ganglion and suprarenal medullaLesser splanchnic nerve: T 10 and 11; synapses ataorticorenal and superior mesenteric gangliaLeast splanchnic nerve: T 12; synapses at renalplexusPressure (distension), fullness and motion sensations travel with parasympathetic innervation (e.g. thevagus nerve)Pain afferents travel with sympathetics to the level of the preganglionic originReferred pain [important clinical concept]: perceivedat the level of the preganglionics that serve the area

PELVIS and PERINEUMPelvic brim (inlet) is bounded by sacral promontory,arcuate and pectineal lines, and pubic symphysis

Most common shape of inlet in females is gynecoid,with the transverse diameter being slightly greaterthan the AP diameter

Orientation of the pelvis: ASIS and pubic tuberclelie on the same vertical plane

Pelvic diaphragm is primary support for all pelvicviscera; muscle complex separates pelvis fromperineum, which lies inferior

Two major components of pelvic diaphragm are(1) levator ani and (2) coccygeus

Levator ani consists of two major portions,pubococcygeus and iliococcygeus; pubococcygeus isthe portion of the levator ani that serves as theprimary support of the pelvic organs

Urinary bladderStrong muscular wall known as the detrusor muscleApex is located anterior and is continuous with theurachus, the fibrous cord that is the remnant of theallantois; the urachus forms the median umbilical ligament; base is located posterior and is outlined bythe trigone, which is bounded by the two ureters andthe urethra; oblique course of the ureter acts as valve

Blood supply: superior and inferior vesical arteriesMicturition reflex is entirely parasympathetic; S2 - 4(pelvic splanchnic nerves)

Chief artery to rectum and anal canal is superiorrectal, the terminal branch of inferior mesenteric;also supplied by middle and inferior rectal arteriesPectinate line of anal canal serves as important divide line: for lymphatic drainage; superior to line: toinferior mesenteric and internal iliac nodes; inferior toline, to superficial inguinal nodesSomatic innervation below line, visceral afferents superior to pectinate lineSite of portacaval anastomosesLine between internal and external hemorrhoids

OVARY: several important facts appear on boards

Ovarian artery arises from aorta directly (L2)Venous drainage: IVC on right, renal vein on leftPara-aortic group of lumbar lymph nodes

Ovarian blood vessels are conveyed by the suspensory ligament; this ligament does not suspend

Two remnants of gubernaculum in females are(1) round ligament of uterus, that courses from theuterus through the deep inguinal ring, and in theinguinal canal to end in the labium majus(2) ovarian ligament: connects ovary to the uterus

Uterine tube: Fimbriae of infundibulum open into peritoneal cavity; ampulla is the site of fertilization

Usual uterine position is anteverted and anteflexed;angle between uterus and vagina is approximately900 (anteverted) and angle between uterine body andcervix is about 150 (anteflexed)Uterine support: pelvic diaphragm (pubococcygeuspart of levator ani), UG diaphragm, bladder andareolar tissue, cardinal and uterosacral ligamentsCardinal (lateral cervical) ligament conveys uterineblood vessels; uterine artery courses superior to the ureter; ureter is at risk with a hysterectomyLymph nodes: external iliac, internal iliac, commoniliac, sacral, superficial inguinal and lumbar

Vagina: fornix is continuous recess around cervix Relationships: lateral, levator ani and ureter Anterior: uterus and bladderPosterior: perineal body, pouch of Douglas and rectum

Support is similar to that of uterus: pelvic diaphragm,UG diaphragm, organs, areolar tissue, and ligaments

Arteries: vaginal, uterine and middle rectalLymphatics: superior portion to internal iliac nodes;inferior portion to superficial inguinal nodes

Seminal vesicle is a highly coiled gland that secretesfructose into seminal fluid; it lies lateral to vasdeferens; ducts join inside of prostate to form ejaculatory ductThe fluid secreted by the seminal vesicle comprisesthe bulk of the seminal fluid

Separated from rectum by Denonvilliers fascia

Prostate: lies on UGD; paired lateral and medianlobes; so-called posterior lobe is really part oflateral lobeTraversed by urethra and the ejaculatory ductsBase of prostate lies in contact with bladder; apex ofprostate lies on UGDProstatic venous plexus lies between capsule of prostate and its fibrous sheath; drains to vertebralvenous plexus (of Batson); metastasis to brainArteries: inferior vesical, middle rectal and internalpudendalProstatic ducts open into prostatic sinuses, whichlie lateral to urethral crest

Internal iliac arteryPosterior division: superior gluteal (exits superior topiriformis), lateral sacral and iliolumbar

Anterior division: umbilical, obturator, (in females, uterine and vaginal), inferior vesical, middle rectal; terminal branches are internal pudendal and inferiorgluteal; (superior vesical arises from umbilical)

Although located in the pelvis, the ovary does not gets its supply from the internal iliac; supplied by theaorta directly

Sacral plexus supplies the lower limbVentral rami L4 S3Anterior division: tibial, nerve to obturator internusand nerve to quadratus femorisPosterior division: common fibular, superior gluteal and inferior gluteal

While in the pelvis, the nerves lie medial to thepiriformis, and as they exit, all pass inferior to thepiriformis except the superior gluteal nerve (whichpasses superior)

Boundaries of the perineum (pelvic outlet)Anterior: pubic symphysisAnterolateral: ischiopubic ramiLateral: ischial tuberositiesPosterolateral: sacrotuberous ligamentsPosterior: coccyx

Horizontal line/plane between ischial tuberositiesforms two triangles, anal and urogenital

Ischioanal fossa is a fat-filled space bounded by:Medial: anal canal and levator aniLateral: fascia overlying obturator internus; pudendalcanal lies within fascia of obturator internusSuperior (apex): levator ani joins fascia of obturatorinternusInferior (base): skin; posterior: coccyxAnterior: extends into UG triangle as a recess

Superficial perineal spaceIschiocavernosus: compresses venous outflow maintaining erection; bulbospongiosus: functions toempty urethra and compresses deep dorsal vein anderectile tissue; superficial transverse perineus:stabilizes other musclesContains the crura and bulb of the penis

Paired corpus cavernosum; each is continuous withcrus; unpaired corpus spongiosum: contains urethra,continuous with bulb and glansTunica albuginea = CT capsule around penisDeep arteries lie within corpora cavernosa to supplyerectile tissue; dorsal arteries course on dorsum of penisVeins: superficial dorsal vein drains to superficial external pudendal (tributary of great saphenous); deepdorsal vein drains to prostatic plexusGlans of penis drains DEEP inguinal lymph nodes

Common site of injury is in superficial space; urinecollects in penis, scrotum and passes up abdominalwall; does not spread to anal triangle nor to thigh due to fascial attachments

Fascial continuities of Colles fascia, dartos, andScarpas fascia allows for the spread of urine

Superficial space contains Bartholins gland, crus ofthe clitoris, and the vestibular bulb

Perineal body: central point of perineum, importantwith episiotomyMuscles attached: bulbospongiosus, superficial transverse perineus, deep transverse perineus,external anal sphincter, and pubovaginalis (portionof pubococcygeus of the pelvic diaphragm)Fascia attached: Colles, perineal membrane, superior fascia of UGD, inferior fascia of pelvic diaphragm, and fascia around muscles (Gallaudets)

The urogenital diaphragm (UGD) in both sexes aidsthe pelvic diaphragm in supporting the bladder and the reproductive organs of the pelvis

The UDG is composed of two layers of fascia, thesuperior fascia of the UGD and the perinealmembrane, and two muscles: deep transverse perineus and sphincter urethrae

In males, it also contains Cowpers gland (in females,homologue is Bartholins gland, which is in thesuperficial space)

Pudendal nerve arises from sacral plexus, S2 - 4; exitspelvis by the greater sciatic foramen and enters theperineum by the lesser sciatic foramenCourses in pudendal canal (fascia of obturatorinternus); its branches are the inferior rectal nerve,perineal nerve and dorsal nerve of the penis or clitoris

The pudendal nerve innervates ALL of the muscles of the perineum

Clinically, cutaneous innervation is an importantconsideration due to pudendal nerve blocks

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

FASCIA1.Investing fascia: collar around entire neck, invests SCMand trapezius2.Infrahyoid fascia: surrounds the four strap muscles3. Visceral fascia has two layers: (a) pretracheal fascia lies anterior to trachea and surrounds thyroid gland; and(b) buccopharyngeal fascia lies posterior4.Prevertebral fascia: - surrounds muscles of vertebral column; alar fascia is anterior layer of prevertebral fascia;danger space lies between alar and prevertebral 5.Carotid sheath (paired) contains common and internal carotid arteries, CN X, internal jugular vein & deep cervical lymph nodes; sympathetic trunk lies posterior and ansa cervicalis lies anterior

POSTERIOR TRIANGLEBoundaries: clavicle (middle 1/3) , SCM, trapezius Muscles of floor (from apex inferiorly): semispinaliscapitis, splenius capitis, levator scapulae, posteriorscalene, middle scalene, anterior scalene

Platysma muscle overlies pectoralis major, deltoid,and posterior triangle; innervated by cervical branchof CN VII

Spinal accessory nerve: emerges from behind SCM, innervates both SCM & trapezius; nerve can be injured with removal of lymph nodes causing shoulder to sag

Cutaneous nerves:1.Great auricular - parallels external jugular; prominence of external jugular is indicator of heart failure2.Lesser occipital3.Anterior cutaneous nerve of neck4.Supraclavicular

Between anterior and middle scalenes: brachial plexus and subclavian arteryEither the plexus and/or the artery can becompressed between the scalene muscles

Anterior to anterior scalene: subclavian vein, phrenicnerve, branches of thyrocervical trunk:1.Suprascapular2.Transverse cervical3.Ascending cervical

Anterior triangleBoundaries: SCM, mandible and midlineCarotid triangle: omohyoid, posterior belly digastricand SCMMuscular triangle: omohyoid, SCM and midlineDigastric (submandibular): mandible and two belliesof digastric muscle Submental: hyoid bone and paired anterior belliesof digastric

Suprahyoid muscles: ones that elevate hyoidand larynx with swallowingDigastric: anterior belly (CN V3) pulls hyoid forward; posterior belly (CN VII) pulls hyoidposteriorStylohyoid (CN VII); geniohyoid (C1 via CN XII);mylohyoid (CN V3)Infrahyoid muscles: ones that depress hyoid andlarynx; thyrohyoid is innervated by C1 via CN XII;sternohyoid, sternothyroid and omohyoid are musclesinnervated by the ansa cervicalis

Cervical plexus: ventral rami C1 - 4; communicates with the sympathetic chain and with CN X, XI & XII

Ansa cervicalis is loop formed by C1 - 3Cutaneous branches:great auricular, lesser occipital, transverse cervical and supraclavicular

Muscular branches: phrenic; to prevertebral muscles

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

Internal jugular vein: continuation of sigmoidsinus at inferior aspect of jugular foramenCourses within carotid sheathTributaries: pharyngeal, facial, lingual (especiallyimportant because this is the rationale for puttingnitroglycerin under the tongue), superior thyroid,and middle thyroidEnds by joining subclavian to form brachiocephalicvein (at venous angle)

Three portions of the pharynx1.Nasopharynx: base of skull to soft palate (CV2); communicates with paired nasal cavities & auditory tubes and oropharynx2.Oropharynx: CV2 to hyoid bone (CV3); communicates with oral cavity, nasopharynx andlaryngopharynx3.Laryngopharynx: extends to CV6; (level of cricoid cartilage); communicates with oropharynx, larynx and esophagus

Pharyngeal muscles: two groupsLongitudinal muscles elevate when swallowing:1.Stylopharyngeus: arises from styloid process(only muscle innervated by CN IX)2.Salpingopharyngeus: arises from auditory tube3.Palatopharyngeus: arises from palateCircular muscles propel foodSuperior, middle and inferior constrictors;the inferior fibers of the inferior constrictor arecontinuous with the esophagus to form the cricopharyngeus, that acts as an upper esophagealsphincter; (innervated by recurrent laryngeal nerve)

OPENINGS of the pharyngeal wall:Above superior constrictor: auditory tube and levator veli palatini

Between superior and middle: CN IX, stylohyoidligament and stylopharyngeus

Between middle and inferior, through thyrohyoidmembrane: superior laryngeal artery and internallaryngeal nerveBelow inferior: inferior laryngeal artery andrecurrent laryngeal nerve

Major cartilages of larynxThyroid: unpaired; vocal cords attach to its posteriorsurface; Adams appleCricoid: CV6; unpaired, signet ring (only completering of entire respiratory system)Epiglottis: unpaired; looks like tennis racket Arytenoid: paired and articulate with cricoid bysynovial joints; has vocal and muscular processes

Vocal cords extend from thyroid cartilage toarytenoid cartilage

Posterior cricoarytenoid: only muscle to abductvocal cords (thereby opening the rima glottidis); antagonistic muscles: lateral cricoarytenoid andtransverse and oblique arytenoidsCricothyroid is only muscle to increase tension;thyroarytenoid and vocalis are antagonistic muscles

Motor: external branch of superior laryngeal is motorto cricothyroid; recurrent laryngeal is motor all othersSensory: internal branch is sensory to larynx superiorto vocal cords; recurrent laryngeal is sensory belowvocal cords

Piriform recess: site where a fishbone can be lodged; can pierce mucosa and injure internallaryngeal nerve

Rima glottidis: opening between vocal cordsAditus: opening to larynxVestibular folds = false vocal cordsVestibule: region superior to false vocal cordsVentricle: region between false and true cords

Sagittal suture: between parietal bonesCoronal: between frontal and paired parietal bonesLambdoidal: between occipital and parietalSquamosal: between temporal and parietal

Fontanelles Paired: sphenoid and mastoidUnpaired: sagittal and coronal sutures intersect atbregma, site of anterior fontanelleLambda, where sagittal and lambdoidal suturesmeet, site of posterior fontanelle

Pterion: overlies anterior branch of middlemeningeal arteryUnion of four bones: frontal, parietal, sphenoid, andTemporal

These bones are relatively thin at the pterion

Middle meningeal arises from part one of maxillaryartery passes through foramen spinosum; artery supplies both dura mater and calvaria

Severe blow to the head tears the artery; events:brief concussion, lucid for several hours, coma; needto operate since blood is compressing brain

Epidural bleeding is arterial bleeding

Sphenoidal ridge: separated anterior fossa andmiddle fossa; petrosal ridge separates middle fossa and posterior fossa

Significant foramen to rememberInternal acoustic meatus for CN VII and CN VIIIFor the three divisions of CN V, superior orbitalfissure, foramen rotundum and foramen ovaleOptic canal for CN II and ophthalmic arteryForamen spinosum for middle meningeal arteryJugular foramen for CM IX, CN X and CN XI

Emissary veins pass through calvaria, communicating veins of scalp with dural sinuses; no valves, so blood can flow in either direction

Diploic veins: begin within diploe; drain in or out

Arachnoid villi terminate in the superior sagittal sinus; return of CSF to the circulatory system

Cavernous sinus: contains internal carotid arteryand CNVI; CN III, IV & V1 are located within itslateral wall; communicates with ophthalmic veinsand pterygoid plexus and drains to superior andinferior petrosal sinuses

Hormones from both anterior and posterior lobes ofthe pituitary drain to the cavernous sinus

Enlargement of the pituitary gland can compress thestructures within the cavernous sinus as well as CN II

Numerous arteries to the scalp with extensiveanastomoses; all arteries enter peripherally Three branches from external carotid: superficialtemporal, occipital and posterior auricularTwo branches from internal carotid: supraorbital andsupratrochlear

Clinically, wounds to the scalp are seriousThe aponeurotic layer holds lacerations open, so extensive bleeding occurs with a wound to the scalp

All muscles of facial expression are innervated byCN VII

Orbicularis oculi: closes eyeBuccinator keeps food from collecting betweenteeth and oral vestibule; buccal branch of CN VII ismotor to buccinator while buccal branch of CN V iscutaneous to skin over cheek and it is sensory tomucosa inside of the mouth

Parotid gland: Largest salivary gland; infected bymumps virus

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

CN V is cutaneous to the face; all three divisions innervate the skin of the face and scalp

CN VII is motor to muscles of facial expressionCN VII is not cutaneous to faceCourses within parotid but does not innervate parotidDivides into two trunks: upper trunk (temporofacial)and lower trunk (cervicofacial) give rise to fiveterminal branches: temporal, zygomatic, buccal, mandibular and cervical

Lateral pterygoid muscle attaches to the disc of theTMJ; this muscle pulls the disc of the TMJ forwardand is concerned with opening the mouth

Temporalis, masseter and medial pterygoid all closethe jaw

The auriculotemporal nerve is sensory to the TMJ;important with pain associated with TMJ syndrome

Paranasal sinusesFrontal drains to middle meatus via frontonasal ductMaxillary: largest; drains superiorly to middle meatus; problem clinicallySphenoid drains to sphenoethmoid recessEthmoidAnterior: middle meatusMiddle: middle meatusPosterior: superior meatus

CN V1 & CN V2 innervate paranasal sinuses and nasal cavityCN I: innervates roof, superior concha and superiorpart of nasal septumArteries: sphenopalatine is chief arteryAnterior and posterior ethmoidal and septalbranch of superior labial

Kiesselbachs plexus is located on nasal septum

Hyoglossus depresses tongueStyloglossus elevates & retracts tonguePalatoglossus elevates tongue; innervated by CN XGenioglossus-anterior fibers protrude-posterior fibers retractExcept palatoglossus, innervated by CN XIISensory: lingual nerve (CN V3) to anterior 2/3 forgeneral sensation and chorda tympani (CN VII) fortaste; CN IX innervates root of the tongue, bothtaste and general sensation

Palatine (major): between anterior and posteriorpillars, formed by palatoglossal andpalatopharyngeal arches Lingual: on dorsum of tonguePharyngeal: in nasopharynx; adenoids whenenlargedTubal (lateral pharyngeal band): near opening of auditory tube

Waldeyers tonsillar ring: entire collection oftonsillar tissue

Superior oblique (SO) and inferior oblique (IO)attach to the posterior side of the equator of the eyeSO rotates eye medially causing it to look down and out (abduct and depress); IO rotates eye laterallycausing it to look up and out (SO4 LR6 )3Elevate: SR and IO; depress: IR and SOAbduct: LR, SO, IO; adduct: MR, SR, IRInjury to CN VI causes eye to turn inInjury to CN IV, diplopia when looking downInjury to CN III: ptosis, dilated pupil, no lightreflex; eye is turned down and out

Ophthalmic veins

Superior: formed by confluence of angular, supraorbital, and supratrochlear veins; drains tocavernous sinus

Inferior: drains eyelids; divides and passes through both superior and inferior orbital fissures;communicates with pterygoid plexus

CN I: telencephalonCN II: diencephalonCN III & IV: midbrainCN V - VIII: ponsCN IX - XII: medulla

Special sensation: CN I - olfaction, CN II vision;CN VIII hearing; CN VII, IX and X taste

Motor only: CN III, IV and VI for eye muscles;CN XI for trapezius and SCM; CN XII tongue

Facial nerve leaves the brain by passing through the internal acoustic meatus; while in the temporal bone, it has two important branchesGreater petrosal: parasympathetic fibers to pterygopalatine ganglion; distribution to lacrimal gland and mucous glands of nose and mouthChorda tympani: taste and parasympathetic to submandibular and sublingual glands

CN VII exits the skull at the stylomastoid foramen and on face, it is only motor to muscles of facial expression

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

Branches of CN V carry postganglionicparasympathetic fibers for CN III, VII and IX

CN III: ciliary ganglion: accommodation of lens and constriction of pupil

CN VII: pterygopalatine ganglion: lacrimal, nasal, palatal and pharyngeal glands CN VII: submandibular ganglion: submandibular and sublingual glands

CN IX: otic ganglion: parotid glands

************Subscapularis Subscapular nerve C5-6Supraspinatus and Infraspinatus Suprascapular nerve C5-6Teres minor Axillary nerve C5-6

************Flexor poliicis longus is the feather like deep flexor muscle of forearmAbductor pollicis longus is an extensor muscle**************************************************************************************************************************************************************************************************************************************************************************************