Abdomen- Abdominal Aorta, AAA, Celiac Trunk, SMA, IMA

1) Anatomy of the aorta

a) What level does the aorta enter the abdomen and what are the surface markings?
• Enters at: T12, behind median arcuate ligament.
• Surface markings: T12 to L4
o T12: 4cm above transpyloric plane in midline
o L4: 2cm below and left to umbilicus (at the level of supra-cristal plane) which
connects the highest parts of 2 iliac crests.

*The transpyloric plane lies midway between the jugular notch of the sternum and the upper
border of the pubic symphysis, or approximately a hand’s breadth below the xiphisternal joint,
and level with the lower part of the body of the first lumbar vertebra.

b) Know the branches of the aorta – may be shown on an aortogram

c) What are the posterior branches

• Lumbar Arteries
• Median Sacral Artery

d) Identify the vena cava and renal veins

• Pierces diaphragm at T8
• L1-L2: Renal Arteries

e) What lies anterior to the renal (artery?)

• SMA

2) Vascular system in abdomen

a) Identify Aorta, IVC

b) Where do they pass through diaphragm?

• T8: Vena Cava
• T12: Aortic Hiatus

c) Where does bifurcation occur?

• L4: Common Iliac Arteries
• L5: Common Iliac Veins- come together to form IVC

d) Name posterior branches of aorta — how many pairs of lumbar arteries

• Lumbar Arteries (4 paired lumbar arteries L1-L4)
• Median Sacral Artery

e) Which 2 structures cross the aorta anteriorly

 • Left renal vein.
• 3rd part of duodenum

*Celiac Trunk, SMA, Left Renal Vein, Splenic Vein, Body of Pancreas, 3rd Part of Duodenum,
Root of Mesentery

f) Identify 3 main branches of aorta supplying Gl tract, and their branches — on the
aortogram
• Celiac Trunk, Superior Mesenteric Artery, Inferior Mesenteric Artery
• Salah Notes (pg. 2- Abdomen Anatomy: Abdominal Aortic Branches)

• Celiac Trunk Branches:

o Left Gastric Artery
 o Splenic Artery:
o Common Hepatic Artery: Proper Hepatic (Right & Left Hepatic), Right Gastric,
Gastroduodenal, Cystic Artery (occasionally, otherwise from Right Hepatic)

• SMA Branches:
o Inferior Pancreaticoduodenal Artery
o Jejunal & Ileal- arteries pass between the layers of the mesentery and form
anastomotic arcades – from which smaller, straight arteries (known as the “vasa
recta”)
o Ileocolic Artery
o Right Colic Artery
o Middle Colic Artery

• IMA Branches:
o Left Colic Artery
o Sigmoid Artery
o Superior Rectal Artery

g) Identify the pathology in the picture — AAA

• Infrarenal saccular aneurysm

h) In which plane does aortic dissection occur: tunica media

• Aortic dissection is due to a dissection plane within the media layer that can cause the
aorta to rupture
• Dissecting Aortic aneurysm: Separation of layers of arterial wall, with propagation of
dissection proximally and distally

3) Aorta & IVC

4) Anatomy- Abdominal aorta- abdominal aorta from picture of post abdominal wall specimen

a) Vertebral level of abdominal aorta, level in diaphragm opening

• Abdominal Aorta: T12-L4
• Opens at T12 in Diaphragm

b) Surface marking of abdominal aorta (2.5 cm above the transpyloric plane)

• Surface markings: T12 to L4
o T12: 4cm above transpyloric plane in midline
o L4: 2cm below and left to umbilicus (at the level of supra-cristal plane) which
connects the highest parts of 2 iliac crests.

c) Tributaries of IVC (T8-L5)

• T8: Hepatic Veins (x3- RHV, MHV, LHV), Inferior Phrenic Vein
• L1: Suprarenal Vein, Renal Vein
 • L2: Gonadal Vein
• L1-L5: Lumbar Veins (L1-L4)
• L5: Common Iliac Vein (formation of IVC)

d) Vessels immediately in front of abdominal aorta

• Celiac Trunk
• SMA
• Left Renal Vein
• Splenic Vein

e) Picture of angiogram given- Identify the branches supplying the gut

• Celiac Trunk, SMA, IMA

f) Shows picture of infra renal aneurysm- define aneurysm (didn’t accept more than 1.5
times)
• Abnormal dilation of an arterial wall
• Weakening of an artery wall that creates a bulge, or distention, of the artery.

g) Abdominal dissection definition

• Separation of layers of arterial wall with propagation of dissection proximally and
distally

h) Occurs through which layers (which muscle layer)

• Tunica Media

5) Abdominal Aorta

a) Point out the aorta

b) Point out the IVC

c) Branches of aorta (specifically which are the posterior branches, which branches supply
the GI tract and at what level does it exit)
• AA Branches: Inferior Phrenic Arteries, Celiac Trunk, Middle Adrenal Arteries, SMA,
Renal Arteries, Gonadal Arteries, Lumbar Arteries, IMA, Median Sacral Artery, Common
Iliac Arteries
• Posterior Branches: Lumbar Arteries, Median Sacral Artery
• GI Tract Supply:
o Celiac Trunk: T12
o SMA: L1
o IMA: L3

d) Which level does the aorta enter the abdominal cavity

• T12
e) Which level does it bifurcate
• L4

f) What structures overlie the aorta

• Celiac trunk, SMA, Left Renal Vein, Splenic Vein, Body of Pancreas, 3rd part of
Duodenum, Root of Mesentery

g) Point out the tributaries of the IVC

• Hepatic Veins, Inferior Phrenic Veins, Suprarenal Veins, Renal veins, Right Gonadal
Vein, Lumbar Veins, Common Iliac Veins

h) Identify the left and right gonadal vein (the left couldn’t be seen actually, was hidden
between all the other structures)
i) Shown mesenteric angiogram. asked the identify the branches

j) Shown CT angiogram of AAA. asked to identify it (saccular, infrarenal AAA)

k) What is a dissecting aneurysm

• Separation of layers of arterial wall with propagation of dissection proximally and
distally

l) What is the pathogenesis

• An aortic aneurysm is a permanent localized dilatation associated with a diameter ≥ 3.0
cm.
o If left untreated, the aortic wall continues to weaken and becomes unable to
withstand the forces of the luminal blood pressure resulting in progressive
dilatation and rupture.
• In a dissecting aneurysm a rupture in the intima, the innermost coat of the artery, permits
blood to enter the wall of the aorta, causing separation of the layers of the wall.
• Abdominal aortic aneurysms tend to occur when there is a failure of the structural
proteins of the aorta.
o What causes these proteins to fail is unknown, but it results in the gradual
weakening of the aortic wall.
o The decrease in structural proteins of the aortic wall, such as elastin and collagen,
has been identified

m) What are the causes?

• Hypertension due to atherosclerosis
• Hypertension due to smoking
• Marfan Syndrome
• Syphilis
• Bicuspid Aortic Valve

n) Which is the most common cause worldwide (hypertensive sec to atherosclerosis sec to
smoking)
• Hypertension sec to atherosclerosis or sec to smoking.

o) What runs across the aorta -left renal vein, pancreas, duodenum
• Celiac Trunk, SMA, Left Renal Vein, Splenic Vein, 3rd Part of Duodenum, Head of
Pancreas, Root of Mesentery

p) What drains into IVC

• Common Iliac Veins- Forms at L5 by confluence of common iliac veins; IVC pierces
central tendon diaphragm at T8

q) Where does aorta start

 • Thoracic Aorta begins at T4 (angle of Louis), courses downward through posterior
mediastinum, pierces diaphragm at T12, and ends at L4 (just below umbilicus) the
surface marking.

r) What is aneurysm
• Abnormal dilation of a wall of an artery

s) Causes for Aneurysm -true due to weakening of tunica media, false - post traumatic
• Median Cystic Necrosis (True Aneurysm)
• Post-Traumatic (False Aneurysm)

• True Aneurysm: Saccular, Fusiform

• False Aneurysm: Extravasation of Blood into Extravascular Connective Tissue
• Dissecting Aneurysm: Extravasation of Blood into Tear in Intima

6) Specimen of Aorta

a) Name branches and identify

b) IVC and branches

c) Aneurysms

7) Anatomy: Abdominal Aorta

a) Point out the aorta

b) Point out the IVC

c) Branches of aorta (specifically which are the posterior branches, which branches supply
the GI tract)

d) and at what level does it exit

e) Which level does the aorta enter the abdominal cavity

f) Which level does it bifurcate

g) What structures overlie the aorta: duodenum 1 and 4, head of pancreas, liver

h) Point out the tributaries of the IVC

i) Identify the left and right gonadal vein (the left couldn’t be seen actually, was hidden
between all the other structures)
j) Shown mesenteric angiogram, asked the identify the branches

k) Shown CT angiogram of AAA. Asked to identify it (saccular, infrarenal AAA)

m) What is a dissecting aneurysm

n) What is the pathogenesis

o) What are the causes?

p) Which is the most common cause worldwide (hypertensive sec to atherosclerosis sec to
smoking)

8) Anatomy- Abdominal aorta. Specimens- Abdominal aortogram, picture from Netter's

atlas of anatomy.
a) Name various branches of AA.
b) Identify infrarenal aneurysm.

c) Define what an aneurysm is

9) Anatomy- Aorta and abdominal branches and correspondence to other organs

10) Anatomy. Thorax/Abdomen

a) What is this? tricuspid valve, papillary muscle, chordae tendineae.

b) What is function of chordae tendineae?

• Prevent av prolapse during ventricular systole
c) What is this?
• Azygous vein (it looks bigger than you think, please don’t confuse it with right
brachiocephalic trunk or right brachiocephalic vein)
d) Name me tributaries? bronchial veins, esophageal veins, hemi azygous veins, intercostal
veins
• Right Superior Intercostal vein
• Hemizygous Vein
• Accessory Hemizygous Vein
• Pericardial Veins
• Mediastinal Veins
• Lower Right Posterior Intercostal Veins
• Esophageal Veins
• Bronchial Veins

e) What is this?
• Gallbladder
f) Surface anatomy? (L1- transpyloric plane and mid clavicular line)
• An angle between 9th costal cartilage and lateral margin of rectus sheath (Salah)
• It typically protrudes beyond the lower border of the liver and may touch the anterior
abdominal wall.
• A clinical landmark for the fundus of the gallbladder is at the level of the 9th costal, at
the intersection of the lateral border of the right rectus abdominis and the costal
margin.

g) What is this?
• Spleen

h) Surface anatomy? (Space of traube. between 9th and 11th rib etc.)
 • Parallel to ribs 9,10,11 on left side

i) Blood supply of spleen?

• Arterial Supply: Splenic artery
• Venous Drainage: Splenic Vein merges with SMV to form Portal Vein

j) Describe it's course from it's branch off celiac axis

• Arises from Celiac Trunk
• Passes to left above Upper Border of Pancreas
• Behind the stomach separated by Lesser Sac
• During its course, it is contained within Splenorenal ligament.
• Terminates into 5 branches which supply the segments of spleen.

k) What does it supply? (duodenum, pancreas, spleen)

• Spleen, Fundus of Stomach, Greater Curvature of Stomach, Body & Tail of pancreas
• In addition to supplying the spleen, the splenic artery also gives rise to several important
vessels:
o Left gastroepiploic: supplies the greater curvature of the stomach. Anastomoses
with the right gastroepiploic artery.
o Short gastrics: 5-7 small branches supplying the fundus of the stomach.
o Pancreatic branches: supply the body and tail of the pancreas.

l) What is this?
• Sympathetic chain

m) Vertebral levels?
• T1 to L2 (preganglionic fibers correspond to spina nerves T1-L2)

n) How does it connect to spinal nerves? (preganglionic via ventral rami through
communicans)
• Through ganglion + white ramus communicans + grey ramus communicans

11) AAA– ANATOMY

12) Station 7 (Anatomy)- Thorax and abdomen; Pointed to following structures, asked to
identify:

a) Pulmonary trunk

b) Tricuspid valve

c) What are the structures connecting papillary muscles to valve cusps?

• Chordae Tendineae
d) What is the function of the chordae tendineae?
• Prevent av prolapse during ventricular systole

e) Azygos vein

f) Tributaries of azygos vein

g) Sympathetic trunk

h) Contributory spinal cord levels to sympathetic trunk

i) Duodenum

j) How many parts of duodenum?

• 4 parts- superior part, descending part, horizontal part and ascending part

k) What 2 ducts join and enter the duodenum?

• Common bile duct and the pancreatic duct unify to a conjoint duct at the
Hepatopancreatic ampulla (Ampulla of Vater) and empties into the descending (D2) part
of the duodenum
• At the opening there is an elevation of the mucosa, the Major duodenal papilla (Papilla of
Vater)
• Many people have an accessory pancreatic duct which empties into an additional papilla,
the minor duodenal papilla (Papilla of Santorini)

l) Which part of the duodenum do they enter?

• Second Part

m) Gallbladder fundus

n) Pathophysiology of radiation of pain to shoulder tip in gallbladder pathology

• An inflamed gall bladder may irritate the diaphragm.
• Roots of the phrenic nerve (C2,3,4) that supply the diaphragm are the same as
supraclavicular nerve supplying the shoulder tip.
 Abdomen- IVC, Liver, Gall Bladder, Pancreas, Spleen

1) Anatomy station.

a) Abdominal aorta branches.

• T12: Inferior Phrenic Artery
• T12: Celiac Trunk
• L1: SMA
• L1: Superior Adrenal Artery
• L1-L2: Renal Artery
• L2: Gonadal Arteries
• L1-L4: Lumbar Arteries
• L3: IMA
• L4: Median Sacral Artery
• L4: Common Iliac Artery Bifurcation

b) IVC tributaries. (T8-L5)

• T8: Hepatic Veins (x3- RHV, MHV, LHV), Inferior Phrenic Vein
• L1: Suprarenal Vein, Renal Vein
• L2: Gonadal Vein
• L1-L5: Lumbar Veins (L1-L4)
• L5: Common Iliac Vein (formation of IVC)

c) Abd aorta surface marking.

• Enters at: T12, behind median arcuate ligament.
• Surface markings: T12 to L4
o T12: 4cm above transpyloric plane in midline
o L4: 2cm below and left to umbilicus (at the level of supra-cristal plane) which
connects the highest parts of 2 iliac crests.

*The transpyloric plane lies midway between the jugular notch of the sternum and the upper
border of the pubic symphysis, or approximately a hand’s breadth below the xiphisternal joint,
and level with the lower part of the body of the first lumbar vertebra.

d) Bifurcation level and marking.

• L4: Common Iliac Arteries
• L5: Common Iliac Veins- come together to form IVC

e) Show me different arteries supplying GIT.

f) What crosses in front of aorta transversely - 3 structures.
• Celiac Trunk
• SMA
• Left Renal Vein
• Splenic Vein
• 3rd part of Duodenum
 • Head of Pancreas
• Root of Mesentry

2) Thorax and Abdomen- This is a cadaveric station.

a) Point to the pulmonary trunk, ascending aorta

b) Branches of the ascending aorta

• Right Coronary Artery
• Left Coronary Artery

c) Right ventricle: Name the structures (tricuspid valve, chordae tendineae, papillary
muscles), their function
• Tricuspid Valve: prevent backflow of blood from the right ventricle to the right atrium.
• Chordae Tendineae: Prevent av prolapse during ventricular systole.
• Papillary Muscles: stabilizes position of tricuspid valve to maintain the unidirectional
blood flow.
d) Origin of sympathetic chain
• T1-L2

e) What joins the sympathetic chain to the spinal nerves

• grey rami communicans

f) Identify spleen, blood supply

• Splenic Artery (Branch of Celiac Trunk)

g) what may be injured during a splenectomy

• Tail of Pancreas

h) Anatomy of the splenic artery and what it supplies

• Splenic Artery: Gives off 3 branches- Pancreatic Artery (supplies body and tail of
pancreas); Short Gastric Arteries (supplies fundus of stomach); Left gastroepiploic artery
(supplies greater curvature of stomach)
• Splenic Artery rises from Celiac Trunk
• Passes to left above Upper Border of Pancreas
• Behind the stomach separated by Lesser Sac
• During its course, it is contained within Splenorenal ligament
• Terminates into 5 branches which supply the segments of spleen

i) Identify gallbladder, surface marking

• At the angle between 9th costal cartilage and lateral margin of rectus sheath

j) Why would a patient with RUQ pain also have shoulder tip pain? Explain referred pain.
 • Diaphragm is innervated by Phrenic Nerve (C3, C4, C5)
• An inflamed gall bladder may irritate the diaphragm
• Roots of phrenic nerve that supply the diaphragm are the same as supraclavicular nerve
(C4, C5) supplying the shoulder tip

3) Anatomy-Thorax and abdomen

a) Azygos vein and tributaries

• Right Superior Intercostal vein

• Hemizygous Vein
 • Accessory Hemizygous Vein
• Pericardial Veins
• Mediastinal Veins
• Lower Right Posterior Intercostal Veins
• Esophageal Veins
• Bronchial Veins

b) Pulmonary trunk

c) Ascending aorta and branches: Right and Left Coronary Arteries arising from Aortic Sinus
opposite to Aortic Valve

d) Papillary muscles and function

• Papillary Muscles: stabilizes position of tricuspid valve to maintain the unidirectional
blood flow

e) Sympathetic trunk and the limits

[Link]
trunk

• Sympathetic trunk lies on each side of vertebral column

• Ganglionated chain present bilaterally extending from the base of the skull to the
coccyx.
• Gives preganglionic fibers of sympathetic nervous system to corresponding spinal nerves
T1-L2
• Connects Ganglion to spinal nerve via gray and white communicans.
• Sympathetic nerves leave sympathetic chain via spinal nerves forming plexuses around
blood vessels (cardiac & pulmonary plexuses; greater & lesser splanchnic nerves).

f) Duodenum and parts

• 4 parts- Superior, Descending, Inferior, Ascending

g) Landmark of gallbladder
• At the angle between 9th costal cartilage and lateral margin of rectus sheath

h) Splenic artery and supply

i) Location and ribs of spleen

• Opposite 9th, 10th, 11th ribs

j) Artery behind D1
• Gastroduodenal Artery

k) Referred pain to shoulder tip

4) Liver
a) Identify the lobes

b) Falciform ligament

c) Boundaries of caudate lobe (Caudate lobe is present in posterior surface)

• Left by Fissure for Ligamentum Venosum
• Right by Groove for Inferior Vena Cava
• Inferiorly by porta hepatis
• Above it is continuous with Superior Margin

d) Name the main artery that supplies the liver and stomach
 • COMMON Hepatic Artery

e) What are its branches

• Common Hepatic Artery (from Celiac Trunk):
o Proper Hepatic Artery (Right & Left hepatic Artery)
o Right Gastric Artery
o Gastroduodenal Artery
o Cystic Artery (occasionally, but mainly come from Right Hepatic Artery)

f) What is the venous drainage of the liver

• Hepatic Veins (x3) to IVC

g) What ligaments attach the liver to the diaphragm

• Falciform Ligament
• Right Triangular Ligament
• Left Triangular Ligament
• Upper Coronary Ligament
• Lower Coronary Ligament

h) Organs damaged by knife just under the Xiphoid. (Answer he wanted was left lobe of liver
and diaphragm. I said heart first, but he kept pushing for liver and diaphragm)

i) How far does the left lobe of the liver extend to normally (he said YES! When I said left mid
clavicular line. Anyhow guess =S)
• Follows upper limit of Diaphragm, Left 5th Rib between mid-clavicular line.

j) What divides left and right lobe of liver.

• Anatomical:
o Falciform Ligament (anteriorly)
o Fissure for Ligamentum Teres & Ligamentum Venosum (posteroinferiorly)
• Surgical: line passing from IVC to fossa of GB

k) What attaches liver to diaphragm (have to point on specimen.)

• Falciform Ligament
• Right Triangular Ligament
• Left Triangular Ligament
• Upper Coronary Ligament
• Lower Coronary Ligament

l) Identify quadrate lobe and name its boundaries. (Quadrate Lobe is present in Inferior
Surface)
• Right by Fossa of Gall Bladder
• Left by Fissure for Ligamentum Teres
• Superiorly (or Posteriorly) by Porta Hepatis
• Inferiorly by Inferior Border of Liver
m) What are the first 2 organs injured in a stab wound to the epigastrium?
• Left lobe of Liver
• Stomach

5) Next given specimen of Heart

a) Identify atria, ventricles, SVC, IVC

b) What demarcates the left and right lobes of the liver?

• Falciform Ligament Anteriorly
• Fissure for Ligamentum Venosum & Ligamentum Teres Posteriorly

c) What is the venous drainage of the liver?

• Hepatic Vein into IVC

d) What branch of the celiac trunk supplies both the stomach and the liver?
• Common Hepatic Artery

e) In what structure does it run to reach the porta hepatis?

• Hepatoduodenal Ligament
o The common hepatic artery is a branch of the celiac trunk and courses anterior to
the pancreas before giving off the gastroduodenal artery inferiorly, where it then
becomes the hepatic artery proper, entering the hilum of the liver via the
hepatoduodenal ligament.
o The hepatoduodenal ligament is the portion of the lesser omentum extending
between the porta hepatis of the liver and the superior part of the duodenum.
o Contains Portal Vein, Hepatic Artery Proper, & Common Bile Duct
f) Point out the quadrate lobe

g) What are the boundaries of the quadrate lobe?

h) What are lobes of liver.

• 2 anatomical Lobes: Right & Left Lobe
• 2 accessory Lobes: Caudate & Quadrate Lobe
• Caudate & Quadrate are anatomically part of right lobe of liver, but functionally they
belong to left lobe because they receive blood from left branches of hepatic artery and
portal vein and drain bile to left hepatic duct.

i) Identify H (histopathology?) and portal triad. Shown(?)

• Portal Triad: Hepatic Artery, Portal Vein, Bile Duct

6) Gall Bladder
a) Gallbladder surface anatomy?
• L1 transpyloric plane and mid clavicle line

b) Why would a patient with RUQ pain also have shoulder tip pain? Explain referred pain.

c) Spleen surface anatomy? Space of traube, between 9th and 11th rib

d) what may be injured during a splenectomy

d) Blood supply of spleen? splenic artery, describe its course from its branch off celiac axis;
course: - (she wanted to hear lienorenal ligament in particular)

e) What does it supply?

Stomach, Pancreas, Spleen

f) What drains into the thoracic duct?

• The thoracic duct drains the lower extremities, pelvis, abdomen, left side of the thorax,
left upper extremity, and left side of the head and neck.
• It originates at the cisterna chyli (when present) and terminates at the junction of the left
subclavian and left internal jugular veins.

g) What is this? Sympathetic chain.

h) Vertebral levels? T1 to L2

i) How does it connect to spinal nerves? Preganglionic via ventral rami through communicants
(grey rami communicants)
j) What structure must be preserved in splenectomy?
• Gastrosplenic ligament
o Thin delicate structure that connects the superior third of the greater curvature of
the stomach to the splenic hilum.
o This ligament contains the left gastroepiploic and short gastric vessels and their
associated lymphatics
o Individual ligation of short branches of the splenic artery and vein, preserving the
left gastroepiploic artery and short gastric arteries, to maintain adequate
gastric perfusion.

k) What 2 other structures does it supply?

-Short Gastric Artery: fundus of stomach
-Left Gastroepiploic Artery: Greater Curvature of Stomach

l) Identify this structure.

• Duodenum

m) How many parts does it have?

• Four

n) Which part does ampulla of vater open into?

• 2nd Part

o) Which structures open into the duodenal papillae?

• Major Duodenal Papilla (Papilla of Vater): junction of common bile duct and pancreatic
duct
o Major Duodenal Papilla: bile and enzymes for digestion
• Minor Duodenal Papilla: Accessory Pancreatic Duct (of Santorini)
o Minor Duodenal Papilla: drains the dorsal pancreatic bud during fetal
development.

p) What do they drain?

• Main Pancreatic Duct (or Wirsung): drains head, body, tail (opens into major duodenal
papilla)

q) What blood vessel runs posterior to D1?

• Gastroduodenal Artery
• Portal Vein

7) ANATOMY- You are to assist a surgeon on pancreatectomy. You are to revise anatomy
with the surgeon.
-Given few pictures on the upper abdominal contents (pro-section images & some from Netter’s
Atlas)

a) Asked to point out pancreas, parts of the pancreas.

b) Asked to point out stomach & it's borders/curvatures.

c) Blood supply of these structures

• Stomach
o Arterial Supply
 ▪
Left Gastric Artery (from Celiac Trunk)- lesser curvature, cardia
▪
Right Gastric Artery (Common Hepatic Artery)- lesser curvature, antrum,
pylorus
▪ Right Gastroepiploic Artery (from Gastroduodenal Artery)- greater
curvature, antrum, pylorus
▪ Left Gastroepiploic Artery (from Splenic Artery)- greater curvature
▪ Short Gastric Arteries (from Splenic Artery)- fundus
o Venous Drainage:
▪ Left Gastric Vein (to Portal Vein)
▪ Right Gastric Vein (to Portal Vein)
▪ Right Gastroepiploic Vein (to SMV)
▪ Left Gastroepiploic Vein (to Splenic Vein)
▪ Short Gastric Veins (to Splenic Vein)

d) Which part of pancreas are intraperitoneal & retroperitoneal.

• All is retroperitoneal except for tail!

e) What are immediate posterior relations of the uncinate process?

• Abdominal Aorta
• IVC

f) Describe the development of pancreas?

• Ventral Bud from Hepatic Diverticulum; gives rise to lower part of head and uncinate
process
• Dorsal Bud: from dorsal aspect of Duodenum; gives rises to upper part of head, neck,
body tail

g) Describe the ducts of the pancreas.

h) Greater & lesser curvature

i) Stomach: Celiac axis, to breakdown the branches.

j) Pancreas: celiac & SMA

k) Peritoneal Relations of Duodenum

D1 first 2cm & tail are intraperitoneal. Others retroperitoneal.

l) Dorsal & ventral buds.

m) Main & accessory duct of pancreas.

8) Surface anatomy of transpyloric plane.

*halfway between pubic symphysis and suprasternal notch; at L1
a) Identify surface landmarks of gallbladder, mid actually line section through cadaver at
L1.

b) Identify 5 organs.

c) Path of splenic artery

d) Blood supply to the stomach

e) Patient post left hemi has low ufo. D/w consultant

9) Anatomy- picture of cadaver L1 level.

a) Name 5 organs you can see.

• Neck of Pancreas
• Pylorus of Stomach
• Second part of Duodenum
• Hilum of Kidney
• Fundus of Gall Bladder

b) Surface anatomy of gallbladder.

c) Costal cartilage in mid axillary line?

• 8th, 9th, 10th
d) Origin of splenic artery.

e) Organs that touch the spleen.

• Anterior: Fundus of Stomach
• Posterior: Diaphragm, 9,10,11th ribs
• Medially: Tail of pancreas, left kidney
• Inferiorly: left colic flexure

f) Falciform ligament

g) What peritoneal ligament (coronary and triangular)

10) Thoracic and Abdominal Anatomy

a) Azygous vein

b) Papillary muscles

c) Spleen, Pancreas, Duodenum, Gall Bladder

d) Pancreatic and Bile Duct

11) Anatomy- Transpyloric plane

a) Define transpyloric plane (Gave 3 definitions, examiner liked none of them).

• Also known as Addison's plane, is an imaginary horizontal plane, located halfway
between the suprasternal notch of the manubrium and the upper border of the
symphysis pubis at the level of the first lumbar vertebrae, L1.

b) Asked to show fundus of gallbladder on the patient.

c) Asked to show costal cartilage of mid-axillary line.

• 8th, 9th, 10th Ribs
• In the anterior thorax, the first 7 pairs of ribs are attached to the sternum or breastbone by
cartilage.
• The lower 5 ribs do not attach to the sternum.
• The 8th, 9th, and 10th ribs are attached to each other by costal cartilage.
• The 11th and 12th ribs, known as “floating ribs,” are not attached in any way to the
sternum; they move up and down in the anterior chest, allowing for full chest expansion.
f) iPad image showed transpyloric plane transverse section, asked five organs to point.
g) Showed diaphragm and asked what structure. Diaphragm is very thin and hard to
see.

e) End of spinal cord level in adult.

• L1

f) Lieno-renal and lieno-gastric ligaments and contents.

 • Gastrosplenic ligament (Leino-gastric) – anterior to the splenic hilum, connects the
spleen to the greater curvature of the stomach.
o Contains: Left Gastro Epiploic Artery, Short Gastric Arteries, and associated
lymphatics
• Splenorenal ligament (Leino-Renal) – posterior to the splenic hilum, connects the
hilum of the spleen to the left kidney.
o Contains: Splenic artery, Splenic Vein and tail of the pancreas

12) Anatomy:

a) Right Heart- Papillary Muscles, chordae tendinae, azygous vein tributaries and
drainage, SVC)

b) Purpose of chordae tendinae

c) Branches of ascending aorta (coronary arteries)

d) Anatomy of spleen (ribs overlying 9-11)

e) Duodenum

f) Organs supplied by splenic artery

g) What not to damage during splenectomy (tail of pancreas)

h) Describe course of splenic artery (coeliac trunk, lienorenal ligament, posterior to

stomach)

i) Surface markings of gallbladder

j) Why referred pain to shoulder tip

13) Anatomy: Stomach and pancreas- 1 picture from Netter’s and 2 pictures of prosections

a) What is this (points at picture of prosection)

• Stomach

b) Identify all the parts of the stomach (fundus, cardia, body, antrum, pylorus)

c) Blood supply to the stomach? (Wanted more than left and right gastric and
gastroepiploic and where they from)

d) What is this?
• Pancreas
e) Blood supply of pancreas
• Superior Pancreaticoduodenal Artery (SPDA) (>Gastroduodenal Artery >Common
Hepatic> Celiac Trunk)- supply uncinate process and head
o Divides into 2 branches: Anterior SPDA, Posterior SPDA
• Inferior Pancreaticoduodenal Artery (IPDA) (>SMA, >AA)- supply uncinate process and
head
o Divides into 2 branches: Anterior IPDA, Posterior IPDA
• Each PDA and its Anterior & Posterior Branches form Arcades and supply neck
• Pancreatic Artery (>Splenic Artery >Celiac Trunk)- supply body and tail

f) Peritoneal relation of body of pancreas and tail of pancreas

• All is retroperitoneal except for tail

g) Describe briefly the ducts of pancreas

h) What vein lies behind neck of pancreas? Portal Vein

i) What vein lies behind body of pancreas Splenic vein?

j) Embryological development of pancreas?

k) Peritoneal relation of duodenum

• First part of duodenum lies within peritoneum, rest are retroperitoneal.

l) What lies behind and in front of duodenum at D3

• Ant: Superior mesenteric vessels, root of mesentery, coils of jejunum
• Post: right psoas major, right ureter, IVC, abdominal aorta, right gonadal vessels
• Sup: Head of pancreas + uncinate process
• Inf: coils of jejunum

m) Name 3 things that islet cells secrete

• Alpha cells: glucagon
• Beta cells: insulin
• D cells: somatostatin

14) Anatomy: pancreas and surrounding anatomy.

a) Structures passing in front of uncus

• Superior Mesenteric Artery
• Superior Mesenteric Vein

b) Behind D3
• Post: right psoas major, right ureter, IVC, abdominal aorta, right gonadal vessels
c) Blood supply of pancreas

d) Embryology of pancreas

e) Blood supply of stomach

15) Pancreas anatomy: Straightforward

a) Blood Supply

b) Parts

c) Ducts

d) Embryology

e) Islet cells and hormones- name 4

• Alpha cells: glucagon
• Beta cells: insulin
• D cells: somatostatin
• PP cells or F cells: Pancreatic polypeptide

f) Duodenum peritoneal covering

g) Relations

First part:
• Superiorly: Epiploic foramen being divided from it by the portal vein and bile duct.
• Inferiorly: Head and neck of the pancreas.
• Anteriorly: Quadrate lobe of the liver and gallbladder.
• Posteriorly: Portal vein, gastroduodenal artery, and common bile duct (CBD).

Second part:
• Anteriorly: Gallbladder and right lobe of the liver, transverse colon, transverse mesocolon
(commencement), and coils of the small intestine.
• Posteriorly: Right kidney and right renal vessels, right edge of the inferior vena cava (IVC),
and right psoas major muscle.
• Medially: Head of the pancreas.
• Laterally: From below upward, ascending colon, right colic flexure, and right lobe of the liver.

Third part:
• Anteriorly: Root of the mesentery, superior mesenteric vessels, and coils of the jejunum.
• Posteriorly: Right psoas major, right ureter, IVC, abdominal aorta, and right gonadal vessels.
• Superiorly: Head of the pancreas with its uncinate process.
• Inferiorly: Coils of the jejunum.
Fourth part:
• Anteriorly: Transverse colon and transverse mesocolon.
• Posteriorly: Left psoas major muscle, left sympathetic chain, left gonadal vessels, and inferior
mesenteric vein.
• Superiorly: Body of the pancreas.
• On to the left: Left kidney and left ureter.
• On to the right: Upper part of the root of mesentery.

16) Anatomy- Intraabdominal

a) Where is the pancreas.

b) Where is the stomach.

c) Describe blood supply and point to them.

d) Tell me the parts of stomach.

e) Relation of duodenum and pancreas to peritoneum

f) Tell me embryology of the pancreas

g) Tell me the ducts and where they drain into

h) What is in front D3, what vessel.

• Superior Mesenteric Vessels

i) What is behind it.

• Right psoas major, right ureter, IVC, abdominal aorta, and right gonadal vessels.

j) What is behind body of pancreas

• Splenic Artery

k) What is behind neck

• Portal Vein

l) What is the space behind stomach called

• Lesser Sac

m) What ligament connects tail pancreas to the spleen.

• Leinorenal (Splenorenal) Ligament

17) Station (5) Anatomy- Thorax and abdomen

a) Heart anatomy- Papillary muscles and chordae tendinea and functions

b) Identify azygos vein. What are its tributaries?

c) Identify pulmonary trunk

d) Lung hilar anatomy

e) Surface landmark for gallbladder (must include lateral margin of rectus abdominis)

f) Identify spleen. What ribs cover spleen?

• 9-11th ribs

g) Splenic artery anatomy and supply - pancreas, stomach

18) Anatomy- Heart, abdomen anatomy- Exact repeat of previous questions, examiner
basically pointed to structures or asked me to name structures

a) Heart: Identify the pulmonary trunk, identify the ascending aorta

b) What are the 2 branches of the ascending aorta (left/right coronary arteries)

c) Identify the papillary muscles

d) What is the function of chordae tendinae (to prevent prolapse of the mitral valve during
systole)

19) Abdomen:

a) Identify the azygos vein, name 2 tributaries to this

• Hemiazygos and Accessory Hemiazygos

b) Where does it drain into

• SVC

c) Identify the spleen

d) In a splenectomy, what structure must you be careful to preserve

• tail of pancreas

e) Describe the course of the splenic artery

• Torturous course over body of pancreas, gives off short gastric and left gastroepiploic
artery prior to supplying spleen
f) What other 2 structures besides the spleen does it supply
• Stomach and pancreas

g) Identify the duodenum, how many parts are there

• 4

h) What are the 2 ducts that enter the duodenum and where do they enter
• Enters at D2 (descending), the pancreatic duct and accessory pancreatic duct

i) Identify the sympathetic chain, what connects the spinal nerves to the sympathetic chain
• the rami communicantes

j) Coeliac trunk, pancreas (terrible quality photographs)

20) Upper GI, Pancreas relations, lesser sac

21) HPB (Transpyloric plane anatomy prosection)

a) Name the major structures in the area

b) Explain formation of the pancreas

c) Explain renal vessels

22) Anatomy pathology- Thorax and abdomen

a) Identify tricuspid valve, chordate tendinae, papillary muscle, pulmonary artery and vein

b) Name azygos vein and tributaries (2)

c) Spleen supply, ribs, structures to be wary when splenectomy (pancreas tail)

d) Duodenum - how many parts

e) Gastroduodenal artery behind duodenum: Behind first part of duodenum

f) Referred pain mechanism

23) Anatomy- Stomach/Pancreas

a) Cardia/fundus/pyloric antrum
b) Name blood supply of stomach and pancreas

c) What are space behind stomach? Lesser Sac

d) Point where is pancreas, Show ducts of pancreas

e) What is peritoneal relation of head/body/tail of pancreas?

f) What is peritoneal relation of 1/2/3/4th part of duodenum?

g) What substances are produced by tumors of islet cells? (Name 3 substances)

h) What vessel goes anterior to 3rd part of duodenum and what vessels are posterior

i) If you do Whipple’s, what vessels do you encounter?

• Whipple’s (aka Pancreaticoduodenectomy)- 4 arteries, 4 veins
o Abdominal Aorta
o Superior Pancreaticoduodenal arteries
o Inferior Pancreaticoduodenal arteries
o SMA
o SMV
o PV
o Left Renal Vein
o Splenic Vein

24) Anatomy- abdominal. Started off with surface anatomy on a live person.

a) Surface anatomy of gall bladder

b) Surface anatomy of the transpyloric plane? structures at this level? vertebral level?

Then went through a transverse prosection of the abdomen - some really strange questions
which I could not answer!
c) Like what is behind the lesser sac?? (don't know what he was after) and am I looking at this
from an inferior or superior view?)
• The diaphragm, pancreas, left kidney, left adrenal gland, and duodenum with their
overlying peritoneum and the transverse mesocolon represent the posterior boundary.

d) The remainder of the questions were fine: asked - identify 4 abdominal structures in this
image? (so liver, spleen, pancreas, left kidney etc.)

e) Then pointed to a vessel (this was the splenic artery)

f) And asked about its course - here he was looking for the lienorenal ligament.

g) What other structures pass through this ligament?

h) What are the branches of the splenic artery which supply the stomach and what
structure do they pass through?

25) ABDOMEN: Assisting consultant in WHIPPLE procedure he will ask some questions.

a) Stomach blood supply

b) Pancreas blood supply

c) Development intraperitoneal part

d) Names tumor origin from pancreas

e) Identify this - IMV

f) Where it drain- Into splenic vein

g) Where portal vein form?

• Portal vein forms at the point where your superior mesenteric vein (SMV) and
splenic vein meet

h) Duodenum intraperitoneal part, 3rd part ant and post relations, ask about lesser sac.

26) Pancreas / surrounding anatomy / stomach (also a Q on the development of pancreas!)

27) ANATOMY: Abdominal anatomy mainly focused on Pancreas, Stomach and
Duodenum, very straightforward again, blood supply mostly, Pringles maneuver, nerves,
etc.

• Pringles Maneuver: a finger can be inserted into epiploic foramen and squeezed against a
thumb anteriorly.
o This is to squeeze and control hemorrhage at Portal Triad

28) APS- Stem was about one line about this patient with chest pain. I have no idea how
this links to the below question about trunk and abdomen anatomy but yea. My examiner
for this station was cool, he looked a bit like Magneto (the Sir Ian McKellen one).

a) So anyways, identify some structures (Heart, pulmonary artery, vein, azygous vein)

b) Sympathetic chain from T1 to L2

c) What is the sympathetic chain and what connects it to the spinal cord.

d) Blood supply of pancreas and spleen

e) Where is the spleen located

f) Other random anatomy things which you really should know.

29) Anatomy- Abdomen (transpyloric plane)

a) On SP: demonstrate surface anatomy for GB, midaxillary line

b) What costal cartilage at costal margin

• The costal margin is the medial margin formed by the cartilages of the seventh to tenth
ribs.
• It attaches to the body and xiphoid process of the sternum.
• The thoracic diaphragm attaches to the costal margin.
• The costal angle is the angle between the left and right costal margins where they join the
sternum.
c) On photo of cadaver- transverse section of transpyloric plane- Identify 4 organs
Looking from feet or from head
• Pylorus of Stomach
• Second Part of Duodenum
• Fundus of Gall Bladder
• Hilum of Kidney

d) Organs that touch the spleen

• Anterior- Stomach
• Posterior: Diaphragm, Left lung, Ribs 9-11th
• Inferior: Left colic flexure (splenic flexure)
• Medial: Left Kidney, Tail of Pancreas

e) Blood supply of spleen- specifically lienorenal ligament

• Splenic Artery, Splenic Vein contained within Leinorenal ligament

f) Splenic artery supplies what arteries to the stomach

• Short Gastric Arteries- Fundus of Stomach
• Left Gastroepiploic Artery- Greater Curvature of Stomach

g) Other ligament of spleen connecting to left kidney

• Splenorenal ligament (Leino-Renal)– posterior to the splenic hilum, connects the hilum
of the spleen to the left kidney. The splenic vessels and tail of the pancreas lie within this
ligament
h) What muscle is this?
• Diaphragm

30) Abdomen (SP present)

a) Landmarks for the transpyloric plane

b) Point out the midaxillary line

c) Point out the costal margin

d) What ribs make up the costal margin? 7-10th ribs

e) (cross section of abdomen) point out 4 organs

f) Blood supply of the spleen?

g) Where does this run?

h) Blood supply of the stomach that comes from the splenic artery

i) Where does this run?

j) Pointed to perihepatic space, falciform ligament: what are the names of these
spaces/structures
• The liver is covered by visceral peritoneum except at the bare area, bed of the
gallbladder, and porta hepatis.
• The investing peritoneum becomes contiguous with the adjacent structures such as the
diaphragmatic peritoneum, lesser omentum, and ligamentum teres.
• The perihepatic space is composed of different spaces, mainly the right subphrenic and
subhepatic spaces.

31) Heart, thorax, abdomen: 3 prosections.

a) Abdomen: If stabbed in the epigastric region from inferior to superior what structures at
risk?
• Diaphragm and left lobe of liver.

b) Where does left lobe of liver extends to on surface anatomy?

• Left midclavicular line

c) What are the lobes of the liver? right and left

d) show me the quadrate lobe.

e) What are the boundaries of quadrate and caudate lobes?

• caudate:
o laterally: IVC
o medially ligamentum venousum
 o superior: hepatic veins
o Inferior: porta hepatis
• Quadrate:
o medial: ligamentum teres
o Lateral: gallbladder
o superior: porta hepatis

f) What structure separates right and left lobes of liver? falciform ligament

g) Identify it.

h) What does it connect to? anterior abdominal wall & diaphragm

i) What are the attachments of the liver to the diaphragm?

• Rt and left coronary ligaments (continuation of falciform ligaments).
• Right and left triangular ligaments.

j) What are the bony attachments of the diaphragm?

• xiphoid process of sternum
• lumbar vertebrae
• ribs attachments 7-12 ribs

32) Abdominal- Transpyloric Plane

a) Demonstrate anatomical landmarks on SP: Muprhy's point, transpyloric plane, subcostal

margin

b) Clinical photo: prosected specimen (transpyloric plane), name organs, diaphragm, vessels

c) Discuss liver segments

d) Portal triad

e) Spleen vasculature and ligaments

33) Station 7 anatomy- Transpyloric plane

a) Show picture of transpyloric plane in axial section

b) what view is it (liver on right side, so it is looking upward)

c) point out 5 organs on the picture

d) What is the name of space separated by falciform ligament- right subphrenic space & left
anterior subphrenic space

e) what is the ligament between gastro and spleen

f) what is the course of splenic artery

g) what is the ligament contain the splenic artery, what else in the ligament

h) what is the blood vessel branch from splenic artery that supply the gastro

i) name 3 organ can be damaged by splenectomy

33) Anatomy of the trunk

a) Identify the pulmonary trunk

b) What are the branches of the ascending aorta

c) Identify the azygous vein

d) Identify the sympathetic chain

e) What connects the sympathetic chain with the spinal nerves

f) Identify the duodenum. How many parts

g) What artery lies behind the first part of the duodenum

h) Identify the spleen

i) What is the surface marking of the spleen

j) What structure is most likely to be damaged in a splenectomy

k) Identify the fundus of the gallbladder

l) What is the surface marking of the fundus of the gallbladder

m) Why does cholecystitis cause shoulder tip pain

 Abdomen- Esophagus, Stomach, Duodenum, Appendix, Diaphragm

1) Anatomy

a) Identify parts of the stomach

b) Embryology of Pancreas.
• Ventral Bud from Hepatic Diverticulum develops Uncinate process and lower part of
head.
• Dorsal bud from Dorsal part of Duodenum develops upper part of head, neck, body tail.

c) What is Barrett's esophagus?

• Metaplasia of lower esophageal mucosa from stratified squamous epithelium to non-
ciliated columnar epithelium with Goblet Cells
• Response of lower esophageal stem cells to acidic stress
• May progress to dysplasia and adenocarcinoma

d) Tell the blood supply of stomach with reference to the arteries of origin
(Arterial Supply: Supplied by branches of celiac trunk (foregut)
• Arterial Supply
o Left Gastric Artery (from Celiac Trunk)
o Right Gastric Artery (Common Hepatic Artery)
o Right Gastroepiploic Artery (from Gastroduodenal Artery)
o Left Gastroepiploic Artery (from Splenic Artery)
o Short Gastric Arteries (from Splenic Artery)
• Venous Drainage:
o Left Gastric Vein (to Portal Vein)
o Right Gastric Vein (to Portal Vein)
o Right Gastroepiploic Vein (to SMV)
o Left Gastroepiploic Vein (to Splenic Vein)
o Short Gastric Veins (to Splenic Vein)

e) Pancreaticoduodenal artery- Pancreas Blood Supply

• Superior Pancreaticoduodenal Artery (SPDA) (>Gastroduodenal Artery >Common
Hepatic> Celiac Trunk)- supply uncinate process and head
o Divides into 2 branches: Anterior SPDA, Posterior SPDA
 • Inferior Pancreaticoduodenal Artery (IPDA) (>SMA, >AA)- supply uncinate process and
head
o Divides into 2 branches: Anterior IPDA, Posterior IPDA
• Each PDA and its Anterior & Posterior Branches form Arcades and supply neck
• Pancreatic Artery (>Splenic Artery >Celiac Trunk)- supply body and tail

f) What are the parts of pancreas?

• Uncinate process, Head, neck, body, tail

g) Where does major and minor pancreatic ducts open?

• 2nd part of duodenum
• Main pancreatic duct (of Wirsung): drains head, body and tail → opens into major duodenal
papilla.
• Accessory pancreatic duct (of Santorini): drains the uncinate process → opens into minor
duodenal papilla.

h) What are structures are related to the body of pancreas?

i) What are the peritoneal relations of the pancreas and the stomach?
• Pancreas: All is retroperitoneal except for tail
• Stomach: almost entirely covered in peritoneum, except where vessels run along the
curvatures and where the peritoneum reflects to form ligaments, or attachments to other
viscera.
o These include the hepatogastric ligament from the lesser omentum, and the
gastrophrenic, gastrosplenic, and gastrocolic ligaments from the greater
omentum.

j) What structures are related to the 2nd and 3rd parts of duodenum during surgery?
 • Second Part:
o It is 3 inches long descending vertically from L1 to L3.
o The bile duct opens in its postero-medial aspect
o The bile duct usually unites with the main pancreatic duct to form the ampulla of
Vater & opens at the major duodenal papilla
o The accessory pancreatic duct opens separately at the minor duodenal papilla 1
inch above the major duodenal papilla.
o Relations:
▪ » Anterior: the liver & the transverse colon.
▪ » Posterior: the Rt. kidney & Rt. psoas major.

• Third Part:
o It is 4 inches in length at the level of L3 vertebra.
o It is covered by peritoneum anteriorly & inferiorly.
o Relations:
▪ Anterior: superior mesenteric vessels at root of mesentery
▪ M.B: Superior mesenteric vein lies on the right side of superior mesenteric
▪ Posterior: the aorta, IVC, origin of the inferior mesenteric artery, Rt. ureter
and psoas major.
▪ Superior: head of pancreas
▪ Inferior: small intestine

FROM SALAH:
• Second part:
• Anteriorly: Gallbladder and right lobe of the liver, transverse colon, transverse mesocolon
(commencement), and coils of the small intestine.
• Posteriorly: Right kidney and right renal vessels, right edge of the inferior vena cava (IVC),
and right psoas major muscle.
• Medially: Head of the pancreas.
• Laterally: From below upward, ascending colon, right colic flexure, and right lobe of the liver.

• Third part:
• Anteriorly: Root of the mesentery, superior mesenteric vessels, and coils of the jejunum.
• Posteriorly: Right psoas major, right ureter, IVC, abdominal aorta, and right gonadal vessels.
• Superiorly: Head of the pancreas with its uncinate process.
• Inferiorly: Coils of the jejunum.

2) Esophagus

a) Level of Esophagus
• At lower border of cricoid cartilage (C6) to cardia of stomach (T11)

b) Surface mark beginning of Esophagus

• C6

c) Border of post mediastinum.

• Lower 8 Thoracic vertebrae (T5-T12)

d) Identify: Sympathetic chain, azygous vein, descending aorta, phrenic, Left Vagus
(recurrent laryngeal).
e) Arterial supply, Venous drainage, Lymphatic drainage of entire Esophagus.

Artery Vein Lymphatics Epithelium

Upper Third Inferior Thyroid Inferior Thyroid Deep Cervical Striated
Middle Third Thoracic Aorta Azygous Mediastinal Striated +Smooth
Lower Third Left Gastric Left Gastric Gastric Smooth

f) What is achalasia?
• Motility disorder with inability to relax lower esophageal sphincter (LES)
 • Due to damage of ganglion cells in Myenteric Plexus
• Ganglion cells of myenteric plexus are located between inner circular (IC) and outer
longitudinal (OL) layers of muscularis propria (and are important for regulating bowel
motility and relaxing LES)
o Mucosa
o Submucosa
o Muscularis Propria (IC- myenteric plexus- OL)
o Adventitia (Thoracic esophagus has an adventitia because it is not covered by
peritoneum; esophagus lacks a mucus layer (Serosa) and its surface cells do not
secrete bicarbonate ions)
• Characterized by
o incomplete LES relaxation
o increased LES tone
o lack of peristalsis of the esophagus

g) Microscopic features of achalasia. (hypertrophied MP without myenteric plexus)

• Hypertrophied musculature with absence of myenteric plexus

h) What is Barrett’s esophagus?

i) Why do we care if Barrett’s?

• Increased risk of developing adenocarcinoma

j) What is the histological normal lining of esophagus? And in Barrett's?

• Normal: NKSSE Non-Keratinized Stratified Squamous Epithelium
• Barrett: Non-Ciliated Columnar Epithelium with Goblet Cells

3) Diaphragm

a) What are the boundaries of the Posterior Mediastinum.

• Superior: transverse plane between sternal angle to the intervertebral disc between
vertebrae TIV and TV (or plane from sternal angle to lower border ofT4)
• Inferior: diaphragm (vertical part of diaphragm)
• Anterior: posterior pericardium
• Posterior: posterior chest wall (T5 to T12)

Anterior • Pericardium
• Vertical Part of Diaphragm
Posterior Lower 8 thoracic vertebrae
On each side Mediastinal Pleura

b) Name me 6 things that lie in the posterior mediastinum. (V TTApESS)

• Esophagus
• Thoracic aorta
 • Azygos vein
• Thoracic duct and associated lymph nodes
• Vagus Nerve
• Sympathetic trunk
• Thoracic splanchnic nerves
c) Complications of perforated esophagus?
• Mediastinitis
• Emphysema

d) What epithelium lines esophagus?

• Stratified squamous (non-keratinizing) cells

e) What level does esophagus begin at?

• C6 vertebra (starts at the cricoid cartilage from the oropharynx)

d) What level does it end at?

• T11(by joining the cardiac orifice of the stomach)

e) What part of the diaphragm is that?

• T10- Enters muscular part of diaphragm through esophageal hiatus

f) What is the blood supply of the esophagus?

• Upper 1/3: inferior thyroid artery (thyrocervical trunk from subclavian artery)
• Middle 1/3: esophageal branches of descending aorta
• Lower 1/3: left gastric and inferior phrenic arteries

g) What is the venous drainage of esophagus?

• Upper 1/3: inferior thyroid vein
• Middle 1/3: azygos vein
• Lower 1/3: left gastric vein

h) What is the lymphatic drainage of esophagus?

• Upper 1/3: deep cervical nodes
• Middle 1/3: mediastinal nodes
• Lower 1/3: nodes along left gastric blood vessels and celiac nodes (gastric)

i) What two structures leave an indentation in esophagus?

• Aortic arch
• Left main bronchus
• Left Atrium

j) What is the most common esophageal tumor?

• Squamous cell carcinoma

k) What happens in Barrett’s esophagus?

 • Metaplasia of SCC to columnar cells — premalignant condition.

l) What is achalasia?
• Abnormal peristalsis with resultant failure of LES to relax.

m) What is the pathophysiology behind achalasia?

• Absence or destruction of Auerbach’s (myenteric) plexus
• May be idiopathic, or due to Trypanosoma Cruzi infection in Chagas Disease

4) Abdomen

a) What’s the border of posterior mediastinum? contents?

b) Which level Esophagus enters Diaphragm? T10

c) What part of diaphragm? Muscular part at Right Crus

d) Where esophagus begins? level

e) What LN does esophagus drain to?

f) Arterial supply plus drainage?

g) What is the cells lining the esophagus?

h) What is Barrett’s esophagus?

i) What risk?

5) HPB (Transpyloric plane anatomy pro-section)

a) Name the major structures in the area

• SMA
• Portal Vein
• Neck of Pancreas
• Pylorus of Stomach
• Second part of Duodenum
• Sphincter of Oddi
• Hilum of Kidney
• Duodenojejunal Flexure
• Fundus of Gall Bladder

b) Explain formation of the pancreas

• Ventral Bud from Hepatic Diverticulum; gives rise to lower part of head and uncinate
process
 • Dorsal Bud: from dorsal aspect of Duodenum; gives rises to upper part of head, neck,
body tail

c) Explain renal vessels

• The hilum of the right kidney lies just below, while that of the left lies just above the
transpyloric plane, about 5 cm from the middle line.
• The hilum contains the renal vein anteriorly, the renal artery in the middle, and the ureter
posteriorly

d) Identify the duodenum, how many parts are there

• 4

e) What are the 2 ducts that enter the duodenum and where do they enter
• Enters at D2 (descending), the pancreatic duct and accessory pancreatic duct

f) ID: appendix, caecum, ascending colon

g) How to know the caecum from the ascending colon: The blind lower end

h) Ovary Fallopian tubes, Recto-uterine pouch- alternative name

• Douglas pouch

i) Interpretation of initial and localized pain i.e. Its afferent pathway (read this in Raftery
book page 450 OSCE 2.1) (referred pain occur at area of high sensory input & final pain
neuron sends pain back to the site of origin)
• The initial pain in the central abdomen at the level of the umbilicus is referred pain.
o Referred pain occurs due to nerve fibers in areas that have a high level of sensory
input, e.g. skin, and nerve fibers from areas that have low levels of sensory input,
e.g. internal organs, coming together in the same area of the spinal cord.
• Afferent pain-conducting fibers from the viscera combine with afferent pain-conducting
fibers from the skin on one central neuron of the spinothalamic tract. Impulses from the
viscera travel in the same central pathway as pain impulses from the skin to reach the
same final sensory neuron in the brain.
• The final sensory neuron projects pain sensation to the skin in the place from which it
usually receives pain signals.
• Appendix is derivative of midgut
o Midgut relates to T10 segment, which is the periumbilical area of central
abdomen, and therefore pain is experienced in central abdomen in periumbilical
area
• As an inflamed appendix proceeds, the inflamed serosal peritoneum abuts against the
parietal peritoneum of right lower quadrant, which has somatic innervation
o The pain is now well localized to the RIF
o Pain is then experienced at the Site of inflammation near the classic site of
McBurney point
• Pain is therefore 2 separate pains: one visceral and other sharp somatic pain; it cannot be
said that pain moves in this case.
j) ID: external & amp; internal oblique muscle, origin & nerve supply, direction of the
muscles
• EOM:
o Origin: Outer surface of lower 8th ribs (5-12) (outer surface of ribs 5-12)
o Insertion:
▪ Anterior 2/3 of outer lip of iliac crest
▪ Linea alba
▪ Pubic tubercle
▪ Pubic Crest
▪ ASIS
o Nerve Supply: Ventral Rami of lower six thoracic nerves T7-T12
o Direction of fibers: downwards, forwards, medially

• IOM:
o Origin:
▪ Thoracolumbar fascia
▪ Anterior 2/3 iliac crest
▪ Lateral 2/3 inguinal ligament
o Insertion:
▪ Cartilages of lower 3 ribs (10-12)
▪ Conjoint tendon
▪ Pubic crest
▪ Linea Alba
o Nerve Supply:
▪ Lower six thoracic nerves (T7-T12)
▪ Ilio-hypogastric and Ilioinguinal Nerves
o Direction of fibers: diagonal direction, in which the muscle fibers run along the
ribs.

k) Which fleshy muscle in front of deep inguinal ring.

• Transverse abdominis

l) In appendicectomy we open the external oblique muscle in which direction?

• External oblique aponeurosis is exposed and incised in direction of fibers

m) Stomach/pancreas

n) cardia/fundus/pyloric antrum

o) Name blood supply of stomach

p) Name blood supply of pancreas

q) Space behind stomach: Lesser Sac

r) Point where is pancreas

s) What is peritoneal relation of head/body/tail of pancreas

• All is retroperitoneal except for tail

t) What is peritoneal relation of 1/2/3/4th part of duodenum

• D1 first 2cm & tail are intraperitoneal. Others retroperitoneal.

u) Ducts of pancreas

v) What substances are produced by tumors of islet cells? name 3

• Alpha cells: glucagon
• Beta cells: insulin
• D cells: somatostatin

w) What vessel goes anterior to 3rd part of duodenum and what vessels are posterior
• Anterior: Superior Mesenteric Vessels
• Posterior: IVC, Abdominal Aorta

x) If you do Whipple’s, what vessels do you encounter

• Whipple’s (aka Pancreaticoduodenectomy)- 4 arteries, 4 veins
o Abdominal Aorta
o Superior Pancreaticoduodenal arteries
o Inferior Pancreaticoduodenal arteries
o SMA
o SMV
o PV
o Left Renal Vein
o Splenic Vein

y) Identify
6) Pro-Section showing stomach, pancreas, duodenum

a) Id this. Shown stomach.

b) Id parts of stomach

c) Shown vessels of celiac axis. Describe blood supply of stomach and show branches on the
image

d) Id pancreas
e) Describe development of pancreas. Epithelial proliferation from duodenum, ventral and
dorsal pancreatic bud, asked me to stop.

f) Peritoneal relation of pancreas.

• Except tail, rest is retro peritoneal.

g) Blood supply of pancreas. Sup and inf pancreaticoduodenal. Don’t forget splenic artery

h) Describe the ductal drainage system of pancreas. Said major duct drains part of head and
all of body and tail opens at major duodenal papilla. Minor duct drains uncus and part of head.

i) Vessel present behind body of pancreas? Splenic A

j) Space present behind pancreas. Lesser sac

k) Vessel present behind neck? portal vein

l) Peritoneal relations of duodenum? Said except 1st cm of 1st part, rest is retroperitoneal

m) Vessels present in front and behind 3rd part of duodenum. In front Sup mesenteric
vessels, behind inf mesenteric vein.

7) Esophagus (picture):

a) Three parts of the esophagus

b) Arterial supply

c) Venous supply

d) Lymph drainage

e) Boundaries and contents of the posterior mediastinum

f) Potential complications of OGD 4x

• OGD: (oesophago-gastroduodenoscopy) as it inspects the (o)esophagus, (g)astro
(stomach) and (d)uodenum
• Risks: Bleeding, infection, perforation, duodenal hematoma

g) Pathophysiology of achalasia/esophageal strictures

h) Exit of Esophagus which part of the diaphragm

i) Surface marking of the beginning of the esophagus top vs bottom of cricoid?

j) Identify azygos vein

8) Posterior mediastinum - a lot of focus on the oesophagus (blood/lymph/nerve)

9) Esophagus

a) Level of Esophagus

b) Surface mark beginning of Esophagus. (C6)

c) Border of post mediastinum.

d) Identify: Sympathetic chain, azygous vein, descending aorta, phrenic, Left vagus
(recurrent laryngeal).

e) Arterial supply, Venous drainage, Lymphatic drainage of entire esophagus.

f) What is achalasia?

g) Microscopic features of achalasia.

h) What is Barrett's Esophagus?

i) Why do we care if Barret's?

j) What is the histological normal lining of esophagus? And in Barrett's?

10) Anatomy- Esophagus

a) Posterior mediastinum boundaries

b) Contents

c) Show the contents of Posterior mediastinum on a photograph

d) Where is the thoracic duct on the photograph

e) At what level does the esophagus entre the abdomen and pierce what
• T10
• Pierces muscular layer of Diaphragm and entering through Right Crus
f) Blood supply of the esophagus

g) Venous drainage of the esophagus

h) Lymphatic draining

i) What is Achalasia Cardia

j) Where is the pathology in Achalasia Cardia

k) What is the epithelium of the esophagus

l) What is Barrett's esophagus

m) What is the Dysplasia and what has happened here and cause.
• Response of lower esophageal stem cells to acidic stress

11) Anatomy: Model of Bowel Prosection

a) Identify stomach- Cardia, fundus, Pylorus. Greater and lesser curvature, antrum

b) Identify duodenum and pancreas

c) Which part of duodenum intraperitoneal

f) Identify Pancreas: Which part intraperitoneal, what runs in it - Tail of the pancreas,
splenic vessels

g) Blood supply to pancreas: sup pancreatic duodenal from gastroduodenal artery, Inf
pancreaticoduodenal from SMA, Pancreatic branches of splenic artery

h) Blood supply to stomach

i) Structure post to duodenum 3rd part

j) where does pancreatic duct opens, how many ducts: 2 ducts, Major pancreatic duct (Duct of
Wirsung) & minor pancreatic duct (Duct of Santorini) Opens separately.

k) Embryological origin of pancreas: Pancreas originates from Dorsal and Ventral buds.

l) Which part from which: Doral pancreas forms the head, body and tail. The Ventral forms the
Uncinate process and part of the head

m) Anatomy of stomach — blood supply and parts, anatomy and relations of the pancreas
including blood supply

n) Peritoneal relations of the pancreas

12) Thorax

a) Identify: Symp chain, azygous vein, descending aorta, phrenic, L vagus (recurrent
laryngeal).

b) Arterial supply, Venous drainage, Lymphatic drainage of entire oesophagus.

c) What is achalasia?

d) Microscopic features of achalasia.

e) What is Barrett’s esophagus?

f) Why do we care if barrett's?

g) What is the histological normal lining of esophagus? And in Barrett’s?

13) Thorax and abdomen

a) Abdominal wall muscles, nerve roots

b) Nerve at risk of injury during appendicectomy.

 Abdomen- EOM, IOM, Inguinal Canal, Urinary Bladder

1) EOM & IOM

a) External and Internal Oblique and Attachments:

• External Oblique:
o Origin: outer surface of ribs 5-12
o Insertion: iliac crest, pubic tubercle, linea alba, pubic crest, ASIS
o Innervation of External Oblique ventral rami of lower six thoracic nerves T7-T12
(N: thoracoabdominal nerve T7-11 & Subcostal nerve T12)
o Action: contains the abdominal viscera; may contract to raise intr-abdominal
pressure; moves trunk to one side
o Direction of fibers: Downwards, forwards, medially
• *Linea Alba: attached from Xiphoid process of Sternum to Pubic Symphysis

• Internal Oblique:
o Origin: inguinal ligament, iliac crest, thoracolumbar fascia
o Insertion: linea alba, pubic creast, conjoint tendon, cartilage of ribs 10-12
o Nerve Supply: lower six thoracic nerves T7-T12 (N: thoracoabdominal N T6-11,
subcostal T12, iliohypogastric; ilioinguinal (L1)
o Direction: lateral side of abdomen

b) Nerve root of inguinofemoral: (genitofemoral?)

• Genitofemoral nerve (from lumbar plexus L1-L2)
o Genital branch L1 and L2 (with spermatic cord through deep inguinal ring into
scrotum)
o Femoral branch L1 & L2 (with external iliac artery under inguinal ligament –skin
over anterior surface of upper part of thigh)

2) Pelvis, Genitourinary Tract

a) Identify bladder
b) Blood supply of the bladder:
• Arterial: Superior and Inferior Vesical arteries via the internal iliac artery
• Venous Drainage: vesical venous plexus to Internal iliac vein

c) What are the peritoneal relations:

• Covers Superior surface and upper part of the posterior surface.

d) Identify the internal iliac artery

e) What is the muscle of the bladder wall?
• Detrusor muscle

f) Innervation of the Detrusor?

• Sympathetic: inhibit contraction of muscle (T10-L2)
• Parasympathetic: Stimulate contraction of muscle (S2-S4)

Sympathetic - hypogastric n. (T10-L2)

Parasympathetic - pelvic splanchnic nerves (S2-4)

g) What is the muscle in the wall:

• Detrusor

h) What is the histo of this muscle?

• Smooth muscle fibers

i) Epithelial lining of bladder:

• Transitional epithelium (or urothelium)

j) Nerve supply of Bladder: (Vesical and prostatic plexuses)

• Primarily parasympathetic via pelvic splanchnic nerves

k) What are the symptoms of bladder CA?

• Painless hematuria

l) Urinary tract infection- Systemic symptoms (he looked disdainful) Irritative symptoms.
(frequency, urgency, nocturia)
• Irritative: Burning, frequency, urgency, hematuria, dysuria, or suprapubic pain
• Complicated UTI symptoms include all of those listed above, as well as fever, chills,
flank pain, sepsis from a urological source, cystitis symptoms lasting >7 days, known
multiple antibiotic resistance, permanent Foley or suprapubic catheters, acute mental
status changes (especially in older individuals) and high-risk patient populations
(pregnancy, immunocompromised state, renal transplantation, abnormal urinary function
as in patients with neurogenic or dysfunctional bladders, immediate post-urological
surgery, renal failure, pediatrics, etc).

m) Most common cancer of the bladder (give 2):

• TCC and SCC

p) What is transitional epithelium

• A transitional epithelium (also known as urothelium) is made up of several layers of
stratified epithelium that become flattened when stretched.
• The main function of transitional epithelium is to allow tissue to expand and contract.
• For example, the transitional epithelium lines the inner walls of the urinary bladder, and
this tissue allows the bladder to expand when the bladder fills with urine.
q) Where is transitional epithelium found
• Urethra, Ureters, Urinary Bladder

3) Orientate model of bladder/penis

a) Identify structures on the posteroinferior aspect of the bladder

• Females: Posteriorly, the anterior wall of the vagina sits behind the bladder in females.
o Vesicouterine Pouch
o Terminal Part of 2 ureters

• Males: In males, the rectum is located posterior to the bladder.

o Rectovesical Pouch
o 2 vas deferens
o Terminal Part of 2 ureters
b) Identify the ureters

c) How does the ureter enter the bladder?

• At the base of bladder at the corner of trigone

d) Identify the opening of the ureters on the inner surface of the bladder
e) Relations of the peritoneum to the bladder: covers dome of bladder only
• The superior part and part of the posterior surfaces of the bladder are covered by
peritoneum.
• The inferior portion and inferolateral sides of the bladder are covered by endopelvic
fascia.

f) Layers encountered when doing suprapubic catheterization

• Skin
• Subcutaneous tissue
• Scarpa’s fascia
• Linea Alba
• Transversalis Fascia
• Preperitoneal fat

4) Abdomen

a) Identify external oblique, internal oblique, attachments, direction of fibers

b) Muscles forming conjoint tendon
• Internal oblique muscle and transverse abdominis muscle

c) Identify ovaries, tubes, appendix, terminal ileum, cecum, Douglas pouch

• The pouch of Douglas (cul-de-sac) represents the caudal extension of the peritoneal
cavity.
o It is the rectouterine pouch in the female and the rectovesical pouch in the male.
d) Referred pain of appendicitis to umbilicus
• Pain initially starts in the periumbilical region as visceral pain from the appendix is
conveyed in nerve fibers entering the spinal cord at the T10 level (the T10 dermatome
covers the level of the umbilicus).
• Irritation of the parietal peritoneum by an inflamed appendix later on causes localization
of pain to the RIF.
e) pain on flexing hip, psoas muscle
• Psoas sign: Pain on passive extension of the right thigh.
o It is present when the inflamed appendix is retrocecal and overlying the right
psoas muscle.
• Obturator sign: Pain on passive internal rotation of the hip when the right knee is flexed.
o It is present when the inflamed pelvic appendix is in contact with the obturator
internus muscle.

f) Ilioinguinal nerve injury during appendicitis

• Injury to the ilioinguinal and iliohypogastric nerves after a McBurney's incision have
been reported to cause paralysis of the conjoint tendon that may lead to the development
of an indirect inguinal hernia.

5) Anatomy (on Magnified photo, Bone, & living persons for surface anatomy)

a) Appendix, caecum, ascending colon

b) How to know the caecum from the ascending colon (the blind lower end)

c) Ovary, Fallopian tubes, Recto uterine pouch, it's alternative name (Douglas pouch)
d) Interpretation of initial and localized pain i.e. Its afferent pathway (read this in Raftery
book page 450 OSCE 2.1)

e) Identify: external & internal oblique muscle, origin & nerve supply, direction of the
muscles

f) Which fleshy muscle in front the deep inguinal ring.

• Transverse Abdominis

g) In appendicectomy we open the external oblique muscle in which direction?

• Direction of fibers (downwards, forwards, medially)

6) Anatomy 3:

a) Identify external oblique, internal oblique, attachments, direction of fibers

b) Muscles forming conjoint tendon

c) Identify ovaries, tubes, appendix, terminal ileum, cecum, douglas pouch

d) Referred pain of appendicitis to umbilicus, pain on flexing hip, psoas muscle

e) Ilioinguinal nerve injury during appendicitis.

7) Station 6: Anatomy- Abdomen

a) Given anterior abdominal wall and cross section about the level of appendix
• McBurney point is defined as a point two-thirds from the umbilicus to the anterior
superior iliac spine.

b) Ext oblique muscle origin, nerve supply

c) Conjoint tendon- what makes it up

d) Muscle in front of the deep ring

• transverse abdominis

e) Nerve injured during an appendectomy that now results in patient having a hernia-
ilioinguinal, as well the nerve root
• Ilioinguinal nerve (L1)

f) Identify structures

g) Embryological remnant one should think about in differentials for RIF pain
• Meckel’s Diverticulum

h) Explain about Referred pain

i) Identify caecum, appendix, ileum, external oblique, internal oblique and transverse
abdominis muscles

j) Name positions for the appendix

• Retrocecal
• Subcecal
• Pelvic
• Pre-ileal
• Post-ileal

8) Genitourinary Tract

a) Identify bladder

b) Blood supply of the bladder:

• Vesical arteries via the internal iliac artery

c) Identify the internal iliac artery

d) What is the muscle of the bladder wall?

• Detrusor muscle

e) Innervation of the Detrusor? (primarily parasympathetic via pelvic splanchnic nerves?)

f) Most common cancer of the bladder (give 2):

• TCC and SCC

g) What is transitional epithelium

h) Where is transitional epithelium found

i) Orientate model of bladder/penis

j) Identify structures on the posteroinferior aspect of the bladder

k) Identify the ureters

l) How does the ureter enter the bladder?

m) Identify the opening of the ureters on the inner surface of the bladder

n) Relations of the peritoneum to the bladder:

• Covers dome of bladder only

o) Layers encountered when doing suprapubic catheterization.

 Thorax: Heart

A) Thorax Anatomy- Instructions state that a man was stabbed in 2 places — by the lung
hilum and just inferior to xiphisternum. 2 specimens present — a) Heart b)
Thorax/Abdominal cavity which has the right side of the liver present (but left side
dissected away), the diaphragm, the aortic arch.

1) If stabbed in xiphisternum, what structures would be damaged?

• Left lobe liver
• Diaphragm

2) Point to the right atrium and left ventricle

3) Point to the pulmonary trunk

4) What does the pulmonary trunk divide into? Left and right pulmonary arteries.

5) What level does the pulmonary trunk divide? T5

6) How many cusps does the pulmonary valve? 3

7) Name the cusps? Anterior, left and right.

8) Name this structure? Coronary Sinus

9) What is the pulmonary ligament?

• Parietal and visceral pleura that extends from hilum to the dome of the hemidiaphragm.
• Pleural fold that connects the mediastinal surface of the lung and the pericardium to allow
expansion of pulmonary veins with increased blood flow.

10) What lies in the lung hilum and how many of each structure? (Bronchus, 2 arteries, 2
veins)
• Both lungs Anterior to Posterior: Pulmonary Veins (x2), Pulmonary Artery, Bronchus
• Bronchus (2 in Right lung, 1 in Left ling), pulmonary artery, pulmonary veins (x2 each),
hilar lymph nodes, bronchial artery, bronchial vein, autonomic nerves

11) What structure is the most anterior at the hilum?

• Pulmonary vein
12) Attachments of diaphragm: (Lumbar vertebrae, costal (7-12), Xiphisternum)

Origin Sternal Part Costal Part Vertebral Part (crura and arcuate
• Xiphoid • Inner surface of ligaments)
process lower six costal • Right Crus (L1, L2, L3)
of cartilages • Left Crus (L1, L2)
sternum • Median Arcuate Ligament
(between the 2 crura)
• Medial Arcuate Ligament
(extends from side of body
of L1to tip of transverse
process of L2)
• Lateral Arcuate Ligament
(extends from the tip of
the transverse process of
L1 and is inserted into the
lower border of 12th rib)
Insertion Central aponeurotic tendon
Actions Inspiration and forced expiration
Innervation Phrenic Nerve (C3, 4, 5)- “3, 4, 5, keeps the diaphragm alive”
Blood Inferior Phrenic Artery
Supply

13) What 2 structures run through the central tendon of the diaphragm?
• IVC
• Right Phrenic Nerve

14) How far does the left lobe of the liver extend?
• Left midclavicular line

15) What ligaments attach the liver to the diaphragm? (Coronary ligaments +Triangular
ligaments)
• Falciform Ligament
• Right Triangular Ligament
• Left Triangular Ligament
• Upper Coronary Ligament
• Lower Coronary Ligament

16) Through what ligament does the porta hepatis run?

• Hepatoduodenal Ligament
o The common hepatic artery is a branch of the celiac trunk and courses anterior to
the pancreas before giving off the gastroduodenal artery inferiorly, where it then
 becomes the hepatic artery proper, entering the hilum of the liver via the
hepatoduodenal ligament
o The hepatoduodenal ligament is the portion of the lesser omentum extending
between the porta hepatis of the liver and the superior part of the duodenum.
o Contains Portal Vein, Hepatic Artery Proper, & Common Bile Duct

17) Point to the quadrate lobe.

18) What are the boundaries of the quadrate lobe? (Posterior: porta hepatis; On the right:
fossa gallbladder; On the left: fossa for the umbilical vein)
• Right by Fossa of Gall Bladder
• Left by Fissure for Ligamentum Teres
• Superiorly (or Posteriorly) by Porta Hepatis
• Inferiorly by Inferior Border of Liver

19) What is the venous drainage of the liver?

• Hepatic veins

20) What does that drain into?

• IVC

21) What vessel provides blood supply to the stomach and liver?
• Common hepatic artery

B) Anatomy: Thorax and upper abdomen prosections (specimens all hard as wax).
Posterior view coronal section of heart and mediastinum.

1) What is this?
 • Pulmonary trunk

2) What structure here?

• Pulmonary valve

3) What branches does the pulmonary trunk have?

• Right and Left pulmonary arteries

4) Identify this:
• Papillary muscles

5) What structure are they attached to in this specimen?

• Tricuspid valve

6) What connects them to atrioventricular valves?

• Chordae Tendinae

7) What is their function?

• Chordae Tendineae: Prevent av prolapse during ventricular systole

8) Saggital section thorax and mediastinum- Identify azygos vein.

9) Name 2 tributaries or structures that drain into the azygos vein.
• Right Superior Intercostal vein
• Hemizygous Vein
• Accessory Hemizygous Vein
• Pericardial Veins
• Mediastinal Veins
 • Lower Right Posterior Intercostal Veins
• Esophageal Veins
• Bronchial Veins

10) Where does azygos vein drain into?

• SVC

11) What is this?

• Thoracic sympathetic trunk

12) Where do the preganglionic fibres that supply sympathetic trunk come from?
• From corresponding spinal nerves T1-L2

13) What connects the sympathetic trunk to the spinal nerves?

• Through rami communicants (grey rami communicants)

14) Anterior view of thorax and upper abdo. Identify the spleen.

15) What is the blood supply of spleen?

• Splenic Artery: Gives off 3 branches- Pancreatic Artery (supplies body and tail of
pancreas); Short Gastric Arteries (supplies fundus of stomach); Left gastroepiploic artery
(supplies greater curvature of stomach)
• Splenic Artery rises from Celiac Trunk
• Passes to left above Upper Border of Pancreas
• Behind the stomach separated by Lesser Sac
• During its course, it is contained within Splenorenal ligament
• Terminates into 5 branches which supply the segments of spleen

16) Describe course of splenic artery.

17) What structure must be preserved in splenectomy?

• Gastrosplenic ligament
• Thin delicate structure that connects the superior third of the greater curvature of the
stomach to the splenic hilum.
• This ligament contains the left gastroepiploic and short gastric vessels and their
associated lymphatics
• Individual ligation of short branches of the splenic artery and vein, preserving the left
gastroepiploic artery and short gastric arteries, to maintain adequate gastric perfusion.

18) What 2 other structures does it supply?

• Short Gastric Artery: fundus of stomach
• Left Gastroepiploic Artery: Greater Curvature of Stomach

19) Identify this structure.

• Duodenum
20) How many parts does it have?
• Four

21) Which part does ampulla of vater open into?

• 2nd Part

22) Which structures open into the duodenal papilllae?

• Major Duodenal Papilla (Papilla of Vater): junction of common bile duct and pancreatic
duct
o Major Duodenal Papilla: bile and enzymes for digestion
• Minor Duodenal Papilla: Accessory Pancreatic Duct (of Santorini)
o Minor Duodenal Papilla: drains the dorsal pancreatic bud during fetal
development.

23) What do they drain?

• Main Pancreatic Duct (or Wirsung): drains head, body, tail (opens into major duodenal
papilla)

24) What blood vessel runs posterior to D1?

• Gastroduodenal Artery
• Portal Vein

C) Anatomy- Thorax anatomy

Stem: Patient stabbed in chest twice and just under xiphoid sternum; Specimens of heart,
lung and thorax cut transversely to show diaphragm.

a) Identify right atrium, pulmonary trunk, aortic valve, right auricle

b) How many cusps does pulmonary valve have?

c) What does pulmonary trunk divide into?

d) Identify hilum of lung

e) What is in the hilum, identify all the components

f) How many pulmonary veins are there in each lung

• 2

g) Which is most anterior in hilum?

• Pulmonary Vein

h) What level is the hilum at?

• T5 to T7
i) What passes through central tendon of diaphragm
• IVC
• Right Phrenic Nerve

j) What are the bony attachments of the diaphragm

• Sternal Part: Xiphoid Process of Sternum
• Costal Part: T7-T12 costal cartilage Inner Surface
• Vertebral Part: Right Crura (L1-L3); Left Crura (L1-L2); Median Arcuate Ligament
(between 2 crura); Medial Arcuate Ligament (body of L1 to tip of transverse process of
L2); Lateral Arcuate Ligament (tip of transverse process of L1to lower border of 12th rib)

k) What are the ligaments of the diaphragm (I just said median arcuate ligament and he
moved on. Didn't get to say the rest)
• Median Arcuate
• Medial Arcuate
• Lateral Arcuate

l) Organs damaged by knife just under the xiphiod. (Answer he wanted was left lobe of liver
and diaphragm. I said heart first but he kept pushing for liver and diaphragm)
• Left Lobe of Liver
• Diaphragm

m) How far does the left lobe of the liver extend to normally (he said YES! When I said left
mid-clavicular line. Anyhow guess =S)
• Midclavicular Line

n) What divides left and right lobe of liver.

• Anatomical:
o Falciform Ligament (anteriorly)
o Fissure for Ligamentum Teres & Ligamentum Venosum (posteroinferiorly)
• Surgical: line passing from IVC to fossa of GB

o) What attaches liver to diaphragm (have to point on specimen)

• Falciform Ligament
• Right Triangular Ligament
• Left Triangular Ligament
• Upper Coronary Ligament
• Lower Coronary Ligament

p) Identify quadrate lobe and name its boundaries.

• Right by Fossa of Gall Bladder
• Left by Fissure for Ligamentum Teres
• Superiorly (or Posteriorly) by Porta Hepatis
• Inferiorly by Inferior Border of Liver
D) Thorax: A one page long useless scenario given on how a guy got stabbed in the
xiphisternum. Also clearly states that this station is not to check our clinical management
and only anatomy will be tested related to this region (meaning thorax and abdomen).
Waste of time and more importantly, energy. When you go in, a really sweet examiner
standing next to three dissected specimens of heart, thorax and left lung (I said sweet
examiner because I accidentaly discarded the gloves from my previous station in a
hazardous waste bin since it's a natural reflex, this guy ran to get me gloves himself lol).
Anyway, told me to pick up the heart.

1) Identify the chamber of the heart, pulmonary trunk, aorta.

2) Then pointed to the right auricle and said what is this.

3) Then moved to the left lung specimen, asked me to pick it up, asked to identify the
pulmonary artery, veins and main bronchus.

4) Asked what level does the pulmonary trunk divide at; I seemed to wonder for a moment
before I answered and he said lets come back to this (again, very sweet).
• T5

5) He then asked me what the pulmonary ligament is and where it attached, and I didn't
want to blurt out something I wasn't too sure of (bad habit) so I said I'll skip that.
 • Pleural fold that connects the mediastinal surface of the lung and the pericardium to allow
expansion of pulmonary veins with increased blood flow (a Pleural sleeve that surrounds
the hilum- it gives a dead space into which pulmonary veins can expand during increased
venous return)
• It extends downward in a sheet-like manner from the inferior margin of the pulmonary
hilus to the diaphragm and loosely attaches the medial surface of the lung to the
mediastinum

6) Then moved to the thorax and abdomen dissected specimen, asked me to pick up the
liver and identify the lobes, falciform ligament, boundaries of caudate lobe (couldn't get
them all so he said let’s move to the next question, I was happy to)
• Caudate lobe is present in posterior surface
• Left by Fissure for Ligamentum Venosum
• Right by Groove for Inferior Vena Cava
• Inferiorly by porta hepatis
• Above it is continuous with Superior Margin
7) Name the main artery that supplies the liver and stomach, what are its branches?
• Common Hepatic Artery (from Celiac Trunk):
o Proper Hepatic Artery (Right & Left hepatic Artery)
o Right Gastric Artery
o Gastroduodenal Artery
o Cystic Artery (occasionally, but mainly come from Right Hepatic Artery)

8) What is the venous drainage of the liver?

• Hepatic Veins (x3) to IVC
9) What ligaments attach the liver to the diaphragm (kept pushing till I named all of
them and then smiled).
• Falciform Ligament
• Right Triangular Ligament
• Left Triangular Ligament
• Upper Coronary Ligament
• Lower Coronary Ligament

10) Finally asked about the actual scenario saying what organs do you think would be
damaged in a stab wound directed 45 degrees towards the left shoulder- I said left lobe of
liver, heart- he stopped me there and said no before the heart - so I said diaphragm and he
grinned and said okay we are done but do you want to go back to the question about the
pulmonary ligament? I was about to blurt out something but bell rang.
• Left lobe of Liver
• Diaphragm

E) Station 4 - Anatomy - heart, thoracic cavity and abdomen (examiner say the heart is
made from real heart!!!)

1) What is this?
• Chordae tendineae

2) What is it attach to?

• The papillary muscle and cusps of Tricuspid Valve

3) What’s its function it is?

• Tricuspid Valve: prevent backflow of blood from the right ventricle to the right atrium
• Chordae Tendineae: Prevent av prolapse during ventricular systole
• Papillary Muscles: stabilizes position of tricuspid valve to maintain the unidirectional
blood flow

4) Point out the pulmonary trunk and aorta

5) What are the branches of ascending aorta?

• Left and right coronary artery

6) What is it?
• Azygos vein

7) Name two other trifurcation of azygos vein

• Hemiazygos and accessory hemiazygos

8) What is it?
 • Sympathetic trunk

9) Which spine level it is from?

• T1 to L2

10) What does it call connecting the spinal nerve and organ?
Ganglion (didn't get the answer though)

11) What is it?

• Duodenum

12) What parts it has?

• 4 parts- Superior, Descending, Inferior, Ascending

13) Ampulla of Vater open to which part?

• 2nd part

14) What duct is drained though the ampulla of vater?

• Pancreatic duct and common bile duct

15) When you do splenectomy, need to preserve what structures?

• Gastrosplenic Ligament (Leino-gastric)
• Splenorenal Ligament (Leino-Renal)

16) What runs in them?

• Gastrosplenic Ligament: left gastroepiploic artery and short gastric arteries
• Splenorenal Ligament: Splenic artery, Splenic Vein and tail of the pancreas

F) Thoracic and abdominal anatomy.

1) Show pulmonary trunk

2) What is this structure? And branches (possibly aorta)

3) Behind the heart and points to hemiazygos vein - tributaries?

• The hemiazygos vein is the asymmetric counterpart to the azygos vein and forms part of
the azygos venous system.
• The hemiazygos vein is formed by the confluence of the left ascending lumbar and left
subcostal veins.
• Tributaries:
o left posterior 8th-11th intercostal veins
o left superior phrenic vein
o left renal vein (occasionally)
o IVC (occasionally)
4) Splenic artery and branches
• Splenic Artery: Gives off 3 branches- Pancreatic Artery (supplies body and tail of
pancreas); Short Gastric Arteries (supplies fundus of stomach); Left gastroepiploic artery
(supplies greater curvature of stomach)

G) Station 1 (Anatomy) Prosection of thorax and abdomen.

1) Identify the ascending aorta and arch of aorta.

2) Tell me the branches of the ascending aorta
• Right and left coronary arteries

3) Identify the right ventricle

4) What is this structure

• tricuspid valve, papillary muscles

5) What is this structure?

• cordae tendonae

6) Function of this structure?

• Chordae tendonae attach the valve and papillary muscles thereby preventing the prolapse
of the tricuspid valve during the contraction

7) Identify the azygous vein

8) What are the tributaries of the azygous system?

• The posterior intercostal veins and lumbar veins on the right and on the left hemiazygous
vein and assessory hemiazygous vein

9) Identify the sympathetic trunk

10) What levels of spinal cord contribute to it

• T1 to L2

11) What communicates the spinal roots and post ganglionic fibres?
• Gray rami communicantes

12) Identify spleen.

13) Blood supply of the spleen

14) Tell me the course of the splenic artery

• Splenic Artery rises from Celiac Trunk
• Passes to left above Upper Border of Pancreas
• Behind the stomach separated by Lesser Sac
• During its course, it is contained within Splenorenal ligament
• Terminates into 5 branches which supply the segments of spleen

15) What structures are supplied by the splenic artery apart from the spleen?
• Splenic Artery: Gives off 3 branches- Pancreatic Artery (supplies body and tail of
pancreas); Short Gastric Arteries (supplies fundus of stomach); Left gastroepiploic artery
(supplies greater curvature of stomach)
16) What is this structure?
• Duodenum

17) How many parts?

18) What ducts enter into it?

• A smaller accessory duct from the Pancreas attaches to the duodenum just superior to the
Ampulla of Vater.
• The Common Bile Duct and the Pancreatic Duct combine together and enter the
Duodenum at the Ampulla of Vater connected to the left lateral wall inside the curve of
the duodenum on the Pancreatic side.

19) From where?

20) Identify this structure.

• Gallbladder

21) Surface anatomy of the gall bladder- Landmark of gallbladder

• At the angle between 9th costal cartilage and lateral margin of rectus sheath

H) Anatomy (Thorax and abdomen)- with cadaver.

1) Identify pulmonary trunk, papillary muscle, chordae tendinae.

2) What is the function of chordae tendinae?

3) Identify ascending aorta.

4) What are the branches of ascending aorta?

5) What is this structure?

• Azygous vein

6) What are the tributaries of azygous vein?

7) What is this structure?

• Sympathetic chain

8) Which spinal segments contribute sympathetic chain?

• T1-L2

9) What connects sympathetic chain to spinal nerves?

• Preganglionic via ventral rami through communicants (grey rami communicants)
10) Identify spleen.

11) On which ribs does the spleen lie?

• 9-11th ribs

12) What structure is susceptible to injury during isolation and ligation of splenic artery?
• Tail of pancreas

13) Describe the course of splenic artery.

• Torturous course over body of pancreas, gives off short gastric and left gastroepiploic
artery prior to supplying spleen

14) Which other organs does it supply?

• Pancreatic Artery (supplies body and tail of pancreas)
• Short Gastric Arteries (supplies fundus of stomach)
• Left gastroepiploic artery (supplies greater curvature of stomach)

15) Identify duodenum.

16) How many parts?

17) Which artery lies behind the first part?

• gastroduodenal artery

18) Which structures open into the ampulla of Vater?

• Common Bile Duct, Pancreatic Duct

19) Where does AOV drain into?

• 2nd part of duodenum

20) What is this?

• Fundus of gall bladder

21) Surface marking of it.

• Transpyloric plane: lies midway between the jugular notch of the sternum and the upper
border of the pubic symphysis,

22) Why does cholecystitis cause shoulder tip pain?

• Diaphragm is innervated by Phrenic Nerve (C3, C4, C5)
• An inflamed gall bladder may irritate the diaphragm
• Roots of phrenic nerve that supply the diaphragm are the same as supraclavicular nerve
(C3, C4) supplying the shoulder tip

I) Thorax/Abdomen/ Heart
1) What is this?
• tricuspid valve, papillary muscle, chordae tendinae.

2) What is function of chordae tendinae?

• prevent av prolapse during vent systole

3) Branches of the ascending aorta.

4) What is this?
• Azygous vein (it looks bigger than you think, please don’t confuse it with right
brachiocephalic trunk or right brachiocephalic vein).

5) Name me tributaries?
• Bronchial veins, Esophageal veins, hemi azygous veins, intercostal veins

6) Specimen of heart. Where is the ascending aorta?

7) Where is the brachiocephalic trunk?

8) Where is the recurrent laryngeal nerve on left?

9) What are the branches of the ascending carotid?!?

10) Where is the left vagus nerve (identified in left carotid sheath)
**In above picture: 15, 17, 20, 22, 29 are important!

11) What is this- points to ascending aorta

12) What is this- points to arch of aorta

13) What are the branches of the arch of aorta?

• Brachiocephalic trunk: gives off Right Common Carotid Artery & Right Subclavian
Artery
• Left common carotid artery
• Left subclavian artery

14) What are the branches of the pulmonary trunk?

 • left and right pulmonary arteries

J) A 3D model of heart; blood supply to the brain; cervical vertebra; identify the
azygous vein, brachiocephalic trunk and the sympathetic chain on a picture of a
cadaver.

K) Trunk and thorax

-Stab wound x 3: epigastrium, 2x thorax
-Prosection of heart, mediastinum
1) Identify the right atrium, left ventricle, and pulmonary trunk

2) identify the pulmonary valve. How many cusps are there in the valve?
• 3

3) Identify this triangular structure

• Auricle of right atrium

4) Name the structures that pass through the hilum of the lung?

5) Which is the most anterior?

6) What are the branches of the pulmonary trunk?

7) What are the first 2 organs injured in a stab wound to the epigastrium?
• Left Lobe of Liver
• Diaphragm

8) What demarcates the left and right lobes of the liver?

• Anatomical:
o Falciform Ligament (anteriorly)
o Fissure for Ligamentum Teres & Ligamentum Venosum (posteroinferiorly)
• Surgical: line passing from IVC to fossa of GB

9) What is the venous drainage of the liver?

• Hepatic Vein into IVC

10) What branch of the celiac trunk supplies both the stomach and the liver?
• Common Hepatic Artery

11) In what structure does it run to reach the porta hepatis?

• Hepatoduodenal Ligament

12) Point out the quadrate lobe.

13) What are the boundaries of the quadrate lobe?

• Right by Fossa of Gall Bladder
• Left by Fissure for Ligamentum Teres
• Superiorly (or Posteriorly) by Porta Hepatis
• Inferiorly by Inferior Border of Liver

14) What are lobes of liver.

• 2 anatomical Lobes: Right & Left Lobe
• 2 accessory Lobes: Caudate & Quadrate Lobe
• Caudate & Quadrate are anatomically part of right lobe of liver, but functionally they
belong to left lobe because they receive blood from left branches of hepatic artery and
portal vein, and drain bile to left hepatic duct
L) Heart:

1) Show me Rt atrium and left ventricle.

2) Pointed to 1 structure what is this? I said atrium appendage. (?!)

3) Show me pulmonary trunk.

4) What are the parts of pulmonary trunk?

• right and left pulmonary arteries

M) Anatomy- Thorax and Abdomen

1) Identify Pulmonary Trunk

2) Identify Ascending Aorta

3) Branches of the Ascending Aorta: Right and Left Coronary Arteries

4) Identify Sympathetic Trunk

5) Source of Trunk: T1 to L2

6) Tributaries of the Azygos Vein: Inferior Phrenic Veins, Posterior Intercostal Veins,
Esophageal Veins (give 3)

7) Identify Papillary Muscle and Chordae Tendineae

8) Function: Prevent AV valve from prolapsing

 Thorax: Lungs

A) Lung Anatomy- Left lung specimen

1) Identify the pulmonary artery, veins and main bronchus.

2) Asked what level does the pulmonary trunk divide at: T5

3) what the pulmonary ligament is and where it attached

• Parietal and visceral pleura that extends from hilum to the dome of the
hemidiaphragm.
 • Pleural fold that connects the mediastinal surface of the lung and the pericardium to
allow expansion of pulmonary veins with increased blood flow

4) Identify hilum of lung

5) What is in the hilum, identify all the components

• Both lungs Anterior to Posterior: Pulmonary Veins (x2), Pulmonary Artery, Bronchus
• Bronchus (2 in Right lung, 1 in Left ling), pulmonary artery, pulmonary veins (x2
each), hilar lymph nodes, bronchial artery, bronchial vein, autonomic nerves

6) How many pulmonary veins are there in each lung

• Two

7) Which is most anterior in hilum

• Pulmonary Vein

8) What level is the hilum at

• T5 to T7

9) What passes through central tendon of diaphragm

• IVC
• Right Phrenic Nerve

10) What are the bony attachments of the diaphragm

Origin Sternal Part Costal Part Vertebral Part (crura and

• Xiphoid • Inner surface arcuate ligaments)
process of lower six • Right Crus (L1, L2, L3)
• Left Crus (L1, L2)
 of costal • Median Arcuate
sternum cartilages Ligament (between the
2 crura)
• Medial Arcuate
Ligament (extends from
side of body of L1to tip
of transverse process of
L2)
• Lateral Arcuate
Ligament (extends from
the tip of the transverse
process of L1 and is
inserted into the lower
border of 12th rib)
Insertion Central aponeurotic tendon
Actions Inspiration and forced expiration
Innervation Phrenic Nerve (C3, 4, 5)- “3, 4, 5, keeps the diaphragm alive”
Blood Inferior Phrenic Artery
Supply

11) What are the ligaments of the diaphragm (I just said median arcuate ligament and he
moved on. Didn’t get to say the rest)
• Median Arcuate
• Medial Arcuate
• Lateral Arcuate

B) Lung Anatomy

1) Hila of lung, Which lung?

2) Identify bronchus.

3) What is pulmonary ligament.

4) Description of outline of pleura.

• The pleural cavity is a fluid filled space that surrounds the lungs. It is found in the
thorax, separating the lungs from its surrounding structures such as the thoracic cage
and intercostal spaces, the mediastinum and the diaphragm. The pleural cavity is
bounded by a double layered serous membrane called pleura.

• Pleura is formed by an inner visceral pleura and an outer parietal layer. Between these
two membranous layers is a small amount of serous fluid held within the pleural
cavity. This lubricated cavity allows the lungs to move freely during breathing.
• Boundaries:
o Superior: root of neck (above rib 1)
o Inferiorly: diaphragm and costal margin
o Medially: mediastinum
o Laterally: thoracic wall

5) Describe the locations of transverse and horizontal fissure of right lung.

• Oblique fissure – Runs from the inferior border of the lung in a superoposterior
direction, until it meets the posterior lung border.
• Horizontal fissure– Runs horizontally from the sternum, at the level of the 4th rib, to
meet the oblique fissure.

6) Specimen of lung and heart- Pick them up and name the parts. I spoke for a while
until the chap got bored and moved on.
7) Section of calf demonstrating DVT- what is it? (blood clot that forms in the deep veins
of LL and it propagates proximally)
• Deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually
of the leg, but can occur in the arms and the mesenteric and cerebral veins.
o DVT usually involves the lower limb venous system, with clot formation
originating in a deep calf vein and propagating proximally.
o Deep-vein thrombosis is a major medical problem accounting for most cases
of pulmonary embolism.

8) Describe the course of the clot from leg to lung.

• Popliteal vein → femoral vein → Ext. Iliac Vein → Common Iliac Vein → IVC →
right atrium → AV valve → pulmonary valve → pulmonary artery

9) Given specimen of right lung, why right lung?

• Right Lung: groove for arch of azygous vein; 2 bronchus in hilum (eparterial and
hyparterial bronchi)
• Left Lung: groove for arch of aorta

10) Shown the hilum, identify the structures

11) Number of bronchopulmonary segments in each lung

• 10

12) What happens if clot

• PE

13) Show on skeleton the surface markings of the lungs on both sides
• Apex: curved line from the sternoclavicular joint to 3 cm above the junction between
the medial 1⁄3 and the middle 1⁄3 of clavicle
 • Anterior border: Sternoclavicular joint to the xiphisternal joint behind the lateral
border of the sternum (left lung deviates laterally from the sternum at the 4th costal
cartilage to form the cardiac notch)
• Inferior border: Line drawn between 6th rib MCL, 8th rib MAL, 10th rib vertebral
column
• Posterior border: Transverse process of C7 – T10
• Hilum: Opposite T5, T6, T7
• Carina: At the level of T4

14) Usual questions on right bronchus- where foreign body will lodge and why
• Right Lower Lobe
• Due to the vertical orientation of the right main bronchus

15) What are the surface markings to determine vertebra level- mentioned the inferior
angle of scapula and spine of scapula; Also wanted me to mention C7 as the most prominent
vertebra to count downwards
• Posterior border: Transverse process of C7 – T10
o C7: from external occipital protuberance palpate down the hollow nuchal line
and prominent C7 spinous process is at base of neck
▪ Two lower neck bones (C6 and C7) often stick out under the skin at
shoulder level, because this is an inflection point: a place where the
spine changes curvature, from inward (neck) to outward
(shoulders).

C) Lung anatomy- an outline

1) Orientate the lung (right lung)

2) What nerve lies in front and what behind?

• Ant: phrenic nerve
• Post: sympathetic chain; also Vagus Nerve posterior to Hilum

3) Name the fissures

• Right Lung: Oblique and Horizontal Fissure
• Left Lung: Oblique Fissure

4) How many bronchi pulmonary segments are there?

• 10
5) Talk about DVT

6) What is the best test? (PE: CT angiogram and V/Q scan)

• CT pulmonary angiogram

7) Talk through the path of a clot starting in the calf – deep veins of the calf -- & going to
popilteal vein, femoral vein, ext iliac, common iliac, ivc, atrium, AV valve, pulmonary valve
to the pulmonary artery
• Popliteal vein → femoral vein → Ext. Iliac Vein → Common Iliac Vein → IVC →
right atrium → AV valve → pulmonary valve → pulmonary artery

8) Lower long saphenous vein anatomy with some lung anatomy surface anatomy
• Arises from the dorsal veins of the foot
• Passes anterior to the med malleolus
• Rises in the med aspect of the calf
• Lies 4 finger breath post to the med condyle of the femur
• Rises up the med aspect of the thigh before ending in the SFJ medial to the femoral
artery.

9) What nerve is in close relation to this vein

• Saphenous nerve

10) X-ray of a pneumothorax

11) Where would you insert a chest drain

• Triangle of safety- 5th intercostal space mid-axillary line
o Anterior border of Latissimus Dorsi
o Lateral border of Pectoralis major
o Line superior to the horizontal level of nipple
o Apex below axilla
12) If tension, where do you decompress?
• Mid clavicular line, 2nd intercoastal space

13) Identify the sympathetic chain

14) what connects the spinal nerves to the sympathetic chain
• Rami communicants’

15) Identify sympathetic chain, name 2 structures which sympathetic fibers leave with
• Spinal nerves, blood vessels

16) Identify right atrium, pulmonary trunk, aortic valve, right auricle
17) How many cusps does pulmonary valve have
• 3

18) What does pulmonary trunk divide into

• Right and Left Pulmonary Arteries
•

D) Thorax

1) Surface anatomy of the right pleura

• Apex: one inch above medial 1/3 of clavicle
• Anterior Margin: extends vertically from sterno-clavicular joint to xiphisternal joint
(6th costal cartilage)
• Inferior Margin: passes around the chest wall on 8th rib at mid-clavicular line, 10th rib
in mid-axillary line and finally reaching to 12th rib adjacent to vertebral column
posteriorly (T12 spine)
 • Posterior Margin: along the vertebral column from the apex (C7) to inferior margin
(T12 spine)
•

2) Surface anatomy of the horizontal and oblique fissure

• Oblique Fissure: represented by a line extending from T4 and obliquely extending at
6th costal cartilage
• Horizontal fissure (right lung): represented by a line extending from 4th right costal
cartilage to meet oblique fissure

3) Pulmonary hilum – what the structures are at the hilum

4) Path of the vagus nerve

• In the Head: the vagus nerve originates from the medulla of the brainstem
o It exits the cranium via the jugular foramen, with the glossopharyngeal (IX)
and accessory (XI) nerves
o Within the cranium, the auricular branch arises- this supplies sensation to the
posterior part of the external auditory canal and external ear.

• In the Neck: the vagus nerve passes into the carotid sheath, travelling inferiorly with
the internal jugular vein and common carotid artery.
o At the base of the neck, the right and left nerves have differing pathways:
▪ RIGHT vagus nerve passes anterior to the subclavian artery and
posterior to the sternoclavicular joint, entering the thorax.
 ▪LEFT vagus nerve passes inferiorly between the left common carotid
and left subclavian arteries, posterior to the sternoclavicular joint,
entering the thorax.
o Several branches arise in the neck:
▪ Pharyngeal branches – Provides motor innervation to the majority of
the muscles of the pharynx and soft palate.
▪ Superior laryngeal nerve – Splits into internal and external branches.
The external laryngeal nerve innervates the cricothyroid muscle of the
larynx. The internal laryngeal provides sensory innervation to the
laryngopharynx and superior part of the larynx.
▪ Right recurrent laryngeal nerve – Hooks underneath the right
subclavian artery, then ascends towards to the larynx. It innervates the
majority of the intrinsic muscles of the larynx.

• In the Thorax: the right vagus nerve forms the posterior vagal trunk, and the left
vagus forms the anterior vagal trunk. Branches from the vagal trunks contribute to the
formation of the esophageal plexus, which innervates the smooth muscle of the
esophagus.
o Two other branches arise in the thorax:
▪ Left recurrent laryngeal nerve – hooks under the arch of the aorta,
ascending to innervate the majority of the intrinsic muscles of the
larynx.
▪ Cardiac branches – regulate heart rate and provide visceral sensation to
the heart

• The vagal trunks enter the abdomen via the esophageal hiatus, an opening in the
diaphragm.

• In the Abdomen: the vagal trunks terminate by dividing into branches that supply the
esophagus, stomach and the small and large bowel (up to the splenic flexure).

5) Path of the recurrent laryngeal nerve behind the aorta

• Recurrent laryngeal nerve [RLN]: the RLN is also a branch of the vagus nerve.
• Left RLN is found inferior to the aortic arch and posterior to ligamentum arteriosum
• The right vagus continues posteriorly to the root of the right lung giving off the right
RLN which loops around the right subclavian artery.
• The recurrent laryngeal nerves then continue superiorly bilaterally and pass posterior
to the lobe of the thyroid gland as they travel along the lateral surfaces of the trachea
and esophagus in the tracheoesophageal groove.
• The nerves pass posterior to the cricothyroid joint as they enter the larynx at this level
through fibers of the inferior constrictor muscles of the pharynx.
• At this point, the RLN becomes the inferior laryngeal nerve.
6) Path of a DVT from leg to the pulmonary artery

E) Thorax:

1) This is the hilum of the lung what are the structures? (2 veins, 1 artery, 1 bronchus)

2) Identify them.

3) What attaches the lung to the diaphragm?

• Pulmonary ligament

F) Scenario not important. (Anatomy) case of stab injury – injury to liver and
diaphragm External Heart photo- not so clear—asked to identify- rt atrium, left
ventricle…….

1) Pulmonary trunk divide into

• Right and Left pulmonary artery

2) Contents of lung root

• Both lungs Anterior to Posterior: Pulmonary Veins (x2), Pulmonary Artery, Bronchus
• Bronchus (2 in Right lung, 1 in Left ling), pulmonary artery, pulmonary veins (x2
each), hilar lymph nodes, bronchial artery, bronchial vein, autonomic nerves
3) Most anterior and posterior in root
Anterior: Pulmonary Vein
Posterior: Bronchus

4) Pulmonary ligament
• Parietal and visceral pleura that extends from hilum to the dome of the
hemidiaphragm
• Pleural fold that connects the mediastinal surface of the lung and the pericardium to
allow expansion of pulmonary veins with increased blood flow

5) Identify caudate, quadrate, ligamentum teres

6) Boundaries of quadrate lobe

 • Right by Fossa of Gall Bladder
• Left by Fissure for Ligamentum Teres
• Superiorly (or Posteriorly) by Porta Hepatis
• Inferiorly by Inferior Border of Liver

7) Venous drainage of liver

• Hepatic Vein into IVC

8) Stab in epigastrium organs most risk of injury

• Left lobe of Liver
• Diaphragm

9) Surface marking of liver (left lobe)

• Follows upper limit of Diaphragm, Left 5th Rib between mid-clavicular line

10) What structure divide lobe of liver

• Anatomical:
o Falciform Ligament (anteriorly)
o Fissure for Ligamentum Teres & Ligamentum Venosum (posteroinferiorly)
• Surgical: line passing from IVC to fossa of GB

11) Attachment of liver to diaphragm

• Falciform Ligament
• Right Triangular Ligament
• Left Triangular Ligament
• Upper Coronary Ligament
• Lower Coronary Ligament

12) Level of carina

• T4

13) How many cups are in mitral valve/pulmonary valve

• Mitral Valve: 2
• Pulmonary Valve: 3

14) What is Subclavian steal syndrome?

• Stenosis of subclavian artery proximal to the origin of the vertebral artery
• Retrograde flow of blood in vertebral artery at expense of vertebrobasilar circulation
(so called steal) to supply upper limb
Thorax- Thoracic Inlet & Mediastinum, Posterior Mediastinum, Sympathetic Trunk

1) Posterior mediastinum

a) Point to post mediastinum

b) Boundaries of post mediastinum

Anterior • Pericardium
• Vertical Part of Diaphragm
Posterior Lower 8 thoracic vertebrae
On each side Mediastinal Pleura

c) Contents of post mediastinum (she didn't let me until I answered them all)
• Esophagus
• Thoracic aorta
 • Azygos vein
• Thoracic duct and associated lymph nodes
• Vagus Nerve
• Sympathetic trunk
• Thoracic splanchnic nerves

d) Level esophagus starts and surface marking

• C6 vertebra (starts at the cricoid cartilage from the oropharynx)

e) What level pierces diaphragm right crus

• T10
• Pierces muscular layer of Diaphragm and entering through Right Crus

f) Blood supply of esophagus

Artery Vein Lymphatics Epithelium

Upper Third Inferior Thyroid Inferior Thyroid Deep Cervical Striated
Middle Third Thoracic Aorta Azygous Mediastinal Striated +Smooth
Lower Third Left Gastric Left Gastric Gastric Smooth

g) Venous return of esophagus

h) Lymph drainage of esophagus

i) Type of tissue of esophagus (she wanted stratified squamous not squamous only)
• Non-keratinized Stratified Squamous Epithelium

j) Define Barrett esophagus

• Metaplasia of lower esophageal mucosa from stratified squamous epithelium to non-
ciliated columnar epithelium with Goblet Cells
• Response of lower esophageal stem cells to acidic stress
• May progress to dysplasia and adenocarcinoma

k) Clinical significance of Barrett

• Increased risk of developing adenocarcinoma

l) What makes an indent on the esophagus in the thorax (she wanted by the arch of aorta
and left bronchus)
• Aortic arch
• Left main bronchus
• Left Atrium

m) Complications of perforated esophagus (she wanted hemorrhage, pneumothorax and

hemothorax- also she didn't allow me to go for the next question until saying it)
• Hemorrhage
• Pneumothorax
• Hemothorax

n) Post mediastinum contents

o) Diaphragmatic openings & attachment
• T8 (8 letters) = Vena cava
• T10 (10 letters) = Esophagus
• T12 (12 letters) = Aortic hiatus

Level T8 T10 T12

Location Central tendon Right Crus Behind Median Arcuate Ligament
Structures IVC Esophagus Aorta
Right Phrenic Nerve Vagus Nerves Azygous Vein
Thoracic Duct

• Attachments:

Origin Sternal Part: Costal Part: Vertebral Part (crura and arcuate
• Xiphoid • Inner ligaments):
process surface of • Right Crus (L1, L2, L3)
of the the lower • Left Crus: (L1, L2)
sternum six costal • Median Arcuate Ligament
cartilages (between 2 crura)
• Medial Arcuate Ligament
(extends from side of body of
L1 to the tip of transverse
process of L2)
• Lateral Arcuate ligament
(extends from the tip of the
transverse process of L1 and
is inserted into the lower
border of 12th rib)
Insertion: Central aponeurotic tendon
Actions: Inspiration and forced expiration
Innervation: Phrenic Nerve (C3, C4, C5) “3, 4, 5 keeps diaphragm alive”
Blood Inferior phrenic artery
Supply:

p) Meralgia paresthetica
• Disorder characterized by tingling, numbness, and burning pain in the outer side of
the thigh.
• The disorder occurs when the lateral femoral cutaneous nerve is compressed or
squeezed as it exits the pelvis.
• Tight clothing, obesity or weight gain, and pregnancy are common causes of meralgia
paresthetica.

2) Anatomy - Posterior mediastinum esp. esophagus

a) Boundaries

Anterior • Pericardium
 • Vertical Part of Diaphragm
Posterior Lower 8 thoracic vertebrae
On each side Mediastinal Pleura

b) Esophagus - surface markings

• At lower border of cricoid cartilage (C6) to cardia of stomach (T11)

c) Epithelium
• NKSSE Non-Keratinized Stratified Squamous Epithelium

d) Arterial supply

Artery Vein Lymphatics Epithelium

Upper Third Inferior Thyroid Inferior Thyroid Deep Cervical Striated
Middle Third Thoracic Aorta Azygous Mediastinal Striated +Smooth
Lower Third Left Gastric Left Gastric Gastric Smooth

e) Venous drainage

f) Lymph node drainage

g) Achalasia
• Motility disorder with inability to relax lower esophageal sphincter (LES)
• Due to damage of ganglion cells in Myenteric Plexus
• Ganglion cells of myenteric plexus are located between inner circular (IC) and outer
longitudinal (OL) layers of muscularis propria (and are important for regulating bowel
motility and relaxing LES)
o Mucosa
o Submucosa
o Muscularis Propria (IC- myenteric plexus- OL)
o Adventitia (Thoracic esophagus has an adventitia because it is not covered
by peritoneum; esophagus lacks a mucus layer (Serosa) and its surface cells
do not secrete bicarbonate ions)
• Characterized by
o incomplete LES relaxation
o increased LES tone
o lack of peristalsis of the esophagus
• Microscopic features of achalasia: Hypertrophied musculature with absence of
myenteric plexus

h) Barrett's esophagus

i) Through which part of the diaphragm does it exit the thorax.

• T10- Enters muscular part of diaphragm through esophageal hiatus

3) Discussion of the mediastinum on a wet specimen

a) Discuss Barrett’s esophagus monitoring and treatment

 • Monitoring: Current guidelines for Barrett’s esophagus patients recommend
endoscopic surveillance intervals of 3–5 years for patients without dysplasia, 6–12
months for those with low-grade dysplasia (LGD), and every 3 months for HGD
patients.
• Treatment: diet and lifestyle changes (cessation of smoking, avoid acidic foods);
avoid lying down right after meals; head elevation when laying down; proton pump
inhibitor therapy; cryoablation therapy.

b) Identify lungs, heart, phrenic nerve and vagus nerve

c) Anatomy of lung and its blood supply
• Lungs are roughly cone shaped, with an apex, base, three surfaces and three borders.
• The left lung is slightly smaller than the right – this is due to the presence of the heart.
• Each lung consists of:
• Apex – The blunt superior end of the lung. It projects upwards, above the level of the
1st rib and into the floor of the neck.
• Base – The inferior surface of the lung, which sits on the diaphragm.
 • Lobes (two or three) – These are separated by fissures within the lung.
• Surfaces (three) – These correspond to the area of the thorax that they face. They are
named costal, mediastinal and diaphragmatic.
• Borders (three) – The edges of the lungs, named the anterior, inferior and posterior
borders.

• Lungs are supplied with deoxygenated blood by the paired pulmonary arteries.
• Once the blood has received oxygenation, it leaves the lungs via four pulmonary
veins (two for each lung).
• The bronchi, lung roots, visceral pleura and supporting lung tissues require an extra
nutritive blood supply. This is delivered by the bronchial arteries, which arise from
the descending aorta.
• The bronchial veins provide venous drainage. The right bronchial vein drains into
the azygos vein, whilst the left drains into the accessory hemiazygos vein.

d) Surface anatomy of the pleura and lung fissures

• Apex: curved line from the sternoclavicular joint to 3 cm above the junction between
the medial 1⁄3 and the middle 1⁄3 of clavicle
• Anterior border: Sternoclavicular joint to the xiphisternal joint behind the lateral
border of the sternum (left lung deviates laterally from the sternum at the 4th costal
cartilage to form the cardiac notch)
• Inferior border: Line drawn between 6th rib MCL, 8th rib MAL, 10th rib vertebral
column
• Posterior border: Transverse process of C7 – T10
• Hilum: Opposite T5, T6, T7
• Carina: At the level of T4
e) May get asked about thoracic outlet syndrome or subclavian steal syndrome
• Subclavian steal syndrome? Retrograde flow of blood flow down to the vertebral
artery due to steno-occlusive disease in the subclavian artery proximal to the vertebral
artery. This will lead to brainstem ischemia on arm exercise.
• Thoracic outlet syndrome? Compression of the neurovascular bundle (brachial plexus,
subclavian artery) between the scalenus Medius and scalenus anterior → neurological
and vascular symptoms in the arm.

4) Anatomy – Esophagus

a) Boundaries of posterior mediastinum

b) Contents

c) Blood supply and LN drainage of esophagus

d) Natural constrictors in esophagus- ABCD

Structure Distance From Incisors Level

Cricoid Cartilage 15cm C6
Arch of Aorta 22.5cm T3
Left Principal Bronchus 27cm T6
Diaphragmatic Hiatus 40cm T10

• cervical constriction (narrowest point): due to the cricoid cartilage at the level of
C5/6.
• thoracic constriction: due to the aortic arch at the level of T4/5.
• abdominal constriction: at the esophageal hiatus at the level of T10/11

e) Complications of perforation of posterior surface of MID esophagus while

performing endoscopy.
• Mediastinitis
• Septicemia
• Empyema
• Death

f) What is Barrett’s esophagus and Achalasia.

5) Anatomy 2: Mediastinum & Esophagus

a) What are the boundaries of posterior mediastinum?

b) What structures run in it (name 6) - show me on the model if possible

c) What is the standard length and surface markings of the esophagus?

• 25cm
• The esophagus is subdivided into three anatomical segments: cervical, thoracic, and
abdominal.
 • The cervical segment begins at the cricopharyngeus and terminates at the suprasternal
notch.
• The thoracic segment lies between the vertebral column and the trachea in the
superior mediastinum, extending from the suprasternal notch to the diaphragm.
• The final segment, the abdominal segment, runs from the diaphragm to the fundus of
the stomach.

d) Where does it exit the thoracic cavity?

• At the T10 level from right crus of diaphragm

e) What is the blood supply of the esophagus?

f) What is the lymphatic drainage of the esophagus?

g) What is important about the venous drainage of the esophagus?

• Portosystemic anastomosis at lower esophagus between left gastric and azygous

h) What is Barrett’s esophagus?

i) What is achalasia?

6) Posterior mediastinum

a) Landmarks

b) Blood supply, lymphatic drainage of esophagus

c) Diaphragm - openings, levels

7) Posterior Mediastinum, Heart, Spleen

8) ANATOMY- Picture provided no prosections

a) Upper thorax- Aortic arch and branches

b) Vagus nerve and type of supply
• Sensory: Innervates the skin of the external acoustic meatus and the internal surfaces
of the laryngopharynx and larynx. Provides visceral sensation to the heart and
abdominal viscera.
• Special Sensory: Provides taste sensation to the epiglottis and root of the tongue.
• Motor: Provides motor innervation to the majority of the muscles of the pharynx, soft
palate and larynx.
• Parasympathetic: Innervates the smooth muscle of the trachea, bronchi and gastro-
intestinal tract and regulates heart rhythm.
COURSE:
• In the Head: the vagus nerve originates from the medulla of the brainstem
o It exits the cranium via the jugular foramen, with the glossopharyngeal (IX)
and accessory (XI) nerves
o Within the cranium, the auricular branch arises- this supplies sensation to the
posterior part of the external auditory canal and external ear.

• In the Neck: the vagus nerve passes into the carotid sheath, travelling inferiorly with
the internal jugular vein and common carotid artery.
o At the base of the neck, the right and left nerves have differing pathways:
▪ RIGHT vagus nerve passes anterior to the subclavian artery and
posterior to the sternoclavicular joint, entering the thorax.
▪ LEFT vagus nerve passes inferiorly between the left common carotid
and left subclavian arteries, posterior to the sternoclavicular joint,
entering the thorax.
o Several branches arise in the neck:
▪ Pharyngeal branches – Provides motor innervation to the majority of
the muscles of the pharynx and soft palate.
▪ Superior laryngeal nerve – Splits into internal and external branches.
The external laryngeal nerve innervates the cricothyroid muscle of the
larynx. The internal laryngeal provides sensory innervation to the
laryngopharynx and superior part of the larynx.
▪ Right recurrent laryngeal nerve – Hooks underneath the right
subclavian artery, then ascends towards to the larynx. It innervates the
majority of the intrinsic muscles of the larynx.

• In the Thorax: the right vagus nerve forms the posterior vagal trunk, and the left
vagus forms the anterior vagal trunk. Branches from the vagal trunks contribute to the
formation of the esophageal plexus, which innervates the smooth muscle of the
esophagus.
o Two other branches arise in the thorax:
▪ Left recurrent laryngeal nerve – hooks under the arch of the aorta,
ascending to innervate the majority of the intrinsic muscles of the
larynx.
▪ Cardiac branches – regulate heart rate and provide visceral sensation to
the heart

• The vagal trunks enter the abdomen via the esophageal hiatus, an opening in the
diaphragm.

• In the Abdomen: the vagal trunks terminate by dividing into branches that supply the
esophagus, stomach and the small and large bowel (up to the splenic flexure).

c) Thyroid gland and blood supply.

• Located in the anterior neck and spans the C5-T1 vertebrae.
• Consists of two lobes (left and right), which are connected by a central isthmus
anteriorly – this produces a butterfly-shape appearance.
• Lobes of the thyroid gland are wrapped around the cricoid cartilage and superior rings
of the trachea.
 • Gland is located within the visceral compartment of the neck (along with the trachea,
Esophagus and pharynx)
o This compartment is bound by the pre-tracheal fascia.

Superior Thyroid First branch of ECA Lies in close

Artery proximity to the
external branch of the
superior laryngeal
nerve (innervates the
larynx)
Arterial Supply
Inferior Thyroid Artery From Thyrocervical Lies in close
Trunk > Subclavian proximity to the
Artery recurrent laryngeal
nerve (innervates the
larynx)
Thyroid Ima Artery From Brachiocephalic Supplies the anterior
(10%) Trunk surface and isthmus of
the thyroid gland
Venous Drainage Superior Thyroid Vein Drain into IJV
(all 3 form a Middle Thyroid Vein
venous plexus Inferior Thyroid Vein Drains into Brachiocephalic Vein
around the gland)

d) Supply of recurrent laryngeal nerve

• Supplies innervation to all of the intrinsic muscles of the larynx, except for the
cricothyroid muscles, as well as sensation to the larynx below the level of the vocal
cords

COURSE:
• Recurrent laryngeal nerve [RLN]: the RLN is also a branch of the vagus nerve.
• Left RLN is found inferior to the aortic arch and posterior to ligamentum arteriosum
• The right vagus continues posteriorly to the root of the right lung giving off the right
RLN which loops around the right subclavian artery.
• The recurrent laryngeal nerves then continue superiorly bilaterally and pass posterior
to the lobe of the thyroid gland as they travel along the lateral surfaces of the trachea
and esophagus in the tracheoesophageal groove.
• The nerves pass posterior to the cricothyroid joint as they enter the larynx at this level
through fibers of the inferior constrictor muscles of the pharynx.
• At this point, the RLN becomes the inferior laryngeal nerve.

e) Describe Erb's palsy and Klumpke's palsy.

• Erb's paralysis: Damage to the upper nerve roots (C5, C6)
o Motor affection: (waiter’s tip deformity)
o Paralysis of arm abductors (supraspinatus + deltoid) → arm adduction
o Paralysis of arm external rotators (infraspinatus +teres minor) → arm internal
rotation
o Paralysis of forearm flexors and supinators (biceps, brachialis, brachioradialis)
→ forearm extension and pronation
 o Sensory affection: loss of sensation of radial side of arm and forearm
• Klumpke’s paralysis: Injury to lower trunk (C8, T1)
o Motor affection: (claw hand deformity)
o Paralysis of all intrinsic muscles of the hand
o Paralysis of wrist flexors (except flexor carpi radialis)
o Hyperextension of MCP joints with flexion of IP joints
o Sensory affection: loss of sensation over ulnar border of forearm and hand
 UPPER LIMB- Brachial Plexus, Shoulder

1) Shoulder anatomy

a) piece the clavicle scapula and humerus

b) what’s the surgical and anatomical neck
c) parts of the scapula
d) greater and lesser tuberosity

e) range of motion of shoulder joint

• Flexion: 90 degrees
• Extension: 45 degrees
• Abduction: 180 degrees
• Adduction: 45
• Lateral Rotation: 45 degrees
• Medial Rotation: 55 degrees
f) factors affecting stability of a shoulder joint
• The shoulder girdle is composed of the clavicle and the scapula, which articulates
with the proximal humerus of the upper limb.
• Four joints are present in the shoulder:
o A) sternoclavicular (SC): synovial saddle joint and is the only joint that
connects the upper limb to the axial skeleton.
▪ It connects the clavicle to the manubrium of the sternum and gets
stabilization from the costoclavicular ligament.
o B) acromioclavicular (AC): plane synovial joint that connects the acromion of
the scapula to the clavicle.
▪ It receives stabilization primarily from the coracoclavicular ligament,
and secondary stabilizers are super and inferior acromioclavicular
ligaments.
o C) scapulothoracic joints: not a true joint, but rather the articulation of the
scapula gliding over the posterior thoracic cage.
o D) glenohumeral joint: highly moveable ball-and-socket synovial joint that is
stabilized by the rotator cuff muscles that attach to the joint capsule, as well as
the tendons of the biceps and triceps brachii.

g) what does shoulder joint need to do to complete abduction? internally rotate

h) muscle that stabilizes shoulder joint

• Rotator cuff muscles
i) identify supraspinatus infraspinatus teres minor and subscapularis. What’s the nerve
supply?

Supraspinatus (Rotator • Function: Initiation of arm abduction (first 15 degrees),

Cuff) stabilize glenohumeral joint
• Origin: Posterior scapula, superior to the scapular
spine/supraspinous fossa
• Insertion: Top of the greater tubercle of the humerus
• Innervation: Suprascapular nerve (C5, C6)

Infraspinatus (Rotator • Function: Lateral rotation of the arm, stabilize

Cuff) glenohumeral joint
• Origin: Posterior scapula, inferior to the scapular
spine/Infraspinous fossa
• Insertion: Greater tubercle of the humerus, between the
supraspinatus and teres minor insertion
• Innervation: Suprascapular nerve (C5, C6)

Teres minor (Rotator • Function: Lateral rotation of the arm, stabilize

Cuff) glenohumeral joint
• Origin: Inferior angle of the scapula
• Insertion: Inferior aspect of the greater tubercle
• Innervation: Axillary nerve (C5, C6)

Subscapularis (Rotator • Function: Adduction and medial rotation of the arm,

Cuff) stabilize glenohumeral joint
• Origin: Anterior aspect of the scapula
• Insertion: Lesser tubercle of the humerus
• Innervation: Subscapular nerves (C5, C6, C7)
j) identify functional parts of the Pectoralis major
• Function:
o Clavicular head flexes and adducts arm
o Sternal head adducts and medially rotates the arm
o Accessory for inspiration
• Origin:
o Clavicular head: medial half clavicle
o Sternocostal head: Lateral manubrium and sternum, six upper costal cartilages
and external oblique aponeurosis (abdominal head in picture below?)
 • Insertion: Intertubercular groove of the proximal humerus on its lateral aspect
• Innervation: Medial and lateral pectoral nerves (C6, C7, C8)

k) nerve root supply of pec major

l) actions of deltoid
 • Function:
o Anterior aspect is responsible for flexion and medial rotation of the arm
o Middle aspect is responsible for the abduction of the arm (up to 90 degrees)
o The posterior aspect is responsible for extension and lateral rotation of the arm
• Origin: Lateral clavicle, acromion and scapular spine
• Insertion: Deltoid tuberosity
• Innervation: Axillary nerve (C5, C6)

m) axillary nerve damage, what’s the consequence

• Inability to abduct shoulder over 15 degrees
• Loss of sensation over the badge area

n) where does the brachial plexus run?

• posterior triangle of neck
• passes between scalene anterior and medius

2) Brachial plexus and Shoulder anatomy- Articulate the clavicle and humerus.

a) MRI shoulder photos

b) What is this?
• LEFT clavicle
c) What is this?
• Scapula

d) What is this?
• Humerus

e) Scapula- Where is infraspinatus fossa; Where is supraspinatus fossa; Scapula

anatomy Attachments of muscles

f) Where does the subscapularis go

• Origin: Subscapular fossa of scapula
• Insertion: Lesser tubercle of humerus
g) Where is the acromion

h) Where is the corocoid process

i) Where is the glenoid fossa

j) How does any joint retain stability

 • As a general rule, the more ligaments a joint has, and the tighter they are, the more
stable the joint is!

k) How about specific about the shoulder joint?

• The tone of the surrounding muscles contributes greatly to the stability of a joint.
• A good example of this is the support provided by the rotator cuff muscles, which
keep the head of the humerus in the shallow glenoid cavity of the scapula.
• If there is a loss of tone, such as in old age or stroke, the shoulder can dislocate.

• Stability:
o Rotator cuff muscles – surround the shoulder joint, attaching to the
tuberosities of the humerus, whilst also fusing with the joint capsule. The
resting tone of these muscles act to compress the humeral head into the
glenoid cavity.
o Glenoid labrum – a fibrocartilaginous ridge surrounding the glenoid cavity. It
deepens the cavity and creates a seal with the head of humerus, reducing the
risk of dislocation.
o Ligaments – act to reinforce the joint capsule and form the coracoacromial
arch.
o Biceps tendon – it acts as a minor humeral head depressor, thereby
contributing to stability.

l) What muscles make up the rotator cuff?

m) Where do they attach on the humerus?

n) Where is the greater and lesser tuberosity

3) 2 upper limb shoulder girdle all bones involved: clavicle, humerus, scapula

a) Prosection: chest wall, shoulder girdle

b) MRI shoulder

c) identify this bone (clavicle). Which side is it from? Name the parts of the clavicle
d) identify this bone (scapula). Which side is it from? Name the parts of the scapula

e) identify this bone (humerus). Which side is it from? Name the parts of the superior
aspect of the bone. Where is the surgical neck? Where is the anatomical neck?

f) please articulate the scapula and humerus

• Scapula has two main articulations:
o Glenohumeral joint – between the glenoid fossa of the scapula and the head of
the humerus.
▪ ball and socket-type synovial joint
▪ extension, flexion, abduction, adduction, internal rotation, external
rotation, circumduction
o Acromioclavicular joint – between the acromion of the scapula and the
clavicle.
▪ plane type synovial joint, which under normal physiological conditions
allows only gliding movement.
▪ As it attaches the scapula to the thorax, it allows an additional range of
motion to the scapula and assists in arm movement such as shoulder
abduction and flexion.
g) please articulate the clavicle and scapula

h) what movements take place at the shoulder joint? Show me using the scapula and
humerus.

i) what contributes to the stability of the shoulder joint?

• Rotator cuff muscles, glenoid labrum, ligaments, biceps tendon

j) of these, which is the most important?

• Rotator cuff

k) what are the components of the rotator cuff?

l) identify these muscles please (points to supraspinatus, infraspinatus, teres minor,

subscapularis). What innervates them?

m) identify this muscle (pec major). What innervates it?

n) what is this structure?

• Cephalic vein in arm piercing clavipectoral (deltopectoral) fascia
o) what is this structure? (Long head of biceps). From where does it originate? What
attaches to the humerus medially and laterally to it?
• Origin:
o Short head - Apex of the Coracoid process of the scapula
o Long head - Supraglenoid tubercle of the scapula
 o Mnemonic: 'You walk Shorter to a street Corner. You ride Longer on a
Superhighway.'
• Insertion:
o Radial tuberosity of radius and forearm fascia (as bicipital aponeurosis)
• Nerve Supply: Musculocutaneous nerve (C5- C6)

• Medial Relation: Coracobrachialis

• Lateral Relation: Brachialis

p) what are these structures? (Long and lateral head of triceps). What innervates them?
• Origin:
o Long head – infra-glenoid tubercle of the scapula
o Medial head - posterior surface of the humerus (inferior to radial groove)
o Lateral head - posterior surface of the humerus (superior to radial groove)
• Insertion: Olecranon of ulna and fascia of forearm
• Innervation: Radial nerve (C6-C8)
q) what passes through this space? (Quadrangular space)
• Axillary Nerve
• Posterior Circumflex Humeral Artery & Vein
r) what does the axillary nerve supply?
• Teres Minor
• Deltoid

s) identify the structures you see on the MRI of the shoulder

4) Upper limb

a) 1st Rib, point out sup/inf/latera/medial surfaces

 • First rib: is the widest, shortest and has the sharpest curve of all the ribs. The head
only articulates with the body of the T1 vertebra and therefore only one articulatory
surface is present.
• Each rib articulates posteriorly with two thoracic vertebrae; by the costovertebral
joint.
• An exception to this rule is that the first rib articulates with the first thoracic vertebra
only.

b) How does it articulate with sternum and acromion (I think this is asking about clavicle)
• Sternal (medial) End:
o The sternal end contains a large facet – for articulation with the manubrium of
the sternum at the sternoclavicular joint.
 o The inferior surface of the sternal end is marked by a rough oval depression
for the costoclavicular ligament (a ligament of the SC joint).
• Acromial (lateral) End:
o The acromial end houses a small facet for articulation with the acromion of the
scapula at the acromioclavicular joint. It also serves as an attachment point for
two ligaments:
▪ Conoid tubercle – attachment point of the conoid ligament, the medial
part of the coracoclavicular ligament.
▪ Trapezoid line – attachment point of the trapezoid ligament, the lateral
part of the coracoclavicular ligament.

c) Give you scapula, demonstrate how it articulates

d) Point out important parts of scapula: Supraspinatus fossa, ISP fossa

e) Give you humerus, show how it articulates, point out greater/lesser troch, surgical
neck, bicipital groove

f) Show me all how the joint moves (demonstrating with the bones) during abduction

g) Rotator cuff muscles and innervation

h) Pectoralis major and innervation

i) What is the other important function of Pec Major?

• Respiratory muscle

j) Point out axillary nerve

k) Serratus Anterior – 9 or 10 slips from 1st to 8th ribs attached to medial border of scapula
• Origin:
o Superior part: Ribs 1-2, Intercostal fascia
o Middle part: Ribs-3-6
o Inferior part: Ribs 7-8/9 (variably extends to rib 10 (+ external oblique
muscle))
• Insertion: Scapula
o Superior part: Anterior surface of superior angle
o Middle part: Anterior surface of medial border
o Inferior part: Anterior surface of inferior angle and medial border
• Innervation: Long thoracic nerve (C5- C7)
 o Mnemonics: 'SALT' (stands for serratus anterior - long thoracic) & 'C5, 6, 7
raise your arms to heaven!'

l) Nerve involved: Bell’s Nerve (?)

m) Trapezius –external occipital protuberance, superior nuchal line, spinous process of C7,
then spinous process of all thoracic vertebrae) inserts on lateral 3rd of clavicle, medial
acromion, as an aponeurosis over spine of scapula; Innervation CN XI
• Origin:
 o Descending part (superior fibers): medial third of the superior nuchal line,
external occipital protuberance, nuchal ligament
o Transverse part (middle fibers): spinous processes and supraspinous ligaments
of vertebrae T1-T4 (or C7-T3)
o Ascending part (inferior fibers): spinous processes and supraspinous ligaments
of vertebrae T4-T12
• Insertion:
o Descending part (superior fibers): lateral third of clavicle
o Transverse part (middle fibers): medial acromial margin, superior crest of
spine of scapula
o Ascending part (inferior fibers): lateral apex of the medial end of scapular
spine
• Innervation:
o Motor: accessory nerve (CN XI)
o Motor/Sensory: anterior rami of spinal nerves C3-C4 (via cervical plexus)

n) Brachial plexus
o) What is the motor loss when patient has lesion of the upper trunk?
• Erb’s palsy (C5, C6)

p) if lower roots are affected, what is it called?

• Klumpke palsy (C8, T1)

q) what would be the motor and sensory deficits?

• Erb’s Palsy:
o Motor affection: (waiter’s tip deformity)
▪ Paralysis of arm abductors (supraspinatus + deltoid) → arm adduction
▪ Paralysis of arm external rotators (infraspinatus +teres minor) → arm
internal rotation
▪ Paralysis of forearm flexors and supinators (biceps, brachialis,
brachioradialis) → forearm extension and pronation
o Sensory affection: loss of sensation of radial side of arm and forearm
 • Klumpke’s Palsy:
o Motor affection: (claw hand deformity)
▪ Paralysis of all intrinsic muscles of the hand
▪ Paralysis of wrist flexors (except flexor carpi radialis)
▪ Hyperextension of MCP joints with flexion of IP joints
o Sensory affection: loss of sensation over ulnar border of forearm and hand

r) Points and asked to identify superior trunk of brachial plexus. What roots do these
originate from?
• Superior: C5, C6
• Middle: C7
• Inferior: C8, T1

5) Rotator cuff origin and attachments

a) Medial epicondyle of humerus

b) MRI of shoulder asked where head of humerus is; deltoid; glenoid; long heads of triceps
and biceps.

c) What nerve is damaged surgical humeral neck fractures.

• Axillary Nerve

d) Movements of humerus
 • Glenohumeral joint – between the glenoid fossa of the scapula and the head of the
humerus.
o ball and socket-type synovial joint
o extension, flexion, abduction, adduction, internal rotation, external rotation,
circumduction
• Humeroulnar joint is formed between the humerus and ulna
o hinge type synovial joint
o allows flexion and extension of the arm.
• Humeroradial joint is formed between the radius and humerus
o hinge type synovial joint
o allows movements like flexion, extension, supination, and pronation

e) Identify Pectoralis major on picture, origin + functions and nerve supply

6) Point out the acromion and coracoid process

a) What are rotator cuff muscles and origins and attachments

b) Point out spiral groove. What nerve runs in it?

• Radial Nerve

c) Point out medial epicondyle. What nerve. What are the cutaneous deficits of radial
and Ulnar nerve.
• Ulnar Nerve at Medial Epicondyle
o Ulnar nerve- passes posterior to the elbow through the ulnar tunnel (small
space between the medial epicondyle and olecranon).
 o Ulnar Nerve Cutaneous Sensation: hypothenar area; dorsum of the skin of the
medial hand, medial half of the fourth digit, and fifth digit.
• Radial Nerve:
o Sensory – Innervates most of the skin of the posterior forearm, the lateral
aspect of the dorsum of the hand, and the dorsal surface of the lateral three and
a half digits.
o Motor – Innervates the triceps brachii and the extensor muscles in the forearm.

d) Why is grip strength weaker if radial nerve is affected. (You can’t grip things if you
can’t extend the wrist)
• Radial nerve Injury: Wrist Drop
• Following a radial nerve injury, the extrinsic extensor function of the hand and wrist
is lost.
• This results in an inability to extend the fingers and wrist and affects grip strength and
finger flexion and has a large influence on thumb usage.

7) Brachial plexus

a) Roots, trunks, divisions and cords

b) What happens C5-C6 injured

c) Shoulder, nerves of upper limb

8) Anatomy of the upper limb

a) Answer questions on surface anatomy and movements on a model patient

b) Identify nerves, vessels and muscles on a pro-section

c) Be sure to know the dermatomes

9) Anatomy – Skeleton RC anatomy including origin/insertion and innervation

a) Shoulder joint – Show bony landmarks, Rotator cuff, which muscles, origin &
insertion.

b) Osteology of humerus, clavicle &scapula- asked to identify parts of the bone whether
clavicle was right or left. superior and inferior surface. And to articulate clavicle and
scapula.

c) What nerve is damaged surgical humeral neck fractures.

d) Movements of humerus

e) Identify deltoid and its movements and its parts.

• Function:
o Anterior aspect is responsible for flexion and medial rotation of the arm
o Middle aspect is responsible for the abduction of the arm (up to 90 degrees)
o The posterior aspect is responsible for extension and lateral rotation of the arm
• Origin: Lateral clavicle, acromion and scapular spine
• Insertion: Deltoid tuberosity
 • Innervation: Axillary nerve (C5, C6)

f) Identify Pectoralis major on picture + functions and nerve supply

10) Theme: Upper limb Anatomy- No processions. Only ATLAS pictures from Netter.

a) Asked for Shoulder joint.

b) Asked to pick scapula clavicle humerus make joint

c) Show where are rotator cuff muscle on picture and nerve supply

d) Showed an MRI of shoulder asked where head of humerus and deltoid and glenoid,
long heads of triceps and biceps is. (The picture is same which is in a book I don’t know
where I saw it).
11) Qn 17: Anatomy Upper limb

a) Name the bones (clavicle, humerus and scapula) and asked for parts as pointed

b) Which side to they belong

c) Articular humerus with scapula

d) Elicit movements of shoulder joint on bones

e) Articulate clavicle with scapula

f) Factors responsible for joint stability

g) Rotator cuff and nerve supply

h) Pec major origin and insertion and nerve supply

i) Function of pec major

12) Anatomy: shoulder girdle anatomy

a) rotator cuff muscles, innervation, action.

b) Deltoid muscle: function, nerve innervation.

c) MRI coronal plane of shoulder and identify parts (repeat)

d) pectoralis major and parts

13) Anatomy- brachial plexus

a) What are the nerve roots of the brachial plexus?

• C5-T1

b) Which nerve roots would account for an upper trunk injury? (C5, C6)

c) lustrate on this person (live patient sat on couch)

• Upper Lesion: Erb's Palsy (C5,6)
o Physical Exam: Clinically, the arm will be adducted, internally rotated, at
shoulder; pronated, extended at elbow (“waiter’s tip”)

d) what sensory deficit this patient would have on account of an upper trunk injury?
• Erbs Palsy:
o Deformity: Arm: Hangs by the side, adducted and medially rotated
▪ Forearm: Extended and pronated
▪ The deformity is known as "Policeman's tip hand" or "Porter's tip
hand".
o Disability: Abduction and lateral rotation of the arm (shoulder)
▪ Flexion and supination of forearm.
▪ Biceps and supinator jerks are lost.
o Sensations are lost over a small area over the lower part of the deltoid.

e) illustrate on this patient the sensory deficit you would expect if the musculocutaneous
nerve was injured?
• Most significant is entrapment of the musculocutaneous nerve within the
coracobrachialis muscle, leading to biceps brachii and brachialis weakness and
atrophy with accompanying loss of sensation in the lateral forearm.

f) Which muscles are innervated by the musculocutaneous nerve?

• coracobrachialis, biceps brachii, and brachialis muscles
g) Point to the live person's coracoid process (surface anatomy)?
• coracoid process is palpable just below the lateral end of the clavicle (collar bone). It
is otherwise known as the "Surgeon's Lighthouse" because it serves as a landmark to
avoid neurovascular damage.

h) Which three muscles attach to the coracoid process?

• Pectoralis minor
• Coracobrachialis
• short head of biceps brachii

i) Test the function of the deltoid on this patient? (basically test shoulder abduction on
the live person).
• All heads of the deltoid work together to produce abduction of the Shoulder Joint. It
helps lift the arm front, side, and backward.

j) Examiner then took me to a skeleton and asked the following: show me where the
spinal nerves come out from?
• There are 31 bilateral pairs of spinal nerves, named from the vertebra they correspond
to.
• For the most part, the spinal nerves exit the vertebral canal through the intervertebral
foramen below their corresponding vertebra.
• Therefore, there are 12 pairs of thoracic spinal nerves, 5 pairs of lumbar spinal nerves,
5 pairs of sacral spinal nerves, and a coccygeal nerve.

k) What about C8 spinal nerve?

• The cervical spinal nerves differ from this pattern.
• C1-C7 spinal nerves emerge from the vertebral canal above the corresponding
vertebra, with an eighth pair of cervical spinal nerves emerging below the C7
vertebra, meaning there are a total of 8 pairs of cervical spinal nerves while there are
only 7 cervical vertebrae.
 • The sacrum differs from the rest of the vertebral column in that its individual
vertebrae are fused together, thus there are no intervertebral foramina. The spinal
nerves instead pass through the sacral foramina.

l) Which muscles are responsible for shoulder abduction beyond 90 degrees? (answer
here is serratus anterior and trapezius)

m) point on the skeleton their origins and attachments?

• Trapezius: Accessory nerve (CN XI); Anterior rami of the spinal nerves C3 and C4
o consists of three parts:

Part Origin Insertion:

Descending part Superior nuchal line; Lateral third of the clavicle
External occipital
protuberance
Transverse part Spinous processes of the Acromion of the scapula;
vertebra T1-T4 (or C7 to T3) Spine of the scapula
Ascending part Spinous processes of the Medial part of the spine of
thoracic vertebrae T4-T12 the scapula

• Serratus Anterior:
o Origin: Anterior surfaces of the first 8 or 9 ribs.
o Insertion: Anterior surface of medial border of scapula.
o Innervation: Long thoracic nerve (C5-C7).

14) Anatomy- shoulder

a) Erb's Palsy- nerve root C5/C6

b) which dermatome affected in Erb's Palsy

c) Supraspinatus origin and insertion

• Origin: Posterior scapula, superior to the scapular spine/supraspinous fossa
• Insertion: Top of the greater tubercle of the humerus

d) Muscles that rotate the scapula

• Upward rotation: trapezius and serratus anterior muscles.
• Downward rotation is accomplished by the force of gravity as well as:
o latissimus dorsi
o levator scapulae
o rhomboids
o Pectoralis major and minor

e) Skin affected by axillary nerve damage

f) Attachments to coracoid process

g) Nerve supply to biceps

• Musculocutaneous Nerve
h) Other muscles supplied by musculocutaneous nerve

15) Upper limb

a) C5, C6 roots come from where — show in skeleton

b) Initiator of shoulder abduction

• Supraspinatus

c) Demonstrate checking power of shoulder abductors and elbow flexors

• The first 0-15 degrees of abduction is produced by the supraspinatus.
• The middle fibers of the deltoid are responsible for the next 15-90 degrees.
• Past 90 degrees, the scapula needs to be rotated to achieve abduction – that is carried
out by the trapezius and serratus anterior

• biceps brachii, brachialis, and brachioradialis are the primary elbow flexors.

o Brachialis is an elbow flexor that originates from the distal anterior humerus
and inserts onto the ulnar tuberosity.
o The brachialis is one of the largest elbow flexors and provides pure flexion of
the forearm at the elbow.
d) Nerve supply of deltoid

e) Sensory supply of axillary nerve, radial nerve

• Radial Nerve:
o Sensory – Innervates most of the skin of the posterior forearm, the lateral
aspect of the dorsum of the hand, and the dorsal surface of the lateral three and
a half digits.
o Motor – Innervates the triceps brachii and the extensor muscles in the forearm.

f) Muscles supplied by and sensory distribution of musculocutaneous nerve

g) Action of brachioradialis
• Brachioradialis: flexion and supination of the forearm.

h) Demonstrate reflex supplied by C5, C6

i) Muscles required for overhead abduction — serratus anterior, trapezius

j) Origin of serratus anterior, its nerve supply

k) Show coracoid on patient

l) Muscle attachments to coracoid

m) Name elbow flexors

• biceps brachii, brachialis, and brachioradialis are the primary elbow flexors.

n) Which nerves will be damaged with excessive stretching of neck to one side — Upper
trunk — C5, C6

16) upper limb

a) traction injury between head and shoulder in road traffic accident- which injury are
you suspecting?
• Upper Brachial Plexus Injury
• Traction, also known as stretch injury, is one of the mechanisms that cause brachial
plexus injury. The nerves of the brachial plexus are damaged due to the forced pull by
the widening of the shoulder and neck.

• Upper brachial plexus injuries occur when the head and neck are violently moved
away from the ipsilateral shoulder. The shoulder is forced downward whereas the
head is forced to the opposite side. The result is a stretch, avulsion, or rupture of the
upper roots (C5, C6, C7), with preservation of the lower roots (C8, T1).
b) root value of upper trunk of brachial plexus

c) show on skeleton where the nerves exit from

d) muscles of abduction

e) show origin and insertion of these muscles with nerve supply

f) show on actor how to test power of shoulder abduction, elbow flexion

g) show the jerks of these root values

h) muscles supplied by musculocutaneous nerve

i) show sensory distribution of musculocutaneous nerve and radial nerve

j) show sensory distribution of axillary nerve

k) function of brachioradialis and nerve supply

• Brachioradialis reflex: flexion and supination of the forearm.
o Brachioradialis is innervated by the radial nerve (from the root values C5-C6)
that stems from the posterior cord of the brachial plexus.

17) Shoulder girdle

a) Bones: clavicle, humerus, scapula

b) Prosection: chest wall, shoulder girdle

c) MRI shoulder

d) identify this bone (clavicle). Which side is it from? Name the parts of the clavicle

e) identify this bone (scapula). Which side is it from? Name the parts of the scapula

f) identify this bone (humerus). Which side is it from? Name the parts of the superior
aspect of the bone.

g) Where is the surgical neck? W here is the anatomical neck?

h) please articulate the scapula and humerus

i) please articulate the clavicle and scapula

j) what movements take place at the shoulder joint? Show me using the scapula and
humerus.

k) what contributes to the stability of the shoulder joint?

l) of these, which is the most important? (Rotator cuff)

m) what are the components of the rotator cuff?

n) identify these muscles please (points to supraspinatus, infraspinatus, teres minor,

subscapularis). What innervates them?

o) identify this muscle (pec major). What innervates it?

p) what is this structure? (Cephalic vein in arm piercing clavipectoral fascia)

q) what is this structure? (Long head of biceps). From where does it originate? What
attaches to the humerus medially and laterally to it?

r) what are these structures? (Long and lateral head of triceps). What innervates them?

s) what passes through this space? (Quadrangular space)

t) what does the axillary nerve supply?

u) identify the structures you see on the MRI of the shoulder

18) Anatomy: Shoulder

a) piece the clavicle scapula and humerus

b) what’s the surgical and anatomical neck

c) parts of the scapula

d) greater and lesser tuberosity

e) range of motion of shoulder joint

f) factors affecting stability of a shoulder joint

g) what does shoulder joint need to do to complete abduction? (internally rotate)

h) muscle that stabilizes shoulder joint

i) identify supraspinatus infraspinatus teres minor and subscapularis. what’s the nerve
supply

j) identify functional parts of the pec major

k) nerve root supply of pectoralis major

l) actions of deltoid

m) axillary nerve damage, what’s the consequence

n) where does the brachial plexus run? (posterior triangle of neck)

o) MRI shoulder photos

19) ANATOMY STATION- Anatomy of rotator cuff with nerve supply

a) pec major nerve supply

b) attachment of humerus + clavicle + scapula.

c) MRI of the area.

d) Identify supraspinatus, teres minor, subscapularis, deltoid

e) bones of glenohumeral joint labrum on MRI

• The glenohumeral articulation involves the humeral head with the glenoid cavity of
the scapula, and it represents the major articulation of the shoulder girdle.
f) Identify cadaver bones clavicle scapula humerus and their side and how they
articulate together

g) Identify parts of humerus and medial and lateral ends of the clavicle and all the parts
of the scapula

h) Common nerve to be damaged in shoulder dislocation and its effects

• Anterior shoulder dislocation is the most common occurring dislocation at the
shoulder which can cause direct trauma (compression or traction) to the axillary
nerve.
• In patients presenting after dislocation or fracture, signs of trauma will be evident on
physical exam.
o During external rotation and abduction, one may note the weakness of the
deltoid and teres minor muscles.

i) All the movements of shoulder demonstrate

j) Identify pec major it’s innervation and its 2 muscle components and their separate
functions.
• Innervation: Lateral and medial pectoral nerves (C5-T1)
• The pectoralis major muscle is a fan-shaped muscle that consists of three parts that
originate from three different sites:
o The clavicular part originates from the anterior surface of the medial half of
the clavicle.
▪ clavicular part helps to flex the extended arm up to 90°
 o The sternocostal part originates from the anterior surface of sternum and the
anterior aspects of the costal cartilages of ribs 1-6.
▪ sternocostal part facilitates the extension of the flexed arm by pulling it
downwards.
o The smallest, abdominal part originates from the anterior layer of the rectus
sheath.

k) One special function of Pec Major other than movement of shoulder

• Function: Flexion, adduction, and medial rotation of the arm at the glenohumeral
joint; clavicular head causes flexion of the extended arm; sternoclavicular head causes
extension of the flexed arm

l) Components of stability of the shoulder

m) Nerve supply of all the rotator cuffs and their innervations

n) Function of deltoid muscle separately

20) Qn 17: Anatomy Upper limb

a) Name the bones (clavicle, humerus and scapula) and asked for parts as pointed

b) Which side to they belong

c) Articular humerus with scapula

d) Elicit movements of shoulder joint on bones

e) Articulate clavicle with scapula

f) Factors responsible for joint stability

g) Rotator cuff and nerve supply

h) Pec major origin and insertion and nerve supply

i) Function of pec major

21) Anatomy (all candidates had an issue with that station): Shoulder anatomy, scapula
and Clavicle

a) side

b) articulate

c) shoulder girdle, what gives stability?

d) muscles, ligaments, capsule (forgot), labrum and negative pressure within the joint
e) what are the muscles? rotator cuff? name them?

f) point them on plastic dissection, action of each and nerve supply

g) action of teres major and point to muscle? bell rang!

h) others were asked more questions on muscles detailed actions, nerve supply to
different heads and MRI image

22) Shoulder- Given scapula, clavicle, humerus

a) Identify some structures on these

b) Rotator cuff structure identification

c) Nerve supply

d) Given an MRI of the shoulder joint- asked to identify muscles

23) Brachial plexus injury

Stem: RTA with shoulder weakness and upper limb deformity
Anatomy of RC and testing of UL power
Discussion of site of lesion and deficits (to demonstrate dermatomes)

24) Anatomy:

a) Identify Thyroid on prosection image (Blood supply and venous drainage, nerves at risk
during thyroidectomy)

b) muscles supplied by recurrent laryngeal.

c) Identify aortic arch and branches on prosection.

d) Identify this nerve (I think it was the Vagus, image was not great),

e) Identify the recurrent laryngeal.

f) Identify this (it was part of the brachial plexus, I guessed at posterior cord)

g) what are it's nerve roots?

h) Motorcyclist suffers forced depression of shoulder, what nerve palsy may occur (Erb's)

i) what deformity? (waiters tip)

j) was asked to describe the joint positions in the waiter's tip deformity
25) Anatomy of shoulder with rotator muscle groups and scapula/clavicle/ humerus
detailing’s

26) UL (upper limb)

a) Name rotator cuff muscles

b) what nerve innervates deltoid

c) demonstrate abduction

d) explain supraspinatus/deltoid action in abduction

e) what nerve innervates brachioradialis

f) what is the action of brachioradialis

g) what nerve innervates biceps and brachialis

h) where does this nerve supply for sensation

i) point out the coracoid process on the SP

j) point out rotator cuff muscles origins and attachments

k) lower limb- where does the quadratus femoris originate and attach

l) where do the gluteal muscles originate and attach

m) what is the name of the condition where the nerve running under inguinal ligament is
compressed

n) point out groove where radial nerve runs on the skeleton

o) demonstrate what would happen to thenar movements if ulnar nerve is affected

p) why do patients complain of weak grip if their radial nerve is affected

27) Anatomy- Upper limb- Skeleton provided

a) What nerve supplies deltoid?

• The axillary nerve supplies two muscles in the arm:
o deltoid (a muscle of the shoulder)
o teres minor (one of the rotator cuff muscles).

b) Sensory deficit if nerve palsy?

 • numbness to the lateral shoulder region, atrophy of the deltoid and teres minor
muscles

c) What nerve supplies biceps?

• Musculocutaneous nerve (root C5, C6)

d) Area of sensation supplied by this nerve

• Most significant is entrapment of the musculocutaneous nerve within the
coracobrachialis muscle, leading to biceps brachii and brachialis weakness and
atrophy with accompanying loss of sensation in the lateral forearm.

e) Other muscles supplied by musculocutaneous nerve

• musculocutaneous nerve innervates the three muscles of the anterior compartment of
the arm: the coracobrachialis, biceps brachii, and brachialis muscles.

f) Radial nerve - sensory distribution

g) Function of pectoralis major?

• Adduction, or depression, of the arm (in opposition to the action of the deltoideus
muscle) and rotation of the arm forward about the axis of the body

h) Demonstrate biceps and brachioradialis reflex on specimen

• Brachioradialis reflex: flexion and supination of the forearm.
o Brachioradialis is innervated by the radial nerve (from the root values C5-C6)
that stems from the posterior cord of the brachial plexus.
• Biceps reflex: flexion of the forearm. You will feel the biceps tendon contract if the
biceps reflex is stimulated by the tap on the brachioradialis tendon.
o Innervated by the musculocutaneous nerve, which is innervated by C5, C6 and
C7 nerve roots.

i) What myotomes? (for biceps and brachioradialis?)

• C6: Elbow Flexion
j) Muscles involved in full abduction of arm?
• Primary muscles involved in the action of arm abduction include:
o Supraspinatus
o Deltoid
o Trapezius
o Serratus Anterior

k) What muscles involved in rotation of scapula

 • Upward rotation is accomplished by the trapezius and serratus anterior muscles.
• Downward rotation is accomplished by the force of gravity as well as the latissimus
dorsi, levator scapulae, rhomboids, and the pectoralis major and minor muscles.

l) Trapezius/serratus anterior supplied by what nerve?

• Serratus Anterior: Long thoracic nerve (C5-C7)
• Trapezius: Accessory nerve (CN 11)

m) Surface marking of coracoid process on SP

• coracoid process is palpable just below the lateral end of the clavicle (collar bone).
• It is otherwise known as the "Surgeon's Lighthouse" because it serves as a landmark
to avoid neurovascular damage.

n) What muscles attach to coracoid process?

• Pectoralis minor
• Coracobrachialis
• short head of biceps brachii

28) Upper Limb

a) What bone is this? Where does the fracture usually occur?

• Clavicle; Middle 1/3
b) Tell me about the rotator cuff muscles. Origin and insertion.

c) Show me on the skeleton.

d) Rotator cuff muscles

Anterior Posterior
Supraspinatous muscle
Teres minor muscle
Subscapularis muscle
Infraspinatous muscle

e) Muscle Origin Insertion

Supraspinatus Supraspinous fossa Greater tubercle of of scapula humerus
Intraspinatus Infraspinous fossa of scapula
Teres minor Middle 2/3 of lateral border of scapula
Subscapularis Medial 2/3 of Lesser tubercle of subscapular fossa humerus

f) Show me the spiral groove. What nerve runs through it?

• Radial nerve

g) Point out spiral groove.

h) What nerve runs behind the medial epicondyle?

• Ulnar nerve

i) Show me the sensory deficit.

• Medial 1.5 fingers

j) he asked specifically if both dorsal and palmar surface: yes!

k) What is the only thenar muscle affected in ulnar nerve palsy/injury?

• Adductor pollicis

29) Bones of upper limb (humerus, scapula, clavicle). Rotator cuff muscles and their
nerve supply

30) Anatomy: Upper limb again....

a) Point out the acromion and coracoid process

b) What are rotator cuff muscles and origins and attachments

c) Point out spiral groove. What nerve runs in it

d) Point out medial epicondyle. What nerve.

e) What are the cutaneous deficits of radial and ulnar nerve.

f) Why is grip strength weaker if radial nerve is affected. (You can’t grip things if you cant
extend the wrist)

g) What is the origin and attachment of gluteus medius and its function. (He didn't let me go
with a vague pointing around the iliac crest for the origin lol)

h) What is the origin and insertion of the quadratus femoris (I forgot)

i) What is the main flexor of the hip

j) Pointed to ASIS. What is this and what muscle attaches here

k) What nerve is this.

• Lateral cutaneous nerve

l) What is the condition if this nerve is compressed.

31) Anatomy: bones of upper limb scattered, arrange, show major muscle attachments,
discuss nerve injuries of the upper limb and their effect at different levels.

32) Anatomy Station 3: Skeleton upper and lower

a) Point to coracoid and acromion

b) Point fossa of scapula

c) What are the rotator cuff muscles

d) Origin and insertion of each one point on the skeleton

e) Point to ASIS

f) Muscle attached to it
 • sartorius

g) Cutaneous nerve related to it

• lateral cutaneous nerve of the thigh

h) Condition if nerve compressed:

• meralgia paresthetica

i) Gluteus medius and minimus origin and insertion

j) Quadratic femoris origin and insertion

k) Identify the spiral groove which nerve run on it

l) medial epicondyle and ulnar nerve.

m) loss of sensation if ulnar nerve damage

n) loss of sensation in radial nerve (he wanted the first digital web space)

o) which of the thenar muscle effect if ulnar nerve damaged.

• The majority of the thenar muscles are innervated by the median nerve (T1).
• The exception is the deep head of flexor pollicis brevis, which together with the
adductor pollicis muscle, receives innervation via the ulnar nerve (C8, T1).

33) Station 6 anatomy- Brachial plexus: Question

a) show on skeleton c5 and c6 nerve root (patient have upper trunk injury)
• First cervical root exits above the C1 vertebra.
• Second cervical root exits between the C1-C2 segment
• Remaining roots exit just below the correspondingly numbered vertebra.

b) show on simulated patient the dermatome

c) what is the nerve root of musculocutaneous nerve

• C5, C6, C7
d) what is the muscle of its innervation
• Innervates the three muscles of the anterior compartment of the arm:
o Coracobrachialis
o biceps brachii
o brachialis muscles
• It is also responsible for cutaneous innervation of the lateral forearm.

e) what attach to coracoid process

f) what is the attachment of trapezius and serratus anterior

• Trapezius: Accessory nerve (CN XI); Anterior rami of the spinal nerves C3 and C4
o consists of three parts:

Part Origin Insertion:

Descending part Superior nuchal line; Lateral third of the clavicle
External occipital
protuberance
Transverse part Spinous processes of the Acromion of the scapula;
vertebra T1-T4 Spine of the scapula
Ascending part Spinous processes of the Medial part of the spine of
thoracic vertebrae T4-T12 the scapula

• Serratus Anterior:
o Origin: Anterior surfaces of the first 8 or 9 ribs.
o Insertion: Anterior surface of medial border of scapula.
o Innervation: Long thoracic nerve (C5-C7).

g) what is the action of coracobrachialis, how to assess

• Origin: Coracoid process of the scapula
• Insertion: Anteromedial surface of the humerual shaft
• Nerve Supply: Musculocutaneous nerve (C5- C7)
• Action: Adduction and flexion of the arm at the shoulder joint

• Look at video: [Link]

34) Anatomy- Skeleton (weird one) random questions from upper and lower limb

a) asked for rotator cuff, nerves, insertion points

b) Pelvis

c) Lateral cutaneous nerve of the thigh and how the entrapment of that nerve is called.
• Meralgia paresthetica (also known as lateral femoral cutaneous nerve entrapment) is a
condition characterized by tingling, numbness and burning pain in your outer thigh.
d) Pelvic muscles.

35) Upper Limb c5/6 lesion following RTA

36) Anatomy: thorax identification.

a) Right and left subclavian artery

b) right and left common carotid artery

c) Right and left recurrent, Vagus

d) Parts of thyroid blood supply and venous drainage

e) embryology of thyroid

f) thyroglossal cyst

g) Trunks of brachial plexus

h) Erb’s Palsy motor and sensory

i) Klumpke palsy

37) Anatomy- Cyclist in crash with brachial plexus injury.

a) Specimen- Articulated cervical vertebrae. Simulated patient.

b) List nerve root values of brachial plexus.

c) How to test for nerve injuries. Show on vertebrae. (is this asking for brachial plexus
injury?)
[Link]

• Upper Lesion: Erb's Palsy (C5,6)

o Physical Exam: Clinically, the arm will be adducted, internally rotated, at
shoulder; pronated, extended at elbow (“waiter’s tip”)
o C5 deficiency
▪ axillary nerve deficiency (weakness in deltoid, teres minor)
▪ suprascapular nerve deficiency (weakness in supraspinatus,
infraspinatus)
▪ musculocutaneous nerve deficiency (weakness to biceps)
o C6 deficiency
▪ radial nerve deficiency (weakness in brachioradialis, supinator)

• Lower Lesion: Klumpke Palsy (C8, T1)

o Physical Exam: Deficit of all of the small muscles of the hand (ulnar and
median nerves)
o Clinically, presents as “claw hand.”
▪ wrist held in extreme extension because of the unopposed wrist
extensors
▪ hyperextension of MCP due to loss of hand intrinsic muscles
▪ flexion of IP joints due to loss of hand intrinsic muscles

• Total Palsy (C5-T1)

o Physical Exam
▪ Leads to a flaccid arm
▪ Involves both motor and sensory

d) where cervical nerves exit (above)

• First cervical root exits above the C1 vertebra.
• Second cervical root exits between the C1-C2 segment
• Remaining roots exit just below the correspondingly numbered vertebra.
e) Palpate the coracoid process on the simulated patient.

f) What 3 muscles are attached to the coracoid process?

• Pectoralis minor
• Coracobrachialis
• short head of biceps brachii

38) Neck anatomy, brachial plexus, injuries etc. – Erb’s and Klumpke palsy, root
involved

39) STATION 18 — ANATOMY- You are an orthopedic registrar who will be taking
some medical students for anatomy lesson. You are revising your bony anatomy.
*NOTE: SOME OF THE SKELETON USED WAS NOT VERY OBVIOUS. ESP THE
SPIRAL GROOVE (even the examiner agreed on this difficulty).

a) Given bony skeleton. Needed to identify many things from UL to LL: humerus spiral
groove, greater & lesser tuberosity.

b) coracoid process & the muscles attached there

• Ligaments:
o Coracoclavicular (trapezoid, conoid)
o Coracoacromial
o Coracohumeral
• Muscles:
 o Pectoralis minor (insertion)
o Coracobrachialis (origin)
o Short head of biceps (origin)

c) what structure through the spiral groove

d) what happens if this structure is injured.

• Radial Nerve Damage: Weakness, loss of coordination of the fingers.
o Problem straightening the arm at the elbow.
o Problem bending the hand back at the wrist or holding the hand.
o Pain, numbness, decreased sensation, tingling, or burning sensation in the
areas controlled by the nerve.

e) Identify rotator cuff's origin & insertion points.

f) Identify gluteus medius insertion & origin sites.

g) Identify quadratus femoris.

h) Identify medial epicondyle of humerus.

40) Anatomy: Skeleton model

a) Identify acromion, coracoid process

b) What are the rotator cuff muscles?

c) What are their origins and insertions? Demonstrate it

d) Identify medial epicondyle

e) What nerve travels near it

f) Sensory distribution of ulnar nerve

g) Show me spiral groove

h) What nerve runs there and sensory distribution of radial nerve

i) Why do you get weak grip when radial nerve gets injured?

41) Anatomy- Show on skeleton

a) Identify acromion and coracoid process

b) Tell me the rotator cuff muscles and show on skeleton origin and insertion

c) show me the spiral groove and what runs in it

d) show me medial epicondyle and what runs under it

e) Tell me one major sensory loss when the radial nerve is injured

42) Klumpkes paralysis and a volley of questions on upper limb anatomy. Examiner
had a whole skeleton in front of him; muscle attachments, nerve supply of muscles
and root value of nerves (I remember suprascapular)
 UPPER LIMB- Arm and Forearm

1) Anatomy- Upper limb

Stem is fall with swelling around elbow. Specimen of upper limb. (Veins were frigging
colored in bright red); Probably got a few more questions which I can’t remember.
Didn't feel too good for this station.

a) Identify bones of upper limb (humerus, ulna, radius)

b) Orientated them

c) Which part of the humerus is involved in the elbow joint

• Trochlea of Humerus
• Capitulum of Humerus
d) Which part of ulnar and radius participates in the elbow joint. Asked to identify
EXACTLY.
• The elbow joint consists of two separate articulations:
o Trochlear notch of the ulna and the trochlea of the humerus.
o Head of the radius and the capitulum of the humerus.

e) where is olecranon.

f) Showed Xray of supracondylar fracture. What is this fracture?

g) What are you worried about?
• Brachial Artery and Anterior Interosseous Nerve Injury
h) How do you assess for this? (I said check brachial pulse. Asked if got any distal pulses.
Also said check for neurological deficit but he was not impressed. Kept asking for more but I
really dunno what he was getting at)
[Link]
• Vascular Evaluation: Both radial and ulnar pulses must be palpated at the wrist of the
injured extremity.
• Neurologic Evaluation:
o Anterior Interosseous Nerve Branch (AIN) of the median nerve is most prone
to get involved in postero-lateral displacement of the distal fracture fragment.
▪ A child may present with no sensory loss in hand but a weak" OK
sign" (e.g., more of a pincer grasp than an OK sign) on physical
examination.
o Radial nerve impingement most commonly occurs when the distal fracture
fragment is displaced postero-medially.
▪ It can be examined with decreased sensation in dorsal aspect of the
hand and weak wrist extensors.
o Ulnar nerve is prone to injury following flexion type of supracondylar
fractures and loss of sensation in its distribution can be examined following
weakness of intrinsic muscles of the hand.

i) Ask for cutaneous distribution of median nerve.

• Gives rise to the:
o palmar cutaneous branch, which innervates the lateral aspect of the palm
o digital cutaneous branch, which innervates the lateral three and a half fingers
on the anterior (palmar) surface of the hand.

j) What happens if median nerve cut at elbow. State the functional loss. (I didn't
understand properly so I said all the loss of the various muscles and numbness. He was not
impressed until I said loss of flexion of fingers, abduction of thumb and flexion of wrist)
• Flexion of Fingers
 • Abduction of Thumb
• Flexion of Wrist

k) If you asked the patient to flex the wrist, what would happen. (Basically ulnar
deviation)
• Ulnar Deviation

l) Asked about ulnar paradox

• FDP: flexor digitorum profundus
o medial part of FDP (muscle bellies of the little and ring finger) is innervated
by the ulnar nerve (UN)
o while the lateral part (muscle bellies of the middle and index fingers) is
innervated by the anterior interosseous branch of the median nerve, C8 and T1

• If the ulnar nerve lesion occurs more proximally (closer to the elbow), the flexor
digitorum profundus muscle may also be denervated.
o As a result, flexion of the IP joints is weakened, which reduces the claw-like
appearance of the hand.

2) Upper limb: Scenario about a young boy who had a fall - again it also said we are
going to test your knowledge of upper limb anatomy. Lol. Best station for everyone
because examiner was literally the cutest person I have ever seen. Old guy with shiny
silver hair, extremely adorable. He gave me left humerus, radius and ulna and asked me
to articulate them.

a) Asked to identify the olecranon, trochlea, capitulum, radial head.

b) Then asked me where biceps insert.
• There are three muscles located in the anterior compartment of the upper arm – biceps
brachii, coracobrachialis and brachialis.
• They are all innervated by the musculocutaneous nerve.
• A good memory aid for this is BBC – biceps, brachialis, coracobrachialis.

Origin Insertion
Biceps Brachii • Long head: supraglenoid Both heads insert distally
tubercle of the scapula into the radial tuberosity
• Short head: coracoid process of and the fascia of the
the scapula. forearm via the bicipital
aponeurosis.
Brachialis Medial and lateral surfaces of the Ulnar tuberosity, just distal
humeral shaft to the elbow joint.
Coracobrachialis Coracoid process of the scapula Passes through the axilla,
and attaches the medial
side of the humeral shaft, at
the level of the deltoid
tubercle.
c) Then gave an X-Ray of a supracondylar fracture with soft tissue swelling anteriorly
(was very jumpy and happy when I said soft tissue swelling - apparently no one else had
picked it up before me and I was the 7th person here). Then asked me what I would be
worried in such an injury - I said neurovascular status. He said neuro first or vascular, I said
vascular, and he got happy at that too (unbelievable I know).

d) Then took me to a dissected upper limb specimen and said show me the cubital fossa
and its boundaries and its contents. I started with the superficial/roof and said here is the
median cubital vein and he's like that's not important, let’s move on - arteries nerves and
tendons quickly (lol). I named all, showed him the courses.
• Cubital fossa is triangular in shape and consists of three borders, a roof, and a floor:
o Lateral border – medial border of the brachioradialis muscle.
o Medial border – lateral border of the pronator teres muscle.
o Superior border – horizontal line drawn between the epicondyles of the
humerus.
o Roof – bicipital aponeurosis, fascia, subcutaneous fat and skin.
o Floor – brachialis (proximally) and supinator (distally).

• Its contents are (lateral to medial):

o Radial nerve – travels along the lateral border of the cubital fossa and divides
into superficial and deep branches.
▪ It has a motor and sensory function in the posterior forearm and hand.
o Biceps tendon – passes centrally through the cubital fossa and attaches the
radial tuberosity (immediately distal to the radial neck).
▪ It gives rise to the bicipital aponeurosis which contributes to the roof of
the cubital fossa.
o Brachial artery – bifurcates into the radial and ulnar arteries at the apex of the
cubital fossa.
▪ The brachial pulse can be felt in the cubital fossa by palpating medial
to the biceps tendon.
o Median nerve – travels medially through the cubital fossa, exiting by passing
between the two heads of the pronator teres.
▪ It has a motor and sensory function in the anterior forearm and hand.

• Roof of the cubital fossa also contains several superficial veins.

o Notably, the median cubital vein, which connects the basilic and cephalic
veins and can be accessed easily – a common site for vene-puncture.
e) He said what would you expect with a radial nerve injury- I said wrist drop, he grinned.
Didn't want details.
• Radial nerve Injury: Wrist Drop
o Following a radial nerve injury, the extrinsic extensor function of the hand and
wrist is lost.
o This results in an inability to extend the fingers and wrist and affects grip
strength and finger flexion and has a large influence on thumb usage.

f) Asked me about ulnar nerve injury and ulnar paradox IN DETAIL- WOULDN'T LET
ME GO TILL I DEMONSTRATED IT ON MY OWN HAND.
g) Then asked me about the difference in action of flexor digitorum superficialis and
flexor digitorum profundus- based on their attachments.

ORIGIN INSERTION INNERVATION

flexor • Humeroulnar head: Sides of Median Nerve
digitorum Medial epicondyle of middle
superficialis humerus, coronoid phalanges of
process of ulna digits 2-5
• Radial head:
Proximal half of
anterior border of
radius
flexor Proximal half of anterior Palmar • Digits 2-3: Median
digitorum surface of ulna, interosseous surfaces of nerve (anterior
profundus membrane distal interosseous nerve)
phalanges of • Digits 4-5: Ulnar
digits 2-5 nerve (C8, T1)

h) He told me to assume he was a patient and to check his profundus and superficialis
function separately - got very happy when I demonstrated it. Said good at the end and
beamed with pride lol.
• flexor digitorum superficialis: Flexing PIP joint
o Metacarpophalangeal and proximal interphalangeal joints 2-5: Finger flexion
• flexor digitorum profundus: Flexing DIP joint
o Metacarpophalangeal and interphalangeal joints 2-5: Finger flexion
3) Forearm anatomy; all muscle, nerves- very easy.

a) identify radius and ulna, articulate with each other, articulate with the humerus

b) Identify trochlea, capitulum, radial tuberosity, bicipital tendon, median and ulnar
nerve
c) median nerve injury (motor and sensory)
• Motor functions: Innervates the flexor and pronator muscles in the anterior
compartment of the forearm (except the flexor carpi ulnaris and part of the flexor
digitorum profundus, innervated by the ulnar nerve).
o Also supplies innervation to the thenar muscles and lateral two lumbricals in
the hand.
• Sensory functions: Gives rise to the palmar cutaneous branch, which innervates the
lateral aspect of the palm, and the digital cutaneous branch, which innervates the
lateral three and a half fingers on the anterior (palmar) surface of the hand.

d) ulnar nerve injury (motor); ulnar paradox

4) Anatomy- Extensor compartment of Upper Limb — Forearm and hand

There was no pro-section; only few photos were shown. There was a plastic model of
skeleton of hand and 2 forearm bones.

a) Identify different muscles and tendons as pointed out by the examiner

b) Identify dorsal interosseus followed by its function, nerve supply and show on your
own hand its action

Dorsal Interossei
Origin o Adjacent sides of metacarpal bones 1-5
o Each interossei originates from the lateral and medial surfaces of
the metacarpals.
Insertion o They attach into the extensor hood and proximal phalanx of each
finger.
Innervation Deep branch of ulnar nerve (C8-T1)
Action o Abduction of the digits.
o Assists in flexion at the metacarpophalangeal joints and extension
at the interphalangeal joints.
c) Identify the extensor communis tendon and its function
• Extensor digitorum communis is a superficial extensor muscle located in the posterior
compartment of the forearm.
o It shares a common synovial tendon sheath along with other extensor muscles
which helps to reduce friction between the tendon and the surrounding
structures.
• Primarily, the extensor digitorum communis extends medial four digits at the
metacarpophalangeal joints and secondarily at the interphalangeal joints.
o It also acts to extend the wrist joint.

d) Identify the styloid process of radius

e) Identify different bones of the wrist, specifically each and every carpal bones
5) Anatomy: Elbow /forearm anatomy

6) Station: Anatomy of extensor compartment of Arm

a) Name the muscles, Muscle attachments, Nerve supply of muscles, blood supply.

b) Anatomical snuff box boundaries

• Snuffbox is triangularly shaped, it has three borders, a floor, and a roof:
o Ulnar (medial) border: Tendon of the extensor pollicis longus.
o Radial (lateral) border: Tendons of the extensor pollicis brevis and abductor
pollicis longus.
o Proximal border: Styloid process of the radius.
o Floor: Carpal bones; scaphoid and trapezium.
o Roof: Skin.
c) Radial tuberosity

d) Name carpal bones

e) Significance of blood supply to scaphoid and the condition (AVN), why it happens
• Scaphoid has proximal and distal poles with a waist between the two.
 • Blood supply to the scaphoid bone is predominantly from branches of the radial artery
(dorsal carpal branch).
• These enter the dorsal ridge and supply 80% of the proximal pole via retrograde flow.
• The second source is from the superficial palmar arch, a branch of the volar radial
artery, which enters the distal tubercle and supplies the distal pole.
• The retrograde nature of the blood supply means that fractures at the waist of the
scaphoid leave the proximal pole at high risk of avascular necrosis.

f) Identify dorsal digital expansion and explain its function

• Extensor expansion of hand (dorsal digital expansion) is the triangular complex by
which the extensor tendon inserts onto the phalanges.
• Function: hold the extensor tendons in place and allow the extensors, lumbricals, and
interossei to effect extension at the proximal and distal interphalangeal joints.
7) ANATOMY: Skeleton with flags attached and a series of questions to answer

a) Flags pointing to the greater tubercle of the humerus – which 3 muscles attach here,
where else do they attach and what’s their function
• three of the rotator cuff muscles – supraspinatus, infraspinatus and teres minor – they
attach to superior, middle and inferior facets (respectively) on the greater tuberosity
b) Flags pointing to the mid-humerus – radial nerve

c) Likewise – ulnar nerve, lateral cutaneous nerve of the thigh, common peroneal nerve –
what are their functions?

d) Three muscles that attach to greater trochanter

e) Functions of muscles that attach to the lesser trochanter

8) Surface anatomy

a) Muscle attachments of the greater and lesser tuberosity of the humerus

• Greater Tubercle: supraspinatus, infraspinatus and teres minor – they attach to
superior, middle and inferior facets (respectively)
• Lesser Tubercle: Subscapularis muscle attaches at this tubercle and the transverse
ligament of the shoulder also attaches on its lateral part

b) rotator cuff etc.

c) Muscle attachments of the lesser trochanter

d) Attachments at the ASIS

• Sartorius

e) Recognize meralgia paraesthetica

f) Relations of the radial groove

9) Osteology of scapula and humerus. Rotator cuff muscles and origin. Lunar and radial
nerve injury.
10) Anatomy- Upper Limb

a) Plain x- Ray showing supracondylar fracture of distal humerus?

b) Identify humerus, ulna, Radius & articulate them

c) What is this? (Trochlea and trochlear notch, capitellum &. Radial head)

d) WHAT IS THIS (median nerve, brachial artery, biceps tendon, radial nerve).

e) What sensory and motor deficit in median nerve injury at the elbow.
• If the median nerve is damaged at the elbow region, it is known as a proximal injury
to the median nerve.
• Proximal injury to the median nerve often presents with the hand of benediction, a
sign that occurs when an individual is unable to make a complete fist.
• No flexion of 1st and 3rd finger joints on 1st and 2nd fingers

f) Why ulnar paradox at the wrist

g) How to test flexor digitoxin profundus tendons of little and ring fingers.

11) Anatomy station: Child fallen from tree. Swelling at elbow. Anatomy station:

a) SC humerus. Articulate bones.

b) Median nerve supply

c) Relation of median nerve, brachial artery, and radial nerve.

d) Ulnar paradox muscle?

e) Median nerve injury above elbow results in?

f) Radial nerve course and relation to humerus., show artery, nerve etc.
• Radial nerve is the terminal continuation of the posterior cord of the brachial plexus.
It therefore contains fibers from nerve roots C5 – T1.
o The nerve arises in the axilla region, where it is situated posteriorly to the
axillary artery.
▪ It exits the axilla inferiorly (via the triangular interval), and supplies
branches to the long and lateral heads of the triceps brachii.
o The radial nerve then descends down the arm, travelling in a shallow
depression within the surface of the humerus, known as the radial groove.
o As it descends, the radial nerve wraps around the humerus laterally, and
supplies a branch to the medial head of the triceps brachii.
▪ During much of its course within the arm, it is accompanied by the
deep branch of the brachial artery.
o To enter the forearm, the radial nerve travels anterior to the lateral epicondyle
of the humerus, through the cubital fossa.
o The nerve then terminates by dividing into two branches:
▪ Deep branch (motor) – innervates the muscles in the posterior
compartment of the forearm.
▪ Superficial branch (sensory) – contributes to the cutaneous innervation
of the dorsal hand and fingers.
g) Brachioradialis action.
• Brachioradialis is a muscle within the superficial compartment of the
posterior forearm.
o The medial edge of the brachioradialis forms the lateral border of the cubital
fossa.
• Attachments:
o Originates: from the proximal aspect of the lateral supracondylar ridge of
humerus.
o Insertion: It attaches to the distal end of the radius, just proximal to the radial
styloid process.
• Actions: Flexion at the elbow
• Innervation: Radial nerve.
• Blood supply: Radial artery.
12) UL & LL: on SKELETON POINT for me:

a) origin and insertion of rotator cuff muscles and their nerves

b) radial groove identify, structures in it?

c) Radial nerve sensation loss

d) What will damage in medial epicondyle fracture, tell sensory and motor loss

e) Ask about adductor policies.

f) What is this? ASIS

g) muscle attach on it?

h) Nerve compress here and condition name (Myalgia Paresthetica)

i) Next move on to Gluteus Medius & quadratus femoris origin and insertion

j) Trendelenburg test

k) point to Pubic tubercle and its relations with inguinal and femoral hernia.

13) Station 19- There is a skeletal model, and you are given a pointer.

a) show me the attachments and origins of the rotator cuff muscles

b) Show me the spiral groove

c) What nerve runs in it

• Radial nerve

d) Identify the medial epicondyle

e) what will you get in fractures there?

• Ulnar Nerve Injury

f) show me on your hand what is the area supplied by the ulnar nerve (show both
palmar and dorsum)
• Ulnar Nerve Cutaneous Sensation: hypothenar area; dorsum of the skin of the medial
hand, medial half of the fourth digit, and fifth digit.
g) What is the principal flexor of the hip

h) Where is the insertion. Show me.

i) What muscle has its origin at the ASIS?

j) What is its nerve supply?

k) What nerve runs under the inguinal ligament?

l) What syndrome happens if this nerve is caught?

m) show me the origin and insertion of the gluteus medius and minimus

n) show me the origin and insertion of the quadratus femoris

 UPPER LIMB- Hand, Anatomical Snuff Box

1) Hand

a) Shown X-ray of hand. Identify all the carpal bones

b) Shown bony model of hand

c) Point out the attachments of the flexor retinaculum.

• Proximal: Pisiform & Tubercle of scaphoid
• Distal: Hook of hamate & Trapezium
d) What are the structures running through the carpal tunnel?
• median nerve and nine tendons:
o four tendons of the flexor digitorum superficialis
o four tendons of the flexor digitorum profundus
o tendon of the flexor pollicis longus.

e) Shown cadaveric hand. Asked to identify: Median nerve, Ulnar nerve.

f) What is this structure? Ulnar artery

g) How to test for sufficient ulnar artery supply to hand? Allen’s Test

h) Describe Allen’s test.

• Used to assess collateral blood flow to the hands

i) Where do the tendons of FDS and FDP insert?

• FDS: split tendon on middle phalangeal bases of 2nd, 3rd, 4th, & 5th digits
• FDP: passes through split tendon of FDS to insert into terminal phalanx
j) Demonstrate how to test for FDS.
• flexor digitorum superficialis: Flexing PIP joint
o Metacarpophalangeal and proximal interphalangeal joints 2-5: Finger flexion
• flexor digitorum profundus: Flexing DIP joint
o Metacarpophalangeal and interphalangeal joints 2-5: Finger flexion
o

k) What are the movements of the thumb? Demonstrate on yourself.

l) What is the innervation of all the muscles moving the thumb?

m) Name all the movements of the thumb and demonstrate it to me. Show me which
muscles control these movements and what is their innervation?

n) Show me the median nerve distribution of the hand. They ask for the extent of the
dorsum also.

The median nerve is derived from the medial and lateral cords of the brachial plexus. It
contains fibres from roots C6-T1 and can contain fibres from C5 in some individuals.

After originating from the brachial plexus in the axilla, the median nerve descends down the
arm, initially lateral to the brachial artery. Halfway down the arm, the nerve crosses over
the brachial artery, and becomes situated medially. The median nerve enters the anterior
compartment of the forearm via the cubital fossa.
In the forearm, the nerve travels between the flexor digitorum profundus and flexor digitorum
superficialis muscles. The median nerve gives off two major branches in the forearm:

• Anterior interosseous nerve – supplies the deep muscles in the anterior forearm.

• Palmar cutaneous nerve – innervates the skin of the lateral palm.

(The functions of these nerves are explored in more detail later in the article).

After giving off the anterior interosseous and palmar cutaneous branches, the median nerve
enters the hand via the carpal tunnel – where it terminates by dividing into two branches:

• Recurrent branch – innervates the thenar muscles.

• Palmar digital branch – innervates the palmar surface and fingertips of the lateral
three and half digits. Also innervates the lateral two lumbrical muscles.

o) What muscles make up the thenar eminence; What is the nerve supply of thenar eminence?

Muscle Nerve Supply

Abductor pollicis brevis Median nerve (T1)
Flexor pollicis brevis superficial head: Median nerve (T1)
deep head: ulnar nerve (C8, T1)
Opponens pollicis Median nerve (T1)

p) What are the boundaries of the anatomical snuffbox?

• Snuffbox is triangularly shaped, it has three borders, a floor, and a roof:
o Ulnar (medial) border: Tendon of the extensor pollicis longus.
 o Radial (lateral) border: Tendons of the extensor pollicis brevis and abductor
pollicis longus.
o Proximal border: Styloid process of the radius.
o Floor: Carpal bones; scaphoid and trapezium.
o Roof: Skin.

q) Demonstrate to me where is the anatomical snuffbox.

r) What is in the anatomical snuffbox? Radial Artery

s) What is the significance of snuffbox tenderness?

• highly sensitive test for scaphoid fracture

t) Why do you get AVN in scaphoid #?

• poor blood supply to the proximal pole, particularly in comparison with the abundant
supply to the distal two-thirds of the scaphoid

u) How do you test for collateral circulation of the hand? Describe the test for me.
• Allen Test

v) Identify the superficial palmar arch (on prosection). What is the supply?
• Ulnar Artery
w) What are the roots of the ulnar nerve? What does it supply in the hand?
• C8-T1

The majority of the intrinsic hand muscles are innervated by the deep branch of the ulnar
nerve:

• Hypothenar muscles (flexor digiti minimi brevis, abductor digiti minimi, opponens
digiti minimi)
• Medial two lumbricals
• Adductor pollicis
 • Palmar and dorsal interossei of the hand

The palmaris brevis is an exception to this rule and is innervated by the superficial branch of
the ulnar nerve. The other muscles of the hand (lateral two lumbricals and the thenar
eminence) are innervated by the median nerve.

2) Hand and thumb anatomy

a) hand extensors!!
• The extensor tendon compartments of the wrist are six tunnels which transmit the
long extensor tendons from the forearm into the hand.
• They are located on the posterior aspect of the wrist. Each tunnel is lined internally by
a synovial sheath and separated from one another by fibrous septa.

Compartment 1 • Extensor pollicis brevis

• Located on the lateral (radial) • Abductor pollicis longus
aspect of the wrist.
• These tendons form the lateral
border of the anatomical snuffbox.
Compartment 2 • Extensor carpi radialis longus
• Separated from compartment 3 by • Extensor carpi radialis brevis
Lister’s tubercle – a bony
prominence of the distal aspect of
the radius.
Compartment 3 • Extensor pollicis longus
• forms the medial border of the
anatomical snuffbox.
Compartment 4 • Extensor digitorum
• Extensor indicis
Compartment 5 • Extensor digiti minimi
Compartment 6 • Extensor carpi ulnaris

b) extensor mechanism
• Extensor tendon compartments of the wrist are anatomical tunnels on the back of the
wrist that contain tendons of muscles that extend (as opposed to flex) the wrist and the
digits (fingers and thumb).
• The extensor tendons are held in place by the extensor retinaculum.

c) why in radial nerve injury there is weak grip (he wanted specifically the synergistic
work between extensors and flexors to strengthen the grip)
• Radial nerve Injury: Wrist Drop
o Following a radial nerve injury, the extrinsic extensor function of the hand and
wrist is lost.
o This results in an inability to extend the fingers and wrist and affects grip
strength and finger flexion and has a large influence on thumb usage.
3) Anatomy: Hand anatomy: forearm/hand specimen with visible tendons and nerves.
hand skeleton.

a) Xray hand of iPad. names of carpal bones.

b) show me ulnar nerve and median nerve.

c) show me flexor retinaculum.

d) bony attachments of flexor retinaculum.

e) What passes in the tunnel?

• Flexor Carpi Radialis Tendon

f) Does FCR (flexor carpi radials) run inside the carpal tunnel? No.

g) Show me thumb movements and tell me which muscles and nerve innervation of
each.

h) Median nerve sensory distribution in hand.

i) Show me FDS and FDP. Where do they attach to?

j) Identify palmar arch.

k) What is the main contributor? Ulnar Artery

l) How do you test for adequacy of blood supply? Allen's test

m) show me

4) Anatomy.

a) carpal bones

b) identify muscles in posterior forearm, innervations, blood supply

• muscles in the posterior compartment of the forearm are commonly known as the
extensor muscles.
• The general function of these muscles is to produce extension at the wrist and fingers.
• They are all innervated by the radial nerve.
• The muscles in this compartment are organised into two layers; deep and superficial.
• These two layers are separated by a layer of fascia.
• Blood supply is from the radial recurrent, posterior, anterior interosseous and
interosseous recurrent arteries.

Superficial Brachioradialis • Origin: proximal aspect of the

lateral supracondylar ridge of
humerus
 • Insertion: distal end of the radius,
just before the radial styloid
process.
Extensor carpi radialis Longus • Origin: lateral supracondylar ridge
of the humerus
• Insertion: metacarpal bones II and
III
Extensor carpi radialis brevis • Origin: lateral epicondyle
• Insertion: metacarpal bones II and
III
Extensor Digitorum Communis • Origin: lateral epicondyle
• Insertion: tendon continues into in
the distal part of the forearm,
where it splits into four, and inserts
into the extensor hood of each
finger.
Extensor Digiti Minimi • Origin: lateral epicondyle of the
humerus
• Insertion: attaches, with the
extensor digitorum tendon, into the
extensor hood of the little finger.
Extensor Carpi Ulnaris • Origin: lateral epicondyle of the
humerus
• Insertion: base of metacarpal V
Anconeus • Origin: lateral epicondyle
• Insertion: posterior and lateral part
of the olecranon.
Deep Supinator • Origin: two heads of origin. One
originates from the lateral
epicondyle of the humerus, the
other from the posterior surface of
the ulna.
• Insertion: insert together into the
posterior surface of the radius.
Abductor pollicis longus • Origin: interosseous membrane
and the adjacent posterior surfaces
of the radius and ulna.
• Insertion: lateral side of the base of
metacarpal I.
Extensor pollicis brevis • Origin: posterior surface of the
radius and interosseous membrane
• Insertion: base of the proximal
phalanx of the thumb
Extensor pollicis longus • Origin: posterior surface of the
ulna and interosseous membrane
• Insertion: distal phalanx of the
thumb
 Extensor Indicis • Origin: posterior surface of the
ulna and interosseous membrane,
distal to the extensor pollicis
longus
• Insertion: extensor hood of the
index finger.

c) anatomical snuff box

d) significance of blood supply to scaphoid and the condition (AVN)

• Scaphoid has proximal and distal poles with a waist between the two.
• Blood supply to the scaphoid bone is predominantly from branches of the radial artery
(dorsal carpal branch).
 o These enter the dorsal ridge and supply 80% of the proximal pole via
retrograde flow.
• The second source is from the superficial palmar arch, a branch of the volar radial
artery, which enters the distal tubercle and supplies the distal pole.
• The retrograde nature of the blood supply means that fractures at the waist of the
scaphoid leave the proximal pole at high risk of avascular necrosis.

e) Identify dorsal digital expansion and explain its function

• Extensor expansion of hand (dorsal digital expansion) is the triangular complex by
which the extensor tendon inserts onto the phalanges.
• Function: old the extensor tendons in place and allow the extensors, lumbricals, and
interossei to effect extension at the proximal and distal interphalangeal joints.
5) Station 9 (Anatomy)- Hand

6) Hands carpal tunnel; Hands ulnar deficit.

7) Anatomy- Extensor compartment of the hand

a) Muscles of extensor compartment

b) Showed cadaver dissection on iPad, asked to identify tendons.

c) Asked to show anatomy snuff box on the hand, asked boundaries.

d) Asked about scaphoid fracture.

e) Extensor hood (aka Dorsal Digital Expansion)

f) Origins and insertions of all extensors on bone assembled hand.

8) Hand anatomy (very detailed questions asking to identify exact tendons in the
hands, their insertions etc. — I knew very little of this)
9) Hand bone, Intrinsic muscle hand

10) Anatomy (Hand and forearm)- hand X-ray, skeleton and cadaver.

a) Identify carpal bones- on X-ray as well as the skeleton.

b) What is the significance of scaphoid fracture?

c) Identify the flexor retinaculum. What are its attachments?

d) Identify median nerve and ulnar nerve.

e) Which intrinsic hand muscles does median nerve supply?

f) What is the sensory innervation of the median nerve?

g) What structures pass through the carpal tunnel?

h) Identify flexor digitorum superficialis and profundus.

i) Identify distal attachments of FDS and FDP.

j) How will you test the function of FDS and FDP separately?

k) Identify common flexor origin.

• superficial anterior forearm muscles share a common origin on the common flexor
tendon that arises from the medial epicondyle of humerus.
• The common flexor tendon is the convergence of 5 muscles; these are superficial
anterior forearm muscles:
o pronator teres
o flexor carpi radialis
o flexor carpi ulnaris
o palmaris longus
o flexor digitorum superficialis
l) What is the root value for intrinsic muscles of the hand?
• Ulnar Nerve (C8, T1)

• Four muscle groups comprise the intrinsic hand; These are the:
o 1) Thenar: Abductor Pollicis Brevis, Flexor Pollicis Brevis, Opponens Pollicis
o 2) Hypothenar: Abductor Digiti Minimi, Flexor Digiti Minimi Brevis,
Opponens Digiti Minimi
o 3) Lumbricals: 4 in hand
▪ Each lumbrical originates from a tendon of the flexor digitorum
profundus.
▪ They pass dorsally and laterally around each finger, and inserts into the
extensor hood.
▪ Actions: Flexion at the MCP joint and extension at the interphalangeal
(IP) joints of each digit.
▪ Innervation: The lateral two lumbricals (of the index and middle
fingers) are innervated by the median nerve. The medial two
 lumbricals (of the little and ring fingers) are innervated by the ulnar
nerve.
o 4) Interossei
▪ located between the metacarpal bones of the hand. They can be divided
into two groups – dorsal and palmar.
▪ In addition to their actions of abduction (dorsal interossei) and
adduction (palmar interossei) of the fingers, the interossei also assist
the lumbricals in flexion at the MCP joints and extension at the IP
joints. PAD DAB!

Dorsal Originates from Attach into the Action: Abduction of Innervation:

Interossei: the lateral and extensor hood the digits. Ulnar nerve.
4 medial surfaces and proximal Assists in flexion at
of the phalanx of each the
metacarpals. finger. metacarpophalangeal
joints and extension at
the interphalangeal
joints.
Palmar Each interossei Attaches Action: Adduction of Innervation:
Interossei: originates from a into the extensor the digits. Ulnar nerve.
3 medial or lateral hood and Assists in flexion at
surface of a proximal the
metacarpal phalanx of same metacarpophalangeal
finger. joints and extension at
the interphalangeal
joints.

m) What is this structure? (Ulnar artery and superficial palmar arch)

n) How will you test sufficient ulnar artery supply to the hand?

o) Describe Allen's test.

p) Movements of the thumb and innervation for each muscle

 Lower Limb- Pelvis, Thigh, Hip

1) Lower Limb Anatomy

a) Identify ITB, muscles attached (gluteus maximus, tensor fascia lata) function (lock knee
in extension- lateral knee stabilization)

b) Identify gluteus medius, nerve supply (superior gluteal nerve- L4-S1), function while
walking (pelvic tilt); function: abduction of hip joint
c) Identify biceps femoris (short/long head), nerve supply (sciatic nerve, he wanted specific
nerves gg – found out later short head innervated by common peroneal branch, long head by
tibial branch)

d) Identify semitendinosus, semimembranosus, function (flex knee)

• semitendinosus and semimembranosus together form the upper medial boundary of
the popliteal fossa.
• It's primary action is knee flexion, knee internal rotation and hip extension
e) Identify common peroneal nerve, landmark (neck of fibula)
f) muscle groups supplied by common peroneal nerve (anterior and lateral compartment)

g) sensory distribution (posterior and lateral aspect of leg, dorsum of foot)

h) Identify gastrocnemius, nerve supply (tibial nerve)

i) FHL weakness plus dorsum numbness – suspect L5 nerve root

j) Name all the nerves

k) Name all the muscles of the hip (the usual): can be divided into three main groups:
• Iliopsoas group
• Gluteal muscles
• Hip adductors

Iliopsoas • Muscles: iliacus, psoas major, and psoas minor

group
• Main function: flexion of the trunk and thigh, lateral flexion of the
trunk (excluding psoas major and minor only)

• Innervation: anterior rami of spinal nerves L1-L3 and femoral nerve

(L2-L4) (iliacus only)
Gluteal • Muscles: gluteus maximus, gluteus medius, gluteus minimus, and
muscles tensor fasciae latae
(superficial)
• Main function: varied – extension, external and internal rotation,
abduction and adduction of the thigh

• Innervation: superior (L4, S1) and inferior (L5-S2) gluteal nerves

Gluteal • Muscles: piriformis, gemellus superior, obturator internus, gemellus
muscles inferior, obturator externus, and quadratus femoris
(deep)
• Main function: external rotation and abduction of the thigh;
stabilizes head of femur

• Innervation: varied – nerve to piriformis (S1-S2), nerve to obturator

internus (L5-S2), nerve to quadratus femoris (L4-S1), obturator
nerve (L3-L4)
 Hip • Muscles: Gracilis, pectineus, adductor longus, adductor brevis,
adductors adductor magnus, and adductor minimus

• Main function: Adduction of the thigh at the hip joint

• Innervation: Obturator nerve (L2-L4) and femoral nerve (L2-L3)

(pectineus only)

l) If have injury here (gluteal region) what can be injured

• Superior Gluteal Nerve
o Damage to this nerve results in characteristic loss of motor function that
presents as a disabling gluteus medius limp, a phenomenon known as the
Trendelenburg or gluteal gait.
o In this condition, the weakened gluteus medius muscle causes a shift in the
center of gravity to the unaffected limb.
o Bilateral superior gluteal nerve lesions often result in a waddling gait.

m) Name LL vessels

Thigh & Femoral Artery

Gluteal • main artery of the lower limb (continuation of the EIA)
Region becomes the femoral artery when it crosses under the inguinal ligament and
enters the femoral triangle.

profunda femoris artery: from the posterolateral aspect of the femoral artery.
It travels posteriorly and distally, giving off three main branches:
Perforating branches
Lateral femoral circumflex artery
Medial femoral circumflex artery

popliteal artery: branch of femoral artery after it moves through adductor

canal, and enters the posterior compartment of the thigh, proximal to the knee
Other Obturator artery
Arteries • arises from the internal iliac artery in the pelvic region. It descends via
of the the obturator canal to enter the medial thigh, bifurcating into two
Thigh: branches: Anterior branch & Posterior branch

Superior & inferior gluteal arteries

• These arteries also arise from the internal iliac artery, entering the
gluteal region via the greater sciatic foramen.
In the Popliteal Artery
Leg • At the lower border of the popliteus, the popliteal artery terminates by
dividing into the anterior tibial artery and Tibioperoneal Trunk
• tibioperoneal trunk bifurcates into the posterior tibial artery
and fibular (peroneal) artery
In the Dorsalis pedis (a continuation of the anterior tibial artery)
Foot • dorsalis pedis artery begins as the anterior tibial artery enters the foot. It
passes over the dorsal aspect of the tarsal bones, then moves inferiorly,
 towards the sole of the foot. It then anastomoses with the lateral plantar
artery to form the deep plantar arch.
Posterior tibial
• enters the sole of the foot through the tarsal tunnel. It then splits into
the lateral and medial plantar arteries. These arteries supply the
plantar side of the foot and contributes to the supply of the toes via the
deep plantar arch.

n) Something about foot drop and where the areas of injury could be
• Foot drop is an inability to lift the forefoot due to the weakness of dorsiflexors of the
foot.
o This, in turn, can lead to an unsafe antalgic gait, potentially resulting in falls.
• A) Most commonly, foot drop is caused by an injury to the peroneal nerve.
o Some common ways the peroneal nerve is damaged or compressed include:
Sports injuries, Diabetes, Hip or knee replacement surgery, Spending long
hours sitting cross-legged or squatting, Childbirth, Time spent in a leg cast
• B) Neurological conditions can contribute to foot drop. These include: Stroke,
Multiple sclerosis (MS), Cerebral palsy, Charcot-Marie-Tooth disease
• C) Muscle disorders. Conditions that cause the muscles to progressively weaken or
deteriorate may cause foot drop. These include: Muscular dystrophy, Amyotrophic
lateral sclerosis (Lou Gehrig's disease), Polio

2) Identify gluteus medius

a) Nerve supply: Superior gluteal nerve.

b) Action and consequence of weakness: Abduction and medial rotation of the lower limb.
It stabilises the pelvis during locomotion, preventing ‘dropping’ of the pelvis on the
contralateral side.

c) Causes of weakness of gluteus medius: damage to superior gluteal nerve

Weakness causes drooping of the pelvis to the contralateral side while walking.

d) Describe tredelenburg test

• A positive Trendelenburg sign usually indicates weakness in the hip abductor
muscles consisting of the gluteus medius and gluteus minimus.
• A positive sign is defined by a contralateral pelvic drop during a single leg stance.

3) What is the principle flexor of the hip? Iliopsoas

a) Where is the insertion. Show me. iliopsoas ends in a tendon that inserts to the lesser
trochanter of femur.
• iliopsoas is a muscle in the anterior compartment of the thigh. It is comprised of two
separate muscles; the psoas major and iliacus. These muscles arise in the pelvis and
pass under the inguinal ligament into the anterior compartment of the thigh – where
they form a common tendon.
o Psoas major – originates from the lumbar vertebrae
o Iliacus – originates from the iliac fossa of the pelvis.
o They insert together onto the lesser trochanter of the femur.

b) What muscle has its origin at the ASIS? Sartorious

c) What is its nerve supply? Femoral nerve (L2-L3)

d) What nerve runs under the inguinal ligament? Lateral cutaneous nerve of thigh

e) What syndrome happens if this nerve is caught? Meralgia paresthetica

f) show me the origin and insertion of the gluteus medius and minimus

Gluteus Medius Origin: gluteal surface of the ilium

Insertion: lateral surface of the greater trochanter
Action: Abduction and medial rotation of the lower limb. It stabilises
the pelvis during locomotion, preventing ‘dropping’ of the pelvis on
the contralateral side.
Nerve Supply: Superior gluteal nerve
Gluteus Origin: ilium
Minimus Insertion: converges to form a tendon, inserting to the anterior side of
the greater trochanter.
Action: Abduction and medial rotation of the lower limb. It stabilises
the pelvis during locomotion, preventing ‘dropping’ of the pelvis on
the contralateral side.
Nerve Supply: Superior gluteal nerve
Origin: gluteal (posterior) surface of the ilium, sacrum and coccyx.
 Gluteus Insertion: fibres slope across the buttock at a 45 degree angle and
Maximus insert onto the iliotibial tract and gluteal tuberosity of the femur
Action: main extensor of the thigh, and assists with lateral rotation.
However, it is only used when force is required, such as running or
climbing.
Nerve Supply: Inferior gluteal nerve

g) show me the origin and insertion of the quadratus femoris (note: intertrochanteric
crest insufficient- need to say pubic tubercle for insertion of quadratus femoris- I don’t even
know why this is?!)
• origin: Ischial tuberosity
• insertion: quadrate tuberosity on the Intertrochanteric crest of femur
h) Look at the provided LL angiogram, which one is SFA? What are the 3 branches?
• SFA terminates as popliteal artery, which then branches off as anterior and posterior
tibial artery
i) Anterior thigh - Identify femoral vein.
j) What structure is medial? (Femoral canal)

k) What structures are found in femoral sheath? femoral artery and femoral vein

l) Is femoral nerve inside femoral sheath? No!

m) What structure is this? (Rectus femoris- also look at prosection above picture at “i”)
n) What function? Extension of the knee joint and flexion of the hip joint.

o) Point out ITB. What inserts into ITB? (gluteus maximus, tensor fascia lata)

p) What does the ITB do when standing at attention? lock knee in extension
q) Posterior gluteal region, reflected gluteus maximus - What is this structure? (Gluteus
medius.) Nerve supply? Superior Gluteal nerve

r) What is its function when marching? It stabilises the pelvis during locomotion,
preventing ‘dropping’ of the pelvis on the contralateral side.

s) Posterior thigh - Identify biceps femoris. How many heads? Nerve supply?
• Long head originates from the ischial tuberosity of the pelvis.
• Short head originates from the linea aspera on posterior surface of the femur.
• The two heads form a tendon which inserts onto the head of the fibula.
• Innervation:
o Long head is innervated by the tibial part of the sciatic nerve
o Short head is innervated by the common fibular part of the sciatic nerve.

t) Identify common peroneal nerve. What muscles does it supply? What sensory supply?
• Nerve roots: L4 – S2
• Motor: Innervates the short head of the biceps femoris directly. Also supplies (via
branches) the muscles in the lateral and anterior compartments of the leg.
• Sensory: Innervates the skin of the lateral leg and the dorsum of the foot.

u) What happens in common peroneal nerve transection? Foot Drop

v) What is this? (Gastrocnemius.)

w) Is it affected if I cut the common peroneal nerve?

x) If no trauma but got loss of dorsiflexion and numbness of dorsum of foot, where do I look
for the lesion? Common Peroneal Nerve Compression, Sciatic nerve compression between
the two heads of the piriformis muscle leading to foot drop has been reported. (cannot find
answer)
4) Lower Limb

a) surface markings of DP and PT pulses

• dorsalis pedis pulse is palpable on the dorsum of the foot in the first intermetatarsal
space just lateral to the extensor tendon of the great toe.
• The posterior tibial pulse can be felt behind and below the medial malleolus.

b) surface mark EHL

• situated between the Tibialis anterior and the Extensor Digitorum Longus in the
anterior compartment of the lower leg

How to Palpate: place your fingers on the dorsum of the big toe and ask the patient to extend
the big toe (often extension of big toe can not be performed without extending the other toes).
Move your fingers to the prominent tendon to the big toe while the toes alternately are
extended and then relaxed.
c) Shown skeleton, which bones make up hip joint, stabilizing factors, why iliofemoral
ligament strongest? Muscles of walking and climbing stairs on cadaver.
• Bones making up hip joint: thighbone or femur, and the pelvis, which is made up
of three bones called ilium, ischium and pubis. The ball of the hip joint is made by
the femoral head while the socket is formed by the acetabulum.
• Hip Joint stabilizing factors: ligaments of the hip joint act to increase stability. They
can be divided into two groups – intracapsular and extracapsular:

Intracapsular Extracapsular
• Only • 3 main extracapsular ligaments, continuous with
intracapsular the outer surface of the hip joint capsule:
ligament is the
ligament of • Iliofemoral ligament – arises from the anterior
head of femur. It inferior iliac spine and then bifurcates before
is a relatively inserting into the intertrochanteric line of the
small structure, femur. It has a ‘Y’ shaped appearance, and
which runs from prevents hyperextension of the hip joint. It is the
the acetabular strongest of the three ligaments.
fossa to the
fovea of the • Pubofemoral – spans between the superior pubic
femur. rami and the intertrochanteric line of the femur,
reinforcing the capsule anteriorly and inferiorly. It
• It encloses a has a triangular shape, and prevents excessive
branch of the abduction and extension.
 obturator artery
(artery to head • Ischiofemoral– spans between the body of the
of femur), a ischium and the greater trochanter of the femur,
minor source of reinforcing the capsule posteriorly. It has a spiral
arterial supply orientation, and prevents hyperextension and
to the hip joint. holds the femoral head in the acetabulum.

• Iliofemoral ligament strongest: prevents excess extension; attaches the anterior

inferior iliac spine (AIIS) to the intertrochanteric crest of the femur.
• Muscles of walking: quadriceps and hamstrings, the calf muscles and the hip
adductors
• Muscles of climbing stairs: quadriceps muscles (located at the front of your thighs)
are especially important because they help stabilize the knee joint and take some of
the load off of your knees when climbing stairs.

d) Deltoid ligament anatomy.

• Deltoid ligament (aka medial collateral ligament) is a strong, triangular band that
reinforces the medial aspect of the ankle joint.
• This ligament is important to stabilize the ankle joint in eversion and prevent
dislocations of the joint (over-eversion).
• The medial collateral ligament has a proximal attachment on the apex and borders of
the medial malleolus. From here, the ligament fans out and inserts onto the talus,
calcaneus, and navicular bones.

e) Asked to identify the tendons with a metal pointer.

f) move the SP’s foot when the following muscles are used: Peroneus longus and brevis
together. Eversion

g) Attachment of Peroneus Longus and Peroneus Brevis

• Peroneus longus:
 o Origin: Proximal Fibula
o Insertion: Medial Cuneiform, 1st metatarsal
• Peroneus Brevis:
o Origin: Distal Fibula
o Insertion: Tuberosity of 5th Metatarsal

h) Muscles of dorsi flexion: tibialis anterior.

i) What to expect when gluteus medius injured.

j) What does gluteus medius do in walking.

k) Muscles of Plantar Flexion: gastrocnemius, soleus, and plantaris

l) Tibialis anterior and tibialis posterior together. Inversion

m) Gastrocnemius and soleus together. Plantar flexion

n) Nerve root of knee extension, flexion, Foot dorsiflexion and plantar flexion
• Knee Extension: L2, 3, 4
• Knee Flexion: L5, S1, S2
• Dorsiflexion: L4, L5
• Plantar Flexion: S1, S2

o) Nerve root value of plantar reflex: S1

p) Cutaneous supply of dorsal surface of foot and ventral surface of foot.

5) Lower limb – asked to identify bits like:

a) biceps femoris, tensor fascia lata.

b) Gastrocnemius?

c) Asked about nerve supply for biceps heads and what inserts into TFL. What is the
function of this muscle.
• Tensor fasciae latae is found superficial in the anterolateral aspect of the thigh,
spanning from the anterior portion of the iliac crest to the superior portion of the tibia,
onto which it inserts via the iliotibial tract.

d) Name the 4 (although examiner said 3 to me, just label deep/sup post as post)
compartments of LLs and their nerve supply.

Anterior Tibialis Anterior

• four muscles Originates from the lateral surface of the tibia
that act to Attaches to the medial cuneiform and the base of metatarsal I.
dorsiflex and Extensor digitorum longus (lies laterally and deep to the tibialis
invert the anterior. Its four tendons can be palpated on the dorsal surface of
foot. the foot.)
• innervated by Originates from the lateral condyle of the tibia and the medial
the deep surface of the fibula.
fibular nerve The fibres converge into a tendon, which travels onto the dorsal
(L4-S2). The surface of the foot.
arterial The tendon splits into four and each tendon inserts onto a toe.
supply is Extensor Hallucis Longus is positioned deep to tibialis anterior
through the and extensor digitorum longus. Its tendon emerges from between
the two muscles to insert onto the big toe.
anterior tibial
artery. Originates from the medial surface of the fibular shaft.
The tendon crosses anterior to the ankle joint and attaches to the
base of the distal phalanx of the great toe.
Peroneus Tertius
Originates with the extensor digitorum longus from the medial
surface of the fibula.
Its tendon descends onto the dorsal surface of the foot and attaches
to the fifth metatarsal.
Lateral Peroneus longus (is the larger and more superficial muscle within
• common the compartment).
function of • The fibularis longus originates from the superior and lateral
the muscles surface of the fibula and the lateral tibial condyle.
is eversion – • The fibres converge into a tendon, which descends into the
turning the foot, posterior to the lateral malleolus.
sole of the • The tendon crosses under the foot, and attaches to the bones
foot on the medial side, namely the medial cuneiform and base
outwards. of metatarsal I.
• They are Peroneus Brevis (deeper and shorter than the fibularis longus).
both • Originates from the inferolateral surface of the fibular shaft.
innervated by The muscle belly forms a tendon, which descends with the
the fibularis longus into the foot.
 superficial • It travels posteriorly to the lateral malleolus, passing over
fibular nerve. the calcaneus and the cuboidal bones.
• The tendon then attaches to a tubercle on the 5th metatarsal.
Posterior • three muscles within the superficial compartment of the
Superficial posterior leg.
• muscles in • They all insert onto the calcaneus (heel bone) of the foot,
this via the calcaneal tendon.
compartment Gastrocnemius is the most superficial of all the muscles in the
act to posterior leg. It has medial and lateral heads and forms the
plantarflex characteristic “calf” shape of the leg.
and invert the • The lateral head originates from the lateral femoral condyle.
foot. The medial head originates from the medial femoral
• They are condyle.
innervated by • The two heads combine to form a single muscle belly.
the tibial • Distally, the muscle belly converges with the soleus muscle
nerve (a to form the calcaneal tendon. This inserts onto the
branch of the calcaneus.
sciatic Soleus is a flat muscle located underneath the gastrocnemius. It
nerve). gets its name from its resemblance to a sole – a flat fish.
• Blood supply • Originates from the soleal line of the tibia and proximal
chiefly from fibula.
the posterior • The muscle converges with the fibers of the gastrocnemius
tibial artery. to form the calcaneal tendon, which inserts onto the
calcaneus.
Plantaris
• Originates from the lateral supracondylar line of the femur.
• The fibres condense into a tendon which travels down the
leg, between the gastrocnemius and soleus muscles.
• It blends with the calcaneal tendon and inserts onto the
calcaneus.
Posterior Deep • four muscles in the deep compartment of the posterior leg.
• muscles in • One muscle, the popliteus, acts only on the knee joint.
this • The remaining three muscles (tibialis posterior, flexor
compartment hallucis longus and flexor digitorum longus) act on the
act to ankle and foot.
plantarflex Popliteus is located behind the knee joint, forming the base of the
and invert the popliteal fossa.
foot. • There is a bursa (sac-like structure containing a small
• They are amount of synovial fluid) that lies between the popliteal
innervated by tendon and the posterior surface of the knee joint – it is
the tibial called the popliteus bursa.
nerve (a • Originates from the lateral condyle of the femur and the
branch of the lateral meniscus of the knee joint.
sciatic • It inserts onto the proximal tibia, immediately above the
nerve). origin of the soleus muscle.
• Blood supply Flexor Digitorum Longus is a thin muscle and is located medially
chiefly from within the posterior leg.
the posterior • Originates from the medial surface of the tibia and attaches
tibial artery. to the plantar surfaces of the lateral four digits.
 Flexor Hallucis Longus muscle is located laterally within the
posterior compartment (this is slightly counter-intuitive, as it is the
opposite side to the great toe).
• Originates from the posterior surface of the fibula and
attaches to the plantar surface of the phalanx of the great
toe.
Tibialis Posterior is the deepest out of the four muscles. It lies
between the flexor digitorum longus and the flexor hallucis longus.
• Originates from the posterior surface and interosseous
membrane of the tibia and fibula.
• The tendon enters the foot posterior to the medial malleolus
and attaches to the plantar surfaces of the medial tarsal
bones.

e) Muscles of posterior compartment of LL

f) Demonstrate knee and ankle jerk and nerve roots tested. Tendon tapper provided. Patient
was easy to elicit reflexes from.
• Knee Jerk: L3, L4
• Ankle Jerk: L5, S1
g) Dermatomes and Myotomes of LL
h) Attachments of peroneus longus, brevis, tertius

i) Causes of foot drop

j) Show S1 dermatome

k) Arterial supply of foot

l) Asked about the deltoid ligament, ATFL, CFL and PTFL and its attachments.

m) Also asked about what happens to the DP and PT after it leaves the foot (I only said
that the DP enters into the foot though the 1st web space, becomes the plantar arches and
gives off the digital arteries)
• Dorsalis pedis artery: It is the continuation of the anterior tibial artery and gives off
four branches that can be easily remembered with a mnemonic.
o FADT: First dorsal metatarsal, Arcuate, Deep plantar, Tarsal
 o The dorsalis pedis descends to supply the tarsals as well as the dorsal part of
the metatarsals. Next it dives deeper into the foot and anastomoses with the
lateral plantar artery to form the deep plantar arch.
• Posterior tibial artery: A branch of the popliteal artery; supplies the posterior
compartment of the leg.
o It gives off two branches; medial and lateral plantar arteries.
o PTA wind behind the medial malleolus and pass anteriorly to enter the foot via
the tarsal tunnel.
o The posterior tibial artery divides to form the medial and lateral plantar
arteries that broadly supply the sole of the foot.
o The medial and lateral plantar arteries supply the toes via the deep plantar
arch.
o The medial plantar supplies part of the hallux (big toe), the lateral plantar
supplies the vast majority of the foot.

6) Muscles of Hip

a) Glut. Medius et minimus origin and attachment

b) Quadratus femoris

c) Identify muscles. (gluteus maximus, medius and minimus)

d) Functions and nerve supply

e) Pointed to iliotibial tract

f) What is its function (stabilizes knee)

g) Femoral triangle

h) Bicep femoris (two heads and their nerve supply)

i) Muscles of leg and function

7) Anatomy

a) What is the origin and attachment of gluteus medius and its function. (He didn’t let me go
with a vague pointing around the iliac crest for the origin lol.)

b) What is the origin and insertion of the quadratus femoris (I forgot)

c) What is the main flexor of the hip

d) Pointed to ASIS. What is this and what muscle attaches here

e) What nerve is this. Lateral cutaneous nerve

f) What is the condition if this nerve is compressed.

8) Lower Limb

a) What is this? (points to ASIS) Anterior superior iliac spine.

b) What attaches here? Sartorius (he just wanted one answer).

c) What runs here? (pointed to region just beside ASIS under imaginary “inguinal
ligament”) Lateral femoral cutaneous nerve

d) What condition does this cause? Meralgia paresthetica

e) What is the major flexor of the hip? Ilipsoas.

f) What does it attach to? Lesser trochanter.

g) Asked about gluteus muscles; origin and insertion (point out on the skeleton).

l) Asked about function of gluteus medius/ minimus.

Want to hear Trendelenburg sign. And good side sags. Due to loss of hip abductors.

m) Where does quadratus femoris insert? Show on skeleton. Intertrochanteric crest.

n) Where does quadratus femoris originate? Ischial tuberosity.

9) Sciatic nerve anatomy- Cadaveric specimen

a) Sciatic nerve runs midpoint between which 2 landmarks: line drawn between GT and
Ischial tuberosity
b) Alternative courses of the sciatic nerve
• Sciatic nerve exits beneath the piriformis.
• Alternatively, either the whole nerve may pass through piriformis, or it may divide
high with one division passing through or around the piriformis.

c) Nerve roots: L4-S3

d) Point out hamstrings

• posterior compartment of the thigh are collectively known as the hamstrings.
• They consist of the biceps femoris, semitendinosus and semimembranosus.

e) What actions at hip and knee: extend at the hip, and flex at the knee

f) Point out popliteal fossa contents

• Its contents are (medial to lateral):
o Popliteal artery
o Popliteal vein
o Tibial nerve
o Common fibular nerve (common peroneal nerve)
g) What muscle is this (gluteus medius)

h) What does it do

i) What is Trendelenburg’s sign

10) Lower Limb/Hip

a) Name all the nerves

b) Name all the muscles of the hip (the usual)

c) If have injury here (gluteal region) what can be injured

d) Name LL vessels

e) Something about foot drop and where the areas of injury could be

11) Anatomy: posterior thigh

a) Sciatic nerve - identify, bony landmarks, Anatomical variation of its emergence, root
values

b) Gluteus medius - identify, nerve supply, function

c) Trendelenburg test- describe, causes of positive test

d) Hamstrings- identify (examiner kept confusing ST for short head of biceps femoris??!!),
origin, function at hip and knee, individual function of SM/ST and BF

e) Popliteal fossa - contents, structures at risk in # femur: popliteal artery

f) Popliteal nodes drainage: superficial regions of the posterolateral aspect of the leg and the
plantar aspect of the foot.

g) Name 1 swelling arising from each structure in the popliteal fossa

• Baker’s cyst (popliteal cyst) refers to the inflammation and swelling of the
semimembranosus bursa – a sac-like structure containing a small amount of synovial
fluid. It usually arises in conjunction with osteoarthritis of the knee.
o Whilst it usually self-resolves, the cyst can rupture and produce symptoms
similar to deep vein thrombosis.
• POPLITEAL ARTERY: Aneurysm is a dilation of an artery, which is greater than
50% of the normal diameter. The popliteal fascia (the roof of the popliteal fossa) is
tough and non-extensible, and so an aneurysm of the popliteal artery has
consequences for the other contents of the popliteal fossa.
• POPLITEAL VEIN: Deep vein thrombosis
• Adventitial cyst of the popliteal artery
• Various neoplasms (such as rhabdomyosarcoma).
• NERVE: Neuroma

12) LL hip Anatomy

LL anatomy of hip point, gluteal region and thigh
Thigh innervation and ligaments (inc iliotibial band syndrome)

13) Station- Post. thigh Anatomy

a) Scaitic Nerve - identification, root values, anatomy, variations.

b) Landmark of sciatic Nerve

c) Trendelenburg test - which muscles tested, the nerve supply.

d) Causes of positive Trendelenburg test

e) Identify hamstring - actions, nerve supply.

f) Content of popliteal fossa

g) Pathology from each one of them

14) Back of thigh and gluteal region with reflected Gluteus maximus

a) Identify sciatic nerve

b) Root value: L 4,5; S 1,2,3

c) 2 points to surface mark it in gluteal region: midway between Gt and ischial tuberosity

d) Identify Gluteus medius. Origin and insertion. N supply- sup gluteal nerve

e) Action of gluteus med during walking – prevents drooping of pelvis on opposite side

f) Clinical test if Gluteus med is weak- Trendelenburg test

g) other causes of a positive Trendelenburg test- divide into fulcrum, lever and power
h) Name hamstring muscles

i) Identify Biceps, semi membranous, semi tendinous

j) Actions of hamstring muscles-flexion at knee joint, weak extensors at hip, med and lat
rotation in a semi flexed knee

k) Structures in popliteal fossa

l) Which structure is at risk in supracondylar femur fracture? Pop artery

m) Causes of a swelling in popliteal fossa according to structure of origin. Said popliteal

vein thrombosis for vein, examiner waits, I corrected to varicosity. Examiner says you should
be kicking yourself for that.

15) Identify ASIS

a) Name one muscle that attaches there - Sartorius

b) Nerve that travels just next to ASIS (lateral cutaneous nerve of thigh) and what is
condition when it gets injured? Meralgia paresthetica

c) Origin and insertion of gluteus medius

d) Function of gluteus medius

e) Origin and insertion of quadratus

16) Lower Limb

a) Identify Sciatic Nerve

b) Nerve roots

c) The bony landmarks from which it emerges: ischial tuberosity and greater trochanter

d) Variations of its normal course in the buttock

• Normal: from under pyriformis
• Can be over pyriformis or under gamellus superioris

e) Identify gluteus medius

• Nerve supply
• Action and consequence of weakness
• Causes of weakness of gluteus medius

f) Describe tredelenburg test

g) Contents of the Popliteal Fossa

 • Identify Popliteal artery
• Identify common peroneal and tibial nerve

h) Structures that may be damaged in a supracondylar fracture

i) Possible causes of a swelling in the posterior knee (popliteal fossa)

Skin; Subcutaneous; Vascular; Bony

j) Where does the lymph nodes in the popliteal fossa drain from?
• from the lateral leg and foot, following the course of the short saphenous vein

17) Anatomy- hamstrings, gluteal region, popliteal fossa

a) Point to hamstrings on diagram

b) Origins of the hamstrings muscles

Biceps Femoris • The long head originates from the ischial

• Two heads (long head and tuberosity of the pelvis.
short head) and is the most • The short head originates from the linea aspera
lateral of the muscles in on posterior surface of the femur.
the posterior thigh. • Together, the heads form a tendon, which
• The common tendon of the inserts into the head of the fibula.
two heads can be felt • Innervation: Long head innervated by the tibial
laterally within the part of the sciatic nerve, whereas the short
popliteal fossa (posterior head is innervated by the common fibular part
knee region). of the sciatic nerve.
Semitendinosus • Originates from the ischial tuberosity of the
• largely tendinous muscle. pelvis.
• It is situated on the medial • Attaches to the medial surface of the tibia.
aspect of the posterior • Innervation: Tibial part of the sciatic nerve.
thigh and superficial to the
semimembranosus.
Semimembranosus • Originates from the ischial tuberosity (more
• flattened and broad superiorly than the origin of the
muscle. semitendinosus and biceps femoris).
• It is located deep to the • Attaches to the medial tibial condyle.
semitendinosus on the • Innervation: Tibial part of the sciatic nerve.
medial aspect of the
posterior thigh.
c) Identify sciatic nerve on diagram

d) What are the 2 bony landmarks associated with the sciatic nerve?

e) Course of sciatic nerve

• Sciatic nerve is derived from the lumbosacral plexus.
• After its formation, it leaves the pelvis and enters the gluteal region via greater sciatic
foramen.
• It emerges inferiorly to the piriformis muscle and descends in an inferolateral
direction.
• As the nerve moves through the gluteal region, it crosses the posterior surface of the
superior gemellus, obturator internus, inferior gemellus and quadratus femoris
muscles.
• It then enters the posterior thigh by passing deep to the long head of the biceps
femoris.
• Within the posterior thigh, the nerve gives rise to branches to the hamstring muscles
and adductor magnus.
• When the sciatic nerve reaches the apex of the popliteal fossa, it terminates by
bifurcating into the tibial and common fibular nerves.

f) Gluteal muscles and their nerve supply

g) Identify structures in popliteal fossa on diagram (from deep to superficial)

• tibial and common fibular nerves are the most superficial of the contents of the
popliteal fossa.
 o They are both branches of the sciatic nerve. The common fibular nerve
follows the biceps femoris tendon, travelling along the lateral margin of the
popliteal fossa.
• deepest structure is the popliteal artery.
o It is a continuation of the femoral artery, and travels into the leg to supply it
with blood.
 LOWER LIMB- Popliteal Fossa, Femoral Triangle, Adductor Canal

1) Anatomy- femoral triangle, adductor canal

Anterior Thigh- Patient had 10cm laceration 10cm inferior and parallel to inguinal
ligament.

a) Boundaries of femoral triangle (Include Floor, Roof, medial, lateral borders) &
contents
• Femoral triangle is a wedge-shaped area located within the superomedial aspect of the
anterior thigh.
o It acts as a conduit for structures entering and leaving the anterior thigh.
• The femoral triangle consists of three borders, a floor and a roof:
o Roof – fascia lata.
o Floor – pectineus, iliopsoas, and adductor longus muscles.
o Superior border – inguinal ligament (a ligament that runs from the anterior
superior iliac spine to the pubic tubercle).
o Lateral border – medial border of the sartorius muscle.
o Medial border – medial border of the adductor longus muscle. The rest of this
muscle forms part of the floor of the triangle.
• The inguinal ligament acts as a flexor retinaculum, supporting the contents of the
femoral triangle during flexion at the hip.
• The femoral triangle contains some of the major neurovascular structures of the lower
limb. Its contents (lateral to medial) are:
o Femoral nerve – innervates the anterior compartment of the thigh, and
provides sensory branches for the leg and foot.
o Femoral artery – responsible for the majority of the arterial supply to the lower
limb.
o Femoral vein – the great saphenous vein drains into the femoral vein within
the triangle.
o Femoral canal – contains deep lymph nodes and vessels.
• The femoral artery, vein and canal are contained within a fascial compartment –
known as the femoral sheath.
• Acronym for the contents of the femoral triangle (lateral to medial) – NAVEL: Nerve,
Artery, Vein, Empty space (allows the veins and lymph vessels to distend to
accommodate different levels of flow), Lymph nodes.
b) What vessels will be cut – superficial femoral, circumflex vessels. What muscles will be
cut (Quadriceps femoris, sartorius, adductor longus)

c) What nerve is this – femoral nerve, (root value: L2, L3, L4) what 4 muscle supplied by
it?
• Innervates the anterior thigh muscles that flex the hip joint (pectineus, iliacus,
sartorius) and extend the knee (quadriceps femoris: rectus femoris, vastus lateralis,
vastus medialis and vastus intermedius).

d) What muscles does it supply

e) What cutaneous supply of saphenous nerve: medial leg and calf, terminating distally at
the “ball” of the great toe

f) Boundaries of adductor canal

• Adductor canal (Hunter’s canal, subsartorial canal) is a narrow conical tunnel located
in the thigh.
• It is approximately 15cm long, extending from the apex of the femoral triangle to the
adductor hiatus of the adductor magnus. The canal serves as a passageway from
structures moving between the anterior thigh and posterior leg.
• The adductor canal is bordered by muscular structures:
o Anteromedial – Sartorius.
o Lateral – Vastus medialis.
o Posterior – Adductor longus and adductor magnus.
• The adductor canal runs from the apex of the femoral triangle to the adductor hiatus –
a gap between the adductor and hamstring attachments of the adductor magnus
muscle.
g) What runs through adductor canal
• The adductor canal serves as a passageway for structures moving between the anterior
thigh and posterior leg.
• It transmits the femoral artery, femoral vein (posterior to the artery), nerve to the
vastus medialis and the saphenous nerve – the largest cutaneous branch of the femoral
nerve.
• As the femoral artery and vein exit the canal, they are called the popliteal artery and
vein respectively.

h) What exits adductor hiatus: femoral artery & femoral vein

i) Femoral sheath, which structures: femoral artery & femoral vein

j) Boundaries of femoral canal opening

• femoral canal is an anatomical compartment located in the anterior thigh. It is the
smallest and most medial part of the femoral sheath. It is approximately 1.3cm long.
• The femoral canal is located in the anterior thigh within the femoral triangle.
• It can be thought of as a rectangular shaped compartment with four borders and an
opening:
o Medial border – lacunar ligament.
o Lateral border – femoral vein.
o Anterior border – inguinal ligament.
o Posterior border – pectineal ligament, superior ramus of the pubic bone, and
the pectineus muscle.
• The opening to the femoral canal is located at its superior border, known as the
femoral ring. The femoral ring is closed by a connective tissue layer – the femoral
septum. This septum is pierced by the lymphatic vessels exiting the canal.

k) Contents of femoral canal

• The femoral canal contains:
o Lymphatic vessels – draining the deep inguinal lymph nodes.
o Deep lymph node – the lacunar node.
o Empty space.
o Loose connective tissue.
• The empty space allows distension of the adjacent femoral vein, so it can cope with
increased venous return, or increased intra-abdominal pressure.

l) What is the purpose of the empty space in the femoral canal? accommodate expansion
of femoral vessels

m) Moved on to the subsartorial (ADDUCTOR) canal- What are the surfaces of the
subsartorial canal?
• The midpoint between the anterior superior iliac spine (ASIS) and the patellar base
corresponds to the femoral triangle.
• The AC is located a few centimeters distal to this region. For reference, the following
are the borders of the femoral or Scarpa triangle:
o Proximal border - inguinal ligament
o Lateral border - medial border of sartorius
o Medial border - medial border of adductor longus
o Floor - iliopsoas, pectineus, adductor longus, and adductor brevis muscles
o Apex - the intersection between the medial borders of the sartorius and
adductor longus muscles
n) Which nerves runs in it? saphenous nerve, nerve to the vastus medialis

o) Which artery runs in it? superficial femoral artery

p) Showed 2 angiogram, one of the pelvic artery angiogram and one of the LL
angiogram.
q) Show me the femoral artery

r) What are the branches of the femoral artery?

• Mnemonic: Do Princesses Sew Sweet Superhero Dresses?
o Descending genicular artery
o Profunda femoris artery
o Superficial epigastric
o Superficial circumflex iliac
o Superficial external pudendal
o Deep external pudendal arteries
s) Show me the profunda femoris on the angiogram?

2) Femoral triangle, borders, contents.

a) Femoral ring and canal.

• femoral ring is the superior rounded opening of the conical femoral canal.
• Its boundaries are:
o medial: lacunar ligament
o anterior: medial part of the inguinal ligament
o lateral: femoral vein within the intermediate compartment of the femoral
sheath
o posterior: pectineal ligament overlying the pectineus muscle and its fascia
covering the superior pubic ramus
b) Muscles of anterior compartment of thigh

Iliopsoas • is comprised of two separate Innervation: The psoas

muscles; the psoas major and major is innervated by
iliacus. anterior rami of L1-3,
• These muscles arise in the pelvis while the iliacus is
and pass under the inguinal innervated by the femoral
ligament into the anterior nerve.
 compartment of the thigh – where
they form a common tendon.
• Unlike many of the anterior thigh
muscles, the iliopsoas does not
perform extension of the leg at the
knee joint.
• Attachments: The psoas major
originates from the lumbar
vertebrae, and the iliacus
originates from the iliac fossa of
the pelvis. They insert together
onto the lesser trochanter of the
femur.
Quadriceps Vastus Lateralis Innervation: Femoral
Femoris • Proximal attachment: Originates nerve.
• consists of from the greater trochanter and
four the lateral lip of linea aspera of
individual the femur.
muscles Vastus Intermedius Innervation: Femoral
• four • Proximal attachment: Originates nerve.
muscles from the anterior and lateral
collectively surfaces of the femoral shaft.
insert onto Vastus Medialis Innervation: Femoral
the patella • Proximal attachment: Originates nerve.
via the from the intertrochanteric line and
quadriceps medial lip of the linea aspera of
tendon. the femur.
• The Rectus Femoris Innervation: Femoral
patella, in • Attachments: Originates from the nerve.
turn, is anterior inferior iliac spine and
attached to the ilium of the pelvis. It attaches
the tibial to the patella via the quadriceps
tuberosity femoris tendon.
by the
patella
ligament.
Sartorius • longest muscle in the body. Innervation: Femoral
• It is long and thin, running across nerve.
the thigh in a inferomedial
direction.
• The sartorius is positioned more
superficially than the other
muscles in the leg.
• Attachments: Originates from the
anterior superior iliac spine, and
attaches to the superior, medial
surface of the tibia.
 Pectineus • flat, quadrangular-shaped muscle Innervation: Femoral
which contributes to the floor of nerve. May also receive a
the femoral triangle. branch from the obturator
• Attachments: Originates from the nerve.
pectineal line of the pubis bone. It
inserts onto the pectineal line on
the posterior aspect of the femur,
immediately inferior to the lesser
trochanter.

c) adductor canal and contents

d) nerve roots of femoral.

e) Branches of profunda femoris.

• medial circumflex femoral artery
• lateral circumflex femoral artery
• 3 x perforating arteries
f) Identify Sciatic Nerve

g) sciatic nerve path.

h) Hamstring muscles – origin /insertion.

i) Contents of popliteal fossa

j) What can give rise to a lump in popliteal fossa – name one lump per tissue (Skin,
artery, vein, nerve, muscle, joint)

3) lower Limb Anatomy

a) Sciatic Nerve roots

b) The bony landmarks from which it emerges: ischial tuberosity and greater trochanter

c) Variations of its normal course in the buttock

• Normal: from under pyriformis
• Can be over pyriformis or under gamellus superioris

4) Contents of the Popliteal Fossa

a) Identify Popliteal artery

b) Identify common peroneal and tibial nerve

c) Structures that may be damaged in a supracondylar fracture: popliteal artery

d) Possible causes of a swelling in the posterior knee (popliteal fossa)- Skin;

Subcutaneous; Vascular; Bony
e) Where does the lymph nodes in the popliteal fossa drain from? from the lateral leg and
foot, following the course of the short saphenous vein

f) There is a skeletal model and you are given a pointer.

5) Anatomy

a) Femoral triangle (some dumb butcher, cleaved his own thigh during work)

b) Boundaries, contents, identify muscles and fem oral vessels

c) Boundaries of femoral canal, what's the importance (lymphatics)

d) Branches of femoral nerve, Identify LI, L2, L3 dermatomes

e) Look at the provided LL angiogram, which one is SFA? What are the 3 branches?
• SFA terminates as popliteal artery, which then branches off as anterior and posterior
tibial artery

6) Anterior thigh- Butcher injured himself while cutting, injury- 10 cm long cut parallel
to inguinal ligament, 10 cm below inguinal ligament.

a) What are boundaries of femoral triangle? Contents?

b) What structures would be injured by the cut? Arteries, veins, nerves, muscles

c) Femoral sheath, femoral canal

d) Muscles supplied by femoral nerve

• innervate anterior thigh muscles or flexors of the hip (pectineus, iliacus, sartorius) and
the extensors of the knee (quadriceps femoris)

e) What passes through adductor canal?

f) Saphenous nerve anatomy, and sensory area

 • Saphenous nerve is a cutaneous branch of the femoral nerve in the lower limb.
• Arises from the posterior division of the femoral nerve at the level of the mid-thigh.
• It accompanies the femoral artery within the adductor canal (a muscular tunnel
located in the thigh).
• At the end of the canal, the adductor hiatus, the saphenous nerve pierces the fascia
between the sartorius and gracilis muscles on the medial aspect of the knee.
• It then travels superficially along the medial side of the leg (accompanied by the long
saphenous vein) – supplying the skin on the medial aspect of the knee, leg, and foot.

• Saphenous nerve supplies cutaneous innervation to the skin of the anteromedial knee,
leg and foot.

7) Pic of right gluteal region and popliteal fossa

a) Sciatic nerve: identify & anatomical Landmark, route value, variations with regard
to the sciatic nerve exit the pelvis

b) show hamstring muscles with its origin & action

c) Identify Gluteus medius, nerve supply, action, Trendelenburg test

d) Identify Popliteal fossa-boundaries, contents superficial to deep, LN draining the

area

e) D/D of lump from popliteal fossa (examiner wants to hear examples from each 1
structure like from vein-popliteal vein varicosities; from artery, nerve, fat, bone)

f) Most common structure in popliteal fossa can injured during surgery: common peroneal
nerve (not sure?)

8) Lower limb- anatomy prosection (posterior view of leg):

a) sciatic nerve anatomy and landmarks

b) gluteal muscles and nerve supply

c) identify various hamstring muscles

d) structures in popliteal fossa

e) causes of lump in popliteal fossa

f) venous drainage of lower leg: veins of the lower limb can be divided into two groups –
deep and superficial:

• Deep veins are located underneath the deep fascia of the lower limb, accompanying
the major arteries.
o As a general rule, the deep veins accompany and share the name of the major
arteries in the lower limb. Often, the artery and vein are located within the
same vascular sheath – so that the arterial pulsations aid the venous return.
o FOOT & LEG: main venous structure of the foot is the dorsal venous arch,
which mostly drains into the superficial veins.
▪ veins from the arch penetrate deep into the leg, forming the anterior
tibial vein.
▪ On the plantar aspect of the foot, medial and lateral plantar veins arise.
These veins combine to form the posterior tibial and fibular veins.
▪ The posterior tibial vein accompanies the posterior tibial artery,
entering the leg posteriorly to the medial malleolus.
▪ On the posterior surface of the knee, the anterior tibial, posterior tibial
and fibular veins unite to form the popliteal vein. The popliteal vein
enters the thigh via the adductor canal.
o THIGH: Once the popliteal vein has entered the thigh, it is known as the
femoral vein. It is situated anteriorly, accompanying the femoral artery.
▪ The deep vein of the thigh (profunda femoris vein) is the other main
venous structure in the thigh. Via perforating veins, it drains blood
from the thigh muscles. It then empties into the distal section of the
femoral vein.
 ▪The femoral vein leaves the thigh by running underneath the inguinal
ligament, at which point it is known as the external iliac vein.
o GLUTEAL REGION: drained by inferior and superior gluteal veins. These
empty into the internal iliac vein.

• Superficial veins are found in the subcutaneous tissue. They eventually drain into the
deep veins.
o There are two major superficial veins – the great saphenous vein, and the
small saphenous vein.
o Long saphenous vein is formed by the dorsal venous arch of the foot, and the
dorsal vein of the great toe. It ascends up the medial side of the leg, passing
anteriorly to the medial malleolus at the ankle, and posteriorly to the medial
condyle at the knee.
▪ As the vein moves up the leg, it receives tributaries from other small
superficial veins. The great saphenous vein terminates by draining into
the femoral vein immediately inferior to the inguinal ligament.
▪ Surgically, the great saphenous vein can be harvested and used as a
vessel in coronary artery bypasses.
o Small saphenous vein is formed by the dorsal venous arch of the foot, and the
dorsal vein of the little toe. It moves up the posterior side of the leg, passing
posteriorly to the lateral malleolus, along the lateral border of the calcaneal
tendon.
▪ At the level of the knee, the short saphenous vein passes between the
two heads of the gastrocnemius muscle and empties into the popliteal
vein in the popliteal fossa.
9) Lower limb

a) Mass at back of popliteal fossa, what could it be if it arises from Skin, subcutaneous
tissue, Muscle, Bone, Joint

b) Sciatic nerve- Root value

c) Anatomical variations in relation to pyriformis — above it, through it

d) Passes between which two bone prominences in gluteal region

e) Contents of popliteal fossa, their relations to each other

f) Actions of hamstrings — functions of individual muscles

g) Identify muscles in picture — gluteus medius

h) Nerve supply to [Link]

i) Function of abductors
• pelvic stabilization during walking and running; abduction and rotation at the hip joint
 • primary hip abductor muscles include the gluteus medius, gluteus minimus, and
tensor fasciae latae.
• secondary hip abductors include the piriformis, sartorius, and superior fibers of the
gluteus maximus.

j) What is meant by positive trendelenberg test

10) lower limb popliteal fossa

a) identify the gluteus medius from picture

b) nerve supply

c) function

d) explain Trendelenburg sign

e) causes of Trendelenburg sign

f) identify sciatic nerve

g) variations of sciatic nerve

h) show the bony prominences between which sciatic nerve passes

i) identify the muscles of hamstring muscles and their origin and their function

j) identify structures in popliteal fossa

k) dd of swelling than can happen in popliteal fossa

l) tell the drainage of popliteal lymph nodes in superficial and deep drainage

11) Anatomy- Identify this muscle on prosection image (Gluteus Maximus)

a) what is its nerve supply.

b) What is the Function of Gluteus MEDIUS.

c) What are the bony landmarks associated with the sciatic nerve.

d) The sciatic nerve passes under piriform is, what are the other 2 anatomical variants
in relation to piriform is.

e) Identify the three ham string muscles on a prosection.

f) Identify the structures in the popliteal fossa in a prosecution image (popliteal artery,
vein, tibial and common fibular nerve).
g) What structure is at risk in a supracondylar fracture.

h) Rapid fire differentials for a popliteal swelling due to skin, artery, vein, joint

12) Anatomy 3:

a) boundaries of femoral triangle (see 1a)

b) identify femoral artery and vein (see 1a)

c) femoral nerve and m. Supplied by? (see 1c)

d) susartorial canal and boundaries, contents (see 1f)

e) surface anatomy of femoral artery

f) surface anatomy of saphenofemoral junction: accurately represented as lying within a
square between 1 and 4 cm lateral and 0–3 cm below the pubic tubercle

g) boundaries of femoral ring

• femoral ring is the superior rounded opening of the conical femoral canal.
• Its boundaries are:
o medial: lacunar ligament
o anterior: medial part of the inguinal ligament
o lateral: femoral vein within the intermediate compartment of the femoral
sheath
o posterior: pectineal ligament overlying the pectineus muscle and its fascia
covering the superior pubic ramus
h) contents of femoral sheath: femoral artery & femoral vein

13) Lower Limb: Scenario of man stabbed just 10cm below and parallel to the inguinal
ligament.

a) Mention the structures vulnerable to injury?

b) Identify inguinal ligament

c) borders of inguinal canal, contents: inguinal canal is bordered by anterior, posterior,

superior (roof) and inferior (floor) walls. It has two openings – the superficial and deep rings.
• Walls
o Anterior wall – aponeurosis of the external oblique, reinforced by the internal
oblique muscle laterally.
o Posterior wall – transversalis fascia.
• Roof – transversalis fascia, internal oblique, and transversus abdominis.
• Floor – inguinal ligament (a ‘rolled up’ portion of the external oblique aponeurosis),
thickened medially by the lacunar ligament.
• A helpful mnemonic to remember the walls of the inguinal canal is: MALT: (2M, 2A,
2L, 2T)
• Starting from superior, moving anticlockwise in order to posterior:
o Superior wall (roof): 2 Muscles
▪ internal oblique Muscle
▪ transversus abdominis Muscle
o Anterior wall: 2 Aponeuroses
▪ Aponeurosis of external oblique
▪ Aponeurosis of internal oblique
o Lower wall (floor): 2 Ligaments
▪ inguinal Ligament·
▪ lacunar Ligament
o Posterior wall: 2 Ts
▪ Transversalis fascia
▪ conjoint Tendon

• Contents of the inguinal canal include:

o Spermatic cord (biological males only) – contains neurovascular and
reproductive structures that supply and drain the testes.
o Round ligament (biological females only) – originates from the uterine horn
and travels through the inguinal canal to attach at the labia majora.
 o Ilioinguinal nerve – contributes towards the sensory innervation of the
genitalia.
▪ Note: only travels through part of the inguinal canal, exiting via the
superficial inguinal ring (it does not pass through the deep inguinal
ring)
▪ This is the nerve most at risk of damage during an inguinal hernia
repair.
o Genital branch of the genitofemoral nerve – supplies the cremaster muscle and
anterior scrotal skin in males, and the skin of the mons pubis and labia majora
in females.

d) Femoral ring

e) boundaries, femoral canal

f) femoral artery surface anatomy

g) femoral nerve and its root value

h) 4 muscles supplied by it

i) Sartorius muscle

j) adductor longus, adductor (sub-sartorial) canal boundaries and contents

k) branches of femoral artery and profunda femoris artery

l) angiogram (aorto-iliac) in iPad identify arteries

m) dermatomes of the lower limb

14) Anatomy: Femoral triangle and adductor canal (basically just mug Snell pg. 575)

a) Points to sartorius. What is this muscle?

b) Where is its origin?

c) Which surface does it form in the femoral triangle? Medial Border

d) What are the other boundaries of the femoral triangle?

• The femoral triangle consists of three borders, a floor and a roof:
o Roof – fascia lata.
o Floor – pectineus, iliopsoas, and adductor longus muscles.
o Superior border – inguinal ligament (a ligament that runs from the anterior
superior iliac spine to the pubic tubercle).
o Lateral border – medial border of the sartorius muscle.
o Medial border – medial border of the adductor longus muscle. The rest of this
muscle forms part of the floor of the triangle.

e) What makes up the floor of the femoral triangle?

f) What does it contain? Femoral Nerve, Artery, Vein

g) Moved on to the subsartorial canal?

• The adductor canal is bordered by muscular structures:
o Anteromedial – Sartorius.
o Lateral – Vastus medialis.
o Posterior – Adductor longus and adductor magnus.

h) What are the surfaces of the subsartorial canal?

• The midpoint between the anterior superior iliac spine (ASIS) and the patellar base
corresponds to the femoral triangle.
• The AC is located a few centimeters distal to this region. For reference, the following
are the borders of the femoral or Scarpa triangle:
o Proximal border - inguinal ligament
o Lateral border - medial border of sartorius
o Medial border - medial border of adductor longus
o Floor - iliopsoas, pectineus, adductor longus, and adductor brevis muscles
o Apex - the intersection between the medial borders of the sartorius and
adductor longus muscles
i) Which nerves runs in it?

j) Which artery runs in it?

k) Showed 2 angiogram, one of the pelvic artery angiogram and one of the LL
angiogram.

l) Show me the femoral artery

m) What are the branches of the femoral artery?

n) Show me the profunda femoris on the angiogram?

15) Anatomy- Lower limb anatomy

a) Femoral triangle

b) Name four muscles you can see

c) Femoral canal (boundaries and function)

d) Adductor canal

e) Dermatome

f) Supply of saphenous nerve

g) Roots of femoral nerve

h) Landmark of femoral artery

i) CT Angio and branches of femoral artery

 LOWER LIMB- Leg

1) Articulate tibia and fibula (handed me fibula upside down)

a) Show how ankle mortise fits together

• The distal tibia and fibula articular portions together form the ankle mortice, which
contains the body of talus bone.
• The ankle joint entires three malleoli
o the lateral malleolus (distal end of the fibula)
o medial malleolus (medial lower end of the tibia)
o and the posterior malleolus.

b) What kind of joint is distal tib-fib joint (syndesmotic)

• A syndesmosis is a complex fibrous joint between two bones and connected by
ligaments and a strong membrane with slightly movement allowed.
• The distal tibiofibular syndesmosis/inferior tibiofibular joint is a syndesmotic joint.

c) Show (using own ankle) movement of ankle joint purely (dorsi and plantar flexion)
• The ankle joint is a hinge type joint, with movement permitted in one plane. Thus,
plantarflexion and dorsiflexion are the main movements that occur at the ankle
joint.
 • Eversion and inversion are produced at the other joints of the foot, such as the subtalar
joint.

d) Show (using own ankle) movements of subtalar joint (inversion/eversion)

e) Which position is ankle more stable in and why (dorsiflexion due to wider talus
anteriorly)

f) Describe main component of deltoid ligament (think he wanted tibionavicular?)

• The deltoid ligament, originating from the medial malleolus, fans out into four
components before attaching to the talus, calcaneus, and navicular:
o anterior tibiotalar
o posterior tibiotalar
o tibiocalcaneal
o tibionavicular
• posterior tibiotalar ligament (PTTL) is the strongest component of the deltoid
ligament complex.

g) Show where lateral collateral ankle ligaments attach on skeleton

o lateral collateral ligament (complex) of the ankle is a set of three ligaments that resist
inversion of the ankle joint.
o They are more commonly injured than the medial collateral (deltoid) ligament of the
ankle.
o They run from the lateral malleolus of the fibula to the talus and calcaneus.
h) Identify sustentaculum tali
i) Identify bones of foot and medial + lateral longitudinal arches
j) Tendons on anterior of foot
k) Blood supply of foot (wanted details of how PT splits into medial and lateral plantar
arteries to form plantar arch, where DP pierces through dorsum of foot to plantar side, and
which plantar artery it joins with)
o Dorsalis pedis (a continuation of the anterior tibial artery)
o dorsalis pedis artery begins as the anterior tibial artery enters the foot. It passes
over the dorsal aspect of the tarsal bones, then moves inferiorly, towards the
sole of the foot. It then anastomoses with the lateral plantar artery to form the
deep plantar arch.
o Posterior tibial
o enters the sole of the foot through the tarsal tunnel. It then splits into the
lateral and medial plantar arteries. These arteries supply the plantar side of
the foot and contributes to the supply of the toes via the deep plantar arch.
2) Leg anatomy, guy fell from horse, leg crushed (doesn’t say which part of the leg)
[Repeat]

a) On the SP, show me where is the lateral malleolus. Which bone does it belong to?
Fibula

b) What are the compartments of the leg (not the thigh)

Anterior Tibialis Anterior

Originates from the lateral surface of the tibia
 • four muscles Attaches to the medial cuneiform and the base of metatarsal I.
that act to Extensor digitorum longus (lies laterally and deep to the tibialis
dorsiflex and anterior. Its four tendons can be palpated on the dorsal surface of
invert the the foot.)
foot. Originates from the lateral condyle of the tibia and the medial
• innervated by surface of the fibula.
the deep The fibres converge into a tendon, which travels onto the dorsal
fibular nerve surface of the foot.
(L4-S2). The The tendon splits into four and each tendon inserts onto a toe.
arterial Extensor Hallucis Longus is positioned deep to tibialis anterior
supply is and extensor digitorum longus. Its tendon emerges from between
through the the two muscles to insert onto the big toe.
anterior tibialOriginates from the medial surface of the fibular shaft.
artery. The tendon crosses anterior to the ankle joint and attaches to the
base of the distal phalanx of the great toe.
Peroneus Tertius
Originates with the extensor digitorum longus from the medial
surface of the fibula.
Its tendon descends onto the dorsal surface of the foot and attaches
to the fifth metatarsal.
Lateral Peroneus longus (is the larger and more superficial muscle within
• common the compartment).
function of • The fibularis longus originates from the superior and lateral
the muscles surface of the fibula and the lateral tibial condyle.
is eversion – • The fibres converge into a tendon, which descends into the
turning the foot, posterior to the lateral malleolus.
sole of the • The tendon crosses under the foot, and attaches to the bones
foot on the medial side, namely the medial cuneiform and base
outwards. of metatarsal I.
• They are Peroneus Brevis (deeper and shorter than the fibularis longus).
both • Originates from the inferolateral surface of the fibular shaft.
innervated by The muscle belly forms a tendon, which descends with the
the fibularis longus into the foot.
superficial • It travels posteriorly to the lateral malleolus, passing over
fibular nerve. the calcaneus and the cuboidal bones.
• The tendon then attaches to a tubercle on the 5th metatarsal.
Posterior • three muscles within the superficial compartment of the
Superficial posterior leg.
• muscles in • They all insert onto the calcaneus (heel bone) of the foot,
this via the calcaneal tendon.
compartment Gastrocnemius is the most superficial of all the muscles in the
act to posterior leg. It has medial and lateral heads and forms the
plantarflex characteristic “calf” shape of the leg.
and invert the • The lateral head originates from the lateral femoral condyle.
foot. The medial head originates from the medial femoral
• They are condyle.
innervated by • The two heads combine to form a single muscle belly.
 the tibial • Distally, the muscle belly converges with the soleus muscle
nerve (a to form the calcaneal tendon. This inserts onto the
branch of the calcaneus.
sciatic Soleus is a flat muscle located underneath the gastrocnemius. It
nerve). gets its name from its resemblance to a sole – a flat fish.
• Blood supply • Originates from the soleal line of the tibia and proximal
chiefly from fibula.
the posterior • The muscle converges with the fibers of the gastrocnemius
tibial artery. to form the calcaneal tendon, which inserts onto the
calcaneus.
Plantaris
• Originates from the lateral supracondylar line of the femur.
• The fibres condense into a tendon which travels down the
leg, between the gastrocnemius and soleus muscles.
• It blends with the calcaneal tendon and inserts onto the
calcaneus.
Posterior Deep • four muscles in the deep compartment of the posterior leg.
• muscles in • One muscle, the popliteus, acts only on the knee joint.
this • The remaining three muscles (tibialis posterior, flexor
compartment hallucis longus and flexor digitorum longus) act on the
act to ankle and foot.
plantarflex Popliteus is located behind the knee joint, forming the base of the
and invert the popliteal fossa.
foot. • There is a bursa (sac-like structure containing a small
• They are amount of synovial fluid) that lies between the popliteal
innervated by tendon and the posterior surface of the knee joint – it is
the tibial called the popliteus bursa.
nerve (a • Originates from the lateral condyle of the femur and the
branch of the lateral meniscus of the knee joint.
sciatic • It inserts onto the proximal tibia, immediately above the
nerve). origin of the soleus muscle.
• Blood supply Flexor Digitorum Longus is a thin muscle and is located medially
chiefly from within the posterior leg.
the posterior • Originates from the medial surface of the tibia and attaches
tibial artery. to the plantar surfaces of the lateral four digits.
Flexor Hallucis Longus muscle is located laterally within the
posterior compartment (this is slightly counter-intuitive, as it is the
opposite side to the great toe).
• Originates from the posterior surface of the fibula and
attaches to the plantar surface of the phalanx of the great
toe.
Tibialis Posterior is the deepest out of the four muscles. It lies
between the flexor digitorum longus and the flexor hallucis longus.
• Originates from the posterior surface and interosseous
membrane of the tibia and fibula.
• The tendon enters the foot posterior to the medial malleolus
and attaches to the plantar surfaces of the medial tarsal
bones.
c) What are the nerves that supply each compartment?

d) What are the muscles in the posterior compartment

e) Dermatomal area supplied by deep and superficial peroneal nerves, sural and
saphenous nerves

f) Show on the SP and name the movements of the muscles I describe to you: Tib
Post+Tib Ant, Peroneus Longus+Brevis, Gastroc+Soleus
• Muscles of dorsi flexion: tibialis anterior.
• Muscles of Plantar Flexion: gastrocnemius, soleus, and plantaris
• Gastrocnemius and soleus together. Plantar flexion
• Tibialis anterior and tibialis posterior together. Inversion
• move the SP’s foot when the following muscles are used: Peroneus longus and brevis
together. Eversion

g) Demonstrate to me the knee and ankle reflexes. What nerve roots are you testing?

h) Attachment of peroneus brevis and tertius

i) Sensory supply area of L5 and S1 nerve root

j) Now let’s talk about the man in the scenario, you have assessed his leg and he is still in
a lot of pain, he complains there is altered sensation in his foot and you cannot feel the
pulse. What condition are you most concerned about? Compartment syndrome.

3) Lower limb- STEM: Young man fell off the horse, trapped under for hours.
Questions: Live patient lying there.

a) Surface mark lateral malleolus, what bone is it from: fibula

• situated on the outer side of the ankle.
• Its lateral surface faces outwards and is easily palpable due to its subcutaneous nature.
• The front surface is rough and rounded, providing attachment for the anterior
talofibular ligament.
• The medial surface faces inward toward the tibia and talus.

b) Surface mark EHL

• situated between the Tibialis anterior and the Extensor Digitorum Longus in the
anterior compartment of the lower leg
How to Palpate: place your fingers on the dorsum of the big toe and ask the patient to extend
the big toe (often extension of big toe can not be performed without extending the other toes).
Move your fingers to the prominent tendon to the big toe while the toes alternately are
extended and then relaxed.

c) Show the movement of TA+TP, PL+PB, gastrocnemius + soleus

• Muscles of dorsi flexion: tibialis anterior.
• Muscles of Plantar Flexion: gastrocnemius, soleus, and plantaris
• Gastrocnemius and soleus together. Plantar flexion
• Tibialis anterior and tibialis posterior together. Inversion
• move the SP’s foot when the following muscles are used: Peroneus longus and
brevis together. Eversion

d) Attachments of peroneus longus, brevis, tertius

e) Causes of foot drop

• Foot drop is an inability to lift the forefoot due to the weakness of dorsiflexors of the
foot.
o This, in turn, can lead to an unsafe antalgic gait, potentially resulting in falls.
• A) Most commonly, foot drop is caused by an injury to the peroneal nerve.
o Some common ways the peroneal nerve is damaged or compressed include:
Sports injuries, Diabetes, Hip or knee replacement surgery, Spending long
hours sitting cross-legged or squatting, Childbirth, Time spent in a leg cast
• B) Neurological conditions can contribute to foot drop. These include: Stroke,
Multiple sclerosis (MS), Cerebral palsy, Charcot-Marie-Tooth disease
 • C) Muscle disorders. Conditions that cause the muscles to progressively weaken or
deteriorate may cause foot drop. These include: Muscular dystrophy, Amyotrophic
lateral sclerosis (Lou Gehrig's disease), Polio

f) Myotomes of LL + reflexes (show how your elicit knee jerk, ankle jerk) Show S1
dermatome

g) Name peripheral nerves of LL

h) Name compartments of the LL and nerve supply

i) Muscles of posterior compartment of LL

j) Patient complaining of intense pain of LL given stem, what do you suspect

(compartment syndrome)

4) Lower leg Anatomy

a) Compartment muscles and nerves

b) Action

c) Sensation

d) Reflexes

e) Dermatomes

5) Anatomy- Stem was this lady was riding a horse and fell off. now with multiple
injuries over the lower limb. basically, just an excuse to whack you on questions about
the LL; anatomy of lower limb.

a) Identify gluteus max, med, mini, tensor fascia lata, ITB

b) nerve supple of glut med

c) basis of trendenlenburg gait/sign

d) identify rectus femoris, insertion to where?

• Origin: Anterior inferior iliac spine, supraacetabular groove
• Insertion: Tibial tuberosity (via patellar ligament), patella

e) pointed to rubbery thing around fibula head - common peroneal nerve

f) what happens in a palsy of this: foot drop

g) which compartments does it supply

• Anterior compartment: deep fibular nerve (aka deep peroneal nerve)
 • Lateral compartment: superficial fibular nerve (aka superficial peroneal nerve)

h) where is the sensory loss

• COMMON PERONEAL NERVE
o Nerve roots: L4 – S2
o Motor: Innervates the short head of the biceps femoris directly. Also supplies
(via branches) the muscles in the lateral and anterior compartments of the leg.
o Sensory: Innervates the skin of the lateral leg and the dorsum of the foot.

i) patient cannot extend the big toe at all. where are the other possible lesions, easy
question
• Extensor hallucis longus is innervated by the deep fibular nerve (root value L5 and
S1)

6) Anatomy of Lower limbs (Simulated patient)

a) Demonstrate action of the EHL

• Metatarsophalangeal and interphalangeal joint 1: toe extension
• talocrural joint: foot dorsiflexion
• EXTENDS Big Toe, INVERSION of foot, DORSIFLEXION of ankle

• Manual Muscle test

o Patient position : supine or sitting.
o Test: extension of metatarsophalangeal and interphalangeal joints of the big
toe.
o Pressure: against dorsal surface of distal phalanges of the big toe in the
direction of flexion.

b) Demonstrate action of the tibialis anterior/tibialis posterior

• Tibialis Anterior: Dorsiflexion and Inversion
• Tibialis Posterior: Plantarflexion

c) Demonstrate action of the peroneus brevis and peroneus longus

• Lateral Compartment of leg muscles: Eversion

d) Show how you feel the dorsalis pedis and posterior tibial pulses
• dorsalis pedis pulse is palpable on the dorsum of the foot in the first intermetatarsal
space just lateral to the extensor tendon of the great toe.
• The posterior tibial pulse can be felt behind and below the medial malleolus.

e) What are the compartments of the leg

f) What are the innervations for the individual compartments

g) Attachments of peroneus longus/tertius/brevis

• Peroneus Tertius: fifth metatarsal.
• Peroneus Longus: medial cuneiform and base of metatarsal I.
• Peroneus Brevis: tubercle on the 5th metatarsal
h) Sensory distribution for deep and superficial peroneal nerve

i) Approach to foot drop

• Approach to the Patient: The approach to a patient depends upon the etiology of foot
drop and the nature of the compressive lesion. Based on the evaluation and diagnostic
findings, many options exist.

• Surgical Options:
o In trauma cases, for nerve transection, nerve reconstruction should take place
within 72 hours of injury.
▪ Primary nerve repair techniques, autologous nerve grafts are usually
performed.
o For complete nerve compression, necrolysis and nerve decompression should
be performed. Return to function has been reported in about 97%.
▪ A surgical release may be necessary for patients with equinus
deformity.
o In cases of significant nerve dysfunction, nerve or tendon transfers may be
required.
o For the other etiologies, treatment is initially conservative because there may
be a chance of partial or complete resolution of symptoms spontaneously
overtime.

• Conservative Management:
o This includes physical therapy and or splinting and pharmacological therapy to
manage pain. The goals of conservative management are to stabilize the gait,
prevention of falls and contractures.
o Physical therapy focuses on stretching and strengthening muscles.
o Electrical stimulation techniques of the weekend dorsi flexors have shown
promise.
o A home exercise program should be an integral part of therapy- specifically to
maintain the strength and range of motion of muscle groups that are working
in the prevention of flexion contracture.
o Splinting is utilized to minimize contractures.
o For complete nerve palsies with insufficient recovery, an ankle-foot orthosis
(AFO) to prevent further plantarflexion should be ordered. Sufficient
education and training should be included to assist in the proper usage and
maintenance of the brace.
o For patients with numbness, instructions for skincare to prevent abrasions and
ulcerations are a significant part of management and are often coordinated
with the orthotist fabricating the AFO.
o For pain management, topical analgesics, serotonin reuptake inhibitors,
membrane stabilizers, and opioids can be used. But are not likely to result in
clinical recovery.
o Follow up electrodiagnostic studies to reassess the situation, looking for
reinnervation should also be part of the treatment planning.

j) Level of lesion if unable to dorsiflex toe and loss of sensation of 1st web space
• Deep peroneal nerve involved.
7) Anatomy. Lower limbs

a) surface markings of DP and PT pulses

b) move the SP’s foot when the following muscles are used.
i. Peroneus longus and brevis together. Eversion
ii. Tibialis anterior and tibialis posterior together. Inversion
iii. Gastrocnemius and soleus together. Plantar flexion

c) Name the 4 (although examiner said 3 to me, just label deep/sup post as
post) compartments of LLs and their nerve supply.

d) Demonstrate knee and ankle jerk and nerve roots tested. Tendon tapper provided.
Patient was easy to elicit reflexes from.
• Knee Jerk: L3, L4
• Ankle Jerk: L5, S1
e) Dermatomes and Myotomes of LL
8) Anatomy- Lower limb

a) name hamstring muscle and nerve supply

Biceps Femoris • The long head originates from the ischial

• Two heads (long head and tuberosity of the pelvis.
short head) and is the most • The short head originates from the linea aspera
lateral of the muscles in on posterior surface of the femur.
the posterior thigh. • Together, the heads form a tendon, which
• The common tendon of the inserts into the head of the fibula.
two heads can be felt • Innervation: Long head innervated by the tibial
laterally within the part of the sciatic nerve, whereas the short
popliteal fossa (posterior head is innervated by the common fibular part
knee region). of the sciatic nerve.
Semitendinosus • Originates from the ischial tuberosity of the
• largely tendinous muscle. pelvis.
• It is situated on the medial • Attaches to the medial surface of the tibia.
aspect of the posterior • Innervation: Tibial part of the sciatic nerve.
thigh and superficial to the
semimembranosus.
Semimembranosus • Originates from the ischial tuberosity (more
• flattened and broad superiorly than the origin of the
muscle. semitendinosus and biceps femoris).
• Attaches to the medial tibial condyle.
 • It is located deep to the • Innervation: Tibial part of the sciatic nerve.
semitendinosus on the
medial aspect of the
posterior thigh.

b) name muscle of anterior compartment

c) name muscle in posterior compartment

d) surface mark the posterior tibial artery and dorsalis pedis artery
• dorsalis pedis pulse is palpable on the dorsum of the foot in the first intermetatarsal
space just lateral to the extensor tendon of the great toe.
• The posterior tibial pulse can be felt behind and below the medial malleolus.

e) dermatome of superficial peroneal and deep peroneal nerve

f) muscle for eversion and inversion

g) what complication if patient complain of numbness of anterior compartment and big

toe extension pain: deep peroneal nerve involvement (peroneal nerve injury)

9) Anatomy: lower limb. A semulator lying down knees and below bare. Muscles,
movements, nerve supply. Knee and ankle jerks, how to perform and what is the root
value.
 LOWER LIMB- Foot and Ankle

1) Tibia, Fibula, foot bones- Anatomy: Given a tibia, fibula foot skeleton, and cadaveric
specimen of leg/foot

a) Please put the tibia and fibula in its correct orientation.

b) Now place it on the foot in the right orientation – Have to put the tib and fib together
and put it on the talus of the foot correctly.

c) Name the bones of the foot (and point on the skeleton)

d) There are 4 ligaments that make up the medial collateral ligament of the foot. What are
they and show me their attachments.

e) What are the lateral ligaments of the foot that attach to fibula?

f) What type of joint is the inferior tibiofibular joint?

g) Points at doral foot tendons – Name these tendons: Tibialis anterior, Ext hallucis longus,
Ext digitorium, Peroneus tertius

h) Show me on yourself, w hat movements occur at the ankle joint?

i) What movements occurs at the subtalar joint?

2) Articulate tibia and fibula

a) Name the bones of the foot

b) What constitutes the lateral longitudinal arch?

c) In which position is the ankle joint most stable, and why?

d) What are the tendons in the anterior of the foot

e) What is the arterial supply of the foot? How do the dorsal and plantar supplies
anastomose?

f) What are the actions of the ankle joint? Where does inversion/eversion take place?

g) What is the medial ankle ligament? (deltoid)

h) Where does it attach to? (He was fine with navicular, talus and calcaneus)

i) What is this? – points to sustentaculum tali

j) What is the lateral ankle ligament components? 3 main: ATFL, PTFL and CFL

k) bones that make up medial and lateral arch. Remember that lateral arch distally includes
4th metatarsal too apart from just the 5th. Got this wrong.

l) medial and lateral collateral ligaments. NOT the deltoid ligaments.

m) identify extensor tendons in dorsum of foot from medial to lateral

n) which muscles invert evert foot, most stable position of ankle..

3) Foot and ankle:

a) identify all the bones of the foot.

b) orient right tibia and fibula and position them with foot model.

c) type of distal tibiofibular joint, and what bone is commonly fractured with its injury.
(lateral malleolus)

d) identify lateral arch of the foot

e) what ligaments form the medial and lateral collateral ligaments of ankle joint

f) What type of joint is distal Tibiofibular joint? fibrous

g) what is this part of bone: sustintaculum tali.

h) what bones form the midtarsal joints, and show movements of ankle and midtarsal joints in
your own foot.

i) ankle is more stable in which position. (dorsiflextion, bcz talus is in its widest diameter)

j) show me the palpable pulses in the foot, and how the form circulation in the foot.

k) what muscle causes foot inversion

4) Anatomy 1: Foot & Ankle

a) Name all the bones

b) Name all the ligaments on the medial (4) and lateral aspect (3) - and point them out.

c) What bones make up the lateral arch?

d) Demonstrate on yourself the movements of the ankle joint.

e) What are the tendons of anterior compartment and identify them on the specimen.

f) Which tendons invert the foot

g) Where would you identify the pulse on the dorsum of the foot

5) Ankle anatomy: identify bones of foot and orientate tibia and fibula.

a) Movements at ankle and subtalar joints

b) lateral longitudinal arch

c) muscles causing eversion?

d) Muscles causing inversion?

e) Identify ligaments of ankle joint with their individual parts.

f) What arteries cross ankle joint?

g) How to palpate them?

h) Identify extensor hallucis.

i) Muscles of anterior compartment?

j) Identify posterior tibial artery, how does it supply plantar aspect of foot.

k) What joint is the lower tibiofibular joint?

6) Anatomy- Ankle and foot- photographs again plus bone model of foot

a) One very impractical question on how we will articulate tibia and fibula via photographs-
difficult to understand the question.

b) Bones of foot identify

c) arches

d) blood supply of foot

e) Ankle and sub-talar movement

f) tendons causing inversion- identify.

7) Anatomy - Ankle dissection + Tibia Fibula Ankle Foot bones

a) Identify all foot bones.

b) Articulate tibia, fibula and ankle joint

c) Ligaments of ankle

d) Demonstrated ankle joint movement on myself

e) Inversion and eversion - muscles involved

f) Bones are involved in arches of foot?

g) Joint between distal tibia and fibula - type. What injury occurs if it disrupts?

h) Major pulses in foot and how to pulsate them

i) Arterial arches of foot

j) Identify tendons in anterior of ankle joint

8) Lower limb

a) Nerve and reflex root values

b) Muscle spotters and identify muscles for foot movements

c) Ask human model to do the movements

d) What are the tendons, nerves and blood vessels behind the medial malleolus
d) Point out the dorsalis pedis and posterior tibial pulses, the EHL tendon and the sensory
area of the deep peroneal nerve

9) Anatomy- Foot anatomy

a) Shown bones of foot, name the arches and constituents.

b) Fix tibia/fibula together with talas

c) Which position is most stable?

d) Deltoid ligaments of ankle

e) Lateral collateral ligaments of ankle

f) List all the tendons present on anterior foot

g) Which muscles cause inversion?

h) Where are the PTA and dorsalis pedis artery?

10) Anatomy: Given a tibia, fibula foot skeleton, and cadaveric specimen of leg/foot. in
the right orientation – Have to put the tibia and fibula together and put it on the talus of
the foot correctly.

a) Please put the tibia and fibula in its correct orientation. Now place it on the foot.

b) Name the bones of the foot (and point on the skeleton).

c) What bones make up the lateral longitudinal arch of foot?

d) There are 4 ligaments that make up the medial collateral ligament of the [Link] are they
and show me their attachments?

e) What are the lateral ligaments of the foot that attach to fibula?

f) What type of joint is the inferior tibiofibular joint?

g) Points at dorsal foot tendons – Name these tendons: Tibialis anterior, Ext. hallucis longus,
Ex. digitorum, Peroneus tertius.

h) Show me on yourself, what movements occur at the ankle joint? What

i) What are the movements occurring at the subtalar joint?

11) Anatomy Stations- Foot/Ankle

a) Name bones of foot

b) Deltoid ligament

c) Which position is the ankle most stable

d) Put tibia and fibula together

e) Tendons of foot

f) Arterial supply of foot

g) Inversion - what muscles/nerve

h) Actions of ankle joint

12) Foot/ankle (bones)- Standard foot ankle session, name the bones of the foot, classify
the distal tibulo fibular joint, all the components of the medial and lateral ankle
ligaments, attachment of the arches (demonstrate). Demonstrate ankle movements when
asked.

13) Anatomy- tibia/fibula, ankle

a) Orient the tibia/fib u la

b) Name each bone of the foot

c) Subtalar joint- talo-navicular and calcaneo-cuboid

d) Name bones that form medial and lateral arches of foot

e) Sustentaculum tali (alternatively, the talar shelf], which gives attachment to the plantar
calcaneo-navicular (spring) ligament, tibiocalcaneal ligament, and medial talocalcaneal
ligament.

f) Medial ankle collateral ligament

g) Lateral ankle collateral ligament

h) Which position is the ankle most stable

i) Movements of ankle

j) Show tendons and name muscles of all compartments of LL

k) Landmarks of dorsalis pedis and posterior tibial artery

1) Blood supply of foot

m) Muscles responsible for inversion of foot & eversion of foot

14) Ankle and foot

a) how to put a Tib and fib together- its superior and inferior articulations.

b) identify sustentac tali

c) bones that make up medial and lateral arch. Remember that lateral arch distally includes 4th
metatarsal too apart from just the 5th. Got this wrong.

d) medial and lateral collateral ligaments. NOT the deltoid ligaments.

e) identify extensor tendons in dorsum of foot from medial to lateral

f) which muscles invert evert foot, most stable position of ankle.

15) Anatomy: Ankle - all images of prosections/diagram of bones, structures labelled

with letters
a) Name bones of foot and point to letter they correspond to

b) Which bones make up lateral arch

c) Identify + name: structures behind medial malleolus, muscles involved in inversion of foot

d) Where is dorsalis pedis and posterior tibial palpated, describe + show on images

e) What is the blood supply to the foot

f) Actions at the tibio-talar joint - dorsiflexion, plantarflexion

g) Actions at the sub-talar joint - inversion, eversion

h) Demonstrate inversion and eversion (examiner stood up to see me demonstrate)

i) Which muscles are responsible for eversion - peroneus longus, brevis

j) Ligaments of the medial ankle

k) Ligaments damaged in medial malleolus fracture

16) A construction worker attended A&E with injury to right lateral leg

a) Which muscles cause ankle inversion, eversion, planter-flexion

b) Nerve roots for ankle, knee reflex, check these reflexes on patient
c) Palpate dorsalis pedis and post tibial pulses

d) Identify Extensor hallucis longus, anterior tibialis in pro-section

e) Dermatome of big toe

f) Know the symptoms of compartment syndrome

17) Station- Pts. with leg injury

(4 pictures from 4 sides, 2 small are away; I could not see anything)
Others I cant remember- its like note mostly; Completed, need to wait for at least minute

a) Fibula attachment in tibia

b) Tarsal bones, ligaments identification

c) Attachment of deltoid ligament Ligaments

d) Demonstration of movement of ankle

e) Inversion eversion demonstrate, joint responsible