Anatomy_Head, Brain, Neck, Autonomic Nervous System

Eustachian tube
The Eustachian tube, also known as the pharyngotympanic tube or auditory tube connects the middle ear to the
nasopharynx. The posterolateral third of the tube is bony and the remainder cartilaginous. The bony part of the
Eustachian tube perforates the petrous temporal bone. The Eustachian tube in a child is shorter and more horizontal. The
opening of the auditory tube lies above the soft palate adjacent to the tubal tonsil.

The cartilaginous part of the Eustachian tube is intimately related to the greater wing of the sphenoid, although the tube
does not penetrate it.

The cartilaginous part of the Eustachian tube is intimately related to the greater wing of the sphenoid, not the lesser wing.

MUSCLES OF FACIAL EXPRESSION

The facial muscles are subcutaneous (just under the skin, in the same plane as the platysma) muscles that control facial
expression. They generally originate on bone and insert on the skin of the face. The facial muscles are innervated by cranial
nerve VII, also known as the facial nerve. The facial muscles are derived from the second pharyngeal arch.

There are several small muscles of facial expression that do not have a bony attachment. For example, risorius arises from
the parotid fascia and inserts to the modiolus- a meeting place of several facial muscles at the lateral aspect of the mouth.

long buccal nerve

The long buccal nerve innervates the buccal mucosa and the lateral pterygoid. It is a minor branch of the mandibular
division of the trigeminal nerve.

Major facial nerve branches

 Temporal branch.
 Zygomatic branch.
 Buccal branch.
 Marginal mandibular branch.
 Cervical branch.

lingual nerve
The lingual nerve (shown in blue) is one of three major branches of the posterior division of the mandibular division of the
trigeminal nerve. The other two major nerves are the auriculo-temporal nerve and the inferior alveolar nerve.

Chorda tympani
The chorda tympani is a branch of the facial nerve that carries taste fibres from the anterior two-thirds2/3 of the tongue,
and parasympathetic fibres to the submandibular and sublingual glands.

Oral cavity malignancies

Oral cavity malignancies are usually squamous-cell carcinomas and 35% of these occur on the tongue. They tend to be
located on the lateral edge of the tongue. These types of cancer are associated with tobacco smoking, low fruit/vegetable
diet, and alcohol consumption.
 Although tongue cancers as a whole are the most common oral cavity cancers, these are mostly found on the anterior
two-thirds of the tongue rather than on its base.

acoustic neuroma
This patient has presented with symptoms consistent with a vestibular schwannoma also known as an acoustic neuroma.
These are benign primary intracranial tumours arising from the myelin forming cells of the vestibulocochlear nerve (CN VIII).
These can cause symptoms associated with hearing and vertigo. As they grow in size they can compress the facial nerve,
although this tends to be late in the disease process, or often due to damage of the nerve from surgical excision. More
commonly, the trigeminal nerve is affected.

The foramen lacerum

The internal carotid artery, a branch from the ascending pharyngeal artery, and the greater petrosal nerve traverse the
foramen lacerum. This would not cause the symptoms described.

foramen magnum
The foramen magnum transmits the medulla oblongata, spinal arteries, the spinal accessory nerve, and the vertebral
arteries.

The foramen rotundum

The foramen rotundum transmits the maxillary branch of the trigeminal nerve. This would not account for the symptoms
described.

The foramen spinosum

1. The foramen spinosum transmits the middle meningeal artery and vein and the meningeal branch of mandibular nerve.
This would not account for the symptoms described.

Lateral pterygoid
The lateral pterygoid muscle is important for active opening of the mouth – drawing the condyle and disc forwards from the
mandibular fossa.

Buccinator
The buccinators has a role of assisting with chewing, although it is not technically regarded as a muscle of mastication.
Specifically, it has a role in holding the cheek to the teeth during chewing, and is supplied by the facial nerve.

The facial nerve supplies the muscles of facial expression including innervating buccinator. This muscle is involved in
emptying the buccal sulcus during mastication.

Masseter
The masseter is a muscle of mastication, although its main role is closure of the mouth.

Medial pterygoid
The action of the medial pterygoid is to elevate the mandible, protract it, and laterally displace the mandible. It is a muscle
of mastication and supplied by the mandibular branch of the trigeminal (nerve to medial pterygoid).

Temporalis

 The temporalis muscle is a muscle of mastication whose main role is to close the mouth and elevate the jaw. Its posterior
fibres have a role in retracting the jaw as well.
foramen ovale
The mandibular division of the trigeminal nerve is the correct answer. This nerve passes through the foramen ovale with the
accessory meningeal artery, lesser petrosal nerve, and emissary veins; the otic ganglion is at the entrance to the
foramen.

The greater petrosal nerve

This nerve follows are tortuous course from the facial nerve. First it travels in the petrous temporal bone, travels over the
foramen lacerum, then through the pterygoid canal to reach the pterygopalatine ganglion. It is the lesser petrosal nerve
that passes through the foramen ovale.

EYE
The iris separates the anterior and posterior chambers. These regions, however, should not be confused with the anterior
and posterior segments. The posterior segment consists of the vitreous humour, and structures posterior to this including
the optic nerve and retina.

The lens represents the posterior limit of the anterior segment.

The cornea represents the most anterior structure of the eyeball. It is transparent, and has protective qualities. Its
curvature assists in refracting light.

The pupil represents the aperture within the iris muscle that allows light to fall on the retina.

The ciliary processes are continuous with the choroid. The suspensory ligaments of the lens originate from the posterior
surface.

stapedius muscle
The stapedius muscle within the middle ear dampens (less strong) sound. It is innervated by one of the branches of the
facial nerve (nerve to stapedius), which is given off before the facial nerve exits the stylomastoid foramen. Therefore
injury to the facial nerve at the level of the parotid would not affect this muscle.
somatic sensation to the face
The somatic sensation to the face is supplied by the branches of the trigeminal nerve, not the facial nerve.

Levator palpebrae superioris

Levator palpebrae superioris is supplied by the superior division of the oculomotor nerve and sympathetic fibres carried on
the internal carotid artery. The facial nerve is not involved.

taste sensation
The taste sensation from the anterior two-thirds of the tongue are carried by the chorda tympani, which joins the lingual
nerve (branch of the trigeminal nerve) in its extra-cranial portion. The intra-cranial portion is carried by the facial nerve but
would not be affected by damage to the facial nerve at the level of the parotid.

submandibular gland
The facial artery arises from the external carotid artery, on the anteromedial surface. It gives off an ascending palatine
artery and tonsillar artery. The facial artery passes deep to the posterior belly of digastric and then runs on the posterior
surface of the submandibular gland.

The hypoglossal nerve runs deep to the submandibular gland rather than running through it. This nerve is at risk of injury
in submandibular gland excision.

The submandibular gland lies superficial to the hyoglossus muscle.

The submandibular gland lies within the digastric triangle (part of the anterior triangle). This triangle is bound inferiorly by
the two bellies of the digastric muscle and superiorly lies bound by the lower border of the mandible. Therefore the
submandibular gland lies superior to the digastric muscle.

The marginal mandibular branch of the facial nerve lies superiorly and superficially to the submandibular gland. Its close
relationship with the gland is the reason why surgeons will have a tendency to maintain more than one finger’s breadth
from the inferior margin of the mandible before making their initial incision for excision of the gland. Damage to the
marginal mandibular branch leads to ipsilateral paralysis of the muscles supplying mouth expression, leading to drooping
of the corner of the mouth and drooling.

The lingual nerve lies deep the submandibular gland and is intimately related to the submandibular duct. Descends lateral
to it then goes under and medially and then ascends medially) It is at risk of injury during these procedures.
The mylohyoid muscle lies between the superficial and deep parts of the submandibular gland.

The internal jugular vein lies deep and laterally to the submandibular gland.

The external carotid artery lies deep and laterally to the submandibular gland.

The submandibular duct (Wharton’s duct) is about 5 cm long and its wall is much thinner than that of the parotid duct. It
begins from numerous branches from the deep surface of the submandibular gland and runs forward between the
mylohyoid and the hyoglossus and genioglossus, then between the sublingual gland and the genioglossus and opens by a
narrow orifice on the summit of a small papilla, at the side of the frenulum linguae, near the midline in the anterior aspect
of the floor of the mouth. On the hyoglossus it lies between the lingual and hypoglossal nerves, but at the anterior border
of the muscle it is crossed laterally by the lingual nerve. The terminal branches of the lingual nerve ascend on its medial
side.

The digastric muscle is inferior to the submandibular gland. The mylohyoid lies deep to the superficial lobe of the
submandibular gland. The mylohyoid separates the superficial and deep lobes of the submandibular gland.

The lingual nerve lies laterally to the submandibular duct and medial to the gland. It is at risk in submandibular gland
excision along with the hypoglossal nerve.

The facial vein is superficial to the submandibular gland.

The cervical branch of the facial nerve passes inferiorly to the submandibular gland.

The facial artery passes over the posterior surface of the submandibular gland in a groove.
tongue
The lymphoid tissue at the base of the tongue is also known as the lingual tonsil. It forms a part of Waldeyer’s ring – a ring
of lymphoid tissue within the pharynx. These lymphoid structures may become enlarged from benign causes (eg reactive
secondary to infection) or malignancy (primary or secondary).

The circumvallate (vallate) papillae are large and flat topped, and found anteriorly to the terminal sulcus of the tongue in
two rows forming a V-shape (vary in number from 8 to 12). The circumvallate papillae get special afferent taste innervation
from cranial nerve IX, the glossopharyngeal nerve, even though they are anterior to the sulcus terminalis. The rest of the
anterior two-thirds of the tongue gets taste innervation from the chorda tympani. Ducts of lingual salivary glands, known as
Von Ebner's glands empty a serous secretion into the base of the papillae.

The fungiform papillae represent normal structures and are interspersed among the filiform papillae, usually situated on
the tip and sides of the tongue. They have taste buds on their upper surface which can distinguish the five tastes: sweet,
sour, bitter, salty, and umami.

Foliate papillae are short vertical folds and are present on each side of the tongue.[2] They are located on the sides at the
back of the tongue, just in front of the palatoglossal arch of the fauces. Because their location is a high risk site for oral
cancer, and their tendency to occasionally swell, they may be mistaken as tumors or inflammatory disease. Taste buds, the
receptors of the gustatory sense, are scattered over the mucous membrane of their surface. Serous glands drain into the
folds and clean the taste buds. Lingual tonsils are found immediately behind the foliate papillae and, when hyperplastic,
cause a prominence of the papillae.

The filiform papillae represent normal structures situated on the anterior two-thirds of the tongue. Filiform papillae are
the most numerous of the lingual papillae. They are fine, small, cone-shaped papillae covering most of the dorsum of the
tongue. They are responsible for giving the tongue its texture and are responsible for the sensation of touch. Unlike the
other kinds of papillae, filiform papillae do not contain taste buds.
Nasal meatuses
The posterior ethmoidal sinus drains into the superior meatus.

It is the nasolacrimal duct that drains into the inferior meatus.

The frontal sinus and the anterior ethmoid cells (sinus) drains into the infundibulum of the middle meatus.

The maxillary sinus and middle ethmoidal cells (ethmoid bulla) open into the middle meatus

The sphenoidal sinus drains into the sphenoethmoidal recess, which is posterior and superior to the superior concha.

The middle meatus contains the bulla ethmoidalis (or the ethmoid bulla). The ethmoid bulla is caused by bulging lamella of
the middle ethmoidal cells and may be a pneumatised cell – and thereby forming a large prominent anterior air cell – or just
a bony prominence – termed torus ethmoidalis.

facial nerve
The buccinator is one of the muscles of facial expression, and is therefore supplied by the facial nerve (buccal branch). The
facial nerve exits the skull via the stylomastoid foramen and enters the parotid gland, where it splits into five terminal
branches – temporal, zygomatic, buccal, marginal mandibular and cervical.

Digastrics muscle
The posterior belly of the digastric muscle is supplied by the digastric branch of the facial nerve.

The anterior belly of digastric is supplied by the nerve to mylohyoid, from the inferior alveolar nerve – a branch of the
mandibular division of the trigeminal nerve.

Medial pterygoid
The medial pterygoid muscle is supplied by the V3 nerve (mandibular branch of the trigeminal nerve), via the nerve to the
medial pterygoid muscle. The nerve to the medial pterygoid also supplies two other muscles: the tensor veli palatini and
the tensor tympani.

mylohyoid muscle
The mylohyoid muscle and anterior belly of the digastric muscle are supplied by the mylohyoid nerve (or nerve to
mylohyoid), a branch of the mandibular division of the trigeminal nerve.

temporalis muscle

The temporalis muscle is supplied by the mandibular division of the trigeminal nerve, as are the other muscles of
mastication.

trigeminal nerve
The ophthalmic and maxillary divisions of the trigeminal nerve are largely sensory, although they do carry parasympathetic
and sympathetic nerve fibres. They do not innervate skeletal muscle however.

angle of the mandible

The angle of the mandible is supplied by the great auricular nerve (C2–C3).
anterior division of the mandibular branch of the trigeminal nerve
The inner cheek mucosa is supplied by the buccal branch of the anterior division of the mandibular branch of the
trigeminal nerve – the only sensory branch of the anterior division.

The anterior division of the mandibular division of the trigeminal nerve contains branches to lateral pterygoid, masseter
and temporalis muscles and buccal skin. Injury to this nerve produces deviation of the jaw towards the side of the lesion
on protrusion due to the unopposed action of the contralateral lateral pterygoid.

Sensation to the lower teeth and gums is via the inferior alveolar nerve, which comes from the posterior division of the
mandibular division of the trigeminal nerve.

tongue
The tongue is retracted up and back by the styloglossus muscle, protruded by genioglossus and depressed by the
hyoglossus. All these muscles are innervated by the hypoglossal nerve (CN XII).

It is active during the voluntary phase of swallowing, not passive

EUSTACHIAN TUBE
The cartilaginous part of the Eustachian tube gives attachment to the tensor veli palatini muscle. This muscle is innervated
by the nerve to medial pterygoid, which is a branch of the mandibular branch of the trigeminal nerve.

The palatine tonsils are situated in the oropharynx while the Eustachian tube opens into the nasopharynx. Its opening is
surrounded by the tubal tonsil. It can be obstructed by enlarged adenoids, which can increase the risk of glue ear (chronic
otitis media with effusion).

The Eustachian tube opens on swallowing under the action of the salpingopharyngeus and tensor palati muscles.

The Eustachian tube drains the middle ear. The opening to the Eustachian tube from the middle ear is situated in the
inferior anterior and medial aspect of the middle ear.

PAROTID GLAND
The medial wall of the capsule is separated from the carotid sheath by the styloid process and associated muscles
(stylopharyngeus, stylohyoid, styloglossus)

The duct passes anteriorly and superficial to the masseter.

The fibrous capsule of the parotid gland is an upward extension of the deep investing layer of cervical fascia that attaches
to the zygomatic arch.

The external carotid artery passes through the gland, supplying it as it does so, before dividing into its terminal branches,
the superficial temporal and maxillary arteries. The facial nerve passes through the gland, but does not innervate it, and
divides into its five terminal branches. Other structures that lie within the gland include the retromandibular vein and,
often, lymph nodes.

The parotid receives blood from the external carotid artery as it passes through the gland. The posterior auricular artery
comes off from the external carotid, before the external carotid artery divides into its two terminal branches, the maxillary
and the superficial temporal branches.
The parotid duct is approximately 5 cm long. The parotid duct crosses the masseter, turning around its anterior border to
pass through the buccal fat pad and pierce the buccinator. When intraoral pressure is raised, the submucous part of the
parotid duct is compressed by the [Link] opening of the parotid duct (Stenson’s duct) is opposite the second upper
molar tooth. The parotid duct opens on the middle third of a line between the intertragic notch of the auricle and the
midpoint of the philtrum, opposite the second upper molar.

The parasympathetic supply to the parotid gland is from the inferior salivatory nucleus via the tympanic and lesser
petrosal branches of the glossopharyngeal nerve that project to the otic ganglion (preganglionic). Postganglionic fibres pass
from the otic ganglion to the parotid via the auriculotemporal nerve (a branch of the mandibular nerve).

Thyroid arteries
The structures at risk are classically the recurrent laryngeal nerve which is most at risk, followed by the external branch of
the superior laryngeal nerve.

The superior thyroid artery is closely related to the external branch of the superior laryngeal nerve. It may be injured in
dissection of the superior pedicle of the thyroid lobe.

The inferior thyroid artery is related to the recurrent laryngeal nerve. It may be injured in the inferior sub-platysmal
dissection and dissection of the inferior thyroid pedicle.

Ascending palatine artery

The ascending palatine artery is a branch of the facial artery and is closely related to the superior pharyngeal constrictor,
not the superior laryngeal nerve.

PALATINE TONSILLAR BED

The external palatine vein drains the tonsil, into the pharyngeal plexus which subsequently drains into the internal jugular
vein. The venous plexus around the tonsillar bed is a common source of bleeding after tonsillectomy.

ICA is located 2-2.5 cm lateral and posterior to the palatine tonsils

The palatine tonsillar bed contains the glossopharyngeal nerve. This nerve is responsible for the referred otalgia when
the tonsils become inflamed or when patients have undergone tonsillectomy. The glossopharyngeal nerve has a tympanic
nerve called Jacobson’s nerve, which is responsible for this phenomenon.

The floor the palatine tonsillar bed is bound by the superior constrictor muscle.

The tonsil is supplied by the tonsillar branch of the facial artery, which runs alongside the styloglossus, after which it
penetrates the superior pharyngeal constrictor to enter the palatine fossa.

The palatine fossa lies in the oropharynx, not the oral cavity.

oropharynx
The oropharynx is bound anteriorly by the base of the tongue and palatoglossal folds. The superior boundary is the soft
palate. The inferior boundary is the superior surface of the epiglottis. The posterior boundary is the posterior pharyngeal
wall.
tongue
The extrinsic muscles of the tongue are supplied by the hypoglossal nerve. The palatoglossus muscle however is supplied
by the vagus nerve.

Although the extrinsic muscles of the tongue are innervated by the hypoglossal nerve (with the exception of palatoglossus),
the tongue deviates (goes) towards the side of the injury, not away.

uvula
The muscles of the soft palate are innervated by the vagus nerve. Injury causes deviation away from the side of injury.

Lingual nerve
The lingual nerve supplies the somatic sensation to the anterior two-thirds of the tongue. Therefore, loss of sensation to
the tongue ipsilaterally to the side of nerve injury may result in ulceration (eg from accidentally biting the tongue). The
lingual nerve is a branch of the mandibular division of the trigeminal nerve. Taste sensation from the anterior two-thirds of
the tongue is derived from the chorda tympani branch of the facial nerve, which runs with the lingual nerve.

Spinal accessory nerve injury

The spinal accessory nerve is not at risk during submandibular gland excision, and injury to this nerve does not affect the
tongue as the spinal accessory nerve supplies the sternocleidomastoid muscle and trapezius muscles. Injury to this nerve
would be expected to result in weakness in shoulder elevation and turning of the head in the ipsilateral direction.

superior orbital fissure

The branches of the ophthalmic division (frontal, lacrimal and nasociliary) exit through the superior orbital fissure along with
oculomotor nerve, trochlea nerve, and abducens nerve.

temporomandibular joint
The TMJ is an atypical synovial condyloid joint. It consists of two cavities separated by an articular disc. The articular
surfaces of the temporal bone and the mandible are covered by fibrocartilage rather than hyaline cartilage.

The capsule of the TMJ lies anteriorly to the squamo-tympanic fissure. The temporomandibular joint is a synovial joint
situated between the condyle of the mandible below and the mandibular fossa of the temporal bone above. Although it a
synovial joint, it is lined by fibrous cartilage (rather than hyaline cartilage typical of synovial joints). The joint is surrounded
by a capsule that is attached beyond the limits of the articular surfaces, strengthened medially and laterally by collateral
ligaments. Posteriorly, the capsule is attached to the anterior edge of the squamo-tympanic fissure. Medially, it runs along
the suture between the temporal and sphenoid bones and attaches anteriorly to the anterior end of the articular eminence.
Laterally, the capsule is attached to the articular tubercle, which forms the lateral limit of the articular eminence and the
prominent ridge of the bone forming the lateral lip of the glenoid cavity. The joint is stable anteriorly but is laxed
posteriorly as it is attached well below the articular surface to the neck of the condyle.

The upper compartment of the TMJ is responsible for protrusion and retraction of the jaw, as well as side-to-side
movement.

The lower compartment is responsible for elevation and depression of the mandible.

Oculomotor nerve
Parasympathetic fibres from the Edinger–Westphal nucleus are carried along the oculomotor nerve and then its inferior
division to synapse in the ciliary ganglion. These parasympathetic fibres then supply the ciliaris and sphincter pupillae
muscles.
Facial nerve
The facial nerve carries multiple parasympathetic fibres. These travel on the greater petrosal nerve through the petrous
temporal bone, then deep petrosal nerve. These particular fibres synapse in the pterygopalatine ganglion to subsequently
supply the lacrimal, and nasal glands.

Other parasympathetic fibres travel with the chorda tympani, synapse in the submandibular ganglion, and innervate the
submandibular and sublingual glands.

The buccal branch of the facial nerve supplies the buccinator and orbicularis oris muscle. Injury to the facial nerve can
occur in parotid surgery as well as middle ear and temporal bone surgery, as this represents the course of the facial nerve.
Facial nerve monitoring is used to assess facial nerve proximity and to minimise the risk of intra-operative injury.

The chorda tympani carries taste sensation from the anterior two-thirds of the tongue. It separates from the facial nerve
within the temporal bone and is therefore not part of the facial nerve at the level of the parotid gland. The chorda tympani,
after separating, form the facial nerve, then runs back into the middle ear to run on the posterior wall. It travels between
the pars flaccida and over the handle of the malleus. It passes through the petrous temporal bone before leaving the skull
via the petrotympanic fissure. The chorda tympani then enters into the infratemporal fossa to join the lingual nerve.

nasolacrimal duct
The nasolacrimal duct is a membranous canal, about 18 mm in length, which extends from the lower part of the lacrimal sac
to the inferior meatus of the nose. It ends as the plica lacrimalis (Hasner’s fold), formed by a fold of the mucous
membrane. It is contained in an osseous canal, formed by the maxilla, the lacrimal bone and the inferior nasal concha. It is
narrower in the middle than at either end and is directed downward, backward and a little lateralward. The mucous lining
of the lacrimal sac and nasolacrimal duct is covered with columnar epithelium, which in places is ciliated.

middle ear
The middle ear contains the malleus, incus and stapes.

The medial wall of the middle ear has a rounded projection representing the first turn of the cochlea.

The facial nerve runs medial to the middle ear cavity and superior to the promontory and oval window.

The internal carotid artery runs anterior and inferior to the middle ear cavity.

The internal jugular vein is located inferior to the middle ear cavity. Thin bone separates the middle ear from the bulb of
the internal jugular vein.

Lesser palatine nerve

Although the lesser palatine nerve innervates the tonsil as well as the soft palate, it does not have auricular branches and
therefore is not responsible for referred pain to the ear.

Superior laryngeal nerve

The superior laryngeal nerve innervates the larynx above the level of the vocal cords via its internal branch. Its external
branch innervates the cricothyroid muscle.

Cerebral veins
The superior cerebral veins, 8 to 12 in number, drain the superior, lateral and medial surfaces of the cerebral
hemispheres and are mainly lodged in the sulci between the gyri, but some run across the gyri. They open into the
superior sagittal sinus, which can be seen below running in the superior aspect of the falx cerebri.
Inferior petrosal sinus drains the cavernous sinus. It meets the sigmoid sinus at the level of the jugular foramen to form
the internal jugular vein.

The superior petrosal sinus connects the cavernous sinus to the transverse sinus.

Great cerebral vein drains the internal cerebral veins.

The superior and inferior ophthalmic veins, sphenoparietal sinus, superficial middle cerebral veins drain into the
cavernous sinus but not the superior cerebral veins.

lacrimal gland
Sympathetic supply to the lacrimal gland is via the nerve of the pterygoid canal, which runs with the lacrimal nerve, one of
the three major branches of the ophthalmic division of the trigeminal nerve. The lacrimal nerve also carries
parasympathetic fibres from the zygomatic branch of the maxillary nerve from pterygopalatine ganglion.

Sensation to the inside of the mouth

Sensation to the inside of the mouth is supplied by the buccal nerve – a branch of the mandibular branch of the trigeminal
nerve. This nerve is not to be confused with the buccal branch of the facial nerve, which supplies muscles of facial
expression.

Eye movements
The medial rectus muscle is responsible for adduction of the eye.

The inferior oblique elevates, externally rotates and abducts the eye.

The superior oblique muscle depresses, internally rotates and abducts the eye.

The inferior rectus muscle depresses the eye.

The lateral rectus muscle is an extraocular muscle that serves primarily to abduct the eye from the midline. It arises from
the lateral part of the tendinous ring within the posterior orbit, and inserts into the lateral sclera of the eye anterior to the
equator but posterior to the sclerocorneal junction. The lateral rectus muscle is innervated by the abducens nerve (CN VI).

ophthalmic artery
The ophthalmic artery is a direct branch of the internal carotid artery. The artery lies inferolateral to the optic nerve. It
gives off a number of branches, the first and one of the smallest being the central retinal artery.

anterior cerebral artery

The anterior cerebral artery is formed from the bifurcation of the internal carotid artery into the anterior and middle
cerebral arteries. It passes around the genu of the corpus callosum and mainly supplies the medial aspects of the frontal
lobe.
supratrochlear nerve
The ophthalmic division of the trigeminal nerve divides into the three main branches: the frontal nerve, the lacrimal nerve
and the nasociliary nerve. The supratrochlear is a direct branch of the frontal nerve.

The supratrochlear nerve is a direct terminal branch of the frontal nerve and supplies the superior-medial orbital skin,
superior to the medial canthus. It is medial to the supra-orbital nerve. The nerve passes above the pulley of the superior
oblique and gives off a descending filament to join the infratrochlear branch of the nasociliary nerve.

Lacrimal
The lacrimal nerve is one of the three main branches of the ophthalmic division of the trigeminal nerve. However, the supra-
trochlear nerve is not one of its branches. It does not have any branches, and supplies the skin above the lateral canthus. It
also carries parasympathetic fibres (from the pterygopalatine ganglion) to the lacrimal gland from the zygomaticotemporal
nerve.

Nasociliary

The supratrochlear nerve is a branch of the frontal nerve and not the nasociliary nerve. The nasociliary nerve has five main
branches: the long and short ciliary nerves, the anterior and posterior ethmoidal nerves, the infra-trochlear nerve and the
communicating branch to the ciliary ganglion.

middle meningeal artery

Injury to the middle meningeal artery typically causes injury at the level of the pterion. It is the anterior branch of the
middle meningeal artery which is damaged. This branch runs beneath the pterion where it is vulnerable to [Link]
lentiform shape of the haematoma is formed by the suture lines of the skull stopping further expansion.

Although the middle meningeal artery is indeed a branch of the first part of the maxillary artery, the maxillary artery is a
branch of the external carotid rather than internal carotid artery.

The middle meningeal artery passes through the foramen spinosum.

Passing through the foramen ovale are the mandibular branch of trigeminal nerve, accessory meningeal artery, emissary
veins, and occasionally the lesser petrosal nerve.

The middle meningeal artery is a branch of the maxillary artery in the infratemporal fossa. The maxillary artery enters the
infratemporal fossa before running forwards between the heads of lateral pterygoid passing into the pterygopalatine
fossa. The middle meningeal artery passes through the foramen spinosum. The dura mater is supplied by the anterior,
middle and posterior meningeal arteries.

Μiddle meningeal artery is the largest artery that supplies the dura and also the calvaria. While the maxillary artery does
give off branches in the pterygopalatine fossa region, the middle meningeal artery comes off more proximally, deep to
the ramus of the mandible. It is particularly prone to damage caused by temporal bone fractures.

sternocleidomastoid
The sternocleidomastoid muscles are su+pplied by the spinal root of the accessory nerve.
olfactory foramina
The olfactory foramina are located in the anterior cranial fossa. They are located within the cribriform plate, a part of the
ethmoid bone. The fibres of the olfactory nerve originate from the superior surface of the superior concha, medial
aspect of the superior nasal septum, and the inferior surface of the cribriform plate. These fibres pass through the
olfactory foramina and synapse in the olfactory bulb on the superior surface of the cribriform plate. The cranial nerve exits
from the skull are summarised in the image below.

ANATOMY OF SCALP
Has motor innervation supplied by the facial nerve. The occipitofrontalis is supplied by the facial nerve.

The scalp drains to the lymph nodes of the neck. The submandibular lymph and deep cervical nodes drain the anterior scalp
while the retro-auricular and occipital nodes drain the posterior scalp.

The blood supply to the scalp is from branches of both the internal and external carotid arteries. Two such tributaries from
the internal carotid are the supraorbital and supratrochlear arteries.

The aponeurosis of the scalp is separated from the epicranium by loose connective tissue (the plane of cleavage in scalping),
facilitating gliding movements. From superficial to deep, the scalp has five basic layers.

Five layers of the scalp

Skin

Connective tissue

Aponeurosis

Loose areolar tissue

Pericranium

The first 3 layers are bound together as a single unit. This single unit can move along the loose areolar tissue over the
pericranium, which is adherent to the calvaria

There is no C1 dermatome. There is however a C1 nerve root.

Sensory supply :

Supratrochlear nerve - A branch of the ophthalmic division of the trigeminal nerve; this nerve supplies the scalp in the
medial plane at the frontal region, up to the vertex
Supraorbital nerve - Also a branch of the ophthalmic division of the trigeminal nerve; this nerve supplies the scalp at the
front, lateral to the supratrochlear nerve distribution, up to the vertex

Zygomaticotemporal nerve - A branch of the maxillary division of the trigeminal nerve; it supplies the scalp over the
temple region

Auriculotemporal nerve - A branch of the mandibular division of the trigeminal nerve; it supplies the skin over the
temporal region of the scalp

Lesser occipital nerve - A branch of the cervical plexus (C2); it supplies the scalp over the lateral occipital region

Greater occipital nerve - A branch of the posterior ramus of the second cervical nerve; it supplies the scalp in the
median plane at the occipital region, up to the vertex

ophthalmic artery
Τhe ophthalmic artery arises from the internal carotid, just as that vessel is emerging from the cavernous sinus, on the
medial side of the anterior clinoid process and enters the orbital cavity through the optic foramen (canal), below and lateral
to the optic nerve. It then passes over the nerve to reach the medial wall of the orbit and thence horizontally forward,
beneath the lower border of the superior oblique and divides it into two terminal branches, the frontal and dorsal nasal.
As the artery crosses the optic nerve it is accompanied by the nasociliary nerve and is separated from the frontal
nerve by the rectus superior and levator palpebrae superioris.
SPHENOPALATINE ARTERY
The sphenopalatine artery supplies the posterior nasal mucosa. It is a branch of the third part of the internal maxillary
artery, passes through the sphenopalatine foramen into the cavity of the nose, at the back part of the superior meatus.
Here it gives off its posterior lateral nasal branches, which spread forward over the conchae and meatuses, anastomose
with the ethmoidal arteries and the nasal branches of the descending palatine and assist in supplying the frontal, maxillary,
ethmoidal and sphenoidal sinuses. Crossing the undersurface of the sphenoid, the sphenopalatine artery ends on the nasal
septum as the posterior septal branches; these anastomose with the ethmoidal arteries and the septal branch of the
superior labial. In severe posterior nasal bleeds that are uncontrolled with non-operative management the artery can be
ligated or can undergo haemostasis with diathermy. The sphenopalatine artery is also one of the vessels that contributes to
Kiesselbach’s plexus (Little’s area – shown below in the image on the anterior nasal septum), in addition to anterior
ethmoidal/posterior ethmoidal arteries, superior labial arteries, and greater palatine artery.
One branch of the sphenopalatine artery descends in a groove of the vomer to the incisive canal.

pterion
The pterion represents a weak point of the skull at the junction of the parietal, frontal, squamous temporal bone, and
greater wing of the sphenoid. Fractures occurring here classically have a tendency to injure the middle meningeal artery,
the anterior division of which runs upon its deep surface.

ophthalmic veins
The superior and inferior optic veins exit from the orbit via the superior and inferior orbital fissure respectively. The
inferior ophthalmic vein occasionally exits via the superior orbital fissure, or joins the superior orbital vein.

corneal reflex
The afferent limb (sensation) of the corneal reflex is carried on the ophthalmic division of the trigeminal nerve, and the
efferent limb (the motor reflex) is via the zygomatic branches of the facial nerve to orbicularis oculi, which results in
blinking.

Injury at the level of the parotid would lead to lower motor neurone paralysis of the ipsilateral orbicularis oculi
and the corneal reflex would therefore be lost.

Dry mouth
The parasympathetic innervation to the salivary glands of the oral cavity do not pass through the parotid gland. The
parasympathetic supply to the parotid comes from the lesser petrosal nerve, which branches from the geniculate ganglion
in the middle ear and synapses within the otic ganglion, and is carried on the auriculotemporal nerve to the parotid gland.
The parasympathetic nerve supply to the sublingual glands and submandibular gland are carried via the chorda tympani
branch of the facial nerve, which joins the lingual nerve to supply the glands. Damage to the facial nerve after it exits from
the skull at the stylomastoid foramen would not lead to a dry mouth as the parasympathetic supply has already been given
off in the middle ear.

salivatory nucleus

The superior salivatory nucleus innervates the submandibular gland and the sublingual gland and is part of the facial nerve[1]

The inferior salivatory nucleus innervates the parotid gland by way of the otic ganglion and forms the parasympathetic
component of the glossopharyngeal nerve.[1]

Numbness of cheek
Somatic sensation to the cheek is supplied by the maxillary and mandibular divisions of the trigeminal nerve.

inferior alveolar nerve

The inferior alveolar nerve enters the deep aspect of the mandible at the mandibular (=inferior alveolar foramen) foramen
and exits at the mental foramen as the mental nerve. The mental nerve innervates the skin of the ipsilateral lower lip and
chin, hence the numbness of the lip. The inferior alveolar nerve can be seen in the image branching from the mandibular
(V3) branch of the trigeminal nerve.
Numbness of hard palate
The hard palate is supplied by the greater palatine nerve, which is a branch of the maxillary division of the trigeminal
nerve.

SPINAL ARACHNOID MATER

Above, the spinal arachnoid mater is continuous with the cranial arachnoid. Below, it widens out and invests the cauda
equina and the nerves proceeding from it.

The spinal part of the arachnoid is a thin, delicate, tubular membrane loosely investing the spinal cord.

It is separated from the dura mater by the subdural space, but here and there this space is traversed by isolated connective-
tissue trabeculae, which are most numerous on the posterior surface of the spinal cord.
The arachnoid consists of bundles of white fibrous and elastic tissue intimately blended together. Its outer surface is
covered with a layer of low cuboidal mesothelium. The inner surface and the trabeculae are likewise covered by a
somewhat low type of cuboidal mesothelium, which in places is flattened to a pavement type.

A rich plexus of nerves derived from the motor root of the trigeminal, the facial and the accessory nerves, are found
in the arachnoid.

denticulate ligaments

The denticulate ligaments are part of the pia mater which help to connect the spinal cord to the arachnoid and
dura mater.

Thyroidectomy
When the superior thyroid arteries are ligated, the external laryngeal nerves running alongside can be easily damaged. The
external laryngeal nerve is a branch of the superior laryngeal nerve, which is a branch of the vagus nerve.

The internal laryngeal nerves pass above and behind the root of the superior thyroid arteries and are therefore usually
outside the operative field.

The phrenic nerves are protected as they lie behind the prevertebral fascia.

Both transverse cervical nerves run in the subcutaneous fascia. Horizontal skin-crease thyroidectomy incisions run
parallel with their course and, therefore, most branches of these cutaneous nerves are spared.

The inferior thyroid artery should be ligated in continuity before the inferior thyroid veins. Mass ligation
should not be performed because of the risk of injury to the recurrent laryngeal nerve.

The superior thyroid artery arises from the external carotid artery and enters the upper pole of the thyroid gland close to
the external laryngeal nerve, which supplies the cricothyroid muscle, a tensor of the vocal cord. Damage to this nerve
causes the loss of high-pitched phonation.

The inferior thyroid artery, absent in 5%, arises from the thyrocervical trunk of the subclavian artery.
VOCAL LIGAMENTS
The conus elasticus is mostly yellow, elastic tissue. It is the lateral part of the cricothyroid membrane. Superiorly,
its free edge forms part of the vocal ligaments.

The cricothyroid muscle attaches to the vocal cords and is the only tensor of the larynx.

The posterior cricoarytenoid (highlighted in green below) is innervated by the inferior laryngeal nerve, which is a
continuation of the recurrent laryngeal nerve. The posterior cricoarytenoid is the only muscle that abducts the vocal
folds. If this muscle is denervated, the vocal folds may be paralysed in an adducted position, which would prevent air from
entering the trachea.

Thyroarytenoid muscles relaxes the vocal folds by drawing the arytenoid cartilages towards the thyroid.

Arytenoid muscles adducts the vocal folds.

Lateral cricoarytenoid muscles adducts the vocal folds.

Cricothyroid is the only laryngeal muscle innervated by the external branch of the superior laryngeal. It tenses the vocal
ligaments by tipping the thyroid cartilage forward relative to the cricoid cartilage.

larynx
The epiglottis is part of the larynx. It’s purpose is to close during swallowing so that food goes into the oesophagus, rather
than the trachea

The inferior edge of the medial and lateral thyrohyoid ligaments form the superior border of the thyroid cartilage.

The thyroepiglottic ligament connects the thyroid cartilage to the lower edge of the epiglottis.

The conus elasticus is mostly yellow, elastic tissue. It is the lateral part of the cricothyroid membrane. Superiorly, its free
edge forms part of the vocal ligaments.

inferior thyroid artery

The inferior thyroid artery is a branch of the thyrocervical trunk, which arises from the subclavian artery. The inferior
thyroid artery supplies the inferior pole of the thyroid gland and gives off oesophageal branches. In addition, it supplies
both the superior and inferior parathyroid glands. The course of the inferior thyroid artery is closely related to the
recurrent laryngeal nerve: in a thyroidectomy, therefore, it is preferable to ligate the artery lateral to the gland to avoid
neural damage.

In around 10% of people, a thyroid ima artery arises from the brachiocephalic trunk or the arch of the aorta.

posterior triangle of neck

The posterior triangle lies between the posterior border of sternocleidomastoid, the anterior border of trapezius and the
clavicle. Posterior: The borders of the posterior triangle are formed by the posterior border of the sternocleidomastoid
muscle, anterior border of trapezius and the clavicle. Lymph node excision from the posterior triangle can result in damage
to the accessory nerve. About an inch superior to the ‘base’/middle third of the clavicle lies the inferior belly of omohyoid.
This divides the posterior triangle into two further sub-triangles. The more superior of these triangles is known as the
occipital triangle; the more inferior one, the subclavian triangle .

anterior triangle of neck

The borders of the anterior triangle are formed by the anterior border of sternocleidomastoid muscle, the mandible and the
midline. The anterior triangle is further subdivided into four triangles; submental, submandibular, carotid and muscular.
external jugular vein
The external jugular vein drains most of the scalp and side of the face. It begins near the angle of the mandible and is
formed from the union of posterior division of the retromandibular and posterior auricular veins, receiving
branches from the posterior external and transverse cervical veins.

The external jugular vein has two pairs of valves, which do not prevent regurgitation of the blood upward. The lower
pair are placed at its entrance to the subclavian vein, the upper (in most cases) about 4 cm above the clavicle.

The external jugular vein lies anterior to scalenus anterior and pierces the deep fascia of the neck, usually posterior to
the clavicular head of the sternocleidomastoid muscle before draining into the subclavian vein.

Due to its valves, t cannot be used for central line

common carotid artery

The common carotid arteries supply the neck and head. On the right, it arises from the brachiocephalic artery; on the left, it
arises from the aortic arch. Thereafter, the anatomical structures of the right and left are the same. The common carotid
artery lies in the carotid sheath with the internal jugular vein and the vagus nerve. The common carotid artery terminates at
its bifurcation into the external carotid artery and the internal carotid artery. Anterior to it are sternomastoid, sternohyoid,
sternothyroid and platysma. Posterior to the artery are the transverse processes of C4–C6. The oesophagus, thyroid and
the airway structures are medial to it.

The external carotid artery is a branch of the common carotid artery that supplies the head and neck. It begins at the level
of C4, which corresponds roughly to the upper border of the thyroid cartilage.

The carotid sheath encloses the common carotid arteries (medial), the internal jugular vein (lateral) and the vagus nerve
(between the two).

The right common carotid artery bifurcates at the level of the upper border of the lamina of the thyroid cartilage. This is
around the level of the fourth cervical vertebra.

The cervical sympathetic chain is posterior to the common carotid arteries.

The right common carotid artery branches off the brachiocephalic artery. The left common carotid artery is a branch of the
aortic arch.

The CCA lies posterior to the lobes of the thyroid gland.

RECURRENT LARYNGEAL NERVE

Both right and left recurrent laryngeal nerves run in a groove between the trachea and oesophagus and are closely related
to the inferior thyroid artery.

The recurrent laryngeal nerve arises from the vagus nerve (cranial nerve X), which passes through the jugular foramen.

The left recurrent laryngeal nerve lies posterior to the ligamentum arteriosum.

The left recurrent laryngeal nerve winds around the aortic arch. The right is related to the subclavian artery.

Level of the jugular notch

The jugular or suprasternal notch is at T2 vertebral level
elective routine tracheostomy- heavy bleeding

Anterior jugular veins and inferior thyroid veins may be encountered during tracheostomy.

Damage to the hypoglossal nerve

Damage to the hypoglossal nerve will result in weakness of the extrinsic muscles of the tongue on the ipsilateral side. The
tongue will therefore deviate to the weakened side.

Ansa cervicalis
The ansa cervicalis supplies the sternohyoid, sternothyroid and omohyoid. Injury to the ansa cervicalis may lead to a
change in voice quality over time.

Thyrohyoid and geniohyoid are supplied by C1 spinal nerve, not the Ansa cervicalis
Ansa cervicalis is formed by C1, C2, C3

ALL strap muscles EXCEPT thyrohyoid

Suprahyoid-infrahyoid muscles
The suprahyoid muscles are four muscles located above the hyoid bone in the neck. They are the digastric ant and sup
belly), stylohyoid, geniohyoid, and mylohyoid muscles. They are all pharyngeal muscles, with the exception of the
geniohyoid muscle.
The infrahyoid muscles, or strap muscles, are a group of four pairs of muscles in the anterior (frontal) part of the neck. The
four infrahyoid muscles are: the sternohyoid, sternothyroid, thyrohyoid and omohyoid muscles.

Internal- external jugular vein

The internal jugular vein receives the facial, pharyngeal, lingual and superior and middle thyroid veins. It is formed from the
sigmoid and inferior petrosal sinus and continues to the brachiocephalic vein.

The external jugular arises from the junction of the posterior auricular vein and the posterior division of the
retromandibular vein and drains into the subclavian. The transverse cervical vein is a tributary of the external jugular vein

Note that the anterior portion of the retromandibular vein proceeds forward to the anterior facial vein, and together
they join to form the common facial vein.

ANATOMY OF THE THYROID GLAND

Berry’s ligament is a suspensory ligament. It was first described by James Berry in 1888. Berry’s ligament connects the
thyroid to the cricoid cartilage and upper trachea.

The superior parathyroid glands are more constant in position than the inferior. Because of their embryological migration,
the inferior glands may be situated among the pretracheal lymph nodes or in the thymus as far as 10 cm from the thyroid.

The thyroid venous plexus usually drains via three pairs of veins: the superior and middle thyroid veins drain into the
internal jugular; the inferior thyroid veins drain into the brachiocephalic vein.

The superior veins drain into the internal jugular vein; the inferior veins are very constant and drain into the
brachiocephalic veins; and the middle veins are variable and often multiple.
The middle thyroid veins are the least constant of the thyroid veins.

Under the middle layer of deep cervical fascia, the thyroid has an inner true capsule, which is thin and adheres
closely to the gland. Extensions of this capsule within the substance of the gland form numerous septae, which divide it into
lobes and lobules. The lobules are composed of follicles, the structural units of the gland, which consist of a layer of simple
epithelium enclosing a colloid-filled cavity.

Unilateral recurrent laryngeal nerve section results in the ipsilateral vocal cord lying motionless in the mid- or cadaveric
position. The voice is hoarse and weak. If both recurrent laryngeal nerves are divided, then the glottic space is narrowed
and stridor develops.

The isthmus is normally inferior to the thyroid cartilage and in front of the second and third tracheal rings,
although variations are common.

While the superior thyroid artery is a branch of the external carotid artery, the inferior thyroid artery arises from the
subclavian artery, via the thyrocervical trunk. Additionally, the thyroidea ima artery (present in 5–10% of the population).

The thyroidea ima artery, when present, usually arises from the brachiocephalic trunk (innominate artery) and ascends in
front of the trachea to the lower part of the thyroid gland, which it supplies. It varies greatly in size and appears to
compensate for deficiency or absence of one of the other thyroid vessels. It occasionally arises from the aortic arch, the
aorta, the right common carotid, the subclavian or the internal mammary.
 The thyroid gland initially moves up on swallowing before returning to its normal position.

The thyroid gland lies deep to the myofascial layer (platysma, strap muscles and investing layer of deep cervical fascia),
closely applied to the thyroid and cricoid cartilages.

Note that during thyroidectomy, the strap muscles should be divided in their upper half, to avoid damaging the ansa
cervicalis which is in the lower half.

The thyroid gland is highly vascular, normally accounting for 5% of cardiac output (same with skin)

anatomical differences between adults and child ren make intubation more difficult

There are several anatomical differences between adults and children that make their intubation more difficult:

 Head size: children have a relatively larger head, which tends to flex the head on the neck, making airway obstruction more
likely.
 Tongue size: the relatively larger tongue in children tends to flop back and obstruct the airway in the obtunded child, which
means that there is less room in the mouth when intubation is being carried out.
 Larynx: The larynx is positioned more cephalic in children.
 Trachea: the trachea is shorter in children.
 Finally, the narrowest point of a child’s airway is the cricoid ring; in adults, it is the glottis.

The larynx is positioned more cephalic (glottis at C3 in infants compared with C6 in adults).

LEAST LIKELY TO BE ENCOUNTERED ON LEFT CAROTID ENDARTERECTOMY

Correct answer: Pleural membranes are usually a little deeper and lateral to the site of carotid endarterectomy (CEA).

Discussion:

The sympathetic trunk lies alongside the cervical vertebrae, immediately behind the carotid artery, and has three cervical
ganglia (superior, middle and inferior).

The facial vein drains into the internal jugular vein. The internal jugular vein is identified and retracted during the procedure
and facial vein may be ligated and divided to mobilise the internal jugular vein.

During a left carotid endarterectomy (CEA), the thoracic duct may be seen.

Digastrics muscle
The posterior belly of digastric is innervated by the digastric branch of the facial nerve.

Anterior belly of digastric is innervated by the mylohyoid nerve, a branch of the posterior division of the mandibular branch
of the trigeminal nerve.

The trachea commences just below the cricoid cartilage (at the level of C6).

Within the thorax and on the right, the trachea is in contact with the pleura, vagus and subclavian artery. On its left,
the trachea is in contact with the left recurrent laryngeal nerve, aortic arch and the left common carotid and subclavian
arteries. The trachea ends at the upper border of T5, where it bifurcates.
The bifurcation of the right common carotid artery is associated with the upper border of the lamina of the thyroid cartilage,
at approximately the level of the fourth cervical vertebra.

recurrent laryngeal nerves (RLN)

The two recurrent laryngeal nerves (RLN) arise from the vagus nerve. They supply four intrinsic muscles of the larynx -
Lateral cricoarytenoid, posterior cricorytenoid, transverse and oblique interarytenoid and thyroarytenoid. The RLN does not
supply the cricothyroid muscle.

The RLN also sends branches to the inferior constrictor muscle and cricopharyngeus muscle before entering the larynx.

The RLN also supplies the mucosa below the vocal cord and the subglottis.

The cricothyroid muscles are innervated by the external branch of the superior laryngeal nerve.

The supraglottic region receives its sensory innervation from the internal branch of the superior laryngeal nerve.

posterior triangle of neck- contents

The inferior belly of the omohyoid muscle and its intermediate tendon pass diagonally through the posterior triangle.
Other components of the posterior triangle include, splenius capitis, levator scapulas, the anterior, middle and posterior
scalene muscles and the spinal accessory nerve.

The great auricular nerve turns upwards round the lateral border of the sternocleidomastoid muscle outside the triangle.

Lying medially, outside the triangle, are the roots of the brachial plexus, sandwiched between the scalenus anterior and
medius muscles.

Lateral rotation of the neck/turning of the head

The movement takes place at the atlanto-axial joint about a vertical axis through the odontoid process of the axis.

Lateral rotation of the neck/turning of the head is limited by the vertical alignment of the two attachments of the
contralateral sternocleidomastoid muscle (contralateral mastoid process and sternoclavicular joint).

The atlanto-occipital joint enables flexion and extension of the neck.

Carotid canal
The carotid canal is found on the inferior surface of the petrous part of the temporal bone. It ascends vertically at first and
then bends and runs horizontally forward and medially. It transmits the internal carotid artery and the carotid plexus of
nerves into the cranium.

The internal carotid artery passes superiorly from the carotid canal in the base of the skull, emerging via that part of the
foramen lacerum which is not occluded by cartilage. Other contents of foramen lacerum:, artery of pterygoid canal, greater
petrosal nerve, emissary veins.
 Transverse cervical nerve
Local anaesthetic can be injected along the posterior border of the sternocleidomastoid (between the superior and inferior
thirds) – the nerve point of the neck for a cervical plexus block. The transverse cervical nerve emerges as a single trunk
behind the posterior border of the sternocleidomastoid and is superficial to the muscle.

Greater occipital nerve

The greater occipital nerve arises from the medial branch of the dorsal primary ramus of C2. Its course is through the
trapezius muscle before reaching the occiput.

Phrenic nerve
The phrenic nerve arises from the ventral rami of C3–C5, and lies superficial to the anterior scalene muscle.

cavernous sinus
The cavernous sinus sits anteriorly to the petrosal sinuses, which then connect it to the internal jugular vein. The cavernous
sinus is a blood-filled space.

The internal carotid artery passes through the cavernous sinus with the associated sympathetics.

The abducens nerve (CN VI) passes through the cavernous sinus and can be affected in thrombosis. It lies very close to the
internal carotid artery whereas CN III, IV and V sit laterally in the wall of the cavernous sinus. Although the optic nerve is
closely related to the cavernous sinus, it does not pass directly through it.

foramen magnum
pass through foramen magnus

 The spinal roots of the accessory nerve enter into the skull inferiorly through the foramen magnum; they exit through the
jugular foramen with the vagus and glossopharyngeal nerves.
 Apical ligament of the dens connects the second cervical vertebra to the skull in the anterior portion of the foramen
magnum
 The meninges continue through the foramen to surround the spinal cord.
 The lower end of the medulla passes through the foramen. Sometimes the cerebellar tonsils also pass, to a varying degree,
inferiorly through it and therefore can be compressed.
 Spinal arteries
 Vertebral arteries

posterior cerebral arteries

The basilar artery arises from the right and left vertebral arteries joining. It gives off numerous branches to the cerebellum
and pons before ending as a bifurcation to form the paired posterior cerebral arteries. These supply the occipital and
posteromedial temporal lobes.

The superior cerebellar arteries arise from the distal basilar artery, but not from its terminal bifurcation.

hypothalamus
The mamillary bodies lie on the inferior surface of the hypothalamus. The mamillary bodies are small round structures
consisting of two groups of nuclei. They have a role in memory and form part of the limbic system.

The hypothalamus makes up the floor of the third ventricle.

The posterior (NOT anterior) portion of the hypothalamus contains the nerve endings of neurosecretory cells, which run
down through the infundibular stalk to the pituitary gland

The optic chiasm is located immediately below the hypothalamus. This is relevant clinically as growing
tumours in the hypothalamus can compress the optic chiasm.

The hypothalamus is continuous with the pituitary gland via the pituitary stalk, also known as the infundibulum. The
infundibulum passes down through the dura mater of the diaphragma sellae.

CSF

CSF is important in the regulation of brain function in many ways, for example:

 CSF pH and PCO2 on respiration

 CSF sodium chloride on vasopressin (AVP)
 CSF carriage of neuromodulators, e g opioids

It plays a minor role in supplying glucose to inaccessible areas also.

CSF is produced largely by the choroid plexus, which are capillary loops covered by specialised ependymal cells
located in the ventricular system.(in all ventricles). A small amount is produced by the ependymal cells.

The ependymal is a layer of ciliated epithelial cells that lines the ventricles and central canal of the spinal cord. Ependymal
cells are one of the glial cells of the central nervous system. The others are astrocytes, phagocytic microglia and
oligodendrocytes.

CSF has lower concentrations of potassium, glucose and protein but greater concentrations of sodium and chloride than
blood.

It is produced at a rate of 0.35-0.5 ml/min.

 CSF is distributed approximately as 20ml in the ventricles, 45ml in the cranial subarachnoid space, and the rest in the
spinal subarachnoid space and central canal.

In normal adults, the CSF volume 150 mL; 1/6 of the CSF is contained in the ventricles; the rest is contained in the
subarachnoid space in the cranium and spinal cord. The normal rate of CSF production is approximately 20 mL per
hour.

foramen lacerum
The foramen lacerum is located in the middle cranial foramen. It allows passage of the meningeal branch of the
ascending pharyngeal artery and the emissary vein (coming from the cavernous sinus), throughout its whole length.
Structures that only partially transverse the foramen lacerum are the internal carotid artery and the greater petrosal
nerve.

internal acoustic meatus

The internal acoustic meatus allows passage of the facial and vestibulocochlear nerves, as well as the labyrinthine artery.

foramen ovale
The foramen ovale allows passage of multiple structures : otic ganglion (lies just inferior), V3 cranial nerve (mandibular
branch of trigeminal nerve), accessory meningeal artery, lesser petrosal nerve, and emissary veins.

Optic lesions
 Bitemporal hemianopia → The central location of the pituitary gland within the sella turcica causes compression of the
medial aspects of the optic chiasm. The resultant visual field defect is bitemporal hemianopia.
 Bitemporal inferior quadrantanopia→ Craniopharingioma may initially present as a lower bitemporal quadrantopia, the
lesion is usually found superior to the optic chiasm.
 Homonymous hemianopia→ The cause of a homonymous hemianopia may be congenital, or secondary trauma, stroke, or
neoplastic lesions occurring from the optic tract to the visual cortex.
 Binasal hemianopia→ This visual field defect is rarely seen in clinical practice. It is caused by bilateral lesions affecting the
uncrossed optic fibres for example atheroma/calcification of the internal carotid arteries.
 Unilateral visual loss→ Unilateral field loss is caused by a lesion that is anterior to the optic chiasm.

ACOUSTIC NEUROMA
Acoustic neuroma is also known as a vestibular schwannoma, it is a benign, slow growing tumour that arises from the
Schwann cells of the vestibulocochlear (8th) cranial nerve.

They make up around 8% of all intracranial tumours.

The majority are unilateral (approximately 95%).

Recurring and severe headaches are uncommon and occur only with very large tumours. Common symptoms include
hearing loss, tinnitus, pressure in the ear, and vertigo. The most common presenting symptom is hearing loss.

Up to 90% of patients present with a gradual progressive unilateral deafness, often associated with tinnitus.
The third ventricle
The third ventricle is bounded laterally by the thalamus. It communicates superolaterally with the lateral ventricles.

The ventricular system of the brain comprises four communicating cavities which are responsible for the production and
transport of cerebrospinal fluid (CSF). CSF travels from the lateral (first and second) ventricles to the third ventricle via the
foramen of Monro, and from there to the fourth ventricle via the cerebral aqueduct (of Sylvius). The system is continuous
with the central spinal canal to bathe the spinal cord. Clinically this is relevant in hydrocephalus, which occurs when there is
an abnormal accumulation of CSF in the ventricles of the brain. The most common site of obstruction is at the
cerebral aqueduct.

Lateral ventricles
The first and second ventricles of the brain are together known as the lateral ventricles due to their position in each of the
cerebral hemispheres. They are superior to the thalamus. They are the largest ventricles in the ventricular system of the
brain and lie superior to the thalamus. Their volume increases with advancing age.

The interventricular foramen of Monro connects the two lateral ventricles to the third ventricle.

The fourth ventricle

The fourth ventricle receives CSF from the third ventricle. It is situated between the pons and the medulla oblongata.

The foramina of Magendie (midline) and Lushka (lateral) in the roof of the fourth ventricle communicate directly into the
subarachnoid space.

Brain haematomas Dx

Acute subdural haematoma: This elderly man is on warfarin therapy for atrial fibrillation and the current level of
anticoagulation is higher than the usual therapeutic limits (INR is normally kept between 2 and 3 for atrial fibrillation). In
such patients, an acute subdural haematoma can occur without significant head injury. The history of trauma followed by
fluctuating confusion and conscious level in an elderly patient is a classical presentation of an acute subdural
haematoma. The elderly in general are more at risk of subdural haematomas because of various factors, including thinner
cortical bridging veins that tear readily, increased subdural space, as well as increased probability of falls and use of
medications that alter blood clotting (including aspirin and other non-steroidal anti-inflammatory drugs).

Chronic subdural haematoma:. Chronic subdural haematoma presents with a much longer, insidious course (often over
weeks/months). In this case, the occurrence of headache, impaired conscious level and focal signs, as well as the over-
anticoagulation, make an acute subdural haematoma much more likely.

subarachnoid haemorrhage: Subarachnoid haemorrhage is usually associated with significant trauma or a ruptured
aneurysm.

Intraparenchymal haematoma: Intraparenchymal haematoma usually occurs in the context of trauma, hypertension or
presence of an underlying neoplastic lesion. It is less common than a subdural haematoma.

extradural haematoma: Extradural haematoma is associated with significant head trauma.

Wernicke’s area
Wernicke’s area is responsible for comprehension of language and is located in the temporal lobe of the dominant
cerebral hemisphere. Wernicke’s area is responsible for language comprehension. Damage to this area causes receptive
dysphasia, in which speech will be fluent but lack meaning. Patients with this condition are generally unaware that their
words lack meaning. Wernicke’s aphasia is mostly caused by stroke.

Broca’s area

Broca’s area is responsible for speech production but it is found in the frontal lobe of the dominant hemisphere, which
is generally the left hemisphere. Patients with Broca’s aphasia can understand language but cannot form speak fluently.

trigeminal nerve
The trigeminal nerve’s three terminal divisions exit the skull via the superior orbital fissure, the foramen rotundum and the
foramen ovale. This is correct – the ophthalmic nerve [V1] exits from the superior orbital fissure, the maxillary nerve [V2]
from the foramen rotundum and the mandibular nerve [V3] from the foramen ovale.

The trigeminal nerve develops from the first arch.

Although the trigeminal nerve is the major general sensory nerve of the head and innervates some muscles of the lower
jaw, it is the vagus nerve [X] that is the longest of the cranial nerves . However, the trigeminal nerve is the largest
of the cranial nerves, exiting as a large sensory root and small motor root from the anterolateral surface of the pons.

supply the temporal lobe

Both the posterior and middle cerebral arteries supply the temporal lobe. The MCA supplies the superior aspect, whereas
the PCA supplies the inferior surface. Similar to many regions of the brain, there is a watershed area in which two major
origins of blood supply overlap.

MENINGES
The meninges comprises the outermost dura mater, innermost pia mater and arachnoid mater in between these two.

Folds of the dura mater form the falx cerebri and the tentorium cerebella. The falx cerebri is a crescent-shaped fold of
dura mater that descends vertically. The tentorium cerebelli is an extension of the dura mater separating the occipital lobes
from the cerebellum.

The arachnoid mater is delicate and impermeable. It is in contact with the dura mater, which is thick and fibrous.

The pia mater is the innermost layer of the meninges, and runs deep into the fissures. However, it is highly vascular.

The subdural space separates the arachnoid from the dura but nothing lies in it except a thin film of lymph. The
subarachnoid space contains CSF and the delicate meshwork of arachnoid strands.

pterion
The pterion is the point at which frontal, parietal, temporal and sphenoid bones join and is the thinnest point of the skull.
Clinically this is relevant because the anterior branch of the middle meningeal artery runs beneath it. A blow to the head in
this area can injure this artery causing an extradural haematoma.
 external occipital protuberance
The external occipital protuberance is a thickened prominence of the occipital bone. The trapezius muscle and
nuchal ligament attach to it.

Cisterna magna
The cisterna magna is the largest of the 3 main openings in the subarachnoid space, located between the cerebellum
and the dorasal surface of the medulla oblongata.

The CSF produced in the ventricular system drains into it from the fourth ventricle via the foramina of
Magendie and Lushka.

Control respiration
2. Cerebral cortex. Although not normally required, the cerebral cortex can control the breathing rate and depth using
conscious control.
3. Hypothalamus. The hypothalamus is one of the many influences on the respiratory centres that control breathing.
4. Medulla oblongata. The medulla, where the respiratory group of neurones lies, includes the dorsal respiratory group and
the ventral respiratory group.
5. Pons. The pons includes the pneumotaxic and apneustic centres, the latter of which is under constant inhibition from the
medulla.

brainstem
These are the three main components of the brainstem – the midbrain (mesencephalon), the pons (metencephalon) and
the medulla oblongata (myelencephalon).

The pons is the largest part of the brainstem. The cerebellopontine angle is significant since intracranial growths
can be found here. Early symptoms come from the compression of cranial nerve 8 – the vestibulocochlear nerve.

The fourth cerebral ventricle is closely related to the brainstem, lying behind the pons and medulla oblongata.

The diencephalon is occasionally included, but is generally felt to be above the brainstem.

 The first two cranial nerves arise from the cerebrum,

 III – X and XII originate in the brainstem.
 Cranial nerve XI has a component arising from the brainstem (the cranial accessory) and component arising from the
upper segment of the spinal cord (the spinal accessory).
 Origin of cranial nerves: 2-2-4-4 (cm2,mp4:
o cerebrum :I, II
o midbrain: III, IV
o pons: V, VI, VII, VIII
o Medulla: IX, X, XI, XII

LOCATED IN THE POSTERIOR FOSSA

From the pons the facial nerve crosses the posterior fossa of the skull before it passes laterally upwards into the petrous
temporal bone to exit through the skull the internal acoustic meatus.
 The internal carotid artery enters the skull through the carotid canal in the middle cranial fossa of the skull base.

Middle cerebral artery

The middle cerebral artery (MCA) is the largest cerebral artery and is the most commonly affected vessel by cerebrovascular
accident. The artery supplies the majority of the outer convex brain surface such as the lateral aspect of the parietal
lobe and cortex, the basal ganglia and the posterior and anterior internal capsules. Infarctions that occur in the MCA
distribution result in contralateral paralysis and sensory loss of the face and upper limb. Aphasia occurs if the infarction is
in the dominant hemisphere, and hemineglect if the non-dominant side is affected.

The most common stroke is from infarction in the territory of the middle cerebral artery (MCA), which does not usually
cause a coma. The MCA supplies the lateral surface of the cortex and temporal pole.

The cortical branches of the MCA supply the lateral surface of the hemisphere except for

1. the frontal pole and a strip along the superomedial border of the frontal and parietal lobes supplied by the anterior
cerebral artery,
2. the lower temporal and occipital pole convolutions supplied by the posterior cerebral artery.

Occlusion of its inferior division is commonly associated with Wernicke’s aphasia, while occlusion of the superior division
causes Broca’s aphasia.

Strokes that involve the entire MCA distribution in the left hemisphere cause combined dysfunction of the two areas.
Speech output is non-fluent, and comprehension of spoken language is severely impaired, as well as naming, repetition,
reading and writing. Most patients are initially mute or say a few words. Related signs include right hemiplegia,
hemisensory loss and homonymous hemianopia.

Posterior cerebral artery

The posteroventral nucleus of the thalamus and inferior temporal gyrus are supplied by the posterior cerebral artery.
Infarctions involving the posterior cerebral artery result in contralateral hemianopsia with macular sparing.

The posterior cerebral artery supplies the optic tract, cerebral peduncle, internal capsule and thalamus.

Anterior cerebral artery

The anterior one-third of the corpus callosum, including the superior frontal gyrus, is supplied by the anterior cerebral
arteries. Infarctions involving the anterior cerebral artery result in contralateral paralysis and sensory loss of the lower
limb.
The anterior cerebral arteries supply most of the medial and superior surfaces and the frontal pole , while the middle
cerebral arteries supply the lateral surface and temporal pole.

Posterior inferior cerebellar artery

PICA occlusion may cause infarction of the posterior inferior cerebellum, inferior cerebellar vermis and lateral medulla.
Vertigo, nausea and truncal ataxia are the most common presenting features.

Basilar artery

Strokes involving the vertebrobasilar circulation lead to a focal brainstem syndrome. Acute occlusion of the basilar artery
may cause brainstem or thalamic ischaemia or infarction. Patients with acute occlusion of the basilar artery will present
with sudden and dramatic neurological impairment.

Internal carotid artery

The internal carotid, apart from providing the primary supply to the brain via the anterior and middle cerebral arteries, also
supplies the walls of the cavernous sinus, the pituitary gland and the trigeminal ganglion.

Strokes related to the carotid artery and its cerebral branches are usually associated with focal epilepsy, a contralateral
sensory/motor deficit and a psychological deficit. This answer is wrong as it would also give signs and symptoms from
the occlusion of the anterior cerebral artery, not only of the middle as in the scenario.

posterior communicating artery

The posterior communicating artery runs between the middle and posterior cerebral arteries in the circle of Willis. This
connections within circle of Willis provide an anastomotic system to compensate if blood supply was to be compromised.
Compromise here can however cause contralateral homonymous hemianopia, but would not cause global aphasia.

Diaphragma sellae
The diaphragma sellae is a small dural structure that covers hypophysial fossa in the sella turcica of the sphenoid bone. An
opening in the middle of the diaphragma sellae allows the passage of the infundibulum. This structure connects the
hypothalamus to the pituitary gland. The dural partitions of the brain are projections of dura mater that subdivide the
cranial cavity: the falx cerebri, the tentorium cerebelli, the falx cerebelli and the diaphragma sellae.

Falx cerebri
The falx cerebri is a crescent-shaped downward projection, a double fold of dura mater that runs between the cerebral
hemispheres. Anteriorly, it attaches to the ethmoid bone at the crista galli and the frontal crest of the frontal bone. It
attaches to the tentorium cerebelli inferior-posteriorly.

Tentorium cerebelli
The tentorium cerebelli is a double fold of dura mater that forms the roof the posterior fossa and separates the
supratentorial and infratentorial compartments.

Falx cerebelli
The falx cerebelli is a variably present and projection of dura mater in the posterior cranial fossa. It forms attachments to
the occipital bone and to the tentorium cerebelli superiorly. It is found in the midline between the cerebellar hemispheres
Tentorial notch
The tentorial notch is an oval opening formed by the anterior and medial borders of the tentorium cerebelli.

Pass through tendinous ring

“OPTIC ULNA”

Optic nerve, ophthalmic artery-vein-sympathetics

Upper division of occulomotor

Lower division of occulomotor

Nasocilliary

Abducens

diencephalon
. The forebrain comprises the cerebrum (telencephalon) and the diencephalon. The diencephalon is part of the forebrain

The diencephalon consists of the thalamus and hypothalamus. The hypothalamus regulates growth via the production
of growth hormone-releasing hormone, sexual maturation from gonadotrophin-releasing hormone and suppresses appetite
with corticotropin-releasing hormone. The hypothalamus is affected in Prader–Willi syndrome, which is a chromosomal
disorder usually due to partial deletion of paternal chromosome 15. Symptoms are wide ranging and are related to the
hormones secreted by the hypothalamus.
 pituitary gland
The pituitary gland is superior in relation to the sphenoid sinus, which lies inferiorly. This is clinically significant in pituitary
surgery, as the gland is accessed via a trans-sphenoidal approach.

The diaphragma sellae is a reflection of the dura mater – not the pia mater. It covers the superior surface of the pituitary
gland, with a small round opening for the passage of the infundibulum.

It is the posterior lobe of the pituitary gland that is known as the neurohypophysis. It has embryological origins from the
forebrain. It secretes antidiuretic hormone (ADH) and oxytocin.

Both lobes of the pituitary share the same venous drainage. It is the arterial supply that differs between the lobes.

sympathetic chain
The sympathetic chain sits paraspinally from the upper neck to the coccyx. It is the site of connections of pre- and post-
ganglionic nerve fibres of the sympathetic chain.

cranial parasympathetic ganglia

all below are cranial parasympathetic ganglia where pre- and post-ganglionic parasympathetic fibres synapse. They also
have sympathetic and sensory branches that pass through the ganglia without synapsing.

1. Otic. The otic ganglia receive parasympathetic innervation from the inferior salivary nucleus by the glossopharyngeal
nerve, along with the lesser petrosal nerve. It has sympathetic branches passing through from the superior cervical
ganglion, a sensory root to the parotid gland, and a motor supply to the medial pterygoid, tensor tympani and tensor veli
palatini muscles.
2.
3. Submandibular. The parasympathetic root comes from the superior salivary nucleus through the facial nerve, chorda
tympani and lingual nerve to supply the oral mucosa and submandibular and sublingual glands. Sympathetic roots come
with the facial artery from the carotid plexus, and a sensory root via the lingual nerve.
4.
5. Pterygopalatine. This has parasympathetics from the greater petrosal branch of the facial nerve to the mucous
membranes, via deep branches of the trigeminal nerve. Sympathetic branches arise from the superior cervical ganglion.
There is a sensory component passing through the ganglion, from the sphenopalatine branches of the maxillary nerve.
6.
7. Ciliary. The parasympathetic roots come from the Edinger–Westphal part of the oculomotor nucleus. Sympathetic
branches that pass through come from the superior cervical ganglion, and a sensory root is from a branch of the nasociliary
nerve.

vagal influence of heart

Each myocyte has its own intrinsic rate. A contraction is usually initiated by the cell with the fastest intrinsic rate, the
sinoatrial (SA) node. At rest the SA node is under significant vagal influence, which acts in a parasympathetic manner,
slowing heart rate. Removal of this speeds the heart rate up.

vagus nerve
The vagus nerve supplies parasympathetic fibres to all of the abdominal organs, which receive blood from the coeliac trunk
or superior mesenteric artery. This means that the vagus supplies parasympathetic to the entire gastrointestinal tract, up to
the last part of the transverse colon at the splenic flexure.
 The end of the transverse colon and all gastrointestinal structures distal to that point receive parasympathetic
innervation from the pelvic splanchnic nerves and blood from the inferior mesenteric artery. So, the ascending colon,
caecum, jejunum and ileum would all be affected by damage to the vagus nerve. The sigmoid colon, which receives
parasympathetic innervation from the pelvic splanchnics, would not be affected.

AUTONOMIC CONTROL OF THE PUPIL

Sympathetic innervation from superior cervical ganglia of T1 and parasympathetic innervation from cranial nerve III.

Sympathetic responses are related to the fight-or-flight response and the pupil will dilate. Sympathetic fibres originate
from the thoracic cord (T1) and enter the sympathetic chain. Post-ganglionic fibres from the superior cervical ganglion
supply the eye, removal of which results in unbalanced parasympathetic innervation. In this scenario, the metastatic disease
has damaged the sympathetic innervation of the pupil on the side ipsilateral to T1.

most common post-ganglionic neurotransmitter in the sympathetic system

Unlike pre-ganglionic neurotransmission, which uses acetylcholine (ACh), and sweat glands, which also use ACh in post-
ganglionic transmission, the most common post-ganglionic neurotransmitter in the sympathetic system is noradrenaline.

hyperhidrosis of the trunk and upper limbs

Although surgical intervention for such conditions is controversial, many patients with uncontrolled symptoms will be
willing to attempt an intervention that has shown some success.

A sympathectomy of the upper thoracic sympathetic chain (T2-T3) could help her symptoms. The most common approach
today is a video-assisted thoracoscopic surgical (VATS) procedure, sometimes bilaterally at one operation, sometimes
staged. T1 would be spared to avoid Horner syndrome.

hyperhidrosis trewatment

 For facial hyperhidrosis, ablation of T2 and T3 can decrease sweating, as can sympathectomy of the lower third of the
stellate ganglion.
 For palmar sweating, T2 and sometimes T3 ganglia must be ablated.
 For axillary sweating, at least T3 and sometimes T4 and T5(Ahn, et al., personal communication, July 2003).
 For plantar sweating, the L2,L3,L4 ganglia should be ablated, but, because sexual side effects can occur with ablation at
this level, sympathectomy for plantar symptoms is rarely done.

pelvic plexuses
The pelvic plexuses supply the viscera of the pelvic cavity. They are situated at the sides of the rectum in men and at the
sides of the rectum and vagina in women. The pelvic plexuses are formed on either side by

1. a continuation of the superior hypogastric plexus (the hypogastric nerve),

2. the sacral parasympathetic efferent fibres from the second, third and fourth sacral nerves (pelvic splanchnic nerves)
3. the sacral splanchnic nerves from the sympathetic trunk.

Lambert–Eaton myasthenic syndrome (LEMS)

At around 0.3/100 000, this is a rare autoimmune disorder, which often presents as a result of a paraneoplastic syndrome
in small-cell lung cancer. However, only a tiny fraction of those with small-cell cancer actually have LEMS.
Multiple system atrophy
This progressive fatal disorder presents most commonly with loss of coordination along with autonomic dysfunction. It is
twice as common in men but overall is rare. Some unusual presentations of Parkinson’s disease are misdiagnosed as
multiple system atrophy.

prevalence of autonomic dysfunction

Parkinson’s disease is the second most common degenerative disorder after Alzheimer’s disease. The prevalence of
autonomic dysfunction varies greatly between studies due to the methodology used, but has been reported to be as
high as 80%.

Trauma to the spinal cord can damage its autonomic function at the level of injury. Bladder and bowel control are the
most frequently affected. This, however, remains a relatively uncommon cause of autonomic dysfunction compared with
other causes

Anatomy_ Abdominal Vessels, Abdominal Viscera, Abdominal Wall

& Cavity, Perineum, Pelvis
PORTAL VEIN
The portal vein is formed by the union of the splenic vein and superior mesenteric veins posterior to the neck of the
pancreas. It runs along with the hepatic artery proper and common bile duct to form the three components of the portal
triad.

The portal vein receives tributaries including the right and left gastric veins and para-umbilical veins. The portal vein also
receives cystic veins from the gall-bladder.

The hepatoduodenal ligament is a double layer of peritoneum – the free edge of the lesser omentum – that encompasses
the triad. This is clinically relevant in liver surgery where the hepatoduodenal ligament may be clamped with a large
atraumatic haemostat to halt blood flow and control bleeding from the liver. This is known as the Pringle manoeuvre.

The portal vein lies between the two layers of the lesser omentum running in the free edge. The portal vein is formed by
the confluence of the superior mesenteric vein (lying to the right of the artery) and the splenic vein, behind the neck of the
pancreas. It is about 8 cm long. The portal vein lies between the two layers of the lesser omentum, running almost
vertically in the free edge where the lesser omentum forms the anterior boundary of the epiploic foramen. The portal vein
is found behind the hepatic artery and common bile duct. The terminals of the portal vein and the hepatic artery form,
with the hepatic ductules, the triads of the liver in the corners of the hexagonal lobules. The central veins drain into the
hepatic veins. In trauma scenarios, liver haemorrhages can be controlled by temporary compression of the portal vein and
hepatic artery in the edge of the lesser omentum (hepato-duodenal ligament). This is known as Pringle’s manoeuvre.

It divides into two main branches, the left and right portal veins. The right portal vein goes on to divide into the anterior
and posterior portal veins supplying segments V, VIII and VI, VII respectively.
Segment I (the caudate lobe) may be supplied by the right or left portal veins.

The left portal vein supplies segments II, III and IV of the liver.

The portal vein provides 75% of blood supply to the liver, but only 50% of its oxygen supply.

spermatic cord
‘3 arteries, 3 nerves, 3 other things’

Nine structures lie within the spermatic cord: three arteries (testicular, cremasteric, artery to the vas deferens); three
nerves (genital branch of the genitofemoral nerve, sympathetic fibres, ilioinguinal nerve – this is outside the cord but
travels with it) and three other structures (pampiniform plexus, vas deferens, lymphatics).

There are three covering fascial layers – external and internal spermatic and cremasteric fascia.

The pampiniform plexus is a network of veins found within the spermatic cord. It provides venous return from the testes
and plays a part in testicular temperature regulation. A varicocele is an abnormal enlargement of this structure.

Lipomas of the cord are sometimes found during inguinal hernia repairs but they are not contained within the cord.

inguinal ligament
The inguinal ligament is also known as Poupart’s ligament, named after Francois Poupart who gave it relevance with
regards to inguinal hernia repairs.

Alcock’s canal

Alcock’s canal is a fascial tunnel of obturator internus fascia, on the lateral wall of the ischiorectal fossa, which conveys
the pudendal nerve and vessels. It is not related to the femoral canal.
Cooper’s ligament
The pectineal ligament is also known as Cooper’s ligament, and should not be confused with the suspensory ligaments of
the breast, also known as the ligaments of Cooper.

duct of Santorini
The duct of Santorini is the accessory pancreatic duct (opens 2cm proximal/superior to the opening of the main pancreatic
duct)

inguinal canal
The conjoint tendon is formed by the confluence of tissues from the internal oblique and transverses abdominis muscles of
the abdominal wall. It lies in the medial one-third of the inguinal canal, posterior to the superficial ring. Conjoint +
transversalis fascia = medial 1/3 of posterior wall (posterior wall strongest in its medial part opposite to the external ring)

The lateral 2/3 of the posterior wall of the inguinal canal is formed by the transversalis fascia.

The superficial ring is the exit to the inguinal canal 1cm above and lateral to the pubic tubercule. The external (or
superficial) inguinal ring is formed by a V-shaped defect in the external oblique aponeurosis. The visible landmark for the
superficial inguinal ring are the intercrural fibres that run at right angles across the external oblique aponeurosis. The
inguinal canal with its borders is shown in the image below, with the deep inguinal ring seen laterally and the superficial ring
seen medially at either end. The deep inguinal ring is at the midpoint of the inguinal ligament (shown below), which is
midway between the anterior superior iliac spine (ASIS) and the pubic tubercle.

Transversus abdominus muscle forms the roof of the inguinal canal.

Inguinal ligament forms the floor of the inguinal canal along with the lacunar ligament medially

The inferior epigastric vessels are medial to the deep inguinal ring.

Transversalis fascia forms the lateral aspect of the posterior wall throughout the inguinal canal and is joined by the conjoint
tendon medially.

The aponeurosis of the external oblique helps form the anterior wall and is assisted laterally by the internal oblique.
(anterior wall strongest in its lateral part, opposite to the internal ring)

The inguinal canal also carries the ilioinguinal nerve along with the round ligament in women.

The ilioinguinal nerve is carried along with the spermatic cord in the inguinal canal in men but not within the cord (as does
the Lipoma of the cord).
 Laparoscopic triangles

hepatorenal space
The hepatorenal space/pouch (of Morisson) is a potential space and lies between the right lobe of the liver and right
kidney. It forms the second most dependent part of the peritoneal cavity, apart from the pelvis, in the supine abdomen
and communicates freely with the lesser sac, the right paracolic gutter and right subphrenic space. Intraperitoneal fluid
or pus can easily accumulate in the hepatorenal pouch.

small bowel
Valvulae conniventes, also known as plicae circulares, are thin circular mucosal folds in the small bowel. These structures
give the small bowel the distinct radiological appearances of lines appearing to pass across the full width of the lumen.

large bowel
 Omental appendices. Omental appendices are peritoneal-covered fatty accumulations associated with the large bowel.
 Taeniae coli. The longitudinal muscles of the large bowel are segregated into three bands, which are known as the taeniae
coli.
 Haustra. The large bowel’s circular muscles form sacculations known as haustra. Do not cross the full width of the lumen

Pyramidalis muscle
This is a small, triangular, vertical muscle that lies anterior to the rectus abdominis and attaches to the linea alba having
originated at the front of the pubis and pubic symphysis. It is innervated by the ventral portion of T12 and supplied by the
inferior and superior epigastric arteries. Its action is to tense the linea alba. It is naturally absent in up to 12% of the
population.

Frequently absent muscles

Pyramidalis (12% absent)

Plantaris (12% absent)

Peroneus tertius (17% absent)

Umbilical hernia
An umbilical hernia protrudes through the umbilical cicatrix to lie in the subcutaneous tissues. They will often resolve as the
child grows and few will require surgical treatment. Those that do can be repaired with the Mayo ‘vest-over-pants’
approach. There is a higher incidence in Afro-Caribbean children than in Caucasian.
Paraumbilical hernias are more frequently repaired using a mesh, rather than the Mayo technique. They are also less
common than umbilical hernias in this age group.

differences between the jejunum and ileum

The jejunum makes up the proximal two-fifths of the small intestine while the ileum makes up the distal three-fifths.
There is no macroscopic demarcation between the two, but macroscopic features help differentiate the two.

The jejunum is mainly found in the left upper quadrant of the abdomen and is characterised by less prominent arterial
arcades and longer vasa recta when compared with the ileum.

The jejunum is larger in diameter and has a thicker wall than the ileum.

The jejunum has fewer lymphatic follicles (Peyer’s patches) than the ileum.

Valvulae conniventes are mucosal folds of the small intestine which start at the second part of the duodenum. They are
present in the jejunum, where they are large and thick, decrease in size in the distal ileum.

The ileum has more mesenteric fat and less prominent plicae circularis (mucosal folds) than the jejunum.

The ileum has less prominent plicae circularis in comparison with the jejunum. The jejunum has a thicker wall, and more
prominent plica circularis, with long straight arteries. The ileum, on the other hand, has less prominent plica circularis but
has thinner walls.

Abdominal wall fascias

Colle’s fascia is the deeper membranous layer of the superficial perineal fascia. It attaches to the ischiopubic rami and
the perineal membrane, which divides the prostate from the base of the penis. The fascia is continuous with the dartos
fascia of the scrotum, with the superficial penile fascia (that covers the clitoris and penis), and with Scarpa’s fascia of the
abdominal wall.

Camper’s fascia is the fascia that is superficial to Scarpa’s fascia and is not continuous with Colles’.

Transversalis fascia continues to become the internal spermatic fascia.

The layers of the anterior abdominal wall are: skin, subcutaneous tissue, superficial fascia (Camper’s fascia and Scarpa’s
fascia), external oblique muscle, internal oblique muscle, transversus abdominis muscle, transversalis fascia, preperitoneal
fatty tissue, and peritoneum. These are clinically important to know for all abdominal surgery.

Scarpa’s fascia is the deeper layer to Camper’s fascia and is thin and membranous. It contains very little, or no, fat.
Scarpa’s fascia continues below the inguinal ligament and fuses with the fascia lata of the thigh. It also forms the
fundiform ligament of the penis and is known as Colle’s fascia once it advances posteriorly along the perineum.

The Dartos fascia is the continuation of Scarpa's fascia into the scrotum. It contains smooth muscle fibres.

External spermatic fascia  Bucks Fascia (encloses urethra)

The fascia of penis (Buck's fascia ; deep fascia of the penis ; Gallaudet's fascia) is a layer of deep fascia covering the three
erectile bodies of the penis
Buck's fascia is continuous with the external spermatic fascia in the scrotum and the suspensory ligament of the penis.

Ureter constrictions

The ureter has three distinct narrowings in its passage from the kidney to the bladder.

The lumen of the ureter is not of equal diameter throughout the ureters entire length. It has three distinct narrowings,
these are the pelviureteric junction proximally, then the crossing of the iliac vessels, and distally the vesicoureteric junction
in the pelvis. These are possible sites of ureteric calculus impaction and are useful landmarks when assessing a plain
radiograph of the abdomen or a computed tomography scan of the kidneys, ureters and bladder (CTKUB).

The pelviureteric junction is the point at which the renal pelvis becomes continues with the ureter and is the first point of
constriction at which renal stones can become lodged

At the point at which the ureters cross the common iliac vessels the ureters are slightly constricted. Stones lodged here are
more unusual than stones lodged at the ureteropelvic or ureterovesical junction.

The ureterovesical junction is the point at which the ureters enter the wall of the bladder, and is a site of
ureteral constriction at which renal stones may lodge. It is the most common site of impaction as it has the
smallest diameter of the options listed. Generally for a stone to impact it must have a diameter of 2 mm or greater.

nephrectomy

The subcostal neurovascular bundle is relatively protected from risk of injury because it lies in the costal groove.

The lower border of the parietal pleura crosses the twelfth rib at the lateral border of the erector spinae, and passes in
horizontally to the lower border of the twelfth thoracic vertebrae. There is, therefore, a triangle of pleura in the
costovertebral angle below the medial part of the twelfth rib, behind the upper pole of the kidney  susceptible to
injuries

The adrenal glands are anatomically well protected. They lie anterosuperior to the upper part of each kidney, within their
own compartment of the renal fascia. Care must be taken during a nephrectomy to avoid damage to the adrenals, but
these are not easily damaged by a careful surgeon using a posterior approach.

The renal fascia of Gerota surrounds the perinephric fat, which lies outside the renal capsule.

Gerota’s fascia, or the renal fascia, surrounds the kidney and the adrenal gland. It is found in the retroperitoneum, posterior
to the colon.

The renal artery is posterior to the renal vein.

The adrenal gland lies over the medial border above the hilum and simple nephrectomy is indicated in cases of non-
functioning kidneys

The best approach for a ruptured kidney is through the anterior abdominal wall by a midline incision.

The hilum of the kidney is separated from the tail of the pancreas by the peritoneum.
 Renal hilum

The right renal vein lies immediately anterior to the right renal artery (it can be seen in grey anterior to the right renal
artery below) and, therefore, is the most anterior structure in the renal hilum. The renal vein lies immediately anterior to
the renal artery as it enters the hilum.

The ureter is posterior in relation to the artery and is the most posterior structure which enters the right renal hilum.

So the renal hilum, from anterior to posterior, includes the renal vein, renal artery and ureter.

foregut
The foregut begins at the mouth and ends just inferior to the major duodenal papilla, where it gives way to the midgut.

The major duodenal papilla, below which point the foregut ends and midgut begins, is the point at which the common
bile duct and pancreatic duct empty into the duodenum.

Femoral hernias
Femoral hernias present with a swelling inferior and lateral to the pubic tubercle, and are due to peritoneum
herniating into the femoral canal – the boundaries of which are shown below. Although they are more common in
women, they can occur in men. They are likely to strangulate due to the presence of the lacunar ligament medially.

Femoral hernias are palpable lumps/ bulges found within the femoral triangle and are more common in women. They
are differentiated from inguinal hernias by being found below and lateral to the pubic tubercle. They are caused by
herniation of abdominal contents through the femoral canal (shown in purple in the image below). The management is
surgical in nature.

Other differential diagnoses of a femoral hernia include: inguinal hernia, saphena varix, lymphadenopathy, lipoma, femoral
aneurysm, sarcoma, ectopic testes and obturator hernia.

femoral triangle

The femoral triangle has a roof and a floor:

 roof of the femoral triangle: fascia lata

 floor of the femoral triangle: pectineus, iliopsoas and adductor longus.

There are three borders of the femoral triangle: superior, medial and lateral (shown in the image below):

 superior – inguinal ligament

 medial – medial border of adductor longus
 lateral – medial border of sartorius.

femoral sheath

The femoral sheath contains the femoral canal, femoral vein and femoral artery (from medial to lateral). It does not
contain the femoral nerve.
Amyand’s hernia
This is an inguinal hernia containing an inflamed appendix.

Obturator hernia
Obturator hernias overall very rare but are more common in women. The pain worsens with hip extension, medial
rotation and abduction.

Spigelian hernia
This occurs through a defect in the Spigelian fascia at the edge of the rectus abdominus muscle. They are
uncommon.

LINEA SEMILUNARIS
The linea semilunaris marks the lateral margin of the rectus muscle and sheath, passing from the pubic tubercle to
the costal cartilage at the tip of the ninth rib, which overlies the fundus of the gall-bladder on the right.
It corresponds to, but is not necessarily formed by the division of the aponeurosis of the internal oblique above the
arcuate line.

The inferior epigastric vessels and medial umbilical ligament cross the linea seminularis posteriorly
below the arcuate line, before ascending in the posterior compartment of the rectus sheath.
The anterior abdominal wall would be greatly weakened both physically and functionally by cutting along the semilunar
line as the nerve supply to the rectus abdominis muscle and overlying skin would be interrupted. Furthermore, Langer’s
lines on the abdomen are horizontal.

Spigelian hernias occur at the edge of the linea semilunaris, typically at the level of the arcuate line.
The three borders of Hesselbach’s triangle are the inferior epigastric artery, the inguinal ligament and the lateral border of
the rectus abdominis muscle (linea semilunaris).

Superior epigastric vein

The superior epigastric vein anastomoses with the inferior epigastric vein at the level of the umbilicus and drains the upper
abdominal wall and some of the diaphragm. It is not encountered during an inguinal hernia repair.

inferior epigastric vessels

The inferior epigastric vessels cross the linea seminularis posteriorly and lie on the inner surface of the transversus
abdominis and are covered by parietal peritoneum. Their superficial position is marked on the image below.

Remember: the peritoneum lies over the inferior epigastric vessels to make the lateral umbilical fold.

duodenum
The joining of the pancreatic duct and the bile duct forms the ampulla of Vater, which enters the second part of the
duodenum at the major duodenal papilla. The hepatopancreatic ampulla enters the second part of the duodenum at the
major duodenal papilla. It is through this papilla that endoscopic retrograde cholangiopancreatography can enable the relief
of obstructive jaundice via placement of a biliary stent.

D1(L1), D2(L1,2,3) D3(L3), D4(L3,2)

The second, third and fourth (ascending) parts of the duodenum are all retroperitoneal structures. Only the first part
(superior, D1) is intraperitoneal.

The descending part of the duodenum lies lateral to the head of the pancreas.

The fourth part of the duodenum, also known as D4, or the ascending duodenum, ascends to the inferior border of the body
of the pancreas, curves anteriorly and forms the jejunum, where it terminates at the duodenal-jejunal junction or flexure,
as you can see in the image below. Superiorly it is related to the stomach, posteriorly to the left psoas muscle and
the aorta, and inferiorly to the jejunal loops.

The third part of the duodenum lies in the subcostal plane (L3) and follows the inferior margin of the pancreatic head. It lies
posterior to the superior mesenteric vessels, which can be seen in the image below travelling anteriorly to D3. It
overlies the aorta and the beginning of the inferior mesenteric artery . The root of the small bowel mesentery is
attached near its termination on the left.

The second part of the duodenum overlies the right ureter and renal vessels in the hilum of the right kidney, separated
from the renal artery by the vein.

The transverse colon crosses the second part of the duodenum.

The duodenal bulb is the part of the duodenum closest to the stomach. The major duodenal papilla is found in the
descending part of the duodenum, rather than the duodenal bulb.

The major duodenal papilla is situated at the medial side of the descending portion of the duodenum, a little below its
middle and about 7 to 10 cm from the pylorus. The common bile and pancreatic ducts unite and open by a common orifice
on the sum mit of the duodenal papilla.

annular pancreas
Annular pancreas can either partially or completely encompass the second part of the duodenum resulting in stenosis
and proximal dilatation. It most commonly symptomatic (66%). Clinically, this may result in abdominal pain and
vomiting. Annular pancreas is an embryological anomaly that can result in duodenal obstruction. It can be complete or
incomplete. It affects both children and adults causing post-prandial satiety, abdominal pain and vomiting and is diagnosed
using a CT scan or MRI.

Characteristic computed tomography (CT) scan findings include: complete or incomplete encasing of the 2nd part of the
duodenum by the pancreas, duodenal narrowing and dilatation of the proximal duodenum.

An annular pancreas develops due to failure of the ventral bud to rotate with the duodenum, resulting in its encasement.
This process typically happens in the 7th week of gestation.

Down’s syndrome, pancreatitis and pancreatic cancer are associated with having an annular pancreas.

A third of cases (33%) are an incidental finding and patients are asymptomatic. In children, it commonly presents as
duodenal obstruction, whereas adults typically present with signs and symptoms of pancreatitis.
Hepatic H-shape
Gall-bladder, IVC, ligamentum teres, ligamentum venosum, porta hepatis form the H shape that divides the visceral
surface of the liver.

OMENTAL FORAMEN
(epiploic foramen or foramen of Winslow)

The free edge of the lesser omentum forms the anterior border of the epiploic foramen and it can be seen to the right of
the stomach in the first image below. The lesser omentum is a double fold of peritoneum and between these layers are the
common bile duct, hepatic artery, and portal vein. The lesser sac itself can be seen from the side in the second image below,
posterior to the stomach.

The posterior boundary is formed by the peritoneum covering the inferior vena cava.

The caudate, not the quadrate lobe of the liver is the superior border of the foramen of Winslow.

The inferior boundary comprises the peritoneum covering the commencement of the duodenum and the hepatic artery, the
latter passing forward below the foramen before ascending between the two layers of the lesser omentum.

Calot’s triangle
The three borders of Calot’s triangle are cystic duct, common hepatic duct and inferior border of the liver . Calot’s
triangle lies between the inferior border of the liver, cystic duct and common hepatic duct and usually contains the cystic
artery. The cystic artery must be divided in cholecystectomy, which is why the triangle is very important to identify.

pancreas
The head of the pancreas lies in the transpyloric plane. The head of the pancreas is related to the hilum but does not
overlie the right kidney. The tail of the pancreas is, however, anterior to the left kidney.

The transpyloric plane (L1) transects the pancreas obliquely, passing through the midpoint of the neck, with most
of the head below the plane, and most of the body and tail above.

The transverse mesocolon is attached to the head, neck and body of the pancreas.

The uncinate process lies posterior to the superior mesenteric vessels,

The inferior mesenteric vein passes behind the body of the pancreas, where it joins the splenic vein.
 Portal Vein forms posterior to the neck of the pancreas

The superior mesenteric artery passes posterior to the pancreatic neck as it arises from the abdominal aorta.

The uncinate process is an extension of the inferior half of the head toward the left; it is of varying size and is wedged
between the superior mesenteric artery and the aorta – seen as the most inferior part of the pancreas below.

left colic flexure

The left colic flexure, also called the splenic flexure, is the point where the colon takes a sharp downward turn. This flexure
is the point where the transverse colon ends and the descending colon begins. It is located immediately inferior to the
spleen, so an enlarged spleen must move medially to avoid this colic flexure. (limits the straight-vertical-downward
movement of the spleen)

Ligament of Treitz

The suspensory muscle of the duodenum or ligament of Treitz is a thin sheet of muscle derived from the right crus of the
diaphragm – it suspends the fourth part of the duodenum from the posterior abdominal wall. It has no effect on the spleen.

Psoas major
The psoas major muscle is one of the posterior abdominal wall muscles that lies posterior to the kidneys. The psoas major
lies immediately posterior to the kidneys bilaterally and arises from the transverse processes, lateral aspects of vertebral
bodies and intervertebral discs of T12 to L5.

Erector spinae
The erector spinae muscles are a group of muscles of the back. It is made up of three muscles, from medial to lateral, the
spinalis, longissimus and iliocostalis. These muscles lie posteromedial to the kidneys, not immediately posterior.

suprarenal (adrenal) gland

The right lobe of the liver is an anterior relation of the right (pyramidal) suprarenal gland – the image below shows the
abdomen seen from the posterior aspect, and the right adrenal gland can be seen against the liver, as it touches the bare
area of the liver. The anterior surface of the right suprarenal gland is overlapped medially by the inferior vena cava.

The suprarenal glands lie in the posterior abdomen, lying between the upper pole of the kidneys and the diaphragm. The
suprarenal glands have a rich blood supply, which is supplied via three arteries:

 superior adrenal artery – arises from the inferior phrenic artery

 middle adrenal artery – arises from the abdominal aorta
 inferior adrenal artery – arises from the renal arteries.

The right and left adrenal veins drain the glands. The right adrenal vein drains into the inferior vena cava, whereas the left
adrenal vein drains into the left renal vein.

The right suprarenal gland is pyramidal in shape

The left suprarenal gland is semi-lunar or crescentic shape.

 lesser sac

The lesser sac is a potential peritoneal space within the peritoneal cavity, seen in the images below as the space behind the
stomach.

The anterior relations of the lesser sac are:

 visceral peritoneum along the posterior stomach

 lesser omentum
 gastrocolic omentum.

The transverse mesocolon , the greater omentum and the visceral/parietal peritoneum that covers the diaphragm,
pancreas, left kidney and duodenum form the posterior wall.

The gastrosplenic and lienorenal ligaments form its left lateral border.

The right gastric vessels like between the two layers of omentum. The right and left gastric arteries supply the lesser
omentum as they lie between its two peritoneal layers.

The free edge of the lesser omentum is attached to the first 2 cm of the first part of the duodenum below and the
fissure of the ligamentum venosum (NOT teres) above. The common hepatic duct is joined by the cystic duct to form the
common bile duct in the free edge of the lesser omentum.
superior mesenteric artery (SMA)
The origin of the superior mesenteric artery (SMA) lies behind the neck of the pancreas (at the L1 level) – it can be
seen inferiorly in the image. The SMA supplies the entire small intestine except the proximal duodenum. The SMA also
supplies the caecum, ascending colon and half the transverse colon.

The SMA passes forwards and downwards in front of the uncinate process and the third part of the duodenum.
Throughout, the superior mesenteric vein lies to its right.

The splenic vein grooves the posterosuperior aspect of the pancreas and passes above the SMA. (splenic artery is superior
to the pancreas)

The SMA is posterior to the splenic vein – it can be seen passing beneath the neck of the pancreas and under the splenic
vein.

The superior mesenteric artery (SMA) crosses anterior to the third part of the duodenum. If the angle of the SMA is
particularly acute, it can cause duodenal obstruction at this level (Wilkie’s syndrome).

The SMA passes anterior to the left renal vein, Compression of the left renal vein between the SMA and the
aorta is known as nutcracker syndrome.

ureter
The ureter is lined by transitional epithelium. The ureter is lined by transitional epithelium, consisting of multiple layers of
epithelial cells that contract and expand.
middle colic artery
The middle colic artery is the branch from the superior mesenteric artery (SMA) that supplies the transverse colon. This is
the most distal part of the colon that receives blood from the SMA. Branches from the middle colic form an anastomosis
with the marginal artery, which would be able to supply the descending colon, sigmoid colon and rectum if the inferior
mesenteric artery was occluded.

testis
The nerve supply is via the lesser splanchnic nerve and the coeliac ganglion with postganglionic fibres accompanying the
testicular arteries.

The testis is usually descended by birth having developed from the gonadal ridge on the posterior abdominal wall. Its thick,
whitish covering is the tunica albuginea.

Lymphatic drainage follows the arterial supply to the para-aortic nodes.

The spermatic cord contains the pampiniform plexus – a single testicular vein is formed more distally over psoas
major.

biliary drainage system

The biliary drainage system is shown below broken down section by section. The distal part of the common bile duct lies
in front of the right renal vein. The common bile duct lies to the right of the hepatic artery. Joining the pancreatic duct at
the ampulla of Vater, which opens into the second part of the duodenum through the major duodenal papilla.

CBD crosses a groove between the head of the pancreas and the second part of the duodenum, posteriorly to the second
part of the duodenum, in front of the right renal vein.

The common bile duct runs anterior to the portal vein. The common bile duct contains no muscle..

The common bile duct contains no muscle → cannot give bile colic!

spleen
The spleen lies in the concavity of the left hemidiaphragm with its long axis lying along the tenth rib, extending between
ribs nine and eleven. It is fully invested in peritoneum, making it a peritoneal structure. The arterial supply is the
splenic artery, which reaches the spleen via the lienorenal ligament. Venous drainage is via the splenic vein into the
portal vein.

Occasionally the spleen may be absent and is replaced with multiple splenunculi.

right hemicolectomy
The right gonadal artery can be easily damaged during a right hemicolectomy.

The right ureter can be easily damaged during a right hemicolectomy

The ileocolic artery is the terminal branch of the superior mesenteric artery and its right branch is usually ligated during
a right hemicolectomy. (not the whole artery!!!!!)

The right colic artery is a branch of the superior mesenteric artery and supplies the ascending colon and must be identified
and ligated in a right hemicolectomy.
small bowel mesentery
The small bowel mesentery contains the superior mesenteric artery supplies the mid-gut, which includes the large bowel as
far as the distal transverse colon. The veins in the mesentery are all tributaries of the portal system.

The root of the small bowel mesentery extends from a point to the left of the L2 vertebra, at the duodenojejunal
junction, down to the right sacroiliac joint.

The nerves are postganglionic sympathetic and preganglionic parasympathetic fibres (vagus nerve) from the superior
mesenteric plexus. The superior mesenteric artery supplies the mid-gut, which includes the large bowel as far as the distal
transverse colon. The transverse mesocolon lies anterior to the small bowel mesentery.

transverse mesocolon
The transverse mesocolon is attached to the head, neck and body of the pancreas. Entering the lesser sac between the
transverse mesocolon and body of pancreas is a common method for laparoscopic mobilisation of the splenic flexure.

The head of the pancreas overlies the right renal vessels (but not the right kidney itself).

The transpyloric plane (L1) transects the pancreas obliquely, passing through the midpoint of the neck, with most of the
head below the plane, and most of the body and tail above.

The neck of the pancreas, rather than the body, is in the transpyloric plane

uterine artery
The uterine artery arises from the anterior division of the internal iliac artery and runs medially on the levator ani towards
the uterine cervix. It crosses above and in front of the ureter, to which it supplies a small branch, about 2 cm
from the cervix. [The ureter lies lateral to the uterine cervix and above its lateral fornix ]. Reaching the side of the
uterus, it ascends in a tortuous manner between the two layers of the broad ligament to the junction of the Fallopian tube
and uterus. It then runs laterally towards the hilum of the ovary and ends by anastomosing with the ovarian artery. It
supplies branches to the uterine cervix, the vagina, the body of the uterus, and from its terminal portion branches are
distributed to the Fallopian tube and the round ligament of the uterus.

Median sacral artery

The median sacral artery is a small posterior branch of the aorta that supplies the coccyx, lumbar vertebrae and sacrum
External iliac artery
The branches of the external iliac artery are the inferior epigastric, deep circumflex iliac artery and the common femoral
artery. They supply the lower abdominal wall, the iliac bone and the lower limb respectively

Corona mortis

lienorenal ligament
The lienorenal ligament connects the hilum of the spleen to the left kidney. It is highlighted in blue below. The splenic
artery and vein are carried within it, as is the pancreatic tail.

Wilms’ tumour (nephroblastoma) is the commonest type of renal tumour of childhood, representing 20% of all childhood
malignancies. DOES NOT CROSS the midline

aorta
The inferior phrenic arteries branch from the aorta immediately after it enters the abdomen through the aortic hiatus –
they can be seen as the first branches in the image below. They pass superolaterally and run under the crura to supply the
diaphragm.

The left renal vein crosses in front of the aorta and inferior to the superior mesenteric artery – it can be seen travelling
under the SMA and in front of the aorta in the image below.

The aorta bifurcates into the common iliac arteries at L4. It is also the level at which the median sacral artery arises. The
intercristal plane, which is an imaginary horizontal line between the highest points of the iliac crests, lies at the L4/5 level.
The image demonstrates that the aorta bifurcates one vertebral level higher than the IVC forms (at L5)
 .

 Inferior phrenic arteries: Paired parietal arteries arising posteriorly at the level of T12. They supply the diaphragm.

 Coeliac artery: A large, unpaired visceral artery arising anteriorly at the level of T12. It is also known as the celiac trunk
and supplies the liver, stomach, abdominal oesophagus, spleen, the superior duodenum and the superior pancreas.

 Superior mesenteric artery: A large, unpaired visceral artery arising anteriorly, just below the celiac artery. It supplies
the distal duodenum, jejuno-ileum, ascending colon and part of the transverse colon. It arises at the lower level of L1.

 Middle suprarenal arteries: Small paired visceral arteries that arise either side posteriorly at the level of L1 to supply
the adrenal glands.

 Renal arteries: Paired visceral arteries that arise laterally at the level between L1 and L2. They supply the kidneys.

 Gonadal arteries: Paired visceral arteries that arise laterally at the level of L2. Note that the male gonadal artery is
referred to as the testicular artery and in females, the ovarian artery.

 Inferior mesenteric artery: A large, unpaired visceral artery that arises anteriorly at the level of L3. It supplies the large
intestine from the splenic flexure to the upper part of the rectum.

 Median sacral artery: An unpaired parietal artery that arises posteriorly at the level of L4 to supply the coccyx, lumbar
vertebrae and the sacrum.

 Lumbar arteries: There are four pairs of parietal lumbar arteries that arise posterolaterally between L1 and L4 to
supply the abdominal wall and spinal cord.

inferior mesenteric vein

The inferior mesenteric vein drains the upper rectum and left sided colon – highlighted in green below. Its tributaries are
the superior rectal vein, rectosigmoid veins, sigmoid veins and the left colic vein. It drains to the splenic vein, which
then forms the hepatic portal vein with the superior mesenteric vein. Occasionally, the inferior mesenteric vein drains
into the confluence of the portal vein or into the superior mesenteric vein.

The internal rectal venous plexus lies above the dentate line and drain to the superior rectal vein and then the inferior
mesenteric vein (portal venous system).

Supply of rectum
The inferior mesenteric artery (IMA) arises from the aorta at the level of L3. It supplies the GI tract from the distal third of
the transverse colon to the upper third of the rectum. The branch supplying the upper rectum is the superior rectal artery,
which can be seen as the most inferior branch of the IMA in green in the image below.

The middle rectal artery supplies the lower part of the rectum (a branch from the internal iliac artery).

Obturator artery
The obturator artery is a branch of the anterior trunk of the internal iliac artery. It runs anteriorly along the margin of the
pelvic inlet before exiting the pelvis via the obturator canal. It supplies the obturator externus muscle, the medial
compartment of the thigh, and the femur.

BLOOD SUPPLY TO THE FOREGUT

The short gastric arteries are branches of the splenic artery and course in the gastrosplenic ligament, which connects
the greater curve of the stomach to the hilum of the spleen. It also contains the left gastroepiploic vessels.

The gastroduodenal artery passes posterior to the first part of the duodenum. This is important clinically as a posterior
duodenal ulcer can erode into it, causing an upper GI haemorrhage.

The hepatic artery (proper) branches before entering the porta hepatis, but not in the free edge of the lesser omentum
(the hepatoduodenal ligament).

The gastroduodenal artery, a branch of the common hepatic, gives off the superior pancreaticoduodenal artery which
supplies the head and uncinate process of the pancreas. However, the body and tail of the pancreas are supplied mainly by
the pancreatic branches of the splenic artery.

The gastroduodenal artery is a branch of the common hepatic artery. It passes posteriorly to D1 before bifurcating into the
right gastroepiploic and superior pancreaticoduodenal arteries. A duodenal ulcer in the posterior wall of D1 could
therefore erode into it, as demonstrated in the image below, causing an upper GI haemorrhage.

Only the superior pancreaticoduodenal artery is a branch of the gastroduodenal artery. The inferior pancreaticoduodenal
artery is a branch of the superior mesenteric artery.

COELIAC TRUNK
The coeliac trunk trifurcates into the splenic, left gastric and common hepatic arteries, which are coloured individually in
the image below. It occasionally gives off one of the inferior phrenic arteries.

The coeliac trunk is the supply to the embryonic foregut.

The coeliac trunk arises from the anterior surface of the aorta at the level of T12.
 The coeliac trunk is related to the right coeliac ganglion and the caudate process of the liver on the right, and the left
coeliac ganglion and cardia of the stomach on the left. Inferiorly, it is in relation to the upper border of the pancreas
and the splenic vein.

(Batson’s) plexus
The veins of the internal vertebral venous (Batson’s) plexus are clinically significant because they are valveless and can
serve as a route for metastases in prostatic cancer.

BLOOD FLOW TO THE LIVER

The hepatic artery (proper) accounts for 25% of total blood flow to the liver. The hepatic artery proper is a branch of the
common hepatic artery. It maintains constant blood flow to the liver by autoregulation – arterial flow decreases when
portal venous flow increases, and vice versa. The remaining 75% is from the portal vein. Blood flow to the liver via the
hepatic artery and portal vein accounts for 25% of resting cardiac output (same as kidney)

Normal portal venous pressure is approximately 5–7 mmHg.

The pressure should be less than the pressure in the inferior vena cava by 5 mmHg. If the pressure difference
(hepatic venous pressure gradient – HVPG) is greater than 5 mmHg then portal hypertension is diagnosed.

PORTO-SYSTEMIC ANASTOMOSIS
Most common site→ oesophagus .

The left gastric vein receives blood from the superficial oesophageal veins, which drain the lower third of the oesophagus.
The left gastric vein drains into the portal system. The oesophageal veins, which drain the upper two-thirds of the
oesophagus, drain to the azygous system. The superficial oesophageal veins become engorged (as varices) in portal
hypertension due to them being a porto-systemic anastomosis. The Azygos system is shown below in the image, with the
azygos vein draining the right side of the thorax, and the hemiazygos and accessory hemiazygos veins draining the left side.

Other sites:

 Between the superior rectal vein and the internal pudendal vein. This portacaval anastomosis causes anorectal varices.
These are not to be confused with haemorrhoids, which are prolapsed rectal venous plexuses.
 At the bare area of the liver. Intraparenchymal branches of the right portal system anastomose with the phrenic vein at
this portacaval anastomosis.
 In the falciform ligament (falsiform varices). The free edge of the falciform ligament is the ligamentum teres hepatis. It
contains the obliterated umbilical vein and paraumbilical veins. In portal hypertension, the umbilical vein can become
recanalised.
 Between portal system and anterior abdominal wall veins. Portal hypertension can lead to engorgement of paraumbilical
veins which give rise to the clinical sign of caput medusae.

gonadal vessels
The gonadal vessels originate from the abdominal aorta at the level of the L2 vertebra and descend into the pelvis anterior
to the inferior vena cava as well as the ureters (‘water under the bridge’). It is important to identify the ureter and
gonadal vessels during mobilisation of the left and right colon.

middle suprarenal arteries

The middle suprarenal arteries are small direct branches of the abdominal aorta at the level of L1.
 internal iliac artery
The internal iliac artery is a branch of the common iliac artery – it is shown with its major branches in the image. It divides
into two branches, the posterior division and the anterior division.

The posterior division gives off the superior gluteal artery (shown in turquoise) which supplies gluteus medius and minimis,
and the lateral sacral (green).

The anterior division gives off the inferior gluteal artery which supplies gluteus maximus.

All the muscles of the buttock are therefore supplied by the internal iliac artery, so compromise of this vessel would lead to
visible buttock wasting.

The blood supply of the penis is mainly derived from the pudendal artery (a branch of the internal iliac artery) and so this
would also suggest the internal iliac artery was affected.

Leriche syndrome.
Impotence and buttock claudication would raise suspicion of aortoiliac occlusive disease. Aortoiliac occlusive disease refers
to complete occlusion of the aorta distal to the renal arteries. If these two symptoms are present along with absent or
weak femoral pulses, they form a triad known as Leriche syndrome.

inferior vena cava (IVC)

The IVC passes through the diaphragm at the level of T8, along with the right phrenic nerve and lymph nodes. The caval
hiatus in the central tendon is shown below. Each of the three holes has three structures passing through them:

 Caval foramen – IVC, lymphatics, right phrenic nerve (left phrenic nerve pierces diaphragm separately)
 oEsophageal hiatus – oesophagus, vagal trunks, left gastric vessels
 Aortic hiatus – aorta, thoracic duct, azygous vein.

The inferior vena cava is formed by the confluence of the common iliac veins at the level of L5.

The IVC lies to the right of the aorta (NOT posterior)

The IVC is posterior to the caudate lobe.

The inferior vena cava (IVC) passes posterior to third part of the duodenum.

The right renal artery passes posterior to the IVC.

ligamentum teres (hepatis)

The ligamentum teres (hepatis) is the free edge of the falciform ligament. It contains the obliterated umbilical vein and
paraumbilical veins

splenic artery
The splenic artery is a branch of the coeliac axis as shown below. It has a tortuous course, passing along the superior border
of the pancreas and posterior to the body of the stomach. It can be eroded into by a posterior gastric ulcer.
right renal artery
The right renal artery usually arises slightly lower than the left. It passes posterior to the inferior vena cava (IVC), the right
renal vein, the head of the pancreas and the duodenum – it can be seen emerging from behind the IVC in the image below.
It divides before reaching the renal hilum and, as with the left renal artery, gives branches which supply the adrenal gland
and the proximal ureter. It would not be safe to divide this vessel, although occasionally there can be accessory renal
arteries present branching directly off of the aorta.

The left renal artery arises from the left side of the aorta at approximately the level of L1–L2 and passes posterior to the
left renal vein, the body of the pancreas and the splenic vein.

oesophageal varices
The superficial oesophageal veins drain the lower third of the oesophagus to the left gastric vein and are the
veins which cause the haemmorhhage.

The oesophageal veins are veins draining the oesophagus to the systemic circulation (mostly via the azygous and
inferior thyroid veins).

Portal hypertension secondary to alcoholic liver cirrhosis causes reversal of flow at portacaval anastomoses resulting in
dilated superficial oesophageal veins (cf. caput medusae, anorectal varices).

The left gastric vein drains the lesser curve of the stomach. It receives the superficial oesophageal veins.

blood supply of the oesophagus

The blood supply of the oesophagus can be divided into thirds. The upper third is supplied by oesophageal branches from
the inferior thyroid artery, the middle third by branches from the thoracic aorta, and the lower third by oesophageal
branches from the left gastric artery.

male urethra
The male urethra is typically divided into three parts: prostatic, membranous, and penile (or spongy).

The membranous urethra pass through the urogenital diaphragm, surrounded by the external urethral sphincter.

The external urethral sphincter is distal to the verumontanum, so during a trans-urethral resection of the prostate
the resection is limited to the verumontanum distally to avoid incontinence.

The ‘fossa navicularis’ is a normal small dilatation found in the distal penile urethra.

The anterior urethra is lined with pseudostratified columnar epithelium, whereas distally it is lined by squamous
epithelium.

The urethra is widest at the prostatic part.

tunica albuginea
The tunica albuginea of the penis is a fibrous membrane of the penis that surrounds the corpora cavernosa. It has a role in
maintaining penile erection.
 Tunica albuginea of testicles (Latin for white coat) is a dense layer of tissue which encases the testes and connects to the
layers of fibres which surround the epididymis, the first in a series of ducts which transport sperm out of the testes and
into the penis

external anal sphincter

The external anal sphincter is a voluntary muscle innervated by the somatic inferior rectal nerves, originating from
the pudendal nerve. The pudendal nerve arises from the S2–S4 nerve roots of the anterior division of the sacral plexus. It is
responsible for innervation of the perineum and the pelvic floor. The internal anal sphincter is involuntary and is innervated
by post-ganglionic parasympathetic fibres. Severe, untreated perianal sepsis can lead to sphincter dysfunction and faecal
incontinence. Faecal incontinence can also be a complication of drainage of an abscess in that region, which results in
damage of the external anal sphincter.

Prostatic nerve plexus

The prostatic nerve plexus contain cavernous nerves which provide parasympathetic innervation. It is responsible
for the vascular changes which result in erection:

 ‘P’ – Parasympathetic = Point (erection).

 ‘S’ – Sympathetic = Shoot (ejaculation).

ectopic pregnancy

The majority of ectopic pregnancies (80%) occur in the ampulla of the Fallopian (uterine) tubes. The uterine (or
Fallopian) tube begins at the infundibulum and progresses medially to include the ampulla, the isthmus and the intramural
portion.

The isthmus is the second most common site of ectopics at 12%.

Only 5% of ectopic pregnancies occur here and therefore is not the most likely site of implantation.
 Only 1.4% of all ectopic pregnancies occur within the abdominal cavity.

In total, 0.2% of all ectopic pregnancies occur in the ovaries. Along with the cervix, it is the most unlikely site of
implantation.

External iliac lymph nodes

There are about 8–10 external iliac lymph nodes. These receive efferent lymphatics from the inguinal nodes, the
lymphatics of the iliac fossa, and the lower anterior abdominal wall and afferent lymphatics from the superior aspect of
the bladderand the other pelvic viscera.

The external iliac lymph nodes sit above the pelvic brim, along the external iliac vessels.

Superficial inguinal lymph nodes

The superficial inguinal lymph nodes run parallel to and below the inguinal ligament and vertically along the great
saphenous vein.

In the perineum, it drains the lower part of the anal canal and the vagina. It is also involved in drainage of external
genitalia (excluding the testes), lower abdominal wall below the umbilicus and lower limb.

The pelvic part of the rectum and the anal canal represent different lymph drainage territories. The pectinate line separates
the two territories, but communication does exist between them (ie the lymphatics of the anal canal communicate with
the perineal and rectal lymphatics). The lymph of the perineum and the anal canal is drained to the superficial inguinal
lymph nodes, whereas the lymph of the pelvic territory flows to iliac and lumbar nodes.

Internal iliac lymph nodes

The internal iliac lymph nodes are found along the internal iliac vessels. They are responsible for the drainage of the:

 gluteal region
 inferior pelvic viscera
 deep perineum.

Subsequently, it drains into the common iliac nodes.

Sacral lymph nodes

The sacral lymph nodes receive lymph from the rectum, bladder, prostate or cervix and the posterior pelvic wall.

Para-aortic lymph nodes

Para-aortic nodes drain the iliac nodes, which receive lymph from the pelvis and lower limb. In addition, it drains the
adrenal glands, kidneys and gonads.

cervix

The cervix is composed of two regions:

 Endocervix – proximal part of the cervix lined by simple columnar epithelium. The endocervical canal is contained within
the internal os and the external os.
 Ectocervix – distal part of the cervix which starts at the external os and projects into the vagina. It is lined by stratified
squamous non-keratinised epithelium.

The uterine cervix is located posterior to the urinary bladder and anterior to the rectum.

uterus

The uterine wall consists of three main layers which are (from inner to outermost) the endometrium, myometrium and
perimetrium.

Lymphatic drainage of the uterus is via the iliac, sacral, aortic and inguinal lymph nodes.

The lymphatic drainage of the uterus is as follows:

 fundus: para-aortic nodes

 body and cervix: internal and external iliac nodes; superficial inguinal nodes (LNds of the round ligament).

The pelvic floor musculature provides the primary support to the uterus. The ligaments which provide secondary support
are the broad ligament, round ligament, ovarian ligament, cardinal ligament and uterosacral ligament.

The uterus is covered by peritoneum anteriorly and superiorly except for the vaginal part of the cervix.

Lymphatic drainage of the ovaries

Lymphatic drainage of the ovaries is via the para-aortic nodes.

vagina
The nerve supply to the lower vagina is primarily from somatic nerves. The pudendal nerve gives rise to sensory nerve
fibres of the lower vagina whereas the sacral nerve roots give rise to pain fibres.

MALE URETHRA

The male urethra is a narrow fibromuscular tube through which urine and semen from the bladder and ejaculatory ducts
travel. It usually measures between 16–20 cm in length. It is generally divided into three parts from proximal to distal:

 prostatic
 membranous
 spongy or penile

The penile urethra is the longest part of the urethra, measuring about 15 cm in length. It is the first site to encounter a
catheter difficulty, but does not often cause difficulties unless there are strictures present requiring dilatation under local or
general anaesthetic using metal dilators.

The membranous urethra measures about 1.5–2 cm in length and is the shortest, least dilatable and the narrowest
part of the man urethra, often resulting in resistance on catheterisation.
 The prostatic urethra is about 3 cm in length and is lined by transitional epithelium. It is the widest and most distensible
part of the man urethra hence should not produce any resistance during catheterisation in a patient with a normal prostate.
The prostatic urethra runs through the prostate gland, dividing the prostate into a left and right lateral lobe. The paired
ejaculatory duct perforates the prostate, course through the central zone of the prostate and opens into the middle
of the prostatic urethra at the verumontanum.

Note that the verumontanum is not part of the urethra, but is the collective name for the ductile entrances into the
prostatic urethra.

The internal urethral sphincter is an involuntary sphincter that controls the bladder neck and the prostatic urethra above
the openings of the ejaculatory ducts.

prostate
The prostate is a fibromuscular and glandular organ that consists of four lobes: anterior, posterior, median and lateral.
The lateral lobes lie on either side of the urethra.

The prostatic venous plexus drains the prostate gland. This plexus drains into the internal iliac veins and also has
connections to the internal vertebral venous plexus and the Batson’s venous plexus.

The lymphatic drainage of the prostate primarily drains to the obturator and internal iliac lymphatic channels. There is
also lymphatic communication with the external iliac, presacral and para-aortic nodes.

The prostate gland is histologically divided into three zones:

 central zone
 peripheral zone (cancer)
 transitional zone (BPH)

The peripheral zone is commonly associated with malignant cells resulting in prostate carcinoma, whereas the transitional
zone is where BPH occurs.

The arterial supply of the prostate gland is derived from the prostatic arteries, which originate from the internal iliac
arteries.
 bulbourethral glands
The bulbourethral or Cowper’s gland are a pair of small exocrine glands located in the urogenital diaphragm(inside
deep perineal pouch) that produce an alkaline mucous secretion before ejaculation that drains into the spongy urethra
to neutralise traces of acidic urine in the urethra. Their ducts pierce the urogenital diaphragm and enter the superficial
inguinal pouch

ANAL CANAL
Venous drainage above the dentate line occurs via the superior rectal vein into the inferior mesenteric vein.

Below the dentate line, venous drainage occurs via the inferior rectal vein into the internal pudendal vein.

Arterial supply:

 above the dentate line: superior rectal artery (from ima)

 below the dentate line: inferior rectal artery (from the internal pudendal artery).

The anal canal is made up of a circular muscular layer that forms the internal and external anal sphincters. This is unlike
the rest of the gastrointestinal (GI) tract, which has both circular and longitudinal fibres.

Innervation above the dentate line and to the internal anal sphincter is attributed to the pelvic plexus (sympathetic) and
parasympathetic with afferent sensory contributions (pelvic splanchnic nerves). Below dentate line and external sphincters
from pudendal nerve

The demarcation between the rectum above and the anal canal below is the anorectal ring or anorectal
flexure, where the puborectalis muscle forms a sling around the posterior aspect of the anorectal junction, kinking
it anteriorly.

The anal canal is completely extraperitoneal. The length of the anal canal is about 4 cm (range, 3-5 cm), with
two thirds of this being above the pectinate line (also known as the dentate line) and one third below the
pectinate line.

The epithelium of the anal canal between the anal verge below and the pectinate line above is variously
described as anal mucosa or anal skin. The author believes that it should be called anal skin (anoderm), as it
looks like (pigmented) skin, is sensitive like skin (why a fissure-in-ano is very painful), and is keratinized (but
does not have skin appendages).

The pectinate line is the site of transition of the proctodeum below and the postallantoic gut above. It is a
scalloped demarcation formed by the anal valves (transverse folds of mucosa) at the inferior-most ends of the
anal columns(of Morgagni). Anal glands open above the anal valves into the anal sinuses. The pectinate line is
not seen on inspection in clinical practice, but under anesthesia the anal canal descends down, and the pectinate
line can be seen on slight retraction of the anal canal skin.

The anal canal just above the pectinate line for about 1-2 cm is called the anal pecten or transitional zone.
Above this transitional zone, the anal canal is lined with columnar epithelium (which is insensitive to cutting). Anal
columns (of Morgagni) are 6-10 longitudinal (vertical) mucosal folds in the upper part of the anal canal.

RECTUM
The sigmoid colon loses its mesentery and becomes the rectum at the level of S3.

The lymphatic drainage is divided into the upper third (inferior mesenteric group of nodes) and lower two-thirds (internal
iliac nodes) (similar to the arteria supply)
 There is no rectal mesentery – the mesorectum is a clinical term for the visceral pelvic fascia that contains pararectal lymph
nodes

Arterial supply of the rectum is by all three rectal arteries: superior, middle and inferior. The blood supply is
predominantly from the superior rectal artery, with variable contributions from the middle and inferior rectal vessels.
The inferior rectal vessels may often provide a significant blood supply to the rectum.

 The upper third is covered by peritoneum anteriorly and laterally.

 The middle third only anteriorly.
 The lower third is not covered by any peritoneum.

URINARY BLADDER
The urinary bladder is drained by the vesical venous plexus lying on the inferolateral surface. Veins from this venous
plexus then drain into the internal iliac veins.

Only the superior surface and some of the base of the urinary bladder are covered by peritoneum.

Dysfunction of the bladder trigone can result in vesicoureteric reflux.

The parasympathetic system is responsible for innervation of the detrusor muscle which causes contraction.

Arterial supply is primarily via the superior vesical branch of the internal iliac artery.

 In males, this is supplemented by the inferior vesical artery,

 In females this is supplemented by the vaginal arteries.
 In both sexes, the obturator, internal pudendal and inferior gluteal arteries may also contribute small branches.

Venous drainage is achieved by the vesical venous plexus, which empties into the internal iliac veins. The vesical plexus in
males is in continuity at the retropubic space with the prostate venous plexus (plexus of Santorini), which also receives
blood from the dorsal vein of the penis

Lymph drainage

 The superolateral aspect of the bladder drains into the external iliac lymph nodes.
 The neck and fundus drain into the internal iliac, sacral and common iliac nodes.

Nervous Supply

Neurological control is complex, with the bladder receiving input from both the autonomic (sympathetic and
parasympathetic) and somatic arms of the nervous system:

 Sympathetic – hypogastric nerve (T12 – L2). It causes relaxation of the detrusor muscle, promoting urine retention.

 Parasympathetic – pelvic nerve (S2-S4). Increased signals from this nerve causes contraction of the detrusor muscle,
stimulating micturition.

 Somatic – pudendal nerve (S2-4). It innervates the external urethral sphincter, providing voluntary control over micturition.
 In addition to the efferent nerves supplying the bladder, there are sensory (afferent) nerves that report to the brain. They
are found in the bladder wall and signal the need to urinate when the bladder becomes full.

The Bladder Stretch Reflex

The bladder stretch reflex is a primitive spinal reflex, in which micturition is stimulated in response to stretch of the bladder
wall. It is analogous to a muscle spinal reflex, such as the patella reflex.

During toilet training in infants, this spinal reflex is overridden by the higher centres of the brain, to give voluntary control
over micturition.

PELVIC FLOOR
The three components of the pelvic floor are: levator ani muscles, (ischio)coccygeus muscle and fascia coverings of the
muscles.

The levator ani is a large sheet of muscles made up of three paired muscles, which are the pubococcygeus, puborectalis
and iliococcygeus muscles.

The branches of the pudendal nerve innervate the three muscles which make up the levator ani.

The puborectalis muscle is key in maintaining faecal continence. It relaxes during defaecation.

The pelvic floor plays a major role in supporting the pelvic viscera. Factors that can damage the pelvic floor include:

 gynaecological surgery/colorectal surgery

 number of vaginal deliveries
 overweight/ obesity
 family history of muscular/connective tissue disorders.

Scrotal layers
Skin, dartos fascia (a continuation of Scarpa's fascia), external spermatic fascia, cremaster muscle and fascia, internal
spermatic fascia, parietal layer of tunica vaginalis, visceral layer of tunica vaginalis, tunica albuginea of testis

LYMPHATIC DRAINAGE OF THE TESTES

During development, the testes descend downwards and drag with them the blood supply and lymphatic drainage. This
means malignancy that spreads to local lymph nodes will be present in para-aortic nodes, relatively concealed
compared with inguinal lymphadenopathy.

The skin of the scrotum drains into the inguinal lymphatics whereas the testes themselves drain into the para-aortic
lymph. If a malignancy invades both these structures, then it is possible for both lymphatics to be involved.

ischiorectal fossa
The ischiorectal fossa is a prism-shaped potential space adjacent with its inferior aspect formed by perineal skin. Levator ani
lies medial and superior to the fossa.

Obturator internus is found lateral to the ischiorectal fossa.

The sphincter ani internus is found medial to the ischiorectal fossa.

Transversus perinei superficialis is anterior to the ischiorectal fossa.

Bordered by gluteus maximus (posterior)

anal canal

Lymph from the lower anal canal (below dentate line) drains via the superficial inguinal nodes.

The levator ani forms part of the deep external anal sphincter and the canal lies below this muscle.

The anal canal has no longitudinal muscular coat

The external anal sphincter is innervated by the inferior rectal branch of the pudendal nerve (S2–S4), while the
internal sphincter receives a sympathetic supply from the pelvic plexus.

The upper anal canal is thrown into vertical folds called anal columns.

Above the dentate line, which is visible as a wavy line at the level of the internal anal sphincter, the canal is lined by
columnar epithelium, below this level this changes to squamous epithelium.

transverse perineal muscles

The transverse perineal muscles do indeed pass between the urethra and the anus into a central tendinous portion.

They lie anterior to the anus and posterior to the urethra, passing from the ischial tuberosities through a central tendinous
portion.
 anatomical borders of the perineum
The anatomical borders of the perineum are:

 Anterior – pubic symphysis.

 Posterior – tip of the coccyx.

 Laterally – inferior pubic rami and inferior ischial rami, and the sacrotuberous ligament.

 Roof – pelvic floor.

 Base – skin and fascia.

The perineum can be subdivided by a theoretical line drawn transversely between the ischial tuberosities. This split forms
the anterior urogenital triangle and the posterior anal triangle. These triangles are associated with different components of
the perineum.

Anal Triangle
The anal triangle is the posterior half of the perineum. It is bounded by the coccyx, sacrotuberous ligaments, and a
theoretical line between the ischial tuberosities.

The main contents of the anal triangle are:

 Anal aperture – the opening of the anus.

 External anal sphincter muscle – voluntary muscle responsible for opening and closing the anus.

 Ischioanal fossae (x2) – spaces located laterally to the anus.

 Pudendal nerves (x2)

The anal aperture is located centrally in the triangle with the ischioanal fossae either side. These fossae contain fat and
connective tissue, which allow for expansion of the anal canal during defecation. They extend from the skin of the anal
region (inferiorly) to the pelvic diaphragm (superiorly).

Another important anatomical structure within the anal triangle is the pudendal nerve, which supplies the whole perineum
with somatic fibers.

Urogenital Triangle
The urogenital triangle is the anterior half of the perineum. It is bounded by the pubic symphysis, ischiopubic rami, and a
theorectical line between the two ischial tuberosities. The triangle is associated with the structures of the urogenital system
– the external genitalia and urethra.

Structurally, the urogenital triangle is complex, with a number of fascial layers and pouches. Unlike the anal triangle, the
urogenital triangle has an additional layer of strong deep fascia; the perineal membrane. This membrane has pouches on its
superior and inferior surfaces.

The layers of the urogenital triangle (deep to superficial):

 Deep perineal pouch – a potential space between the deep fascia of the pelvic floor (superiorly) and the perineal
membrane (inferiorly).
  It contains part of the urethra, external urethral sphincter, the vagina and the deep transverse perineal muscles in
the female.

 In males, it contains the urethra, the external urethral sphincter, bulbourethral glands and the deep transverse
perineal muscles.

 Perineal membrane – a layer of tough fascia, which is perforated by the urethra (and the vagina in the female). The role of
the membrane is to provide attachment for the muscles of the external genitalia.

Superficial perineal pouch – a potential space between the perineal membrane (superiorly) and the superficial perineal
fascia (inferiorly). It contains the erectile tissues that form the penis and clitoris, and three muscles – the
ischiocavernosus, bulbospongiosus and superficial transverse perineal muscles. The greater vestibular glands
(Bartholin’s glands)(female) and the ducts of the bulbourethral glands(male) are also located in the superficial
perineal pouch. The pouch is bounded posteriorly to the perineal body.

Perineal fascia – a continuity of the abdominal fascia that has two components:

Deep fascia (continuous with bucks fascia): covers the superficial perineal muscles and protruding structures (e.g. penis &
clitoris).

Superficial fascia is composed of a further two layers of fascia:

o Superficial layer – continuous with Camper’s fascia of the anterior abdominal wall

o Deep layer/Colles’ fascia – continuous with Scarpa’s fascia of the anterior abdominal wall

 Skin – The urethral and vaginal orifices open out onto the skin.
 nerve innervation of the testis

The testes share T10 innervation with the ureter and the umbilicus, which is why testicular pain can often be felt in the
abdomen and ureteric colic is sometimes accompanied by perception of pain in the testes.

S2–4 innervate the posterior leg, sitting area and penis/labia.

The Perineal Body

The perineal body is an irregular fibromuscular mass. It is located at the junction of the urogenital and anal triangles – the
central point of the perineum. This structure contains skeletal muscle, smooth muscle and collagenous and elastic fibres.

Anatomically, the perineal body lies just deep to the skin. It acts as a point of attachment for muscle fibres from the
pelvic floor and the perineum itself:

 Levator ani (part of the pelvic floor).

 Bulbocavernosus muscle.

 Superficial and deep transverse perineal muscles.

 External anal sphincter muscle.

 External urethral sphincter muscle fibres.

In women, it acts as a tear resistant body between the vagina and the external anal sphincter, supporting the posterior part
of the vaginal wall against prolapse.

In the male, it lies between the bulb of penis and the anus.
Anatomy_thorax
diaphragm
The diaphragm is innervated centrally by the left and right phrenic nerves, and peripherally by the inferior intercostal
nerves.

The phrenic nerves are supplied by the ventral rami of the C3, 4 and 5 nerve roots, carrying both motor and sensory
information to and from the diaphragm. They both travel anterior to the hila of the lungs, and over the pericardium.

These nerve roots also supply cutaneous innervation over the shoulder region, hence irritation of the pleura or peritoneum
of the diaphragm causes referred pain to the tip of the shoulder. More inferiorly, diaphragmatic irritation is referred directly
to the chest wall via the inferior intercostal nerves. Phrenic nerve supply = C3, 4, 5 keep the diaphragm alive.

sympathetic trunk
The sympathetic trunk is formed from the T1–L2 spinal segments, with the preganglionic sympathetic

neurons travelling with the anterior rami of the T1–L2 spinal nerves and reaching the sympathetic chain via white rami
communicantes. Certain organs, such as the viscera of the thorax or abdomen, receive their sympathetic innervation via
splanchnic nerves which are derived from these sympathetic fibres in the sympathetic chain, and visceral sensation (eg pain)
is conducted back along them via visceral afferent fibres.

This is why cardiac pain is referred to the left arm - the heart receives its sympathetic innervation from the T1–T4/5 roots
via the cardiac plexus, and these cutaneously supply the chest, shoulder and arm. The visceral pain is referred back along
the visceral afferent nerves to the cutaneous dermatome of that spinal root – for cardiac pain, the T1–4 dermatomes.

phrenic nerve
The phrenic nerve on both sides originates from the ventral rami of the third to fifth cervical nerves. It passes inferiorly
down the neck to the lateral border of the scalenus anterior, then it passes medially across the border of scalenus anterior
parallel to the internal jugular vein that lies inferomedially.

The right phrenic nerve pierces the diaphragm in its tendinous portion just slightly laterally to the inferior vena caval
foramen. It then forms three branches on the inferior surface of the diaphragm: anterior, lateral and posterior. These ramify
out in a radial manner from the point of perforation to supply all but the periphery of the muscle.

coronary system

The coronary system consists of left and right coronary arteries, which arise immediately above the aortic valve. They are
unique in that they fill during diastole, when not occluded by valve cusps and when not squeezed by myocardial
contraction.

The right coronary artery arises from the right coronary sinus, giving off branches supplying the right atrium and right
ventricle. It then continues as the posterior descending coronary artery, which supplies the posterior portion of the
interventricular septum and the posterior left ventricular wall. The left coronary artery divides into the left anterior
descending (LAD) and circumflex arteries. The LAD runs in the anterior interventricular groove and supplies the anterior
septum and the anterior left ventricular wall. The left circumflex artery gives off branches that supply the left atrium and
left ventricle.

The sinus node is supplied by the right coronary artery in around 60% of people
The arteriovenous (AV) node is supplied by the right coronary artery in around 90%.

The posterior descending coronary artery supplies the posterior one-third of the interventricular septum and the right and
left ventricles (coloured grey in the image). The posterior descending coronary artery most commonly originates from the
right coronary artery (in around 85% of individuals) – a right-dominant system. It may also arise from the left coronary
artery (a left-dominant system), or as a variation of the two. In around 15% of patients, the posterior descending (posterior
interventricular) artery does not arise from the right coronary artery, instead arising directly from the left coronary artery
(in around 10%) or via a co-dominant system where it arises from both (in around 20%).

The right coronary artery supplies the SA node in around 60% of people.

The right coronary artery supplies the AV node in around 85–90% of people, via the AV nodal branch.

The right coronary artery arises from the right aortic sinus (anterior coronary cusp) and travels beneath the right atrial
appendage, giving off the right marginal artery, before terminating posteriorly as the posterior descending artery (in
around 85% of individuals).

The left coronary artery arises from the left coronary cusp, runs a short distance between the pulmonary trunk and
the left atrial appendage (left auricle) and divides into the anterior descending and circumflex branches, with the
circumflex giving off the left marginal. The distribution of blood supply to the myocardium is broken down in anterior and
posterior views in the images below.

[The posterior aortic sinus/cusp is also known as the non-coronary cusp as it does not give rise to a coronary artery.]

The left circumflex artery branches from the left coronary artery after it emerges from beneath the left atrial appendage,
and travels posteriorly in the left atrioventricular groove (left coronary sulcus).

The right atrium is supplied by the right coronary artery. Although the right coronary artery gives off the posterior
descending artery in around 85% of people (a right-dominant system), occlusion of the posterior descending coronary artery
alone would not affect the right atrium.

The anterior two-thirds of the interventricular septum is supplied by the anterior descending artery (also known as
anterior interventricular) – a branch of the left coronary artery. The anterior interventricular (anterior descending)
artery supplies the anterior and lateral left ventricle and the anterior two-thirds of the interventricular septum. Occlusion
leads to widespread ST elevation and left ventricular infarction with a high mortality – it is also known as the
‘ widowmaker’ artery .

The anterior left ventricle is supplied by the anterior descending artery, along with the anterior two-thirds of the
interventricular septum.
infra-clavicular subclavian vein cannulation
Although there are various landmarks used for approaches to the subclavian vein, a commonly used landmark for infra-
clavicular subclavian vein cannulation is 1–2 cm inferior and 0.5-1cm lateral to the clavicular transition point
(which is approximately the junction of the medial one-third and lateral two-thirds of the clavicle), with the
needle directed towards the suprasternal notch. In obese patients , the standard position for right subclavian central
venous cannulation is 2 cm under the mid-point of the clavicle and 1 cm laterally. In thin patients the standard position
for insertion is 1 cm under the mid-point of the clavicle and 0.5 cm laterally.

It is also worth bearing in mind that this procedure is normally performed under ultrasound guidance. Risks include
pneumothorax, chylothorax (on the left due to damage to the thoracic duct), nerve injury, and arterial puncture.

The major hazard of the subclavian approach is arterial puncture, as the artery lies close to the vein. If subclavian vein
cannulation is attempted and fails, it is not advised to attempt to place a subclavian line on the opposite side due to the risk
of inducing bilateral pneumothoraces. If there is unilateral lung pathology it is usually best to place the subclavian line in the
ipsilateral side to avoid the risk of a pneumothorax in the good lung.
Although a supra-clavicular approach to subclavian vein cannulation is possible, the landmarks would be 1 cm superior and
lateral (not medial) to the junction of the lateral aspect of the sternocleidomastoid muscle and the clavicle.

azygos lobe
The azygos lobe is the commonest accessory lobe, seen in around 1% of people and around 0.5% of chest radiographs
(It is seen as a ‘reverse comma sign’ behind the medial end of the right clavicle)

It is an embryological variant, where the azygos vein causes a deep impression in the right upper lobe during development.
The lobe is seen superior to the right hilum, separated from the rest of the lung by a groove containing the
azygos vein. It is not a true lobe however, as it does not have its own separate bronchus.

CONGENITAL CARDIAC DEFECTS THAT COULD BE ASSOCIATED WITH HIS SUDDEN

DEATH
Bicuspid aortic valve. Aortic stenosis is associated with ‘drop attacks’ such as described here, as the stenosed valve causes
a fixed limitation on maximal cardiac output which is then unable to maintain cerebral perfusion with peripheral
vasodilation. This is also why anaesthesia in patients with severe aortic stenosis is more risky. The classic triad for aortic
stenosis is heart failure, angina, and syncope.

Bicuspid aortic valves are prone to early calcification, causing aortic stenosis that presents in middle-age rather than in the
elderly. They are also associated with sudden death. Bear in mind that the commonest congenital causes of sudden
cardiac death are arrhythmogenic conditions such as a long QT interval, Brugada or catecholaminergic polymorphic
VT (CPVT).

While isolated dextrocardia can be associated with severe cardiac anomalies, dextrocardia with situs inversus has a low
incidence of accompanying defects and the heart functions normally. Although dextrocardia and situs inversus can be
associated with other abnormalities such as Kartagener syndrome (bronchiectasis, sinusitis, and situs inversus), it is not
commonly associated with sudden cardiac death.

Isolated patent foramen ovale is of no haemodynamic significance. It can however lead to paradoxical embolic
phenomena such as stroke/TIA. These paradoxical emboli can very rarely cause myocardial infarction (MI) (and therefore
potentially sudden death), but would not be associated with syncopal episodes as described.

The relatively common (1–2% of people) bicuspid aortic valve leads to accelerated calcific stenosis, which is associated
with syncope and sudden death.

Small ventricular septal defects are insignificant, whereas large defects lead to massive left to right shunts. Small
ventricular septal defects are usually of no significance and close early in childhood. If large, they lead to shunting of blood
from the left to the right side of the heart due to the left–right pressure gradient. If untreated this will eventually progress
to Eisenmenger’s syndrome (particularly with pulmonary outflow obstruction), in which right-sided heart pressures become
higher than left-sided pressures and deoxygenated blood is shunted from right to left. They are not commonly associated
with sudden cardiac death.

A single coronary artery is not common, but does occur. When present, there is no clinical consequence unless disease
(such as atheroma) affects the vessel.
 signs on chest X-ray can arouse suspicion of a blunt aortic injury

 widened mediastinum (more common)

 obliteration of the aortic knuckle
 depression of the left main bronchus
 large left-sided haemothorax
 pleural cap (blood above the left lung apex) (less common)
 depression of right bronchus.

A widened mediastinum should arouse suspicion of aortic injury, and is a sensitive indicator. However, it is non-
specific, and aortic injury can occur without evidence of mediastinal widening.

Chest radiographs are the initial screening investigation performed for the trauma patient with blunt thoracic injuries,
however the sensitivity and specificity for detection of aortic injuries is variable and suspicious clinical or radiological
findings warrant a chest CT.

Depression, not elevation, of the left main bronchus is an indicator of aortic injury. Depression of the right main bronchus
may also be seen in combination with deviation of the trachea to the right.

aortopulmonary window
The aortopulmonary (AP) window is an area identified on AP chest radiographs, and can be abnormal with thoracic aortic
aneurysms, but is not particularly useful in the identification of aortic injury in the trauma patient.

X-ray consolidation
Lower lobe consolidation typically causes the diaphragmatic borders to become indistinct, in contrast to middle lobe
consolidation which causes the right heart border to become indistinct, and lingular consolidation which involves the left
heart border.

Kerley B lines
Kerley B lines are one of the signs of pulmonary oedema, caused by oedema of the septae between the lung lobules.

Pulmonary oedema in CXR:

1. Alveolar bat-wing shaped shadowing

2. Kerley B lines
3. Cardiomegaly
4. Dilated upper lobe vessels
5. pleural Effusions

Thoracic duct
Remember the thoracic duct begins on the right side of the thorax only up to the level of the sternal angle, where it
crosses over to the left.
The thoracic duct enters the posterior mediastinum along with the aorta as the continuation of the cisterna chyli. It
ascends on the right side between the aorta and the azygos vein until the T4–T5 level (at the manubriosternal angle ,
same level as the bifurcation of the trachea) where it crosses to the left, draining eventually in to the junction of the left
subclavian and left internal jugular veins.

Initially the thoracic duct runs in a groove between the aorta (on the left) and the azygos vein (on the right). It lies
immediately posterior to the oesophagus.

At the thoracic inlet , it lies to the left of the oesophagus and arches forward over the dome of the left pleura, draining
into the left brachiocephalic vein. It also lies anterior to the Lt subclavian and Lt vertebral artery and Posterior to Lt
common carotid artery.

The thoracic duct crosses the diaphragm at the aortic hiatus (T12) and ascends the superior and posterior
mediastinum between the descending thoracic aorta (to its left) and the azygos vein (to its right). The thoracic duct ascends
anterior to the posterior intercostal vessels and has several valves.

The right bronchomediastinal trunk drains into the right subclavian vein.
 At the root of the neck, the thoracic duct receives the left jugular, subclavian and bronchomediastinal lymph trunks,
although they may occasionally drain directly into the adjacent large vessels. The thoracic duct therefore conveys all the
lymph from the lower limbs, pelvic cavity, abdominal cavity, left side of the thorax, head and neck and the left
arm.

A right-sided subclavian line would not be at risk of damaging the thoracic duct, but a left-sided might, with the subsequent
complication of chylothorax.

Lung apex
The apices of the lungs extend 2.5 cm above the medial end of the clavicle, and the cervical pleura (also known as the
dome or cupola) lies immediately posterior to the subclavian vein and artery. Pneumothorax is a recognised
complication of subclavian line insertion, and is more likely in left-sided placement as the left apex often extends
up above the first rib.

level of the xiphoid process

The T7 dermatome is around the level of the xiphoid process . The dermatomes are shown on the image below.

The nipple is at the level of the T4 dermatome. As the lesions are below the nipple, they must involve a more inferior
dermatome.

The T10 dermatome is at the level of the umbilicus , which is lower than the lesions indicated here.

The L1 dermatome is in the region of the inguinal ligament .

β1-Adrenoceptors

β1-Adrenoceptors are present in the heart and are both chronotropic and ionotropic.

β2-Adrenoceptors are present in blood vessels, causing vasodilation; in gut smooth muscle causing relaxation; in
bronchial smooth muscle causing relaxation; and in the bladder wall causing relaxation.

At standard mediastinoscopy, what is the least likely lymph node station to be sampled?
Aortopulmonary (subaortic) nodes are difficult to access via mediastinoscopy as the aorta is ‘in the way’ of the
advancing mediastinoscope. They are accessed via thoracoscopy [such as video-assisted thoracoscopic surgery (VATS)]
rather than mediastinoscopy.

Normal placement for a chest drain

The normal placement for a chest drain is in the 5th intercostal space, mid-axillary line, just above the 6th rib. The
boundaries of the ‘safe triangle’ for insertion are:

 posteriorly – the lateral border of latissimus dorsi

 anteriorly – the lateral border of pectoralis major
 inferiorly – 5th intercostal space (at the level of the nipple in men, or the inframammary crease in women)
 superiorly – base of axilla.
Although it is possible to place a chest drain in the second intercostal space, mid-clavicular line, this is not the usual
location. Therefore of the options listed, the mid-clavicular line would be LEAST useful in terms of chest tube placement and
is therefore is the correct answer.

foreign body impacted in brochial tree

The right main bronchus is angled downwards in comparison with the left, which is more horizontal. It is also wider and
shorter than the left, and is therefore the most common site for inhaled foreign objects to lodge. The right lower lobe
bronchus is a direct continuation of the right main bronchus as it runs inferiorly, and is therefore the most likely final
destination of inhaled objects.

If the patient has aspirated the foreign object while lying supine, it is likely to fall in to the superior segmental bronchus
of the right inferior lobe, which branches posteriorly.

Moderator band (septomarginal trabecula)

The moderator band runs from the interventricular septum to the anterior papillary muscle of the right
ventricle. It carries the right bundle branch to the anterior papillary muscle. The conducting system of the heart is
shown schematically below.

The chordae tendineae anchor the papillary muscles to the leaflets of the mitral and tricuspid valves. They do not play a
role in the conducting system of the heart.

The crista terminalis demarcates the border between the primordial atrium and the sinus venarum. It is seen as a vertical
line running between the superior and inferior vena cava in the internal aspect of the right atrium. On the external aspect
of the atrium is the sulcus terminalis, which corresponds to the crista terminalis. The sinoatrial (SA) node is located in the
upper aspect of the crista terminalis.

The papillary muscles are attached to the cusps of the mitral and tricuspid valves by the chordae tendineae. They do not
play a part in the conducting system of the heart. Do not get confused with the anterior papillary muscle of the RIGHT
ventricle, which receives the moderator band from the interventricular septum – part of the conducting system of the heart
that carries the right bundle branch.

The pectinate muscles (musculi pectinati) are the name given to the muscular ridges in the anterior right atrium.
They do not play a specific part in the conducting system of the heart, other than transmitting sinoatrial (SA) nodal
impulses towards the arteriovenous (AV) node.

costodiaphragmatic recess
The costodiaphragmatic recess is the most inferior recess between the lungs and pleura when upright. The
costodiaphragmatic recess is between the 8th and 10th intercostal spaces in the mid-axillary line. It is the area where the
parietal pleura attached to the thoracic wall reflects on to the dome of the diaphragm. Remember that the pleura extends
approximately two rib spaces below the lungs. The lungs are located at the 6th rib in the mid-clavicular line, 8th rib in the
mid-axillary line, and the 10th rib posteriorly. The pleura extends further, to the 8th rib anteriorly, 10th rib laterally and
12th rib posteriorly.

Costomediastinal recess is behind the sternum, and would in any case be difficult to access via thoracocentesis.
Sternoclavicular joint
The clavicle articulates with the manubrium superolaterally on each side. The sternoclavicular joint is an atypical synovial
saddle, multiaxial joint with an intervening cartilaginous disc dividing it into two separate cavities . The articular
surfaces are lined with fibrocartilage.

TMJ joint is similar: has intervening disc ,its atypical synovial CONDYLOID and line with fibrocartilage

The second rib articulates with the manubrium and sternum at the level of the manubriosternal angle. (T4/5)

Nipple
The nipple is at the level of the T4 dermatome, approximately at the fourth intercostal space in the midclavicular line and
the fifth intercostal space in the mid-axillary line (although this is variable in women).

Root of the lung

The lung hila sit either side of the heart in the mediastinum. The lung hila are at approximately the 3rd and 4th costal
cartilages, corresponding to the T5/T6 vertebrae posteriorly (below sterna angle of lwis).

Endothoracic fascia
Endothoracic fascia lies between the inner aspect of the chest wall and the parietal pleura, and it is this layer that
provides a cleavage plane for the parietal pleura in pleurectomy.

Other fascias of Thorax:

Deep fascia of the chest wall lies external to the ribs, enveloping muscle groups. It is not related to the pleura.

The parietal pleura lines the inner aspect of the chest, and includes the costal pleura as well as the diaphragmatic pleura
and mediastinal pleura.

The visceral pleura is the serous membrane that covers the lung, in contrast to the parietal pleura, which lines the inside of
the chest cavity and mediastinum.

pericardial sinus

The transverse pericardial sinus lies posterior to the aorta and pulmonary trunk, and anterior to the superior vena cava
(SVC). It can be used in cardiac surgery, as seen below, to interrupt flow from the heart and enable coronary bypass.
The oblique pericardial sinus, by contrast, is a blind-ending sinus posterior to the heart (below the transverse sinus) that
ends between the left and right pulmonary veins.

brachiocephalic vein
The left and right brachiocephalic veins join together on the right side of the mediastinum to form the SVC. The left
brachiocephalic therefore has to run horizontally across the mediastinum to reach the right side.

Heart embryology
The heart is the first organ in the embryo to begin functioning, and it begins to beat in the fourth week of
development. The primordium of the heart forms in the cardiogenic plate located at the cranial end of the embryo.
Angiogenic cell clusters, which lie in a horseshoe-shaped configuration in the plate, coalesce to form two endocardial tubes.
These tubes are then forced into the thoracic region due to cephalic and lateral foldings, where they fuse together forming
a single endocardial tube during the third week.

The heart begins to beat in the fourth week at about the same time that the septum primum appears and the
bulboventricular loop is formed (shown in the images between days 24 and 35).

From the fourth week onwards, septa begin to grow in the atria, ventricle and bulbus cordis to form right and left atria, right
and left ventricles and the two great vessels – the pulmonary artery and the aorta. By the end of the eighth week,
partitioning is completed and the fetal heart has formed .

The sinus venosus gives rise to the smooth part of the right atrium (the sinus venarum – as opposed to the auricle, which
develops from the primitive atrium) and the coronary sinus.

The trabeculated portion of the right atrium (auricle) is formed from the primitive atrium.

The aortic vestibule of the left ventricle develops from the bulbus cordis.
The fossa ovalis is the site of the foramen ovale in the embryo. It is formed by the closure of the foramen ovale, through
fusion of the septum primum and septum secundum.

The trabeculated part of the right ventricle is formed from the

primitive ventricle.

Endoderm
Endoderm is one of the three embryonic germ-cell layers (the others being ectoderm and mesoderm). It forms the
epithelium of the gastrointestinal tract, respiratory system, auditory system, and urinary system.

skin
The dermis of the skin forms from mesoderm.
 adrenal
The adrenal cortex is derived from mesoderm, and the medulla from ectoderm.

Gonads
The gonads develop broadly from intermediate mesoderm.

Lens
The lens of the eye is ectodermal in origin, from the lens placode.

oesophagus

The oesophagus is divided into three with relation to its blood supply. The upper third is supplied by the inferior thyroid
artery (highlighted below); the middle third is supplied by direct branches from the descending thoracic aorta (oesophageal
arteries); finally, the distal third is supplied by ascending branches from the left gastric artery.

The ascending pharyngeal artery does not supply the oesophagus, it supplies a variety of structures around the base of the
skull.

azygos vein
The azygos vein ascends up the right side of the midline and behind the right main bronchus. The fact that it is at risk
can be appreciated when you see its location in the image below. It curves forward over the right main bronchus to join
the superior vena cava (SVC).

The hemiazygos vein crosses from the left side to anastomose with the azygos vein around the T8 level

The azygos vein arches over the right main bronchus from behind and drains directly in to the SVC at the T4/5 level (the
transthoracic plane), which approximates to the manubriosternal angle.

The azygos vein itself is on the right side, and receives blood from the posterior intercostal veins and segmental veins of
the abdomen, It passes through the diaphragm via the aortic opening at T12 and ascends on the right side of the vertebral
bodies posterior to the oesophagus. It terminates by arching over the hilum of the right lung to enter the SVC at the T4/5
level. On the left a variable pattern exists, which usually involves an accessory hemiazygos vein (superiorly) and
hemiazygos vein (inferiorly).

coronary sulcus
right atrioventricular groove (otherwise known as the coronary sulcus).

manubriosternal angle (angle of Louis)

The level of the manubriosternal angle (angle of Louis) corresponds to the T4/5 vertebral level or T4/5 intervertebral disc,
otherwise known as the transthoracic plane. The image below shows the mediastinum, with the transthoracic plane drawn
on in yellow. At this level,

 the aortic arch begins and ends

 the azygos vein joins the superior vena cava (SVC) by arching over the right main bronchus
 the trachea also bifurcates
 the thoracic duct moves from the right to the left.
 the second costal cartilage
 the left recurrent laryngeal nerve loops around the aortic arch .
 the carina

brachial plexus
The neurovascular bundle referred to is the brachial plexus, the roots of which emerge from the intervertebral foraminae of
the C5-T1 vertebrae and pass between the anterior and middle scalene muscles.

scalene
The anterior scalene runs from the transverse processes of C3–C6 to insert on to the scalene tubercle of the first rib (it is
highlighted in green in the image).

The middle scalene originates from the transverse processes of C5–C7 to insert on to the first rib more posteriorly.

They serve as the anterior and posterior borders of the nerve roots of the brachial plexus as they emerge from the
intervertebral foraminae of the C5–T1 vertebrae.

The posterior scalene muscle attaches to the second rib

RESPIRATORY EFFORT
contribute to his respiratory effort:

Contraction of the intercostal muscles. The external intercostals raise the ribs during inspiration, as they are aligned so
that their fibres run infero-medially. Their contraction therefore raises the ribs and expands the ribcage. This action is in
contrast to the internal intercostals, which are active during expiration.

Descent of the hemidiaphragms. The diaphragm is active in both normal and increased respiration. In normal quiet
breathing the diaphragm itself is the major active muscle, whereas the accessory muscles of respiration are recruited
during increased work of breathing.
An increase in the vertical dimension of the chest

The long thoracic nerve of Bell (supplying the serratus anterior, one of the accessory muscles of respiration)

The first rib does not move during respiration, and therefore does not contribute to respiratory effort.

The internal oblique muscles act during forced expiration, but do not act alone – there are other muscles that assist such
as the latissimus dorsi and the anterior abdominal wall muscles.

Larynx sensation
The recurrent laryngeal nerve supplies sensation below the vocal cords,

and the superior laryngeal nerve supplies the mucosa of, AND above, the vocal cords.

right atrium
The right atrium forms the right border of the heart, lies anterior to the left atrium and so its posterior wall is the
interatrial septum.

The sinoatrial node lies near the opening of the superior vena cava, in the upper part of the crista terminalis

The coronary sinus (responsible for the venous drainage of the myocardium) opens into the atrium above both the
opening of the inferior vena cava and the septal cusp of the tricuspid valve.

Musculi pectinati are located in the anterior part and the auricle of the right atrium (the embryological remnant of the
true atrium). The posterior wall of the right atrium is smooth, and is derived from the sinus venarum. The right atrium
itself forms the right border of the heart between the superior vena cava and IVC. The right atrium can be seen opened
from the front below – the auricle and its musculi pectinati within can be seen highlighted in red.

The fossa ovalis (highlighted in green in the image) is found on the interatrial septum, which forms the posteromedial wall
of the right atrium. It is formed by the closure of the foramen ovale at birth, when the septum primum and septum
secundum fuse.

Triangle of Koch
Used as an anatomical landmark for location of the atrioventricular node during electrophysiology procedures such as
pacing or ablation.

Defined by the following structures within the right atrium:

(1) The ostium of the coronary sinus, posteriorly;

(2) the anterior-septal leaflet commissure;

(3) the tendon of Todaro (a tendinous structure connecting the valve of the inferior vena cava ostium to the central fibrous
body), posteriorly.
 VAGUS NERVE
The vagus nerve arises from the medulla and exits the skull through the jugular foramen. It travels in the carotid sheath
between the internal jugular vein and the common carotid artery in the neck.

In the chest it lies posterior to the hilum of the lung, while the phrenic nerve travels anterior to the hilum.

The left vagus travels on the anterior aspect of the oesophagus, while the right one travels on the posterior side.

Both left and right nerves enter the abdominal cavity at the level of T10 (oesophageal hiatus).

diaphragmatic openings

The sliding hernia occurs as a result of the stomach and oesophagus moving cranially through the oesophageal opening of
the diaphragm into the thoracic cavity. Three sets of structures pierce the diaphragm at three vertebral levels:

 T8 = Right phrenic nerve and inferior vena cava (IVC); these pierce the diaphragm through the central tendon (caval
opening).

 T10 = Vagus nerve and oesophagus; these pierce the diaphragm through its right crus (oesophageal opening).

 T12 = Azygos vein, thoracic duct and abdominal aorta; these pass posterior to the diaphragm through the aortic opening.

THORACIC AORTIC ARCH

 .
 The arch is entirely superior to the manubriosternal joint (above angle of Louis). The aortic arch begins and ends ends
at the level of the T4 vertebra.
 It arches over the right pulmonary artery.

 The apex of the arch lies posteroinferior to the left brachiocephalic vein.
 The arch is symmetrically covered by the pleura from both sides, which meet in the midline behind the manubriosternal
joint

 The apex of the arch gives attachment to the pretracheal fascia,

 The arch is connected to the left pulmonary artery by the ligamentum arteriosum (remnant of the foetal ductus
arteriosus)
phrenic nerve
The phrenic nerve runs over the anterior surface of scalenus anterior and enters the chest by descending from the
medial lower border of the scalenus anterior muscle, between the subclavian vein and artery .

This can be seen in the upper part of the image below, where the phrenic nerves are highlighted in yellow.

The autonomic fibres in the phrenic nerve are sympathetic and pass from the superior (C1–C4) and middle (C5/C6)
sympathetic cervical ganglia as grey rami into the C3–C5 roots of the phrenic nerve, and innervate blood vessels in the
diaphragm.

The nerve lies on the fibrous pericardium and is sensory to the mediastinal and diaphragmatic pleura, and also to the
diaphragmatic peritoneum.

Which one of the following structures make an indentation on the left lung, but not the right
lung?
Aortic arch . There is a deep groove superiorly for the arch of the aorta – the impression of the arch and the descending
thoracic aorta can be seen in the medial surface of the left lung.

The oesophagus grooves the left lung above the arch of the aorta and below the hilum, however there is also a vertical
groove for the oesophagus on the right lung.

Impressions on the mediastinal surface of the right lung include the trachea, vagus, superior vena cava, right atrium
and subclavian artery.
The inferior vena cava leaves an impression on the right lung anterioinferiorly from the root of the lung.

The medial surfaces of both lungs lie in close proximity to several mediastinal structures:

Left Lung Right Lung

 Oesophagus
 Heart
 Heart
 Arch of aorta
 Inferior vena cava
 Thoracic aorta
 Superior vena cava
 Oesophagus
 Azygous vein

trachea
The trachea (C6-T5) commences at the lower border of the cricoid cartilage (highlighted in yellow in the image). It is
palpable in the jugular notch, bifurcates in the transthoracic plane and is innervated by the recurrent laryngeal nerves.

The left main bronchus bifurcates inside the left lung and is not as vertical as the right main bronchus.

SYMPATHETIC TRUNK
The thoracic sympathetic chain lies on the heads of the ribs, anterior to the posterior intercostal vessels,
immediately under cover of the pleura, with the splanchnic nerves passing from the chain medially and anteriorly
over the vertebral bodies.

The thoracic sympathetic chain receives white rami from all the intercostal nerves, and passes into the abdomen over
psoas major and under the medial arcuate ligament of the diaphragm.

In around 80% of people the inferior cervical ganglion fuses with the first thoracic ganglion to form the stellate
ganglion (otherwise known as the cervicothoracic ganglion). The stellate ganglion lies at the level of C7, in front of
the neck of the first rib.

Superior cervical ganglion: C1-4

Midldle cervical ganglion: C5-6

Inferior cervical ganglion: C7 (stellate ganglion: C7,C8,T1)

 left brachiocephalic vein
The left brachiocephalic vein (labelled ‘brachiocephalic vein’ below) drains blood from:

1. the cervical vertebrae via both vertebral veins;

2. the thyroid gland by the inferior thyroid veins;
3. the first left intercostal space via the left superior intercostal veins;
4. all the other anterior intercostal spaces by the anterior intercostal veins draining into the internal thoracic veins.

The thoracic duct enters the vein at its commencement behind the left sternoclavicular joint.

Thoracic outlet syndrome

Cervical rib is present in about 0.5% of the population, of which 60% are symptomatic. Symptoms due to the
presence of a cervical rib depend on the structure it is compressing. Neurological symptoms are the most common
presentation, usually compression of the C8 and T1 nerve roots, which causes pain and paraesthesiae on the ulnar
aspect of the arm and forearm and wasting of the small muscles of the hand. Vascular changes are seen less often. The arm
can become swollen as a result of venous compression.

Compression of the subclavian artery can lead to thrombus formation, emboli, ischaemic changes, and even gangrene.

Dx

Klumpke’s paralysis is a palsy affecting the lower trunk of the brachial plexus. It results in paralysis of the intrinsic hand
muscles and numbness in the C8/T1 dermatome. Changes with movement and swelling of the arm would not be seen.

Erb’s palsy affects C5/6 and is most commonly caused by shoulder dystocia during labour.

Cubital tunnel syndrome . This results in compression of the ulnar nerve through the cubital tunnel (b/w the two heads
of FCU) at the level of the medial epicondyle.

hemiazygos vein
The hemiazygos vein (shown in yellow in the image) is formed beneath the diaphragm at the junction of the left ascending
lumbar and subcostal veins. It travels up in to the thorax through the left crus of the diaphragm and ascends on the left
 side to around the T8-T9 level, where it crosses over to join the azygos vein on the right, travelling behind the
oesophagus when it does so.

Within the thorax the relations of the oesophagus

Within the thorax the relations of the oesophagus are:

 anterior:
o left common carotid artery
o trachea
o left main bronchus
o pericardium
 posterior:
o thoracic vertebrae
o thoracic duct
o hemiazygos vein
o the descending aorta
 on the left:
o left subclavian artery
o aortic arch
o left vagus nerve and its recurrent laryngeal branch
o thoracic duct
o left pleura
 on the right:
o right pleura
o azygos vein.

The aortic arch is anterior to the oesophagus initially, and as the arch descends it becomes the descending thoracic aorta,
which is to the left of the oesophagus initially, then posterior to the oesophagus at the T10 level where the oesophagus
passes through the diaphragm.

The right common carotid artery arises from the brachiocephalic trunk and ascends within the carotid sheath into the neck
as an antero-lateral relation of the oesophagus in the cervical region

The left common carotid artery arises directly from the aortic arch and ascends upwards towards the neck within the
carotid sheath. It is an anterior-left relation to the oesophagus in the cervical region.

flail chest
A flail chest occurs when three or more contiguous ribs are fractured anteriorly and posteriorly, leaving a discrete
disconnected segment of the thoracic wall that lacks bony continuity with the rest of the thoracic cage. Paradoxical
respiration, such as in the case described, occurs due to changes in intrathoracic pressure. Flail chest classically results from
high energy blunt trauma, as in high-speed road traffic accidents. The definitive management of flail chest is to re-expand
the affected (contused or collapsed) lung, ensure adequate oxygenation, provide sufficient pain relief and judicious fluid
resuscitation. Some patients may benefit from a short period of intubation and positive pressure ventilation. Surgical
stabilisation of the chest is an option but is rarely necessary in the management of flail chest.
pleura
The pleura is a serous membrane that invests the lung itself (visceral pleura) and lines the cavity containing the lung
(parietal pleura). These two parts of the membrane are continuous at the lung hilum and enclose a small space occupied by
about 5–10 ml of fluid produced mainly by the parietal layer. Due to the elasticity of the lungs, intrapleural pressure is
usually negative during quiet inspiration and expiration, but during forced expiration contraction of expiratory muscles
raises the pressures in the pleural spaces and within the lungs and bronchi.

NERVES SUPPLIES THE TRACHEA

The recurrent laryngeal nerve (shown in purple below) supplies all the intrinsic muscles of the larynx, except for the
cricothyroid, which is supplied by the external branch of the superior laryngeal nerve. The recurrent laryngeal nerve also
supplies sensation to the trachea below the vocal cords.

On the left it forms as the vagus nerve passes over the aortic arch and runs underneath the arch to run up to the larynx in
the trachea-oesophageal groove.

lingula
The lingula is a branch of the left upper lobe. The left lung is divided into upper and lower lobes by a long deep oblique
fissure.

The upper lobe has a wide cardiac notch on its anterior border. The anteroinferior part of the upper lobe also has a small
tongue-like projection called the lingula.

Lung anatomy
The right lung (the medial border of which is shown below) has three lobes – the upper and middle are separated by the
horizontal fissure, and the middle and lower by the oblique fissure.
Within the lung hila, the pulmonary artery lies superiorly, the pulmonary veins inferiorly, and the bronchi posteriorly (not
anteriorly).

The anterior border of the left lung has a lateral deviation at the 4th to 6th costal cartilages to accommodate the heart.

The human lung is composed of approximately 300 million alveoli each around 0.3 mm in diameter.

‘safe triangle’ for chest drain insertion

The ‘safe triangle’ for chest drain insertion is described as a triangle formed by the anterior border of latissimus dorsi, the
lateral border of pectoralis major, with the base at the 6th rib and the apex below the axilla. Typically, a chest drain is
inserted in the 5th intercostal space, at the mid-axillary line or just anterior, entering just above the 6th rib to avoid
damaging the intercostal neurovascular bundle which runs on the inferior aspect of the 5th rib. Once placed, the chest drain
should be pointed upward in the pleural cavity if a pneumothorax is being drained, and downward if fluid eg a pleural
effusion is being drained.

midline sternotomy
A midline sternotomy is performed to gain access to the mediastinum and the heart. Structures at risk include the
brachiocephalic artery, the left common carotid artery, the left subclavian artery, both brachiocephalic veins (shown in the
image below), trachea, oesophagus, phrenic nerves, both vagi, thoracic duct, left recurrent laryngeal nerve and thymus in
children.

The internal thoracic (or internal mammary) arteries run 2 cm laterally to the lateral edge of the sternal border and
are therefore unaffected by a midline sternotomy.

Serratus anterior

The long thoracic nerve (of Bell) arises from the C5, 6 and 7 nerve roots. It runs over the anterior aspect of serratus
anterior, innervating it.
 Serratus anterior arises from the upper 8 ribs and inserts on to the medial border on the thoracic aspect of the
scapula, holding it against the rib cage – it is shown in blue from the anterior aspect below. It is at risk of injury in radical
breast surgery, causing paralysis of serratus anterior and in turn winging of the scapula.

Serratus anterior, when contracting, protracts the scapula. Contraction of the upper or lower aspect of the muscles
therefore rotates the scapula.

spinal nerves
Dorsal and ventral primary rami are the first branches from spinal nerves.

Dorsal rami provide sensory innervation to the skin over the back and give motor innervation to the true back muscles;

ventral rami supply sensory innervation to the skin over the limbs and the skin over the ventral side of the trunk, as well as
motor innervation to the skeletal muscles of the neck, trunk and extremities.

The dorsal and ventral roots of spinal nerves are not directly responsible for any sensory innervation to the skin. Dorsal and
ventral rootlets emerge from the spinal cord to form the dorsal and ventral roots. The ventral roots contain efferent motor
fibres to skeletal muscles, while the dorsal roots contain afferent sensory fibres. These roots combine to form the spinal
nerve, which then gives off the primary rami.

dorsal scapular nerve

The dorsal scapular nerve is a motor nerve from the C5 nerve root of the brachial plexus directly and innervates
the rhomboids and levator scapulas. These muscles help to retract and elevate the scapula, so these movements would
be weakened following that damage.

Ther suprascapular nerve is from the superior trunk of the brachial plexus (C5-6) and passes beneath the suprascapular
ligament (suprascapular vessels pass above)

transverse cervical artery

The transverse cervical artery is a branch of the thyrocervical trunk (from the first part of the subclavian artery).

It gives off the superficial cervical artery (supplying trapezius) and usually the deeper dorsal scapular artery (which
supplies levator scapulas and the rhomboids).

The dorsal scapular artery can also branch directly from the third part of the subclavian artery.

The thyrocervical trunk arises near the origin of the subclavian artery, ascends vertically and soon divides into four
branches: “SITA”

 suprascapular artery,
 inferior thyroid artery,
 transverse cervical artery.
 ascending cervical artery,
 subclavian artery
Subclavian artery must not be ligated because it supplies:

 the thyroid gland via the inferior thyroid artery, a branch of the thyrocervical trunk
 the breast, rectus abdominus and diaphragm via the internal thoracic artery
 the brainstem, cerebellum and posterior cerebral circulation via the vertebral arteries
 the upper limb and muscles of the back.

aortic valve

The aortic valve lies in the centre of the heart when viewed from above, with the pulmonary valve lying anteriorly, the
mitral valve to the left, and the tricuspid valve to the right.
 The aortic valve, along with the tricuspid and pulmonary valves, consists of three leaflets. However, a proportion of patients
(1–2%) are born with a congenitally bicuspid valve, which predisposes them to calcification, aortic stenosis and
regurgitation in later life. Unicuspid and quadricuspid valves are also possible.

The right coronary artery arises from the right aortic sinus, and the left coronary artery from the left.

The posterior sinus has no artery arising from it, and is therefore referred to as the non-coronary sinus.

The atrioventricular node (not the SA node) lies approximately between the right and non-coronary cusps of the aortic
valve in the triangle of Koch.

upper limb-breast
biceps brachii
The biceps brachii muscle has two heads – the short head arising from the coracoid process of the scapula, and the long
head arising from the supraglenoid tubercle – these two heads are shown in the image. The tendon of the long head
travels through the capsule of the glenohumeral joint and the intertubercular sulcus of the humerus and is therefore at
risk of rupture. Its tendon inserts distally on to the radial tuberosity, making it a powerful supinator of the forearm,
particularly when the elbow is flexed. The tendon also gives off the bicipital aponeurosis distally, which forms a sheet of
fascia that covers the antecubital fossa.

Biceps brachii lies superficially to brachialis in the arm, not laterally to it.

Although its name suggests that biceps brachii has two heads, it is not uncommon to find a third head arising from the
superior aspect of brachialis. It is therefore not a particularly ‘constant’ muscle.

Biceps is indeed supplied by the musculocutaneous nerve (as are all the muscles in the anterior compartment of the arm),
but the nerve roots of the musculocutaneous nerve are C5, C6 and C7, not C7 and C8.

There are three muscles in the anterior compartment of the arm (biceps brachii, brachialis, and coracobrachialis) which
are all supplied by the musculocutaneous nerve (C5–7 origin). The brachialis lies posterior to the biceps brachii muscle.

Anatomically it is one of the most variable muscles in the human body by origin, insertion and number of muscle bellies.

extensor retinaculum

Both the flexor and extensor retinacula are important in preventing bowstringing of the long tendons attaching to the
fingers and thumb. The extensor retinaculum is shown below (labelled by its other name, the dorsal carpal ligament). The
tendons running beneath it are separated into discrete compartments. In order, they contain, from radial to ulnar:

 1st – Extensor pollicis brevis and abductor pollicis longus

 2nd – Extensor carpi radialis longus and extensor carpi radialis brevis
Lister’s tubercle
 3rd – Extensor pollicis longus
 4th – Extensor digitorum and extensor indicis
 5th – Extensor digiti minimi
 6th – Extensor carpi ulnaris

The second and third compartments are separated by the dorsal tubercle of the radius, otherwise known as Lister’s
tubercle.

The brachioradialis muscle inserts on to the distal radius, proximal to the styloid process. It does not therefore pass under
the extensor retinaculum.

axillary fascia
The axillary fascia is continuous with the brachial fascia of the arm, and continues directly into the arm as the axillary
sheath, enclosing the axillary artery, vein, and the brachial plexus.

posterior interosseous nerve (PIN)

The radial nerve enters the forearm anterior to the lateral epicondyle between brachialis and brachioradialis. Proximal
to supinator, it divides into the superficial branch (purely sensory), and the deep branch – the posterior interosseous
nerve (PIN).

The PIN travels between the two heads of supinator to reach the posterior compartment of the forearm, where it runs
between the superficial and deep groups of extensor muscles, supplying them all.

antecubital fossa

The boundaries of the antecubital fossa are:

 proximally – a line between the two epicondyles of the humerus

 laterally – brachioradialis and the other extensor muscles
 medially – pronator teres and the other flexor muscles
 roof – skin, subcutaneous fascia, bicipital aponeurosis and brachial/antebrachial fascia
 floor – brachialis and supinator.
radial nerve

The radial nerve arises as one of the two terminal branches of the posterior cord of the brachial plexus (the other being the
axillary), and travels with the profunda brachii artery in the spiral groove of the humerus. It is therefore in direct contact
with the humerus and is at risk in mid-shaft humeral fractures. This can be seen in the image below of the arm from the
posterior aspect.

The other nerves that are in direct contact with the humerus are: the axillary nerve at the level of the surgical neck
(where it is also at risk from humeral neck fractures), and the ulnar nerve, posterior to the medial epicondyle of the
humerus where it travels between the two heads of flexor carpi ulnaris (FCU) in the cubital tunnel.

It is the radial nerve itself, not its posterior interosseous branch, that runs between brachioradialis and brachialis
proximal to the lateral epicondyle. The radial nerve travels in the spiral groove of the humerus posteriorly from medial to
lateral, and pierces the lateral intermuscular septum to become anterior to the lateral epicondyle at the elbow. It travels
between brachioradialis and brachialis before branching in to its superficial and deep (posterior interosseous) branches
proximal to supinator.

It is the ulnar nerve, not the PIN, that enters the forearm posterior to the medial epicondyle between the two heads of
flexor carpi ulnaris.

It is the median nerve that enters the forearm between the two heads of pronator teres, not the posterior interosseous
branch of the radial.

It is the brachial artery that lies between the biceps tendon (laterally) and the median nerve (medially).

nerves that come into close contact with the humerus

Three nerves come into close contact with the humerus: the radial nerve contacts the humerus in the spiral groove; the
axillary at the surgical neck; and the ulnar at the medial epicondyle.

median cubital vein

The median cubital vein joins the basilic and cephalic veins obliquely across the antecubital fossa of the arm, and is
commonly used for blood sampling.
The median nerve and brachial artery are the deep relations of the median cubital vein and can potentially be damaged
during venous access.

Deltopectoral triangle
The cephalic vein runs in the deltopectoral groove between the deltoid and pectoralis major muscles in the anterior upper
arm, before piercing the clavipectoral fascia in the clavipectoral triangle to join with the axillary vein

long thoracic nerve

The long thoracic nerve (of Bell) is formed directly from the C5, C6 and C7 roots. It travels posteriorly to the C8 and T1
roots, and superficially over the serratus anterior muscle in the medial axilla where it is vulnerable to damage during
axillary dissection.

It is at risk of damage, particularly in axillary or breast surgery, but also from wounds to the chest wall eg from a blade. As
serratus anterior inserts into the medial under-surface of the scapula (that is, the surface closest to the chest wall), damage
to the long thoracic nerve leads to winging of the ipsilateral scapula when the arms are outstretched and pressed up
against a wall.

breast
The breast is considered to be a modified apocrine (NOT sebaceous) sweat gland (in contrast with eccrine sweat glands)

The base of the breast extends from the lateral sternal border to the mid-axillary line horizontally, and from the
second to the sixth ribs vertically, overlying the pectoralis major muscle by two-thirds, and extending over the serratus
anterior laterally by one-third.

Overall, the breast lies over pectoralis major, serratus anterior, external oblique, and rectus abdominis fascia.

The majority of the breast lies on the deep fascia, and is bounded posteriorly by the pectoral fascia (for two-thirds), and
the fascia of serratus anterior (for the other third).

The mammary gland has around 15–20 lobules, supported and divided by Cooper’s ligaments. Each of which is drained
by a lactiferous duct. All of the ducts converge and open independently at the nipple.

Breast size in the non-lactating breast is mainly due to fat content rather than glandular content. Breast size increases
during pregnancy due to expansion of glandular tissue.

Montgomery’s tubercles are the sebaceous glands that surround the nipple in the areola.

The retromammary bursa is a potential space that lies between the pectoral fascia and the breast.

Usually the majority (>75%) of lymph from the breast drains to the axillary lymph nodes, initially to the pectoral nodes,
then onwards to the other groups as shown in the image. The remainder drains mostly to the internal thoracic chain
(parasternal) nodes, and the contralateral breast, but also to the inferior phrenic lymph nodes for the inferior quadrants,
and the supraclavicular/inferior deep cervical for upper quadrants.

Rotter’s nodes (interpectoral nodes) lie between the pectoralis minor and major muscles. They are not always present.

The standard views taken on a mammogram are cranio-caudal (CC) and mediolateral oblique (MLO) (not truly
mediolateral).
 The cutaneous supply to the breast itself varies by position – anterior branches of the 1st to 6th intercostal nerves
medially, and laterally by lateral branches of the 2nd to 7th intercostal nerves

The blood supply to the breast is chiefly from the lateral thoracic artery (from the axillary), and the internal thoracic
(60%) (from the subclavian). It also receives a contribution from the pectoral branch of the thoracoacromial artery, and
the second to sixth intercostal arteries.

Chief venous drainage of the breast is to the axillary vein, not the subclavian vein directly. There is also some drainage to
the internal thoracic veins bilaterally.

Two-thirds of the breast cover the pectoralis major muscle whereas one-third covers the serratus anterior muscle.

The nipple is a marker for the T4 dermatome (not T3).

annular ligament
The annular ligament is an important feature in enabling pronation and supination of the forearm. It encircles the head
of the radius, as shown in the image, holding the head of the radius in the radial notch of the proximal ulna, forming the
proximal radioulnar joint.

The annular ligament forms about four-fifths of the osteofibrous ring and is attached to the anterior and posterior
margins of the radial notch. A few of its lower fibres continues around below the radial notch, forming a complete fibrous
ring.

 The superficial lateral surface of the annular ligament is strengthened by the radial collateral ligament of the elbow, and
affords origin to part of the supinator muscle.
 Its deep surface is smooth and lined by synovial membrane, which is continuous with that of the elbow joint.
 A thickened band that extends from the inferior border of the annular ligament below the radial notch to the neck of the
radius is known as the ‘quadrate ligament’

Subluxation of the radial head due to a tear in the distal part of the annular ligament is responsible for a ‘pulled elbow’
(or nursemaid’s elbow), particularly common in younger children.

The annular ligament arises from the anterior aspect of the radial notch of the ulna, and encircles the head of the radius,
inserting back into the posterior aspect of the radial notch and blending with the radial collateral ligament. It does not arise
from the humerus.

spinal accessory nerve

The spinal accessory nerve innervates sternocleidomastoid and trapezius. The patient is noted to be able to elevate the
shoulder in the question, indicating trapezius (and the spinal accessory nerve) is intact. Trapezius acts in combination with
serratus anterior to rotate the scapula (and therefore the glenoid cavity) with arm abduction, but incidence of scapular
winging due to trapezius paralysis is much rarer than long thoracic injury.

brachial plexus

3 branches from roots (LSD)

 Long thoracic nerve (serratus anterior)

 Nerve to Subclavius
 Dorsal scapular ( levator scapulae, rhomboid major, and rhomboid minor)

1 from trunk: Suprascapular nerve

0 from divisions

3 branches from lateral cord (LML)

 Lateral pectoral nerve

 Musculocutaneous nerve
 Lateral root of the median nerve.

Five branches from medial cord (Miss Mary Makes Me Unhappy):

 Medial pectoral nerve

 Medial cutaneous nerve of forearm
 Medial cutaneous nerve of arm
 Medial root of median nerve
 Ulnar nerve.

The primary nerve supply to the pectoralis minor muscle comes via the medial pectoral nerve (C8, T1) It is
positioned LATERAL to the lateral pec nerve

Five branches from posterior cord (2 STAR):

 2 Subscapular nerves (upper/lower)

 Thoracodorsal nerve
 Axillary nerve
 Radial nerve.

Various muscles attach the scapula (shoulder blade) to the chest wall and help maintain normal scapular control. These
muscles include trapezius, levator scapulas, rhomboids major, rhomboids minor, pectoralis minor and serratus anterior. The
latissimus dorsi has a small attachment at the base of the scapula but does not significantly contribute to scapular stability.
Of these muscles, the serratus anterior and the trapezius are the most important.

 A winging scapula is nearly always associated with partial or complete paralysis of either of these muscles. Weakness or
paralysis of the serratus anterior, secondary to palsy of the long thoracic nerve, is the commonest cause of winging. The
long thoracic nerve (from the C5-C7 roots) is thin, fragile and runs an anatomical course in the neck and upper thorax that
makes it susceptible to damage by compression or trauma. Commoner causes include: surgery (eg radical mastectomy,
lymph node biopsy from axilla); stretch injury during sports (as in this case); viral/post-infectious (brachial neuritis); and
other causes of neuropathy (vascular, toxic etc.).
 Accessory nerve (XI) damage can also produce scapular winging via weakness of trapezius, but this would be milder, is
rarer, and would be expected to be associated with weakness of shoulder elevation, which this patient does not have. The
other options listed would tend to be associated with other symptoms and signs. Nerve conduction studies and
electromyography would help confirm the diagnosis.
lesion at C8
The hypothenar muscles are innervated by the ulnar nerve via C8 and T1. They comprise flexor digiti minimi (brevis),
abductor digiti minimi and opponens digiti minimi in a mirror of the thenar muscles.. A complete lesion at C8 would
therefore lead to a complete paralysis of the intrinsic muscles of the hand, including the hypothenar muscles.

The radial nerve is supplied by all the spinal roots of the brachial plexus (C5–T1), however the general principle in the
arm is that the more distal muscles receive the lower spinal roots. Triceps, for example, is innervated by the radial
nerve via the C6, C7 and C8 roots, therefore a lesion at C8 would produce minimal weakness. Abductor pollicis longus,
extensor pollicis longus and extensor pollicis brevis however, are innervated chiefly by C8 (with some contribution from C7),
therefore a C8 lesion would produce marked weakness in these muscles.

reflex roots
1,2 – buckle my shoe 3,4 – kick the door 5,6 – pick up sticks 7,8 – shut the gate

 S1, 2 = ankle jerk

 L3, 4 = knee jerk

 C5, 6 = biceps and brachioradialis

 C7, 8 = triceps.

anatomical snuffbox
The dorsal border of the anatomical snuffbox is the extensor pollicis longus tendon.

The palmar border is formed by both the abductor pollicis longus and the extensor pollicis brevis tendons, as shown in the
image.

Proximally the border is formed by the radial styloid process.

The floor is formed by the trapezium and scaphoid.

radial artery
As it leaves the cubital region, the radial artery passes medial to the biceps tendon, and superficial to the insertion of
the pronator teres muscle. At the wrist, the artery passes across the floor of the anatomical snuffbox over the
trapezium, and enters the hand between the two heads of the first dorsal interosseous and the oblique and
transverse heads of the adductor pollicis muscles, continuing as the deep palmar arch. The arch is completed medially
by a branch of the ulnar artery and allows for anastomosis between these two arteries.

carpal bones

The proximal row of carpal bones from lateral to medial are scaphoid, lunate, triquetral, and pisiform.

The distal row of carpal bones from lateral to medial are trapezium, trapezoid, capitate, and hamate.

carpal tunnel- ulnar tunnel

The carpal tunnel contains ten structures: 4 × FDP tendons, 4 × FDS tendons, the FPL tendon and the median nerve – these
can be seen in the image below in section.
 Palmaris longus lies anterior/superficial to the flexor retinaculum, inserting into both it and the palmar fascia.

The flexor carpi radialis tendon passes in its own canal in the lateral part of the flexor retinaculum, therefore lies outside
of the carpal tunnel

As the median nerve passes through the tight tunnel, it is liable to compression. This manifests as paraesthesia over the
palmar thumb, index, middle and radial half of the ring finger. Note the palmar cutaneous branch of the median nerve,
which supplies sensation to the palm is given off proximally to the carpal tunnel and is therefore usually spared in carpal
tunnel syndrome.

Long-term compression of the median nerve in the carpal tunnel leads to wasting of the thenar muscles.

The ulnar nerve and artery do not pass through the carpal tunnel. Instead they pass superficial to the flexor retinaculum on
the ulnar palmar aspect of the wrist through Guyon’s canal , between the pisiform bone and the hook of the hamate.
The flexor retinaculum forms the roof of the carpal tunnel, and is attached to the tubercle of the scaphoid and crest of the
trapezium on the radial side, and the hook of the hamate and pisiform bones on the ulnar side.

pronator quadratus
The pronator quadratus lies over the distal interosseous membrane between the ulna and the radius. It is a broad flat
muscle and therefore does not have a tendon in the same way as the long flexor muscles. It is innervated by the deep
branch of the median nerve – the anterior interosseous nerve.

Axillary artery
Screw The Lawyer Save A Patient

The axillary artery can be divided into three parts by pectoralis minor.

1. Superior thoracic (first part)

1. Thoracoacromial (second part)

2. Lateral thoracic (second part)

1. Subscapular artery (third part)

2. Anterior circumflex humeral artery (third part)
3. Posterior circumflex humeral artery (third part)

The axillary artery begins at the lateral border of the first rib as the continuation of the subclavian artery, and ends at the
inferior border of the teres major. The axillary artery becomes the brachial artery at the inferior border of teres major.
 The axillary artery is contained within the axillary sheath, along with the axillary vein and the cords of the brachial plexus.
The axillary sheath is a continuation of the prevertebral fascia of the neck.

The axillary artery runs anterior to the upper digitations of serratus anterior.

musculocutaneous nerve
The musculocutaneous nerve arises from the lateral cord of the brachial plexus. It is motor to the flexor compartment of
the arm, supplying brachialis, biceps brachii and coracobrachialis (NOT brachioradialis). It then continues as its terminal
branch – the lateral cutaneous nerve of the forearm – supplying sensation to the anterolateral forearm.

regimental badge area

Sensation over the shoulder is from the axillary nerve laterally (via its cutaneous branch, the superior lateral cutaneous
nerve of the arm, which is tested in the regimental badge area), and from the supraclavicular nerves superiorly (from the
C3 and C4 nerve roots).

Hand muscles supplied by the median nerve

LOAF muscles

 Lateral two lumbricals

 Opponens pollicis
 Abductor pollicis brevis
 Flexor pollicis brevis (superficial head). Deep head is by the deep br of the ulnar nerve
The abductor pollicis brevis is one of the three thenar muscles (the others being the opponens pollicis and flexor pollicis
brevis – shown below in the image). These three muscles, along with the lateral (radial) two lumbricals, are supplied by the
median nerve, with all other intrinsic muscles of the hand being supplied by the ulnar nerve.

Adductor pollicis is innervated by the deep branch of the ulnar nerve (C8, T1). It is a fan-shaped deep muscle within the
palm with two heads (oblique and transverse) that inserts into the medial base of the proximal phalanx of the thumb. The
radial artery travels between the two heads to form the deep palmar arch

The motor supply to the thenar eminence is via the recurrent motor branch of the median nerve, which is given off
immediately after the nerve has passed through the carpal tunnel. Complete injury to the median nerve at the wrist would
lead to paralysis of the above muscles, alongside loss of sensation over the palmar aspect of the first (radial) three and a
half digits, and the dorsal tips of the same. Remember that the palmar cutaneous branch of the median nerve is given off
proximal to the flexor retinaculum, and so palmar sensation might be spared if the injury is distal to that branch.

The median nerve is most commonly injured at the wrist. This leads to wasting of the thenar eminence especially
abductor pollicis brevis. There is loss of sensation over the radial three and a half fingers and radial side of the palm (ie if
the palmar cutaneous branch of the medial nerve is involved) but the only autonomous areas of median
nerve supply are over the pulp pads of the index and middle fingers.

Hand muscles supplied by the ulnar nerve

Adductor pollicus is supplied by the ulnar nerve (via its deep motor branch), like all the intrinsic muscles of the hand with
the exception of the Lumbricals 1 and 2, Opponens pollicis, Abductor pollicis brevis and Flexor pollicis brevis muscles.
 autonomous areas of median nerve supply
The median nerve is most commonly injured at the wrist. This leads to wasting of the thenar eminence especially abductor
pollicis brevis. There is loss of sensation over the radial three and a half fingers and radial side of the palm (ie if the palmar
cutaneous branch of the medial nerve is involved) but the only autonomous areas of median nerve supply are over the
pulp pads of the index and middle fingers.

(ante)cubital fossa

The (ante)cubital fossa is a triangular area formed by a line between the two epicondyles of the humerus, the lateral border
of the pronator teres muscle and the medial border of brachioradialis. The roof is formed by antebrachial fascia, reinforced
by the bicipital aponeurosis. Its contents are shown in the image below - from lateral to medial:

 the radial nerve, beneath brachioradialis laterally

 the biceps tendon
 the brachial artery
 the median nerve.

radial artery
The radial artery passes under the brachioradialis, reaching the wrist where its pulsations are felt against the radius on the
palmar surface, before winding laterally around radius and crossing the floor of the anatomical snuffbox to enter the palm
between the two heads of the first dorsal interosseous muscle.

Radial artery terminates as the deep palmar arch supplying the hand. The two heads of the adductor pollicis muscle
originate from the second and third metacarpals, inserting together on to the base of the proximal phalanx of the thumb,
with the radial artery travelling between the two heads to form the deep palmar arch.

The radial recurrent artery arises from the lateral (radial) aspect of the radial artery and anastomoses with the radial
collateral artery (from the profunda brachii).

Related structures that entry forearm-wrist

The ulnar artery lies under the pronator teres and flexor digitorum superficialis muscles in the medial forearm. It
runs laterally to the ulnar nerve and the flexor carpi ulnaris tendon. It enters the hand by passing above the flexor
retinaculum through Guyon’s canal, along with the ulnar nerve. It terminates in the hand as the superficial palmar arch.

The median nerve enters the forearm beneath the biceps aponeurosis, medial to the brachial artery, by piercing the two
heads of pronator teres. It runs in the plane between the flexor digitorum profundus and superficialis muscles and
enters the palm through the carpal tunnel.

The radial nerve supplies the posterior extensor compartment of the forearm. It divides anterior to the lateral epicondyle
of the humerus in to the superficial branch (which runs beneath brachioradialis), and the deep posterior interosseous
branch which enters the forearm between the two heads of supinator and runs between the superficial and deep
extensors.
brachioradialis

Beer-Raising muscle (flexes elbow with forearm in neutral)

Breaks the Rule in that it is a flexor But supplied by the Radial nerve

Behind it is the Radial nerve in the cubital fossa

Attaches to the Bottom of the Radius (distal aspect proximal to the styloid).

lumbricals
The lumbricals arise from the FDP tendons, and insert into the lateral side of the extensor expansion of the fingers.
The radial two are unipennate (innervated by median nerve), and the medial two bipennate (innervated by ulnar
nerve), as seen in the image. Their action is to flex the MCPJs and extend the IPJs (PIPs, DIPs) in the fingers. They have
a split innervation – the radial (lateral) two being innervated by the median nerve, and the ulnar (medial) two being
innervated by the ulnar nerve. The lumbricals and interossei act together to flex the MCPJs and extend the IPJs of the
fingers.

Extensor Carpi radialis brevis (ECRB) and longus ECRL

ECRB arises from the lateral epicondyle of the humerus (common extensor origin) and inserts in to the base of the third
metacarpal on its dorsal surface. It extends and abducts the hand at the wrist, and therefore does not contribute to finger
extension. It is innervated by the posterior interosseous branch of the radial nerve.

ECRL arises from the lateral supracondylar ridge of the humerus (higher than ECRB), and is therefore innervated by the
radial nerve proper before it divides into its deep and superficial branches at the proximal aspect of supinator. It inserts
into the dorsal aspect of the second metacarpal, extending and abducting the wrist. It does not contribute to finger
extension.

‘hand of benediction
The hand is held typically with the index finger straight ‘pointing finger’
 This is referring to the ‘hand of benediction’, when the patient, with high median nerve damage, tries to make a fist and
is unable to flex the distal interphalangeal joint (DIPJ) or proximal interphalangeal joint (PIPJ) of the index or middle fingers
due to paralysis of both FDS, and lateral half of FDP. This would not occur with damage at the wrist as FDS and FDP
innervation would remain intact.

Median and ulnar nerves – Some common features

 Each supplies half of flexor digitorum profundus:
 each supplies 2 lumbricals;
 each has a palmar cutaneous nerve;
 each supplies an eminence group of muscles (ulnar: hypothenar; median: thenar);
 each enters the forearm through two heads (ulnar: heads of flexor carpi ulnaris; median: heads of pronator teres)
 each run b/w FDP and FDS (ulnar medial; median lateral)
 Each has no branches in the upper arm;
 each makes two fingers claw when cut at the wrist;
 each supplies a palmaris (median: palmaris longus; ulnar: palmaris brevis).

Damage to the median nerve at the wrist

Damage to the median nerve at the wrist would affect sensation in the radial 3 ½ fingers, but may not lead to loss of
sensation over the radial palm as the palmar cutaneous branch of the median nerve is given off before the carpal tunnel.

However, damage to the median nerve at the wrist may also damage the palmar cutaneous branch, which is given off
before it enters the carpal tunnel and provides sensation to the radial aspect of the palm.

In terms of motor function, median nerve damage at the wrist would lead to weakness of the four LOAF muscles supplied
by the median nerve in the hand – the lateral two lumbricals, opponens pollicis, abductor pollicis brevis, and flexor pollicis
brevis.

Supraspinatus
Supraspinatus (shown in red below) initiates abduction of the humerus at the glenohumeral joint (the first 10–15°) and
is innervated by suprascapular nerve (C5). In supraspinatus tendon rupture, patients usually initiate abduction by leaning
to the affected side to allow gravity to abduct the arm enough for deltoid to take over.

Deltoid is a strong abductor of the arm, but does not initiate abduction – this role is performed by supraspinatus. Deltoid is
innervated by the axillary nerve.

painful-arc syndrome
In painful-arc syndrome, there is pain on abduction between 60° and 120° (the middle third of the arc), but the
extremes of movements are painless. The initial phase of abduction is lost in patients with a complete tear of the
supraspinatus tendon (rotator cuff tear). The patient is unable to initiate abduction of the shoulder because the
supraspinatus causes the first 10–15° of abduction followed by the deltoid which helps to 90° of abduction.

Teres minor
Teres minor is one of the four rotator cuff muscles, arising from the lateral scapula and inserting most inferiorly (inferior
facet) on to the greater tubercle. It is an external rotator of the humerus and not an abductor. It is innervated by the
axillary nerve (C5 C6) which is a continuation of the posterior cord from the brachial plexus. It innervates teres minor and
deltoid muscles. One way to remember this is that a child (minor) needs help (an auxiliary).
 Teres Major is innervated by the lower subscapular nerve

Subscapularis
Subscapularis is one of the four rotator cuff muscles, inserting anteriorly on to the lesser tubercle of the humerus. It is
therefore an internal rotator of the arm, not an abductor.

Infraspinatus
Infraspinatus is one of the four rotator cuff muscles, acting to externally rotate the arm, not abduct it.

basilic vein
The medial cutaneous nerve of the forearm accompanies the basilic vein, and the lateral cutaneous nerve follows the
cephalic vein.

The basilic vein forms at the ulnar aspect of the dorsum of the hand and continues up the medial aspect of the arm to join
with the venae comitantes of the brachial artery in the mid-arm to form the axillary vein. It is the cephalic vein that pierces
the clavipectoral fascia.

The basilic vein is a continuation of the ulnar side of the dorsal venous arch in the hand. It lies medially to the biceps
tendon in the cubital fossa and is medial to the medial cutaneous nerve of the forearm in the arm it. It communicates with
the cephalic vein via the median cubital vein. The basilic vein pierces the deep fascia of the arm (brachial fascia)
approximately half way up the arm – this is illustrated nicely in the image below. It runs with the brachial artery for a
short distance before joining with the venae comitantes of the brachial artery at the inferior border of teres major to
form the axillary vein.

clavipectoral fascia
The region of the clavipectoral fascia is supplied by the supraclavicular (not suprascapular-C5) nerves from the C3
and C4 dermatomes.

axilla

The axilla is a pyramidal space that provides a conduit for neurovascular structures passing from the neck to the arm. The
boundaries of the axilla are shown in the image below in axial section:

 medially: serratus anterior, with ribs 1–4 and their intercostal muscles underlying
 superiorly/the apex: first rib, clavicle and superior scapula, which together form the cervico-axillary canal.
 inferiorly: skin, subcutaneous tissue, and axillary fascia
 laterally: bicipital groove (intertubercular sulcus)
 anteriorly: pectoralis major and minor
 posteriorly: latissimus dorsi, teres major and subscapularis, as well as the humerus and scapula.

The floor of the axilla is the axillary fascia. The clavipectoral fascia arises from the clavicle and encloses the pectoralis
minor before fusing with the axillary fascia
Numbness over the medial arm is a recognised complication of axillary surgery, but results from division of the
intercostobrachial nerve, which is the lateral cutaneous branch of the second intercostal nerve – T2, rather than the
third intercostal.

Level I nodes lie lateral to the pectoralis minor, level II lie behind and level III medial to pectoralis minor.

median nerve

The median nerve supplies all the muscles in the anterior compartment of the forearm, apart from the flexor carpi ulnaris
and the ulnar half of the flexor digitorum profundus (both of which are supplied by the ulnar nerve). Therefore, with
median nerve anaesthesia the little finger and ring fingers can still be flexed (due to the action of the ulnar half of FDP).
The radial nerve supplies the wrist extensors (ECRL, ECRB and ECU) – hence no wrist drop. The ulnar nerve supplies the
palmar and dorsal skin of the ulnar side of the hand, hence no anaesthesia there, and it also supplies the interossei muscles
of the hand, which effect abduction and adduction of the fingers.

The median nerve is usually tested in the hand by asking the patient to abduct the thumb against resistance from the
anatomical position, testing for the action of abductor pollicus brevis – one of the thenar muscles supplied by the recurrent
motor branch of the median nerve. The anterior interosseous branch of the median nerve can be tested with flexion at the
thumb interphalangeal (IPJ)

Cutaneously, the median nerve supplies the palmar surface of the thumb, index, middle and half of the ring
finger, and the dorsal surface of the tip of the thumb, index, middle, and half of the ring finger.

The median nerve enters the hand through the carpal tunnel, where it sits between then flexor pollicis longus and the
most radial flexor digitorum superficialis tendon. the flexor carpi radialis tendon is superior to the flexor retinactulum. Bear
in mind that the distal wrist crease marks the proximal aspect of the flexor retinaculum.
The medial root of the median nerve is a continuation of the medial cord, not the lateral cord. The lateral root of the
median nerve is the continuation of the lateral cord of the brachial plexus; the lateral root is joined by the medial root of
the median nerve to form the median nerve.

Median nerve relation to the brachial artery: LAMe; latreral anteriormedial

 The palmar cutaneous branch is given off proximal to the carpal tunnel, an average of 4 cm proximal to the distal wrist
crease, and travels superficial to the flexor retinaculum to supply sensation to the palm. It usually remains as one distinct
branch as it passes in to the palm, usually underlying the thenar crease, but may branch proximal to the distal wrist crease.
It is important in carpal tunnel surgery, as the incision must be planned to avoid its transection, which would lead to
absence of palmar sensation on the radial side. The fact that the palmar cutaneous branch does not travel through the
carpal tunnel explains why palmar symptoms are usually absent in carpal tunnel syndrome, as sensation to the fingers is
provided via the common digital nerves which branch directly from the median nerve after it emerges from the carpal
tunnel, rather than the palmar cutaneous branch which supplies the palm only. This is shown in the image below, with the
palmar cutaneous branch supply highlighted in blue.

It is the superficial branch of the radial nerve (not the median) that runs through the anatomical snuffbox to
supply the radial side of the dorsum of the hand.

ligaments of Cooper
The suspensory ligaments of the breast (ligaments of Cooper) are fibrous bands of connective tissue that extend from the
deep layer of fascia covering the pectoralis major muscle, interdigitate between the lobules and lobes of the breast, and
insert into the dermis. These ligaments provide shape and support to the breast tissue, and are responsible for the
‘peau d’orange’ appearance associated with lymphoedema of malignancy – the ligaments remain firmly attached to the
dermis despite the surrounding oedema of the skin.

Tubercles of Montgomery are small accessory sebaceous glands on the areola. The retromammary bursa is the posterior
aspect of the breast between it and the pectoralis fascia..( Breasts are modified apocrine glands)

Taking a history of breast pathology

– LMNOP:

 Lump (ask about all the features of the lump)

 Mammary changes
 Nipple discharge/changes
 Obvious risk factors, eg previous breast cancer
 Pain.

Flexor pollicis brevis

Flexor pollicis brevis is one of the four muscles innervated by the median nerve (ut also from the ulnar nerve) in the hand,
the others being the lateral (radial) two Lumbricals, Opponens pollicis and Abductor pollicis brevis. It lies on the ulnar
aspect of the thenar eminence, as demonstrated in the image below, and would be tested by asking the patient to flex the
thumb while palpating the muscle in the thenar eminence (remembering that FPL also contributes to thumb flexion and is
innervated by the anterior interosseous branch of the median nerve in the forearm - the median nerve is more
commonly tested via the action of abductor pollicis brevis).
tendon of the long head of biceps
The tendon of the long head of biceps runs within the bicipital groove and in the capsule of the glenohumeral joint to
insert on to the supraglenoid tubercle. It can be seen in the image below running in the bicipital groove of the humerus.
The long head can therefore be easily seen during shoulder arthroscopy and used for orientation.

The tendon of the long head of biceps is the only tendon to pass through the glenohumeral joint and is invested in a
synovial sleeve. The tendon is clearly visible during arthroscopy of the shoulder, and is therefore often used to orientate
the camera.

Latissimus Dorsi
Latissimus dorsi originates from the spinous process of T6–T12, the thoracolumbar fascia and iliac crests. It inserts into the
middle of the bicipital (intertubercular) groove of the humerus.

elbow joint
The elbow joint consists of three joints: between the ulna and the humerus (trochlea and trochlear notch); between the
radius and humerus (radial head and capitulum/capitellum); and finally between the radius and ulna (proximal radioulnar
joint). It allows movement only in one plane.

Remember that supination and pronation of the forearm occur at the proximal and distal radioulnar joints.

thumb carpometacarpal joint

The thumb carpometacarpal joint is an example of a saddle (ellipsoid) joint, in that it permits movement in two planes –
the elbow only permits movement in one plane.

Pivot joints
Pivot joints, such as between the C1 (atlas) and C2 (axis) vertebrae, allow only rotational movement.

Bicondylar joints
Bicondylar joints allow flexion and extension, as well as abduction and adduction, such as at the metacarpophalangeal
joints of the hand.

brachial artery
The brachial artery is the direct continuation of the axillary artery, beginning at the inferior border of teres major. It gives
off the profunda brachii (deep artery of the arm and the largest branch with the most superior origin) proximally, which
accompanies the radial nerve in the spiral groove of the humerus – it can be seen winding behind the humerus in the
image.
The brachial artery continues anterior to brachialis and medial to biceps brachii, where it can be palpated against the
humerus on the medial arm.

It terminates in the cubital fossa opposite the neck of the radius as the radial and ulnar arteries. The ulnar artery is the
larger of the two terminal branches of the brachial artery (the radial is the smaller branch).

The most superior branch of the brachial artery is the profunda brachii. The nutrient humeral artery (where present) arises
inferior to it from the lateral aspect of the brachial artery.

cephalic vein
The cephalic vein begins at the radial aspect of the dorsum of the hand in the anatomical snuffbox and ascends up the
lateral aspect of the arm. The cephalic vein runs alongside the lateral cutaneous nerve of the forearm, rather than deep to
it. It continues up the lateral aspect and arches over to run in the deltopectoral groove where it pierces the clavipectoral
fascia to join with the axillary vein.

suprascapular nerve
Both supraspinatus and infraspinatus are supplied by the suprascapular nerve (C5, C6) which is a branch from the upper
trunk of the brachial plexus. The suprascapular nerve runs through the suprascapular notch, below the transverse
scapular ligament, supplying both muscles.

The suprascapular nerve carries fibres from the C5 and C6 nerve roots, and goes on to innervate the supraspinatus and
infraspinatus muscles. It runs laterally across the posterior triangle of the neck, deep to trapezius and omohyoid,
passing below the superior transverse scapular ligament (in contrast with the suprascapular artery, which runs above it),
supplying supraspinatus. It then curves around the lateral border of the spine of the scapula to supply infraspinatus in
the infraspinous fossa.

supraspinatus
The supraspinatus does indeed form part of the rotator cuff mechanism, arising from the supraspinous fossa of the scapula
and inserting on to the greater tubercle of the humerus most superiorly. It is however innervated by the suprascapular
nerve

Teres major
Teres major arises from the angle of the scapula and inserts in to the medial edge of the bicipital groove of the humerus. It
therefore is not one of the rotator cuff muscles.

rotator cuff
The rotator cuff consists of the supraspinatus (suprascapular n. C5), infraspinatus (suprascapular n. C5, 6), teres minor
(axillary nerve C5), and subscapularis (upper and lower subscapular nerves C5, 6). All muscles of the rotator cuff mechanism
attach from the scapula to the head of the humerus.

The cuff is covered anteriorly by the coracoacromial arch with the subacromial bursa in between. The main role of the cuff
is to stabilise the humeral head within the glenoid. Deltoid, teres major and biceps brachii muscles play no role in the
formation of the rotator cuff.

scaphoid

The scaphoid articulates with the trapezium on its anterolateral aspect, as can be seen in the image below.
Blood supply to the scaphoid is chiefly via the dorsal carpal branch of the radial artery, with some contribution from the
superficial palmar branch of the radial artery on the palmar surface. Both of these arteries supply the distal pole and
then supply the proximal pole in a retrograde fashion through interosseous perforators.

When the scaphoid fractures through the waist, the fracture line severs the blood supply to the proximal fragment, and
avascular necrosis of the proximal pole is therefore a common complication. Tenderness in the anatomical snuffbox may be
the only clinical sign of the fracture before radiological evidence develops (often around 2 weeks later). # at the distal pole
also cause avascular necrosis of the proximal pole.

Carpal bones

The proximal row of carpal bones comprises (from lateral to medial) the scaphoid, lunate, triquetrum and pisiform. The
scaphoid is the largest of the proximal row of carpal bones, and articulates proximally with the radius. The tubercle of the
scaphoid forms one of the attachments for the flexor retinaculum, as do the hook of the hamate, trapezium, and
pisiform.

The capitate forms the third of the distal row of carpal bones (from lateral to medial), and is the largest bone in the carpus.

The hamate is one of the distal row of carpal bones, which are (from lateral to medial): trapezium, trapezoid, capitate and
hamate. The hamate has a process, the hook, on the palmar aspect that forms one of the attachments of the flexor
retinaculum.

The trapezium is the most radial of the distal row of carpal bones, sitting immediately beneath the first metacarpal on the
radial aspect (remember the trapezium is by the thumb). The crest of the trapezium forms one of the radial attachments
for the flexor retinaculum.

The trapezoid is the second of the distal row of the carpal bones (from lateral to medial).
 NERVE COURSE IN AT THE FORAERM
 The anterior interosseous nerve arises from the median nerve as it passes between the two heads of the pronator teres
muscle. It then descends vertically on the anterior aspect of the interosseous membrane between flexor digitorum
profundus and flexor pollicis longus.
 In the forearm, Median nerve nerve travels between the flexor digitorum profundus and flexor digitorum superficialis
muscles.
 Ulnar nerve enters the forearm posterior to the medial epicondyle of the humerus, between the two heads of flexor carpi
ulnaris. It runs between FCU and flexor digitorum profundus (FDP) muscle. It accompanies the ulnar artery, which is medial
to the ulnar nerve
 Superficial br. of radial nerve is under brachioradiali, accompanying the radial artery
 PIN is b/w the superficial and deep extensors muscles of the forearm

ULNAR NERVE SUPPLY IN THE FOREARM

The ulnar nerve is a terminal branch of the medial cord of the brachial plexus. It has no branches in the arm, and enters the
forearm posterior to the medial epicondyle of the humerus, between the two heads of flexor carpi ulnaris. It runs
between FCU and flexor digitorum profundus (FDP) muscle (as does the median nerve) to the ulnar aspect of the wrist,
where it enters the hand through Guyon’s canal, on the superficial ulnar aspect of the wrist between the pisiform bone and
the hook of the hamate. In the forearm it supplies only flexor carpi ulnaris and the ulnar (medial) half of flexor digitorum
profundus.

Extensor carpi ulnaris is a posterior compartment muscle, arising from the lateral epicondyle of the humerus and
inserting in to the dorsal fifth metacarpal. It is therefore supplied by the radial nerve via its deep posterior interosseous
branch.

Subscapularis
Subscapularis (shown in green below in the image of the shoulder) arises from the subscapular fossa on the costal surface
of the scapula and inserts to the lesser tubercle of the humerus (the only rotator cuff muscle to do so – the others insert on
to the greater tubercle). It is innervated by the upper and lower subscapular nerves (C5, C6, C7). It acts to internally rotate
and adduct the arm, and along with the other three rotator cuff muscles, stabilises the humerus in the glenoid cavity.

Palmaris longus
Palmaris longus does not run through the carpal tunnel – it runs superficial to the flexor retinaculum and inserts into it and
the palmar aponeurosis. It is absent in around 15% of people.

ulnar nerve- Cubital tunnel

The ulnar nerve enters the forearm by winding around the posterior aspect of the medial epicondyle of the humerus, and
travelling between the two heads of flexor carpi ulnaris in a fibro-osseous channel known as the cubital tunnel .

The two heads of FCU arise from the medial epicondyle of the humerus, and the olecranon/posterior ulna respectively.
These bony landmarks (medial epicondyle and olecranon) form the medial and lateral borders of the cubital tunnel, with
the roof formed by the cubital tunnel retinaculum, and the floor by the capsule of the elbow joint.

The cubital tunnel is an important site of entrapment of the ulnar nerve, with cubital tunnel syndrome being the second
most common nerve entrapment of the upper limb after carpal tunnel syndrome. Symptoms include pain, paraesthesia,
and numbness in the ring and little fingers as well as weakness of the hand, and chronic compression can lead to clawing.

The ulnar nerve runs in the forearm between the flexor carpi ulnaris (FCU) and flexor digitorum profundus (FDP) muscles,
supplying all of FCU and the ulnar (medial) half of FDP. It is therefore superficial to FDP rather than deep to it.
The ulnar nerve is the terminal branch of the medial cord of the brachial plexus, but the nerve roots of the medial cord are
C8 and T1, not C5, C6 and C7 (these are the nerve roots of the long thoracic nerve of Bell).

The ulnar nerve wraps around the posterior aspect of the medial epicondyle of the humerus, not the lateral epicondyle. It
is the radial nerve that passes anterior to the lateral epicondyle, between brachialis and brachioradialis.

The ulnar nerve enters the hand through Guyon’s canal, which is a space superficial to the flexor retinaculum on the ulnar,
palmar, aspect of the wrist, between the pisiform bone and the hook of the hamate. (pisohamate lig. Posterior/deep-
retinaculum anterior)

The ulnar nerve supplies all the dorsal and palmar interossei in the hand, via its deep motor branch. Loss of the dorsal
interossei leads to loss of finger abduction, and loss of palmar interossei leads to loss of adduction.
In the forearm, the ulnar nerve supplies flexor carpi ulnaris (FCU) and the ulnar half of FDP (to the little and ring fingers),
whereas in the hand it supplies all the intrinsic muscles with the exception of the lumbricals 1 and 2, opponens pollicis,
abductor pollicis brevis and flexor pollicis brevis muscles.

When the ulnar nerve is transected at the wrist, power is lost to the lumbricals of the little and ring finger, as well as the
other intrinsic muscles of the hand leading to unopposed extension at those MCPJs (remember the lumbricals flex the
MCPJs and extend the IPJs).

If the lesion is at the level of the wrist, the power to the ulnar half of FDP is preserved, and the IPJs are therefore flexed,
leading to the claw hand appearance of extended MCPJs and flexed IPJs in the ring and little fingers.

If, the nerve is transected at the elbow, power to the ulnar half of FDP is also lost, leading to less flexion at the IPJs of the
ring and little fingers and therefore a less deformed appearance, but a less functional hand – the ulnar paradox.

thoracodorsal nerve
The thoracodorsal nerve innervates latissimus dorsi (in yellow below), which extends and internally rotates the humerus, as
well as being a powerful adductor of the shoulder. The thoracodorsal nerve, a branch of the posterior cord of the brachial
plexus, arises between the upper and lower subscapular nerves. It derives its fibres from C6, C7 and C8. It follows the
course of the subscapular artery, along the posterior wall of the axilla to the apex of the latissimus dorsi.

The latissimus dorsi is responsible for adduction, extension and internal rotation of the humerus, and in the scenario
described it is the affected muscle due to injury to the thoracodorsal nerve. The latissimus dorsi is a key muscle for
climbing, as it powerfully adducts and depresses the humerus, enabling the trunk to be brought up to the arm, for example
in pull-ups.

Teres Major

Teres Major (lower subscapular nerve) internally rotates and adducts the arm.

CONCERNING THE MUSCLES OF THE FOREARM, WHICH ONE OF THE FOLLOWING

TENDONS IS MOST VULNERABLE TO DAMAGE FROM A CENTRAL LACERATION?

Flexor carpi radialis (FCR)

The FCR is one of the five superficial muscles of the flexor compartment of the forearm – shown in green below. It
arises from the medial epicondyle and inserts radial/lateral to the carpal tunnel (not through it), onto the second
metacarpal.
It is radial to the palmaris longus tendon and, along with it, would be at risk from a palmar wrist laceration. The median
nerve is reliabley located between the FCR tendon and palmaris longus.

Dx

Flexor pollicis longus is a deep muscle of the flexor compartment of the forearm, innervated by the anterior interosseous
branch of the median nerve. Its tendon runs beneath the flexor retinaculum in the carpal tunnel on the radial side, making
it relatively well protected from a palmar aspect laceration.

Supinator is a deep muscle of the posterior compartment of the forearm, arising from the lateral epicondyle of the humerus
and lateral ulna, inserting into the proximal one-third of the radius. It is not at risk in a palmar laceration.

The Flexor carpi ulnaris (FCU) inserts in to the hook of the hamate and 5th metacarpal (MCP) via the pisiform bone,
which sits within the FCU tendon. As it sits on the very ulnar-most aspect of the wrist it is less at risk than the FCR tendon
from a central laceration.

axillary vein

The axillary vein is formed by the union of the basilic vein (which runs up the medial/ulnar aspect of the forearm and arm)
and the venae comitantes of the brachial artery at the inferior border of teres major.

Erb–Duchenne’s palsy
Injury to the upper trunk or superior roots is otherwise known as Erb’s palsy (or Erb–Duchenne’s palsy) with the arm is held
in the characteristic ‘waiter’s tip’ position: adducted, internally rotated and pronated with an extended elbow.

biceps reflex
The biceps reflex is mediated by the C5 and C6 roots, which travel via the upper trunk, then the lateral cord and the
musculocutaneous nerve to reach the biceps muscle. Each C5 and C6 spinal nerve is formed from dorsal (sensory) and
ventral (motor) roots, mediating the afferent and efferent parts of the reflex arc respectively. Injury to the upper trunk
would therefore result in loss of the biceps reflex.

Klumpke’s palsy
The lower trunk is comprised of the C8 and T1 roots. Damage to the lower trunk results in Klumpke’s palsy, with or without
a Horner’s syndrome. C8 and T1 contribute to both the ulnar and median nerves, and therefore power is lost to all the
small muscles of the hand, including the lumbricals and interossei, which leads to hyperextension at the MCPJs and
flexion at the IPJs.

ANTERIOR DELTOPECTORAL APPROACH TO THE SHOULDER JOINT

In the deltopectoral approach an incision is made following the line of the deltopectoral groove. The deltopectoral fascia is
encountered first and the cephalic vein is surrounded in a layer of fat and is used to identify the interval.

pectoralis minor

The pectoralis minor (in red below) originates from the 3rd to 5th ribs and inserts onto the coracoid process of the
scapula, acting to stabilise the scapula, or elevate the ribs as an accessory muscle of respiration when the humerus is
stabilised. It is innervated by the medial pectoral nerve.

Serratus anterior (C5,6,7)

The serratus anterior originates from the 1st to 8th ribs (8 digitrations)and inserts into the anterior medial border
of the scapula, helping to stabilise the scapula against the thoracic wall. Paralysis of the long thoracic nerve causes scapular
winging.

Pectoralis major
The pectoralis major originates from the sternum, clavicle and 1st-6th costal cartilages. It inserts in to the lateral
bicipital groove.

Latissimus dorsi
The latissimus dorsi originates from a broad area over the lower back, including the spinous processes of T6 to T12, iliac
crest and thoracolumbar fascia. It inserts in to the floor of the bicipital groove between pectoralis major (laterally) and
teres major (medially) [ “Lady b/w the two majors”]
Misdhaft humeral fracture
The radial nerve divides into the deep motor (posterior interosseous) and superficial sensory branches just proximally to
the supinator at the lateral epicondyle.

The superficial branch travels beneath the brachioradialis (with radial artery) to supply sensation to the radial dorsum of
the hand, tested at the first dorsal web space (shown in red in the image). Sensation here would therefore be lost
with a radial nerve lesion in the arm.

Supination occurs chiefly through the action of two muscles: biceps brachii, (innervated by the musculocutaneous nerve)
and supinator (which is innervated by the radial nerve, posterior interosseous branch). Although the supinator would be
paralysed in this type of injury, supination would not be lost as the musculocutaneous nerve remains intact.

Although the radial nerve innervates abductor pollicis longus, the abductor pollicis brevis is innervated by the median
nerve and therefore thumb abduction is weakened but not lost with a radial nerve injury.

Elbow extension is mediated by the triceps, which is innervated by the radial nerve. However, the branches to the long
and medial heads of triceps arise high in the arm, proximal to the spiral groove, and therefore the triceps is not
completely paralysed with a mid-shaft humeral fracture. The branch to the lateral head of triceps arises within the
spiral groove.

Lower Limb

medial (adductor) compartment of the thigh

The medial (adductor) compartment of the thigh contains adductor longus, adductor brevis, adductor portion of adductor
magnus, gracilis, pectineus and obturator externus. They are all supplied by the obturator nerve except the pectineus,
which is supplied by the femoral nerve.
 anterior compartment of the leg

The muscles of the anterior compartment of the leg are shown below in the image. They are:

 tibialis anterior
 extensor hallucis longus
 extensor digitorum longus
 peroneus tertius (not always present).

They are all supplied by the deep peroneal nerve and receive their blood supply from the anterior tibial artery.
 The peroneus brevis is found in the lateral compartment of the leg, along with the peroneus longus.

deltoid ligament
The deltoid ligament is a strong triangular ligament that holds the talus to the medial malleolus of the distal tibia.

medial longitudinal arch,

here are three arches in the foot: the medial longitudinal arch, the lateral longitudinal arch and the transverse arch. The
image shows the foot from below. Ligaments that support the medial longitudinal arch include the

 long plantar ligament,

 short plantar ligament (plantar calcaneocuboid ligament),
 spring ligament (plantar calcaneonavicular ligament),
 interosseous ligament (talocalcaneal ligament),
 deltoid ligament (medial collateral ankle ligament)
 plantar aponeurosis (deep plantar fascia).
The plantar calcaneonavicular ligament (or spring ligament), not the plantar talonavicular ligament supports the medial
longitudinal arch.

anterior cruciate ligament (ACL) injury

This is a classical presentation of anterior cruciate ligament (ACL) injury – a ‘pop’ after deceleration followed by immediate
swelling (haemathrosis). The Lachman’s test is used for examination of the ACL when there is suspicion of a torn ACL.

Immediate swelling (haemathron) due to tear of middle geniculate artery

ACL  abul. The ACL (highlighted in blue) is attached to the anteromedial intercondylar area of the tibia and passes
backwards, upwards and laterally to the medial surface of the lateral femoral condyle, limiting anterior movement of the
tibia on the femur.

linea aspera
The linea aspera runs along the posterior aspect of the femoral shaft – it is shown in the image below of the proximal
femur from the posterior aspect. It is the point of attachment for many muscles of the lower limb, and for the lateral and
medial intermuscular septums.

femoral triangle
From lateral to medial, the femoral triangle contains the femoral nerve and its branches, the femoral artery and its
branches, including the profunda femoris , the femoral vein with its main tributary the long saphenous vein and the
femoral canal. Many people, unsurprisingly, get the following mixed up – femoral triangle, femoral sheath, femoral canal
and femoral ring.

The femoral triangle lies under Scarpa’s fascia. Within this space lies the femoral nerve laterally and the femoral sheath.

Within the femoral sheath, lie the femoral artery laterally and the femoral vein medially; medial to the vein lies the
femoral canal.
 The femoral canal is a term used to the space that lies medially to the femoral vein – it is thought that this is space for the
femoral vein to expand into during walking (when there is increased venous return).

The femoral ring is essentially the superior opening of the femoral canal. The image shows the femoral triangle with (from
lateral to medial): the femoral nerve, artery, vein and canal.

common fibular (peroneal) nerve

The common peroneal (fibular) nerve arises from the sciatic nerve in the at the apex of the popliteal fossa, from the
L4/L5/S1 and S2 nerve roots. The common fibular (peroneal) nerve branches from the sciatic at the lower border of the
short head (its branching point is variable in the posterior thigh).

The common fibular (peroneal) nerve innervates the short head of biceps femoris (part of the hamstrings) flexing the
knee. It also gives off two branches:

 Superficial fibular nerve: Innervates the foot evertors in the lateral compartment of the leg: fibularis longus and fibularis
brevis.
 Deep fibular nerve: Innervates the muscles of the anterior compartment of the leg: anterior tibialis, extensor digitorum
longus, extensor hallucis longus and some intrinsic (extensor pollicis brevis) foot muscles. These muscles are responsible
for foot dorsiflexion and extension of the toes.

The long head of biceps femoris is innervated by the tibial nerve.

As it exits the popliteal fossa, it courses around the neck of the fibula in the lateral compartment of the leg. In the
popliteal fossa it does not enter the fossa but traverses along its superolateral border (bicep femoris)

The common fibular (peroneal) nerve usually gives off two purely sensory and two mixed branches.

Common fibular (peroneal) nerve entrapment results in a high stepping gait, where the patient is noted to lift the
affected foot excessively from the ground during the swing phase, to overcome their inability to dorsiflex the foot and
therefore to avoid the foot hitting the floor. This results in excessive hip and knee flexion. It is sometimes called slapping gait
as the affected foot ‘slaps’ the floor. [A shuffling gait is associated with Parkinson’s disease]
deltoid ligament
The deltoid ligament attaches to the medial malleolus of the tibia, and inserts via four separate parts into the
sustentaculum tali of the calcaneus, the calcaneonavicular (spring) ligament, the navicular tuberosity and the
medial surface of the talus.

An eversion injury can rupture the deltoid due to traction force.

Syndesmotic ligament
The syndesmotic ligament is made up of several ligaments – the tibiofibular ligament, the interosseous ligament and the
fibular ligaments. An injury to this complex would cause instability at the ankle

anterior talofibular ligament

The anterior talofibular ligament originates from the lateral malleolus and inserts into the lateral aspect of the talar neck.

The anterior talofibular ligament is a lateral ligament of the ankle and prevents the foot from sliding forward in relation to
the shin. It is typically injured in inversion injuries.

Posterior talofibular ligament

The posterior talofibular ligament originates from the posterior border of the fibula and inserts into the posterior lateral
talus. The posterior talofibular ligament is a lateral ligament of the ankle as well. It less commonly injured.

Calcaneofibular ligament
The calcaneofibular ligament originates from the lateral malleolus and inserts into the lateral wall of the calcaneus. The
calcaneofibular ligament is one of three ligaments that form the lateral collateral ligament of the ankle joint. It
vulnerable to inversion injuries.

femoral nerve
It supplies the anterior thigh muscles – the quadriceps group, which extends the leg at the knee. The femoral nerve also
gives several branches to the skin on the anteromedial side of the lower limb. The femoral nerve is the largest branch of
the lumbar plexus (posterior divisions of L2,3,4). It forms in the abdomen within the substance of the psoas major muscle
and descends posterolaterally through the pelvis to the midpoint of the inguinal ligament.

Anterior division of femoral nerve sensory + sartorius The medial cutaneous nerve is one of two branches of the
anterior division of the femoral nerve; the other branch is the intermediate cutaneous nerve.

obturator nerve
The obturator nerve (anterior divisions of L2, L3, L4) exits the obturator foramen and divides into anterior and posterior
branches. The anterior branch innervates adductor brevis, adductor longus, and gracilis – shown in the image below. The
posterior branch pierces obturator externus and innervates obturator externus and part of adductor magnus.
deep circumflex iliac artery
The deep circumflex iliac artery arises from the external iliac artery. It is responsible for arterial supply of the
iliacus.
Anterior branch of the obturator artery
This branch supplies the pectineus, obturator externus, adductor muscles and gracilis. It is not involved in supplying the
femoral head or neck.

Posterior branch of the obturator artery

The posterior branch of the obturator artery supplies some of the deep gluteal muscles.

Femoral artery
The surface marking of the femoral artery is the mid-inguinal point [half-way between pubic symphysis and anterior
superior iliac spine (ASIS)], which lies just medial to the position of the deep inguinal ring, which is at the midpoint of the
inguinal ligament (half-way between pubic tubercle and ASIS). The femoral artery is subcutaneous in the femoral triangle,
separated from skin by the fascia lata.

digital rectal examination (DRE)

On DRE, the structures that can be palpated in either sex are: the coccyx and lower sacrum posteriorly; the ischial spines
and ischiorectal fossas are lateral; and the anorectal ring at the anorectal junction.

In men, the prostate can be felt (but normal seminal vesicles are not usually palpable).
In women, the cervix can be felt through the vaginal wall, with the uterosacral ligaments laterally, and sometimes the
ovaries.

ACETABULUM
The ilium, ischium and pubis together form the acetabulum. It can be fractured in road traffic accidents when vehicles
collide head-on, driving the engine and steering column into the lower limbs, which drives the femur posteriorly into the
acetabulum with force, causing a fracture.

SACRAL PLEXUS
The sacral plexus is derived from the anterior rami of the L4-S4 spinal nerves. At each sacral vertebral level, paired spinal
nerves leave the spinal cord via the anterior sacral foramina. These are joined by the lumbosacral trunk (formed by the
anterior rami of the L4-L5 spinal nerves) anterior to the piriformis to form the sacral plexus.

Pudendal nerve (S2-S4 ) is part of the sacral plexus!

pudendal nerve entrapment

Regular cyclists are at risk of pudendal nerve entrapment (also known as Alcock canal syndrome). The pudendal
nerve arises at the S2–S4 roots and supplies sensory and somatic fibres to the external genitalia and the urinary and anal
sphincters. Other than scrotal and penile paraesthesia and an unusual sensation during ejaculation, pathology of the
nerve can lead to urinary and faecal incontinence.

sciatic nerve

The sciatic nerve is indeed the largest nerve in the body and with a width of about 2 cm, it has a ‘band-like’ appearance. Its
course is as follows:
 it travels from the pelvis into the gluteal region through the greater sciatic foramen
 travels inferiorly to the piriformis muscle (although this is variable and the nerve can pass through piriformis or occasionally
above piriformis)
 enters posterior thigh, passing deep to the long head of the biceps femoris
 bifurcates at the apex of the popliteal fossa into: tibial nerve and common fibular (peroneal) nerves.

The sciatic nerve is derived from the lumbosacral plexus. The nerve roots of the sciatic nerve are L4–S3

The sciatic nerve crosses the posterior surface of the obturator internus, superior and inferior gemellus and quadratus
femoris muscles.

The bifurcation of the sciatic nerve marks an important anatomical landmark and occurs at the apex of the popliteal fossa.
Here it becomes the tibial and common fibular (peroneal) nerves. It is worth noting that although the point of bifurcation is
described as the apex of the popliteal fossa it too is variable and can occur anywhere throughout the posterior thigh.
femoral canal
This space allows for expansion of the femoral vein, for example, when there is increased venous return during walking. The
femoral canal is shown in the femoral triangle in the images below.
portals in knee arthroscopy

The common fibular (peroneal) nerve winds round the neck of the fibula. The posterolateral portal is usually placed
between the lateral collateral ligament and the biceps femoris tendon, and thus the common peroneal nerve is at risk of
being damaged here.

The saphenous nerve and vein pass along the posteromedial border of the knee, and so could be injured by placement of
the posteromedial portal .

superficial fibular (peroneal) nerve

The superficial fibular (peroneal) nerve supplies the peroneus longus and brevis muscles, and sensation to the skin over
the greater part of the dorsum of the foot, except the first webspace (which is supplied by the deep peroneal
nerve) , the lateral aspect of the foot including the lateral 1½ toes (supplied by the sural nerve) and the nail beds (post
tibial nerve via lateral and medial plantar nerves)

It travels through the lateral compartment of the leg. It passes forwards between the peronei and the extensor
digitorum longus, pierces the deep fascia at the lower third of the leg to become superficial and divides into medial
and intermediate dorsal cutaneous nerves. In its course between the muscles, the nerve gives off muscular branches to the
peroneus longus and brevis and cutaneous filaments to the skin of the lower part of the leg.

Injury impairs foot eversion only NOT dorsiflexion.

Anatomy of Knee injuries-
The anterior cruciate ligament provides stability to the knee joint. High impact sports that involve rapid changes of direction
or direct lower limb trauma are often associated with injuries to the ligament. It originates from the medial aspect of the
lateral femoral condyle to insert into the intercondyloid tibial eminence – shown in blue in the image. Lachman’s test
requires the knee to be flexed to 20–30°, and is positive when the tibia can be pulled abnormally anteriorly from a fixed
femur.

The lateral collateral ligament can be injured when there is a varus force to the knee – that is, a force on the medial aspect of
the knee. The varus stress test can be used to assess this.

The medial collateral ligament can be injured when a valgus force is applied to the knee. The valgus stress test can be used
to assess for this. The medial collateral ligament is adherent to the medial meniscus, which can easily be damaged at the
same time. The McMurray’s test may be positive if there is meniscal involvement in the injury.

Patella tendon injury usually arises from a jumping or explosive load on the knee. There is a ‘popping’ noise heard at the
time of injury. Patients are unable to straight leg raise if it has been torn.

Posterior cruciate ligament injury can be diagnosed with the posterior drawer test. The classical description of how this
injury is sustained is the knee hitting the dashboard of a car – essentially, a direct blow to a flexed knee.

Palpation sites of lower limb

The pulse of the dorsalis pedis pulse is palpated lateral to the extensor hallucis longus tendon distal to the dorsal
navicular prominence and medial to the extensor digitorum longus tendon.

The posterior tibial artery can be palpated at a point anterior to the Achilles’ tendon and posterior to the medial
malleolus. It is palpated as part of a routine lower limb neurovascular examination.

The peroneal artery arises from the posterior tibial artery. It runs in the posterior compartment between tibialis posterior
and flexor hallicus longus and supplies the muscles of the lateral (peroneal) compartment of the leg. It is palpable at a point
superior and anterior to the lateral malleolus, but is rarely palpated as part of a routine lower limb neurovascular
examination.

The profunda femoris is a deep branch of the common femoral artery and is not usually palpable.

The popliteal artery is not always easily palpable. To find it, ask the patient to flex their knee to 90°, while pressing your
fingers into the popliteal fossa and holding the sides of the knee.

Femoral artery: palpation at the mid-inguinal point

gluteus maximus
The gluteus maximus is the most superficial muscle and is supplied by the inferior gluteal nerve. It extends and laterally
rotates the hip. The superior and inferior gluteal arteries supply the gluteus maximus and are branches of the internal iliac
artery.

sciatic nerve

The sciatic nerve originates from nerve roots L4 to S3. It is the largest nerve in the body and innervates the muscles in the
posterior compartment of the thigh and the hamstring portion of adductor magnus. Its major branches are the:
 tibial nerve: L4–S3
 common peroneal nerve: L4–S2

Deep fibular nerve

The deep fibular nerve supplies sensation to the 1st web space of the dorsum of the foot. It also provides motor function to
the extensor muscles in the anterior compartment of the leg. An injury to the deep peroneal nerve results in foot drop.

Sural nerve
The sural nerve is a sensory nerve in the calf region (sura) of the leg. It is made up of branches of the tibial nerve and
common fibular nerve, the medial cutaneous branch from the tibial nerve, and the lateral cutaneous branch from the
common fibular nerve.

This nerve provides sensation to the lateral part of the foot (including the lateral 1½ toes) and ankle, it runs with the short
saphenous vein on the leg.

Medial plantar nerve

The medial plantar nerve is a branch of the posterior tibial nerve (L4–S3; a branch of the sciatic nerve).

The medial plantar nerve gives off plantar digital nerves that provide sensation to the medial two-thirds of the sole of the
foot , the medial three and half digits. and the dorsal surfaces to the nail beds

It is responsible for flexion of all of the toes, and also abduction of the big toe.

The lateral plantar nerve provides cutaneous sensation to the plantar aspect of the 5th and lateral aspect of the 4th toe
and the medial one-third of the sole

The sural nerve supplies sensation to the lateral aspect of the foot and the posterior lateral aspect of the leg.

Tibial nerve injury

A tibial nerve injury results in loss of ankle and toe plantarflexion, weakened foot inversion and loss of sensation to the
plantar aspect of the foot.

prepatellar bursitis- Housmaid’s knee

The prepatellar bursa (labelled in green) lies between the patella and the overlying skin.
This patient has prepatellar bursitis – sometimes known as ‘housemaid’s knee’. This is caused by recurrent, minor injury to
the kneecap, eg where the patient spends a long time kneeling forwards and putting pressure on their patella.

Knee bursae

There are four anterior bursae, four posterior bursae, two medially and two laterally – 12 in total. They are fluid-filled
sacs which reduce friction over bony prominences, and can be either communicating or non-communicating with the knee
joint.

Inflammation of the infrapatellar bursa, found between the skin and tibial tuberosity, is often known as ‘Clergyman’s
knee’.

Suprapatellar always communicate with knee capsule

Semimembranosus bursa may communicate, but not always.

Prepatellar and infrapatellar do NOT communicate

From posterior bursae, popliteal bursa always communicate

knee
The knee is a modified synovial hinge joint. The presence of a cavity and synovial fluid makes the joint freely movable. The
‘hinge’ describes the flexion–extension movements, however the knee also permits rotation and slight varus/valgus
movements. It is therefore typically described as a modified hinge joint. There are many different ways of classifying joints
in the body. The easiest way is to consider the structure of joints (fibrous, cartilaginous and synovial), and the function of
the joints (immovable, slightly movable, and freely movable).

The knee joint can flex to about 135 degrees, maximised by the posterior rollback of the femur on the tibia during flexion.

During knee flexion, the tibia undergoes internal rotation. This is aided by the contraction of popliteus muscle
subsartorial or Hunter’s canal

The adductor canal (also known as the subsartorial or Hunter’s canal) is a 15-cm long tunnel bounded by vastus medialis
(antero)laterally, and adductor longus and magnus posteriorly. The canal serves as a passage for the superficial femoral
artery, femoral vein, saphenous nerve and the nerve to vastus medialis to pass into the popliteal fossa – these structures
(excepting the nerve to vastus medialis) can be seen in the canal in the image. The adductor canal begins where the
sartorius crosses over the adductor longus and ends at the adductor hiatus in the adductor magnus muscle.

Vastus medialis is the anterolateral border of the canal

Sartorius is the supero-medial border.

Adductor magnus, along with adductor longus, forms the posterior border of the canal.

DYNAMIC STABILITY OF THE PATELLA

The dynamic stabilisers of the patella are the quadriceps muscles (rectus femoris, vastus medialis, vastus lateralis, and
vastus intermedialis) anteriorly, and the hamstring muscles (semi-membranosus, semi-tendinosus, and biceps femoris)
posteriorly, and gastrocnemius medially and laterally.

popliteal fossa
The popliteal fossa is a diamond-shaped space at the back of the knee.

The superomedial border is formed by the semitendinous and semimembranosus muscles and the superolateral border by
biceps femoris muscle.

The inferior borders are formed by the medial and lateral heads of gastrocnemius.

The roof of the popliteal fossa is formed by the fascia lata.

The floor is formed by the posterior femur, the popliteus muscle and the knee joint

The contents (deep → superficial) include the popliteal artery, popliteal vein, tibial nerve, common peroneal nerve and
small saphenous vein. Also, there are lymph nodes and connective tissue. From medial to lateral: AVN: artery vein nerve

per vaginam
The ischial spines are palpable per vaginam, and allow the guidance of a needle to the pudendal canal for transvaginal
pudendal nerve block.

Sacral cornua
In the natal cleft, the sacral cornua are important surface markings for the sacral hiatus, through which a needle is passed
for caudal epidural anaesthesia

transtubercular plane
The transtubercular plane is an important landmark for lumbar puncture and transects the L5 vertebra (the supracristal
plane, which passes through the L4 lumbar spine, can also be used).
femoral sheath
The femoral sheath is a downward continuation of the abdominal fascia (transversalis and iliacus) about 2.5 cm below the
inguinal ligament. The sheath lies medially to the femoral nerve. Within the sheath itself, the structures are – from lateral to
medial – artery, vein, ‘empty space’, lymphatics. The ‘empty space’ and lymphatics are better known as the femoral canal,
and this space is for the femoral vein to expand into during periods of increased venous return, eg walking. The femoral
canal is where femoral hernias can develop, and commonly strangulate due to the sharp lacunar ligament on the medial
aspect of the canal opening.

ACL RECONSTRUCTION
The natural load to failure of the ACL is about 2000 Newtons. Grafts for ACL reconstruction can be categorised as
autograft (patient’s own tissue) or allograft (from cadavers). Autografts use either the hamstring (semitendinosus, along
with gracilis) or patella tendon. The ACL is shown below in blue.

saphenous nerve

The saphenous nerve is a branch of the femoral nerve and supplies skin on the medial side of the lower leg. Its area of
distribution is shown in the image below in light blue.
HIP JOINT
The hip joint is a ball and socket synovial joint

The capsule of the hip joint is very thick and dense, much more so than the capsule in the shoulder joint. It is thickest and
strongest anteriorly, where there is the most resistance.

The lateral rotators of the hip are the quadratus femoris, obturator internus, obturator externus, piriformis, gemellus
superior and gemellus inferior muscles.

The iliofemoral ligament is the strongest ligament in the human body and does indeed prevent overextension of the
hip joint. It originates from the anterior inferior iliac spine, and inserts into the intertrochanteric line of the femur.

The rim of the acetabular labrum keeps the head of the femur inside the acetabulum, enclosing it beyond its equator, so
increasing hip stability.

great saphenous vein

The great saphenous vein is found anterior to the medial malleolus. This is in contrast to the small saphenous vein which is
posterior to the lateral malleolus – shown below.

tuberosity of the tibia

The tuberosity of the tibia gives attachment to the patellar tendon. The quadriceps femoris muscle (comprising rectus
femoris, vasti medialis, intermedius and lateralis) attaches to the tibial tuberosity via the quadriceps tendon proximally,
which becomes the patellar tendon distal to the patella (a sesamoid bone witting within the substance of the tendon)

Tensor fascia lata

The tensor fascia lata arises from the outer surface of the anterior iliac crest, and inserts in the iliotibial tract.

Pectineus

The pectineus muscle arises from the pectineal line of the pubis, and inserts into the pectineal line of the femur, at its
medial surface.
 Short head of the biceps femoris
The short head of biceps femoris arises from the lateral lip of the linea aspera, the lateral supracondylar ridge of femur
and the lateral intermuscular septum of the thigh; it inserts onto the fibular head.

Adductor brevis

The adductor brevis arises from inferior ramus and body of the pubis, and inserts into the upper third of the linea aspera.

Grooves of malleoli
 The lateral malleolus is grooved by the peroneus brevis tendon;
 the medial malleolus is grooved by the tibialis posterior tendon.

Tibialis posterior
The tibialis posterior’s main function is to support the medial arch and the foot when walking. The tibialis posterior tendon
is shown in blue in the image below of the foot from below – it can be seen dividing in to two at the level of the plantar
calcaneonavicular ligament, with the superficial slip inserting on to the navicular and the deeper slip inserting on to the 2 nd –
4th metatarsals.

Injury to flexor digitorum longus

Injury to flexor digitorum longus typical presents with difficulty walking and pain in the affected foot and ankle. It is
classically caused by the patient tripping and falling. Flexor digitorum longus is responsible for the movement
of toes 2–5, as well as plantar flexion of the foot.

Injury or pathology to flexor hallucis longus

Injury or pathology to flexor hallucis longus causes pain the affected foot. It is classically seen in ballet
dancers, because of their need to repetitively plantar flex the feet; and of course, is so also seen in sportsmen or other
dancers who need to do this too
‘calf strain’
Gastrocnemius is recruited when the human body needs to undertake explosive movements eg jumping, running. In
layman’s terms, injury to it is known as a ‘calf strain’. There is often tenderness to the medial belly

Injury to soleus is also known as a ‘calf strain’ in layman’s terms. There is tenderness to the lateral belly on palpation

attached to the greater trochanter

Piriformis, gluteus medius, gluteus minimus, obturator internus, obturator externus, vastus lateralis and the gemelli are
all attached to the greater trochanter of the femur.

Gluteus maximus attaches to the gluteal tuberosity of the femur.

Sartorius inserts into the anteromedial surface of the tibia( with gracilis, semitendinosus (SGT muscles).

structures on the lateral aspect of the knee joint

The correct order of superficial to deep structures on the lateral aspect of the knee joint is skin, fibular (lateral) collateral
ligament, popliteus muscle tendon and lateral meniscus. The popliteus muscle tendon runs between the lateral collateral
ligament and the lateral meniscus.

tibio-peroneal (TP) trunk

The tibio-peroneal (TP) trunk is the direct continuation of the popliteal artery. The TP trunk then divides into the peroneal
and posterior tibial arteries.

Psoas abscess
The psoas muscle originates from the lateral surfaces of the T12–L5 vertebrae, and inserts alongside the iliacus muscle as
the iliopsoas tendon at the lesser trochanter of the femur . The psoas muscle acts to flex the hip joint. Psoas abscess is a
recognised complication of Crohn’s disease and can also develop secondary to appendicitis, renal infection and spinal
tuberculosis.
sural nerve

The tibial nerve is the large terminal branch of the sciatic nerve. It arises at the apex of the popliteal fossa, giving off a small
cutaneous branch – the medial sural cutaneous nerve. This is a purely sensory nerve.

The sural nerve is formed by this branch from the tibial and another from the common fibular nerve – its distribution is
seen below in red.

Posterior femoral cutaneous nerve

The posterior femoral cutaneous nerve originates from the sacral plexus. It innervates the skin to the posterior thigh, leg
and perineum.

Trochanteric anastomosis
The trochanteric anastomosis provides circulation around the head of the femur. It includes the superior and inferior
gluteal artery and the medial and lateral circumflex femoral arteries

Medial circumflex artery of which provides the main supply to the femur.

It is formed by the deep branch of superior gluteal artery, with ascending branches of both lateral and medial circumflex
femoral arteries. The inferior gluteal artery usually joins the anastomosis.

Branches from the anastomosis passes along the femoral neck with the retinacular fibers of the capsule.

The cruciate anastomosis is often confused with the trochanteric anastomosis. However, the latter is a network between
the superior gluteal artery and medial/lateral circumflex femoral arteries. But essentially, its function is the same as
that of the cruciate anastomosis; it provides the collateral blood flow to support the femoral head and to the
popliteal artery (distal leg).
 Cruciate anastomosis
The cruciate anastomosis is an arterial network located on the posterior surface of the proximal femur. It is found at the
level of the lesser trochanter, just below the femoral attachment of the quadratus femoris muscle. Some authors refer to it
as the collateral circulation at the hip joint.

The cruciate anastomosis (“FILM”)is formed by the:

 First perforating branch of deep femoral artery

 Inferior gluteal artery

 Lateral circumflex femoral artery

 Medial circumflex femoral artery

The function of the cruciate anastomosis is to provide an alternative route for the blood supply of the lower limb when
there is a blockage of the blood flow between the external iliac and femoral arteries.

The cruciate anastomosis is often confused with the trochanteric anastomosis. However, the latter is a network between
the superior gluteal artery and medial/lateral circumflex femoral arteries. But essentially, its function is the same as
that of the cruciate anastomosis; it provides the collateral blood flow to support the femoral head and to the
popliteal artery (distal leg).

Iliolumbar arteries

The iliolumbar arteries, from the posterior division of the internal iliac artery, divide into lumbar and iliac branches, and
supply the pelvic and spinal muscles.

FEMORAL ARTERY
The femoral vein is posterior to the artery in the adductor canal. As it exits the canal, it comes to lie medial to the artery.

The femoral artery gives off the descending genicular artery in the adductor canal.

The femoral artery lies anterior to adductor brevis.

The femoral artery lies anterior to the adductor longus.

The profunda femoris goes deep to adductor longus

The femoral artery is anterior to the psoas muscle. It enters the thigh halfway between the anterior superior iliac spine and
the symphysis pubis, passing underneath the inguinal ligament. It lies on the psoas tendon which separates it from the
capsule of the hip joint.

popliteal artery
The popliteal artery is a continuation of the superficial femoral artery (also simply known as the femoral artery) as it passes
through the adductor hiatus. It the deepest structure found in the popliteal fossa. The fossa also contains the popliteal vein,
tibial nerve, the common peroneal nerve, and lymph nodes. The popliteal fossa can be seen below, with the popliteal artery
lying deepest.
 The common femoral artery divides into the superficial femoral artery (also known simply as the femoral artery) and the
profunda 3 cm distal to the inguinal ligament.

RESPONSIBLE FOR THE HIND FOOT EQUINUS DEFORMITY

 Achilles tendon

The ankles are rotated internally in club foot deformity. Much of surgery concerns either tenotomy or lengthening of the
Achilles tendon.

Psoas major
Psoas major originates from the transverse processes of the L1–L5 vertebrae, and the sides of the T12–L5 vertebral bodies
and intervertebral discs, and inserts onto the lesser trochanter of the femur along with the iliacus muscle as the combined
iliopsoas tendon. As it runs anterior to the hip joint underneath the inguinal ligament, its action is to flex the hip joint.

The psoas major is innervated by the anterior rami of L1–L3, and iliacus is innervated by the
femoral nerve (specifically the L2–3 nerve roots).

O’Donoghue’s triad
The triad of injury involving tear of the anterior cruciate ligament, medial collateral ligament and meniscal tear is
known as the O’Donoghue’s or the unhappy triad.

Meniscal tear associated with this kind of injury occur in the vast majority (80%) to the lateral meniscus and only
in 20% in the medial meniscus. While O’Donoghue’s original description was of medial meniscal injury, this was revised
in the early 1990s to describe lateral meniscal tears.

st
Priority in treatment involves reconstruction of the anterior cruciate (1 )ligament with a graft either from the
patellar tendon or from the semitendinosus. During the procedure the meniscal tear(1st) can also be corrected. Depending
on the grade of injury, the medial collateral ligament (2nd)may heal with immobilisation.

Recovery after surgery from an unhappy triad injury is 4–8 months and can in some cases last up to 1 year.

Greater sciatic foramen

The greater sciatic notch is converted into the greater sciatic foramen by the sacrospinous ligament. The greater sciatic
foramen acts as a major passage for neurovascular structures travelling from the pelvis to the lower limb. The structures
entering and exiting this foramen are broadly divided into two depending on whether they lie above the piriformis muscle
or below it:

 suprapiriform foramen – superior gluteal vessels and nerve

 infrapiriform foramen
o inferior gluteal vessels
o internal pudendal vessels (re-enters)
o nerves of the sacral plexus:
 inferior gluteal nerve
 sciatic nerve
 pudendal nerve(re-enters)
 posterior femoral cutaneous nerve
 nerve to obturator internus (re-enters)
 nerve to quadratus femoris.

Lesser sciatic foramen

The lesser sciatic foramen is the space between the sacrospinous and sacrotuberous ligaments. It contains: the pudendal
nerve; the nerve and tendon to obturator internus; and the internal pudendal vessels

 The pudendal nerve and the internal pudendal vessels exit the pelvis via the greater sciatic foramen and enter the perineum
through the lesser sciatic foramen.
 Similarly, the nerve to the obturator internus leaves the pelvis via the greater sciatic foramen and soon re-enters the pelvis
through the lesser sciatic foramen.

Piriformis syndrome
Piriformis syndrome is an entrapment neuropathy of the sciatic nerve resulting in radicular pain radiating into the
buttocks. Paraesthesia may also result from prolonged or more severe entrapment. The sciatic nerve itself emerges from
beneath piriformis (although occasionally through or even from above it)

Superior gluteal nerve

The superior gluteal nerve is formed from the L4 – S1 nerve roots and is responsible for the motor supply to the gluteus
medius and minimus and tensor fasciae latae muscle. It exits the pelvis through the greater sciatic foramen, passing
over the piriformis muscle.

inferior gluteal nerve

The inferior gluteal nerve arises from the posterior divisions of L5–S2 nerve roots. It supplies gluteus maximus. A
posterior approach to the hip in surgical procedures may result in damage to the inferior gluteal
nerve either by dissection of the nerve or by stretching and retraction of the nerve.

Femoral nerve
The femoral nerve arises from the posterior divisions of L2–L4 roots of the lumbar plexus and provides motor supply to the
anterior compartment of the thigh and sensory supply to the hip, anterior and medial thigh, knee and leg.

The femoral nerve arises from posterior divisions of L2–L4 roots of the lumbar plexus. It emerges from the lateral border of
the psoas muscle to descend between the iliacus and psoas muscles, and sends a motor branch to iliacus before passing
under the inguinal ligament. Its course below the inguinal ligament is shown below – it terminates as the cutaneous
saphenous nerve.

Genitofemoral nerve

The genitofemoral nerve is formed by the branches of the anterior rami of L1 and L2 spinal nerves of the lumbar plexus. It
divides into the genital and femoral branches just above the inguinal ligament. In men, it travels with the spermatic cord
and supplies motor fibres to the cremaster and dartos muscles. It also supplies sensory fibres to the spermatic fasciae and
tunica vaginalis of the testis. In addition, it supplies sensory innervation to the upper part of the scrotum.

Damage to this nerve could result it numbness of the upper scrotum

Ilioinguinal nerve

The ilioinguinal nerve arises from the L1 nerve root and is predominantly sensory. In men – cutaneous sensation to the root
of the penis and anterior scrotum, as well as the anterior portion of the upper medial thigh. In women – cutaneous
sensation to the anterior portion of the upper medial thigh, mons pubis and labia majora.

Pudendal nerve
The pudendal nerve is formed by the ventral rami of the sacral spinal nerves from S2, S3 and S4. . It emerges from the
pelvis and courses through the gluteal region through the greater sciatic foramen, below the piriformis muscle.

It maintains voluntary urinary continence by facilitating contraction of the external urethral sphincter. It also helps to
maintain voluntary faecal continence via contraction of the external anal sphincter. Damage to this nerve could result in
urinary or faecal incontinence.

Cyclists may develop pudendal nerve entrapment syndrome (also known as Alcock canal syndrome), which can present
with various symptoms including pain, urinary and faecal incontinence and sensory disturbances of the perineum and
genitalia due to irritation, entrapment or damage of the pudendal nerve.

profunda femoris artery

The profunda femoris artery (deep femoral artery – shown in green below) arises from the posterolateral aspect of the
common femoral artery (after it branches, the common femoral artery becomes simply the femoral artery). Its main
branches are the medial and lateral circumflex arteries (shown in yellow), which supply the femoral head via retinacular
arteries that travel in the joint capsule. If damaged, ischaemia and avascular necrosis of the femoral head may result.

mid-shaft fracture of the femur

In mid-shaft femoral fractures, the proximal fragment becomes abducted and externally rotated due to the
action of Gluteus medius

The gluteus medius is the major hip abductor and inserts into the posterolateral surface of the greater
trochanter of the femur. It is supplied by the superior gluteal nerve.

Quadratus femoris
Quadratus femoris is a lateral hip rotator as well as an adductor. It does not play a part in abduction of the hip

Piriformis
The piriformis muscle laterally rotates the extended hip joint and inserted into the medial side of the superior border of
the greater trochanter.

Obturator internis

Obturator internus is responsible for the lateral rotation of the extended hip joint and abduction of the flexed hip. It is
innervated by the nerve to obturator internus and inserts into the medial surface of the greater trochanter.

Obturator externis
The obturator externus laterally rotates the thigh at the hip joint and inserts at the greater trochanter. However, it is not
responsible for abduction.
 profunda femoris artery

The profunda femoris artery (deep femoral artery – shown in green below) is a large vessel arising from the lateral and
posterior part of the femoral artery, from 2 to 5 cm below the inguinal ligament.

At first it lies laterally to the femoral artery.

It then runs behind it and the femoral vein to the medial side of the femur, giving off the medial and lateral femoral
circumflex arteries.

It passes down behind the adductor longus, ending at the lower third of the thigh in a small branch that pierces the
adductor magnus and is distributed on the back of the thigh to the hamstring muscles. It gives 4 perforating arteries

linea aspera
The linea aspera is a ridge running down the posterior aspect of the femur. It forms a point of attachment for the following
muscles:

1. vastus medialis, lateralis,

2. adductor magnus, longus, brevis
3. short head of biceps femoris.

calcaneonavicular (spring) ligament

The calcaneonavicular (spring) ligament – labelled in the image of the foot seen from below - connects the plantar surface
of the navicular bone to the sustentaculum of the calcaneus. It also gives support to the head of the talus, supports a
significant amount of body weight, and maintains the medial longitudinal arch of the foot. Injury to this can lead to a flat
foot deformity.
deltoid ligament
Injury to the deltoid ligament requires high energy and is often injured in association with lateral malleolus
fractures causing translation of the talus, not a flat foot deformity.

syndesmotic ligament complex

The ankle syndesmosis is a group of ligaments connecting the distal tibia and fibula. Disruption causes widening of the distal
tibial–fibular joint, which would cause instability at the ankle, not a flat foot deformity.

posterior cruciate ligament (PCL)

The posterior cruciate ligament (PCL) is stronger, but shorter and less oblique in its direction, than the anterior. It is shown
in yellow in the image below. It is attached to the posterior intercondyloid fossa of the tibia and to the posterior extremity
of the lateral meniscus and passes upward, forwards and medialward, to be fixed into the lateral and front part of the
medial condyle of the femur. This configuration allows the PCL to resist forces pushing the tibia posteriorly relative to the
femur.

Hip dislocation
Posterior (90%) >>>anterior (10%)

Posterior hip dislocation is frequently associated with a posterior rim of the acetabulum fracture. Car drivers or
motorcyclists who are sitting with hip and knee flexed and then hit their knee hard are likely to sustain a dislocation.

Posterior: hip and leg in slight flexion, adduction, internal rotation

Anterior: hip and leg in extension, external rotation, abduction

In hip septic arthritis hip is in flexion, abduction external rotation (to relieve tension)

Attached to the lateral surface of the greater trochanter

The gluteus medius and minimus (abductors) insert into the greater trochanter on the lateral side.

The external rotators of the hip are attached to the medial, superior and posterior surfaces of the greater trochanter. The
obturator externus attaches to the trochanteric fossa on the medial aspect of the greater trochanter.

SPINE

SPINAL STENOSIS
The ligamentum flavum posteriorly can thicken and hypertrophy, narrowing the spinal canal causing spinal

stenosis.
The spinal canal is anterior to the ligamentum flavum but posterior to the intervertebral vertebral discs and posterior
longitudinal ligament. The spinal cord ends at L1.

Ligamentum flavum
This structure (plural ligamenta flava) passes between the laminae of adjacent vertebrae on each side and are thin broad
ligaments forming part of the posterior surface of the vertebral canal. They are primarily formed from elastic tissue
fibres.
 Supraspinous ligament
This connects the tips of the vertebral spinous processes from C7 to the sacrum. This would have been an
understandable response to the question as the ligament becomes known as the ligamentum nuchae above the
level of C7.

Ligamentum nuchae
The ligamentum nuchae is the structure described here – a triangular, sheet-like structure in the median sagittal plane.
The base of the triangle is attached from the external occipital protuberance to the foramen magnum, and the apex to
the tip of the spinous process of C7.

Tectorial membrane
The tectorial membrane is within the vertebral canal and is the upper part of the posterior longitudinal ligament
connecting C2 to the base of the skull. It does not extend to C7. This is not to be confused with the tectorial membrane of
the inner ear.

Posterior longitudinal ligament

This lines the anterior surfaces of the vertebral canal and is attached to the vertebral bodies and intervertebral discs. The
upper part of the posterior longitudinal membrane is known as the tectorial membrane. It does not attach to the spinous
processes of the spine.

ORIENTATION OF THE ARTICULAR FACETS

 Thoracic: The vertical positioning, along with the coronal plane of the thoracic vertebral articular facets, allows a large
degree of rotation in this region of the spine.
 Lumbar: Although lumbar vertebral articular facets are positioned vertical, they are positioned in a more parasagittal
plane, which allows lateral and forward flexion/extension.
 Cervical: The cervical articular facets are relatively horizontal
 Sacral: The sacrum is almost completely fused in adults, so it has little articulation.
LUMBOSACRAL PLEXUS
The lumbosacral trunk (L4/L5) passes anterior to the ala of the sacrum, under cover of the common iliac vessels, and joins
the S1 ventral ramus anterior (deep) to the piriformis muscle.

The adductor muscles are supplied by the L2–L4 roots of the lumbar plexus. They are supplied by anterior divisions.

The splanchnic nerves also known as the nervierigentes originate from S2, S3 and often S4

Sympathetic grey rami connect with all spinal nerve roots.

VERTEBRAL LEVEL
NoaH Told MariaH To Try Cervical Counting

Cervical vertebral level landmarks

C1: Nose (base), Hard palate

C2: Teeth

C3: Mandible, Hyoid bone

C4: Thyroid cartilage (upper) Adams apple

C5: Thyroid cartilage (lower)

C6: Cricoid cartilage

C7: Cricoid cartilage (just below) , Stellate ganglion

C3 is related to the mandible and the hyoid bone, so is the correct answer here. The strap muscles, or infrahyoid muscles
either originate from or insert onto the hyoid bone.

C4 is more closely related to the upper aspect of the thyroid cartilage (the Adam’s apple), which lies between C4 and C5.
This C4 level helps to remember that embryologically the thyroid cartilage is a 4th arch derivative.

The cricoid cartilage is a 6th arch derivative, and is related to C6.

laminae

The laminae lie on both sides of the vertebral arch, between the transverse processes and the spinal process.

The pedicles complete the arch and are between the transverse processes and the body.

INTERNAL VENOUS PLEXUS OF THE SPINE

The extradural or epidural fat is the location for introducing epidural anaesthesia and where the epidural catheter
should be sited. Within this area lies the valveless, internal, vertebral venous plexus

The plexus does sit within the spinal canal but not outside the fat; it is instead within the fat.

Atlanto-occipital joint
The atlanto-occipital joint allows the head to nod (flexion-extension). It is a synovial joint, which is the articulation between
the atlas and the occipital bone.

Atlanto-occipital dislocation is a serious injury in which there is a ligamentous separation of the spinal column from the
skull. Most cases are fatal.

spinothalamic tract
The spinothalamic tract conveys pain, temperature (lateral spinothalamic- decussates 1-2 levels above), crude touch and
pressure (anterior spinithalamic- decussates at the medulla) sensations from one side of the body to the contralateral side
of the brain. Vibration and joint position sense (proprioception) are conveyed via the posterior column. The first neurone
of the spinothalamic tract synapses in the dorsal horn; the next neurone crosses to the contralateral side of the spinal cord
and synapse in the thalamus; the third neurone arises in the thalamus to pass to the cortex.

dens
The dens is anterior in the spinal canal and anterior to the spinal cord. To protect the spinal cord, an exceptionally strong
transverse ligament traverses the space between the dens and the cord.

The dens takes up a third of the anteroposterior space of the spinal canal and the cord another third. The remaining third,
or two-sixths, are either side of the cord to prevent compression on movement. The dens does not sit in the centre of the
spinal canal.

Spinal Orientation
Descending spinal tracts (motor): first exit arms (medial) then legs (lateral)

Ascending tracts (sensory): first enter legs (medial) then arms (lateral)
Anterior spinal artery

Arising from the vertebral arteries, the anterior spinal artery supplies the anterior spinal cord.

Posterior spinal arteries

The posterior spinal artery supplies the spinal cord. It usually arises from the posterior inferior cerebellar artery (PICA-
75% of cases), but may arise from the vertebral arteries in 25% of cases.

Adamkwietz artery
The artery of Adamkiewicz, also known as the great anterior radiculomedullary artery or arteria radicularis anterior
magna, is the name given to the dominant thoracolumbar segmental artery that supplies the spinal cord. It anastomosis
with the anterior spinal artery, supplying arterial blood to the spinal cord from T8 to the conus medullaris
th th
The artery of Adamkiewicz has a variable origin but most commonly arises on the left (~80%), at the level of the 9 -12
intercostal artery (~70%), from the radiculomedullary branch of the posterior branch of the intercostal or lumbar artery,
which arises from the thoracic or abdominal aorta respectively