e-MRCS ANATOMY

MISC
 The trigeminal nerve is the major sensory nerve to the face except over the angle of the jaw. The angle of the jaw is
innervated by the greater auricular nerve.
 Recurrent laryngeal nerve injury may complicate thyroid surgery in up to 1- 2% of cases.
 The first branch of the external carotid artery is the superior thyroid artery. The inferior thyroid artery is derived
from the thyrocervical trunk. The other branches are illustrated below.
 The abducens nerve (CN VI) has a long intra cranial course and is thus susceptible to raised intra cranial pressure. It
also passes over the petrous temporal bone and 6th nerve palsies are also seen in mastoiditis.
 Mobilisation of the hepatic flexure and right colon are standard steps in open adrenal surgery from an anterior
approach. Mobilisation of the liver is seldom required.
 The foramen spinosum (which transmits the middle meningeal artery and vein) lies in the sphenoid bone.
 The gonadal vessels and ureter are important posterior relations that are at risk during a right hemicolectomy.
During latter stages of the procedure, the ileocolic artery and vein are traced along the anterior aspect of the
duodenum. At this point it is possible to injure these, the superior mesenteric vein or the middle colic vein, injury to
any of these can result in torrential bleeding that is very difficult to control.
 Pronator teres is innervated by the median nerve. Palmaris brevis is innervated by the ulnar nerve
Palmatis longus → median nerve (AIN)
 Dural sac terminates at S2, which is why it is safe to undertake an LP at L4/5 levels. The spinal cord itself terminates
at L1.
 The auriculotemporal nerve is closely related to the middle meningeal artery and may be damaged in this scenario.
The nerve supplies sensation to the external ear and outermost part of the tympanic membrane. The angle of the
jaw is innervated by C2,3 roots (greater auricular) and would not be affected. The posterior third of the tongue is
supplied by the glossopharyngeal nerve.
 The posterior interosseous nerve does not innervate the elbow joint.
 The thoracoacromial artery arises from the second part of the axillary artery. It is a short, wide trunk, which pierces
the clavipectoral fascia, and ends, deep to pectoralis major by dividing into four branches (ABCD: acromial,
pectoral(breast), clavicular, deltoid).
 The thyrocervical trunk is a branch of the subclavian artery. It arises from the first part between the subclavian
artery and the inner border of scalenus anterior. It branches off the subclavian distal to the vertebral artery.
 The right recurrent laryngeal nerve has no relation to the brachiocephalic artery.
 During the Hardinge style lateral approach to the hip the transverse branch of the lateral circumflex artery is
divided to gain access.
 The short head of biceps femoris, which may occasionally be absent, is innervated by the common peroneal
component of the sciatic nerve. The long head is innervated by the tibial division of the sciatic nerve.
 The shoulder joint is a shallow joint, hence its great mobility. However, this comes at the expense of stability. The
fibrous capsule attaches to the anatomical neck superiorly and the surgical neck inferiorly
 The extensor hallucis longus tendon lies medial to the dorsalis pedis artery.
 Palmaris brevis - Ulnar nerve
Palmar interossei- Ulnar nerve
Adductor pollicis - Ulnar nerve
Abductor pollicis longus - Posterior interosseous nerve
Abductor pollicis brevis - Median nerve
 The left main bronchus lies at T6. Topographical anatomy of the thorax is important as it helps surgeons to predict
the likely structures to be injured in trauma scenarios (so popular with examiners)
 The left renal vein runs across the surface of the aorta and may require deliberate ligation during juxtarenal
aneurysm repair.
 Sartorius may need to be retrtacted for beter access to the femoral artery
 During a TEP repair of inguinal hernia the only structure to lie posterior to the mesh is peritoneum. The question is
really only asking which structure lies posterior to the rectus abdominis muscle. Since this region is below the
arcuate line, the transversalis fascia and peritoneum lie posterior to it. Bucks fascia lies in the penis.
 The oesophagus extends from C6 (the lower border of the cricoid cartilage) to T11 at the cardioesophageal
junction. Note that in the neonate the oesophagus extends from C4 or C5 to T9.
 Stylohyoid is innervated by the facial nerve.
 Mylohyoid is innervated by the mylohyoid branch of the inferior alveolar nerve.
 Loose areolar tissue of sculp is the most dangerous area when performing minor surgery in the scalp as infections
can spread easily. The emissary veins that drain this area may allow sepsis to spread to the cranial cavity.
 Pectoralis minor is supplied by the medial pectoral nerve
 The space between the vocal cords is referred to as Rima glottidis. The rima glottidis is the narrowest part of the
laryngeal cavity.
In children younger than 10 years of age, the narrowest portion of the airway is below the glottis at the level of the
cricoid cartilage.
 The trabeculae carnae are located in the right ventricle.
 The middle finger has no attachment of the palmar interosseous.
 There are no valves which is why it is relatively easy to insert a CVP line from the internal jugular vein into the
right atrium.
 'VC goes with VC' →The ligamentun Venosum and Caudate is on same side as Vena Cava [posterior].
 External jugular vein: line from angle of mandible to the middle of the clavicle
 Stensen duct: in the middle third of the line from tragus of ear to the philtrum (upper medial lip)

Periosteum
Periosteum is a membrane that covers the outer surface of all bones, except at the joints of long bones. Endosteum
lines the inner surface of all bones.

Periosteum consists of dense irregular connective tissue. Periosteum is divided into an outer 'fibrous layer' and inner
'cambium layer' (or 'osteogenic layer'). The fibrous layer contains fibroblasts, while the cambium layer contains
progenitor cells that develop into osteoblasts and chondroblasts. These osteoblasts are responsible for increasing the
width of a long bone and the overall size of the other bone types. After a bone fracture the progenitor cells develop into
osteoblasts and chondroblasts, which are essential to the healing process.

As opposed to osseous tissue, periosteum has nociceptive nerve endings, making it very sensitive to manipulation. It
also provides nourishment by providing the blood supply. Periosteum is attached to bone by strong collagenous fibers
called Sharpey's fibres, which extend to the outer circumferential and interstitial lamellae. It also provides an
attachment for muscles and tendons.

Periosteum that covers the outer surface of the bones of the skull is known as 'pericranium' except when in reference to
the layers of the scalp.
Levels
Transpyloric plane
Level of the body of L1

 Pylorus stomach
 Left kidney hilum (L1- left one!)
 Fundus of the gallbladder
 Neck of pancreas
 Duodenojejunal flexure
 Superior mesenteric artery
 Portal vein
 Left and right colic flexure
 Root of the transverse mesocolon
 2nd part of the duodenum
 Upper part of conus medullaris
 Spleen

Can be identified by asking the supine patient to sit up without using their arms. The plane is located where the lateral
border of the rectus muscle crosses the costal margin.

Anatomical planes
Subcostal plane Lowest margin of 10th costal cartilage

Intercristal plane Level of body L4 (highest point of iliac crest)

Intertubercular plane Level of body L5

Common level landmarks

Inferior mesenteric artery L3

Bifurcation of aorta into common iliac arteries L4

Formation of IVC L5 (union of common iliac veins)

 Vena cava T8
Diaphragm apertures  Oesophagus T10
 Aortic hiatus T12

Common fascias
Waldeyers fascia- Posterior ano-rectum
Sibsons fascia- Lung apex
Bucks fascia- Base of penis (continuous with Colles)
Gerotas fascia- Surrounding kidney
Denonvilliers fascia- Between rectum and prostate
Nerve signs
Froment's sign

 Assess for ulnar nerve palsy

 Adductor pollicis muscle function tested
 Hold a piece of paper between their thumb and index finger. The object is then pulled away.
 If ulnar nerve palsy, unable to hold the paper and will flex the flexor pollicis longus to compensate (flexion of
thumb at interphalangeal joint).

Phalen's test

 Assess carpal tunnel syndrome

 More sensitive than Tinel's sign
 Hold wrist in maximum flexion and the test is positive if there is numbness in the median nerve distribution.

Tinel's sign

 Assess for carpal tunnel syndrome

 Tap the median nerve at the wrist and the test is positive if there is tingling/electric-like sensations over the
distribution of the median nerve.

Types of joint
There are three main types of joint, fibrous, cartilaginous and synovial

Type of joint Features Example

Sutures- skull
Comprise sutures, gomphoses and syndesmoses
Fibrous Gomphoses-Peg to socket e.g. teeth
Tough connective tissues unite the joints
Syndesmosis-tibiofibular joint
Epiphyseal growth plates
Cartilaginous Joints united by layer of hyaline cartilage
Symphysis pubis
Bone ends permitted free movement
Synovial joints Hip/ knee
Bone ends covered by cartilage and surrounded by fluid

Nerve lesions during surgery

A variety of different procedures carry the risk of iatrogenic nerve injury. These are important not only from the patients
perspective but also from a medicolegal standpoint.

The following operations and their associated nerve lesions are listed here:

 Posterior triangle lymph node biopsy and accessory nerve lesion.

 Lloyd Davies stirrups and common peroneal nerve.
 Thyroidectomy and laryngeal nerve.
 Anterior resection of rectum and hypogastric autonomic nerves→ impotence.
 Axillary node clearance; long thoracic nerve, thoracodorsal nerve and intercostobrachial nerve.
 Inguinal hernia surgery and ilioinguinal nerve.
 Varicose vein surgery- sural and saphenous nerves.
 Posterior approach to the hip and sciatic nerve.
 Carotid endarterectomy and hypoglossal nerve.
Upper Limb
Cords of the brachial plexus
The brachial plexus cords are described according to their relationship with the axillary artery. The cords pass over the
1st rib near to the dome of the lung and pass beneath the clavicle immediately posterior to the subclavian artery.

Lateral cord

 Anterior divisions of the upper and middle trunks form the lateral cord
 Origin of the lateral pectoral nerve (C5, C6, C7)

Medial cord

 Anterior division of the lower trunk forms the medial cord

 Origin of the medial pectoral nerve (C8, T1), the medial brachial cutaneous nerve (T1), and the medial
antebrachial cutaneous nerve (C8, T1)

Posterior cord

 Formed by the posterior divisions of the 3 trunks (C5-T1)

 Origin of the upper and lower subscapular nerves (C7, C8 and C5, C6, respectively) and the thoracodorsal nerve
to the latissimus dorsi (also known as the middle subscapular nerve, C6, C7, C8), axillary and radial nerve

Thoracodorsal nerve
This nerve arises between the two subscapular nerves. It passes inferomedially over subscapularis and accompanies the
thoracodorsal vessels along the anterolateral surface of latissimus dorsi which it innervates.
Extensor retinaculum
The extensor retinaculum is a thickening of the deep fascia that stretches across the back of the wrist and holds the
long extensor tendons in position.
Its attachments are:

 The pisiform and triquetral medially

 The end of the radius laterally

The extensor retinaculum attaches to the radius proximal to the styloid, (in contrast flexor retinaculum attaches on
the radial side to the scaphoid and trapezium bones) thereafter it runs obliquely and distally to wind around the ulnar
styloid (but does not attach to it). It attaches to the pisiform and triquetral medially, (in contrast flexor retinaculum
attaches on the ulnar side to the pisiform and hook of haammate)

Structures related to the extensor retinaculum

 Basilic vein
 Dorsal cutaneous branch of the
Structures ulnar nerve
superficial to the  Cephalic vein
retinaculum  Superficial branch of the radial
nerve

1st. Abductor pollicis longus

Structures Extensor pollicis brevis tendons
passing deep to 2nd. Extensor carpi radialis longus
the extensor tendon
retinaculum Extensor carpi radialis brevis
tendon
6 compartments 3rd. Extensor pollicis longus tendon
Each 4th. Extensor digitorum
compartment Extensor indicis tendon
has its own 5th. Extensor digiti minimi tendon
synovial sheath. 6th. Extensor carpi ulnaris tendon

The radial artery

The radial artery passes between the lateral collateral ligament of the wrist joint and the tendons of the abductor
pollicis longus and extensor pollicis brevis, in the anatomical snuffbox.

Froment's sign
This is a description of Froment's sign, which tests for ulnar nerve palsy. It mainly tests for the function of adductor
pollicis. This is supplied by the deep branch of the ulnar nerve.

Remember the anterior interosseous branch (of the median nerve), which innervates the flexor pollicis longus (hence
causing flexion of the thumb IP joint), branches off more proximally to the wrist.

Musculocutaneous nerve

 Branch of lateral cord of brachial plexus

Path

 It penetrates the coracobrachialis muscle

 Passes obliquely between the biceps brachii and the brachialis (beneath biceps) to the lateral side of the arm
 Above the elbow it pierces the deep fascia lateral to the tendon of the biceps brachii
 Continues into the forearm as the lateral cutaneous nerve of the forearm

Innervates

 Coracobrachialis
 Biceps brachii
 Brachialis

Median nerve
The median nerve is formed by the union of a lateral and medial root respectively from the lateral (C5,6,7) and medial
(C8 and T1) cords of the brachial plexus; the medial root passes anterior to the third part of the axillary artery.
The nerve descends lateral to the brachial artery, crosses to its medial side (usually passing anterior to the artery).

It passes deep to the bicipital aponeurosis and the median cubital vein at the elbow.

It passes between the two heads of the pronator teres muscle, and runs on the deep surface of flexor digitorum
superficialis (within its fascial sheath).

Near the wrist it becomes superficial between the tendons of flexor digitorum superficialis and flexor carpi radialis,
deep to palmaris longus tendon.

It passes deep to the flexor retinaculum to enter the palm, but lies anterior to the long flexor tendons within the
carpal tunnel.

Branches
Region Branch
Upper arm No branches, although the nerve commonly communicates with the musculocutaneous nerve
Pronator teres
Pronator quadratus
Flexor carpi radialis
Forearm Palmaris longus
Flexor digitorum superficialis
Flexor pollicis longus
Flexor digitorum profundus (only the radial half)
Distal
Palmar cutaneous branch
forearm
Hand Motor supply (LOAF)
(Motor)
 Lateral 2 lumbricals
 Opponens pollicis  recurrent branch of median nerve
 Abductor pollicis brevis recurrent branch of median nerve
 Flexor pollicis brevis
o Superficial head: recurrent br of median n
 Region Branch
o Deep head: deep branch of ulnar n

 Over thumb and lateral 2 ½ fingers

Hand  On the palmar aspect this projects proximally, on the dorsal aspect only the distal regions are
(Sensory) innervated with the radial nerve providing the more proximal cutaneous innervation.

Patterns of damage
Damage at wrist

 e.g. carpal tunnel syndrome

 paralysis and wasting of thenar eminence muscles and opponens pollicis (ape hand deformity)
 sensory loss to palmar aspect of lateral (radial) 2 ½ fingers

Damage at elbow, as above plus:

 unable to pronate forearm

 weak wrist flexion
 ulnar deviation of wrist

Anterior interosseous nerve (branch of median nerve)

 leaves just below the elbow

 results in loss of pronation of forearm and weakness of long flexors of thumb and index
finger

Adductor pollicis is innervated by the ulnar nerve.

Medial two lumbricals innervated by the ulnar nerve.

Loss of the median nerve will result in loss of function of the flexor muscles. However, flexor carpi ulnaris will still
function and produce ulnar deviation and some residual wrist flexion. High median nerve lesions result in complete loss
of flexion at the thumb joint.

Ulnar nerve injury at wrist

Branches of the ulnar nerve in the wrist and hand
At the wrist the ulnar nerve divides into superficial and deep branches.

The superficial branch lies deep to the palmaris brevis. It divides into two; to produce digital nerves, which innervate
the skin of the medial third of the palm and the palmar surface of one and a half fingers.

The deep branch arises from the nerve on the flexor retinaculum lateral to the pisiform bone. It passes posteriorly
between the abductor and short flexor of the little finger supplying them, and supplying and piercing the opponens
digiti minimi near its origin from the flexor retinaculum, turns laterally over the distal surface of the Hook of the Hamate
bone. It eventually passes between the two heads of adductor pollicis with the deep palmar arch and ends in the first
dorsal interosseous muscle. In the palm the deep branch also innervates the lumbricals and interosseous muscles.

Axilla
Boundaries of the axilla
Medially Chest wall and Serratus anterior (and upper half of external oblique)
Laterally Humeral head
Floor Subscapularis
Anterior aspect Lateral border of Pectoralis major
Fascia Clavipectoral fascia

Content:
Derived from C5-C7 and passes behind the brachial plexus to enter the axilla. It lies on the
Long thoracic nerve (of Bell) medial chest wall and supplies serratus anterior. Its location puts it at risk during axillary
surgery and damage will lead to winging of the scapula.
Thoracodorsal nerve and
Innervate and vascularise latissimus dorsi.
thoracodorsal trunk
Lies at the apex of the axilla, it is the continuation of the basilic vein. Becomes the
Axillary vein
subclavian vein at the outer border of the first rib.
Traverse the axillary lymph nodes and are often divided during axillary surgery. They
Intercostobrachial nerves
provide cutaneous sensation to the axillary skin.
Lymph nodes The axilla is the main site of lymphatic drainage for the breast.

During a routine level 1 axillary exploration which is where the majority of sentinel nodes will be located, the
nerves most commonly encountered are the intercostobrachial nerves.

The thoracodorsal trunk runs through the nodes in the axilla. If injured it may compromise the function and blood supply
to latissimus dorsi, which is significant if it is to be used as a flap for a reconstructive procedure.

Beware of damaging the thoracodorsal trunk if a latissimus dorsi flap reconstruction is planned.

Winging of the scapula is most commonly the result of long thoracic nerve injury or dysfunction. Iatrogenic damage
during the course of the difficult axillary dissection is the most likely cause in this scenario. Damage to the rhomboids
may produce winging of the scapula but would be rare in the scenario given.

The clavipectoral fascia is situated under the clavicular portion of pectoralis major. It protects both the axillary vessels
and nodes. During an axillary node clearance for breast cancer the clavipectoral fascia is incised and this allows
access to the nodal stations. The nodal stations are; level 1 nodes inferior to pectoralis minor, level 2 lie behind it and
level 3 above it. During a Patey Mastectomy surgeons divide pectoralis minor to gain access to level 3 nodes. The
use of sentinel node biopsy (and stronger assistants!) have made this procedure far less common.

A 44 year old lady who works as an interior decorator has undergone a mastectomy and axillary node clearance to treat
breast cancer. Post operatively, she comments that her arm easily becomes fatigued when she is painting walls. What is
the most likely explanation?

The most likely explanation for this is that the thoracodorsal nerve has been injured. This will result in atrophy of
latissimus dorsi and this will become evident with repetitive arm movements where the arm is elevated and moving up
and down (such as in painting). Injury to the pectoral nerves may produce a similar picture but this pattern of injury is
very rare and the pectoral nerves are seldom injured in breast surgery.
Radial nerve
Mnemonic for radial nerve muscles: BEST

B rachioradialis
E xtensors
S upinator
T riceps

Continuation of posterior cord of the brachial plexus (root values C5 to T1)

Path

 In the axilla: lies posterior to the axillary artery on subscapularis, latissimus dorsi and teres major.
 Enters the arm between the long head of triceps and the brachial artery (medial to humerus).
 Spirals around the posterior surface of the humerus in the groove for the radial nerve.
 At the distal third of the lateral border of the humerus it then pierces the intermuscular septum and descends
in front of the lateral epicondyle.
 At the lateral epicondyle it lies deeply between brachialis and brachioradialis where it then divides into a
superficial and deep terminal branch.
 Deep branch crosses the supinator (b/w its heads or piercing it) to become the posterior interosseous nerve.

The radial nerve passes through the triangular interval to leave the axilla. The superior border of this is bounded
by the teres major muscle to which the radial nerve is closely related. The oother 2 borders are the two heads of the
tricep. The radial nerve (and the profunda femoris) run in its groove on between the lateral and the medial head of the
triceps.
The ulnar nerve lies anterior to the medial head.

The axillary nerve passes through the quadrangular space.

Regions innervated
 Triceps
 Anconeus
Motor (main nerve)  Brachioradialis
 Extensor carpi radialis longus and brevis

 Supinator
 Extensor carpi ulnaris
 Extensor digitorum
Motor (posterior  Extensor indicis
interosseous branch)  Extensor digiti minimi
 Extensor pollicis longus and brevis
 Abductor pollicis longus

The area of skin supplying the proximal phalanges on the dorsal aspect of the hand is supplied by
Sensory the radial nerve (this does not apply to the little finger and part of the ring finger). Nail beds are
innervated by the median nerve!!

Muscular innervation and effect of denervation

 Anatomical
Muscle affected Effect of paralysis
location
Shoulder Long head of triceps Minor effects on shoulder stability in abduction
Arm Triceps Loss of elbow extension
Supinator
Brachioradialis Weakening of supination of prone hand and elbow flexion in mid
Forearm
Extensor carpi radialis longus and prone position
brevis

The cutaneous sensation of the upper limb- illustrating the contribution of the radial nerve

Axillary artery
The axillary artery extends from the outer border of the first rib to the lower border of teres major, where it becomes
the brachial artery. The vessel is subdivided into three zones; the first part lies above pectoralis minor, the second part
is behind the muscle and the third part lies inferior to it.

The superior thoracic artery is the first branch of the axillary artery arises from the first part
Two branches arise from the second part, thoraco acromial and lateral thoracic
Three branches from the third part, subscapular artery, anterior and posterior circumflex humeral arteries

Mnemonic for axillary artery branches

Screw The Lawyer Save A patient
Superior thoracic artery
Thoracoacromial artery
Lateral thoracic artery
Subscapular artery
Anterior humeral circumflex artery
Posterior humeral circumflex artery

First part  medial cord posteriorly. Other cords superolaterally

Together with the axillary vein, the artery is enclosed within the cords of the brachial plexus. Both vessels are contained
within the axillary sheath, a prolongation of the prevertebral fascia. Posteriomedial to the sheath lies the first
intercostal space, the superior aspect of the serratus anterior and the long thoracic nerve. Within the sheath, the medial
cord of the brachial plexus lies behind the artery. Anteriorly lies the clavipectoral fascia. Superolaterally, lie the lateral
and posterior cords of the brachial plexus. Inferomedially lies the axillary vein.

Second part  medial cord medial, lateral lateral and posterior posterior
Posterior to the second part lies the posterior cord of the brachial plexus and the subscapularis muscle. Anteriorly, lie
pectoralis minor and major. The lateral cord of the brachial plexus lies laterally. Medially, lies the medial cord of the
brachial plexus, here it separates the artery from the vein.

Third part
Posterior to the artery lie suscapularis, latissimus dorsi and teres major. Interspersed between the vessel and
subscapularis are the axillary and radial nerves. Anterior to the vessel is the medial root of the median nerve. Laterally,
the lies the median and musculocutaneous nerves and coracobrachialis. The axillary vein is related medially.

Scapular anastomosis

The scapular anastomosis is a system connecting certain subclavian artery and their corresponding axillary
artery, forming a circulatory anastomosis around the scapula. It allows blood to flow past the joint in case of
occlusion, damage, or pinching of the following scapular arteries:
  Transverse cervical artery
 Dorsal scapular artery (the anastomosing branch of the transverse cervical)
 Suprascapular artery
 Branches of subscapular artery
 Branches of thoracic aorta

The transverse cervical artery gives off a branch, the dorsal scapular artery, which accompanies the dorsal scapular
nerve and runs down the vertebral border of the scapula to its medial edge and inferior angle. The dorsal scapular
artery anastomoses with the subscapular artery, providing an alternate route to the 3rd part of the axillary
artery in the event of a slowly forming occlusion.

The suprascapular artery branches off from the thyrocervical trunk, which in turn arises from the first part of
the subclavian artery. This suprascapular artery crosses over the suprascapular ligament, passes through the
supraspinous fossa and turns around the lateral border of the spine of the scapula and supplies the infraspinous
fossa as far as the inferior angle.

The subscapular artery branches from the third part of the axillary and supplies the subscapularis muscle in the
subscapular fossa as far as the inferior angle. The subscapular artery gives off a circumflex scapular branch that
enters the infraspinous fossa on the dorsal surface of the bone, grooving the axillary border.

All these vessels anastamose or join to connect the first part of the subclavian with the third part of the
axillary, providing a collateral circulation. This collateral circulation allows for blood to continue circulating if the
subclavian is obstructed.

Abductor pollicis brevis

Origin Fleshy fibres from the flexor retinaculum, scaphoid and trapezium
Insertion Via a short tendon into the radial side of the proximal phalanx of the thumb
Recurrent branch of median nerve in the palm.

Nerve

Abducts the thumb at the carpometacarpal and metacarpophalangeal joints, causing it to travel anteriorly at
right angles to the plane of the palm and to rotate medially (e.g. typing). When the thumb is fully abducted
Actions there is angulation of around 30 degrees between the proximal phalanx and the metacarpal. Because of the
direction of the muscle, abduction involves medial rotation of the metacarpal, and the abductor is used along
with opponens pollicis in the initial stages of thumb opposition
Flexor Pollicis brevis

Posterior interosseous nerve

 Emerges from supinator between the superficial extensor muscles and lowest fibres of supinator
 It gives recurrent branches which innervate extensor digitorum, extensor digiti minimi and extensor carpi ulnaris
 It then passes with the posterior interosseous artery superficial to the abductor pollicis longus supplying it. It
supplies branches to extensor pollicis longus and brevis and extensor indicis and ends as a small gangliform
enlargement at the back of the carpus from which the intercarpal joints are supplied.

The radial nerve may become entrapped in the arcade of Frohse which is a superficial part of the supinator muscle
which overlies the posterior interosseous nerve. This nerve is entirely muscular and articular in its distribution. It
passes postero-inferiorly and gives branches to extensor carpi radialis brevis and supinator. It enters supinator and
curves around the lateral and posterior surfaces of the radius. On emerging from the supinator the posterior
interosseous nerve lies between the superficial extensor muscles and the lowermost fibres of supinator. It then gives
branches to the extensors.

Ulnar nerve
Origin

 C8, T1

Supplies (no muscles in the upper arm)

 Flexor carpi ulnaris

 Flexor digitorum profundus
 Flexor digiti minimi
 Abductor digiti minimi
  Opponens digiti minimi
 Adductor pollicis
 Interossei muscle
 Third and fourth lumbricals
 Palmaris brevis

Path

 Posteromedial aspect of upper arm to flexor compartment of forearm, then along the ulnar. Passes beneath the
flexor carpi ulnaris muscle, then superficially over the flexor retinaculum into the palm of the hand.

The ulnar nerve arises from the medial cord of the brachial plexus (C8, T1 and contribution from C7). The nerve
descends between the axillary artery and vein, posterior to the cutaneous nerve of the forearm and then lies anterior
to triceps on the medial side of the brachial artery. In the distal half of the arm it passes through the medial
intermuscular septum, and continues between this structure and the medial head of triceps to enter the forearm
between the medial epicondyle of the humerus and the olecranon. It may be injured at this site in this scenario.
Branches
Branch Supplies
Flexor carpi ulnaris
Muscular branch
Medial half of the flexor digitorum profundus
Palmar cutaneous branch (Arises near the middle of
Skin on the medial part of the palm
the forearm)
Dorsal cutaneous branch Dorsal surface of the medial part of the hand
Cutaneous fibres to the anterior surfaces of the medial one and
Superficial branch
one-half digits
Hypothenar muscles
All the interosseous muscles
Deep branch Third and fourth lumbricals
Adductor pollicis
Medial head of the flexor pollicis brevis

Effects of injury
 Wasting and paralysis of intrinsic hand muscles (claw hand)
 Wasting and paralysis of hypothenar muscles
Damage at the wrist
 Loss of sensation medial 1 and half fingers

 Radial deviation of the wrist

Damage at the elbow  Clawing less in 4th and 5th digits

ulnar paradox : due to the more proximal level of transection the hand will typically not have a claw like
appearance that may be seen following a more distal injury. The first dorsal interosseous muscle will be affected as it is
supplied by the ulnar nerve. The effects are potentiated when flexor digitorum profundus is not affected, and the
clawing is more pronounced.More proximally sited ulnar nerve lesions produce a milder clinical picture owing to the
simultaneous paralysis of flexor digitorum profundus (ulnar half).
Injury to the ulnar nerve in the mid to distal forearm will typically produce a claw hand. This consists of flexion of the
4th and 5th interphalangeal joints and extension of the metacarpophalangeal joints.

Ulnar artery
Path

 Starts: middle of antecubital fossa

 Passes obliquely downward, reaching the ulnar side of the forearm at a point about midway between the elbow
and the wrist. It follows the ulnar border to the wrist, crossing over the flexor retinaculum. It then divides into
the superficial and deep volar arches.

Relations
Deep to- Pronator teres, Flexor carpi ulnaris, Palmaris longus
Lies on- Brachialis and Flexor digitorum profundus
Superficial to the flexor retinaculum at the wrist

The median nerve is in relation with the medial side of the ulnar artery for about 2.5 cm. And then crosses the
vessel, being separated from it by the ulnar head of the Pronator teres

The ulnar nerve lies medially to the lower two-thirds of the artery.

In the middle of the forearm, the artery is overlapped by the flexor carpi ulnaris and on the flexor retinaculum it is
covered by a superficial layer from that structure. In its distal two-thirds, flexor digitorum superficialis lies on its radial
side, and the ulnar nerve is situated on its ulnar side.

Branch

 Anterior interosseous artery

Humerus
The humerus extends from the scapula to the elbow joint. It has a body and two ends. It is almost completely covered
with muscle but can usually be palpated throughout its length. The smooth rounded surface of the head articulates with
the shallow glenoid cavity. The head is connected to the body of the humerus by the anatomical neck. The surgical
neck is the region below the head and tubercles and where they join the shaft and is the commonest site of fracture.
The capsule of the shoulder joint is attached to the anatomical neck superiorly but extends down to 1.5cm on the
surgical neck.

The greater tubercle is the prominence on the lateral side of the upper end of the bone. It merges with the body below
and can be felt through the deltoid inferior to the acromion. The tendons of the supraspinatus and infraspinatus are
inserted into impressions on its superior aspect. The lesser tubercle is a distinct prominence on the front of the upper
end of the bone. It can be palpated through the deltoid just lateral to the tip of the coracoid process.

The intertubercular groove passes on the body between the greater and lesser tubercles, continuing down from the
anterior borders of the tubercles to form the edges of the groove. The tendon of biceps within its synovial sheath
passes through this groove, held within it by a transverse ligament.

The posterior surface of the body is marked by a spiral groove for the radial nerve which runs obliquely across the
upper half of the body to reach the lateral border below the deltoid tuberosity. Within this groove lie the radial nerve
and brachial vessels and both may be affected by fractures involving the shaft of the humerus.

The lower end of the humerus is wide and flattened anteroposteriorly, and inclined anteriorly. The middle third of the
distal edge forms the trochlea. Superior to this are indentations for the coronoid fossa anteriorly and olecranon fossa
posteriorly. Lateral to the trochlea is a rounded capitulum which articulates with the radius.

The medial epicondyle is very prominent with a smooth posterior surface which contains a sulcus for the ulnar nerve
and collateral vessels. It's distal margin gives attachment for the ulnar collateral ligament and, in front of this, the
anterior surface has an impression for the common flexor tendon.

Scaphoid bone
The scaphoid has a concave articular surface for the head of the capitate and at the edge of this is a crescentic surface
for the corresponding area on the lunate.
Proximally, it has a wide convex articular surface with the radius. It has a distally sited tubercle that can be palpated.
The remaining articular surface is to the lateral side of the tubercle. It faces laterally and is associated with the
trapezium and trapezoid bones.

The narrow strip between the radial and trapezial surfaces and the tubercle gives rise to the radial collateral carpal
ligament.

A fall onto an outstretched hand is a common mechanism of injury for a scaphoid fracture. This should be suspected
clinically if there is tenderness in the base of the anatomical snuffbox. A tendon rupture would not result in bony
tenderness.

Blood supply
This is from the scaphoid tubercle vessels (superficial palmar arch vessels) that comprise 20% and the dorsal ridge
vessels (dorsal carpal branch vessels) that supply 80%, via retrograde flow.

The dorsal carpal branch vessels supply 80% of the scaphoid via retrograde flow. There is a minor supply from the
superficial palmar arch vessels that supplies the distal 20% of the scaphoid.

Forearm flexor muscles

Muscle Origin Insertion Nerve supply Action
Flexes and abducts the
Flexor carpi Common flexor origin and Front of bases of second and third carpus, part flexes the
Median
radialis surrounding fascia metacarpals elbow and part pronates
forearm
Palmaris
Common flexor origin Apex of palmar aponeurosis Median Wrist flexor
longus
Flexor carpi Small humeral head arises Pisiform and base of the fifth Ulnar nerve Flexes and adducts the
ulnaris from the common flexor metacarpal carpus
origin and adjacent fascia.
Ulnar head comes from
medial border of
olecranon and posterior
 Muscle Origin Insertion Nerve supply Action
border of ulna
Long linear origin from Via tendons in the fibrous flexor
Flexor of
Flexor common flexor tendon, sheath. At the level of the
metacarpophalangeal joint
digitorum adjacent fascia and septa metacarpophalangeal joint each Median
and proximal
superficialis and medial border of the tendon split into two, these bands
interphalangeal joint
coronoid process pass distally to their insertions
Upper two thirds of the Medial part=
medial and anterior ulnar, lateral
Flexor surface of the ulna, Via tendons that lie deep to those part=anterior Flexes the distal
digitorum medial side of the of flexor digitorum superficialis to interosseous interphalangeal joints and
profundus olecranon, medial half of insert into the distal phalanx nerve the wrist
the interosseous
membrane

Brachial plexus
The brachial plexus extends from the neck to the axilla. It is formed by the ventral rami of the fifth to the eighth cervical
nerves with the ascending part of the first thoracic nerve.

Location of the plexus

The ventral rami which form the plexus enter the lower part of the posterior triangle of the neck in series with the
ventral rami of the cervical plexus. The second part of the subclavian artery lies immediately anterior to the lower two
rami. The upper three rami intermingle and pass inferolaterally towards the axilla and subclavian artery. They are
enclosed within an extension of the prevertebral fascia. In the neck the plexus lies deep to platysma, the
supraclavicular nerves, inferior belly of omohyoid and the transverse cervical artery. It then passes deep to the clavicle
and the suprascapular vessels, to enter the axilla, and thence surround the second part of the axillary artery

Composition of the plexus

Ventral rami, the roots of the plexus, lie between scalenus medius and anterior.

As they enter the posterior triangle, the upper two (C5,6) and lower two (C8, T1) roots of the plexus unite to form the
upper and lower trunks of the plexus respectively. Meanwhile, C7 continues as the middle trunk. The lower trunk may
groove the superior surface of the first rib posterior to the subclavian artery, and the root from the first ventral ramus is
always in contact with it.

Each trunk divides into ventral and dorsal divisions which are destined to supply the anterior (flexor) and posterior
(extensor) parts of the upper limb.

The cords of the plexus are formed in the axilla. The dorsal divisions unite to form the posterior cord (C5-8). The ventral
divisions of the upper and middle trunks unite to form the lateral cord (C5-7), while the ventral divisions of the lower
trunk continues as the medial cord (C8-T1). The cords are named according to their relationship to the axillary artery.
Each cord terminates by dividing into two main branches at the beginning of the third part of the artery.

Sympathetic communications
The fifth and sixth cervical ventral rami receive grey rami communicantes from the middle cervical ganglion, while the
two or more grey rami communicantes pass from the inferior cervical ganglion to the seventh and eighth cervical ventral
rami. The first thoracic ventral ramus receives its grey ramus from the cervicothoracic ganglion. Its for this reason that
inferior plexus injury can be complicated by a Horners syndrome.

Summary
Origin Anterior rami of C5 to T1
 Roots, trunks, divisions, cords, branches
 Mnemonic:Real Teenagers Drink Cold Beer
Sections of the plexus

 Located in the posterior triangle

 Pass between scalenus anterior and medius
Roots

 Located posterior to middle third of clavicle

 Upper and middle trunks related superiorly to the subclavian artery
Trunks  Lower trunk passes over 1st rib posterior to the subclavian artery

Divisions Apex of axilla

Cords Related to axillary artery

When the brachial plexus is injured in the axilla as a result of a crutch palsy the radial nerve is most commonly
injured and results in a wrist drop. The ulnar nerve arises from the medial cord and is rarely affected as a result of this
injury mechanism.

Erb's palsy→ trunks C5-6.

Phrenic nerve
Origin

 C3,4,5

Supplies

 Diaphragm, sensation central diaphragm and pericardium

Path

 The phrenic nerve passes with the internal jugular vein across scalenus anterior. It passes deep to prevertebral
fascia of deep cervical fascia.
 Left: crosses anterior to the 1st part of the subclavian artery. (Vagus anterior to the interval CCA-subclavian)
 Right: Anterior to scalenus anterior and crosses anterior to the 2nd part of the subclavian artery. (vagus
anterior to the 1st part)
 On both sides, the phrenic nerve runs posterior to the subclavian vein and posterior (and medial) to the
internal thoracic artery as it enters the thorax.
 The key point is that the phrenic nerve runs posterior to the medial aspect of the first rib.
Superiorly, it lies on the surface of scalenus anterior.

Right phrenic nerve

  In the superior mediastinum: anterior to right vagus and laterally to superior vena cava
 Middle mediastinum: right of pericardium
 It passes over the right atrium to exit the diaphragm at T8

Left phrenic nerve

 Passes lateral to the left subclavian artery, aortic arch and left ventricle
 Passes anterior to the root of the lung
 Pierces the diaphragm alone

Clavicle
The clavicle extends from the sternum to the acromion and helps prevent the shoulder falling forwards and downwards.
The inferior surface is irregular and strongly marked by ligaments at each end. Laterally, lies the trapezoid line and this
runs anterolaterally. Posteriorly, lies the conoid tubercle. These give attachment to the conoid and trapezoid parts of the
coracoclavicular ligament. The medial part of the inferior surface has an irregular surface which marks the surface
attachment of the costoclavicular ligament. The intermediate portion is marked by a groove for the subclavius muscle.
Medially, the superior part of the bone has a raised surface which gives attachment to the clavicular head of
sternocleidomastoid. Sternohyoid gains attachment to the posterior surface.
Laterally there is an oval articular facet for the acromion and a disk lies between the clavicle and acromion. The capsule
of the joint is attached to the ridge on the margin of the facet.

The subclavian vein lies behind subclavius and the medial part of the clavicle. It rests on the first rib, below and in
front of the third part of the subclavian artery, and then on scalenus anterior which separates it from the second part
of the artery (posteriorly).

Shoulder joint

 Shallow synovial ball and socket type of joint.

 It is an inherently unstable joint, but is capable to a wide range of movement.
 Stability is provided by muscles of the rotator cuff that pass from the scapula to insert in the greater tuberosity
(all except sub scapularis-lesser tuberosity).

Glenoid labrum

 Fibrocartilaginous rim attached to the free edge of the glenoid cavity

 Tendon of the long head of biceps arises from within the joint from the supraglenoid tubercle, and is fused
at this point to the labrum.
 The long head of triceps attaches to the infraglenoid tubercle  outside the joint

Fibrous capsule

 Attaches to the scapula external to the glenoid labrum and to the labrum itself (postero-superiorly)
 Attaches to the humerus at the level of the anatomical neck superiorly and the surgical neck inferiorly
 Anteriorly the capsule is in contact with the tendon of subscapularis, superiorly with the supraspinatus tendon,
and posteriorly with the tendons of infraspinatus and teres minor. All these blend with the capsule towards
their insertion.
  Two defects in the fibrous capsule; superiorly for the tendon of biceps. Anteriorly there is a defect
beneath the subscapularis tendon.
 The inferior extension of the capsule is closely related to the axillary nerve at the surgical neck and this nerve
is at risk in anteroinferior dislocations. It also means that proximally sited osteomyelitis may progress to septic
arthritis.

Movements and muscles

Anterior part of deltoid

Pectoralis major
Flexion
Biceps
Coracobrachialis

Posterior deltoid
Extension Teres major
Latissimus dorsi

Pectoralis major
Latissimus dorsi
Adduction
Teres major
Coracobrachialis

Mid deltoid
Abduction
Supraspinatus

Subscapularis
Anterior deltoid
Medial rotation
Teres major
Latissimus dorsi

Posterior deltoid
Lateral rotation Infraspinatus
Teres minor

Important anatomical relations

Brachial plexus
Anteriorly
Axillary artery and vein

Suprascapular nerve
Posterior
Suprascapular vessels

Axillary nerve
Inferior
Circumflex humeral vessels
The intermediate portion of the deltoid muscle is the chief abductor of the humerus. However, it can only do this after
the movement has been initiated by supraspinatus. Damage to the tendon of supraspinatus is a common form of
rotator cuff disease.

Axillary nerve

 Terminal branch of the posterior cord of the brachial plexus

 Root values C5 and C6
 Descends posterior to the axillary artery at the lower border of subscapularis and then passes through
quadrangular space with the posterior circumflex humeral vessels
 Divides into anterior and posterior branches
 Innervates deltoid muscle and small patch of skin over deltoid

The posterior circumflex humeral vessels which are branches of the axillary artery are related to the axillary nerve within
the quadrangular space.

Cervical ribs

 0.2-0.4% incidence
 Most cases present with neurological symptoms (60%)
 Consist of an anomalous fibrous band that often originates from C7 and may arc towards, but rarely reaches
the sternum
 Congenital cases may present around the third decade, some cases are reported to occur following trauma
 Bilateral in up to 70%
  Compression of the subclavian artery may produce absent radial pulse on clinical examination and in particular
may result in a positive Adsons test (lateral flexion of the neck towards the symptomatic side and traction
of the symptomatic arm- leads to obliteration of radial pulse)
 Treatment is most commonly undertaken when there is evidence of neurovascular compromise. A transaxillary
approach is the traditional operative method for excision.
 occur as a result of the elongation of the transverse process of the 7th cervical vertebra. It is usually a fibrous
band that attaches to the first thoracic rib.

Brachial artery
The brachial artery begins at the lower border of teres major as a continuation of the axillary artery. It terminates in the
cubital fossa at the level of the neck of the radius by dividing into the radial and ulnar arteries.
The profunda brachii artery is the largest branch and then continues in the radial groove of the humerus.
Relations
Posterior relations include the long head of triceps with the radial nerve and profunda vessels intervening. Anteriorly it
is overlapped by the medial border of biceps.
It is crossed by the median nerve in the middle of the arm.
In the cubital fossa it is separated from the median cubital vein by the bicipital aponeurosis.
The basilic vein is in contact at the most proximal aspect of the cubital fossa and lies medially.

The brachial artery begins at the lower border of teres major and terminates in the cubital fossa by branching into the
radial and ulnar arteries. In the upper arm the median nerve lies closest to it in the lateral position. In the cubital fossa
it lies medial to it.

Relations of median nerve to the brachial artery:

Lateral -> Anterior -> Medial

The median nerve descends lateral to the brachial artery, it usually passes anterior to the artery to lie on its medial side.
It passes deep to the bicipital aponeurosis and the median cubital vein at the elbow. It enters the forearm between the
two heads of the pronator teres muscle.

The brachial artery is not closely related to the cephalic vein

Hand
Anatomy of the hand

 8 Carpal bones
Bones  5 Metacarpals
 14 phalanges

7 Interossei - Supplied by ulnar nerve

Intrinsic Muscles
 4 palmar-adduct fingers
 4 dorsal- abduct fingers

Intrinsic muscles Lumbricals

 Flex MCPJ and extend the IPJ.

 Origin deep flexor tendon and insertion dorsal extensor hood mechanism.
  Innervation: 1st and 2nd- median nerve, 3rd and 4th- deep branch of the ulnar nerve.

 Abductor pollicis brevis

Thenar eminence  Opponens pollicis
 Flexor pollicis brevis

 Opponens digiti minimi

Hypothenar eminence  Flexor digiti minimi brevis
 Abductor digiti minimi

Flexor digitorum superficialis and flexor digitorum profundus are responsible for causing flexion. The superficialis
tendons insert on the bases of the middle phalanges; the profundus tendons insert on the bases of the distal
phalanges. Both tendons flex the wrist, MCP and PIP joints; however, only the profundus tendons flex the DIP joints.

Fascia and compartments of the palm

The fascia of the palm is continuous with the antebrachial fascia and the fascia of the dorsum of the hand. The palmar
fascia is thin over the thenar and hypothenar eminences. In contrast, the central palmar fascia is relatively thick.

The palmar aponeurosis covers the soft tissues and overlies the flexor tendons. The apex of the palmar aponeurosis is
continuous with the flexor retinaculum and the palmaris longus tendon. Distally, it forms four longitudinal digital
bands that attach to the bases of the proximal phalanges, blending with the fibrous digital sheaths.
A medial fibrous septum extends deeply from the medial border of the palmar aponeurosis to the 5th metacarpal.
Lying medial to this are the hypothenar muscles. In a similar fashion, a lateral fibrous septum extends deeply from
the lateral border of the palmar aponeurosis to the 3rd metacarpal. The thenar compartment lies lateral to this
area.
Lying between the thenar and hypothenar compartments is the central compartment. It contains the flexor tendons
and their sheaths, the lumbricals, the superficial palmar arterial arch and the digital vessels and nerves.

The deepest muscular plane is the adductor compartment, which contains adductor pollicis.

Short muscles of the hand

These comprise the lumbricals and interossei. The four slender lumbrical muscles flex the fingers at the
metacarpophalangeal joints and extend the interphalangeal joint. The four dorsal interossei are located between the
metacarpals and the three palmar interossei lie on the palmar surface of the metacarpals in the interosseous
compartment of the hand.

Long flexor tendons and sheaths in the hand

The tendons of FDS and FDP enter the common flexor sheath deep to the flexor retinaculum. The tendons enter the
central compartment of the hand and fan out to their respective digital synovial sheaths. Near the base of the proximal
phalanx, the tendon of FDS splits to permit the passage of FDP. The FDP tendons are attached to the margins of the
anterior aspect of the base of the distal phalanx.
The fibrous digital sheaths contain the flexor tendons and their synovial sheaths. These extend from the heads of the
metacarpals to the base of the distal phalanges.
Palmar Interossei [ palmars abduct// dorsals adduct// PAD-DAB)

Note that there are 4 palmar interossei.

 The first is a small slip of muscle which arises from the ulnar side of the base of the first metacarpal and passes
between the head of the first dorsal interosseous and the oblique head of adductor pollicis to insert into the ulnar
base of the of the proximal phalanx of the thumb.
 The second arises from the ulnar side of the body of the second metacarpal and is inserted into the ulnar side of
the extensor hood of the index.
 The third and fourth palmar interossei arise from the radial sides of the bodies of the 4th and 5th metacarpals
respectively and insert into the radial sides of the extensor hoods of the ring and little fingers.
 Middle finger has NO palmar interossei muscle attachment

Subclavian artery
Path

 The left subclavian comes directly off the arch of aorta

 The right subclavian arises from the brachiocephalic artery (trunk) when it bifurcates into the subclavian and the
right common carotid artery.
 From its origin, the subclavian artery travels laterally, passing between anterior and middle scalene muscles,
deep to scalenus anterior and anterior to scalenus medius. As the subclavian artery crosses the lateral border of
the first rib, it becomes the axillary artery. At this point it is superficial and within the subclavian triangle.

The artery and vein are separated by scalenus anterior. This muscle runs from the transverse processes of C3,4,5 and 6
to insert onto the scalene tubercle of the first rib.

Branches

 Vertebral artery
 Internal thoracic artery
 Thyrocervical trunk
 Costocervical trunk
 Dorsal scapular artery

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

 inferior thyroid artery,

  suprascapular artery,
 ascending cervical artery,
 transverse cervical artery dorsal scapular a.

The costocervical trunk originates from the posterior surface of the subclavian artery, runs posteriorly and
splits into the following branches:

 deep cervical artery,

 superior intercostal artery.

Triceps
 Long head- infraglenoid tubercle of the scapula.
 Lateral head- dorsal surface of the humerus, lateral and proximal to the groove of the radial nerve
 Medial head- posterior surface of the humerus on the inferomedial side of the radial groove and
Origin
both of the intermuscular septae

 Olecranon process of the ulna. Here the olecranon bursa is between the triceps tendon and
olecranon.
 Some fibres insert to the deep fascia of the forearm, posterior capsule of the elbow (preventing the
Insertion
capsule from being trapped between olecranon and olecranon fossa during extension)

Innervation Radial nerve

Blood
Profunda brachii artery
supply

Action Elbow extension. The long head can adduct the humerus and and extend it from a flexed position

Accessory nerve
The cranial root of the accessory nerve arises from the caudal two thirds of the nucleus ambiguus and the caudal four
fifths of the dorsal nucleus of the vagus. The cranial root emerges as four rootlets from the dorsolateral surface of the
medulla oblongata below those of the vagus. It then traverses the jugular foramen. On exiting the jugular foramen it
separates from its spinal part. Where upon its cranial fibres joint those of the vagus to innervate some of the palatal
muscles. The fibres arising from the spinal root exit near the junction between the spinal cord and the medulla. The
fibres pass rostrally to unite with the cranial roots to exit through the jugular foramen. As outlined above these separate
on exiting the foramen. The spinal part then crosses the transverse process of the atlas, and is crossed by the occipital
artery as it does so.

It descends obliquely, medial to the styloid process, stylohyoid and the posterior belly of digastric. It then reaches the
upper part of sternocleidomastoid to enter its upper surface. It typically exits this muscle a little above the midpoint of
the posterior aspect of it. This point is usually 4-6cm below the tip of the mastoid process. It crosses the posterior
triangle on the levator scapulae separated from it by the pre vertebral layer of deep cervical fascia. At this point, the
nerve is superficial and related to the superficial cervical lymph nodes.

Approximately 3-5 cm above the clavicle it passes behind the anterior border of trapezius which it innervates.

Anatomical snuffbox
Posterior border Tendon of extensor pollicis longus
Anterior border Tendons of extensor pollicis brevis and abductor pollicis longus

Proximal border Styloid process of the radius

Distal border Apex of snuffbox triangle

Floor Trapezium and scaphoid

Content Radial artery, ECRB, ECRL

Carpal bones
The wrist is comprised of 8 carpal bones, these are arranged in two rows of 4. It is convex from side to side posteriorly
and concave anteriorly.

 Scaphoid- Lunate –Triquetrum- Pisiform

 Trapezium- Trapezoid -Capitate -Hamate

No tendons attach to: Scaphoid, lunate, triquetrum (stabilised by ligaments)

The carpal tunnel contains median nerve plus nine flexor tendons:

 Flexor digitorum profundus

 Flexor digitorum superficialis
 Flexor pollicis longus

The tendon of flexor digitorum profundus lies deepest in the tunnel and will thus lie nearest to the hamate bone.

Anterior interosseous nerve

The anterior interosseous nerve (volar interosseous nerve) is a branch of the median nerve that supplies the deep
muscles on the front of the forearm, except the ulnar half of the flexor digitorum profundus.

It accompanies the anterior interosseous artery along the anterior of the interosseous membrane of the forearm,
in the interval between the flexor pollicis longus and flexor digitorum profundus , supplying the whole
of the former and (most commonly) the radial half of the latter, and ending below in the pronator quadratus and wrist
joint.

Innervation
The anterior interosseous nerve classically innervates 2.5 muscles: These muscles are in the deep level of the anterior
compartment of the forearm.

 Flexor pollicis longus

 Pronator quadratus
 The radial half of flexor digitorum profundus (the lateral two out of the four tendons).

When damaged it classically causes:

 Pain in the forearm

  Loss of pincer movement of the thumb and index finger (innervates the long flexor muscles of flexor pollicis
longus & flexor digitorum profundus of the index and middle finger)
 Minimal loss of sensation due to lack of a cutaneous branch

Pectoralis major muscle

Origin From the medial two thirds of the clavicle, manubrium and sternocostal angle

Insertion Lateral edge of the bicipital groove of the humerus

Nerve supply Lateral pectoral nerve + medial pec. nerve

Actions Adductor and medial rotator of the humerus

Interossei
Four palmar and four dorsal interossei occupy the spaces between the metacarpal bones.

Each palmar interossei originates from the metacarpal of the digit on which it acts.
Each dorsal interossei comes from the surface of the adjacent metacarpal on which it acts.

As a result the dorsal interossei are twice the size of the palmar ones.
The interossei tendons, except the first palmar, pass to one or other side of the metacarpophalangeal joint posterior to
the deep transverse metacarpal ligament. They become inserted into the base of the proximal phalanx and partly into
the extensor hood

They are all innervated by the ulnar nerve

Dorsal interossei abduct the fingers, palmar interossei adduct the fingers.

Clinical notes
Along with the lumbricals the interossei flex the metacarpophalangeal joints and extend the proximal and
distal interphalangeal joints. They are responsible for fine tuning these movements.

When the interossei and lumbricals are paralysed the digits are pulled into hyperextension by extensor digitorum and
a claw hand is seen.

Elbow joint
The brachialis inserts some of its fibres into the fibrous joint of the elbow capsule and when it contracts, it helps to flex
the joint.

This large synovial joint is of the hinge variety of joint, the bones of the forearm articulate with the lower end of the
humerus. The upper ends of the radius and ulnar are bound together by the anular ligament of the radius in
such a way as to permit movement between these two bones at what is described as the proximal radio-ulnar joint. The
elbow and the proximal radio-ulnar joints have a common fibrous capsule and synovial cavity, and though the
anular ligament plays a part in the structure of both joints, it is described with the proximal radio-ulnar joint.

Articular surfaces
The humeral articular surface at the elbow comprises the grooved trochlea, the spheroidal capitulum, and the sulcus
between them. This composite surface is covered by a layer of articular cartilage. The capitulum is confined to the
anterior and distal aspects of the bone, but the trochea extends round the distal end of the bone from the lower edge of
the coronoid fossa on the front of the humerus to the lower edge of the olecranon fossa posteriorly. The articular
surface covering the ulnar surface of the elbow joint is interrupted along the deepest part in a transverse line. Then
trochlear notch articulates with the trochlea of the humerus forming a saddle shaped joint with it. The radial surface
has a slight concavity to the proximal surface of the head which articulates with the capitulum while its raised margin
lies on the capitulotrochlear groove. This surface of the head is covered with articular cartilage which is continuous with
that round the sides in the radio-ulnar joint.

The radial and ulnar surfaces are most fully in contact with the corresponding humeral surfaces when the forearm is in
a position midway between full pronation and supination and the elbow is fixed to a right angle.

Fibrous capsule
The joint is encased within a fibrous capsule that is relatively weak anteriorly and posteriorly, its strengthened at
the sides to form the radial and ulnar collateral ligaments. The anterior part of the capsule is attached to the front of
the humerus immediately superior to the radial and coronoid fossae, to the anterior border of the coronoid process of
the ulna, and to the anterior part of the anular ligament of the radius. The brachialis muscle covers the greater part of
the front of the capsule, and some of its deep fibres insert into the capsule.
The posterior part of the capsule is very weak in its median part. However, the tendon of triceps inserts at this site and
supports it and also draws it upwards in extension.

The radial collateral ligament is a strong triangular shaped thickening of the fibrous capsule. Its apex is attached
superiorly to the antero-inferior aspect of the lateral epicondyle of the humerus in close relation to the common
extensor muscles whose common origin overlies this site. Distally, the broad base of the ligament blends with the
anular ligament of the radius, and is attached both in front and behind to the margins of the radial notch on
the ulna.

The ulna collateral ligament is comprised of three capsular condensations which are continuous with one another.

 An anterior band passes from the front of the medial epicondyle of the humerus to the medial edge of the
coronoid process of the ulna; it is closely related to the common origin of the superficial flexor muscles.
 A posterior band is attached above to the back of the medial epicondyle and below to the medial edge of the
olecranon.
 A transverse band stretches between the attachments of the anterior and posterior bands on the coronoid process
and the olecranon. The lower edge of this transverse ligament is free , a small amount of synovial
membrane may protrude through the space between this and the underlying bone.

Synovial membrane
The attachments of the synovial membrane generally follow those of the fibrous capsule.

Nerve supply
The elbow joint derives its nerve supply from the musculocutaneous, median, radial and ulnar nerves.
Movements
Movement occurs around a transverse axis, a movement of flexion when the forearm makes anteriorly a diminishing
angle with the upper arm and extension when the opposite occurs. The axis of movement passes through the humeral
epicondyles and is not at right angles with either the humerus or bones of the forearm. In full extension with the
forearm supinated, the arm and forearm form an angle which is more than 180 degrees, the extent to which this angle
is exceeded is termed the carrying angle. The carrying angle is masked when the forearm is pronated.

Thoracoacromial artery
The thoracoacromial artery (acromiothoracic artery; thoracic axis) is a short trunk, which arises from the forepart of the
axillary artery, its origin being generally overlapped by the upper edge of the Pectoralis minor.

Projecting forward to the upper border of the Pectoralis minor, it pierces the coracoclavicular fascia and divides into four
branches: pectoral, acromial, clavicular, and deltoid.

Branch Description

Pectoral Descends between the two Pectoral muscles, and is distributed to them and to the breast, anastomosing
branch with the intercostal branches of the internal thoracic artery and with the lateral thoracic.

Runs laterally over the coracoid process and under the Deltoid, to which it gives branches; it then
Acromial
branch
pierces deltoid and ends on the acromion in an arterial network formed by branches from the
suprascapular, thoracoacromial, and posterior humeral circumflex arteries.

Clavicular
Runs upwards and medially to the sternoclavicular joint, supplying this articulation, and the Subclavius.
branch

Deltoid Arising with the acromial, it crosses over the Pectoralis minor and passes in the deltopectoral groove
branch with the cephalic vein, between the Pectoralis major and Deltoid, and gives branches to both muscles.

quadrangular space
The quadrangular space is bordered by the humerus laterally, subscapularis and teres minor superiorly, teres major
inferiorly and the long head of triceps medially. It lies lateral to the triangular space. It transmits the axillary nerve and
posterior circumflex humeral artery.
Brachiocephalic artery
The brachiocephalic artery is the largest branch of the aortic arch. From its aortic origin it ascends superiorly, it initially
lies anterior to the trachea and then on its right hand side. It branches into the common carotid and right subclavian
arteries at the level of the sternoclavicular joint.

Relations

 Sternohyoid
 Sternothyroid
Anterior  Thymic remnants
 Left brachiocephalic vein
 Right inferior thyroid veins

 Trachea
Posterior  Right pleura

 Right brachiocephalic vein

Right lateral  Superior part of SVC

 Thymic remnants
 Origin of left common carotid
Left lateral  Inferior thyroid veins
 Trachea (higher level)

Branches
Normally none but may have the thyroidea ima artery (10-15%)

Thumb muscles
There are 8 muscles:
1. Two flexors (flexor pollicis brevis and flexor pollicis longus)
2. Two extensors (extensor pollicis brevis and longus)
3. Two abductors (abductor pollicis brevis and longus)
4. One adductor (adductor pollicis)
5. One muscle that opposes the thumb by rotating the CMC joint (opponens pollicis).

Flexor and extensor longus insert on the distal phalanx moving both the MCP and IP joints.

intrinsic hand muscles

Mnemonic for intrinsic hand muscles
'A OF A OF A'

A bductor pollicis brevis

O pponens pollicis
F lexor pollicis brevis
A dductor pollicis (thenar muscles)
O pponens digiti minimi
F lexor digiti minimi brevis
A bductor digiti minimi (hypothenar muscles)

Radius
The radius is one of the two long forearm bones that extends from the lateral side of the elbow to the thumb side of the
wrist. It has two expanded ends, of which the distal end is the larger. Key points relating to its topography and relations
are outlined below;

The annular ligament connects the radial head to the radial notch of the ulna.
Upper end

 Articular cartilage- covers medial > lateral side

 Articulates with radial notch of the ulna by the annular ligament
 Muscle attachment- biceps brachii at the tuberosity

Shaft
Muscle attachment

Lower end

 Quadrilateral
 Anterior surface- capsule of wrist joint
 Medial surface- head of ulna
 Lateral surface- ends in the styloid process
 Posterior surface: 3 grooves containing:

1. Tendons of extensor carpi radialis longus and brevis

2. Tendon of extensor pollicis longus
3. Tendon of extensor indicis

Suprascapular nerve
The suprascapular nerve arises from the upper trunk of the brachial plexus. It lies superior to the trunks of the
brachial plexus and passes inferolaterally parallel to them. It passes through the scapular notch, deep to trapezius.
It innervates both supraspinatus and infraspinatus and initiates abduction of the shoulder. If damaged, patients may be
able to abduct the shoulder by leaning over the affected side and deltoid can then continue to abduct the shoulder.
Breast
The breast itself lies on a layer of pectoral fascia and on the following muscles:
1. Pectoralis major
2. Serratus anterior
3. External oblique

Breast anatomy

Nerve supply Branches of intercostal nerves from T4-T6.

 Internal mammary (thoracic) artery

 External mammary artery (laterally)
 Anterior intercostal arteries
Arterial  Thoraco-acromial artery
supply
60% of the arterial supply to the breast is derived from the internal mammary artery. The external
mammary and lateral thoracic arteries also make a significant (but lesser) contribution. This is of
importance clinically in performing reduction mammoplasty procedures.
Venous
Superficial venous plexus to subclavian, axillary and intercostal veins.
drainage

 70% Axillary nodes

Lymphatic
 Internal mammary chain
drainage
 Other lymphatic sites such as deep cervical and supraclavicular fossa (later in disease)

Klumpkes Paralysis
A C8, T1 root lesion is called Klumpke's paralysis and is caused by delivery with the arm extended. Features of Klumpkes
Paralysis

 Claw hand (MCP joints extended and IP joints flexed)

 Loss of sensation over medial aspect of forearm and hand
 Horner's syndrome
 Loss of flexors of the wrist

Horners syndrome
Horners syndrome, clinical features:

 Ptosis
 Miosis
 Enopthalmos
 Anhydrosis

Primarily a disorder of the sympathetic nervous system. Extent of symptoms depends upon the anatomical site of the
lesion.
Proximal lesions occur along the hypothalamospinal tract
Distal lesions are usually post ganglionic e.g. at level of internal carotid artery or beyond.

The anhidrosis will be mild in a distal lesion and at worst only a very limited area of the ipsilateral face will be
anhidrotic.

Long thoracic nerve

 Derived from ventral rami of C5, C6, and C7 (close to their emergence from intervertebral foramina)
 It runs downward and passes either anterior or posterior to the middle scalene muscle
 It reaches upper tip of serratus anterior muscle and descends on outer surface of this muscle, giving branches
into it
 Winging of Scapula occurs in long thoracic nerve injury (most common) or from spinal accessory nerve injury
(which denervates the trapezius) or a dorsal scapular nerve injury

Winging of Scapula
Causes due to nerve lesions:

1. long thoracic nerve injury (most common)

2. spinal accessory nerve injury (which denervates the trapezius)
3. dorsal scapular nerve injury (rhomboid, levator scapulae)

Gantzer muscle
Anterior interosseous lesions occur due to fracture, or rarely due to compression. The Gantzer muscle is an aberrant
accessory of the flexor pollicis longus and is a risk factor for anterior interosseous nerve compression.
Remember loss of pincer grip and normal sensation indicates an interosseous nerve lesion.

Cephalic vein
Path

 Dorsal venous arch drains laterally into the cephalic vein

 Crosses the anatomical snuffbox and travels laterally up the arm
 At the antecubital fossa connected to the basilic vein by the median cubital vein
 Pierces deep fascia of deltopectoral groove to join axillary vein

The cephalic vein is a favored vessel for arteriovenous fistula formation and should be preserved in
patients with end stage renal failure

The cephalic vein penetrates the clavipectoral fascia (but not the pectoralis major) prior to terminating in the axillary
vein.
Basilic vein
The basilic and cephalic veins both provide the main pathways of venous drainage for the arm and hand. It is continuous
with the palmar venous arch distally and the axillary vein proximally.

Path

 Originates on the medial side of the dorsal venous network of the hand, and passes up the forearm and arm.
 Most of its course is superficial.
 Near the region anterior to the cubital fossa the vein joins the cephalic vein.
 Midway up the humerus the basilic vein passes deep under the muscles.
 At the lower border of the teres major muscle, the anterior and posterior circumflex humeral
veins feed into it.
 It is often joined by the medial brachial vein before draining into the axillary vein.

It is used in arteriovenous fistula surgery during a procedure known as a basilic vein transposition.

The basilic vein drains into the axillary vein and although PICC lines may end up in a variety of fascinating locations the
axillary vein is usually the commonest site following from the basilic. The posterior circumflex humeral vein is
encountered prior to the axillary vein. However, a PICC line is unlikely to enter this structure because of its angle of
entry into the basilic vein.

Lower Limb
Trendelenburg test
Injury or division of the superior gluteal nerve results in a motor deficit that consists of weakened abduction of
the thigh by gluteus medius, a disabling gluteus medius limp and a compensatory list of the body to the weakened
gluteal side. The compensation results in a gravitational shift so that the body is supported on the unaffected limb.

When a person is asked to stand on one leg, the gluteus medius usually contracts as soon as the contralateral leg leaves
the floor, preventing the pelvis from dipping towards the unsupported side. When a person with paralysis of the
superior gluteal nerve is asked to stand on one leg, the pelvis on the unsupported side descends, indicating that the
gluteus medius on the affected side is weak or non functional ( a positive Trendelenburg test).

This eponymous test also refers to a vascular investigation in which tourniquets are placed around the upper
thigh, these can help determine whether saphenofemoral incompetence is present.

Anterior tibial artery

 Begins opposite the distal border of popliteus

 Terminates in front of the ankle, continuing as the dorsalis pedis artery
  As it descends it lies on the interosseous membrane, initially between anterior tibialis and extensor
hallucis longus.
 Passes between the tendons of extensor digitorum and extensor hallucis longus distally (crossed
superficially by the extensor hallucis longus tendon from lateral to medial)
 It is related to the deep peroneal nerve. The nerve lies anterior to the middle third of the vessel and lateral
to it in the lower third. (Nerves always lateral to arteries on the lower limb)

Sciatic nerve
The sciatic nerve is formed from the sacral plexus and is the largest nerve in the body. It is the continuation of the main
part of the plexus arising from ventral rami of L4 to S3. These rami converge at the inferior border of piriformis to
form the nerve itself. It passes through the inferior part of the greater sciatic foramen and emerges beneath piriformis,
being the most lateral stracture. Medially, lie the inferior gluteal nerve and vessels and the pudendal nerve and
vessels. Posteriorly is the posterior femoral cutaneous nerve of thigh. It runs inferolaterally under the cover of
gluteus maximus midway between the greater trochanter and ischial tuberosity . It passes
between the long and short head of the bicep femoris (resting on the short head and the
abductor magnus). It receives its blood supply from the inferior gluteal artery. The nerve provides cutaneous
sensation to the skin of the foot and the leg. It also innervates the posterior thigh muscles and the lower leg and foot
muscles. The nerve splits into the tibial and common peroneal nerves approximately half way down the posterior
thigh. The tibial nerve supplies the flexor muscles and the common peroneal nerve supplies the extensor muscles and
the evertor muscles of the foot.

Summary points

Origin Spinal nerves L4 - S3

Articular Branches Hip joint

 Semitendinosus
Muscular branches in upper leg  Semimembranosus
 Biceps femoris
  Part of adductor magnus

 Posterior aspect of thigh (via cutaneous nerves)

 Gluteal region
Cutaneous sensation  Entire lower leg (except the medial aspect)

Terminates At the upper part of the popliteal fossa by dividing into the tibial and peroneal nerves

 The nerve to the short head of the biceps femoris comes from the common peroneal part of the sciatic and the
other muscular branches arise from the tibial portion.
 The tibial nerve goes on to innervate all muscles of the foot except the extensor digitorum brevis (which is
innervated by the common peroneal nerve).

Obturator nerve

The obturator nerve arises from L2, L3 and L4 by branches from the ventral divisions of each of these nerve roots. L3
forms the main contribution and the second lumbar branch is occasionally absent. These branches unite in the
substance of psoas major, descending vertically in its posterior part to emerge from its medial border at the lateral
margin of the sacrum. It then crosses the sacroiliac joint (crosses external iliac vessels and ureter, being most
superficial) to enter the lesser pelvis, it descends on obturator internus, being the most lateral structure on the
obturator fascia, to enter the obturator groove. In the lesser pelvis the nerve lies lateral to the internal iliac vessels and
ureter, and is joined by the obturator vessels lateral to the ovary or ductus deferens.

Supplies

 Medial compartment of thigh

 Muscles supplied: external obturator, adductor longus, adductor brevis, adductor magnus (not the lower part-
sciatic nerve), gracilis
 The cutaneous branch is often absent. When present, it passes between gracilis and adductor longus near the
middle part of the thigh, and supplies the skin and fascia of the distal two thirds of the medial aspect.

Obturator canal

 Connects the pelvis and thigh: contains the obturator artery, vein, nerve which divides into anterior and
posterior branches.

Common peroneal nerve

Derived from the dorsal divisions of the sacral plexus (L4, L5, S1 and S2).

This nerve supplies the skin and fascia of the anterolateral surface of the leg and the dorsum of the foot. It also
innervates the muscles of the anterior and peroneal compartments of the leg, extensor digitorum brevis as well as the
knee, ankle and foot joints.

It is laterally placed within the sciatic nerve. From the bifurcation of the sciatic nerve it passes inferolaterally in the
lateral and proximal part of the popliteal fossa, under the cover of biceps femoris and its tendon. To reach the
posterior aspect of the fibular head. It ends by dividing into the deep and superficial peroneal nerves at the point where
it winds around the lateral surface of the neck of the fibula in the body of peroneus longus, approximately
2cm distal to the apex of the head of the fibula. It is palpable posterior to the head of the fibula.

Branches

Nerve to the short head of biceps

In the thigh
Articular branch (knee)

In the popliteal fossa Lateral cutaneous nerve of the calf

Neck of fibula Superficial and deep peroneal nerves

The common peroneal nerve lies under the lateral aspect of biceps femoris and is therefore at greatest risk of
injury. The tibial nerve may also be damaged in such an injury (but is not listed here). The sural nerve branches off more
inferiorly.

Positioning legs in Lloyd- Davies stirrups can carry the risk of peroneal nerve neuropraxia if not done carefully.

Sartorius

 Longest strap muscle in the body

 Most superficial muscle in the anterior compartment of the thigh
 Forms the Pes anserinus with Gracilis and semitendinous muscle

Origin Anterior superior iliac spine

Medial surface of the of the body of the tibia (upper part). It inserts anterior to gracilis and
Insertion
semitendinosus

Nerve Supply Anterior (superficial) division of Femoral nerve (L2,3 -root values for sartorius)
 Flexor of the hip and knee, slight abducts the thigh and rotates it laterally
 It assists with medial rotation of the tibia on the femur. For example it would play a pivotal role
Action in placing the right heel onto the left knee ( and vice versa)

Important The middle third of this muscle, and its strong underlying fascia forms the roof of the adductor canal ,
relations in which lie the femoral vessels, the saphenous nerve and the nerve to vastus medialis.

Most of the branches of the superficial femoral nerve are cutaneous. However, it does also supply sartorius.

Femur

 Extends from a rounded head, which articulates with the acetabulum down to the knee joint where the two large
condyles at it's inferior aspect articulate with the tibia.
 The superior aspect comprises a head and neck which pass inferolaterally to the body and the two trochanters.
These lie at the junction between the neck and the body.
 The neck meets the body of the femur at an angle of 125
o
.
 Developmentally, the neck is part of the body but is demarcated from it by a wide rough intertrochanteric crest, this
continues inferomedially as a spiral line that runs below the lesser trochanter. Medially, the intertrochanteric line
 gives attachment to the inferior end of the iliofemoral ligament. The neck is covered by synovial membrane up to
the intertrochanteric line. The posterior aspect of the neck is demarcated from the shaft by the
intertrochanteric crest and only it's medial aspect is covered by synovium and the joint capsule.
 The greater trochanter has discernible surfaces that form the site of attachment of the gluteal muscles.Laterally, the
greater trochanter overhangs the body and this forms part of the origin of vastus lateralis
 Viewed anteriorly, the body of the femur appears rounded. Viewed laterally, it has an anterior concavity which gives
fullness to the anterior thigh. Posteriorly, there is a ridge of bone, the linea aspera. The surface of the anterior
aspect of the body forms the origin of the vastus intermedius. More medially, it forms the origin of vastus medialis.
 The upper and middle aspects of the linea aspera form part of the origin of the attachments of the thigh adductors.
Inferiorly, it spans out to form the bony floor of the popliteal fossa. At the inferior aspect of the popliteal surface the
surface curves posteriorly to form the femoral condyles.
 The structures that are attached to the inferior aspect of the linea aspera split with it as it approaches the popliteal
fossa. Thus the vastus medialis and adductor magnus continue with the medial split and the biceps femoris and
vastus intermedius along the lateral split.

Blood supply
The femur has a rich blood supply and numerous vascular foramina exist throughout it's length. The blood supply to the
femoral head is clinically important and is provided by the medial circumflex femoral (biggest supplier) and lateral
circumflex femoral arteries (Branches of profunda femoris). Also from the inferior gluteal artery. These form an
anastomosis and travel to up the femoral neck to supply the head. Main head blood supply is via the
retinacular vessels.

Femoral triangle anatomy

Boundaries

Superiorly Inguinal ligament

Laterally Sartorius

Medially Adductor longus

Floor Iliopsoas, adductor longus and pectineus

 Fascia lata and Superficial fascia
 Superficial inguinal lymph nodes (palpable below the inguinal ligament)
Roof  Long /Great saphenous vein

Contents

 Femoral vein (medial to lateral)

 Femoral artery-pulse palpated at the mid inguinal point
 Femoral nerve
 Deep and superficial inguinal lymph nodes
 Lateral cutaneous nerve
  Great saphenous vein (vein when superficial is roof, but when it pierces the cribiform
fascia it become content..)
 Femoral branch of the genitofemoral nerve

The mid inguinal point is midway between the anterior superior iliac spine and the symphysis pubis

The mid inguinal point in the surface marking for the femoral artery.

The iliacus lies posterior to the femoral nerve in the femoral triangle. The femoral sheath lies anterior to the iliacus and
pectineus muscles.
Gluteal region
Gluteal muscles

 Gluteus maximus: inserts to gluteal tuberosity of the femur and iliotibial tract
 Gluteus medius: attach to lateral greater trochanter
 Gluteus minimis: attach to anterior greater trochanter
 All extend and abduct the hip

Deep lateral hip rotators

 Piriformis
 Gemelli
 Obturator internus
 Quadratus femoris

Mnemonic for muscle attachment on greater trochanter is POGO:

 Piriformis
 Obturator internus
 Gemelli
 Obturator externus

The quadratus femoris fibres pass laterally to be inserted into the quadrate tubercle on the intertrochanteric
crest of the femur. The other muscles all insert on the trochanteric fossa lying medial to the greater trochanter.

Nerves
 Gluteus medius
 Gluteus minimis
Superior gluteal nerve (L4,L5, S1)  Tensor fascia lata

Inferior gluteal nerve (L5, S1, S2) Gluteus maximus

The inferior gluteal artery runs on the deep surface of the gluteus maximus muscle. It is a branch of the internal iliac
artery. It is commonly divided during the posterior approach to the hip joint .

Damage to the superior gluteal nerve will result in the patient developing a Trendelenberg gait. Affected patients are
unable to abduct the thigh at the hip joint. During the stance phase, the weakened abductor muscles allow the pelvis to
tilt down on the opposite side. To compensate, the trunk lurches to the weakened side to attempt to maintain a level
pelvis throughout the gait cycle. The pelvis sags on the opposite side of the lesioned superior gluteal nerve.

The inferior gluteal artery arises from the anterior trunk of the internal iliac artery
The superior gluteal artery arises from the posterior trunk of the internal iliac artery
Superior gluteal nerve

 Arises from dorsal surface of the sacral plexus (L4, L5, S1)
 Passes into gluteal region together with superior gluteal vessels
 Supplies gluteus medius and minimus

Inferior gluteal nerve

 Arises from dorsal surface of sacral plexus (L5, S1 and S2)

 Runs medial to the posterior femoral cutaneous nerve
 Enters gluteal region at inferior border of piriformis
 Supplies gluteus maximus

Foot- anatomy
Arches of the foot
The foot is conventionally considered to have two arches.

 The longitudinal arch is higher on the medial than on the lateral side. The posterior part of the calcaneum forms
a posterior pillar to support the arch.
o The lateral part of this structure passes via the cuboid bone and the lateral two metatarsal bones.
o The medial part of this structure is more important. The head of the talus marks the summit of this
arch, located between the sustentaculum tali and the navicular bone. The anterior pillar of the medial
arch is composed of the navicular bone, the three cuneiforms and the medial three metatarsal bones.
 The transverse arch is situated on the anterior part of the tarsus and the posterior part of the metatarsus. The
cuneiforms and metatarsal bases narrow inferiorly, which contributes to the shape of the arch.

Intertarsal joints

Formed by the cylindrical facet on the lower surface of the body of the talus and the posterior
facet on the upper surface of the calcaneus. The facet on the talus is concave anteroposteriorly,
Sub talar joint
the other is convex. The synovial cavity of this joint does not communicate with any other
joint.

Talocalcaneonavicular The anterior part of the socket is formed by the concave articular surface of the navicular bone,
joint posteriorly by the upper surface of the sustentaculum tali. The talus sits within this socket

Highest point in the lateral part of the longitudinal arch. The lower aspect of this joint is
Calcaneocuboid joint
reinforced by the long plantar and plantar calcaneocuboid ligaments.

The talocalcaneonavicular joint and the calcaneocuboid joint extend across the tarsus in an
Transverse tarsal joint irregular transverse plane, between the talus and calcaneus behind and the navicular and
cuboid bones in front. This plane is termed the transverse tarsal joint.

Formed between the convex anterior surface of the navicular bone and the concave surface of
Cuneonavicular joint
the the posterior ends of the three cuneiforms.

Intercuneiform joints Between the three cuneiform bones.

Between the circular facets on the lateral cuneiform bone and the cuboid. This joint contributes
Cuneocuboid joint
to the tarsal part of the transverse arch.
A detailed knowledge of the joints is not required for MRCS Part A. However, the contribution they play to the overall
structure of the foot should be appreciated

Ligaments of the ankle joint and foot

Muscles of the foot

Nerve
Muscle Origin Insertion Action
supply

Medial side of the Medial

Abductor Medial side of the calcaneus, flexor
base of the proximal plantar Abducts the great toe
hallucis retinaculum, plantar aponeurosis
phalanx nerve

Via 4 tendons into

Flexor Medial Flexes all the joints of the lateral 4
Medial process of the calcaneus, plantar the middle
digitorum plantar toes except for the
eponeurosis. phalanges of the
brevis nerve interphalangeal joint.
lateral 4 toes.

Together with flexor

digit minimi brevis
Abductor Lateral
From the tubercle of the calcaneus and into the lateral side Abducts the little toe at the
digit plantar
from the plantar aponeurosis of the base of the metatarsophalangeal joint
minimi nerve
proximal phalanx of
the little toe

From the medial side of the plantar Into the proximal

Flexor surface of the cuboid bone, from the phalanx of the great Medial
Flexes the metatarsophalangeal
hallucis adjacent part of the lateral cuneiform toe, the tendon plantar
joint of the great toe.
brevis bone and from the tendon of tibialis contains a sesamoid nerve
posterior. bone

Arises from two heads. The oblique head

arises from the sheath of the peroneus
longus tendon, and from the plantar
Lateral side of the
surfaces of the bases of the 2nd, 3rd and Lateral Adducts the great toe towards the
Adductor base of the proximal
4th metatarsal bones. The transverse plantar second toe. Helps maintain the
hallucis phalanx of the great
head arises from the plantar surface of nerve transverse arch of the foot.
toe.
the lateral 4 metatarsophalangeal joints
and from the deep transverse metatarsal
ligament.

Via four thin

tendons which run Extend the
forward and metatarsophalangeal joint of
medially to be the medial four toes. It is unable
Extensor On the dorsal surface of the foot from the
inserted into the Deep to extend the interphalangeal
digitorum upper surface of the calcaneus and its
medial four toes. peroneal
brevis associated fascia joint without the
The lateral three
tendons join with assistance of the
hoods of extensor lumbrical muscles.
digitorum longus.
Nerves in the foot

Lateral plantar nerve

Passes anterolaterally towards the base of the 5th metatarsal between flexor digitorum brevis and flexor accessorius.
On the medial aspect of the lateral plantar artery. At the base of the 5th metatarsal it splits into superficial and deep
branches.

Medial plantar nerve

Passes forwards with the medial plantar artery under the cover of the flexor retinaculum to the interval between
abductor hallucis and flexor digitorum brevis on the sole of the foot.

Plantar arteries
Arise under the cover of the flexor retinaculum, midway between the tip of the medial malleolus and the most
prominent part of the medial side of the heel.

 Medial plantar artery. Passes forwards medial to medial plantar nerve in the space between abductor hallucis
and flexor digitorum brevis.Ends by uniting with a branch of the 1st plantar metatarsal artery.
 Lateral plantar artery. Runs obliquely across the sole of the foot. It lies lateral to the lateral plantar nerve. At
the base of the 5th metatarsal bone it arches medially across the foot on the metatarsals

Dorsalis pedis artery

This vessel is a direct continuation of the anterior tibial artery. It commences on the front of the ankle joint and runs to
the proximal end of the first metatarsal space. Here is gives off the arcuate artery and continues forwards as the
first dorsal metatarsal artery. It is accompanied by two veins throughout its length. It is crossed by the extensor
hallucis brevis

Hip joint

 Head of femur articulates with acetabulum of the pelvis

 Both covered by articular hyaline cartilage
 The acetabulum forms at the union of the ilium, pubis, and ischium
 The triradiate cartilage (Y-shaped growth plate) separates the pelvic bones
 The acetabulum holds the femoral head by the acetabular labrum
 Normal angle between femoral head and shaft is 130o

Intracapsular Ligaments

 Transverse ligament: joints anterior and posterior ends of the articular cartilage
 Head of femur ligament (ligamentum teres): acetabular notch to the fovea. Contains arterial supply to head of
femur in children.

Extracapsular ligaments

 Iliofemoral ligament: inverted Y shape. Strongest lig. in the human body. Anterior iliac spine to the
trochanteric line
 Pubofemoral ligament: acetabulum to lesser trochanter
 Ischiofemoral ligament: posterior support. Ischium to greater trochanter.
Blood supply
Medial circumflex femoral (most important) and lateral circumflex femoral arteries (Branches of profunda
femoris). Also from the inferior gluteal artery. These form an anastomosis and travel to up the femoral neck to supply
the head.

sciatic foramina

Structures passing through the lesser and greater sciatic foramina (medial to lateral): PIN

 Pudendal nerve
 Internal pudendal artery
 Nerve to obturator internus

Popliteal fossa
Boundaries of the popliteal fossa

Laterally Biceps femoris above, lateral head of gastrocnemius and plantaris below

Medially Semimembranosus and semitendinosus above, medial head of gastrocnemius below

Floor Popliteal surface of the femur, posterior ligament of knee joint and popliteus muscle

Roof Superficial and deep fascia

Contents

 Popliteal artery and vein

 Small saphenous vein
 Common peroneal nerve
 Tibial nerve
 Posterior cutaneous nerve of the thigh
 Genicular branch of the obturator nerve( from posterior division)
 Lymph nodes

The contents of the popliteal fossa from medial to lateral are: AVN
Popliteal artery deepest
Popliteal vein
Tibial nerve most superficial
Common peroneal nerve most superficial

The sural nerve is a branch of the tibial nerve and usually arises at the inferior aspect of the popliteal fossa. However,
its anatomy is variable.

Biceps femoris

The biceps femoris is commonly injured in sports that require explosive bending of the knee as seen in sprinting,
especially if the athlete has not warmed up first. Avulsion most commonly occurs where the long head attaches to
the ischial tuberosity. Injuries to biceps femoris are more common than to the other hamstrings.

The biceps femoris is one of the hamstring group of muscles located in the posterior upper thigh. It has two heads.

Long head

Origin Ischial tuberosity

Insertion Fibular head

Action Knee flexion, lateral rotation tibia, extension hip

Innervation Tibial division of sciatic nerve (L5, S1, S2)

Arterial supply Profunda femoris artery, inferior gluteal artery, and the superior muscular branches of popliteal artery

Short head

Origin Lateral lip of linea aspera, lateral supracondylar ridge of femur

Insertion Fibular head

Action Knee flexion, lateral rotation tibia

Innervation Common peroneal division of sciatic nerve (L5, S1, S2)

Arterial supply Profunda femoris artery, inferior gluteal artery, and the superior muscular branches of popliteal artery

Saphenous vein
The sural nerve is related to the short saphenous vein below the knee and for this reason full length stripping of the
vein is no longer advocated.

Long saphenous vein

This vein may be harvested for bypass surgery, or removed as treatment for varicose veins with saphenofemoral
junction incompetence.

 Originates at the 1st digit where the dorsal vein merges with the dorsal venous arch of the foot
 Passes anterior to the medial malleolus and runs up the medial side of the leg
 At the knee, it runs over the posterior border of the medial epicondyle of the femur bone
 Then passes laterally to lie on the anterior surface of the thigh before entering an opening in the fascia lata
called the saphenous opening
 It joins with the femoral vein in the region of the femoral triangle at the saphenofemoral junction

Tributaries

 Medial marginal
 Superficial epigastric
 Superficial iliac circumflex
  Superficial &deep external pudendal veins

The deep external pudendal artery runs under/ inferiorly the long saphenous vein close to its origin and may be
injured. It is at greatest risk of injury during the flush ligation of the saphenofemoral junction. Provided an injury is
identified and vessel ligated, injury is seldom associated with any serious adverse sequelae.

Short saphenous vein

 Originates at the 5th digit where the dorsal vein merges with the dorsal venous arch of the foot, which
attaches to the great saphenous vein.
 It passes around the lateral aspect of the foot ( inferior and posterior to the lateral malleolus) and runs
along the posterior aspect of the leg (with the sural nerve)
 Passes between the heads of the gastrocnemius muscle, and drains into the popliteal vein, approximately at or
above the level of the knee joint.

Femoral nerve
Root values L2, 3, 4

 Pectineus
 Sartorius
Innervates  Quadriceps femoris
 Vastus lateralis/medialis/intermedius
 Rectus femoris

 Medial cutaneous nerve of thigh

Branches  Saphenous nerve
 Intermediate cutaneous nerve of thigh
Path
Penetrates psoas major and exits the pelvis by passing under the inguinal ligament to enter the femoral triangle, lateral
to the femoral artery and vein.

Mnemonic for femoral nerve supply

(don't) M I S V Q Scan for PE

M edial cutaneous nerve of the thigh
I ntermediate cutaneous nerve of the thigh
S aphenous nerve

V astus
Q uadriceps femoris
S artorius

PE ectineus
Femoral Nerve:

Anterior division→ cutaneous + sartorius

Posterior division → rest muscles

Lateral cutaneous nerve of the thigh

 Cutaneous nerve arising from posterior surface of the second and third lumbar ventral rami
 Emerges from the lateral border of psoas major anterior to the iliac crest, and passes between iliacus and
iliac fascia
 Enters thigh posterior to the lateral end of the inguinal ligament, medial to the anterior superior iliac spine
 It pierces the fascia lata 10cm inferior to the anterior superior iliac spine and divides into 2 branches
o Anterior branch supplies skin and fascia of the anterolateral surface of the knee
o Smaller posterior branch supplies the skin and fascia on the lateral part of the upper leg between the
greater trochanter and distal third of the thigh

The lateral cutaneous nerve supplies sensation to the anterior and lateral aspect of the thigh. Entrapment is commonly
due to intra and extra pelvic causes. Treatment involves local anaesthetic injections.

structures posterior to the medial malleolus

Tom Dick And Nervous Harry

T ibialis posterior tendon

flexor Digitorum longus
A rtery
N erve
H allucis longus
Adductor canal

 Also called Hunter's or subsartorial canal

 Immediately distal to the apex of the femoral triangle, lying in the middle third of the thigh. Canal
terminates at the adductor hiatus.

Borders Contents

Saphenous nerve

Laterally Vastus medialis muscle Nerve to vastus medialis

Posterior br of obturator nerve

Posteriorly Adductor longus, adductor magnus Superficial femoral artery

Roof Sartorius Superficial femoral vein

Lower limb- Muscular compartments

Anterior compartment

Muscle Nerve Action

Tibialis anterior Deep peroneal nerve Dorsiflexes ankle joint, inverts foot

Extensor digitorum longus Deep peroneal nerve Extends lateral four toes, dorsiflexes ankle joint

Peroneus tertius Deep peroneal nerve Dorsiflexes ankle, everts foot

Extensor hallucis longus Deep peroneal nerve Dorsiflexes ankle joint, extends big toe

Peroneal compartment

Muscle Nerve Action

Peroneus longus Superficial peroneal nerve Everts foot, assists in plantar flexion

Peroneus brevis Superficial peroneal nerve Plantar flexes the ankle joint

Superficial posterior compartment

<muscle< b=""></muscle<> Nerve Action

Gastrocnemius Tibial nerve Plantar flexes the foot, may also flex the knee

Soleus Tibial nerve Plantar flexor

Deep posterior compartment

Muscle Nerve Action

Flexor digitorum longus Tibial Flexes the lateral four toes

Flexor hallucis longus Tibial Flexes the great toe

Tibialis posterior Tibial Plantar flexor, inverts the foot

Foot- Cutaneous sensation

Region Nerve

Lateral border Sural

Dorsum (not 1st web space) Superficial peroneal

1st Web space Deep peroneal

Extremities of toes Medial and lateral plantar nerves

Proximal plantar Tibial

Medial plantar Medial plantar nerve

Lateral plantar (inferior aspect) Lateral plantar nerve

The sural nerve supplies the lateral aspect of the foot. It runs alongside the short saphenous vein and may be injured in
short saphenous vein surgery.

Genitofemoral nerve
Supplies
Small area of the upper medial thigh.

Path

 Arises from the first and second lumbar nerves.

 Passes obliquely through psoas major, and emerges from its medial border opposite the fibrocartilage between
the third and fourth lumbar vertebrae.
 It then descends on the surface of psoas major, under cover of the peritoneum
 Divides into genital and femoral branches.
 The genital branch passes through the inguinal canal, within the spermatic cord, to supply the skin and fascia of
the scrotum. The femoral branch enters the thigh posterior to the inguinal ligament, lateral to the femoral
artery. It supplies an area of skin and fascia over the femoral triangle.
 It may be injured during abdominal or pelvic surgery, or during inguinal hernia repairs.

The motor and sensory fibres of the genitofemoral nerve are tested in the cremasteric reflex. A small contribution is
also played by the ilioinguinal nerve and thus the reflex may be lost following an inguinal hernia repair.
Superficial peroneal nerve
Supplies

 Lateral compartment of leg: peroneus longus, peroneus brevis (action: eversion and plantar flexion)
 Sensation over dorsum of the foot (except the first web space, which is innervated by the deep peroneal nerve)

Path

 Passes between peroneus longus and peroneus brevis along the length of the proximal one third of the fibula
 10-12 cm above the tip of the lateral malleolus, the superficial peroneal nerve pierces the fascia
 6-7 cm distal to the fibula, the superficial peroneal nerve bifurcates into intermediate and medial dorsal
cutaneous nerves

Knee joint
The knee joint is a synovial joint, the largest and most complicated. It consists of two condylar joints between the femur
and tibia and a sellar joint between the patella and the femur. The tibiofemoral articular surfaces are incongruent,
however, this is improved by the presence of the menisci. The degree of congruence is related to the anatomical
position of the knee joint and is greatest in full extension.

Knee joint compartments

 Comprised of the patella/femur joint, lateral and medial compartments (between femur
condyles and tibia)
Tibiofemoral  Synovial membrane and cruciate ligaments partially separate the medial and lateral
compartments

 Ligamentum patellae
Patellofemoral  Actions: provides joint stability in full extension

Fibrous capsule
The capsule of the knee joint is a complex, composite structure with contributions from adjacent tendons.

The capsule does not pass proximal to the patella. It blends with the tendinous expansions of vastus
Anterior fibres
medialis and lateralis

Posterior These fibres are vertical and run from the posterior surface of the femoral condyles to the posterior
fibres aspect of the tibial condyle

Attach to the femoral and tibial condyles beyond their articular margins, blending with the tibial
Medial fibres
collateral ligament

Lateral fibres Attach to the femur superior to popliteus, pass over its tendon to head of fibula and tibial condyle

Bursae
  Subcutaneous prepatellar bursa; between patella and skin
 Deep infrapatellar bursa; between tibia and patellar ligament
Anterior  Subcutaneous infrapatellar bursa; between distal tibial tuberosity and skin
 Suprapatellar bursa

 Bursa between lateral head of gastrocnemius and joint capsule

Laterally  Bursa between fibular collateral ligament and tendon of biceps femoris
 Bursa between fibular collateral ligament and tendon of popliteus

 Bursa between medial head of gastrocnemius and the fibrous capsule

 Bursa between tibial collateral ligament and tendons of sartorius, gracilis and semitendinosus
Medially  Bursa between the tendon of semimembranosus and medial tibial condyle and medial head of
gastrocnemius

Posterior Highly variable and inconsistent

Ligaments

Medial
collateral Medial epicondyle femur to medial tibial condyle: valgus stability
ligament

Lateral
collateral Lateral epicondyle femur to fibula head: varus stability
ligament

Anterior
cruciate Anterior tibia to lateral intercondylar notch femur: prevents tibia sliding anteriorly
ligament

Posterior tibia to medial intercondylar notch femur: prevents tibia sliding posteriorly. The posterior

Posterior cruciate ligament is separated from the popliteal vessels at its origin by the oblique
cruciate popliteal ligament.It is attached above to the upper margin of the intercondyloid fossa and
ligament posterior surface of the femur close to the articular margins of the condyles, and below to the posterior
margin of the head of the tibia. The transverse ligament is located anteriorly.

Patellar
Central band of the tendon of quadriceps femoris, extends from patella to tibial tuberosity
ligament

Menisci
Medial and lateral menisci compensate for the incongruence of the femoral and tibial condyles.
Composed of fibrous tissue.
Medial meniscus is attached to the tibial collateral ligament.
Lateral meniscus is attached to the loose fibres at the lateral edge of the joint and is separate from the fibular collateral
ligament. The lateral meniscus is crossed by the popliteus tendon.
Nerve supply
The knee joint is supplied by the femoral, tibial and common peroneal divisions of the sciatic and by a branch from the
obturator nerve. Hip pathology pain may be referred to the knee.

Blood supply
Genicular branches of the femoral artery, popliteal and anterior tibial arteries all supply the knee joint.

The posterior aspect of the patella is intrasynovial and the knee itself comprises the largest synovial joint in
the body. It may swell considerably following trauma such as ACL injury. Which may be extremely painful owing to rich
innervation from femoral, sciatic and ( a smaller) contribution from the obturator nerve. During full extension all
ligaments are taut and the knee is locked.

Fascial compartments of the leg

Compartments of the thigh

Formed by septae passing from the femur to the fascia lata.

Compartment Nerve Muscles Blood supply

 Iliacus
 Sartorius
Anterior compartment Femoral  Quadriceps femoris Femoral artery

 Adductor longus/magnus (adductor

part)/brevis
 Gracilis Profunda femoris artery and
Medial compartment Obturator
 Obturator externus obturator artery

 Semimembranosus
 Semitendinosus
Posterior compartment (2  Biceps femoris Branches of Profunda femoris
Sciatic
layers)  Adductor magnus (ischial part) artery

Compartments of the lower leg

Separated by the interosseous membrane (anterior and posterior compartments), anterior fascial septum (separate
anterior and lateral compartments) and posterior fascial septum (separate lateral and posterior compartments)

Compartment Nerve Muscles Blood supply

 Tibialis anterior
 Extensor digitorum longus
Anterior Deep peroneal  Extensor hallucis longus Anterior tibial artery
compartment nerve  Peroneus tertius

 Muscles: deep and superficial compartments

Posterior Tibial (separated by deep transverse fascia) Posterior tibial
compartment  Deep: Flexor hallucis longus, Flexor digitalis longus, Peroneal artery
Tibialis posterior, Popliteus
 Compartment Nerve Muscles Blood supply
 Superficial: Gastrocnemius, Soleus, Plantaris

 Peroneus longus/brevis
Lateral Superficial
compartment peroneal

Femoral canal
The femoral canal lies at the medial aspect of the femoral sheath. The femoral sheath is a fascial tunnel containing both
the femoral artery laterally and femoral vein medially. The canal lies medial to the vein.

Borders of the femoral canal

Laterally Femoral vein

Medially Lacunar ligament

Anteriorly Inguinal ligament

Posteriorly Pectineal ligament

Image showing dissection of femoral canal

Contents

 Lymphatic vessels
 Cloquet's lymph node

Physiological significance
Allows the femoral vein to expand to allow for increased venous return from the lower limbs.

Pathological significance
As a potential space, it is the site of femoral hernias. The relatively tight neck places these at high risk of strangulation.

Femoral hernias exit the femoral canal below and lateral to the pubic tubercle. Femoral hernia occur mainly in women
due to their difference in pelvic anatomy. They are at high risk of strangulation and therefore should be repaired.

Lateral malleolus
Structures posterior to the lateral malleolus and superficial to superior peroneal retinaculum

 Sural nerve
 Short saphenous vein

Structures posterior to the lateral malleolus and deep to superior peroneal retinaculum
  Peroneus longus tendon
 Peroneus brevis tendon

The calcaneofibular ligament is attached at the lateral malleolus

Deep peroneal nerve

Origin From the common peroneal nerve, at the lateral aspect of the fibula, deep to peroneus longus

Nerve root
L4, L5, S1, S2
values
 Pierces the anterior intermuscular septum to enter the anterior compartment of the lower leg
(accompanied by anterior tibial artery which enters the anterior compartment from an opening
Course and at the sup part of interosseous membrane))
relation  Passes anteriorly down to the ankle joint, midway between the two malleoli

Terminates In the dorsum of the foot

 Tibialis anterior
 Extensor hallucis longus
 Extensor digitorum longus
Muscles
 Peroneus tertius
innervated
 Extensor digitorum brevis

Cutaneous
Web space of the first and second toes
innervation
 Dorsiflexion of ankle joint
 Extension of all toes (extensor hallucis longus and extensor digitorum longus)
Actions  Eversion of the foot

After its bifurcation past the ankle joint, the lateral branch of the deep peroneal nerve innervates the extensor
digitorum brevis and the extensor hallucis brevis
The medial branch supplies the web space between the first and second digits.

The deep peroneal nerve lies in the anterior muscular compartment of the lower leg and can be compromised by
compartment syndrome affecting this area. It provides cutaneous sensation to the first web space. The superficial
peroneal nerve provides more lateral cutaneous innervation.

Adductor longus
Origin Anterior body of pubis

Insertion Middle third of linea aspera

Action Adducts and flexes the thigh, medially rotate the hip

Innervation Anterior division of obturator nerve (L2, L3, L4)

Greater sciatic foramen
Contents
 Sciatic Nerve
 Superior and Inferior Gluteal Nerves
 Pudendal Nerve
 Posterior Femoral Cutaneous Nerve
Nerves
 Nerve to Quadratus Femoris
 Nerve to Obturator internus

 Superior Gluteal Artery and vein

 Inferior Gluteal Artery and vein
Vessels  Internal Pudendal Artery and vein

Piriformis
The piriformis is a landmark for identifying structures passing out of the sciatic notch

 Above piriformis: Superior gluteal vessels

 Below piriformis: Inferior gluteal vessels, sciatic nerve (10% pass through it, <1% above it), posterior
cutaneous nerve of the thigh

Greater sciatic foramen boundaries

Anterolaterally Greater sciatic notch of the ilium

Posteromedially Sacrotuberous ligament

Inferior Sacrospinous ligament and the ischial spine

Superior Anterior sacroiliac ligament

Structures passing between both foramina (Medial to lateral)

 Pudendal nerve
 Internal pudendal artery
 Nerve to obturator internus

Contents of the lesser sciatic foramen

 Tendon of the obturator internus

 Pudendal nerve
 Internal pudendal artery and vein
 Nerve to the obturator internus

Ankle joint
The ankle joint is a synovial joint composed of the tibia and fibula superiorly and the talus inferiorly.
Ligaments of the ankle joint

 Deltoid ligament (medially)

 Lateral collateral ligament
 Talofibular ligaments (both anteriorly and posteriorly)

The calcaneofibular ligament is separate from the fibrous capsule of the joint. The two talofibular ligaments
are fused with it.

The components of the syndesmosis are

 Antero-inferior tibiofibular ligament

 Postero-inferior tibiofibular ligament
 Inferior transverse tibiofibular ligament
 Interosseous ligament

Movements at the ankle joint

 Plantar flexion (55 degrees)

 Dorsiflexion (35 degrees)
 Inversion and eversion movements occur at the level of the sub talar joint

Nerve supply
Branches of deep peroneal and tibial nerves.

Psoas Muscle
Origin T12-L5
The deep part originates from the transverse processes of the five lumbar vertebrae, the superficial part originates from
T12 and the first 4 lumbar vertebrae.
Insertion
Lesser trochanter of the femur.

Innervation
Anterior rami of L1 to L3.

Action

Flexion and external rotation of the hip. Bilateral contraction can raise the trunk from the supine position.
Posterior tibial artery

 Larger terminal branch of the popliteal artery

 Terminates by dividing into the medial and lateral plantar arteries
 Accompanied by two veins throughout its length
 Position of the artery corresponds to a line drawn from the lower angle of the popliteal fossa, at the level of
the neck of the fibula, to a point midway between the medial malleolus and the most prominent part of the
heel

Relations of the posterior tibial artery

Proximal to distal

Tibialis posterior
Anteriorly Flexor digitorum longus
Posterior surface of tibia and ankle joint

Tibial nerve 2.5 cm distal to its origin

Fascia overlying the deep muscular layer
Posterior
Proximal part covered by gastrocnemius and soleus
Distal part covered by skin and fascia

The tibial nerve is closely related to the posterior tibial artery. The tibial nerve crosses the vessel posteriorly
(superficially) approximately 2.5cm distal to its origin. At its origin the nerve lies medial and then lateral after it
crosses the vessel as described.

Ankle reflex
The ankle reflex is elicited by tapping the Achilles tendon with a tendon hammer. It tests the S1 and S2 nerve roots. It is
typically delayed in L5 and S1 disk prolapses.

Abdomen- Pelvis
Hesselbach's triangle
Direct hernias pass through Hesselbachs triangle.

Superolaterally Epigastric vessels

Medially Lateral edge of rectus muscle

Urogenital triangle
The urogenital triangle is formed by the:

 Ischiopubic inferior rami

 Ischial tuberosities

A fascial sheet is attached to the sides, forming the inferior fascia of the urogenital diaphragm.

It transmits the urethra in males and both the urethra and vagina in females. The membranous urethra lies deep to this
structure and is surrounded by the external urethral sphincter.

Superficial to the urogenital diaphragm lies the superficial perineal pouch. The superficial perineal pouch is a
compartment bounded superficially by the superficial perineal fascia, deep by the perineal membrane (inferior fascia of
the urogenital diaphragm), and laterally by the ischiopubic ramus. In males this contains:

 Bulb of penis
 Crura of the penis/ Clitoris
 Superficial transverse perineal muscle
 Posterior scrotal /labial arteries
 Posterior scrotal/ labial nerves
 + erectile tissue
 proximal part of the spongy urethra in males
 ducts of bulburethreal gland in males
 greater vestibular glands in females

Epiploic Foramen
The epiploic foramen has the following boundaries:

Anteriorly (in the free edge of the lesser Bile duct to the right, portal vein behind and hepatic artery to the
omentum) left.

Posteriorly Inferior vena cava

Inferiorly 1st part of the duodenum

Superiorly Caudate process of the liver

During liver surgery bleeding may be controlled using a Pringles manoeuvre, this involves placing a vascular clamp across
the anterior aspect of the epiploic foramen. Thereby occluding:
  Common bile duct
 Hepatic artery
 Portal vein

Embryology of the diaphragm and diaphragmatic hernia

Embryology

The diaphragm is formed between the 5th and 7th weeks of gestation through the progressive fusion of the septum
transversum, pleuroperitoneal folds and via lateral muscular ingrowth. The muscular origins of the diaphragm are
somites located in cervical segments 3 to 5, which accounts for the long path taken by the phrenic nerve. The
components contribute to the following diaphragmatic segments:

 Septum transversum - Central tendon

 Pleuroperitoneal membranes - Parietal membranes surrounding viscera
 Cervical somites C3 to C5 - Muscular component of the diaphragm

Diaphragmatic hernia

Type of hernia Features

Anteriorly located (usually right)

Minimal compromise on lung development
Morgagni Minimal signs on antenatal ultrasound
Usually present later
Usually good prognosis

MOST COMMON

Posteriorly located (Usually Left)

Bochdalek hernia Larger defect
Often diagnosed antenatally
Associated with pulmonary hypoplasia
Poor prognosis

The posterior hernias of Bochdalek are the most common type and if not diagnosed antenatally will typically present
soon after birth with respiratory distress. The classical finding is that of a scaphoid abdomen on clinical examination
because of herniation of the abdominal contents into the chest. Bochdalek hernias are associated with a number of
chromosomal abnormalities such as Trisomy 21 and 18. Infants have considerable respiratory distress due to hypoplasia
of the developing lung. Historically this was considered to be due to direct compression of the lung by herniated viscera.
This view over simplifies the situation and the pulmonary hypoplasia occurs concomitantly with the hernial
development, rather than as a direct result of it. The pulmonary hypoplasia is associated with pulmonary hypertension
and abnormalities of pulmonary vasculature. The pulmonary hypertension renders infants at risk of right to left
shunting (resulting in progressive and worsening hypoxia).

Diagnostic work up of these infants includes chest x-rays/ abdominal ultrasound scans and cardiac echo.

Surgery forms the mainstay of treatment and both thoracic and abdominal approaches may be utilised. Following
reduction of the hernial contents a careful search needs to be made for a hernial sac as failure to recognise and correct
this will result in a high recurrence rate. Smaller defects may be primarily closed, larger defects may require a patch to
close the defect. Malrotation of the viscera is a recognised association and may require surgical correct at the
same procedure (favoring an abdominal approach).

The mortality rate is 50-75% and is related to the degree of lung compromise and age at presentation (considerably
better in infants >24 hours old).

Gastroduodenal artery
Supplies

Pylorus, proximal part of the duodenum, and indirectly to the pancreatic head (via the anterior and posterior superior
pancreaticoduodenal arteries)

Path

The gastroduodenal artery most commonly arises from the common hepatic artery of the coeliac trunk. It terminates by
bifurcating into the right gastroepiploic artery and the superior pancreaticoduodenal artery

The gastroduodenal artery arises at the superior part of the duodenum and descends behind it to terminate at its lower
border. It terminates by dividing into the right gastro-epiploic artery and the superior pancreaticoduodenal artery. The
right gastro-opiploic artery passes to the left and passes between the layers of the greater omentum to anastomose
with the left gastro-epiploic artery.

Penile erection
Physiology of erection
 Sympathetic nerves originate from T11-L2 and parasympathetic nerves from S2-4 join to form
pelvic plexus.
 Parasympathetic discharge causes erection, sympathetic discharge causes ejaculation and
Autonomic
detumescence.

Somatic Supplied by dorsal penile and pudendal nerves. Efferent signals are relayed from Onufs nucleus (S2-4) to
nerves innervate ischiocavernosus and bulbocavernosus muscles.

Autonomic discharge to the penis will trigger the veno-occlusive mechanism which triggers the flow of arterial blood
into the penile sinusoidal spaces. As the inflow increases the increased volume in this space will secondarily lead to
compression of the subtunical venous plexus with reduced venous return. During the detumesence phase the arteriolar
constriction will reduce arterial inflow and thereby allow venous return to normalise.

Priapism
Prolonged unwanted erection, in the absence of sexual desire, lasting more than 4 hours.

Classification of priapism

Low flow priapism Due to veno-occlusion (high intracavernosal pressures).

 Most common type

 Often painful
  Often low cavernosal flow
 If present for >4 hours requires emergency treatment

Due to unregulated arterial blood flow.

High flow priapism
 Usually presents as semi rigid painless erection

Recurrent priapism Typically seen in sickle cell disease, most commonly of high flow type.

Causes

 Intracavernosal drug therapies (e.g. for erectile dysfunction>

 Blood disorders such as leukaemia and sickle cell disease
 Neurogenic disorders such as spinal cord transection
 Trauma to penis resulting in arterio-venous malformations

Tests

 Exclude sickle cell/ leukaemia

 Consider blood sampling from cavernosa to determine whether high or low flow (low flow is often hypoxic)

Management

 Ice packs/ cold showers

 If due to low flow then blood may be aspirated from copora or try intracavernosal alpha adrenergic agonists.
 Delayed therapy of low flow priapism may result in erectile dysfunction.

The penis takes autonomic nerves from the nervi erigentes that lie near the seminal vesicles. These may be
compromised by direct surgical trauma (such as use of diathermy in this area) and also by radiotherapy that is used in
these patients pre operatively. The result is that up to 50% of patients may develop impotence following rectal
cancer surgery.

Adrenal gland embryology

First detected at 6 weeks' gestation, the adrenal cortex is derived from the mesoderm of the posterior abdominal wall.
Steroid secretion from the fetal cortex begins shortly thereafter. Adult-type zona glomerulosa and fasciculata are
detected in fetal life but make up only a small proportion of the gland, and the zona reticularis is not present at all.
The fetal cortex predominates throughout fetal life. The adrenal medulla is of ectodermal origin, arising from neural
crest cells that migrate to the medial aspect of the developing cortex.

The fetal adrenal gland is relatively large. At 4 months' gestation, it is 4 times the size of the kidney; however, at
birth, it is a third of the size of the kidney. This occurs because of the rapid regression of the fetal cortex at birth. It
disappears almost completely by age 1 year; by age 4-5 years, the permanent adult-type adrenal cortex has fully
developed.

Anatomic anomalies of the adrenal gland may occur. Because the development of the adrenals is closely associated
with that of the kidneys, agenesis of an adrenal gland is usually associated with ipsilateral agenesis of the kidney, and
fused adrenal glands (whereby the 2 glands join across the midline posterior to the aorta) are also associated with a
fused kidney.

Adrenal hypoplasia occurs in the following 2 forms: (1) hypoplasia or absence of the fetal cortex with a poorly formed
medulla and (2) disorganized fetal cortex and medulla with no permanent cortex present. Adrenal heterotopia describes
a normal adrenal gland in an abnormal location, such as within the renal or hepatic capsules. Accessory adrenal tissue
(adrenal rests), which is usually comprised only of cortex but seen combined with medulla in some cases, is most
commonly located in the broad ligament or spermatic cord but can be found anywhere within the abdomen. Even
intracranial adrenal rests have been reported

In an ectopic kidney, the adrenal gland is most likely to be found in its normal location

Liver
Structure of the liver
 Supplied by right hepatic artery
 Contains Couinaud segments V to VIII (-/+Sg I)
Right lobe

 Supplied by the left hepatic artery

 Contains Couinaud segments II to IV (+/- Sg1)
Left lobe

 Part of the right lobe anatomically, functionally is part of the left

 Couinaud segment IV
 Porta hepatis lies behind
Quadrate lobe  On the right lies the gallbladder fossa
 On the left lies the fossa for the umbilical vein

 Supplied by both right and left hepatic arteries

 Couinaud segment I
 Lies behind the plane of the porta hepatis
Caudate lobe  Anterior and lateral to the inferior vena cava
 Bile from the caudate lobe drains into both right and left hepatic ducts

Between the liver lobules are portal canals which contain the portal triad: Hepatic Artery, Portal Vein, tributary of
Bile Duct.

Relations of the liver

Anterior Postero inferiorly

Diaphragm Oesophagus

Xiphoid process Stomach

Duodenum

Hepatic flexure of colon

Right kidney
 Gallbladder

Inferior vena cava

Porta hepatis

Postero inferior surface, it joins nearly at right angles with the left sagittal fossa, and separates the caudate
Location
lobe behind from the quadrate lobe in front
 Common hepatic duct
 Hepatic artery
 Portal vein
Transmits  Sympathetic and parasympathetic nerve fibres
 Lymphatic drainage of the liver (and nodes)

Ligaments
 2 layer fold peritoneum from the umbilicus to anterior liver surface
 Contains ligamentum teres (remnant umbilical vein)
Falciform ligament  On superior liver surface it splits into the coronary and left triangular ligaments

Ligamentum teres Joins the left branch of the portal vein in the porta hepatis

Ligamentum venosum Remnant of ductus venosus

Arterial supply

 Hepatic artery
 The portal vein transports 70% of the blood supply to the liver, while the hepatic artery provides 30%. The
portal vein contains the products of digestion. The arterial and venous blood is dispersed by sinusoids to the
central veins of the liver lobules; these drain into the hepatic veins and then into the IVC. The caudate lobe
drains directly into the IVC rather than into other hepatic veins.

Venous

 Hepatic veins
 Portal vein

Nervous supply

 Sympathetic and parasympathetic trunks of coeliac plexus

Left colon
Position
  As the left colon passes inferiorly its posterior aspect becomes extraperitoneal, and the ureter and gonadal
vessels are close posterior relations that may become involved in disease processes
 At a level of L3-4 (variable) the left colon becomes the sigmoid colon and wholly intraperitoneal once again
 The sigmoid colon is a highly mobile structure and may even lie on the right side of the abdomen
 It passes towards the midline, the taenia blend and this marks the transition between sigmoid
colon and upper rectum

Blood supply

 Inferior mesenteric artery

 However, the marginal artery (from the right colon) contributes, this contribution becomes clinically significant
when the IMA is divided surgically (e.g. During AAA repair)

The spleen is commonly torn by traction injuries in colonic surgery. The other structures are associated with bleeding
during colonic surgery but would not manifest themselves as blood in the paracolic gutter prior to incision of the
paracolonic peritoneal edge.

The inferior mesenteric vein drains into the splenic vein, this point of union lies close to the duodenum and this surgical
maneouvre is a recognised cause of ileus.

Beware of ureteric injury in colonic surgery.

Bucks- Colles fascia

Bucks fascia is a layer of deep fascia that covers the penis it is continuous with the external spermatic fascia and the
penile suspensory ligament. The membranous part of the urethra may partially pass through Bucks fascia as it passes
into the penis. However, the spongiose part of the urethra is contained wholly within Bucks fascia.

Scarpas fascia superficial penile fascia colles fascia

External oblique fascia external spermatic fascia bucks fascia  inferior perineal fascia/membrane
Epigastric artery
The inferior epigastric artery arises from the external iliac artery immediately above the inguinal ligament. It then passes
along the medial margin of the deep inguinal ring. From here it continues superiorly to lie behind the rectus abdominis
muscle.

Bladder
The empty bladder is contained within the pelvic cavity. It is usually a three sided pyramid. The apex of the bladder
points forwards towards the symphysis pubis and the base lies immediately anterior to the rectum or vagina. Continuous
with the apex is the median umbilical ligament, during development this was the site of the urachus.
The inferior aspect of the bladder is retroperitoneal and the superior aspect and upper posterior are covered by
peritoneum. As the bladder distends it will tend to separate the peritoneum from the fascia of transversalis. For this
reason a bladder that is distended due to acute urinary retention may be approached with a suprapubic catheter that
avoids entry into the peritoneal cavity.

The trigone is the least mobile part of the bladder and forms the site of the ureteric orifices and internal urethral
orifice. In the empty bladder the ureteric orifices are approximately 2-3cm apart, this distance may increase to 5cm in
the distended bladder.
Arterial supply

The superior and inferior vesical arteries provide the main blood supply to the bladder. These are branches of the
internal iliac artery.

Venous drainage

In males the bladder is drained by the vesicoprostatic venous plexus. In females the bladder is drained by the
vesicouterine venous plexus. In both sexes this venous plexus will ultimately drain to the internal iliac veins.

Lymphatic drainage

Lymphatic drainage is predominantly to the external iliac nodes, internal iliac and obturator nodes also form sites
of bladder lymphatic drainage.

Innervation

Parasympathetic nerve fibres innervate the bladder from the pelvic splanchnic nerves (S2-S4). Sympathetic nerve fibres
are derived from L1 and L2 via the hypogastric nerve plexuses. The parasympathetic nerve fibres will typically cause
detrusor muscle contraction and result in voiding. The muscle of the trigone is innervated by the sympathetic nervous
system. The external urethral sphincter is under conscious control. During bladder filling the rate of firing of nerve
impulses to the detrusor muscle is low and receptive relaxation occurs. At higher volumes and increased intra vesical
pressures the rate of neuronal firing will increase and eventually voiding will occur.

the hypogastric plexuses provide autonomic control of the bladder. However, voluntary control of the urethral
sphincter is provided by the pudendal nerve.
Accessory spleens
- 10% population
- 1 cm size
- locations: hilum of the spleen, tail of the pancreas, along the splenic vessels, in the gastrosplenic ligament, the
splenorenal ligament, the walls of the stomach or intestines, the greater omentum, the mesentery, the gonads

Scrotal sensation
The scrotum is innervated by the ilioinguinal nerve and the pudendal nerve.

The ilioinguinal nerve arises from L1 and pierces the internal oblique muscle. It eventually passes through the
superficial inguinal ring to innervate the anterior skin of the scrotum.

The pudendal nerve is the principal nerve of the perineum. It arises in the pelvis from 3 nerve roots. It passes through
both greater and lesser sciatic foramina to enter the perineal region. The perineal branches pass anteromedially and
divide into posterior scrotal branches. The posterior scrotal branches pass superficially to supply the skin and fascia of
the perineum. It cross communicates with the inferior rectal nerve.

Rectus abdominis

 Arises from the pubis.

 Inserts into 5th, 6th, 7th costal cartilages.
 The muscle lies in the rectal sheath, which also contains the superior and inferior epigastric artery and vein. It lies
in this muscular aponeurosis above the arcuate line BUT the aponeurosis is deficient below the arcuate line.
 Action: flexion of thoracic and lumbar spine.
 Nerve supply: anterior primary rami of T7-12.

Lymphatic drainage of the ovaries, uterus and cervix

 The ovaries drain to the para-aortic lymphatics via the gonadal vessels.
 The uterine fundus has a lymphatic drainage that runs with the ovarian vessels and may thus drain to the para-
aortic nodes. Some drainage may also pass along the round ligament to the inguinal nodes.
 The body of the uterus drains through lymphatics contained within the broad ligament to the iliac lymph
nodes.
 The cervix drains into three potential nodal stations; laterally through the broad ligament to the external iliac
nodes, along the lymphatics of the uterosacral fold to the presacral nodes and posterolaterally along
lymphatics lying alongside the uterine vessels (broad ligament) to the internal iliac nodes.

Tumours of the uterine body will tend to spread to the iliac nodes initially. Tumour expansion
crossing different nodal margins this is of considerable clinical significance, if nodal clearance is performed
during a Wertheims type hysterectomy.
Renal arteries

 The right renal artery is longer than the left renal artery
 The renal vein/artery/pelvis enter the kidney at the hilum

Relations
Right Anterior- IVC, right renal vein, the head of the pancreas, and the descending part of the duodenum

Left Anterior- left renal vein, the tail of the pancreas

Branches

 The renal arteries are direct branches off the aorta (upper border of L2- right side and L1 - left side)
 In 30% there may be accessory arteries (mainly left side). Instead of entering the kidney at the hilum, they usually
pierce the upper or lower part of the organ.
 Before reaching the hilum of the kidney, each artery divides into four or five segmental branches (renal vein
anterior and ureter posterior); which then divide within the sinus into lobar arteries supplying each pyramid and
cortex.
 Each vessel gives off some small inferior suprarenal branches to the suprarenal gland, the ureter, and the
surrounding cellular tissue and muscles.

Appendix

 Location: Base of caecum.

 Up to 10cm long.
 Mainly lymphoid tissue (Hence mesenteric adenitis may mimic appendicitis).
 Caecal taenia coli converge at base of appendix and form a longitudinal muscle cover over the appendix. This
convergence should facilitate its identification at surgery if it is retrocaecal and difficult to find (which it can be
when people start doing appendicectomies!)
  Arterial supply: Appendicular artery (branch of the ileocolic).
 It is intra peritoneal.
 derived from the midgut which is why early appendicitis may present with periumbilical pain

McBurney's point

 1/3 of the way along a line drawn from the Anterior Superior Iliac Spine to the Umbilicus

6 Positions:

 Retrocaecal 74%
 Pelvic 21%
 Postileal
 Subcaecal
 Paracaecal
 Preileal

Uterus
The non pregnant uterus resides entirely within the pelvis. The peritoneum invests the uterus and the structure is
contained within the peritoneal cavity. The blood supply to the uterine body is via the uterine artery (branch of the
internal iliac). The uterine artery passes from the inferior aspect of the uterus (lateral to the cervix) and runs alongside
the uterus. It frequently anastomoses with the ovarian artery superiorly. Inferolaterally, the ureter is a close relation
and ureteric injuries are a recognised complication when pathology brings these structures into close proximity.

The supports of the uterus include the central perineal tendon (the most important). The lateral
cervical, round and uterosacral ligaments are condensations of the endopelvic fascia and provide additional structural
support. Damage to this structure is commonly associated with the development of pelvic organ prolapse, even when
other structures are intact.
Urethral anatomy
Female urethra
The female urethra is shorter and more acutely angulated than the male urethra. It is an extra-peritoneal structure and
embedded in the endopelvic fascia. The neck of the bladder is subjected to transmitted intra-abdominal pressure and
therefore deficiency in this area may result in stress urinary incontinence. Between the layers of the urogenital
diaphragm the female urethra is surrounded by the external urethral sphincter, this is innervated by the pudendal
nerve. It ultimately lies anterior to the vaginal orifice. The entire female urethra drains to the internal iliac nodes.

Male urethra
In males the urethra is much longer and is divided into four parts.

Extremely short and lies between the bladder and prostate gland.It has a stellate lumen and is
Pre-prostatic
between 1 and 1.5cm long. Innervated by sympathetic noradrenergic fibres, as this region is composed
urethra
of striated muscles bundles they may contract and prevent retrograde ejaculation.

Prostatic This segment is wider than the membranous urethra and contains several openings for the transmission
urethra of semen (at the midpoint of the urethral crest).

Membranous Narrowest part of the urethra and surrounded by external sphincter. It traverses the perineal
urethra membrane 2.5cm postero-inferior to the symphysis pubis.
 Travels through the corpus spongiosum on the underside of the penis. It is the longest urethral
segment.It is dilated at its origin as the infrabulbar fossa and again in the glans penis as the navicular
Penile urethra
fossa. The bulbo-urethral glands open into the spongiose section of the urethra 2.5cm below the
perineal membrane.

The lymphatic drainage of the spongy urethra and the glans peni s is to the deep inguinal nodes. The prostatic and
membranous urethra drains to the internal iliac nodes.

The urothelium is transitional in nature near to the bladder and becomes squamous more distally.

The membranous urethra is the least distensible portion of the urethra and is the first site of resistance to be
encountered on inserting the catheter. This is due to the fact that it is surrounded by the external sphincter.

Inguinal canal
Location

 Above the inguinal ligament

 The inguinal canal is 4cm long
 The superficial ring is located anterior to the pubic tubercle
 The deep ring is located approximately 1.5-2cm above the half way point between the anterior superior iliac spine
and the pubic tubercle

Boundaries of the inguinal canal

 External oblique aponeurosis
 Inguinal ligament
Floor  Lacunar ligament

 Internal oblique
 Transversus abdominis
Roof

Anterior wall External oblique aponeurosis

 Transversalis fascia
 Conjoint tendon
Posterior wall

 Internal ring
 Transversalis fascia
Laterally  Fibres of internal oblique

 External ring
 Conjoint tendon
Medially

Contents

Males Spermatic cord and ilioinguinal nerve As it passes through the canal the spermatic cord has 3 coverings:
  External spermatic fascia from external oblique
aponeurosis
 Cremasteric fascia
 Internal spermatic fascia

Round ligament of uterus and ilioinguinal

Females
nerve

The external oblique aponeurosis forms the anterior wall of the inguinal canal and also the lateral edge of the
superficial inguinal ring. The rectus abdominis lies posteromedially and the transversalis posterior to this.
The ilioinguinal nerve may have been entrapped in the mesh causing a neuroma.

Superior vena cava

Drainage

 Head and neck

 Upper limbs
 Thorax
 Part of abdominal walls

Formation

 Subclavian and internal jugular veins unite to form the right and left brachiocephalic veins
 These unite to form the SVC
 Azygos vein joins the SVC before it enters the right atrium

Relations

Anterior Anterior margins of the right lung and pleura

Posteromedial Trachea and right vagus nerve

Posterior aspects of right lung and pleura

Posterolateral
Pulmonary hilum is posterior

Right lateral Right phrenic nerve and pleura

Left lateral Brachiocephalic artery and ascending aorta

Developmental variations
Anomalies of the connection of the SVC are recognised. In some individuals a persistent left sided SVC
drains into the right atrium via an enlarged orifice of the coronary sinus.
More rarely the left sided vena cava may connect directly with the superior aspect of the left atrium, usually associated
with an un-roofing of the coronary sinus.

The commonest lesion of the IVC is for its abdominal course to be interrupted, with drainage
achieved via the azygos venous system. This may occur in patients with left sided atrial isomerism.

A patient presents with superior vena caval obstruction. How many collateral circulations exist as alternative pathways
of venous return?

There are 4 collateral venous systems : Despite this, venous hypertension still occurs.
  Azygos venous system
 Internal mammary venous pathway
 Long thoracic venous system with connections to the femoral and vertebral veins (2 pathways)

Persistent left superior vena cava is the most common anomaly of the thoracic venous system. It is prevalent in 0.3%
of the population and is a benign entity of failed involution during embryogenesis.

Gallbladder

 Fibromuscular sac with capacity of 50ml

 Columnar epithelium

Relations of the gallbladder

Anterior Liver
 Covered by peritoneum
 Transverse colon
Posterior  1st part of the duodenum

Laterally Right lobe of liver

Medially Quadrate lobe of liver

Arterial supply
Cystic artery (branch of Right hepatic artery)

Venous drainage
Directly to the liver

Nerve supply
Sympathetic- mid thoracic spinal cord, Parasympathetic- anterior vagal trunk

Common bile duct

Origin Confluence of cystic and common hepatic ducts

 Medially - Hepatic artery
 Posteriorly- Portal vein
Relations at origin

 Duodenum - anteriorly
 Pancreas - medially and laterally
Relations distally  Right renal vein - posteriorly

Arterial supply Branches of hepatic artery and retroduodenal branches of gastroduodenal artery

Hepatobiliary triangle

Medially Common hepatic duct

Inferiorly Cystic duct

Superiorly Inferior edge of liver

Contents Cystic artery

Do not confuse the blood supply of the bile duct with that of the cystic duct.

The bile duct has an axial blood supply which is derived from the (proper)hepatic artery and from retroduodenal
branches of the gastroduodenal artery. Unlike the liver there is no contribution by the portal vein to the blood
supply of the bile duct.

Damage to the hepatic artery during a difficult cholecystectomy is a recognised cause of bile duct
strictures. In this scenario the distal vessels have been removed as the patient is undergoing a resection.

Rectum
The rectum is supplied by 3 main vessels

 Superior rectal artery from inferior mesenteric artery

 Middle rectal artery from the internal iliac artery
 Inferior rectal artery from the internal pudendal artery

The rectum is approximately 12 cm long. It is a capacitance organ. It has both intra and extraperitoneal components.
The transition between the sigmoid colon is marked by the disappearance of the tenia coli.The extra peritoneal rectum
is surrounded by mesorectal fat that also contains lymph nodes. This mesorectal fatty layer is removed surgically during
rectal cancer surgery (Total Mesorectal Excision). The fascial layers that surround the rectum are important clinical
landmarks, anteriorly lies the fascia of Denonvilliers. Posteriorly lies Waldeyers fascia.

Fascial layers surrounding the rectum:

 Anteriorly lies the fascia of Denonvilliers

 Posteriorly lies Waldeyers fascia

Extra peritoneal rectum

 Posterior upper third

 Posterior and lateral middle third
 Whole lower third

Relations

Rectovesical pouch
Bladder
Anteriorly (Males) Prostate
Seminal vesicles

Nervi erigendes

Recto-uterine pouch (Douglas)

Anteriorly (Females) Cervix
Vaginal wall

Sacrum
Posteriorly Coccyx
Middle sacral artery

Levator ani
Laterally
Coccygeus
Arterial supply
Superior rectal artery

Venous drainage
Venous drainage is via the corresponding superior, middle and inferior rectal veins. The superior rectal vein empties
into the portal venous system, whilst the middle and inferior rectal veins empty into the systemic venous system.
Anastomoses between the portal and systemic veins are located in the wall of anal canal, making this a site of
portocaval anastomosis.

Lymphatic drainage

 Mesorectal lymph nodes (superior to dentate line). Lymphatic drainage of the rectum is via the pararectal
lymph nodes, which drain into the inferior mesenteric nodes. Additionally, the lymph from the lower aspect of
the rectum drains directly into the internal iliac lymph nodes.
 Inguinal nodes (inferior to dentate line)
 External
oblique muscle
External oblique forms the outermost muscle of the three muscles comprising the anterolateral aspect of the abdominal
wall. Its aponeurosis comprises the anterior wall of the inguinal canal.

Branches Level Paired Type

Inferior phrenic T12 (Upper border) Yes Parietal
Coeliac T12 No Visceral
Superior mesenteric L1 No Visceral
Middle suprarenal L1 Yes Visceral
Renal L1-L2 Yes Visceral
Gonadal L2 Yes Visceral
Lumbar L1-L4 Yes Parietal
Inferior mesenteric L3 No Visceral
Median sacral L4 No Parietal
Common iliac L4 Yes Terminal

The left renal vein lies behind of the SMA as it branches off the aorta. Whilst juxtarenal AAA may sometimes require the
division of the left renal vein, direct involvement of the SMA may require a hybrid surgical bypass and subsequent
endovascular occlusion.

The median sacral artery leaves the aorta a little above its bifurcation. It descends in the midline anterior to L4 and L5.

Spleen- function
The spleen is a reticuloendothelial organ, it develops in the dorsal mesogastrium at around 5 weeks gestation. At this
stage it has an irregular surface and migrates to the left upper quadrant over the following weeks. In most cases the
irregular hillocks on the spleen surface unify, when they fail to do so, accessory spleens may develop and are found in
around 20% of people.

The spleen is composed of both red and white pulp. In the red pulp, blood filled venous sinuses are found. In the white
pulp, reticuloendothelial cords and white lymphoid follicles are present. Blood flows into the spleen at a rate of 150ml
per minute. As blood passes through the spleen, the erythrocytes have to pass through fine endothelial fenestrations,
older and less deformable erythrocytes are trapped during this process and destroyed. Red cell inclusion bodies such as
parasites or residual nuclear components are split off during this process which is termed pitting.

Functions of spleen
Maintenance of the quality of erythrocytes in the red pulp by removal of senescent and dysfunctional cells
Antibody production in the white pulp
Removal of antibody coated bacteria and blood cells from the circulation

Because of these important functions, the spleen is seldom removed. Indications for splenectomy include major trauma
and uncontrollable haemorrhage and the treatment of haemolytic anaemia.

The absence of a spleen has minimal long term effects on the haematologic profile.

In the immediate post operative period, both leucocytosis and thrombocytosis are seen.

In the longer term, the main manifestations are visible on the blood film and include visible nuclear remnants (Howell
Jolly bodies), denatured haemoglobin (Heinz bodies), basophilic stippling and occasional nucleated erythrocytes.
The main risk following splenectomy is overwhelming sepsis with encapsulated organisms. Patients should receive the
pneumococcal vaccine and long term antibiotic prophylaxis.

The reticuloendothelial cells are concerned with the immune functions of the spleen and these are therefore
concentrated in the white pulp.

Transpyloric plane
Level of the body of L1

 Pylorus stomach
 Left kidney hilum (L1- left one!)
 Fundus of the gallbladder
 Neck of pancreas
 Duodenojejunal flexure
 Superior mesenteric artery
 Portal vein
 Left and right colic flexure
 Root of the transverse mesocolon
 1st part of the duodenum
 Upper part of conus medullaris
  Spleen

Can be identified by asking the supine patient to sit up without using their arms. The plane is located where the lateral
border of the rectus muscle crosses the costal margin.

Pudendal canal
The pudendal canal is located along the lateral wall of the ischioanal fossa at the inferior margin of the obturator
internus muscle. It extends from the lesser sciatic foramen to the posterior margin of the urogenital diaphragm. It
conveys the internal pudendal vessels and nerve.

Deep perineal pouch

The perineal pouch is surrounded inferiorly by the inferior fascia of the urogenital diaphragm. This fascial boundary
extends laterally to form the medial wall of the ischiorectal fossa. The pouch is bounded superiorly by the superior
fascia of the urogenital diaphragm and this lies beneath the levator ani muscle.

Contents of the deep perineal pouch

Pancreas
The pancreas develops from a ventral and dorsal endodermal outgrowth of the duodenum. The ventral arises close to,
or in common with the hepatic diverticulum, and the larger, dorsal outgrowth arises slightly cranial to the ventral
extending into the mesoduodenum and mesogastrium. When the buds eventually fuse the duct of the ventral
rudiment becomes the main pancreatic duct.

There is an arterial watershed in the supply between the head and tail of the pancreas. The head is supplied by
the pancreaticoduodenal artery and the tail is supplied by branches of the splenic artery.

The pancreas is a retroperitoneal organ and lies posterior to the stomach. It may be accessed surgically by dividing the
peritoneal reflection that connects the greater omentum to the transverse colon. The pancreatic head sits in the
curvature of the duodenum. Its tail lies close to the hilum of the spleen, a site of potential injury during splenectomy.

Relations
Posterior to the pancreas

Inferior vena cava

Common bile duct
Pancreatic head
Right and left renal veins
Superior mesenteric vein and artery

Pancreatic neck Superior mesenteric vein, portal vein

Pancreatic body- Left renal vein

Ingerior mesenteric vein

Crus of diaphragm
Psoas muscle
Adrenal gland
Kidney
 Aorta

Pancreatic tail Left kidney

Anterior to the pancreas

1st part of the duodenum

Pancreatic head Pylorus
SMA and SMV(uncinate process)

Stomach
Pancreatic body
Duodenojejunal flexure

Pancreatic tail Splenic hilum

Superior to the pancreas

Coeliac trunk and its branches common hepatic artery and splenic artery

Grooves of the head of the pancreas

2nd and 3rd part of the duodenum

Arterial supply

 Head: pancreaticoduodenal artery

 Rest: splenic artery

Venous drainage

 Head: superior mesenteric vein

 Body and tail: splenic vein

Ampulla of Vater

 Merge of pancreatic duct and common bile duct

 Is an important landmark, halfway along the second part of the duodenum, that marks the anatomical transition
from foregut to midgut (also the site of transition between regions supplied by coeliac trunk and SMA).

The superior mesenteric artery arises from the aorta and passes anterior to the lower part of the pancreas. Invasion of
this structure is a relative contra indication to resectional surgery.

Abdominal wall
The 2 main muscles of the abdominal wall are the rectus abdominis (anterior) and the quadratus lumborum (posterior).
The remaining abdominal wall consists of 3 muscular layers. Each muscle passes from the lateral aspect of the quadratus
lumborum posteriorly to the lateral margin of the rectus sheath anteriorly. Each layer is muscular posterolaterally and
aponeurotic anteriorly.

Muscles of abdominal wall

 Lies most superficially
 Originates from 5th to 12th ribs
 Inserts into the anterior half of the outer aspect of the iliac crest, linea alba and pubic tubercle
External oblique  More medially and superiorly to the arcuate line, the aponeurotic layer overlaps the rectus
abdominis muscle
 The lower border forms the inguinal ligament
 The triangular expansion of the medial end of the inguinal ligament is the lacunar ligament.

 Arises from the thoracolumbar fascia, the anterior 2/3 of the iliac crest and the lateral 2/3 of the
inguinal ligament
 The muscle sweeps upwards to insert into the cartilages of the lower 3 ribs
Internal oblique  The lower fibres form an aponeurosis that runs from the tenth costal cartilage to the body of the
pubis
 At its lowermost aspect it joins the fibres of the aponeurosis of transversus abdominis to form the
conjoint tendon.

 Innermost muscle
 Arises from the inner aspect of the costal cartilages of the lower 6 ribs , from the anterior 2/3 of
the iliac crest and lateral 1/3 of the inguinal ligament and thoracolumbar fascia
 Its fibres run horizontally around the abdominal wall ending in an aponeurosis. The upper part
Transversus
runs posterior to the rectus abdominis. Lower down the fibres run anteriorly only.
abdominis  The rectus abdominis lies medially; running from the pubic crest and symphysis to insert into the
xiphoid process and 5th, 6th and 7th costal cartilages. The muscles lies in a aponeurosis as
described above.
 Nerve supply: anterior primary rami of T7-12

Surgical notes
During abdominal surgery it is usually necessary to divide either the muscles or their aponeuroses. During a midline
laparotomy it is desirable to divide the aponeurosis. This will leave the rectus sheath intact above the arcuate line and
the muscles intact below it. Straying off the midline will often lead to damage to the rectus muscles, particularly below
the arcuate line where they may often be in close proximity to each other.

Ilioinguinal nerve
Arises from the first lumbar ventral ramus with the iliohypogastric nerve. It passes inferolaterally through the
substance of psoas major and over the anterior surface of quadratus lumborum. It pierces the internal oblique muscle
and passes deep to the aponeurosis of the external oblique muscle. It enters the inguinal canal and then passes through
the superficial inguinal ring to reach the skin.

Branches

 To supply those muscles of the abdominal wall through which it passes.

 Skin and fascia over the pubic symphysis, superomedial part of the femoral triangle, surface of the scrotum, root
and dorsum of penis or labium majus in females.
Testicular embryology
Until the end of foetal life the testicles are located within the abdominal cavity. They are initially located on the
posterior abdominal wall on a level with the upper lumbar vertebrae (L2). Attached to the inferior aspect of the testis is
the gubernaculum testis which extends caudally to the inguinal region, through the canal and down to the superficial
skin. Both the testis and the gubernaculum are extra-peritoneal.
As the foetus grows the gubernaculum becomes progressively shorter. It carries the peritoneum of the anterior
abdominal wall (the processus vaginalis). As the processus vaginalis descends the testis is guided by the gubernaculum
down the posterior abdominal wall and the back of the processus vaginalis into the scrotum.
By the third month of foetal life the testes are located in the iliac fossae, by the seventh they lie at the level of the deep
inguinal ring.

The processus vaginalis usually closes after birth, but may persist and be the site of indirect hernias. Part closure may
result in development of cysts on the cord.

A testis at the base of the penis is ectopic, not listed is the superficial inguinal pouch (one of the commonest ectopic
sites). A testis located at deep or superficial rings or intra canalicular is not ectopically located.

The gubernaculum is a ridge of mesenchymal tissue that connects the testis to the inferior aspect of the scrotum. Early
in embryonic development the gubernaculum is long and the testis are located on the posterior abdominal wall. During
foetal growth the body grows relative to the gubernaculum, with resultant descent of the testis.

Lymphatic drainage of the vagina

The lymph vessels from the superior aspect of the vagina join the internal and external iliac nodes, those from the
inferior aspect of the vagina drain to the superficial inguinal nodes.
Ligament of Treitz
The suspensory muscle of the duodenum which is referred to as the ligament of Treitz is most important. The ligament
of Treves is located between the ileum and caecum.

Duodenum
This is the first and widest part of the small bowel. It has a diameter of around 4-5cm. Its commencement is
immediately distal to the pylorus and it runs for around 25cm where it becomes the jejunum at the region of the
duodenojejunal flexure. It comprises four parts, superior, descending, horizontal and ascending. Of these, the horizontal
is the longest segment. The first 2-3cm of the superior duodenum are intraperitoneal. The remainder is largely
retroperitoneal with the exception of the final 1-2cm.

Medial relations of the duodenum include the superior pancreatico-duodenal artery and the pancreatic head. The
descending duodenum is closely related to the commencement of the transverse colon which has little in the way of
mesentery at this area. Posterior to the descending duodenum lies the right kidney.
The horizontal part passes transversely to the left with an upward deflection as it does so. From right to left it crosses in
front (=posterior relatrons) of the right ureter, right psoas major, right gonadal vessels and IVC. It terminates anterior
to the aorta. Anteriorly, it's relations include the superior mesenteric vessels and the root of the small bowel.

The ascending part runs to the left of the aorta and upwards to the level of L2. It terminates by binding abruptly
forwards as the duodenojejunal flexure. Posteriorly, are the left sympathetic trunk, left psoas major and left gonadal
vessels. Anteriorly, it gives attachment to the root of the mesentery, while the left kidney lies laterally and the
uncinate process of the pancreas lies medially.

The region of the duodenojenunal flexure is fixed in position by the suspensory muscle of the duodenum. This
fibromuscular band blends with the musculature of the flexure and passes upwards deep to the pancreas to gain
attachment to the right crus of the diaphragm. It is referred to eponymously as the ligament of Treitz.
Rectus abdominis muscle
The rectus sheath is formed by the aponeuroses of the lateral abdominal wall muscles. The rectus sheath has a
composition that varies according to anatomical level.

1. Above the costal margin the anterior sheath is composed of external oblique aponeurosis, the costal cartilages are
posterior to it.
2. From the costal margin to the arcuate line, the anterior rectus sheath is composed of external oblique aponeurosis
and the anterior part of the internal oblique aponeurosis. The posterior part of the internal oblique aponeurosis and
transversus abdominis form the posterior rectus sheath.
3. Below the arcuate line the aponeuroses of all the abdominal muscles lie in anterior aspect of the rectus sheath.
Posteriorly lies the transversalis fascia and peritoneum.

The arcuate line is the point at which the inferior epigastric vessels enter the rectus sheath.

A transverse incision two thirds of the way between umbilicus and the symphysis pubis lies below the arcuate line and
the posterior wall of the rectus sheath is deficient at this level and is least likely to be divided.

Scrotal and testicular anatomy

Spermatic cord
Formed by the vas deferens and is covered by the following structures:
Layer Origin
Internal spermatic fascia Transversalis fascia
Cremasteric fascia From the fascial coverings of internal oblique
External spermatic fascia External oblique aponeurosis

Contents of the cord

Vas deferens Transmits sperm and accessory gland secretions
Testicular artery Branch of abdominal aorta supplies testis and epididymis
Artery of vas deferens Arises from inferior vesical artery
Cremasteric artery Arises from inferior epigastric artery
Pampiniform plexus Venous plexus, drains into right or left testicular vein
Sympathetic nerve fibres Lie on arteries, the parasympathetic fibres lie on the vas
Genital branch of the genitofemoral nerve Supplies cremaster
Lymphatic vessels Drain to lumbar and para-aortic nodes

Scrotum

 Composed of skin and closely attached dartos fascia.

 Arterial supply from the anterior and posterior scrotal arteries
 Lymphatic drainage to the inguinal lymph nodes
 Parietal layer of the tunica vaginalis is the innermost layer

Testes

 The testes are surrounded by the tunica vaginalis (closed peritoneal sac). The parietal layer of the tunica
vaginalis adjacent to the internal spermatic fascia.
 The testicular arteries arise from the aorta immediately inferiorly to the renal arteries.
  The pampiniform plexus drains into the testicular veins, the left drains into the left renal vein and the right
into the inferior vena cava.
 Lymphatic drainage is to the para-aortic nodes.

The testicular venous drainage begins in the septa and these veins together with those of the tunica vasculosa converge
on the posterior border of the testis as the pampiniform plexus. The pampiniform plexus drains to the testicular vein.
The left testicular vein drains into the left renal vein. The right testicular vein drains into the inferior vena cava.

Ureter

 25-35 cm long
 Muscular tube lined by transitional epithelium
 Surrounded by thick muscular coat. Becomes 3 muscular layers as it crosses the bony pelvis
  Retroperitoneal structure overlying transverse processes L2-L5
 Lies anterior to bifurcation of iliac vessels
 Blood supply is segmental; renal artery, aortic branches, gonadal branches, common iliac and internal iliac
 Lies beneath the uterine artery

The ureters enter the bladder at the upper lateral aspect of the base (posterior surface) of the bladder. They are about
5cm apart from each other in the empty bladder. Internally this aspect is contained within the bladder trigone.

The upper ureter drains to the para-aortic nodes, the lower ureter drains to the common iliac nodes.

The ureter lies anterior to L2 to L5 and stones may be visualised at these points, they may also be identified over
the sacro-iliac joints.
The ureter develops from an outpouching that arises from the mesonephric duct. The mesonephric duct is associated
with the metanephric duct that develops within the metenephrogenic blastema. This forms the site of the ureteric bud
which branches off the mesonephric duct.

Superior mesenteric artery

The SMA leaves the aorta at L1. It passes under the neck of the pancreas prior to giving its first branch the inferior
pancreatico-duodenal artery.

 Branches off aorta at L1

 Supplies small bowel from duodenum (distal to ampulla of vater) through to mid transverse colon
 Takes more oblique angle from aorta and thus more likely to recieve emboli than coeliac axis

Relations of superior mesenteric artery

Superiorly Neck of pancreas
Third part of duodenum
Postero-inferiorly
Uncinate process
Posteriorly Left renal vein
Right Superior mesenteric vein

Branches of the superior mesenteric artery

 Inferior pancreatico-duodenal artery

 Jejunal and ileal arcades
 Ileo-colic artery
 Right colic artery
 Middle colic artery

Abdominal aorta
Abdominal aortic topography
Origin T12
Termination L4
Posterior relations L1-L4 Vertebral bodies
Anterior relations Lesser omentum
Liver
Left renal vein
Inferior mesenteric vein
 Third part of duodenum
Pancreas
Parietal peritoneum
Peritoneal cavity
Right crus of the diaphragm
Right lateral relations Cisterna chyli
IVC (becomes posterior distally)
4th part of duodenum
Left lateral relations Duodenal-jejunal flexure
Left sympathetic trunk

The aorta is accompanied by the thoracic duct as it traverses the aortic hiatus. The vagal trunks accompany the oesophagus
which passes through the muscular part of the diaphragm. The right phrenic nerve accompanies the IVC as it passes through the
caval opening. The left phrenic nerve passes through the muscular part of the diaphragm anterior to the central tendon on the
left.

Oesophagus

 25cm long
 Starts at C6 vertebra, pierces diaphragm at T10 and ends at T11
 Squamous epithelium

Constrictions of the oesophagus

Structure Distance from incisors
Cricoid cartilage 15cm
Arch of the Aorta 22.5cm
Left principal bronchus 27cm
Diaphragmatic hiatus 40cm

Constrictions of the oesophagus : ABCD

A- Arch of the Aorta
B- Left main Bronchus
C- Cricoid Cartilage
D- Diaphragmatic Hiatus

Relations
 Trachea to T4
 Recurrent laryngeal nerve
Anteriorly  Left bronchus, Left atrium
 Diaphragm

 Thoracic duct to left at T5

 Hemiazygos to the left T8
Posteriorly  Descending aorta
 First 2 intercostal branches of aorta
  Thoracic duct
Left  Left subclavian artery

 Azygos vein
Right

Arterial, venous and lymphatic drainage of the oesophagus

Artery Vein Lymphatics Muscularis externa
Upper third Inferior thyroid Inferior thyroid Deep cervical Striated muscle
Mid third Aortic branches Azygos branches Mediastinal Smooth & striated muscle
Lower third Left gastric Left gastric (portal circulation) Gastric Smooth muscle

Nerve supply

 Upper half is supplied by recurrent laryngeal nerve

 Lower half by oesophageal plexus (vagus)

Histology

 Mucosa :Non-keratinized stratified squamous epithelium

 Submucosa: glandular tissue
 Muscularis externa (muscularis): composition varies. See table
 Adventitia

The wall lacks a serosa which can make the wall hold sutures less securely.

The oesophagus has no serosal covering and hence holds sutures poorly. The Auerbach's and Meissner's nerve plexuses
lie in between the longitudinal and circular muscle layers and submucosally. The sub mucosal location of the
Meissner's nerve plexus facilitates its sensory role.

Inferior vena cava

Origin

 L5

Path

 Left and right common iliac veins merge to form the IVC.
 Passes right of midline
 Paired segmental lumbar veins drain into the IVC throughout its length
 The right gonadal vein empties directly into the cava and the left gonadal vein generally empties into the left
renal vein.
 The next major veins are the renal veins and the hepatic veins
 Pierces the central tendon of diaphragm at T8
 Right atrium

Relations

Anteriorly Small bowel, first and third part of duodenum, head of pancreas, liver and bile duct, right common iliac
 artery, right gonadal artery

Posteriorly Right renal artery, right psoas, right sympathetic chain, coeliac ganglion

Levels

Level Vein

T8 Hepatic vein, inferior phrenic vein, pierces diaphragm

L1 Right suprarenal vein, renal vein

L2 Gonadal vein

L1-5 Lumbar veins

L5 Common iliac vein, formation of IVC

The lack of valves in the IVC is important clinically when it is cannulated during cardiopulmonary bypass, using
separate SVC and IVC catheters, such as when the right atrium is to be opened. Note that there is a non functional
valve between the right atrium and inferior vena cava.

Inferior mesenteric artery

The IMA is the main arterial supply of the embryonic hindgut and originates approximately 3-4 cm superior to the aortic
bifurcation. From its aortic origin it passes immediately inferiorly across the anterior aspect of the aorta to eventually
lie on its left hand side. At the level of the left common iliac artery it becomes the superior rectal artery.

Branches
The left colic artery arises from the IMA near its origin. More distally up to three sigmoid arteries will exit the IMA to
supply the sigmoid colon.

The inferior mesenteric artery leaves the aorta at L3. It supplies the left colon and sigmoid. Its proximal continuation to
communicate with the middle colic artery is via the marginal artery.

Diaphragm apertures
Diaphragm aperture levels

Vena cava T8
Oesophagus T10
Aortic hiatus T12

Another memory aid (depending upon your learning style):

I ate 10 Eggs At 12' I (IVC) ate (T8) 10 (T10) eggs (eosophagus) At (aorta) 12 (T12)
Renal anatomy
Each kidney is about 11cm long, 5cm wide and 3cm thick. They are located in a deep gutter alongside the projecting
vertebral bodies, on the anterior surface of psoas major. In most cases the left kidney lies approximately 1.5cm
higher than the right. The upper pole of both kidneys approximates with the 11th rib (beware pneumothorax during
nephrectomy). On the left hand side the hilum is located at the L1 vertebral level and the right kidney at level L1-2. The
lower border of the kidneys is usually alongside L3.

The table below shows the anatomical relations of the kidneys:

Relations
Relations Right Kidney Left Kidney
Quadratus lumborum, diaphragm, psoas major, Quadratus lumborum, diaphragm, psoas major,
Posterior
transversus abdominis transversus abdominis
Anterior Hepatic flexure of colon Stomach, Pancreatic tail
Superior Liver, adrenal gland Spleen, adrenal gland

Fascial covering
Each kidney and suprarenal gland is enclosed within a common layer of investing fascia, derived from the transversalis
fascia. It is divided into anterior and posterior layers (Gerotas fascia).

Renal structure
Kidneys are surrounded by an outer cortex and an inner medulla which usually contains between 6 and 10 pyramidal
structures. The papilla marks the innermost apex of these. They terminate at the renal pelvis, into the ureter.
Lying in a hollow within the kidney is the renal sinus. This contains:
1. Branches of the renal artery
2. Tributaries of the renal vein
3. Major and minor calyces's
4. Fat

Structures at the renal hilum

The renal vein lies most anteriorly, then renal artery (it is an end artery) and the ureter lies most posterior.

Remember L1 ('left one') is the level of the hilum of the left kidney
The 11th and 12th ribs lie posterior to the kidneys and may be encountered during a posterior approach. A
pneumothorax is a recognised complication of this type of surgery.

Anal sphincter

 Internal anal sphincter composed of smooth muscle continuous with the circular muscle of the rectum. It
surrounds the upper two- thirds of the anal canal and is supplied by sympathetic nerves.
 External anal sphincter is composed of striated muscle which surrounds the internal sphincter but extends more
distally. The nerve supply of the external anal sphincter is from the inferior rectal branch of the pudendal nerve (S2
and S3) and the perineal branch of the S4 nerve roots.

Pudendal nerve
The pudendal nerve originates from the ventral rami of the second, third, and fourth sacral nerves (S2, S3, S4).

It passes between the piriformis and coccygeus muscles and exits the pelvis through the the greater sciatic foramen. It
crosses the spine of the ischium and reenters the pelvis through the lesser sciatic foramen. It passes through the
pudendal canal.

The pudendal nerve gives off the inferior rectal nerves. It terminates into 2 branches: perineal nerve, and the dorsal
nerve of the penis or the dorsal nerve of the clitoris.

3 divisions of the pudendal nerve:

 Rectal nerve
 Perineal nerve
 Dorsal nerve of penis/ clitoris

All these pass through the greater sciatic foramen.

The pudendal nerve innervates the perineum. It passes between piriformis and coccygeus medial to the sciatic nerve.

The pudendal nerve innervates the posterior vulval area and is routinely blocked in procedures such as
episiotomy.

Traction and compression of the pudendal nerve by the foetus in late pregnancy may result in late onset pudendal
neuropathy which may be part of the process involved in the development of faecal incontinence.

Splenic anatomy
The spleen is the largest lymphoid organ in the body. It is an intraperitoneal organ, the peritoneal attachments condense
at the hilum where the vessels enter the spleen. Its blood supply is from the splenic artery (derived from the coeliac axis)
and the splenic vein (which is joined by the IMV and unites with the SMV).

 Embryology: derived from mesenchymal tissue

 Shape: clenched fist
 Position: below 9th-12th ribs
 Weight: 75-150g

1,3,5,7,9,11 (odd numbers up to 11)

The spleen is: 1 inch thick, 3 inches wide, 5 inches long, weighs 7oz (150-200g), lies between the 9th and 11th ribs
Relations

 Superiorly- diaphragm
 Anteriorly- gastric impression
 Posteriorly- kidney
 Inferiorly- colon
 Hilum: tail of pancreas and splenic vessels
 Forms apex of lesser sac (containing short gastric vessels)

During splenectomy the tail of the pancreas may be damaged. The pancreatic duct will then drain into the splenic bed,
amylase is the most likely biochemical finding. Glucagon is not secreted into the pancreatic duct.

The lienorenal ligament lies most posteriorly. The antero-lateral connection is via the phrenicocolic ligament. Anteriorly
the gastro splenic ligament. These structures condense around the vessels at the splenic hilum.

Most of the gut is derived endodermally except for the spleen which is from mesenchymal tissue.

Colon anatomy
The colon commences with the caecum. This represents the most dilated segment of the human colon and its base
(which is intraperitoneal) is marked by the convergence of teniae coli. At this point is located the vermiform appendix.
The colon continues as the ascending colon, the posterior aspect of which is retroperitoneal. The line of demarcation
between the intra and retro peritoneal right colon is visible as a white line, in the living, and forms the line of incision
for colonic resections.

The ascending colon becomes the transverse colon after passing the hepatic flexure. At this location the colon becomes
wholly intra peritoneal once again. The superior aspect of the transverse colon is the point of attachment of the
transverse colon to the greater omentum. This is an important anatomical site since division of these attachments
permits entry into the lesser sac. Separation of the greater omentum from the transverse colon is a routine operative
step in both gastric and colonic resections.

At the left side of the abdomen the transverse colon passes to the left upper quadrant and makes an oblique inferior
turn at the splenic flexure. Following this, the posterior aspect becomes retroperitoneal once again.

At the level of approximately L4 the descending colon becomes wholly intraperitoneal and becomes the sigmoid
colon. Whilst the sigmoid is wholly intraperitoneal there are usually attachments laterally between the sigmoid
and the lateral pelvic sidewall. These small congenital adhesions are not formal anatomical attachments but frequently
require division during surgical resections.

At its distal end the sigmoid passes to the midline and at the region around the sacral promontary it becomes the upper
rectum. This transition is visible macroscopically as the point where the teniae fuse. More distally the rectum passes
through the peritoneum at the region of the peritoneal reflection and becomes extraperitoneal.

Arterial supply
Superior mesenteric artery and inferior mesenteric artery: linked by the marginal artery.
Ascending colon: ileocolic and right colic arteries
Transverse colon: middle colic artery
Descending and sigmoid colon: inferior mesenteric artery
Venous drainage
From regional veins (that accompany arteries) to superior and inferior mesenteric vein

Lymphatic drainage
Initially along nodal chains that accompany supplying arteries, then para-aortic nodes.

Embryology
Midgut- Second part of duodenum to 2/3 transverse colon
Hindgut- Distal 1/3 transverse colon to anus

Peritoneal location
The right and left colon are part intraperitoneal and part extraperitoneal. The sigmoid and transverse colon are generally
wholly intraperitoneal. This has implications for the sequelae of perforations, which will tend to result in generalised
peritonitis in the wholly intra peritoneal segments.

Colonic relations

Region of colon Relation

Caecum/ right colon Right ureter, gonadal vessels
Hepatic flexure Gallbladder (medially)
Splenic flexure Spleen and tail of pancreas
Distal sigmoid/ upper rectum Left ureter
Rectum Ureters, autonomic nerves, seminal vesicles, prostate, urethra (distally)

Quadratus lumborum
Origin: Medial aspect of iliac crest and iliolumbar ligament
Insertion: 12th rib
Action: Pulls the rib cage inferiorly. Lateral flexion.
Nerve supply: Anterior primary rami of T12 and L1-3

Omentum

 The omentum is divided into two parts which invest the stomach. Giving rise to the greater and lesser omentum.
The greater omentum is attached to the inferolateral border of the stomach and houses the gastro-epiploic
arteries.
 It is of variable size but is less well developed in children. This is important as the omentum confers protection
against visceral perforation (e.g. Appendicitis).
 Inferiorly between the omentum and transverse colon is one potential entry point into the lesser sac.
 Several malignant processes may involve the omentum of which ovarian cancer is the most notable.

The vessels supplying the omentum are the omental branches of the right and left gastro-epiploic arteries. The colonic
vessels are not responsible for the arterial supply to the omentum. The left gastro-epiploic artery is a branch of the
splenic artery and the right gastro-epiploic artery is a terminal branch of the gastroduodenal artery.

Coeliac plexus
The coeliac plexus is the largest of the autonomic plexuses. It is located on a level of the last thoracic and first lumbar
vertebrae. It surrounds the coeliac axis and the SMA. It lies posterior to the stomach and the lesser sac. It lies
anterior to the crura of the diaphragm and the aorta. The plexus and ganglia are joined by the greater and lesser
splanchnic nerves on both sides and branches from both the vagus and phrenic nerves.

Prostate gland
The prostate gland is approximately the shape and size of a walnut and is located inferior to the bladder. It is separated
from the rectum by Denonvilliers fascia and its blood supply is derived from the internal iliac vessels (via inferior
vesical artery).

The internal sphincter lies at the apex of the gland and may be damaged during prostatic surgery, affected individuals
may complain of retrograde ejaculation.

Summary of prostate gland

Arterial supply Inferior vesical artery (from internal iliac)

Venous drainage Prostatic venous plexus (to paravertebral veins)

Lymphatic drainage Internal iliac nodes

Innervation Inferior hypogastric plexus

 Transverse diameter (4cm)

Dimensions  AP diameter (2cm)
 Height (3cm)

 Posterior lobe: posterior to urethra

 Median lobe: posterior to urethra, in between ejaculatory ducts
Lobes  Lateral lobes x 2
 Isthmus

 Peripheral zone: subcapsular portion of posterior prostate. Most prostate cancers are here
 Central zone
Zones  Transition zone (most BPH)
 Stroma

Relations

Pubic symphysis
Anterior
Prostatic venous plexus

Denonvilliers fascia
Posterior Rectum
Ejaculatory ducts

Venous plexus (lies on prostate)

Lateral
Levator ani (immediately below the puboprostatic ligaments)

Adrenal gland anatomy

Anatomy
Location Superomedially to the upper pole of each kidney
 Diaphragm-Posteriorly,
 Kidney-Inferiorly,
Relationships of the right adrenal
 Vena Cava-Medially, Hepato-renal pouch and bare area of the liver-
Anteriorly
 Crus of the diaphragm-Postero- medially,
Relationships of the left adrenal  Pancreas and splenic vessels-Inferiorly,
 Lesser sac and stomach-Anteriorly
 Superior adrenal arteries- from inferior phrenic artery,
Arterial supply  Middle adrenal arteries - from aorta,
 Inferior adrenal arteries -from renal arteries
Venous drainage of the right adrenal Via one central vein directly into the IVC
Venous drainage of the left adrenal Via one central vein into the left renal vein

The left adrenal gland is slightly larger than the right. It is crescent in shape and its concavity is adapted to the medial
border of the upper part of the left kidney.

 The upper area is covered by peritoneum of the omental bursa which separates it from the cardia of the stomach.
 The lower area is in contact with the pancreas and splenic artery and is not covered by peritoneum.
 On the anterior surface is a hilum from which the suprarenal vein emerges.
 The lateral aspect rests on the kidney.
 The medial is small and is on the left crus of the diaphragm.

Lower genitourinary tract trauma

 Most bladder injuries occur due to blunt trauma

 85% associated with pelvic fractures
 Easily overlooked during assessment in trauma
 Up to 10% of male pelvic fractures are associated with urethral or bladder injuries

Types of injury

Urethral injury  Mainly in males

 Blood at the meatus (50% cases)
 There are 2 types:

i.Bulbar rupture
- most common
- straddle type injury e.g. bicycles
- triad signs: urinary retention, perineal haematoma, blood at the meatus

ii. Membranous rupture

- can be extra or intraperitoneal
- commonly due to pelvic fracture
- Penile or perineal oedema/ hematoma
- PR: prostate displaced upwards (beware co-existing retroperitoneal haematomas
as they may make examination difficult)

- Investigation: ascending urethrogram

 - Management: suprapubic catheter (surgical placement, not percutaneously)
External genitalia injuries (i.e., the
penis and the scrotum)
Bladder injury
 Secondary to injuries caused by penetration, blunt trauma, continence- or
sexual pleasure-enhancing devices, and mutilation
 rupture is intra or extraperitoneal
 presents with haematuria or suprapubic pain
 history of pelvic fracture and inability to void: always suspect bladder or
urethral injury
 inability to retrieve all fluid used to irrigate the bladder through a Foley
catheter indicates bladder injury
 investigation- IVU or cystogram
 management: laparotomy if intraperitoneal, conservative if extraperitoneal

Caecum
 Proximal right colon below the ileocaecal valve
Location  Intraperitoneal

 Psoas
 Iliacus
Posterior relations  Femoral nerve
 Genitofemoral nerve
 Gonadal vessels

Anterior relations Greater omentum

Arterial supply Ileocolic artery

Lymphatic drainage Mesenteric nodes accompany the venous drainage

 The caecum is the most distensible part of the colon and in complete large bowel obstruction with a competent
ileocaecal valve the most likely site of eventual perforation.
The ileo - colic artery supplies the caecum and would require high ligation during a right hemicolectomy. The
middle colic artery should generally be preserved when resecting a caecal lesion.
This question is essentially asking you to name the vessel supplying the caecum. The SMA does not directly supply the
caecum, it is the ileocolic artery which does this.

Thoracic duct

 Continuation of the cisterna chyli in the abdomen.

 Enters the thorax at T12.
 Lies posterior to the oesophagus for most of its intrathoracic course. Passes to the left at T5.
 Lymphatics draining the left side of the head and neck join the thoracic duct prior to its insertion into the
junction between left subclavian and internal jugular veins.
 Lymphatics draining the right side of the head and neck drain via the subclavian and jugular trunks into the right
lymphatic duct and thence into the mediastinal trunk and eventually the right brachiocephalic vein.
 Its location in the thorax makes it prone to injury during oesophageal surgery. Some surgeons administer
cream to patients prior to oesophagectomy so that it is easier to identify the cut ends of the duct.

The thoracic duct lies posterior to the oesophagus and passes to the left at the level of the Angle of Louis. It exits the
thorax at T12 together with the aorta.

Coeliac axis
The coeliac axis has three main branches.

 Left gastric
 Hepatic: branches-Right Gastric, Gastroduodenal, Superior Pancreaticoduodenal, Cystic (occasionally).
 Splenic: branches- Pancreatic, Short Gastric, Left Gastroepiploic

It occasionally gives off one of the inferior phrenic arteries.

Relations
Anteriorly Lesser omentum
Right Right coeliac ganglion and caudate process of liver
Left Left coeliac ganglion and gastric cardia
Inferiorly Upper border of pancreas and renal vein
During a radical gastrectomy the lesser omentum will need to be divided to gain access to the coeliac axis. This forms
one of the nodal stations that will need to be taken.

Abdominal incisions
 Commonest approach to the abdomen
 Structures divided: linea alba, transversalis fascia, extraperitoneal fat, peritoneum (avoid
Midline incision falciform ligament above the umbilicus)
 Bladder can be accessed via an extraperitoneal approach through the space of Retzius
 Mass closure- Jerkins rule

 Parallel to the midline (about 3-4cm)

Paramedian  Structures divided/retracted: anterior rectus sheath, rectus (retracted laterally), posterior
incision rectus sheath, transversalis fascia, extraperitoneal fat, peritoneum
 Incision is closed in layers
  Similar location to paramedian but rectus displaced medially (and thus denervated)
Battle  Now seldom used

Kocher's Incision under right subcostal margin e.g. Cholecystectomy (open)

Lanz Incision in right iliac fossa e.g. Appendicectomy

Oblique incision centered over McBurneys point- usually appendicectomy (less cosmetically
Gridiron
acceptable than Lanz

Gable Rooftop incision

Pfannenstiel's Transverse supra pubic, primarily used to access pelvic organs

McEvedy's Groin incision e.g. Emergency repair strangulated femoral hernia

Rutherford Extraperitoneal approach to left or right lower quadrants. Gives excellent access to iliac vessels and is
Morrison the approach of choice for first time renal transplantation.

Transverse colon

 The right colon undergoes a sharp turn at the level of the hepatic flexure to become the transverse colon.
 At this point it also becomes intraperitoneal.
 It is connected to the inferior border of the pancreas by the transverse mesocolon.
 The greater omentum is attached to the superior aspect of the transverse colon from which it can easily be
separated. The mesentery contains the middle colic artery and vein. The greater omentum remains attached to
the transverse colon up to the splenic flexure. At this point the colon undergoes another sharp turn.

Relations
Superior Liver and gall-bladder, the greater curvature of the stomach, and the lower end of the spleen

Inferior Small intestine

Anterior Greater omentum

From right to left with the descending portion of the duodenum, the head of the pancreas, convolutions of the
Posterior
jejunum and ileum, spleen

The middle colic artery supplies the transverse colon and requires high ligation during cancer resections. It is a branch of
the superior mesenteric artery.

Thorax
Lung anatomy
The right lung is composed of 3 lobes divided by the oblique and transverse fissures. The left lung has two lobes divided
by the oblique fissure.The apex of both lungs is approximately 4cm superior to the sterno-costal joint of the first rib.
Immediately below this is a sulcus created by the subclavian artery. Left apex is more superior than the right (more
commonly injured during central lines)

The pleural reflections encase the hilum of the lung and continue inferiorly as the pulmonary ligament. It encases the
pulmonary vessels and bronchus. The azygos vein is not contained within it.

The vagus nerve is the most posteriorly located structure at the lung root. The phrenic nerve lies most
anteriorly.

Peripheral contact points of the lung

 Base: diaphragm
 Costal surface: corresponds to the cavity of the chest
 Mediastinal surface: Contacts the mediastinal pleura. Has the cardiac impression. Above and behind this
concavity is a triangular depression named the hilum, where the structures which form the root of the lung
enter and leave the viscus. These structures are invested by pleura, which, below the hilum and behind the
pericardial impression, forms the pulmonary ligament
 The suprapleural fascia (Sibson's fascia) runs from C7 to the first rib and overlies the apex (copula) of both
lungs.It lies between the parietal pleura and the thoracic cage.

Right lung
Above the hilum is the azygos vein; Superior to this is the groove for the superior vena cava and right innominate vein;
behind this, and nearer the apex, is a furrow for the innominate artery. Behind the hilum and the attachment of the
pulmonary ligament is a vertical groove for the oesophagus; In front and to the right of the lower part of the
oesophageal groove is a deep concavity for the extrapericardiac portion of the inferior vena cava.

The root of the right lung lies posterior to the superior vena cava and the right atrium, and below the azygos
vein.

The right main bronchus is shorter, wider and more vertical than the left main bronchus and therefore the route taken
by most foreign bodies.

Left lung
Above the hilum is the furrow produced by the aortic arch, and then superiorly the groove accommodating the left
subclavian artery; Behind the hilum and pulmonary ligament is a vertical groove produced by the descending aorta, and
in front of this, near the base of the lung, is the lower part of the oesophagus.

The root of the left lung is inferior to the aortic arch and anterior to the descending aorta.

Inferior borders of both lungs

 6th rib in mid clavicular line

 8th rib in mid axillary line
 10th rib posteriorly

The pleura runs two ribs lower than the corresponding lung level.

Bronchopulmonary segments
Segment number Right lung Left lung
1 Apical Apical
2 Posterior Posterior
3 Anterior Anterior
4 Lateral Superior lingular
5 Medial Inferior lingular
6 Superior (apical) Superior (apical)
7 Medial basal Medial basal
8 Anterior basal Anterior basal
9 Lateral basal Lateral basal
10 Posterior basal Posterior basal

Heart anatomy
The walls of each cardiac chamber comprise:

 Epicardium
 Myocardium
 Endocardium

Cardiac muscle is attached to the cardiac fibrous skeleton.

Relations
The heart and roots of the great vessels within the pericardial sac are related to the posterior aspect of the sternum,
medial ends of the 3rd to 5th ribs on the left and their associated costal cartilages. The heart and pericardial sac
are situated obliquely two thirds to the left and one third to the right of the median plane.

The pulmonary valve lies at the level of the left third costal cartilage.
The mitral valve lies at the level of the fourth costal cartilage.

Coronary sinus
This lies in the posterior part of the coronary groove and receives blood from the cardiac veins. The great cardiac vein
lies at its left and the middle and small cardiac veins lie on its right. The smallest cardiac vein (anterior cardiac vein)
drains into the right atrium directly.

Aortic sinus
Right coronary artery arises from the right aortic sinus, the left is derived from the left aortic sinus, which lies
posteriorly.

Features of the left ventricle as opposed to the right

Structure Left Ventricle

A-V Valve Mitral (double leaflet)
Walls Twice as thick as right
Trabeculae carnae Much thicker and more numerous

Right coronary artery

The RCA supplies:

 Right atrium
 Diaphragmatic part of the right ventricle
 Usually the posterior third of the interventricular septum
 The sino atrial node (60% cases)
 The atrio ventricular node (80-90% cases)

Left coronary artery

The LCA supplies:

 Left atrium
 Most of left ventricle
 Part of the right ventricle
 Anterior two thirds of the inter ventricular septum
 The sino atrial node (remaining 40% cases)

Innervation of the heart

Autonomic nerve fibres from the superficial and deep cardiac plexus. These lie anterior to the bifurcation of the
trachea, posterior to the ascending aorta and superior to the bifurcation of the pulmonary trunk. The parasympathetic
supply to the heart is from presynaptic fibres of the vagus nerves.

Valves of the heart

Mitral valve Aortic valve Pulmonary valve Tricuspid valve
2 cusps 3 cusps 3 cusps 3 cusps
First heart sound Second heart sound Second heart sound First heart sound
1 anterior cusp 2 anterior cusps 2 anterior cusps 2 anterior cusps
Attached to chordae tendinae No chordae No chordae Attached to chordae tendinae

The musculi pectinati are found in the atria, hence the reason that the atrial walls in the right atrium are irregular
anteriorly.
The musculi pectinati of the atria are internal muscular ridges on the anterolateral surface of the chambers and they are
only present in the area derived from the embryological true atrium.
Sinoatrial node

 Located in the wall of the right atrium in the upper part of the sulcus terminalis from which it extends anteriorly
over the opening of the superior vena cava.
 In most cases it is supplied by the right coronary artery.
 It has a complicated nerve supply from the cardiac nerve plexus that takes both sympathetic and
parasympathetic fibres that run alongside the main vessels.

No single one of the above nerves is responsible for direct cardiac innervation (which those who have handled the
heart surgically will appreciate).

The heart receives its nerves from the superficial and deep cardiac plexuses. The cardiac plexuses send small branches to
the heart along the major vessels, continuing with the right and left coronary arteries. The vagal efferent fibres emerge
from the brainstem in the roots of the vagus and accessory nerves, and run to ganglia in the cardiac plexuses and within
the heart itself.

The background vagal discharge serves to limit heart rate, and loss of this background vagal tone accounts for the
higher resting heart rate seen following cardiac transplant.

Sites of auscultation
Valve Site
Pulmonary valve Left second intercostal space, at the upper sternal border
Aortic valve Right second intercostal space, at the upper sternal border
Mitral valve Left fifth intercostal space, just medial to mid clavicular line
Tricuspid valve Left fourth intercostal space, at the lower left sternal border

Prosthetic heart valves on Chest X-rays

The aortic and mitral valves are most commonly replaced and when a metallic valve is used, can be most readily
identified on plain x-rays.
The presence of cardiac disease (such as cardiomegaly) may affect the figures quoted here.

Aortic
Usually located medial to the 3rd interspace on the right.

Mitral
Usually located medial to the 4th interspace on the left.

Tricuspid
Usually located medial to the 5th interspace on the right.

Please note that these are the sites at which an artificial valve may be located and are NOT the sites of auscultation.
Mediastinum
Region between the pulmonary cavities.
It is covered by the mediastinal pleura. It does not contain the lungs.
It extends from the thoracic inlet superiorly to the diaphragm inferiorly.

Mediastinal regions

 Superior mediastinum (between manubriosternal angle and T4/5)

 Middle mediastinum
 Posterior mediastinum
 Anterior mediastinum

Region Contents
 Superior vena cava
 Brachiocephalic veins
 Arch of aorta
 Thoracic duct
 Trachea
Superior mediastinum  Oesophagus
 Thymus
 Vagus nerve
 Left recurrent laryngeal nerve
 Phrenic nerve

 Thymic remnants
 Lymph nodes
Anterior mediastinum
 Fat

 Pericardium
 Heart
 Aortic root
Middle mediastinum
 Arch of azygos vein
 Main bronchi

 Oesophagus
 Thoracic aorta
 Azygos vein
 Thoracic duct
Posterior mediastinum
 Vagus nerve
 Sympathetic nerve trunks
 Splanchnic nerves

The vertebral bodies lie outside of the mediastinum, as do the lungs.

Angle of Louis
Mnemonic for lower sternal angle:
Red, white, blue and air 2
Red- arch of aorta
White- the thoracic duct crosses at the midline
Bue- azygous joins the svc
Air- tracheal bifurcation
2- costal cartilage of the second rib

At the level of the Angle of Louis (Manubriosternal angle), is the surface marking for the aortic arch. The oesophagus is
posteriorly located and at less risk.

Anatomical structures at the level of the manubrium and upper sternum

 Left brachiocephalic vein
 Brachiocephalic artery
Upper part of the manubrium  Left common carotid
 Left subclavian artery

 Costal cartilages of the 2nd ribs

 Transition point between superior and inferior mediastinum
 Arch of the aorta
Lower part of the manubrium/ manubrio-sternal
 Tracheal bifurcation
angle
 Union of the azygos vein and superior vena cava
 The thoracic duct crosses to the midline

Chest drains
There are a number of different indications for chest drain insertion. In general terms large bore chest drains are
preferred for trauma and haemothorax drainage. Smaller diameter chest drains can be used for pneumothorax or
pleural effusion drainage.

Insertion can be performed either using anatomical guidance or through ultrasound guidance. In the exam, the
anatomical method is usually tested.

It is advised that chest drains are placed in the 'safe triangle'. The triangle is located in the mid axillary line of the 5th
intercostal space. It is bordered by:
Anterior edge latissimus dorsi, the lateral border of pectoralis major, a line superior to the horizontal level of the
nipple, and the apex below the axilla.

Another triangle is situated behind the scapula. It is bounded above by the trapezius, below by the latissimus dorsi, and
laterally by the vertebral border of the scapula; the floor is partly formed by the rhomboid major. If the scapula is drawn
forward by folding the arms across the chest, and the trunk bent forward, parts of the sixth and seventh ribs and the
interspace between them become subcutaneous and available for auscultation. The space is therefore known as the
triangle of auscultation.

'Safe Triangle' for chest drain insertion:

5th intercostal space, mid axillary line

Within the intercostal spaces there are thin, strong muscles, intercostal vessels, nerves and lymphatics. There are 3
intercostal muscle layers corresponding to the lateral abdominal wall; external, internal, innermost intercostals. At
the mid axillary line there are thin intracostals which is an extension of the internal intercostal muscle. In each
intercostal space lies the neurovascular bundle, comprising, from superior to inferiorly; the posterior intercostal vein,
artery and nerve, lying protected in the subcostal groove of the rib above and situated between the second and
third layer of the intercostal muscles.
These blood vessels anastomose anteriorly with the anterior intercostal vessels, which arise from the internal thoracic
artery and vein.

The intercostal vein is more superior than the artery and is thus slightly less susceptible to injury.

Sternotomy
A median sternotomy is the commonest incision utilised to access the heart and great vessels.
A midline incision is made from the interclavicular fossa to the xiphoid process and the fat and subcutaneous tissues are
divided to the level of the sternum. The periosteum may be gently mobilised off the midline, although vigorous
periosteal stripping is best avoided. A bone saw is used to divide the bone itself. Posteriorly the reflections of the
parietal pleura should be identified and avoided (unless surgery to the lung is planned). The fibrous pericardium is
incised and the heart brought into view. Bleeding from the bony edges of the cut sternum is stopped using roller ball
diathermy or bone wax. The left brachiocephalic vein is an important posterior relation at the superior aspect of the
sternotomy incision and should be avoided. More inferior the thymic remnants may be identified. At the inferior
aspect of the incision the abdominal cavity may be entered (though this is seldom troublesome).

The interclavicular ligament lies at the upper end of a median sternotomy and is routinely divided to provide access.
The pleural reflections are often encountered and should not be intentionally divided, if they are, then a chest drain will
need to be inserted on the affected side as collections may then accumulate in the pleural cavity. Other structures
encountered include the pectoralis major muscles, again if the incision is truly midline then these should not require
formal division. The close relationship of the brachiocephalic vein should be borne in mind and it should be avoided,
iatrogenic injury to this structure will result in considerable haemorrhage.

Thoracic aorta
Origin T4
Terminates T12
 Anteriorly (from top to bottom)-root of the left lung, the pericardium, the oesophagus, and the
diaphragm
 Posteriorly-vertebral column, azygos vein
Relations
 Right- azygos veins, thoracic duct
 Left- left pleura and lung

 Lateral segmental branches: Posterior intercostal arteries

 Lateral visceral: Bronchial arteries supply bronchial walls and lung excluding the alveoli
Branches
 Midline branches: Oesophageal arteries

thoracic cord lesion

A thoracic cord lesion causes spastic paraperesis, hyperrflexia and extensor plantar responses (UMN lesion),
incontinence, sensory loss below the lesion and 'sensory' ataxia.These features typically manifest several weeks
later, once spinal shock (in which areflexia predominates) has resolved.
Head-Brain-Neck
Pharyngeal arches- pouches
Pharyngeal arches develop during the fourth week of embryonic growth from a series of mesodermal outpouchings of
the developing pharynx.
They develop and fuse in the ventral midline.

Pharyngeal pouches form on the endodermal side between the arches.

There are 6 pharyngeal arches, the fifth does not contribute any useful structures and often fuses with the sixth arch.
The dorsal ends of the cartilages of the first and second pharyngeal arches articulate superior to the tubotympanic
recess. These cartilages form the malleus, incus and stapes. At least part of the malleus is formed from the first arch
and the stapes from the second arch. The incus is most likely to arise from the first arch.
Pharyngeal arches
Pharyngeal Skeletal
Muscular contributions Endocrine Artery Nerve
arch contributions
Muscles of mastication
Maxilla
Anterior belly of digastric
Meckels cartilage Maxillary
First Mylohyoid n/a Mandibular
Incus External carotid
Tensor tympanic
Malleus
Tensor veli palatini
Buccinator
Platysma
Muscles of facial Stapes
Inferior branch of
expression Styloid process
Second n/a superior thyroid artery Facial
Stylohyoid Lesser horn and
Stapedial artery
Posterior belly of upper body of hyoid
digastric
Stapedius
Thymus
Greater horn and Common and internal
Third Stylopharyngeus Inferior Glossopharyngeal
lower part of hyoid carotid
parathyroids
Cricothyroid
Thyroid and Superior Right- subclavian artery,
Fourth All intrinsic muscles of the Vagus
epiglottic cartilages parathyroids Left-aortic arch
soft palate

Right -Pulmonary
All intrinsic muscles of the Cricoid, arytenoid
artery, Left- Pulmonary
Sixth larynx (except and corniculate n/a Vagus
artery and ductus
cricothyroid) cartilages
arteriosus

5-7-9-10
Trigeminal
Facial
Glossopharyngeal
Vagus

Lingual nerve

 Sensory nerve to the mucosa of the presulcal part of the tongue, floor of mouth and mandibular lingual
gingivae
 Arises from posterior trunk of the mandibular nerve (branch of trigeminal)
  Course runs past tensor veli palatini and lateral pterygoid (where it is joined by the chorda tympani branch of
the facial nerve). Emerging from the cover of the lateral pterygoid it proceeds antero inferiorly lying on the
surface of the medial pterygoid and lies close to the medial aspect of the mandibular ramus. At the junction of
the vertical and horizontal rami of the mandible it is anterior to the inferior alveolar nerve. It then passes below
the mandibular attachment of the superior pharyngeal constrictor. Eventually, it lies on the periosteum of the
root of the third molar tooth. It then passes medial to the mandibular origin of mylohyoid and then passes
forwards on the inferior surface of this muscle

The lingual nerve is closely related to the third molar and up to 10% of patients undergoing surgical extraction of
these teeth may subsequently develop a lingual neuropraxia. The result is anaesthesia of the ipsilateral anterior aspect
of the tongue. The inferior alveolar nerve innervates the teeth themselves.

Stensen's (parotid) duct opens in the rear of the mouth cavity near the second upper molar.

carotid endarterectomy
During a carotid endarterectomy the sternocleidomastoid muscle is dissected, with ligation of the common facial vein
and then the internal jugular is dissected exposing the common and the internal carotid arteries.
The nerves at risk during the operation include:

 Hypoglossal nerve (anterior)

 Greater auricular nerve (anterior)
 Superior laryngeal nerve (posterior)

The sympathetic chain lies more posteriorly and is less prone to injury in this procedure.

Internal carotid artery

The internal carotid artery is formed from the common carotid opposite the upper border of the thyroid cartilage. It
extends superiorly to enter the skull via the carotid canal. From the carotid canal it then passes through the cavernous
sinus, above which it divides into the anterior and middle cerebral arteries.

Relations in the neck

 Longus capitis
 Pre-vertebral fascia
 Sympathetic chain
Posterior
 Superior laryngeal nerve (from the vagus n, which is posterolaterally; so SLN will be cross
posteriorly)

 External carotid (near origin)

 Wall of pharynx
Medially
 Ascending pharyngeal artery

 Internal jugular vein (moves posteriorly at entrance to skull)

Laterally  Vagus nerve (most posterolaterally)

 Sternocleidomastoid
 Lingual and facial veins
Anteriorly
 Hypoglossal nerve

Relations in the carotid canal

  Internal carotid plexus
 Cochlea and middle ear cavity
 Trigeminal ganglion (superiorly)
 Leaves canal lies above the foramen lacerum

Path and relations in the cranial cavity

The artery bends sharply forwards in the cavernous sinus, the aducens nerve lies close to its inferolateral aspect.
The oculomotor, trochlear, opthalmic and, usually, the maxillary nerves lie in the lateral wall of the sinus.

Near the superior orbital fissure it turns posteriorly and passes postero-medially to pierce the roof of the cavernous
sinus inferior to the optic nerve. It then passes between the optic and oculomotor nerves to terminate
below the anterior perforated substance by dividing into the anterior and middle cerebral arteries.

Branches

 Anterior and middle cerebral artery

 Ophthalmic artery
 Posterior communicating artery
 Anterior choroid artery
 Meningeal arteries
 Hypophyseal arteries

Common carotid artery

The right common carotid artery arises at the bifurcation of the brachiocephalic trunk, the left common carotid arises
from the arch of the aorta. Both terminate at the level of the upper border of the thyroid cartilage (the lower border of
the third cervical vertebra) by dividing into the internal and external carotid arteries.

Left common carotid artery

This vessel arises immediately to the left and slightly behind the origin of the brachiocephalic trunk. Its thoracic portion
is 2.5- 3.5 cm in length and runs superolaterally to the sternoclavicular joint.

In the thorax
The vessel is in contact, from below upwards, with the trachea, left recurrent laryngeal nerve, left margin of the
oesophagus. Anteriorly the left brachiocephalic vein runs across the artery, and the cardiac branches from the left
vagus descend in front of it. These structures together with the thymus and the anterior margins of the left lung and
pleura separate the artery from the manubrium.

In the neck
The artery runs superiorly deep to sternocleidomastoid and then enters the anterior triangle. At this point it lies within
the carotid sheath with the vagus nerve and the internal jugular vein. Posteriorly the sympathetic trunk lies between
the vessel and the prevertebral fascia. At the level of C7 the vertebral artery and thoracic duct lie behind it. The
anterior tubercle of C6 transverse process is prominent and the artery can be compressed against this structure (it
corresponds to the level of the cricoid).
Anteriorly at C6 the omohyoid muscle passes superficial to the artery.
Within the carotid sheath the jugular vein lies lateral to the artery.

Right common carotid artery

The right common carotid arises from the brachiocephalic artery. The right common carotid artery corresponds with the
cervical portion of the left common carotid, except that there is no thoracic duct on the right. The oesophagus is less
closely related to the right carotid than the left.
Summary points about the carotid anatomy

Path
Passes behind the sternoclavicular joint (12% patients above this level) to the upper border of the thyroid cartilage, to
divide into the external (ECA) and internal carotid arteries (ICA).

Relations

 Level of 6th cervical vertebra crossed by omohyoid

 Then passes deep to the thyrohyoid, sternohyoid, sternomastoid muscles.
 Passes anterior to the carotid tubercle (transverse process 6th cervical vertebra)-NB compression here stops
haemorrhage.
 The inferior thyroid artery passes posterior to the common carotid artery.
 Then : Left common carotid artery crosses the thoracic duct, Right common carotid artery crossed by recurrent
laryngeal nerve
Internal jugular vein
Each jugular vein begins in the jugular foramen, where they are the continuation of the sigmoid sinus. They terminate
at the medial end of the clavicle where they unite with the subclavian vein.

The vein lies within the carotid sheath throughout its course.

Below the skull the internal carotid artery and last four cranial nerves are anteromedial to the vein. XI, X, IX exit from
the jugular foramen. XII (hypoglossal) exits from the hypoglossal canal, which lies medial to the jugular foramen.

Thereafter it is in contact medially with the internal (then common) carotid artery. The vagus lies posteromedially.

At its superior aspect, the vein is overlapped by sternocleidomastoid and covered by it at the inferior aspect of the
vein.

Below the transverse process of the atlas it is crossed on its lateral side by the accessory nerve.

At its mid point it is crossed by the inferior root of the ansa cervicalis.

Posterior to the vein are the transverse processes of the cervical vertebrae, the phenic nerve as it descends on the
scalenus anterior, and the first part of the subclavian artery.

On the left side its also related to the thoracic duct.

jugular foramen
The jugular foramen may be divided into three compartments:

 Anterior compartment transmits the inferior petrosal sinus

 Middle compartment transmits cranial nerves IX, X and XI
 Posterior compartment transmits the sigmoid sinus

Anterior triangle of the neck

Boundaries
Anterior border of the Sternocleidomastoid
Lower border of mandible
Anterior midline

Sub triangles (divided by Digastric above and Omohyoid)

 Muscular triangle: Neck strap muscles

 Carotid triangle: Carotid sheath
 Submandibular Triangle (digastric)

Contents of the anterior triangle

Submandibular gland
Submandibular nodes
Digastric (submandibular) triangle Facial vessels
Hypoglossal nerve
Lingual nerve
Strap muscles
Muscular triangle
Jugular vein
Carotid sheath (Common carotid, vagus and internal jugular vein)
Carotid triangle
Ansa cervicalis
Nerve supply to digastric muscle

 Anterior: Mylohyoid nerve

 Posterior: Facial nerve

Should the strap muscles require division during surgery they should be divided in their upper half. This is because
their nerve supply from the ansa cervicalis enters in their lower half.

To access the sub mandibular gland a transverse incision 3cm below the mandible should be made. Incisions located
higher than this may damage the marginal mandibular branch of the facial nerve.

The transverse cervical nerve lies within the posterior triangle (the transverse cervical nerve divides into superior and
inferior branches of the anterior margin of SCM).

The anterior jugular vein is formed in the submental region and descends in the superficial fascia near the median
plane. It passes inferior to enter the suprasternal space, it is linked to the contralateral anterior jugular vein by the
jugular venous arch .

Posterior triangle of the neck

Boundaries

Apex Sternocleidomastoid and the Trapezius muscles at the Occipital bone

Anterior Posterior border of the Sternocleidomastoid

Posterior Anterior border of the Trapezius

Base Middle third of the clavicle

Contents

 Accessory nerve
 Phrenic nerve
Nerves  The three trunks of the brachial plexus
 Branches of the cervical plexus: Supraclavicular nerve, transverse cervical nerve, great auricular
nerve, lesser occipital nerve

 External jugular vein

Vessels
 Subclavian artery (third part- lateral to scalene anterior)

 Inferior belly of omohyoid

Muscles  Scalene

Lymph  Supraclavicular
nodes  Occipital

ansa cervicalis is a content of the anterior triangle of the neck, NOT POSTERIOR
The external jugular vein runs obliquely in the superficial fascia of the posterior triangle. It drains into the subclavian
vein. During surgical exploration of this area the external jugular vein may be injured and troublesome bleeding may
result.

The internal jugular vein and carotid arteries are located in the anterior triangle. The third, and not the second, part of
the subclavian artery is also a content of the posterior triangle

Submandibular gland
Relations of the submandibular gland
Platysma, deep fascia and mandible
Submandibular lymph nodes
Superficial Facial vein (facial artery near mandible)
Marginal mandibular nerve
Cervical branch of the facial nerve
Facial artery (inferior to the mandible)
Mylohyoid muscle
Hyoglossus muscle
Deep
Lingual nerve
Sub mandibular duct
Hypoglossal nerve
Submandibular ganglion

The marginal mandibular nerve lies deep to platysma. It supplies the depressor anguli oris and the depressor labii
inferioris. If injured it may lead to facial asymmetry and dribbling.

Submandibular duct (Wharton's duct)

 Opens lateral to the lingual frenulum on the anterior floor of mouth.

 5 cm length
 Lingual nerve wraps around Wharton's duct. As the duct passes forwards it crosses medial to the nerve to lie
above it and then crosses back, lateral to it, to reach a position below the nerve.
As the nerve descend it is lateral to the duct. Then goes inferior to it and crosses to its medial side and then
ascends medial to it.
 Hypoglossal nerve is also in close relationship to the Wharton’s duct (inferior to the duct)
 Sup to inferor: lingual n, Wharton’s duct, hypoglossal nerve

Innervation

 Sympathetic innervation- Derived from superior cervical ganglion

 Parasympathetic innervation- Submandibular ganglion via lingual nerve (chorda tympani, facial nerve)

Arterial supply
Branch of the facial artery. The facial artery passes through the gland to groove its deep surface. It then emerges onto
the face by passing between the gland and the mandible.

Venous drainage
Anterior facial vein (lies deep to the Marginal Mandibular nerve)
Lymphatic drainage
Deep cervical and jugular chains of nodes

Three cranial nerves may be injured during submandibular gland excision.

1. Marginal mandibular branch of the facial nerve

2. Lingual nerve
3. Hypoglossal nerve

Hypoglossal nerve damage may result in paralysis of the ipsilateral aspect of the tongue. The nerve itself lies deep to
the capsule surrounding the gland and should not be injured during an intracapsular dissection. The lingual nerve is
probably at greater risk of injury. However, the effects of lingual nerve injury are sensory rather than motor.

The facial artery lies between the gland and mandible and is often ligated during excision of the gland. The lingual
artery may be encountered but this is usually later in the operative process as Whartons duct is mobilised.

When approaching the submandibular gland the facial vein and submandibular lymph nodes are the most superficially
encountered structures.

Each sub mandibular gland has a superficial and deep part, separated by the mylohyoid muscle. The facial artery passes
in a groove on the superficial aspect of the gland. It then emerges onto the surface of the face by passing between the
gland and the mandible. The facial vein is encountered first in this surgical approach because the incision is made 4cm
below the mandible (to avoid injury to the marginal mandibular nerve).

Vagus nerve
The vagus nerve has mixed functions and supplies the structures from the fourth and sixth pharyngeal arches. It also
supplies the fore and midgut sections of the embryonic gut tube. It carries afferent fibres from these areas (viz; pharynx,
larynx, oesophagus, stomach, lungs, heart and great vessels). The efferent fibres of the vagus are of two main types. The
first are preganglionic parasympathetic fibres distributed to the parasympathetic ganglia that innervate smooth muscle
of the innervated organs (such as gut). The second type of efferent fibres have direct skeletal muscle innervation, these
are largely to the muscles of the larynx and pharynx.

Origin and course

The vagus arises from the lateral surface of the medulla oblongata by a series of rootlets. It is related to the
glossopharyngeal nerve cranially and the accessory nerve caudally. It exits through the jugular foramen and is
contained within its own dural sheath alongside the accessory nerve. In the neck it descends vertically in the carotid
sheath where it is closely related to the internal and common carotid arteries. It leaves the neck and enters the
mediastinum. On the right it passes anterior to the first part of the subclavian artery, on the left it lies in the
interval between the common carotid and subclavian arteries.
In the mediastinum both nerves pass postero-inferiorly and reach the posterior surface of the corresponding lung root.
These then branch into both lungs. At the inferior end of the mediastinum these plexuses reunite to form the formal
vagal trunks that pass through the oesophageal hiatus and into the abdomen. The anterior and posterior vagal trunks
are formal nerve fibres these then splay out once again sending fibres over the stomach and posteriorly to the coeliac
plexus. Branches pass to the liver, spleen and kidney.

Communications and branches

Communication Details
Superior ganglion Located in jugular foramen
Communicates with the superior cervical sympathetic ganglion, accessory nerve
Communication Details
Two branches; meningeal and auricular (the latter may give rise to vagal stimulation following
instrumentation of the external auditory meatus)
Communicates with the superior cervical sympathetic ganglion, hypoglossal nerve and loop between
first and second cervical ventral rami
Inferior ganglion
Two branches; pharyngeal (supplies pharyngeal muscles) and superior laryngeal nerve (inferomedially-
deep to both carotid arteries)

Branches in the neck

Branch Detail
Arise at various points and descend into thorax
Superior and inferior
On the right these pass posterior to the subclavian artery
cervical cardiac
On the left the superior branch passes between the arch of the aorta and the trachea to
branches
connect with the deep cardiac plexus. The inferior branch descends with the vagus itself.
Arises from vagus anterior to the first part of the subclavian artery, hooks under it, and
Right recurrent
ascends superomedially. It passes close to the common carotid and finally the inferior thyroid
laryngeal nerve
artery to insert into the larynx

Branches in the thorax

Branch Details
Arises from the vagus on the aortic arch. It hooks around the inferior surface of the arch, posterior to
Left recurrent
the ligamentum arteriosum and passes upwards through the superior mediastinum and lower part of
laryngeal
the neck. It lies in the groove between oesophagus and trachea (supplies both). It passes with the
nerve
inferior thyroid artery and inserts into the larynx.
Thoracic and
There are extensive branches to both the heart and lung roots. These pass throughout both these
cardiac
viscera. The fibres reunite distally prior to passing into the abdomen.
branches

Abdominal branches
After entry into the abdominal cavity the nerves branch extensively. In previous years the extensive network of the distal
branches (nerves of Laterjet) over the surface of the distal stomach were important for the operation of highly selective
vagotomy. The use of modern PPI's has reduced the need for such highly selective procedures. Branches pass to the
coeliac axis and alongside the vessels to supply the spleen, liver and kidney.

Cranial nerve lesions

May be injured in basal skull fractures or involved in frontal lobe tumour extension. Loss of
Olfactory nerve olfactory nerve function in relation to major CNS pathology is seldom an isolated event and thus it is
poor localiser of CNS pathology.
Optic nerve Problems with visual acuity may result from intra ocular disorders. Problems with the blood supply
such as amaurosis fugax may produce temporary visual distortion. More important surgically is the
pupillary response to light. The pupillary size may be altered in a number of disorders.

Nerves involved in the resizing of the pupil connect to the pretectal nucleus of the high midbrain,
bypassing the lateral geniculate nucleus and the primary visual cortex. From the pretectal nucleus
neurones pass to the Edinger - Westphal nucleus, motor axons from here pass along with the
oculomotor nerve. They synapse with ciliary ganglion neurones; the parasympathetic axons from
this then innervate the iris and produce miosis. The miotic pupil is seen in disorders such as Horner's
 syndrome or opiate overdose.
Mydriasis is the dilatation of the pupil in response to disease, trauma, drugs (or the dark!). It is
pathological when light fails to induce miosis. The radial muscle is innervated by the sympathetic
nervous system. Because the parasympathetic fibres travel with the oculomotor nerve they will be
damaged by lesions affecting this nerve (e.g. cranial trauma).
The response to light shone in one eye is usually a constriction of both pupils. This indicates intact
direct and consensual light reflexes. When the optic nerve has an afferent defect the light shining on
the affected eye will produce a diminished pupillary response in both eyes. Whereas light shone on
the unaffected eye will produce a normal pupillary response in both eyes. This is referred to as the
Marcus Gunn pupil and is seen in conditions such as optic neuritis. In a total CN II lesion shining the
light in the affected eye will produce no response.
The pupillary effects are described above. In addition it supplies all ocular muscles apart from
Oculomotor nerve lateral rectus and superior oblique. Thus the affected eye will be deviated inferolaterally.
Levator palpebrae superioris may also be impaired resulting in impaired ability to open the eye.
Trochlear nerve The eye will not be able to look down.
Largest cranial nerve. Exits the brainstem at the pons. Branches are ophthalmic, maxillary and
mandibular. Only the mandibular branch has both sensory and motor fibres. Branches converge to
form the trigeminal ganglion (located in Meckels cave). It supplies the muscles of mastication and
also tensor veli palatine, mylohyoid, anterior belly of digastric and tensor tympani. The detailed
descriptions of the various sensory functions are described in other areas of the website. The
Trigeminal nerve
corneal reflex is important and is elicited by applying a small tip of cotton wool to the cornea, a
reflex blink should occur if it is intact. It is mediated by: the naso ciliary branch of the ophthalmic
branch of the trigeminal (sensory component) and the facial nerve producing the motor response.
Lesions of the afferent arc will produce bilateral absent blink and lesions of the efferent arc will
result in a unilateral absent blink.
The affected eye will have a deficit of abduction. This cranial nerve exits the brainstem between
Abducens nerve the pons and medulla. It thus has a relatively long intra cranial course which renders it susceptible
to damage in raised intra cranial pressure.
Emerges from brainstem between pons and medulla. It controls muscles of facial expression and
taste from the anterior 2/3 of the tongue. The nerve passes into the petrous temporal bone and
into the internal auditory meatus. It then passes through the facial canal and exits at the
stylomastoid foramen. It passes through the parotid gland and divides at this point. It does not
Facial nerve
innervate the parotid gland. Its divisions are considered in other parts of the website. Its motor
fibres innervate orbicularis oculi to produce the efferent arm of the corneal reflex. In surgical
practice it may be injured during parotid gland surgery or invaded by malignancies of the gland and
a lower motor neurone on the ipsilateral side will result.
Exits from the pons and then passes through the internal auditory meatus. It is implicated in
sensorineural hearing loss. Individuals with sensorineural hearing loss will localise the sound in
webers test to the normal ear. Rinnes test will be reduced on the affected side but should still
Vestibulo-cochlear work. These two tests will distinguish sensorineural hearing loss from conductive deafness. In the
nerve latter condition webers test will localise to the affected ear and Rinnes test will be impaired on the
affected side. Surgical lesions affecting this nerve include CNS tumours and basal skull fractures. It
may also be damaged by the administration of ototoxic drugs (of which gentamicin is the most
commonly used in surgical practice).
Exits the pons just above the vagus. Receives sensory fibres from posterior 1/3 tongue, tonsils,
pharynx and middle ear (otalgia may occur following tonsillectomy). It receives visceral afferents
from the carotid bodies. It supplies parasympathetic fibres to the parotid gland via the otic
Glossopharyngeal
ganglion and motor function to stylopharyngeaus muscle. The sensory function of the nerve is
nerve
tested using the gag reflex.
The glossopharyngeal nerve supplies this area and the ear and otalgia may be the result of referred
pain.
 Leaves the medulla between the olivary nucleus and the inferior cerebellar peduncle. Passes
Vagus nerve through the jugular foramen and into the carotid sheath. Details of the functions of the vagus nerve
are covered in the website under relevant organ sub headings.
Exists from the caudal aspect of the brainstem (multiple branches) supplies trapezius and
Accessory nerve sternocleidomastoid muscles. The distal portion of this nerve is most prone to injury during surgical
procedures.
Emerges from the medulla at the preolivary sulcus, passes through the hypoglossal canal. It lies on
Hypoglossal nerve
the carotid sheath and passes deep to the posterior belly of digastric to supply muscles of the
tongue (except palatoglossus). Its location near the carotid sheath makes it vulnerable during
carotid endarterectomy surgery and damage will produce ipsilateral defect in muscle function.
Cranial nerves carrying parasympathetic fibres
X IX VII III (1973)

The parasympathetic functions served by the cranial nerves include:

III (oculomotor) Pupillary constriction and accommodation
VII (facial) Lacrimal gland, submandibular and sublingual glands
IX (glossopharyngeal) Parotid, carotid sinus nerve
X (vagus) Heart and abdominal viscera, aortic arch baroreceptors nerve
The optic nerve carries no parasympathetic fibres.

The cranial preganglionic parasympathetic nerves arise from specific nuclei in the CNS. These synapse at one of four
parasympathetic ganglia; otic, pterygopalatine, ciliary and submandibular. From these ganglia the parasympathetic
nerves complete their journey to their target tissues via CN V (trigeminal) branches (ophthalmic nerve CNV branch 1,
Maxillary nerve CN V branch2, mandibular nerve CN V branch 3)

Facial nerve
The chorda tympani branches inside the facial canal and will therefore be unaffected by this most unfortunate event!
The corneal reflex is mediated by the opthalmic branch of the trigeminal nerve sensing the stimulus on the cornea, lid or
conjunctiva; the facial nerve initiates the motor response of the reflex.

The facial nerve is the main nerve supplying the structures of the second embryonic branchial arch. It is predominantly
an efferent nerve to the muscles of facial expression, digastric muscle and also to many glandular structures. It contains
a few afferent fibres which originate in the cells of its genicular ganglion and are concerned with taste.

Supply - 'face, ear, taste, tear'

 Face: muscles of facial expression

 Ear: nerve to stapedius
 Taste: supplies anterior two-thirds of tongue
 Tear: parasympathetic fibres to lacrimal glands, also submandibular, submental, small salivary glands

Path
Subarachnoid path

 Origin: motor- pons, sensory- nervus intermedius

  Pass through the petrous temporal bone into the internal auditory meatus with the vestibulocochlear nerve.
Here they combine to become the facial nerve.

Facial canal path

 The canal passes superior to the vestibule of the inner ear

 At the medial aspect of the middle ear, it becomes wider and contains the geniculate ganglion.

- 3 branches:
1. greater petrosal nerve
2. nerve to stapedius
3. chorda tympani

Stylomastoid foramen

 Passes through the stylomastoid foramen (tympanic cavity anterior and mastoid antrum posteriorly)
 Posterior auricular nerve and branch to posterior belly of digastric and stylohyoid muscle

Face
Enters parotid gland and divides into 5 branches:

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

Damage to the nerve in the bony canal may result in impaired innervation to stapedius and therefore sounds are no
longer dampened. Another cause of hyperacusis is increased activity in the tensor tympani muscle, this is innervated by
the trigeminal nerve.

Chorda tympani
The chorda tympani branch of the facial nerve passes forwards through itrs canaliculus into the middle ear, and crosses
the medial aspect of the tympanic membrane, b/w the two layers of pars flaccida. It then passes antero-inferiorly
through petrotympanic fissure, in the infratemporal fossa, where it joins the lingual nerve. It distributes taste fibres to
the anterior two thirds of the tongue.

Buccal branch supplies

Zygomaticus minor Elevates upper lip

Risorius Aids smile
Buccinator Pulls corner of mouth backward and compresses cheek
Levator anguli oris Pulls angles of mouth upward and toward midline
Orbicularis Closes and tightens lips together
Nasalis Flares nostrils and compresses nostrils
Trigeminal nerve
The trigeminal nerve is the main sensory nerve of the head. In addition to its major sensory role, it also innervates the
muscles of mastication.

Distribution of the trigeminal nerve

 Scalp
 Face
 Oral cavity (and teeth)
Sensory
 Nose and sinuses
 Dura mater

 Muscles of mastication
 Mylohyoid
 Anterior belly of digastric
Motor
 Tensor tympani
 Tensor palati

 Ciliary
 Sphenopalatine
Autonomic connections (ganglia)  Otic
 Submandibular
Path

 Originates at the pons

 Sensory root forms the large, crescentic trigeminal ganglion within Meckel's cave, and contains the cell bodies
of incoming sensory nerve fibres. Here the 3 branches exit.
 The motor root cell bodies are in the pons and the motor fibres are distributed via the mandibular nerve. The
motor root is not part of the trigeminal ganglion.

Branches of the trigeminal nerve

Ophthalmic nerve Sensory only
Maxillary nerve Sensory only
Mandibular nerve Sensory and motor

Sensory
Exits skull via the superior orbital fissure
Sensation of: scalp and forehead, the upper eyelid, the conjunctiva and cornea of the eye, the nose
(including the tip of the nose, except alae nasi), the nasal mucosa, the frontal sinuses, and parts of the
meninges (the dura and blood vessels).
Ophthalmic
The lateral aspect of the external nose is innervated by lateral nasal branches of the anterior ethmoidal
nerve. The ethmoidal nerve is a branch of the nasociliary nerve which is one of the divisions of the
trigeminal.
Exit skull via the foramen rotundum
Maxillary Sensation: lower eyelid and cheek, the nares and upper lip, the upper teeth and gums, the nasal
nerve mucosa, the palate and roof of the pharynx, the maxillary, ethmoid and sphenoid sinuses, and parts of
the meninges.
Exit skull via the foramen ovale
Mandibular
Sensation: lower lip, the lower teeth and gums, the chin and jaw (except the angle of the jaw), parts of
nerve
the external ear, and parts of the meninges.

Motor
Distributed via the mandibular nerve.
The following muscles of mastication are innervated:

 Masseter
 Temporalis
 Medial pterygoid (lateral pterygoid plate to medial side of angle and ramus of mandible) ->closes mouth
 Lateral pterygoid (lateral pterygoid plate to TMJ capsule and condyloid process of mandible)-> opens mouth

Other muscles innervated include:

 Tensor veli palatini

 Mylohyoid
 Anterior belly of digastric
 Tensor tympani
Spinothalamic tract
The spinothalamic tract transmits impulses from receptors which measure crude(light) touch, pressure, pain
and temperature. The spinothalamic tract comprises the lateral and anterior spinothalamic tracts, the lateral
typically transmits pain and temperature and the anterior crude(light) touch and pressure.

Neurones transmitting these signals will typically ascend by one or two vertebral levels in Lissaurs tract prior to
decussating in the spinal cord itself. Neurones then pass rostrally in the cord to connect at the thalamus.

Spinothalamic tract- Pain and temperature

Vestibulospinal tract- Motor neuronal signals relating to posture
Cuneate fasciculus- Fine touch, pressure and proprioception
Posterior spinocerebellar tract- Proprioceptive signals to cerebellum
Anterior corticospinal tract- Conveys motor signals from precentral gyrus to motor cells within the cord

Cerebrospinal fluid
The CSF fills the space between the arachnoid mater and pia mater (covering surface of the brain). The total volume of
CSF in the brain is approximately 150ml. Approximately 500 ml is produced by the ependymal cells in the choroid
plexus (70%), or blood vessels (30%). It is reabsorbed via the arachnoid granulations which project into the venous
sinuses.

Circulation
1. Lateral ventricles (via foramen of Munro)
2. 3rd ventricle
3. Cerebral aqueduct (aqueduct of Sylvius)
4. 4th ventricle (via foramina of Magendie and Luschka)
5. Subarachnoid space
6. Reabsorbed into the venous system via arachnoid granulations into superior sagittal sinus

Composition

 Glucose: 50-80mg/dl
 Protein: 15-40 mg/dl
 Red blood cells: Nil
 White blood cells: 0-3 cells/ MM3
CAVERNOUS SINUS
Mnemonic for contents of cavernous sinus:
O TOM CAT

Occulomotor nerve (III)

Trochlear nerve (IV)
Ophthalmic nerve (V1)
Maxillary nerve (V2)
Carotid artery
Abducent nerve (VI)
T

OTOM=lateral wall components

CA= components within sinus

The cavernous sinuses are paired and are situated on the body of the sphenoid bone. It runs from the superior orbital
fissure to the petrous temporal bone.

Relations

Medial Lateral

Pituitary fossa
Temporal lobe
Sphenoid sinus

Contents

(from top to bottom:)

Oculomotor nerve
Lateral wall components Trochlear nerve
Ophthalmic nerve
Maxillary nerve

(from medial to lateral:)

Contents of the sinus Internal carotid artery (and sympathetic plexus)
Abducens nerve

Blood supply
Ophthalmic vein, superficial cortical veins, basilar plexus of veins posteriorly.

Drains into the internal jugular vein via: the superior and inferior petrosal sinuses
Trapezius
Medial third of the superior nuchal line of the occiput
External occipital protruberance
Origin
Ligamentum nuchae
Spines of C7 and all thoracic vertebrae and all intervening interspinous ligaments
Posterior border of the lateral third of the clavicle
Insertion Medial border of the acromion
Upper border of the crest of the spine of the scapula
Nerve supply Spinal portion of the accessory nerve

Elevation of the shoulder girdle

Actions
Lateral rotation of the scapula

The accessory nerve has a number of lymph nodes applied to it near the sternocleidomastoid muscle. It is particularly at
risk if SCM is mobilized. If injured, the trapezius muscle and SCM will be paralysed.

Ear- anatomy
The external aspect of the tympanic membrane is lined by stratified squamous epithelium. This is significant clinically in
the development of middle ear infections when this type of epithelium may migrate inside the middle ear.

The ea r is composed of three anatomically distinct regions.

External ear
Auricle is composed of elastic cartilage covered by skin. The lobule has no cartilage and contains fat and fibrous tissue.

External auditory meatus is approximately 2.5cm long.

Lateral third of the external auditory meatus is cartilaginous and the medial two thirds is bony.
The region is innervated by the greater auricular nerve. The auriculotemporal branch of the trigeminal nerve supplies
most of the external auditory meatus and the lateral surface of the auricle.

Middle ear
Space between the tympanic membrane and cochlea. The aditus leads to the mastoid air cells is the route through
which middle ear infections may cause mastoiditis. Anteriorly the eustacian tube connects the middle ear to the naso
pharynx.
The tympanic membrane consists of:

 Outer layer of stratified squamous epithelium.

 Middle layer of fibrous tissue.
 Inner layer of mucous membrane continuous with the middle ear.

The tympanic membrane is approximately 1cm in diameter.

The chorda tympani nerve passes on the medial side of the pars flaccida.

The middle ear is innervated by the glossopharyngeal nerve and pain may radiate to the middle ear following
tonsillectomy.

Ossicles
Malleus attaches to the tympanic membrane (the Umbo).
Malleus articulates with the incus (synovial joint).
Incus attaches to stapes (another synovial joint).

Internal ear
Cochlea, semi circular canals and vestibule

Organ of corti is the sense organ of hearing and is located on the inside of the cochlear duct on the basilar membrane.

Vestibule accommodates the utricule and the saccule. These structures contain endolymph and are surrounded by
perilymph within the vestibule.

The semicircular canals lie at various angles to the petrous temporal bone. All share a common opening into the
vestibule.

Foramina of the base of the skull

 Foramen Location Contents

Mnemonic: OVALE

Otic ganglion
V3 (Mandibular nerve:3rd branch of
Foramen ovale Sphenoid bone trigeminal)
Accessory meningeal artery
Lesser petrosal nerve
Emissary veins

Middle meningeal artery

Foramen spinosum Sphenoid bone
Meningeal branch of the Mandibular nerve

Foramen
Sphenoid bone Maxillary nerve (V2)
rotundum

Base of the medial pterygoid plate.

Located between the sphenoid, the Internal carotid artery*
Foramen lacerum/
apex of the petrous temporal and the Nerve and artery of the pterygoid canal
carotid canal
basilar part of the occipital
Greater petrosal nerve

Anterior: inferior petrosal sinus

Intermediate: glossopharyngeal, vagus, and accessory
nerves.
Jugular foramen Temporal bone
Posterior: sigmoid sinus (becoming the internal jugular
vein) and some meningeal branches from the occipital and
ascending pharyngeal arteries.

Anterior and posterior spinal arteries

Foramen magnum Occipital bone Vertebral arteries
Medulla oblongata

Stylomastoid Stylomastoid artery

Temporal bone
foramen Facial nerve

Oculomotor nerve (III)

Recurrent meningeal artery
Trochlear nerve (IV)
Superior orbital
Sphenoid bone Lacrimal, frontal and nasociliary branches of ophthalmic
fissure
nerve (V1)
Abducent nerve (VI)
Superior ophthalmic vein

*= In life the foramen lacerum is occluded by a cartilagenous plug. The ICA initially passes into the carotid canal which
ascends superomedially to enter the cranial cavity through the foramen lacerum.
Circle of Willis
The two internal carotid arteries and two vertebral arteries form an anastomosis known as the Circle of Willis on the
inferior surface of the brain.

Each half of the circle is formed by:

1. Anterior communicating artery (branch of anterior cerebral artery)
2. Anterior cerebral artery
3. Internal carotid artery
4. Posterior communicating artery
5. Posterior cerebral arteries and the termination of the basilar artery

The circle and its branches supply; the corpus striatum, internal capsule, diencephalon(thalamus,
hypothalamus) and midbrain.

There is minimum mixing of blood passing through the vessels.

Vertebral arteries

 Enter the cranial cavity via foramen magnum

 Lie in the subarachnoid space
 Ascend on anterior surface of medulla oblongata
 Unite to form the basilar artery at the base of the pons

Branches:

 Posterior spinal artery

 Anterior spinal artery
 Posterior inferior cerebellar artery

Basilar artery
Branches:

 Anterior inferior cerebellar artery

 Labyrinthine artery
 Pontine arteries
 Superior cerebellar artery
 Posterior cerebral artery

Internal carotid arteries

Branches:

 anterior cerebral artery.

 middle cerebral artery,
 ophthalmic artery,
  anterior choroidal artery,
 posterior communicating artery,
 superior hypophyseal artery.

Parotid gland
Anatomy of the parotid gland
Location Overlying the mandibular ramus; anterior and inferior to the ear.
Crosses the masseter, pierces the buccinator and drains adjacent to the 2nd upper molar
tooth (Stensen's duct).
Mid third of the line from the tragus to philtrum/medial upper lip

Salivary duct

Structures passing
through the gland
 Facial nerve (Mnemonic: The Zebra Buggered My Cat; Temporal Zygomatic, Buccal,
Mandibular, Cervical)
 External carotid artery
 Retromandibular vein
 Auriculotemporal nerve

 Anterior: masseter, medial pterygoid, superficial temporal and maxillary artery, facial
nerve, stylomandibular ligament
Relations  Posterior: posterior belly digastric muscle, sternocleidomastoid, stylohyoid, internal
carotid artery, mastoid process, styloid process

Arterial supply Branches of external carotid artery

Venous drainage Retromandibular vein
Lymphatic drainage Deep cervical nodes
Parasympathetic-otig ganglion CNIX
Sympathetic-Superior cervical ganglion
Nerve innervation
Sensory- Greater auricular nerve

Parasympathetic stimulation produces a water rich, serous saliva. Sympathetic stimulation leads to the
production of a low volume, enzyme-rich saliva.

The greater auricular nerve and in particular its lobular branch is commonly injured in parotid surgery and consent
usually makes particular reference to this. In a superficial parotidectomy, the facial nerve should not be injured and this
is less common than a greater auricular nerve injury. Where facial nerve paresis occurs, its usually transient.

The facial nerve is the most superficial structure in the parotid gland. Slightly deeper to this lies the retromandibular
vein, with the ECA lying most deeply.
Structures passing through the parotid gland

 Facial nerve and branches

 External carotid artery (and its branches; the maxillary and superficial temporal)
 Retromandibular vein
 Auriculotemporal nerve

The mandibular nerve is well separated from the parotid gland.

The maxillary vein joins to the superficial temporal vein and they form the retromandibular vein which then runs
through the parotid gland.
The auriculotemporal nerve runs through the gland. Following a parotidectomy this nerve may be damaged and during
neuronal regrowth may then attach to sweat glands in this region. This can then cause gustatory sweating/ Freys
Syndrome
The facial nerve branch is the marginal mandibular branch and this is related to the gland.

supraorbital fissure
Mnemonic for the nerves passing through the supraorbital fissure:

Live Frankly To See Absolutely No Insult

Lacrimal
Frontal
Trochlear
Superior Division of Oculomotor
Abducens
Nasociliary
Inferior Division of Oculomotor nerve

The opthalmic artery arises from the internal carotid immediately after it has pierced the dura and arachnoid. It runs
through the optic canal below the optic nerve and within its dural and arachnoid sheaths. It terminates as the
supratrochlear and dorsal nasal arteries.

Tonsil
Anatomy

 Each palatine tonsil has two surfaces, a medial surface which projects into the pharynx and a lateral surface that
is embedded in the wall of the pharynx.
 They are usually 25mm tall by 15mm wide, although this varies according to age and may be almost completely
atrophied in the elderly.
 Their arterial supply is from the tonsillar artery, a branch of the facial artery.
 Its veins pierce the constrictor muscle to join the external palatine or facial veins. The external palatine vein is
immediately lateral to the tonsil, which may result in haemorrhage during tonsillectomy.
 Lymphatic drainage is the jugulodigastric node and the deep cervical nodes.

Tonsillitis

 Usually bacterial (50%)- group A Streptococcus. Remainder viral.

 May be complicated by development of abscess (quinsy). This may distort the uvula.
- Indications for tonsillectomy include recurrent acute tonsillitis, suspected malignancy, enlargement causing sleep
apnoea.
- Dissection tonsillectomy is the preferred technique with haemorrhage being the commonest complication. Delayed
otalgia may occur owing to irritation of the glossopharyngeal nerve.

The external palatine vein lies immediately lateral to the tonsil and if damaged may be a cause of reactionary
haemorrhage following tonsillectomy.

The glossopharyngeal nerve is the main sensory nerve for the tonsillar fossa. A lesser contribution is made by the lesser
palatine nerve. Because of this otalgia may occur following tonsillectomy.

Mouth innervation (lower jaw)

The branches of the lower molar and premolar teeth are supplied by branches of the inferior alveolar nerve. Those of
the canine and incisors by the incisive branch of the same nerve. The gingiva and supporting structures are innervated
by the lingual nerve.

Lacrimal apparatus
Comprises the lacrimal gland and its ducts, lacrimal canaliculi, lacrimal sac and naso lacrimal duct. It lies anteriorly in
the superolateral region of the orbit and is divided into 2 parts by the levator palpebrae superioris.

Numerous ducts empty glandular secretions into the lateral part of the superior fornix of the conjunctiva. The fluid so
produced finally accumulates in the lacrimal lake from which it drains via the lacrimal canaliculi, one with each eyelid.
Passing medially, the lacrimal canaliculi eventually join the lacrimal sac between the anterior and posterior lacrimal
crests, posterior to the medial palpebral ligament and anterior to the lacrimal part of the orbicularis oculi muscle. When
the orbicularis oculi muscle contracts during blinking, the small lacrimal part of the muscle dilates the lacrimal sac and
draws tears into it.

Lacrimal gland
Consists of an orbital part and palpebral part. They are continuous posterolaterally around the concave lateral edge of
the levator palpebrae superioris muscle.

The ducts of the lacrimal gland open into the superior fornix. Those from the orbital part penetrate the aponeurosis of
levator palpebrae superioris to join those from the palpebral part. Therefore excision of the palpebral part is
functionally similar to excision of the entire gland.

Nasolacrimal duct
Descends from the lacrimal sac to open anteriorly in the inferior meatus of the nose.

Innervation
Secretomotor fibres from the parasympathetic nervous system. The preganglionic parasympathetic neurons leave the
CNS in the facial nerve, enter the greater petrosal nerve and continue with this nerve until it becomes the nerve of
the pterygoid canal. The nerve of the pterygoid canal eventually joins the pterygopalatine ganglion where the pre-
ganglionic parasympathetic neurons synapse on post ganglionic parasympathetic neurons. The post ganglionic neurons
join the maxillary nerve and continue with it until the zygomatic nerve branches from it, and travels with the
zygomatic nerve until it gives off the zygomaticotemporal nerve which eventually distributes the post ganglionic
parasympathetic fibres in a small branch that joins the lacrimal nerve.

Sympathetic innervation follows a similar path to the parasympathetic path described above. Post ganglionic
sympathetic fibres originating in the superior cervical ganglion travel along the plexus surrounding the internal carotid.
They leave this plexus as the deep petrosal nerve and join the parasympathetic fibres in the nerve of the pterygoid
canal. Passing through the pterygopalatine ganglion (do NOT synapse), the parasympathetic fibres from this point
onwards follow the same path as the parasympathetic fibres to the lacrimal gland.
Greater petrosal + deep petrosal nerve= nerve to pterygoid canal
Vessels
Arterial supply is from branches of the ophthalmic artery and venous drainage is to the ophthalmic veins

Lacrimation reflex
Occurs in response to conjunctival irritation (or emotional events). The conjunctiva will send signals via the opthalmic
nerve. These then pass to the superior salivary centre. The efferent signals pass via the greater petrosal nerve
(parasympathetic preganglionic fibres) and the deep petrosal nerve which carries the post ganglionic sympathetic fibres.
The parasympathetic fibres will relay in the pterygopalatine ganglion, the sympathetic fibres do not synapse. They in
turn will relay to the lacrimal apparatus.

Ansa cervicalis
Branch of C1
Superior root
Anterolateral to carotid sheath

Derived from C2 and C3 roots, passes Posterolateral to the internal jugular vein (may lie either deep or
Inferior root
superficial to it)

Sternohyoid
Sternothyroid
Omohyoid
Innervation
NOT thyrohyoid (from C1 directly)

NOT geniohyoid (C1 directly)

The ansa cervicalis lies anterior to the carotid sheath. . It may be exposed by division of the pretracheal fascia at the
posterolateral aspect of the thyroid gland. The pre vertebral fascia lies more posteriorly and division of the investing
layer of fascia will not expose this nerve.

The nerve supply to the inferior strap muscles enters at their inferior aspect. Therefore when dividing these muscles
to expose a large goitre, the muscles should be divided in their upper half.

The ansa cervicalis is composed of a superior and inferior root, derived from C1, C2 and C3. The superior root arises
where the nerve crosses the internal carotid artery. It descends anterior to the carotid sheath in the anterior triangle. It
is joined in the region of the mid neck by the inferior root. The inferior root may pass either superficially or deep to the
internal jugular vein.

Vertebral artery
The vertebral artery is the first branch of the subclavian artery. Anatomically it is divisible into 4 regions:

 The first part runs to the foramen in the transverse process of C6. Anterior to this part lies the vertebral and
internal jugular veins. On the left side the thoracic duct is also an anterior relation.
 The second part runs superiorly through the foramina of the the transverse processes of the upper 6 cervical
vertebrae. Once it has passed through the transverse process of the axis it then turns superolaterally to the
atlas. It is accompanied by a venous plexus and the inferior cervical sympathetic ganglion.
 The third part runs posteromedially on the lateral mass of the atlas. It enters the sub occipital triangle, in the
groove of the upper surface of the posterior arch of the atlas. It then passes anterior to the edge of the
posterior atlanto-occipital membrane to enter the vertebral canal.
 The fourth part passes through the spinal dura and arachnoid,in the subarachnoid space, running superiorly
and anteriorly at the lateral aspect of the medulla oblongata. At the lower border of the pons it unites to
form the basilar artery.

The vertebral artery passes through the foramina which are located in the transverse processes of the cervical vertebra,
it does not traverse the intervertebral foramen.

Visual field defects

Lesions before optic chiasm:
Monocular vision loss = Optic nerve lesion
Bitemporal hemianopia = Optic chiasm lesion

Lesions after the optic chiasm:

Homonymous hemianopia = Optic tract lesion
Upper quadranopia = Temporal lobe lesion
Lower quadranopia = Parietal lobe lesion

 left homonymous hemianopia means visual field defect to the left, i.e. Lesion of right optic tract
 homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal-Superior)
 incongruous defects = optic tract lesion;
congruous defects = optic radiation lesion or occipital cortex
Homonymous hemianopia

 Incongruous defects: lesion of optic tract

 Congruous defects: lesion of optic radiation or occipital cortex
 Macula sparing: lesion of occipital cortex

Homonymous quadrantanopias

 Superior: lesion of temporal lobe

 Inferior: lesion of parietal lobe
 Mnemonic = PITS (Parietal-Inferior, Temporal-Superior)

Bitemporal hemianopia

 Lesion of optic chiasm

 Upper quadrant defect > lower quadrant defect = inferior compression, commonly a pituitary tumour
 Lower quadrant defect > upper quadrant defect = superior compression, commonly a craniopharyngioma

Parathyroid glands- anatomy

 Four parathyroid glands

 Located posterior to the thyroid gland
 They lie within the pretracheal fascia

Embryology
The parathyroids develop from the extremities of the third and fourth pharyngeal pouches. The parathyroids derived
from the fourth pharyngeal pouch are located more superiorly and are associated with the thyroid gland. Those
derived from the third pharyngeal pouch lie more inferiorly and may become associated with the thymus.

Blood supply
The blood supply to the parathyroid glands is derived from the inferior and superior thyroid arteries[1]. There is a rich
anastomosis between the two vessels. Venous drainage is into the thyroid veins.

Relations
Laterally Common carotid
Medially Recurrent laryngeal nerve, trachea
Anterior Thyroid
Posterior Pretracheal fascia
The common carotid artery is a lateral relation of the inferior parathyroid.

Oxyphil cells are typically found in parathyroid glands

Root of the neck

Thoracic Outlet

 Where the subclavian artery and vein and the brachial plexus exit the thorax and enter the arm.
 They pass over the 1st rib and under the clavicle.
 The subclavian vein is the most anterior structure and is immediately anterior to scalenus anterior and its
attachment to the first rib.
 Then subclavian artery passes between the anterior and middle scalene muscles.
 At the level of the first rib, the lower cervical nerve roots combine to form the 3 trunks of the brachial plexus.
The lowest trunk is formed by the union of C8 and T1, and this trunk lies directly posterior to the artery and
is in contact with the superior surface of the first rib.

Recurrent laryngeal nerve

 Branch of the vagus nerve

Path
Right

 Arises anterior to the subclavian artery and ascends obliquely next to the trachea, behind the common carotid
artery
 It is either anterior or posterior to the inferior thyroid artery

Left

 Arises left to the arch of the aorta

  Winds below the aorta
 Ascends along the side of the trachea

Then both

 Pass in a groove between the trachea and oesophagus

 Enters the larynx behind the articulation between the thyroid cartilage and cricoid
 Distributed to larynx muscles

Branches to

 Cardiac plexus
 Mucous membrane and muscular coat of the oesophagus and trachea

Innervates

 Intrinsic larynx muscles (excluding cricothyroid)

External carotid artery

The external carotid commences immediately lateral to the pharyngeal side wall. It ascends and lies anterior to the
internal carotid and posterior to the posterior belly of digastric and stylohyoid.

More inferiorly it is covered by sternocleidomastoid, passed anteriorly/superficially by hypoglossal nerves, lingual

and facial veins.
It then pierces the fascia of the parotid gland finally dividing into its terminal branches within the gland itself.

Surface marking of the carotid

This is an imaginary line drawn from the bifurcation of the common carotid passing behind the angle of the jaw to a
point immediately anterior to the tragus of the ear.

Branches of the external carotid artery

It has six main branches, three in front, two behind and one deep.

Superior thyroid
Three in front Lingual
Facial

Occipital
Two behind
Posterior auricular

Deep Ascending pharyngeal

It terminates by dividing into the superficial temporal and maxillary arteries in the parotid gland.

Lymphatic drainage of the auricle

 The lateral surface of the upper half drains to the superficial parotid lymph nodes
 The cranial/ medial surface of the superior half drains to the mastoid nodes and deep cervical lymph nodes
 The lower half and lobule drain into the superficial cervical lymph nodes.
carotid sheath
Contents of carotid sheath:
Common carotid artery
Internal carotid artery
Internal jugular vein
Vagus nerve

 At its lower end the carotid sheath is related to sternohyoid and sternothyroid.
 Opposite the cricoid cartilage the sheath is crossed by the superior belly of omohyoid.
 Above the cricoid cartilage the sheath is covered by the sternocleidomastoid muscle.
 Opposite the hyoid bone the sheath is crossed obliquely by the hypoglossal nerve.
 Above the level of the hyoid the vessels pass deep to the posterior belly of digastric and stylohyoid.

The carotid sheath is crossed anteriorly by the hypoglossal nerves and the ansa cervicalis.

The cervical sympathetic chain lies posteriorly between the sheath and the prevertebral fascia.

Embryological aortic arches

 The aortic arches are a series of six paired embryological vascular structures which give rise to the great arteries
of the neck and head.
 The first and second arches disappear early. A remnant of the 1st arch forms part of the maxillary artery. The
external carotid buds from the horns of the aortic sac left behind by the regression of the first two arches.
 The third aortic arch constitutes the commencement of the internal carotid artery, and is therefore named the
carotid arch. It contributes to the common carotid artery and the proximal portion of the internal carotid artery.
 The fourth right arch forms the right subclavian as far as the origin of its internal mammary branch. The fourth left
arch forms the arch of the aorta between the origin of the left carotid artery and the termination of the ductus
arteriosus.
 The fifth arch regresses or forms incompletely.
 The proximal part of the sixth right arch persists as the proximal part of the right pulmonary artery while the distal
section degenerates; The sixth left arch gives off the left pulmonary artery and forms the ductus arteriosus.
Thyroid gland

 Right and left lobes connected by isthmus

 Surrounded by sheath from pretracheal layer of deep fascia
 Apex: Lamina of thyroid cartilage
 Base: 4th-5th tracheal ring
 Pyramidal lobe: from isthmus
 May be attached to foramen caecum at the base of the tongue

Relations
 Sternothyroid
 Superior belly of omohyoid
Anteromedially  Sternohyoid
 Anterior aspect of sternocleidomastoid

Posterolaterally Carotid sheath

 Larynx
 Trachea
 Pharynx
 Oesophagus
Medially
 Cricothyroid muscle
 External laryngeal nerve (near superior thyroid artery)
 Recurrent laryngeal nerve (near inferior thyroid artery)

 Parathyroid glands
Posterior  Anastomosis of superior and inferior thyroid arteries

 Anteriorly: Sternothyroids, sternohyoids, anterior jugular veins

Isthmus  Posteriorly: 2nd, 3rd, 4th tracheal rings (attached via Ligament of Berry)

Blood Supply
 Superior thyroid artery (1st branch of external carotid)
 Inferior thyroid artery (from thyrocervical trunk)
Arterial
 Thyroidea ima (in 10% of population -from brachiocephalic artery or aorta)

 Superior and middle thyroid veins - into the IJV

Venous  Inferior thyroid vein - into the brachiocephalic veins

The pretracheal fascia encloses the thyroid and is unyielding. Therefore tense haematomas can develop.

The superior thyroid artery is the first branch of the external carotid artery as it arises near the level of the superior
horn of the thyroid cartilage. The superior thyroid artery then moves anterior, inferior, and towards the midline behind
the sternothyroid muscle to the superior pole of the lobe of the thyroid gland.
The inferior thyroid artery reaches the posterior surface of the lateral lobe of the thyroid gland at the level of the
junction of the upper two thirds and lower third of the outer border. (level of C6)

Cranial venous sinuses

The cranial venous sinuses are located within the dura mater. They have no valves which is important in the
potential for spreading sepsis. They eventually drain into the internal jugular vein.

They are:
1. Superior sagittal sinus The superior sagittal sinus is unpaired. It begins at the crista galli, where it may
communicate with the veins of the frontal sinus and sometimes with those of the nasal cavity. It arches
backwards in the falx cerebri to terminate at the internal occipital protuberance (usually into the right
transverse sinus). The parietal emissary veins link the superior sagittal sinus with the veins on the exterior
of the cranium. The superior sagittal sinus is at greatest risk in a vertex injury
2. Inferior sagittal sinus
3. Straight sinus
4. Transverse sinus
5. Sigmoid sinus
6. Confluence of sinuses
7. Occipital sinus
8. Cavernous sinus

The sigmoid sinus is joined by the inferior petrosal sinus to drain into the internal jugular vein.

Sympathetic nervous system- anatomy

The cell bodies of the pre-ganglionic efferent neurones lie in the lateral horn of the grey matter of the spinal cord in the
thoraco-lumbar regions.
The pre-ganglionic efferents leave the spinal cord at levels T1-L2. These pass to the sympathetic chain.
Lateral branches of the sympathetic chain connect it to every spinal nerve. These post ganglionic nerves will pass to
structures that receive sympathetic innervation at the periphery.

Sympathetic chains
These lie on the vertebral column and run from the base of the skull to the coccyx.
Cervical
Lie anterior to the transverse processes of the cervical vertebrae and posterior to the carotid sheath.
region
Thoracic Lie anterior to the neck of the upper ribs and and lateral sides of the lower thoracic vertebrae.They are
region covered by the parietal pleura
Lumbar Enter by passing posterior to the medial arcuate ligament . Lie anteriorly to the vertebrae and medial to
region psoas major.

Sympathetic ganglia

 Superior cervical ganglion lies anterior to C2 and C3.

 Middle cervical ganglion (if present) C6
 Stellate ganglion- anterior to transverse process of C7, lies posterior to the subclavian artery, vertebral artery
and cervical pleura.
 Thoracic ganglia are segmentally arranged.
 There are usually 4 lumbar ganglia.

Clinical importance
  Interruption of the head and neck supply of the sympathetic nerves will result in an ipsilateral Horners
syndrome.
 For treatment of hyperhidrosis the sympathetic denervation can be achieved by removing the second and
third thoracic ganglia with their rami. Removal of T1 will cause a Horners syndrome and is therefore not
performed.
 In patients with vascular disease of the lower limbs a lumbar sympathetomy may be performed,
either radiologically or (more rarely now) surgically. The ganglia of L2 and below are disrupted. If L1 is
removed then ejaculation may be compromised (and little additional benefit conferred as the preganglionic
fibres do not arise below L2.

Pituitary Gland
The pituitary gland is located within the sella turcica within the sphenoid bone in the middle cranial fossa. It is covered
by a dural fold and weighs around 0.5g. It is attached to the hypothalamus by the infundibulum. The anterior pituitary
receives hormonal stimuli from the hypothalamus by way of the hypothalamo-pituitary portal system. It develops from
a depression in the wall of the pharynx (Rathkes pouch).

Although the optic chiasm is closely related to the pituitary, and craniopharyngiomas may compress this structure
leading to bitemporal hemianopia, it is separated from the chiasm itself by a dural fold.

Anterior pituitary hormones

 Growth hormone
 Thyroid stimulating hormone
 ACTH
 Prolactin
 LH and FSH
 Melanocyte releasing hormone

Posterior pituitary hormones

 Oxytocin (via a positive feedback loop)

 Anti diuretic hormone

The pituitary is covered by a sheath of dura and an expanding haematoma at this site may compress the optic chiasm
in the same manner as an expanding pituitary tumour.

Trachea
Trachea
Location C6 vertebra to the upper border of T5 vertebra (bifurcation)
Arterial and venous supply Inferior thyroid arteries and the thyroid venous plexus.
Nerve Branches of vagus, sympathetic and the recurrent nerves

Relations in the neck

Anterior(Superior to inferior)
 Isthmus of the thyroid gland
 Inferior thyroid veins
 Arteria thyroidea ima (when that vessel exists)
 Sternothyroid
 Sternohyoid
 Cervical fascia
  Anastomosing branches between the anterior jugular veins

Posterior Oesophagus.
 Common carotid arteries
 Right and left lobes of the thyroid gland
Laterally  Inferior thyroid arteries
 Recurrent laryngeal nerves

Relations in the thorax

Anterior

 Manubrium, the remains of the thymus, the aortic arch, left common carotid arteries, and the deep cardiac
plexus

Lateral

 In the superior mediastinum, on the right side is the pleura and right vagus;
on its left side are the left recurrent nerve, the aortic arch, and the left common carotid and subclavian
arteries.
basilar artery
The posterior inferior cerebellar artery is the largest of the cerebellar arteries arising from the vertebral artery.

The labyrinthine artery is long and slender and may arise from the lower part of the basilar artery. It accompanies
the facial and vestibulocochlear nerves into the internal auditory meatus.

The posterior cerebral artery is often larger than the superior cerebellar arter.y

Occlusion of the posterior cerebral artery causes contralateral loss of the visual field

The oculomotor nerve lies between the superior cerebellar and posterior cerebral arteries

Larynx
The larynx lies in the anterior part of the neck at the levels of C3 to C6 vertebral bodies. The laryngeal skeleton consists
of a number of cartilagenous segments. Three of these are paired; arytenoid, corniculate and cuneiform. Three are
single; thyroid, cricoid and epiglottic. The cricoid cartilage forms a complete ring (the only one to do so).
The laryngeal cavity extends from the laryngeal inlet to the level of the inferior border of the cricoid cartilage.
Divisions of the laryngeal cavity
Laryngeal vestibule Superior to the vestibular folds
Laryngeal ventricle Lies between vestibular folds and superior to the vocal cords
Infraglottic cavity Extends from vocal cords to inferior border of the cricoid cartilage

The vocal folds (true vocal cords) control sound production. The apex of each fold projects medially into the laryngeal
cavity. Each vocal fold includes:

 Vocal ligament
 Vocalis muscle (most medial part of thyroarytenoid muscle)

The glottis is composed of the vocal folds, processes and rima glottidis. The rima glottidis is the narrowest potential
site within the larynx, as the vocal cords may be completely opposed, forming a complete barrier.

In children younger than 10 years of age, the narrowest portion of the airway is below the glottis at the level of the
cricoid cartilage.

Muscles of the larynx

Muscle Origin Insertion Innervation Action
Posterior Posterior aspect of Muscular process of Recurrent
Abducts vocal fold
cricoarytenoid lamina of cricoid arytenoid Laryngeal
Muscular process of Recurrent
Lateral cricoarytenoid Arch of cricoid Adducts vocal fold
arytenoid laryngeal
Posterior aspect of Muscular process of Recurrent
Thyroarytenoid Relaxes vocal fold
thyroid cartilage arytenoid laryngeal
Transverse and Recurrent Closure of intercartilagenous
Arytenoid cartilage Contralateral arytenoid
oblique arytenoids laryngeal part of the rima glottidis
Depression between Vocal ligament and vocal
Recurrent Relaxes posterior vocal
Vocalis lamina of thyroid process of arytenoid
laryngeal ligament, tenses anterior part
cartilage cartilage
Anterolateral part of Inferior margin and horn of External
Cricothyroid Tenses vocal fold
cricoid thyroid cartilage laryngeal

Blood supply
Arterial supply is via the laryngeal arteries, branches of the superior and inferior thyroid arteries. The superior laryngeal
artery is closely related to the internal laryngeal nerve. The inferior laryngeal artery is related to the inferior laryngeal
nerve. Venous drainage is via superior and inferior laryngeal veins, the former draining into the superior thyroid vein
and the latter draining into the middle thyroid vein, or thyroid venous plexus.

Lymphatic drainage
The vocal cords have no lymphatic drainage and this site acts as a lymphatic watershed.
Supraglottic part Upper deep cervical nodes
Subglottic part Prelaryngeal and pretracheal nodes and inferior deep cervical nodes
The aryepiglottic fold and vestibular folds have a dense plexus of lymphatics associated with them and
malignancies at these sites have a greater propensity for nodal metastasis.
Facial nerve -Upper Vs Lower motor neurone lesions
Upper motor neurone lesions of the facial nerve- Paralysis of the lower half of face.
Lower motor neurone lesion- Paralysis of the entire ipsilateral face.
The nucleus of the facial nerve is located in the caudal aspect of the ventrolateral pontine tegmentum. Its axons exit the
ventral pons medial to the spinal trigeminal nucleus.

Any lesion occurring within or affecting the corticobulbar tract is known as an upper motor neuron lesion. Any
lesion affecting the individual branches (temporal, zygomatic, buccal, mandibular and cervical) is known as a lower
motor neuron lesion.

Vomiting
Reflex oral expulsion of gastric (and sometimes intestinal) contents - reverse peristalsis and abdominal contraction

The vomiting centre is in part of the medulla oblongata and is triggered by receptors in several locations:

 Labyrinthine receptors of ear (motion sickness)

 Over distention receptors of duodenum and stomach
 Trigger zone of CNS - many drugs (e.g., opiates) act here
 Touch receptors in throat

Retromandibular vein

 Formed by a union of the maxillary vein and superficial temporal vein

 It descends through the parotid gland and bifurcates within it
 The anterior division passes forwards to join the facial vein, the posterior division is one of the tributaries of the
external jugular vein

Disorders of the oculomotor system

Nerve Path Nerve palsy features
 Large nucleus at the midbrain Ptosis
 Fibres pass through the red nucleus and the Eye down and out
Oculomotor
pyramidal tract; through the cavernous Unable to move the eye superiorly, inferiorly,
nerve
sinus into the orbit medially
Pupil fixed and dilated
 Longest intracranial course
 Only nerve to exit the dorsal
aspect of brainstem
Trochlear Vertical diplopia (diplopia on descending the stairs)
nerve
 Nucleus at midbrain, passes between the Unable to look down and in
posterior cerebral and superior cerebellar
arteries, through the cavernous sinus into
the orbit

Abducens Nucleus lies in the mid pons Convergence of eyes in primary position
nerve Lateral diplopia towards side of lesion
 Nerve Path Nerve palsy features
Eye deviates medially

lower border of the cricoid cartilage

In the midline from above down, the following structures are felt

Structure Level

Hyoid C3

Notch of the thyroid cartilage C4

Cricoid cartilage(termination) C6

The lower border of the cricoid cartilage- C6 corresponds to the commencement of the trachea and also to the
following:

 Junction of larynx with trachea

 Junction of pharynx with oesophagus
 Level at which the inferior thyroid artery enters the thyroid gland
 The level at which the vertebral artery enters the transverse foramen in the 6th cervical vertebra
 Level at which the superior belly of omohyoid crosses the carotid sheath
 The level of the middle cervical sympathetic ganglion
 The level at which the carotid artery can be compressed against the transverse process of C6 (carotid
tubercle).

Scalene muscles
The 3 paired muscles are:

 Scalenus anterior: Elevate 1st rib and laterally flex the neck to same side
 Scalenus medius: Same action as scalenus anterior
 Scalenus posterior: Elevate 2nd rib and tilt the cervical spine

Innervation Spinal nerves C4-6

Origin Transverse processes C2 to C7

Insertion First and second ribs

 The brachial plexus and subclavian artery pass between the anterior and middle scalenes
through a space called the scalene hiatus/fissure.
Important  The subclavian vein and phrenic nerve pass anteriorly to the anterior scalene as it crosses
relations over the first rib.
The anterior scalene muscle is an important anatomical landmark and separates the subclavian vein (anterior) from the
subclavian artery (posterior).

Middle meningeal artery

 Middle meningeal artery is typically the third branch of the first part of the maxillary artery, one of the two
terminal branches of the external carotid artery. After branching off the maxillary artery in the infratemporal
fossa, it runs through the foramen spinosum to supply the dura mater (the outermost meninges) .
 The middle meningeal artery is the largest of the three (paired) arteries which supply the meninges, the
others being the anterior meningeal artery and the posterior meningeal artery.
 The middle meningeal artery runs beneath the pterion. It is vulnerable to injury at this point, where the skull is
thin. Rupture of the artery may give rise to an extra dural hematoma.
 In the dry cranium, the middle meningeal, which runs within the dura mater surrounding the brain, makes a
deep indention in the calvarium.
 The middle meningeal artery is intimately associated with the auriculotemporal nerve which wraps around
the artery making the two easily identifiable in the dissection of human cadavers and also easily damaged in
surgery.

Lymphatic drainage of the tongue

 The lymphatic drainage of the anterior two thirds of the tongue shows only minimal communication of
lymphatics across the midline, so metastasis to the ipsilateral nodes is usual.
 The lymphatic drainage of the posterior third of the tongue have communicating networks, as a result early
bilateral nodal metastases are more common in this area.
 Lymphatics from the tip of the tongue usually pass to the sub mental nodes and from there to the deep cervical
nodes.
 Lymphatics from the mid portion of the tongue usually drain to the submandibular nodes and then to the deep
cervical nodes.
 Mid tongue tumours
o that are laterally located will usually drain to the ipsilateral deep cervical nodes,
o those from more central regions may have bilateral deep cervical nodal involvement.

Tumours of the posterior third of the tongue will typically metastasise early and bilateral nodal involvement is well
recognised, this is most often true of centrally located tumours and those adjacent to the midline as the lymph vessels
may cross the median plane at this location.

Erbs Palsy
C5, C6 lesion

The features include:

 Waiter's tip position

 Loss of shoulder abduction (deltoid and supraspinatus paralysis)
 Loss of external rotation of the shoulder (paralysis of infraspinatus)
 Loss of elbow flexion (paralysis of biceps, brachialis and brachioradialis)
 Loss of forearm supination (paralysis of Biceps)
This is commonly known to be associated with birth injury when a baby has a shoulder dystocia.

cerebellopontine angle
The cerebellopontine angle is located between the superior and inferior limbs of the angular cerebellopontine fissure
formed by the petrosal cerebellar surface folding around the pons and middle cerebellar peduncle. The cerebellopontine
fissure opens medially and has superior and inferior limbs that meet at a lateral apex.

The fourth through the eleventh cranial nerves are located near or within the angular space between the two limbs
commonly referred to as the cerebellopontine angle.

The commonest lesion to affect this site is an acoustic neuroma. Therefore the vestibulocochlear nerve is
commonly compromised.

Larger lesions may also affect the facial nerve which lies closest to this site.

Sternocleidomastoid
Anatomy

Rounded tendon attached to upper manubrium sterni and muscular head attached to medial third of the
Origin
clavicle

Insertion Mastoid process of the temporal bone and lateral area of the superior nuchal line of the occipital bone

Innervation Spinal part of accessory nerve and anterior rami of C2 and C3 (proprioception)
 Both: extend the head at atlanto-occipital joint and flex the cervical vertebral column. Accessory
muscles of inspiration.
Action  Single: lateral flexion of neck, rotates head so face looks upward to the opposite side

Sternocleidomastoid divides the anterior and posterior triangles of the neck.

Suboccipital triangle
Spine
Intervertebral discs

 Consist of an outer annulus fibrosus and an inner nucleus pulposus.

 The anulus fibrosus consists of several layers of fibrocartilage.
 The nucleus pulposus contains loose fibres suspended in a mucoprotein gel with the consistency of jelly. The
nucleus of the disc acts as a shock absorber.
 Pressure on the disc causes posterior protrusion of the nucleus pulposus. Most commonly in the lumbrosacral
and lower cervical areas.
 There is one disc between each pair of vertebrae, except for C1/2 and the sacrococcygeal vertebrae.

Prolapsed disc
A prolapsed lumbar disc usually produces clear dermatomal leg pain associated with neurological deficits.

Features

 Leg pain usually worse than back

 Pain often worse when sitting

The table below demonstrates the expected features according to the level of compression:

Sensory loss over upper anterior –lateral thigh/knee

Weak quadriceps
L3 nerve root compression
Reduced knee reflex
Positive femoral stretch test

Sensory loss over lower anterior- lateral thigh/knee + medial leg

L4 nerve root compression Weak quadriceps

Reduced knee reflex
Positive femoral stretch testor sciatic stretch test

Sensory loss dorsum of foot

Weakness in foot and big toe dorsiflexion
L5 nerve root compression
Reflexes intact
Positive sciatic nerve stretch test

Sensory loss posterolateral aspect of leg and lateral aspect of foot

Weakness in plantar flexion of foot
S1 nerve root compression
Reduced ankle reflex
Positive sciatic nerve stretch test

Management

 Similar to that of other musculoskeletal lower back pain: analgesia, physiotherapy, exercises
  Persistent symptoms, muscular weakness, bladder or bowel dysfunction are indications for urgent MRI
scanning to delineate the disease extent to allow surgical planning
 Plain spinal x-rays have no useful role in establishing the extent of disk disease

nerve roots and their reflexes

To remember nerve roots and their reflexes:

1-2 Ankle (S1-S2)

3-4 Knee (L3-L4)
5-6 Biceps (C5-C6)
7-8 Triceps (C7-C8)

Spinal disorders
 Loss vibration and proprioception
Dorsal column lesion  Tabes dorsalis, SACD

Spinothalamic tract lesion  Loss of pain, sensation and temperature

Central cord lesion  Flaccid paralysis of the upper limbs

 Normally progressive
 Staph aureus in IVDU,
Osteomyelitis  normally cervical region affected
 Fungal infections in immunocompromised
 Thoracic region affected in TB

Infarction spinal cord  Dorsal column signs (loss of proprioception and fine discrimination)

 UMN signs
 Malignancy
Cord compression  Haematoma
 Fracture

 Hemisection of the spinal cord

 Ipsilateral paralysis
Brown-sequard syndrome
 Ipsilateral loss of proprioception and fine discrimination
 Contralateral loss of pain and temperature

Dermatomes

 C2 to C4
o The C2 dermatome covers the occiput and the top part of the neck.
o C3 covers the lower part of the neck to the clavicle.
o C4 covers the area just below the clavicle.
 C5 to T1 Situated in the arms.
o C5 covers the lateral arm at and above the elbow.
 o C6 covers the forearm and the radial side of the hand.
o C7 is the middle finger,
o C8 is the medial aspect of the hand, and
o T1 covers the medial side of the forearm.
 T2 to T12 The thoracic covers the axillary and chest region.
o T3 to T12 covers the chest and back to the hip girdle.
o The nipples are situated in the middle of T4.
o T10 is situated at the umbilicus.
o T12 ends just above the hip girdle.
 L1 to L5
o The cutaneous dermatome representing the hip girdle and groin area is innervated by L1 spinal cord.
o L2 and 3 cover the front part of the thighs.
o L4 and L5 cover medial and lateral aspects of the lower leg.
 S1 to S5
o S1 covers the heel and the middle back of the leg.
o S2 covers the back of the thighs.
o S3 cover the medial side of the buttocks and
o S4-5 covers the perineal region.
o S5 is of course the lowest dermatome and represents the skin immediately at and adjacent to the anus.

Myotomes

Upper limb
Elbow flexors/Biceps C5

Wrist extensors C6

Elbow extensors/Triceps C7

Long finger flexors C8

Small finger abductors T1

Lower limb

Hip flexors (psoas) L1 and L2

Knee extensors (quadriceps) L3

Ankle dorsiflexors (tibialis anterior) L4 and L5

Toe extensors (hallucis longus) L5

Ankle plantar flexors (gastrocnemius) S1

The anal sphincter is innervated by S2,3,4

Spinal cord

 Located in a canal within the vertebral column that affords it structural support.
 Rostrally it continues to the medulla oblongata of the brain and caudally it tapers at a level corresponding to
the L1-2 interspace (in the adult), a central structure, the filum terminale anchors the cord to the first coccygeal
vertebra.
 The spinal cord is characterised by cervico-lumbar enlargements and these, broadly speaking, are the sites
which correspond to the brachial and lumbar plexuses respectively.

At the 3rd month the foetus's spinal cord occupies the entire length of the vertebral canal. The vertebral column then
grows longer exceeding the growth rate of the spinal cord. This results with the cord being at L3 at birth and L1-2 by
adulthood.

The spinal cord is approximately 45cm in men and 43cm in women. The denticulate ligament is a continuation of the pia
mater (innermost covering of the spinal cord) which has intermittent lateral projections attaching the spinal cord to the
dura mater.

There are some key points to note when considering the surgical anatomy of the spinal cord:

* During foetal growth the spinal cord becomes shorter than the spinal canal, hence the adult site of cord termination
at the L1-2 level.

* Due to growth of the vertebral column the spine segmental levels may not always correspond to bony landmarks as
they do in the cervical spine.

* The spinal cord is incompletely divided into two symmetrical halves by a dorsal median sulcus and ventral median
fissure. Grey matter surrounds a central canal that is continuous rostrally with the ventricular system of the CNS.

* The grey matter is sub divided cytoarchitecturally into Rexeds laminae.

* Afferent fibres entering through the dorsal roots usually terminate near their point of entry but may travel for varying
distances in Lissauers tract. In this way they may establish synaptic connections over several levels

* At the tip of the dorsal horn are afferents associated with nociceptive stimuli. The ventral horn contains neurones that
innervate skeletal muscle.

The key point to remember when revising CNS anatomy is to keep a clinical perspective in mind. So it is worth classifying
the ways in which the spinal cord may become injured. These include:

 Trauma either direct or as a result of disc protrusion

 Neoplasia either by direct invasion (rare) or as a result of pathological vertebral fracture
 Inflammatory diseases such as Rheumatoid disease, or OA (formation of osteophytes compressing nerve roots
etc.
 Vascular either as a result of stroke (rare in cord) or as complication of aortic dissection
 Infection historically diseases such as TB, epidural abscesses.

The anatomy of the cord will, to an extent dictate the clinical presentation. Some points/ conditions to remember:
  Brown- Sequard syndrome-Hemisection of the cord producing ipsilateral loss of proprioception and upper motor
neurone signs, plus contralateral loss of pain and temperature sensation. The explanation of this is that the
fibres decussate at different levels.
 Lesions below L1 will tend to present with lower motor neurone signs

Lumbar puncture
Lumbar punctures are performed to obtain cerebrospinal fluid. In adults, the procedure is best performed at the level of
L3/L4 or L4/5 interspace. These regions are below the termination of the spinal cord at L1.

During the procedure the needle passes through:

 The supraspinous ligament which connects the tips of spinous processes and the interspinous ligaments
between adjacent borders of spinous processes
 Then the needle passes through the ligamentum flavum, which may cause a give as it is penetrated
 A second give represents penetration of the needle through the dura mater into the subarachnoid space. Clear
CSF should be obtained at this point
Vertebral column

 There are 7 cervical, 12 thoracic, 5 lumbar, and 5 sacral vertebrae.

 The spinal cord segmental levels do not necessarily correspond to the vertebral segments. For example, while
the C1 cord is located at the C1 vertebra, the C8 cord is situated at the C7 vertebra. While the T1 cord is
situated at the T1 vertebra, the T12 cord is situated at the T8 vertebra. The lumbar cord is situated between T9
and T11 vertebrae. The sacral cord is situated between the T12 to L2 vertebrae.

Cervical vertebrae
The interface between the first and second vertebra is called the atlanto-axis junction. The C3 cord contains the phrenic
nucleus.

Muscle Nerve root value

Deltoid C5,6

Biceps C5,6

Wrist extensors C6-8

Triceps C6-8

Wrist flexors C6-T1

Hand muscles C8-T1

Thoracic vertebrae
The thoracic vertebral segments are defined by those that have a rib. The spinal roots form the intercostal nerves that
run on the bottom side of the ribs and these nerves control the intercostal muscles and associated dermatomes. The
spinous process is formed by 2 laminae posteriorly.

Lumbosacral vertebrae
Form the remainder of the segments below the vertebrae of the thorax. The lumbosacral spinal cord, however, starts
at about T9 and continues only to L2. It contains most of the segments that innervate the hip and legs, as well as the
buttocks and anal regions.

Cauda Equina
The spinal cord ends at L1-L2 vertebral level. The tip of the spinal cord is called the conus. Below the conus, there is a
spray of spinal roots that is called the cauda equina. Injuries below L2 represent injuries to spinal roots rather than the
spinal cord proper.

artery of Adamkiewicz
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 arises from the radiculomedullary branch of the posterior branch of the intercostal  or lumbar artery, which arises
from the thoracic or abdominal aorta  respectively
The artery of Adamkiewicz has a variable origin but most commonly arises 1:

 on the left (~80%)

 at the level of the 9th-12th intercostal artery (~70%)

It anastomosis with the anterior spinal artery, supplying arterial blood to the spinal cord from T8 to the
conus medullaris