INTRODUCTION TO ABDOMINAL CAVIITY d.

large intestines/ colon (cecum and appendix,

ascending, transverse, descending, sigmoid colon,
(Dr. Laygo)
rectum)
e. liver with the biliary tree
 hepatic duct
 gall bladder
 cystic duct
o hepatic + cystic duct =
 common bile duct
o + pancreatic duct = drains in the
duodenum
f. pancreas
g. adrenal glands/ suprarenal glands
h. kidneys, superior part of the ureter
i. different nerves, lymphatics, BV
 abdominal aorta, inferior vena cava

Subdivisions of the Abdominal Wall

1. anterior abdominal wall
- lower thoracic cage, external and internal
oblique muscles, transversus abdominis
- region of the body trunk which lies in between the
diaphragm and the pelvic inlet 2. lateral right and left abdominal wall
- region below the pelvic inlet is called pelvic cavity - corresponds to the flanks
- no floor, continuous with the pelvic cavity - lumbosacral fascia = aponeurosis of the external
- extends from the lower part of thoracic cage until the oblique muscle
level of the 5th anterior ICS (level of the nipple) o strong fascial bond, whitish structure
- superior border: diaphragm (roof of the abdominal 3. posterior abdominal wall
cavity) - lower thoracic spine
- inferior border: pelvic inlet - 5 lumbar spine
- in supine position: lower thoracic cage protects the - muscles: quadratus lumborum, psoas muscles,
upper organs (liver, stomach and spleen) iliopsoas muscle (below the pelvic inlet)
- LIVER
o most commonly injured in the abdominal region Layers of the Abdominal Wall
during blunt trauma 1. skin
2. superficial fascia
Contents: - Camper's fascia - fatty superficial layer
1. peritoneal cavity - Scarpa's fascia - deep membranous layer
 enclosed by parietal peritoneum
 visceral peritoneum – which usually covers the 3. muscles and their aponeurosis
abdominal organs - External oblique muscle
- Internal oblique muscle
- Midline: rectus abdominis muscle
2. gastrointestinal organs
- Behind: posterior rectus sheath made-up of
a. lower part of the esophagus transverse abdominal muscle
b. stomach
c. small intestines (duodenum, jejunum, ileum) 4. fascia transversalis
5. preperitoneal fat/ extraperitoneal fat
6. peritoneum
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Surface Landmarks of the Abdominal Wall:
 xiphoid process (T9)
- is the thin cartilaginous lower part of the sternum.
It is easily palpated in the depression where the
costal margins meet in the upper part of the
anterior abdominal wall
- xiphisternal junction is identified by feeling the
lower edge of the body of the sternum, and it lies
opposite the body of the ninth thoracic vertebra
soft tubular spermatic cord can be felt emerging
from the ring and descending over or medial to the
pubic tubercle into the scrotum. Palpate the
spermatic cord in the upper part of the scrotum
between the finger and thumb and note the
presence of a firm cordlike structure in its
posterior part called the vas deferens
- In the female, the superficial inguinal ring is
smaller and difficult to palpate; it transmits the
round ligament of the uterus.

 costal margin
- reaches its lowest level at the 10th costal cartilage,
which lies opposite the body of the third lumbar
vertebra
 iliac crest
- felt along its entire length and ends in front at the
anterior superior iliac spine and behind at the
posterior superior iliac spine
 pubic tubercle
- an important surface landmark
- it may be identified as a small protuberance along
the superior surface of the pubis
 symphysis pubis
- is the cartilaginous joint that lies in the midline
between the bodies of the pubic bones
- It is felt as a solid structure beneath the skin in the
midline at the lower extremity of the anterior
abdominal wall
- the pubic crest is the name given to the ridge on
the superior surface of the pubic bones medial to
the pubic tubercle
 linea alba
- is a vertically running fibrous band that extends
from the symphysis pubis to the xiphoid process
and lies in the midline
- it is formed by the fusion of the aponeuroses of
the muscles of the anterior abdominal wall and is
represented on the surface by a slight median
groove
- more prominent above the umbilicus
 linea semilunaris
- is the lateral edge of the rectus abdominis muscle
and crosses the costal margin at the tip of the
ninth costal cartilage
- to accentuate the semilunar lines, the patient is
asked to lie on the back and raise the shoulders off
the couch without using the arms.
- to accomplish this, the patient contracts the rectus
abdominis muscles so that their lateral edges stand
out
 sternal costal margin
- costal margin + lateral edges of xiphoid process

 inguinal ligament
- lies beneath a skin crease in the groin. It is the
rolled-under inferior margin of the aponeurosis of
the external oblique muscle
- it is attached laterally to the anterior superior iliac
spine and curves downward and medially, to be
attached to the pubic tubercle

 superficial inguinal ring

- is a triangular aperture in the aponeurosis of the
external oblique muscle and is situated above and
medial to the pubic tubercle
- In the adult male, the margins of the ring can be
felt by invaginating the skin of the upper part of
the scrotum with the tip of the little finger. The

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Abdominal Quadrants Shapes of the Abdomen
- point of reference: lies from the xiphoid process
down to the symphysis pubis

a. flat
- when abdominal wall falls in the line from xiphoid
process to the symphysis pubis

b. scaphoid
- underneath the point of reference

c. globular
- goes over the point of reference

d. distended
- when whole of abdominal wall is anterior to the
line

e. flabby
- enlarged abdomen due to thickened anterior
abdominal wall

ANATOMICAL LANDMARKS
a. umbilicus
- indentation
- normally located between the xiphoid process and
symphysis pubis but nor constant
- always located at the midline
ABDOMEN
b. subcostal margin
(Dr. Quitiquit) - composed of cartilages of anterior 7th, 8th, 9th and
10th ribs
- located between the diaphragm and pelvis (extent of
the abdomen) c. xiphoid process
- most inferior portion of sternum
Bony components: - angle between b and c = xiphisternal/ subcostal
 Posterior: vertebra angle
 Anterior and lateral: no bones
o only muscles and fascia, skin d. iliac crest
- superior border of the iliac bone
Structures that can be palpated:
a. xiphoid process e. ASIS
b. symphysis pubis - elevated portion of the anterior part of the iliac
c. anterior superior iliac spine (ASIS) crest
d. subcostal margin - opposite at the back PSIS
e. iliac

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 f. inguinal ligament ABDOMINAL LINES
- rolled fascia derived from the external oblique 1. midline
aponeurosis 2. subcostal plane
- extends from the ASIS all the way to pubic tubercle - at the level of the 10th costal cartilage and level of
L3
g. linea alba
- line located at the midline extending from the 3. intertubercular plane
xiphoid process all the way to the symphysis pubis - level of iliac tubercle
- more prominent in linea alba - body of L5
- connects the 2 tubercles of the iliac bone
h. linea semilunaris/ Spigelian line
- lateral border of the rectus abdominis muscle 4. transpyloric plane
- horizontal
i. symphysis pubis - passes thru the costal cartilage of the 9th rib
- junction between 2 pubic bone located at the - structures found:
midline a. pancreas
b. pylorus
INTRA-ABDOMINAL ORGANS PALPABLE c. hilum of the spleen
a. aorta d. 2nd portion of duodenum
- lie flat and palpate at the middle (very thin
individual) 5. transcristal plane
- abdominal aorta: bifurcates into 2 branches at the - horizontal
level of L4 - connects the 2 iliac crest

b. liver 6. midinguinal/ mid-clavicular line

- right upper portion of the abdomen but mostly - vertical
covered by the lower ribs
- 2 fingerbreadths below the subcostal margin 7. McBurney’s point
- approximates the base of appendix
c. gallbladder - get umbilicus and ASIS: create a line then divide
- fundus of gallbladder into 3
o palpate at the junction of the subcostal margin - the point where you divide the middle and lateral
and Spigelian line 1/3

d. stomach ABDOMINAL QUADRANTS

- normally can’t be palpated unless it is enlarged or - make use of the midline and transverse line at the
with tumor/ mass level of the umbilicus

e. spleen 1. RUQ
- located on the left upper portion and the long axis - majority of the liver and gallbladder
of the spleen is located at the 10th rib
2. RLQ
f. kidneys - appendix, R. fallopian tube and ovary
g. ascending colon
- hard to palpate unless enlarged 3. LUQ
- stomach, spleen
h. urinary bladder
i. uterus and ovaries

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4. LLQ
- sigmoid colon, L. fallopian tube and ovary, some of
the small intestine

ABDOMINAL REGIONS
- subcostal line – above
- transtubercular plane – below
- right and left midinguinal line

Middle:
1. epigastric region – stomach
2. umbilical region – umbilicus
3. hypogastric region – urinary bladder and uterus for
females

Lateral:
1. right and left hypochondriac region
2. right and left lumbar region
3. right and left iliac region

CLINICAL CORRELATIONS:
a. ascitis
- presence of fluid in the peritoneal cavity

b. abdominal pain
c. acute abdomen
- medical or surgical conditions
i.e. acute appendicitis, pancreatitis, cholescystitis

d. exploratory laparotomy
e. localization of signs and symptoms

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 ABDOMINAL WALL 2. Scarpa’s fascia
 above the umbilicus 2 layers are indistinct
(Dr. Tanyee)
 below the umbilicus, Scarpa’s fascia is well-
developed
LAYERS:
 goes beyond the inguinal ligament and blends
a. skin
with the fascia lata of the thigh
- skin is loosely attached to the underlying
 attached on each side to the margins of the
structures except at the umbilicus, where it is
pubic arch; it is here referred to as Colles' fascia
tethered to the scar tissue
- natural lines of cleavage in the skin are constant
c. deep fascia
and run downward and forward almost
- is merely a thin layer of connective tissue covering
horizontally around the trunk
the muscles; it lies immediately deep to the
- umbilicus is a scar representing the site of
membranous layer of superficial fascia
attachment of the umbilical cord in the fetus
o it is situated in the linea alba (b/n L3 and L4)
o consist of four tubes: d. muscles and their aponeurosis
1. urachus
2. left and right umbilical arteries
3. umbilical vein

b. superficial fascia

1. external oblique muscle

1. Camper’s fascia
 forward, downward medially fibers
 fatty layer is continuous with the superficial fat
 is a broad, thin, muscular sheet
over the rest of the body and may be extremely
 origin: from the outer surfaces of the lower
thick
eight ribs
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  fans out to be inserted into:
o the xiphoid process
o the linea alba
o the pubic crest
o the pubic tubercle
o the anterior half of the iliac crest
 most of the fibers are inserted by means of a
broad aponeurosis
o tendinous
o has 3 thickenings:
a. inguinal ligament
 attaches to the ASIS and to the
pubis tubercle
b. lacunar ligament/ Gimbernat’s
ligament
 extends backward and upward to
the pectineal line on the superior
ramus of the pubis
 its sharp, free crescentic edge
forms the medial margin of the
femoral ring
c. pectineal ligament/ Cooper’s
ligament
 reaching the pectineal line, the
lacunar ligament becomes
continuous with a thickening of
the periosteum called the
pectineal ligament
o consists of reflected fibers which
originates from the inferior crus of the
superficial inguinal ring and the lacunar
ligament
 superficial inguinal ring
o opening of the external oblique muscle
located above and medial the pubic
tubercle
2. internal oblique muscle
 is also a broad, thin, muscular sheet that lies
deep to the external oblique
 most of its fibers run at right angles to those of
the external oblique
 muscle fibers radiate as they pass upward and
forward
 origin:
o thoracolumbar fascia
o anterior two thirds of the iliac crest
o lateral two thirds of the inguinal ligament
 insertion:
o lower borders of the lower three ribs and
their costal cartilages
o xiphoid process
o linea alba
o symphysis pubis
 near their insertion, the lowest tendinous
fibers are joined by similar fibers from the
transversus abdominis to form the conjoint
tendon
o is attached medially to the linea alba, but
it has a lateral free border
o formed by the transversus abdominis
muscle and internal oblique muscle

3. transversus abdominis muscle

 is a thin sheet of muscle that lies deep to the
internal oblique, and its fibers run horizontally
forward
 origin:
o from the deep surface of the lower six
costal cartilages (interdigitating with the
diaphragm)
 triangular ligament/ reflected inguinal o lumbar fascia
ligament o anterior two thirds of the iliac crest

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 o lateral third of the inguinal ligament.
 insertion:
o xiphoid process
o linea alba
o symphysis pubis
 the lowest tendinous fibers join similar fibers
from the internal oblique to form the conjoint
tendon, which is fixed to the pubic crest and
the pectineal line
 note that the posterior border of the external
oblique muscle is free, whereas the posterior
borders of the internal oblique and
transversus muscles are attached to the
lumbar vertebrae by the lumbar fascia
FUNCTION (ABDOMINAL MUSCLES)
a) likened to a corset; forms elastic musculotendinous
corset that maintains the intraabdominal pressure
keeping the viscera intact
b) contracts simultaneously with the diaphragm to aid
urination, defecation, vomiting and parturition/
giving birth (valsalva maneuver)
c) contracts alternately with the diaphragm to aid
exhalation
d) aids in the lateral bending of the trunk
e. transversalis fascia
 is a thin layer of fascia that lines the transversus
abdominis muscle and is continuous with a similar
layer lining the diaphragm and the iliacus muscle
 the femoral sheath for the femoral vessels in the
lower limbs is formed from the fascia transversalis
and the fascia iliaca that covers the iliacus muscle
 well-developed below the inferior portion of the
internal oblique and transversus abdominis
RECTUS SHEATH
- is a long fibrous sheath that encloses
a. rectus abdominis muscle
b. pyramidalis muscle (if present)
c. contains the anterior rami of the lower six
thoracic nerves
d. superior and inferior epigastric vessels
e. lymph vessels.
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- formed mainly by the aponeuroses of the three
lateral abdominal muscles
- location:
a. above the costal margin
o anterior wall is formed by the aponeurosis
of the external oblique
o posterior wall is formed by the thoracic
wall—that is, the fifth, sixth, and seventh
costal cartilages and the intercostal
spaces
b. between the costal margin and the level of the
anterior superior iliac spine
o the aponeurosis of the internal oblique
splits to enclose the rectus muscle
o external oblique aponeurosis is directed in
front of the muscle
o transversus aponeurosis is directed
behind the muscle
c. Between the level of the anterosuperior iliac
spine and the pubis
o aponeuroses of all three muscles form the
anterior wall
o posterior wall is absent
o rectus muscle lies in contact with the
fascia transversalis
- It should be noted that where the aponeuroses forming
the posterior wall pass in front of the rectus at the level
of the anterior superior iliac spine, the posterior wall
has a free, curved lower border called the arcuate line.
At this site, the inferior epigastric vessels enter the
rectus sheath and pass upward to anastomose with the
superior epigastric vessels.
 - insertion:
o fifth, sixth, and seventh costal cartilages
o xiphoid process

- when it contracts, its lateral margin forms a curved

ridge that can be palpated and often seen and is
termed the linea semilunaris. This extends from the tip
of the ninth costal cartilage to the pubic tubercle.

- is divided into distinct segments by three transverse

tendinous intersections: one at the level of the xiphoid
process, one at the level of the umbilicus, and one
halfway between these two
o are strongly attached to the anterior wall of the
rectus sheath

Rectus Abdominis Muscles Pyramidalis

- is a long strap muscle that extends along the whole - is often absent
length of the anterior abdominal wall - arises by its base from the anterior surface of the pubis
- it is broader above and lies close to the midline, being (pubic bone)
separated from its fellow by the linea alba - inserted into the linea alba
- arises by two heads - action: tenses the linea alba
o front of the symphysis pubis - it lies in front of the lower part of the rectus abdominis
o pubic crest

MUSCLES OF THE ANTERIOR ABDOMINAL WALL

Name of
Muscle Origin Insertion Nerve Supply Action
External Lower eight ribs Xiphoid process, linea Lower six thoracic Supports abdominal contents; compresses
oblique alba, pubic crest, nerves and abdominalcontents; assists in flexing and
pubic tubercle, iliac iliohypogastric and rotation of trunk; assists inforced expiration,
crest ilioinguinal nerves (L1) micturition, defecation, parturition, and
vomiting
Internal Lumbar fascia, Lower three ribs and Lower six thoracic As above
oblique intermediate line iliac costal cartilages, nerves and
crest, lateral two thirds xiphoid process, linea iliohypogastric and
of inguinal ligament alba, symphysis pubis ilioinguinal nerves (L1)
Transversus Lower six costal Xiphoid process linea Lower six thoracic Compresses abdominal contents
cartilages, lumbar alba, symphysis pubis nerves and
fascia, iliac crest, lateral iliohypogastric and
third of inguinal ilioinguinal nerves (L1)
ligament
Rectus Symphysis pubis and Fifth, sixth, and Lower six thoracic Compresses abdominal contents and flexes
abdominis pubic crest seventh costal nerves vertebral column; accessory muscle of
cartilages and xiphoid expiration
process
Pyramidalis Anterior surface of Linea alba 12th thoracic nerve Tenses the linea alba
(if present) pubis

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 - one of the terminal branches of the internal
thoracic/ mammary artery
- enters the upper part of the rectus sheath
NERVE AND BLOOD SUPPLY between the sternal and costal origins of the
OF THE ABDOMEN diaphragm
- descends behind the rectus muscle, supplying the
(Dr. Tanyee) upper central part of the anterior abdominal wall,
and anastomoses with the inferior epigastric artery
NERVE SUPPLY
- nerves of the anterior abdominal wall
2. inferior epigastric artery
- they pass forward in the interval between the internal
- branch of the external iliac artery just above the
oblique and the transversus muscles
inguinal ligament
- the thoracic nerves are the lower five intercostal nerves
- runs upward and medially along the medial side of
and the subcostal nerve
the deep inguinal ring
- they supply the skin of the anterior abdominal wall, the
- it pierces the fascia transversalis to enter the
muscles, and the parietal peritoneum. (Compare with
rectus sheath anterior to the arcuate line
the intercostal nerves, which run forward in the
- it ascends behind the rectus muscle, supplying the
intercostal spaces between the internal intercostal and
lower central part of the anterior abdominal wall,
the innermost intercostal muscles).
and anastomoses with the superior epigastric
-
artery
a. lower six thoracic and
o the lower six thoracic nerves pierce the
3. lateral
posterior wall of the rectus sheath to supply a. deep circumflex iliac artery
the rectus muscle and the pyramidalis (T12 o a branch of the external iliac artery just above
only)
the inguinal ligament
o they terminate by piercing the anterior wall of
o it runs upward and laterally toward the
the sheath and supplying the skin
anterosuperior iliac spine and then continues
along the iliac crest
b. first lumbar nerves
o it supplies the lower lateral part of the
o the first lumbar nerve has a similar course, but
abdominal wall
it does not enter the rectus sheath
o it is represented by the iliohypogastric nerve,
b. lower two posterior intercostal arteries
which pierces the external oblique o branches of the descending thoracic aorta
aponeurosis above the superficial inguinal ring
o and by the ilioinguinal nerve, which emerges
c. four lumbar arteries
through the ring o branches of the abdominal aorta,
o they end by supplying the skin just above the
o (b and c) pass forward between the muscle
inguinal ligament and symphysis pubis
layers and supply the lateral part of the
abdominal wall
- the dermatome of T7 is located in the epigastrium
over the xiphoid process, that of T10 includes the
3 small branches of femoral artery
umbilicus, and that of L1 (T11-L1)lies just above
a. superior external pudendal artery
the inguinal ligament and the symphysis pubis
- do not supply the anterior portion of abdomen
BLOOD SUPPLY
b. superficial epigastric artery
ARTERY - courses upward, dissecting the umbilical ligament
1. superior epigastric artery at the are of Camper’s fascia

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c. superficial circumflex iliac artery it drains downward to the superficial inguinal
- follow the coarse of inguinal ligament just below it nodes

VEINS b. deep lymph vessels

a. superficial veins
- form a network that radiates out from the
umbilicus
- above, the network is drained into the axillary vein
via the lateral thoracic vein
- below, into the femoral vein via the superficial
epigastric and great saphenous veins
- a few small veins, the paraumbilical veins, connect
the network through the umbilicus and along the
ligamentum teres to the portal vein
- this forms an important portal–systemic venous
anastomosis
b. deep veins
- the superior epigastric, inferior epigastric, and
deep circumflex iliac veins, follow the arteries of
the same name and drain into the internal thoracic
and external iliac veins
- the posterior intercostal veins drain into the azygos
veins, and the lumbar veins drain into the inferior
vena cava
- the deep lymph vessels follow the arteries and
drain into the internal thoracic, external iliac,
posterior mediastinal, and para-aortic (lumbar)
nodes
Clinical correlation:
Groin flap
- basis: inferior epigastric artery
- vascularize cutaneous fat flap to cover the defect
of the dorsal aspect of the hand
- 4 to 10 days
Obstruction of portal vein circulation
- the superficial veins around the umbilicus and the
paraumbilical veins become grossly distended
- the distended subcutaneous veins radiate out from
the umbilicus, producing in severe cases the
clinical picture referred to as caput medusae

GROUP:
 upper group – above umbilicus
 below/ lower group – below umbilicus
o freely anastomose with each other at the
thoracoepigastic vein

 paraumbilical vein – serve to communicate the

systemic venous circulation to portal vein circulation

LYMPH DRAINAGE
a. superficial lymph vessels
- the lymph drainage of the skin of the anterior
abdominal wall above the level of the umbilicus is
upward to the anterior axillary (pectoral) group of
nodes, which can be palpated just beneath the
lower border of the pectoralis major muscle
- below the level of the umbilicus, the lymph drains
downward and laterally to the superficial inguinal
nodes
- the lymph of the skin of the back above the level of
the iliac crests is drained upward to the posterior
axillary group of nodes, palpated on the posterior
wall of the axilla; below the level of the iliac crests,

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  deeper layer
 membranous
 contains no fat, coarse above the
THE INGUINAL REGION inguinal ligament to insert in the
(Dr. E. Manalo) fascia lata
 I fingerbreadth below the ligament
 Inserts in the pubic tubercle and
- a.k.a. “inguino-abdominal region” or “inguinal trigone”
arches
- transmits BV, nerves and muscles from abdomen to the
 becomes Colle’s fascia in the
thigh
perineum
- region between the abdomen and the thigh
- boundaries:
c. external oblique muscle
a. inferior boundary – inguinal ligament
o fuses with serratus anterior and latissimus
b. lateral boundary – lateral margins of rectus
dorsi muscle
abdominis muscle
o fibers continues with internal oblique muscle
c. superior border – imaginary horizontal line from
the ASIS to the lateral margin of the rectus o its aponeurosis fuses with the aponeurosis of
abdominis muscle the internal oblique to form the anterior
rectus sheath to insert in the linea alba
- layers of the abdomen: o lower part is thickened = inguinal ligament
a. skin  where BV, nerves and muscles passes
o movable and smooth through
o landmarks:
 ASIS d. internal oblique muscle
 Pubis tubercle o insertion: four lower ribs
 Umbilicus o Its aponeurosis fuse with the aponeurosis of
the external oblique to form anterior rectus
b. superficial fascia sheath
o fused above the umbilicus, separable into 2 o … with the aponeurosis of the transversus
layers below the umbilicus abdominis muscle to form the posterior rectus
o Camper’s fascia sheath and inserts in the linea alba
 consists of adipose tissue (panniculus o Lower part is inserted in the pubic crest as the
adiposus) conjoint/ conjoined tendon
 BV and nerves are located
 Femoral artery e. transversus abdominis muscle
 superficial inferior epigastric artery o origin: lumbodorsal fascia (some fibers blends
o crosses the inguinal ligament and with the fibers of the diaphragm)
coarse towards the umbilicus
f. transversalis fascia/ endo-abdominal fascia
 superficial extermal pudendal artery o a CT layer that lines the entire abdominal
o crosses the spermatic cord cavity between the transversus abdominis
towards the scrotum muscle and the peritoneum

 superficial circumflex iliac artery g. preperitoneal fat

o fatty tissue before the peritoneum
o runs parallel to along the inguinal
ligament
h. peritoneum
o Scarpa’s fascia o serous membrane that lines the abdominal
cavity
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Special Features of Lower Abdominal Wall
1. The 3 flat muscles of the abdomen namely: internal
oblique, external oblique and transversus abdominis
muscle forms an elastic inguinal arcade that helps
maintain intra-abdominal pressure
- Inguinal arcades are traversed by the spermatic
cord (males); round ligament (females)
- arcade collapses when the abdomen is tensed
- relaxed abdomen opens the arcade
Ligaments:
1. Inguinal/ Poupart’s ligament
- derived from external oblique aponeurosis
- thickened portion of the EOA that extends from
the ASIS up to the pubic tubercle
2. Lacunar/ Gimbernat’s ligament
- a part of the inguinal ligament that extends
downwards, backwards and laterally to insert into
the pectineal line
- it is the pectineal portion of the inguinal ligament

3. Cooper’s ligament
- the part of the lacunar ligament that passes
laterally as it inserts into the pectineal line

4. Triangular ligament
- is the reflected inguinal ligament
- fold of inguinal ligament
2. Hesselbach’s triangle - originates from the inferior crus of external lingual
- Located in the lower abdominal wall ring, passes behind the spermatic cord and
- floor: transversalis fascia medially into the linea alba between the conjoint
o weakness: inguinal hernias (direct) tendon and the superior crus of the external
inguinal ring
- lateral border: inferior epigastric vessels
- medial border: lateral border of rectus abdominis 5. Conjoint/ Conjoined ligament
- base: inguinal ligament - Falx inguinalis
- anatomical landmark in differentiating inguinal - formed by fusion of aponeurosis of Transversus
hernias into direct or indirect abdominis and the internal oblique as it inserts
into the symphysis pubis and pubic crest
3. Scrotal extensions
Abdomen Scrotum and labia 6. Interfoveolar ligament of Hesselbach
- Skin - Skin - lies on top of the Transversus abdominis muscle
- Camper’s fascia - Darton’s fascia lateral to the inferior epigastric vessels
- Scarpa’s fascia - Colle’s fascia 7. Pectineal ligament
- External oblique - External spermatic - free edge of the lacunar ligament
muscle
- Internal oblique - Cremaster Muscle
muscle
- Transversus - No corresponding
abdominis muscle layer
- Transversalis fascia Internal spermatic
- Pre-peritoneal fat - Areolar and fat
- Peritoneum - Procerus vaginalis
(extension of the
peritoneum t
scroum or labis)

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Inguinal Rings
1. superficial inguinal ring
- subcutaneous or external abdominal ring
- a detect in the external oblique aponeurosis
- triangular thinned out portion of the EOA
- apex: lateral to the pubic tubercle
- base: lateral half of the pubic crest medial o the
pubic tubercle
- superior crus: aponeurosis of external oblique,
this detect is covered by inter-crural fibers,
attached to the pubic crest and symphysis pubis
- inferior crus: medial end of the inguinal ligament
2. deep inguinal ring
- defect/ opening to the transversalis fascia leading
into the internal spermatic fascia, entrance to the
inguinal canal
- located approximately 1 fingerbreadth above the
inguinal ligament at its midpoint just lateral to the
inferior epigastric artery
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THE INGUINAL CANAL
- a cleft that takes an oblique course through the
inguinal region with the abdominal between the
internal and external inguinal rings
- averages 4-5 cm in length
- the entrance to the inguinal canal is the deep or
internal inguinal and the exit is through the
superficial ring
- anterior wall: is made up of the external oblique
muscle throughout the canal and on the lateral half
by the fleshy fibers of the internal oblique muscle
- posterior wall: transversalis fascia throughout and
the conjoint tendon at the medial half
- roof: arched lower border of the internal oblique
muscle and transversus abdominis muscle
- floor: inferior border of the inguinal ligament,
lacunar ligament and transversalis fascia
- contents: spermatic cord (males)
round ligament (females)
BLOOD VESSELS AND NERVES
1. arteries
originate from:
a. femoral artery
o superficial inferior epigastric artery
o superficial external pudendal artery
o superficial circumflex iliac artery
b. internal iliac artery
o deep internal epigastric artery
o deep circumflex artery
2. veins follow the course of the artery
3. nerves
a. ilio-inguinal nerve
o originates from L1
o pierces the internal oblique muscle
o runs through the inguinal canal, exits
through the external ring and is sensory to
the anterior aspect of the scrotum or the
labia majora
b. iliohypogastric nerve
o originates from L1
o pierces the external oblique aponeurosis
just above the external ring
 o is sensory to the skin of the hypogastric area
2. hydrocele of the cord
c. genital branch of the Genito-femoral nerve - collection of fluid in the processus vaginalis
o originates from L1 and L2 - contains fluid, in contrast with hernia, hernia
o accompanies the spermatic cord/ round contains viscera
ligament thru the inguinal canal - diagnostic maneuver (to differentiate the 2):
o is motor to the cremaster muscle (cremaster TRANSILLUMINATION
reflex) o flashlight over the protrusion
o sensory to the tunica vaginalis (covering of o (+) presence of hallow hydrocoele
the testis derived from the processus o (-) hernia
vaginalis)
AUSCULTATION
CLINICAL CORRELATION o stethoscope
1. inguinal hernia o presence of bowel sounds (hernia)
- (hernia) a protrusion of viscera, CT, adipose tissue o hydrocoele (-)
through an anatomic opening
- consists of: - common in children (bulge in the area that does
a. mouth – opening not spontaneously disappear or reduced over at
b. sac rest
c. contents – can be any viscera (i.e. intestines,
appendix, omentum, ovaries and fallopian 3. varicocele
tubes) - collection of varicose veins in the scrotal and
- types of inguinal hernia: inguinal areas
a. indirect hernia – internal ring - palpate: “BAG OF WORMS”
b. direct hernia – defect is through the - more common on the left because the left
transversalis fascia testicular veins drain to the left renal vein (smaller
dm)
- femoral hernia – femoral ring - right testicular vein = inferior vena cava

INDIRECT HERNIA DIRECT HERNIA FEMORAL HERNIA

FREQUENCY  most common  less common  least common
AGE  often in children  over age 40  all ages
(congenital) (acquired)
lifting heavy objects
straining due to
constipation
SEX  both sexes  adult males  females
DEFECT  unobliterated or patent  weakness of the  enlarged femoral ring
processus vaginalis transversalis fascia  protrusion medial to
femoral sheath
ORIGIN  above inguinal ligament  above inguinal ligament  below the femoral ring
midpoint (internal ring) medially near pubic
tubercle (external ring:
Hesselbach’s triangle)
RELATION TO INFERIOR  lateral  medial  medial
EPIGASTRIC VESSELS because the internal ring is because the Hesselbach’’s
just lateral to inferior triangle is media to it
epigastric vessels
COURSE  often goes into the  rarely scrotal  never
scrotum
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Combination
ON PHYSICAL of hydrocoele and hernia
hernia? YES tip of
touches  anterior bulge touches  empty inguinal canal
EXAMINATION finger
- water comes from the peritoneal fluid side of the finger
- opening is too small for the viscera
- but as the child grows older = diameter of the
opening grows bigger also. So viscera now can
enter through this opening

Herniotomy
- surgical repair in infants/ children
- the sac is opened
- contents are reduced back to the abdominal cavity
- neck of the sac is ligated
- sac is excised

Hernioraphy
- repair of the layers of the inguinal region
- strengthening of the layers

Incarcerated Hernia
- when the hernia becomes irreducible
Strangulated hernia
- vascular supply is compromised
- needs emergency operation

Do you operate on all hydrocoele? No need if it disappears

spontaneously.

If it compresses the testis? Yes. (because it will affect

fertility)

Varicocoele (varicocoelectomy)? Yes. Because there is an

increase blood temperature (compromises spermatogenesis
= decreased sterility)

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 The Peritoneum  may be patent or obliterated
 the patent tubes associated with these folds
(Dr. E. Manalo)
a. lesser omentum is the peritoneal fold –
attached to the common bile duct
 thin, glistening internal lining of abdominal cavity
b. broad ligament – attached to the fallopian
 consisting of a sheet of mesothelial-serosal cells
supported by connective tissue attached to the tube/ uterine tubes
transversalis fascia surrounding the abdominal cavity c. mesentery – attached to the small intestines
beneath the abdominal muscles d. mesocolon – attached to large intestines
Divisions e. meso-appendix – attachment for the appendix
1. parietal – lines the anterolateral and posterior
abdominal cavity wall  obliterated tubes
2. visceral – the part of peritoneum that lines the f. median umbilical ligament – uracus/ allantoic
intraperitoneal organs in varying degrees; forms the duct
serosal layer of the GIT
2. arteries
Peritoneal Cavity  may be patent or obliterated
 lined by the peritoneum  patent:
 contains only peritoneal fluid aside from the a. right and left gastro-pancreatic fold – contains
intraperitoneal organs the hepatic artery
 the fluid serves as a lubricant that allows movement of b. para-duodenal fossa ligament – left gastric
the intraperitoneal organs
arteries and ascending branch of left colic
artery
Divides into 2:
1. lesser peritoneal sac/ lesser omental bursa
o caused by diversion of the peritoneum around  obliterated:
the transverse colon c. median umbilical ligament – umbilical artery

2. greater peritoneal sac/ greater omental bursa 3. arteries and veins

o which the intraperitoneal organs are located  patent:
a. lateral umbilical ligament – inferior epigastric
vessels
 these 2 cavities communicates with each other by
o mesoappendix - for the appendicial
means of “Epiploic Foramen of Winslow”
 boundaries: vessels
- superiorly: gallbladder and liver
- anteriorly: lesser omentum that contains the b. superior ileocecal fold – contains appenditial
common bile duct, portal vein and the hepatic vessels
artery c. suspensory ligament of the ovary – contains
- inferiorly: first part of the duodenum the ovarian vessels and the anterior cecal
- posteriorly: inferior vena cava vessels
- importance: safe surgical guide for gallbladder and
common bile duct surgeries 4. veins
 patent:
Peritoneal Folds (mesenteries/ ligaments) a. superior duodenal fossa ligament and para
 peritoneal reflections or projections of intraperitoneal duodenal fossa ligament
organs that reduce the abdominal cavity into slits,  inferior mesenteric veins
fossa, gutters
 obliterated:
1. ducts (tubes)
b. falciform ligament
 peritoneal folds attached to ducts serving as their
c. ligamentum teres hepatis – obliterated
mesenteries
umbilical vein

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5. not associated with tubes or vessels DIAPHRAGMATIC REFLECTION
a. right and left triangular ligaments of the liver - peritoneum beneath the diaphragm
b. phrenico-colic ligament – diaphragm to colon - covers the inferior surface of the diaphragm
c. coronary ligament – superior surface of the liver - peritoneum cavity not well-defined
d. right and left paracolic folds – ascending and
descending colon INTRAPERITONEAL ORGANS
e. inferior duodenal fossa folds - completely/ partially covered by peritoneum
f. inferior ileocecal folds – membranes associated a. alimentary tract
with appendix (Lane's and Jackson's membrane) b. most of the liver
g. ovarian ligament (pelvic)
h. gastrocolic ligament RETRO-PERITONEAL ORGANS
i. leion-renal ligament
- behind/ posterior to the peritoneum
a. kidneys
Peritoneal fossa, recesses, and gutters
b. pancreas
1. omental bursa (lesser sac) c. aorta
2. above the greater omentum d. duodenum
- left and right subphrenic space (below the e. base area of liver
diaphragm) f. ureters
- hepatoneal recess/ pouch – between liver and
kidney EXTRAPERITONEAL ORGANS
- located beneath/ below/ inferior the peritoneum
3. below the greater omentum a. urinary bladder
- duodenal fossa b. rectum
a. superior c. pelvic organs
b. inferior
c. paraduodenal
d. retroduodenal

- cecal fossae
a. superior
b. inferior
c. retrocecal
d. intersigmoid fossa
e. pelvic fossa (retrovesical)
f. retro-omental fossa
g. panacolic gutters

GREATER OMENTUM
- fusion of 2 parietal peritoneum layers at the greater
curvature of the stomach that hangs down like an
apron over the small intestines and the transverse
colon
- highly mobile gravitating towards the site of infection
(limit the infection in the area/site of infection)
- e.g. acute appendicitis

GLISSON'S CAPSULE
- peritoneal reflection over the liver
- capsule of the liver

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 GASTOESOPHAGEAL JUNTION STOMACH
(Dr. Quitiquit) (Dr. Quitiquit)

- a.k.a. lower esophageal sphincter/ cardia

- it is the point where the distal esophagus becomes
gastric pouch
- 0.5 to 2.5 cm lies intra-abdominally
- it lies at the level of T11-T12 externally
- internally, seen as the transition of stratified
squamous epithelium to a stratified columnar
epithelium
- the wall is thickened and acts as a valve (sphincter =
thickening)
- prevents regurgitation (loose = vomiting)
- it allows swallowing but prevents reflux
- normally at 15 cmH2O pressure
o pressure increase = regurgitation
- the stomach can accommodate up to 2L of fluid in
one time
- factors that relaxes LES:
a. alcohol
b. chocolate
c. external smell
d. caffeine * 1. Body of stomach
* 2. Fundus
- blood supply: * 3. Anterior wall
ARTERIAL * 4. Greater curvature
a. inferior phrenic artery * 5. Lesser curvature
b. left gastric artery * 6. Cardia
VEIN * 9. Pyloric sphincter
a. inferior phrenic vein * 10. Pyloric antrum
b. left gastric vein * 11. Pyloric canal
* 12. Angular notch
* 13. Gastric canal
* 14. Rugal folds

- a.k.a. GASTER
- widest and thickest part of the GIT
- most vascular of the GIT tract
- “pear-shaped” organ
o In thin individuals: J-shaped
o In obese: transversely oriented

- most proximal abdominal organ of the GIT

- majority located at the LUQ
- fixed proximally by the GE junction and distally at the
Gastroduodenal junction

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 gastric outlet syndrome – obstruction in the GD o transverse colon
junction o greater omentum
- mid-portion or the body of the stomach is relatively
mobile d. laterally
- s/s related to stomach is located at the epigastric o spleen
region o lateral diaphragm
- derived from the:
a. foregut e. posteriorly
o from esophagus to end of duodenum o pancreas
(Ligament of Treitz) o diaphragmatic crura
o blood supply – celiac artery o renal capsule
o retroperitoneal nerve and vessels (IVC and
b. mid gut abdominal aorta(
o from jejunum to mid portion of the o splenic hilum
transverse colon
o blood supply – superior mesenteric artery - GROSS ANATOMY
a. 2 openings
c. hindgut o cardia – proximal
o mid portion of the transverse colon to the o pylorus – distal
anus
o blood supply – inferior mesenteric artery b. 2 valves
o lower esophageal sphincter – proximal
- FUNCTION: o pyloric valve – distal
a. food storage, digestion, mixing
o stays in the stomach approximately 4 hours c. 2 curvatures
o Cardiac angle/ incissura cardiac
b. kills and inhibits digested microorganisms with o Incissura angularis/ amgular notch
HCL
o abdominal colic/ spasms – jumping after d. 2 surfaces
eating o anterior
o posterior
c. both endocrine and exocrine functions by
elaborating enzymes
e. 2 omenta
o lesser omentum – lesser curve
- RELATED STRUCTURES:
o greater omentum – greater curve
a. anteriorly
o left lateral lobe of liver
o diaphragm
- ANATOMIC DIVISIONS
o anterior chest and abdominal wall
a. fundus
o area above line drawn thru cardiac notch
b. superiorly
o left lobe of liver
b. body/ corpus
o diaphragm
o from fundus down to the line of angular
o distal esophagus notch

c. pylorus
c. inferiorly o after angular notch line

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 o 2 subdivisions: d. left gastroepiploic
 Pyloric antrum e. right gastroepiploic – drains to superior
 Pyloric canal – where the duodenal/ mesenteric vein
pyloric valve is located splenic vein and superior mesenteric vein = will
drain to the portal vein

INNERVATION
a. Vagus nerve (CN X)
o enters the abdomen by joining the
esophagus thru the esophageal hiatus
o parasympathetic
o when it reaches the distal esophagus will
divide into:
 Left trunk – anteriorly
 Hepatic branch
 supplies the liver and gallbladder
 pyloric branch
 anterior nerve of Latarjet
 supplies pylorus and anterior
part
 most distal of the pyloric branch

 Right trunk – posteriorly

 celiac branch
 supplies rest of the viscera and
pancreas

b. Celiac Plexus
o sympathetic
o arises from 5th to 8th thoracic artery

LYMPHATIC DRAINAGE
- BLOOD SUPPLY o follows arterial supply of stomach and eventually
ARTERIAL SUPPLY drain into the celiac nodes → thoracic duct
o derived mainly from branches of the Celiac
artery a. left gastric node
a. left gastric artery – supplies lesser curve  drains cardia and medial half of body of
b. right gastric artery – also supplies the lesser stomach
curve
c. short gastric arery b. right gastric node
d. gastroduodenal artery  drains lesser curve of the antrum and
e. left-gastroepiploic artery pylorus
f. right-gastroepiploic artery
c. right gastroepiploic node
VENOUS DRAINAGE:  drains 60% of distal greater curve
a. left gastric vein portal vein
b. right gastric vein d. left gastroepiploic node
c. short gastric vein splenic vein  fundus and 40% of proximal greater curve
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 - CLINICAL CORRELATIONS:
a. acid related disorders
 peptic ulcer
 erosions, sore or holes in the mucosa/
wall of the stomach and duodenum
 either gastric ulcer/ duodenal ulcer
 GRAHAM PATCH – putting omentum on
the repaired area where you have the
perforations

b. gastritis
 inflammation of stomach
 secondary to acid, drugs (aspirin, anti-
steroidal and steroids)
 stress hypersensitivity
c. Vagotomy
 truncal vagotomy – cut vagus nerve
 selective/ highly selective/ parietal
vagotomy = cut branches only

d. Gastrectomy
 remove whole stomach (total)
 remove part (partial/ subtotal)

e. Gastrotomy
 opening of stomach

f. Billroth operation

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 SMALL INTESTINE - descends up to L3 then bends sharply to the left
and becomes the 3rd part of the duodenum
(Dr. Laygo) - crossed by transverse colon
- once crossed it is divided into supracolic and
- part of GIT between the stomach (pyloric sphincter) infracolic compartments
and ileocecal junction - relations:
 anterior: fundus of gallbladder, right lobe of
- components:
liver, transverse colon and coils of SI (jejunum
a. duodenal
and ileum)
b. jejunum
 posterior: hilus of the right kidney, right ureter
c. ileum
 lateral: ascending colon, right colic flexure,
right lobe of the liver
DUODENUM  medially: head of pancreas, halfway down,
- history: 1 foot long posteromedially – common bile duct and main
- after the stomach panreatic duct terminates
- c-shaped tube
- length: 25 cm (10 inches)
- 1st, shortest, lightest, and with the thickest wall accessory pancreatic duct
- most fixed portion of the small intestine - drains 1.9 cm above the main pancreatic duct (duct
- extent: pylorus (pyloric sphincter) and the duodenal- of Wirsung) and common bile duct
jejunal junction - “duct of Santorini”
- location: epigastric and umbilical regions - opening “minor duodenal papilla”
- peritoneal relations:
o 1st 2.5 cm : covered by peritoneum anteriorly medioduodenal papilla
and posteriorly - drainage = duct of common bile duct and main
o upper border – lesser omentum pancreatic duct
o lower border – greater omentum
“valves of Kerckring”
- Intraperitoneal
- other parts: retroperitoneal – partially covered 3. horizontal part
- length: 8cm
- passes horizontally to the left side on the subcostal
PARTS OF THE DUODENUM
plane
1. superior part
- crosses the body of L3
- 5 cm long (2 inches) - found on the right and left infracolic compartments
- start at the pylorus (L1) and passes backward, - crosses the ff:
upward and to the right – lies on transpyloric plane a. right psoas muscle
- relations: b. ureter
o anteriorly: quadrate lobe and gallbladder c. IVC
o posteriorly: lesser sac, gastroduodenal artery, d. abdominal aorta
common bile duct, portal vein, IVC
 portal triad - anterior boundary of the - ends at the left side of body of L3
Epiploic foramen together with hepatic - relations:
artery o anterior: root of mesentery of SI, superior
mesenteric vessels, coils of jejunum
o superiorly: epiloic foramen (communication of o posterior: right ureter, right psoas muscle, IVC
the lesser and greater sac and aorta
o inferiorly: head of the pancreas o superior: head of pancreas
o inferior: coils of jejunum
2. descending duodenum
- length: 8 cm (3 inches)
- runs vertically downward in front of the hilus of
the right kidney and on right side of L2 and L3
vertebra
- clinical correlation:
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 o superior mesentereric vessels may cause
duodenal obstruction secondary to
compression of these vessels
o treatment: bypass/ resection – anastomosis of
the proximal and distal portion and put above
the duodenum
o resection of obstructed area
o gastroduodenal bypass
o blunt abdomina trauma
 force compression by L3
 rupture of the transverse duodenum/
perforation of postero aspect
 increase abdominal circumference
 common site of duodenal perforation
1st part:
a. supraduodenal
b. retroduodenal
o branch of gastroduodenal artery (branch of
common hepatic artery
o main terminal of GD artery
 right gastroepiploic artery
 superior pancreatico-duodenal artery
Rest of duodenum – arterial arcade of:
a. anterior to duodenum and pancreas branch – from
superior and inferior pancreotico-duodenal artery

4. ascending part b. posterior located behind

- length: 5 cm (2in)
- shortest part  superior pancreatico-duodenal artery - GD artery
- run upward along the left side of the abdominal  inferior pancreatico-duodenal artery – from superior
aorta on the left psoas muscle messenteric artery
- ends about 1 inch to the left of the median plane
at the L2 level Venous Drainage
- bends sharply forward – duodeno-jejunal flexure - lies along the arteries
- relations - right GE vein – superior mesenteric vein
o anterior: root of mesentery, coils of SI - superior and inferior PD – superior mesenteric vein
o posterior: left margin of aorta, medial border - SMV joins the splenic vein to form portal vein
of left psoas
Lymphatic Drainage
Vascular Arch of Treitz - upward via PD lymph node → GD LN → celiac group
- found in the space between the duodenum and of LN
kidney - downward via inferior PD LN → SM LN
- formed by left colic artery and inferior mesenteric
vein – as they ascend together near the left border Nerve Supply
of duodenum to the root of the transverse
mesocolon Sympathetic nerve
1. from celiac plexus
2. from SM plexuses of nerves
Duodenal flexure
- usually retroperitoneal in location
Parasympathetic nerve
- lies to the left of the L1-L2 disk
1. vagus nerve
- originate at the middle of L2 or even L3
- relations:
o posterior: lumbar portion of diaphragm Meissner's plexus of nerves
o superior: inferior border of pancreas - submucosa of duodenum
o lateral: internal border of left kidney
o anterior: posterior wall of stomach Auerbach's plexus
- between circular and longitudinal muscles of
duodenum
Suspensory Ligament (muscle) of Treitz
- band of fibrous muscular tissue from GJ flexure
and towards the ascending portion of duodenum
and inserts to the right pillar of diaphragm
Arterial supply of duodenum FIVE DUODENAL FOSSA

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 a. paraduodenal fossa THE JEJUNUM AND ILEUM
- lies to the left of duodenojejunal flexure
(Dr. Laygo)
- boundary:
o right: aorta
- 6 to 7 m long
o left: kidney - 2 ft jejunum
o superior: pancreas and renal vessels - 3 ft ileum
o anterior: IMV runs in to anterior wall of fossa - occupies the greater part of the abdominal cavity
- most mobile part of the small intestine
- clinical correlation: (+) herniation at this area - mesentery
o fan shaped structure which suspends the jejunum
compress IMV → hemorrhoids
and ileum from that of the posterior abdominal
o treatment: surgical wall
o opens to the right and upward (especially to o root 15 cm long: directed obliquely inferiorly and
strangulated hernia) to the right from left side of the 2nd lumbar
vertebra to the right sacroiliac joint
b. superior duodenojejunal fossa o crosses the following structures:
- downward a. horizontal part of duodenum
b. abdominal aorta
- 1 inch in depth
c. IVC
- In front of L2 d. psoas major muscles
e. right ureter
c. inferior duodenojejunal folds f. right testicular/ right ovarian vessels (gonadal
- directed upward vessels)
- In front of L3
- proximal part of the jejunum and distal part of ileum
have shorter mesenteries = less mobile from the other
- b and c formed by two peritoneal folds
part of the small intestine
- both peritoneal folds - consists of 2 layers of peritoneum between duodenal
o pass to the left from the terminal portion of and ileal vesssels, lymphatics, nerves and
the duodenum. IMV pass along their extraperitoneal fatty tissues
extremities
Valves of Kerckwing
d. inferior duodenal fossa - permanent circular folds of the mucosa and
submucosa which are present throughout the
- extends behind the 3rd part (horizontal) of
intestinal wall
duodenum - more prominent in the proximal duodenum
- less prominent as it goes down to the distal ileum
e. mesenterico parietal fossa (Waldeyer)
- located behind the 1st part of the mesojejunum Peyer's patches
- immediately behind the superior mesenteric artery - large submucosal aggregates of lymphatic tissue
and below the duodenum usually present in the ileum along its anti-mesenteric
- orifice faces to the left border
- boundaries:
o anterior: Superior mesenteric artery Vasa Recta
o posterior: lumbar vertebra - straight arterial branches arising from the arterial
arcades within the mesentery and extends directly
- clinical correlation: orifice is big enough for small to the intestinal wall
bowel to herniate at this area without any s/s or
difficulty/ strangulation

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 Jejunum Ileum
LOCATION Upper part of the Lower part LYMPHATIC DRAINAGE
peritoneal cavity - starts from the intestinal villi (lymphatic structure
and on the left called lacteals) – then eventually empty to the plexus
side of the of lymphatics vessels along the jejunum and ileum
transverse - lymphatics vessels passes between the 2 layers of
mesocolon mesentery → “mesenteric LN”
LUMEN Wider Narrower
- classification of mesenteric LN
WALL Thicker Thinner
a. marginal/ peripheral
COLOR Reddish Lighter
o near the intestinal wall
PRESENCE OF More and closer Less and fart
PLICAE apart
CIRCULARIS b. intermediate LN
MESENTERY Located above Usually attached o located at the middle portion of the arterial
and to the left of below and to the arcades
the abdominal right of
aorta abdominal aorta c. central group of LN
VASA RECTA 1 or 2 arcades Complicated o main mesenteric nodes (celiac LN and SM LN)
Usually long with arterial arcade
infrequent branch 3-4 or more with NERVE SUPPLY
passing to the numerous short - comes from the vagus nerve as well as splanchnic
intestinal wall terminal branches nerve through the celiac ganglion and the nerve
FAT DEPOSITS Near the root but Deposited all plexuses around the mesenteric artery
scanty in the throughout
intestinal wall CLINICAL CORRELATION:
PEYER’S PATCHES Inconspicuous to Present, Meckel's diverticulum
absent numerous in - congenital defect which is due to the persistent
membrane in yolk sac
lower ileum along - located distal 100 cm of ileum; usually located
the anti— about 1 foot from the ileocecal junction
mesenteric - usually at the anti-mesenteric border of distal
border ileum
- causes of RLQ pain – inflamed Meckels’s
BLOOD SUPPLY OF JEJUNUM AND ILEUM diverticulum
- UTI and acute appendicitis – other causes
ARTERY
- originate from the left aspect of SMA which is
located just behind the pancreas → aorta → enters
the mesentery after coming out from the inferior
aspect of pancreas and crosses the uncinate process
of pancreas then → goes downward towards the
right iliac fossa
- terminal branch: ileocolic artery 9below the
intestinal artery
- jejunal artery – jejunum
- ileal artery – ileum
o from the superior mesenteric artery

VEINS
- accompanies the arteries
- drains all the way to SMV
- portal vein = splenic vein + SMV
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 ABDOMINAL AORTA

unpaired branches paired branches paired branches

upper portion lower portion

celiac artery superior mesenteric a. inferior mesenteric a.

left gastric splenic common hepatic

esophageal branches
GD hepatic proper
hepatic branches supraduodenal
retroduodenal left hepatic
sup. post. duodenal right gastric
right gastric epiploic

pancreatic (dorsal, superior, great pancreatic) right hepatic

left gastric epiploic cystic artery

splenic

short gastric

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 superior mesenteric artery

inferior PD middle colic intestinal ileocolic

ant. post. right left jejunum ileum ascending branch

colic ileal

cecal

appendicular

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CELIAC ARTERY/ AXIS/ TRUNK  usually lies behind on the body wall peritoneum,
- most proximal/ ventral unpaired branch of the on the floor of the Bursa omentalis (lesser omental
abdominal aorta cavity)
- arises from the front of abdominal aorta just below  eventually reaches the bare area of the stomach
the level of the upper portion of L1 vertebra and gives of the:
- about 1-2 cm long
- passes horizontally forward above the upper margin a. esophageal branches
of the pancreas and divides behind the posterior b. hepatic branches – passes towards the left
body wall peritoneum into the following lobe of the liver between the layers of the
- around the celiac artery are celiac LN as well the lesser omentum
celiac plexus of nerves including the ganglia

a. LEFT GASTRIC ARTERY - goes downward along the lesser curvature of the
stomach usually thru the hepatogastric ligament
 smallest branch of the celiac artery
terminates by anastomosing with the branches of the
 course: courses upward and to the left toward the
right gastric artery (from the hepatic artery proper)
cardiac end of the stomach
lesser omentum
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 a. hepatogastric ligament – lower portion of the liver
growing towards the lesser curvature
b. hepatoduodenal – covers the portal triad
- cholescystoduodenal and cholechoduodenal
b. SPLENIC ARTERY
- largest branch of the celiac artery
- arises from the left side of the celiac trunk distal to
the left gastric artery
- going towards the hilum of the spleen
1. left gastric epiploic artery
o goes along with the upper portion of the
greater curvature of the stomach
2. short gastric artery/ vasa brevia
o small branches
o supplies the upper part of the stomach (fundus)
c. COMMON HEPATIC ARTERY
- bigger than the left gastric artery
- runs forward and to the right along the upper
border of the pancreas and upper margin of the
upper duodenum passing behind to the lesser
omentum
1. GASTRODUODENAL ARTERY
o short thick trunk
o coming from the CHA
o at the upper border of the first part of the
duodenum
o passes behind and divides in its inferior border
o terminates: right gastro epiploic artery
anterior superior PD artery
o then passes the duodenum and the head of
the pancreas giving of its proximal branches:
 Supraduodenal artery
o slender branch
o descends into the anterior and posterior
surface of the first part of the duodenum
SUPERIOR MESENTERIC ARTERY
 Posterior Superior PD Artery
o arises behind the duodenum from the first 2
cm of the GD artery
o passes to the right anteriorly to the common
bile duct
o going along the posterior aspect of the head
of the pancreas
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o gives off duodenal and pancreatic branches
and eventually anastomose with the
branches with the posterior inferior PD
artery at the posterior part of the pancreas
 Retroduodenal Artery
o small multiple branches at the inferior
aspect of the 1st part of the duodenum just
proximal to its terminal division
 Right Gastroepiploic Artery
o passes to the right → left along the greater
curvature side of the stomach between the
layers of the gastro colic ligament
o anatomose with the branch of the left
gastroepiploic artery
 Anterior Superior PD Artery
o usually descends across the head of the
pancreas near the sulcus between the
duodenum and the pancreas
o it gives off duodenal and pancreatic
branches
o anastomose with the anterior inferior PD
artery which comes from the SMA
2. PROPER HEPATIC ARTERY
- continuation of the common hepatic artery
- distal to GD artery
- ascends between the layer of the
hepatoduodenal ligament
- gives off near its beginning the right gastric
artery
- supplies the distal portion of the lesser curvature
- anastomose with the left gastric artery
- terminates: right hepatic artery and
 supply the right lobe of the liver
 gives of cystic artery which supplies the
gallbladder
left gastric artery
 supplies the quadate and quadrate lobe and
left lobe of the liver
- supplies all of the small intestine except the proximal
part of the duodenum
- supplies the cecum, ascending colon and most of the
transverse colon and the embryonic midgut
- arises from the aorta behind the neck of the lower ½
of the L1
- eventually passes across the uncinate process and
third part of the duodenum to enter the mesentery
 - gives off the following branches:
SM vein – follow the course of the arteries
a. inferior PD artery Inferior PD vein – portal vein
o will branch out into anterior and posterior
branch PORTAL VENOUS SYSTEM
- empties all venous blood from the GIT except the
b. middle colic lower part of the anal canal
o will branch into right and left - drains veins of the spleen and pancreas
o right branch - supplies the proximal part of - portal venous system
he transverse colon - supplies 75% of blood to the liver
o left branch - distal part - divides into right and left branches at the porta
hepatis
c. intestinal artery - formed by the SMV and splenic vein
- tributaries:
o will branch into jejunal and ileal artery
a. INF MV
o 12 – 15 in no. b. SUP MV
o arises from the convex left side of the c. right gastric vein
superior mesenteric artery d. splenic vein
o each will eventually divide into 2 parts e. superior PD vein
which unites with the adjacent branches to
form the arterial arcade LYMPHATICS
- goes to the celiac trunk of LN and SM LN then drains
d.ileocolic/ ileocecal artery into thoracic duct
o terminal branch of the SMA
o divides in into cecal artery – proximal
portion of the ascending colon
o ascending branch – anastomose with the
distal right colic branch
 more superior branch

VENOUS DRAINAGE
UPPER GIT
- left gastric vein/ coronary vein
- right gastric vein
o drains into the portal vein

- prepyloric vein drains into the right gastric vein

(landmark)

- right gatsroepiploic vein + ant sup PD vein = terminal

branches
o drains into superior mesenteric vein

- middle colic vein + gastro colic vein = drains in SMV

- left gastroepiploic vein → splenic vein → portal vein

- short gastric vein → splenic vein → portal venous

system

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RADIOGRAPH
(Dr. Aragon)
Oral Cavity
- x-ray of impacted tooth – embedded with bone
- determine no. of teeth, tooth not erupted
Esophagus
- esophagogram – examine and with contrast material
- barium swallow – plain chest x-ray
- EGD
- plain chest x-ray – intrathoracic (must)
o barium swallow, double contrast (barium and air
together) – get lateral and oblique views even
supine/ Trendelenburg position
- esophageal normal constrictions
o cricopharyngeal
o esophagogastric junction – distal constriction
o aortic – crossing of left main bronchus
 elder: more dilated aorta (can produce an
impressions)
- normal: no bulge, hump and out-pouching
o outside of the constrictions and should be
smooth
- chest and abdomen – radiograph
- radiograph in the abdomen – administration of
artificial contrast (barium and iodine)
- natural contrast – provided by tissues
o fat – dark
o muscle/ blood/ fluid – white or opaque but not
as opaque as metals
o gas – luminal location with in the stomach
WHAT TO EXAMINE:
Gas Pattern
- presence of gas enable to see the lumen of the organ
such as stomach (food, talking), colon
- visibility in a hollow organs – appearance will be
dictated by the position of patient
- supine position
- appear:
o gas at the superior aspect of the lumen
o after stomach – pockets of air within the colon
o amount of air – not the same (variable)
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- (-) gas – appear uniform soft tissue opacity
o increase gas – increase gas forming bacteria
o decrease gas – abnormal (obstruction)
 vomiting after eating
- (+) gas – obscure shadow of retroperitoneal organs
- extraluminal air
o can determine peptic ulcer disease
o air outside/ leak to peritoneal cavity
(pneumoperitoneum)
- soft tissue masses/ densities of fluid collections
o (n)RUQ – liver
o (n)LUQ – spleen – splenic flexure (above)
- splenomegaly (down splenic flexure)
- gallbladder – not seen (difficult to determine)
o due to material contrast – bile
CALCIFICATIONS
- bones (normal)
- kidney and gallbladder (-) normal
o once radiopaque (+) stones
o appear: kidney – stag horn
o calculi: ginger roots
- gallbladder – rounded
- foreign bodies
o swallowed radiopaque materials (coin, ring,
dentures)
- up (right)
o above diaphragm
o below diaphragm (right liver)
o left upper portion – spleen
o dark lines – fat at the psoas muscle (at the side
of the vertebra)
o right kidney – easily seen
o left kidney – not easily seen
o dark shadow → (fat/air) → treatment once (+) in
peritoneum
o falciform ligament → divides the liver
CLINICAL CORRELATION
 chronic pancreatitis
- (+) calcification (popcorn like)due to inflammation
 splenic calcifications
 hepatosplenomegaly
- edge of liver (near iliac crest
- spleen → go down – border
 - (+) in leukemia
 ascites
- sagging flunks
- obscured liver ILEOCECAL REGION
(Dr. Quitiquit)
 esophagram
- barium swallow → determine the normal contour
of esophagus CECUM
- radiograph – white esophagus - a blind-ended sac that projects downward in the
- flouroscope – black right iliac region below the ileocecal region
- clinical correlation: - blind-ended pouch that is situated in the right iliac
 bird's beak – achalasia fossa
- attached to its posteromedial surface is the appendix
UPPER GI SERIES AND LOWER GI - presence of peritoneal folds in the vicinity of the
 Stomach
cecum creates the superior ileocecal, the inferior
- mosaic pattern – honeycomb like; gastric fundus
- body – horizontal/ trunk lines ileocecal, and the retrocecal recesses
- antrum – smooth - as in the colon, the longitudinal muscle is restricted
to three flat bands, the teniae coli, which converge
 Duodenum on the base of the appendix and provide for it a
- 1st part: bulb “duodenal bulb” complete longitudinal muscle coat
- (+) opacity in the rectum → barium swallow → - 5 cm width including the height
reach the rectum 1-2 hours - thinnest wall in comparison with the rest of the GIT
- mucosal patterns: little chicks appearance (distal - significance: common site of perforation once (+)
duodenum) obstruction of large intestine primarily at the distal
- caliber of the intestines are not the same because colon
of peristalsis – if uniform (abnormal) - widest part of the large intestine
- mobile compared to ascending colon which is fixed
CT scan and ULTRASOUND posteriorly
- liver, gallbladder, pancreas - relations:
o anteriorly: coils of small intestine, sometimes
GALLBLADDER (CT scan) part of the greater omentum, and the anterior
- wall thickness – not more than 3 mm thickness abdominal wall in the right iliac region
- transverse dm – not more than 4 cm o posteriorly: the psoas and the iliacus muscles,
the femoral nerve, and the lateral cutaneous
nerve of the thigh
 appendix is commonly found behind the
cecum

o medially: the appendix arises from the cecum on

its medial side

- Blood Supply
o Arteries
 Anterior and posterior cecal arteries form
the ileocolic artery, a branch of the
superior mesenteric artery

o Veins
 The veins correspond to the arteries and
drain into the superior mesenteric vein

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 o lymph drainage  medial
- terminal ileum
 the lymph vessels pass through several
- mesentery
mesenteric nodes and finally reach the - omentum – medially
superior mesenteric nodes
 lateral
o Nerve Supply - right paracolic gutter – space lateral to the colon
 branches from the sympathetic and - abdominal wall
parasympathetic (vagus) nerves form the
superior mesenteric plexus  anterior
- greater omentum
- anterior abdominal wall
- coils of small intestine

internal relationship
- internal wall of ileum would continue laterally
having an upper and lower lips and meet/ fuse
laterally to form the frenulum of ileocecal valve
- upper lip: ileocolic lip
- lower lip: ileocecal lip

ileocecal valve
- prevent food good back to ileum
- internally, it appears as a projecting fold of mucous
membrane showing 2 thick rounded lips
- location: in the anterior abdominal wall (at the
junction of the right semilunar line and
spinoumbilical line
- a rudimentary structure, consists of two horizontal
folds of mucous membrane that project around
ILEOCECAL JUNCTION the orifice of the ileum
quadrant: RLQ - plays little or no part in the prevention of reflux of
region: right iliac region cecal contents into the ileum.
right iliac fossa – indentation in iliac region - the circular muscle of the lower end of the ileum
(called the ileocecal sphincter by physiologists)
extent of ileocecal junction: serves as a sphincter and controls the flow of
include distal portion of ileum (about 2 cm) and cecum contents from the ileum into the colon
- smooth muscle tone is reflexly increased when the
boundary with ascending colon cecum is distended; the hormone gastrin, which is
- create a transverse line level where ileum enters the produced by the stomach, causes relaxation of the
cecum muscle tone.

boundary:
 posterior
- psoas muscle
- lateral cutaneous nerve of the thigh
- external iliac artery
- (+) appendicitis
- psoas's sign: pain at the Psoas muscle once
contracted
o hyperthesia in the skin of the thigh
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APPENDIX
- Location and Description
o the appendix is a narrow, muscular tube
containing a large amount of lymphoid tissue
o it varies in length from 3 to 5 in. (8 to 13 cm).
The base is attached to the posteromedial
surface of the cecum about 1 in (2.5 cm)
below the ileocecal junction
o remainder of the appendix is free. It has a
complete peritoneal covering, which is
attached to the mesentery of the small
intestine by a short mesentery of its own, the
mesoappendix
o appendix lies in the right iliac fossa, and in
relation to the anterior abdominal wall its base
is situated one third of the way up the line
joining the right anterior superior iliac spine to
the umbilicus (McBurney's point)
o Inside the abdomen, the base of the appendix
is easily found by identifying the teniae coli of
the cecum and tracing them to the base of the
appendix, where they converge to form a
continuous longitudinal muscle coat
- Common Positions of the Tip of the Appendix
o the tip of the appendix is subject to a
considerable range of movement and may be
found in the following positions:
a) hanging down into the pelvis against the
right pelvic wall
b) coiled up behind the cecum
c) projecting upward along the lateral side of
the cecum
d) in front of or behind the terminal part of
the ileum
o first and second positions are the most
common sites
- Blood Supply
o Arteries
 appendicular artery is a branch of the
posterior cecal artery
o Veins
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 appendicular vein drains into the
posterior cecal vein
o Lymph Drainage
 lymph vessels drain into one or two nodes
lying in the mesoappendix and then
eventually into the superior mesenteric
nodes
o Nerve Supply
 supplied by the sympathetic and
parasympathetic (vagus) nerves from the
superior mesenteric plexus
 afferent nerve fibers concerned with the
conduction of visceral pain from the
appendix accompany the sympathetic
nerves and enter the spinal cord at the level
of the 10th thoracic segment
- wormlike appearance or “vermiform appendix”
- located 2 cm below from the ileocecal junction –
base of appendix
- tip of appendix assumes several position downwards,
upward... etc.
- localization: base on clock position
- when tip goes beyond to the pelvic region – PELVIC
INLOCATION
- behind cecum – RETROCECAL
o 60% is at this area
- ileal in location – towards the ileum
- location:
o right lower quadrant
 female - ovary and FT
 male – appendicitis
o right iliac region
- clinical consideration:
o 2 cecum – 2 appendices (duplication)
o mal rotation – dextrocardia
o pain at left side
o failure of rotation → counter clockwise → cecum
not at right
o long appendix towards to the left
- size: 5 cm/ 5-10 in length
o half cm (0.5 cm) in length
- blood supply:
 artery b. venous obstruction
o from the posterior branch of posterior colic  infiltration of bacteria at the wall of
artery (also supply cecum) from ileocolic artery appendix
from SMA and supply it by appendicial artery
drainage
o drain to posterior colic → ileocolic → SMV c. vascular obstruction
 gangrene to the area due to decrease
- nerve supply blood supply
o vagus nerve  increases pressure further
o involve the parietal peritoneum – localized pain
d. perforation
- mesentery and membrane
a. mesoappendix - once (+) obstruction → cascade of event to
o mesentery of appendix perforation → perforated → bacteria at the
o contains the appendicular vessels and peritoneum (treatment lavage)
nerves.
STAGE
b. bloodless fold of Treves a. stage I
o small/ thin membrane that connects the - congestive stage
distal position of ileum and cecum - obstruction of LN

c. ileocecal fossa
o underneath the fold of Treves b. stage II
- suppurative stage
d. Jackson’s membrane - venous obstruction
o membrane that runs anterior to the cecum
and connects the distal ileum to the lateral c. stage III
abdominal wall - gangrenous stage
o not constant - decrease arterial supply

e. Lane's membrane d. stage IV

o last kink - perforative/ perforation
o may produce kink to the ileum
o membrane connects distal ileum to the  treatment:
- appendectomy (surgical treatment)
posterior abdominal wall
- once not treated → circulation → septicemia →
perforates → infection to the perineum →
- clinical correlation
peritonitis generalized → hepatic/ liver abscess →
APPENDICITIS
septicemia and controlled bleeding/ DIC → shock
o causes: obstruction of lumen of appendix due to
→ death
 foreign material
 food
 lymphoid follicles inside the lumen of
appendix → inflammation
 (+) continuous mucous secretion
↓
 not able to drain to cecum
↓
 build up of pressure
↓
a. obstruction of lymphatics
 edema – nerve supply is stimulated
o generalized abdominal pain
o vomiting

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 LARGE INSTESTINE
(Dr. Quitiquit)

General characteristics:
1. bigger size
2. presence of haustrations
- out pouching in the wall

3. presence of taenia coli

- longitudinal band of muscles that extends from RIGHT COLIC/ HEPATIC FLEXURE
cecum to the sigmoid colon - angle or bend forming the junction of the ascending
colon and transverse colon
4. presence of appendices epiplocae - less acute angle
- fatty tissues - located anterior to the kidney and inferior to the
- only found in the large intestine gallbladder and liver
- hepatocolic ligament ~ attached to the inferior
ASCENDING COLON border of the liver
- between cecum and hepatic flexure
- 5-8 inches TRANSVERSE COLON
- covered by peritoneum anteriorly - situated between the 2 flexure
- fixed posteriorly; not mobile - 18-20 inches
- related posteriorly to the - longest part of the large intestine
o iliacus muscle - oriented in a horizontal line
o quadratus lumborum muscle - inferior to the stomach
o lower part of the kidney - extends from the hepatic flexure to the splenic
flexure
- medially: kidney and IVC - posterior lip = where the greater omentum is
- laterally: paracolic gutter attached to
- anteriorly - anterior lip = greater curvature of the stomach
o greater omentum - related posteriorly to the 2nd part of the duodenum
o coils of the small intestine and head of pancreas
o anterior abdominal wall - anteriorly: greater omentum and anterior abdominal
wall
- mobile and covered totally by peritoneum

LEFT COLIC/SPLENIC FLEXURE

- lies at a higher level compared to the right colic
flexure
- limited above by the tail of the pancreas and base of
the spleen
- phrenicocolic ligament attaches the flexure to the
diaphragm at the level of 10-11th rib; usually
bloodless

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 - more acute angle formed o middle colic artery
o connected with each other forming an arcade
DESCENDING COLON
- a.k.a. iliac colon - VASCULAR ARCADES OF DRUMMOND
- 10-11 inches long o seen only in large arteries
- boundary: from the splenic flexure to the pelvic inlet
- covered by peritoneum anteriorly - IMA – left hemi colon
- fixed posteriorly o Left colic artery
- no mesentery o Sigmoidal artery
- crosses 5 muscles: o Superior hemorrhoidal artery
o diaphragm o anastomose with the branches of the middle
o transversus abdominis colic
o quadratus lumborum
o iliacus muscle
o psoas major muscle - VENOUS DRAINAGE
o SMV ~ portal vein
SIGMOID COLON o IMV → splenic vein → joins the superior
- a.k.a. pelvic colon mesenteric vein → portal vein
- located at the pelvis
- 5-35 inches (10-15) long CLINICAL CORRELATION
- It ends at the 3rd sacral vertebra (where rectum - barium enema
starts) o wall covered by barium
- where taenia coli and appendices epiplocae ends o air inside the large intestine
- prone to volvulus
o because of the length of the sigmoid colon… it is - colonoscopy
prone to twist or loop o inserted into the rectal area all the way into the
o causes obstruction cecum

- possess a long mesocolon which makes it very - megacolon

mobile o associated with Hirschprung’s disease
o has an inverted V shape o defect in the nerve supply in the anal-rectal
o tip of the V – guides us in identifying in the left region
ureter o anal valve – no relaxation
o the apex of the V has a recess called as o accumulation of stool
intersigmoid recess which aids as a guide to the
left ureter - right hemicolectomy
o removal of the right hemi colon
BLOOD SUPPLY o from the mid portion of the transverse portion
- based on 2 arteries → distal portion ileum
- right hemi colon – supplied by SMA
o ascending colon, right part of transverse colon - left hemicolectomy
o removal of the left hemi colon
- left hemi colon (distal half) – IMA o from the mid portion of the transverse colon →
descending colon
o right colic artery ~ upper portion of the
ascending colon, flexures - cystic dilatation
o iliocolic artery ~ lower portion of the ascending - if tumor is smooth ~ most probably benign
colon, cecum, appendix
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 - if tumor is like cauliflower ~ most probably malignant leading to sigmoid colon closed loop/
obstruction (VOLVULUS)

PARTS OF THE PELVIC MESOCOLON

a. lateral limb
- extends along the iliac artery from the middle of
the external iliac artery to the middle of the left
common iliac artery

b. middle limb
- extends from middle of left common iliac artery to
the middle of S3

INTERSIGMOID RECESS
- a.k.a. Fossa Intersigmoidea
SIGMOID COLON, RECTUM, AND - a small funnel shaped pouch which is commonly
present at the junction of the 2 roots of the sigmoid
ANAL CANAL mesocolon
(Dr. Laygo) - it can either be located deep or superficial
- significance: this usually serves as a useful landmark in
SIGMOID COLON/ PELVIC COLON the identification of left ureter
- starts at the area of the pelvic brim and terminates at o left ureter just above the LCIA
recto-sigmoid junction o loops of small intestine enter the fossa or in
- vertebral landmark: S3 between mesocolon and parietal peritoneum →
- this is the point where the peritoneal investment and would result to internal/ intraperitoneal hernia
mesentery of the sigmoid colon terminates
- can go as far as the RLQ area MESOSIGMOID MEMBRANE
- a.k.a. Lane’s first and last kink
2 DIVISIONS: - is a thickening and shortening of the peritoneum of left
a. Iliac segment iliac fossa
- fixed segment of sigmoid colon - it binds junction of iliac and pelvic colon to the pelvic
- part of the sigmoid colon that lies in the iliac fossa brim
- it has no mesentery - this is usually avascular

b. pelvic segment BLOOD SUPPLY

- mobile segment of the sigmoid colon
- provided w/ a mesentery
- long omega shaped coil of large intestine that is
continuous with the iliac colon above and the
rectum below
- pelvic mesocolon
o suspends the pelvic colon from the posterior
wall of pelvis
o mesentery of sigmoid colon
o line of mesenteric attachment resembles an
inverted “V”
o in cases where mesentery is very long reaches
RLQ, sigmoid colon may twist upon itself
- from sigmoidal artery which arises close to the angle
between left colic artery and inferior mesenteric artery
- these are about 5-8 branches
- they usually pass thru mesosigmoid and divide near the
small intestine into ascending branch which
anastomose with descending branch of the left colic
- the descending branch of sigmoidal artery has a weak/
no anastomosis with superior rectal artery
VENOUS DRAINAGE
- collected by sigmoidal vein
↓
IMV

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 ↓ f. endoscopic internal morphology of sigmoid colon and
Splenic vein rectum has a big difference in the internal gross
↓+ appearance of mucosa
SMV
↓ - starts at level of S3
Portal vein - divided into 3 parts
↓ 1. upper 1/3
IVC o covered by peritoneum anteriorly and at the
sides
LYMPHATICS
- thru left colic LN 2. middle 1/3
↓ o covered anteriroly
IM group of LN
↓ 3. lower 1/3
Ileolumbar chain of LN o has no peritoneum
↓
Thoracic duct - average length: 12.5 cm
↓ - location: at posterior pelvic area
Junction of left subclavian vein and - course: it follows the sacrococcyx curve and it
left internal jugular vein terminates 2.5 cm in front of the tip of the coccyx by
bending backward and downward to form the anal
NERVE SUPPLY canal
- supplied by parasympathetic innervations (S 2, S3 and S4) - the RECTUM has 3 lateral curves/ flexures
o responsible for acceleration of motor and o left side: upper and lower rectal curve
secretory activity o right side: middle rectal curve
o stimulates peristalsis
o opens rectal sphincter - highly vascular

- sympathetic (T11, T12, S1 and S2) RECTAL FOLDS/ VALVES of HOUSTON

o inhibitory effect on peristalsis and secretory - usually cresenteric horizontal folds arising transversely
function from lateral aspect of the bowel
o constriction of ileocolic/ ileocecal valve and rectal - just below the lower rectal valve you have the rectal
sphincter ampulla
o dilated portion of the lower portion of rectum
RECTUM o this serves as the transient space for fecal material
Recto Sigmoid Junction
a. there is a narrowing of the diameter of the colon RELATIONSHIPS
b. absence of peritoneal investment involvement of the Posterior: superior hemorrhoidal vessels
gut sacrum
c. disappearance of true mesentery below the recto- coccyx
sigmoid junction ano-coccygeal body
d. spreading out of the taenia coli or the 3 longitudinal
taenia at the recto-sigmoid junction Posterolateral: pelvic diaphragm
e. appendices epiplocae end up above the sigmoid colon Levator ani muscle
- from rectum down A.E. disappear Coccygeus muscle
Piriform muscle

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 o lying between sacrum, coccyx, and rectum → medial - middle rectal vein
sacral vessels ↓
o other: sympathetic trunk, lower lateral sacral vessels Internal iliac vein
and nerves, coccygeal nerve ↓
common iliac artery
RECTAL STALKS/ LATERAL LIGAMENT ↓
- suspensory ligament situated in the lower 2/3 of the IVC
sacrum
- are condensations of areolar tissue around middle - internal rectal vein
hemorrhoidal vessels ↓
- located 1 inches levator ani Internal pudendal vein
- extends from S3 to rectal wall ↓
- also contains S2 and S3 called NERVI ERIGENTES Internal iliac vein
together with middle hemorroidal vessels ↓
common iliac vein
↓
IVC

IN FEMALES LYMPHATIC DRAINAGE

- upper 2/3 - peri-rectal LN
o int. usually separate the uterus from the upper - embedded in the peri-rectal CT just outside the
1/3 of the vagina muscular coat
- from the upper and lower group of LN goes to the
- lower 1/3 inferior mesenteric group of lymphnode
o directly related to the middle 1/3 of vagina
- upper middle group of lymph node
BLOOD SUPPLY ↓
superior 1/3 rectal group of lymphnode
- superior hemorroidal artery ↓
o from IMA inferior mesenteric group of lymph node

- middle rectal/ hemorroidal artery - few from middle group of LN

o from internal iliac artery
- inferior rectal/ hemorroidal artery
o from internal pudendal artery → from internal
iliac artery
o branch of internal iliac artery (Alcock’s canal)
o follow the middle rectal artery towards the
internal iliac group f LN
- few from lower part
o follow the inferior rectal and internal pudendal
towards the internal iliac group of LN

VENOUS DRAINAGE ANAL CANAL

- superior rectal vein - terminal portion of the large intestine
↓ - 4 cm long (1.5 in)
IM vein - Starts from anorectal ring to the hairy skin of the anal
↓ verge
splenic vein - runs downward and backward at right angle to the
↓ rectum between the levator ani muscle and
portal vein terminates in the anus/ anal orifice
- relations:

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 o anterior
male
 perineal body – dense fibrinous tissue that
separates the anus from the transverse
perineal muscle
 membranous urethra – located beneath the
(arrow up)
 bulb of the penis - “root of the penis”
female
 lower 1/3 of vaginal canal
o posterior
 anococcygeal body: fibrous tissue located
between the anal canal and coccyx
 blends above the median raphe of levator
ani muscles
o lateral
 puborectal muscle component of levator ani
muscle
 fat filled Ischiorectal fossa
- landmark
a. anocutaneous line - “ANAL VERGE”
 in state of apposition (kissing position),
epithelium is thrown into folds by
involuntary action of muscle - “Corrugator
of Anal Skin
b. Hilton's line - “INTERSPHINCTER WHITE LINE”
 more blue in color than white
 more palpable than visible
 marks the non-muscular interval between
internal and external
 lies halfway between the anal verge and
more superior pectinate line
c. Pecten
 located directly above the Hilton's line
 about 1/8 – 1/3 of an inch in width
 upper edge – composed of Serrated Margin
that resembles the teeth of a comb
 heavy deposits of fibrous tissue under
d. Pectinate/ Dentate line
 located at the upper border of pecten
 comb-like arrangement brought by anal
papillae which are continuous above with
Columns of Morgagni
- anal valves
o irregular folds which connects the bases of
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papillae
- 2 sphincters
1. internal
 lower thickened portion of the circular
muscle of the bowel
 encloses upper 2/3 of anal canal
 part of the levator ani muscle
2. external
 subcutaneous muscle placed superficial to
the internal anal sphincter
a. subcutaneous
o without bony attachments
o surrounds anus
o decussates anteriorly (winds around
anteriorly)
b. superficial fibers
o arises from anococcygeal body,pass
around the sides of anus, inserted to
perineal body
c. deep fibers
o no direct bony attachment
o encircles lower ½ of anal canal
o forms the true sphincteric muscle
o intimately associated with Puborectal
portion of levator ani
- the external sphincter is supplied by the perineal
branch of 4th sacral and inferior hemorroidal nerves
- blood supply
superior rectal artery
middle rectal artery
inferior rectal artery
- venous drainage
superior rectal vein → IMV
middle rectal vein → internal iliac vein
inferior rectal vein → internal pudendal vein →
internal iliac vein
- lymphatic drainage
superior rectal → inferior group of LN
middle rectal → internal iliac group of LN
 inferior rectal → internal pudendal group of LN →  on the right side usually extends up to
internal iliac group of LN 5th ICS or as far up to the upper border
of the 5th rib
 on the left side, superior surface is at
the level of the 6th rib
 related to the diaphragm

 anterior surface
 on the left side, up to the 8th rib
 on the right side, below as 10th costal
rib

 inferior surface
 looking at it from below
 palpable inferior edge especially when
liver is enlarged
 most accessible to physical examination

THE LIVER  posterior surface

(Dr. E. Manalo)  left side: related to the esophagus,
stomach and lesser omental bursa
- a.k.a. hepar  right side: related to the duodenum,
- largest gland in the body right suprarenal gland, IVC, hepatic
- extremely vascular and multifunctional flexure of the colon
- reddish in color
- enclosed by Glisson’s capsule - location
- dual blood supply o in the RUQ (foremost of is part) of the abdomen
o the blood represents 29% of the cardiac output beneath the diaphragm undercover of the ribs
and the blood supply is via the Hepatic artery
which provides 350 cc/min and portal vein which - the liver is divided into 2 lobes by the Falciform
provides 1,100 cc/min ligament in a 6:1 ratio (R:L lobe)
- the upper surface of the liver is attached to the
- venous drainage: hepatic vein drains directly to the diaphragm via the Triangular ligament
IVC o fusion of 2 layers of coronary ligament

- surface anatomy - liver is completely covered by peritoneum except in:

o pyramidal in shape a. bare area of the liver
o base: right side of the liver is convex , extends b. fossa/ groove for IVC
c. gallbladder fossa
from the level of the 7th-11th rib corresponding to
the diaphragm
- “BARE AREA” of the liver
 or as far down as the 10th pleural reflection
o is a relatively large triangular area located
 or corresponding to the lowest portion of
the lungs up to the 8th rib posteriorly devoid of peritoneum
o it is directly attached to the diaphragm by means
o apex: left side of areolar CT which contains the veins of Retzius
 superior surface o its base is in contact with the IVC, right
suprarenal gland, diaphragm
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 o its apex is formed by the 2 layers of the right TRUE/ FUNCTIONAL DIVISIONS
coronary ligaments that fuse to form the right - segmental areas of liver
triangular ligament - lobes are divided into superior and inferior

- the inferior surface of the liver is characterized by the NERVES

letter “H” - left or anterior vagus nerve and sympathetic nerve
LEFT LIMB of “H” - enters through porta hepatis along with bile duct,
o divides the liver into L and R lobes portal vein and hepatic artery
o anteriorly, it is formed by the ligamentum teres
which continuous anteriorly as the falciform LYMPHATICS
ligament; posteriorly as the ligamentum - found in the following:
venosum (obliterated ductus venosus) a. porta hepatis
b. along the falciform ligament draining into the
RIGHT LIMB OF “H” mediastinal LN
o anterior: gallbladder c. celiac LN near celiac artery
o posterior: IVC d. around the IVC draining to the thoracic LN

TRANSVERSE/ BAR OF “H” - all are outside in the liver

o represented by Porta hepatis
o a.k.a. transverse groove
o it is deep, wide, 2 inches in length
o contains: common bile duct, hepatic artery,
portal vein (anterior → posterior)
o nerves and lymphatics ~ found in porta hepatis
o infront: anterior
 quadrate lobe of the liver, between the
gallbladder and ligamentum teres
 posterior: caudate lobe of the liver located
between IVC and ligamentum venosum

o lesser omentum is attached to the edges of the

porta hepatis

ANATOMIC SURGICAL DIVISION

- based on prevailing arrangement and distal of the
branches of the bile ducts, portal vein and hepatic
artery
- important in doing lobectomy
- SEGMENT:
I = dorsal
II = left lobe posterior
III = left lobe anterior
IV = quadrate lobe
V = right lobe anterolateral and posterior
VI = right lobe posterior inferior
VII = right lobe superior posterior
VIII = right lobe anterior superior

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 c. ascitis
d. GI bleeding
e. encephalopathy
f. cutaneous stigmata

Portal hypertension – when portal venous pressure rises

above 20 cm H2O
- how to measure portal venous pressure?
o wedge hepatic vein pressure
o endoscopy
o visceral angiography

- normal pressure: 8 – 10 mmHg (20 cmH2O/ 15 Torr)

- brought about by obstruction to venous outflow
relative to portal venous outflow in relation to portal
venous inflow means:
a. increased resistance to portal venous outflow
(into IVC: normal – 0 mmHg)
b. increased perfusion (portal venous perfusion) –
PORTAL HYPERTENSION increased inflow into portal vein
c. both conditions may occur at the same time
(Dr. E. Manalo)
ETIOLOGY:
Case:
- either obstruction to venous outflow or increase
R.F., a 48 y/o male, fertilizer and insecticide manufacturer
venous inflow
(exposure to CCl4), a known heavy alcoholic (alcoholic
- causes:
cirrhosis) complains of:
a. intrahepatic obstructive disease of venous inflow
 hematemesis – vomiting of blood
– outflow system
 melena – dark stools
o comprises 95% of etiology
 (+) history of hepatitis
o such as:
o alcoholic cirrhosis – post-hepatic cirrhosis
physical examination: (manifestation of liver disease)
o biliary cirrhosis – hepatitis
- jaundice – yellowish discoloration of the skin
o toxic hepatitis – exposure to chemicals
- ascitis – accumulation of fluid in peritoneum
(CCl4)
- hepatosplenomegaly
o parasitic infections – schistosomiasis
- spider angiomata – caput medusa
- asterixis o congenital hepatic fibrosis – biliary atresia
o liver flap due to substances that are not common in infants and newborn
detoxified going back to systemic circulation and
nervous system o hemochromatosis – increased deposition
of iron in the liver
- hemorrhoids o portal venous and collateral venous
obstruction
clinical impression: cirrhosis with portal hypertension o cirrhosis – necrosis, damage to hepatic
parenchyma/ hepatocyte which would
clinical presentation: signs of liver disease result to widespread fibrosis/ scarring
a. jaundice with nodule formation
b. hepatosplenomegaly  constriction – increase pressure

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 b. extrahepatic obstructive disease
o outside the liver
o thrombosis of portal vein in neonatal
omphalitis (infection of umbilicus)
o obstruction to outflow system in:
 congestive heart failure b. superior rectal veins with middle and inferior rectal
 constrictive pericarditis vein and pelvic venous plexuses
 Budd-Chiari syndrome – obstruction of - forming hemorrhoids which may bleed
hepatic vein

Consequences:
1. sudden increase PV pressure/ obstruction of venous
PS
- resulting to severe fluid and electrolyte loss

2. chronic
- development of collateral circulation
- PV pressure rising gradually
- alternative pathway c. paraumblical vein from left portal vein with superficial
and deep gastric veins (superior and inferior veins)
a) porto-systemic shunt - results to spider angiomata/ caput medusae
o from portal vein to another systemic vein

b) porto-caval shunt
o from portal vein to IVC

PORTAL VENOUS CIRCULATION

d. colic and splenic veins with renal veins and veins of
body wall including veins of Retzius with mesenteric
and peritoneal vein
- blood sips out in dilated veins causing ascitis

PORTO-CAVAL SHUNTS
a. esophageal branches of left gastric vein anastomose to
from shunt with azygous vein (coronary vein) PATHOLOGIC ANATOMY
- most significant - anastomosing shunts formed with portal HPN have no
- development of esophageal varices which are valves
dilated and tortuous → easily erodes → leading to - collaterals has the least resistance, they dilate and
UGI bleeding (hematemesis) erode causing bleeding

TREATMENT
a. blood transfusion

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b. balloon tamponade – inflamed balloon in the o palpable – splenomegaly
esophageal varices
c. esophageal varices ligation with rubber or - anatomic features:
hemorroidal/ rectal ligation o visceral surfaces
d. vasopressin - vaconstrictor  posterior – convex “diaphragmatic surface”
e. sclerotherapy – injection of sclerosing agent (100%  rest on the diaphragm
alcohol)
f. porto-systemic decompression – surgical procedure  anterior – “gastric surface”
where PV is anastomose directly to IVC  comes in contact with the stomach
- porto-caval: directly to IVC  contains the hilum of spleen
- spleno-caval
- meso-caval – mesenteric vein to IVC  inferior – “colonic surface”
 comes in contact with splenic flexure of
the colon

 internal – “renal surface”

 comes in contact with left kidney

SPLEEN
(Dr. Manalo)
- also called lien
- general features:
o purplish, soft, highly vascular, encapsulated organ
o average dimensions:
 12cm in length
 7cm width
 4 cm AP diameter
o weighing an average of 100 – 150 grams
o located high up at the posterior left upper
quadrant of abdomen undercover of the
peritoneum except at its hilum, posterior to the
mid-axillary line, opposite to 9th, 10th and 11th ribs
o long axis is parallel to 10th rib
o retroperitoneal organ
o function: blood forming and destroying organ of
the body, contains large amount of lymphatic
tissue and also stores in its sinusoid
o relationship to blood stream:
 located along the blood stream and not along
the lymphatic stream
- accessory spleen
o occur in 11% of population
o located at the hilum of spleen, tail of the pancreas,
omentum, mesentery and walls of intestines
o hilum
 located at the anterior/ gastric surface
 where BV enter and leave the spleen
 posterior to the hilum is the groove for the tail of
the pancreas
 attached to the hilum is the splenorenal and
gastrosplenic ligament
o mesenteric and ligamentous attachment
a. leino-renal ligament/ spleno-renal ligament
o extends from spleen to kidney
o contains the splenic BV and tail of pancreas
b. gastro-splenic ligament
o extends from stomach to spleen
o contains the short gastric vessels and left
gastro-epiploic vessels
c. phrenico-colic (costo-colic) ligament
o extends form splenic flexure of the colon
upwards towards the diaphragm opposite to
10th and 11th ribs
o forms a floor on which the spleen rest on
o surgical importance: necessary to mobilize
this ligament during splenic flexure and
splenic surgery

- splenic notch - relationships

o significant anatomic feature on the superior - refer to “surfaces”
surface of spleen - peritoneal cavity separate the spleen

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 - pleural cavity from the ribs e. tumor and cysts
- diaphragm f. hypersplenism
- upper 3rd of spleen related to left lung g. splenomegalybody

- Blood vessels
o Arteries
 splenic artery
 branch of celiac artery that coarse
towards the left on the superior border of
the body and tail of pancreas and crosses
the left kidney to reach the hilum of
spleen
 does not enter the spleen as 1 large vessel
instead it divides into 5-8 branches as it
enter the spleen
 before reaching the hilum it gives off the
left-gastro epiploic artery and short
gastric artery

o Venous drainage ABDOMINAL AORTA

 splenic vein
 formed at the hilum of spleen (Dr. E. Manalo)
 the left gastro epiploic and other vein in
the greater curvature → splenic vein - begins at the level of T12 as it passes through the aortic
 coarse to the right in the spleno-renal orifice of the diaphragm
behind the pancreas below the splenic - at the lower border of T12 body or IVD of T12 and L1
artery - largest artery
 on its coarse it is joined by IMV and - ends by bifurcation of left and right common iliac artery
splenic vein joins the SMV to form PV at the level of L4
behind the neck of the pancreas - branches:
a. celiac artery
o Lymphatics 1. left gastric artery
2. splenic artery – short gastric and left gastro
 even if spleen is lymphatic organ, lymphatics
epiploic
are poorly developed
3. common hepatic artery – right gastric artery,
 lymphatic are found only in the capsule of
gastroduodenal artery (right gastroepiloic and
spleen (capsular lymph) and largest trabeculae
superior PD artery), right (cystic artery) and
at the hilum of spleen
left hepatic
1. capsule splenic nodes →
2. trabecular suprapancreatic node b. inferior phrenic artery - same level with celiac
artery
- Innervations o side of abdominal aorta
 non-myelinated nerves from the celiac plexus
accompyaning the splenic artery into the hilum of c. suprarenal artery
the spleen d. renal artery
e. SMA
- Clinical correlation a. middle colic artery
 splenectomy – surgical removal of spleen b. inferior PD artery – meets superior PD artery
 indications: to form anterior and posterior arcade
a. traumatic injuries c. jejunal artery – left side
b. hemolytic jaundice d. ilial artery – left side
c. Gaucher's disease – CHO storage disease e. ileocolic artery
i. ascending branch – meets right colic
d. splenic anemia
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 artery
ii. descending branch – ileocecal artery
which divides into 2 (posterior and
anterior)
iii. posterior gives appendicial artery

f. right colic
o with ascending and descending branch
(meet ascending branch of ileocolic
artery)

f. gonadal artery – either testicular (male) or ovarian

artery (female)

g. IMA
a. left colic artery
i. ascending branch – splenic flexure
ii. descending branch – descending colon

b. sigmoidal artery – to sigmoid artery

c. superior hemorroidal/ rectal artery
d. middle hemorroidal/ rectal artery
INFERIOR VENA CAVA
 inferior hemorroidal/ rectal artery (Dr. E. Manalo)
o branch of pudendal artery from left
common iliac artery - largest vein
- begins at the level of L5
h. medial sacral artery - formed by the junction of common iliac veins
i. 4 lumbar artery - ends at the level of T8 piercing the diaphragm at the
o 5th lumbar artery – arise from common iliac vena caval orifice
artery - tributaries
a. 2 major hepatic vein (left and right)
o directly into the IVC as it enters diaphragm
then to right atrium
b. portal vein
c. splenic vein
d. IMV
e. SMV → joins splenic vein → PV
f. left gastic vein – drains into PV
g. renal vein
h. suprarenal vein
i. inferior phrenic vein
j. right gonadal vein – to IVC
k. left gonadal vein – left renal vein
l. middle sacral vein – drains in ascending branch of
vein

o 5th lumbar vein → common iliac vein →

azygous and hemiazygous

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  posterior: hilum of right kidney
o right renal vessels
o right crus of diaphragm
o post. PD arcade
o right gonadal vein
o distal common bile duct

 uncinate process
 extension of the lower left part of the
posterior surface of the head usually
passing behind the PV and IMV and in
front of the abdominal aorta and IVC
 located between the SMA and aorta with
the left renal vein above the 3rd and 4th
position of duodenum below
 may be absent
 complete encircle SMV

PANCREAS b. neck
(Dr. Laygo)  1.5 to 2 cm long
 fixed between celiac trunk above and SMV
- lies transversely, retroperitoneally between the below
duodenum at the right and spleen at the left side  lying over the SMV below and PV above
- fixed organ  right side – related with GDa as it gives off
- relations: anterior superior PDa
o above: omental bursa
o anterior: transverse mesocolon c. body
o superior: duodenum, pylorus, liver, stomach  lies to the left of SM vessels and it is related to
spleen (R to L; superior and anterior portion) the 4th portion of duodenum, ligament of
o inferior: duodenum, jejunum, transverse Treitz, some jejunal loops as well as the left
side of transverse colon
mesocolon, spleen
 relations:
o posterior: between the hilum of right kidney and
 left: SMA
hilum of spleen, celiac artery, IMA
 right: SMV
: right hilum of kidney, IVC, PV, SMV, abdominal
 superiorly:
aorta, left kidney and hilum of spleen ( R to L)
o celiac artery
- parts: o hepatic artery (right)
a. head o splenic vein (left)
 lies to the right of SM artery and vein
 firmly fixed to the medial aspect of the 2nd  anteriorly covered by double peritoneum
portion and 3rd portion of duodenum of the posterior wall of omental bursa
 junction of the neck of pancreas marked which is related to transverse mesocolon
anteriorly by an imaginary line from the PV  eventually the double peritoneum – other
above and SMV below layer covers the anterior portion and
other layer covers the posterior surface
 relations:
 posteriorly :
 anterior: related to PD arcade partly
o abdominal aorta
anterior branches of SPDa and IPDa

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 o origin of SMA
o left crus of diaphragm INNERVATIONS
o left adrenal glands - celiac nerve ganglia
o perineal fascia - some from SM ganglion
o left renal vessels
o left kidney CLINICAL CORRELATIONS
o splenic vein - periumbilical area
- severe: flanks, back of flanks
d. tail o referred pain: pancreatitis/ KOH pancreatitis
 relatively short and its tip reaches the visceral
surface of the spleen
 usually covered/ enveloped by splenorenal
ligament together with splenic artery and vein
 (+) outer ligament which forms the posterior
layer of gastrosplenic ligament which
eventually encloses the small gastric vessels.
These ligament is avascular.

PANCREATIC DUCT GALLBLADDER

- located anteriorly to the numerous pancreatic
vessels
- man pancreatic duct – joined by accessory duct of
Santorini
- greatest dm is at the head of the pancreas
- join CBD to form ampulla of vater
DUCT OF SANTORINI
- minor duodenal papilla
- drain 5-6 cm above major duodenal papilla
- 1.5 – 2cm from the pyloric sphincter
- Variations of ducts: drains separately (normal)
BLOOD SUPPLY
ARTERIES
- mainly from the superior PDa which is a branch of
GDa and from inferior PDa which is a branch of IMA
- conspicuously present is splenic artery
- richly vascularize organ
VENOUS DRAINAGE
- superior PDv → GDv → portal venous sys
- pancreatic v. → splenic v. → PV
LYMPHATICS
- upper part – head, superior portion of pancreas, go
to celiac groups of LN
- inferior part – PD LN and Plienal LN
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(Dr. Laygo)
- pear-shaped organ located at the inferior aspect of the
right lobe of the liver
- length: 7 – 10 cm long
- capacity: 1 to 1 ½ ounce of bile
o can contain 2-3x the normal capacity
o beyond the limit – rupture
- location: underside of the inferior border of the right
lobe of the liver
o attached to the liver by areolar CT which contains
multiple small lymphatics and veins
o only portion not in direct contact with the liver are
covered by peritoneum
 fundus
 lateral surface of gallbladder
o suspended by mesentery – almost completely
covered by peritoneum in some cases
- size: 7 – 10 cm long
o fundus – 2.5 – 3 cm wide
o markedly distended – contains 200-300 mL of bile
- parts:
a. fundus
  rounded blind-end of GB which projects 0.5-1
cm beyond the free edge of the right lobe of
liver
 sometimes kink/ notch creating the “Phrygian
cap” appearance
 protrudes at inferior aspect – covered by
peritoneum
 top of fundus – lies in contact with abdominal
wall opposite to the 9th costal cartilage at
infrasternal angle
b. body
 largest segment of GB
 entire superior surface of GB is usually closely
attached to the visceral surface of the liver
over the area of the so called “GB bed”
 intimately related to the liver
 clinical correlation:
 infection in the GB – (+) infection in the
liver
 common cause of hepatic abscess
 cholecystitis
 early CA of GB – metastasize in the liver
 rupture of GB secondary to cholelithiasis –
rupture in between the GB and liver
including the surrounding areas such as
duodenum, etc.
 free surface of the body and infundibulum of
GB lies enclose approximation to the 1st
portion and superior segment of the 2nd part
of duodenum
 CC: cholecystoduodenal fistula –
secondary to GB stones
 Intestinal obstruction – secondary GB
stone
 no peritoneum between posterior GB and the
liver
c. infundibulum (Hartmann’s pouch)
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 situated between its body and neck
 overhanging pouch – shallow diverticulum by
the right edge of lesser omentum:
cholecystoduodenal ligament of
hepatoduodenal ligament
 cholecystoduodenal ligament
 avascular
 attach infundibulum with duodenum
 double layer peritoneal layer fold derived
from the inferior margin of the right free
border of hepatoduodenal ligament
 clinical correlation
 helps guide to surgeon to the major
vascular and ductal structure
(importance) lying in the biliary fossa and
tractions on the infundibulum for full
exposure of neck and cystic duct
d. neck
 starts from upper part of infundibulum
 narrows and curve upon itself in the form of
“S”
 directed superiorly, dorsally and to the left
 eventually narrows into a will mark
constriction as it junction with the cystic duct
 5-6 mm
 occupies the deepest part of the cystic fossa
close to the right lateral free border of
hepatoduodenal ligament
- Spiral Valve of Heister
o infolding of the wall of the cystic duct
o maintains patency of the cystic duct
o difficult catheterization or probing
o closely related to duodenum, jejunum, liver and
abdominal wall, transverse colon
- cystic duct
 o average length: 5 cm (5-8 cm)
o diameter: 3 – 12 mm LYMPHATICS
o starts from the neck of GB to porta hepatis then o may go directly to the GB via multiple small
joins the common hepatic duct to form the CBD lymphatic channels
o tortuous in appearance due to spiral valve of o may drain to cystic duct into a single LN/ series
Heister overlying the cystic duct called cystic node of Calot
o passes downward with CHD before joining CBD
INNERVATIONS
- blood supply o travels via the hepatic plexus beginning at the
ARTERIES celiac plexus extending superiorly towards the GB
o cystic branch of right hepatic artery along the hepatic artery and PV
 divide into anterior branch – peritoneal o hepatic plexus
surface of GB  from afferent sympathetic and
 posterior branch – area between the GB and parasympathetic vagal fibers
liver
- clinical correlation
o right hypochondrium
o relationship with cystic duct o epigastrium
 lies superior to cystic duct o right scapular region
 variations:  areas of referred pain of extrahepatic pain
 may arise anterior to cystic duct
 left to cystic duct o gallstone – ULZ – calcifications
 dorsal to cystic duct o rupture – liver, transverse colon, abdominal wall,
duodenum
o Cystic triangle of Calot
 left – common hepatic duct (formed by right BILIARY DUCTS (EXTRAHEPATIC DUCTS)
and left hepatic duct)
(Dr. Laygo)
 right – cystic duct
 superior (apex) – hilum/ inferior edge of the
- starts at the liver as segmental bile ducts with the GB
liver
↓ ↓
right left hepatic artery

common hepatic duct

hepatic duct → ↓
o cystohepatic triangle
common bile duct
 can be found in the apex of the triangle of
main pancreatic duct → ↓
Calot
ampulla of Vater
 cystic artery, right hepatic artery, accessory
↓
right hepatic artery, 90% of accessory hepatic
major duodenal papilla
duct
in duodenum

VENOUS
RIGHT AND LEFT HEPATIC DUCT
o no single/ major cystic vein draining the GB
- 1 to 3 cm length
o only multiple small veins drains GB then go the
- lie within the extrahepatic position just inferior to the
liver bed/ cystic duct → veins of CBD → portal porta hepatis
venous system - unite to form CHD just 1 cm below the porta hepatis

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  once perforated – pyloric ulcer
COMMON HEPATIC DUCT  ligated CBD – jaundice
- average length: 4 cm (2-6.5 cm)
- coarse inferiorly and slightly to the right within in the c. infraduodenal segment
free edge of lesser omentum o intrapancreatic segment
- cross by the right hepatic/ cystic artery o length: 2-3 cm
- right hepatic duct is in close relationship with right o related to the head of pancreas posteriorly
hepatic artery in about 90% of cases o intrapancreatic – run within the pancreas
o starts as a gentle curve to the left as it
COMMON BILE DUCT descends relatively close to the left
- divided into 4 segments descending duodenum
- join with main PD o about halfway along its pancreatic coarse, it
- formed by CHD and CD starts to curve gently towards the right and
- average length: 8 cm (5-17cm) makes an almost 90% turn to the right to enter
- average width: 0.5 to 1 cm (5-10mm) the posteromedial surface/ aspect of
- segments: descending duodenum at above its midpoint
a. supraduodenal segment
o longest CBD
o above the duodenum o relations of intrapancreatic segment
o length: 2.5 cm  superior ½ of the 3rd portion of CBD
o lies within the right free border of related to GDa just left to CBD
hepatoduodenal ligament  superior PDa crosses the 3rd portion of
o PV – lies dorsal to it, separated with loose CBD
areolar CT  PDv runs in the posterior surface of
 surgical consideration – aspiration of PV pancreatic head related to the left of CBD
and CBD with cutting
d. Intraduodenal segment
o palpable between the left index finger place in o most common entry: CBD and MPD → major
the epiploic foramen and thumb place at the duodenal papilla
ventral surface of CBD o variations: CBD and MPD open independently
 PRINGLE MANEUVER into the bowel; (-) ampulla
 c.s. controls blood flow going to the liver o common channel before ampulla
once it is compressed by the finger

b. retroduodenal segment
o behind the middle portion of the 1st part of the
duodenum o passes through the ductal wall obliquely
o length: 2.5 – 4.5 cm similar to the passage of ureter towards the
o gastroduodenal artery - lies just to the left of bladder
the retroduodenal portion o length: 2 cm
o passes 1st to the smooth muscle then to
submucosal portion then penetrates into the
major duodenal papilla
o site of penetration: posteromedial wall of
o right side: hepatic artery duodenum just superior to the crossing of
o closely related to the middle colic artery duodenum by the transverse colon
o just inferior to the pylorus and superior  about 7cm distal to pylorus
portion of duodenum
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AMPULLA OF VATER
- formed within the intraduodenal portion of common
bile duct as a result of the junction of the lumen of CBD
and MPD
- length: 3 – 11 mm
- extends from the point of confluence of 2 ducts to just
proximal to there exit to a single opening to the
duodenal papilla
- ampulla – narrows before it exits via the major
duodenal papillae

SPHINCTER OF ODDI
- guards the distal biliary tract

SPHINCTER OF BOYDEN
- sheath of circular muscle enclosing the CBD as it
pierces the duodenal wall to the main pancreatic
papillae
BLOOD SUPPLY RADIOLOGY
ARTERIES
(Dr. Aragon)
- cystic artery, right hepatic artery
o supraduodenal of CBD
GALLBLADDER
o CHD
- wall thickness: 3mm
o lower part of right hepatic duct
- clinical consideration:
o cholecystitis
- posterior superior PDa, occasionally by
o (+) tumor (CA of gallbladder) – common in
supraduodenal branch
elderly
o retroduodenal segment
 increases wall thickness

- ant. and post. superior PDa

o edema of gallbladder
o intrapancreatic
 kidney problem
o intraduodenal
 heart failure
 increase wall thickness 2° to anasarca
VENOUS DRAINAGE
(generalized edema)
- superior portion of CBD – joins the liver directly
- inferior portion of CBD – goes toward the portal
PANCREAS
venous system
- normal dimension: head, body, tail
- pancreatic duct
LYMPHATICS
o very thin – normal less than 1 mm
- CBD → LN at CBD → LN around the porta hepatis
o normally not seen
- some cases, LN at CBD → pancreatic group of LN →
o if seen
superior major group of LN
 abnormal and beyond 1 mm
- related to pancreas: intrapancreatic/ infraduodenal
 (+) in jaundice
segment
 elderly
 weight loss 2° to biliary CA affecting the flow
INNERVATIONS
of pancreatic juice
- hepatic nerve plexus supply the biliary duct system
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SPLEEN
- located at the left side
- seldom to observe
- normally in UTZ: located at the top or above the
kidneys
o its inferior portion hug the superior portion of
kidney
- abnormal: if beyond half of the left kidney
o or reaching down the iliac fossa
o or cross the inguinal area
 splenomegaly – can’t be diagnose if seen in
radiograph only; cause should be known
first
LIVER
- hepatic veins, PV – seen well in slender individuals
- the thicker the body fat the more difficult for the
sounds to travel
- 3 factors that impair UTZ imaging
o Increase thickness – adipose tissue
o (+) overlying gas – stomach, transverse colon
 difficult for pancreas to see
o (+) calvarium (bones)
 brain due to skull
- can see confluence of vena cava
- PV – have brighter walls
- Hepatic vein – thin, hardly seen
- Intrahepatic bile duct – normally, not visible by
traditional UTZ
- CBD – can be seen; normally, 6 mm, can add ±2 cm if
patient is above 60 y/o
o as age increases, caliber increases but nor
beyond 8mm
SMALL INTESTINE AND COLON
EXAMINATIONS OF COLON
- colonoscopy – direct vision of colon done by
gastroenterologist
- imaging: CT scan, UTZ, and x-ray
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- x-ray (barium enema) – classic and commonly used in
examining colon
- types of enema:
o cleansing enema
 commonly used
 administration of substance to the rectum
to colon → irritation of colon → defecation
 soap suds solution
 molasses
o barium enema
- PROCEDURE
o plain x-ray of abdomen
o normally recognizable structures
 stomach – with gas
 colon – usual adult
 average adult – (-) gas in small intestine
 infants and children – stomach, large
intestine, small intestine filled with gas
 newborn – start swallowing
 first few hours, (+) gas to stomach and
small intestine
 24 hours – (+) gas in small intestine and
large intestine up to the rectum
 If (-) abnormal due to
 no swallowing
 obstruction
 brain surgery
o right places of organs
 small intestine – central
 large intestine – peripheral; surrounds the
location of small intestine
- (+) barium suspension (barium enema)
o 1 to 1.5 L of barium suspension – depends to the
tolerance and age of patient
o introduce suspending gradually in the rectum
o monitor the flow of contrast material as it
ascends by doing fluoroscopic examination
o sigmoid colon – most redundant, tortuous
o loosen bands in the segment – haustrations
 presence of it differentiates the large
intestine to small intestine even the caliber
 increase caliber – large intestine
 o medial portion of ascending colon – (+)
transition of caliber signifies terminal colon o preparation
o oval shadows in colon – retained fecal materials  laxatives
o in doing it get frontal, AP, PA and right and left  NPO at midnight
oblique, decubitus, standing and tredenlenburg
o splenic flexure – overlapping shadows in
________
o oblique – check CA in overlapping splenic flexure
o preparation: defecate and urinate
 evacuation of barium after x-ray material

o cecum – largest portion and commonly rupture

due to complete obstruction due to increase
pressure
 9 cm transverse dm
 beyond – impending for rupture

- CT SCAN
o cut colon depending on the site

- VIRTUAL CT COLONOGRAPHY INTRODUCTION TO THE PELVIS,

o utilized CT scan and x-ray with high softwars
PERINEUM AND GLUTEAL REGION
where in it reconstruct organs in actual
colonoscopy (Dr. Laygo)

- INDICATION FOR IMAGING PELVIS – region of the body that lies below the abdomen
o rectal bleeding
 2° to hemorrhoids Surface Landmarks
 hemorrhoids might co-exist with CA 1. iliac crest
- one being palpated when you do regional
 once limited diagnosis –
anesthesia
observation/digital rectal exam
- level of L4
- it is where spinal anesthesia is usually done
 must use other imaging diagnostic to
o safe – because of the presence of the
determine other underlying cause of
bleeding subarachnoid space which terminates at the
level of S2
o beyond 50 y/o
- L2 – where spinal cord terminates
 increase frequency of colonic CA

2. ASIS
o constipation
- anterior end of iliac crest
 might be due to CA already
- where then distal end of the Poupart’s ligament is
attached
o children with constipation (3-7 y/o)
 different with infant and adult
3. PSIS
 might due to congenital patient
- posterior surface of iliac crest
 volvulus
- level of S2
 (-) colonic genesis
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 o where subarachnoid space terminates b. adnexae (fallopian tubes and ovaries)
c. urinary bladder
4. pubic tubercle
- located anteriorly males:
- upper border of the pubis a. seminal vesicles
- where the medial end of the Poupart’s ligament is b. prostate gland
attached c. vas deferens

5. symphysis pubis Pelvic bone – composed of innominate bones or hip bones

- important anatomical and surgical landmark a. ilium
- cartilaginous joint that is located at the midline of b. ischium
the pubic bone c. pubic bone

6. pubic crest Pelvis is divided into 2 parts:

- a ridge on the pubic bone at the superior surface a. false pelvis/ greater pelvis
- located medial to the pubic tubercle o no clinical importance
o boundaries:
7. spinous processes of the sacral bone  behind by the lumbar vertebrae
- joined together  laterally – iliac fossae (covered by iliacus
muscle)
- in the midline, they usually form the median sacral  in front – lower end of the anterior
crest abdominal wall
o located at the upper most portion of the Natal
cleft o considered as a part of the abdominal cavity
 area that separates the 2 buttocks in the o during pregnancy (3 months after) – uterus will
midline go up and will be supported by the false pelvis
o during birth – false pelvis guides the fetus to the
8. sacral hiatus true pelvis
- situated at the posterior aspect of the lower end of
the sacrum b. true pelvis/ lesser pelvis
- termination of the extradural space o bowl-shaped structure that contains and
- located about 5 cm above the tip of the coccyx protects the lower parts of the intestinal tract,
- located beneath the skin of the Natal cleft urinary tract as well as the internal organs of
reproduction
9. coccyx o 3 parts:
- located at the distal end of the vertebral column 1. pelvic inlet
- inferior surface or tip of coccyx is actually palpated  measured and compared to the
in the Natal cleft about 1 in. behind the anus diameter of the head of the fetus
- clinical significance:  boundaries:
o dislocation of the tip of coccyx posteriorly – sacral promontory
 rectal examination – palpate the anterior laterally – iliopectineal line
surface of the tip of the coccyx anteriorly – symphysis pubis
 glove hand – push the tip of the coccyx
porteriorly 2. pelvic outlet
 boundaries:
internally, the pelvic cavity contains pelvic viscera posteriorly – coccyx
females: laterally – ischial tuberosities
a. uterus anteriorly – pubic arch
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  behind g. maximus – gluteus medius
3. pelvic cavity  deep inside of g. medius – gluteus minimus
 located between no. 1 and 2
 short curved canal with shallow anterior 2. neurovascular structures
wall and a much deeper posterior wall  piriformis
 important in obstetrics o below: intrapiriformic space
 a.k.a. birth canal o vital structures comes out at the sciatic
foramen
PERINEUM a. sciatic nerve
- a diamond shaped structure which is bounded b. inferior gluteal vessels and nerve
anteriorly – symphysis pubis c. inferior pudendal vessels and nerve
posteriroly – tip of coccyx o above: suprapiriformic space
laterally – ischial tuberosities a. superior gluteal vessels
- divided into 2 triangles b. superior gluteal nerve
a. anterior triangle
o a.k.a. the urogenital triangle  clinical significance:
o contains: o deep IM injection is done at the upper outer
 female – external female genitalia (labia quadrant of the buttocks
minora and majora, clitoris), vaginal and o why? Neurovascular structures are located at
urethral orifice the upper inner and lower inner quadrants
 male – male external genitalia (scrotum,
PELVIS
orchids, and penis)
(Dr. Tanyee)
b. posterior triangle
o a.k.a. the anal triangle PELVIS
o contains the anal opening - link between the upper trunk and lower trunk
- likened into a basin with 4 walls:
anterior, posterior, lateral and inferior wall
GLUTEAL REGION
- quadrilateral space
- with rigid ring
- bounded:
o importance: transfer of weight from the upper
above – iliac crest
below – gluteus maximus muscle into the lower trunk
medially – lateral margin of the sacrum and coccyx o breakage will cause INSTABILITY
laterally – tensor fascia lata  there must be a point of breakage (2 points)
 anterior and posterior
Buttocks  if only one – considered still as stable
- termed as NATIS
- small rounded elevation which is separated from its a. vertical shear
adjoining buttocks by a deep fissure called Natal cleft  disruption of the symphysis pubis and
- limited inferiorly by a groove called Gluteal fold (or the bone
fold of the buttocks)
- bulging of the buttocks b. open-book mechanism/ A-P compression
o consists of thick layer of fats  disruption of the post. sacroiliac joint
- lower part of the buttocks
o made-up of large gluteus maximus muscle c. internal compression
 breakage of the bon
 disruption of the sacroiliac joint
Important Structures
1. gluteus maximus muscle
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 o if bone is destroyed – ligament is spared (vice a. contains and protects the pelvic organ
versa) o lower GIT, GUT, internal reproductive
organs
- female
o pelvic inlet and outlet b. common site for bone marrow biopsy
o importance: where fetus will pass through c. site for harvesting bone graft
o disruption: difficulty in giving birth d. attachment of muscles
o immediate complication: hypovolemia e. allow transfer of weight from the vertebral
 damage of the tributaries of the internal column to the appendicular skeleton
pudendal vessels
o transfer of weight
o sacrum – neurologic injuries STANDING
L5
- physical examination: INJURY ↓
INSPECTION Sacrum
a. Destot’s sign ↓
o hematoma in the inguinal and scrotal area Sacroiliac joint
↓
Acetabulum
↓
b. Roux’s sign Femoral head
o decreased in the distance between the SITTING
greater trochanter and ischial spine Lumbar spine
↓
c. Earle’s sign Ischial tuberosity
o during rectal examination = can be palpated
= hematoma/ bony prominence - cavities
Pelvic brim/ Pelvic inlet
PALPATION o boundary:
 lateral compression anteriorly – upper part of symphysis pubis
 ASIS compression laterally – iliopectineal line (arcuate line)
 symphysis pubis compression posteriorly – sacral promontory (upper anterior
o (+) pain once (+) disruption of pelvic ring margin of S1)

- orientation o above: False pelvis/ greater pelvis

Standing Position o below: True pelvis/ lesser pelvis
a. ASIS and symphysis pubis
o lie in the same vertical plane False pelvis
o boundary:
b. sacrum posterior: L5, S1
o anterior or concave surface lateral: iliac fossa
o facing forward but downward anterior: abdominal muscle

c. pelvic surface of the posterior pubis True pelvis

o facing backward and upward o pelvic inlet
o pelvic outlet
- functions: boundaries:
anterior – lower part of the symphysis pubis
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 posterior – tip of coccyx 2. intermediate lip – internal oblique
lateral – sacrotuberous ligament, pubic arch 3. inner lip – transversus abdominis

o pelvic cavity – with walls and floor  superior border: ASIS and PSIS
 a little posterior to the ASIS: Iliac
BONY PELVIS tubercle
- consists of (2) innominate bone/ hip bone, (1)  thicker palpable 2” above and
sacrum, (1) coccyx superior of ASIS
 level of L5
INNOMINATE BONE/ HIP BONE
- with 3 bones: Ilium, ischium, and pelvic bone b. outer surface/ gluteal surface
- not fused between age 4-16 o wavy in appearance due to the presence of
o triradiate cartilage – present below 12-16 years 1. inferior gluteal line
of age apex of the sciatic notch
 ossified beyond 16 years of age ↓
 point of fusion of the 3 bones ends: AIIS

- anterior border: has 2 equal concavities which is 2. middle/ anterior gluteal line
divided by anterior inferior iliac spine sciatic notch
- posterior border: has unequal concavities divided by ↓upward
posterior inferior iliac spine anterior to the iliac tubercle
o smaller – superior concavity 3. posterior gluteal line
o larger – inferior concavity sciatic notch
Sciatic notch ↓upward
 divided by ischial spine iliac crest
 greater s. notch – above
 lesser s. notch – below o forms 4 areas
 below inferior gluteal line – attachment
Ilium of the capsule of iliofemoral ligament
- largest among the 3 hip bone and the reflected head of the rectus
- fun-shaped femoris
- broader/superior part: ALA/ WING  between inferior and middle gluteal line
- body – like a handle – attachment of gluteus minimus
- 2 surfaces:  between middle and posterior gluteal
a. inner surface line – attachment of the gluteus medius
o iliac fossa - smooth part  behind posterior gluteal line –
o posterior part – forms the sacroiliac joint attachment of the gluteus maximus
 articulate with the ilium
 tuberosity of the ilum – rough Pubic bone
 auricular surface – smooth - located anteriorly
- with a body and 2 rami
o Iliac crest - 2 rami: superior and inferior rami
 highest/ superior point o joined together by a fibrocartilage to form
 at the level of L4 symphysis pubis
 landmark for epidural and spinal
anesthesia Ischium
 3 lips – attachments of the muscles - located posteriorly
1. outer lip – external oblique muscles - parts:

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 a. body
b. ischial tuberosities – rough
c. ramus
- acetabulum
o cup-like structure
o facing laterally forward and downward
o where femoral head articulates
o 2 parts
a. Horse-shoe shaped articular surface –
where the head of femur articulates
b. Acetabular fossa – rough part
 with acetabular notch
 converted into a foramen by
transverse acetabular ligament
o structures passing through:
articular branches of the
obturator artery and medial
femoral circumflex artery
- union of 3 bones forms an opening: OBTURATOR
FORAMEN
o differs in shape in male (rounded) and female
(triangular)
o obliterated/ closed by obturator membrane
except at the superior part
o superior part – forms a canal
 passageway of obturator nerves and vessels
SACRUM
- consists of 5 fused vertebrae
- wedge-shaped
- with (1) concave surface anteriorly, (1) convex
surface posteriorly, (2) lateral articular surfaces
(articulates with innominate bones)
- with 8 openings anteriorly
o anterior sacral foramina
o relatively large superiorly – smaller inferiorly
o transmits the anterior rami of sacral nerves
(exits) and lateral sacral arteries (enters)
- posteriorly
o corresponds with the median crest
o 4 pairs of sacral foramina
o relatively smaller than anterior part
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o posterior rami of sacral nerve
- sacral hiatus – due to the failure of lamina of lower
vertebra to fuse (S4-S5)
 importance: caudal and epidural anesthesia
- prominence – KORNU
 remnants of the inferior articular process
- sacral canal contents
 anterior and posterior rami of the lumbar, sacral
and coccygeal nerve roots
 filum terminale
 fibrofatty materials
 dura mater (S2 level)
COCCYX
- 4 fused bones
- consists only of the body except coccygeal 1
- coccygeal 1 with rudimentary transverse process
- kornu – remnants of the superior articular process
JOINTS
- anterior: symphysis pubis (cartilaginous joint)
- posterior: sacroiliac joint
o likened to a suspension bridge
o stabilizer: sacroiliac ligament
a. posterior sacroiliac ligament
 most important and strongest ligament
 divided into:
SHORT LIGAMENT
 responsible for rotational ligament
LONG LIGAMENT
 responsible for vertical stability
b. iliolumbar ligament
 from transverse process of L5 –
attached to the sacral tuberosity S1
 prevent forward displacement of L5 in
relation to S1
c. anterior S1 ligament
 with limited contribution
- sacrococcygeal joint
- L5-S1
LIGAMENT
1. sacrotuberous ligament a. anterior wall
- arises from the posterior surface of sacrum and o bounded by symphysis pubis and body of the
coccyx pubic bone
- insertion: ischial tube o shallowest among the 4 walls
- prevents rotational and vertical instability
b. lateral wall
2. sacrospinous ligament o formed by the hip bone below the iliopectineal
- anterolateral surface of the sacrum and inserts line and obturator muscle
in the ischial spine
- prevents rotational instability c. posterior wall
o most extensive wall formed by the sacrum,
coccyx and piriformis muscle

d. floor/ inferior wall

o formed by the pelvic diaphragm
 consists of 2 muscles: levator ani muscle and
coccygeus muscle
 origins:
 back of the body of the pubis
 tendinous arch – thickening in the
pelvic fascia
CLASSIFICATION OF PELVIS  ischial spine
1. gynecoid – female pelvis; round with enlarged
transverse dm - lining of the walls
2. android – male pelvis; heart-shaped o pelvic fascia
3. platypelloid – long transverse dm a. parietal pelvic fascia
4. anthropoid – long anterior to posterior dm  lines the wall of the pelvic cavity
(bones, muscles and ligaments)
MALE FEMALE  ex. Lateral wall – obturator muscle –
BONE QUALITY Thicker Delicate, thin obturator fascia
FALSE PELVIS Deeper Shallower
PELVIC INLET Heart-shaped Transversely
b. visceral pelvic fascia
oblong
 lines the visceral organs
PELVIC OUTLET Narrower Wider
 thin loose CT but has a thickening that
PELVIC CAVITY Longer but Shorter but
narrower roomier will give additional support
DISTANCE Narrower Wider  ex. Pubovesical – bladder and pubic
BETWEEN THE bone
TWO ASIS

PELVIS
- rigid ring
o during special cases like pregnancy it becomes
accommodating because of the presence of o pelvic peritoneum
estrogen, progesterone and relaxin  reflection of your peritoneum
o softening of the ligament
PELVIC DIAPHRAGM
- likened into a basin and has walls with several holes - consists of:
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 A. Levator ani muscle
a. anterior part
o male – sphincter urethra
o female – sphincter vagina
o forms a sling in the urogenital junction
b. intermediate part
o puborectalis muscle – forms a sling in the
anorectal junction
o pubococcygeus muscle – inserts into
perineum body
c. posterior part
o iliococcygeus muscle – forms a sling in the
coccyx
 perineum body
o located at the vagina and anorectal junction
 anococcygeal body
o located at the tip of the coccyx and anus
note: perineum body and anococcygeal body – mass
of fibrous tissue that serves as a connection of the
levator ani muscle
B. Coccygeus muscle
o arises from the ischial spine and inserts into the
lateral aspect of the sacrum and coccyx
- functions of the pelvic diaphragm:
a. acts as a sphincter to the vagina
b. keeps the pelvic visceral organs in place during
increase in the intrapelvic pressure
c. sphincter action on the anorectal junction
- located below the pelvic diaphragm (separates the
perineum from the pelvic cavity)
- located between the thighs
- abduction – wider; adduction – smaller
- diamond-shaped
- boundaries:
anteriorly – symphysis pubis
laterally – ischial tuberosity
posteriorly – tip of coccyx
- divided into two triangle by an imaginary line
traversing the ischial tuberosities
a. urogenital area
o anterior part
o consists of:
1. external genitalia
male – scrotum, penis, orchids
female – vaginal and urethral orifices, labia
minora and majora
2. superficial perineal pouch
- limited inferiorly by Colle’s fascia
o inserted
laterally – ischial tuberosities
posteriorly – urogenital diaphragm
anteriorly – no point of attachment
*prone to injury – bulb of the penis
particularly in the bulbourethral area
which may rupture and cause spillage
of the urine → goes up into the
abdomen
- boundary: from the perineal membrane
to the Colle’s fascia

- structures found:
- injury in pelvic diaphragm (difficulty in childbirth)
a. uterine prolapsed
MALE
b. cystocele (prolapsed of bladder)
a. root of the penis
c. stress incontinence
 crus of the penis ( R and L) –
d. rectal incontinence
enclosed by ischiocavernosus
m./bulbocavernosus m.
- pelvic diaphragm deficient anteriorly
o obliterated by the urogenital diaphragm found in
 bulb of the penis – enclosed by
the deep perineal pouch
bulbospongiosus m.

PERINEUM
b. superficial transverse perineal muscle
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 c. perineal body
d. perineal branch of the pudendal nerve
FEMALE
a. root of clitoris
 crus of the clitoris (R and L) –
enclosed by ischiocavernosus m./
bulbocavernosus m.
 bulb of the clitoris – splits into 2
and surrounds the vaginal orifice
which acts as a sphincter
- enclosed by bulbospongiosus
m. – underneath this →
vesitubular bulb
b. superificial transverse perineal muscle
c. perineal body
d. perineal branch of the pudendal nerve
3. deep perineal pouch
- obliterates the opening in the pelvic
diaphragm
- contents:
UROGENITAL DIAPHRAGM
 consists of deep transverse
perineal muscle and sphincter
urethra muscle
MALE
a) membranous part of the urethra
b) sphincter urethra muscle
c) deep transverse perineal muscle
d) internal pudendal vessels and their
branches
e) bulbourethral gland
f) dorsal nerve to the penis
FEMALE
a) part of the urethra
b) part of the vagina
c) sphincter urethra
d) deep transverse perineal muscle
e) internal pudendal vessels and their
branches
f) dorsal nerve to the clitoris
b. anal triangle
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o posterior part
o within this triangle – ischiorectal fossa
 wedge-shaped
 boundaries:
base – skin
medially – levator ani muscle
laterally – obturator muscle and hip
bone
 structures found:
 dense fatty tissues
 pudendal canal/ Alcock’s canal
 transmits the following:
internal pudendal vessels
 int. pudendal artery –
branch of internal iliac
artery
 inferior rectal artery arises
from the internal
pudendal artery
pudendal nerves – arises from
S2,S3 and S4; supplies the
perineum
THE MALE REPRODUCTIVE GENITALIA
(Dr. Manalo)
THE PENIS
- the copulatory organ in the male
- consists:
a. root – fixed posterior part
b. body – mobile anterior part which ends distally
as the glans penis
- the root, body and glans consists of fibroelastic
erectile tissues cylinders
a. 2 Corpora cavernosa
o located dorsally
o at the root of the penis begins as the left
and right crura over the midpoint of the
ischiopubic rami
o covered by the ischiocavernosus muscle
o at the body, unite side by side to fuse
distally with the glans penis
b. 1 Corpus spongiosum
o located ventrally and is traversed by the
urethra
 o it is also called Corpus cavernosum urethra
o at the root, begins as a free-dilated sac
which is called the bulb of the penis
o at the body, it courses upwards and
obliquely ventral to the Corpora cavernosa
and flares/ expands distally to become the
glans penis (head of the penis)
- superficial structures of the penis
a. prepuce/ foreskin
o distal extension of the skin of the penis that
forms a hood or a cuff that covers the glans
penis in an uncircumcised male
o remove during circumcision
b. frenulum
o fold of akin at the ventral side of the glans
that attaches it to the prepuce
c. buck’s fascia
o fibromembranous fascia beneath the
superficial fascia
 continuous with the Colle’s fascia
 devoid of subcutaneous fat
d. suspensory ligament
o thickened fibroelastic triangular membrane
o its apex is attached to the lower end of linea
alba and symphysis pubis
o courses beneath the junction of the body
and root of the penis to form a sling
e. superficial dorsal vein
o located in the superficial fascia visible at the
middle midline of the dorsal skin
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o divides into left and right tributaries to drain
into the internal pudendal vein
f. deep dorsal vein
o located in the deep fascia just beneath the
Buck’s fascia
o drains in the prostatic venous plexuses
g. dorsal artery
o located in the deep fascia
o on both sides of the deep dorsal vein are
terminal branches of the internal pudendal
artery
h. dorsal nerve
o located on each side of dorsal artery are
terminal branches of the pudendal nerve
o anterior rami of S2, S3 and S4
o nerve that is anesthetize during circumcision
i. tunica albuginea
o fibroelastic tissue surrounding each of the
erectile tissue cylinders forming a midline
partition to separate the right and left
corpora cavernosa
THE MALE URETHRA
- both a part of the male reproductive and urinary
system
- consists of:
a. prostatic urethra
o length: 2.5 – 3 cm
o widest and most distensible/ dilatable
segment
o traverse through the prostate
 b. membranous urethra/ sphincter urethra
o shortest and narrowest
o length: 1.75 cm
o traverse through the urogenital diaphragm
c. penile urethra
o traverses the Corpus spongiosum
o average length: 20 cm (depends)
o bulb of the penis – it is called
bulbousurethra
o body – cavernosus/ spongy urethra
o extends from the inferior fascia of the
urogenital diaphragm up to the external
urethral hiatus
o just before the opening it dilates to form the
Fossa Navicularis
SCROTUM
- pendulous, pouch-liked sac of skin and fascia in
which the testes are suspended at the ends of the
spermatic cord
- layers:
a. skin – thin delicate and darkly colored, forms a
single pouch
b. superficial fascia – devoid of fat
c. Darto’s muscle and fascia – contraction of which
causes the skin to wrinkle in cold weather and
to smoothen out in warm weather
d. external spermatic fascia – derived from
external abdominal oblique
e. cremaster muscle – derived from internal
abdominal oblique; contraction draws the testis
upwards toward the external inguinal ring
f. internal spermatic fascia – derived from the
transversalis fascia
g. tunica vaginalis testis – derived from the
peritoneum
TESTES
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- paired, ovoid, slightly flattened organs with their long
axis slightly oblique
- superior part is tilted anteriorly suspended in the
scrotum at the of the spermatic cord
- average length: 4 cm
- width: 2.5 cm
- covered anteriorly and laterally by the tunica
vaginalis
2 layers of tunica vaginalis:
a. parietal – outer covering
b. visceral – adherent in the testes
- further covered by a fibrous capsule called the tunica
albuginea
- posterior and superior part of testis contains the
epididymis
EPIDIDYMIS
- elongated body applied in the posterior and superior
surface of the testes
- divided into 3 parts: caput, corpus, caudal
- from the epididymis extends the Vas deferens
SPERMATIC CORD
- a bundle that extends from the tail of epididymis up
to the internal inguinal ring
- covered by spermatic fascia, Cremaster fascia,
internal spermatic fascia, processus vaginalis and
pre-peritoneal fat
- consists of the ff:
a. processus vaginalis – corresponds to
peritoneum
b. Vas deferens – genital duct found in the
spermatic cord
c. arteries
1. testicular/ internal spermatic artery
o origin: abdominal aorta in the
lumboiliac region
o descends in front of the Vas deferens
 2. artery of the Vas (Dr. Manalo)
o origin: inferior vesical artery (inferior
artery of urinary bladder) Includes:
1. sigmoid colon/ pelvic colon
3. cremasteric artery - its upper part can be lifted up in the abdomen
o origin: inferior epigastric artery - lower part remains fixed to the posterior
abdominal wall by the mesosigmoid
d. veins
1. Pampiniform plexus of veins – immediate 2. rectum
venous drainage of testis and Vas Deferens - occupies the lower posterior part of the pelvic
o drains into the testicular vein cavity conforming to the curvature of the sacrum
o consists of three groups: and coccyx
a. anterior group – surrounds the
testicular artery 3. urinary bladder
b. middle group – surrounds the Vas - occupies the anterior lower part of the pelvic
deferens cavity behind the pubis
c. posterior group – does not
surround any structure 4. ureters
- can be seen through the posterior peritoneum at
2. testicular vein both sides of the pelvic cavity descending through
o right testicular vein drains into inferior the urinary bladder
vena cava
o left testicular vein drains into left renal 5. Vas deferens
vein - the principle ductal component of the spermatic
cord
e. lymphatics - in its course: with 3 segments:
o 2 sets: a. scrotal segment
1. to the external iliac lymph nodes o begins at the lower end of the tail of the
2. lumbar LN around the aorta and IVC epididymis, ascends behind the testis
medial to the epididymis up to the
f. nerve external inguinal ring
1. genital branch of the genitor-femoral nerve
(L1 and L2) b. inguinal segment
o motor to the cremaster muscle o traverses the inguinal canal from the
o sensory to the tunica vaginalis external ring to the internal ring

2. sympathetic nerve c. pelvic segment

o from the aortic and renal plexus o Vas deferens leaves the other
components of the spermatic cord behind
3. pelvic plexus o from the internal ring, it courses
o from T10 to testes downward, backwards and medially
o T11, T12 and L1 – to the epididymis crossing the ureters towards the base of
the prostate gland and descends medial
4. pudendal nerve
o anterior rami of S2, S3 and S4 - after crossing the ureter the Vas deferens dilates
to form the Ampulla of the Vas
MALE PELVIC VISCERA o surrounded by the rectovesical fascia/
Denonvillier’s fascia
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- the Vas deferens joins the duct of the seminal
vesicle to become the ejaculatory duct which
courses through the substances if the prostate
gland
o duct common to the seminal vesicle and Vas
deferens
o opens in the posterior wall of the prostatic
urethra specifically inside an elevation called
the Verumontanum/ Colliculus seminalis
 at its summit – opening – leading to the
Utriculus Musculinus
- blood supply: Artery of the Vas (branch of the
inferior vesical artery)
- clinical correlation: cut/ tied during vasectomy
6. Seminal vesicle
- pelvic viscera associated with the male
reproductive system
- paired, contorted sac-like structure
- evagination of the Vas deferens
- length: 5 cm
- diameter: 1 cm
- contains a single tube, 10-15 cm in length by 3-4
mm in dm that is folded upon itself
- its lower end forms a duct that joins the Vas
deferens to form the ejaculatory duct
- located behind urinary bladder and in front of the
lower part of the rectum
- blood supply: inferior vesical artery and middle
hemorrhoidal/ rectal artery
7. Prostate gland
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- largest gland associated with the male
reproductive system
- normally diverging 20gr in weight
- a solid organ consisting of fibromuscular and
glandular tissue
- located beneath the urinary bladder up to the
urogenital diaphragm
- surrounds the 1st part of the male urethra
- broader than long
- approximately 3 cm in length and 3.5 cm in
breadth
- has 2 capsules:
a. true – consist of the condensation of the
surrounding CT
b. false – visceral layer of the pelvic fascia
o surrounds the lower part of the urinary
bladder
prostatic (pudendal) plexus of veins – located
between the capsules which is joined by the deep
dorsal veins by the penis
- Retroprostatic pouch of Proust
o space between the prostate gland and the
rectum behind
- surfaces:
a. apex – rests on the urogenital diaphragm
b. base – in contact with the inferior surface of
the urinary bladder and contain the inferior
vesical vessels
c. anterior surface – faces the “Retropubic
spaces of Retzius”
o space behind the pubis
o separated from the space by the
puboprostatic ligament
d. posterior surface – faces the pouch of Proust
anterior to the rectum
 e. (2) lateral surface – supported by the anterior - normal sperm count per ejaculate: 3.5 cc
fibers of the levator ani muscles - sperm count per cc: 120 M
range: 35-200M/cc
- lobes of the prostate gland:
a. anterior lobe 2. Impotence/ Erectile dysfunction
o extends from the anterior wall of the - inability to attain and maintain erection
urethra, occupying most of the anterior
surface 3. Priapism
- persistent/ sustained painful erection
b. posterior lobe
o occupies the most of the posterior surface 4. Chordee
behind the middle lobe - fibrous band causing the penis to bow
o the lobe that can be palpated by means of
digital rectal examination 5. Hydrospadias
- external urethral meatus is located ventrally
c. 2 lateral lobe
o occupies most of the base of the prostate
gland

d. middle lobe
o most important lobe
o most common site for adenomas
o impinges on the urethra
o contains most of the glandular tissues
which are subcervical and subtrigonal
gland of Albarran

- prostatic sinus and ducts

o prostate gland have multiple ducts 6. Epispadias
o open in a gutter at the sides of the - external urethral meatus is located dorsally
Verumontanum called the prostatic sinus

- blood supply: inferior vesical artery and middle

hemorrhoidal/ rectal artery

Clinical Correlation of the Male Genitalia

1. Male infertility 7. Benign Prostatic Hypertrophy (BPH)

- oligospermia – decrease sperm count (below - adenomas
20M/cc) - middle of the prostate gland
causes of oligospermia: - CA of the prostate
a. undescended testes
b. degenerate germinal epithelium 8. Balanitis
c. abnormal sperm - inflammation and swelling of the penis

- azospermia – no sperm 9. Orchitis

i.e. vasectomy - swelling of the testes

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 2.
10. Epididymo-orchitis
- inflammation of the epididymis and orchids
- viral mumps, bacterial infection (STD)
11. Phimosis
- failure to retract the prepuce over the glans
Paraphimosis
- failure to put the prepuce over the glans after
retraction
12. Peyronie’s disease
- fibrous thickening of the Corpora cavernosa
causing bending or angulation during erection
labia majora
- round lateral masses homologous to the scrotum
in the male
- has CT, sebaceous gland, hair follicles…
- anterior extremities will join the mons pubis
forming the ANTERIOR LABIAL COMMISURE
- posterior EXTERMITIES will join the forming the
POSTERIOR LABIAL COMMISURE
- multipara – delivered >2 babies
o smiling; can see the underlying structures
- nullipara – one that has not yet delivered a baby
o apposed labia majora
o covers the underlying structures
- covered with skin, so anything that can affect the
skin will also the affect the l. majora
o sebaceous cysts
o pimple
o hematoma
o lipoma
o hemangioma
o pubic lice

3. labia minora
- medial of labia majora
- thin folds of reddish tissue
- a.k.a. lymphae
ANATOMY OF THE FEMALE - devoid of sebaceous gland and adipose tissue
GENERATIVE TRACT - more of a CT type
- anteriorly: will divide into lamellae
(Dr. Balajo)
o inferior lamella fuses with the clitoris forming
the FRENULUM OF CLITORIS
EXTERNAL GENERATIVE ORGAN o superior lamellae unite to form the PREPUCE
OF CLITORIS
PUDENDA = VULVA
- anterior to perineum - posteriorly aspect fuses to form the FOURCHETTE

1. mons pubis 4. clitoris

- a.k.a. mons veneris - not within the vestibule
- fat-filled portion overlying the symphysis pubis - female erogenous organ
- childhood: absence of hair - homologous to penis
- puberty: presence of curly hair called - parts: glans, body (corpora cavernosa), crura
“Escutcheon” - with nerve endings
o female hair distribution o mediators of erotic sensation called the
o shape: inverted triangle with the base over the Genital corpuscles
symphysis pubis  found sparsely in l. majora but abundant
in l. minora especially in the clitoris
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5. vestibule
- medial to l. minora
- almond-shaped structure
- perforated with six openings:
a. urethral meatus
b. ducts of Skene’s gland/ paraurethral gland –
inferolateral to (a)
c. vaginal introitus
d. ducts of Bartholin’s gland/ paravestibular
gland – lateral to (c)
- FOSSA NAVICULARIS – space between the vaginal
opening and fourchette
o once the woman gives birth FN and fourchette
(flattened) will no longer be appreciated
o flattened posterior commissure will be sutured
o virgin/nullipara: hymen; (+) FN and fourchette
- BARTHOLIN’S GLAND
o provides lubrication during sexual stimulation
o opening of the ducts: pinpoint
 depends on hygiene and sexual habits,
opening of the duct can be easily clogged
by dirt, infection
 accumulation of secretion inside the gland
 bacterial: GC, bartholinitis
 Bartholin’s abscess – management:
drainage with incision
 Bartholin’s cyst – management: excision/
marsupialization
 Indicated for reproductive period
 incise in the inner part
(mucocutaneous junction – between
the vestibule and labia minora)
 evacuate the contents then leave it
be
 suture the lining of the cyst to the
vaginal mucosa
- VESTIBULAR BULBS
o homologous to anlage of corpus spongiosum
of penis
o located beneath the skin
o composed of aggregates of veins
o during the trauma – my injure VB and my
cause hematoma
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 monitor after delivery of baby the
puerpera and peritoneum
6. hymen
- membrane covering the vaginal opening
- maybe crescentric, circular, septate or fimbriated
- not all hymen will bleed on first coitus
- hymenal myrtiform caruncles – remnants of
hymen after delivery
- clinical correlation: imperforate hymen
o average age of menarche: 10-14 y/o
o common cause of the absence of menarche
o during pubertal period, develop cyclic pains
but no evidence of bleeding
o accumulation of blood inside the vagina:
HEMATOCOLPOS
o HEMATOMITRA – enlargement of the
abdomen, uterus filling-up with blood
 obese not obvious
o HEMATOSALPINX – blood in the fallopian tube
o irritation of the peritoneum → acute abdomen
o management: HYMENECTOMY: crochet, flap,
evacuate, suture flap into vestibule
INNERVATION
- pudendal nerve
- genital branch of genitofemoral nerve
BLOOD SUPPLY
- pudendal artery
VENOUS DRAINAGE
- pudendal veins
LYMPHATIC DRAINAGE
- superficial inguinal LN
- interiliac LN
PERINEUM
- posterior to the vulva
- support provided by the:
a. pelvic diaphragm – inner part
o levator ani muscle – pubococcygeus,
iliococcygeus, puborectalis
 “deep vaginal constrictor”
 Kegel’s exercise/ pubococcygeal
exercise – aid in increasing the tome of
the muscle
 o coccygeus muscle

b. urogenital diaphragm – upper part

o deep tranverse perineal m.
o constrictor urethra
o internal and external fascial coverings
o from the pubic arch to the ischial
tuberosities
o superficial to the urogenital diaphragm
 superficial transverse m.
 ischiocavernosus – origin: ischial spines
 external anal sphincter BLOOD SUPPLY
 bulbocavernosus - internal pudendal artery and its branches (inferior
 encircles the vagina = superficial rectal and posterior labial)
vaginal sphincter
VENOUS DRAINAGE
PERINEAL BODY - internal pudendal nerve
- 5 cm
- 1 cm = multipara INNERVATION
- prerectal fibers of: - pudendal nerve and its branches
a. levator ani muscle
b. rectovaginal muscle LYMPHATIC DRAINAGE
c. levator vagina muscle - superficial inguinal tract
d. rectococcygeus - lymph glands of deep inguinal tract
e. deep transverse perineal muscle
f. superior levator fascia
g. superficial transverse perineal muscle
h. superior and inferior fascia of urogenital VAGINA
diaphragm - boundaries
i. superficial external sphincter ani anterior: urinary bladder
j. bulbocavernosus posterior: rectum
k. CT membrane that form base of l. majora and
superficial perineal fascia - functions
a. excretory canal of uterus
- descend of the presenting part: vaginal wall and b. female organ of copulation
perineal body thins out c. part of birth canal

EPISIOTOMY - collapsed in comparison to the bladder and rectum

- crowning: optimum time for episiotomy because it is empty
- vagina very distensible
- fourchette, posterior vaginal commissure and FN - embryology
thins our upper part (cervix, uterus, fallopian tube): derived
- incision on perineal body from the Mullerian ducts
o middle or R or L mediolateral lower part: urogenital sinus
o always start at the angulation
- septa
- avoid vestibule bulb – hematoma; increase bleeding
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 vesicovaginal septum: separate the vagina from the o frequent childbirth and or big baby vesicovaginal
UB and rectovaginal septa will thin out
rectovaginal septum: posteriorly; separates lower ¾ o vesicovaginal thins out: CYSTOCELE
of the vagina from the rectum  posterior urethra vesical angle herniates
upper ¼ - direct in contact with the Cul de Sac of towards vaginal wall
Douglas  s/s: frequent urination, feeling of urinary
retention
- length  URETHROCELE: passing out of urine during
anterior: 6-8 cm coughing, sneezing… etc
posterior: 7-10cm  management: anterior colporrhaphy

- fornices: (space) o rectocele thins out: RECTOCELE

anterior  herniation of rectum
(2) lateral  manifestation: constipated, obstipated
posterior: deeper  management: posterior colporrhaphy,
o significance: on internal examination normally  associated with perineurrhaphy
the posterior fornix is shallow
 if anything occupies the posterior peritoneal o ENTEROCELE
cavity, posterior fornix is bulging/ shallow  intestines herniates
 clinical correlation: severe abdominal pain  bulging mass outside the vaginal opening
 reproductive age woman single/ married  real type of hernia
 s/s of acute abdomen  management: vaginal hysterectomy, repair
 think of ECTOPIC PREGNANCY of enterocele
 CULDOCENTESIS
 poke through the posterior fornix o UTERINE PROLAPSE
 aspirate  problem of the uterine ligament are
 if non-clotting blood: hemoperitoneum; elongated
maybe due to ectopic pregnancy,  uterus will descend
rupture c. lutem cysts  4th degree uterine prolapsed (PROCEDENTIA
 purulent: pyoperitoneum; ruptured UTERI)
tuboovarian abscess  associated with cystocele, rectocele and
 if clotting blood: remove at once; sometimes enterocele
poked into a BV  management: vaginal hysterectomy with AP
colporrhaphy
- vascular supply
upper 1/3: cervicovaginal branches of uterine o VAGINAL VAULT PROLAPSE/ COLPOCELE
arteries  vaginal stump not sutured properly
middle 1/3: inferior vesical artery  important step: suspension of the vaginal
lower 3rd: middle rectal and internal pudendal artery stump and ligaments

- lymphatic drainage INTERNAL GENERATIVE ORGANS

upper 1/3: iliac nodes
middle 1/3: internal iliac nodes UTERUS
lower 1/3: inguinal LN - position: slight anteversoflexion
o angulation between the body of the uterus and
- clinical correlation cervix
o uterus in pelvic region o retroflex – body of uterus points towards the
sacrum; cervix points posteriorly
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 o verso – relationship of the longitudinal axis of U:C 2:1
the whole uterus with the cervix in relation to
the birth canal o adult nulliparous: 6-8 cm
o standing – horizontal uterus; cervix – points to 50-70 gr.
the ischial spine U:C 1:1

- ovaries located in the posterior part of the uterus o term pregnancy: 1100 gr.
- anatomical relationship o multiparous: 9-10 cm
posterior: rectum 80 gr.
anterior: urinary bladder U:C 3:1

- covering o after menopause: uterus atrophy

posterior wall: covered almost entirely by the
serosa/ peritoneum
o lower part of the posterior wall forms the
anterior boundary of Cul de Sac of Douglas/
recto-uterine pouch
- uterus from Mullerian duct
upper part: FT
middle part: fusion of the body of uterus and cervix
lower part: fusion of cervix and vagina

anterior wall: upper portion is covered by the serosa o abnormality: no fusion of 2nd part of the
o reflected towards UB Mullerian duct
o vesico-uterine fold of the peritoneum  bicornuate uterus
 septate uterus
lateral wall: not covered directly  double cervices
 vaginal septum: longitudinal and transverse
- shape: flattened pear
o anterior: concave - ligaments
o posterior: convex a. broad ligament
o (+) myoma no concavity and convexity o wing like structure in the lateral aspect of
- parts: the uterus
a. cervix – vaginal; supravaginal o uterus attached to lateral pelvic wall
b. isthmus – area between the body and the cervix o parts:
o forms the lower uterine segment during superior aspect
pregnancy medial 2/3 – suspends FT via mesosalpinx
o significant part during delivery outer 1/3 – suspends outer surface of FT
(infundibulum – infundibulopelvic ligament)
c. body – corpus
d. cornua – where fallopian tubs are inserted base of the broad ligament
e. fundus – dome-shaped thickening – cardinal’s ligament or
Mackenrodt’s ligament
- cervix – vaginal portion area of cervix – parametrium
o nullipara – conical in shaped
o multipara – slit
 big baby – fish mouth b. round ligament
 laceration at 3 and 9 o’clock position o arises from the anteroinferiorly to the
attachment of the FT in the lateral aspect of
- size the uterus
o before puberty: 2.5-3.5 cm o goes outward, forward and inserts to
superior margin of symphysis pubis
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 o correspond to gubernaculums testis in male
- suspended to broad ligament to left pelvic wall via
c. uterosacral ligament mesosalpinx
o in lower posterior aspect of the uterus - divisions: lateral to medial
o arises at the level of internal cervical OS a. infundibulum – with fimbriae/ fingerlike
o inserts to S2-S3 structure
o form lateral boundaries of Cul de Sac of o project to propel ovum towards ampulla in
Douglas ovulation
o 1 elongated fimbria very near the ovary:
- blood supply Fimbria ovarica – to catch ovum and propel
o uterine artery – at the level of the cardinal towards FT
ligament goes to the internal cervical OS → goes
upward → uterus b. ampulla – widest part
 from internal iliac artery c. isthmus – narrowest segment
d. interstitial – embodied within uterine cornua
o ovarian artery – from the aorta
 anastomose with the ovarian branch of the - clinical correlation
uterine artery tubal pregnancy
o most common type: ampulla 93%
o CS: too much bleeding – ligate the uterine artery o isthmic: (4%) earliest to manifest
o cervical: 0.1%
- venous supply o abdomen: 0.03%
o uterine vein o interstitial: 2.5%
o ovarian vein o pelvic chronic pain: pelvic inflammatory disease
 left: left renal vein  oviduct - first to be affected
 right: IVC

- innervation
o SNS OVARIES
o PNS – pelvic nerves and S2-S4 - homologous to testis
 uterovaginal plexus of Frankenhauser at the - functions:
area of cervix a. development and extrusion of ova
b. secretion of steroid hormone
- clinical correlation:
o myoma uteri - size
 most common uterine tumor o childbearing period: 2.5-5 cm x 1.5-3 cm x 0.6-
 rarely malignant 1.5 cm
 if 2-3 cm, no need to remove unless
there is menorrhagia or it causes infertility - pearly white – during younger age
menopause – diminished; wrinkled
 types: submucous, subserous
- location: ovarian fossa of Waldeyer
FALLOPIAN TUBES (OVIDUCTS) o bifurcation of the common iliac to internal and
- 8-14 cm long external iliac
o If too long – maybe a cause of infertility
- attachments
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 o posterior aspect of broad ligament via  median sacral artery
mesovarium o direct branch of abdominal aorta
o anterior pole with the uterus via uteroovarian o arises from the bifurcation of iliac artery
ligament
o lateral pole with the lateral wall of pelvis via  ovarian artery
suspensory ligament of ovary o corresponds to the internal spermatic artery in
 same with infundibulopelvic ligament of males
uterus o originate from the aorta below the origin of the
renal artery
- clinical correlation:
ovarian tumor INTERNAL ILIAC ARTERY/ HYPOGASTRIC ARTERY
o increase in size - main blood supply to the pelvis
o removal of ovaries: oophorectomy - 1.5 in. long
o cut ligaments - narrower than the external iliac iliac in adult but 2x
o FT cuddles ovaries – hard to separate – salpingo- larger in fetus because of the presence of the
oophorectomy umbilical branch
o oophorocystectomy - course: pass post. to the ureter and anteromedial to
the internal iliac vein
o ureter – anterior to hypogastric artery (“water
over the bridge”)

- divides at the superior border of the greater sciatic

foramen
- divisions:
1. posterior division
 all are parietal
 will go to the muscles, skin, wall
a. iliolumbar artery
b. lateral sacral artery
c. superior gluteal artery
NEUROVASCULAR STRUCTURE OF PELVIS 2. anterior division
 both parietal and visceral branches
(Dr. Quitiquit)  parietal branch
a. obturator artery
PELVIC ARTERY b. internal pudental artery
 external iliac c. inferior gluteal artery
o after crossing the inguinal ligament it becomes the
femoral artery  visceral branch
o main blood supply of the lower extremities a. umbilical artery
b. superior vesical artery
 internal iliac artery/ hypogastric artery c. inferior vesical artery
o major blood supply of the pelvis and pelvic organs d. middle hemorrhoidal artery
e. uterine artery
 superior hemorrhoidal artery f. vaginal artery
o from IMA
o only artery in pelvis which is not a branch of POSTERIOR BRANCH
internal or external iliac artery
ILIOLUMBAR ARTERY
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 - to iliacus and lumbar muscles - gives off superior vesical artery and becomes
- located at the 5th lumbar segment obliterated thereafter to become the medial
- divides terminally into 2 branches: iliac and lumbar umbilical ligament
- iliac supplying iliac fossa - iliacus muscle - makes internal iliac artery big in fetus
- lumbar providing spinal branch into the vertebral - origin of artery to Vas
canal and muscle there
SUPERIOR VESICAL ARTERY
LATERAL SACRAL ARTERY - supplies superior part of the bladder
- divides into 2 - from umbilical artery
- pass through sacral foramen
- supply muscle and skin on the back of the sacrum INFERIOR VESICAL ARTERY
- gives-off a branch called the artery of vas deferens in
SUPERIOR GLUTEAL ARTERY males
- largest branch
- exits through the upper part of greater sciatic VAGINAL ARTERY
foramen - corresponds to the inferior vesical artery in males
- supplies the gluteus muscles
MIDDLE HEMORRHOIDAL ARTERY
ANTERIOR BRANCH - arises from the internal pudendal artery/ inferior
PARIETAL vesical artery
OBTURATOR ARTERY - included in the rectal stalk or lateral rectal
- accompanied by its own vein and nerve - nor constant in origin
- NAV going down (superior to inferior) - supplies vagina, seminal vesicles and prostate gland
- divides into medial and lateral branch and rectum (middleportion)
- supplies the obturator internus muscles and hip
joints UTERINE ARTERY
- divides into:
INTERNAL PUDENDAL ARTERY a. descending – supplies lateral pelvic wall, parietal
- leaves the pelvis via greater sciatic foramen portion
- passes through the Alcock’s canal to gain access b. horizontal – parametrial portion (part of uterus)
through the perineum c. ascending – parauterine portion (surrounding
- branches into: the uterus)
o inferior rectal artery - branches into:
o scrotal/ labial artery a. ureteral
o bulbar artery b. uterine proper
o penile artery c. fundic round ligament
d. tubal
INFERIOR GLUTEAL NERVE e. ovarian
- terminal and largest branch of the anterior branch *forms a plexus around the uterus
- leaves pelvis via lower part of greater sciatic foramen
and exits in the buttocks between the piriformis and LYMPHATIC DRAINAGE
gemellus muscles  internal iliac nodes – associated with internal iliac
artery
VISCERAL  external iliac nodes – associated with external iliac
UMBILICAL ARTERY artery
- proceeds upward from the bladder to the umbilicus  common iliac nodes
 external inguinal nodes – can find gland of
Rosenmuller or nodes of Cloquet

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 located inside the sides of the vessels, follow the - gross anatomy:
course of the vessels o lateral: convex
o medial: concave
VEINS o major vessels and nerves – at medial portion
 follow the course of the pelvic artery “HILUM”
o internal iliac vein
o ovarian/ testicular vein - “RENAL SINUS”
o medial sacral vein o indentation; passage of vessels
o common iliac vein
 can ligate internal iliac artery and vein because it has a - FIBROUS RENAL CAPSULE – immediate covering
lot of anastomoses with the other vessels that supply - PERINEPHRIC FAT – fatty layer; acts as an insulator
the pelvis - PERINEPHRIC CAPSULE/ FASCIA – (+) outer surface
 plexi of the pelvis: o covers both kidneys and adrenal glands
a. uterine plexus – uterus
b. vesical plexus – urinary bladder - embryology
c. prostatic plexus – prostate gland
KIDNEYS
NERVE SUPPLY - nephros
 superior hypogastric nerve - 11 cm long; 130-150 g
o also called as the presacral nerves - right kidney lower than left kidney due to (+) of right
o supplies the bladder, rectum and internal genitalia liver
except the ovary and fallopian tubes - hilum
 internal hypogastric nerve - renal sinus – medial cavity where renal pelvis and
o supplies rectum, anal canal, uterus, vagina, urethra vessels pass through
and portion of urinary bladder - surface anatomy:
 pelvic splanchnic nerves (parasympathetic) o upper poles reach T12
o supplies pelvic viscera o lower pole – 2 cm above transumbilical plane
 lumbosacral and coccygeal plexus o medial border – 5 cm from the aorta
o supplies the lower extremities o hilus – near transpyloric plane

KIDNEYS, URETERS AND

- anterior relations: 2nd part of duodenum, tail of
ADRENAL GLANDS pancreas, right and left colic flexures
(Dr. Quitiquit) - posterior relations: diaph. arcuate ligaments, psoas
muscles, subcostal nerves, quadrates lumborum
muscles, iliohypogastric and ilioinguinal nerves
Solid organs
- kidney, liver, spleen, adrenal glands, pancreas
- structures:
- problem: prone to injury in blunt abdominal trauma
o frontal section - reveal an outer cortex and inner
- spleen and kidneys – major organs injured
medulla
 thicker: 2/3 of the thickness
KIDNEYS
 contains pyramids and columns
- bean-shaped, paired organ
- retroperitoneal
- functions for filtration
o chronic renal failure – no clearance of
metabolites
o for dialysis

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 URETER
- distal continuation of the renal pelvis extending
down to the urinary bladder
- 25 cm long
- parts:
o upper – abdominal portion (common iliac)
o lower – pelvic portion

- lies at the subperitoneal plane and adheres to the

peritoneum
- blood supply - therefore also at retroperitoneal area
o renal arteries - 3 constrictions:
 direct branch of aorta a. at junction of pelvis and ureter
 1 cm below SMA b. when ureter crosses iliac vessel
c. when ureter enters urinary bladder – narrowest
o kidney divided into segments based on the portion
division of the artery which do not anastomose
with each other o constrictions – sites where stones can lodge
↓
anteriorly Obstruction: no passage of urine
apical ↓
upper Kidney enlarges – HYDRO
middle NEPHROSIS
lower ↓
Chronic
posteriorly ↓
apical Destroyed
posterior Kidneys
lower
o renal veins - blood supply:
 anastomose with each other o renal artery above
o vesical artery inferiorly
o renal nerves
 from L1, L2 and T12 - innervations:
o renal and intermesenteric plexi above
- RENAL PELVIS o inferior hypogastric nerve below
o expanded, funnel-shaped upper end of the o testicular/ ovarian plexus
ureter
o fused major calyces ADRENAL GLANDS
o location: partly within the sinus and partly - “suprarenal glands”
outside the renal tissue - also in pairs
o internally: divides into 2 stalks - right – more triangular in shape
 CRANIAL major calyx left – crescenteric
 CAUDAL major calyx - situated on each side of the celiac trunk and are 5 cm
from each other medially
o major calyxes will divide into minor calyxes - at birth: almost covers the upper 1/3 of the kidney
o renal papillae will project at the minor calyx - yellowish to brownish in color
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 - cross section: outer cortex ECTOPIC KIDNEY
inner medulla - located in the pelvis
- normal embryology – goes up as it develops
- surface anatomy:
o lies in front the crura of the diaphragm at the
level of T12-L1 body
o anteriorly: related to liver, spleen and pancreas
o left adrenal gland: pancreas, splenic a. , stomach
o right adrenal gland: liver and IVC

- venous drainage:
o suprarenal vein
 single large vessel
 leaves anterior surface of the gland
 right: IVC
 left: left renal vein

- nerve supply:
o from greater and lesser splanchnic nerves
o branch from posterior vagal trunk
o 1st and 2nd lumbar sympathetic ganglia

CLINICAL CORRELATIONS:

HORSESHOE KIDNEYS
- developmental abnormality
- inferior lobes connected
- obstruction on calices/ ureters – prone to
HYDRONEPHROSIS; non-functional kidneys

DIALYSIS URINARY BLADDER

- external filtration of blood through a machine (Dr. Laygo)
- types:
a. hemodialysis - location (female): behind the symphysis pubis,
b. peritoneal dialysis – fluid inserted in the anterior to the uterus
abdomen → filtered by the abdomen - in infant:
o empty bladder – fusiform in shape
LITHIASIS o UB muscles not yet well developed
- (+) of stone within the body o median umbilical ligament – remnant of the
- ureterolithiasis – ureter
uracus
- cystolithiasis
 attaches the fundus of the UB to umbilicus
- urethrolithiasis
- urolithiasis – general term
- in adult:
o 2 ureters above → going towards the sides of
HYDRONEPHROSIS
the UB
- 2˚ to (+) of stones (obstruction), tumors, streaks

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 - 4 surfaces
o (1) superior surface
o (2) inferolateral surface
o (1) posterior s. – just below the fundus of the UB
- UB connected to prostatic urethra through the neck
of the UB
o Male:
 neck continuous with the 1st portion of the
urethra
 (+) internal urethral orifice – controls the
flow of urine from UB to urethra
o Female:
 urethra not divided in to segment
 neck connected directly to urethra proper
 cc: urinary incontinence because internal
urethral orifice is not well developed
- PUBOVESICAL/ PUBOPROSTATIC LIGAMENT
o strong ligamentous structure
o attaches the anterior surface of the distal UB and
the anterior surface of the prostate towards the
pubic bone
- in erect position
o UB rests on the base of the prostate gland
o prostatic and vesical plexus – seen in the
anterior surface of distal UB and prostate gland
 causes severe hemorrhage
o remains fixed as it fills
o UB continues to rise
 500 cc – level of umbilicus
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 I L – level of epigastric area
o Internal urethral orifice – relax → flow urine →
UB contracted and empty
o cc: urinoma – urine appears like a mass
 can’t feel urinary distention
 insert IFC to empty it esp. to older patient
o UB appears black in UTZ
- distended UB
o pelvic ULZ in female – distended UB
o each side – extends as far as the round ligament
o superiorly – continuous with median umbilical
ligament
o median umbilical ligament – filled with fatty and
areolar tissue in inflammatory involvement
- ligament
a. puboprostatic ligament – males
pubovesical ligament – females
b. medial – extension of pubovesical/
puboprostatic ligament
- coats
a. serous coat
o posteriorly: UB is closely related to the
rectum
o related to the prostate gland and symphysis
pubis
 just behind: presence of fat pad or
“RETROPUBIC SPACE OF RETZIUS”
 urethroscope – examine bladder and
urethra
b. fascia coat – subcutaneous coat
c. muscular coat – detrusor muscle
d. submucosal coat
e. mucosal coat
- interior of the bladder
o mucosa if empty
 presence of mucosal folds
  rugae appearance ↓
Superior and inferior vesical vein
o distended ↓
 mucosa appears to be smooth Obturator and internal pudendal vein
↓
o clinical correlation Internal iliac vein
 chronic urethral obstruction (prostatic ↓
enlargement) Common iliac vein
 distension of UB ↓
 hypertrophied mucosal folds IVC

- TRIGONE (trigonum vesicae) - lymphatics

o found inside the UB internal iliac group of LN
o area located below the 2 ureteral orifice(base) ↓
going towards the internal urethral orifice (apex) Paraaortic group of LN
o interureteric ridge – connects 2 ureteral orifice
- nerve supply
o sympathetic
o parasympathetic

- read on nerve erigentes

o triangular in shape
o elastic and tightly bond by underlying mucosa
o thinner than the rest of the mucosa
o appears pink on cystoscopy
o sides: lateral boundary
 line going down from ureteral orifice →
urethral orifice

o internal urethral orifice

 corresponds to the area of the neck of the THE URETHRA
UB (Dr. Laygo)
 serves as an internal urethral sphincter
Male Urethra
- arterial supply - long fibroelastic, muscular tube
o internal iliac artery – a direct branch of the aorta - 15-10 cm long
o obturator and internal pudendal artery - divided by superior and inferior transverse perineal
o superior and vesical artery – from internal iliac fascia
artery - parts:
o middle rectal/ hemorrhoidal artery – enclosed by
the lateral rectal ligament/ rectal stalk

- venous drainage
venous plexuses around the UB
↓
Middle hemorrhoidal vein

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  clinical significance: area commonly
injured during instrumentation (e.g.
indwelling Folley catheter, cystoscopy)

o begins at the apex of prostate and ends at

the bulb of penis
a. prostatic urethra o traverses the deep perineal space
o above the superior fascia o surrounded by sphincter urethrae and
o below the neck of the UB perineal membrane
o 3 cm long o posterolateral area – bulbourethral gland of
o begins at the internal urethral orifice and Cowper’s
ends at the superior border of the o circular fibers – sphincter urethrae/
transverse perineal fascia compressor urethrae
o descends through the prostate gland  sphincter like action
o terminates by piercing through the superior  voluntary muscle
fascia of urogenital diaphragm
o lumen is narrowest superiorly and inferiorly c. spongy urethra
o widest and most dilatable portion of the o below inferior fascia up to the urethral
male urethra orifice
o parts: o divides into 2:
1. urethral crest – median longitudinal ridge bulbous – bulb of the penis
of the posterior wall of the urethra mobile – penile urethra
 on each side: prostatic sinus →
where numerous ducts usually o longest part , 15-16 cm long
terminates o passes through the bulb of the penis
(bulbous) and corpus spongiosum (spongy)
2. seminal colliculus (verumontanum) and ends at the external urethral meatus
 elevated portion at the middle part o lumen is about 5 mm in dm
of the prostatic urethra o parts of dilatation:
 bulb of penis – intrabulbar fossa
3. cul de sac – prostatic utricle  glans penis – navicular fossa/ navicular
 5 mm long fossa
 opening of the ejaculatory duct – o glands in spongy:
each side of the prostatic utricle 1. ducts of bulbourethral gland
 VD joins the _________ SV to form  opens about 3 cm distal to perineal
the ED muscle
 prostatic utricle – homologous of
the uterus and vagina 2. urethral glands
 numerous on dorsal surface of
b. membranous urethra urethra
o located within the transverse perineal  secretes jelly-like substance
muscle
o below the superior fascia Female Urethra
o above the inferior fascia - short, muscular tube
o shortest, 1-2 cm long - 4 cm long
o thinnest, narrowest - lined by mucous membrane
- superior ½ equivalent to prostatic urethra
- inferior ½ equivalent to membranous urethra
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 - passes anteroinferiorly from the UB which is SV VD
posterior and inferior to symphysis pubis ↓
- external urethra meatus Epididymis
o located anterior to vagina/ just below the clitoris
o inferior end is surrounded by sphincter urethrae Membranous Urethra
- most common site of injury during catheterization
- paraurethral glands located at the superior part of - location of the balloon: opening of the interior
the female urethra urethral orifice
- paraurethral glands usually drains the paraurethral
ducts → drains near the external urethral meatus
- clinical correlation:
o honeymoon cystitis – inflammation
o bloody urine, hypogastric pain, dysuria
o treatment: antibiotics

- sphincter urethral muscles not well developed

- areas commonly injured: prostatic, membranous and
penile urethra
- gross bleeding coming from the external urethral
meatus

Bulbous Urethra
- affected in straddle type of injury
- “Cowboy type injury”
- gross hematuria

Penile Urethra
- prone to fracture → partial or total transection →
gross hematuria
- catheterization is a no, no during urethral injury

CLINICAL CORRELATION (MALE AND FEMALE URETHRA) - retrograde urethrocystography

↓
BPH (Benign Prostatic Hypertrophy) Inject dye to the external urethral meatus
- enlargement of the prostatic urethra ↓
- impinges the prostatic urethra Positive injury
- cystoscopy – PG is in kissing position ↓
Dye will not flow continuously or
Retrograde passage of infection ↓
infection → prostatic urethra Extravasation of the dye
↓
Prostatic sinus - treatment: do UB decompression
↓ o insert cystocatheter or venocatheter
Prostatic utricle ↓
↓ Insertion should not be too high because you
Ejaculatory duct might injure the intestinal organs
↓ ↓ ↓

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 Decompress the UB o lateral branch of the iliohypogastric nerve
(L1)
PRESENCE OF STONE o anterior ramus of T12
 located at the fossa navicularis/ between the fossa
navicularis and urethral meatus b. upper medial border
 Treatment: o subsurd by the posterior rami of the upper
Local anesthesia 3 lumbar nerves and upper 3 sacral nerves
↓
Open urethral meatus c. upper lateral border
↓ o lateral cutaneous nerve to the thigh
Remove the stone  comes from the anterior rami of L2-L3
↓
Submit stone for urine stone analysis d. lower medial border
o innervated by the anterior rami of the upper
Cystocele 3 sacral (S1, S2, S3)
- common pathologic condition in females o posterior cutaneous nerve to the thigh
- protrusion of the inferior UB at the distal part of the
vagina FASCIA
- must be differentiated to uterine prolapsed - superficial fascia
o relatively thick fatty layer
Urinary Tract Infection (UTI) o varies
- very common in women especially those who are o gives prominence to your butt
sexually active o covers gluteus maximus

- deep fascia
o inferiorly → continuous downward
↓
Deep fascia of the thigh (fascia lata)
↓
Thickens laterally into iliotibial tract
↓
Terminates distally at proximal part of the tibia
GLUTEAL REGION ↓
(Dr. Tanyee) Gerdy’s tubercle (distal insertion)

- a.k.a. buttocks, ass, butt MUSCLES

- boundaries: a. gluteus maximus muscle
anterolaterally – tensor fascia lata o 2nd structure that gives prominence to the
superiorly – iliac crest buttocks
posterior – lateral border of sacrum o 1st origin: area posterior to the gluteal line of the
inferiorly – gluteal fold line
2nd – lateral portion of the sacrum
- 2 buttocks are separated by natal cleft 3rd – sacrotuberous ligament

- divided into 4 quadrants by an imaginary line middle o Insertion:

of iliac crest and greater trochanter osseous – femoral tubercle or gluteal tuberosity
a. upper lateral/ outer border of the femur
non-osseous – iliotibial tact
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o innervation: inferior gluteal nerve
o actions:
3. extends and laterally rotates the hip joints
4. maintains the knee in extended position
through the iliotibial tract
5. when you stoop – it extends the trunk;
truncal extension when one assumes a
stooping position
o standing position – g. maximus covers the ischial
tuberosities
o sitting position – not covered
o bursa: minimizes the friction between the two
opposing structures
1. confined between the tendinous insertion of
iliotibial tract and greater trochanter
2. laterally between the tendinous insertion
and vastus lateralis m.
3. between the muscles and ischial
tuberosities
LATERAL HIP ROTATORS
b. gluteus medius muscle
o origin: from the outer surface of the ilium
between the posterior gluteal and anterior
gluteal line (middle gluteal line)
o insertion: lateral surface of the greater
trochanter
o bony structures: hip bone and proximal portion
of femur
o innervation: superior gluteal nerve
o action:
1. abducts the hip
joints
2. anterior fibers
act as a medial rotator of the hip joints
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3. together with
g. minimus, it helps maintains the pelvis
from tilting downward (standing in one foot)
c. gluteus minimus muscle
o origin: between the anterior and inferior gluteal
line
o insertion: anterior surface of the greater
trochanter
o innervation: superior gluteal nerve
o action: share the same action with the g. medius
muscle
d. tensor fascia lata muscle
o anterior boundary
o origin: outer edge of the iliac crest between the
ASIS and iliac tubercle
o insertion: iliotibial tract
o innervation: superior gluteal nerve
o action: maintains the knee in an extended
position through the iliotibial tract
e. piriformis muscles
o origin: partly w/in the pelvis; anterolateral
surface of the sacrum
o insertion: anterior border of the greater
trochanter
o innervation: anterior rami of S1-S2
f. superior gemellus muscle
o origin: ischial spine
o insertion: upper border of the greater
trochanter
o innervation: nerve to the obturator internus
muscle
g. inferior gemellus muscle
o located below the superior gemellus m.
o origin: upper margin of the ischial tuberosities
o insertion: upper border of the greater
trochanter
o innervation: nerve to the quadratus femoris
muscle
h. obturator internus muscle
o pelvic muscle which exits to the gluteal region
 o origin: obturator membrane (obliterates the
obturator foramen) and the bones forming the
obturator foramen
↓ g.
Goes outward passes thru the lesser sciatic
foramen and
↓ -
Inserts in the upper border of the greater
trochanter
o innervation: nerve to the obturator internus
muscle
o superior gemellus m., inferior gemellus m. and
obturator internus m. are collectively called the
TRISEPTAL TENDON because they all inserts at
the upper border of the greater trochanter
i. quadratus femoris muscle
o origin: from the lower lateral margin of ischial
tuberosity
o insertion: quadrate tubercle of femur
o innervation: nerve to the quadratus femoris
muscle
LIGAMENTS
- sacrotuberous ligament and sacospinous ligament
o converts the sciatic notch into a foramen
FORAMINA
- serves as the entry or exit of muscular, vascular
structures from the pelvic region going to the gluteal
region
- greater sciatic foramen
o divides into 2 space/ fossa by the piriformis
muscle
a. supra piriformic space - above
b. infra piriformic space - below
o structures that exits here:
a. piriformis muscle
b. sciatic nerve
c. posterior cutaneous nerve to the thigh
d. superior and inferior gluteal vessels
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e. nerve to the obturator internus muscle and
quadratus femoris muscle
f. pudendal nerve
superior and inferior gluteal nerve
h. internal pudendal vessels
lesser sciatic foramen
o structures that exits:
a. tendon of the obturator internus muscle
b. nerve to the obturator internus muscle
c. pudendal nerve
d. internal pudendal vessels
ARTERIES
a. superior gluteal artery
- exits the pelvic cavity and goes towards the greater
sciatic foramen above the piriformis muscle
- comes from the posterior division of the internal
iliac artery
- supply all gluteal region
b. inferior gluteal artery
- termination of the anterior division of the internal
iliac artery
- below the piriformis muscle
- supplies the whole gluteal region
c. trochanteric anastomoses
- consists of the following:
1. superior gluteal artery
2. inferior gluteal artery
3. middle femoral circumflex artery
4. lateral femoral circumflex artery
3 and 4 – comes from the profunda femoris
artery
- provides main blood supply to the femoral head
d. cruciate anastomoses
- supplies the femoral head
- consists of the following:
1. inferior gluteal artery
2. medial femoral circumflex artery
3. lateral femoral circumflex artery
4. 1st perforating branch of the profunda femoris
artery
NERVES o pierce by the gluteus medius sometimes g.
a. sciatic nerve maximius
- longest nerve of the body
- comes from L4, L5, S1, S2 and S3 - FAT WALLET SYNDROME
- 2 components: o irritation of sciatic nerve
1. lateral – common peroneal nerve o paresthesia – weakness in distal/ lower
2. medial – tibial nerve extremities
o muscle strain – compression of the sciatic nerve
o they together up to the posterior aspect of the
knee STRUCTURES BELOW THE PIRIFORMIS MUSCLE LEAVING
o in some cases, the 2 are separated THE GREATER SCIATIC FORAMEN (LATERAL TO MEDIAL)
o common peroneal nerve - exits the piriformis a. sciatic nerve
muscle or above the piriformis muscle b. posterior cutaneous nerve to the thigh
c. inferior gluteal nerve
- does not innervate the gluteal region d. nerve to the obturator internus muscle
e. internal pudendal vessels
b. posterior cutaneous nerve to the thigh f. pudendal nerve
- cutaneous in nature
- from S1-S3
- passes behind the sciatic nerve
- superficial to the biceps femoris muscle
- branches:
1. gluteal branch
2. perineal branch – back of scrotum (m); labia
majora (f)
3. cutaneous branch to the back of the thigh and
part of the leg

c. superior gluteal nerve

d. inferior gluteal nerve
e. nerve to the obturator internus muscle
f. nerve to the quadratus femoris muscle

g. pudendal nerve PELVIC REGION AND HIP JOINT

- exits the pelvic cavity passing through the greater
sciatic foramen below the piriformis muscle then
(Dr. Abiog)
temporarily courses at the pelvic cavity exits to the
lesser sciatic foramen going to the perineum “IN ART AND CULTURE, A WOMAN’S HIPS ARE OFTEN
together with the internal pudendal vessels VIEWED AS A SYMBOL OF FERTILITY”
passing through the Alcock’s canal
Surface Anatomy
Clinical Correlation - Waist-Hip ratio (WHR)
- safe zone for intramuscular injection: upper outer/ o measure waist and hip
lateral quadrant o F = 0.7
o from ASIS to iliac tubercle o M = 0.9

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 o beyond → oversize o ASIS – where sartorius muscle originates
o AIIS – … rectus femoris
Anatomical Landmark o Gluteal line – anterior, inferior, posterior
- highest level of iliac crest o acetabulum
- gluteus maximus and gluteus medius  ilium – superior
- ischial tuberosity – sitting bone  ischium – low/ behind
- intergluteal cleft  pubis – anterior below
o from cervical plum line should go along with it or
else compensated scoliosis o ischial tuberosity
o line falling to center of gravity  connects with inferior ramus of pubis
↓
- greater tubercle/ tubersity – lateral prominence obturator foramen
- skin dimple
o PSIS o ischial spine
o correspond to S2  needle insertion to anesthetize the
o sacroiliac jt perineum for painless delivery
o also known as “anal dimples of Venus”  located between the ischial spine and ischial
tuberosity
Pelvic Girdle  nerve: pudendal nerve
- consist of:
o pelvis Femur
o upper part of femur - head – articulates with the acetabulum
- neck – common fracture site
- functions: - greater and lesser trochanter – connects it by:
a. provides support and protection to abdominal o posterior – intertrochanteric crest
organ o anterior – intertrochanteric line
b. transmits force from the head, arms and trunk to
the lower extremities - clinical significance: determine the names of fracture

Pelvis Hip Joint

- “Basin” - a.k.a. acetabulofemoral joint
- consist of: - most structurally stable, yet mobile, single joint in
o sacrum the body
o coccyx - major component of the locomotor system
o coxal bone (innominate bone) - participates:
 ilium – superior o in elevating and lowering body as in climbing or
 ischium – low and behind rising from chair
 pubis – anterior and below o in bringing foot towards body/ hands – as in
putting on a shoe
- it is formed by the pelvic bone (7 joints)
o lumbosacral - for every step, hip adduction creates a force to
o sacroiliac balance 85% of body weight
o sacrococcygeal - gluteus medius – contracts to keep balance and iliac
o symphysis pubis level balance
o hip joint (acetabulofemoral)
- acetabular lip (lambrum acetabulare)
o not a perfect circle
- landmark of hip bone
o deepens acetabulum
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 o helps hold head of femur all three ligaments common action intending to limit
o transverse acetabular ligament – bridges notch internal rotation
o cotyloid variety of the enarthrodial (ball and
socket joint) d. ligament of the head
o 3 cardinal planes: o previously known as ligamentum teres
 sagittal plane – flexion, extension, o little function as a ligament but it guides
hyperextension artery to the head of femur particulary
 coronal/ frontal plane – adduction, acetabular artery a branch of obturator
abduction artery
 horizontal/ vertical plane – external
rotation, internal rotation HIP JOINT KINESIOLOGY
- angle of femur
- stability and strength of the hip joint a. angle of inclination
o lies solely with the articular shape o along head and neck (longitudinal neck)
o ligament: strong with thickenings of capsule o body-straight line
 not visible in cadavers

o 22 muscles present
o (-) pressure intraarticularly inside the capsule to
keep it in place

- Ligaments:
a. iliofemoral ligament/ Y-ligament of Bigelow o normal angle: 125˚
o from ASIS to intertrochanteric line (anterior) o baby – angle of inclination is 140˚
o prevents: o cc: coxa vara – less than 110˚
 undue extension coxa valga – more than 140˚ (decrease
 abduction weight bearing)
 lateral rotation
b. angle of anteversion
b. pubofemoral ligament
o the bursa is located above it
 cc: once inflamed – painful inguinal area
 a.k.a. iliopectineal bursitis

o from superior pubic ramus

o checks abduction o normal: 12˚
o assists Y-ligament in checking hip extension o anteversion 35˚ - inward feet, in-toe-in-gait
o ballet dancer – it is relaxed (split) o retroversion 5˚ - Charlie Chaplin, out-toe-in-
gait
c. iliofemoral ligament - clinical correlation:
o less-well developed, from ischial rim of o internal tibial torsion
acetabulum  produce in toe-in gait
o spiral direction is decreased by flexion and  common cause of gait
increased by extension
o checks internal rotation o in toe – in agit
 squinting patellae
 internally rotated feet

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 a. Epiphyseal arteries
- assessment o 1. lateral epiphyseal artery – 4/5 of the
o length of thigh is assessed in congenital hip epiphysis
dislocation o 2. medial epiphyseal artery – 1/5 of the
o Alley’s test epiphysis
 bend knee and hip together
 not the same length b. Metaphyseal arteries
 bulbous fold – gluteal fold o 3. inferior metaphyseal artery – 2/3 of the
metaphysic
o Trendelenburg test o 4. superior metaphyseal artery – 1/3 of the
 stand on affected side (1 foot) metaphysic
 checks if gluteus medius is weak
 result: (+) deepening - NB: 1,3 and 4 comes from the median circumflex
“sway” on affected area artery
 true feminine 2 – comes from acetabular branch of the obturator
 inherent weakness of g. medius artery from external iliac artery
 short lever area
 normal: both sides - Clinical significance: aseptic necrosis/ avascular
necrosis
- blood supply: o when blood supply is cut off at the femoral
o deep femoral artery head
 direct branch of femoral artery
 divides into: KINESIOLOGY OF THE HIP JOINT
a. medial circumflex femoral artery - 22 muscles acting on the hip joint
 hip joint and head of femur - 31 – 311 – 4261
 retinacular artery - 3 flexors
 posteriorly, it hooks around the a. Psoas muscle
upper femoral portion o origin: T12 – L5
 importance: particularly the o insertion: lesser trochanter
retinacular artery, it supplies the o action: strong hip flexor
femoral head (when fractured, BS is
cut-off causing aseptic necrosis) b. Iliacus muscle
o origin: Iliac fossa
b. lateral circumflex femoral artery o insertion: lesser trochanter
 ascending branch – will supply the o action: hip flexor
head of the femur
 will have perforating branch c. rectus femoris
o origin: AIIS
external iliac → inguinal ligament → o biarticular muscle
femoral artery → deep femoral artery → a and b o insertion: tibial tuberosity – patella ligament
o obturator artery o action: HIP JOINT (flexor)
 acetabular artery – finds its way PATELLA JOINT – external kicking muscle
↓
Ligamentum teres - 1 flexor-adductor
↓ a. Pectineus muscle – cross-leg (female)
1/5 of the femoral head (epiphyses portion)
- 3 extensors
- Trueta Studies
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 a. Biceps femoris muscle
o Long head – biarticular - IM injection: upper lateral border
o Short head – monoarticular o avoid sciatic nerve
 passes underneath the piriformis
b. Semitendinous muscle  87% will pass under the sciatic nerve

c. Semimembranous muscle - 2/3 of individual – psoas minor is present (1 side of the

body)
o Hamstrings: o origin: T12 – L1
 medial – semitendinous and o insertion: pecten line
semimembranous o no affect on the hip joint
 lateral – biceps
 weak hamstring – causes low back pain - Fat wallet syndrome
o Inflammation to piriformis muscle
- 1 extensor-external rotator o Impinges the sciatic nerve
a. Gluteus maximus muscle – fleshy portion o “piriformis syndrome”
o Cycling, climbing stairs, running o Pain along the course of sciatic nerve
o Screw muscle
- Bursa
- 1 abduction o between the greater trochanter and g. maximus
a. Gluteus medium muscle – responsible for the ilitibial tract
rounded contour at the side of your butt if well o forms between a muscle and a bony area
developed o bursitis – inflammation
o nodule – ischiogluteal bursitis/ ischial bursitis
- 4 adduction “Weaver’s bottom”
a. Gracilis – most superficial of the medial
compartment of the thigh - Sports injury/ vehicular accident
b. Adduction longus o fracture: between the greater and lesser
c. Adduction brevis trochanter
d. Adduction magnum o fractures below the trochanter – subtrochanteric
fracture
- 2 internal rotators
o or in the neck: cut-off blood supply causing
a. Tensor fascia latae
necrosis
b. Gluteus minimus
o treatment: Hip implant/ hip prosthesis
o 50% of cases the cause is unknown:
- 6 deep external rotators
o other causes: patients taking steroids, patients
a. Pirifomis muscle
with Rheumatoid arthritis
b. Obturator internus muscle
c. Obturator externus muscle
- posterior dislocation of the hip
d. Superior gemellus muscle
o the extremity is shortened with the hip flexed,
e. Inferior gemellus muscle
internally rotated and adducted
f. Quadratus femoris muscle
o the involved extremity is resting on the uninvolved
thigh
- 1 flexor-abductor-external rotators
a. Sartorius muscle – longest muscle
- anterior dislocation of the hip
Sartorial position “de kwatro”
o flexed, abducted and externally rotated position of
the extremity
CLINICAL CORRELATION
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 Functions:
- hip arthritis a. supplies muscle of skin on the anterior and medial
o hip rotation: 0 – 45˚ sides of the thigh
o if less than 30˚ a sign of hip joint problem b. supplies skin on the medial side of the leg and foot

- ottopelvis/ protrusio acetabule Origin

o medial displacement of the femoral head bulging - ventral rami of L1 and L3 and a variable part of L4
into the acetabulum with usually a small communication from T12
- at its origin, it is embedded in the psoas major
- snapping hip syndrome muscle
o a condition characterized by a snapping sensation
and often an audible ‘popping’ noise on hip flexion
and extension T12 ---------- subcostal nerve
o causes: Iliohypogastric
a. iliotibial band snap L1 ---------
o most common cause of snapping hip ilioinguinal
syndrome sensory
o when the iliotibial band (IL band) snaps L2 ---------- genitofemoral
over the greater trochanter cremaster

b. iliopsoas tendon snap L3 ---------- lateral cutaneous n. to the thigh

o the iliopsoas tendon can catch on a bony
prominence of the pelvis and cause a snap
when the hip is flexed
o usually when the iliopsoas tendon is the
cause of snapping hip syndrome, patient
have no problem but may find the
snapping annoying
c. hip labral tear
o a tear of the cartilage within the hip joint
– the least common cause
o a loose flap of cartilage may cause within
the joint may cause a snapping sensation
when the hip is moved
o typically causes a snapping sensation but
rarely an audible pop
o may also cause unsteady feeling and
patient may grab for support when the
hip snaps
(lateral femoral cut. Nerve)
-------- posterior ------ femoral nerve
L4 ----anterior----- obturator nerve
accessory obturator nerve
------- lumbosacral
L5
Accesory obturator nerve
- if present it supplies the pectineus muscle
Obturator nerve
- sometimes supplies the pectineus muscle
Lateral cutaneous nerve to the thigh
- goes down to Iliacus muscle, hooks around ASIS,
passes around the inguinal ligament
- can be impinged by the inguinal ligament or the ASIS

Femoral Nerve
LUMBOSACRAL PLEXUS - if impinged – very painful
(Dr. Abiog) - palpate for the pulsations in the femoral artery
- lateral – nerve
LUMBAR PLEXUS - median – vein
- usually supplies the pectineus muscle

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 - anterior branches of L4, L5, S1, S2 and S3 unite to
form tibial nerve
- posterior branch of the lumbosacral trunk S1 and S2
(L4-L5) unite to form common fibular peroneal nerve
- these 2 regularly lie in a common CT sheath in the
thigh
o tibial nerve more medial in location
Obturator Artery
- main nerve supply of the median compartment of FROM THE ANTERIOR PART
the thigh - part of the posterior femoral cutaneous nerve (S1-S3)
- pudendal nerve S2-S4 – center for micturation and
SACRAL PLEXUS defecation
 lower motor neuron connection
Functions:
a. supplies the musculator of the gluteal region OTHER BRANCHES FROM THE POSTERIOR PART
b. give rise to the sciatic nerve that supplies the - superior gluteal L4-S1
posterior muscles of the thigh and all the muscle - inferior gluteal L5-S2
below the knee - part of the posterior S1-S3 cutaneous nerve
- lateral - common fibular L4-S2
Formation - more medial - tibial nerve L4-S3
- union part of the ventral ramus of L4 with all of the
ventral ramus of L5 to form a lumbosacral trunk and - important structures:
by the union of this trunk with the ventral rami of S1 o posterior cutaneous nerve
to S3 or S1 to S4 o pudendal nerve
o superior gluteal nerve – g. medius, g. minimus,
L4 tensor fascia latae
o inferior gluteal nerve – g. maximus
L5 ------- superior gluteal nerve
PELVIC SPLANCHNIC NERVE
S1 ------ inferior gluteal nerve - parasympathetic nerve (S2-S4) to inferior hypogastric
------ common peroneal artery (pelvic) plexus
S2 (fibular nerve) sciatic n.
------- tibial nerve Clinical correlation
S3 ------ ant. and post. femoral nerve - rupture of pubococcygeus muscle during delivery
when episiotomy is not done
------- pudendal nerve - herniated lumbar disc
S4 - protrusion of nucleus pulposus
- problem on the left side - lean on the right
Pelvic splanchnic nerve

Sacral Plexus and Branches

THIGH REGION
SCIATIC NERVE
- longest and biggest nerve that supplies the lower (Dr. Cariaga)
extremities
I. SURFACE ANATOMY

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 - Patella o fracture to neck
o not a good reference point for measurement  lead to necrosis of head due to
of the leg because it is movable(can be interruption of blood supply
sideways and move up and down during  avascular necrosis
assessment)  treatment: replacement of femur/
hip joint
- ASIS
o proximal point of the thigh c. greater and lesser trochanter
o good reference point for the measurement of o between the two is the trochanteric area
the leg  common site for fracture to occur 2°
o continues to become the iliac crest to osteoporosis
 fragile bone
- Pubic tubercle
o anterior d. subtrochanteric area
o below lesser trochanter
- Greater trochanter
o not a good reference because some patients e. femoral shaft
do not have a well developed/ prominent o thin part of the femur
greater trochanter o it widens distally to form bilobular
structure called “femoral condyle” divides
- iliac crest into lateral and medial posterior
o continuation of ASIS o significance: for biomechanical reason
 carry weight for balance –
- PSIS disseminate the weight
o forms a dimple
III. BOUNDARIES
- popliteal folds and popliteal fossa
o posterior - superior/ proximal
anterior
- proximal part of the thigh is muscular and it goes o pubic tubercle
distally as a tendinous structure at the end and can o inguinal ligament
be palpated at the condyle of the femur  ASIS to pubic tubercle

II. BONY ANATOMy o gluteal fold

- Femur  iliac crest to PSIS
Parts:  posterior
a. neck
o not smooth as the head - inferior/ distal
o rough – find a lot of BV on it o 3 inches above patella – anterior
o popliteal fascia
b. head  soft tissue boundary
o covered with ligaments and arteries  posterior
o articulates with acetabulum
o BV – from distal to proximal IV. SKIN
 are unique according to its - thickness
arrangement - sensitivity – medial (anterior) part more sensitive
than lateral part of the thigh
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 - nice to know! tip of the 2nd finger is the most
sensitive part in the body
V. SUPERFICIAL FASCIA
- with 2 distinct layer in proximal portion and
distally, they blend with each other
A. superficial fatty (Camper’s)
- contents:
a. cutaneous nerve – either posterior or
anterior, purely sensory
o anterior femoral cutaneous nerve –
branch of femoral nerve
o cutaneous nerve of obturator nerve –
terminal branch of main obturator
nerve
o posterior femoral cutaneous nerve –
terminal branch of sciatic nerve
b. superficial vein
o veins in superficial fascia
o some do not have accompanying
artery
1. great saphenous vein/ magnus vein
 anterior vein
 most prominent
 longest vein
 useful vein – courses in the
dorsum → ankle → middle of the
thigh
 clinical correlation: bypassed
heart surgery
 great saphenous vein is
harvested for bypass
2. superficial circumflex iliac vein
 from ASIS – drain its area
3. superficial epigastric vein
 drains lower part of abdomen
4. superficial pudendal vein
 drains perineal area
NB: 2, 3 and 4 are accompanied by its respective
artery and usually drain in great saphenous vein
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5. anterior/ lateral saphenous vein
6. median saphenous vein
c. lymphnodes
o lymphatic vein drain to it
1. parallel to Poupart’s ligament
 proximal – area where 2
superficial vein is located
2. perpendicular to Poupart’s ligament
 distal LN
 drain in the vicinity with great
saphenous vein
both will drain to deeper inguinal LN
then to paraaortic LN
B. deep membranous (Scarpa’s)
- thick especially laterally
- covers muscle of the thigh
- insertion of upper ¾ of g. maximus and tensor
fascia latae
- boundaries:
o proximal – iliac crest, inguinal ligament,
pubic tubercle
o distal – blends with tendons, periosteum,
popliteal fossa
- serves as “tight fitting sleeve”
- divides thigh into 3 compartments
- deep LN
o from deep group of nodes of lower
extremities
NB: both superficial and deep LN drain into external iliac
ANTERIOR THIGH MUSCLES
a. Sartorius muscle
- “tailor’s muscle”
- most superficial, ribbon-like
- bi-articular
- origin: ASIS
- insertion: middle aspect of tibia, “pes anserinus”
- actions:
o tailor cross-leg composition
o flex-hip joint and external rotation
 o knee-joint rotation and flexion o safe site = UOQ of buttocks
o innervation: femoral nerve o avoid hitting the sciatic nerve
o anterior region of the thigh – seldom use for
b. Iliopsoas muscle IM injection because if it is frequently injected
- 2 part origin: there, it will cause bleeding leading to scar
o Psoas – L1-l5 transverse process formation → adhesion of quadratus femoris
o Iliacus – iliac fossa/ sacrum (inner surface of it) o (+) adhesion – lose gliding characteristic of QF
 NO FLEXION ACTIVITY
- insertion: lesser trochanter
- action: strongest hip flexor - “articularis genu” of Vastus intermedius
- innervation: L2/L3 spinal nerve o prevents synovial tissue to be cut once bones
femoral nerve (L2) glide with each other
- tendon vs. ligament; tendon arrangement

c. Quadratus femoris muscle d. Pectineus muscle

- with four heads - anterior/ medial group
o rectus femoris – superficial layer - sometimes under adductor group
o vastus lateralis – lateral - origin: superior pubic ramus
o vastus medialis – medial - insertion: below lesser trochanter
o rectus intermedius – underneath the RF; close - action: can be extension/ adduction
to the bone - innervations: femoral nerve, sometimes by
- ¼ biarticular obturator nerve
- common insertion: patella
- origin: relative to linea aspera MEDIAL THIGH MUSCLES
- action: hip and knee joint flexion - member of obturator group/ adductor group
- vastus lateralis - all originate: pubic tubercle/ superior pubic ramus
o forms the bulk of the muscles of athletes - insertion: continuous with each other

- vastus medialis
o “workhorse” especially in last 15˚ prominent a. Adductor longus muscle
due to low insertion, marked obliquity, thin - most anterior
fascia - not the longest muscle
o most effective in 15˚ extension (0-15˚) - origin: pubic tubercle
o prevent lateral gliding of patella and is - insertion: medial aspect of femur
attached to the patella to maintain its position - located between V. medius and V. magnus
o with oblique fibers at the lower part in
transverse and longitudinal axis of the femur b. Adductor brevis muscle
o oblique fibers: if not well developed, it will not - shortest
- posterior to A. longus
hold the patella and will have lateral
- origin: inferior pubic ramus
dislocation
- insertion: linea aspera
 not on the knee cap but on its lateral side
- separates anterior and posterior branch of
obturator nerve
o treatment: will attach oblique fibers/ v.
medialis lower than the insertion to pull
c. Adductor magnus
patella medially to prevent lateral dislocation
- fan-shaped; massive
- with broad base insertion
- clinical correlation: during IM injection
- with oblique and longitudinal fibers
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 - origin: ischial ramus and ischial tubercle
- insertion: long, from upper linea aspera to
adductor tubercle
o with tendinous insertion
- with osteotendinous opening
o opening of bones and tendons of A. magnus
o opening – BV will cross the anteromedial
aspect of the thigh to supply the posterior
aspect
o Adductor hiatus
 biggest osteotendinous opening
 where femoral artery will pass and
change its name into popliteal artery as
well as its accompanying vein
- parts:
o anterior transverse- posterior obturator
nerve
o anterior oblique – posterior obturator nerve
o posterior longus – tibial nerve of sciatic
nerve
d. Obturator externus muscle
- most posterior
- encircles the external surface of obturator
foramen
- origin: surface of obturator foramen
- insertion: trochanteric fossa
e. Gracilis muscle
- most medial
- longest muscle in adductor group
- origin: inferior pubic tubercle
- insertion: pes anserinus (way below knee joint)
- biarticular muscle – crosses 2 joints
- innervation: anterior obturator nerve
- “pes anserinus”
o common insertion of Sartorius muscle,
gracilis muscle and semitendinosus muscle
o located anteromedial aspect of tibia
o “foot of a goose”
o insertion: anterior, medial and posterior
muscular compartment
 anterior – sartorius muscle
 medial – gracilis muscle
 posterior – semitendinosus muscle
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POSTERIOR THIGH MUSCLES
- hamstrings
- origin: muscles at ischial tubrosities
- insertion: below the knee joint
- biarticular muscle – crosses hip and knee joint
- action: adduction of hip joint and flexes knee joint
- with 3 members, except the short head of biceps
femoris
- innervated by the tibial branch of sciaitic nerve
a. Biceps femoris muscle
- short head
o origin: linea aspera of femur
o innervation: common peroneal nerve
- long head
o origin: ischial tuberosity and lower part of
sacrotuberous ligament
o innervation: tibial nerve
- insertion: fibular band – lateral to the femur
b. Semitendinosus muscle
- origin: long head of biceps femoris
- insertion: medial tibial condyle, pes anserinus
- innervation: tibial branch of sciatic nerve
c. Semimembranosus muscle
- origin: ischial tuberosity
- insertion: medial tibial condyle – membranous
insertion in posterior aspect of tibia
KNEE JOINT
- between tibia and femur
- more patellar articulating in the surface of the femur
- patellar tendon
o pulls the tibia
o if QF contracts – increase force to extend legs
o effective to strengthen the knee
- articularis genu
 o move patella away as it glides with each other
o if (-), it will move patella down and destroy 2.
synovial tissue and fluid will leak further
destroying the femur
o provides lubricating fluid within synovial cavity
Femoral vein
- with tributaries similar to femoral artery
- with 2 big differences:
o - with great saphenous vein

- femur – with articulation – gliding movement of  no accompanying vein

patella to femur

o with 3 branches:
NEUROVASCULAR STRUCTURES
 epigastric vein
OF THE THIGH REGION  circumflex vein
(Dr. Cariaga)  external pudendal vein

1. Femoral artery superficial veins with accompanying artery

- under inguinal ligament – level where external iliac
artery name will be changed
- it is called the popliteal artery once it passes the
Adductor hiatus
- branches:
Superficial
a. superficial circumflex artery
b. superficial epigastric artery
c. superficial external pudendal artery
Deep
d. Profunda femoris artery
o biggest branch
o deep femoris artery
o same size as femoral artery
o with big caliber – it supplies the entire
anterior thigh muscles
o have a counterpart vein
o branches:
 medial femoral circumflex
 lateral femoral circumflex
most proximal and rounds the femur
 descending branch – proceeds
towards the knee joint
 perforating branch – crossing a
certain bone particularly at the
osteotendinous opening
 very important branch because it
supplies the posterior thigh
muscles
 passes through the
osteotendinous opening
drains → great saphenous vein → femoral vein
- 3 branches:
a. profunda femoris vein
b. great saphenous vein
c. descending genicular vein
- lie position in relative to artery
3. Obturator vessels
- from internal iliac
- anastomose with medial femoral circumflex
vessels and inferior gluteal vessels
- supplies obturator muscles and medial aspect of
the thigh
4. Femoral nerve
- from L2, L3 and L4
- r/n to fern vessels; most lateral (VAN)
- covered with femoral sheath
- from lumbosacral plexus – arises proximal to
where the common iliac vessels
- appears in the thigh after crossing the inguinal
ligament
- many branching 1” below inguinal ligament:
a. muscular – Sartorius m., QF, pectineus m.,
iliacus m.
b. anterior/ intermedial femoral cutaneous
nerve
c. articualr branches to joints
d. saphenous nerve
o sensory, passes through the Hunter’s
canal joining the femoral artery and vein

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 o 2 big vessels near it will disappear at knee
region at the adductor hiatus
o provides sensation at the arterial aspect
of the knee joint
o can be destroyed during operation
because it is not that important
- nerve to the FOOT – PRESERVED!
- clinical correlation:
o DM – blood supply is compromised
o If (+) infection – healing process is slow
o regimen: shoes should be loose
5. Obturator nerve
- L2, L3, L4
- from lumbar plexus, anterior portion
- branches:
a. anterior – a. longus, a. brevis, gracilis
cutaneous nerve
b. posterior – a. brevis and 2/3 of a. magnus
- comes from somewhere in the pelvic region in the
vicinity of the obturator vessels
- clinical correlation:
o cerebral palsy
 brain injury due to delivery
 can be due to prolonged labor or forceful
delivery
 spasms, can’t control movement
 particular spasticity: seesaw gait
 hypercontracting knee
 obturator nerve – hyperactive
 treatment: cut obturator nerve or cut the
origin of the obturator group of muscle
SAPHENOUS HIATUS (FOSSA OVALIS)
- opening in the deep fascia
- 1” below medial end of inguinal ligament
- longer length than
- width – less than 1”
- structures passing through:
a. great saphenous vein
b. medial saphenous vein
c. lateral saphenous vein
d. 3 superficial vessels
e. lymph vessels
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ADDUCTOR HIATUS (HIATUS TENDINOSUS)
- adductor magnus opening
- structures passing through:
a. femoral arteries and vein
b. saphenous nerve
FEMORAL TRIANGLE
- boundaries:
superior: inguinal ligament
lateral: Sartorius muscle
medial: adductor longus
- floor (lateral to medial)
o iliacus m., pectineus m., adductor longus m.
- roof: deep fascia
- contents: artery, vein, nerve
- apex: femoral artery, femoral vein, adductor longus,
profunda femoris artery and vein
HUNTER’S CANAL
- muscular canal in midthigh
- from Scarpa’s triangle to adductor hiatus
- boundaries:
anterolateral: v. lateralis muscle
posterior: adductor longus (prox) to adductor
magnus (distal)
medial: intermuscular septa
anteromedian: Sartorius and subsartorius facsia
- a canal from which the femoral vessels passes
through from proximal up to distal portion
- structures that passes through:
o femoral artery and vein
o Saphenous nerve
- cc: area where you can practically ligate the femoral
artery and the entire limb can still be safe due to
collateral circulation, provided by profunda femoris
- if cut/ ligate before/ proximal to profunda femoris, it
will lead to compromised blood supply of the entire
LE
- femoral artery at this canal is covered by Sartorius
muscle
CLINICAL CORRELATION:
1. Congenital
a. CHD (congenital hip dysplasia/ dislocation)
  hip outside acetabulum  posterior – most common, once bumped
anterior to the knee
b. coxa plama  central
 flat, not rounded femoral head  anterior – rare
 problem in blood supply  treatment: hip replacement
 N: surface of the acetabulum and head of o indications: necrosis of the head and
femur is not directly in contact due to articular erosion of the bone towards pelvic cavity
cartilage which is transparent in x-rays o types:
 partial
2. Non-traumatic conditions  total – rim the acetabulum, lower
a. Infections: osteomyelitis shell and placed an implant anchored
 periosteal reaction and thickening of the to the medullary cavity of femur
periosteum laterally
 infection of the bone and in the medullary
contents of the bone b. Fracture injuries
 femoral head moves close to the acetabulum,  femoral neck fracture
no joint capsule, no more cartilage,  inter-trochanteric fracture
trabecualtion of the bone continuous with the  femoral shaft fracture
ilium
 infection of the cartilage (remnants) c. Vascular injuries
↓  arterial
scrape the necrotic tissue and fuse it  venous
↓
fused hip joint 4. Surgical procedures
a. Approaches
 lumbar spine compensates when moving  to the hip: anterior, posterior, lateral, medial
 to the shaft: ??????
b. osteoarthritis
 disrupted smoothness of the head and b. Amputations
acetabulum due to the destruction of the  fore-quarter amputation
articular cartilage  hip disarticulation
 can’t move hips (bone to bone movement)  amputation above the knee (high, mid, low)

c. cardiac catherization (diagnostic and therapeutic

“stent”)

d. hernias
 inguinal – abdominal contents thru inguinal
ring into scrotum
 femoral – abdominal contents thru inguinal
canal into femoral fossa

3. Traumatic conditions
a. Hip dislocation
 hip is dislocated centrally into the acetabulum

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 1. roof
o made-up of the skin and fascia
o fascia: superficial and deep popliteal fascia
o deep popliteal fascia – comes from the deep
fascia of the thigh/ FASCIA LATA

2. floor
o popliteal surface
o oblique popliteal ligament
o insertion of semimembranosus muscle
o popliteus muscle and fascia

- Boundaries:
1. femoral triangle
o medial side
 semimembranosus
 semitendinosus – consist mostly of the
femoral triangle

o lateral side
 biceps femoris muscle

2. tibial (lower) triangle

o medial side
 medial head of gastrocnemius muscle

o lateral side
 lateral head of gastrocnemius muscle
 beneath: plantaris muscle (counterpart
of palmaris longus in the upper
extremities) inserts in the heel of the
foot

POPLITEUS MUSCLE
- origin: within the capsule of knee joint
o lateral aspect of the lateral condyle of femur

- insertion: posterior aspect of the tibia above the

popliteal line

- course: tendinous origin passes downward and

backward, separates the lateral semilunar cartilage
from that of the lateral ligament of the knee joint
THE POPLITEAL FOSSA and inserts thru the inferolateral aspect of the
posterior aspect of capsular ligament
(Dr. Laygo)
- functions:
INTRODUCTION a. flexor of the leg
- diamond-shaped structure located at the posterior b. acts as a medial rotator of the tibia when the knee
aspect of the knee is flexed
- lozenge-shaped
- made up of 2 triangles: superior and inferior - nerve supply: medial (tibial) nerve
- Parts:

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CONTENTS OF POPLITEAL FOSSA: POPLITEAL NERVE
1. fat, popliteal vessels - tibial nerve
- serves as a cushion for popliteal vessels - common fibular/ peroneal nerve
- if (-) there's a higher tendency for PV to be injured
POPLITEAL LYMPH VESSELS
2. tibial and common fibular (peroneal) nerve - 6 popliteal lymph nodes located at the popliteal fossa
3. short saphenous vein - coming from the anterior and posterior lymphatic
4. posterior femoral cutaneous nerve of the posterior vessels
cutaneous nerve of the thigh - lymphatic vessels – run towards the femoral vein and
5. articular branch of the obturator nerve drains in the deep inguinal LN
6. popliteal lymph nodes
7. popliteal bursa SURAL NERVE
- cutaneous nerve coming from the common fibular
POPLITEAL ARTERY nerve and a part of the tibial nerve
- originates from the femoral artery (after crossing the - supplies the cutaneous area of the lower portion of
adductor hiatus) the legs and lateral aspect of the foot
- passes downward at the lower border of the
popliteus muscle eventually gives-off the terminal arrangement: AVN – artery being in the deepest portion
branches:
a. anterior tibial artery
Clinical significance: cystic lesion of the popliteal fossa
b. posterior tibial artery

GENICULAR ANASTOMOSES
- anastomosis around the knee joint
- anastomosis between the lower branches of the
femoral artery, branches of popliteal artery,
branches of anterior and posterior tibial artery
- above:
o medial side: descending branch of the medial
circumflex femoral artery anastomose with
medial branch of the superior genicular artery
branch of the popliteal artery
o lateral side: descending branch of the lateral
circumflex femoral artery anastomose with
lateral branch of the superior genicular artery
branch of popliteal artery

- below: inferior genicular artery

o medial side: medial branch anastomose with the
anterior tibial recurrent artery branch of
anterior tibial artery
o lateral side: lateral branch anastomose with the
posterior tibial recurrent artery branch of
posterior tibial artery
- middle genicular artery coming from the popliteal
KINESIOLOGY OF THE
artery anastomose with the middle collateral artery KNEE REGION
coming from the deep femoral artery
(Dr. Abiog)
POPLITEAL VEIN
- shaft – upper rounded
- union of the anterior and posterior tibial vein
- distal triangular – for weight bearing and stress
- joined by the short saphenous vein from the/ in the
resistance as in jumping and jogging
subcutaneous portion of the posterior aspect of the
- epicondyle vs. condyle? difference
thigh by penetrating the deep popliteal fossa

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 TYPE OF DIARTHRODIAL AND DEGREES OF FREEDOM

1. femorotibial joint – medial to lateral

- adductor tubercle - 1st reference as to type: “TROCHOGINGLYMUS”
- intercondylar fossa a. ginglymus (hinge)
o between lateral and medial condyle o medial and lateral femorotibial joint
o corresponds/ articulate with tibia o flexion-extension

- medial tibial plateau b. trochoid (pivot)

o landmark of the length of lower extremities o medial and lateral femorotibial joint
o some degree of rotation
- iliotibial band
o continuation of TFL - 2nd reference as to type
o cc: iliotibial band syndrome o condyloid or codylar type
 “snapping” syndrome
 once thickened band - 1st reference vs.
o ginglymus – elbow
- patella o pivot (trochoid) – neck
- gastrocnemius muscle
o long head - 2nd reference
o anterior to LH – short head o moves along the sagittal plane

- articularis genu (articular muscle) 2. patellofemoral joint

o origin: femur - plane (arthrodial or gliding)
o insertion: upper portion of the suprapatellar -
bursa PATELLA
o action: pulls up the suprapatellar tendon and - knee cap
retracts it during extension - a sesamoid bone in tendon of quadratus femoris
 protects suprapatellar bursa muscle
- flat and triangular
KNEE JOINTS - articular surface – smooth, divided by a ridge
- largest and most complex joint between into a larger lateral and smaller medial facet
- probably evolved from 3 separate joints
o in man, 1 single joint cavity but 3 separate LIGAMENT
articulation a. patellar ligament
- bone to bone relationship – ligament
- stability brought about by: o QF goes around the whole of patella even up
a. ligaments – 4 to the inferior pole → that makes it a tendon
b. muscles – 12 (muscle to bone relationship)
c. cartilage – lateral and medial meniscus b.(2) collateral ligament
d. condylar configuration – unique for femur and tibia - medial – tibial (TCL/MCL)
for stability of the knee o functions:
KINESIOLOGY OF THE KNEE JOINT  provides medial stability
 prevents lateral angulation (bending)
 check extension, hyperflexion and lateral
- 3 joints (articulation) articulating surface
rotation
o lateral tibiofemoral
o medial
- lateral – fibular (FCL/LCL)
o patellofemoral
o functions:
 provides lateral stability
- 1 joint capsule/cavity
 prevents medial angulation (bending)
o suprapatellar bursa
 checks hyperextension

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b. cruciate ligament
- anterior cruciate ligament
o one of the most important tendon of the body
o function:
 checks extension, lateral rotation
 prevents anterior slipping of tibia on
femur (or posterior displacement of femur
on tibia)

- posterior cruciate ligament

o checks flexion and lateral rotation
o prevents posterior slipping of tibia on femur
(or anterior displacement of femur on tibia)

note: collateral and cruciate ligament – major static

stabilizer of knee region

Clinical Correlation
- middle third of patellar ligament/ tendon
o use to replace torn ACL
o reconstructive surgery

c. other ligaments
- oblique popliteal ligament
o related to semimenbranosus from lateral
femur, over condyles to posterior head of tibia
o checks extension

- ligament of Wrisberg
MENISCUS
o a.k.a. post. meniscofemoral ligament
a. medial meniscus
- crescent-shaped (oval)
- arcuate popliteal ligament
- deepens medial tibial condyle
o related to popliteus muscle origin
- more commonly injured
o from lateral condyle of femur to styloid o 7-8x than lateral
process of fibula o longer and less securely attached
o check medial rotation of leg
o force applied to the lateral side

- coronary ligament
b. lateral meniscus
o from capsule to periphery of menisci and tibia
- nearly circular
o helps hold menisci in place - deepens lateral tibial condyle

- transverse ligament MUSCLES CONTROLLING THE KNEE JOINT

o interconnects anterior parts of 2 menisci
- dynamic stabilizer

BURSA
1. Quadra
a. rectus femoris muscle
- biarticular
- kicking muscle
- origin: AIIS
- insertion: patellar ligament and tibial tubercle
- action: knee extension and hip flexion

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 o insertion: middle post. Calcaneus
b. vastus medialis muscle
c. vastus lateralis muscle KINESIOLOGY OF THE KNEE JOINT
d. vastus intermedius muscle
b, c, d - 1ST 20° of flexion
o unlocking mechanism of knee by popliteus
monoarticular muscle
origin: linea aspera o gliding motion

2. - at 40°, rocking motion

hamstrings
a. semimembranosus muscle o with a drag by the posterior cruciate ligament
b. semitensinosus muscle
insertion: pes anserinus - further, rolling motion
- moving from a flexed position to extension
c. biceps femoris muscle – short and long head o last 20°of extension, tibia externally rotates into
insertion longhead: Gerdy's tubercle its “screw-home mechanism”

- dancing joint
origin: iliac tubercle
SUMMARY OF KNEE ACTIONS
innervation:
*tibial nerve – all except short head of FLEXION
BFM - semimembranosus muscle*
*common peroneal nerve – short head - semitendinosus muscle*
of BCM - biceps femoris muscle*
- sartorius muscle
action: flexion of knee, extension of hip
- gracilis muscle
medial hamstring – medial rotation - popliteus muscle
lateral hamstring – lateral rotation - gastrocnemius muscle
- plantaris muscle
3. unclassified
- inserts in all places and are not protected EXTENSION
a. Sartorius muscle – O: AIIS Quadratus femoris muscle
b. Gracilis muscle – medial compartment - rectus femoris muscle
c. Popliteus muscle – from popliteal fossa - vastus medialis muscle
o origin: TRIPARTITE TENDON OF THE POPLITEAL - vastus lateralis muscle
 arcuate popliteal ligament - vastus intermedius muscle
 lateral femoral condyle
 fibular head
INTERNAL ROTATION
 posterior horn of lateral meniscus
proximal attachment - popliteus muscle
- semimembranosus muscle
- sartorius muscle
- gracilis muscle
o insertion: post. Tibia above soleal line – distal
attachment EXTERNAL ROTATION
o nerve supply: tibial nerve - biceps femoris muscle
o action: internal rotation of tibia and
withdraws lateral meniscus ONE JOINT AND TWO JOINT
- monoarticular
d. Gastrocnemius muscle – from the leg o semimembranosus
e. Plantaris muscle o vastus lateralis muscle*
o origin: lower lateral supracondylar line o vastus intermedius muscle*

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 o popliteus muscle* - upper course: lies beneath the muscle of
o biceps femoris muscle – short head anterior compartment
- lower course: lies superficially in front of lower
- biarticular end of tibia, behind superior extensor
o rectus femoris muscle retinaculum
o sartorius muscle
- medial side: tendon of extensor hallucis longus
o gracilis muscle
- lateral side: extensor digitorum longus, deep
o semimembranosus muscle*
o semitendinosus muscle* peroneal nerve
o biceps femoris muscle – long head* - terminates in front of ankle joint → dorsalis
o gastrocnemius muscle pedis artery
o plantaris muscle - branches:
o anterior and posterior tibial recurrent artery
o medial and lateral anterior malleolar artery

b. posterior tibial artery

NEUROVASCULAR STRUCTURES
OF THE LEG
(Dr. Laygo)
POPLITEAL ARTERY
- commences as it pass through adductor hiatus
- passes under fibrous arch of Soleus
- at lower border of popliteus, it divides into
a. anterior tibial artery
- smaller terminal branch of popliteal artery
- course: passes forward → interosseous
membrane → descends on anterior surface of
interosseous membrane
- accompanied by deep peroneal nerve
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- bigger terminal branch of the popliteal artery
- begins at lower border of popliteus muscle
- downward deep to gastrocnemius muscle,
soleus, deep transverse fascia of the leg
- lies on posterior surface of tibialis posterior
muscle above
- below : posterior surface of tibia
- tibial nerve: lies first on medial side then crosses
posteriorly to posterior tibial artery and to its
lateral side
- at the lower part of the leg: posterior tibial
artery lies in front of medial border of
tendocalcaneus
o passes behind med. malleolus deep to flexor
retinaculum
- terminates as medial and lateral plantar arteries
- separated from the medial malleolus by the ff:
o tendon of tibialis posterior
o tendon of flexor digitorum longus
- branches:
1. fibular (peroneal) artery
o muscular branches
o nutrient artery to the fibula
o largest and most important branch of
posterior tibial artery
o begins inf. to the distal border of the
popliteus muscle and tendinous arch of
soleus
o descends obliquely towards the fibula
and passes along the medial side of the
fibular bone within the flexor hallucis
muscle or between fibular bone and the
 intermuscular septum and tibialis
posterior muscle
o located either within hallucis muscle →
above
 downward: intermuscular septum
and tibialis posterior muscle
o muscular branches: going to popliteus
and muscle of the posterior and lateral
compartments of the legs
o communicating branch: connects
peroneal artery to that of the posterior
tibial artery
o anastomosing branch to cruciate artery
 posterior tibial artery pierces to the
intermuscular septum and passes
towards dorsum of foot and
eventually anastomose to the
cruciate artery (branch of dorsalis
pedis artery)
2. circumflex fibular artery
o arises from posterior tibial artery at the
knee and passes lateral over to the neck
of the fibula to eventually anastomose
with the vessels around the knee joint
3. nutrient artery of the tibia
o provides nutrient to the tibial bone
o passes through the nutrient foramen
o largest artery in the human body
o nutrient foramen of tibia
 located just distal to the soleal line
in the posterior aspect/ surface of
the tibia
4. calcaneal artery
o supplies the heel region or
tendocalcaneous region of the leg
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o passes medial and posterior to the
tendocalcaneous and eventually
anastomose with the branches of the
fibular artery
5. malleolar artery
o join the network of vessels in the
medial malleolus
o posterior malleolar branch anastomose
with the anterior malleolar branch of
the anterior tibial artery
TIBIAL NERVE
- supplies posterior compartment of leg
- lower terminal branch of sciatic nerve
- origin: anterior branch of ventral rami (L4 – S3)
- course: descends thru the middle of popliteal fossa
→ posterior to popliteal artery and vein
- distal popliteus → deep to tendinous arch of soleus
muscle → medial plane of calf (deep to soleus)
- runs inferior to tibialis posterior muscle with
posterior tibial vessels → leaves posterior
compartment of leg → flexor retinaculum
- in distal portion of the leg
o between medial malleolus and calcaneus muscle
lies between posterior tibial vessel and tendon
of flexor hallucis longus muscle
- postero-inferior to medial malleolus → medial and
lateral plantar nerves → terminal branches of tibial
nerve
o gives branches to all muscle of posterior
compartment of legs
- cutaneous branch
o medial sural cutaneous nerve unites with the
communicating branch of the common
peroneal nerve → 2 main origin of the sural
nerve
o SURAL NERVE
 supplies the skin of the lateral and posterior
parts of the inferior third of the leg and
lateral side of the foot
- articular branches: supplies knee joint
 - terminates as medial calcaneal nerve supplying the
skin of the heel region including the weight-bearing
surface
- clinical correlation: laceration of popliteal fossa and
posterior dislocation of knee joint may damage tibial
nerve
o may cause paralysis of all muscle in the posterior
compartment of the leg and intrinsic muscle of
the sole of the foot
o manifest as: paralysis of plantar flexion of the
foot
COMMON PERONEAL NERVE
- lateral and smaller branch of sciatic nerve
- course: passes over the posterior aspect of the head
of the fibula
- clinical correlation: (+) fracture at the head of fibula
o CPN courses around neck of fibula
o if injured: (+) paralysis
 inability of dorsiflexion or eversion of the
foot
 manifest as foot drop
 stepping gait = foot is raised higher than
is necessary so the toes does not hit the
ground
 foot is brought down suddenly
- branches:
a. deep peroneal nerve
o nerve of the anterior crural compartment
o supplies all the muscle of the anterior
compartment of the leg as well as articular
branches to the ankle joint
b. superficial peroneal nerve
o nerve of the lateral compartment of the leg
o lies anterolateral to the fibula between the
fibular muscle and the extensor digitorum
longus
o supplies the peroneus muscle and then it
pierces deep into the deep fascia to become
superficial in the distal 1/3 of the leg
o it passes in the superficial fascia to supply
the skin in the distal part of the anterior
surface of the leg nearlt all the dorsum of
the foot and most of the digits
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CUTANEOUS NERVE OF LEG
1. lateral sural cutaneous nerve
2. superficial peroneal nerve
3. saphenous nerve
4. posterior cutaneous nerve of the thigh
5. medial sural cutaneous nerve
6. sural nerve
VENOUS DRAINAGE OF LEG
1. venae comitantes of the anterior and posterior tibial
arteries
- a.k.a. anterior and posterior tibial veins
- unite together to form popliteal vein
- numerous small vessels in the medial aspect of
the leg will become great saphenous vein
- the short saphenous vein which usually starts at
the lateral venous arch of the foot → will
eventually pierce the deep fascia and terminates
at the popliteal vein
2. numerous small vessels on the posterior aspect of
the leg
3. communicating veins of the deep veins of the foot
4. anastomosing branch that runs upward and medially
to join the great saphenous vein
LYMPHATICS
- the greater part of skin and superficial fascia infront
of legs
- lymphatics goes upward and medially towards the
great saphenous vein and drains vertical group to
superficial inguinal LN
- lymphatics in the upper lateral part of the front of
the leg will eventually pass through the short/ small
saphenous vein and eventually drains into the
popliteal LN
 o when in flexed position – overhang of the
lateral condyle/ superior extension of the
lateral condyle
 important in stabilizing the patella

 anterior view: presence of a depression

 intercondylar sulcus or the trochlear
groove – accommodates the patella

 posterior view
 2 condyles are separated by intercondylar
notch
 attachment by: 2 cruciate ligament,
ligamentum mucosum (intrapatellar
fold), meniscofemoral ligament
(Ligament of Wrisberg, Ligament of
Humphrey)

2. PROXIMAL TIBIA

 tibial condyle/ tibial plateau

 lateral view:
 downward inclination – 7-10 ˚
(anterior to posterior)
 therefore not flat, not straight
 important in maintenance of
tibiofemoral joint, if (-) excessive
hyperextension

 with 2 articular surface – separated by

intercondylar area
a. lateral – smaller (AP – convex), dome-
shape
THE KNEE  important in “screw-home
(Dr. Tanyee) mechanism”

b. medial – flattened, wider

- very remarkable in structure (anatomically,
biochemically)  intercondylar area
- most vulnerable and complicated joint  devoid of articular cartilage
- most exposed part to excessive forces  divided into anterior and posterior
- 3 osseous part: intercondylar area
1. DISTAL FEMUR  with tibial spines/ eminences
o consist of
 divided into:
a. lateral femoral condyle a. lateral tibial spine -
 longer in terms of AP width and posteriorly placed
medial to lateral width b. medial tibial spine -
anteriorly placed
b. medial femoral condyle
 no structures attached in the
o 2 surfaces: tibial spine
a. anterior - oval-shape  functions:
b. posterior - spherical in shape a. prevents translation of
femur
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 b. protects the attachment of a. outer superficial layer
ligaments (ACL and anterior  forms the deep fascia which encloses the
and posterior horn of pes anserinus
menisci)
b. middle layer
3 JOINTS:  superficial medial collateral ligament
a. lateral tibiofemoral joint
b. medial tibiofemoral joint c. deep layer
a and b – hinge joint  deep layer of the medial collateral ligament

c. patellofemoral joint – gliding/ plain joint o lateral side

 most unstable joint in the body a. outer layer
 deep fascia of the thigh
knee-joint motion:  iliotibial band
o hyperextension – 10˚  biceps femoris muscle
o internal/ external rotation – 8 to 12˚  lateral patellar retinaculum
o full flexion – 140˚(posterior part of the leg and femur
touches one another) b. middle layer
- superficial lateral collateral ligament
3. PATELLA - left inferior genicular vessels
 largest sesamoid bone
 situated within the quadriceps tendon a. deep layer
 has an apex and a base - popliteus tendon
 with 4 surfaces - capsule
a. anterior surface - triangular - deep component of the fibular (lateral)
b. articular surface – oval collateral ligament
 divided into seven facets theoretically
 divided by a vertical/ medial ridge STATIC STABILIZERS
(lateral and medial)
1. extracapsular ligament (anterior to posterior)
 most medial facet: ODD FACET
 Wiberg classification:
a. ligamentum patella/ patellar notch
TYPE 1 – vertical ridge divides articular
 formed by the tendon of rectus femoris
surface into 2 equal facets
muscle as it precedes distally
TYPE 2 – 2 unequal facets
b. capsule
lateral much bigger than
 surrounds the entire knee except anteriorly
medial facet
where the capsule is replaced by the patella
TYPE 3 – medial facet no longer
and ligamentum patella
recognizable
TYPE 4 - odd facet
c. medial collateral ligamentum
 superficial and deep
o leg in extension – inferior pole of patella
 attachment: from lateral condyle of femur to
touches the femoral condyle
the proximal aspect of the tibia
o 45˚ flexion – facet in contact with the femoral
 7 cm below the joint line (distal extension
condyle
of the MCL)
o 140˚ flexion – odd facet in contact with femoral
condyle
 valgus stabilizer of the knee joint (primary
restraint)
LIGAMENTOUS RESTRAINTS OF KNEE JOINT
o deep fascia
d. lateral collateral ligament
o capsule – ligaments can be intracapsular,
 from the lateral femoral condyle to the
extracapsular, or intracapsular but extrasynovial/ fibular head
intrasynovial
 varus stabilizer of the knee joint
o medial side of the knee with 3 layers:

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 e. posteriorly: oblique popliteal ligament
 distal expansion of the semimembranosus
muscle and inserts to tibia
 reinforces/ strengthens the capsule
posteriorly
2. intracapsular but extrasynovial ligament
a. anterior cruciate ligament
 from medial aspect of lateral condyle and into
the anterior intercondylar area
 consists of 3 bundles that are intertwined with
each other
 function:
 prevents forward displacement of the
tibia in relation to the femur
 prevents backward displacement of the
femur in relation to the tibia
 secondary valgus stabilizer
 prevents excessive hyperextension
 helps in stability during internal rotation
b. posterior cruciate ligament
 from lateral surface of the medial condyle,
inserts into the posterior intercondylar area
 functions:
 prevents backward displacement of tibia
in relation to femur
 prevents forward displacement of femur
in relation to tibia
3. intracapsular but intrasynovial ligament
MENISCUS
 divided into:
a. lateral – almost circular in shape
- not in contact with fibular (lateral)
collateral ligament because of the
presence of popliteus tendon
- with 2 horns:
 anterior horn
 attached to the intercondylar
area behind the anterior cruciate
ligament
 posterior horn
 attached to intercondylar area in
front of posterior cruciate
ligament
b. medial – C-shape
- fixed because it is attached with the
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medial collateral ligament
- anterior horn – inserted to the anterior
intercondylar area anterior to ACL
- posterior horn – inserted to the posterior
intercondylar area anterior to PCL
note: 2 menisci (lateral and medial) – connected by the
transverse ligament of the knee
clinical correlation
- most commonly injured in multidirectional injury/
acute injury of the ACL: lateral meniscus
- chronic insufficiency of the ACL – injury of medial
meniscus
 attached to tibia via coronary ligament (THOREK –
attached to the tibia and femur)
 function:
a. increases the depth of tibial condyle
b. shock-absorber
 cross-section: triangular in shape
 divided into 2 zones:
 outer 1/3 – red zone; vascular
 inner 2/3 – white zone; avascular
 meniscofemoral ligament
- Ligament of Wrisberg – seen from behind
- Ligament of Humphrey – located anterior to
the PCL
 this serves to attach the posterior horn of
the lateral meniscus ton the medial
femoral condyle that passes anterior to
the PCL
- connects meniscus to the femoral condyle
OTHER STRUCTURES
1. fat pad
 believed to supply BV to femoral condyle
 intrapatellar fold
 connects the fat pad into the intracondylar
notch
2. synovial/ plica
 normal embryonic synovial septa that may
persist in adult life
 median patellar fold
 ligamentum mucosum
 superior patellar plica
 displacement: clicking sensation
BURSAE
- synovial lined tissue located between 2 rubbing 1. access integrity of cruciate ligament
strucures to minimize friction and attrition
ANTERIOR CRUCIATE LIGAMENT
1. anterior bursa a. anterior drawer's test
- 90˚ knee-flexion
a. prepatellar bursa
- between the inferior pole and proximal part of b. lachman's test
the tendon - 30-40˚ knee flexion
- irritation: housemaid's knee - more sensitive than Drawer's test

b. superficial infrapatellar bursa POSTERIOR CRUCIATE LIGAMENT

- located anterior to the distal part of the a. posterior drawer's test
ligamentum patella - elevate the leg with 90˚ hip flexion, 90˚ knee
flexion
c. deep infrapatellar bursa - if complete tear – leg will drop
- located between proximal tibia and - or push leg posteriorly
ligamentum patella - frank injury – will sag

d. suprapatellar bursa 2. access integrity of collateral ligaments

- attached to genu articularis
- has a communication with the knee joint MEDIAL COLLATERAL LIGAMENT
- valgus stress test
2. posterior bursa - flex the knee 30-40˚
- located between the 2 heads of gastrocnemius - stabilize the knee on one side, grab the foot
- move towards the outside
a. popliteal bursa - it determines also if ACL is injured
- between lateral head of gastrocnemius and
popliteus tendon LATERAL COLLATERAL LIGAMENT
- if distended: popliteal cyst (herniation of the - varus stress test
popliteal bursa) - reversed

b. semimembranosus bursa 3. access integrity of menisci

- between medial head of gastrocnemius and
semimembranosus muscle - MacMurray's test
 knee-flexion; pushed the leg
- a and b normally communicates with the knee  internally and externally rotate the leg while
joint the knee is in flexion

3. medial bursa  if there is a palpable or audible click – injured

a. between pes anserinus and tibial collateral meniscus
ligament  locking sensation of the knee
b. between the semimembranosus muscle and tibial
collateral ligament UNHAPPY TRIAD OF THE KNEE: (tear of)
c. between semimembranosus muscle and tibia a. medial collateral ligament
b. medial meniscus
4. lateral bursa c. ACL
a. between the biceps femoris tendon and fibular
collateral ligament BONES OF THE LEG
b. between the popliteus tendon muscle and lateral - consists of 2 joints: proximal and distal tibiofemoral
collateral ligament joint
c. between the popliteus tendon muscle and femoral - with 4 compartments: divided by intermuscular
condyle compartment
a. 1 anterior – extensor group
PHYSICAL EXAMINATION b. 1 lateral – everter group

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 c. 2 posterior – flexor group  enclosed by a capsule and reinforced by:
1. anterior superior tibiofibular ligament
- each compartment has its own nerve and blood 2. posterior superior tibiofibular ligament
supply
- tibia and fibula – almost equal in length b. distal tibiofibular joint
a. tibia – medial  syndesmotic type or fibrous type: no motion
b. fibula – lateral  stabilized by:
1. anterior inferior tibiofibular ligament or
- long bone has 3 parts: anterior syndesmotic ligament
2. posterior syndesmotic ligament
METAPHYSIS 3. inferior transverse ligament
a. proximal metaphysis – tibial plateau 4. interosseous ligament
 anterior: tibial tubercle, ligamentum
patella INTEROSSEOUS MEMBRANE
 lateral to this: Gerdy's tubercle and - arises from interosseous border of the tibia down
insertion of iliotibial band and lateral to the fibula
 posterior: fossa for semimembranosus - 2 openings
 lateral aspect of tibial condyle, facet for
a. superior – where anterior tibial vessels will
articulation
enter to the anterior compartment and vein
from anterior to back
b. distal metaphysis: metaphyseal flaring
 distal plafon b. inferior – for the perforating branch of peroneal
1. medial malleolus artery from behind going anteriorly
2. lateral malleolus
- distal tibiofibular ligament: continuation of
DIAPHYSIS interosseous membrane
 shaft – triangular in shape
 3 borders and surfaces

EPIPHYSIS

5 SURFACES OF TIBIA CIRCULATORY SYSTEM OF THE LOWER

LEG
a) medial – medial malleolus
b) 1 anterior (Dr. Laygo)
c) 1 lateral – articulates with distal part of fibula
d) 1 posterior - (+) groove for tibialis posterior tendon POPLITEAL TRIFURCATION
e) 1 articular surface
 plafone – wider anterior than posteriorly
Popliteal Artery
 AP view: concave
 medial to lateral view: convex
 CHAPUT'S TUBERCLE – attachment of anterior
syndesmotic ligament
anterior tibial artery posterior tibial artery
- majority of the weight is born by the tibia
- fibula: 17% (maintain stability of the ankle joint)

2 JOINTS post. tibial fibular artery

a. proximal tibiofibular joint
 synovial type
branches
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  has a medial and lateral branches
post. medial malleolar posterior lateral malleolar located at the medial and lateral
medial calcalneal a. lateral calcaneal a. side of the toes
 supplies the adjacent side of the
toes
DORSALIS PEDIS ARTERY
- continuation of anterior tibial artery  4th dorsal metatarsal artery gives off
- opposite the ankle joint additional branch to the lateral side of
- course: directed forward across the dorsum of the the 5th toe
foot to the proximal end of the 1st Intermetatarsal
space dorsal metatarsal artery
- terminates into:
o 1st dorsal metatarsal artery gives branches into
o deep plantar artery small post. perforating branch anterior perforating branch
↓ anastomose with ↓
- lies against the bones and ligaments of the dorsum plantar arch plantar metatarsal artery
- crossed near its termination by the tendon of EHB
muscle 4. 1st dorsal metatarsal artery
- accompanying structure: o same with the other dorsal metatarsal
o at its lateral side: medial branch of the deep artery which divides into 2 to supply the
peroneal nerve adjacent side of the 1st and 2nd toes
o 2 venae comitantes o gives-off a branch which crosses the 1st
metatarsal bone beneath the tendon of EHL
- Branches: to supply the medial side of the great toe
1. lateral tarsal artery
o arises over the navicular bone and supplies note: it is believed that the posterior perforating
the EDB muscle branch will eventually enlarged to become the deep
o anastomose with the branches of arcuate plantar artery
artery, anterior lateral malleolar artery,
lateral plantar artery and the perforating 5. deep plantar artery
branches of fibular artery o continuation of the dorsalis pedis artery
2. medial tarsal artery o enlargement of post. perforating branch of
o composed of 2 or 3 branches which ramify 1st dorsal metatarsal artery
in the medial border of the foot o course: descends into the sole of the foot
o anastomose with the medial malleolar bypassing between the 2 heads of origin of
artery the 1st dorsal interosseous muscle
o unite with the lateral plantar artery forming
3. arcuate artery the plantar arch
o largest branch o deep plantar + lateral plantar artery =
o arises at the level of the bases of the plantar arch
metatarsal bones
o beneath the tendons of EDL and EDB muscle PLANTAR ARTERIAL ARCH
o anastomose with the lateral tarsal and - comparable with the deep palmar arterial artery
lateral plantar arteries - continues with the lateral plantar artery and
o gives-off 3 dorsal metatarsal artery completed medially by its union with the deep
plantar artery of the dorsalis pedis artery
- 80% of cases, formed primarily by the deep plantar
2 dorsal digital artery of the dorsalis pedis

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 - usually convex forwards and lies across the bases of a. communicating fibular artery
the metatarsal bones and the origin of the b. posterior tibial artery
interosseus muscle c. perforating branch of fibular artery
- plantar side: located deep into the adductor hallucis d. anterior lateral malleolar artery
muscle
- gives off: 4. malleolar anastomosis
a. 4 plantar metatarsal artery - around medial and lateral malleolus
b. 3 perforating artery
c. twigs to the tarsal joints and muscle of the a. medial malleolar artery especially anterior medial
compartment malleolar artery
d. pair of plantar digital artery b. anterior lateral malleolar artery anastomose with
posterior malleolar artery which divides into lateral
ANASTOMOSIS and medial branch
1. cruciate anastomosis c. medial tarsal artery
- around the hip joint d. medial calcaneal artery

a. inferior gluteal branch of the internal iliac artery 5. anastomosis at lateral dorsum of foot
anastomose with the medial and lateral circumflex a. perforating branch of fibular artery
artery of the femoral artery b. lateral anterior malleolar artery
b. obturator artery anatomose with medial femoral
circumflex artery - important in obstruction – serves as collateral
c. pubic branch of obturator artery + pubic branch of circulation
the deep inferior epigastic artery
d. external pudendal artery + internal pudendal VENOUS DRAINAGE
artery - lateral malleolar side
o lateral venous plexus join to form the short
- cc: obstruction of femoral artery at proximal part saphaneous vein → popliteal vein
of the thigh → cruciate anastomosis will take over
- medial malleolar side
o dorsal venous arch → join together to form the
great saphenous vein
2. genicular anastomosis RADIOGRAPH OF LOWER LEG
- around the knee joint
a. descending branch of the lateral femoral
(Dr. Aragon)
circumflex artery
b. descending genicular branch of femoral artery DIFFERENT MODALITIES
c. popliteal artery → medial superior genicular - x-ray
artery, lateral superior genicular artery, medial o 2 dimensional – ht and wt (no depth)
inferior genicular artery, lateral inferior genicular o determine alignment of bones
artery and middle genicular artery o very little help in smooth tissues, arteries and
from below: veins
d. posterior tibial recurrent artery – from anterior o 90% used in bones
tibial artery)
e. circumflex fibular artery – from posterior tibial - determine metals present
artery o wires, metallic pins
f. anterior tibial recurrent artery o metal fixator
o metal screw – small compared to actual size
3. anastomosis above tibio-fibular syndesmosis

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 - determine fractures o towards transducer – red
o deformities forms bony bridge/ bony calus o away from transducer – blue
o color comes on and off depending on
respiration of patient (whether inspiration/
expiration)

 anatomically, the pulsation of artery corresponds

- AP view + lateral view = right angle (90˚ relationship)
- BV, muscles, ligaments, tendons, LN – not visible
- usefulness:
o calcified bones
 cartilaginous structures– radioluscent
 small rounded bones defects – determine
previous location of metabolic screw
o determine alignment of joints, not for soft
tissues
to pulsations of the heart
 pulsation of vein – doesn’t correspond to heart
pulsation
 compression of transducer of artery and vein
o little pressure – collapse of vein
o carotid – more resilient vs jugular vein – easy
to collapse
 color flow doppler can also be used in examining
ligaments, tendons and parts of muscles
 not always 100% correct

- repair: bone 2. Arteriogram

o if artery is severed - no point of repair – so  principle: use needle tip → into lumen → inject
amputate radioactive material (H2O soluble iodine) → get
o extensive fracture – tissue unperfused radiographs → made easier with continuous CINE
o physical assessment: inspect, percuss, palpate, imaging (like video) to determine:
auscultate o continuity of blood supply
o inspect color o leakage
 dark gray/ cyanotic o where to amputate
 pinkish – good blood supply o if leg can still be saved

o palpate – dorsalis pedis artery 3. CT angiography

 where to detect pulsation  done in 10-15 minutes
 equal on both right and left – good arterial 4. MRI angiography
flow  utilized magnetism
 swollen – difficult to palpate arteries  adv: no contrast material needed
 disadv: longer time (30 min or more), cant be used
IMAGING EXAMINATION if patient has metallic implants such as screw
1. Color Doppler UTZ
 with color flow detector 5. Nuclear imaging
 (+) blood flow – show as color signal through that  not use to idenfity antomic structures
vessel  can determine abnormalities such as infections and
 blood flow: from femoral artery → popliteal artery malignant tumors
→ tibial artery → dorsalis pedis  can determine tumor and infection earlier
 right and left can be comopared compared to conventional x-ray
 arteries with accompanying veins
 show color signal which is red and blue (but the 6. Ultrasound
equipment will not tell us whether red is artery or  younger age group
blue is vein) o babies in utero/ to be delivered
 color – dependent on direction of blood flow
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 o mother is examined – determine AOG of the  if more than 1 cm, (+) accumulation of
baby synovial fluid 2˚ to infection, tumor, hge d/t
o determine age of baby especially 2nd and 3rd trauma
trimester using skeletal system particularly:
 calcarium (head) FOOT
 femur  “dorsoplantar” view
 length of tibia  overlap of distal tibia and fibula
 examine talus and calcaneus – sep. lateral radiograph
o biometry of fetuses and ankle joint
 38th weeks – distal femoral epiphysis  determine fracture – difficult to determine talus and
 36th weeks – proximal tibial ossification calcaneus
center  CT – more sensitive
 clinical correlation:
 determine if baby is mature or immature during o ↓ - BOEHLER’S ANGLE
the time of birth o not less than 28˚
o scrotum – darker than skin with wrinkles – o if less than – history of trauma, (+) fracture
beyond 38th week (mature)
o at birth – 2 ossification centers NOTE: not all things that are normal and abnormal are
 calcaneus shown by imaginf modalities
 talus
 hand – capitate (2nd and 3rd mos)

 chronological age should correspond to skeletal

maturation
o epiphysis – open – (+) growth
o if close – (-) growth
 can be lengthened through surgical
procedure

KNEE
 AP and lateral view
 special views needed because if AP view only difficult
to evaluate and can’t determine precise sunrise view ANATOMY OF THE LEG
 special view: SKYLINE VIEW/ SUNRISE VIEW (Dr. Abiog)
o for patella – flexed knee and put radiographic
facet BONE
o behind patella – (+) patellofemoral jt space 1. Tibia
o fabella – present in 10% of all normal knees  shin bone
 normal anatomical variant, small cousin of  2nd largest bone (femur – largest)
patella  proximal – medial and lateral condyles
 ossification – close to posterior margin of  shaft – anterior border
femoral condyle, about 1 cm o broad, convex, smooth medial surfaces and
lateral interosseous border

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  lower – medial malleolus, articular surface for
talus, posterior groove of FHL
2. Fibula
 calf bone
 most slender of lone bones
 proximal – head with superior articular surfaces
(styloid process)
 shaft – 3 borders and 3 surfaces
 distal – lateral malleolus
note: tibiofibular joint IS NOT a part of knee joint
- interosseous membrane forms part of the joint
JOINTS
1. Superior tibiofibular joint
 diarthrodial type = gliding type
2. Interosseous membrane
 type of joint: synarthrosis or syndesmosis
 fiber inclined downward and lateralward from the
lateral border of tibia to anteromedial border of
fibula
3. Inferior tibiofibular joint
 type of joint: syndesmosis
 not gliding because of the presence of 4 ligaments:
o anterior inferior tibiofibular ligament
o posterior inferior tibiofibular ligament
o interosseous ligament (main reason for being
syndesmosis)
o inferior transverse ligament
 spasms of ankle does not injure the ligament
clinical correlation: high ankle sprain
- the ligaments are destroyed = longer pain than the
normal ankle sprain where the ligaments are not
destroyed
- test: Squeeze Test
o if there is a tear, the distal portion opens up
o injuries all stabilizing/ supporting lig.
COMPARTMENTS OF THE LEG (12 muscles)
1. anterior (4)
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 bounded by tibia, fibula, interosseous membrane,
anterior intermuscular septum
a) tibialis anterior
 nearest to tibial bone
 insertion: medial and inferior surfaces of
medial cuneiform and base of 1st metatarsal
 action: dorsiflexes ankle, inverts foot
 innervation: deep fibular (peroneal) nerve (L4
and L5)
b) extensor digitorum longus
 insertion: middle and distal phalanges of
lateral four digits
 action: extends lateral 4 digits and dorsiflex
ankle
 innervation: deep fibular (peroneal) nerve (L5-
S1)
c) extensor hallucis longus
 insertion: dorsal aspect of base of distal
phalange of great toe
 action: extends great toe and dorsiflex ankle
 innervation: deep fibular (peroneal) nerve (L5-
S1)
d) fibularis tersius
 insertion: dorsum of base of 5th metatarsal
 action: dorsiflexes ankle and aids in eversion
of foot
 innervation: deep fibular (peroneal) nerve (L5-
S1)
clinical correlation: most dangerous compartment -
presence of BV and nerves
o swelling – impingement of structure
o impingement of anterior tibial nerve or deep
peroneal/ fibular nerve
o treatment: FASCIOTOMY – opening of the fascia to
treat the underlying impingement of the nerve/
artery
2. lateral compartment (2)
 action: foot eversion, weak plantarflexor
a) fibularis longus
 insertion: base of 5th metatarsal and lateral
cuneiform
  bigger flexor digitorum longus
- medially located
b) fibularis brevis - inserts in the lateral 4 digits
 insertion: dorsal surface of tuberosity of
lateral side of base of 5th metatarsal tibialis posterior
 smaller - distal attachment: tuberosity of navicular,
cuneiform, cuboid and bases of 2nd, 3rd
3. posterior compartment (6) and 4th metatarsals
- transverse intermuscular septum – divides it into *because of these insertions – it anchors
superficial and deep muscle of the leg

a) superficial (3) - dynamically speaking, it is responsible for

insertion: posterior surface of calcaneus via the medial arch
calcaneal tendon - weakness: flatfootedness, pronated foot,
innervation: tibial nerve (S1 and S2) pes planus
triceps surae: Runner’s leg – strain of tibialis posterior
o head of gastrocnemius
o head of soleus - 2 main action:
o head of plantaris o plantar flexor – passes behind the
medial malleolus > ankle joint
gastrocnemius o foot invertor – because it is medially
- 2 heads from condyles of femur (lateral located
and medial)
- biarticular muscle – crosses knee and flexor hallucis longus
ankle joint - laterally going to medial
- action: plantar flexor - inserts to the big toe
if foot is anchored on ground = knee - origin: lateral portion of the leg
extensor
if foot is free = knee flexor

plantaris
- in between gastrocnemius and soleus
- 2-4 in long
- tendon is the one seen during dissection
(longer than the muscle)
- action: plantar flexor (effect is weaker as ANKLE AND FOOT
compared to gastrocnemius)
(Dr. Abiog)
- biarticular component: crosses knee and
ankle joint
TARSAL (7)
- at lateral supracondylar bone
 Talus – ankle bone
- insertion: calcaneus
 Calcaneus – heel bone
 Navicular – boat-shaped
soleus
- monoarticular  Cuboid
- action: plantar flexor and stabilizes the  3 Cuneiform (medial, intermediate, lateral) – wedge
foot or ankle shape

b) deep compartment METATARSAL (5)

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PHALANGES (14) o sensitive to pressure, swelling, BS:
impingement of the posterior tibial nerve
JOINTS o TARSAL TUNNEL SYNDROME
a. talocalcaneal/ subtalar joint
b. talonavicular joint ANKLE JOINT
c. calcaneocuboid joint
d. tarsometatarsal joint a. TALOTIBIAL (TALOCRURAL, ANKLE MORTISE) JOINT
e. metatarsophalangeal joint  talus articulates with the distal tibia
f. interphalangeal joint  bones:
g. proximal interphalangeal joint 1. medial malleolus – distal continuation of the
h. distal interphalangeal joint tibia

RETINACULUM 2. lateral malleolus – distal continuation of the

1. Extensor retinacula fibula
 holds extensor tendon in place  neck (fibula) – where common peroneal
 prevents bow stringing of the tendons nerve will hook around
 lower
a) superior (transverse crural)
b) inferior (cruciate crural) 1 and 2 grips the talus
- superficial – Y-shape
- deep 3. talus
 mechanical keystone at the apex of the
2. Fibular (peroneal) retinaculum foot
 lateral aspect  a.k.a. ASTRAGALUS
 holds the fibularis muscle (brevis and longus) in  peculiarity – no muscle inserted here
place  3 parts:
 superior fibular retinaculum – prevent a) head – in front, articulates with
bowstringing navicular and calcaneus forming
 inferior fibular retinaculum – joins the superior talonavicular and talocalcaneus joint
part of the inferior extensor retinaculum b) neck – constriction between head
 fastens 2 tendons – prevents bow stringing of and body
the tendon c) body – rests on the anterior part of
the calcaneus
3. Flexor retinaculum (Laciniate ligament)
 holds flexor tendon in place TROCHLEA
 converts bony grooves into 4 osseofibrous  under c)
canals for the following structure (medial to  means “pulley”
lateral):  superior, posterior part of talus
a. tendon of tibialis posterior
b. tendon of the FDL …body
c. posterior tibial artery and vein  superior surface and both sides of body
d. tibial nerve support and articulates with the tibia and
e. tendon of the FHL fibula
 2 sides are gripped between the tibia
 clinical correlation: (medial) and fibula (lateral) malleolus that
o Osseofibrous canal – passageway of forms the ankle mortise
posterior tibial nerve o within this mortise, talus function as a
hinge joint
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  adduction  abduction
 posteriorly, has a medial and lateral
tubercles with intervening groove for FHL SUMMARY OF ANKLE/ FOOT MOVEMENTS
tendon PLANTAR FLEXORS – transverse axis
 inferiorly has a deep groove – SULCUS  gastrocnemius*
TALI  soleus*
 tibialis posterior
 flexor hallucis longus
 type of diarthrodial joint: ginglymus (hinge)
 flexor digitorum longus
o motion along the sagittal plane and
 peroneus longus – running behind the lateral
transverse axis malleolus
neutral position: 90˚  peroneus brevis
 dorsiflexion – 0-20˚  plantaris
 plantar flexion – 0-50˚ DORSIFLEXORS
 tibialis anterior*
 extensor digitorum longus
o motion along coronal plane and longitudinal
 extensor hallucis longus
axis
 peroneus tertius – small brother of EDL
 eversion – lateral surface moves upward INVERTORS
 inversion – medial surface moves upward  tibialis anterior*
 tibialis posterior*
b. TALOCALCANEAL (SUBTALAR) JOINT  flexor hallucis longus
 joints below the talus in relation to the calcaneus  flexor digitorum longus
 bones: talus and calcaneus  extensor hallucis longus
EVERTORS
 type of joint: arthrodial (plane and gliding)
 peroneus brevis*
 movement about the longitudinal axis:
 peroneus longus*
 inversion – elevation of the medial border and  peroneus tertius
depression of the lateral border of the foot  extensor digitorum longus
 eversion
LIGAMENT
c. TALONAVICULAR OF THE TCN JOINT AND  important in stabilizing the talotibial joint
CALCANEOCUBOID JOINT
 anteriorly, surgical tarsal joint 1. medial collateral ligament (Deltoid)
 together with the talocalcaneal joint it forms the a) anterior and posterior tibiotalar ligament
midtarsal joint/ transverse tarsal joint b) tibionavicular ligament
 a.k.a. Chopart’s, midtarsal, transverse tarsal joint c) tibiocalcaneal ligament
 bones:
 talus, navicular and partly calcaneus  protects one from injury
 calcaneus and cuboid  (+) fracture/ sprain: POTT’S fracture (break MCL)

 type of diarthrodial joint: arthrodial (plane, 2. lateral collateral ligament

gliding) - non-axial a) anterior talofibular ligament
 movement: b) posterior talofibular ligament
 inversion/ eversion c) calcaneofibular ligament – most inferior
 partly adduction/ abduction connection

COMPLEX MOVEMENTS OF:  clinical correlation:

SUPINATION PRONATION  high sprain injury – posterior inferior tibiofibular
 inversion  eversion and anterior inferior tibiofibular ligament breaks
 plantarflexion  dorsiflexion

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  85˚- 90˚ ankle sprain – involvement of the anterior
talofibular ligament (inversion sprain)
o plantarflexion with inversion – sacrificial sprain
BOWSTRING LIGAMENT
a. plantar calcaneonavicular ligament
 a.k.a. spring ligament
 sustentacular ligament - attached to PCN
 major contributor to the middle plantar arch
 (+) looseness: collapse – FLATFOOT
 most distinctly human part of man’s anatomy and
comments that is the hallmark that separates him from
all the other members of the animal kingdom
 pes (foot) vs. talipes (congenital foot abnormalities)
 2 surfaces: plantar and dorsal
 2 borders: medial (tibial) and lateral (fibular)
 big/ great toe: hallux
 toes are numbered beginning with the big toe
(digit I)
 little toe (digit V) – digitus minimus (littlest toe)

b. plantar calcaneocuboid ligament/ short plantar Surface Anatomy

ligament  includes 33/34 joints:
 talocalcaneal joint
c. long plantar ligament  talonavicular joint
 tarsometatarsal joint (1-5)
ANKLE INJURIES  metatarsalphalangeal joint
 25% of running and jumping injuries  interphalangeal joint
 53% of basketball injuries o 1st – hallux (no PIP and DIP)
 involves: o PIP and DIP – 2nd -5th digits
a. anterior talofibular ligament
 6-10 mm wide, 20 mm long, 2 mm thick  26 bones:
 direction follows the foot  7 tarsal bone
 increased strain with increase plantar flexion  5 metatarsal bone
 weakest ligament – disrupts at forces between  14 phalanges
6-56 kg
 … to form a half-dome
b. calcaneofibular ligament  half-dome is kept from flattening by:
 20-25 mm long, 6-8 mm dm a. ligaments
 bridges both ankle… b. plantar aponeurosis
 increased strain in dorsiflexion c. tendons of the foot extrinsic
 2nd weakest ligament d. intrinsic muscles of the foot

c. posterior talofibular ligament  3 functional segments:

 greatest tension when ankle is dorsiflexed
 thickest of the 3 LCL
 Mechanism of injury:
 plantarflexion and inversion can injure ATFL and
further inversion will lead to other ligamental
instabilities
FOOT
 evolved from the flexible grasping organ of the arboreal
pre-human to the relatively rigid weight-bearing
platform of the human
a. posterior (hindfoot)
 lies directly under the tibia and support it
 talus (at the apex of the foot) and calcaneus
(hind portion of the foot in contact with the
ground)
b. middle (midfoot)
 5 tarsal bones that form as irregular rhomboid
with medial base and lateral apex
 navicular, cuboid and 3 cuneiforms
c. anterior (forefoot)
 5 metatarsal bones

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  14 phalangeal bones
 big toe or hallux or digit 1 – has 2 phalanges Transverse Tarsal Joint
 other lateral toe – digits II-V have 3 each - aka surgeons tarsal joint/ midtarsal joint/ Chopart’s
joint
Arches of the Foot - consist of talonavicular joint and calcaneocuboid
joint
1. longitudinal – 2 columns of bone - used to be a practice of surgeons to amputate in this
part
a. medial - not ideal level of amputation
 calcaneus → talus → navicular → 3 cuneiforms  tendency of the foot to plantarflexed because of
→ 3 medial metatarsals the strong pull of gastrocnemius
 most important: it bears most of the weight
Tarsometatarsal Joint
b. lateral - aka Lisfrank’s joint
 calcaneus → cuboid → lateral metatarsal - plantar flexion problem
 balances weight
Type of Joint Action
2. transverse Subtalar Plane type of Inversion/
synovial joint eversion
Talocalcaneo Synovial joint Gliding and
navicular Talonavicular rotator
part is ball and movements
socket are possible

Calcaneocuboid Plane type of Inversion/

synovial jont eversion
Tarsometatarsal Plane type of Gliding or
synovial joint sliding
Intermetatarsal Plane type of Gliding or
synovial joint sliding
Metatarsophalangeal Condyloid type Flexion/
of synovial jointextension
some
abduction/
adduction
I nterphalangeal Hinge type of Flexion/
synovial joint extension
JOINTS OF THE ANKLE AND FOOT Degrees of Freedom Diarthrodial
- talocrural (talotibial) Non-axial Gliding/ irregular/ plane
- subtalar (talocalcaneal) joint/ arthrodial
- talonavicular and calcaneocuboid Uni-axial Trochoid (pivot), ginglymus
(hinge)
 abduction and adduction
Bi-axial Condyloid
 partly inversion and eversion
Tri-axial Ball and socket

- calcaneonavicular
First Layer of Foot Intrinsics
- 5 tarsometatarsal
 abductor hallucis
- 5 metatarsophalangeal
o abducts big toe
- Interphalangeal join
o medially located
 PIP
o nerve: medial plantar nerve
 DIP

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 flexor digitorum brevis
 abductor digiti minimi
o lateral portion
o nerve: lateral platar nerve
Second Layer
 quadratus plantae
o nerve: lateral plantar nerve
- older – rotate and adduct further
 producing pain at the metatarsal area
 METATARSALJIA
Hammer Toes
- deformity in which the proximal phalange is
permanently flexed at the metatarsophalangeal joint
and the middle phalanx is plantarflexed at the
interphalangeal joint

 lumbricales Claw Toes

o both medial and lateral planatr nerve - characterized by hypertension of the
metatarsophalangeal joint and flexion of the distal
 tendon of FDL
 tendodn of FHL Callus
- hardening/ thickening of keratinized skin
Third Layer
Club foot
 FHB
- aka talipes equinovarus
o (+) in hand: flexor digiti minimi
- characteristic findings:
 equinus deformity
 adductor hallucis
 pes varus
o oblique head
 calcaneus inverted
o transverse head
 shortened heel cord of Achilles tendon

 flexor digiti minimi brevis

Common Foot Deformity
1. Pes equinus
Fourth Layer
 foot in plantarflexion
 plantar interosseous muscles
 tight tibialis posterior
 dorsal interosseous muscles
 walk with metatarsal
 tendon of tibialis posterior
 tendon of fibularis/ peroneus longus 2. Pes calcaneus
 tight tibialis anterior
 walking in your calcaneus

Intrinsic Muscle of the Dorsum of the Foot 3. Pes valgus

 extensor hallucis brevis  medial side of foot
o not always present
4. Pes varus
 extensor digitorum brevis  lateral side of the foot
 dorsal interossei - 4
always present 5. Pes cavus
 high medial arch
Clinical Correlation:
Hallux vagus 6. Pes planus
- aka bunion  flat-footedness, pronated foot
- lateral deviation of the great toe  flattened arach

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 Neuromuscular and Musculoskeletal Correlation Knee extension – L3, L4
- quadriceps muscle
Practice
- single most important variable in learning with motor ANKLE
task
- the amount, type and variability of practice directly Dorsiflexion
affects the extent of skill acquisition and retention - L4, L5
- tibialis anterior muscle
Dermatomes of Lower Limb
- L1 – inguinal hallux extension by EHL – L5
- L2
- L3 Plantarflexion – S1, S2
- L4 – medial malleolus, anteromedial
- L5 – anterolateral of the leg LE Reflexes Segmental Level
- S1 – lateral side of ankle and foot Patellar knee jerk L2, L3, L4
 posterolateral portion of leg Medial hamstring L5, S1
Achilles (ankle jerk) S1, S2
- S2
- S3 – ischial tuberosity
- S4 and S5 – perianal area

Femoral nerve
- changes its name to SAPHENOUS NERVE after
passing the knee
- supply medial portion of the leg

Obturator nerve
- medial portion of the leg

Posterior cutaneous nerve to the thigh

- SI, S2, S3
- medial part of the thigh

Lateral sural cutaneous ANKLE AND LEG

(Dr. Cariaga)
peripheral nerve – foot plantar and
- dorsum innervation SURFACE ANATOMY
- see Netter!!!!
LATERAL MALLEOLUS
Segmental Innervations of Lower Limb - more pointed
- posteriorly situated
Hip flexion – L2
- iliopsoas muscle MEDIAL MALLEOLUS
- more rounded
Hip extension – L5, S1, S2 - anteriorly situated
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 - half an inch higher than the lateral malleolus FOOT – triangular structure
- apex – heel
 presence of a depression anterior to lateral/ medial - base – large and smalle toe
malleolus bounded by the presence of tibialis anterior
tendon PROMINENCE OF TENDON
o easy access to the ankle joint - Achilles tendon – posterior
- anterior tibialis tendon – anterior to the depression
 lateral malleolus = anterior to it = tendon of extensor
digitorum longus SKIN AND SUBCUTANEOUS TISSUE
o access to ankle joint 1. dorsal aspect
o there will be bulging if there is an increase  loose, thin
collection of fluid inside the ankle joint  edema prone – tissues are loosely connected to
the subjacent structures
PULSATIONS  hair
- anterior tibial/ dorsalis pedis artery
o lateral to tibialis anterior tendon is the 2. plantar aspect
pulsations of the anterior tibial artery (as it  thick, fat-padded
crosses the ankle joint, it is called the dorsalis  fibrous sept
pedis) o not edema prone – anchored by strips of
fibrous tissues towards the underlying bone
- posterior tibial artery o stabilizes one from walking
o posterior to the medial malleolus
 septasebaceous and sweat glands – increase in
note: dual blood supply of the leg – anterior and posterior plantar area
tibial artery
BONY ANATOMY
TH
BASE OF 5 METATARSAL
- bony structure ANKLE MORTISE
- easily palpable in most specimen - AP view – position in which intermalleolar axis
- lateral side parallel to x-ray film
- movement of ankle joint: plantar flexion and
dorsiflexion
- joint between: talofibular, talotibial
 movement: dorsiflexion/ plantarflexion

POSTERIOR ASPECT OF ANKLE - inversion – limited by medial malleolus

Prominence of the Achilles tendon - eversion – limited by lateral malleolus
- located posteriorly  increase inversion/ eversion – instability of ankle
- depression immediately medial and lateral to the mortise
Achilles tendon
- access point for the synovial cavity of the ankle joint Note: weight of body borne of tibia down to talus, fibula
o but anterior part is more preferred stabilizes the talus
o why not posteriorly? might puncture the
posterior tibial artery TALOCALCANEAL/ SUBTALAR
- joint between calcaneus and talus
BALLS OF THE FEET - movement: inversion, eversion
- prominence of heads of the metatarsal bones
BONES OF THE FOOT
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a. HINDFOOT
- calcaneus, talus
- side view: talus above the calcaneus
- calcaneus – biggest bone in the foot, bores the
weight of the talus
 articulates with the cuboid
- talus – keystone
o above and superior to calcaneus
o doesn’t have any corresponding bone in the
hand
UNIQUE BONE
o no muscle attachment
o 70% of its surface is covered with cartilage
o unique blood supply
 main body of talus bounded superiorly by
tibia and inferiorly by calcaneus
 passes to the neck area then → main body
 clinical correlation: common site of
fracture in the talus is the neck area
o disruption the BS → aseptic necrosis
o parts:
 head
 neck
 body
- talonavicular and calcaneocuboid joint
o little inversion/ eversion
o plantar flexion/ dorsiflexion
b. MIDFOOT
- navicular, cuboid, 3 cuneiforms
- navicular – articulation to the posterior aspect of
the talus (talonavicular joint)
note: movement between the different tarsal bones are
much less pronounce
o little dorsiflexion/ plantar flexion, inversion/
eversion
c. FOREFOOT
- bones that comprises the metatarsal phalanges
- 1st metatarsal articulates with the 1st cuneiform
- 2nd metatarsal articulates with the 2nd cuneiform
- 3rd metatarsal articulates with the 3rd cuneiform
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- 4th and 5th metatarsal articulates mainly at the
cuboid
- movement (metatarsal): very minimal movement
- metatarsophalangeal joint
o dorsiflexion, plantar flexion, abduction,
adduction
o point of reference of axis – 2nd toe
 MCP – point of reference (hand): middle
finger
- PIP and DIP – dorsiflexion and plantar flexion
note: joint between the hindfoot and midfoot collectively
known as – MIDTARSAL JOINT/ CHOPART’S JOINT
- joint between the midfoot and forefoot – LISFRANC’S
JOINT
- during surgery:
o amputate foot – Chopart’s amputation or
Lisfranc’s amputation
LIGAMENTOUS STRUCTURE
- holds the different bones together
- identified to which they are attached to
a. lateral collateral ligament complex
 lateral aspect of the foot
 made-up of 3 ligaments
o anterior and posterior talofibular ligament
o calcaneofibular ligament
 weaker
b. medial collateral ligament complex
 triangular in shape/ Deltoid ligament
purpose of collateral ligaments: stabilizes the ankle
mortise; prevents excessive inversion/ eversion
o excessive: tear off of the LCL (ankle sprain)
o most commonly torn ligament is the anterior
talofibular ligament
o test: apply pressure on ATFL (+ - pain and swelling)
c. spring ligament
 aka plantar calcaneonavicular ligament – seen
undersurface
 plantar and dorsal calcaneocuboid ligament
 oriented in an oblique manner
 o maintains the longitudinal arch of the foot - action in the ankle and foot
which serves as a spring of the foot to prevent
flatfootedness Intrinsic
- originates below the ankle
d. metatarsophalangeal ligament - action below the ankle
 medial and lateral ligament
 no dorsal and plantar ligament EXTRINSIC INTRINSIC
EXTENSOR Anterior leg Extensor hallucis
e. interphalangeal ligament GROUP – found compartment brevis
at the dorsal Lateral leg Extensor digiti
 lateral and medial ligament – limits aspect of the compartment brevis
abduction/adduction foot
 (+) plantar ligament FLEXOR GROUP Posterior leg
 volar plate ligament – prevents excessive – found at the compartment
dorsiflexion plantar aspect (superficial) + PLANTAR
of the foot popliteus muscle MUSCULATURE
Posterior leg (4 LAYERS)
DEEP FASCIA
compartment
- ankle and foot
(deep)
- thickenings of the deep fascia: restraint movement
of tendon both in the anterior aspect especially in NOTE: popliteus muscle – no action on the foot
the lateral aspect
- condensation of the deep fascia: retinaculum – intermalleolar axis – divides area into anterior and
prevents bowstringing posterior
- anterior: - all muscles and tendons anterior to intermalleolar
 superior extensor retinaculum – transverse axis – dorsiflex ankle
crucial - all muscles and tendons posterior to intermalleolar
 inferior extensor retinaculum – cruciate axis – plantarflex ankle
 prevents bowstringing of the extensor tendons
longitudinal axis
- medial lacinate ligament: - perpendicular to the 1st line at the middle of tibia
 important relationship - divides foot into medial (inversion) and lateral
 tibialis posterior (eversion)
 flexor digitorum longus
 flexor hallucis longus
 in between FDL and FHL = posterior tibial artery,
vein and nerves

- lateral:
 superior peroneal retinaculum
 inferior peroneal retinaculum
 restraint of the peroneus longus and brevis
tendons

- plantar – thickened to form the plantar aponeurosis

MUSCLE

Extrinsic
- originates above the ankle
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 not part of 2nd layer
- Flexor digitorum longus
- Flexor halucis longus
 are foreleg muscles
Plantar Musculature
- intrinsic flexor of the foot HAND FOOT
Lumbricales Lumbricales - but not well
1st layer – superficial layer utilized as in the hand
Extensor digitorum Extensor digitorum longus
- Abductor hallucis muscle communis
- Abductor digiti V Flexor digitorum profundus Flexor digitorum longus
 origin: calcaneus Flexor digitorum Flexor digiti brevis
superficialis/ sublimis
 insertion: proximal phalange
I: middle phalange
-encircles the deep tendon
- Flexor digiti brevis -same as the foot
 origin: calcaneus
 insertion: middle phalange

2nd layer
- Quadratus plantae
 (-) in upper extremity
 origin: calcaneus
 insertion: tendons of digitorum longus
 function: redirect the vector forces of obliquely
oriented flexor digitorum longus; redirect
direction of foot

- Lumbricales (4)
 (+) in hand
 function in hand: important in mediating the
forces of long extensor and flexor, prevent
pulling of EDL and FDL to maintain muscular
action finely
used in playing the piano - action on digits to
prevent pulling
3rd layer
- Flexor hallucis brevis
insertion: middle phalange
- Adductor hallucis
 transverse belly – forefoot
 oblique belly – comes from the midfoot
 insertion: proximal phalange

 origin: FDL - Flexor digiti V

 insertion: EDL - innervation:
 innervation:  medial side – medial plantar nerve
FOOT  lateral side – lateral plantar nerve
o 1 – middle plantar nerve  exception!!!! Adductor hallucis
o 3 – lateral pnatar nerve o action on the big toe
o located at the medial side but IS NOT
but… HAND innervated by the medial planatr nerve
o 2 – radial nerve nerve o innervated by the lateral plantar nerve
o 2 – ulnar nerve
4th layer
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 - shortest muscle
- interossei
 action:
o plantar: adduction (PAD)
o dorsal: abduction (DAB)

NERVES Generalization:
- Cutaneous: superficial peroneal nerve - BV of foot and ankle supplied by anterior and
deep peroneal nerve posterior tibial a/v (dual blood supply)
saphenous nerve - deep vessels – lying in the deep fascia
 always paired
- Sural nerve (lateral/medial)
- Medial calcaneal - superficial vessels – purely veins
- Lateral plantar
- Medial plantar CLINICAL CORRELATION

- deep peroneal nerve a. bones/ ligaments

 supply the extensor hallucis brevis and extensor
digitorum brevis and intrinsic muscles of the toes
- illustration cutaneous nerve dorsal/ plantar: See
Netter!!!
1. arches of the foot – transverse and longitudinal
a) calcaneus – touch the ground
b) navicular and cuboid – do not touch the
ground
c) cuneiform – do not touch the ground

- mixed nerve – posterior tibial nerve ÷ medial and - longitudinal arch

lateral plantar nerve  prominent on lateral side and not from
the medial transverse
ARTERIES/ VEINS  front to back
- anterior tibial artery and vein
 peroneal - medial arch
 malleolar (medial/ lateral)  transverse – medial side
 tarsal (medial/ lateral)
 arcuate 2. deformities (congenital and acquired) of ankle
 dorsal metartarsal  of ankle:
 dorsal digital o planus/ cavus
o varus/ valgus
o equinus/ calcaneus
- superficial  complex
 short/ long saphenous o equinovarus/ calcaneovalgus
 NAV – arrangement according to layer
 Pes equinus
o horse
o standing on metatarsal not on the foot

 of toes:
o hallux valgus
o hallux varus – everted; BUNION

3. injuries
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  edema o pain when patient walks
 ankle sprain (inversion/ eversion injury)
 fractures:  megalodactyly
o bi-malleolar fracture o very big toe
 medial malleolus
 lateral malleolus  syndactyl
o lobster foot
o trimalleolar fracture
 medial malleolus  club foot
 lateral malleolus o talipes equinovarus
 3rd – posterior lip of the tibia o ankle is used as the foot
o other forms: simple – varus/ valgus; equinus/
o Pott’s/ cotton fracture calcaneus
o Talar neck fracture
b. nerves
 dislocations – ankle, subtalar, pantalar  short leg cast syndrome
 tarsal tunnel syndrome
4. operative interventions
 placement of operative incisions c. muscles
 triple arthrodesis  plantaris tendon donor
 amputations:  tight Achilles tendon
o Syme’s  plantar fasciitis
 cut at the level of tibia
 remove talus and calcaneus d. vessels
 most common  vein graft
 heel pad cover the whole stump  good collateral circumflex

o Boyd’s e. skin
 remove anterior aspect of calcaneus  edema fluid
and some part of talus  pressure sores/ bony prominence
o Pirogoff
o Chopart’s
o Lisfranc’s

other clinical correlation:

 distal tibiofibular ligament

o if broken, use extra long screw to connect tibia and
fibula

 ankle fusion
o fuse talus and calcaneus
o fuse talus with navicular and cuboid

 calcaneal sprain

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