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Head and Neck
Loubomir E. Antonio, M.D.
Bones of Skull
Cranium
Eight (8) Bones
Fronta
!arieta (")
#cci$ita
%em$ora (")
&$henoid
Ethmoid
Facial Bones
Fourteen (') bones
• *gomatic(")
• Ma+iae (")
• Nasa bones(")
• Lacrima (")
• omer (')
• !aatine (")
• -nerior concha (")
• Mandibe (')
New Born Skull
Fontanelles
Anterior fontanelle “Bregma”
Diamond/sha$edBet0een
%0o ha1es o ronta bone
%0o $arieta bones
2osed b* 18 months
Posterior fontanelle “Lamba”
%rianguar
Bet0een
%0o $arieta bones
#cci$ita bone
2osed b* !rst "ear of life
CL#N#CAL S#$N#F#CANC%
De$ressed 3 Deh*dration
Buging 3 -ncreased -2!
&astoi ProcessNot $resent at birth
De1eo$s during 4rst " *ears o ie
CL#N#CAL S#$N#F#CANC%
Force$s dei1er* ma* resut to Facia ner1e in5ur*
Ault Skull
Sutures
/ 4brous t*$e ( s*narthroses )
/ 6ormian or -nca bones in bet0een sutures
Coronal Suture
• Fronta bone
• !arieta bone
Sagittal Suture
• !arieta bones
Lamboi Suture
• !arieta bone• #cci$ita bone
Ault Skull
Pterion
%hinnest $art o atera 0a
Bet0een
Anteroinerior corner o the $arieta bone
7reater 0ing o s$henoid
#N'(AC(AN#AL )%&*(()A$%S
%+iural 3 Ant. di1ision midde meningea arter*
Subural 3 2erebra 1eins
Subarachnoi 3 Aneur*smAngioma
#ntraParench"mal 3 Lenticuostriate arter*
#N'(AC(AN#AL )%&*(()A$% ,#NFAN'-
E+cessi1e moding
%ears anterior attachments o a+ cerebri to tentorium cerebei
Beeding comes rom9
$reat Cerebral .ein
Straight sinus
#nferior Sagittal sinus
S/0LL F(AC'0(%
Adut
/ ikened to an eggshell
/ s$intering o bone
:oung chid/ ikened to a table tennis ball
/ ;$ond racture<
F(AC'0(%S *F C(AN#AL F*SSA%
Anterior Cranial Fossa
/ E$ista+is
/ =hinorrhea
/=acoon>s e*e
/ E+o$hthamos
&ile Cranial Fossa ,%A/%S'-
/ #torrhea=hinorrhea
/ Damage to 2N ?,,@
/ Damage to 2N ,8
Posterio Cranial Fossa
/ Batte>s sign
/ Damage to 2N ,'C,''
Nasal fractures
/ most common
/ considered o$en ractures
/ damage to muco$eriosteum
/ se$ta hematoma
&a2illofacial fractures
/ acia s0eing
/ di$o$ia
/ maoccussion o$en bite deormities
/ anesthesia$aresthesia in the cheek or
u$$er gum (inraorbita ner1e)
Le Fort Classi!cation of &a2illofacial Fractures
A('%(#AL S0PPL3 Anterior 2ircuation/ -2A
!osterior 2ircuation/ A
4%N*0S 5(A#NA$%
&u$erior sagitta sinus
-nerior sagitta sinus
7reat 1ein o 7aen
&traight sinus
%rans1erse sinus
&igmoid sinus
CL#N#CAL S#$N#F#CANC%
6ueckenstet7s 'est
() FA#L0(% o the cerebra 1enous $ressure to rise as measured b*
a umbar ta$ in the sub arachnoid s$ace u$on com$ression o the -
signi4es obstruction at the 1ertebra cana or meninges (tumor)
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Ca.ernous Sinus Contents
2Ns ---, -, ',"
and -
-2A
CL#N#CAL S#$N#F#CANC%
2a1ernous &inus %hrombosis
inections in the dangerous area o the ace
thrombosis o the facial vein
organisms ascend through inf. ophthalmic vein
CSF PA')A3
2horoid $e+us
Latera 1entrices
oramen o Monroe
?rd 1entrice
aueduct o &*1iusiter
th 1entrice
oramen o Luschka
and Magendie
&ubarachnoid s$ace
Arachnoid granuations
Cranial Ner.e # *lfactor" Ner.e
#actor* ner1e ces /G #actor* bub /G #actor* tract /G#actor* area
'"+e9 &ensor*
Function9 &mes
Lesion9 Anosmia
Foramen9 2ribiorm $ate
#nner.ate (egion9Nasa 2a1it*
Cranial ner.e ## *+tic Ner.e
=etina /G #$tic chiasm /G #$tic tract /G L7B /G #$tic
radiation /G isua corte+
'"+e9 &ensor*
Function9 ision
Lesion9 isua 4ed de4cits (Ano$sia)
Foramen9 #$tic cana
#nner.ate (egion9 #rbit
Cranial ner.e ### *culomotor Ner.e
Anterior midbrain /G Latera 0a 2a1ernous &inus /G
&#F /G E#M>s e+ce$t &# and L=
s$hincter $u$iae
2iiar* musces
'"+e9 Motor
Functions9
• E#Ms
adduction most im$ortant action (media rectus)
• 2onstricts $u$i (s$incter $u$iae)
• Accomodation (ciiar* musce)
• =aises u$$er e*eid (e1ator $a$iae)
Lesion9 Di$o$ia, aterae+terna strabismus
Foramen9 &u$erior oribita 4ssure
#nner.ate (egion9 #rbit
Cranial ner.e #4 : 'rochlear Ner.e
!osterior midbrain /G Latera 0a ca1ernous &inus /G &#F /G
&u$erior #biue
'"+e9 Motor
Function9
De$resses and abducts e*eba (&u$erior obiue)
-ntorts
Lesion9
6eakness ooking do0n 0ith adducted e*e
DiIcut* going do0n stairs
Head tits a0a* rom esioned side
Foramen9 &u$erior orbita 4ssure
#nner.ate (egion9 #rbit
Cranial ner.e 4# Abucent Ner.e
Bet0een $onsmedua /G 2a1ernous &inus 0-2A /G &#F /G
Latera =ectus
'"+e9 Motor
Function9 Abducts e*eba (atera rectus)
Lesion9 di$o$ia, mediainterna strabismus, oss o $arae gaJe
Foramen9 &u$erior orbita 4ssure
#nner.ate (egion9 #rbit
Cranial Ner.e 4 : 'rigeminal Ner.e
Anterior $ons
/ sma motor root
/arge sensor* root %rigemina 7angion
%rigemina 7angion ( anterior border )/ arises the ? di1isions
Cranial ner.e 41:*+hthalmic Ner.e
!asses in the atera 0a o 2a1ernous &inus /G &#F
Nasociiar*
Post. Ethmoida
#nratrochear
Long ciiar* ner1e
Anterior ethmoida /G External nasal nerve ( ti$ o
nose )
Sensor* br. %o ciiar* gangion
Fronta 3 di1ides into su$raorbitatrochear ner1es
Lacrima
zygomaticotemporal branch of V2 lacrimal
gland'"+e9 &ensor*
Function9 7enera sensation o oreheadsca$cornea
Lesion9
• Loss o sensation in skin o oreheadsca$
• Loss o bink reKe+ 0 2N --
#nner.ate (egion9 #rbit and sca$
Cranial ner.e 4; &a2illar" Ner.e
Foramen rotundum /G $ter*go$aatine ossa -#F
&eningea branch
<*gomaticotem$ora acrima gand ( 0 acrima ner1e
o ' )
<*gomaticoacia
$angionic branches 3 '* ner1es going to $ter*go$aatine
gangion
Posterior &u$erior A1eoar&idde &u$erior A1eoar
Anterior &u$erior A1eoar
'"+e9 &ensor*
Function9 7enera sensation o $aatae, nasa ca1it*, ma+iar* ace,
ma+iar* teeth
Lesion9 Loss o genera sensation in skin o1er ma+ia, ma+iar* teeth
Foramen9 Foramen rotundum
#nner.ate (egion9 !ter*go$aatine ossa (ea1e b* o$enings to ace
ora, and nasa ca1it*)
Cranial ner.e 4= &anibular Ner.e
Foramen o1ae /G -nratem$ora ossa
'"+e9 Mi+ed
&otor9 &N%&*N#C9 &" Ass &eets 'he 'oilet
&*oh*oid
Anterior digastric
&usces o mastication
'ensor 1ei $aatini
'ensor t*m$ani
Sensor"9 &N%&*N#C9 L#BA$
Lingua ner1e
#nerior A1eoar
Bucca ner1e
Auricuotem$ora ner1e
$angion ( otic gangion )
Lesion9
Loss o genera sensation in skin o1er mandibe, mandibuar teeth,
tongue
6eakness in che0ing
a0 de1iation to0ard 0eak side
%rigemina neuragia (intractabe $ain in ", ? territor*)
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Foramen9 Foramen #1ae
#nner.ate (egion9 -nratem$ora ossa
#N>0(3 '* ')% L#N$0AL N%(4%
2#=&E inratem$ora ossa
inerior to su$erior constrictor
(cose* reated to ast moar tooth)
1
submandibuar triange
In cases of clumsy extraction of impacted 3rd molar tooth
Cranial Ner.e 4## : Facial Ner.e
Type: Mi+ed
Function:
&otor9 muscles of facial expression, posterior belly of
digastric, stylohyoid, stapedius
Sensory
'aste to anterior twothirds of tongue!palate
"utonomics
&ai1ates (submandibular, sublingual glands#
%ears (lacrimal gland )
Makes mucus (nasal and palatine glands#Lesion9
• 2orner o mouth droo$s, can>t cose e*e, can>t 0rinke
orehead, oss o bink reKe+, h*$eracusis
• Ateration or oss o taste (ageusia)
• E*e dr* and red
Foramen9 -nterna auditor* meatus
#nner.ate (egion9 Face, nasa and ora ca1it*, branches ea1e ski
in st*omastoid oramen, $etrot*m$nic 4ssure, or hiatus o acia cana
Cranial ner.e 4### 4estibulocochlear Ner.e
estibue AND semicircuar cana G estibuar gangion G -nt.
acoustic meatus G Brainstem2erebeum
2ochea /G &$ira gangion /G -nterna acoustic meatus /G
Auditor* 2enter
'"+e9 &ensor*
Function9
Hears
Linear acceeration (gra1it*)
Anguar acceeration (head turning)
Lesion9 Loss o baance, n*stagmus
Foramen9 -nterna auditor* meatus
#nner.ate (egion9 -nner ear
Cranial Ner.e #? $losso+har"ngeal Ner.e
'"+e9 Mi+ed
Function9
&enses $har*n+, carotid sinusbod*
&ai1ates ($arotid gand)
%astes ($osterior one third o tongue)
Motor to one musce / st*o$har*ngeus
Lesion9 Loss o gag reKe+ 0ith 2N
Foramen9 uguar oramen
#nner.ate (egion9 Neck$har*n+tongue
Cranial Ner.e ? 4agus Ner.e
'"+e9 Mi+ed
Function9
Musces o $aate and $ha*n+ or s0ao0ing e2ce+t tensor veli
palatini (2N ) and stylopharyngeus (2N -)
%o a musces o ar*n+ ($honates)
&ensation to ar*n+ and ar*ngo$har*n+
&ensation to ar*n+ and 7- tract
%o 7- tract smooth musce and gands in oregut and midgut
Lesion9
Nasa s$eech. Nasa regurgitation (due to $aate 0eakness)
D*s$hagia, $aate droo$
1ua $ointing C*N'(ALA'%(AL rom aOected side
Hoarseness4+ed 1oca cord
Loss o gag reKe+ 0ith -
Loss o cough reKe+
Foramen9 uguar oramen
#nner.ate (egion9 Neck !har*n+ Lar*n+ %hora+ Abdomen
Cranial Ner.e ?# S+inal Accessor" Ner.e
Brainstem : ;roots, &otor anSensor": Ner.usintermeius -
#nternal acousticmeatus
Facial canalChorda tympani$etrot*m$anic
4ssure-nratem$ora
ossa
#nner %ar@&ile earNerve to
stapedius
5oins ingua ner1e$eniculate an lion
Brainstem uguaroramen Neck 3P*S'%(#*( toS'L*P)A(3N$%0S
#&P*('AN'B(ANC)%S
%*m$anic branchesser $etrosa ner1e
#tic gangion 0
!arotid gand
Auricuotem$oraner1e
2arotid branch2arotid bod*sinus
!har*ngea branch
!har*ngea $e+us( 0 2N and &N& )
Lingua branch!osterior '? o
tongue
Ner1e to
Brainstem uguaroramen Neck/0ithin the carotidsheath
#&P*('AN'B(ANC)%S, neck -9
Cardiac branches2ardiac $e+us
(ecurrent ar*ngeaner1e ALL-ntrinsic musces oar*n+ %?C%P' CRICO!"ROI#
Auricuar branches %*m$anic
membrane!inna
&eningea branches
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'"+e9 Motor
Function9
%urn head to o$$osite side (Sterocleidomastoid )
Ee1ates and rotates sca$ua (Trape$ius)
Lesion9
6eakness turning head to o$$osite side
&houder droo$
Foramen: uguar oramen
#nner.ate (egion9 Neck
Cranial Ner.e ?## )"+oglossal Ner.e
Brainstem G H*$ogossa cana G Neck do0n to lower border o&O$+,(%%" #IG'$RIC G crosses ext-int+ Carotid arteries .
ee+ to mylohyoid G below lingual nerve and submandibuar duct
#&P*('AN' B(ANC)%S9
&eningeal branch
5escening branch , C1 -
/ 5oins descending cervical nerve ( 2"2? ) to orm ANSA
C%(4#CAL#S
to su$$* &%E=N#H:#-D, #M#H:#-D, &%E=N#%H:=#-D
Ner.e to ')3(*)3*#5
Ner.e to $%N#*)3*#5
ALL musces o the tongue %?C%P' &'%'OG%O$$)$
'"+e9 Motor
Function9 Mo1es tongue (styloglossus, hyoglossus, genioglossus,
and intrinsics. +alatoglossus b* +har"ngeal +le2us-Lesion9 %ongue $ointing #PS#LA'%(AL side o $rotrusion
Foramen9 H*$ogossa cana
%nnervated &egion: %ongue
&%&*(#<%
A musces o the tongue are su$$ied b* 2N'"
E2E!% '"("T)*()SS+S
( $har*ngea $e+us 2N,'C)
A musces o the $aate are su$$ied b* the $har*ngea $e+us
E2E!% TES)& -E((% '"(("T%%
(2N 3 ?di1ision)
&%&*(#<%
A musces o the $har*n+ are su$$ied b* the $har*ngea $e+us
E2E!% ST()'/"&*E+S
( 2N - )A intrinsic musces o the ar*n+ are su$$ied b* the recurrent
ar*ngea ner1e
E2E!% 0&%0)T/&)%1
(E+terna branch 3 &u$erior ar*ngea ner1e )
Summar" of 'ongue #nner.ation
Sensation
Anterior "?rds
&ensation CN 4= ('rigeminal manibular)
%aste CN 4## (Facial)
!osterior '?rd
&ensation and %aste
Main* CN #? ($losso+har"ngeal),
E+treme $osterior CN ? (4agus)
&otor
2N ?## ()"+oglossal)
Scal+
la"ers
“S0"('”
Skin
Connecti1e tissue o su$er4cia ascia
A$oneurosis
Loose 2onnecti1e %issue ( angerous la"er )
Periosteum o sku and bones
*(B#'
!*ramida in sha$e*rbital &argin
&u$erior/ronta bone
Latera/ ronta and J*gomatic
-nerior/ J*gomatic and ma+ia
Media/ma+ia and ronta
%3% '(A0&A
/ Least $rotected rom the ("TE&"( side
Blowout Fractures
/ e+$odes %FE&%)&( into the Ma+iar*
sinus resuting to di$o$ia, in5ur* to
inraorbita ner1e and entra$ment o
inerior rectus musce
LA2=-MAL A!!A=A%&
Lacrima gand Lacrima $unctum
Lacrima canaicui
Lacrima sac
Nasoacrima duct
-nerior nasa concha
M-DDLE EA=
Su+erior wall
tegmen t*m$ani ($etrous bone)
Anterior wall
thin bone $ate -2A
" o$enings %ensor t*m$ani
Eustachian tube
Posterior wall
aditus to mastoid antrum
$*ramid 3 sta$edius tendon
&eial wall atera 0a$romontor* o inner ear
" 0indo0s o1a
round
Lateral wall
t*m$anic membrane(dKat)
e$it*m$anic recess
#nferior wall
%hin bone $ate -
#NF%C'#*NS AN5 *'#'#S &%5#A
- !athogenic organisms ascending through the
pharyngotympanic tube rom the naso$har*n+
C*&PL#CA'#*NS
Acute Mastoiditis&igmoid sinus %hrombosis
/ thru the mastoid antrum
Meningitiscerebra abscess
/ su$erior*Facia ner1e $as*Lab*rinthitisertigo
/ media*
#sseus membranous ab*rinth &ensor* organ
estibue
&emicircuar 2ana
2ochea
trice and &accue Macua
&emicircuar Ducts 2rista am$uaris
2ochear Duct organ o 2orti
C*C)L%A
&caa 4estibui
&caa Mediacochear duct
nerve
!ter*go$aatine
gangion&ubmandibuar
&ubingua gand
St"lomastoiforamenLacrimaNasa!aata gands Ant."? tongue
!osterior auricuar
&t*oh*oid
!osterior be* odigastric
!har*ngea$e+us
/ su$$*ALL musces o!har*n+ %?C%P' $"%O&!'R"NG()$
* musceso sot $aate%?C%P' (N$ORV(%I &'%'INI
Su$erior ar*ngeaner1e
-nternaar*ngea ner1e 3S%NS*(3 to ar*n+
E+ternaar*ngea ner1e 3*NL3 &*'*( to
CRICO!"ROI#
" roots
Cranial root 3 rombrainstem
uguar oramen
Neck
/ &2M
Foramen
magnum
/ %ra$eJius
S+inal root 3 2'to 2P
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&caa '*m$ani
Membranes
(eissner>s
Basiar
NASAL CA4#'3
Lateral nasal wall
su$erior turbinate
midde turbinate
-nerior turbinate
&eial nasal wall
se$ta cartiage
$er$endicuar $ate o ethmoid1omer
&N%&*N#C
/ iss Litte $irs ASS
/ iessebach>s $e+us
Litte>s Area
$reater !aatine arter*
Anterior Ethmoida arter*
S$heno$aatine arter*
Su$erior abia arter*
PA(ANASAL S#N0S%S
&$henoida sinus
Ethmoida sinus
Anterior Midde
!osterior
Fronta sinus
Ma+iar* sinus
5(A#NA$%
S+henoethmoial recess
&$henoida sinus
Su+erior meatus
!osterior ethmoida sinus
&ile meatus
Fronta sinus
Anterior ethmoida sinus
Midde ethmoida sinus
Ma+iar* sinus
#nferior meatus
Nasoacrima duct&uscles of Facial %2+ression
-nner1ated b* termina branches o acia ner1e
'em$ora
<*gomatic
Bucca
&andibuar
Cer1ica
2Ten ebras 4it 5y 0hee67
F(%3 S3N5(*&%
!ost/gustator* s0eating due to damage to auriculotemporal and
great auricular nerve ( traumasurger*)
Both 4bers ma* inner1ate a s0eat gand
A stimuus intended or sai1a $roduction resuts to s0eat secretion
instead
'(*0BL%S*&% BL%%5#N$ AF'%( A '*S#LL%C'*&3
Damage to external palatine vein ocated 5ust atera to the tonsis
at the tonsiar ossa
*(AL CA4#'3 L%S#*NS
60#NC/%7S 5#S%AS% 4S 60#NS3
Quincke>s disease 3 angioedema of uvula
Quins* 3 peritonsillar abscess
&uscles of &astication
• &asseter
• %em$orais & 3 Munching
• &edia !ter*goid
• Latera !ter*goid L / Lo0ers
'riangles of the Neck
Posterior 'riangle
• #cci$ita triange
• &u$raca1icuar triange
Anterior 'riangle
• 2arotid triange
• Digastric triange
• &ubmenta triange
• Muscuar triange
Posterior 'riangle
Bounaries
• 'ra+eius ($osterior)
• Sternocleiomastoi (anterior)
• 2a1ice (inerior)
5i.ie b* *moh"oi into
• #cci$ita triange
• &u$raca1icuar triange
Floor
• Anterior scalene
• &ile Scalene
• Posterior Scalene
• Le.ator sca+ulae
• S+lenius Ca+itis
Posterior 'riangle
Contents
-n scalene inter.al (bet0een anterior R midde scaene)
• 'hree ,=- trunks of brachial +le2us
• Subcla.ian arter"S+inal accessor" ner.e (CN ?#) to
• &ternoceidomastoid
• %ra$eJius
Phrenic ner.e (anterior surace o anterior scaene)
2utaneous branches o cer1ica $e+us
• greater auricuar,
• esser occi$ita,
• trans1erse cer1ica,
• su$raca1icuar ner1es
Anterior 'riangle
Bounaries
Anterior border o sternoceidomastoid
Anterior midine
Bod* o mandibe
SubtrianglesDigastric triange
&ubmenta triange
Muscuar triange
2arotid triange
5igastric 'riangle
Bounaries
• Lo0er border o mandibe
• !osterior be* o digastric
• Anterior be* o digastric
Contents
• &ubmandibuar gand
• &ubmandibuar duct
• &ubmandibuar *m$h node
• 2N --
• 2er1ica mandibuar branch o 2N --
• &ubmenta branch o acia 1esses
Submental 'riangle
Bounaries
Mentum o mandibe
Anterior beies o digastric musces
H*oid bone
Foor M*oh*oid
A$e+ Mandibuar s*m$h*sis
Contents
&ubmenta *m$h nodes
&uscular 'riangle
Bounaries
• Midine o neck
• &u$erior be* o omoh*oid
• Anterior border o sternoceidomastoid
=oo &tra$ musces
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Contents
4iscera of neck
• %h*roid gand
• &u$erior ar*ngea ner1e
• =ecurrent ar*ngea ner1e
• %rachea
• Eso$hagus
Caroti 'riangle
Bounaries
&ternoceidomastoid
!osterior be* o digastric
&u$erior be* o omoh*oid
Contents 2arotid sheath
&N%&*N#C
CA(*'#5 S)%A') C*N'%N'S
- &ee 3 -nterna 2arotid Arter*
'C 3 agus Ner1e
cc 3 2ommon 2arotid Arter*
- 3 -nterna uguar ein
Fascial La"ers
Su+er!cial cer.ical fascia
%hin a*er encosing
$at*sma musce
2utaneous ner1es
&u$eri4ca 1eins
&u$er4cia *m$h nodes
Fascial La"ers
5ee+ cer.ical fascia &u$$orts musces, 1esses, 1iscera o neck
2ondenses to orm
1D #n.esting la"er
%ra$eJius
&ternoceidomastoid
;D Pretracheal la"er
Lar*ngea cartiages
%h*roid
!arath*roid
-nrah*oid musces
Fascial La"ers
5ee+ cer.ical fascia
=D Pre.ertebral la"er
#1er $re1ertebra musces, 1ertebra coumn
Forms A2illar" Sheath
ED Caroti Sheath
2ommon carotid arter*
-nterna carotid arter*
-nterna 5uguar 1ein
agus ner1e
(etro+har"ngeal s+ace
“5anger s+ace”
(etro+har"ngeal abscess airwa" com+ression
%racking to thora+ and mediastinum
%2ternal Caroti Arter"
Branches9
S"( F)' S5
Su$erior th*roid
Ascending $har*ngea
Lingua
Facia
*cci$ita
Posterior auricuar Su$er4cia tem$ora
&a+iar*
'h"roi $lan
-sthmus is at e1e o ;n =r Eth trachea ring
Bloo Su++l"9
&u$erior th*roid arter*
-nerior th*roid arter*
%h*roidea ima
4enous rainage
&u$erior th*roid 1ein
Midde th*roid 1ein
-nerior th*roid 1ein
PA(A')3(*#5 $LAN5
Four () se$arate gands
&ecretes Parath"roi )ormone
Bood &u$$*
• Su+erior
th"roi arter"D
• #nferior
th"roi arter"
Lar"n2
2artiages
= un+aire9
%h*roid
2ricoid
E$igottis
= +aire9
Ar*tenoid
2ornicuate
2uneiorm
#ntrinsic Lar"ngeal &uscles
'%NS%S 3 2=-2#%H:=#-D
(%LA?%S 3 %H:=#H:#-D (#2AL-& )
AB50C'*( 3 !#&%E=-#= 2=-2#A=:%EN#-D
A550C'*(S 3 %=AN&E=&E A=:%EN#-D
#BL-QE A=:%EN#-D
Latera cricoar*tenoid
Phar"n2Parts
Naso$har*n+
#ro$har*n+
Lar*ngo$har*n+ (h*$o$har*n+ )
Circular &uscles
&u$erior constrictor
Midde constrictor
-nerior constrictor
Longituinal muscles
&t*o$har*ngeus
&a$hingo$har*ngeus
F*(%#$N B*53 #N$%S'#*N
P3(#F*(& S#N0S
most common site or the odging o ingested shar$ oreign bodies (
8shbones )
C%(4#CAL PL%?0SAnterior rami C1:CE s$ina ner1es
Cutaneous
Lesser occi$ita
7reater auricuar
%rans1erse cutaneous
&u$raca1icuar
C%(4#CAL L3&P)N*5%S
Le.el 1 &ubmenta &ubmandibuar
Le.el ; $$er 5uguar
Le.el = Mid 5uguar
Le.el E Lo0er 5uguar
Le.el &ubocci$ita
Le.el G 2entra
%HE END
Back an S+ine
Loubomir E. Antonio, MD
4ertebral Column
2entra $iar o the bod*
!rotects the s$ina cord
&u$$orts 0eight o the head and trunk
%ransmits to hi$ bones and o0er imbs
Fe+ibe, &egmented
• ertebrae
• -nter1ertebra discs
4ertebral Column
2ur1atures ()
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2er1ica !osterior conca1it* (Lordosis)
%horacic !osterior con1e+it* (S*$hosis)
Lumbar !osterior conca1it* (Lordosis)
&acra !osterior con1e+it* (S*$hosis)
4ertebral Column
Parts
Bod*
ertebra arch
Peicles
Laminae
$rocesses
&$inous (') %rans1erse (")
Articuar ()
4ertebral Column
• &$inous $rocess
– Directed $osterior*
• unction o t0o aminae
• %rans1erse $rocess
– Directed atera*
• unction o aminae and $edices
Function
– e1ers
– attachment or musces, igaments
4ertebral Column
Articuar !rocess
ertica* arranged
▪ %0o su$erior
▪ %0o inerior
!edices are notched on u$$er and o0er borders
▪ &u$erior 1ertebra notch
▪ -nerior 1ertebra notch
Forming -nter1ertebra oramen
▪ %ransmit s$ina ner1es
▪ And bood 1esses
Cer.ical 4ertebra
2haracteristics
ertebra oramen
▪ Large
▪ %rianguar
&u$erior articuar $rocesses
▪
&ma▪ Fat
▪ Face back0ard, R u$0ard
-nerior articuar $rocesses
▪ Face do0n0ard R or0ard
Cer.ical 4ertebra
2haracteristics
Foramen trans.ersarium
▪ %rans1erse $rocess
▪ !assage o the .ertebral arter" an
.eins
&$ines
▪ &ma
▪ Bi4d
At"+ical Cer.ical 4ertebrae
First cer1ica 1ertebra (Atas)
No bod*, No s$inous $rocessAnterior arch
!osterior arch
Latera mass (each side)
Articuar suraces
$$er as$ect (#cci$ita cond*es o sku)
Lo0er as$ect (A+is)
At"+ical Cer.ical 4ertebrae
&econd cer1ica 1ertebra (A+is)
#dontoid $rocess
$eg/ike
!ro5ects u$0ard rom su$erior surace o bod*
=e$resents body of atlas that has fused /ith the axis
At"+ical Cer.ical 4ertebra
&e1enth cer1ica 1ertebra
Longest s$inous $rocess
N*' bi4d
Large trans1erse $rocess
&ma oramen trans1ersarium
5*%S N*' transmit 1ertebra arter*
Cer.ical 4ertebral Fracture
>eHerson7s fracture 3 disru$tion o the ring o atas 0 dis$acement
o atera masses
)angman7s fracture 3 racture o the odontoid and $edices o a+is
'horacic 4ertebra2haracteristics
Bod*
Medium siJed, heart/sha$ed
ertebra Foramen
&ma, circuar
&$ines
Long, incined do0n0ard
2haracteristics
Costal facets
▪ !resent on sides, and on trans1erse
$rocess
▪ %'', %'" T no acets on trans1erse
$rocess
&u$erior articuar $rocess
▪ Facets ace back0ard, atera*
-nerior articuar $rocess▪ Facets ace or0ard, media*
Lumbar 4ertebrae
• 2haracteristics
– Bod*
• Massi1e, kidne* sha$ed
– !edices
• &trong
– Laminae
• %hick
– ertebra oramina
• %rianguar
– %rans1erse $rocesses
• Long, sender
Lumbar 4ertebrae
2haracteristics
&$inous $rocesses▪ &hort, Kat, uadranguar, $ro5ect
back0ard
&u$erior articuar $rocesses
▪ Facets ace media*
-nerior articuar $rocesses
▪ Factes ace atera*
No rib acets, no oramina in the trans1erse $rocesses
Sacral 4ertebrae
&acrum
Fi1e rudimentar* 1ertebrae used together
&inge 0edge sha$ed bone
Sacral 4ertebrae
2haracteristics
&acra $romontor*
Anterior u$$er margin o 'st sacra 1ertebrae
Buges or0ard into $e1ic ca1it*
-m$ortant obstetric andmark
Sacral 4ertebrae
2haracteristics
&acra cana
Formed rom sacra oramina
2ontains
!art o cauda euina
Meninges (u$ to o0er border &")
Lo0er sacra ner1e roots
2occ*gea ner1e roots
Fium terminae
Sacral 4ertebrae
2haracteristics
&acra Hiatus
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Faiure o the Pth and sometimes th sacra 1ertebra to meet in the
midine
Anterior R !osterior sacra oramina
!assage o anterior and $osterior rami o the u$$er our s$ina ner1es
Sacral 4ertebrae
Articuations
$$er border (base)
Pth umbar 1ertebrae
Narro0 inerior end
2occ*+
Latera*
%0o hi$ bones
&acroiiac 5ointsCocc"geal 4ertebrae
2occ*+
Four () used together
&inge
&ma
%rianguar
4rst cocc*gea 1ertebra common* not used 0ith "nd
Atlanto:occi+ital >oints
bet0een
#cci$ita cond*es
Latera masses o the atas
Ligaments
Anterior Atanto/occi$ita membrane
!osterior Atanto/occi$ita membrane
&o.ements , 3%S >oint -
Fe+ion
E+tension
Latera Ke+ion
N* rotation
Atlantoa2ial >oints
bet0een
#dontoid $rocess and anterior arch o atas (')
Latera masses o bones (")
&o.ement , No >oint -
=otation i atas 0 head on a+is
Ligaments
A$ica 3 rom dens to anterior margin oramen
magnum
Aar 3 atera to a$ica igament
2ruciate 3 dens to atas and oramen magnum
Membrana tectoria 3 u$0ard e+tension o $osterior
ongitudina igament >oints Between 'wo 4ertebral Boies
2o1ered b* thin $ate o h*aine cartiage
-nter1ertebra disc o 4brocartiage in bet0een
Ligaments
Anterior longituinal ligaments
Posterior longituinal ligaments
2ontinuous bands do0n the anterior and $osterior surace o the
1ertebra coumn
rom the sku to the sacrum
#nter.ertebral 5iscs
2haracteristics
1@Eth of length o 1ertebra coumn
%hicker in cer.ical and lumbar regions
Annulus !brosus orms $eri$her* o the disc
Fibrocartiage
2oagen 4bers arranged in aternating concentric a*ers
#nter.ertebral 5iscs 2haracteristics
Nucleus +ul+osus orms centra $art o disc
▪ #1oid mass o geatinous materia
▪ Norma* under $ressure
▪ 6ith ad1ancing age,
▪ decrease in 0ater content
▪ =e$aced b* 4brocartiage
No discs
▪ bet0een 4rst t0o cer1ica 1ertebrae
▪ -n sacrum
▪ -n cocc*+
#nter.ertebral 5iscs
Herniation o the nuceus $u$osus
Freuent* occurs in the
▪ Lower lumbar region ,&ost
common-
Due to sudden increase in com$ression oad on
1ertebra coumn
=u$ture o annuus 4brosus
Nuceus $u$osus herniates posteriorly into
1ertebra cana
2om$ression o s$ina ner1e roots, s$ina ner1e, or
s$ina cord
>oints Between 'wo 4ertebral Arches
&*no1ia 5oints
Bet0een ad5acent su$erior and inerior articuar
$rocessesLigaments
&u$ras$inous igament
▪ 2onnect ad5acent s$ines
-nters$inous igament
▪ 2onnect ad5acent s$ines
Ligamentum Ka1um
▪ 2onnect ad5acent aminae
Ligamentum Nuchae
▪ 2er1ica region
▪ %hickening o su$ras$inous and
inras$inous igaments
&o.ements of 4ertebral Column
%*$e and range in regions de$end on
%hickness o inter1ertebra discs
&ha$e and direction o the articuar $rocesses
2er1ica region most mo1abe&uscles of the Back
7rou$ings
&u$er4cia
2onnected 0ith shouder girde
-ntermediate
-n1o1ed 0ith mo1ements o the thoracic cage
Dee$ or !ost1ertebra
ertebra coumn
Post.ertebral &uscles
2assi4cation
&u$er4cia* running musces
Erector s$inae
-iocostais
Longissimus
&$inais
Post.ertebral &uscles2assi4cation
-ntermediate obiue running musces
%rans1ersos$inais
&emis$inais
=otatores
Muti4dus
Post.ertebral &uscles
2assi4cation
Dee$est Musces
-nters$inaes
-ntertrans1ersari
Post.ertebral &uscles
&uscles of longest length lie su+er!ciall"
From sacrum to rib anges, trans1erse $rocesses,
u$$er 1ertebra s$ines
#ntermeiate length run obliIuel" From trans1erse $rocesses to the s$ines
Shortest an ee+est muscles
From s$ines and trans1erse $rocesses o ad5acent
1ertebrae
&uscular 'riangles
Auscultator" triangle
&ite on back 0here breath sounds most easi* hear 1ia stethosco$e
Boundaries
Latissimus dorsi
%ra$eJius
Media border o &ca$ua
=homboid ma5or (Koor)
&uscular 'riangles
Lumbar 'riangle
&ite 0here $us ma* emerge rom the abdomina 0a
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Boundaries
Latissiumus dorsi
!osterior border o the e+terna obiue
-iac crest
S+inal Cor
2*indrica in sha$e
From &eulla *blongata (o brain)
Begins su$erior* at
Foramen magnum
End inerior* at
Lo0er border 'st umbar 1ertebrae (Aduts)
#ccu$ies u$$er "?rds o the 1ertebra cana
S+inal Cor&urrounded b* three (?) meninges
Dura mater
Arachnoid mater
!ia mater
Additona $rotection b*
2erebros$ina Kuid
&ubarachnoid s$ace
S+inal Cor
• Enargements
– 2er1ica
• #rigin o brachia $e+us
– Lumbar
• #rigin o umbar $e+us
• Lo0er end
– 2onus meduaris – Fium terminae
• $ia mater $roongation
• From conus meduaris to back o cocc*+
S+inal Cor
Fissures
Anterior median 4ssure
Midine on the anterior surace o the cord
!osterior median 4ssure
Midine on the $osterior surace o the cord
S+inal Cor
=oots (?' $airs)
Anterior
▪ Motor
!osterior
▪ &ensor*
▪ 0 $osterior root gangion =oots in regions
$$er cer1ica region
▪ &hort, run amost horiJonta*
Lumbar, &acra beo0 e1e o termination o cord
▪ ertica eash o ner1es around !lum
terminale
▪ Caua eIuina
S+inal Cor
=oots
!ass though inter1ertebra oramina
nite to orm s+inal ner.es 0hich di1ides into
Anterior ramus (arge)
!osterior ramus (smaer)
Both contain motor and sensor* 4bers
Bloo Su++l" of S+inal Cor
Arteries!osterior s$ina arteries
Arise direct* or indirect* rom the 1ertebra arteries
&u$$* $osterior '?rd o s$ina cord
Bloo Su++l" of S+inal Cor
Arteries
Anterior s$ina arteries
Arise rom 1ertebra arteries
nite to orm a singe arter*
&u$$* anterior "?rds o s$ina cord
!osterior s$ina arteries
Arise direct* or indirect* rom the 1ertebra arteries
&u$$* $osterior '?rd o s$ina cord
=adicuar arteries
Branches o regiona arteries
=einorce anterior and $osterior s$ina arteries
4eins
Drain into interna 1ertebra 1enous $e+us
&eninges of S+inal Cor
Dura Mater
E+terna membrane,
Dense 4brous tissue
Encoses s+inal cor and caua eIuina
Abo1e, continuous 0ith dura co1ering brain
Beo0, dura ends on !lum terminale
▪ at e1e o lower borer of the ;n
sacral .ertebra
7i1es sheaths to a s$ina ner1e roots
&eninges of the S+inal Cor
Arachnoid Mater
Deicate, im$ermeabe membrane
Lies 0ithin the dura, outside the $ia
&e$arated rom $ia mater b* subarachnoi s+ace (4ed 0ith
cerebros+inal Jui)
&eninges of the S+inal Cor
Arachnoid Mater
Abo1e, continuous 0ith arachnoid co1ering the
brain
Beo0, end on the !lum terminale
▪ At the e1e o lower borer of the ;n
sacral .ertebra
2ontinues aong s$ina ner1e roots orming sma
atera e+tensions o subsrachnoid s$ace
&eninges of the S+inal Cor
!ia Mater
ascuar membrane
2ose* co1ers s$ina cord
%hickened on either side bet0een ner1e roots
(ligamentum enticulatum)
E+tends aong each ner1e root as ar as the s$ina
ner1e
-nerior* $roonged oO the o0er end o the s$ina
cord as the !lum terminale
Lumbar +uncture
,S+inal 'a+-
!atient on the side 0ith 1ertebra coumn 0e Ke+ed
Abo1e or Beo0 th umbar s$ine
Lies 0ithin imaginar* ine bet0een highest $oints on iiac crests
Lumbar +uncture
,S+inal 'a+-
Neede $asses through the oo0ing structures to
subarachnoi s+ace
&kin
Fascia
&u$ras$inous igament
-nters$inous igament
Ligamentum Ka1um
Fatt* tissue (interna 1ertebra 1enous $e+us)
Dura mater
Arachnoid mater
%HE END
'hora2
Loubomir E. Antonio,M.D.
Bones of the 'horacic all
&ternum
Manubrium
Bod* o the &ternum
i$hoid !rocess
=ibs
%*$ica =ib
At*$ica =ib
2er1ica =ib
2osta 2artiages
B*N% &A((* B#*PS3
&%E=NM
&ite o red hemato$oiesis throughout ie
S'%(NAL AN$L% *F L*0#S
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Articuation o manubrium 0ith the bod*
Landmark
;n costa cartiage
-nter1ertebra disc between Eth an th thoracic .ertebrae
unction o Ascending aorta and aortic arch
unction o aortic arch and descending thoracic aorta
Biurcation o the trachea
unction o the su$erior mediastinum and inerior mediastinum
(ibs
'" $airs
Attached $osterior* to thoracic 1ertebrae
(?) categories
%rue ribs ( ribs ' to )Fase ribs ( ribs 8 to 'C )
Foating ribs ( ribs '' and '" )
'3P#CAL (#BS 3 ribs ? to
A'3P#CAL (#BS 3 ribs ',",'C,'','"
PA('S *F A '3P#CAL (#B
)ea 3 attached to 1ertebra bod*
Neck
'ubercle 3 attached to trans1erse $rocess
&hat
Ange
Cer.ical rib
2ongenita 1ariation
C.PU o $eo$e
From trans1erse $rocess o Kth cer1ica 1ertebra
'horacic outlet s"nrome
!ressure on the o0er trunk o the brachia $e+us or subca1ian arter*(#B F(AC'0(%S
(ibs to 1
Most common* ractured ribs
Se.ere localie +ain
/ most im$ortant s*m$tom
Flail Chest
/ section o chest 0a disconnected to the thoracic 0a
/ $arado+ic breathing
/ under*in ung contusion
&uscles of the 'horacic all
Dia$hragm
-ntercosta Musces
E+terna -ntercosta
Fibers T do0n0ard, or0ard
-nterna -ntercosta
Fibers T do0n0ard, back0ard
-nnermost -ntercostaFibers T trans1erse, incom$ete a*er
Le1atores costarum ('")
&erratus $osterior
&u$erior
-nerior
5ia+hragm
#rigin
i$hoid $rocess,
o0er @ costa cartiages
'/? umbar 1ertebrae b* crura and media and atera arcuate
igaments
-nsertion
2entra tendon
Embr*onic #rigin
&N%&*N#C9 Se.eral Parts Buil 5ia+hragm
Se$tum trans1ersum Peuri$eritonea od
Bod* 0a
5orsa mesenter*
5ia+hragmatic )ernias
Congenital
-ncom$ete usion o the se$tum trans1ersum, $euro$eritonea od,
and dorsa mesenter* rom the bod* 0a
? sites
'. at the back, usua* et 3 Bochdaek>s hernia
". in ront 3 Morgagni>s hernia
?. thru eso$hagea hiatus
AcIuire
/ 0eakness in the muscuature
'. &iding
". !ara eso$hagea
5ia+hragm
Action
&*S' #&P*('AN' musce o IN$&IR'ION
-ncreases 1ertica diameter o the thora+ b* $uing do0n centra
tendon
Assists in raising the o0er ribs
-nner1ation
Phrenic ner.e ,C=:C-
Neele 'horacentesis
Liesa1ing or tension $neumothora+
Drain Kuid, bood or $us
Ma* be done 'N(RIOR and %'(R'% at ;n #CS, AB*4% the ?rd rib
'ube 'horacostom"
Eth or th #CS
$reerred site at anterior a+iar* ine
Ma* be done at a o0er -2& but N*' L*%( than th rib on either
side ( dome o dia$hragm )
#ntercostal S+aces
&$aces bet0een ribs contain
E+terna intercosta
-nterna intercosta
-ntercosta 1ein
-ntercosta arter*
-ntercosta ner1e
;4AN< V do0n0ard
-nnermost intercosta
Lined interna* b* enothoracic fascia, R
+arietal +leura5ia+hragm
Actions
eight iting musce
Abdomina straining
#ns$iration
'horaco/abdomina $um$
(%&%&B%(M
2% ate 9#, ten 9;<# E**s ""T twelve 9;=#7
#2 , right $hrenic(%8)
%so$hagus, 1a$us ner1es (%'C)
Aorta, AJ*gous 1ein, 'horacic duct (%'")
2 8
E 'C
A '"
Paral"sis of the 5ia+hragm
%raumatic%hra$eutic sectioning o the $hrenic ner1eMa* ha1e to incude the accessor* $hrenic ner1e rom 2P ( ner1e to
subca1ius )
SN#FF '%S'
Penetrating #nuries to the 5ia+hragm
An* $enetrating in5ur* BEL#6 the N-!!LE anterior* and the -nerior
ange o the &2A!LA
Associated intra abdomina in5uries
#ntercostal 4essels
Each intercosta s$ace
(') arge !osterior intercosta arter*
(") sma Anterior intercosta arteries
!osterior intercosta 1ein
Drain aJ*gous or hemiaJ*gous 1eins
Anterior intercosta 1eins
Drain into the interna thoracic and muscuo$hrenic 1eins
Posterior #ntercostal Arteries
First "
/ branches o su+erior intercostal arter",
branch o costocer.ical trunk o subcla.ian arter"
Last
/ branches o the thoracic aorta
Anterior #ntercostal Arteries
First @
/ branches o the internal thoracic arter"
Last P
/ branches are rom the musculo+hrnic arter",
a termina branch o internal thoracic arter"
#nternal 'horacic Arter"
From 4rst $art o subcla.ian arter"
Descends direct* behind the !rst si2 costal cartilages
-n ront o the +arietal +leura
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Lies a 4nger breath atera to sternum
%erminates in Gth intercostal s+ace, di1iding to
Su+erior es+igastric arter"
&usculo+hrenic arteries
L*m$hatic Drainage o the thora+
Ner.es of 'horacic wall
-ntercosta ner1es
Anterior rami o !rst ele.en ,11- thoracic s$ina ner1es
Enters intercosta s$ace
=uns inerior* to intercosta 1esses (AN)
-n intercosta groo1e
Bet0een innermost and interna intercosta musces
#ntercostal ner.esFirst si+ (@) ner1es
distributed 0ithin their intercosta s$aces
th, 8th, th intercosta ner1es
Lea1e anterior ends o the intercosta s$aces
!assing dee$ to costa cartiages
Enter abdomina 0a
'Cth, ''th intercosta ner1es
!ass or0ard direct* into abdomina 0a
-ntercosta ner1es
First intercosta ner1e
Large branch
oins anterior ramus o the 8th cer1ica ner1e
Forms o0er trunk o brachial +le2us
=emainder is sma
-ntercosta ner1es
&econd intercosta ner1e oined b* media cutaneous ner1e o the arm b* intercostobrachial
ner.e
&u$$ies skin o arm$it, and u$$er media side o arm
area of +ain referre to b" coronar" arterial isease
(%F%((%5 PA#N
!neumonia!umonar* thromboemboism
/ abdomina $ain, tenderness and rigidit*
'horacic ca.it"
Di1ided into meiastinum media*, and $eurae and ungs atera*
Abo1e T 'horacic outlet
Anterior* su$erior border o the manubrium sterni
!osterior* 4rst thoracic 1ertebra
Latera* media borders o the 4rst ribs and costa cartiages
Ao0s $assage
Eso$hagus
%rachea
Man* 1esses, ner1esiening of the &eiatinum
G PCU or G 8cms
Norma* LE&& %HAN PCU o the trans1erse diameter o the chest
&een in cardiomega*, $ericardia eOusion, $ericardia tam$onade
Shifting of the &eiastinum
#PS#LA'%(AL
/ side o ateectasis
C*N'(ALA'%(AL
/ &ide o tension $neumothora+
&eiastinal #nfections
From a dee$ inection in the neck
From an eso$hagea $eroration
Mediastinits
&eiastinosco+"
2hamberain $rocedure
/ obtain sam$es o tracheobronchia *m$nodes through thesubsterna s$ace
'rachea
Mobie, cartiaginous membranous, 4broeastic tube
/sha$ed rings
A$$ro+ in. ('?cm) in ength, 1in (".Pcm) in diameter
2ontinuation o ar*n+ at o0er border o cricoi cartilage ,Gth
cer.ical .ertebra-
Descends in midine o neck
Ends in thora+ e1e o sterna ange (bet0een %/%P) di1iding into
=ight $rinci$a (main) bronchi
Let $rinci$a (main) bronchi
Com+ression of the 'rachea
Enarged th*roid
Aortic arch aneur*sm
Bronchi
=ight $rinci$a (main) bronchus
ierO shorterO more .ertical
Beore entering hium, gi1es oO
&u$erior obar bronchus
#n entering the hium, di1ides to
Midde obar bronchus
-nerior obar bronchus
Bronchi
Let $rinci$a (main) bronchus
NarrowerO longerO more horiontal
!asses beo0 arch of the aorta
-n ront o eso+hagus
#n entering hium, di1ides to&u$erior obar bronchus
-nerior obar bronchus
#nhale Foreign Bo"
2ommon on chidren
!ins, scre0s, nuts, bots, peanuts, chicken bones, to*s, tooth
sua* enters the =-7H% $rimar* bronchus
Pleurae
%0o serous sacs surrounding and co1ering the ungs
!arts
Parietal +leura
Lines thoracic 0a
%horacic surace o dia$hragm
Latera surace o mediastinum
&ensiti1e to pain0 temperature0 touch0 pressure
4isceral +leura
#uter suraces o ungs-nterobar 4ssures
&ensiti1e to stretch
Pleurae
!eura ca1it* ($eura s$ace)
&itike s$ace that se$arates $arieta and 1iscera $eurae
2ontains sma amount o +leural Jui
Lubricates a$$osing $eura suraces
Costoia+hragmatic recess
%o/est area o $eura ca1it* into 0hich the ungs e+$and during dee$
ins$iration
LN7 H-LM
(ight
most su$erior structure !rimar* bronchus
“e+arterial”
Left most su$erior structure !umonar* arter*
$rimar* bronchus beo0 the arter* hence9
“h"+arterial”
Cer.ical 5ome of the Pleura an A+e2 of Lungs
unerabe to stab 0ounds at the root o the neck
Damage b* anesthetist neede in brachia $e+us ner1e bock
Lung an Pleural (eJections
Lungs Pleura
&icla.icular rib @ 8
&ia2illar" 8 'C
Para.ertebral 'C '"
Lungs, obes and 4ssures
=ight ung
&ight* arger
*bliIue !ssure
)oriontal !ssure
Di1ides right ung into
$$er obe
Midde obe
Lo0er obe
Lungs, obes and 4ssures
Let ung
#n* one 4ssure (obliIue !ssure)
%0o obes
$$er obe
Lo0er obe
Broncho+ulmonar" segments
2haracteristics
&ubdi1ision o a ung obe
!*ramida in sha$e, a$e+ to0ard ung root
&urrounded b* connecti1e tissue
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Has o0n
segmenta bronchus,
segmenta arter*,
*m$h 1esses,
autonomic ner1es
Segmental .ein N*' inclue
in connecti1e tissue bet0een ad5acent segments
Diseased segment can be remo1ed surgica*
Bloo Su++l" of the Lungs
!umonar* arteries
Deo+*genated bood to a1eoi
Bronchia arteries
/ o+*genated boodPericarium
Midde mediastinum
Fibroserous sac encosing
Heart
=oots o great 1esses
!arts
Fibrous $ericardium
&erous $ericardium
!ericardia sinuses
Ner1e su$$*
!hrenic ner1es
Pericarial Lesions
!ericarditis
inKammation o the serous $ericardium
)amman7s sign ( $ericardia riction rub )
!ericardia tam$onade accumuation o Kuid or bood in the $ericardia s$ace
Beck7s tria ( h*$otension, neck 1ein distention, distant heart
sounds )
Pericariocentesis
Neede is introduced to the left o the +i$hoid $rocess in an u+war
and backwar direction in an ange E egrees to the skin
!re1ents damage to the $eura and ungs due to the $resence o
cardiac notch
)eart
• Hoo0 muscuar organ
• Midde mediastinum
• !*ramida
• %hree (?) suraces
– &ternocosta (anterior)
– Dia$hragmatic (inerior)
– Base ($osterior)
• A$e+
– Directed do0n0ard, or0ard, to the et
– Pth et intercosta s$ace
– A$$ro+ =Din ,cm- from miline
)eart
&tructure
Di1ided b* 1ertica se$ta into our () chambers
=ight atria (anterior)
Let atria ($osterior)
=ight 1entrice (anterior)
Let 1entrice ($osterior)
6as 0 three (?) a*ers
%+icarium outer 1iscera a*er o serous $ericardium
&"ocarium thick a*er o cardiac musce
%nocarium thin inner a*er
(ight Atrium
2onsists o2a1it* and
Aurice
unction is e+terna 1ertica groo1e (sulcus terminalis), 0hich
#n the inside orms a ridge (crista terminalis)
5unction bet0een sinus 1enosus and right atrium $ro$er
!art $osterior to ridge T smooth 0aed
-nterior o aurice T roughened b* bundes o musce 4bers (musculi
+ectinati)
(ight atrium
#$enings
&u$erior 1ena ca1a
$$er $art o the right atrium
a1eess
-nerior 1ena ca1a
Larger
Lo0er $art o right atrium
=udimentar* 1a1e
2oronar* sinus
Bet0een inerior 1ena ca1a and atrio1entricuar ori4ce
=udimentar* 1a1e
=ight atrio1entricuar ori4ce
Anterior to inerior 1ena ca1a
'ricus+i .al.e
(ight atrium
Feta remnants
Fossa o.alis
&hao0 de$ression
&ite o foramen o.ale (etus)Annulus o.alis
$$er margin o ossa o1ais
ie on atria se$tum, se$arating right rom et atrium
=ight 1entrice, $a$iar* musces
• 'rabeculae carneae
– !a$iar* musces
• Attached b* bases to 1entricuar 0a
• A$e+ to 4brous cords (chorae
tenineae) to cus$s o tricus+i .al.e
– &oerate ban
• Large ridge attached to
– &e$ta 0a
– Atrio1entricuar 0a
• 2on1e*s $art o right bunle branch
o conducting s*stem
–
&im$e $rominent $ro5ectionsLeft atrium
Main ca1it* and
Aurice
-nterior contains muscuar ridges (simiar to right)
#$enings
!umonar* 1eins ()
" rom each ung
!osterior 0a
a1eess
Atrio1entricuar ori4ce
&itral .al.e
Left .entricle
Large* behind right 1entrice, 0 sma $ortion $ro5ecting on the et
orms et heart margin and a$e+
#$enings
Atrio1entricuar ori4ce
Aortic #ri4ce
Aortic .estible, beo0
6as
?+ thicker than right 1entrice
'rabecular carneae
; +a+illar" muscles
N* moerator ban
Heart sounds
• First sound
– 2ontraction o 1entrices
– 0losure of tricuspid and mitral valves
• &econd sound
– Sharp closure of aortic and pulmonary valves
• Best heard
– 'ricus+i .al.e T right ha o o0er end o bod*
o sternum
– &itral .al.e T a$e+ beat – Pulmonar" .al.e T media end o "nd et
intercosta s$ace
– Aortic .al.e T media end o "nd right intercosta
s$ace
Conucting s"stem
Modi4ed 2ardiac Musce Bood &u$$*
&inoatria node ($acemaker) both
Atrio1entricuar node =2A
Atrio1entricuar bunde =2A
=ight branch L2A
Let branch both
Bood su$$* o the heart
Arteria su$$*
=ight coronar* arter*
Let coronar* arter*
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enous drainage
2oronar* sinus
7reat cardiac 1ein
&ma cardiac 1ein
Midde cardiac 1ein
Anterior cardiac 1ein
enae cordae minimae
=ight 1s Let Dominance
;=ight dominance<
Posterior inter.entricular arter"
Large branch o right coronar* arter*
;Let dominance<
Posterior inter.entricular arter"Branch o et coronar* arter*
Coronar" Arter" 5isease
Functiona end arteries
Acute thrombosis on to$ o chronic atheroscerosis
&%EM- 1s N&%EM-
4enous rainage
=ight Atrium
Main 1enous drainage C*(*NA(3 S#N0S
#NL: " drains direct* to right atrium
anterior cariac .ein
.enae coris minimae ;hebesian veins<
Ner.e su++l" of the heart
Autonomic ner1ous s*stem 1ia cariac +le2uses
S"m+athetic !bers
&inoatria node, atrio1entricuar node, cardiac musces, coronar*
arteries2ardiac acceeration
-ncrease orce o contraction
Diation o coronar* arteries
Ner.e su++l" of the heart
Autonomic ner1ous s*stem 1ia cariac +le2uses
Paras"m+athetic !bers
agus ner1es
&inoatria node, atrio1entricuar node, coronar* arteries
=educed rate
=educed orce o contraction
2onstriction o coronar* 1esses
$ross anatomic changes in fetal circulation at birth
2osure o foramen o.ale due to
decreased $ressure in inerior 1ena ca1a
-ncreased $umonar* bood Ko0
2onstriction o uctus arteriosus ligamentum arteriosus
Dimished $umonar* 1ascuar resistance&hit Ko0 across rom right to et (etus) to et to right (neonate)
2onstriction o uctus .enosus V ligamentum .enosum
Large .eins of the thora2
Barchioce$haic 1eins
&u$erior 1ena ca1a
AJ*gous 1ein
-nerior hemiaJ*gous 1ein
&u$erior hemiaJ*gous 1ein
-nerior 1ena ca1a
!umonar* 1eins
A"gous .ein
Has 1ariabe origin
2ommon* ormed b* union o
right ascening lumbar .ein and
right subcostal .ein
Ascends throughaortic o+ening in the dia$hragm at the
e1e o the th thoracic .ertebra
Arches or0ard to 5oin su+erior .ena ca.a
#nferior hemia"gous .ein
Formed b* union o
Let ascending umbar 1ein
Let subcosta 1ein
Ascends through et crus o the dia$hragm to 5oin the aJ*gous 1ein
Su+erior hemia"gous .ein
Formed b* union o
Fourth intercosta 1ein
Eighth intercosta 1ein
oins aJ*gous 1ein
Large arteries of the thora2
Aorta
Ascending aorta
Arch o the aorta
Descending aorta
!umonar* trunk
Aorta
• Di1ided into our $arts
'. Ascending aorta
". Arch o ascending aorta
?. Descending aorta
. Abdomina aorta
First ? $arts, are in the thora+
Ascening aorta
Arises rom et 1entriceAscends behind sternum to e1e o sterna ange
2ontinuous 0ith the arch o the aorta
%hree (?) buges behind each aortic cus$ sinuses of the aorta
;sinuses of Valsalva<
Branches
(ight coronar" arter" (anterior aortic sinus)
Left coronar" arter"
($osterior aortic sinus)
Arch of the Aorta
2ontinuation o ascending aorta
Arches u$0ard, back0ard, and to the et
Behind the manubrium sterni and
-n ront o the trachea
Le1e o the sterna ange
2ontinous 0ith descending aorta
=eated inerior* toroot o the et ung
Ligamentum arteriosum
Let recurrent ar*ngea ner1e
Biurcation o the $umonar* trunk
Arch o the Aorta
%hree (?) Branches rom con1e+ surace
Brachioce$haic arter*
Let common carotid arter*
Let subca1ian arter*
5escening Aorta
2ontinuation o the arch o the aorta
Let side o o0er border o the bod* o the Eth thoracic .ertebra
,sternal angle-
Descends through +osterior meiastinum unti
anterior surace o 1;th thoracic .ertebra
Enters the abdomen behind the dia$hragm
Becomes continous 0ith abdomina aorta
5escening aorta
Branches
!osterior intercosta arteries
!ass to the o0er nine intercosta s$aces
&ubcosta arteries
Aong o0er border o '"th rub to enter abdomina 0a
!ericardia arteries
Eso$hagea arteries
Bronchia arteries
L"m+h .essels
%horacic duct
=oot o the et side o neck
L*m$h rom
Lo0er imbs
!e1ic ca1it*
Abdomina ca1it*Let side o thora+
Let side o head, neck
Let u$$er imb
At termination, recei1es
left >ugular, subclavian, mediastinal lymph trun6s
But these 1esses ma* drain inde$endent* into neighboring great
1eins
L"m+h .essels
'horacic uct
Begins in abdomen as
Cisterna ch"li (a diated sac)
Ascends through aortic o$ening in dia$hragm
right sie of the escening aorta
=eaches left borer of eso+hagus
Foo0s eso$hagus to root o neck
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%urns atera* behind carotid sheath
Enters beginning o left brachioce+halic .ein
L"m+h .essels
(ight l"m+hatic uct
=oot o right side o neck,
beginning o right brachioce$haic 1ein
Drains *m$h rom
=ight side head, neck
=ight u$$er imb
=ight side o thora+
&ometimes absent
Large ner.es of the thora2
agus ner1e!hrenic ner1e
%horacic $art o s*m$athetic trunk
4agus ner.es
(ight .agus ner.e
2rosses anterior to subcla.ian arter"
Descends laterall" to the trachea
&eial to a"gous .ein
=uns behin root o right ung
2ontributes to the +ulmonar" +le2us
Posterior to eso+hagus
2ontributes to eso$hagea $e+us
Lea1es thora+ and enters abdomen through eso$hagea o$ening
4agus ner.es
Left .agus ner.e
Descends into thora+ between
Left common carotiLeft subcla.ian arteries
Descends behin root o et ung
2ontributes to +ulmonar" +le2us
Anterior to eso+hagus
2ontributes to eso+hageal +le2us
Enters abdomen through eso$hagea o$ening
Phrenic ner.es
From anterior rami o ?rd, th, Pth cer1ica ner1es
(ight +hrenic ner.e
Descends in thora+ aong right side o 1ena ca1a
-n front of root o right ung
!asses o1er $ericardium into the dia$hragm
Phrenic ner.es
Left +hrenic ner.e
descends aong et side o et subca1ian arter*
2rosses et side o the aortic arch and et 1agus ner1e
!asses in front of root o et ungDescends on $ericardium into dia$hragm
Phrenic ner.es
%he #NL: motor su$$* to the dia$hragm
&ensor* branches to
!ericardium
Mediastina $arieta $eura
!eura co1ering u$$er and o0er suraces o dia$hragm
'horacic +art of s"m+athetic trunk
Most atera structure in the mediastinum
''/'" segmenta* arranged gangia
stellate ganglion
First gangion oten used 0ith inerior cer1ica gangion
Do0n0ard on heads o the ribs
Lea1es thora+ $assing behind media arcuate igament
2ontinuous 0ith umbar $art o s*m$athetic trunk
'horacic +art of s"m+athetic trunk Branches
2ardiac, Aortic,!umonar*, Eso$hagea branches
From 4rst 41e gangia
&$anchnic ner1es
&u$$* abdomina 1iscera
7reater s$anchnic
7angia P/
Lesser s$anchnic
7angia 'C/''
Lo0est s$anchnic
Last thoracic gangion
%so+hagus
Muscuar tube
A$$ro+ 'Cin ("Pcm)
2ontinuous 0 $harn*+
#$$osite @th cer1ica 1ertebrae
!asses through dia$hragm
Le1e o 'Cth thoracic 1ertebra
%hree (?) constrictions
Beginning
2rossing o et bronchus
!iercing the dia$hragm
%so+hagus
Bood su$$*
$$er ?rd
inerior th*roid arter*
-nerior th*roid 1ein
Midde ?rdbranches rom descending thoracic aorta
AJ*gous 1ein
Lo0er ?rd
Let gastric arter*
Let gastric 1ein
V tributar* to $orta 1ein
V +ortos"stemic anastomosis
'h"mus
Fattened
Biobed structure
Bet0een sternum and $ericardium
2ontinues to gro0 unti $ubert*
-m$orant source o
%/*m$hoc*tes
%he End
Abomen
Loubomir E. Antonio, M.D.
Surface &arkings
; 4ertical lines
/ mid $oint o A&-& and s*m$h*sis $ubis
; )oriontal lines
&ubcosta $ane9 L=
-ntertubercuar $ane L
(egions
E$igastrium
= and L H*$ochondriac
mbiica
= and L Lumbar
H*$ogastric
= and L -iac
'rans+"loris Plane- 'ddison1s plane
- Le1e o L1 , th costal cartilage -
Structures
undus o 7B
termination o adut s$ina cord
$*orus o stomach
neck o $ancreas
hium o kidne*
AN'%(#*( AB5*&#NAL ALL
Skin
Su+er!cial fascia
supercial fatty 3Camper1s fascia4
deep membranous 3$carpa1s fascia4
/ ades atera* and abo1e
/ inerior* uses 0ith dee$ ascia o the thigh
/ orms a tubuar sheath or the $eniscitoris
/ attached to the sides o $ubic arch ( 2oe>s
ascia )
/ uses 0ith $erinea bod* and $erinea
membrane
5ee+ fascia
&uscles
Ner.es
Skin
Ner.e Su++l"
From Anterior =ami o
• lower si2 ,G- thoracic
– Lo0er P intercosta ner1es
– &ubcosta ner1es
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• First lumbar ner.es
– -ioh*$ogastirc
– -ioinguina ner1es
Skin
Bloo Su++l"
Arteries
• Midine
– &u$erior e$igastric arter*
– -nerior e$igastric arter*
• Fanks
– -ntercosta
– Lumbar
– Dee$ circumKe+ iiac arteries
Skin
Bloo Su++l"
eins
• Abo1e
– A+iar* 1ein
– 1ia Latera thoracic 1ein
• Beo0
– Femora 1ein
ia
– &u$er4cia e$igastric 1ein
– 7reat sa$henous 1eins
Skin
Bloo Su++l"
eins
2onnection bet0een su+erior an inferior .ena ca.aeSmall +araumbilical .eins
Aong ligamentus teres to +ortal .ein
;0aput 5edusae7
Skin
L"m+h 5rainage
&u$er4cia
2utaneous
Abo.e umbilicus
Anterior a+iar* *m$h nodes
Below umbilicus
&u$eri4cia inguina *m$h nodes
(ectus Sheath
Long 4brous sheath a$oneuroses
Contents9
=ectus abdominis
Anterior rami o o0er @ thoracic ner1esL*m$h 1esses
&u$erior and inerior e$igastric 1esses
!*ramidais
(ectus Sheath
Between Costal margin an AS#S
-nterna obiue s$its to co1er rectus abdominis
Below AS#S an Abo.e +ubis
A a$oneuroses $ass anterior*
De4cient $osterior*
Arcuate line of 5ouglas
/ o0er crescent sha$ed edge o the $osterior 0a
(ectus Sheath
Linea alba
Fibrous band
Fusion o a$oneurosis at midinerom 2i+hoi +rocess to +ubic s"m+h"sis
'rans.erse 'eninous intersections
(') Le1e o +i$hoid
(') in bet0een
(') Le1e o umbiius
Linea Semilunaris
“S+iegelian Line”
Lateral ege o the rectus abdominis
2rosses margin o ti$ o the ninth costa cartiage
Conoint 'enon
#nternal obliIue
Lo0er ree border
Lo0est tendinous 4bers
5oined b* trans.ersus abominis
&trengthens media ha o $osterior 0a o inguina cana
#nguinal Ligament
Pou+art7s ligament
Lo0er border o E+terna obiue a$oneurosis
2onnects Anterior &u$erior -iac &$ine (A&-&) to $ubic tuberce
Media end lacunar ligament ,$imbernat7s ligament-
2ontinuous 0ith +ectineal ligament ,Coo+er7s ligament-
T thickening o $eriosteum
Lo0er border,
Attached to ascia ata
Fascia 'rans.eralis
%hin a*er o ascia ining trans1erais musce
2ontinuous 0ith ascia iiaca (o iacus musce) %ogether orms emora sheath
Femoral sheath Q F' R F#
#nguinal Canal
Length A$$ro+ '.Pin (cm)
!arae and abo1e inguina igament
5ee+ inguinal ring
#1a o$ening in %rans1erais ascia
Abo1e inguina igament
Margins attachment or interna s$ermatic ascia
Su+er!cial inguinal ring
%rianguar sha$ed deect on E+terna obiue a$oneurosis
Abo1e and media to $ubic tuberce
Margins gi1e attachment to e+terna s$ermatic ascia
#nguinal Canal
alls
Anterior• E+terna obiue a$oneurosis
• -nterna obiue
Posterior
• 2on5oint tendon, media*
• Fascia trans1erais, atera*
Su+erior
• Arching 4bers o the interna obiue and trans1ersus
#nferior
• -nguina and acunar igaments
#nguinal Canal
Function
Ao0s structures to $ass
rom %estes to Abdomen S+ermatic cor
terus to abium ma5us (oun ligament of uterus
Both se+es transmit #lioinguinal ner.e
)esselbach7s 'riangle&eiall"9
=ectus abdominis
#nferiorl"9
-nguina igament
Laterall"9
-nerior e$igastric 1esses
#nguinal )ernia
&ite o $otentia 0eakness in both se+es
Abo.e inguinal ligament
/ lateral to inerior e$igastric 1esses
-ndirect -nguina Hernia
/ meial to inerior e$igastric 1esses
Direct -nguina Hernia
Below inguinal ligament
Femora hernia
S+ermatic Cor Contents&N%&*N#C9 Protruding Pies 5on>t Contribute 'o A $ood Se+ Lie
Pam$iniorm $e+us
Processus 1aginais remnants
5eerens, 1as
Cremasteric arter*
'esticuar arter*
Arter* to 1as
$enita branch, genitoemora ner1e
S*m$athetics
L*m$hatics
Processus .aginalis
!eritonea di1erticuum ormed in etus
!asses through o0er $art o anterior abdomina 0a to orm inguina
cana
S+ermatic cor
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Co.erings
%2ternal s+ermatic fascia
From e+terna obiue
Attached to margins o su$er4cia inguina ring
Cremasteric fascia
From interna obiue
#nternal s+ermatic fascia
From ascia trans1ersais
Attached to margins o dee$ inguina ring
$ubernaculum testis
Muscuoigamentous cord
2onnects eta testis 0 Koor o scrotum
-m$ortant roe in descent o testisHomoog &ound ligament of ovary and uterus
Scrotum
#ut$ouching o o0er $art o anterior abdomina 0a
2ontains
%estes
E$idid*mis
Lo0er ends o s$ermatic cord
Scrotum
La"ers
'. Skin
". Su+eri!cal fascia “5artos muscle”
?. %2ternal s+ermatic fascia
. Cremasteric fascia
P. #nternal s+ermatic fascia
@. 'unica .aginalis
N*'%9 ransversus abdominis has N* contribution to the ormation oscrota 0a
'estes
!aired o1oid organs
!roduce
&$ermatoJoa
%estosterone
'unica albuginea
#uter 4brous ca$sue o testis
%+ii"mis
Lies $osterior to testis
2oied tube a$$ro+ "Ct (@m) ong
!arts
)ea
Bo"
'ail
4as eferens emerges rom tai
%+ii"misBloo Su++l"
'esticular arter"
• From abdomina aorta
'esticular .ein
• From testis and e$idid*mis (+am+iniform +le2us)
• =educed to singe 1ein though inguina cana
(#$)'9
• -2
L%F'9
• Let =ena ein
Peritoneum
• &erous membrane
• Lubricates suraces T ree mo1ement
Parietal la"er
• Lines 0as
4isceral la"er• 2o1ers organs
Peritoneal ca.it"
• !otentia s$ace in bet0een
– Maes Close
– Femaes 2ommunicates through uterus, 1agina
Peritoneum
$reater sac
• Main com$artment
• From dia$hragm to $e1is
Lesser Sac
• &maer
• Lies behind stomach
%+i+loic foramen
• Ao0s ree communication bet0een both
Peritoneal 5eri.ati.es
" a*ered ods
Ligaments
#mentum
Mesenter*
Lesser Sac
Behin stomach and esser omentum
Left margin
&$een
7astros$enic omentum
&$enicorena igament
(ight margin
7reater sac (main $art o $eritonea ca1it*)
%hrough e+i+loic foramen%+i+loic Foramen
Bounaries
Anterior
• Free border o esser omentum
Bile uct9 Anterior
)e+atic arter"9 Posterior to the L
Portal .ein9 Posterior to the (
Posterior
• -nerior 1ena ca1a
Su+erior
• 2audate obe o the i1er
#nferior
• First $art o the duodenum
Peritoneal S+aces
Sub+hrenic s+aces
,et/een diaphragm and liver (ight anterior
Left anterior
Posterior sub+hrenic s+ace
Clinically5 provide sites for the accumulation of pus
Peritoneal $utters
Paracolic gutters
Lie on atera and media sides o ascending and descending coons
!ro1ide channes or mo1ement o inected Kuid in the $eritonea ca1it*
Ner.e Su++l" of the Peritoneum
Parietal +eritoneum
Lower G thoracicO !rst lumbar ner.es
!ain, tem$erature, touch, $ressure
4isceral +eritoneum
Autonomic ner.es on mesenteries
&tretch
Stomach
PartsFunus
• dome/sha$ed
Bo"
• rom cardiac ori4ce to incisura angularis
P"loric Antrum
• incisura anguaris to $*orus
P"lorus
• Most tubuuar $art o stomach
• %hick muscuar 0a (+"loric s+hincter)
• 2a1it* (+"loric canal)
Stomach
Parts
Lesser cur.ature
• =ight border o stomach
• 2onnected to li.er b* lesser omentum
$reater cur.ature• Longer
• From et cardiac ori4ce aong et border o stomach
• $astros+lenic omentum@ ligament e+tends rom u$$er
$art to s+leen
• $reater omentum e+tends rom o0er $art to trans.erse
colon
Stomach
Parts
Cariac ori!ce
N# anatomic s$hincter
!h*sioogic s$hincter
P"loric ori!ce
Anatomic and $h*sioogic +"loric s+hincter ormed
&tomach, Bood &u$$*
Arteries
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Lesser cur.ature
• =ight gastric
• Let gastric
$reater cur.ature
• =ight gastroe$i$oic
• Let gastroe$i$oic
Funus
• &hort gastric arteries W s$enic arter*
&tomach, Bood &u$$*
4eins
Drain into Portal Circulation
=ight gastric 1ein
Let gastric 1einS+lenic .ein
&hort gastric 1ein
Let gastroe$i$oic 1ein
Su+erior mesenteric .ein
=ight gastroe$i$oic
5uoenum
2/sha$ed tube
A$$ro+ 'Cin ("Pcm)
2ur1es around head o $ancreas
Begins at +"loric s+hincter
Ends b* becoming the eunum
;n =r an Eth +ortion9 retro+eritoneal
5uoenum
First +art
• %rans$*oric $ane
•
Le.el of L1MSecon +art
• 6ain pancreatic ducts $ierce media 0a V unite to orm
am+ulla ,of 4ater- o$ening into maor uoenal +a+illa
,of irsung-
• 'ccessory pancreatic duct0 o$ens to &inor uoenal
+a+illa ,of Santorini-
5uoenum
'hir +art
• HoriJonta in ront o the 1ertebra coumn
• Anterior* crossed b*
– (oot of mesenter" of small intestine
– Su+erior mesenteric .essels
Fourth +art
• $0ard and et to uoenoeunal Je2ure
• hed in $ostion b* Ligament of 'reit
>eunum #leum
>eunum
• a$$ro+ 8t (".Pm)
• $$er et
• 6ider
• %hicker
• =edder in coor
&eckel7s 5i.erticulum
2ongenita anoma*
!ersistent $ortion o the .itellointestinal uct
antimesenteric border o ieum
(ule of ;s
; ft from iliocecal unction
; inD in length
;T of ini.iuals
Beeding ma* occur rom ad5acent iea mucosa
N*' the di1erticuum
CecumBind/ended $ouch 0ithin right iiac ossa
2om$ete* co1ered 0 $eritoneum
oined on et side b* terminal ilieum
at 5unction o cecum and ascending coon
A$$endi+ at +osteromeial surace
#leocecal 4al.e
%0o horiJonta ods o mucous membrane
Around ori4ce o ieum
#leocecal s+hincter
&$hincter that contros Ko0 o contents rom ieum into coon
A++eni2
Narro0 muscuar tube
Large amount o *m$hoid tissue in its 0a
A$$ro+ 'in (".Pcm)
2om$ete $eritonea co1ering
#0n &esoa++eni2 0
• A$$endicuar 1eses and ner1es
'aniae coli o cecum con1erge to orm its continuous muscuar coat
Ascening colon
A$$ro+. Pin ('?cm) ong
2ecum to inerior surace o right obe o i1er ((ight colic Je2ure)
2ontinuous 0ith trans1erse coon
!eritoneum co1ers ront and sides
'rans.erse Colon
• A$$ro+ 'Pin (?8cm) ong
• mbiica, and h*$ogastric regions
Left colic Je2ure
• higher than the right• Hed u$ b* Phrenocolic ligament
'rans.erse mesocolon
• Attached to su$erior border o trans1erse coon
• &us$ends it rom $ancreas
$osterior a*ers o greater omentum, attached to inerior border
'rans.erse mesocolon
Arteries
!ro+ima "?rds
• &ile colic arter" W su+erior mesenteric arter"
Dista '?rd
• Left colic arter" W inferior mesenteric arter"
4eins
• &u$erior mesenteric 1ein
• -nerior mesenteric 1ein
'rans.erse Colon
L"m+h rainage!ro+ima "?rds
Colic noes su+erior mesenteric noes
Dista '?rd
#nferior mesenteric noe
'rans.erse Colon
Ner.e su++l"
!ro+ima "?rds
• Su+erior mesenteric +le2us
– &*m$athetic
– aga
Dista '?rd
• #nferior mesenteric +le2us
• $e1ic s$anchnic ner1es
– &*m$athetic
– !aras*m$athetic
5escening Colon
A$$ro+ 'Cin ("Pcm) ong
From et coic Ke+ure to $e1ic brim
!eritoneum co1ers ront and sides
Sigmoi Colon
A$$ro+ 'C/'Pin ("P/?8cm) ong
From escening colon in ront o +el.ic brim
%o rectum in ront o =r sacral .ertebra
Attached to $osterior $e1ic 0a b* an/sha$ed sigmoi mesocolon
Li.er
Largest organ o bod*
Di1ided b* falciform ligament into
&ma left lobe
Large right lobe
(ight lobe urther di1ided b*
gall blaerO !ssure of ligamentum teresO #4CO !ssure of
ligamentum .enosum into
6uarate lobe Cauate lobe
Li.er
Porta )e+atis ,hilus-
• !osteroineior surace o i1er
• $$er $art esser omentum attached to margins
2ontains
• (ight an left he+atic ucts
• (ight an left branches of he+atic arter"
• Portal .ein
• Ner.es
• L"m+h .essels
Li.er
Fissure for the ligamentum teres
Bet0een et obe and uadrate obe
Ligamentum teres X 4brous remains o umbilical .ein
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Fissure for the ligamentum .enosum
Bet0een et obe and caudate obe
Ligamentum .enosum X Fibrous remains o the uctus .enosus
Li.er
$roo.e for the inferior .ena ca.a
Bet0een right obe and caudate obe
He$atic 1eins 5oin inerior 1ena ca1a
Fossa for the $allblaer
Bet0een right obe and uadrate obe
N# $eritoneum bet0een the gabadder and right obe o i1er
!eritonea Ligaments
Falciform ligament
Attaches i1erto dia$hragm abo1e
%o anterior abdomina 0a beo0
&icke/sha$ed ree margin
contains ligamentum teres
Peritoneal Ligaments
Coronar" ligament
Attaches i1er to dia$hragm
La*ers 0ide* se$arated orming ;bare area< o i1er de1oid o
co1ering
(ight triangular ligament
/sha$ed od
right e+tremit* o the coronar* igament
2onnects $osterior surace o the right obe o i1er to dia$hragm
Left triangular ligament
reKection rom u$$er surace o the et obe o the i1er to the
dia$hragmLesser *mentum
Attached abo1e to the margins o the
$orta he$atis
Fissure or the igamentum 1enosum
Attached beo0 to esser cur1ature o stomach
$allblaer
!ear/sha$ed sac
Lies in undersurace o i1er
A$$ro+ ?Cm
Parts
• Fundus
• Bod*
• Neck
– 2ontinuous 0 c"stic uct
Bile 5ucts
)e+atic 5uct
(ight an left he+atic ucts (rom each obe bie canaicui 1ia
+orta he+atis) V orm common he+atic uct
oined b* c"tic uct common bile uct
C"stic uct
&/sha$ed
2onnects neck o gallblaer 0 Common he+atic uct
Forming Common bile uct
“S+iral .al.e of )eister”
Common Bile 5uct
nion o c*tic duct 0ith common he$atic duct
oins main +ancreatic uct am+ulla of .ater maor uoenal
+a+illa ,of irsung-
“S+inchter of *i”
2ircuar smooth musce
&urrounds both ducts and am$ua
Pancreas
Parts)ea
Disc sha$ed 0ithin conca1it* o 2/sha$ed duodenum
0ncinate +rocess
!ro5ection to et rom o0er $art to head behind su$erior mesenteric
arteries
Neck
Narro0
2onnects head to bod*
-n ront o beginning o $orta 1ein
Pancreatic uct
&ain +ancreatic uct ,irsung-
• #$ens to second $art o duodenum
• 6ith bie duct
• ia am+ulla of .ater
Accessor" uct ,Santorini-
• #ten absent
• Drains u$$er ha o head
• #$en into duodenum on the minor uoenal +a+illa
S+leen
Largest singe mass o *m$hoid tissue
Lies beneath dia$hragm, thO 1thO 11th rib
#1oid 0 notched anterior border
&urrounded b* $eritoneum
$astros+lenic ligament
• From hius to stomach
• 2ontains short gastric, et gastroe$i$oic 1esses
S+lenicorenal ligament
• %o et kidne*• 2ontains s$enic 1esses, tai o $ancreas
Bloo Su++l"
Celiac arter" ,foregut-
• Lo0er third o eso$hagus to
• Midde second o duodenum
Su+erior mesenteric arter" ,migut-
• Midde second $art o duodenum to
• Dista third o trans1erse coon
#nferior mesenteric ,hingut-
• Dista third o trans1erse coon to
• Ha 0a* do0n ana cana
Celiac arter" ,'runk-
From ront o abdomina aorta, through dia$hragm
'erminal Branches
Let gastric
&$enicHe$atic
Left gastric arter"
=uns to cardiac end o stomach
7i1es oO a e0 eso$hagea branches
%urns right aong lesser cur.ature
Anastomoses 0ith right gastric arter"
S+lenic arter"
Largest branch o ceiac trunk
=uns
aong u$$er border o $ancreas
Behind stomach
Enters s+lenicorenal ligament to hium o s$een
S+lenic arter"O branches
1D Pancreatic branches
;D Left gastroe+i+loic arter"
• From Near hium o s$een
• %o greater cur1ature o stomach
• 6ithin gastros$enic omentum, 7reater omentum
• Anastomoses 0ith right gastroe+i+loic
S+lenic arter"O branches
=D Short gastric arteries
• P/@ in no.
• %o undus o stomach
• =un 0ithin gastros$enic omentum
• Anastomose 0ith left gastric arter"
• Left gastroe+i+loic arter"
)e+atic arter"
Ascends 0ithin lesser omentum
-n ront o o$ening o lesser sac
Let o the bie duct
Front o $orta 1ein
At +orta he+atis Di1ides into
right he+atic arter"left he+atic arter"
)e+atic Arter"O branches
(ight gastric arter"
%o et in esser omentum, aong esser cur1ature
Anastomoses 0ith et gastric arter*
$astrouoenal arter"
Descends behind 4rst $art o duodenum
Di1ides into
(ight gastroe+i+loic arter" V greater cur1ature
Su+erior +ancreaticouoenal arter" V "nd $art duodenum, head
o $ancreas
(ight he+atic arter"
7i1es oO c"stic arter"
Left he+atic arter"
Su+erior &esenteric Arter"
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=eations
From ront o abdomina aorta
Behind neck o $ancreas
Front o ?rd $art o duodenum
Do0n0ard to right in root o mesenter* o sma intestine
Su+erior &esenteric Arter"O Branches
#nferior +ancreaticouoenal arter"
$$er border o the ?rd $art o duodenum beo0 the head o $ancreas
&ile colic arter"
-n trans1erse mesocoon V trans1erse coon
=ight branch anastomoses 0ith right colic
Let branch anastomoses 0ith left colic
Su+erior &esenteric Arter"O Branches(ight colic arter"
• Branch o ieocoic
• &u$$ies ascening colon
#leocolic arter"
• 7i1e oO
Su+erior branch V anatomoses 0ith right coic
#nferior branch V anastomoses 0ith end o su$erior mesenteric arter*
• 7i1es rise to
– Anterior cecal arter"
– Posterior cecal arter" V A++enicular arter"
Su+erior &esenteric Arter"
>eunal an #leal branches
'"/'P in number
Arise rom et side o su+erior mesenteric arter"
Arteries di1ide and unite to orm arcades
&ma, straight branches su$$* intestine#nferior &esenteric Arter"
Arises rom abdomina aorta
A$$ro+ '.Pin (?.8cm) abo1e aortic biurcation
Arter* runs do0nard and to the et
2rosses et common iiac arter*
Becomes su+erior iliac arter"
#nferior &esenteric Arter"O Branches
Left colic arter"
• Di1ides into ascending and descending branches
• &u$$*
– istal =r of trans.erse colon
– Left colic Je2ure
– 0++er +art of escening colon
Sigmoi arteries
• "/? in number
• &u$$ies escening sigmoi colon
#nferior &esenteric Arter"O Branches
Su+erior rectal arter"
• 2ontinuation o inferior mesenteric arter"
• Descends into $e1is behind rectum
• &u$$ies
– (ectum
– 0++er half of anal canal
• Anastomoses 0ith
– &ile (ectal Arter" W #ntenal #liac Arter"-
and
– #nferior (ectal Arter" ,W #nternal Puenal-
&arginal arter"
Anastomosis o coonic arteries
Aong conca1e margin o arge intestine
Begins at ieocoic 5unction
End at 5unction o sigmoid coon and rectum
Portal .enous s"stemPortal .ein
A$$ro+. "in (Pcm) ong
nion o
• Su+erior mesenteric .ein
• S+lenic .eins
Ascends to +orta he+atis
• Behind 4rst $art o duodenum
• -n ree margin o lesser omentum
• Di1ides to right and et termina branches
Portal .enous s"stem
Portal .ein
Drains bood orm 7astrointestina tract
• %o/er end of esophagus
• o half/ay do/n anal canal
• As 0e as rom
– Pancreas
– $allblaer
– Bile ucts
– S+leen
Portal 4enous S"stem 'ributaries
1D S+lenic .ein
=ecei1es
• &hort gastric
• Let gastroe$i$oic
• -nerior mesenteric
• !ancreatic
;D #nferior mesenteric .ein=ecei1es
• &u$erior recta
• &igmoid
• Let coic
Portal 4enous S"stem 'ributaries
=D Su+erior mesenteric .ein
=ecei1es
• e5una
• -ea
• -eocoic
• =ight coic
• Midde coic
• -nerior $ancreaticoduodena
• =ight gastroe$i$oic
ED Left gastric .ein
Drains et $ortion o esser cur1atureDista $art o eso$hagus
D (ight gastric .ein
Drains right $ortion o esser cur1ature
GD C"stic .ein
Drains gabadder
Portal:S"stemic Anastomosis
#&P*('AN'M
'. Dista ?rd, Eso$hagea branches o et gastric 1ein (!orta)
V Midde ?rd, eso$hagea branches o aJ*gous 1eins (&*stemic)
“%so+hageal .arices”
". &u$erior recta 1eins (!orta)
V Midde and -nerior recta 1eins (&*stemic)
“)emorrhois”
Portal:S"stemic Anastomosis
#&P*('AN'M
?. Paraumbilical .eins (in falciform ligament 0 ligamentum
teres) rom et branch o $orta 1ein ($orta)
&u$er4cia 1eins o anterior abdomina 0a (&*stemic)
“Ca+ut meusae”
. eins o ascending and descending coon, duodenum, $ancreas i1er
($orta)
V rena, umbar, $hrnenic 1eins (s*stemic)
/ine"s
• !aired organs
• =etro$eritonea
=ight kidne* o0er than et due to i1erY
)ilus
• 2onca1e border o kidne*
• E+tends to ca1it* o renal sinus
%ransmits
• =ena 1ein
• =ena arter*
• reter• &*m$athetic ner1e 4bers
;.A..A.<
/ine"s
2o1erings rom 0ithin to 0ithout
Fibrous ca+sule
• %rue ca$suerena ca$sue
• 2ose* a$$ied to outer surace
Perirenal fat
• Fat co1ering 4brous ca$sue
(enal Fascia
• ;$erotas fascia<
• Encoses kidne* and su$rarena gands
Pararenal fat
• E+terna to rena ascia
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/ine"sO Structure
*uter corte2
• E+tends into medua bet0een ad5acent $*ramids ((enal
columns)
#nner meulla
• '" rena $*ramids (base to0ard corte+9 a$e+ / renal +a+illa
oriented media*)
• &eullar" ra"s
&triations rom bases o $*ramids to corte+
/ine"sO Structure
(enal Pel.is
$$er e+$anded end o ureter
Di1ided into 'wo maor cal"ces&ubseuent* di1ided into ;:= minor cal"ces
Each minor ca*+ indented b* a$e+ o rena $*ramid (renal +a+illa)
/ine"sO Bloo Su++l"
Arter"
• =ena arter*
4ein
• =ena 1ein
L"m+h rainage
• Latera aortic *m$h nodes
– Around rena arter* origin
Ner.e su++l"
• =ena s*m$athetic $e+us
0reters
Muscuar tubes e+tend rom kidne*s to $osterior surace o urinar*
badder
A$$ro+ 'Cin ("Pcm) ong(enal +el.is
Lies 0ithin renal hilus
$$er e+$anded end o ureter
recei1es ma5or ca*ces
0reteric Constrictions
'. unction o $e1is and ureter
". 2rossing o $e1ic brim
?. !iercing o badder 0a
0reter
Arteries
$$er end
• (enal arter"
Midde
• 'esticular@ o.arian arter"
-nerior end
• Su+erior .esicular arter"
4einseins corres$ond to arteries
Su+rarenal ,Arenal- $lans
Located to u$$er $oes o kidne*s
=etro$eritonea
&urrounded b* rena ascia
&e$arated rom kidne*s b* $erirena at
Has
Corte2 (*eo0 coored)
&eulla (bro0n coored)
Su+rarenal ,Arenal- $lans
Arteries
#nferior +hrenic arter"
Aorta
(enal arteries
4eins
(ight su+rarenal .ein inferior .ena ca.aLeft su+rarenal .ein left renal .ein
Aorta
Abominal aorta
Enters through aortic o$ening in dia$hragm ,'1;-
Di1ides into common iiac ,LE-
Aorta
Branches
'. 'hree ,=- anterior .isceral
• 2eiac arter*
• &u$erior mesenteric
• -nerior mesenteric
". 'hree ,=- lateral .isceral
• &u$rarena arter*
• =ena arter*
• %esticuar o o1arian arter*
Aorta
Branches
?. Fi.e ,- lateral abominal
• -nerior $hrenic arter* (')
• Four umbar arteries ()
. 'hree ,=- terminal
• %0o common iiac arteries (")
• Median sacra arter* (')
Common #liac Arteries
%ermina branches o abdomina aorta
=un do0n0ard and atera*
Di1ide into e+terna and interna iiac arteries
2rossed anterior* b* ureter on each side#nferior .ena ca.a
Formed b* union o common iiac 1eins (LP)
!ierces centra tendon o dia$hragm at (%8)
%o right atrium
#nferior .ena ca.aO tributaries
'ributaries
' %0o (") anterior 1iscera
• He$atic 1eins
". %hree (?)atera 1iscera
• =ight su$rarena 1ein
• =ena 1eins
• =ight testicuaro1arian 1ein
Let drains to et rena
#nferior .ena ca.aO tributaries
'ributaries
?. Fi1e (P) atera abdomina 0a tributaries-nerior $hrenic 1ein (')
Four umbar 1eins ()
. %hree (?) 1eins o origin
%0o common iiac 1eins (")
Median sacra 1ein (')
L"m+hatics on +osterior abominal wall
C"sterna Ch"li ,thoracic uct-
Eongated sac in abdomen
Lies on right side o aorta (L'/L")
=ecei1es
-ntestina trunk
=ight and Let umbar trunks
L*m$h 1esses rom o0er $art o thora+
Lumbar Ple2us Branches, L1L;L=LE -
&N%&*N#C9 # ;2 $et Lai *n Fria"
#ioinguina (L')
#ioumbar (L')
$enita branch, genitoemora ner1e (L'L")
Latera cutaneous ner1e o the thigh (L"L?)
*bturator (L"L?L)
Femora (L"L?L)
A arise lateral to $soas %?C%P'9
7enita branch, genitoemora ner1e ( anterior )
#bturator ner1e ( medial )
S"m+athetic trunk
Enters abdomen behind media arcuate igament
=uns do0n0ard aong media border o $soas musce
#n bodies o umbar 1ertebrae
Enter $e1is behind common iiac 1esses
!ossess /P segmenta* arranged gangia
&uscles of Posterior Abominal all
!soas
Quadratus umborum-iacus
Ner1e su$$* Lumbar $e+us E2E!% -iacus ( emora ner1e )
%HE END
• Pel.is an Perineum
• Loubomir E. Antonio, M.D.
• Bon* !e1is
Four ,E- bones
• %0o (") hi$s bones
• &acrum
• 2occ*+
Pel.ic brim com+ose of9
• &acra $romontor* ($osterior*)
• -io$ectinea ines (atera*)
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• &*m$h*sis $ubis (anterior*)
5i.ies +el.is into9
• False +el.is (greater $e1is) / AB#E
• 'rue +el.is (esser $e1is) / BEL#6
• 'rue Pel.is
Pel.ic #nlet
• &acra $romontor* ($osterior*)
• -io$ectinea ines (atera*)
• &*m$h*sis $ubis (anterior*)
*utlet
• 2occ*+ ($osterior*)
• -schia tuberosities (atera*)
• !ubic arch (anterior*)Ca.it"
• Bet0een inet and outet
• &hort cur1ed cana
• &hao0 anterior 0a
• Dee$er $osterior 0a
• %rue $e1is
Ligaments
• &acrotuberous igament
• &acros$inous igament
Di1ide sciatic notches to
$reater sciatic foramen
Lesser sciatic foramen
• Sacroiliac oint
• &trong s*no1ia 5oint
Between
•
&acrum• -iac bones
Su++orte b"
• !osterior sacroiiac igament
• -nterosseous sacroiiac igament
• Anterior sacroiiac igament (thin)
%ransmit 0eight o bod* rom 1ertebra coumn to bon* $e1is
Ner.e Su++l"
• &acra $e+us
• S"m+h"sis +ubis
2artiagenous 5oint
Bet0een t0o $ubic bones
• Articuar surace co1ered b* h*aine cartiage
• 2onnected b* 8brocartilagenous disc
• oint surrounded b* igaments
• No mo1ement $ermitted
• Sacrococc"geal oint
2artiagenous 5oint
Bet0een sacrum and cocc*+
2ornua o sacrum and cocc*+ 5oined b* igaments
7reat dea o mo1ement $ossibe
Ligaments rea+ed during $regnanc*
• &e+ diOerences o $e1is
• alls of the +el.is
Anterior wall
• Bodies o $ubic bone
• !ubic rami
• &*m$h*sis $ubis
• &acrotuberous igament
• &trong
From
• Lateral +art of Sacrum an Cocc"2 and
• Posteroinferior #liac s+ine
%o V• #schial tuberosit"
$re1ent o0er end o sacrum rom being rotated b* the bod*
• &acros$inous igament
&trong
%rianguar sha$ed
Base lateral +art of sacrum an cocc"2
A$e+ s+ine of ischium
!re1ent o0er end o sacrum rom being rotated b* the bod*
• -nerior $e1ic 0a (!e1ic Foor)
• &u$$ort $e1ic 1iscera
Formed b* +el.ic ia+hragm
• Le1ator ani musce
• &ma cocc*gea musces
• !e1ic asciae
-ncom$ete anterior*
• Ao0s $assage o urethra (and 1agina)
• !EL-2 F=A2%=E
• Musces o the !e1ic 6as and Foor
• !iriormis
• #bturator internus
• Le1ator ani
– !uborectais
– !ubococc*geus
– -iococc*geus
• 2occ*geus
• !e1ic Fasciae
Parietal +el.ic fascia• Line $e1ic 0as
• 2ontinuous 0ith ascia ining abdomina 0as
• !e1ic Fasciae
4isceral +el.ic fascia
• 2o1ers a $e1ic 1iscera
• Parametrium 3 ascia around cer1i+
• !e1ic $eritoneum
• Lines $e1ic 0as
• =eKected onto $e1ic 1iscera
• 2ontinuous 0ith 1iscera $eritoneum
• Ner1es o the !e1is
• &acra !e+us
• Branches o umbar $e+us
• Autonomic ner1es
• Sacral +le2us
#n $osterior $e1ic 0a-n front of +iriformis
Formed b* anterior rami of LE:LO S1:SE ner.es
Lumbosacral trunk ,Lumbar +le2us-
• 2ombination o L and LP
• !asses into $e1is
• oins sacra ner1es
• Sacral Ple2us Branches
&N%&*N#C9 N* Priests See$s Sound* #nside Nuns 6uarters
Ner1e to *bturator internus
Posterior cutaneous ner1e o the thigh
Sciatic ner1e
Su$erior gutea ner1e
#nerior gutea ner1e
Ner1e to 6uadratus emoris
,ranches that leave the pelvis through Greater sciatic foramen
• Sacral Ple2us Branches
,ranches to the pelvic muscles0 viscera and peritoneum
!udenda ner1e
Ner1e to $iriormis musce
!e1ic s$anchnic ner1es ( &"&?& )
• Lumbar Ple2us
&N%&*N#C9 # ;2 $et Lai *n Fria"
#ioinguina
#ioumbar
$enita branch, genitoemora ner1e
Latera cutaneous ner1e o the thigh
*bturator
Femora
• Autonomic ner1es
Pel.ic +art of s"m+athetic trunk
2ontinuous 0ith umbar $art
%0o trunks come together in rom o cocc*+
&*m$athetic trunk has /P segmenta gangiaBranches
• $ra" rami communicantes
– $acral nerves
– Coccygeal nerves
• Fibers to h"+ogastric +le2uses
• Autonomic ner1es
Pel.ic s+lanchnic ner.es
• &arasympathetic part of autonomic nervous system
• From S;O=OE
• !regangionic 4bers V gangia o h*$ogastric $e+uses
• Autonomic Ner.es
Su+erior )"+ogastric Ple2us
#n front of +romontor"
Di1ides to
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• =ight h*$ogastric ner1e
• Let h*$ogastric ner1e
2ontinuation o
• Aortic $e+us and
• Branches o ?rd, th umbar s*m$athetic gangia
• 2ontains
– Sympathetic
– Sacral parasympathetic
– -isceral a?erent
• Autonomic Ner.es
#nferior )"+ogastric Ple2us
From
• h"+ogastric ner.e (o su$erior h*$ogastric $e+us)• Pel.ic s+lanchnic ner.e
2ontains
• &ostganglionic sympathetic
• &re*and*post ganglionic parasympathetic
• Visceral a7erent
&u$$*
• Large bo0e rom left colic @exure to upper half of anal
canal
• Arteries of Pel.is
False Pel.is
• 2ommon -iac arter*
• E+terna -iac arter*
'rue Pel.is
• -nterna -iac arter*
– Anterior di1ision
–
!osterior di1ision• &u$erior =ecta arter*
• #1arian arter*
• Median sacra arter*
• Common #liac Arter"
Ends at $e1ic inet in ront o the sacroiiac 5oint
Di1ides into
• E+terna iiac
• -nterna iiac
• %2ternal #liac
Media border o $soas
Foo0s $e1ic brim
Branches
• #nferior e+igastric
• 5ee+ circumJe2 iliac
Lea1es ase $e1is as femoral arter"
• #nternal #liac
Lea1es $e1is thorugh greater sciatic foramen
Di1ides into
• Anterior i.ision
• Posterior i.ision
&u$$*
• &elvic viscera
• &erineum
• &elvic /alls
• ,uttoc8s
• #nternal #liac Arter" Branches
&N%&*N#C9 # &iked *ur #nsatiabe -nterns 0dders 0nder the 5esk
#nerior gutea
&idde recta
*bturator
#nerior 1esica
#nterna $udenda
0mbiica &u$erior 1esica0terine agina
the
5eerentia
• Posterior 5i.ision of #nternal #liac
#ioumbar arter*
Latera sacra arteries
Su$erior gutea arteries
• Su+erior (ectal Arter"
Direct continuation o inerior mesenteric arter*
&u$$ies
• mucous membrane o rectum
• $$er ha o ana cana
• *.arian Arter"
From abdomina aorta (L' e1e)
!asses do0n0ard behin the $eritoneum
Enters sus+ensor" ligament of o.ar"
!asses into broad igament
Enters o1ar* through meso1arium
• &eian Sacral Arter"
• Biurcation o the aorta (LLP )
• Descends o1er anterior surace o the sacrum and cocc*+
• eins o the !e1is
Fase !e1is
• E+terna -iac 1ein
%rue !e1is
• -nterna -iac 1ein
• &u$erior recta 1ein• #1arian 1ein
• Median &acra 1ein
• %2ternal #liac 4ein
• Begins behind inguina igament
• 2ontinuation o emora 1ein
• =uns media* to arter*
• oins interna iiac 1ein V common iliac .ein
• =ecei1es
– #nferior e+igastric
– 5ee+ circumJe2 iliac
• #nternal #liac 4ein
• nion o tributaries corres$onding to branches o internal
iliac arter"
• ascends in ront o sacroiiac 5oint
• oins e+terna iiac V common iliac .ein
•
Su+erior (ectal 4ein5rains
• =ecta mucous membrane
• Mucous membrane o u$$er ha o ana cana
#m+ortantM +ortal:s"stemic anastomosis
as it unites 0ith inferior mesenteric vein
• *.arian 4ein
(ight o1arian 1ein
drains into inferior vena cava
• &eian Sacral 4ein
• &ma
Drains into
• #nferior .ena ca.a or
• Left common iliac .ein
• Sigmoi Colon
• 'C/'Pin ("P/?8cm) ong
• From +el.ic brim to S=
• Attached to $osterior $e1ic 0a b* sigmoid mesocoon
• (ectum
A$$ro+. Pin ('?cm) ong
From &? to ti$ o cocc*+
!ierces $e1ic Koor V ana cana
'eritoneum only co.ers upper =!3rds
• (ectum
(ectal am+ulla
• Diated o0er $ortion
'rans.erse fols , )ouston7s .al.es-
• %hree (?) semicircuar ods
su+erior : L
mile : (
inferior : L
• (ectum
Arteries
• &u$erior recta arter* W inerior mesenteric arter*• Midde recta arter* W interna iiac arter*
• -nerior recta arter* W interna $udenda arter*
• (ectum
4eins
• &u$erior recta 1ein V $orta s*stem
• Midde recta 1ein V s*stemic s*stem
• -nerior recta 1ein V s*stemic s*stem
• (ectum
L"m+h rainage
• !ararecta nodes
• V inerior mesenteric nodes
• V interna iiac nodes
• =ectum
Ner.e Su++l"
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• -nerior h*$ogastric $e+uses
– &*m$athetic
– !aras*m$athetic
• 0reters
Muscuar tube rom kidne* to $osterior surace o badder
Enter $e1is crossing biurcation o common iiac arteries
• =uns do0n atera 0a o $e1is
Enters atera ange o badder
• In males, crossed b* .as eferens
• In females, turns or0ard meiall" beneath broa
ligament
• crossed b* uterine arter"
• 0reteric Constrictions %hree (?) constrictions
'. 6here rena +el.is oins ureter
". 6here it is kinked as it crosses the +el.ic brim
?. 6here it +ierces the blaer wall
• 0rinar" Blaer
Ma+ ca$acit* a$$ro+ PCCm
!*ramida
A+e29
• connected to umbilical ligament (remains o urachus)
Base9
• aces $osterior*
• trianguar
Neck9
• $oints inerior*
Su+ralateral angles9
•
entr* o ureters#nferior angle9
• e+it o urethra
Su+erior surface9
• co1ered 0 $eritoneum
• 0rinar" BlaerO #nterior
'rigone
• -nterna surace
&mooth mucous membrane adheres to under*ing musce
0reteral *+enings
&ma sit ike o$ening at atera anges
#nterureteric rige runs in bet0een
• orms u$$er imit o trigone
• 0rinar" BlaerO #nterior
#$ening o urethra beo0
-n maes, median obe o $rostate buges sight* u$0ard
0.ula .esicae
• &0eing behind urethra ori4ce
• 0rinar" BlaerO muscular coat
5etrusor muscle
• %hree (?) interacing a*ers o smooth musce 4bers
S+hincter .esicae
• 2ircuar musce at neck o badder
• 0rinar" blaerO ligaments
Ligaments rom $e1ic ascia
Hod badder neck in $ace
Pubo+rostatic ligament
• maes
Pubo.esical ligament
• emaes
• 0rinar" Blaer
Arteries
Internal Iliac artery 9
• &u$erior 1esica arter*• -nerior 1esica arter*
4eins
Internal Iliac vein
• 0rinar" Blaer
L"m+h rainage
• -nterna -iac nodes
• E+terna -iac nodes
Ner.e Su++l"
Inferior !ypogastric plexus
• &*m$athetic
• !aras*m$athetic
• 4as 5eferens
• %hick/0aed tube
• A$$ro+ '8in (Pcm) ong
• From o0er endtai o e$idid*mis
• %hrough inguina cana
• 2rosses ureter to reach $osterior badder
• E+$ands orming am+ulla
• oins seminal .esicle
• V eaculator" uct
• %aculator" uct
• %0o (")
From union o
• 4as eferens
• 5uct of seminal .esicle
• #$en into +rotastic urethra
• Seminal 4esiclesMuch coied tube embedded in connecti1e tissue
Located on
• !osterior surace o badder
• Latera $art o 1as deerens
2ontribute
• Fluid
• Fructose
• "scorbic acid
• "mino acids
• 'rostaglandins
• Prostate
7anduar
&urrounds $rostatic urethra
• Beo0 neck o badder
• Abo1e urogenita dia$hragm
Fibrous ca$sue• And 4brous sheath X 1iscera a*er o $e1ic ascia
Base9
• ies su$erior* against badder neck
A+e29
• ies inerior* against urogenita dia$hragm
• Prostate
• E5acuator* ducts o$en into $rostatic urethra at atera
margins o Prostatic utricle
Lobes
• Anterior
• &ile@meian
– Behind urethra, abo1e e5acuator* ducts
• (ight lateral
• Left lateral
• Prostate
Arteries
• -nerior 1esica
• Midde recta
• Prostate
L"m+h rainage
• -nterna -iac nodes
Ner.e Su++l"
• -nerior h*$ogastric $e+us
• *.aries
Found in *.arian fossa
• De$ression near atera 0a o $e1is
• Bounded b* external and internal iliac arteries
&eso.arium
• Attaches o1ar* to back o broad igament
)ilum
• Entr* o o1arian 1esses and ner1es
• *.aries
$erminal e+ithelium• Modi4ed area o $eritoneum co1ering o1ar*
• %hin 4brous ca$sue ('unica albugina) beneath
*uter Corte2
• 2ontains o.arian follicles
#nner &eulla
• Ligaments of *.aries
Sus+ensor" Ligament
• Latera $art o broad igament
• 2onnects meso1arium to atera $e1ic 0a
• 2ontains
– Bood
– L*m$hatic 1esses
– Ner1es
(oun Ligament
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• =emains o u$$er $art o gubernaculum
• (Round ligament of uterus : lo/er part;
• Media margin o o1ar* to atera 0a o uterus
• *.aries
Arteries
• #1arian arter* W abdomina aorta
• eins
*.arian .ein
V (right) inerior 1ena ca1a
V (et) et rena 1ein
• 0terine tubes
$$er border o broad igament
2onnects $eritonea ca1it* in region o o1ar* 0ith ca1it* o uterusPro.ies
• Conuit or s$ermatoJoa to reach o1um
• &ite or fertiliation o the o1um (usua* the am+ulla)
• Nourishment or ertiiJed o1um
• 'rans+orts o1um to ca1it* o uterus
• 0terine 'ubes
Four 9A# parts
1D #nfunibulum
• Funne/sha$ed
• 0 4mbrae dra$ed o1er o1ar*
;D Am+ulla
• 6idest $art
=D #sthmus
• Narro0est $ortion o tube
• ust atera to uterus
ED #ntramural• !ierces uterine 0a
• 0terine tubes
Arteries
• terine and o1arian arteries
4eins
• terine and o1arian 1eins
L"m+h rainage
• -nterna iiac
• !ara/aortic nodes
Ner.e su++l"
• &u$erior h*$ogastric $e+us
• -nerior h*$ogastric $e+us
&*m$athetic, !aras*m$athetic
• 0terus
Funus
• Abo1e entrance o uterine tubes
Bo"
• Beneath entrance o uterine tubes
Cer.i2
• !ierces anterior 0a o 1agina
• #nternal os
– terine o$ening
• %2ternal os
– agina o$ening
• 0terus
!ositions
Ante.ersion
• For0ard bending o uterus on ong a+is o 1agina
AnteJe2ion
• For0ard bending o uterus aong ong a+is o bod* o uterus
on cer1i+
• 0terine Su++ort
Pel.ic ia+hragm/ Most -m$ortant
!erinea bod*
%rans1erse cer1ica ( cardina ) igaments
!ubocer1ica igament
&acrocer1ica igament
• Broa ligaments
%0o/a*ered ods o $eritoneum
Latera margins o uterus VLatera $e1ic 0as
Contains
• 0terine tube (in u$$er ree border)
• (oun ligaments o o1ar* and o the uterus
• 0terine an o.arian
– Bloo .essels
– L"m+h .essels
– Ner.es
Litte su$$ort or the uterus
• (oun ligament of uterus
&u$eroatera ange o uterus
inguina cana
subcutaneous tissue o abium ma5us
Assists in uterine
• Ante1ersion
• AnteKe+ion
• 0terus
Arteries
• terine arter* W interna iiac
• #1arian arter*4eins
• terine 1ein
• #1arian 1ein
• 0terus
L"m+h rainage
Fundus
#1arian arter* V
• !ara/aortic nodes (e1e L')
Bod* and 2er1i+
• -nterna and e+terna iiac nodes
Ner.e Su++l"
• -nerior h*$ogastric $e+us
&*m$athetic, !aras*m$athetic
• 4agina
Femae genita cana
•
E+cretor* duct or menstrua Ko0• Birth cana
Muscuar tube bet0een 1u1a and uterus
2er1i+ $ierces anterior 0a
)"men
• Mucosa od ound in 1irgins
• !erorated at center
• 4agina
Area surrounding cer1i+
Four fornices
• Anterior
• !osterior
• =ight atera
• Let atera
=eations
+pper half:
bet0een
• $e1is (anterior*) and
• rectum ($osterior*)
(ower half:
0ithin $eritoneum
• rethra (anterior*)
• Ana cana ($osterior*)
• 4aginaO Su++ort
0++er thir
• Le1atores ani musces
• %ranscer1ica igament
• !ubocer1ica igament
• &acrocer1ica igament
&ile thir
• rogenita dia$hragm
Lower thir
• !erinea bod*
• 4aginaArteries
• agina arter* W interna iiac arter*
• agina branch o uterine arter*
4eins
• -nterna iiac 1eins
• 4agina
L"m+h rainage
$$er ?rd
V interna R e+terna iiac nodes
Midde ?rd
V interna iiac nodes
Lo0er ?rd
V su$eri4cia inguina nodes
Ner.e Su++l"
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• -nerior h*$ogastric $e+us
• 4isceral +el.ic fascia
2o1ers su$$orts $e1ic 1iscera
2ondensed to orm
• !ubocer1ica igament
• %rans1erse cer1ica igament
• &acrocer1ica igament
Parametrium
• !e1ic ascia in region o uterine cer1i+
• Peritoneum in the Female Pel.is
!asses o1er
• rinar* badder
• terus• agina
• Front o rectum
(ectouterine +ouch ,of ouglas-
• !eritonea $ouch bet0een 1agina and rectum
• Most inerior $art o $eritonea ca1it*
• Perineum
Beo0 $e1ic dia$hragm
Diamond/sha$ed
Boundaries
Anteriorl"9
• s*m$h*sis $ubis
Posteriorl"
• ischia tuberosities
5i.ie into two b"
• imaginar* ine bet0een tuberosities
Anterior triangle U urogenita triangePosterior triangle U ana triange
• 0rogenital 'riangle
0rogenital ia+hragm
Muscuoascia dia$hragm
Fis ga$ bet0een $ubic arch
Formed b*
• Sphincter urethrae
• 1eep transverse perineal muscles
(bet0een su$erior and inerior ascia a*ers)
#nferior $erinea ascia X +erineal membrane
• 0rogenital 'riangle
Perineal bo"
&ma mass o 4brous tissue
• Attached to center o the posterior margin of the urogenital
diaphragm
Larger in emaes
• !ro1ides su$$ort to $osterior 1agina 0a
• !ro1ides attachment to musces in the $erineum
• Perineal Pouches
• &u$er4cia $erinea $ouch
• Dee$ $erinea $ouch
• Su+eri!cial Perineal Pouch
Close +osteriorl" an laterall"
Anteriorl"9
&$ace communicates ree* 0ith $otentia s$ace bet0een
• su$er4cia ascia o anterior abdomina 0a (ScarpaBs
fascia) and
• anterior abdomina musces
• S0P%(F#C#AL P%(#N%AL P*0C) ,contents-
;B - 7 & &<
Bubos$ongiosus-schioca1ernosus
7reat 1estibuar gands (Barthoin>s)
&u$er4cia trans1erse $erinei
&crota ner1es
• 5%%P P%(#N%AL P*0C) ,contents-
Dorsa ner1e o $enis (men)
&$hicter urethrae
Bubourethra gands (2o0$er>s) (men)
Membranous $art o urethra
!udenda 1esses and ner1es
Dee$ trans1erse $erinei
;5ont Sto$ Banging &* Perineum 5ear<
• &ale %2ternal $enitalia
#nterior
%hree (?) c*inders o erectie tissue
6ithin tubuar sheath o ascia
Cor+ora ca.ernosa
• %0o (")
• Dorsa
Cor+us s+ongiosum
• #ne (')
• entra
• Forms 7ans !enis
• 2ontains $enie $art o urethra
• &ale %2ternal $enitalia
(oot of +enis
-n supericial perineal pouch
? masses o erectie tissue• Bulb V Cor+us s+ongiosum
• Midine
• %ra1ersed b* urethra
• 2o1ered b* bulbos+ongiosus muscle
• (ight an Left crura V cor+ora ca.ernosa
• Attached to side o $ubic arch
• 2o1ered b* #schiocar.ernosus muscle
• &ale e2ternal genitalia
Arteries
• Dee$ arteries o $enis
• Branches o dorsa arter*
4eins
• Dee$ dorsa 1ein
• L*m$h Drainage
7ans
•
Dee$ inguina• E+terna iiac
&kin
• &u$e4cia inguina nodes
Erectie tissue
• -nterna iiac
Ner.e Su++l"
• !udenda ner1e
• Bulbourethral
,Cow+er7s $lans-
• %0o (") sma gands
• Dee$ $erinea $ouch
• Fibers o s$hincter urethrae musce
• #$en into $enie urethra
• Prostatic 0rethra
iestO &ost ilatable
0rethral crest
• Longitudina ridge on $osterior 0a
Prostatic sinus
• on sides o crest
• #$ening o $rostatic gands
Prostatic utricle
• Anaogue o uterus and 1agina
• Edge o mouth (") e5acuator* ducts
• &embranous 0rethra
• %hrough urogenita dia$hragm
• &urrounded b* s$hincter urethrae
• ShortestO Least ilatable
• Penile 0rethra
E+terna meatus
• Narrowest $art o entire urethra
Fossa terminais (na1icuar ossa)
• rethra 0ithin bub o $enis
• Bubourethra gands• #$en to $enie urethra beo0 urogentia dia$hragm
• Female %2ternal $enitalia ,4ul.a-
• Mons $ubis
• Labia ma5ora
• Labia minora
• 2itoris
• 7reater 1estibuar gands
• 4estibule of the 4agina
• &$ace bet0een abia minora
A$e+
• 2itoris
Foor
• #$enings o the urethra
• agina
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• Ducts o greater 1estibue gands
• $reater 4estibular $lans
%0o (")
• Mucus/ secreting gands
Duct o each gand V groo1e bet0een h*men and $osterior $art o
abium minus
• Female 0rethra
From badder neck V e+terna meatus
• '.Pin (?.8cm) ong
%hrough
• rogenita dia$hragm
• &$hincter urethrae
#$ens into surace below citoris-n ront o 1agina
• &uscles of 0rogenital 'riangle
• &u$er4cia trans1erse $erinea musce
• Bubos$ongiosus
• -schioca1ernosus
• Dee$ trans1erse $erinea musce
• &$hincter urethrae
A su$ied b* $erinea branch o $udenda ner1e
• Anal Canal
• '.Pin (cm) ong
• Beo0 $e1ic dia$hragm
• =ecta am$ua V anus
Anal Columns
• ertica ods on mucous membrane
• #n $$er ha o ana cana (Lo0er ha is smooth)
Anal 4al.es • &ma semiunar ods
• 2onnect ana coumns together
• Anal Canal
Musce coat
• #uter ongitudina a*ers
• -nner circuar a*er o smooth musce
#n.oluntar" #nternal s+hincter
• %hickening o circuar a*er at u$$er end
4oluntar" %2ternal s+hincter
• &urround interna s$hincter 0ith coar o stri$ed musce
!arts
• $ubcutaneous
• $upercial
• #eep
• Anal Canal
Puborectalis
• &ing ormed rom 4bers o le.ator ani muscle
• Attached anterior* to $ubic bone
• Around 5unction o rectum and ana cana
• !us or0ard to make ange more acute
Anorectal ring
Distinct ring at anorecta 5unction, rom
• #nternal s+hincter
• 5ee+ +art of e2ternal s+hincter
• Puborectalis
• Anal Canal
Arteries
$$er ha
• Su+erior rectal arter"
Lo0er ha
• #nferior rectal arter"
4eins
$$er ha • &u$erior recta 1ein V inerior mesenteric 1ein
Lo0er ha
• -nerior recta 1ein V interna $udenda 1ein
• Anal Canal
L"m+h rainage
$$er ha
• !ararecta nodes V inerior mesenteric nodes
Lo0er ha
• Media grou$ o su$er4cia inguina nodes
• Anal Canal
Ner.e Su++l"
$$er ha
(and internal anal s+hincter)
• sensiti1e to stretch
V hypogastric plexus
Lo0er ha
(and e2ternal anal s+hincter)
• !ain
%em$erature
%ouch
!ressure
• V inferior rectal nerves
• #schiorectal Fossa
6edge/ sha$ed s$ace on each side o ana cana
Base9
• &u$er4cia9 skin
%ge9• 5unction o media and atera 0as
&eial all9
• e1ator ani musce
• Ana cana
Lateral wall9
• Lo0er $art o obturator internus musce and $e1ic ascia
• #schiorectal Fossa
Fat/4ed,
Ao0s distention during deecation
Puenal canal
• Fascia cana
• Media side o ischia tuberosit*
• !assage
– !udenda ner1e
– -nterna $udenda 1esses
•
&uscles of Anal 'riangle%2ternal Anal s+hincter
• &ubcutaneous $art
• &u$er4cia $art
• Dee$ $art
Ner1e &u$$* $erinea branch o &
Puborectalis muscle
Ner1e &u$$* !erinea branch o &
!erinea branch o $udenda ner1e
$$er E+tremit*
Loubomir E. Antonio, M.D.
Bones of the Shouler $irle
2a1ice
&ca$ua
Fractures
Cla.icular fracture
Most common* ractured bone in the bod*
Fa on the shouder or outstretched hand
unction o m?rd and dista ?rd
Dista ragment goes do0n0ard, media and or0ard b* $ectorais
ma5or
Media end $ued u$0ard b* &2M
Fractures
&ca$uar racture
=esut o se1ere trauma
=un/o1er accident 1ictims, 1ehicuar crashes
=euire itte treatment
Bone of the Arm
Humerus
Head
Anatomica neck
7reater tuberosit*
Lesser tuberosit*Bici$ita groo1e (bice$s tendon)
&urgica neck
Detoid tuberosit*
Bone of the Arm
Humerus
&$ira groo1e (radia ner1e and dee$ arter* o arm
Media e$icond*e
Latera e$icond*e
2a$ituum (head o radius)
%rochea (trochear notch o una)
=adia ossa
2oronoid ossa (coronoid $rocess o una)
#ecranon ossa
Fractures
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Humera head
7reater tuberosit* 3 $ued b* &,-,%
Lesser tuberosit* 3 $ued b* &
&urgica neck / most common site
Humera shat
$ro+ima to detoid insertion
$ro+ima ragment adducted b*
!M,LD,%M
dista ragment $ued b* D,BB,%B
dista to detoid insertion
$ro+ima ragment abducted b* D
dista ragment $ued b* BB, %B
/ radia ner1e at risk4olkmann7s #schemic Contracture
2ontracture o musces o the orearm oo0ing ractures o the distal
end o the humerus
/ brachia arter* s$asm eading to ischemic
necrosis
Bones of the Forearm
• =adius
Latera bone o orearm (sca$hoid and unate)
– Head (circuar)
– Neck
– Bici$eta tuberosit* (bice$s brachii)
– &hat
• -nterosseous border
• -nterosseous membrane
– &t*oid $rocess
–
nar notch – Dorsa tuberce
Bones of the Forearm
na
Media bone o orearm
#ecranon
%rochear notch
2oronoid $rocess
&hat
-nterosseous border
Head
&t*oid $rocess
Fractures of the Forearm
Colle7s fracture
racture o the dista end o the radius 0ith the dista ragment
dis$aced dorsa* ; dinner for8 deformity ;
Smith7s fracture
racture o the dista end o the radius 0ith the dista ragment
dis$aced 1oar*
$aleai7s fracture
racture o the $ro+ima end o the radius 0ith disocation o D=
&onteggia7s fracture
racture in the shat o una 0ith anterior disocation o the radia head
and ru$ture o annuar igament
Bones of the rist
2ar$a bones
;Scared (overs T ry 'ositions T hat T hey 0annot /andle4
'. Sca$hoid (na1icuar)
". Lunate
?. 'riuetra
. Pisiorm
P. 'ra$eJium
@. 'ra$eJoid
. Ca$itate8. )amate
Bones of the )an
• Metacar$a Bones
– Base
– &hat
– Head
• !haanges
– ? or each Digit
• !ro+ima
• Midde
• Dista
– E+ce$t %humb (")
• !ro+ima
• Dista
Shouler >oint
• &houder 5oint
(7enohumera 5oint)
– 7enoid ca1it*
• &hao0
• 7enoid abrum (4brocartiagenous)
– &*no1ia Ba/and/socket 5oint
– 2a$sue
• 7enoid abrum
• Anatomica neck
• &trengthened b* tendons o =otator cuO
musces
Shouler >oint
• Ligaments – 7enohumera
• ? bands that strengthen anterior $art o
ca$sue
• &u$erior band and -nerior band 3
$rimar* igamentous su$$ort
• Midde 3 strongest stabiiJing igament
– %rans1erse humera Ligament
• 7a$ bet0een grater and esser
tuberosities
• Hods tendon o the bice$s musce in
$ace
Shouler >oint
• Ligaments
– 2oracohumera Ligament
• E+tends rom the root o the coracoid
$rocess to the greater tuberosit* o thehumerus
• &trengthens ca$sue abo1e
– Accessor* Ligament
• 2oracoacromia igament
• !rotects su$erior as$ect o 5oint
Shouler Lesions
Shouler 5islocation
/ most common* disocated arge 5oint
/ 'nterior more common than $osterior
/ im$ingement o axillary nerve
Shouler Se+aration
/ acromioclavicular dislocation due to tearing o the
coracoclavicular ligament
: cases o se1ere bo0 to the $oint o the shouder
Shouler mo.ements
=:;:1 ASS rule
E1er* ? degree abduction o arm X " degree abductiion o shouder
5oint
' degree b* rotation o sca$ua
At '"Cdegree abduction
7reater tuberosit* o humerus hits atera edge o acromion
%lbow >oint
Ebo0 5oint
%rochea and ca$ituum o humerus
%rochear notch and head o the radius
&*no1ia hinge 5oint
Encosed b* ca$sue
Ebo0 oint
Mo1ements
Fe+ion
E+tension
2arr*ing Ange
6hen e+tended'C degrees in maes
'@ degrees in emaes
Disa$$ears on Ke+ion
%lbow >oint
-m$ortant =eations
Anterior*
Median Ner1e
Brachia Arter*
Media*
nar ner1e as it $asses behind the media e$icond*e o humerusY
Su+erior (aioulnar >oint
&u$erior =adiounar 5oint
Head o radius and annuar igament
=adia notch o una
&*no1ia $i1ot 5oint (trochoid)
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&*no1ia membrane
Lines ca$sue
2ontinuous 0ith that o ebo0 5oint
Su+erior (aioulnar >oint
Mo1ements
!ronation
&u$ination
More $o0eru than $ronation
#nferior (aioulnar >oint
-nerior =adiounar oint
Head o una
nar notch o radius
&*no1ia $i1ot 5oint2a$sue
Encoses 5oint
&trengthened b* anterior and $osterior igaments
#nferior (aioulnar >oint
Mo1ements
!ronation
&u$ination
rist >oint
6rist 5oint (=adiocar$a 5oint)
Dista end o radius (trianguar cartiaginous
articuar disc)
&ca$hoid, Lunate, %riuetra
&*no1ia cond*oid oint
Bia+ia
Ba and socket but 0 no rotation
rist >oint Ner1e &u$$*
Anterior interosseous ner1e (rom Median ner1e)
Dee$ branches o =adia and nar ner1es
Mo1ements
Fe+ion
E+tension
Abduction
Adduction
N* (otation (done b* radiounar 5oint $ronation/
su$ination)
rist >oint
-m$ortant =eations
Anterior
Median ner1e
nar ner1e
Latera*=adia arter*
Car+ometacar+al >oints
2ar$ometacar$a oints
2ar$a bones
Metacar$a bones
&*no1ia giding 5oints
Ligaments
Anterior
!osterior
-nterosseous
Car+ometacar+al >oint of 'humb
%humb car$ometacar$a 5oint
%ra$eJium
&adde sha$ed base o 4rst metacar$a bone
&*no1ia sadde 5oint (bia+ia)
Mo1ement Fe+ion
E+tension
Abduction
Adduction
=otation (#$$osition)
&etacar+o+halangeal >oints
Metacar$o$haangea 5oints
2on1e+ heads o metacar$as
2onca1e bases o $ro+ima $haanges
&*no1ia cond*oid 5oint
#nter+halangeal >oint
-nter$haangea 5oint
!ro+ima
Midde
Dista
&*no1ia hinge 5oints
&imiar structure as metacar$o$haangea 5oint
Mo1ements
Fe+ion
E+tension
&uscles of the Shouler (egion
2onnect u$$er imb to 1ertebra coumn
&N%&*N#C9 'he Lone (anger Likes (iding
'ra$eJius
Latissimus Dorsi
(homboid minor
Le1ator &ca$uae
(homboid ma5or
Ner.e Su++l"
%ra$eJius 2N'', 2?2
Latissimus dorsi %horacodorsa ner1e
=homboid minor
Le1ator sca$ua Dorsa sca$uar ner1e
=homboid ma5or
&uscles of the Shouler (egion
2onnecting u$$er imb to thoracic 0a
!ectorais ma5or
!ectorais minor
&ubca1ius
&erratus anterior
Ner.e Su++l"
!ectorais minor Media $ectora ner1e
!ectorais ma5or Media and Latera $ectora ner1e
&N%&*N#C9 %he Ma5or has ", %he minor
on* '
&edia 3 more ( both )
Latera 3 less ( Ma5or on* )
&ubca1ius ner1e to subca1ius
&erratus anterior ong thoracic ner1e
'he La" Between 'wo &aors
-N&E=%-#N
%eres ma5or 3 at medial i$ bici$ita groo1e
Latissimus dorsi 3 <oor o bici$ita groo1e
!ectorais ma5or 3 lateral i$ bici$ita groo1e
&uscle of the Shouler (egion
2onnecting sca$ua to humerus
Detoid
=otator cuO &u$ras$inatus
-nras$inatus
%eres minor
&ubsca$uaris
%eres ma5or
Ner.e Su++l"
Detoid A+iar* ner1e
&u$ras$inatus &u$rasca$uar ner1e
-nras$inatus
%eres minor A+iar* ner1e
&ubsca$uaris $$er and o0er subsca$uar ner1e
%eres ma5or Lo0er subsca$uar ner1e
(otator CuH &uscles
A inserts into the greater tuberosit* %?C%P' Subsca+ularis ( esser
tuberosit* )
&u$ras$inatus Abducts
-nras$inatus and %eres minor Latera* rotates&ubsca$uaris Media* rotates
(otator CuH 'eninitis
$ubacromial bursitis
E+cessi1e o1erhead acti1it* o the u$$er imb
Degeneration o subacromia bursa e+$oses the su$ras$inatus to
riction at the acromion
/ pain on mid abduction o the arm ( to 1= egrees )
Su+ras+inatus 'enon (u+ture
/ inabiit* to initiate abduction o the arm
/ i assisted in the rst => degrees o abduction, the detoids
can com$ete the abduction to right ange
#m+orant Lanmark
6uarangular s+ace
%ocated immediately belo/ shoulder ?oint
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&u$erior &ubsca$uaris
-nerior %eres ma5or
Latera &urgica neck o humerus
Media Long head o trice$s
%ransmits A2illar" ner.e and Posterior humeral circumJe2 arter"
'riangular S+aces
0++er 'riangular S+ace
/ &u$erior %eres minor
/ -nerior %eres ma5or
/ Latera Long head trice$s
%ransmits circumJe2 sca+ular .essels
Lower 'riangular S+ace
: &u$erior %eres ma5or/ Media Longhead trice$s
/ Latera Media head trice$s
%ransmits (aial ner.e an Profuna brachii
&uscles of the 0++er arm
Anterior Fascia com$artment
Bice$s brachii
2oracobrachiais
Brachiais
!osterior Fascia com$artment
%rice$s
Cubital fossa
• &kin de$ression
– %rianguar sha$ed
– -n ront o ebo0
• Boundaries
– Latera* Brachioradiais – Media* !ronator teres
– Base imaginar* ine bet0een e$icond*es o
humerus
2ontents from meial to lateral
Median ner1e
Brachia arter*
%endon o bice$s brachii
=adia ner1e
Anterior Fascial Com+artement of Forearm
'. !ronator teres
". Fe+or car$i radiais
?. !amaris ongus
. Fe+or car$i unaris
P. Fe+or digitorum su$er4ciais
@. Fe+or $oicis ongus
. Fe+or digitorum $roundus8. !ronator uadratus
Forearm anterior com+artment
-nner1ated b* Median ner1e %?C%P'9
Fe+or car$i unaris
Fe+or digitorum $roundus (media ha unar ha)
/ LNA= NE=E
Lateral fascial com+artment of forearm
'. Brachioradiais
". E+tensor car$i radiais ongus
Both su$$ied b* radia ner1e
Posterior Fascial Com+artment of the Forearm
'. E+tensor car$i radiais bre1is
". E+tensor digitorum
?. E+tensor digiti minimi
. E+tensor car$i unaris
P. Anconeus
@. &u$inator
. Abductor $oicis ongus
8. E+tensor $oicis bre1is
. E+tensor $oicis ongus
'C. E+tensor indicis
A su$$ied b* the =adia ner1e
=adia Ner1e
Abductor $oicis ongus
Brachioradiais
Anconeus
'rice$s
%+tensors
Su$inator
ANA%#M-2AL &NFFB#
Bounaries
AnteriorLatera A!#L E!B
!osteriorMedia E!#L
Car+al 'unnel
2ontains
Media ner1e
Fe+or digitorum su$er4ciais tendons ()
Fe+or digitorum $roundus tendons ()
Fe+or $oicis ongus tendon
Small muscles of han
Lumbricals ()
Fe+es M2!, E+tends -! ( )
#nterossei (8)
!amar ()
Dorsa ()
AC'#*N9 !AD DAB
Pamar 3 Aducts
5orsa / Abducts
Palmaris bre.is
-m$ro1es gri$
Ner.e Su++l"
-ntrinsic Musces o the Hand
A nar ner1e %?C%P'9 %ateral t/o %umbricals
'henar )"+othenar &uscles
&N%&*N#C9 *ne For A And / A For *ne
%henar Musces H*$othenar Musces
/ *$$onens $oicis / Abductor digiti minimi
/ Fe+or $oicis bre1is / Fe+or digiti minimi
/ Abductor $oicis bre1is / *$$onens digiti minimi/ Adductor $oicis
6edian nerve E2E!% 'll )lnar nerve
Auctor +ollicis
( )lnar nerve )
'humb &uscles #nner.ation
SnuObo+ grou$ A =adia ner1e
A!#L E!B E!#L
'henar Musces A Median E2E!%
Adductor $oicis ( unar )
#$$onens $oicis
Fe+or $oicis bre1is
Abductor $oicis bre1is
Adductor $oicis
Fe+or $oicis ongus Median ner1e
A2illar" arter"
2ontinuation o subca1ian arter*
Begins at lateral borer of !rst rib, unti
Lower borer of teres maor musce (brachia arter*)
=eated to the cors o the brachia $e+us
Encosed 0ith them in the a+iar* sheath
A2illar" arter"
Di1ided into ? $arts b* the +ectoralis minor
&N%&*N#C9 Scre0 'he La0*er Sa1e A Patient
'st $art
/ Su$reme or Highest %horacic Arter*
"nd $art
/ 'horacoacromia Arter*
/ Latera %horacic Arter*
?rd
$art/ Subsca$uar Arter*
/ Anterior Humera 2ircumKe+ Arter*
/ Posterior Humera 2ircumKe+ Arter*
Shouler >oint Arterial Anastomosis
'st $art o subca1ian arter*
&u$er4cia cer1ica arter*
%h*rocer1ica trunk
Anastomose 0ith
?rd $art o a+iar* arter*
&ubsca$uar arter*
Anterior circumKe+
!osterior circumKe+
Brachial arter"
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Begins at lower borer of teres maor (rom a+iar*
arter*)
Descends through anterior com$artment o arm on
brachialis muscle
Enters cubita ossa
Ends at e1e o neck of raius, di1ides into
=adia arter*
nar arter*
Brachial arter"
Branches
Muscuar branches
Nutrient arter* (to humerus)
Profuna brachii arter"
▪ Large branch
▪ Foo0s radia ner1e in s$ira groo1e
▪ !osterior com$artment o arm
&u$erior unar coatera arter*
▪ Foo0s unar ner1e
-nerior unar coatera arter*
▪ !art o anastomosis around ebo0 5oint
(aial arter"
&maer than unar arter*
Begins at cubita ossa, neck o radius
=adia $useY
Latera* tendon o brachioradiais
Media* tendon o Ke+or car$i radiais
(aial arter" 6rist T 0inds around atera side o the car$us to the
$ro+ima s$ace bert0een 'st and "nd metacar$a bones
!asses anterior* into $am bet0een t0o heads o 4rst dorsa
interosseous musce
oins dee$ branch o the unar arter* V
ee+ +almar arch
0lnar arter"
Larger than radia arter*
Begins at cubita ossa, neck o radius
Descends through
Anterior com$artment
Enters $am in front of Ke+or retinacuum
6ith unar ner1e
Ends b* orming su+er!cial +almar arch V su$er4cia
$amar branch o radia arter*
4eins of u++er limb&u$er4cia 1eins
Dorsa 1enous net0ork
2e$haic 1ein
Basiic 1ein
Median cubita 1ein
Median 1ein o the orearm
Dee$ 1eins
enae comitantes
A+iar* 1ein
4ein Catheteriation
Basiic 1ein
ein o choice or centra 1ein catheteriJation
-ncreases in diameter as it ascends the arm and is in direct ine 0ith
the a+iar* 1ein
A2illar" .ein
Formed b* union o 1enae comitantes o brachia arter* 0basiic 1ein
Ascends aong media border to 4rst rib
=ecei1es tributaries corres$onding to branches o the a+iar*
arter*
Aso recei1es ce$haic 1ein
A2illar" l"m+h noes
Drain *m$h rom
$$er imb
Latera $art o breast
&u$er4cia *m$h 1esses rom throacoabdomina
0a abo1e e1e o umbiicus
"C/?C *m$h nodes
A2illar" L"m+hnoe Le.els
Le.el #
&ubsca$uar or !osterior
E+terna mammar* or Anterior
A+iar* 1ein or Latera
Le.el ##
2entra
-nter$ectora ; =otter>s nodes<
Le.el ###
-nra or subca1icuar
Su+ratrochlear ,Cubital- l"m+h noes
-n su$er4cia ascia o cubita ossa
2ose to trochea
L*m$h rom meial 4ngers, media hand, orearm
Ascend to the atera a+iar* *m$h nodes$$er imb *m$hatic drainage summar*
Brachial +le2us
;&oT on1a 0u4ao<
(oots (P)
'runks (?)
5i1isions
(? anterior, ? $osterior)
Cords (?)
Branches
(P termina branches)
Brachial Ple2us
=oots
Enter base o the neck bet0een
▪ &caenius anterior
▪ &caenius medius
%runks and di1isions
2ross $osterior triange o neck
2ords
Arranged around a+iar* arter* in the a+ia
Encosed in a+iar* sheath 0ith a+iar* arter* and
1ein
(oots ,-
P roots (anterior rami o 2P,2@,2,28,%')
Branches
Dorsa &ca$uar (2P)
=homboid minor
=homboid ma5or
Le1ator sca$uae
Long thoracic (2P/2@/2)
&erratus anterior
'runks ,=-
&u$erior&u$sca$uar ner1e (2P/2@)
&u$ras$inatus
-nras$inatus
Ner1e to &ubca1ius (2P/2@)
&ubca1ius
Midde
-nerior
Cors ,=-
&eial cor
Media $ectora ner1e !ectorais ma5or
minor
Media cutaneous ner1e o the arm
Media cutaneous ner1e o the orearm
Lateral cor
Muscuocutaneous ner1e Anterior arm
com$artment musces
Latera $ectora ner1e !ectorais
ma5or
Posterior cor
&ubsca$uar ner1e
$$er
&ubsca$uaris
Lo0er
&ubsca$uaris %eres ma5or
%horacodora ner1e Latissimus
dorsi
A+iar* ner1e Detoid and
%eres minor
=adia ner1e ABA%E&
Branches
From atera to media
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&N%&*N#C9 &* Aunt (a$ed &* 0nce
&uscuocutaneous ner1e
A+iar* ner1e
(adia ner1e
&edian ner1e
0nar ner1e
Brachial +le2us inuries
0++er trunk lesions
%rb:5uchenne Pals"
Dis$acement o head to the o$$osite side and
de$ression o the shouder on same side
Fas on shouder
-nants during diIcut dei1er* ;waiter7s ti+<
▪ Hangs b* side
▪ Media* rotated
▪ Forearm $ronated
Brachial +le2us inuries
Lower trunk lesions
/lum+ke7s +als"
%raction in5ur*
E+cessi1e abduction o the arm
First thoracic ner1e usua* torn
&ma musces o hand $ara*Jed
;Claw han<
Brachial +le2us inuries
Long thoracic ner.e (2P/2@/2) esion
Bo0s or surgica in5ur* to ner1e
!ara*sis o serratus anterior;inge sca+ula<
DiIcut* raising the arm abo1e the head
Brachial +le2us inuries
A2illar" ner.e (2P/2@) esion
-nerior disocation o the shouder 5oint
Fracture o the surgica neck o the humerus
Quadranguar s$ace
Detoid $ara*sis and atro$h*
Loss o cutaneous sensation o1er o0er ha o
detoid
Brachial +le2us inuries
(aial ner.e (2P/2@/2/28/%') esion
Midshat humera racture
Ner1e in s$ira groo1e
;rist ro+<
nabe to e+tend 0ristnabe to e+tend 4ngers
Brachial +le2us inuries
&eian ner.e (2P/2@/2/28/%') Lesions
&u$racond*ar ractures o the humerus
6ounds $ro+ima to Ke+or retinacuum
;A+elike han<
▪ %humb rotated
▪ %humb adducted
▪ %henar eminence
▪ !ara*sis
▪ Atro$h*
▪ Fattening
Brachial +le2us inuries
0lnar ner.e (28/%') Lesions
Behind media e$icond*e o humerus
-n ront o Ke+or retinacuum o 0rist Hand sma musce $ara*is
▪ e+ce$t or (median ner1e)
▪ thenar eminence musces
▪ 4rst t0o umbricas
%humb cannot be adductedY
Metacar$o$haangea h*$ere+tension
?rd and th umbrica $ara*sis
-nterosseous $ara*sis
-nter$haangea 5oint Ke+ion
;Claw han<
%HE END
Lo0er E+tremit*
Loubomir E. Antonio, M.D.
)i+
-ium
-schium
!ubis
meets at the acetabuum
Bones of the thigh
Femur
!atea
Femur
Head
Hemis$heric ("?)
Fo1ea ca$itis
Ligament o the head
▪ #bturator arter*
Neck
7reater trochanter
Lesser trochanter
-ntertrochanteric ine
▪ -ioemora igament
-ntertrochanteric crest
▪ Quadrate tuberce
Femur
&hat
Linea as$era
Media su$racond*ar ridge
Adductor tuberce
Latera su$racond*ar ridge
7utea tuberosit*
!o$itea surace
2ond*es
Media cond*e
Latera cond*e
-ntercond*ar notch
Media e$icond*e
Latera e$icond*e
A.ascular Necrosis of the Femoral )ea
2ommon in A50L'S 0ith emora neck ractures
%he sma branch o the obturator artery 0ithin the igamentum teres
emoris is insuIcient to su$$* the emora head
ncommon in a chid due to ree anastomoses bet0een media emora
circumKe+ arter* and the obturator arter*
Co2a .alga .sDCo2a .ara
Norma ange bet0een emora neck and shatAduts '"P degrees
2hidren '@C degrees
2o+a 1aga -N2=EA&ED
2ongenita disocation o the hi$
Adduction is imited
2o+a 1ara Decreased
Femora neck ractures and
&i$$ed ca$ita emora e$i$h*ses
Abduction is imited
Femoral Neck Fracture
Patella
Largest sesamoi bone (de1eo$s 0ithin a tendon)
%endon o the Iuarice+s femoris
%rianguar sha$ed
Ligamentum $ateae
connects to tibia tuberosit*
!osterior surace
Articuates 0ith cond*es o emur
'ibia
LargeO weight bearingO meial bone of leg
Latera cond*e
#1a articuar acet or head o 4bua
Media cond*e
Latera meniscus
Media meniscus
-ntercond*ar eminence
%ibia tuberosit*
Media maeous
Fibula
Musce attachment
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No articuation 0ith knee
Head
&t*oid $rocess
Articuar surace
&hat
-nterosseous membrane
Latera maeous
Bones of the foot
%arsa bones
2acaneum
%aus
Na1icuar
2uboid2uneiorm bones
Metatasa bones and $haanges
Calcaneum
Largest bone o the oot
Articuations
Abo1e taus
Front cuboid
!osterior surace
!rominence o the hee
Media surace
Large sheKike ridge
“Sustentaculum tali”
▪ Assists in su$$orting the taus
Cuboi
Articuation
Anterior end o cacaneum5ee+ groo.e on inferior as+ect
&eroneus longus tendon
Cuneiform bones
%hree (?)
&ma
6edge/sha$ed
&aintenance of trans.erse arch of foot
Articuations
!ro+ima* na1icuar
Dista* 4rst ? metatarsas
&etatarsal bones
Fi1e (P)
Numbered media to atera
Head
&hat
Base th metatarsal
%uberce
&eroneus brevis tendon attachment
)i+ oint
Articuation
Head o emur
Acetabuum
&*no1ia ba/and/socket 5oint
)i+ oint
#liofemoral ligament of Bigelow
&trongestY Most im$ortantY
-n1erted :
Base anteroinerior iiac s$ine
Limbs u$$er and o0er $art o intertrochanteric ine o emur
=esists
H*$ere+tension o hi$Latera rotation o hi$
)i+ oint
Ner1e su$$*
Femora
#bturator
&ciatic
Ner1e to uadratus emoris
Mo1ements
Fe+ion
E+tension
Abduction
Adduction
Latera rotation
Media rotation
2irumduction
)i+ >oint
-m$ortant reations
Anterior*
emora 1esses
Femora ner1e
!osterior*
&ciatic ner1e
/nee oint
&*no1ia hinge 5oint
Bet0een emur and tibia
&*no1ia giding 5oint
Bet0een $atea and emur
/nee >oint Ca+suleEncoses the knee 5oint
%2ce+t anteriorl" (ca$sue de4cient)
&*no1ia membrane $ouches u$0ard beneath uadrice$ts tendon
2Suprapatellar bursa7
/nee oint
%2tra ca+sular Ligaments
Ligamentum $ateae
Latera coatera igament
Media coatera igament
#biue $o$ititea igament
#ntraca+sular ligaments
2ruciate igaments
▪ Anterior cruciate igament
▪ !osterior cruciate igament
/nee oint
Latera coatera igament$eparated rom the atera meniscus b* the popliteus muscle
/nee oint
Media 2oatera Ligament
Strongl" attache to meial meniscusM
Cruciate
&N%&*N#C9 PA&7s APPL%S
Posterio cruciate $asses Anterior and &edia
Anterior cruciate $asses Posterior and Latera
nha$$* %riad o #>Donoghue
&edia coatera
igament
Anterior cruciate
&edia meniscus
Bursae
Su+ra+atellar Bursa
▪ Largest▪ 'l/ays communicates 0ith knee 5oint
Pre+atellar Bursa
▪ Housemaid>s knee!rostitute>s knee
#nfra+atellar Bursa
▪ 2erg*man>s kneeicar>s
knee
Ankle oint
#nferior trans.erse tibio!bular ligament dee$ens
socked into 0hich taus 4ts
&*no1ia hinge 5oint
Encosed b* ca$sue
Ankle oint ligaments
&eial ,5eltoi- ligament
▪ &tronger than ateraY
▪ Attachments
▪ A$e+ ti$ o media maeous▪ Beo0 dee$ 4bers to media
surace o the bod* o the
taus
▪ &u$er4cia 4bers
media side o taus
sustentacuum tai
!antar
cacaneona1icuar
igament
%uberosit* o
na1icuar bone
Ankle oint
&*no1ia membrane ines ca$sue
Ner1e su$$*
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Dee$ $eronea
%ibia
Mo1ements
DorsiKe+ion (toes $oint u$0ard)
!antar Ke+ion (toes $oint do0n0ard)
#ntertarsal oint
'alocalcaneona.icular oint
Articuation
▪ =ounded head o the taus
▪ $$er surace o sustentacuum tai o
cacaneum
▪ !osterior conca1e surace o na1icuar
bone &*no1ia 5oint
Plantar calcaneona.icular ,s+ring- ligament
▪ Anterior border o sustentacuum tai to
▪ -nerior surace and tuberosit* o the
na1icuar bone
▪ Su++orts hea of talus
#ntertarsal oints
&ubtaar, %aocacaneona1icuar,cacaneocuboid)
#n.ersion
▪ Mo1ement o oot so that soe aces
media*
%.ersion
▪ Mo1ement o oot so that soe aces
atera*
in1ersion more e+tensi1e than e1ersion
$luteal (egion Bounded
&u$erior* iiac crest
-nerior* od o the buttock
7utea musces
Fascia
&u$er4cia ascia
▪ %hick
▪ es$ in 0omen, and im$regnated 0ith
arge uantities o at.)
Dee$ ascia
▪ 2ontinous beo0 0ith ascia ata o thigh
▪ &$its to encose guteus ma+imus
musce
#m+ortant ligaments
&tabiiJe the sacrum
!re1ent its rotation b* 0eight o the 1ertebra coumn Sacrotuberous ligament
!osteroinerior iiac s$ine, atera $art o sacrum,
cocc*+ to
ischia tuberosit*
Sacros+inous ligament
Latera $art o the sacrum, cocc*+ to
&$ine o the ischium
#m+ortant foramina
7reater sciatic oramen
!iriormis musce
&ciatic ner1e
!osterior cutaneous ner1e o thigh
&u$erior gutea ner1e
-nerior gutea ner1e
Ner1e to obturator internus
Ner1e to uadratus emoris
!udenda ner1e
&u$erior gutea arter* and 1ein
-nereior gutea arter* and 1ein
-nterna $udenda arter* and 1ein
#m+ortant foramina
Lesser sciatic foramen
!udenda ner1e
-nterna $udenda 1esses
Ner1e to obturator internus
%endon o obturator internus
$luteal &uscles
&N%&*N#C9 $ods $reatest $it 'o Peo$e iS *utstanding # 6
$uteus ma+imus
$uteus medius
$uteus minimus
'ensor ascia atae
Piriormis
Su$erior gemeus
*bturator internus
#nerior gemeus
6uadratus emoris
%rendeenburg>s %est
Factors that determine hi$ stabiit* 0hen standing in one eg
7uteus mediusminimus
Head o the emur ocated inside acetabuum
-ntact emora neck and
ange
$luteal &uscles
#nferior gluteal ner.e
7uteus ma+imus E+tends and atera*
rotates thigh
E+tends knee 5oint
Su+erior gluteal ner.e
7uteus medius Abducts thigh, tits $e1is
7uteus minimus
%ensor ascia atae Assists 7. ma+imus in e+tending
thigh
Sacral Ple2us
Small lateral rotators of the thigh
!iriormis
&u$erior gemeus
#bturator internus
-nerior gemeus
Quadratus emoris
'high
&a$henous o$ening
!assage
▪ 7reat sa$henous 1ein
▪ &ma branches o emora arter*
▪ L*m$h 1esses
▪ 2ribiorm ascia (oose connecti1e
tissue)
Femoral 'riangle
Boundaries
&u$erior* inguina igament
Latera* sartorious musce
Media* the adductor ongus musce
2ontains NA4%L rom atera to media
Femora ner1e
Femora arter*
Femora .ein
%m$t* s$ace
-nguina l*m$h nodes ( Rosenmuller1s-Clo@uet1s
node)
Aemoral nerve is outside the emora sheath
Floor of Femoral 'riangle
-io/$soas
!ectineus
Adductor ongus
Femoral Canal
&ma media com$artment o the emora sheath occu$ied b*
*m$haticsA$$ro+ ength
C.Pinches('.?cm) in
!otentia* 0eak area in 0a o abdomen
Femora hernia
Femoral (ing
$$er o$ening o the emora cana
Fied b* e+tra$eritonea at
;emora se$tum<
-m$ortant reations
Anteriorl"9
▪ inguina igament ( !ou$art>s igament )
Posteriorl"9
▪ $ectinea igament ( 2oo$er>s igament
Laterall"9
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▪ emora 1ein
&eiall"9
▪ acunar igament ( 7imbernat>s
igament)
'high &uscles
Anterior Com+artment
&artorius
-io$soas
!ectineus
Quadrice$s emoris
&eial Com+artment
7raciis
Adductor ongusAdductor bre1is
Adductor magnus
#bturator e+ternus
Posterior Com+artment
Bice$s emoris
&emitendinosus
&emimembranosus
Adductor magnus
$eneralities of thigh muscles
Anterior com+artment
Femora ner1e %?C%P' Psoas (umbar $e+us)
%high Ke+ors %?C%P' 4astus musces (eg e+tensors)
%0o musces that crosses both hi$ 5oint and knee 5oint
Sartorius ;ailor1s muscle<
(ectus femoris
$eneralities of thigh muscles&eial com+artment
#bturator ner1e
%high adductors %?C%P' obturator e2ternus (atera* rotates thigh
at hi$ 5oint)
Adductor magnus aso recei1es inner1ation rom sciatic
$eneralities of thigh muscles
Posterior com+artment
&ciatic ner1e tibia $ortion %?C%P' short hea bice+s femoris
(common $eronea ner1e)
Leg Ke+ors %?C%P' auctor magnus (e+tends thigh at hi$)
/nee region
!o$itea ossa
Boundaries
▪ Laterall"
▪ Abo1e
bice$s emoris
▪ Beo0
Latera head o
gastronemius
Latera head o
$antaris
▪ &eiall"
▪ Abo1e
&emimembranosus
&emitendinosus
▪ Beo0
Media head o the
gastrocnemius
Anterior Com+artment of the Leg
Peroneus tertius
%+tensor digitorum ongus
'ibiais anterior
%+tensor haucis ongus
Ner1e &u$$* Dee$ $eronea ner1e
Lateral Com+artment of the Leg
Peroneus ongus
Peroneus bre1is
Ner1e &u$$* &u$er4cia $eronea ner1e
Posterior Com+artment of the Leg
&u$er4cia grou$
7astrocnemius
!antaris
&oeus
Dee$ grou$
!o$iteus
Fe+or digitorum ongus
Fe+or haucis ongus
%ibiais $osterior
Ner1e &u$$* %ibia ner1e
$eneralities of Leg Com+artments
Anterior
Dee$ $eronea ner1e
DorsiKe+ors o the oot
Lateral
&u$er4cia $eronea ner1e
!antar Ke+ors
Posterior
%ibia ner1e
!antar Ke+ors
Peroneus .s 'ibialis &uscle;n letter rule
!eroneus musces
%.erts oot
!antar Ke+
%ibiais musces
#n.erts oot
!antar Ke+
&uscle on the 5orsum of the Foot
%2tensor igitorum bre.is
#rigin
▪ 2acaneum
-nsertion
▪ Four tendons into the $ro+ima $haan+
o the big toe (sometimes caed
e+tensor haucis bre1is)
▪
Long e+tensor tendons into "nd
,?rd
, th
toes
Action
▪ E+tends 'st, "nd,?rd, th toes
-nner1ation
▪ Dee$ $eronea ner1e
Sole of foot
Dee$ ascia
!antar a$oneurosis
Foot arches (?)
Media ongitudina arch
Calcaneona.icular ,s+ring- ligament
Latera ongitudina arch
%rans1erse arch
&uscles of the Sole
First la"er
Abductor haucis M!N
Fe+or digitorum bre1is M!N
Abductor digiti minimi L!N
Secon la"er
Lumbricas 'M!N, "?L!N
Quadratus $antae L!N
&uscles of the Sole
'hir la"er
Fe+or haucis bre1is M!N
Adductor haucis L!N
Fe+or digiti minimi bre1is L!N
Fourth la"er
%ibiais $osterior %N
-nterossei L!N
dorsa
? $antar
!eroneus ongus &!NArches o the Foot
&eian longituinal
/ argest
/ most im$ortant
Latera ongitudina
%rans1erse
Mechanism o Arch &u$$ort
&ha$e o the stone
-nerior edges tied together
%ie beam
&us$ension bridge
Femoral Arter"
2ontinuation o the e+terna iiac arter*
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Begins
behind inguina igament
Mid0a* bet0een anterosu$erior iiac s$ine and
s*m$hisis $ubis ,“femoral +ulse”-
Descends through emora triange and adductor
cana,
Enters $o$itea s$ace as +o+liteal arter"
Femora Arter* Branches
&N%&*N#C9 Si+ S0eet Se+* Ladies Put &* Pants 5o0n 5ai*
Su$er4cia circumKe+ iiac
Su$er4cia e$igastric
Su$er4cia e+terna $udenda
Latera emora circumKe+Prounda emoris
&edia emora circumKe+
Perorators
5ee$ e+terna $udenda
5escending genicuar
Arterial Anastomoses
'rochanteric Anastomosis
Su$erior gutea
Latera emora circumKe+
#nerior gutea
&edia emora circumKe+
Cruciate Anastomosis
&edia emora circumKe+
#nerior gutea
Latera emora circumKe+
First $erorating branch o $rounda brachii
Po+liteal arter"
2ontinuation o emora arter*
#$ening o adductor magnus to o0er border o $o$iteus musce
Di1ides into anterior an +osterior tibial arteries
Anastomosis aroun the knee
5escening genicular arter"
Lateral femoral circumJe2 arter"
Po+liteal arter"
Anterior tibial arter"
Posterior tibial arter"
Anterior tibial arter"
From biurcation o tibia arter*
!asses or0ard bet0een tibia and 4bua through the u$$er
$art o the interosseous membrane
Enters anterior com$artment o eg
Descends 0ith ee+ +eroneal ner.e
ront o anke, becomes orsalis +eis arter"
Anterior tibial arter"
“Anterior tibial +ulse”
Anke, mid0a* bet0een maeoi,
Media* %endon o e+tensor haucis ongus
Latera* %endons o e+tensor digitorum ongus
5orsalis +eis arter"
Begins ront o anke, continuation o anterior tibia arter*
Ends entering soe through $ro+ima $art o s+ace between
1st an ;n metatarsal bones
oins lateral plantar artery0 com$etes $antar arch
5orsalis +eis arteries
Branches
Latera tarsa arter*Dorsum o oot
Arcuate arter*
Latera* across bases o metatarsa bones, gi1es oO branches to the
toes
First dorsa metatarsa arter*
Both sides o big toe
5orsalis +eis arter"
“orsalis +eis +ulse”
Latera* tendons o e+tensor digitorum ongus
Media* tendon o e+tensor haucis ongus
Posterior tibial arter"
From biurcation o $o$itea arter* in $oitea ossa
Descends in $osterior com$artment o the eg
Accom$anied b* tibial ner.e
Arter* terminates behin meial malleolus
Media and atera $antar arteries
“+osterior tibial +ulse”
▪ Bet0een media maeous and hee
Posterior tibial arter"
Branches
Peroneal arter"
/ Largest branch
Muscuar branches
Nutrient arter*
Anastomotic branches
Posterior tibial arter"
%ermina branches
&eial +lantar arter"&maer than atera $antar arter*
For0ard aong media border o oot
0ith medial plantar nerve
Posterior tibial arter"
%ermina branches
Lateral +lantar arter"
Larger
For0ard, dee$ to abductor haucis and Ke+or digitorum bre1is
Bith lateral plantar nerve
End cur1ing media* to orm lateral +lantar arch
!erorating arteries
Metatarsa artereis
Digita arteries
5orsal .enous network
Dorsum o oot
DrainedMedia* great sa+henous .ein
Latera* small sa+henous .ein
$reat sa+henous .ein
Ascends in front o media maeous
Accom$anied b* sa+henous ner.e
Ascends in eg in su$er4cia ascia
!asses behind knee
2ur1es around media side o thigh $asses through
sa$henous o$ening in dee$ ascia
oins emora 1ein
$reat sa+henous .ein
!osseses numerous valves
2onnected to
&ma sa$henous 1ein
▪ b* branches $assing behind the knee
Dee$ 1eins▪ ia $erorating 1eins, media side o ca
'ributaries
&u$er4cia circumKe+ iiac 1ein
&u$er4cia e$igastric 1ein
&u$er4cia e+terna $udenda 1ein
Small sa+henous .ein
From atera side o dorsa 1enous net0ork o oot
Ascends behin atera maeous
Accom$anies sural ner.e
!asses u$ back o eg, $ierces dee$ ascia entering $o$itea
ossa
Drains into $o$itea 1ein
4enae commitantes
Dee$ 1eins accom$an*ing res$ecti1e arteries
Dee$ 1eins o anterior an +osterior tibial arteries unite to or
+o+liteal .einPo+liteal .ein
Formed b* union of anterior an +osterior tibial
arteries .enae comitantes
End b* $assing through o$ening o adductor magnus to
become femoral .ein
=ecei1es man* tributaries incuding rom small sa+henous
.ein
Femoral .ein
2ontinuation o +o+liteal .ein through o$ening o adductor
magnus
Ascends through adductor cana and emora triange
Accom$anied b* femoral arter"
Ascends behind inguina igament
2ontinous 0ith e2ternal iliac .ein
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=ecei1es great sa+henous .ein
Su+er!cial inguinal noes
-n su$er4cia ascia beo0 inguina igament
Drain into dee$ inguina nodes
)oriontal grou+
&u$er4cia *m$h 1esses
▪ anterior abdomina 0a beo0 umbiicus
▪ !erineum
▪ E+terna genitaia (not testes)
▪ Lo0er ha o ana cana
▪ &kin o buttocks
Su+er!cial inguinal noes
4ertical grou+Lies aong termina $art o great sa$henous 1ein
=ecei1es most o the su$er4cia *m$h 1esses o o0er imb
%?C%P'
back and atera side o ca
Latera side o oot
(!o$itea nodes)
5ee+ inguinal noes
sua* three (?) in number
Aong media side o emora 1ein
-n emora cana
=ecei1e a *m$h rom
su$er4cia inguina nodes and
dee$ structures o o0er imb
Drain into e+terna iiac nodes
Po+liteal l"m+h noes
&ituated in the $o$itea ossa
=ecei1e su$er4cia *m$h 1esses accom$an*ing sma
sa$henous 1ein
5rain lateral sie of foot
Back an lateral sie of calf
Drain into dee$ inguina nodes
Ner.es of the lower limb
Femora ner1e
#bturator ner1e
&ciatic ner1e
%ibia ner1e
2ommon $eronea ner1e
Femoral ner.e
Lumbar $e+us
L;:L=:LE
Enters thigh behind inguina igament
Lies atera to emora 1esses %erminates into anterior and $osterior di1isions
Femoral ner.eO branches
2utaneous branches
&eial cutaneous ner.e of thigh
▪ &kin on media side o thigh
#ntermeiate cutaneous ner.e of thigh
▪ &kin on anterior side o thigh
Sa+henous ner.e
▪ -nra$atear branch to skin
▪ &kin on media side o eg
▪ &kin on media side o oot as ar as ba
o big toe
*bturator ner.e
Lumbar $e+us
L;:L=:LE
Latera side o $e1is to reach obturator cana$$er $art o obturator oramen
Di1ides into anterior and $osterior di1isions
Sciatic ner.e
From sacra $e+us
LE:L:S1:S;:S=
!asses through greater sciatic oramen
Below +iriformis
Co.ere b" gluteus ma2imus
!osterior com$artment o thigh
Di1ides into
%ibia ner1e and
2ommon $eronea ner1e
'ibial ner.e
Descends through $o$itea ossa
!osterior com$artment o eg
Dee$ to gastrocnemius and soleus
Di1ides into meial an lateral +lantar ner.es
'ibial ner.eO branches
2utaneous branches
Sural ner.e
&kin on ca
&kin on back o eg
Latera border o oot
Latera side o itte toe
&eial calcaneal ner.e
&kin o1er media side o hee
'ibial ner.eO branches &eial +lantar ner.e
(dee$ to haucis musce 0 media $antar arter*)
2utaneous branch
▪ Media $art o soe
▪ Media ?.P toes and nai beds
Muscuar branch
▪ Abductor haucis
▪ Fe+or digitorum bre1is
▪ Fe+or haucis bre1is
▪ First umbrica
'ibial ner.eO branches
Lateral +lantar ner.e
(dee$ to abductor haucis, Ke+or digitorum bre1is, 0 atera $antar
arter*)
2utaneous branch
▪ Latera $art o soe▪ Later '.P toes and nai beds
Muscuar branch
Fe+or digitorum accessorius
Abductor digiti minimi
Fe+or digiti minimi bre1is
Adductor haucis
-nterosseous musces
"nd, ?rd, th umbricas
Common +eroneal ner.e
%hrough $o$itea ossa
Latera* aroun neck of !bula
!iercing $eroneus ongus
Di1ides into
&u$er4cia $eronea ner1e
Dee$ $eronea ner1e
Lower Limb Ner.e #nuriesFemoral ner.e lesions
&tab
7unshot 0ounds
!entrating in5uries
Quadrice$s $ara*Jed
No knee e+tension
&ensor* oss
Media side o o0er $art o eg
Media border o oot at ar as ba o the big toes
*bturator Ner.e
=are* in5ured in $enetrating in5uries
Behing the Koor o emora triange
2om$ressed in
Anterior hi$ disocations
!arturition
#bturator hernia)owshi+7s (omberg Sign
: $aresthesia o media as$ect o the thigh
/ $ara*sis o adductor musces e+ce$t adductor magnus
$ortion
Sciatic Ner.e
Sciatic ner.e lesion
Bad* $aced intramuscuar in5ections in gutea
region
Fracture disocations o hi$
Hamstring musce $ara*sis
6eakend knee Ke+ion
A musces beo0 knee, $ara*Jed
“F**' 5(*P”
Page 37
8/20/2019 Anatomy Super Supplement
http://slidepdf.com/reader/full/anatomy-super-supplement 37/37
6eight o oot causes it to assume a $antar Ke+ed
$osition
Loss o skin sensation beo0 the knee, E+ce$t or
▪ narro0 $art o eg
▪ Media border o the oot as ar as the
ba o the big toe
Sciatica
!ain aong the distribution o sciatic ner1e
$osterior thigh
$osterior and atera sides o eg
atera side o oot
- 2om$ressed b*
herniated nuceus $u$osusintra$e1ic tumorinKammation
Common Peroneal Ner.e
E+$osed at the area o the neck o 4bua
Fractures, casts, s$ints
Anterior and atera com$artment musces $ara*Jed
'ali+es %Iuino.arus eformit"
Foot is Plantar Je2e and #n.erte
'ibial Ner.e
=are* in5ured in $enetrating in5uries
Dee$ to gastrocnemius and soeus
'ali+es Calcaneo.algus eformit"
“clubfoot”
Foot is 5orsiJe2e : %.erte
'enon (eJe2es
&N%&*N#C9
'/" bucke m* shoe &'&"
?/ kick the door L?LP/@ $ick/u$ sticks 2P2@
/8 shut the gate 228
%HE END