Anatomy

U world
Supplement to First Aid
 MSS

Upper Extremity
 Rotator cuff injury
• Rotator cuff: (SITS)
– Supraspinatus,
– Infraspinatus,
– Teres Minor and
– Subscapularis
• Most commonly injured: Supraspinatus
tendon
• Presentation: Pain on Abduction of arm
Impingement Test: Supraspinatus
Jobe’s Test or Empty can test
GH joint is the most common dislocated joint in body

Anterior
dislocations are
more common
than posterior

Cause: due to forceful external rotation and abduction of arm

Nerve: Axillary n. injury
Result: Deltoid paralysis (flattening) and lateral arm sensation loss
 Radial Head
Subluxation

• Most common elbow injury in kids (age 1-4)

• Injury: Due to sharp pull on hand while forearm is pronated and
elbow extended
• Annular ligament tears
– After age 5, the annular ligament thickens and becomes stronger, less
likely to tear
• Child presents (similar position of injury) with arm held close to
body with forearm pronated and elbow extended
 Scaphoid Fracture
Outstretched arm fall. Present w/
Anatomical snuff box tenderness Risk: Avascular Necrosis (radial a.)
 “Winged Scapula”- Long Thoracic n.
• Serratus anterior muscle paralysis
– Pt asked to press against a wall and “Winged” scapula deformity
occurs
– Unable to abduct the arm higher than horizontal position or >90°
• First 90° abduction due to Deltoid and Supraspinatus muscle
• Long Thoracic n. injury
– Penetrating trauma (knife fight)
– Iatrogenic (Radical Mastectomy- axillary node dissection)
Long Thoracic n. (Serratus Anterior m.)
• 0- 90° Abduction
• Supraspinatus (10-15°)
• Deltoid (>30°)
• Long head of biceps

Winged scapula

• 90°-180° Abduction
• Serratus
Anterior
Radial n. Injury Posterior Arm
“Wrist Drop” From
- Mid-shaft humerus Axillary n.
fractures
- “Crutch” palsy
- Supplies extensors
muscles (posterior) and
sensory to posterior
arm Radial n.
- Wrist drop b/c can’t
extend
Radial n. course
 Ulnar n.
Passes by Medial epicondyle in
arm (most common injury site)
and the guoyon’s canal over
Hook of hamate (another site of
injury)
 Guoyon’s canal
Nerve passing by
hook of hamate

Ulnar n. injury  Claw-Hand deformity

 Courses w/
brachial a.
between biceps
brachii and
brachialis m.

Median
n.
C6-T1 Antecubital
fossa
 Median n. supply to muscles in hand

See loss of
Thenar
eminence w/
median n.
damage 
“ape hand”
deformity
Median n. injury • Injury
– Suicide attempts
– Carpal tunnel syndrome
• Tx: release flexor retinaculum
• Denervation atrophy
– Loss of thenar eminence so “ape
hand” deformity
– Benedict/Bishop/pope hand when
asked to make fist
• Loss of sensation
– Palmar surface
– 1st three and ½ fingers
 Procedures and Nerve Injuries
• Radical Mastectomy – Long thoracic n.
• Thyroidectomy- Recurrent Laryngeal n.
– Recurrent laryngeal during ligation Inferior thyroid a.
– External branch of superior laryngeal nerve during ligation of superior thyroid a.
• Delivery of child- (Shoulder Dystocia)
– Musculocutaneous and Suprascapular n.
– “Head and shoulder violently stretched apart”
– Erb-Duchenne palsy (Waiter’s Tip)
– Shoulder adducted, arm pronated, elbow extended
 MSS

Lower Extremity
Common Peroneal (Fibular) n.
(FOOT DROP)
Prone to injury b/c
superficial location
especially lateral blow
to leg or during leg
cast

Common peroneal 
superficial peroneal
and deep peroneal n.

Deep peroneal
innervates anterior
compartment which
dorsiflexes foot

Superficial peroneal
innervates lateral
compartment
(everts foot)
 Sensory Innervation: Peroneal n.

Posterior
Leg

 Sciatic n. branches to Tibial n. and Common Peroneal n. in popliteal

fossa (posterior leg)
 Superficial peroneal n. provides sensation to dorsum of foot
 Deep peroneal n. provides sensation to skin b/w 1st and 2nd toe
Shows
branching
of sciatic n
to Tibial
and
Common
Peroneal n.

Tibial n –
Posterior
thigh
(plantarflex
and invert).
Sensory to
sole of foot
 Femoral n. injury
• Can be due to big retroperitoneal hematoma, trauma, stretch injury,
etc
• Innervates quadriceps muscles so:
– Presentation: difficulty w/ climbing stairs and “knee buckling”
• Sensory loss:
– Anterior and medial thigh
– Medial leg (saphneous n.)
• Saphneous nerve is the largest purely sensory branch of femoral n.
• Patellar reflex diminished
 Superior Gluteal n. Injury
• Gluteus medius and minimus muscles weaken
• Result: Waddling gait
• Cause: Supero-medial buttock injections
• Positive Trendelenburg’s sign
– Injury is:
• C/L side of dropped hip/pelvis
• I/L side of standing leg
– Pic: We see Right sided n. injury
 Superior Gluteal n. injury
Superolateral
quadrant-
safest place
for buttock
injections

Superomedial
injection can injure
superior gluteal n.

The other three

quadrants can cause
injury to sciatic
nerve
 Femoral Head
supply
• Medial femoral circumflex a. provides the
majority of the blood to femoral head and
neck
– Courses posteriorly
– Injury to this vessel can cause avascular necrosis
of femoral head.
• Lateral femoral circumflex a.
– Courses anteriorly
– A source of blood supply of femoral head and
neck
• Obtruator artery
– Injury more important/crucial in kids
ACL- origin: Lateral Femoral condyle
PCL- origin: Medial Femoral condyle
 ACL tear- Anterior Drawer Test
Knee flexed
90° and
place
anterior
traction the
tibia

Note: Lachman’s
test for ACL tear
is MORE sensitive
 PCL tear- Posterior Drawer test

Knee flexed
90° and
place
posterior
traction the
tibia
PCL tear
 Terrible ‘Unhappy’ Triad

• Lateral blow to the

knee
• ACL tear
• Tibial (Medial)
collateral
ligament
• Medial
Lateral collateral Meniscus tear
ligament is stronger
than medial
• Prepatellar bursitis AKA
“housemaid’s knee:
• Due to repeated kneeling of
knee
• Now common in: roofers,
plumbers and carpet layers
• Symptoms: knee pain,
swelling, redness, unable to
flex knee,
• Signs: Erythema and
Crepitance with edema

• Anserine bursitis
• Overuse in athletes
• Chronic trauma in OBESE pts
• Pain at medial aspect of
knee
 Psoas Muscle
Located Paravertebral B/L
 Common Deformities
Presentation Nerve Injured

Wrist Drop Radial n

Claw Hand Ulnar n.

Winging of Scapula Long Thoracic n

Ape hand Median n

Foot Drop Common Peroneal n.

Head and neck

Brief
 Jugular Foramen (Vernet)
Syndrome

Jugular foramen (CN IX, X, XI)

- Loss of taste from posterior
1/3 of tongue (CN IX)
- Reduced parotid gland secretion
(CN IX)
- Loss of gag reflex (CN IX, X)
- Dysphagia (CN IX, X)
- Dysphonia/hoarseness (CN X)
- Soft palate drop with deviation of
uvula C/L to site of lesion (CN
X)
- Sternocleidomastoid and
trapezius muscLe paresis (CN
XI)
Foramen Spinosum- Middle meningeal
artery & vein
 Pancoast Tumors

• Apical lung tumors or Pancoast

tumors locally invade and cause
variety of symptoms
• Horner Syndrome
• Ptosis
• Miosis
• Anhydrosis
• SVC syndrome
• Arm weakness due to brachial
nerve plexus compression.
• Hoarseness secondary to recurrent
laryngeal nerve compression
• Piriform recess
• Foreign bodies (fish, chicken
bones) can get stuck here
• Attempts to remove foreign
body or a sharp fish bone
itself can damage the thin
membrane that overlies the
piriform recess
• Internal laryngeal nerve
which is a branch of the
superficial laryngeal nerve
which is a branch of the
Vagus nerve (CN X) can get
damaged
• Internal laryngeal carries only
autonomic and sensory fibers
unlike recurrent or external Conclusion:
laryngeal nerves which carry
motor to vocal cords
FB usually lodge in piriform recess
• It mediates the afferent and pose a risk of damaging
(sensory) limb of cough reflex Internal Laryngeal nerve and
ABOVE the vocal cords losing the cough reflex
Chest
• Right Atrium- majority of the R border of heart on P-A chest films
• Right Ventricle- Anterior wall of heart (best seen with lateral films)
• SVC & IVC – superior & inferior borders of cardiac silhouette
Thoracentesis should
be preformed b/w the
visceral pleura and
parietal pleura and on
the Upper border of rib
to avoid damaging
intercostal n, a, v (which
course at the lower border of ribs)
Note:
Light
purple-
Lung

Midclavicular Midaxillary Paravertebral

line
Visceral 6th rib 8th rib 10th rib
(Lung) Pleura
Parietal 8th rib 10th rib 12th rib
Pleura
Aspiration Pneumonia
Upper lobe: Posterior segment
Lower lobe: Superior segment
GI
 Cardiovascular Dysphagia
(rare but due to LA enlargement from mitral stenosis and LV hypertrophy)
 Chest CT
Trachea- Radiolucent structure (identify this first)
Esophagus- located behind trachea and anterior to vertebral bodies
(GERD)
Two big blobs- aorta (ascending and descending)

Trachea

Azygous v.
Esophagus
 Abdominal CT
A- 2nd part of
duodenum (lies by
the head of
pancreas)

B- Pancreas

C- IVC (lies to the R

side of vertebral
column)

D- Aorta (lies to the L

side of vertebral
column)

E- jejunum loops

• Pancreas Head by the 2nd part of duodenum, L2 vertebrae.

• Body overlies L Kidney, aorta, IVC and SMA, L1-L2
• Tail lies in splenorenal ligament
 Blood supply of GI tract
• Foregut: all structures from mouth to 2nd part of duodenum
– Celiac trunk (except mouth, pharynx and proximal esophagus)
– Liver, gallbladder and pancreas are foregut derivative structures (endoderm)
– Note: Spleen is NOT a foregut derivative structure (mesoderm) but gets
its blood supply from splenic a. ( celiac a. which supplies foregut)
• Midgut: 3rd part of duodenum  proximal 2/3 of transverse colon
– SMA
• Hindgut: distal 1/3 transverse colon  rectum
– IMA
 Note: spleen is NOT a
foregut structure
Foregut: all structures from
mouth to 2nd part of duodenum
Celiac trunk (except mouth,
pharynx and proximal esophagus)

Midgut: 3rd part of duodenum

 proximal 2/3 of transverse
colon
SMA

Hindgut: distal 1/3 transverse

colon  rectum
IMA
Venous drainage – Hepatic Portal v. (NOT IVC)
• Gastric ( hepatic portal v.)
• SMA ( hepatic portal v.)
• IMA ( splenic v.  hepatic portal v.)
 GI Ulcers
• Most Gastric ulcers occur at the lesser curvature (LC) of the stomach and
tend to hemorrhage
– Proximal LC: Left gastric (Celiac trunk)
– Distal LC: Right gastric ( Proper hepatic a.)

• Duodenal ulcers are more common than gastric ulcers. Found in the
bulb.
– Anterior bulb: Perforate
– Posterior bulb: Hemorrhage through gastroduodenal a. ( common
hepatic a. )
Most gastric ulcers  lesser curvature  hemorrhage L. gastric a. ( from
celiac trunk)
 Duodenum

1st part
- NOT
Retroperitoneal

2nd part
(Celiac a.)

3rd part (SMA)

 Duodenum
• 1st part:
– Horizontal; emerges from pylorus of stomach
– ONLY part NOT Retroperitoneal
• 2nd part:
– Vertical; lies close to head of pancreas
– Has ampulla of Vater (where CBD and pancreatic duct merge and secrete)
• 3rd part:
– Horizontal; courses over ab. Aorta & IVC
– closely assoc w/ uncinate process of pancreas & SMA (tumor invasion)
Uncinate process of Pancreas
- Part of head
- Close assoc w. SMA and SMV
CBD + Main
pancreatic duct

Drain into
ampulla of
Vater (2nd part
duodenum)

SMA and
plexus

courses over 3rd

part of
duodenum
SMA Syndrome

- When the angle

b/w SMA and
aorta decreases
less than 20°
(norm 45°) it can
compress the
transverse
portion of
duodenum (3rd
part) causing S&S
of SBO.

- Usually occurs
secondary to
rapid weight loss
(lose mesenteric
fat pad) or spinal,
scoliosis surgery
Lesser Omentum

- Double layer of peritoneum

- Liver  lesser curvature of
stomach and beginning of
duodenum
- Consists of hepaogastric
ligament and
hepatoduodenal ligament
- Hepatic a. , CBD, portal vein,
lymphatic . (hepatoduodenal)
- R & L gastric a. and gastric
veins lie by (hepatogastric)

- During gastric band surgery,

we go through the lesser
omentum in order to encircle
the cardiac part of stomach or
upper stomach
• Proper Hepatic a.
• CBD
• portal vein
Hepatoduodenal ligament R &L Gastric a. and
of lesser omentum gastric v.
 Gallstone Ileus
• Occurs in pt’s with long-standing Cholelithiasis (middle- elderly age
women)
• Large (>2.5 cm) stone lodges through cholecyst-enteric fistula and
enters duodenum
• Caliber of duodenum and jejunum is big so stone passes through
• Stone gets stuck at the ileocecal valve. Causes air from intestine to travel
to biliary tree and gallbladder
• S&S: SBO  (N/V/distention)
• Dx: Ab imaging  Shows air in Gallbladder and biliary tree
(Pneumobilia)
• Tx: Surgical removal of stone. Don’t usually operate on fistula
Cholecystenteric
Fistula Gallstone ileus

- Very important to realize

that gallstone in the
duodenum doesn’t enter
through the biliary tree
or ampulla of vater

- It enters through a fistula

that forms between the
weak gallbladder wall
and the duodenum.

- Fistula allows air to enter

gallbladder and biliary
tree (pneumobilia)
Pneumobilia in Gallstone Ileus
 Retroperitoneal Organs
• Vessels
– Abdominal aorta SADPUCKER
– IVC and branches  Suprarenal glands (adrenal
glands)
• Solid organs
 Aorta and Inferior Vena Cava
– Pancreas (except tail) [hint: tail moves]  Duodenum – second, third,
– Kidneys and fourth segments
– Adrenal Glands  Pancreas – head, neck, and
• Hollow organs body
 Ureters
– 2nd and 3rd part of duodenum (part of 4th  Colon – ascending,
part) descending
– Ascending and descending colon  Kidneys
– Rectum  Esophagus
– Ureters  Rectum
– Bladders
• MSS
– Vertebral Column and pelvic muscles
 Retroperitoneal hematoma
• Due to blunt or penetrating abdominal trauma
– 50% of pts w/ blunt trauma
• Usually after MVA (seat belts, steering wheels)  get pancreatic injury
• Pancreatic injury can present with mild sx or asymptomatic hence imp.
to check for hematomas by CT especially in stable pt’s w/ blunt
abdominal trauma
• [Side note: FAST scan is done in trauma bay to evaluate for Hemoperitoneum or
pericardial effusion after MVA, looks for blood by liver, spleen, heart and pelvis. FAST-
Focused assessment Sonography of Trauma]
Retroperitoneal
hematoma can
compress and injure
femoral nerve causing
anterior thigh paresis
Pancreatic hemorrhage signs
Late findings

Grey- Turner sign: Flank

hemorrhage

Cullen sign: Peri-umbilical

 Cirrhosis
and
portal
HTN

• Liver cirrhosis  fibrosis of vessels  portal HTN

• Leads to splenomegaly, paraumbilical veins engorgement, hemorrhoids and
esophageal varices due to the 4 portocaval anastomoses site.
• The portal vein is found in the R hepatic lobe and is located anterior to IVC (CT
identification)
GU
Hernias

- Both inguinal (direct and

indirect hernias) lie above the
inguinal ligament.

- Indirect inguinal hernias are

more common than direct
hernias especially in males

- Direct are medial to epigastric

vessels and found in
Hesselbach’s triangle

- Indirect are found in deep

inguinal ring/ internal inguinal
ring and lateral to epigastric
vessels.
- Deep inguinal ring is an
opening in transversalis
fascia
 Femoral hernia
• More common in females
• Found below inguinal ligament
• Prone to incarceration b/c femoral canal is small thus causes
bowel obstruction (N/V/ Ab. Pain distention)
• Incarceration  Strangulation within a few hours; ischemic
necrosis results (fever)
• Emergent surgery
 Horseshoe Kidney

- Most times fused at the

inferior pole, sometimes
superior pole

- Inferior mesenteric a.
prevents it from ascending.

- Prone to infections, renal

stones and hydronephrosis but
nml functioning kidney

- Associated with chromosomal

aneuploidy syndromes
(Trisomy 13, 18, 21) and
Turner’s syndrome (XO)
Ureter

- At risk for injury during pelvis

surgeries

- The gonadal arteries and veins

cross OVER the ureter in the
middle

- Once the ureter crosses over the

common iliac, it is now known
to be in true pelvis

- In the pelvis, it crosses over

common iliac a. and is found
anterolateral to the internal
iliac artery
“ Water under the
bridge”

- Ureter (water) lies

under the Uterine
vessels (bridge)
- Do not confuse with
ovarian vessels
which travel lateral
to ureter when
crossing over the
common iliac a in
the pelvic brim.
Ureter at DANGER:

• Hysterectomy:
• Ureter lies
underneath
uterine a.
• Ovarectomy
• Ureter and
ovarian
vessels cross
pelvic inlet so
both at risk
11/12TH Rib Fracture- Kidney injury
 - Iliac fossa
Transplanted kidney - Attach donor renal a 
recipient ext/internal iliac
a.
- Transplant ureter or attach to
old ureters (recipient’s ureter)
 Lymph node drainage
• Para-aortic nodes: Testes b/c follows embryological origin
(retroperitoneal)
– Also blood supply to testes is from aorta
• Superficial Inguinal- All cutaneous drainage below umbilicus,
including external genitalia (scrotum and labia) and anus up to
pectinate line
• Deep inguinal- glans penis and clitoris drain directly. Afferent
from superficial inguinal nodes
• External iliac- drain superficial and deep inguinal nodes
Patent
Process
Vaginalis
(Communicating
hydrocele )
Varicocele
• Left testes more
common
• b/c Left testicular v.
drains  Renal v.
 IVC
• L renal vein travels
b/w aorta and SMA
so can be
compressed easily
especially if SMA
engorges
• Anterior urethra- Damaged during saddle injuries (fence or falling off bike
injuries) – urine leaks beneath deep fascia of Buck
• Posterior urethra- Membranous portion is the weakest part and is prone to
injury during pelvic fractures (MVA). Urine leak into retropubic space
• Urethral injury-
• S&S: full bladder sensation, inability to void, high riding boggy
prostate, blood at urethral meatus
• Foley is C/I
 Pudendal nerve
block • Intravaginal pudendal block
in OB (palpate ischial spine)
• Nerve runs behind • Done when its too late for
ischial spine and epidural anesthesia
sacrospinous ligament