Anatomy

Vertebral levels
C3 • Hyoid bone
• Bifurcation of the common carotid artery
C4
• Thyroid cartilage

• Cricoid cartilage
C6 • Trachea begins (end of larynx)
• Esophagus begins (end of pharynx)
T1 • Sternoclavicular joint
• Superior angle of scapula
T2
• Suprasternal notch
• Thoracic plane or plane of Ludwig
• Sternal angle of louis
T4 • Arch of aorta
• Bifurcation of trachea (carina)
• Division between superior and inferior mediastinum
• Azygos vein drains into SVC
T8 • Inferior vena cava hiatus [I ate (8) 10 Eggs At 12]
T9 • Xiphisterna joint
T10 • Esophageal hiatus
T12 • Aorta hiatus

• Transpyloric plane = Addison’s plane (halfway between suprasternal (jugular) notch and SP)
• 9th costal cartilage
• Pylorus of stomach
• Fundus gallbladder (near the midclavicular line)
L1 • Neck of pancreas • Tip the 9th costal cartilage ⇋ GB fundus
• Conus medullaris (end of spinal cord)
• Superior mesenteric artery origin
• Hilum of kidneys (Lt → L1, Rt → L2)
• Duodenal jejunal flexure
• Renal veins
L2 • Thoracic duct begins
• Azygos and hemiazygos begin
L3 • Umbilicus, umbilical dermatome → T10
• Iliac crest (supracristal plane)
L4
• Bifurcation of abdominal aorta into left and right common iliac arteries
L5 • IVC formed (convergence of right and left common iliac veins)

S1 • Sacral promontory

• Posterior superior iliac spine

S2
• Dural sac ends

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 Anatomy
Clinchers for nerve supply

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 Anatomy

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 Anatomy

Muscles and n. supply of hand

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 Anatomy

Biliary tree

Ampulla of Vater = Hepatopancreatic ampulla at the 2nd part of the duodenum

- This
is where
celiac
trunk
stops

supplying the gut and the superior mesenteric artery takes over

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 Anatomy

Notes
• Flexor digitorum superficialis → Primary flexes MCP and proximal IP joints as well as thumb and wrist
• Organs in the retroperitoneal space → Pancreas, Duodenum, Aorta
• Posterior perforation of gastric ulcer will lead to accumulation of fluid in → Lesser sac, gastric contents and
pus will result in the formation of an abscess which will then pass into the peritoneal cavity through the
foramen of Winslow leading to generalized peritonitis
• Posterior perforation of pyloric and duodenal ulcer will result in accumulation in → Retroperitoneal space
• Deep tendon reflexes
- S1,2 – “buckle my shoe” → Achilles reflex
- L3,4 – “kick the door” → Knee reflex
- C5,6 – “pick up sticks” → Biceps reflex
- C6,7 – “straight up to heaven” → Triceps reflex
- L1,2 – “testicles move” → Cremasteric reflex
- S3,4 – “winks galore” → Anal reflex
• Remember, Superior oblique is the muscle used when reading
• 5th injury → Jaw deviation (at the same side)
• 12th injury → Tongue deviation (at the same side)
• 7th injury → Facial deviation (towards the opposite side)
• 10th injury → Uvular deviation (towards the opposite side)
• Lymph nodes drainage
- Skin (scrotum, valva, perineum) → Superficial inguinal LNs
- Drain all below umbilicus → Superficial inguinal LNs,
except Gonads and Lateral foot
- Gonads (testis, ovaries) → Para-aortic LNs
- Lateral foot → Popliteal LNs
- Deep lymphatics of lower leg, glans, clitoris → External
iliac LNs
- Tip of the tongue → Submental LNs
- Anterior 2/3 of the tongue → Submandibular LNs
- Posterior 1/3 of the tongue → Jugulo-omohyoid LNs
(deep cervical LNs)
- Posterior oropharynx → Jugular LNs (Deep cervical LNs)
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• Ptosis + mydriasis + exophthalmos → Oculomotor
• Ptosis + miosis + enophthalmos → Horner $
• Chest drain:
- Should be inserted in the 5th intercostal space at the superior border of the lower rib and anterior to the
mid-axillary line
- Safe triangle: pectoralis major anteriorly, latissimus dorsi posteriorly, 5 th ICS inferiorly, base of axilla
superiorly
- Order of intercostal vessels going down (VAN): vein, artery, then nerve
• Inability to move the shoulder → Spinal accessory (CN11) injury → Test it by shrugging the shoulders
• Trigeminal → Mandibular branch → Inferior alveolar nerve → lower teeth + Chin & lower lib (via Mental N)
• Biceps tendon rupture:
- Proximal → Popeye muscle appearance + minimal loss function [Popeye still strong]
- Distal → Caused by flexion against resistance with elbow at a right angle + sudden sharp tearing
sensation + swollen elbow + weakness of flexion and supination
• Golfer’s elbow → Medial epicondylitis + all flexors to fingers and pronator injured (same as baseball players,
construction and plumber’s injury)
• Tennis elbow → Lateral epicondylitis + wrist extensors affected
• De Quervain’s disease → Pain under the foot of the thumb (same as Washer woman and Mummy thumb)
• Contralateral sensory loss/hemiplegia, dysphasia, homonymous hemianopia → Cerebral infarct
• Quadriplegia, locked-in $, vertigo, diplopia or other cranial nerve palsies → Brainstem infarct
• Only pontine hemorrhage has quadriplegia = locked in $
• Ataxic hemiparesis, pure motor loss, pure sensory loss, sensorimotor loss, dysarthria → Lacunar infarcts
• Pure motor loss + dysarthria → Lacunar infarct (posterior limb of internal capsule)
• Pure sensory loss → Lacunar infarct (thalamus)
• Sensor + motor involvement + loss of cortical function (aphasia, agnosia, neglect and visual field defects →
Cerebral infarcts
• Locked-in $ “pseudo coma” → patient is aware but cannot move or communicate verbally due to complete
paralysis of nearly all voluntary muscles in the body except for vertical eye movements and blinking
• Dysarthria → disorder of articulation and pronunciation
• Dysphasia → disorder of language (affects formulation of sentences and thoughts)
• Maxillary nerve carries sensory information from the following
- Lower eyelid
- Cheek
- Nares and upper lip
- Upper teeth and gums
- Nasal mucosa
- Palate
- Roof of the pharynx
- Maxillary, ethmoid and sphenoid sinuses and part of meninges
• Nerve roots and dermatomes
- C1, C2 → Neck flexion and neck extension
- C3 → Lateral neck flexion and diaphragm (C3,4,5). Dermatome → Clavicles
- C4 → Shrugging shoulders (via spinal accessory). Dermatome → Clavicles
- C5 → Movement of shoulders, raising of the arm and flexion of the elbow. Dermatome → Deltoid region
- C6 → External rotation (supination) of the arm, extension of the elbow and wrist and pronation of the
wrist. Dermatome → Lateral arm/forearm
- C7 → Wrist flexion and small muscles of the hand. Dermatome → Middle finger
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- C8 → Finger extension, thumb abduction and thumb extension. Dermatome → Little finger
- T1 → Finger abduction and adduction
• Prepatellar bursa
- Frontal bursa of the knee joint. A superficial bursa with a thin synovial lining between skin and patella
- Occurs in housemaids “housemaid’s knee”. Commonly seen in people who kneel such as plumbers
- Common cause of swelling over the anterior inferior patella
- Symptoms: Redness, inability to flex the knee, pain and swelling is localized over site of bursa
- Relieved by rest
• Infrapatellar → inferior “clergyman/jumper’s knee”
• Suprapatellar → Superior to the knee cap
• Para → anterior
• Pes anserine → Infero-medial
• Cancer head of the pancreas = 2nd part of duodenum = CBD → jaundice due to obstruction
• Above the midpoint of inguinal ligament (ASIS-Pubic tubercle) by 2.5cm → Deep inguinal ring
• Mid inguinal point (ASIS-Pubic symphysis) = Femoral artery pulsation
• TIP → Tibial nerve, Inversion and Plantar flexion
• PED → Peroneal nerve, Eversion and Dorsiflexion
• Superior Quadrantanopia → Temporal lobe
• Inferior Quadrantanopia → Parietal lobe
• PITS – Parietal inferior, Temporal superior
• Long-term memory problems, language impairment and a change in sexual behavior → Temporal lobe
• Changes in personality and social behavior → Frontal lobe
• Visual field defects can be cause by lesion in Temporal, Parietal or Occipital lobes
• Glioma = brain or spinal cord tumor
• Venous drainage of medial ankle → Long/great saphenous vein
• Venous drainage of lateral ankle → Short saphenous vein
• Sensory supply of medial foot → Saphenous nerve
• Sensory supply of lateral foot → Sural nerve
• Foot drop → Common peroneal, Sciatic or Superficial peroneal n.
• Foot drop or loss of sensation between 1st and 2nd toes and pain on the dorsum of foot → Deep peroneal n.
• Deep peroneal n. (deep fibular n.) can be caused by overusing the anterior leg muscles, tight-fitting shoes
(ski boot $) or crossing legs for a long time
• Crutch palsy → Radial nerve compression against crutches
• Saturday night palsy → Radial nerve compression against a chair/operating table for a long time
• 5th ICS and anterior to the mid-axillary line → Chest drain insertion
• 5th ICS and medial to mid-clavicular line → Apex beat
• Dupuytren’s contracture
- Formation of thickened fibrous tissue within the palmar fascia
- The ring or 5th finger is permanently in a flexed position
- RF: family history, smoking, alcohol excess, DM and heavy manual work
- Managed by Fasciectomy
• Phrenic nerve (C3,4,5) → Diaphragm
• Hoarseness in lung cancer patients is due to RLN injury (branch of 10th)
• Injury to RLN: unilateral → HOV, bilateral → Aphonia
• Injury to the external (superior) laryngeal nerve → Changes to the voice pitch (Dysphonia)
• Indices = index finger

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• Policies = thumb
• Digitiminimi = little finger
• All intrinsic muscles of the hand are innervated by the ulnar nerve except the thenar muscles (AFO) and
lateral two lumbricals → supplied by C8 and T1 via the median nerve
• If ulnar nerve injury occurs after a high lesion → Ulnar paradox → 4th and 5th fingers are in a fully extended
state
• Ulnar n. roots → C8, T1
• Median n. roots → C5, T1
• All cervical nerves emerge above their corresponding vertebrae except C8 emerge below the C7 vertebrae
(between C7 and T1)
• When requesting a cervical X-ray, lowest vertebrae that’s needed to be seen in a lateral film is C7/T1

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