Professional Documents
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Reda Anatomy
Reda Anatomy
This is a just summary of short notes for the MRCS part A exam, they are NOT meant to replace any text
books or references. Merely intended for a quick read with common question topics and revision points for
the exam.
Taken mainly from eMRCS.com and reorganized with illustrations added (google search) and some info from
other websites.
Acknowledgements
• eMRCS.com
• medcomic.com
• Gray’s Anatomy
• Netter’s Anatomy series
• Wikipedia.org
• Various other sources… too many to mention or remember
Mohamed Reda
1
Carotid canal:
• Internal carotid artery
Foramen spinosum:
• Middle meningeal artery
Hypoglossal canal:
• [XII] Hypoglossal nerve
Stylomastoid foramen:
• [VII] Facial nerve
Jugular foramen:
(posterior cranial fossa/ neck)
• [IX] Glossopharyngeal nerve
• [X] Vagus nerve
• [XI] Accessory nerve
• Internal jugular vein
Foramen magnum:
(posterior cranial fossa/ neck)
• Spinal cord
• Vertebral arteries
Homonymous hemianopia
• Incongruous defects: lesion of optic tract Lesions before optic chiasm:
• Congruous defects: lesion of optic radiation or occipital cortex Monocular vision loss = Optic nerve lesion
• Macula sparing: lesion of occipital cortex Bitemporal hemianopia = Optic chiasm lesion
Bitemporal hemianopia
• Lesion of optic chiasm
• Upper quadrant defect > Lower quadrant defect = inf. chiasmal compression, commonly a pituitary tumour
• Lower quadrant defect > Upper quadrant defect = sup. chiasmal compression, commonly a craniopharyngioma
Relations
Medial Lateral
Pituitary fossa Temporal lobe
Sphenoid sinus
Blood supply
Ophthalmic vein, superficial cortical veins, basilar
plexus of veins posteriorly.
Drains into the internal jugular vein via: the
superior and inferior petrosal sinuses
Sternocleidomastoid
Trapezius
Ant midline of the neck
Anterior scalene
Middle scalene
Posterior scalene
Anterior belly of
digastric muscle
Hyoid bone
Muscular triangle
Nerves •
Accessory nerve
•
Phrenic nerve
•
Three trunks of the brachial plexus
•
Branches of the cervical plexus: Supraclavicular nerve, transverse cervical
nerve, great auricular nerve, lesser occipital nerve
Contents
Retromandibular vein
Supraclavicular nerves
Embryology
The parathyroids develop from the extremities of the third and fourth pharyngeal pouches. The parathyroids derived
from the fourth pharyngeal pouch are located more superiorly and are associated with the thyroid gland. Those derived
from the third pharyngeal pouch lie more inferiorly and may become associated with the thymus.
Blood supply
The blood supply to the parathyroid glands is derived from the inferior and superior thyroid arteries (Thyrocervical trunk
and the ECA respectively). There is a rich anastomosis between the two vessels. Venous drainage is into the thyroid veins.
Relations
Laterally Common carotid
Medially Recurrent laryngeal nerve, trachea
Anterior Thyroid
Posterior Pretracheal fascia
Thyrohyoid
Inferior thyroid a.
Thyrocervical trunk
Left subclavian a. Right recurrent
laryngeal nerve
Inferior thyroid
veins
Pyramidal
lobe
Thyroid
gland
Left lobe
thyroid
Motor Innervation
All of the motor innervation is provided by Hypoglossal (XII) except for the palatoglossus muscle which is provided by
Vagus (X).
Sensory
Anterior two-thirds (oral)
• General sensation mandibular
nerve [V3] via lingual nerve Posterior one-third (pharyngeal)
• Special sensation (taste) • General and special (taste)
facial nerve [VII] via chorda sensation via Glossopharyngeal nerve [IX]
tympani glossopharyngeal nerve [IX] Chorda tympani (from [VII])
Lingual nerve
(from [V3])
Motor
Hypoglossal
nerve [XII]
Intrinsic muscle Deep lingual vein
Genioglossus Dorsal lingual vein
Lingual artery
Common carotid artery
Palatoglossus Internal jugular vein
vagus nerve [X] Sternocleidomastoid branch of occipital artery
Hyoglossus muscle
Lingual nerve
Submandibular ganglion
Hypoglossal nerve
Innervation
• Sympathetic innervation- Derived from superior cervical ganglion
• Parasympathetic innervation- Submandibular ganglion via lingual nerve
Arterial supply
Branch of the facial artery. The facial artery passes through the gland to groove its deep
surface. It then emerges onto the face by passing between the gland and the mandible.
Venous drainage
Anterior facial vein (lies deep to the Marginal Mandibular nerve)
Lymphatic drainage
Deep cervical and jugular chains of nodes
Parasympathetic stimulation produces a water-rich, serous saliva. Sympathetic stimulation leads to the production of a
low volume, enzyme-rich saliva.
Transverse facial artery and vein Superficial temporal artery and vein
Retromandibular vein
Buccinator
Marginal mandibular
branches
Cervical branches
Path
Passes behind the sternoclavicular joint (12% patients above this level) to the upper border of the thyroid
cartilage, to divide into the external (ECA) and internal carotid arteries (ICA).
Relations
• Level of 6th cervical vertebra crossed by omohyoid
• Then passes deep to the thyrohyoid, sternohyoid, sternomastoid muscles.
• Passes ant. to the carotid tubercle (transverse process 6th cervical vertebra). NB: compression here stops hge.
• The inferior thyroid artery passes posterior to the common carotid artery. Then:
o Left common carotid artery crosses the thoracic duct
o Right common carotid artery crossed by recurrent laryngeal nerve
Branches
• Anterior and middle cerebral artery
• Ophthalmic artery
• Posterior communicating artery
• Anterior choroid artery
• Meningeal arteries
• Hypophyseal arteries
The internal carotid does not have any branches in the
neck.
It terminates by dividing into the superficial temporal and maxillary arteries in the parotid gland.
Occipital artery
Path
Origin: apex of the midline of the aortic arch
Passes superiorly and posteriorly to the right
Divides into the right subclavian and right common carotid artery
Relations
Anterior • Sternohyoid
• Sternothyroid
• Thymic remnants
• Left brachiocephalic vein
• Right inferior thyroid veins
Posterior • Trachea
• Right pleura
Right lateral • Right brachiocephalic vein
• Superior part of SVC
Left lateral • Thymic remnants
• Origin of left common carotid
• Inferior thyroid veins
• Trachea (higher level)
Branches
Normally none but may have the thyroidea ima artery
Subclavian Artery
Path
• The left subclavian comes directly off the arch of aorta
• The right subclavian arises from the brachiocephalic
artery (trunk) when it bifurcates into the subclavian
and the right common carotid artery.
• From its origin, the subclavian artery travels laterally,
passing between anterior and middle scalene muscles,
deep to scalenus anterior and anterior to
scalenus medius. As the subclavian artery
crosses the lateral border of the first rib,
it becomes the axillary artery. At this point it is superficial
and within the subclavian triangle.
Thyrocervical trunk
Left subclavian a.
Right subclavian a. Internal
Rib I thoracic
artery
Left common
carotid artery
The cranial preganglionic parasympathetic nerves arise from specific nuclei in the CNS. These synapse at one of four
parasympathetic ganglia; otic, pterygopalatine, ciliary and submandibular. From these ganglia the parasympathetic
nerves complete their journey to their target tissues via CN V (trigeminal) branches (ophthalmic nerve CNV branch 1,
Maxillary nerve CN V branch2, mandibular nerve CN V branch 3)
[XI]
The trigeminal nerve is the main sensory nerve of the head. In addition to its major sensory role, it also innervates the
muscles of mastication.
Path
• Originates at the pons
• Sensory root forms the large, crescentic trigeminal ganglion within Meckel's cave, and contains the cell bodies
of incoming sensory nerve fibres. Here the 3 branches exit.
• The motor root cell bodies are in the pons and the motor fibres are distributed via the mandibular nerve. The
motor root is not part of the trigeminal ganglion.
Branches of the trigeminal nerve Exit of branches of trigeminal nerve from the skull
“Standing Room Only”
Ophthalmic nerve Sensory only
V1 - Superior orbital fissure
Maxillary nerve Sensory only
V2 - foramen Rotundum
Mandibular nerve Sensory and motor
V3 - foramen Ovale
Sensory
Ophthalmic Exits skull via the superior orbital fissure
Sensation of: scalp and forehead, the upper eyelid, the conjunctiva and cornea of the eye, the nose (via
anterior ethmoidal from nasociliary, including the tip of the nose, except alae nasi), the nasal mucosa,
the frontal sinuses, and parts of the meninges (the dura and blood vessels).
Maxillary Exit skull via the foramen rotundum
nerve Sensation: lower eyelid and cheek, the nares and upper lip, the upper teeth and gums, the nasal
mucosa, the palate and roof of the pharynx, the maxillary, ethmoid and sphenoid sinuses, and parts of
the meninges.
Mandibular Exit skull via the foramen ovale
nerve Sensation: lower lip, the lower teeth and gums, the chin and jaw (except the angle of the jaw), parts of
the external ear, and parts of the meninges.
Motor (Distributed via the mandibular nerve.) The trigeminal nerve is the major sensory nerve to the face
The following muscles of mastication are innervated: except over the angle of the jaw which is supplied by the
• Masseter greater auricular nerve.
• Temporalis
• Medial pterygoid
• Lateral pterygoid The lateral aspect of the external nose is innervated by
lateral nasal branches of the anterior ethmoidal nerve. The
Other muscles innervated include: ethmoidal nerve is a branch of the nasociliary nerve (V1).
• Tensor veli palatini
• Mylohyoid
• Anterior belly of digastric
• Tensor tympani
Path
Subarachnoid path
• Origin: motor- pons, sensory- nervus intermedius
• Pass through the petrous temporal bone into the internal auditory meatus with the vestibulocochlear nerve.
Here they combine to become the facial nerve.
Stylomastoid foramen
• Passes through the stylomastoid foramen (tympanic cavity anterior and mastoid antrum posteriorly)
• Posterior auricular nerve and branch to posterior belly of digastric and stylohyoid muscle
Face
Enters parotid gland and divides into 5 branches: “The Zebra Buggered My Cat”
• Temporal branch
• Zygomatic branch
• Buccal branch
• Marginal mandibular branch
• Cervical branch
Abdominal branches
After entry into the abdominal cavity the nerves branch extensively. In previous years the extensive network of the distal
branches (nerves of Laterjet) over the surface of the distal stomach were important for the operation of highly selective
vagotomy. The use of modern PPI's has reduced the need for such highly selective procedures. Branches pass to the
coeliac axis and alongside the vessels to supply the spleen, liver and kidney.
Branches to
• Cardiac plexus
• Mucous membrane and muscular coat of the oesophagus and trachea
Innervates
• Intrinsic larynx muscles (excluding cricothyroid)
Ligamentum arteriosum
GenioHyoid
ThyroidHyoid
Superior Omohyoid
SternoThyroid
SternoHyoid
Inferior Omohyoid
Nerve to
geniohyoid
(C1)
Thyrohyoid
1. External ear
• Auricle is composed of elastic cartilage covered by skin. The lobule
has no cartilage and contains fat and fibrous tissue.
• External auditory meatus is approximately 2.5cm long.
• Lateral third of the external auditory meatus is cartilaginous and the
medial two thirds is bony.
• The region is innervated by the greater auricular nerve.
• The auriculotemporal branch of V 3 supplies most the of external
auditory meatus and the lateral surface of the auricle.
2. Middle ear
Space between the tympanic membrane and cochlea. The aditus leads to
the mastoid air cells is the route through which middle ear infections may
cause mastoiditis. Anteriorly the eustacian tube connects the middle ear
to the naso pharynx.
The tympanic membrane consists of:
• Outer layer of stratified squamous epithelium.
• Middle layer of fibrous tissue.
• Inner layer of mucous membrane continuous with the middle ear.
The tympanic membrane is approximately 1cm in diameter.
The chorda tympani nerve passes on the medial side of the pars flaccida.
The middle ear is innervated by the glossopharyngeal nerve and pain may radiate to the middle ear following
tonsillectomy.
Ossicles
Malleus attaches to the tympanic membrane (the Umbo).
Malleus articulates with the incus (synovial joint).
Incus attaches to stapes (another synovial joint).
3. Internal ear
• Cochlea, semicircular canals and vestibule
• Organ of corti is the sense organ of hearing and is located on
the inside of the cochlear duct on the basilar membrane.
• Vestibule accommodates the utricule and the saccule. These
structures contain endolymph and are surrounded by
perilymph within the vestibule.
• The semicircular canals lie at various angles to the petrous
temporal bone. All share a common opening into the vestibule.
Pharyngotympanic tube
Blood supply
Lacrimal branch of the ophthalmic artery (from ICA).
Venous drainage is to the superior ophthalmic vein.
Innervation
The gland is innervated by the secretomotor parasympathetic fibres from the pterygopalatine ganglion which in turn may
reach the gland via the zygomatic or lacrimal branches of the maxillary nerve or pass directly to the gland. The
preganglionic fibres travel to the ganglion in the greater petrosal nerve (a branch of the facial nerve at the geniculate
ganglion). Lacrimal gland
Pterygoid canal
Pterygopalatine ganglion
ICA
Nasolacrimal duct Sympathetic
Descends from the lacrimal sac to open anteriorly in the inferior meatus of the nose. Nerve of plexus
pterygoid canal
Lacrimation reflex
Occurs in response to conjunctival irritation (or emotional events). The conjunctiva will send signals via the ophthalmic
nerve. These then pass to the superior salivary centre. The efferent signals pass via the greater petrosal nerve
(parasympathetic preganglionic fibres) and the deep petrosal nerve which carries the post ganglionic sympathetic fibres.
The parasympathetic fibres will relay in the pterygopalatine ganglion, the sympathetic fibres do not synapse. They in turn
will relay to the lacrimal apparatus.
Tonsillitis
• Usually bacterial (50%) - group A Streptococcus. Remainder viral.
• May be complicated by development of abscess (quinsy). This may distort the uvula.
• Indications for tonsillectomy include recurrent acute tonsillitis, suspected malignancy, enlargement causing sleep
apnoea.
• Dissection tonsillectomy is the preferred technique with haemorrhage being the commonest complication. Delayed
otalgia may occur owing to irritation of the glossopharyngeal nerve.
Parietal peritoneum
Lineal alba Rectus abdominis Transversus abdominis
External Oblique
Parietal peritoneum
Transversus abdominis
Muscles of abdominal wall
• Lies most superficially
External oblique
ligament
• The muscle sweeps upwards to insert into the cartilages of the lower 3 ribs
• The lower fibres form an aponeurosis that runs from the tenth costal cartilage to the body of the pubis
• At its lowermost aspect it joins the fibres of the aponeurosis of transversus abdominis to form the
conjoint tendon.
• Innermost muscle
• Arises from the inner aspect of the costal cartilages of the lower 6 ribs, from the anterior 2/3 of the iliac
crest and lateral 1/3 of the inguinal ligament
Transversus
abdominis
• Its fibres run horizontally around the abdominal wall ending in an aponeurosis. The upper part runs
posterior to the rectus abdominis. Lower down the fibres run anteriorly only.
• The rectus abdominis lies medially; running from the pubic crest and symphysis to insert into the xiphoid
process and 5th, 6th and 7th costal cartilages. The muscles lie in an aponeurosis as described above.
• Nerve supply: anterior primary rami of T7-12
Surgical notes
During abdominal surgery it is usually necessary to divide either the muscles or their aponeuroses. During a midline
laparotomy it is desirable to divide the aponeurosis. This will leave the rectus sheath intact above the arcuate line and
the muscles intact below it. Straying off the midline will often lead to damage to the rectus muscles, particularly below
the arcuate line where they may often be in close proximity to each other.
Quadratus lumborum
Origin: Medial aspect of iliac crest and iliolumbar ligament
Insertion: 12th rib
Action: Pulls the rib cage inferiorly. Lateral flexion.
Nerve supply: Anterior primary rami of T12 and L1-3
Transversus abdominis
Muscle and aponeurosis
Extraperitoneal fascia
Parietal peritoneum
Visceral peritoneum
Superficial fascia
fatty layer
(Camper’s fascia)
Superficial fascia
membranous layer
(Scarpa’s fascia)
Anterior superior
iliac spine
Superficial
inguinal ring
Boundaries of the inguinal canal “MALT” Transversalis fascia Inferior epigastric artery
ASIS
Inferior
epigastric
vessels Femoral a. and v. Pubic symphysis
Deep ring
Contents
Male: Spermatic cord* and
ASIS
ilioinguinal nerve
Female: Round ligament of
uterus and ilioinguinal nerve
Lacunar ligament
Scrotum
• Composed of skin and closely attached dartos fascia.
• Arterial supply from the anterior and posterior scrotal arteries
• Lymphatic drainage to the inguinal lymph nodes
• Parietal layer of the tunica vaginalis is the innermost layer
Genital branch of genitofemoral nerve
Testicular a. and pampiniform plexus
Layers of the scrotum Cremasteric vessels Parietal peritoneum
“Some Damn Englishman Called It The Extraperitoneal fascia
Testes”
• Skin Artery to ductus deferens
• Dartos fascia and muscle
• External spermatic fascia
• Cremasteric fascia
• Internal spermatic fascia
• Tunica vaginalis
• Testes
Ext. oblique aponeurosis
Testes Internal oblique muscle
• The testes are surrounded by
Transversus abdominis
the tunica vaginalis (closed
peritoneal sac). The parietal Deep inguinal ring
layer of the tunica vaginalis Conjoint tendon
adjacent to the internal
spermatic fascia. Superficial inguinal ring
• The testicular arteries arise
from the aorta immediately
inferiorly to the renal
arteries.
• The pampiniform plexus
drains into the testicular
veins, the left drains into the
left renal vein and the right
into the inferior vena cava.
• Lymphatic drainage is to the
para-aortic nodes
The ascending colon becomes the transverse colon after passing the
hepatic flexure. At this location the colon becomes wholly intra
peritoneal once again. The superior aspect of the transverse colon is
the point of attachment of the transverse colon to the greater
omentum. This is an important anatomical site since division of these
attachments permits entry into the lesser sac. Separation of the
greater omentum from the transverse colon is a routine operative
step in both gastric and colonic resections.
At the left side of the abdomen the transverse colon passes to the left
upper quadrant and makes an oblique inferior turn at the splenic
flexure. Following this, the posterior aspect becomes retroperitoneal
once again.
At its distal end the sigmoid passes to the midline and at the region
around the sacral promontary it becomes the upper rectum. This
transition is visible macroscopically as the point where the teniae
fuse. More distally the rectum passes through the peritoneum at the
region of the peritoneal reflection and becomes extraperitoneal.
Arterial supply
Superior mesenteric artery and inferior mesenteric artery: linked by
the marginal artery.
Ascending colon: ileocolic and right colic arteries
Transverse colon: middle colic artery
Descending and sigmoid colon: inferior mesenteric artery
Venous drainage
From regional veins (that accompany arteries) to superior and inferior mesenteric vein
The inferior mesenteric vein drains into the splenic vein, this point of union lies close to the duodenum and this surgical
maneuver is a recognized cause of ileus.
The middle colonic vein drains into the SMV, if avulsed during mobilisation then dramatic haemorrhage can occur and be
difficult to control.
Lymphatic drainage
Initially along nodal chains that accompany supplying arteries, then para-aortic nodes.
Peritoneal location
The right and left colon are part intraperitoneal and part extraperitoneal. The sigmoid and transverse colon are generally
wholly intraperitoneal. This has implications for the sequelae of perforations, which will tend to result in generalised
peritonitis in the wholly intra peritoneal segments.
Colonic relations
Region of colon Relation
Caecum/ right colon Right ureter, gonadal vessels
Hepatic flexure Gallbladder (medially)
Splenic flexure Spleen and tail of pancreas
Distal sigmoid/ upper rectum Left ureter
Rectum Ureters, autonomic nerves, seminal vesicles, prostate, urethra (distally)
Stomach
Liver
Short gastric veins
Spleen
Arteria recta
Greater omentum Right colic artery Sigmoid arteries
Superior rectal artery
Appendicular artery
Relations
Superior Liver and gall-bladder, the greater curvature of
the stomach, and the lower end of the spleen
Inferior Small intestine
Anterior Greater omentum
Posterior From right to left with the descending portion of
the duodenum, the head of the pancreas,
convolutions of the jejunum and ileum, spleen
Rectum
The rectum is approximately 12 cm long. It is a capacitance organ. It has both intra and extraperitoneal components. The
transition between the sigmoid colon is marked by the disappearance of the tenia coli.The extra peritoneal rectum is
surrounded by mesorectal fat that also contains lymph nodes. This mesorectal fatty layer is removed surgically during
rectal cancer surgery (Total Mesorectal Excision). The fascial layers that surround the rectum are important clinical
landmarks, anteriorly lies the fascia of Denonvilliers. Posteriorly lies Waldeyers (presacral) fascia.
Right common iliac artery
Left internal
Extra peritoneal rectum iliac artery Superior
• Posterior upper third Left common rectal
iliac artery artery Right internal
• Posterior and lateral middle third
iliac artery
• Whole lower third
(Females) Cervix
Vaginal wall
Posteriorly Sacrum
Coccyx
Middle sacral artery
Laterally Levator ani
Coccygeus
Superiorly Diaphragm
Anteriorly Gastric impression
Relations
Posteriorly Kidney
Inferiorly Colon
Hilum Tail of pancreas and splenic vessels (splenic artery divides
here, branches pass to the white pulp transporting plasma)
Function Descending
• Filtration of abnormal blood cells and foreign bodies such as bacteria. colon
• Immunity: IgM. Production of properdin, and tuftsin which help target Greater
fungi and bacteria for phagocytosis. omentum
• Haematopoiesis: up to 5th month gestation or in haematological
disorders. Small
intestine
• Pooling: storage of 40% platelets.
• Iron reutilization
• Storage monocytes
Splenorenal lig.
Left kidney
Caudate lobe
Falciform Suprarenal
Left triangle ligament impression Fundus of GB Hepatic duct
Bare area
ligament Body of GB
Neck of GB Quadrate lobe
Fissure for
ligamentum teres
Right lobe Left lobe
Gastric Renal impression
impression
Porta hepatis
Left lobe Rt lobe Cystic duct
Neck of GB
Esophageal
impression Body of GB
Ligaments
Falciform ligament • 2 layer fold peritoneum from the umbilicus to anterior liver surface
• Contains ligamentum teres (remnant umbilical vein)
• On superior liver surface it splits into the coronary and left triangular ligaments
Ligamentum teres Joins the left branch of the portal vein in the porta hepatis
Ligamentum venosum Remnant of ductus venosus
Arterial supply
• Hepatic artery
Venous
• Hepatic veins
• Portal vein
Nervous supply
• Sympathetic and parasympathetic trunks of coeliac plexus
Bile duct
Arterial supply Splenic artery
Cystic artery (branch of Right hepatic artery) Right gastric artery
Supraduodenal
Venous drainage artery
Directly to the liver
Nerve supply
Sympathetic- mid thoracic spinal cord,
Parasympathetic- anterior vagal trunk
Hepatobiliary triangle
Medially Common hepatic duct
Inferiorly Cystic duct
Superiorly Inferior edge of liver
Contents Cystic artery
Bile duct
Bile
duct
Descending part
of duodenum
Main pancreatic duct
Relations
Posterior to the pancreas
Head Inferior vena cava
Common bile duct
Right and left renal veins
SMA and SMV
Neck SMV, portal vein Aorta
Body Left renal vein Inferior vena cava
Crus of diaphragm
Psoas muscle Right kidney
Adrenal gland
Kidney
Aorta
Tail Left kidney
Venous drainage
• Head: superior mesenteric vein
• Body and tail: splenic vein
Ampulla of Vater
• Merge of pancreatic duct and common bile duct
• Is an important landmark, halfway along the second part
of the duodenum, that marks the anatomical transition
from foregut to midgut (also the site of transition
between regions supplied by coeliac trunk and SMA).
Inferior pancreaticoduodenal artery
Diaphragm
Coeliac trunk
Abdominal aorta anterior branches
Middle suprarenal artery
Marginal artery
Aorta
Marginal artery
Middle colic artery
Right colic artery Inferior mesenteric artery
Marginal arteries
Left colic artery
Ileocolic artery
Descending colon
Ascending colon
Sigmoid arteries
Appendicular artery
Appendix
Relations
Anteriorly Lesser omentum
Right Right coeliac ganglion and caudate process of liver
Left Left coeliac ganglion and gastric cardia
Inferiorly Upper border of pancreas and renal vein
Gastroduodenal artery
Supplies
Pylorus, proximal part of the duodenum, and indirectly to the pancreatic head (via the anterior and posterior superior
pancreaticoduodenal arteries)
Path
The gastroduodenal artery most commonly arises from the common hepatic artery of the coeliac trunk. It terminates by
bifurcating into the right gastroepiploic artery and the superior pancreaticoduodenal artery (anterior and posterior)
Branches
The left colic artery arises from the IMA near its origin. More distally up to three sigmoid arteries will exit the IMA to
supply the sigmoid colon.
4. Fat
Ureter
Left kidney
1st constriction
Ureteropelvic junction
2nd constriction
Entrance to bladder
The ureter develops from the mesonephric duct. The mesonephric duct is associated with the metanephric
duct that develops within the metanephrogenic blastema. This forms the site of the ureteric bud which
branches off the mesonephric duct.
The right renal vein is very short and lies more inferiorly.
Relations
Anterior Pubic symphysis
Prostatic venous plexus
Posterior Denonvilliers (Rectoprostatic) fascia
Rectum
Ejaculatory ducts
Lateral Venous plexus (lies on prostate)
Levator ani (immediately below the puboprostatic ligaments)
During liver surgery or trauma, bleeding may be controlled using a Pringles maneuver, this involves placing a vascular
clamp across the anterior aspect of the epiploic foramen. Thereby occluding:
• Common bile duct
• Hepatic artery
• Portal vein
Relations
Anteriorly Small bowel, first and third part of duodenum, head of pancreas, liver and bile duct, right
common iliac artery, right gonadal artery
Posteriorly Right renal artery, right psoas, right sympathetic chain, coeliac ganglion
Mnemonic for the Inferior vena cava tributaries: “I Like To Rise So High”
• Iliacs
• Lumbar
• Testicular
• Renal
• Suprarenal
• Hepatic veins
The supports of the uterus include the central perineal tendon (perineal body) (the most important). The lateral cervical,
round and uterosacral ligaments are condensations of the endopelvic fascia and provide additional structural support.
Mediastinal regions
• Superior mediastinum (between manubriosternal angle and T4/5)
• Middle mediastinum
• Posterior mediastinum
• Anterior mediastinum
Region Contents
• Superior vena cava
• Brachiocephalic veins
Superior mediastinum
• Arch of aorta
• Thoracic duct
• Trachea
• Oesophagus
• Thymus
• Vagus nerve
• Left recurrent laryngeal nerve
• Phrenic nerve
• Thymic remnants
Anterior
• Lymph nodes
• Fat
• Pericardium
mediastinu
• Heart
Middle
• Aortic root
m
• Azygos vein
Posterior
• Thoracic duct
• Vagus nerve
• Sympathetic nerve trunks
• Splanchnic nerves
Relations
Anteriorly • Trachea to T4
• Recurrent laryngeal nerve
• Left bronchus, Left atrium
• Diaphragm
Posteriorly • Thoracic duct to left at T5
• Hemiazygos to the left T8
• Descending aorta
• First 2 intercostal branches of aorta
Left • Thoracic duct
• Left subclavian artery
Right • Azygos vein
Nerve supply
• Upper half is supplied by recurrent laryngeal nerve
• Lower half by oesophageal plexus (vagus)
Histology
• Mucosa :Non-keratinized stratified squamous epithelium
• Submucosa: glandular tissue
• Muscularis externa (muscularis): composition varies. See table
• Adventitia
Right lung
• Above the hilum is the azygos vein; Superior to this is the groove for the superior vena cava and right
innominate vein; behind this, and nearer the apex, is a furrow for the innominate artery. Behind the hilum and
the attachment of the pulmonary ligament is a vertical groove for the oesophagus; In front and to the right of
the lower part of the oesophageal groove is a deep concavity for the extrapericardial portion of the inferior
vena cava.
• The root of the right lung lies behind the superior vena cava and the right atrium, and below the azygos vein.
• The right main bronchus is shorter, wider and more vertical than the left main bronchus and therefore the route
taken by most foreign bodies.
Left lung
• Above the hilum is the furrow produced by the aortic arch, and then superiorly the groove accommodating the
left subclavian artery; Behind the hilum and pulmonary ligament is a vertical groove produced by the
descending aorta, and in front of this, near the base of the lung, is the lower part of the oesophagus.
• The phrenic nerve lies anteriorly at this point (hilum of left lung). The vagus passes anteriorly and then arches
backwards immediately superior to the root of the left bronchus, giving off the recurrent laryngeal nerve as it
does so.
• The root of the left lung passes under the aortic arch and in front of the descending aorta.
Bronchopulmonary segments
Segment number Right lung Left lung
1 Apical Apical
2 Posterior Posterior
3 Anterior Anterior
4 Lateral Superior lingular
5 Medial Inferior lingular
6 Superior (apical) Superior (apical)
7 Medial basal Medial basal
8 Anterior basal Anterior basal
9 Lateral basal Lateral basal
10 Posterior basal Posterior basal
Relations
The heart and roots of the great vessels within the
pericardial sac are related to the posterior aspect of the
sternum, medial ends of the 3rd to 5th ribs on the left and
their associated costal cartilages. The heart and pericardial
sac are situated obliquely two thirds to the left and one third
to the right of the median plane.
The pulmonary valve lies at the level of the left third costal
cartilage.
The mitral valve lies at the level of the fourth costal cartilage.
Coronary sinus
This lies in the posterior part of the coronary groove and receives blood from the cardiac
veins. The great cardiac vein lies at its left and the middle and small cardiac veins lie on its
right. The smallest cardiac vein (anterior cardiac vein) drains into the right atrium directly.
Aortic sinus
Right coronary artery arises from the right aortic sinus, the left is derived
from the left aortic sinus, which lies posteriorly.
Formation
• Subclavian and internal jugular veins unite to form the right and left brachiocephalic veins
• These unite to form the SVC
• Azygos vein joins the SVC before it enters the right atrium
Relations
Anterior Anterior margins of the right lung and pleura
Posteromedial Trachea and right vagus nerve
Posterolateral Posterior aspects of right lung and pleura
Pulmonary hilum is posterior
Right lateral Right phrenic nerve and pleura
Left lateral Brachiocephalic artery and ascending aorta
Developmental variations
Anomalies of the connection of the SVC are recognised. In some individuals a persistent left sided SVC drains into the
right atrium via an enlarged orifice of the coronary sinus. More rarely the left sided vena cava may connect directly with
the superior aspect of the left atrium, usually associated with an un-roofing of the coronary sinus. The commonest lesion
of the IVC is for its abdominal course to be interrupted, with drainage achieved via the azygos venous system. This may
occur in patients with left sided atrial isomerism.
Aortic
Usually located medial to the 3rd interspace on the right.
Mitral
Usually located medial to the 4th interspace on the left.
Tricuspid
Usually located medial to the 5th interspace on the right.
Please note that these are the sites at which an artificial valve may be located and are NOT the sites of auscultation.
Carpal bones
Sally Likes To Play The Tiny Chrome Harmonica
She Looks Too Pretty Try To Catch Her
Scared Lovers Try Positions That They Can't Handle
Latissimus
dorsi
Cut edge
of deltoid
Surgical neck
of humerus
Medial lip of
intertubercular
sulcus
Quadrangular
space
Triangular interval
Teres major Deltoid tuberosity
of humerus
Long head
of triceps
brachii
The radial nerve and profunda brachii vessels lie between the lateral and medial heads
Coracobrachialis muscle
Radial tuberosity
Humeral head of
pronator teres
Humeral head of
flexor carpi ulnaris
Ulnar head of
pronator teres Ulnar head of
Ulnar artery flexor carpi ulnaris
Median nerve
Pisohamate ligament
Pisiform
Pisometacarpal ligament
Hook of hamate
Humero-ulnar head of
flexor digitorum
superficialis
Interosseous
membrane
Flexor
Flexor digitorum digitorum
superficialis profundus
Flexor digitorum
superficialis
tendon (cut)
Extensor carpi
radialis longus
Extensor carpi
radialis brevis
Extensor carpi
ulnaris
Supinator
(deep head)
Supinator
(superficial head)
Extensor indicis
Extensor carpi
radialis longus
Extensor carpi
radialis brevis
Abductor
pollicis longus
Extensor digiti minimi Extensor
pollicis brevis
Posterior View
Radial artery
Flexor retinaculum
Clinical notes
Along with the lumbricals the interossei flex the metacarpophalangeal joints and extend the proximal and distal
interphalangeal joints. They are responsible for fine tuning these movements. When the interossei and lumbricals are
paralysed the digits are pulled into hyperextension by extensor digitorum and a claw hand is seen.
1st dorsal
interosseous muscle
Anatomical
snuffbox
Extensor pollicis brevis tendon
Extensor pollicis
longus tendon
Abductor pollicis longus tendon
Cephalic vein
Anatomical snuffbox
Extensor pollicis longus tendon
Subscapularis
Subscapular artery
Projecting forward to the upper border of the Pectoralis minor, it pierces the coracoclavicular fascia and divides into four
branches: pectoral, acromial, clavicular, and deltoid.
Branch Description
Pectoral Descends between the two Pectoral muscles, and is distributed to them and to the breast,
branch anastomosing with the intercostal branches of the internal thoracic artery and with the lateral thoracic.
Acromial Runs laterally over the coracoid process and under the Deltoid, to which it gives branches; it then
branch pierces that muscle and ends on the acromion in an arterial network formed by branches from the
suprascapular, thoracoacromial, and posterior humeral circumflex arteries.
Clavicular Runs upwards and medially to the sternoclavicular joint, supplying this articulation, and the Subclavius.
branch
Deltoid Arising with the acromial, it crosses over the Pectoralis minor and passes in the same groove as the
branch cephalic vein, between the Pectoralis major and Deltoid, and gives branches to both muscles.
Relations
• Posterior relations include the long head of triceps with the radial nerve and profunda vessels intervening.
• Anteriorly it is overlapped by the medial border of biceps.
• It is crossed by the median nerve in the middle of the arm.
• In the cubital fossa it is separated from the median cubital vein by the bicipital aponeurosis.
• The basilic vein is in contact at the most proximal aspect of the cubital fossa and lies medially.
Relations
Deep to- Pronator teres, Flexor carpi radialis, Palmaris Flexor carpi
ulnaris (cut)
longus
Lies on- Brachialis and Flexor digitorum profundus
Superficial to the flexor retinaculum at the wrist
Common
The median nerve is in relation with the medial side of the interosseous artery
artery for about 2.5 cm. And then crosses the vessel, being
Flexor digitorum
separated from it by the ulnar head of the Pronator teres
Posterior superficialis
interosseous
The ulnar nerve lies medially to the lower two-thirds of the artery Anterior
artery interosseous
artery
Branch
• Anterior interosseous artery
Perforating
Radial Artery branches of anterior
interosseous artery
Brachioradialis
tendon (cut) Interosseous
membrane
Flexor pollicis
longus
Deep
palmar arch
Superficial
palmar arch
Path
• Originates on the medial side of the dorsal venous network of the hand, and passes up the forearm and arm.
• Most of its course is superficial.
• Near the region anterior to the cubital fossa the vein joins the cephalic vein.
• Midway up the humerus the basilic vein passes deep under the muscles.
• At the lower border of the teres major muscle, the anterior and posterior circumflex humeral veins feed into it.
• It is often joined by the medial brachial vein before draining into the axillary vein.
Clavicle
Clavipectoral triangle
Biceps brachii
Basilic vein
Musculocutaneous nerve
• All muscles in anterior
compartment of arm
Median nerve
• Most flexors in forearm
• Thenar muscles in hand
Axillary nerve
• Superior lateral
cutaneous nerve of arm
Radial nerve
• Inferior lateral
cutaneous nerve of arm
Radial nerve • Posterior cutaneous
• Inferior lateral T2 nerve of arm
cutaneous • Posterior cutaneous
nerve of arm nerve of forearm
Musculocutaneus nerve
• Inferior lateral
Musculocutaneus nerve
cutaneous
• Inferior lateral
nerve of arm
cutaneous nerve of
arm
Median nerve
Median nerve
ANTERIOR POSTERIOR
Intercostobrachial nerve
(lateral cutaneous branch of T2)
Superior subscapular nerve
Thoracodorsal nerve
Inferior subscapular nerve
Innervates
• Coracobrachialis
• Biceps brachii
• Brachialis
Median Nerve
The median nerve is formed by the union of a lateral and medial root respectively from the lateral (C5,6,7) and medial
(C8 and T1) cords of the brachial plexus; the medial root passes anterior to the third part of the axillary artery. The nerve
descends lateral to the brachial artery, crosses to its medial side (usually passing anterior to the artery). It passes deep to
the bicipital aponeurosis and the median cubital vein at the elbow.
It passes between the two heads of the pronator teres muscle, and runs on the deep surface of flexor digitorum
superficialis (within its fascial sheath).
Near the wrist it becomes superficial between the tendons of flexor digitorum superficialis and flexor carpi radialis, deep
to palmaris longus tendon. It passes deep to the flexor retinaculum to enter the palm, but lies anterior to the long flexor
tendons within the carpal tunnel.
Branches
Region Branch
Upper arm No branches, although the nerve commonly communicates with the musculocutaneous nerve
Pronator teres
Flexor carpi radialis
Palmaris longus
Forearm Flexor digitorum superficialis
Pronator quadratus
Flexor pollicis longus
Flexor digitorum profundus (only the radial half)
Distal forearm Palmar cutaneous branch
Motor supply (LOAF)
• Lateral 2 lumbricals
Hand (Motor) • Opponens pollicis
• Abductor pollicis brevis
• Flexor pollicis brevis
• Over thumb and lateral 2 ½ fingers
Hand (Sensory) • On the palmar aspect this projects proximally, on the dorsal aspect only the distal regions are
innervated with the radial nerve providing the more proximal cutaneous innervation.
Patterns of damage:
Damage at wrist
• e.g. Carpal tunnel syndrome
• Paralysis and wasting of thenar eminence muscles and opponens pollicis (ape hand deformity)
• Sensory loss to palmar aspect of lateral (radial) 2 ½ fingers
Damage at elbow, as above plus:
• Unable to pronate forearm
• Weak wrist flexion
• Ulnar deviation of wrist
Anterior interosseous nerve (branch of median nerve)
• Leaves just below the elbow
• Results in loss of pronation of forearm and weakness of long flexors of thumb and index finger
• Loss of pincer movement of the thumb and index finger.
Path
• Posteromedial aspect of upper arm to flexor compartment of forearm, then along the ulnar. Passes beneath the
flexor carpi ulnaris muscle, then superficially through the flexor retinaculum into the palm of the hand.
Branches
Branch Supplies
Muscular branch Flexor carpi ulnaris
Medial half of the flexor digitorum profundus
Palmar cutaneous branch (Arises near Skin on the medial part of the palm
the middle of the forearm)
Dorsal cutaneous branch Dorsal surface of the medial part of the hand
Superficial branch Cutaneous fibres to the anterior surfaces of the medial one and one-half
digits
Deep branch Hypothenar muscles
All the interosseous muscles
Third and fourth lumbricals
Adductor pollicis
Medial head of the flexor pollicis brevis
Effects of injury
Damage at the wrist • Wasting and paralysis of intrinsic hand muscles (claw hand)
• Wasting and paralysis of hypothenar muscles
• Loss of sensation medial 1 and half fingers
Damage at the elbow • Radial deviation of the wrist
• Clawing less in 4th and 5th digits
Radial nerve
Lateral cutaneous
nerve of the
forearm
Humeral head
of pronator teres
Flexor carpi
ulnaris
Ulnar head
of pronator teres
Flexor digitorum
superficialis
Anterior
interosseous nerve
Flexor digitorum
profundus
Brachioradialis
tendon (cut)
Palmar branch
Palmar branch
(of ulnar nerve)
(of median nerve)
Radial Nerve
Continuation of posterior cord of the brachial plexus (root values C5 to T1)
Path
• In the axilla: lies posterior to the axillary
artery on subscapularis, latissimus dorsi
and teres major.
• Enters the arm between the brachial artery
and the long head of triceps (medial to humerus).
• Spirals around the posterior surface of the humerus Triangular
in the groove for the radial nerve. interval
• At the distal third of the lateral border of the
humerus it then pierces the intermuscular septum
and descends in front of the lateral epicondyle. Profunda
• At the lateral epicondyle it lies deeply between brachii
brachialis and brachioradialis where it then divides artery
into a superficial and deep terminal branch.
• Deep branch crosses the supinator to become the
posterior interosseous nerve.
Radial nerve
Regions innervated (in radial groove)
Motor (main • Triceps
nerve) • Anconeus
• Brachioradialis
• Extensor carpi radialis
Inferior
Motor • Supinator lateral
(posterior • Extensor carpi ulnaris cutaneus
interosseous • Extensor digitorum nerve of
the arm
branch) • Extensor indicis
• Extensor digiti minimi
• Extensor pollicis longus
• Extensor pollicis brevis
• Abductor pollicis longus
Sensory The area of skin supplying the
Posterior
proximal phalanges on the
cutaneus
dorsal aspect of the hand is nerve of
supplied by the radial nerve forearm
(this does not apply to the
little finger and part of the ring
finger)
Glenoid labrum
• Fibrocartilaginous rim attached to the free edge of the glenoid cavity
• Tendon of the long head of biceps arises from within the joint from the supraglenoid tubercle, and is fused at
this point to the labrum.
• The long head of triceps attaches to the infraglenoid tubercle
Fibrous capsule
• Attaches to the scapula external to the glenoid labrum and to the labrum itself (postero-superiorly)
• Attaches to the humerus at the level of the anatomical neck superiorly and the surgical neck inferiorly
• Anteriorly the capsule is in contact with the tendon of subscapularis, superiorly with the supraspinatus tendon,
and posteriorly with the tendons of infraspinatus and teres minor. All these blend with the capsule towards
their insertion.
• Two defects in the fibrous capsule; superiorly for the tendon of biceps. Anteriorly there is a defect beneath the
subscapularis tendon.
• The inferior extension of the capsule is closely related to the axillary nerve at the surgical neck and this nerve is
at risk in anteroinferior dislocations. It also means that proximally sited osteomyelitis may progress to septic
arthritis. Subacromial bursa
(subdeltoid) Long head of biceps brachii tendon
Fibrous membrane
Pectoralis major
Long head of triceps
Synovial sheath
Synovial membrane
Redundant capsule
Redundant synovial
membrane in adduction
Breast anatomy
Nerve supply Branches of intercostal nerves from T4-T6.
Arterial supply • Internal mammary (thoracic) artery (60% of arterial supply)
• External mammary artery (laterally)
• Anterior intercostal arteries
• Thoraco-acromial artery
Venous drainage Superficial venous plexus to subclavian, axillary and intercostal veins.
Lymphatic • 70% Axillary nodes
drainage • Internal mammary chain
• Other lymphatic sites such as deep cervical and supraclavicular fossa (later in disease)
Contents
Long thoracic nerve (of Bell) Derived from C5-C7 and passes behind the brachial plexus to enter the axilla. It lies on
the medial chest wall and supplies serratus anterior. Its location puts it at risk during
axillary surgery and damage will lead to winging of the scapula.
Thoracodorsal nerve and Innervate and vascularise latissimus dorsi.
thoracodorsal trunk
Axillary vein Lies at the apex of the axilla, it is the continuation of the basilic vein. Becomes the
subclavian vein at the outer border of the first rib.
Intercostobrachial nerves Traverse the axillary lymph nodes and are often divided during axillary surgery. They
provide cutaneous sensation to the axillary skin.
Lymph nodes The axilla is the main site of lymphatic drainage for the breast.
Triceps brachii
Artery
Medial intermuscular septum (brachial)
Nerve
Cubital fossa
(Median)
Line between
lateral and medial
epicondyles
Bicipital
Forearm flexors aponeurosis
Radial artery
Brachioradialis
Ulnar artery
Medial cutaneous
nerve of the forearm
Pronator teres
(humeral head)
Supinator
Radial artery
Nerves
Superior gluteal nerve (L5, S1) • Gluteus medius
• Gluteus minimis
• Tensor fascia lata
Inferior gluteal nerve Gluteus maximus
Damage to the superior gluteal nerve will result in the patient developing a
Trendelenberg gait. Affected patients are unable to abduct the thigh at the hip
joint. During the stance phase, the weakened abductor muscles allow the
pelvis to tilt down on the opposite side. To compensate, the trunk lurches to
the weakened side to attempt to maintain a level pelvis throughout the gait
cycle. The pelvis sags on the opposite side of the lesioned superior gluteal
nerve.
Piriformis
Is a landmark for identifying structures passing out of the sciatic notch
• Above piriformis: Superior gluteal vessels
• Below piriformis: Inferior gluteal vessels, sciatic nerve (10%
pass through it, <1% above it), posterior cutaneous nerve of
the thigh
Superficial external
pudendal artery
Deep external
pudendal artery
Deep artery of the thigh
Femoral Artery
Beginning:
Behind inguinal lig. At the mid inguinal point as a
continuation of the external iliac artery.
Path:
• Its upper ½ lies superficial in the femoral triangle
• Its lower ½ lies deep in the subsartorial canal
Termination:
At the junction of upper 2/3 and lower 1/3 of the
thigh by passing through the opening in adductor
magnus m. to become the popliteal artery.
Branches:
Superficial branches Deep branches
• Superficial epigastric artery • Profunda femoris artery
• Superficial external pudendal artery • Deep external pudendal artery
• Superficial circumflex iliac artery • Descending genicular artery
Tributaries
• Medial marginal
• Superficial epigastric
• Superficial iliac circumflex
• Superficial external pudendal veins
Genitofemoral Nerve
Supplies
Small area of the upper medial thigh.
Path
• Arises from the first and second lumbar nerves.
• Passes obliquely through psoas major, and emerges from its medial border opposite the fibrocartilage between
the third and fourth lumbar vertebrae.
• It then descends on the surface of psoas major, under cover of the peritoneum
• Divides into genital and femoral branches.
• The genital branch passes through the inguinal canal, within the spermatic cord, to supply the skin and fascia of
the scrotum. The femoral branch enters the thigh posterior to the inguinal ligament, lateral to the femoral
artery. It supplies an area of skin and fascia over the femoral triangle.
• It may be injured during abdominal or pelvic surgery, or during inguinal hernia repairs.
Traction and compression of the pudendal nerve by the foetus in late pregnancy may result in late onset pudendal
neuropathy which may be part of the process involved in the development of faecal incontinence.
Path
Penetrates psoas major and exits the pelvis by passing
under the inguinal ligament to enter the femoral triangle,
lateral to the femoral artery and vein.
V astus
Q uadriceps femoris
S artorius
PE ectineus
Supplies
• Medial compartment of thigh
• Muscles supplied: external obturator,
adductor longus, adductor brevis, adductor
magnus (not the lower part-sciatic nerve),
gracilis
• The cutaneous branch is often absent.
When present, it passes between gracilis
and adductor longus near the middle part
of the thigh, and supplies the skin and
fascia of the distal two thirds of the medial
aspect.
Obturator canal
• Connects the pelvis and thigh: contains the
obturator artery, vein, nerve which divides
into anterior and posterior branches.
Summary points
Origin Spinal nerves L4 - S3
Articular Branches Hip joint
Muscular • Semitendinosus
branches in upper • Semimembranosus
leg • Biceps femoris
• Part of adductor magnus
Cutaneous • Posterior aspect of thigh (via cutaneous nerves)
sensation • Gluteal region
• Entire lower leg (except the medial aspect) Major nerves of the LL
Terminates At the upper part of the popliteal fossa by dividing (colors indicate regions of
into the tibial and peroneal nerves motor innervation)
• The nerve to the short head of the biceps femoris comes from the common peroneal part of the sciatic and the
other muscular branches arise from the tibial portion.
• The tibial nerve goes on to innervate all muscles of the foot except the extensor digitorum brevis (which is
innervated by the common peroneal nerve).
Sciatic nerve
Branches
In the thigh Nerve to the short head of biceps
Articular branch (knee)
In the popliteal Lateral cutaneous nerve of the calf
fossa
Neck of fibula Superficial and deep peroneal nerves
Contents
• Femoral vein (medial to lateral)
• Femoral artery-pulse palpated at the mid
inguinal point
• Femoral nerve
• Deep and superficial inguinal lymph nodes
• Lateral cutaneous nerve
• Great saphenous vein
• Femoral branch of the genitofemoral nerve
• The iliacus lies posterior to the femoral nerve in the femoral triangle.
• The femoral sheath lies anterior to both the iliacus and pectineus.
Contents
• Lymphatic vessels
• Cloquet's lymph node
Physiological significance
Allows the femoral vein to expand to allow for
increased venous return to the lower limbs.
Pathological significance
As a potential space, it is the site of femoral hernias.
The relatively tight neck places these at high risk of
strangulation.
Adductor Canal
• Also called Hunter's or subsartorial canal
• Immediately distal to the apex of the femoral
triangle, lying in the middle third of the thigh.
Canal terminates at the adductor hiatus.
Borders
Laterally Vastus medialis muscle
Posteriorly Adductor longus, adductor magnus
Roof Sartorius
Contents
Saphenous nerve
Superficial femoral artery
Superficial femoral vein
(posterior to the artery in the upper part then
posterolat.`)
Contents
• Popliteal artery and vein
• Small saphenous vein
• Common peroneal nerve
• Tibial nerve
• Posterior cutaneous nerve of the thigh
• Genicular branch of the obturator nerve
• Lymph nodes
The tibial nerve lies superior to the vessels in the inferior aspect of the popliteal fossa. In the upper part of the fossa the
tibial nerve lies lateral to the vessels, it then passes superficial to them to lie medially. The popliteal artery is the deepest
structure in the popliteal fossa.
Plantar arteries
Arise under the cover of the flexor retinaculum, midway between the tip of the medial malleolus and the most
prominent part of the medial side of the heel.
• Medial plantar artery. Passes forwards medial to medial plantar nerve in the space between abductor hallucis
and flexor digitorum brevis.Ends by uniting with a branch of the 1st plantar metatarsal artery.
• Lateral plantar artery. Runs obliquely across the sole of the foot. It lies lateral to the lateral plantar nerve. At the
base of the 5th metatarsal bone it arches medially across the foot on the metatarsals
Blood supply
Medial circumflex femoral and lateral circumflex femoral arteries (Branches of profunda femoris). Also from the inferior
gluteal artery. These form an anastomosis and travel to up the femoral neck to supply the head.
Fibrous capsule
The capsule of the knee joint is a complex, composite structure with contributions from adjacent tendons.
Anterior The capsule does not pass proximal to the patella. It blends with the tendinous expansions of vastus
fibres medialis and lateralis
Posterior These fibres are vertical and run from the posterior surface of the femoral condyles to the posterior
fibres aspect of the tibial condyle
Medial fibres Attach to the femoral and tibial condyles beyond their articular margins, blending with the tibial
collateral ligament
Lateral fibres Attach to the femur superior to popliteus, pass over its tendon to head of fibula and tibial condyle
Bursae
Anterior • Subcutaneous prepatellar bursa; between patella and skin
• Deep infrapatellar bursa; between tibia and patellar ligament
• Subcutaneous infrapatellar bursa; between distal tibial tuberosity and skin
Laterally • Bursa between lateral head of gastrocnemius and joint capsule
• Bursa between fibular collateral ligament and tendon of biceps femoris
• Bursa between fibular collateral ligament and tendon of popliteus
Medially • Bursa between medial head of gastrocnemius and the fibrous capsule
• Bursa between tibial collateral ligament and tendons of sartorius, gracilis and semitendinosus
• Bursa between the tendon of semimembranosus and medial tibial condyle and medial head of
gastrocnemius
Posterior Highly variable and inconsistent
Ligaments
Medial collateral ligament
Lateral collateral ligament
Anterior cruciate ligament
Posterior cruciate ligament
Patellar ligament
Menisci
Medial and lateral menisci compensate for the incongruence of the femoral and tibial condyles.
Composed of fibrous tissue.
Medial meniscus is attached to the tibial collateral ligament.
Lateral meniscus is attached to the loose fibres at the lateral edge of the joint and is separate from the fibular collateral
ligament. The lateral meniscus is crossed by the popliteus tendon.
Nerve supply
The knee joint is supplied by the femoral, tibial and common peroneal divisions of the sciatic and by a branch from the
obturator nerve. Hip pathology pain may be referred to the knee.
Blood supply
Genicular branches of the femoral artery, popliteal and anterior tibial arteries all supply the knee joint.
Nerve supply
Branches of deep peroneal and tibial nerves.
Cervical vertebrae
The interface between the first and
second vertebra is called the atlanto-
axis junction. The C3 cord contains
the phrenic nucleus.
Muscle Root value
Deltoid C5,6
Biceps C5,6
Wrist extensors C6-8
Triceps C6-8
Wrist flexors C6-T1
Hand muscles C8-T1
Thoracic vertebrae
The thoracic vertebral segments are
defined by those that have a rib. The
spinal roots form the intercostal
nerves that run on the bottom side of
the ribs and these nerves control the
intercostal muscles and associated
dermatomes.
Lumbosacral vertebrae
Form the remainder of the segments
below the vertebrae of the thorax.
The lumbosacral spinal cord,
however, starts at about T9 and
continues only to L2. It contains most
of the segments that innervate the
hip and legs, as well as the buttocks
and anal regions.
Cauda Equina
The spinal cord ends at L1-L2 vertebral level. The tip of the spinal cord is
called the conus. Below the conus, there is a spray of spinal roots that is
called the cauda equina. Injuries below L2 represent injuries to spinal
roots rather than the spinal cord proper.
There are some key points to note when considering the surgical anatomy of the spinal cord:
• During foetal growth the spinal cord
becomes shorter than the spinal canal,
hence the adult site of cord
termination at the L1-2 level, while in
neonates it’s L3.
• Due to growth of the vertebral column
the spine segmental levels may not
always correspond to bony landmarks
as they do in the cervical spine.
• The spinal cord is incompletely divided
into two symmetrical halves by a
dorsal median sulcus and ventral
median fissure. Grey matter surrounds
a central canal that is continuous
rostrally with the ventricular system of
the CNS.
• The grey matter is sub divided
cytoarchitecturally into Rexeds
laminae.
• Afferent fibres entering through the
dorsal roots usually terminate near
their point of entry but may travel for
varying distances in Lissauers tract. In
this way they may establish synaptic
connections over several levels
• At the tip of the dorsal horn are
afferents associated with nociceptive
stimuli. The ventral horn contains
neurones that innervate skeletal
muscle.
The key point to remember when revising CNS anatomy is to keep a clinical perspective in mind. So it is worth classifying
the ways in which the spinal cord may become injured. These include:
• Trauma either direct or as a result of disc protrusion
• Neoplasia either by direct invasion (rare) or as a result of pathological vertebral fracture
• Inflammatory diseases such as Rheumatoid disease, or OA (formation of osteophytes compressing nerve roots
etc.
• Vascular either as a result of stroke (rare in cord) or as complication of aortic dissection
• Infection historically diseases such as TB, epidural abscesses.
The anatomy of the cord will, to an extent dictate the clinical presentation. Some points/ conditions to remember:
• Brown- Sequard syndrome-Hemisection of the cord producing ipsilateral loss of proprioception and upper
motor neurone signs, plus contralateral loss of pain and temperature sensation. The explanation of this is that
the fibres decussate at different levels.
• Lesions below L1 will tend to present with lower motor neurone signs
Any lesion occurring within or affecting the corticobulbar tract is known as an upper motor neuron lesion. Any lesion
affecting the individual branches (temporal, zygomatic, buccal, mandibular and cervical) is known as a lower motor
neuron lesion.
Branches of the facial nerve leaving the facial motor nucleus (FMN) for the muscles do so via both left and right posterior
(dorsal) and anterior (ventral) routes. In other words, this means lower motor neurons of the facial nerve can leave
either from the left anterior, left posterior, right anterior or right posterior facial motor nucleus. The temporal branch
travels out from the left and right posterior components. The inferior four branches do so via the left and right anterior
components. The left and right branches supply their respective sides of the face (ipsilateral innervation). Accordingly,
the posterior components receive motor input from both hemispheres of the cerebral cortex (bilaterally), whereas the
anterior components receive strictly contra-lateral input. This means that the temporal branch of the facial nerve
receives motor input from both hemispheres of the cerebral cortex whereas the zygomatic, buccal, mandibular and
cervical branches receive information from only contralateral hemispheres.
Now, because the anterior FMN receives only contralateral cortical input whereas the posterior receives that which is
bilateral, a corticobulbar lesion (UMN lesion) occurring in the left hemisphere would eliminate motor input to the right
anterior FMN component, thus removing signaling to the inferior four facial nerve branches, thereby paralyzing the right
mid- and lower-face. The posterior component, however, although now only receiving input from the right hemisphere,
is still able to allow the temporal branch to sufficiently innervate the entire forehead. This means that the forehead will
not be paralyzed.
The same mechanism applies for an upper motor neuron lesion in the right hemisphere. The left anterior FMN
component no longer receives cortical motor input due to its strict contralateral innervation, whereas the posterior
component is still sufficiently supplied by the left hemisphere. The result is paralysis of the left mid- and lower-face with
an unaffected forehead.
A lesion on either the left or right side would affect both the anterior and posterior routes on that side because of their
close physical proximity to one another. So, a lesion on the left side would inhibit muscle innervation from both the left
posterior and anterior routes, thus paralyzing the whole left side of the face (Bells Palsy). With this type of lesion, the
bilateral and contalateral inputs of the posterior and anterior routes, respectively, become irrelevant because the lesion
is below the level of the medulla and the facial motor nucleus. Whereas at a level above the medulla a lesion occurring in
one hemisphere would mean that the other hemisphere could still sufficiently innervate the posterior facial motor
nucleus, a lesion affecting a lower motor neuron would eliminate innervation altogether because the nerves no longer
have a means to receive compensatory contralateral input at a downstream decussation.
Upper motor neurone lesions of the facial nerve- Paralysis of the lower half of face.
Lower motor neurone lesion- Paralysis of the entire ipsilateral face.
Sympathetic chains
These lie on the vertebral column and run from the base of the skull to the coccyx.
Cervical Lie anterior to the transverse processes of the cervical vertebrae and posterior to the carotid sheath.
region
Thoracic Lie anterior to the neck of the upper ribs and lateral sides of the lower thoracic vertebrae. They are
region covered by the parietal pleura
Lumbar Enter by passing posterior to the medial arcuate ligament. Lie anteriorly to the vertebrae and medial
region to psoas major.
Sympathetic ganglia
• Superior cervical ganglion lies anterior to C2 and C3.
• Middle cervical ganglion (if present) C6
• Stellate ganglion- anterior to transverse process of C7, lies posterior to the subclavian artery, vertebral artery
and cervical pleura.
• Thoracic ganglia are segmentally arranged.
• There are usually 4 lumbar ganglia.
Clinical importance
• Interruption of the head and neck supply
of the sympathetic nerves will result in an
ipsilateral Horner’s syndrome.
• For treatment of hyperhidrosis the
sympathetic denervation can be achieved
by removing the second and third thoracic
ganglia with their rami. Removal of T1 will
cause a Horners syndrome and is
therefore not performed.
• In patients with vascular disease of the
lower limbs a lumbar sympathetomy may
be performed, either radiologically or
(more rarely now) surgically. The ganglia
of L2 and below are disrupted. If L1 is
removed, then ejaculation may be
compromised (and little additional benefit
conferred as the preganglionic fibres do
not arise below L2.
These develop during the fourth week of embryonic growth from a series of mesodermal outpouchings of the developing
pharynx.
They develop and fuse in the ventral midline. Pharyngeal pouches form on the endodermal side between the arches.
There are 6 pharyngeal arches, the fifth does not contribute any useful structures and often fuses with the sixth arch.
Pharyngeal arches
Arch Muscular contributions Skeletal Endocrine Artery Nerve
First • Muscles of mastication • Maxilla N/A • Maxillary • Mandibular
• Ant. belly of digastric • Meckel’s cartilage • External carotid
• Mylohyoid • Incus
• Tensor tympanic • Malleus
• Tensor veli palatini
Second • Buccinator • Stapes N/A • Inferior branch • Facial
• Platysma • Styloid process of superior
• Muscles of facial expression • Lesser horn and thyroid artery
• Stylohyoid upper body of hyoid • Stapedial artery
• Posterior belly of digastric
• Stapedius
Third • Stylopharyngeus • Greater horn and • Thymus • Common and • Glossopharyngeal
lower part of hyoid • Inferior Internal carotid
parathyroids
Fourth • Cricothyroid • Thyroid and • Superior • Right • Vagus
• All intrinsic muscles of the epiglottic cartilages parathyroids Subclavian artery
soft palate • Left aortic arch
Sixth • All intrinsic muscles of the • Cricoid, arytenoid n/a • Right: • Vagus and
larynx (except cricothyroid) and corniculate Pulmonary artery recurrent laryngeal
cartilages • Left: Pulmonary nerve
artery and ductus
arteriosus
Anatomical planes
Subcostal plane Lowest margin of 10th costal cartilage
Intercristal plane Level of body L4 (highest point of iliac crest)
Intertubercular plane Level of body L5