Stud navt with ai BASIC SCIENCE Raat = Vy RCS Arevision quide for surgical trainees THIRD EDVTION eC le eters eb att ok ala un ec1A. ANATOMY (UPPER LIMB) — MRCS NOTES - REDA Bones of the UL.. ‘Muscles of the UI Muscles of the Shoulder Muscles of the Arm and Forearm.. Extensor retinaculum / Dorsal Wrist Compartments. Neuroanatomic Relationships in the Forearm. Muscles of the Hand and Wrist. 16 Hand v7 Arteries of the UI Axillary artery. Brachial artery. Ulnar artery 2B Radial artery. 2B Veins of the UL 24 Basilic vein. Nerves of the UL. Brachial plexus 25 ‘Summary of Upper Extremity Innervation. 26 Musculocutaneous nerve 7 Median nerve. Ulnar nerve. Radial nerve at Joints of the UL 33 Shoulder joint. Important Regions Of the UL ...0.nsunene Breast Avilla 37 Cubital Fossa 38 Surface Anatomy. 39Bones of the UL Submcaptarfoia raglenoidubercle Spat ar ronal ange Fp Strsinustns Spine ch ch Re sp connecting supraspinons 4 i and aspires sae) Greer tubercle Inala hetcle Deiter adil prove Deol mance. Interior surface Arterion Pectralis majormmce Corrie { bacon msc Conc game” Toperies muscle Stemocteldomstld Delo muse’ Steen Supaspinass muscle Tress ~ Detoid muscle corals major mince Supropinaus muscle r Inrspinaus muscle Tees minor muncle Triceps brachit muscle Pecos mao peri muscle MUSE Omebyoid sce Triceps eres major slp ofexg) muscle Pectoras jr must long bead) a Origins Lass cs! msc betas [B Ivertins orc marian muscle ‘Serr ameor muscle Ante SS {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 2 Detioid muse "Intetubercular ‘Glencid sues: ord eo of = ‘rear tberc Head of Ihumeres Delt tuberosity Medial snprconayar gr, rouge y cones rool sa ata co al epeonhe Anterior view Anterior view - Posterior view Jrepecus muscle eto muscle Biceps brachii muscle ‘long head Coracobra and subscapular Biceps brah muscle Inraspnatus muscle samen sip a Tors mor mile Pearl ra cop — ies bai ad mace Coca mse rere Trae = Tonthead = sm coneschs toa ea no Did muscle maa chs mace arco spans mel esp tens ca brchils Tre ed fastens mace muscle Pronator teres muscle numeral ead) oe tendon see | Common flexor tendon ¢ a en ee ce Ss ‘men idecondarea — £ WEY cnn oreo snow fens cma! ics ech ectirtadns imal er Brachialis muscle- ee ; ‘muscle humeroulnar head) Pronator teres mesce ulnar head) ‘Muscle attachments Triceps brachii mou mocle Flexor palici ongus muscle (ulnar bead) [i Insertions {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA‘Orcranon | _ Lawl Medal epcondle ape “okerann Sinem Nek dal rte fu Tuberosiy Urea Rats In extension: posterior view In extension: lateral view {nm extension: medal view Lateral epicondhle ‘Capea Head Nec Ametior bade nteroscous bore Inrosseous sanare a ‘expt adiais tongs orn sunny es a eee, Ulnar (igmsich notch ‘of ulna ek a ict Radius, ‘ulna f st. shines tect Sutngat. om ee sero R= Seen ‘ancl bone dil end {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 4Anterior volar) ‘rachioradialis muscle Brachial muscle [extensor eal radalis longus muscle roniot tse rustle (ese Hea Pronato teres, lever xenscr carpi adilis brevis, ‘apt radial palais eatenscr digiorum, extensor Tongus, Fexor carp ulnar, Aesor digitorum serials (humeroulnar head muscles or dgitorum superfialis muscle imeroulnar head nator wre muscle ulnar ead Supinator muscle Fexoe digtowum sipertcais muscle adil heath Fler dighorum profindis muccl Pronater teres muscle. lox polis lngus muscle Pronstr qparais muscle Note: Attachments of nine frncies of hand net so exon exp unarismuscle Fatensor cap ulhas muscle Floor digitorum supertiiais muscle exor digitorum profundus muscle HE Ogi NN nerton {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDAPosterior dorsal) Note: Attachments of intrinsic muscles of hand not shown caps bach muscle medal esd) Triceps brachitendon Flexor capi ulnaris muscle (humeral “Arconess muscle corgi via common exortenden) Fexor carp ulna muscle (alma origin ——— Flexor digtorum rotund muscle Supinstr muscle -Ancuctor plies longs muscle {Extensor carp uals muscle (una org) Pronatrteres muscle Lxtensor polis longs mace stnsor polis brevis muscle Extensor indics muscle. ina Eero carr ongus musco . : Brachioradalis muscle [tensor carpi radials revs muscle Abaco pilics longus muscle ‘extensor exp nats muscle corso digitorum muncle (ental band Lonsorpolics brevis muscle Extensor digit mini mace xaensor pollicis longus muscle Extensor digitorum muscle (tera bands on EE insertions {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDAMetacspal hone Dorsal tubercle Anterior (palmar view 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 stock of Canta peu seal ; steam — Seghoid interval : nar una radu Wrist x-ray, AP Wrist x-ray, lateral Capiate TWapezium: Scaphoid sot Triquetsum Lunate Disa ‘ulna radus u ‘Wrist x-ray, oblique ‘Wrist x-ray, ulnar deviation 1A. ANATOMY UPPER LIMB) = MRCS NOTES - REDA Aiquetum ‘syoid — ina Captate LunateMuscles of the UL Muscles of the Shoulder i or Ie ‘Action Clavicle, scapula Trapezius sp.cr-T12 ae Rotating scapula Cranial nerve Xi Extending, adducting, Latssimus dorsi 5° 76-55, 1lum | Humerus (115) internally rtating Thoracodorsal nerve humerus Rhomboid major SP T2-TS Scapula (medial border) | Adducting scapula Dorsal scapular nerve Rhomboid minor SP C?-11 Scapula (medial spine) | Adductng scapula Dorsal scapular nerve Transverse Scapula (superior Elevating, rotating Levatorscapulae orocess C1.C4 medial) scapula Se “oe sternum, ribs, ‘Adducting, internally | Medial andilateral Pertoralis major | clavicle Humers (aterallTS) tating arm pectoral nerves Pectoralis minor Ribs 3-5 ‘Scapula (coracoid) Protracting scapula Medial pectoral nerve Subclavius Rib 1 Inferior clavicle Deoressing clavicle Upper trunk nerves Setratus anterior Ribs 1-9 Scapula (ventral medial) | Preventing winging Long thoracic nerve Lateral clavicle, | Humerus (deltoid Dettoid scapula tuberosty) Abducting arm Aallary nerve ‘Adducting, internally | Lower subscapular Tetes major Inferor scapula Humerus(mediallTS) — Poeting extendingarm nerve Internally rotating arm, Subscapulars venval scapula Humerus (lesser providing anterior noe gend ower tuberosity) pra subscapular neives ‘Abducting and Supraspinatus Superior scapula | Humerus (GT) externally rotating atm, | Suprascapular rerve providing stability A Providing stability, infraspin jorsal scapula | Humerus uprascapular nerve pass earn hae externally rotating arm SYPTAP scapula Providing stability, Teres minor (dowels | Humers (67) tatemaly rotating arm lary nerve Traperius Levator scapulae Rhomboid minor Rhomboid major Deltoid: Pectoralis major Teres major: Latissimus dorsi {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 8Supraspinatus _Syprascapular notch (foramen) Surgical neck ‘of humerus ‘Medial lip of intertubercular suleus Teres major Deltoid tuberosity of humerus Long head of triceps brachit Cut edge of lateral head of triceps brachii {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 8Muscles of the Arm and Forearm ma Insertion mn ie Coracaid Mid-humerus (medial) | Flexion, adduction | Musculocutanecus Coracoid (hort head) Radial tuberosity ‘Supination, flexion Musculocutaneous upraglenoid (ong, head) {Anterior humerus Ulnar tuberosity (anterior) Flexingforearm — Musculocutaneous, Radial Triceps brachii Infraglenoid (long head) | Clecranon Extending forearm Radial Posterior humerus (Elbow extension) (ateral head) The longhead can Blood supply by Fosterior humerus ‘adduct the Profunda brachi (medial head)* humerus and ard artery ‘exiendit froma floxed position The radial nerve and profunda brachii vessels lie between the lateral and medial heads Transverse humeral ligament Long head of biceps. brachii muscle Short head of biceps brachii muscle Lateral head of triceps brachi Coracobrachialis muscle Radial groove of humerus Long head of triceps brachi Brachialis muscle Medial head of triceps brachi Lateral head of triceps brachi Bicipital aponeurosis (cut) —— Tuberosity of uina Radial tuberosity {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 10Pronator teres ‘Medial epicondyle and coronoid Mid-lateral radius | Pronatine. Median nerve flexing forearm Flexor carpiradialis Medial epicondyle 2&3" MCbases — Flexingwrist_ _ Median nerve Paimaris longus | Medial epicondyle Palmar aponeurosis | Flexing wrist Median neve Flexor carpi ulnatis | Medial epicondyle and posterior ulna _Pisiform Flexingwrist_ Uhar nerve Flexor digitorum | Medial epicondyle, proximal anteror Base of middle FlexingPIP | Median nerve superficialis ulna and anterior radius phalanges joint Uinar neve Humeral head of nator teres a Humeral head of flexor carpi ulnaris Brachial artery Uinarhead of Pronator teres Ulnar head of Unnarartery flexor carpi ulnaris Median nerve aceiaey: Flexor carplradialis Palmaris longus Pronator teres (cut) Flexor carpi ulnaris ——— Pisohamate ligament Pisitorm Pisometacarpal ligament amar aponsurecio Hook of hamate {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA aFlexor digitorum | Arteriar and Base of distal Flexing DIP joint Median-arteriorinterosseous/ulnar profundus medialulne phalanges nerves Flexor polis longus Arterior and Base ot distal Flexing IP joint, Median-anteriorinterosseous nerve lateralradius phalanges _ thumb Pronatorquadratus | Distal ulna Volar radius Prorating hand Median-anteriorinterosseous nerve superficialis Median nerve Interosseous membrane Flexor digitorum Flexor digitorum rficialis profundus Flexor digitorum superficialis tendon (cut) {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 2Brachioradialis Lateral supracondylar Lateral distal radius | Flexing forearm | Radial nerve humerus Extensor capi Lateral supraconiylar Second metacarpal Extending wrist ‘Radial nerve radialislongus humerus base Extensor carpi Lateral epicondyle of humerus Third metacarpal Extending wrist | Radial nerve racialis brevis base ‘Anconeus__Lateralepicondyle ofhumerus Proximal dorsal ulna Extending forearm Radial nerve Extensor Lateral epicondyle ofhumerus Extensor aponeurosis | Extending digits ‘Radial-posterior digtorum interosseous newe Extensor digti_| Common extensor tendon Smmalifingerextensor Extending small ‘Radial-posterior minim expansion over PI finger interosteous nerve Extensor carpi | Lateral epicondyle ofhumerus | Ffth metacarpal base Extending/adducting | Radial-posterior ulraris hand interosseous nee Extensor carpi radials longus Brachoratiais ‘rconeus Extensor carpi radialis brevis Extensor carpi ulnaris [Beensor gt mini! Extensor digitorum Extorsortinaculum Anterior View Posterior View {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA BOrigin ie Supinator Lateralepicondyle of | Dorsolateral radius Supinating forearm | Radisl-posterior humerus, uina interosseous nerve ‘Abductor Dorsal ulnafradius Firstmetacarpalbase Abducting/extending Radiel-posterior pollicis longus thumb interosseous nerve Extensor pollicis Dorsal radius Thumb proximal phalanx Extending thumb —__‘Radial-posterior brevis base MCP joint interosseous nerve Extensor policis Dorsolateral ulna Thumb dorsal phalanx Extending thumb IP fRadiel-posterior base joint interosseous nerve Extensor incicis Dersolateral ulna index finger extensor Extending index Radial-posterior proprius apparatus (ulnarty) finger interosseous nerve Supinator (deep head) Supinator (superticlatnea) Interossoous ‘membrane ‘Abductor pellicislongus Extensor indicis Extnsor polis brevis. Extensor carpi radialis longus Extensor carpi radialis brevis Abductor pollicielongus Extensor pollicis brevis, Posterior View {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 14Extensor retinaculum / Dorsal Wrist Compartments The extensor rentinaculum is a thickening of the deep fascia that stretches across the back of the wrist and holds the long extensor tendons n position, Its attachments are: ‘©The pisiform and triquetral medially Structures superficial to the retinaculum ‘© Theend of the radius laterally se * Dorsal cutaneous branch of the ulnar nerve Beneath the extensor retinaculum fibrous septa form six * Cephalic vein compartments that contain the extensor muscle tendons. * Superficial branch of the radial nerve Each compartment has its own synovial sheath. er De Quervain’s tenosynovitis Extensor pollcis brevis, u Extensor carpi redialis longus, Extensor tendinitis (intersection syndrome) Extenscr carpi radialis brevis i Extensor pollicis longus Rupture at listers tubercle (after wrist fractures) Drummer’s tendinitis of the wrist Vv Extensor digitorum communis Extensor tenosynovitis Extenser ingicis proprius v Extenser digiti minimi Rupture (rheumatoid arthritis: Vaughn Jackson syndrome) vi Extenser carpi ulnaris “Snapping at ulnar styloid Palmaris longus tendon Flexer retinaculum Median nerve Flexor catpiradialis tendon Flexor pollicis longus tendon Carpal tune! ‘Abductor pollicis longus tendon Flexor digitorum profundus tendons Extensor pollicis brevis tendon Extensor carpi ulnaris. = a Q cephal Radal anery Basic vain Extensor pollicis longus tendon Extensor digiti minimi tendon Extensor carpi radials longus tendon Extensor digitorum tendons brevis tendon Extensor indicis tendon Neuroanatomic Relationships in the Forearm Rac |_Between brachialis and brachioradialis Posterior interosseous _ Splits supinator ‘Superficial radial __ Between brachicradialis and extensor carpi radialis longus Median Medial to brachial artery at elbow Anterior interosseous Splits pronator teres and runs between flexor digitorum superficialis and flexor digitorum profundus Between flexor pollics longus and flexor digitorum profundus Ulnar Between flexor carpi ulnaris and flexor digitorum profundus. The radial artery passes between the lateral collateral ligament of the wiist joint ond the tendons of the abductor pollicis longus and extensor pollicis brevis. SS {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 15Muscles of the Hand and Wrist i M1 o Co Abductor pollicis | Scaphoid, trapezoid Base of proximal phalanx, | Abducting thumb Mediannerve brevis radal side ‘Opponens Trapezium Thumb metacarpal ‘Abducting flexing, Median nerve policis rotating (medially) Flexor polliés | Trapezium, capitate Base of proximal phalanx, | Flexing MC® joint Median, ulnar brevis radal site nerves ‘Adductor pallies Capitate, second and 8359 of proximal phalanx, Adducting thumb Ulnar nerve third metacarpals ular side Palmaris brevis TCL, palmar lear palm Retractng skin Ulnar nerve aponeurosis, Abductor digti | Fisiform Base of proxmal phalanx, | Abducting small finger | Ulnar nerve ri ulnar side Flexor cit Hamate, TCL Base of proximal phalanx, | Flexing MC? joint Ulnarnerve minimal brevis ulnar side ‘Opponens dgiti Hamate, TCL smal-tinger metacarpal | Abducting, flexing, Ulnar nerve ri rotating (lateraly) Intrinsic Muscles Lumbrical Flexor digtorum | Lateral bands radial) | tending proximal | Median, ulnar profundus interphalangeal joint nerves Doesal ‘Adjacent metacarpals | Proximal phalanx Abducting, flexing Ulnar nerve interosseous base/extensor apparatus | MCP jeint Volar ‘Adjacent metacarpals | Proximal phelanx ‘Adducting flexing Ulnar nerve interosseous base/extensor apparetus | MCP joint Transverse head of acductor pollicis Radial artery Abductor (deep pamar ch) digit minimi Sesamoid bone Oblique head Deep branch. of adductor of ulnar artery pollicis ‘and nerve Flexor carpi ulnaris ~ Flexor diiti minim brevis Flexor pollicis brevis, ‘Abductor pollicis and first palmar interosseous insert into medial side of ‘extensor hood Flexor pollicis, brevisand abductor pol brevis insert into; lateral side of extensor hodd } ‘Opponens pollicis ‘Median nerve Flexor retinaculum Recurrent branch of mediannerve ‘Abductor polics brevis, {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 16Hand ‘Anatomy of the hand Bones ‘© Carpal bones +S Metacarpals +14 phalanges Intrinsic Muscles Tinterossei - Supplied by ulnar nerve + 3 palmar adduct fingers © Adorsal- abduct fingers Intrinsic muscles Lumbricals © Flex MCP and extend the 1 ‘© Origin deep flexor tendon and insertion dorsal extensor hoad mechanism. ‘+ Innervation: 1st and 2nd- median nerve, 3rd and 4th- deep branch of the ulnar nerve. Thenar eminence “= Abductor pollicis brevis Opponens poticis Flexcr pollicis brevis ‘Opponens digit! minim’ Flexor digiti minim brevis 4 _Abductor digiti minimi Hypothenar eminence Fascia and compartments of the palm The fascia of the palm is continuous with the antebrachial fascia and the fascia of the dorsum of the hand. The palmar fascia is thin over the thenar and hypothenar eminences. In contrast, the central palmar fasca is relatively thick. The palmar aponeurosis covers the soft tissues and overlies the flexor tendons. The apex of the palmar ‘aponeurosis s continuous with the flexor retinaculum and the ppalmarislongus tendon, Distal, it farms four longitudinal digital bbands that attach to the bases of the proximal phalanges, blending with the fibrous digital sheaths. ‘A medial fibrous septum extends deeply from the medial border of the palmar aponeurosis to the Sth metacarpal. Lying medial to this are the hypothenar muscies. Ina similar fashion, a lateral fibrous septum extends deeply from the lateral border of the palmar aponeuresis to the ard metacarpal. The thenar compartment lies lateral to this area Lying between the thenar and hypothenar compartments is the central compartment. It contains the flexor tendons and their sheaths, the lumbricals, the superficial palmar arterial arch and the digital vessels and nerves The deepest muscular plane is the adductor compartment, which contains adductor pollicis. SS {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA uvShort muscles of the hand ‘These comprise the lumbricals and Interoscei. The four slender lumbrical muscles flex the fingers at the ‘metacarpophalangeal oints and extend the interphalangeal joint. The four dorsel Interossei are located between the metacarpals and the four palmar interossei lie on the palmar surface of the ‘metacarpals in the interosseous compartment of the hand. Long flexor tendons and sheaths in the hand. ‘The tendons of FDS and FDP enter the common flexor sheath deep tothe flexor retinaculum. The tendons enter the central compartment of the hand and fan cut to ‘their respective digital synovial sheaths. Near the base of the proximal phalanx, the tendon of FOS splits to permit the passage of FDP. The FOP tendonsare attached to the ‘margins of the anterior aspect of the base of the distal phalanx ‘The fibrous digital sheaths contain the flexor ‘tencions and their synovial sheaths. These extend from the heads of the metacarpéle to the base of the distal phalanges. SS {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 18Interossei Origin and insertion “Three palmar and four dorsal interosael occupy the =paces between the They are all Dorsal interossei metacarpal bones. Each palmar interossei originates from the innervated by | abduct the fingers, metacarpal of the digit on which itacts. theulnarnerve palmar interossei Each dorsal interossei comes from the surface of the adjacent adduct the fingers metacarpal on which it acts. As a result, the dorsal interossei are twice the size of the palmar ones. The interossei tendons, except the frst palmar, pass to one oF other side of the metacarpaphalangeal joint posterior to the deep transverse metacarpal ligament. They become inserted into the base of the proximal phalanx and partly into the extensor hood Clinical notes Alorg with the lumbricals the interossettlex the metacarpophalangeal joints and extend the proximal and distal interphalangeal joints. They are responsible for fine tuning these movements. When the interoscei and lumbricals are paralysed the digits are pulled into hyperextension by extensor digitorum and a claw hand is seen, Dorsal interosset (palmar view) Polmar interosse (palmar view) {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 19Anatomical snuffbox Posterior border (medially) | Tendon of extensor policis longus Anterioc border (laterally) Tendons of extensor pollicis brevis and abductor pollicis longus Proximal border Styloid process ofthe radius Distal border Avex of sufbox triangle Hloor ‘Trapetium and scaphoid Content Radial artery dorsal Radial artery —— Radial artery ‘Anatomical ——} Extensor —f Anatomical Snuffoox Cephalic vein Radial artery Abductor pollicis longus tendon Extensor pollicis brevis tendon /OTES-REDA 20Arteries of the UL Axillary artery 1 Sup. Thoracic a ‘Medial to serratus anterior and pectoral muscles, NTheracoacromial a |_ Four branches: delteid, acromial, pectoralis, clavicular Lateral thoracic. a Descends to serratus anterior IM Subscapular a. (largest br.) | Two branches: thoracodorsal and circumflex scapular (triangular space) Anterior humeral circumflex a. Blood supply to humeral head: arcuate artery lateral to biciptal groove Posterior humeral circumflex Branch n the quadrangular space accompanying the axillary nerve dh {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA aBrachial artery The brachial artery begins atthe lower border of teres malor as 2 eantinuation of theailary artery. Iterminates inthe cubital foss at the level ofthe neck of the ratus by dividing into the radial and uinar arteries Relations Posterlor relations include the long head of triceps with the radial nerve and profunda vessels intervening, anteriorly Its overlapped by the medial border of biceos. It is crossed by the median nerve in the middle of the arm. In the cubital fossa Its separated from the median cubital vein by the bicipital aponeuross. The basil vein is in contact at the most proxmal aspect of the cubital fossa and lies medially, Anterior circumflex humeral artery Posterior circumflex humeral artery ‘Superior ulnar collateral artery Inferior ulnar collateral artery {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 2Ulnar artery Path © Starts: middle of entecubital fossa ‘* Passes obliquely downward, reaching the ulnar side of the forearm at a point about midway between the elbow and the wrist. It follows the ulnar border to the wrist, crossing over the flexor retinaculum. it then divides into the superficial and deep volar arches, Relations Deep to- Pronator teres, Flexor carpi racialis, Palmaris longus Lies on- Brachialis and Flexor digitorum profundus Superficial tothe flexcr retinaculum at the wrist The median nerve isin relation with the medial side of the artery for about 25 cr. And then crosses the vessel, being seperated from itby the ulnar head of the Pronator teres, The ulnar nerve lies medially tothe lower two-thirds of the artery Branch ‘© Anterior interosseous artery Radial artery Superficial branch of radial nerve of anterior — interosseous Ulnar nerve Ulnar artery Flexor digitorum profundus Pronator quadratus {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 23Veins of the UL Basilic vein The basilic and cephalic veins both provide the main pathways of venous drainage for the arm and hang. It is continuous with the palmar venous arch distally and the axillary vein proximally 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 basiic 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. Itis often joined by the medial brachial vein before draining into the axillary vein. Clavicle Clavipectoral triangle Deltoid Pectoralis major Axillary vein Cephalic vein Biceps brachii Basilic vein Cubital fossa Basilic vein Dorsal venous network of hand {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 24Nerves of the UL Brachial plexus Origin ‘Anterior rami of C5 to Ti Sections of © Roots, trunks, civsions, cords, branches the plews Mnemonic :Real Teenagers Drink Cold Beer Roots © Located in the posterior triangle © Pass between scalenus anterior and medius Trunks © Located posterior to middle third of clavicle '* Upper and middle trunks related superiorly to the subclavian artery ‘* Lower trunk passes over 1st rib posterior to the subclavian artery Divisions Apex of axilla Corde Related to axillary artery Radial nerve. Ulnar nerve {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 25Mnemonic branches off the posterior cord © Subscapular (upper and lower] © Thoracodorsal ‘Superior cervical ‘sympathetic ganglion Cords Inferior cervical (medial, lateral, posterior) ‘sympathetic ganglion ‘Anterior scalene tendon ‘Summary of Upper Extremity Innervation Neve: Mu! at Musculocutaneous — Coracobrachialis, biceps, brachialis (lateral cord) ‘Axilary (posterior cord) | Deltoid, teres minor Radial (posterior cord) Triceps, brachioradialis, extensor carpi radials longus and brevis Posterior interosseous Supinator, extensor carpi uinars, extensor digitorum, extensor digiti minim, abductor pollcis longus, extensor pollicis longus and brevis, extensor indicis oroprius Median(medial and Pronator teres, flexor carpi radalis, palmaris longus, flexor digtorum superfiialis, lateral cord) abductor pollicis brevs, supinator head of flexor pollicis brevis, opronens pollicis, first and second lumbrical muscles ‘Anterior interosseous | Flexor digitorum profundus (frst and second}, flexor pollicis longus, pronator quadratus Ulpar (medial cord) Flexor carpi unaris, flexor digitorum profundus (third and fourth), palmaris brevis, abductor digiti minimi, opponens digiti minimi, flexor digit’ minimi, third ané fourth lumbrical muscles, interossei, adductor pollicis, deep head of flexor pollicis brevis {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 26Musculocutaneous nerve + Branch of lateral cord of brachial plexus ‘© It penetrates the coracobrachialis muscle ‘© Passes obliquely between the biceps brachii and the brachialis to the lateral side of the arm ‘* Abore the elbow it pierces the deep fascia lateral to the tendon of the biceps brachii Continues into the forearm as the lateral cutanecus nerve of the forearm, Innervates ‘© Corecobrachialis © Biceps brachi © 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 11) 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 toits medial side (usually passing anterior to the artery). It passes deep to the bicipital aponeurosis and the median cutital vein at the elbow. It passes between the two heads of the pronator teres muscle, and runs on the deep surface of flexor digitorum superficial (within its fascial sheath. Near the wrist it becomes superficial between the tendans of flexor digitorum superfcialis and flexor carpi radialis, deep to palmaris longus tendon. It passes deeo to the flexor retinaculum to enter the palm, but lies anterior to the long flexor tendons within the carpal tunnel. Branches Upper arm Nobranches, although the nerve cammonly communicates with the musculocutaneous nerve Forearm Pronator teres Flexor carpi radialis Palmaris longus Flexor digitorum superficiais, Flexor polics longus Flexor digitorum profundus (only the radial half) Distal forearm Palmar cutaneous branch Hand (Motor) Motor suppiy (LOAF, = Lateral 2 lumbricals + Opponens pollicis ‘© Abductor pollicis brevis * _Flecor pollicis brevis, Hand (Sensory) = Over thumb and|ateral 2% fingers ‘© Onthe 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 © eg. 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 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 lass of pronation of forearm and weakness of lorg flexors of thumb and index finger SS {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 2Ulnar nerve Origin + 371 Supplies (no muscles in the upper arm) | Yinar nerve: Mafia P ‘© Flexor carpi ulnaris, Medial 2lumbricals ‘+ Flexor digitorum profundus ‘Adductor polis, Flexor digiti minim Flexor digitorum profundus/Flexor carpi ulnaris © Abductor digit minimi Interossei © Opponens digit! minim Abductor and Opponens and flexor digiti mirimi (hypothenar eminence) © Adductor pollicis Palmaris brevis ‘© Interossei muscle © Third and fourth lumbricals Innervates all intrinsic muscles of the hand + Palmarisbrevis, (EXCEPT 2: thenar muscles & fist two lumbricals - supplied by median n.) Path ‘* Posteromedial aspect of upper arm to flexor comoartment of forearm, then along the ulner. Passes beneath the flexor carpi ulnaris muscle, then superficially through the flexor retinaculum into the palm of the hand, Branches Emin Ete Muscular branch Flexor carp’ ulnaris ‘Medial half of the flexor digitorum profundus Palmar cutaneous branch (Arises near Skin on the mecial part cf 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 enterior surfaces of the medial one and one-half iit: Deep branch Hypothenar muscles Allthe interosseous muscles ‘Third and fourth lumbricals ‘Adductor pollicis ‘Medial head ofthe flexor policis 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 haif fingers Damage at the elbow Radial deviation of the wrist CClawing less in 4th and Sth digits SS {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 28Musculocutaneous nerve: Musculocutaneous nerve Medial epicondyle SS {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 29Median nerve Ulnar nerve of pronator teres of radial nerve Ulnar head of of radial nerve Pronator teres. (cut) Dorsal branch (of ulnar nerve) branch (of median nerve) {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 30Radial nerve Continuation of posterior cord of the brachial plesus (rect values CS to T1) Path © Inthe axilla: les posterior to the axilary 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 in the groove for the radial nerve. ‘© Atthe distal third of the lateral border of the humerusit then pierces the intermuscular septum and descends in front ef the lateral epicondyle. © Atthe lateral epicondyle itlies deeply between brachialls and brachioradialis where it then divides into a superficial and deep terminal branch, © Deep branch crosses the supinator to become the posterior interosseous nerve. Regions innervated Motor(main + iriceps nerve) © anconeus «© Bracioradialis «Extensor carpi radialis Motor * Supinator (posterior « —Extersor carpiulnaris, Interosseous + Extensor digitorum branch) © Extersor indicis © Extersor digiti minimi * Extersor pollicis longus «© Extersor pollicis brevis, + _Abdustor polliis longus ‘Sensory ‘The area of skin supplying the proximal phalanges on the orsal aspect of the hand Is supplied by the radial nerve (this does not apply to the little finger and part of the ring Finger) ‘Muscular innervation and effect of denervation Branch to medial head of triceps brachi Medial epicondyfe- Uhar nerve. Muscle affected Shoulder ‘Long head of triceps ‘Minor effects on shoulder stability in abduction Ann Triceps Loss of elbow extension Forearm Supinator Weakening of supination of prone hand and Brechioradialis elbow flexion in mid prone position Extensor carpi radialis longus and brevis {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA Ese‘Superficial branch Posterior.Joints of the UL Shoulder joint ‘Shallow synovial ball and socket type of joint. itis an nnerentiy unstable joint, But s capable toa wide range of movement + Stability & provided by muscles ofthe rotator cu that pass from the scapula insert in the greater tuberosity (all except sub scapularis-lesser tuberosity). Glenoid labrum ‘© Fibrocartilaginousrim attached to the free edge of the glenoid cavity ‘* Tendon af the long head of biceps arises from within the joint from the supraglenoid tubercle, andi fused at this point to the lebrum. ‘¢ The long head of triceps attaches to the infraglenoid tubercle Fibrous capsule ‘* Attachesto the scapula external to the slenoid labrum and to the labrum itself (nostero-superiorly) ‘© Attachesto the humerus at the level of the anatomical neck superiorly and the surgical neck inferiorly ‘© Anteriorly the capsuleis in contact with the tendon of subscapularis, supericrly with the supraspinatus tendon, and posteriorly with the tendons of infraspinatus and teres minor. All thase blend with the capsule towards, their insertion ‘© Twodefects in the fibrous capsule; superiorly for the tendon of biceps. Anteriorly there is a defect beneath the subscapularis tendon ‘+ The nferior extension of the capsule is dosely related to the axillary nerve at the surgical neck and this nerve is at risk in anteroinferior dislocations. It also means that proximally sted osteomyelitis may progress to septic artis, Subacromial bursa (Gubdeteid) Long head of biceps brachil tendon subtencinoue bursa of subscapularis Pectoralis major Long head of wiceps Short head of biceps brach coracobrachials {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 33Infraspinatus ‘Movernents and muscles ‘Acromion Ciavicle Supraspinatus Flexion Antetior part of deltoid Pectoralis major Biceps Coracobrachials Extension Posterior deltoid Teres major latissimus dorsi ‘Adduction Pocteralis major latissimus dorsi ‘eres major Coracobrachials ‘Abduction Mid deltoid Supraspinatus Medial rotation | Subscapuaris Anterior deltord ‘eres major Latissimus dorsi Lateral rotation Posterior deltoid Infraspinatus Teres minor Important anatomical relations ‘Anteriorly | Grackial plexus Axillary artery and vein Posterior Suprascapular nerve Suprescapular vessels Inferior axillary nerve. Gircumflex humeral vessels, Teres minor Subscapularis — Coracoid process Head of humerus Superior glenohumeral ligament Coracohumeral Midsle glenohumeral igament ligament Aperture for subtendinous Transverse bursa of subscapularis humeral ligament Coracohumeral ligament, Long head of biceps brachil tendon. Fibrous membrane of int capsule: ‘Synovial sheath Synovial membrane Long head of biceps brachii tendon Redundant capsule Redundant synovial membrane in adduction WRCSNOTES - REDA 34/mportant Regions of the UL Breast The breast itself lis on a layer of pectoral fascia and the following muscles: 1. Pectoralis major 2. Serratus anterior 3. External oblique Breast anatomy Nerve supply | Branches of intercostal nerves from T4-16 Arterialsupply Internal mammary (thoracic) artery External mammary artery (laterally) + Anterior intercostal arteries #Thoraco-acremialartery Venousdrainage | Superficial venous plexus to subclavian, axillary and intercostal veins. Lymphatic © 70%Axilary nodes drainage © Internal mammary chain Other lymphatic stes such as deep cervical and supraclavicular fossa (later in disease) Pectoral axillary nodes {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 35ST {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 36Boundaries of theaxilla Axilla Medially chest wall and Serratus anterior laterally Humeral head Floor subscapularis ‘Anterior aspect Lateral border of Pectoralis major Fascia Clavipectoral fascia Contents Long thoracic nerve (of Bell) Derived from CS-C7 and passes behind the brachial plexus to enter the axilla. [lies on the medial chest wall and supplies serratus anterior. Its location puts itat risk during axillary surgery and damage will lead to winging of the scapula Thoracodorsal nerve and thoracedorsal trunk Innervate and vascularise latissimus dorsi. Axllary vein Lies at the apex of the axila, itis the continuation of the basilc vein, Becomes the subclavian vein at the outer border of the fist rb. Intercostobrachial nerves “Traverse the axillary mph 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. SS {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 37Cubital Fossa Braciialls SS {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 38Surface Anatomy SS {1A ANATOMY [UPPER LIMB) ~ MRCS NOTES - REDA 39Biceps femoris (long head) Medial ischial tuberosity ular head/lateral tibia Biceps (short head) Lateral linea aspera/lateral Lateral tibial condyle eroneal intermuscular septum Semitendinesus Distal medial ischial tuberosity | Anterior tibial erest Tibial ‘Semimembranosus Proximal lateral ischial tuberosity Oblique popliteal ligament Tibial Posterior capsule Posterior/medial tibia Popliteus Medial meniscus Quadratus femoris ‘Adductor magnus Long head of biceps femoris Hamstring part of adductor magnus ‘Semitendinosus ‘Semimembranosus 18, ANATOMY (LOWER UMB) ~MRCS NOTES REDA 15SE 18, ANATOMY (LOWER UMB) ~MRCS NOTES REDA 16Muscles of the Leg Tibial anterior Lateral titia Medial cuneiform, | Dorsiflexing, inverting | Deep peroneal 4) firstmetatarsal | foot nerve Extensor hallucis Mid-fibule Grest toe, distal Dorsiflexing, extending | Deep peroneal (L5) longus phalanw toe nerve Extensor Tibial condyle/fibula | Toe, middle and Dorsiflexing, extending | Deep peroneal (L5) digtorum longus distal phalanges toe nerve Peroneus tertius Fibula and extensor Fifthmetatarsal | Everting, dorsiflexing, | Deep peroneal (51) torum longus tendon abducting foot nerve Peroneus longus Proximal fibula ‘Medial cuneiform, | Everting, plantar Superficial peroneal firstmetatarsal___ flexing, abducting foot __(S1) nerve Peroneus brevis | Distal fibula Tuberosity offifth | Everting foot Supericial peroneal metatarsal (1) nerve ¥ } | Exnsor ] aon | Tongus i membrane | Fibuaris Anterior \ longus border of fibula tortive ] Extencor halluis longus Fibularis brevis Fibular trochiea SS 18, ANATOMY (LOWER UMB) ~MRCS NOTES REDA 7ma Gastrocnemius | Posterior medial and | Calcaneus, Plantar flexing foot Tibial (51) nerve lateral femoral condyles Soleus Fibule/tibia| Calcaneus Plantar flexing foot Tibial (51) nerve Plantaris Lateral femoral condyle | Caleaneus Plantar flexing foot Tibial (S41) nerve Ligament sparing sistance between fibular and tba origins of soleus .Gasirocnemius Lateral Caleanael(Achiles) tendon 18, ANATOMY (LOWER UMB) ~MRCS NOTES REDA 18Ponliteus lateral femoral condyle, | Proximal Flexing, internally Tibial (5, SI) nerve fibuler head rotating knee Flexor fallucis Fibula Great toe, distal Plantar flexing great toe Tibial (51) nerve lorgus phalanx Flexor cigitorum Tibia Second to fifth toes, Plantar flexing toes, foot | Tibial (51, $2) nerve lorgus distal phalanges, Tibialis posterior Tibia, fibula, interasseous membrane Navicular, medial cuneiform Inverting/plenter flexing foot Tibial (L4, 15) nerve 18, ANATOMY (LOWER UMB) ~MRCS NOTES REDA 19Muscles of the Ankle and Foot Origin Extensor digtorum Superolateral Base of proximal Deep peroneal brevis calcaneus phalanges nerve ‘AbductorhallucisCalcaneal Base of great | Abcucting great toe Mecial plantar tuberosity toe, proximal nerve phalanx Flexor digitorum Calcaneal Distal phalanges Flexing toes Medial plantar brevis tuberosity of secondto rerve fifth toes ‘Abductor digiti——Calcaneal Base of small Abcucting small toe Lateral plantar mini tees toe nerve ‘Quadratus plantae Medial and Flexor digtorum | Helpingtflex distal phalanges | tateral plantar lateral calcaneus __longus tendon nerve Lumbrical muscles Flexor cigitorum Extensor Flexing metatarsophalangeal | Medial and oretietercorae eter fey featenendira lateral plantar longus tendon | interphalangeal joint nerves Flexor digitorum Tiba/fibula Distal phalanges | Fleying toes, inverting foot _—_Tibialnerve longus and flexor of digits hallucis longus Flexor digitorum digit mini Flexor digitorum brevis ‘Cut plantar aponeurosis ‘Celcaneal tuberosity 18, ANATOMY (LOWER UMB) ~MRCS NOTES REDA 20Third Plantar Layer Flexor hallucis brevis Cuboid/leteral_—| Proximal phalanxof Flexing great toe | Medial plantar nerve cuneiform great toe ‘Adductorhallucis Oblique: second to Froximal phalanx of Adductinggreat —_Lateralplartar nerve fourth metatarsals | greattoe lateral) toe Flexor cigitiminimi Base of fifth Froximal phalanx of | Flexing small toe Lateral plantar nerve brevis metatarsal head _| smalltoe Fourth Plantar layer Dorsal iterosseous Metatarsal Dorsal extensors ‘Abducting Lateral plantar nerve Plantarinterosseous Third to fifth Proximal phalanges Adductingtoes Lateral plantar nerve (peroneus longus ane metatarsals medially tibialis posterior) Fibula/tiia Medial Fverting/inverting Superficial cuneiform/navicular___foot peronealtibial nerve 'Note: For abduction and adduction in the foot, the second toe serves as the reference. Tendon of flexor halluois longus Oblique heat Transverse head Flexor brevis fibularis ) Tendon of tibialis longus muscle 18, ANATOMY (LOWER UMB) ~MRCS NOTES REDA anGreater sciatic foramen Contents Sclatle Nerve Superior and Inferior Gluteal Nerves Pudendal Nerve Posterior Femoral Cutaneous Nerve Nerve to Quadratus Fomoris, Nerve to Obturator internus Superior Gluteal Artery and vein Inferior Gluteal Artery and vein Internal Pudendal Artery and vein Piriformis Isa landmark for identifying structures passing aut of the sciatic natch ‘* bore piriformis: Superior gluteal vessels © Below piriformis: inferior gluteal vessels, sciatic nerve (10% pase through it, <1% above it), posterior cutaneous nerve of the thigh Greater sciatic foramen boundaries Anterolaterally | Greater sciatic notch of the ilum Posteromedially | Sacrotuberous ligament Inferior ‘Sacrospinous ligament and the ischial spine Superior ‘Anterior sacroiliac ligament Contents of the lesser sciatic foramen + Tendon of the obturator internus © Pudendal neve * Internal pudendal artery and vein © Nerve tothe obturator internus Structures passing between both foramina (ttedial to lateral) PIN © Puderdal nerve ‘© Internal pudendal artery ‘+ Nerve to obturator internus SE 18, ANATOMY (LOWER UMB) ~MRCS NOTES REDA 2Fascial compartments of the leg Compartments ofthe thigh Formed by septae passing from the femur to the fascla lata Blood “Anterior compartment Femoral tiacus Femoral artery # Tensor fascine latae + sarcorivs © Quadriceps femoris Medial compartment ‘Obturator | = Adductor Profunda femoris artery and longus/magnus/brevs obturator artery © Graci # _Obturator externus Posterior compartment (2 Scatic—«”-Semimembranosus Branches of Prfunda femoris artery layers) © Semitendinosus + Biceps femoris Compartments of the lower leg Separated by the interosseous membrane (anterior and posterior compartments}, antericr fascial septum (separate anterior and lateral compartments) and posterior fascial septum (separate lateral and posterior compartments) Compartment D Muscles Cerri Anterior Deep peroneal | @ Tibialis anterior Anterior tibial ‘compartment ewe ‘© Batensor digitorum longus artery ‘© Bitensor hallucs longus + Peroneus tertius Posterior Tibial ‘© Muscles: deep and superficial compartments Posterior tibial ‘compartment (separated by deep transverse fascia) © Deep: Flexor hallucis longus, Flexor digitalis longus, Tibialis posterior, Popliteus Superficial: Gastrocnemius, Soleus, Plantaris Lateral Superficial ‘© Peroneus langus/brevis, Peroneal artery ‘compartment peroneal SE 18, ANATOMY (LOWER UMB) ~MRCS NOTES REDA 23Arteries of LL Anterior tibial artery Begins opposite the distal border of popliteus ‘Terminates in front of the ankle, continuing as the dorsalis pedis artery {sit descends it lies on the interosseous membrane, distal part ofthe tibia and front of the ankle joint Passes between the tendons of extensor digitorum and extensor hellucis longus distally Itis related to the deep peroneal nerve, it lies anterior to the middle third of the vessel and lateral to itin the lower third Posterior tibial artery ‘© Larger terminal branch of the popliteal artery ‘= Terminates by dividing into the mecial and lateral plantar arteries ‘© Accompanied by two veins throughout its length ‘© Position of the artery corresponds toa line drawn from the lower angle of the popliteal fossa, at the level of the neck Of the fibula, toa point midway between the megial malleolus and the mast prominent part of the hee! Relations of the posterior tibial artery (Proximal to distal) ‘Anterlorly TTbialis posterior Flexor digitorurs longus Posterior surface of tibia and ankle joint | Posterior Tibial nerve 2.5 cm distal to its origin Fascia overlying the deep muscular layer Proximal part covered by gastrocnemius and soleus Distal part covered by skin and fascia SE 18, ANATOMY (LOWER UMB) ~MRCS NOTES REDA 24Inferior gluteal artery ‘Sacrotuberous ligament ‘membrane. Common iliac artery Inferior gluteal artery 18, ANATOMY (LOWER UMB) ~MRCS NOTES REDA 25Pubic symphysis ‘Superior gluteal artery Inferior gluteal artery Vastus medialis muscle —| Gracilis muscle Artery in adductor canal: ‘Third perforating artery Rectus femoris muscle ‘Vastus lateralis muscle Vastus medialis muscle Sartorius muscle 18, ANATOMY (LOWER UMB) ~MRCS NOTES REDA 6Lateral femoral circumflex artery First perforating artery Second perforating artery Gracilis muscle Third perforating artery Adductor \Vastus intermedius muscle Adductor magnus muscle Adductor hiatus Cut vastus medialis muscle ‘Quacriceps femoris tendon Sartorius muscle Popiteal artery Deep artery of thigh. A. Anterior view. B. Posterior view. 18, ANATOMY (LOWER UMB) ~MRCS NOTES REDA anImportant Regions Femoral triangle anatomy Boundaries Superiorly | inguiral ligament laterally Sartorius Medially __Adductor longus Floor liopsoas, adductor longus and pectineus Roof © Fascia lata and Superficial fascia © Superfcialinguinal lymph nodes (palpable below the inguinal ligament) Long saphenous vein 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 genttofemoral nerve Inguinal ligament Pubic symphysis Femoral triangle Pectineus muscle ‘Adductor longus muscle Femoral nerve Gracilis muscle Teena ‘Adductor magnus muscle Lymphatics Femoral triangle Adductor canal 18, ANATOMY (LOWER UMB) ~MRCS NOTES REDA 39Femoral canal The femoral canal lies at the medial aspect of the femoral sheath. The femoral sheath isa fascial tunnel conta ing both the femoral artery laterally and femoral vein medially, The canal les medial to the vel, Borders of the femoral canal laterally Femoral vein Medially lacunar ligament ‘Anteriorly Inguinal igament Posteriorly Pectineal ligament Contents © Lymphatic vessels © Cloquet's lymph nade Physiological significance Allows the femoral vein to expand ta allow for increased venous return to the lower limbs. Pathological significance ‘As a potential space, itis the site of femoral hernias. The relatvely 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. \Vastus medialis muscle ‘Acductor longus, adductor magnus Sartorius ‘Superficial femoral artery ‘Superficial femoral vein (posterior to the artery in the upper part then osterolat. Inforior vena cava. Psoas major Inguinal ligament Femoral nerve- Femoral sheath Lymphatics in femoral canal artery n Adductor canal artery 18, ANATOMY (LOWER UMB) ~MRCS NOTES REDA 40Popliteal fossa Boundaries of the popiteal fossa laterally Biceps femors above, lateral head of gastrocnemius and plantaris below Medially Serimembranosus and semitendinosus above, medial head of gastrocnemius below Floor __Popliteal surface of the femur, posterior ligament of knee joint and popliteus muscle Roof Superficial and deep fescia Contents Popliteal artery and vein Small saphenous vein Common peroneal nerve Tibial nerve Posterior cutaneous nerve of the thgh 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 les lateral to the vessels, it then passes superficial to them to lie medially. The popliteal artery is the deepest structure in the popliteal fossa, ‘Adductor magnus muscle| Pudendal (Alcock’s) canal The pudendal canal is cated along the lateral wall ofthe ischioanal fossa atthe inferior margin ofthe obturator internus muscle. It extends from the lesser sciatic foramen to the posterior margin ofthe urogenital digphragm. It conveys the internal pudendal vessels and nerve SE 18, ANATOMY (LOWER UMB) ~MRCS NOTES REDA anFoot - Anatomy Arches of the foot ‘The foot is conventionally considered to have two arches. 4 Thelongtudinal ach is higher on tho medialthan on the laterl sd. The posterior partof the calcaneum forms a posterior pill to support the atch, The lateral part of this structure passes via the cuboid bone anc’ the lateral two metatarsal bones. The mesial part ofthis structure is more important. The head af the talus marks the summit of this arch, located between the sustentaculum tali and the navicular bone. The anterior pllarof the media arch is composec of the navicular tone, the three cunciforms and the medial three metatarsal bones +The transverse arch issitusted on the anterior part ofthe tarsus andthe postericr partof the metatarsus. The cureiforms and metatarsal bates narrow inferiorly, which contributes to the shape of the arch. A ak, Sher plantar igamort SE 18, ANATOMY (LOWER UMB) ~MRCS NOTES REDA a2Cavernous sinus The cavernous sinuses are paired and are situated on the body of the sphenoid bone. It runs from the superior erbital fissure to the petrous temporal bone, Binsin Sculomotormerve(i) “Trches nee) ‘Abcscent nerve Ophir V1 Matar ere V3) ona section eee ain poser ew Contents: “OTOM CAT” "Lateral wallcomponents | Giom topo Bationay TT) Cavernous sinus syndrome is most Ceulomater nerve (i) commonly coused by cavernous Trochlear nerve () sinus tumours. Diagnosis is based on opts ane (Wa) signs of pain, ophthalmoplegia, axilary nerve (Vs " ‘Contents ofthe sinus (fiom medal to lateral) proptosis, trigeminal nerve lesion Internal Cartid artery (nd sympathetic plexus) (9Phthalmic branch) and Horner's Abducens nerve (VI) syndrome, Internal carotid artery Cavernous sinus Relations Oculomotor nerve Pituitary fossa ‘Temporal lobe Sphenoid sinus Trochlear nerve Ophthalmic nerve siood suppy Abducent nerve su Ophthalmic vein, superficial cortical veins, basilar plexus of veins posteriorly Drainsinto the internal jugular vein via: the Sphenoidal sinus superior and inferior petosal sinuses Maxillary nerve ‘Superior ophthalmic Inferior ophthalmic vein Circular venous. ples Cavernous sinus: ‘Superior petrosal sinus \ Inferior petrosal 1G ANATOMY (HEAD & K) MRCS NOTES -REDA 5Sternocleidomastoid Anatomy Origin Rounded tendon attached to upper manubrium stemi and muscular head attached to medial third of the clavicle Insertion Mastod process of the temporal bone and lateral area of the superior nuchal ine of the occipital bone Innervation Spinal part of accessory nerve and anterior ram of C2 ard C3 (proprioception)* ‘Action Both: extend the head at atlanto occipital joint and flex the cervical vertebral column. Accessory muscles of inspiration. ‘+ _ Single: lateral flexion of neck, rotates head so face looks upward to the opposite side “The motor supply to the sternocleidomostoid is from the accessory nerve. The ansa cervicalis supplies sensory information from the muscle. Sternocleidomastoid civides the anterior and postericr triangles ofthe neck Sternocleidomastoid Spleniuscapiis muscle Antrioe selene muscle Postoror seslonemusdo Mice scalene musce Trapezius muscle Acromien Inter belly ofomohyoid line of the neck Posterior tangle {IC ANATOMY (HEAD & NECK)~ MRCS NOTES REDA 6Scalene muscles The3 paired muscles are: ‘© Scalenusanterior: Elevate Ist rb and laterally flex the neck to same side ‘© Scalenus medius: Same action as scelenus anterior ‘© Scalenus posterior: Elevate 2nd rib and tit neck to opposite side Innervation Spinal nerves C-6 Origin ‘Transverse processes C2 to C7 Insertion First and second ribs Important ‘© The brachial plexus and subdavien artery pass between the anterior and middle scalenes relations through a space called the scalene hiatus/fissure © The subclavian vein and phrenic nerve pass anteriorly to the anterior scalene as it crosses over the first rib, ectus capitis anterior muscle Rectus capitis lateral muscle Longus capitis muse Lovator sapulae muscle Longus cai muscle Antetorscalene Middle satene Thoracic outlet syndrome The scalenes are st rise of adhering to the fascia surrounding the brachial plexus or shortening causing compression of the brachial plexus when it pastes between the claviele and lst rib causing thoracie outlet syndrome. {IC ANATOMY (HEAD & NECK)~ MRCS NOTES REDA 7Anterior triangle of the neck Boundaries cee ee Lower border of mandible Anterior midline Sub triangles (divided by Digastric above and Omohyoid) © Submandibular Triangle (Digastric) ¢ Muscular triangle: Neck strap muscles ‘+ Carotid triangle: Cerotid sheath Contents of the anterior triangle Digastric triangle | Submandivular gland (submandibular) submandibular nodes Facial vessels Hypoglossal nerve Muscular ‘Strap muscles triangle External jugular vein Carotidtriangle Carotid sheath (Commen carotig, Vagus and UV) Ansa cerviealis ‘Nerve supply to digastric muscle '* Anterior: Mylohycid nerve © Posterior: Facial nerve Stylohycid muscle Submandibular triangle Posterior belly of digastri Anterior bally of digastric muscle ‘Submental triangle Hyoid bone Muscular triangle ‘Trapezius muscle Superior belly of omohyoid {IC ANATOMY (HEAD & NECK)~ MRCS NOTES REDA 8Posterior triangle of the neck Boundaries Apex Sternocleidomastoid and the Trapecius muscles at the Occipital bone Anterior Posterior border of the Sternodeidomastoid Posterior Anterior border of the Trapezius Base Middle third of the clavicle Contents Neves + Accessory nerve Phrenic nerve Three trunks ofthe brachial plexus ‘© Branches ofthe cervical plexus: Supraclavicular nerve, transverse cervical nerve, great auriulaenerve, leer occipital nerve Vessels © External ugular vein © Subclavian artery (3! part) Muscles © Inferior belly of omohyoid © Sealene Lymph nodes Supraclavicular The UV does not le in the posterior triangle. !lowever, the terminal branches of the external jugular vein do, Pesteror sever vel Posteo eeraljuguar vee “Taneverecervel nove Lesser occipital neve Great auricular newe Aeceesey nen Be Trapenivs musce {IC ANATOMY (HEAD & NECK)~ MRCS NOTES REDA 9© Four parathyroid glands Parathyroid glands- anatomy © Located posterior to the thyroid gland ‘© They lie within the pretracheal fascia Embryology The parathyraids develop from the extremities of the third and fourth pharyngeal pouches. The parathyroid: 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(1}. There isa rich anastomosis between the two vessels. Venous drainage is into the thyreid veins. Relations Laterally Common caretid Medially Recurrent laryngeal nerve, trachea Anterior Thyroid Posterior Pretracheal fascia Superior thyroid artery Posterior glandular branch Inferior thyroid artery. Left subclavian a, ‘Superior parathyroid gland Inferior parathyroid gland laryngeal nerve Left recurrent laryngeal nerve Thyrohyoid "muscle Superior thyroid artery end vein Arteror olandular branch: ida thyroid ven Inferior thyroid a. Fight recurrent laryngeal nerve Thyrocervieal trunk rene Left vagus nerve Inferior thyroid Left recurrent veins laryngeal neve IC ANATOMY HEAD & NECK) -MRCS NOTES - EDA 10Thyroid gland + Right and lft lobes connected by isthmus + Surrounded ty sheath from pretracheal ayer of deep fascia # Aver\aminaof thyroid cartilage. Base:ath-Sth tracheal rng © Pyramidal lobe: from isthmus. Mnemonic “Rings 2,3,4 make the isthmus floor” # Maybe attached 1 foramen caecum at the base of the tongue Anteromedially © —Sternathyroid © Sternchyoid ‘© Superior belly of omohyoid ¢ _Anteriar aspect of sternocleidomastoid Posterolaterally | Carord sheath £ | Medialy © Laryne—# Ostophagus # Fsternal laryngeal nerve (near superior thyroid >) 3 © Trachea © Cricothyroid Recurrent laryngeal nerve (near inferior thyroid 2.) 2 © Pharynx muscle Posterior Parathyroid glands Anas a Sp oa nd SS Isthmus © Anterorly: Sternothyroids, sternohycids, anterior jugular veins ‘© _Posteriorly: 2nd, 3rd, Ath tracheal rings (attached via Ligament of Berry) Blood Supply Artoral + Superior thyroid artery (Ast branch of external carotid) 4 Inferior thyroid artery (rom thyrocervical trunk) © _Thyroidea ima (in 10% of population -from brachiocephalic artery or aorta) Venous 4 Superior and middie thyroic veins - nto the UV 4 _Inferine thyroid vein into the brachiocephalic veins The tongue ‘+The lymphatic drainage of the enterior two thirds of the tongue shows only minimal communication of lymphatics acrass the midline, so metastasis to the ipsilateral nodes is usual ‘©The lymphatic drainage of the posterior third of the tongue have communicating networks, as a result early bilateral nodal metastases ere more common in this area. ‘+ Lymohatics from the tio of the tongue usually pass to the sub mental nodes and from there tothe deep cervical nodes. ‘© Lymphaties from the mid portion of the tongue usually drain to the submandibular nodes and then to the deep cervical nodes. Mid tongue tumours that are laterally located will usually drain to the ipsilateral deep cervical nodes, those fram more central regians may have bilateral deep cervical nodal involvement. The glossopharyngeal nerve supplies general sensation to the pasterior third of the tongue and contributes to the gag reflex. Taste to the anterior two thirds of the tongue is supplied by the facial nerve, the trigeminal supplies general sensation, this is mediated by the mandibular branch of the trigeminal nerve (via the lingual nerve). glossopharyngeal Hypogiossal nerve [XII] Hyoglossus Styloglossus IC ANATOMY HEAD & NECK) -MRCS NOTES - EDA FaySubmandibular gland Relations of the submandibular gland Platysma, deep fascia and mandible submandibular lymoh nodes Facial vein (facial artery near mandible) ‘Marginal mancibuler neve Cervical branch of the facial nerve Facial artery (inferior to the mandible) Mylobyoid muscle Sub mandibular duct Hyoglossus muscle Lingual nerve Submandibular ganglion Hypoglossal nerve Superfc Deep Submandibular duct (Wharton's duct) ‘© Opens lateralto the lingual frenulum on the anterior floor of mouth. = Semlength ‘¢ Lingual nerve wraps around Wharton's duct. As the duct passes forwards it crosses medial to the nerve to lle above it and then crosses back, lateral to it, 10 reach a position below thenerve. 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 togroove its deep surface. It then emerges onto the face by passing between the gland and the mandible. Venous drainage Anterior facial vein (lies deep te the Marginal Mandibular nerve) Lymphatic drainage Deep cervical and jugular crains of nodes Three cranial nerves may be injured during submandibular gland excision. ‘© Marginal mandibular branch of the facial nerve = Lingual nerve © Hypoglossal nerve Hypoglossal nerve damage may result in paralysis of the ipsilateral aspect of the tongue. The nerve itself lies deep to the capsule surrounding the gland and should not be injured during an intracapsular dissection. The lingual nerve is probably at greater risk of injury. However, the effects of lingual nerve injury are sensory rather than motor. Subingual gland {1 ANATOMY (HEAD & NECK) MRCS NOTES -REDA 2Parotid gland ‘Anatomy of the parotid gland Location Overlying the mandibular remus, anterior and inferior to the ear. Salvary duct Crosses the masseter, pierces the buccinator and drains adjacent to the 2nd upper molar tooth (Stensen's duct) ‘Structures passing through + Facial nerve (Nnemonic: The Zebra Buggered My C: the gland Mandibular, Cervical) + extemal carotid artery * Retromandibuiar vein + Auriculotemporal nerve ‘emporal Zygomatic, Buccal, Relations ‘Anterior: masseter, medial pterygoid, superficial temporal and maxillary artery, facial nerve, styiomanditular ligament «Posterior: posterior belly digastric muscle, sternocleidomastoid, stylohyoid, internal carotid artery, mastoid process, stylcid process ‘Arterial supply Branches of external carotid artery Venous drainage Retromandibular vein Lymphatic drainage Deep cervical nodes Nerve innervation + Parasympathetie-Secretametor # Sympathetic-Superior cervical ganglion «Sensory: Greater auricular nerve Parasympathetic stimulation produces a water rich, serous saliva. Sympathetic stimulation leads to the production of a low volume, enzyme-rich saliva. “Temporal branches: Facial nerve [Vil] Parotd gland External carotid artery External jugular vein 1G ANATOMY (HEAD & K) MRCS NOTES -REDA BCircle of Willis The two intemal carotid arteries and two vertebral arteries form an anastomosis known as the Circe of Wills on the Inferior surface of the brain, Each half of the circle is formed by 1. Anterior communicating artery 2. Anterior cerebral artery 3. Internal carotid artery 4. Posterior communicating artery 5. Posterior cerebral arteries and the termination of the basilar artery The circle and its branches supply; the corpus striatum, Internal capsule, diencephalon and midbrain Vertebral arteries Basilar artery Internal carotid arteries, Enter the cranial cavity via foramen | Branches: Branckes magnum Anterior inferiorcerebellsrartery | © Posterior communicating artery Liein the subarachneid space © Labyrinthine artery © Anterior cerebral artery Ascend on anterior surface of ‘© Pontine arteries Middle cerebral artery medulls oblongata Superior cerebelar artery + Anterior choroid artery * Unite toform the basilar artery at | @ Posterior cerebral artery the base of the pons Branches: * Posterior spinal artery # Anterior spinal artery # Posterior interior cerebellar artery Anterior cerebral Anterior Pituitary gland communicating Anterior cerebral Internal Cerebral carotid (cut) - Posterior arterial communicating circle Middle Posterior cerebral cerebral Anterior inferior cerebellar Posterior inferior cerebellar Anterior spinal SS IC ANATOMY HEAD & NECK) -MRCS NOTES - EDA 14Vertebral artery The vertebralartery isthe first branch of the subclavian artery. Anatomically iti divisible into 4 regions: ‘= The rst partrunsto the foramen in the transverse process of 6. Anterior to this part lie the vertebral and internal jugular veins. On the left side the thoracic duct is also an anterior relation, ‘© The second part runs superiorly through the foramina of the transverse processes of the uaper 6 cervical vertebrae. Once it has passed through the transverse process f the axis it then turns superolateraly tothe atlas. It is accompanied by a venous plexus and the inferior cervical sympathetic ganglion ‘© The third part runs posteromecially on the lateral mass ofthe atlas. It enters the sub occipital triangle, in the {grocve of the upper surface of the posterior arch of the atlas. It then passes anterior to the edge of the posterior atlanta-occgital membrane ta enter the vertebral canal ‘© The fourth part passes through the spinal dura ard arachnoid, running superiorly and anteriorly at the lateral aspect of the medulla oblongata. At the lower border of the pons it unites to form the basilar artery. Inferior thyroid artery. Transverse cervical artery {1 ANATOMY (HEAD & NECK) MRCS NOTES -REDA 15Common carotid artery The right common carotid artery arises at the bifurcation of the brachiocephalic trunk. The feffomman carotid arses from the arch of tre aorta, Both terminete at the lev! ofthe upper border ofthe thyroid cartilage C4/C3 (the lower Border ofthe third cervical vertebra) by dividing into the interraland external carotic arteries Left common carotid artery Thisvessel arses immediately tothe lft and slighty behind the orig of the brachiocephalic unk. ts thoracic portion is2.5-3.5¢m length and uns superoateraly tothe sternoclavicular joint inthe thorox The vessel sn contact, from below upwards wth the trachea leftrecurrent laryngeal nerve, left margn ofthe oesophagus. Anterior the leftbrachiocenhalic vein runs across the artery, and the cardiac branches from the left vagus descend in fontof it These suctures together withthe thymus and the anterior margins ofthe lt lungand pleura separate the artery from the manus, Inthe neck The artery runs superiorly deep tostemoclesdomastod and then enters the antesior triangle. At this point it ies waitin the carota sheath wit the vagus nerve ard the internal jugular vein. Posteioy the sympathetic trunk les betwren the vessel and the prevertehralfasea. tthe eve! oF7 the vertebral artery and horace dct ie behind it. The anterior tubercle of 06 transverse process is prominent and the artery can be compressed against this structure (it corresponds to the level of the cricoid). anterior tC the omohyoid muse passes superfcal tothe artery. Within the carotid sheath the jugular vein lies lateral to the artery. ‘ight common carotiartey The ight common carotid srzes fom the brachiocephalic artery. The right common carotid artery corresponds with the cervical portion of the left common carotid, except that there is no thoracic duct on the right. The oesophagus i less closely elated to the right carotid than the lf Path Passes behind the sternoclavicular joint (12% patients above this level) to the upper border of the thyrcid cartilage, to divide into the external (ECA) and internal carotid arteries (ICA). Relations Level of 6th cervical vertebra crossed by omehyoid Then passes deep to the thyrotiyoid, stemohyoid, sternomastoid muscles. Passes ant. to the carctid tubercle (transverse process 6th cervical vertebra). NB: compression here stops hee. The inferior thyroid artery passes posterior to the common carotid artery. Then: (0 Left common caratid artery crosses the thoracic duct © Right common carotid artery crossed by recurrent laryngeal nerve {IC ANATOMY (HEAD & NECK)~ MRCS NOTES REDA 16Middle meningeal artery ‘* Middle meningeal artery istypically the third branch cf the first part of the maxillary artery, one of the two terminal branches ofthe external cerotié artery. Ater branching off the maxillary artery in the infratemporal fossa, it runs through the foramen spinosum to supply the dur mater (the outermost meninges). ‘© The middle meningeal artery is the largest of the three (paired) arteries which supply the meninges, the others being the anterior meningeal artery and the posterior meringeal artery. ‘¢ The middle meningeal artery runs beneath the pterion. It is vulnerable to injury at this point, where the skulis thin, Rupture of the artery may give rise to an extra dural hematoma ‘* Inthe dry cranium, the middle meningeal, which runs within the dura mater surrounding the brain, makes a deep indention in the calvsrium. ‘+ The middle meningeal artery isintimately associated with the euriculotemporal nerve which wraps round the artery making the two easiy identifiablein the dissection of human cadavers and also easly damaged in surgery {1 ANATOMY (HEAD & NECK) MRCS NOTES -REDA 19Brachiocephalic artery The brachiocephalic ateryis the largest branch of the aortic arch. From its aortic oign it ascends superirh, intially lies anterior to the trachea and then on ts righthand side tranches into the common carotid and right subclavian arteries at the level ofthe sternoclavicular int Path COrigin- apex af the midline of the aortic arch Passes superiorly and posteriorly to the right. Divides into the right subclavian and right commen carotid artery Relations Anterior | « Sternohyoid «© Sternothyroid Thymic remnants «Left brachiocephalic vein «Right inferior thyrcid veins © Trachea + fight pleura Right lateral «Right brachiocephalic vein «Superior part of SVC Leftlateral «thymic remnants + Origin of left common carotid «Inferior thyroid veins «Trachea (higher level) Posterior Branches Normally none but may have the thyroidea ima artery Subclavian artery Path + Thee subclavian comes directly of the arch of sort ©The right subclavian arses from the brachiocephalic artery trunk) when it bifurcates int the subclavian and the right common carotid artery, + From its origin, the subdavion artery travels laterally, pasing between anterior and mile sealene muscles, deep to scalenus anterior and anterior to Scalenus mecius s the subclavian artery crosses the lateral border of the fist rb, it becomes the axillary artery A this point its Superficial and within the subdavien triangle Branches “VITC&D” © Vertebral artery © Internal thoracic artery © Thyrocervical trunk © Costocervical trurk © Dorsal scapular artery {IC ANATOMY (HEAD & NECK)~ MRCS NOTES REDA 20Each jugular vein begins in the jugular foramen, the medial end of the clavicle where they unite with the subclavian vein The veinllies within the carotid sheath throughout its course, Below the skull the internal carotid artery and last four cranial nerves are anteromedal to the vein, Thereafter itis in contact medially with the internal then common) carotid artery. The vagus les posteromedially. [At Its superior aspect, the vein s overlapped by sternocleidomastoid and covered by it at the Inferior aspect of the vein. Below the transverse process of the atlas itis crossed an its lateral side by the accesscry nerve. Atits mid pointit is crossed by the Inferior root of the ansa cervicalis. Posterior to the vein are the transverse processes of the cervical vertebrae, the phenic nerve asit descends on the scalenus anterior, and the first part of the subclavian artery, On the left side its also related to the thoracic duct. Internal jugular vein where they are the contusion ofthe sigmoid sinus. They terminate at ‘Superior thyrod vein idle thy vein Infor tryngea! vein Exceral jaar vein Subeinan ven {IC ANATOMY (HEAD & NECK)~ MRCS NOTES REDA aCranial nervelesions Cranial nerves Olfactory nerve May be injured in basal sul fractures or involvediin frontal lobe tumour extension, Loss of olfactory nerve function in relation ta major CNS pathology s seldom anisolated event and thus it 's poor localiser of CNS pathology. Optic nerve Problems with visual acuity may result from intra ocular disorders. Problems with the blood supply such 2¢ amaurosis fugae may produce temporary visual distortion. More important surgically isthe pupillary response to light. The pupillary size may be altered in a number of disorders. Nerves involved in the resizing of the pupil connect ta the pretectal nucleus of the high midbrain, bypassing, the Isteral geniculate nucleus and the primary vieual cortex. From the pretectal nucleus neurones pass to the Edinger - Westphal nucleus, motor axons from here pass along with the oculomotor nerve. They synapse with cliary ganglion neurones; the parasympathetic axons from this then innervate the iris and praduce miosiz. the miotic pupilis seen in dizorders such ae Horner's syndrome or opiate overdose. Mydriasisis the dilatation of the pupil in response to disease, trauma, drugs (or the darkl). tis pathological when light fails to induce miosis. The radial muscle is innervated by the sympathetic nervous system. Because the parasympathetic fibres travel with the aculomator nerve they will be damaged by lesions affecting this nerve (e.g. cranial trauma). The response to light shone in one eye is usuelly a constriction of both pupils, This indicates intact direct and consensual light reflexes. When the optic nerve has an afferent defect the ight shining on the affected eye will produce a diminished pupillary response in both eyes. Whereas light shone on the unaffected eye will produce a normal pupillary response in both eyes. Thisis referred toas the Marcus Gunn pupilandis seen in conditions such as optic neuritis. Ina total CN Il lesion shining the light in the affected eye will produce no response, ‘Oculomator The pupillary effects are described above. In addition, it supplies all ocular muscles apart from lateral rectus and superior oblique. Thus the affected eye will he deviated inferolaterally. levator palpebrae superioris may also be impaired resulting in impaired abilty to open the eye. Trochlear nerve The eye will not be able to look down, Trigeminal nerve Largest cranial nerve. Exits the brainstem at the pons. ranches are ophthalmic, maxilary and mandibular. Only the mandibular branch has both sensory and motor fibres. ranches converge to form the trigeminal ganglion (located in Meckels cave). It supplies the muscles of mastication and alzo tensor vali palatine, mylahyaid, anterior belly of d gastric and tensor tympani. Check textbook ‘or detailed descriptions of the various sensory functions. The comeal reflex is important and is elicited by applying a small tip of cotton wool to the cornea, a reflex blink should occur if it is intact itis mediated by: the naso elliary brench of the ophthalmic branch of the trigeminal (sensory component) and the facial nerve producing the motor response. Lesions of the afferent arc will produce bilateral absent blink and lesions of the efferent arc wil result ina unilateral absent blink ‘Abducens nerve The affected eye will have a defcit of abduction. This cranial nerve exits the brainstem between the pons and meculla. It thus has a relatively lone intra cranial course which renders it susceptible to damage in raised intra cranial pressure. Facial nerve ‘merges from brainstem between pons and medulla. I controls muscles of facial expression and taste from the anterior 2/3 of the tongue. The nerve pasces into the petiaus temporal bone and into the internal auditory meatus. It then passes through the facial canal andexits at the stylomastoid foramen. It passes through the parotid gland and divides at this point. It does not innervate the paratid gland. Its divisions are considered in other parts of the website, ts motor fibres innervate orbicularis ocul to produce the efferent arm of the corneal reflex. In surgical practice it may be injured during parotid gland surgery or invaded by malignancies of the gland and a lower motor neurone on the ipsilateral side will result Vestibulo- cochlear nerve {Exits from the pons and then passes through the internal auditory meatus. tis implicated in sensorineural hearing loss. individuals with sensorineural hearing loss wil localise the sound in webers test to the normal ear. Rinnes test will be reduced on the affected side but should stil work. These two tests wil distinguish sensorineural hearing loss from conductive deafness. In the latter condition webers test will localise to the affected ear end Rinnes test will be impaired on the affected side. Surgical lesions affecting this nerve include CNS tumours end basal skull fractures. It may also be damaged by the administration of ototoxic drugs (of which gentamicin is the most commonly used in surgical practice). Glossopharyngeal nerve its the pons just above the vagus, Receives sensory fibres from posterior 1/3 tongue, tonsils, pharynx and middie ear (otalgia may occur following tonsillectomy). It receives visceral afferents from the carotid bodies. It supplies parasympathetic fibres to the parotid gland via the otic ganglion and motor function to stylopharyngeaus muscle, The sensory function of the nerve is ested using the gag reflex (CK) ~ MRCS NOTES REDA 2Vagus nerve Leaves the medulla between the olivary nucleus and the inferior cerebellar peduncle. Passes through the jugular foramen and into the carotid sheath, Details ofthe functions of the vagus nerve are covered in the website under relevant organ sub headings. ‘Accessory nerve Exists from the caudal aspect of the brainstem (multiple branches) supplies trapezius and sternocleidomastoid muscles. The distal portion of this nerve is most prone to injury during surgical procedures, Hypoglassal Emerges irom the medulla at the preolivary sulcus, passes through the hypoglossal canal. lies on neve ‘the carotid sheath and passes deep to the posterior belly of digastric to supply muscles of the ‘onaue (except palatoalossus) ts location near the carotid sheath makes it vulnerable during carotid endarterectomy surgery and damage will produce ipsilateral defect in muscle function Cranial nerves carrying parasympathetic fibres x 0« vill (1973) ‘The parasympathetic functions served by the cranlal nerves include: lil (oculomotor) Pupillary constriction and accommodation Vil (facial) Lacrimal gland, submandibular and sublingual glands Ix iglossopharyngeal| | Parotid X (vagus) Heart and abdominal viscere The optic nerve carries no parasympathetic flores. The cranial preganglionic parasympathetic nerves arise trom specific nuclet in the CNS. These synapse at one of four parasympathetic ganglia; otic, pterygopslatine, ciliary and submandibular. From these ganglia the garasympathetic nerves complete their journey to their target tissues via CN V (trigeminal) branches (ophthalmic nerve CNV branch 1, Maxillary nerve CN V ranch?, mandibular nerve CN V branch 3) “Temporal lobe Optic nerve fi) Pons. ‘Oculometor nerve fll) ‘Trochilear nerve [IV] Facial nerve [Vi] ‘Abducent ‘Vagus nerve [X] Hypoglossal nerve [Xl] Cerebellum SS {IC ANATOMY (HEAD & NECK)~ MRCS NOTES REDA 23Trigeminal nerve The trigeninal neive Is the main sensory nerve of the head. in addition to Its majar sensory role, italso innervates the muscles of mastication Distribution of the trigeminal nerve ‘Sensory Scalp Face ral cavity (and teeth) Nose and sinuses Dura mater ‘Muscles of mastication Mylohyoid Anterior belly of cigastrie Tensor tympani Tensor palati © Ciliary Sphenopalatine Otic Submandibular ‘© Originates at the pons ‘+ Sensory root forms the large, erescentic trigeminal ganglion within Meckel's cave, and contains the cell bodies of i yming sensery nerve fibres. Here the 3 branches exit ‘* The motor root cell bodies are in the pons and the metor fibres are distributed via the mandibular nerve. The ‘motor root isnot part of the trigeminal ganglion. Branches of the trigerrinal nerve ‘Ophthaimicnerve sensory only Maxillary nerve Sensory only Mandibularnerve Sensory and motor Sensory ‘Ophthalmic | Exits skull via the suverior orbital fissure Sensation of: scalp end forehead, the upper eyelid, the conjunctiva and cornes ofthe eye, the nese {inelucing the tip of the nose, except alae nasi), the nasal mucosa, the frontal sinuses, and parts of the meninges (the dura and blood vessels) Maxilary | Ext skull via the foremen rotundum newe Sensation: lower eyelid and cheet, 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 | (xt skull va the foramen ovale newe Sensation: lower lip, the lower teeth and gums, the chin and jaw lexcept the angle of the jaw), parts of the external eat, and parts of the meninges. Motor Distributed via the mandibular nerve, The following muscles of mastication are innervated: + Masseter + Temporalis © Mecial pterygoid © Lateral pierygoid Other muscles innervated include: © Tensor Mylehyod Anterior belly of digastric Tensor tympani palatini SS IC ANATOMY HEAD & NECK) -MRCS NOTES - EDA 24The lateral aspect of the external nose is innervated by lateral nasal branches of the anterior ethmoidal nerve. The ethmoidol nerve is a branch of the nasoctiary nerve of the divisions of the trigeminal.Facial nerve The facial nerve is the main nerve supplying the structures of the second embryonic branchial arch. It is predominantly an efferent nerve to the muscles of facial expression, digastric muscle and also te many glandular structures. It contains @ few afferent fibres which originate in the cells of its genicular ganglion and are conceined with taste. Supply - Yace, ea, taste, tear’ © Face: muscles of facial expression © Ear:nerve to stapedius ‘© Taste: supplies anterior two-thirds of tongue ‘+ Tear: parasympathetic fibres to lacrimal glands, aso salivary glands Path Suberachnoid path ‘© Origin: motor- pons, sensory- nervus intermedius ‘© Pass through the petrous temporal bone into the internal auditory meatus with the vestibulacochlear nerve, Here they combine to become the facial nerve, Facial canal path ‘©The canal passes superior to the vestibule of the inner ear ‘* At the medial aspect of the middle ear, it becomes wider and contains the geniculate ganglion. 3 branches: 1. Greater (superficial) petrosal neve 2. Nerveto stapedius 3. Chorda tympani Stylomastoid foramen ‘© Passes through the stylomastaid foramen (tympanic cavity anterior and mastoid antrum posteriorly) ‘© Posterior auricular nerve and branch to posteriar belly of digastric and stylahyoid muscle Face Enters parotid gland and divides into 5 branches: © Temporal branch © 2ygomatic branch © Buccal branch ‘* Marginal mandibular branch = Cervical branch Temporal branches. Posterior auricular neve {IC ANATOMY (HEAD & NECK)~ MRCS NOTES REDA 26The chorda tympani branch of the fecial nerve passes forwards through itrs canaiculus into the middle ear, and crosses the medial aspect of the tympanic membrane. It then passes antero-inferiorly in the infratemporal fossa, Itdistributes taste fibres to the anterior two thirds of the tonave. Facial nerve [VII — Temporotacial branch Mastoid process Digastrie branch branch ‘ Digastric muscle Mandible {IC ANATOMY (HEAD & NECK)~ MRCS NOTES REDA 27Vagus nerve res from the The vagus nerve has mixed functions and supplies the str fourth and sith pharyngeal arches. It also supplies the fore and midgut sections of the embryonic gut tube. It carries afferent fibres from these areas, (viz; pharynx, larynx, oesophagus, stomach, lungs, heart and great vessels), The efferent fibres of the vagus are of two main types. The first are preganglionic parasympathetic fibres distributed to the parasympathetic ganglia that innervate smooth muscle of the innervated organs (such as gut) The second type of efferent fibres have direct skeletal muscle innervation, these are largely to the muscles of the larynxand pharynx. Origin and course The vagus arises from the lateral surface of the medulla oblongata by a series of rootleis, Ibis related to the glossopharyngeal nerve cranially and the accessory nerve caudally It exits through the jugular foramen and is contained within ts own dural sheath alongside the accessory nerve. In the neck it descends vertically in the carotid sheath where itis closely related to the internal and cornmon carotid arteries. leaves the neck and enters the mediastinum, On the right it passes anterior to the first part of the subclavian artery, on the left it les in the interval between the common carotid and subclavian arteries, In the mediastinum both nerves pass posters: inferiorly and reach the posterior surface of the corresponding lung root. These then branch into both lungs. At the inferior end of the mediastinum these plexuses reunite to form the formal vagal trunks that pass through the oesophageal hiatus and into the abdamen. The anterior and posterior vagal trunks are formal nerve fibres these then splay out once again sendirg fibres over the stomach and posteriorly to the coeliac plexus. Branches pass to the liver, spleen and kidney. Communications and branches ation Details Located in jugular foramen. ‘Communicates with the superior cervical sympathetic ganglion, accessory nerve Two branches; meningeal and auricular (the latter may give rise to vagal stimulation following instrumentation of the external auditory meatus) Inferior ‘Communicates with the superior cervical ganglion ‘sympathetic ganglion, hypoglossal nerve and loop between first and second cervical ventral rami Two branches; pharyngeal (supplies pharyngeal muscles) and Superior laryngeal nerve (inferomedially- deep to both carotid arteries) nme ‘Superior ganglion Branches in the neck se deo /narthyri for es) ‘ranch ra ‘Superior and Arise at various points and descend into thorax inferior ‘On the right these pass posterior to the subclavian cervicalcartiac artery branches Onthe left the superior branch passes between ‘the arch of the aorta and the trachea to connect with the deep cardiac plexus. The inferior branch descends with the vagus tre Right recurrent. Arses from vagus anterior to the frst part of the laryngeal nerve | subclavian artery, hooks under it, and ascends superomedialy.t passes close to the common carotid and finaly the inferior thyroid artery to insert into the larynx IC ANATOMY HEAD & NECK) -MRCS NOTES - EDA 28 Pulmonary trunk