mbryolo iSense Notes By Reda HarbPharyngeal arches These develop during the 4th 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 stuctures and often fuses with the sixth arch. Pharyngeal Muscular arch contributions FirsT Muscles of masTication Anterior belly of digastric & Mylohyoid ‘Tensor tympanic ‘Tensor veli palatini Second Buccinator Platysma Muscles of facial expression Stylohyoid Posterior belly of digastric. Stapedius Third Stylopharyngeus Fourth Cricothyroid All intrinsic muscles of the sott palate sixth All intrinsic. muscles of the larynx (except cricothyroid) Skeletal contributions Endocrine Maxilla na Meckels cartilage Incus Malleus Stapes nla Styloid process Lesser horn and upper body of hyoid Greater horn Thymus and lower part Inferior of hyoid parathyroids Thyroid and Superior epiglottic parathyroids cartilages Cricoid, na arytenoid and corniculate cartilages Artery Maxillary External carotid Inferior branch of superior thyroid artery Stapedial artery Common and internal carotid Right- ‘subclavian artery, Lef-aortic. arch Right & Left Pulmonary arteries ductus arteriosus Nerve Mandibular of Trigeminal V3 Seventh Vi Facial Glossopharyngeal Vagus Superior laryngeal nerve Vagus recurrent laryngeal nerveBranchial pouch derivatives 0 Ns aN ‘st pouch ar, toms, bottom to top I fear), 2 tonsils), ed pare 3 dorsal (bottom for inferion parathyroid), 3rd pouch Dorsal wings inferior Sd pouchcontrhaesio’3 3 Yet to= thy parathyroid, structures thyinus, lft and ee Ventral wings thymus. right inferior parathyroid). P S-pouch suctures ead up below 4th-pouch structures. ‘4th pouch Dosa wings - superior parathyrids Vental wings ~ timobranchial body ~ parafllcular (C) cel of thy Ectoderm Mesoserm Endoderm Inteor parathyroid bud trom 3rd ‘pharyngeal pouch Sepa aay Lrimopraryneatvoay ba tom - pharyngeal pouch Tracheoesophageal Esophageal atresia (FA) with distal tracheoesophagea fistula (TER) isthe mast common (85%). ‘anomalies Polyhyclramnios in utero. Neonates drool, choke, and vomit with frst feeding, TEF allows air to enter stomach (visite on CXR). Cyanoss is 2° to laryngospasm (to avoid reFax-telated aspiration) (Clinical tes: al to pass nasogautric tube into stomach, Jn Hype, the fistula resembles the ler H. In pure EA the CXR shows gals abdomen, Tacwcesepage 8+ Median clefttip:resuts trom failure of the medial nasal Cleft lip and palate prominences to merge and form = | feintematary segments + Unilateral cleft lip: result rom failure of the mavilary ‘Median Cleftlip i prominence to morge with the a medial nasal prominence on the tected se, io + Combined cleft lip and palate (45%) + Bilateral cleft lip: results du to Uniatral cet + Isolated cleft palate (40%) failure of maxillary prominences f ® Isolated cleft lip (15%) tomect and unite with the medial p in RA © foramen ovale shuts © prostaglandin levels decrease as no more flow from umbilical vein ¥ umbilical vein > ligamentum teres ¥ ductus venosus > ligamentum venosum ¥ foramen ovale > fossa ovalis Y ductus arteriosus > ligamentum arteriosum (left recurrent laryngeal winds around it)Congenital heart disease Acyanotic - most common causes + Ventricular septal defects (VSD) - most common, accounts + Atrial septal defect (ASD) + Patent ductus arteriosus (PDA) Coarectation of the aorta + Aortic valve stenosis for 30% VSDs are more commen than ASDs. However, in adult patients ASDs are the more common new diagnosis as they generally present later. Cyanotic - most common causes + Tetralogy of Fallot + Transposition of the great arteries (TGA) Tricuspid atresia Pulmonary valve stenosis, Congenital heart diseases mnasis—"blue babies” Often diagnosed ally or become evident immediately ‘urgent surgical ince ofa PDA. Early Pi after birth, Usually eq 1 ma ne Persistent tuncus _Truncus arteriosus fils to divide into arteriosus pulmonary trank and aotta due to lack of aorticopalmonary septum formation; most patients have accompanying VSD. Ditranspositionof Aorta leaves RV (anterior) and pul ‘great vessels ior) ~ separation of sstemic and pulmonary ciculations. Not compatible with life unless a shuntis present to allow rising ef blood (eg, VSD, PDA, or patent foramen oval. Due to faire ofthe aortcopalmonary septum to sal Without srgical in 1 infants die within the first few months of life U0 wear ums Acyanotie at presentation; cyanaris may occur year late Frequency: VSD > AsD Ventricular septal defect Most common congeni Asymptomaticat birth, later or remain asymptomatic throughout life Teadto LN ay manifest weeks “Mos self resolve; lager lesions m ‘overload and HE. Atrial septal defect Defect in inter: al septm [loud SI; wide fixed split $2. Ostium secundum defects Findings: ostinm prinnam defects rarer yet tustlly occur with ether cardiae anomalies, Spmptoms range from none to HE. Distinct from patent foramen ovale in that sepa ae missing tisue rather than unfused. Patent ductus arteriosus In etal period, su In neonatal peviod, | pulmonary vasculae resistance + shunt becomes lft to right idlor LV ane ‘machine-like = progremive RVI Associated wth a continuou ‘muri, Paterey is maintained by PGE synthesis and low O; tension. Uncorrected 2, Transposition (2 switched vessels) 3 Tricuspid atresia (3 = Tit) 4. Tetralogy of Fallot (4 = Tetra) S-TAPVR (5 letters in the vate ‘eptu Rightio-Left shunts: eaRLy eyanosis, Leftto Right shunts: “LateR” cyanosis « saturation tin RV and pulmonary rten: (0, saturation # in RA, RV, and pl artery, May lead to paradexical emboli ‘aystemic venous emboli wse ASD to bypiss hangs and become systemic arterial emboli) of PDA: PGE keeps ductus Going (may be necessary to stain life in conditions sch as te n ofthe great rsseh posi PDA is normal in utero and after birth,TOF Tetralogy of Fallot (TOF) is the most common cause of cyanotic congenital heart disease* It typically presents at around 1-2 months, although may not be picked up unti the baby is 6 months old Features ventricular septal defect (VSD) right ventricular hypertrophy right ventricular outfiow tract obstruction, puimonary stenosis overriding aorta The severity of the right ventricular outiow tract obstruction determines the degree of cyanosis and clinical severity Other features + cyanosis causes a right-to-left shunt ejection systolic murmur due to pulmonary stenosis (the VSD doesn't usually cause a murmur) a right-sided aortic arch is seen in 25% of patients chest x-ray shows a boot-shaped’ heart, ECG shows right ventricular hypertrophy Management + surgical repair is often undertaken in two parts + cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm “however, at birth transposition of the great arteries is the more common lesion as patients with TOF generally present at around 1-2 months Tetralogy of Fallot Caansed by anterosuperior displacement ofthe PROVE. infundibular septum, Most common cause of — Squatting: t SVR, 4 rightto-left shunt, improves eatly childhood eyanoss. cyanosis, @ Pulmonary infundibular stenosis (most ‘Treatment: early surgical correction, portant determinant prognosis) © Right vertriclar hypertrophy (RVH)— bootshaped heart an CXR El Overiing arta vs Pulmonary stenosis foicesight4o-lef low across VSD = RVH, “tet spells (oien caused by eryng, fever, and exercise duet exacerbation of RV outflow obatrction) Eisenmenger Uncorrected left-to-right shunt (VSD, ASD, syndrome PDA) = t pulmonary Hood flow - pathologie remodeling of vasculature ~ pulmonary arterial hypertension, RVH occurs to ‘compensate ~ shunt becomes right to left. Causes lte eyanosis, clubbing B, and poleythemia, Age of onset varies conus Coarctation ofthe Aorie narrowing near imertion of ucts aorta ateriosus Cinstactal"). Asie with . bhuspd sorte vahe, other Heart deeds, and (4 tem, Turner syndrome. Hypertension in upper eee extremities and weak delayed pulse inlower Qa) oan extremities (braciaTemoral dea) With age, o intercotal aterics enlarge duc to collateral circulation; arteries erode ribs + notched appearance n CXR. Complications include HE, tik of cerebral hemortha atysins),sortic rupture, and possible endocaniits. (berry "Ventricular septal defect Ventricular septal defects are the most common cause of congenital heart disease. They close spontaneously in around 50% of cases. Non-congenital causes include post myocardial infarction Features + Classically a pan-systolic murmur which is louder in smaller defects Complications + aortic regurgitation” + infective endocarditis + Eisenmenger’s complex + right heart failure “aortic regurgitation is due to a poorly supported right coronary cusp resulting in cusp prolapse Ventricular septal ‘Most common congenital cardiac defect. , saturation t in RV and palmonary artery. defect Asymptomatic at birth, may manifest weeks later or remain asymptomatic throughout life. Most self resolve; larger lesions may lead to LV overload and HE. Bochdalek Bosterior Bad affect respiration A B Honma Shera Morgagai anterior ( good ) Ones ater asymptomatic found incidentally e Neonate Cysnosed Dyspnae Bowel sounds in chest Scaphoid Abdomen. occurs due to : a _ Failure of obliteration of pleuroperitoneal canal Uochdiechena —Voqnaibeniaanoberectsorhenis — Caidhenia — Faiture of development of Pleuroperitoneal folds Septum transversum - thickened sheet of mesoderm between cardiogenic area and cranial margin of disc, later caudal and anterior to gut tube ~ septum transversum > central tendon of diaphragm = septum transversum also makes VENTRAL MESENTERY for caudal portion of foregut: liver, stomach, spleen - complete diaphragm develops from: © septum transversum somatic mesoderm from body wall mesentery of oesophagus pleuroperitoneal membrane myoblasts from cervical somites oo00Pancreasandspleen —Pancreas—derived from foregut. Ventral pancreatic buds contribute to uncinate process and main pancreatic duct. The dorsal pancreatic bud alone becomes the body, tail isthmus, and accessory pancreatic duct. Both the ventral and dorsal buds contribute to pancreatic head. Annular pancreas—ventral pancreatic bud abnormally encircles 2nd part of duodenum: forms a ring of pancreatic tissue that may cause duodenal narrowing E¥ and vomiting Pancreas divisum—ventral and dorsal parts fail to fuse at 8 weeks. Common anomaly; mostly asymptomatic, but may cause chronic abdominal pain and/or pane Spleen arises in mesentery of stomach (hence is mesodermal) but has foregut supply (celiac trunk = splenic artery} Hirschsprung disease Congenital megocolon characterized by lack Risk t with Down syndiome of ganglion cellslenteric nervous plexuses. _Explosive expulsion of feces (squit sign) (Auerbach and Meissner plewuses) in distal ~ empty rectum on digital exam. segment of colon. Duc te Diagnosed by absence of ganglionic cells on cell migration. Associated with mutations in rectal suction biopsy ‘Treatment: resection. and fa within 48 hours ~ chronic constipation, Normal portion of the colon proximal to the nglionie segment is dilated, resulting in a transition zone.” cystic fibrosis centres Autosomal recessive; defect in CFTR gene on chromoson Most common lethal genetic disease in Caucasian population, ParioenrsoL0gr CFTR encodes an ATP-gated Cl channel that secretes CI- in lungs and Gl tract, and reabsorbs Grin sweat glands. Most common mutation -* misfolded protein ~ protein retained in RER and not transported to cell membrane, causing § CI (and HO) secretion; t intracellular CF results in compensatory t Na* reabsorption via epithelial Na’ cls + t H,O reabsorption = abnormally thick mucus secreted into lungs and Cl tract. t Na* reabsorption also causes more negative transepithelial potential difference. Daatoss 1 CF concentration (> 60 mEq/L) in sweat is diagnostic. Can present with contraction alkalosis and hypokalemia (ECF effects analogous to a patient taking a loop diuretic) because of ECF H,OINa’ losses and concomitant renal K'/H* wasting, t immunoreactive trypsinogen (newborn screening), Thyroid development ‘Thyroid diverticulum commonly a deletion of Phe508. rises from floor of Foramencecun——, primitive pharynx and descends into neck. Connected to tongue by thyroglossal ieotial duct, which normally disappears but may thyroplossl persist as cysts or the pyramidal lobe of uct thyroid. Foramen cecum is normal remnant of thyroglossal duct. Most common ah ectopic thyroid tissue site is the tongue = (lingual thyroid). Removal may result in “trachea hypothyroi present, tis the only thyroid tissueGastroschisis: Isolated abnormality, bowel lies outside abdominal wall through defect located to right of umbilicus. Exomphalos: Liver and gut remain covered with membranous sac connected to ‘umbilical cord. It is associated with other developmental defects. Minor omphalocele: There is protrusion of a small portion of the intestine only and the size of the defect is < $ em in diameter. Major omphalocele: There is protrusion of the intestines, liver, and other organs and the diameter of the defect is > $ em. Liver ~ diverticulum from duodenal endoderm - pushes into septum transversum -> ventral mesentery - gall bladder = ventral outpouching Pancreas = outgrowth of hepatic diverticulum - dorsal bud > accessory pancreatic duct / minor papilla - ventral bud > uncinate process, manjor papilla along with bile Bladder ~ at cloacal membrane (no mesoderm) urogenital septum grows in to divide hindgut from allantois ~ urogenital septum > perineum = widening of gut on allantoic side = urogenital sinus > bladder, urethra male: only prostatic and membranous urethra female: entire urethra ~ allantois > urachus > median umbilical ligament‘Stomach HII Glands associated wit reaut Seven HE Dwvatves of reont TEI Dorit of midout IH Dericatves of indout HH Nersigestve organ ‘Transverse colon ‘Asconding colon Descenang colon cecum. ‘Sigmold colon Rectum and anal canal Hidout “anomie Urogenital septum Pugs: Mesonepiic —< _§ Urogenital ‘membrane Foregut eo Forgut segue -Anerorntesinal pra! tamer eaaee Dose nesenery of ox cout Ponorerinestina portal Hie gut ~~ Esophegus La al tubs wth un bud ‘Septum transversum Hepatic bud caliac artery ‘Ventral pancreatic bud Spleen Vitlointetinal duct Dorsal pancreatic duct Gecdl dtedcshar Neteslarheunentoeer Dorsal aorta Infrioe mesenteric artery Ht PE ‘Anomalies in relation to the vitefointestinal duct (see arrows). (A) Meckel's diverticulum; (8) Patent vitellointestinal duct; (C) ‘Umbiical sinus; (D) Cyst atached to the abdominal wall. A cyst may also be seen aitached to the gut. or embedded in the abdominal wall as shown in E’; (E) Stencsis of gut at the ste of attachment of duct: (F) Vitellointestinal duct represented by a fibrous cord, An umbilical growth arising from remnants of the duct is also shown Anterior Terminal ‘abdominal wal leum Blumbiicusstomach ble det be ck Ven i pencrene Dora presto i i cosa Venta panroatc poncretc oe Es a Duct vt bd ecasoy. nacscary nn pared, va ‘duct duct Ta ‘Anastomosis between Head- ‘Body Bie dct dorsal od vr! Unals rcess perce, Bleu ue of oral bud Maka pnsreate duct Development of pancreas: (A) Appearance of dorsal and ventral pancreatic buds before rotation of gut; (B) Rotation of ventral ‘and dorsal pancreatic buds with rotation of duodenal loop; (C and D) Shifting of ventral pancreatic bud to the left along with bile cuct; (E) Fusion of dorsal and ventral pancreatic buds 8. Umbilical polypAllantos Visicouretheal eansl Bladder \Nesonephris duct Primitive urethra Urogenital sinus Mesonephric duct Pelvic part of ‘urogenital sinus Qo Ed Prati par of urogenital snus Aand B: Subdivicions of the primitive urogenital sinus. Aleo see Figure 16.3 Mesonephios: Mesonephric Cloaca Metaneptros. Noptrogenic cord ‘A and B: (A) Lateral view of embryo showing pronephros, mesonephros and metanepiros; (B) The mesonephric duct ‘opening into the coaca and giving off the ureteric bud Nesorephre duct Glomeruus — Pronephric tubule i Pronepiros and part of mesonephros degenerate Excretory ‘mesoneptric tubule r Nephrogenic cord Mesonephric tubule Dorsal aorta Mesonephric duct Melanephric blastema Uretoric bud Cloacal tubarcie— 4 Common excretory duct Rectum ‘Some details of developing pronephros, mesonephros and metanephros. The pronephros and pronephric duct degenerate soon after formation, The proximal part of the mesonephros shows segmentation (In craniocaudal sequence). The ‘segments contain functional excretory tubules that dran into the mesonephric duct. Most of these tubules disappear by the time the metanephros forms the definitive kidneyKidney from intra-embryonic intermediate mesoderm nephric part or urogenital ridge pronephros > regresses early, non-functional mesonephros > functional, regresses metanephros > definite kidney duct from pronephros through mesonephros to urogenital sinus = mesonephric duct (Wolffian duct) mesonephric duct outpouching/metanephric diverticulum > ureteric bud > metanephros Urogenital system male: female: same origin as kidney, from from intra-embryonic intermediate mesoderm gonadal part of urogenital ridge migrating primordial germ cells enter and induce sex-specific differentiation = end of indifferent stage (germ cells originate from epiblast?) germ cells > spermatogonia / oocytes SRY (XY gene product), SOX9 crucial for development of testes mesonephrie duet > vas deferens > epididymis > seminal vesicle duct > regresses to prostratic utricle, appendix of the testes, ejaculatory duct mesonephrie mesenchyme > Leydig cells (make androgens!) making testosterone requires S-alpha reductase sex cords > sertoli cells (Muellerian inhibitory substance to suppress formation of femal genitalia!) + seminiferous tubules (spermatogenesis) gubernaculum guides descent of testes > gubernaculum > scrotal ligament genital tubercle / urogenital folds > penis > corpora cavernosa > corpus spongiosum s folds > serotum paramesoneph: labioserotal swel mesonephrie duet > regresses to Gartner’s c: paramesonephric duct > fallopian tubes > uterus > top of vagina (inf end of vagina develops from urogenital sinus (sinovaginel bulb)) - mesonephric mesenchyme > thecal cells (make corpuls lutcum to make progesterone but also androgens) - sex cords break up and condense around germ cells > primary follicles gubernaculum > round ligament of ovary and uterus genital tubercle > clitoris > corpus cavernosa > bulbospongiosum urethral folds > labia minora labioscrotal swellings > labia majora n wall of vaginaAllantois ‘Anal membrane Urogenital membrane | Vesicourethral canal Definitve urogenital snus Geritalsweling \ Piimitve urethral old _/ > tatim maus—/* Ugena membane Pia ty seal nanteane Urinary bladder Primitive urethra Polvic part of UGS hal part of UGS ‘Membranous urethra Peni urethra Development of urethra: (A) Primitive urogenital sinus (UGS) showing opening of mesonephric ducts; (B) Primtive UGS divided into vesicourethral canal and definitive UGS. Mesonephric ducts and ureters open separately at the junction of the two parts; (C) Vesicourethral canal subdvided into urinary bladder and primitive urethra, The definite urogental sus (UGS) divides into pelvic and phallic parts; (D) The female urethra is formed from the primitive urethra and irom part of the pelvic portion of UGS. The rest ofthe pelvic part of UGS forrrs the vestibule; (E) In the male, the prostatic urethra is formed in the same way as the femele urethra. The membranous urethrais derived from the pelvic part of UGS. The penile urethra is derived from the phallic part of UGS. Red circles = openings of mesonephric ducts and ureters. Biue = part derived from mesoderm, Green = ectoderm‘Embryonk structure Gubernaculum Urocenitalsinus Mailrian eminence nus tubercle) Phallis/gental tubercle Urageital fold Labioscroa swelings Indiferent gonad Primordiaigern cells Comtex—sexcods Medals Mesonephvi tubules Mesonephic (Wotfian) duct Paramesonephrc (Materiales Urinary bladder. Ureter ‘Opening of. ul Seminal vesicle ejaculatory ducts ce ‘Appendix of epididymis: Superior aberrent: Peradioymis uctules Epididyis Testis A Inferior aberrant ductules Male derwative CGubernaculum testis forts Descent Urinary bladder Urethra Prostate cand Bulbourethal lard Seminal olieubs Body andalans penis Corpora Cavernoss and corpus spongiosum Veal aspect of peris and penile raphe > Fypospadius Scretum and scrotal aphe Paroopheron (Female derivative Round igament of ovary and round ligament of uterus Urinary Bade Urethra Vagina Urea and paraurethal lands Geatervestbuler lands Hymen Body and olans of ltrs Latia minora Labia mar, mons pubis Testis Ovary Spematezos ow Seminferous| tubules Ovarian flies, (eparmategoni andSerto cll ete testis ete ova uci eferentes Epoophoran (003 effeentia Paddys Patoophoron ‘Appendix of Appendix f rary epididymis Epididyms Ductofepeorhoron Ducts deferens Becuatoy/ dues Seminal vesicle rete pis calyces and colectng toules ‘Append of testis Pratl cyst (rydoud of Moxgagn) Uterine ube Prostatic ticle ures Upper part of vagina Ducts deferens Urerine tube Uterus Ganners duct ‘Some structures derived from the mesonephric ducts. (A) In the male, these are the epididymis, the ductus deferens, the seminal vesicles and ejaculatory ducts. The appendix of the epididymis is a vestigial remnant; (B) In the female, most of the duct disappears, some remnants are seen as the epooghoron. For complete list of derivatives of the mesonephric ducts see textDue to an acquired weakness in the tranversalis fascia, Increased incidence with age, COPD. hernia protrudes directly through the weakness (Hesselbach’s Triangle), without traversing the inguinal canal. Due to a patent processus vaginalis; a congenital defect which allows for the hernia to traverse the inguinal canal & superficial ring going into the scrotum as an indirect inguinoscrotal hernia Congenital hernia By Vasinal nydrocete CCongental nydrocole —— Infantiehemia — [Ed interstitial hemia Bil Hydrocele of cond Infartile hydrocele ‘Anomalies of processus vaginalis Abnormal persistence of the processus vaginalis can lead to hemia (passage into it of abdominal contents, Indicated by arrows); or nydrocele (collecton of fluid, shown as dots). Vanous types of hemia and hhydrocele are shownCryptorchidism A congenital undescended testis is one that has failed to reach the bottom of the scrotum by 3 months of age. At birth up to 5% of boys will have an undescended testis, post natal descent occurs in most and by 3 months the incidence of cryptorchidism falls to 1-2%. In the vast majority of cases the cause of the maldescent is unknown. A proportion may be associated with other congenital defects including: Patent processus vaginalis Abnormal epididymis Cerebral palsy Mental retardation Wilms tumour Abdominal walll defects (e.g. gastroschisis, prune belly syndrome) Differential diagnosis These include retractile testes and, in the case of absent bilateral testes the possibility of intersex conditions. A retractile testis can be brought into the scrotum by the clinician and when released remains in the scrotum. If the examining clinician notes the testis to return rapidly into the inguinal canal when released then surgery is, probably indicated. Reasons for correction of cryptorchidism Reduce tisk of infertity ‘Allows the testes to be examined for testicular cancer Avoid testicular torsion Cosmetic appearance Males with undescended testis are 40 times as likely to develop testicular cancer (seminoma) as males without undescended testis The location of the undescended testis affects the relative risk of testicular cancer (50% intra-abdominal testes) Treatment + Orchidopexy at 6- 18 months of age. The operation usually consists of inguinal exploration, mobilisation of the testis and implantation into a dartos pouch. + Intra-abdominal testis should be evaluated laparoscopically and mobilised. Whether this Is a single stage or two stage procedure depends upon the exact location. After the age of 2 years in untreated individuals the Sertoli cells will degrade and those presenting late in teenage years may be better seived by orchidectomy than to try and salvage a non functioning testis with an increased risk of malignancy. This is due to an overactive cremasteric reflex & affects children. ‘The testis appears to Panera descended, but may be noticed within the scrotum after a warm bath. Treatment is becomes less retractile with age. The testis descends to an abnormal position after exiting the superficial inguinal ring. include the superficial inguinal pouch, perineum, root of penis & within the femoral canal. Det lniteea ti ing underscended testis prematurely stops its descent anywhere along the normal path of 1¢ gubmaculum. True Ectopic ‘Abdominal Prepenite ‘Superflat ‘ectopie scot! mauine! Perea!Spina bifida ‘Spondylolysis ‘Spondylolisthesis Craniorachischisis Completely open brain ‘and spina cord Spina vida occulta Non fusion of the vertebral arches during embryonic development Three categories; myelomeringocele, spina bifida occulta and meningocele Myelomeningocele is the mast severe type with associated neurological defects that may persist in spite of anatomical closure of the defect Up to 10% of the population may have spina bifida occulta, in this condition the skin and tissues (but not not bones) may develop over the distal cord. The site may be identifiable by a birth mark or hair patch The incidence of the condition is reduced by use of folic acid supplements during pregnancy Congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/ LS May be asymptomatic and affects up to 5% of the population ‘Spondylolysis is the commonest cause of spondylolisthesis in children ‘Asymptomatic cases do not require treatment This occurs when one vertebra Is displaced relative to its Immediate inferior vertebral body May occur as a result of stress fracture or spondyloiysis ‘Traumatic cases may show the classic ‘Scotty Dog’ appearance on plain films Treatment depends upon the extent of deformity and associated neurological symptoms, minor cases may be actively monitored. Individuals with racicular symptoms or signs will usually require spinal decompression and stabilisation a? é AL 4 x) q in ® Q VF AS. cy Open brain ar Occipital skull and spine defects with ‘extreme revoftenonolthe head of stl vat Meningocete IMyelomeningocete ‘Closed asyrptomatic ND inwhichsome Deficiency olat east two vertebral Protusion ofthe mennges|ledwith CSF) Gpen spina cord thevertebracarenotcompetelyclosed archessnerecovered with alipoma twougha deectiathe skull orspine—_(withameningea ys)‘Anencephaly Craniorachischisis Open spina bifida Iniencephaly Encephalocele Spondyleyss : | : staat ito Sones Pas ere Spondybisthesis ¢ifanation ne vee (Gres facture sd tat etd tan) sleig oferta)ciate (hems) Talipes Equinovarus ‘ Congenital talipes equinovarus. 4 Features: + Equinus of the hindfoot * Adduction and varus of the midfoot ry ) + High arch J j Most cases in developing countries. Incidence in UK is 1 per 1000 live births. It is more common in males and is bilateral in 50% cases. There is a strong familial link(1). It may also be associated with other developmental disorders such as Down's syndrome. Key anatomical deformities (2): Adducted and inverted calcaneus Wedge shaped cistal calcaneal articular surface Severe Tibio-talar plantar flexion Medial Talar neck inclination Displacement of the navicular bone (medially) Wedge shaped head of talus Displacement of the cuboid (medially) Management Conservative first, the Ponseti method is best described and gives comparable results to surgery. It consists of serial casting to mold the foot into correct shape. Following casting around 90% will requite a Achilles tenotomy. This is then followed by a phase of walking braces to maintain the correction. Surgical correction is reserved for those cases that fail to respond to conservative measures. The procedures involve multiple tenotomies and lengthening procedures. In patients who fail to respond surgically an Ilizarov frame reconstruction may be attempted and gives good resultsUpper Limb lorful eS by Reda HarbyBrachial Plexus iSense C5root > Dorsal Scapular nerve(RhomboidsMm&Levatorscapulae) , Phrenic nerve 5C6C7 roots > Long thoracic N. of bell ( Serratus anterior ) Upper Trunk > Suprascapular nerve (Inira/supraspinatuses ) , N. fo subclavins Lateral Cord > Laveral root of median nerve , laveral pectoral, musculocutaneous Medial Cord > Medial root of median nerve , Medial pectoral , Medial cutaneous n.arm , Medial cutaneous n.forearm , ULnar Posterior Cord > not ULNAR ; Upper & Lower Subscapular , N. to Latissimus dorsi , Axillary, Radialbbb: PP Waiter’s tip kLumpke's Lower roots Klawing (Erb-Duchenne Palsy) C5 & C6 inj Suprascapular nerve , N. to subclavius , Musculocutaneous , Axillary ‘Supraspinatus (abductor of the shoulder) infraspinatus (lateral rotator of the shoulder) Sub-clavius (depresses the clavicle) Biceps brachii (supinator of the forearm, flexor of the elbow, weak flexor of the shoulder) Brachialis (flexor of the elbow) Coracobrachialis (flexor of the shoulder) Deltoid (abductor of the shoulder) Teres minor (lateral rotator of the shoulder) Loss of sensation down the lateral side of the forearm. sctoralis major ernocostal part of the the forearm will be pronated because of loss of the Porter or waiter hinting for a tip (B (Klumpke's Palsy) C8 & T3 injury : Ulnar & Medi: inury Hand Clwing loss of Wrist Flexion (F ) Loss of sensation along the medial side arm , forearm, hand, and medial two fingers. (C8 & T1 ) RedaRecall &, : Lower lesions of the brachial plexus can also be produced by the presence of a cervical rib or malignant metastases from the lungs in the lower deep cervical lymph nodes. remember also superior sulcus ( pancoast tumor ) in the lung apex. aslo T1 carries sympathetics so its injury results in Horner syndrome ( ptosis, miosis, hemianhidrosis, enophthalmos).BRACHIAL PLEXUS ere ‘rain Suproctavicola Branches Dorsal scapular ‘om ‘tong race Aerio ramiot ¢5-C7 ‘Subetevian ‘Sper trun ecg fers tom C5 and C8 and often C4 Supraicpular Supra trunk recsing fbersFom 5 and C8 snd often C4 bnfracaviewar branches Lateral pectoral Lateralcord receiving fers ftom C5-C7 ‘useulocutsneots Lateral cord rcevng bers fron C5-C7 Mosien Lateralroot of medan neve is ternal branch ilar cor (65, C7; medal ot ot median ‘eve ia terminal ranch of mail cord (aT) ‘odil pectoral Nesta ord aceite from C8, 71 ‘Modi cutaneous Nodal ord acevg ets Nom 8,71 serveat art dia cutaneous Medal ord receiving fiber from 8,1 serve at forearm ear “arminal rach of mall cord oceing fore fom 6, Tt and often 7 ‘Upper subscapular anchof posterior crt receiving fers rom C5 Thoracodorsal —_Branchof posterior cord receiving fer ron Boe ower subscapular Branchof posterior cord receiving fers rom 06 seainy ‘Tarmina rach of psteror cod reeeng fers fom C5 and 06 fadlal ‘Taina branch of poster cad reeting fhers fom C510 71 ‘Arter ramus of C5 wit requentcontitutlon | Pires selenis meds, descends on deep sure of homboids| ‘Desends postr 008 an TY rami and pases - sition an auction of CNC ané MP jit of hur ost; sensory bss same as for mein nerve rr tbo and i deviate tall site ering oof west jot; ‘exon Dons of ing and te geist lion at MP ina extension at PP and DP ois of landing inger ‘est, adduction and auton of NP oof dts 25 ost ‘dducon ofan st sensors on paar an dal ‘spect fit nc medial hao rngfnges ‘Rexion at MP joint and extension at PP and DIP joints of litle 2nd rg ns os: ann nd attr of ins ot Gigits 2-5 lost; adduction of thumb Wost, sensory loss same as or ‘nar verve injury at elbow puta je, msc it PP ranted oh salto rt Merchighr sina dow lew clawing anenecty ronal oki elees ect opyntanced te ssi Rear ave Sonus puradoe thee telaion helene econ EDP which nd tu scl ein of 1P jens wth prevaticn fpr faving ‘est Pestngaganst a wal cases gg ot seapule “Bt Aluct shoul join to horzontel and ask fatiento hot postion aginst domward ul Writ on -asence of rum epesiion and of banascton “Bs Mike an "0° with hun and nd ger (aw handLate! Posterior § Cond of brachial pleaus ‘Medal Med brachial Medial anbrachial ‘anes ner Musevlocuaneoss neve ‘dominant neve ta anterior ompartment muscles of 300) Medan neve a (dominant nerve to ateror Anterior Compartment uses of forearm, thenar hand muscles) sal Radial nerve arene (posterior cutaneous {dominant newe t postion ewe of e compartment muscles ct ‘im aad Frese. Muscuincuanenus nene Matera cutaneous perv ol over Ula nerve ‘dominant nenve to ‘musles of hand fexor ‘epi lnasis, ant medial Radial nerve hal of exo digitorum ‘supericial brane). ‘refunds in forearm. Ulnar nerve TD Inserconebractial Radal neve tone gam Muscuscutineous nen teal taneous ‘erve offre) Radial nerve (stpericial branch Ulnar neve Median neve Uinnenates nail bad) Nerves of upperlimbiSenseAnterior (palmar) view Supraclavicular nerves (from cervical plesusC3, 4) spate aed rir aa brachial ctancous nerve (C5, 6 Rail nerve Inferior lateral [brachial cutaneous ewe (C5, 6) | ateral antl brachial colar Posterior (dorsal) view Serio elite (3,4) Radial newe Posterie brachial etanwenas nerve (C58) Inver atoral bevel Intercosto- cutaneous nerve brachial Posterior antebrachis nerve 72) ‘cutaneous nerve ‘ard metal (151 6-8), ceulaneous nerve erve IC5, 6(7) bom om musculocutaneous porve Medial Lateral aniebrachial cutaneous antebrrack nerve eutaneous (C5,517) from museulocutaneous (5,70) Ulnar nerve (C8, 7D) nerve) Radial neve Radial neve ial rane _— ss? ey ‘Superfctal branch Palmar Dorsal ranch ‘and dorsal ‘ranch anddorst tranches (Cos) Sigal nerves ‘Common Proper and palnar proper Sigtal palmar ranches Sigal Medan nerve Median nerve Palmar brarch Proper palmar and gla nerves ‘Cammon ard rope palmar ipa peo ‘Note: Dison variable between ulnar and alia {ora innervation on dorsum of hand and often aligns with ‘middle of 4th digit instead of 3rd digitas shown,ereron ato aia (trio part ero (nid part Spal patron part ‘A Posterior View SUPERFICIAL BACK AND DELTOID MUSCLES ‘SUPERFICIAL BACK (POSTERIOR AXIO-APPENDICULAR) AND DELTOID MUSCLES ‘apedius Bevaes, etc, and ote scapula pat : loves, rare pr wees, and asc a dereoee ’ scapula: dseendg andasoerding arta torn ‘Sip otalon of scapula Latissimus dorsi Sou nt Intertubercular sulcus Extends, adducts, and medially rotates shoulder joint; devates: vet, Boacoumber ical yoo of humors ody tarda duringcnting tovater srransese Sain Bova seapla ana its its old atin by rotating seapuiae of wapula capa ‘Rhomboid einor eremee ‘Medial beer of soap trem Fetract scapula and rotate it to depress glnoid cavity; ti snd major ao Jove of sine toner anda scam hraciwal tae ous “To vertebre ttle = an (einai (avert part teres and rely tates shuler ison pi: ses rie prt beets salir: sal cca ‘poster part extends and laterally rotates shouderjcintincsion Previous SIND scar Asillpryatery Aslan artery dod be tras minor muscle “Thorscororsl nene. Thoracedorsal artery Toraendorsl vein Long thoracic rene ata ane Axillary lymph node dissection. 4L.ND, /xilary lymph noce dissection; SLNB sentinel iymph node biopsy(B) Transverse section of thorax (Gid intercostal space level) ‘Anterosuperior view intercostal voins (C) Veins of mammary gland Anterior viewWhich of the following nerves supplies the skin on the palmar aspect of the thumb? Lateral cord of brachial plexus Musculocutaneous nerve y brachial plexus Biceps brachii Pronator teres Pronator teres. Flexor carpi radialis, Palmaris longus Flexor pollicis fongus Flexor digitorum superficialis Pronator quadratus Flexor digitorum profundus (lateral half to digits 2, 3) Thenar ee Lumbricals iia Innervation of arm: = Anterior compartment of arm |= Anterior compartment of forearm Musculocutaneous : Biceps Brachialis Partially Coracobrachialis then continues as Lateral cutaneous nerve of forearmA 10 year old boy is admitted to the emergency department following a fall. On examination, there is deformity and swelling of the forearm. The ability to flex the fingers of the affected limb is impaired. However, there is no sensory impairment. Imaging confirms a displaced forearm fracture. Which of the nerves listed below is likely to have been affected? oe ects eee eee Si5%e"Spconaviar ect ereslencereoie— oro Dial eee ea anaes ae Coe — ‘The anterior interosseous nerve is a branch of the median nerve that supplies the deep muscles on the front of the forearm, except the ulnar half of the flexor digitorum profundus. It accompanies the anterior interosseous artery along the anterior of the interosseous membrane of the forearm, in the interval between the flexor pollicis longus and flexor digitorum profundus, supplying the whole of the former and (most commonly) the radial half of the latter, and ending below in the pronator quadratus and wrist joint. innervates 2.5 muscles: + Flexor pollicis longus + Pronator quadratus + The radial half of flexor digitorum profundus (the lateral two out of the four tendons). ‘These muscles are in the deep level of the anterior compartment of the forearm. AIN Reda mnemos: AIN OKEY SIGN \Normal*ok'sign ‘Abnormal ‘pinch’ sign‘A.40 year old lady trips and falls through a glass door and sustains a severe laceration to her left arm, Amongst her injuries it is noticed that she has lost the ability to adduct the fingers of her left hand. Injury to which of the following nerves is most likely to account for her examination findings? Medial cord of brachial plexus Fromerts Sign (Add. Pl, nar) Flexor carpi ulnatis Flexor digitorum. profundus (medi half to digts 4, 5) Palmar Interosset Adductor. Palmaris brovie Hypothenar muscles Lumbricals to interossei 4 aia (©) Anterior view Ulnar nerve iSense Median nerve (c8-C8) Palmar culaneous nom branches: (C68) Ulnar nerve Uinar nerve ‘Mecian nerve (C8, T1) Radal nerve, Dorsal (cutaneous) spa test branch of ulnar brenen nerve (C8, T1) Medial cutaneous Radial nerve, nerve of forearm superficial branch Postarior cutaneous (C6-ca) nerve of forearm Lateral cutaneous nerve of forearm Anterior (palmar) viewsA.23 year old man is involved in a fight outside a nightclub and sustains a laceration to his right arm. On examination, he has lost extension of the fingers in his right hand. Which nerve injured Profunda brachii artery (Seep brachial artery Rodial nerve iSense iSense Radial nerve: Anatomical neck of humerus fracture Lower triangular spance ‘Mid shaft humerus fracture Lateral epicondyle fracture Drop (elbow , wrist, fingers ) First dorsal web space sensory loss Deep radial ( Posterior interosseous ) is motor deep in the muscles but Superficial radial is sensory goes to the skintiSense Rotator cuff muscles Subscapularis : leave the lesser tubercle to me &you SIT on the Greater one’ “Supraspinatus *Infraspinatus “Teres minor Greaier tubercle Intertubercular euleus ‘Supraspinatus Infraspinatus Gienoid cavity *Rotaior cuff muscles of scapula Teres minor " *Subscapulatic Left numerus Subscapularis (B) Right anterolateral view SCAPULOHUMERAL MUSCLES Mace = Fromalanaeime = tsatenmer ‘Supraspinatis(§) Supraspious asa scapula Sue aceon grater Mier {nates abaucto at shauler on ofhumeus wih tatoo meses Irraspinatus()_lntaspins ssa of cana Nile facet net tuterce of mis atraly rotates stuleonhelpto bod ‘Tees minor 1) Sper artollaterd bor of capuls nero facet ngredter tubercle of ‘urmeral eat in leno cay of scapula i ‘Subscapularis(S) — Subscanular fossa ‘Lesser tubercle of hemerus ‘Medial rotates shader joint and adducts it; fel hot humeral headin geno cay Teres majo? earns eet resto esser tuber (redial Ip a as Nevada nse, ficial gre) fumesorcs rok” Tyce tk Suparis cereal ry, airy aetory (eins tert to erga of 18) ‘hoacn-:romi at Dot ascending bean ota brah any (ep ary of am) Coal are ie racial aren, rach rerSubclavian Artery ‘The arterial supply to the upper limb begins as the subclavian artery. On the right, the subclavi from the brachiocephalic trunk. On the left, it branches directly from the arch of aorta. ‘The subclavian artery travels laterally towards the axilla. It can be divided into three parts based on its position relative to the anterior scalene muscle: artery arises, + First part -origin of the subclavian artery to the medial border of the anterior scalene. «Second part ~ posteriorto the anterior scalene. + Third part - lateral border of anterior scalene to the lateral border of the first rib. Subclavian Artery > VIT C & D Vertebral , Internal thoracic , Thyrocervical , Costocervical , Dorsal ‘Scapular [At the lateral border of the first rib, the subclavian artery enters the axilla ~ andis renamed the axillary artery. Axilla: Axillary Artery The axillary artery lies deep to the pectoralis minor and is enclosed in the axillary sheath (a fibrous layer that covers the artery and the three cords of the brachial plexus). Importantly, the artery can be divided into three parts based on its position relative to the pectoralis minor muscle: + First part - proximal to pectoralis minor > Superior thoracic artery + Second part — posterior to pectoralis minor > Thoracoacromial artery & Lateral thoracic artery + Third part distal to pectoralis minor > Subscapular artery & Anterior and posterior circumflex arteries The anterior and posterior circumflex humeral arteries form an anastomotic network around the surgical neck of the humerus and can be damaged in cases of fractur At the lower border of the teres major muscle, the axillary artery is renamed the brachial artery. Immediately distal to the teres major, the brachial artery gives rise to. the profunda brachii (deep artery), which travels with the radial nerve in the radial groove of the humerus and supplies structures in the posterior aspect of the upper arm (e.g. triceps brachii). The profunda brachii terminates by contributing to an anastomotic network around the elbow joint. The brachial artery proper descends down the arm, As it moves through the cubital fossa, underneath the bicipital aponeurosis, the brachial artery terminates by biurcating into the radial and ulnar arteries.Clavicular branch Pectoral branch Superior thoracic artery Anterior cicumilex humeral artery: Lateral thoracic artery Posteriarcitcumlex humeral artery Subseapular artory CCircumlex scapular Brachial artery x artery Thoracodorsal artery Profunda brechii (deep brachial artery Level ojlower marginof {eres major muscle is landmark for narme Radial collateral artery change rom axiary a Middle collateral artery Superior ular collateral artery Inferior ulnar collateral artery Radial recurrent artery Recurrent interosseous artery Posterior Anterior ulnar recurrent artery Interosseous artery Posterior ulnar recurrent artery Commoninterosseous artery Anterior interosseous artery Ulnar anery Superficial palmar branch of radial artery ‘Deep palmar arch Dorsal carpal arier Princes palicis artery oer Deep palmar branchof unar artery Palmar metacarpal arteries Palmar digital artery ‘Common palmar digital arteries Propes palmar digital arteriesiSense Hand Muscles Paina Views xitoo Palmar inerosse!(Adducton) MUSCLES OF HAND Muse |imise NNN ©«—« Reda iSense Medain vs Ulnar Fight: ‘atc pti bres Median nerve > All of the flexors in the forearm eee except FCU and medial half of FDP eppnens pots Adc potlss Ulnar nerve > all intrinsic hand muscles Except LOAF : L: Latoral two lumbricals. ‘Abcuctor ight mi Opponens pollicis. =— Abductor pollicis brevis. Flexor digiti minimi brevis F: Flexor pollicis brevis. pene igi inns Lumet 102 Lumb 3 nd 4 riers 1-4 Patarletrosse 1-2Fos(-4 iSense Carpal tunnel syndrome x» Common eo heath ct FDS ard FDP ‘Atrophy of thenar eminence, Sexor tendons thumb adductod and extendod 3 5 (F) Simian hana Copitate (D) Inferior view of transverse MAL of lett wrist‘Sense Sunff Box Extensor pollicis longus (EPL) tendon (A) Medial view of pronated hand Extensor pollicis brevis (EPB) tendon Anatomical snuff box Extensor retinaculum Superficial Site of styloid process of radius branch of Radial artery in anatomical snuff box radial nerve EPB tendon EPL tendon (B) Medial view of pronated hand trapezium bone Abductor pollicis longus’ —_Base of 1st metacarpal When the thumb is extended, a triangular hollow appears between the tendon of the extensor policis longus (EPL) medially and the tendons of the extensor pollicis brevis (EPB) and abductor policis longus (APL) laterally. B. The floor of the snuff box, formed by the scaphoid and trapezium bones Crossed by the radial artery as it passes diagonally from the anterior surface of the radius to the dorsal surface of the hand. Remember that the scaphoid is supplied bybranches from radial artery from distal part so it is subject to Avascular necrosis when fracturedIsense Various MRCS Notes Supaticia branch of aia Radley ‘Arteries are ahvays afraid so they hide internally Ulnar n. is Ulnar to the Ulnar a. Radial nis Radial to the Racial a Recurrent branch arises from the median nerve after passing from carpal tunner and supplies the thenar muscles Cubital Fossa: TAN Tendon Artery Neve Median nerve crosses the brachial aretery from Lateral then Anterior Medail LAMEnjoy Studying AnatomyLower Limb iSense Colorful Notes by Reda Harly ef\s vg https://m.facebook.com/MRCSMECourses/ /© 10 2 Te Tr 7 Ai ne ‘A. Anterior Vew B. Posterior View . Anterior View ‘Two different dermatome maps are commonly used. ‘A-and B, The dermatome pattern of the lower limb according to Foerster (1933 ) is preferred by many because of its correlation with clinical findings. This one will be used in MRCS. C.and D. The dermatome pattern of the lower limb according to Keegan and Garrett (1948 ) is preferred by others for its aesthetic uniformity and obvious correlation with development. Although depicted as distinct zones, adjacent dermatomes overlap considerably, except along the axial line.tera rotaton ‘pole Abduction, Lateral rotation orsiflexion Medial rotation Planuarflesion Extersion{ove of Homan Pain Numbness Weakness ‘roy Rofews , NX uu ! J Lower tac. ti, ss dacs pwatrltral igh Arteromedil ne je esac; | Seer ois ante Ks ar auaicps uadicps diinihed nerve oot a y og Changes oe » Dersifsion Moe lament or great dinnished snd os pasion diay tis sralkng on ! taper, tel ot seed eat | dap may Plantar ~~ 2 fod of iootane = seat - my be Sete dieu the. walking on . ack of al “h Ane jo wees swale | dined font and toe Gasrocne orate ‘Mtsacal c Bisacal rus ae tolews Leer back, Thighs Variable thighs, ees les nso Se srtlor feet andor | paresis of them paiva tas andor aybe tkpendng variable bowel and a nen of toy be er ison Biteal incon “” may be rence Ant jo ee diminhed bilateral ‘or absent iSense Dise Herniation Levels & rootsInercostal neve (T11) J I Anterior division Subeostal nerve (112) 4 } 1 Posterior division lliotypogastri: newe. ath yguinal nerve (L1) ‘To psoas major and Geritofemora nerve (LI, 2) femoral cutaneous 23) Gerital branch (L1) and: Femoral branch (L2) ‘To psoasmajor and iiacus muscles Anterior branches. Lumbosacral trunk: Nerve to quacratus femoris (and inferior sgemellus) muscles Superior gluteal ene (L#'5, SI) [Nowve to pirfarmis muscle (St, 2) Obturator nerve (12, 3,4) Accessory obturator nerve (13, 4 (inconsian Inferior gluteal nerve (U5, St, 2 Femoral nerve (2,3, 4 Sciatic nerve Fostenortemeral ’ ; s Ded cosy ge icles cctaneous newe St, 23) 7 Pudendal nerve ($2, 3,4) common < Anococeygeal nerves Psronea ene . Obtutator nerve Sciatic J (U4, 5,51, 2) Iniesior anal Tibial neve (rectal) nerve (U4,5,51,2,3) Posterice femoral Dorsal nerve of penisjclitris cutanecusnerve Perined nerve and posterierscrotal/posterior labial nervesInnervation of high: pair guteal 3 tteal Infor geal » | conpartnent Bi tree compariment Sciatic nerve (iat ‘andcommon tae) Bi Poser cmparnent Seritendnoss. ctr mages. oth Seninentranosis ices fers Postion compartment Deep fbuar peroneal nerve a i ofleg ‘upericil uee (peroneal ere ils teri | est) ates [Fos bron hee antment ‘tig | bus (peaneu. tere tensor tigtore | compartment lens eg Roars erones) tertus Tmeration of eg: Lelie I Aer compartment Bi tera compictmsn Bi Poster compartment | FXO" digitorum brevis] Giepadsokarfet, | Rovor halis bev lumal to 2nd agit ‘A.Anteior View B. Posterior View Reda Colorful iSense MOTOR INNERVATION OF LOWER LIMBiSense MOTOR INNERVATION OF LOWER LIMB ~ om nnn — Obturator {Lumber planss (22-14) Anterior branch: siducter ongus, adductor ie ay fete ot me — Sa sn wenn = =e mss of posteaeconpartnent lg, and oof foot Scie neve ‘commen fbr (prone) Shor head ire fener, muss of ator and Iter compartments ote and dorsum foot ‘Superficial ular peroneal) (Conman tut neve Deep fbutariperoteal) Muscles of anterior conpertent ofleg an dorsi of fotLata evanaas beach of ‘subset neve (712) Latnraetanous ‘are of gh, ster branehes oer etoneous branches of emo rave tara grou) ‘alee etanaass anes teal nerve (medal grasp) Paster cutaneous neve ‘ttn ‘ntopatel ranch st sepmacone ner tera suralcutanenus reve ‘rom amon bua novel Lata sur eatinoous ‘neve (om common ‘ular ere) Motil sal catanous nerve om bi nerve) ‘Sommunicang bancn ‘wpe fur (penne nerve coring dvsal gia serve dial caaneal tances il nere Lateal ool cueous nev of ‘ox termination of sual neve ep for ene A toon Wow toon ene Nedalpan B. Posterior View Reda Recalls: Nerves affected during Appendicectomy & Inguinal hernia repair surgery: orgie nerve near ASIS or meralgia paraesthetica Jataeral skin thigh numbness > lateral femoral cutaneous ‘The most common affected nerve , recurrent direct inguinal hernia or reduced sensation over medial side and root of penis and anteromedial side of scrotum > ilioinguinal ‘motor to the intemal oblique and transversusabdominal muscles > iliohypogastric leg weakness > femoralSubcostaln. (712) — m1 White and gray rami communicantes us iohypogaetien 2 Hoinguinale, Genittemoral Venta ramiof sonra cut U3 | spinal on. noth Gray mi communicantes Ls Muscular branches nn << mee Obvwrater Lumbosacral trunk ~ bs EERE Anterior division Poserior division (CUTANEOUS NERVES OF LOWER LIMB seve vga conseauagspina tos) eae otseatant sk of amar Suboatal ral culanenu bach) 12am rus aes era erst prion ina anti part tae ert ane ante to grater rochanlor’ ichypogastic Lurnbarpows(L1; oxasionay T12) (Paral ae Got Lateral ctareous ranch supp suerolaral ture of utock ional Lumbar pews LI; ozasionly T12) Passes through inguinal canal Ingural fo emo branch supliesskin cer medal anal tagle,...cermernber ental Lumbar pews LI-1) ‘Desoeasartenorsuroe of oes jor Femoral ran sips skin over itera part o femora tial; genital ranch supplies anterio serum ora mara Lateral cutneous neve of igh Lumbar lenus L2-L3 Passes deepto nga igament, 2-3 em medal Skin on anteso ant tater aspects of wigh tw ater super ic spine ote clans trances lunar pews via feral nerve (2-14) Ase in femoral angle pits fsck ata long Skin otanerer an most aspect of tigh tho path of etre muccla Cutaeous ranchofobtatorneve Lumbar pws va oiursor seve 2-L4 Following is destet between addutorslonows Skin o middle patof mil thoy and tres, oburor neve pices fascia iat to ‘ache sn of high Posteioecusneoisnene ofttioh Sara pleas (S1-S3, Ente otal reson via reir sciticfozmen Supply skin postr ih and ponte ssa deepto gus maximus; then desends ep ‘fascia ata eminal branches pier fascial Saphenous nerve Lumbar plewsvia feral vere L9-L Traverses adduct canal but does nc pass Sin on medal sie oles and hot ‘trough addctr hats ‘Supericia foular nerve (Conmon ar nerve (L4-S1) ‘Aer suppyng fiber misces,perrates deep Sno ater eg end dorsum toot ‘ascot ep Deep ular neve CConmonfbuar nerve 5) ‘Aer supplyng muses on dsm a fot, Sin of web betwen grat an 2nd toes ‘eros der fascln superior tohrasof fst and 2d metatarsals Sualnene “Tha anécomon flr reves $1-S2) Mes suralutaeous branch of til neve ard Skin of posterolateral leg and aera narginot fot Iatra’eralctanboue anc of common flr ‘nerve merge al vaying els n posterior ig Mil plantar nero Tia neve (L445) Passes beneen fist anc secand layers of ant Skin of medal sido soe, and olan aspect, smusees ‘a, nn be of mia 9 toe Later plantar nen “hia nev 51-52) ‘Passes beeen fist an second ayes of ant Stn o ated sole, and santa spect sides, and smusces ral beds of eral 3 toes Calatel neves “Thala sural nerves (1-52) ‘raneres or cakaneal uber Sin othe Superior cial neves LiL pester rat course laterally n subcutaneous issue Snover superar and onal pas of buttock Medi clu nenes 1-53 ptr rami From dorsal sacra orang enter eying Skin of mel butok ar intent cet subetangos tte Inferie linalneries Postarorcutansus rere ot ‘isa dept gla matinus emerge am Sin finer but (verjig gta fe) ‘hgh (S283) ‘beneath inferior baer of museiSense LL Nerve Lesions “rauma atfemora wale Pale racure trate nerve ‘eter ip astraton adcalreopubiprosatecemy ‘Supe gtealnewe Suny Pdr tp dean Polemyets Inari lta one Sucgery Posto tip dshestion [Common percnest new low to lateral apectctieg ‘Thialnereat pote! ssa Trauma at pple fossa sen of thigh is weakened Exorsion fg islost ‘Sensry os on antericthigh and mesial lg ‘auction o ths os Sensiy os on oda igh (luteus medus ard minimus function sot ‘Abo pul cotter plve up evel and ebducton of igh ro lost tutes maximus unc is st ‘Abit ori roma seated poston cm tars or inc, or mp slost Everson ooo est Darsiexionot cis lot Entarion ots 8st ‘Sense ns on anterolateral kg and dorsi fot Inversion tots weatoned Pana exon ofc ost Sensory ss on sol oot Toa eta Anestesla rn antocrbigh (ters meds ep or “wading gat” altho Tredolrury gn Paton wil an the ody rk backward athe tka Per il resent wit ot pra exed (oot op") sad inverted Part cant star on 10 "Foot sap” alr wil rest wth ot dersifines ar eves Pate ean sad on esLumbar ‘Sacral inguinal (i ‘Suparor gute nerva (L410 St) onypogaetic (1) ‘Sciatic nere (L4to $2) Gentoremoral 3,12 Inferior gluteal nerve (LS to $2) Femoral nerve (L2t0 La » Pudendl neve $2 10 $4) Tiialnewe 4-83 Common fibular nerve 82 ‘Suranerve Posterior rami (Lt to L3) Posterior rami ($1 to $3) From lumbar plexis Lstoral cutaneous nerve of thigh Obturatornerve + Antaor cutaneous + From sacral plexus nerves of thigh Posterior cutaneous ‘obturator nerve Femoral nerve nerve of thigh + Lateral clanecus of calf Common Peroneal nerve Saphenous nerve ‘Saphenous nerve Suprficial pernnoeal nerve ‘Sura nerve Sura rave Medial caleae deep perneal nerve Medial plantar nerve Lateral plantar nerveCuts maxis Tens ascie atae iaeus modus ne ririnus al uacatus eons Genet aut Prrfomis btuator intertue ana ema teu oe B. Posterolateral Views Apo (MUSCLES OF GLUTEAL REGION er vari ‘ptr ain hi tc se dei en ‘dal surface of sacrum zd cozy, cone o bse Fars 0 tal ‘aon, stead igh ané assis in ‘sacrobarus gant ‘ubeosty ‘sing Funk tom axed positon Globus resus Edema surface of lum between anteior Lateral surace prea trocanter of ‘and posterior tea nes; tea fasca femur ee ‘tes ps alten opostegst ee er 3 Sain nd aban poeta ‘aor el es atten Fae gut ean comes , bly tended ines Tewor facie Aerio supetor ie pit and ac cst oti Wat al ata ater IS tos TH condyle (ery tubercle of tea Piven Sur dee gear toh ot a Sokongan a = 5 utr wit ded pean Orrin picasa ntenenar e ear ere ‘Medal surface of greater trochanter of ee Sir emote ie tems by cmon eins bie aaa ety utoustenes Laerbuceret cal aesy ante uber on tercte Lary ats i ots cesta femurLateral ext cf thigh (12,13) Femoraln. (12, 13,14) Obuuratorn. acu Psoas major m. (lower par) Artcular brane Sartorius ms, (ext and weflerter Pectineusm. Anterior cutaneous ects femoris branches of femoral m.(euta reflected) vastus intermedius. Vastus media Vastus haerals Axticularis wens, Infapstellar branch of, ‘phen Medial cutaneous na. of Tegibranches ot saphenous) Tanevated by foal ere shown Cutaneous TnnenationLatoral compartment = Common nerve Superficial fibular n. ‘* Common action Plantar flexion and eversion Posterior compartment + Common nerve: Tibial n * Common action: Hip extension and knee flexio, _—skin ‘Superficial fascia Deep fascia Medial compartment * Common newe ‘Obturatorn. + Common action Hip acuction Antetior compartment ‘= Common nerve: Femoral * Common action: Knee extensio A Cross-section of thigh Posterior compartment * Common nerve: Tibial n * Common action: Piantar flexion and flexion of digit ‘Anterior compartment ‘© Common nerve: Deep fibular n * Common action: Dorsfiexion and inversio B Cross-section of leg Cross-section ofthe thigh (A) and leg (B)Giveus maximus rors Superix genes btuator teas infer gemes biti vat uadrats fears Addr magnus 1 semitendinosus Seminemtranosis ‘scops femais ‘hex need Biceps f> Senimanbraraei femoris Lang head Posteri Views: (MUSCLES OF POSTERIOR THIGH (HAMSTRING) Somiteinasus ‘Mafalsurtace of sus prt of ia xin hip inte nes nt and folate mci; when ip ane ne Joints ae fed, can extend tuk ‘Semiembranosus Posteo gto medal conde oui Ee) ‘ck tachment fms oblique pple ‘igament io aera feral conte Biceps femoris Long he: ischial bert, Lala sie of bead ou tendon i sot at Flxes knee joint and rotates it this ste by four colateraligament of nee lateraly;exends tp jit (e.g. when ‘Sot ead nea aspera and inating a wali gat) lateral supracondyar lin of fru ‘obtusa ntre ‘anggemat Lateral Hip Rotators : P-GO GO - Q: f Piriformis Gemellus superior Obturator internus Gemellus inferior Obturator externus Quadratus femoris : irein Pos minor soas major tiaeus Tiogectinest sh psoas ‘tori Views ‘ansr asian ate sartrus Rectustemats Wists eis Lines aspera stutter E. iopsoas. F. and (3. Attachments of anterior muscles of thigh. H. Posterior attachment of vastus medialis and lateralis. [MUSCLES OF ANTERIOR THIGH opsoas Poms maor Later aspects of 172-5 verre an ‘iscs; rans rests of bar veretrae acs ac est, ac fsa, alo sacrum and ‘ner eave gamete “Tensor fascia ise Antero super ae spn andar part ofl erest Sarvs ‘ler supra spe an super part ‘of noth inferior tot (uadricens femoris ecu fenoris Aes infra pre andium super ‘oaceabulim Vocus abrals Greate troctante and ietera ip of nea sper o femur sus meas Intertochase ne and medal ip of ie ‘aspera of enor asus inemecios Antrrand trl suranesofbody of frur a Flexes and stabilizes" hip joint | = ot maemo ene ag enn Bac pate and by pail tpament to bialtubersty, cial and irl Edens kee jit rectus femaris ao ‘nat alo atch fo Sn are patella via leads pean hes ays ‘eaneseses je (mesial and Istoral patellar retinacula) eaeosc tasers: Dy Pecos Aatuckrrovs Sais Ti omcrongs | aucermagus cota ene A. Overview of attachments. B, Pectineus, adductor longus, and gracilis. C, Adductor brevis. D. Adductor magnus, [MUSCLES OF MEDIAL THIGH Posthewe ‘Adductorengus Body ofpubis infra to pubic crest ‘Adductr evs Body ofpubisan iro ube mus Poca of omur at init ever -Aactoand foaahipot: srocharter ‘ass wih medal reion of hip int ‘Mid thr of linea aspera of femur ae ‘Addu joint Pectneal ie anproxnal pat of nea ‘Adachi jontan, to some aspem of femur centent lees it ‘Addi nagmus nein pubic amus.ramus of cium lel tuerosiy, nes aspera, med ‘Adachi oot ts actu (asduct pat and shiltuberesty ——suprzondar re (auto part, and paraiso fees poi, ands ‘star erleo femur at pet hating pat etendsit Gras ‘ody ofpubisand inferior pubic amus Super pat of mesa surtace of tia ‘Acoso exes knee Joint and telps tate medaly Dbiuator ems Margins of abratorforamenancobtuntor Trctaner oss of femur Lately tates hip jan: —— seasies fea of femur in‘Tranevereintermuseular septum Postriorntrmisculer sptum of log la Down asa of as sstoro teri ntermuscular septum of ep Interossenve membrane Anterior cmparimentot lg (A) AnterosuperorVew Dap asia gat, seamen ie pete Bese Dep facia landed with atau ofan Investing asia Popliteus Flexor hallue’s longus Flexor digital lorgus Tibialis posterior ‘Anterior Compartment Deep peroneal n. : Superficial Tibial n. Posterior compartment Deep Posterior compartment Lateral compartment sueetial paroreal Tibialis anterior Anterior tibial artery Extensor digitorum longus Extensor hallucis longus Peroneus tertius Posterior tibial artery Gastrocnemius Soleus Plantaris Popliteus Flexor hallucis longus Flexor digitalis longus Tibialis posterior Peroneus longus Peroneal artery Peroneus brevisQvatices femors (a ptoarigament Neck of ut samtosdinasis uae (pereneus| brevis THB Pena muse atactnent TBE ott scat atte TBE somerus atschnent sal maleoks us caleou. ois Naver Fears pra ans ‘Fibulars (peroneus) tertus —— a tbr Fron 5) enc alc tes Prats ia bn roa phan Extensor digitorum longus: ‘Eteasr hllucs longus, -— Distal phalanx a Nmoneror ane otsioeviws (MUSCLES OF ANTERIOR COMPARTMENT OF LEG ‘Tibals arterior Lateral condyle and super hao ital Medan fr suraces of medi Dorsiiees ankle ont nd imerts sufaceot ta ‘anefrm ad as of fit metatarsal foot Estansor talus longus Mil pat oanteixsuace of buleané Dos aspect of bse of stl phalanx of ‘tends grt te and corsieres eee atone ‘reative lx) nk joint Eins digitorum Literal sandy of tia an super the outs Midland distal shalanges oat ‘tends ara os gts and — tantra suace ofintersseous membrane fur digs orstlexes arkejint Faris beronus) _lferothid o anteror suave of fibua and Dorsum of tase oft meats Dorsitexes anoint nd acs Interosseus membrane tert in everson of footCommon our Dosp fear (peraneat) nerve (peronea) nerve Supercar (Poraneat) nerve Talis artrior outa (pens) bogus Extensor baluc longus Fula (pens) ‘revs — ssteoor strum longus ute porous) ‘ertus ‘COMMON, SUPERFICIAL, AND DEEP FIBULAR (PERONEAL) NERVES Petorato rach of ‘(pore artery. Ineo exensor retnam (cut ard retracted, peri (cutana retract) a ——~— Conmon feroneal Sciienerve Forms asscatienere frets atthe apex of poplin fssandolows Skin os ater partof posterior spect of le via the later ura medal Dodero cep lemons; ws ard ecko ula, cng nto cutanens nerve; tera spect ot kee J wa is ular ‘super cial and dep bute rves ‘Supt Peronesl_ Connon Deep Peroneal Connon ‘ses deep to fularis longs and escesds in ateral compartment of ular nane HP eres cr fasoa a doa soe o boca clone branch Ful lngus an brew and shin on ist thi of antler furac of ane dorsum ot fot ‘ss dee ofularis longus: pastes tough eters iginrumlongus, _Antere muscles lg, dorsum of fot, ané skin o retinal ular nane S206 roses emer an canines on doeu fot le drsal spe of rts crossed vt ere ranches(MUSCLES OF LATERAL COMPARTMENT OF LEG Fularisperoneus) longus Head an superior wo this of Base offirst metatarsal an medal cuneiform tral eurace of bla Fouls porous brevis err wo this ofateral_ Dsl surface of uterosiy on aera sd of ssrface ota ‘bis oth mata.Fula Fee digitorum. longus (MUSCLES OF POSTERIOR COMPARTMENT OF LEG ‘Superficial muses Gasroenenis tera hea tera aspect of itera Prana aes ankle ort when knee int ‘any of emu Is eendet raises el curing waling, and teres ee pint. Medal head opie surace of ‘emu, superar to medial onde Solas Poster aspect of head of bus, Paeteicurtce of cleaous ve Prana ees anklet dependent of ‘super fou of poster suace of Saeanen tendon (endooneanes) knee poston and states lyon fot ‘le elie a meal bode of baa Plartais beri end ater supraconyar ‘Waly assists gistocnemis in plar {ne femur and ebiqu opie, "exng ako and xing ee ink Famer ‘Deep muscles Popes Lateral sro of tral condyle of Paster surtce of hia serio o ‘mura eral enscas seal ine Fleortaluciskngus feo two tds of postr suace Base ofcistal phalanx of eat to Fens gat oe a al jis and pin- ‘bua andineris part inteos- alt) ‘ar flets ankle pint sppors medal ‘sous memtrane longtuina arto ot Floor digtonmiongus Medialpart postriosuacaot Bases dit phaungs of tral Fees Intra fur isan plantar iain soe le. and ty a four dgts exes anklet suppts longi road endo to Fla ‘Til posterior btoreseousmemtane,postror Taberosty of naviear,cunelor, and ‘sarface of ta infortosoleline bold and bees of metatarsals 2-4 and posterior surface of foulArteries of Lower Limb Anery of round ‘of femoral head ——Necratized bone Disruption of blood supply Blood supplied to femal head mainly via mei Creu lemora artery. Branches eavense femoral neck and enay be ton by acre, result Inostennecrns ot heat, (Dsshedline eles oral fame ed) femoral artery Func lermrs 2r8ty tery igament of head of omar Grater ocinter Medial and lateral circumflex femoral arteries in femoral triangle ‘The ligament of the head of the femur usually contains the artery of the ligament of the head of the femur, ( teres ) abranch of the obturator artery. The artery enters the head of the femur only when the center of the ossification has extended to the pit (fovea ) for the ligament of the head (12th to L4th year ) ‘When present, this anastomosis persists even in advanced age; however, in 20% of persons, it is never established. Fractures of the femoral neck often disrupt the blood supply to the head of the femur. ‘The medial circumflex femoral artery supplies most of the blood to the head and neck of the femur and is often torn when the femoral neck is fractured, In some cases, the blood supplied by the artery of the ligament of the head mey be the only blood received by the proximal fragment of the femoral head, which may be inadequate. Ifthe blood vessels are ruptured, the fragment of bone may receive no blood and undergo AVN(evra extonus. Medal] Orcumtex Pectneus Lateral] taries Ferra tory. Adicts nous ieus naximes Profunda enor * onidate ‘atery (oop extoy ‘anastomosis Mos an eral ‘super evicuar arenes Sipe snc: superor bus maximus Deep tranch. run between gluteus mei nd nim, spying both an enor esciaeatae fer glutexs macmus, obturator ines, ‘ose fenorisané sper part han sting muscles No srectresn geal region (upp exer tenia and musces in pernea regin) amsting mace n posterior compartment posteoxporian of vas laters in anterer ompartmen femur (via femoral nutrent are ls); renfore artealsuplyof scat nerve “Antrrpartof gal reyon Suppes most oa! to ead ant neck of en; hip regon‘decor iatus Sopa weal ‘areata rere moat ‘etilar Posteri iat Nedial ants ‘A Posterior ow escarding ranch fom iar enor curtain Desrening ‘gencular Popiteal Supe tral Superior medi gencular sect Ine tate pnicuar nrior mesial wicate -Aeteir ia recent Ante bil eatiog banc ot ular pro tral atl Moca mata Dorsal pedis eich (dors sean of ot) Nei tr B. nore ViewFemoral artery Adtuctor hiatus Superior tara Super mec ‘ooneur ov Popiiteal Infor itera! Infotor modi ‘genicutr —= Anterior tibial Posterior tibia Fibular (peronea Perforating bane Medial panta. Lateral plantar (A Posterior view ftom lateral femora ocreiog omic eum any Superior medial poncular ‘Superoateral- genieuee Infosior mac! gencular Inferior tera sgonicuer etorating branch of fila (peroneal) Lateral malta Lateral rsa (©) Anterior viewArteries of Lower Limb Femoral Artery It is a continuation of the external iliac artery at MIP In the femoral triangle, the profunda femoris artery arises from the posterolateral aspect of the femoral artery. It travels posteriorly and distally, giving off three main branches: Perforating branches Lateral femoral circumflex artery Medial femoral circumflex artery CFA , DFA, SFA After ex 1g the femoral triangle, the femoral artery continues down the anterior surface of the thigh, via atunnel known as the adductor canal. ‘The adductor canal ends at an opening in the adductor magnus, called adductor hiatus. The femoral artery moves through this opening, and enters the posterior compartment of the thigh, proximal to the knee, The femoral artery is now known as Popliteal artery. Popliteal artery descends down the posterior thigh, giving rise to genicular branches that supply the knee joint. It moves through the popliteal fossa, exiting between the gastrocnemius and popliteus muscles. At the lower border of the popliteus, the popliteal artery terminates by dividing into Anterior tibial artery & ‘Tibioperoneal trunk ; bifurcates into Posterior tibial artery & Peroneal artery : Posterior tibial artery - continues inferiorly, along the surface of the deep posterior leg muscles. Itenters the sole of the foot via the tarsal tunnel, accompanying the tibial nerve Fibular (peroneal) artery ~ descends posteriorly to the fibula, within the posterior compartment of the leg. It gives rise to perforating branches, which penetrate the intermuscular septum to supply muscles in the lateral compartment of the leg. Anterior tibial artery, passes anteriorly between the tibia and fibula, through a gap in the interosseous membrane. It then moves inferiorly down the leg, Itruns down the entire length of the leg, and into the foot, where it becomes Dorsalis pedis artery its pulse palpated lateral to EHL tendonBoundaries ofthe popliteal fossa Popliteal Fossa Laterally _Bleape femeris above, lateral head of gastrocnemius and plantaris below Medially __Semimembranosus and semitendinosus above, medial head of gastrocnemius below Floor Popliteal surface of the femur, posterior ligament of knee jointand poplteus muscle Roof Superficial and deep fascia Contents From Superficial to deep & Fram Lateral to Medial NVA + Spices Common peroneal nerve Tibial nerve Poplteal vein Popliteal artery Lymph nodes Pop. LNS Small saphenous vein Posterior cutaneous nerve of the thigh Genicular branch of the obturator nerve Detaled anatomy The tibial nerve lies superior to the vessels in the inferior aspect of the pogliteal 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, That's why itis dificult to be auscultated Biceps femoris muscle Posterior cutaneous ‘Semimembranosus muscle (short head) nerve of thigh ‘Adductor magnus muscle Femoral vein Sciatic neve Linea aspera Femoral artery Biceps femoris muscle (long head) Adductor hiatus Popliteal fossa Plantaris muscle fibular nerve Medial head of Lateral head of gastrocnemius gastrocnemius muscle ‘small saphenous Popliteus muscle ‘Small saphenous vei Posterior cutaneous nerve of thighFemoral Triangle Boundaries Superiorly Literally Medially Floor Inguinal ligament Sartorius Adductor longus lliopsoas, pectineus and adductor longus Poof © Fascia lata ane superficial fascia * Superficial inguinal lymoh nodes (palpable below the inguinal ligament) ® Long saphenous vein Contents Femoral vein (medial to lateral) + Great saphenous vein Femoral artery-pulse palpated at MIP Femoral narve + Lateral femoral cutaneous nerve of the thigh + Surface projections ofthe femoral triangle region. AdL, fadductor longus; FeA,fernoral artery FN femoral ner Femoral branch of the genitofemoral nerve FY, femoral veins Ip, iopsoas; Pe, pectineus; Sar, sartorius, Deep and superficial inguinal lymph nodes Adductor "Hunter's" Canal Hunter's canal, also known as the subsartorial or adductor canal, runs from the apex of the femoral triangle to popliteal fossa, ‘Arloor superior tic sine Boundaries Inquire igament laterally Vastus medialis muscle Femoral newe Posterionly ‘Adducter lorgus, adductor magnus sont Roof Sartorius pe Contents Pubic tubercle apex Saphenous nerve femora triangle Superficial femoral artery Femoral vein G.amerir view -Aaducter canal Nerve to vastus medialis,Pecrere Origin Insertion capsule “i Tal artariorttcler Ps esa aL Anterior colliculus of medial cer sos Rae 2 |e amin FJ osterior store (den) | Posteomeulsf medal Medial alus& mesial tubercle ==s Anterior eer ESE EEE vee Posterior tlfbuar EEG Transvesely to talus posterioy calsneolar Tere st ORS EIST Posterior tibitalar part Tibiocalcaneal part \\ Feta ‘Medal igament of ankle “this jont (delioid garment) Tibionavcuar part Anietiortbiotalar part A of calcaneus bone Prartarcaleaneonavicula ligament Fibula Tibia Aterirtalofbularligament Matlotar fossa Posterior talofibuarigament CCaleancofibuar ligament (A) Medial and (B) lateral views ofthe right ankle joint. Reda Recall : Eversion injury ( VaL.gus force ) > Detoid parts while Inversion injury ( varus force )> LCL partsTom fibore of anterior taloibular Igament Injury to the anterior talofibular ligament due to excessive inversion with plantarflexion is the most common ankle injury The second most common ankle injury occurs at the calcaneofibular ligament and results in anterolateral rotary instability of the ankle joint. Fractured fibula Tom posterior ular ligament Lateral matieotus Medial. (deltoid) ligament ligament Pott fracture-disiocation of ankleReda Harby iSense Cartootinzed mnemonics Structures passing behind the medial malleolus : Deep to flexor retinaculum (Posteromedially) ‘Tom Does Very Nice Hacks from behind jerry ( posterior ) Tendon of flexor digitorum longus Posterior Tendon of tial artery bias posterior Flexor Digitorum longus tendon Posterior tibial Vessels Posterior tibial Nerve Flexor Hallucis longus tendon Tibial nerve — Pulse of posttibial artery midway between hee ‘and medial maleous, Ca, calcaneus; FDLT, flexor digitorum longus tendon; FHLT, flexor hellucis longus tendon MMa, medial malleolus; PTA, posterior tibial artery; TAT, tibialis anterior tendon; TiPT, tibialis Posterior tendon; TN, tibial nerve. Structures deep to extensor retinaculum (Anterior): #, Ge WW Tom Has Very Nice Dog & Pig infront of him ( anterior ) Tibialis anterior sari arr gine Extensor Hallucis longus : sae wie Anterior tibial Vessels iis longus (5) Tibial Nerve Extensor Extensor hallucis brevis Digitorum longus maa = Extensor digitorum longus (8) Peroneus tertius extonsor Fulani totus (6) (©) Superolateral view Extensor digitorum brevis (3)ETI Caleaneus, Talus, Navicular 3cuneiform 3medial metatarsals Ligaments Interosseus igaments Plantar aponeurosis Long planter ligament Deltoid and spring ligaments Muscles Tibialis anterior & posterior Short muscles of the bg toe Navcular Talus. — (A) Medial longitudinal arch (medial view) Tendon a tbiais posterior Media! —— mermesiate | Cuneitoen bones aera cuboid (©) Transverse arch (anterior view) Tibialis posterior Tibialis anterior Flexor hallucis longus ibularis longus: Dynamic support Intrinsic plantar Passive supporty (1) Plantar aponeurosis Ligaments Interosseus ligaments Muscles Peroneus longus Transverse head of adductor hallucis Lateral cunetterm 5th metatarsal (8) Lateral longitudinal arch (lateral view) Medial longitudinal arch (dark) ‘Lateral longitudinal arch (ight) (©) Superior view ‘The ealeaneus is commen {both engitusinal arches Calcaneal tendon calcaneonavicular ligament (4) Long plantar igament (2) Short plantar ligament (3) (E) Medial longitudinal arch (medial view)ASIS of the pelvis Mid-inguinal point Femoral pulse hallucis longus Midpoint of the inguinal ligament Deep linguinal Ring is just above this point Pubic tubercle 0 EHL tendo! Pubic symphysis Tong Sphenous vein surgery associated with Saphenous nerve in Shoxt Sphenous vein surgery associated with Sural nerve injuryAbductors of thigh Active Paralyzed (A) (B) Posterior views (c) When a person who has suffered a lesion of the superior gluteal nerve is asked to stand on one leg, the pelvis on the unsupported side descends , indicating that the gluteus medius and minimus on the supported side are weak or nonfunctional (+veTrendelenburg test ) Other causes of this sign include fracture of the greater trochanter (the distal attachment of gluteus medius) and dislocation of the hip joint. When the pelvis descends on the unsupported side, the lower limb becomes, in effect, too long and does not clear the ground when the foot is brought forward in the swing phase of walking. To compensate, the individual leans away from the unsupported side, raising the pelvis to allow adequate room for the foot to clear the ground as it swings forward. This results in a characteristic ‘waddling’ or gluteal galt. Other ways to compensate is to lift the foot higher as it is brought forward, resulting in the so-called steppage gaitEnjoy Studying Anatomy by Reda HarbyLocation Sphenoid bone Temporal bone _ Occipital Tectorial membranes & Apical ligament of the dens ense Foramina by Reda Harby "tic ganglion " eeessory meningeal artery | (Mandibularnerve of Trigeminal —_—esser petrosal nerve _ missary vein Middle meningeal artery MINA ‘Meningeal branch of the Mandibular nerve IWIN) ICA (passes along its superior surface ; does not traverse it) Nerve of the pterygoid canal (Vidiann.) (deep petrosalvsupeicialgreetrpetrosal) Artery of the pterygoid canal Optic nerve + 3 layers of dura - infection of meningesis seen as papilledema Ophthalmic artery (end artery) ‘Sympathetic nerves Frontal, Lacrimal, Nasocllary branches of ophthalmic nerve. Superior & inferior civisions of oculomotor & Trochlear & Abducens Superior Inferior ophthalmic veins "Sympathetic plexus around ICA Deep petrosal nerve Internal carotid artery Emissary veins ‘Anterior: inferior petrosal sinus Intermediate: glossopharyngeal, vagus, and accessory nerves. (9, 10,11) Posterior: sigmoid sinus (becoming the internal jugular vein) and some meningeal branches from the occipital and ascending pharyngeel arteries. Stylomastold artery Facial nerve Vertebral & Ant. & Post. Spinal Arteries Spinal root of Accessory n. & Lower end of medulla oblongataiSense Foramina by Reda Harby Superior orbital fissure : Frontal , lacrimal , Nasociliary branches of ophthalmic nerve Superior & inferior divisions of oculomotor & Trochlear & Abducens Superior & Inferior ophthalmic veins Optic Canal : Optic nerve + 3 layers of dura Ophthalmic artery Sympathetic nerves Foramen Rotund : Maxillary nerve Rx Foramen OVALE : Otic Ganglion \V3 Mandibular branch of Trigeminal V Accessory meningeal artery Lesser Petrosal Nerve Emissiary Veins Foramen Spinosum : Middle Meningeal artery MMA Meningeal branch of Mandibular nerve MMN Foramen Lace" ICA (passes along its superior surface ; does not traverse| Nerve of the pterygoid -anal (Vidian n.) - (DP+ScP) Artery of the pterygoid canal Jugular Foramen : glossopharyngeal, vagus, and accessory (9, 10,11) nerves inferior petrosal sinus unites with sigmoid sinus (becoming the internal jugular vein) Hypoglossal canal : Hypoglossal nerve Foramen Magnum : Vertebral & Ant. & Post. Spinal Arteries Spinal root of Accessory & Lower end of medulla oblongata ‘Tectorial membranes & Apical ligament of the densiSense Foramina by Reda Harby Foramen cecum — ciao Foramina of cibeform plate: --—-Ojfactory nerves (CN) Emissary vein to superior sagittal sinus ‘Antericr ethmoidal artery, vein, and newe Posterior ethmoidal foramen --—~ Posterior ethnoidal atery, vein, and nerve ‘Optic nerve (CN tard its dura Ophthalmic artery, sympathetic nerves ‘Frontal, Lacrimal Nasociliary branches ofophihalmic n Superior & inferior divisions of oculomotor 4 Trochlosr &eAbducens Superior & lafetior ophthalmic veins Foraamen eotundur = Maxi nerve (CN V2) Spphenoiial emissary foramen (of Vesaus) Gneonstant) (Otic ganglion , V3, Acessory Meningeal artery Lesser petroml nove, Hrniiary veins Forsmen ovALE-~ (Middle meningeal artery NMA. a Meningeal branch of the Mandibular none MAIN plerjgod cana, CA :psssesoverit not traversing ={ seats pls aud eral aos atey. pt nerve msn ioe Leszor pene nerve Greater petcesl nerve Face rrvs(CN ih Vostbulacachlear nerve (CN Vii) abyrinhine artery ndolymphetic dict Emissay ven Gassopharyoga ages aecesory9, 10,11 inferior petrosal sinus and sigmoid sinus {I]V) _meningsal branches from the occipita and ascending pharyngeal arteries. { Hypoglossal nerve (CN X11) \Condylarcanal(inconstant) ~ Vertebral & An. & Post. Spinal Arteries Spal ot of Acs Lower end ofmedala {storia membranes Api ligament of fhe dens