LMB

IMBBS
S AYear
ND BOne
ACK

LIVING ANATOMY
Surface, Radiological and
Clinical Anatomy

STAFF COPY
Name: …………………….
Group: …………………….
 MB BS Living Anatomy
(Surface, Radiological and Clinical Anatomy)

Practical Anatomy in the Living Subject

Upper Limb

Each group should nominate a willing subject who should strip to the waist. If possible, there
should be more than one volunteer. Suitable drawing materials, which will easily wash off,
are provided, although these are not essential.

BONY LANDMARKS

The clavicle lies immediately deep to the deep fascia between the neck and the front of the
chest and can be both felt and seen. It extends from the top of the shoulder to the upper end of
the sternum. Draw your finger along it from one end to the other. Note that in its medial two
thirds it is curved with its convexity forwards to give room for the passage of vessels and
nerves between the neck and the axilla. (This is seen as the supraclavicular fossa). The medial
end of the clavicle articulates with the superior surface of the sternum and projects above it
producing a prominence that is easily felt. Elevate the scapula - i.e. the model should shrug his
shoulder. Notice the movement which occurs at this joint. The model should now circumduct
his upper limb. Notice how much movement occurs at this joint.

1. Recall what type of joint this is; does it have any special features? (The
sternoclavicular joint)

Synovial, some describe it as a ball and socket joint, others a saddle joint.
It has an articular disc.

Below the junction of the lateral and intermediate thirds of the clavicle there is a depression
called the infraclavicular fossa. In this fossa about 2 cm below the clavicle press your finger
laterally under the deltoid. The tip of the coracoid process of the scapula produces the
indistinct resistance. Do not confuse this with the lesser tubercle of the humerus, which lies
just lateral to it. To distinguish between them once you have found the bony prominence, ask
the model to rotate his arm. The coracoid process will not move whereas the humerus will be
felt moving under the palpating fingers. The lateral end of the clavicle articulates with the
medial margin of acromion of the scapula (the subcutaneous flattened piece of bone about 2.5
cm wide that lies on top of the shoulder). The upper surface of the acromion and clavicle lie in
nearly the same plane. The acromioclavicular joint is therefore inconspicuous but it can be
detected easily if the limb is moved.

The scapula is obliquely placed at a tangent to the posterolateral part of the upper thorax
covering parts of the second to seventh ribs, and although it is thickly covered with muscle a
great part of its outline can be made out. Find the acromion at the top of the shoulder. Draw a
line along the crest of the spine of the scapula, the long ridge that runs in a medial direction
and slightly downwards from the acromion border of the scapula. Palpate the medial border
through the muscle that covers it and trace it to the upper and lower angles of the scapula. The
upper angle overlies the second rib. The lower angle much more easily felt than the upper,
usually overlies the seventh rib. Draw in the lower angle. Thus the rib felt inferior to the

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 MB BS Living Anatomy
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scapula is usually the eighth rib and the lower ribs can be counted from it.

The scapula is very moveable. When the arm hangs loosely by the side, the medial border is
about 3-5 cms from the midline. When the arms are folded across the chest (protraction of the
scapula) the scapulae are drawn apart and their medial borders are 10-12 cms from the
midline. When the scapulae are retracted, (bracing the shoulders) they approximate about 3
cms from each other. Elevate the upper limb above the head by abducting the humerus
through 1800. Note that the inferior angle moves laterally and the medial border now makes an
angle of about 450 with the vertical. This movement of the scapula is called either lateral
rotation (with reference to the inferior angle) or upward rotation (with reference to the glenoid
cavity).

Place the fingers on the lateral side of the arm just below the acromion and rotate the arm. The
upper end of the humerus is felt moving under cover of the deltoid muscle; the part felt is the
greater tubercle. The lesser tubercle is felt on the front. The intertubercular sulcus can also be
felt.

2. What lies in this groove?

Tendon of the long head of biceps

Follow the shaft downwards until, as the elbow is approached, the humerus widens from side
to side and acquires fairly sharp margins, the lateral and medial supracondylar ridges. The
lateral ridge is the more outstanding and more easily felt. The projecting ends of the ridges
are the epicondyles of the humerus. The lateral epicondyle is not prominent but is easily felt in
the upper part of a shallow depression at the back of the limb. The medial epicondyle is very
prominent. It can be seen as well as felt.

The ulnar nerve passes behind the medial epicondyle and can be rolled between the finger and
the bone. This is the so-called “funny bone” since if it is accidentally knocked, one feels a
tingling sensation in the medial part of the hand, which is the area that the nerve supplies.
When the arm hangs loosely by the side, the medial epicondyle fits into the curve of the waist.
When the arm is held with the palm looking forward, (the humerus in external rotation) the
forearm is not in line with the upper arm but is directed outwards in the so-called carrying
angle. When the humerus is internally rotated, the medial epicondyle points posteriorly and
the lateral epicondyle to the front.

The olecranon process of the ulna is the bony prominence felt at the back of the elbow. With
the top of the elbow placed on the bench with the forearm vertical the dorsal margin of the
ulna may be palpated subcutaneously all the way to the styloid process of the ulna at the wrist.
With the hand in the supine position, the styloid process can be seen and felt at the postero-
medial margin of the forearm. When the forearm is pronated the smooth rounded prominence
seen in this position is the head of the ulna.

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 MB BS Living Anatomy
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3. In this position where is the ulnar styloid?

Lateral side (the radius has crossed to the medial side)

The head of the radius is identified at a point just distal to the lateral epicondyle of the
humerus. With the elbow extended a transverse groove should be felt between the humerus
and the head of the radius in the depression at the back of the limb (between the ulna and the
extensors of the forearm). Pronate and supinate the hand and feel the head of the radius rotate.
The distal end of the radius is a block of bone that can be felt at the distal end of the forearm
on both front and back and also on the lateral side. When the living thumb is stretched out
from the palm a hollow appears between the tendons on the lateral side of the back of the
wrist. This hollow is popularly known as the anatomical snuffbox, and the styloid process of
the radius is the bone felt in the proximal part of this floor.

4. Can you name these tendons?

Abductor pollicis longus, extensor pollicis brevis (lat) and extensor pollicis longus (med)

MUSCLES OF THE SHOULDER REGION

Serratus anterior can be most easily seen on well-developed individuals on the lateral aspect
of the chest when the arm is held abducted. The lowermost digitations which converge on the
inferior angle of the scapula, can be seen attached to the 5th to 8th ribs along a laterally
oblique line from about the level of the nipple (in the male).

5. What is this muscle’s nerve supply?

Long thoracic nerve (C5,6,7)

6. How might one test the integrity of this nerve?

Push against a wall – winged scapula,

Paralysis = difficulty in abducting beyond horizontal

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Trapezius. The subject should elevate his shoulders against resistance. The uppermost fibres
of the muscle can be seen tensing.

7. The integrity of which cranial nerve is required for this movement?

Accessory (CN XI)

8. What are the other actions of this muscle?

Superior fibres elevate scapula

Middle fibres retract scapula posteriorly
Inferior fibres depress scapula
Superior + Inferior – rotate scapula

Pectoralis Major. The muscle can be demonstrated by asking the subject to place his hands on
his hips and push inwards. The muscle is seen to stand out. Note that only the lower
sternocostal part of the muscle is contracted. The clavicular part is relaxed. To demonstrate
the clavicular portion, ask the subject to push his hands together above his head. The
sternocostal portion should be relaxed.

The subject should now be asked to adduct the horizontally abducted arm against resistance.
Pectoralis major is seen to form the anterior fold of the axilla and Latissimus Dorsi the
posterior fold.

9. How could these muscles be described to be acting? What is the most common action
for these powerful muscles? (not adduction of the humerus)

Stabilisation of the humerus (keeping the head in the glenoid cavity)

Teres major can also be felt at the lateral border of the scapula during this exercise.

Ask the subject to maintain a horizontally abducted arm against resistance. In this position
deltoid should be well demonstrated.

10. What might weakness in this muscle after fracture of the humerus indicate?

damaged Axillary nerve (# at surgical neck)

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 MB BS Living Anatomy
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11. What other simple test might lead you to confirm your diagnosis? - Think of cutaneous
nerve supply!

Test ‘Regimental Badge’ area (C5)

Emerging from the lateral wall of the axilla and passing to the medial side of the arm there is a
distinctive triangular elevation formed by coracobrachialis and the short head of biceps
muscle is the medial bicipital furrow. Biceps is demonstrated by flexing the supinated forearm
against resistance.

12. What spinal segments are tested in this manoeuvre?

C5/C6 (flexion), C6 (supination)

Triceps can be felt at the back of the arm by extending the forearm against resistance.

13. Which nerve is required for this action?

Radial nerve (C7/C8)

To demonstrate the action of a synergist, grasp the subject’s hand as in a handshake. Ask the
subject to supinate his hand in this position while you resist this action. Feel the triceps
muscle. It should be contracting.

14. How do you explain this action?

In order to keep the elbow in a constant position, triceps has to balance the action of biceps
Biceps is a supinator

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 MB BS Living Anatomy
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VESSELS AND NERVES

The superficial veins of the forearm can most easily be seen if a constriction (rubber tubing) is
held around the upper part of the arm and the subject forcefully opens and closes his hands.
Outline the basilic, cephalic and median cubital veins. Knowledge of these veins is essential
in order to find a subcutaneous vein for intravenous infusions.

The axillary artery. The first part is situated medially to pectoralis minor muscle and lies deep
to the floor of the infraclavicular fossa under cover of the clavipectoral fascia. The second part
is deeply placed under cover of pectoralis minor (below the medial to the coracoid). The third
part is covered anteriorly in its upper part by pectoralis major. The distal part however can be
felt pulsating in the axilla in the groove behind the coracobrachialis muscle. Bleeding distal to
this point can be controlled by digital pressure of the artery against the humerus.

15. Why shouldn’t a tight tourniquet be applied at this point?

Because it would cause nerve compression – radial nerve in spiral groove.

Note that tourniques are normally used to compress superficial veins not deep arteries.

The course of the artery can be marked by a line drawn (on the horizontally outstretched upper
limb) from the centre of the clavicle passing a little below the coracoid process to the medial
bicipital groove behind coracobrachialis.

The brachial artery is felt lying superficially in the medial bicipital furrow where it can be
compressed against the shaft of the humerus (brachial pressure point). More distally it enters
the cubital fossa along the medial margin of the biceps muscle and passes under cover of the
bicipital aponeurosis. It ends by dividing into radial and ulnar arteries, at the level of the neck
of the radius. Draw in the artery. Note the proximity of the artery to the median cubital vein in
the cubital fossa. There is a risk at this point that the artery may be pierced in error while
aiming an injection needle for the vein. This danger should be borne in mind when injecting
any potentially irritant drugs (such as Pentothal) at this site.

The course of the radial artery can be shown by a slightly laterally convex line drawn from the
tendon of the biceps to a point just medial to the styloid process of the radius at the anterior
aspect of the wrist where the radial pulse should easily be palpated.

The ulnar artery is shown by a line from the biceps tendon slightly convex medially to the
lateral side of the pisiform where the ulnar pulse should be felt.

The median nerve lies antero-lateral to the axillary artery on the lateral wall of the axilla
behind the elevation produced by the coracobrachialis muscle. It then passes along the medial
bicipital furrow with the brachial artery. It crosses the brachial artery at the midpoint of the
arm to lie along its medial side. At the elbow the relations are therefore:- biceps tendon most
laterally, then brachial artery pulse then median nerve.

The radial nerve runs down the lateral wall of the axilla posterior to the axillary artery in the
groove behind coracobrachialis. Below the posterior wall of the axilla it passes between the

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 MB BS Living Anatomy
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medial and long heads of triceps muscle in the spiral groove on the posterior aspect of the
humerus. In the relaxed arm it may be palpated at this site and a tingling sensation may be
experienced in the area of its distribution if it is compressed. Although it is deeply situated, a
temporary paralysis of the extensor muscles may result from severe compression of the nerve,
e.g. by drunks going to sleep or some time with their arm resting over the back of a chair - the
“Saturday Night palsy’. After passing through the spiral groove, its course may be shown by a
line passing obliquely forwards to the front of the lateral epicondyle.

The ulnar nerve also passes down the lateral wall of the axilla behind coracobrachialis, then in
the bicipital groove lateral to the axillary artery and makes for the posterior aspect of the
medial epicondyle where it can be felt as noted earlier. At the wrist it lies on the ulnar side of
the ulnar pulse. Both then pass to the radial side of the pisiform bone, which you can see and
feel at the base of the hypothenar eminence.

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 MB BS Living Anatomy
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Practical Anatomy in the Living Subject

Lower Limb

Note: When the section says "Identify" or asks "Where are ... ?", "Test" or "Trace", you are
required not just to provide an answer BUT TO CARRY OUT THE EXERCISE ON THE
SUBJECT.

GLUTEAL REGION

Identify the greater trochanter. If the subject will allow, also identify the ischial tuberosity,
and posterior superior iliac spine (often more easily identified by the presence of a skin
dimple). It may be easier and less embarrassing to find these on yourself.

The sciatic nerve arches through the midpoint of firstly, the posterior superior iliac spine and
ischial tuberosity, and secondly, the ischial tuberosity and greater trochanter. This nerve is
commonly damaged following 'intramuscular' injection into the gluteal region.

Now identify the anterior superior iliac spine. Place your thumb onto this, and span your
hand posteriorly, so that your fingers point backwards. The area of skin covered by your hand
is known as 'the safe area' where injections into the gluteal region should be made.

16. Which muscle is most likely to receive the injection?

Gluteus medius

Palpate the greater trochanters on both sides whilst the subject is standing upright. Now ask
the subject to lift one foot off the ground.

17. What happens to the relationship of the greater trochanters to one another, and what is
the explanation?

The trochanters remain at the same level.

The gluteus medius and minimus prevent pelvic tilting on opposite side.

Now feel the contraction of the gluteus medius whilst the subject performs this action.

Ask the subject to stand with his/her weight on one leg, with the knee flexed by about 20o.
Note the lower end of the iliotibial tract which stands out as a hard band on the lateral side of
the knee. Follow the tract upwards as far as you can.

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 MB BS Living Anatomy
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HIP JOINT

Examine the normal range of movements at the hip joint. Describe how you would measure
this, and discuss the muscles involved and the limiting factors in each movement. N.B. For
limbs, the range and extent of movements is always compared on the two sides, as well as
with some (more or less) statistical norm.

Flexion

90-115 degrees (60 with hamstrings stretched)

Limited by trunk (or hamstrings when taut)

Extension

15-30 degrees
Limited by iliofemoral and pubofemoral Ligaments

Medial Rotation

30-45 degrees
Limited by ischiofemoral ligament

Lateral Rotation

45-60 degrees
Limited by pubofemoral ligament

Adduction

15-45 degrees with part flexion

Limited by other limb

Abduction

50-60 degrees
Limited by pubofemoral ligament and greater trochanter abutting on to hip bone.

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ANTERIOR THIGH

Ask the subject to sit with his/her legs straight and held above the floor. Feel the contractions
of the quadriceps on the front of the thigh. Attempt to identify the parts of this muscle.

ADDUCTOR MUSCLES

Ask your subject to sit with the feet touching each other on the floor. With the knees flexed
at 90o, and separated by about 30cm, ask the subject to press his/her FEET together (keeping
knees apart). Note the adductors on the medial side of the thigh. The femoral triangle is
usually evident as a depression, and hence sartorius is also seen.

Palpate the medial epicondyle of the femur and adductor tubercle. Feel the tendon of
adductor magnus inserting into the adductor tubercle.

HAMSTRING MUSCLES

Palpate the condyles of both tibia and femur, and the head of the fibula.

Hamstring muscles: Ask your subject to sit with knee flexed at 90o and try to flex it further
against resistance. Feel the tendons of the hamstrings on the back of the thigh, just proximal
to the knee.

18. Can you distinguish the three tendons? Name them.

Biceps (lat) and semitendinosus / semimembranosus (med)

Ask the subject to walk normally whilst feeling his gluteus maximus.

19. Does the gluteus maximus contract during the hip extension phase of the walk? If not,
which muscles cause hip extension?

Hamstrings (incl. adductor magnus, hamstring portion)

20. Are different muscles used to extend the hip whilst stepping up against gravity?

Gluteus maximus

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Ask the subject to bend over to touch his/her toes, and straighten up again, whilst you palpate
the hamstrings and gluteus maximus.

21. Which muscles are active in lifting the trunk?

Hamstrings mostly – Gluteus maximus has been brought forward by the tilting of the pelvis.
It is no longer in a strong position to extend the hip

POPLITEAL FOSSA

Identify the boundaries of the popliteal fossa. With the knee flexed at about 90o, press deeply
into the popliteal fossa, and feel for the pulsation of the popliteal artery. This is usually easier
with the knee flexed to relax the fascia over the fossa, and also if the leg is supported, to
allow the hamstrings to relax.

KNEE JOINT

Demonstrate how you would test the integrity of;

a) the tibial collateral ligament;
b) the fibular collateral ligament;
c) the anterior cruciate ligament;
d) the posterior cruciate ligament;
e) the menisci.

Palpate the patella, quadriceps tendon and patellar ligament inserting into the tibial tuberosity.

LEG

Ask your subject to sit with the knee flexed and ankles plantar flexed, and to press the toes
against the ground. Feel gastrocnemius and soleus on the back of the calf, and note their
continuation into the tendocalcaneus. Alternatively, these can be seen by asking your subject
to stand on tip-toes.

Palpate the tibia. The medial surface and anterior border of this bone is palpable throughout
its length.

22. Is the fibula palpable throughout its length? If not, why not?

Proximal (head, neck) and distal (lateral malleolus) ends only, due to presence of muscles

At the proximal end of the fibula, examine the insertion of the biceps femoris into its head.

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23. What lies immediately distal to this insertion?

Common peroneal nerve

Palpate the tendon of tibialis anterior during dorsiflexion of the foot.

Lateral to the tibialis anterior tendon is the tendon of extensor hallucis longus. Lying between
it and the tendons of extensor digitorum longus is the neurovascular bundle of the anterior
compartment. The artery (anterior tibial) may be felt here, but is more easily palpated as the
artery runs over the dorsum of the foot (where it becomes the 'dorsalis pedis artery').

Behind the medial malleolus, the pulsation of the posterior tibial artery should be felt. As in
the extensor compartment, the neurovascular bundle lies between the hallucis longus and
digitorum longus muscles (in this case, flexors).

ANKLE JOINT

Feel the bony prominences of the medial and lateral malleoli.

24. Which lies more distally?

Lateral malleolus

Any alteration in this relationship implies a fracture with displacement (recall radial and ulnar
styloid processes of the upper limb).

About 2.5cm below and in front of the medial malleolus, lies the tuberosity of the navicular
bone. A tendon can be felt inserting into this on the plantar side.

25. To which muscle does this belong?

Tibialis posterior

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 MB BS Living Anatomy
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Practical Anatomy in the Living Subject

Neck and Back

Each group should nominate at least two people who will be the subjects. All members of the
group should be able to locate the landmarks outlined below.

1. Spinous Process

As a group the spinous processes should be visible as a line of bumps running down the
centre of the back. They are designed for the attachment of muscles, ligaments and fascia.

It is possible to identify the region of the spinal column by the shape of the processes. In the
lumbar region, the processes are larger than the other regions with the ends being rather blunt.
As the vertebrae are larger than those of other regions, there are spaces between the processes.
In the thoracic region the smaller processes are closer together and many are angled
downwards. The cervical spines are the shortest and smallest and are more difficult to
palpate. They are also deeper and are overlain by the ligamentum nuchae.

With the subject seated and the neck slightly flexed place your finger along the centre of the
back and locate the line of processes. Slide your finger on the spines and note the differences
in size and orientation of the processes.

Ask the subject to slowly flex and extend the spine and note the movements of the processes.

Move the fingers laterally from the midline and palpate the transverse process of the
vertebrae.

2. Bony Landmarks

Several specific spinal processes can be located with the help of intersecting bony landmarks.

a) L4
The subject should be standing and the both iliac crests located. Place the thumbs on the top
of the iliac crest and slide medially. The vertebra in the midline is L4.

b) T12
The subject should be standing. Explore the posterior inferiorly aspect of the rib cage and
find the 12th ribs. Gently follow the ribs upwards and medially. The vertebra found in the
midline should be T12. This may be a difficult vertebra to find due to the mass of muscle
covering the ribs near the midline.

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c) T7
The subject should be standing and the shoulders relaxed. Find the inferior angle of the
scapula. Keep one hand on the scapula and slide the other medially. The vertebra in the
midline should be T7.

d) T2
The subject should be standing and the shoulders relaxed. Find the superior angle of the
scapula. Keep one hand on the scapula and slide the other medially. The vertebra in the
midline should be T2.

e) C7
This spinal process is more prominent than the other cervical vertebrae. With the subject in
the prone position slide the fingers from the base of the skull down the midline of the neck.
The bump felt at the base of the neck is C7.

3. Muscles of the spine

a) Erector spinae
With the subject prone lay both hands on either side of the lumbar vertebrae. Ask the subject
to raise and lower their feet slightly. This causes the erector spinae to contract to stabilise the
pelvis. Move your hands inferior to the sacrum and then superiorly to the thoracic region.
Ask the subject to extend their spine and neck to contract the muscle. Try and find the
muscle fibres in the neck. Ask the subject to relax the muscles and using your fingers, assess
the texture of the muscles.

b) Transversospinalis
With the subject in the prone position locate the erector spinae muscles once more. At the
midline, try to push the fibres laterally to explore the deeper fibres of transversospinalis.

c) Splenius Capitis
With the subject in the prone position locate the trapezius muscle. Find its lateral edge and
palate just lateral to it. This is splenius capitis.

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