SURFACE = ‘The visible landmarks ate produced mostly by the bones. The palpable landmarks felt through tive skin are represented by the muscles, tendons, arteries by their pulsations, and the nerves by rolling against bones. Muscles become palpable tihen they contract against resistance offercd by the Surface landmarks (Fig 28.1. 28.2, 28.3) The clavicle, the spinous and the acromial processes of scapula are conspicuous around the ‘shoulder girdle. because they are sub-cutaneous. Tip of the acromion canbe easily fel lateral 10 the acromio-clavicular joint ‘Acromial ‘angle is located where the lower” border of the crest of spine of the scapula meets the lateral border of the acromion, It is an important landmark to measure the length of the ‘upper limb. adial artery lore arm) Radial N | (Superficial biceps Flex. carp, |Pisiform | A sone Ena Ulnar Med. | (Fore arm) artery epieondyle | Key 1 Tendon of flexor carps 2 Tendon of palmarts longs ANATOMY Fite sub-cutaneots erest of spine, when traced medially, meets the medial (vertebral) border of the scapula at the level of third thoracic (T.) spine ‘This is an important landmark at the back for the starting point of oblique fissure of the lung, about [Link] lateral tothe T. spine ste of scapula overlaps the seventl e the seventy Inferior a imtercostat space and ligs ope thoracic CT.) spine, Ls felt beneath the upper part of laissimaus dorsi and found to move Taterall) during abduction of the shoulder joint The tip of the coracoid process of the scapula projects almost straight forward. and 1s palpable about 2 Sem below the junction af medial three- foneth and lateral one-fourth of the clavicle tts overlapped by the anterior fibres of the deltoid Lesser tubercle of the humerus is fet through the deltoid at a point about [Link] below the tip of the acromion. Greater tubercle of the humerus is felt as the Lar epieondste c | aga Tendon off {lront of arm) Avallary Palsation of sila I \ Median 8. Ulnar N. (arm) (arm)most Lateral bony point in the rounded contour of the shoulder region. ‘Anterior fold of the axilla becomes prominent ayhen the arm is adducted against resistance from the abducted position. Itis formed by the rolled up Jower border of the pectoralis major: Posterior fold of the axilla fics at a lower level and is more rounded than the anterior fold, Posterior fold is formed by the latissirmus dorsi medially and teres major laterally; itis palpable by adopting the similar procedure for the anterior fold Insertion of the deltoid can be casily felt at the middle of lateral side of the shaft of the when the arm is maintained in abducted humerus. position Coracobrachialis can be identified as a muscular prominence in abducted arm, along the proximal half of the medial margin of the biceps brachii Tendon of biceps brachii becomes prominent and can be grasped in the cubital fossa, when the elbow is flexed against resistance. Medial epicondyle of humerus is easily felt as conspicuous landmark in a flexed elbow. When the posterior aspect of the extended elbow is palpated. three bony features can be identified Apex of the olecranon side of the middle line process 1s felt on the inner | Axillary nerve Tip of aeramion i back of arm Fig, 28.2. Back of SUREACE ANATOMY 261 Lateral epicondyle of humerus 1s readily palpable in the upper part of a depression on the lateral side of the olecranon precess. Head of the radius is situated below the lateral epicondyle in the depression or dimple described ove: it can be felt to move during supination and pronation of the forearm. When the elbow is flexed, the lines joining the tip of the olecranon and the two epicondyles form an isoceles triangle Head of the ulna forms a rou medial side of the led bony of the elevation on the wnst in a pronated hand ss of ulna projects down ‘The styloid proces al side of the word from the ulnar head on the media wrist. “The styloid process of radius is palpable by following the lover part of the lateral border of the radius, and about 1.25 cm below and the slightly on a morc anterior plane than the styloid process of ulna ‘Tendons of flexor carpi radialis and palmaris Jongus—When the wrist joint is lexed against resistance, two tendons become prominent om the fateral side of the front ofthe wrist; the lateral one for flexor carpi radialis and the medial one for palmaris longus jexor carpi ulnaris stands out Tendon of fl side of the wrist, prominently along the medial back of abducted armESS TIALS OF HI 262, vhen the joint is flexed against resistance. Traced tpelow the tendon reaches the pisiform bone Anatomical snuff box—lt is seen as a depression in the extended thumb on the lateral side of the wrist, The box is bounded in front by the tendons of abductor pollicis longus and extensor policis brevis, and behind by the tendon of extensor pollicis longus Dorsal tubercle of lister is palpable on the postertor surface of the lower end of radius near its middle, and lies in line with the cleft between the middle and index fingers. Pisiform bone is felt as an elevation at the base of the hypothenar cminence, where the tendon of the flexor carpi ulnaris reaches for attachment. Hook of the hamate bone is palpable by gentle pressure through the hypothenar eminence about | Radiat f\ > | en FI i Uiaar verve Radial N. fr eee f cinaran Median nerve | Deep palmar arch [MAN ANATOMY 2em below the pisiform bone, and lies in line with the ulnar border of the ring finger ‘Tuberele of the scaphoid is felt at the base of the thenar eminence: it is overlapped partly by the tendon of flexor carpi radialis Crest of the trapezium is palpable on deep pressure through the thenar eminence, and lies about 2 cm below the tubercle of the scaphoid. Heads of the metacarpals are demarcated by the prominence of knuckles ‘Metacarpo-phalangeal joiat lies about 2 cm distal to the creases at the junction between the igits and the palm. caesar ‘The arm is held at right angle to the trunk and the palm is directed upward ( Key 1 = Medial epicondyle 2 = Lateral epicondyle 3. = Tendon of bieeps brachii 4 ~ Bifurcation of brachial art 5 = Point at thejunction of upper + and tower | 4 of a tine joining medial cpwondvle and | pisiform bone 6 ~ Point 76m above the wnst 7 ~ Point at the pulsation of radia 4 Point on radial side of pis | 9 ~ Pasiform bone 10 ~ Tubercle of scaphoid 11 = Crest of trapezium | 12 = Hook of hs | 13. Point in the middle of palm along the distal horder of extended thumb \ 14 Flexor Reunaculam \ 15 — Tendon of Flexor carps tadiahs 16 = Tendon of Palmans longus 17 = Tendon of Flexor carpi ulnanisPoints 1, Take a point at the middle of the lower order of the clavicle, 2, Another point at the junction of anterior one-third and posterior two-thirds of the lateral ‘wall of the axilla, where the pulsation ofthe artery is folt immediately below the prominence of the ‘coraco-brachialis muscle. Join the two points by a straight line which represents the axillary artery. ‘Note When the arm is placed by the side of | the trunk, the line for the artery describes a | gentle curve with the convexity directed upward | | and laterally, On raising the arm above the head, {the line presents a concavity upward and ‘medially. asta ers corresponds to line by joining the following points 1. A point in the axilla at the termination of axillary artery (see above), 2. Apoint in the cubital fossa about 1 cm below the bend of the elbow and just medial tothe tendon of biceps brachii. At this point brachial artery bifurcates into radial and ulnar arteries Fig. 28.1) The line joining the two points passes along the medial side of the upper part of the arm, and then deviates slightly laterally at the point of termination in the cubital fossa Radial artery vhs the forearm 1. A point about 1 cm below the bend of the elbow and just medial to the tendon of biceps brachii; 2, Another point above the front of the wrist between the anterior border of the lower part of radius and the tendon of the flexor carpi radialis Pulsation of the artery is commonly felt in this interval ‘The line joining these two points represents the artery, which presents a lateral convexity in ‘upper one-third, and undergoes a vertical course in the lower two-thirds (Fig, 28 3) SURFACE ANATOMY Atthe wrist 1. In addition to the last point in the forearm, take a point in the anatomical snuff box just below the tip of the styloid process of the radius, 2. Apoint in the proximal part of the first nter~ metacarpal space, where the artery enters the palm Join these point by a line to represent the artery. In this part artery passes obliquely downward and laterally deep to the tendons of abductor pollicis longus, extensor pollicis brevis and longus and superficial to the lateral ligament ‘fthe sist joint, and finally disappears between the two heads of the first dorsal interosscous muscle Ainar artery 1. Take a point about 1 cm below the bend of the elbow, just medial to the tendon of biceps brachit 2. A point on the radial side of the pisiform bone Join this point to the medial epicondyle by a straight line, take a point on this line at the junction of upper one third and lower two-thirds ‘Wipe out the proximal part of the line above this ‘point (Fig. 28.3). Join this new point with the first point by a Jine which slopes downward and medially, and the rest of the line extends vertically downwards, The total course of the ulnar artery 1s thus represented by the oblique upper part and vertical lower part the composite line juperficial palmar arch 1. A point on the radial side of the pisiform bone: 2. A point on the hook of the hamate bone about 2 cm below the first point and in line with the ulnar border of the ring finger Draw a horizontal helping line across the palm. along the distal border of the extended thumb (Fig 283) 3. Take a point near the middle of the thenar inence Join the points (1) and (2) by a vertical line and the points (2) and (3) by a curved line which is convex distally; but the summit of the convexity does not extend below the horizontal line drawn across the palm. Finally. wipe out the horizontal264 Thus the superficial palmar arch is represented by a°J" shaped curved line palmar arch L. Take a point just distal to the hook of the ‘hamate bone. 4 Draw a horizontal line from this point 4 cm Aaterally. This represents the deep palmar arch, ‘ESSENTIALS OF HUMAN ANATOMY. 2. Put a point at the junction of upper one- third and lower two-thirds of a line joining the dorsal aspect of the hicad of radius to the dorsal tubercle of Lister, 3. A point on the dorsal tubercle of Lister. Join these points by a line which crosses the elevation produced by brachioradialis and superficial extensor muscles in the upper parl which liesabout 1.25 em proximal iothe superficial 1 sory nerve palmar arch and describes a shght convexity towards the fingers. Radial nerve abe arm 1A point at the junction of the anterior 4rd ‘and posterior $rd_of the lateral wall of axilla where the pulsation of the axillary artery is felt (see the terminal point for the axillary artery): 2. A point at the junction of upper trd and lower 3rd ofa line joining the insertion of the deltoid and the lateral epicondyle of the humerus, 3. Put a point on the front of the elbow at the evel of lateral epicondyle, about 1 cm lateral 10 46 the fore arm the tendon of biceps brachii (Fig. 28.2) Join the points (1) and (2) by an oblique line in ‘the back of the arm across the elevation produced by the long and lateral head of the triceps. It corresponds to the radial nerve in the spiral groove, and the second point demarcates the site Where the nerve pierces the lateral intermuscular septum. The line is continued by joining the points (2) and (3) to mark the course of the nerve in the anterior compartment of the arm (n the fore arm 1. Put a point 1 cm lateral to the tendon of biceps brachii at the level of the lateral epicondyle; 2. A point at the junction of upper two-thirds and lower one-third of the lateral border of the fore arm. 3. A point in the anatomical snuff box Join these points by a line which represents em 1, A point at the termination or axillary artery (see above); 2 Apoint at the middle of the medial border of the arm 3. Pur a poim behind the base of the medial st the bone epicondsle by rolling presents Join these points by a line wh. the ulnar nerve in the arm. The second point is the site where the nerve pierces the medial inter~ ‘mascular septum and then descends behind the ‘medial epicondyle. 1. As mentioned before. a point on the dorsal aspect of the base of the medial epicondste 2, Apointon the radial side ofthe pisiform bone. ‘A line joining these points represents the ulnar nerve in the fore arm. < Median nerve 1A point at the termination of axillary artery (see the axillary 2, A point about 1 cm below the bend of the elbow, just medial to the tendon of biceps brachit: 3. Put a point in front of the wrist in between the tendons of patmaris longus and flexor carpi radialis: these tendons are made prominent by producing flexion of the wrist against resistance The line joining these points represents the entire course of median nerve superficial terminal branch of the radial nerve in hae nerve (Circumflex nerve) he fore the torsab Mark a point 2 cm above the mid-point of a line joining the tip of the acromion and the insertion of the deltoid muscle Draw a horizental line through this point across the rounded prominence of the deltoid. thts corresponds with the axillary nerve. Posterior interosseous nerve (Deep terminal branch of Radial nerve) 1, Apoint 1 cm lateral to the tendon of biceps brachii at the level of lateral epicondyle; :SURFACE ANATOMY ‘Musculo-cutancous nerve 1, Take a point about 3 cm above the termi nation of axillary artery. (see axillary artery), 2. Put another point lateral to the tendon of ‘biceps brachii ‘about 2 cm above the bend of the tlbory, where the nerve pierces the deep fascia ‘and continues as the lateral cutaneous nerve of the forearm. Join these points by an oblique line which ‘crosses the prominence of coracobrachialis and the biceps brachii \Arexor retinaculum of the hard 1, A point on the pisiform bone; 2. A point on the tubercle of the scaphoid 3. Puta point on the hook of the hamate: 4, Apoint on the crest of the trapezium. Join the first and second points by a line concave upward: it represenis the upper limit 0} flexor retinaculum and corresponds to the lower of the two transverse creases in front of the wrist Join the third and fourth points by a line concave downwards and represents the lower limit of the retinaculum; it lies about 2 em below the upper limit Fig. 28:3). 1. Puta point on the salient lower part of the anterior border of the radius. 2. Take a point 2 em above the first point; 3. Apoint on the tip of the styloid process of the ulna 4. Take a point 2 cm below the third point om the medial side of the carpus Join the second and third points by a line. a {first and fourth points by another line, Both the lines slope downwards and medially across the back of the wrist, and represent the upper and Jower limits of the extensor retinaculum Common synovial sheath of the flexor tendons of the digits: 1, Draw the outlines of the flexor retinaculum as described above; 2, Take a point 2.5 cm above the retinaculum on the lateral edge of the tendon of the flexor carpi ulnaris, and another point at the same distance above the retinaculum on the medial edge of the tendon of flexor carpi radialis: 268 Join these points by a line which is extended towards and through the retinaculum, Continue the medial portion of the sheath distally along the tendon of the little finger upto the base of the distal phalanx, but the rest of common synovial sheath docs iol extend in the palm distal to the level of extended thumb Digital synovial sheaths of the middle three fingers + Each digital sheath extends from the base of the distal phalanx to the head of the corresponding metacarpal bone. INFERIOR EXTREMITY Front of the thigh Surface landmarks (Fig. 284) Fold of the groin—It isan oblique skin crease. unction of the front of thigh and LI, and corresponds to abdominal a the inguinal ligament. ‘Anterior superior iliac spine—t for palpable, occasionally visible, clevation at the lateral end of the fold of groin. Pubic tubercle—It is palpable as a small elevation at te medial end of the fold of groin Mid-inguinal point represents the mid-point petween the anterior superior iliac spine and the top of the symphysis pubis. ‘Adduetor tubercle —It is the highest point on the medial condyle of femur, and can be identified by placing the hand fat, with the fingers pointing below, on the medial side ofthe thigh and traci downwards to the knee. During such procedure the tip of the middle finger comes in contact with, the adductor tubercle, where cord-like tendon of adductor magnus recognised on deep pressure reaches the tubercle ms a Centre of the saphenous opening (oss 11 1s represemted by & point about 3 te 4 cm below and lateral to the pubic tubercle Femoral artery 1. Find out a point midway be superior iliac spine and the symp! inguinal point): tween the anterior jhysis pubis (mid- __— am ayr 266, ESSENTIALS OF HUMAN ANATOMY 2, Another point in the adductor tubercle; Join these points by a line; Upper two-thirds of the line represents the femoral artery, which shouldbe drawn when the thigh is flexed, slightly abducted and rotated laterally (Fig, 28.4, , \ | Saphenous | ‘opening Femoral nerve: Femoral | artery | Pai ‘Adductor tubercle Great saphenous vein za Fig, 284, Front of the thigh Femoral vein After surtace projection of the femoral artery, the femoral vein lies close to the medial side of the artery in the upper part, and behind the artery inmost ofits course with slight lateral melination in the lower part Femoral nerve Take a point about 1.2 em Jateral to the mid- inguinal point, and draw a vertical line from that point for a distance of about 2.5 cm. This represents the femoral nerve. Great saphenous vei in the thigh (Fig. 28.4) It is represented by a line joining the adductor tubercle and the centre of the saphenous opening (vide supra). Gluteal region and back of the thigh Surface landmarks (Fig. 28 5) Hliac crest—It extends from the anterior superior to posterior superior iliac spines and represents the junction of the back of the trunk and gluteal region leateraea of | | tuberosity Gluteal fold ‘aoe? | sincere | middle and lower- - i. third at the back Upper ae of thigh ‘of popliteal fossa Popliteal artery Common Line of ean }—knce oan i | Lower angle of | Tibial nerve in g gle 0: | iteal fo popliteal fossa | Fig. 28. Gluteal region and back of thigh ‘Tubercle of iliac crest lies about 5 cm behind and above the anterior superior iliac spine: transtubercular plane joining the tubercles of both iliac crests passes through the upper border of fifth lumbar spine, Supra-cristal plane is represented by a line Joining the highest point of both iliac crests, and passes behind through the fourth lumbar spine. Posterior superior iliac spine is represented by a skin dimple at the back A horizontal line joining posterior surperior spines of both sides passes through the second sacral spine, where spinal dura and arachnoid maters end, and sub- arachnoid space filled with C.S.F. extends.Greater trochanter of fermur—It lies about a hand’s breadth below the tubercle of the iliac crest, Gluteal fold—It isa horizontal skin fold which ‘marks the upper limit of the back of thigh, 1! docs not correspond to the lower border of gluteus ‘maximus, and is formed by the fibrous adheston petween the skin and deep fascia. ‘Tuberosity of the isehium—I is palpable in semiflexed hip joint about 5 cm above the gluteal fold and the same distance from the median plane. Nelaton’s line—Ii is represented by a fine joining the anterior superior iliac spine and the most prominent part of ischial tuberosity, Under normal condition, the Nelaton’s line crosses the apex of the greater trochaner and the centre of the acetabulum, Bryant's triangle (a) Draw a horizontal line from the anterior superior iliac spine backwards, with the subject in recumbent posture; (b) Drop a perpendicular line from the above ‘mentioned horizontal line to the top of greater trochanter: (© Complete the triangle by joining the anterior superior iliac spine and the top of greater trochanter, ‘When the sides of Bryant's triangles are compared between the sound and the affected sides, upward or backward displacement of the greater trochanter can be assessed in dislocation of hip joint Sciatic nerve (a) Drawa line joining the posterior superior iliac spine and ischial tuberosity. Take @ point about 2.5 em lateral to the mid-point of that line, which represents entry of the sciatic nerve in the gluteal region (Fig, 28.5), (b) Take another point just medial to the inid-point ofa line joining ischial tuberosity to the apes of greater trochanter. (©) Put a point at the upper angle of popliteal fossa, Join these points by a broad line which passes downwards and laterally, and represents the sciatic nerve. k CE ANATOMY, a LEGAND FOOT Surface landmarks (Figs. 28.6, 28.7, 28.8) ‘Tubercle of tibia—It is a subcutancous projection of the upper end of tibia, where the Tigamentum patellae 1s attached in its upper part and the subcutaneous anterior border of tibia extends below Head of the fibula—Itis a slight elevation on the posterolateral aspect of the upper part of leg ind lies vertically below the posterior part of the Tateral condyle of the femur Neck of the fibula—It is a constriction below the head of fibula, where the common peroneal nerve can be rolled against it ‘Medial malleolus—It is vistbl the lower end of the subcutaneous medial surface of the shaft of the tibia Lateral malleolus—It projection on the lateral side of the ankle, and lies fia lower level and on a more posterior plane than the medial malleolus. Head of talus — \ jle prominence at is a conspicuous | Sustentaculum tal Fig, 28.6, Foot and leg — medial side, Head of the talus—I\ lies about 3 cm in front of the lower end of tibia and can be felt when the foot is passively inverted. Sustentaculum tali of the caleaneus can be felt about 2 cm vertically below the medial malleolus. Tuberosity of the navicular bone is @ conspicuous bony projection, felt about 2.5 cm in front of the sustentaculum tali Peroneal tubercle—It lies about 2 cm below the tip of the lateral malleolus.‘Tubercle at the base of the fifth metatarsal can be felt half-way along the lateral border of the foot. Lateral malleolus Head of talus Peroneal tubercle Tubercle at the base of fifth metatarsal bone Fig. 28.7. Foot and leg ~ lateral side. Anterior tibial artery (a) Take a point 2.5 cm below the medial side of the head of the fibula (Fig. 28.8) (©) Put another point midway between the medial and lateral matleol Join these points by a line which passes downwards and slightly medially. Deep peroneal nerve (anterior tibial) (@) Puta point on the lateral side of the neck of fibula (b) Take two points, as mentioned above, for the anterior tibial artery Joint these points by a line, which passes downwards and medially in the upper part and then follows vertically in line with the anterior tibial artery Superficial peroneal nerve (musculo-cutanicous) (@) A point on the lateral aspect of the neck of fibula; (b) Another point at the junction of the middle and lower one-third of the leg, on the anterior border of the peroncus longus where the nerve pierces the deep ‘The peroneus longus is made prominent by eversion and plantar flexion of the foot. Join these points by a line. Dorsalis pedis artery (a) A point midway between the wo malleolt (b) Another point at the proximal end ofthe firs intermetatarsal space (Fig, 28.8) Join these points by a line which represents the artery. Patella — Tubercle of tibia | Deep peroneal anes | nerve (Ant. —/ | tibial nerve) | Superficial peroneal nerve (Museulo- cutaneous) ‘Scene eel ‘eunaculum Inferior extensor Dorsalis pedis retinaculam arters Fig. 28.8. Front of the leg and ihe dorsum of foot Superior extensor retinaculum It is represented by a broad band 3 cm wide from the anterior border of the subcutaneous triangular area of fibula to the lower part of the anterior border of tibia (Fig, 28.8) Inferior extensor retinaculum The stem of the retinaculum is represented by a band about 1.5 cm wide, which extends medially from the anterior part of the upper surface of the calcaneus across the dorsum of the foot (Fig. 28.8). On the medial side of the tendon of extensor digitorum longus the band divides into wo diverging limbs, each about 1 em wide. The upper Jimb is attached to the medial malleolus: the lowerSURFACE ANALUMY ‘limb passes round the medial side of the foot and —_{b) Take point at the lower limit of popliteal fossa. blends with the plantar aponcurosis, Popliteal artery The artery is represented by joining the following points (Fig. 28.8), Popliteat fossa tibial artery Tibial nerve (in les) Tendo- caleaneus Fig. 28.9. Back of leg and popliteal fossa 1. Draw a horizontal line on the back of the thigh at the junction of the middle and lower-third. and take a point on the horizontal line 2.5 em ‘medial to the middle line of the back of thigh. 2, Put a point in the middle line at the level of. knec joint, which corresponds to the upper margins of the tibial condyles. 3. Take a point on the mid-line of the back of the leg at the level of tibial tubercle Join the first and second points by a line which passes downwards and laterally, and continue the line vartically to the third point ‘Tibial nerve (Medial popliteal) (@) Puta point at the upper angle of the popliteal fossa (Fig. 28.5). Join these points by a line which represents the nerve: at first the nerve lies lateral 10 the popliteal artery and then descends on its medial side after crossing dorsal to the vessel ‘Tibial nerve (posterior tibial) in the leg (a) A point at the lower limit of popliteal fossa: (b) Another point midway between the medial rnalleolus and the tendo calcaneus (Fig. 28.9), A line joining these points represents the posterior tibial nerve ‘Common peroneal nerve (lateral popliteal nerve) (a) A point at the upper angle of the popliteal fossa’ (b) A point at the back of the head of fibula (c) Another point on the lateral side of the neck: of fibula A line joining these points represents the nerve, which accompanies the medial side of the tendon of biceps femoris (Fig. 28.5). Fleyor retinaculum Medial plantar Lateral plantar Fig, 28.10, Medial side and sole of the foot Posterior tibial artery (a) A point in the middle line of leg at the level of the neck of fibula, in line with the tibial tubercle; (b) Another point midway between the tibial malleolus and the tendo caleaneous A line joining these points represents the artery (Fig, 28.9)270 ae Flexor retinaculum Itis represented by a broad band, 2.5 em wide, which extends downwards and backwards from ‘the medial malleolus to the medial side of the heel, ‘The lower border of the retinaculum passes from the tip of the malleolus to the medial tubercle of the calcaneus (Fig, 28.10) ‘Medial plantar artery and nerve {a) Mark a point midway between the medial malleolus and the prominence of the heel. (b) Take another point in the first interdigital cleft as far as the navicular bone. SENTIALS OF HUMAN ANATOMY Join these points by a line which extends forward (Fig. 28.10) Lateral plantar artery and nerve (a) Apoint midway between the medial malleolus and the prominence of the heel (b) A point about 2.5 cm medial to the tubercle at the base of fifth metatarsal bone (©) A point at the proximal end of the first intermetatarsal space (Fig. 28.10) {A line joining these points passes first forward and laterally, and then turns medially