100 Concepts Anatomy

TRIAL MODE a valid license will remove this message.
. See the keywords property of this PDF for more information.
Understand first, then memorize and apply
100 must important

GA conceptions
Dr. Mavrych, MD, PhD, DSc

Dr. Bolgova, MD, PhD
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
Dear students, you can use this presentation like a guide during your
preparing for GA exams.
It does NOT cover all material of the Gross Anatomy course.
To complete GA material you should work with ALL professors
presentations.
Good Luck and All the best!
Dr. Mavrych
1. Lumbar puncture (tap) and

Epidural anesthesia
When lumbar puncture is
performed, the needle
enters the subarachnoid
space to extract
cerebrospinal fluid (CSF)
or to inject anesthetic to
epidural space.
l The needle is usually adults
inserted between L3/L4 or
kids L4/L5. Level of horizontal
line through upper points
of iliac crests.
l Remember, the spinal cord
may ends as low as L2 in
adults and does end at L3
in children and dural sac
extends caudally to level of
S2.
l
Spinal cord ends L2: Conus Medullaris

End Dura Sac S2: Cauda Equina w/ Filum terminale
8 cervical SN (above)
12 thoracic SN
5 lumbar SN (below body)
5 Sacral SNs
1 coccygeal SN
PLL
l
l
ALL
6*
10*
Conus medullaris
Cauda Equina w/ FT
dura matter 7
subdural spac
subd
space 8
Arachnoid matter 9

Lamina= front smooth of arches
Pedicles= attachment of bodies to arches
Processes= protuberances and "attachments" (articular=restricts movement, spinous &
transverse muscle attachment & movement)
facets= attachments of other vertebrae or bones
Body=large part where attachment of intervertebral disc (gelatinous nucleus pulposus,
peripheral anulus fibrosus)
3. Abnormal curvatures of the

spine
2. Herniated IV disc
l
3
4
Patients typically have history

of back pain that may radiate
down to the lower limb.
Herniation of disc usually
occurs in lumbar ((L4/L5 or
L5/S1)) or cervical regions
(C5/C6 or C6/C7) of
individuals younger than age
50.
Herniated lumbar disc usually
compreses the nerve root one
number below: traversing root
(e.g., the herniation L4/L5 will
compress L5 root).
The pain begins soon after
patient lifted some heavy thing.
Lower limb reflexes are
decreased on the affected
side
Anterior longitudinal ligament protects 9-3oclock around vertebral body

Posterior longitudinal ligament protects 6oclock vertebral arch
herniations are typically posterior laterally (4-5 or 7-8oclock)
Kyphosis is an exaggeration of
the thoracic curvature that may
occur in elderly persons as a result
of osteoporosis (multiply
compression fracture of vertebral
bodies) or disk degeneration.
l
Lordosis is an exaggeration of the
lumbar curvature that may be
temporary and occurs as a result
of pregnancy, spondylolisthesis
or potbelly.
Leg lengths:
l
Scoliosis is a complex lateral
short bone:
deviation, or torsion, that is
Coxa Vara
caused by poliomyelitis, a leglength discrepancy, or hip disease. <100deg
Long bone:
Coxa Valga
>130deg
Degenerative osteoarthritis:
Spondylosis: immobility or fusion of vertebral joints
Spondylolysis: degeneration of articulating part of vertebrae
Spondylolisthesis: forward displacement of vertebrae
l
TRIAL MODE a valid license will remove this message. See the keywords property of this PDF for more information.
4. Upper limb fractures:

Humerus fractures
Sites of potential injury to major
nerves in fractures of the humerus:
1. Axillary nerve and posterior
humeral circumflex artery at the
surgical neck.
deep
2. Radial nerve and profunda brachii
artery at midshaft. Midshaft
fracture affect origin of brachialis
Posterior between triceps brachii
muscle.
3. Brachial artery and median nerve
at the supracondylar region.
cubital fossa
4. Ulnar nerve at the medial
epicondyle.
ulnar epicondylar groove
posteriorly and medial to
olecranon
Dr. Mavrych, MD, PhD,
DSc prof.mavrych@gmail.com
Fracture of distal radius:

l
Quadrangular Space: teres major, teres

minor, long head biceps brachii, humerus
Scaphoid fracture
Transverse fracture within the distal 2 cm of

the radius. Most common fracture of the
forearm (after 50).
Smith's fracture results from a fall or a blow
on the dorsal aspect of the flexed wrist
and produces a ventral angulation of the
wrist. The distal fragment of the radius is
ANTERIORLY displaced.
Colles' fracture results from forced
extension of the hand, usually as a result of
trying to ease a fall by outstretching the
upper limb. Distal fragment is displaced
DORSALLY - dinner fork deformity.
Often the ulnar styloid process is avulced
(broken off)
Boxers fracture
proximal carpal fracture

l
Pain occurs primarily on the

lateral side of the wrist,
especially during wrist extension
and abduction
l Scaphoid fracture may not show
on X-ray films for 2 to 3 weeks,
but a deep tenderness will be
present in the anatomical
snuffbox.
l The proximal fragment may
undergo avascular necrosis
because the blood supply is
interrupted.
deep radial artery could be compromised
l
Mallet or Baseball Finger
Necks of the metacarpal

bones are frequently
fractured during fistfights.
l Typically, fractures of 2d and
Boxer's Fracture d
3 metacarpals are seen in
professional boxers, and
fractures of 5th and sometimes
4th metacarpals are seen in
unskilled fighters.
l
Occurs as a result of a fall onto

the palm when the hand is
abducted Extension & abduction of wrist
Brawler's Fracture
5. Rotator cuff muscles SITS
This deformity results from the DIP joint suddenly

being forced into extreme flexion (hyperflexion)
when, for example, a baseball is miscaught or a
finger is jammed into the base pad.
l These actions avulse the attachment of the
extensor digitorum tendon to the base of the
distal phalanx. As a result, the person cannot
extend the DIP joint. The resultant deformity bears
some resemblance to a mallet.
Forced Flexion of DIP
l
Support the shoulder joint by

forming a musculotendinous
rotator cuff around it
l Reinforces joint on all sides
except inferiorly, where
dislocation is most likely
Rotator cuff muscles are:
l Supraspinatus Initiate Abduction, Suprasacular n
l Infraspinatus Lat rotation, Suprascapcular n
l Teres minor Lat rotation, Axillary n
l Subscapularis Med. rotation, Upper & Lower
l
Right humerus
Subscapular ns
6. Abduction of the upper limb
Subacromial bursitis &

Tearing of supraspinatus tendon
l
(0-15) Abduction of the

upper extremity is initiated
by the supraspinatus
muscle ((suprascapular
suprascapular
nerve).
(15-110) Further abduction
to the horizontal position is a
function of the deltoid
muscle ((axillary
axillary nerve).
(110-180) Raising the
extremity above the
horizontal position requires
scapular rotation by action
accessory
of the trapezius ((accessory
nerve CNXI) and serratus
anterior ((long
long thoracic
nerve).
Subacromial bursitis (inflammation of

the subacromial bursa) is often due to
calcific supraspinatus tendinitis,
causing a painful arc of abduction.
The same symptoms will be in case of
inflammation or trauma of the
supraspinatus tendon (MRI !torn!
tendon)

Supraspinatus tendon is most commonly ruptured.
7. Three Elbows: Student's elbow

(Subcutaneous olecranon bursitis)
l
The olecranon, to which the triceps

tendon attaches distally, is easily
palpated. It is separated from the
skin by only the olecranon bursa,
which allow the mobility of the
overlying skin.
Repeated excessive pressure and
friction may cause this bursa to
become inflamed, producing a
friction subcutaneous olecranon
bursitis.
Tennis elbow
(Lateral epicondylitis)
l
l
1.
2.
3.
4.
Lateral epicondylitis: repeated

forceful flexion and extension of the
wrist resulting strain attachment of
common extensor tendon and
inflammation of periosteum of
lateral epicondyle. Pain felt over
lateral epicondyle and radiates
down posterior aspect of forearm.
Pain often felt when opening a
door or lifting a glass
Origins of following muscles may
be affected:
Extensor Carpi Radialis Extends and abducts
Longus & Brevis
the hand
Extensor Digitorum Extends fingers and wrist
Extensor Digiti Minimi
Extensor Carpi Ulnaris Extends and adducts
Radial n
Golfers elbow
(Medial epicondylitis)
l
l
1.
2.
3.
4.
the hand
8. Arterial anastomoses
around the scapula
Medial epicondylitis is
inflammation of the common
flexor tendon of the wrist
where it originates on the
medial epicondyle of the
humerus.
Origins of following muscles
may be affected:
Pronator Teres Pronates forearm
Flexor Carpi Radialis Flexes and abducts wrist
(Median n)
Palmaris Longus flexes wrist
Flexor Carpi Ulnaris flexes and adducts Wrist
Ulnar n
Blockage of the
Subclavian or Axillary
artery can be bypassed
by anastomoses
between branches of
the Thyrocervical and
Subscapular arteries:
l
Transverse cervical
off thyrocervical trunk
l
Suprascapular
l
Subscapular
l
Circumflex scapular
off subscapular
Suprascapular a above the Transverse Superior

Scapular Ligament anastamoses with the
Circumflex Scapular a from the triangular space
(Teres major/minor and long head biceps brachii)
9. Cubital fossa
Anterior Elbow joint
1.
2.
3.
LATERAL
MEDIAL l
1.
2.
3.
10. Carpal Tunnel Syndrome
Contents from lateral to medial:

Biceps brachii tendon
Brachial artery
Median nerve
Subcutaneos structures from lateral to
medial:
Cephalic vein
Median cubital vein:: joins cephalic
and basilic veins
Basilic vein
l
l
Sites of venipuncture is usually median

cubital vein because:
l
Overlies bicipital aponeurosis, so deep
structures protected
Biceps Brachii m (flex and supinate forearm)
l Not accompanied by nerves
O: Longhead supraglenoid tubercle, Shorthead
coracoid process)
I: to Radial
TuberosityMD, PhD, DSc prof.mavrych@gmail.com
Dr. Mavrych,
Venous blood is darker/purpleish and flows passively
Arterial blood is cherry red and has a pulse
Cubital Tunnel Syndrome: Compression of ulnar epicondylar groove via tendon of Flexor
Carpi Ulnaris, Ulnar n is compressed: Claw hand and weakened adduction of wrist
11. Test of the proximal and

distal interphalangeal joints

ULNAR TUNNEL SYNDROME: Compression at the wrist between pisiform and hook of hamate
carpal bones causes hypoesthesia of medial 1.5 fingers and weakened instrinsic ms (Partial Claw
hand bc flexors of forearm are unaffected)
12. Lesion of UL nerves

Upper Brachial Palsy
l
PIP FDS
Proximal Interphalangeal joint

Flexor Digitorum Superficialis
Median n
l
Pins and needles or anesthesia

of the lateral 3.5 digits
palm sensation is not affected
because superficial palmar
cutaneous branch passes
superficially to carpal tunnel
Apehand deformity - absent
of OPPOSITION
Recurrent Median n to Thenar ms are affected
Results from a lesion that

reduces the size of the carpal
tunnel (fluid retention, infection,
dislocation of lunate bone)
Median nerve most sensitive
structure in the carpal tunnel
and is the most affected
Clinical manifestations:
Injury of upper roots and trunk

Usually results from excessive
increase in the angle between the
neck and the shoulder stretching or
tearing of the superior parts of the
brachial plexus (C5 and C6 roots or
superior trunk)
May occur as birth injury from
forceful pulling on infant's head
during difficult delivery
DID
DIP - FDP
Distal Interphalangeal Joint

DIPS- Flexor Digitorum Profundus
Ulnar and Median ns
MCPs- Lumbricals
Metacarpal phalangeal joint
Birth injury or Fall causes

Superior Trunk Damage:
Erb's Palsy
Upper Brachial Palsy
Lower Brachial Palsy

(Klumpke paralysis)
(Erb-Duchenne palsy)
Inferior Trunk damage C8-T1
In all cases, paralysis of the muscles of the

shoulder and arm supplied by C5 and C6 spinal
nerves (roots) of the upper trunk.
Combination lesions of axillary, suprascapular
and musculocutaneous nerves with loss of the
shoulder mm and anterior arm.
As result patient has waiters tip hand:
adducted shoulder
medially rotated arm

Wrist flexed
extended elbow
loss of sensation in the lateral aspect of the

upper limb
Axillary C5-C6
Musculocutaenous C5-7
Median C6-T1
Injury of lower roots and

trunk
May occur when the upper
limb is suddenly pulled
superiorly: stretching or
tearing of the inferior parts
of the brachial plexus (C8
and T1 roots or inferior
trunk)
E.g., grabbing support
during falling from height
or as a birth injury, or
TOS thoracic outlet
syndrome
hand
paralysis (open extended hand), ulnar and
Dr. Mavrych, MD, PhD,Full
DSc
prof.mavrych@gmail.com
median n damage, thumb is extended bc radial n still good
Lower Brachial Palsy

(Klumpke paralysis)
Injury to musculocutaneous
nerve
Ulnar and Median Nerve Lesions
All intrinsic muscles of the hand

supplied by the C8 and T1 roots of
the lower trunk affected.
Combination lesions of ulnar
nerve (claw hand)
) and median
nerve (ape hand)
Loss of sensation in the medial
aspect of the upper limb and
medial 1,5 fingers.
May include a Horner syndrome
Usually results from lesions

of lateral cord
Greatly weakens flexion of

elbow (biceps and brachialis
muscles) and supination of
forearm (biceps muscle)
weakened adduction (coracobrachialis m)
l May be accompanied by
anesthesia over lateral
aspect of forearm
Lateral musculocutaneous n of forearm
l
Median n lesion: Ape hand/benediction with lateral 3 digits are extended, wrist is extended
Ulnar n lesion: Claw hand with medial 2 digits extended
Radial n lesion: Drop Wrist with flexion of the wrist
Cutaneous innervation
reality, in case of superficial branch of
of the hand Inradial
nerve lesion it will be skin deficit
13. Cardiac catheterization
between 1 & 2 digits on the dorsum of the

hand ONLY because of nerve overlapping
l
Dorsum: 1,5-U and 3,5 R
The femoral artery is

used for cardiac
catheterization
It can be cannulated
for left cardiac
angiography & also
for visualizing the
coronary arteries a
long, slender catheter
is inserted
percutaneously and
passed up the
external iliac artery,
common iliac artery,
aorta, to the left
ventricle of the heart
Palm: 1,5-U and 3,5 M
A catheter can also be passed through a peripheral vein (femoral vein) into IVC, the
R atrium,
R ventricle,
pulm trunk and pulm arteries. Intracardiac pressures, blood
Dr. Mavrych,
MD, PhD,
samples, and visualization of great vessels using Xray
14. Injury of the gluteal region

Fractures of Femoral Neck
l
Avascular necrosis
of femoral head
A common fracture in
elderly women with
osteoporosis is fracture of
the femoral neck.
Fractures of the femoral
neck cause shortness and
lateral rotation of the lower
limb. Coxa Vara <100deg
Fractures of the femoral
neck often disrupt the blood
supply to the head of the
femur.
At present time the best way
in case of femoral neck
fracture is hip replacement.
Transcervical fracture
disrupts blood supply to
the head of the femur via
retinacular arteries (from
medial circumflex femoral
artery) and may cause
avascular necrosis of the
femoral head if blood
supply through the ligament
to the head is inadequate.
Fractures of neck and head of femur will disrupt the cruciate anastamosis that includes the medial circumflex
femoral a & ascending and transverse lateral circumflex femoral aa with Retinacular branches that anastamose
with the acetabular branch of obturator a within Ligamentum Teres
congenital dislocations are more common in females > males
Injury to sciatic nerve
Posterior hip dislocations

l
l
l
Weakened hip
extension and knee
flexion
Footdrop (lack of
dorsiflexion)
Flail foot (lack of
both dorsiflexion and
plantar flexion)
Cause of injury:
caused by
improperly placed
gluteal injections
but may result from
posterior hip
dislocation
Gluteal injections should be done with palm over
& Piriformis syndrome: Trucker's
who sit all day piriformis m
greater trochanter, pinky on ASIS and middle finger on
Dr. Mavrych,
MD, PhD,
compress n, numbness and tingling
mid axillary
line, thumb
point posteriorly,
the V between
to the affected side.
middle and ring finger is site of injection.
l
Superior gluteal
nerve injury
Normal
Right
superior
gluteal nerve
injury
They are most common. A head-on

collision that causes the knee to
strike the dashboard may dislocate
the hip when the femoral head is
forced out of the acetabulum.
l The joint capsule ruptures inferiorly
and posteriorly (fracture of ishium),
allowing the femoral head to pass
through the tear in the capsule
(tearing of ishiofemoral lig.) and
over the posterior margin of the
acetabulum onto the lateral surface
of the ilium, shortening and
anterior
medial rotating the limb.
pubofemoral lig
may also tear
Posterior dislocations can damage the sciatic n.
bc it is weakest
l
Injury to inferior gluteal nerve
possibly also due to Piriformis syndrome

The superior gluteal nerve
l
may be injured during surgery,
posterior dislocation of the
hip or poliomyelitis.
l
Paralysis of the gluteus
medius and gluteus minimus
muscles occurs so that the
ability to pull the pelvis up
and abduction of the thigh
are lost.
Trendelenburg sign:
l If the superior gluteal nerve on
the right side is injured, the left
pelvis falls downward when the
patient raises the left foot off the
ground.
l Note that side is contralateral to
the nerve injury.
Patient stands and raises

L leg, if the L leg drops, it
is standing right leg nerve
injury
passes through superior piriformis fossa w/ inferior gluteal a & v
Weakened hip extension

(gluteus maximus), most
noticeable when climbing
stairs or standing from a
seated position
Cause of injury: posterior
hip dislocation, surgery in
this region
Inferior gluteal n passes through inferior
piriformis fossa with the sciatic n,
posterior femorial cutaneous n, Superior
gluteal a & v, pudendal n, and internal
pudendal a & v
tearing off
Injury of obturator
nerve Waddleing Gait (lateral leg swing/drag)
l
Affects Obturator externus, Adductor longus,

brevis, magnus (paritally), pectineus, gracilis
lateral rotation weakness and poor adduction
Difficulty adducting thigh

(e.g., crossing legs while
sitting)
Decreased sensation
over upper medial thigh
Cause of injury: anterior
hip dislocation, radical
retropubic prostatectomia
passes through obturator
canal that is covered by
obturator membrane in
obturator foramen
15. Avulsion fractures

of the hip bone and
hamstrings muscles
l
Avulsion fractures occur

where muscles are
attached - ischial
tuberosities
Hamstrings muscles:
1. Biceps femoris (long head)
2. Semitendinosus
3. Semimembranosus
l
Action: extension of hip
joint and flexion of knee
joint
l
Nerve supply Tibial
nerve (short head of
biceps femoris is supplied
by the common fibular
nerve)
Dr. Pseudohamstrings:
Mavrych, MD, PhD,Adductor
Magnus (obturator & tibal ns), Biceps femoris ms (tibial &
common peroneal ns)
16. Structures under inguinal

ligament:
Femoral hernia
Inguinal lig.
l
l
l
l
l
l
From lateral to
medial side:
Iliopsoas muscle
Femoral nerve w/ circumflexes &
Femoral arteryperforating br
Femoral vein & great saphenous v br
Femoral canal
Deep inguinal lymph nodes
Femoral Triangle: Superior inguinal ligament, Medially adductor longus m,

laterally sartorius m, it lies on top of pectinius m and iliopsoas ms
Inguinal lig serves as flexor retinaculum. Psoas m and Femoral n pass from pelvis
to anterior
thigh, MD,
External
becomes
femoral vessels
Dr. Mavrych,
PhD,iliac
DSc
The inguinal canal runs perpendicular to the femoral canal
17. Knee joint injuries:

Unhappy triad
l
l
1.
2.
3.
FN
FA
FV
Sartorius m
A femoral hernia passes below

inguinal ligament through the femoral
ring into the femoral canal to form a
swelling in the upper thigh inferior and
lateral to the pubic tubercle
l The hernial sac may protrude through
the saphenous hiatus into the
Adductor magnus m superficial fascia
l A femoral hernia occurs more
frequently in females and is dangerous
because the hernial sac may become
strangulated
l An aberrant obturator artery is
vulnerable during surgical repair
l
Loop of bowel gets pulled downward into femoral canal, aberrant obturator a off
Dr. Mavrych,external
MD, PhD,
iliacDSc
would
cross bowel and becomes vulnerable
Laceration of the Femoral a can be compensated by the perforating branch of femoral a
and the lateral superior genicular a that anastamoses with the descending lateral
femoral circumflex a.
Femoral v ligation can be compensated via the great saphenous v
Tibial collateral ligament

(medial collateral ligament)
Because the lateral side of the

knee is struck more often
(e.g., in a football tackle), the
tibial collateral ligament is
the most frequently torn
ligament at the knee.
The unhappy triad of athletic
knee injuries involves:
Tibial collateral ligament
Medial meniscus
Anterior cruciate ligament
MCL, MM, ACL tears
Fibular collateral ligament

(lateral collateral ligament)
l
Rounded cord between

lateral epicondyle of femur
and head of fibula
Does NOT blend with joint
capsule and does NOT
attach to lateral meniscus
Limits extension and
adduction of leg at knee
Broad flat band

extending from medial
epicondyle of femur to
medial condyle and
shaft of tibia
Blends with capsule and
firmly attaches to
medial meniscus
Limits extension and
abduction of leg at
knee
Rupture of the
cruciate ligaments
l
With rupture of the anterior

cruciate ligament, the tibia
can be pulled forward
excessively on the femur,
exhibiting anterior drawer
sign.
In the less common rupture of

the posterior cruciate
ligament, the tibia can be
pushed backward excessively
on the femur, exhibiting
posterior drawer sign.
drawer sign is movement of the leg in
opposition of the femur 5mm
Prepatellar bursa
Suprapatellar bursa
articularis
genu m
Knee jerk reflex
Prepatellar bursa: between

superficial surface of patella
and skin. May become
inflamed and swollen
(prepatellar bursitis).
Suprapatellar bursa: superior

extension of synovial cavity
between distal end of femur
and quadriceps muscle and
tendon. Usual place for intraarticular injections. May
become inflamed and swollen
(suprapatellar bursitis).
Posterior to Rectus femoris m
and vastis intermedialis m
The patellar reflex

is tested by tapping
the patellar Rectus femoris m
ligament with a
reflex hammer to
elicit extension at
the knee joint. Both
afferent and
efferent limbs of
the reflex arch are
in the femoral
nerve (L2-L4).
Knee jerk reflex:

tests spinal nerves
L2-L4.
18. Ankle joint injuries:

Ankle sprains
l
l
Sprains are the most common

ankle injuries
A sprained ankle is nearly
always an inversion injury,
involving twisting of the weightbearing plantarflexed foot.
The lateral ligament (anterior
talofibular ligament) is injured
because it is much weaker than
the medial ligament.
In severe sprains, the lateral
malleolus of the fibula may be
fractured.
Potts fracture
l
l
l
It is fracture-dislocations of
the ankle joint
Reason - forced eversion
(abduction) of the foot
The Deltoid ligament
avulses the medial
malleolus and after that
fibula fractures at a
higher level
Pott's fracture
Eversion injury is Deltoid ligament at medial malleolus
19. Injures of the leg and foot:

Fracture of the fibular neck
Ankle jerk reflex

Calcaneous Tendon Reflex
l
l
Achilles tendon reflex is

tested by tapping the
calcaneal tendon to elicit
plantar flexion at the ankle
joint.
Both afferent and efferent
limbs of the reflex arc are
carried in the tibial nerve
(S1, S2).
May cause an injury to the common

nerve which winds
peroneal nerve,
laterally around the neck of the
fibula.
This injury results in paralysis of all
muscles in the anterior and lateral
compartments of the leg
(dorsiflexors and evertors of the
foot) and loosing sensation on the
dorsum of the foot.
Causing foot drop.
Ankle jerk reflex: tests

spinal nerves S1-S2.
Flexors take over (Plantar flexion)
Rupture of the Achilles tendon

and Triceps surae muscle
Plantar Fasciitis (calcaneal spur)

l
Avulsion or rupture of the calcaneal

(Achilles) tendon disables the triceps
sure muscle (gastrocnemius & soleus)
so that the patient cannot plantar flex
the foot.
Triceps surae muscle:
l 2 Heads of Gastrocnemius m.
l 1 Head - Soleus muscle
l Plantaris
l small fusiform belly with long thin
tendon;
l sometimes may become
hypertrophy
l
Plantar fasciitis is the

most common hindfoot
problem in runners. It
causes pain on the
plantar surface of the
foot and heel.
Point tenderness is
located at the proximal
attachment of the plantar
aponeurosis to the
medial tubercle of the
calcaneus and on the
medial surface of this
bone.
20. Injury of tibial nerve

SOLE OF FOOT TIBAL n BRANCHES
l
l
l
l
In popliteal fossa: loss of

plantar flexion of foot (mainly
gastrocnernius and soleus
muscles) and weakened
inversion (tibialis posterior
muscle), causing
calcaneovalgus.
Inability to stand on toes
Loss of sensation and
paralysis of intrinsic muscles
Popliteal fossa from superficial to

of the sole of the foot
deep, contains:
l Tibial nerve
l Popliteal vein
Femoral vessels after passing through adductor haitus/
l Popliteal artery Hunter's canal, Sartorius canal, to become popliteal vessels
Popliteal Fossa is bordered by Semitendinosus, Semimembranosus, Biceps

Dr. Mavrych,
MD, and
PhD,
femoris,
quadracepts
(gastronemius, plantaris, and soleus ms)
On soil of the foot there are two terminal

branches of tibial n:
l Medial plantar nerve supplies:
1.
Abductor hallucis,
2.
Flexor hallucis brevis
3.
Flexor digitorum brevis
4.
1st lumbrical muscles
l skin of medial 3.5 digits
l Lateral plantar nerve supplies:
l All intrinsic plantar muscles which
are not innervated by medial plantar
nerve
l skin of lateral 1.5 digits
Adductor hallucis (oblique & transverse
heads), Quadratus Plantae, Flexor Digiti
minimi, abductor digiti minimi, DABs,
PADs, lateral 3 lumbricals
Common Fibular/Common Peroneal n does not pass in popliteal

fossa, instead it goes around neck of fibula
21. Breast:
Carcinoma of the Breast
l
Lymphatic drainage
of the breast
Carcinomas of the
breast are malignant
tumors, usually
adenocarcinomas
arising from the
epithelial cells of the
lactiferous ducts in the
mammary gland
lobules
1. It enlarges, attaches
to suspensory
(Coopers) ligaments,
and produces
shortening of the
ligaments, causing
depression or dimpling
of the overlying skin.
Suspensory/Cooper's lig sround the lobules of mammary glands.

$$Million dollar space: Retromammary space behind Pect Major or between
fat pad and Pect Major for insertion of breast implants
75%
25%
It is important because
of its role in the
metastasis of cancer
cells.
Most lymph (> 75%),
especially from the
lateral breast
quadrants, drains to
the axillary lymph
nodes, initially to the
anterior (pectoral)
nodes for the most
part.
Most of the remaining
lymph, particularly from
the medial breast
quadrants, drains to the
parasternal lymph
nodes or to the
opposite breast.
Lymph from
breast->Interpectoral
"Rotter's" lymph nodes -> axillary lymph nodes->
Dr. Mavrych,
MD, PhD,
clavicular nodes-> R lymphatic duct or L Thoracic duct -> subclavian vs >brachiocephalic vs -> SVC-> heart
Rotter's nodes are a way breast cancer can metastasize by bypassing axillary nodes
Mastectomy
Breast infection
l
Radical mastectomy, a more extensive surgical

procedure, involves removal of the breast, pectoral
muscles, fat, fascia, and as many lymph nodes as
possible in the axilla and pectoral region.
1. During a radical mastectomy, the long thoracic
nerve may be lesioned during ligation of the lateral
thoracic artery. A few weeks after surgery, the
female may present with a winged scapula and
weakness in abduction of the arm above 90
because serratus anterior m. paralysis.
2. The intercostobrachial nerve may also be
damaged during mastectomy, resulting in skin
deficit of the medial arm. T2 intercostal n branch gives
sensation to skin of axilla and

medial cutaneous arm
Mastitis is an infection of the tissue

of the breast that occurs most
frequently during the time of
breastfeeding (1 to 3months after the
delivery of a baby).
This infection causes pain, swelling,
redness, and increased temperature
of the breast.
It can occur when bacteria, often from
the baby's mouth, enter a milk duct
through a crack in the nipple.
It can occur in women who have not
recently delivered as well as in women
after menopause.
22. Thoracic wall & Diaphragm:

Intercostal spaces
Diaphragm:
Paralysis of half and ruptures
C3, 4, 5 keeps the Diaphragm alive!
Intercostal blood vessels

and nerves:
l run between the
internal intercostal and
innermost intercostal
muscles in the costal
groove
l arranged from superior
to inferior as vein,
artery, nerve
Paralysis of the half

of the Diaphragm
may result from injury
or operative division of
the phrenic nerve of
same side
It can be detected
radiologically.
Paradoxical
movement: dome of
diaphragm of injured
side pushed superiorly
by abdominal viscera
during inspiration
Flail Chest: One or more broken ribs in two separate places instead of descending
upon inspiration the broken area will sink in as chest wall moves out
upon expiration the broken area will push out as chest wall moves in
Dangerous bc lungs can be punctured
l
Most vulnerable
structures intercostal
nerve and posterior
intercostal artery
because they are not
covering by ribs.
Skin->Fascia->Fat->External Intercostal m \\ //->Internal Intercostals // \\

-> Intercostal VAN-->Innermost Intercostals == -> Fascia -> Parietal Pleura-->
Thoracocentesis: Ribs 9-10 (9th intercostal space), above rib avoid VAN, remove fluid in
pleural cavity
Pericardiocenetesis: Left 5-6th intercostal space near sternum, Infrasternal (xiphoid) angle up
to left shoulder for Cardiac Tamponade due to Pleural effusion
Phrenic nerve
Bochdalek Hernia: common hernia on the posterolateral L side of diaphragm,

fatal congenital hernia that causes pulmonary hypoplasia.
Morgangi Hernia: rare hernia on anteromedial R side of diaphragm, not fatal bc
musculature typically creates spincter
Sliding hernia: Stomach slides up through diaphragm bc of short esophagus
Rolling/paraesophageal hernia stomach slides up next to esophagus
Diaphragmatic ruptures
l
Arises from the anterior

branches C3-C5 nerves and
lies in front of the anterior
scalene muscle.
Runs anterior to the root of
the lung,, whereas the vagus
nerve runs posterior to the
root of the lung.
Innervates the fibrous
pericardium, the
mediastinal and
diaphragmatic pleurae
(sensory innervation), and
the diaphragm for motor
and its central tendon for
sensory.
Diaphragmatic injuries are

relatively rare and result from
either blunt trauma or
penetrating trauma.
Presently, 80-90% of blunt
diaphragmatic ruptures result
from motor vehicle crashes.
The majority (80-90%) of blunt
diaphragmatic ruptures have
occurred on the left side.
side
Blunt trauma typically produces
large radial tears measuring 5-15
cm, most often at the
posterolateral aspect of the
diaphragm.
I ate 10 eggs at noon! Vessels entering the diaphragm

Inferior vena cava T8
Esophagus T10
Aorta T12
P-A projection
23. Cardiac hypertrophy

Left atrial enlargement
(hypertrophy) secondary to
mitral valve failure may
compress on the
esophagus and manifest
as dysphagia (difficulty in
swallowing).
l It may be observed as a
filling defect in the
esophagus by barium
swallow on the lateral
thoracic X-Ray
mitral valve failure/tenting keeps
causes mitral regurgitation into L
atrium during systole, pressure
dilates the LA as well as
decreases BP causing heart to
work harder to pump blood to
aorta resulting in hypertrophy
Cardiac Shadow
Right border is formed by:

1. SVC,
2. Right atrium
Left border is formed by:
1. Aortic arch
2. Pulmonary trunk
3. Left auricle
4. Left ventricle
24. Auscultation of Heart

Valves
Auscultation sites for

mitral and aortic murmurs
Right 2 ICS
PSL
Left 2 ICS
PSL
Left 4 ICS
PSL
Left 5 ICS
MCL
A heart murmur is heard downstream
l
l
VALVE
ANAT.
AUSCULTATION SITE
Dr. Mavrych,
MD,
PhD,LOCATION
P
3rd CC
2nd LT ICS
A
3rd ICS
2nd RT ICS
M
4th CC
cardiac apex (5th Lt ICS MCL)
T
4th ICS
Rt inferior most ST (5th RT ICS)
(3344)
(2255)
25. Conducting System

of the Heart
Sinoatrial (SA) node
l
regurgitation
Stenosis
Aortic Systole (HOOT Dub)
Pulm Systole (HOOT Dub)
Tricuspid Diastole (Lub hoot)
Mitral Diastole (Lub hoot)
Regurgiation
Aortic Diastole (Lub hoot)
Pulm Diastole (Lub hoot)
Tricuspid Systole (hoot Dub)
Mitral Systole (hoot Dub)
26. Blood supply of the Heart:

Right coronary artery (RCA)
site where contraction of heart muscle is

initiated (pacemaker of the heart)
Crista Terminalis separates
l situated in the upper part of the sulcus
terminalis just near to the opening of pectinate muscles w/ sinus
the SVC
venarum
Atrioventricular (AV) node
l the AV node receives impulses from the
SA node; situated in the lower part of
the atrial septum near coronary sinus
Atrioventricular bundle of His
l descends from the AV node to the
membranous portion of the ventricular
septum where it divides into the left and
right bundle branches
l Right bundle branch passes down to
reach the moderator band - right
ventricle Septomarginal trabeculae
l left bundle branch passes down left
side of ventricular septum
l
from the valve:
stenosis is orthograde direction from valve

insufficiency is retrograde direction from valve
It supplies major parts of the right

atrium and the right ventricle.
It anastomoses with the marginal
branch of the left coronary artery
posteriorly
Branches:
1. Anterior cardiac branches
supplies the right atrium
2. Nodal branch supplies the (1) SA
node, (2) AV node
3. Marginal artery supplies the right
ventricle Small cardiac vein
4. Posterior interventricular artery
supplies (1) diafragmatic (inferior)
surface of both ventricles and (2)
posterior 1/3 of the IV septum
l
l
Middle cardiac vein
Purkinje Fibers throughout walls of ventricles

stimulate contractile cells
Dr. Mavrych,
PhD,ofDSc
Triangle
of Koch: MD,
Location
AV node
in R Atria
Valve of coronary sinus (Thebesian) & IVC (Valve of Eustice) meet
to form tendon of todaro, which joins the Septal leaflet of Tricuspid valve
Left coronary artery

(LCA)
Blood supply of the conducting

system
"Widow Maker"
Branches:
1. Anterior (descending)
interventricular artery most
common place of MI descends in the
anterior interventricular sulcus and
provides branches to the (1) anterior
heard wall, (2) anterior 2/3 of IV
septum, (3) bundle of His, and (4)
Great cardiac vein
apex of the heart.
2. Circumflex artery winds around the
left margin of the heart in the
atrioventricular groove to anastomose
with the right coronary artery
posteriorly; supplies the left atrium
and left ventricle
SA node RCA
AV node RCA
AV bundle (and
moderator band)- LCA
mo
When
l
a MI occurs, a coronary bypass
graft can be completed using the
internal thoracic artery (used to be Great
saphenous v)
Great cardiac v, middle cardiac v, small cardiac v, L marginal v drain into Coronary Sinus which empties in Triangle of Koch at RA
27. Congenital cardiac defects:

Atrial Septal Defect (ASD)
Ventricular Septal
Defect (VSD)
It is less frequent than

VSD
l Ventricular septal defect
(VSD) is the most common
l It results from failure to
of the congenital heart defects
close of the foramen
l It may be found in the
ovale after birth (failure of
membranous part of the
the septum primum and
ventricular septum and
septum secundum to
results from failure to fuse of
fuse) Patent Foramen Ovale
the membranous portion with
the muscular portion of the
l Postnatally, ASDs result
ventricular septum
in left-to-right shunting
l In this case, present leftto(between right and left
right shunt (right ventricular
atrium) and are nonhypertrophy (RVH)) and
cyanotic conditions.
again non-cyanotic.
l If it is small, has no
l Necessary surgery for large
clinical significance & if
defects
large - necessary surgical
Muscular VSD rarest when there is a hole
repair
in the trabeculated inferior ventricle wall
Ostium secundum: MOST common resorption of lower septum primum or incomplete septum secundum
(fatal)
leaves open foramen ovale
Ostium primum: non fusion of septum primum with septum intermedium leaves open foramen primum
Hypoplastic L heart syndrome: premature closure of FO leaving underdeveloped L heart
l
Patent Ductus Arteriosus (PDA)

It results from failure of the ductus
arteriosus (a connection between the
pulmonary trunk and aorta)) to constrict and
close after birth.
l Prostaglandin E and low O2 tension sustain
patency of the ductus arteriosus in the fetal
period.
l PDA is common in premature infants and in
cases of maternal rubella infection.
l Left to-right shunt increased pressure in
pulmonary circulation (pulmonary
hypertension) and is non-cyanotic
l Treatment: surgical division and ligation
imperative. In great danger is left recurrent
nerve (wrapping aorta arch). Injure of this
nerve results in hoarseness.
Ductus arteriosus (fetal lung bypass from pulmonary trunk to aorta) should immediately
close post birth by contraction of muscular wall and become lig. arteriosus, L recurrent
laryngeal
n (CNX)
wrapsDSc
around
it. Increase BP post birth creates increased BP in pulm
Dr.
Mavrych,
MD, PhD,
circulation, less blood to body slightly decreases O2
l
Aneurysm of the aorta

l
Aneurysm of the aortic arch:

compresses the left recurrent
laryngeal nerve,, leading to
coughing, hoarseness, and
paralys is of the ipsilateral vocal
cord. It may cause dysphagia
(difficulty in swallowing), resulting
from pressure on the esophagus,
and dyspnea (difficulty in
breathing), resulting from
pressure on the trachea, root of
the lung, or phrenic nerve
Aneurysm of the thoracic aorta

may compress and tug on the
trachea with each cardiac systole
so that the aneurysm can be felt
by palpating the trachea at the
sternal notch (T2).

L Recurrent Laryngeal n innervates Intrinsic Laryngeal ms: Posterior
cricoarytenoid (PCA)-abducts vocal cords*, Transverse arytenoid-whisper,
Thyroarytenoid-low pitch, vocalis-opera singer
Abdominal aortic aneurysm

l
Coarctation of the Aorta
It is a localized dilatation of the

aorta. It is typically happened
just above of the bifurcation at
level of L4 and crossed by 3rd
part of duodenum.
Pulsations of a large aneurysm
can be detected to the left of
the midline at the umbilical
region.
Acute rupture of an abdominal
aortic aneurysm is associated
with severe pain in the
abdomen or back (mortality rate
is nearly 90%).
Surgeons can repair an
aneurysm by opening it and
inserting a prosthetic graft.
28. Aspiration of Foreign

Bodies & Bronchopulmonary
segments
It results from congenital

narrowing of the aorta distal to the
offshoot of the left subclavian
artery.
l Cardinal clinical sign: higher blood
pressure in the upper limbs
compared to the lower limbs.
l Coarctation of the aorta results in
the intercostal arteries providing
collateral circulation between the
internal thoracic artery and the
thoracic aorta to provide blood
supply to the lower parts of the
body
l Coarctation of the Aorta
characteristic X-ray picture:
serrated appearance of inferior
borders of ribs (rib
rib notching)
notching
Preductal stenosis proximal to ductus arteriosus causes deoxygenated blood w/
lowMD,
BP to
the DSc
body (life
threatening)
Dr. Mavrych,
PhD,
Postductal stenosis w/ obliterated ductus ateriorsus is more common
l
Right lung:
10 bronchopulmonary segments
Aspiration of Foreign Bodies:

l
Inhalation of FBs (e.g. pins,
parts of teeth, screws, nuts,
bolts, toys) into the lower
respiratory tract is common,
especially in children
l
More likely to enter the right
primary bronchus and pass into
the middle or lower lobe
bronchi
l
If the vertical position of the
body, the foreign body usually
falls into the posterior basal
segment of the right inferior
lobe.
Laying down on back, it will go into posterior superior lobe
Dr. Mavrych, MD,
PhD,
Liquids
(Mendleson
syndrome) will go to BOTH superior
segmental bronchus of Lower Lobes (SULL)
Superior lobe:
1. Apical
2. Anterior
3. Posterior
Middle lobe:
4. Lateral
5. Medial
Inferior lobe:
6. Superior
7. Anterior basal
8. Posterior basal
9. Lateral basal
10. Medial basal
1
3
2
6
10
9
29. Lung diseases:

Pneumonia
l
1
l
2
l
9
6
Left lung:
9 bronchopulmonary segments
Superior lobe:
1. Apicoposterior
2. Anterior
3. Superior lingularsurrounds cardiac notch
4. Inferior lingular
Inferior lobe:
5. Superior
6. Anterior basal
7. Posterior basal
8. Lateral basal
9. Medial basal
Pneumonia is an inflammation
of the lung, caused by an
infection or chemical injury to the
lungs.
Three common causes are
bacteria, viruses and fungi.
Symptoms: cough, chest pain,
fever, and difficulty in breathing.
Chest x-rays: areas of opacity
(seen as white) of the lung
parenchyma and enlargement of
bronchomediastinal lymph
nodes (mediastinal widening).
Bronchogenic Carcinoma
Bronchogenic carcinoma
may lead to:
1
l
l
Arises in the mucosa of the

large bronchi
Produces as persistent,
productive cough or
hemoptysis spitting blood
Early metastasis to thoracic
(bronchomediatinal) lymph
nodes
Hematogenous spread to the
brain, bones, lungs,malignant cells
suprarenal glands spread through blood
A tumor at the apex of the
lung (Pancoast
(
tumor)) may
result in thoracic outlet
syndrome
1. Thoracic outlet syndrome ((TOS)

TOS)
l It can cause pressure on the lower
trunk of the brachial plexus C8-T1
and subclavian artery by cervical
rib or pancoast tumor. It results in
pain down the medial side of the Blue arm
forearm and hand and atrophy of
the intrinsic hand muscles)
2. Horner syndrome: compression of cervical
sympathetic trunk
symp
l miosis - constriction of the pupil
due to paralysis of the dilator
pupillae muscle Long ciliary n of CNV1-> SNS br
l ptosis - drooping of the eyelid due
to paralysis of the superior tarsal
muscle pseudoptosis bc NOT CNIII lesion
SNS compression to smooth ms
l hemianhydrosis - loss of sweating
on one side Sweat glands are SNS
Qs about Auscultation
and penetrated wounds
Bronchogenic carcinoma
may lead to:
3. Superior vena cava
syndrome, which causes
dilation of the head and
neck veins, facial swelling,
and cyanosis Blue Face & arm
4. Dysphagia as a result of
esophageal obstruction
5. Hoarseness as a result of
recurrent laryngeal nerve
involvement
6. Paralysis of the
diaphragm as a result of
phrenic nerve involvement
3
6
30. Open pneumothorax &

pleura
l
l
It is entry of air into a pleural

cavity causing lung collapse.
Open pneumothorax due to stab
wounds of the thoracic wall which
pierce the parietal pleura so that
the pleural cavity is open to the
outside air via the lung or through
the chest wall.
Air moves freely through the
wound during inspiration and
expiration. During inspiration, air
enters the chest wall and the
mediastinum will shift toward other
side and compress the opposite
lung. During expiration, air exits
the wound and the mediastinum
moves back toward the affected
side.
To listen to breath sounds of the

superior lobes of the right and left
lungs, the stethoscope is placed on
the superior area of the anterior
chest wall (above the 4th rib for the
right lung & above 6th for the left
one).
For breath sounds from the
middle lobe of the right lung, the
stethoscope is placed on the
anterior chest wall between the 4th
and 6th ribs
For the inferior lobes of both
lungs, breath sounds are primarily
heard on the posterior chest wall.
Pleura & Pleural Cavity
1. Cervical pleura may be affected in

case of improper subclavian
venipuncture.
2. Costodiaphragmatic Recess is
deepest place in pleural cavity, around
the chest wall, there are two rib
interspaces separating the inferior
limit of parietal pleural reflections from
the inferior border of the lungs and
visceral pleura:
Midclavicular line - between ribs 6-8
Midaxillary line - between ribs 8-10
Paravertebral line between ribs 10-12
1.
2.
3.
Costodiaphragmatic Recess is where fluid is

retained during pleural effusion
Stab Wounds & Open pneumothorax:
Straight in air can move in and out with each respiratory cycle, No air trapping (listen to ventilation of wound)
At an angle air can move in with inspiration BUT with expiration skin acts as flap and closes trapping air inside collapsing the lung
Nerve supply of the pleura
31. Mediastinum
Superior
p
mediastinum
Parietal Pleura sensitive to general

sensibilities (pain, temperature, touch,
and pressure) - somatic sensory
innervation:
l costal pleura intercostal nerves
block may be used to decrease
thoracic pain
l mediastinal pleura phrenic nerve
l diaphragmatic pleura phrenic nerve
over the domes and lower 6 intercostal
nerves around the periphery
Improperly done
sternal puncture
may affect
structures related
to the posterior
surface of the
manubrium
sternum:
l In upper part
Left
brachiocephalic
vein
l In lower part
Aortic arch
Azygous vein and ascending
aortic arches
Trachea and Pulmonary artery
bifurcations
esophagus and thoracic duct
change directions (cross over)
l
Visceral Pleura sensitive to stretch but

insensitive to general sensibilities;
autonomic nerve supply from the
pulmonary plexus
Cervicothoracic Stellate Gangion down to T11 and Subcostal sympathetic ganglion comprise the thoracic
Ribs 1-2 down to transverse thoracic
sympathetic trunk
Dr. muscles
Mavrych,ofMD,
PhD,(T2)/Plane
of ludwig/angle of louis
Innervate
the PhD,
ribs, abdominal
wall, pulmonary and cardiac plexus, and esophageal plexus Dr. Mavrych, MD,plane
Vagus CNX assists plexus of thorax for vocal cords and swallowing, and gives off recurrent laryngeal and
superior external laryngeal to the larynx muscles
Pericardial sinus: behind pulm trunk and aorta place fingers to

clamp/ligate great vessels during surgical procedures
Thoracic duct
A Duck between 2 Gooses

Thoracic duct between azygos v and esophagus
Constrictions of the esophagus

25cm long/10in Barium swallow allows Xray visualization
Function conveys to the

blood all lymph from the
lower limbs, pelvic cavity,
abdominal cavity, left side
of the thorax, left side of
the head & neck, and left
upper limb ((3/4
3/4 of the
body)
Tributaries at the root of the

neck
l Left jugular lymph trunk
l Left subclavian lymph
trunk
l Left bronchomediastinal
lymph trunk
There are sites where ingested

foreign bodies can lodge or
where strictures may develop
following ingestion of caustic
fluids, common sites of
esophageal carcinoma
1. C6 - where the pharynx joins

the upper end (6" from the 15cm
upper incisors)
2. T4-T5 - where the aortic arch
and left main bronchus cross 22.5-27.5cm
its anterior surface (10" from the
upper incisors)
3. T10 - where it passes through
the diaphragm into the
stomach (16" from the upper 40cm
incisors)
R lymphatic duct drains 1/4 of body from R jugular

lymph trunk, R subclavian lymph trunk, and R
bronchomediastinal lymph trunk
32. Anterior abdominal wall

l
Referred abdominal pain
The liver and gallbladder

are in the right upper
quadrant;
The stomach and spleen
are in the left upper
quadrant;
RH
The cecum and appendix

are in the right lower
quadrant;
The end of the descending
colon and sigmoid colon
are in the left lower
quadrant.
RL
RI
LH
LL
LI
Pain arising out of the

foregut derived structures
is referred to the
epigastric region.
region

midgut derived structures
is referred to the
umbilical region.

hindgut derived
structures is referred to
the hypogastric region.
of abdominal
Camper's Fascia, Scarpa's Fascia, Galludets Fascia (superficial
Ext oblique),
Oblique
\\//, (deep ext oblique, superficial int oblique),
Dr. Layers
Mavrych,
MD, PhD, wall:
DSc Skin,
Dr. Mavrych,
MD,Ext
PhD,
DSc m
Inter Oblique m //\\, (deep int oblique, superficial transversalis ab), Transversalis abdominus m, deep TA fascia, Extraperitoneal fat, parietal peritoneum
.
Arcuate line is where lateral abdominal ms tendons merge with Rectus abdominus (linea semilunaris), Above arcuate line int oblique superficial fascia is above rectus abdominus (3 layers
of fascia), Below arcuate line ALL fascias above rectus abdominis (6 layers) typically inferior to umbilicus
Nerve supply of the

anterior abdominal wall
l
33. Herniations
Hernia consist of 3 parts:
Indirect Inguinal Hernia
Important DEEP ARTERIES lie in

the neurovascular plane:
plane
1. Superior epigastric internal thoracic a
2. Posterior intercostals arteries
3. Lumbar arteries
4. Deep circumflex iliac artery
external iliac a
5. Inferior epigastric
from femoral a just past
femoral ring (inguinal lig)
PortalMD,
Caval
anastamosis
of paraumbilical veins off hepatic portal v with superficial
Dr. Mavrych,
PhD,
epigastric veins (Caput Medusae- swiggly veins on belly button)
Transversalis fascia is the FIRST

STRUCTURE which is crossed by
any abdominal hernia
Hernial sac is a pouch

(diverticulum) of peritoneum and
has a neck and a body
Hernial contents may consist of
any structure found in the
abdominal cavity (more offen
loops of small intestine and
piece of omentum major)
Hernial coverings are formed
from the layers of the abdominal
wall through which the hernial
sac passes
Important SUPERFICIAL
ARTERIES ((supply
supply skin)
skin are:
1.
Superficial epigastric
from femoral a
2.
Superficial circumflex iliac
Therefore totally 7 nerves:

lower 5 intercostals, 1
subcostal and L1
(iliphypogastric and
ilioinguinal) nerves supply
ilioinguinal
the anterior abdominal wall.
L1 can be anaesthetized by
injecting 1 inch (2.5 cm)
superior to the anterior
superior iliac spine.
All nerves and deep blood
vessels lie in the
neurovascular plane:
between internal oblique
and transversus muscles
T5-T11
T12
L1
Arterial supply of the anterior

abdominal wall:
Indirect inguinal hernia is the most

common form of hernia and is believed
to be congenital in origin (boys 0-3
years).
It passes through the deep inguinal ring
lateral to the inferior epigastric
vessels, inguinal canal, superficial
inguinal ring and descend into the
scrotum.
An indirect inguinal hernia is about 20
times more common in males than in
females, and nearly 1/3 are bilateral.
It is more common on the right
(normally, the right processus vaginalis
becomes obliterated after the left; the
right testis descends later than the left).
aponerocis of internal
oblique fascia and
tranversalis fascia
TIE ICE
Transversalis Fascia becomes Internal Spermatic Fascia
Internal Oblique m & Fascia becomes Cremasteric m & Fascia
External Oblique fascia becomes External Spermatic Fascia
Surrounds the Spermatic cord within the inguinal canal:
3 as: cremasteric (inferior epigastric), ductus deferans (internal iliac-inferior vesicle),
gonadal a (aorta)
3 ns: genital br (motor genitofemoral), ANS, ilioinguinal
3 others: Pampiniform plexus (IVC and Lrenal), Ductus Deferens, Lymphatics
Process Vaginalis/Gubernaculum
Direct Inguinal Hernia

l
l
Direct inguinal hernia composes

about 15% of all inguinal hernias.
During a direct inguinal hernia,
the abdominal contents will
protrude through the weak area of
the posterior wall of the inguinal
canal medial to the inferior
epigastric vessels in the inguinal
[Hesselbach's] triangle and after
that through superficial inguinal
ring. It never descends into the
scrotum.
It is a disease of old men with
weak abdominal muscles. Direct
inguinal hernias are rare in women,
and most are bilateral.

Mavrych,
PhD, DSc
Insertprof.mavrych@gmail.com
finger into superficial inguinal ring, if you can feel hernia at TIP Dr.
of finger
than itMD,
is indirect
hernia
at the lateral inguinal fossa.
If you can feel something lateral to finger it is direct hernia pushing towards Hesselbach's triangle (medial inguinal fossa between medial and lateral
umbilical folds. The inferior epigastric vessels reside within Lateral umbilical fold (functional), the inferior border is the inguinal lig.
34. Peritoneal structures:

Lesser omentum
Epiploic (winslows) foramen
Consist of 2 ligaments:
l hepatogastric
l hepatoduodenal
Contents :
l Right & Left gastric
vessels
l Connective and fatty
tissue
and Portal triad:
l Bile duct
l Portal vein
l Proper hepatic artery
Anteriorly: The free

border of the
hepatoduodenal
ligament, containing
portal triad (DVA).
Posteriorly: IVC
Superiorly: Caudate
lobe of the liver.
Inferiorly: The 1st

part of the
duodenum.
Site of Pringles Manuver to block blood supply to liver and investigate

Dr. Mavrych,
Liver bleeds: block Hepatic Artery Proper, Hepatic
Portal MD,
Vein,PhD,
and Common
Bile Duct. Use thumb anterior, and index posterior within Winslow foramen.
If R side bleeds: aberrant R Hepatic artery from SMA
If L side bleeds: aberrant L Heptatic artery from L Gastric
If double bleed accessory arteries come from elsewhere.
Douglas (rectouterine) pouch
Culdocentesis
In women only!
l
l
Rectouterine pouch
(pouch of Douglas):
deeper point of
peritoneal space in
vertical position of the
female body between the
rectum and the cervix of
uterus.
It is space of the pelvic
abscess location.
Vesicouterine pouch
Culdocentesis is
aspiration of fluid from
the cul-de-sac of
Douglas (rectouterine
pouch) by a needle
puncture of the
posterior vaginal
fornix near the midline
between the uterosacral
ligaments
Because the
rectouterine pouch is
the lowest portion of
the female peritoneal
cavity, it can collect
inflammatory fluid
(pelvic abscess).
Males have a vesicorectal pouch, fluid can accumulate in these peritoneal areas if there is a pelvic abscess.
Dr. Mavrych, MD,
PhD, DSc
Dr.kidney
Mavrych,
Morrison's
pouch
is where fluid accumulates if the person is lying down (between
and MD,
liver)PhD, DSc prof.mavrych@gmail.com
FOREGUT
35. Smart Table

FOREGUT
MIDGUT
HINDGUT
Esophagus
Transverse colon
Duodenum (2nd, 3rd,
(distal 1/3)
Stomach
4th
Descending colon
Duodenum (1st and
parts)
Sigmoid colon
2nd parts)
Jejunum
Rectum (anal canal
Ileum
Liver
above pectinate line)
Cecum (with
Pancreas
Appendix)
Biliary apparatus
IMV to splenic v to
Ascending colon
Gallbladder
hepatic portal v to liver
1st part duodenum is
Transverse colon
to IVC
suspended by greater
(proximal 2/3)
SMV joins splenic v to
omentum and hepato
form hepatic portal v
2nd part of duodenum is
duodenal lig
where Spincter of Oddi/
Ampula of Vader/major
papilla of the Wirsung major
Pancreatic
duct empties
along with the common bile
duct
MIDGUT
HINDGUT
Artery: CA
Artery: SMA
Artery: IMA
Parasympathetic
innervation: vagus
nerves, CNX
Parasympathetic
innervation: vagus
nerves, CNX
Parasympathetic
innervation: pelvic
splanchnic nerves, S2-S4
Sympathetic
innervation:
Preganglionics: greater
splanchnic nerves, T5-T9
Postganglionics:
celiac ganglion
Sympathetic
innervation:
Preganglionics: lesser
splanchnic nerves, T10T11
Postganglionics:
superior mesenteric
ganglion
Sympathetic
innervation:
Preganglionics: lumbar
splanchnic nerves, L1-L2
Postganglionics: inferior
mesenteric ganglion
Sensory Innervation:
DRG T5-T9
DRG T10-T11
DRG L1-L2
Referred Pain:
Epigastrium
Referred Pain:
Umbilical
Referred Pain:
Hypogastrium
Dr. Mavrych,
Retroperitoneal
Organs: MD,
SAD PhD,
PUCKER
Suprarenal glands, Aorta, Duodenum (2-3rd), Pancreas, Ureters, Colon, Kidneys, Esophagus, Rectum
DPC are secondary retroperitoneal
37. Congenital diaphragmatic

hernia
36. Posterior gastric ulcer

1. Posterior gastric ulcer may
erode through the posterior
wall of the stomach into the
Omental bursa (Lesser
peritoneal sac) and affect
pancreas resulting in
referred pain to the back.
2. Erosion of splenic artery is
very common in posterior
gastric ulcers as well
because of the proximity of
the artery to this wall.
This can damage the vagal

trunks as they pass through
the hiatus and resulting in
hyposecretion of gastric
juice.
Often due to shortened esophagus
Colon
l
Features of the large intestine:
2.
3.
l
Appendices epiploic
Sacculations
(haustrations)
Taeniae coli
The taeniae coli meet
together at the base of
the appendix where they
form a complete
longitudinal muscle coat
for the appendix.
Meckel's diverticulum is a congenital

anomaly representing a persistent portion of
the vitellointestinal duct.
This condition is often asymptomatic but
occasionally becomes inflamed if it contains
ectopic gastric, pancreatic, or endometrial
tissue, which may produce ulceration.
Meckel's diverticulum is located on the
Ileum about 2 feet (61 cm) before the
ileocecal junction and SMA supply it. It
occurs in 2% of patients and is about 2 inches
(5 cm) long.
The diverticulum is clinically important
because diverticulitis, liberation, bleeding,
perforation, and obstruction are complications
requiring surgical intervention and frequently
mimicking the symptoms of acute
appendicitis.
commonly presents at 2yo, 2:1 males to females

40. Features of the large

intestine
1.
It is seen in infants
and the mortality rate is
high because of left
lung hypoplasia.
39. Meckel's
diverticulum
Outpouch of intestines into rectum
A sliding hiatal hernia which

occurs in individuals past
middle age is caused by
the hernia of cardia of the
stomach into the thorax
through the esophageal
hiatus of the diaphragm.
Fundus of stomach through
Hernia of stomach or
intestine through a
posterolateral defect
in diaphragm
(foramen of
Bochadalek).
Improper fusion of pleuroperitoneal

membranes with septum transversarus
Most L sided bc liver and R side closes first.
38. Sliding hiatal hernia

l
The ascending colon lies

retroperitoneally and lacks a
mesentery.
It is continuous with the
transverse colon at the right
(hepatic) flexure (1) of colon.
The transverse colon (3) has
its own mesentery called the
transverse mesocolon
(intraperitoneal position).
It becomes continuous with the
descending colon at the left
(splenic) flexure (2) of colon.
The sigmoid colon (4) is
suspended by the sigmoid
mesocolon (intraperitoneal
position).
1
3
Ascending colon (R colic a, iliocolic a w/ appendicular a-SMA)

Transverse colon (Middle colic a, marginal a-SMA)
Dr. Mavrych,
MD, PhD,
DSc
Descending
colon
(L colic
a-IMA)
Sigmoid colon (Sigmoid branches of IMA)
Rectum (Superior Rectal a from IMA, Inferior and medial rectal-internal iliac a)
41. Pain of Appendicitis
Mc Burney's point
In appendicitis, first pain is

referred around the umbilicus.
Visceral pain in the appendix is
produced by distention of its
lumen or spasm of its muscle.
The afferent pain fibers enter
the spinal cord at the level of
T10 segment,
segment and a vague
referred pain is felt in the region
of the umbilicus.
Later if parietal peritoneum

gets involved, and then the pain
is shifted laterally to the Mc
Burneys point. Here the pain
is precise, severe, and localized
(second pain)
This point indicates

the surface marking
of the base of the
appendix.
It is a point at the
junction between the
lateral 1/3 and
medial 2/3 of a line
joining the right
anterior superior iliac
spine with the
umbilicus.
McBurney's point lies 2/3 from umbilicus to ASIS OR 1/3 from ASIS to umbilicus
42. Volvulus
43. Hirschsprung's Disease

l
l
Because of its extreme mobility,

the Jejunum, Ileum and
Sigmoid colon sometimes
rotates around its mesentery.
It results in avascular necrosis
corresponding part of interstine.
This may correct itself
spontaneously, or the rotation
may continue until the blood
supply of the gut is cut off
completely.
l
l
It is a rare congenital abnormality that

results in obstruction because the
intestines do not work normally.
It is commonly found in Down Syndrome
children. males>females
The inadequate motility is a result of an
aganglionic section (congenital absents
of postganglionic parasympathetic
neurons inside of the intestinal wall) of the
intestines resulting in megacolon.
In a newborn, the main signs and
symptoms are failure to pass a
meconium stool within 1-2 days after
birth, reluctance to eat, bile-stained
(green) vomiting, and abdominal
distension.
Treatment is removal of the aganglionic
portion of the colon.
NCCs did not travel correctly to the colon resulting in lack of

innervation
to the large bowel, no parastalic movements results in
megacolon
44. Branches of Abdominal aorta

and Mesenteric ischemia
l
l
l
l
Celiac trunk (CA) originates

from the aorta at the lower
border of T12 vertebra
Superior mesenteric artery
originates at the lower
border of L1 vertebra
Renal arteries originate at
approximately L2 vertebra
Inferior mesenteric artery
originates at L3 vertebra
Two terminal branches are
common iliac arteries at
the level of L4 vertebra
CELIAC ARTERY (TRUNK)

l
Origin: T12, just below the

aortic opening of the between crura of
diaphragm
diaphragm.
The CA passes above the

superior border of the
pancreas and then divides
into three retroperitoneal
branches:
Left gastric artery (1)
Common hepatic artery (2)
Splenic artery (3)
3
2
l
l
l
Ovarian/testicular (gonadal) as arise between L2-3
1st off Celiac Trunk
2nd off Celiac Trunk
Left gastric artery
Common hepatic artery
The left gastric artery (1)

courses upward to the left to
reach the lesser curvature of
the stomach and may be
subject to erosion by a
penetrating ulcer of the
lesser curvature of the
stomach.
Branches:
l Esophageal branches (2) - to
the abdominal part of the
esophagus
l Gastric branches (3) supply
the left side of the lesser
curvature of the stomach and
make anastomosis with right
gastric artery.
l
OFF Common Hepatic a of Celiac Trunk
Proper hepatic artery

l
4
3
1
2
l
2
1
l
l
The common hepatic artery

(1) passes to the right to
reach the superior surface of
the first part of the duodenum,
where it divides into its two
terminal branches:
Proper hepatic artery (2)
Gastroduodenal artery (3)
OFF Common Hepatic a of Celiac Trunk
Gastroduodenal artery
Proper hepatic artery (1) gives

off right gastric artery (2) and
then ascends within the
hepatoduodenal ligament of the
lesser omentum to reach the
porta hepatis, where it divides
into the right (4) and left (3)
hepatic arteries.
The right and left arteries enter the
two lobes of the liver,, right
hepatic artery gives cystic artery
(5) to the gallbladder.
Right gastric artery (2) supplies
the right side of the lesser
curvature of the stomach where it
anastomoses the left gastric
artery.
2
l
Gastroduodenal artery (1)

descends posterior to the first
part of the duodenum (may be
penetrating ulcer in this place)
and divides into two branches:
Right gastroepiploic artery (2)
(supplies the right side of the
greater curvature of the
stomach where it anastomoses
the left gastroepiploic)
Superior pancreaticoduodenal
arteries (3) (supply the head of
the pancreas, where they
anastomoses the inferior
pancreaticoduodenal arteries
from the SMA).
3rd off Celiac Trunk
Splenic artery
Ligature of the hepatic artery:

l
The hepatic artery may be

ligated proximal to the origin
of its gastroduodenal branch,
a collateral circulation to the
liver is established through
the left and right gastric
arteries, left and right
gastroepiploic and
gastroduodenal arteries.
The right hepatic artery

may be mistakenly ligated
during holecystectomy in
Calot triangle together with
the cystic artery, right lobe
hepatic necrosis commonly
occurs.
Anastamoses of the L gastric, L

gastroepiploic, and Lgastroduodenal
arteries with the R side will cause
retrograde flow into the proper hepatic
artery to supply the liver
Splenic artery (1) runs a

tortuous horizontal course to
the left along the upper border
of the pancreas, behind the
peritoneum of the posterior
wall of the lesser sac, forming a
part of the stomach bed.
The splenic artery may be
penetrating ulcer of the
posterior wall of the stomach
into the lesser sac.
sac
N.B. The splenic vein runs a
more straight course below the
artery and behind of the
pancreas.
SUPERIOR MESENTERIC ARTERY (midgut)
Splenic artery BRANCHES

Splenic (1) a. is retroperitoneal
until it reaches the tail of the
pancreas, where it enters the
2
splenorenal ligament to enter
the hilum of the spleen.
4 Branches:
l Branches to the spleen (2)
l Branches to the neck, body, and
tail of pancreas (3)
l Left gastroepiploic (4) artery that
supplies the left side of the
greater curvature of the stomach
where it anastomoses the right
gastroepiploic
l Short gastric (5) branches that
supply fundus of the stomach
5
1
3
6
2
4
SMA Branches:
l (1) Inferior
pancreaticoduodenal
arteries
l (2)Jejunal and
(3)
Ileal branches
l (4) Ileocolic artery
l Ascending branch
l Anterior cecal artery
l Posterior cecal artery
l (5) Appendicular
artery
l (6) Right colic artery
l (7) Middle colic artery
Marginal artery anastamoses the iliocolic a,

vasa recta-SMA, with the L colic, sigmoid a
and vasa recta of the IMA
INFERIOR MESENTERIC ARTERY
Mesenteric ischemia
l
IMA Branches:
l (1) Left colic artery
l (2) Sigmoid arteries
l (3) Superior rectal artery
45. Biliary system & gallstones

Bile is secreted by the liver cells,
stored, and concentrated in the
gallbladder and later it is
cystic a from R hepatic
a
delivered
to the duodenum.
l The gallbladder lies in its fossa
on the visceral surface of the
Calot's Triangle
liver right side of quadrate lobe.
l It stores and concentrates bile,
which enters and leaves it
through the cystic duct.
l The cystic duct joins the
common hepatic (from left
and right hepatic) due to form
the common bile duct.
Atherosclerosis, which slows the

amount blood flowing through arteries, is
a frequent cause of chronic mesenteric
ischemia.
Ischemia occurs when blood cannot flow
through arteries as well as it should, and
intestines do not receive the necessary
oxygen to perform normally. Mesenteric
ischemia usually involves SMA and small
intestine.
Mesenteric ischemia primarily affects
organs which locate far away from
anastomoses with CA & IMA. Usually
blood supply of the Jejunum and Ileum is
most compromised.
Mesenteric ischemia typically occurs in
people older than age 60 with history of
smoking and high cholesterol level.
Biliary system
Sphincter of Oddi
Ampula of Vader
Amp
The common bile duct descends in

hepatoduo
ligament,
the hepatoduodenal
ligament,
then passes posterior to the first
part of the duodenum
duo
It penetrates the
t head of the
pancreas where
whe it joins the main
and they form the
pancreatic duct
d
hepatopancreatic ampulla
hepatopancre
(sphincter of
o Oddi)
Oddi), which drains
into posteromedial wall the
second part of the duodenum at the
major duodenal papilla
Tumor in the head of the pancreas can block the duct and cause jaundice
Blockage of the cystic or common bile duct via gall stones can cause gall bladder rupture w/ refered
pain to the shoulder (C3-5 phrenic n), and backflow of pancreatic enzymes that digest the pancreas
and the spleen via splenic artery branches
Cholelithiasis (gallstones)
l
2
l
The distal end of the hepatopancreatic ampulla (Bile duct) is the

narrowest part of the biliary passages
and is the common site for impaction
of gallstones.
As result of common hepatic (1), bile
duct (2), or hepatopancreatic
ampulla (3) obstruction patient will
have yellow eyes and jaundice
Gallstones may also lodge in the
cystic duct. A stone lodged in the
cystic duct (4) causes biliary colic
(intense, spasmodic pain in the
gallbladder) but doesn't produce
jaundice.
Gall stone
the cystic
will cause backflow to the gall bladder (burst)
Dr. Mavrych,
MD,inPhD,
DScduct
Gallstones
l
The fundus [1] of the gallbladder is

in contact with the transverse colon
and thus gallstones erode through the
posterior wall of the gallbladder and
enter the transverse colon. They are
passed naturally to the rectum
through the descending colon and
sigmoid colon.
Gallstones lodged in the body [2] of

the gallbladder may ulcerate through
the posterior wall of the body of the
gallbladder into the duodenum
(because the gallbladder body is in
contact with the duodenum) and may
be held up at the ileocecal junction,
producing an intestinal obstruction.
BUT NOT jaundice bc Common bile duct is still releasing bile properly to the stomach
47. Portal Hypertension &

Portocaval shunts
46. Nerve supply of the liver

and gallbladder
The liver receives parasympathetic innervation

from the vagi nerves (CNX), reaching it through
the celiac plexuses around the supplying arteries.
The preganglionic fibers synapse on the cells of
the uxtramural plexuses in hilum of the liver and
shot postganglionic fibers supply organs.
Portal hypertension is a
common clinical condition, and
for this reason portal-systemic
anastomoses should be
remembered.
Sympathetic fibers of preganglionic neurons

T5-T9 segments (IML) come through the
sympathetic trunk and form greater splanchnic
nerves. They contribute to the celiac plexus,
where postganglionic neurons are located.
Branches of celiac plexus reach the liver wrapping
around the branches of the celiac artery.
[1] Extrahepatic portocaval

shunt for the treatment of
portal hypertension: the
splenic vein may be
anastomoses to the left renal
vein after removing the
spleen.
[2] Intrahepatic portocaval
shunt : between portal vein
and hepatic veins
Sensory innervation of the liver: by the right

phrenic nerve ((C3-C5
(C3-C5).
C3-C5).
C3-C5
). Pain may radiate to the
right shoulder.
shoulder
Large intestine metastases &

Portocaval anastomosis
l
l
l
l
Metastases of the Large intestine

cancer typically rich the Liver via
portal venous system: Rectum IMV - splenic vein - portal vein Liver
If there is an obstruction to flow
through the portal system (portal
hypertension), blood can flow in a
retrograde direction and pass
through anastomoses to reach the
caval system.. Sites for these
anastomoses include:
(1) esophageal veins
(2) paraumbilical veins
(3) rectal veins
Dr.
Diverting blood from portal venous system to the systemic venous system by creating a
communication between the hepatic portal vein and the IVC.
Mavrych,
MD,
PhD,
Side to side
shunts
connecting
the portal system to the IVC, End to side connection with
separation and connection of end and head of portal caval system to IVC. And typical
splenorenal central shunt all allow portion of blood to IVC to decrease flow to liver.
Esophageal anastomosis
l
Anastomosis between the

tributaries of the left gastric
vein (portal vein) and the
tributaries of the azygous
vein (SVC) in the wall of the
lower end of the esophagus.
In portal hypertension these

veins enlarge in the wall of the
esophagus and later burst
into the lumen of the
esophagus (esophageal
varices) resulting in
hematemesis (vomiting red
blood).
(4) R, L and middle colic vs anastamose with

Esophageal branches of the L Gastric v will anastomose with azygous
Renal, suprarenal and gonadal vs, No clinical Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com
name however represents as varicocele on the
abdomen
Rectal anastomosis
Umbilical anastomosis
l

paraumbilical veins (portal
vein) and the superior and
inferior epigastric veins
(SVC and IVC) in anterior
abdominal wall around the
umbilicus.
In portal hypertension, this
anastomosis gets enlarged
and dilated veins form caput
Medussae around the
umbilicus.

superior rectal vein
(inferior mesenteric vein
and then portal vein)
vein and
inferior rectal vein which
drains into the internal iliac
vein (from IVC system).
In portal hypertension
(chronic alcoholics) this
anastomosis gets dilated
resulting in internal
hemorrhoids and bleeding
per anus from superior
rectal vein.
Superior Rectal vein (IMV) anastomoses with middle and inferior rectal vs (internal iliac v &
Dr. Mavrych,
PhD,v)DSc
internalMD,
pudendal
duringprof.mavrych@gmail.com
portal hypertension Rectal varices (Hemorrhoids)
Internal hemorrhoids are painless superior to pectinate line at internal rectal venous plexus.
External hemorrhoids are painful due to blockage of external rectal venous plexus, where
Nociceptors (pain) are located.
48. Pancreas:
Head and uncinate process
l
1st part of Duodenum
2nd part of
duodenum
Cancer of the head

of the pancreas
The head of the pancreas

rests within the C-shaped
area formed by the 1st-3rd parts of
duodenum
duodenum and is
traversed by the common
bile duct.
It includes the uncinate

process which is crossed
by the superior
mesenteric vessels.
4th part of duodenum
Cancer of the head of the

pancreas compresses the bile
duct and results in
OBSTRUCTIVE TYPE OF
JAUNDICE.
Pain will be conveyed to sensory
neurons T5-T9 dorsal root
ganglia via celiac plexus and
greater splanchnic nerve.
This type of jaundice is NOT
usually associated with fever.
Hepatitis also causes jaundice
but is associated with the
fever.
3rd part of duodenum

If the cancer blocks the Wirsung duct, it can cause pancreatic enzymes to digest the
Dr. Mavrych,
MD, PhD,
pancreas
and theDSc
spleen
via splenic artery.
Neck of the pancreas
Body of the pancreas
3
1
Posterior to the
neck of the
pancreas is the site
of formation of the
PORTAL VEIN.
VEIN
(1)Splenic vein
joins with (2)
superior
mesenteric vein to
form (3) portal vein.
The body passes to the

left and anterior to the (1)
aorta and the (2) left
kidney. posterior to the stomach
The (3) splenic artery

undulates along the
superior border of the
body of the pancreas with
the splenic vein coursing
posterior to the body.
body
1
3
2
2
The splenic artery is tortuous and has branches

going down to perforate the pancreas.
Arterial supply of the

pancreas
Tail of the pancreas
Head and Duodenum:

l
The tail of the pancreas

enters the splenorenal
ligament to reach the
hilum of the spleen
spleen.
It is the only part of the
pancreas that is
intraperitoneal.
Tail of the pancreas may
be mistakenly removed
during spleenectomy
(ligation of splenic artery
and vein) and resulting in
sugar diabetes because it
contains a lot endocrine
cells.
Endocrine pancreas contains

islet of langerhans that secretes
insulin (B cells glucose uptake)
and glucagon (A cells glucose
release)
Annular Pancreas
l
l
1.
2.
3.
l
Annular pancreas is caused by

malformation during the
development of the pancreas,
before birth.
Occurs when the ventral and dorsal
pancreatic buds form a ring around
the duodenum,, thereby causing an
obstruction of the duodenum and
polyhydramnios
Symptoms:
Feeding intolerance in newborns
Fullness after eating
Nausea and bile-stained vomiting
(Projectile vomiting)
Half of cases are not diagnosed
until symptoms occur in adulthood.
Polyhyrdaminos (>1500mL) AF in the amnion bc the fetus is unable to

recycle
Also caused by esophageal atresis.
Dr. Mavrych, drink
MD, and
PhD,
DScit.prof.mavrych@gmail.com
Relations of the Spleen and

Left Kidney
l
The spleen follows

the contour of 10th rib
and extends from the
superior pole of the
left kidney to just
posterior to the
midaxillary line.
The border between
spleen and upper
pole of the left kidney
is 11th rib.
parietal lateral plate mesoderm
l
l
3
1
2
(1) Superior
pancreaticoduodenal arteries - Off Common
Hepatic a of
branches of gastroduodenal
Celiac trunk
artery.
(2) Inferior pancreaticoduodenal
arteries - branches of SMA
This region is important for
collateral circulation because
there are anastomoses between
these branches of the CA and
SMA.
Neck, Body, and Tail of the

l
pancreas:
Pancreatic branches of the (3) Off celiac trunk
Splenic artery.
49. Spleen:
RUPTURE
Rapture of the Spleen
l
l
l
Rapture of the spleen may be

result of the left 9th and 10th ribs
fracture or blunt trauma of the
left upper abdomen.
The spleen is a peritoneal organ
in the upper left quadrant that is
deep to the left 9th, 10th, and 11th
ribs.
The spleen follows the contour of
rib 10 (axis of the spleen).
When blood collected deep to the
diaphragm phrenic nerve
irritates and pain may irradiate to
left shoulder.
When spleen is ruptured, it
cannot be sutured therefore
removing is required.
Prenatally the spleen is primary source for hematopoiesis, post birth it is site of RBC
sequester, destruction, and filtration, it produces lymphoctyes and immune
surveillance, it recycles iron and globin. (Not vital organ)
The spleen has gastric, colic, renal, and costal impressions. It contains many
lymphatic nodules, red pulp (blood sinuses) and white pulp (germinal centers).
50. Kidney:
Dimensions and position
l
During life, kidneys are

reddish brown and measure
approximately 11-12 cm in
length, 5-6 cm in width, and
2.5-3 cm in thickness.
thickness
They are extending from the
level of T12 to the level of L3,
the right kidney lying about
2-3 cm lower than the left
one.
The lateral border of the
kidney is convex. Its medial
border is convex at both ends
but concave in the middle
where there is the hilum of
the kidney (L1).
Hilum of the kidney contains the renal v

(front), renal a (middle), and ureter (back).
Kidneys are intermediate mesoderm from
mesonephric duct and metanephric cap.
Anterior relations
of the right kidney
APICAL
Pouch of Morison
ANTEROSUPERIOR
L2
ANTEROINFERIOR
Anterior relations
of the left kidney
1. Right suprarenal gland pyramidal
2. 2nd part of the
duodenum
3. Right lobe of the liver
4. Right colic flexure ascending colon to
5. Small intestine
transverse colon
Short renal v and Long renal a
INFERIOR
Left suprarenal gland semilunar

Stomach
Spleen
Body of pancreas and
L1
splenic vessels
5. Descending colon
6. Small intestine
Long renal v and short renal a
1.
2.
3.
4.
Suprarenal glands/adrenal glands have 3 sources of

bloody supply: Phrenic artery (superior), aorta (mid),
and renal artery (inferior)

APICAL
POSTERIOR
INFERIOR
segments of posterior kideny
Renal (Gerota) fascia
Perinephric abscess
Pus around the kidney within the perinephric/renal fascia
Enclosing the perinephric fat is

a membranous condensation
of the extraperitoneal fascia the renal fascia (3).
The suprarenal glands (4) are
also enclosed in this fascial
compartment, usually
separated from the kidneys by
a thin septum.
N.B. The renal fascia must
be incised in any surgical
approach to this organ.
Paranephric fat surrounds the

renal fascia and collagen bundles
thether the renal vessels and
kidneys in a fixed position even
though supine to erect
movements (~3cm) occurs during
inspiration.
51. Nephrolithiasis
l
Renal calculi are solid concretions

(crystal aggregations) formed in the
kidneys from dissolved urinary minerals.
There are several types of kidney
stones. The majority are calcium
oxalate stones, followed by calcium
phosphate stones.
Kidney stones typically leave the body
by passage in the urine stream, and
many stones are formed and passed
without causing symptoms.
If stones grow to sufficient size before
passage (at least 2-3 mm), they can
cause obstruction of the ureter (renal
colic).
Kidney stones that can form and become located in

Dr. Mavrych, MD,
PhD, DSc prof.mavrych@gmail.com
the calices of the kidneys, ureters or bladder.
Renal colic is abdominal pain that courses down from
loin to groin as stone moves anteroinferiorly.
Most infections of the perinephric

space occur as a result of extension
of an ascending urinary tract
infection, commonly in association
with nephrolithiasis or tuberculosis.
Perinephric abscess typically
descends down between 2 sheets of
the renal fascia along the psoas
major muscle.
In case if abscess locates behind of
the psoas major muscle it descends
down and may affect hip joint.
If abscess spreads up itll reach the
diaphragm and irritate phrenic
nerve. As result patient will feel pain
in shoulder region.
loosely attached renal fascia in anterior and posterior

layers can allow extension of abscess
3 constrictions of ureter:
1
l
l
Ureter located on the anterior

surface of the Psoas major
muscle and has 3 constrictions:
1st constriction is at the
pelviureteric junction (level of L1)
2d constriction lies at the level of
pelvic brim (level of the sacroiliac
joint)
3d constriction appears where
ureter lies obliquely in the wall of
urinary bladder (level of ischial
spine)
Staghorn calculi
52. Suprarenal glands

l
Renal stone that develops in the

renal pelvis and greater calices,
calices
and in advanced cases has a
branching configuration which
resembles the antlers of a stag.
Staghorn calculi are composed of
magnesium ammonium
phosphate, which forms in urine
that has an abnormally high pH
(above 7.2).
This high pH usually develops
because of recurrent urinary tract
infection with microorganisms
such as Proteus mirabilis.
They are endocrine glands

having cortex and medulla.
The adrenal cortex [1]
secretes aldosterone,,
corticosteroids and
genital hormones.
The chromaffin cells of the adrenal medulla [2]

secrete two catecholamines: epinephrine and
norepinephrine, which affect smooth muscle, cardiac
muscle, and glands in the same way as sympathetic
l
stimulation.
2
l Sympathetic stimulation or hypersecretion of
catecholamines ((tumor
tumor of adrenal medulla or
sympathetic chain ganglia)) resulting in: episodes of
tachycardia, sweating and high blood pressure.
Congenital Adrenal Hyperplasia (CAH):
Nephroptosis: Drop kidney >3cm when standing, suprarenal glands stay in place within perinephric fat, ureters coil/kink.
excessive androgen production bc of cortex
Ectopic kidneys: abnormal location and formation congenitally.
hyperplasia causing virilization of female genitals
Horseshoe kidney: inferior poles of kidneys fuse during embryonic development and are inhibited from ascending by IMA
Pancake kidney: inferior and superior poles of kidneys fuse into disc shape organ, also inhibited by IMA.
Pelvic kidney: failure of ascent of kidneys so they remain in pelvic region still attached to embryological renal vessels off common iliacs.
Renal agenesis (absent of kidneys) is common cause of oligohydraminos (<400mL AF) that can lead to pulmonary hyperplasia.
Hydronephrosis: extreme dilation of renal pelvis and calices due to obstruction of renal ureters, typically due to accessory renal vessels.
Unpaired tributaries of IVC

l
3
2
l
1
4
53. Varicocele
The right renal (1) vein is

much shorter than the left.
Both veins lie anterior to the
corresponding artery in
hilum of kidneys.
The long left renal vein (2)
is joined by the left
suprarenal (3) and left
gonadal (4) (testicular or
ovarian) veins before it
reached IVC.
l
l
Right suprarenal vein and

right gonadal vein drain
directly to IVC (unpaired
IVC tributaries).
It is enlargement of the
pampiniform plexus that
produces a wormlike scrotal
mass and enlargement of the
spermatic cord. Varicocele
may be reason of low sperm
count.
Varicocele formation is usually
on the left side and may
disappear in supine position
of the body.
Varicocele may indicate
kidney disease or may signal
a retro peritoneal malignancy
obstructing the testicular
vein.
Nutcracker Syndrome: L Renal v passed UNDER the SMA

ABOVE
Aorta. Compression will cause backflow into the
Dr. Mavrych, MD, and
PhD,
L gonadal vein to pampiniform plexus.
.
May be mistaken for Hydrocele (fluid/blood) within tunica
vaginalis of the scrotum, but when lying down Hydrocele
DOES NOT Disappear!
Pampiniform plexus
54. Hydrocele
l
Each testicular or ovarian vein is

formed by coalescence of a
pampiniform plexus:
plexus the
testicular at the deep inguinal
ring, the ovarian at the margin of
the superior aperture of the
pelvis.
The veins run accompanied by
the corresponding arteries. The
left pampiniform plexus enters
the left renal vein; the right one
enters directly the IVC inferior
to the renal vein.
That is why varicocely
(engorgement of the pampiniform
plexus that produces a scrotal
mass) is more often located on
the left.
The tunica vaginalis testis or

other remnants of the processus
vaginalis may form a hydrocele
or hematocele.
In spermatic cord it is smooth
sausage-shaped structure that
persists under gentle
compression and isnt disappear
in supine position.
In the scrotum with
transillumination, a hydrocele
produces a reddish glow,
whereas light will not penetrate
other scrotal masses such as a
hematocele, solid tumor, or
herniated bowel. spermatocele
Testicular torsion is twisting of the testis within the

scrotum, it can cause ischemia to the blood vessels
and must be corrected quickly or may lose testis.
Cryptochidism: failure of testis to descend by age 6-9mo can cause infertility
55. Hemorrhoids:
Venous drainage from rectum
l
External hemorrhoids
Above pectinate line: superior

rectal vein [1] into portal
system [2].
PAINLESS
Below pectinate line: inferior

rectal vein [3] into inferior
vena cava [4].
PAINFUL
56. Perineal pouches:

Deep perineal pouch
Internal hemorrhoids
2
2
2
Hemorrhoids are masses that

typically protrude from anus
during defecation.
Hemorrhoids are commonly
associated with constipation,
extended sitting and straining at
the toilet, pregnancy, and
disorders that hinder venous return.
1. External hemorrhoids are
dilated tributaries of the inferior
rectal veins (IRV) BELOW THE
PECTINATE LINE and are painful
because the mucosa is supplied by
somatic afferent fibers of the
inferior rectal nerves (from
pudendal).
2. Internal hemorrhoids
are dilated tributaries of the
superior rectal veins
(SRV) ABOVE THE
PECTINATE LINE and are
not painful because the
mucosa is supplied by
visceral afferent fibers.
Internal hemorrhoids
frequently develop in
chronic alcoholics
because of liver cirrhosis
and portal hypertension
syndrome.
Bound inferiorly by perineal membrane and superiorly by pelvic diaphragm.

The deep perineal pouch is
formed by the fasciae and
muscles of the urogenital
diaphragm.
It contains:
1. Sphincter urethrae
muscle
2. Deep transverse
perineal muscle
3. Bulbourethral
(Cowper) glands (in
the male only)) - ducts
perforate perineal
membrane and enters
bulbar urethra.
Dorsal neurovascular structures
of the glans penis and clitoris
Bound laterally by Ishiopubic rami
Superficial perineal pouch

1. Ischiocavernosus muscle related to the Crus of the
penis (Male) & Crus of the clitoris (Female)
2. Bulbospongiosus muscle related to the Bulb of & deep internal pudendal vessels
and pudendal n (dorsal VAN)
vestibule (Female) & Bulb of the penis (Male)
Urine leaks
Straddle injury or false passage of catheter

After a crushing blow or a
3. Superficial transverse perineal muscle related to the
penetrating injury, the spongy
Perineal body (both genders)
urethra commonly ruptures
within the bulb of the penis,, and
1
urine leaks into the superficial
perineal pouch.
2
l The superficial perineal fascia
keeps urine from passing into the
3
thigh or the anal triangle, but after
distending the scrotum and penis,
urine can pass over the pubis into
the anterior abdominal wall deep
to the deep layer of superficial
abdominal fascia.
Fractures of the pelvic girdle can rupture the intermediate urethra and
cause extravasation of urine and blood into deep peritoneal pouch that may
Dr. Mavrych,
MD, PhD,
Mavrych, MD, pass
PhD,through
Essential
for integrity
of theDSc
pelvic
floor, Damage leads to prolapse of uterus, rectum, and urinaryDr.
bladder
urogenital hiatus to bladder and prostate.
Males: between bulb of penis and anus, Females: between vagina and anus
Congenital persistence of allantois into urachus of the umbilicus can cause
Episiotamies in mediallateral incisions are made to widen pouch for labor, and to fix prolapses.
urine to leak from belly button.
l
57. Ischiorectal abscess

l
3
1
58. Cystocele
(hernia of bladder)
Ischiorectal abscess [1] is an important

surgical condition which usually results
from spread of an infection through the
external sphincter ani into the
ischiorectal fossa [2].
Ischiorectal abscess is a surgical
emergency which should be
immediately drained by a wide cruciate
incision through the skin of the base of
the fossa to avoid fistula formation.
A surgeon should avoid lateral wall of
ischiorectal fossa because here located
Pudendal (Alcock's) canal [3] with
pudendal nerve and internal pudendal
artery.
Fistulas are abnormal connections of organs and

Dr. Mavrych, MD,
PhD,Ischiorectal
tissues,
abscesses can travel to both sidess
and spread infection through the fat fad that raps
posteriorly around the rectum. Incisions must be made
as medial as possible. If Pudental canal is affected
there will be no arousal. Abscesses are also prone to
supralevator, internsphincteric, or perianal.
59. Paracentesis of Urinary

cystotomy of a full bladder, as the
Bladder Suprapubic
empty bladders lies just at height of pubis
In extreme cases it can lead to

vaginal prolapse
60. Prostate tumors:

Prostate cancer
l
Sup
Suprapubic
aspiration:
l Urine can be removed from
the bladder without penetrating
the peritoneum by inserting a
needle JUST ABOVE the
pubic symphysis.
l The needle passes
successively through skin,
superficial and deep layers of
superficial fascia, linea alba,
transversalis fascia,
extraperitoneal connective
tissue, and wall of the bladder.
Loss of bladder support in

females by damage to the
pelvic floor during childbirth
(e.g., laceration of perineal
muscles or a lesion of the
nerves supply).
It can result in protrusion of
the bladder onto the
anterior vaginal wall and
loss of urine when a women
strains or coughs.
It usually begins in the posterior

lobe of the gland, and early
stages are often asymptomatic,
may be found during digital
rectal examination.
Full bladder during exam to
keep prostate in place
Prostatic malignancies tend to
metastasize to vertebrae and
the brain because the prostatic
venous plexus has numerous
connections with the vertebral
venous plexus via sacral veins.
veins
Benign hypertrophy of prostate (BHP) is

common after middle age in majority of males
distorts the prostatic urethra (middle lobe).
Malignant tumors are irregular and hard and
often found in posterior lobe due to its
proximity to seminal vesicles and lymph.
A
does not transverse peritoneum
Benign hypertrophy of the

prostate (BHP) typically middle lobe
l
l
BHP is common in men after

middle age.
Prostate adenoma (benign
hypertrophy) usually involves
median lobe.
lobe
BHP is a common cause of
urethral obstruction, leading
to nocturia (need to void
during the night), dysuria
(difficulty and/or pain during
urination), and urgency
(sudden desire to void).
The prostate is examined for
enlargement and tumors by
DIGITAL RECTAL
examination.
Prostatectomy
A prostatectomy may be performed
through a suprapubic [1] or
perineal [2] incision or
transurethrally [3].
l Because of damage to nerves in
1
the capsule of the prostate and
around the urethra (cavernosus
nerves) can cause impotence
(erectaile dysfunction) and/or
urinary incontinence.
l Pelvic splanchnic nerves may be
3
injured in case of intensive
dissection of pelvic lymph nodes
Transurethral
(prostatic cancer ectomy) and as
resection of the
th
result autonomic innervation of
prostate = TURP
TUR
derivate of hindgut may be
allows preservation of affected.
neurovasculature
l

Posterior lobe is mostly metastatic and spreads via Batson's plexus (male has lower back pain)
61. Male urethra

Prostatic 1st part
Membranous 2nd part
It is the widest and the most

dilatable part.
l It is spindle shaped (middle part is
dilated)
l Its posterior wall presents the
following features:
opening of seminal
glandscolliculus
1.
Seminal
2.
Openings of the 2 ejaculatory
ductus deferens ducts are seen on each side on
the seminal colliculus.
3.
Ducts of the prostate gland open
into the male urethra
l
Passes through the

urogenital
diaphragm to enter
the bulb of the penis
It is the shortest,
NARROWEST and
the least dilatable part
It is surrounded by the
external sphincter
urethra
Bulbourethral
glands lie
posterolateral to this
part inside of
urogenital diaphragm
(deep perineal
pouch)

Seminal vesicles secrete alkaline fructose solution that nourishes and provides energy for the sperm.
Prostate gland secretes a milky fluid (20% of semen volume) and plays role in sperm activation.
Bulbourethral glands (cowper's glands) secrete mucous solution that neutralizes urine within the urethra.
Spongy 3rd part
2 sphincters of the urethra

l
l
Longest part: average 15

cm in length.
Passes through the bulb
and corpus spongiosum
of the penis to open at the
external urethral orifice on
the tip of the glans penis.
There are two dilatations
bulbar fossa (in the
beginning) and navicular
fossa (in the glans penis)
Ducts of the
bulbourethral glands
open into the floor of the
spongy part in its
beginning
1. Internal urethral
sphincter is made of
smooth muscles in the
neck of the bladder
and has sympathetic
innervation
2. External urethral
sphincter has skeletal
muscle fibers and
surrounds the
membranous part of
urethra, supplied by
the perineal branch of
the pudendal nerve
The 1st and 2nd parts of the urethra are urogenital endoderm and the external urethra meatus is ectoderm
The ductus deferens is intermediate mesoderm of the remaining mesonephric duct/tubules
Muscle of the bladder is Detrusor m, the urinary trigone is where the
entrance of the 2 ureters and exit of bladder meet. Internal urethral
sphincters are involuntary.
63. Pudendal nerve (S2-S4)
62. Ejaculatory duct

l
It is a very narrow duct

2 cm long
Formed by union of
ductus deferens and
duct of seminal vesicle
It serve to passage of
seminal fluid from
ductus deferens to
prostatic urethra.
It is PRINCIPAL SOMATIC ((motor

motor and
sensory) nerve to supply perineum.
l Lies against ischial spine as it passes
through lesser sciatic foramen to
traverse pudendal canal on lateral
wall of ischiorectal fossa.
Branches:
l 1. Inferior rectal nerve
l
1
2
Dr. Mavrych,CREMASTERIC
MD, PhD, DSc prof.mavrych@gmail.com
REFLEX: Genitofemoral
Supplies external anal sphincter

muscle and skin around anus
2. Perineal nerve
l Deep branch is motor nerve to muscles
of urogenital triangle.
l Superficial branch gives cutaneous
posterior scrotal/labial branches.
3. Dorsal nerve of penis or clitoris
l Supplies body, prepuce, and glans of
penis or clitoris
l
Dr. Mavrych,
PhD, DSc
nerve L1-2, Genital branch:
withinMD,
inguinal
canal
with the cremasteric m and fascia acts as
motor division to pull testis up. Femoral branch is the sensory division of the reflex that is stimulated by touch and temperature
Pudendal nerve block

To relieve pain for the mother and
prepare for an episiotomy, a
pudendal nerve block may be
administered during early labor.
The nerve may be blocked in 2 ways
either:
1. by piercing the vaginal wall
posterolaterally near the ischial
spine or
2. percutaneously along the medial
side of the ischial tuberosity.
l Note: Pain from uterine contractions is
unaffected because pelvic visceral
pain is carried by afferent fibers
accompanying autonomic nerve fibers.
Doctors hand is placed between the baby's head and the pudendal nerve.
l
Micturition reflex
64. Nerve supply of pelvic

viscera
Parasympathetic innervation:
l Preganglionic neurons are located in sacral parasympathetic n.
(S2-S4) in the spinal cord.
l Their processes run into pelvic splanchnic nerves and relay with
postganglionic neurons located inside of pelvic organs in the
intramural plexus.
plexus
Sympathetic innervation:
l Sympathetic fibers of preganglionic neurons T12-L2 segments (IML)
come through the sympathetic trunk and form sacral splanchnic
nerves.
l They contribute to the inferior hypogastric plexus,
plexus where
postganglionic neurons are located. Branches of inferior hypogastric
plexus reach organs wrapping around the branches of the internal iliac
artery.
Sensory innervation:
l The sensory fibers from S2-S4 dorsal root ganglia move together
with parasympathetic and carry pain sensations from the organs.
PNS Pelvic Splanchnic nerves to intramural plexus

Sympathetic
Trunk
to Sacral
Splanchnic nerves to inferior hypogastric plexus
Dr.SNS
Mavrych,
MD, PhD,
DSc
Sensory DRG ride with PNS for PAIN
65. Erection and ejaculation

l
Facilitating emptying:
l Parasympathetic fibers (pelvic
splanchnic nn.) stimulate
DETRUSOR MUSCLE [1]
contraction and involuntary relax
internal sphincter [2].
l Somatic motor fibers (pudendal
nerve) cause voluntary
relaxation of external [3] urethral
sphincter.
Inhibiting emptying:
l Sympathetic fibers (sacral
.) inhibit detrusor
splanchnic nn.)
muscle [1] and stimulate
internal sphincter [2].
PNS & Pudendal to pee!

SNS to stop!

1. Erection: PNS S2-4 fill blood, Ischiocavernosus m keeps erect, and bulbospongiosus m
prevents venous drainage.
2. Emission: SNS move sperm from epididymis and cause gland secretions
3. Ejaculation: SNS Closure of Internal sphincter, contraction of urethral m and
bulbospongiosus m
4. Remission: blood leaves
67. Torsion of the spermatic

cord
66. Cryptorchism
l
Afferent fibrous: Dorsal nerve of penis or clitoris from

Pudendal nerve (DRG S2-S4)
Efferent fibrous:
l Erection: Parasympathetic fibers (S2-S4) from the
Pelvic splanchnic nerves dilate arteries supplying
erectile bodies of the penis, allowing them to fill with
blood. Somatic motor (S2-S4) fibrous from the
pudendal nerves cause contraction of
ischiocavernosus and bulbospongiosus muscles to
press the root of the penis and relax external urethral
sphincter.
l Ejaculation: Sympathetic fibers (L1-L2) from the
Inferior hypogastric plexus (Sacral splanchnic
nerves) cause contraction of smooth muscle of
epididymis, ductus deferens, seminal vesicles, and
prostate; sympathetic nerve fibers stimulate internal
urethral sphincter to prevent semen from entering
bladder or urine entering prostatic urethra.
Undescended testes
(cryptorchism) when the testes
fail to descend into the scrotum.
This normally occurs within 3
months after birth.
The undescended testes may be
found in the abdominal cavity or
in the inguinal canal.
If neglected, malignant
transformation may occur in the
undescended testis.
N.B. In case of cryptorchism,
spermatogenesis is arrested
and the spermatogenic tissue is
damaged leading to permanent
sterility in bilateral cases.
Main components of the spermatic cord:

l Ductus deferens
l Testicular artery direct branch of
Aorta
l Pampiniform plexus to become
single testicular vein (right ! IVC, left
! Left renal vein)
l
Torsion of the spermatic cord

produces acute pain with swelling
because of twisting of testicular
artery that can result in testicular
avascular necrosis.
Repair requires a high scrotal incision
to untwist the cord,, and the testis is
sutured to the scrotal septum to
prevent recurrence.
68. Lymphatic drainage of the

male viscera
n
Testis & epididymis lumbar

lymph nodes
Scrotum superficial inguinal
nodes
Penis:
n
n
n
Lymphatic drainage from the

female viscera
n
skin - superficial inguinal nodes

glans deep inguinal nodes
body and roots internal iliac
nodes
Prostate gland & bladder - internal

iliac nodes
Anal canal:
n
n
above pectinate line - internal iliac

below pectinate line - superficial
inguinal nodes
Ovary and uterine tubes to Lumbar

lymph nodes
Uterus:
n
lateral angle and teres ligament
Superficial inguinal lymph nodes
n
fundus and upper part of the body
- Lumbar lymph nodes
n
lower part of the body - External
iliac lymph nodes
n
cervix - External & Internal iliac
Vagina:
n
Superior to hymen - to External &
internal iliac
n
Inferior to hymen - to Superficial
inguinal nodes
All external genitalia (with exception glans clitoris) - Superficial inguinal
lymph nodes
Glans clitoris Deep inguinal
Deep inguinal nodes-> superficial inguinal nodes-> internal & external iliac nodes-> lumbar nodes-> paraaortic nodes-> thoracic duct
69. Arterial supply of the uterus

and Hysterectomy
4
2
1
3
Hysterectomy
l
The uterus is almost exclusively

supplied by the uterine arteries
[1] (from internal iliac artery):
l Uterine a. crosses pelvic floor in
cardinal ligament [2]
passessuperior
below the
l Ureter passes
andUterine
anterior(bridge
to uterine
artery[3]
artery
over
water)
l Ascending branch [4] of uterine
artery comes along lateral wall of
uterus within broad ligament.
Note: During hysterectomy ureter in the

greatest risk because of close relations
with uterine artery and cervix of the
uterus.
Uterine a anastamosis with

Ovarian a from aorta on lateral
sides of the uterus. Both need to
be taken out so that the pt does not
bleed out.
.
The Uterine a is homologous to the
ductus deferens a in males and the
Ovarian a is the testicular a in
males
70. Parts of the uterine tube

oviduct, fallopian tube, ovarian tube...
l
Hysterosalpingography
Pierces uterine wall to Cornua

open into uterine cavity
of the uterus
Narrowest part of tube

just lateral to uterus
Ampulla
l
Isthmus
l
No contraction of bladder and no relaxation of

internal sphincter.
Uterine part
l
Hysterectomy is surgical removing of the

uterus and may include removing of the cervix
(total) and the vagina (radical).
Blood supply to the ovaries is saved in case of
partial hysterectomy ovarian suspensory
ligament should be left intact because contain
ovarian artery (direct branch of abdominal
aorta) and vein.
In case of total hysterectomy (with cervix)
pelvic splanchnic nerves may be affected.
Thats resulting in bladder dysfunction
because of detrusor urine muscle loose
parasympathetic innervation.
Medial continuation of
infundibulum comprising
about half of uterine tube
Usual site of fertilization
Infundibulum
l
Funnel-shaped expansion
of lateral end, fringed with
fimbriae
Overlies ovary and
receives oocyte at
ovulation
Ampulla is the site of ectopic pregnancy if the fertilized

Dr. Mavrych,
MD,
PhD,
ovum
does
notDSc
make
its way to the fundus of the uterus.
The instillation of
viscous iodine
through the
external os [1] of
the uterine cervix
allows the lumen of
the cervical canal
[2],, the uterine
cavity [3],, and the
different parts of
the uterine tubes
[4] to be visualized
on X-ray.
Can be used to detect uterine tube

obstructions or malformations of uterus/
vagina (bicornate uterus)
The Uterine Triad: Fallopian tube, Round lig of uterus (inguinal

canal), and ovarian lig come off the fundus of the uterus.
71. Branches of the Internal

iliac artery
Anterior Division
Posterior Division
1. Obturator
1. Iliolumbar
2. Umbilical
w/ superior
vesicle of bladder
3 Inferior gluteal
goes back up
2. Lateral sacral
to medial sacral a
3. Superior gluteal
4. Internal pudendal
Internal iliac artery
between lumosacral trunk & S1
alcock's canal
to medial sacral a
obturator canal
gluteus maximus
maxi
urachus
5. Inferior vesical (males)

bladder
or
Vaginal (females)
gluteus med & min
bladder
6. Middle rectal
7. Uterine (females)
coccygeus m
ductus deferens
aberrant or accessory arteries are common in obturator, inferior vesicle
72. Fracture of the

anterior cranial fossa
l
genitals
Craniosyntosis-FGFR2 gene mt
73. Cranial Malformations
Fracture of the anterior cranial

fossa (Cribriform plate of the
Ethmoid bone) is suggested by
anosmia, periorbital bruising
(raccoon eyes), and CSF leakage
from the nose (rhinorrhea).
74. Epidural hematoma
Bean Bleed
Skull fracture near pterion often

causes epidural hematoma from
torn middle meningeal artery
(foramen spinosum).
spinosum)
l Unconsciousness and death are
rapid because the bleeding
dissects a wide space as it strips
the dura from the inner surface of
the skull, which puts pressure on
the brain.
l An epidural hematoma forms a
characteristic biconvex pattern
on computed tomography
images.
can push uncus through foramen magnum and compress CNIII causing pupillary
dilation (SNS) bc no PNS to constrictor, eye points down and out (CNVI and IV take
over), ptosis bc levator palpebrae m
Subdural Hematoma: blood spread over brain, Shaken Baby
Syndrome, coup and counter coup injuries, cause bleeding from
bridging veins
l
[A] Scaphocephaly: premature

closure of the sagittal suture, in
which the anterior fontanelle is small
or absent, results in a long, narrow,
wedge-shaped cranium.
[C] Oxycephaly: premature closure
of the coronal suture results in a
high, tower-like cranium.
When premature closure of the
coronal or the lambdoid suture occurs
on one side only, the cranium is
twisted and asymmetrical, a condition
known as plagiocephaly [B].
76. Infection of the Cavernous

sinus
Structures which may be affected by
cavernous sinus thrombosis:
thrombosis
1. Structures that pass through
sinus directly:
Internal carotid artery (in case
of laceration - arteriovenous
fistula)
Abducens nerve CN VI (in case
of lesion - internal squint)
2.
Structures on lateral wall of

sinus:
Oculomotor nerve (CN III)
Trochlear nerve (CN IV)
V1
V2
Medial Rectus adduction takes over (cross-eyed) initially, if bleed persists

structures will be affected: loss of eye movements and
Dr. Mavrych, MD, then
PhD,lateral
DSc wall
visual acuity. Loss of sensory to face
77. Pituitary gland tumors and

transsphenoidal operation
Dangerous triangle of the face
2
l
1
l
The middle third of the face

is a "danger area because
infection there may produce
thrombophlebitis of the facial
vein that can spread to the
cavernous sinus via swelling of v w/ blot
ophthalmic veins or clot that goes to brain
pterygoid venous plexus.
Septicemia leads to
meningitis and cavernous
sinus thrombosis, both of
which can cause neurological
damage and are lifethreatening. bacterial infection response
Facial v (cheeks)-> angular v (lateral nose)-> opthalmic v (super& inferior eye)-> Cavernous sinus (BRAIN)
Hormones of the pituitary

gland
l
Releasing and inhibiting factors

from neurosecretory cells of the
hypothalamus reach pituitary
gland thought special capillary
network hypophyseal portal
system and control the production
of adenohypophyseal hormones
(ACTH, FSH, LH, TSH, prolactin
and somatotropin).
Hormones of neurohypophysis
(ADH and Oxytocin) are secreted
in hypothalamus and transported
through axons to pituitary gland.
ACTH-> adrenal gland-> cortisol

FSH-> follicles of ovaries
LH-> ovaries and leydig cells
Dr. Mavrych,TSH->
MD, PhD,
DSc
thyroid
gland
for release of T4&T3 TH
Prolactin-> mammary gland
Somatotrophin-> GH -> bones and muscles
.
ADH/Vasopressin to collecting duct and DCT of nephron-> water reabsorption
Oxy to uterus for uterine contractions and orgasm
79. Bell's palsy
Can be corrected using CNXI

spinal accessory n transplant
l
It is idiopathic unilateral facial

paralysis.
Terminal branches of CN VII
may be injured by parotid
cancer or inflammation injury as passes
(parotitis) by surgery to through parotid gland
remove a parotid tumorw/ retromandibular v
foramen).and external carotid a
(stylomastois foramen)
foramen
Manifestations:
l unable to close lips and eyelids on affected side
l eye on affected side is not lubricated (dry eye)
l unable to whistle, blow a wind instrument, or chew effectively
l facial distortion due to contractions of unopposed contralateral facial
muscles
Lesion of CNVII at internal acoustic meatus causes no saliva/tears, hyperacoustics (stapedius m),
imbalance and distorted hearing (CNVIII)
Mavrych,
MD,ganglion
PhD, DSc
LesionDr.
past
geniculate
causes
hyperacoustics and Bell's
Lesion at chorda tympani causes no taste, no saliva from submandibular& sublingual glands
Lesion at stylomastoid foramen causes Bells
Pituitary tumors [1] may extend

superiorly through opening in the
diaphragma sella, producing
disturbances in endocrine system.
system
Superior extension of a tumor may
cause visual deficit owing to pressure
on the optic chiasm [2], the place
where the optic nerve fibers cross.
The transsphenoidal operation is the
most common operation for a pituitary
tumor. The surgical approach for it is
through the nose, nasal cavity and
sphenoidal sinus [3]
[3]. This surgical
approach provides the best exposure
of the tumor at the lowest risk.
78. Trigeminal nerve
Infraorbital
foramen
Skin of face supplied

by branches of the
three divisions of the
[1] TRIGEMINAL
NERVE (CN V)
Except for a small

area over the angle
of the mandible
which is supplied by
the [2] great
auricular nerve
(C2-C3) cervical
plexus
CNV1:
sensory
to forehead,
sinuses, nose, dilator pupillae (SNS) and sensory
Dr. Mavrych,
MD, PhD,
DSc
blinking reflex, (VII is motor)
CNV2: sensory to cheeks, nose, upper mouth, tears (SNS/PNS)
CNV3: sensory to chin, lower mouth, ant 2/3 tongue (taste is VII), ears, scalp,
muscles of mastication
80. Epistaxis
l
Epistaxis (nosebleed)
most often occurs from
the anterior nasal septum
(Kiesselbach's area),
where branches of the
sphenopalatine,
anterior ethmoidal,
greater palatine, and
superior labial (from
facial) arteries converge.

Splenopalantine and Greater palantine as are most vulnerable bc
they are in Atrium of middle meatus
81. Sinusitis
Sphenoiditis
Ethmoiditis
l
Relationships of the
sphenoidal sinus are clinically
important ; because of potential
injury during pituitary
surgery and the possible
spread of infection.
Infection can reach the sinuses
through their ostia from the
nasal cavity or through their
floor from the nasopharynx.
Infection may erode the walls to
reach the cavernous sinuses,
pituitary gland, optic nerves,
or optic chiasma
Infection in the ethmoidal

sinuses can erode the medial
wall of the orbit, resulting in
orbital cellulites that can
spread to the cranial cavity.
In orbital cavity infection may
erode structures related to the
medial orbital wall:
l Medial rectus muscle
l Superior oblique muscle
l Nasociliary nerve
No adduction, no down and out rotation of the eye,

and constricted pupils w/ lack of corneal reflex
(sensory: touch eye and no blink)
Temporal Maxillary Junction
84. Movements at the TMJs
83. Cheeks
l
1
2
3
l
Form the lateral, movable walls of

the oral cavity and the zygomatic
prominences of the cheeks over the
zygomatic bones.
Buccinator [1] principal muscle
of the cheek.
Buccal pad of fat encapsulated
collection of fat superficial to
buccinator.
Parotid duct [2] from Parotid gland
[3] perforate buccinator and opens in
inner surface of the cheek right
opposite 2nd upper molar tooth
85. Innervation of the tongue
Lick your wounds
1. Sensory anterior 2/3:: general lingual n. (V3),

taste chorda tympani (CNVII)
2. Sensory posterior 1/3:: general and taste
glossopharyngeal (CNIX)
3. Motor hypoglossal (CNXII)
A lesion of the chorda tympani lose of the taste
sensation anterior 2/3 of the tongue
A lesion of the lingual nerve lose of both
general and taste sensation anterior 2/3 of the
tongue bc chorda tympani runs with lingual n
A lesion of CN XII (hypoglossal canal) allows the
contralateral, unparalyzed genioglossus muscle to
pull the protruded tongue toward the paralyzed side
(deviation and atrophy of the tongue).
weaker unparalyzed genioglossus m is

unable to maintain contraction of
tongue out, the opposite side takes
over and pushes tongue to the side of
lesion.
Note: In case of mandibular nerve

damage mandible (when it is
protruded) deviate toward the side of
lesion because of Lateral pterygoid
weakness.
All 4 muscles of
mastication are
innervated by V3:
1. Temporalis
elevation &
retraction
2. Masseter - Strong
elevation
3. Medial
closes jaw
pterygoid elevation
4. Lateral Only muscle to
pterygoid -open jaw/mouth
protrusion
Tensor veli palatini m prevents inhale of food and equalizes the air
DSc toprof.mavrych@gmail.com
pressure
protect tympanic membrane
Tensor tympani dampens the sound from chewing
86. Gag reflex

l
Touching the posterior part of the

pharynx results in muscular
contraction of each side of the
pharynx - gag reflex:
l Afferent limb: CN IX
l Efferent limb: CN X
Injury to the
GLOSSOPHARYNGEAL NERVE
(CN IX) will result in a negative
gag reflex No longer sensed
Touching the soft palate or posterior pharynx will be sensed

via CNIX pharyngeal branch (afferent) and stimulate a
response (efferent) through CNX pharyx, larynx, and palate
ms to "gag"
87. Palatine tonsils
Tonsillitis
l
Receives main blood supply

from tonsillar branch of
facial artery
Drained by lymph vessels
mainly to jugulodigastric
lymph node, which is body's
most frequently enlarged
lymph node
Nerve supply: tonsillar
plexus of nerves formed by
branches of CN IX and CN X
During palatine tonsillectomy, the

peritonsillar space facilitates tonsil
removal, except after capsular
adhesion to the superior constrictor.
If the glossopharyngeal nerve
CNIX is injured, taste and general
sensation from the posterior 1/3 of
the tongue are lost.
Hemorrhage may occur, usually
from the tonsillar branch of the
facial artery; if the superior
constrictor is penetrated, a high
facial artery or tortuous internal
carotid artery may be injured.
Found between Faucel Pillars and become highly inflamed during infection
Tonsilectomy and adenoectomy can risk the tonsilar a and v.
.
Pharyngeal,
Tubal, Palatine, Lingual Tonsils (Waldeyer's ring of lymph tissue)
88. Muscles of Soft Palate
89. Lymph drainage from face

structures
CNV3 prevents inhalation of food & equalizes

1. Preauricular (parotid
(parotid ) (on front
pressure to protect tympanic membrane
1. Tensor veli palatini and
of auricle) receive lymph from
2. Levator veli palatini elevates
anteriolateral part of scalp
the soft palate during swallowing
(including eyelids)
to prevent food entering to the
2. Submandibular (in digastric or
1
nasopharynx
submandibular ") from all air
3. Palatoglossus and
sinuses, nose and adjacent
cheek, upper lip and lateral
4. Palatopharyngeus depress
parts of lower lip.
soft palate and pulls walls of
pharynx superiorly
3. Submental (in submental ")
3
2
from the chin, tip of the tongue
5. Uvular muscle shortens uvula
and central part of the lower
and pulls it superiorly
lip.
CNX innervation via pharyngeal branch
ALLOWS EFFICIENT SWALLOWING!
Lesion to Vagus can be seen as Uvula deviation to
opposite of lesion
Triangles of neck:
Carotid: post digastric, omohyoid, SCM contain internal jugular v, common
carotid a, and vagus
Swallowing has 3 stages:
Submandibular/submental: growth of lip can be throat cancer (CNVII, XII)
1. chew to create bolus (CNV3), tongue rise to hard palate (CNX, IX, VII, XII),
Muscular: isthmus of thyroid larynx and trachea
hyoid elevates, and fauceal pillars up and back
Posterior: Trapezius, SCM, clavical contain ext jugular v, and brachial plexus
2. Seal nasopharynx w/ soft palate and epiglottis (CNX)
3. constrictors contract and pull up larynx to push bolus down
90.
Blow-out fracture
No look down, no sensation to upper mouth and
bleeding from branch of external carotid a
l A blow-out fracture of the
orbital floor typically is not
involve the orbital rim and is
caused by blunt trauma to the
orbital contents (e.g., by a
handball). Content of orbital
cavity blow-out in maxillary
sinus.
l Blow-out fractures may damage:
1.
Inferior rectus muscle
2.
Infraorbital nerve (from
maxillary V2)
Branches of External Carotid Artery
3.
Infraorbital artery
Some = Superior Thyroid A.
(hemorrhaging).
Angry = Ascending Pharyngeal A.
Lady = Lingual A.
Found = Facial A.
Dr.Out
Mavrych,
MD,A.PhD, DSc prof.mavrych@gmail.com
= Occipital
P = Posterior Auricular A.
M = Maxillary A.
S = Superficial Temporal A.
91. Muscles of the orbit
Muscle
Superior rectus
Inferior rectus
Medial rectus
Lateral rectus
Superior oblique
Inferior oblique
Levator pulpebra superior
Action
Elevates and adducts
pupil
Depresses and adducts
pupil
Adducts pupil
Abducts pupil
Depresses and abducts
pupil
Elevates and abducts
pupil
Elevates upper eyelid
Innervation
CN III
CN III
CN III
CN VI
CN IV
CN III
CN III
92. Strabismus Eyes are not aligned

Oculomotor Nerve Palsy (CNIII)
Trochlear Nerve Palsy (CNIV)
Oculomotor Nerve Palsy

(external squint) affects most of the
extraocular muscles
l Manifestations:
levator palpebrae superioris is out
l ptosis,
.
l fully dilated pupil,
constrictor pupilae (PNS) is out
l and eye is fully depressed and
abducted (down and out) due to
unopposed actions of superior
oblique and lateral rectus,
respectively.
Eyes are looking in opposite directions
Lesions of this nerve or its nucleus

cause paralysis of the superior
oblique and impair the ability to turn
the affected eyeball infero-medially
(pupil look superio-laterally)
The characteristic sign of trochlear
nerve injury is diplopia (double
vision) when looking down (e.g.,
when going down stairs)
No cheating muscle (down and out)

l The person can compensate for the
person will turn head to mimic contraction
diplopia by inclining the head

anteriorly and laterally toward the side
of the normal eye.
inferior oblique is
unopposed so eye looks
up and out
Abducens Nerve Palsy (CNVI)
93. Horner syndrome

Sympathetic trunk compression
l
Abducens Nerve Palsy

(internal squint). Injury to abducens
nerve paralysis of lateral rectus
inability to abduct the affected
eye
Affected eye is fully adducted by
the unopposed action of the medial
rectus that is supplied by CN III
94. Otitis Media
Middle ear inflammation
Hearing is diminished because of

pressure on the eardrum and CNVIII
reduced movement of the ossicles.
Taste may be altered because the
chorda tympani is affected.CNVII
Infection spreading posteriorly
cause mastoiditis.
Infection that spreads to the
middle cranial fossa can cause
meningitis or temporal lobe
abscess, and infection moving
through the floor may produce
sigmoid sinus thrombosis.
Penetrating injury to the neck,

Pancoast tumor, or thyroid carcinoma
may cause Horner syndrome by
interrupting ascending preganglionic
sympathetic fibers anywhere between
their origin in the T1 segment (IML) of
spinal cord and their synapse in the
Superior cervical ganglion.
It includes the following signs:
l Constriction of the pupil (miosis) PNS
l Drooping of the superior eyelid sup. tarsal
(ptosis),
paralysis
l Redness and increased temperature
of the skin (vasodilation)
l Absence of sweating (anhydrosis)
Perforation of the
Tympanic Membrane
May result from otitis media and is
one of several causes of middle ear
(conduction) deafness
l Causes: foreign bodies in external
acoustic meatus, excessive pressure
(as in diving), trauma
l Because chorda tympani directly
Pars flaccida relates to the posterior surface of the
tympanic membrane it may be
damaged and resulting in loss of
taste over anterior 2/3 of the tongue
Umbo
and secretion of the sublingual and
refracted cone of light
submandibular glands
l Minor perforation heal spontaneously;
pars tensa
large ones require surgical repair
l
Anterior inferior incisions based on cone of light for surgery
95. Thyroid and parathyroid

glands
Anatomical relations
of tthe
o
e thyroid
t y o d gland
ga d
Hormones:
l The thyroid gland is the body's largest endocrine
gland. It produces thyroid hormone (T3 & T4),
which controls the rate of metabolism (increase
the temperature of the body), and calcitonin, a
hormone controlling calcium metabolism (reduce
decrease osteoclasts
blood calcium Ca2+).
l After total thyroidectomy may develop lower
temperature of the body and hypercalcemia.
l
The hormone produced by the parathyroid

glands, parathormone (PTH), controls the
metabolism of phosphorus and calcium in the
blood (increase Ca2+ level).increase osteoclasts
1
l
Anterolateral
infrahyoid muscles
Posterolateral
COMMON CAROTID
ARTERY [1]
Medial larynx,
TRACHEA [2],
pharynx, esophagus,
cricothyroid muscle,
recurrent laryngeal
nerve [3]
Posterior
parathyroid glands
[4]
Superior thyroid a off external common carotid and inferior

thyroid gland
off thyrocervical
trunk of subclavian
Dr. Mavrych,
MD, PhD,
External laryngeal n w/ superior thy a & Recurrent laryngeal n
w/ inferior thy a
CS of the neck
Recurrent laryngeal n to laryngeal ms (PCA*) abducts vocal cords

Dr. Mavrych,
PhD, DSc
External MD,
laryngeal
n to prof.mavrych@gmail.com
cricothyroid for high pitch
Median cervical cyst

l
Carotid Sheath
& CNX
Buccopharyngeal membrane
RETROPHARYNGEAL SPACE
Alar Fascia
DANGER ZONE
Prevertebral fascia
Retropharyngeal area allows infection to spread to posterior mediastinum

DANGER ZONE allows infection to spread to abdomen
Variation of parathyroid
glands position
l
The superior parathyroid

glands, more constant in
position than the inferior ones.
The inferior parathyroid
glands are usually near the
inferior poles of the thyroid
gland, but they may lie in
various positions
In 1-5% of people, an inferior
parathyroid gland is deep in
the superior mediastinum
inside the thymus because of
common embryonic origin.
This makes surgery dangerous bc parathyroid

glands are essential for life as Ca2+ is needed
for neuronal pathways, bones, muscle
contractions, etc....
Usually presents as a painless

midline mass on the anterior aspect
of the neck just below of the hyoid
bone and moves during
swallowing together with thyroid
gland because of relation with
pretracheal layer of cervical fascia
and infrahyoid muscles of the neck.
Remanent of the thyroglossal canal
(thyroid gland originally from
epithelium of the tongue).
Treatment: surgical excision
96. Larynx
3
1
2
Cavity of the Larynx - 2 Folds:

l Vestibular folds [1] (false vocal
cords) Morgangni ventricle between them
l Vocal folds [2] (true vocal cords)
1
2
Rima vestibuli gap between the

vestibular folds
Rima glottidis [3] gap between
the vocal folds anteriorly and
vocal processes of the arytenoid
cartilages posteriorly is most
narrow place in the larynx (it
limits size of intubation tube
during endotrachial anaesthesia)
Piriform recess at hyoid-> epiglottis is where small sharp objects get stuck
Zenker's
is outpouch of pharynx at inferior constrictor where food gets caught
Dr. Mavrych, MD,
PhD,Diverticulum
in killians triangle and gets infected leading to hallitosis (bad breath)
Muscles of the Larynx
Cricothyrotomy
Transverse arytenoid (whisper), Thyroarytenoid (low pitch), vocalis (opera singer)- ADDUCTORS
Abductors
l Posterior cricoarytenoid
abducts vocal folds (the only
abductors of the vocal folds)
l It is innervated by recurrent
laryngeal nerve (CNX
vagus).
Most intrinsic ms of the larynx
Interruption of recurrent
laryngeal nerve results in
hoarseness because the
corresponding vocal fold
does not abduct and deviate
toward the midline.
Dr. Mavrych, MD,
Superior Laryngeal n gives

branches to internal (vocal cords)
and external to cricothyroid ms
(high pitch)
PhD,
lesionDSc
causes
weak low pitch voice
98. Retropharyngeal space
A cricothyrotomy is an emergency
procedure that relieves an airway
obstruction (e.g. swallowed foreign
bodies or abnormal tissue growths).
A hollow needle is inserted into the
midline of the neck, just below the
thyroid cartilage (needle
cricothyrotomy).
More frequently, a small incision is made
in the skin over the Cricothyroid
membrane, and another one is made
through the membrane between the
cricoid and thyroid cartilage.. A tube
that enables breathing is inserted through
the incision.
99. Axillary sheath
Between Buccopharyngeal fascia and Alar fascia of Carotid sheaths

l
It is interval between pharynx

fascia)
(Bucco-pharyngeal
Bucco-pharyn
fascia)
and prevertebral fascia
May provide a passageway of
infection from pharynx
p
to
posterior media
mediastinum
(mediastinitis !90%!mortality!
rate).
Derived from the prevertebral

fascia
Encloses the subclavian artery
and brachial plexus as they
emerge in the interval between the
scalenus anterior and medius
muscles (Interscalenus
(
space)
Extends into the axilla
DANGER ZONE: Alar Fascia to prevertebral fascia and

Dr. Mavrych,
MD, PhD,
infection
spreads
farther to abdomen
Dr. BRACHIAL
Mavrych, MD, PLEXUS
PhD, DSc prof.mavrych@gmail.com
BRANCHES:
MARMU, LT, DS, SS, SC, LP, MP, AP, USS, TD, LSS, Mca, Mcf
100. Posterior Triangle of the

Neck Clavical, SCM, Trapezius
Veins external jugular vein,
subclavian vein.
l Arteries occipital artery.
l Nerves Accessory nerve (XI),
trunks of the brachial plexus, branches
of cervical plexus, phrenic nerve.
l Lymph nodes superficial cervical
nodes along external jugular vein.
CN XI (accessory nerve) supply:
l Sternocleidomastoid muscle - face
looks upward to the opposite side
l Trapezius - superior fibers elevate,
middle fibers retract, and inferior fibers
depress scapula.
l
CN XI
External Jugular v, Brachial Plexus
Good Luck!
Carotid Triangle of the Neck:
Posterior digastric, omohyoid, SCM
Contains: Internal jug v, common carotid, CNX

100 Concepts Anatomy

Hochgeladen von

Dokumentinformationen

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

100 Concepts Anatomy

Hochgeladen von

Copyright:

Verfügbare Formate

TRIAL MODE a valid license will remove this message.

. See the keywords property of this PDF for more information.

Understand first, then memorize and apply

100 must important

Dr. Mavrych, MD, PhD, DSc

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

1. Lumbar puncture (tap) and

Spinal cord ends L2: Conus Medullaris

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

3. Abnormal curvatures of the

Patients typically have history

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Anterior longitudinal ligament protects 9-3oclock around vertebral body

4. Upper limb fractures:

Fracture of distal radius:

Quadrangular Space: teres major, teres

Transverse fracture within the distal 2 cm of

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

proximal carpal fracture

Pain occurs primarily on the

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Mallet or Baseball Finger

Necks of the metacarpal

Occurs as a result of a fall onto

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

5. Rotator cuff muscles SITS

This deformity results from the DIP joint suddenly

Support the shoulder joint by

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

6. Abduction of the upper limb

Subacromial bursitis &

(0-15) Abduction of the

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Subacromial bursitis (inflammation of

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

7. Three Elbows: Student's elbow

The olecranon, to which the triceps

Lateral epicondylitis: repeated

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Suprascapular a above the Transverse Superior

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Anterior Elbow joint

10. Carpal Tunnel Syndrome

Contents from lateral to medial:

Sites of venipuncture is usually median

Overlies bicipital aponeurosis, so deep

11. Test of the proximal and

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

12. Lesion of UL nerves

Proximal Interphalangeal joint

Pins and needles or anesthesia

Recurrent Median n to Thenar ms are affected

Results from a lesion that

Injury of upper roots and trunk

Distal Interphalangeal Joint

Birth injury or Fall causes

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Upper Brachial Palsy