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Keywords List

Coronal (Frontal) Plane: divides body into anterior (ventral) & posterior (dorsal)
Axial Plane: divides body into superior (cephalad) & inferior (caudad)
Sagittal (Median) Plane: divides body into right & left (medial/lateral)
Proximal: closer to torso or beginning of a system
Distal: farther from torso or beginning of system
Superficial: closer to surface of body or body part or organ
Deep: farther from surface of body or body part or origin
Intermediate: somewhere between superficial & deep
Fascia: visibly organized, sheet-like connective tissue of varying thickness & composition
Superficial Fascia: substrate of skin; contains varying amounts of adipose tissue
Axial Skeleton: Skull, spinal column, ribs & sternum, hyoid bone
Appendicular Skeleton: pectoral girdle (scapula & clavicle), pelvic girdle (hip bones),
free limbs
Sesamoid Bones: Bones that develop in tendons over high stress regions of a joint; part
facing joint cavity is covered with articular hyaline cartilage; often acts as a moveable
pulley, reducing friction, modifying pressure, & altering a tendons direction of pull for best
mechanical advantage. IE: patella of knee, thumb, great toe, fabella
o Condyle: rounded articulated knob
o Facet: smooth, flat, concave/convex articulating surface
o Head: prominent expanded end of a long bone
Extensions & Projections:
o Crest: narrow ridge
o Epicondyle: projection superior to condyle
o Line: slightly raised elongated ridge
o Process: any bony prominence
o Protuberance: outgrowth or protruding part of bone
o Spine: sharp, slender, narrow process
o Trochanter: massive process unique to femur
o Tubercle: small rounded process
o Tuberosity: large tubercle, usually roughened surface
o Alveolus: pit or socket (tooth socket)
o Fossa: (ditch) a shallow basin of variable size
o Foveola: tiny pit
o Sulcus/Groove: groove for tendon, nerve, or blood vessel
o Canal: tubular passage or tunnel in a bone
o Fissure: slit through a bone
o Foramen: rounded hole of short length in a bone
o Meatus: opening or passage, usually air-filled
Red Marrow: hematopoietic; mainly in axial skeleton, ilium, some in head & metaphysis
of humerus; glenoid (scapula); neck & metaphysis of femur
Yellow Marrow: mainly fat; in rest of skeleton
Synarthrosis: solid joint with limited or no movement
o Fibrous joint: non-osseous bonding material is collagenous
Suture: bone-collagenous sutural element- bone (cranium)
Syndesmosis: bone-interosseous membrane or ligament bone (radius &

Gomphosis: mandibular alveolus-complex collagenous periodontium-dental

cement (teeth)
o Primary Cartilaginous Joint (Synchondrosis): growth plates of bones.
Eventually ossification supervenes forming bony union (synostosis) (epiphyseal line)
o Secondary Cartilaginous Joint (Symphysis): bone-hyaline cartiliagefibrocartilaginous pad or disk-hyaline cartilage-bone. Permits limited movement
(amphiarthrosis). IE: pubic symphysis & intervertebral disks
Physis: (epiphyseal growth plate) location of germinal proliferative centers
Metaphysis: site of addition of matured cartilage; where osteogenesis occurs
Diaphysis: growing long bone
Synostosis: ossified physis; forms epiphyseal line
Harris Lines: growth arrest lines produced after a period of arrest of 10 days or more
following disease state or malnutrition that has interrupted bone growth
Avulsion Fractures: fracture through the growth plate in the pediatric population
Apophysitis: inflammation through the growth plate
Diarthrosis: cavitated, synovial joint permitting movement
o Joint capsule: fibrous capsule + synovial membrane
Fibrous capsule: merges with periosteum of joining bones
Ligaments: thickenings of the fibrous capsule
o Synovial membrane: vascularized cellular membrane that secretes viscous
synovial fluid, containing synovial mucin which is rich in hyaluronate
o Synovial Joint Modifications:
Articular Disk: fibrocartilaginous pad-like extension of fibrous capsule that
completely divides a joint into 2 cavities
Meniscus: crescent-shaped, fibrocartilaginous extensions of fibrous capsule
of knee joint
o Synovial Modifications:
Synovial Sheath: flattened synovial sac
Bursa: flattened synovial sac that reduced friction & pressure between either
a tendon, muscle or skin overlying bony prominences
o Synovitis: inflammation of synovium; can lead to joint effusion, & protrude as
synovial cyst
o Tenosynovitis: inflammation of synovial tendon sheath
o Bursitis: inflammation of bursa
Pulmonary Circulation: blood that undergoes exchange & passes through 1 set of
capillaries before returning to heart
Systemic Circulation: blood that may pass through exchange vessels or bypass them
Nephron Circulation: arterial capillary bed, glomerulus, is interposed between proximal
afferent & distal efferent arterioles. Efferent arteriole then ramifies to a 2 nd true capillary
bed, peritubular capillaries
Portal System: consists of true capillary beds connected to beds of venous capillaries
called sinusoids via portal vessels. Venous blood travels in venules, then veins, then in a
single hepatic portal vein, which enters liver & ramifies into sinusoids where additional
exchange occurs.
Hypophyseal Portal System: short & long portal vessels (postcapillary veins) connect
proximal neural capillary beds with venous sinusoids of pars distalis
Musculovenous Pump: contracting muscle that milks valve-oriented blood towards the
Varicose veins: the result of Valvular incompetence in the lower limb

Thrombophlebitis: inflammation of a vein in response to thrombosis; can dislodge, travel

to the right heart & form a pulmonary thromboembolism
Homans Sign: the pain produced in the calf with passive dorsiflexion of the foot in the
acute phase of deep vein thrombosis & thrombophlebitis
Hematogenous: spread or metastasis through veins
Anastomosis: joining of similar blood vessels such that the net flow in some point of the
anastomosis is zero
o End-to-End Anastomosis: two blood vessels from different anatomical sources
form a blunt union
o Transveral anastomosis: connecting vessel joints 2 vessels
o Convergence anastomosis: 2 vessels converge to form a single vessel
o Accompanying Veins (venae comitantes): course with & surround medium-size
arteries & are bound in the same noncompliant vascular sheath
Angiosome: a 3D territory of tissue supplied by a source artery & its accompanying veins
Functional End Artery: a set of vessels whose anastomoses are insufficient to prevent
ischemia with blockage of one of the arteries
Anatomical End Artery: an artery that does not engage in anastomoses IE: central
artery of the retina, renal interlobular arteries
Arteriole-Muscular Venule Connections (Preferential Thoroughfare Channels),
Small Artery- Small vein Connections (Arteriovenous Shunts): connections
between arterial & venous vessels but technically not anastomoses because there is no
zero flow point
Arteriovenous Fistulas: abnormal connections between arteries & veins
Vascular Ectasia: abnormal dilatation of a blood vessel, especially in capillary beds in the
GI tract that can lead to an incompetent arteriovenous fistula & blood loss
Primary Lymphoid Organs: thymus gland, red bone marrow. Production of lymphocytes
Secondary Lymphoid Organs: Spleen (reservoir for macrophages), Mucosa-associated
lymphoid tissue, Lymph nodes
Lymphatic vessels: lymphatic capillaries, afferent lymphatic vessels (to lymph node),
efferent lymphatic vessels (exiting lymph node), lymphatic trunks, lymphatic ducts
Afferent lymphatic vessels: 3-4 afferent lymphatic vessels enter a lymph node
Efferent lymphatic vessels: a single efferent lymphatic vessels leaves a lymph node
Lymphangitis: inflammation of lymphatic vessels
Lymphedema: edema of a drained region that is high in protein
Chyle: lymph from the lacteals of the small intestine; dense & milky from the
Lymphocenters: clusters of lymph nodes draining a region
Lymphogenous metastis: lymphatic pathways & lymph nodes serve as a means to
disseminate cancer cells
Sentinel node: node of high probability that cancer cells from a tumor will drain first
Lymphoscintigraphy: tumor site is injected with radioactive lymphatic-avid material to
identify & evaluate nodes for metastasis
Signal node: palpable, cancerous node that signals presence of primary carcinoma deep
within body
Lymphadenitis: inflammation of lymph node due to infection; tends to be tender, warm,
enlarged, soft & movable
Central Nervous System: comprised of neuronal cell bodies, nerve fibers, & connective
tissues of brain & spinal cord; communicates with other functional components of body via

o Nucleus: collection of neuronal cell bodies within CNS

Peripheral Nervous System: comprised of neuronal cell bodies, nerve fibers, &
connective tissues outside the CNS; connects & conveys information between peripheral
structures & the CNS
o Ganglion: collection of neuronal cell bodies outside the CNS
Neuron: anatomical unit of the nervous system consisting of cell body, dendrites, & an
Motor (Efferent)Neuron: multipolar; carries information away from CNS
Somatic (general) Motor Neurons: cell bodies in nuclei within ventral horn of spinal
cord; stimulate contraction
Sensory (Afferent) Neuron: pseudounipolar; carries information towards CNS; cell
bodies are in ganglia outside CNS; central process projects into dorsal horn of spinal cord
Somatic (general) Sensory Neurons: convey sensation from somatic structures (pain,
touch, temperature)
White Matter: bundles of myelinated fibers arranged in discrete tracts
Gray Matter: arranged into ventral (anterior), dorsal (posterior, somatic & autonomic
sensory) & lateral (autonomic motor) horns
Ventral Rami: innervate everything else & form plexuses
Dorsal Rami: innervate zygapophyseal joints, intrinsic back muscles, & skin of 2/3rds of
the back
Cervical Plexus: formed by C1-C4
Brachial Plexus: formed by C5-T1
Lumbar Plexus: formed by T12/L1-L4
Sacral Plexus: formed by L4-S3 (paired with lumbar plexus to form lumbosacral plexus)
Dermatome: region of skin innervated by a single spinal nerve
Cutaneous Nerves: have autonomic motor fibers & sensory fibers
Myotome: mass of muscle innervated by a single spinal nerve; have motor fibers &
autonomic motor & somatic sensory fibers
o Important Dermatomes:
T4: across nipple
T6: across xiphoid process
T10: across umbilicus
T12: across top of pubic bone
L1: across groin fold
Anesthesia: loss of sensation
Hypesthesia: reduced sensation
Analgesia: loss of pain sensation
Hypalgesia: reduced pain sensation
Paresthesia: uncomfortable sensation
Dysesthesia: painful sensation
Concordant Parethesia/Pain: paresthesia & pain produced during procedures that
indicate the physician is in the right place
Autonomous Dermatomal Region/Zone: a region where there is lack of dermatomal
o C5: skin over deltoid
o C6: thumb pad
o C7: pad of index finger
o C8: pad of little finger
o T1: skin over anteromedial elbow
Motor Unit: somatic motor neuron & all the muscle fibers to which it is connected

Paralysis: complete loss of muscle cell contraction as a result of lesion of a somatic motor
Paresis: profound weakness in a mytome as a result of injury to a particular spinal nerve
or its ventral ramus
Rami Levels of Motor Innervation
o C5: shoulder abduction
o C6,C7: shoulder adduction, elbow flexion/extension, wrist flexion/extension
o C6, C7, C8: pronation/supination
o C7: finger extension
o C7, C8: finger flexion
o C8: deep extension & thumb (pollicis) abduction, deep flexion
o T1: intrinsics of the hand
ANS: part of the PNS responsible for monitoring & regulating visceral functions; carries
signals to & from visceral structures such as internal organs, glands, & blood vessels via
visceral motor (efferent) & visceral sensory (afferent) neurons
o Sympathetic Division: primarily responsible for motor innervation of smooth
muscle lining blood vessels, cardiac muscle & sweat glands, & sensory innervation
of viscera
o Parasympathetic Division: primarily response for motor innervation of smooth
muscle lining digestive tract, cardiac muscle, & salivary glands & sensory
innervation of viscera
Somatic Motor Neurons: innervate skeletal muscle; have single neuronal pathway from
CNS to skeletal muscle. Cell bodies are multipolar 7 located in the ventral horn of the
spinal cord; axons are myelinated & directly innervate somatic peripheral effectors
(skeletal muscles)
Visceral Motor Neurons: innervate smooth muscle, modified cardiac muscle, & glands;
have a 2-motor-neuron-pathway with a preganglionic neuron (1 st multipolar neuron in
lateral horn of spinal cord with myelinated axon) which synapses with a postganglionic
neuron (cell body in a ganglion with unmyelinated axon which innervates visceral
peripheral effector)
Sudomotor: eccrine sweat glands
Pilomotor: piloerector muscles
Vasomotor: vasoconstriction & vasodilation in skeletal muscle
Lateral Horn: has preganglionic cell bodies found from T1-L2 spinal cord segments
Ventral Root: has preganglionic axons to spinal nerves T1-L2 (& somatic motor axon)
Spinal Nerve: carry somatic motor axons, somatic sensory fibers & postganglionic
sympathetic axons. T1-L2 also have visceral sensory fibbers & preganglionic motor axons
White Ramus Communicans: connects spinal nerves T1-L2 anatomically to ventral rami
with sympathetic trunk ganglion. Carries preganglionic motor axons & visceral sensory
Gray Ramus Communicans: connects all spinal nerves (anatomically to ventral rami)
with sympathetic trunk ganglion. Carries postganglionic motor axons to spinal nerve.
Accepts visceral sensory fibers from spinal nerves C1-C8, & L3-Co1
Sympathetic Trunk (paravertebral) Ganglion: contains postganglionic cell bodies
Splanchnic nerve: connects sympathetic trunk ganglia with prevertebral ganglia. Carries
preganglionic motor axons & visceral sensory fibers
Prevertebral Ganglion: contains postganglionic cell bodies whose axons are distributed
to abdominopelvic viscera by coursing in the adventition of the arteries supplying those
Spinal Nerve Innervation Distribution:

o T1-L2: trunk
o C1-C4: neck
o C5-C8: upper limb
o L3-S4: lower limb
Autonomic Sensory Innervation:
o Somatic Sensory Neurons: innervate skin, muscle, joints. Convey pain,
temperature, touch, proprioception. Cell bodies located in dorsal root ganglia of
spinal nerves C2-Co1. Pathway same as motor, up to spinal nerve, through dorsal
root to dorsal horn.
o Visceral Sensory Neurons: innervate viscera, glands, blood vessels. Convey
distension, nausea, hunger. Cell bodies located in dorsal root ganglia of spinal
nerves T1-L2 & S2-S4. Pathway same as motor, up to spinal nerve, through dorsal
root & to dorsal horn.
Viscerosomatic Referred Pain: pain from a visceral organ that is interpreted by the
brain as coming from a somatic region of the body having the same spinal cord segmental
Raynauds Phenomenon: the condition when it is associated with a pre-existing disease
state such as diabetic neuropathy
Raynauds Disease: used to describe the condition when it is idiopathic
Raynauds Characteristics: abnormal, episodic vasospasm of the digits in response to
cold exposure. Upon warming, the affected digits undergo reactive hyperemia, becoming
engorged with blood. Characteristic biphasic or triphasic color response of affected digits,
from pallor to cyanosis. & upon rewarming, rubor. During rubor phase there is considerable
pain & throbbing
Complex Regional Pain Syndrome:
o Type I (Reflex Sympathetic Dystrophy): abnormal sympathetic response to soft
tissue injury marked by pain & swelling of a distal extremity accompanied by
vasomotor instability, trophic skin changes & rapid development of bone
Phase I: period of sympathetic hypoactivity; allodynia, hyperesthesia &
hyperrpathia (hyperalgesia); anhidrosis, edema, pain, throbbing, tender joints
Phase II: period of sympathetic hyperactivity; intense vasoconstriction,
pallor, cyanosis, skin mottling, cold intolerance
Phase III: persistent sympathetic hyperactivity causing gradual atrophy of
skin & subcutaneous tissue with flexion contracture & osteopenia
o Type II (Causalgia): characterized by persistent pain in limb after injury to a
peripheral nerve or major nerve trunk; a complication of brachial plexus surgery or
decompression; persistent pain is said to be in the form of burning & throbbing. Also
focal vasomotor & sudomotor abnormalities, with localized sweating & edema of
affected limb. Does not appear to progress to atrophy as CRPS Type I.
Dysautonomia: autonomic dysfunction associated with disease states
o Idiopathic:
Shy-Drager Syndrome: cases of multiple system atrophy in which
autonomic failure predominates
o Autoimmune:
Acute Pandysautonomic Neuropathy: autonomic failure due to ganglionic
anti-nicotinic acetylcholine receptor antibodies (postsynaptic Ach receptor
Guillain-Barre Syndrome: autoimmune acute polyneuropathy; 2/3rds of
patients have some degree of autonomic failure

Paraneoplastic: autonomic neuropathy & failure associated with small cell

carcinoma (type of lung cancer) due to carcinoma secreting anti-nuclear antibody
Type I
o Toxins:
Botulinum toxin: binds to presynaptic cholinergic terminals & block Ach
release leading to widespread autonomic depression
Tetanus: tetanospasmin blocks inhibitory post-synaptic potentials regulating
preganglionic autonomic neurons leading to widespread autonomic
overactivity (sweat, high BP)
Semen: pH 7.2-7.8; transient buffer effect is 6.0-6.5, optimal for sperm motility; fertility
requires more than 20 million/mL & 60% having motility with forward progression
Vagina: pH 4.3; bactericidal & spermicidal
Sperm Capacitation: removal of cholesterol & epididymal glycoproteins. Results in
increased motility & directionality in response to cumulus-oocyte complex & follicular fluid
chemoattractants & progesterone & thermal stimuli of uterine tube
Sperm Lifesspans: 80 hours in uterine tube, 20 hours if capacitated
Fertilization Steps
o Penetrate corona radiata: assisted by sperm hyaluronidase
o Attach to ZP3 protein of Zona Pellucida: initiate acrosome reaction & release
acrosomal enzymes
o Penetrate Zona Pellucida: acrosin enzyme to digest zona pellucida
o Cross Perivitelline space: initiation of cortical reaction; complete meiosis with 2 nd
polar body
o Bind ovum plasma membrane: release of ovum cortical granules to denature
zona pellucida; ZP3 protein is lost preventing polyspermy; corona radiata is lost;
zona pellucida becomes semipermeable to nutritive substances of uterine tube
o 2nd Meiotic Division: reduction of DNA to half of typical somatic cell (haploid)
Zona Pellucida: promotes maturation of oocyte & follicle, permits only species-specific
fertilization, initiates acrosome reaction, prevents polyspermy, permeable to tubal
nutritive substance, immunological barrier to maternal rejection, keeps blastomeres
together during cleavage, facilitates trophoblast differentiation, prevents premature
Accomplishments of Fertilization: Stimulates secondary oocyte to complete 2nd meiotic
division for haploid state & half DNA content, restores diploid number of chromosomes
with somatic cell DNA content, sex of future embryo determined by spermatozoon,
produces genetically unique product, activates maternal RNA transcripts & zygote
metabolism for cleavage & early embryonic development
Parental Imprinting: maternal chromosomes favor embryonic development; paternal
chromosomes favor placental development; maleness of placenta & decreased
immunological privilege may play a role in preeclampsia
Cleavage Steps:
o Single polar body of secondary oocyte/ovum & 2 polar bodies of fertilized ovum (2
o Cleavage: mitosis without cell growth
o Blastomeres: daughter cells
o Compaction: increasing numbers of blastomeres compacted by zona pellucida
o Morula: 16-cell stage; looks like mulberry
o Cavitation: cells of morula begin to segregate & produce eccentrically placed
cavity; 4 days after fertilization
o Blastocyst: cells after cavitation with blastocyst cavity; about 110 cells

Trophoblast layer: outer layer of cells next to zona pellucida; supplies embryo
with nutrition. Differentiates into placenta
o Embryoblast: inner mass that contains cell that will form the embryo; as few as 10
cells go on to develop into individual
o Poles: embryonic pole trophoblasts digest zona pellucida; blastocyst hatches from
zona pellucida at day 4.5-5. Embryonic pole undergoes implantation into uterine
wall (day 6)
o Ovum Transport: if fertilization occurs, zygote is transported through uterine tube;
transport is timed to maximize fertilization within 20 hours of ovulation; implanation
at day 6. Secondary oocyte delayed in ampulla for 1 day to prepare for fertilization
(physiological amullary isthmic junction block for 1-2 days). Enters uterine cavity at
day 4 as advanced morula (rise in progesterone helps b break through block).
Implantation completed by 12 days after fertilization
Blastocyst Stages:
o Day 8: human chorionic gonadotropic maintains corpus luteum of pregnancy for
progesterone production (6-8 wks). Firsts detected 6-8 days after pregnancy.
Doubles in concentration in maternal blood every 2-3 days, reaching peak at 60-90
days of pregnancy. Falls to plateau concentration 20 wks to term
o Day 9: embryo is almost completely implanted into uterine wall; extraembryonic
endoderm (hypoblast cells line cytotrophoblast container) goes onto develop into
gut & derivatives; lacunae developing in syncitiotrophoblast & will fill with maternal
o Day 12: complete implantation; eroded maternal blood vessels/dilated sinusoids
have connected with trophoblastic lacunae; cell to cell transferring of substance
between embryo & maternal blood
o Day 13: extraembryonic endoderm pinches off from exocoelomic cavity to form
definitive yolk sac.. extraembryonic mesoderm reinforces chorionic cavity as
chorionic plate, reinforces definitive yolk sac & amniotic cavity, & forms body stalk;
lacunae replete with maternal blood; cytotrophoblast villi formation
Extraembryonic Mesoderm: provides CT support for amnion & definitive yolk sac, forms
chorionic plate & body stalk, forms support for placental villi (those closes to embryo
expand, branch & grow forming chorion frondosum), serves as center for vasculogenesis
(de novo blood vessel development), angiogenesis (sprouting of new blood vessels from
existing ones), & hematopoiesis (blood cell development)
Hemangioma: most common tumors of infancy; abnormally dense collections of capillary
blood vessels. Often associated with facial structures.
Sites of Ectopic Pregnancy
o Tubal: cause rupture & hemorrhage
o Placenta Previa: close to internal os (opening) of uterus; too close to cervical
opening. Can bridge the opening as they grow & tear away from wall causing
bleeding & spontaneous abortion. Placenta presents ahead of fetus
Chorion Maturation Steps:
o Primary villus: projection of cytotrophoblast covered by syncytiotrophoblast
o Secondary villus: layers around central extraembryonic mesoderm core from
chorionic plate
o Tertiary villus: development of fetal capillaries & sinusoids within mesodermal
Amniocentesis: performed at 15-20 wks pregnancy; prenatal screening
Chorionic Villi Sampling: performed at 11 wks. Prenatal screening

Molar Pregnancy: part of a spectrum of gestational trophoblastic neoplasia; may lead to

development of malignant tropohoblastic disease (choriocarcinoma) excessive paternal
imprinting. Can result in hemorrhage, & secretion of excessive hCG can cause gestational
Neural Tube Defects & Amniotic Fluid
o Excessive Amniotic Fluid: polyhydramnios; due to failure of fetus to swallow or
process fluid in GI tract. Can be caused by anencephaly
o Too Little Amniotic Fluid: oligohydramnios; due to failure of fetus to urinate into
the amniotic fluid; amniotic fluid is necessary for lung maturation & mechanical
buffering; newborn is delivered with anuria, poorly developed lungs, squashed facial
features, stumpy digits, & clubbed feet (Potter sequence)
Lecithin-Sphingomyelin Ratio: a good indicator of development of alveolar surfactant
(keeps alveoli from collapsing when newborn starts to breathe air); ratio of less than 1.5 is
not good these infants have a high risk of respiratory distress syndrome
Bilaminar Germ Disc: embryho at 2 weeks with epiblast & hypoblast
Amnioblasts: formed in epiblast
Hypoblast: cells line definitive yolk sac
Definitive Yolk Sac: source of vitamins A, B12, & E, & folic acid
Epiblast Fate Map
o Primitive Streak: groove where cells sink into the midline & internalize
o Polarities: hypoblast = ventral, epiblast = dorsal, oropharyngeal membrane =
cranial, opposite pole = caudal
o Cloacal Membrane: spot-welded region that forms in the caudal region of the
bilaminar embryo; demarcates future site of the anal canal & terminal portions of
the urogenital system
o Cilia: confer laterality (left-right differences) through their beating at Hensons
node. They beat leftward, moving various signaling factors

Cell Lineages
o Zygote


Inner Cell Mass


Embryonic Endoderm:
Neural ectoderm, neural
crest, surface ectoderm

Primordial Germ Cellsc Mesoderm:
c mesoderm
(definitive yolk sac)

(chorionic plate,
chorionic villi, body
stalk, support for
amnion & definitive
yolk sac,
Neurulation (20-23 day embryo)
o Neural tube: closes first in middle then cranially & caudally
o Cranial Neuropore: closes at 25 days

c Mesoderm

o Caudal Neuropore: closes at 28 days

Derivatives of Embryonic Ectoderm
o Surface ectoderm: epidermis, hair, nails, subcutaneous glands, mammary glands,
adenopophysis, membraneous inner ear, lens, anoderm of anal canal, oral
epithelium, ameloblasts (tooth enamel), sensory epithelium of nasal cavity
o Neural tube ectoderm (neural plate; neural placode): brain & cranial motor
neurons, spinal cord & motor neurons, retina, pineal gland, infundibulum
o Neural crest: CT & bones of face & skull, cranial nerve ganglia, calcitonin cells of
thyroid gland, conotruncal septum of heart, odontoblasts, dermis of face & neck,
dorsal root ganglia, sympathetic trunk & prevertebral ganglia, enteric neurons,
adrenal medulla, schwann cells, glial cells, forebrain meninges, melanocytes,
vascular smooth muscle of face & forebrain
Embryonic Mesoderm (17-20 day embryo)
o Lateral infolding progresses
o Endoderm rolled into tube
o Intercellular clefts develop
o Lateral plate layers develop:
Somatopleure: parietal layer
Splanchnopleure: visceral layer
Embryonic Endoderm Derivatives: epithelial lining of respiratory tract, GI tract,
tympanic cavity & pharyngotympanic tube, most of the urine-collecting portion of the
urinary system, distal genital system, parenchyma of thyroid, parathyroid, liver &
pancreas, reticular stroma of thymus & palatine tonsils
Derivatives Intraembryonic Mesoderm
o Paraxial Mesoderm: axial skeleton (except cephalic structures), axial muscles,
anterolateral body wall muscles, dermis of skin, limb muscles
o Intermediate Mesoderm: nephron, gonads, efferent ductules, epididymis, ductus
deferens, seminal vesicles, ejaculatory ducts, uterine tubes, uterus, upper 1/3 rd of
vagina, adrenal cortex
o Parietal Mesoderm: limb skeleton, parietal pleurae, parietal pericardium, parietal
o Visceral Mesoderm: wall of respiratory tract, wall of GI tract, walls of peritoneal
organs, hemangioblastic tissues (blood cells, vascular endothelium, epicardium,
myocardium, endocardium), mesenteries
Mechanisms of Twinning
o Dizygotic/Fraternal: double ovulation & fertilization; normal development of
zygotes & 2 implanting blastocyst
Diamniotic-Dichorionic Implantation: each has its own amnion & chorion;
normal development
Twin-Twin Transfusion Syndrome: implant too close together & chorions &
placentae fuse; anastomosis of placental vessels allows 1 twin to dominate
for obtaining maternal blood supply
o Monozygotic/Identical:
Diamniotic-Dichorionic: Separation of 2-cell blastomeres/early embryo;
leads to 2 complete, identical blastocyst
Diamniotic-Monochorionic: inner cell mass splits to form 2 separate inner
cell masses with common trophoblastic layer (20% of all twinning); common
implantation with common chorionic cavity & common placenta; possible
twin-twin transfusion syndrome

Monoamniotic-Monochorionic: rarest condition; splitting of bilaminar germ

disc after amnion has formed; problems of embryos twisting & twin-twin
transfusion syndrome & conjoined twinning
Consequences of Twin-Twin Transfusion Syndrome: fetus papyraceus (twin ends up
sucked dry)
Consequences of Monoamniotic Monochorionic Twinning: craniopagus (head to
head fusion), pygopagus (rump to rump fusion), thoracopagus (chest to chest fusion)
Common reasons for chest discomfort: observable anatomical basis,
osteoligamentous, pneumonia, pneumothorax, complicated severe asthmatic attack, left
ventricular failure, pleural effusion, pulmonary embolism, aortic dissection/rupture, foreign
Functions of Rib Cage: protection, prevent paradoxical motion
True Ribs: vertebrosternal, 1-7
False Ribs: vertebrochondral: 8-10
Floating Ribs: vertebral, 11-12
Thoracic Vertebra: form zygapophyseal joints with cephalad & caudad vertebrae; have
spinous process, & articular facets for heads of ribs
Sternum: manubrium (upper segment), gladiolus (body), xiphoid process (cartilaginous);
rich erythropoietic center; fractures are rare; can be caved in (pectus excavatum) or
bowed out (pectus carinatum)
Manubriosternal Juction: 1st rib articulates with manubrium via synchondrosis (little
Structure of Rib: head with 2 articular facets or demifacets, capitular facets separated
by interarticular crest (inferior capitular facet larger, articulates with superior
costocapitular demifacet); neck oof rib, tubercular facet (ribs 1-10) to articulate with
costotubercular facet of transverse process of vertabra, shaft of rib (roughened for muscle
attachment), costal angle (site of highest frequency of rib fracture), costal groove (V-A-N)
Somite: dermatome, Myotome, sclerotome
Derivatives of Sclerotome: vertebra & joint surfaces, annulus fibrosus of intervertebral
disk, ribs, spinal meninges, tendons of intrinsic back muscles
Derivatives of Dermatome: dermis, blade of scapula
Derivatives of Myotome: intrinsic back muscles, limb muscles, anterolateral body wall
Cleidocranial Dysostosis (Dysplasia): clavicles are absent or hypoplastiic; delayed
ossification of skull bones & fontanelles close late oro fail to close; supernumerary teeth.
Patients can approximate their shoulders in the midline
Angle of Louis: level of T4/T5 intervertebral disk
Traubes Semilunar Space: for spleen; 6th rib costal margin midaxillary line
Xiphisternal Junction: level of T9
Larreys Point: landmark for performing pericardiocentesis; apex of left xiphi-costal
Rib Flail/Flail Chest: fracture of panel of ribs, usually at angles & costochondral
junctions; get paradoxical motion & decreased vital capacity
Rib Fracture: generally occurs at angle; pain while attempting to sleep supine is
Thoracic Outlet Syndrome: neurovascular problems arising between first rib & clavicle
Pancoasts tumor: apical lung adenocarcinoma; erosion of a rib or clouding of its
contours may be sign of metastasis

Condrocalcinosis: calcification with old age; causes dowagers hump (increased

Costochondritis: inflammation usually at synovial joints; can mimic angina pectoris
Tietzes Syndrome: intensely painful inflammation of synovial joints of unknown
etiology; may be due to microtrauma of joints after thoracic strain (coughing, vomiting,
strong laughter, weightlifting)
Rib Infection: becomes infectious foreign body & must be resected
Ewings Sarcoma: tends to develop on lateral side of osseous portion of rib; onion-skin
appearance in CXR due to concentric regions of bone growth & destruction
Chondrosarcoma: cancer of cartilage; tendency to develop between sternocostal joint &
costochondral junction; locally invasive
Anaplastic Sarcoma: favors the sternum; locally invasive
External Intercostal Layer: external intercostal muscle that is well-developed
posteriorly whose fibers course anteroinferiorly from cephalad rib to subjacent rib (hands
in pockets)
Internal Intercostal Layer: muscle is well developed anteriorly near sternum, but as it
courses posteriorly just beyond the midaxillary line, it fads & continues as an internal
intercostal membrane; direction of fibers is orthogonal to external intercostal muscle, from
cephalad rib to subjacent rib; (hands on boobs!)
Innermost Intercostal Layer: muscle fibers are best developed laterally & then become
transparent membranes anteriorly at level of costochondral junctions & posteriorly at the
level of the angle of the ribs; orientation of fibers is similar to internal intercostal layer; Vshaped fibers (Christmas tree)
Intercostal Neurovasculature: superior to inferior in costal groove order is vein, artery,
nerve (VAN)
Coarctation of Aorta: congenital stenosis of descending thoracic aorta distal to the takeoff of the left subclavian artery. Pressure & blood flow proximal to the stenosis is high,
expanding collateral arteries about the scapula & anastomosis with posterior intercostal
arteries distal to the stenosis. High flow causes posterior intercostal arteries to become
torturous, which notches the inferior border of the ribs; causes the aortic knuckle to
resemble a 3 in CXR
Notching of the lower borders of ribs: indicates dilatation of posterior collaterals
joining the posterior intercostal arteries; may be due to stenosis of a portion of the
descending thoracic aorta due to gradual atherosclerosis
Azygos & hemiazygos: accept most of the posterior intercostal veins
Descending thoracic aorta: gives rise to most of the posterior intercostal arteries
Thoracic Ventral Rami: give rise to intercostal nerves
Superior Costotransverse Ligament: the rami of the thoracic spinal nerves course to
respective sides of the ligament. Syndesmophytes (osteophytes) in the ligament can
compress these neural structures; attaches a rib to the transverse process of the cephalad
Branches of Typical Intercostal nerve: rami communicantes, collateral branch to rib
below, lateral cutaneous branch, anterior cutaneous branch, motor branches to segmental
intercostal muscle, motor branches to levatores costarum muscles, motor branches to
serratus posterior muscles
2nd Intercostal nerve: has a lateral cutaneous branch that is intercostalbrachial nerve,
which supplies skin of the armpit. Called the heart nerve because it carries referred pain
during myocardial ischemia
First 11 intercostal nerves: supply sensory innervation to parietal pleura

Lower 5 intercostal nerves & subcostal nerve: supply anterolateral abdominal wall
muscle, skin & parietal peritoneum
Thoracotomy: cutting into thorax
Thoracostomy: inserting a tube into the thorax
Hemothorax: blood in the thorax
Pneumothorax: air in the pleural cavity
Thoracentesis: pleurocentesis; inserting a needle to reduce the abnormal situation in the
pleural cavity
To anesthetize an intercostal space for these procedures: anesthetize the main
branch of the intercostal nerve of the superjacent rib, & the collateral of the same nerve to
the subjacent rib. Posteriorly, you can anesthetize the nerve before it gives off the
collateral but hard to do because of back muscles
Lymphatic Drainage of Thorax:
o Deep fascia & deeper: infection/metastasis follows arteries deeply; drains to
internal thoracic lymph nodes (internal mammary lymph nodes) & along sides of
descending thoracic aorta (para-aortic nodes)
o Superficial Fascia (dermis & skin): direction of drainage is determined by line
encircling umbilicus
Above the line posteriorly: drains to posterior axillary lymph nodes
Above the line anteriorly: drains to anterior axillary lymph nodes
Below the line: drains to superficial inguinal lymph nodes
Septum Transversum: visceral mesoderm near the heart that segregates caudally where
it is invaded by the liver parenchyma; forms a large part of the thoracoabdominal
diaphragm & contributes to the formation of the liver sinusoids
Development of the Thoracic Cavity (pleural cavities & midline pericardial
o Cranial part of intraembrynoic body cavity occupied by developing heart future
pericardial cavity
o Lung buds bulge into future pericardial cavity
o Pleuropericardial folds divide future pericardial cavity into definitive pericardial
cavity & more dorsal pleural cavity; pleuropericardial folds contain veins (right
becomes inferior vena cava) & phrenic nerves
o Pleuropericardial folds fuse & separate 2 pleural cavities from pericardial cavity
o Lungs grow & push & enlarge pleural cavities ventrolaterally to almost completely
surround midline pericardial cavity
o Parenchymal portion = mesothelium that secretes & absorbes serous fluid
Costodiaphragmatic Recess: inferior pouch of the pleural cavity; lungs never
completely fill this recess
Costophrenic angles: limits of the lung tissue form these
Sibsons Fascia: a thickened fascia that protects the cervical pleura & apex of the lung
Innervation of Visceral & Parietal Pleurae: visceral pleura & lung are insensitive to
pain; parietal pleurae are heavily innervated with pain fibers
Chilaiditis Syndrome: constant swallowing of air & sputum from pneumonia produces
gas in the GI tract; the distended loop of the bowel insinuates itself between the stomach
& diaphragm or diaphragm & liver
Relationship between pleural cavity, lungs & rib cage
o Anteriorly: ribs 2-4 pleural cavities are in contact behind the sternum (anterior
junction line)
o Anteriorly: ribs 4-6 right parietal pleura stays midline, left parietal pleura deviates

o Midclavicular line: lung inferior limit is rib 6, parietal pleura inferior limit is rib 8
o Mixaxillary Line: lung inferior limit is rib 8, parietal pleura inferior limit is rib 10
o Scapular Line: lung inferior limit is rib 10, parietal pleura inferior limit is rib 12
Becks Triad: hallmark feature of cardiac tamponade; rising central venous pressure
manifesting as jugular venous distension & distension of other head, neck & upper limb
veins, diminished heart sounds, diminished arterial & pulse pressures; pericardiocentesis
is performed to relieve pressure of cardiac tamponade
o Trendelenberg Position: head elevated 15-30 degrees with respect to feet &
supine; position used to perform pericardiocentesis; insert needle 45 degree angle
to body into left xiphi-costal angle (Larreys Point) aimed at left shoulder
Cardiothoracic Ratio: normal-sized heart silhouette in PA CXR should fit in width of 1
lung field or of chest cavity
Sniff Test: check for hemidiaphragm paralysis; paralyzed hemidiaphragm moves
paradoxically upward
Pleural Effusion: tend to collect in costodiaphragmatic recess & eventually blunt
normally sharp costophrenic angle
Pneumothorax: air in the pleural space; causes partial collapse of the lung
Pneumoconiosis: lung disease caused by inhalation of aerosolized particulates; chronic
irritation leads to chronic pleuritic & pleural adhesions
Bulla: air-filled space of the lung greater than 1 cm in diameter; usually seen in
Bleb: air-filled alveolar dilatation in the lung less than 1 cm in diameter
Open Pneumothorax: pneumothorax retaining communication with atmospheric air;
caused by wounding of parietal pleura but sometimes by a spontaneous variety retaining a
communication with pulmonary air; has danger of converting to tension pneumothorax
Tension Pneumothorax: air comes into the cavity with inspiration, but has a check-valve
closed effect with expiration; pressure continues to rise in the pleural space as a result
Apical Bullous Lung Disease: of unknown etiology; occurs in the pediatric population,
generally in asthenic males. Prone to recurring pneumothoraces.
Carinal Cartilage: last tracheal ring; surrounds the beginning of the main bronchi
Tracheomalacia: disease states can put long-term pressure on the trachea causing
chondromalacia of the tracheal rings; leads to segmental collapse with inspiration
Traumatic/Iatrogenic Tracheoesophageal fistula: a rare complication of endoscopy of
the trachea or esophagus in which the unsupported wall of the trachea abutting the
esophageal wall provides opportunity for fistula formation.
Congenital Tracheoesophageal Fistula: if septation & separation fails in some part of
the laryngeotracheal tube, TEF develops; incompatible with postnatal life, except the H
Carina: internal keel of the carinal cartilage
Right tracheobronchial angle: 25 degrees
Left tracheobronchial angle: 40 degrees
Hemoptysis: coughing up of blood;
Bronchial veins: superficial veins return to venous system via azygos & hemiazygos
Interbronchial angle: almost 90 degrees
Widening/Flatteningo f interbronchial angle: left atrial enlargement, upper lobar
atelectasis, carinal lymphadenopathy
Air Bronchogram: patent airways that become visible out to the tertiary divisions &

Bronchiectasis: permanent dilation of airways as a result of long-term inflammatory

processes of airways
Where is the Pneumonia? If it obscures:
o Superior right heart border: RUL
o Right atrial border: RML
o Superior left heart border: LUL
o Much of the ventricular border: Lingula
o Either hemidiaphragm: lower portion of the respective LL
o If in contact with either heart border but not obscuring it: behind the heart
in the upper portion of the respective LL
Types of Acquired Atelectasis:
o Extrapulmonary: pneumothorax & pleural effusion
o Intrapulmonary: collapsing segments pull on surrounding structures; the
atelectatic portion is still held in contact with parietal pleura but something pliable
has to give. Can:
Shift in fissure of lung
Pull on root of lung causing a change in interbronchial angle
Pull on enough to shift trachea
Pull up on left diaphragm (peaking)
Reduce normal space of ribs
Any combination of these
Early Signs of Heart Failure
o Cephalization: caliber of lower pulmonary veins begins to constrict & that of upper
pulmonary veins increases
o Perihilar Haze: distinct pattern of hilar vessels becomes vlurred because of
increasing interstitial edema
o Kerley B Lines: interstitial edema builuds up in interlobular septa producing lines
at base of the lungs adjacent to Correras Line
o Peribrronchial Cuffing: edema of the segmental bronchi walls
Late Signs of Heart Failure
o Bats Wing Pattern: summation of shadows in high lymphatic flow toward the hila
o Intersitial edema producing Kerley A Lines more centrally
o Larger bilateral pleural effusionis
o Alveolar patchiness indicating spillover into alveoli
How to View a PA Chest X-Ray
o R: Rotation of Patient: medial end of clavicles should be equidistant from midline
spinous processes
o I: Inspiratory Effort: should be able to count 10 ribs posteriorly, 8 ribs anteriorly;
lung markings (vessels) should be apparent right out to Correras Line. Left hilar
point is generally higher (rib 6) than right (6 th intercostal space). Left should never
be lower than right.
o P: Position of Tubes after Procedures
o A: Airway: contour & disposition of trachea, interbronchial angle, & secondary
o B: Bones: rib fracture, rib notching, coarctation of aorta, glenohumeral articulation,
humeral fracture
o C: cardiac silhouette, costophrenic angles, Kerley B lines
o D: Diaphragm: contours & disposition
o E: Emphysema: blebs, bullae, cysts, pneumatoceles, subcutaneous emphysema
How to View a Left Lateral Chest X-Ray

Lung areas: retrosternal area (airspace) (right ventricle); recrocardiac area

(airspace) (left atrium)
o Cardiac Silhouette
o Diaphragm: right hemidiaphragm extends from anterior chest wall to posterior
costophrenic angle; left has fundic gas buggle & extends from posterior aspect of
heart shadow to posterior costophrenic angle
o Thoracic Vertebrae: lower vertebrae appear more transradiant (darker) than
middle & upper levels
Obtuse Border/Margin: left border of the heart wit hthe left atrial appendage,
pulmonary trunk & aortic arch
Inferior border/Acute Margin: right ventricle over to apex (left ventricle)
Sternocostal Surface: formed by the right ventricle & atrial appendage
Diaphragmatic Surface: formed by left ventricle & some of the right ventricle
Apex beat: apex strikes anterior 5th intercostal space
Base: left atrium & roods of the great vessels connecting the heart to the mediastinum
Coronary Sulcus: atrioventricular sulcus, largely obscured by the pulmonary trunk &
aorta; visible posteriorly at the base & represent the position of the cardiac fibrous
Crux of the Heart: point of junction of interatrial, coronary, & posterior interventricular
sulci; divides the coronary sulcus into right & left portions
Right atrium: divided into rough-walled anterior portion (pectinate muscles) & smooth
walled venous component (sinus venarum) by terminal crest (crista terminalis) which is
represented by the terminal groove (sulcus terminalis); this groove contains the SA node.
Right atrial appendage (auricle) projects anteriorly covering part of ascending aorta &
proximal portion of right coronary artery. Sinus venarum receives superior & inferior vena
cava & coronary sinus. Inferior vena cavae has Eustachian valve (was foraemen ovale) &
plays a role in formation of crytogenic emboli; Fossa ovalis is remnant of septum primum
that patches foramen ovale. Superior lip of this is limbus fossae ovalis. Above limbus
fossae ovalis is intervenous tubercle & tricuspid valve. In atrial wall above opening of
coronary sinus is AV node
AV Node: located in triangle of Koch. Triangle is bordered by tendon of Todaro
Left atrium: entirely smooth-walled except for atrial appendage. Receives right & left
pairs of superior & inferior pulmonary veins. May exhibit probe patency from right to left
atria if valve for foramen ovale didnt close completely.
Trabeculae carnae: ridges & arches lining ventricular walls
Papillary muscles: connected to the cusps of the AV valves by chordae tendineae
Right Ventricle: commences at right AV orifice. Guarded by the tricuspid valve. Anterior
papillary muscle receives communication from right bundle branch by septomarginal
trabecula (moderator band). Septal cusp attaches to membraneous interventricular
septum. Inflow of right ventricle is separated from smooth walled ouflow tract (conus
arteriorosus or infundibulum) by the supraventricular crest. Summit of right ventricular
outflow tract is the pulmonary (semilunar) valve
COPD: causes constriction of pulmonary arterial branches & pulmonary hypertension.
Characteristics include overaeration of lungs, flattening of hemidiaphragms, dilated
pulmonary trunk & central branches, pruning of peripheral arterial branches, pulmonary
Left Ventricle: commences at left AV orifice. Guarded by the mitral (bicuspid) valve. 2
papillary muscles & chordae tendineae & cusps are thicker than right counterparts.
Anterolateral papillary muscle is supplied by the LAD & LCX, and posteromedial papillary

muscle is supplied by the PDA. Smooth walled outflow tract, aortic vestibule, ends with the
aortic (semilunar) valve, having right coronary, left coronary, & posterior non-coronary
Cardiac Fibrous Skeleton: gasket of collagenous fibers situated between the atria &
ventricles. supports the orifices & attached valves & prevents their collapse, the
ventricular myocardial syncytial bands directly begin & end on the skeleton, & it serve as
an electron conduction barrier between atria & ventricles
Atrial Myocardium: superficial atrial fibers begin on the fibrous skeleton & wind through
the atrial septum. Superficial fibers wring dimension of the chambers with atrial systole, &
conduct to ensure impulses largely originating in the right atrium are rapidly brought to
the left. Deep atrial fibers are restricted to each atrium. They direct blood toward AV
orifices & form quasi-functional sphincters to minimize retrograde flow of blood into the
Aortic Valve Stenosis: common feature of the aged heart; leads to left ventricular
hypertrophy & eventually left atrial hypertrophy
Right Coronary Arteries: proximal RCA gives off conus artery, SA nodal arteria, right
atrial branches & right anterior ventricular arteries. Acute marginal artery demarcates
beginning of distal RCA, which gives off posterior descending artery. SA node, AV node, &
common AV bundle receive their blood supply from the right coronary artery
Left Coronary Arteries: divide into left anterior descending artery (divided into proximal
LAD & distal LAD). Circumflex artery (divided into 2 obtuse marginal arteries)
Conduction System: SA node (supplied by RCA) innervated by right vagus nerve. AV
node (supplied by RCA) innervated by left vagus nerve. Common AV bundle of His
(supplied by RCA) as is right bundle branch. Left bundle branch is supplied by LCA.
Occlusions of RCA give rise to conduction block.
Postganglionic Sympathetic Fibers:
o Superior cervical sympathetic cardiac nerve derived from superior cervical ganglion
o Middle cervical sympathetic cardiac nerve derived from cervicothoracic (stellate)
o Postganglionic fibers from thoracic sympathetic ganglia T2-T5
o Intercostobrachial Nerve (large component of T2) heart nerve
Thebesian Veins: smallest cardiac veins, drain their respective myocardia
Coronary Sinus: 80% of blood draining here comes from left ventricle via great cardiac
vein; site of drainage from posterior vein of left ventricle & oblique vein of left atrium
Small cardiac vein : courses in right part of coronary sulcus; drains distal field of right
coronary artery
Middle cardiac vein: accompanies PDA
Anterior cardiac veins: drains proximal field of right coronary artery
Lymphatics of the Heart:
o Right: follows RCA, right trunk, left brachiocephalic node, left bronchomediastinal
trunk, left lymphovenous portal (thoracic duct)
o Left: follows LCA, left trunk, inferior tracheobronchial node, right superior
tracheobronchial nodes, right bronchomediastinal trunk, right lymphovenous portal
(right lymphatic duct)
Primary Heart Field: cardiac crescent cranial to the oropharyngeal membrane
Cardiac Crescent: forms left ventricle, most of atria, & has a minor contribution to the
outflow tract & right ventricle
Secondary Heart Field: cells from this inner portion of the cardiac crescent form most of
the outflow tract & right ventricle & contribute to the formation of the atria

Proepicardium Cells: form most of the visceral pericardium (epicardium), the coronary
arteries, & the fibroblasts of the heart; eventually form the definitive epicardium, & layer
becomes continuous with parietal mesothelial layer
Cardiac Neural Crest Cells: invade the developing heart & contribute to the walls of the
outflow tract & the conotruncal septum; play a critical role for the formation of the atrial &
membranous ventricular septa
Conotruncal Septum: divide the outflow tract into the pulmonary trunk & the aorta
FROM 18-22 DAYS:
o Myocardial Primordium: develops from the visceral mesoderm of the developing
pericardial cavity
o Visceral Mesoderm: gives rise to the endocardial tubes; eventually fuse to form a
single tube
o Pericardial Cavity: with lateral infolding, encircles developing heart
o Visceral Mesothelium: forms the scaffold for the myocardium & the contact
support for the epicardium; is eventually displaced by invading proepicardium cells
o Dorsal Mesocardium: eventually breaks down, leaving developing heart free in
pericardial cavity
o Parietal Mesoderm: forms parietal pericardium
Primordial Heart: formed from fusing of endocardial tubes, with fusion occurring in the
cranial-caudal direction; with cranial infolding, the heart primordium & pericardial cavity
undergo 180 degree roation so they end up on the underside of the embryo
Endocardial Tube: comes to lie in front of part of gut tube which will become future
First heart beat: 20-22 days of development
Five Parts of Embryonic Heart & Their Fates
o Sinus Venosus: becomes sinus venarum, coronary sinus, & oblique vein of the left
atrium (Oblique Vein of Marshall)
o Primitive Atrium: becomes rough walled parts of right & left atria & their atrial
appendages (auricles)
Right atrium: distinction between rough & smooth walls is separated by
crista terminalis, with pectinate muscle emanating from crista terminalis
lining anterior aspects of RA
Left atrium: incorporation of 4 pulmonary veins largely displaces most of
the embryonic rough wall, leaving it almost entirely smooth walled with rough
wall restricted to left auricle
o Primitive Left Ventricle: forms trabeculated part of left ventricle
o Bulbus Cordis:
proximal portion becomes primitive right ventricle, which later becomes
trabeculated portion of right ventricle
Conus Cordis: middle portion that becomes conus arteriorsus
(infundibulum) of right ventricle & aortic vestibule of left ventricle (the
smooth outflow regions of each ventricle)
Truncus Arteriosus: distal portion that becomes the pulmonary trunk &
ascending thoracic aorta
o Aortic Sac: becomes aortic arch branches, proximal pulmonary artery branches, &
ductus arteriorsus
Septation of Atria
o Semptum primum grows down from roof of primitive atrium to bottom of primitive
atrium to form left & right atria without completely fusing with floor; gap formed is
ostium primum

Ostium secundum develops by cell death in top part of septum primum before
ostium primum is completely closed by septum primum fusion with floor; maintains
flow while atria are developing
o in region of AV junction, endocardial cushions (mound of cardiac cells) push in
from all sides to separate atria from ventricles & provide anchoring point for
interatrial & interventricular septa; complete AV separation
o septum secundum grow to right of floppy septum primum; free edge of septum
secundum is thickened (crista dividens)
o foramen ovale: gap left in septum secundum; low on right atrium
o right to left shunt maintained by blood pushing against floppy, valve-like septum
primum & flowing over top of valve into left atrium (septum primum = valve of
foramen ovale)
o with first breaths, pulmonary blood flow from left atrium causes pressure in left
atrium to rise greater than right atrium
o valve-like free upper edge of septum primum pushed against rigid septum
secundum & crista dividens, & foramen ovale closes
o Crista dividens becomes limbus fossa ovalis in right atrium
o Free edge of septum primum becomes foramen ovale in left atrium
Muscular part of IV septum: formed by selective cavitation through cell death; as
ventricle grows outwards, relatively solid ventricle is sculpted out by cell death except for
center (forming partition)
Derivatives of Aortic Arches
o 1 & 2- drop out & become small arteries
o 3 becomes common carotid formed by remaining cranial extension of dorsal aorta;
external carotid develops by sprouting out from proximal part of 3 rd arch
o 4 arches of aorta from left common carotid to left subclavian arteries on left;
proximal portion of right subclavian artery on right
o 6- left pulmonary artery & ductus arteriorsus, right pulmonary artery
Left umbilical vein: carries oxygenated blood from placenta to fetus; becomes sole
source of oxygenated blood after right vein degenerates during development
Fetal circulation at the heart
o 50% of oxygenated blood courses through fetal liver & then to IVS via hepatic veins,
where it gets a little desaturated
o Diversion to vena cava by ductus venosus (50%); mixed with desaturated blood in
o Ductus venosus: has a pressure sensitive sphincter; if pressure in umbilical vein
is too high, sphincter closes & diverts more blood to liver & dissipate pressure that
can damage fetal heart
o Blood travels from IVC to RA & is directed through foramen ovale to LA by
Eustachian valve
o Most of SVC blood is prevented from mixing with oxygenated umbilical vein blood;
diverted to right ventricle by cascading over intervenous tubercle
o Lungs dont function in gas exchange; exhibit high pulmonary resistance blood in
pulm. Artery is diverted to aortic arch through ductus arteriosus
o Ductus arteriosus: prevents overload of incompliant lungs & resistance supports
growth of right ventricle for transition into neonatal life
o Umbilical arteries: oxygen saturation 58% by time it reaches this point
Ductus venosus: closes by unknown mechanism; sphincter constricts & shunts umbilical
venous blood to liver, causing pressure in right atrium to fall; becomes ligamentum

venosum in left sagittal fissure of liver connecting left branch of hepatic portal vein with
left hepatic vein
Umbilical vein: closes over time but remains patent neonatally, can be used
therapeutically. Occlude to form round ligament of liver from umbilicus in falciform
ligament to left sagittal fissure, then connecting to left branch of hepatic portal vein
DA becomes fibrous connection between left pulmonary artery & aortic arch
ligamentum arteriosum
Distal part of umbilical arteries occlude & become medial umbilical ligaments
Atrial Septal Defect: secundum atrial septal defect; pressure in left atrium is high after
birth, causing oxygenated blood to be shunted to left atrium. Acyanotic. Can cause
enlarged right atrium, right ventricle (causing convexity of normally slightly concave left
auricle),& pulmonary trunk (obliterating distinction between aortic knuckle & pulmonary
Ebstein anomaly: some of right ventricle is incorporated into right atrium (atrialization
dysfunction). Distorts normal architecture of tricuspid valve, resulting in severe tricuspid
Valvular dysfunction. Right heart has to work harder. Called box-shaped heart
Perimembranous VSD: involves membranous ventricular septum because of active
growth required to form it. Left heart pressure is higher than right; left to right shunt.
Tetralogy of Fallot:
o Pulmonary infundibular stenosis
o Right ventricular hypertrophy
o Perimembranous VSD
o Cyanotic (aorta overrides VSD & desaturated blood makes it to systemic circulation)
o Patent ductus arteriosus
o Boot-shaped heart
Persistent Truncus Arteriosus: failure of development of conotruncal septum &
contribution to membranous interventricular septum. Cyanotic. Causes left tracheal
Patent Ductus Arteriosus: seen in many cyanotic conditions because level of oxygen
desaturation causes ductus to remain patent. Pulmonary stenosis & greater aortic
pressure expands ductus retrograde into pulmonary artery, leading to enlargement of
pulmonary artery. Left to right shunt.
Transposition of Great Arteries: arteries get hooked up to wrong ventricle. Cyanotic.
Egg-on-string appearance.
Tricuspid atresia: right atrioventricular orifice & valve fail to develop; patent foramen
ovale & PDA. Cyanotic.
Common Stenoses of Aorta & Pulmonary Artery & their Valves
o Isolated pulmonary Valvular & arterial stenosis: PDA provides flow to lungs for
oxygenation. Acyanotic
o Aortic Valvular stenosis: acquired stenosis. Enlargement of left ventricle & left
atrium because of resistance of stenotic aortic valve.
o Aortiic Valvular Atresia: no blood can go from left ventricle to aorta. Left ventricle
is hypoplastic. Only outflow is pulmonary artery supplying lungs & systemic
circulation. When it returns to left atrium it is shunted to right atrium & mixing with
venous blood. Cyanotic.
Anomalies of aortic sac
o Vascular Rings, Slings & Compressors: affect trachea, esophagus, or both.
Airway obstruction accompanied by stridor (especially expiratory). If esophagus is
involved, there is dysphagia lusoria (dysphagia caused by act of nature)

If dorsal aorta fails to degenerate: double aortic arch that forms vascular ring
around esophagus & trachea
o Aberrant right subclavian artery: indentation of esophagus, trachea is displaced
& compressed
o Aberrant left pulmonary artery: courses between esophagus & trachea. Indents
esophagus & trachea airway
o Left aortic arch loses connection with descending aorta: double aortic arch
with left one being incomplete. Right gives off left common carotid, right common
carotid, & right subclavian & forms main connection with descending thoracic aorta.
Left arch is broken leaving a stump (Kommerells diverticulum). Horsehoe clamp
around trachea
Displaced innominate artery: may be taught & over trachea such that it compresses
tracheal rings. Can lead to gradual tracheomalacia, tracheal compression, & dyspnea.
Eisenmenger Syndrome: high flow through pulmonary artery persists, resulting in
pulmonary arterial resistance increasing & pulmonary hypertension. Right ventricle begins
to hypertrophy to such a point that shunt from left to right reverses. Body is supplied with
deoxygenated blood. Cyanotic. Previous high pressure through lungs causes damage &
scar tissue in lunges which reduces oxygen transfer & decreased oxygen saturation in
blood. Leads to increased production of RBCs (polycythemia). More immature blood cells
enter vasculature leading to hyperviscosity syndrome & formation of microthromboemboli
in small vessels. Patients have uncontrolled bleeding & random clots
Persistent Hypoxia: cyanosis, clubbing of digits
Manubriosternal joint: sternal angle, angle of Louis, T4/T5 ivd
Inferior vena cava: T8/T9 ivd (+right phrenic nerve)
Xiphisternal junction: T9V
Esophagus: T10 (+ vagal trunks)
Descending aorta: T12 (+ thoracic duct)
Burkells surgical classification:
o anterior & middle mediastina: separated by curvilinear line that passes anterior
to heart shadow & then superiorly passes posteriorly to anterior surface of trachea,
cutting off great vessels. Contains pulmonary artery & branches, superior vena
cava, aortic arch & branches, thymus, anterior lymphatics & fatty areolar tissue
o middle mediastinum: separated from posterior by smooth curvilinear line
posterior to trachea & heart shadow. Contains pericardial cavity & heart proper,
pulmonary veins, inferior vena cava, trachea & bifurcation, main bronchi
o posterior mediastinum: contains osteoligamentous elements, pulmonary sulci,
sympathetic trunk & splanchnic nerves, azygos & hemiazygos venous systems,
esophagus, descending aorta, thoracic duct, paravertebral lymphatics & fatty
areolar tissue
Osteoligamentous layer: thoracic vertebrae & disks, posterior ribs, pulmonary sulci, &
assoc. ligaments (especially anterior longitudinal ligament)
Spinal arcuate lines: smooth imaginary lines drawn along contours of vertebral bodies &
posterior elements of vertebrae
Anterior vertebral line: connects anterior surface of vertebral bodies. There should be
uniformity in this line
Enthesopathies: abnormalities where anterior longitudinal ligament attaches to vertebral
body along anterior spinal line.
Enthesis: attachment point of a ligament or tendon onto a bone

Osteophytes: (syndesmophytes) grow into ligaments & severe vertebral lipping of edges
of vertebral bodies occurs
Posterior vertebral line: aligns posterior surface of vertebral bodies
Spinolaminar line: spinolaminar junctions of vertebrae; junction of spinous process with
laminae of vertebral arch; posterior boundary of spinal canal
Neurovascular layer
o Arterial Layer: descending thoracic aorta & posterior intercostal arteries
Thoracic aortic aneurysm: abnormal dilatation of thoracic aorta. Can erode
left anterior surface vertebral bodies distorting anterior spinal line
Aortic aneurysm with dissection: force of blood in true lumen can dissect
along fracturing tunica media, forming a false lumen
Marfans Syndrome: patients prone to aortic dissection
Aortic Isthmus: take-off of left subclavian artery & third pair of posterior
intercostal arteries; marked by ligamentum arteriosum
o Venous Layer: azygos system & posterior intercostal veins
Superior Vena Cava Syndrome: trauma to superior vena cava or
encroachment via metastasis causes this syndrome. Venous pressures in
head & arm veins can approach 200-500 mm Hg. If it involves azygos arch
thus curtains collateral routes, may be more serious & result in fatal cerebral
edema. In pediatric setting SVC syndrome is a medical emergency
Gradual Superior Vena Cava Syndrome: if SVCS is gradual, collateral
chest & abdominal veins can enlarge. Venous return from upper body gets
back to right heart by flowing through femoral system & eventually inferior
vena cava
o Lympathic Layer: thoracic duct
Chylomediastinum: injury to thoracic duct resulting in 1500 ml?day of chyle
extravasating into mediastinum
Chylothorax: chyle seets into pleural space
Chylopericardium: chyle seeps into pericardial space
o Nervous Layer
Sympathetic trunk
Greater splanchnic
Digestive Layer: esophagus & plexues; vagal trunks
o Gastroesophageal venous plexus: in portal hypertension, this plexus can
become varicose posing danger of rupture. Normally smooth luminal contour
demonstrates worm-like, space taking lesions which are the varices into the
projecting lumen
o Sengstaken-Blakemore Tube: tube with 2 inflatable section to tamponade
hemorrhage from ruptured gastroesophageal varicies above & below diaphragm
o Esophagus 4 Constricted Points: upper esophageal constrictor (cricopharyngeus
muscle 70% of obstructions by foreign objects), left of esophagus (aortic arch &
left main bronchus- 15% of obstructions by foreign objects), anterior wall (left
atrium, basis for fistula formation), esophagus through diaphragm (angle leftward to
enter stomach 15% of obstruction by foreign objects)
o Phrenic ampulla: normal manometric pause prior to relaxation of lower
esophageal sphincter
o Schatzkis Ring: constriction at esophageal hiatus; B ring or congenital narrow
mucosal ring that develops at lower end of esophagus

Boerhaaves Syndrome: tears in left wall of esophagus above diaphragm after

severe case of vomiting; tears can violate left pleural cavity causing
o Leiomyoma: benign smooth muscle neoplasm; displaces contrast in esophageal
o Diverticulum: outpouching of mucosa; covered with rest of wall layers is true
diverticulum; just an outpouching of mucosa without rest of wall is false
Respiratory Layer: trachea & bifurcation, lymphocenters
o Tracheoinnominate fistula: placement of endotracheal tube can erode anterior
margin of trachea, ulcerate the innominate artery, & result in this
o Right paratrachael stripe: trachea is in contact with right mediastinal parietal
pleura; with lung contrast in PA CXR this line shows up
o Pneumomediastinum: air in the mediastinum
o Hammans Sign: crunching or clicking sound with heart beat; indication of air in
the mediastinum
o Lung Cancer: occurs in right lung = stays rightward. Occurs in left lung upper lobe
= stays leftward, lower lobe = crosses to right & tracks rightward
Great Arterial Layer: proximal (ascending aorta), aortic arch, pulmonary trunk
o Pulmonary arterial embolism: can be iatrogenic air from misplacement of central
line into right side of heart or a thromboembolism from dislodged thrombus. Most
common is from deep venous thrombosis of lower limb.
o Economy class syndrome: susceptible patients that were seated for a long time
o Oligema: reduced blood flow to a tissue region
o Westermarks Sign: vascular cut-off sign
o Hamptons Hump: wedge-shaped consolidation projection from parietal pleura
into the lung
o Melting sign: consolidation melts away from periphery towards center of
consolidation when embolism clears
Great venous Layer: superior & inferior venae cavae
o Aortic nipple: the left superior intercostal vein can be large; as it crosses aortic
arch it can show up as a small radiodense bump
o Azygos Lobe of Right Upper Lobe: azygos arch can loop more laterally & pinch
off part of the right upper lobe producing a fissure
Glandular Layer: Thymus Gland
o Sail Sign: thymus gland that is considerably larger in newborn produces sail sign in
pediatric PA or AP CXR
o Aberrant retrosternal thyroid tissue: thyroid tissue that extends inferiorly
behind sternum; can become goitrous
o Pembertons Sign: symptoms of goiter compressing on trachea are aggravated
when patients arms are raised above head which draws more of goiter behind the
sternum causing greater compression-related symptoms & faintness
Ovulatory Crypsis: hidden ovulation; important feature is breast of sexually mature
Nipple: resides over 4th intercostal space; important for sexual attraction. Uniquely
human. Changes in sympathetic tone increase relief of nipple & areola
Montgomery Glands: frequent sites of staphylococcal infections; left untreated can
result in mastitis & subareolar abscess
Coopers Ligaments: suspensory ligaments that run through the fascial layers from deep
pectoral fascia to the skin & nipple

Lactiferous lobes: drain to a lactiferous duct that drains onto nipple

Lactiferous lobules: several in each lobe; drain to several acini
Terminal duct & its acini (alveoli) comprise terminal duct lobular unit
Fibroglandular stroma: parenchyma is encased in stroma of more fibrous tissue that is
continuous with suspensory ligaments
Keratinizing squamous epithelium: dips into orifices at nipple & then abruptly changes
Double-layered cuboidal epithelium: lines ducts & their sinuses
Terminal duct lobular unit: successive branch of large ducts eventually lead to this
Terminal duct: branches into a grapelike cluster of small acini to form a lobule
Axillary tail: ducts extend into subcutaneous tissue of chest wall & into axilla
Myoepithelial cells: form meshlike pattern on basement membrane; assist in milk
ejection during lactation & provide structural support to lobules
Luminal epithelial cells: only cells capable of producing milk
Stem cells: postulated to give rise in both luminal myoepithelial cells
Interlobular stroma: consists of dense fibrous connective tissue admixed with adipose
Intralobular stroma: envelopes acini of lobules & consists of breast-specific, hormonallyresponsive fibroblast-like cells admixed with scattered lymphocytes
Colustrum: after delivery of baby luminal cells of lobules produce colostrum (high in
protein) which changes to milk (higher in fat & calories) over the next 10 days
Breast: main endocrine regulator of calcium metabolism during lactation; releases large
amounts of PTH-like peptide & calcitonin; careful mobilization of calcium from trabecular
bone while maintaining & expanding cortical component
Blood Supply:
o Arteries: internal thoracic artery, lateral thoracic artery, intercostal arteries
o Venous: axillary & subclavian veins, azygos system
Lymphatics: axillary chain has good sentinel nodes
o Level 1: pectoral nodes
o Level 2: central nodes
o Level 3: apical nodes
Venous drainage: go reverse of arterial supply; cancer cells can spread via these routes
to vertebral column
Sensory: Intercostal nerves T2-T6, with nipple at T4.
Mastalgia/Mastodynia/Mammalgia: pain from breast
Mammary ridges: epidermal band-like thickenings; milk lines; these degenerate except
for the normal positions in the thoracic region
Polythelia: supernumerary nipples, usually in axillary region, that are often mistaken as
Polymastia: additional functional breast tissue
Amastia: breast fails to develop, or just nipple & areola are present
Inverted nipple: nipple fails to evert
Thelarche: breast development; precedes menarche by 2 years
Breast Quadrants: upper outer, lower outer, upper inner, lower inner
Fibrocystic Disease: mammary dysplasia
Mediolateral Oblique View: observer is the detector looking at the breast; placed on
right in right MLO and left in left MLO; divides breast into upper & lower halves; in image,
breast points toward direction it is name for (IE left breast image points left)
Craniocaudal View: detector is looking up at breast from underneath; image seen is
rotated clockwise & placed on right for right CC or left for left CC. divides breast into outer
& inner halves

Incidence of carcinoma: concentrated to upper outer quadrant

Cancerous tumor: causes edema of lymphatics & pulls on Coopers ligaments, distorting
the normal breast contour. Veins may be more evident due to increased vascularity
Spot Views: compression/close up views. Focuses in closer at lesion
Other methods of Imaging
o X-ray mammogram
o Contrast Enhanced MRI using gadolinium: detects tissue with high metabolic
o Lymphoscintigraphy: Tc is bound to sulfur colloid which has avidity for lymphatics.
Compound is injected & sentinel nodes will light up. These can be found with a
Geiger probe.
Breast Cancer: favors lungs & spinal column for metastasis