Anatomy notes

Back and ANS

o Intervertebral disk numbers correlate with the vertebral
body above them
Composed of annulus fibrosis which is the fibrotic
rings
Also nucleus pulposus- inner soft elastic compressible
part for shock absorption.
Remnant of the notochord
Herniated disk- nucleus pulposus herniates through
the annulus fibrosis
Herniated disk compresses the spinal nerve
roots one below the number the disk correlates
to. (herniation of C5 compresses C6 roots)
o Pia mater
Denticulate ligaments- bilateral thickenings of pia
mater that separate ventral and dorsal roots of the
spinal nerves and anchor the dura mater
Filum terminale- continuation of the pia mater to the
lower end of the spinal cord. Part of the cauda
eqquina which is composed of ventral and dorsal
roots of lumbar and sacral nerves
o Epidural space- Between inner walls of vertebral canal and
dura mater. Contains fat and internal vertebral venous
plexus
o Subarachnoid space- between arachnoid and pia layers
and contains CSF
o L1 or L2 is the conus medullaris which is the inferior limit of
the spinal cord.
o DRG- psuedounipolar cell bodies
o Spinal nerves from C1-C7 exit above their same number
vertebrae while T1 and below exit below
o Lumbar puncture path:
Skin, superficial fascia, deep fascia, supraspinous
ligament, interspinous ligament, interlaminar space,
epidural space, dura, arachnoid, subarachnoid space
o ANS
Preganglionic neurons are formed by neuroectoderm
while post ganglionic is formed by neural crest
Thorax
o Arterial supply of breast
Medial portion- internal thoracic (internal mammary)branch of subclavin

Lateral portion- lateral thoracic artery which is a

branch of the axillary artery and runs along side the
long thoracic nerve (winged scapula)
Lymph drainage
Lateral portion- nipple superior and inferior segments
as well to the axillary nodes and the pectoral group
Medial- parasternal nodes- cancer can spread from
this route from breast to breast
Tracheoesophageal fistula- communication between
trachea and esophagus caused by malformation of the
tracheoesophagel septum
Distal third of the trachea
Associated with polyhydramnios
Innervation of pleura
Intercostal nerves supply the costal and peripheral
diaphragmatic
Phrenic cupplies the central diaphragmatic and
mediastinal pleura
Lungs
Right lung has oblique and horizontal fissure while
left only has oblique
Oblique projects to the 5th intercostal space
while the horizontal follows the 4th rib
Lymph
Thoracic duct carries all lymph below the diaphragm
and on the left side of the trunk and head above the
diaphragm
Right lymphatic duct drains everything from the right
and neck and right side of trunk above diaphragm
Nodes
Bronchopulmonary (hilar) nodes- hilium of
lungs and receive drainage from both
superficial and deep lymphatic plexuses. Drain
to tracheobronchial nodes
Tracheobronchial nodes- bifurcation of the
trachea and drain into left and right
bronchomediastinal nodes
Bronchomediastinal nodes- right and left side
of trachea and drain superiorly into right
lymphatic duct or thoracic duct
ASD
Secundum- excessive reorption of septum primum or
underdevelopment of septum secundum

Primum- less common and because the septum

premium failed to fuse with the endocardial cushions.
Occur in the lower aspect of the atrial wall
Tetraology of the fallot- AP septum fails to align properly
and shifts to the right (cyanotic)
Pulmonary stenosis- Most important
Overriding aorta
Membranous interventricular septal defect
Right ventricular hypertrophy
Transposition of the great vesicles- when AP septum fails to
develop in a spiral fashion
Persistence truncus arteriosus- partial development of the
AP septum
Only one vessel leaves heart and receives blood from
both right and left ventricle
Recurrent laryngeal nerve comes off of the vagus nerve
and if damaged can cause vocal cord paralysis
Left is more likely to be damaged
Phrenic nerve arises fromC3-5 and is the sole motor
innervator of the diaphragm
Referred pain is in the shoulder
Heart
Right border- right atrium
Left border- left ventricle
Superior border- right and left auricles
Inferior border- diaphragm
Anterior- right ventricle
Posterior- left atrium
Diaphragm surface is the left ventricle
2nd intercostal space to 6th
diaphragm
caval hiatus- T8 level within central tendon
IVC and some branches of phrenic nerve
Esophageal hiatus- T10 level within muscle of right
curs
Transmits esophagus and anterior and
posterior vagus trunks
Esophageal hiatial hernia- abnormally large
and the stomach protrudes into the pleural
cavity and it makes the esophageal sphincter
incompetent- GERD
Aortic hiatus- T12 level
Transmits the aorta and thoracic duct

o
o

Abdomen
o Layers:
Skin, superficial fascia (camper-fatty, scarpafibrous), external oblique, internal oblique,
transverse abdominis, transverse fascia,
extraperitoneal, parietal peritoneum
Inguinal canal
o Roof- internal abdominal oblique and the transverse
abdominis
o Anterior- aponeurosis of the external abdominal oblique
o Floor- inguinal ligament
o Posterior medial area- aponuerotic fibers of internal abdominal
oblique and transversus abdominus muscles
lateral- formed by transversalis fascia
weak area
inferior epigastric artery and veino inguinal canal itself is located lateral to inferior epigastric
vessels and superior to the inguinal ligament
o contents:
round ligament in females
ilioinguinal nerve
causes the cremasteric reflex (sensory)
o motor response is by gentifemoral nerve
spermatic cord in males
contains: testicular artery
o pampiniform venus plexus
o vas deferens
o autonomic nerves
o lymphatics
o indirect hernia
protrude through deep inguinal ring lateral to the
inferior epigastric vessels
passes through the inguinal canal, superficial ring
and continues and coils into the scrotum
found within spermatic cord covered by 3 layers of
spermatic fascia
o direct hernia
protrude though the weak area of the posterior wall
of the inguinal canal medial to the inferior epigastric
vessels
pass through hasselbachs triangle
lateral- inferior epigastric vessels

o
o

o
o

medial- rectus abdominis muscle

inferior- inguinal ligament
femoral hernias- in femoral canal
femoral triangle: inguinal ligament, Sartorius,
adductor longus muscles
pass below inguinal ligament
femoral sheath contains femoral artery, vein and
canal- in triangle
lateral to medial- nerve, artery, vein
Intraperitoneal organs- mobile organs completely enclosed
by the visceral peritoneum. Suspended by mesentery
Stomach, liver, gallbladder, spleen, 1st part of
duodenum, tail of pancreas, jejunum, ileum,
appendix, transverse colon, sigmoid colon
Retroperitoneal organs- partially covered by parietal
peritoneum. Fixed and immobile
Secondary- secondarily and retroperitoneal and
visceral peritoneum
Duodenum 2nd and 3rd parts, head neck and
body of pancreas, ascending colon, descending
colon, upper rectum
Primary- never had mesentery
Kindeys, adrenal, ureters, aorta, IVC, lower
rectum, anal canal
Diaphragmatic surface of the liver and the diaphragm
forms the falciform ligament which is an extension of the
visceral peritoneum
Extension of the visceral peritoneum between the visceral
surface of the liver and the first part of the duodenum and
lesser curvature of the stomach forms the hepatoduodenal
and hepatogastric ligaments of the lesser omentum
2nd part of the duodenum receives the common bile duct
above the pectinate line has visceral ANS sensory
innervation while below has somatic
above has portal venous drainage while below has
caval
above drains to iliac lymph nodes while below drains
to superficial inguinal nodes
above has painless internal hemorrhoids while below
has external painful hemorrhoids
above is from the endoderm while below is the
ectoderm
celiac trunk supplies structures derived from the foregut

left gastric artery comes off of it and supplies the

lesser curvature
may be eroded by an ulcer from the lesser
curvature
splenic artery supplies the spleen,
neck body and tail of pancreas,
left gastroepiploic artery which supplies the
greater curvature of the stomach
short gastric which supplies the fundus of
stomach
can be eroded from a penetrating ulcer from
the posterior wall of the stomach
gastroduodenal artery can be penetrated due to a
ulcer of the posterior wall of the duodenum
common hepatic artery goes to superior surface of
the first part of the duodenum and divides into 2
terminal branches
proper hepatic artery- dividies into right and
left hepatic arteries and the right one gives rise
to the cystic artery
gastroduodenal artery- gives rise to right
gastroepiploic artery and superior
pancreaticoduodenal arteries
o SMA supplies the midgut
Inferior pancreaticoduodenal artery which
anastomose with superior branch of the
gastroduodenal artery in head of pancreas
Aneurysm of SMA may cause left renal vein to be
compressed
o IMA supplies the hindgut
Blood supply to the bladder is by the branches of the internal
iliac and umbilical arteries
o Parasympathetic innervation is from S2-S4
Innervates detrusor muscle which contracts for
micturition
Damage causes spastic bladder- responds to a
minimum amount of stretch and causes incontinence
o Sympathetic stimulation is L1-L2
Innervates the internal urethral sphincter which
contracts to prevent leakage
Damage causes atonic bladder which causes full
bladder with constant drip
o External urethral sphincter and is relaxed during
micturition and is innervated by the pudendal nerve

Pudendal nerve block is used to anesthetize the

perineum as the nerve crosses posterior to the ischial
spine
Blood testis barriers is formed by the tight junctions between
sertoli cells that protect primary spermatocytes and their
progeny
Seminal vesicles secrete 70% of ejaculate and is rich in
spermatozoa activating substances such as fructose, citrate,
prostaglandins and several proteins
Upper limb
o anterior division fibers- musculocutaneous, median, ulnar
anterior arm and forearm
o posterior divison fibers- axillary and radial
posterior arm and forearm
o musculocutaneous
flex elbow and supination biceps brachii
o median nerve
flex wrist and all digits, pronation
opposition of thumb
lumbricals 2 and 3
flex MP and extend PIP and DIP
lateral 3 part of palm sensory
supracondylar fracture of humerus
o ulnar nerve
flex wrist and digits 4 and 5
abduct (DAB) and adduct (PAD) digits 2-5
flex MP and extend PIP and DIP 4 and 5
adduct the thumb
medial 1 of palm sensory
medial epicondyle fracture
o axillary nerve
abduct the shoulder 15-110 degrees
lateral rotation of the shoulder- teres minor
surgical neck fracture
o radial nerve
extend MP elbow and wrist
supination supinator
dorsum of the hand sensory
mid shaft humeral fracture
o Dorsal scapular nerve- rhomboids
o Long thoracic nerve- serratus anterior
o Suprascapular nerve- supraspinatus and infraspinatus
o Lateral pectoral- pec major

Medial pectoral- pec major and minor

Upper subscapular nerve- subscapularis
Middle subscapular- lattissimus dorsi
Lower subscapular nerve- subscapularis and teres major
Medial brachial cutaneous nerve- skin of medial arm
Medial antebrachial cutaneous nerve- skin of medial
forearm
o Waiters tip- C5 and C6 damaged
Affects axillary, suprascapular and
musculocutaneous nerve
Shoulder medially rotated
Sensory loss on lateral forearm to base of thumb
o Lower brachial plexus- C8-T1- claw hand
Primarily effects ulnar nerve
Sensory loss on medial forearm and medial 1
digits
o Dislocation of the glenohumoral joint can injure the axillary
or radial nerve
o Scaphoid is the most frequently fractured carpal bones
Can cause avascular necrosis if separated from its
blood supply
o Lunate is the most frequently dislocated bone
o Fracture of hook of hamate- fall on outstretched hand
Can cause ulnar nerve damage
Lower limb
o Lumbosacral plexus
Femoral nerve- posterior divisions of L2-4
Anterior compartment of thigh- extend knee,
flex hip
Sensory on anterior thigh medial leg and foot
Saphenous serve- sensory of medial leg and
medial leg
Obturator nerve- anterior divisions L2-4
Medial thigh compartment- adduct thigh and
medially rotate thigh
Sensory of medial thigh
Tibial nerve- anterior divisions of L4-S3
Posterior compartment of the thigh- flex knee
and extend thigh
Posterior compartment of leg- plantar flex foot,
flex digits, inversion
Sensory loss on leg and plantar foot
o
o
o
o
o
o

o
o
o
o

Sural nerve- combination of peroneal and tibial

branches
o Supplies posterior leg and lateral side of
the foot- sensory
Common fibular nerve- posterior divisions L4-S2
Can be damaged if compressed by piriformis
muscle
Also damaged commonly at the neck of fibula
Divides in the proximal leg into superficial and
deep fibular nerves
Short head of biceps femoris- flex knee
Superficial fibular nerve- lateral compartment
of leg- fibularis longus, fibularis breviseversion
o Sensory loss on anterolateral leg and
dorsum of foot
Deep fibular- foot drop
o Extension of the digits, inversion
o Sensory loss on web between first toe
and second toe
Superior gluteal nerve- posterior divisions L4-S1
Gluteus medius + minimus- stabilize pelvis,
abduct hip
trendelenburgs gait
Inferior gluteal nerve- posterior divisions L5-S2
Gluteus maximus- extension of hip and lateral
rotation of thigh
Difficulty rising from seated position or
climbing stairs
Tibial and common fibular nerve travel through
gluteal region and thigh region called sciatic nerve
Damaged if hip is posteriorly dislocated
Medial circumflex artery- can be damaged by femoral neck
fracture and cause avascular necrosis of head of femur
Anterior tibila artery courses with deep fibular nerve
Dorsalis pedis artery- pulse on dorsum of the foot lateral to
extensor halluces longus tendon
Posterior tibial artery- courses with tibial nerve in posterior
compartment of leg and passes posterior to medial
malleolus
Fibular artery supplies the lateral compartment of the
leg

Tibial shaft fractures can lacerate the anterior or

posterior tibial arteries causing either anterior or
posterior compartment syndromes
o Fracture of the femoral neck can compromise the blood
supply leading to avascular necrosis of the head of the
femur
Head and neck
o Thoracic outlet syndrome is the compression of the
brachial plexus and the subclavian artery within the
scalene triangle
Caused by pancoast tumor, a cervical rib or
hypertrophy of the scalene muscles
Numbness and pain on medial aspect of the forearm
and hand
Claw hand, weak radial pulse, compression of
cervical trunk
o Internal carotid just has the ophthalmic artery and brain
supply
o External carotid artery has
Superior thyroid, Ascending pharyngeal, lingual,
facial , occipital, posterior auricle, superficial
temporal, maxillary
o Pharyngeal fistula- when pouch 2 and groove 2 persist
which forms a fistula found along the anterior border of the
SCM muscle
o Cavernous sinus thrombosis- infection spreading from
superficial and deep face which compresses CN 3,4 and
maxillary 5
Neuroscience
o Primary brain tumors
Glioblastoma multiforme- grade 4 astrocytoma- MC
brain tumor
Highly malignant, can cross the midline, areas
of necrosis surrounded by rows of neoplastic
Astrocytes Rosenthal fibers, immunostaining with GFAP
Oligodendroglioma Slow growing, fried-egg appearance,
calcifications
Ependymoma Ependymal origin, can lead to hydrocephalus
Rosettes and pseudorosettes
Medulloblastoma

Cerebellar tumor, small round blue

psuedorosettes
Meningioma- 2nd MC tumor
Attaches to the dura, psammoma bodies,
compresses brain w/o attachment
schwannoma- 3rd MC tumor
CN 8 and CN7 signs
Retinoblastoma
Sporadic is unilateral and familial is bilateral
Small round blue cells may have rosettes
Craniopharyngioma
Derived from rathkes pouch
Calcified, can encroach on pituitary stalk or
optic chiasm
Histology: adamantinoma (tumor of tooth)
o Upper motor vs lower motor neuron injuries
UMN- spastic paralysis with hyperreflexia, Babinski,
increased muscle tone, diffuse atrophy of muscles,
decreased speed of voluntary movements and a
large area of the body effected
LMN- flaccid paralysis, areflexia, fasiculations,
decreased muscle tone, atrophy of muscle(s), loss of
voluntary movements, small area of body effected
o Identify spinal cord
Large ventral horn
Yes: C5-T1, L2-S2
No: T2-L1, C1-4
Dorsal columns present
Yes: above T5
No: below T5
Lateral horn present
Yes: T1-L2
No: C1-8, L3-S5
Cranial nerves
o 3+4 arise from midbrain
o 5-8 in the pons
o 9,10,12 in the medulla
Eyeball movement lesions
o CN 6- same side eye cant look laterally
o PPRF- in pons- neither eye can look to that side
o MLF- cant look medially
o Frontal eye field- cant look to the opposite side but will drift
back

Brainstem vascular supply

o Vertebral- ASA and PICA off of it
Come together to form basilar
Labyrinthine artery which follows CN 8 and
supplies the inner ear
AICA- pons and anterior and inferior regions of
cerebellar
Superior cerebellar artery- supplies rostral pons
and the superior region of cerebellum
Pontine branches- supply pons via paramedian
and circumferential vessels
o Basilar- AICA, paramedian, superior cerebellar, posterior
cerebral
Direct basal ganglia pathway- disinhibition in the direct pathway
results in an increased level of cortical excitiation and the
promotion of movement
Indirect basal ganglia pathway- disinhibition in the indirect
pathway results in a decreased level of cortical excitation and
suppression of unwanted movement
Open angle glaucoma- increased IOP due to decreased
reabsorption of aqueous humor. Painless visual loss, if untreated
blindness
Close angle glaucoma- Painful condition with increased IOP due
to blockage of the canal of Schlemm
Neurosyphillis and diabetes has Argyll Robertson pupil which is
no direct or consensual light reflex
Adie pupil- reacts sluggishly to light but better to accommodation
o Ciliary ganglion lesion
Asomatognosia-neglect- non dominant parietal lobe
Gerstmann syndrome- alexia with agraphia- angular gyrus lesion
(39)