UNIVERSITY OF ILLINOIS

COLLEGE OF MEDICINE
AT
URBANA-CHAMPAIGN

TWENTY-NINTH EDITION
FIRST YEAR CURRICULUM

Fall 2001

GROSS ANATOMY LABORATORY GUIDE

BOOK I

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 ACKNOWLEDGMENTS

Terrence J. Frick, M.D., prepared this document initially as a dissection guide

designed specifically for our course in Human Gross Anatomy. Since that time
Ms. Martha Sweeney, Ms. Lori Garrett, Mr. Paul Lamberti, and Drs. Connie
Christ, Jonathan Henry and Jo Ann Cameron have made editorial changes and
provided useful additions. Special thanks are due to Carol Kubitz, David Cox,
and Joan Poletti for providing expert medical illustrations and page layout. We
now have a Laboratory Guide that provides both instruction for dissection and
direction for study of the prosected specimens. We encourage our students to
make suggestions for continued improvement of the Laboratory Guide.

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BODY ORIENTATION AND BASIC MOVEMENTS, AND LOWER
EXTREMITY SKELETAL ELEMENTS AND JOINT ANALYSIS

BODY ORIENTATION

Anatomical Position Standing erect with head, eyes, and toes directed forward, the heels
and toes together, and the upper limbs hanging by the sides with the palms facing
anteriorly.

Planes of the Body

Median plane: vertical plane passing lengthwise through midline of body. Divides
body into right and left halves. Median sagittal or midsagittal planes pass through
Median Plane.

Sagittal planes: vertical planes passing through the body parallel to the median
plane. (parasagittal, paramedian).

Coronal planes: any vertical planes passing through the body at right angles to
median plane, dividing it into anterior and posterior portions. (frontal).

Horizontal planes: any planes passing through the body at right angles to both the
median and coronal planes. Divides the body into superior and inferior portions.
(transverse).

Sections of the Body

Longitudinal sections: run lengthwise in direction of long axis of body or any of its
parts. They are applicable regardless of position of the body. May be cut in
median, sagittal, or coronal planes.

Vertical sections: same as longitudinal sections except they denote sections that are
taken through the body in anatomical position.

Transverse sections: cut at right angles to longitudinal axis of body or its parts (i.e.,
transverse section of foot is in coronal plane).

Oblique sections: not cut in one of the main planes of body; they slant or deviate
from the perpendicular or horizontal.

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 Directional Terms

Superior: toward the head.

Inferior: toward the feet.
Anterior: nearer to front of body (ventral).
Posterior: nearer to back of body (dorsal).
Medial: nearer to median plane of body or one of its parts.
Lateral: farther away from median plane of body or one of its parts.
Proximal: nearer to attachment of limb or structure.
Distal: farther from attachment of limb or structure.
Superficial: nearer to surface.
Deep: farther from surface.
Parietal: pertaining to outer wall of body cavity.
Visceral: pertaining to an organ, or the covering of an organ.
Contralateral: on opposite side of body.
Ipsilateral: on same side of body.
Combined terms: i.e., inferomedially, anteroinferior.

ANALYSIS OF JOINT ACTION

Flexion: a movement which generally decreases the angle between the bones or
parts of the body. However, one must learn the specific movements that define
flexion of a particular body part.
Extension: a movement which generally increases the angle between bones or parts
of body. However, one must learn the specific movements that define extension
of a particular body part.
Abduction: moving away from median plane.
Adduction: moving toward the median plane.
Opposition: the thumb pad is brought to a finger pad.
Reposition: movement of thumb from opposition back to anatomical position.
Protraction: movement anteriorly (mandible, scapula).
Retraction: movement posteriorly (mandible, scapula).
Elevation: lifting, raising, or moving a part superiorly (shoulder shrug).
Depression: letting down, lowering, or moving a part inferiorly.

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 Circumduction: combination of successive movements of flexion, abduction,
extension and adduction so that distal end forms a circle.
Rotation: revolving of a part of the body around its long axis (medial/internal,
lateral/external).
Eversion (foot): turns plantar surface of foot away from median plane of body
(sole faces laterally).
Inversion (foot): turns plantar surface of foot toward median plane of body
(sole faces medially).
Pronation (forearm): rotates radius medially about the ulna so that the palm faces
posteriorly and dorsum of the hand faces anteriorly.
Supination (forearm): radius rotates laterally about the ulna so that the palm faces
anteriorly and dorsum of hand faces posteriorly.

LOWER EXTREMITY SKELETAL ELEMENTS AND ARTHROLOGY

The two major functions of the lower extremity are: (1) locomotion and (2) stabilization
of the body. Our consideration of the lower extremity will emphasize the structural
components which implement and facilitate these functions. The lower extremity comprises
the pelvic girdle, femur, tibia and fibula, tarsals, metatarsals, and phalanges. These skeletal
elements form the basic structural regions of the lower extremity the gluteal region, thigh,
leg, and foot. Within these regions there are compartments containing muscles that work
together to accomplish a particular function. The concept of compartmentalization is ex-
tremely useful for understanding the structure and function of the extremities as well as most
other areas of the body.

SKELETAL ELEMENTS OF THE LOWER EXTREMITY

Pelvic girdle Sacrum (composed of 5 fused sacral vertebrae)
2 Hip Bones (each has an ilium, an ischium, and pubis)

Femur (Thigh)

Patella (Knee Cap)

Tibia and Fibula (Leg)

Foot
Tarsals (talus, calcaneus, navicular, medial, intermediate, and lateral
cuneiforms, and cuboid)

(5) Metatarsals and (5) Digits composed of Phalanges (great toe has
2 phalanges, and the 4 lesser toes have 3 phalanges each)

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ARTICULATIONS AND JOINT ACTION ANALYSIS OF THE LOWER
EXTREMITY
Pelvic girdle
1. Pubic symphysis - unites two hip bones, fibrocartilaginous disc
2. Sacroiliac - unites hip bones to the vertebral column, synovial, amphiarthrosis

Limb
1. Hip - synovial, ball and socket

2. Knee - synovial, modified hinge because some rotation is possible.

Flexion - lateral rotation of femur occurs when flexion of fully extended weighted
leg commences (unlocking the knee).
Extension - medial rotation of the femur occurs at full extension of the weighted
leg (locking the knee). Femur and menisci move over tibia during rotation,
femur moves over menisci during flexion and extension.

3. Proximal tibiofibular - synovial, amphiarthrosis

4. Interosseous - fibrous, syndesmosis, amphiarthrosis

5. Distal tibiofibular - syndesmosis, amphiarthrosis

6. Ankle (talocrural) - synovial, hinge permits dorsiflexion and

plantar flexion of the foot.

7. Subtalar (talus and calcaneus) - synovial, pivot, acts as a mitered hinge, permits
rotation, eversion, and inversion of the foot.

8. Transverse tarsal (mid-tarsal) joint comprises the talonavicular and calcaneocuboid

joints- synovial, pivot, permits a rigid or flexible foot depending upon the
position of the subtalar joint. An inverted foot is more rigid than an everted foot.
These joints allow you to keep your balance while walking across an uneven
terrain.

9. Other Intertarsal (navicular, cuboid, medial, intermediate, and lateral cuneiforms);

Tarsometatarsals; and Intermetatarsals - synovial, gliding

10. Metatarsophalangeal - synovial, condyloid

11. Interphalangeal - synovial, hinge

Arches of the Foot (This is covered during Week 4, FYI only for now)

Longitudinal (sagittal) -
Medial (calcaneus, talus, navicular, cuneiforms, and medial 3 metatarsals)
Lateral (calcaneus, cuboid, and lateral 2 metatarsals)

Transverse - cuneiforms and cuboid

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 PROSECTION OF THE LOWER EXTREMITY

Before you begin to work, check for a few of the various palpable bony markings.

anterior superior iliac spine - superior-most spine at the anterolateral edge

of the iliac bone
pubic symphysis - the midline junction between the 2 pubic bones
pubic tubercle - found at the lateral edge of the pubis
patella - in a drawing, check the position of the patella relative to the knee joint
shaft of the tibia - runs the length of the leg just below the skin
medial malleolus of the tibia and lateral malleolus of the fibula - the ‘ankle
bones.’ Which of these bones sits higher than the other?

See the curriculum for a more complete list. Many of these points are more easily palpated in the living.

WEEK ONE — SUPERFICIAL LOWER EXTREMITY

Begin by inspecting the anterior aspect of the lower limb. Note how the limb sits in a laterally rotated
position. It lies this way due to the stronger lateral rotators of the thigh. Because of this, the view
from above will not exactly correlate with drawings of the anterior aspect of the thigh.

1. SKINNING THE ANTERIOR AND MEDIAL THIGH Remember to cut through the skin only
and not the underlying fascia as this would sever important structures. First make a cut
along the inguinal ligament (i.e., from the anterior superior iliac spine to the pubic tubercle).
Then make an incision from the mid-point of the inguinal ligament to the tibial tuberosity.
Now make cuts from the tibial tuberosity laterally and medially for a few inches. Starting at a
corner, reflect the skin flaps to expose the anterior and medial compartments. Don’t try to
uncover the posterior area at this time as you can’t see what you’re doing. DO NOT remove
the fatty superficial fascia with the skin as there are structures to find in it. Be more careful
on the medial side where the great saphenous vein lies, especially near the knee where
there is less fat. The less subcutaneous tissue your
specimen has, the greater care you must use. Anterior superior
iliac spine
Superficial structures As the fatty fascia is cleaned
away, these structures should be retained:

superficial epigastric artery and vein

superficial iliac circumflex artery and vein
external pudendal artery and vein
great saphenous vein Patella
anterior femoral vein
superficial inguinal lymph nodes Lateral tibial
saphenous nerve condyle
lateral femoral cutaneous nerve
femoral nerve, cutaneous branches
intermediate branches
medial branches
Skinning the Anterior
cutaneous branches of obturator nerve
femoral branch of genitofemoral nerve and Medial Thigh

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 The first four structures emanate from the saphenous opening, an oval-shaped opening in
the deep fascia 4 cm below and lateral to the pubic tubercle. These are branches of the
femoral vessels. The great saphenous vein has no corresponding artery and is the longest
vein in the body. It will have many tributaries in the thigh which can be removed though you
may want to save the anterior femoral vein. The slender saphenous nerve leaves the
adductor canal to travel with the vein just proximal to the knee. Leave the nerve and vein
attached to each other with connective tissue.

The superficial inguinal lymph nodes are also found near the saphenous opening. They
are located in a horizontal group just below the inguinal ligament and a vertical group along
the great saphenous vein. If they are at all enlarged (1-2 cm diameter), they will be easy to
retain along with some of the interconnecting lymph vessels.

Start cleaning near the knee and work proximally. Run your probe longitudinally through the
fat in the area where structures should be. When found, bluntly clean along the length of the
structure. If you find the great saphenous vein first, it will lead you to a number of other
things. The cutaneous nerves lie superficial to the deep fascia and become larger as
followed proximally. There may be several branches found for each nerve. Take care not to
cut too deeply. If you see muscle fibers, you are below the deep fascia and must return to
the proper depth. Once you find the listed structures, simply strip away the remaining fat.

2. SKINNING ANTERIOR AND LATERAL LEG AND DORSUM OF THE FOOT Beginning
where you left off from the thigh, make a longitudinal incision along the medial edge of the
shaft of the tibia to a point just below the malleolus of the ankle. Reflect the skin flap laterally
to uncover the anterior and lateral compartments only. Do not reflect over the posterior
compartment (which begins immediately on the medial side) as you may destroy the
superficial structures that can’t be seen. Make an incision along the center of the dorsal foot
as far as the base of the toes. Reflect the skin to the edge of the foot. Note that there is less
fat in the leg than in the thigh, with skin directly on the medial tibial shaft. There is practically
no fat on the dorsum of the foot. Work carefully.

Superficial structures.

great saphenous vein and saphenous nerve small saphenous vein and sural nerve
superficial fibular (peroneal) nerve deep fibular (peroneal) nerve
dorsal venous arch

Follow the great saphenous vein from the thigh into the medial leg. Soon after it passes
the knee, it will be joined by the saphenous nerve which should be cleaned along with the
vein. The nerve is sensory to the medial leg and foot. The great saphenous vein originates
from the dorsal venous arch and travels anterior to the medial malleolus. The dorsal
venous arch is a delicate structure just proximal to the toes and superficial to the deep
fascia and the underlying tendons. It also continues on its lateral side, giving rise to the
small saphenous vein which passes behind the lateral malleolus then travels up the middle
of the calf. Only a small part of it is seen now and perhaps the end of the sural nerve that
travels with it. One half to two thirds of the way down the leg the superficial fibular (pero-
neal) nerve becomes cutaneous by passing out of the deep fascia of the lateral compart-
ment next to the tibial shaft. It branches numerous times as it passes over the dorsal foot.
Clean the nerve and leave its distal ends attached to the foot with connective tissue. The
deep peroneal nerve pierces the deep fascia between the first and second toes to supply
the skin between them. The nerve is small.

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3. Skinning the posterior thigh and leg Skin the posterior thigh starting proximally at the
gluteal fold. Search near the gluteal fold for inferior cluneal
nerves. There are no structures to save in the superficial
fascia of the posterior thigh above the popliteal fossa. The
posterior femoral cutaneous nerve is running in the midline
of the thigh and is found by using a scalpel and grooved
director to make a longitudinal slit in the deep fascia. Watch
out for sural nerve and small saphenous vein from the
popliteal fossa on down.

Superficial structures of the posterior leg The small

saphenous vein begins as the lateral extension of the dorsal
venous arch and passes behind the lateral malleolus. It
passes through the deep fascia in the popliteal fossa and
drains into the popliteal vein. Occasionally it will continue up
and drain into a perforating vein instead. The sural nerve
begins at the union of the medial sural cutaneous branch
of the tibial nerve and the fibular (peroneal) communicat-
ing branch of the common fibular (peroneal). This Y- Skinning the Posterior
shaped nerve travels with the small saphenous vein. Some- Thigh and Leg
times the two branches will not be seen uniting. Care must
be exercised when dissecting out this nerve.

WEEK TWO — ANTERIOR AND MEDIAL THIGH, ANTERIOR AND

LATERAL LEG, DORSAL FOOT, AND GLUTEAL REGION
1. THE ANTERIOR THIGH

Tensor fascia latae and the iliotibial tract Although tensor fascia latae (TFL) is actually
a gluteal muscle, find it now to get an accurate idea of the anterior edge of the iliotibial
tract. The tract is the thickened lateral portion of the deep fascia of the thigh, running from
the iliac tubercle to the lateral condyle of the tibia. You will keep the tract in place while
removing the rest of the deep fascia. Clean back the skin and superficial fascia posterior to
the anterior superior iliac spine and below the iliac crest. The TFL is a thin muscle between
two layers of deep fascia at the top of the tract. Place the grooved director along the anterior
edge of the muscle and make a straight cut through the deep fascia to the knee. The rest of
the deep fascia should be reflected medially, bluntly separating it from the underlying
muscles to which it may adhere. Cut around the cutaneous nerves that you found and
continue to follow them deep to the deep fascia. Note that the sartorius muscle is enclosed
by the deep fascia. Free it as the deep fascia is removed.

Structures in the Anterior Compartment.

sartorius muscle deep femoral artery and vein

rectus femoris muscle perforating arteries
vastus lateralis, intermedius, medialis muscles medial and lateral femoral circumflex
iliopsoas muscle artery and vein
femoral nerve descending genicular artery
femoral artery and vein

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 Use your probe and fingers to separate the muscles. Clean away any extra fat. Each muscle
has a branch of the femoral nerve running to its deep surface and these should be retained.
Sartorius wraps over the other muscles starting superiorly and lateraly at the anterior
superior iliac spine, and running inferiorly and medially to the proximal medial tibial shaft.
The quadriceps join together; their common tendon encloses the patella (a sesamoid
bone) and is called the patellar ligament below the patella (it is functionally, though not
structurally, a ligament!). The three vastus muscles (medial, lateral, intermediate) originate
from the femoral shaft and no attempt should be made to clean them off the shaft. Only a
small part of iliopsoas is seen; superior and lateral to the femoral vessels. It is actually two
muscles, iliacus and psoas major, which originate in the pelvic cavity. Follow the filaments
of the femoral nerve back to its short main trunk and clean it. The nerve lies in the cleft
between the two parts of iliopsoas. Note that the intermediate and medial branches of
anterior cutaneous nerve originate from the femoral nerve. The femoral artery and vein
will be found medial to the femoral nerve. They are surrounded by the femoral sheath and
will appear to be one large structure at first. Gently separate the vessels and clean off their
branches. The deep femoral artery originates about 4 cm below the inguinal ligament. As it
runs over adductor magnus m., it sends off four perforating arteries that pass through the
muscle and enter the posterior compartment. The medial and lateral femoral circumflex
arteries (MFC and LFC) arise from the deep femoral 80% of the time and from the femoral
in the other cases. The LFC is larger, with ascending, intermediate, and descending
branches. Both the LFC and MFC run to musculature and the head of the femur.

The adductor canal One branch of the femoral nerve follows the femoral vessels. This is
the saphenous nerve which later travels with the great saphenous vein. Follow it along its
course. The femoral vessels, saphenous nerve, and deep lymphatics travel together in a
muscular cleft called the adductor canal. The femoral artery gives off its last branch, the
descending genicular artery while in the canal. This branch runs to the knee’s collateral
circulation. The femoral vessels leave the canal by passing through an opening in the
adductor magnus insertion called the adductor hiatus. The muscular corridor is walled by
the edges of the sartorius, vastus medialis, and adductor longus and magnus muscles.

2. THE MEDIAL THIGH

Structures in the Medial Compartment.

pectineus muscle adductor magnus muscle

gracilis muscle obturator artery
adductor longus muscle obturator nerve
adductor brevis muscle (obturator externus muscle)

Begin by cleaning the gracilis muscle which is the most medial of the group. It is a long
slender muscle and inserts on the proximal medial shaft of the tibia. Note how its form is
similar to sartorius but its origin is from the opposite side of the thigh. Carefully clean the
medial edge of the muscle to preserve its innervation from the obturator nerve. Pectineus
lies partially deep to the femoral vessels. It originates on the pecten (cock’s comb) of the
pubis. It is similar in form to iliopsoas but more medial in position. This muscle is usually
innervated by a branch of the femoral nerve though it is in the medial compartment.
Adductors longus, brevis, and magnus overlie each other in the medial compartment.
Adductor longus is the most anterior and is quite long, passing deep to sartorius before
inserting on the linea aspera. Adductor brevis is found deep to the upper half of longus.

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 There is a good deal of connective tissue between brevis and pectineus and they may first
appear to be one muscle. Bluntly clean out the line of their separation. Note that the
obturator nerve (after passing out the obturator foramen) splits and sends branches along
each side of the brevis. Preserve these branches as much as possible while bluntly
removing the fascia from between the adductors. Adductor magnus is particularly large.
Its lower fibers are called its “hamstring” portion and are innervated by the tibial nerve and
extend the thigh, while the adducting fibers are innervated by the obturator nerve. Note again
the opening (adductor hiatus) in its insertion on the linea aspera for the femoral vessels.
Observe the medial femoral circumflex branches that help supply the compartment. Fi-
nally, a few dissectors may be asked to cut pectineus and adductor longus away from their
origins to expose the obturator externus muscle as it originates on the outer surface of the
obturator membrane. Do this ONLY if instructed to do so.

The Femoral Triangle All the components of this triangle have now been cleaned. Its
borders consist of the inguinal ligament, sartorius, and medial edge of adductor longus. The
floor of the triangle is made of iliopsoas, pectineus, and adductor longus. Note how the
femoral nerve, artery, vein, and lymphatics (NAVeL) enter the triangle by passing deep to
the inguinal ligament. The artery shifts from a lateral to anterior position relative to the vein
as it heads toward the adductor canal.

3. THE ANTERIOR LEG

Pull off the overlying deep fascia except for the areas where it is thickened to form
retinacula. Start at the tibia and work laterally. Use the scalpel to separate the tibialis ante-
rior from the deep fascia as it originates on it strongly in the upper leg. The retinacula serve
by holding the tendons down and keeping them from bowing out while the muscles contract.
All prosectors should save the inferior extensor retinaculum which runs from the calca-
neum laterally to the medial malleolus and plantar fascia medially. Use a drawing from an
atlas to determine where to cut its outline. Pull the deep fascia up with a forceps as you cut it
to avoid damaging the extensor tendons. A few prosectors will be asked to save the supe-
rior extensor retinaculum which runs from the distal end of the fibula to the distal tibia.

The muscles of the anterior compartment from medial to lateral are:

tibialis anterior, extensor hallucis longus, extensor digitorum longus, fibularis (peroneus)
tertius.

These muscles are easily separated by running your finger between them. Don’t try to follow
them too far proximally as all the muscles join together into one mass. Place your finger or
blunt probe deeply into the space between tibialis anterior and extensor digitorum longus
proximally or tibialis anterior and extensor hallucis longus distally and pull out the neu-
rovascular bundle consisting of the anterior tibial artery and veins and deep fibular
(peroneal) nerve. Separate the nerve from the vessels along their course. A fourth smaller
muscle, fibularis (peroneus) tertius, is found most laterally.

4. THE LATERAL LEG

Only two muscles are found in this compartment, fibularis (peroneus) longus and brevis
(fibularis (peroneus) tertius though named similarly, is in the anterior compartment). Longus
originates from the upper fibula; brevis distally and deep to the longus muscle. Keep the
superior and inferior fibular (peroneal) retinacula intact but remove the other deep fascia.

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 Make sure that brevis’ insertion onto the base of the 5th metatarsal can be seen and that the
longus tendon is seen wrapping around the cuboid and heading for the sole of the foot (to
insert on the 1st metatarsal). Note that both tendons run behind the lateral malleolus. The
blood supply to this compartment is from the fibular (peroneal) artery though it will not be
seen until the posterior compartment is opened. It is located there and sends in muscular
branches through the posterior intermuscular septum.

Some prosectors will be asked to expose the common fibular (peroneal) nerve as it wraps
around the neck of the fibula to enter the lateral compartment. At this point it enters fibularis
(peroneus) longus and bifurcates into the superficial and deep fibular (peroneal) nerves.
Place the grooved director where the nerve is last seen before entering the muscle. Run a
scissors along the director and reflect as much muscle as necessary.

5. DORSUM OF THE FOOT

The superficial components (cutaneous nerves, veins) and extrinsic muscle tendons have
already been cleaned. The intrinsic muscles are:
Extensor hallucis brevis Extensor digitorum brevis
Clean extensor hallucis brevis and extensor digitorum brevis and their delicate tendons
now. Extensor digitorum brevis’ tendons usually run only to the 2nd-4th toes. The bellies of
these muscles are found deep to the extrinsic muscles’ tendons and should be exposed.
The deep fibular (peroneal) nerve and anterior tibial artery continue together after cross-
ing the ankle and the artery acquires the name dorsalis pedis artery. This nerve vessel
pair (along with extensor hallucis brevis) is commonly found between the extensor hallucis
longus and digitorum longus tendons. A pulse can be taken here in the living. Occasionally
the artery will deviate laterally early in its course and it will be difficult to find. The dorsalis
pedis bifurcates and sends a branch, arcuate artery, over the bases of the metatarsals. A
second branch, the deep plantar artery, runs between the 1st and 2nd metatarsals to
anastomose with the plantar arch. Dorsal metatarsal arteries arise from the arcuate
artery. Clean off the skin from a few toes and note how the extensor tendon widens to form
a fascial sheath called the extensor expansion.

Two groups of interossei muscles are responsible for abduction and adduction of the toes.
Abduction is defined as movement away from the central axis of the second toe. Hence,
movement of the 2nd toe to either side is called abduction. The dorsal interossei abduct,
and the plantar interossei adduct (mnemonic: DAB & PAD). While these muscles are
found in the deepest part of the plantar foot, the dorsal interossei are actually seen easiest
from the dorsum. You can see them between the metatarsals. Note that two of the muscles
are running to the 2nd toe (one on each side). In the hand, the 3rd finger serves as the axis
for the interossei.

6. THE GLUTEAL REGION

Skinning the gluteal region The skin and considerable superficial fascia can be removed
together in the gluteal region. Start at the midline of the sacrum and use the prominent iliac
crest as the superior border. Leave at least an inch of skin around the anal opening. The
area bounded by the tip of the coccyx and ischial tuberosities is known as the anal triangle.
Do not clear out this fat-filled space as it is a part of the perineal dissection. Work
inferolaterally as you pull off the skin and fascia. Attempt to expose the superior and inferior

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extents of gluteus maximus simultaneously. The
Iliac crest
maximus’ fibers are course and large; care must be
taken while removing overlying fascia. Note that along
the superior edge of maximus a small part of gluteus
medius’ inferiorly directed fibers are seen under a deep
fascia layer. The deep fascia is thin over maximus but
thickens on the posterior thigh. The posterior femoral
cutaneous nerve passes out from under the inferior
edge of maximus, so work carefully as you clean this
area. It continues down the center of the thigh deep
to the deep fascia and sends branches through it.
Much of maximus inserts on to the iliotibial tract and
it assists tensor fasciae latae in keeping the knee
extended while standing. Be sure to retain this Skinning the Gluteal Region
connection.

The superior gluteal region Cut the maximus longitudinally starting at the middle of the
superior border. Use the grooved director and scalpel. Cut the entire muscle which may take
several tries due to its thickness. Retain any vessels or nerves running into maximus. As the
lateral portion of the muscle is reflected, the greater trochanter of the femur is seen.
Gluteus medius begins just below the iliac crests and it should be sectioned transversely
about 2-1/2" from its insertion. Deep to medius the gluteus minimus muscle is seen. There
is a fair amount of connective tissue between medius and minimus and it should be pulled
out with forceps. In this connective tissue, the superior gluteal nerve and vessel
branches are found and will be cleaned. Almost all the branches of these vessels and
nerves are seen between medius and minimus. If the gluteal muscles tear easily and seem
very wet, allow them to sit for a few hours or overnight (covered). Occasionally these
muscles are not well-preserved (they will look red and fresh). If this is the case, spray them
often with embalming fluid.

The inferior gluteal region The rest of the muscles of the gluteal region are found in this
order from superior to inferior:

Piriformis
Superior gemellus
Obturator internus
Inferior gemellus
Quadratus femoris
Obturator externus

Piriformis is a large fleshy muscle located just inferior to medius. It is known as the
“keystone” to this region as the blood supply is divided by its presence and structures leave
the greater sciatic foramen above or below it. Note the origin of the piriformis on a skeleton
(inner surface of the sacrum). The sciatic nerve (largest in the body) enters the region
below piriformis. On rare occasions it passes through piriformis or the nerve may be seen in
its separate tibial and common fibular (peroneal) components along its entire length. The
gemelli (twins) and obturator internus are massed together as they run to the greater
trochanter. Obturator internus is purely a tendon at this point so the muscle tissue on each
side are the gemelli. They can be only minimally separated. Quadratus femoris runs from

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 the ischial tuberosity to the quadrate tubercle and is several inches wide. Some dissectors
will be asked to cut quadratus longitudinally at its edge to expose the underlying obturator
externus. Only a small part of externus can be seen by this procedure. The inferior gluteal
vessels and nerve, posterior femoral cutaneous nerve, and several other structures pass
out the greater sciatic foramen below piriformis. The inferior gluteal nerve runs to maximus
only. The superior and inferior gluteal vessels supply the structures above and below
piriformis respectively. Note that six gluteal muscles insert on the greater trochanter; which
do not?

A number of neurovascular elements exit and enter the pelvis to and from the gluteal region
via the greater and lesser sciatic foramina. Structures which pass through the GSF include:
the piriformis muscle, the superior and inferior gluteal arteries, veins and nerves, the sciatic
nerve, the posterior femoral cutaneous nerve, the nerve to obturator internus, the nerve to
quadratus femoris, the internal pudendal artery and vein, and the pudendal nerve. Those
structures which pass through the LSF include the tendon of obturator internus, the nerve to
obturator internus, the internal pudendal artery and vein, and the pudendal nerve.

Ligaments and bony landmarks The ischial tuberosity, greater trochanter, sacros-
pinous ligament, and sacrotuberous ligament should be identified and made visible at
this time by removing excess fat and fascia. Look at the available ligament preps first.
Maximus originates in part from sacrotuberous and should be scraped back with a scalpel. If
sacrospinous is cleaned, preserve the internal pudendal vessels and nerves that wrap over
it and pass out the lesser sciatic foramen for the perineum. They are very important to later
dissectors.

WEEK THREE — POSTERIOR THIGH AND LEG, AND PLANTAR FOOT

Using the grooved director, cut a line from maximus’ insertion on the iliotibial tract to the tract’s
insertion on the lateral tibia. This defines the edges of the iliotibial tract and removes the remaining
deep fascia from the thigh.

1. THE POSTERIOR THIGH

The hamstrings and other posterior compartment structures Biceps femoris, semiten-
dinosus, and semimembranosus all originate from the ischial tuberosity. These large
muscles can be easily separated and the large amount of fat removed. Biceps femoris is
found on the lateral side by itself. Its short head originates from the lower linea aspera.
Semitendinosus is found superficial to semimembranosus on the medial side (T on top).
Semitendinosus has a thin, round tendinous insertion to the proximal medial tibial shaft
(sartorius and gracilis also insert here). Clean off the posterior surface of adductor magnus
which is now seen deep to semimembranosus. Note again the adductor hiatus and the
femoral vessels passing through this opening in magnus’ insertion. The sciatic nerve runs
on the posterior surface of adductor magnus and gives off muscular branches to the
hamstrings. Preserve as many of these as possible. The sciatic usually divides into tibial and
common fibular (peroneal) portions in the lower third of the thigh.

The popliteal fossa The fossa is bounded by biceps femoris, semitendinosus and
semimembranosus superiorly, and the two heads of gastrocnemius (with plantaris also
on the lateral side) inferiorly. The space is deep and filled with fat and about six lymph

14
 nodes. The fat should be carefully removed to exhibit the vessels and nerves of the fossa.
Clean all the way to the posterior aspect of the femur. The common fibular (peroneal) nerve
runs along the edge of biceps femoris to approach the lateral compartment. Centrally, from
superficial to deep, the tibial nerve, popliteal vein, and popliteal artery are found. The
artery is still anterior to the vein, as it was in the femoral triangle, but that now means it is the
deepest structure. This accounts for the difficulty in taking a popliteal pulse. Note again that
the small saphenous vein drains into the popliteal vein and see the origins of the sural
nerve. The popliteal artery gives off four genicular arteries here (superior lateral and
medial, inferior lateral and medial). These constitute the collateral circulation of the knee. Do
not mistake the geniculars for muscular vessels nearby. The geniculars run right next to the
bone and do not run into the musculature.The popliteus muscle which covers the lower
floor of the fossa will be seen later. Note how ‘low’ in the fossa movement occurs. The
heads of gastrocnemius originate fairly high, on the femur’s condyles.

2. THE POSTERIOR LEG

The triceps surae of the posterior leg The superficial posterior compartment contains
three muscles:
gastrocnemius soleus plantaris
Gastrocnemius and soleus join together to form the tendo calcaneus which inserts on the
calcaneum. Do not try to separate these muscles where their fibers blend together but do
clean out the fat between them. Soleus originates on the tibia and therefore has no action at
the knee. Plantaris originates from the lateral femur and runs between gastrocnemius and
soleus. It has a small short belly connected to a long thin tendon that inserts on the medial
side of tendo calcaneus. It is often referred to as the ‘freshman’s nerve’ because of its
similar appearance and course to the tibial nerve. None of you would mistake this for a
nerve, right?

The deep aspect of the posterior leg compartment Some of you may be asked to reflect
the triceps surae at the tendo calcaneus or points of origins to better visualize the deep
muscles. PERFORM THIS ONLY IF ASKED. The popliteus muscle runs diagonally from
the lateral femur to the tibia. It is a wide but extremely thin muscle that flexes and laterally
rotates the femur on a fixed tibia. This movement ‘unlocks’ the knee, allowing flexion after
hyperextension. The popliteal artery passes over popliteus and bifurcates into the anterior
and posterior tibial arteries at its lower border. Note that the anterior tibial artery can be
seen in the posterior compartment before it passes through the interosseus membrane. The
three other deep muscles from lateral to medial are:
flexor hallucis longus tibialis posterior flexor digitorum longus
As you clean these muscles, observe the close relationship between flexor hallucis longus
and the nearby fibularis (peroneus) muscles of the lateral compartment. Note that the ten-
dons of tibialis posterior and flexor digitorum longus cross before they reach the ankle.
The tibial nerve and posterior tibial vessels run with the tendons, passing behind the
medial malleolus. About one-third of the way down the leg the posterior tibial artery gives off
the fibular (peroneal) artery which heads laterally and inferiorly. While it sits in the poste-
rior compartment, it is the blood supply to the lateral compartment of the leg. Preserve the
flexor retinaculum which runs from medial malleolus to the calcaneum.

15
3. THE PLANTAR FOOT

Superficial aspects Remove the skin and superficial

fascia of the foot to expose the plantar aponeurosis. This
thickening of the deep fascia covers the central sole.

Bluntly separate the aponeurosis from the deeper

structures, cut it near the calcaneum, and reflect it
forward leaving it attached distally near the phalanges.

Intrinsic musculature The muscles of this area are

organized into four layers for convenience:
Layer 1 Abductor hallucis, flexor digitorum Skinning the Plantar Foot
brevis, abductor digiti minimi
Layer 2 Quadratus plantae, lumbricals, flexor digitorum longus tendon, flexor hallucis
longus tendon
Layer 3 Flexor hallucis brevis, adductor hallucis, flexor digiti minimi brevis
Layer 4 Interossei, fibularis (peroneus) longus tendon, tibialis posterior tendon

Layer 1: The abductors are at the lateral and medial extremes of the foot and insert on to
the sides of the ‘big’ and ‘little’ toes. Flexor digitorum brevis lies centrally and
runs to the middle phalanges of the four lesser toes. Separate the deep surface of
this muscle from underlying vessels, nerves, and muscles. Cut it near its
calcaneal origin and reflect it forward. This is the final muscle that many prosectors
will cut.

Layer 2: The most apparent part of this layer consists of the tendons of the muscles from
the posterior leg; flexor hallucis longus and flexor digitorum longus. The other
two muscles of this layer are directly related to the flexor digitorum longus tendon.
The quadratus plantae is a rectangular-shaped muscle that assists in flexing the
lesser toes. The lumbicals are four small muscles that originate from the flexor
digitorum longus tendon and insert on the extensor expansion of each lesser toe.
The flexor digitorum brevis tendons split to allow the longus tendons to pass
through them on their way to the distal phalanges. This is analogous to the
tendons in the hand.

Layer 3: A few dissectors will be asked to section the flexor digitorum longus tendon
beyond quadratus’ insertion to better view these deeper structures. Flexor
hallucis brevis is fairly large and runs along the first metatarsal to insert on the
proximal phalange on both sides of the flexor hallucis longus tendon. Flexor digiti
minimi brevis is a relatively small muscle that is just medial to abductor digiti
minimi. Adductor hallucis is found deep to the flexor digitorum longus tendon. It
has two separate heads that join together to insert on the first toe. The oblique
head runs diagonally across the bottom of the foot. The transverse head runs
along the heads of the metatarsals and often the aponeurosis and flexor digitorum
brevis must be pulled farther forward to expose it.

16
 Lumbosacral Plexus

T12

Subcostal (T12)
L1

Lumbosacral Plexus
Iliohypogastric (L1)
L2
Ilioinguinal (L1)
Genitofemoral (L1, 2)

Lateral femoral cutaneous (L2, 3)

L3

L4

Femoral (L2, 3, 4)

L5
Obturator (L2, 3, 4)

Lumbosacral Trunk

Superior gluteal
(L4, 5, S1) S1
Piriformis
(S1, 2)

Inferior gluteal
(L5, S1, 2) S2
Sacral Plexus

Obturator internus
(L5, S1, 2)
Quadratus femoris
S3
(L4, 5, S1)

Sciatic

Common
fibular (peroneal)
S4
Tibial
(L4, 5, S1, 2) (L4, 5, S1, 2, 3)
Posterior femoral
cutaneous (S1, 2, 3)
Pudendal (S2, 3, 4)
S5

17
 Layer 4: In the specimens that have the flexor digitorum longus tendon cut, the fibularis
(peroneus) longus tendon may be seen as it heads towards the first metatarsal
and medial cuneiform. The dorsal interossei have already been seen from the
dorsum of the foot. The three plantar interossei are seen between flexor digiti
minimi and the oblique head of adductor hallucis. Do not try to separate these
small muscles.

Nerves and vessels. The tibial nerve and posterior tibial vessels pass behind the
medial malleolus and divide to form the medial and lateral plantar nerves and vessels.
The lateral plantar nerves and vessels are larger and have a greater distribution. The
nerves break up into common and then proper plantar digital nerves as they approach
the toes. Work to preserve the nerves and vessels concurrently with work on the muscles.
The lateral plantar artery dives under the oblique head of adductor hallucis to form the
plantar arch. A few dissectors will be asked to section this head to expose the arch. This
must be slowly sectioned in slices because the arch directly underlies it. Remember that as
the plantar arch heads towards the first toe, it anastomoses with the deep plantar branch
of dorsalis pedis and provides plantar metatarsal arteries.

IIiac crest

Anterior
gluteal line ILIUM

Anterior superior
Posterior superior iliac spine
iliac spine
Posterior
gluteal line Inferior gluteal line
Posterior inferior Anterior Inferior
iliac spine iliac spine
Greater sciatic notch

ISCHIUM Articular surface

Acetabular fossa
Ischial spine Acetabular notch

Lesser sciatic notch Pubis

Ischial tuberosity Interior pubic
ramus

Obturator foramen

Ischial ramus

Lateral aspect of the right hip bone

18
 IIiac crest
Tubercle of crest Iliac fossa
Anterior superior
iliac spine Iliopectineal line
Superior ramus of pubis
Anterior inferior Pubic tubercle
iliac spine Crest of pubis
Head of femur Pecten pubis
Greater trochanter
Intertrochanteric line Body of Pubis
Lesser trochanter
Pubic arch, left half
Pubic symphysis
Obturator foramen
Ischial tuberosity

Femur

Tuberosity
Neck of
fibula
Anterior border
Patella Medial surface
Lateral epicondyle Adductor tubercle
Lateral surface
Medial epicondyle
Lateral condyle Medial condyles Tibia
Apex of Head Medial and
Head lateral condyles
Neck
Tuberosity

Fibula Tibia
Lateral
malleolus Medial malleolus
Anterior view of the bones Talus
of the pelvis and thigh Calcaneus
Cuboid Navicular
Base of 5th Cuneiforms
metatarsal
Metatarsals

Proximal phalanx
Distal phalanx

Anterior view of the bones

of the leg and foot

19
 Iliaccrest

Posterior superior Ilium

iliac spine Tubercle of crest
Posterior inferior
iliac spine Ischium Neck of femur
Greater sciatic notch
Greater trochanter
Ischial spine
Lesser sciatic notch Intertrochanteric crest
Ischial tuberosity
Lesser trochanter
Gluteal tuberosity
Pectineal line

Linea aspera
Femur

Medial supracondylar line

Lateral supracondylar line
Adductor tubercle
Popliteal surface
Intercondylar notch
Medial condyle Lateral femoral condyle
Medial condyle Lateral tibial condyle
Apex of head
Head of fibula
Soleal line Neck
Fibula
Tibia

Soleal line
Posterior view of the bones
of the pelvis and thigh
Fibula
Tibia

Medial
malleolus Lateral malleolus
Talus Calcaneus
Navicular Cuboid
Cuneiforms
Metatarsals
Proximal
Middle
Distal

Posterior view of the bones

of the leg and foot
20
 LOWER EXTREMITY — STRUCTURE LIST
MUSCLES:
Gluteus maximus Soleus
Gluteus medius Plantaris
Gluteus minimus Popliteus
Piriformis Tibialis posterior
Superior gemellus Flexor digitorum longus
Inferior gemellus Flexor hallucis longus
Obturator internus Tibialis anterior
Obturator externus Extensor hallucis longus
Quadratus femoris Extensor digitorum longus
Biceps femoris (2 heads) Fibularis (peroneus) tertius
Semitendinosus Fibularis (peroneus) longus
Semimembranosus Fibularis (peroneus) brevis
Iliopsoas Extensor hallucis brevis
Sartorius Extensor digitorum brevis
Rectus femoris Flexor digitorum brevis
Vastus lateralis Quadratus plantae
Vastus intermedius Abductor hallucis
Vastus medialis Flexor hallucis brevis
Tensor fasciae latae Abductor digiti minimi
Gracilis Adductor hallucis (2 heads)
Pectineus Flexor digiti minimi brevis
Adductor longus Lumbricals (4)
Adductor brevis Plantar interossei (3)
Adductor magnus Dorsal interossei (4)
Gastrocnemius

ARTERIES:
Superior gluteal Posterior tibial
Inferior gluteal Fibular (peroneal)
Superficial epigastric Medial calcaneal
Superficial iliac circumflex Medial plantar
External pudendal Lateral plantar
Femoral Plantar arch
Deep femoral Plantar metatarsals
Medial femoral circumflex Proper plantar digitals
Lateral femoral circumflex (with
ascending and descending branches) Anterior tibial
Perforating branches Dorsalis pedis
Descending genicular Arcuate
Popliteal Dorsal metatarsals
Medial superior genicular Proper dorsal digitals
Lateral superior genicular Deep plantar artery
Medial inferior genicular
Lateral inferior genicular

21
VEINS:
Great saphenous Deep femoral
Anterior femoral Popliteal
Femoral Small saphenous
Superficial iliac circumflex Dorsal venous arch
Superficial epigastric Metatarsal dorsal digitals
External pudendal Proper dorsal digitals
Venae comitantes

NERVES:
Lateral femoral cutaneous
Femoral nerve
Intermediate cutaneous branches
Medial cutaneous branches
Saphenous
Obturator
Superior and Inferior cluneal branches
Middle cluneal branches
Superior gluteal
Inferior gluteal
Nerve to obturator internus
Nerve to quadratus femoris
Posterior femoral cutaneous
Sciatic
Sural
Common fibular (peroneal)
Lateral sural cutaneous
Fibular (peroneal) communicating branch
Deep fibular (peroneal)
Superficial fibular (peroneal)
Common dorsal digitals
Proper dorsal digitals
Tibial
Medial sural cutaneous
Medial calcaneal
Medial plantar and lateral plantar
Common plantar digitals
Proper plantar digitals

FASCIA, ETC.:
Inguinal and popliteal lymph nodes Tendo calcaneus
Fascia lata Flexor retinaculum
Iliotibial band (tract) Superior extensor retinaculum
Femoral sheath, canal, and triangle Inferior extensor retinaculum
Adductor canal Superior fibular (peroneal) retinaculum
Adductor hiatus Inferior fibular (peroneal) retinaculum
Patellar ligament Plantar aponeurosis

LIGAMENTS:
Sacrotuberous Arcuate popliteal
Sacrospinous Tibial collateral
Inguinal Fibular collateral
Teres ligament of head of femur Anterior cruciate
Ischiofemoral Posterior cruciate
Iliofemoral Transverse ligament of the knee
Pubofemoral Anterior and posterior ligaments of the head
Acetabular labrum of the fibula
Transverse acetabular Interosseous membrane
Obturator membrane Anterior and posterior tibiofibulars
Medial patellar retinaculum Deltoid (medial collateral)
Lateral patellar retinaculum Anterior and posterior talofibulars
Medial meniscus Calcaneofibular
Lateral meniscus Long plantar
Oblique popliteal Plantar calcaneonavicular (spring)
22
JOINTS

Pubic symphysis Subtalar

Sacroiliac Transverse tarsal
Intertarsal
Hip Metatarsophalangeal
Knee Interphalangeal
Proximal and Distal Tibiofibular
Interosseous Medial longitudinal arch of the foot
Ankle Lateral longitudinal arch of the foot
Transverse arch of the foot

BONES AND BONY MARKINGS:

Pelvis (ilium, ischium, and pubis) Thigh (femur)

Iliac crest Head of femur

Tubercle of iliac crest Fovea capitis
Anterior superior iliac spine Great trochanter
Anterior inferior iliac spine Lesser trochanter
Posterior superior iliac spine Neck of femur
Posterior inferior iliac spine Intertrochanteric crest
Auricular surface of Ilium Intertrochanteric line
Iliopectineal line Linea aspera
Pubic tubercle Medial and lateral epicondyles
Superior and inferior rami of pubis Intercondylar notch of femur
Pubic symphysis Medial and lateral condyles
Greater sciatic notch Adductor tubercle
Lesser sciatic notch
Ischial spine Leg (tibia, fibula and patella)
Ischial tuberosity
Obturator foramen and groove Tibial tuberosity
Acetabulum Medial and lateral condyles
Acetabular fossa Intercondylar eminence
Acetabular notch Soleal line
Iliac fossa Medial and lateral malleoli
Inferior gluteal line Head of fibula
Middle (anterior) gluteal line Patella
Posterior gluteal line superior vs. inferior edges
Sacral canal anterior vs. posterior surfaces
Sacral foramina
Sacral hiatus Foot (talus, calcaneus, navicular, cuboid,
cuneiforms, metatarsals, and phalanges)

Sustentaculum tali
Calcaneal tuberosity
Base of fifth metatarsal
Groove for fibularis (peroneus) longus
tendon on cuboid

23
 KEY TO LOWER EXTREMITY X-RAYS
A C

1. Iliac crest 1. Body of femur

2. Ala of ilium 2. Patella
3. Lateral part of sacrum 3. Adductor tubercle
4. Sacroiliac joint 4. Medial epicondyle of femur
5. Anterior superior iliac spine 5. Lateral epicondyle of femur
6. Posterior inferior iliac spine
7. Anterior inferior iliac spine 6. Medial condyle of femur
8. Acetabular fossa 7. Intercondylar fossa
9. Ischial spine 8. Lateral condyle of femur
10. Greater trochanter of femur 9. Intercondylar eminence
11. Intertrochanteric crest 10. Medial condyle of tibia
12. Lesser trochanter 11. Lateral condyle of tibia
13. Ischial tuberosity 12. Apex of head of fibula
14. Superior ramus of pubis 13. Head of fibula
15. Pubic symphysis 14. Body of fibula
16. Inferior ramus of pubis 15. Body of tibia
17. Obturator foramen 16. Tibial tuberosity
18. Neck of femur 17. Epiphyseal plate
19. Head of femur
20. Fovea on head of femur D
21. Greater sciatic notch
1. Body of femur
B 2. Condyles of femur
3. Patella
1. Head of femur 4. Intercondylar eminence
2. Fovea on head of femur 5. Tibial condyles
3. Neck of femur 6. Tibial tuberosity
4. Greater trochanter 7. Epiphyseal plate
5. Lesser trochanter 8. Body of tibia
6. Intertrochanteric crest 9. Head of fibula
7. Acetabular fossa 10. Body of fibula
8. Anterior superior iliac spine
9. Anterior inferior iliac spine E
10. Ischial tuberosity
11. Body of femur 1. Body of fibula
And all other structures visible that were 2. Lateral malleolus
labelled in “A” 3. Body of tibia
4. Medial malleolus
5. Inferior tibiofibular joint
6. Body of talus
7. Calcaneus
8. Navicular

24
 F H

1. Medial malleolus 1. Femoral a.

2. Lateral malleolus 2. Lateral femoral circumflex a.
3. Body of talus 3. Medial femoral circumflex a.
4. Navicular 4. Deep femoral a.
5. Calcaneus 5. Perforating branches of deep femoral a.
6. Cuneiforms 6. Obturator a.
7. Cuboid
8. 1st metatarsal I
9. 5th metatarsal
10. Sesamoid bone 1. Popliteal a.
11. Proximal phalanges 2. Superior lateral genicular a.
12. Distal phalanges 3. Inferior medial genicular a.
4. Anterior tibial a.
G 5. Posterior tibial a.
6. Fibular (peroneal) a.
1. Medial malleolus
J
2. Lateral malleolus
3. Body of talus 1. Posterior tibial a.
4. Calcaneus 2. Fibular (peroneal) a.
5. Navicular
6. Medial cuneiform
7. Intermediate cuneiform
8. Lateral cuneiform Be sure to look at the other x-rays in the enve-
9. Cuboid lope so you can recognize these structures on
10. Base of 1st metatarsal more than one shot.
11. Base of 5th metatarsal
12. Body of 2nd metatarsal Also there are some very good pictures of
13. Head of 3rd metatarsal artificial joints, dislocations, and fractures.
14. Sesamoid bones
15. Proximal phalanges
16. Middle phalanges
17. Distal phalanges

25
26
 PROSECTION OF THE UPPER EXTREMITY

Before beginning the prosection, attempt to find these easily palpable bony markings of the upper
limb. Knowing their locations will make the rest of the work much easier.

Clavicle — Just below the skin and palpable along its length. S-shaped with the convex part
nearest the midline. Articulates with the manubrium of the sternum medially and the
acromion of the scapula laterally. The acromial end of the clavicle is higher than the
acromion.
Humerus — The greater tubercle can be felt through the deltoid just below the acromion. It
is an important insertion point for shoulder muscles. The medial and lateral
epicondyles are found at the elbow and serve as origins for most of the forearm
muscles.
Scapula — The ‘shoulder blade’ floats between layers of back muscles. The acromion is the
lateral extremity of the spine of the scapula. The spine can be followed to the medial
border. The spine lies opposite the spine of the third thoracic vertebra. The medial
border extends from the superior to inferior angles of the scapula and crosses the
second to seventh ribs.
Radius — The head of the radius is found two cm. (about 1") below the lateral epicondyle.
Note its rounded shape on a skeleton. The styloid process can be felt in the
‘anatomical snuffbox’ near the thumb.
Ulna — The olecranon (bony protruberance at the elbow) is found in the same plane as the
epicondyles when the forearm is extended. The head of the ulna becomes prominent
distally when the forearm is pronated. Note that the heads of ulna and radius are not
at the same ends of the forearm.
Carpals — The wrist bones are not easily felt in the cadaver at this time. They can be fairly
easily palpated in the living. These bones are found at a position more proximal than
most imagine. The wrist joint (and carpals) begin at the first skin crease in the
anterior forearm.

The upper limb is quite freely movable and the relative position of structures changes with
new positions of the arm. For this reason ANATOMICAL POSITION came into being. The
upper limb is in anatomical position when it is at the side with the thumbs out (i.e., thumbs
lateral, radius lateral to ulna, etc.). All references to the limb are as if it is in this position no
matter which way it actually lies.

Follow the described procedures on the side identified by your instructor for a superficial
dissection. When the superficial work is complete have your instructor look it over.

WEEK ONE — SUPERFICIAL UPPER EXTREMITY, ANTERIOR

COMPARTMENTS OF THE ARM AND FOREARM,
AND LATERAL FOREARM
1. SKINNING THE PECTORAL REGION AND UPPER LIMB Begin in the midline and work
laterally. Palpate the clavicle superiorly and use it as your upper limit. It is important to
leave the neck undisturbed. The costal margin serves as the inferior limit. It is formed by
the junction of the costal cartilages running to the sternum. If the specimen is female, the

27
 breast tissue can be removed en masse. The glandular
tissue has degenerated in these older specimens but the
lactiferous sinuses and ducts which lie immediately behind
the nipple can often be found. All the skin can now be
removed from the upper body wall and the axilla. The skin
in the axilla is particularly thin and none of the underlying
fascia should be taken with it.

Make a midline longitudinal incision along the arm from

the shoulder to the wrist (i.e., along the center of biceps
brachii and the center of the anterior compartment). Be
sure to cut through the skin only as many of the superficial
Skinning the Pectoral Region veins are near the surface, particularly at the back of the
hand and cubital fossa. Cut through the skin transversely
at the elbow so there will be separate skin flaps for the arm
and forearm. Also remove the skin from the dorsal surface of the hand at this time. Where
the superficial fascia is particularly thin, scrape the scalpel blade along the skin or use the
scissors to separate skin and fascia.

Superficial structures.

cephalic vein
basilic vein
median cubital vein
median antebrachial vein
(if present)
dorsal venous network
medial antebrachial cutaneous nerve
lateral antebrachial cutaneous nerve
superficial radial nerve
posterior antebrachial cutaneous nerve
medial and superior lateral brachial cutaneous nerves
posterior brachial cutaneous nerve
intercostobrachial nerve
dorsal branches of ulnar nerve and superficial radial nerve
common and proper dorsal digital

While the prosection of the superficial veins and cutaneous nerves are described separately,
they are to be cleaned at the same time.

Note: The anterior intercostal vessels from the internal thoracic and anterior cutaneous
branches of the intercostal nerves are all located near the sternal border.

The superficial veins Near the wrist and cubital fossa the veins are near the surface and
can be easily seen. Use these areas as starting points for cleaning. Run the blunt probe
along the surface of the vein to remove overlying fascia. There are no important structures
superficial to the veins. The cephalic vein runs on the lateral side of the forearm and arm.
It originates at the dorsal venous network which lies on the dorsal surface of the hand. The
network is irregular and will vary in form and completeness from one individual to the next.
The basilic vein originates on the medial side of the network. The basilic runs first on the
posterior forearm and then the anterior. It pierces the deep fascia in the lower brachium. The

28
 median cubital vein joins the cephalic and basilic veins over the cubital fossa and often
receives a median antebrachial vein. The cephalic vein above the cubital fossa is often
very small and may not make it to the axillary vein. Recall that the patterns of the superficial
veins are highly variable so don’t be distraught if yours aren’t “textbook.” Note: the basilic
vein becomes the axillary vein as it crosses the lower border of teres major.
This is independent of where the brachial veins drain into it.

Cutaneous nerves A number of the cutaneous nerves run along the superficial veins. By
digging in the fatty tissue along the veins the nerves can be exposed and then cleaned.

medial antebrachial nerves - basilic vein

lateral antebrachial nerves - cephalic vein in forearm
superficial radial nerves - cephalic vein near wrist

As the nerves are cleaned, leave the distal ends attached to the deep fascia. This allows
their identity to be easily determined later. The medial antebrachial pierces the deep fascia
with the basilic vein and has two major branches. The lateral antebrachial pierces the deep
fascia in the lower lateral arm and runs with the cephalic vein over the forearm. The
superficial radial nerve emerges from the deep fascia 3/4 of the way down the forearm
under the cephalic vein. The other cutaneous nerves do not follow the veins but can be
found by checking their position in an atlas, probing along the nerve path (usually
longitudinally) from its approximate point of origin, and then cleaning along the length of the
nerve. The medial and posterior brachial nerves have only short lengths. The posterior
antebrachial begins on the posterior arm and extends over the center of the posterior
forearm. If you work near the axilla look for the intercostobrachial nerve, a nerve loop
between the medial brachial cutaneous and the second (and sometimes third) intercostal
nerves. The loop can be found by looking near the second intercostal space (between ribs
two and three) near the midaxillary line.

2. THE ANTERIOR ARM

Structures in the Anterior Compartment.

lateral and medial intermuscular septa deep brachial artery and veins
deltoid muscle superior and inferior ulnar collateral arteries
biceps brachii muscle ulnar nerve
brachialis muscle musculocutaneous nerve
coracobrachialis muscle radial nerve
brachial artery and veins

First clean off any fascia remaining on the anterior and lateral surfaces of the deltoid
muscle. Look for the superior lateral brachial cutaneous nerve on the deltoid muscle
surface. Carefully remove the deep fascia from the anterior compartment, working around
any cutaneous nerves. Note the deep fascia attachment to the intermuscular septa. The
intermuscular septa run from the fascia to the humerus and divide the arm into anterior and
posterior compartments. If you clean some of the deep fascia off the anterior forearm at this
time be sure to leave the bicipital aponeurosis, the superficial part of biceps that is a
thickened band of deep fascia running medially over the anterior forearm musculature.
Clean biceps brachii free from the surrounding connective tissue. Leave the innervation
and blood supply attached to the muscle (a practice that should be followed through with the
other muscles). The long head is more lateral and appears to be shorter because the

29
 tendon runs under the shoulder capsule to the supraglenoid tubercle. The short head
originates from the coracoid process with coracobrachialis. Coracobrachialis should be
cleaned carefully as it falls apart easily. The musculocutaneous nerve passes through the
center of this muscle. Musculocutaneous sends branches to all the anterior compartment
muscles and then leaves this compartment to terminate as the lateral antebrachial cutane-
ous nerve.

Brachialis underlies biceps and as it is cleaned the nerves and vessels of the compartment
are exposed. The basilic vein and medial antebrachial cutaneous nerve are mostly
medial and travel together. The brachial artery and median nerve also travel together.
They are found superficially on the medial side in the groove between biceps and brachialis.
The median nerve is lateral to the artery in the upper half of the arm and crosses over at the
midpoint to become the more medial of the pair. The ulnar nerve, which like the median has
no branches in the anterior arm, runs along the medial side of the brachial artery in the
upper arm and passes into the posterior compartment at the midpoint. The ulnar collateral
arteries are small branches of the brachial that contribute to the collateral circulation of the
elbow. The superior ulnar collateral travels with the ulnar nerve from its midpoint origin
into the posterior compartment. The inferior ulnar collateral branches off a few inches
lower and lies on brachialis as it passes into the medial anterior forearm. Recall that the
brachial artery is the direct continuation of the axillary as it passes the inferior border of teres
major. Approximately two inches beyond this point it gives rise to the deep brachial artery
which supplies the posterior compartment and runs between the long and medial heads of
triceps with the radial nerve.

3. THE ANTERIOR FOREARM Before removing the deep fascia, it may be necessary to free
the distal ends of the cutaneous nerves. If possible, leave them attached to nearby
structures if this will not interfere with the deep dissection. While removing the deep fascia
retain the bicipital aponeurosis, the insertion of biceps that blends into the deep fascia over
the medial musculature. As before, prosection of the musculature and nerves are described
separately but must be worked on concurrently.

. Anterior compartment musculature.

Middle: flexor digitorum superficialis
Superficial: flexor carpi ulnaris
palmaris longus Deep: flexor digitorum profundus
flexor carpi radialis flexor pollicis longus
pronator teres pronator quadratus

The superficial muscles have a common point of origin on the medial epicondyle of the
humerus (Hence, they all flex the forearm in addition to their other actions!). These common
origins cannot be separated very far proximally. Note that the most lateral muscles of the
posterior compartment wrap over the radius and first appear to be anterior compartment
muscles. Retain the flexor retinaculum, a condensation of deep fascia across the wrist that
holds down the flexor tendons. Flexor carpi radialis, flexor carpi ulnaris, and palmaris
longus between them, all lie on the same level and should be easy to identify. The palmaris
longus tendon runs over the flexor retinaculum to insert onto the palmar aponeurosis. At
least a small part of the aponeurosis must be retained or the muscle will hang loose. Clean
pronator teres along its length from the medial epicondyle to the radius. It has humeral and
ulnar heads; the median nerve runs between them as it enters the forearm.
Flexor digitorum superficialis is a large broad muscle that lies directly under the afore-
mentioned muscles and splits into four tendons distally to run to the middle phalanges of the

30
 lesser four fingers. Flexor digitorum profundus and flexor pollicis longus sit on the
interosseus membrane. Profundus is large like superficialis and runs to the distal phalanges
of the lesser four fingers. Flexor pollicis longus is located laterally and runs to the distal
phalanx of the thumb. Pronator quadratus is found at the distal end of the anterior com-
partment. It is quite thin and quadrangular in shape, lying on the interosseus membrane.
Pull all the overlying tendons to the side to clean off the overlying fascia.
Vessels and nerves of the anterior compartment.

ulnar nerve common interosseus artery

ulnar artery anterior interosseus artery and nerve
radial artery radial recurrent artery
median nerve anterior and posterior ulnar recurrent
radial nerve arteries
Elbow arterial anastomoses.

Radial recurrent - Radial collateral

Interosseous recurrent - Middle collateral
Anterior ulnar recurrent - Inferior ulnar collateral
Posterior ulnar recurrent - Superior ulnar collateral

As the brachial artery enters the forearm it bifurcates into the radial and ulnar arteries.
The radial artery runs over the biceps tendon and then runs down the lateral forearm on
flexor pollicis longus. Just after its origin the radial artery gives rise to a branch that heads
back towards the elbow, the radial recurrent artery. The radial recurrent sits superficially
on the supinator muscle and anastomoses with the radial collateral artery. The ulnar artery
runs deep and soon gives rise to the anterior and posterior ulnar recurrents which anas-
tomose with the inferior and superior ulnar collaterals respectively. Soon after these
origins the ulnar artery sends off the common interosseus artery. This vessel bifurcates to
form the anterior and posterior interosseus arteries which run on each side of the inter-
osseus membrane. The interosseus recurrent is a branch of the posterior interosseus. It is
found in the posterior compartment and anastomoses with the middle collateral artery.

The median nerve runs down the center of the anterior compartment deep to flexor
superficialis. It is sometimes buried in flexor superficialis deep fibers. In the upper forearm
the median nerve gives off an anterior interosseus branch that runs with the anterior
interosseus artery. Remember, the deep fibers of pronator teres that surround the nerve are
its ulnar head and they should be preserved. After passing behind the medial epicondyle,
the ulnar nerve passes into the anterior compartment by running through flexor carpi ulnaris.
Near the middle of the forearm the ulnar nerve and artery meet and run together. They pass
superficial to the flexor retinaculum under the thin, subcutaneous, fascial carpal ligament.

4. THE CUBITAL FOSSA The “elbow pit” is a triangular space bounded by brachioradialis,
pronator teres, and a line joining the epicondyles of the humerus. The floor of the
space is made of brachialis and supinator. Biceps tendon passes through this space to
insert on the radius. The bicipital aponeurosis may need to be trimmed to work on the
deeper structures here. As previously noted, the median nerve passes through the fossa
while the brachial artery and radial nerve each bifurcate here. The cubital (supratrochlear)
lymph nodes may be seen superficially in this area.

WEEK TWO – PECTORAL REGION, AXILLA, BRACHIAL PLEXUS,

31
 AND PALMAR HAND
1. THE PECTORAL REGION Remove the superficial fascia from the area. The deep fascia is
strongly adherent to serratus and the beginnings of the abdominal muscles that lie on the
chest wall. First insert the closed scissor blades and loosen the deep fascia by spreading
the blades, then cut away the facia. Note the anterior intercostal vessels (from the internal
thoracics) and cutaneous nerves. The terminal portion of the cephalic vein runs in the
groove between the deltoid and upper fibers of pectoralis major. It dives deep to drain into
the axillary vein. Great care should be taken to preserve it. Its size is considerably vari-
able.

The pectoral muscles and associated structures. The following items are found in part
or whole in this area.

pectoralis major muscle. serratus anterior muscle.

pectoralis minor muscle. long thoracic nerve
cephalic vein lateral thoracic vessels
medial and lateral intercostobrachial nerve
pectoral nerves subclavius muscle.
thoracoacromial artery
branches

Pectoralis major is a well-developed muscle that originates from the sternum and costal
cartilages. There is often a small abdominal origin too. More importantly the clavicular head
arises from the clavicle and blends in with the rest of the muscle. There may be a cleft
between the clavicular head and the sternocostal portion but it should be reflected as one
muscle. Most prosectors will reflect by pulling the muscle laterally from its origin toward the
arm. The grooved director can be run along the edge of the origin or the scalpel can be
placed parallel to the thoracic wall to free the muscle. Care should be taken to leave the
underlying intercostal muscles undisturbed. Others will be asked to cut pectoralis near the
narrow portion of the muscle in the axillary fold as this better preserves the nerves and
vessels in this region. Now pectoralis minor can be clearly seen. It is much smaller,
originating from the third through fifth ribs. Minor inserts on the coracoid process of the
scapula while major runs to the humerus. Minor should be reflected in the same manner as
major in your preparation.

The vessels in this area should be saved and kept in place. Later their origin as pectoral
branches of the thoracoacromial trunk will be seen. This trunk is a branch of the axillary
artery. The medial pectoral nerve (from the medial cord) supplies pectoralis major and
minor. The lateral pectoral nerve (from the lateral cord) innervates major and sometimes
minor as well. The medial pectoral nerve is more lateral and runs through minor to major.
The lateral nerve runs with the thoracoacromial branches approaching the muscle from the
medial side.

Serratus anterior has a tooth-shaped or serrated origin on the lateral thoracic wall. The
origin interdigitates with the origin of the external oblique abdominal muscle. The portion of
the external oblique on the thorax may be cleaned. The small lateral cutaneous nerves
pierce through serratus near the midaxillary line at each intercostal space. The long
thoracic nerve and lateral thoracic vessels pass inferiorly from the axilla over serratus.
They supply this muscle and should be carefully saved and left attached to the body wall.

Subclavius is a small muscle that runs from the first rib to a groove on the underside of the
32
 clavicle. Attempt to expose it, but if you can’t find it now don’t worry; it will be found in the
neck prosection.

2. THE AXILLA The prosection of the axilla will be described in two major sections: the
axillary artery with its branches and the brachial plexus. Though they are described as two
separate procedures, all the structures are pursued at the same time. Be very familiar with
the region and procedures before you begin.

The axilla is a pyramid-shaped space whose base is the skin of the arm-pit and whose apex
is directed superiorly towards the root of the neck. The opening between the apex and the
neck is known as the cervicoaxillary canal and allows for the passage of the brachial plexus
and axillary artery. The four walls of the axilla consist of the anterior axillary fold (pectoralis
major), the posterior axillary fold (latissimus dorsi), the lateral thoracic wall, and the
humerus. If you have not encountered the intercostobrachial nerve as yet it should be
identified now. It is a nerve loop running between the medial brachial cutaneous nerve and
the second (and sometimes third) intercostal cutaneous nerve. Try to keep the loop intact. If
your specimen exhibits a pronounced set of axillary lymph nodes, retain them, keeping them
connected by the lymph vessels and connective tissue.

The axillary artery and branches This vessel is the direct continuation of the subclavian
artery as it passes the lower border of the first rib. It becomes the brachial artery at the
lower border of teres major. For convenience in studying, the axillary artery is divided into
three parts by position relative to pectoralis minor (proximal, deep and distal to the muscle).
Note that the first part has one branch, second part two, and the third part three.
Part 1: highest (supreme) thoracic

Part 2: thoracoacromial trunk (acromial, pectoral, clavicular, and deltoid br.’s)

and lateral thoracic artery

Part 3: subscapular trunk (scapular circumflex and thoracodorsal branches),

anterior humeral circumflex, posterior humeral circumflex
The lower branches of the axillary artery are to be found first and then the remaining upper
ones. This same method works well for identifying the branches later as the upper branches
are more irregular in origin.

Follow the brachial artery superiorly from the origin of the deep brachial branch.
Approximately 2.5 cm. (1") above this point, the anterior and posterior humeral
circumflex arteries are found. They come off the axillary together and wrap around each
side of the surgical neck of the humerus. The posterior branch is larger, and runs with the
axillary nerve under the cover of the deltoid. Occasionally there is no anterior branch. The
subscapular trunk arises just above this point. It runs inferiorly for several inches and then
bifurcates to form the thoracodorsal and scapular circumflex arteries. The thoracodorsal
continues along an inferior course and runs into the anterior surface of latissimus dorsi
which it supplies. The scapular circumflex passes along the anterior aspect of subscapu-
laris and sends a branch through the triangular space. The scapular circumflex participates
in the collateral circulation of the shoulder with the transverse cervical and suprascapular
arteries. The lateral thoracic artery originates under the cover of pectoralis minor, then
passes inferiorly along the lateral thoracic wall. It supplies serratus anterior and should be
left attached to this muscle. It runs parallel to the long thoracic nerve though there may be

33
 Main branches Cords Divisions Trunks Ventral primary rami

Dorsal scapular nerve C5

Suprascapular
nerve C6
Lateral pectoral nerve
Nerve to C7
subclavius

Axillary nerve C8

Musculocutaneous
nerve
T1
Axillary
artery

Thoracodorsal nerve
Long
Radial Upper and lower thoracic
nerve subscapular nerves nerve

Medial pectoral nerve

Median
nerve Medial cutaneous Axillary vein
nerve of the arm
Ulnar nerve
Medial cutaneous nerve
of the forearm

Axilla Posterior triangle of neck

Brachial Plexus with Axillary Artery and Pectoralis Minor Muscle

an inch or so between them. The thoracoacromial trunk will be found adjacent to the
medial edge of pectoralis minor. This artery sends branches to the clavicular, pectoral,
deltoid, and acromial regions. The supreme thoracic artery is a small branch and may be
difficult to find. It runs to the first intercostal space. There is a fair amount of
variability in the origins of these vessels. When in doubt, identify the branches by the
areas they distribute to.

The basilic vein runs along the medial arm and when it passes the lower border of teres
major is called the axillary vein. The points that the brachial venae comitantes and cephalic
vein drain into are variable.

The brachial plexus Have a good diagram of the plexus in hand while working. As the
branches are found and identified, review their courses and distribution.

medial, lateral, and posterior cords musculocutaneous nerve

34
 medial brachial cutaneous nerves medial and lateral pectoral nerves
medial antebrachial cutaneous long thoracic nerve
ulnar nerve radial nerve
median nerve axillary nerve
upper and lower subscapular nerves thoracodorsal nerve

The ventral primary rami and trunks of the brachial plexus will not be found until the prosec-
tion of the neck. Prosect bluntly, spreading the fascia with blunt probe or scissors. Remove
all the fatty fascia from the area so that the structures can be viewed with the utmost clarity.

The ulnar, median, and musculocutaneous nerves have already been identified in the
brachium. Follow them proximally and note how they form the characteristic “M”
configuration with the ulnar and musculocutaneous nerves on the medial and lateral sides
respectively and the median nerve as the centerpiece. These nerves are the direct
continuation of the medial and lateral cords which can be cleaned at this time. The medial
cord also gives rise to the medial pectoral, medial brachial, and medial antebrachial
cutaneous nerves. Clean any length of these nerves that remains in fascia. The lateral
pectoral nerve is a small branch of the lateral cord which should also be completely
cleaned at this time.

The posterior cord structures are a little harder to work with because of their location under
all the other axillary contents. Relocate the radial nerve (seen running to the posterior
compartment of the arm) and the axillary nerve (running with the posterior humeral
circumflex vessels). Follow them superiorly until they join together to form the posterior cord.
These nerves form an inverted “Y.” The thoracodorsal nerve also leads back to the cord.
The upper and lower subscapular nerves are found on each side of the thoracodorsal,
and run to subscapularis. The lower subscapular also runs to teres major. The slender
subscapular nerves will be lost if care is not taken while removing the fat from subscapularis.

A final reminder to clean the axilla thoroughly. The structures are difficult enough to see with
the best prosection. Review the relationships of serratus
anterior and subscapularis.

3. THE PALMAR HAND

The superficial palm Remove the skin and fascia

down to the palmar aponeurosis. The aponeurosis
covers the central area only. All but a small proximal
portion of it must be reflected in order to see the
deeper structures. Leave some of it for palmaris
longus to insert on. Separate the aponeurosis bluntly
from underlying structures. The superficial palmar arch
and nerves are directly under the aponeurosis and will
be severed if great care is not taken. Try to locate the
palmaris brevis, a small transversely directed muscle
over the hypothenar eminence (the rise below the little
finger). This muscle inserts into the skin and
corrugates it when contracted.
Skinning the Palmar Hand
Thenar eminence: flexor pollicis brevis

35
 Brachial Plexus
Main Branches Cords Divisions Trunks Roots
Dorsal Scapular
Nerve (C5) C5
Suprascapular
Nerve (C5, 6)

r
erio
Sup C6
Nerve to
Lateral Pectoral Subclavius
Nerve (C5, 6, 7)* (C5, 6)

d
ral Cor
Late
C7
le
Midd

Musculocutaneous

36
Nerve Axillary Nerve
(C5, 6, 7) (C5, 6) C8
ord
sterior C
Po
Radial Nerve
(C5, 6, 7, 8, T1) ior
Infer
Median Nerve
T1
Nerve (C5, 6)

(C5, 6, 7, 8, T1)
Thoracodorsal
Nerve (C6, 7, 8)

Nerve (C5, 6)
Upper Subscapular

Lower Subscapular Long Thoracic

Nerve
Medial Cord (C5, 6, 7)

Ulnar Nerve T2
(C8, T1) Medial Pectoral
Medial Antebrachial Nerve (C8, T1)
Cutaneous Nerve Medial Brachial
(C8, T1) Nerve (C8, T1) Intercostobrachial
Cutaneous Nerve (T2)

*Note: There is frequently a connection between the lateral

and medial pectoral nerves, which is not illustrated here.
 abductor pollicis brevis
opponens pollicis
Hypothenar eminence: palmaris brevis
flexor digiti minimi brevis
abductor digiti minimi
opponens digiti minimi
Central compartment: adductor pollicis: oblique and transverse heads
lumbricals
palmar interossei
Vessels and nerves: superficial palmar arch
superficial palmar branch of the radial artery
common and proper palmar digital nerves and arteries
deep palmar arch
deep branch of the ulnar nerve
median nerve

Clean the superficial palmar arch. It is the main continuation of the ulnar artery but also
receives a small superficial branch of the radial artery. Clean the arch bluntly and then follow
the common palmar digital arteries from the arch to the bases of the fingers. Here they
bifurcate to form the proper palmar digital arteries which run up the sides of the fingers. In
the hand the median and ulnar nerves give rise to common palmar digital nerves. In the
mid-palm they split to form proper palmar digital nerves which parallel the arteries. The
nerves of the hand begin deep to the superficial arch. Use the scissors to cut along the
tendon sheaths in the fingers to expose the superficialis and profundus tendons. Note how
the superficialis tendon splits as it inserts on the middle phalanx and allows the profundus
tendon to pass through the middle on its way to the distal phalanx like a thread through the
eye of a needle. On the deep surface of the tendons the vinculae run from the bones
carrying vessels and nerves for the tendons. Clean off the tendons on one or two fingers.
The lumbricals are found to be in a similar position to those in the foot. They originate on
the profundus tendons and wrap around to insert on the extensor expansions of the four
lesser fingers.

The muscles of the thenar and hypothenar eminences can be cleaned in the same manner
as they are essentially mirror images. The abductor and flexor muscles lie more superfi-
cial with the flexors nearest the center of the palm. The opponens are found deep to the
other two muscles. There may be some difficulty in separating the flexor and abductor. Look
for the natural division of these muscles. Adductor pollicis is not a member of thenar
eminence but runs to the thumb from the central compartment. It has oblique and transverse
heads which should be separated and cleaned.

The deep palm Not all dissectors will do this; check with the instructor. First reflect
the palmar aponeurosis and expose the superficial palmar arch. Preserve the arch for
comparison to the deep arch. Do not cut through the deep tendons! The deep palmar arch
can now be easily cleaned. It runs with the deep branch of the ulnar nerve which should also
be preserved. The deep arch originates between the first and second metacarpals from the
radial artery and receives a small anastomosis from the ulnar artery. The palmar interossei
are seen in the lateral part of the central compartment. Remove any fascia from these
muscles so that they may be seen.

WEEK THREE — SUPERFICIAL BACK, POSTERIOR ARM

37
 AND FOREARM, AND DORSAL HAND
The superficial muscles of the back relate to the shoulder and arm. The deep back muscles keep
the spine erect and are not of interest to us at this time.

1. SUPERFICIAL BACK

Skinning the back The entire back will be done, but work
on only one side at a time. Make a longitudinal incision
along the spines of the vertebrae from the iliac crest below
to the superior nuchal line which is found above the occipi-
tal bone of the skull. Reflect the skin laterally as far as the
posterior axillary fold at this time. Superiorly follow the
arched superior border of trapezius as the limit. Do not clean
above the muscle as the delicate structures of the posterior
triangle of the neck are here. It is usually helpful to place
dissecting blocks under the chest. This allows the head to fall
forward and smooths the skin and underlying trapezius.

The muscles of the superficial back These are the

structures to be found on the back:

trapezius muscle. infraspinatus

latissimus dorsi teres major & minor
rhomboids major & minor serratus anterior
levator scapulae subscapularis
supraspinatus accessory nerve-
Cranial nerve XI
Skinning the Back
Remove the fatty superficial fascia that covers the trapezius (trapezoid shaped) and latissi-
mus dorsi (broad, dorsal muscle). The deep fascia is bound to it and will be removed con-
currently. The thickness of the fascia varies from one person to the next. It is usually deeper
over the lower back and thinner over the shoulder blades and vertebral spines. Clean it off
with the scalpel working in the same direction as the underlying muscle fibers. This keeps
the muscles from being torn. Latissimus originates from the lower six thoracic and the
lumbar vertebrae via the thoracolumbar fascia. Fatty tissue can be found superficial and
deep to it. As the superior edge of trapezius is cleaned try to expose and preserve the
accessory nerve which innervates this muscle, along with C3 and C4. It can be found by
imagining a line drawn from 1/3 the way down sternocleidomastoid muscle to 2/3’s the way
down trapezius. The nerve follows this course and then passes deep to the anterior border
of trapezius. Leave the nerve intact even when this muscle is reflected. The other nerves
seen are branches of the dorsal rami of the spinal nerves; they pass from the deep back
muscles, which they innervate to become cutaneous nerves.

Reflect trapezius from its origins on the vertebral spines. Run the grooved director along the
origin and cut through this muscle only, using the scalpel. Be sure that only trapezius is
being reflected. The rhomboids and levator scapulae often adhere to the undersurface so
look for them and separate them from trapezius if necessary. Make sure to reflect all of the
muscle including the upper part which extends fairly high on the back of the head. Stop

38
 when the insertions on the clavicle and spine of the scapula are reached. Do not disturb
splenius capitis and semispinalis capitis which underlie the upper part of trapezius.

Clean latissimus and the diamond-shaped thoracolumbar fascia. The muscle attaches to
the tip of the inferior angle of the scapula and must be cut loose from this insertion.
Carefully work the superior border of latissimus free from fascia and neighboring muscles. It
tends to adhere firmly to the soft and fleshy teres major.

Rhomboids major and minor run obliquely from the spines of the cervical and thoracic
vertebrae to the medial border of the scapula. These broad, thin muscles usually have to be
separated from each other. The larger rhomboid major is the inferior of the pair. Levator
scapulae inserts into the superior angle of the scapula. Follow it superiorly for only a few
inches as it makes up part of the floor of the posterior triangle of the neck farther along. A
few specimens will have the rhomboids reflected from their origins so the medial border of
the scapula can be lifted to show the subscapular fossa. One expects to see subscapu-
laris first by this approach, but it is covered by serratus anterior, running from the lateral
body wall to the medial edge of the scapula. These relationships became apparent when
the pectoral region and axilla were cleaned. The dorsal scapular nerve and vessels are
found deep to the levator scapulae and rhomboid muscles’ attachments to the scapula. The
suprascapular artery crosses above the transverse scapular ligament while the supras-
capular nerve crosses the scapular notch below the ligament.

Supraspinatus and infraspinatus are covered by a strong layer of deep fascia that must
be carefully removed. Pierce the fascia with the tips of the curved scissors and then spread
the blades. This loosens the fascia from the underlying muscle and it can be removed.

Teres major and minor originate from the lateral edge of the scapula below the spine.
Teres major is the larger, more inferior muscle. Follow them to where they cross the long
head of triceps only at this time. Note how these muscles run anterior (teres major) and
posterior (teres minor) to the long head of triceps to reach the humerus. This is reflected in
their actions (medial and lateral rotation respectively). Work carefully to accurately separate
the teres muscles and infraspinatus.

The deltoid muscle is shaped like an inverted triangle or delta. It originates from the same
parts of scapular spine and clavicle that trapezius inserts on. Look for the superior lateral
brachial cutaneous nerve from the axillary nerve on the lateral surface of the deltoid. Its
sensory area is an important clue when the axillary nerve is damaged. Clean only the poste-
rior fibers of the muscle at this time. Some prosectors will be asked to cut the deltoid away
from its origins on the clavicle and scapular spine to show the axillary nerve and posterior
humeral circumflex artery that travel together around the surgical neck of the humerus.
This also exposes many of the insertions of the shoulder muscles.

2. THE POSTERIOR ARM This area will go quickly because there is little to be done. Sepa-
rate the long, lateral, and medial heads of triceps as much as possible. The long head
extends down from the infraglenoid tubercle. Clean it carefully and separate it from the teres
muscles that pass on each side of it. The medial head can be seen behind the medial
intermuscular septum, running down then blending into the long head. A few prosectors will
cut the lateral head longitudinally in its center using the scalpel and grooved director. This
exposes the underlying portion of the medial head and the radial nerve and deep brachial
artery which run together in the upper half of the posterior forearm. The deep brachial gives

39
 off the radial and middle collateral arteries which participate in the collateral circulation of
the elbow. The middle collateral runs between the lateral and medial heads while the radial
collateral passes toward the lateral epicondyle. Note that the radial nerve passes from
posterior to anterior compartment near the midpoint of the arm. The triceps has a small
triangular extension that runs from the lateral epicondyle to the ulna and is named anco-
neus (Gr. elbow). The muscle is hidden by a strong covering of deep fascia that can be
removed quickly after loosening by passing scissors under it and spreading the blades.

At this time clean off any connective tissue that is blocking a clear view of the insertions of
pectoralis major and latissimus dorsi on the humerus. Note that the pectoralis insertion
passes anterior to biceps and latissimus’ passes posterior.

3. THE POSTERIOR FOREARM extensor digiti minimi

Muscles of the posterior forearm Deep: extensor indicis

extensor pollicis longus
Lateral: brachioradialis supinator
extensor carpi radialis longus extensor pollicis brevis
extensor carpi radialis brevis abductor pollicis longus
deep radial nerve
Superficial: extensor digitorum superficial radial nerve
extensor carpi ulnaris
interosseus recurrent artery

The “lateral” group of muscles wrap around the radius and at first appear to be anterior
compartment muscles. These three muscles are innervated by the radial nerve. Though
there may not be an official lateral compartment, it is helpful to think of there being one as
the muscles have the same origin, innervation, and similar action. The superficial group plus
the extensor carpi radialis brevis have a common origin from the lateral epicondyle of the
humerus. The muscles cannot be successfully separated very far towards their origin.
Retain the extensor retinaculum which extends from the pisiform and hamate to the distal
radius. The superficial radial nerve runs under the cover of brachioradialis until it reaches
the wrist (it is entirely sensory). Extensor digitorum splits into four tendons to run to the
four lesser fingers. On its medial edge is an extra slip of muscle named extensor digiti
minimi. Its extra tendon to the little finger can easily be seen on the back of the hand.
Extensor carpi ulnaris lies just medial to this muscle and inserts on the base of the fifth
metacarpal.

Extensor indicis lies deep to these muscles laterally. It sends a second tendon to the index
finger. Extensor pollicis longus sits just lateral to extensor indicis. Its tendon runs to the
distal phalanx of the thumb. The extensor pollicis brevis and abductor pollicis longus
muscles run together; they wrap over the radius and cover the distal part of the “lateral”
muscles. Occasionally the bellies of these muscles grow together and cannot be separated.
Supinator is a wide thin muscle in the proximal part of the compartment. It is best seen as it
wraps over the radius. The deep radial nerve which innervates this compartment, pierces
through supinator and then runs with the posterior interosseus artery in the deep central
posterior compartment. The posterior interosseous artery sends its branch, the in-
terosseous recurrent artery proximally to the elbow. About two thirds of the way down, the
anterior interosseus artery passes through the interosseus membrane to help supply the
posterior compartment.

40
 The anatomical snuffbox is a space bounded by extensor pollicis longus tendon on one
side and extensor pollicis brevis-abductor pollicis longus tendons on the other side. The
radial artery passes through the space over the scaphoid bone on its way to the dorsal
hand. Clean the fascia away so the artery can be clearly seen.

4. THE DORSAL HAND If you prosect the dorsal hand at the same time as the posterior
forearm, the musculature will be much more easily identified. Clean the muscles of the
tendons of the posterior forearm as they pass over the hand. The tendons are joined

Coracoid process
Superior angle
Acromion Clavicle
Sternal end
Lesser tubercle
Greater tubercle
Intertubercular groove Scapula
Medial border
Surgical neck

Deltoid tuberosity Inferior angle

Humerus Lateral border

Lateral supracondylar ridge Medial supracondylar ridge

Lateral epicondyle Coronoid fossa
Medial epicondyle
Capitulum Trochlea
Head of radius Coronoid process
Tuberosity of radius Tuberosity of ulna

Radius Ulna

Head of ulna
Styloid process of radius Styloid process of ulna
Carpal bones

Metacarpal bones
Proximal phalanx
Distal phalanx (1st) Proximal
(2nd) Middle Phalanges
(3rd) Distal

Anterior view of the bones of the upper extermity

41
together in spots by intertendinous intersections. Clean and preserve these. Separate the
extensor digiti minimi and extensor indicis tendons from the extensor digitorum tendons. The
four dorsal interossei can be clearly seen from this side, lying between the metacarpals.
Remove the covering fascia; loosening by spreading the scissor blades and then pulling it
off. The large muscle filling the space between the thumb and index finger is the first dorsal
interosseous.
Superior angle
Suprascapular notch
Spine of scapula
Acromioclavicular joint
Acromion
Lateral angle
Greater tubercle
Head
Infraspinous Anatomical Neck
fossa
Surgical neck

Deltoid tuberosity

Groove for the radial nerve

Humerus

Lateral supracondylar ridge

Lateral epicondyle

Medial epicondyle Head of radius

Olecranon Process

Posterior border

Ulna Radius

Head of ulna Dorsal radial tubercle

Styloid process Styloid process of radius
Carpal bones

Metacarpal bones
Proximal phalanx
(1st) Proximal Distal phalanx
Phalanges (2nd) Middle
(3rd) Distal

Posterior view of the bones of the upper extermity.

42
 Rough area for finger pads
For flexor digitorum profundus

Distal phalanx Rough area for finger pads

Head of middle
phalanx
For fibrous sheath
Head of proximal
phalanx

Head
5th metacarpal
Tubercle

Hook of hamate
Tubercle of trapezium
Pisiform Trapezoid
Triquetrum Tubercle of scaphoid
Lunate

Palmar view of the hand

Smooth area for fingernail

Distal

Phalanges Middle

Proximall

Proximal phalanx

Head

Body (shaft) Metacarpal

Base
Capitate
Carpals Trapezoid Hamate
Trapezium
Triquetrum
Scaphoid
Lunate

Dorsal view of the hand

43
 UPPER EXTREMITY — STRUCTURE LIST
MUSCLES:
Trapezius Flexor pollicis longus
Latissimus dorsi Pronator quadratus
Rhomboid major Brachioradialis
Rhomboid minor Extensor carpi radialis longus
Levator scapulae Extensor carpi radialis brevis
Supraspinatus Extensor digitorum
Infraspinatus Extensor digiti minimi
Subscapularis Extensor carpi ulnaris
Teres minor Anconeus
Teres major Abductor pollicis longus
Pectoralis major Extensor pollicis brevis
Pectoralis minor Extensor pollicis longus
Serratus anterior Extensor indicis
Subclavius Supinator
Deltoid Abductor pollicis brevis
Coracobrachialis Flexor pollicis brevis
Biceps brachii (short and long heads) Opponens pollicis
Triceps brachii (lateral, medial, and long Adductor pollicis (transverse
heads) and oblique heads)
Brachialis Palmaris brevis
Pronator teres Abductor digiti minimi
Flexor carpi radialis Flexor digiti minimi brevis
Palmaris longus Opponens digiti minimi
Flexor carpi ulnaris Lumbricals (4)
Flexor digitorum superficialis Dorsal interossei (4)
Flexor digitorum profundus Palmar interossei (3)

ARTERIES:
Axillary Ulnar
Supreme thoracic Anterior ulnar recurrent
Thoracoacromial trunk Posterior ulnar recurrent
Clavicular, acromial, deltoid, Common interosseous
pectoral branches Anterior interosseous
Lateral thoracic Posterior interosseous
Subscapular trunk and recurrent branch
Scapular circumflex Deep palmar branch of ulnar
Thoracodorsal Superficial palmar arch
Anterior humeral circumflex Common palmar digitals
Posterior humeral circumflex Proper palmar digitals
Radial
Brachial Radial recurrent
Deep brachial Superficial palmar branch of radial
Radial collateral Deep palmar arch
Middle collateral Princeps pollicis
Superior ulnar collateral Radialis indicis
Inferior ulnar collateral Palmar metacarpals
Dorsal carpal arch
Dorsal metacarpal branches
44
VEINS:
Cephalic Axillary
Basilic Brachial venae comitantes
Median cubital Dorsal venous network
Median antebrachial (where present) Dorsal metacarpals
Median cephalic (where present) Dorsal digitals
Median basilic (where present)

NERVES: Lower subscapular (C5, 6)

Axillary (C5, 6)
Spinal accessory (CN XI) Superior l ateral brachial cutaneous
Suprascapular n. (C5, 6) Radial (C5-T1)
Dorsal scapular (C5) Posterior brachial cutaneous
Intercostobrachial (T2) Posterior antebrachial cutaneous
Long thoracic (C5, 6, 7) Superficial radial
Medial cord (anterior divisions) Deep radial
Medial pectoral (C8, T1) Lateral cord (anterior divisions)
Medial brachial cutaneous (C8, T1) Lateral pectoral (C5, 6, 7)
Medial antebrachial cutaneous (C8, T1) Musculocutaneous (C5, 6, 7)
Ulnar (C8, T1) Lateral antebrachial cutaneous
Deep and dorsal branches of ulnar Median (C6-T1)
Posterior cord (posterior divisions) Anterior interosseous
Upper subscapular (C5, 6) Common palmar digitals and proper palmar
Thoracodorsal (C6, 7, 8) digitals of respective named nerves, above

FASCIA, ETC.:

Bicipital aponeurosis Flexor retinaculum

Lateral brachial intermuscular septum Extensor retinaculum
Medial brachial intermuscular septum Extensor expansions
Palmar aponeurosis
LIGAMENTS:

Acromioclavicular Ulnar collateral (elbow)

Coracoclavicular (conoid, trapezoid) Radial collateral (elbow)
Coracoacromial Anular
Superior and inferior transverse scapular Interosseous membrane
Glenoid labrum Radial carpal collateral
Glenohumeral (shoulder) capsule Ulnar carpal collateral
Elbow capsule Deep transverse metacarpal

JOINTS:

Acromioclavicular Interosseous
Sternoclavicular Wrist
Shoulder Intercarpal
Elbow Metacarpophalangeal
Proximal and Distal Radioulnar joints Interphalangeal

45
BONES AND BONY MARKINGS:

Shoulder (scapula and clavicle) Forearm (radius and ulna)

Scapula Olecranon process

Spine of scapula Coronoid process
Suprascapular notch (also scapular Head of radius vs. head of ulna
or superior notch) Bicipital tuberosity of radius
Acromion process Styloid processes of radius and ulna
Coracoid process Interosseous margins of radius and ulna
Glenoid fossa Trochlear notch of ulna
Supraspinous fossa Dorsal tubercle of distal radius
Infraspinous fossa
Hand (trapezium, trapezoid, capitate, hammate,
Clavicle scaphoid, lunate, triquetrum, and pisiform)
medial vs. lateral ends Hook of hamate
superior vs. inferior surfaces Tubercle of scaphoid
conoid tubercle Tubercle of trapezium

Arm (humerus)

Head of humerus
Greater tubercle
Lesser tubercle
Intertubercular groove
Anatomical neck
Surgical neck
Radial groove (Spiral groove)
Deltoid tuberosity
Medial and Lateral supracondylar ridges
Capitulum
Trochlea
Medial and lateral epicondyles of humerus
Olecranon fossa
Coronoid fossa
Radial fossa

46
 KEY TO UPPER EXTREMITY X-RAYS
A D

1. Clavicle 1. Shaft of radius

2. Conoid tubercle 2. Head of ulna
3. Acromioclavicular joint 3. Styloid process of radius
4. Acromion process 4. Styloid process of ulna
5. Coracoid process 5. Scaphoid
6. Glenoid fossa 6. Lunate
7. Head of humerus 7. Triquetral/triangular
8. Greater tubercle of humerus 8. Pisiform
9. Lesser tubercle of humerus 9. Trapezium
10. Anatomical neck of humerus 10. Trapezoid
11. Surgical neck of humerus 11. Capitate
12. Lateral border of scapula 12. Hamate
13. Medial border of scapula 13. Base of 1st metacarpal
14. Scapular spine 14. Shaft of 1st metacarpal
15. Head of 1st metacarpal
16. Sesamoid bone
17. Proximal phalanx of 1st
digit (thumb)
B 18. Distal phalanx of 1st digit
19. 2nd metacarpal
1. Shaft of humerus 20. Proximal phalanx of 2nd
2. Lateral supracondylar ridge digit
3. Lateral epicondyle 21 Middle phalanx of 2nd digit
4. Olecranon 22. Distal phalanx of 2nd digit
5. Coronoid process
6. Trochlear notch
7. Head of radius E
8. Neck of radius
9. Anterior fat pad Identify any structures from “D”
and note epiphyseal plates and
epiphyses which indicate these
are shots of a young person.
C

1. Shaft of humerus
2. Olecranon fossa F, J
3. Medial epicondyle of humerus
4. Lateral epicondyle of humerus Note the neat ring! Then note
5. Head of radius the implant proximal to the 1st
6. Trochlea metacarpal. J’ shows same with
7. Capitulum a pin inserted for immobilization.
8. Olecranon process
9. Shaft of ulna
10. Shaft of radius
11. Radial tuberosity

47
G

Rheumatoid arthritis

Fracture of clavicle

Fracture of middle phalanx

1. Axillary a.
2. Thoracoacronial arterial trunk
3. Posterior humeral circumflex a.
4. Anterior humeral circumflex a.
5. Subscapular arterial trunk
6. Scapular circumflex a.
7. Thoracodorsal a.
8. Lateral thoracic a. (common variation seen here)
9. Brachial a.
10. Deep brachial a.

1. Brachial a.
2. Radial a.
3. Ulnar a.
4. Radial recurrent a.
5. Ulnar recurrent aa.
6. Common interosseous a.
7. Posterior interosseous a.
8. Anterior interosseous a.
9. Superficial palmar arch
10. Common palmar digital aa.
11. Proper palmar digital aa.
12. Deep palmar arch
13. Princeps pollicis a.

48
 Brachial a & vv.
Median nerve
Biceps brachii m.

Basilic v. Musculocutaneous n.

Cephalic v.
Ulnar n.

Brachialis m.
Radial n.
Brachioradialis m.

Triceps m.

Humerus

Left Mid-Arm Cross Section #907 Inferior Surface

Ulnar a & vv.
Ulnar n. Median nerve
Radial a.
Superficial br.
of radial n.

Flexors Cephalic v.

Radius
Anterior
Ulna interosseous
artery
Post Nerve
interos-
seous Artery

Extensors

Left Mid-Forearm Cross Section #901 Inferior Surface

49
50
 PROSECTION OF THE THORAX
The prosection of the thorax is destructive in nature. The superficial structures are removed or
reflected to show the deeper. Work to keep the components in their original position as much as
possible. Also clean all structures very completely as this will allow a better view of the more hidden
items. Before beginning the prosection find the following landmarks. It is also possible to locate the
position of the deep structures by using these superficial landmarks (an important skill for the clini-
cian).

Clavicle — subcutaneous along its length. S-shaped with its convex part more medial. It articulates
with the manubrium and first costal cartilage medially.

Sternum — found in the midline and divided into three identifiable parts.

manubrium — the short superior part of the sternum. The suprasternal (jugular) notch is
found at its upper edge and serves as a landmark for the level between the second and third
thoracic vertebrae.

body — the long, middle part of the sternum articulates with the manubrium at the sternal
angle. The two parts meet at an angle here that is easily palpable. The second costal
cartilage meets the sternum here and serves as the easiest point from which to count ribs.
The sternal angle is at the level between the fourth and fifth thoracic vertebrae.

xiphoid process — this final point-shaped portion is irregular in its size and shape. It may
point inwards or out and can extend as far as the umbilicus. The xiphisternal joint is at the
level of the ninth thoracic vertebra.

Costal margin — the lower costal cartilages join together to form this peak shaped ridge which
separates the thorax from the abdomen. The lowest attached rib (the tenth) extends
inferiorly to the level of L3.

Vertebrae and ribs — the seventh cervical vertebra has the most prominent spine in the back and
is often called the vertebra prominens. The first four thoracic spines are easily palpated and
the others are felt with more difficulty. Note how the spines sweep downward and lie over
the body of the lower vertebrae. The ribs can be palpated along their length. They head
inferiorly to the midaxillary line and then move upwards to meet the sternum. It is always
best to begin counting at the second rib where it meets the sternal angle.

WEEK ONE — THE THORACIC WALL, ANTERIOR MEDIASTINUM,

AND VISCERA IN SITU
1. SKINNING THE PECTORAL REGION The thorax
has been skinned during the upper limb prosection.
If not, begin at the midline and reflect the skin as far
back as the posterior axillary fold. The superior edge
should run along the clavicle but not extend into the
neck at all. Inferiorly follow the line of the costal
margin not working into the abdomen. Clean pectoralis
major. The anterior cutaneous branches of the
intercostal nerves and branches of the anterior
intercostal arteries may be seen emerging at
each intercostal space 1/2" lateral to the sternum. Skinning the Pectoral Region
51
 Reflect pectoralis major laterally from the sternum and clavicle. The underlying pectoralis
minor should also be cleaned and reflected laterally. The lateral pectoral nerve and
thoracoacromial artery branches run to pectoralis from above. Leave these structures
intact and the muscles attached to the upper limb as other students may prosect this region
later.

Clean the fascia off serratus anterior so that the muscle fibers are clearly visible. It may be
cleaned by running a scissors along the muscle fibers and spreading the blades to loosen
the fascia. The origin of serratus interdigitates with the origin of the external oblique
abdominal muscle which runs over the costal margin inferiorly towards the midline. Rectus
abdominis also originates from the sternum and surrounding thoracic wall. This pair of
strap-like muscles run to the pubic symphysis. The junction between the ribs and costal
cartilages can be clearly seen. In older specimens these cartilages are ossified.

2. OUTER ASPECT OF THORACIC WALL The muscles that overlie the intercostal spaces
must be reflected to see the intercostal spaces along their length. Reflect serratus
posteriorly and the external oblique towards the abdomen as far as the costal margin. The
musculature can be loosened from the ribs by running the scapel parallel to their surface.
The muscles can be bluntly separated from the spaces.

external intercostal muscles

internal intercostal muscles
anterior intercostal membrane
intercostal nerves
transversus thoracis muscle
innermost intercostal
internal thoracic artery
anterior intercostal arteries
parietal pleura
intercostal veins and arteries

The muscles that fill the intercostal spaces are organized into three layers as are the
muscles of the anterolateral abdominal wall.The external intercostals are the outermost
layer of muscle with fibers that run inferiorly and medially like hands into pockets. The layer
begins at the vertebrae but thins out at the costochondral junction. The outer layer is
completed by the anterior intercostal membrane, a translucent covering that runs to the
edge of the sternum. Simply remove the overlying fascia from the second intercostal space
to expose the external intercostal and anterior intercostal membrane.

The second layer of muscles are the internal intercostals. Their fibers run perpendicular to
the external’s which makes their identification more simple. This layer is incomplete
posteriorly to the costal angle which is filled in by the posterior intercostal membrane. The
internal intercostals can be seen through the anterior intercostal membrane. In the third
intercostal space, reflect the external intercostals superiorly. Run the grooved director under
the lower edge of the muscle. Run the scalpel along the director to cut the muscle. Use the
scalpel and forceps to reflect superiorly a small section of the muscle. Make sure the outer
layer only is being pulled up. Continue until all the exposed muscle has been reflected as
one sheet.

The third layer is called transversus thoracis and is made up of three incomplete groups:
sternocostalis, innermost intercostal, and subcostal muscles. The neurovascular
bundle of intercostal vessels and nerves runs between the second and third layers.
Sternocostalis originates from the inner surface of the lower sternum and inserts on the
second through sixth ribs. It radiates up and away from the sternum, in groups of fibers. In
the fourth intercostal space reflect the external intercostals as previously described.

52
 Reflect the internals by running the grooved director along the superior rib and pulling the
muscle down. The parietal pleura (which overlies the thoracic walls) lies directly below
most of this muscle. The pleura is thin and transparent; try to keep it from being torn as the
musculature is reflected. Near the sternum some of the sternocostalis fibers may be seen if
the overlying fatty fascia is cleaned away. The internal thoracic artery is a branch of the
subclavian that runs along the sternum 1/2" from its lateral edge. The internal thoracic and
its venae comitantes are superficial to the pleura and should be exposed now. The anterior
intercostal arteries arise from this vessel.

Expose the neurovascular bundle. The intercostal vein is most superior, followed by the
artery and nerve (VAN). They sometimes wander out of their described position as they
travel around the rib. The bundle runs at the lower edge of each rib. Remove the lower
portion of the costal cartilage from the third or fourth rib. Carefully shave away the cartilage
with a sharp scalpel. The neurovascular bundle will be found superficial to the parietal
pleura, so if this level is reached without finding them look lower in the intercostal space.

3. OPENING THE THORACIC CAVITY When opening the cavity it is important to leave the
viscera undisturbed and undamaged. Use the grooved director and scalpel or scissors to cut
through the soft tissue of the intercostal spaces. A rib cutter is used to crack the ribs but a
scissors will be needed to “finish them off” and get through attached tissue. The cut edges of
the rib are VERY SHARP so work carefully around them. Before pulling the rib cage up, run
your hand along the inner surface to gently break any adhesions between the wall and
lungs.

Use the bone saw or rib cutters to cut

transversely through the manubrium of
2nd rib
the sternum. It will be obvious that the
marrow cavity was filled with red marrow.
Run the grooved director along the first Body of
interspace to section the musculature sternum
from the manubrium to the anterior
axillary fold (former position of pectoralis
major). The internal thoracic vessels will
be severed at this time. Break through 6th intercostal
space
the second rib angling inferiorly and
laterally. Cut through the second inter-
costal space muscles as before, in a
direction towards the midaxillary line.

Cut through ribs and intercostal spaces

along the midaxillary line until reaching
the sixth intercostal space. At the sixth
interspace cut medially through the
Cutting the Thoracic Cage
muscles to the point where the costal
cartilages join together to attach to the sternum. Do not break through this attachment. The
front of the thoracic wall will be left connected to the cage so that its proper relationship can
be observed. Repeat this procedure on the opposite side. When lifting the front piece open,
note the sternopericardial ligaments; this thickened tissue anchors the pericardium to the
sternum.

53
4. INNER ASPECT OF THE THORACIC WALL The following structures are found on the
inner aspect of the thoracic wall.

transversus thoracis muscle

sternocostalis muscle
innermost intercostal muscles
musculophrenic artery
superior epigastric artery
sternopericardial ligaments

Clean away any fat that blocks a clear view of sternocostalis, the first part of the transver-
sus thoracis. The fibers radiate from the sternum in a fan-like configuration. Locate the
superior cut edge of the internal thoracic vessels. On one side cut back the overlying
muscle so the vessels may be seen along their entire course. The vessels split at the sixth
interspace to form the superior epigastric and musculophrenic arteries. The superior
epigastric runs inferiorly and passes into the rectus abdominis muscle which it supplies.
The vessels will anastomose with the inferior epigastric (a branch of the external iliac) which
also supplies this muscle. The musculophrenic artery runs along the costal margin and
gives off anterior intercostal branches to the remaining intercostal spaces. Leave the thin
parietal pleura attached to the wall. The intercostal vessels and nerves can be seen through
the pleura. Laterally, the neurovascular bundle first becomes visible after emanating from
behind muscle fibers. These are the innermost intercostals, the second part of the trans-
versus thoracis. They are directed the same way as the internal intercostals and cross one
intercostal space. The neurovascular bundle runs between the middle and inner muscle
layers so it is first seen where this intermittent layer stops. This is also the easiest way to tell
the innermost from internal intercostals.

5. THE ANTERIOR MEDIASTINUM Only a few structures are found in this small part of the
inferior mediastinum. The fatty remains of the thymus which lie over the pericardium should
be reflected upward. The connective tissue remains of the sternopericardial ligaments can
be cleaned away. Small diaphragmatic lymph nodes may be seen inferiorly.

6. THE THORACIC VISCERA IN SITU Now is the time to view the organs of the thorax in
their proper positions. Thoughtfully observe the relative positions of the structures. The
thorax is divided into two pleural spaces that include the lungs and are bounded by the
parietal pleura, and the mediastinum — the central area that contains the heart, great
vessels, and much more.

lungs
visceral pleura phrenic nerve
cardiac notch pericardiacophrenic vessels
root of the lung brachiocephalic veins
diaphragm arch of aorta and branches
parietal pericardium superior and inferior vena cava
costodiaphragmatic recess pericardium
costomediastinal recesses pericardial sinuses
The lungs are covered by the thin and shiny visceral pleura. The lungs differ in size and
shape. The right lung is divided into three lobes which usually can be seen unless they have
fused together by adhesions. The left lung has only two lobes. The smaller left lung also has
a scalloped anterior edge, the cardiac notch, that makes room for the heart. If there is a red

54
or white cheesy material between the lungs and thoracic wall it must be cleaned out. It is
coagulated blood. The radially directed muscle fibers of the diaphragm are easily seen as
they run up from the edge of the costal margin and ribs to the central tendon which lies
beneath the heart. This thin muscular sheet is usually pushed farther up on the right side
due to the presence of the liver beneath it. Run your hand down into the thin slit of space
between the diaphragm and thoracic wall, being careful of sharp rib edges. This is the
costodiaphragmatic recess; the lungs do not extend down into this area.

In the adult, the fatty remains of the thymus are seen in the superior aspect of the
mediastinum overlying the great vessels and heart. The heart is enclosed in a sac of
parietal pericardium. Often a good deal of fat surrounds the sac. The phrenic nerve
(motor innervation to the diaphragm) and pericardiacophrenic vessels run together on the
surface of the pericardium. They run in front of the root of the lung on each side. The
outline of the great vessels can be seen in the superior mediastinum. The brachiocephalic
veins overlie the arch of the aorta and its branches. The superior vena cava forms at the
junction of the brachiocephalics on the right.

The pericardium The relationships between the heart and pericardium are quite similar to
those between the lungs and pleura. The heart’s outer epicardium is actually its serous
layer of visceral pericardium. The parietal pericardium consists of a thin inner serous layer
and a tough outer fibrous layer. An I-shaped incision will be used to open the pericardium.
Make a midline longitudinal incision with the grooved director and scalpel or scissors. Make
a short transverse cut superiorly and a longer one below. The heart can now be seen and it
is first noted that it lies on its right side with the apex extending leftward laterally. The infe-
rior vena cava passes directly through from the diaphragm into the right atrium without
receiving any tributaries in the thorax.

The pericardial sinuses are nonvascular spaces formed by the folding of the pericardium
around the origins of the great vessels. The transverse sinus runs transversely between
the great arteries and veins and can be exhibited by running a probe or finger behind the
aorta and pulmonary arteries (and in front of the superior vena cava and pulmonary veins)
within the pericardial sac. The probe will pass from one side to the other. The oblique
sinus is found between the posterior surface of the heart and the pericardium. It is shaped
like an inverted U or pocket and is formed by the foldings of the pericardium around the
great veins (superior and inferior vena cava, pulmonary veins). Run a finger up behind the
heart working superiorly and feel the extent of this inverted pocket.

At this time show the other students in your group the thoracic wall structures and
undisturbed thoracic cavity. Do not proceed further until this is done.

55
WEEK TWO — MIDDLE MEDIASTINUM AND HEART
1. REMOVING THE LUNGS When the lungs are taken out of the thorax it is important to
leave the mediastinal structures uncut and in place. Begin by running your fingers along the
surfaces of the lungs and gently breaking any adhesions between them and the thoracic
wall or diaphragm. The pulmonary vessels and bronchi pass into the lung at its root or hilum.
Run your hand around the root and feel its extent. The lungs should be cut right at the
root so that the proper relationships here can be appreciated. If the incision is made too
far into the lung the vessels and bronchi will have bifurcated and their correct positions are
not identifiable. This also leaves a large piece of lung attached to the middle mediastinum.
Remove the right lung first. Using a sharp scalpel cut through a small part of the root and
then continue a little at a time. It is necessary to cut on a slight curve along the heart. On the
left side the hilum is in close proximity to the thoracic aorta posteriorly so extra care must be
taken. The inferior lobe of the left lung extends a good deal behind the heart so it must be
slowly worked out from behind. Break any remaining adhesions as the lungs are pulled
away. Set lungs carefully aside for later study.

Most of this section will deal with the heart and its coverings. View the important features and
coronary vessels of the heart on a model first. Most of the prosections will have the heart
removed for ease of work but some will leave it in place to retain the relationships to the great
vessels and the foldings of the pericardium.

2. THE PHRENIC NERVES AND PERICARDIACOPHRENIC VESSELS Before the

pericardium is opened these structures must be located and cleaned so that they are not
severed. The phrenic nerve originates at roots C3, 4, and 5 in the neck’s cervical plexus
and passes along the pericardium in front of the root of the lung on each side. They are
covered by the fatty connective tissue outside the pericardium. Bluntly pull through this
tissue from superior to inferior (following their route) until these items are seen. Leave the
pericardiacophrenic vessels attached to the phrenic nerve with connective tissue. These
vessels originate from the internal thoracics and help supply the pericardium, and
diaphragm. Leave the structures attached to the pericardium so their correct relationship can
be seen.

3. REMOVING THE HEART Pass the grooved director behind the inferior vena cava and cut
through it. The apex of the heart will be freely movable now. First loosen the superior vena
cava from the surrounding tissue by running a probe or finger around its circumference
within the pericardial sac. Then section the vessel a short distance from its junction with the
right atrium. Recall that the aorta passes behind the pulmonary trunk so that at first it ap-
pears to emanate from the right ventricle. Separate and section the aorta 1 1/2" from its
origin in a manner similar to that used with the vena cava. Work bluntly around the pulmo-
nary trunk and transect it shortly after its origin from the conus arteriosus of the right
ventricle. Make sure that it is cut before the ligamentum arteriosum and the bifurcation into
the right and left pulmonary arteries. Pull the heart up and out apex first. The short rem-
nants of the pulmonary veins will come with the heart. Note the position of the heart in the
mediastinum. Replace and store lungs in chest to retain their shape.

anterior: right ventricle and atrium apex: left ventricle

inferior (diaphragmatic): right and left ventricles, right atrium base: left atrium

56
 Left common carotid artery
Brachiocephalic trunk Left subclavian artery
Left brachiocephalic vein
Right brachiocephalic vein

Ligamentum arteriosum

Superior vena cava Left pulmonary artery

Ascending aorta Left pulmonary veins

Pulmonary artery
Right pulmonary artery Left auricle
Right pulmonary veins
Coronary groove (sulcus)
(atrioventricular groove)

Right atrium
Left ventricle
Right border of heart
Coronary groove (sulcus)
Left border of heart
(atrioventricular groove)
Right ventricle
Anterior interventricular groove

Inferior vena cava

Apex of heart

Inferior border of heart

Anterior View of Heart and Great Vessels

4. THE HEART AND GREAT VESSELS The following features should be located.
External features: Vessels:
anterior and posterior ascending aorta
interventricular sulci pulmonary trunk
coronary sulcus superior vena cava
right and left atria inferior vena cava
right and left auricles pulmonary veins
right and left ventricles
base, apex
conus arteriosus

The interventricular sulci are longitudinal furrows that lie over the interventricular
septum. The coronary sulcus is an indentation that divides the atria and ventricles by
encircling the heart. The auricles are small ear-shaped appendages on the atria that are the
embryonic remnants of the primitive right atrium. The conus arteriosus is a muscular
extension of the right ventricle over the left that is derived from the bulbis cordis.

57
Left common carotid artery Brachiocephalic trunk
Left subclavian artery

Right brachiocephalic vein

Arch of aorta Arch of azygos vein

Ligamentum arteriosum
Branch to superior lobe
Left pulmonary artery
Superior vena cava

Superior Right pulmonary artery

Left pulmonary
veins
Inferior
Superior Right
Cut edge of pericardium pulmonary
Left atrium Inferior veins

Coronary groove (sulcus) Right border of heart

(atrioventricular groove) Right atrium

Left ventricle
Inferior vena cava

Posterior
interventricular groove Right ventricle

Posterior View of Heart and Great Vessels

5. CORONARY VESSELS The surface structures of the heart and coronary vessels can be
found with the heart in place or removed. First make sure that the surfaces of the heart can
be identified correctly. Point the apex down and look for the small “dog ears” or auricles of
the atria which are seen anteriorly. The anterior surface can also be ascertained by locating
the cone-shaped conus arteriosus of the right ventricle that serves as origin to the
pulmonary trunk.

Coronary Vessels:
left coronary artery with anterior interventricular branch and circumflex branch with
left marginal branch, and posterior artery of the left ventricle branch
right coronary artery with right marginal and posterior interventricular branches
coronary sinus
great cardiac vein
middle cardiac vein
small cardiac vein
anterior cardiac veins

The coronary vessels are found in artery-vein pairs for the most part. Use these pairs to
remember the position of the vasculature.

58
 Arch of aorta

Pulmonary trunk

Left coronary artery

Sinuatrial nodal Circumflex branch
artery
Anterior interventricular
artery
Right coronary Left marginal artery
artery Atrioventricular nodal artery

Posterior interventricular
artery
Right marginal
artery

Anterior View of Coronary Arteries

anterior interventricular a. — great cardiac v.
circumflex branch, left coronary a. — great cardiac v.
right marginal branch, right coronary a. — small cardiac v.
posterior interventricular a. — middle cardiac v.

Few of the cadaveric hearts will exhibit the coronary vessels without first removing overlying
fat. Work slowly and carefully leaving the vessels firmly attached to the myocardium. Use
the grooved director to pull away fat, always working in the direction the vessels travel. Start

Arch of aorta

Superior
vena cava

Left pulmonary artery Sinuatrial

nodal artery
Left coronary artery
Right pulmonary
veins
Circumflex
branch Right coronary
artery
Atrioventricular
nodal artery

Anterior Posterior interventricular

interventricular artery
artery Marginal artery

Posterior View of Coronary Arteries

59
 Great cardiac vein
Anterior
cardiac veins

Coronary sinus
Middle
cardiac vein
Small cardiac
vein

Anterior View of Cardiac Veins

Great
cardiac vein

Coronary sinus
Posterior left
ventricular vein
Small
cardiac vein

Middle
cardiac vein

Posterior View of Cardiac Veins

at the origin of the coronary arteries from the ascending aorta. The arteries emanate
immediately from the aorta after leaving the heart. The right coronary passes in front of
the right auricle and behind the right side of the pulmonary trunk. The left coronary origi-
nates behind the left side of the pulmonary trunk. Before following the right coronary locate
the anterior cardiac veins that pass directly from the right ventricle into the right atrium.
They will pass over the right coronary artery and therefore, must be found first to be pre-
served. The right coronary passes along the coronary sulcus and at the right edge of the
heart gives rise to the small right marginal artery which passes towards the apex. The right
coronary continues in the coronary sulcus until it reaches the posterior interventricular
sulcus which it passes down as the posterior interventricular artery. The small cardiac
vein begins with the right marginal artery, runs up to the coronary sulcus, and heads

60
 posteriorly to drain into the coronary sinus. The left coronary artery almost immediately
gives off the anterior interventricular artery which passes down the anterior interventricu-
lar sulcus. The left coronary continues in the coronary sulcus as the circumflex branch that
may give off a left marginal artery. The left coronary artery may give off a single posterior
artery of the left ventricle at the left margin of the heart, and then it fades out or anasto-
moses with the right coronary artery. The great cardiac vein begins in the anterior interven-
tricular sulcus and then passes along the atrioventricular groove with the circumflex artery
branch. When it joins the posterior vein of the left ventricle it becomes the coronary
sinus. The coronary sinus may be partially covered by atrial muscle fibers. The middle
cardiac vein of the posterior interventricular sulcus also drains into the sinus. Note that all
the veins of the heart drain into the sinus (which has its own opening in the right atrium)
except for the anterior cardiac veins and smallest (thebesian) cardiac veins, the latter
draining directly into the chamber they overlie. The sinoatrial node is supplied by both
coronary arteries while the atrioventricular node and bundle are supplied by the right
coronary. There may be major variations in the courses of these vessels; be prepared.

6. OPENING THE HEART Many methods may be used to expose the inner aspects of the
heart. One method is described here. Some hearts with particularly good coronary vessels
will not be opened. Check with the instructors first. With any method the hard coagulated
blood found inside the chambers must be carefully removed to keep from damaging the
more delicate aspects such as chordae tendinae. Adequate exposure of the right atrium is
found by making an incision from the superior to inferior vena cava. The left atrium can be
opened by a cut from the pulmonary veins from one side to the other. Starting at the apex,
cut the ventricles with a coronal incision that splits each ventricle in half and shows the
sectioned interventricular septum between them. Stop before reaching the coronary sulcus.

7. THE INNER ASPECT OF THE HEART

tricuspid and bicuspid (mitral) valves interventricular septum

pulmonary and aortic semilunar valves papillary muscle
interatrial septum chordae tendinae
fossa ovalis septomarginal trabecula
pectinate muscle conus arteriosus
crista terminalis aortic sinus
opening for the coronary sinus trabeculae carnae

Open the right atrium and look at the inner surfaces. The interatrial septum divides the
upper chambers of the heart. The fossa ovalis is a shallow oval depression in the septum.
It marks the position of the fetal foramen ovale, an important bypass that carried blood to
the left side of the heart. The roughened portion of the atrial wall is composed of pectinate
muscle. The crista terminalis is the ridge that divides the pectinate muscle from the
smooth part of the wall. Recall that the smooth portion is derived from the sinus venarum
while the roughened part is from the primitive atrium. The opening for the coronary sinus
is located posteriorly near the opening for the inferior vena cava. Clear away any coagulated
blood that may cover it.

The tricuspid and mitral valves are atrioventricular valves that are located in the right and
left ventricles respectively. They are composed of flattened valve flaps that are connected to
the walls of the ventricle by the thin strand like chordae tendinae and papillary muscles.
The valves close due to the build up of pressure in the ventricle during systole and prevent

61
 backflow into the atria. The papillary muscles do not close the valve but keep the flaps from
pulling back too far when they do, like a spring on a screen door. The pulmonary and
aortic valves are semilunar; three half moon shaped cusps emanate from the vessel walls.
If the pulmonary artery has been cut the cusps can be examined closely. Look down into the
ascending aorta to see the aortic valve. Immediately behind the cusps the aorta is bowed
out as the aortic sinuses. Two of these sinuses serve as origins for the coronary arteries.

The inner surface of the ventricle is irregular due to the presence of the trabeculae carnae
(meaty little beams). The papillary muscles originate off the trabeculae. The
interventricular septum is thick and muscular below and membraneous in its upper third.
The wall of the left ventricle is normally three times thicker than the wall of the right. This
gives it the strength to build up enough pressure to send blood throughout the body. The
septomarginal trabecula or moderator band carries a part of the right branch of the AV
bundle to the wall of the right ventricle. Look for a trabecula running from the septum to the
wall in the inferior right ventricle. Note that the inner surface of the conus arteriosus is
smooth. A ridge named the supraventricular crest divides the smooth conus from the
remainder of the right ventricle.

WEEK THREE — LUNGS AND SUPERIOR AND POSTERIOR MEDIASTNA

1. EXTERNAL FEATURES OF THE LUNGS Compare and contrast the external aspects of
the right and left lungs. The impressions on their outer surfaces differ because of the various
viscera they lie next to. Be sure to find the following items.

Right lung Left lung

oblique and horizontal fissures oblique fissure

superior, middle, and inferior lobes superior and inferior lobes
apex lingula
costal, mediastinal, and apex
diaphragmatic surfaces costal, mediastinal, and
cardiac impression diaphragmatic surfaces
pulmonary ligament cardiac impression
cardiac notch
pulmonary ligament

grooves (or sulci) for the:

subclavian artery subclavian artery

azygos vein aortic arch
thoracic aorta
esophagus

The horizontal fissure on the right lung begins at the middle of the oblique fissure and
serves as the upper border of the middle lobe. The outlines of the small divisions of the lung
can often be seen because of the carbon deposits along their edges. The base and
diaphragmatic surface of the lungs are one and the same thing. Each lung has a cardiac
impression (larger on the left) but only the left lung has a cardiac notch. The grooves on the
lung are easily seen if the tissue has been well preserved and isn’t too soft. Look at the

62
 Superior vena cava
Left pulmonary veins
Sinuatrial node

Atrioventricula node Left atrium

Atrioventricula bundle Mitral valve (cusp)

Tricuspid valve (cusp) Chordae tendineae
Right and left Interventricular septum
bundle branches

Anterior papilary Wall of left ventricle

muscle

Septomarginal
trabecula

Interior of the Heart

roots of each lung. In each lung the primary bronchi are posterior, pulmonary arteries
superior, and pulmonary veins anterior and inferior. The right lung exhibits two divisions of
the bronchus (eparterial and hyparterial) very quickly as this lung is larger and the bronchi
must serve the superior lobe. There are two divisions of the pulmonary artery and three of
the pulmonary vein. Bronchopulmonary lymph nodes can be seen along the cut edge and
are often blackened by deposits. The pulmonary ligament is the inferior extension of the
pleura and the contents of the hilum. It is formed as the lung buds first extend into the pleura
and then pull superiorly.

Many pathological changes can be seen in the lungs. The extensive dark patches are due to
accumulation of pollutants from the environment or smoking. Balloon like areas in the lung
are due to the breakdown of the alveolar walls in emphysema. Metastatic tumors appear as
numerous hardened areas in the lung.

Remove any remaining blood clots from the thoracic cavity. The most posterior part of the
transversus thoracis layer can now be seen. The subcostals are found in the area near the
costal angles of the ribs. They run in the same direction as the internal intercostals but cross
two or three intercostal spaces.

2. STRUCTURES OF THE SUPERIOR MEDIASTINUM Read through the sections on the

superior and posterior mediastinum before continuing as many of the structures in each area
are continuous. The phrenic and vagus should be found and cleaned before moving on to
the vessels as certain important branches (like the left recurrent laryngeal) may be lost
otherwise.

63
 thymic remains superior vena cava
brachiocephalic veins phrenic nerves
internal thoracic vessels arch of the aorta
brachiocephalic artery left common carotid artery
left subclavian artery vagus nerves
left recurrent laryngeal nerve ligamentum arteriosum
cardiac plexus pulmonary trunk and arteries
arch of the azygos vein trachea
esophagus thoracic duct

3. NERVES IN THE SUPERIOR MEDIASTINUM First reflect back any remaining thymus. If
possible keep some of the degenerated gland attached to nearby structures. Follow the
phrenic nerves superiorly from their position anterior to the roots of the lungs. The right
phrenic nerve travels over the lateral surface of the right brachiocephalic vein and superior
vena cava. The left phrenic nerve lies first on the left brachiocephalic vein and then passes
over the arch of the aorta before the arch gives rise to the left common carotid artery. The
vagus nerves can be followed back from where they pass behind the roots of the lung. The
right vagus nerve runs posterior to the superior vena cava and then passes deep to the
arch of the azygos vein. The left vagus nerve lies along the left common carotid as it enters
the thorax, then on the left lateral surface and the arch of the aorta, and then passes
posterior to the root of the left lung along the thoracic aorta. Each vagus nerve has a
recurrent laryngeal branch that heads back up to the neck and innervates most of the intrin-
sic muscles of the larynx associated with voice production. The right recurrent laryngeal
nerve recurs around the first part of the subclavian artry and will not be seen until the neck
prosection. The left recurrent laryngeal nerve branches off as the left vagus passes the
aortic arch. The left recurrent loops around the arch immediately adjacent to the ligamen-
tum arteriosum (the remnant of the fetal ductus arteriosus connecting the pulmonary trunk
and aortic arch). Bluntly follow the vagus and its recurrent branch. The recurrent continues
by running in the groove between the trachea and esophagus until it reaches the larynx. The
vagus nerves also give off a number of branches to the cardiac plexus while in the superior
mediastinum. The cardiac plexus distributes autonomic fibers to the heart and lungs.

4. THE GREAT VESSELS Clean off the superior vena cava and follow it back to its origin
where the right and left brachiocephalic veins join. The left brachiocephalic vein is much
longer and crosses over to the right side of the thorax. These veins are thin walled and have
to be cleaned and manipulated with great care. The left superior intercostal vein drains
the left second and third intercostal spaces. It crosses the aortic arch superficial to the vagus
nerve and passes into the left brachiocephalic vein. Retain this connection. The right
superior intercostal vein drains into the azygos vein which will be cleaned later.

The arch of the aorta runs superiorly, and then to the left and posteriorly. The surrounding
fibrous tissue is directly continuous with the tunica adventitia. Clean away the connective
tissue noting the small branches of the superficial cardiac plexus that pass over the arch.
The brachiocephalic artery is the first branch of the arch and it passes superiorly behind
the left brachiocephalic vein to eventually become the right common carotid and
subclavian arteries. The left common carotid artery arises next and heads superiorly.
Right next to it is the left subclavian artery. Clean these major branches as far as possible
without entering the neck. The ligamentum arteriosum lies in the inner surface of the arch.
The pulmonary trunk also travels beneath the arch and should be cleaned at this time,
following the trunk to the origin of the right and left pulmonary arteries.

64
5. DEEP STRUCTURES The trachea lies posterior to the great vessels in the superior
mediastinum. A large amount of loose connective tissue surrounds the trachea and it
should be pulled away with forceps. The trachea is composed of C-shaped hyaline cartilage
rings which open posteriorly towards the adjacent esophagus and widen when a bolus of
food passes. A fibroelastic membrane closes off the open part of the ring. The trachea
divides just below the sternal angle and a special cartilage named the carina is found here.
Remember that the left recurrent laryngeal nerve is running in the groove between the
trachea and esophagus on the left side. The esophagus will be cleaned more fully during
work in the posterior mediastinum. The thoracic lymphatic duct runs on the deep surface
of the esophagus and is easier to locate inferiorly.

6. POSTERIOR MEDIASTINUM While working on the posterior mediastinum it will be

necessary to push the pericardium and heart (if still in place) to one side or the other. Work
carefully so the more superficial structures are not disturbed. Completely remove the fatty
tissue from the deep structures so that others can view them completely.

thoracic aorta vagus nerves/anterior and posterior vagal trunks

esophagus chain of thoracic sympathetic ganglia
posterior intercostal vessels intercostal nerves
azygos vein arch of the azygos vein
hemiazygos vein accessory hemiazygos vein
thoracic duct greater, lesser, and least splanchnic nerves
subcostal muscles anterior longitudinal ligament

Strip the parietal pleura back from the posterior mediastinal contents. On one side pull the
pleura away from the posterior thoracic wall at the same time. On the other, stop before
reaching the level of the sympathetic ganglia. Be especially careful when working over the
bodies of the vertebrae as the thoracic splanchnic nerves are here and are very delicate.
The pleura can be removed by simply pulling on it from its cut edge.

Expose the neurovascular bundle in a few intercostal spaces on the side the pleura has
been removed. The posterior intercostal vein, artery, and intercostal nerve are large
and easy to see and found in the VAN configuration. Follow them as far as the costal angle.
The subcostal part of the transversus thoracis group is now seen; the fibers run in the same
direction as the internal intercostals but cross two or three intercostal spaces.

Autonomic nerves. The vagus nerves not only supply parasympathetic fibers to the thorax
but pass through the diaphragm to innervate the gut as far as the transverse colon. The
vagus nerves come to lie on the esophagus and send fibers to the esophageal plexus. The
right vagus nerve moves behind the esophagus and is known as the posterior vagal
trunk while the left vagus nerves moves in front to become the anterior vagal trunk.
They pass through the diaphragm in this configuration. Use the grooved director to clean
the vagi near the esophagus. Pull away the fatty fascia but retain the branches of the vagus
to the esophagus. Clean the fat completely from the esophagus. The outer longitudinal
layer of muscle can be seen. The esophagus sits on the left side of the posterior
mediastinum. Sympathetic fibers originate with thoracic and upper lumbar spinal nerves.
The sympathetic ganglia (L. knots) sit next to the bodies of the vertebrae and are linked
together into a chain. The chain continues superiorly into the neck to supply sympathetic
fibers to the head and neck. Use forceps and grooved director to bluntly pull away the fat
from the ganglia so they stand out clearly. On each side thin fibers arise from the ganglia to
travel towards the midline on the bodies of the vertebrae. They coalesce to form the

65
 greater, lesser, and least splanchnic nerves. The thoracic splanchnics are preganglionic
sympathetic fibers that have passed through the ganglia and will supply innervation to the
autonomic plexus in the abdomen. The greater arises from T5-9, lesser from T10-11, and
least from T12. It may not be possible to see the least splanchnic nerve because it
originates so low.

The thoracic aorta and azygos system of veins. Remove any loose connective tissue
from the aorta. The posterior intercostal arteries are seen to arise here for all except the
first two interspaces. These are supplied by the subclavian artery. The aorta also sends
branches to other mediastinal structures and the lungs. The azygos vein and its tributaries
drain the intercostal spaces. The azygos begins in the abdomen at the junction of the
ascending lumbar and subcostal veins. The azygos usually sits on the right side of the
vertebral bodies and drains the right side of the thoracic wall. It receives the superior
intercostal vein on the right side. It ends as the arch of the azygos, draining into the
superior vena cava. The hemiazygos system drains the left side of the thoracic wall. It drains
to the azygos system across the midline via several communicating veins. The spaces
above the communication on the left are drained by the accessory hemiazygos vein, while
spaces inferior to the communication drain to the hemiazygos vein. Occasionally the
hemiazygos is partially or completely absent and in this case, the azygos moves closer to
the midline and receives the veins.

Lymphatic drainage. The thoracic duct is the largest lymphatic vessel in the body;
receiving the lymph from the lower extremities, abdomen, left upper limb, and left halves of
the thorax, neck, and head. It begins in the abdomen as the cisterna chyli, an elongated
lymph sac. It passes through the diaphragm on the right side of the aorta and moves to the
left while traveling on the bodies of the vertebrae. It drains into the junction of the left internal
jugular and subclavian veins in the neck. For all its importance, the duct is small and a bit
difficult to find. It is only as wide as the end of a blunt probe and is white since there are no
erythrocytes inside to add color. Lift the esophagus and look just medial to the azygos vein.
It is fragile so don’t pull on it very hard while cleaning. The thick anterior longitudinal
ligament lies on the anterior surface of the vertebral bodies beneath the thoracic duct and
nearby veins.

7. DIAPHRAGM Further dissection of the diaphragm will be done when the abdomen is
dissected. Although you will see the diaphragm from the superior surface only, you should
be aware of its general structure, its function during respiration and as the boundary
between the thoracic and abdominopelvic cavities. The muscle arises peripherally from the
inner surfaces of the xiphoid process, lower six ribs and their cartilages, and two crura from
the lumbar vertebrae. It inserts on the central tendon of the diaphragm. The somatic
motor innervation is supplied by the phrenic nerves centrally and branches of adjacent
intercostal nerves peripherally. The diaphragm contracts during inspiration, descending and
enlarging the vertical dimension of the thoracic cage.

The attachments of the diaphragm to the thoracic wall and the reflections of the superior
diaphramatic surface with the costal surfaces of the parietal pleura define the location and
extent of pleural recesses formed by these reflections. Review the location of the
costodiaphragmatic recess at the midclavicular, midaxillary, and posterior locations. The
fibrous peridardium attaches to the diaphragm over the central tendon.

Several structures in the posterior mediastinum traverse the diaphragm to enter or leave the
abdominopelvic cavity through specific hiatuses: inferior vena cava leaves the abdomen

66
 through the caval hiatus at thoracic level T8; the esophagus and vagal trunks enter the
abdomen through the esophageal hiatus at thoracic level T10; and the thoracic aorta
becomes continuous with the abdominal aorta as it passes through the aortic hiatus at
thoracic level T12 and the origins of the azygos and hemiazygos veins enter thoracic cavity
in this region as well.

WEEK FOUR —BACK, SUBOCCIPITAL REGION, AND LAMINECTOMY

1. SKINNING THE BACK Reflect the thick skin of the back
from the vertebral spines laterally. Reflect as far as the
iliac crest inferiorly and along the anterior border of trape-
zius above. Do not go beyond trapezius as this would
uncover and disturb structures in the posterior triangle of
the neck. Trapezius originates as high as the external
occipital protuberance and superior nuchal line of the skull,
so be sure to skin beyond the skin crease on the back of
the head which approximates the extent of this muscle.
The skin does not have to be reflected in one piece but
should be removed in strips of manageable size. Do not
remove the underlying fascia at the same time; there are
nerves and vessels here that will be preserved. Skinning
and further work is easier if blocks are placed under the
shoulders so that the head and neck fall forward, smooth-
ing out the skin and musculature.

2. THE SUPERFICIAL BACK MUSCULATURE These

muscles must be cleaned and reflected at this time. In
addition, you may clean and separate the muscles on the
scapula: supraspinatus, infraspinatus, deltoid, and teres
minor. These muscles are innervated by branches of the
brachial plexus and they are concerned with function of the
upper extremity.
trapezius Skinning the Back
latissimus dorsi and thoracolumbar fascia
rhomboid major and minor
levator scapulae
When unsure about a procedure or the identity of a structure, be sure to ask questions first;
it is too easy to incorrectly divide or reflect the musculature here which creates a mass of
loose tissue that no one can understand. The prosection will exhibit different depths of the
back on each side and each prosector will be asked to prepare things differently, so stay in
contact with your instructors. Some dissectors will also perform laminectomies.

3. SERRATUS POSTERIOR MUSCLES These muscles are unique from the other back
muscles in that they are innervated segmentally by branches of intercostal nerves (ventral
primary rami) rather than branches of dorsal primary rami. Serratus posterior superior is
an accessory inspiratory muscle that runs from the spines of C7 through T3 to the second
through fifth ribs. Serratus posterior inferior originates on the spines of T11-12 and L1-2
and inserts on the lower borders of ribs 9-12 and it assists in respiration by drawing ribs
down and stabilizing the lower ribs. Reflect these muscles from the vertebrae laterally,
bluntly loosening them from the underlying musculature.

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4. SPLENIUS Splenius means bandage and splenius cervicis and capitis are wide
muscles that wrap like bandages over erector spinae and other deep muscles. Together
they originate from the lower half of ligamentum nuchae and the spines of C7 through T6.
Capitis inserts on the superior nuchal line and mastoid process of the skull while cervicis
runs to the transverse processes of the second to fourth cervical vertebrae. Clean away the
overlying fascia and then look for the division between the two muscles. This can be quite
difficult to find; use the fact that one is running around the neck and the other’s fibers run to
the head to make the split. Using the grooved director, reflect splenius capitis and cervicis
back from their origins on one side only (Certain prosectors will be asked to reflect these on
both sides).

5. THE ERECTOR SPINAE While this group of musculature is broken down into three bands,
and each of these are further subdivided regionally, it is important to realize that they all
work together and that the subgroups are not fully separated as the origins and insertions
overlap completely. The muscles are covered by the thoracic part of the thoracolumbar
fascia, a thin transparent layer as compared to the lumbar portion which serves as origin to
latissimus. Carefully pull this fascia off the erector spinae.

The erector is divided into the following groups from lateral to medial.
Iliocostalis lumborum
thoracis
cervicis
Longissimus thoracis
cervicis
capitis
Spinalis thoracis
cervicis (may not be present)

Begin with the lateral iliocostalis group. Simply pull the strip of muscles up from their
medial edge so that the bellies are away from the thoracic wall and the origins and insertion
can be seen. In the cervical region, be sure to just separate the iliocostalis portion which has
thinned out considerably. The longissimus group should be separated in the same manner.
Though it crosses over the lumbar region, these fibers are a part of the thoracic part. The
longissimus capitis fibers begin medial to longissimus cervicis and then pass over them
to insert on the mastoid process, while longissimus cervicis inserts on the transverse pro-
cesses. Refer to an atlas to be sure of the correct relations here as this is one of the
trickier separations. Get help from an instructor if needed. Note that the capitis fibers
are just lateral to the broad semispinalis capitis. The spinalis group runs from spine to
spine over the different regions. Spinalis thoracis is the easiest part to demonstrate. Just pull
the belly of the muscle away from the spines so it may be seen. The cervical portion can be
harder to find. Thoracis runs from T2 to T9 while cervicis passes from C2 to C4. The spinalis
capitis part cannot be seen as a separate muscle; it is integrated into semispinalis capitis.

There are many divisions of the transversospinalis group. Refer to an atlas for guidance.
At least find the divisions described in this text. Carefully study the atlas and watch fiber
direction while reflecting as the muscles can be tightly bound together. Most of these
muscles originate on transverse processes and insert on spines.

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6. THE SEMISPINALIS MUSCLES

Semispinalis capitis runs from the transverse processes of the first through sixth thoracic
vertebrae to the space between the superior and inferior nuchal lines of the occipital bone.
The large muscle covers a good part of semispinalis cervicis and thoracis. This muscle
should be reflected with a transverse cut near its insertion, near the place the greater
occipital nerve pierces the muscle. Do not cut the nerve but work around it leaving it intact.
The suboccipital muscles lie immediately deep and must be kept undisturbed. Some suboc-
cipital nerve (C1) fibers innervate semispinalis capitis and should be left attached if possible.

Semispinalis thoracis and cervicis are now seen. They are continuous and no clear
division can be made between them. Cervicis inserts from C2 to C5 while thoracis inserts
from C6 to T6. Some of the higher fibers of multifidus can be seen deep to the semispinalis
fibers. They also run from transverse process to spine although they insert only two to four
segments above their origin, unlike semispinalis which inserts four to six segments above.

7. MULTIFIDUS AND ROTATORES The multifidus muscle runs the length of the vertebral
column but is thickest in the lumbar region. To demonstrate this muscle, the overlying
erector spinae will be reflected from its origins on one side. First, clean off the most inferior
parts of the origin of erector; these parts extend along the most posterior parts of the iliac
crest and on the sacrum. Now use the scissors to cut through the tendinous parts of the
origin on the spines, iliac crest, and sacrum. Starting at the spines, bluntly seperate the
fibers of erector spinae and multifidus, working laterally and deeper as it is done. The
muscles can be distinguished by the fact that erector’s fibers travel superiorly and multifidus’
move in towards the spines. Cut away the remaining fibers of erector spinae, pulling the
muscle superiorly and out of the way. Try not to cut too deeply or the quadratus lumborum, a
muscle of the posterior abdominal wall, may be damaged. Reflect the muscle about half way
up the back cutting any remaining attachments. Note how thick multifidus is at its origins and
how it thins out as it travels superiorly. Find the place where multifidus’ fibers disappear
under semispinalis thoracis. The rotatores are the deepest muscles located in the groove
between the spinous and transverse processes along the entire length of the vertebral
column. They originate on the transverse process of one vertebra and insert on the spinous
process of the next most superior vertebra. They are most easily sen in the thoracic region.
They rotate the superior vertebra to the opposite side.

8. OTHER MINOR MUSCLES OF THE DEEP BACK

intertransversarii levator costarum

interspinalis quadratus lumborum

The intertransversarii run between the transverse processes all along the vertebral
column. They are best seen where they are largest, in the lumbar region. Feel for the lateral
extent of the large transverse processes here and then clean away the fascia that lies over
the spaces between them to see the muscle fibers.

Levatores costarum are accessory muscles of inspiration. They are small feather-shaped
muscles that come in long and short varieties; passing from a transverse process to a rib,
two or one intercostal spaces below, respectively.

Interspinalis runs between the tops of the vertebral spines in the lumbar and cervical
regions. They are best seen by taking the supraspinal ligaments off the space between a
few lumbar spines and clearing out the connective tissue to expose the muscle fibers.

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 Quadratus lumborum is a large, wide muscle passing from the iliac crests to the twelfth
ribs, covered by the throacodorsal fascia. Do not pierce this fascia.

9. THE SUBOCCIPITAL REGION

THE SUBOCCIPITAL MUSCLES The muscles in this area are quite soft and “mushy” when
the overlying semispinalis capitis is first reflected. Allow the tissue to dry some before
proceeding. The musculature must be cleaned slowly and with care; the fascia here is
tough but must be fully removed to make for a clear display of the region.

rectus capitis posterior minor

rectus capitis posterior major
obliquus capitis superior
obliquus capitis inferior
greater occipital nerve (dorsal ramus C2)
suboccipital nerve (dorsal ramus C1)
vertebral artery

Recall that the atlas is the first vertebra and the axis is the second. Begin cleaning the
muscles near the midline and work outwards. Rectus capitis posterior minor runs to the
inferior nuchal line from the spine of the atlas. These paired muscles are small. Rectus
capitis posterior major passes from an origin on the spine of the axis to the inferior nuchal
line just lateral to the rectus capitis posterior minor. Obliquus capitis superior runs from
the transverse process of the atlas to the inferior nuchal line. Obliquus capitis inferior runs
from the spine of the axis to the transverse process of the atlas. The two oblique muscles
and rectus capitis posterior major outline the suboccipital triangle. The greater occipital
nerve passes from below obliquus capitis inferior, over the triangle to the scalp.The suboc-
cipital nerve runs from inside the triangle to the suboccipital muscles and semispinalis
capitis.Use the scissors to spread the fascia in the triangle and locate the fibers of the
suboccipital nerve.Use the probe to feel for the arch of the atlas which is found deep in the
triangle. The vertebral artery runs just above the arch and should be cleaned at this time.
The vertebral artery begins as a branch of the subclavian and then passes superiorly in the
transverse foramina of the cervical vertebrae. Above the atlas it passes medially to run
through the posterior atlantoccipital membrane and up into the foramen magnum. The
vertebral arteries run along the brain stem and join together to form the basilar artery which
is an important contribution to the circle of Willis. Clean any remaining fascia that makes
structures in the deep back difficult to see. Check the structures list to make sure all the
items are accounted for. Use the ligament specimens to locate the following:

anterior longitudinal ligament ––– anterior atlanto-occipital membrane

posterior longitudinal ligament ––– tectorial membrane
ligamentum flavum ––– posterior atlanto-occipital membrane
alar ligament
apical dental ligament
superior, inferior, and transverse bands of the cruciate ligament

The anterior longitudinal ligament is a thick band found on the anterior surface of the
vertebral bodies, and it extends superiorly as the anterior atlanto-occipital membrane. The
posterior longitudinal ligament runs along the posterior surface of the bodies inside the
vertebral canal. The tectorial membrane is the broadened superior extension of this

70
 Suboccipital nerve Rectus capitus
Semispinalis capitis
posterior minor
Splenius
Rectus capitus
Occipital artery posterior major

Posterior
Superior atlantooccipital
oblique membrane
Longissimus
capitis Transverse
Greater process, C1
occipital Vertebral artery
nerve
Transverse
process, C2
Splenius
Inferior oblique
Semispinalis Semispinalis cervicis
capitis Interspinalis
Trapezius

The Suboccipital Triangle

ligament from the atlas to the occipital bone. The two alar ligaments run from the side of
the odontoid process (dens) of the axis up and out to the occipital bone. The odontoid
process was originally a part of the body of the atlas. The apical dental ligament passes
from the odontoid straight up to the occipital. The ligamentum flavum (L., yellow) fills the
space between the vertebral arches. It is composed of yellow elastic tissue. The posterior
atlanto-occipital membrane is the similar ligament that fills the space between the atlas
and occipital bone. The cruciate ligament lies between the tectorial membrane and the
odontoid process. Its transverse band spans between the lateral masses of the atlas, and its
superior and inferior bands span between the body of the axis and the edge of the foramen
magnum.

10. LAMINECTOMY. Some of the dissectors will be asked to perform a laminectomy to expose
the spinal canal and its contents. The instructors will provide instruction and assistance for
this procedure. All students should study these preparations and locate several important
structures that can be seen only on these specimens.

laminae internal vertebral venous plexus

spinous processes spinal cord
intervertebral foramina posterior median sulcus
epidural (extradural) space conus medullaris
dura mater ventral root
subdural space dorsal root
arachnoid membrane dorsal root ganglion
subarachnoid space cauda equina
pia mater (filum terminale, denticulate ligaments)

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 On the piece of vertebral arch that was removed during the laminectomy, identify the strong
elastic ligamentum flavum, the yellowish ligament that holds adjacent vertebral lamina and
spines together. The extradural or epidural space is found just within the bony vertebral
canal and it is filled with fatty connective tissue, and internal vertebral venous plexus. The
internal vertebral plexus is important clinically because the veins do not have valves and
blood can flow in either direction spreading cancer cells or viruses. Dura mater, the tough
outer-most layer of the connective tissue meninges surrounding the spinal cord, will be
incised along the dorsal midline exposing the arachnoid mater. Just beneath the dura mater
is the subdural space, a thin layer (potential space) filled with lymph during life. The
arachnoid mater is the thin membranous middle meningeal layer. The collapsed
subarachnoid space that used to house the cerebral spinal fluid is found between the
arachnoid mater and the pia matter. The spinal cord is completely surrounded by the pia
mater, the innermost of the meninges, containing delicate spinal cord blood vessels.
Extensions of the pia mater form denticulate ligaments on each side of the spinal cord to
help anchor it to the dura mater. The pia mater terminates as a delicate filament, the filum
terminale, at the S2 vertebral level. Remember, the spinal cord has two enlargements,
which are not visible on this preparation, cervical (at vertebral level C3-T2) and lumbar (at
vertebral level T9-T12). However, the end of the spinal cord, the conus medullaris, is easily
located at the level of L1-L2 vertebrae. The dissectors will expose at least one example of a
dorsal root and dorsal root ganglion and a ventral root. The cauda equina is the
collection of ventral and dorsal roots caudal to the conus medullaris.

A B Lamina
Spinous
process Vertebral Facets for
foramen tubercle of rib

Transverse
process Body

C D
Articular
facet

Superior
articular
Pedicle process Facets for
head of rib

Lamina

Spinous process

A to C. Superior views of thoracic vertebrae (T1,T6 and T12 respectively)

D. Lateral view of two typical thoracic vertebrae.

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A Head
Neck
Tubercle
Crest of head

Angle

Costal groove

External surface

Internal surface

Cup for costal

cartilage

Superior
B articular
facet

Articular facet for

T6
tubercle of 6th rib
Crest of
head

Vertebral
body T7
Spinous
process
to T6

7th rib

A. Posterior view of two typical ribs, right side; the 3rd to

10th ribs are considered "typical." B. Posterolateral view
of a costovertebral joint.

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 THORAX AND DEEP BACK — STRUCTURE LIST
MUSCLES:

Diaphragm Transversus thoracis

External intercostals Innermost intercostals
Internal intercostals Sternocostalis
Subcostals

NERVES:

Intercostals Esophageal plexus

Right and left phrenic Aortic plexus
Right and left vagus Sympathetic trunk
Left recurrent laryngeal Greater splanchnic
Cardiac plexus Lesser splanchnic
Pulmonary plexus Least splanchnic

ARTERIES:

Internal thoracic Thoracic aorta

Pericardiacophrenic Posterior intercostals
Anterior intercostals Left subclavian
Musculophrenic Right and left highest intercostals
Superior epigastric

VEINS:

Right and left brachiocephalic Azygos

Anterior and posterior intercostals Hemiazygos
Highest intercostal Accessory hemiazygos
Right and left superior intercostals Pulmonary

LUNGS, ETC.:

Left lung Right lung

Apex Apex
Base Base
Superior lobe Superior, middle, and inferior lobes
Lingula Oblique and horizontal fissures
Oblique fissure Cardiac impression
Inferior lobe Grooves for subclavian a. and azygos v.
Grooves for thoracic aorta, subclavian a.,
and esophagus Trachea
Cardiac impression Carina
Cardiac notch Right and left primary bronchi
Diaphragmatic surfaces
Pulmonary ligament Costal surfaces
Hilus (root) Mediastinal surfaces
Costodiaphragmatic recess
Costomediasteinal recess

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HEART AND GREAT VESSELS:

Anterior and posterior interventricular sulci Posterior vein of the left ventricle
Coronary sulcus
Right and left auricles Great cardiac v.
Right and left atria Middle cardiac v.
Fossa ovalis Anterior cardiac vv.
Pectinate muscles Pulmonary trunk
Coronary sinus Right and left pulmonary aa.
Tricuspid valve Aortic arch
Bicuspid valve (mitral) Brachiocephalic trunk
Interatrial septum Left common carotid a.
Interventricular septum Left subclavian a.
Right and left ventricles Pulmonary vv.
Trabeculae carnae Inferior vena cava
Papillary muscles Superior vena cava
Chordae tendinae
Moderator band (septomarginal trabecula) Pulmonary valve
Sinus venarum, crista terminalis Anterior semilunar cusp
Conus arteriosus Right semilunar cusp
Pulmonary semilunar valves Left semilunar cusp
Aortic semilunar valves Aortic valve
Aortic sinus Left semilunar cusp
Ligamentum arteriosum Right semilunar cusp
Ascending aorta Posterior semilunar cusp
Right coronary a. Tricuspid valve
Marginal branch Anterior cusp
Posterior interventricular branch Posterior cusp
Left coronary a. Septal cusp
Circumflex a. with left marginal branch Bicuspid valve
Posterior a. of the left ventricle Anterior cusp
Anterior interventricvular branch Posterior cusp

ETC.:

Esophagus Pericardium, fibrous and serous,

Parietal pleura parietal vs. visceral
Pleural cavity Pericardial cavity and sinuses
Visceral pleura Thoracic duct
Sternopericardial ligaments

LIGAMENTS:

Anterior and posterior sternoclavicular Costoxiphoid

Costoclavicular Costal cartilage
Posterior antlanto-occipital membrane Superior, inferior and transverse
Anterior atlanto-occipital membrane bands of cruciate
Alar (2) Anterior longitudinal
Apical dental Posterior longitudinal
Tectorial membrane Ligamentum flavum

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SUBOCCIPITAL REGION:

Trapezius Longissimus capitis

Levator scapulae Rectus capitis posterior major
Splenius cervicis Rectus capitis posterior minor
Splenius capitis Obliquus capitis superior
Semispinalis cervicis Obliquus capitis inferior
Semispinalis capitis Vertebral artery
Suboccipital nerve (dorsal ramus C1) Occipital artery
Greater occipital nerve (dorsal ramus C2)

BACK MUSCLES:

Latissimus dorsi Semispinalis thoracis

Rhomboid major Semispinalis cervicis
Rhomboid minor Semispinalis capitis
Serratus posterior superior Levator costarum
Serratus posterior inferior Multifidus
Erector spinae Intertransversarii
Iliocostalis lumborum Interspinales
Iliocostalis thoracis Rotatores
Iliocostalis cervicis
Longissimus thoracis Thoracolumbar fascia
Longissimus cervicis
Longissimus capitis
Spinalis thoracis

LAMINECTOMY:

Laminae Internal vertebral venous plexus

Spinous processes Spinal cord
Intervertebral foramina Posterior median sulcus
Epidural space Ventral root
Dura mater Dorsal root
Subdural space Dorsal root ganglion
Arachnoid membrane Conus medullaris
Subarachnoid space Cauda equina
Pia mater
Denticulate ligaments
Filum terminale

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JOINTS:

Sternoclavicular joint Costovertebral (synovial, ribs 1-12 with adjacent

Intervertebral joints
Symphyses (adjacent vertebral bodies
and intervertebral discs)
Synovial (between adjacent superior and
inferior articular facets)
Syndesmoses (between adjacent
laminae and between adjacent
spinous processes)
Manubriosternal joint (symphysis)
vertebrae)
Costochondral (synchondroses, ribs 1-7 with
costocartilages, and ribs 8-10 with
costocartilages immediately superior)
Interchondral (synovial 8-7, 9-8;
syndesmosis 9+10)
Costosternal (costocartilages 1-7 with sternum)
1st joint is synchondrosis; rest are
synovial.

Xiphisternal joint (synchondrosis)

BONES AND BONY MARKINGS:

Vertebral Column Ribs

Vertebrae (know distinguishing features Head of rib

particular to different vertebral levels) Crest of rib
Neck of rib
Body Tubercle of rib
Intervertebral disc Angle of rib
Pedicles Costal groove
Laminae Distinguishing features of ribs
Vertebral arch 1 through 12
Vertebral canal
Transverse processes
Spinous processes
Superior and inferior articular facets
Intervertebral foramina

Sternum

Manubrium
Jugular notch
Sternal angle (Angle of Louis)
Body
Articular facets for ribs and clavicle
Xiphoid process

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 KEY TO THORAX X-RAYS
A D

Black DASHED line = diaphragm; note its 1. Body of 6th thoracic vertebra
higher position on the right due to the 2. Spinous process
liver. 3. Transverse process
Purple DASHED line = superior vena cava 4. Intervertebral disk
Purple DOTTED line = right brachiocephalic vein 5. Lamina
Red DASHED line = right atrium 6. Pedicle
Green DOTTED line = inferior vena cava 7. Rib
Green SOLID line = aortic arch 8. 12th rib
Red SOLID line = pulmonary trunk
Black SOLID line = left auricle E
Purple SOLID line = left ventricle
1. Right primary bronchus
1. costodiaphragmatic recess area 2. Eparterial bronchus (to upper lobe)
2. clavicle 3. Hyparterial bronchus (to middle
and lower lobes)
B 4. Middle lobe bronchus
5. Hilum of right lung
1. Clavicle 6. Hilum of left lung
2. 1st rib 7. Aortic arch
3. air in trachea 8. Left ventricle
4. Aortic arch
5. Pulmonary trunk Note the division of the primary
6. Left auricle bronchi (eparterial and
7. Left ventricle hyparterial) into secondary
8. Superior vena cava bronchi (lobar) and those into
9. Inferior vena cava tertiary bronchi (segmental)
10. Pulmonary vessels which are indicated by red loops.
11. Right atrium
12. Diaphragm
13. Costodiaphragmatic recess area F
14. Scapula
Note coin lodged in esophagus

1. Esophagus
2. Trachea
3. Heart

78