ANATOMY:

The diaphragm:
Insertion into the central tendon.
ORIGIN;
Sternal; from the xiphisternum
Costal: from the lower six ribs and costal cartillages.
The vertebral attachment:
Right crus body of L1 to L3
Left crus body L1 to 2.
Medial arcuate ligament: attachment at the transverse process
Lateral arcuate ligament: one attachment at the transverse process and other at the 12th rib tip.
DIAPHRAGMATIC OPENINGS:
Aortic At T12,
Also allows the thoracic duct and azygos vein
Median arcuate ligament….
Esophageal At T10, made from the right crus of hemidiaphragm.

Allows esophagus along with right and left vagus nerve

Vena Cava AT T8,
Allows IVC along with right phrenic nerve,
 Splanchnic nerves Minor openings
Sympathetic chains Medial arcuate ligament

VASCULATURE OF THE THORACIC WALL:

arteries There are posterior and anterior intercostal arteries (both of which give
collaterals)

GENERALLY:
For first six spaces, internal thoracic artery (branch of the 1st part of subclavian
artery) gives anterior intercostal arteries.
For the rest, musculophrenic (terminal branch of Int thoracic artery) gives the
anterior intercostal arteries.

As far as the posterior are concerned,

1st 2 arteries come from the costocervical trunk which is in turn a branch of the
subclavian artery.
The rest of them come from the thoracic aorta.

BRANCHES OF INTERNAL THORACIC ARTERY:

Superior epigastric (which enters the rectus) and musculophrenic artery.
Perforating branches for skin and breast.
Mediastinal branches for thymus.

VEINS Posterior veins drain into azygos, hemiazygos and accessory hemiazygos vein

Anterior veins drain into internal thoracic vein and thence brachiocephalic vein.

LYMPHATIC Intercostal spaces drain into internal thoracic nodes.

DRAINAGE Intercostal spaces drain into posterior intercostal nodes and paraaortic nodes

Skin of anterior wall into ant axillary and of posterior wall into post axillary

NERVES:
The intercostal nerves are anterior rami of spinal nerves.
They have following branches; lateral cutaneous branch and anterior cutaneous branch.
Pleural branches and peritoneal branches (derived from 7th to 11th cutaneous nerves).

The 1st nerve joins the c8 to form part of the brachial plexus. It therefore has no sensory supply in
dermatome.
The 2nd nerve….joins the medical cutaneous nerve of arm through intercostobrachial nerve. and
therefore supplies the medial arm and axilla.
Thoracic outlet Bounded by the superior edge of manubrium sterni, 1st rib, T1 vertebral body.
It allows esophagus, trachea, and vessels and lung apices.
Abdominal Xiphisternum, costal margin and T12.
boundary
mediastinum Superior. From thoracic outlet to a line between sternal angle and T4 vertebra(
lower edge)

Superior mediastinum contents:

Thymus(remains), brachiocephalic veins and SVC
BCS arteries along with arch of aorta and accompanying left recurrent laryngeal
nerve.
Phrenic nerves and vagus nerve
Trachea, esophagus
Sympathetic trunk
(azygos vein near its entry)
Anterior mediastinum:
Sternopericardial ligaments

Middle
Phrenic nerve and pericardiacophrenic artery and vein.
Roots of great arteries
Bifurcation of trachea. Tracheobronchial nodes

Posterior:
Azygos and hemiazygos veins
Esophagus (along with vagus nerve)
Thoracic aorta
Sympathetic trunk
Thoracic duct
LUNGS and PLEURA:
Visceral and parietal pleura are continuous at the hilum, the pulmonary ligament is a pleural recess
near the hilum which allows for expansion during inspiration. Costodiaphragmatic recess is another
pleural recess.

NERVE SUPPLY:
Parietal pleura is supplied by intercostal nerves and the phrenic nerve( for the mediastinal aspect
and the pleura covering central portions of diaphragm).

Relations of trachea:

Anteriorly: sternum, thymus, left brachiocephalic vein, origin of brachiocephalic and left common
carotid artery and arch of aorta
 Posteriorly: esophagus, and left recurrent laryngeal nerve
Right

Right vagus nerve and the azygos vein as it crosses to enter the brachiocephalic vein
pleura
Left:
Left vagus nerve
Aortic arch plus left common carotid and left subclavian artery.
Left pleura

LYMPHATIC DRAINAGE OF LUNGS:

Deep plexus starts at the level of bronchioles and follows the bronchovascular route.
Superficial plexus lies deep to the visceral pleura and follows the fissures of the lungs.

Bronchopulmonary segments:
Structural, functional and surgical unit of lung.
Has segmental bronchus, artery , lymph vessels and autonomic nerves.
Segmental veins lie in the connective tissue between segments.

The tracheobronchial tree:

3 lobar bronchi on right and 2 lobar on left, then are the segmental bronchi, then after several
divisions terminal bronchi, then bronchioles( respiratory as well as non-respiratory).
Superior bronchus of the right lobe arises before entering the lung.

Lung fissures:
Right has oblique and horizontal fissure
Left only has oblique fissure

Artery:
The bronchioles , visceral pleura and connective tissue are supplied by bronchial arteries which
are branches of thoracic aorta.
Veins: the bronchial veins exit the hilum and enter the azygos and hemiazygos veins

HEART AND PERICARDIUM:

There is a fibrous pericardium and a serous pericardium. Fibrous is attached to the central tendon of
the diaphragm below and to the sternum via sternopericardial ligament.
The visceral and parietal aspects of the visceral pericardium are continuous at the roots of the
arteries.
SINUSES:
TRANSVERSE SINUS: this is the recess between the two pericardial tubes. One tube covering the
aorta and pulmonary artery while the other covering the four pulmonary veins and superior and
inferior vena cava.
OBLIQUE SINUS: the tube covering the veins is in the form of an inverted J, and the cul de sac is
called the oblique sinus.
The right atrium:
It has the right atrium (derived from sinus venosus and thus smooth walled) and the auricle
(derived from the right atrium proper and lined by pectinate muscles). The two are divided by the
sulcus terminalis on the outside and a corresponding crista terminalis on the inside.

The openings: SVC opening, IVC and coronary sinus opening( the latter two are guarded by
rudimentary valves).

The fossa ovalis is also present on the interatrial septum, which is surrounded by the annulus of
the fossa ovalis.

The right ventricle:

This has muscular ridges called trabeculae carnae.

Papillary muscles are also present along with chordae tendinae.

Septomarginal trabeculae( or moderator band); which carries right branch of AV bundle.

The left atrium:

The left ventricle:
This has trabeculae and papillary muscles.
No moderator band is there.
 Mitral valve: Aortic valve: Pulmonary valve: Tricuspid valve:
Anterior and posterior Two anterior and It is followed by Anterior, septal and
valve. posterior infundibulum inferior cusps(also
called posterior)
It has one anterior and
An aortic vestibule right and left
leads to aortic valve. posterior. The leaflets
don’t have any proper
The cusps. naming.
Anterior right and left.
The right and left
coronary arteries arise
from these.
Posterior.

The conduction channels:

SA node is located in the sulcus terminalis near the SVC,
The AV node is located in the lower interatrial septum.
Then the AV bundle which runs through the membranous IV septum. At the beginning of the
muscular septum, this divides into left and right branches and finally the purkinje fibres.

All of these are supplied by the RCA. The right bundle branch is supplied by both the RCA and LCA.

The coronary circulation:

Dominance depends upon which artery supplies the posterior interventricular artery.

LCA gives rise to the LAD and left circumflex. Atrial branches , anterior ventricular and posterior
ventricular branches are also given.

RCA runs in the right AV groove and then turns on the posterior surface.
VEIN:
Anterior IV vein runs in the ant IV septum, then continues along the great cardiac vein on the left
side, it is joined on the left side by left marginal vein and by the middle cardiac vein which is in the
posterior IV groove.
From the right side, small cardiac vein enters the coronary sinus.
Anterior cardiac veins drain directly into the right atrium.

In summary, the tributaries of coronary sinus are great, middle, small cardiac vein and posterior vein
of left ventricle and the oblique vein of left atrium. (oblique vein of marshall)

These large veins drain most of the external myocardium. The inner myocardium drains via the small
Thebesian veins.

Cardiac pain:
The afferents are carried by the sympathetic nerves into T1 and T4 segments.

Azygos vein:
This is formed by the union of right ascending lumbar vein and subcostal vein. Ascends and takes the
posterior intercostal veins. Ends into the SVC at T4(or may be T5 according to snell review).
2nd to 4th veins join to form the superior intercostal vein which drains into azygos vein. The 1st drains
into the right brachiocephalic vein directly.

Hemiazygos vein:
This is formed by the union of left ascending lumbar vein and subcostal vein. Receives lower left 3
posterior intercostal veins. At the level of T8. It passes through the left crus of the diaphragm.
Accessory hemiazygos vein:
It receives the 5th to 8th intercostal veins. And the left superior intercostal vein which is made from
the 2nd to 4th vein. The first vein drains directly into the left braciocephalic vein.

The branches of the thoracic aorta:

Posterior intercostal and subcostal arteries.
Pericardiacophrenic
Esophageal and bronchial.

Thoracic duct:
It drains the abdomen down to the lower limbs and the left thorax, upper limb and head and neck.
It begins at a dilated sac, the cisterna chylii, then goes up , it finally ends into the left brachiocephalic
vein (before ending it receives the bronchomediastinal trunk, the jugular and subclavian lymph
trunks.

Right lymphatic duct.

It has right jugular, subclavian and bronchomediastinal trunks as the tributaries. In some cases, there
is no right lymphatic duct and the three abovementioned trunks open independently into the veins.

The vagus nerve:

It descends in the thorax, passes behind the root of the lung and left moves on the anterior surface
of the esophagus and the right moves onto the posterior surface of esophagus.
Recurrent nerve:
Right hooks around the subclavian artery, left hooks around the arch of aorta.
BRANCHES:
Cardiac, pulmonary , esophageal branches

Phrenic nerve:
This is made of C3 and 4, 5 Right passes anterior to the SVC while the left passes anterior to the left
subclavian, then arch of aorta. Finally both cross in front of the root of the lungs and then pass along
the pericardium.
It gives motor supply to phrenic nerve, also sensory supply to pericardium, medial pleura, pleura
covering the diaphragm( central aspect, while the outer pleura is supplied by the intercostal nerves)

Thoracic Sympathetic chain:

It contains 11 or 12 ganglia. The first thoracic ganglion is fused with the last cervical to make the
stellate ganglion or cervicothoracic ganglion.
White ramus communicantes carries preganglionic fibres to the ganglion. It also carries the afferent
fibres.
Grey ramus communicantes carries post ganglionic fibres from the ganglion to the corresponding
thoracic spinal nerve.

THE SPLANCHNIC NERVES:

Greater splanchnic nerves; 5 to 9 ganglion
Lesser splanchnic nerve: 10 to 11 ganglion
Least splanchnic nerve: 12th ganglion

Left recurrent laryngeal nerve arises at the level of sternal notch. Right doesn’t enter thorax.
The cardiac notch lies in the upper lobe of left lung. Lingual is also part of the left upper lobe.

Some points from Rabia Ali MCQs:

Hemiazygo left crura
s vein
Subcostal Pass behind lateral arcuate ligament
vessels
Arterial Pericardiacophrenic artery and musculophrenic artery which is branch of the
supply of internal thoracic artery.
the
diaphragm Superior phrenic artery; branches of the thoracic aorta.
Inferior phrenic artery; branches of the abdominal aorta.
Suprapleur Also called as sibson’s fascia.
al It is attached to the inner margin of 1st rib and to the transverse process of C7.
membrane
Esophagus It starts at C6 and ends at T11.
.

Arterial supply:
Inferior thyroid artery
Then esophageal branches of thoracic aorta
Left gastric artery

Venous supply:
Inf thyroid vein, azygos vein and left gastric vein

Nerve:
Left recurrent laryngeal nerve
Vagus nerve(right and left which form the esophageal plexus)
Trachea Extends from C6 to T4/5.

In deep inspiration or standing , it goes to the level of T6.

15-20 cartillages in trachea.

The carina is 25cm from incisor.

High tracheostomy: above isthmus and low tracheostomy below isthmus

Apex of 9cm from the median plane.
the heart
The mcqs points:
Left atrium dilation can constrict the esophagus.
Cricopharyngeus is the narrowest opening of the esophagus
Internal intercostal membrane is the aponeurosis of the inner intercostal muscle. Located from the
angle till backwards.
External intercostal membrane is the aponeurosis of external intercostal muscle, located at the front
from the costal cartilage to the sternum.
Chest tube insertion at 4th space in midaxillary line.
Esophagus middle constriction is supposed to be left bronchus.
Esophagus top level is C6 or cricoid.
An injury near the pulmy vein entry into the heart will ooze blood between pericardium and
myocardium.

The lung and heart surface anatomy:

The lungs are at the sixth rib at the midclavicular line, 8th rib in midaxillary line, and T10 vertebra.
the pleura are at the 8,10 and 12.

Markings of heart:
Right 3rd costal cartilage_______left 2nd intercostal space.
I
Right 6th costal cartilage ____________apex beat
Anterior cusp gives rise to the RCA, while left posterior gives rise to LCA

The cardiac Superficial plexus:

plexus Lies anterior to the aortic arch and between aortic arch and pulmonary artery. It
involves the sympathetic fibres as well as fibres from the left vagus

Deep plexus:
Lies between aortic arch and the pulmonary artery. It involves the vagi, recurrent
laryngeal nerve and the sympathetic nerves.
NOTE: sympathetic efferents arise from the T1 to T4 segments , synapse in the
thoracic ganglia and reach the cardiac plexus.
Afferents:
Carried by sympathetic as well as the vagi(vagal afferents involved in mediating
reflexes).
The sympathetic afferents eventually carry fibres to the T1-4 segments of spinal
cord.
RCA Atrial branches supply the SA node
The right marginal artery continues along the inferior border.

All in all, it supplies the RA, RV, interatrial septum and AV node and also supplies
portion of LA and LV….
LCA It supplies the IV septum(anterior two third ) and the AV bundle contained in it.
Also supplies the LA and LV.
Supraventric This separates the conus arteriosus(infundibulum to pulmonary artery) from the
ular crest rest of RV.
Right heart Involves the SVC on X ray. (also involves IVC actually)
border
Phrenic nerve doesn’t lie posterior to the atrium, and the atrium also doesn’t lie
anterior to the ventricle.
 Triangle of Koch is between the tendon of todaro, orifice of coronary sinus and
the septal leaflet of tricuspid valve.
Lung 7th Medial basal segment.
segment
The middle lobe has two segments only

Mitral valve opening is 4-6cm2

Coronary Have anastomoses at arteriolar level, yet they are functionally end arteries .
arteries
They run in corresponding AV grooves.
Inhaled Usually pass to right middle or lower lobe(but in key lower lobe is written).
bodies
The cardiac conduction system is supposed to be generally subendocardial
The SA node may be subepicardial.

The coronary vessels are subepicardial.

Before birth, the LA has lesser pressure than RA so Foramen ovale valve is patent.

After birth, the LA has higher pressure which closes the foramen ovale.
 Endocardial cushions fuse dividing the single AV canal into paired canals.
They also contribute to interatrial and interventricular cushions.
Bronchus is posterior
Artery is superiro and vein is inferior at the lung root.
In the midaxillary line, you can check for the three lung lobes by steth.

In midclavicular line, inferior lobe will be missed

On the back, the middle lobe will be missed.

Length of Right is 2.5cm

bronchi Left is 5cm
Surface Surface projection of fissures
projections
of fissures Oblique fissure:
Start from T4, then reach laterally at rib 6, continue along 6th rib and cartillage.

Horizontal fissure: along rib 4 and costal cartillage , only anteriorly.

Right bronchial artery
Arises from right 3rd posterior intercostal artery.
 Left bronchial artery:
Superior arises from arch of aorta
Inferior arises from thoracic aorta

Ligamentum Connects the pulmy trunk with arch of aorta.. verified through gray’s and snells.
arteriosum
thymus Arises from third pharyngeal pouch,
It produces T cells, (committed progenitor cells from bone marrow go to the
thymus for further differentiation and division).

It has no role in B cell maturation.

Pretracheal Spreads to ?????
fascia
infection
Phrenic Lies anterior to the anterior scalene and subclavian artery in the neck. It doesn’t
nerve lie posterior to brachial plexus

Inferior wall Due to RCA

MI
IVC I chose the ascending lumbar vein as a collateral.
thrombosis
Vagus nerve

On entering thorax, right vagus is in close contact with trachea….not so close, but
close

A person had stab to neck. Afterwards he had a swelling in the neck which bulged
even more with coughing and sneezing.
Injury to suprapleural membrane.
Anteriro scalene; doesnt attach to the second rib.
Right recurrent nerve doesn’t enter thorax
Superficial thoracic wall drains to the axillary nodes
Deep wall to intercostal and parasternal nodes
Subcostals are located posteriorly near angle of ribs

Transversus thoracis are located anteriorly.

Cisterna chylii lies opposite L1 and L2 and to the right of abdominal aorta

At T5, it crosses to the left of midline.

Thoracic duct has valves, it also doesn’t drain the right lung, in addition to head,
neck and upper limb.

It is also known as van Hoorne’s duct, pecquets duct, left lymphatic duct,
alimentary duct.

Thoracic vertebra is heart shaped

thoracic lower, cervical upper diagram

Area above suprasternal notch supplied by C3 and C4, not by thoracic nerve.
The thoracic nerve supply the area below the sternal angle.
 ANTERIOR MEDIASTINUM doesn’t contain phrenic nerve.
Both the Subclavian arteries pass behind the SC joint but book has written only
right
Trachea 4cm
length in
neonates
Pulmy vein lies posterior to artery (atleast doesn’t lie anterior)
Azygos enters SVC outside pericardium
Lateral arcuate ligament is continuous with quadratus lumborum and the medial
arcuate liagemnt with the psoas major
Sternum has 3 transverse ridges and thus is made from 4 sternebrae…..
Apex of lung extends 2.5cm above the clavicle.

During child tracheostomy, which will be at risk. Brachiocephalic vein

Trachea has vagus nerve as lateral relation.
SVC obstruction
Innervation of larynx

Thus the trachea is also supplied by RL nerve.

Congenital diaphragmatic hernia:
Failure of the pleuroperitoneal membrane to fuse or form.
The most common site is Left posterolateral. It is usually associated with left
pulmonary hypoplasia.
Artery of Adamkiewicz arises from aorta at T9-12.

The anterior spinal arteries are reinforced along their length by spinal medullary
arteries. The largest spinal medullary artery is artery of Adamkiewicz.

Phrenic nervehas greater contribution from C4.

 Right superior pulmonary vein drains superior and middle lobe
Bronchial artery:
Right arises from 3rd posterior intercostal arteries or from left upper bronchial
artery.

Left bronchial artery arises from the aorta at the level of T5 and left lower
bronchial artery arises at the level of left principal bronchus. I
Xiphoid lies at the level of T10.

Abdomen:
Artery For the medial region:
Superior and inferior epigastric artery.

Laterally:
Intercostal arteries 10th and 11th , and deep circumflex iliac artery.

FOR THE SUPERFICIAL SKIN:

Musculophrenic artery
And the superficial epigastric and superficial circumflex iliac branches of the femoral
artery.

Vein The venous flow passes above into the axillary vein by the lateral thoracic vein and
into the femoral vein below by greater saphenous vein and superficial epigastric
artery.

Nerve Cutaneous nerves supplied by the T7 to T12( the lower six thoracic nerves which
include the lower five intercostal nerves and the subcostal nerve)
And L1 (ilioinguinal and iliohypogastric nerves) which supplies area over the inguinal
ligament and pubic symphysis.

SOME INSIGHT INTO THE PATH;

After leaving the intercostal spaces, the nerves move inferomedially in the abdomen
between IO and TA, pierce the rectus sheath and move behind the rectus muscle,
on reaching the midline, they give anterior cutaneous branches which pierce the
rectus muscle.
Lymph For the superficial aspect:
nodes Above umbilicus to axillary nodes
Below umbilicus to superficial inguinal nodes

For deep:
Parasternal nodes along internal thoracic artery
Lumbar nodes along abdominal aorta
External iliac nodes along external iliac artery.

The SUPERFICIAL FASCIA:

The superficial fatty layer (Camper’s fascia) is continuous with the superficial fascia elsewhere.

The deep membranous layer(Scarpa’s fascia) has certain attachments. It is attached below to the
fascia lata(deep fascia of the thigh) one finger breadth below the inguinal ligament, medially its
attached to the linea alba and pubic symphysis. It moves onto the dorsum of penis and contributes
to the suspensory ligament of penis.
It is continuous with the Colle’s fascia also termed the superficial perineal fascia.

The two fascia fuse over the penis and become the superficial fascia of penis and on the scrotum as
the superficial fascia which houses the Dartos muscle.

The rectus sheath:

The rectus muscle has three tendinous intersections.
1. At xiphoid process
2. Between the two
3. At level of umbilicus

Rectus sheath till the level of ASIS: anteriorly anterior lamina of IO and EO aponeurosis.
Posteriorly posterior lamina of IO aponeurosis and TA aponeurosis. The lower limit of posterior
lamina is the arcuate line.

Below it.
All three aponeurosis move in front of the rectus muscle and join the linea alba.

Linea semilunaris Lateral edge of rectus muscle. Touches the costal margin at the tip of 9th
costal cartilage.
Conjoint tendon It’s the combined tendinous insertion of fibres of IO and TA into pubic crest
and pectineal line(pecten pubis)
Inguinal ligament Lower edge of the EO aponeurosis that is folded upon itself.

The medial edge of the inguinal ligament is attached to the pectineal

line(pecten pubis) in the form of lacunar ligament.

Fascia This fascia is continuous with the fascia covering iliacus and also the fascia
transversalis which lines the abdominal aspect of diaphragm.
The femoral sheath is derived from fascia transversalis.
Deep inguinal ring Defect in transversalis fascia.
1.25cm above midinguinal point
Superficial Defect in EO aponeurosis.
inguinal ring 1.25cm superolateral to pubic tubercle
Inguinal canal Around 4cm passage from deep to superficial inguinal ring.
Inguinal canal Ilioinguinal nerve and the spermatic cord. In females it transfers the round
contents ligament of the uterus.
Hernia The indirect hernia is lateral to the epigastric artery, it has a narrower neck,
more common in males. Seen in young.
One point is that it is medial and superior to the pubic tubercle, while
femoral is inferolateral.

Bubonocele; that hernia which is in the canal

Funicular; not reached the scrotum but out of canal
Complete: reached the scrotum
 Pectineal ligament; these are fibres from the lacunar ligament, which extend
along the pectineal line.

The abdominal regions and planes:

4 region system incorporates the transumbilical pain along with the median plane.
9 region system incorporates the midclavicular plane(extending from the midclavicle to the mid-
inguinal point).
The intertubercular plane: its at the level of the iliac tubercle, 5cm posterior to the ASIS) at the level
of L5.

The subcostal plane: just below the costal margin(which is made by rib 10 and not 12 which are
floating ribs). Its at the level of L3.
Transpyloric plane may also be used; it passes through the tip of 9th costal cartilage. This is at the
level of L1.

The transversalis fascia:

It is continuous with the fascia lining the abdominal aspect of diaphragm, fascia covering the back
muscles like iliacus, and also the pelvic fascia referred to as the parietal pelvic fascia or the
endopelvic fascia.

Extraperitoneal fascia or fat:

This separates the transvesalis fascia and other fascia from the peritoneum. It is present throughout
the abdomen and pelvis, contains the various vessels and thus moves into mesentery.

Some notes from embryology:

Gubernaculum connects the lower edge of developing gonad to labioscrotal swelling. It is converted
into round ligament of uterus.
The processus is anterior to the gubernaculum during descent.

SPERMATIC CORD:
Epiploic foramen: omental foramen/foramen of winslow: CONNECTS LESSER SAC(omental bursa)
AND GREATER SAC.
Anteriorly: portal vein, hepatic artery and common bile duct
Posteriorly: IVC
Superiorly: caudate lobe of liver
Inferiorly: first part duodenum

Greater sac:
It is attached to the greater curvature of stomach, this then goes down as an apron, it then gets
reflected on itself. The posterior layer thus formed as a result of reflection gets adherent to the
peritoneum covering superior aspect of transverse colon and also the transverse mesocolon before
finally blending with the peritoneum covering posterior abdominal wall.
The lesser omentum: derived from ventral mesentery(while greater from dorsal)
It connects the lesser curvature of stomach and first part of duodenum to the inferior surface of
liver. It is divided into parts (arbitrarily) the hepaticogastric ligament and the hepaticoduodenal
ligament. The free inferior edge of the hepaticoduodenal ligament makes the anterior edge of
epiploic foramen.
The omentum contains the left and right gastric arteries near the lesser curvature. The greater
omentum contains right and left gastro-epiploic arteries near the greater curvature.
The mesentery, transverse mesocolon and meso-sigmoid are derivatives of the dorsal mesentery.
Mesentery:
It extends from the DJ and ends at the ileocecal junction. The root of mesentery extends from just to
the left of L2 vertebral body to upper part of right sacro-iliac joint. The length is 15cm.

Transverse Meso-colon: attached to the head and body of pancreas.

Mesosigmoid:
The root is in the shape of an inverted V. the apex of V lies at the level of the common iliac
bifurcation.
The left limb goes along the medial edge of psoas major. The right limb descends from the apex to
the S3

STOMACH:
Diagram showing various parts.

The vasculature of stomach:

Celiac trunk gives the left gastric artery.
Right gastric artery arises from the hepatic artery proper.
Left gastroepiploic artery and short gastric arteries(towards the fundus) are branches of the splenic
artery(a branch of the celiac axis)
Right gastroepiploic artery arises from the gastroduodenal artery which in turn is a branch of the
hepatic artery proper.

Pyloric orifice is just to the right of midline in the transpyloric plane(L1 vertebra level)
SMALL INTESTINE:
General rule, duodenum has the widest calibre, then jejunum and then ileum. It is 6 to 7m in length.

DUODENUM:
20-25cm. only a little proximal part of it is peritoneal-the portion which is enveloped in the
hepaticoduodenal ligament.
1st part Also called the duodenal cap or ampulla.
Extends from the pyloric orifice till the neck of gall bladder.
2nd Descending part
Descends from L1 level till L3 level.
Relations: medially lies the pancreas, anteriorly the root of meso-colon (transverse) and the
right kidney.

Major papilla and minor papilla opens in the medial wall .

The junction between foregut and mid gut lies just distal to the major papilla.
3rd Inferior part:
It crosses anterior to the aorta, IVC and is in turn crossed by the SMA and SMV.
4th part It ascends to the level of L2.
It ends at the DJ flexure.
 Arterial Gastroduodenal artery which is a branch of the hepatic artery proper, gives the anterior
supply and posterior superior pancreaticoduodenal arteries.

SMA gives rise to the inferior pancreaticoduodenal artery which has anterior and posterior
branches. The first jejunal artery also supplies this part of the gut.

JEJUNUM:
Proximal 2/5th lies mainly in the left upper quadrant,
Thicker walls and circular folds of mucosa called the plicae circularis
Less developed arterial arcades and longer vasa recta.
Blood supply through the jejunal branches of SMA.
ILEUM:
Distal 3/5th
Thinner wall, well developed arterial arcades and shorter vasa recta
Ileal branches of the SMA along with the ileocolic artery.

POSTERIOR DU erodes into more commonly the posterior superior pancreaticoduodenal artery(less
so, the gastroduodenal artery)
ANTERIOR DU perforation: causes peritonitis.
Meckel’s diverticulum: remnant of the vitelline duct or yolk sac. It is 2inch long, found in 2% of
population, 2ft from ileocecal junction, 2% of diverticula are symptomatic.

Large intestine:
It is a 1.5m canal.
it has haustra, taenia coli( not present on the rectum), and the appendix epiploicae (fat pouches in
the peritoneum)

appendix locations:

Most common is retrocaecal , then pelvic. Arterial supply is via the appendicular artery which is a
branch of ileocolic artery.

COLON:
The splenic flexure is higher and more posteriorthan the hepatic flexure and is connected to the
diaphragm by phrenico-colic ligament.
Recto-sigmoid junction lies at S3.

The arteries:
Ileocolic artery , right colic artery for ascending colon.
Middle colic is also branch of SMA.
Left colic mainly supplies descending colon and is a branch of IMA.
Sigmoidal arteries branch of IMA.

A marginal artery may be formed by a connection between the arteries.

Rectal arteries:
Superior From IMA
Middle From internal iliac artery.
Inferior from internal pudendal artery.
Diverticular disease of sigmoid:
Sigmoid has the least diameter as far as colon is concerned. And thus a high intraluminal pressure
which can cause diverticulae.
Diverticulitis can have the following complications.
Pelvic abscess.
Inflammatory mass compressing the left ureter.
A fistula with urinary bladder.

Liver: largest of the viscus.

The two associated recesses are continuous anteriorly.
1. Hepatorenal recess(between liver and kidney and suprarenal gland)
2. Subphrenic space ( its divided into right and left by the falciform ligament)
Bare area of liver:
It’s the area on the diaphragmatic surface, where the liver is directly in contact with the diaphragm
without any intervening peritoneum.
The posterior boundary and anterior boundary of the bare area are the peritoneal reflections from
the liver onto the diaphragm called the posterior and anterior coronary ligaments. The junction of
these reflections marks the site of the right and left coronary ligaments.
Caudate lobe On right side is groove for IVC, and on the left side is groove for ligamentum
venosum
Quadrate lobe On right side is fossa for gall bladder nad on left side is groove for ligamentum
teres.
Right and left Divided by falciform ligament and the ligamentjm teres and ligamentum
lobe venosum.

In reality, the lobe is divided by a parasagittal line passing from the fossa of gal,
bladder to IVC.
The eight lobes are divided into Couinad’s segments:

The first segment is caudate lobe.

 Right lobe contains V, VI, VII and VIII

Gall bladder:
Sits in the gall bladder fossa and has a neck, fundus and a gall bladder. The neck has a spiral valve ,
the valve of Heisner. Cystic artery is a branch of the right hepatic artery.
Pancreas:
It consists of the head, neck, body and tail. Uncinate process lies posterior to the SMA and vein,
while the neck lies anterior to the SMA , and the splenic vein joins with the SMV here to form the
portal vein.
The vasculature of pancreas:
Anterior superior and posterior superior pancreatic arteries which are branches of gastroduodenal
artery.
Anterior and posterior inferior pancreaticoduodenal arteries which are branches of the SMA.
Greater pancreatic artery which is a branch of the splenic artery.
Dorsal pancreatic artery which is a branch of the splenic artery.

The pancreas is retroperitoneal in most of its part except for the tail which is enclosed in splenorenal
ligament.

The papillae:
Minor papilla enters duodenum earlier and marks the site of accessory duct.
CBD joins the main pancreatic duct in head of pancreas and forms the hepatopancreatic ampulla of
vater.
Some embryology:
The dorsal bud gives rise to head, body and tail and neck.
Ventral bud gives part of head and uncinated process.

Gastrosplenic ligament: contains the short gastric vessels and the gastro-omental vessels.
Splenorenal ligament: contains the splenic vessels.
The spleen is covered by peritoneum except at the hilum.
PROBABLY: spleen is related to the stomach fundus, the splenic flexure of colon and the left kidney.
Abdominal aorta:
Starts at the aortic hiatus at T12 and bifurcates at the level of L4. At its distal end, it lies slightly to
the left of the midline.
It has anterior branches, lateral branches.
Anterior are celiac, SMA and IMA.
Celiac It arises at upper part of L1.
It has three branches; left gastric artery, common hepatic artery and the
splenic artery.

Left gastric artery is the shortest branch of celiac artery. It ascends along the
lesser curvature till the cardia of stomach where it gives off esophageal
branches and then curves back to descend along the lesser curvature.

Splenic artery: it passes in the splenorenal ligament. In addition to supplying

the spleen, it gives rise to short gastric arteries and the dorsal pancreatic and
great pancreatic artery.

Common hepatic artery:

It gives off hepatic artery proper and the gastroduodenal artery.
Hepatic artery divides into right and left near the porta hepatis. Right hepatic
artery gives rise to the cystic artery.

Gastroduodenal artery:
This gives the right gastric artery and right gastro-omental artery.
Anterior and posterior superior pancreaticoduodenal artery

SMA It arises at the level of the lower part of L1.

Anteriorly lie: the neck of pancreas and the splenic vein
Posterior relations include the uncinate process of pancreas, left renal vein,
and 3rd part of duodenum.

The branches:
1st branch is the inferior pancreaticoduodenal artery.
On right side, middle colic, right colic and ileocolic branches are present in
turn.
On left side, jejunal and ileal branches are present.
 A line in the book states that right colic artery is an inconsistent branch.

The marginal artery which supplies the colon is called the marginal artery of
Drummond.
IMA Arises at the level of L3.
It has the following branches
Left colic
Sigmoid( 2-4 branches)
Superior rectal( this travels in the sigmoid mesocolon to reach the pelvis. On its
way it crosses anterior to the left common iliac artery.

Portal vein:
Splenic vein joins with the SMV behind the neck of pancreas. At the level of L2.
It ascends in the free edge of the lesser omentum to reach the liver.
Tributaries include: right and left gastric veins and paraumbilical veins which accompany the
ligamentum teres.

Splenic vein:
This is present along the splenic artery.
The tributaries include:
Short gastric vein, pancreatic vein, left gastro-omental vein, and IM vein.

SM vein:
Jejunal , ileal branches, ileocolic , right colic and middle colic vein.
In addition, right gastroepiploic vein and inferior pancreatico-duodenal vein.

IM vein: drains the left colic, sigmoid and superior rectal vein.

Some sites of portosystemic anastomosis:

Gastro-esophageal junction: left gastric vein with azygos vein branches.
Paraumbilical: paraumbilical veins with superficial systemic veins
Ano-rectal junction: superior rectal vein with middle and inferior rectal vein.
Lymphatics:
Celiac nodes drain from foregut and likewise, the IM nodes drain to SM nodes which in turn drain to
celiac nodes.
Innervation:
Sympathetic , parasympathetic through the vagus.
SYMPATHETIC TRUNKS:
In the neck lie posterior to carotid sheaths.
In the upper thorax along the necks of ribs,
In the lower thorax along the lateral aspects of vertebra.
In the abdomen, anterior to the vertebral bodies and anterior sacrum.
Finally ending anterior to coccyx as ganglion impar.

The sympathetic input comes from T1 to L2 segments of spinal cord.

Ganglia:
Three cervical, 11-12 thoracic, 4 lumbar, 4-5 sacral, one coccygeal.

Greater splanchnic nerve: carries mainly preganglionic sympathetic fibres and synapses in the celiac
ganglion
Lesser nerve: synapses in the aorticorenal ganglion
Least nerve: ends in the renal plexus.

Lumbar splanchnic nerves:

These nerves end in the prevertebral plexus
Sacral splanchnic nerves:
These end in the inferior hypogastric plexus.
Pelvic splanchnic nerves:
These arise directly from the S2-4 spinal segments and not from the sympathetic ganglia. These are
the only splanchnic nerves which carry parasympathetic fibres. These end up in the inferior
hypogastric plexus and then reach the prevertebral plexus. From there, they supply the
parasympathetic innervation to the hindgut.

ABDOMINAL prevertebral plexus:

This consists of cell bodies of post ganglionic sympathetic fibres , some may be scattered and some
may be arranged in forms of ganglia.

i. Celiac plexus:
this consists of two aortic ganglia, aorticorenal ganglia and SM ganglia.
Travels along the celiac artery and the SM artery.
ii. Aortic plexus:
Extends from the SM artery till the bifurcation of common iliac.
IM ganglion is present in this plexus.

gives secondary plexus which travels along the IM artery, spermatic plexus and the
external iliac artery.
iii. Superior hypogastric plexus: it is the last part of pre-vertebral plexus. It divides into
hypogastric nerves which supply the inferior hypogastric plexus.
NOTE: vagus nerve is for the foregut and hindgut while the pelvic splanchnic nerve innervates
the hindgut and pelvic viscera.
Submucosal plexus is called the meissners plexus while the myenteric plexus is also known as
Auerbach’s plexus.
Ribs XI and XII don’t have any neck or tubercles
Lateral arcuate ligament is thickening of quadratus fascia (T process of L1 to tip of 12th rib)
Medial is thickening of psoas major fascia. ( body of L1 to T process of L1).

Blood supply of diaphragm:

Superiorly musculophrenic, pericardiacophrenic and superior phrenic artery.
Inferiorly inferior phrenic artery.

Psoas muscle sheath: this is of importance because the muscle arises from the IV discs. Tb of the
disc can spread along the muscle as a psoas abscess.

Congenital diaphragmatic hernias:

Morgagni hernia: between the xiphoid and costal cartillages.
Bochdalek hernia: failure of the pleuroperitoneal canals to close leading to a hernia defect. The
most common site is left posterolateral.
 Left dome of diaphragm is at 5th space, while the right dome is at 5th rib(note that rib is higher
than space).

KIDNEYS:
Extend from T12 to L3,
Right is lower than left,
Left is longer, slender and closer to midline,

Dimensions:

Anterior relations:

Superiorly the left rib is related to the 11th rib and 12th rib, right is related to 12th rib.

In addition , posterior relations also include the subcostal vessels and nerves. Ilioinguinal and
iliohypogastric nerves.
The renal fascia:
Kidney is covered by renal capsule, then perinephric fat, and finally the gerota’s or renal fascia.
The gerota’s fascia fate:
Superiorly it covers adrenal gland, then the two layers fuse wih each other and with the fascia
covering diaphragm.
Inferiorly, the two layers enclose the ureter.
Laterally, the layers fuse with each other and with the transversalis fascia.
Medially, the anterior layer fuses with the adventitia of aorta or IVC. The posterior layer fuses with
fascia of the psoas major.

Kidney structure:
Capsule is easily detachable from the kidney except in case of disease processes.
The renal hilum is a slit in the kidney which is continuous with the renal sinus. It possesses a pale
cortex, which sends in bands of tissue into the medulla( the renal columns) dividing the latter into
medullary pyramids. The pyramids open into the minor calyces, major calyces and ultimately the
renal pyramids.

Vessels:
The renal vein is anterior to the renal artery. The urinary pelvis is posterior most.
At the hilum, the renal artery divides into anterior and posterior most.

NOTE that since IVC is on right , the right renal vein is shorter, and the left is longer. It is sandwiched
between SM artery and aorta and can be compressed by aneurysm.
Furthermore, the left renal artery is longer and lies posterior to the IVC.

The ureteric constrictions:

Ureteropelvic junction.
Crossing of common iliac arteries
Insertion into bladder.
Course: travels retroperitoneally along the medial edge of psoas muscle.

Kidney lymphatic drainage: to the lateral aortic nodes.

.
Ureter blood supply:
Superior part through renal artery,
Then gonadal artery
Then common iliac
Thereafter, internal iliac artery in the pelvic cavity.

Ureter innervation:
The visceral afferents go to T11 to L2. Thus the pain is felt in abdomen(loin), pubic region, scrotum
and labia majora.
Adrenal gland:
Right is pyramidal in shape, while left is semilunar in shape. (left is larger)
Relations:
Anterior: liver, and IVC.
Posteriorly: diaphragm

Left gland:
Stomach, pancreas
Posteriorly; diaphragm.

Vessels:
Suprarenal vein drains on right side into IVC, and on left side into left renal vein.
Suprarenal arteries:
Superior arises from inferior phrenic
Middle is branch of thoracic aorta.
Inferior is branch of renal artery.
Suprarenal innervation: from T8-11 via the prevertebral plexus or directly from the sympathetic
trunk.

Aorta:
Bifurcates at lower part of L4 . can be 2.6cm below the umbilicus or a plane passing through the
highest point of the iliac crest.
The abdominal aorta branches:
Posterior branches:
Lumbar arteries 4 pairs
Median sacral artery: arises just proximal to aortic bifurcation and moves anterior to the sacral
bodies and then in front of the coccyx.

Lateral:
Inferior phrenic
Middle suprarenal
Renal

Anterior
Celiac, SMA, IMA and then the paired gonadal arteries.
IVC;
Origins at the level of L5 from confluence of common iliac veins:
Tributaries:
Lumbar veins, common iliac veins
Renal veins
Suprarenal veins
Right gonadal veins
Hepatic veins
Inferior phrenic veins
Relations of the IVC:
The left common iliac artery crosses it anteriorly, then the right gonadal arteries also cross it. Head
of pancreas, 1st part and 3rd part of duodenum are also related to it. Liver is located posteriorly.

In case of IVC obstruction, ascending lumbar veins provide accessory pathway via the azygos and
aceessory hemiazygos vein

Surface anatomy and vertebral levels of various vessels.

The lumbar plexus:
Its located in the substance of the psoas major. The branches are named in relation to psoas major
muscle.
Lateral: iliohypogastric, ilioinguinal(both L1) and femoral nerve (L2-4) and lateral femoral cutaneous
nerve or lateral cutaneous nerve of thigh. (L2,3)
Medial: obturator nerve (L2-4)
Anterior: genitofemoral nerve. (L1,2)

Iliohypogastric nerve Supplies skin of posterolateral gluteal region

plus pubic region

Travels between transversus and IO

Ilioinguinal nerve This pierces the IO to enter the inguinal canal ,
and then exits through the superficial ring.

Supplies
Anterior scrotum, root of penis and medial
thigh
Mons pubis, labia majora in females.
Genitofemoral nerve Genital branch travels through the inguinal
canal. It innervates the cremasteric muscle.
 Skin in upper scrotum. Mons pubis and labia
majora in females.

Femoral branch ; it supplies upper anterior

thigh.
Lateral cutaneous nerve of thigh Supplies anterior and lateral aspect of thigh to
the level of knee.
Obturator nerve This nerve passes through the obturator canal.

Gains access to medial compartment of thigh.

Supplies medial compartment muscles.

Skin of medial aspect of thigh
Femoral nerve This supplies the skin of anterior aspect of thigh
through the intermediate cutaneous nerves.

The saphenous nerve(which is a branch of the

said nerve) is supplies the medial aspect of leg.

Lymphatics:
The two groups of nodes are the pre-aortic nodes and the right and left para-aortic nodes also called
lumbar nodes.
The pre-aortic nodes are connected by a one trunk and the two right and left are connected by
separate trunks(lumbar trunks). The three trunks join at the cisternal chylii.
Pre-aortic nodes(celiac , SM and IM drain foregut, midgut and hindgut)
Para-aortic nodes( kidneys, gonads, suprarenal glands, body wall).

The lumbar plexus:

Femoral nerve L2,3,4 and obturator nerve L2,3,4
Ilioinguinal nerve and iliohypogastric nerve….L1
genitofemoral nerveL1,2
lateral cutaneous nerve of thigh L2,3,4
SNELLS MCQS:

The options are….the inguinal hernia can be strangulated by the lacunar ligament which was
incorrect.

THE UMBILICUS IS inconsistently located but usually at L4.

 the highlighted is the wromg one and
correct answer

All of the non-highlighted in 93mcq are anastomotic pathways.

the highlighted option is correct….

 psoas major lies in between

lateral thoracic vein

the peritoneum completely surrounds

only fundus

E is the wrong one.

 it begins above pelvic brim
Renal medulla has approx. 12pyramids.

Sigmoid colon receive sympathetic innervation from L1 to2 .

Mcq book:
Which one is present in the peritoneal cavity:
Fallopian tube, ovary, proximal part of duodenum and round ligament of uterus . round ligament of
uterus is not present, all of the rest are present.

An option was there, left ureter lies in sigmoid mesocolon, which was wrong, the root however
crosses left ureter.
Root of mesentery passes over 3rd duodenum
Cystic artery is present in lesser omentum( hepatoduodenal ligament to be precise)

All are lesser omentum contents except

short gastric artery
Gastroepiploic artery.
Lesser omentum is posteriorly:
So in short, posterior wall comprises of pancreas, left kidney and adrenal, commencement of
aorta.
Neither right kidney nor the right adrenal are posterior relations.

Morrisons pouch:
It is the hepatorenal pouch. Or right subhepatic space.

Internal spermatic fascia is derived from transversalis fascia

During femoral hernia repair swelling appears at the operation site, what is the injury
Femoral vein

What passes behind inguinal ligament:

Psoas major and also femoral branch of genitofemoral nerve.
Spermatic cord starts at deep ring and goes to scrotum.
Skin of superficial gluteal region goes to superficial inguinal nodes.
Superficial inguinal nodes are grouped into proximal group (which may be termed horizontal
group )which drains buttocks, external genitalia, scrotum, labia majora.
Distal group drains the lower limb.
Processus vaginalis arises from parietal peritoneum.
Covers testis and epididymis as tunica vaginalis. The initial portion obliterates, thus the spermatic
cord is not covered.
TRANSPYLORIC PLANE:
Location: lower part of L1 or L1/2 disc,
Tip of 9th costal cartilage is also present at this point.
DJ flexure
Origin of SMA
portal vein origin
Pylorus(occasionally)
Hilum of left kidney (right kidneys is slightly lower)
Origin of renal arteries
Termination of spinal cord.

Truncal vagotomy decreases acid secretion and is a treatment for duodenal ulcers.
After cholecystectomy surgeon places drain in right subhepatic space.
During esophagectomy , the stomach is mobilized, which vessel is protected.
Right gastroepiploic is the main artery. Right gastric may also be involved in some extent.
The first and second part receive supply from right gastric, right gastro-epiploic, hepatic,
supraduodenal
Main arteries of duodenum are superior and inferior pancreaticoduodenal arteries.
Paraduodenal recess contains gthe Inferior mesenteric vein
Ileocolic intussusception is the most common variety.
Obturator sign is seen with pelvic appendix.
Ascending colon has mesentery in 25% of patients .( from radiopedia)
The cecum is 6cm in length
Pathology wants to inject dye into liver, he will reach through
Hepatoduodenal ligament.
Structure between celiac trunk and SMA, pancreas
Liver is 2% of body weight. Around 1.5kg.
Splenic dimension; 9-14cm long
Floating spleen or wandering spleen:
The ligaments are lax and the spleen can go down and exert rectal as well as bladder symptoms.
Which is not present in the lesser omentum
Left hepatic duct is extrahepatic and may be included
Hepatic plexus surrounds the vessels.
Head of pancreas lies anteriorly to IVC.
COMMON bile duct is 6-8cm long and has a diameter of 7mm, it lies on right of hepatic artery.

Hepatic zones:
CBD supply:
Mainly through right hepatic artery reinforced by the cystic artery.

Additional arteries are posterior superior pancreaticoduodenal artery and retroduodenal artery.
(which supply lower part).
Pancreas:
Posterior relations:
Splenic vein, left kidney, left crus of diaphragm

Splenic artery is superior

Grey turner’s sign: bruising in flanks
Cullen sign: bruising around umbilicus
Upper poles lie more medially than lower poles.
Ilioinguinal nerve is a posterior relation of kidney.
Splenic vein lies posterior to body of pancreas
Portal vein is formed at NECK not body.
Left renal vein crosses below SMA
Gall bladder lymphatic supply:
Gall bladder and cystic duct drains into cystic node, from where lymphatics pass along free edge
of lesser omentum to celiac nodes.

Hepatic ducts and superior BD can send lymph to hepatic nodes in porta hepatis. Then to celiac
nodes.
Proximal CBD sends to celiac nodes directly.
Renal artery divides into anterior and posterior divisions before hilum, then a total of five
segmental arteries arise, then lobar(12 in number to each pyramid) and then interlobar, arcuate
and finally interlobular.

Fetal gland is proportionally larger, the neonatal is also larger, it regresses in few weeks to normal
infantile size. The cortex mainly involutes.

Cortex derived from celomic epithelium

Adrenal glands separated from kidney by small amount of fibrous tissue.
Ureter enters the pelvic brim at the end of common iliac or start of external iliac.
The gonadal arteries cross ureter anteriorly, while the common iliac artery lies posteriorly.

Ureter passes through broad ligament, is closely related to cervix , vaginal fornix.
Uterine artery is for some portion above it, but then crosses it anteriorly.
Ureter derives sympathetic supply from T10-12, and L1 and S2to4 through aortic plexus, superior
and inferior hypogastric plexus.
Right renal artery crosses in front of IVC
IVC lies in the bare area of liver.
Spleen doesn’t arise from endoderm, it’s a mesoderm derivative
Stab wound inferolateral (right side) to umbilicus may injure IVC
Mcq:
Which doesn’t pass from left to right
Hemiazygos, left brachiocephaliac and left renal vein do cross
Left gonadal vein slightly deviates to the right, but in essence doesn’t cross the midline, eventually
ending up into the
Left umbilical vein persists while the right disappears during development.
Right vitelline vein contributes to the portal vein.
Adrenal gland supplied by greater splanchnic nerve
Left gastric artery doesn’t reach out to the fundus. It just supplies lesser curvature and gives
esophageal branches.
Spleen:
Has a fibrous capsule( whether it is tough or not is not known)
Accessory spleen can be found anywhere , most common site is near hilum in gastrosplenic
ligament or greater omentum.
Transversus abdominus and IO are supplied by T7-12 and L1 intercostal, subcostal , along with
Rectus and EO by T7-12 intercostal and subcostal nerves.
Superficial epigastric artery arisies from femoral artery.
Free end of small intestine occupies left infracolic compartment( rubbish logic)
Thoracic duct is 45cm long (no source found)
Most difficult complication after billroth surgery is dumping syndrome.
Gall bladder has no submucosa, mucosa has folds which are flattened out when bladder is
distended.
Liver lymphatics: (superficial and deep lymphatics are seen)
Most of inferior, anterior and superior surface to hepatic nodes at porta hepatis.
Most of deep liver lymphatics also drain to hepatic nodes.

Posterior surface nodes around

NOTE:
As we move from duodenum to jejunum to ileum,
The thickness decreases, and the length increases(jejunum is 2/5th while ileum is 3/5th).
Structure immediately medial to femoral hernia is lacunar ligament.
Tendinous intersections of rectus
Column of bertin: renal columns of bertin….cortex extensions in medulla.
Review of renal supply:
Anterior and posterior divisions, then five segmental arteries.
Lobar arteries to each pyramid, then interlobar arteries which travel in renal columns, then at
corticomedullary junction arcuate arteries, then radial arteries (interlobular arteries)
Structure between T12 and L1 is pancreas,
Other options were duodenum, which is at L1 because pylorus is at L1,
Then jejunum which was outright wrong as was kidney.
Lumbar hernia from inferior lumbar triangle.
Superficial external pudendal emerges from saphenous opening/hiatus

Transversus abdominus….
Insertion into linea alba, pubic crest and pectineal line
Fetal liver is 5% of the body weight . that cant be confirmed. However, 4-5% weight is there at
infancy.
Volkman’s canal
 Lumbar sympathectomy:
Which ganglion be spared. L1
Which branch of renal artery supplies glomerulus.
interlobular
The jejunum offers feathery appearance on barium

Pelvis and perineum:

The bones fuse at the acetabulum at 16-18Y of age.
The arcuate line separates the upper and lower parts of the ilium, with the lower part forming the
portion of the pelvic cavity.
The tubercle of iliac crest and iliac tuberosity are two things. Iliac tubercle is a commonly known
thing.
Pubic bone: this bone’s superior surface is called pubic crest.
Superior ramus: it bears a superior border termed pectin pubis or pectineal line which is continuos
with the linea terminalis or arcuate line. The inferior border of the ramus bears the obturator
groove.

Sacrum:
This has anterior and posterior sacral foramina for anterior and posterior rami respectively.
It has an ala, promontory. Sacral hiatus at the posterior surface.
Coccyx:
It has no vertebral canal, consists of 4 vertebrae.
One cornu on each side, rudimentary transverse process.

Lumbosacral joint:
It consists of an intervertebral joint along with two zygapophyseal joints between superior facet of
sacrum and inferior facet of L5.
Ligamentous support: iliolumbar and lumbosacral ligaments between transverse process of L5 to
ilium and sacrum.
Anterior part of the IV disc is thicker than the posterior part due to posterior angulation of sacrum.
Sacroiliac joints:
These are synovial joints between articular facets of the iliac bone and sacrum. They tend to fibrose
with age or even ossify.

Pubic symphysis: the bony surfaces are lined by hyaline cartilage, and there is a fibrocartilage in
between.
Gender difference between pelvis

Three bony rings. The bony inlet and the two obturator foraminae
4 fibro-osseus rings: the greater and lesser sciatic foramina made by sciatic notches and ligaments.

The ligaments of pelvic girdle:

Contents passing through various foramina:
Greater sciatic:
Above piriformis; superior gluteal vessels and nerves

Below: inferior gluteal vessels and nerves

Internal pudendal vessels and pudendal nerve
Nerve to obturator internus
Lesser sciatic foramen:
It doesn’t communicate with pelvic cavity, its rather a gateway between gluteal region and
perineum.
THE ATTACHMENT OF PELVIC DIAPHRAGM IS SUCH THAT LESSER FORAMEN IS BELOW IT AND
GREATER IS ABOVE IT AND THUS RELATED TO PELVIC CAVITY.
Internal pudendal vessels and pudendal nerve
Nerve to obturator internus pass through it ( they pass through both lesser and greater sciatic
foramen)
Obturator foramen:
Obturator nerve and vessels.
Pelvic outlet

The pelvic floor:

Consists of pelvic diaphragm, perineal membrane and muscles of deep perineal pouch.
Pelvic diaphragm consists of the coccygeus and levator ani.

The parts of the levator ani:

Pubococcygeus:
Arises from posterior aspect of pubis body.
It has three parts
Puboprostaticus, pubovaginalis and puboanalis.
Puborectalis: forms a sling around rectum
Maintaining an angle called the perineal flexure.
Iliococcygeus: it arises from the tendinous arch on the obturator internus fascia.

The anorectal angle and defecation:

The puborectalis keeps this angle at 90 which acts as a pinch valve, during the process the muscle
relaxes and the angle increases to 130-140.
During defecation, the anal canal descends and goes back.
The circular muscle of rectum propel the feces out, the longitudinal muscle acts to bring the rectum
back in place.
Perineal membrane:
This is a triangular fascial structure located in the subpubic arch. the posterior margin is free. There
is a space between pubic arch and the anterior margin of the membrane. It has openings for urethra
and vagina. It provides attachment to external genitalia.
Above the membrane is a space which contains perineal muscles. This is called the deep perineal
pouch.

Muscles in the deep perineal pouch:

External urethral sphincter
Compressor urethrae and sphincter urethrovaginalis are two other muscles present in this pouch in
females. All three contribute tourinary continence in females.
Deep transverse perineal muscles.
Perineal body:
A connective tissue structure in midline.
Has attachments of superficial and deep transverse perineal muscles, external anal sphincter,
bulbospongiosus and perineal membrane.

Rectum:
It immediately lies anterior to sacrum and follows its concavity. It has three lateral curvatures as
well, upper and lower to the right and middle one to the left. The distal part is expanded and called
rectal ampulla. It lacks taenia, haustra and appendix epiploicae.
ANAL CANAL:

The anal canal has longitudinal folds called anal columns which are joined by crescentic folds called
anal valves. Between canals and columns lie the anal sinuses.
Pectinate line: line of anal membrane , end of hind gut, made from anal valves.

Anal Pecten: transition zone having non keratinized stratified squamous epithelium. Lies between
pectinate line and anocutaneous or white line.
White line is where keratinized epithelium starts.

Urinary bladder:
This is in the form of an inverted pyramid. It has two inferolateral surfaces and a superior surface
and a base together with an apex.
The base is directed posteriorly and has the trigone in it. The bladder trigone has a smooth mucosal
surface that is closely adherent to the bladder wall. The mucusa elsewhere has folds and is not
adherent to the bladder wall.
The neck of the urinary bladder is the most fixed part of the bladder, which is held in place by
ligaments. Pubovesical ligament in females and the puboprostatic ligament in males(because the
prostate surrounds the bladder neck).
Denonvilliers fascia lies between bladder and rectum and is formed by the obliterated rectovesical
pouch.

THE BLADDER IS ABDOMINAL IN CHILDREN AND DESCENDS WITH AGE SO THAT IT IS PELVIC IN
ADULTS.
Urethra:
The urethra is around 4cm long in females. It opens at the vestibule, anterior to the vagina. Skene’s
gland are a pair of paraurethral glands.
Male urethra:
Its 20cm long. At first bend, it turns anteriorly and at the second turns inferiorly( the second turn
straightens during erection)

Parts:
preprostatic It is around 1cm.
There is an internal urethral sphincter around it which prevents retrograde
ejaculation.
prostatic Around 4cm.
It bears a midline mucosal elevation called the urethral crest.
At either side of this crest are the prostatic sinuses,which house the
openings of the prostatic glands’ ducts.
The crest is enlarged in the middle where its referred to as the seminal
colliculus, it is a landmark for prostate during TURP.
 membranous It passes through the perineal membrane and the deep perineal pouch.
It bears the external urethral sphincter
Spongy urethra It is enclosed in the corpus spongiosum.
It has two dilations or bulbs, one at the base , this bulb has the openings of
the bulbourethral glands, while another bulb is the navicular fossa which is
near the end.

Bulborethral gland is present in the deep perineal pouch.

The testes:

The testes are surrounded by a thick capsule called tunica albuginea.

The channels:
Spermatic cords, straight ducts, network of ducts called rete testes located in the mediastinum
testes. Efferent ductules which open into head of epididymis.

Epididymis:
It consists of essentially two parts.

During passage through epididymis, spermatozoa acquire the ability to move. It also stores
spermatozoa.

Ductus deferens:
It connects the epididymis to the ejaculatory ducts.
After ascending through the scrotum and inguinal canal, it arises out of the deep ring lateral to
inferior epigastric artery, then enters the pelvic cavity crossing the external iliac vessels. It runs along
the wall of the pelvis. It crosses ureter near the bladder. It dilates near its end to form the ampulla.
Lastly , it joins the duct of seminal vesicle to form the ejaculatory duct which passes into the
prostate.

Seminal vesicle: these arise as outgrowths of the ductus deferens and lie immedialtely lateral to it at
the base of the bladder. It contributes significantly to the volume of the ejaculate.
Prostate:
It develops from 30-40 glands which develop from the urethral epithelium, these glands grow into
the urethral walls which grow and ultimately the epithelium and CT in the walls forms the prostate.
The glands retain their individual openings.

The ovaries:
These are located high in the abdomen , and then migrate onto the lateral pelvic walls just below the
pelvic inlet. They are suspended by a posterior extension of broad ligament called the broad
ligament. The egg is released into the peritoneal cavity which is then taken up by the uterine tubes.
Uterine tubes:
They have an infundibulum with fimbria, then ampulla which is dilated and is the site of fertilization
and the isthmus. Then there is the intramural part(located in uterine body).

Angle of anteflexion is between cervix and uterus.

Anteversion is between cervix and vagina.

Vaginal vault: the superior part of vagina which is dilated and encloses the cervix.
The vaginal fornices: 4 in number , anterior posterior and tow lateral.

The uterine supports:

Levator ani, perineal body, perineal membrane.
Three ligaments: anteriorly pubocervical, transverse cervical or cardinal( most important), and
posteriorly uterosacral ligament.
The rectovaginal septum is the fascia between vagina and rectum
Fascia in men:
The prostatic fascia surrounds the prostate anteriorly and laterally, while the rectovesical septum
surrounds it posteriorly and separates it and the bladder base from rectum.

The umbilical folds of peritoneum:

Median covers urachus
Medial covers the remnants of umbilical arteries.
Rectum and peritoneum:
Upper third, anterior and lateral walls
Middle third; anterior walls only
Lower third, no peritoneum.

Rectouterine folds:
These folds are lateral extensions of rectouterine pouch of douglas which lie superiorly to the
uterosacral ligaments.
The broad ligament:
This ligament has three parts.
Mesometrium
Mesosalpinx: most superior part
Mesovarium: arises from the posterior aspect of the broad ligament.

INFUNDIBULOPELVIC LIGAMENT or suspensory ligament of ovary:

The ovarian arteries and veins reach the superior surface of the ovary through this ligament, it
contains the vessels enclosed within peritoneum.
Ligament of ovary:
It connects to the inferior pole of the ovary and continues as the round ligament of uterus. It is a
remnant of the gubernaculum.

Sacro-coccygeal plexus:
Pudendal nerve:
Formed by the ventral divisions of S2,3,4
 sciatic
Superior gluteal L4 to S1
Inferior gluteal L5 to S2
Nerve to obturator internus
and gemellus superior L5 to
S2
Quadratus femoris and
gemellus inferior . L4 to S1
Tibial nerve:
L4 to S2, dorsal division
Hamstring muscles except biceps’ short head, and posterior
compartment of the leg
Common fibular nerve
L4 to S3, ventral division
Supplies the short head of biceps femoris, and anterior and lateral
compartment of leg
Gluteus medius and minimus
Gluteus maximus
Passes through greater foramen and also through lesser foramen
Pass below piriformis through greater foramen and enter the
gluteal area and lower limb.

Posterior cutaneous nerve

fo thigh S1 and S3
Perforating cutaneous nerve It passes through the sacrotuberous ligament and not through any
foramen.

Coccygeal plexus
Main contribution from S5 and Co , which arise below the pelvic
floor, then penetrate the coccygeus muscle to enter pelvic cavity,
here they are joined by S4 and anococcygeal nerve is thus formed.
It penetrates through the muscle to supply the skin of the anal
triangle.

Sacral sympathetic chain:

It lies anterior to the sacrum and has 4 ganglia, and medial to the anterior sacral foramina. It
communicates with the sacral nerves via grey rami communicantes.
The two trunks join on the ganglion impar which lies anterior to coccyx.

It also sends branches to the pelvic plexus , the sacral splanchnic nerves.

Pelvic part of prevertebral plexus:

The superior hypogastric plexus which lies anterior to L5 body, divides into two branches, the
hypogastric nerves. These nerves are joined by the pelvic splanchnic nerves and the resulting plexus
is called the inferior hypogastric plexus.
It gives off the following subsidiary plexuses.
Rectal
Uterovaginal
Prostatic
Vesical.

Cavernous nerves which supply the erectile tissue of the penis arise from the prostatic plexus and
pass through the deep perineal pouch and reach their target organ. In females, clitoris is likely
supplied by uterovaginal plexus.

Functions of the sympathetic and parasympathetic plexuses briefly:

SNS: the root level is T10-L2, which reaches the pelvic plexus through hypogastric nerves and also
through sacral splanchnic nerves.
Contraction of internal urethral and anal sphincter.
Ejaculation

PNS: contraction of bladder

Erection

Internal Arises from common iliac between L5 and S1.

iliac
artery It divides into anterior and posterior trunks at the level of superior border of greater
sciatic foramen

posterior trunk has following branches:

Iliolumbar artery (which divides into an iliac branch and a lumbar branch as well).
Lateral sacral arteries( 2 in number, enter the anterior sacral foramina and supply the
structures in the veterbal canal and surrounding bone).
Superior gluteal artery: largest branch of internal iliac artery.
Anterior trunk:
1. Umbilical artery:
It gives rise to the superior vesical artery. Distal to the origin of the superior
vesical artery, the artery fibroses and forms the medial umbilical ligament,
the peritoneal fold overlying it is the medial umbilical fold.
2. Inferior vesical artery/ vaginal artery( in females)
3. Middle rectal artery.
 4. Obturator artery(passes along with the nerve and vein to the adductor region
of thigh.
5. Internal pudendal artery: passes through the greater foramen below
piriformis and then through lesser foramen, then enters the perineum.
6. Inferior gluteal artery: it is a large terminal branch of the anterior trunk.
7. Uterine artery: it travels in the broad ligament to reach the uterine cervix,
then ascends at the lateral aspect of uterus, it moves along the tubes and
finally anastomoses with branches of the ovarian artery.
NOTE: the uterine artery and the ovarian artery enlarge during pregnancy to enhance
the blood flow.

Median sacral artery:

It arises from the aorta prior to its bifurcation. It gives rise to the last pair of lumbar
arteries.

Deep dorsal vein of penis or clitoris:

It passes through the gap between perineal membrane and pubic arch to enter the
prostatic plexus of veins or vesical plexus(in females).

Superficial skin of penis and clitoris drains to external pudendal vein which is a
tributary of great saphenous vein.
Rectal venous plexus:
Median sacral vein drains either into the left common iliac vein or junction of common iliac veins

LYMPHATICS:
Most of the pelvic viscera drain to internal iliac and external iliac nodes, then lateral aortic nodes
and finally cisterna chylii.

Perineum:
A diamond shaped region with following boundaries.
Ceiling formed by levator ani
Pelvic outlet forming the peripheral boundaries.
Lateral walls are of little height and are formed by the pelvic walls below the attachment of levator
ani.

Its divided into urogenital and anal triangle by an imaginary line passing between the ischial
tuberosities. This imaginary line is also the posterior extent of the perineal membrane. Furthermore,
the midpoint of this line is the site of perineal body.

ischio-anal fossa: these are fat filled gutters formed between the lateral pelvic wall(ischiopubic
ramus, obturator internus) laterally and the levator ani medially.

The external anal sphincter has three parts: deep , superficial and subcutaneous
Superficial perineal pouch:
It lies between the perineal membrane and membranous layer of superficial fascia. It contains the
roots of the penis and clitoris and the muscles which surround them.

Female erectile tissue:

Corpora cavernosa arise from the pubic arch through the crura, these then join and form the body of
clitoris.
Bulbs of vestibule surround the vaginal opening, and contribute to the formation of glans clitoris.
They are the equivalent of corpus spongiosum.

Greater vestibular glands: these are the equivalents of bulbourethral glands, but the latter are found
in deep pouch and the former in superficial pouch.
Ligaments of the penis:
The fundiform ligament penis; extending from the linea alba to encircle the penis and uniting
inferiorly.
Suspensory ligament of the penis; extending from the pubic symphysis to attach to dorsal aspect of
penis.
The muscles of the superficial perineal pouch:
Superficial transverse perineal muscles along with the bulbospongiosus and ischiocavernosus.

SUPERFICIAL FASCIA OF the urogenital triangle:

The deep membranous layer is called Colle’s fascia. It is attached posteriorly to the perineal
membrane, thus the anal triangle doesn’t have this layer. Laterally, its attached to the ischiopubic
rami. It is continuous with the Scarpa’s fascia of the anterior abdominal wall. It encloses the penis,
scrotum, labia and clitoris.
Sites of urethral rupture/injury:
The pudendal nerve: it runs in the pudendal canal with internal pudendal artery and gives the
following branches:
Inferior rectal: which supplies the external urethral sphincter
Dorsal nerve of penis: which is sensory; mainly to the glans.
Perineal nerve: which supplies the muscles of the superficial and deep perineal pouch.

The internal pudendal artery:

It’s the main artery of perineum;
It has inferior rectal artery and perineal artery.

Distal artery has following branches:

Artery to bulb of penis(bulb of vestibule in females); supplying bulb and the corpus spongiosum
Urethral branch: penile urethra
Terminal branches: deep artery and dorsal artery. The former enters the crura and supply the corpus
cavernosa, the latter runs on the dorsal aspect of penis and supplies the glans.

External pudendal artery: a branch of femoral artery.

The veins usually accompany the arteries:
The deep dorsal vein of penis drains the corpora cavernosa and glans and enters the prostatic plexus
and vesical plexus (in females).
External pudendal vein drains into femoral vein , superficial dorsal veins of penis drain into external
pudendal vein.

LYMPHATICS:
Deep perineum Internal iliac nodes
superficial penis Superficial inguinal and external iliac nodes
and clitoris,
scrotum and
labia majora
Glans penis, Deep inguinal nodes
Glans clitoris,
terminal vagina
and labia
minora

Mcq book:
A block of sympathetic innervation will cause loss of pain and filling sensation
Pelvic splanchnic nerves arise from S2-4 (with 4 being variable) . S1 has absolutely no role.
Posterior divisions of sacral plexus:
The superior and inferior gluteal nerves

The superior and inferior gemellus nerves are ventral divisions.

NOTE: the sacral plexus is formed from anterior rami of the spinal nerves, which divide into
anterior and posterior divisions.
Female pelvis w.r.t spine is tilted forwards.
Hirschsprung disease; involves pelvic splanchnic nerve????
Its just the absence of intestinal ganglion cells.
Absence of the afferents of bladder will cause
Overflow incontinence,

Hemoperitoneum causes guarding of the muscles because the parietal peritoneum is innervated
by the ilioinguinal and iliohypogastric nerves , which also innervate the abdominal muscles.
Trigone tumor spreads to external and internal iliac nodes.
For bladder

DDDDDDDDDDDDd
Ccccccccc

A is wrong because it relaxes….

AAAAAAAAAAA

Fetal head is occipitoanterior after internal rotation which is due to levator ani muscle.

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Prostate mets to skull due to vertebral venous plexus
Pouch of douglas can be approached most efficiently through posterior fornix of vagina.
Other approach can be anterior rectal wall
Narrowest part of male urethra is at the external meatus

EEEEEEEEEEEEEEEE
Internal anal sphincter receives blood supply from hypogastric plexus

Deep inguinal
Prostate cancer spreading to internal iliac nodes
Cervical spreading to internal and external iliac nodes

Prostate lobes
Supports of vagina from snells

UROGENITAL DIAPHRAGM
Mcq:
In males internal iliac nodes are not palpable on DRE,
Bulb of penis, seminal vesicles and prostate are

Rectum nerve supply

Uterosacral ligaments can be palpated through the per rectal examination

Incontinence after LSCS may be due to vesicovaginal fistula,
Ureteric injury is not common during C section.
Anorectal ring
Coverings of testes:
Skin dartos, external spermatic fascia, cremaster, internal spermatic fascia
Tunica vaginalis, tunica albuginea, tunica vasculosa.

Venous drainage of the penis:

Superficial system: consists of the superficial dorsal vein which drains into GSV via external
pudendal vein

Intermediate system consists of the deep dorsal vein and the circumflex veins which drain into
prostatic plexus. It drains the distal two thirds of penis and corpora cavernosa

Deep system drains the proximal third of the penis and consists of cavernosal veins, it ultimately
drains into the internal pudendal vein.

Which muscle is cut during episiotomy:

Bulbospongiosus and superficial transverse perineal muscle.

Pain on defecation; the sensory supply for the skin is via the pudendal nerve, while the pain due
to stretch will be from autonomic nerves.

More specifically, the inferior rectal branch of pudendal nerve.

Lymph drainage from perianal skin:
Ischiorectal abscess drainage:
Injury to inferior rectal nerves may be there.
Urogenital diaphragm is attached to the ischiopubic ramus exactly, the MCQ in book had pubic
arch and ischial ramus as optipons
Urogenital diaphragm is formed by all of the following except
Colles fascia- the answer.

Other options: deep transverse perineal muscles , perineal membrane, sphincter urethrae.

AP diameter of pelvic outlet is 13.5cm, transverse is 11cm

Midcavity has both diameters equal and at 12cm
Least common site of ectopic pregnancy.
Tube > ovary and abdomen> cervix> cesarian scar. So cervix should be least common site
Uterine
Vagina lymphatics:

Uterus lymphatics:

Lymph passes to the superficial inguinal nodes through lymphatics along round ligament.

In addition, obturator nodes are an important group of nodes not mentioned in snells.
Mackenrodt’s ligament is cardinal ligament.
Suspensory ligament is the infundibulopelvic ligament which carries the ovarian vessels.
Ovarian fossa:
MCQ: which structure likely to be injured during surgery for ovarian mass buried in ovarian fossa,

Answer written is internal iliac vessels

Why not obturator artery.
Wrong regarding vas deferens:
Crosses ureter in region of ischial spine
Separated from base of bladder by peritoneum

Shotgun perineum is a congenital anomaly in women.

Females do have an internal urethral sphincter

What is not a vaginal sphincter:

Bulbospongiosus, pubovaginalis
External and internal urethral sphincter: I believe these two are not vaginal sphincters.

Bar of mercier

Trigone is not developed from the urogenital sinus rather it arises from the incorporation of
mesonephric ducts in the urogenital sinus.

Bladder is supplied by the vesical plexus which is an anterior division of the inferior hypogastric
plexus. It consists of fibres from the sympathetic plexus via inferior hypogastric nerves and
parasympathetics from the pelvic splanchnic nerves.
Bladder afferents are more carried by parasympathetics than sympathetics. A minor detail from
Gray’s.
Types of pelvis in females:

Gynecoid>android> anthropoid> platypelloid.

Prostate: this weighs 8g in puberty.
The BPH gland is 40g and above.

The main bulk of the gland is made by lateral lobes.

Pelvis with narrow subpubic angle and inverted spines

Android pelvis likely…..
Nerve damage in lateral pelvic wall.
Pudendal or obturator?

Pudendal canal is located in the ischiorectal fossa. Which is below the true pelvic cavity.
Rectum distension sensations carried in visceral afferents. May be parasympathetic.
True conjugate is also called anatomic conjugate.

Lateral fornix of vagina is related to ureter.

Mediolateral episiotomy is made to prevent injury to external anal sphincter.
CA rectum first drains para-rectal nodes.

The rectum and anal canal till dentate line drains to para-rectal nodes , which drain to nodes along
superior rectal artery and finally to pre-aortic nodes.

Lower rectum drains also to internal iliac nodes via lymphatic channels that accompany the
inferior and middle rectal arteries into internal iliac nodes.

Lower anal canal drains to inguinal nodes.

Vagina lymphatic below hymen is to medial group of superficial inguinal nodes.

Ovarian tumour pain referred to thigh by obturator nerve. This nerve lies in the ovarian fossa.
 Epididymis is covered partly by tunica vaginalis.

Testes and epididymis are supplied by testicular artery. Artery to ductus deferens and cremasteric
artery have minor contributions.

Lower limb:
Diagram showing the three gluteal lines and

Type of pelvic fractures:

Angle between shaft and the neck of femur:
125 degrees.

Bony features of the femur:

The head has a central pit called FOVEA CENTRALIS for the ligamentum teres.( this is non-articular).
The greater trochanter and lesser trochanter are connected anteriorly by the intertrochanteric line
and posteriorly by the intertrochanteric crest.
The crest bears a quadrate tubercle for attachment of quadratus femoris.

The linea aspera; it’s a line on posterior aspect of femus, superiorly it diverges into a pectineal
line(spiral line) and the gluteal tuberosity to which the gluteus maximus inserts.

SOME INSERTIONS:
Lesser trochanter: iliopsoas muscle.
Greater trochanter: the lateral surface provides attachment to the gluteus medius and minimus.
medial surface to obturator externus, internus and the gemelli. And also the piriformis.

Intertrochanteric fractures.

HIP JOINT:
The acetabular area is enhanced by the fibrocartilage called acetabular labrum. The acetabular notch
is converted into an acetabular foramen by the transverse acetabular ligament.

Ligamentum teres: this carries a branch of the obturator artery.

The synovial membrane is attached to the margins of articular surface of the femur and acetabulum.
Interestingly, the membrane after its attachment to the head of femur goes down to the neck of
femur and then reflects back to attach to the acetabular margin.

The fibrous joint capsule:

Its attached to the acetabular margins, transverse acetabular ligament and laterally to the
intertrochanteric line anteriorly and just proximal to the intertrochanteric crest posteriorly.
Its supported by three ligaments;
Iliofemoral: attached to ilium between AIIS and acetabular margin, to femur at the intertrochanteric
line. It has a Y shape due to a thinner attachment at the central part of the intertrochanteric line.
Pubofemoral: from iliopubic eminence
Ischiofemoral: supports the posterior aspect of the joint capsule, extends from ischium
posteromedial to the acetabulum and inserts onto greater trochanter.

Arterial supply of hip joint:

Medial and lateral circumflex femoral artery ( branches of profunda femoris artery)
Superior and inferior gluteal artery
Obturator artery
First perforating branch of profunda femoris artery.

Inguinal ligament is the demarcation line between femoral and external iliac vessels.
Great saphenous vein drains into femoral vein, while the short saphenous vein drains intopopliteal
vein. Popliteal vein becomes the femoral vein superior to the knee joint.

Lymphatics:
Superficial inguinal Lie along the inguinal ligament and drain into external iliac nodes
nodes
Drain gluteal region, perineum, lower abdomen and superficial regions
of lower limb.
Deep inguinal nodes Lie along the femoral vein and drain into external iliac nodes.
Drain the lower limb as well as the glans
Popliteal nodes

Fascia:
The fascia lata is the deep fascia of the thigh and gluteal region, it merges inferiorly with the deep
fascia of the leg.
Iliotibial tract: thickening of the fascia lata. Superiorly it is associated with two muscles tensor and
the gluteus maximus. Its proximal attachment is to the iliac tubercle and inferiorly to below the
knee.

Saphenous opening:
An opening in fascia lata through which GSV passes.

Femoral triangle:
Base: inguinal ligament
Lateral boundary: medial edge of Sartorius
Medial boundary: medial edge of adductor longus

The involved muscles or contents: iliopsoas, pectineus and adductor longus muscle.
Femoral vein, artery , nerve are the contents
Femoral sheath:
This sheath is made from iliacus fascia anteriorly and transversalis fascia posteriorly.
It has three compartments, enclosing artery, vein and lymphatics. The medial most compartment
,which contains the lymphatics, is called the femoral canal.

Trendelenberg sign:
A positive sign is seen in superior gluteal nerve injury which affects the gluteus medius and minimus.
When you stand on the affected side, the other side drops.

Gluteal region:
The deeper muscles like piriformis, quadratus femoris, obturator internus and gemelli are lateral
rotators of the thigh.
The gluteal muscles are extensors, and lateral rotators and abductors.

NOTE: gluteus maximus; superficial part attaches to the iliotibial tract, while the deeper part
attaches at the gluteal tuberosity of the femur.
Anecdote about superior gluteal artery:

The superior and gluteal veins drain into pelvic plexus of veins.
They are also connected to the superficial gluteal veins which drain into femoral vein.

LYMPHATICS OF GLUTEAL REGION:

Deep lymphatics drain into internal iliac nodes, while superficial drain into superficial inguinal
nodes.
Thigh:
Its superior border is inguinal ligament anteriorly and the gluteal fold posteriorly. This corresponds
to inferior margin of gluteus maximus and quadratus femoris.

FEMUR:
Mid shaft has 3 surfaces anterior , medial and lateral
Proximal and distal has 4 surfaces.

Patella:
Almost triangular with apex inferiorly, posterior surface has medial and lateral facets for articulation
with the condyles of femur. Lateral is larger than the medial one.

Tibia:
To the tibial tuberosity, patellar ligament is attached.
Tibial plateau is the upper part of the tibia comprising of the condyles, intertubercular area. The
middle part of the intertubercular area is raised which is called the intertubercular eminence, which
in turn bears the tubercles.
Tibia has 3 borders and 3 surfaces, anterior border, interosseus border and lateral border. Surfaces
include posterior, medial and lateral. The medial surface of tibia is subcutaneous.

Pes anserinus muscles:

Sartorius, gracilis and semi tendinosus.
Fibula:
Fibular neck is related to common peroneal nerve.
Fibula apex is related to biceps femoris and lateral collateral ligament.

Anterior compartment muscles:

Role of articularis genu: attached to the suprapatellar bursa and pulls it during extension at the knee
joint.
The rectus muscle can flex the hip and extend the knee, vasti only have action at the knee joint.
Iliopsoas is only a hip flexor.
Sartorius can flex the hip and the knee

Adductor compartment:
All except obturator internus, which is a lateral rotator of thigh, are adductors.
In addition gracilis may flex the knee joint. And adductor longus and magnus may medially rotate the
thigh.

Concept clearing diagram related to pectin pubis(superior border of pubic ramus), pubic
crest(superior border of pubic bone)

Posterior compartment of thigh:

All flex the knee joint and extend the hip joint.
In addition, since biceps has lateral attachment, it laterally rotates thigh and leg, and the other two
which have medial attachment medially rotate the hip and knee joint.

The arteries of the thigh:

Femoral artery Continuation of external iliac,
Passes through femoral triangle, then adductor canal and passes through
adductor hiatus to become the popliteal artery in the popliteal fossa.
It has four arterial branches initially, superficial epigastric, superficial and deep
external pudendal

Profunda It is a lateral branch of the femoral artery passes between the various
femoris adductor group of muscles which includes pectineus befor piercing the
adductor magnus to enter the popliteal fossa.

It has medial and lateral circumflex femoral arteries and 3 to 5 penetrating

arteries.

Lateral circumflex artery: it has ascending branch

Transverse branch
Descending branch ( involved in the popliteal anastomosis)

Perforating arteries:
Penetrate through the adductor muscle near its attachment to linea aspera.
 The perforators sends ascending and descending artery to form an
anastomotic channel.
Cruciate artery

Formed by lateral and medial circumflex, inferior gluteal and ascending branch
of first perforating artery.

Obturator artery This arises from the internal iliac artery (anterior artery).
And passes though the obturator canal.

It gives off an acetabular branch which passes through ligamentum teres.

NERVES:
Femoral nerve It divides into anterior and posterior divisions.

The saphenous nerve accompanies the femoral artery in the adductor canal ,
but doesn’t pass through the adductor hiatus and emerges through the various
layers as a cutaneous nerve.

Obturator nerve It enters the obturator canal,

 It divides into anterior and posterior division above adductor brevis.
Sciatic nerve It lies on the adductor magnus muscle in the posterior compartment of the
thigh and is crossed by the long head of biceps femoris.

Tibial nerve: hamstring compartment including adductor magnus and except

short head of biceps.
Also posterior compartment of leg,
Intrinsic muscles of foot except first two dorsal interossei which are supplied
by fibular nerve.
Cutaneous innervation

Fibular nerve:

KNEE JOINT:
This is the largest synovial joint of the body. It is a hinge joint.
MENISCI:
Made of fibrocartilage,
The medial cartilage is attached to the joint capsule as well as the medial collateral ligament, the
lateral meniscus is attached to the popliteus tendon , but has no attachment to the joint capsule,
thus the lateral is more mobile than medial. The attachment of the menisci lie in the intertubercular
area. Transverse ligament connects the menisci anteriorly.

The synovial membrane is attached to the margins of the articular surfaces as well as the superior
and inferior outer margins of the menisci.
The cruciate ligaments don’t lie within the synovial cavity but lie within the joint capsule.

The folds in the synovial cavity:

The edges of the infrapatellar fat pat make indentations and thus folds in the synovial cavity called
as alar folds.

Infrapatellar fat pad itself creates a sharp midline fold which attaches to the intertubercular
eminence.

BURSA:
Subpopliteal recess between popliteus tendon and lateral meniscus as well as the suprapatellar
bursa (between distal femur and quadriceps femoris tendon are connected to knee cavity.
Prepatellar bursa
Superficial and deep infrapatellar bursa

The fibrous capsule:

Medially, tibial collateral ligament blends with the capsule. Capsule is attached to the medial
meniscus.
 Laterally, fibular collateral ligament is at some distance from the capsule with an intervening
bursa.
Anteriorly, it’s attached to the margins of patellar ligament.

Oblique popliteal ligament; it is derived from the semimembranosus tendon as a superior

reflection which travels superiorly from medial to lateral.

The popliteus muscle through an opening in the capsule, and is also located in the joint capsule.

CRUCIATE LIGAMENT:
ACL arises from tibia from the anterior intercondylar area and then attaches to lateral wall of
intercondylar fossa of femur.
PCL arises from tibia from posterior intercondylar area and then attaches to medial wall of
intercondylar fossa of femur.

KNEE JOINT LOCKING MECHANISM:

Extension brings the flat and broad articular surfaces of femur in contact with tibia adding to
stability.
Line of centre of gravity passes anterior to tibia.
Femur medially rotates on tibia , which makes the ligaments taut.

For unlocking: popliteus laterally rotates the femur

KNEE JOINT ANASTOMOSIS:
Descending genicular artery from femoral artery
Descending branch of lateral circumflex femoral artery
Superior medial and superior lateral genicular artery –from femoral artery
Inferior medial and inferior lateral genicular artery- from popliteal artery
recurrent branch of anterior tibial artery
circumflex fibular artery branch of posterior tibial artery.
The popliteal fossa:
Boundaries:
Superiorly:
Semimembranosus and tendinosus medially and biceps on lateral aspect

Inferiorly:
The heads of gastrocnemius make the boundaries. Laterally, plantaris muscle also contributes to
some extent.

ROOF:
Deep fascia of thigh (fascia lata) and deep fascia of leg

FLOOR: the fibrous capsule of the knee joint.

CONTENTS:
Popliteal artery and vein along with the tibial nerve and the common fibular nerve.
ROOF: houses the short saphenous vein in the superficial fascia and also the posterior cutaneous
nerve of thigh.
LEG:
Its divided into anterior , posterior and lateral compartments through an interosseus membrane and
two septa which extend from fibula to the deep fascia which surrounds the leg.

FIBULA:

The diagram represents the three borders and three surfaces of fibula, medial crest separates the
posterior surface into two parts.
The malleolar fossa is for the attachment of posterior talofibular ligament.
Interosseus membrane:
In addition to providing a connection between bones, they also provide an interface for muscle
attachment.

The muscles of leg (posterior group of leg):

Mainly plantarflex the foot and toes and invert the foot. Supplied by tibial nerve.
Superficial group consists of soleus, gastrocnemius and plantaris.

Deep group consists of flexor digitorum longus, flexor hallucis longus and tibialis posterior
Vessels and nerves of leg:
Popliteal artery:
It descends from adductor hiatus, then travels through the popliteal fossa. It passes through the
tendinous attachment of soleus(the arch between fibular and tibial attachments) and divides into
anterior and posterior tibial arteries.
Anterior supplies the anterior compartment while the posterior supplies the posterior and lateral
compartment.

Branches of posterior:
Perforating which pierce interosseus membrane to communicate with anterior
Fibular artery: this sends branches to lateral compartment which pierce the intermuscular septum
to enter and supply the lateral compartment.
Circumflex fibular artery: it supplies the knee area.
Vein:
Tibial nerve:
This accompanies the posterior tibial vessels in the posterior compartment of leg.
 Sural nerve: a cutaneous branch of tibial nerve which supplies posterolateral leg and lateral foot
arises between heads of gastrocnemis, travels on the muscle and pierces deep fascia in mid leg to
become cutaneous.

Medial calcaneal nerve: supplies medial and plantar aspect of heel.

Lateral compartment of the leg:

It has no major arteries and is supplied by branches of fibular artery.
The common fibular nerve:
It passes around the neck of fibula. Then divides into superficial and deep fibular nerves(which goes
to anterior compartment). Superficial nerve remains in the lateral compartment and passes
downwards deep to the fibularis longus muscle.
It supplies the lateral leg and dorsum of foot.
ANTERIOR COMPARTMENT OF LEG:
The vessels and nerves:
Anterior tibial nerve arises from popliteal artery, passes through interosseus membrane, runs
through anterior compartment. It gives an ascending branch to the knee joint anastomosis and
distally gives anterior medial malleolar and anterior lateral malleolar branch which contribute to
anastomosis around the ankle joint.
It continues on the foot as the dorsalis pedis artery.
The deep fibular nerve originates in the lateral compartment, then pierces the intermuscular
septum to enter anterior compartment. Here, it runs with the anterior tibial artery.
Foot bones:
talus Superiorly it articulates with tibia, medial and lateral malleolus.
This has three facets inferiorly for articulation with calcaneus.
Posteriorly, it has medial and lateral tubercles between which lie a groove for flexor
hallucis longus.

Talar fractures and the blood supply:

Calcaneus bone:
The surface of bone has three parts
Superior part(has a bursa between it and Achilles)
Middle part( insertion of Achilles)
Inferior part( calcaneal tuberosity---- it extends on the plantar surface)

THE LATERAL SURFACE has two tubercles:

One is the attachment of calcaneofibular part of lateral collateral ligament.
Other is the fibular trochlea(peroneal tubercle). This is related to the tendons of
fibularis longus and brevis.
Sustentaculum tali: a shelf like projection which projects from the medial surface of
calcaneus. It has the middle articular facet on superior surface, and a groove for FHL
on inferior surface.

Superior surface has posterior and anterior facets. Anterior to the posterior facet is
the calcaneal sulcus. This along with the sulcus tali on the talus forms the tarsal sinus.

Navicular:
The tarsal bones are divided into three sets proximal (talus and calcaneus) ,
intermediate(navicular) and distal(cuboid and cuneiforms)

Navicular has a tubercle which is one of the insertion sites of tibialis posterior.
Distal group:
Cuboid: articulates posteriorly with calcaneus and anteriorly with 4th and 5th
metatarsal

Cuneiforms: articulate posteriorly with navicular and anteriorly 1,2 and 3rd
metatarsals. One cuneiform with one metatarsal.

Medial cuneiform is the largest of cuneiforms.

2nd metatarsal is the longest.

5th metatarsal base has tuberosity , which is insertion site of fibularis brevis.
1st digit has 2 phalanges, while the others have 3.

1st metatarsal head is associated with 2 sesamoid bones.

The bases of 2nd to 5th metatarsals articulate with each other at lateral and medial
aspects.
The ankle joint:
A synovial hinge joint allowing dorsi and plantar flexion.
The surfaces are joint socket formed by tibia’s inferior surface, medial malleolus and lateral
malleolus and talus.
JOINT STABLE IN DORSIFLEXION:

Medial collateral ligament of ankle joint:

Deltoid ligament:
In essence, it extends from navicular tuberosity to the medial tubercle of talus.
Consists of 4 parts:
Anterior tibiotalar
Tibionavicular(also attached to the spring ligament, plantar calcaneonavicular ligament)
Tibiocalcaneal; attached to the sustentaculum tali)
Posterior tibiotalar: attached to the medial tubercle of talus.

Lateral collateral ligament:

It consists of anterior and posterior talofibular joint along with calcaneofibular joint.

Foot movements:
Inversion and eversion involve the turning of the whole of the foot , while pronation and supination
involve the rotation of distal foot with respect to proximal foot.

NOTE: cubonavicular joint is fibrous.

Other joints involved in tarsal bones are subtalar, talocalcaneonavicular joint and calcaneocuboid
joint. The latter two are referred to as the transverse talar joint.

Ankle joint injury:

OTHER TARSAL JOINTS:
Subtalar joint Between the posterior articular facet of talus and that of calcaneus.
Supporting ligaments are lateral, medial , posterior and interosseous
talocalcaneal ligament(which lies in the tarsal sinus)
Talocalcaneonavicular
ligament

Components:
Anterior and middle facets of talus and calcaneus

Head of talus with navicular

Spring ligament with a corresponding articular surface on inferior surface

of talus

MOVEMENTS: along with the subtalar joint, involved in inversion and

eversion. Also involved in supination and pronation.

LIGAMENTS:
Superiorly:
Dorsal talonavicular ligament

Inferiorly: spring ligament: extending from sustentaculum tali to navicular

tuberosity

Interosseous talocalcaneal ligament also plays a part.

Laterally: calcaneonavicular part of bifurcate ligament

Bifurcate ligament The stem of this Y shaped ligament is attached to the superior surface of
anterior calcaneus.

The arms are attached to dorsal surfaces of navicular and

cuboid(calcaneocuboid)
Calcaneocuboid joint The ligaments:
Short and long plantar ligaments.

Short plantar ligament: extending from calcaneal tubercle to inferior

surface of cuboid.

Long plantar ligament: extending from inferior surface of calcaneus

between tuberosity and tubercle to inferior surface of cuboid. Superficial
fibres reach out to bases of metacarpals.
Strongest support of lateral arch.
Tarsometatarsal joint These along with the transverse tarsal joints are involved in supination
and pronation
MTP joints These are ellipsoid synovial joints .
Mainly flexion and extension,
But limited abduction, circumduction and lateral rotation may be
involved.

The joint capsules are reinforced by lateral and medial collateral

ligaments and plantar ligaments which have grooves on their plantar
aspect.

Deep Transverse metatarsal ligament:

4 in number and connect the MTP joints, the ligaments blend with the
plantar ligaments of MTP joints.

IP joints Synovial hinge joint.

 Just like the MTP joint, ligaments are lateral and medial collateral
ligaments and plantar ligament.

Tarsal tunnel:
This is made by bony surfaces covered by flexor retinaculum.
The surfaces include medial malleolus, medial and posterior surface of talus, inferior part of
sustentaculum tali, and medial surface of calcaneus.

The contents:
TP, FDL and posterior tibial artery vein and tibial nerve, and FHL

Pulse of posterior tibial artery midway between heel and medial malleolus.

Extensor retinaculum:
Superior retinaculum:
Attached to anterior borders of distal tibia and fibula.

Inferior retinaculum: Y shaped

Stem attached to superior surface of calcaneus
Superior arm attached to the medial malleolus.
Inferior arm moves over the foot to blend with plantar aponeurosis.

Contents:
Medial to lateral
TA, EHL, dorsalis pedis artery, EDL and Fibularis tertius(the latter two in the same compartment??)
 Fibular retinacula:
Superior connects the lateral malleolus to the lateral calcaneal surface.

Inferior is connected around the fibular trochlea. There are two separate compartments for the
longus and brevis tendons.

The arches of foot:

Medial and lateral longitudinal arch
Transverse arch. it is the highest at a coronal plane that passes through talar head , while flattens
out at the heads of metatarsals.

Ligaments: spring ligament, plantar calcaneocuboid, long plantar, plantar aponeurosis

Muscles: which maintain the support dynamically during walking are TA, TP and fibularis longus.

Plantar aponeurosis:
Superficial transverse metatarsal ligament….
Proximal attachment is to medial tuberosity of calcaneus. Distally it attaches to bones, joints and
skin.

Fibrous tunnels:

The tendons of FDL, FD brevis and FHL are enclosed in fibrous sheaths.
Which extend from anterior to MTP to distal phalanges.

Extensor hoods:
 The extensor tendons of EDL, EHL and Extensor digitorum brevis expand to form the extensor
hoods.

The base of the hood is attached to the deep transverse metatarsal ligament.
Middle part of hood is attached to middle phalanx of 2nd to 5th digits and proximal phalanx of 1st
digit.
Distal part is attached to distal phalanx.

Intrinsic muscles of foot:

All the muscles are innervated by tibial nerve except FOR EXTENSOR DIGITORUM BREVIS AND first
two dorsal interossei…..

Extensor compartment intrinsic muscles:

The arteries:
Posterior tibial artery passes through the tarsal tunnel,
Then divides into lateral and medial plantar artery in the sole of the foot.

Lateral plantar artery:

It moves till the base of 5th metatarsal staying at the level of second layer of muscles, it then
arches to form the DEEP PLANTAR ARCH. which is deep to the FDL and FDB tendons.

Branches of lateral plantar artery:

Digital artery to lateral aspect of fifth digit, other digital arteries arise from plantar metatarsal
arteries.
Plantar metatartsal arteries arise from the deep plantar arch.
3 Perforating arteries(from plantar arch) in the lateral three web spaces which communicate with
branches of the dorsalis pedis artery.
In medial most web, there is communication with deep plantar artery of dorsalis pedis artery.

Medial plantar artery:

Eventually Communicates with the digital artery on medial aspect of 1st toe.

It also sends other branches as well , i.e. superficial branches which also contribute to the digital
arteries of the medial 3 web spaces as shown in the diagram

Dorsalis pedis artery: pulses can be found medial to the EHL tendon.

It is continuation of anterior tibial artery anterior to ankle joint.

It continues distally and passes between the heads of 1st dorsal interosseus to enter the sole of
foot as the deep plantar artery.

Branches:
Medial and lateral tarsal arteries; supply the ankle joint.

Arcuate artery:
It gives rise to dorsal metatarsal arteries , which move in the lateral three web spaces which in
turn give off digital branches supplying adjacent surfaces of 2nd to 5th digits. A digital branch to the
lateral surface of 5th digit is also a branch of arcuate artery.

The first dorsal metatarsal artery is the last branch of dorsalis pedis artery, and supplies digital
arteries to the adjacent surfaces of 1st two digits, as well as the branch to the medial surface of
the big toe.
Nerves:

Tibial nerve:
It passes through the tarsal tunnel along with the posterior tibial artery and gives rise to the
medial calcaneal nerve which supplies the heel.

It then divides into medial and lateral plantar nerves, which accompany the medial and lateral
plantar arteries.

Medial nerve supplies the medial anterior two thirds of the sole, and medial three and a half
digits.

Muscles supplied are abductor hallucis, FDB, flexor hallucis brevis and 1st lumbrical, all other
muscles are supplied by lateral plantar division.

Lateral plantar nerve:

Supplies the lateral anterior two thirds of the sole and the lateral 1 and a half digit. It has a
superficial branch which gives rise to cutaneous nerves while the deep branch moves along with
the deep plantar arch.
Morton neuroma: its an enlarged common plantar nerve, usually that in the third web space, the
reason is that the third space nerve is larger as it receives contribution from lateral and medial
plantar artery as well. Also during walking the nerve is compressed between foot and the
overlying deep transverse metatarsal ligament and thus irritated.

Deep fibular nerve:

Supplies the extensor digitorum brevis and the first two dorsal interossei and the skin of the first
webspace and adjacent surfaces of 1st and 2nd digits.

It is lateral to the dorsalis pedis artery, continues on the foot

 Superficial fibular nerve: supplies most of the dorsal surface of the foot , except for a portion
Dermatomes:

SNELLS MCQ:
Knee extended, what limits the flexion at hip:
Hamstring muscles. because they are stretched in extended knee.
Posteriorly dislocated hip fracture might affect sciatic nerve.

This posteriorly dislocated hip fracture breaks the posterior rim of acetabulum. The head of femur
might be fractured as well.
Abduction of hip joint limited by pubofemoral ligament…
Extension limited by iliofemoral ligament.
Flexion of hip with knee flexed is limited by anterior abdominal wall.
Adductor longus supplied by anterior division of obturator nerve.
Lymph from nailbed of 1st toe drains to vertical group of superficial inguinal nodes.

This might imply that medial is more frequently torn than lateral ligament.
Lymph from lateral side of foot drains to popliteal nodes.
Lymph from skin around anus drains into medial group of horizontal superficial inguinal nodes.
Lymph from medial side of knee drains into vertical group of superficial inguinal nodes.
All of above
Sprained ankle from excessive eversion will involve deltoid ligament.

SAPHENOUS OPENING is 4cm inferolateral to pubic tubercle.

MCQ book:
Inability to stand from sitting position:
Gluteus maximus may be involved.
Meralgia paresthetica: involvement of lateral cutaneous nerve of thigh.
Cutaneous nerve in area of greater saphenous vein venesection.
Medial surface of tibia is subcutaneous.
Doesn’t involve any important relation,
The closest possible nerve will be deep fibular nerve which is in relation with tibialis anterior
muscle.
Which nerve is 2cm inferior and lateral to pubic tubercle.

Nerve involved in tarsal tunnel syndrome.

Great saphenous vein

Cruciate and trochanteric anastomosis

Retinacular arteries are involved in arterial supply of the head of femur.

Superficial external pudendal artery along with deep externa; pudendal artery is a branch of the
femoral artery.

Long saphenous vein:

Communicates with the short saphenous vein , deep veins of lower limb.
Also receives the superficial epigastric, superficial circumflex iliac, superficial and deep external
pudendal veins.

Unhappy triad:
This occurs when a lateral force is applied on the knee with the foot fixed.
ACL +medial meniscus+ tibial aka medial collateral ligament.
Femur is longest and strongest bone.
Iliofemoral ligament is the strongest ligament of the hip joint capsule.
Posterior dislocation of hip joint:
Flexion, internal rotation and adduction

Triple arthrodesis:
TC, TN and CC joints(talo-calcaneal, talo-navicular, calcaneo-cuboid)
If ankle is sprained, lateral ligament will be involved as its weaker.
MCQ:
Inversion associated injury, what is spared?
Lareral malleolus
Base of 5th metatarsal
Sustentaculum tali
Extensor digitorum brevis( key chose this option)
Talus has no muscular attachment…
Pillar of medial arch…supposed to be the highest point;;;which is talus.

ACL prevents femur’s backward dislocation.

Polio contracture of iliotibial tract.
Causes abduction of hip and hip flexion
Knee flexion
Lateral rotation of tibia

Varus deformity of knee does NOT happen, valgus deformity might happen.
NOTE: navicular has no physical joint with calcaneus.
Most commonly fractured long bone is tibia.
Muscle forming inferior relation of hip joint. Obturator externus.