Anatomy Lecture Notes – Midterm 2006



Anatomy Lecture Notes--midterm review by Stephanie Swanson

Thorax:

Breast:

Cooper’s Ligaments- suspensory ligaments

Glands/Lobules(ducts(sinuses(nipple

Retromammary space- behind the breast- allows for movement

Blood Supply: Internal Thoracic Artery( on anterior chest parasternal and Lateral thoracic artery ( lateral anterior chest

Lymph Drainage: parasternal lymph nodes + apical lymph nodes (75% here)

Superficial Chest:

Cephalic vein (in deltopectoral triangle)

Medial/Lateral cutaneous vessels and nerves

Anterior Muscles:

|Pectoralis Major |adduction, medial rotation, flexion of humerus |medial and lateral |pectoral branch of thoracocromial |

| |at shoulder |pectoral nerve |trunk a. |

|Pectoralis Minor |depresses tip of shoulder, protracts scapula |medial pectoral n. | |

|External intercostals|inspiration, moves ribs up (inferomedially) |Intercostal nerves |Intercostal arteries |

|Internal intercostals|Expiration/inspiration (superiorlaterally) | | |

|Innermost intercostal|act with internal intercostals | | |

|Transversus thoracis |depress costal cartilages | |internal thoracic a. |

Also know where they attach to(

Pec major – clavicle, sternum, ribs, humerus

Pec minor – ribs 3, 4, 5 to corocoid process

Intercostals – rib to rib (note direction above)

Trans. Thoracis – sternum to ribs

Branches off the axillary artery—Screw The Lawyer, Save A Patient( Superior thoracic, Thoracoacromial, lateral thoracic, subscapular, anterior and posterior circumflex humeral

Chest Wall:

Intercostals Vein, Artery, Nerve (VAN) ( on top of ribs

-**when putting a needle do it above the rib

These run between the internal and innermost muscles

T4 = nipple

Sympathetic Trunk- from superior cervical ganglia down

Thorax Bone Structure:

Coracoid process (what attaches here)

Acromion

Clavicle

Sternum (3 parts) ( sternal angle (where rib 2 attaches, level of T4/5, where trachea bifurcates, aortic arch stops and starts, separates superior and inferior mediastinum, top of azygos vein arch)

Ribs ( neck, head, facets, body, intercostal groove (for intercostal vessels) ( **attach to their own vertebral body and the one above it and to transverse process of the same vertebrae

intercostal VAN (vein artery nerves), they run on inferior aspect of ribs, in the costal groove, not on top or rib as stated in review.  Collateral branches run on top.  Needle placement is on top of rib.  See p 63 of text.

Also, innermost intercostals probably act with external intercostals.  See p 7 of dissector.

-ribs 1, 10, 11, 12 have one facet to their own vertebrae

Scapula (spine, fossas)

Vertebra (lamina, body, canal, pedicle, transverse foramen, spinous process, transverse process, IV disc: nucleus pulpolsis + annulus fibrosis)

True ribs 1-7; False ribs 8-10; floating ribs 11-12

Lungs + Pleura:

Pleura ( parietal (outer layer), visceral (on lungs) layers

Costodiaphragmatic recess( fills when you breathe – at the inferior of the lung- potential space

Lung-

Root- just the arteries, veins, bronchi

Hilum- root + pulmonary ligament

Pulmonary Arteries (deoxygenated blood) – superior – run with bronchi

Pulmonary Veins (oxygenated blood) – inferior – run segmentally

Bronchial Arteries- off of aorta to supply blood to lung tissues

Trachea ( bifurcates at second rib into primary bronchi (right and left) ( lobar ( segmental bronchi

**azygos vein comes up and loops around the right lung hilum

Lymph Nodes: drain up and around to trachea- can cross over

Innervation of Pleura:

Somatic: mainly to parietal pleura ( sensation to pain

Autonomic: mainly to visceral pleura ( pain insensitive

Alveoli-little sacs- respiratory part of the lung (rest is conducting portion)

Right lung: has three lobes: superior, middle, inferior with two fissures

**Horizontal fissure separates the superior from the middle lobe

**Oblique fissure separates the inferior lobe from the superior and middle

**on the right: middle lobe is mostly on the posterior and superior is mostly anterior

Left lung: has 2 lobes + lingula: superior, inferior (oblique fissure separates them) – also has the cardiac notch

**on the left: inferior lobe is mostly seen posterior (aka if someone gets stabbed there) and superior lobe is anterior

Heart and Great Vessels:

Sits tilted in the chest cavity:

Anterior – right ventricle

Posterior – left atrium

Thymus –in children –remnant in adults-

over the superior portion of the heart

Phrenic nerve runs on the pericardial sac with the pericardiacophrenic vessels- to the diaphragm

Auricles- accessory heart muscles that help contract

and open the atria

Apex of the heart

Blood flow: Coronary Sinus/SVC/IVC ( right atrium (deoxygenated from body + heart) ( right ventricle ( pulmonary trunk ( right and left pulmonary arteries (deoxygenated) ( lungs ( 4 pulmonary veins (oxygenated) ( left atrium ( left ventricle ( ascending aorta ( arch of the aorta ( descending aorta

**note: 2 pulmonary arteries, 4 pulmonary veins

Pericardial Sac: 2 layers: Fibrous (outer) and Serous (visceral and parietal pleural layers)

Left ventricular walls are thicker because of more power needs to get body to the whole body (and therefore pressure is higher)

Three layers/membranes in the heart: endocardium, myocardium, epicardium

Cardiac Sinuses:

Transverse Sinus- goes all the way through between pulmonary veins/ SVC and pulmonary trunk/aorta

Oblique Sinus- goes under the heart between IVC and between pulmonary arteries (blind end)

Coronary Arteries and Veins:

Aorta gives off two branches after leaving the heart: right and left coronary arteries (RCA/LCA)

RCA ( SA nodal artery, right marginal artery, left posterior descending (LPD)

LCA ( circumflex artery, left marginal artery, left anterior descending (LAD),

Veins:

Great ( LAD

Middle ( PDA

Small ( RCA/right marginal

Coronary sinus is on the posterior( drains into RA

Valves:

right atria to right ventricle = tricuspid valve with anterior, posterior and septal cusps

left atria to left ventricle = mitral/bicuspid valve with anterior and posterior cusps

Semilunar valves: aortic (left, right, posterior); pulmonic (anterior, left, right) ( remember this by PLAR- circle the A for aortic, and you have PLR leftover (posterior, left, right) and circle the P for pulmonic, and you have LAR leftover (left, anterior, right)

Cusps are held by chordae tendinea which attach to papillary muscles in the ventricles

In the atria the rough looking muscles are pectinate muscles

In the ventricles they are trabeculae carnea

Fossa Ovale ( embryonic remnant of physiological shunt to left atrium

In the right atria there is a Crista Terminale which is a smooth ridge separating the pectinate muscles from the smooth muscle – also there is a conus arteriosus (infundibulum) that leads to pulmonary trunk: Netter Plate 216)

SA Node (pacemaker of the heart) is in the right atrium ( fibers go to the AV node in the bottom part of the right atrium ( fibers to interventricular septum ( right bundle branch ( moderator band and Purkinje fibers (left bundle branch to left ventricle) ( conducts impulses to papillary muscles

Diastole= relaxed ventricles - tri and bicuspids open – semilunars closed

Systole= contracted ventricles – semilunars open – tri and bi open

Posterior Thorax/Wall:

Vertebrae are the most posterior – with descending aorta and esophagus, azygos veins on top (**thoracic duct runs in between azygos and esophagus)

Azygos Veins- azygos are on the right, hemiazygos on the lower left, and accessory azygos on the upper left

Left recurrent laryngeal nerve comes down (branching off the vagus) and goes posterior to the ligamentum arteriosum (remnant of the ductus arteriosus) and then goes back up to larynx

Right recurrent laryngeal nerve comes down under the right subclavian artery and back up

Vagus (CN X) nerve runs down medial to the phrenic and wraps into a plexus around the esophagus and branches to the heart– then sends parasympathetics to the thorax (and then abdomen)

-PNS has long preganglionics, and short postganglionics (innervates viscera)

Thoracic duct- runs with (posterior) esophagus from the abdomen (from the cysterna chyli) delivering lymph into the left subclavian vein (where it gives off the left internal jugular vein)

Sympathetic Trunk- (T1-L2) runs lateral to the vertebral bodies on the posterior wall- contains sympathetic fibers and ganglia (cell bodies) – connects to ventral rami (intercostal nerves) by rami communicates (grey=post/ white=pre)– starts at the superior cervical ganglia in brain (NOT the spinal cord-only connects to spinal cord) – and ends in lumbar splanchnics—send off greater, lesser, and least splanchnics in the thorax (all preganglionic sympathetics)

-SNS has short preganglionics, and long post ganglionics (innervates blood vessels and glands)

Nervous System:

| |Somatic |Visceral |

|Afferent(Dorsal Horn(Dorsal Root |GSA: touch, temp, proprioception, sharp |GVA: all of viscera (organs) in the gut: |

|Ganglia(Dorsal Root(Sensory(Info to CNS |pain—only part in the abdomen is the omenta|dull pain (bellyache) |

|Efferent(Ventral Horn(Ventral |GSE: skeletal muscle |GVE: smooth muscle |

|Root(Motor(Away from CNS | |-SNS/PNS- 2 ganglia system (always run with|

| | |VA) |

Dermatomes represent the area of the skin supplied by the nerve root- these are segmental

Cutaneous innervation is different – it represents different nerve sensory areas on the skin

Back and Spinal Cord:

33 vertebrae – 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, 4 coccyx

C1 = atlas (has no body)

C2 = axis (with dens/odontoid process)

C2, 3 have bifid spinous processes

Vertebral artery runs through transverse foramen

Spinal nerves run through vertebral foramen

Vertebra and all its parts:

Note connections to ribs discussed in thorax (above)

Intervertebral Disc- consists of nucleus pulposis (squishy inside; remnant of notochord) and annulus fibrosus (fibrous outside)

Ligaments:

Nuchal ligament: from occipital bone of skull to first couple spinous processes

Intraspinous ligaments: from spinous process to spinous process

Anterior longitudinal ligament: most anterior thing- anterior of body

Posterior longitudinal ligament: posterior of body – anterior of the canal

Ligamentum Flava: posterior of the canal (the pop when you do a lumbar puncture)

Extrinsic muscles- are involved with the movements of upper limbs- innervated by anterior/ventral rami

Intrinsic muscles- are deep and support and move vertebral column- innervated by the posterior/dorsal rami

Back Muscles:

|Type |Muscle Group |Muscle Name |Muscle Function |Nerve Innervation |Arterial Supply |

|Extrinsic |Superficial |Trapezius |elevate, depress, |accessory spinal |transverse cervical |

| | | |adduct, & medially |nerve (CN XI) | |

| | | |rotate scapula | | |

| | |Latissimus Dorsi |extend, adduct, & |Thoraco-dorsal |thoracodorsal |

| | | |medially rotate humerus| | |

| | |Levator Scalpulae |elevate scapula |dorsal scapular |Transverse cervical |

| | |Rhomboid Minor |retract scapula |dorsal scapular |dorsal scapular |

| | |Rhomboid Major |retract scapula |dorsal scapular |dorsal scapular |

| |Intermediate |Serratus Posterior |elevate ribs |ventral rami |Intercostal a. |

| | |Superior | | | |

| | |Serratus Posterior |depress ribs |ventral rami |Intercostal a. |

| | |Inferior | | | |

|Intrinsic |Deep |Spino-transversales: |together: pull head |dorsal rami |segmentally: deep |

|(innervated | |1. Splenius capitus |back, extend neck; | |cervical, intercostal, |

|by | |2. Splenius Cervicis |individually: move head| |subcostal, lumbar |

|posterior/dor| | |to same side as | | |

|sal rami) | | |contraction | | |

| | | | | | |

| | | | | | |

| | |Erector Spinae: |maintain upright |dorsal rami | |

| | |1. Iliocostalis |posterior, bend back | | |

| | |2. Longissimus | | | |

| | |3. Spinalis | | | |

Bone Structures:

Scapula (spine, coracoid, acromion, supraspinous fossa, infraspinous fossa, suprascapular notch, superior, medial, lateral, inferior borders)

Suprascapular notch- suprascapular artery goes over the ligaments in it, the nerve goes through the notch (remember the army goes over, the navy goes under)

Suboccipital Triangle- underneath the trapezius in the back of the neck this holds the vertebral artery, posterior arch of C1, and the greater occipital nerve (off of C2)

Spinal Cord:

Extends from brain to L1/L2 in adult (the whole spinal column in infants)

There are two enlargements: cervical (for extra tissue for upper limbs) and lumbosacral (extra tissue for lower extremity)

**Spinal nerves exit the transverse foramen above the vertebra for the cervical nerves, and below for all the rest

Though there are 33 vertebrae there are only 31 spinal nerves (8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal)

Vertebral houses the spinal cord in the vertebral canal- spinal cord is protected by layers of connective tissue membranes (meninges) and spaces:

Pia mater: adhered to spinal cord (like a viscera) ( extends inferiorly into the filum terminale and medially into denticulate ligaments

Subarachnoid Space: between the pia and arachnoid maters( holds the CSF (this is where we do lumbar punctures

Arachnoid mater: thin, shiny membrane on the surface of the dura mater

Subdural Space: between the arachnoid and the dura maters( this is where you often get subdural hematomas even though this is a potential space

Dura mater: thickest, most external, white membrane(offers good protection

Epidural Space: this is where we do epidurals( contains fat with vessels

Arterial supply to the spinal cord starts superior with the vertebral artery ( branches to anterior spinal artery / segmental arteries ( Artery of Adamkiewicz is very important because it supplies a huge portion of the thoracic spinal cord arteries ( occlusion here would cause a major effect on spinal cord

There is an extensive venous plexus drainage system ( segmental veins go to IVC

Scapula and Deltoid Region:

Muscles:

|  |Muscle Name |Muscle Function |Nerve Innervation |Arterial Supply |Origin |Insert |

| | | | | | | |

| |Serratus Anterior |Rotation/protraction of |Long Thoracic Nerve |Lateral Thoracic artery |ribs 8-9 |scapula |

| | |scapula | | | | |

Remember: a Lat between two Majors – on the humerus insertions are: pec major, lat. Dorsi, teres major (lateral to medial)

Muscles of Rotor Cuff: SITS : supraspinatus – infraspinatus – teres minor – subscapularis

Bone Structure:

Humerus: greater tubercle (for SIT), lesser tubercle (for subscap), deltoid tuberosity (for deltoid), radial groove (for radial nerve), intertubercular groove (for long head of biceps tendon), anatomical (upper) and surgical necks (lower) ( inferior humerus is in arm (below)

Quadrangular space: Axillary nerve runs with post. circumflex humeral artery

Borders: long head of triceps, teres minor, teres major, humerus

Upper triangular space: circumflex scapular vessels

Lower triangular space: radial nerve and deep branchial artery

Borders: long head of triceps, teres major, medial head of triceps

Shoulder joint:

Bursa: sacs with fluid so that they help slide the joint

Glenohumeral ligaments

Coracoacromial ligament

Acromioclavicular ligament

Glenoid Fossa

Vessels in shoulder have lots of anastomosis- so can bypass a blockage more easily

Brachial Plexus:

Axilla:

Anterior: pec major/minor

Posterior: subscapularis

Medial: serratus anterior/ribs/intercostals

Axillary Sheath: contains arteries, vessels, nerves

Plexus: C5-T1 roots

Really Thirsty? Drink Cold Beer ( roots, trunks, divisions, cords, branches

End branches are MARMU (musculocut, axillary, radial, median, ulnar)

Really you just need to know how to draw it, with the small branches-

Innervation of Brachial Plexus:

|Dorsal Scapular | |Rhomboid major/minor |

|Long thoracic | |Serratus anterior |

|Suprascapular | |Supra and infraspinatus |

|Nerve to subclavius | |Subclavius |

|Lateral pectoral | |Pec. major |

|Musculocutaneous |Skin to lateral side of forearm |anterior compartment of arm |

|Medial pectoral | |Pec. major/minor |

|Medial cutaneous of arm |Skin medial of distal 1/3 of arm | |

|Medial cutaneous of forearm |Skin medial of forearm | |

|Median |palm surface lat. 3.5 digits & lateral side |Ant. compartment of forearm, 3 thenar of thumb, 2 |

| |of palm and mid of wrist |lateral lumbrical muscles (no flexor carpi ulnaris & |

| | |flexor digitorum profundus) |

|Ulnar |palm surface of med. 1.5 digits & dorsal of |intrinsic muscles of hand (no median nerve ones), flexor|

| |med 1.5 digits |carpi ulnaris, med. Flexor digitorum profundus) |

|Superior subscapular | |subscapularis |

|Thoracodorsal | |latissimus dorsi |

|Inferior subscapular | |subscapularis, teres major |

|Axillary |upper lateral part of arm |deltoid, teres minor |

|Radial |Post. arm/forearm, lower lat. Surface of |posterior compartment of arm/forearm |

| |arm, dorsal lateral of hand) | |

Arm:

Bone Structure:

Humerus: medial and lateral epicondyles, coronoid fossa (anterior), olecranon fossa (posterior), trochlea (medial), capitulum (lateral)

Forearm: ulna (olecranon)- by the pinky finger / radius (styloid process)- by the thumb- articulates with the scaphoid and lunate

-interosseus membrane goes between two bones

|Muscle Group |Muscle Name |Muscle Function & Facts |Nerve Innervation |Arterial Supply |

|Anterior |Biceps brachii |flex arm (long head) & forearm, supinate if |Musculo-cutaneous |brachial |

| | |elbow is flexed | | |

| |brachialis |flex forearm | |brachial + radial recurrent |

| |Coraco-brachialis |flex forearm, adduct arm | |brachial |

|Posterior |Triceps brachii |extend forearm at elbow, long head can adduct|radial |profunda brachii |

| | |or extend arm at shoulder | | |

also know insertions:

Biceps- long head (supraglenoid tubercle of the scapula), short head (coracoid process), both originate from radius bone

Brachialis- from ulna to humerus

Coracobrachialis- from coracoid process to humerus

Triceps- long head (inferior border of scapula), lateral head (humerus), medial head (humerus) – all insert into biceps tendon onto olecranon

Cubital fossa: at the elbow- borders (medial = protonator teres / lateral = brachioradialis / proximal = biceps brachii) ( median cubital vein runs here with biceps tendon and brachial artery

|Superficial |Brachioradialis |Accessory flexor of elbow |Radial nerve |Radial recurrent |

|Posterior | | | | |

| |Extensor carpi ulnaris|Extends & adducts wrist |Posterior interosseous |Ulnar artery |

| | | |(a continuation of the | |

| | | |deep branch of radial | |

| | | |nerve) | |

| |Extensor digiti minimi|Extends little finger | |Interosseous recurrent from |

| | | | |ulnar |

| |Extensor digitorum |Extends fingers & wrist | |interosseous recurrent & |

| | | | |posterior interosseous |

| |Extensor carpi |Extends & abducts wrist |Deep branch of radial |Radial artery |

| |radialis brevis | | | |

| |Extensor carpi |Extends & abducts wrist |Radial nerve |Radial artery |

| |radialis longus | | | |

| |Anconeus |Abduction of ulna in pronation; |Radial nerve |interosseous recurrent |

| | |accessory extensor of elbow | | |

|Deep Posterior |Supinator |Supination |Posterior interosseous |recurrent interosseous |

| | | |(continuation of deep | |

| | | |branch of radial nerve)| |

| |Extensor indicis |Extends index finger | |Posterior interosseous |

| |Extensor pollicis |Extends IP joint of thumb (also CMC &| | |

| |longus |MCP joints) | | |

| |Extensor pollicis |Extends MCP joint of thumb (also CMC | | |

| |brevis |joint) | | |

| |Abductor pollicis |Abducts carpometacarpal joint of | | |

| |longus |thumb | | |

Hand:

Bone Structure:

Phalanges (3)

Metacarpal (1)

Carpals (8)

DIP: distal interphalangeal joint

PIP: proximal interphalangeal joint

MCP: metacarpophalangeal joint

CMC: carpometacarpal joint

Wrist Bones:

Some Lovers Try Positions That They Can’t Handle ( Scaphoid Lunate Triquetrum Pisiform Trapezium Trapezoid Capitate Hamate-Hook of hamate–where the ulnar nerve lies

Pisiform is a sesamoid bone

Muscles:

|Type |Muscle Group |Muscle Name |Muscle Function & Facts |Nerve Innervation |Arterial Supply |

|Intri|  |Palmaris brevis |deepens cup of palm & improve grip; origin at |ulnar |ulnar artery |

|nsic | | |palmar aponeurosis & insertion in dermis of skin | | |

| |  |Dorsal interossei |(DAB) abduct index, middle, & ring finger; flexion|ulnar |dorsal and palmar |

| | |(4 bipennate) |& extension of fingers (through dorsal hoods) | |metacarpal |

| | |Palmar interossei |(PAD) adduct thumb, index, ring, & little fingers;| |palmar metacarpal |

| | |(4 unipennate) |flexion & extension of fingers (through dorsal | | |

| | | |hoods) | | |

| |  |Adductor pollicis |Adducts thumb & opposes thumb to rest of digits in| |deep palmar arterial arch |

| | | |gripping | | |

| |Thenar (FAO) |Opponens metacarpal |Medially rotates thumb; rotates & flexes |Recurrent branch |Radial artery |

| | |pollicis |metacarpal I so pad faces pads of fingers |of median | |

| | | |(opposition) | | |

| | |Abductor pollicis |Abducts thumb at metacarpophalangeal joint | | |

| | |brevis | | | |

| | |Flexor pollicis brevis |Flexes thumb at metacarpophalangeal joint | | |

| |Hypothenar |Opponens digiti minimi |Rotates metacarpal V toward the palm (lateral |ulnar |ulnar artery |

| |(FAO) | |rotation) - movement less dramatic than thumb's | | |

| | | | | | |

| | | | | | |

| | |Abductor digiti minimi |Abducts little finger at metacarpophalangeal joint| | |

| | |Flexor digiti minimi |Flexes little finger at metacarpophalangeal joint | | |

| | |brevis | | | |

| |Lumb-ricals |Medial (bipennate) |Flex metacarpophalangeal joints while extending |ulnar |superficial palmar |

| | | |interphalangeal joints | |arterial arch |

| | |Lateral (unipennate) | |median | |

Palmar aponeurosis – membrane that helps keep the “cup” part of the palm

Extensor retinaculum – membrane covering the extensor muscles

Flexor retinaculum – membrane covering the flexor muscles

Carpal Tunnel: covered by the transverse carpal ligament-contains flexor pollicis longus (in its own sheath), flexor digitorum superficialis (2 on top of two- digits 3 and 4 on top of 2 and 5) and profundus (4 in a row)—median nerve also runs here

Abdomen:

Regions of the abdomen:

Quadrants- xiphoid to pubic symphysis and horizontal through umbilicus

8 regions- subcostal and interspinous horizontal lines and two vertical midclavicular lines- right hypochondrium, epigastric, left hypochondrium, right flank, umbilical, left flank, right inguinal, hypogastric, left inguinal

Muscles:

| |Muscle Name |Muscle Function & Facts |Nerve Innervation |Arterial Supply |

|Abdo|External Oblique |Compress abdominal contents; flex trunk |Ventral rami T7-T12 |superior epigastric, inferior epigastric |

|mina| |(bilateral); bend trunk laterally (unilateral -| | |

|l | |to same side) | | |

|Wall| | | | |

| |Internal Oblique |Compress abdominal contents; flex trunk |Ventral rami T7-L1; |superior epigastric, inferior epigastric |

| | |(bilateral); bend trunk laterally (unilateral -|iliohypogastric, | |

| | |to same side) |ilio-inguinal | |

| |Trans-versus |Compress & support abdominal contents |Ventral rami T7-L1; |superior epigastric, inferior epigastric |

| |Abdom-inis | |iliohypogastric, | |

| | | |ilio-inguinal | |

| |Rectus Abdominis |Compress abdominal contents; flex vertebral |Ventral rami T7-T12 |superior epigastric, intercostal, |

| | |column; tense abdominal wall | |subcostal, inferior epigastric |

| | | | | |

| | | | | |

| |Pyramidalis |Tenses linea alba |ventral rami T12 |subcostal & inferior epigastric |

|Post|Psoas major |Flexion of thigh at hip joint; flexion & |Ventral rami L1-L3 |subcostal (=T12) & lumbars |

|erio| |laterally bending of lumbar vertebral column | | |

|r | | | | |

|Abdo| | | | |

|mina| | | | |

|l | | | | |

|Wall| | | | |

| |Psoas minor |Weak flexion & lateral bending of of lumbar |Ventral rami L1 (L1 = |lumbars |

| | |vertebral column |iliohypogastric & | |

| | | |ilioinguinal) | |

| |Quadratus lumborum|Depress & stabilize 12th rib; laterally bend |ventral rami T12-L4; |subcostal & lumbars |

| | |the trunk |T12=subcostal nerve | |

| |Iliacus |Flexes the thigh at hip joint; flexes pelvis on|Femoral |iliolumbar |

| | |thigh if thigh is fixed | | |

| | | | | |

| | | | | |

| |Diaphragm |inspiration: pushes the abdominal viscera |Phrenic |inferior & superior phrenic; |

| | |inferiorly, ↑ vol. of thoracic cavity | |musculophrenic |

Bone Structure:

Lumbar vertebrae- posterior

Iliac crest and Ilium bone – inferior

-anterior superior iliac spine

Ribs- superior

Pubic tubercle

Abdominal Wall:

Anterior: Skin ( camper’s fascia (fatty) ( scarpa’s fascia (membranous) ( rectal sheath ( internal oblique ( external oblique ( transversalis abdominus ( transversalis fascia

Arcuate line – where the rectus sheath goes anterior completely

-above:

-below:

Nerves/arteries are segmental to the abdominal wall

-T10 is the umbilicus

Iliohypogastric nerve – sensation to suprapubic region

Internal thoracic from thorax comes down and splits ( musculophrenic + superior epigastrics (anastomose with inferior epigastrics)

Iliac circumflex arteries-also anastomose with epigastrics laterally

Diaphragm is superior portion with right and left crus

Right = caval hiatus (T8) with IVC and phrenic

Right = esophagus hiatus (T10) with vagus

Left and Right = aortic hiatus (T12) with thoracic duct, azygos veins, greater splanchnics

**Remember: I ate (8) 10 eggs at noon (12)

Anterior wall folds:

Median fold- with embryological urachus

Medial folds- remnants of umbilical vessels

Lateral folds- inferior epigastrics

Hesselbach’s triangle- medial=lateral edge of rectus abdominus / lateral=inferior epigastric vessels / inferior=inguinal ligament

Spermatic Cord/Testis:

Inguinal ligament- runs from anterior superior iliac spine to pubic tubercle- made from external oblique

Internal ring of the inguinal canal- genitofemoral nerve passes through it with the spermatic cord (**NOT the ilioinguinal nerve)- made from the internal oblique

External ring of the inguinal canal- ilioinguinal nerve + genitofemoral nerve passes through it with the spermatic cord- made from the transversalis abdominus

Ilioinguinal nerve- sensory on the testes

Dartos muscle- regulates testes temperature but wrinkling the testes

Spermatic cord: cremasteric muscle, vas deferens, genital branch of the genitofemoral nerve, ilioinguinal nerve, pampiniform plexus, testicular artery

In the testes--layers:

Tunica albuginea- white adherent fascia

Tunica vaginalis- loose anterior sac

Internal oblique ( cremasteric muscle

External oblique ( external spermatic fascia

Transversalis abdominis ( nothing (ends before testes)

Transversalis fascia ( internal spermatic fascia

Flow of sperm: STEVE – seminephrous tubules ( epididymis (superior-posterior) ( vas deferens ( ejaculatory duct

Abdomen GI:

Greater omentum- from stomach/transverse colon hanging down over intestines

Colon: ascending (from cecum/appendix) ( right colic flexure ( transverse colon ( splenic/ left colic flexure ( descending colon ( sigmoid colon ( rectum ( anus

-colon has haustra (pocket-appearance by semilunar folds) made by tenia coli muscles (lead to appendix)

Lesser omentum- stomach to liver-creates lesser sac/epiploic foramen (IVC-posterior, portal vein-anterior)

Small intestine: order: Dow Jones Industrial

( duodenum- C-shaped, ampulla of vater (where bile duct comes in), ligament of Treitz holds duo to diaphragm-has semi-circular folds

( jejunum-feathery appearance due to lots of semi-circular folds-

( ileum-smooth with solitary lymph tissue (peyer’s patches)

Stomach: regions: cardiac, fundus, body, pyloric (antrum then canal) – greater and lesser curvatures

-Rugae –folds in the stomach

Retroperitoneal Structures: AC/DC Rocker Kids Party Down ( Asc. and desc. Colon, rectum, kidneys, pancreas, duodenum

Enteric Nervous System: motor and sensory neurons in the GI in two plexuses: independent systems but can be influenced by autonomics (SNS/PNS)

-Myenteric/Auerbach’s and Submucosal/Meissner’s- both help in GI functions

Peripheral Visceral Nerves: efferent = PNS/SNS (pre and post ganglionic) // afferent = one fiber

Liver: most of liver is under ribs

4 lobes: right (biggest), left, caudate (top posterior), quadrate (bottom posterior)

Right and left lobes are separates by the falciform ligament (attaches liver to anterior abdominal wall) and ligamentum teres hepatis (embryonic remnant)

Hepatogastric and hepatoduodenal ligaments- forms lesser sac (anterior)

Liver triad: portal vein (from all GI organs (portal venous system), common bile duct, hepatic artery at inferior

Hepatic vein goes superior to IVC (systemic venous system)

Right and left hepatic duct ( common hepatic duct ( combine with cystic dust ( common bile duct ( combine with pancreatic duct ( into duodenum

Gallbladder: between right lobe and quadrate (remember GQ: gallbladder next to quadrate)

Pancreas: head in the arms of the duodenum ( body ( tail near spleen

-sends pancreatic duct to combine with bile duct- there is an accessory pancreatic duct also (see embryo: pancreas development)

Posterior of the body are the SMA/SMV

Splenic artery runs along body and tail to spleen

Spleen: filters blood- splenic artery is torturous from the celiac trunk

Abdominal Arteries:

Unpaired- celiac trunk, SMA, IMA

Paired- inferior phrenics, suprarenals, renal, gonadal, lumbar

Abdominal Veins:

note: IMV goes to splenic vein

remember: lymphatics follow blood supply ( so gonads drain lymph to lumbar aortic area

Posterior Abdominal Wall:

IVC on the right and aorta on left-

Diaphragm- has arches across the back-

Median arch- aorta

Medial– psoas muscles

Lateral- quad. laborum

Nerves: there is a plexus and ganglia for every artery (basically… i.e. SMA ( SMA plexus and ganglia

Lumbar plexus, sacral plexus ( even though these are basically sympathetic the vagus comes down and travels through them

On the wall:

Some Idiots Ignore Lab, F’s Given Out ( subcostals, iliohypogastric, ilioinguinal, lateral cutaneous of the thigh, femoral, genitofemoral (on psoas muscles), obturator

Kidneys: blood supply from aorta – lots of variations- right kidney is lower

Perirenal fat- closest to kidney- inside of the fascia

Perarenal fat- outside of fascia

Filters in this order: cortex( medulla ( pyramids ( renal papilla ( minor calyx ( major calyx ( renal pelvis ( ureter ( bladder ( urethra

Suprarenal glands: above the kidneys- secrete norepinephrine and epinephrine ( three blood supplies: from inferior phrenics, aorta, and renal arteries

Clinical Problems: note this is not all the blue boxes in the text (look them up!)

Breast Cancer- some can affect cooper’s ligaments and causes peau du orange appearance

Pneumothorax- air in pleural cavity ( to fix put in chest tube around rib 6 above the rib

Chylothorax- lymph in the pleural cavity

Hemothorax- blood in the pleural cavity ( to fix put chest tube in between ribs 8 and 9 above the rib in the axillary region

Pleuritis/Pleurisy- inflammation of the pleura-painful

Fractured Ribs

COPD- people with breathing use their accessory breathing muscles

Right Bronchi is more vertical so more likely to aspirate

Pericarditis- inflammation of heart sac

Pericardial effusion- is a buildup of fluid in the space between the heart and the sac around the heart

Cardiac tamponade- pressure on heart

Hemopericardium- blood in sac

Heart Attack – myocardial infarction

Referred pain from the heart ( to the left shoulder

Auscultation of the Heart ( right 2nd rib space = aortic / left 2nd rib space = pulmonic / left 3rd rib space = 2nd pulmonic / 4th rib space = tricuspid / 5th rib space midclavicular (below the nipple) = mitral

Tumor in the vertebral canal - can impinge on spinal cord

Meningitis – infection in the spinal column in the meninges

Lumbar Puncture – have patient either on side in fetal tucked position on sitting up tucked- feel for iliac crests, go over to L4/L5 and stick needle into either epidural (to give anesthesia) or subarachnoid (for CSF)

Shoulder Dislocation – most common anterior-inferiorly because not as many tendons that direction

Bursitis–inflammation of the bursa- most common in subacromial bursa

Winged Scapula – injury to long thoracic nerve (to serratus anterior muscles)

Clavicle Break – if broken the proximal clavicle can move upward (because of sternocleidomastoid) and the distal clavicle can move downward (because of pec major, etc)

**Problems with nerves to Hand- DR CUMA (

dropwrist = radial nerve clawhand = ulnar nerve median nerve = apehand/benediction

Colles Fracture- fracture of the scaphoid (most common falling on your hand fracture)

Hand Dislocation – most common dislocation is the lunate

Carpal tunnel syndrome- median nerve is squeezed and get apehand (above)

Caput medusa- in portal HTN get this pouching out of the umbilicus because these vessels connect systemic and portal system

Inguinal Hernias-

Direct=medial to inferior epigastrics in the hesselbach’s triangle or through abdominal wall

Indirect=lateral to inferior epigastrics in spermatic cord

-often from persistent processus vaginalis

Varicose Vein/Varicocele- of the pamp. plexus cause infertility because no temperature regulation

GERD- gastroesophageal reflux disease-acid reflux

Hiatal Hernia- esophageal hernia into thorax

Stomach Cancer

Ulcers- irritations of GI lining- can go all the way through and eat into pancreas from stomach or to gastroduodenal artery from duodenum

Crohn’s Disease- inflammation of intestines

Diverticulosis- outpocketing of intestines- mainly in descending/sigmoid colon

Meckel’s Diverticulum- remnant of the vitelline duct- in the ileum (look at embryo)

Portal Hypertension- an increase in portal vein pressure because of liver cirrhosis or blockage in liver( can get enlarged spleen ( causes systemic/portal anastomoses to open up ( esophagus, umbilical, rectal, intestinal (colon)

Pancreatic Cancer- aggressive tumor, no real symptoms until its to late

Pancreatitis- inflammation of the pancreas

Horseshoe Kidney-sometimes to get one big kidney shaped like horseshoe, stops at the IMA

Kidney Stones- crystal calcifications in the kidney

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