Reda Note Anatomy

1A.
ANATOMY (UPPER LIMB) – MRCS NOTES - REDA

Bones of the UL ............................................................................................................................................... 2
Muscles of the UL ............................................................................................................................................ 8
Muscles of the Shoulder ............................................................................................................................. 8
Muscles of the Arm and Forearm ............................................................................................................. 10
Extensor retinaculum / Dorsal Wrist Compartments .............................................................................. 15
Neuroanatomic Relationships in the Forearm......................................................................................... 15
Muscles of the Hand and Wrist ................................................................................................................ 16
Hand .......................................................................................................................................................... 17
Arteries of the UL .......................................................................................................................................... 21
Axillary artery............................................................................................................................................ 21
Brachial artery........................................................................................................................................... 21
Ulnar artery ............................................................................................................................................... 23
Radial artery .............................................................................................................................................. 23
Veins of the UL .............................................................................................................................................. 24
Basilic vein................................................................................................................................................. 24
Nerves of the UL ............................................................................................................................................ 25
Brachial plexus .......................................................................................................................................... 25
Summary of Upper Extremity Innervation............................................................................................... 26
Musculocutaneous nerve ......................................................................................................................... 27
Median nerve ............................................................................................................................................ 27
Ulnar nerve................................................................................................................................................ 28
Radial nerve .............................................................................................................................................. 31
Joints of the UL .............................................................................................................................................. 33
Shoulder joint............................................................................................................................................ 33
Important Regions of the UL ........................................................................................................................ 35
Breast ........................................................................................................................................................ 35
Axilla .......................................................................................................................................................... 37
Cubital Fossa ............................................................................................................................................. 38
Surface Anatomy........................................................................................................................................... 39
1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 1

Bones of the UL

Carpal bones
Sally Likes To Play The Tiny Chrome Harmonica
She Looks Too Pretty Try To Catch Her
Scared Lovers Try Positions That They Can't Handle

Muscles of the UL
Muscles of the Shoulder
Muscle Origin Insertion Action Innervation
Clavicle, scapula
Trapezius SP C7-T12 Rotating scapula Cranial nerve XI
(acromion, SP)
Extending, adducting,
Latissimus dorsi SP T6-S5, ilium Humerus (ITG) internally rotating Thoracodorsal nerve
humerus
Rhomboid major SP T2-T5 Scapula (medial border) Adducting scapula Dorsal scapular nerve
Rhomboid minor SP C7-T1 Scapula (medial spine) Adducting scapula Dorsal scapular nerve
Transverse Scapula (superior Elevating, rotating
Levator scapulae C3, C4 nerves
process C1-C4 medial) scapula
Sternum, ribs, Adducting, internally Medial and lateral
Pectoralis major Humerus (lateral ITG)
clavicle rotating arm pectoral nerves
Pectoralis minor Ribs 3-5 Scapula (coracoid) Protracting scapula Medial pectoral nerve
Subclavius Rib 1 Inferior clavicle Depressing clavicle Upper trunk nerves
Serratus anterior Ribs 1-9 Scapula (ventral medial) Preventing winging Long thoracic nerve
Lateral clavicle, Humerus (deltoid
Deltoid Abducting arm Axillary nerve
scapula tuberosity)
Adducting, internally Lower subscapular
Teres major Inferior scapula Humerus (medial ITG)
rotating, extending arm nerve
Rotator cuff muscles
Internally rotating arm,
Humerus (lesser Upper and lower
Subscapularis Ventral scapula providing anterior
tuberosity) subscapular nerves
stability
Abducting and
Supraspinatus Superior scapula Humerus (GT) externally rotating arm, Suprascapular nerve
providing stability
Providing stability,
Infraspinatus Dorsal scapula Humerus (GT) Suprascapular nerve
externally rotating arm
Scapula Providing stability,
Teres minor Humerus (GT) Axillary nerve
(dorsolateral) externally rotatjng arm
Trapezius Levator scapulae

Rhomboid minor
Latissimus
dorsi

Supraspinatus Suprascapular notch (foramen)
Cut edge
of deltoid
Surgical neck
of humerus
Medial lip of
intertubercular
sulcus
Quadrangular
space
Triangular interval
Teres major Deltoid tuberosity
of humerus
Long head
of triceps
brachii
Cut edge of lateral head

of triceps brachii

Muscles of the Arm and Forearm
Muscles of the Arm
Coracobrachialis Coracoid Mid-humerus (medial) Flexion, adduction Musculocutaneous
Biceps brachii Coracoid (short head) Radial tuberosity Supination, flexion Musculocutaneous
Supraglenoid (long
head)
Brachialis Anterior humerus Ulnar tuberosity (anterior) Flexing forearm Musculocutaneous,
Radial
Triceps brachii Infraglenoid (long head) Olecranon Extending forearm Radial
Posterior humerus (Elbow extension).
(lateral head) The long head can Blood supply by
Posterior humerus adduct the Profunda brachii
(medial head)* humerus and and artery
extend it from a
flexed position
The radial nerve and profunda brachii vessels lie between the lateral and medial heads
Transverse humeral ligament
Short head of biceps

brachii muscle
Coracobrachialis muscle
Radial tuberosity

Superficial Flexors of the Forearm
Pronator teres Medial epicondyle and coronoid Mid-lateral radius Pronating, Median nerve
flexing forearm
Flexor carpi radialis Medial epicondyle 2nd & 3rd MC bases Flexing wrist Median nerve
Palmaris longus Medial epicondyle Palmar aponeurosis Flexing wrist Median nerve
Flexor carpi ulnaris Medial epicondyle and posterior ulna Pisiform Flexing wrist Ulnar nerve
Flexor digitorum Medial epicondyle, proximal anterior Base of middle Flexing PIP Median nerve
superficialis ulna and anterior radius phalanges joint
Humeral head of
pronator teres
Humeral head of
flexor carpi ulnaris
Ulnar head of
pronator teres Ulnar head of
Ulnar artery flexor carpi ulnaris
Median nerve
Flexor carpi ulnaris
Pisohamate ligament
Pisiform
Pisometacarpal ligament
Hook of hamate

Deep Flexors of the Forearm
Flexor digitorum Anterior and Base of distal Flexing DIP joint Median–anterior interosseous/ulnar
profundus medial ulna phalanges nerves
Flexor pollicis longus Anterior and Base of distal Flexing IP joint, Median–anterior interosseous nerve
lateral radius phalanges thumb
Pronator quadratus Distal ulna Volar radius Pronating hand Median–anterior interosseous nerve
Humero-ulnar head of
flexor digitorum
superficialis
Interosseous
membrane
Flexor
Flexor digitorum digitorum
superficialis profundus
Flexor digitorum
superficialis
tendon (cut)

Superficial Extensors of the Forearm
Brachioradialis Lateral supracondylar Lateral distal radius Flexing forearm Radial nerve
humerus
Extensor carpi Lateral supracondylar Second metacarpal Extending wrist Radial nerve
radialis longus humerus base
Extensor carpi Lateral epicondyle of humerus Third metacarpal Extending wrist Radial nerve
radialis brevis base
Anconeus Lateral epicondyle of humerus Proximal dorsal ulna Extending forearm Radial nerve
Extensor Lateral epicondyle of humerus Extensor aponeurosis Extending digits Radial–posterior
digitorum interosseous nerve
Extensor digiti Common extensor tendon Small finger extensor Extending small Radial–posterior
minimi expansion over P1 finger interosseous nerve
Extensor carpi Lateral epicondyle of humerus Fifth metacarpal base Extending/adducting Radial–posterior
ulnaris hand interosseous nerve
Extensor carpi
radialis longus
Extensor carpi
radialis brevis
Extensor carpi
ulnaris
Anterior View Posterior View

Deep Extensors of the Forearm
Supinator Lateral epicondyle of Dorsolateral radius Supinating forearm Radial–posterior
humerus, ulna interosseous nerve
Abductor Dorsal ulna/radius First metacarpal base Abducting/extending Radial–posterior
pollicis longus thumb interosseous nerve
Extensor pollicis Dorsal radius Thumb proximal phalanx Extending thumb Radial–posterior
brevis base MCP joint interosseous nerve
Extensor pollicis Dorsolateral ulna Thumb dorsal phalanx Extending thumb IP Radial–posterior
longus base joint interosseous nerve
Extensor indicis Dorsolateral ulna Index finger extensor Extending index Radial–posterior
proprius apparatus (ulnarly) finger interosseous nerve
Supinator
(deep head)
Supinator
(superficial head)
Abductor pollicis longus
Extensor indicis
Extensor carpi
radialis longus
Extensor carpi
radialis brevis
Abductor
pollicis longus
Extensor digiti minimi Extensor
pollicis brevis
Posterior View

Extensor retinaculum / Dorsal Wrist Compartments
The extensor rentinaculum is a thickening of the deep fascia that stretches across the back of the wrist and holds the
long extensor tendons in position.
Its attachments are:
• The pisiform and triquetral medially Structures superficial to the retinaculum
• The end of the radius laterally • Basilic vein
• Dorsal cutaneous branch of the ulnar nerve
Beneath the extensor retinaculum fibrous septa form six • Cephalic vein
compartments that contain the extensor muscle tendons. • Superficial branch of the radial nerve
Each compartment has its own synovial sheath.
Compartment Contents Pathologic Condition
I Abductor pollicis longus De Quervain’s tenosynovitis
Extensor pollicis brevis
II Extensor carpi radialis longus, Extensor tendinitis (intersection syndrome)
Extensor carpi radialis brevis
III Extensor pollicis longus Rupture at Lister’s tubercle (after wrist fractures)
Drummer’s tendinitis of the wrist
IV Extensor digitorum communis Extensor tenosynovitis
Extensor indicis proprius
V Extensor digiti minimi Rupture (rheumatoid arthritis: Vaughn-Jackson syndrome)
VI Extensor carpi ulnaris Snapping at ulnar styloid
Palmaris longus tendon

Flexor retinaculum
Median nerve
Flexor carpi radialis tendon
Flexor digitorum
superficialis tendons Flexor pollicis longus tendon
Extensor pollicis brevis tendon
Extensor carpi ulnaris Cephalic vein
Radial artery
Extensor pollicis longus tendon

Extensor digiti minimi tendon Extensor carpi radialis longus tendon
Extensor digitorum tendons Extensor carpi radialis brevis tendon

Extensor indicis tendon
Neuroanatomic Relationships in the Forearm

Nerve Relationships
Radial Between brachialis and brachioradialis
Posterior interosseous Splits supinator
Superficial radial Between brachioradialis and extensor carpi radialis longus
Median Medial to brachial artery at elbow
Anterior interosseous Splits pronator teres and runs between flexor digitorum superficialis and flexor digitorum
profundus
Between flexor pollicis longus and flexor digitorum profundus
Ulnar Between flexor carpi ulnaris and flexor digitorum profundus
The radial artery passes between the lateral collateral ligament of the wrist joint and the tendons of the abductor pollicis
longus and extensor pollicis brevis.

Muscles of the Hand and Wrist
Thenar Muscles
Abductor pollicis Scaphoid, trapezoid Base of proximal phalanx, Abducting thumb Median nerve
brevis radial side
Opponens Trapezium Thumb metacarpal Abducting, flexing, Median nerve
pollicis rotating (medially)
Flexor pollicis Trapezium, capitate Base of proximal phalanx, Flexing MCP joint Median, ulnar
brevis radial side nerves
Adductor pollicis Capitate, second and Base of proximal phalanx, Adducting thumb Ulnar nerve
third metacarpals ulnar side
Hypothenar Muscles
Palmaris brevis TCL, palmar Ulnar palm Retracting skin Ulnar nerve
aponeurosis
Abductor digiti Pisiform Base of proximal phalanx, Abducting small finger Ulnar nerve
minimi ulnar side
Flexor digiti Hamate, TCL Base of proximal phalanx, Flexing MCP joint Ulnar nerve
minimi brevis ulnar side
Opponens digiti Hamate, TCL Small-finger metacarpal Abducting, flexing, Ulnar nerve
minimi rotating (laterally)
Intrinsic Muscles
Lumbrical Flexor digitorum Lateral bands (radial) Extending proximal Median, ulnar
profundus interphalangeal joint nerves
Dorsal Adjacent metacarpals Proximal phalanx Abducting, flexing Ulnar nerve
interosseous base/extensor apparatus MCP joint
Volar Adjacent metacarpals Proximal phalanx Adducting, flexing Ulnar nerve
interosseous base/extensor apparatus MCP joint
Flexor digiti minimi brevis
Three hypothenar muscles

Three thenar muscles
Abductor pollicis and first

palmar interosseous insert
Transverse head of into medial side of
adductor pollicis extensor hood
Opponens Flexor pollicis

digiti brevis and
minimi abductor pollicis
Radial artery brevis insert into
Abductor lateral side of
(deep palmar arch)
digiti minimi extensor hood
Sesamoid bone Opponens pollicis
Oblique head Deep branch Recurrent branch of

of adductor of ulnar artery median nerve
pollicis and nerve
Abductor pollicis brevis
Flexor carpi ulnaris
Median nerve
Flexor retinaculum

Hand
Anatomy of the hand
Bones • 8 Carpal bones
• 5 Metacarpals
• 14 phalanges
Intrinsic Muscles 7 Interossei - Supplied by ulnar nerve
• 3 palmar-adduct fingers
• 4 dorsal- abduct fingers
Intrinsic muscles Lumbricals
• Flex MCPJ and extend the IPJ.
• Origin deep flexor tendon and insertion dorsal extensor hood mechanism.
• Innervation: 1st and 2nd- median nerve, 3rd and 4th- deep branch of the ulnar
nerve.
Thenar eminence • Abductor pollicis brevis
• Opponens pollicis
• Flexor pollicis brevis
Hypothenar eminence • Opponens digiti minimi
• Flexor digiti minimi brevis
• Abductor digiti minimi
Fascia and compartments of the palm

The fascia of the palm is continuous with the antebrachial fascia and
the fascia of the dorsum of the hand. The palmar fascia is thin over the
thenar and hypothenar eminences. In contrast, the central palmar
fascia is relatively thick. The palmar aponeurosis covers the soft
tissues and overlies the flexor tendons. The apex of the palmar
aponeurosis is continuous with the flexor retinaculum and the
palmaris longus tendon. Distally, it forms four longitudinal digital
bands that attach to the bases of the proximal phalanges, blending
with the fibrous digital sheaths.
A medial fibrous septum extends deeply from the medial border of the
palmar aponeurosis to the 5th metacarpal. Lying medial to this are the
hypothenar muscles. In a similar fashion, a lateral fibrous septum
extends deeply from the lateral border of the palmar aponeurosis to
the 3rd metacarpal. The thenar compartment lies lateral to this area.
Lying between the thenar and hypothenar compartments is the
central compartment. It contains the flexor tendons and their sheaths,
the lumbricals, the superficial palmar arterial arch and the digital
vessels and nerves.
The deepest muscular plane is the adductor compartment, which
contains adductor pollicis.

Short muscles of the hand
These comprise the lumbricals and
interossei. The four slender lumbrical
muscles flex the fingers at the
metacarpophalangeal joints and extend
the interphalangeal joint. The four dorsal
interossei are located between the
metacarpals and the four palmar
interossei lie on the palmar surface of the
metacarpals in the interosseous
compartment of the hand.
Long flexor tendons and sheaths in the hand

The tendons of FDS and FDP enter the
common flexor sheath deep to the flexor
retinaculum. The tendons enter the central
compartment of the hand and fan out to
their respective digital synovial sheaths.
Near the base of the proximal phalanx, the
tendon of FDS splits to permit the passage of
FDP. The FDP tendons are attached to the
margins of the anterior aspect of the base of
the distal phalanx.
The fibrous digital sheaths contain the flexor
tendons and their synovial sheaths. These
extend from the heads of the metacarpals to
the base of the distal phalanges.

Interossei
Origin and insertion Nerve supply Actions
Three palmar and four dorsal interossei occupy the spaces between the They are all Dorsal interossei
metacarpal bones. Each palmar interossei originates from the innervated by abduct the fingers,
metacarpal of the digit on which it acts. the ulnar nerve palmar interossei
Each dorsal interossei comes from the surface of the adjacent adduct the fingers
metacarpal on which it acts. As a result, the dorsal interossei are twice
the size of the palmar ones.
The interossei tendons, except the first palmar, pass to one or other side
of the metacarpophalangeal joint posterior to the deep transverse
metacarpal ligament. They become inserted into the base of the
proximal phalanx and partly into the extensor hood
Clinical notes
Along with the lumbricals the interossei flex the metacarpophalangeal joints and extend the proximal and distal
interphalangeal joints. They are responsible for fine tuning these movements. When the interossei and lumbricals are
paralysed the digits are pulled into hyperextension by extensor digitorum and a claw hand is seen.
Dorsal interossei (palmar view) Palmar interossei (palmar view)

Anatomical snuffbox
Posterior border (medially) Tendon of extensor pollicis longus
Anterior border (laterally) Tendons of extensor pollicis brevis and abductor pollicis longus
Proximal border Styloid process of the radius
Distal border Apex of snuffbox triangle
Floor Trapezium and scaphoid
Content Radial artery
Anatomical Snuffbox

Arteries of the UL
Axillary artery
Part Branch Course
I Sup. Thoracic a. Medial to serratus anterior and pectoral muscles
II Thoracoacromial a. Four branches: deltoid, acromial, pectoralis, clavicular
Lateral thoracic a. Descends to serratus anterior
III Subscapular a. (largest br.) Two branches: thoracodorsal and circumflex scapular (triangular space)
Anterior humeral circumflex a. Blood supply to humeral head: arcuate artery lateral to bicipital groove
Posterior humeral circumflex Branch in the quadrangular space accompanying the axillary nerve
a.

Brachial artery
The brachial artery begins at the lower border of teres major as a continuation of the axillary artery. It terminates in the
cubital fossa at the level of the neck of the radius by dividing into the radial and ulnar arteries.
Relations
Posterior relations include the long head of triceps with the radial nerve and profunda vessels intervening. Anteriorly it is
overlapped by the medial border of biceps.
It is crossed by the median nerve in the middle of the arm.
In the cubital fossa it is separated from the median cubital vein by the bicipital aponeurosis.
The basilic vein is in contact at the most proximal aspect of the cubital fossa and lies medially.

Ulnar artery
Path
• Starts: middle of antecubital fossa
• Passes obliquely downward, reaching the ulnar
side of the forearm at a point about midway
between the elbow and the wrist. It follows the
ulnar border to the wrist, crossing over the flexor
retinaculum. It then divides into the superficial
and deep volar arches.
Relations
Deep to- Pronator teres, Flexor carpi radialis, Palmaris
longus
Lies on- Brachialis and Flexor digitorum profundus
Superficial to the flexor retinaculum at the wrist
The median nerve is in relation with the medial side of the

artery for about 2.5 cm. And then crosses the vessel, being
separated from it by the ulnar head of the Pronator teres
The ulnar nerve lies medially to the lower two-thirds of the

artery
Branch
• Anterior interosseous artery
Radial artery

Veins of the UL
Basilic vein
The basilic and cephalic veins both provide the main pathways of venous drainage for the arm and hand. It is continuous
with the palmar venous arch distally and the axillary vein proximally.
Path
• Originates on the medial side of the dorsal venous network of the hand, and passes up the forearm and arm.
• Most of its course is superficial.
• Near the region anterior to the cubital fossa the vein joins the cephalic vein.
• Midway up the humerus the basilic vein passes deep under the muscles.
• At the lower border of the teres major muscle, the anterior and posterior circumflex humeral veins feed into it.
• It is often joined by the medial brachial vein before draining into the axillary vein.
Clavicle
Clavipectoral triangle
Biceps brachii
Basilic vein
Median cubital vein

Cephalic vein

Nerves of the UL
Brachial plexus
Origin Anterior rami of C5 to T1
Sections of • Roots, trunks, divisions, cords, branches
the plexus • Mnemonic :Real Teenagers Drink Cold Beer
Roots • Located in the posterior triangle
• Pass between scalenus anterior and medius
Trunks • Located posterior to middle third of clavicle
• Upper and middle trunks related superiorly to the subclavian artery
• Lower trunk passes over 1st rib posterior to the subclavian artery
Divisions Apex of axilla
Cords Related to axillary artery

Mnemonic branches off the posterior cord
• Subscapular (upper and lower)
• Thoracodorsal
• Axillary
• Radial
Summary of Upper Extremity Innervation

Nerves Muscles Innervated
Musculocutaneous Coracobrachialis, biceps, brachialis
(lateral cord)
Axillary (posterior cord) Deltoid, teres minor
Radial (posterior cord) Triceps, brachioradialis, extensor carpi radialis longus and brevis
Posterior interosseous Supinator, extensor carpi ulnaris, extensor digitorum, extensor digiti minimi, abductor
pollicis longus, extensor pollicis longus and brevis, extensor indicis proprius
Median (medial and Pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis,
lateral cord) abductor pollicis brevis, supinator head of flexor pollicis brevis, opponens pollicis, first
and second lumbrical muscles
Anterior interosseous Flexor digitorum profundus (first and second), flexor pollicis longus, pronator
quadratus
Ulnar (medial cord) Flexor carpi ulnaris, flexor digitorum profundus (third and fourth), palmaris brevis,
abductor digiti minimi, opponens digiti minimi, flexor digiti minimi, third and fourth
lumbrical muscles, interossei, adductor pollicis, deep head of flexor pollicis brevis

Musculocutaneous nerve
Path
• Branch of lateral cord of brachial plexus
• It penetrates the coracobrachialis muscle
• Passes obliquely between the biceps brachii and the brachialis to the lateral side of the arm
• Above the elbow it pierces the deep fascia lateral to the tendon of the biceps brachii
• Continues into the forearm as the lateral cutaneous nerve of the forearm
Innervates
• Coracobrachialis
• Biceps brachii
• Brachialis
Median nerve
The median nerve is formed by the union of a lateral and medial root respectively from the lateral (C5,6,7) and medial
(C8 and T1) cords of the brachial plexus; the medial root passes anterior to the third part of the axillary artery. The nerve
descends lateral to the brachial artery, crosses to its medial side (usually passing anterior to the artery). It passes deep to
the bicipital aponeurosis and the median cubital vein at the elbow.
It passes between the two heads of the pronator teres muscle, and runs on the deep surface of flexor digitorum
superficialis (within its fascial sheath).
Near the wrist it becomes superficial between the tendons of flexor digitorum superficialis and flexor carpi radialis, deep
to palmaris longus tendon. It passes deep to the flexor retinaculum to enter the palm, but lies anterior to the long flexor
tendons within the carpal tunnel.
Branches
Region Branch
Upper arm No branches, although the nerve commonly communicates with the musculocutaneous nerve
Forearm Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor digitorum superficialis
Flexor pollicis longus
Flexor digitorum profundus (only the radial half)
Distal forearm Palmar cutaneous branch
Hand (Motor) Motor supply (LOAF)
• Lateral 2 lumbricals
• Opponens pollicis
• Abductor pollicis brevis
• Flexor pollicis brevis
Hand (Sensory) • Over thumb and lateral 2 ½ fingers
• On the palmar aspect this projects proximally, on the dorsal aspect only the distal regions are
innervated with the radial nerve providing the more proximal cutaneous innervation.
Patterns of damage
Damage at wrist
• e.g. carpal tunnel syndrome
• paralysis and wasting of thenar eminence muscles and opponens pollicis (ape hand deformity)
• sensory loss to palmar aspect of lateral (radial) 2 ½ fingers
Damage at elbow, as above plus:

• unable to pronate forearm
• weak wrist flexion
• ulnar deviation of wrist
Anterior interosseous nerve (branch of median nerve)

• leaves just below the elbow
• results in loss of pronation of forearm and weakness of long flexors of thumb and index finger

Ulnar nerve
Origin
• C8, T1
Supplies (no muscles in the upper arm) Ulnar nerve: Mafia P

• Flexor carpi ulnaris Medial 2 lumbricals
• Flexor digitorum profundus Adductor pollicis
• Flexor digiti minimi Flexor digitorum profundus/Flexor carpi ulnaris
• Abductor digiti minimi Interossei
• Opponens digiti minimi Abductor and Opponens and flexor digiti minimi (hypothenar eminence)
• Adductor pollicis Palmaris brevis
• Interossei muscle
• Third and fourth lumbricals Innervates all intrinsic muscles of the hand
• Palmaris brevis (EXCEPT 2: thenar muscles & first two lumbricals - supplied by median n.)
Path
• Posteromedial aspect of upper arm to flexor compartment of forearm, then along the ulnar. Passes beneath the
flexor carpi ulnaris muscle, then superficially through the flexor retinaculum into the palm of the hand.
Branches
Branch Supplies
Muscular branch Flexor carpi ulnaris
Medial half of the flexor digitorum profundus
Palmar cutaneous branch (Arises near Skin on the medial part of the palm
the middle of the forearm)
Dorsal cutaneous branch Dorsal surface of the medial part of the hand
Superficial branch Cutaneous fibres to the anterior surfaces of the medial one and one-half
digits
Deep branch Hypothenar muscles
All the interosseous muscles
Third and fourth lumbricals
Adductor pollicis
Medial head of the flexor pollicis brevis
Effects of injury
Damage at the wrist • Wasting and paralysis of intrinsic hand muscles (claw hand)
• Wasting and paralysis of hypothenar muscles
• Loss of sensation medial 1 and half fingers
Damage at the elbow • Radial deviation of the wrist
• Clawing less in 4th and 5th digits

Radial nerve
Continuation of posterior cord of the brachial
plexus (root values C5 to T1)
Path
• In the axilla: lies posterior to the axillary
artery on subscapularis, latissimus dorsi and
teres major.
• Enters the arm between the brachial artery
and the long head of triceps (medial to
humerus).
• Spirals around the posterior surface of the
humerus in the groove for the radial nerve.
• At the distal third of the lateral border of the
humerus it then pierces the intermuscular
septum and descends in front of the lateral
epicondyle.
• At the lateral epicondyle it lies deeply
between brachialis and brachioradialis where
it then divides into a superficial and deep
terminal branch.
• Deep branch crosses the supinator to
become the posterior interosseous nerve.
Regions innervated
Motor (main • Triceps
nerve) • Anconeus
• Brachioradialis
• Extensor carpi radialis
Motor • Supinator
(posterior • Extensor carpi ulnaris
interosseous • Extensor digitorum
branch) • Extensor indicis
• Extensor digiti minimi
• Extensor pollicis longus
• Extensor pollicis brevis
• Abductor pollicis longus
Sensory The area of skin supplying the
proximal phalanges on the
dorsal aspect of the hand is
supplied by the radial nerve
(this does not apply to the
little finger and part of the ring
finger)
Muscular innervation and effect of denervation

Anatomical location Muscle affected Effect of paralysis
Shoulder Long head of triceps Minor effects on shoulder stability in abduction
Arm Triceps Loss of elbow extension
Forearm Supinator Weakening of supination of prone hand and
Brachioradialis elbow flexion in mid prone position
Extensor carpi radialis longus and brevis

Joints of the UL
Shoulder joint
• Shallow synovial ball and socket type of joint.
• It is an inherently unstable joint, but is capable to a wide range of movement.
• Stability is provided by muscles of the rotator cuff that pass from the scapula to insert in the greater tuberosity (all
except sub scapularis-lesser tuberosity).
Glenoid labrum
• Fibrocartilaginous rim attached to the free edge of the glenoid cavity
• Tendon of the long head of biceps arises from within the joint from the supraglenoid tubercle, and is fused at
this point to the labrum.
• The long head of triceps attaches to the infraglenoid tubercle
Fibrous capsule
• Attaches to the scapula external to the glenoid labrum and to the labrum itself (postero-superiorly)
• Attaches to the humerus at the level of the anatomical neck superiorly and the surgical neck inferiorly
• Anteriorly the capsule is in contact with the tendon of subscapularis, superiorly with the supraspinatus tendon,
and posteriorly with the tendons of infraspinatus and teres minor. All these blend with the capsule towards
their insertion.
• Two defects in the fibrous capsule; superiorly for the tendon of biceps. Anteriorly there is a defect beneath the
subscapularis tendon.
• The inferior extension of the capsule is closely related to the axillary nerve at the surgical neck and this nerve is
at risk in anteroinferior dislocations. It also means that proximally sited osteomyelitis may progress to septic
arthritis. Subacromial bursa
(subdeltoid) Long head of biceps brachii tendon
Deltoid Subtendinous bursa of subscapularis
Fibrous membrane
Pectoralis major
Long head of triceps
Short head of biceps brachii and

coracobrachialis

Infraspinatus
Movements and muscles
Flexion Anterior part of deltoid
Pectoralis major
Biceps
Coracobrachialis
Extension Posterior deltoid
Teres major
Latissimus dorsi
Adduction Pectoralis major
Latissimus dorsi
Teres major
Coracobrachialis
Abduction Mid deltoid
Supraspinatus
Medial rotation Subscapularis
Anterior deltoid
Teres major
Latissimus dorsi
Lateral rotation Posterior deltoid
Infraspinatus
Teres minor
Important anatomical relations

Anteriorly Brachial plexus
Axillary artery and vein
Posterior Suprascapular nerve
Suprascapular vessels
Inferior Axillary nerve
Circumflex humeral vessels
Superior glenohumeral ligament

Coracohumeral Middle glenohumeral ligament
Subtendinous bursa of ligament
subscapularis
Coracohumeral ligament
Synovial sheath
Synovial membrane
Long head of biceps

brachii tendon
Redundant capsule
Redundant synovial
membrane in adduction

Important Regions of the UL
Breast
The breast itself lies on a layer of pectoral fascia and the following muscles:
1. Pectoralis major
2. Serratus anterior
3. External oblique
Breast anatomy
Nerve supply Branches of intercostal nerves from T4-T6.
Arterial supply • Internal mammary (thoracic) artery
• External mammary artery (laterally)
• Anterior intercostal arteries
• Thoraco-acromial artery
Venous drainage Superficial venous plexus to subclavian, axillary and intercostal veins.
Lymphatic • 70% Axillary nodes
drainage • Internal mammary chain
• Other lymphatic sites such as deep cervical and supraclavicular fossa (later in disease)

Axilla
Boundaries of the axilla
Medially Chest wall and Serratus anterior
Laterally Humeral head
Floor Subscapularis
Anterior aspect Lateral border of Pectoralis major
Fascia Clavipectoral fascia
Contents
Long thoracic nerve (of Bell) Derived from C5-C7 and passes behind the brachial plexus to enter the axilla. It lies on
the medial chest wall and supplies serratus anterior. Its location puts it at risk during
axillary surgery and damage will lead to winging of the scapula.
Thoracodorsal nerve and Innervate and vascularise latissimus dorsi.
thoracodorsal trunk
Axillary vein Lies at the apex of the axilla, it is the continuation of the basilic vein. Becomes the
subclavian vein at the outer border of the first rib.
Intercostobrachial nerves Traverse the axillary lymph nodes and are often divided during axillary surgery. They
provide cutaneous sensation to the axillary skin.
Lymph nodes The axilla is the main site of lymphatic drainage for the breast.

Cubital Fossa

Surface Anatomy

1B. ANATOMY (LOWER LIMB) – MRCS NOTES - REDA
Bones of the Pelvis and Lower Limbs ............................................................................................................. 2
Muscles of LL ................................................................................................................................................... 9
Gluteal region.............................................................................................................................................. 9
Muscles of the Pelvis and Hip................................................................................................................... 10
Muscles of the Thigh ................................................................................................................................. 14
Muscles of the Leg .................................................................................................................................... 17
Muscles of the Ankle and Foot ................................................................................................................. 20
Greater sciatic foramen ............................................................................................................................ 22
Fascial compartments of the leg .............................................................................................................. 23
Arteries of LL ................................................................................................................................................. 24
Anterior tibial artery ................................................................................................................................. 24
Posterior tibial artery ............................................................................................................................... 24
Veins of LL ..................................................................................................................................................... 29
Saphenous vein ......................................................................................................................................... 29
Nerves of LL ................................................................................................................................................... 30
Genitofemoral nerve ................................................................................................................................ 31
Pudendal nerve ......................................................................................................................................... 32
Femoral nerve ........................................................................................................................................... 33
Obturator nerve ........................................................................................................................................ 34
Sciatic nerve .............................................................................................................................................. 35
Common Peroneal (Common Fibular) (Lat. Popliteal) nerve .................................................................. 37
Deep peroneal (Deep fibular) (Ant. Tibial) nerve .................................................................................... 38
Important Regions ........................................................................................................................................ 39
Femoral triangle anatomy ........................................................................................................................ 39
Femoral canal ............................................................................................................................................ 40
Adductor canal .......................................................................................................................................... 40
Popliteal fossa ........................................................................................................................................... 41
Pudendal (Alcock’s) canal ......................................................................................................................... 41
Foot - Anatomy ......................................................................................................................................... 42
Joints of LL ..................................................................................................................................................... 45
Hip joint ..................................................................................................................................................... 45
Knee joint .................................................................................................................................................. 46
Ankle joint ................................................................................................................................................. 49
Surface Anatomy........................................................................................................................................... 50
1B. ANATOMY (LOWER LIMB) – MRCS NOTES - REDA 1

Bones of the Pelvis and Lower Limbs

Muscles of LL
Gluteal region
Gluteal muscles
• Gluteus maximus: inserts to gluteal tuberosity of the femur and
iliotibial tract
• Gluteus medius: attach to lateral greater trochanter
• Gluteus minimis: attach to anterior greater trochanter
• All extend and abduct the hip
Deep lateral hip rotators

• Piriformis
• Gemelli
• Obturator internus
• Quadratus femoris
Nerves
Superior gluteal nerve (L5, S1) • Gluteus medius
• Gluteus minimis
• Tensor fascia lata
Inferior gluteal nerve Gluteus maximus
Damage to the superior gluteal nerve will result in the patient developing a
Trendelenberg gait. Affected patients are unable to abduct the thigh at the hip
joint. During the stance phase, the weakened abductor muscles allow the
pelvis to tilt down on the opposite side. To compensate, the trunk lurches to
the weakened side to attempt to maintain a level pelvis throughout the gait
cycle. The pelvis sags on the opposite side of the lesioned superior gluteal
nerve.

Muscles of the Pelvis and Hip
Muscle Origin Insertion Nerve Segment
Flexors
Iliacus Iliac fossa Lesser trochanter Femoral L2-L4 (P)
Psoas Transverse processes of L1-L5 Lesser trochanter Femoral L2-L4 (P)
Pectineus Pectineal line of pubis Pectineal line of femur Femoral L2-L4 (P)
Rectus femoris Anterior inferior iliac spine, Patella and tibial tubercle Femoral L2-L4 (P)
acetabular rim
Sartorius Anterior superior iliac spine Proximal medial tibia Femoral L2-L4 (P)
Adductors
Posterior adductor Inferior pubic ramus/ischial Linea aspera/adductor Obturator (P) and L2-L4 (A)
magnus tuberosity tubercle sciatic (tibial)
Adductor brevis Inferior pubic ramus Linea aspera/pectineal line Obturator (P) L2-L4 (A)
Adductor longus Anterior pubic ramus Linea aspera Obturator (A) L2-L4 (A)
Gracilis Inferior symphysis/pubic arch Proximal medial tibia Obturator (A) L2-L4 (A)
Pes anserinus: Goose's Foot
Combination of sartorius, gracilis and semitendinous tendons inserting into the anteromedial proximal tibia.

Muscle Origin Insertion Nerve Segment
External Rotators
Gluteus maximus Ilium, posterior gluteal line Iliotibial band/gluteal Inferior gluteal L5-S2 (P)
sling (femur)
Piriformis Anterior sacrum/sciatic notch Proximal greater Piriformis S2 (P)
trochanter
Obturator Ischiopubic rami/obturator Trochanteric fossa Obturator L2-L4 (A)
externus
Obturator Ischiopubic rami/obturator Medial greater Obturator internus L5-S2 (A)
internus membrane trochanter
Superior gemellus Outer ischial spine Medial greater Obturator internus L5-S2 (A)
trochanter
Inferior gemellus Ischial tuberosity Medial greater Quadratus femoris L5-S1 (A)
trochanter
Quadratus femoris Ischial tuberosity Quadrate line of femur Quadratus femoris L5-S1 (A)
Abductors
Gluteus medius Ilium between posterior and Greater trochanter Superior gluteal L4-S1 (P)
anterior gluteal lines
Gluteus minimus Ilium between anterior and Anterior border of Superior gluteal L4-S1 (P)
inferior gluteal lines greater trochanter
Tensor fasciae Anterior iliac crest Iliotibial band Superior gluteal L4-S1 (P)
latae (tensor
fasciae femoris)
A, anterior; P, posterior.
Mnemonic for muscle attachment

on greater trochanter: POGO:
• Piriformis
• Obturator internus
• Gemelli
• Obturator externus

Muscles of the Thigh
Muscle Origin Insertion Innervation
Muscles of the Anterior Thigh
Vastus lateralis Iliotibial line/greater Lateral patella Femoral
trochanter/lateral linea aspera
Vastus medialis Iliotibial line/medial linea Medial patella Femoral
aspera/supracondylar line
Vastus intermedius Proximal anterior femoral shaft Patella Femoral

Muscle Origin Insertion Innervation
Muscles of the Posterior Thigh
Biceps femoris (long head) Medial ischial tuberosity Fibular head/lateral tibia Tibial
Biceps (short head) Lateral linea aspera/lateral Lateral tibial condyle Peroneal
intermuscular septum
Semitendinosus Distal medial ischial tuberosity Anterior tibial crest Tibial
Semimembranosus Proximal lateral ischial tuberosity Oblique popliteal ligament Tibial
Posterior capsule
Posterior/medial tibia
Popliteus
Medial meniscus

Muscles of the Leg
Anterior Compartment
Tibialis anterior Lateral tibia Medial cuneiform, Dorsiflexing, inverting Deep peroneal (L4)
first metatarsal foot nerve
Extensor hallucis Mid-fibula Great toe, distal Dorsiflexing, extending Deep peroneal (L5)
longus phalanx toe nerve
Extensor Tibial condyle/fibula Toe, middle and Dorsiflexing, extending Deep peroneal (L5)
digitorum longus distal phalanges toe nerve
Peroneus tertius Fibula and extensor Fifth metatarsal Everting, dorsiflexing, Deep peroneal (S1)
digitorum longus tendon abducting foot nerve
Lateral Compartment
Peroneus longus Proximal fibula Medial cuneiform, Everting, plantar Superficial peroneal
first metatarsal flexing, abducting foot (S1) nerve
Peroneus brevis Distal fibula Tuberosity of fifth Everting foot Superficial peroneal
metatarsal (S1) nerve

Superficial Posterior Compartment
Gastrocnemius Posterior medial and Calcaneus Plantar flexing foot Tibial (S1) nerve
lateral femoral condyles
Soleus Fibula/tibia Calcaneus Plantar flexing foot Tibial (S1) nerve
Plantaris Lateral femoral condyle Calcaneus Plantar flexing foot Tibial (S1) nerve

Deep Posterior Compartment
Popliteus Lateral femoral condyle, Proximal tibia Flexing, internally Tibial (L5, S1) nerve
fibular head rotating knee
Flexor hallucis Fibula Great toe, distal Plantar flexing great toe Tibial (S1) nerve
longus phalanx
Flexor digitorum Tibia Second to fifth toes, Plantar flexing toes, foot Tibial (S1, S2) nerve
longus distal phalanges
Tibialis posterior Tibia, fibula, Navicular, medial Inverting/plantar flexing Tibial (L4, L5) nerve
interosseous membrane cuneiform foot

Muscles of the Ankle and Foot
Dorsal Layer
Extensor digitorum Superolateral Base of proximal Extending Deep peroneal
brevis calcaneus phalanges nerve
First Plantar Layer
Abductor hallucis Calcaneal Base of great Abducting great toe Medial plantar
tuberosity toe, proximal nerve
phalanx
Flexor digitorum Calcaneal Distal phalanges Flexing toes Medial plantar
brevis tuberosity of second to nerve
fifth toes
Abductor digiti Calcaneal Base of small Abducting small toe Lateral plantar
minimi tuberosity toe nerve
Second Plantar Layer
Quadratus plantae Medial and Flexor digitorum Helping flex distal phalanges Lateral plantar
lateral calcaneus longus tendon nerve
Lumbrical muscles Flexor digitorum Extensor Flexing metatarsophalangeal Medial and
longus tendon digitorum joint, extending lateral plantar
longus tendon interphalangeal joint nerves
Flexor digitorum Tibia/fibula Distal phalanges Flexing toes, inverting foot Tibial nerve
longus and flexor of digits
hallucis longus

Third Plantar Layer
Flexor hallucis brevis Cuboid/lateral Proximal phalanx of Flexing great toe Medial plantar nerve
cuneiform great toe
Adductor hallucis Oblique: second to Proximal phalanx of Adducting great Lateral plantar nerve
fourth metatarsals great toe (lateral) toe
Flexor digiti minimi Base of fifth Proximal phalanx of Flexing small toe Lateral plantar nerve
brevis metatarsal head small toe
Fourth Plantar Layer
Dorsal interosseous Metatarsal Dorsal extensors Abducting Lateral plantar nerve
Plantar interosseous Third to fifth Proximal phalanges Adducting toes Lateral plantar nerve
(peroneus longus and metatarsals medially
tibialis posterior) Fibula/tibia Medial Everting/inverting Superficial
cuneiform/navicular foot peroneal/tibial nerve
Note: For abduction and adduction in the foot, the second toe serves as the reference.

Greater sciatic foramen
Contents
Nerves • Sciatic Nerve
• Superior and Inferior Gluteal Nerves
• Pudendal Nerve
• Posterior Femoral Cutaneous Nerve
• Nerve to Quadratus Femoris
• Nerve to Obturator internus
Vessels • Superior Gluteal Artery and vein
• Inferior Gluteal Artery and vein
• Internal Pudendal Artery and vein
Piriformis
Is a landmark for identifying structures passing out of the sciatic notch
• Above piriformis: Superior gluteal vessels
• Below piriformis: Inferior gluteal vessels, sciatic nerve (10%
pass through it, <1% above it), posterior cutaneous nerve of
the thigh
Greater sciatic foramen boundaries

Anterolaterally Greater sciatic notch of the ilium
Posteromedially Sacrotuberous ligament
Inferior Sacrospinous ligament and the ischial spine
Superior Anterior sacroiliac ligament
Contents of the lesser sciatic foramen

• Tendon of the obturator internus
Structures passing between both foramina
• Pudendal nerve (Medial to lateral) PIN
• Internal pudendal artery and vein • Pudendal nerve
• Nerve to the obturator internus • Internal pudendal artery
• Nerve to obturator internus

Fascial compartments of the leg
Compartments of the thigh
Formed by septae passing from the femur to the fascia lata.
Compartment Nerve Muscles Blood supply
Anterior compartment Femoral • Iliacus Femoral artery
• Tensor fasciae latae
• Sartorius
• Quadriceps femoris
Medial compartment Obturator • Adductor Profunda femoris artery and
longus/magnus/brevis obturator artery
• Gracilis
• Obturator externus
Posterior compartment (2 Sciatic • Semimembranosus Branches of Profunda femoris artery
layers) • Semitendinosus
• Biceps femoris
Compartments of the lower leg

Separated by the interosseous membrane (anterior and posterior compartments), anterior fascial septum (separate
anterior and lateral compartments) and posterior fascial septum (separate lateral and posterior compartments)
Compartment Nerve Muscles Blood supply
Anterior Deep peroneal • Tibialis anterior Anterior tibial
compartment nerve • Extensor digitorum longus artery
• Extensor hallucis longus
• Peroneus tertius
Posterior Tibial • Muscles: deep and superficial compartments Posterior tibial
compartment (separated by deep transverse fascia)
• Deep: Flexor hallucis longus, Flexor digitalis longus,
Tibialis posterior, Popliteus
• Superficial: Gastrocnemius, Soleus, Plantaris
Lateral Superficial • Peroneus longus/brevis Peroneal artery
compartment peroneal

Arteries of LL
Anterior tibial artery
• Begins opposite the distal border of popliteus
• Terminates in front of the ankle, continuing as the dorsalis pedis artery
• As it descends it lies on the interosseous membrane, distal part of the tibia and front of the ankle joint
• Passes between the tendons of extensor digitorum and extensor hallucis longus distally
• It is related to the deep peroneal nerve, it lies anterior to the middle third of the vessel and lateral to it in the lower
third
Posterior tibial artery

• Larger terminal branch of the popliteal artery
• Terminates by dividing into the medial and lateral plantar arteries
• Accompanied by two veins throughout its length
• Position of the artery corresponds to a line drawn from the lower angle of the popliteal fossa, at the level of the neck
of the fibula, to a point midway between the medial malleolus and the most prominent part of the heel
Relations of the posterior tibial artery (Proximal to distal)

Anteriorly Tibialis posterior
Flexor digitorum longus
Posterior surface of tibia and ankle joint
Posterior Tibial nerve 2.5 cm distal to its origin
Fascia overlying the deep muscular layer
Proximal part covered by gastrocnemius and soleus
Distal part covered by skin and fascia

Deep artery of thigh. A. Anterior view. B. Posterior view.

Veins of LL
Saphenous vein
Long saphenous vein
This vein may be harvested for bypass surgery, or removed as
treatment for varicose veins with saphenofemoral junction
incompetence.
• Originates at the 1st digit where the dorsal vein
merges with the dorsal venous arch of the foot
• Passes anterior to the medial malleolus and runs up
the medial side of the leg
• At the knee, it runs over the posterior border of the
medial epicondyle of the femur bone
• Then passes laterally to lie on the anterior surface of
the thigh before entering an opening in the fascia
lata called the saphenous opening
• It joins with the femoral vein in the region of the
femoral triangle at the saphenofemoral junction
Tributaries
• Medial marginal
• Superficial epigastric
• Superficial iliac circumflex
• Superficial external pudendal veins
Short saphenous vein

• Originates at the 5th digit where the dorsal vein
merges with the dorsal venous arch of the foot,
which attaches to the great saphenous vein.
• It passes around the lateral aspect of the foot
(inferior and posterior to the lateral malleolus) and
runs along the posterior aspect of the leg (with the
sural nerve)
• Passes between the heads of the gastrocnemius
muscle, and drains into the popliteal vein,
approximately at or above the level of the knee
joint.
The sural nerve is related to the short saphenous vein. The

saphenous nerve is related to the long saphenous vein below
the knee and for this reason full length stripping of the vein is
no longer advocated.

Nerves of LL
Lumbosacral Plexus Divisions and Innervations
Nerve Level Muscles Innervated
Anterior Division
Tibia L4-S3 Semimembranosus, semitendinosusbiceps brachii (long head),
adductor magnus, superior gemellus, soleus, plantaris, popliteus,
tibialis posterior, flexor digitorum longus, flexor hallucis longus
Quadratus femoris L4-S1 Quadratus femoris, inferior gemellus
Obturator internus L5-S2 Obturatorius internus, superior gemellus
Pudendal S2-S4 Sensory: perineal
Motor: bulbocavernosus, urethra, urogenital
Coccygeus S4 Coccygeus
Levator ani S3-S4 Levator ani
Posterior Division
Peroneal L4-S2 Biceps (short head), tibialis anterior, extensor digitorum longus,
peroneus tertius, extensor hallucis longus
Peroneus longus and brevis, extensor hallucis brevis, extensor
digitorum brevis
Superior gluteal L4-S1 Gluteus medius and minimus, tensor fascia lata
Inferior gluteal L5-S2 Gluteus maximus
Piriformis S2 Piriformis
Posterior femoral cutaneous S1-S3 Sensory: posterior thigh

Important Neurologic Features of Lower Extremity
Joint Function Neurologic Level
Hip Flexion T12-L3
Extension S1
Adduction L2-L4
Abduction L5
Knee Flexion L5, S1
Extension L2-L4
Ankle Dorsiflexion L4, L5
Plantar flexion S1, S2
Inversion L4
Eversion S1
Innervation of the Thigh

Nerve Components Muscles Innervated
Femoral L2-L4 Iliacus, psoas major (lower part), sartorius, pectineus, quadriceps, articularis genus
Obturator L2-L4 Obturator externus, hip adductors (brevis, longus, magnus), gracilis
Sciatic L4-S3 Peroneal division: short head of biceps femoris
Tibial division: hamstrings (semitendinosus, semimembranosus), part of adductor
magnus, long head of biceps femoris
Innervation of Lower Extremity

Femoral Iliacus, psoas, quadriceps femoris (rectus femoris, vastus lateralis, vastus intermedius,
and vastus medialis)
Obturator Adductor brevis, adductor longus, adductor magnus (along with tibial nerve), gracilis
Superior gluteal Gluteus medius, gluteus minimus, tensor fascia lata
Inferior gluteal Gluteus maximus
Sciatic Semitendinosus, semimembranosus, biceps femoris (long head [tibial division] and short
head [peroneal division]), adductor magnus (with obturator nerve)
Tibial Gastrocnemius, soleus, tibialis posterior, flexor digitorum longus, flexor hallucis longus,
medial and lateral plantar nerves
Deep peroneal Tibialis anterior, extensor digitorum longus, extensor hallucis longus, peroneus tertius,
extensor digitorum brevis
Superficial peroneal Peroneus longus, peroneus brevis
Innervation of the Ankle and Foot

Medial plantar Flexor hallucis brevis, abductor hallucis, flexor digitorum brevis, first lumbrical muscle
Lateral plantar Pronator quadratus, abductor digiti minimi, flexor digiti minimi, adductor hallucis, interossei,
second to fourth lumbrical muscles
Genitofemoral nerve
Supplies
Small area of the upper medial thigh.
Path
• Arises from the first and second lumbar nerves.
• Passes obliquely through psoas major, and emerges from its medial border opposite the fibrocartilage between
the third and fourth lumbar vertebrae.
• It then descends on the surface of psoas major, under cover of the peritoneum
• Divides into genital and femoral branches.
• The genital branch passes through the inguinal canal, within the spermatic cord, to supply the skin and fascia of
the scrotum. The femoral branch enters the thigh posterior to the inguinal ligament, lateral to the femoral
artery. It supplies an area of skin and fascia over the femoral triangle.
• It may be injured during abdominal or pelvic surgery, or during inguinal hernia repairs.

Pudendal nerve
The pudendal nerve arises from nerve roots S2, S3 and S4 and exits the pelvis through the greater sciatic foramen. It re-
enters the perineum through the lesser sciatic foramen. It travels inferior to give innervation to the anal sphincters and
external urethral sphincter. It also provides cutaneous innervation to the region of perineum surrounding the anus and
posterior vulva.
Traction and compression of the pudendal nerve by the foetus in late pregnancy may result in late onset pudendal
neuropathy which may be part of the process involved in the development of faecal incontinence.

Femoral nerve
Root values L2, 3, 4
Innervates • Pectineus
• Sartorius
• Quadriceps femoris
• Vastus lateralis/medialis/intermedius
Branches • Medial cutaneous nerve of thigh
• Saphenous nerve
• Intermediate cutaneous nerve of thigh
Path
Penetrates psoas major and exits the pelvis by passing
under the inguinal ligament to enter the femoral triangle,
lateral to the femoral artery and vein.
Mnemonic for femoral nerve supply

(don't) M I S V Q Scan for PE
M edial cutaneous nerve of the thigh

I ntermediate cutaneous nerve of the thigh
S aphenous nerve
V astus
Q uadriceps femoris
S artorius
PE ectineus

Obturator nerve
The obturator nerve arises from L2, L3 and L4 by
branches from the ventral divisions of each of these
nerve roots. L3 forms the main contribution and the
second lumbar branch is occasionally absent. These
branches unite in the substance of psoas major,
descending vertically in its posterior part to emerge
from its medial border at the lateral margin of the
sacrum. It then crosses the sacroiliac joint to enter
the lesser pelvis, it descends on obturator internus
to enter the obturator groove. In the lesser pelvis
the nerve lies lateral to the internal iliac vessels and
ureter, and is joined by the obturator vessels lateral
to the ovary or ductus deferens.
Supplies
• Medial compartment of thigh
• Muscles supplied: external obturator,
adductor longus, adductor brevis, adductor
magnus (not the lower part-sciatic nerve),
gracilis
• The cutaneous branch is often absent.
When present, it passes between gracilis
and adductor longus near the middle part
of the thigh, and supplies the skin and
fascia of the distal two thirds of the medial
aspect.
Obturator canal
• Connects the pelvis and thigh: contains the
obturator artery, vein, nerve which divides
into anterior and posterior branches.

Sciatic nerve
The sciatic nerve is formed from the sacral plexus and is the largest nerve in the body. It is the continuation of the main
part of the plexus arising from ventral rami of L4 to S3. These rami converge at the inferior border of piriformis to form
the nerve itself. It passes through the inferior part of the greater sciatic foramen and emerges beneath piriformis.
Medially, lie the inferior gluteal nerve and vessels and the pudendal nerve and vessels. It runs inferolaterally under the
cover of gluteus maximus midway between the greater trochanter and ischial tuberosity. It receives its blood supply from
the inferior gluteal artery. The nerve provides cutaneous sensation to the skin of the foot and the leg. It also innervates
the posterior thigh muscles and the lower leg and foot muscles. The nerve splits into the tibial and common peroneal
nerves approximately half way down the posterior thigh. The tibial nerve supplies the flexor muscles and the common
peroneal nerve supplies the extensor muscles and the abductor muscles.
Summary points
Origin Spinal nerves L4 - S3
Articular Branches Hip joint
Muscular branches in upper leg • Semitendinosus
• Semimembranosus
• Biceps femoris
• Part of adductor magnus
Cutaneous sensation • Posterior aspect of thigh (via cutaneous nerves)
• Gluteal region
• Entire lower leg (except the medial aspect)
Terminates At the upper part of the popliteal fossa by dividing into the tibial and peroneal nerves
• The nerve to the short head of the biceps femoris comes from the common peroneal part of the sciatic and the
other muscular branches arise from the tibial portion.
• The tibial nerve goes on to innervate all muscles of the foot except the extensor digitorum brevis (which is
innervated by the common peroneal nerve).
Sciatic nerve
Lateral popliteal nerve

Medial popliteal nerve
(Common fibular/peroneal
(Tibial nerve)
nerve)
Superficial peroneal/fibular
Deep peroneal/fibular nerve
Posterior tibial nerve nerve (musculocutaneous
(Anterior tibial nerve)
nerve)
Medial planter nerve Lateral planter nerve

Common Peroneal (Common Fibular) (Lat. Popliteal) nerve
Derived from the dorsal divisions of the sacral plexus (L4,
L5, S1 and S2).
This nerve supplies the skin and fascia of the anterolateral

surface of the leg and the dorsum of the foot. It also
innervates the muscles of the anterior and peroneal
compartments of the leg, extensor digitorum brevis as well
as the knee, ankle and foot joints.
It is laterally placed within the sciatic nerve. From the

bifurcation of the sciatic nerve it passes inferolaterally in
the lateral and proximal part of the popliteal fossa, under
the cover of biceps femoris and its tendon. To reach the
posterior aspect of the fibular head. It ends by dividing into
the deep and superficial peroneal nerves at the point where
it winds around the lateral surface of the neck of the fibula
in the body of peroneus longus, approximately 2cm distal to
the apex of the head of the fibula. It is palpable posterior to
the head of the fibula.
Branches
In the thigh Nerve to the short head of biceps
Articular branch (knee)
In the popliteal Lateral cutaneous nerve of the calf
fossa
Neck of fibula Superficial and deep peroneal nerves

Deep peroneal (Deep fibular) (Ant. Tibial) nerve
Origin From the common peroneal nerve, at the
lateral aspect of the fibula, deep to
peroneus longus
Nerve root L4, L5, S1, S2
values
Course and • Pierces the anterior intermuscular
relation septum to enter the anterior
compartment of the lower leg
• Passes anteriorly down to the ankle
joint, midway between the two malleoli
Terminates In the dorsum of the foot
Muscles • Tibialis anterior
innervated • Extensor hallucis longus
• Extensor digitorum longus
• Peroneus tertius
• Extensor digitorum brevis
Cutaneous Web space of the first and second toes
innervation
Actions • Dorsiflexion of ankle joint
• Extension of all toes (extensor hallucis
longus and extensor digitorum longus)
• Inversion of the foot
After its bifurcation past the ankle joint, the lateral branch of
the deep peroneal nerve innervates the extensor digitorum
brevis and the extensor hallucis brevis
The medial branch supplies the web space between the first
and second digits.

Important Regions
Femoral triangle anatomy
Boundaries
Superiorly Inguinal ligament
Laterally Sartorius
Medially Adductor longus
Floor Iliopsoas, adductor longus and pectineus
Roof • Fascia lata and Superficial fascia
• Superficial inguinal lymph nodes (palpable below the inguinal ligament)
• Long saphenous vein
Contents
• Femoral vein (medial to lateral)
• Femoral artery-pulse palpated at the mid
inguinal point
• Femoral nerve
• Deep and superficial inguinal lymph nodes
• Lateral cutaneous nerve
• Great saphenous vein
• Femoral branch of the genitofemoral nerve

Femoral canal
The femoral canal lies at the medial aspect of the femoral sheath. The femoral sheath is a fascial tunnel containing both
the femoral artery laterally and femoral vein medially. The canal lies medial to the vein.
Borders of the femoral canal

Laterally Femoral vein
Medially Lacunar ligament
Anteriorly Inguinal ligament
Posteriorly Pectineal ligament
Contents
• Lymphatic vessels
• Cloquet's lymph node
Physiological significance
Allows the femoral vein to expand to allow for
increased venous return to the lower limbs.
Pathological significance
As a potential space, it is the site of femoral hernias.
The relatively tight neck places these at high risk of
strangulation.
Adductor canal
• Also called Hunter's or subsartorial canal
• Immediately distal to the apex of the femoral
triangle, lying in the middle third of the thigh.
Canal terminates at the adductor hiatus.
Borders
Laterally Vastus medialis muscle
Posteriorly Adductor longus, adductor magnus
Roof Sartorius
Contents
Saphenous nerve
Superficial femoral artery
Superficial femoral vein
(posterior to the artery in the upper part then
posterolat.`)

Popliteal fossa
Boundaries of the popliteal fossa
Laterally Biceps femoris above, lateral head of gastrocnemius and plantaris below
Medially Semimembranosus and semitendinosus above, medial head of gastrocnemius below
Floor Popliteal surface of the femur, posterior ligament of knee joint and popliteus muscle
Roof Superficial and deep fascia
Contents
• Popliteal artery and vein
• Small saphenous vein
• Common peroneal nerve
• Tibial nerve
• Posterior cutaneous nerve of the thigh
• Genicular branch of the obturator nerve
• Lymph nodes
The tibial nerve lies superior to the vessels in the inferior aspect of the popliteal fossa. In the upper part of the fossa the
tibial nerve lies lateral to the vessels, it then passes superficial to them to lie medially. The popliteal artery is the deepest
structure in the popliteal fossa.
Pudendal (Alcock’s) canal

The pudendal canal is located along the lateral wall of the ischioanal fossa at the inferior margin of the obturator internus
muscle. It extends from the lesser sciatic foramen to the posterior margin of the urogenital diaphragm. It conveys the
internal pudendal vessels and nerve.

Foot - Anatomy
Arches of the foot
The foot is conventionally considered to have two arches.
• The longitudinal arch is higher on the medial than on the lateral side. The posterior
part of the calcaneum forms a posterior pillar to support the arch. The lateral part of
this structure passes via the cuboid bone and the lateral two metatarsal bones. The
medial part of this structure is more important. The head of the talus marks the
summit of this arch, located between the sustentaculum tali and the navicular bone.
The anterior pillar of the medial arch is composed of the navicular bone, the three
cuneiforms and the medial three metatarsal bones.
• The transverse arch is situated on the anterior part of the tarsus and the posterior
part of the metatarsus. The cuneiforms and metatarsal bases narrow inferiorly,
which contributes to the shape of the arch.

Intertarsal joints
Sub talar joint Formed by the cylindrical facet on the lower surface of the body of the talus and the
posterior facet on the upper surface of the calcaneus. The facet on the talus is concave
anteroposteriorly, the other is convex. The synovial cavity of this joint does not communicate
with any other joint.
Talocalcaneonavicular The anterior part of the socket is formed by the concave articular surface of the navicular
joint bone, posteriorly by the upper surface of the sustentaculum tali. The talus sits within this
socket
Calcaneocuboid joint Highest point in the lateral part of the longitudinal arch. The lower aspect of this joint is
reinforced by the long plantar and plantar calcaneocuboid ligaments.
Transverse tarsal joint The talocalcaneonavicular joint and the calcaneocuboid joint extend across the tarsus in an
irregular transverse plane, between the talus and calcaneus behind and the navicular and
cuboid bones in front. This plane is termed the transverse tarsal joint.
Cuneonavicular joint Formed between the convex anterior surface of the navicular bone and the concave surface
of the the posterior ends of the three cuneiforms.
Intercuneiform joints Between the three cuneiform bones.
Cuneocuboid joint Between the circular facets on the lateral cuneiform bone and the cuboid. This joint
contributes to the tarsal part of the transverse arch.
A detailed knowledge of the joints is not required for MRCS Part A. However, the contribution they play to the overall
structure of the foot should be appreciated

Nerves in the foot
Lateral plantar nerve
Passes anterolaterally towards the base of the 5th metatarsal between flexor digitorum brevis and flexor accessorius. On
the medial aspect of the lateral plantar artery. At the base of the 5th metatarsal it splits into superficial and deep
branches.
Medial plantar nerve

Passes forwards with the medial plantar artery under the cover of the flexor retinaculum to the interval between
abductor hallucis and flexor digitorum brevis on the sole of the foot.
Plantar arteries
Arise under the cover of the flexor retinaculum, midway between the tip of the medial malleolus and the most
prominent part of the medial side of the heel.
• Medial plantar artery. Passes forwards medial to medial plantar nerve in the space between abductor hallucis
and flexor digitorum brevis.Ends by uniting with a branch of the 1st plantar metatarsal artery.
• Lateral plantar artery. Runs obliquely across the sole of the foot. It lies lateral to the lateral plantar nerve. At the
base of the 5th metatarsal bone it arches medially across the foot on the metatarsals
Dorsalis pedis artery

This vessel is a direct continuation of the anterior tibial artery. It commences on the front of the ankle joint and runs to
the proximal end of the first metatarsal space. Here is gives off the arcuate artery and continues forwards as the first
dorsal metatarsal artery. It is accompanied by two veins throughout its length. It is crossed by the extensor hallucis brevis
Ligaments of the Intertarsal Joints

Ligament Common Name Origin Insertion
Interosseous talocalcaneal Cervical Talus Calcaneus
Calcaneocuboid/calcaneonavicular Bifurcate Calcaneus Cuboid and navicular
Calcaneocuboid-metatarsal Long plantar Calcaneus Cuboid and first to fifth metatarsals
Plantar calcaneocuboid Short plantar Calcaneus Cuboid
Plantar calcaneonavicular Spring Sustentaculum tali Navicular
Tarsometatarsal Lisfranc Medial cuneiform Second metatarsal base
Foot Neuromuscular Interactions

Foot Function Muscle Innervation
Inversion Tibialis anterior Deep peroneal nerve (L4)
Tibialis posterior Tibial nerve (S1)
Dorsiflexion Tibialis anterior, extensor digitorum longus, Deep peroneal nerve: tibialis anterior (L4),
extensor hallucis longus extensor digitorum longus, and extensor
hallucis longus (L5)
Eversion Peroneus longus and peroneus brevis Superficial peroneal nerve (S1)
Plantar flexion Gastrocnemius-soleus complex, flexor digitorum Tibial nerve (S1)
longus, flexor hallucis longus, tibialis posterior
(also hindfoot inverter)

Joints of LL
Hip joint Mnemonic lateral hip rotators:
• Head of femur articulates with acetabulum of the pelvis P-GO-GO-Q (top to bottom)
• Both covered by articular hyaline cartilage • Piriformis
• The acetabulum forms at the union of the ilium, pubis, and ischium • Gemellus superior
• The triradiate cartilage (Y-shaped growth plate) separates the pelvic bones • Obturator internus
• The acetabulum holds the femoral head by the acetabular labrum • Gemellus inferior
• Normal angle between femoral head and femoral shaft is 130o • Obturator externus
• Quadratus femoris
Ligaments
• Transverse ligament: joints anterior and posterior ends of the articular cartilage
• Head of femur ligament (ligamentum teres): acetabular notch to the fovea. Contains arterial supply to head of
femur in children.
•
Extracapsular ligaments
• Iliofemoral ligament: inverted Y shape. Anterior iliac spine to the trochanteric line
• Pubofemoral ligament: acetabulum to lesser trochanter
• Ischiofemoral ligament: posterior support. Ischium to greater trochanter.
Blood supply
Medial circumflex femoral and lateral circumflex femoral arteries (Branches of profunda femoris). Also from the inferior
gluteal artery. These form an anastomosis and travel to up the femoral neck to supply the head.
Nerve supply of lateral hip rotators

• Piriformis: ventral rami S1, S2
• Obturator internus: nerve to obturator internus
• Superior gemellus: nerve to obturator internus
• Inferior gemellus: nerve to quadratus femoris
• Quadrator femoris: nerve to quadrator femoris

Knee joint
The knee joint is a synovial joint, the largest and most complicated. It consists of two condylar joints between the femur
and tibia and a sellar joint between the patella and the femur. The tibiofemoral articular surfaces are incongruent,
however, this is improved by the presence of the menisci. The degree of congruence is related to the anatomical position
of the knee joint and is greatest in full extension.
Knee joint compartments

Tibiofemoral • Comprised of the patella/femur joint, lateral and medial compartments (between femur condyles
and tibia)
• Synovial membrane and cruciate ligaments partially separate the medial and lateral
compartments
Patellofemoral • Ligamentum patellae
• Actions: provides joint stability in full extension
Fibrous capsule
The capsule of the knee joint is a complex, composite structure with contributions from adjacent tendons.
Anterior The capsule does not pass proximal to the patella. It blends with the tendinous expansions of vastus
fibres medialis and lateralis
Posterior These fibres are vertical and run from the posterior surface of the femoral condyles to the posterior
fibres aspect of the tibial condyle
Medial fibres Attach to the femoral and tibial condyles beyond their articular margins, blending with the tibial
collateral ligament
Lateral fibres Attach to the femur superior to popliteus, pass over its tendon to head of fibula and tibial condyle
Bursae
Anterior • Subcutaneous prepatellar bursa; between patella and skin
• Deep infrapatellar bursa; between tibia and patellar ligament
• Subcutaneous infrapatellar bursa; between distal tibial tuberosity and skin
Laterally • Bursa between lateral head of gastrocnemius and joint capsule
• Bursa between fibular collateral ligament and tendon of biceps femoris
• Bursa between fibular collateral ligament and tendon of popliteus
Medially • Bursa between medial head of gastrocnemius and the fibrous capsule
• Bursa between tibial collateral ligament and tendons of sartorius, gracilis and semitendinosus
• Bursa between the tendon of semimembranosus and medial tibial condyle and medial head of
gastrocnemius
Posterior Highly variable and inconsistent
Ligaments
Medial collateral ligament Medial epicondyle femur to medial tibial condyle: valgus stability
Lateral collateral ligament Lateral epicondyle femur to fibula head: varus stability
Anterior cruciate ligament Anterior tibia to lateral intercondylar notch femur: prevents tibia sliding anteriorly
Posterior cruciate ligament Posterior tibia to medial intercondylar notch femur: prevents tibia sliding posteriorly
Patellar ligament Central band of the tendon of quadriceps femoris, extends from patella to tibial tuberosity
Menisci
Medial and lateral menisci compensate for the incongruence of the femoral and tibial condyles.
Composed of fibrous tissue.
Medial meniscus is attached to the tibial collateral ligament.
Lateral meniscus is attached to the loose fibres at the lateral edge of the joint and is separate from the fibular collateral
ligament. The lateral meniscus is crossed by the popliteus tendon.
Nerve supply
The knee joint is supplied by the femoral, tibial and common peroneal divisions of the sciatic and by a branch from the
obturator nerve. Hip pathology pain may be referred to the knee.
Blood supply
Genicular branches of the femoral artery, popliteal and anterior tibial arteries all supply the knee joint.

Ligaments of the Knee
Ligament Origin Insertion Function
Retinacular Vastus medialis and Tibial condyles Forms anterior capsule
vastus lateralis
Posterior fibers Femoral condyles Tibial condyles Forms posterior capsule
Oblique popliteal Semimembranosus Lateral femoral condyle/posterior Strengthens capsule
tendon capsule
Deep MCL Medial epicondyle Medial meniscus Holds medial meniscus to
femur
Superficial MCL Medial epicondyle Medial condyle of tibia Resists valgus force
Arcuate Lateral femoral Posterior tibia/fibular head Posterior support
condyle, over popliteus
Lateral collateral Lateral epicondyle Lateral fibular head Resists varus force
Anterior cruciate Anterior intercondylar Posteromedial lateral femoral Limits
tibia condyle hyperextension/sliding
Posterior cruciate Posterior sulcus of tibia Anteromedial femoral condyle Prevents
hyperflexion/sliding
Coronary Meniscus Tibial periphery Meniscal attachment
Wrisberg Posterolateral meniscus Medial femoral condyle (behind Stabilizes lateral meniscus
posterior cruciate ligament)
Humphrey Posterolateral meniscus Medial femoral condyle (in front) Stabilizes lateral meniscus
Transverse Anterolateral meniscus Anteromedial meniscus Stabilizes menisci
meniscal
MCL, medial collateral ligament.

Ankle joint
The ankle joint is a synovial joint composed of the tibia and
fibula superiorly and the talus inferiorly.
Ligaments of the ankle joint

• Deltoid ligament (medially)
• Lateral collateral ligament
• Talofibular ligaments (both anteriorly and
posteriorly)
The calcaneofibular ligament is separate from the fibrous
capsule of the joint. The two talofibular ligaments are fused
with it.
The components of the syndesmosis are

• Antero-inferior tibiofibular ligament
• Postero-inferior tibiofibular ligament
• Inferior transverse tibiofibular ligament
• Interosseous ligament
Movements at the ankle joint

• Plantar flexion (55 degrees)
• Dorsiflexion (35 degrees)
• Inversion and eversion movements occur at the
level of the sub talar joint
Nerve supply
Branches of deep peroneal and tibial nerves.
Ankle Joint Ligaments

Ligament Origin Insertion
Capsule Tibia Talus
Deltoid Medial Medial
malleolus malleolus
Tibionavicular Medial Navicular
malleolus tuberosity
Tibiocalcaneal Medial Sustentaculum
malleolus tali
Posterior tibiotalar Medial Inner side of
malleolus talus
Anterior tibiotalar Medial Medial surface
malleolus of talus
Anterior tibiofibular Lateral Transversely to
malleolus talus anteriorly
Posterior tibiofibular Lateral Transversely to
malleolus talus posteriorly
Calcaneofibular Lateral Obliquely to
malleolus calcaneus
posteriorly

Surface Anatomy

1C. ANATOMY (HEAD & NECK) – MRCS NOTES - REDA
Foramina of the base of the skull ................................................................................................................... 2
Visual field defects .......................................................................................................................................... 3
Cranial venous sinuses.................................................................................................................................... 4
Cavernous sinus .............................................................................................................................................. 5
Sternocleidomastoid....................................................................................................................................... 6
Scalene muscles .............................................................................................................................................. 7
Anterior triangle of the neck .......................................................................................................................... 8
Posterior triangle of the neck ......................................................................................................................... 9
Parathyroid glands- anatomy ....................................................................................................................... 10
Submandibular gland.................................................................................................................................... 11
Parotid gland ................................................................................................................................................. 13
Lymphatic drainage of the tongue ............................................................................................................... 11
Circle of Willis ............................................................................................................................................... 14
Vertebral artery ............................................................................................................................................ 15
Common carotid artery ................................................................................................................................ 16
External carotid artery .................................................................................................................................. 17
Internal carotid artery .................................................................................................................................. 17
Middle meningeal artery .............................................................................................................................. 19
Brachiocephalic artery .................................................................................................................................. 20
Subclavian artery .......................................................................................................................................... 20
Internal jugular vein...................................................................................................................................... 21
Cranial nerves ............................................................................................................................................... 22
Trigeminal nerve ........................................................................................................................................... 24
Facial nerve ................................................................................................................................................... 26
Vagus nerve................................................................................................................................................... 28
Recurrent laryngeal nerve ............................................................................................................................ 30
Ansa cervicalis ............................................................................................................................................... 31
Ear Anatomy.................................................................................................................................................. 32
Lacrimal system ............................................................................................................................................ 34
Tonsil ............................................................................................................................................................. 35
1C. ANATOMY (HEAD & NECK) – MRCS NOTES - REDA 1

Foramina of the base of the skull
Foramen Location Contents
Foramen ovale Sphenoid bone Otic ganglion
V 3 (Mandibular nerve:3rd branch of trigeminal)
“OVALE” Accessory meningeal artery
Lesser petrosal nerve
Emissary veins
Foramen spinosum Sphenoid bone Middle meningeal artery
Meningeal branch of the Mandibular nerve
Foramen rotundum Sphenoid bone Maxillary nerve (V 2 )
Foramen lacerum / Sphenoid bone Base of the medial pterygoid plate.
carotid canal Internal carotid artery*
Nerve and artery of the pterygoid canal
Jugular foramen Temporal Anterior: inferior petrosal sinus
bone Intermediate: glossopharyngeal, vagus, and accessory nerves.
Posterior: sigmoid sinus (becoming the internal jugular vein) and some
meningeal branches from the occipital and ascending pharyngeal arteries.
Foramen magnum Occipital bone Anterior and posterior spinal arteries
Vertebral arteries
Medulla oblongata
Stylomastoid Temporal Stylomastoid artery
foramen bone Facial nerve
Superior orbital Sphenoid bone Lacrimal branch of ophthalmic nerve (V 1 )
fissure Frontal branch of ophthalmic nerve (V 1 )
Recurrent meningeal artery
“Live FRankly To See Trochlear (IV)
Absolutely No Superior Division of Oculomotor (III), Superior ophthalmic vein
Insult” Abducens (VI)
(3, 4, 5 1 , 6, R) Nasociliary branch of ophthalmic nerve (V 1 )
Inferior Division of Oculomotor nerve (III)
*= In life the foramen lacerum is occluded by a cartilagenous plug. The ICA initially passes into the carotid canal which
ascends superomedially to enter the cranial cavity through the foramen lacerum.
NB. The hypoglossal nerve passes through the hypoglossal canal. The optic canal transmits the optic nerve.

Visual field defects
• Left homonymous hemianopia means visual field defect to the left, i.e. Lesion of right optic tract
• Homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal-Superior)
• Incongruous defects = optic tract lesion; congruous defects = optic radiation lesion or occipital cortex
Homonymous hemianopia
• Incongruous defects: lesion of optic tract Lesions before optic chiasm:
• Congruous defects: lesion of optic radiation or occipital cortex Monocular vision loss = Optic nerve lesion
• Macula sparing: lesion of occipital cortex Bitemporal hemianopia = Optic chiasm lesion
Homonymous quadrantanopia Lesions after the optic chiasm:

• Superior: lesion of temporal lobe Homonymous hemianopia = Optic tract lesion
• Inferior: lesion of parietal lobe Upper quadrantanopia = Temporal lobe lesion
• Mnemonic = PITS (Parietal-Inferior, Temporal-Superior) Lower quadrantanopia = Parietal lobe lesion
Bitemporal hemianopia
• Lesion of optic chiasm
• Upper quadrant defect > Lower quadrant defect = inf. chiasmal compression, commonly a pituitary tumour
• Lower quadrant defect > Upper quadrant defect = sup. chiasmal compression, commonly a craniopharyngioma

Cranial venous sinuses
The cranial venous sinuses are located within the dura mater. They have no valves which is important in the potential for
spreading sepsis. They eventually drain into the internal jugular vein. They are:
• Superior sagittal sinus
• Inferior sagittal sinus
• Straight sinus
• Transverse sinus
• Sigmoid sinus
• Confluence of sinuses
• Occipital sinus
• Cavernous sinus

Cavernous sinus
The cavernous sinuses are paired and are situated on the body of the sphenoid bone. It runs from the superior orbital
fissure to the petrous temporal bone.
Contents: “O TOM CAT”

Lateral wall components (from top to bottom:) Cavernous sinus syndrome is most
Oculomotor nerve (III) commonly caused by cavernous
Trochlear nerve (IV) sinus tumours. Diagnosis is based on
Ophthalmic nerve (V 1 ) signs of pain, ophthalmoplegia,
Maxillary nerve (V 2)
proptosis, trigeminal nerve lesion
Contents of the sinus (from medial to lateral:)
Internal Carotid artery (and sympathetic plexus) (ophthalmic branch) and Horner's
Abducens nerve (VI) syndrome.
Relations
Medial Lateral
Pituitary fossa Temporal lobe
Sphenoid sinus
Blood supply
Ophthalmic vein, superficial cortical veins, basilar
plexus of veins posteriorly.
Drains into the internal jugular vein via: the
superior and inferior petrosal sinuses

Sternocleidomastoid
Anatomy
Origin Rounded tendon attached to upper manubrium sterni and muscular head attached to medial third of
the clavicle
Insertion Mastoid process of the temporal bone and lateral area of the superior nuchal line of the occipital bone
Innervation Spinal part of accessory nerve and anterior rami of C2 and C3 (proprioception)*
Action • Both: extend the head at atlanto-occipital joint and flex the cervical vertebral column. Accessory
muscles of inspiration.
• Single: lateral flexion of neck, rotates head so face looks upward to the opposite side
*The motor supply to the sternocleidomastoid is from the accessory nerve. The ansa cervicalis supplies sensory
information from the muscle.
Sternocleidomastoid divides the anterior and posterior triangles of the neck.
Sternocleidomastoid
Levator scapulae muscle
Anterior scalene muscle

Middle scalene muscle
Inferior belly of omohyoid
Trapezius
Ant midline of the neck

Scalene muscles
The 3 paired muscles are:
• Scalenus anterior: Elevate 1st rib and laterally flex the neck to same side
• Scalenus medius: Same action as scalenus anterior
• Scalenus posterior: Elevate 2nd rib and tilt neck to opposite side
Innervation Spinal nerves C4-6

Origin Transverse processes C2 to C7
Insertion First and second ribs
Important • The brachial plexus and subclavian artery pass between the anterior and middle scalenes
relations through a space called the scalene hiatus/fissure.
• The subclavian vein and phrenic nerve pass anteriorly to the anterior scalene as it crosses over
the first rib.
Rectus capitis anterior muscle

Rectus capitis lateral muscle
Anterior scalene
Middle scalene
Posterior scalene
Thoracic outlet syndrome

The scalenes are at risk of adhering to the fascia surrounding the brachial plexus or shortening causing compression of
the brachial plexus when it passes between the clavicle and 1st rib causing thoracic outlet syndrome.

Anterior triangle of the neck
Boundaries
Anterior border of the Sternocleidomastoid
Lower border of mandible
Anterior midline
Sub triangles (divided by Digastric above and Omohyoid)

• Submandibular Triangle (Digastric)
• Muscular triangle: Neck strap muscles
• Carotid triangle: Carotid sheath
Contents of the anterior triangle

Digastric triangle Submandibular gland
(submandibular) Submandibular nodes
Facial vessels
Hypoglossal nerve
Muscular Strap muscles
triangle External jugular vein
Carotid triangle Carotid sheath (Common carotid, Vagus and IJV)
Ansa cervicalis
Nerve supply to digastric muscle

• Anterior: Mylohyoid nerve
• Posterior: Facial nerve Stylohyoid muscle
Submandibular triangle Posterior belly of digastric
Anterior belly of
digastric muscle
Hyoid
Muscular triangle
Superior belly of omohyoid

Posterior triangle of the neck
Boundaries
Apex Sternocleidomastoid and the Trapezius muscles at the Occipital bone
Anterior Posterior border of the Sternocleidomastoid
Posterior Anterior border of the Trapezius
Base Middle third of the clavicle
Contents
Nerves • Accessory nerve
• Phrenic nerve
• Three trunks of the brachial plexus
• Branches of the cervical plexus: Supraclavicular nerve, transverse cervical nerve, great
auricular nerve, lesser occipital nerve
Vessels • External jugular vein
• Subclavian artery (3rd part)
Muscles • Inferior belly of omohyoid
• Scalene
Lymph nodes • Supraclavicular
• Occipital
The IJV does not lie in the posterior triangle. However, the terminal branches of the external jugular vein do.
Retromandibular vein
Lesser occipital nerve

Great auricular nerve

Parathyroid glands- anatomy
• Four parathyroid glands
• Located posterior to the thyroid gland
• They lie within the pretracheal fascia
Embryology
The parathyroids develop from the extremities of the third and fourth pharyngeal pouches. The parathyroids derived
from the fourth pharyngeal pouch are located more superiorly and are associated with the thyroid gland. Those derived
from the third pharyngeal pouch lie more inferiorly and may become associated with the thymus.
Blood supply
The blood supply to the parathyroid glands is derived from the inferior and superior thyroid arteries[1]. There is a rich
anastomosis between the two vessels. Venous drainage is into the thyroid veins.
Relations
Laterally Common carotid
Medially Recurrent laryngeal nerve, trachea
Anterior Thyroid
Posterior Pretracheal fascia
Thyrohyoid
Inferior thyroid a.
Thyrocervical trunk
Left subclavian a. Right recurrent
laryngeal nerve
Inferior thyroid
veins

Thyroid gland
• Right and left lobes connected by isthmus
• Surrounded by sheath from pretracheal layer of deep fascia
• Apex: Lamina of thyroid cartilage. Base: 4th-5th tracheal ring
• Pyramidal lobe: from isthmus. Mnemonic “Rings 2,3,4 make the isthmus floor”
• May be attached to foramen caecum at the base of the tongue
Anteromedially • Sternothyroid • Sternohyoid

• Superior belly of omohyoid • Anterior aspect of sternocleidomastoid
Posterolaterally Carotid sheath
Medially • Larynx • Oesophagus • External laryngeal nerve (near superior thyroid a.)
Relations
• Trachea • Cricothyroid • Recurrent laryngeal nerve (near inferior thyroid a.)

• Pharynx muscle
Posterior • Parathyroid glands • Anastomosis of superior and inferior thyroid arteries
Isthmus • Anteriorly: Sternothyroids, sternohyoids, anterior jugular veins
• Posteriorly: 2nd, 3rd, 4th tracheal rings (attached via Ligament of Berry)
Blood Supply
Arterial • Superior thyroid artery (1st branch of external carotid)
• Inferior thyroid artery (from thyrocervical trunk)
• Thyroidea ima (in 10% of population -from brachiocephalic artery or aorta)
Venous • Superior and middle thyroid veins - into the IJV
• Inferior thyroid vein - into the brachiocephalic veins
The tongue
•
The lymphatic drainage of the anterior two thirds of the tongue shows only minimal communication of
lymphatics across the midline, so metastasis to the ipsilateral nodes is usual.
• The lymphatic drainage of the posterior third of the tongue have communicating networks, as a result early
bilateral nodal metastases are more common in this area.
• Lymphatics from the tip of the tongue usually pass to the sub mental nodes and from there to the deep cervical
nodes.
• Lymphatics from the mid portion of the tongue usually drain to the submandibular nodes and then to the deep
cervical nodes. Mid tongue tumours that are laterally located will usually drain to the ipsilateral deep cervical
nodes, those from more central regions may have bilateral deep cervical nodal involvement.
The glossopharyngeal nerve supplies general sensation to the posterior third of the tongue and contributes to the gag
reflex. Taste to the anterior two thirds of the tongue is supplied by the facial nerve, the trigeminal supplies general
sensation, this is mediated by the mandibular branch of the trigeminal nerve (via the lingual nerve).

Submandibular gland
Relations of the submandibular gland
Platysma, deep fascia and mandible
Superficial
Submandibular lymph nodes
Facial vein (facial artery near mandible)
Marginal mandibular nerve
Cervical branch of the facial nerve
Facial artery (inferior to the mandible)
Mylohyoid muscle
Sub mandibular duct
Deep
Hyoglossus muscle
Lingual nerve
Submandibular ganglion
Hypoglossal nerve
Submandibular duct (Wharton's duct)

• Opens lateral to the lingual frenulum on
the anterior floor of mouth.
• 5 cm length
• Lingual nerve wraps around Wharton's
duct. As the duct passes forwards it
crosses medial to the nerve to lie above it
and then crosses back, lateral to it, to
reach a position below the nerve.
Innervation
• Sympathetic innervation- Derived from superior cervical ganglion
• Parasympathetic innervation- Submandibular ganglion via lingual nerve
Arterial supply
Branch of the facial artery. The facial artery passes through the gland to groove its deep
surface. It then emerges onto the face by passing between the gland and the mandible.
Venous drainage
Anterior facial vein (lies deep to the Marginal Mandibular nerve)
Lymphatic drainage
Deep cervical and jugular chains of nodes
Three cranial nerves may be injured during submandibular gland excision.

• Marginal mandibular branch of the facial nerve
• Lingual nerve
• Hypoglossal nerve
Hypoglossal nerve damage may result in paralysis of the ipsilateral aspect of the tongue. The nerve itself lies deep to the
capsule surrounding the gland and should not be injured during an intracapsular dissection. The lingual nerve is probably
at greater risk of injury. However, the effects of lingual nerve injury are sensory rather than motor.

Parotid gland
Anatomy of the parotid gland
Location Overlying the mandibular ramus; anterior and inferior to the ear.
Salivary duct Crosses the masseter, pierces the buccinator and drains adjacent to the 2nd upper molar
tooth (Stensen's duct).
Structures passing through • Facial nerve (Mnemonic: The Zebra Buggered My Cat; Temporal Zygomatic, Buccal,
the gland Mandibular, Cervical)
• External carotid artery
• Retromandibular vein
• Auriculotemporal nerve
Relations • Anterior: masseter, medial pterygoid, superficial temporal and maxillary artery, facial
nerve, stylomandibular ligament
• Posterior: posterior belly digastric muscle, sternocleidomastoid, stylohyoid, internal
carotid artery, mastoid process, styloid process
Arterial supply Branches of external carotid artery
Venous drainage Retromandibular vein
Lymphatic drainage Deep cervical nodes
Nerve innervation • Parasympathetic-Secretomotor
• Sympathetic-Superior cervical ganglion
• Sensory- Greater auricular nerve
Parasympathetic stimulation produces a water rich, serous saliva. Sympathetic stimulation leads to the production of a
low volume, enzyme-rich saliva.

Circle of Willis
The two internal carotid arteries and two vertebral arteries form an anastomosis known as the Circle of Willis on the
inferior surface of the brain. Each half of the circle is formed by:
1. Anterior communicating artery
2. Anterior cerebral artery
3. Internal carotid artery
4. Posterior communicating artery
5. Posterior cerebral arteries and the termination of the basilar artery
The circle and its branches supply; the corpus striatum, internal capsule, diencephalon and midbrain.
Vertebral arteries Basilar artery Internal carotid arteries

• Enter the cranial cavity via foramen Branches: Branches:
magnum • Anterior inferior cerebellar artery • Posterior communicating artery
• Lie in the subarachnoid space • Labyrinthine artery • Anterior cerebral artery
• Ascend on anterior surface of • Pontine arteries • Middle cerebral artery
medulla oblongata • Superior cerebellar artery • Anterior choroid artery
• Unite to form the basilar artery at • Posterior cerebral artery
the base of the pons
Branches:
• Posterior spinal artery
• Anterior spinal artery
• Posterior inferior cerebellar artery

Vertebral artery
The vertebral artery is the first branch of the subclavian artery. Anatomically it is divisible into 4 regions:
• The first part runs to the foramen in the transverse process of C6. Anterior to this part lies the vertebral and
internal jugular veins. On the left side the thoracic duct is also an anterior relation.
• The second part runs superiorly through the foramina of the transverse processes of the upper 6 cervical
vertebrae. Once it has passed through the transverse process of the axis it then turns superolaterally to the
atlas. It is accompanied by a venous plexus and the inferior cervical sympathetic ganglion.
• The third part runs posteromedially on the lateral mass of the atlas. It enters the sub occipital triangle, in the
groove of the upper surface of the posterior arch of the atlas. It then passes anterior to the edge of the
posterior atlanto-occipital membrane to enter the vertebral canal.
• The fourth part passes through the spinal dura and arachnoid, running superiorly and anteriorly at the lateral
aspect of the medulla oblongata. At the lower border of the pons it unites to form the basilar artery.

Common carotid artery
The right common carotid artery arises at the bifurcation of the brachiocephalic trunk. The left common carotid arises
from the arch of the aorta. Both terminate at the level of the upper border of the thyroid cartilage C4/C3 (the lower
border of the third cervical vertebra) by dividing into the internal and external carotid arteries.
Left common carotid artery
This vessel arises immediately to the left and slightly behind the origin of the brachiocephalic trunk. Its thoracic
portion is 2.5- 3.5 cm in length and runs superolaterally to the sternoclavicular joint.
In the thorax
The vessel is in contact, from below upwards, with the trachea, left recurrent laryngeal nerve, left margin of the
oesophagus. Anteriorly the left brachiocephalic vein runs across the artery, and the cardiac branches from the
left vagus descend in front of it. These structures together with the thymus and the anterior margins of the left
lung and pleura separate the artery from the manubrium.
In the neck
The artery runs superiorly deep to sternocleidomastoid and then enters the anterior triangle. At this point it lies
within the carotid sheath with the vagus nerve and the internal jugular vein. Posteriorly the sympathetic trunk
lies between the vessel and the prevertebral fascia. At the level of C7 the vertebral artery and thoracic duct lie
behind it. The anterior tubercle of C6 transverse process is prominent and the artery can be compressed against
this structure (it corresponds to the level of the cricoid).
Anteriorly at C6 the omohyoid muscle passes superficial to the artery.
Within the carotid sheath the jugular vein lies lateral to the artery.
Right common carotid artery
The right common carotid arises from the brachiocephalic artery. The right common carotid artery corresponds
with the cervical portion of the left common carotid, except that there is no thoracic duct on the right. The
oesophagus is less closely related to the right carotid than the left.
Path
Passes behind the sternoclavicular joint (12% patients above this level) to the upper border of the thyroid
cartilage, to divide into the external (ECA) and internal carotid arteries (ICA).
Relations
• Level of 6th cervical vertebra crossed by omohyoid
• Then passes deep to the thyrohyoid, sternohyoid, sternomastoid muscles.
• Passes ant. to the carotid tubercle (transverse process 6th cervical vertebra). NB: compression here stops hge.
• The inferior thyroid artery passes posterior to the common carotid artery. Then:
o Left common carotid artery crosses the thoracic duct
o Right common carotid artery crossed by recurrent laryngeal nerve

Internal carotid artery
The internal carotid artery is formed from the common carotid opposite the upper border of the thyroid cartilage. It
extends superiorly to enter the skull via the carotid canal. From the carotid canal it then passes through the cavernous
sinus, above which it divides into the anterior and middle cerebral arteries.
Posterior • Longus capitis

• Pre-vertebral fascia Mnemonic for branches of the
• Sympathetic chain
cerebral portion of the internal carotid
Relations in the neck
• Superior laryngeal nerve

Medially • External carotid (near origin) artery
• Wall of pharynx 'Only Press Carotid Arteries
• Ascending pharyngeal artery Momentarily'
Laterally • IJV (moves posteriorly at entrance to skull)
• Vagus nerve (most posterolaterally)
Anteriorly • Sternocleidomastoid Ophthalmic
• Lingual and facial veins
• Hypoglossal nerve
Relations in the carotid canal

• Internal carotid plexus
• Cochlea and middle ear cavity
• Trigeminal ganglion (superiorly)
• Leaves canal lies above the foramen lacerum
Path and relations in the cranial cavity

The artery bends sharply forwards in the cavernous
sinus, the aducens nerve lies close to its inferolateral
aspect. The oculomotor, trochlear, opthalmic and,
usually, the maxillary nerves lie in the lateral wall of
the sinus. Near the superior orbital fissure it turns
posteriorly and passes postero-medially to pierce the
roof of the cavernous sinus inferior to the optic nerve.
It then passes between the optic and oculomotor
nerves to terminate below the anterior perforated
substance by dividing into the anterior and middle
cerebral arteries.
Branches
• Anterior and middle cerebral artery
• Ophthalmic artery
• Posterior communicating artery
• Anterior choroid artery
• Meningeal arteries
• Hypophyseal arteries
The internal carotid does not have any branches in the
neck.

External carotid artery
The external carotid commences immediately lateral to the pharyngeal side wall. It ascends and lies anterior to the
internal carotid and posterior to the posterior belly of digastric and stylohyoid. More inferiorly it is covered by
sternocleidomastoid, passed by hypoglossal nerves, lingual and facial veins.
It then pierces the fascia of the parotid gland finally dividing into its terminal branches within the gland itself.
Surface marking of the carotid

This is an imaginary line drawn from the bifurcation of the common carotid passing behind the angle of the jaw to a point
immediately anterior to the tragus of the ear.
'Some Angry Lady Figured Out PMS' (in order)
Branches of the external carotid artery Superior thyroid (superior laryngeal artery branch)
It has six main branches, three in front, two behind and one deep. Ascending pharyngeal
Three in front Superior thyroid Lingual
Lingual Facial (tonsillar and labial artery)
Facial Occipital
Two behind Occipital Posterior auricular
Posterior auricular Maxillary (inferior alveolar artery, middle meningeal a.)
Deep Ascending pharyngeal Superficial temporal
It terminates by dividing into the superficial temporal and maxillary arteries in the parotid gland.
Occipital artery
Internal carotid artery

Ascending pharyngeal
artery
External carotid artery
Superior thyroid artery

Middle meningeal artery
• Middle meningeal artery is typically the third branch of the first part of the maxillary artery, one of the two
terminal branches of the external carotid artery. After branching off the maxillary artery in the infratemporal
fossa, it runs through the foramen spinosum to supply the dura mater (the outermost meninges).
• The middle meningeal artery is the largest of the three (paired) arteries which supply the meninges, the others
being the anterior meningeal artery and the posterior meningeal artery.
• The middle meningeal artery runs beneath the pterion. It is vulnerable to injury at this point, where the skull is
thin. Rupture of the artery may give rise to an extra dural hematoma.
• In the dry cranium, the middle meningeal, which runs within the dura mater surrounding the brain, makes a
deep indention in the calvarium.
• The middle meningeal artery is intimately associated with the auriculotemporal nerve which wraps around the
artery making the two easily identifiable in the dissection of human cadavers and also easily damaged in
surgery.

Brachiocephalic artery
The brachiocephalic artery is the largest branch of the aortic arch. From its aortic origin it ascends superiorly, it initially
lies anterior to the trachea and then on its right hand side. It branches into the common carotid and right subclavian
arteries at the level of the sternoclavicular joint.
Path
Origin- apex of the midline of the aortic arch
Passes superiorly and posteriorly to the right
Divides into the right subclavian and right common carotid artery
Relations
Anterior • Sternohyoid
• Sternothyroid
• Thymic remnants
• Left brachiocephalic vein
• Right inferior thyroid veins
Posterior • Trachea
• Right pleura
Right lateral • Right brachiocephalic vein
• Superior part of SVC
Left lateral • Thymic remnants
• Origin of left common carotid
• Inferior thyroid veins
• Trachea (higher level)
Branches
Normally none but may have the thyroidea ima artery
Subclavian artery
Path
• The left subclavian comes directly off the arch of aorta
• The right subclavian arises from the brachiocephalic artery (trunk) when it bifurcates into the subclavian and the
right common carotid artery.
• From its origin, the
subclavian artery travels
laterally, passing between
anterior and middle scalene
muscles, deep to scalenus
anterior and anterior to
scalenus medius. As the
subclavian artery crosses the
lateral border of the first rib,
it becomes the axillary
artery. At this point it is
superficial and within the
subclavian triangle.
Branches “VIT C & D”

• Vertebral artery
• Internal thoracic artery
• Thyrocervical trunk
• Costocervical trunk
• Dorsal scapular artery

Internal jugular vein
Each jugular vein begins in the jugular foramen, where they are the continuation of the sigmoid sinus. They terminate at
the medial end of the clavicle where they unite
with the subclavian vein.
The vein lies within the carotid sheath

throughout its course. Below the skull the
internal carotid artery and last four cranial
nerves are anteromedial to the vein. Thereafter
it is in contact medially with the internal (then
common) carotid artery. The vagus lies
posteromedially.
At its superior aspect, the vein is overlapped by

sternocleidomastoid and covered by it at the
inferior aspect of the vein.
Below the transverse process of the atlas it is

crossed on its lateral side by the accessory
nerve. At its mid point it is crossed by the
inferior root of the ansa cervicalis.
Posterior to the vein are the transverse
processes of the cervical vertebrae, the phenic
nerve as it descends on the scalenus anterior,
and the first part of the subclavian artery.
On the left side its also related to the thoracic

duct.

Cranial nerves
Cranial nerve lesions
Olfactory nerve May be injured in basal skull fractures or involved in frontal lobe tumour extension. Loss of
olfactory nerve function in relation to major CNS pathology is seldom an isolated event and thus it
is poor localiser of CNS pathology.
Optic nerve Problems with visual acuity may result from intra ocular disorders. Problems with the blood supply
such as amaurosis fugax may produce temporary visual distortion. More important surgically is the
pupillary response to light. The pupillary size may be altered in a number of disorders. Nerves
involved in the resizing of the pupil connect to the pretectal nucleus of the high midbrain, bypassing
the lateral geniculate nucleus and the primary visual cortex. From the pretectal nucleus neurones
pass to the Edinger - Westphal nucleus, motor axons from here pass along with the oculomotor
nerve. They synapse with ciliary ganglion neurones; the parasympathetic axons from this then
innervate the iris and produce miosis. The miotic pupil is seen in disorders such as Horner's
syndrome or opiate overdose.
Mydriasis is the dilatation of the pupil in response to disease, trauma, drugs (or the dark!). It is
pathological when light fails to induce miosis. The radial muscle is innervated by the sympathetic
nervous system. Because the parasympathetic fibres travel with the oculomotor nerve they will be
damaged by lesions affecting this nerve (e.g. cranial trauma).
The response to light shone in one eye is usually a constriction of both pupils. This indicates intact
direct and consensual light reflexes. When the optic nerve has an afferent defect the light shining
on the affected eye will produce a diminished pupillary response in both eyes. Whereas light shone
on the unaffected eye will produce a normal pupillary response in both eyes. This is referred to as
the Marcus Gunn pupil and is seen in conditions such as optic neuritis. In a total CN II lesion shining
the light in the affected eye will produce no response.
Oculomotor The pupillary effects are described above. In addition, it supplies all ocular muscles apart from
nerve lateral rectus and superior oblique. Thus the affected eye will be deviated inferolaterally. Levator
palpebrae superioris may also be impaired resulting in impaired ability to open the eye.
Trochlear nerve The eye will not be able to look down.
Trigeminal nerve Largest cranial nerve. Exits the brainstem at the pons. Branches are ophthalmic, maxillary and
mandibular. Only the mandibular branch has both sensory and motor fibres. Branches converge to
form the trigeminal ganglion (located in Meckels cave). It supplies the muscles of mastication and
also tensor veli palatine, mylohyoid, anterior belly of digastric and tensor tympani. Check textbook
for detailed descriptions of the various sensory functions. The corneal reflex is important and is
elicited by applying a small tip of cotton wool to the cornea, a reflex blink should occur if it is intact.
It is mediated by: the naso ciliary branch of the ophthalmic branch of the trigeminal (sensory
component) and the facial nerve producing the motor response. Lesions of the afferent arc will
produce bilateral absent blink and lesions of the efferent arc will result in a unilateral absent blink.
Abducens nerve The affected eye will have a deficit of abduction. This cranial nerve exits the brainstem between the
pons and medulla. It thus has a relatively long intra cranial course which renders it susceptible to
damage in raised intra cranial pressure.
Facial nerve Emerges from brainstem between pons and medulla. It controls muscles of facial expression and
taste from the anterior 2/3 of the tongue. The nerve passes into the petrous temporal bone and
into the internal auditory meatus. It then passes through the facial canal and exits at the
stylomastoid foramen. It passes through the parotid gland and divides at this point. It does not
innervate the parotid gland. Its divisions are considered in other parts of the website. Its motor
fibres innervate orbicularis oculi to produce the efferent arm of the corneal reflex. In surgical
practice it may be injured during parotid gland surgery or invaded by malignancies of the gland and
a lower motor neurone on the ipsilateral side will result.
Vestibulo- Exits from the pons and then passes through the internal auditory meatus. It is implicated in
cochlear nerve sensorineural hearing loss. Individuals with sensorineural hearing loss will localise the sound in
webers test to the normal ear. Rinnes test will be reduced on the affected side but should still work.
These two tests will distinguish sensorineural hearing loss from conductive deafness. In the latter
condition webers test will localise to the affected ear and Rinnes test will be impaired on the
affected side. Surgical lesions affecting this nerve include CNS tumours and basal skull fractures. It
may also be damaged by the administration of ototoxic drugs (of which gentamicin is the most
commonly used in surgical practice).
Glossopharyngeal Exits the pons just above the vagus. Receives sensory fibres from posterior 1/3 tongue, tonsils,
nerve pharynx and middle ear (otalgia may occur following tonsillectomy). It receives visceral afferents
from the carotid bodies. It supplies parasympathetic fibres to the parotid gland via the otic ganglion
and motor function to stylopharyngeaus muscle. The sensory function of the nerve is tested using
the gag reflex.

Vagus nerve Leaves the medulla between the olivary nucleus and the inferior cerebellar peduncle. Passes
through the jugular foramen and into the carotid sheath. Details of the functions of the vagus nerve
are covered in the website under relevant organ sub headings.
Accessory nerve Exists from the caudal aspect of the brainstem (multiple branches) supplies trapezius and
sternocleidomastoid muscles. The distal portion of this nerve is most prone to injury during surgical
procedures.
Hypoglossal Emerges from the medulla at the preolivary sulcus, passes through the hypoglossal canal. It lies on
nerve the carotid sheath and passes deep to the posterior belly of digastric to supply muscles of the
tongue (except palatoglossus). Its location near the carotid sheath makes it vulnerable during carotid
endarterectomy surgery and damage will produce ipsilateral defect in muscle function.
Cranial nerves carrying parasympathetic fibres

X IX VII III (1973)
The parasympathetic functions served by the cranial nerves include:

III (oculomotor) Pupillary constriction and accommodation
VII (facial) Lacrimal gland, submandibular and sublingual glands
IX (glossopharyngeal) Parotid
X (vagus) Heart and abdominal viscera
The optic nerve carries no parasympathetic fibres.
The cranial preganglionic parasympathetic nerves arise from specific nuclei in the CNS. These synapse at one of four
parasympathetic ganglia; otic, pterygopalatine, ciliary and submandibular. From these ganglia the parasympathetic
nerves complete their journey to their target tissues via CN V (trigeminal) branches (ophthalmic nerve CNV branch 1,
Maxillary nerve CN V branch2, mandibular nerve CN V branch 3)

Trigeminal nerve
The trigeminal nerve is the main sensory nerve of the head. In addition to its major sensory role, it also innervates the
muscles of mastication.
Distribution of the trigeminal nerve

Sensory • Scalp
• Face
• Oral cavity (and teeth)
• Nose and sinuses
• Dura mater
Motor • Muscles of mastication
• Mylohyoid
• Anterior belly of digastric
• Tensor tympani
• Tensor palati
Autonomic • Ciliary
connections • Sphenopalatine
(ganglia) • Otic
• Submandibular
Path
• Originates at the pons
• Sensory root forms the large, crescentic trigeminal ganglion within Meckel's cave, and contains the cell bodies
of incoming sensory nerve fibres. Here the 3 branches exit.
• The motor root cell bodies are in the pons and the motor fibres are distributed via the mandibular nerve. The
motor root is not part of the trigeminal ganglion.
Branches of the trigeminal nerve

Ophthalmic nerve Sensory only
Maxillary nerve Sensory only
Mandibular nerve Sensory and motor
Sensory
Ophthalmic Exits skull via the superior orbital fissure
Sensation of: scalp and forehead, the upper eyelid, the conjunctiva and cornea of the eye, the nose
(including the tip of the nose, except alae nasi), the nasal mucosa, the frontal sinuses, and parts of the
meninges (the dura and blood vessels).
Maxillary Exit skull via the foramen rotundum
nerve Sensation: lower eyelid and cheek, the nares and upper lip, the upper teeth and gums, the nasal
mucosa, the palate and roof of the pharynx, the maxillary, ethmoid and sphenoid sinuses, and parts of
the meninges.
Mandibular Exit skull via the foramen ovale
nerve Sensation: lower lip, the lower teeth and gums, the chin and jaw (except the angle of the jaw), parts of
the external ear, and parts of the meninges.
Motor
Distributed via the mandibular nerve.
The following muscles of mastication are innervated:
• Masseter
• Temporalis
• Medial pterygoid
• Lateral pterygoid
Other muscles innervated include:

• Tensor veli palatini
• Mylohyoid
• Anterior belly of digastric
• Tensor tympani

The lateral aspect of the external nose is innervated by lateral nasal branches of the anterior ethmoidal nerve. The
ethmoidal nerve is a branch of the nasociliary nerve which is one of the divisions of the trigeminal.

Facial nerve
The facial nerve is the main nerve supplying the structures of the second embryonic branchial arch. It is predominantly
an efferent nerve to the muscles of facial expression, digastric muscle and also to many glandular structures. It contains a
few afferent fibres which originate in the cells of its genicular ganglion and are concerned with taste.
Supply - 'face, ear, taste, tear'

• Face: muscles of facial expression
• Ear: nerve to stapedius
• Taste: supplies anterior two-thirds of tongue
• Tear: parasympathetic fibres to lacrimal glands, also salivary glands
Path
Subarachnoid path
• Origin: motor- pons, sensory- nervus intermedius
• Pass through the petrous temporal bone into the internal auditory meatus with the vestibulocochlear nerve.
Here they combine to become the facial nerve.
Facial canal path

• The canal passes superior to the vestibule of the inner ear
• At the medial aspect of the middle ear, it becomes wider and contains the geniculate ganglion.
3 branches:
1. Greater (superficial) petrosal nerve
2. Nerve to stapedius
3. Chorda tympani
Stylomastoid foramen
• Passes through the stylomastoid foramen (tympanic cavity anterior and mastoid antrum posteriorly)
• Posterior auricular nerve and branch to posterior belly of digastric and stylohyoid muscle
Face
Enters parotid gland and divides into 5 branches:
• Temporal branch
• Zygomatic branch
• Buccal branch
• Marginal mandibular branch
• Cervical branch

The chorda tympani branch of the facial nerve passes forwards through itrs canaliculus into the middle ear, and crosses
the medial aspect of the tympanic membrane. It then passes antero-inferiorly in the infratemporal fossa. It distributes
taste fibres to the anterior two thirds of the tongue.

Vagus nerve
The vagus nerve has mixed functions and supplies the structures from the
fourth and sixth pharyngeal arches. It also supplies the fore and midgut
sections of the embryonic gut tube. It carries afferent fibres from these areas
(viz; pharynx, larynx, oesophagus, stomach, lungs, heart and great vessels).
The efferent fibres of the vagus are of two main types. The first are
preganglionic parasympathetic fibres distributed to the parasympathetic
ganglia that innervate smooth muscle of the innervated organs (such as gut).
The second type of efferent fibres have direct skeletal muscle innervation,
these are largely to the muscles of the larynx and pharynx.
Origin and course

The vagus arises from the lateral surface of the medulla oblongata by a series
of rootlets. It is related to the glossopharyngeal nerve cranially and the
accessory nerve caudally. It exits through the jugular foramen and is
contained within its own dural sheath alongside the accessory nerve. In the
neck it descends vertically in the carotid sheath where it is closely related to
the internal and common carotid arteries. It leaves the neck and enters the
mediastinum. On the right it passes anterior to the first part of the
subclavian artery, on the left it lies in the interval between the common
carotid and subclavian arteries.
In the mediastinum both nerves pass postero-inferiorly and reach the
posterior surface of the corresponding lung root. These then branch into
both lungs. At the inferior end of the mediastinum these plexuses reunite to
form the formal vagal trunks that pass through the oesophageal hiatus and
into the abdomen. The anterior and posterior vagal trunks are formal nerve
fibres these then splay out once again sending fibres over the stomach and posteriorly to the coeliac plexus. Branches
pass to the liver, spleen and kidney.
Communications and branches

Communication Details
Superior Located in jugular foramen
ganglion Communicates with the superior cervical
sympathetic ganglion, accessory nerve
Two branches; meningeal and auricular (the latter
may give rise to vagal stimulation following
instrumentation of the external auditory meatus)
Inferior Communicates with the superior cervical
ganglion sympathetic ganglion, hypoglossal nerve and loop
between first and second cervical ventral rami
Two branches; pharyngeal (supplies pharyngeal
muscles) and superior laryngeal nerve
(inferomedially- deep to both carotid arteries)
Branches in the neck (see before / parathyroid for pics)

Branch Detail
Superior and Arise at various points and descend into thorax
inferior On the right these pass posterior to the subclavian
cervical cardiac artery
branches On the left the superior branch passes between
the arch of the aorta and the trachea to connect
with the deep cardiac plexus. The inferior branch
descends with the vagus itself.
Right recurrent Arises from vagus anterior to the first part of the
laryngeal nerve subclavian artery, hooks under it, and ascends
superomedially. It passes close to the common
carotid and finally the inferior thyroid artery to
insert into the larynx

Branches in the thorax (see before for pics)
Branch Details
Left recurrent Arises from the vagus on
laryngeal the aortic arch. It hooks
nerve around the inferior surface
of the arch, posterior to the
ligamentum arteriosum and
passes upwards through
the superior mediastinum
and lower part of the neck.
It lies in the groove
between oesophagus and
trachea (supplies both). It
passes with the inferior
thyroid artery and inserts
into the larynx.
Thoracic and There are extensive
cardiac branches to both the heart
branches and lung roots. These pass
throughout both these
viscera. The fibres reunite
distally prior to passing into
the abdomen.
Abdominal branches
After entry into the abdominal cavity the nerves branch extensively. In previous years the extensive network of the distal
branches (nerves of Laterjet) over the surface of the distal stomach were important for the operation of highly selective
vagotomy. The use of modern PPI's has reduced the need for such highly selective procedures. Branches pass to the
coeliac axis and alongside the vessels to supply the spleen, liver and kidney.

Recurrent laryngeal nerve
Branch of the vagus nerve
Right Left
• Arises anterior to the subclavian artery and • Arises left to the arch of the aorta
ascends obliquely next to the trachea, behind • Winds below the aorta
the common carotid artery • Ascends along the side of the trachea
• It is either anterior or posterior to the inferior
thyroid artery
Then both
• Pass in a groove between the trachea and oesophagus
• Enters the larynx behind the articulation between the thyroid cartilage and cricoid
• Distributed to larynx muscles
Branches to
• Cardiac plexus
• Mucous membrane and muscular coat of the oesophagus and trachea
Innervates
• Intrinsic larynx muscles (excluding cricothyroid)
Inferior vagal ganglion

Superior laryngeal nerve
Right vagus ne Internal laryngeal nerve

External laryngeal nerve
Right recurrent laryngeal Left recurrent laryngeal
Ligamentum arteriosum
Left pulmonary artery

`Ansa cervicalis
Superior Branch of C1 anterolateral to carotid
root sheath
Inferior Derived from C2 and C3 roots, passes
root posterolateral to the internal jugular
vein (may lie either deep or superficial
to it)
Innervation Sternohyoid
Sternothyroid
Omohyoid
The ansa cervicalis lies anterior to the carotid sheath.

The nerve supply to the inferior strap muscles enters at
their inferior aspect. Therefore, when dividing these
muscles to expose a large goitre, the muscles should be
divided in their upper half.
Ansa cervicalis muscles:

“GHost THought SOmeone
Stupid Shot Irene”
GenioHyoid
ThyroidHyoid
Superior Omohyoid
SternoThyroid
SternoHyoid
Inferior Omohyoid

Ear Anatomy
The ear is composed of three anatomically distinct regions.
1. External ear
• Auricle is composed of elastic cartilage covered by skin. The lobule
has no cartilage and contains fat and fibrous tissue.
• External auditory meatus is approximately 2.5cm long.
• Lateral third of the external auditory meatus is cartilaginous and the
medial two thirds is bony.
• The region is innervated by the greater auricular nerve. The
auriculotemporal branch of the trigeminal nerve supplies most the of
external auditory meatus and the lateral surface of the auricle.
2. Middle ear
Space between the tympanic membrane and cochlea. The aditus leads to
the mastoid air cells is the route through which middle ear infections may
cause mastoiditis. Anteriorly the eustacian tube connects the middle ear
to the naso pharynx.
The tympanic membrane consists of:
• Outer layer of stratified squamous epithelium.
• Middle layer of fibrous tissue.
• Inner layer of mucous membrane continuous with the middle ear.
The tympanic membrane is approximately 1cm in diameter.
The chorda tympani nerve passes on the medial side of the pars flaccida.
The middle ear is innervated by the glossopharyngeal nerve and pain may radiate to the middle ear following
tonsillectomy.
Ossicles
Malleus attaches to the tympanic membrane (the Umbo).
Malleus articulates with the incus (synovial joint).
Incus attaches to stapes (another synovial joint).
3. Internal ear
• Cochlea, semicircular canals and vestibule
• Organ of corti is the sense organ of hearing and is located on
the inside of the cochlear duct on the basilar membrane.
• Vestibule accommodates the utricule and the saccule. These
structures contain endolymph and are surrounded by
perilymph within the vestibule.
• The semicircular canals lie at various angles to the petrous
temporal bone. All share a common opening into the vestibule.

Lacrimal system
Lacrimal gland
Consists of an orbital part and palpebral part. They are continuous
posterolaterally around the concave lateral edge of the levator
palpebrae superioris muscle.
The ducts of the lacrimal gland open into the superior fornix. Those
from the orbital part penetrate the aponeurosis of levator palpebrae
superioris to join those from the palpebral part. Therefore, excision of
the palpebral part is functionally similar to excision of the entire gland.
Blood supply
Lacrimal branch of the ophthalmic artery. Venous drainage is to the
superior ophthalmic vein.
Innervation
The gland is innervated by the secretomotor parasympathetic fibres from the pterygopalatine ganglion which in turn may
reach the gland via the zygomatic or lacrimal branches of the maxillary nerve or pass directly to the gland. The
preganglionic fibres travel to the ganglion in the greater petrosal nerve (a branch of the facial nerve at the geniculate
ganglion).
Nasolacrimal duct
Descends from the lacrimal sac to open anteriorly in the inferior meatus of the nose.
Lacrimation reflex
Occurs in response to conjunctival irritation (or emotional events). The conjunctiva will send signals via the ophthalmic
nerve. These then pass to the superior salivary centre. The efferent signals pass via the greater petrosal nerve
(parasympathetic preganglionic fibres) and the deep petrosal nerve which carries the post ganglionic sympathetic fibres.
The parasympathetic fibres will relay in the pterygopalatine ganglion, the sympathetic fibres do not synapse. They in turn
will relay to the lacrimal apparatus.

Tonsil
Anatomy
• Each palatine tonsil has two surfaces, a medial surface which projects into the pharynx and a lateral surface that
is embedded in the wall of the pharynx.
• They are usually 25mm tall by 15mm wide, although this varies according to age and may be almost completely
atrophied in the elderly.
• Their arterial supply is from the tonsillar artery, a branch of the facial artery.
• Its veins pierce the constrictor muscle to join the external palatine or facial veins. The external palatine vein is
immediately lateral to the tonsil, which may result in haemorrhage during tonsillectomy.
• Lymphatic drainage is the jugulodigastric node and the deep cervical nodes.
Tonsillitis
• Usually bacterial (50%) - group A Streptococcus. Remainder viral.
• May be complicated by development of abscess (quinsy). This may distort the uvula.
• Indications for tonsillectomy include recurrent acute tonsillitis, suspected malignancy, enlargement causing sleep
apnoea.
• Dissection tonsillectomy is the preferred technique with haemorrhage being the commonest complication. Delayed
otalgia may occur owing to irritation of the glossopharyngeal nerve.

1D. ANATOMY (ABDOMEN) – MRCS NOTES - REDA
Abdominal wall ............................................................................................................................................... 2
External oblique muscle ................................................................................................................................. 3
Inguinal canal .................................................................................................................................................. 5
Scrotal and testicular anatomy ...................................................................................................................... 6
Colon anatomy ................................................................................................................................................ 7
Caecum .......................................................................................................................................................... 10
Transverse colon ........................................................................................................................................... 10
Left colon....................................................................................................................................................... 11
Rectum .......................................................................................................................................................... 11
Anal sphincter ............................................................................................................................................... 12
Spleen ............................................................................................................................................................ 13
Liver ............................................................................................................................................................... 14
Gallbladder .................................................................................................................................................... 16
Pancreas ........................................................................................................................................................ 17
Abdominal aorta ........................................................................................................................................... 18
Abdominal aortic branches .......................................................................................................................... 19
Coeliac axis .................................................................................................................................................... 20
Gastroduodenal artery ................................................................................................................................. 20
Inferior mesenteric artery ............................................................................................................................ 21
Renal anatomy .............................................................................................................................................. 22
Ureter ............................................................................................................................................................ 23
Adrenal gland anatomy ................................................................................................................................ 24
Prostate gland ............................................................................................................................................... 25
Epiploic (Omental) Foramen......................................................................................................................... 26
Inferior vena cava ......................................................................................................................................... 27
Diaphragm apertures .................................................................................................................................... 28
Uterus ............................................................................................................................................................ 29
1D. ANATOMY (ABDOMEN) – MRCS NOTES - REDA 1

Abdominal wall
The 2 main muscles of the abdominal wall are the rectus abdominis (anterior) and the quadratus lumborum (posterior).
The remaining abdominal wall consists of 3 muscular layers. Each muscle passes from the lateral aspect of the quadratus
lumborum posteriorly to the lateral margin of the rectus sheath anteriorly. Each layer is muscular posterolaterally and
aponeurotic anteriorly.
Lineal alba Rectus abdominis
Parietal peritoneum
Lineal alba Rectus abdominis Transversus abdominis
External Oblique
Parietal peritoneum
Transversus abdominis
Muscles of abdominal wall
• Lies most superficially
External oblique
• Originates from 5th to 12th ribs

• Inserts into the anterior half of the outer aspect of the iliac crest, linea alba and pubic tubercle
• More medially and superiorly to the arcuate line, the aponeurotic layer overlaps the rectus abdominis
muscle
• The lower border forms the inguinal ligament
• The triangular expansion of the medial end of the inguinal ligament is the lacunar ligament.
• Arises from the thoracolumbar fascia, the anterior 2/3 of the iliac crest and the lateral 2/3 of the inguinal
Internal oblique
ligament
• The muscle sweeps upwards to insert into the cartilages of the lower 3 ribs
• The lower fibres form an aponeurosis that runs from the tenth costal cartilage to the body of the pubis
• At its lowermost aspect it joins the fibres of the aponeurosis of transversus abdominis to form the
conjoint tendon.
• Innermost muscle
• Arises from the inner aspect of the costal cartilages of the lower 6 ribs, from the anterior 2/3 of the iliac
crest and lateral 1/3 of the inguinal ligament
Transversus
abdominis
• Its fibres run horizontally around the abdominal wall ending in an aponeurosis. The upper part runs
posterior to the rectus abdominis. Lower down the fibres run anteriorly only.
• The rectus abdominis lies medially; running from the pubic crest and symphysis to insert into the xiphoid
process and 5th, 6th and 7th costal cartilages. The muscles lie in an aponeurosis as described above.
• Nerve supply: anterior primary rami of T7-12
Surgical notes
During abdominal surgery it is usually necessary to divide either the muscles or their aponeuroses. During a midline
laparotomy it is desirable to divide the aponeurosis. This will leave the rectus sheath intact above the arcuate line and
the muscles intact below it. Straying off the midline will often lead to damage to the rectus muscles, particularly below
the arcuate line where they may often be in close proximity to each other.
Quadratus lumborum
Origin: Medial aspect of iliac crest and iliolumbar ligament
Insertion: 12th rib
Action: Pulls the rib cage inferiorly. Lateral flexion.
Nerve supply: Anterior primary rami of T12 and L1-3

External oblique muscle
External oblique forms the outermost muscle of the three muscles comprising the anterolateral aspect of the abdominal
wall. Its aponeurosis comprises the anterior wall of the inguinal canal.
Origin Outer surfaces of the lowest eight ribs

Insertion • Anterior two thirds of the outer lip of the iliac crest.
• The remainder becomes the aponeurosis that fuses with the linea alba in the midline.
Nerve supply Ventral rami of the lower six thoracic nerves
Actions Contains the abdominal viscera, may contract to raise intra-abdominal pressure. Moves trunk to one
side.
Muscle and aponeurosis
Superficial fascia (Camper’s) Superficial fascia (Scarpa’s)
Extraperitoneal fascia
Parietal peritoneum
Visceral peritoneum

Superficial fascia
fatty layer
(Camper’s fascia)
Superficial fascia
membranous layer
(Scarpa’s fascia)
Parietal peritoneum Extraperitoneal fascia

Inguinal canal
• Located above the inguinal ligament
• The inguinal canal is 4cm long
• The superficial ring is located anterior to the pubic tubercle
• The deep ring is located approximately 1.5-2cm above the half way point between the anterior superior iliac spine
and the pubic tubercle
Anterior superior
iliac spine
Superficial
inguinal ring
Boundaries of the inguinal canal “MALT” Transversalis fascia Inferior epigastric artery
Roof (Superior wall) • Internal ablique Muscle
“2 Muslces” • Transversus abdominis Muscle
Anterior wall • External oblique Aponeurosis
“2 Aponeurosis” • Internal oblique Aponeurosis ASIS
Floor (Inferior wall) • External oblique aponeurosis
“2 Ligaments” • Inguinal Ligament Inguinal Deep inguinal
ligament ring
• Lacunar Ligament
Posterior wall • Transversalis fascia Spermatic cord
“2 Ts” • Conjoint Tendon
Laterally • Internal ring
• Transversalis fascia
• Fibres of internal oblique
Inferior
Medially • External ring epigastric
• Conjoint tendon vessels Femoral a. and v. Pubic symphysis
Deep ring
Contents
Male: Spermatic cord* and
ASIS
ilioinguinal nerve
Female: Round ligament of
uterus and ilioinguinal nerve
*As it passes through the

canal the spermatic cord has
3 coverings:
• External spermatic fascia External iliac a.
• Cremasteric fascia
• Internal spermatic fascia
External iliac v.
Superficial inguinal ligament
Lacunar ligament
Right inguinal triangle - Internal view

Scrotal and testicular anatomy
Spermatic cord
Formed by the vas deferens and is covered by the following structures:
Layer Origin
External spermatic fascia External oblique aponeurosis
Cremasteric fascia From the fascial coverings of internal oblique
Internal spermatic fascia Transversalis fascia
The tunica vaginalis is derived from peritoneum, it secretes the fluid that fills the hydrocele cavity.
Contents of the cord

Vas deferens Transmits sperm and accessory gland secretions
Testicular artery Branch of abdominal aorta supplies testis and epididymis
Artery of vas deferens Arises from inferior vesical artery
Cremasteric artery Arises from inferior epigastric artery
Pampiniform plexus Venous plexus, drains into right or left testicular vein
Sympathetic nerve fibres Lie on arteries, the parasympathetic fibres lie on the vas
Genital branch of the genitofemoral nerve Supplies cremaster
Lymphatic vessels Drain to lumbar and para-aortic nodes
Scrotum
• Composed of skin and closely attached dartos fascia.
• Arterial supply from the anterior and posterior scrotal arteries
• Lymphatic drainage to the inguinal lymph nodes
• Parietal layer of the tunica vaginalis is the innermost layer
Genital branch of genitofemoral nerve
Testicular a. and pampiniform plexus
Layers of the scrotum Cremasteric vessels Parietal peritoneum
“Some Damn Englishman Called It The Extraperitoneal fascia
Testes”
• Skin Artery to ductus deferens
• Dartos fascia and muscle
• External spermatic fascia
• Cremasteric fascia
• Internal spermatic fascia
• Tunica vaginalis
• Testes
Ext. oblique aponeurosis
Testes Internal oblique muscle
• The testes are surrounded by
the tunica vaginalis (closed
peritoneal sac). The parietal Deep inguinal ring
layer of the tunica vaginalis Conjoint tendon
adjacent to the internal
spermatic fascia. Superficial inguinal ring
• The testicular arteries arise
from the aorta immediately
inferiorly to the renal
arteries.
• The pampiniform plexus
drains into the testicular
veins, the left drains into the
left renal vein and the right
into the inferior vena cava.
• Lymphatic drainage is to the
para-aortic nodes

Colon anatomy
The colon commences with the caecum. This represents the most Right paracolic gutter
dilated segment of the human colon and its base (which is Transverse colon
intraperitoneal) is marked by the convergence of teniae coli. At this
point is located the vermiform appendix. The colon continues as the
ascending colon, the posterior aspect of which is retroperitoneal. The
line of demarcation between the intra and retro peritoneal right
colon is visible as a white line, in the living, and forms the line of
incision for colonic resections.
The ascending colon becomes the transverse colon after passing the
hepatic flexure. At this location the colon becomes wholly intra
peritoneal once again. The superior aspect of the transverse colon is
the point of attachment of the transverse colon to the greater
omentum. This is an important anatomical site since division of these
attachments permits entry into the lesser sac. Separation of the
greater omentum from the transverse colon is a routine operative
step in both gastric and colonic resections.
At the left side of the abdomen the transverse colon passes to the left
upper quadrant and makes an oblique inferior turn at the splenic
flexure. Following this, the posterior aspect becomes retroperitoneal
once again.
At the level of approximately L4 the descending colon becomes

wholly intraperitoneal and becomes the sigmoid colon. Whilst the Ascending colon
Transverse colon
sigmoid is wholly intraperitoneal there are usually attachments
laterally between the sigmoid and the lateral pelvic sidewall. These
small congenital adhesions are not formal anatomical attachments
but frequently require division during surgical resections.
At its distal end the sigmoid passes to the midline and at the region
around the sacral promontary it becomes the upper rectum. This
transition is visible macroscopically as the point where the teniae
fuse. More distally the rectum passes through the peritoneum at the
region of the peritoneal reflection and becomes extraperitoneal.
Arterial supply
Superior mesenteric artery and inferior mesenteric artery: linked by
the marginal artery.
Ascending colon: ileocolic and right colic arteries
Transverse colon: middle colic artery
Descending and sigmoid colon: inferior mesenteric artery
Venous drainage
From regional veins (that accompany arteries) to superior and inferior mesenteric vein
The inferior mesenteric vein drains into the splenic vein, this point of union lies close to the duodenum and this surgical
maneuver is a recognized cause of ileus.
The middle colonic vein drains into the SMV, if avulsed during mobilisation then dramatic haemorrhage can occur and be
difficult to control.
Lymphatic drainage
Initially along nodal chains that accompany supplying arteries, then para-aortic nodes.

Embryology
Midgut: Second part of duodenum to 2/3 transverse colon
Hindgut: Distal 1/3 transverse colon to anus
Peritoneal location
The right and left colon are part intraperitoneal and part extraperitoneal. The sigmoid and transverse colon are generally
wholly intraperitoneal. This has implications for the sequelae of perforations, which will tend to result in generalised
peritonitis in the wholly intra peritoneal segments.
Colonic relations
Region of colon Relation
Caecum/ right colon Right ureter, gonadal vessels
Hepatic flexure Gallbladder (medially)
Splenic flexure Spleen and tail of pancreas
Distal sigmoid/ upper rectum Left ureter
Rectum Ureters, autonomic nerves, seminal vesicles, prostate, urethra (distally)
Stomach
Liver
Short gastric veins
Spleen
Portal vein Left gastric vein
Left gastro omental vein

Splenic vein

Liver Xiphoid process Stomach Inferior mesenteric artery
Superior mesenteric artery
Left colic artery
Middle colic artery
Arteria recta
Left colic artery Right colic artery Sigmoid arteries
Superior rectal artery

Caecum
Location • Proximal right colon below the ileocaecal valve
• Intraperitoneal
Posterior relations • Psoas
• Iliacus
• Femoral nerve
• Genitofemoral nerve
• Gonadal vessels
Anterior relations Greater omentum
Arterial supply Ileocolic artery
Lymphatic drainage Mesenteric nodes accompany the venous drainage
The caecum is the most distensible part of the colon and in complete large bowel obstruction with a competent ileocaecal
valve the most likely site of eventual perforation. Taenia coli
Appendicular artery
Positions of the appendix

Subcaecal
Transverse colon
• The right colon undergoes a sharp turn at the level of the hepatic flexure to become the transverse colon.
• At this point it also becomes intraperitoneal.
• It is connected to the inferior border of the pancreas by the transverse mesocolon.
• The greater omentum is attached to the superior aspect of the transverse colon from which it can easily be
separated. The mesentery contains the middle colic artery and vein. The greater omentum remains attached to the
transverse colon up to the splenic flexure. At this point the colon undergoes another sharp turn.
Relations
Superior Liver and gall-bladder, the greater curvature of
the stomach, and the lower end of the spleen
Inferior Small intestine
Anterior Greater omentum
Posterior From right to left with the descending portion of
the duodenum, the head of the pancreas,
convolutions of the jejunum and ileum, spleen

Left colon
Position
• As the left colon passes inferiorly its posterior aspect becomes extraperitoneal, and the ureter and gonadal
vessels are close posterior relations that may become involved in disease processes
• At a level of L3-4 (variable) the left colon becomes the sigmoid colon and wholly intraperitoneal once again
• The sigmoid colon is a highly mobile structure and may even lie on the right side of the abdomen
• It passes towards the midline, the taenia blend and this marks the transition between sigmoid colon and upper
rectum
Blood supply
• Inferior mesenteric artery
• However, the marginal artery (from the right colon) contributes, this contribution becomes clinically significant
when the IMA is divided surgically (e.g. During AAA repair)
Rectum
The rectum is approximately 12 cm long. It is a capacitance organ. It has both intra and extraperitoneal components. The
transition between the sigmoid colon is marked by the disappearance of the tenia coli.The extra peritoneal rectum is
surrounded by mesorectal fat that also contains lymph nodes. This mesorectal fatty layer is removed surgically during
rectal cancer surgery (Total Mesorectal Excision). The fascial layers that surround the rectum are important clinical
landmarks, anteriorly lies the fascia of Denonvilliers. Posteriorly lies Waldeyers (presacral) fascia.
Right common iliac artery
Extra peritoneal rectum Left internal
iliac artery Superior rectal artery
• Posterior upper third Left common
iliac artery Right internal
• Posterior and lateral middle third
iliac artery
• Whole lower third
Anteriorly Rectovesical pouch

(Males) Bladder
Prostate
Seminal vesicles
Anteriorly Recto-uterine pouch (Douglas)
Relations
(Females) Cervix
Vaginal wall
Posteriorly Sacrum
Coccyx
Middle sacral artery
Laterally Levator ani
Coccygeus
Arterial supply Venous drainage

Superior rectal artery Superior rectal vein
Inferior rectal artery
Lymphatic drainage Internal pudendal artery
• Mesorectal lymph nodes (superior to dentate line) Middle rectal artery
• Inguinal nodes (inferior to dentate line) Arterial supply to the rectum and anal canal. Posterior view

Anal sphincter
• Internal anal sphincter composed of smooth muscle continuous with the circular muscle of the rectum. It surrounds
the upper two- thirds of the anal canal and is supplied by sympathetic nerves.
• External anal sphincter is composed of striated muscle which surrounds the internal sphincter but extends more
distally.
• The nerve supply of the external anal sphincter is from the inferior rectal branch of the pudendal nerve (S2 and S3)
and the perineal branch of the S4 nerve roots. “S2, 3, 4 Keeps the poo off the floor”

Spleen
The spleen is the largest lymphoid organ in the body. It is located in the left upper quadrant of the abdomen and its size
can vary depending upon the amount of blood it contains. The typical adult spleen is 12.5cm long and 7.5cm wide. The
normal spleen is not palpable. It is an intraperitoneal organ. The peritoneal attachments condense at the hilum where
the vessels enter the spleen. The spleen is almost entirely covered by peritoneum, which adheres firmly to its capsule.
Recesses of the greater sac separate it from the stomach and kidney. It develops from the upper dorsal mesogastrium,
remaining connected to the posterior abdominal wall and stomach by two folds of peritoneum; the lienorenal ligament
and gastrosplenic ligament. Its blood supply is from the splenic artery (derived from the coeliac axis) and the splenic vein
(which is joined by the IMV and unites with the SMV)
• Embryology: derived from mesenchymal tissue 1,3,5,7,9,11 (odd numbers up to 11)
• Shape: clenched fist (influenced by the state of the colon and stomach) 1 inch thick, 3 inches wide, 5 inches long,
• Position: below 9th-12th ribs weighs 7oz (150-200g), lies between the
• Weight: 75-150g 9th and 11th ribs
Superiorly Diaphragm
Anteriorly Gastric impression
Relations
Posteriorly Kidney
Inferiorly Colon
Hilum Tail of pancreas and splenic vessels (splenic artery divides
here, branches pass to the white pulp transporting plasma)
White Immune function. Contains central trabecular artery. The

Contents
pulp germinal centres are supplied by arterioles called Rib IX

penicilliary radicles. Stomach
Red pulp Filters abnormal red blood cells. Spleen
Function Descending
• Filtration of abnormal blood cells and foreign bodies such as bacteria. colon
• Immunity: IgM. Production of properdin, and tuftsin which help target Greater
fungi and bacteria for phagocytosis. omentum
• Haematopoiesis: up to 5th month gestation or in haematological
disorders. Small
intestine
• Pooling: storage of 40% platelets.
• Iron reutilization
• Storage monocytes
Disorders of the spleen

Massive splenomegaly
• Myelofibrosis
• Chronic myeloid leukaemia Lesser omentum
• Visceral leishmaniasis (kala-azar)
• Malaria
• Gaucher's syndrome Stomach
Other causes (as above plus)

• Portal hypertension e.g. secondary to cirrhosis Gastrosplenic
• Lymphoproliferative disease e.g. CLL, Hodgkin's ligament
• Haemolytic anaemia
• Infection: hepatitis, glandular fever
• Infective endocarditis Spleen
• Sickle-cell*, thalassaemia Visceral
• Rheumatoid arthritis (Felty's syndrome) peritoneum
*the majority of adult patients with sickle-cell will have an atrophied spleen due to
repeated infarction
Splenorenal lig.
Left kidney

Liver
Structure of the liver
Right lobe • Supplied by right hepatic artery
• Contains Couinaud segments V to VIII (-/+Sg I)
Left lobe • Supplied by the left hepatic artery
• Contains Couinaud segments II to IV (+/- Sg1)
Quadrate lobe • Part of the right lobe anatomically, functionally is part of the left
• Couinaud segment IV
• Porta hepatis lies behind
• On the right lies the gallbladder fossa
• On the left lies the fossa for the umbilical vein
Caudate lobe • Supplied by both right and left hepatic arteries
• Couinaud segment I
• Lies behind the plane of the porta hepatis
• Anterior and lateral to the inferior vena cava
• Bile from the caudate lobe drains into both right and left hepatic ducts
Between the liver lobules are portal canals which contain the portal triad: Hepatic Artery, Portal Vein, tributary of Bile
Duct.
Relations of the liver

Anterior Postero inferiorly
Diaphragm Oesophagus
Xiphoid process Stomach
Duodenum
Hepatic flexure of colon
Right kidney
Gallbladder
Inferior vena cava
Porta hepatis
Location Postero inferior surface, it joins nearly at right angles with the left sagittal fossa, and separates the
caudate lobe behind from the quadrate lobe in front
Transmits • Common hepatic duct
• Hepatic artery
• Portal vein
• Sympathetic and parasympathetic nerve fibres
• Lymphatic drainage of the liver (and nodes)
Caudate lobe
Falciform Suprarenal
Left triangle ligament impression Fundus of GB Hepatic duct
Bare area
ligament Body of GB
Neck of GB Quadrate lobe
Fissure for
ligamentum teres
Right lobe Left lobe
Gastric Renal impression
impression
Porta hepatis
Left lobe Rt lobe Cystic duct
Neck of GB
Esophageal
impression Body of GB
Porta hepatis Fundus of GB

Bile duct
Quadrate lobe
Portal vein Hepatic artery
Fissure for
Colic impression Caudate lobe ligamentum
venosum

The cystic duct lies outside the porta hepatis and is an important landmark in laparoscopic cholecystectomy. The
structures in the porta hepatis are:
• Portal vein
• Hepatic artery
• Common hepatic duct
These structures divide immediately after or within the porta hepatis to supply the functional left and right lobes of the
liver.
The porta hepatis is also surrounded by lymph nodes, that may enlarge to produce obstructive jaundice and
parasympathetic nervous fibres that travel along vessels to enter the liver.
Ligaments
Falciform ligament • 2 layer fold peritoneum from the umbilicus to anterior liver surface
• Contains ligamentum teres (remnant umbilical vein)
• On superior liver surface it splits into the coronary and left triangular ligaments
Ligamentum teres Joins the left branch of the portal vein in the porta hepatis
Ligamentum venosum Remnant of ductus venosus
Arterial supply
• Hepatic artery
Venous
• Hepatic veins
• Portal vein
Nervous supply
• Sympathetic and parasympathetic trunks of coeliac plexus

Gallbladder
• Fibromuscular sac with capacity of 50ml Right hepatic artery Common hepatic duct
• Columnar epithelium
Gallbladder Left hepatic artery
Relations of the gallbladder Hepatic artery proper
Anterior Liver Portal vein
Posterior • Covered by peritoneum Cystic
Gastroduodenal
artery
• Transverse colon Common hepatic artery
• 1st part of the duodenum
Laterally Right lobe of liver Cystic
Medially Quadrate lobe of liver duct
Bile duct
Arterial supply Splenic artery
Cystic artery (branch of Right hepatic artery) Right gastric artery
Supraduodenal
Venous drainage artery
Directly to the liver
Nerve supply
Sympathetic- mid thoracic spinal cord,
Parasympathetic- anterior vagal trunk
Common bile duct

Origin Confluence of cystic and common hepatic ducts
Relations at • Medially - Hepatic artery
origin • Posteriorly- Portal vein
Relations • Duodenum – anteriorly
distally • Pancreas - medially and laterally
• Right renal vein - posteriorly
Arterial Branches of hepatic artery and retroduodenal
supply branches of gastroduodenal artery
Hepatobiliary triangle
Medially Common hepatic duct
Inferiorly Cystic duct
Superiorly Inferior edge of liver
Contents Cystic artery
Right hepatic duct
Common hepatic duct Common

hepatic duct
Bile duct
Bile
duct
Descending part
of duodenum
Main pancreatic duct

Pancreas
The pancreas is a retroperitoneal organ and lies posterior to the stomach. It may be accessed surgically by dividing the
peritoneal reflection that connects the greater omentum to the transverse colon. The pancreatic head sits in the
curvature of the duodenum. Its tail lies close to the hilum of the spleen, a site of potential injury during splenectomy.
Relations
Posterior to the pancreas
Head Inferior vena cava
Common bile duct
Right and left renal veins
SMA and SMV
Neck SMV, portal vein
Body Left renal vein
Crus of diaphragm
Psoas muscle
Adrenal gland
Kidney
Aorta
Tail Left kidney
Anterior to the pancreas

Head 1st part of the duodenum
Pylorus
Gastroduodenal artery
SMA and SMV (uncinate process)
Body Stomach
Duodenojejunal flexure
Tail Splenic hilum
Superior to the pancreas

Coeliac trunk and its branches common
hepatic artery and splenic artery
Grooves of the head of the pancreas

2nd and 3rd part of the duodenum
Arterial supply
• Head: pancreaticoduodenal artery
• Rest: splenic artery
Venous drainage
• Head: superior mesenteric vein
• Body and tail: splenic vein
Ampulla of Vater
• Merge of pancreatic duct and common bile duct
• Is an important landmark, halfway along the second part
of the duodenum, that marks the anatomical transition
from foregut to midgut (also the site of transition
between regions supplied by coeliac trunk and SMA).
Blood supply of the pancreas. Posterior view

Abdominal aorta
Abdominal aortic topography
Origin T12
Termination L4
Posterior relations L1-L4 Vertebral bodies
Anterior relations Lesser omentum
Liver
Left renal vein
Inferior mesenteric vein
Third part of duodenum
Pancreas
Parietal peritoneum
Peritoneal cavity
Right lateral relations Right crus of the diaphragm
Cisterna chyli
Azygos vein
IVC (becomes posterior distally)
Left lateral relations 4th part of duodenum
Duodenal-jejunal flexure
Left sympathetic trunk
Abdominal aorta anterior branches

Abdominal aortic branches
'Prostitutes Cause Sagging Swollen Red Testicles [in men] Living In Sin':
Branches Level Paired Type
Inferior Phrenic T12 (Upper border) Yes Parietal
Coeliac T12 No Visceral
Superior mesenteric L1 No Visceral
Middle Suprarenal L1 Yes Visceral
Renal L1-L2 Yes Visceral
Testicular (in men) Gonadal L2 Yes Visceral
Lumbar L1-L4 Yes Parietal
Inferior mesenteric L3 No Visceral
Median Sacral L4 No Parietal
Common iliac L4 Yes Terminal

Coeliac axis
The coeliac axis has three main branches. “Left Hand Side (LHS)”
• Left gastric
• Hepatic: Branches- Right Gastric, Gastroduodenal, Superior Pancreaticoduodenal, Cystic (occasionally).
• Splenic: Branches- Pancreatic, Short Gastric, Left Gastroepiploic
It occasionally gives off one of the inferior phrenic arteries.
Relations
Anteriorly Lesser omentum
Right Right coeliac ganglion and caudate process of liver
Left Left coeliac ganglion and gastric cardia
Inferiorly Upper border of pancreas and renal vein
Gastroduodenal artery
Supplies
Pylorus, proximal part of the duodenum, and indirectly to the pancreatic head (via the anterior and posterior superior
pancreaticoduodenal arteries)
Path
The gastroduodenal artery most commonly arises from the common hepatic artery of the coeliac trunk. It terminates by
bifurcating into the right gastroepiploic artery and the superior pancreaticoduodenal artery

Inferior mesenteric artery
The IMA is the main arterial supply of the embryonic hindgut and originates approximately 3-4 cm superior to the aortic
bifurcation. From its aortic origin it passes immediately inferiorly across the anterior aspect of the aorta to eventually lie
on its left hand side. At the level of the left common iliac artery it becomes the superior rectal artery.
Branches
The left colic artery arises from the IMA near its origin. More distally up to three sigmoid arteries will exit the IMA to
supply the sigmoid colon.

Renal anatomy
Each kidney is about 11cm long, 5cm wide and 3cm thick. They are located in a deep gutter alongside the projecting
vertebral bodies, on the anterior surface of psoas major. In most cases the left kidney lies approximately 1.5cm higher
than the right. The upper pole of both kidneys approximates with the 11th rib (beware pneumothorax during
nephrectomy). On the left hand side the hilum is located at the L1 vertebral level and the right kidney at level L1-2. The
lower border of the kidneys is usually alongside L3.
Relations Right Kidney Left Kidney
Posterior Quadratus lumborum, diaphragm, psoas major, Quadratus lumborum, diaphragm, psoas major,
transversus abdominis transversus abdominis
Anterior Hepatic flexure of colon Stomach, Pancreatic tail
Superior Liver, adrenal gland Spleen, adrenal gland
Structures related to the posterior surface of each kidney
Fascial covering
Each kidney and suprarenal gland is enclosed within a common layer of investing fascia, derived from the transversalis
fascia. It is divided into anterior and posterior layers
(Gerota’s fascia).
Renal structure
Kidneys are surrounded by an outer cortex and an
inner medulla which usually contains between 6 and
10 pyramidal structures. The papilla marks the
innermost apex of these. They terminate at the renal
pelvis, into the ureter.
Lying in a hollow within the kidney is the renal sinus.
This contains:
1. Branches of the renal artery
2. Tributaries of the renal vein
3. Major and minor calyces's
4. Fat
Structures at the renal hilum

The renal vein lies most anteriorly, then renal artery
(it is an end artery) and the ureter lies most
posterior.

Ureter
• 25-35 cm long
• Muscular tube lined by transitional epithelium
• Surrounded by thick muscular coat. Becomes 3 muscular layers as it crosses the bony pelvis
• Retroperitoneal structure overlying transverse processes L2-L5
• Lies anterior to bifurcation of iliac vessels
• Blood supply is segmental; renal artery, aortic branches, gonadal branches, common iliac and internal iliac
• Lies beneath the uterine artery

Adrenal gland anatomy
Location Superomedially to the upper pole of each kidney
Relationships Right adrenal Left adrenal
Anteriorly: Hepato-renal pouch and bare area of the liver Anteriorly: Lesser sac and stomach
Inferiorly: Kidney Inferiorly: Pancreas and splenic vessels
Posteriorly: Diaphragm Posteromedially: Crus of the diaphragm
Medially: Vena Cava
Arterial Superior adrenal arteries - from inferior phrenic artery
supply Middle adrenal arteries - from aorta
Inferior adrenal arteries - from renal arteries
Venous Right adrenal Left adrenal
drainage Via one central vein directly into the IVC Via one central vein into the left renal vein
The right renal vein is very short and lies more inferiorly.

Prostate gland
The prostate gland is approximately the shape and size of a walnut and is located inferior to the bladder. It is separated
from the rectum by Denonvilliers fascia and its blood supply is derived from the internal iliac vessels (via inferior vesical
artery). The internal sphincter lies at the apex of the gland and may be damaged during prostatic surgery, affected
individuals may complain of retrograde ejaculation.
Arterial supply Inferior vesical artery (from internal iliac)

Venous drainage Prostatic venous plexus (to paravertebral veins)
Lymphatic drainage Internal iliac nodes
Innervation Inferior hypogastric plexus
Dimensions • Transverse diameter (4cm)
• AP diameter (2cm)
• Height (3cm)
Lobes • Posterior lobe: posterior to urethra
• Median lobe: posterior to urethra, in between ejaculatory ducts
• Lateral lobes x 2
• Isthmus
Zones • Peripheral zone: subcapsular portion of posterior prostate. Most prostate cancers are here
• Central zone
• Transition zone
• Stroma
Relations
Anterior Pubic symphysis
Prostatic venous plexus
Posterior Denonvilliers (Rectoprostatic) fascia
Rectum
Ejaculatory ducts
Lateral Venous plexus (lies on prostate)
Levator ani (immediately below the puboprostatic ligaments)
Denonvilliers (rectoprostatic) fascia separates the rectum from the prostate.

Waldeyer’s (presacral) fascia separates the rectum from the sacrum

Epiploic (Omental) Foramen
Also called foramen of Winslow
The epiploic foramen has the following boundaries:
Anteriorly (in the free edge of the lesser Bile duct to the right, portal vein behind and hepatic artery to the
omentum) left.
Posteriorly Inferior vena cava
Inferiorly 1st part of the duodenum
Superiorly Caudate process of the liver
During liver surgery bleeding may be controlled using a Pringles manoeuvre, this involves placing a vascular clamp across
the anterior aspect of the epiploic foramen. Thereby occluding:
• Common bile duct
• Hepatic artery
• Portal vein
Bleeding from liver trauma or a difficult cholecystectomy can be controlled with a vascular clamp applied at the epiploic
foramen.

Inferior vena cava
Path
Level Vein
• Origin: L5
T8 Hepatic vein
• Left and right common iliac veins merge to form the IVC.
Inferior phrenic vein
• Passes right of midline
Pierces diaphragm
• Paired segmental lumbar veins drain into the IVC throughout its
L1 Suprarenal veins
length
Renal vein
• The right gonadal vein empties directly into the cava and the left
L2 Gonadal vein
gonadal vein generally empties into the left renal vein.
• The next major veins are the renal veins and the hepatic veins L1-5 Lumbar veins
• Pierces the central tendon of diaphragm at T8 L5 Common iliac vein
• Right atrium Formation of IVC
Relations
Anteriorly Small bowel, first and third part of duodenum, head of pancreas, liver and bile duct, right
common iliac artery, right gonadal artery
Posteriorly Right renal artery, right psoas, right sympathetic chain, coeliac ganglion
Mnemonic for the Inferior vena cava tributaries: “I Like To Rise So High”
• Iliacs
• Lumbar
• Testicular
• Renal
• Suprarenal
• Hepatic veins

Diaphragm apertures
Diaphragm aperture levels
T8 (8 letters) = Vena cava
T10 (10 letters) = Oesophagus
T12 (12 letters) = Aortic hiatus

Uterus
The non-pregnant uterus resides entirely within the pelvis. The peritoneum invests the uterus and the structure is
contained within the peritoneal cavity. The blood supply to the uterine body is via the uterine artery (branch of the
internal iliac). The uterine artery passes from the inferior aspect of the uterus (lateral to the cervix) and runs alongside
the uterus. It frequently anastomoses with the ovarian artery superiorly. Inferolaterally the ureter is a close relation and
ureteric injuries are a recognised complication when pathology brings these structures into close proximity.
The supports of the uterus include the central perineal tendon (perineal body) (the most important). The lateral cervical,
round and uterosacral ligaments are condensations of the endopelvic fascia and provide additional structural support.

1E. ANATOMY (THORAX) – MRCS NOTES - REDA
Mediastinum ................................................................................................................................................... 2
Sternal angle ................................................................................................................................................... 2
Trachea ............................................................................................................................................................ 4
Oesophagus ..................................................................................................................................................... 5
Lung anatomy ................................................................................................................................................. 6
Phrenic nerve .................................................................................................................................................. 8
Thoracic duct ................................................................................................................................................... 9
Heart anatomy .............................................................................................................................................. 10
Superior vena cava........................................................................................................................................ 12
Thoracic aorta ............................................................................................................................................... 13
Prosthetic heart valves on Chest X-rays....................................................................................................... 13
1E. ANATOMY (THORAX) – MRCS NOTES - REDA 1

Mediastinum
Region between the pulmonary cavities.
It is covered by the mediastinal pleura. It does not contain the lungs.
It extends from the thoracic inlet superiorly to the diaphragm inferiorly.
Mediastinal regions
• Superior mediastinum (between manubriosternal angle and T4/5)
• Middle mediastinum
• Posterior mediastinum
• Anterior mediastinum
Region Contents
• Superior vena cava
• Brachiocephalic veins
Superior mediastinum
• Arch of aorta
• Thoracic duct
• Trachea
• Oesophagus
• Thymus
• Vagus nerve
• Left recurrent laryngeal nerve
• Phrenic nerve
• Thymic remnants
Anterior
• Lymph nodes
• Fat
• Pericardium
mediastinu
• Heart
Middle
• Aortic root
m
• Arch of azygos vein

• Main bronchi
• Oesophagus
• Thoracic aorta
Mediastinum
• Azygos vein
Posterior
• Thoracic duct
• Vagus nerve
• Sympathetic nerve trunks
• Splanchnic nerves

Sternal angle
Anatomical structures at the level of the manubrium and upper sternum
Upper part of the • Left brachiocephalic vein
manubrium • Brachiocephalic artery
• Left common carotid
• Left subclavian artery
Lower part of the • Costal cartilages of the 2nd ribs
manubrium / • Transition point between superior and inferior mediastinum
manubrio-sternal • Arch of the aorta
angle • Tracheal bifurcation
• Union of the azygos vein and superior vena cava
• The thoracic duct crosses to the midline

Trachea
Trachea
Location C6 vertebra to the upper border of T5 vertebra (bifurcation)
Arterial and venous supply Inferior thyroid arteries and the thyroid venous plexus.
Nerve Branches of vagus, sympathetic and the recurrent nerves
Relations in the neck

Anterior • Isthmus of the thyroid gland
(Superior • Inferior thyroid veins
to • Arteria thyroidea ima (if exists)
inferior) • Sternothyroid
• Sternohyoid
• Cervical fascia
• Anastomosing branches between the
anterior jugular veins
Posterior Oesophagus.
Laterally • Common carotid arteries
• Right and left lobes of the thyroid gland
• Inferior thyroid arteries
• Recurrent laryngeal nerves
Relations in the thorax

Anterior
• Manubrium, the remains of the thymus, the aortic arch, left common carotid arteries, and the deep cardiac
plexus
Lateral
• In the superior mediastinum, on the right side is the pleura and right vagus; on its left side are the left recurrent
nerve, the aortic arch, and the left common carotid and subclavian arteries.

Oesophagus
• 25cm long. Starts at C6 vertebra, pierces diaphragm at T10 and ends at T11
• Squamous epithelium. The oesophagus has no serosal covering and hence
holds sutures poorly. The Auerbach's and Meissner's nerve plexuses lie in
between the longitudinal and circular muscle layers and submucosally. The
sub mucosal location of the Meissner's nerve plexus facilitates its sensory role.
Constrictions of the oesophagus

Structure Distance from incisors
Cricoid cartilage 15cm
Arch of the Aorta 22.5cm
Left principal bronchus 27cm
Diaphragmatic hiatus 40cm
Relations
Anteriorly • Trachea to T4
• Recurrent laryngeal nerve
• Left bronchus, Left atrium
• Diaphragm
Posteriorly • Thoracic duct to left at T5
• Hemiazygos to the left T8
• Descending aorta
• First 2 intercostal branches of aorta
Left • Thoracic duct
• Left subclavian artery
Right • Azygos vein
Arterial, venous and lymphatic drainage of the oesophagus

Artery Vein Lymphatics Muscularis externa
Upper third Inferior thyroid Inferior thyroid Deep cervical Striated muscle
Mid third Aortic branches Azygos branches Mediastinal Smooth & striated muscle
Lower third Left gastric Left gastric Gastric Smooth muscle
Nerve supply
• Upper half is supplied by recurrent laryngeal nerve
• Lower half by oesophageal plexus (vagus)
Histology
• Mucosa :Non-keratinized stratified squamous epithelium
• Submucosa: glandular tissue
• Muscularis externa (muscularis): composition varies. See table
• Adventitia

Lung anatomy
The right lung is composed of 3 lobes divided by the oblique and transverse fissures. The left lung has two lobes divided
by the oblique fissure.The apex of both lungs is approximately 4cm superior to the sterno-costal joint of the first rib.
Immediately below this is a sulcus created by the subclavian artery.
Peripheral contact points of the lung

• Base: diaphragm
• Costal surface: corresponds to the cavity of the chest
• Mediastinal surface: Contacts the mediastinal pleura. Has the cardiac impression. Above and behind this
concavity is a triangular depression named the hilum, where the structures which form the root of the lung
enter and leave the viscus. These structures are invested by pleura, which, below the hilum and behind the
pericardial impression, forms the pulmonary ligament
Right lung
• Above the hilum is the azygos vein; Superior to this is the groove for the superior vena cava and right
innominate vein; behind this, and nearer the apex, is a furrow for the innominate artery. Behind the hilum and
the attachment of the pulmonary ligament is a vertical groove for the oesophagus; In front and to the right of
the lower part of the oesophageal groove is a deep concavity for the extrapericardiac portion of the inferior
vena cava.
• The phrenic nerve lies anteriorly at this point (hilum of left lung). The vagus passes anteriorly and then arches
backwards immediately superior to the root of the left bronchus, giving off the recurrent laryngeal nerve as it
does so.
• The root of the right lung lies behind the superior vena cava and the right atrium, and below the azygos vein.
• The right main bronchus is shorter, wider and more vertical than the left main bronchus and therefore the route
taken by most foreign bodies.
Left lung
• Above the hilum is the furrow produced by the aortic arch, and then superiorly the groove accommodating the
left subclavian artery; Behind the hilum and pulmonary ligament is a vertical groove produced by the
descending aorta, and in front of this, near the base of the lung, is the lower part of the oesophagus.
• The root of the left lung passes under the aortic arch and in front of the descending aorta.
Inferior borders of both lungs

• 6th rib in mid clavicular line
• 8th rib in mid axillary line
• 10th rib posteriorly

The pleura runs two ribs lower than the corresponding lung level.
Bronchopulmonary segments
Segment number Right lung Left lung
1 Apical Apical
2 Posterior Posterior
3 Anterior Anterior
4 Lateral Superior lingular
5 Medial Inferior lingular
6 Superior (apical) Superior (apical)
7 Medial basal Medial basal
8 Anterior basal Anterior basal
9 Lateral basal Lateral basal
10 Posterior basal Posterior basal

Phrenic nerve
Origin
• C3,4,5
Supplies
• Diaphragm, sensation central diaphragm and pericardium
Path
• The phrenic nerve passes with the internal jugular vein
across scalenus anterior. It passes deep to prevertebral
fascia of deep cervical fascia.
• Left: crosses anterior to the 1st part of the subclavian
artery.
• Right: Anterior to scalenus anterior and crosses anterior
to the 2nd part of the subclavian artery.
• On both sides, the phrenic nerve runs posterior to the
subclavian vein and posterior to the internal thoracic
artery as it enters the thorax.
Right phrenic nerve
• In the superior mediastinum: anterior to right vagus
and laterally to superior vena cava
• Middle mediastinum: right of pericardium
• It passes over the right atrium to exit the diaphragm
at T8 via vena cava hiatus.
Left phrenic nerve
• Passes lateral to the left subclavian artery, aortic
arch and left ventricle
• Passes anterior to the root of the lung
• Pierces the diaphragm alone

Thoracic duct
• Continuation of the cisterna chyli in the abdomen.
• Enters the thorax at T12. Lies within the posterior and superior mediastinum.
• Lies posterior to the oesophagus for most of its intrathoracic course. Passes to the left at T5.
• Lymphatics draining the left side of the head and neck join the thoracic duct prior to its insertion into the left
brachiocephalic vein.
• Lymphatics draining the right side of the head and neck drain via the subclavian and jugular trunks into the right
lymphatic duct and thence into the mediastinal trunk and eventually the right brachiocephalic vein.
• Its location in the thorax makes it prone to injury during oesophageal surgery. Some surgeons administer cream
to patients prior to oesophagectomy so that it is easier to identify the cut ends of the duct.

Heart anatomy
The walls of each cardiac chamber comprise:
• Epicardium
• Myocardium
• Endocardium
Cardiac muscle is attached to the cardiac fibrous skeleton.
Relations
The heart and roots of the great vessels within the
pericardial sac are related to the posterior aspect of the
sternum, medial ends of the 3rd to 5th ribs on the left and
their associated costal cartilages. The heart and pericardial
sac are situated obliquely two thirds to the left and one third
to the right of the median plane.
The pulmonary valve lies at the level of the left third costal
cartilage.
The mitral valve lies at the level of the fourth costal cartilage.
Coronary sinus
This lies in the posterior part of the coronary groove and receives blood from the cardiac
veins. The great cardiac vein lies at its left and the middle and small cardiac veins lie on its
right. The smallest cardiac vein (anterior cardiac vein) drains into the right atrium directly.
Aortic sinus
Right coronary artery arises from the right aortic sinus, the left is derived
from the left aortic sinus, which lies posteriorly.
Features of the left ventricle as opposed to the right

Structure Left Ventricle
A-V Valve Mitral (double leaflet)
Walls Twice as thick as right
Trabeculae carnae Much thicker and more numerous
Conus arteriosus Absent
Right coronary artery

The RCA supplies:
• Right atrium
• Diaphragmatic part of the right ventricle
• Usually the posterior third of the interventricular septum
• The sino atrial node (60% cases)
• The atrio ventricular node (80% cases)
Left coronary artery

The LCA supplies:
• Left atrium
• Most of left ventricle
• Part of the right ventricle
• Anterior two thirds of the inter ventricular septum
• The sino atrial node (remaining 40% cases)
Innervation of the heart

Autonomic nerve fibres from the superficial and deep cardiac plexus.
These lie anterior to the bifurcation of the trachea, posterior to the
ascending aorta and superior to the bifurcation of the pulmonary trunk.
The parasympathetic supply to the heart is from presynaptic fibres of the vagus nerves.

Valves of the heart
Mitral valve Aortic valve Pulmonary valve Tricuspid valve
2 cusps 3 cusps 3 cusps 3 cusps
1st heart sound 2nd heart sound 2nd heart sound 1st heart sound
1 anterior cusp 2 anterior cusps 2 anterior cusps 2 anterior cusps
Attached to chordae tendinae No chordae No chordae Attached to chordae tendinae

Superior vena cava
Drainage
• Head and neck
• Upper limbs
• Thorax
• Part of abdominal walls
Formation
• Subclavian and internal jugular veins unite to form the right and left brachiocephalic veins
• These unite to form the SVC
• Azygos vein joins the SVC before it enters the right atrium
Relations
Anterior Anterior margins of the right lung and pleura
Posteromedial Trachea and right vagus nerve
Posterolateral Posterior aspects of right lung and pleura
Pulmonary hilum is posterior
Right lateral Right phrenic nerve and pleura
Left lateral Brachiocephalic artery and ascending aorta
There are 4 collateral venous systems:

• Azygos venous system
• Internal mammary venous pathway
• Long thoracic venous system with connections to the femoral and vertebral veins (2 pathways)
Despite this, venous hypertension still occurs in SVC obstruction.
Developmental variations
Anomalies of the connection of the SVC are recognised. In some individuals a persistent left sided SVC drains into the
right atrium via an enlarged orifice of the coronary sinus. More rarely the left sided vena cava may connect directly with
the superior aspect of the left atrium, usually associated with an un-roofing of the coronary sinus. The commonest lesion
of the IVC is for its abdominal course to be interrupted, with drainage achieved via the azygos venous system. This may
occur in patients with left sided atrial isomerism.

Thoracic aorta
Origin T4
Terminates T12
Relations • Anteriorly: (from top to bottom) Root of the left lung, the pericardium, the oesophagus, and the
diaphragm
• Posteriorly: Vertebral column, Azygos vein
• Right: Hemiazygos veins, Thoracic duct
• Left: Left pleura and lung
Branches • Lateral segmental branches: Posterior intercostal arteries
• Lateral visceral: Bronchial arteries supply bronchial walls and lung excluding the alveoli
• Midline branches: Oesophageal arteries
Prosthetic heart valves on Chest X-rays

The aortic and mitral valves are most commonly replaced and when a metallic valve is used, can be most readily
identified on plain x-rays.
The presence of cardiac disease (such as cardiomegaly) may affect the figures quoted here.
Aortic
Usually located medial to the 3rd interspace on the right.
Mitral
Usually located medial to the 4th interspace on the left.
Tricuspid
Usually located medial to the 5th interspace on the right.
Please note that these are the sites at which an artificial valve may be located and are NOT the sites of auscultation.

1F. ANATOMY (MISCELLANEOUS) – MRCS NOTES - REDA
Lumbar puncture ............................................................................................................................................ 2
Vertebral column ............................................................................................................................................ 3
Spinal cord....................................................................................................................................................... 4
Upper Vs Lower motor neurone lesions - Facial nerve ................................................................................. 5
Sympathetic Nervous System - Anatomy ...................................................................................................... 6
Pharyngeal arches ........................................................................................................................................... 7
Levels ............................................................................................................................................................... 8
1F. ANATOMY (MISCELLANEOUS) – MRCS NOTES - REDA 1

Lumbar puncture
Lumbar punctures are performed to obtain cerebrospinal fluid. In adults, the procedure is best performed at the level of
L3/L4 or L4/5 interspace. These regions are below the termination of the spinal cord at L1.
During the procedure the needle passes through:

• The supraspinous ligament which connects the tips of spinous processes and the interspinous ligaments
between adjacent borders of spinous processes
• Then the needle passes through the ligamentum flavum, which may cause a give as it is penetrated
• A second give represents penetration of the needle through the dura mater into the subarachnoid space. Clear
CSF should be obtained at this point

Vertebral column
• There are 7 cervical, 12 thoracic, 5 lumbar, and 5 sacral vertebrae.
• The spinal cord segmental levels do not necessarily correspond to the vertebral segments. For example, while the C1
cord is located at the C1 vertebra, the C8 cord is situated at the C7 vertebra. While the T1 cord is situated at the T1
vertebra, the T12 cord is situated at the T8 vertebra. The lumbar cord is situated between T9 and T11 vertebrae. The
sacral cord is situated between the T12 to L2 vertebrae.
Cervical vertebrae
The interface between the first and
second vertebra is called the atlanto-
axis junction. The C3 cord contains
the phrenic nucleus.
Muscle Root value
Deltoid C5,6
Biceps C5,6
Wrist extensors C6-8
Triceps C6-8
Wrist flexors C6-T1
Hand muscles C8-T1
Thoracic vertebrae
The thoracic vertebral segments are
defined by those that have a rib. The
spinal roots form the intercostal
nerves that run on the bottom side of
the ribs and these nerves control the
intercostal muscles and associated
dermatomes.
Lumbosacral vertebrae
Form the remainder of the segments
below the vertebrae of the thorax.
The lumbosacral spinal cord,
however, starts at about T9 and
continues only to L2. It contains most
of the segments that innervate the
hip and legs, as well as the buttocks
and anal regions.
Cauda Equina
The spinal cord ends at L1-L2 vertebral level. The tip of the spinal cord is
called the conus. Below the conus, there is a spray of spinal roots that is
called the cauda equina. Injuries below L2 represent injuries to spinal
roots rather than the spinal cord proper.

Spinal cord
• Located in a canal within the vertebral column that affords it structural support.
• Rostrally it continues to the medulla oblongata of the brain and caudally it tapers at a level corresponding to the L1-
2 interspace (in the adult), a central structure, the filum terminale anchors the cord to the first coccygeal vertebra.
• The spinal cord is characterised by cervico-lumbar enlargements and these, broadly speaking, are the sites which
correspond to the brachial and lumbar plexuses respectively.
The spinal cord is approximately 45cm in men and 43cm in women. The denticulate ligament is a continuation of the pia
mater (innermost covering of the spinal cord) which has intermittent lateral projections attaching the spinal cord to the
dura mater and suspends the spinal cord in the dural sheath.
There are some key points to note when considering the surgical anatomy of the spinal cord:
• During foetal growth the spinal cord
becomes shorter than the spinal canal,
hence the adult site of cord
termination at the L1-2 level, while in
neonates it’s L3.
• Due to growth of the vertebral column
the spine segmental levels may not
always correspond to bony landmarks
as they do in the cervical spine.
• The spinal cord is incompletely divided
into two symmetrical halves by a
dorsal median sulcus and ventral
median fissure. Grey matter surrounds
a central canal that is continuous
rostrally with the ventricular system of
the CNS.
• The grey matter is sub divided
cytoarchitecturally into Rexeds
laminae.
• Afferent fibres entering through the
dorsal roots usually terminate near
their point of entry but may travel for
varying distances in Lissauers tract. In
this way they may establish synaptic
connections over several levels
• At the tip of the dorsal horn are
afferents associated with nociceptive
stimuli. The ventral horn contains
neurones that innervate skeletal
muscle.
The key point to remember when revising CNS anatomy is to keep a clinical perspective in mind. So it is worth classifying
the ways in which the spinal cord may become injured. These include:
• Trauma either direct or as a result of disc protrusion
• Neoplasia either by direct invasion (rare) or as a result of pathological vertebral fracture
• Inflammatory diseases such as Rheumatoid disease, or OA (formation of osteophytes compressing nerve roots
etc.
• Vascular either as a result of stroke (rare in cord) or as complication of aortic dissection
• Infection historically diseases such as TB, epidural abscesses.
The anatomy of the cord will, to an extent dictate the clinical presentation. Some points/ conditions to remember:
• Brown- Sequard syndrome-Hemisection of the cord producing ipsilateral loss of proprioception and upper
motor neurone signs, plus contralateral loss of pain and temperature sensation. The explanation of this is that
the fibres decussate at different levels.
• Lesions below L1 will tend to present with lower motor neurone signs

Upper Vs Lower motor neurone lesions - Facial nerve
The nucleus of the facial nerve is located in the caudal aspect of the ventrolateral pontine tegmentum. Its axons exit the
ventral pons medial to the spinal trigeminal nucleus.
Any lesion occurring within or affecting the corticobulbar tract is known as an upper motor neuron lesion. Any lesion
affecting the individual branches (temporal, zygomatic, buccal, mandibular and cervical) is known as a lower motor
neuron lesion.
Branches of the facial nerve leaving the facial motor nucleus (FMN) for the muscles do so via both left and right posterior
(dorsal) and anterior (ventral) routes. In other words, this means lower motor neurons of the facial nerve can leave
either from the left anterior, left posterior, right anterior or right posterior facial motor nucleus. The temporal branch
travels out from the left and right posterior components. The inferior four branches do so via the left and right anterior
components. The left and right branches supply their respective sides of the face (ipsilateral innervation). Accordingly,
the posterior components receive motor input from both hemispheres of the cerebral cortex (bilaterally), whereas the
anterior components receive strictly contra-lateral input. This means that the temporal branch of the facial nerve
receives motor input from both hemispheres of the cerebral cortex whereas the zygomatic, buccal, mandibular and
cervical branches receive information from only contralateral hemispheres.
Now, because the anterior FMN receives only contralateral cortical input whereas the posterior receives that which is
bilateral, a corticobulbar lesion (UMN lesion) occurring in the left hemisphere would eliminate motor input to the right
anterior FMN component, thus removing signaling to the inferior four facial nerve branches, thereby paralyzing the right
mid- and lower-face. The posterior component, however, although now only receiving input from the right hemisphere,
is still able to allow the temporal branch to sufficiently innervate the entire forehead. This means that the forehead will
not be paralyzed.
The same mechanism applies for an upper motor neuron lesion in the right hemisphere. The left anterior FMN
component no longer receives cortical motor input due to its strict contralateral innervation, whereas the posterior
component is still sufficiently supplied by the left hemisphere. The result is paralysis of the left mid- and lower-face with
an unaffected forehead.
On the other hand, a lower motor neuron lesion is a bit different.
A lesion on either the left or right side would affect both the anterior and posterior routes on that side because of their
close physical proximity to one another. So, a lesion on the left side would inhibit muscle innervation from both the left
posterior and anterior routes, thus paralyzing the whole left side of the face (Bells Palsy). With this type of lesion, the
bilateral and contalateral inputs of the posterior and anterior routes, respectively, become irrelevant because the lesion
is below the level of the medulla and the facial motor nucleus. Whereas at a level above the medulla a lesion occurring in
one hemisphere would mean that the other hemisphere could still sufficiently innervate the posterior facial motor
nucleus, a lesion affecting a lower motor neuron would eliminate innervation altogether because the nerves no longer
have a means to receive compensatory contralateral input at a downstream decussation.
Upper motor neurone lesions of the facial nerve- Paralysis of the lower half of face.
Lower motor neurone lesion- Paralysis of the entire ipsilateral face.

Sympathetic Nervous System - Anatomy
The cell bodies of the pre-ganglionic efferent neurones lie in the lateral horn of the grey matter of the spinal cord in the
thoraco-lumbar regions.
The pre-ganglionic efferents leave the spinal cord at levels T1-L2. These pass to the sympathetic chain.
Lateral branches of the sympathetic chain connect it to every spinal nerve. These post ganglionic nerves will pass to
structures that receive sympathetic innervation at the periphery.
Sympathetic chains
These lie on the vertebral column and run from the base of the skull to the coccyx.
Cervical Lie anterior to the transverse processes of the cervical vertebrae and posterior to the carotid sheath.
region
Thoracic Lie anterior to the neck of the upper ribs and lateral sides of the lower thoracic vertebrae. They are
region covered by the parietal pleura
Lumbar Enter by passing posterior to the medial arcuate ligament. Lie anteriorly to the vertebrae and medial
region to psoas major.
Sympathetic ganglia
• Superior cervical ganglion lies anterior to C2 and C3.
• Middle cervical ganglion (if present) C6
• Stellate ganglion- anterior to transverse process of C7, lies posterior to the subclavian artery, vertebral artery
and cervical pleura.
• Thoracic ganglia are segmentally arranged.
• There are usually 4 lumbar ganglia.
Clinical importance
• Interruption of the head and neck supply of the sympathetic nerves will result in an ipsilateral Horner’s
syndrome.
• For treatment of hyperhidrosis the sympathetic denervation can be achieved by removing the second and third
thoracic ganglia with their rami. Removal of T1 will cause a Horners syndrome and is therefore not performed.
• In patients with vascular disease of the lower limbs a lumbar sympathetomy may be performed, either
radiologically or (more rarely now) surgically. The ganglia of L2 and below are disrupted. If L1 is removed, then
ejaculation may be compromised (and little additional benefit conferred as the preganglionic fibres do not arise
below L2.

Pharyngeal arches
These develop during the fourth week of embryonic growth from a series of mesodermal outpouchings of the developing
pharynx.
They develop and fuse in the ventral midline. Pharyngeal pouches form on the endodermal side between the arches.
There are 6 pharyngeal arches, the fifth does not contribute any useful structures and often fuses with the sixth arch.
Pharyngeal arches
Arch Muscular contributions Skeletal Endocrine Artery Nerve
First • Muscles of mastication • Maxilla N/A • Maxillary • Mandibular
• Ant. belly of digastric • Meckel’s cartilage • External carotid
• Mylohyoid • Incus
• Tensor tympanic • Malleus
• Tensor veli palatini
Second • Buccinator • Stapes N/A • Inferior branch • Facial
• Platysma • Styloid process of superior
• Muscles of facial expression • Lesser horn and thyroid artery
• Stylohyoid upper body of hyoid • Stapedial artery
• Posterior belly of digastric
• Stapedius
Third • Stylopharyngeus • Greater horn and • Thymus • Common and • Glossopharyngeal
lower part of hyoid • Inferior Internal carotid
parathyroids
Fourth • Cricothyroid • Thyroid and • Superior • Right • Vagus
• All intrinsic muscles of the epiglottic cartilages parathyroids Subclavian artery
soft palate • Left aortic arch
Sixth • All intrinsic muscles of the • Cricoid, arytenoid n/a • Right: • Vagus and
larynx (except cricothyroid) and corniculate Pulmonary artery recurrent laryngeal
cartilages • Left: Pulmonary nerve
artery and ductus
arteriosus

Levels
Transpyloric plane
Level of the body of L1
• Pylorus stomach
• Left kidney hilum (L1- left one!)
• Fundus of the gallbladder
• Neck of pancreas
• Duodenojejunal flexure
• Superior mesenteric artery
• Portal vein
• Left and right colic flexure
• Root of the transverse mesocolon
• 2nd part of the duodenum
• Upper part of conus medullaris
• Spleen
Can be identified by asking the supine
patient to sit up without using their arms.
The plane is located where the lateral
border of the rectus muscle crosses the
costal margin.
Anatomical planes
Subcostal plane Lowest margin of 10th costal cartilage
Intercristal plane Level of body L4 (highest point of iliac crest)
Intertubercular plane Level of body L5
Common level landmarks

Inferior mesenteric artery L3
Bifurcation of aorta into common iliac arteries L4
Formation of IVC L5 (union of common iliac veins)
Diaphragm apertures • Vena cava T8
• Oesophagus T10
• Aortic hiatus T12

Reda Note Anatomy

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1A.

ANATOMY (UPPER LIMB) – MRCS NOTES - REDA

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 1

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 2

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 7

Trapezius Levator scapulae

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 8

Cut edge of lateral head

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 9

Transverse humeral ligament

Short head of biceps

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 10

Flexor carpi ulnaris

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 11

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 12

Anterior View Posterior View

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 13

Abductor pollicis longus

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 14

Palmaris longus tendon

Extensor pollicis brevis tendon

Extensor carpi ulnaris Cephalic vein

Extensor pollicis longus tendon

Extensor digitorum tendons Extensor carpi radialis brevis tendon

Neuroanatomic Relationships in the Forearm

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 15

Three hypothenar muscles

Abductor pollicis and first

Opponens Flexor pollicis

Oblique head Deep branch Recurrent branch of

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 16

Fascia and compartments of the palm

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 17

Long flexor tendons and sheaths in the hand

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 18

Dorsal interossei (palmar view) Palmar interossei (palmar view)

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 19

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 20

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 21

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 22

The median nerve is in relation with the medial side of the

The ulnar nerve lies medially to the lower two-thirds of the

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 23

Median cubital vein

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 24

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 25

Summary of Upper Extremity Innervation

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 26

Damage at elbow, as above plus:

Anterior interosseous nerve (branch of median nerve)

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 27

Supplies (no muscles in the upper arm) Ulnar nerve: Mafia P

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 28

Muscular innervation and effect of denervation

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 31

Deltoid Subtendinous bursa of subscapularis

Short head of biceps brachii and

1A. ANATOMY (UPPER LIMB) – MRCS NOTES - REDA 33

Important anatomical relations

Superior glenohumeral ligament