Anatomy Board Review

Dr. Larry Cochard

Feinberg School of Medicine, 2011-12

Copyright C 2012, L. Cochard, Northwestern University

 Back and Spine

-- Coverings of spinal cord

-- Levels of spinal nerves
-- Herniated disk
-- Whiplash injuries
Epidural vs. Subarachnoid Anesthesia
Spinal cord
ends L1

Cauda equina in
subarachnoid space
(lumbar block/tap)

Dural sac ends

at S1

Sacral nerves
are epidural
 Vertebra:
Herniated Discs Affect Nerves Below
Roots: L4
Ligaments: Posterior
longitudinal L4
Anterior L5
longitudinal Ligamentum L5
flavum between Cut
laminae pedicle

More medial hernia affects more

Supra- and roots:
interspinous

Same for cervical

herniation, but for
a different reason:
nerve numbering
Whiplash–
Hyperextension Injury

Soft tissue injury to

anterior/lateral structures—
anterior longitudinal ligament
with ruptured disc, & longus
coli/scalene muscles.

Can also stretch trachea/

larynx and cause
concussion or other brain
injury.
Clinical Symposia, Vol. 32, No. 1, Ciba-Geigy
 Heart and Lungs

•Position in thorax
•Origin of great vessels
•Coronary arteries
•Auscultation of valve sounds
•Muscle of Respiration
•Referred Pain
 Heart Position in Thorax
It’s about the length of
the body of the sternum:

-- ribs 2-6
-- from sternal angle
to xiphoid process

Note left and right

pleural sacs almost
touch each other.

CIBA Clinical Symposia,

Vol. 17, No. 3, 1965 Costo-diaphragmatic recess of parietal pleura
 Brachiocephalic Anterior Schematic
veins
Left pulmonary
Superior artery
vena cava Pulmonary veins
Aorta
R. pulmonary Pulmonary
artery trunk Left ventricle is the
Right
auricle left margin
Right atrium
is the right
margin of the heart Right ventricle RV
is anterior LV
RA
Inferior vena cava LA

Grant’s Atlas of Anatomy, CT: T8

Williams & Wilkins, 9th ed., 1991 Descending aorta
Coronary Arteries :They run in the atrio-ventricular and
interventricular grooves
.
Left coronary artery
SA
node
Circumflex
Right coronary branch

artery
Anterior
AVnode Interventricular

LAD

Marginal branch
Grant’s Atlas of Anatomy,
Posterior interventricular Williams & Wilkins, 9th ed., 1991
Semilunar valves compared with right atrio-ventricular
and left atrio-ventricular valves
Aortic semilunar
Pulmonary semi-
valve
lunar valve
Right A-V
Left atrio- valve
ventricular
Valve tricuspid

Bicuspid, mitral

Clemente’s atlas of Anatomy, Urban

& Schwarzenberg, 3rd ed., 1987
Lung position in thorax: middle lobe of right lung
and lingula of left upper lobe are against the heart.
Inferior lobes are posterior
Right lung lobes: PA x-ray Right lung lobes: lateral x-ray

Left lung lobes: PA view Left lung lobes: lateral view

 Muscles of Respiration

Scalenes &
Sternocleidomastoid

Pectoralis minor

Serratus Ant. Internal

intercostal
External
intercostal

Diaphragm
C3-5 phrenic
nerve Abdominal muscles

Inspiration Expiration
Referred pain from angina radiates down medial side of arm
Ventricular sensory fibers enter the stellate ganglion (T1).
(Heart sensation is from mid cervical to mid thoracic levels.)
T1 is the lowest ventral ramus of the brachial plexus (C5-T1).

T1

Grant’s Atlas of Anatomy, 10th Ed.,

Essential Clinical Anatomy,
Lippincott Williams & Wilkins, 1999
2nd Ed., LW&W, 2002.
 Digestive System
-- Arterial supply to gut
-- Portal-caval anastomoses
-- Visceral sensory pain &
autonomic pathways
-- Bile duct system
-- Anal canal
-- Retroperitoneal organs
 Celiac trunk: splenic, left gastric, and common
hepatic arteries supplying the abdominal foregut
Left Esophageal branches
L. & R.
Hepatic gastric
Short gastric
Cystic Common
hepatic
Hepatic

Gastroduodenal
Supra-
duodenal
Splenic

Superior
Pancreaticoduodenal Right & Left Gastroepiploic
 Superior mesenteric artery for midgut;
Inferior mesenteric artery for hindgut
Superior mesenteric:
Ileocolic (I.C.)
Right colic (R.C.)
Middle colic (M.C.)
Intestinal branches
Inferior mesenteric:
Left colic (L.C.)
Sigmoid branches
Superior rectal (S.R.)

Grant’s Method of Anatomy, 11th ed.,

Williams & Wilkins, 1989
 Important Sites of Portal-Caval Anastomosis
Inferior vena cava Esophageal veins–
(“caval” systemic azygous system
venous return) (hemorrhage)

Splenic
Para-umbilical
Sup. mesenteric Portal system of
veins– veins from GI
Inf. mesenteric
superificial capillaries to
epigastric veins liver sinusoids
(caput
medusa) Superior rectal veins—
branches of internal iliacs
(hemorrhoids)
Primarily retroperitoneal organs:
-- Bladder/prostate gland
-- Kidneys
-- Vagina/cervix
-- Rectum
-- Aorta/IVC

Secondarily retroperitoneal organs:

-- Ascending and descending colon
-- Duodenum
-- Pancreas
Cross-sectional anatomy: pancreas relationships

Peritoneal cavity
11
Duodenum Duodenum
12 5
5 4 6
6 5 3 6
8 6 10
2 1
7

9
9

The head of the pancreas is in the

curve of the duodenum. The
superior mesenteric vessels pass
under the body of the pancreas. Level of
1- aorta 5- pancreas head9- kidneys section above
2- IVC 6- small intestine 10- descending colon
3- SMA 7- left renal artery11- transverse colon
4- SMV 8- left renal vein 12- gall bladder
After Sauerland, Grant’s Dissector, 12th ed., LW&W,
Gut Sympathetics:
Innervation Preganglionic
neurons in
spinal cord
(T5-L2);
Vagus nerve
Synapse with
postganglionic
Parasympathetics:
preganaglionic neurons in
neurons in
brainstem (vagus) or spinal sympathetic
cord (S2-4) (pelvic chain or
splanchnic nerves); prevertebral
synapse in ganglia in gut ganglia;
wall Splanchnic
nerve postganglionic
fibers travel
with arteries to
reach target
organs
Enteric plexus
Visceral sensory fibers travel with sympathetic splanchnic nerves to
enter the sympathetic trunk, communicating rami, and spinal nerves
On the left: cardio-
pulmonary and thoracic
splanchnic nerves and
plexuses on/to viscera.

On the right: collateral

ganglia on arteries, lumbar
splanchnic nerves, and
formation of the pelvic
plexus from continuation
of the aortic plexus.
Note pelvic splanchnic
nerves (parasympathetic and
visceral sensory) from
sacral ventral rami
 King & Showers,
Visceral Sensory Spinal Cord Human Anatomy &
Physiology, 6th ed.,

Segments Via Splanchnic nn. Saunders,

1969

Note:
T1 (ventricles)
-- Thoracic splanchnics do
foregut and midgut
T7-9
-- Lumbar (and pelvic (Kidneys
splanchnics) do hindgut/ 10-L1)
pelvis L1
-- Few spinal segments for
T10
all of small intestine L5
 Bile and Pancreatic Duct System

Left and right hepatic ducts

Cystic Common hepatic duct

duct
(Common) bile duct

Main pancreatic duct

from ventral bud

Gall stones lodge at sphincter

Of Oddi/major duodenal papilla
 Anal Canal
Note:

-- Anal glands opening

into crypts
-- Pectinate line at bottom
of columns (site of
cloacal membrane)
-- White line where
epithelium changes
-- Three parts (colored)
of external sphincter
(subcutaneous,
Clinical Symposia, Vol. 37, superficial, deep) White line
No. 6, CIBA-Geigy, 1985
 Hemorrhoids: Dilated
Rectal/Anal Veins

Internal hemorrhoids get

visceral sensory innervation—
no pain

External hemorrhoids get

general sensory (somatic)
innervation– intense pain,
itching, etc.

Clinical Symposia, Vol. 37,

Types: External Internal Mixed
No. 6, CIBA-Geigy, 1985
 Urogenital
-- Kidney stones
-- Pelvic diaphragm
-- Innervation
-- Pouches
-- Uterus relationships
Common sites for kidney
stones to lodge:

Renal pelvis

Common iliac vessels

Entrance to bladder

Clinical Symposia, Vol. 38,

No. 3, CIBA-Geigy, 1986
Pelvic Plexus (Inferior Hypogastric Plexus)

Lumbar splanchnics supplying

sympathetics & visceral sensory
to superior hypogastric plexus
(and on to pelvic plexus)

Ventral rami of sacral plexus

(e.g., pudendal nerve)

Pelvic splanchnic nerves

(parasympathetic and
visceral sensory)

Hollinshead’s Textbook of Anatomy,

3rd ed., Harper & Row, 1974
Spinal nerve innervation: In UG diaphragm
-- Pelvic and UG diaphragms
-- External anal sphincter & ext. urethral spinchter
-- External genital organs (sensory, somatomotor)
Parasympathetic innervation:
-- Intestines/rectum (peristalsis; defecation)
-- Bladder (urination)
-- Erectile arteries (genital erection)

Sympathetic innervation:
-- Arterial smooth muscle (blood pressure)
-- Ureters
-- Ductus deferens (ejaculation)
-- Sphincters (pyloric, internal urethral, internal anal)
Female UG &Pelvic Diaphragms UG diaphragm

Labia majora– folds of

superficial body wall

Central tendon
Levator ani:
Pubococcygeus
Iliococcygeus

Clemente Anatomy, A Regional Atlas,

4th ed., Williams & Wilkins, 1997
Two pouches: the deep “pouch” is the interior of
the UG diaphragm. The superficial pouch is the
scrotum or labia majora (superficial body wall)
containing the external genital organs
Deep body wall

Deep
pouch
Scarpa’s Scarpa UG Diaphragm
fascia
Perineal membrane
Scrotum
Colle’s fascia
Superficial pouch
Grant’s Method of Anatomy, 11th
Colle’s fascia
Ed., Williams & Wilkins, 1989
 The superficial pouch of Colle’s fascia is tightly
ttached to the back edge of the UG diaphragm and
perineal body and fascia lata of the thigh.
Deep (investing) fascia
Scarpa’s fascia

Blood or urine in
the superficial pouch
can only pass upward
into the body wall
between the superficial
and deep layers.
Posterior View of Uterus and It’s Ligaments
Round ligament Ampulla of
of uterus (old gubernaculum) uterine tube
Grant’s Atlas , 8th ed., Suspensory
W&W, 1983 Ligament of
ovary

Ovarian vessels Ovarian

In suspensory Mesovarium (MO)
ligament
ligament Mesosalpinx

Broad ligament MO
(mesometrium)
Uterine artery Parasagittal section:
 Body Wall
-- Inguinal canal & hernia
-- Lymphatic drainage of breast
 Spermatic Cord and Inguinal Canal X = Site of direct
hernia
Inferior Note 2 layers forming
epigastric conjoint tendon:
artery

X
1 2

Deep ring/internal
spermatic fascia from
transversalis fascia
Sup. ring, external Cremaster from internal oblique
spermatic fascia from external oblique
Indirect (congenital) hernia
passes through inguinal canal

Enters deep inguinal

ring lateral to the inferior
epigastric artery
A direct inguinal hernia is:

-- NOT through the

inguinal canal

-- Medial to inferior
epigastric artery

-- Under the conjoint tendon

medial to the inguinal canal
Femoral Sheath & Hernia
Envelops the artery, vein, and
lymphatics. The latter compartment
is the femoral canal (hernial site).

N. A.
V.
L.

Greater saphenous vein

(preaxial) Grant’s Atlas of Anatomy, 8th Ed.,
Williams & Wilkins, 1983
Some types of hernia:

-- Inguinal (shown)
-- Femoral (shown)
-- Obturator
-- Diaphragmatic
-- Lumbar
-- Umbilical (not just omphalocele)
Lymph Drainage of Breast Subclavian
trunk

1. Upper lateral breast

to axillary nodes

2. To opposite breast

Unusual paths:

3. Parasternal nodes
deep to body wall

4. Superficial inguinal
nodes.
 Limbs
Select clinical points (e.g., hand, nerve-bone
relations)

Nerve deficits are included for completeness;

these will be addressed by Dr. Perkins
 Brachial Plexus: flexor compartment
nerves yellow, extensor green
Coracoid process
C5
Long head, biceps C6
C7
Short head & C8
coraco-
T1
brachialis

Terminal branches Cords Divisions Trunks Roots

Bone Injuries Separation at acromioclavicular joint
Dislocation through capsule
(anatomical neck)
Surgical neck (axillary nerve &
posterior humeral circumflex a.
through quadrangular space)

Midshaft (spiral groove) (radial

nerve & profunda brachial a.
through triangular space) Medial
epi-
Distal (median nerve, brachial a.) condyle
(ulnar
nerve)
 Nerve functions indicated
Anterior division nerve injuries
are lost in nerve injury
Musculocutaneous: arm flexor
compartment. Shoulder and elbow
flexion; supination. Shoulder and
elbow extended; forearm pronated

Median: pronators, anterior

forearm compartment, thenar
muscles. Wrist and finger flexion;
thumb function except adduction.
Ape hand or sign of
Papal benediction

Ulnar (and lower plexus injury): intrinsic hand muscles and

hypothenar compartment. Abduction/adduction of digits 2-5;
IP extension; MP flexion. Claw hand
 Posterior division nerve injuries

Axillary: deltoid and

teres minor. Loss of
shoulder abduction with
weakness in all shoulder
movements.

Radial: arm and forearm extensor compartments;

supinator. Wrist drop; pronated forearm. (Elbow
seldom affected because triceps branches have a
very high origin off the radial nerve.)
Other nerve injuries Suprascapular to rotator cuff except
subscapularis; weakness in shoulder
lateral rotation and abduction.
Upper plexus; loss of the suprascapular and
Musculocutaneous and a bit of the radial;
Waiter’s tip: medial rotation of the arm,
arm, pronation of the forearm,
flexed wrist.
Long thoracic from C5,6, &7
roots (not shown) to serratus
anterior; winging of the
scapula (loss of shoulder
girdle protraction).

Thoracodorsal (not shown from posterior cord) to latissimus dorsi;

weakness in shoulder adduction, extension, and medial rotation.
 Clinical Considerations in the Hand
Median nerve in Ulnar nerve and
carpal tunnel artery are
Recurrent branch to superficial to
thenar compartment carpal tunnel
is superficial and
vulnerable
Synovial tendon
sheath of digit V
Midpalmar space is continuous with
deep to flexor common sheath
tendons in carpal tunnel

Cutaneous branches of median and ulnar nerves to sides of digits

 Colles (“dinner fork”) fracture of radius from a fall

Scaphoid most
Styloid process
common carpal
more proximal
bone fractured
in compression
injuries

Distal radius/hand displaced dorsally & proximally

Lumbar Plexus: flexor
compartment nerves yellow,
extensor green

Femoral nerve to quadruceps.

Hip flexion, knee extension, hip
lateral rotation. Weakness in hip
flexion and knee extension. Knee
collapses with activity.

Obturator nerve to adductors.

Hip adduction and medial rotation.
Weakness in hip adduction.
Leg widely abducts in swing
phase of gait cycle.
 Sacral Plexus: flexor compartment
nerves yellow, extensor green

Superior gluteal nerve: gluteus medius and

minimus. Hip adduction and medial rotation.
Positive Trendelenberg sign. Pelvis tilts to
opposite side. To compensate, trunk (center of
gravity) moved over affected side.

Inferior gluteal nerve: gluteus maximus. Hip

extension and lateral rotation. Weakness in
hip extension. Can walk OK, but difficulty in
getting out of a chair, climbing, stairs, etc.
 Sacral Plexus: flexor compartment
nerves yellow, extensor green

Tibial nerve (half of sciatic): hamstrings,

calf, and all plantar foot muscles. Knee
Flexion, plantarflexion at ankle, and toe
movements. Loss of knee flexion and
plantarflexion. Increased arch of foot
(pes cavus) and claw foot.

Common fibular nerve (half of sciatic):

anterior dorsiflexors (deep fibular nerve)
Tibial and evertors (superficial fibular nerve).
Foot drop and steppage gait (to clear
foot from the ground). Foot is inverted.
 Head and neck
-- Neck injuries and clinical relationships
(larynx, scalene triangle, etc.)
-- Lymphatic drainage
-- Dural sinuses, epidural and subdural bleeding
-- Syndromes and nerve loss
-- Orbit clinical anatomy
-- Nasal cavity
-- Autonomics
Scalenus Anticus Syndrome
Compression of the
brachial plexus and/or
the subclavian artery in
the interscalene triangle
between the anterior and
middle scalene muscles.
To test, stretch/contract the
muscles:
-- inspriation
-- laterally bend neck
(to opposite side)
-- rotate to same side
Clinical Symposia, Vol 23, No. 2, Ciba-Geigy, 1971
(transverse processes further away)
 Costo-clavicular Syndrome

Nerve/vascular
compression
between the
clavicle and
first rib.

Clinical Symposia, Vol 23, No. 2, Ciba-Geigy, 1971

Hyperflexion Injury

This can disrupt the

articulations between
cervical vertebrae and
result in dislocation
or sliding of one vertebra
on another.

Clinical Symposia, Vol. 32, No. 1, Ciba-Geigy

 Hyperflexion II

Posterior structures are

torn– interspinous
ligaments and joint
capsules that result in
anterior dislocation of
the cervical spine with
possible spinal cord
damage.

Clinical Symposia, Vol. 32, No. 1, Ciba-Geigy

Compression Injury

The bodies of cervical

vertebrae are crushed
to varying degrees.

Clinical Symposia, Vol. 32, No. 1, Ciba-Geigy

 Compression II

Spinal cord damage

can result in more
severe cases.

Clinical Symposia, Vol. 32, No. 1, Ciba-Geigy

Major Head Lymphatics
Superficial cervical ring

Internal jugular
lymphatics
(part of deep cervical)
Parallel posterior route
Part of deep
along nerve XI ring/sheath

Transverse cervical nodes

All converge on jugular trunk
Netter’s Atlas of Human Anatomy,
Ciba/Geigy, 1989
 Emergency Airway; Recurrent Laryngeal Nerves

Membranes:
Laryngeal cartilages:
Thyrohyoid
membrane Thyroid cartilage

Cricothyroid
membrane Cricoid cartilage
(site of “high”
airway entrance)
Recurrent (inferior)
laryngeal nerves lateral
to trachea & vulnerable
Grant’s Atlas, 8th Ed., in thyroidectomy
Williams & Wilkins, 1983
 All are innervated by the
Intrinsic Laryngeal Muscles inferior laryngeal nerve except
the cricothyroid by external.
Ary-
epiglottic
muscle

Oblique &
Transverse
arytenoid

Posterior
crico-arytenoid
Netter Atlas of Human Anatomy, Cricothyroid
ICON Learning Systems, 1997
Posterior cricoarytenoid Lateral cricoarytenoid Transverse arytenoid
opens the glottis closes the glottis closes the glottis

Thyroarytenoid
Cricothyroid lowers pitch:
raises pitch: (shortens
(stretches cords)
cords)
 Dural sinuses are venous channels between the two
layers of dura; all converge on internal jugular vein
Middle meningeal artery branch Emmisary veins
They drain
blood from the
brain & connect
with veins of
the scalp. Dura
Arachnoid
Pia
The superior
sagittal sinus
(X-section, right) Cerebral veins
receives all CSF
via tufts of arachnoid (arachnoid granulations)
extending into the sinus. Netter Atlas, Ciba-Geigy, 1989
 Dural Sinuses: Medial View Netter Atlas, Ciba-Geigy, 1989

Flow sequence:
Superior sagittal sinus
Transverse sinus
Sigmoid sinus
Internal jugular vein
Inferior sagittal sinus
(joining great cerebral
vein)
Straight sinus
Transverse sinuses, etc.

Cavernous sinus Superior/inferior petrosal sinuses

Sigmoid sinus
Cavernous Sinus: Coronal-Section

III
IV Internal carotid a.
VI
V1 Hypophysis
V2 (pituitary gland)

Sphenoid sinus

-- Nerves to orbit (and V2) pass through it.

-- Internal carotid artery passes through it.
-- Flanks body of the sphenoid (sella turcica).
Netter Atlas, Ciba-Geigy, 1989
Epidural bleeding is Bone
arterial from the Dura
middle meningeal
artery

Subdural bleeding is
venous from cerebral
veins at the superior
sagittal sinus Dura

Arachnoid
Subarachnoid bleeding
will be arterial if from
cerebral arteries (e.g.,
ruptured aneurisms)
 Subarachnoid
blood
Intracerebral e.g., from a
in CSF between
arachnoid and
bleeding ruptured
aneurysm
pia; follows
contour
of brain

Subdural Epidural
bleeding bleeding
between dura between bone
and arachnoid; and dura;
irregular in convex in
shape shape
 Nerve Function
2- 3,4,6- Overview
1-
Smell Vision Eye
movement 5- Face sensation, jaw
muscle function

7- Face muscle function,

taste, salivation
8- Hearing and balance

9- Pharynx sensation,
parotid salivation
11- Neck
muscles 10- Motor to pharynx, palate,
12- Tongue muscles larynx, visceral smooth
muscle; visceral sensation
Netter Atlas, Ciba-Geigy, 1989
Nerves: Note Their Targets (Muscle, Eye, Lacrimal)

VI to lateral rectus Blue: ethmoid

air cell
IV to superior mucosa
oblique

V1 (general sensory): III to everything

Frontal, lacrimal, nasociliary else
(frontal becomes supraorbital/supratrochlear)
Grant’s Atlas, 8th Ed.,
Williams & Wilkins, 1983
Testing the Oculomotor Nerve.

-- No levator palpebrae
superioris function.

-- Pupil dilated (no

parasympathetics).

-- Pupil stays in the

down & out quadrant
because lateral rectus
& superior oblique
are still working.
 Bell’s Palsy of the
Facial Nerve

-- Have patient “make a

face” to contract muscles
-- Expressionless on affected
side (patient’s right here)
-- Cannot close eye; hard to
keep food/liquid in mouth
(orbicularis oris/buccinator
lost on affected side)
-- Taste and lacrimal gland
may also be affected
 Cervical Sympathetic Ganglia
Presynaptics synapse in
the superior, middle, and
inferior (with T1 = stellate)
ganglia.
Postsynaptics follow arteries
or join cranial nerves.

Horner’s Syndrome:
-- Vasodilation
-- Pinpoint pupils
-- Ptosis (droopy eyelid)
The Anatomical Primer,
University Park Press, 1977 Vertebral artery
-- No sweating
 Horner’s Syndrome:
Loss of Head Sympathetics
-- Ptosis (loss of superior tarsus muscle)

-- Pinpoint pupils (loss of pupil dilator)

-- No sweating

-- Vasodilation
 Parasympathetic Ganglia, Nerves, & Functions
Ciliary (III) Ciliary muscle & pupil constrictor
Pterygopalatine
(VII)
Lacrimal
Otic (IX) gland, nasal
Parotid and palatal
gland mucosa
Submandibular
(VII)
Submandibular and
Netter Atlas of Human Anatomy
CIBA-GEIGY, 1989 sublingual glands
 Another way to look at parasympathetics

V1 Accommodation
III
and pupil constriction
Lacrimal secretion
V2
V2 Nasal and palatal
VII
mucous secretion
V3
Submandibular/sublingual
salivary secretion
V3
IX Parotid secretion
 Parasympathetic Pathways
Nerve Ganglion Path Function
Short ciliary

V1 Accommodation
Ciliary and pupil constriction
III
Zygomatic
Greater V2 Lacrimal secretion
petrosal
Pterygo-
palatine Palatine Nasal and palatal
VII mucosa secretion
Chorda tympani Lingual
V3
Submandibular/sublingual
Submandibular
Auriculotemporal
Lesser petrosal
salivary secretion
V3
IX Otic Parotid secretion
Drainage of Paranasal Air Sinuses into Nasal Cavity
Spheno-ethmoidal recess:
sphenoid sinus
Middle meatus:
frontal sinus,
maxillary sinus, Superior meatus:
anterior ethmoid posterior ethmoid
air cells air cells

Inferior meatus:
nasolacrimal
duct (tears)

A meatus is the space below a concha

Middle meatus: hiatus semilunaris & ethomoid bulla
Wire from frontal sinus Wire from sphenoid sinus
through fronto-nasal into spheno-ethmoidal
duct recess
*
Ethmoid bulla over
hiatus semilunaris

Wire into
maxillary sinus

Opening of nasolacrimal duct

* posterior ethmoid air cells opening into superior meatus