Back and Shoulder

Occipital n., C2
A purely cutaneous nerve
Suboccipital n.
A motor nerve, lying deeper in the triangle
Trapezius m.
Attaches at the level of T12
Nerve: spinal component of the spinal
accessory n., CN XI, seen on the anterior
aspect of the trapezius m.
This nerve also innervates the
sternocleidomastoid m.
Blood: superficial branch of the transverse
cervical a.
Action: elevate, retract and rotate the scapula
Abducts above 90 degrees
Lesion: cant elevate (shrug) shoulder
These 3 muscles have the same nerve and blood
supply
Levator scapulae m.
Attaches C1-C4
Rhomboid minor m., comes off opposite the
spine of the scapula, T3
Attaches C7-T1
Rhomboid major m.
Attaches T2-T5
Rhomboids let you stick your chest out
Nerve: dorsal scapular n.
Seen on the anterior aspect of the scapula
Blood: deep branch of the transverse
cervical a.
Accompanies the nerve to these muscles
Serratus posterior superior m., lies under the
rhomboids
Latissimus dorsi m.
Inserts into the floor of the intertubercular
groove
Action: hand-cuff position
Powerful adductor of humerus.
Nerve: thoracodorsal n. from the posterior
cord of the brachial plexus
Serratus posterior inferior m., lies under the
latissimus dorsi
Erector spinae m.
Spinalis m., closest to the spine
Longissimus m., in the middle, goes all the
way to the mastoid process
Iliocostalis m., most lateral, from iliac crest to
the ribs
Rotator cuff muscles, SITS
Supraspinatus m.
Infraspinatus m.
Teres minor m.
Subscapularis m.
Supraspinatus m.
Action: 1
st
15 degrees abduction
Nerve: suprascapular n.
Runs below the suprascapular ligament,
which is suspended over the suprascapular
notch
Blood: suprascapular a.
Runs above the suprascapular ligament,
which is suspended over the suprascapular
notch
Suprascapular a. arises most commonly from
the 1
st
part of the subclavian a., or
occasionally from the 2
nd
or 3
rd
part
Army over the bridge, Navy under the bridge
Artery runs above the suprascapular ligament
Nerve runs below the suprascapular ligament
Attaches on the highest facet of the greater
tuberosity of the humerus
Injury of supraspinatus m.
Inserts under the acromion, thus it is the most
commonly torn in a rotator cuff injury
The tendon passes under the acromion. One
can develop bony spurs on the under side of
the acromion, which will start to tear away
the tendon, until eventually the tendon
ruptures
Loss the first 15 degrees of abduction, so
person will hang the shoulder down to let
gravity allow them to overcome the first 15
degrees, then they can use the deltoid and
trapezius to abduct the arm the rest of the
way
Infraspinatus m.
Nerve: suprascapular n., like
the supraspinatus m.
Attaches on the middle facet of the greater
tuberosity of the humerus
Action: laterally rotates humerus, a much
stronger lateral rotator than teres minor m.
Teres minor m.
Action: laterally rotates humerus
Attaches on the inferior facet of the greater
tuberosity of the humerus
Nerve: axillary n.
Action: laterally rotates humerus
Teres major m.
Action: medially rotates humerus, as does
pectoralis major and latissimus dorsi
Attaches at the medial lip of the
intertubercular groove
Pectoralis m. attaches at the lateral lip of the
intertubercular groove
Latissimus dorsi attaches in the floor of the
intertubercular groove
Nerve: lower subscapular n., C6, C7
Deltoid m.
Abducts 15-90 degrees: lateral fibers do
Abduction
Nerve: axillary n. from the posterior cord of
the brachial plexus
Anterior fibers flex the humerus
Posterior fibers extend the humerus
Know the attachments of every muscle on the
scapula (see Bony Landmarks)
Spaces Back and Shoulder
Quadrangular space
Bounded by:
Subscapularis tendon superiorly
Teres major tendon inferiorly
Long head of the triceps brachii m. medially
Humerus laterally
Passing through the quadrangular space are the:
Axillary n., turns superiorly
Posterior circumflex humeral a., runs across
laterally to muscle
Clinical:
Surgical head fracture of humerus will most
likely damage the contents of the quadrangular
space
To test for axillary n. damage, do muscle test
for deltoid, which is the major abductor of
the arm
Triangular interval
Bounded by:
Teres major m. superiorly
Long head of the triceps brachii m. medially
Humerus laterally
Passing through the triangular interval are the:
Radial n.,
Profunda brachii a.
Clinical:
Mid-humeral fracture will most likely
damage the contents of the triangular interval
If the radial n. is damaged, it can cause wrist
drop
To test for radial n. damage, do muscle test for
extensor muscles of elbow and wrist
Triangular space
Bounded by:
Teres minor m. superiorly
Teres major m. inferiorly
Long head of the triceps brachii m. laterally
Passing through the triangular space are the:
Circumflex scapular a. and v.
Theres NO nerve in this space
Triangle of auscultation
Location:
Near inferior angle of scapula on lower medial
border of scapula
Bounded by:
Trapezius m. medially
Rhomboideus major m. superiorly
Latissimus dorsi m. inferiorly
Clinical:
Use this space to listen to (auscultate) lungs
since the stethoscope can be placed close to
the thoracic wall at this location, with
minimum impedance of sound through muscle
Lumbar triangle = Triangle of Petit
Bounded by:
Latissimus dorsi m. medially
External abdominal oblique m. laterally
Iliac crest inferiorly
Notes:
Its floor is the internal abdominal oblique m.
May be the site of an lumbar hernia
Spinal Cord
Dura matter, extends to S2
Epidural space, above the dura matter
There will be probe inserted into the space in
exam
Between the dura matter and the bone of the
vertebrae
Contains fat and blood vessels
Clinically important
Subdural space, between dura and arachnoid
matter
Clinically not very significant
Arachnoid matter, a filmy layer under the dura
matter
Subarachnoid space, between arachnoid and
pia matter
Clinically very important
Contains cerebral spinal fluid
Conus medullaris, the end of the spinal cord
Ends at the level of the intervertebral space
between L1-L2 in adults
End at L3 in newborn
Filum termminale internum, an extension of
pia matter within the vertebral column
Called the externum when it exits the sacral
canal
Cauda equina
Denticulate ligaments, tooth-like processes of
pia matter
They separate the dorsal rootlet from the
ventral rootlet, a reference used in surgery
Dorsal rootlet is above the denticulate
ligament
Ventral rootlet is deep to the denticulate
ligament
Prevents the spinal cord from swishing in the
dural sac in the spinal canal
They end at the level of T12-L1
Dorsal rootlet, purely sensory
Ventral rootlet, purely motor, deeper than the
dorsal rootlet
Dorsal root ganglion, a bulge of nerve sitting
outside of the dural sac
Spinal nerve, formed by the joining of the
ventral and dorsal rootlet immediately after the
dorsal root ganglion
Immediately after forming a spinal nerve, it
divides into
Dorsal rami
Ventral rami, much larger

Upper Limb

Cephalic v.
Originates on the lateral aspect of the
dorsum venous arch of the hand
In the shoulder region, it can be seen draining
into the axillary v. in the deltopectoral
groove
Brachial plexus
Formed by the joining of ventral rami from C5-
T1
The divisions are Rodney Thomas Drinks Cold
Beer
Roots
Trunks
Divisions
Cords
Branches
There are 5 roots, from ventral rami of C5, C6,
C7, C8, T1
There are 3 trunks formed by merging of roots
Superior trunk, formed from C5 and C6
Middle trunk, formed from C7
Inferior trunk, formed from C8 and T1
Upper trunk palsy, an injury to the upper
trunk, C5, C6, is very serious: Erbs Palsy
(Waiters tip)
Suprascapular n., C5, C6, which supplies 2
muscles
Supraspinatus m., abduct 0-15 degrees
Infraspinatus m.
Axillary n., C5, C6, which supplies 2
muscles
Deltoid m., abducts 15-90 degrees
Teres minor m.
Musculocutaneous n., C5, C6, which
supplies 3 muscles
Brachialis m.
Biceps brachii m.
Coracobrachialis m.
Functionally, you would lose
Abduction from 0-90 degrees
You would NOT lose
Flexion of the elbow because there are
many other flexors
Supination, but it would be greatly
weakened from loss of biceps brachii
Lower trunk palsy, an injury the lower trunk,
C8, T1
Mimics an injury to the ulnar n. from injury
to the medial epicondyle
Patient presents with
Claw hand
Abducted wrist from loss of wrist adduction
Klumpkes palsy
Each trunk divides into 2 divisions
Anterior divisions are the flexor part
Posterior divisions are the extensor part
Cords
Form from merged divisions
Named for their spatial relationship with the
2
nd
part of the axillary a., which is underneath
pectoralis minor m.
Posterior cord
Sits posterior to the 2
nd
part of the axillary a.,
Formed from all 3 posterior divisions of the 3
trunks
Lateral cord
Sits lateral to the 2
nd
part of the axillary a.
Formed from anterior divisions of superior
and middle trunks
Medial cord
Sits medial to the 2
nd
part of the axillary a.
Formed from the anterior division of the
inferior trunk
Terminal branches from the cords
During the test, be sure to first determine which
cord the nerve is coming from, determine if the
cord is lateral, medial, or posterior relative to
the axillary a.
a. Lateral cord
Has 3 branches, from superior to inferior
1. Lateral pectoral n.
Innervates the pectoralis major m.
2. Musculocutaneous n.
Called musculocutaneous because it
supplies 3 muscles of the arm muscles and
then becomes cutaneous for the lateral
forearm
Pierces through the coracobrachialis m.
ID by this feature
Runs between the biceps brachii m. and
the brachialis m.
Becomes cutaneous at the forearm,
becoming the lateral cutaneous n. of the
forearm = lateral antebrachial cutaneous
n., at the cubital fossa
Travels down to the wrist on the lateral
aspect of the forearm
Innervates 3 muscles, all flexors of the arm
Coracobrachialis m.
Biceps brachii m.
Brachialis m.
3. Median n., lateral root
The lateral root of the lateral cord unites
with the medial root of the medial cord to
form the median n.
Seen running directly down the midline of
the arm, toward the cubital fossa
Innervates all flexor muscles of the
forearm, EXCEPT
1 muscles which are innervated by the
ulnar n.
Flexor carpi ulnar m.
Flexor digitorum profundus m.,
medial 1/2
1 muscle which is innervated by the
radial n.
Brachioradialis m.
Even though, it can be seen passing through
the arm, the median n. does NOT innervate
anything in the armonly the forearm and
hand
b. Medial cord
Has 5 branches
The first 2 are cutaneous nerves that branch
off above the M-shape of the nerves
The middle 2 do NOT supply the arm, but
have functions in the forearm and hand
The last 1 goes to pectoralis major and
minor
1. Medial cutaneous n. of forearm =
Medial antebrachial cutaneous n.
Thicker and longer of the 2, which goes
all the way to the forearm
Seen passing next to the ulnar n., the more
lateral of the 2
A cutaneous nerve of the forearm
2. Medial cutaneous n, of arm = Medial
brachial cutaneous n.
Much thinner and shorter branch, which
stops at the cubital fossa
Seen as the more medial of the 2
A cutaneous nerve of the arm
3. Median n., medial root
The medial root of the medial cord unites
with the lateral root of the lateral cord to
form the median n.
Seen running directly down the midline of
the arm, toward the cubital fossa
Innervates all flexor muscles of the
forearm, EXCEPT
1 muscles which are innervated by the
ulnar n.
Flexor carpi ulnar m.
Flexor digitorum profundus m.,
medial 1/2
1 muscle which is innervated by the
radial n.
Brachioradialis m.
Even though, it can be seen passing through
the arm, the median n. does NOT innervate
anything in the armonly the forearm and
hand
4. Ulnar n., C8, T1
Inner leg of the M
Seen running down the medial aspect of the
arm, and passing behind the medial
epicondyle of the humerusID by this
feature
Even though, it can be seen passing through
the arm, the ulnar n. does NOT innervate
anything in the armonly the forearm and
hand
Injury to the medial epicondyle, can injure
the ulnar n., and patient would present with
Claw hand
Abducted wrist from loss of wrist
adduction
5. Medial pectoral n.
Innervates
Pectoralis minor m., pierces through this
muscle to reach pectoralis major m.
Pectoralis major m.
Thinner than antebrachial n.
Stops in cubital fossa
c. Posterior cord
You need to know all the branches coming
off the posterior cord
For ID, the other 2 cords (lateral and medial)
will have to be pinned back to one side to
expose the posterior cord, which is a big clue
that youre looking at the posterior cord and
its branches
Has 5 branches
The first 3 are small branches that come off
early
The last 2 are large branches further down
From superior to inferior the branches of the
posterior cord are
1. Upper subscapular n.
1
st
branch, comes off posteriorly
Innervates subscapularis m., which is also
innervated by the lower subscapular n.
2. Thoracodorsal n. (used to be called the
middle subscapular n.)
A long nerve seen running down to the
latissimus dorsi m.
Innervates the latissimus dorsi m.
3. Lower subscapular n.
Innervates
Teres major m.
Subscapularis m., inferior part
The only muscle that inserts on the
lesser tuberosity of the humerus
Is part of the rotator cuff
Has dual innervationmust name both
on exam
Upper subscapular n.
Innervates only the subscapularis m.
Lower subscapular n.
Innervates 2 muscles: subscapularis
m. and teres major m.
The posterior cord then divides into the
following 2 terminal branches
4. Axillary n.
Seen as large branch that immediately dives
posteriorly
Runs through the quadrangular space,
accompanied by the posterior circumflex
humeral a.
Runs around the surgical neck of the
humerus
Innervates
Deltoid m.
Teres minor m.
Branches: Upper Lateral Cutaneous
Nerve of the Arm
Dislocation of the shoulder is always
anterior and inferior, and would injury the
axillary n.not the radial n.
Sensory loss
Over the shulder, remember the
regimental sign where loss is at and
above the level of military stripes on the
sleeve
When popping the shoulder back into
place, to avoid a lawsuit, make sure you
sensory test first before you touch the arm
at all! Then pop the shoulder into place,
and sensory test again!
If you dont document sensory loss before
you do the adjustment, you can be sued
when patient later claims that you caused
the sensory loss during the adjustment
Fracture of the surgical neck of the
humerus would injure the axillary n. and
the posterior circumflex humeral a.. Nerve
damage would cause
Sensory loss: regimental sign
Motor loss
Deltoid paralysis, thus loss off abduction
between 15-90
Teres minor m. cant be clinically tested,
but it is a lateral rotator, thus weakend
lateral rotation
5. Radial n.
Runs through the triangular interval of the
arm where it is accompanied by the
profunda brachii a., the 1
st
branch off the
brachial a.
Both nerve and artery can be seen on the
posterior arm when the lateral and long
heads of the triceps are spread apart
Fracture in the midshaft of the humerus
would injure the radial n. and the profunda
brachii a.. Nerve damage would cause
Wrist droponly extension of the wrist is
lost
Has the person lost the ability to extend
the shoulder or elbow? No, because the
radial n. gives off branches to the triceps
much earlier than when it goes to the
spiral groove
Branches: Lower Lateral Cutaneous
Nerve of the Arm, Posterior Cutaneous
Nerve of the Forearm, posterior Cutaneous
Nerve of the Arm

Other nerves of the axilla region
These nerves are direct branches from the
ventral rami, not from one of the brachial plexus
cords
Dorsal scapular n.
From ventral ramus C5
Innervates:
Levator scapulae m.
Rhomboid minor m.
Rhomboid major m.
Long thoracic n.
From ventral rami of C5, C6, C7
Seen running along the surface of the serratus
anterior mm.
Innervates: serratus anterior m.
C5, C6, C7: raise your arms to heaven
Injury to the long thoracic n. results in loss of
protraction of the scapula, causing a winged
scapula
Vessels of the arm
Axillary v. runs above the axillary a.
Axillary a.
Is seen when the axillary v. is reflected back
Begins at the lateral border of the 1
st
rib
Ends at the inferior border of teres major m.,
where it becomes the brachial a.
Has 3 regions defined by their relationship to
pectoralis minor m.
The 1
st
part has 1 branch
The 2
nd
part has 2 branches
The 3
rd
part has 3 branches
1
st
part of axillary a.
Between the lateral border of the 1
st
rib and
the medial border of the pectoralis minor
m.
Has 1 branch
Supreme (Superior) thoracic a.wont
be tested
A tiny branch that extends to the upper
thoracic wall
Supplies 1
st
and 2
nd
ICS and superior
part of serratus anterior m.
2
nd
part of axillary a.
Posterior to (underneath) pectoralis minor
m.
Has 2 branches
Thoracoacromial trunk:- Pierces the
clavicopectoral fascia before giving off
4 branches, CAPD
Clavicular branch
Acromial branch
Pectoral branches, the only identifiable
branches
Deltoid branch
Lateral thoracic a.
Follows the border under the pectoralis
minor m.
Can be seen entering the thoracic wall
Supplies the pectoralis mm., axillary
lymph nodes, and breast
3
rd
part of axillary a.
Between the lateral border of the pectoralis
minor m. and the inferior border of the
teres major m.
Has 3 branches: 2 lateral branches and 1
medial branch
The 2 lateral branches are
Anterior circumflex humeral a.
Tiny branch that sits above the much
larger posterior circumflex humeral a.
Runs to the anterior aspect of the
humerus
Posterior circumflex humeral a.
Much larger branch than the anterior
circumflex humeral a.
Runs to the posterior aspect of the
humerus
Through the quadrangular space,
accompanied by axillary n.
The 1 medial branch
Subscapular a., the largest branch of the
axillary a., which divides into 2 branches
Circumflex scapular a.
A much larger branch than the
thoracodorsal a.
Passes behind the scapula to its dorsal
aspect
Very important for collateral
circulation around the scapula
Appears in the triangular space of the
scapula, between the teres minor m.
and teres major m.
Thoracodorsal a.
The continuation of the subscapular a.,
Seen running down toward the
latissimus dorsi m.
Accompanied by the thoracodorsal n.
If the medial branch is tagged before it
starts to branch, you would say
subscapular artery
If the medial branch is tagged after it
branches then it will either be
Thoracodorsal a., seen running
downward to the latissimus dorsi m.
Circumflex scapular a., a much thicker
branch seen going immediately behind
the scapula
Brachial a.
Begins at the point where the axillary a. passes
the inferior border of the teres major m.
In the arm, the brachial a. gives off a branch
Profunda brachii a.
The 1
st
branch off the brachial a.
Anterior branch anastomose with
radial recurrent branch of radial artery
in front of lateral epicondyle
Posterior branch anastomose with
interosseous recurrent branch of the
posterior interosseous artery behind the
lateral epicondyle
Runs through the triangular interval of the
humerus, accompanied by the radial n.
In the cubital fossa, the brachial a. divides
into
Radial a., which runs laterally along the
radial side of forearm
Ulnar a., which runs medially along the
ulnar side of the forearm

Lymph nodes
central lymph nodes are defined as
the group of lymph nodes situated
deep to the pectoralis minor at the
base of the axilla
apical lymph nodes are medial to the
medial border of the pectoralis minor
subscapular nodes are found on the
posterior wall of the axilla
Nerves of the Arm
Musculocutaneous n.
Called musculocutaneous because it supplies
3 muscles of the arm muscles and then
becomes cutaneous for the lateral forearm
Innervates 3 muscles, all flexors of the arm
Coracobrachialis m.
Biceps brachii m.
Brachialis m.
Pierces through the coracobrachialis m.
Runs between the biceps brachii m. and the
brachialis m.
At the cubital fossa, it becomes the lateral
cutaneous n. of the forearm = lateral
antebrachial cutaneous n.
Travels down to the wrist on the lateral
aspect of the forearm
Radial n.
From posterior cord of brachial plexus
Pathway
Sits in the spiral groove of the humerus,
seen between the long head and lateral head
of the triceps m.
Accompanied by the profunda brachii a. in
arm
Enters cubital fossa
Volkmanns contracture: damage to the
brachial artery at distal end of humerus.
Innervates
Triceps brachii m.
Anconeus m.
Median n.
Does not innervation anything in the arm, only
the forearm
Muscles of the arm
Subscapularis m.
Attachments:
Subscapular fossa
Lesser tuberosity of the humerus
The only muscle that inserts on lesser
tuberosity of humerus
Action:
Medially rotates arm
Adducts arm
Holds humeral head in glenoid fossa as part
of rotator cuff
Nerve: has dual innervationif asked for its
innervation on exam, you must name both
nerves
Upper subscapular n., C5, C6, C7
Innervates only the subscapularis m.
Lower subscapular n., C5, C6, C7
Innervates 2 muscles: subscapularis m. and
teres major m.
Coracobrachialis m.
Attachments:
Coracoid process
Midshaft of the humerus, just lateral to the
deltoid tuberosity
Action: adduct and flex the shoulder
Muscle used to tuck a newspaper under your
arm against your ribs
Nerve: musculocutaneous n., C5, C6, C7
Biceps brachii m.
Has 2 heads, the long head is more medial
The Long head is Lateral, and has a Long
tendon which runs through the
intertubercular (bicipital) groove in the
head of the humerus
The short head is more medial since it
attaches to the coracoid process
If you see one head tagged for ID, you need
to specifically identify that head
If the tag is in the muscle belly, then you
would say biceps brachii
Attachments:
Short head: coracoid process
Long head: supraglenoid tuberosity
Radial tuberosity of the radius
[Long head of triceps attaches at the
infraglenoid tuberosity]
[Coracobrachialis m. and pectoralis
minor m. also attach on the coracoid
process]
Action:
Supinates the forearmthe strongest
supinator
If asked which muscle is the strongest
supinator in the upper limb, you would say
biceps brachiiNOT the supinator
muscle
If asked what is the strongest action of
biceps brachii, you would say supination
Long head flexes the shoulder (and some
elbow), since it crosses both shoulder and
elbow joints
Short head flexes the elbow only, since it
only crosses the elbow
Biceps brachii is our wine-opening
muscleunscrews the cork then pulls it out
of the bottle
Nerve: musculocutaneous n., C5, C6, C7
Brachialis m.
Lies under the bicep brachii m.
Attachments:
Midshaft of the humerus
Coronoid process of the ulnaNOT
coracoid
Ulnar tuberosity
Action: purely a flexor of the elbow
Does NOT cross the shoulder joint, thus it
has no action on the shoulder
Does NOT go to the radius, thus it cannot
pronate or supinate
Nerve: musculocutaneous n., C5, C6, C7
Triceps
Has 3 heads
Long head
Is most medial
Attaches to the infraglenoid tuberosity
[Long head of biceps brachii attaches to
the supraglenoid tuberosity]
Lateral head
Lies over the spiral groove
Proximal and lateral to the spiral groove of
the humerus, which has the radial n. and
profunda brachii a. in it
Medial head
Deeper, seen when long and lateral heads
are separated apart
Distal and medial to the spiral groove of
the humerus, which has the radial n. and
profunda brachii a. in it
Radial n. and profundi brachii a. are seen when
the laternal and long heads of the triceps are
spread apart
If there is a midshaft fracture of the humerus,
it would injure the radial n. and profunda
brachii a.
The 3 portions come together in a common
tendon and attach to the olecranon of the ulna
Action: one of the chief extensors of the elbow
Fracture or avulsion of the olecranon process
would cause off of the triceps attachement,
thus loss of extension of the elbow
Anconeus m.
A small, relatively unimportant triangular
muscle
Usually blends with the triceps near the elbow
Lies partly over the supinator on the proximal
ulna
Action: helps extend the forearm
Forearm
To orient yourself on the forearm
Look for the thumb side, which is the radial or
lateral side
Look for the little finger, which is the ulnar or
medial side
Use the brachioradialis m. as a landmark
It sits between the flexor and extensor
compartments
You can figure out the other muscles relative
to the brachioradialis
Cubital fossa
From lateral to medial: TANtendon, artery,
nerve
Lateral: tendon of biceps brachii, which
attaches to the radial tuberosity
Middle: brachial a.
Medial: medial n.median is medial
Important orientation for taking blood pressure.
Ask patient to flex the forearm, feel for the
tendon of biceps brachii, and just lateral to that
you feel the pulsation of the brachial artery
Vessels of the forearm
Cephalic v.
Superficial vein
Begins on the lateral aspect of the dorsal
venous network of the hand
Ascends along the anterolateral surface of the
forearm and arm
Anterior to the elbow it communicates with
the median cubital v.
Courses along the deltopectoral groove and
enters the deltopectoral triangle where it
pierces the clavipectoral fascia and joins the
axillary v.
Basilic v.
Superficial vein
Begins on the medial aspect of the dorsal
venous network of the hand
Ascends along the medial aspect of the
forearm and inferior aspect of the arm
Communicates with the median cubital v.
anterior to the elbow
Passes deeply, piercing the brachial fascia
and runs parallel to the brachial a. to the
axilla, and joins the axillary v.
Median cubital v.
Superficial vein, passing anterior to the cubital
fossa
Joins the cephalic v. (more lateral) with the
basilic v. (more medial)
Common site for venipuncture
If needle pierces through the vein it can
contact the median n.
Medial antebrachial cutaneous is slightly
medial to the medial cubital vein and could
be injured by a needle. If the needle had
gone laterally, it might have injured the
lateral antebrachial cutaneous nerve
Arteries of the forearm
Brachial a. divides into 2 arteries at the cubital
fossa
Radial a.
Runs laterally along the radial side of
forearm toward the thumb
Runs through the anatomical snuff box
Then pierces through between the 2 heads of
the 1st dorsal interossei m.
Then it forms most of the deep palmar arch
Ulnar a.
Tends to be substantially larger than the
radial a.
Runs medially along the ulnar side of the
forearm toward the little finger
Gives off a short trunk called the common
interosseus trunk, which soon gives off 2
branches
Anterior interosseus a.
Seen running on top of the interosseus
membrane
Accompanied by the anterior
interosseus n., from the median n.
Posterior interosseus a.
From the ventral aspect, seen going deep
into the extensor compartment
Runs w/ deep branch of radial
nerve.
Continues down the forearm, accompanied
by the ulnar n.
The ulnar a. and ulnar n. cross the wrist
above the flexor retinaculum, through
Guyons canal, to the palm of the hand
where it forms the ulnar a. forms the
superficial palmar arch
Superior and inferior ulnar collateral
arteries contribute to the collateral
circulation of the elbow on its medial aspect.
The superior ulnar collateral
anastomoses with the posterior ulnar
recurrent artery (branch of ulnar) behind
the medial epicondyle
The inferior ulnar collateral
anastomoses with the anterior ulnar
recurrent artery in front of the medial
epicondyle.

Nerves of the Forearm
Median n.
From the lateral (C6, C7) and medial (C8, T1)
cords of brachial plexus
Innervates all the muscle of the forearm,
EXCEPT
1 muscles which are innervated by the
ulnar n.
Flexor carpi ulnaris m.
Flexor digitorum profundus m., medial
Pathway
Enters cubital fossa medial to the brachial a.
Passes between heads of pronator teres
Descends between flexor digitorum
superficialis and flexor digitorum profundus
Passes through carpal tunnel to reach hand
Gives off a branch to the thenar eminence,
recurrent branch of median n., C8, T1
Gives off 2 branches, seen in the ventral aspect
of the forearm
1. Anterior interosseous n.
Branches from median n. in the distal
cubital fossa
Accompanied the anterior interosseus a.
on the surface of the shiny interosseus
membrane
Supplies motor to deeper muscles of the
forearm
Flexor digitorum profundus m., lateral

Flexor pollicis longus
Pronator quadratus
2. Palmar cutaneous branch of median n.
Branches from median n. just proximal to
flexor retinaculum
Passes between tendons of palmaris longus
and flexor carpi radialis
Runs superficial to flexor retinaculum
Supplies cutaneous to palm
Ulnar n.
Accompanied by the ulnar a., a branch of the
brachial a.
Only supplies motor to 1 muscles of the
forearm
Flexor carpi ulnaris m.
Flexor digitorum profundus m., medial
Plays a much larger role in the hand
Radial n.
From posterior cord of brachial plexus
Innervates all the extensor muscles of the
forearm, PLUS one flexor, the
brachioradialis m.
Pathway
Sits in the spiral groove of the humerus,
seen between the long head and lateral head
of the triceps m.
Accompanied by the profunda brachii a. in
arm
Enters cubital fossa
Descends between brachialis m. and
brachioradialis m.
At the level of the lateral epicondyle of
humerus, it divides into superficial and deep
branches
Gives off 2 branches, best seen on dorsal
aspect of the forearm
1. Superficial branch of the radial n.
The thinner of the 2 branches of the radial
n., which branch just superior to the
supinator m.
Best seen emerging at the lateral wrist,
where it crosses over the anatomical snuff
box to the dorsum of the lateral hand
Purely a cutaneous nerve to dorsum of the
hand on its lateral aspect, thumb and first
few fingers
Pathway
Passes anterior to pronator teres m.
Passes under the brachioradialis m.
Crosses over the anatomical snuff box as
it passes to the superficial aspect of the
dorsum of the hand
2. Deep branch of the radial n.
The largest of the 2 terminal branches
Supplies motor innervation to posterior
compartment
Pathway
Arises from radial n. just distal to the
elbow
Pierces the supinator m.ID by this
feature
Winds around the lateral neck of the
radius
After is pierces the supinator m. it
becomes the posterior interosseus n.
It reaches the wrist joint and
carpal bones for proprioceptive
sense from these structures
Accompanied by the posterior
interosseus a. from the common
interosseus trunk of the ulnar a.
If this nerve is tagged before dividing into
its superficial and deep branches, you
would say radial n.
If this nerve is tagged after dividing into its
superficial and deep branches, but before
piercing the supinator m., you would say
deep branch of the radial n.
If this nerve is tagged after piercing the
supinator m., you would say posterior
interosseus n.
Note:
Both the anterior and posterior interosseus
arteries are from the same source, the common
interosseus trunk from the ulnar a.
The anterior and posterior interosseus nerves
are from different sources
Anterior interosseus n. is from the median
n.
Posterior interosseus n. is from the radial
n., the continuation of the deep branch of the
radial n. after it exits the supinator m.
Flexor compartment of the forearm
Contains the flexors and pronators of the
forearm
All muscles in this forearm compartment are
innervated by the median n. and/or ulnar n.
EXCEPT
Brachioradialis m. is innervated by the radial
n.
Median n. innervates all but 1 muscles
Ulnar n. innervates 1 muscles
Flexor carpi ulnaris m.
Flexor digitorum profundus m., medial
(ulnar
The anterior compartment communicates with
the central compartment of the palm through
the carpal tunnel
Generally the fascial compartments of the
limbs usually contain fluids and infections,
thus preventing spread to other compartments
The anterior compartment of forearm is an
exception due to its communication with the
central compartment of the palm
Common flexor tendon attached to the medial
epicondyle
Avulsion or fracture of the medial epicondyle
would effect the flexors of the forearm
Common extensor tendon attaches to the
lateral epicondyle
Interosseous membrane
Shiny, silvery membrane between radius and
ulna
From lateral to medial at the anterior wrist are
Abductor pollicis longus m. (not a flexor, but
most lateral)
Brachioradialis m. (doesnt cross wrist, ends at
distal radius)
Radial a.
Flexor carpi radialis m.
Flexor pollicis longus m.
Median n.
Palmaris longus m : Gives off Palmar
aponuerosis
If damages, we get
Duputyrens contracture.
Palmar aponeurosis goes over
carpul tunnel.
Flexor digitorum superficialis m. (2 of the 4
tendons)
Ulnar a.
Ulnar n.
Flexor carpi ulnaris m.
Brachioradialis m.
Superficial muscle coming from lateral elbow
Attachments:
Proximal 2/3 of lateral supracondylar ridge
of the humerus
Lateral surface of distal end of the radius
NOTE: it does NOT cross the wrist
Action:
Holds hand between pronation and
supination, hand shaking position (palm
facing medially)
Flexes elbow, only when it in hand
shaking position
Brachioradialis is our beer drinking
muscle
Condition equivalent to tennis
elbow, this muscle is involved.
Commonly involved in colles
fracture coz it inserts into
distal end of radius.
Biceps brachii is our wine-opening
muscle
Nerve: radial n., C5, C6, C7
This is the only flexor that is innervated by
the radial n., which normally innervates the
extensors
Superficial flexor compartment
Common flexor tendon
Common attachment on the medial epicondyle
of the flexor muscles
To help remember how the muscles are
running in the superficial flexor compartment
Turn your palm up, hook your thumb behind
the medial epicondyle and spread your four
fingers over the forearm
Index finger = pronator teres m.
Middle finger = flexor carpi radialis m.
Ring finger = palmaris longus m. (if
present)
Little finger = flexor carpi ulnaris m.
Flexor carpi radialis m.
Extends from medial epicondyle to the thumb
Its belly is just medial to brachioradialis
Attachments:
Medial epicondyle of humerus
Base of 2
nd
metacarpal
Action: flexes and abducts hand at wrist
Nerve: median n., C6, C7
Radial pulse is lateral to this.
Palmaris longus m.
Extends from medial epicondyle to the center
of the wrist
Its belly lies half under flexor carpi radialis m.
Has a very small muscle belly with a long thin
tendon running to the middle of wrist
When you pop up the tendons at the wrist,
you see 2 tendons in the middle at the wrist
The medial one of the 2 is the palmaris
longus m.
The lateral one of the 2 is the flexor carpi
radialis m.
10% of people dont have this muscle
Similar to plantaris m. since it contributes
very little to function, and is excellent for
doing tendon grafts
Attachments:
Medial epicondyle of humerus
Distal half of flexor retinaculum and palmar
aponeurosis
Action:
Flexes hand at wrist
Tightens palmar aponeurosis
Nerve: median n., C7, C8
Flexor carpi ulnaris m.
Most medial of the superficial muscles
Extends from the medial epicondyle to little
finger side of wrist
Has 2 heads: humeral and ulnar heads
Attachments:
Humeral head: medial epicondyle of humerus
Ulnar head: olecranon and posterior border
of ulna
Pisiform
Hook of hamate
5
th
metacarpal
Action: flexes and adducts hand at wrist
Nerve: ulnar n., C7, C8
Pronator teres m.
The short muscle running from the medial
epicondyle to under the brachioradialis m.
Attachments:
Medial epicondyle of humerus
Coronoid process of ulna
Middle of lateral surface of radius
Action: pronates forearm (turns palm
downward) and flexes elbow
Nerve: median n., C6, C7
Deep flexor compartment
Flexor digitorum superficialis m.
Lies under flexor carpi radialis m. and
palmaris longus m.
Has 2 heads: humoroulnar and radial heads
IDd by its 4 tendons passing under the flexor
retinaculum
Attachments:
Humeroulnar head:
Medial epicondyle of humerus
Coronoid process of ulna
Radial head:
Superior half of anterior border of radius
Action: flexes fingers
Nerve: median n., C7, C8, T1
Flexor digitorum profundus m.
Lies deep to flexor digitorum superficialis m.
IDd by its 4 tendons passing under the flexor
retinaculum
Attachments:
Proximal of medial and anterior surface of
ulna and interosseous membrane
Bases of distal phalanges of medial 4 digits
Action: flexes fingers, assists with flexion of
hand
Nerve: has dual innervation
Medial part: ulnar n., C8, T1
Lateral part: median n., C8, T1
If a tag is in the belly of this muscle and you
are asked what is the innervation for this
muscle?, you would say median and ulnar
nerves
If a tag is only in the lateral part, you would
say median n.
Flexor pollicis longus m.
Lies deep along the lateral aspect of ventral
forearm
Looks feathery
Attachments:
Anterior surface of radius and interosseous
membrane
Base of the distal phalanx of thumb
Action: flexes thumb
Nerve: anterior interosseous n. from median
n., C8, T1
Pronator quadratus m.
Lies in the proximal of forearm, deep to
flexor digitorum profundus m. and flexor
pollicis longus m.
Attachments:
Distal of anterior surface of ulna
Distal of anterior surface of radius
Action: pronates forearm, binds radius and
ulna together
Nerve: anterior interosseous n. from median
n., C8, T1
Extensor compartment of the forearm
Contains the extensors and supinators of the
forearm
All muscles in this forearm compartment are
innervated by the radial n., directly or by its
deep branch
With palm down, orient yourself by locating the
brachioradialis m.
Runs toward the thumb, as the most lateral
muscle
Its the only flexor muscle innervated by the
radial n.
From lateral to medial at the posterior wrist are
Abductor pollicis longus m.
Extensor pollicis brevis m.
Extensor carpi radialis longus m.
Extensor carpi radialis brevis m.
Extensor pollicis longus m.
Extensor indicis m. (under lateral extensor
digitorum tendons)
Extensor digitorum m. (4 tendons)
Extensor digiti minimi m.
Extensor carpi ulnaris m.
Superficial extensor compartment
Common extensor tendon
Common attachment on the lateral epicondyle
of the extensor muscles
Extensor carpi radialis longus m.
Lies next to brachioradialis m.
Its belly and long tendon lie over extensor
carpi radialis brevis m.
Attachments:
Lateral supracondylar ridge of humerus
Base of 2
nd
metacarpal
Action: extends and abducts hand at wrist
Nerve: radial n., C6, C7
On ID, you must write the full name of this
muscle, all 4 words
Extensor carpi radialis brevis m.
Lies underneath extensor carpi radialis longus
m.
Longus is always on top of brevis
Attachments:
Lateral epicondyle of humerus
Base of 3rd metacarpal
Action: extends and abduct hand at wrist
Nerve: deep branch of radial n., C7, C8
In classic tennis elbow, this muscle along w/
Extensor digitorum is damaged.
Extensor digitorum m.
In the extensor compartment, there is NO
superficialis or profundus
IDs by its 4 tendons, one of which is about
the length of the forearm
Attachments:
Lateral epicondyle of humerus
Extensor expansion of medial 4 digits
Action:
Extends 5
th
digit
Nerve: posterior interosseous n., C7, C8,
from the deep radial n.
Extensor digiti minimi m.
Its thin tendon is medial to the 4 tendons of
extensor digitorum m.
Attachments:
Lateral epicondyle of the humerus
Extensor expansion of the little finger
Action:
Extends the little finger
The Austin Powers muscle, with his little
pinky raised up
Nerve: posterior interosseous n., C7, C8,
from the deep radial n.
Extensor carpi ulnaris m.
Its tendon runs to the ulnar wrist, medial to
extensor digiti minimi m.
Attachments:
Lateral epicondyle of humerus, and posterior
border of ulna
Base of 5
th
metacarpal
Action:
Extends and adducts the hand at wrist
Nerve: posterior interosseous n., C7, C8,
from the deep radial n.
Outcropping muscles of the deep extensor
compartment
The outcropping muscles pass over the tendons
of extensor carpi radialis longus and brevis mm.
Abductor pollicis longus m.
One of the outcropping muscles
Start deep and emerge near the radial wrist
Lies superior and lateral to extensor pollicis
brevis m.
Passes over the tendons of
Extensor carpi radialis longus m.
Extensor carpi radialis brevis m.
Attachments:
Posterior surface of ulna, radius, and
interosseous membrane
Base of 1
st
metacarpal
Action:
Abducts and extends thumb
Remember: abductors are always on the
outside
Nerve: posterior interosseous n., C7, C8,
from the deep radial n.
Extensor pollicis brevis m.
One of the outcropping muscles
Lies inferior and medial to abductor pollicis
longus m.
Passes over the tendons of
Extensor carpi radialis longus m.
Extensor carpi radialis brevis m.
Attachments:
Posterior surface of radius and interosseous
membrane
Base of proximal phalanx of thumb
Action:
Extends thumb
Nerve: posterior interosseous n., C7, C8,
from the deep radial n.
Extensor pollicis longus m.
One of the outcropping muscles
ID by its tendon seen running to the thumb
Tendon lies medial to extensor carpi radialis
brevis m. and lateral to extensor indicis
Attachments:
Posterior surface of middle 1/3 of ulna and
interosseous membrane
Base of distal phalanx of thumb
Action:
Extends thumb
Nerve: posterior interosseous n., C7, C8,
from the deep radial n.
Extensor indicis m.
ID by
Tendon seen running to the index finger
Most medial muscle belly of the deep
extensors
Tendon just medial to extensor pollicis
longus m. at wrist
Short muscle covered completely by the
extensor digitorum m.
Attachments:
Posterior surface of ulna and interosseous
membrane
Extensor expansion of index finger
Action:
Extends index finger
Nerve: posterior interosseous n., C7, C8,
from the deep radial n.
Supinator m.
Wraps around the proximal radius
Attachments:
Lateral epicondyle of the humerus, radial
collateral and anular ligaments, supinator
fossa, and crest of the ulna
Lateral, posterior, and anterior surfaces of
proximal 1/3 of radius
Action:
Supinates forearm = rotates radius to turn
palm anteriorly
Nerve: deep radial n., C5, C6
Seen piercing through the supinator m.

Hand
Vessels of the hand
Superficial palmar arch coming from the
ulnar a.
Anastomoses with the radial a., but it is
primarily formed by the ulnar a.
the arch is completed on the radial
side by the superficial palmar
branch of the radial artery
The radial artery is the main source
of blood to the deep palmar arterial
arch, which is completed on the
ulnar side by the deep branch of the
ulnar artery.
o runs deep in the hand, along
with the deep ulnar nerve
Nerve supply of the hand
Motor supply to the hand
All the muscle in the hand are innervated by
the deep branch of ulnar n. EXECPT for
LOAF muscles, which are innervated by the
median n.
Lateral 2 lumbricals
Plus, the thenar eminence, by the recurrent
branch of median n.
Opponens pollicis m.
Abductor pollicis brevis m.
Flexor pollicis brevis m.
Digital branches of the ulnar n.
The ulnar n. and ulnar a. do NOT pass under
the flexor retinaculum
They pass over the retinaculum through
Guyons canal
Cutaneous supply to the digits
Medial n. supplies cutaneous to the first 3
digits
Ulnar n. supplies cutaneous to the medial 1
digits
Flexor compartment of the hand
Flexor retinaculum
Tendon sheath that passes over the carpal
tunnel
Carpal tunnel
If an instrument is placed passing through the
tunnel, you would say carpal tunnel
If a pin is in the tendon over the tunnel, you
would say flexor retinaculum
Guyons tunnel
Ulnar n. and a. pass through this tunnel
Thenar eminence, big muscle pad at base of
thumb
Nerve: recurrent branch of median n., C8,
T1
A branch of the median n.
A motor nerve to the thenar eminence
Seen crossing over flexor pollicis brevis m.
toward abductor pollicis brevis m.
If the recurrent branch is cut, the person loses
the ability to grasp, thus it is called the
million dollar nerve
Consists of 3 muscles
Abductor pollicis brevis m.
Outermost of the 3 since it abducts
Action: abducts thumb and helps oppose it
Flexor pollicis brevis m.
Medial to abductor pollicis brevis m.
(closer to palm)
Action: flexes thumb
Opponens pollicis m.
Under the other two
Action: draws thumb
Flexor pollicis longus m.
Its tendon is seen running through the thenar
eminence
Hypothenar eminence, muscle pad at base of
little finger
Nerve: ulnar n.
Consists of 3 muscles
Abductor digiti minimi m.
Outermost of the 3 since is abducts
Action: abducts little finger
Flexor digiti minimi brevis m.
Medial to abductor digiti minimi m.
Action: flexes little finger
Opponens digiti minimi m.
Under abductor digiti minimi m.
Action: draws little finger toward thumb
Flexor digitorum superficialis m.
The most superficial tendons seen in the palm
These tendons run only to the middle phalanx
where they splits, and the flexor digitorum
profundus tendons passes between on their
way to the distal phalanx
Flexor digitorum profundus m.
Tendons that lie under the flexor digitorum
superficialis
These tendons give rise to the lumbricals
These tendons run to the distal phalanx
Lumbrical mm.
Seen connecting the tendons of the flexor
digitorum profundus in the palm
Nerves:
Lateral 2 lumbricals: median n.
Medial 2 lumbricals: ulnar n.
Palmaris brevis m.
A tiny muscle that passes over proximal aspect
of the hypothenar eminencewont be tested
Adductor pollicis m.
Has 2 heads
Oblique head
Transverse head
Nerve: ulnar n., even though it on the lateral
side of the palm
Palmar interossei mm.
Very deep, not easy to see
Action: adduct digits
PAD Palmars are for ADductions
Dorsal interossei mm.
Seen from dorsum of hand, easier to see than
palmar interossei
1
st
dorsal interossei
Broad superficial muscle between thumb and
index finger metacarpals
Has 2 heads at wrist
Pierced by radial a. between the 2 heads of
the 1
st
dorsal interossei, near wrist
Action: abduct digits
DAB Dorsals are for Abductions
Superficial palmar arch
Formed mainly by the ulnar a.
Forms an anastomosis with the radial a.
If asked where is this vessel is mainly from,
you would say ulnar a.
Deep palmar arch
You wont see
Formed mainly by the radial a.
Digital branches of the median n.
Branches in lateral aspect of palm near the
base of the first 2 fingers
Medial n. supplies cutaneous to the lateral 3
fingers
Digital branches of the ulnar n.
Branches in medial aspect of palm near the
base of the little finger
Ulnar n. supplies cutaneous to the medial 1
fingers
Superficial radial n.
Seen crossing over the anatomical snuff box
Supplies only cutaneous to lateral dorsum of
the hand
It does NOT supply the nail beds, which are
supplied by the medial and ulnar nn.
Ulnar n.
Seen medial to the proximal end of the
hypothenar eminence
Runs over the carpal tunnel, NOT through it
Runs along with ulnar a.
Cutaneous supply to last 1 fingers, plus their
nail beds
Median n.
Runs through the carpal tunnel
Cutaneous supply to first 3 fingers, plus
their nail beds
Flexor retinaculum
Ligament that forms the roof of the carpal
tunnel
Carpal tunnel
Has 9 tendons passing through it
4 from flexor digitorum superficialis m.
4 from flexor digitorum profundus m.
1 from flexor pollicis longus m.
Ulnar and Radial Bursa also found
Flexor pollicis longus is enclosed in
its own synovial sheath in the
carpal canal, called the radial
bursa
The tendons from flexor digitorum
profundus and flexor digitorum
superficialis are all contained in a
common synovial sheath, called the
ulnar bursa
Median n. is sandwiched in between these
tendons
Carpal tunnel syndrome affects the median
n.
Ulnar n. does NOT pass through the carpal
tunnel, thus it is not affected in carpal tunnel
syndrome
Extensor compartment of the hand
Dorsal interossei mm.
Seen on the dorsal aspect of the hand between
the long metacarpal bones
There are 4 dorsal interossei mm.
1
st
dorsal interosseus m.
Broad superficial muscle between the
metacarpals of the thumb and index finger
Has 2 heads at wrist
Pierced by radial a. between the 2 heads of
the 1
st
dorsal interossei, near wrist
Action: abduct digits
DAB Dorsals are for Abductions
In ID, you must say 1
st
dorsal interosseus
musclenot just interosseus muscle
Anatomical snuff box
Lies between the tendons of
Laterally: abductor pollicis longus and
extensor pollicis brevis
Medially: extensor pollicis longus
Floor: scaphoid bone
The scaphoid bone is commonly fractured,
and particularly prone to avascular
necrosis
Seen when thumb is fully extended (pointing
up)
Radial a. passes through the snuff box
Superficial branch of the radial n. passes
over the snuff box
Dorsal expansion = Extensor expansion
The shiny tendon through which the tendons
of the fingers pass on the dorsal aspect of the
fingers
Lumbricals and interossei insert into the
sides of the dorsal expansion

Most commonly dislocated carpal bone is
Lunate, most commonly fractured is
scaphoid.

Coracoclavicular ligament is very
strong. When this ligament is torn, a
patient will have a third degree
separated shoulder

Axis of rotation @ distal radio-ulnar
joint is styloid process of ulna

Most shoulder dislocations still occur
in the anteroinferior direction, with
the humeral head dislocating forward
and downward.
A dislocated shoulder occurs when the
humeral head slips out of the labrum;
this often happens in the anterior
direction

A syndesmosis is a fibrous membrane
or ligament that joins two bones. The
connections between the shafts of the
radius and ulna and the tibia and
fibula are 2 classical examples of
syndesmoses


Lower Limb

Hip joint more stable than Shoulder joint
because head of femur is more inside the
acetabulum.
Articulur cartilage is hyaline articulage here
TMJ is synovial joint not covered by
hyaline cartilage.
Head of femur supplied by small branch of
obturator artery.
Illifemoral Ligament: strongest of the body
Prevents hyperextension of hip joint.
Also called ligament of Bigelow
Attached from ASIS to inter
tronchanteric line.
Prevents backward falling of the body

Pubofemoral ligament: limits abduction and
lateral rotation
Illiopsoas bursa.
Ischiofemoral ligament: weakest of all ligament.
Limits medial rotation.
It is the ligament that is most
likely to be injured if the femur is
dislocated posteriorly
Illipsoas attached to lesser trochanter
Hip joint can be dislocated posterioly which can
more likely injure sciatic nerve.
(Slide 11 Dr. Sam D)
(Slide 12: D)
Medial and lateral femoral circumflex arteries
provide the anastomoses around neck of femur
Medial circumflex femoral is the chief
source.
(Slide 16: D)
Thigh
External oblique aponeurosis
Inguinal ligament, formed by the lower aspect
of the external oblique aponeurosis
Spermatic cord [testis removed]
Cross-section of penis near pubic symphysis
shows
Corpus cavernosum
Corpus spongiosum, with spongy urethra
Deep fascia
A stocking-like covering over the entire lower
limb
Separates muscles from each other and invests
them
Prevents bulging of the muscles during
contraction
Makes the muscles more efficient in pumping
blood toward the heart
Divided into 2 regions
Fascia lata, the deep fascia of the thigh
Crural fascia, the deep fascia of the leg
Saphenous ring (opening)
A deficiency in the deep fascia lata inferior to
the medial part of the inguinal ligament
Great saphenous v. passes through the ring to
enter the femoral v.
Iliotibial tract
The conjoint aponeurosis of the
Gluteus maximus m.
Tensor fascia lata m.
Extends from the iliac tubercle to the lateral
condyle of the tibia
Femoral triangle
Bounded by
Base of triangle, superior aspect: inguinal
ligament, which ends medially as the lacuna
ligament
Medial: adductor longus m.
Lateral: sartorius m.
Floor: iliopsoas m. laterally, and pectineus m.
medially
Apex: the beginning of the adductor canal, at
the junction of sartorius and adductor longus
mm.
In order from lateral to medial
N Femoral n.
A Femoral a.
V Femoral v.
E Empty space
L Lacuna ligament or Lymph nodes
Femoral n., L2, L3, L4
Breaks up very quickly into a series of nerve
branches
If all its branches were tagged as one group,
you would say its the femoral nerve
Outside of Femoral sheath
Saphenous n. is one of the many branches of
the femoral n.
Supplies cutaneous innervation to the medial
aspect of the foot
It can be IDs at 2 points
a. As it enters the adductor canal at the
apex of the triangle along with the femoral
a. and v.
NOTE: the saphenous n. does NOT exit
the adductor hiatus
b. As it passes anterior to the medial
malleolus, accompanied by the great
saphenous v.
Femoral a.
A continuation of the external iliac a., which
changes its name to the femoral a. once it
passes under the inguinal ligament
Runs with the femoral v.
Enters the adductor canal along with the
femoral v. and saphenous n.
Profunda femoris a. = Deep artery of thigh
A large branch off the femoral a., soon after it
passes under the inguinal ligament
Parallels the course of the femoral a., but goes
deeper
The main blood supply to the thigh
Also supplies the Hamstring compartment
Branches are known as arterial
perforators.

The femoral a. itself contributes very little
direct blood supply of the thigh. It continues
on as the popliteal a. which supplies the leg
Profunda femoris a. divides into 2 branches
Medial circumflex femoral a.
The most important artery of the cruciate
anastomosis, which supplies the head and
neck of the femur
Lateral circumflex femoral a.
descending branch of the
lateral circumflex femoral
artery anastamoses with both
the descending genicular
branch of the femoral artery as
well as the lateral superior
genicular branch of the
popliteal artery
o These connections
provide collateral
circulation to the knee
and leg
Cruciate anastomosis
Forms a cross
It is the blood supply to the head and neck of
the femur
Superior part of the cross: a branch of the
inferior gluteal a.
Lateral part of the cross: lateral circumflex
femoral a.
Medial part of the cross: medial circumflex
femoral a.
Inferior part of the cross: 1
st
perforating
branch of the profunda femoris a.
Femoral v.
Runs with the femoral a.
You can tell that its the femoral v. (and not
the great saphenous v. because the femoral v.
is deeper and passed through the adductor
canal along with the femoral a. and saphenous
n.
Great saphenous v.
A superficial vein, thus it does NOT enter the
adductor canal
Accompanied by the saphenous n., from the
knee to the foot
Pathway
Originates from the medial aspect of the
dorsal venous arch
Passes anterior to the medial malleolus
Passes posterior to the medial condyle of the
femur
Comes through the saphenous ring in the
fascia lata
Empties into the femoral v.
Empty space
Allows for veins to expand so more blood can
return to heart.
Has the femoral ring and the femoral canal
A potential site for femoral hernias, where
parietal peritoneum comes through
Hernias Tend to be U- shaped in
nature
More common in women
Pieces of bowel can come down with the
transversalis fascia pushing through.
Pubic tubercle is landmark
Any hearnia above it is called Inguinal
Any hernia below it is called femoral
They tend to be strangulated for 2 reasons
There is a sharp boundary on the
lacunar ligament
Modification of inguinal ligament
This can cause strangulation of
femoral hernia which can result in
necrosis of intestine.
Accessory obturator artery: present
sometimes which can cause bleeding
while cutting the lacunar ligament.
Branch of inferior epigastric
artery.
The saphenous ring where the great
saphenous vein enters, where it can be
caught up
Perforating veins are first ones to get
valve failures.
Lesser (Small) saphenous vein more
likely to be varicosed on calf muscles.
Great saphenous more like to varicose on
the medial side of thigh.
An obturator hernia is a protrusion of a
loop of bowel through the obturator
canal.
with a loop of ilium passing
inferiorly, posterior to the
superior pubic ramus
Lacuna ligament
Has a sharp lateral edge that can cause
strangulation of a femoral hernia
Wont have to ID, but know about it
Adductor canal = Hunters canal
Runs from the apex of the femoral triangle to
the adductor hiatus distal to the attachment of
the adductor magnus m. on the adductor
tubercle of the femur
Between the vastus medialis m. and the
adductor muscles, and converted into a canal
by the overlying sartorius m.
Has the following that passes through it
Femoral a.
Femoral v.
Saphenous n.
When the femoral a. and v. exit through the
adductor hiatus, they change their names to
the popliteal a. and v.
Note: the saphenous n., which entered the
adductor canal, does NOT exit the adductor
hiatus
Anterior Thigh
Femoral n., L2, L3, L4
Innervates the
Quadriceps femoris mm.
Sartorius m.
Pectineus m., which is also innervated by
the obturator n.
Branches to form the saphenous n.
Supplies cutaneous innervation to the medial
aspect of the foot
It can be IDs at 2 points
a. As it enters the adductor canal at the
apex of the triangle along with the femoral
a. and v.
NOTE: the saphenous n. does NOT exit
the adductor hiatus
b. As it passes anterior to the medial
malleolus, accompanied by the great
saphenous v.
Sartorius m.
Attachments:
ASIS, then crosses anterior thigh
Pes anserinus, on the medial aspect of the
tibia
Actions: puts you in a tailors position, a
cross-legged position
You need to know the difference between its
action at the hip and its action at the knee
If you asked for the sartorius action at the
hip, you would say
Laterally rotates hip
Flexes hip
Abducts hip
If you asked for the sartorius action at the
knee, you would say
Medially rotates knee
Flexes knee
Sartorius is the roof of the
adductor canal.
The sartorius m. divides the muscles of the
anterior compartment of the thigh into 2
groups
1. Anterior group
Femoral n. innervates everything in the
anterior thigh
2. Abductor group
Obturator n. innervates everything in the
adductor region, with 2 exceptions
Pectineus m. is innervated by 2 nerves
Obturator n.
Femoral n.
Adductor magnus m. has 2 portions,
each with a different nerve
Tibial n. innervates the hamstring
portion
Obturator n. innervates the adductor
portion
Quadriceps femoris mm. consist of 4 muscles
1. Rectus femoris m.
You can see that its the rectus femoris
because it is straight
Attachments
AIIS, anterior inferior iliac spine
Rectus femoris m. is the only quadriceps
muscle that crosses the hip, thus its the
only quadriceps that can also flex the hip
2. Vastus lateralis m.
3. Vastus intermedius m.
Lies under rectus femoris m.
4. Vastus medialis m.
Quadriceps tendon is the common tendon of
all 4 muscles at the knee
Attaches to the base (superior aspect) of the
patella ; becomes the patellar tendon.
At the apex (inferior aspect) of the patella it
continues as the patellar ligament which
attaches to the tibial tuberositynot
quadriceps tendon
The quadriceps tendon/patellar ligament
inserts into the tibial tuberosity
Main action: Extension at the knee joint
Rectus femoris m. also crosses the hip, thus
it can also flex the hip
Nerve: femoral n., L2, L3, L4
Knee Jerk: tests the value of L3 L4
Iliopsoas m.
Lies just medial to the sartorius origin
From this perspective, only small part of its
most inferior portion is visible as it inserts into
the lesser trochanter of the femur
Attachments:
Psoas major: sides, discs and transverse
processes of T12-L5
Psoas minor: sides and discs of T12-L1
Iliacus m.: iliac crest and fossa
Insertion: lesser trochanter of the femur
The iliopsoas m. is the only muscle that
attaches at the lesser trochanter of the
femur
Nerve: L1, L2, L3
Medial Thigh
Action: adducts thigh
Nerve: obturator n
Travels thru obturator foramen
accompanied by obturator artery
Can be compressed in females by
ovarian enlargement (Poly cystic ovarian
disease)
Pain in medial side of leg

Seen under the adductor longus m.
Innervates all of the adductor group with 2
EXCEPTIONS
Pectineus m. is also receives innervated by
the femoral n.
The hamstring portion of adductor magnus
m. is innervated by the tibial n.
Adductor longus m.
Most superficial of the adductor muscles, just
lateral to the gracilis m.
Most commonly affected muscle in groin
strain
The femoral artery is superficial to
adductor longus, while the deep femoral
artery is deep to adductor longus.
Pectineus m.
Lies just lateral to adductor longus m.
Lies just medial to the femoral vein, forming
the medial floor of the femoral triangle
Has dual innervation
Femoral n.
Obturator n.
If asked What is the nerve supply to
pectineus muscle?, you must write both
nerves femoral nerve and obturator nerve
Adductor brevis m.
Lies under adductor longus m.
Obturator n. passes anterior to adductor
brevis m. and sends a posterior branch through
the muscle
Obturator externus m.
Lies under the pectineus m.
Its fibers run transversely, left to right
Adductor magnus m.
A huge muscle
The upper aspect lies under adductor brevis m.
Seen more clearly from the posterior view
Nerves:
Has 2 portions, each with a different nerve
Tibial n. innervates the hamstring portion
Obturator n. innervates the adductor
portion

Forms the Adductor Hiatus
Gracilis m.
The most medial muscle of the thigh
Runs in a straight course
Attachments:
Pubis
Pes anserinus on the medial aspect of the
tibia
Action:
Crosses both the hip and knee joints, thus it
Flexes the knee
Slightly adducts the thigh
Innervated by Obturator nerve
Gluteal Region
Tensor fascia lata m.
Lies within the iliotibial tract at the superior
end
Considered to be part of the gluteal region
based on its innervation, but it is seen in the
anterior thigh
Nerve: superior gluteal n.
Tensor fascia lata is NOT supplied by the
femoral n. even though it seems to be part of
the anterior region
In fact it is part of the gluteal region, not the
anterior thigh region
Gluteus maximus m.
Main action: forced extension, NOT ordinary
extension as when walking
Extends the thigh when rising from sitting or
climbing
Attachments:
2/3 into the iliotibial tract
1/3 into the gluteal tuberosity of the femur
Considered part of the medial group due to its
other actions:
Laterally rotates thigh
Extension of hip Joint: Major action!!
Nerve: inferior gluteal n (L5, S1, S2)
A long nerve that exits the pelvis below the
piriformis m. through the greater sciatic
foramen to reach the ventral aspect of the
gluteus maximus m.
Dont give any intramuscular injection until
6yrs of age coz this muscle doesnt develop
until 6yrs of age.
Injection giving in
superiolateral quadrant.
o Nerve injured can be
superior gluteal
nerve.
Lateral group of muscles in the gluteal region
The actions of these muscles are
Chief stabilizers of the hip
Medial hip rotators
Abductors of the thigh
1. Gluteus medius m.
A fan-shaped muscle that lies just superior to
the piriformis m.
Attachment: greater trochanter
Nerve and blood: superior gluteal n. and a.,
which lies between the gluteus medius m. and
gluteus minimus m.
The superior gluteal n. and a. exit the pelvis
above the piriformis m. through the greater
sciatic foramen
2. Gluteus minimus m.
Lies under the gluteus medius m., also just
superior to the piriformis m.
Attachment: greater trochanter
Nerve and blood: superior gluteal n. and a.,
which lies between the gluteus medius m. and
gluteus minimus m.
Main action of gluteus medius and minimus:
The chief stabilizers of the hip joint
If asked what is the main action of gluteus
medius and minimus?, you would say they
are the chief stabilizers of the hip joint
They are responsible for holding the weight
over the hip joint, keeping the hip joints
level when a leg is lifted off the ground
Other actions of gluteus medius and minimus:
Medially rotates thigh, these are the medial
rotators of the thigh
Abducts thigh
Superior gluteal n. innervates
Gluteus medius m.
Gluteus minimus m.
Tensor fascia lata m.
If the superior gluteal n. is injured, we lose
the 2 muscles that are the primary stabilizes of
the hip joint, causing a condition called
Trendelenburg sign
Injury to the superior gluteal n. is very
commonly seen in poliomyelitis
To test, stand behind patient, place your hands
on their hips, eye level with their pelvis, then
asked the patient to stand on one leg.
If the unsupported pelvis goes upward, thats
normal.
If the unsupported pelvis descends, thats a
(+) Trendelenburg sign. It indicates a weak
gluteus medius m. on the supported side
Patient will fall toward the opposite side of
the lesion
Medial group of muscles in the gluteal region
The actions of these muscles are
Lateral hip rotators
Abductors of the thigh
1. Piriformis m.
Nerve: nerve to piriformis
A key muscle to the gluteal region
Anything that exits above the piriformis is
the superior gluteal n., a., v.
Everything else exits below the piriformis,
including
Inferior gluteal n., a., v.
Sciatic n., L4, L5, S1, S2, S3
Internal pudendal a. and v.
Pudendal n.
2. Superior gemellus m.
Lies just inferior to the piriformis m.
Nerve: nerve to obturator internus
3. Tendon of obturator internus m.
Lies just inferior to the superior gemellus m.
Nerve: nerve to obturator internus, which
also supplies superior gemellus m., above it
Remember: obturator internus m. is the only
muscle that passes through the lesser sciatic
foramen
If asked which muscle passes through the
lesser sciatic foramen?, you would say
obturator internus muscle
4. Inferior gemellus m.
Lies just inferior to the tendon of obturator
internus m.
Nerve: nerve to quadratus femoris
5. Quadratus femoris m.
Lies just inferior to the inferior gemellus m.
Nerve: nerve to quadratus femoris, which
also supplies inferior gemellus m.
NOTE: The gemellus muscles receive the
innervation of the muscle below them
Sacrotuberous ligament
Sacrospinous ligament, deep to the
sacrotuberous ligament
Exiting between these 2 ligaments are the
Internal pudendal a. and v., blood supply to
the perineum
Pudendal n., S2, S3, S4, nerve supply to the
perineum
These 3 exit via the greater sciatic foramen
and reenter via the lesser sciatic foramen,
traveling within Alcocks canal
So if you see vessels or a nerve passing
below the sacrotuberous ligament, you know
they are the internal pudendal a. and v., and
pudendal n.
Posterior Thigh
Sciatic n.
The largest nerve in the body
Innervates
Posterior thigh muscles
Everything from the knee down
Runs down the posterior leg
Formed from by the joining of
Lumbosacral trunk, L4, L5
S1, S2, S3
Composed of 2 nerves which divide into the
Tibial n., the larger of the 2, and more
medial
Common peroneal n.
It important to orient yourself so you can tell
medial from lateral, since the nerve running
medially has to be the tibial n., and the nerve
running laterally has to be the common
peroneal n.
Tibial n.
Runs more medially down the thigh to the
center of the popliteal fossa
Innervates 2 main regions
1. All the posterior thigh muscles, such as the
hamstrings, EXCEPT
Short head of biceps femoris m., which is
innervated by the common peroneal n.
Adductor portion of adductor magnus
m., which is innervated by the obturator n.
2. All the posterior compartment of the
leg, which are the plantar flexors
After passing posterior to the medial
malleolus, the tibial n. divides into
Lateral plantar n.
Medial plantar n.
If the tibial n. is injured, the person cant
plantar flex the ankle, which means they cant
lift their heel, and the heel will drag along the
ground, a condition called a shuffling gait
Common peroneal n.
Runs down the thigh to the lateral aspect of the
knee
Wraps around the neck of the fibula, and at
this point is very superficial and, thus, easily
prone to injury
Innervates
1. Only one muscle in the posterior thigh
short head of biceps femoris m.
2. All the muscles of anterior and lateral
compartments of leg
In the leg the common peroneal n. divides into
2 nerves
Deep peroneal n., innervates the anterior
compartment of leg
Dorsiflexes the ankle
Inverts the foot
Superficial peroneal n., innervates the
lateral compartment of leg
Everts the foot
Weakly plantar flexes the ankle
If the neck of the fibula is tagged, and you are
asked, What happens if the bone is fractured
at this point, you would say the common
peroneal nerve is damaged
If the common peroneal n. is injured, the
person loses their deep and superficial
peroneal nn., thus losing both the anterior and
lateral compartments. The result is that they
cant dorsiflex the ankle, cant extend the toes,
and cant evert the foot, which means they
cant lift the foot or toes, and their toes will
drag along the ground, a condition called foot
drop
To compensate and avoid dragging their toes,
the person develops a gait in which they lift
their leg very high
Foot drop = common peroneal n. damage =
fibular fracture
Hamstrings
To qualify as a true hamstring muscle, the
muscle must
a. Attach at the ischial tuberosity
b. Cross both the hip joint and knee joint, thus
they
Extend the thigh
Flex the knee
Nerve: tibial n.
The hamstrings consist of 3 muscles
1. Long head of the biceps femoris m.
Most lateral muscle of the 3 hamstring
muscles
Attachments:
Ischial tuberosity
Head of the fibula, on lateral knee
Note: the short head of the biceps femoris m.
is NOT a true hamstring
To ID, you must say long head or short
head of the biceps femoris muscle
2. Semitendinosus m.
Attachments:
At the ischial tuberosity, it is just medial to
the biceps femoris m.
Pes anserinus at the medial tibia
To ID, notice that it half muscle and half
tendon
3. Semimembranosus m.
Attachments:
Ischial tuberosity
Medial tibia, superior to the pes anserinus,
NOT in it
Lies immediately under semitendinosus m.
To ID, notice that is half membranous and
half muscle
Short head of the biceps femoris m.
Is NOT a true hamstring muscle since it
Does not attach at the ischial tuberosity
Does not cross the hip joint
Nerve: common peroneal n.
It is important in that it is the only muscle in
the posterior thigh that receives the common
peroneal n.
The true hamstrings are innervated by the
tibial n.
Adductor magnus m.
Is part of the adductor region, NOT posterior
thigh, however, it can be seen most clearly
from the posterior aspect
It has 2 portions
Adductor portion
More superior portion, with fibers running
toward the adductors
Attachments:
Inferior ramus of the pubis
Gluteal tuberosity and linea aspera
Nerve: obturator n.
Hamstring portion
More inferior portion, with a prominent
tendon
Attachments:
Ischial tuberosity
Adductor tubercle of the femur
Nerve: tibial n.
Adductor hiatus
Formed at the junction of the adductor portion
and hamstring portion of the adductor magnus
m.
The opening is just superior to the adductor
tubercle of the femur
You need to be able to differentiate between
artery, vein, and nerve at the apex of the
femoral triangle, and at the adductor hiatus
At the adductor hiatus, the popliteal v. is the
most superficial vessel, and the popliteal a.
lies beneath the vein
At the apex of the femoral triangle, the
femoral a. is the most superficial, and the
femoral v. lies beneath the artery, which is
very unusual in the body
After the femoral a. and v. pass through the
adductor canal, they exit the adductor hiatus as
the popliteal a. and v., with the popliteal v. as
the most superficial vessel
Knee joint
Orient yourself to find the 3 bones of the knee
joint
Femur
Tibia
Fibula, located on the lateral aspect
Femur
Lateral condyle
IDs by locating the fibula below it
Medial condyle
Tibia
Lateral condyle
IDs by locating the fibula beside it
Medial condyle
Tibial plateau
On the anterior aspect of the flexed knee
Lateral meniscus, under the lateral condyle
Medial meniscus, under the medial condyle
The medial meniscus is more often injured
because it is NOT mobile since it is attached to
the medial collateral ligament
The menisci are made out of fibrocartilage
Anterior cruciate ligament, ACL
Attachmentsthese are tested in the USMLE
From anterior surface of the tibial plateau
To the medial aspect of the lateral condyle
If the anterior cruciate ligament were tagged,
and it asked what action does this ligament
help to prevent?, you would say
hyperextension of the knee joint
The ACL prevents the tibia from sliding
anteriorly forward
Prevents the femur from
sliding backwards in
relation to tibia.
Not attached to any
menisci.
The anterior cruciate ligament is 4 times more
likely to be injured than the posterior cruciate
ligament
To test, do an anterior draw sign
On the lateral aspects of the knee, the collateral
ligaments prevent any excessive adductive or
abduction of the knee
Medial collateral ligament, MCL = Tibial
collateral ligament
Attaches to the medial meniscus, which in
turn attaches to the anterior cruciate
ligament, producing the unhappy triad
A lateral blow to the knee, when the knee is
flexed and the foot is firmly planted on the
ground, can tear the medial meniscus and push
it medially and tear the anterior cruciate
ligament, which in turn can tear the medial
meniscusthus the unhappy triada very
common sports injury
Lateral collateral ligament, LCL = Fibular
collateral ligament
The tendon of the popliteus m. passes
underneath the lateral collateral ligament,
which separates the lateral collateral ligament
from the lateral meniscus
Thus, the lateral collateral ligament is NOT
attached to the lateral meniscus, thus leaving
the lateral meniscus much more mobile and far
less prone to injury than the medial meniscus.
An injury to the lateral collateral ligament
does not effect the lateral meniscus
On the posterior aspect of the extended knee
Posterior cruciate ligament, PCL
Attachments
From posterior surface of the tibia
To the medial aspect of the medial condyle
If the posterior cruciate ligament were tagged,
and it asked what action does this ligament
help to prevent?, you would say
hyperflexion of the knee joint
The PCL prevents the tibia from sliding
posteriorly backward
Prevents the femur from
sliding forward on the tibia
Posterior meniscofemoral ligament
Passes posterior to the posterior cruciate
ligament
Attaches on the lateral aspect of the medial
condyle of the femur with the posterior
cruciate ligament, but then attaches to the
posterior aspect of the lateral meniscus
Give reinforcement to the posterior aspect of
the knee joint
Leg
Orient yourself by looking for the
Tibia and the big toe, which are on the medial
side
Fibula and little toe, which are on the lateral
side
Anterior
compartment
Lateral
compartment
Posterior
compartment
Deep peroneal
n.
Superficial
peroneal n.
Tibial n.
Dorsiflexes
ankle
Extends toes
Inverts foot
Everts foot
Plantar
flexion
Plantar flexes
ankle
Flexes toes
Injury to the common peroneal
n. = foot drop
Injury to the
tibial n. =
shuffling gait
Injury to the sciatic n. effects all the above =
peculiar gait, person has great difficulty
walking because most of the work is done at the
hip instead of thigh and leg

Unlike the hip and thigh, you dont need to
know the attachments of the muscles of the leg,
EXCEPT for those that are unusual such as
Tibialis anterior m., which attaches at the
medial base of the 1
st
metatarsal under the
medial aspect of the foot
Inversion will not be lost in foot
drop coz Tibialis posterior still
does inversion.
Peroneus longus m., which attaches at the
lateral base of the 1
st
metatarsal under the
medial aspect of the foot
Peroneus brevis m., which attaches at the
base of the 5
th
metatarsal
Its best to think of the muscles of the leg with
respect to their compartment, which associated
the muscles with their action and nerve supply
When you ID a muscle of the leg, be sure to
follow its tendon to see where it attaches
Anterior Leg
Medial aspect of the tibia has no muscle
attachments, a good orientation point when
viewing the anterior compartment
Responsible for
Dorsiflexion of the ankle via anterior tibialis
m.
Extension of the toes
Inversion of the foot via tibialis anterior m.,
turning soles inward
Deep peroneal n.
a. As a motor nerve, it innervates
All of the muscles of the anterior
compartment
2 muscles of the dorsum of the foot
Extensor hallucis brevis m.
Extensor digitorum brevis m.
Best seen just with anterior tibial a. and v.,
just superior to the ankle between the
tendons of tibialis anterior and extensor
hallucis longus
b. As a cutaneous nerve, it innervates the skin
of 1
st
dorsal web space
Best seen in the 1
st
web space between the
big toe and 2
nd
toe
If a pin were placed in the 1
st
web asking
what is the cutaneous nerve supply to this
area?, you would say deep peroneal n.
Anterior tibial a. and v.
Accompany the deep peroneal n. from the
knee to the dorsum of the foot
Best seen with the deep peroneal n. just
superior to the ankle, between the tendons of
tibialis anterior and extensor hallucis longus
The artery becomes the dorsalis pedis a. after
passing the ankle joint,
Dorsalis pedis a.
Runs between the 1
st
and 2
nd
metatarsals,
pierces through the 1
st
dorsal interosseous,
and joins the plantar arch
Its where the pedal pulse is taken
The muscles of the anterior compartment, from
most medial to lateral, are:
Tibialis anterior m.
Attachments:
Lateral condyle of the tibia
Base of the 1
st
metatarsal under the medial
foot
IDd as the most medial tendon at the
anterior ankle, passing anterior to the medial
malleolus, then under the medial foot
Action:
Invert the foot, due to its attachment at the
base of the 1
st
metatarsal under the medial
foot
Dorsiflexes foot
Extends the toes
Extensor hallucis longus m.
ID by
Its muscle portion seen just lateral to tibialis
anterior near the ankle
Its tendon running to the big toe
Action: extends big toe
Extensor digitorum longus m.
ID by
Its muscle portion runs the length of the
anterior leg, the most lateral tendon at the
anterior ankle
Its division into 4 different tendons
Action: extends all toes, except big toe
Peroneus tertius m.wont be tested
A small part of the extensor digitorum
longus that is sometimes named as a separate
muscle
Its tendon attaches near the little toe
Lateral Leg
Responsible for
Eversion of the foot, turning soles outward
Weak plantar flexion of the ankle
Superficial peroneal n.
As a motor nerve, it innervates the muscles of
the lateral compartment
Best seen as it pierces through the extensor
digitorum longus m.,
just medial to the peroneus mm.
As a cutaneous nerve, it innervates the skin
over the entire dorsum of the foot
EXCEPT the skin of 1
st
dorsal web space,
which is supplied by the deep peroneal n.
Seen branching over the dorsum of the foot
Peroneus longus m.
More superficial of the 2 peroneus mm.
Attachment: lateral base of the 1
st
metatarsal
under the medial aspect of the foot
Action:
Everts the foot
Weakly plantar flexes ankle
fibularis longus runs from
the lateral side of the foot
across the entire sole of the
foot, traveling deep to the
long plantar ligament
Peroneus brevis m.
Lies under the peroneus longus m.
Attachment: base of the 5
th
metatarsal
Action:
Everts the foot
Weakly plantar flexes ankle
Inversion done @ Subtalar joint.
Common peroneal n.
Is NOT part of the lateral compartment, but
from the lateral view of the leg, you can best
see how it superficially wraps around the head
of the fibula
Posterior Leg
Responsible for
Plantar flexion of the ankle via gastrocnemius
and soleus mm., standing on your toes
Flexion of the toes
Slight inversion of the foot via posterior
tibialis m.
Popliteal fossa, the diamond-shaped depression
of the posterior knee
Bounded by
Superolaterally: biceps femoris m.
Superomedially: semimembranosus m.,
lateral to which is the semitendinosus m.
Inferolaterally: lateral head of
gastrocnemius m.
Inferomedially: medial head of
gastrocnemius m.
Contains the
Lesser saphenous v.
Tibial n., runs centrally in popliteal fossa
Common peroneal n., runs laterally to the
popliteal fossa
Popliteal lymph nodes
Popliteal a. and v.
The artery divides into
Anterior tibial a., runs in anterior
compartment, and becomes
Dorsalis pedis a.
Posterior tibial a., runs in posterior
compartment, and gives off
Peroneal a., not really seen since it runs
in the bulk of the flexor hallucis longus
m.
Sciatic nerve divides here: Tibial
continues all the way down, common
peritoneal runs laterally.
Stab Wound: 1
st
one to be injured is Tibial
nerve, Popliteal vein then popliteal artery
Popliteal artery is the
deepest structure here so it
can be palpated.
Blood pressure can be
taken here.
Small saphenous vein is the
superificial vein tht drains
into popliteal vein.
Tibial n.
Between the heads of the gastrocnemius m.
Innervates the muscles of the posterior
compartment
Injury to the tibial n. causes a shuffling gait,
unable to lift their heel off the ground
Lesser saphenous v.
Originates on the lateral aspect of the dorsal
venous arch
Runs posterior to the lateral malleolus, and on
top of the gastrocnemius m.
Drains into the popliteal v. in the popliteal
fossa
Accompanies the sural n.
NOTE:
Great saphenous v.
Originates on the medial aspect of the
dorsal venous arch
Runs anterior to the medial malleolus
Sural n.
Accompanies the lesser saphenous v. on the
surface of the gastrocnemius m. and around
the posterior lateral malleolus
Runs to the lateral foot where it give cutaneous
supply to the lateral foot
Formed by union of branches from the tibial
and common peroneal nn.
Superior medial and lateral genicular aa.
Branches from the popliteal a.
Seen just superior to the 2 heads of the
gastrocnemius m.
Inferior medial and lateral genicular aa.
Branches from the popliteal a.
Pass just superior to the popliteus m.
Pes anserinus
On the superomedial aspect of the tibia where
the tendons of 3 muscles attach, from most
superior to most inferior
Semitendinosus m.
Gracilis m.
Sartorius m.
Gastrocnemius m.
Has 2 heads
Soleus m.
A flat muscle that lies under the gastrocnemius
m.
Triceps surae
The 3 calf muscles, composed of the 2 heads
of the gastrocnemius m. and the soleus m.,
which form a common tendon, the Achilles
tendon = calcaneal tendon, which attaches to
the posterior calcaneus
Plantaris m.
A small muscle with a very long tendon that
runs from the popliteal fossa to the medial
aspect of the Achilles tendon to the posterior
calcaneus
The muscle portion seen deep to the 2 heads of
the gastrocnemius m.
The tendon portion seen under the
gastrocnemius m. and above the soleus m.
The tendon of the plantaris m. is NOT included
in the Achilles tendon since the plantaris m. is
often missing in people
The tendon is useful for tendon grafts
Popliteus m.
Thin triangular muscle that lies under the
Plantaris m. (if one is there)
Popliteal a. and v.
Tibial n.
Action: unlocks the fully extended knee by
laterally rotating the femur 5 on the tibial
plateau, so that flexion can occur
Its tendon runs under the lateral collateral
ligament, separating the lateral collateral
ligament from the lateral meniscus
Its muscle attaches to the posterior tibia,
superior to the soleal line
Deep muscles and vessels of the posterior
compartment
Actions of these muscles
Plantar flexion
Flexion of the toes
The following are IDd by looking at the medial
malleolus region
From anterior to posterior, starting just behind
the tibia, and going outward toward the
Achilles tendon
Passing behind the medial malleolus
Remembered as: Tom, Dick, and A Very
Nervous Harry
Tibialis posterior m.
If you see a tendon immediately behind the
tibia, posterior to the medial malleolus, you
know it must be the tibialis posterior m.
Flexor digitorum longus m.
The tendon immediately posterior to the
posterior tibialis m. tendon
Posterior tibial a.
Artery is palpable.
Just posterior to the flexor digitorum longus
m.
Just after medial malleolus, it divides into
Medial plantar a.
Lateral plantar a.
Posterior tibial vv.
Just posterior to the posterior tibial a.
Usually the artery is accompanied by 2
posterior tibial veins
Tibial n.
Just posterior to the posterior tibial vv.
Just after medial malleolus, it divides into
Medial plantar n.
Lateral plantar n.
In ID, its important to include the words
anterior or posterior when referring to the
tibial arteries and veins, but the tibial n. is just
called tibial n.
Test by asking patient to stand on
toes.
Flexor hallucis longus m.
The most posterior, near the Achilles tendon
A thicker muscle than flexor digitorum longus
m. because we use our big toe to push off
when we walk, responsible for the spring in
our step
Ankle
Ankle Jerk tests S1.
Medial malleolus
Anterior to the medial malleolus are the
Tibialis anterior tendon
Great saphenous v., drains the medial aspect
of the dorsal venous arch
Saphenous n., a branch of the femoral n.,
cutaneous innervation to the medial aspect of
the foot
Posterior to the medial malleolus, from most
anterior to posterior, are the
Posterior tibialis tendon
Flexor digitorum longus tendon
Posterior tibial a. and vv.
Tibial n.
Flexor hallucis longus tendon
All Covered by flexor retinaculum
Lateral malleolus
Posterior to the lateral malleolus are the
Peroneus longus tendon
Peroneus brevis tendon
Peroneal a.
Lesser saphenous v., drains the lateral aspect
of the dorsal venous arch
Sural n., cutaneous innervation to the lateral
aspect of the foot
Main foot invertors
Tibialis anterior, attaches to base of 1
st

metatarsal
Tibialis posterior, attaches to bottom of
navicular
Main foot evertors
Peroneus longus, attaches to base of 1
st

metatarsal
Peroneus brevis, attaches to base of 5
th

metatarsal
Main foot dorsiflexors
Tibialis anterior, attaches to base of 1
st

metatarsal
Main foot planar flexors: Supplied by Tibial
nerve from S1 and S3.
****** STAND ON S1 (PLANTERflexion)
and SIT ON S3 (Pudendal nerve)
Gastrocnemius: White muscle fibers
Less mitochondria, less
myoglobin, less hemoglobin so
it can be easily fatigued.
Soleus: Reb muscle fibers.
Fatigue resistant.
Mainly a walking muscle.
Has a lot of vinous sinusoids.
Tibialis posterior, attaches to bottom of
navicular
Foot
Cutaneous nerve supply to the foot
Lateral aspect of foot
Sural n.
Medial aspect of foot
Saphenous n.
Dorsal aspect of foot (except 1
st
dorsal web)
Superficial peroneal n.
1
st
dorsal web
Deep peroneal n.
Medial 3 toes
Medial plantar n.
Lateral 1 toes
Lateral plantar n.
Heel area: sensation by calcaneal branch of
tibial nerve.
Babinskis sign: Dorsiflexion of Toes;
Upper motor neuron lesion.
Normal in child below 2yrs of age.
Dorsal Foot
Deep peroneal n.
As a motor nerve, it innervates
All of the muscles of the anterior
compartment
2 intrinsic muscles of the dorsum of the foot
Extensor hallucis brevis m.
Extensor digitorum brevis m.
As a cutaneous nerve, it innervates the skin of
1
st
dorsal web space
Best seen in the 1
st
web space between the
big toe and 2
nd
toe
Superficial peroneal n.
Has NO motor function in foot
As a motor nerve, it innervates muscles of
the lateral compartment
As a cutaneous nerve, it innervates the skin
over the entire dorsum of the foot
EXCEPT the skin of 1
st
dorsal web space,
which is supplied by the deep peroneal n.
Seen branching over the dorsum of the foot
Dorsalis pedis a.
A continuation of the anterior tibial a.
Found between the tendons of Flexor
digitorum longus and Flexor hallucis
longus.
Seen between the 1
st
and 2
nd
metatarsals
It gives off a branch that pierces through the
1
st
dorsal interossei m. to form the plantar
arch, which is a very important source of
blood supply to the sole of the foot
Extensor hallucis brevis m.
ID by
Its muscle portion on top of the dorsum of
the foot between the tendons of extensor
hallucis longus and extensor digitorum
longus
Its tendon running to the big toe
Action: extends big toe
Extensor digitorum brevis m.
ID by
Its muscle portion on the dorsum of the foot
just lateral to and passing under the long
tendon of extensor digitorum longus m.
Action: extends all toes, except big toe
Plantar Foot
Orient yourself by looking for the
Big toe, which is medial
Little toe, which is lateral
You dont know have to know the attachment of
all the muscles on the sole of the foot, but you
should be aware of what the muscle are
Abductor hallucis m.
Runs along the medial aspect of the foot, from
the medial calcaneus to the medial big toe
Called the gateway to the sole since
everything that is important to the blood and
nerve supply of the sole of the foot must pass
under the abductor halluicis m.
Tom, Dick and A Very Nervous Harry are
seen running under abductor hallucis m.
when looking at the lateral view of the foot
Tibial n.
Divides into 2 nerves, seen when the abductor
hallucis m. is reflected on the lateral aspect of
the foot: medial plantar n. and lateral
plantar n.
Also gives off calcaneal branch that supplies
heel of foot.
Medial plantar n., off the tibial n.
Very similar to the median n. in the hand
Passes above the big flexor hallucis longus
tendon
As a motor nerve, it innervates 4 muscles
Flexor digitorum brevis m.
Flexor hallucis brevis m.
Abductor hallucis m.
1
st
medial lumbrical m.
As a cutaneous nerve, it innervates the medial
3 digits
Big toe to medial aspect of the 4
th
toe
If there is a pin in the medial aspect of the 4
th

toe, and you are asked to give the nerve
supply, you would say medial plantar nerve
Lateral plantar n., off the tibial n.
Very similar to the ulnar n. in the hand
As a motor nerve, it innervates all of the other
muscles on the sole of the foot
As a cutaneous nerve, it innervates the lateral
1 digits
Little toe to lateral aspect of the 4
th
toe
If there is a pin in the lateral aspect of the 4
th

toe, and you are asked to give the nerve
supply, you would say lateral plantar nerve
Lateral plantar a.
Runs near the lateral planter n.
A portion is seen lateral to the tendon of flexor
digitorum brevis, then it dives deep into the
foot to form the plantar arch
Medial plantar a.
Not as significantwont be tested
The muscle of the sole are divided into 4 layers
1
st
layer
Flexor digitorum brevis m.
Most superficial of the sole muscles, when
viewed from the bottom of the foot
Has 4 tendons going toward the toes
Abductor hallucis m.
Most medial of the sole muscles, running from
the medial calcaneus to the medial big toe
The gateway to the sole muscle
Abductor digiti minimi m.
Runs along the lateral aspect of the foot, from
the lateral calcaneus to the lateral little toe
2
nd
layer
To see this next layer, you have to reflect the
tendon of the flexor digitorum brevis m.
Flexor digitorum longus tendon
Runs just under the flexor digitorum brevis
tendon
Seen when the flexor digitorum brevis tendon
is reflected back
Quadratus plantae m.
A square muscle that attaches to the flexor
digitorum longus tendon near the heel
Runs from the calcaneus, and attached to the
posterolateral margin of the flexor digitorum
longus
Lumbrical mm.
4 tiny lumbrical muscles the lie between the
tendons of the flexor digitorum longus m.
Medial plantar n. innervates only the 1
st

(most media)l lumbrical muscle
Lateral planter n. innervates the other
lumbrical muscles
3
rd
layer
To see this next layer, you have to reflect the
tendon of the flexor digitorum longus m.
Flexor hallucis longus tendon
A big tendon running to the big toe
The broad flexor hallucis brevis m. is visible
underneath the tendon on both sides
Adductor hallucis m.
Has 2 heads that make the shape of the number
7
Transverse head, fibers run width-wise
across the foot
Oblique head, fibers run the length the foot
If there is a pin in this muscle and you asked
to be specific, you must ID it as the
transverse head or oblique head of the
adductor hallucis m.
If there is a pin in this muscle and there is no
request to be specific, you can ID the muscle
as adductor hallucis muscle
Flexor hallucis brevis m.
A broad muscle belly that passes to the big toe
Just lateral to the abductor hallucis m.
Flexor digiti minimi m.
A muscle belly that passes to the little toe
Just medial to the abductor digiti minimi m.
4
th
layer
To see this final layer of interossei muscles, you
have to look between the heads of the adductor
hallucis m.
You should know the actions and innervation
of the 2 sets of interossei muscles
Plantar interossei mm.
3 small muscles that run between the long
metatarsals 3-5
Action: adduct digits
PAD Plantars are for ADductions
Nerve: lateral plantar n.
3 plantar interossei mm.
1 on the 3
rd
toe
1 on the 4
th
toe
1 on the 5
th
toe
Dorsal interossei mm.
4 small muscles that run between the long
metatarsals 1-5, seen on the dorsal aspect of
the foot, NOT the sole
They are the dorsal complement of the plantar
interossei mm. on sole of the foot, but have
opposite action
Action: abduct digits
DAB Dorsals are for ABductions
Nerve: lateral plantar n.
4 dorsal interossei mm.
2 on each side of the 2
nd
toe
1 on the 3
rd
toe
1 on the 4
th
toe

Sustantaculum tali: Where talus sits on
calcaneous.
The tendon of flexor hallucius longus passes
under sustentaculum tali
The plantar calcaneonavicular ligament
(spring ligament) connects the sustentaculum
tali with the plantar surface of the navicular
bone. It provides major support for the
medial longitudinal arch of the foot.
The deltoid ligament is on the medial side of
the ankle--this ligament stabilizes the ankle
joint during eversion and prevents the ankle
from dislocating


Thorax
Thoracic Wall
Pectoralis major m.
Inserts into the lateral lip of the
intertubercular groove
Innervated by the lateral pectoral nn. (more
superior) and medial pectoral n., seen on the
dorsal aspect of the muscle
They are called lateral and medial not
because of their position, but because they
come off of the lateral cord or medial cord
So the pectoralis major m. is innervated by
both nerves
Pectoralis minor m. lies under the pectoralis
major m.
Innervated by the medial pectoral n. (more
inferior) which pierces through pectoralis
minor on its way to innervate pectoralis major
Medial is more (goes to 2 muscles), lateral is
less (goes to 1 muscle)
Pectoralis minor passes over the subclavian a.
and v.
Coracoid process, the bony beak-like process
of the scapula where pectoralis minor attaches.
Be aware of where this is on the scapula
Thus, the pectoralis minor m. helps stabilize
the scapula
To be able to ID these nerves in an exam, the
lab will have to show the lateral pectoral n.
coming off the lateral cord and the medial
pectoral n. coming off the medial cord, so look
for origins
The blood supply for the pectoralis mm. are the
pectoral branches of the thoracoacromial
trunk, which run on the underside of pectoralis
major
Thoracoacromial trunk can be IDd as the
thicker artery from which several smaller
arteries branch off
Serratus anterior m., attached directly to the
ribs in a saw-tooth pattern
Innervated by the long thoracic n., C5, C6,
C7 raise your arms to heaven
Lesion: winging of the scapula, loss of
protraction of the scapula
Deltopectoral groove, in between pectoralis
major and deltoid
Cephalic vein runs in the deltopectoral groove
Know where the cephalic vein starts and where
it drains
The cephalic vein starts on the lateral aspect of
the dorsal venous network of the hand and
drains into the axillary v.
Intercostal brachial n.
Comes through the thoracic wall in ICS 2, and
travels over towards the axilla
Its the lateral cutaneous branch of T2
Breastwont be tested
External aspect of the anterior wall
The muscles in the intercostals spaces
External intercostal mm.
Run downward and forward
Become membranous as they approach the
sternum (origin)
Internal intercostal mm.
Run upward and forward
Seen under the membrane of the external
intercostal mm., closer to the sternum (origin
is posterior)
Innermost intercostal mm. wont be tested
Inner aspect of the anterior wall
First orient yourself to see which end of the
thoracic wall is superior and which in inferior so
you can tell right from left accurately
Internal thoracic a. (lighter one), and next to it
is the internal thoracic v.
On either side of the sternum, seen on the
posterior surface
A branch of the subclavian a.
Gives significant blood supply to the breast
Gives of the anterior intercostal aa. in ICS 1-
6
Then divides at ICS 7 into a lateral branch and
a medial branch
Musculophrenic a. is the lateral branch,
which supplies ICS 7-9
Superior epigastric a. is the medial branch
Posterior intercostal aa. supplies ICS 10 and
11, comes directly off the thoracic aorta, no
anterior intercostals
Subcostal a., supplies under 12
th
rib, comes
directly off the thoracic aorta, no anterior
intercostals
Transversus thoracis m., attaches to 2
nd
-6
th

costal cartilages, depresses ribs
Lungs
You need to be able to ID a right lung from a
left lung, by looking at the hilum of the lung,
and a few other key features
Each lung has 10 bronchopulmonary
segments
The bronchopulmonary segments in the lobes of
the lungs
Right lung Left lung
Superior lobe 3 3
Middle lobe (rt) or
Lingula (lf)
2 2
Inferior lobe 5 5
If the lingula were tagged, and you were asked
How many pulmonary segments are there?,
you would say, two
You know its a left lung when you see
On the hilum side
The impression for the arch of the aorta and
descending thoracic aorta
If you saw pins in the arch of the aorta in
the exam, and you were asked What
formed this impression?, you would say
arch of the aorta, not just aorta
If you saw pins in the impression below the
arch, and you were asked What formed
this impression?, you would say
descending thoracic aorta
No eparterial bronchus
Pulmonary artery is above the pulmonary
bronchus, which is above the pulmonary
veins
Be able to ID the pulmonary artery and
pulmonary bronchus
Pulmonary veinswont be tested
On the anterior aspect, the left lung has 10
segments
Oblique fissure, dividing the lung into
A superior lobe, has 5 pulmonary
segments 1 & 2: apico posterior, 3:
anterior, plus sup lingular and inf lingular
of Lingula (4 & 5)
An inferior lobe, has 5 pulmonary
segments sup apical and 4 basal: absent,
anterior medial, lateral, & posterior
(NO horizontal fissure in left lung)
Cardiac impression at the base, formed by
the heart
Cardiac notch, along edge
Lingula, a little tongue-like process at the
end of the cardiac notch
Has 2 pulmonary segments
You know its a right lung when you see
On the hilum side
Eparterial bronchus
You have to say eparterial bronchus, not
just bronchus so that the examiner knows
that you know its the right lung
In the right lung, the eparterial bronchus is
above the pulmonary artery, which is above
the pulmonary veins
In the left Lung, arteries are superior to
the bronchus
On the anterior aspect, the right lung has 10
segments
Oblique fissure and horizontal fissure,
dividing the lung into
A superior lobe, has 3 pulmonary
segments apical, posterior, anterior
A middle lobe, has 2 segments lateral,
medial
An inferior lobe, has 5 pulmonary
segments superior apical and 4 basal:
medial, anterior, lateral, posterior

Oblique fissure: separates the lower lobe
from middle and upper lobe in right lung

Horizontal fissure: separates the middle lobe
from upper lobe in right lung.
Phrenic n., C3, C4, C5 keep the diaphragm
alive
Runs anterior to the lung root
Sole motor innervation to the diaphragm
Diaphragm refers pain to the T4 dermatome,
over the shoulders
Vagus n.
Runs posterior to the lung root

Irritation of tracheobronchal lymph nodes
will effect left recurrent laryngeal nerve coz
it is related to aorta, which is related to left
bronchus.

Thoracocentesis to be done @ Mid axillary
line in costodiaphragmatic recess @ level
intercostal space 9 @ TOP of RIB or
BOTTOM of the intercostals space.

Because of the oblique fissure, posterior
surface of LEFT lung and RIGHT lung is
made entirely of inferior lobe.
Heart
The first thing you should do is orient yourself
Look for the apex
If you see the large aorta and pulmonary trunk,
then you know you are looking at the anterior
surface
You need to know the coronary arteries and
cardiac veins, and which ones run with which
Apex, points to the left, a good orientation point
Ascending aorta
Pulmonary trunk, located just left of the aorta
Right coronary a., comes from the right
semilunar cusp of the aortic valve and runs in
the atrioventricular groove
SA nodal a., a small branch
Marginal a., a branch that runs along the
margin of the heart
Is accompanied by the small cardiac v.
Right marginal aint lying in coronary
sulcus
Posterior descend a. (PDA) or posterior
interventricular a.
Runs to the posterior aspect of the heart to
the apex
Supplies the posterior 1/3 of the
interventricular septum
The PDA usually comes from the right
coronary a., making the heart a right
dominant heart
If the PDA comes from the left coronary a.
via the circumflex a., the heart is a left
dominant heartabout 15%
If the left coronary a. is blocked in a left
dominant heart, you lose the entire blood
supply to the interventricular septum
The PDA is accompanied by the middle
cardiac v.
Left coronary a. comes from the left
semilunar cusp of the aortic valve, and quickly
divides into
Left anterior descending (LAD) or anterior
interventricular a.
Runs on the anterior surface of the heart in
the anterior interventricular groove
Supplies the anterior 2/3 of the
interventricular septum
Supplies the Apex of heart
Right ventricle receives blood from the
anterior interventricular artery
Runs to the apex where it anastomoses with
the PDA
The LAD is accompanied by the great
cardiac v.
Circumflex a., a large branch that runs under
the left auricle in the atrioventricular groove
Supplies the Apex of heart
Supplies Left ventricle, also mitral valve in
L. ventricle.
Supplies L. Atrium and ventricle
Coronary sinus
Wraps around the posterior aspect of the
atrioventricular groove
Drains into the right atrium
Drains all the veins of the heart EXCEPT the
small anterior cardiac veins which drain
directly into the right atrium
Great cardiac v. runs with the LAD
Middle cardiac v. runs with the PDA
Small cardiac v. runs with the marginal a.
wont be tested
Transverse pericardial sinus
Posterior to the aorta and pulmonary trunk
During coronary bypass surgery, after opening
the pericardial sac, the surgeons finger is
passed through the transverse pericardial sinus,
and a clamp is placed around the aorta and
pulmonary trunk to stop or divert the
circulation of blood while performing cardiac
surgery
Right atrium
Right auricle
Superior vena cava
Inferior vena cava
Crista terminalis, a ridge that separates the
sinus venarum (smooth area) from the
pectinate m. (rough area)
SA node (cant see), at the top of the rough area
AV node (cant see), at the bottom of the rough
area
Sulcus terminalis, the external aspect of the
crista terminalisnot on review list
Sinus venarum
The smooth part of atrial wall, formed by the
absorption of the right horn of the sinus
venosus
Pectinate m.
The rough part of atrial wall, formed from the
primitive atrium
Remember pectinate muscle is only found in
the atria, and trabeculae carneae is only found
in the ventricles
Fossa ovalis, looks like a flat thumbprint on the
atrial wall
A remnant of foramen ovale
Limbus ovalis is the ridge around the fossa
ovalis
If you see pins on the ridge, you should say
limbus ovalis
If you see pins on the flat thumbprint, you
should say fossa ovalis
Opening of the coronary sinus
Right ventricle
Trabeculae carneae, the muscular ridges of the
ventricle
Moderator band = septomarginal trabecula
Runs from the base of the septal wall to the
base of the anterior papillary muscle
Carries the right bundle branch of the AV
bundle
Anterior papillary m.
Posterior papillary and septal papillary
mm.wont be tested in the right ventricle,
too small
Chordae tendineae are strings that connect the
papillary m. to a cusp of the tricuspid valve
Tricuspid valve, between right atrium and right
ventricle
Infundibulum = Conus arteriosus is the
smooth-walled area that leads into the
pulmonary trunk
Pulmonary valve, a semilunar valve between
right ventricle and pulmonary trunk
Be able to ID the 3 cusps
Anterior cusp of pulmonary valve, more
lateral
Left cusp of pulmonary valve, more
posterior
Right cusp of pulmonary valve, more
anterior
Left atrium
Left atrium has nothing of any testing value in it
4 pulmonary veins enter its posterior wall
Left ventricle
Trabeculae carneae
Anterior papillary m. on the anterior wall
Posterior papillary m. , on the posterior wall
Right ventricle has 3 papillary muscles, one
per cusp of tricuspid valve
Left ventricle has 2 papillary muscles, one per
cusp of bicuspid valve
Chordae tendineae
Mitral valve = bicuspid valve, between left
atrium and left ventricle
Aortic valve, a semilunar valve, between the
left ventricle and aorta
Be able to ID the cusps
Posterior (noncoronary) cusp of aortic
valve, more lateral
Left cusp of aortic valve, more posterior
Right cusp of aortic valve, more anterior
Large vessels of the heart
Pulmonary trunk, from the right ventricle
Pulmonary arteries, from the pulmonary trunk
Ascending aorta, from left ventricle
4 pulmonary veins, drain into the left atrium
Superior vena cava, drains into the right atrium
Inferior vena cava, drains into the right atrium
Arch of the aorta, has great vessels that come
off it, from right to left they are the
Brachiocephalic a., which divides form the
right common carotid a. and right subclavian
a.
Left common carotid a.
Left subclavian a.
Mediastinum
Arch of the aorta
Begins and ends at T4
The great vessels that come off it, from right to
left are the
Brachiocephalic trunk
Left Common carotid a.
Left Subclavian a.
ABCS
Superior vena cava, ascends just right of the
ascending aorta, and divides into 2 branches
Right brachiocephalic v. extends upward
from the superior vena cava, passes to the
right, passing anterior to brachiocephalic trunk
Left brachiocephalic v. curves to the left
from the superior vena cava, passing anterior
to the aortic arch
The brachiocephalic veins are formed from the
Internal carotid v.
Subclavian v.
The point where these 2 veins meet is
called the venous angle
Right venous angle receives lymph from
right lymphatic duct
Left venous angle receives lymph from
thoracic duct
Trachea
Bifurcates into the main bronchi at T4
Anterior to esophagus
Bifurcation is posterior to right and left
pulmonary arteries, which are posterior to
right and left pulmonary veins
Esophagus, a muscular tube
Runs posterior to the trachea, in upper thorax
Runs anterior to the aorta, in lower thorax
Azygous system
Drains the veins of the posterior walls of the
thorax and abdomen, and mediastial,
esophageal, and bronchial veins
Azygous v.
Lies along the right posterior aspect of the
esophagus
Ascends posterior to right main bronchus, then
arches anteriorly over the bronchus to empty
into superior vena cava
The internal thoracic vein would provide a
collateral route for drainage if the azygos vein
was obstructed.
Forms a connection between the SVC and IVC
Formed from the joining of the
Right ascending lumbar vv.
Right subcostal v.
Left superior intercostal vv.
Drains the 1
st
3
rd
ICS on the left side
Drain into left brachiocephalic vein.
The right superior intercostals vein drains
into the azygos vein, which in turn drains
into the superior vena cava.
Accessory hemiazygous v.
Lies along the left side of the vertebral column
Drains T5-T8 on the left side
Hemiazygous v.
Inferior to accessory hemiazygous v., along
left side of vertebral column
Drains the inferior 3 posterior intercostal vv.,
T12-T9 on the left side
Crosses over to right and drains into the
azygous v. at T9
The accessory hemiazygous v. and hemiazygous
v. can only be seen when the aorta is pulled
strongly to the right, thus its a difficult area to
pin for ID
Thoracic duct lies posterior to the esophagus
Posterior to the esophagus, between the
azygous v. and descending thoracic aorta, a
duct between 2 gooses
A thin-walled, dull white duct, often beaded
because of numerous valves
Begins in the cisterna chyli = chyle cistern, a
dilated sac at the inferior end of the thoracic
duct, at the level of L1
Ascends through the aortic hiatus in the
diaphragm, at T12, along with
Aorta
Azygous vein
Crosses over to the left side around T4-5
Drains:
Everything below the diaphragm
Left upper quadrant above the diaphragm
Drains into the left venous angle
At the commencement of the left
brachiocephalic v.
Between the left internal jugular v. and left
subclavian v.
[Right lymphatic duct drains the right upper
quadrant into the venous angle on the right-
hand side]
Descending thoracic aorta, a large white artery
Descends along the left side of the vertebral
column
Lies posterior to the esophagus
Right phrenic n., C3, C4, C5
Goes through the diaphragm at the level of T8
along with the inferior vena cava via the vena
caval foramen
Right vagus n.
Branches to form the right recurrent laryngeal
n. part of the neck which we havent done
yet, so it wont be tested
Becomes the posterior vagal trunk, descends
along the lower lateroposterior aspect
esophagus, and passes through diaphragm at
T10 along with esophagus and left vagus n.
Left vagus n.
Passes anterior to the arch of the aorta
Branches to form the left recurrent laryngeal
n., which passes behind the ligamentum
arteriosum, and comes out behind the arch of
the aorta
If you dont ID it as the left, it will be
marked wrong
Becomes the anterior vagal trunk, and
descends along the lower lateroanterior aspect
esophagus, and passes through diaphragm at
T10 along with esophagus and right vagus n.
L.A.Left is Anterior
Esophageal plexus
Formed by the joining of the right and left
vagal nerves
Sits onto top of the esophagus
Ligamentum arteriosum
Remnant of the fetal ductus arteriosus
Joins the pulmonary trunk to the aortic arch
Left recurrent laryngeal n.
A branch of the left vagus n., CN X
Passes behind the ligamentum arteriosum
Goes under and behind the arch of the aorta
Runs in the tracheoesophageal groove
Supplies motor and sensory to the larynx
Sensory to the mucosa below the level of
the true vocal cords
Motor to
All muscles of the larynx EXCEPT
cricothyroid m., which is innervated by
the external laryngeal n.
Posterior cricoarytenoid m.one of the
most important muscles in the body
Its the only ABductor of the true vocal
cords, which makes it essential in
maintaining an open airway
Without the posterior cricoarytenoid m.,
the airway cannot open, cant breath
Note: Right recurrent laryngeal n. goes
under and behind the right subclavian a.
Clinical
An aneurysm of the arch of the aorta or lung
tumor can compress recurrent laryngeal n.
resulting in hoarseness and a possible degree
of stridor
Intercostal spaces have a vein, artery, and nerve
(in that order, VAN) running just inferior to the
ribs
Right/Left posterior intercostal nn., from
thoracic ventral rami
Right posterior intercostal aa.
Branches off the descending thoracic aorta
which lies to the left of the vertebral column
Must cross over the vertebral column from the
left, unlike the left posterior intercostal aa.,
which dont need to cross the vertebral column
Right posterior intercostal vv. drain into the
azygous v.
Left posterior intercostal vv. drain into the
Left superior intercostal vv.
Accessory hemiazygous vv.
Hemiazygous vv.
Sympathetic trunk or sympathetic chain
Runs along side the vertebral column on both
sides
Found on the posterior wall of the thorax,
lying on the heads of the ribs
Rami communicans are short branches that
connect the sympathetic chain to the
intercostal n.
In gross dissection, you cant tell which one
is gray or white
Greater splanchnic n., running from T5
T9/10
Any medial branch that you see coming from
the sympathetic trunk is going to be the greater
splanchnic n.
The greater splanchnic nerves contain
general visceral afferent (GVA) an
preganglionic sympathetic general visceral
efferent (GVE) fibers
Its the only splanchnic nerve you can see at
this level since the diaphragm/liver block the
viewing of the lesser splanchnic n. (T10-T11)
and least splanchnic n.
Subcostal m. is not high-yieldwont be tested
The 3 openings in the diaphragm
At T8, through the vena caval foramen
Inferior vena cava
Right phrenic n.
The left phrenic n. does NOT pass through a
foramen
At T10, through the esophageal hiatus
Esophagus
Anterior and posterior vagal trunks
Esophageal branches of the left gastric a.
At T12, through the aortic hiatus
Descending aorta
Azygous v.
Thoracic duct

The tubercle of a rib articulates with the
transverse process of the vertebra of the same
number
The head of the rib is the part of the
rib that articulates with the demifacets
of two adjacent vertebral bodies.
o Articulates w/ same # and one
above!!!!!