100 Concepts of Developmental and Gross Anatomy

Understand first, then memorize and apply
100 most important

D&GA conceptions
Edition 4.4
Dr. Mavrych MD PhD, Dr. Bolgova MD PhD
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

1. Early Embryology
Week 1: Beginning of Development
 Fertilization occurs in the ampulla
of the uterine tube with the fusion of
the male and female pronuclei to
form a zygote.
 During the first 4-5 days of the first
week, the zygote undergoes rapid
mitotic division (cleavage) in the
oviduct to form a morula before
entering the cavity of the uterus.
 Fluid develops in the morula,
resulting in a blastocyst that
consists of an inner cell mass the
embryoblast (becomes the
embryo) and the outer cell - the
trophoblast (becomes the
placenta) and then implantation
begins.

Ectopic Pregnancy
 The blastocyst normally implants within
the anterior or posterior walls of the
uterus.
 Ectopic tubal pregnancy is the most
common form. It usually occurs when the
blastocyst implants within the ampulla of
the uterine tube because of delayed
transport.
 Ectopic abdominal pregnancy typically
occurs in the rectouterine (Douglas)
pouch.
 Clinical signs: bleeding, abdominal pain
(may mimic appendicitis), last menses 60
days ago, positive pregnancy test, and
culdocentesis showing intraperitoneal
blood.

Week 2: Formation of the bilaminar
Embryo & Pregnancy testing
 The embryoblast differentiates into the
epiblast and hypoblast, forming a
bilaminar embryonic disk.
 The amniotic cavity and yolk sac form.
The prochordal plate marks the site of the
future mouth.
 Human Chorionic Gonadotropin hCG is
a glycoprotein, produced by the
syncytiotrophoblast, which stimulates
the production of progesterone by the
corpus luteum.
 hCG can be assayed in maternal urine at
day 10 and is the basis for early
pregnancy testing. hCG is detectable
throughout pregnancy.

Embryonic Weeks 3-8
 The critical events of the 3rd
week are gastrulation and
early development of the
nervous and cardiovascular
systems.
 Castrulation is the process that
establishes 3 primary germ
layers that derive from epiblast:
ectoderm, mesoderm, and
endoderm.
 Major organ systems begin to
develop during the embryonic
period (weeks 3-8), causing a
craniocaudal and lateral body
folding of the embryo.
 By the end of the embryonic
period (week 8), the embryo has
a distinct human appearance.

Smart table 1: Germ layers
Ectoderm Mesoderm Endoderm
Epidermis, hair, nails Muscles Epithelium of GI tract
Enamel of teeth Dermis of skin Epithelium of Respiratory
Parotid gland Bone, Cartilage system
Mammary glands Blood and lymph vessels Epithelium of Biliary
Neuroectoderm: Heart apparatus
All neurons CNS Adrenal cortex Epithelium of Urinary
Retina Spleen bladder, Urethra, Vagina
Neural crest: Kidney Liver
Adrenal medulla Testes, Ovaries Pancreas
All neural ganglia Dura mater Submandibular gland
Pia and arachnoid mater Sublingual gland
Aorticopulmonary septum Notochord: Thyroid
Endocardial cushions Nucleus pulposus Parathyroid

2. Lumbar puncture (tap) and
Epidural anesthesia
 When lumbar puncture is
performed, the needle enters
the subarachnoid space to
extract cerebrospinal fluid
(CSF) or to inject anesthetic
to epidural space.
 Remember, the spinal cord
may ends as low as L2 in
adults and does end at L3 in
children.
 The dural sac extends
caudally to level of S2.
 The needle is usually

inserted between L3/L4 or
L4/L5. Level of horizontal line
through upper points of
iliac crests.

3. Spine abnormalities
Herniated IV disc
 IV disc herniations typically occur in
lumbar (L4/L5 & L5/S1) or cervical regions
(C5/C6 & C6/C7). Herniations generally
affect individuals at 30-50 years old.
 Patients typically have history of back
pain that may radiate down to the lower
limb. The pain begins soon after patient
lifted some heavy thing.
 Herniated lumbar disc usually compresses
the nerve root one number below:
traversing root (e.g., the herniation L4/L5
will compress L5 root).
Lower limb reflexes are decreased on the

affected side:
 Patellar tendon reflex - herniation of IV
discs L2/L3 or L3/L4
 Achilles tendon reflex - herniation of
L5/S1

Abnormal curvatures of the spine
 Kyphosis is an exaggeration of the thoracic
curvature that may occur in elderly persons
as a result of osteoporosis or IV disk
degeneration.
 Lordosis is an exaggeration of the lumbar
curvature that may be temporary and occurs
as a result of pregnancy, spondylolisthesis
or potbelly.
 Scoliosis is a complex lateral deviation, or
torsion, that is caused by poliomyelitis, a
leg-length discrepancy, or hip disease.
 Osteoporosis is a age related process
characterized by a decrease in the density
of bone, decreasing its strength and
resulting in bones fractures (vertebral
bodies, hip and distal radius).

4. Upper limb fractures
Clavicle fractures
 Weakest part of clavicle -

junction of medial 2/3 and lateral
1/3 of the bone.
 The patient characteristically
supports the sagging limb with
the opposite hand.
 Subclavian vessels and trunks
of the brachial plexus are at risk
in fractures of the middle third,
because they lie behind only the
thin subclavius muscle.

Humerus fractures
Sites of potential injury to major nerves
in fractures of the humerus:
1. Axillary nerve and Posterior
humeral circumflex artery at the
surgical neck.
2. Radial nerve and profunda
brachii artery at midshaft.
Midshaft fracture affect origin of
Brachialis muscle.
3. Median nerve and Brachial artery
at the supracondylar region.
4. Ulnar nerve at the medial
epicondyle ("funny bone" ).

Fracture of distal radius
 Transverse fracture within the distal 2 cm of
the radius. Most common fracture of the
forearm (after 50).
 Smith's fracture results from a fall or a blow
on the dorsal aspect of the flexed wrist and
produces a ventral angulation of the wrist. The
distal fragment of the radius is ANTERIORLY
displaced.
 Colles' fracture results from forced extension
of the hand, usually as a result of trying to
ease a fall by outstretching the upper limb.
Distal fragment is displaced DORSALLY -
“dinner fork deformity”. Often the ulnar
styloid process is avulsed (broken off).

Scaphoid fracture
 Occurs as a result of a fall onto
the palm when the hand is
abducted (see the picture).
 Pain occurs primarily on the lateral
side of the wrist, especially during
wrist extension and abduction.
 Scaphoid fracture may not show on
X-ray films for 2 to 3 weeks, but a
deep tenderness will be present in
the anatomical snuffbox.
 The proximal fragment may
undergo avascular necrosis
because the blood supply is
interrupted.
 Radial artery and superficial
branch of the radial nerve are
structures at the greatest risk in
this fracture.

Boxer’s fracture
 Necks of the metacarpal bones
are frequently fractured during
fistfights.
 Typically, fractures of 2d and 3d
metacarpals are seen in
professional boxers, and
fractures of 5th and sometimes 4th
metacarpals are seen in unskilled
fighters.

Mallet or Baseball Finger
 This deformity results from the DIP joint suddenly being
forced into extreme flexion (hyperflexion) when, for
example, a baseball is miscaught or a finger is jammed
into the base pad.
 These actions avulse the attachment of the extensor
digitorum tendon to the base of the distal phalanx. As
a result, the person cannot extend the DIP joint. The
resultant deformity bears some resemblance to a mallet.

5. Shoulder dislocation
& Rotator cuff muscles (SITS)
 The glenohumeral joint is the
most frequently dislocated large
1
joint
 In anterior dislocation [2], (most
common) muscle traction usually
pulls the dislocated humeral head
into the subcoracoid position.
Rotator cuff [1] reinforces joint on all
sides except inferiorly, where
dislocation is most likely. SITS:
2
Greater tubercle
 Supraspinatus (abduction)
 Infraspinatus (supination) Right humerus

 Teres minor (supination)
Lesser tubercle
 Subscapularis (pronation)

6. Abduction of the upper limb
1. (0º-15º) Abduction of the upper extremity
is initiated by the supraspinatus muscle
(suprascapular nerve).
2. (15º-110º) Further abduction to the

horizontal position is a function of the
deltoid muscle (axillary nerve).
3. (110º-180º) Raising the extremity above

the horizontal position requires scapular
rotation by action of the trapezius
(accessory nerve CNXI) and serratus
anterior (long thoracic nerve).

Subacromial bursitis &
Tearing of supraspinatus tendon
 Subacromial bursitis (inflammation of the
subacromial bursa) is often due to calcific
supraspinatus tendinitis, causing a
painful arc of abduction.
 The same symptoms will be in case of
inflammation or trauma of the
supraspinatus tendon (MRI→ torn tendon)

7. 4 elbows:
Student's elbow
(Subcutaneous
olecranon bursitis)
 The olecranon, to which the
triceps tendon attaches distally,
is easily palpated. It is separated
from the skin by only the
olecranon bursa, which allows
the mobility of the overlying skin.
 Repeated excessive pressure
and friction may cause this bursa
to become inflamed, producing a
friction subcutaneous
olecranon bursitis.

Pulled elbow
(Dislocation of the
head of radius)
 In adults, the head of the radius
is not dislocated without tearing
the anular ligament.
 Young children are prone to

dislocation of the immature
head of the radius from the
encircling anular ligament, a
"pulled elbow," caused by
sudden traction on an extended
forearm.

Tennis elbow
(Lateral epicondylitis)
 Lateral epicondylitis: repeated forceful

flexion and extension of the wrist resulting
strain attachment of common extensor
tendon and inflammation of periosteum of
lateral epicondyle. Pain felt over lateral
epicondyle and radiates down posterior
aspect of forearm. Pain often felt when
opening a door or lifting a glass
 Origins of following muscles may be affected:

1. Extensor Carpi Radialis Longus
2. Extensor Carpi Radialis Brevis
3. Extensor Digitorum
4. Extensor Digiti Minimi
5. Extensor Carpi Ulnaris

Golfer’s elbow
(Medial epicondylitis)
 Medial epicondylitis is
inflammation of the
common flexor tendon
of the wrist where it
originates on the medial
epicondyle of the
humerus.
 Origins of following
muscles may be affected:
1. Pronator Teres
2. Flexor Carpi Radialis
3. Palmaris Longus
4. Flexor Carpi Ulnaris

8. Arterial anastomoses
around the scapula
 Blockage of the
Subclavian or Axillary
artery can be bypassed
by anastomoses
between branches of the
thyrocervical trunk
superiorly:
 Transverse cervical
 Suprascapular
and subscapular arteries

inferiorly:
 Subscapular
 Circumflex scapular

9. Cubital fossa
 Sites of venipuncture is usually
median cubital vein because:
 Overlies bicipital aponeurosis,
so deep structures protected
 Not accompanied by nerves
 Contents of cubital fossa from
lateral to medial:
1. Biceps brachii tendon
2. Brachial artery
3. Median nerve
 Subcutaneous structures from
lateral to medial:
1. Cephalic vein
2. Median cubital vein
3. Basilic vein

10. Carpal Tunnel Syndrome
 Results from a lesion that reduces
the size of the carpal tunnel (fluid
retention, infection, dislocation of
LUNATE bone).
 Median nerve – most sensitive
structure in the carpal tunnel and is
the most affected.
 Clinical manifestations:
 Pins and needles or anesthesia
of the lateral 3.5 digits
 palm sensation is not affected
because superficial palmar
cutaneous branch passes
superficially to carpal tunnel
 Apehand deformity - absent
of OPPOSITION

11. Test of the proximal (PIP) and
distal (DIP) interphalangeal joints
 PIP – Flexor digitorum

superficialis (FDS)
 DID - Flexor digitorum

profundus (FDP)

12. Lesion of UL nerves
Upper Brachial Palsy
 Injury of upper roots
and trunk
 Usually results from
excessive increase in
the angle between the
neck and the shoulder
stretching or tearing of
the superior parts of the
brachial plexus (C5 and
C6 roots or superior
trunk)
 May occur as birth
injury from forceful
pulling on infant's head
during difficult delivery

Upper Brachial Palsy
(Erb-Duchenne palsy)
 In all cases, paralysis of the muscles of the shoulder
and arm supplied by C5 and C6 spinal nerves (roots)
of the upper trunk.
 Combination lesions of axillary, suprascapular and
musculocutaneous nerves with loss of the shoulder
mm and anterior arm.
 As result patient has “waiter’s tip” hand:
 adducted shoulder
 medially rotated arm
 extended elbow
 loss of sensation in the lateral aspect of the
upper limb

Lower Brachial Palsy
(Klumpke paralysis)
 Injury of lower roots and
trunk
 May occur when the upper
limb is suddenly pulled
superiorly: stretching or
tearing of the inferior parts of
the brachial plexus (C8 and
T1 roots or inferior trunk)
 E.g., grabbing support during
falling from height or as a
birth injury, or TOS –
thoracic outlet syndrome

Lower Brachial Palsy
(Klumpke paralysis)
 All intrinsic muscles of the hand
supplied by the C8 and T1 roots of the
lower trunk affected.
 Combination lesions of ulnar nerve
(“claw hand”) and median nerve
(“ape hand”)
 Loss of sensation in the medial
aspect of the upper limb and medial
1,5 fingers.
 May include a Horner syndrome

Smart table 2: Nerves of the Upper limb
Nerve Innervated region Clinical sign
Axillary C5-6 Deltoid, teres minor and shoulder Lost of abduction
region’s skin
Musculocutane Flexors of the arm and skin of the Weakness of flexion &
ous C5-6 lateral forearm supination in elbow
Radial C5-T1 Extensors the arm, forearm and Wrist drop (lost of wrist
posterior skin of upper limb extension)
Median C5-T1 Flexors of the forearm (except 1.5*), Ape hand (lost of thumb
5** of the hand:3thenar + 2lumbricals opposition)
Ulnar C8-T1 Flexors of the hand (except 5**) and Claw hand (clawing
1.5* forearm (FDU + 0.5 FDP) digits 4 & 5)
Long thoracic Serratus anterior Winged scapula
Suprascapular Supraspinatus Pain & problems with
initiation of abduction

Cutaneus innervation of the hand
Palm sensation does not
In reality, in case of superficial
affected in case of the
branch of radial nerve lesion it will
carpal tunnel syndrome
be skin deficit between 1 & 2 digits
(superficial palmer branch
on the dorsum of the hand ONLY
come above of the
because of nerves overlapping
retinaculum).
Dorsum: 1.5=U and 3.5=R Palm: 1.5=U and 3.5=M

Important dermatomes
to know:
Upper limb
 C6 - Thumb
 C7 – Fingers 2-4
 C8 - Little finger
Trunk
 T4 – Nipple
 T7 – Xiphoid process
 T10 – Umbilicus
 L1 – Pubis
 Note: Dermatome is a
Lower Limb strip of skin innervated
 L4 - Big toe by one DRG (dorsal
 L5 - Toes 2-4 root ganglion)
 S1 - Little toe

13. Cardiac catheterization
 The femoral artery is
used for cardiac
catheterization
 It can be cannulated for

left cardiac angiography
& also for visualizing the
coronary arteries – a
long, slender catheter is
inserted percutaneously
and passed up the
external iliac artery,
common iliac artery,
aorta, to the left
ventricle of the heart

14. Injury of the gluteal region
Fractures of Femoral Neck
 A common fracture in elderly
women with osteoporosis is
fracture of the femoral neck.
 Fractures of the femoral neck
cause shortness and lateral
rotation of the lower limb.
 Fractures of the femoral neck
often disrupt the blood supply
to the head of the femur.
 At present time the best way in
case of femoral neck fracture is
hip replacement.

Avascular necrosis
of femoral head
 Transcervical fracture
disrupts blood supply to the
head of the femur via
retinacular arteries (from
medial circumflex femoral
artery) and may cause
avascular necrosis of the
femoral head if blood supply
through the ligament to the
head is inadequate.

Posterior hip dislocations
 They are most common. A head-on
collision that causes the knee to strike
the dashboard may dislocate the hip
when the femoral head is forced out of
the acetabulum.
 The joint capsule ruptures inferiorly and
posteriorly (fracture of ishium),
allowing the femoral head to pass
through the tear in the capsule (tearing
of ishiofemoral lig.) and over the
posterior margin of the acetabulum onto
the lateral surface of the ilium,
shortening and medial rotating the
limb.

Injury to sciatic nerve
 Weakened hip
extension and knee
flexion
 Footdrop (lack of
dorsiflexion)
 Flail foot (lack of both
dorsiflexion and plantar
flexion)
 Cause of injury:
caused by improperly
placed gluteal
injections but may
result from posterior
hip dislocation

Smart table 3: Nerves of the Lower limb
Nerve Innervated region Clinical sign

Femoral L2-4 Muscles and skin of the Lost of knee extension
anterior thigh
Obturator L2-L4 Muscles and skin of the Lost of thigh adduction
medial thigh
Tibial L4-S3 Muscles of posterior thigh Lost of plantar flexion, everted
(except 0.5*), leg and plantar foot
foot
Common fibular 0.5*- short head of biceps Foot drop, inverted foot
L4 – S2 femoris
Superficial Lateral leg muscles Inverted foot
fibular (evertors), skin of the dorsum
of the foot
Deep fibular Muscles of the anterior leg Foot drop
and dorsum of the foot
Superior gluteal Gluteus medius & minimus Trendelenburg sign
Inferior gluteal Gluteus maximus Problem with climbing stairs or
standing from a seated position

Trendelenburg sign
Normal Right
superior  The superior gluteal nerve may
gluteal nerve be injured during surgery,
injury posterior dislocation of the hip
or poliomyelitis.
 Paralysis of the gluteus medius
and gluteus minimus muscles
occurs so that the ability to pull
the pelvis up and abduction of
the thigh are lost.
Trendelenburg sign:
 If the superior gluteal nerve on
the right side is injured, the left
pelvis falls downward when the
patient raises the left foot off the
ground.
 Note that side is contralateral to
the nerve injury.

15. Avulsion fractures
of the hip bone and
hamstrings muscles
 Avulsion fractures occur
where muscles are
attached to ischial
tuberosity
Hamstrings muscles:
1. Biceps femoris
2. Semitendinosus
3. Semimembranosus
 Action: extension of hip
joint and flexion of knee
joint
 Nerve supply – Tibial
nerve (short head of biceps
femoris is supplied by the
common fibular nerve)

16. Structures under inguinal
ligament
From lateral to medial
side:
 Iliopsoas muscle
 Femoral nerve
 Femoral artery
 Femoral vein
 Femoral canal (ring)

Femoral hernia
Inguinal lig.
 A femoral hernia passes below

inguinal ligament through the femoral
ring into the femoral canal to form a
swelling in the upper thigh inferior and
lateral to the pubic tubercle
 The hernial sac may protrude through
the saphenous hiatus into the
superficial fascia
 A femoral hernia occurs more
frequently in females and is dangerous
because the hernial sac may become
strangulated
 An aberrant obturator artery is
vulnerable during surgical repair

Superficial veins of Lower Limb
Great saphenous vein [1]
 Arises from medial side of dorsal
venous arch of foot, passes anterior
to medial malleolus, and ascends on
medial side of leg adjacent to
saphenous nerve, then passes in
the medial side of the thigh and joint
with femoral vein.
Small saphenous vein [2]
 Arises from lateral side of dorsal
venous arch, passes posterior to
2 1 lateral malleolus, and ascends the
posterior leg adjacent to sural
nerve. It pierces popliteal fascia to
end in popliteal vein.

17. Knee joint injuries
Unhappy triad
 Because the lateral side of the

knee is struck more often (e.g.,
in a football tackle), the tibial
collateral ligament is the
most frequently torn ligament
at the knee.
 The UNHAPPY TRIAD of

athletic knee injuries involves:
1. Tibial collateral ligament
2. Medial meniscus
3. Anterior cruciate ligament

Tibial collateral ligament (medial
collateral ligament)
 Broad flat band extending

from medial epicondyle of
femur to medial condyle
and shaft of tibia
 Blends with capsule and
firmly attaches to medial
meniscus
 Limits extension and
abduction of leg at knee

Fibular collateral ligament (lateral
collateral ligament)
 Rounded cord between lateral

epicondyle of femur and head
of fibula
 Does NOT blend with joint
capsule and does NOT attach
to lateral meniscus
 Limits extension and adduction
of leg at knee

Rupture of cruciate ligaments
 With rupture of the anterior

cruciate ligament, the tibia
can be pulled forward
excessively on the femur,
exhibiting anterior drawer
sign.
 ACL attaches to the lateral
condyle of the femur.
 In the less common rupture of

the posterior cruciate
ligament, the tibia can be
pushed backward excessively
on the femur, exhibiting
posterior drawer sign.
 PCL attaches to the medial
condyle of the femur.

Prepatellar & Suprapatellar
bursas
 Prepatellar bursa: between
superficial surface of patella
and skin. May become
inflamed and swollen
(prepatellar bursitis).
 Suprapatellar bursa: superior

extension of synovial cavity
between distal end of femur
and quadriceps muscle and
tendon. Usual place for intra-
articular injections. May
become inflamed and swollen
(suprapatellar bursitis).

Knee jerk reflex
 The patellar reflex is

tested by tapping the
patellar ligament with
a reflex hammer to
elicit extension at the
knee joint. Both
afferent and efferent
limbs of the reflex
arch are in the
femoral nerve (L2-
L4).
 Knee jerk reflex:

tests spinal nerves
L2-L4.

18. Ankle joint injuries
Ankle sprains
 Sprains are the most common
ankle injuries
 A sprained ankle is nearly
always an INVERSION injury,
involving twisting of the weight-
bearing plantarflexed foot.
 The lateral ligament (anterior
talofibular ligament) is injured
because it is much weaker than
the medial ligament.
 In severe sprains, the lateral
malleolus of the fibula may be
fractured.

Pott’s fracture
 It is fracture-dislocations of
the ankle joint
 Reason - forced EVERSION
(abduction) of the foot
 The Deltoid ligament
avulses the medial
malleolus and after that
fibula fractures at a higher
level
Pott's fracture

19. Injures of the leg and foot
Fracture of the fibular neck
 May cause an injury to the common
peroneal nerve, which winds laterally
around the neck of the fibula.
 This injury results in paralysis of all
muscles in the anterior and lateral
compartments of the leg (dorsiflexors
and evertors of the foot) and loosing
sensation on the dorsum of the foot.
 Causing foot drop.

Rupture of the Achilles tendon
Triceps surae muscle
 Avulsion or rupture of the calcaneal

(Achilles) tendon disables Triceps surae
muscle so that the patient cannot plantar
flex the foot.
Triceps surae muscle:

 2 Heads of Gastrocnemius m.
 1 Head - Soleus muscle
 Plantaris
 small fusiform belly with long thin
tendon;
 sometimes may become hypertrophy

Ankle jerk reflex
 Achilles tendon reflex is

tested by tapping the
calcaneal tendon to elicit
plantar flexion at the ankle
joint.
 Both afferent and efferent
limbs of the reflex arc are
carried in the tibial nerve
(S1, S2).
 Ankle jerk reflex: tests spinal

nerves S1-S2.

Plantar Fasciitis
(calcaneal spur)
 Plantar fasciitis is the
most common hindfoot
problem in runners. It
causes pain on the
plantar surface of the
foot and heel.
 Point tenderness is
located at the proximal
attachment of the plantar
aponeurosis to the
medial tubercle of the
calcaneus and on the
medial surface of this
bone.

Injury of tibial nerve
 In popliteal fossa: loss of

plantar flexion of foot (mainly
gastrocnernius and soleus
muscles) and weakened
inversion (tibialis posterior
muscle), causing calcaneovalgus.
 Inability to stand on toes.
 Loss of sensation and paralysis

of intrinsic muscles of the sole of
the foot
 Popliteal fossa from superficial to
deep, contains:
 Tibial nerve
 Popliteal vein
 Popliteal artery

On sole of the foot there are two terminal
branches of tibial n:
 Medial plantar nerve supplies:
1. Abductor hallucis,
2. Flexor hallucis brevis
3. Flexor digitorum brevis
4. 1st lumbrical
 skin of medial 3.5 digits
 Lateral plantar nerve supplies:
 All intrinsic plantar muscles which are

not innervated by medial plantar nerve
 skin of lateral 1.5 digits

20. Breast & Thoracic wall
Intercostal spaces
Intercostal blood vessels
and nerves:
 run between the
internal intercostal and
innermost intercostal
muscles in the costal
groove
 arranged from superior
to inferior as vein,
artery, nerve
 Most vulnerable
structures – intercostal
nerve and posterior
intercostal artery
because they are not
covering by ribs.

Carcinoma of the Breast
 Carcinomas of the
breast are malignant
tumors, usually
adenocarcinomas
arising from the
epithelial cells of the
lactiferous ducts in the
mammary gland lobules
 As the cancer cells
grow, they attach to
suspensory
(Cooper‘s) ligaments,
and produce shortening
of the ligaments,
causing depression or
dimpling of the
overlying skin.

Lymphatic drainage of the breast
 It is important because
of its role in the
metastasis of cancer
cells.
 Most lymph (> 75%),
especially from the
lateral breast
quadrants, drains to
the axillary lymph
nodes, initially to the
anterior (pectoral)
nodes for the most
part.
 Most of the remaining
lymph, particularly from
the medial breast
quadrants, drains to the
parasternal lymph
75% 25% nodes or to the
opposite breast.

Mastectomy
 Radical mastectomy, a more extensive

surgical procedure, involves removal of the
breast, pectoral muscles, fat, fascia, and as
many lymph nodes as possible in the axilla
and pectoral region.
1. During a radical mastectomy, the long
thoracic nerve may be lesioned during
ligation of the lateral thoracic artery. A few
weeks after surgery, the female may present
with a winged scapula and weakness in
abduction of the arm above 90° because
serratus anterior m. paralysis.
2. The intercostobrachial nerve may also be
damaged during mastectomy, resulting in
skin deficit of the medial arm.

Breast infection
 Mastitis is an infection of the
tissue of the breast that occurs most
frequently during the time of
breastfeeding (1 to 3months after
the delivery of a baby).
 This infection causes pain, swelling,
redness, and increased
temperature of the breast.
 It can occur when bacteria, often
from the baby's mouth, enter a milk
duct through a crack in the nipple.
 It can occur in women who have not
recently delivered as well as in
women after menopause.

21. Diaphragm
Openings of the diaphragm
I 8 10 Eggs AAT 12
IVC (and right phrenic nerve)= 8

Esophagus and R + L vagus, esophageal br of Left gastric vessels = 10
Aorta, Azygos vein and Thoracic Duct = 12  Caval (T8): transmits
the IVC and the
terminal branches of
the right phrenic
nerve
 Esophageal (T10):
transmits the
esophagus, right and
left vagus nerves,
esophageal branches
of the left gastric
vessels
 Aortic (T12) transmits
the descending aorta,
thoracic duct,
azygos vein

Paralysis of the half of the
Diaphragm
 Paralysis of the half of

the Diaphragm may
result from injury or
operative division of the
phrenic nerve of same
side
 It can be detected
radiologically.
 Paradoxical
movement: dome of
diaphragm of injured
side pushed superiorly
by abdominal viscera
during inspiration instead
of descending

Phrenic nerve
 It arises from the anterior
primary rami of the C3-C5
nerves and lies in front of the
anterior scalene muscle.
 Phrenic nerve runs anterior to
the root of the lung, whereas
the vagus nerve runs
posterior to the root of the
lung.
 Innervates the fibrous
pericardium, the mediastinal
and diaphragmatic pleurae
(sensory innervation), and the
diaphragm for motor and its
central tendon for sensory.

Diaphragmatic ruptures
 Diaphragmatic injuries are
relatively rare and result from
either blunt trauma or
penetrating trauma.
 Presently, 80-90% of blunt
diaphragmatic ruptures result
from motor vehicle crashes.
 The majority (80-90%) of blunt
diaphragmatic ruptures have
occurred on the left side.
 Blunt trauma typically produces
large radial tears measuring 5-15
cm, most often at the
posterolateral aspect of the
diaphragm.

Congenital diaphragmatic hernia
 Hernia of stomach or
intestine through a
posterolateral defect in
diaphragm (foramen of
Bochadalek).
 It is seen in infants and

the mortality rate is high
because of left lung
hypoplasia.

Sliding hiatal hernia
 A sliding hiatal hernia, which

occurs in individuals past
middle age, is caused by the
hernia of cardia of the stomach
into the thorax through the
esophageal hiatus of the
diaphragm.
 This can damage the vagal

trunks as they pass through
the hiatus and resulting in
hyposecretion of gastric
juice.

22. Cardiac hypertrophy
 Left atrial enlargement
(hypertrophy) secondary
to mitral valve failure
may compress on the
ESOPHAGUS and
manifest as dysphagia
(difficulty in swallowing).
 It may be observed as a
filling defect in the
esophagus by barium
swallow on the lateral
thoracic X-Ray

X-ray of the Thorax (PA projection)
Cardiac Shadow
Right border is formed by:

1. SVC,
2. Right atrium
Left border is formed by:

1. Aortic arch
2. Pulmonary trunk
3. Left auricle
4. Left ventricle

23. Auscultation of heart
valves
Right 2 ICS Left 2 ICS
PSL PSL
Left 5 ICS Left 5 ICS

PSL MCL

Auscultation sites for
mitral and aortic murmurs
≈ 8%
≈ 90%
A heart murmur is heard downstream from the valve:

 stenosis is orthograde direction from valve
 insufficiency is retrograde direction from valve

24. Conducting system of the
heart Sinoatrial (SA) node

 site where contraction of heart muscle is
initiated (pacemaker of the heart)
 situated in the upper part of the sulcus
terminalis just near to the opening of
the SVC
 Atrioventricular (AV) node
 the AV node receives impulses from the
SA node; situated in the lower part of
the atrial septum near coronary sinus
 Atrioventricular bundle of His
 descends from the AV node to the
membranous portion of the ventricular
septum where it divides into the left and
right bundle branches
 Right bundle branch – passes down to
reach the moderator band - right
ventricle
 left bundle branch – passes down left
side of ventricular septum

25. Blood supply of the heart
Right coronary artery (RCA)
 It supplies major parts of the right
atrium and the right ventricle.
 It anastomoses with the marginal
branch of the left coronary artery
posteriorly
Branches:
1. Anterior cardiac branches –
supplies the right atrium
2. Nodal branch – supplies the (1) SA
node, (2) AV node
3. Marginal artery – supplies the right
ventricle
4. Posterior interventricular artery –
supplies (1) diafragmatic (inferior)
surface of both ventricles and (2)
posterior 1/3 of the IV septum

Left coronary artery
(LCA)
Branches:
1. Anterior (descending)
interventricular artery – most
common place of MI descends in the
anterior interventricular sulcus and
provides branches to the (1) anterior
heart wall, (2) anterior 2/3 of IV
septum, (3) bundle of His, and (4)
apex of the heart.
2. Circumflex artery – winds around the
left margin of the heart in the
atrioventricular groove to anastomose
with the right coronary artery
posteriorly; supplies the left atrium
and left ventricle

Blood supply of the conducting
system
 SA node – RCA
 AV node – RCA
 AV bundle (and moderator

band)- LCA

26. Supply of thoracic viscera
Smart table 4
THORAX
Artery: Internal thoracic & thoracic Aorta

Parasympathetic innervation:
•Preganglionic: DMN of Vagus nerves, CNX
•Postganglionic: Terminal gg.
Sympathetic innervation:
•Preganglionic: IML (T1-T4),
•Postganglionic: Sympathetic trunk T1-T4 ganglia,
Thoracic splanchnic nn.
Sensory Innervation: DRG T1-T4
Referred Pain: Left arm (MI)

2
27. Fetal circulation

 Fetal circulation involves 3 shunts:
1. Ductus venous 3
2. Ductus arteriosus
3. Foramen ovale
 After birth: 1
1. Closure of ductus venosus -
Ligamentum venosum
2. Closure of ductus arteriosus -
Ligamentum arteriosum
3. Closure of foramen ovale - Fossa ovale
4. Closure of umbilical arteries and
umbilical vein 4

28. Cardiovascular abnormalities
Atrial Septal Defect (ASD)
 It is less frequent than
VSD
 It results from failure to
close of the foramen
ovale after birth (failure of
the septum primum and
septum secundum to fuse)
 Postnatally, ASDs result
in left-to-right shunting
(between right and left
atrium) and are NON-
CYANOTIC conditions.
 If it is small, has no clinical
significance & if large -
necessary surgical repair

Ventricular Septal
Defect (VSD)
 Ventricular septal defect
(VSD) is the most common of
the congenital heart defects
 It may be found in the
membranous part of the
ventricular septum and
results from failure to fuse of
the membranous portion with
the muscular portion of the
ventricular septum
 In this case, present left–to-
right shunt (right ventricular
hypertrophy (RVH)) and
again NON-CYANOTIC.
 Necessary surgery for large
defects

Tetralogy of Fallot
It is congenital heart disease responsible
for about 9% of all cardiac defects.
 It is CYANOTIC heart disease (right-to-
left shunt) with the following
abnormalities:
1. Pulmonary stenosis (most important)

2. Overriding aorta (receives blood from
both ventricles)
3. Membranous interventricular septal
defect
4. Right ventricular hypertrophy
(develops secondarily)
 Surgical treatment is necessary

Patent Ductus Arteriosus (PDA)
 It results from failure of the ductus
arteriosus (a connection between the
pulmonary trunk and aorta) to constrict
and close after birth.
 Prostaglandin E and low O2 tension
sustain patency of the ductus arteriosus in
the fetal period.
 PDA is common in premature infants and in
cases of maternal rubella infection.
 Left –to-right shunt increased pressure in
pulmonary circulation (pulmonary
hypertension) and is NON-CYANOTIC
 Treatment: surgical division and ligation
imperative. In great danger is left recurrent
nerve (wrapping aorta arch). Injure of this
nerve results in hoarseness.

Coarctation of the Aorta
 It results from congenital
narrowing of the aorta distal to
the offshoot of the left subclavian
artery.
 Cardinal clinical sign: higher
blood pressure in the upper
limbs compared to the lower
limbs.
 Coarctation of the aorta results in
the intercostal arteries providing
collateral circulation between the
internal thoracic artery and the
thoracic aorta to provide blood
supply to the lower parts of the
body
 Coarctation of the Aorta
characteristic X-ray picture:
serrated appearance of inferior
borders of ribs (rib notching)

Thoracic aortic aneurysm
 Aneurysm of the aortic arch:
compresses the left recurrent
laryngeal nerve, leading to
coughing, hoarseness, and
paralys is of the ipsilateral vocal
cord. It may cause dysphagia
(difficulty in swallowing), resulting
from pressure on the esophagus,
and dyspnea (difficulty in
breathing), resulting from pressure
on the trachea, root of the lung, or
phrenic nerve
 Aneurysm of the thoracic aorta

may compress and tug on the
trachea with each cardiac systole
so that the aneurysm can be felt
by palpating the trachea at the
sternal notch (T2).

Abdominal aortic aneurysm
 It is a localized dilatation of the
aorta. It is typically happened
just above of the bifurcation at
level of L3 and crossed by 3rd
part of duodenum.
 Pulsations of a large aneurysm
can be detected to the left of the
midline at the umbilical region.
 Acute rupture of an abdominal
aortic aneurysm is associated
with severe pain in the abdomen
or back (mortality rate is nearly
90%).
 Surgeons can repair an
aneurysm by opening it and
inserting a prosthetic graft.

29. Bronchopulmonary
segments
Aspiration of foreign bodies
Aspiration of Foreign Bodies:
 Inhalation of FB’s (e.g. pins, parts
of teeth, screws, nuts, bolts, toys)
into the lower respiratory tract is
common, especially in children
 More likely to enter the right

primary bronchus and pass into
the middle or lower lobe bronchi
 If the vertical position of the body,

the foreign body usually falls into
the posterior basal segment of
the right inferior lobe.

Right lung:
10 bronchopulmonary segments
Superior lobe:
1. Apical
2. Anterior
3. Posterior
1
Middle lobe:
4. Lateral
5. Medial 3
2
Inferior lobe:
6 4
6. Superior
7. Anterior basal 8 5
8. Posterior basal
9. Lateral basal 10
10.Medial basal 9
7

Left lung:
9 bronchopulmonary segments
Superior lobe:
1. Apicoposterior
2. Anterior
3. Superior lingular
4. Inferior lingular
1
Inferior lobe:
5. Superior 2
6. Anterior basal
7. Posterior basal
3 5
8. Lateral basal
9. Medial basal 7
4
9 8

30. Lung diseases
Pneumonia
 Pneumonia is an inflammation of
the lung, caused by an infection or
chemical injury to the lungs.
 Three common causes are bacteria,
viruses and fungi.
 Symptoms: cough, chest pain,
fever, and difficulty in breathing.
 Chest X-rays: areas of opacity
(seen as white) of the lung
parenchyma and enlargement of
bronchomediastinal lymph nodes
(mediastinal widening).

Bronchogenic Carcinoma
 Arises in the mucosa of the large

bronchi
 Produces as persistent,
productive cough or
hemoptysis
 Early metastasis to thoracic
(bronchomediatinal) lymph
nodes
 Hematogenous spread to the
brain, bones, lungs, suprarenal
glands
 A tumor at the apex of the lung
(Pancoast tumor) may result in
thoracic outlet syndrome

Bronchogenic carcinoma
may lead to:
1
1. Thoracic outlet syndrome (TOS)
 It can cause pressure on the lower
trunk of the brachial plexus C8-T1 and
subclavian artery by cervical rib or
pancoast tumor. It results in pain
down the medial side of the forearm
and hand and atrophy of the intrinsic
hand muscles)
2. Horner syndrome:
2  miosis - constriction of the pupil due to
paralysis of the dilator pupillae muscle
 ptosis - drooping of the eyelid due to
paralysis of the superior tarsal muscle
 hemianhydrosis - loss of sweating on
one side

Bronchogenic carcinoma
may lead to:
3. Superior vena cava
syndrome, which causes
dilation of the head and
neck veins, facial swelling,
and cyanosis
4. Dysphagia as a result of
esophageal obstruction
5. Hoarseness as a result of
recurrent laryngeal nerve
involvement
6. Paralysis of the
3 diaphragm as a result of
phrenic nerve involvement

Lungs auscultation
 To listen to breath sounds of the
superior lobes of the right and left
lungs, the stethoscope is placed on
the superior area of the anterior chest
wall (above the 4th rib for the right
lung & above 6th for the left one).
 For breath sounds from the middle
lobe of the right lung, the
stethoscope is placed on the anterior
chest wall between the 4th and 6th
4 ribs
 For the inferior lobes of both lungs,
6 breath sounds are primarily heard
on the posterior chest wall.

31. Open pneumothorax
Pleura
 It is entry of air into a pleural
cavity causing lung collapse.
 Open pneumothorax – due to stab
wounds of the thoracic wall which
pierce the parietal pleura so that
the pleural cavity is open to the
outside air via the lung or through
the chest wall.
 Air moves freely through the
wound during inspiration and
expiration. During inspiration, air
enters the chest wall and the
mediastinum will shift toward other
side and compress the opposite
lung. During expiration, air exits
the wound and the mediastinum
moves back toward the affected
side.

Pleura & Pleural Cavity
 1. Cervical pleura may be affected in
case of improper subclavian
venipuncture (it results in
pneumothorax).
 2. Costodiaphragmatic recess is
deepest place in pleural cavity, around
the chest wall, there are two rib
interspaces separating the inferior limit
of parietal pleural reflections from the
inferior border of the lungs and visceral
8 pleura:
2 1. Midclavicular line - between ribs 6-8
2. Midaxillary line - between ribs 8-10 –
10 typical place for thoracocentesis
3. Paravertebral line between ribs 10-12

Nerve supply of the pleura
Parietal pleura – sensitive to general
sensibilities (pain, temperature, touch,
and pressure) - somatic sensory
innervation:
 costal pleura – intercostal nerves
block may be used to decrease
thoracic pain
 mediastinal pleura – phrenic nerve
 diaphragmatic pleura – phrenic nerve
over the domes and lower 6 intercostal
nerves around the periphery
Visceral pleura – sensitive to stretch but

insensitive to general sensibilities;
autonomic nerve supply from the
pulmonary plexus

32. Mediastinum
Superior mediastinum
 The sternum is a
common site for
bone marrow
biopsy.
 Improperly done
sternal puncture
may affect
structures related to
the posterior
surface of the
manubrium
sternum:
1. In upper part –
Left brachio-
cephalic vein
2. In lower part –
Aortic arch

Thoracic duct
 Function – conveys to the

blood all lymph from the lower
limbs, pelvic cavity,
abdominal cavity, left side of
the thorax, left side of the
head & neck, and left upper
limb (3/4 of the body)
Tributaries – at the root of the

neck
 Left jugular lymph trunk
 Left subclavian lymph trunk
 Left bronchomediastinal
lymph trunk

Constrictions of the esophagus
1 There are sites where ingested
foreign bodies can lodge or
where strictures may develop
following ingestion of caustic
fluids, common sites of
esophageal carcinoma
2 1. C6 - where the pharynx joins

the upper end (6" from the
upper incisors)
2. T4-T5 - where the aortic arch
and left main bronchus cross
its anterior surface (10" from the
upper incisors)
3 3. T10 - where it passes through
the diaphragm into the
stomach (16" from the upper
incisors)

33. Anterior abdominal wall
1. The liver and gallbladder are in
the right upper quadrant;
2. The stomach and spleen are in

the left upper quadrant;
3. The cecum and appendix are

in the right lower quadrant;
4. The end of the descending

colon and sigmoid colon are in
the left lower quadrant.

Referred abdominal pain
 Pain arising out of the

foregut derived structures is
referred to the epigastric
region.

midgut derived structures is
referred to the umbilical
region.

hindgut derived structures is
referred to the hypogastric
region.

Nerve supply of the
anterior abdominal wall
 Therefore totally 7 nerves:
lower 5 intercostals, 1
subcostal and L1
(iliphypogastric and
ilioinguinal) nerves supply the
anterior abdominal wall.
 L1 can be anaesthetized by
injecting 1 inch (2.5 cm)
superior to the anterior
superior iliac spine.
 All nerves and deep blood
vessels lie in the
neurovascular plane:
between internal oblique and
transversus muscles

Arterial supply of the anterior
abdominal wall
Important SUPERFICIAL
ARTERIES (supply skin)
are:
1. Superficial epigastric
2. Superficial circumflex iliac
Important DEEP ARTERIES lie

in the neurovascular
plane:
1. Superior epigastric
2. Posterior intercostals
arteries
3. Lumbar arteries
4. Deep circumflex iliac artery
5. Inferior epigastric

Body Wall Defects
 Omphalocele - involves
herniation of abdominal viscera
through an enlarged umbilical
ring. Viscera are covered by
amnion.
 Gastroschisis - is a herniation
of abdominal contents through
the body wall directly into the
amniotic cavity. Viscera are not
covered by peritoneum or
amnion

34. Herniations
Hernia consist of 3 parts:
1. Hernial sac is a pouch
1 (diverticulum) of
peritoneum and has a
2 neck and a body
2. Hernial contents may
3 consist of any structure
found in the abdominal
cavity (more often –
loops of small
intestine and piece of
omentum major)
3. Hernial coverings are
formed from the layers
of the abdominal wall
through which the
hernia sac passes

Transversalis fascia is the FIRST STRUCTURE which is
crossed by ANY abdominal hernia
Indirect inguinal
hernia [1]
Normal: between Tunica

vaginalis & Internal
spermatic fascia

Indirect inguinal hernia
 Indirect inguinal hernia is the most
common form of hernia and is believed
to be congenital in origin (boys 0-3
years).
 It passes through the deep inguinal ring
lateral to the inferior epigastric
vessels, inguinal canal, superficial
inguinal ring and descend into the
scrotum.
 An indirect inguinal hernia is about 20
times more common in males than in
females, and nearly 1/3 are bilateral.
 It is more common on the right
(normally, the right processus vaginalis
becomes obliterated after the left; the
right testis descends later than the left).

Direct inguinal hernia
 Direct inguinal hernia composes about
15% of all inguinal hernias.
 During a direct inguinal hernia, the
abdominal contents will protrude
through the weak area of the posterior
wall of the inguinal canal medial to the
inferior epigastric vessels in the
inguinal [Hesselbach's] triangle and
after that through superficial inguinal
ring. It never descends into the
scrotum.
 It is a disease of old men (after 60
years old) with weak abdominal
muscles. Direct inguinal hernias are
rare in women, and most are bilateral.

35. Peritoneal structures
Lesser omentum
 Lesser omentum consists of
2 ligaments:
1. hepatogastric
2. hepatoduodenal
Contents :
 Right & Left gastric vessels
 Connective and fatty tissue
and PORTAL TRIAD:
1. Bile duct
2. Portal vein
3. Proper hepatic artery

Epiploic (Winslow’s) foramen
 Anteriorly: The free

border of the
hepatoduodenal
ligament, containing
portal triad (DVA).
 Posteriorly: IVC
 Superiorly: Caudate
lobe of the liver.
 Inferiorly: The 1st part

of the duodenum

Douglas (rectouterine) pouch
 Rectouterine pouch (pouch

of Douglas): deeper point of
peritoneal space in vertical
position of the female body
between the rectum and the
cervix of uterus.
 It is space of the pelvic
abscess location.

Culdocentesis
 Culdocentesis is
aspiration of fluid from
the cul-de-sac of Douglas
(rectouterine pouch) by a
needle puncture of the
posterior vaginal fornix
near the midline between
the uterosacral ligaments
 Because the rectouterine

pouch is the lowest
portion of the female
peritoneal cavity, it can
collect inflammatory fluid
(pelvic abscess).

36. Derivates from primitive
gut
Smart table 5
FOREGUT MIDGUT HINDGUT
Esophagus Duodenum (2nd, 3rd, 4th Transverse colon (distal

Stomach parts) 1/3)
Duodenum (1st and 2nd Jejunum Descending colon
parts) Ileum Sigmoid colon
Liver Cecum (with Appendix) Rectum (anal canal
Pancreas Ascending colon above pectinate line)
Biliary apparatus Transverse colon
Gallbladder (proximal 2/3)

FOREGUT MIDGUT HINDGUT
Artery: CA Artery: SMA Artery: IMA
Parasympathetic Parasympathetic Parasympathetic

innervation: innervation: innervation:
•Preganglionic: DMN of Preganglionic: DMN of Preganglionic: SPN S2-
vagus nerves, CNX vagus nerves, CNX S4, Pelvic spl. nn
•Postganglionic: •Postganglionic: •Postganglionic:
Terminal gg. Terminal gg. Terminal gg.
Sympathetic Sympathetic Sympathetic
innervation: innervation: innervation:
•Preganglionic: IML T5- •Preganglionic: IML T10- •Preganglionic: IML L1-
T9, Greater spl. nn T11, Lesser spl. nn L2, Lumbar spl. nn
•Postganglionic: •Postganglionic: •Postganglionic:
Celiac ganglion Superior mesenteric g. Inferior mesenteric g.
Sensory Innervation: Sensory Innervation: Sensory Innervation:
DRG T5-T9 DRG T10-T11 DRG L1-L2
Referred Pain: Referred Pain: Referred Pain:

Epigastrium Umbilical Hypogastrium

37. Posterior gastric ulcer
1. Posterior gastric ulcer may

erode through the posterior wall
of the stomach into the
omental bursa (lesser
peritoneal sac) and affect
pancreas resulting in referred
pain to the back.
2. Erosion of splenic artery is

very common in posterior
gastric ulcers as well because
of the proximity of the artery to
this wall.

38. Meckel's diverticulum
 Meckel's diverticulum is a congenital anomaly
representing a persistent portion of the
vitellointestinal duct (connection from the midgut to
the yolk sac incorporated into the umbilical cord,
normally degenerates at 2-3 months of gestation).
 This condition is often asymptomatic but occasionally
becomes inflamed if it contains ectopic gastric,
pancreatic, or endometrial tissue, which may
produce ulceration.
 Meckel's diverticulum is located on the Ileum about 2

feet (61 cm) before the ileocecal junction and SMA
supply it. It occurs in 2% of patients and is about 2
inches (5 cm) long.
 The diverticulum is clinically important because
diverticulitis, liberation, bleeding, perforation, and
obstruction are complications requiring surgical
intervention and frequently mimicking the symptoms
of acute appendicitis.

39. Features of the large
intestine
Features of the large intestine:
1. Appendices epiploic
2. Sacculations (haustrations)
3. Taeniae coli
 The taeniae coli meet
together at the base of the
appendix where they form a
complete longitudinal muscle
coat for the appendix.

Colon
 The ascending colon lies
retroperitoneally and lacks a
mesentery.
 It is continuous with the
transverse colon at the right
(hepatic) flexure (1) of colon. 1
 The transverse colon (3) has 3
its own mesentery called the
transverse mesocolon
(intraperitoneal position).
 It becomes continuous with the
descending colon at the left
(splenic) flexure (2) of colon. 4
 The sigmoid colon (4) is
suspended by the sigmoid
mesocolon (intraperitoneal
position).

40. Appendicitis
 In appendicitis, first pain is referred
around the umbilicus. Visceral
pain in the appendix is produced by
distention of its lumen or spasm of
its muscle.
 The afferent pain fibers enter the
spinal cord at the level of T10
segment, and a vague referred
pain is felt in the region of the
umbilicus (T10 dermatome).
 Later if parietal peritoneum gets

involved, and then the pain is
shifted laterally to the Mc Burney’s
point. Here the somatic pain is
precise, severe, and localized
(second pain)

Mc Burney's point
 This point indicates the
surface marking of the base of
the appendix.
 Mc Burney's point [1] is a
point at the junction between
the lateral 1/3 and medial 2/3
of a line joining the right
anterior superior iliac spine
with the umbilicus.
 Retrocecal is
the most
1 common
position of
appendix [2].
2

41. Volvulus
 Because of its extreme mobility (long

mesentery), the Jejunum (1), Ileum
(2) and Sigmoid colon (3)
sometimes rotates around its
mesentery.
 Volvulus results in avascular
necrosis corresponding part of
intestine.
 This may correct itself
spontaneously, or the rotation may
continue until the blood supply of the
gut is cut off completely.

42. Hirschsprung's Disease
 It is a rare congenital abnormality that
results in intestinal obstruction
(megacolon) because of congenital
absents of postganglionic
parasympathetic neurons (terminal
ganglia, Myenteric plexus) inside of
the wall of the large intestine.
 Reason is defective migration or
differentiation of neural crest cells.
 It is commonly found in Down
Syndrome children.
 In a newborn, the chief signs and
symptoms are failure to pass a
meconium stool within 24-48 hours
after birth, reluctance to eat, bile-
stained (green) vomiting, and
abdominal distension.
 Treatment is removal of the
aganglionic portion of the colon.

43. Branches of Abdominal
aorta and Mesenteric ischemia
 Celiac trunk (CA) originates
from the aorta at the lower
border of T12 vertebra
 Superior mesenteric artery
originates at the lower border of
L1 vertebra
 Renal arteries originate at
approximately L2 vertebra
 Inferior mesenteric artery
originates at L3 vertebra
 Two terminal branches are
common iliac arteries at the
level of L4 vertebra

CELIAC ARTERY (TRUNK)
 Origin: T12, just below the

aortic opening of the
diaphragm.
1
 The CA passes above the
superior border of the
pancreas and then divides
into three retroperitoneal
3
branches:
2  Left gastric artery (1)
 Common hepatic artery (2)
 Splenic artery (3)

Left gastric artery
2  The left gastric artery (1)
courses upward to the left to
reach the lesser curvature of
the stomach and may be
3 subject to erosion by a
penetrating ulcer of the
lesser curvature of the
1 stomach.
Branches:
 Esophageal branches (2) - to
the abdominal part of the
esophagus
 Gastric branches (3) supply
the left side of the lesser
curvature of the stomach and
make anastomosis with right
gastric artery.

Common hepatic artery
 The common hepatic artery
(1) passes to the right to
reach the superior surface of
2 the first part of the duodenum,
1 where it divides into its two
terminal branches:
 Proper hepatic artery (2)
 Gastroduodenal artery (3)
3

Proper hepatic artery
 Proper hepatic artery (1) gives
off right gastric artery (2) and
5 then ascends within the
4
hepatoduodenal ligament of the
lesser omentum to reach the
3
porta hepatis, where it divides
into the right (4) and left (3)
hepatic arteries.
 The right and left arteries enter the
two lobes of the liver, right
1
2 hepatic artery gives cystic artery
(5) to the gallbladder.
 Right gastric artery (2) supplies
the right side of the lesser
curvature of the stomach where it
anastomoses the left gastric
artery.

Gastroduodenal artery
 Gastroduodenal artery (1)
descends posterior to the first
part of the duodenum (may be
subject to erosion by a
penetrating ulcer in this place)
and divides into two branches:
1  Right gastroepiploic artery (2)
(supplies the right side of the
greater curvature of the
2 stomach where it anastomoses
the left gastroepiploic)
 Superior pancreaticoduodenal
arteries (3) (supply the head of
the pancreas, where they
3 anastomoses the inferior
pancreaticoduodenal arteries
from the SMA).

Ligature of the hepatic artery
1. The hepatic artery [1] may
2 be ligated proximal to the
origin of its gastroduodenal
branch, a collateral
circulation to the liver is
established through the left
and right gastric arteries,
left and right
gastroepiploic and
gastroduodenal arteries.
1 2. The right hepatic artery
may be mistakenly ligated
during holecystectomy in
Calot triangle [2] together
with the cystic artery,
right lobe hepatic
necrosis commonly
occurs.

Splenic artery
 Splenic artery (1) runs a
tortuous horizontal course to
the left along the upper border
of the pancreas, behind the
peritoneum of the posterior
wall of the lesser sac, forming a
part of the stomach bed.
1  The splenic artery may be
subject to erosion by a
penetrating ulcer of the
posterior wall of the stomach
into the lesser sac.
 Note: Splenic vein runs a more

straight course below the artery
and behind of the pancreas.

Splenic artery
 Splenic a. (1) is retroperitoneal
5 until it reaches the tail of the
pancreas, where it enters the
1 2 splenorenal ligament to enter
the hilum of the spleen.
3 4 Branches:
 Branches to the spleen (2)
 Branches to the neck, body, and

tail of pancreas (3)
 Left gastroepiploic (4) artery that
supplies the left side of the
greater curvature of the stomach
where it anastomoses the right
gastroepiploic
 Short gastric (5) branches that
supply fundus of the stomach

7
1
6 SMA
branches
2  (1) Inferior
pancreaticoduodenal
arteries
4  (2)Jejunal and (3) Ileal
branches
 (4) Ileocolic artery
 Ascending branch
 Anterior cecal artery
 Posterior cecal artery
 (5) Appendicular
artery
 (6) Right colic artery
3  (7) Middle colic artery
5

1
IMA Branches:
 (1) Left colic artery
 (2) Sigmoid arteries
 (3) Superior rectal artery
 Note: The branches of the SMA

3 and IMA to the colon are
interconnected by a continual
arterial arch - marginal artery of
Drummond. It provides a
collateral circulation between
the parts of the large intestine to
2 prevent mesenteric ischemia.

Mesenteric ischemia
 Atherosclerosis, which slows the
amount blood flowing through arteries, is
a frequent cause of chronic mesenteric
ischemia.
 Ischemia occurs when blood cannot flow
through arteries as well as it should, and
intestines do not receive the necessary
oxygen to perform normally. Mesenteric
ischemia usually involves SMA and
small intestine.
 Mesenteric ischemia primarily affects
organs which locate far away from
anastomoses with CA & IMA. Usually
blood supply of the Jejunum and Ileum
is most compromised.
 Mesenteric ischemia typically occurs in
people older than age 60 with history of
smoking and high cholesterol level.

44. Biliary system & gallstones
 Bile is secreted by the liver cells,
stored, and concentrated in the
gallbladder and later it is delivered
to the duodenum.
 The Gallbladder lies in it’s fossa on
the visceral surface of the liver right
side of quadrate lobe.
 It stores and concentrates bile,
which enters and leaves it through
the Cystic duct.
 The cystic duct joins the Common
hepatic (from Left and Right
hepatic) due to form the Common
bile duct

Biliary system
 The Common bile duct (part of

portal triad) descends in the
hepatoduodenal ligament, then
passes posterior to the first part of
the duodenum.
 It penetrates the head of the
pancreas where it joins the main
pancreatic duct and they form the
hepatopancreatic ampulla, which
terminated by sphincter of Oddi.
 It drains into posteromedial wall
the second part of the duodenum at
the major duodenal papilla

Cholelithiasis (gallstones)
 The distal end of the hepato-pancreatic

ampulla (Common bile duct ) is the
narrowest part of the biliary passages
and is the MOST COMMON SITE for
impaction of gallstones.
4 1  As result of common hepatic (1), bile
duct (2), or duodenal papilla (3)
obstruction patient will have yellow
(icteric) sclera and jaundice.
2
 Gallstones may also lodge in the cystic
3 duct. A stone lodged in the cystic duct
(4) causes biliary colic (intense,
spasmodic pain in the gallbladder) but
doesn't produce jaundice.

Gallstones
 The fundus of the gallbladder is in
contact with the transverse colon [1]
and thus gallstones erode through the
posterior wall of the gallbladder and
enter the transverse colon. They are
passed naturally to the rectum through
the descending colon and sigmoid 2
colon.
 Gallstones lodged in the body of the

gallbladder may ulcerate through the
posterior wall of the body of the 1
gallbladder into the duodenum [2]
(because the gallbladder body is in
contact with the duodenum) and may be
held up at the ileocecal junction,
producing an intestinal obstruction.

Nerve supply of the liver
and gallbladder
 Sensory innervation of the liver: by the right

PHRENIC nerve (C3-C5). Pain may radiate to
the right shoulder.
 The liver receives parasympathetic innervation

from the vagi nerves (CNX), reaching it through
the celiac plexuses around the supplying arteries.
The preganglionic fibers synapse on the cells of
the terminal ganglia in hilum of the liver and shot
postganglionic fibers supply organs.
 Sympathetic fibers of preganglionic neurons

T5-T9 segments (IML) come through the
sympathetic trunk and form greater splanchnic
nerves. They contribute to the celiac plexus,
where postganglionic neurons are located.
Branches of celiac plexus reach the liver wrapping
around the branches of the celiac artery.

45. Portal Hypertension &
Portocaval shunts
 Portal hypertension is a common
clinical condition, and for this
reason portal-systemic
anastomoses should be
remembered.
 [1] Extrahepatic portocaval

shunt for the treatment of portal
hypertension: the splenic vein
may be anastomoses to the left
renal vein after removing the
spleen.
 [2] Intrahepatic portocaval

shunt: between portal vein and
hepatic veins

Large intestine metastases &
Portocaval anastomosis
 Metastases of the large intestine
cancer typically reach the liver via
portal venous system: intestine -
IMV - Splenic vein - Portal vein -
Liver
 If there is an obstruction to flow
through the portal system (portal
hypertension), blood can flow in a
retrograde direction and pass
through anastomoses to reach the
caval system. Sites for these
anastomoses include:
 (1) esophageal veins
 (2) paraumbilical veins
 (3) rectal veins

Esophageal anastomosis
 Anastomosis between the

tributaries of the left gastric vein
(portal vein) and the tributaries of
the azygous vein (SVC) in the
wall of the lower end of the
esophagus.
 In portal hypertension these veins

enlarge in the wall of the
esophagus and later burst into
the lumen of the esophagus
(esophageal varices) resulting in
hematemesis (vomiting red
blood).

Umbilical anastomosis
paraumbilical veins (portal vein)
and the superior and inferior
epigastric veins (SVC and IVC)
in anterior abdominal wall around
the umbilicus.
 In portal hypertension, this
anastomosis becomes enlarged
and dilated veins form “caput
Medussae” around the
umbilicus.

Rectal anastomosis
superior rectal vein (inferior
mesenteric vein and then
portal vein) and inferior
rectal vein which drains into
the internal iliac vein (from IVC
system).
 In portal hypertension (chronic
alcoholics) this anastomosis
becomes dilated resulting in
internal hemorrhoids and
bleeding per anus from
superior rectal vein.

46. Pancreas
Head and uncinate process
 The head of the pancreas
rests within the C-shaped
area formed by the
duodenum and is traversed
by the common bile duct.
 It includes the uncinate

process which is crossed by
the superior mesenteric
vessels.

Pancreatic adenocarcinoma
 Cancer of the head of the pancreas
compresses the bile duct and results in
OBSTRUCTIVE TYPE OF JAUNDICE.
 Pain will be conveyed to sensory neurons T5-
T9 dorsal root ganglia via celiac plexus
and greater splanchnic nerve. To provide
pain relief, during the surgery ablation of the
sensory innervation that carries pain in this
region may be performed by injection 50%
ethanol around celiac artery.
 This type of jaundice is NOT usually
associated with fever.
 Hepatitis also causes jaundice but is
associated with fever.

Neck of the pancreas
 Posterior to the neck

of the pancreas is the
3
1 site of formation of the
PORTAL VEIN.
 (1)Splenic vein joins

2 with (2) superior
mesenteric vein to
form (3) portal vein.

Body of the pancreas
 The body passes to the left

and anterior to the (1) aorta
and the (2) left kidney.
1
 The (3) splenic artery
3
undulates along the superior
border of the body of the
pancreas with the splenic
vein coursing posterior to
2 the body.

Tail of the pancreas
 The tail of the pancreas
enters the splenorenal
ligament to reach the hilum
of the spleen.
 It is the only part of the
pancreas that is
intraperitoneal.
 Tail of the pancreas may be
mistakenly removed during
spleenectomy (ligation of
splenic artery and vein) and
resulting in sugar diabetes
because it contains a lot
endocrine cells.

Arterial supply of the pancreas
Head and Duodenum:
 (1) Superior
pancreaticoduodenal arteries -
branches of gastroduodenal
artery.
 (2) Inferior pancreaticoduodenal
arteries - branches of SMA
 This region is important for
3 collateral circulation because
there are anastomoses between
1 these branches of the CA and
SMA.
2
Neck, Body, and Tail of the
pancreas:
 Pancreatic branches of the (3)
Splenic artery.

Annular Pancreas
 Annular pancreas is caused by
malformation during the development of
the pancreas, before birth.
 Occurs when the ventral and dorsal
pancreatic buds form a ring around the
duodenum, thereby causing an
obstruction of the duodenum and
polyhydramnios
 Symptoms:
1. Feeding intolerance in newborns

2. Fullness after eating
3. Nausea and bile-stained vomiting
 Half of cases are not diagnosed until
symptoms occur in adulthood.

47. Spleen
Rupture of the Spleen
 Rupture of the spleen may be result
of the left 9th and 10th ribs fracture
or blunt trauma of the left upper
abdomen.
 The spleen is a peritoneal organ in
the upper left quadrant that is deep
to the left 9th, 10th, and 11th ribs.
 The spleen follows the contour of rib
10 (axis of the spleen).
 When blood collected deep to the
diaphragm phrenic nerve irritates
and pain may irradiate to left
shoulder.
 When spleen is ruptured, it cannot be
sutured therefore removing is
required.

Relations of the Spleen and Left
Kidney
 The spleen follows the
contour of 10th rib and
extends from the
superior pole of the left
kidney to just posterior
to the midaxillary line.
 The border between

spleen and upper pole
of the left kidney is 11th
rib.

48. Kidneys
Dimensions and position
 During life, kidneys are
reddish brown and measure
approximately 11-12 cm in
length, 5-6 cm in width, and
2.5-3 cm in thickness.
 They are extending from the
level of T12 to the level of
L3, the right kidney lying
about 2-3 cm lower than
the left one.
 The lateral border of the
kidney is convex. Its medial
border is convex at both
ends but concave in the
middle where there is the
hilum of the kidney (L1).

Anterior relations of the right
kidney
1. Right suprarenal gland

2. 2nd part of the duodenum
3. Right lobe of the liver
4. Right colic flexure
5. Small intestine

Anterior relations of the left
kidney
1. Left suprarenal gland

2. Stomach
3. Spleen
4. Body of pancreas and
splenic vessels
5. Descending colon
6. Small intestine

Renal (Gerota) fascia
 Enclosing the perinephric fat is a
membranous condensation of the
extraperitoneal fascia - the renal
fascia (3).
 The suprarenal glands (4) are
also enclosed in this fascial
4 compartment, usually separated
from the kidneys by a thin septum.
 Note: The renal fascia must be

3 incised in any surgical
approach to this organ.

Perinephric abscess
 Most infections of the perinephric

space occur as a result of extension
of an ascending urinary tract
infection, commonly in association
with nephrolithiasis or
tuberculosis.
 Perinephric abscess typically
descends down between 2 sheets
of the renal fascia along the psoas
major muscle.
 In case of an abscess located
behind of the psoas major muscle it
descends down and may affect
hip joint.
 If abscess spreads up it’ll reach the
diaphragm and irritate phrenic
nerve. As result patient will feel
pain in shoulder region.

49. Nephrolithiasis
Staghorn calculi
 Renal calculi are solid concretions (crystal
aggregations) formed in the kidneys from dissolved
urinary minerals.
 If stones grow to sufficient size before passage (at
least 2-3 mm), they can cause obstruction of the
ureter (renal colic).
 Renal stone that develops in the renal pelvis and
greater calices, and in advanced cases has a
branching configuration which resembles the antlers
of a stag.
 Staghorn calculi are composed of magnesium
ammonium phosphate, which forms in urine that
has an abnormally high pH (above 7.2).
 This high pH usually develops because of recurrent
urinary tract infection with microorganisms such as
Proteus mirabilis.

Horseshoe and Pelvic kidney
 [1] Horseshoe kidney

(usually normal renal
function,
1 predisposition to
calculi) is a fusion of
both kidneys at their
ends and failure of the
fused kidney to ascend.
 The horseshoe kidney
hooks under the
origin of IMA.
2  [2] Pelvic kidney is
caused by a failure of
one kidney to ascend.

50. Ureters
3 constrictions of ureter
1  Ureter located on the anterior

surface of the Psoas major
muscle and has 3 constrictions:
 1st constriction is at the
pelviureteric junction (level of L1)
 2d constriction lies at the level of
pelvic brim (level of the sacroiliac
joint)
 3d constriction appears where
ureter lies obliquely in the wall of
2 urinary bladder (level of ischial
spine)

51. Suprarenal glands
 They are endocrine glands
having cortex and medulla.
 The adrenal cortex [1]
secretes corticosteroids:
Aldosterone, Hydrocortisone
and Genital hormones.
 The chromaffin cells of the adrenal medulla [2] secrete two

1 catecholamines: Epinephrine and Norepinephrine, which
affect smooth muscle, cardiac muscle, and glands in the
same way as sympathetic stimulation.
2
 Sympathetic stimulation or hypersecretion of
catecholamines (tumor of adrenal medulla or
sympathetic chain ganglia) resulting in episodes of
tachycardia, sweating and high blood pressure.

Unpaired tributaries of IVC
 The right renal (1) vein is
much shorter than the left.
3 Both veins lie anterior to the
corresponding artery in hilum of
kidneys.
2
 The long left renal vein (2) is
joined by the left suprarenal
1 (3) and left gonadal (4)
4 (testicular or ovarian) veins
before it reached IVC.
 Right suprarenal vein and

right gonadal vein drain
directly to IVC (unpaired IVC
tributaries).

52. Varicocele
 It is enlargement of the
pampiniform plexus that
produces a wormlike scrotal
mass and enlargement of the
spermatic cord. Varicocele
may be reason of low sperm
count.
 Varicocele formation is
usually on the left side and
may disappear in supine
position of the body.
 Varicocele may indicate
kidney disease or may
signal a retro peritoneal
malignancy obstructing the
testicular vein.

Pampiniform plexus
 Each testicular or ovarian vein is

formed by coalescence of a
pampiniform plexus: the
testicular at the deep inguinal
ring, the ovarian at the margin of
the superior aperture of the pelvis.
 The veins run accompanied by the
corresponding arteries. The left
pampiniform plexus enters the
left renal vein; the right one
enters directly the IVC inferior to
the renal vein.
 That is why varicocely
(engorgement of the pampiniform
plexus that produces a scrotal
mass) is more often located on the
left.

53. Hydrocele
 The tunica vaginalis testis or
remnants of the processus
vaginalis of peritoneum may form
a hydrocele.
1. Hydrocele in spermatic cord it is
smooth sausage-like structure
that persists under compression
and doesn’t disappear in supine
position.
2. In the scrotum (communicating
hydrocele) with transillumination,
it produces a reddish glow,
whereas light will not penetrate
other scrotal masses such as a
hematocele, solid tumor, or
herniated bowel. Testis is pressed
by tunica vaginalis against the
internal spermatic fascia.

54. Hemorrhoids
 Hemorrhoids are masses that typically
protrude from ANUS during defecation.
2  External hemorrhoids are dilated tributaries
of the INFERIOR rectal veins [1] (IRV)
BELOW the pectinate line and are PAINFUL
because the mucosa is supplied by somatic
afferent fibers of the inferior rectal nerves (from
pudendal).
 Internal hemorrhoids are dilated tributaries of
1 the SUPERIOR rectal veins [2] (SRV)
ABOVE the pectinate line and are NOT
PAINFUL because the mucosa is supplied by
visceral afferent fibers. It frequently develops
in chronic alcoholics because of liver
cirrhosis and portal hypertension syndrome.

55. Perineal pouches
Deep perineal pouch
The deep perineal pouch is
formed by the fasciae and
muscles of the urogenital
diaphragm.
It contains:
1.Sphincter urethrae muscle
2.Deep transverse perineal
muscle
3.Bulbourethral (Cowper)
glands (in the male only) -
ducts perforate perineal
membrane and enters
bulbar urethra.

Superficial perineal pouch
1. Ischiocavernosus muscle – related to the Crus of the penis
(Male) & Crus of the clitoris (Female)
2. Bulbospongiosus muscle – related to the Bulb of vestibule
(Female) & Bulb of the penis (Male)
3. Superficial transverse perineal muscle – related to the Perineal
body (both genders)
1

Urine leaks
 After a crushing blow or a
penetrating injury, the spongy
urethra commonly ruptures
within the bulb of the penis, and
urine leaks into the superficial
perineal pouch.
 The superficial perineal fascia
keeps urine from passing into the
thigh or the anal triangle, but after
distending the scrotum and penis,
urine can pass over the pubis
into the anterior abdominal wall
deep to the deep layer of
superficial abdominal fascia.

56. Ischiorectal abscess
 Ischiorectal abscess [1] is an important

surgical condition which usually results from
2 spread of an infection through the external
sphincter ani into the ischiorectal fossa [2].
 Ischiorectal abscess is a surgical emergency
which should be immediately drained by a
wide cruciate incision through the skin of the
base of the fossa to avoid fistula formation.
3  A surgeon should avoid lateral wall of
ischiorectal fossa because here located
Pudendal (Alcock's) canal [3] with pudendal
nerve and internal pudendal artery.

57. Urinary Bladder
Cystocele (hernia of bladder)
 Loss of bladder support in
females by damage to the
pelvic floor (levator ani m.)
during childbirth (e.g.,
laceration of perineal
muscles or a lesion of the
nerves supply).
 It can result in protrusion of
the bladder onto the
anterior vaginal wall and
loss of urine when a women
strains or coughs.

Patent urachus
•A patent urachus (distal portion of allantois) needs to be surgically removed.
•The main sign is leakage of urine through the umbilicus.
There are 3 main anatomical

cases:
A. Urachal fistula: there is
free communication between
the bladder and umbilicus;
B. Urachal cyst: there is no
connection between the
bladder and the umbilicus
C. Urachal sinus: the pouch
opens toward the umbilicus

Paracentesis of urinary bladder
Suprapubic aspiration:
 Urine can be removed from the

bladder without penetrating the
peritoneum by inserting a needle
JUST ABOVE the pubic
symphysis.
 The needle passes successively
through skin, superficial and deep
layers of superficial fascia, linea
alba, transversalis fascia,
extraperitoneal connective tissue,
and wall of the bladder.

58. Urogenital System
Development Smart table 6
Adult Female Embryo Adult Male
Ovary Gonads Testes
Uterine tubes, uterus,
Paramesonephric ducts
cervix and upper part of
Mullerian
vagina
Epididymis, ductus
Mesonephric ducts
deferens, seminal
Wolfian
vesicle, ejaculatory duct
Glans and body of
Clitoris Phallus
penis
Labia minora Urogenital folds Ventral aspect of penis
Labia majora Labioscrotal swellings Scrotum

Hypospadias & Epispadias
 Hypospadias occurs when the
urethral folds fail to fuse
completely, resulting in the
external urethral orifice opening
onto the ventral surface of the
penis. It is generally associated
with a poorly developed penis
that curves ventrally, known as
chordee.
 Epispadias occurs when the

external urethral orifice opens
onto the dorsal surface of the
penis. It is generally associated
with exstrophy of the bladder.

59. Prostate tumors
Prostate cancer
 It usually begins in the posterior

lobe of the gland, and early
stages are often asymptomatic,
may be found during digital
rectal examination.
 Prostatic malignancies tend to

metastasize to vertebrae and the
brain because the prostatic
venous plexus has numerous
connections with the vertebral
venous plexus via sacral veins.
M
A
P

Benign hypertrophy of the
prostate (BHP)
 BHP is common in men after
middle age.
 Prostate adenoma (benign
hypertrophy) usually involves
median lobe.
 BHP is a common cause of
urethral obstruction, leading
to nocturia (need to void during
the night), dysuria (difficulty
and/or pain during urination),
and urgency (sudden desire to
void).
 The prostate is examined for
enlargement and tumors by
DIGITAL RECTAL
examination.

Prostatectomy
 A prostatectomy may be performed
through a suprapubic [1] or perineal
[2] incision or transurethrally [3].
 Because of damage to nerves in the
capsule of the prostate and around the
1 urethra (cavernosus nerves) can
2 cause impotence (erectaile
dysfunction) and/or urinary
incontinence.
 Pelvic splanchnic nerves may be
injured in case of intensive dissection
of pelvic lymph nodes (prostatic
3 cancer ectomy) and as result
autonomic innervation of derivate of
Transurethral hindgut may be affected.
resection of the
prostate = TURP

60. Male urethra
 Prostatic part is the widest and the
most dilatable part. Openings of the 2
ejaculatory ducts are seen on each
side on the seminal colliculus.
 Membranous part is in urogenital
diaphragm surrounded by the external
sphincter. It is the shortest, narrowest
part. Bulbourethral glands [1] lie
posterolateral to this part inside of
urogenital diaphragm (deep perineal
pouch)
 Spongy (penile) part (longest) passes
through the bulb and corpus
1 spongiosum of the penis. There are
two dilatations – bulbar fossa (in the
beginning) and navicular fossa (in the
glans penis). Ducts of the bulbourethral
glands open into the bulbar fossa.

2 sphincters of the urethra
1. Internal urethral sphincter

is made of smooth
muscles in the neck of the
bladder and has
sympathetic innervation
1 2. External urethral
sphincter has skeletal
muscle fibers and
2 surrounds the
membranous part of
urethra, supplied by the
perineal branch of the
pudendal nerve

61. Ejaculatory duct
 It is a very narrow duct 2

cm long
 Formed by union of
ductus deferens and
duct of seminal vesicle
 It serve to passage of
seminal fluid from
ductus deferens to
prostatic urethra.

62. Pudendal nerve (S2-S4)
 It is PRINCIPAL SOMATIC (motor and
sensory) nerve to supply perineum.
 Lies against ischial spine as it passes
through lesser sciatic foramen to traverse
pudendal canal on lateral wall of
ischiorectal fossa.
Branches:
 1. Inferior rectal nerve
 Supplies external anal sphincter
muscle and skin around anus
 2. Perineal nerve
3  Deep branch is motor nerve to
1 muscles of urogenital triangle.
 Superficial branch gives cutaneous
2 posterior scrotal/labial branches.
 3. Dorsal nerve of penis or clitoris
 Supplies body, prepuce, and glans of
penis or clitoris

Pudendal nerve block
 To relieve pain for the mother and

1 prepare for an episiotomy, a
pudendal nerve block may be
administered during early labor.
The nerve may be blocked in 2 ways
either:
1. by piercing the vaginal wall
posterolaterally near the ischial
spine or
2. percutaneously along the medial
side of the ischial tuberosity.
2
 Note: Pain from uterine

contractions is unaffected because
pelvic visceral pain is carried by
afferent fibers accompanying
autonomic nerve fibers.

63. Supply of pelvic viscera
Smart table 7
PELVIS
Artery: Internal iliac

Parasympathetic innervation:
•Preganglionic: Sacral parasympathetic n. (S2-S4), pelvic
splanchnic nerves
•Postganglionic: Terminal gg.
Sympathetic innervation:
•Preganglionic: IML (T12-L2), sacral splanchnic nerves.
•Postganglionic: Inferior hypogastric plexus
Sensory Innervation: DRG S2-S4 (with pelvic splanchnic nerves)

Referred Pain: Groin

Micturition reflex
Facilitating emptying:
 Parasympathetic fibers (pelvic
1 splanchnic nn.) stimulate
DETRUSOR MUSCLE [1] contraction
and involuntary relax internal
sphincter [2].
 Somatic motor fibers (pudendal
2
nerve) cause voluntary relaxation of
external [3] urethral sphincter.
Inhibiting emptying:
3  Sympathetic fibers (sacral
splanchnic nn.) inhibit detrusor
muscle [1] and stimulate internal
sphincter [2].

64. Erection and ejaculation
 Afferent fibrous: Dorsal nerve of penis or clitoris from
Pudendal nerve (DRG S2-S4)
 Efferent fibrous:
 Erection: Parasympathetic fibers (S2-S4) from the Pelvic
splanchnic nerves dilate arteries supplying erectile
bodies of the penis, allowing them to fill with blood.
Somatic motor (S2-S4) fibrous from the pudendal nerves
cause contraction of ischiocavernosus and
bulbospongiosus muscles to press the root of the penis
and relax external urethral sphincter.
 Ejaculation: Sympathetic fibers (L1-L2) from the Inferior
hypogastric plexus (Sacral splanchnic nerves) cause
contraction of smooth muscle of epididymis, ductus
deferens, seminal vesicles, and prostate; sympathetic nerve
fibers stimulate internal urethral sphincter to prevent
semen from entering bladder or urine entering prostatic
urethra.

65. Incontinence
 Weakness of the puborectalis

part of the levator ani muscle
may result in rectal incontinence.
 Weakness of the external

sphincter urethrae muscle in the
urogenital diaphragm may result
in urinary incontinence.

66. Cryptorchism
 Undescended testes
(cryptorchism) when the testes fail
to descend into the scrotum. This
normally occurs within 3 months
after birth.
 The undescended testes may be
found in the abdominal cavity or in
the inguinal canal.
 If neglected, malignant
transformation may occur in the
undescended testis.
 Note: In case of cryptorchism,

spermatogenesis is arrested and
the spermatogenic tissue is damaged
leading to permanent sterility in
bilateral cases.

67. Torsion of the spermatic
cord
Main components of the spermatic
cord:
 Ductus deferens
 Testicular artery – direct branch
of Aorta
 Pampiniform plexus to become
single testicular vein (right → IVC,
left → Left renal vein)
 Torsion of the spermatic cord

produces acute pain with swelling
because of twisting of testicular
artery that can result in testicular
avascular necrosis.
 Repair requires a high scrotal
incision to untwist the cord, and
the testis is sutured to the scrotal
septum to prevent recurrence.

68. Lymphatic drainage
of the male viscera
 Testis & epididymis – lumbar lymph
nodes
 Scrotum – superficial inguinal nodes
 Penis:
 skin - superficial inguinal nodes
 glans – deep inguinal nodes
 body and roots – internal iliac
nodes
 Prostate gland & bladder - internal
iliac nodes
 Anal canal:
 above pectinate line - internal iliac
 below pectinate line - superficial
inguinal nodes

Lymphatic drainage from the
female viscera
 Ovary and uterine tubes – to Lumbar
lymph nodes
 Uterus:
 lateral angle and teres ligament –
Superficial inguinal lymph nodes
 fundus and upper part of the body
- Lumbar lymph nodes
 lower part of the body - External
iliac lymph nodes
 cervix - External & Internal iliac
 Vagina:
 Superior to hymen - to External &
internal iliac
 Inferior to hymen - to Superficial
inguinal nodes
 All external genitalia (with exception -
glans clitoris) - Superficial inguinal
lymph nodes
 Glans clitoris – Deep inguinal

69. Arterial supply of the
uterus and Hysterectomy
The uterus is almost exclusively
supplied by the uterine arteries [1]
4 (from internal iliac artery):
 Uterine a. crosses pelvic floor in
2
cardinal ligament [2]
1  Ureter passes posterior and inferior
to the uterine artery [3]
3  Ascending branch [4] of uterine
artery comes along lateral wall of
uterus within broad ligament.
Note: During hysterectomy ureter in the

greatest risk because of close relations
with uterine artery and cervix of the
uterus.

Hysterectomy
 Hysterectomy is surgical removing of the uterus and
may include removing of the cervix (total) and the
vagina (radical).
 Blood supply to the ovaries is saved in case of partial

hysterectomy ovarian suspensory ligament should
be left intact because contain ovarian artery (direct
branch of abdominal aorta) and vein.
 In case of total hysterectomy (with cervix) pelvic

splanchnic nerves may be affected. That results in
bladder dysfunction because of detrusor urine
muscle loose parasympathetic innervation.

70. Parts of the uterine tube
 Uterine part
 Pierces uterine wall to
open into uterine cavity
 Isthmus
 Narrowest part of tube
just lateral to uterus
 Ampulla
 Medial continuation of
infundibulum comprising
about half of uterine tube
 Usual site of fertilization
 Infundibulum
 Funnel-shaped expansion
of lateral end, fringed with
fimbriae
 Overlies ovary and
receives oocyte at
ovulation

Hysterosalpingography
 The instillation of
3 viscous iodine
4
through the
external os [1] of
the uterine cervix
2 allows the lumen of
the cervical canal
1 [2], the uterine
cavity [3], and the
different parts of the
uterine tubes [4] to
be visualized on X-
ray.

Anterior Division
71. Branches of the 1. Obturator
Internal iliac artery 2. Umbilical
3 Inferior gluteal
4. Internal pudendal
5. Inferior vesical (males)

or
Vaginal (females)
6. Middle rectal
7. Uterine (females ONLY)
Posterior Division
1. Iliolumbar
2. Lateral sacral
3. Superior gluteal

72. Skull & Scalp
Cranial Malformations
 [A] Scaphocephaly: premature closure
of the sagittal suture, in which the
anterior fontanelle is small or absent,
results in a long, narrow, wedge-shaped
cranium.
 [C] Oxycephaly: premature closure of the
coronal suture results in a high, tower-
like cranium.
 When premature closure of the coronal or
the lambdoid suture occurs on one side
only, the cranium is twisted and
asymmetrical, a condition known as
plagiocephaly [B].

Layers of the scalp
 1. Skin - sebaceous cysts

 2. Dense Connective tissue - superficial
scalp
lacerations do not gape and result in
severe bleeding
 3. Aponeurosis (Epicranial) - lacerations
throw 3 superficial layers gape widely
because of contraction frontalis and
occipitalis parts of occipitofrontalis muscle
 4. Loose areolar tissue - dangerous area
of the scalp. It contains potential spaces
capable of being distended with fluid
resulting from injury or infection
 5. Pericranium - Bleeding between
pericranium and calvaria during a difficult
birth results in cephalhematoma
(typically limited by borders of parietal
bone)

73. Cranial fosses
Anterior cranial fossa:
 contains Frontal lobe [1]
1
 dura matter is supplied by V1 and 2
anterior meningeal a. (from ethmoidal
3
a.)
Middle cranial fossa:
 contains Temporal lobe [2]
 dura matter is supplied by V2 & V3 and

middle meningeal a. (from maxillary a.)
Posterior cranial fossa:
 contains Cerebellum [3]
 dura mater is supplied by spinal nerves

(via CNX & CNXII) and posterior
meningeal aa. (from ascending
pharyngeal and occipital aa.)

74. Fracture of the
anterior cranial fossa
 Fracture of the anterior cranial fossa
(Cribriform plate of the Ethmoid bone)
is suggested by anosmia, periorbital
bruising (raccoon eyes), and CSF
leakage from the nose (rhinorrhea).

75. Epidural hematoma
 Skull fracture near pterion often
causes epidural hematoma from torn
middle meningeal artery (foramen
spinosum).
 Unconsciousness and death are
rapid because the bleeding dissects
a wide space as it strips the dura
from the inner surface of the skull,
which puts pressure on the brain.
 An epidural hematoma forms a
characteristic biconvex pattern on
computed tomography images.

76. Cavernous sinus infection
Dangerous triangle of the face
 The middle third of the face is a
"danger area“ because infection
2 there may produce thrombophlebitis
of the facial (angular) vein [1] that
3 can spread to the cavernous sinus
via superior ophthalmic vein [2]:
Facial vein - Superior ophthalmic vein
- Cavernous sinus.
 Septicemia leads to meningitis and
cavernous sinus [3] thrombosis,
both of which can cause neurological
damage and are life-threatening.
5 4  Second possible root of the
1 infection: it can spread from upper
molars via pterygoid venous plexus
[4] through inferior ophthalmic vein
[5]: Pterygoid plexus - Inferior
ophthalmic vein - Cavernous sinus.

Cavernous sinus thrombosis
Structures which may be
affected by cavernous
sinus thrombosis:
 Structures that pass
through sinus directly:
1. Internal carotid artery (in
case of laceration -
arteriovenous fistula)
2. Abducens nerve CN VI
(in case of lesion - internal
squint)
 Structures on lateral wall

of sinus:
1. Oculomotor nerve (CN III)
2. Trochlear nerve (CN IV)
3. Ophthalmic nerve V1
4. Maxillary nerve V2

Key:
77. Cranial Nerves S = sensory
M = somatomotor
P = parasympathetic,
Smart table 8 secretomotor
CN, Type, Foramina, Function Lesion

Associated Ganglia
I Olfactory, S, Cribriform Smells Anosmia
plate
II Optic, S, Optic canal Vision Visual deficits (anopsia)
Loss of light rf (+CNIII)
III Oculomotor, M+P, Raises eyelid, moves External strabismus
Superior orbital fissure, eyeball in all directions, +Ptosis +Dilated pupil
Ciliary ganglion constricts pupil, Loss of light rf (+CNII)
accommodates
IV Trochlear , M, Depresses & Trouble reading & going
Superior orbital fissure abducts eyeball down stairs
VI Abducens, M, Abducts eyeball Internal strabismus
Superior orbital fissure

Associated Ganglia
V Trigeminal, Trigeminal neuralgia
Trigeminal ganglion
V1 Ophthalmic, S, General sensation (touch, Loss of general sensation
Superior orbital fissure pain, temperature) of in skin of
forehead/scalp/cornea/nose forehead & nose
Loss of blink rf (+CNVII)
V2 Maxillary, S, General sensation of Loss of general sensation
foramen rotundum palate/nasal cavity/ maxillary in skin over
face/upper teeth maxilla, upper teeth
V3 Mandibular, S+M, General sensation of anterior Loss of general sensation
foramen ovale 2/3 of tongue/ mandibular in skin over mandible,
face/ lower teeth Motor to 4 lower teeth, ant. 2/3 of the
muscles of mastication/ 2 oral tongue. Weakness in
floor / 2 tensors chewing: jaw deviation
toward weak side

Associated Ganglia
VII Facial, M+S+P, To muscles of facial Bell palsy,
Internal auditory expression, stapedius Hypcracusis
meatus, Geniculate (1) Taste of ant. 2/3 of the Loss of blink rf (+CNV)
Submandibular (2) & tongue (1) Loss of taste ant. 2/3
Pterygopalatine (3) gg. Secretomotor for Eye dry and red
submandibular, sublingual
glands (2) / lacrimal gland,
nasal & palaline glands (3)
VIII Vestibulocochlear, Hearing (1) Sensorineural hearing
S, Internal auditory Linear & angular acceleration loss
meatus, Spiral (1) & (2) Loss of balance
Vestibular (2) gg.
IX Glossopharyngeal, Stylopharyngeus m. Loss of gag rf (+CNX)
M+S+P, Jugular General & taste senses (1) for
foramen, Sup. & Inf. gg, post. 1/3 of the tongue/
(1), Otic g. (2) pharynx/ carotid sinus/body
Secretomotor for parotid
gland (2)

Associated Ganglia
X Vagus, M+S+P, To muscles of larynx, palate Dysphagia, palate droop
Jugular foramen, Sup. & pharynx (except tensor Uvula pointing away from
& Inf. gg, (1), Terminal palati (V) & stylopharyngeus the lesion side
gg. (2) (IX)) Hoarseness/loss of vocal
Sensation in larynx and cord abduction
laryngopharynx (1) Loss of gag rf (+CNIX)
(2) To foregut and midgut Loss of cough rf
smooth muscle and glands
XI Accessory, M, Turns head to opposite side Shoulder droop the same
Jugular foramen (sternocleidomastoid) side
Elevates and rotates scapula
(trapezius)
XII Hypoglossal, M, To muscles of the tongue & Deviation of the tongue
Hypoglossal canal infrahyoid (ansa cervicalis) toward the lesion
side on protrusion

78. Pituitary gland tumors and
transsphenoidal operation
2 1
 Pituitary tumors [1] may extend
superiorly through opening in the
diaphragma sella, producing
disturbances in endocrine system.
 Superior extension of a tumor may
cause visual deficit owing to pressure on
the optic chiasm [2], the place where
the optic nerve fibers cross.
 The transsphenoidal operation is the
most common operation for a pituitary
tumor. The surgical approach for it is
through the nose, nasal cavity and
sphenoidal sinus [3]. This surgical
approach provides the best exposure of
the tumor at the lowest risk.
3

Hormones of the pituitary gland
 Releasing and inhibiting factors from
neurosecretory cells of the
hypothalamus reach pituitary gland
thought special capillary network –
hypophyseal portal system and
control the production of
adenohypophyseal hormones
(ACTH, FSH, LH, TSH, prolactin
and somatotropin).
 Hormones of neurohypophysis
(ADH and Oxytocin) are secreted in
hypothalamus and transported
through axons to pituitary gland.

79. Trigeminal nerve
 Skin of face
supplied by
branches of the
three divisions of
the [1]
TRIGEMINAL
NERVE (CN V)
1
 Except for a small
area over the
angle of the
Infraorbital mandible which is
foramen supplied by the [2]
great auricular
nerve (C2-C3) –
cervical plexus
2

80. Bell's palsy
 It is idiopathic unilateral facial
paralysis.
 Terminal branches of CN VII may
be injured by parotid cancer or
inflammation (parotitis) by surgery
to remove a parotid tumor
(stylomastoid foramen).
 Manifestations:
 unable to close lips and eyelids on affected side
 eye on affected side is not lubricated (dry eye)
 unable to whistle, blow a wind instrument, or chew effectively
 facial distortion due to contractions of unopposed contralateral facial

muscles

81. Epistaxis
 Epistaxis (nosebleed)
most often occurs from
the anterior nasal septum
(Kiesselbach's area),
where branches of the
sphenopalatine, anterior
ethmoidal, greater
palatine, and superior
labial (from facial)
arteries converge.

Lateral wall of nasal cavity
 Sphenoethmoidal recess
 receives the opening of the
sphenoidal air sinus
1. Superior meatus
1. Receives opening of posterior
ethmoidal air cells
2. Middle meatus
1. Infundibulum, ethmoidal bulla and
semilunar hiatus
2. Receives openings of frontal and
maxillary sinuses and anterior
and middle ethmoidal air cells
3. Inferior meatus
 Receives opening of
nasolacrimal duct

82.Ethmoiditis
 Infection in the ethmoidal
sinuses can erode the medial
wall of the orbit, resulting in
orbital cellulites that can spread
to the cranial cavity.
 In orbital cavity infection may
erode structures related to the
medial orbital wall:
 Medial rectus muscle
 Superior oblique muscle
 Nasociliary nerve

83. Cheeks
 Form the lateral, movable walls of the
oral cavity and the zygomatic
prominences of the cheeks over the
zygomatic bones.
1  Buccinator [1] – principal muscle of the
cheek.
 Buccal pad of fat – encapsulated
2 collection of fat superficial to buccinator.
3  Parotid duct [2] from Parotid gland [3]
perforate buccinator and opens in inner
surface of the cheek right opposite 2nd
upper molar tooth

84. Movements at the TMJs
All 4 muscles of
mastication are
innervated by V3:
1.Temporalis –
elevation & retraction
2.Masseter -
elevation
3.Medial pterygoid -
elevation
4.Lateral pterygoid
- protrusion
Note: In case of Mandibular nerve (V3)
damage mandible (when it is protruded)
deviate toward the side of lesion because
of Lateral pterygoid weakness.

85. Innervation of the tongue
1. Sensory anterior 2/3: general – lingual n. (V3), taste
– chorda tympani (CNVII)
2. Sensory posterior 1/3: general and taste –
glossopharyngeal (CNIX)
3. Motor – hypoglossal (CNXII)
 A lesion of the chorda tympani – lose of the taste
sensation anterior 2/3 of the tongue
 A lesion of the lingual nerve – lose of both general
and taste sensation anterior 2/3 of the tongue
 A lesion of CN XII (hypoglossal canal) allows the
contralateral, unparalyzed genioglossus muscle to
pull the protruded tongue toward the paralyzed side
(deviation and atrophy of the tongue).

86. Palatine tonsils
 Receives main blood supply
from tonsillar branch of facial
artery
 Drained by external palatine
vein to facial vein
 Lymph drainage mainly to
jugulodigastric lymph node,
which is body's most frequently
enlarged lymph node
 Nerve supply: tonsillar plexus of
nerves formed by branches of CN
IX and CN X

Tonsillitis
 During palatine tonsillectomy, the
peritonsillar space facilitates tonsil
removal, except after capsular
adhesion to the superior constrictor.
 If the glossopharyngeal nerve is
injured, taste and general sensation
from the posterior 1/3 of the tongue are
lost.
 Hemorrhage may occur, usually from
the external palatine vein or tonsillar
branch of the facial artery
 If the superior constrictor is
penetrated, a high facial artery or
tortuous internal carotid artery may
be injured.

Gag reflex
 Touching the posterior part of the
pharynx results in muscular
contraction of each side of the
pharynx - gag reflex:
 Afferent limb: CN IX
 Efferent limb: CN X
 Injury to the
GLOSSOPHARYNGEAL NERVE
(CN IX) will result in a negative gag
reflex

87. Muscles of Soft Palate
1. Tensor veli palatini and
2. Levator veli palatini – elevates the
soft palate during swallowing to
prevent food entering to the
nasopharynx
3. Palatoglossus and
4. Palatopharyngeus – depress soft
palate and pulls walls of pharynx
superiorly
5. Uvular muscle – shortens uvula
and pulls it superiorly

88. Lymph drainage from the
head
1. Preauricular (parotid ) (on front of
auricle) receive lymph from
anteriolateral part of scalp and
lateral face
2. Submandibular (in digastric or
submandibular Δ) – from all air
1 sinuses, nose and adjacent
cheek, upper lip and lateral parts
of lower lip.
4
5 3. Submental (in submental Δ) – from
the chin, tip of the tongue and
3
2 central part of the lower lip.
4. Mastoid (behind the auricle) –
adjacent region of the head.
5. Occipital (occipital region).

89. Blow-out fracture
 A blow-out fracture of the orbital
floor typically is not involve the
orbital rim and is caused by blunt
trauma to the orbital contents (e.g.,
by a handball). Content of orbital
cavity blow-out in maxillary sinus.
 Blow-out fractures may damage:
1. Inferior rectus muscle
2. Infraorbital nerve (from
maxillary V2)
3. Infraorbital artery
(hemorrhaging).

90. Lips and palate congenital
defects
 The intermaxillary segment forms when
the two medial nasal prominences fuse
together at the midline and gives rise to the
philtrum of the lip, four incisor teeth, and
primary palate of the adult. It forms anterior
to the incisive foramen.
 Secondary palate (2 shelves) derivate from
maxillary prominences.
 Maxillary prominences have fused with the
medial nasal prominences (intermaxillary
segment).
 In case of failure of this process, cleft of the
lip or palate will develop.

91. Strabismus
Smart table 9: Muscles of the orbit
Muscle Action Testing CN
Superior Up and medially Look laterally, CN III
rectus then up
Inferior rectus Down and Look laterally, CN III
medially then down
Medial rectus Adducts pupil Look medially CN III

Lateral Abducts pupil Look laterally CN VI
rectus
Superior Down and Look medially, CN IV
oblique laterally then down
Inferior Up and laterally Look medially, CN III
oblique then up
Levator Elevates upper CN III
pulpebra eyelid
superior

Oculomotor Nerve Palsy
 External squint affects most of the extraocular
muscles
 Manifestations: Ptosis, Fully dilated pupil, Eye is
fully depressed and abducted (“down and out”)
due to unopposed actions of superior oblique and
lateral rectus, respectively.
Trochlear nerve palsy

CNIII
 It cause paralysis of the superior oblique and
impair the ability to turn the affected eyeball infero-
medially (“up and out”)
 The characteristic sign of trochlear nerve injury is
diplopia (double vision) when looking down (e.g.,
when going down stairs or reading)
CNIV Abducens Nerve Palsy
 Internal squint because of injury to abducens nerve
 paralysis of lateral rectus  inability to abduct
the affected eye
 Affected eye is fully adducted by the unopposed
CNVI action of the medial rectus that is supplied by CN III

92. Horner syndrome
 Penetrating injury to the neck,
Pancoast tumor, or thyroid carcinoma
may cause Horner syndrome by
interrupting ascending preganglionic
sympathetic fibers anywhere between
their origin in the T1 segment (IML) of
spinal cord and their synapse in the
Superior cervical ganglion.
 It includes the following signs:
 Constriction of the pupil (miosis)
 Drooping of the superior eyelid
(ptosis),
 Redness and increased temperature
of the skin (vasodilation)
 Absence of sweating (anhydrosis)

93. Otitis Media
Complications:
1. Hearing is diminished because of
pressure on the eardrum and
reduced movement of the ossicles.
2. Taste may be altered because the
chorda tympani is affected.
3. Infection spreading posteriorly
cause mastoiditis.
4. Infection that spreads to the
middle cranial fossa can cause
meningitis or temporal lobe
abscess, and infection moving
through the floor may produce
sigmoid sinus thrombosis.

Perforation of the tympanic
membrane
 May result from otitis media and is one of
several causes of middle ear (conduction)
deafness
 Causes: foreign bodies in external
acoustic meatus, excessive pressure (as in
diving), trauma
 Because chorda tympani directly relates
to the posterior surface of the tympanic
membrane it may be damaged and
resulting in loss of taste over anterior 2/3
of the tongue and secretion of the
sublingual and submandibular glands
 Minor perforation heal spontaneously; large
ones require surgical repair

94. Inner ear
 It contains the vestibulocochlear organ
concerned with reception of sound and
maintenance of balance (CNVIII).
 Cochlea: spiral organ (of Corti) –
receptors for hearing (located along the
basilar membrane)
 Vestibule: utricle and saccule are parts
of the balancing apparatus (static
position)
 Semicircular canals: receptors of
angular acceleration (kinetic)
 Anterior – in coronal plane
 Posterior - in sagittal plane
 Lateral – in horizontal plane

95. Thyroid and parathyroid
glands
Hormones:
 The thyroid gland is the body's largest endocrine
gland. It produces thyroid hormone (T3 & T4), which
controls the rate of metabolism (increase the
temperature of the body), and calcitonin, a hormone
controlling calcium metabolism (reduce blood calcium
Ca2+).
 After total thyroidectomy may develop lower
temperature of the body and hypercalcemia.
 The hormone produced by the parathyroid glands,

parathormone (PTH), controls the metabolism of
phosphorus and calcium in the blood (increase Ca2+
level).

Variation of parathyroid glands
position
 The superior parathyroid

glands, more constant in position
than the inferior ones.
 The inferior parathyroid glands
are usually near the inferior
poles of the thyroid gland, but
they may lie in various positions
 In 1-5% of people, an inferior
parathyroid gland is deep in the
superior mediastinum inside the
thymus because of common
embryonic origin.

Anatomical relations of the
thyroid gland
 Anterolateral –
infrahyoid muscles
1  Posterolateral –
COMMON CAROTID
ARTERY [1]
 Medial – larynx,
TRACHEA [2],
pharynx, esophagus,
cricothyroid muscle,
recurrent laryngeal
1 nerve [3]
 Posterior –
parathyroid glands
1 [4]
3

CS of the neck

96. Cervical cysts
Median cervical cyst
 Usually presents as a painless
midline mass on the anterior aspect
of the neck just below of the hyoid
bone and moves during swallowing
together with thyroid gland because of
relation with pretracheal layer of
cervical fascia and infrahyoid muscles
of the neck.
 Remanent of the thyroglossal canal
(thyroid gland originally from
epithelium of the tongue).
 Treatment: surgical excision

Lateral cervical cysts
(Branchial cysts)
 Lateral cervical cysts are

remnants of 2nd, 3rd, and 4th
grooves and filled up by
ectoderm
 There are painless cysts located
on the lateral neck along the
anterior border of the
sternocleidomastoid muscle
 They do NOT move during
swallowing (difference with
median cysts)
 Treatment: surgical excision

97. Larynx
3
Cavity of the Larynx -

2 Folds:
1
2  Vestibular folds
[1] (false vocal
cords)
 Vocal folds [2]
(true vocal cords)
 Rima vestibuli – gap between the
vestibular folds
 Rima glottidis [3] – gap between the
vocal folds anteriorly and vocal
1 processes of the arytenoid cartilages
posteriorly is most narrow place in the
larynx (it limits size of intubation tube
2
during endotrachial anaesthesia)

Muscles of the Larynx
Abductors
 Posterior
cricoarytenoid –
abducts vocal folds (the
only abductors of the
vocal folds)
 It is innervated by
recurrent laryngeal
nerve (CNX vagus).
 Interruption of recurrent
laryngeal nerve results
in hoarseness because
the corresponding vocal
fold does not abduct and
deviate toward the
midline.

98. Cricothyrotomy
 A cricothyrotomy is an emergency
procedure that relieves an airway
obstruction (e.g. swallowed foreign
bodies or abnormal tissue growths).
 A hollow needle is inserted into the
midline of the neck, just below the
thyroid cartilage (needle
cricothyrotomy).
 More frequently, a small incision is
made in the skin over the
Cricothyroid membrane, and
another one is made through the
membrane between the cricoid
and thyroid cartilage. A tube that
enables breathing is inserted
through the incision.

99. Retropharyngeal space
 It is interval between pharynx
(Bucco-pharyngeal fascia) and
prevertebral fascia
 May provide a passageway of
infection from pharynx to
posterior mediastinum
(mediastinitis ≈ 90% mortality
rate).

100. Neck
Axillary sheath
 Derived from the prevertebral
fascia
 Encloses the subclavian artery
and brachial plexus as they
emerge in the interval between the
scalenus anterior and medius
muscles (Interscalenus space)
 Extends into the Axilla

Torticollis
Congenital torticollis
 most commonly caused by a fibrous
tissue tumor in the SCM
 head turns to the side and the face to
turn away from the affected side
 surgical release may be necessary
Spasmodic torticollis
 may involve any bilateral combination
of lateral neck muscles, usually SCM
and trapezius
 involuntary shifting of head laterally or
anteriorly
 shoulder usually elevated and anteriorly
displaced on the side on which chin
turns

Posterior triangle of the neck
 Veins – external jugular vein,
subclavian vein.
 Arteries – occipital artery.
 Nerves – Accessory nerve (XI),

trunks of the brachial plexus,
branches of cervical plexus, phrenic
nerve.
 Lymph nodes – superficial cervical
CN XI nodes along external jugular vein.
CN XI (accessory nerve) supply:
 Sternocleidomastoid muscle - face
looks upward to the opposite side
 Trapezius - superior fibers elevate,
middle fibers retract, and inferior
fibers depress scapula.

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100 most important

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 The needle is usually

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Lower limb reflexes are decreased on the

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 Weakest part of clavicle -

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 Infraspinatus (supination) Right humerus

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2. (15º-110º) Further abduction to the

3. (110º-180º) Raising the extremity above

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 Young children are prone to

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 Lateral epicondylitis: repeated forceful

 Origins of following muscles may be affected:

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and subscapular arteries

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 PIP – Flexor digitorum

 DID - Flexor digitorum

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Dorsum: 1.5=U and 3.5=R Palm: 1.5=U and 3.5=M

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 It can be cannulated for

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Nerve Innervated region Clinical sign

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 A femoral hernia passes below

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 Because the lateral side of the