Gross Anatomy MNTS

Course: Gross Anatomy
The Medical Note-Taking Service Lecturer: Suarez-Quian

Date: 8/13/07
Lecture Number: 1
Class of 2011 Page 1 of 3
NOTICE &DISCLAIMER
Note-Taker: Patrick Nailer The Medical Note-T aking Servic e makes ever y effort to prov ide accurate
Corrected by: Suarez-Quian class notes. Howev er, errors will occur fr om time to time. The user
Approved for distribution: as sumes the risk for any and all error s. We recommend that you use
these notes as a supplement to your own notes.
Introduction
Announcements
A Yahoo group (gusom_2011) has been created to allow our class to communicate about this and future
courses. Links for old and new notes can also be found on the Yahoo group page. Old notes will be
available on a CD (for FREE!) to be handed out the morning of Tuesday, August 14, 2007 outside the
MNTS office. Hardcopies can also be ordered online (not for free) if you prefer paper copies. Both old
and new notes must be ordered by Friday, August 17.
Course Logistics
The course director for Gross Anatomy is Carlos A. Suarez-Quian, Ph.D. His office is located in NE-
213 Med-Dent and his email is suarezc@georgetown.edu. A listing of the other faculty members that
will be teaching anatomy can be found on page ii of the syllabus along with their contact information.
Throughout the course, students are encouraged to inquire about faculty research interests in the hopes
of identifying possible topics for the independent project that we have to complete by the end of our four
years at Georgetown.
Two important people to keep in mind should you need help in lab or, say, lose your syllabus: Chris
Saxon is the Gross Anatomy Lab Manager and is your contact for any issue with the lab component of
the course, i.e. your cadaver needs wetting, fungus is growing, etc. His office is across from the lab
(LE-9 Preclinical Science Bldg.) and he can be reached by email at Crs33@georgetown.edu. For any
other concerns, please contact Ms. Essie Thompson, the Medical Education Coordinator, at
thompsew@georgetown.edu or in her office (NE-118, Med-Dent).
Course: Gross Anatomy Lecturer: Suarez-Quian
Date: 8/13/07
Lecture number: 1
Page 2 of 3
Clinical faculty will give almost half of the anatomy lectures. As a result, it is possible that some
scheduled lectures may be postponed or canceled due to patient needs on a particular morning.
Textbooks
The list of required textbooks can be found on page iii of the syllabus. The page numbers listed in the
lecture/lab schedule refer to pages from Grants Dissector. Some students prefer to use the Netter atlas,
although it is not required. Each table will be provided a copy of Grants Atlas and Dissector in lab.
How to study
Required and recommended websites are listed on page iii of the syllabus. The required website
(http://dml.georgetown.edu/resources/32790.html) includes relevant radiology information and images
that we are expected to learn for the mid-term and final. It is highly recommended that students also
visit a website maintained at Yale (http://info.med.yale.edu/surgery/anatomy/) to periodically test their
understanding of course material. Note: some of the exam questions will be similar to questions posted
on this site. Additionally, movies of dissections can be viewed at
http://dml.georgetown.edu/students/5586.html.
To excel in anatomy, it will be important to keep up with the lecture and lab material, to read ahead,
attend lectures and actively participate in dissections (the midterm and final both include a lab practical).
Dr. Suarez-Quian recommended that students first read Grants Dissector followed by the Grays atlas
for a conceptual summary. The appropriate sections in the syllabus should also be consulted.
Grading
The general grading breakdown can be found on page vii of the syllabus. The top 10% receive Honors,
next 20% High Pass, etc. A grade above 60% usually results in a passing grade although a final decision
will be made at the discretion of the course director. The final exam will consist of the National Shelf
Exam in Gross Anatomy, accounting for 40% of our final grade. This will be a cumulative final.
Course: Gross Anatomy Lecturer: Suarez-Quian
Date: 8/13/07
Lecture number: 1
Page 3 of 3
Dr. Suarez-Quian then provided a brief history of anatomy and dissection. For those of you that are
interested, most of the salient points can be found in the syllabus. In the interest of saving a few trees,
Im not going to reproduce what is already on paper for you.
Thats it, short and sweet for the first lecture. Heres to everyone having a great first year!
Course Gross Anatomy
Lecturer Dr. Suarez
The Medical Note-Taking Service Date 08/13/07
Lecture Number: 2
NOTICE &DISCLAIMER
Note-Taker: Kaelan Young The Medical Note-Taking Service makes every effort to provide accurate
Corrected by: Dr. Suarez class notes. However, errors will occur from time to time. The user
Approved for distribution: assumes the risk for any and all errors. We recommend that you use
Dr. Suarez started out the lecture by stating that the lecture slides will be posted online. When
asked if they will be posted before or after the lecture, he replied that it depended on the lecturer. Some
of the lecturers send emails containing the power-point presentations, which will be posted BEFORE the
lecture, and some bring the disk with the power point with them directly to the class. These
presentations will be posted AFTER the lecture.
Now on to the Anatomy stuff. This lecture basically focused on certain anatomical terms that
are important in the language in medicine. The word anatomy comes from the Greek word temnein
which literally means to cut open. In summary, anatomy is the study of the internal and external body
and the relationships between its parts. It can include structures seen with the naked eye to those that
require high powered microscopes. Gross Anatomy is the focus on those structures that can be seen
without any microscopic technology.
Dr. Suarez proceeded to explain anatomys nomenclature and really how simple it can be! Greek
and Latin are the main roots of the names and if you can learn and understand the context in which the
tissue is functioning, it is easy to figure out the name! For instance, the aorta has three branches: the
Right Brachiocephalic trunk, the Left Common Carotid, and the Left subclavian. These names at first
seem overwhelming but if you break it down, it isnt that hard.
Lets break them down:

Right Brachiocephalic- Well first off, you see that this is the Right artery, meaning there must be a left
(because otherwise, why would it matter?). Then you see the next part of the name. Brachio means
arm and Cephalic means head. Now you know that this is the artery that goes to the right arm and
right side of the head
Left Common Carotid- Again, you can tell there are a right and a left. This one is the left. The word
common implies that this artery splits into two, becoming the deep and superficial carotid arteries.
Carotid comes from the Greek karos which means deep sleep. This can help you remember (with a
bit of imagination) that the carotid goes to the head.
Course: Gross Anatomy Lecturer Dr. Suarez
Date 8/13/07
Lecture number 2
Page 2 of 5
Left Subclavian- This one is a bit easier. You know there is a right and a left and you also know that
this artery lies beneath the clavicle. See, anatomy is easy, right?
Dr. Suarez also mentioned that although anatomists do not really talk about them, veins are very
important structures (of course). Its just that people assume that if you know the arteries, you will
know the veins.
The next important part of this lecture was the outlining of the objectives of the course. They are
(copied by the slides)
1. Medical terminology Regional organization of body

2. Anatomical structures at the gross level in a clinical
context
3. Dissection of human cadaveric material
-Good website to go to:
http://dml.georgetown.edu/students/5586.html
4. Conventional and modern imaging techniques
a. X rays
b. CT
c. MRI
-Good website to go
to:http://dml.georgetown.edu/resources/32790.html
-Actually, this website is required for
learning these imaging techniques
There are many physiological systems (11) and many

medical schools teach anatomy in this organization.
We, however, will learn anatomy via the sections of the
body: 1) Back, 2) Thorax, 3) Abdomen, 4) Pelvis, 5)
Head/Neck, 6) Upper and lower limbs. To start this examination of the human body, however, we need
to understand some terminology.
Anatomical position: This is the standard reference point for studying anatomy. The person is
standing upright with the feet together and the palms facing forward. Thumbs are facing outwards and
fingers are together.
Know these terms. I dont want to define them because I think it is a lot easier to see it in the picture
and I dont want to make this note set any longer with my babble which would just confuse you. Pick
them out of the pictures:
Date 8/13/07
Lecture number 2
Page 3 of 5
Anatomical
Position Anterior vs. Posterior, Cranial vs. Caudal, dorsal vs. ventral. These terms will come up
again and again in all of your courses.
Sections: 1) capital- cut down the surgical plane, 2) Coronal- Cut down the coronal plane,
3) Transverse- cut down the longitudinal plane.
You also have terms like: 1) medial- towards the midline, 2) Lateral- away from the
midline, 3) Deep vs. superficial (Tissues that are superficial are closer to the skin), 4)
dorsal- closer to the core body, 5) proximal- away from the core body
REMEMBER- Everything is RELATIVE. The trachea is anterior to the esophagus
(important to intubation) and a liver that is more inferior to normal may indicate
cirrhosis.
The most superficial structure is the skin but even that has relative components. For
instance, there are two types of fascia in the skin: the subcutaneous (or superficial) and the deep fascia.
The superficial fascia is closer to the outside of the skin while the deep fascia is closer to the inside of
the body.
As a side note, Dr. Suarez mentioned the functions of skin:

1) Protection
2) Containment
3) Heat Regulation
4) Sensation
5) Synthesis and storage of Vitamin D
Date 8/13/07
Lecture number 2
Page 4 of 5
Superior
P
A (Cranial)
O
DS N V Superficial to Deep Deep to Superficial
OT T E
RE E N
SR R T
I R Transverse
A I
LO O A
R R L
Inferior
Superficial to Deep Deep to Superficial
(Caudal)
Coronal
Another important aspect of skin is the tension or Langer lines. These lines occur all over the body and
are important for surgery. For instance, surgical incisions parallel to the lines heal better, have little
scarring, are less likely to cause keloids, and cause the slit like properties of puncture wounds. Stretch
marks are caused by the skin stretching perpendicular to these
tension lines. Langer lines
Action terms these terms have to do with the joints.

Remember that this is all relative to the standard anatomical
position
- Abduct vs. adduct
- Abduct is to take away from the midline and adduct
is bring towards the midline (think of a shoulder moving out
(adducting) and back in (abducting)).
- Flexion vs. Extension
- Flexion is bending the joint while extension is
Date 8/13/07
Lecture number 2
Page 5 of 5
extending the joint. This one is a little weird because the knees and elbows flex in different directions.
However, during embryological development, the arms and legs start off growing in the same direction
and then the legs rotate, causing the joint to bend backward.
- Medial and lateral rotation
- Self explanatory. Medial rotation roles the joint toward the midline and lateral rotates the joint
away from the midline
- Pronation and supination
- Pronation is facing the ground while supination is facing the sky
Movement terms
The last thing that Dr. Suarez did was to pose a question:
Inability to hold a credit card between fingers is due to inability to:
A. circumduct the fingers

B. Adduct the fingers
C. Abduct the fingers
D. Extend the fingers
E. None of the above answers are correct
Answer: B- You are trying to squeeze the fingers toward a midline, therefore adducting the fingers
Hope you enjoyed your first day!

Lecturer: Dr. Hudson
The Medical Note-Taking Service Date: August 13, 2007
Lecture Number: 3
NOTICE &DISCLAIMER
Note-Taker: Caitlin Bump The Medical Note-Taking Service makes every effort to provide accurate
Corrected by: class notes. However, errors will occur from time to time. The user
Professionalism, Ethics, Gross Anatomy
Presented by Dr. Kori Hudson
Note: This lecture will not be on the exam
Beginning of presentation is the video Still Life: The Humanity of Anatomy
Dr. Hudsons background: undergrad, medical school, & residency at UVA, in Emergency Medicine.
Think about why you are here and what it means to be a doctor? Its not like ER or Grays
Anatomy. Its not just important what you think a doctor is. Realize your patients might have a different
view of what a doctor is. You dont have to conform to their view, but you have to recognize it. People
respect doctors.
Anybody can get from here to there and be a good technician. But being a doctor is not about
being a good technician. How do you get from where youre sitting to a practicing professional? And
what does it mean to be a professional?
Professional (paraphrased from Websters):
- characterized by or conforming to the technical or ethical standards of a profession
- a calling requiring specialized knowledge, and often a long intensive academic preparation
Course: Gross Anatomy Lecturer: Dr. Hudson
Date: 8/13/07
Lecture number: 3
Page 2 of 4
- a principle calling, vocation, or employment, the whole body a persons engaged in that
calling
What does it mean to be professional, to act professionally?
- exhibiting courteous, conscientious, and generally businesslike manner in the workplace (i.e
not wearing flip-flops or mini-skirts on the wards, saying yes and no rather than yeah
and uh uh)
How anatomy can be used as a way to practice a new style of learning, working with others, respect for
patients, confidentiality and social responsibility.
A new style of learning what worked in college will not work in medical school. Theres too much to
know and youll have to remember it after the test. Know the material well enough that you can explain
it to the person sitting next to you. Be able to draw a picture of it. Be able to diagram it.
Group learning The more you work together, the more successful each of you will be. The goal is for
everyone to make it through.
Life-long learning youre never going to know it all. You never get to stop studying and learning, and
the medical field changes fast. There are new drugs, antibiotics, techniques, diseases etc. Continuing
Medical Education is a way to practice life-long learning.
Taking responsibility you are responsible for your education. The faculty is here to help, guide, and
impart their knowledge to you, but you have to take responsibility for what youre going to learn. Its
youre decision how long you stay in lab, and if you get up early for that extra review session. You have
to take responsibility for that.

Date: 8/13/07
Lecture number: 3
Page 3 of 4
Working with others even if you arent friends with the people in your anatomy group, youre
colleagues now. And you need to work together like youre colleagues. You share a common goal, and
you need to be successful in achieving that goal. Eventually it will be caring for patients.
Responsibility for the learning of others responsibility for patient care, you will be sharing that
responsibility when youre on the wards and when youre residents.
- If you, as a junior pilot, know that something is wrong, speak up. Working with others is
necessary for successfully treating a patient.
- Medical school is stressful. You need to recognize when you need help, and when youre in
over your head, or when someone else is in over their head. Take care of yourself and each
other. And accept help. Do the things you need to do to keep yourself happy and sane. Be
more than just colleagues, be friends when you can.
Respect for patients the lab can be stressful. Its easy to break down and start cracking jokes.
Remember that each patient you take care of has a story. Something today made them decide to walk in
that door, and its our job to figure out what that is. Its often a memorable event when people interact
with the health-care system. Its our job to help them out.
Confidentiality HIPAA is a law that requires us to keep patient information confidential. Remember
patient privacy should extend to cadavers as well. Remember that not everybody in the community is
sharing this experience.
Social responsibility what does it mean to donate your body to science? Think about whether youd
make a donation of your body to anatomy. How would you act if you knew that potential donors were
going to visit the lab.

Date: 8/13/07
Lecture number: 3
Page 4 of 4
Youre choosing your profession. Youve set yourself on a path. You will be different than your friends.
Thats ok. Youve chosen to be here. But recognize that this profession is different from others that are
out there because we deal, at a very human level, with people, every single day.
Dont forget about your friends and family at home.
Dont give up on doing the activities that you enjoy.
Dont lose sight of your goal and why you are here.
Remember how you got here. All your hard work, youre smart, youre dedicated. Focus that on
being professionals and representing yourselves and your school.
Think about and strive to become the doctor you want to be.
Welcome to the profession

Lecturer: Dr. Wellbery
The Medical Note-Taking Service Date: 8/14/07
Lecture Number: 4
NOTICE &DISCLAIMER
Note-Taker: Shannon Liang The Medical Note-Taking Service makes every effort to provide accurate
Corrected by: Dr. Wellbery class notes. However, errors will occur from time to time. The user
Lecture 4: Our First Patient

**NOTE** Lecture #3 on Professionalism, Ethics, Gross Anatomy by Dr. Hudson was
originally slated as part of lab, and thus not covered by a note-taker. It will not show up on the test, so
treat it as a freebie lecture and take a study break. (And actually, this one wont appear on our exam
it is for personal growth and enlightenment.)
Before class began, 2nd year students helping out with lab gave us their e-mails so that we may
ask for guidance in preparing for our prosection presentations:
LE-A: acb66 (Aaron) LF-A: jpw44 (Jaclyn); bjs22 (Bri)
LE-B: sdl33 (Sean); cmj34 (Chris) LF-B: jpm236 (Jeff); ksd24 (Krysta)
Dr. Caroline Wellbery introduced herself as a physician from the Department of Family
Medicine here at Georgetown University. She teaches mostly 3rd years and residents, so we will interact
with her more later. Dr. Wellbery style lends to using the arts and literature to educate students. Todays
lecture is an illustration of how medicine and humanities are integrated.
First Dr. Wellbery discussed the often feared topic of death. Whether we like it or not, death is
relevant: in 75 years, pretty much everyone in the room will be dead. A common way to deal with death
is not to think about it, in other words, denial. For example, Dr. Wellbery offered story about an elderly
couple, one saying to another When one of us dies, Ill move to Paris. Death can be liberating; it can
erase a low pass in anatomy because once you die, its all irrelevant. In contrast, death can provoke one
to assume responsibility; we are only here for a short span and should do something worthwhile to make
a mark on the world.
However, we not only think about our own death, because other people die too. This is often
more difficult as its hard to rationalize and you have to survive the deaths that precede your own. While
you may appear cold concerning the death of those you do not care about, and indifferent about
those you know nothing about, you may feel emotional about those who matter a great deal to you.
However, just because you dont know the person that died, doesnt mean that you are not affected by
If you die in an elevator, be sure to push the Up button.
-- Sam Levenson
Course: Gross Anatomy Lecturer: Dr. Wellbery
Date: 8/14/07
Lecture Number: 4
Page 2 of 4
the death. Dr. Wellbery gave a personal story about how she was reading the newspaper about a
teenager who snuck out of her home in the wealthy suburbs and encountered a group that sliced her
throat. The last word out of the girls lips was her call for Mommy. This greatly affected Dr. Wellbery
because she has a teenage daughter of own, who sneaks out of the house and is also vulnerable. Even
though Dr. Wellbery didnt know that girl, she can relate it to her own personal experience.
In medicine, there is a dual relationship: one that is disengaged or not emotionally-involved to
the disease or anatomy of patients, and one that is engaged by relating to the patient since this is a
person that has a name, friendships, life, and loves. Rather than referring to the diabetic, an engaged
physician refers to the patient with diabetes.
Next, Dr. Wellbery contrasted two pieces of imagery by a couple medical students who reflected
on their dissections of the heart. The first described the dissection with phrases like no chills, no pang,
no nausea and intellectual curiosity. While beautifully written, it showed no emotional relationship to
the cadaver. The other piece found something in his own life to relate to the experience: his father went
through two cardiac surgeries and the poet described how the dissection made him aware of how close
he was to losing his father and how grateful he is that his father is still alive.
The idea Dr. Wellbery wanted to convey in talking about how one can relate emotionally to
some deaths versus removing oneself from deaths that dont much concern us is that either/both of these
stances are relevant in our practice of medicine. On the one hand we automatically care more about
some patients than others. On the other hand, an uncaring attitude or at least position of distance is
reinforced by the scientific ideology that dominates medicine. We can overcome this dichotomy
somewhat by figuring out what it is about our patients that relates to our own lives (like the medical
student who relates the corpse to his father). Acknowledging our own vulnerability and our own
mortality is an important step in connecting with patients.
To further illustrate this concept, Dr. Wellbery guided a panel of three students and the class in
an analysis of the poem, My Fathers Autopsy by David Gewanter who is an English professor at GU.
Though the poem has an ambiguous title, in the first line it is apparent that it concerns a boys
experience watching his pathologist father working on a cadaver. As you will see, the poem is an
illustration of a disconnected and a connected attitude. Ideally, a self-aware doctor will be able to
combine the best of both of those worlds.
I will transcribe most of the poem, as accurately as possible, and include highlights of the panel
discussion in bullet points.
Date: 8/14/07
Lecture Number: 4
Page 3 of 4
My Fathers Autopsy by David Gewanter

The one he did, that is, and took me to
When I was 13, I turned white as the old woman lying naked there;
Puberty, hormones raging, Jewish coming of age at 13, like M1s inauguration into a new
phase of life
White as the old woman is a simile which relates his fear to her death
This is a moment of empathy because he is relating to her.
But as he clanked out tools I inspected her quickly,
Clanked is a harsh term.
The dead cinder of her nipples, the stiff tuft at her crotch
Remember hes 13 and wants to look at the forbidden regions.
Wouldnt it turn grey?
Hes asking a scientific question guided by vested interests.
Dad took stock of her length, weight, muscle tone,
Telling me or the microphone how she lived,
Father is not very engaged. He is speaking into a microphone like a public statement.
What made her sick. Like being a detective, he said,
Except I answer my own questions. Here touch this.
But I wouldnt, and I wanted her body to resist interrogation,
Prayed weirdly she never said aah for a doctor.
Father and son are going through a scientific endeavor together, but son wants to distance
himself from his father.
The son sees the cadaver as a personhe doesnt even want her to open in any way because he
sees it as a violation of her body and wants to leave her whole.
Then he slit and sawed her down the middle
She opened as easily as a yam, or a duffle bag;
Dipping delicately in, Dad scooped out a handful of stuff,
All jumbly like underwear from Moms dresser.
The cadaver is compared to non-scientific objects (yam and duffle bag) to visually show the
emotional impact this experience is having on the son.
He read her guts like a priest probing
So thin they would glow under the lens-light
At last she yielded him a brown pebble
The pebble is the answer which brings the father excitement.
The son is critical of the father because he is reducing her to the stone.
Which I felt between his fingers and thumb;
Then he put it back. Deaths story,
Deduced from facts hard as boneas he talked me through it,
I could hear the joyful lift in his voice
The father is not ruining the body, it is just for investigation. The father finds pleasure in this.
The sons positive spin shows that he is comfortable with the father now.
There are two sides of medical inquiry: objectivity and subjectivity (not always compatible and
can be exclusive)
As he sat over journals and drinks,
Compact, severe, inward as a microscope,
Date: 8/14/07
Lecture Number: 4
Page 4 of 4
The microscope is an instrument of discovery and is used to say that the father is opaque and
impenetrable.
Now hes home all day waiting for the mail.
Hasnt cut a corpse in years. He calls every weekend,
His news familiar as a backache, and we talk without fear.
The father has outlived his work and now shows vulnerability and mortality.
Some sympathy is evoked.
The son may have had issues with his father, but there seems to be some coming to terms.
Once I thought my pen would open him here
Like the corpse on its single pan of judgment;
But as I cover this pan with pages
He is alive on another one.
The father is more than a small pebble with a tangible answer.
The title now seems a literary autopsy of the father. In a way, the son is dissecting his father, just
as the father dissected the corpse.
The sons passion for literature is analogous to the fathers passion for science/dissections.
For their contributions, the panel received the book Anatomy of Anatomy.
Finally, Dr. Wellbery explained that what we do in science differs from the real world. We cant
dissect living human beings because people are integral wholes; we cant fully understand them. Thus,
we must recognize the limitations, including how to relate to the dead. We must recognize the difference
between empathy, a kind of understanding, and the understanding gained through science.
Lecturer Dr. Suarez-Quian
Lecture Number: 4
NOTICE &DISCLAIMER
Note-Taker: Jonah Lopatin The Medical Note-Taking Service makes every effort to provide accurate
Corrected by: Dr. Suarez-Quian class notes. However, errors will occur from time to time. The user
Nervous System
The nervous system has three main functions:

Sensory input (afferent pathway)- receives information from both the outside environment and
inside our bodies
Integration processes and interprets the constant influx of information
Motor output (efferent pathway) - Dictates a response to effector organs
Divisions of the Nervous System

Compartmentally, the nervous system can be divided into two regionsThe Central Nervous System
(CNS) and the Peripheral Nervous System (PNS). These two systems are divided by a blood-brain
barrier.
The CNS is composed of the brain and spinal cord.
The PNS includes all nervous tissue of the body except the brain and spinal cord. It contains
afferent neurons responsible for carrying impulses to the CNS as well as efferent neurons
responsible for relaying impulses to skeletal muscles, smooth muscles, and glands------. The
PNS can be further divided through functional classifications.
o The somatic nervous system is composed of all afferent (sensory) and efferent (motor)
fibers of the PNS that communicate with skeletal muscles derived from somites
responsible for controlling voluntary actions.
o The autonomic nervous system (ANS) controls our involuntary actions, and through
communicating with cardiac muscle, smooth muscle, and glands, is responsible for self-
regulation through the actions of two opposing autonomic subsystems; the sympathetic
nervous system and parasympathetic nervous systemboth of which will be covered in
depth when we come to our autonomics lecture in 2 weeks.
"Weaseling out of things is important to learn. It's what separates us from the animals... except the weasel."
Homer J. Simpson
Course Gross Anatomy Lecturer Dr. Suarez-Quian
Date 08/15/07
Lecture number 4
Page 2 of 9
Although not directly necessary for Gross Anatomy, the entire nervous system can be divided
into seven functional classes that may be useful to know in case they come up in future lectures. They
are as follows:
GSA- general somatic afferent, sensory fibers of the somatic nervous system. This includes the
receptors for proprioception, touch, pain, and temperature.
GVA- general visceral afferent, sensory fibers from our inner organs
SSA- special somatic afferent, special sensory fibers from the eye and ear.
SVA- special visceral afferent, special sensory fibers from the tongue and nose.
GSE- general somatic efferent, fibers extending from the CNS to the voluntary muscles of the
body
GVE- general visceral efferent, fibers from the CNS to the internal organs of the body
SVE- special visceral efferent, motor fibers to the muscles of the brachial arches
Nervous Tissue
The nervous tissue of the body is composed of neurons and supporting cells. There are three
basic parts to every neuron- the cell body, dendrite(s), and axon- and the specific arrangement of these
components allows neurons to be structurally classified in one of 3 ways:
1. In multipolar neurons an impulse arrives at the dendrites, travels to the cell body, and continues
unidirectionally down the cell axon. This type of neuron can be found in the brain and spinal
cord. Motor neurons are generally multipolar neurons.
2. Bipolar neurons contain 2 processes, one of which carries impulses towards the cell body and
the other which carries them away. These neurons are only found in the retina, inner ear, and
olfactory region of the brain.
3. Unipolar (Pseudounipolar) are functionally the same as bipolar neurons, but have a short stalk
connecting the cell body to two branches of a single long process. All are sensory neurons of the
PNS.
In addition to these structural classifications, neurons can be divided into three distinct
physiological groups; afferent neurons (conduct information from the periphery to the CNS), efferent
neurons (conduct information from the CNS to the periphery), and interneurons (conduct information
between neurons).
Date 08/15/07
Lecture number 4
Page 3 of 9
(Unipolar Neuron)
Sensory Neuron
Interneuron
Motor Neuron
(Multipolar Neuron)
The supporting cells of the nervous system greatly outnumber the neurons and are responsible
for structural support and enhancing conduction rates of neurons. The main supporting cells discussed
were the myelin-producing Schwann cells of the PNS and the oligodendrocytes in the CNS, as well as
astrocytes, microglial cells, and ependymal cells of the CNS. The presence of a myelin insulation
allows for increased conduction rates along the nerve axon, and the presence of these myelin-producing
cells of the PNS and the CNS allow axons to be classified structurally as either myelinated or
unmyelinated.
The supporting cells were also noted to play an important role in a series of pathologies.
o Cancer of the nervous system is due to inappropriate proliferation of the supporting cells
of the nervous system
o The loss of myelin surrounding Cranial Nerve V is responsible painful facial sensations
experienced with tic doloreux
o The loss of myelin-producing supporting cells of the CNS is indicative of multiple
sclerosis
Date 08/15/07
Lecture number 4
Page 4 of 9
Nerves
In the PNS, the complete structure of an individual myelinated nerve axon is covered by a fibrous layer
called the endoneurium to become a nerve fiber. Groups of nerve fibers come together and are
surrounded by another protective layer, the perineurium, to become a nerve fascicle. A nerve is
composed of multiple fascicles, a connective tissue layer, and blood vessels all surrounded by a third
protective layer, the epineurium.
Basic Organization of the Nervous System

The reflex arc is a good example of the neuronal organization of the nervous system. A basic
reflex arc requires a receptor, a neuron to carry the signal from the receptor to the CNS, and at least one
more neuron to further relay that signal to an effector organ. Two types of reflex arcs were described.
o Monosynaptic reflex arc- This type of arc requires only two neurons. The example given in
class was the Patellar reflex. When the patellar tendon is tapped, a stretch receptor in the
quadriceps muscle is activated and sends a signal to the CNS. In the CNS, the afferent neuron
Date 08/15/07
Lecture number 4
Page 5 of 9
synapses directly with a motor neuron, which once activated sends a signal back to the
quadriceps instructing it to contract, extending the lower leg at the knee. Again, in this type of
arc there is only one synapse, between the afferent and efferent neurons within the CNS.
o Polysynaptic reflex arc- this is the more common type of reflex arc. In this arc, a receptor is
activated, sending a signal through an afferent (pseudounipolar) fiber to the CNS, where it
synapses with an interneuron within the spinal cord. The interneuron synapses with an efferent
(multipolar) neuron to send the reflex response back to the muscle, but also synapses with a
pathway that allows the sensation entering the CNS to be ultimately stored in the cerebral cortex
(we will learn more about this in Neuro and dont need to worry about it for this course, just
know that multiple synaptic connections are made in this type of arc.
The spinal cord is the only part of the CNS that we will be studying in Gross Anatomy. It extends from
the foramen magnum to the vertebral level of L2/L3 (and further caudally embryonically). It contains
cervical (C5-T1) and lumbar (L1-S3) enlargements with increased populations of cell bodies through
these segments to allow the fine motions of the upper and lower limbs respectively. A total of 31 spinal
nerves arise from the spinal cord as it travels inferiorly down the body. They can be divided as follows:
o 8 cervical nerves, which exit above the vertebrae for above which they are numbered. As there
only 7 cervical vertebrae, this means that the 8th cervical nerve exits between C7/T1. All spinal
nerves except for those of the cervical region exit beneath the vertebrae for which they are
numbered.
o 12 thoracic spinal nerves
o 5 lumbar spinal nerves
o 5 sacral spinal nerves
o 1 coccygeal spinal nerve
It should be noted again that the cervical spinal nerves are the only spinal nerves to exit the spinal
column above their respective vertebrae.
Not including structures superficial to the vertebral column, the spinal cord is protected by the following
structures:
1. The bony vertebral canal in which the spinal cord is housed
2. The meninges
Date 08/15/07
Lecture number 4
Page 6 of 9
o Dura mater- tough mother, the outermost protective layer

o Arachnoid mater- the intermediate, spidery layer. Deep to the arachnoid mater is the
subarachnoid space, which contains cerebrospinal fluid, or CSF. CSF is continuous between
the brain and spinal and is responsible for providing nutrients to and draining toxins away
from the cells of the CNS as well as providing a dampening action against any trauma to the
CNS.
o Pia mater- the innermost layer. The pia mater is microscopically thin and directly surrounds
the spinal cord throughout its entire length.
A lumbar puncture, LP, is a technique that allows one to assay the CSF. It is generally done to
test for meningitis but can also be used to observe CSF pressure. An LP is performed at the level of the
iliac crest, or approximately L4/L5. The spinal cord ends at about L2, so the only nervous tissue present
at the level of the puncture is the cauda equina, or horses tail. The cauda equina is composed of the
nerve roots and rootlets suspended in CSF, and will usually not be damaged by a lumbar puncture needle
as they are free to float away. In order to reach the CSF, the following layers must be transversed: skin,
superficial fascia, supraspinous ligament (then through an intraspinous process), ligamentum flavum,
dura mater, and arachnoid mater.
Date 08/15/07
Lecture number 4
Page 7 of 9
All 31 spinal nerves are mixed nerves, carrying both motor and sensory components. The
efferent component of each spinal nerve is composed of the ventral roots which have cell bodies
contained within the CNS, and the afferent component of the dorsal roots, which have cell bodies found
in dorsal root ganglion located outside the CNS. Both of these roots initially emerge from the spinal
cord at each level in small groups of rootlets. Shortly after exiting the spinal cord, but still within the
vertebral column, the dorsal and ventral roots join to form a spinal nerve. The spinal nerve then exits an
intervertebral foramina and continues for only a very short distance before splitting into a dorsal ramus
and a larger ventral ramus, both of which are also mixed nerves. The dorsal rami innervate the muscles
and skin of the back, while the ventral rami travel to the voluntary muscles, receptors, and viscera
throughout the rest of the body. There is also a sympathetic chain that travels with the spinal nerve, but
that will be covered in more detail in later lectures. Most nerves observed in Gross Anatomy will likely
be either rami or cranial nerves rather than spinal nerves due to their relatively short length
The white matter observed on the superficial portion of the spinal cord is composed of
myelinated fibers. The white color is due to the high concentration of myelin in this region. The gray
matter is an H-shaped column throughout the spinal cord and contains interneurons as well as cell bodies
which have axons exiting the CNS through the ventral horn at that level.
Date 08/15/07
Lecture number 4
Page 8 of 9
The segmental organization of the spinal nerves is extended to the dermis as the sensory branches of
each spinal nerve innervate distinct, but often overlapping, strips of skin around the body. Each strip of
skin innervated by a single spinal nerve is called a dermatome. Because of this segmentation,
dermatomes are clinically useful in the localization of lesions within the CNS, especially if a bilateral
loss of sensation is identified. The locations of the dermatomes of 5 clinically significant spinal nerves
are listed below.
C4 Top of Shoulders
T4 Level of nipples
T7 Xiphoid process
T10 Umbilicus
L1 Inguinal region
Dermatomes also play an integral role in referred pain, when the pathology of one part of the
body, generally the viscera, is interpreted by the nervous system as pain elsewhere.
Referred pain can be observed with appendicitis. When the appendix is inflamed, the visceral
afferent nerves relay a message to the CNS at the spinal cord segment T10. Initially this will be sensed
as pain in the umbilicus region, which shares a spinal nerve with the appendix. Pain cannot be sensed in
the area of the appendix until the organ becomes inflamed enough to push up against the body wall.
Date 08/15/07
Lecture number 4
Page 9 of 9
Herpes Zoster was the last topic discussed in todays lecture. This is from the same virus that is
responsible for chicken pox, but after the initial infection, the virus crawls up an afferent nerve and
lays dormant in the dorsal root ganglion. In some individuals the virus may become active again and
produce a rash or blisters along a dermatome at the site of the initial infection. Viral lesions of herpes
zoster may be recurrent and will always flare up on the same dermatome.
Lecturer Dr. Lauerman
The Medical Note-Taking Service Date August 15, 2007
Lecture Number: 06
NOTICE &DISCLAIMER
Note-Taker: Brian MacLaughlin The Medical Note-Taking Service makes every effort to provide accurate
Corrected by: Dr. Lauerman class notes. However, errors will occur from time to time. The user
Dr. Lauerman
Department of Orthopaedic Surgery
lauermaw@georgetown.edu
Business:
Dr. Lauerman will not respond to email questions but will be in his office the next two Tuesdays (8/21
and 8/28) at 7:30am for questions. Email Dr. Lauerman ahead of time to let him know you will come
by.
General remark from Dr. Lauerman:
- We must look at structures from several different perspectives to really appreciate 3D anatomy and for
proper interpretation
Lecture Notes Outline:

I. Spine anatomy
A. General Points
B. Bony
C. Intervertebral disks
D. Facets
E. Ligamentous Anatomy
F. Muscles
II. Spinal Cord
A. General Points
B. Blood Supply Spinous
C. Spinal Nerves process
III. Clinical Aspects
Course Gross Anatomy Lecturer Dr. Lauerman
Date August 15, 2007
Lecture number 06
Page 2 of 8
Notes
I. Spine Anatomy the most important structure in the human body
A. General points
Three main functions of spine: 1) transfer load, 2) guide/allow movement within discrete limits,
and 3) protect neurological tissue
Functional spinal unit: a vertebra, the disk below it, the vertebra below that disk and all
associated ligamentous structures
Spine consists of 7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral, and 4 fused coccygeal bones
(33 total)
Size correlations vertebral bodies increase in size and spinal canal increases in cross sectional
size in descent from cervical to lumbar level
Surface anatomical markers
C7 first large spinous process encountered on surface of body as you trace spine down from base of
scull (in anatomist language know as vertebra prominens), followed by T1
L3 Waist level
Midpoint of most cephalad aspect of iliac crests is L4/L5 interspace important for lumbar puncture
a
a
B. Bony
a
a
General Cervical Vertebrae
Cervical Vertebrae
Upper cervical vertebrae = C1 (atlas) and C2 (axis)
C1 is essentially a ring of bone; it lies below the base
of the skull and has no vertebral body.
C2 is more like other vertebrae; it starts to have a body,
but also has a superior protrusion, the dens, which was
supposed to be the body of C1 but attached to C2
in an embryonic stage
Subaxial vertebrae = any cervical vertebrae below C2
Spinous processes of C7 is not bifid while those
of C2-C6 are bifid, and serve as
surgical landmarks.
Lecture number 06
Page 3 of 8
Lamina extends laterally at an angle from spinous process.

Pedicle attaches the lamina to the vertebral body.
Facet joints allow movement between adjoining vertebrae.
Posterior elements vertebral arch (arch formed by the two lamina and spinous process).
Transverse process is unique at cervical level because it has the foramen transversarium for vertebral
artery to travel through up into scull.
Picture: Sagittal view of cervical vertebrae, anterior

A
B surface on left
The imaginary curved line from top arrow tip A to bottom
arrow tip A indicates the posterior cortex of the vertebral
body. The imaginary curved line from top arrow tip B to
bottom arrow tip B indicates the spinolaminar line, where
the lamina comes back and joins the spinous process
(reinforced piece of bone, see bright white = dense). The
interval between the posterior cortex of the vertebral bodies
and the spinolaminar line is where the spinal cord resides.
In trauma situations, look for disruption of the posterior
A B
cortical line or spinolaminar line.
Thoracic Vertebrae
Thorax is naturally kyphotic it has a forward bend. Vertebral bodies are bigger than in cervical and
spinous processes angle up, so spinous process of T6 appears in level with vertebral body of T7 on an x-
ray.
Transverse processes are more prominent and placed more to the posterior than cervical, and have
articulation with the ribs.
The thoracic spine is intrinsically stable part of spine (above T10) because the ribcage acts as a brace for
the spine.
Lecture number 06
Page 4 of 8
Lumbar Spine
Lowest mobile part of spine. Exhibits lordosis, sway, allows us to stand up straight. Vertebral bodies
very big here, transverse process now directly in coronal plane, and pedicles are in the cephalad (upper
half) of the vertebral body.
C. Intervertebral Disks (IVD)

IVDs are situated between two vertebral bodies. They function as shock absorbers and to guide/restrict
motion. Composed of outer annulus fibrosus (AF - the donut) and inner nucleus pulposus (NP - the
jelly). AF composed of stringy and tensile collagen which runs in crossing layers at 30 degree angles to
resist axial rotation in the disk. Too much disk rotation = injury.
NP gelatinous and watery, composed of proteoglycans (keep water in) and is greater than 70% water
by weight.
25% of spinal height is due to IVDs. As we age the disks degenerate and water is lost from NP, so both
height and shock absorption decrease.
D. Facets form follows function

Facet joints allow movement between one vertebrae and the one below it, and restrict and guide
movement in the spine. Inferior facet of superior vertebrae articulates with the superior facet of the
adjoining inferior vertebrae. The thorax doesnt move much because of the ribs, but the cervical and
lumbar spines do. Facet spatial orientation determines spinal movement.
Cervical
No axial rotation (vertical (to the sky) axis) but 45o up off of horizontal (ground) plane in sagittal view.
This defines motion you can do in cervical spine; you cant rotate the head without some bending as
well. Primary area of axial head rotation is in C1 and C2 because of easy rotation around the dens.
Thoracic
More axial rotation than in cervical: 20 degree outward (external) axial rotation and 60 degrees off of
horizontal in sagittal plane.
Lumbar
Not lots of rotation in lumbar region, but lots of flexion and extension: 45 degrees inward axial rotation
and 90 degrees up off of horizontal in sagittal rotation.
Lecture number 06
Page 5 of 8
E. Ligamentous anatomy Anterior

longitudinal
Lots of bands that hold the vertebrae together. ligament
Anterior Longitudinal biggest, attached to
vertebral body
Posterior longitudinal attaches some to fibers
of annulus
Interspinous and supraspinous very strong
Ligamentum flavum high in elastin so appears
yellow; starts at most cephalad part of inferior
lamina and projects to half way under lamina of
superior vertebrae, so helpful guide and protection during dissection under superior lamina.
Specialized cervical ligaments
Dens Synovial
Transverse ligament anchors C1 so it joints
does not move anteriorly (and compress the spinal
cord); reinforced by the alar (occiput to tip of dens)
and cruciform ligaments (runs vertically).
Synovial joints in both anterior and posterior to the dens
Transverse
because lots of rotation around C1 and C2. ligament
F. Muscles
Muscles act as stabilizers, naming not very important for our purposes.
II. Spinal Cord

A. General
Exits the foramen magnum in the skull and gives rise to bilateral spinal nerves at each level.
Two enlargements due to increased anterior horn (motor) cell numbers. More motor cells needed where
more muscles innervated (upper and lower limbs).
1. C4 C6 cervical enlargement which gives rise to brachial plexus
2. T9-T11 lumbar enlargement which gives rise to lumbosacral plexus
Spinal cord terminates in the conus medullaris at about L1/L2, giving rise to the sacral nerve roots.
Below L1/L2, no spinal cord but there is the cauda equina.
Lecture number 06
Page 6 of 8
Covered by the meninges three layers:

1. Dura mater hard mother, thickest layer on outside
2. Arachnoid mater elevated off of spinal cord; subarachnoid space (between arachnoid and
underlying pia) has CSF
3. Pia mater thin and flimsy; adheres to the cord and origins of spinal nerves, continues past
conus medullaris and forms the filum terminalae, also gives rise to denticulate ligaments
B. Blood Supply
Spinal cord is metabolically active, so is both blood supply and blood pressure dependent. Supplied by
three major arteries one anterior (major) and two paired posterior arteries. Aorta gives rise to
segmental vessels at each level that form intercostals vessels, and these give a branch that goes into the
spinal canal and anastamose (form a network) to form one anterior and two posterior spinal arteries.
C. Spinal Nerves
Cervical level nerves exit the intervertebral foramen almost laterally from where they originate.
Eight cervical nerve roots, but only seven cervical vertebrae, so cervical nerve C1 exits superior to C1
vertebral pedicle (between skull and C1), and cervical nerve 2 exits inferior to C1; this pattern continues
down to cervical nerve 8 exiting inferior to C7 (between C7 and T1). Then thoracic nerve T1 exits
below T1 vertebrae, and so on.
C5 nerve always travels just dorsal to the C4-C5 IVD, then exits in the foramen between C4 and C5 and
reconfigures at the brachial plexus, so C5 nerve root very susceptible to injury at this level if there is a
bone spur, fracture or slipped disk, etc.
Lumbar spine paired roots at each level give rise to lumbar and lumbosacral plexus that will form the
sciatic and femoral nerves.
T9-T11 spinal cord enlargement that gives rise to lumbar
and lumbosacral nerve roots, a.k.a. the cauda equina. Roots
initially travel vertically down the
vertebral canal, then turns obliquely across disk
space before exiting. L5 travels across L4-L5 disks space
(it is the most anterior root at the L4-L5 IVD),
wraps under L5 pedicle and exits through L5-S1.
Lecture number 06
Page 7 of 8
L4-L5 disk can still injure the L5 root, but sometimes if pathology occurs in the intervertebral
foramen, can also get L4 compression very laterally in the L4-L5 disk space.
For typical disk bulge (herniation) the disk will move posterior-lateral and will compress the obliquely
traversing L5 root. If foraminal disk herniation then will compress L4 further out.
Make sure to review normal vertebral structures on x-ray images provided in lecture PowerPoint.
III. Clinical Aspects:

- Lumbar puncture
To locate L4/L5 interspace, put your hands over the iliac crest and feel toward the midline, what you are
feeling is the L4 and L5 spinal processes.
- Common upper cervical spinal injury is fracture of the dens (thin bone without much blood supply),
which can damage the spinal cord. A surgeon may put in screws to stabilize the vertebrae if the dens is
fractured. In general, screws are put into the pedicles.
- Scoliosis
Curvature of the spine - typical problem for thoracic region. 3D deformity of curvature with rotation
and sagittal angulation, so get prominence of ribs on convex side combined with shoulder elevation. If
severe enough, surgery can make spine ~50% straighter and prevent further growth.
- Spondylolysis
Breaking of part of the spine. The pars interarticularis is the part of the bone between the superior and
inferior articular facet, and is a high stress area. It is the area that often gets injured in a stress fracture
resulting in spondylolysis.
- Person enters ER with spinal cord injury

Must check their blood supply to spinal cord is normal; if low the spinal cord is at risk for vascular
injury. One problem with spinal cord injury is that you lose sympathetic tone, so BP drops and have
even less blood supply to the spinal cord creates a worsening cycle.
Lecture number 06
Page 8 of 8
- One of most common sites for fracture is T12/L1 the transition zone between rigid thoracic spine
(due to rib cage), and mobile lumbar spine, also because of orientation changes in the facets.
If you have a fracture at the thoracolumbar junction, any or all nerve function below here can be
affected, such as bladder/bowel, hip/toe flexures. Must do a thorough neurological examine of lower
functions. All structures below the waist are at risk and no real pattern as to how they are affected.
-Spinal cord at largest between T9-T11, and the spinal cord/vertebral canal ratio (has implications for
risk of spinal cord injury) is largest at T10, so it is the greatest at risk area for same degree of
fractioning.
-Rheumatoid arthritis
Disease of the synovium. Inflammation
(rheumatoid synovitis) can destroy the
transverse ligament of C1, can even erode
into the dens, and allow for instability of C1/C2.
Therefore can get forward slippage of C1 on C2
(shouldnt move forward more than 1-2 mm).
In image to right, SAC (space available for cord)
is 11mm and ADI (atlanto-dens interval) is 10mm
(shouldnt be more than 3mm). If less than 14mm
of SAC then at risk for spinal cord injury; surgery
is required in this case.
IVD
MRI of herniated disk (sagittal view left)
Note that IVD appears white (lots of water
so white on T2 weighted image).
Axial view (right)
Looking up from patients feet; anterior on top
Thecal sac the water balloon the dura,
the spinal fluid, and the cauda equina inside it
Course GA
The Medical Note-Taking Service Lecturer Dr. CASQ

Date 16 August 2007
Lecture Number: 7
NOTICE &DISCLAIMER
Note-Taker: Rose Fu The Medical Note-Tak ing Serv ice makes every effort to prov ide accurate
Corrected by: UNCORRECTED class notes . However, errors will occur from time to time. The us er
Approved for distribution: assumes the risk for any and all err ors. We rec ommend that y ou us e
Introduction to Radiography
*Short lecture today: Dr. Cormier was unavailable so Dr. Suarez-Quian filled in. The following noteset
corresponds to the lecture given but there are lots of slides which are good for practice especially for the
practical. I think these would be worthwhile to go over.
X-ray:
X-rays are electromagnetic radiation. They are collimated, or
directed, through lead-lined shutters to avoid spreading. When
x-rays encounter something of substance, such as tissues and
bone, its energy is reduced so that less is available to interact
with the photographic film on the opposite side of the body.
Take this image on the left (if it does not reproduce well on
paper, please look to slide 32 on Dr. Cormiers slides): the
portions of the film which are darker are those which have
greater exposure to the x-rays. In other words, the dark
portions are places where the x-rays were not attenuated
significantly by tissues. Thus, the lungs, which are mostly air,
appear darker than bone.
Lyrics:
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Thought he worked his until I handled my biz
There I is - major pain like Damon Wayans
Low down dirty even like his brother Keenan
Schemin - dont bring your girl round me
True player for real, ask Puff Daddy
TRANSLATION:
Your current love interest no longer wishes to hear your fabrications about the length of your member. After I had
sexual intercourse with your woman, she became enlightened as to the proper way it is supposed to be performed;
violently and immorally. It would be in your best interest to keep your woman away from me as my sexual prowess
is very strong. If you are unconvinced, ask Puff Daddy.
Course GA Lecturer CASQ
Date 16 August 2007
Lecture number 7
Page 2 of 4
In the body:
- Air attenuates x-rays a little
- Fat attenuates x-rays more than air, but less than water
- Bone attenuates x-rays the most
*So here, the lungs should be dark. If we observed a white spot in the lungs, it would be
indicative of a growth which would then have to be examined via biopsy to check whether it is
cancerous.
The density of bone and marrow diminishes with age, so the ribs may look lighter than normal on x-
rays. Clinical correlate: osteoporosis, which is a condition where bone composition is normal, but
theres just not enough of it, can be detected by x-rays.
After the X-rays encounters tissue and/or bone, it tends

to spread; that is, the farther away the film is to the
body part we are trying to examine, the more blurry the
image. So, when we want to observe the heart, which
lies more anterior in the thoracic cavity, we would want
to do a Posterior-Anterior (PA) oriented radiograph:
the x-rays come from the back and the film is exposed
at the front of the body. This is the shortest distance
between the film and heart because the heart lies right
under the sternum. The PA oriented radiograph is
shown in the previous page. The image on the right is
of a Lateral radiograph. The direction from which the
x-rays hit the body determine whether it is a right
lateral or a left lateral radiograph. (*oblique refers to
radiographs that are in between lateral and PA.
Date 16 August 2007
Lecture number 7
Page 3 of 4
Fluoroscopy:
Dr. Suarez-Quian briefly talked about contrasting agents for
visualization of soft tissues. Contrasting agents should not be
toxic and must be high density in order to attenuate the
electromagnetic radiation. Some examples are the barium sulfate
enema which emits radiation and can be used to visualize the
colon (right). For visualization of arteries and veins, a digital
angiography can be performed using iodine as the contrast agent.
Iodine has a high atomic mass and is easily excreted via the
urinary system, making it extremely safe and easily tolerated by patients. Iodine can also be used to
visualize the kidneys, ureter and bladder. A series of images can be taken and then superimposed in
order to adjust contrast and define the structures of interest. With digital angiograms, we will now be
looking at images on a computer instead of developed films.
Sonography:
Also known as ultrasound, sonography uses high
frequency sound waves, not electromagnetic radiation,
generated by piezoelectric materials such as quartz.
These sound waves, broadcasted into the patient using
a probe may be absorbed, deflected or reflected by the
patient. The reflected waves are digitized by once it
reaches the transducer, creating real-time images on
the display panel.
Date 16 August 2007
Lecture number 7
Page 4 of 4
Computed Tomography:
Computed tomography uses electromagnetic radiation to
image the body in cross sections. The sections well be given
will be labeled with A (anterior), P (posterior), R (right), and
L (left). However, even if they are not labeled, we should be
aware that the top of the section is always the anterior
portionor the side where the sternum lies. Thus, when we
are looking at the image, the right side of the patient is the left
side of the image. You can imagine looking at a supine patient
from the feet upwards.
Using the CT, it is possible to alter parameters to generate
images depending on the need to visualize bones, tissues, etc. Contrast addition can also render an
arterial visualization.
Magnetic Resonance Imaging:

The body is surrounded with a magnetic field
3000x as strong as that of Earth. (The syllabus
says 4-5x, which is incorrect.) When the body is
subjected to the strong magnetic field, protons
throughout the body line up along the magnetic
field. Protons absorb the energy from a radio
wave and when the pulse ends, the energy
released is detected by sensors and create an
image.
MRIs are more expensive and consumes much
more time than CT scans. However, MRIs are
much better at articulating soft tissues on an image scan. For similar contrast on CT, we would have to
inject vessels with contrast dye. MRI does not require it.
Lecturer Suarez-Quian
The Medical Note-Taking Service Date August 17, 2007
Lecture Number: 8
NOTICE &DISCLAIMER
Note-Taker: Alex Engelman The Medical Note-Taking Service makes every effort to provide accurate
Thoracic Wall and Pleural Cavities

The Thorax is defined as the region between the neck and abdomen. It functions to protect the
thoracic and abdominal organs; resist the negative pressure of the pleural space during inspiration; and
provides attachment and support to the upper limbs and muscles of the upper limbs, neck, abdomen, and
back. The mammary glands are also found in the subcutaneous tissue of the anterior thorax.
Boundaries Bony Thorax Scapula

Ribs Clavicle Vertebrae
The thorax is bounded by the
T1
bony anatomy of the thoracic skeleton. 1

T2
T3
2 T4
This includes the 12 thoracic vertebrae 3
T5
T6
and scapula posteriorly, the ribs laterally, 4
5
T7
T8
R8-10 T9
6
and the sternum and costal cartilage 7
T10
T11
anteriorly. The opening at the superior T12
R11-12
end of the rib cage through which
Sternum Anterior View Costal Posterior View
Margin
cervical structures enter the thorax is
called the superior thoracic aperture, or the inlet. It is bounded by the T1 vertebral body, both of the 1st
ribs and their costal cartilages, and the manubrium of the sternum. Structures that pass through this
opening are the trachea, esophagus, major nerves (including the phrenic, vagus, and recurrent laryngeal
nerves) and vessels (including the common carotid, brachiocephalic, and subclavian arteries and the
internal jugular, brachiocephalic, and subclavian veins). The inferior thoracic aperture is the opening at
the inferior end of the rib cage through which thoracic structures exit the thorax and enter the abdomen.
It is oblique in orientation and is bounded by the T12 vertebral body, both 12th ribs, the costal cartilages
of ribs 7-12, and the xiphisternal joint. The diaphragm closes the thoracic outlet, separating the thorax
from the abdomen, and structures passing though the outlet must traverse the diaphragm (eg. inferior
vena cava and esophagus) or pass posterior to it (eg. descending aorta and thoracic lymph duct).
I like the American-Canadian border, 'cuz if you're walking on the border with a friend, and you
push your friend into Canada, he can't push you back right away, 'cuz first he has to go through
customs. "What brings you to Canada?":[Points to the side] "That asshole." Mitch Hedberg
Course Gross Anatomy Lecturer Suarez
Lecture number 8
Page 2 of 10
Surface Anatomy
The surface anatomy of the thorax Thorax Surface Anatomy
Suprasternal Notch (T2/3)
is important for the clinical observation T1
Sternal Angle T2
of the underlying organs. (Angle of Louis) T3
T4
TH
-Nipples: 4 intercostal space T5
T6
Sternum
th A P
-Apex beat of the heart: 5 intercostal T7
T8
space 3.5 in from midline T

T9
T10
M
-Heart Sounds: 4th intercostal T11
space T12
Aortic valve: 2nd intercostal space Xiphisternal

joint
Apex beat
5th intercostal space
on right sternal border 3.5 from mid-line
Pulmonary valve: 2nd intercostal

on left sternal border
Tricuspid valve: 4th intercostal on left sternal border
Mitral valve: 5th intercostal just lateral to left midclavicular line
There is a mnemonic for these heart sounds. From right to left, top to bottom the valves observed are
Aortic, Pulmonary, Tricuspid, and Mitral. The mnemonic is from right to left, top to bottom: All
Physicians Take Money and the intercostal spaces are 2,2,4,5.
Bony Anatomy
Ribs form the lateral boundary of the thoracic cage. The typical rib has a head, with two
articulating facets for the vertebra at its level and the vertebra above; a neck; a tubercle, which
articulates with the transverse process of the same vertebra; an angle; a distal site for articulation with
costal cartilage; and a costal groove, which runs along the inferior aspect of the rib and houses the
intercostal neurovascular bundle. It is this neurovascular bundle which is to be avoided when piercing
the intercostal space (placing a chest tube or performing a pleurocentesis) by inserting the needle
immediately superior to the rib and angling upwards to avoid the collateral vessels. The intercostal space
is the space between ribs and is named for the rib number above. There are 7 true ribs (1-7) which
attach directly to the sternum via their own costal cartilage; 3 false ribs (8-10) with costal cartilages
which join the cartilage of the rib above (forming the costal margin); and 2 floating ribs which do not
join the sternum at all. The costal cartilage, which joins the rib and sternum, adds flexibility (necessary
for respiratory movement and taken advantage of in thoracotomy) and provides resilience to the ribs in
Lecture number 8
Page 3 of 10
helping to avoid fracture. As ribs age they may undergo ossification, loosing elasticity and becoming
more prone to fracture. Ribs 2-7 are the most likely to break (anterior to the angle) and sharp edges from
broken ribs can damage the underlying lung tissue. Multiple rib fractures can lead to a condition called
flail chest, with paradoxical movement during breathing.
Sternum is the flat, vertically oriented bone that forms the anterior part of the thoracic cage. It
consists of three parts: the manubrium, the body, and the xiphoid process. The manubrium, the
trapezoidal bone at the superior part of the sternum, lies at vertebral level T3/T4. The jugular notch is
the indention on the superior aspect of the manubrium, and lies at the T2 level. On either side of the
jugular (or suprasternal) notch lie the clavicular notches, where the medial end of the clavicle articulates
with the sternum. The body of the sternum lies below the manubrium in a slightly different plane, hence
the junction of the body and manubrium form an easily palpable clinical landmark, the angle of Louis.
The angle of Louis lies at the level of the IV disc between T4 and T5 and is an important landmark as it
is the level of the aortic arch and the bifurcation of the trachea. The body of the sternum is scalloped by
the bilateral costal notches for articulation with the costal cartilages. Below the sternum is the xiphoid
process. The xipho-sternal junction lies at T9 and marks the superior level of the liver, central tendon of
the diaphragm, and inferior border of the heart. The sternum is rarely cracked, but when fractured the
associated damage to underlying heart and mediastinum is associated with a 25-45% mortality rate (how
we lost the peoples princess).
Muscles of the Thorax

Extrinsic Muscles are muscles of the thorax which have to do with movement of the upper
limbs. Posteriorly these include the familiar muscles of the back: trapezius, rhomboids major and minor,
levator scapulae, posterior superior serratus, and latissimus dorsi. The extrinsic muscles of the anterior
thorax are: Pectoralis Major innervated by the medial and lateral pectoral nerves
Pectoralis Minor innervated by the medial pectoral nerve
Serratus Anterior innervated by the long thoracic nerve
Intrinsic Muscles are the intercostal muscles and the transversus thoracis muscles. From
shallow to deep they are:
External Intercostals Fibers oriented as if putting hands in pockets (or from pits to
pubes). Serve to elevate the ribs when the first rib is fixed by the scalene muscles during
inspiration.
Lecture number 8
Page 4 of 10
Internal Intercostals Fibers run perpendicular to external intercostals. Serve to depress

ribs during forced exhalation (again, while the lower ribs are fixed).
-The neurovascular bundle that follows the costal groove runs between the internal and
innermost intercostals.-
Innermost Intercostals probably do something, but we dont care
Transversus Thoracis depress ribs at the midline and secure the internal thoracic
artery/vein to the underside of the sternum.
-All of the intrinsic muscles of the thorax are innervated by the intercostal nerve at that level-
-The blood supply to the intercostal muscles comes from three main arties in each intercostal
space: the posterior intercostal artery (branching directly from the descending thoracic aorta) and
the paired anterior intercostal arteries (branching from the internal thoracic artery).-
Mammary Gland
The mammary glands are accessory to reproduction and are actually modified sweat glands,
therefore have no capsule or sheath and are continuous with the superficial fascia. They consist
primarily of fat, but glandular tissue is present and divided into lobules that feed into lactiferous ducts.
Each duct widens into a lactiferous sinus which then empties into the nipple. The suspensory ligaments
of Cooper (Coopers Droopers as they age) support the breast and divide it into compartments. They run
from the skin to the deep pectoral fascia. The breast is bounded medially by the lateral edge of the
sternum, laterally at the midaxiallary line and vertically by the 2nd and 6th ribs. The superiolateral portion
extends towards the axillary fossa, forming an axillary tail.
-Vasculature: fed medially by the medial mammary branches of the internal thoracic artery
: fed laterally by the lateral mammary braches of the lateral thoracic artery
-Lymph Drainage: Lymph provides a route for metastasis of cancer cells. 75% of the lymph
(especially from the lateral quadrants) drains to the axillary lymph nodes.
: Supraclavicular nodes (upper quadrant) have a high risk of metastasis
: Parasternal nodes provide a route for cancer to spread between breasts
- Breast Cancer: In addition to lymph tracts, the veins draining the breast (intercostal and
vertebral) have no valves and thus can be a route of metastasis.
: 50% of cancers develop in the upper outer quadrant and metastases usually
involve the axillary tail and axillary lymph nodes.
Lecture number 8
Page 5 of 10
: Clinical signs of breast cancer include lymphedema (excess fluid due to

blockage of lymph drainage); puffy skin between dimpled pores (peau dorange
sign); dilated superficial vessels (increased vascular demand of tumor) and skin
dimpling due to tumor invasion of the suspensory ligaments of Cooper.
Thoracic Cavity
The thoracic cavity contains 3 compartments:
the mediastinum [9], containing the heart, great vessels,
trachea, esophagus, and thymus; and the paired,
bilateral potential spaces of the pleural cavities [7,8]
which are filled by the lungs and pleurae. Note if
asked to identify 7 and 8 on the film adjacent, the
correct answer would be lungs, not pleural cavities
(lungs are filled with air and thus radiolucent and dark
on film; while the pleural cavities, were they not only
potential spaces, are only visualized pathologically in
the case of a pneumo- or hemothorax). In healthy lungs,
the pleural space is practically nonexistent; the little space that does remain between the visceral and
parietal pleura is filled with serous fluid which lubricates the pleural surfaces and provides the surface
tension that keeps the lung in contact with the thoracic wall (necessary for the mechanism of respiration)
Respiratory System
The respiratory system is divided into the upper respiratory tract (will be covered later) and the
lower respiratory tract. The lower respiratory tract is comprised of the larynx, which protects the
opening to the trachea and houses the vocal cords, and the trachea, which splits at the angle of Louis
(T4/T5) into the left and right primary bronchi. Both primary bronchi and the trachea have cartilage that
keeps the airway open. The carina is a ridge that divides the two bronchi at the bifurcation. The
orientation of the carina favors the right bronchi, as does the fact that the right primary bronchus is
wider and more vertical, which means that the skittle that disappeared from your nose in 1st grade is
probably rattling around your right lung. Each primary bronchus enters the lung at the hilum (or root)
then divides into secondary bronchi, 2 in the left lobe and 3 in the right. These secondary bronchi divide
Lecture number 8
Page 6 of 10
again into segmental, or tertiary, bronchi which aerate discreet portions of the lung called
bronchopulmonary segments, 10 in each lung. Each bronchopulmonary segment has its own air, venous,
and arterial supply; and it is possible to remove a bronchopulmonary segment without damaging the rest
of the lung. The alveoli are the sites of gas exchange between air and blood and will be covered in
histology.
Pleurae
The pleura is a continuous, The Pleural Cavity
membranous sac which invests the
invading lung and then folds back
on itself to provide the opposing
boundary of the pleural space. The
part of the pleura that invests the
lung is termed the visceral pleura
(visceral pertaining to the covering
of an organ). The part of the pleura
that forms the outer wall, adjacent
to the wall thoracic cavity, is called
the parietal pleura (parietal
pertaining to body cavity). The
parietal pleura is divided into four parts that describe their location. These four are the cervical pleura
(superior), mediastinal (medial), costal (lateral), and diaphragmatic (inferior). The parietal pleura
reflects back on itself in locations where the lungs do not completely fill the pleural cavity during
expiration. These reflections are called the costomediastinal recesses (deep to the sternum, medially) and
costodiaphragmatic recesses (along the oblique base of the lung [T8-T10]) and give the lung space to
expand during respiration.
If the parietal pleura is damaged due to trauma (or visceral pleura damaged due to tumor
metastasis from the lung) air will enter between the parietal and visceral pleurae and create a true space
between the two. The air disrupts the surface tension that keeps the lung adhered to the thoracic wall and
will prevent the lung from expanding. The deflation of the lung in these cases is called secondary
atelectasis (primary being in utero before the lung expands). If air has entered the pleural space, the
condition is known as a pneumothorax. If blood enters the space it is called a hemothorax.
Lecture number 8
Page 7 of 10
The pleura receives blood supply from the intercostal arteries (parietal) and pulmonary and
bronchial vessels (visceral).
Only the parietal pleura receives somatic innervation (via intercostal and phrenic nerves). The
visceral pleura does not receive somatic innervation. Pleurisy is a painful condition of inflammation of
the pleura; but sensation comes only from the parietal pleura.
Surface Projections of the Lungs
The apex (or cupola) of the lung Surface Projections of Pleura and Lungs
Cervical Pleura in Neck
extends superiorly into the neck. The medial
border of the lung runs posterior to the
sternum, and then obliquely down from the 6th
rib anteriorly, to the 8th rib at the midclavicular R. Lung L. Lung
6th
line, and to the 10th rib on the posterior surface. 8th
10th
The anterior border of the left lung deviates

from the midline at the 4th costal cartilage to
Anterior View Posterior View
form the cardiac notch. The parietal pleura Pleura extends below 12th rib
margin at its medial extremity
extends for two ribs below the lung to
accommodate the expanding lung.
Because of the orientation and location of the lungs, care must be taken when performing
procedures within these borders. Central lines are commonly used to administer fluids to sick patients,
especially those whose peripheral veins will not support an IV. They are inserted into the subclavian
vein, inferior to clavicle, and aimed towards the root of the neck. Damage to the parietal pleura of the
cupola of the lung can occur in this region and a hemothorax may occur. Likewise, the parietal pleura
extending to the 12th rib means that parietal pleura damage may occur during kidney surgery.
Lungs
The right lung is larger and wider than the left, but shorter as the right dome of the diaphragm is
higher. Both lungs have oblique fissures but the right has an additional, horizontal fissure, meaning that
the left lung has two lobes (superior and inferior), while the right lung has three lobes (superior, inferior
and middle lobes). The left lung has a deviation on the medial surface, underneath the sternum, to make
room for the heart. It is called the cardiac notch. Below the cardiac notch, the small remaining anterior-
medial extension is called the lingula.
Lecture number 8
Page 8 of 10
The surface projections of the lungs are important for auscultation. Above the nipple on the
front, the superior lobe can be heard on both sides. Below the nipple on the right is the middle lobe;
while below the nipple on the left is still the superior lobe. The inferior lobe can be heard on the
posterior surface.
On the mediastinal surface of the lungs lies
the hilum, or root of the lung. The root of the lung
connects the lung with the heart and trachea. The
hilum is the site at which the airways, vessels, and
nerves enter and exit the lung.
Airways:
-Primary bronchi enter the hilum and split
immediately in the root of the lung. The
primary bronchus on the right side will be
superior to the pulmonary artery and is
called the eparterial bronchus.
Vessels:
-Pulmonary Artery enters superior and
anterior to bronchi
-Pulmonary Veins enter inferior and anterior to bronchi
-Bronchial Arteries supply oxygenated blood to the root, the lung itself, and to the visceral pleura
-Bronchial Arteries and Veins enter very close to the bronchi
Mechanism of Respiration
The objective of inspiration is to increase the volume of the thoracic cavity. There are three
diameters which must be increased to accomplish this.
-Vertical Diameter: from apex to thoracic outlet (1st rib 12th rib)
-Increased by the contraction of the diaphragm
-Antero-Posterior Diameter: from sternum to vertebra
-Increased by external intercostals (when 1st rib is fixed by scalene muscles)
-Transverse: across horizontal plane of thorax (between ribs)
-Increased passively by ribs moving laterally, secondary to external intercostals
Lecture number 8
Page 9 of 10
The increase in volume of the thoracic cavity is accomplished by the diaphragm and the external
intercostals moving the ribs up and out (similar to the motion of a bucket handle) and the sternum up
and forward (similar to the motion of a pump handle).
Eupnea: quiet inspiration involves muscular contraction, but exhalation is a passive process
-Deep: diaphragmatic
-Shallow: costal (external intercostals)
-Eupnea is shallow in pregnant women as the fetus pushes against the diaphragm
Hypernea: forced breathing involving active inspiration and exhalation. Hypernea recruits all the
accessory muscle of respiration to help expand the volume of the thoracic cavity. Usually
involves recruitment of the muscles of the upper limbs, scalene muscles, and serratus
posterior superior to aid in inspiration; and uses transversus thoracis, internal intercostals,
and abdominal muscles for forced expiration.
Doctor Suarez started the lecture with a

clarification of the location of the lumbar
enlargement.
The Lumbosacral enlargement occurs at

vertebral body level T11-L1. The nerves
that originate or terminate in this section of
the spinal cord serve dermatomes L1-S3
and exit the spinal canal in between the
vertebral bodies L1-S3.
Lecture number 8
Page 10 of 10
Lecturer: Dr. Suarez-Quian
The Medical Note-Taking Service Date: 08.20.07
Lecture Number: 09
Class of 2011 Page: 1 of 9
NOTICE &DISCLAIMER
Note-Taker: Aaron Laviana The Medical Note-Taking Service makes every effort to provide accurate
Corrected by: Uncorrected class notes. However, errors will occur from time to time. The user
Lymphatic System:
U
Dr. Saurez began by saying this is one system you really dont see in gross anatomy unless theres real
pathology in your cadavers Nonetheless, expect many exam questions, since its clinically relevant.
U U
-He also stated hes going to follow very much whats on the syllabus
Composition:
U
Lymph: defined as tissue fluid thats clear water (Greek etymology: water, yellowish fluid)
Vessels: - lymphatics
Structures and organs comprising lymphatic tissue:
Red Bone Marrow didnt discuss much on this b/c we will be covering this in detail in histo and micro
3 Main Functions:
U U
1.) Draining interstitial fluid or tissue fluid (at some point weve probably all experienced lymphedema,
or swelling, as a result of obstruction of lymphatic vessels or lymph nodes ie from a burn)
2.) Transporting dietary lipids
3.) Protecting against invasion Hes only going to mention this, not discuss it or test us on this,
since well be getting plenty in immunology (itll seem basic FOR NOW)
Why Lymphatic system exists:
U
Our heart pumps blood and plasma to the rest of the body, stemming first from the aorta or
pulmonary arteries and then traveling through capillaries where blood and plasma return to the heart via
the venous system
This system is 90% efficient, so we must find a parallel system (lymphatic system) to return the
10% fluid lost to general circulation otherwise wed bloat up and the heart would stop pumping since
the circulatory system would lose all its fluid.
Course Lecturer: Dr. Suarez-Quain
Date: 08.20.07
Lecture number: 09
Page 2 of 9
10% of fluid found in plasma does not return back into systemic
circulation via venous return. This becomes the lymph.
SYSTEMIC CIRCULATION PULMONARY CIRCULATION

Lymph node
Lymphatic
capillaries
Subclavian vein Pulmonary blood

capillaries
Lymphatic vessel
Valve
Arteries
Lymph node
Systemic blood capillaries
Lymphatic capillaries
Arrows show direction of flow of lymph and blood
How lymph formation occurs:

Arterial blood and plasma move through arterioles and eventually capillaries. Microscopically, around
the capillaries, are blind-ended vessels (thinner and more valves than veins) called the lymphatics,
which have small openings between their cells. Some of our plasma (fluid in the blood before its has
coagulated; serum, meanwhile, has no clotting factors and is the fluid above the coagulate) proteins will
escape from the capillaries and end up in our tissue. This is due to hydrostatic pressure being greater
than oncotic pressure- or movement into the capillaries- and when enough fluid/protein has escaped it
must return into circulation. At this point, the fluid buildup and thus pressure buildup causes the
lymphatic vessels to open up allowing interstitial fluid to rush in.
Location of lymphatic vessels:
Its located everywhere except those areas lacking circulation. If we dont get circulation to a
particular part of a tissue, theres no excess fluid to return back to circulation.
Its easier to know the places where the lymphatic system doesnt exist (avascular) and assume
everywhere else has lymphatics.
Places without include cartilage, epidermis, cornea of eye, portions of the spleen (even though
U U U U
the spleen is a lymphatic organ itself), bone marrow, and the CNS (Remember we have CSF replacing
U U U U
the function of the plasma for the brain and spinal cord. Without plasma existing anywhere in the CNS,
we dont need lymphatics.)
Date: 08.20.07
Lecture number: 09
Page 3 of 9
The vessels of lymphatic system follow general patterns. Superficially, in our limbs, skin,
abdomen, and thorax they follow the veins. Viscerally, they the arteries in retrograde fashion This is
Visceral opposite arteries; Superficial - veins
The lymphatic system begins as lymph capillaries intertwined btw arterioles and venuoles. They get
larger, turn into vessels, and pass through structures that look like little peas collection of structures
with valves known as lymph nodes. These lymph nodes contain a collection of lymphocytes that play a
key role in our immune system. During infection, these nodes swell with lymphocytes fighting bacteria.
The lymph vessels eventually enlarge, and after passing through several lymph nodes, they pass
through lymph trunks which drain to 2 lymphatic ducks (right lymphatic and thoracic). Lymph
capillaries and vessels wont be seen in cadaver, but ducts (thoracic) will be seen. Its these ducts that
drain into circulation.
Date: 08.20.07
Lecture number: 09
Page 4 of 9
Thoracic duct vs. Right lymphatic duct:

The right lymphatic duct drains right upper quadrant (r side of head, r neck, r thorax, entire right
upper region), and the duct ends where r subclavian vein intersects right internal jugular vein (called r
venous angle).
The thoracic duct drain lymph from the remainder of body and ends @ the intersection of the left
internal jugular and subclavian veins essential to know which parts of the body are drained by which
There are 500 lymph nodes throughout body: superficial (cervical, axillary if you have acne on chest,
this infection can travel to the axillary lymph nodes allowing you to palpate them- , thoracic, inguinal)
vs. deep (tracheo-bronchial, aortic, iliac). You cannot palpate these, but infection can still travel to
them and metastasize. Again, we dont need to know much about their function other than they filter
lymph and are unidirectional. where lymphatic and immune system intersect (lymphocytes, etc)
Bubonic plague (bubos groin)- infection of lymph nodes in inguinal region. First symptoms
were black swollen lymph nodes in groin, and lymphocytes couldnt fight off infection.
Understanding lymphatic direction is essential for how lymph drains and for understanding how a
primary cancer will metastasize downstream from its original site.
Swollen and painless lymph nodes generally associated with cancer
Swollen, tender, and painful generally some type of bacterial infection
Lymph flow: - tissue fluid thats escaped high pressure of arterial system
1.) contraction of our skeletal muscles helps propel lymphatic fluid into larger lymphatic vessels,
trunks, and general circulation (even as we sleep)
2.) every time we inhale we create pressure gradients in our abdomen (low in thorax, high in
abdomen)
3.) Smooth muscle cells surrounding lymphatic vessels
-if any of these goes awry, youll get a buildup of excessive tissue fluid- edema (excessive accumulation
of interstitial fluid)
Causes of edema:
1.) Obstruction of lymph nodes ie cancer metastasis or infection - fluid cannot get through lymph
nodes, so you get buildup
Date: 08.20.07
Lecture number: 09
Page 5 of 9
2) Pregnant uterus problem during late pregnancy When you take into account fetus, uterus, and
placenta this is 20-30 lbs of extra weight crushes lymphatic vessels (blockage) thus encourage
pregnant women to sleep on their side if they get excessive fluid buildup in lower extremities
3.) Excessive lymph formation and increased permeability of blood capillary after injury
When you injure an ankle ice (keeps lymphocytes from recruiting more of a reaction that leads
to swelling) and elevate (gravity helps bring tissue fluid back into circulation). You need gravity to
increase flow through vessels to compensate for torn or damaged lymphatics
4.) Increased capillary pressure that is when youre destroying your liver or the metabolism not
putting out enough protein (ie alcoholics, not putting enough albumin osmotic pressure changes in
vessels, so you get more fluid escaping into tissues leading to edema)
3 Functions of the Lymphatic system:
Function 1: Return of Tissue Fluid (lymph back into circulation)
U U
Lymphatic capillaries are blind vessels composed of overlapping lymphatic endothelial cells. As
tissue fluid increases in the tissue layers, the pressure increases until it reaches a point where tissue
pressure is greater than fluid pressure inside the capillaries. This opens up the overlap btw endothelial
cells. Pressure then builds up inside capillaries with increased fluid, and this reaches a point where
endothelial cells close allowing lymphatic fluid to move up through the vessels
Function 2 (equally important): transports dietary lipids from GI to blood
U
Abdomen nothing more than long tube coiled on itself where we absorb nutrients
The small intestine isnt smooth but is composed of many microscopic folds (villi) inside these
villi are lymphatic vessels called lacteals (bc theyre milky white when you absorb fats think lactose
but its nothing more than fat being absorbed through epithelium and entering lymphatic vessels)
The whole point of this is that when you first take a meal, the fat that you eat bypasses the
metabolism in liver goes through thoracic duct and then into general arterial circulation before
reaching liver. This could be problematic if you ingest poisons. The fat in lymph makes it creamy white
hence its called chyle
Date: 08.20.07
Lecture number: 09
Page 6 of 9
Function 3: Immune Response (lymphocyte activation)

U
Only mentioned briefly nothing more than lymphocytes that fight off infection are made in
bone marrow. Those destined to become B cells develop immunocompetence in red Bone marrow while
those destined to be T cells develop immunocompetence in the Thymus. From here the lymphocytes are
activated in secondary lymph nodes (lymph nodes) and from there they leave and recirculate back to
lymph nodes. This is all you need to know for this course.
Clinical issues of lymphatic system:
Principle 1: which lymph node a particular lesion (infection/cancer) will drain to
U
Mammary gland: 75% drains to axillary lymph nodes

They have a good margin (referring to lumpectomy) means the physician took out the primary tumor
and resected area around to look for metastasis away from primary site. An axillary lymph node
dissection will also be performed the most proximal lymph node to tumor is removed and analyzed for
metastasis. If it did metastasize, then you go to the next lymph node and so on until you find some free
of cancer.
2nd example testicular cancer. In visceral organs lymph drains with arteries. This will not
P P
drain to inguinal region, since testes are visceral organs that migrated into scrotum during development.
Its lymph follows blood supply in retrograde fashion to lymph nodes of aorta (whereas scrotal skin
Date: 08.20.07
Lecture number: 09
Page 7 of 9
would drain to inguinal lymph nodes). Testicular cancer metastasizes to regions where it has ample
spaces to grow (not skin of testes) and then metastasizes all over to regions such as the brain (think
Lance Armstrong)
Principle 2: Know what body regions are drained by an enlarged lymph node(s)
U
Reverse of first principle. In general, theres an imaginary line going across the umbilicus (referred to as
the watershed or transumbilical line), in which, lymphatic drainage above umbilicus drains to superficial
axillary lymph nodes and below this line it drains to superficial inguinal lymph nodes.
Principle 3: When mult. Lymphatic regions are involved, consider systemic disease (worst case
U
scenario)
If a patient has right and left axillary lymph nodes swollen we must assume theres a systemic
infection or a cancer that has metastasized to all of the superficial axillary lymph nodes. You must look
for primary site of cancer.
Date: 08.20.07
Lecture number: 09
Page 8 of 9
Clinical correlates of when the lymphatic system goes awry:

Lymphangitis (-itis inflammation) inflammation of the lymph system inflammation presents on
U U
dorsum of skin b/c skin is tightly adhered to connective tissue on underside of palm to grasp fine things
from tabletop. Imagine skin rolling every time you picked something up. So if we get inflammation of
palmer surface it presents on dorsum
Can be due to burn, insect bite, trauma, etc
Lymphedema (lymph accumulation)
U U
elephantiasis caused by the filarial worm W. Brancrofti in areas with poor sanitation (ie Haiti)
Causes a blockage of the superficial inguinal lymph nodes which leads to large fluid
buildup in the outer scrotal lymphatics (not testes) of males and legs of females
Post-radical mastectomy Here, the axillary lymph nodes are removed, leading to fluid
accumulation (edema). Over time, new lymph vessels will form and take over function of axillary lymph
nodes, but initially the person will suffer swelling must elevate upper limb at night to have gravity
help force fluid down. Other picture on ppt. is a person whose superficial inguinal lymph nodes were
damaged/removed (perhaps due to a physician looking for metastasis of cancer). From low cabin
pressure on airplane, the persons lower limb swelled due to lack of pressure returning lymph to venous
system.
Stages of Lymphedema:
U
Mild edema is still pitting limb size is normal or almost normal size in the morning due to tissue
U U
fluid youre pushing out of the way. After remove pressure the swelling goes back to where it was
previously
Moderate tissue is spongy consistency, non-pitting constant pressure
Severe irreversible swelling and hardening of tissue (fibroses). The tissue dies (becomes necrotic)
and youd have to amputate the limb. This is a perfect medium for bacteria and recurrent infection.
Lymphedema (infection) may result in the following symptoms: rash, red blotchy skin, itchy,
discoloration occurs. Its essentially tissue fluid developing between deep fascia and skin.
Chylous Effusion (see below): If you damage the thoracic duct (which returns 75%-80% of all
lymphatic fluid to general circulation) in thoracic surgery or in an accident (damage the vertebrae which
could damage thoracic duct), the lymph traveling through the thoracic duct will leak into the pleural
cavity. Fat soluble vitamins will drain here, so not only do you get tissue buildup, youre not taking in an
Date: 08.20.07
Lecture number: 09
Page 9 of 9
appropriate diet. The accumulated chylous effusion (fat and nutrients) must be drained and re-inserted
into a vein. Finally, the thoracic duct must be repaired to avoid additional complications.
1 Question was asked at the end of class:

Do lymph nodes regenerate?
No, but lymphatic vessels might regenerate overtime to minimize lymphodema
.If you have any questions feel free to email me, though I can guarantee Dr. Suarez knows more.
Lecture Number: 10
NOTICE &DISCLAIMER
Note-Taker: Lindsay Edwards The Medical Note-Taking Service makes every effort to provide accurate
The Heart (I left my pump in San Francisco)
Announcements: The MP3 for the Aug 15 lecture was not recorded, so we cant access it. Take-home
message: Come to lecture! Dr. Suarez-Quian also read an email about the overwhelming nature of
Wednesdays prossection. Dr. Suarez-Quian answers that the pace of the course is going to pick up, so
we have to learn to manage our time. As far as the pre-lab goes, Dr. Suarez-Quian suggests we watch the
videos. Also, depending on whether your prossection is early or late in the afternoon, tailor your
presentation to be more of a pre-lab or a review. He also empathizes with us. Med school is hard! You
can whine a little, but then move on. Dr. Suarez-Quian says we can do it!
Today well cover the following: historical perspective, normal anatomy, and pathology. Heart
symbolism is big. Imagine if the heart symbol was a pump. Ex. I pump for Jenny. What?
Peter Houghton is the first permanent lifetime recipient of the Jarvik 2000 left ventricular assist device.
Hes been alive for 7 years. He says I have no feelings in response to how he feels.
Mediastinum-
The medistinum is a broad structure that separates the two pleural cavities. The mediastinum is
subdivided into several smaller regions. A transverse (horizontal) plane extending from the sternal angle
(angle of Louis) to the intervertebral disc btw. vertebrae TIV and TV separates the menubrium into the
superior and inferior mediastinum. The pericardial sac further divides the inferior mediastinum into the
anterior, middle (includes pericardial sac and its contents), and posterior mediastinum.
The superior mediastinum includes the SVC, Brachiocephalic v., Arch of aorta, Thoracic duct,
Trachea, Esophagus, Thymus, Vagus n., L. recurrent laryngeal n., and Phrenic n. In the inferior
mediastinum, the anterior mediastinum contains the thymus, lymph nodes, and connective tissue. The
middle mediastinum houses the pericardium, heart, roots of great blood vessels, the arch azygos v., and
Course: Gross Anatomy Lecturer: Dr. Suarez-Quian
Date: 8/21/2007
Lecture number: 10
Page 2 of 9
main bronchii. The posterior mediastinum contains the esophagus; thoracic aorta; the azygous,
hemiazygous, the vagus nerves; sympathetic trunks; and splanic nerves.
The mediastinum represents all 11 physiological systems present in the body. This is an important area!
Cardiovascular Disease (CVD):

An estimated 60,800,000 Americans have >1 type CVD (thats 1 in 5 males and females). Congenital
and acquired diseases of the heart are the leading causes of morbidity and mortality in the U.S. and other
developed countries. Other stats: 50,000,000 Americans have high blood pressure; 7,300,000 myocardial
infarction; 6,400,000 have angina pectoris; 4,500,000 have strokes; 1,000,000 have congenital
cardiovascular defects; and 4,700,000 have congestive heart failure.
Heart disease facts: There are approximately one million deaths per year in the U.S. due to heart
disease of some form; Since 1900, CVD has been the number one killer in the U.S. every year except
1918 (the year of the famous Spanish flu); CVD claims almost 10,500 more lives each year than the next
six leading causes of death combined; 90% of sudden death fatalities (approximately 460,000 per year)
are due to heart disease; Approximately 75% of all sudden cardiac deaths occur in men; 90% of victims
are males between the ages of 45-64; Approximately 15,000 hearts are needed annually for
transplantation, but only about 1-2,000 are available (This is probably b/c of the way we are brought up
to think about the heart).
Alexandrian Medicine:
What do we know about ancient medicine that leads people to put so much emphasis on the heart? At
the time of Hippocrates, there was minor surgery. Not much had changed by the time of Erasistratos and
Herophilos. By 1st century, there was already a textbook, De medicina by Cornelius Celsus. What
happened in between that led to the emphasis on medicine and the heart isnt well documented.
Greek thought (circa 200 B.C.): The concept of the pump wasnt understood. The Greeks
thought the heart had 4 main vessels (2 arteries and 2 veins). Valves were present at the root of the 4
vessels. They pictured the heart as divided into 2 sides. The right side was believed to hold blood
(without pumping), while the left side contained intelligence. Aristostle proved this last bit by pouring
water in the L atrium. He also believed there was a little man in the heart making the lub-dub sounds.
Date: 8/21/2007
Lecture number: 10
Page 3 of 9
By 270 B.C., the Greeks realized the heart was a pump, receiving blood from veins and pumping
it out via arteries. They still didnt understand circulation. They realized the heart had 4 chambers (2
atriums and 2 ventricles). They described the tricuspid and bicuspid valves and that these valves were
anchored to the heart by chords. Erasistratos observed 3 sets of branching structures (arteries, veins, and
nerves), and determined that all tissue had to be composed of the finest branches of these structures. At
homeostasis, there was a normal balance of blood and air. According to Erasistratos, patients who spat
blood suffered from too much blood in the lungs and could be treated by tying the limbs to hold blood
there. This is how the concept of bloodletting originated. George Washington died of too much
bloodletting. Antoine Louis fought against this concept.
Contrary to what some like to think, Western medicine didnt discover everything we know about
medicine. Etched stones found in Ica, Peru, show antomy and suggest that surgical procedures such as
Caesarian sections were performed before 20,000 B.C.E.
**Dr. Suarez-Quian says none of this history will be on the test**
The Pericardial Sac (pericardium):

The pericardium (in the middle mediastinum) is a fibrous sac surrounding the heart and the roots of
great vessels. It consists of 2 components: the fibrous and serous pericardium. The fibrous pericardium
is a tough connective tissue layer that defines the boundaries of the middle mediastinum and functions to
protect the heart against overfilling with blood. The fibrous pericardium is fused to the adventitia of
great vessels, bound to the central tendon of the diaphragm, and attached to the posterior surface of the
sternum.
The serous pericardium is thin and consists of 2 parts: the parietal layer (lines the inner surface
of the fibrous) and the visceral layer (aka epicardium; adheres to heart and forms it outer covering).
There is a potential space with a bit of fluid (to facilitate movement of the heart) btw. the two layers
analogous to the pleural space. Clinical note: Pericarditis is inflammation of the pericardium. Possible
causes include viruses and bacteria. Before oral surgery, an oral surgeon will give the patient a
prophylaxis treatment to help prevent this type of infection. Cardiac tamponade is a condition in which
fluid or blood accumulates in the pericardial cavity. The elevated pericardial pressure puts significant
pressure on the heart, and can cause ineffective pumping of blood, shock, and often death. Ruptured
Date: 8/21/2007
Lecture number: 10
Page 4 of 9
aortic aneurisms, ruptured myocardial infarcts (wall itself ruptures), and penetrating injuries can cause
cardiac tamponade. A patient with cardiac tamponade will slowly go into shock. He may have dec.
arterial & pulse pressures, but these are not pathognomic. His heart sounds will become distant, and
blood will accumulate in his neck veins. Finally, his venous pressure will become elevated, which is
pathognomonic. Cardiac tamponade is treated by a procedure called pericardiocentesis, in which fluid is
aspirated from the pericardium. In order to avoid damage to the pleural cavity, pericardiocentesis is
performed at where there is no parietal pleura, usually at one of 2 spots: 1) through the 5th or 6th
intercostals space at the left sternal border at the cardiac notch of the left lung or 2)through the
infrasternal angle.
We didnt talk about this is lecture, but the following is good to know. The parietal and visceral
layers of the serous pericardium are continuous around the roots of great blood vessels. These zones of
reflection occur in two spaces: one superiorly, surrounding the arteries, aorta and pulmonary trunk, and
one more posteriorly, surrounding the veins, the superior and inferior vena cava and the pulmonary
veins. The spaces formed within these reflections of serous pericardium are called the pericardial
sinuses. The oblique pericardial sinus is the cul-de-sac that forms within the J-shaped reflection
surrounding the more posterior reflection described above. The transverse pericardial sinus is the
passage that forms btw. the two sites of reflection. It lies posteriorly to the ascending aorta and
pulmonary trunk, anteriorly to the superior vena cava, and superiorly to the left atrium. Clinical note:
The location of the transverse pericardial sinus is exploited during coronary by-pass surgery. A surgical
clamp is introduced into the space and blood flow of aorta and pulmonary trunk is stopped momentarily
before great vessels are connected to the bypass machine.
Organization of the Heart:

Be familiar with the location of the following parts of the heart: the left and right atrium, left and right
auricle, coronary sulci (grooves btw. atria and ventricles), anterior and posterior interventicular sulci/
grooves (btw the two ventricles), and the left and right ventricle. Note that the grooves are perpendicular
to one another. The sulci contain major arteries (like the R coronary artery) that provide energy to the
heart, so they are important.
Coronary arteries and veins: Veins are like pajamas--in the heart, they come in S, M, and L.
Date: 8/21/2007
Lecture number: 10
Page 5 of 9
Note the following veins and arteries in the heart: anterior cardiac, small cardiac, middle cardiac, and
great cardiac veins (well see these during the dissection); the right coronary artery (coronary artery
circulation provides energy to the heart) the sinuatrial node branch, the right marginal branch, and the
posterior interventricular branch (in 85% of people, this branch arises from the R coronary artery; in
15%, it comes from the L coronary artery); the left coronary artery; the circumflex; and the left anterior
descending vessel (LAD). Note that the right coronary artery dominates the coronary arterial system.
Clinical note: An arteriorgram is the injection of contrast material or dye into one or more arteries to
make them visible on an x-ray. Blood flow can then be evaluated via fluoroscopy (continuous x-rays).
Werner Theodor Otto Forssmann (1904-1979): first catheterization

As a 1st yr med student, Forrssmann developed the technique for heart catheterization involving
inserting a 65 cm cannula into his own antecubital vein, walking to x-ray, and photographing it in the
right auricle. He published, graduated med school in 1929, was forced out of cardiology residency for
heretical practice and became a urologist, joined Nazi party and was a prisoner of war, and received the
Nobel prize in 1956 with Andre Cournand and Dickinson W. Richards.
Coronary Artery Disease:

Occlusion of a major coronary artery leads to myocardial infarction (inadequate oxygenation of an area
of myocardium and cell death). Occlusion can be partial or full. Slide below shows sites of coronary
artery occlusion in order of frequency.
Date: 8/21/2007
Lecture number: 10
Page 6 of 9
Percutaneous transluminal (coronary) angioplasty is a procedure that widens the coronary artery
at the site of obstruction. A deflated balloon catheter is inserted into the femoral artery in the thigh,
passed through the external and common iliac arteries, into the aorta and finally the coronary artery. The
balloon is inflated at the obstruction, widening the artery and re-establishing circulation. Plaques come
back, however, so a stent in placed at the site. A stent, a short narrow metal or plastic tube (often mesh-
like), is inserted into the lumen of a previously blocked artery to keep it open.
If the coronary artery disease is severe, coronary artery bypass grafting may be necessary. The
great saphenous vein in the lower limb, internal thoracic, or radial artery is harvested, divided into parts,
and used to bypass blocked sections of coronary arteries.
Cardiac Chambers: receiving and discharging chambers. Tattoo this image in your mind:
R atrium- R border of heart in anatomical position; divided into 2 internal continuous spaces indicated
internally by the smooth muscular ridge called the crista terminalis. The sinus of venae cavae lies
posterior to the crista and is smooth. The atrium proper (includes the auricle) lies anterior to the crista
and is covered by ridges called musculi pectinati. The fossa ovalis is the thinnest part btw. the two atria
and is a remnant of the foramen ovale, which allows oxygenated blood to bypass the lungs and enter the
R atrium during fetal circulation. (see Grays pg 163-164 for more on the R atrium)
R ventricle- forms most of anterior surface of heart and a portion of diaphramic surface; contains
anterior, posterior, and septal papillary muscles. The right atrioventricular orifice is closed during
ventricular contraction by the tricuspid valve, so named b/c it has 3 cusps. Each cusp attaches to
papillary muscles via chordae tendoneae. The septomarginal trabecula (the moderator band) tightens the
Date: 8/21/2007
Lecture number: 10
Page 7 of 9
chordate tendoneae so the tricuspid valve can function to prevent backflow from the ventricle to the R
atrium. (more on the R ventricle on Grays pg 164)
L Atrium- forms most of base/posterior surface of heart
L ventricle- anterior to left atrium; contributes to diaphramic, anterior, and left pulmonary heart
surfaces; forms apex; blood enters through left atrioventicular orifice; contains anterior and posterior
papillary muscles (which are a little thicker than R ventricles, b/c they have to pump blood to the body).
(more on the L ventricle on Grays pg 167)
Blood Flow through heart:

Thin-walled atria receive deoxygenated blood into heart. Blood enters the R atrium via the superior and
inferior venae cavae and the coronary sinus. From the R atrium, blood passes into the thick-walled R
ventricle via the right atrioventricular orifice in a horizontal and forward direction. The conus arteriosus
is the outflow tract of the R ventricle and leads to the pulmonary arteries, which carry the blood to the
lungs. Oxygenated blood from the lungs enters the L atrium and, subsequently, the L ventricle via the
left atrioventricular orifice and flows in a forward direction to the apex. From here, the blood is pumped
through the aorta to the body.
The cardiac cycle:
The dub of the "lub-dub sound made by the heart as it beats is caused by the closure of the aortic and
pulmonary valves at the end of ventricular systole. As the left ventricle empties, its pressure falls below
the pressure in the aorta, and the aortic valve closes. Similarly, as the pressure in the right ventricle falls
below the pressure in the pulmonary artery, the pulmonary valve closes. The closing of the
atrioventricular valves at the beginning of ventricular systole cause the lub of the "lub-dub." This
closure is what Aristotle was hearing, not the little man.
Cardiac conduction system:

Initiates and coordinates spontaneous contraction of musculature of atria and ventricles. The conduction
system of the heart is organized into 4 basic components: sinu-atrial node (where pacemaker is located),
conduction travels to atrioventricular node (fed by pos coronary artery, 85% hard right), atrioventricular
bundle, and subendocardial plexus of conduction cells. (More on Grays pg. 177)
Date: 8/21/2007
Lecture number: 10
Page 8 of 9
Finally, Dr. Suarez-Quian said that we arent going to get into radiology, but we can appreciate the
structures (like the heart chambers) on chest film.
Date: 8/21/2007
Lecture number: 10
Page 9 of 9
Lecturer: Dr. Charles Read
Lecture Number: 11
NOTICE &DISCLAIMER
Note-Taker: Brittney Lewis The Medical Note-Taking Service makes every effort to provide accurate
Dr. Charles Read opened up the lecture with background on himself. He remembered how in 1981, his
first year in medical school, he sat in the back row and looked on in awe at the clinicians who lectured to
his class. From this he highlighted that the most significant aspect of making through medical school is
the time and energy put forth. We are all here despite a very intense screening process and thus we are
all capable of learning the information and passing our exams. Finally, he closed his opening with a
welcome to the finest profession in his eyes. It is a profession where we are lucky to have strangers
who every day open up with stories from their lives.
Now, onto the actual lecture. Dr. Reads lecture centered around chest films from different patients. He
started his presentation with a discussion of a normal chest film.
Basic Chest X-Ray

Remember from our radiological imaging lecture by Dr. Suarez what an X-Ray entails. To refresh your
memory, it is basically shadows cast on a plate. This means X-Rays are sent through the patient and
those that travel through the patient and make contact with the film cause the film to turn black. Today,
almost every X-Ray we will encounter is a digital X-Ray (the same idea as the traditional with the
difference being that it is no longer film; but rather, a grid that keeps count of the hits of radiation and
projects a digital picture on a screen).
In this first picture, Dr. Read explained it is in frontal view (the patient is looking at you and you are
looking at the patient). Therefore, the right side of the patient is on the left side of the image and vice
versa. Some landmarks to make sure you orient yourself are:
Heart most of it lies on the patients left
Gastric Bubble this is also on the left
Aortic Arch on the left as well
Course: Gross Anatomy Lecturer: Dr. Read
Date: 08/22/07
Lecture number: 11
Page 2 of 6
When examining the basic

chest X-Ray, you should see
that the bones appear the
whitest, and the spaces
where the lungs occupy and
the trachea appear the
darkest due to being filled
with air. There are several
structures you cannot see on
this X-Ray (i.e.: liver, small
airways, etc) because it only
is able to portray interfacing structures that are of different densities. Another structure to identify are
the ribs. In this view, however, it is typically only the posterior aspects of the ribs which are visible
since the anterior parts of the ribs are attached to the sternum with cartilage. You should also be able to
view the trachea and follow it down to the carina, where it bifurcates into the right and left primary
bronchi. You can also find the carina by following the left primary bronchi where it meets the hilum of
the lung medially to the mediastinum. It is typically around the level of the left primary bronchus that
the carina resides. The carina is a very significant feature because when performing an intubation on a
patient, it is very important to keep the tube above the carina in order to provide air to both lungs. A few
last things he mentioned on this X-Ray are: the costophrenic angles (deep gutters on sides of
diaphragm), fluid-filled vessels of the lungs, and the descending aorta which lies behind the heart).
Lateral View
First, orient yourself. The spine is on the right side of the image and the sternum is on the left side. On
this view, there is a very dramatic change from white to black on the right side of the film as you move
from superior to inferior. This is due to the large amount of soft tissue (such as the Latissimus Dorsi)
the X-Ray must travel through which decreases as you travel inferiorly down the back. Behind the
sternum there is a dark area, the retrosternal air space. Behind this is the trachea. Also, on this view
you notice two diaphragms appear. In anatomy, we learn that the right diaphragm is higher (90% of
people) than the left. The reason behind this is not completely clear. Anatomists say it is because the
liver pushes up on the right diaphragm, whereas radiologists argue it is because the heart pushes down
Date: 08/22/07
Lecture number: 11
Page 3 of 6
on the left diaphragm. Dr. Read added that this is a good pimping (Pimping occurs in clinical settings
with a team of senior and junior students, interns, residents, attendings, etc. The senior member pimps
or asks questions of the junior member in order to expose the lack of knowledge) question. However,
there is no correct answer to this question and thus it is a good pimping question. However, onto
differentiating the right and left
diaphragms in this view. In order to do
this, identify the heart and notice that it
stops the line of the superior diaphragm in
the X-Ray. This means that that must be
the left diaphragm because both the heart
and the diaphragm are of the same density
(soft tissue) and therefore the heart is
occluding the view of the anterior portion
of the left diaphragm.
Frontal View ICU Patient
This X-Ray was used as an example of how

to use an X-Ray to help assure that certain
procedures were carried out effectively.
Endotracheal Tube (breathing tube)
should sit straight down the middle.
Oral/Nasal Gastric Tube (feeding tube)
used to feed the patient and decompress the
stomach.
IV (through either subclavian, jugular, or
femoral veins).
Date: 08/22/07
Lecture number: 11
Page 4 of 6
The most interesting thing Dr. Read pointed out in this picture was the pacing wires in the patient. The
patient had received heart surgery and his heart was not beating so pacing wires were inserted which
would provide the impulses for the heart to start beating. The wires are inserted into the right jugular
through the superior vena cava to the right atrium and into the right ventricle. Once the heart started
beating, the pacing wires would be removed.
Frontal View Tubes Gone Wrong

Take home point: when inserting tubes,
you need to make sure they are inserted
properly.
In this case, you can see the feeding tube
traveling down the midline at first, and
then deviating towards the right side of
the patient. The feeding tube, if inserted
properly, should travel straight down the
esophagus to the stomach. The fact that the tube deviates all the way to the right means it was inserted
into the trachea and down the right primary bronchi down, through the lung and the visceral pleura, and
was lying in the pleural space. This perforation into the pleural space caused a pneumothorax which
required the tube to be removed and a chest tube inserted above the rib (to assure you dont damage the
intercostal vein, artery, and nerve) into the intercostal space to release the built up air in the pleural
space.
An example for all you movie buffs: Dr. Read mentioned in We Three Kings that Mark Wahlberg is
shot in the chest and thus sustains a pneumothorax. George Clooney proceeds to insert a makeshift
chest tube in order to allow the air to escape.
X-Ray with Foreign Object (Prisoner w/suspected

injured trachea)
Dr. Read opened up this picture with the background
on how he worked at DC General where there were
always prisoners coming for health care. For this case,
the prisoner was on his way to court. However, before
Date: 08/22/07
Lecture number: 11
Page 5 of 6
he was able to make the trip his cellmate stabbed him in the neck. The guards feared the inmate may
have had damage to his trachea and thus brought him into DC General. Dr. Read said that, not wanting
to really enter the room since there were three guards (an obvious sign of how dangerous the man was),
he decided to first inspect the X-Ray. Dr. Read noticed the foreign object in the patient (a stolen
handcuff key) and informed the guards who managed to take care of retrieving it.
Frontal View Tension Pneumothorax

As stated earlier, a pneumothorax occurs when air builds in the
pleural space and thus the lung shrinks within the pleural cavity
with the pressure of the air around it. A tension pneumothorax
applies pressure to not only the lungs, but also other structures
such as: heart, trachea, diaphragm.
Frontal View Pleural Effusion

Along with a pneumothorax, a pleural effusion can also
apply pressure on a lung. A pleural effusion occurs when
fluid builds up in the pleural cavity. It appears as a white-
out area in an X-Ray and it pushes on surrounding
structures much like a pneumothorax. A good way to
confirm that it is a pleural effusion (and not a cancerous
tumor, etc) is to take a chest X-Ray with the patient lying
down. In this case, the fluid would move to the side on
which the patient is laying confirming it is a pleural
effusion.
Date: 08/22/07
Lecture number: 11
Page 6 of 6
Frontal View Atelectasis

The last case on which Dr. Read lectured was atelectasis.
Atelectasis occurs when no air is able to reach the lungs.
This also appears as a white-out area on the X-Ray like the
pleural effusion. In this scenario, however, the heart and
trachea are pulled towards the shrunken lung.
To highlight
Three causes of white-out areas:
Fluid in the lungs (pneumonia, trauma causing blood in lungs, etc)
Fluid outside the lungs (pleural effusion)
No air reaching the lungs (atelectasis)
Evidence on these on chest X-Rays (all have white-out):

Fluid in lungs = no volume change, only white-out area
Pleural Effusion = increased volume pushes everything else away
Atelectasis = lung shrinks pulling everything towards it
Finally, Dr. Read wrapped up the class by showing a film on the removal of a tumor which blocked the
entry of air into a lung. Instead of opening up the entire chest, it was performed laparascopically
through three small incisions which allowed the surgeons to cut off the tumor, insert a trash bag, put the
removed tumor into the bag, and then remove the bag with the tumor inside while filming the whole
thing with a small camera.
Lecturer: Dr. Marshall
The Medical Note-Taking Service Date: Aug. 24
Lecture Number: 12
NOTICE &DISCLAIMER
Note-Taker: Kristy Truong The Medical Note-Taking Service makes every effort to provide accurate
Corrected by: Dr. Marshall class notes. However, errors will occur from time to time. The user
Approved for distribution: Yes assumes the risk for any and all errors. We recommend that you use
The thorax is the region between the neck and abdomen. The thorax is a protective cage that protects the
most vital organs: heart and lungs. These are the most important organs in your body from Dr.
Marshalls perspective and thats why you have a bony cage surrounding it. The chest on which
thoracic surgeons operate include the following: skin, subcutaneous tissues, nerves, muscles, bony chest
wall, pleura, lungs, cardiovascular, esophagus, diaphragm, thymus. The thorax contains two pleural
cavities (right and left) and the mediastinum. The two pleural cavities occupy the lateral parts of the
thoracic cavity and each contains one lung. Each pleural cavity is lined by a serous membrane called the
partietal pleura that is only a cell layer think. Each lung is completely covered with visceral pleura
(pulmonary pleura), that is also only a cell layer thick.
The mediastinum is the region between the two pleural cavities. It contains the heart, great vessels,
diaphragm, aorta, trachea, and esophaguseverything inside besides the lungs. The mediastinum also
incorporates the thymus, which in most adults involutes and is replaced by fat.
Skin and Subcutaneous Tissue
One of the conditions that Dr. Marshall described is hyperhydrosis (occurring in 1% of the population,
20% Asians) where a pool of water will fill in the patients hands when they cup their hands in the most
severe cases. The surgical solution is done through 2 needle holes and then cutting the sympathetic
nerve which then stops the sweating that can drip from their hands.
Muscles
Chest wall muscles are important because you can develop tumors and cancers of these muscles. They
have excellent vasculature supply so Dr. Marshall uses them for reconstruction: Latissismus dorsi and
Pectoralis major. Lipomas arise from these muscles as do sarcomas.
Course: Gross Anatomy Lecturer: Dr. Marshall
Date: Aug. 24th
Lecture number 12
Page 2 of 7
Dr. Marshall presented us with a clinical case of a patient with a tumor arising from his pectoralis
muscle - primary sarcoma of the chest wall. The treatment is to take out all the sarcoma, the muscles on
either side of the sarcoma must be removed, meaning that the intercostal muscles and ribs attached to the
muscle must be removed. However, once the ribs are taken out, this can result in a big chest wall defect.
This is reconstructed with methylmethacrylate.
Another case was described how muscle, here the latissimus dorsi, can be used to heal problems
resulting from Empyema, which is pus in the chest. In response, the lung becomes covered with a
fibrous exudate like an orange peel to protect the rest of the body from infection. This can cause the lung
to be unable to ever blow up again. You need to take a muscle to fill the space up to fix the infection
(harvest latissimus through a small incision underneath the armpit). Surprisingly, there are very little
limitations as far as raising arms.
Bony Skeleton
Here Dr. Marshall opened with a list of the sorts of problems that could happen involving the bony
skeleton including fractures of the bones, congenital anomalies, infections in the bones especially the
sternoclavicular joint, and finally tumors, sarcomas and cancers in the chest that invade the bones.
The first conditions discussed were two similar congenital abnormalities, pectis excavatum, which is due
to an overgrowth of the cartilaginous portion of the ribs that then depresses the sternum, and pectus
carinatum, which is the protrusion of the chest for the same reason. A minimally invasive procedure that
treats pectus excavatum bends a metal bar to this defect, puts the bar behind the sternum by tunneling
and pushes the cartilage out, fixing it. The metal bar is left there for a couple of years and then taken the
out, fixing their pectis excavatum condition.
Another patient suffered from metastic disease of the ribs that needed to be taken out. The position of
the tumor required removal or partial removal of the stomach, liver, spine, diaphragm, heart, liver spleen
and retropertineum. The lining around the heart must be reconstructed in this sort of surgery because
when you turn the patient around the heart will flip with no pericardium to support the heart and then
tend to arrest if the heart twists the great vessels causing their blockage. Either cow pericardium or
Date: Aug. 24th
Lecture number 12
Page 3 of 7
gortex can be used to replace the pericardium. Methlymethacrylate, which is bone cement and mesh, is
sculpted to the chest wall defect to reconstruct the rib cage. Dr. Marshall then uses the holes in the mesh
to sow it in.
Lungs
We started out by discussing congenital pathology, benign tumors, and malignant disease in the form of
primary lung cancers and also cancers you get in other parts of the body because the lungs are such great
filters that filter out those tumor cells and metastasis takes place in the lung.
We then discussed the lobar and segmental anatomy of the lung. Knowledge of the anatomy of the
bronchopulmonary segments is essential for surgical resection (removal) of diseased segments. The root
of the lung is formed by structures entering and emerging from the lung at its hilum. The root of the
lung connects the lung with the heart and trachea. The horizontal and oblique fissures divide the lungs
into lobes. The right lung has 3 lobes, the left lung has two. The right lung is larger and heavier than the
left, but it is shorter and wider because the right dome of the diaphragm is higher and the heart and
pericardium bulge more to the left. The anterior margin of the right lung is relatively straight, whereas
this margin of the left lung has a cardiac notch. The cardiac notch primarily indents the anteroinferior
aspect of the superior lobe of the left lung. This often creates a thin, tongue-like process of the superior
lobe- the lingua, which extends below the cardian notch and slides in and out of the costomediastinal
recess during inspiration and expiration.
Lung caner operation of choice is a lobectomy that takes the whole lobe out for the lower recurrence
rate. The lingua is saved. Normal lungs in healthy people are very pink. Older patients have black
pigment in their lungs.
We then discussed 2 diseased states:
Lymphangiomyomatosis- little balloons in lungs that rupture which causes lung collapse.
Lymphangiomyomatosis can be associated with Turners Syndrome, a genetic deformity.
Date: Aug. 24th
Lecture number 12
Page 4 of 7
Emphysema- occurs when the walls of the alveoli break down which causes air trapping. When you
inhale, it fills with air and you can never exhale, and then you inhale some more and so these balloons
develop that never exhale and start pressing on normal lung tissue. The affected lungs form bullae,
whose volume flattens your diaphragm first and you lose the ability to breathe. This is treated by
stapling off balloons and taking them out so the compressed lung can re-expand.
Next, Dr. Marshall discussed the parts of the lung that she operates on- the airway- the trachea and the
bronchi. The trachea bifurcates into primary bronchi (right mainstem and left mainsteam) at the Angle
of Louis. Trachea divides into the right mainstem and left mainstem. The right primary bronchus is
wider and shorter than the left. Small objects that are accidentally inhaled are most likely to end up in
this main bronchus. Each primary bronchus divides into secondary bronchi: 2 in the left lobe, 3 in the
right. Secondary bronchi divide into segmental or tertiary bronchi, giving rise to bronchopulmonary
segments.
Surgeons used to divide the airway and take out the whole lung- pnuemonectomy. Dr. Marshall
considers this not an operation but a disease where you are significantly short of breath. Nowadays,
thoracic surgeons perform parenchymal sparing operations (a sleeve resection) that remove cancerous
parts of the lungs while saving healthy sections that are downstream from the cancerous tissue. This is
accomplished by re-transplanting normal lower lobe back onto the airway using a bronchoscope with a
camera down the mouth into the airway.
Pleura
The pleura is a single cell layer where you can get:

Infections
Empyema- if you have pneumonia (an illness of the lungs and respiratory system in which the alveoli
become inflamed and flooded with fluid) you can get a pleural effusion if bacteria leaks out.
Benign tumors of the pleura
Cancers of the pleura
Mesothelioma associated with asbethos (plaques) big tumor that encases the lung like a sheath. To take
this tumor out, surgeons have to do a pneumonectomy. It is the only thing you can do to cure the patient
Date: Aug. 24th
Lecture number 12
Page 5 of 7
because the tumor is in the pleural space and so it encases the whole lung. If the patient cannot tolerate
taking the lung out, surgeons can use a razor blade to shave the pleura off of the lung but air can leak,
and it can be a bloody procedure. Malignant effusions
Benign effusions
Trapped lung (orange peel covering the lung) - Because it involves the pleura, the pericardium,
diaphragm, and mediastinal pleura has to be taken out. Gortex is used to replace the diaphragm to
prevent the guts from herniating from the peritoneal cavity and a thin piece of gortex is also used to
replace the pericardium. A pericardial effusion (fluid around the heart that presses on the heart) can
result if no holes are made on the pericardial patch.
Diaphragm
Primary tumors of the diaphragm

Holes in the diaphragm -diaphragmatic fenestrations. For example: a patient gets lung rupture every
time she menstruates because she has endometrial implants and lung in her diaphragm that give her an
air leak.
Congenital hernias
Traumatic hernias that can happen from a car accident or a great impact to your abdomen giving
incredible pressure that ruptures your diaphragm which can result in a colon or something inside your
chest.
Paralyzed diaphragms- the diaphragm comes up like a big balloon. Fix the diaphragm with a purse
string- sow stitches and pull up on them and flatten out the diaphragm to prevent paradoxical movement
every time the patient breathes.
Common masses in the mediastinum
Mediastinum- Anterior mediastinum 4 terrible Ts

-Thymus is there- you can get a thymoma (tumor of the thymus)- some patients with a thymoma can
also have myasthenia gravis, a neurological, autoimmune disorder where your cells attack acetylcholine
receptors and so you get first double breathing, trouble breathing, trouble talking. In the past, surgeons
took the thymus out by a saw through the chest, but nowadays transcervical thymectomy is used because
Date: Aug. 24th
Lecture number 12
Page 6 of 7
most of these patients are young and can be suspended by their sternum. The Dr. then works behind their
chin and looks through a deep hole to take their thymus out through a small incision in their neck and
lets them go home the same day. But they have to be hanged. A thymoma less than 4cm can be re-sected
through this approach.
-Thyroid- Remnant from thyroid can track down and you can get thyroid goiter tracking into your chest
-Terrible lymphmoma
-Teratomas
The middle mediastinum is made up of the great vessels and the esophagus (however in our class we
learned that the esophagus is part of the posterior mediastinum).
Dissecting out the esophagus without putting holes in the esophagus.
Esophageal disease:
Esophagial duplication cyst
Bronchogenic cysts
Congenital esophageal disease- holes and connections between the trachea and the esophagus because
they develop together
Benign pathology- Achalasia- failure of relaxation of the lower esophageal sphincter- everything stays
in the esophagus when you swallow and refluxes out when you lay down.
Benign tumors of the esophagus and esophageal cancers esophagectomy
Gastroesophageal junction tumor- esophageal cancer

These arise from reflux. Acid in your stomach is Hydrochloric Acid. Cells in your stomach are
specialized to handle that. If you reflux acid onto esophageal cells which are not used to acid, they begin
to change and undergo displacia and change to become stomach cells called Baretts esophagus. As the
acid continues to injure the mucosa, it continues to make the cells change more. Then you get cancer
arising in those cells from the acid reflux. This (adenoma carcinoma of the esophagus) is becoming
more common in this country.
Treatment:
Incision in the neck and incision in the belly, then take hand up through the hiatus (where the esophagus
passes in the diaphragm at the level of the T10 vertebra, anterior to the aorta) and can strip everything
off the esophagus with your hand because there are no major esophageal vessels although the aorta and
Date: Aug. 24th
Lecture number 12
Page 7 of 7
azygos veins are next to esophagus. There is not much bleeding and this allows you to avoid going into
the chest at all.
Transhiatal esophagectomy- Big vessels of the stomach are tied off but one, so you can leave the
stomach attached, tubularize it and pull it all the way to the neck to replace the esophagus and sow it to
the esophagus in the neck. No more esophageal cancer. So basically you divide the stomach, untwist it
and lengthen it to pull all the way up to the neck. Can gain wait.
Giant leiomyoma- tumor of the esophagus. Put video camera in the chest if not cancer. Because it is
benign, we put it in a bag, break it up and pull it out through little holes.
Posterior Mediastinum Masses

Mass in Paravertebral sulcus- shwannoma-- nerve sheath tumor coming off the sympathetic chain. The
surgeon must dissect the tumor off the spine which is bloody. These are benign tumors the size of a
grapefruit so the tumor is stuck in a bag and pieces are pulled out through a little incision without giving
a big incision.
.
Date: Aug. 24th
Lecture number 12
Page 8 of 7
Date: Aug. 24th
Lecture number 12
Page 9 of 7
Lecture Number: 13
NOTICE &DISCLAIMER
Note-Taker: Shannon Liang The Medical Note-Taking Service makes every effort to provide accurate
AUTONOMIC NERVOUS SYSTEM (ANS)

Dr. Suarez started off by explaining how the radiology laboratory session on the thorax will run.
Different residents will present the same slideshow in each room, but only one residents talk will be
recorded as an mp3 (posted on Blackboard). *NOTE* The slides are similar to what well see on the
exam and well need to identify certain pathologies.
The term autonomic means self-governing, which allows our bodies to function without
conscious awareness. To remember this, the autonomic nervous system works automatically. Sitting in
lecture, our conscious thoughts occupy only a trivial amount of nervous tissue activity. The autonomics
system keeps us alive without thinking about it. Unconscious functions such as breathing, the heart
beating, and digesting require regulation by the autonomic system.
The autonomic nervous system (ANS) is part of the peripheral nervous system, divided into
motor (general visceral efferent) and sensory (general visceral afferent) components. The general
visceral motor system is broken down into two pathways: parasympathetic and sympathetic. The
sensory modality is important so that you are aware of what your organs are doing.
Kids in the back seat cause accidents; accidents in the back seat cause kids.
Date: 8/27/07
Lecture Number: 13
Page 2 of 10
To give a dramatic example of how important the ANS is and its implications of how physicians
practice medicine, Dr. Suarez brought up the case of Terri Schiavo. Suffering brain damage, Terri lived
for 12-13 years despite her brain looking like this. Although she had no conscious thoughts (at least that
we knew of) and could not communicate, Terri could still breathe, digest, and her heart was beating.
Congress thought it was important enough to write amendments to keep feeding her in this condition.
Dr. Suarez was not trying to tell us how to think or what to believe in this debate, but wanted to illustrate
how a person with a brain like this, with almost no cerebral cortex, can carry on normal bodily function.
Normal CT Terris CT
brain image brain image
Now we will describe what allows our bodies to function despite a brain like this. The functions
of the autonomic system include everything that does not require conscious control, such as:
Body temperature
Cardiovascular function
Respiration (see slides for a more complete list)
Digestion
Excretory function
Reproductive function
The differences between the autonomic and somatic motor systems are summarized as follows
(Keep in mind, both have motor and sensory components.):
Somatic Motor System Autonomic Nervous System

Before the motor neuron reaches target organ,
it has to synapse somewhere along its path
Cell body in ventral horn sends a myelinated
Pre-ganglionic axons are myelinated, while
axon to the effector organ (skeletal muscle)
post-ganglionic axons are unmyelinated,
therefore the stimulus travels slightly slower
than somatic motor system
Stimulates a global response (esp.
Stimulates one muscle or muscle group
sympathetic system) affecting many target
tissues/organs (divergence)
Date: 8/27/07
Lecture Number: 13
Page 3 of 10
To better explain divergence, a stimulus leaving a particular level of the spinal cord has various
options. The preganglionic neuron at one level of spinal cord can travel along 4 different pathways:
1) travel up the sympathetic chain, then synapse and exit (through a higher spinal nerve)
2) travel down the sympathetic chain, then synapse and exit (through a lower spinal nerve)
3) synapse in the chain ganglion at the level it exited the spinal cord
4) travel right through the ganglion to target visceral organs (synapse in prevertebral ganglion)
Thus, one level of spinal cord can have a global effect on the body.
Date: 8/27/07
Lecture Number: 13
Page 4 of 10
The anatomical and biochemical differences between parasympathetic and sympathetic systems
are illustrated below.
pre-ganglionic post-ganglionic
Parasympathetic
ACh ACh
Sympathetic short long

ACh NE
Note that the pre-ganglionic sympathetic fiber is short (close to spinal cord in our dissections) compared
to a long post-ganglionic fiber. This is opposite for the parasympathetic fibers. The pre-ganglionic
parasympathetic fiber (i.e. vagus) is long because the parasympathetic ganglia tend to lie in the walls of
the target organs, unlike the sympathetic chain ganglia. This means that there are fewer pre-ganglionic
fibers per section of spinal cord, so the parasympathetic pathway tends to be more localized and discrete
in reaching target organs. Also note that the sympathetic post-ganglionic fiber uses norepinephrine (NE)
as its neurotransmitter. Thus if you block NE, you block the sympathetic response. This is the idea
behind beta blockers which inhibits NE or epinephrine. All other synapses use acetylcholine (ACh) as
the neurotransmitter.
The following chart summarizes the two divisions of the ANS.
Parasympathetic System Sympathetic System
Anatomic description
Thoracolumbar all stimuli comes from
spinal cord levels T1 - L1/L2, pre-ganglionic
Craniosacral - all stimuli leaves CNS by
fibers synapse somewhere along sympathetic
cranial nerves (CN III, VII, IX, X) and
chain ganglia and send post-ganglionic fibers
sacral outflow (S2-S4)
to deliver stimulus throughout whole body
Functional description Fight or Flight response (i.e. when cat hisses
and arches its back, or when Michael Vick
Rest and Repose response (or Rest and asks you to walk his pets)
Digest) active when the body is at rest, ~ increases heart rate
conserves body energy ~ bronchodilation
~ decreases heart rate ~ dilates pupils
~ bronchoconstriction ~ constricts blood vessels to skin and viscera
~ constricts of pupils ~ dilates blood vessels to skeletal muscles
~ promotes digestion ~ simulates arrector pili muscles (goose
~ stimulates defecation and urination bumps)
~ sexual arousal (erection) ~ stimulates sweat glands
When Miller time comes around, ~ ejaculation
parasympathetics take over The hallmark for sympathetic fibers is
divergence to create a global response
Date: 8/27/07
Lecture Number: 13
Page 5 of 10
Sympathetic Nervous System

The sympathetic pathway is more complex than parasympathetic pathway, because it has to go to
every part of the body. When you have to fight or flee, you need a global response which affects all
the organs. For example, while the lungs and heart work harder, other organs (digestive) are shut down.
The sympathetic chain ganglia are attached to ventral rami of spinal nerves by white and gray
rami communicans. The pre-ganglionic fibers send a branch to the ganglia by the white rami
communicans (white because they are myelinated). If it synapses there, the post-ganglionic fibers travel
through the gray rami communicans (gray because they are unmyelinated) and exit through the ventral
rami of the spinal nerve. Though, in the actual dissections, it is difficult to distinguish between white and
gray rami communicans.
As mentioned earlier, from each thoracolumbar level of the spinal cord, a pre-ganglionic fiber
has 4 divergent pathways. There are 31 sympathetic chain ganglia, although many have fused. For
example, in the neck, most of them have fused into 3 principal ganglia. While you may see ganglia
spanning the length of the body (neck to sacrum), all sympathetic stimulus originates from T1-L1/L2.
Therefore, there is no direct connection from the neck to the cervical ganglia, nor from the lumbar
expansion of the spinal cord to the sympathetic chain ganglia of the sacrum.
The prevertebral ganglia, lying anterior to the abdominal aorta, are unpaired. It may surprise you
that during dissection, when you think you are cutting through thick connective tissue, you are actually
cutting through nervous tissue. So how do abdominal surgeons get through this? The nerves must be cut,
so they count on redundancy. We know that the GI will work regardless of if you cut through the
sympathetic chain because in small bowel transplantation, doctors reattach a new bowel but dont attach
the sympathetic chain. Though it wont be as efficient as it was before, it still works.
Sympathetic Pathways to the Periphery

Sympathetic outflow to the hair
and skin leads to vasoconstriction,
because in fight or flee response, you
want blood diverted away from the
periphery to the major muscle masses (to
throw punches, kick, and run away). It
results in cutaneous vasoconstriction
Date: 8/27/07
Lecture Number: 13
Page 6 of 10
(cold skin) and sweat (active sweat glands). Follow the connections in the figure. The pre-ganglionic
fiber leaves at a certain level of spinal cord, travels by the white rami communicans, synapses at the
sympathetic ganglia, the post-ganglionic fiber travels by the gray rami communicans, and goes into the
ventral rami to the periphery. Instead, the pre-ganglionic fiber may go up the sympathetic chain, synapse
there, and exits by the ventral rami of thoracic spinal nerve T1 (example of divergence).
Sympathetic Pathway to the Head

Since sympathetic innervation only leaves
from T1-L1/2, how will we get innervation to the
head and neck? From T1-T4, the pre-ganglionic fibers
do not synapse at these levels. They fibers travel up
the chain and synapses in one of those 3 fused ganglia
of the neck, and the post-ganglionic fiber piggy-backs
onto the blood supply and reaches the target organs.
Sympathetics inhibit lacrimal, nasal and salivary
glands, which leads to dry mouth. In addition,
sympathetic innervation dilates the iris and keeps eyelids open.
Sympathetic Pathway to Thoracic Organs

From T1-T6, sympathetic innervation to the
heart travels all the way up to the cervical ganglia, and
the post-ganglionic fiber travels back down to the
heart in increase the heart rate. The stringy material we
had to get through during our dissections of the great
vessels was the heart plexus (innervation descending
from the cervical sympathetic ganglia). In heart
transplants, the sympathetic innervation is
compromised because we cannot reattach the heart
plexus, and this has implications in managing a patients care.
Date: 8/27/07
Lecture Number: 13
Page 7 of 10
Sympathetic Pathway to the Abdomen

For abdominal innervation, there is no synapse at
the ganglia of the corresponding level. The pre-ganglionic
fibers travel through the sympathetic chain ganglia and
become the splanchnic nerve. They will synapse in the
prevertebral ganglia and the post-ganglionic fibers will
reach the visceral organs (GI tract) to inhibit digestion.
Sympathetic Pathway to the Pelvic Organs

From T10-L2, the pre-ganglionic fibers go down
the chain and synapse at a lower lumbar or sacral chain
ganglia, or travel unsynapsed to the prevertebral
ganglia. This gives rise to sympathetic outflow to the
bladder (inhibits urination and defecation) and penis
(promotes ejaculation).
Sympathetic Pathway of the Adrenal Medulla

The adrenal medulla is a specialized nervous
tissue, receiving pre-ganglionic fibers. Since there are
no post-ganglionic fibers, the epinephrine and
norepinephrine that are released by the adrenal medulla,
will enter circulation and have systemic effects. The
half-lives of Epi and NE are a little longer than that of
the neurotransmitters at the neuromuscular junction.
Once the threat which stimulated the fight of flight
response disappears, with Epi and NE, you are prepared
to respond quickly just in case you encounter another
threat.
Date: 8/27/07
Lecture Number: 13
Page 8 of 10
Parasympathetic Nervous System

Parasympathetic innervation comes from certain cranial nerves
and sacral outflow (S2-S4). It is responsible for the rest and repose
response. The vagus nerve (meaning wanderer) is important because
it innervates heart, lungs, liver, and the GI tract; it regulates
parasympathetic outflow from the neck all the way down to the left
colic flexure. It joins with the sympathetic plexus in viscera.
As if you didnt already know the importance of Viagra, those
who undergo a prostatectomy may lose the ability to have an erection if
the nervous tissue necessary for an erection is damaged in the removal
of the prostate. Viagra increases blood supply to the few nerves that are
left behind from S2-S4. During Thanksgiving, remember this for when
your parents ask what youve learned in medical school: Point and
Shoot. Pointing refers to parasympathetic (erection), and shooting
refers to sympathetic (ejaculation). This explains why males cant
ejaculate and urinate at the same timesympathetic outflow opposes
urination.
Sacral outflow is more localized at the target organ (genitalia, uterus, and bladder). The hallmark
of the parasympathetic system is that it is more specific. For example, you do not want to be voiding
while youre thinking of having an erection, and vice versa. Localization is possible because the post-
ganglionic fibers are located within the target organ itself.
To recap: sympathetics create a global response, using all effort to fight or flee, while the
parasympathetics create a more targeted, organ-specific rest and repose response.
Sensory Component of the ANS

The general visceral sensory system tells us whats happening to our organs. The neurons
monitor stretch, temperature, chemical changes, and irritation within visceral organs. Our brains
interpret this visceral information as feelings of hunger, fullness, pain, nausea, or well-being. For
example, you interpret your GI stretching as fullness.
The visceral sensations are difficult to localize. When you have a tummy ache, you just feel a
general pain in your abdomen. In contrast, if Dr. Suarez slices your index finger off, you can tell which
Date: 8/27/07
Lecture Number: 13
Page 9 of 10
finger and exactly where on the finger you hurt. If you slice through the large intestine, it will not be
painful. However, if you have impacted stool in your GI tract, that is a painful experience. Therefore,
when you have pain from a visceral organ, you cannot not tell precisely where its coming from, only
the general area. A classic example is angina, which is pain due to malfunctioning of the heart muscle.
The pain felt can be in the heart and radiating through the upper limb (intercostal brachial nerve). This is
an example of referred pain. Visceral pain is oftentimes accompanied with referred pain. The
referred pain can project to a completely different area than the pathology. Some text books describe
referred pain as due to reflexive vasoconstriction in the vessels supplying the corresponding somatic
segments.
Just like in the somatic system, there
are reflex arcs, but the main difference is that
the visceral reflex arcs are always
polysynaptic. There are no monosynaptic
reflex arcs like patellar tendon reflex. There
is always an interneuron between the
incoming stimulus and the outgoing signals.
Many parasympathetic and sympathetic
reflexes are listed in the slides, but we didnt
go over them in class.
Levels of ANS Control by the CNS

By kindergarten, each of us should have learned that there are proper and improper times to void
(aka potty training). We just learned that voiding is an autonomic response. However, we can override
this autonomic pathway and can control voiding. Stay turned for Neuroscience when well learn how our
consciousness can override autonomics.
Clinical Correlates: When the Autonomic Nervous System Goes Awry

Facial blushing Excess sympathetic outflow to the face; causes increased heat and sweating to
face. This, in turn, is detected in patients as facial flushing in light skin people.
Hyperhidrosis Excess wetting of hands; the treatment is to remove the sympathetic stimulus to
the palm of the hands by identifying the sympathetic chain with an endoscope and ligate at T3/T4
Date: 8/27/07
Lecture Number: 13
Page 10 of 10
Congenital megacolon Failure of neural crest cells to migrate to the distal colon (thus no
parasympathetic innervation). Therefore the colon cannot relax for a bowel movement and you
build up fecal matter in the colon (distal abdominal distention). The treatment is to remove the
distal colon and get a normal bowel movement.
Reynauds Disease Excess sympathetic vasoconstriction in the fingers and toes, provoked by
exposure to cold or stress. In times of stress, you want to conserve core body temperature, so blood
is diverted away from your fingers and toes to your muscles. The fingers become pale and possibly
frost-bitten because all of the blood is pushed out. It is more common in the elderly population
(9% of elderly women, 4% of elderly men).
Hypertension Overactive sympathetic vasoconstriction due to continual stress (not a plaque

formation). The blood vessels narrow, which increases the work load on the heart and may
precipitate heart attacks. Treatment is with beta blockers (sympathetic inhibitor).
Achalasia Failure to relax at the distal esophagus (autonomic innervation to esophagus is
impaired). Food cannot enter the stomach. Treatment is to insert a balloon to dilate the lower
esophageal sphincter.
Course: GA
Lecturer: Dr. Schiffer
The Medical Note-Taking Service Date: 29 Aug 2007
Lecture Number: 15
NOTICE &DISCLAIMER
Note-Taker: James Robbins The Medical Note-Taking Service makes every effort to provide accurate
Corrected by: Dr. Schiffer class notes. However, errors will occur from time to time. The user
Approved for distribution assumes the risk for any and all errors. We recommend that you use
Abdominal Wall and Peritoneum

Dr. Schiffer started the lecture mentioning the way anatomy should be studied.
1. Lectures- used as an overview of what is important (forest)
2. Syllabus- specific guide for the material (trees)
3. Text- read the overview for a region and look at the clinical questions at the end of chapters
4. Imaging- use netanatomy.com to review images of related structures
He also mentioned the three ways to ask him questions: after lecture of lab (dont interrupt his lab
students), email him, or he comes into the lab on Saturday mornings at 10 a.m. He will bring images to
the lab on Saturdays if the students request it in advance.
OVERVIEW
The abdomen is the region of the body located between the
thorax and the pelvis. It is comprised of an abdominal wall
(muscles, tendons, and fascia) that encloses an abdominal
cavity. The cavity contains the organs of the abdomen. The
area does not have many bones that can be used as
landmarks, but rather uses ones from both the thorax and
pelvis. Superiorly, there are the xiphoid process of the
sternum and costal margin of the ribs. Inferiorly, there are
the posterior superior iliac spine (PSIS), iliac crest, anterior
superior iliac spine (ASIS) connected to the pubic tubercle
via the inguinal ligament, the pubic crest, and pubic
symphysis. See the figure on the left.
Course: Gross Anatomy Lecturer: Dr. Schiffer
Date: 29 Aug 2007
Lecture number: 15
Page 2 of 8
ABDOMINAL REGIONS
With the lack of bony landmarks, the abdomen is broken up in regions used to describe location. There
are two reference systems, the quadrant and region.
Regional (A)-uses midclavicular lines and the
subcostal and transtubercular plane to separate
the body into 9 regions.
Quadrant (B)- this system uses a vertical line
drawn from the xiphoid process to the pubic
symphysis through the median saggital plane to
separate right and left and a horizontal line
through the umbilicus to separate upper from
lower. The result is 4 quadrants.
BOUNDARIES
Superior-diaphragm
Inferior- pelvic inlet (arbitrary as the pelvic and abdominal regions are continuous)
Anterior and Lateral-Abdominal wall formed by rectus abdominis and 3 flat muscles (external and
internal obliques and transversus abdominis.
SURFACE ANATOMY
Xiphoid process- where costal margins meet, superior
landmark
Linea alba- white line running inferiorly from the
xiphoid process to the pubic symphysis
Rectus Abdominis- lateral to linea alba on both sides,
runs to semilunar line (linea semilunaris)
Semilunar line is useful; the gallbladder is located
where it meets the costal margin on the right side.
The 3 flat muscles lie lateral to the semilunar line.
Date: 29 Aug 2007
Lecture number: 15
Page 3 of 8
INNERVATION
The abdomen is innervated by anterior rami of spinal nerves T7-L1. These nerves provide sensory
information for the thickness of the abdomen (skin/dermatomes to parietal peritoneum) and motor
function for the muscles of the anterior wall.
Important Dermatomes-
T7-Xiphoid Process
T10- Umbilicus
L1-Inguinal region
BLOOD VESSELS
The abdominal area is supplied with arterial blood in two ways, from above traveling down or
from below traveling up. The two arteries that do
this are the superior epigastric artery which
branches off the internal thoracic artery and
travels inferiorly and the inferior epigastric
artery, which branches off of the external iliac
artery and travels superiorly. These two vessel
join (anastamose) in the abdomen. The venous
drainage travels in the opposite direction via the
superior and inferior epigastric veins. The
superior and inferior epigastric vessels travel within the rectus sheath posterior to the muscle.
The anastamoses of epigastric vessels is important because it provides an alternate route for
blood to travel if the aorta or vena cava becomes obstructed.
LYMPHATICS
For the abdomen, the umbilicus forms a watershed line
for lymph flow. Lymph located inferior to the
umbilicus drains into the superficial inguinal lymph
nodes. Superior to the umbilicus, lymph from the
anterior body drains to the anterior axillary nodes,
while lymph from the posterior drains to the posterior
axillary lymph nodes.
Date: 29 Aug 2007
Lecture number: 15
Page 4 of 8
STRUCTURES OF THE WALL

Abdominal wall is comprised of 9 layers. They can be arranged according to the Rule of 3s, there are 3
sections (superficial, middle, and deep) with each section containing 3 layers.
Superficial- Skin
Campers fascia (thick layer of fat)
Membranous (Scarpa) fascia- doesnt exist above umbilicus and is anchored to
fascia lata
Middle- External oblique

Internal oblique
Transversus abdominis
Deep- Transversalis fascia

Preperitoneal fat
Parietal peritoneum
Clinical application- Straddling injuries can crush the urethra causing it to rupture (generally in males)
and results in urine leaking. The urine leaks into the space posterior to the membranous fascia and can
cause the skin in the area to appear red and erythematous. Urine cannot go down into the thigh region
because the membranous fascia is attached to the fascia lata of the lower limbs.
MUSCULATURE
Muscles of the abdominal area have three functions.
a. Locomotion- rotation, flexion and lateral flexion of the trunk
b. Protective- without ribs over most of the abdomen, the muscles provide protection to
the organs
c. Compression- contraction of the trunk muscles can assist in force exhalation as well
as defecation, urinating, and child birth
Muscles
a. Rectus Abdominis- runs from the ribs to the pubic symphysis
Date: 29 Aug 2007
Lecture number: 15
Page 5 of 8
b. Pyramidal Muscle- small muscle located

inferiorly and inserts on linea alba
c. External oblique- runs anteromedial, like
external intercostal (aka putting fingers in
pocket)
d. Internal oblique- runs perpendicular to the
external oblique, again like internal intercostal
e. Transversus abdominis- runs horizontally
As the external oblique, internal oblique, and transversus

abdominis approach semilunar line they form flat tendons
(aponeurosis). The aponeuroses run toward the midline
where they attach to the linea alba. In the process they
surround the rectus abdominis and form the rectus sheath.
In the superior of the sheath the aponeuroses form a
sheath on the anterior and posterior of the rectus
abdominis. The anterior part is made of the aponeuroses of
the external and internal obliques. The posterior part is
formed by the apaneuroses of the internal oblique and
transversus abdominis (B). In the inferior of the rectus
sheath, all three apaneuroses are anterior (A). The line that separates these configurations is known as
the Arcuate line. The superior and inferior epigastric vessels travel in this sheath by gaining access at the
Arcuate line.
INGUINAL CANAL
The inguinal canal is a 1.5-2 inch opening that allows passage of the spermatic cord (males) or
the round ligament of the uterus (females). The canal runs just superior to the medial half of the inguinal
ligament with the superficial inguinal ring just superior to the pelvic tubercle (can be palpated as a
landmark). The canal has both a superficial inguinal ring in the external oblique muscle and a deep
inguinal ring in the transversalis fascia. The openings represent weaknesses in the abdominal wall that
resulted as humans became bipeds. The weakness of the inguinal canal is offset in the four following
Date: 29 Aug 2007
Lecture number: 15
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ways: the openings are offset (the superficial and deep openings are not directly behind each other by
rather offset laterally), the canal has a muscular roof (the three layers of muscle provide support for the
openings), the rings are reinforced, and squatting provides extra support from the thighs. Finally, the
ilioinguinal nerve exits the superficial inguinal ring in both sexes and in females there are lymphatics
from the uterus that also exit the canal.
Muscular Contribution to Canal Structure

External oblique-forms the superficial inguinal ring and anterior wall superficial ring (inguinal ligament
forms floor)
-contributes to the external spermatic fascia of the testis and spermatic cord
Internal oblique-forms muscular roof of inguinal canal
-Forms conjoint tendon with the transversus abdominis
-Contributes to the cremaster muscle layer of spermatic cord and testis (this muscle pulls
the testis toward the body)
Transversus abdominis-Forms muscular roof of the inguinal canal
-No contribution to the spermatic fascia because the testis travels under this layer
when it descends
Transversalis fascia-Forms the posterior wall of the inguinal canal and the deep inguinal ring
-Contributes to the internal spermatic fascia
SCROTUM AND SPERMATIC CORD

The scrotum contains the two testes that descended through the inguinal canal. The scrotum has two
sacs, one for each testis. Functionally, it separates the testis from the rest of the body and in doing so,
ensures the proper temperature for spermatogenesis (35o C in testis for spermatogenesis versus 37o C in
the rest of the body). The testis and the spermatic cord are covered by three layers, external spermatic
fascia from the external oblique, the cremaster muscle from the internal oblique, and the internal
spermatic fascia from the transversalis fascia. The spermatic cord contains the ductus deferens, testicular
artery, and pampiniform plexus. The cooler venous blood in the pampiniform plexus cools the arterial
blood entering the testis to ensure the proper temperature in the testis.
In the scrotum, the testis is covered by many layers.

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Lecture number: 15
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Superficial- skin and dartos fascia (no fat) and muscle (gives the wrinkled appearance of
scrotum)
Middle- 3 fascia layers (external spermatic fascia, cremaster muscle, internal spermatic
fascia)
Deep- tunica vaginalis (pinched off from peritoneal sac) that has a visceral (on testis) and
parietal (outer) layer that functions in testis mobility and stability
TESTIS
The testes are egg-shaped structures with an outer covering called the tunica albuginea that divides the
testis into lobes. Each of the lobes contains the seminiferous tubules. Once sperm is produced, it travels
from the tubules to the rete testis to the efferent ductules to the epididymis. Within the epididymis, the
path runs from the head (directly superior to the testis) down through the body to the tail (at the posterior
and inferior border of the testis). The sperm mature in the epididymis before being forced up into the
ductus deferens.
TESTIS DEVLOPMENT AND DESCENT

The testis starts development in the posterior wall and descends downward through the inguinal canal.
During this descent, the testis and spermatic cord pick up the three layers of fascia (external spermatic
fascia, cremaster muscle, internal spermatic fascia). As the testis continue to descend, the scrotum forms
of dartos muscle and skin. As the testes descend into the scrotum, they are invested by the processus
vaginalis which is continuous with the parietal peritoneum. The proximal processus vaginalis
degenerates before birth, but leaves behind a distal covering of the testes called the tunica vaginalis. This
covering has a visceral layer and parietal layer with a potential space in between (just like the lungs).
This important developmental difference is why the lymphatics of the testis drain to the aorta
area (because they arise from that area), while the lymphatics
of the scrotum drain to the superficial inguinal lymph nodes
(because it arises from the skin).
POSTERIOR SURFACE
The posterior surface of the anterior abdominal wall contains
three folds formed by remnants of fetal structures.
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Lecture number: 15
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Median Umbilical Fold-from urachus that carried fetal urine

Medial Umbilical Fold-from umbilical arteries
Lateral Umbilical Fold-inferior epigastric vessels run through this fold and the deep ring of the inguinal
canal is just lateral to this fold
INGUINAL HERNIAS
Inguinal hernias are classified as either direct or indirect based on their location relative to the inferior
epigastric vessels.
Indirect- hernia passes through deep inguinal ring located lateral to the inferior
epigastric vessels
Direct- hernia passes through the inguinal triangle located medially to inferior
epigastric vessels
CLINICAL CORREALATIONS
Cryptorchidism- undescended testis
Vasectomy- surgery to induce sterility by removing a small portion of the ductus deferens
-sperm cannot reach pelvis area and urethra
Showed slides of a man with a large inguinal hernia and a woman with urine leaking out the umbilicus
because the urachus did not degenerate.
Lecture Number: 16
NOTICE &DISCLAIMER
Note-Taker: Patrick Nailer The Medical Note-Taking Service makes every effort to provide accurate
Peritoneum and Abdominal Viscera
Within the abdominal cavity are two important structures: the peritoneal sac and gastrointestinal (GI)
tract. The peritoneal sac is the fourth serous sac weve encountered, the others being the two pleural
sacs and the pericardial sac. Just like these other structures, it is helpful to think of the peritoneal sac as
a fist in a balloon, with a visceral peritoneum adhering closely to the surface of some of the abdominal
organs and a parietal peritoneum lining the abdominal wall, including the diaphragm and parts of the
pelvis. A peritoneal cavity exists between these two peritoneal structures, although this cavity is more of
a potential space rather than an actual one. It is important to realize that pain sensations differ between
the visceral and parietal peritoneum. Whereas pain from the parietal peritoneum is typically localized to
the site of injury, the visceral peritoneum is not sensitive to pain, but rather to stretch or distention, and
injury to this structure usually presents as referred pain elsewhere on the abdominal wall.
The shear extent of the peritoneal sac is impressive, accounting for a surface area larger than the skin.
As the peritoneum reflects back on itself, it forms double-ply sheets that contain the neurovascular
support for organs in the abdominal cavity that it surrounds. The peritoneal attachments between organs
and the posterior abdominal wall are referred to as mesenteries. Omenta are peritoneal folds associated
with the stomach. The lesser omentum extends from the lesser curvature of the stomach to the liver.
The greater omentum drops down from the greater curvature of the stomach to cover the small
intestines and then folds back up to fuse with the transverse colon. The greater omentum, a four-ply
covering restricts adhesions between visceral and parietal peritoneum and also acts as the policeman of
the abdomen by sticking to and walling off areas of inflammation.
In the context of the peritoneum, ligaments are double-ply layers of peritoneum that connect two organs
or an organ to the abdominal wall. Additionally, differences exist between the sexes in the nature of the
peritoneal sac. In males, the peritoneal sac is a totally closed system, with the right and left tunica
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vaginalis in the scrotum a special out pocketing of this sac. Females, by comparison, have two
permanent openings in their peritoneal cavities where the left and right uterine tubes are continuous with
the uterus, vagina and ultimately the external environment. Thus, a potential route for infection exists
through a womans reproductive tract into her abdomen. A temporary opening also occurs in females
during ovulation when the surface of the ovulating ovary ruptures each month into the peritoneal cavity.
When speaking about abdominal organs, it is important to differentiate which organs are
retroperitoneal or intraperitoneal. Retroperitoneal organs are relatively fixed, stable and, as a result,
prone to injury by strong compressive forces. Intraperitoneal organs are covered by the visceral
peritoneum and may be attached to the abdominal wall by a mesentery. These organs are free to move
within the abdominal cavity, reducing the risk of injury due to compression. These organs, however, are
at risk of considerable movement within the abdomen, resulting in complications due to malpositioning,
such as hernias.
Components of the Digestive Tract
Esophagus
The esophagus serves as a muscular tubular connection between the pharynx and the stomach. It has no
direct role in digestion, only the transport of food. Grossly, the esophagus is 10 inches in length and
traverses three body regions. Microscopically, it possesses both skeletal and smooth muscle along its
length. The lower esophageal sphincter is a functional sphincter, not an anatomic one. Although the
abdominal portion of the esophagus is only a half an inch below the esophageal hiatus of the diaphragm,
it is still very important clinically. The mucosal transition between the esophagus and stomach is
referred to as the Z-line and to prevent the regurgitation of gastric contents, three things occur: (1) the
diaphragm act as a site of constriction, (2) the angle at which the esophagus enters the stomach is
intensified by smooth muscle in the stomach closing it off, and (3) an increase in the intra-abdominal
pressure difference between the esophagus and stomach acts as a pressure cuff, keeping the esophagus
closed.
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Stomach
The stomach is designed to store food and convert solid foodstuffs to liquid chyme. From an anterior
view, it is a J-shaped organ defined by several different regions: a cardiac region where the esophagus
opens into the stomach, a cardiac notch or angle between the esophagus and stomach, the fundus
superiorly, the large body segment, and the pylorus which acts as a funnel to move chyme through the
pyloric sphincter into the small intestine (duodenum). Two curvatures define the borders of the stomach:
a concave lesser curvature and convex greater curvature. The stomach curvatures are important
landmarks because of the two omenta associated with them. The lesser omentum, which spans the area
between the liver and the lesser curvature of the stomach, includes the hepatogastric ligament and
small hepatoduodenal ligament. The greater omentum drapes down from the greater curvature of the
stomach over the abdominal cavity, reflects back and fuses with the transverse colon. Where the omenta
join the surfaces of the stomach is where the vascular support for the stomach resides. The area of
the lesser curvature contains the right and left gastric arteries while the greater curvature includes the
right and left gastro-omental arteries. The fundus also receives blood from the short gastric
arteries.
The rotation of the stomach during embryological development results in a space in the peritoneal cavity
behind the stomach, referred to as the omental bursa or lesser sac. This space is found posterior to the
stomach and lesser omentum and anterior to the pancreas and includes only one opening: the omental
foramen. An important portion of the lesser omentum is the hepatoduodenal ligament, which is where
the hepatic artery and portal vein enter the liver and the bile duct exits the liver.
Small Intestine
The small intestine, consisting of the duodenum, jejunum and ileum, is responsible for chemical
digestion and absorption of nutrients. This is achieved by the shear length of the organ (over 20 feet)
and by the fixed folds, plicae circularis, which line the inner surface of the small intestine to increase its
surface area. Additionally, villi found on the surface of mucosal projections are themselves covered by
epithelial cells that contain microvilli, further increasing the surface area to enhance absorption.
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The duodenum, the shortest, widest and most fixed portion of the small intestine, forms a C shape
around the head of the pancreas. It contains four parts. The first segment is intraperitoneal, mobile and
does not contain plicae circularis. It is also where acidic chyme from the stomach first enters the small
intestine and is the most common site of peptic ulcers. The second segment is a descending portion and
receives secretions from the liver in the form of bile and digestive enzymes from the pancreas. Segment
three runs left at L3, anterior to the inferior vena cava and aorta, to become the fourth segment, which
continues superiolaterally to the left. The fourth segment is fixed in place by a suspensory muscle
(ligament of Treitz) and is continuous with the jejunum. The last three segments of the duodenum are
considered retroperitoneal whereas the jejunum is intraperitoneal
The jejunum accounts for close to 2/5 of the length of the small intestine while the ileum accounts for
most of the rest. The transition between the two is a gradual one but there exist anatomical distinctions
between the two. The jejunum has an abundant array of plicae circularis while the ileum has
progressively fewer. Fat in the mesentery of the jejunum does not reach all the way to the jejunal border
whereas in the ileum the mesenteric border is covered with fat. Long vasa recta are found in the
jejunum while shorter ones characterize the ileum. Peyers patches, a part of the lymphatic system, are
found mainly in the ileum. The small intestine ends at the ileocecal junction.
Large Intestine
The large intestine is responsible for water and electrolyte reabsorption and the dehydration of chyme
into semisolid feces for storage and elimination. Chyme first enters the large intestine in the right lower
quadrant (RLQ) at the cecum. The vermiform appendix, a blind ended out pocket, comes off of the
cecum. The cecum continues superiorly as the ascending colon, turns left at the right (hepatic) colic
flexure and continues as the transverse colon, turns inferiorly at the left colic (splenic) flexure to
become the descending, then sigmoid colon. The large intestine is characterized anatomically by fatty
omental appendices and by teniae colia, three bands of longitudinal smooth muscle that constrict the
colon into out pockets called haustra.
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The cecum, appendix, transverse colon and sigmoid colon are intraperitoneal organs. The ascending
and descending colon are retroperitoneal and fixed to the posterior abdominal wall. The mesentery for
the transverse colon is referred to as the transverse mesocolon while the mesentery that supports the
sigmoid colon is called the sigmoid mesocolon. The mesoappendix is the mesentery of the appendix.
The cecum does not have its own mesentery.
Appendix
The location of the appendix is quite variable although it is normally tucked in a retrocecal location. The
base of the appendix, the site at which it connects to the cecum, is constant in location but the worm
segment is variable. An important location is McBurneys point, situated 1/3 of the way along the line
between the umbilicus and the anterior superior iliac spine (ASIS). This point is where the base of the
appendix is found, a useful anatomical reminder when palpating for appendicitis, a common medical
problem. Appendicitis typically presents initially as a vague midgut pain but then progresses to become
an acute, localized RLQ pain.
Neurovascular Support for the GI Tract
To understand the neurovascular support for the GI tract, it is helpful to think of the tract as a series of
three components: the foregut, midgut and hindgut. The foregut consists of the liver, pancreas, stomach,
spleen and first half of duodenum and is supplied by the celiac trunk, a branch of the abdominal aorta.
The midgut, which spans the aboral half of the duodenum to the transverse colon, is supplied by the
superior mesenteric artery (SMA). The hindgut, which begins just before the left colic flexure and
continues down to the rectum and a portion of the anal canal, is supplied by the inferior mesenteric
artery (IMA).
The celiac trunk exits the aorta at the level of T12. Branches of the celiac trunk include the left gastric
artery, splenic artery (the largest branch) and a right common hepatic artery. All of these branches
supply blood to the stomach. The common hepatic artery branches to provide blood to the liver
through the hepatic artery proper and by the gastroduodenal artery inferiorly to provide blood to the
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duodenum and pancreas. An important component of the left gastric artery is that it moves superiorly
and supplies branches to the lower esophagus through the esophageal hiatus.
The superior mesenteric artery branches off of the aorta at the level of L1. As it leaves the aorta, its left
branches supply the jejunum and ileum and right branches supply the transverse colon by way of the
middle colic artery, the ascending colon by way of the right colic artery and the ascending colon,
cecum and the appendix by way of the ileocolic artery and appendicular artery.
The interior mesenteric artery comes off of the abdominal aorta at the level of L3 and provides blood to
the level of the left colic flexure, descending colon, sigmoid colon and rectum. The left colic and
sigmoid arteries terminate as the superior rectal artery in the pelvis.
Hepatic Portal Venous System
Venous drainage of the GI tract (fore-mid-hind gut) occurs by the hepatic portal venous system. By
definition, a portal vein connects two capillary beds and the hepatic portal vein connects the GI tract
to the liver. The portal vein does not contain any valves and therefore blood flow is dependent on
blood pressure (blood flow can easily reverse direction). The portal vein also has a set of important
anastomoses with the systemic venous system such that portal venous hypertension can back up into the
systemic venous system. Blood leaving the liver does so through the hepatic veins which drain into the
inferior vena cava.
Lymphatic Drainage of GI Tract
Very straightforward: lymph flows along the same route but in the opposite direction of the arterial
blood flow. Therefore, the foregut drains into the celiac lymph nodes, the midgut drains into the
superior mesenteric lymph nodes and the hindgut drains into the inferior mesenteric lymph nodes.
Lymph from these three sets of nodes will ultimately flow into the cisterna chyli, which demarcates the
start of the thoracic duct.
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Innervation of the GI Tract
The GI tract has its own nervous system, the enteric nervous system, containing both sensory and
motor fibers. Coursing along the wall of the GI tract, the enteric system is heavily influenced by both the
parasympathetic and sympathetic autonomic nervous systems. The sympathetic nerves innervate the GI
tract by the thoracic splanchnic nerves (greater, lesser, least) and lumbar splanchnic nerves.
Preganglionic sympathetic neuron fibers will synapse in ganglia that are closely associated with the
aorta (celiac ganglia, SMA ganglia, IMA ganglia). These are referred to as prevertebral ganglia.
Postganglionic nerves will leave these ganglia and travel to target organs by following arterial branches
of the aorta (celiac trunk, SMA, IMA).
The parasympathetic system controls the GI tract through the anterior and posterior vagal trunks that
form at the base of the esophagus as well as from the pelvic splanchnic nerves that arise from S2-S4.
As mentioned earlier, sensory innervation of the gut, particularly visceral pain, will present as referred
pain in particular regions of the abdomen. Visceral pain from the foregut will present as pain in the
epigastric region, pain in the midgut refers to the periumbilical region and pain in the hindgut refers to
the suprapubic area.
Liver
The liver is the largest gland and second largest organ in the body. Embryologically it is a foregut
derivative. It performs several different functions including the production of bile, the filtering of blood,
several metabolic actions and acts as a source of blood cells for the fetus. Tucked directly under the
diaphragm in the URQ, it is almost completely protected by the ribs. With deep inspiration, the inferior
border of the liver can be palpated. When trying to understand the functioning liver, it is best to consider
the five fluids that enter and leave the organ. 20-30% of arterial blood enters the liver by way of the
hepatic artery while 70-80% enters the liver by way of the portal vein. The hepatic veins leave the
liver and drain blood into the IVC. Bile, which is stored in the gallbladder to be used for the next meal,
is transported by the biliary tract to the second part of the duodenum. The liver is also a major producer
of lymph; 25-50% of all lymph in the thoracic duct comes from the liver.
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Lecture number: 16
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The liver is an intraperitoneal organ, surrounded by three major recesses caused by peritoneal
reflections: the right and left subphrenic recess (anterior to the liver) and hepatorenal recess
(between the liver and right kidney). These recesses are sites where infectious material can collect in the
peritoneal cavity. The liver also includes a bare area, a region on the posterior surface of the liver next
to the diaphragm that is not covered by peritoneum. Therefore, lymphatic flow can easily occur between
the liver and thorax at this bare region along with the site at which the IVC receives the hepatic veins.
Anatomically, the liver consists of two surfaces: a concave visceral and convex diaphragmatic surface.
The diaphragmatic surface is further divided into a larger right and smaller left lobe by the falciform
ligament. On the visceral surface, the liver can be divided by vessels, structures and ligaments that
course across its surface, forming an H. The horizontal bar of the H refers to the porta hepatis (door to
the liver), which includes 4/5 fluids entering/leaving the liver (the hepatic veins do not leave here). The
ligamentum teres anteriorly and the ligamentum venosum posteriorly occupy the left side upright of
the H while the anterior gallbladder and posterior IVC account for the right side uprights. Most
structures that enter or leave the liver do so through the hepatoduodenal ligament, found on the right
free margin of the lesser omentum. The liver also contains two accessory lobes, the anterior quadrate
and posterior caudate lobes.
Functionally, the liver is also divided into right and left lobes, defined by the branching of the bile ducts,
portal veins and hepatic arteries. In much the same way in which the lung can be divided into
bronchopulmonary segments, the liver can be divided into eight hepatic segments, each containing its
own portion of a bile duct, hepatic artery and portal vein. Each segment can be dissected independently
of the others.
Clinical Correlates
When fluid accumulates in the peritoneal sac, a condition referred to as ascites, it must be tested to
determine its identity. This is done using a needle to aspirate off the liquid, a procedure known as
paracentesis.
Date: 8/31/07
Lecture number: 16
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In gastroesophageal reflux disease (GERD), chyme backs up into the esophagus causing a great deal
of pain to the patient. The long-term effect of this acidic exposure can lead to adenocarcinoma of the
esophagus and gastric cardia and occurs by the re-epithelialization of the esophagus after mucosal
erosion due to chronic gastroesophageal reflux. Many times, patients will believe that they are having a
heart attack, when in reality, they are suffering from gastroesophageal reflux (heartburn).
The unique anatomical characteristics of the different parts of the GI tract can be recognized when using
imaging techniques. For example, when performing a contrast radiograph with a barium swallow, the
jejunum stands out dramatically on account of its extensive plicae circularis, appearing zebra like on
film. The first part of the duodenum, lacking in plicae folds, appears as a smooth cap.
As mentioned earlier, the portal system is sensitive to changes in blood pressure. An increase in venous
pressure (portal hypertension) can cause blood to bypass the liver. Esophageal varices are venous
connections between the esophageal hiatus and the left gastric vein. When the portal system is backed
up with blood, these varices will instead link with the azygous venous system. These varices will then
swell due to blood build up and the risk of hemorrhage increases dramatically. Using an esophagoscope,
these varices can be seen to project into the lumen of the esophagus. Rupturing leads to a great loss of
blood and, in fact, 30% of these bleeding episodes are fatal.
Caput medusa is a condition in which abdominal veins, particularly the paraumbilical veins, dilate due
to an increased venous load caused by portal hypertension.
Lecture Number: GA 16
NOTICE &DISCLAIMER
Note-Taker: Jennifer Payne The Medical Note-Taking Service makes every effort to provide accurate
ABDOMINAL VISCERA II
Dr. Schiffer began the lecture by commenting that even though Michigan disappointed early with
their loss to Appalachian State, it's not over yet: they'll come back and beat Ohio State by the end of the
season. This was met by a mix of cheers and jeers from the crowd.
Lecture Outline:
1. Biliary Tract: series of tubes that transport bile
from liver to duodenum
2. Pancreas
3. Spleen
4. Urinary Tract
5. Suprarenal/Adrenal Glands
BILIARY TRACT
The liver produces (via hepatocytes) and secretes bile. Bile is both a waste and secretory product.
Bile has two notable waste products in it: Bilirubin, which helps make it green, and excess quantities of
cholesterol of which the body is ridding itself. The notable secretory product of bile are the bile acids,
which emulsify ingested fat in the small intestine.
To get to the small intestine (specifically the second/descending part of the duodenum), bile has
to travel through a series of tubes or ducts called the biliary tract. The biliary tract consists of tubes bith
in (intrahepatic) and outside of (extrahepatic) the liver. The extrahepatic portion of the biliary tract
begins with the left and right hepatic ducts, which drain their respective functional lobes. These join to
form the hepatic duct, which then joins with the cystic duct (from the gall bladder) to form the bile
duct (formerly common bile duct, about 3 long). The bile duct moves posterior to the head of the
pancreas to join with the second part of the duodenum. In 75% of people, the bile duct joins with the
Course Lecturer: Dr. Schiffer
Date: 9/5/07
Lecture number: GA 16
Page 2 of 12
pancreatic duct before entering the duodenum to form a common opening; this will be covered more
later.
Three observations:
1. The angle where cystic duct and hepatic duct come together is the cystohepatic angle. In this
angle is where one can find the right hepatic artery and the cystic artery branching off of it. This
is clinically relevant.
2. The cystic duct has a mucosal groove called the spirofold that holds it permanently open: this
allows the bidirectional flow of bile to and from the gallbladder. In effect, when bile is not
needed it can flow backwards into the gallbladder to be stored, and when the bile is needed the
gallbladder contracts and bile flows out to the second (descending) part of the duodenum. This is
important because the liver is constantly producing bile: 6-1200mL/day!
3. Important anatomical relationship: the bile duct has a very close relationship to the head of the
pancreas. It travels in a groove posterior to the head of the pancreas, ultimately becoming
embedded into the pancreas as it gains access to the second part of the duodenum.
GALLBLADDER
Anatomical Relationships:
a pear-shaped organ under the right lobe of the liver
c fundus: lobular portion; tender if inflamed
c body: in the liver and peritoneal cavity, covered by the visceral pleura
c neck: S-shaped area, continuous with the cystic duct
surrounded by
c the anterior abdominal wall anteriorly
c the transverse colon inferiorly
c the duodenum posterior, particularly in the neck region
c if gallbladder ruptures, can rupture through to any of the above structures!
Example: gallstones
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SPHINCTER COMPLEX
In the majority of persons, the bile duct and pancreatic duct join before entering the
second/descending part of the duodenum. About 2/3 of the way down the descending portion of the
duodenum is the major duodenal papilla. The major duodenal papilla is met by the hepatopancreatic
ampulla, the common space where the bile and pancreatic ducts join. This sort of y-shaped structure
is controlled by three sphincters: the sphincter of the bile duct, the sphincter of the pancreatic duct,
and the (greater in size) hepatopancreatic sphincter. The hepatopancreatic sphincter is in the wall of
the hepatopancreatic ampulla and helps control/prevent juices from coming into the duodenum
until/unless signalled. This opening at the tip of the hepatopancreatic ampulla (by the major duodenal
papilla) is also the the narrowest portion of the biliary tract; gallstones are most likely to become
lodged here.
PANCREAS
The pancreas is like the liver (2 ways):
1. gland with primarily a digestive function
2. derived from the foregut.
Functions:
90% exocrine:
c products secreted via ducts, here via
the pancreatic duct
10% endocrine:
c products secreted directly into
bloodstream, usually hormones
c example: insulin
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a reddish toned, lobulated structure
Extends right to left: beginning at the right, has a head tucked into the curvature of the
duodenum and moves left and superiorly to the tail, which extends into the splenorenal
ligament and up against the hilum of the spleen.
In between are the uncinate portion, the neck (behind which are the superior mesenteric
vessels) and the body, the largest portion.
The tail of the pancreas is intraperitoneal; the rest of the pancreas is retroperitoneal.
Duct System
The duct system associated with the pancreas is the exocrine portion. Pancreatic enzymes
concerned with digesting proteins, lipids, nucleic acids and carbohydrates are what's put in to these
ducts. The (main) pancreatic duct begins in the tail portion of the pancreas and angles down at the head
to join with the bile duct (where the major duodenal papilla can be found).
An accessory pancreatic duct opens up to the minor duodenal papilla, just a little bit
upstream of the major duodenal papilla, along the medial wall of the duodenum.
Neurovascular Support
There are two major vascular sources for the pancreas:
1. celiac trunk
c splenic artery: supplies body and tail
c gastroduodenal artery:
superior pancreaticoduodenal artery: one supply of head
anterior and posterior branch
2. superior mesenteric artery
c Inferior pancreaticoduodenal artery: other supply of head
anterior and posterior branch
The anterior and posterior portions of each of the pancreaticoduodenal arteries anastamose near
groove between duodenum and head: vascular arches
Note: it is interesting that the pancreas is supplied by both the celiac trunk and the superior
mesenteric artery, considering it is a foregut structure. Also, the lymph drainage from the head of the
pancreas is via both the celiac and superior mesenteric pathways. Thus the foregut-derived pancreas is
supplied and lymphatically drained via midgut structures.
Date: 9/5/07
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The venous drainage is to the hepatic portal vein. Innervation: pain from the pancreas can
project/refer to the epigastrum and frequently the back.
Clinical Correlate
1. Acute Pancreatitis
a) An inflammation of the pancreas.
b) 60% from gallstones, 20-30% from alcoholism
c) Something activates exocrine cells to become active in the pancreas itself: the pancres begins
digesting itself!
d) 10% patients die: acute, hard to treat.
2. Pancreatic Cancer
a) Spreads venously (to liver) and via lymphatics
b) 60% in head of pancreas
c) The bile duct is right behind the head of the pancreas, thus an enlarged (cancerous) pancreas
can cause bile to back up, giving the patient a jaundiced look.
SPLEEN
The spleen is the largest lymphoid organ in the body.
Functions:
1. Immune surveillance
2. Destroy old/damaged red blood cells
3. Store platelets (1/3 of total in body sit in spleen)
4. Source of blood cells during fetal life (fetal hematopoiesis)
Diaphragmatic surface: smooth, often notched (can palpate)
Hilar surface: important relation to stomach, left colic flexure, tail of the pancreas, and left
kidney. Here also the splenic artery and vein access inside the spleen.
In the left upper quadrant, tucked back, usually doesn't go past midaxillary line
Relationship to left ribs: 9-11, mostly over rib 10.
The spleen is thus protected somewhat by the ribcage, diaphragm, lungs, pleura
c means if you can palpate it, it's big or out of place
c can tell it's the spleen because of its notches
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close to abdomen and, importantly, thoracic organs

Peritoneal Relationships
The spleen is an intraperitoneal organ suspended by two ligaments that form the left
bound of the omental bursa:
1. gastrosplenic
2. splenorenal
Arterial Support
The tortuous splenic artery (via the
celiac trunk) supplies the spleen, stomach, and
pancreas. Its branches relevant to the spleen are the
short gastric (supplies fundus of stomach) and left
gastro-omental arteries. The other branches go to the
hilum of the spleen and the pancreas.
Venous Drainage
The spleen is drained by the hepatic portal system, though not a digestive gland. This
works thus: The splenic vein joins with the superior mesenteric vein behind the neck of the pancreas,
forming the hepatic portal vein.
Why does the spleen drain into the hep portal vein if not a digestive gland? The spleen produces
bilirubin, a major byproduct of hemoglobin breakdown (from the splenic breakdown of red blood cells).
This can be carried venously to the liver, where the bilirubin is processed to be included in bile (the
bilirubin is what makes it green!).
Clinical Correlate
The spleen is the most frequently injured organ in the abdomen. A low thoracic
penetrating injury can puncture the spleen, with the major problem being hemorrhage: with 1/3 of all the
red blood cells in the body here, this makes sense!
Another problem is splenomegaly. If the spleen is three times its normal size, its notches
can be palpated below the costal margin. There are different magnitudes of splenic enlargement.
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URINARY SYSTEM
The urinary system consists of two kidneys (right and left), which produce urine into their
respective (2) ureters, which join at the bladder, urine finally expelled via the urethra. The urinary
system has a role in the abdomen, pelvis, and peritoneum; here we will focus on the abdominal role.
KIDNEYS
The kidneys are retroperitoneal organs: they are not suspended by mesentery and can be found
behind the peritoneum, in front of the transversalis fascia.
Three Major Functions
1. Produce urine as a waste product
2. Electrolyte and water balance
3. Endocrine Function (example: erythropoietin for red blood cells)
Anatomical Relationships
Typically bean-shaped:
c superior pole
Left kidney usually higher than the right
L superior pole: rib 11 and 12
R superior pole: mainly rib 12
Related to the ribs, diaphragm, pleura (lower thoracic wall)
c inferior pole
c concave medially
c convex laterally
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Each kidney and suprarenal gland is surrounded by (in order bordering the kidney on out)
c perirenal fat (think i, inside)
c renal fascia = thick, membranous layer
c pararenal fat: outside the renal fascia on
the posterior side of the kidney
c retroperitoneal space and fat: outside
the renal fascia lateroanteriorly
Hilum of the kidney: concave side of kidney
where fluids gain access to it
c anterior to posterior:
renal vein (blood out)
renal artery (blood in)
renal pelvis (urine out)
c deep within lips of hilum: renal sinus supports the above structures coming in
Arterial Support
25% of the cardiac output travels to the kidneys: Aorta directly branches to renal arteries
(L1) to the 5 segmental arteries that are end arteries. We do not need to know the names of the individual
segments of these arteries. Note: end artery means it has little if any anastamotic/collateral
connections to that artery. That means if it gets blocked, you're sore outta luck: that tissue will infarct.
Venous Drainage
The right and left renal veins are asymmetrical: the right renal vein is shorter. The left
renal vein is longer because it has to go over the abdominal aorta to get to the inferior vena cava (IVC).
Renal Vein Right Left

Length Shorter Longer: traverses over aorta to
get to IVC
Path of Drainage/possible clinical Dump directly to IVC Moves anterior to aorta, posterior
relevance to SMA through nutcracker
angle to get to IVC:
compression can result in kidney
backup of blood!
Tributaries (The gonadal vein and suprarenal Recieves gonadal vein (testic/ov)
vein dump directly into IVC) and suprarenal vein
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Urine Formation and Transport

Use structure to delineate function:
Kidney has three major portions visible if cut coronally:
Capsule
c outer surface
Parenchymal
c Cortex
renal columns around and in between pyramids
c Medulla
form medullary pyramids
at apex of each renal pyramid is a renal papilla: where urine comes out!
At apex of each papilla is a minor calix (cup) that catches urine. 8-
12 minor calices fuse to form 2-3 major calices per kidney, which
then fuse to form a renal pelvis, a funnel type structure that will
eventually narrow down to become the ureter (1/kidney).
URETERS
The ureters are smooth-muscled tubes originating from the kidney as described above. They push
the body's urine down via peristaltic waves to the bladder. In the words of Dr. Schiffer, You could be
standing on your head and urine would still get to your bladder.
The ureters travel retroperitoneally, over the pair of (R and L) psoas major muscles. (If looking
anterior to posterior, can see that the ureters travel on the same level as the tips of the transverse
processes of the lumbar vertebrae.) The ureters then traverse over the pelvic brim to gain access to the
pelvis, then dump into the bladder.
Three places kidney stones (renal calculi) can lodge: **all places where the ureters narrow down**
1. Junction of renal pelvis and ureter
2. Pelvic Brim
3. Wall of Urinary Bladder
**Clinical Correlate:
referred pain = loin to groin: L1 to scrotum/labia majora and L2 to thigh
up to 12% US population will develop a urinary calculus in their lifetime!
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SUPRARENAL/ADRENAL GLANDS
Anatomical Relationships
The suprarenal (or adrenal) glands are located right next to/right above the superior pole
of each kidney. They are not directly connected to the kidney but are enclosed by the renal fascia. The
right adrenal is triangular and the left adrenal is semilunar.
Exteriorly, they are enclosed by a capsule. Underneath this are two parenchymal
structures: first the outer cortex, which produces a variety steroid-type hormones (example: aldosterone)
and secondly the deeper medulla, which produces catecholamine-type hormones, primarily epinephrine,
but also norepinephrine. Visually, the medulla is darker because of oxygenation and also has a vein
running through it. The focus of gross anatomy will be on the medullary portion of the
adrenal/suprarenal gland; the cortex is mainly controlled by factors beyond the scope of general
anatomy.
The medullary portion of the suprarenal gland is composed of post-ganglionic sympathetic
neurons that have transformed their phenotype into endocrine cells. Thus, this is in the scope of gross
anatomy!These adrenal cells are innervated by pre-ganglionic fibers from the splanchnic nerves via the
celiac plexus (no synapse yet!) to the adrenal medulla, where they synapse. This synapse signals
epinephrine/norepinephrine release.
Vascular Support
Most endocrine glands require a strong blood supply, as they need to exert effects via the
bloodstream to the entire body. Each suprarenal gland receives three arteries and generates one vein:
1. Inferior Suprarenal Artery
a) branch of the renal artery (which directly branches from the abdominal aorta)
2. Middle Suprarenal Artery
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a) direct branch off the aorta

3. Superior Suprarenal Artery
a) from inferior phrenic arteries, from the aorta
4. (venous drainage) Suprarenal Vein
a) Left side: into left renal vein
b) Right side: directly into IVC
Note about the Adrenal Gland: In a fetus or newborn, these glands are 10-20x larger than in adults: this
is because the gland is producing lots of hormones that get acted upon by the placenta.
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The Medical Note-Taking Service Date: 09-07-07
Lecture Number: 17
NOTICE &DISCLAIMER
Note-Taker: Jessica Paciorek The Medical Note-Taking Service makes every effort to provide accurate
*Note: Dr. Schiffer will be in the lab on Saturdays at 10am to go over questions and help with review.
Posterior Abdominal Wall
Todays lecture basically finishes up the abdomen we will go over the posterior abdominal wall, which
will reinforce what were doing in lab at the same time. Well also finish up by looking at the pelvic
inlet and diaphragm, as they form the superior/inferior borders of the abdomen.
The posterior abdominal wall is made up of similar layers to the anterior abdominal wall, but arranged
in reverse order, so the first layer you encounter on the posterior abdominal wall is the parietal
peritoneum, followed by the fat and fascia of the extensive retroperitoneal space. This is followed by
the musculoskeletal structures of the posterior abdominal wall. We will look at each of these layers in
more detail.
Posterior Parietal Peritoneum
The parietal peritoneum lines the abdominal cavity and forms

several key reflections. At these reflections, the parietal
peritoneum becomes visceral peritoneum that covers the
abdominal organs, such as the root of the mesentery of the small
intestine and root of the transverse mesocolon. Certain of these
reflections divide the abdominal cavity into a series of gutters
and compartments. The right and left infracolic spaces are
found to the anatomic right and left of the root of the mesentery
of the small intestine inferior to the transverse mesocolon and
greater omentum. The right space is where the superior mesenteric artery and its branches are found,
Date: 09-07-07
Lecture number: 17
Page 2 of 10
while the inferior mesenteric artery is located in the left space. The lateral borders of the abdominal
cavity are framed by the muscular wall of the cavity and the ascending and descending colon. The right
paracolic gutter is found between the ascending colon and the abdominal wall, while the left paracolic
gutter is found between the descending colon and the abdominal wall. The significance of these gutters
and spaces is that fluids in the peritoneal cavity can easily flow from one area to another via these
channels. The gutters provide a pathway along the abdomen, above the liver to the diaphragm, where
fluids may cross into the thoracic cavity. Fluids may likewise
drain inferiorly into the pelvis. The supracolic compartment
is found superior to the transverse colon, while the infracolic
compartment is located inferior to the transverse colon.
In a normal, healthy body, the natural tendency is for
peritoneal fluids to flow superiorly in the paracolic gutters,
and reach the left and right subphrenic spaces. Here, it is
picked up by the diaphragmatic lymphatics. If the volume or
consistency of the fluid is abnormal, this system can easily be
overwhelmed, and the fluid will instead flow in altered
directions including inferiorly and collect in the pelvic cavity.
Patients with excess fluid or pus in the abdomen will usually be advised to sit at a 45 angle, also called
Fowlers position.
Retroperitoneal Space
Behind the parietal peritoneum lies an extensive area known as the retroperitoneal space. It is bordered
anteriorly by the parietal peritoneum and posteriorly by the transversalis fascia. The renal fascia
divides the retroperitoneal space into compartments. These compartments include anterior and posterior
layers of pararenal fat (outside the renal fascia) and perirenal fat (inside the renal fascia).
The kidneys, ureters and suprarenal glands are found in the retroperitoneum and are considered
to be retroperitoneal organs. The ascending colon, descending colon, pancreas and duodenum are all
secondarily retroperitoneal because although they first arose embryologically in the peritoneum, as part
of the developmental process they came to be positioned in the retroperitoneum in the adult. There are
Date: 09-07-07
Lecture number: 17
Page 3 of 10
also major blood vessels found in the retroperitoneal space, including the abdominal aorta and the
inferior vena cava as well as a host of branches and tributaries of these two vessels.
Neurovascular structures of the Retroperitoneal Space
The abdominal aorta enters the abdomen at the level of T12 through the aortic hiatus, posterior to the
diaphragm. It runs inferiorly until it reaches the level of L4, where it bifurcates into the right and left
common iliac arteries. These two arteries provide the major source of blood to the pelvis and lower
limbs. There is also an unpaired medial sacral artery which makes a small contribution to the
bloodflow to the body inferior to the abdomen (this artery would be more prominent if only we still had
a tail!). The iliacs and medial sacral artery together comprise the group of branches off the abdominal
aorta known as the terminal branches. There are several other categories of branches that leave the
abdominal aorta. The first is the unpaired visceral arteries, which include the celiac artery (T12), the
superior mesenteric artery (L1) and the inferior mesenteric artery (L3). These three arteries function as
good landmarks for interpreting the level of a CT scan. There are three paired visceral branches. The
right and left middle suprarenal arteries, right and left renal arteries and right and left gonadal
(testicular/ovarian) arteries all arise from the abdominal aorta. Finally, there are paired parietal
branches, which include the inferior phrenic arteries, found on the inferior side of the diaphragm, and
three or four lumbar arteries, which supply the posterior wall of the abdominal cavity.
The inferior vena cava begins at the level of L5 where the right and left common iliac veins and
the medial sacral vein come together to form the IVC. This vein travels superiorly and leaves the
abdomen at the level of T8 through the caval foramen of the diaphragm. There are three important
venous networks in the abdominal cavity. The portal vein system is made up of the superior mesenteric
vein and splenic vein fusing to form the hepatic portal vein. After passing through the liver, blood is
collected into the right, left and middle hepatic veins which drain into the IVC. The caval system refers
to the veins that drain into the inferior vena cava. These veins are usually paired but exhibit an
asymmetric relationship to the IVC. The right gonadal vein drains into the IVC, while the left gonadal
vein drains into the left renal vein. The right suprarenal vein drains into the IVC, while the left
suprarenal vein drains into the left renal vein. Both the right and left renal veins empty into the IVC at
approximately the level of L1/2. There are also lumbar veins which not only drain into the IVC, but also
are connected to each other by ascending veins. These ascending veins form an important collateral
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Lecture number: 17
Page 4 of 10
channel in the event of an obstruction of the IVC, and give rise to the azygos and hemiazygos veins as
they travel superiorly.
The abdomen is rich in lymphatic structures. There are primary lymph nodes which sit close to
the organs, intermediate lymph nodes which are found in the mesentery, and terminal lymph nodes
which are found close to the abdominal aorta. Clusters of lymph nodes are found around the three major
unpaired branches of the abdominal aorta, and are named for the vessels that they lie close to (celiac,
superior mesenteric and inferior mesenteric). These lymph nodes receive lymph from their respective
drainage fields, and form an intestinal trunk which drains superiorly into the cysterna chili, at the level
of L1-L2, just to the right of the aorta. From here, the lymph will flow into the thoracic duct.
There are five major prevertebral (aortic) nerve plexuses in the abdomen: celiac, superior
mesenteric, renal, inferior mesenteric and superior hypogastric. The names for these plexuses varies
depending on the source that is consulted, Dr. Schiffer suggested going with a naming scheme that
closely mirrors the named blood vessels in the vicinity of the plexus. All together, these plexuses make
up the prevertebral plexus. Ganglia in the prevertebral plexus are for the sympathetic division of the
ANS. There are preganglionic fibers of the sympathetic and parasympathetic nervous system that
traverse these plexuses, as well as visceral afferent fibers coming from the organs to synapse and enter
the CNS. *There is one type of preganglionic sympathetic fiber that doesnt synapse in the prevertebral
ganglia: those that synapse at the adrenal medulla.* The nerves passing through the superior
Date: 09-07-07
Lecture number: 17
Page 5 of 10
hypogastric plexus are mostly involved in the ANS of the pelvis. Pelvic splanchnic nerves emanating
from S2, S3 and S4 are parasympathetic efferents that serve the pelvic organs and also travel superiorly
to innervate the abdominal viscera (hindgut portion).
Musculoskeletal Components of the Posterior Abdominal Wall
The skeletal border of the abdomen is made up of the vertebrae from T12 to L5, rib 12, and the pelvis
(right and left ilium). Note: ile refers to the intestine, while ili refers to the pelvis.
There are five important muscles of the posterior abdominal wall.
The psoas major muscle is a paired muscle that

originates on the vertebral bodies and disks of
vertebrae T12 to L5, and inserts into the femur.
It runs deep to the inguinal ligament, and its
action is to flex the thigh. Note that the psoas
muscle has a thick epimysium fascia surrounding
it. Infections that penetrate under this fascia can
travel the length of the psoas muscle and move
into the anterior thigh, causing pain. The psoas
muscle runs on an oblique angle towards the
lateral abdominal wall. The kidneys are found in close proximity to the psoas, and thus are also
angled with the lower pole slightly more lateral than the superior pole.
The iliacus muscle is found in the iliac fossa and is a fan shaped muscle. It joins the psoas to
form the iliopsoas muscle where they insert together into the femur. The iliacus and psoas major
have similar actions. It is innervated by branches of the femoral nerve.
The quadratus lumborum muscle runs from rib 12 to the iliac crest. Its function is in lateral
flexion of the trunk and fixation of the 12th rib, to aid in respiration. It is innervated by the
subcostal nerve (T12) and by the ventral primary rami of spinal nerves L1 to L4.
Date: 09-07-07
Lecture number: 17
Page 6 of 10
The Transversus abdominus muscles run from the linea alba to the pubic crest, and function to
compress the abdomen. They are innervated by the intercostal nerves from T7-T11, the
subcostal nerve, the iliohypogastric and ilioinguinal nerve (L1).
The diaphragm makes up the superior border of the abdominal cavity. It is innervated by nerves
from C3, C4 and C5 that form the phrenic nerves (C3, C4, C5 keep the diaphragm alive). It
also makes up part of the posterior wall of the abdomen as it slopes inferiorly and posteriorly.
The left crus attaches to the L1 and L2 vertebral bodies, while the right crus attaches to vertebral
bodies from L1-L3. The major function of the diaphragm is in respiration, by contracting to
increase the volume of the thoracic cavity.
The Lumbar Plexus
The lumbar plexus is a nerve rich area that supplies the posterior abdominal wall, as well as some of the
anterior abdominal wall. It also makes a major contribution to the innervation of the lower limbs.
The subcostal nerve is not truly a part of the lumbar plexus, but runs just superior to it. It
emanates from the spinal nerve at T12 and innervates the abdominal muscles, including the
external oblique, internal oblique, transversus abdominus, rectus abdominus and quadratus
lumborum muscles.
The iliohypogastric and ilioinguinal nerves emanate from a single branch at the level of L1.
They emerge lateral to the psoas muscle. The iliohypogastric innervates the internal oblique and
transversus abdominus muscles, as well as providing cutaneous innervation to the lower
abdominal wall. The ilioinguinal nerve runs in front of the quadratus lumborum and follows the
spermatic cord down into the inguinal canal, where it gives of femoral cutaneous branches.
The genitofemoral nerve arises from the level of L1-L2 and pierces the anterior surface of the
psoas muscle. It divides into femoral and genital branches. The genital part functions as the
motor nerve of the cremaster muscle, while the femoral part runs under the inguinal ligament
Date: 09-07-07
Lecture number: 17
Page 7 of 10
inad into the thigh to supply an area of skin inferior to the inguinal ligament (area of the femoral
triangle).
The Lateral cutaneous nerve of the thigh arises at L2-L3 and runs inferolaterally on the iliacus
muscle, travels behind the inguinal ligament and medial to the anterior superior iliac spine
(ASIS) to supply the cutaneous innervation for the anterolateral portion of the thigh down to the
knee. The passage of this nerve under the inguinal ligament is particularly tight, and any
compression of the nerve will lead to a numbness (paresthesia) of the thigh. Sigmund Freud is
said to have suffered from this.
The femoral nerve arises from L2-L3-L4 and emerges lateral to the psoas major muscle. This is
a large nerve that runs down under the inguinal ligament to innervate the iliacus, hip flexors and
knee extensors. It also provides sensory innervation to the anterior thigh.
The obturator nerve arises from L2-L3-L4 and emerges from the medial border of the psoas
major muscle. It passes through the pelvis to supply motor and sensory innervation to the medial
thigh, including the adductor muscles of the thigh.
The lumbosacral trunk is formed from L4 and all of L5, and passes inferiorly to join the sacral
plexus.
Diaphragm
Date: 09-07-07
Lecture number: 17
Page 8 of 10
The diaphragm makes up the superior border of the abdomen. It is a domed structure when relaxed, and
may reach as high as the fifth rib on the right and fifth intercostal space on the left. The diaphragm has
an extensive relationship with the abdomen as many abdominal structures may be found inferior to the
diaphragm, covered by the ribs. The diaphragm is associated with several key structures. The central
tendon of the diaphragm is a broad aponeurosis where the diaphragmatic muscles insert. The inferior
vena cava protrudes through the central tendon at the level of T8. An important clinical aspect of this
placement is that the vena cava will not be collapsed by muscular contractions of the diaphragm during
respiration. At the level of T10 the esophagus protrudes through the diaphragm at the esophageal
hiatus. The aorta passes posterior to the diaphragm at the level of T12, through the aortic hiatus, which
is comprised of the median arcuate ligament of the diaphragm. The medial arcuate ligaments course
over the paired psoas major muscles, while the lateral arcuate ligaments course over the quadratus
lumborum muscles. The diaphragm has three muscular areas a small sternal area, comprised of two
small bundles of muscles on the posterior surface of the diaphragm that attach to the xiphoid process, the
costal area, which attaches to the inferior six ribs and their costal cartilages, and a lumbar area, which
forms two crura the right crura and the left crura. These crura anchor the diaphgram to L1-L3 and
L1-L2 respectively, and the right crura arches around to form the suspensory ligament of Treitz
(suspensory muscle), which supports the duodenum at its junction with the jejunum. The right crus also
forms the esophageal hiatus.
To summarize the three openings of the diaphragm:

T8: Vena caval opening
Right phrenic nerve passes through
T10: Esophageal hiatus
Vagal trunks pass through to innervate abdominal viscera
L gastric artery branches pass through to form esophageal network
T12: Aortic hiatus
Thoracic duct passes through on its way to the left venous angle
Azygos vein passes through on its way to the superior vena cava
Date: 09-07-07
Lecture number: 17
Page 9 of 10
Motor innervation to the diaphragm is by the right and left phrenic nerves. These same nerves provide
sensory innervation in the central regions of both the superior and inferior surfaces. Referred pain from
inflamed pleura and peritoneum will be felt on the shoulders, as the C4 dermatome is at this level. The
most peripheral regions of the diaphragm are innervated by the intercostal nerves.
The inferior border of the abdomen is the pelvic inlet, but this relationship is somewhat arbitrary as the
two cavities are continuous. Several abdominal organs will be found in the pelvis and vice versa. For
example, the peritoneal sac drapes into the pelvis and covers some organs, while the pregnant uterus can
extend up to nearly the level of the xiphoid process. We will cover this in much more detail when we
reach the pelvis lectures.
Clinical Correlates for the Posterior Peritoneum
Psoas Sign is a useful tool for determining if there is intraabdominal pain or inflammation in any
structure associated with (or next to) the psoas major muscle. The patient lies on the unaffected side
while the physician stretches the leg on the affected side. Feeling pain indicates that the inflammation
has been aggravated. This happens, for example, when the appendix is inflamed because it rests on the
psoas muscle. If pain is felt, this is a positive psoas sign (pain at McBurneys point would also help with
diagnosing an inflamed appendix).
Date: 09-07-07
Lecture number: 17
Page 10 of 10
Free air in the abdomen: will appear on a P-A chest film as a dark region under the diaphragm.
Normally you would not be able to distinguish the diaphragm from the liver because they are the same
density, but in this case there will be a black line separating them. Free air can collect in the abdomen
for several reasons, including a perforated duodenal ulcer, which releases gas in to the abdomen, or as a
byproduct of laparoscopic surgery, because the patient is often inflated with gas to make the surgery
easier. Patients will be warned that they may feel some pain on the tops of their shoulders after this
procedure, because the diaphragm may become irritated.
Diaphragmatic hernia: Can be either a congenital defect or caused by trauma. The intraperitoneal
organs are most likely to be the ones that herniate through the diaphragm into the thorax because they
are the most mobile. If this happens during fetal development, the lungs can be compressed, leading to
the development of hypoplastic lungs. This is a very serious condition for the newborn.
One final examplethe DC sniper case from October 2002, one of the victims was shot in the left lower
chest below the nipple line. At this area, there was involvement of both thoracic and abdominal organs.
The Medical Note-Taking Service Lecturer Dr. Fishbein

Date September 10,2007
Lecture Number: 18
NOTICE &DISCLAIMER
Note-Taker: Jennifer Lan The Medical Note-T aking Servic e makes ever y effort to prov ide accurate
Corrected by: UNCORRECTED class notes. Howev er, errors will occur fr om time to time. The user
Multivisceral Transplantation
I. INTRODUCTION
Dr. Fishbein is a Professor of Surgery here at Georgetown. He graduated from Georgetown
University School of Medicine in the 1980s (who doesnt love the 80s?), and works here as a transplant
surgeon and jointly at Childrens Hospital. Georgetown Hospital is actually one of only six places
where multivisceral transplantations are performed (neato!). His lecture today gives us a reality as to the
importance of the anatomy we are learning this year.
Dr. Tom Starzl, who performed the first human liver transplant in 1963, pioneered the field.
Though he was criticized for his work as many of his patients died during his early attempts at liver
transplant, his persistence over the past 40-50 years brought us to where we are today. In the past, babies
who develop ascites (fluid backs up into abdominal cavity) would die shortly after birth, as they would
bleed to death. However, nowadays, infants can be saved with a liver transplant.
Dr. Fishbein gave an overview of a few transplant procedures he performs along with what
anatomical facts that must be taken into consideration. The
lecture was broken down into 6 procedures:
a. Liver Transplantation
i. Ortotopic Whole Liver Transplantation
ii. Split Liver Transplantation
iii. Liver Donor Liver Transplantation
b. Isolated Intestine Transplantation
c. Liver-Intestine Transplantation
d. Multivisceral Transplantation
Homer: Are you saying you're never going to eat any animal again? What about bacon?
Lisa: No.
Homer: Ham?
Lisa: No.
Homer: Pork chops?
Lisa: Dad, those all come from the same animal.
Homer: Heh heh heh. Ooh, yeah, right, Lisa. A wonderful, magical animal.
Course Lecturer Dr. Fishbein
Date September 10, 2007
Lecture number 18
Page 2 of 8
II. LIVER TRANSPLANTATION

Review of the liver
First, lets take a quick review of the segmented structures of the liver. The liver, similar to the lung,
can be divided up into eight segments. The right and left
functional lobes can be divided through the line formed
between the gallbladder fossa and the inferior vena cava.
The left lobe consists of Segments I, II, III, and IV while the
right lobe contains Segments V through VIII. Which lobe is
taken during transplantation, which will be discussed later.
What is unique about these segments, similar to what we
saw in the lungs, is that each segment is its own functional unit. Each of them receives their own
branch of the bile duct, hepatic artery, and portal vein. So removal of one segment does not affect the
other ones.
The liver has key vessels that enter and exit out of it. Remember the Hepatic Triad (three most
important structures): the hepatic portal artery, the bile duct, and the portal vein.
Approximately 30% of the blood the liver receives comes from the hepatic portal artery
(common hepatic artery celiac trunk abdominal aortic), which splits into right and
left hepatic arteries.
About 70% of the blood comes from the portal vein, which receives venous drainage
from the inferior mesenteric vein, the splenic vein, and the superior mesenteric vein.
(Inferior mesenteric vein splenic vein + superior mesenteric vein portal vein)
Remember that the hepatic portal vein drains the GI Tract, the pancreas, the spleen, and
gallbladder. These connections must be taken into consideration when the liver is removed. The liver
filters the blood from these visceral organs before sending it off to the heart.
Orthotopic Whole Liver Transplantation:

Orthotopic means in the same place. So, an orthotopic transplant means that the organ being
transplanted is placed in the same location as where the original organ was located. Versus
heterotopic transplants where the organ is placed in a different location as where the native organ was
Lecture number 18
Page 3 of 8
located. For example, in a kidney transplant, the kidneys are not actually removed, but new kidneys are
placed in the pelvis and anastomsed with the iliac artery and vein.
When the liver is removed, it is preserved in chemicals that slow down its cell metabolism. The
organ is kept at 4C as it is being transported. Then, the surgeons have approximately 12-15 hours to
put it into a new person. The entire procedure requires the surgeon to connect all the new liver to the
inferior vena cava, hepatic veins, portal vein, artery and bile ducts.
Even though liver donation works, there were still a huge percentage of babies dying on the waiting
list in the 1980s because there were very few pediatric donors. So, other procedures were developed
(see following procedures). Each of them has specific anatomical considerations.
Split Liver Transplantation

As mentioned above, the liver has 8 individual
segments. Surgeons usually take Segments II and III
(about 15% of an adult liver), which has an inflow vessel,
based on the left portal vein. The surgeons would take
the left hepatic artery and separate that off from the rest
of the liver and transplant that portion to the infant. If the
infant is larger, surgeons often also take Segment IV, the
quadrate lobe (i.e. for a 7-8 year old). We can use
volume measurements to compare segments since the
vasculature is defined on MRIs and CT scans. So one
liver can potentially save two lives as the left lateral segment graft can be given to an infant and the right
segment to a small adult.
Live Liver Transplantation

Since adults could live with 15% of their liver removed
(i.e. due to cancer), why cant we transplant segments from
live donors? There are many benefits to using a live donor.
First of all, the amount of ischemia is greatly reduced as it
sometimes only takes 15 minutes to move the donated liver
Lecture number 18
Page 4 of 8
segment into the patient while it can take hours to retrieve an entire liver who might live far away.
Split liver transplants are quite useful for infants. A baby can be born with biliary atresia where the
bile duct does not drain properly from the liver to the duodenum (remember where it drains to? Oh yes-
the second part of the duodenum around the L2/L3 level). The build up of biliruben (a breakdown of
catabolism) can cause cirrhosis of the liver. The infant can die of the cirrhosis by 6-8 months of age.
However, with the split liver transplant, an adult donor can donate segments of his/her liver (see split
liver transplantation section).
**Note: You have to always be aware of anomalies. Children who are born with bile ducts can have
other anomalies. For example, the portal vein can be pre-duodenal instead of post-duodenal. Children
can have Splenosis syndrome where they have multiple tiny spleens. These tiny spleens usually do not
function. They also might not have a vena cava (where liver drains into). There is return of blood from
collaterals in the azygos and hemiazygos. Here, surgeons must be careful in grafting the hepatic veins
onto the vena cava stump. As a surgeon, you always have to be aware of such anomalies.
Now, if we can remove segments from the left lobe (15%), can we remove segments from the right
lobe? Remember from the Greek Myth of Prometheus, weve known for a long time that the liver can
grow back. Actually you can often resects up to the other 85% of the liver and have it grow back in a
month and leave behind only the 15%. The right lobe, Segment V through VIII, make up about 65% of
the live, which is big enough for an adult.
**Another note: Again, be on the lookout for variation in vasculature. When reconstructing the liver
into the recipient, youll often find additional venous drainage coming from the anterior of the right
lobe. Normally, the additional venous drainage would drain into the middle hepatic vein. Since the
middle hepatic vein isnt taken out, the surgeons can do fancy reconstruction. They can use a jump graft
from an anterior segment and link it to the middle hepatic. For example, the surgeons can take an
inferior mesenteric vein from donor and link it to the anterior segment and link it to the middle hepatic
vein.
III. INTESTINAL TRANSPLANT

Lecture number 18
Page 5 of 8
Dr. Fishbein is involved in intestinal transplant, which is the least developed and youngest transplant
area. This subspecialty started a decade ago with about 50 cases a year. Present day, it is up to 150
cases of year.
A review of the Intestinal tract
Remember to keep in mind where each part of the intestinal tract receives their blood supply. The key
ones to keep in mind are the unpaired visceral branches of the aorta:
1. Celiac trunk
a. Splenic artery spleen (and also have branches to the stomach and pancreas)
b. Common hepatic liver (with branches to the stomach)
c. Left gastric artery esophagus
2. Superior Mesenteric Artery (SMA) inferior to celiac, around lower L1
a. Middle colic transverse colon
b. Right colic right colic flexure/ascending colon
c. Ileocolic ileal-cecal juncture
3. Inferior Mesenteric Artery (IMA) emerges around L3
a. Left colic descending colon
b. Sigmoid colon
c. Superior Rectal Artery
**Remember the GI tract drains to the Portal Vein: splenic vein + SMV (portal confluence
remember from the radiology slides?) + IMV.
Isolated Intestinal Transplant

Say you get in a car accident but thankfully you wore your seat
belt. The seat belt could potentially lacerate your SMA. In this cause,
you would lose your entire small bowel but can be kept alive through
intravenous feeding. About 80-90% of patients can survivor on
Lecture number 18
Page 6 of 8
intravenous feeding for about a year. However, after 5-8 years, patients would undergo liver failure.
About ten years ago, such a condition would be termed incompatible with life. However, with the
development of bowel transplant, such conditions can be helped.
What happens is a graft of the donors SMA is obtained (remember, the SMA crosses just over
the renal vein). The stomach is immobilized and lifted up superiorly. Surgeons perform a medial
visceral rotation where they rotate medially the retroperitoneal organs. If the surgeon just wants the
graft and not the stomach, they must disconnect the left gastric artery (from celiac) and pylorus of
the stomach. The colon is not usually taken as well since it is innervated by the IMA and therefore not
lost. After removal, the blood will be flushed out of the organs and preserved in solution.
When an isolated intestinal procedure is performed, it is based on the SMA and SMV. When
isolating the SMA and SMV from a donor, there are two techniques that can be used:
1) Central drainage take graft up and get inflow from aorta and outflow from the vena cava.
a. Surgeons create a portacaval shunt where the patients hepatic portal vein is sewn to the
inferior vena cava so that the foregut drains to the vena cava
b. I know, this is not a physiologically normal process as body receives unprocessed food,
but the person actually lives fine (neato!).
c. Knowing youre anatomy is critical here --15% of people have their left renal vein
posterior to aorta and joins the vena cava from behind; some people have half of their
vein go anterior and half go posterior to the aorta. Be on the lookout for these possible
anomalies during surgery! You dont want to by accidentally knick those veins.
2) Portal drainage- connect to portal system
Central Drainage Portal Drainage

Lecture number 18
Page 7 of 8
Liver-Intestine Transplant
A much more complicated procedure is the liver-intestine transplant. Here, the liver, intestine,
and pancreas are removed from the donor and cleaned. The surgeons take the thoracic aorta and
transpose it inferiorly and put it from below to aorta of the recipient.
If you remove the stomach, you have to think about the innervations of the stomach. Remember
the 4 Gooses of the Mediastinum: Azygoose (azygos), Esophagoose (esophagus), and the 2 Vagooses
(vagus). The vagus nerves control the relaxation of the pylorus. Since the stomach is removed from
its vagus nerve, it will never relax and open. The pylorus of the stomach no longer has an intrinsic
reflex to empty out food. Therefore it needs an outflow tract so a pyloroplasty must be performed where
the muscle is cut out and sewn in sideways to provide a channel for the food to flow through. This can
lead to dumping syndrome as less processed food is dumped into the duodenum, causing hormonal
changes (i.e. surge of insulin). A portacaval shunt is placed in as well since the portal vein is now
coming from the small bowel through the SMV and into the liver. The native stomach and spleen is
drained through the portacaval shunt.
Multivisceral Transplant
In a multivisceral transplant (supposedly easier than a liver-intestine transplant), the liver,
stomach, spleen, small and large intestines are replaced. The stomach is of key importance here
because do the removal, the stomach loses its innervations (loses its vagus nerve). A pyloroplasty is
also performed here in the stomach. The overall operation usually takes up to around 12 hours.
There is also a modified multivisceral transplant procedure everything is transplanted except
the liver. In the past, surgeons would just perform a multivisceral transplant. However, since there is
such a demand for a healthy liver, a modified multivisceral transplant was invented. Everything except
the liver is replaced so the GI tract would drain it into the native liver. Dr. Fishbein called it the upside
down liver transplant.
IV. ORGAN REJECTION

The main problem with organ transplant is rejection. It is also a primary problem with the
valves/grafts. However, with the use of efficient immunosuppressants these days, the number of organ
rejections has decreased dramatically. Georgetown has some of the highest survival rates with 80-85%
short-term survival, and 70% long-term survival. Nationally its just about 50%.
Lecture number 18
Page 8 of 8
V. LAST MINUTE QUESTIONS

1. How do you deal with the nerves and the prevertebral plexuses?
Actually, we dont. The body is so clever in that it has its own intrinsic reflex. For example,
the bowel has its own migratory motor complex. The internal system of nerve innervations does
remain intact even if it is not connected to the brain. Same with the lymphaticsthey usually
grow back.
2. How does the incidence of rejection correlate with the number of organs you transplant?
The more organs you transplant, the higher risk of rejection. The bowel has been a big hurdle
since it is a big giant lymph node full of sh*t (hmm, touch). However, the use of
immunosupressants has greatly helped us overcome this obstacle. The liver is actually unique in
that it is less susceptible to rejection. We do not really know why this is the case. It is believed
they have specialized cells that modify the antigens to make it less immunogenic. Actually,
when the liver is transplanted in a multivisceral transplantation, it has a protection over the other
organs (Neato-I like how it looks out for the others, but I think I like the Greater Omentums
policeman powers better :P).
VI. SOME ADVICE

Dr. Fishbein incorporated some topics one should think about when choosing what
specialty to go into. In the field of surgery where new procedures and techniques are formed,
there are no guidebooks. Developing new techniques can be very rewarding but can be
dangerous. Dr. Fishbein gave an example of an incident at Mount Sinai Hospital where the
donor died of infection, which closed the program for several years. There are ups and downs to
each specialty and one should consider all aspects of a career.
Dr. Fishbein concluded with the lecture on two notes:
1. Find something you are passionate about!
2. Look at attendings to see what your life would be like in that particular field, both in the hospital
and private practice.
Hope this helps. Happy studying!

Course: GA
Lecturer: Dr. Dym
The Medical Note-Taking Service Date: 9.11.2007
Lecture Number: 19
NOTICE &DISCLAIMER
Note-Taker: Lindsay Edwards The Medical Note-Taking Service makes every effort to provide accurate
Corrected by: Dr. Dym class notes. However, errors will occur from time to time. The user
Dr. Dym introduced himself and surprised us with his giant model pelvis, Oscar. He will present
the lectures on the pelvis today, tomorrow, and Monday. He warned us that the dissections of the pelvis
are not that satisfying. Things are hard to see and the dissections are difficult, so dont get to frustrated.
Rely on lectures, books, the professors wisdom, etc.
Dr. Dym covered the following in todays lecture: 1. Bony Pelvis, 2. Muscles of Pelvic Floor,
and 3. Perineum including the Anal Triangle and the Urogenital Triangle (both male and female).
Dr. Dym began with an overview of the pelvis. Pelvis means "basin" in Latin. A basin is a wide
shallow container, and so is the pelvis. The bony pelvis is a massive ring of bone interposed between
the moveable segments of the vertebral column and the lower limb. It supports the vertebral column and
rests on the lower limb. It is composed of the two hip bones laterally; formed by the fusion of the ileum,
ischium, and pubis anteriorly; and the sacrum and coccyx posteriorly. Note the pelvic inlet and a pelvic
outlet. The pelvis is divided into the true pelvis (which contains the pelvic cavity) and the false pelvis.
A basin also has a floor to be a competent basin, as does the pelvis--the pelvic floor, also referred to as
the pelvic diaphragm or the levator ani. The internal genital organs and the lower parts of the intestinal
and urinary tracts are located within the pelvis and are supported by the pelvic floor. The perineum lies
below the pelvis. The female pelvis is the birth canal.
The Bony Pelvis

Be familiar with the bony components associated with the pelvis. Dr. Dym didnt spend too
much time on identifying these bones, as he says we will see them in lab. The lateral surface of the pelic
bone has a large articular socket, the acetabulum. Inferior to the acetebulum is the large obturator
foramen. The posterior margin of the bone is marked by two noches (the greater and lesser sciatic
notches) separated by the ischial spine. The posterior margin terminates inferiorly as the ischial
tuberosity. The anterior margin of the pelvic bone is marked by the anterior superior iliac spine (ASIS),
the anterior inferior iliac spine (AIIS), and the pubic tubercle. Dr. Dym noted that the ASIS and pubic
tubercle are in the vertical plane in the anatomical position.
Course: GA Lecturer: Dr. Dym
Date: 9.11.2007
Lecture number: 19
Page 2 of 9
Each iliac bone has three components: the ilium (most superior), pubis (anterior and inferior),
and ischium (posterior and inferior). The ilium is divided into two parts, the body and the ala (wing), by
the arcuate line. The body of the ilium enters into the formation of the acetabulum. The wing of ilium is
the large expanded portion which bounds the greater pelvis laterally, includes the iliac crest (the site of
abdominal, back, and lower limb muscle and fascia attachment), and terminates in the ASIS and
posterior superior iliac spine. The anterolateral surface of the wing is concave and forms the iliac fossa.
The posterior end of the crest thickens to forms the iliac tuberosity. The sacro-iliac joints are synovial
joints btw. the articular facets on the lateral part of the sacrum and similar facets on the ilium.
The pubis is the most anterior of the three principal bones composing either half of the pelvis and
is divided into the body, a superior ramus, and an inferior ramus. The pubic symphysis is the midline
cartilaginous joint uniting the superior rami of the left and right pubic bones. The pelvic inlet is the
space between the lesser circumference of the pelvis, and the edge is called the pelvic brim.
The ischium has a large body and one ramus. The ramus joins with the inferior ramus of the
pubis. The ischial spine marks the posterior margin of the bone and separates the lesser and greater
sciatic notches. The ischial tuberosity on the posteroinferior aspect of the bone is an important
attachment site for lower limb muscles.
The pudendal nerve comes from the ventral rami of S2, S3, and S4 spinal nerves. A pudendal
block is usually given in the second stage of labor just before delivery of the baby. It relieves pain
around the vagina and rectum as the baby comes down the birth canal. The pudendal block gets its name
because a local anesthetic such as lidocaine or chloroprocaine is injected where the pudendal nerve
crosses behind the ischial spine just lateral to the sacrospinous ligament. This can be done through the
vagina or through the overlying skin and allows quick pain relief to the perineum, vulva, and vagina.
Next Dr. Dym showed common differences btw. the male and female pelvises. He says we
shouldnt worry too much about memorizing these, b/c we will find exceptions to these generalizations
in every category. The male (android) pelvis is thick and heavy. It is characterized by a subpubic angle
(the angle formed by the inferior rami of the pubic bones) of less than ninety degrees. The pelvic inlet of
the male pelvis is heart shaped, and the pelvic outlet is small. The ischial spines (bony processes
projecting backward and medialward from the posterior border of the ischium) protrude inward.
The female (gynecoid) pelvis is, by comparison, thin and light. It is characterized by a subpubic
angle of greater than ninety degrees. The pelvic inlet of the female pelvis is rounded, and the pelvic
outlet is large. The ischial spines do not protrude inward.
Date: 9.11.2007
Lecture number: 19
Page 3 of 9
Dr. Dym showed a slide portraying some common pelvic fractures. Pelvic fractures are common
in auto accidents, often anteroposterior compression injuries. These injuries result from relatively
anterior or posterior forces applied to the anterior or posterior superior iliac spine areas and often
involve fractured pubic rami, ruptured ligaments of the symphysis pubis, or injured bladder. One may
fracture the acetabulum (the femoral head is driven through the floor of the acetabulum) in a fall from
above, such as from a ladder or in a rough parachuting landing. Straddle injuries occur when one
straddles an object as one falls, striking the urogenital area with the force of his or her body weight, and
can result in damage to the soft tissues or fracture of the pubic rami. Straddle injuries are common in
children and occur most often during bicycle riding, falls, and playing on monkey bars.
Some clinical notes taken directly from the slide:

Note differences between male and female pelvis (see above); important in forensic medicine.
Pelvic fractures are common in auto accidents anteroposterior compression. Falls from a
height may drive the femoral head through the floor of the acetabulum. (see above)
In fractures there is often soft tissue injury.
During pregnancy, the pelvic joints and ligaments relax (sex hormones, relaxin); there may be a
15% increase in diameters facilitating the passage of the fetus through the pelvic canal.
The AP diameter is the distance from the lower border of the pubic symphysis to the promontory
of the sacrum (~110 cm).
Ischial spines may be a barrier to normal delivery if they are closer than 95 mm (pelvimetry vs.
trial labor). Note that the size of the pelvis is particularly important in obstetrics.
The sacroiliac ligaments are among the strongest in the body and the cause of much lower back
pain.
Note the pudendal block (see above).
Dr. Dym also mentioned that the whole pelvic region is important because of childbirth. There are many
bladder problems, prolapse problems, etc., that must be resolved after the parturition (child birth).
The Muscles of the Pelvic Floor

Know the function and nerve supply of pelvic floor muscles (levator ani or pelvic diaphragm),
piriformis, and obturator internus muscles. There are subdivisions of the levator ani, but we dont need
to know the names. We will not dissect the pelvic floor in lab, but we need to know it very well. The
Date: 9.11.2007
Lecture number: 19
Page 4 of 9
levator ani is closely associated with the bladder, vagina, and rectum, and is supplied by the pudendal
nerve. The levator ani forms a muscular diaphragm which supports the pelvic viscera; is responsible for
the angle between the rectum and anal canal (i.e., it is a major factor in anal canal continence); acts as a
constrictor of the vagina (sphincter vaginae) in the female and is the principal support for the prostate in
the male (levator prostatae); and acts in conjunction with the thoracoabdominal diaphragm to increase
intra-abdominal pressure. It resists downwards thrust, e.g., in forced expiration and coughing. It assists
the anterior abdominal wall muscles in compressing the abdominal contents. It even helps to fix the
trunk during weight lifting.
Injury to the pelvic floor muscles occurs frequently during parturition. The most common
complaint of women after delivering is that "my bottom is falling out". In essence, the pelvic contents
are now supported mostly by skin and fascia since the muscle was completely spread apart during the
delivery. As the muscle slowly "recovers" and adopts its normal position and integrity, it can once again
assume its role of supporting the pelvic viscera.
The pelvic floor forms a muscular diaphragm which supports the pelvic viscera. It is responsible
for the angle between rectum and anal canal, which plays a major role in anal continence. The pelvic
diaphragm acts in conjunction with the main diaphragm to increase intra-abdominal pressure (raises the
pelvic floor and, therefore, assists in compressing abdominal contents).
The pelvic floor can suffer injury. The levator ani may be injured during childbirth. Weakness of
the levator ani (stretching or tearing) may alter the position of the neck of the bladder or the urethra
causing urinary stress incontinence, a condition characterized by the dribbling of urine when intra-
abdominal pressure is increased such as in coughing or lifting. Dr. Arnold Kegel (1894-1981) first
recommended exercises (Kegel exercises) to female patients who had just given birth and were leaking
urine. The Kegel muscles include the pelvic floor muscles as well as other muscles in the perineum.
Many older women still remember their Kegels!
Perineum
The perineum is a diamond-shaped space bounded by the pubic symphysis (anteriorly), the
ischial tuberosities (laterally), and the sacrum and coccyx (postero-laterally). You can see and feel it
from the outside through the skin. The perineum can be divided into two triangles by an imaginary line
through the ischial tuberosities. The urogenital triangle occupies the anterior part of the perineum and is
defined by the pubic symphysis on one side and the ischiopubic rami of the pelvic bone on the other
Date: 9.11.2007
Lecture number: 19
Page 5 of 9
two. In females, it contains the vagina and associated parts of the external genitalia. The anal triangle is
the posterior part of the perineum. Its points are defined by the coccyx bone and the two ischial
tuberosites, and the sides are defined by the perineal membrane and the two sacrotuberous ligaments.
Dr. Dym demonstrated what we will find in the urogenital triangle dissection tomorrow on
Oscar. First we will cut through the skin, followed by superficial fascia, and then we will come to the
triangular-shaped muscle called the urogenital (UG) diaphragm that suspends external genitalia (two
crura and a central bulb) below it. Above this muscle lie the pelvic floor muscles. In the male cadavers,
we will find one opening for the urethra. The female will have two openings, one for the urethra and one
for the vagina. The inferior fascia of the UG diaphragm (perineal membrane) lies inferior to (below) the
UG diaphragm. Note that the crura are erectile tissue. We will remove the crura in lab. The anal triangle
faces posteroinferiorly. The anal aperture is flanked on each side by an ischio-anal fossae. The ischio-
anal fossae are normally filled w/ fat and can become infected. The inferior rectal nerves cross the
ischio-anal fossae toward the anal canal and lower end of the rectum. Dr. Dym suggests we review the
drawings in Grants Atlas (pages 242 and 243).
Dr. Dym didnt describe the muscles in the diagram below, but we should see them in lab
tomorrow.
Dr. Dym reviewed the following notes about the female perineum (taken almost directly from
slide). The perineal body is a fibromuscular region between the lower part of the vaginal canal and the
anal canal. Eight muscles converge on the perineal body, and it acts as crossing beams for the overlying
pelvic structures. The integrity of perineal body is important after childbirth, and tearing may lead to
prolapse of the bladder, uterus, or vagina. The perineal body can also be disrupted by trauma (rape),
Date: 9.11.2007
Lecture number: 19
Page 6 of 9
inflammatory disease, and infection. Note pudendal nerve block (discussed above). The presence of
numerous glands and ducts opening onto the surface make the area prone to infections. Please review
the illustration of the female superficial perineal space below:
An episiotomy is a surgical incision through the perineum made to enlarge the vagina and assist
childbirth. Remember that the integrity of the region depends on the integrity of the perineal body, so
you dont want a tear here. The incision is usually made in a posterolateral direction (mediolateral
episiotomy) to avoid the anal sphincters. The alternative incision is made posteriorly down the midline
(median episiotomy). After delivery, the episiotomy is carefully sutured in layers. An episiotomy is
beneficial in that it speeds up the birth, prevents tearing, protects against incontinence, protects against
pelvic floor relaxation, and heals easier than tears. There are dangers associated with the procedure,
including infection, increased pain, increase in vaginal lacerations, longer healing times, and increased
discomfort when intercourse is resumed.
The perineal membrane is related above to a thin space called the deep perineal pouch, which
contains a layer of skeletal muscle and various neurovascular elements. The superficial pouch contains
mostly external genitalia. Dr. Dym doesnt think we will be questioned directly on the contents of the
two pouches, but we should be aware of their existence.
Dr. Dym reviewed the following notes about the male perineum (taken almost directly from
slide). A urethral rupture in the male can occur following a severe blow to the perineum, which can
result in urine leaking into the superficial perineal space. Well talk more about this tomorrow. The
scrotum may be easily distended from a hernia or from fluid production (orchitis) or from bleeding. The
scrotum can become the size of a grapefruit (or even larger, as we saw in a photo in an earlier lecture).
Date: 9.11.2007
Lecture number: 19
Page 7 of 9
The wall of the scrotum is thin, so the testes can be easily palpated. Palpation of the testes and
epididymis is important in the differential diagnosis between testicular cancer or inflammation of the
epididymis. Please review the illustration of the male superficial perineal space below:
Date: 9.11.2007
Lecture number: 19
Page 8 of 9
Date: 9.11.2007
Lecture number: 19
Page 9 of 9
Lecturer: Dr. Dym
The Medical Note-Taking Service Date: September 12, 2007
Lecture Number: 20
NOTICE &DISCLAIMER
Note-Taker: Alexis Strohl The Medical Note-Taking Service makes every effort to provide accurate class
Corrected by: Dr. Dym notes. However, errors will occur from time to time. The user assumes the risk
Approved for distribution: for any and all errors. We recommend that you use these notes as a supplement
to your own notes.
Review
Dr. Dym started out by going over some general points for todays dissection to help the
prosectors. This was also meant to review some of the information talked about in his previous lecture.
(Images can be seen in Grants Atlas, page 243.) You should be able to palpate the pubic arches.
Against the arches are the crura.
The layers of the tissue were outlined from superficial to deep:
Skin Superficial fascia External genitalia (ischiocavernosus and bulbospongiosus muscles and
erectile tissue) Inferior fascia of UG diaphragm (grayish in color) UG diaphragm muscles
Superior fascia of UG diaphragm Pelvic floor muscles (separates the perineum from the true pelvis
above)
Note: You do not need to know the individual names of the UG diaphragm muscles for this class.
Todays Lecture
Dr. Dym made three general points in regards to studying the anatomy of the pelvic organs:
1.) Emphasize relationships and lymphatic drainage of the pelvic structures. This is important for
understanding the spread of cancer, which is a common problem in the pelvis.
2.) Memorize the male and female median saggital sections. If you do this you will know a lot
about the pelvis (see figures below)
3.) Try to pick up as many clinical correlations as possible through the text, lectures, and instructors.
Remember, all exam questions are clinically oriented
Course: Gross Anatomy Lecturer: Dr. Dym
Date: September 12, 2007
Lecture number: 20
Page 2 of 10
Male Median Saggital Section Female Median Saggital Section
A. Bladder
i. The bladder is a hollow organ with strong muscular walls. It is a temporary reservoir for
urine and it varies in size, shape, position, relationships to other organs, depending on its
fullness.
ii. When empty, the bladder lies behind the pubic bone. When full, it moves up into the
abdomen. In infants the bladder is always in the abdomen, even when empty.
iii. pint of urine in the bladder leads to discomfort. Above 3 pints of urine in the bladder
is painful.
iv. Female bladder orientation (see saggital section above) is posterior to the pubic bone,
anterior to the body of the vagina, inferior to the body of the uterus, and superior to the
urethra. Laterally it is bordered by the levator ani muscles and the side wall of the pelvis.
v. Male bladder orientation is posterior to pubic bone, anterior to rectum, inferior to
intestines, and superior to the prostate gland. Laterally it is also bordered by the levator
ani and the side wall of the pelvis. Note that in the male there is an involuntary internal
sphincter in the neck of the bladder, which is the part closest to the prostatic urethra. This
sphincter constricts during ejaculation to prevent retrograde ejaculation of semen into the
bladder.
Lecture number: 20
Page 3 of 10
vi. The bladder (and most pelvic organs) receives its blood supply from a branch of the
mother artery of the pelvis (internal iliac artery).
B. Urethra
i. Male
1. Muscular tube. 20 cm long from the bladder to the tip of the penis.
2. There are 4 parts of the male urethra:
A. Intramural (inside bladder)
B. Prostatic (where ejaculatory ducts enter)
C. Membranous (goes through the UG diaphragm)
D. Spongy/penile (longer. Goes through the penis)
3. The cannulation is more tortuous in the longer male urethra. Stretching out the
penis straightens out curves and allows for easier insertion of a catheter.
ii. Female
1. Shorter tube, ~4 cm long.
2. Due to the division of the pelvis and the perineum created by the UG diaphragm
and levator ani, the inferior half of the urethra is found in the perineum while the
superior half is in the pelvis. This will be important for understanding lymphatic
drainage patterns.
3. Straighter tube that is easier to cannulate. It is also easier for infections to enter
due to its short length and greater distensability.
iii. Clinical Correlations
1. Suprapubic cystotomy - A full bladder may be cannulated through the anterior
abdominal wall just above the pubic bone. The peritoneum is pushed up and
peeled off the anterior body wall in this situation, which prevents the risk of
peritonitis. (There is a picture of this in the slides on blackboard )
2. Urethral catheterization in the hospital is common. It is done if the patient cannot
urinate or if they need to obtain a clean urine sample.
3. Transurethral resection of bladder cancer is often performed using a cytoscope.
Lecture number: 20
Page 4 of 10
4. In a male, falling on bike handlebars or stepping on a loose manhole cover

(straddling injury) can result in urethral rupture, since the membranous urethra is
right below the pubic bone. This is not very common in females because of the
urethra position, its shorter length, and its greater cushioning.
5. Cystocele: In females, loss of bladder support caused by damage to the perineal
muscles during delivery. The bladder can herniate into the vaginal wall because
the vagina is quite distensible.
C. Vagina
i. Fibromuscular tube that is ~8-10 cm long.
ii. Forms a continuous gutter around the cervix. The parts of the gutter are called fornices
and are defined as anterior, posterior, and two lateral.
iii. Orientation: posterior to the urethra and bladder, anterior to rectum and sacrum, inferior
to cervix, and superior to external opening.
iv. Arterial supply is from the vaginal and uterine branches of the mother artery of the pelvis.
v. Lymphatic drainage is split between the internal iliac nodes (upper 2/3 of vagina) and the
superficial inguinal nodes (bottom 1/3). The superficial inguinal nodes are a set of nodes
in the shape of a T. The cross arm of the T is parallel and just inferior to the ilioinguinal
ligament and the vertical part of the T is perpendicular to the ligament along a large vein,
the greater saphenous vein. Lymph from these superficial nodes drains to deep inguinal
nodes, through the femoral canal and finally joins with the external iliac nodes. Note: In
general lymph drains along the arterial supply to that organ in the reverse direction, with
some exceptions.
vi. Clinical Correlations
1. Due to location, a neoplasm in the vagina can easily attack the bladder or rectum.
2. The parietal and visceral peritoneum actually goes down around the back top
fourth of the vagina. If an amateur abortionist or inexperienced gynecologist
pushes a non-sterile instrument back through the posterior fornix instead of taking
the turn into the uterus, the woman can get peritonitis and die.
3. Vagina can drop (prolapse) if the pelvic floor muscles weaken, especially
common with pregnancy. A cystocele can happen for the same reason.
4. In older people the vagina shrinks and fornices disappear.
Lecture number: 20
Page 5 of 10
5. Interior of vagina and vaginal part of cervix can be examined with a speculum.
6. A neoplasm in the pouch of Douglas (rectouterine space) can be felt with an
examining finger in the vagina. Rectal neoplasm can spread to the vagina.
7. HIV transport across vaginal wall. In the male, if HIV is in the blood stream, how
does it get into semen? It travels via epithelial transport in the seminiferous
epithelium in testes. Similarly, how does HIV get from walls of vagina into blood
stream? Again, epithelial transport across vaginal wall.
D. Uterus
i. Hollow, muscular, pear shaped
organ that is ~8 cm long and has
relatively thick walls. The uterine
cavity is triangular in a coronal
section (see right) and looks like a
slit in the saggital section. There
are three parts to the uterus: body,
fundus (above where fallopian tubes
enter), and cervix.
ii. A nonpregnant uterus has the consistency of a nose where a pregnant uterus has the
consistency of lips.
iii. Orientation: Anterior to the rectum, superior to the vagina and bladder, inferior to the
intestines. Laterally bordered by the
fallopian tubes and ovaries.
iv. There are two angles to be aware of in the
connection between the uterus and the
vagina. A 90 degree angle between the
vagina and cervix (anteversion) and a 170
degeee angle between the vagina and
uterus (anteflexion). These are the
normal conditions. There are different
possibilities for these angles outlined in
the image on the right
Lecture number: 20
Page 6 of 10
(retroverstion/retroflexion), which really only becomes

important when considering pregnancy complications.
v. Lymphatic drainage is split between three areas. To the
para-aortic nodes (ovarian artery comes from the aorta and
lymph typically follows arterial patterns), to the iliac nodes,
and to the superficial inguinal nodes (due to the round
ligament of uterus). Note that a lump in the groin could be
indicative of uterine cancer.
vi. Support for the Uterus and the upper cervix is provided by
the endopelvic, extraperitoneal fascia that is located just above the levator ani. There are
three important thickenings in this fascia:
1. Cardinal ligaments (Mackenrodts ligaments) from the the cervix and upper
vagina to the side walls of the pelvis.
2. Uterosacral ligaments from the uterus/cervix to the sacrum
3. Pubocervical fascia that extends forward to the pubic bones and forms a sling for
the bladder.
There is also the broad ligament that is a double fold of peritoneum connecting the lateral
margin of the uterus to the side wall of the pelvis. The uterus and broad ligament form a
partition in the pelvis with an anterior compartment containing the bladder (uterovesicular
pouch) and a posterior compartment containing the rectum (pouch of Douglas). Lastly, the
round ligament of the uterus passes from the side wall of the uterus through the deep
inguinal ring to the labium magus.
These ligaments keep the uterus in the center through active support and prevent prolapse
when working properly. Furthermore, the cervix and upper vagina are fixed whereas the
rest of the uterus is somewhat floppy. There is also a passive support mechanism from the
surrounding organs keeping the uterus in its proper position. E.g. the intestines are holding
the uterus down.
Lecture number: 20
Page 7 of 10
vii. Clinical Correlations

1. In performing a hysterectomy, the surgeon must be cautious not to cut the ureter
underneath the blood vessels when clamping them off. The ureter lies just next to
the lateral fornix. In fact, a ureteric stone can be palpated on vaginal exam. This
can be remembered this as water under the bridge.
2. The ureter may be compressed by a uterine growth leading to kidney disease.
3. Uterine prolapse is common for women that have gone through menopause.
4. Carcinoma of the cervix is the third most common gynecological disease in
women. This is especially a problem for young women since 30% of cases are
found in women under the age of 30. It is much more of a problem in countries
where women do not get annual pap smears. There is a procedure for removing
early-stage cervical cancer known as the Trachelectomy Technique. The cervix
and upper part of the vagina are removed and the rest of the vagina is sewn onto
the uterus. This procedure allows maintenance of fertility.
E. Fallopian Tubes
i. Above the tubes is the fundus of the uterus, below the tubes is the body of the uterus.
ii. There are many parts of the
fallopian tube: infundibulum
(where the fimbria are
attached), ampulla (widest
part and place where
fertilization occurs), isthmus
(narrowest part), and the
intramural portion (inside
uterus).
iii. The fallopian tube, along with the suspensory ovarian ligament and the round ligament of
the ovary attaches to the round ligament in the side wall of the uterus.
iv. Clinical Correlations
Lecture number: 20
Page 8 of 10
1. There is a potential path for infections (e.g. gonorrhea) to enter the peritoneal
cavity from the exterior by following the vagina, uterus, fallopian tube, peritoneal
cavity, leading to pelvic inflammatory disease.
2. An ectopic pregnancy occurs every 1 in 250 cases. This is where the embryo
implants into the fallopian tube instead of the uterus. It could cause massive
bleeding into the peritoneal cavity if the tube ruptures. Note that a ruptured
tubule could be misdiagnosed as appendicitis since both refer pain to the right
lower quadrant of the abdomen.
3. Tubal ligations are quite common as a birth control method. It is thought to be
irreversible although some claim a 25% re-anastamosis rate using laproscopy.
4. Salpingitis or blockage of the uterine tube can be a cause of infertility.
F. Ovaries
i. The ovaries are bounded by the external iliac artery, internal iliac artery, and obturator
nerve. They hang from the uterus by the ovarian ligament.
ii. Blood supply is given by the suspensory/ infundibular ligament of the ovary.
iii. Lymphatic drainage is to the aortic nodes.
iv. Clinical Correlations
1. It is important to remember that the position of the ovary is variable. The
appendix may lie very close to the ovary on the right side.
2. The ovaries may descend after pregnancy and shrink in size after menopause.
3. They can be the source of pain during intercourse.
4. Laparoscopy is often used to examine the ovaries. There are some labeled
laparoscopic images on blackboard for your review. On the second image you
should also be able to identify the deep internal ring and a hernia coming through.
G. Summary of Lymph Drainage
i. Iliac nodes drain the upper 2/3 of vagina, most of the uterus, prostate gland, seminal
vesicles, bladder, and the upper part of the urethra.
ii. Superficial inguinal nodes drain the lower 1/3 of the vagina, part of the upper uterus via
the round ligament, and the lower part of the urethra.
iii. Paraaortic nodes drain the ovaries, fundus of the uterus, and the fallopian tubes.
Lecture number: 20
Page 9 of 10
H. Prostate
i. Chestnut shaped gland that is part of the male reproductive system. It produces most of
the fluid in the semen.
ii. Orientation: Posterior to the pubic bone, anterior to the rectum, inferior to the bladder,
superior to the UG diaphragm.
iii. Clinical Correlations
1. If the prostate is cancerous or enlarged there are 3 surgical approaches:
A. Transurethral resection through the urethra (TERP)
B. Suprapubic approach (very common)
C. Perineal approach (less common)
2. Benign Prostatic Enlargement (BPH) occurs in all men over the age 50. Leads to
excessive urination at night.
3. Cancer is very common in men over the age of 55. It can be felt during a rectal
exam.
4. Cause of death from prostate is renal failure because it affects the ureters.
5. Lymph drainage from cancer may spread via 3 routes
A. Direct invasion of an adjacent organ
B. Via venous drainage (connections between prostatic and vertebral veins
can aid in spreading the cancer to the skull)
C. Via lymph channels
I. Seminal Vesicles and Vas Deferens
i. The vas deferens and the seminal
vesicles come together and are
referred to as the ejaculatory duct.
It runs into the prostatic urethra.
ii. Clinical Correlations
1. Infection can track from
bladder/urethra up the
epididymis.
2. Vasectomy can be used as a birth control method. It can be reversed in 25-75% of
patients, but is typically unsuccessful after 5 years of vasectomy. After a
Lecture number: 20
Page 10 of 10
vasectomy, the ejaculatory fluid does not contain sperm; all are absorbed into the
epididymis and vas.
3. Seminal vesicles may be ruptured, allowing pus to enter the peritoneal cavity.
They usually cannot be felt in a rectal exam unless they are enlarged or abcessed.
Course: GA
Lecturer: Dr. Pearle
The Medical Note-Taking Service Date: Monday September 27
Lecture Number: 21A
NOTICE &DISCLAIMER
Note-Taker: Kristy Truong The Medical Note-Taking Service makes every effort to provide accurate
Heart/Coronary Diseases:
Atherosclerosis
Coronary heart disease is the most common killer of men and women in United States and the
entire world. Lets start with a couple of definitions. A myocardial infarction (MI) is a cardiac even
that causes damage and death of heart muscle (myocardium) due to ischemia. Ischemia occurs when
myocardial tissue is not getting enough blood. Angina is chest pain associated with this myocardial
ischemia. An MI can be detected by an enzyme analysis and other techniques. Atherosclerosis is a
generic term referring to the development of plaque like material made up of fibrous tissue, fatty
deposits, thrombis, and cholesterol plaques in the arterial wall blocking the artery along its length with
some areas more tightly blocked than others.
Cardiovascular disease (CD) has been a pandemic
-12,000,000 Americans have CAD
6,300,000 with angina
7,200,000 with prior MI
-Costs are enormous
-The prevalence of CD is increasing in the US as the population ages and as diseases that make people
die young (infectious diseases, nutritional disorders) are overcome in the rest of the world.
-The treatment of CD has been a relatively great successful:
The age adjusted mortality has been declining at a rate of 25-30% per decade. The reasons are
thought to be risk factor modification in high risk individuals and improved medical care.
-There is still however a lot to be done since CD is still by far the number 1 cause of death in men and
women from childhood and on:
About 0.5 of patients who experience hearts attacks or die suddenly from CD have had no
warning symptoms in advance. Thats why risk factor assessments and diagnostic tests are so important.
The majority of patients who are discharged from hospitals after MI are not on optimal medical
therapy. Because of this, hospitals and soon individual doctors are going to be graded on whether their
patients are on appropriate therapies as judged by expert committees.
Course: GA Lecturer: Dr. David Pearle
Date: Monday September 27
Lecture number: 21A
Page 2 of 8
It has been in general estimated that two thirds of reduction in mortality from CD is because of
better medical care. And about 1/3 because of risk factor modification: treating high blood pressure for
example involves behavioral things and having effective medicines with minimal side effect profiles.
Note nevertheless that the absolute number of coronary deaths is not changing even though we have
been talking about this very significant reduction in mortality. What happens is people live and die and
actually get CD manifestation at a much older age. It is actually the age adjusted mortality that has been
falling. The manifestations of cardiovascular disease are still going to occur because Americans live
longer but hopefully the clinical consequences occur much later.
Atherosclerotic Disease
Atherosclerosis is a systemic disease and can occur in several vascular beds, including the
coronary, cerebral, and peripheral arteries, and is the principal underlying condition leading to
myocardial infarction, ischemic stroke, and peripheral arterial disease (PAD).
So how does this all happen? Well, we need to start by reviewing a little bit of microscopic anatomy.
Within the arterial wall, there are a number of distinct layers beginning with the thin endothelial single
cell layer which forms the internal border of wall. This layer has remarkable protective and self healing
and self cleaning properties. The intimal layer consists of the endothelium, basement membrane and an
internal elastic membrane. Next is the medial layer, mainly circularly-arranged smooth muscle tissue.
Beyond that lies the adventitial layer, made mostly of connective tissue. Okay, so now that were
orientated, we looked at a lovely picture of an aortic plaque which contains fatty streaks and
inflammation (pizza?).
Figure 1.
So how do these plaques develop? According to the inflammation/injury theory of
atherosclerosis, atherosclerosis is a complex process that is triggered by inflammation that activates
macrophages and makes them attach to the lining of a coronary artery and in fact pass through into the
coronary artery. The now cholesterol carrying macrophage is called a foam cell macrophage which gives
you a pool of cholesterols here. In addition, smooth muscles cells can be drawn into the media to
Lecture number: 21A
Page 3 of 8
contribute to the plaque. A diseased coronary artery will have atherosclerosis everywhere. Larger
plaques will be in one location or another. Also, fatty streaks precursors to atherosclerotic lesions occur
in younger adults. As people get order more diffuse atherosclerosis and larger plaques.
When we talk about plaques, we refer to them as stable or vulnerable. The real danger in
atherosclerosis comes when the plaque ruptures or breaks off
Vulnerable Plaque is associated with one that can rupture and cause a lot of clinical
consequences. A vulnerable plaque has a large lipid or cholesterol pool in the middle, a relatively thin
fibrous cap infiltrated with macrophages and lymphocytes that is prone to rupture and usually does
rupture on the thin edge of the plaque, which causes MI or acute coronary syndrome. When a plaque
ruptures the cholesterol contents and inflammatory tissue within the plaque goes into the blood stream
and causes the generation of thrombis (blood clot activated by platelet and thrombin). Moreover, blood
can enter the plaque and make the plaque more occlusive and the interaction of these things: the plaque
growing as you bleed into it, the activation of platelet and thrombin systems, spasm superimposed on the
coronary artery can result in total occlusion of the coronary artery.
So how does atherosclerosis lead to problems for the patient? Well, the stenosis, or narrowing of
the vascular lumen can be intermittent, (the arteries opening and closing as these dynamic processes go
on), where you only have subtotal or intermittent occlusion of artery. This can lead to unstable angina
where the patient has recurrent episodes of severe pain but there is no evidence of necrosis or tissue
death within the heart. Sometimes the arterial wall just closes and stays closed and thats what results in
MI, as insufficient oxygen is delivered to the heart muscle. If the artery totally occludes, death of tissue
within myocardium is imminent if blood flow to the heart is interrupted for very long and infarction of
various size results.
The ischemia results from an unequal oxygen supply-demand balance, where not enough oxygen
is present to meet the myocardiums demand. The balance of blood flow to the heart can be affected by
decrease of supply (a ruptured plaque, a blocked coronary artery) or an increase in demand by exercise
or drugs
The infarction can be through and through (transmural). When myocardial tissue is not getting
enough blood, arrythmias can develop and they can be potentially fatal arrythmias- chaotic rhythm and
then the heart will not be beating. Ventricular fibrillation can happen even with a small heart attack.
Characteristic ECG associated with transmural MI is ST segment elevation.
Lecture number: 21A
Page 4 of 8
Infarction always happens from inside out. The endocardial surface is much more subject to
ischemia because you have the internal pressure within the cardiac chamber approached to it. Never
outside in except in trauma, always inside out. Can be subendocardial involving the more vulnerable
subendorcardial zone and not transmural. Theoretically this is a smaller heart attack and not as
dangerous. If you have an infarction, the heart can rupture over a couple days period of time up to a
couple of weeks after. This is not an acute event; the area of infarction becomes soft and mushy.
Scar tissued heart is not going to be able to beat effectively. The patient will have heart failure. If
you knock out approximately 20-40% of heart muscle, usually the heart will be too weak to do its job
and the patient will have heart failure. If you knock out more than 40% of heart muscle, not compatible
with life unless something more dramatic has been done.
You can also get a situation where an aneurysm forms (thinning of the wall) or psuedoaneursym,
where the heart has actually ruptured but for one reason the heart walled off locally so the patient didnt
bleed to death. This situation is very unstable.
N.B. The heart is the only organ that receives most of its perfusion during diastole rather than
systole because it is when the heart relaxes that the coronary arteries surrounding it are less constricted
and most of the flow occurs during diastole to the heart (2/3) and 1/3 occurs in systole.
Therapy for Myocardial Infarction

Want to open up artery has quickly as you can if someone is having a MI.
2 ways:
1) Balloons and stents- PCI (percutaenous coronary interventions)
Cath route: The time they hit the ER door to the time you are inflating a balloon in the cat lab should be
less than 90 minutes. Guildelines are being translated into performance criteria as hospital and
individual doctors are increasingly being measured against these performance criteria and ranked as to
how well they meet the performance criteria for treatment of MI and treatment of heart failure.
2) Fibrolytic drugs that have the ability to dissolve blood clots.
Myocardium is necrosing therefore the faster the artery is opened, the less heart muscle will be lost.
Standards from the time the patient hits the ER door until they get a thrombolytic drug should be less
than 30 minutes.
It used to be thought that a coronary artery gradually gets narrower and narrower (like corrosion
in a pipe). We now understand that when someone has a MI (unstable angina or acute coronary
Lecture number: 21A
Page 5 of 8
syndrome) what actually happens is that a plaque ruptures. Unfortunately, a plaque doesnt have to be
90% occlusive to rupture. Sometimes a plaque that may only have narrowed the coronary artery 30%
ruptures and someone with no previous history of symptoms can have a MI as the first manifestation of
the atherosclerosis that has been there for a long time. This can also occur in a carotid or femoral artery.
Factors that can cause coronary heart disease
Cardiovascular Risk Factors
Non-Modifiable:
Family History and other genetic factors- some ethnic groups are more susceptible to atherosclerosis.
Age- The older you get, the more likely you are to have atherosclerosis
Gender- Women are relatively protected from coronary disease in childbearing years. Still, the number
one cause of death in women is coronary disease; it just occurs a little bit later.
Modifiable:
Hypertension
Tobaccos abuse
Dyslipidemia (cholesterol)
Diabetes/ insulin resistance
Physical activity
Obesity
Metabolic syndrome
Visceral Abdominal obesity that is more metabolically active. Men waist size > 40 inches, women > 35
inches
High triglycerides and low HDL(protective, good cholesterol)
High blood pressure
Insulin resistance or glucose intolerance
High CRP (c-reactive protein-non specific marker of inflammation)
Prothrombic state- some people are born with greater clotting tendencies than others. These can be
tested for have a higher risk of coronary disease
US Survey Data
Hypertension: 28.3% of men, 28.7% of women have hypertension over the age of 25
Higher in African Americans
Dramatically increasing over time- thought to be related to aging of population and obesity epidemic.
Lecture number: 21A
Page 6 of 8
% of people with hypertension and know they have hypertension is increasing. More people are aware
they have hypertension because of screening programs, and more are being treated but not being treated
to current goals.
Framington Studies
Follows people from the time they are young and looks at their health habits which cause problems. A
risk score for CD can be identified. Several risk factors used to estimate risk include: age, total
cholesterol, HDL cholesterol, systolic blood pressure, smoking history- points accumulate based on
various risk factors. Adding them together to get a global score that predicts risk for having a
cardiovascular event at 10 years.
High CRP adds to the risk- the higher the CRP, the higher the risk of future MI in people who have no
evidence of coronary disease
Coronary disease demonstrated by any diagnostic technique adds to risk (known coronary disease
instead of a predicted predilection for developing).
Diagnosis for coronary disease
Taking history has about an 80% sensitivity and specificity in diagnosing coronary disease
Risk Factor Analysis (talked about earlier)
Stress Testing
-If you have a blocked coronary artery you may be fine as you sit here and listen to this lecture but most
of you can increase flow through your coronary arteries about 5 fold. So if you make the heart work
which means it needs more flow, that blockage is going to become relatively more important. Whereas
the blockage allows a flow of lets say 5 but if you are going to exercise and you need a flow of 20, then
the blockage may not allow that much flow so the symptoms and the signs associated with inadequate
flow (ischemia) become more apparent. You can force the heart to require more flow by exercising or
you can use certain drugs that imitate exercise.
How to discern lack of adequate blood supply to the heart (end point of ischemia):
Symptoms
ECG- ST segment depression is a classic sign of ischemia on a conventional exercise test. See right
most side in the figure below.
Lecture number: 21A
Page 7 of 8
Figure 2.
Nuclear techniques- use a tracer like thalium that goes anywhere blood goes. What you should see is
uniform tracer (white) when the patient has good flow to the heart. But if there is a blockage in the
coronary artery, if the patient exercises, you are not seeing a uniform donut anymore but you are going
to see a relative lack of tracer.
Figure 3.
-Distribution of a partially blocked coronary artery when the patient exercises (Figure 3):
It is not so much that the flow decreases but it fails to increase as much as it does in the surrounding
zone. So the area that doesnt have coronary blockage you get a 4 increase in flow and it still looks
Lecture number: 21A
Page 8 of 8
white. In the area of coronary blockage you only get a doubling of flow and at least relatively you see a
cold spot, an area where the flow is not increasing proportionally, which is an indication of blockage in
an artery that supplies this part of the heart muscle.
Echocardiographic techniques- if an area of heart muscle is not getting enough blood it stops
contracting vigorously and starts to contract less well. Sound beams are passed down through the chest
and when they hit a solid structure they bounce back. As you can imagine, the farther the structure is
from the transducer at the chest wall, the longer it will take the sound wave to bounce back and you can
translate that into distance and get an image of the heart moving in real time.
-Can see valves and look at the heart muscle.
-So for example if the apex of the heart is not contracting very vigorously,
it will be very obvious that the wall is not moving much vs the surrounding walls which are coming in
vigorously. So if you combine this with an exercise test: Good wall motion of the left ventricle at rest
but as you exercise, and the apex is not getting enough blood, it stops contracting vigorously compared
to the left ventricle.
MRI and CT- is hard to do on the heart because it is moving and beating
Preshaped catheters - come in various sizes
Lecture number: 21A
Page 9 of 8
Lecture number: 21A
Page 10 of 8
Lecturer Dr. Pearle
Lecture Number: 21b
NOTICE &DISCLAIMER
Note-Taker: Brian Renard The Medical Note-Taking Service makes every effort to provide accurate
This is the second part of lecture 21 by Dr. Pearle and will concentrate on therapy for coronary artery
disease. You must understand the general principles of this lecture, but details will not need to be
understood for the exam.
THERAPY
First we discussed how to cause a reduction in cardiovascular (CV) mortality:
Risk factor modification (discussed early)
Improved diagnostic modalities due to artherosclerosis being an asymptomatic disease
Advances in medical therapy
Coronary Care Units-a technique where all types of physicians and nurses are located in one area
of the hospital to perform the quickest and most effective treatment
Defibrillators/Pacemakers
Cardiac Surgery
Percutaneous Coronary Interventions (PCI)
There are many drugs that are used in CV therapy:
Anti-ischemic: nitrates, beta blockers, ranolazine (new drug)
Anti-platelet: Aspirin (very good), clopidogrel (both used in combo with stents)
Anti-thrombotic: warfarin, heparin, bivalrudin
Anti-hypertensive
Cholesterol lowering: lipitor (largest selling drug)
Next we talked about the COURAGE study. This trial was done to determine if PCI plus optimal
medical therapy reduced the risk of death or nonfatal myocardial infarction (MI) in patients with stable
coronary artery disease (CAD) as compared to optimal medical therapy alone. According to the results,
there is no advantage of adding the PCI. This study does have some flaws, but has caused a decrease in
cardiac catheterization and angioplasty by 25% in the past six months. What this means is that we can
treat stable CAD with medical treatment, which is not as exciting or invasive, but safer.
Course Gross Anatomy Lecturer Dr. Pearle
Date 9/13/07
Lecture number 21b
Page 2 of 4
What do you do with a patient with a high risk of ventricular fibrillation?

To treat v-fib, an implanted cardioverter defibrillator (ICD) is put in
under the skin above the rib cage, just under the left clavicle. Leads are
tunnels under the skin to the subclavian or internal jugular vein and finally
into the right ventricle. The instrument can monitor the heart and
recognize when the heart goes into v-fib. At the first sign of v-fib, the
lead will deliver a shock to the heart to get the heart back on pace. This is
a remarkable breakthrough in deceasing mortality.
Coronary By-pass Surgery
The internal thorasic arteries (internal mammary arteries) are
anastomosed into the left ventricle (usually), with less than 1%
mortality. New advancements have continuously been made.
Surgeons are now able to do the surgery off pump, which means
that you dont need a heart-lung machine during surgery. It has
been shown that with the off pump there might be slightly more
problems, but nothing significant. About 2/3 of surgery are done
off pump.
Interventional Cardiology
Interventional cardiology uses balloon angioplasty to remove a plaque in an artery. In the early days
there were two major problems:
1) Abrupt Occlusion
Inflation of a balloon in the artery causes an uncontrolled injury to that artery
When the balloon is deflated, the entire artery would collapse
Re-stenosis
The balloon angioplasty fixes the plaque from 90% to 30% occlusion
In the process of healing (6 wks-3mts) the artery will form a plaque even worse than the
first time
This used to occur in about 30-40% of patients
Date 9/13/07
Lecture number 21b
Page 3 of 4
Solutions
Directional Coronary Atherectomy-uses a cutting blade on the plaque
Laser Angioplasty-vaporizes the plaque
Rotational Atherectomy-drill through the plaque
None of these techniques were a breakthrough, but there are still some applications to each.
The Breakthrough Technique-Stents
Stents avoid:
1) Abrupt Occlusion
2) Re-Stenosis is less than 10% due to the stent blocking the elastic recoil and creating a much
bigger lumen than ballooning alone
a. the larger the artery, the less the re-stenosis rate
b. the shorter the blockage, the less the
re-stenosis rate
More than 90% of CV interventions involve a stent
No worry of tearing the artery due to it being protected by
the stent
However, if re-stenosis does occur, it will be worse than the
original plaque. To solve this problem there are a few solutions:
1) Brachytherapy-intravascular in-stent radiation
Apply local radiation to the area of stent to inhibit tissue growth
2) Drug eluting stents
Date 9/13/07
Lecture number 21b
Page 4 of 4
Use of anti-proliferative drugs or anti-tumor drugs to prevent growth (cancer

drugs)
Drug eluting stents are the most common type used. A drug (anti-proliferative) is embedded on a stent
in the form of a polymer so that it is released slowly and uniformly. This drug will slow healing in order
to prevent re-stenosis. With these drugs, re-stenosis drops to nearly 0% in large arteries. As always,
problems did develop. With drug eluting stents late subacute thrombosis occurs. To block thrombosis
caused by the metal stent, heparin is used during the procedure. Aspirin and Plavix are used long term.
These medications blocked platelet thrombosis until the stent is healed, which means that the endothelial
cells grow over the stent. After healing, subacute thrombosis is dramatically decreased. However, the
anti-proliferative drugs seemed to block healing too well, meaning that even a year after surgery, the
stent still isnt healed and subacute thrombosis is still possible (only 0.1-0.2%). Now, drug eluting
stents are usually avoided in vessels greater than 3mm, because re-stenosis is very unlikely.
Ventricular Assist Devices

Ventricular assist devices are used for badly damaged hearts (refractory heart failure) that cant keep the
patient alive anymore. The majority of time these devices are used for the left ventricle, due to it under
going most of the damage. These devices draw blood from the apex of the heart and return it to the
aorta. These are externally powered and work either by a pumping chamber or an impeller motor. This
is a very small device and does not alter daily life very much. There are problems with these devices,
but as the technology improves people who are unable to receive a transplant should be able to live with
this device in the near future.
Atherosclerosis: Whats Next?

Use of stem cells, bone-marrow derived cells and skeletal muscle cells injected
into the myocardium to grow a new muscle.
A systemic disease: Develop systemic therapies
Translate what we know into practice
Role and implications of inflammation
The genetic revolution
Date 9/13/07
Lecture number 21b
Page 5 of 4
Date 9/13/07
Lecture number 21b
Page 6 of 4
Date 9/13/07
Lecture number 21b
Page 7 of 4
The Medical Note-Taking Service Lecturer Dr. Evans

Date 14 September 2007
Lecture Number: 22
NOTICE &DISCLAIMER
Corrected by: uncorrected class notes . However, errors will occur from time to time. The us er
Lecture 22: Gross Anatomy and Its Role in General Surgery
Dr. Evans started out with slides which are not available on Blackboard I will try my best to describe
them. Although if you open your atlas and find a corresponding picture and follow the text, its pretty
much the same.
Slide 1: The approach to the Abdominal Cavity: Abdominal wall and Inguinal Hernias
Diastasis recti is a lack of fusion in portions of the linea alba. Patients with this congenital
irregularity usually have a bulge in the abdomen. Because it is congenital, this bulge is not considered a
true defect and therefore not considered a true hernia which is defined as a defect in the abdominal wall.
Incarcerated refers to the inability of the hernia to be reduced; it is trapped and the neck of the
hernia is too narrow.
Epigastric hernia is a true defect of the fascia. The greater omentum (the most anterior of the
peritoneal structures, herniates through. The greater omentum is also the most mobile and thus the most
common to herniated and to become incarcerated in the upper abdomen. When a patient presents with
painless hernia, it is usually a greater omental hernia.
Spigelian hernias occur mostly in young women. These usually occur at a location that is
lateral to the rectus abdominus muscle at the arcuate line. (This location can also be reached if you go
two thirds of the distance down from the umbilicus to the bottom of the rectus and move lateral to the
rectus muscle)
Inferior rectus hematoma: student presents with firm bulge on the left side lateral to the
midline. Previously, he had done 1000 sit ups. He suffered a rectus sheath hematoma resulting from the
bursting of the inferior epigastric artery (in this case, it would be the left inferior epigastric vessels,
which arise from the left external iliac artery. It will keep bleeding until the pressure builds up and
equals the pressure in the artery at which point, it will tamponade. Thus, in the vast majority (95%) of
these cases, surgical intervention is not required and rectus hematomas are managed conservatively.
If you require this noteset at a 5th Grade reading level, contact me by email please
Course Gross Anatomy Lecturer Dr. Evans
Lecture number 22
Page 2 of 4
Slide 2: Inguinal Canal

The external oblique aponeuroses make up the roof of the inguinal canal (caution: albeit our
syllabus says the anterior wall, but Dr. Suarez mentioned this would not be on the exam). The floor of
the inguinal canal is the transversalis fascia and serves as a place for potential pathology. Defect
through that fascia leads to a direct inguinal canal; this defect would present as dome-like and therefore,
not likely to become incarcerated. An indirect inguinal hernia would pass through the deep inguinal
ring.
Slide 3: Pancreaticobiliary Disease

The splenic artery runs on the superior pole of the pancreas to the spleen, usually tucked behind
the splenic vein. During acute inflammation of the pancreas (pancreatitis), the collapse of the vein will
happen first. The vein is not as thick as the artery and has slower flow which makes it more likely to
thrombose. Splenic vein thrombosis due to acute pancreatitis will lead to splenomegaly.
On the medial aspect of the 2nd portion of the duodenum, we see the ampula of Vater. Gallstones
from the gallbladder can travel down the cystic duct, the common bile duct and become lodged at the
hepatopancreatic ampula of Vater thereby blocking the pancreatic duct as well. This leads to gallstone
pancreatitis. The pancreas is very sensitive to the pressure elevations within the pancreatic duct.
Slide 4: Radiograph; Contrast Study of the Superior Abdomen

On this radiograph, we can clearly see small ducts coming off the pain pancreatic duct. In acute
pancreatitis, these small ducts are the first ones to be lost. They endure arborization and woody
induration.
There are two ways to view the biliary system:
1. Percutaneous Transhepatic Choliangiography (PTC)
a. insert a small needle into a small biliary radicle and inject contrast material.
b. this method, however, can only visualize one portion of the system (i.e. if you inject the
right lobe, the left lobe will not be visualized)
c. percutaneous cholecystostomy- a procedure in which a needle is inserted into the fundus
of the gallbladder (intercostals space of T9) to drian it.
Lecture number 22
Page 3 of 4
2. Endoscopic Retrograde Coholiangiopancreatography (ERCP)

a. Take an endoscope down until you find the Sphincter of Oddi and inject through that
sphincter to the pancreatic and hepatic ducts.
Slide 5: Closer look at the Pancreas

The majority of adenocarcinomas of the pancreas will occur in the head of the pancreas. If a
person has a 1-4cm tumor, it will occlude the intrapancreatic portion of the bile duct causing bile to back
up patient will present with painless jaundice. This is the best case scenario. Not as good is if the
tumor gets to be bigger, say around 7cm, and starts compressing the duodenum patient will then
present with nausea and vomiting. The worst is if the patient complains of back pain because then, the
tumor has grown to sufficient size and has extended retroperitoneally.
Slide 6: GI Disease
If a clot occurred in the superior mesenteric artery (SMA), where would it travel to downstream?
Since the clot probably will not have a predilection for turning either right or left, it will most likely
travel down to the ileocolic region, which is the straightest path.
Retroperitoneal sarcomas typically occur in the region of the kidney and extend to the aorta and
posterior abdominal wall.
Slide 7: Abdomen with Anterior wall Removed

There is no true space in the abdomen until you open it. When attempting surgery, entering the
upper abdomen is advisable because theres the greater omentum which serves as a buffer to protect
other abdominal structures.
Slide 8+9: Right (Ascending) Colon

We see the appendix curling around. If you cannot find the appendix, just look at the colon and
follow the tinea coli to where they come together. The appendix should be dangling off that point. The
appendix itself can be oriented in many directions which subsequently determines the symptoms with
which a patient with acute appendicitis will present (i.e. if the appendix is tucked up behind the cecum,
the pain from appendicitis will be more in the back side).
Lecture number 22
Page 4 of 4
Slide 10: Stomach

Here he just pointed out the Foramen of Winslow and moved on.
Dr. Evans ended the powerpoint presentation and showed us some clinical cases:
1. small intestine with large tumor (some sort of sarcoma)
2. Gall bladder with multiple gallstones: cholesterol-type stones which are smooth because
theyve formed next to each other as faceted stones. These stones form via unopposed
estrogen effect. This is seen in fatty, forty fertile females.
3. Rectum and anus with prostate. Theres a large cancer of the rectum invading the prostate.
4. Abdominal cavity low-grade liposarcoma (fat tumor).
Lecturer: Dr. Dym
Lecture Number: 23
NOTICE &DISCLAIMER
Note-Taker: Patrick Nailer The Medical Note-Taking Service makes every effort to provide accurate
Corrected by: Dr. Dym class notes. However, errors will occur from time to time. The user
Pelvis III
Blood Supply
The aorta divides into the right and left common iliac arteries at L4, which then divides into the external
and internal iliac arteries. The internal iliac artery is the main artery of the pelvis, dividing into an
anterior and posterior branch. The posterior branch leads to the pudendal artery while the anterior
branch gives branches to different organs in the pelvic cavity. An important landmark in the pelvis is
the piriformis muscle. Superior to this muscle is the superior gluteal artery and below the inferior
gluteal artery. The superior gluteal artery supplies the gluteus medius and minimus while the inferior
gluteal artery supplies the gluteus maximus.
It is important to understand the relationship between the ureter and the uterine artery, as the ureter is
occasionally cut during surgery to the uterus. The ureter runs under the uterine artery: Water under the
bridge.
Lymphatic Drainage
There are lymph nodes associated with the celiac trunk, superior mesenteric artery and inferior
mesenteric artery. Collectively, these are referred to as pre-aortic lymph nodes. Inferiorly, along the
common iliac and internal and external iliac arteries, one can find the iliac lymph nodes. Laterally to the
aorta are the para-aortic lymph nodes, consisting of the lateral aortic lymph nodes (i.e. renal artery
nodes) and lumbar lymph nodes. For the purposes of this course, it is fine to say that all of these lymph
nodes are simply aortic lymph nodes or aortic/caval nodes.
Date: 9/17/07
Lecture number: 23
Page 2 of 4
Superiorly, each of these lymph nodes will drain into the cisterna chyli at L1/L2, the beginning of the
thoracic duct.
Parts of the pelvis and perineum (groin, superficial regions, anterior and posterior abdominal wall) also
drain into the superficial inguinal lymph nodes. These nodes are found horizontally and inferior to the
inguinal ligament and vertically inferior along the great saphenous vein. The superficial inguinal lymph
nodes will then pass to the deep inguinal lymph nodes by an opening in the deep fascia called the
saphenous opening. From the deep inguinal lymph nodes, lymph will pass inferiorly to the inguinal
ligament and drain into the external iliac nodes and then superiorly making its way to the thoracic duct.
Sacral Plexus
The sacral plexus is composed of nerves from the ventral rami of S1-S4. The sciatic nerve, the largest
nerve in the body, descends into the lower limbs from this bundle of nerves. Of note from the sacral
plexus are the sciatic, pudendal (S2-S4) and post femoral cutaneous nerves, plus other unnamed nerves.
The sacral plexus supplies all of the smaller muscles in this area of the pelvis. The sacral plexus may be
compressed by a tumor, such as a carcinoma of the rectum, and can lead to severe pain in the lower
limbs. The head of the fetus can also compress this nerve plexus, also causing pain along the lower
limbs. Pudendal block, a blockage of the sensory stimulation from the pudendal nerve, is a common
anesthetic for women during delivery.
Pelvic Autonomic Nerves
Sacral sympathetic trunks: Provide sympathetic innervation to the lower limb while traveling with
nerves from the sacral plexus.
Periarterial plexuses: Sympathetic nerves located around arteries that enter the pelvis to affect
vasomotion of the arteries they accompany.
Hypogastric plexus: Superior and inferior plexus near the bifurcation of the aorta. This is the most
important route by which sympathetic fibers are conveyed to the pelvic organs.
Pelvic splanchnic nerves: Parasympathetic nerves from the anterior rami of S2-S4. These nerves are
involved in defecation, urination, and erection.
Date: 9/17/07
Lecture number: 23
Page 3 of 4
Note: Dr. Dym recommended reviewing these plexus in the textbook.
Imaging
Dr. Dym then showed a series of images of the pelvis. Make sure to review these slides but below are
some of the general points:
If there is cancer of the bladder, you will likely not see complete filling with contrast.
Contrast imaging of the vas deferens and seminal vesicles indicates the patency of the
ejaculatory duct.
Likewise, contrast can be used to determine the patency of the oviduct in the female through the
use of a hysterosalpingogram.
Pelvic radiographs can be used to image the vagina, showing common things like tampons and
less common things such as gerbils.
A pessary is placed in the vagina to prevent uterine prolapse.
Cervical Cancer
Cancer of the cervix is the third most common form of gynecologic cancer, typically affecting young
women with a significant proportion below the age of 35. Cervical cancer is a slow growth dysplasia of
squamous cells that can be detected by a Pap smear and is 100% treatable. The cancer spreads via
lymphatics of the external and internal iliac nodes and the presacral route to the aortic nodes. With both
primary and recurrent disease, metastases are found to typically include the liver, lung and bone.
Locally, cervical cancer can spread to the sidewall of the pelvis, bladder and rectum. Cervical growths
can also obstruct the ureter
Bladder Cancer
Accounts for the fourth most common form of pelvic malignancy. The urothelial (epithelial cells)
subtype is the most common (90% of cases) and is usually found in patients older than 65 years.
Date: 9/17/07
Lecture number: 23
Page 4 of 4
Pathogenesis is thought to occur through the prolonged exposure to carcinogens in the urine, typically
from cigarette smoke. Bladder cancer leads to irregular filling defects and can present as multicentric
metachronous and synchronous tumors.
Prostate Cancer
In North American men, prostate cancer is the second most common type of diagnosed malignancy and
cause of cancer death. When the malignancy only affects the prostate, prostatectomy using a retropubic
or perineal approach is the common treatment. The prostate and seminal vesicles are removed and an
anastomosis is established between the bladder and membranous urethra, a procedure known as a
vesicourethral anastomosis (VUA). Common complications from surgical removal of the prostate can
include:
Rectovesical fistula: can lead to pneumaturia (air (bubbles) in the urine) and fecaluria (feces in
the urine)
Urinoma: ureter is cut and urine collects at the blunt end encapsulated with fibrous tissue.
Lymphoceles: collection of lymph fluid that can compress the bladder.
Catheter related constricture: the fossa navicularis may be blocked by the catheter leading to a
narrowing of the region and associated pain.
Ovarian Cancer
Represents the deadliest gynecologic malignancy and the fifth most common cause of death from cancer
in women. There are two types: an epithelial carcinoma from the surface of the ovary and malignant
germ cell tumors (stem cells) that begin in egg cells.
Dr. Dym then discussed two case studies, the information of which is nicely laid out on the power point
slides.
Good luck with the test!

Lecturer Dr. Helein Landy
Lecture Number: 24
NOTICE &DISCLAIMER
Note-Taker: Danny Scher The Medical Note-Taking Service makes every effort to provide accurate
Dr. Helein Landy, the chair of the department of Ob/Gyn here at Georgetown, gave us the lecture
today on the clinical aspects of the female pelvic anatomy. She started out by showing several slides on
the basic female anatomy. She showed both internal organs and the external anatomy. I wont go into
detail about these because they were covered in Dr. Dyms lectures.
Then Dr. Landy talked a little bit about the physical exam. She stressed the importance of
making your patient feel comfortable during this exam, especially if it is their first time. To do the basic
vaginal exam, one should use a speculum, which is an instrument that spreads open the walls of the
vagina to get a better view of the cervix. A Pap smear is the collection of cells from the cervix to check
for cervical cancer. It is important to stress to your patients to have this test done annually. You can also
use a rectovaginal exam with one hand, while the other hand is on the abdomen and is able to feel
organs in the abdomen such as the uterus. If the uterus is retroverted, it may be more difficult to palpate.
Then Dr. Landy went into clinical conditions of the external anatomy. An imperforate hymen is
one that is not open, making intercourse and menstruation difficult. Surgery is used to open it.
Hematocolpos may result from an imperforate hymen, where the uterus and vagina is filled with blood.
This prevents menstrual blood from escaping. It is usually discovered when a young girl is not able to
menstruate.
Bartholins Glands, which are attached to the bulb of the vestibule, can develop cysts. This occurs
as a result of mechanical obstruction to the duct. Following obstruction, continued secretion can cause
dilation of the duct. It is usually asymptomatic, but may cause erythema, pain, or fever. It is possible to
drain it with a needle, however, an making an actual incision is much more effective.
Course Gross Anatomy Lecturer Dr. Helein Landy
Date 9/20/07
Lecture number 24
Page 2 of 5
Disorders of pelvic support usually occur once the female has gotten older and has finished her
child bearing. It can also be due to genetic makeup, but it is usually due to age. There are several
disorders that may occur. A cystocele is the protrusion of the bladder into the vagina. An enterocele is
the herniation of the Pouch of Douglas into the rectovaginal septum. A rectocele is protrusion of the
rectum into the vagina. Finally, a urethrocele is a protrusion of the urethra into the vagina. These all
occur due to a loss of fascial support.
Then we discussed two viruses that can affect the external genitalia. Human papillomavirus is a
sexually transmitted disease. It can present with large raised lesions and can be a precursor to cervical
carcinoma. Herpes simplex virus usually presents with what is called kissing lesions. Usually there
will be an enlargement of lymph nodes and can block the urethra.
Dr. Landy went on to talk about an episiotomy, which we talked about in a lecture with Dr. Dym.
To review, an episiotomy is an incision made in the perineum to enlarge the vaginal opening in an effort
to facilitate timely delivery of an infant or to avoid a jagged tear. Previously, it was thought that
episiotomies should be performed on everyone, but that is not the case now.
Moving onto internal clinical anatomy.
Mullerian anomalies can form when the Mullerian ducts do not fuse evenly at the midline.
Usually the septum should disappear when they fuse, but sometimes it doesnt and you get what is called
a septate uterus. There are several degrees of a septate uterus, and you can see them all on the
powerpoint slide. A hysterosalpingogram is a radiograph of the uterus and oviducts. A radio-opaque
material is injected into the cervix to outline the uterine cavity and search for filling defects or blocked
tubes.
An ectopic pregnancy is defined as a pregnancy located in a place other than the endometrial
lining of the uterine cavity. The most common place for this to occur is the fallopian tubes. It is the
Date 9/20/07
Lecture number 24
Page 3 of 5
leading cause of maternal mortality due to hemorrhage. The treatment cant be surgical or with a
chemotherapy agent known as methotrexate.
A hysterectomy is one of the most common surgeries performed in the US second to a C=-
section. There are many reasons why a hysterectomy needs to be performed, and these can be seen on
the powerpoint slide. The surgery can be performed either transvaginally or transabdominally.
Leiomyomas are non-cancerous tumors of smooth muscle that are found on the uterus. They
happen quite frequently, usually in 25% of women. There may be bleeding and pain, but often it is
asymptomatic and observation is the best treatment.
Then we talked a little but about the anatomy of parturition. The cervix becomes dilated and
much thinner during parturition. Also, we talked about the position of the baby before it is delivered.
There is an array of slides showing unengaged and engaged vertex. Sometimes, certain instruments are
used such as forceps or a vacuum. An external cephalic version is when the babys head is not down.
There is a manual rotation of the baby to decrease C-section rate. This procedure only has a 50% success
rate, but there are risks such as fetal distress or a ruptured uterus.
Dr. Landy finished up her talk by talking about pelvic vasculature, which we covered in lectures
and lab.
Good luck on the exam. Monday night is almost here!

Date 9/20/07
Lecture number 24
Page 4 of 5
Date 9/20/07
Lecture number 24
Page 5 of 5
Lecturer: Dr. Lynch
Lecture Number: 25
NOTICE &DISCLAIMER
Note-Taker: John Elliott The Medical Note-Taking Service makes every effort to provide accurate
AGR- Clinical Review of the Male Pelvis
Dr. Suarez led off by saying that regardless if you honor, high pass or simply pass this course, you will
still get a great residency, so dont stress too much.
The cadaver labs will close at 6pm on Sunday night.

Prior to Sunday night please make sure of the following:
-Your lab station is clean
-The books and dissection tools have been placed on the shelves
-Make sure you have a working book stand.
Exam Details:
Exam begins at 9am on Monday morning
Bring two things with you: 1. Two pencils
2. Your Random ID #
-Backpacks, cell phones, electronics etc. are not allowed. Review your
student handbook if you have any questions about test taking policies.
Written Exam: 100 multiple choice questions each worth 1 point (total=100 points)
-Board review style questions with clinical vignette.
-Content will be derived from the syllabus and Grays Anatomy.
-Select the BEST answer, No gripes!
Practical Exam (2 parts) (50 questions @ 2points/question= 100 total points):

-Begins at 12:45pm
Why are hemorrhoids called "hemorrhoids" instead of "assteroids"?-Unknown
Frisbeetarianism is the belief that when you die, your soul goes up on the roof and gets stuck.
-George Carlin
Course: Gross Anatomy Lecturer: Dr. Lynch
Date: 9/20/07
Lecture number: 25
Page 2 of 12
-Bring a clipboard or pad to write on

-No scrubs necessary
-DO wear close toed shoes.
Part 1: 25 Powerpoint images, each multiple choice question is worth two points.
-You will have approx. 3 min. per image.
-Identification only
-Includes some pathology
-No clinical scenarios
Part 2: 25 multiple choice lab questions, each worth two points
How the lab portion will work:

We will be broken into 3 groups (keep your eye out for an email from Dr. Suarez indicating your group
numberand no..you may not switch groups). One group will go to the IHC for an hour to look at the
powerpoint slides. Another group will go to the cadaver lab for pinned questions, and the third group
will be in LA-6 relaxing. Then groups will rotate each hour.
Cadaver Lab
When you enter the lab, find an empty station, claim it as your own, and begin filling out the Scantron
and front page of the exam. There will be stations with questions and rest stations in between. You may
start at either one. Dr. Azzam has an elaborate plan for how we will rotate through the labs. The simple
version: remember who is in front of you, and follow that fine gluteus all the way through the exam.
There is a timer set for approx. 45seconds. The first beep will indicate the start of the exam, and you
will stay at the station you started at. On the second and subsequent beeps, just follow that beautiful
person in front of you to your next station.
The actual cross section images hanging in the halls of the cadaver labs are fair game, but only the ones
of the thorax will be tested.
Date: 9/20/07
Lecture number: 25
Page 3 of 12
Now on to the male pelvis. Dr. Lynch began with several clinical cases:
Case 1:
A 35 y.o. male who presents to the ER with right flank pain, nausea, and vomiting. Has had pain for 48
hours and describes it as sharp, and intermittent with radiation to right groin and testicular region. Pain
is 8 out of 10, and the nausea and vomiting began only within the last two hours. Clinical exam was
mostly normal with exception that crystals were found in urine.
A plain film of abdomen was then presented. Dr. Lynch suggested that we should follow a systematic
approach to viewing these. First check the bony structures, soft tissue, gas pattern, and then look for
other abnormalities. We should also notice without being told that this is a male patient, due to the heart
shape of the pelvic outlet (vs. a round outlet in the female). In this image, we can see a calcification
near the ureter, but exact location is not known because this is a 2D image. To confirm the location,
additional imaging studies are required such as an intravenous pyelogram and excretory urogram.
This involves the intravenous injection of contrast into the intercubital fossa of the arm, which
undergoes glomerular filtration in the kidney, and shows up white on the x-ray. In this image we can
see the entire right ureter, which should normally be partially obstructed due to ureteral peristalsis. In
this case a ureteral calculus is blocking the right ureter, allowing the filling and complete visualization
of the right ureter. This also could have been diagnosed with a non-contrast CT scan, because all
urinary calculi show up white on a CT scan.
Treatment Options:
As long as stone is less than 5mm in diameter, it has a 95% chance of passing on its own.
Other possible treatments include:
-Ureteroscopic laser lithotripsy (laser breaks up stone) or basket extraction.
- Stent placement- is a temporary solution if patient is sick. Come back later and operate.
-Ureterolithotomy- removing stone through incision. Not done much anymore.
Date: 9/20/07
Lecture number: 25
Page 4 of 12
As a general rule, any type of ureteroscopy is traumatic to the ureter, resulting in edema and the
potential of ureter obstruction. A Double J stent is commonly inserted to avoid this problem,
temporarily keeping the ureter patent after a procedure. Is removed in about a week.
Case 2:
A 65 y.o. male presents to the ER with pelvic pain and blood at the urethral meatus following a motor
vehicle accident. Upon examination, notable findings included slightly low blood pressure of 110/70,
relatively high pulse rate of 90, pain with leg movement, and the inability to void.
An X-ray was presented showing damage to the pelvic bones in the pubic region. This gentleman also
showed a positive Throckmorton sign (penis points to the sign of the lesion). He was given a
retrograde urethrogram (contrast into the urethra) which showed extravasation of contrast into the
pelvic region, indicating disruption of the urethra.
Recall that the prostate is held in place by a puboprostatic ligament, the urethra, the bladder neck, and
the dorsal vein complex. If the urethra is completely disrupted due to trauma, there is significant
bleeding due to the disrupted venous plexus, the ligaments can be torn and the prostate moves superiorly
in the pelvis (wont be able to feel in a rectal exam good indication of a disrupted urethra.). A
teardrop bladder may also be an indication of a complete urethral disruption, which gets its shape due
to the hematoma that develops in the bladder.
Treatment
This situation calls for a suprapubic cystotomy (tube inserted through the skin into bladder) for 6-8
weeks. The patient then returns for corrective surgery. Immediate surgery has less success of
maintaining continence, potency and has a higher chance of stricture (abnormal narrowing of the
urethra).
Case 3: Blunt Trauma

Rule of thumb: never get into a car with a full bladder. The dome of the bladder is the weakest point,
and most likely to rupture due to blunt trauma. Remembering that the peritoneum is attached to the
dome of the bladder, a rupture of the bladder will also rupture the peritoneum (intra-peritoneal
rupture) allowing urine leakage into the abdomen. This situation requires immediate surgical
correction. Urine leakage into peritoneal cavity will cause absorption of K+ and other products, causing
Date: 9/20/07
Lecture number: 25
Page 5 of 12
electrolyte imbalances and a host of other problems. If the peritoneum is not ruptured (extra-peritoneal
rupture) it can be corrected with catheter drainage. Dr. Lynch performed this operation on a frat boy
who drank too much bourbon and subsequently fell out of his bunk, rupturing his bladder. Take home
message: urinate before you fall out of your bunk, or install side rails.
Case 4:
A 72 y.o. African American presenting with hematuria (blood in urine), occurring 4 times in 3 months.
This patient has a 20 pack year history of smoking prior to quitting ten years ago. Important b/c
smoking is a risk factor for bladder cancer.
Classifying Blood in urine:

Gross (visible with naked eye) vs. microscopic
Painless (non-infection) vs. painful (infection)
Initial hematuria vs. terminal
Initial- blood initially, then urine is clear. Indicates blood originating from urethra
Terminal- urine initially clear, then blood at the end. Blood originating from prostate.
Total- blood throughout urine stream. Originating from bladder neck or beyond.
Back to the case: RBCs were found in the urine, and urine cytology was positive for malignant cells.
CT of bladder shows a mostly homogenous bladder, with a spot in the bladder basin. Endoscopy of the
bladder mucosa showed an abnormal heaped cauliflower looking mass, typical of a transitional cell
cancer of bladder.
Treatment:
Generally resect and stage. Staging ranges from T0 to T4. T0 indicates the lesion has only invaded the
mucosa. T4 has grown through the muscle wall and extended beyond. If the tumor grows into the
musculature of the bladder wall, it requires a more extensive operation.
This patient required a radical cystectomy, removing the bladder, prostate and seminal vesicles.
Dissection of the lymph nodes is also important, starting around the obturator nerve and internal iliac
all the way up to the inferior mesenteric artery.
So what happens now with the urine output? There are several options:
Date: 9/20/07
Lecture number: 25
Page 6 of 12
1. Transverse Colon Conduit- Remove a section of colon and anastomose the ureters into one end
of transverse colon, then connect the other end to an opening in the skin. Patients must wear a
bag, as urine continuously flows out.
2. Continent Diversion (Indiana Pouch)- removal of terminal ileum up to the hepatic flexure of
ascending colon. Open up both sections and sew back on itself (called detubularizing) so that
peristaltic motion is dampened, and a low pressure collecting pouch is created. Trimmed portion
of terminal ileum is attached to the skin as a stoma. Since it is a continent pouch, a bag is not
required, but catheterization is required. Preferable to younger and more active patients.
3. NeoBladder 50cm of ileum is detubularized, creating a reservoir. This reservoir is sewn onto
the normal urethra, and ureters are attached to it. This new bladder is inserted into the normal
urinary pathway, allowing the patient to void normally. Common side effects include nocturesis
(urination at night) and the requirement for occasional clean intermittent catheterization.
Question from Dr. Suarez regarding stem cell research and bladder implantation
Answer: Wake forest is doing stem cell research for bladders. They are growing transitional cells on a
scaffold and then implanting bladders. However these bladders still only act as a reservoir, not a
working bladder.
The Prostate
The prostate is both a fibromuscular and glandular organ. It is supported anteriorly by the
puboprostatic ligaments, and inferiorly by the urogenital diaphragm. It is separated from the rectum
by the Denonvilliers fascia. It provides nutrients for sperm and contributes 1/3 of the ejaculate.
Diseases of the Prostate:

1. Prostate Cancer- develops in the glandular component of the prostate.
2. BPH (Benign Prostate Hyperplasia)
3. Prostatitis- infection of the prostate.
4. Prostatodynia- thought to be due to tension in the pelvic floor musculature.
Date: 9/20/07
Lecture number: 25
Page 7 of 12
BPH
Symptoms:
-Urinary frequency.
-Hesitancy- takes time to initiate urination.
-Decrease in force and caliber of stream.
-Sense of incomplete emptying.
-Urinary urgency.
Drug Thearpy:
Alpha blockers- block alpha adrenergic fibers of the stromal component of the prostate which
normally cause constriction of the prostatic urethra. Example is Flomax. Better
for reducing symptoms
5 alpha reductase inhibitors treats glandular components, blocking conversion of testosterone
to dihydrotestosterone. Example is Avodart. Over time, this drug is better at
reducing the size of the glandular components of the prostate. Better at
preventing progression of disease.
Minimally invasive treatments (in order from least to most invasive):
Thermotherapy
Transurethral needle ablation
Laser TUR-laser used to resect prostatic tissue
Transurethral resection of prostate- uses a cutting loop to remove tissue.
Open procedures-requires an incision
Thermotherapy
The Prostaprobe is a catheter that delivers microwave thermotherapy to the prostate. Most likely affects
the alpha adrenergic tissues, resulting in a 60% positive response to treatment.
Laser TUR
Essentially vaporizes prostatic tissue. Outpatient procedure, but requires anesthesia. Heat from laser
causes inflammation and edema, requiring a catheter for several days.
Date: 9/20/07
Lecture number: 25
Page 8 of 12
Prostate Cancer
Most common solid tumor found in American men. 1 in 6 men over the age of 50 will be diagnosed
with it, and 1 in 33 will die from prostate cancer. Mortality rates have decreased in the last ten years
from approximately 40,000 per year to approximately 27,000 per year, presumably due to early
detection.
Prior to 1980 there werent any drugs to treat prostate cancer, and diagnosis was based on three late
findings: Lower Urinary Tract Symptoms (LUTS), bone pain from metastases, or abnormal rectal
exam. When men presented with these symptoms, a tissue sample was collected via transurethral
resection of the prostate which was sent to the pathologist for testing. At this time, most of these
samples came back positive for metastatic cancer. Today Dr. Lynch only has one or two patients per
year who have advanced prostate cancer. Three events have changed the way in which prostate cancer
is diagnosed and treated. The advent of alpha bockers for LUTS, PSA screening, and the
development of nerve-sparing radical prostatectomy so that more men are now willing to undergo this
type of surgery.
Prostate cancer is a multifactorial disease with contributions from environmental, biological and genetic
sources. This is illustrated by the fact that the highest incidence of prostate cancer in the world occurs in
African American men in Orange County California. Here in Washington DC, the lowest incidence of
prostate cancer occurs in the far east.
Prostate Cancer Risk Factors

1. Family history- risk doubles with a father or brother with prostate cancer.
2. Diet- diets high in fat content increase the risk, as does obesity. Vitamin E reduces the risk.
Vitamin D may also have a positive affect. Areas that get more sunlight have a lower incidence
of prostate cancer, presumably due to increased Vitamin D.
3. Vasectomy- is no longer considered a risk factor.
4. Androgens- evidenced by the castrati (boys castrated to retain their alto singing voices) in 16th
century Italy who never developed prostate cancer.
5. Aging
6. Environmental only known environmental risk factor is exposure to cadmium.
Date: 9/20/07
Lecture number: 25
Page 9 of 12
7. Ethnicity- higher incidence in African Americans.
Process of Prostate Cancer

A normal prostate undergoes oxidative damage due to some insult stemming from diet, environment,
infection or inflammation which causes proliferative inflammatory atrophy (PIA). This leads to
prostatic interepithelial neoplasia (PIN), which is thought to be a malignant precursor. This leads to
localized prostate cancer. PIN can be differentiated from prostate cancer due to the cancer cells lack of
basement membrane.
Prostate Cancer Prevention

Selenium- reduces the incidence of prostate cancer 9 fold. Now a common supplement.
Vitamin E- reduces risk, but increases risk of death from hemorrhagic stroke.
Lycopene- from processed tomato products-reduces risk.
Soy Products
Vitamin D
Pomegranates- strong anti-oxidants. Found to reduce the PSA doubling time in patients with a
recurrence of prostate cancer subsequent to radical prostatectomy. Apparently a good mixer with
vodka.
Prostate Cancer Prevention Trial

Examined whether or not Finasteride (a 5 alpha reductase inhibitor that is used in treatment of
prostate cancer) could reduce the risk of obtaining prostate cancer. This was a large study that showed
Finasteride reduced the total number of prostate cancers vs. the placebo. However, a surprising result
was that although the total number of cancers decreased, the number of cancers with a high Gleasons
Score were increased. The Gleason Score rates prostate cancer on a scale from 2 (least aggressive) to 10
(most aggressive). So with Finasteride, there were more high grade tumors, despite the lower overall
risk.
Early Detection Controversy

Some argue that there hasnt been evidence to show that early detection through screening has had any
benefit, but Dr. Lynch says that research will be published soon proving that it is beneficial. Regardless,
Date: 9/20/07
Lecture number: 25
Page 10 of 12
prostate cancer mortality has been decreasing in the U.S. and it is thought that PSA testing has lead to
early detection and better cures.
Prostatic Specific Antigen (PSA)

PSA has revolutionized detection of prostate cancer, and remains the most valuable tumor marker we
currently have despite some criticisms. It is especially valuable in monitoring patients who have already
undergone treatment. PSA is a serine protease that is prostate specific, but not prostate cancer specific.
In addition to prostate cancer, PSA can be elevated due to infection, BPH (due to increase in glandular
size of prostate), and ejaculation. The upper limit for normal PSA is 2.5 to 4ng/ml. PSA velocity
measures a patients PSA levels over time, and is useful in alerting the physician to any recent changes
in PSA levels.
When PSA levels change, the patient is scheduled for a transrectal ultrasound and prostate biopsy,
which is accessed by needles passing through the wall of the rectum. 95% of prostate cancers occur in
the peripheral wall of the prostate, which borders the rectum, and is therefore easily accessed.
Formerly, only 6 sextant biopsies were taken, but it was found to be only 75% accurate. Now 12
biopsies are taken which has increased the accuracy to 95%. The biopsies are then taken to the
pathologist who picks the two most prominent types of cancer cells and gives them a Gleason Score.
Under the microscope, the higher the Gleason score, the more bizarre the cancer cell shapes.
Adenocarcinomas are the most prominent form of prostate cancer.
Spread of Cancer
Generally occurs via local extension (ex. into the neighboring bladder), through the lymphatics, or
vascular systems. The venous plexus sitting on top of the prostate drains into the bones of spinal
column which can lead to bone metastases.
Treatment
Watchful waiting- for patients with low grade, low volume disease with less than 10yr life expectancy.
Radical prostatectomy- can be completed perineally (incision between scrotum and rectumno
thanks), retropubically, laparoscopically, and robotically.
Radiation Therapy-via external beam, brachytherapy, or a combination of the two.
Date: 9/20/07
Lecture number: 25
Page 11 of 12
Brachytherapy- implantation of permanent radioactive seeds into the prostate.

Cryosurgery- freezing the prostateHowever impotence rate of 50-60%, so not good for younger
patients.
Both Brachytherapy and Cryosurgery utilize a grid system into which needles are inserted under
ultrasound guidance. The ultrasound probe is inserted into the rectum and the prostate is visualized on
the screen with the same grid system superimposed upon the ultrasound image. It then becomes a matter
of placing the needle into the correct hole. E-7, you sunk my prostate!
Cyberknife- is a more accurate form of external beam radiation therapy. The prostate moves during
the normal breathing cycle. This has traditionally required a wide beam of radiation in order to catch it
in its range of motion. Due to the wide beam, nearby structures were unnecessarily radiated. The
cyberknife not only turns blue in the presence of Orcs, but also can follow the prostate as it moves, and
can therefore deliver a narrower beam directed only at the prostate.
High Intensity Focused Ultrasound (HIFU)-Currently in experimental trials in the US. The downside
is a 50-60% impotence rate, but may have applications in more focal therapy. The Albatherm is one of
the types of machines being used for this therapy. The ultrasound probe is inserted into the rectum and
high intensity ultrasound beams are directed at the prostate.
Hormone Therapy- Prostate cancer is dependent on testosterone for growth, so by adding an anti-
androgen, we can block testosterone. Side effects of this treatment include: loss of libido, impotence,
hot flashes, increased body fat, decreased muscle mass, and bone loss. As with any treatment that
makes you look and feel great, hormone therapy is expensive.
Bilateral Orchiectomy- Remove the testis to get the same effects as above, however most men prefer to
just take a shot once a month.
Radical Prostetectomy- There are two major methods, radical retropubic and robot-assisted
laparoscopic. To remove the prostate, we approach it from along the anterior surface of the bladder,
posterior to the pubic symphysis. The surgeon will transect the puboprostatic ligaments, ligate the
dorsal vein complex, transect the urethra and the lateral vessels, but leaving the neurovascular bundles
Date: 9/20/07
Lecture number: 25
Page 12 of 12
intact. The prostate is removed from the neck of the bladder, as are the seminal vesicles. Finally the
urethra is anastomosed back to the bladder.
The intuitive DaVinci robotic device- is a $1.65 million dollar device. It works by inserting several
ports into the patients abdomen. The robot is then attached to the ports, and the operation is completed
by a surgeon in a remote station several feet away. Is there an advantage to using robotics? While there
is less blood loss with robotics, the transfusion rates are the same between the two methods, so it can be
argued that the blood loss may not be consequential. Robotics utilize five small incisions rather than
one large one. Pain level is similar. Robotics reduces the hospital time by one day. Both require
catheterization. In both cases the patient is able to return to work in the same amount of time.
Interestingly, potency is better with robotics, but continence does not recover as quickly as with
traditional surgery. The additional cost of the robotics is also an issue.
The Future
If the cancer could be identified with imaging, we would be able to use focal therapy such as
cryotherapy and High Intensity Focused Ultrasound to eliminate the cancer. We dont have that
imaging available to us now, so the entire gland must be treated.
Movie-Robotic Prostetectomy
Briefly, the movie showed a 51y.o. male with stage T1c (remember Gleasons scale) prostate cancer. In
the video, the patient had several laparoscopic ports inserted into his abdomen. The robot was attached
to the ports and the surgeon operated via a remote station on the other side of the room. One of the ports
contained a camera, which provided the view for the video. We saw the surgeon use the robotic hands
to slowly dissect his way down from the insertion point at the umbilicus around the front of the bladder
to the prostate. He dissects around the prostate until he identifies the junction between the prostate and
the bladder. He was careful to cut away all of the cancerous prostate, but not to cut into the bladder.
Once the prostate was freed from all of its surrounding attachments, it was placed into an endocatch bag
and removed. The neck of the bladder was then sutured to the urethra, aligning the mucosa of both
surfaces to prevent scarring. Once sealed, the bladder was filled with saline to check for leaks. Vic
Patel completed this procedure in about 1h 20min, whereas it takes most surgeons 3hrs to complete it.
Course: GA
Lecturer: Dr. Banerjee
The Medical Note-Taking Service Date: September 26, 2007
Lecture Number: 28
NOTICE &DISCLAIMER
Note-Taker: Caitlin Bump The Medical Note-Taking Service makes every effort to provide accurate
SKULL, FACE, & SCALP
Dr. Banerjee started the lecture by saying that the skull, face, and scalp are very important because they
are the part of our body that has all five senses: taste, smell, touch, hearing, and sight. It is also a very
important region because of facial expression. His email is ppb@georgetown.edu, feel free to email him.
SKULL
The skull (cranium) consists of two parts:

1. Neurocranium (brain box) - where the brain is located. Has two parts:
a. Calvaria (skull cap) has 8 bones: frontal, parietal, occipital, temporal, sphenoid, &
ethmoid.
b. Cranial base has 6 bones: maxilla, palatine, vomer, sphenoid, temporal, and
occipital
2. Viscerocranium (facial skeleton) - contains the orbital, nasal, and oral (maxilla & mandible)
cavities. Has 14 bones: 2 nasal, 2 zygomatic, 2 palatine, 2 maxillae, 2 lacrimal, 2 inferior
nasal concha, 1 vomer, and 1 mandible.
Sutures are immobile, unflexible fibrous joints between bones. There are four of them:
- coronal, sagittal, lamboid, and squamous,
The points where they meet are the bregma, lambda, nasion, and pterion.
The pterion is very

clinically important
because it is the union of
four bones and indicates
the approximate surface
projection of the middle
meningeal artery. A skull
fracture to this area can
damage the nerve, leading
to the formation of an
epidiurial hematoma,
which can cause death if it
is untreated.
In my opinionk, we dont devote nearly enough scientific research to finding a cure for jerks
Calvin and Hobbes.
Course: Embryology Lecturer: Dr. Gallicano
Date: 8/15/07
Lecture number: 3
Page 2 of 5
The sutures do not fuse until about two years after birth. This incomplete ossification is advantageous
because it provides flexibility for the newborns head as it passes through the birth canal. Consequently,
newborns have soft spots on their heads, called anterior and posterior fontanelles, which later fuse to
become the bregma and lambda, respectively. It takes two years for these fontanelles to completely
ossify. They are clinically important because doctors can monitor the infants bone growth, degree of
hydration, degree of intracranial pressure, and the collection of CSF.
The anterior aspect of the skull is notable because it contains three foramina that each allow a branch
of the trigeminal nerve to exit the skull and innervate the face.
1. Ophthalmic branch (V1) passes through the supraorbital foramen.
2. Maxillary branch (V2) passes through the infraorbital foramen.
3. Mandibular branch (V3) passes through the mental foramen.
MUSCLES OF THE FACE & SCALP
The muscles of the face and scalp are subcutaneous tissue that is tightly attached to the skin. These
muscles moves the skin and changes facial expression.
Muscles of the mouth:
1. Orbicularis oris oral sphincter, closes mouth and protrudes lips
2. Buccinator cheek muscles, keeps food between the teeth, allows us to suck and blow.
3. Levator labil superioris raises upper lip
4. Zygomaticus major smile muscle, draws the corner of the mouth up
5. Depressor anguli oris frown muscle, depress the corner of the mouth
Muscles of the nose:

1. Procerus furrows brown
2. Nasalis two parts that both bring the nasal ala medially
a. transverse nasalis
b. alar nasalis
Muscles of the orbit:

1. Orbicularis oculi consists of two sphincter muscles
a. Orbital part tightly closes eye
b. Palpebral part gently closes eye
Occipitofrontalis Muscles scalp muscles

1. Frontal belly front scalp
2. Occipital belly base of back of head
ARTERIES OF THE FACE
ALL are branches of the External Carotid Artery. The internal carotid artery is the first branch of the
common carotid artery, but it does not branch until it is inside the skull.
External Carotid artery 2nd branch off the common carotid artery. Branches are:
Date: 8/15/07
Lecture number: 3
Page 3 of 5
Facial, Occipital, Posterior Auricular, Maxillary, Transverse Facial, & Superficial Temporal
VENOUS DRAINAGE OF THE FACE
Three of them: Facial vein, Retromandibular vein, Posterior Auricular vein
Danger triangle area

between the eyes, nose,
and upper lip. The facial
vein communicates with
the cavernous sinus and
ophthalmic vein, which is
one of the main venous
drainages within the skull.
Infection here can easily
travel to the brain and
cause meningitis.
LYMPHATIC DRAINAGE OF THE FACE
Superficial lymph nodes drain into deep cervical lymph nodes, which then drain into either the
thoracic duct (on left side) or right lymphatic duct (on the right side).
NERVE SUPPLY OF THE FACE
Sensory Innervation of the Face: Trigeminal Nerve (CN V), consists of 3 divisions:
1. Opthalmic (V1) sensory only, has five terminal branches (supraorbital, supratrochlear,
lacrimal, infratrochlear, & external nasal). Enters through the supraorbital foramen
2. Maxillary (V2) sensory only, has three terminal branches (zygomaticotemporal,
zygomaticofacacial, infraorbital). Enters through the infraorbital foramen.
3. Mandibular (V3) mixed sensory & motor muscles of mastication, has three terminal branches
(auriculotemporal, buccal, mental). Enters through the mental foramen.
Motor Innervation of the Face: Facial Nerve (CN VII), consists of five anterior branches and one
posterior branch:
1. Temporal
2. Zygomatic
3. Buccal
4. Mandibular
5. Cervical
Date: 8/15/07
Lecture number: 3
Page 4 of 5
1. Posterior Auricular
Facial Paralysis the facial nerves come through a very small opening called the stylomastoid
foramen. Disease, injury, or infection in this foramen can depress the facial nerve and cause unilateral
paralysis of the face, called Bells Palsy. The characteristics of the paralysis are:
1. Facial distortion
2. Drooping eyebrow
3. Lower eyelid eversion
4. Inability to close or blink the eye
5. Decreased lacrimation
6. Inability to chew effectively
7. Inability to whistle or blow
In children, the mastoid process is not well developed. This process protects the facial nerve, so in
children there is much greater chance of damage to the facial nerve due to lack of protection.
SCALP
The scalp is a covering of the neurocranium from the superior nuchal lines on the occipital bone to the
supraorbital margins of the frontal bone. Laterally the scalp extends over the temporal fascia to the
zygomatic arch.
The acronym SCALP can actually help you remember the components of the scalp:
1. Skin thin, contains hair & sweat glands
2. Connective tissue thick, dense, richly vascularized
3. Aponeurosis strong tendinous sheet
4. Loose connective tissue sponge-like, allows free movement
5. Pericranium (periosteum) thin, dense layer of connective tissue
BLOOD SUPPLY
Arterial supply to the scalp is continuous with that of the face and is derived from both the external &
internal carotid arteries.
VENOUS DRAINAGE
1. Anterior part of the scalp is drained by the supraorbital & supratrochlear veins
2. Lateral part of the scalp is drained by the superficial temporal & posterior auricular veins.
3. Posterior part of the scalp is drained by the occipital vein
4. Deep part of the scalp is drained by the emissary veins
LYMPHATIC DRAINAGE
Date: 8/15/07
Lecture number: 3
Page 5 of 5
Scalp lymph Superficial lymph nodes Deep cervical lymph nodes Thoracic duct (on left side)
or Right lymphatic duct (on right side)
There are no lymph nodes in the scalp
NERVE SUPPLY
1. Nerve supply to the scalp is continuous with that of the face

2. Anterior to the ears is innervated by branches of the Trigeminal Nerve
3. Posterior to the ears is innervated by Spinal Nerves (C2 & C3)
CLINICAL IMPORTANCE
1. Scalp lacerations bleed profusely because they are held open by dense connective tissue
2. Loose connective tissue layer is the danger area of the scalp, infection can pass into the cranial
cavity through the emissary veins.
3. Infections or fluids can enter the eyelids and the root of the nose from scalp injury and result
black eyes
The Medical Note-Taking Service Date 9.28.07
Lecture Number: ?
NOTICE &DISCLAIMER
Note-Taker: Lauren Waltersdorf The Medical Note-Taking Service makes every effort to provide accurate
Approved for distribution:Yes assumes the risk for any and all errors. We recommend that you use
Cranial Nerves and Autonomic Ganglia
II
III
IV
V
VI VII ,VIII
XIIXIX
XI
Figure 1. Structural organization of the CNs
There are 12 pairs of cranial nerves, thus named for their association with the cranium. They
carry the same fibers as were carried in the spinal nerves (GSA, GSE, GVA, and GVE), along with
additional fibers for the special senses. These include SSA and SVA (smell, taste, vision, hearing, and
balance) and SVE or brachial efferent, which is the motor innervation to the skeletal muscles derived
from the pharyngeal arches (PAs). They also can carry parasympathetic fibers.
The CN I: Olfactory is SSA, responsible for smell/olfaction. Its cranial pathway is from bundles
of bipolar neurons that arise from the olfactory mucosa and travel through the cribriform plate to
synapse in the olfactory bulbs. It may be tested clinically by the recognition of familiar smells. Anosmia
Course Lecturer
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or loss of smell may occur if there is damage to the nerve (injury of ethmoid bone, which contains the
cribriform plate). Head trauma may also cause dripping of CSF into the nasal cavity due to (CSF
rhinorrhea) would be able to identify by testing for glucose (CSF is rich in glucose).
The CN II, Optic, is SSA for vision. Fibers come from retina (extension of brain) thus it has its
own meninges. It passes through the optic canal and fibers from both
nerves meet at the optic chiasm. Half of the nerve fibers continue straight
and the other half cross to the other side becoming optic tracts. The nerve
is tested by pupillary light reflex (PLR). Light is shone in eye and the
pupil should constrict. It is also important to look at the opposite eye to
make sure it constricts as well (consensual reflex). It is pretty easy to
understand what will happen if there is a lesion in one of the optic nerves
or tracts or in the optic chiasm if you draw out a diagram (Figure 2.),
being sure to cross the arrows so that the lateral views are the halves
meeting at the optic chiasm. From the damaged area follow the path of
the nerves associated with it to see which field of vision is compromised. Figure 2. Pathways of optic nerve
Three nerves, CN III: Oculomotor, CN IV: Trochlear, and CN VI: Abducens provide the motor
innervation to the extraocular muscles of the eye (CNIII does 5/7 of the muscles and has
parasympathetic innervation to smooth muscle in the eye for pupillary constriction and accommodation-
near sightedness). They all exit the cranium by superior orbital fissure. They may be tested by
observing conjugate eye movement (parallel gaze). If there is a lesion in one of the nerves you may have
double vision (Diplopia) or Strabismus where the eye moves without proper control. Specifically, in
paralysis of CNIII, palsy will occur revealed by ptosis (full) a down and out gaze, dilated pupils and
diplopa.
*6 out of 12 cranial nerves may be tested by orbital structures
The CN V: Trigeminal is the largest CN and has three divisions V1 (opthalamic), V2 (maxillary),
and V3 (mandibular). V1 and V2 are sensory only, while V3 is mixed (sensory and branchial motor).
Each provides sensory innervation to their respective portions of the skin (Figure 3) plus other important
structures. V3 provides motor innervation to muscles of mastication, which arise from PA#1. V1 travels
from the cavernous sinus and through the superior orbital fissure to the orbit, V2 from the cavernous
Course Lecturer
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sinus and through the foramen rotundum to exit the cranium. Lastly, V3 exits through the foramen ovale
to the infratemporal fossa.
Clinical testing is done by sensation of the forehead, cheek and chin. Also, the cornea reflex where ones
eye automatically closes if cornea is touched. The afferent portion of the reflux is CNV, while the
efferent portion is CN VII. Herpes Zoster, or shingles is an eruption from a virus that remains latent in
the nerves. There is concern for the cornea when this occurs with V1.
Figure 3. Divsions of sensory innervation by CN V
The CNVII: Facial, Provides motor innervation (SVE) to PA#2, the muscles of facial expression
and parasympathetically to certain salivary and lacrimal glands. Sensory is both general, to the external
ear and special (taste) to the anterior 2/3 of the tongue. It travels through the internal auditory meatus
(IAM) through the facial canal and exits via the stylomastoid foramen. To test you may ask patient to
move muscles of the face, or to taste something with the anterior tongue. Bells palsy is unilateral facial
nerve paralysis. Botox is also facial nerve paralysis, thus wrinkles are lessened d/t decreased skin
tension.
The CN VIII: Vestibulocochlear (Statoacustic) is Sensory only, for balance/vestibular and

hearing/cochlear. It passes through the internal acoustic meatus (with the facial nerve) and remains in
temporal bone (inner ear). Tested using a tuning fork and tests for balance (not discussed).
The CN IX: Glossophayngeal provides sensory, both general and special (taste) to the posterior
1/3 of the tongue, carotid sinus/body, oropharynx & tonsils, auditory tube & middle ear. Motor is to the
stylopharyngeus (PA #3) and parasympathetic fibers synapse in the otic ganglion and the postsynaptic
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fibers innervate the parotid salivary gland. It exits through the jugular foramen (with CNX and XI). The
gag reflex is utilized for testing. The afferent portion of the reflex is by CN IX and the efferent portion
by CN X. Isolated lesions of CN IX are not common. Jugular foramen syndrome involves CN IX, X,
and XI together.
The CN X: Vagus is the longest CN (wanders all the way to the left colic flexure). Provides SVE
to PA # 4 & 6 which include most of the muscles of the soft palate and pharynx, the intrinsic muscles of
larynx and the skeletal muscle of esophagus. Parasympathetic motor innervation is to the thoracic &
abdominal viscera and finally, sensory is both general to the laryngopharynx, larynx, trachea, auricle &
EAM, dura, thoracic & abdominal viscera and special with taste. It exits via the jugular foramen,
continuing on to the thorax and abdomen. Again testing is done with the gag reflex as well as uvular
shift (shift is away from lesion) vocal fold movement in the larynx and voice (e.g. hoarseness with
recurrent laryngeal nerve injury).
The CN XI: Accessory provides motor innervation and has both a cranial and spinal root. The
spinal root innervates the SCM and trapezius while the cranial root joins the vagus. The spinal root
begins with C1-5 and enters the cranium through the foramen magnum. It exits again through the jugular
foramen to reach the neck. Clinical testing may be done by raising the shoulders and turning the head
against resistance.
The CN XII: Hypoglossal is strictly motor and travels via its own hypoglossal canal. It innervates
all the intrinsic (contributes to the shape) muscles of the tongue and most of the extrinsic (position) of
the tongue. Tongue protrusion is a useful test. If there is injury to the nerve, the tongue will protrude
towards the side of the lesion.
Concerning the autonomics of the head, all of the parasympathetic innervation is by the III, VII,
IX (X provides parasympathetic innervation below the head to the left colic flexure). Presynaptic axons
synapse in four different ganglia and continue on to their respective viscera (Figure 3). They mostly
piggy back on CN V.
Course Lecturer
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Figure 4. Autonomic fibers synapse in ganglia of the head before reaching their respective viscera.
Sympathetic fibers are postsynaptic from the superior cervical ganglion, which then piggyback
on internal/external carotid arteries and then join with the parasympathetic fibers to the viscera.
Clinically, Horners syndrome is caused by injury to the sympathetic innervation, and recognized by a
partial drooping of the eyelid and a pupil that will not dialate (Figure 4).
Lecture Number: 30
NOTICE &DISCLAIMER
The Orbit
1. Overview
A. Orbit and Contents
The orbit contains eyeball, muscles, nerves, vessels, and
fat. It is pyramidal with four walls. The medial walls are parallel
and lie approximately 1 inch (25cm) away from each other. The
lateral walls lie at right angles to each other and do not extend as far
anterior as do the medial walls.
B. Orbit and Relationship to Other Structures
The orbit sits inferior to the anterior cranial fossa, superior
to the maxillary sinuses, and lateral to the ethmoidal sinuses. This
is significant because it allows one to appreciate the possible
damage specific injuries to the orbit can cause. If an object is
pushed through the roof of the orbit it will enter the anterior cranial fossa and thus could damage the
cerebral cortex. If an object pushes through the floor of the orbit it will communicate with the maxillary
sinus. And if an object pushes through the extremely thin ethmoid bone medially, it will enter the
ethmoidal sinus.
C. Orbit and the Cranial Fossae
The orbit lies inferior to the anterior cranial fossa, however, due to its pyramidal structure, an
object pushed anteroposteriorly through the orbit will enter the middle cranial fossa. This is significant
because it is within the middle cranial fossa that houses important structures such as the pituitary,
internal carotid arteries, and the cavernous sinus.
Also, the bones of the orbital cavity are lined with periosteum which is called periorbita.
Periorbita is continuous with the dura mater of the cranial cavity at the optic canal and the superior
orbital fissure.
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**Clinical Note The general approach for surgeons is through the lateral side of eyeball
because it allows the most access.
2. Bony Walls
A. 6 Bones of the Orbit
The orbital cavity is made up of 6 bones:
sphenoid, frontal, ethmoid, lacrimal, maxillary, and
zygomatic. The zygomatic portion of the lateral wall is
very strong, while the ethmoid portion of the medial wall
is very thin (paper-thin).
**Clinical Note This is why when someone is
punched there is a much greater chance of
fracturing the ethmoid bone, rather than the
zygomatic bone of the orbital cavity (even when
punched from lateral side.)
B. Blow Out Fractures
Blow out fractures occur when the ethmoid bone, medial wall of the orbital cavity, is fractured.
This causes exophthalmos which is the accumulation of blood and fluid within the orbital cavity
leading to the eyeball protruding from the orbit. Graves Disease can also cause exophthalmos as well
due to goiter within the orbits.
3. Surface Anatomy
A. Orbit and Eyeball
The palpebral commissures (joints) is where the upper and lower eyelids come together. At
this junction the medial and lateral canthi are formed as the angles of the fissures. The palpebral
fissure is the opening between the eyelids.
B. Eye
The eye contains a couple specialized parts to know. The cornea is the transparent anterior 1/6
of the outer coat of the eyeball. The cornea covers the colored portion of the eye. The sclera is the
whitish, opaque posterior 5/6 of the outer coat of the eyeball. The iris is teh varied colored portion seen
through the cornea. The pupil is the center of the iris through which the light passes.
The conjunctival sac is the potential space between the eyeball and the eyelids. It is lined with
epithelium on both sides. The palpebral conjuctiva is the mucosa covering the posterior surface of the
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eyelid. This turns back on itself at the conjunctival fornices (superior and inferior) and becomes the
bulbar conjunctiva covering the anterior part of the sclera.
C. Eyelid - **This is the thinnest skin on the body**
The tarsus is dense connective tissue between the palpebral conjunctiva and the superficial
fascia. It contains tarsal glands and tarsal muscles. The tarsal glands are modified sebaceous glands
within the tarsus with ducts that secrete oily secretions that reduce the
evaporation of tears. The tarsal muscles are smooth muscle within the
tendon of the levator palpebrae superioris. It receives sympathetic
innervation from the internal carotid plexus and contracts to elevate the
upper eyelid. The orbital septum is a fibrous membrane from the orbital
margin to the tarsus and it is continuous with the pericranium.
**Clinical Notes The orbital septum plays an important role as the fire
wall in preventing spread of infection from the superficial fascia of the
eyelid to the interior of the orbit and into the brain.
Chalazion inflamed tarsal gland
Sty ciliary gland duct is blocked
Periorbital Ecchymosis (black-eye) blood clot in the superficial skin
Subconjunctival Hemorrhage blood deep to conjunctiva
D. Lacrimal Apparatus
The lacrimal gland is located inside the superolateral orbital margin and extends several ducts
that open into the lateral part of the conjunctival fornix. Blinking moves the fluid toward the medial
angle of the eye. (Dr. SQ mentioned specifically that you do not need to know all of the other terms such
as lacus lacrimalis, papilla, etc. unless it interests you.)
4. Muscles
A. Levator Palpebrae Superioris elevates the upper eyelid
Innervation Oculomotor Nerve (CN III) **This is voluntary. Contrast to tarsus.**
B. Six Muscles work on eyeball.
Four are innervated by Oculomotor (CN III). The two exceptions are Lateral Rectus which is
innervated by Abducens (CN VI) and Superior Oblique which is innervated by Trochlear (CN IV). You
can remember this by the formula: LR6SO4.
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C. Vertical Axis Movement

1. Adductors mainly MR but also SR and IR.
2. Abductors largely LR but also
IO and SO.
D. Horizontal Axis Movement
1. Elevators SR and IO
2. Depressors SO and IR.
E. Anteroposterior Axis Movement
1. Medial Rotators (Intorsion) SR
and SO.
2. Lateral Rotators (Extorsion) IR and IO.
5. Nerves
A. Optic a continuation of the brain that conveys special sensory (vision) to the eye.
B. Oculomotor provides motor innervation to eye muscles (SR, MR, IR, IO, LPS).
1. Enters through the superior orbital fissure and divides into superior and inferior.
2. Conveys parasympathetic pre-ganglionic fibers to the ciliary ganglion. These fibers
allow constriction of pupil and accommodation by the lens of the eye.
**Clinical Note Ptosis is the condition of droopy eyelids due to damage to the
innervation of LPS.
C. Trochlear and Abducens Nerves both enter through superior orbital fissure.
1. Trochlear provides motor to SO.
2. Abducens provides motor to LR.
D. Ophthalmic Division of Trigeminal Nerve (V1)
1. Enters through superior orbital fissure and immediately splits into Lacrimal,
Frontal, and Nasociliary branches.
2. Carry General Sensory Modalities (GSA).
**Post-ganglionic parasympathetic innervation to lacrimal gland is provided through
CN VII via the pterygopalatine ganglion and zygomatic nerves.
E. Parasympathetic Innervation of Eye
1. Preganglionic parasympathetic fibers to eyeball are from CN III.
2. Postganglionic fibers emerge via short ciliary nerves.
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Lecture number: 30
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3. Parasympathetic innervation constricts pupil and accomodates the lens of the eye.
**Clinical Note Pupillary Light Reflex: afferent pathway is through the optic nerve
whereas the efferent pathway is by the oculomotor nerve.
F. Sympathetic Innervation of Eye
1. Postganglionic sympathetic fibers to eyeball are from internal carotid plexus and
traverse the ciliary ganglion without synapsing.
2. Sympathetic innervation of eye dilates pupil.
**Clnical Note Corneal Reflex occurs when the eye is touched, one blinks. The afferent
pathway occurs via V1, and the efferent pathway via CN VII.
**Clinical Note Horner Syndrome occurs when there is interruption of the cervical
sympathetic trunk. It causes a lack of ipsilateral sympathetic innervation which
manifests itself by: miosis (pupillary constriction), ptosis (drooping of eyelid),
vasodilation, and anhydrosis (absence of sweating).
6. Blood Supply
A. Ophthalmic Artery
It arises from the cranial cavity from the internal carotid artery and traverses the optic canal
inferior to the optic nerve. It then turns superiorly to the nerve and travels with nasociliary nerve.
1. Central Artery of Retina arises from ophthalmic artery as it emerges from optic
canal and penetrates the meninges of the optic nerve and supplies the retina.
B. Ophthalmic Vein
The Superior Ophthalmic Vein courses posteriorly within the orbit and receives tributaries
corresponding to branches of the ophthalmic artery. It exits the orbit through the superior orbital
fissure and drains into the cavernous sinus.
**Clinical Note The Facial Vein is in communication with the
Superior Ophthalmic Vein and thus infections on the face may
communicate to the cavernous sinus and cause meningitis.
7. Cavernous Sinus situated bilaterally on each side of the sella
turcica.
**Clinical Note Blow out of the internal carotid artery creates a
communication between arterial and venous blood within the sinus.
A pulse can be seen in the eye each time the heart beats.
The Medical Note-Taking Service Lecturer Dr. Suarez-Quian

Date October 3, 2007
Lecture Number: 31
NOTICE &DISCLAIMER
Note-Taker: Jennifer Lan The Medical Note-T aking Servic e makes ever y effort to prov ide accurate
Corrected by: Uncorrected class notes. Howev er, errors will occur fr om time to time. The user
INTRODUCTION TO THE NECK

So, the neck can be pretty overwhelming with the vast amount of detail you could know. However, Dr.
Suarez- Quian reassured us that it really is straightforward if we just break it down into sections and try
not to focus on the million details. For this note set, I will be following how Dr. Suarez- Quian broke
down the lecture and cover the material to the extent he says we need to know it for this class. Ill try
my best to condense the information as given in the lecture. If you need further detail (i.e. boundaries of
the triangles, etc), please consult your textbook (Lets try to save a few trees ).
An overview of the notes:

I. Background
II. Cutaneous Structures
III. Fascia of Neck
IV. Triangles of the Neck
V. Muscles
VI. Nerves
VII. Arteries, veins, lymphatics
VIII. Viscera
I. Background
Dr. Suarez-Quian started off with a little background on the neck and its importance. The neck
is a very important part of the body since it connects the head to the rest of the body where many
vessels, nerves, air canals, and glands are located. As a physician, you will encounter many problems
with the neck from metastasis to stab wounds. Five to ten percent of all traumas are found in the neck
region. The proximity the neck is to the thorax is also a key concern. Remember, the apex of the lungs
protrude up towards the neck so any neck injury could potentially lead to damage of the thoracic region
such as creating a pneumothorax.
Homer: There's your giraffe, little girl.
Ralph Wiggum: I'm a boy.
Homer: That's the spirit. Never give up.
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II. Cutaneous Structures

A. Platysma Muscle
If you remove the skin and fascia, the first muscle
you encounter is the platysma muscle. This
muscle is worked when you grimace. It is very
superficial and partially attached to skin. Since it
is a part of facial expression, it is innervated by
CN VII.
Damage to CN VII can cause the skin around the platysma muscle to fall away in slack folds.
Careful attention must be taken in surgery or suturing the neck not to accidentally cut the
platysma nerve branches.
B. Cutaneous Nerves
Deep to the platysma muscle, but still very superficial, you
will find the cutaneous nerves. They emerge from the Lesser
occipital
posterior side of the sternocleidomastoid muscle. This plexus
is formed from the ventral rami of C1-C4. There are four
Great
main branches and their names pretty much tell what area auricular
they innervate: Transverse
cervical
Lesser Occipital Nerve (C2)towards the occipital
bone, innervating the skin and scalp posterior to the
auricle
Greater Auricular Nerve (C2,3)innervates the
external portion of the ear
Transverse Cervical Nerve (C2,3)courses Supraclavicular
nerves
anteriorly across the sternocleidomastoid muscle (SCM) to innervate the anterior neck
Supraclavicular Nerve (C3,4)courses down to innervate about the clavicle
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**Clinical Correlate #1** Back to referred pain, remember the diaphragmatic pain referred to
the shoulder? A little reminderthe supraclavicular nerves and the phrenic nerves both arise
from the C3 and C4 segments. So, pain sensed in the diaphragm via phrenic nerve is referred to
the area supplied by the supraclavicular region (the shoulder).
**Clinical Correlate #2** The cervical plexus is a key area for regional anesthesia. An
anesthetic agent can be injected in the area posterior to the SCM. If you want to anesthetize the
posterior of the neck, you would have to inject the agent further back. However, you have to be
wary if the patient has respiratory problems. The phrenic nerve is usually paralyzed during a
cervical plexus block. Remember, the phrenic nerve supplies the diaphragm so you dont want
to compromise the diaphragm of a patient experiencing breathing problems.
C. Superficial Veins
There are a lot of veins found in the neck region similar to what we have seen in the other parts
of the body, they are not always constant. Post. auricular v.
So, just try to pay attention to the key
Retromandibular v.
ones:
Posterior Auricular Vein

+
Retromandibular Vein

External Jugular Vein
The external jugular vein can be found

along the posterior edge of the SCM and
drains in the subclavian vein. Ant. jugular v.
The anterior jugular vein is another

structure to consider. It is composed of
the coalescence of veins under the chins Ext. jugular v.
and drains into the external jugular vein
posterior to the SCM.
III. Fascia
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There are five separate fascial planes in the neck. A good way to think about them is that they are like
stockings within one another.
1. Investing Fascia- encircles all the major muscles of the neck; most superficial layer
2. Prevertebral Fascia- encloses to the vertebral column and the muscles that are plastered to it
3. Pretracheal fascia- encircles the trachea and thyroid glands
4. Carotid Sheaths- two of them, one on each side; cover the carotid arteries, internal jugular veins,
and vagus nerves.
(1) Investing
(2) Prevertebral
(3) Pretracheal
(5) Carotid
**Clinical Correlate #3** The prevertebral fascia extends from the base of skull all the way down
to the thorax. Anterior the vertebral column, it is split into two layers separated by loose connective
tissue. This forms a true space. Therefore, if an infection happens to occur in this dangerous true
space, the infection can spread anywhere from the base of the skull to the thorax. Overall, the fascia
of the neck are important as retaining barriers of infection, limiting the spread of infection from one
area to another.
IV. Triangles of the Neck

The triangles are used as a way to compartmentalize the neck so its easier to study. If we think of
the neck as a cylinder, it would be easier if we divided it up into triangles. Dr. Suarez-Quian stated
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that we do not need to memorize the borders of the triangles, but just to know the triangles and use
them as a way to study the different parts of the neck. Key muscles and structures to look at:
SCM, trapezius, mandible, and the clavicle.
Each triangle can be further divided into smaller triangles

A. Anterior Triangle
Bounded by the inferior border of the mandible, anterior cervical midline, and the SCM. Again,
Dr. Suarez-Quian noted that we do not need to know the boundaries of the triangles. Dr. Suarez-
Quian just listed some defining characteristics of each triangle.
1. Submandibular
Contains the submandibular gland and lymph nodes
2. Carotid
Contains the external carotid artery
Where you can feel for the pulse in your neck
3. Muscular
Contains the strap muscles of the neck: sternohyoid, sternothyroid, and thyrohyoid
muscles (discussed later in the noteset)
4. Sub-mental
Contains the submental lymph nodes and veins
Found the mental nerve in the lower jaw, so the area below is the submental triangle.
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B. Posterior Triangle
Bounded by the SCM, the clavicle, and the trapezius
1. Occipital
Associated with the occipital bone
2. Subclavian
Associated with the subclavian artery and vein and the brachial plexus
V. Muscles of the Neck

A. Muscles of the Posterior Triangle
a. Sternocleidomastoid (SCM)
This muscle extends from the sternum to the mastoid (can easily remember by the name ).
It also attaches partly the clavicle, hence the cleido in the name. This is the muscle that
keeps our head up so when we were babies, we had a hard time keeping our heads up due to
this underdeveloped muscle. Actually, developmentally, we did not have mastoid process as
babies. It develops later on. That is why toddlers have more facial nerve injury because they
do not have mastoid process to protect the entry of the facial nerve.
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So how does the SCM work? Well, whichever way you want to turn your head, the
contralateral SCM flexes. When you want to keep your head up, it uses both muscles. Now,
when you fall asleep while, your SCMs relaxes and your head falls (usually accompanied by
a jerk as you realize you are falling asleep in lecture! I hate it when that happens ). It is
innervated by CNXI Accessory Nerve
b. Trapezius
We saw this while studying the back. Remember, it is what we use to shrug our shoulders
and is also innervated by CNXI. We will discuss more of this when we study the upper limb.
c. Scalenus anterior, medius, and posterior

These muscles form the floor of the posterior triangle. They attach to the first rib and
therefore involved in respiration. These are innervated by the ventral rami of C3-C8
Scalenus med.
Scalenus post.
Scalenus ant.
**Clinical Correlate #4** Scalenus anticus syndrome: The region between the scalenus
anterior and the sclaneus medius is very important. In between these two muscle is
transversed the subclavian artery and the brachial plexus. Therefore, if this interscalene
triangle narrows (i.e. due to hypertrophy), it can cause vascular and neurological impairment
to the upper limb. Another possible cause of constriction is the presence of an extra cervical
rib in the region (present in 1-2% of the population)
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d. Levator Scapulae
We saw this in the back as well and also is used to elevate the scapula. Dont worry too
much about this muscle. We will study this one more when we study the upper limb.
e. Splenius capitis
This muscle is also used to flex and rotate the head. Do not worry about this muscle so much
either.
B. Prevertebral Muscles These muscles are deep in the neck and also used to flex the head nd the
neck. When we have neck pain, it is usually due to these muscles. We do not focus too much on
these muscles in anatomy
a. Longus capitis and Longus colli
C. Suprahyoid and Infrahyoid Muscles Important muscles!!!

Before we talk about these muscles, there are key structures we must point out first. There is the
hyoid bone, which is a bone in the neck with no bony articulation. It has a characteristic U
shape to it. You can feel it if you press on one side and support it and then press on the other
side of your neck. But dont press too hard as it cracks easily. Its a good way to choke
someone (ummmI hope that doesnt come in handy one day?).
Another important structure to appreciate is the thyroid cartilage. This is where we find the
adams apple. We need to know the location of these two structures, hyoid bone and thyroid
cartilage, in order to talk about the suprahyoid and infrahyoid muscles.
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The infrahyoid group of muscles depresses the hyoid bone while the suprahyoid muscles elevates
a. Infrahyoid Muscles -- DEPRESSES

Omohyoidomo means shoulder so it attaches from the shoulder to the hyoid bone.
Sternohyoidattaches from the sternum to the hyoid bone
Sternothyroidattaches from the sternum to the thyroid cartilage
Thyrohyoid attaches from the thyroid cartilage to the hyoid bone
These muscles are innervated mainly by the ansa cervicalis nerve (will discuss later).
b. Suprahyoid Muscles -- ELEVATES

Mylohyoidforms the floor of the
mouth; mylo means flat
o innervated by nerve to
mylohyoid, a branch of the
inferior alveolar nerve
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Geniohyoid- from hyoid bone to lower jaw

o Innervated by C1
Stylohyoid from the stylus (like the needle from a record player) to the hyoid bone
o Innervated by CN VII (facial nerve)
Digastrichas two bellies
o Innervated by two cranial nerves
o Anterior belly by the mylohyoid nerve (branch of mandibular division of CN V)
o Posterior belly by CN VII (facial nerve)
As you can see, these muscles are all innervated by different nerves unlike the infrahyoid muscles
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VI. Nerves of the Neck

A. Vagus Nerve
We saw this nerve in the thorax and abdomen, but it also has some function in the neck. It has
multiple branches:
Auricular Branchsensory branch to auricle, acoustic meatus, and tympanic membrane
Pharyngeal Branchmotor branch; provides motor innervation to muscles of the
pharynx (will discuss more in later
lectures)
**If you damage this branch, youre
uvula will deviate to the contralateral side.
Superior Laryngeal Branch
o Internal Laryngeal Nerve
sensory branch to the larynx
o External Laryngeal Nerve- motor
innervation to circothyroid
muscle
Recurrent Laryngeal Branch
o Remember that it loops around
the right subclavian artery and the
aortic arch in the thorax
o Provides both sensory and motor innervation to the larynx (more about this in
later lectures)
B. Accessory Nerve
We also saw this nerve way back in the first week of school where we dissected the back. We
saw that it innervated the trapezius muscle. It also innervates the SCM here in the neck. If we
damage this nerve, we cannot shrug our shoulders. Damage to this nerve also causes wry neck
or also called torticollis. When the innervation to the SCM is damaged, youre head turns to
contralateral side. Torticollis can also be brought on by infection to the surrounding fascia.
C. Hypoglossal Nerve
Hypo means below + Glossal means Tongue = the nerve that goes to the tongue.
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Damage to this nerve leads to tongue deviation of the afflicted side.

The hypoglossal nerve is associated with the ansa cervicalis nerve.
D. Ansa cervicalis
This is a motor nerve from the cervical plexus that forms a loop route. It innervates the
infrahyoid muscles by pigging back on the
hypoglossal nerve.
E. Phrenic Nerve
Oh our old friend, the phrenic nerve, whom we
saw a lot in the thorax. It emerges from C3,
C4,C5 and travel anterior to the scalenus
anterior muscle. You should know that there
are important vascular structures anterior to the
phrenic nerve: transverse cervical artery,
suprascapular artery, and subclavian vein.
F. Brachial Plexus
The brachial plexus is formed from the ventral rami of C5-T1. Again, we will cover more of this
when we get to the upper limb, but the brachial plexus emerges between the scalenus anterior
and scalenus medius muscle with the subclavian artery in the posterior triangle. Remember, this
is a key area and can be impinged if this triangular area is narrowed.
**Clinical Correlate #5** Interscalene Block: Since we know that the brachial plexus emerges
between the scalenus anterior and medius muscle of the posterior triangle, one can anesthetize
the upper limb by injecting an agent posterior to the SCM towards the brachial plexus. This
avoids general anesthesia, which is a lot better for the patient.
G. Sympathetic Trunk
Remember that the sympathetic nerves are coming from the thorax (thoraco-lumbar),but they
travel to the head and neck region. To do so, they must synapse at certain ganglia:
Superior cervical
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Middle cervical
Inferior cervical
From these ganglia, the post ganglionic nerves piggy back onto the carotid arteries and travel up
into the head.
(Man, I know this is long but just keep on chugging...just a few more pages to go)
VII. Arteries, Veins, and Lymphatics

A. Arteries
There are two main vessels that supply the neck: the common carotid artery and the subclavian
artery. You want to know the major branches of these vessels
i. Common carotid artery
1. Right side: arises from brachiocephalic trunk
2. Left side: arises from aortic arch
3. Bifurcates into the internal and external carotid artery
a. Dilated end forms the carotid sinus which senses change in blood
pressure; innervated by CN IX
b. Also located near bifrucation is the carotid body which senses
oxygen content; innervated by CN IX and X
4. Remember, the internal carotid artery has no branches in the neck. It
branches once it enters the head.
5. Braches of the External Carotid Artery:
Superior Thyroid- supplies thyroid, larynx, anterior neck muscles
Ascending pharyngeal supplies deep aspect of pharynx, palate, and
tonsils
Lingual supplies tongue, tonsils, sublingual glands
Occipital supplies posterior scalp
Posterior Auricular supplies area behind ear and parotid gland
Facial supplies superficial muscles of the fascial expression
Maxillaryterminal branch; supplies structures close to maxilla
Superficial Temporalterminal branch; supplies parotid gland and
temporal region of scalp
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**Some mnemonics that might help:

Several Angry Ladies Fighting Over PMS
Some Anatomists Like Freaking Out Poor Medical Students
**Clinical Correlate #6** You can feel the pulse of the carotid artery in front of the SCM in the
carotid triangle in the anterior triangle
ii. Subclavian Artery

Gives off important branches that travel up the neck. The branches spell VIT C:
Vertebraltravels and enter the vertebra as it enters the head
Internal thoracicpasses into the thorax
Thyrocervical trunksending branch to thyroid and neck
Costcocervical trunksending branch to the ribs and the neck
**Clinical Correlate #7** You can feel the subclavian pulse midway of the clavicle.
B. Veins
i. Internal Jugular Veinfound in the carotid sheath, lateral to the carotid artery
and vagus nerve
ii. Subclavian Veinreceives external jugular vein and all other tributaries; meets
up with the internal jugular vein to form the superior vena cava.
**Clinical Correlate #8** Remember central lines are placed through the subclavian veins.
There is a potential in inducing a pneumo or hemothorax if not done correctly. Also, if the needle
goes too far posteriorly, it can damage the subclavian artery.
C. Lymphatics
The lymphatics of the neck are very complicated. For this course, we need to know that there are
two main lymph nodes:
Superficial Cervical Nodes accompany external jugular vein
Deep Cervical Nodesaccompany the internal jugular vein
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The superficial will ultimately drain into the deep nodes. When we get to third year, we will go
into a lot more detail.
The thoracic duct is a structure of the neck (though we did see it in the thorax, too). It looks like
a small vein that will drains into the V formed by the meeting of the subclavian and internal
jugular vein. On the right side, it is really hard to find the right lymphatic duct due to its
variability.
VIII. Viscera
A. Thyroid Gland
Endocrine gland
Consists of two lobes
40% of people have an extra pyramidal lobe
Since it is an endocrine gland, it has a vast vascular supply
The blood supply to the thyroids are important:
o Superior and Inferior Thyroid arteries from the external carotid artery and the
thyrocervical trunk of the subclavian artery
o Key note: Some people have an extra thyroidea ima artery (see clinical correlate
below)
If you know the arteries, you know the veins:
o Superior Thyroid Veindrains into the internal jugular
o Middle Thyroid Veindrains into the internal jugular
o Inferior Thyroid Vein drains into the left brachiocephalic vein
The lymph drains to the deep cervical nodes
**Clinical Correlate #I Lost Count**Tracheotomy: Usually performed inferior to the thyroid

isthmus. However, you have to be aware that some people have the extra thyroidea ima artery
which can be dangerous if you accidentally puncture it.
B. Parathyroid Gland
4 small parathyroid glands
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Will study more in endocrinology; hardly ever see in gross anatomy
D. Trachea and Esophagus

Remember that the trachea and esophagus are also in the neck. The trachea is anterior to the
esophagus.
Sorry for the ridiculously long note set! It was an info-filled lecture!
Lecturer: Dr. Suarez-Quain
The Medical Note-Taking Service Date: October 5, 2007
Lecture Number: 32
NOTICE &DISCLAIMER
Note-Taker: Alexis Strohl The Medical Note-Taking Service makes every effort to provide accurate
Corrected by: Dr. Suarez-Quain class notes. However, errors will occur from time to time. The user
Temporal Region/Pharynx
Temporal Region
The temporal region got its name because it is the area of the head where gray hairs appear first,
thus showing time. It is important to learn the bones that contribute to this region. There are different
parts of the temporal bone that you should know. The zygomatic process helps give shape to the face.
The mastoid process is a wing on the bone that develops as the SCM muscle gets stronger since this
is one of its attachment points. Other parts of this bone include the styloid process and the external
auditory meatus. These bones are covered by the temporalis muscle, which is covered by a thick
temporal fascia. This muscle of mastication receives motor innervation from the mandibular branch of
the trigeminal nerve (V3). In this region you will also find the auriculotemporal nerve, which is found
anterior to the ear and supplies the anterior part of the skull. The superficial temporal vessels are also
in this region. They are branches of the facial artery and are the ones that you are feeling when you find
the pulse on the side of your head.
Infratemporal Region
This is the area that is below and deep to the
temporal region. It is behind the maxilla bone, deep to
the ramus of the mandible and in front of the mastoid
process. The pterygoid process is in this region across
from the styloid process. Note that pterygoid means
wing-like. In the image to the right the ramus of the
mandible and part of the zygomatic bone have been
Pterygoid process
removed. The sphenoid (wedge-shaped) bone is another
very important structure that you should be familiar with. The orientation of this bone is perpendicular
to the long axis of the skull. (The pterygoid process is part of this bone).
Course: Gross Anatomy Lecturer: Dr Suarez-Quain
Date: October 5, 2007
Lecture number: 32
Page 2 of 6
Muscles of Infratemporal Region:

The muscles in this area are responsible for mastication. They are innervated by V3 (Mandibular
branch of the Trigeminal Nerve). When the ramus of the mandible is removed you encounter the lateral
and medial pterygoid muscles. These muscles got their name because of their association with the
pterygoid process of the sphenoid bone that was described above. The lateral pterygoid acts to open and
protract the lower jaw and is the muscle that
produces larger chewing motions. The medial
pterygoid acts to close and protract the lower jaw
and produces smaller chewing motions. Protraction
is when you stick the lower jaw down and out. The
temporalis muscle inserts in the infratemporal
region and helps in closure and retraction of the
lower jaw. The masseter is not technically found in
this region but it is a major muscle of mastication.
It aids in closure and protraction of the lower jaw.
Blood Vessels of Infratemporal Region:

The only artery that you need to know for this course in this region is the Middle Meningeal
branch Maxillary artery (which is a branch off of the external carotid artery). It is not necessary to
learn the other branches of the Maxillary artery. If you were to injure the maxillary artery and could not
clamp it you could clamp the external carotid
artery. This is okay because the external carotid
has very little to do with the blood supply to the
brain and therefore there is no real harm in
clamping it.
There is also the pterygoid venous plexus
in this area. If you damage the plexus it is
difficult to clamp down all the little veins and the
bleeding can be extensive. This is one of the
dangerous areas of the body for large amounts of
blood loss in the body.
Lecture number: 32
Page 3 of 6
Nerves of the Infratemporal Region

There are a lot of nerves in this area that need to be learned but the only information that you
need to know for this course is what is on the slides. The first is the Mandibular Branch of the
Trigeminal nerve (V3), which innervates the muscles of mastication that were discussed above. It exits
the cranium via the foramen ovale and divides into an anterior and posterior division. The anterior
division is mostly motor and gives off the deep temporal branch to the masseter and the lateral pterygoid
muscles. The posterior branch is mostly sensory and gives off the auriculotemporal nerve, which is a
sensory cutaneous branch. There are some other nerves in this region that are listed on page 321 of the
syllabus: nerve to the mylohyoid, lingual nerve, which joins the chorda tympani from CN VII. Other
nerves that will be discussed are the Maxillary division of the Trigeminal (V2), which is blocked by
dentists in a maxillary nerve block*, and CN VII and CN IX, which provide parasympathetic
innervation to the remaining ganglia in the face. The ciliary ganglion was discussed in the eye lecture,
but we still need to study the other three ganglia: Otic, Pterygopalatine, and Submandibular Ganglia.
*Dentists can also perform a mandibular nerve block from the outside of the cheek but they must insert
the needle deeper to accomplish this.
Temporomandibular Joint (TMJ)
This is a modified hinge joint between the mandibular fossa
and the condylar process. There is an articular disc between the
process and the fossa. When you open your jaw you can feel the
condylar process slip down and forward into the fossa. The three
ligaments seen on the image to the right help keep the joint in place.
This is important because a clinical problem associated with this joint
is dislocations. This can be caused by a fracture of the mandible or
just by yawning. Actions on this joint are controlled by various
muscles and by gravity. These are outlined below:
Action Muscles Involved
Protrusion lateral pterygoid assisted by medial pterygoid
Retraction temporalis (mainly), masseter, geniohyoid, digastric
Elevation masseter (mainly), temporalis, medial pterygoid
Depression gravity, digastric, geniohyoid, mylohyoid muscles
Lecture number: 32
Page 4 of 6
Pterygopaltine Fossa
You need to go inside the skull to see this region, as it is deep to the infratemporal region. It is
located inferior to the sphenoid bone and superior and lateral to the palatine bone. It is posterior to the
maxilla and anterior to the pterygoid process. There are two images of this region seen below.
Sphenopalatine
Foramen
(formed by the sphenoid
and palatine bones)
Ganglia
Recall that in general there are three modalities that go through every autonomic ganglia: general
sensory, preganglionic parasympathetic, and postganglionic sympathetic.
Pterygopalatine Ganglia
-General Sensory: V2 (Maxillary branch of Trigeminal Nerve)

-Preganglionic Parasympathetic: Greater Petrosal nerve (from CN VII)
-Postganglionic Sympathetic: Comes from somewhere in the neck, piggybacks onto the internal carotid
artery and sends off a branch called the Deep Petrosal nerve. This
nerve is the only structure that passes through the foramen lacerum
(Dr. Suarez stressed that this is anatomical trivia and not to worry
too much about it).
The postganglionic fibers go to the nasal cavity. They are
responsible for hayfever symptoms and are stressed when you have
an allergic reaction. The important nerves involved are the
Nasopalatine nerve (the medial nerve in the image to the right) and
the Greater and Lesser palatine nerves (the lateral nerve in the
image).
Lecture number: 32
Page 5 of 6
This ganglia also controls the lacrimal gland. Remember that the lacrimal nerve from CN V is
only sensory to the outer eye. Parasympathetic innervation of the lacrimal nerve is from CN VII NOT
FROM CN V. Follow the pathway below.
Submandibular Ganglion
-General Sensory: Mandibular branch of Trigeminal nerve (V3)
-Preganglionic Parasympathetic: CN VII. (Chorda tympani joins with the linguinal nerve, which ganglia
hangs off of)
-Postganglionic Sympathetic: Netters drawing shows that the fibers dont go directly to the ganglion.
Dr. Suarez is not sure if this is true, but we dont need to worry about it too much. The bottom line is
that the submandibular gland receives both parasympathetic and sympathetic innervation.
- The postganglionic fibers help to regulate the submandibular gland, which produces saliva during rest
and repose for digestion.
Otic Ganglion
-General Sensory: Mandibular branch of Trigeminal nerve (V3)
-Preganglionic Parasympathetic: Lesser Petrosal nerve of CN IX (Hypoglossal)
-Postganglionic Sympathetic: Coming from superior cervical ganglion in the neck and going to the
parotid gland. Again, Dr. Suarez is not sure of the exact path, so just know the basics.
-The auriculotemporal nerve brings postganglionic parasympathetic innervation to the parotid gland.
This is a mixed nerve that also brings general sensory innervation to the area.
Lecture number: 32
Page 6 of 6
Pharynx
The pharynx is a fibromuscular tube with an incomplete
anterior wall. It extends from the base of the skull to the cricoid
cartilage. It has three regions that it opens to: nasopharynx,
oropharynx, laryngopharynx. When you breathe in your breath
comes in through your nose/mouth, down your pharynx and
anteriorly to your larynx. When you swallow food should go from
oropharynx into the esophagus.
In the nasopharynx you find the pharyngeal tonsils near the
base of the skull. These often get infected and have to be removed.
The auditory tube also opens into the nasopharynx, which is guarded by a little piece of cartilage and by
the salpingopharyngeal fold that is a tube and contains a muscle. We will learn more about this when
we study swallowing. One of the reasons that little kids are prone to middle ear infections is that if the
pharyngeal tonsil lymphoid tissue gets inflamed the infection can drop down into the opening of the
auditory tube and travel into the middle ear. In children the opening to the ear is more parallel to the
ground which makes it easier for infection to travel. In adults the opening is more oblique.
The opening of the oropharynx behind the oral cavity is guarded by two arches: the palatoglossal
arch and the palatopharyngeal arch. Between the two is where the true palatine tonsil resides. Do not
confuse the palatine tonsils and the pharyngeal tonsils (adenoids). Removal of the tonsils involves
making an incision through the mucosal membrane to expose the lymphoid tissue. Next you hook the
tonsil and pull it out to expose the blood vessels. There are tonsilar arteries from the facial artery and
the palatine artery. There is also one vein attached. However, the real complications arise from the fact
that posterior to the posterior wall of the oropharynx is the internal carotid. In 99% of people the
internal carotid runs straight through this region. However, in 1% of people this artery has an aneurism
or a tortuous internal carotid artery. Cutting this artery can be fatal for the patient so they now check the
path of your internal carotid before surgery.
Lecturer Dr. Suarez
The Medical Note-Taking Service Date October 10, 2007
Lecture Number: 33
NOTICE &DISCLAIMER
Note-Taker: Stephanie Wappel The Medical Note-Taking Service makes every effort to provide accurate
UNCORRECTED class notes. However, errors will occur from time to time. The user
Mouth, Tongue, and Swallowing
Before lecture began, there were 2 brief announcements from Dr. Suarez:
1) The members of the American Association of Anatomists voted not to attend the Bodies exhibit
because the bodies were not donated they were either purchased or acquired for the exhibit.
However, Dr. Suarez recommends that anyone interested and not ethically opposed should check out the
Bodies exhibit before it leaves Rosslyn on October 14 (so by the time you read this noteset, its probably
left Rosslyn, but if you get a chance to see it in another city, I highly recommend it!).
2) In the Gross Anatomy of Vision lecture, Dr. Suarez didnt go into detail about how to test for specific
eye muscle actions. Hes not sure if that information will be tested on the Shelf exam, but he
recommended reviewing Figure 891 and pages 840-842 in Grays Anatomy, which provides a good
description of normal muscle action of the eye.
Now, lets get down to business with the Mouth, Tongue, and Swallowing lecture. This lecture
focused on three areas of the oral cavity: the mouth proper, the tongue, and the mechanism of
swallowing (called deglutition if you want to impress someone with your cool med school vocabulary).
The major components of the mouth are the oral cavity, teeth, gingivae (gums), tongue, palate, and
palatine tonsils. The main functions of the mouth are grasping (for milk as an infant or food in
general), chewing food, preparing food for digestion (action of salivary glands), and phonation
(speaking).
The lips are the first part of the mouth used for grasping food, then the teeth get involved.
Contrary to popular belief, the colored area we refer to as lips are only a part of the lips (think about it
it wouldnt be very efficient to grasp food with that small area). The actual lip starts at the nasolabial
groove where the face ends and mouth begins. The colored area is the skin of the transitional zone,
and it appears pink/red because it lacks pigment. The pink/red coloring we see is the bed of vascular
tissue beneath the thin layer of skin. The area of the lips where pigmented skin begins is called the
Damian: Youre taking 12th grade Calculus?
Cady: Yeah, I like math.
Damian: Eww, why?
Cady: Because its the same in every country.
Damian: Thats beautiful. This girl is deep.
~Mean Girls.
Course GA Lecturer Dr. Suarez
Lecture number 33
Page 2 of 7
vermillion border. The ridge above the upper lip is referred to the philtrum (love charm in Greek),
and this region is where the eyes focus when first looking at a person. Along with facial symmetry, the
philtrum contributes to human perception of physical attractiveness, so a compromised or missing
philtrum may make the face appear abnormal.
x Clinical Correlate: In many patients with Fetal Alcohol Syndrome, the philtrum fails to form or is
not as prominent. Cleft lip is a congenital anomaly that you may remember from Embryology it
occurs in 1/1000 births, more frequently in males, and the degree of severity varies (small or large,
unilateral or bilateral, etc). Usually, the philtrum is still present in cleft lip patients, but it is turned in
instead of out, so to repair cleft lip the surgeon removes the philtrum then places it in the middle of the
lip. (Side note: Operation Smile is an organization through which physicians travel to third world
countries to repair cleft lips).
x Clinical Correlate: Squamous cell carcinoma of the lip is more common in the lower lip because the
skin is very thin and more exposed to the sun. Lymph drainage depends on the exact location of the
tumor on the lower lip on the periphery, lymph drains to the submandibular lymph nodes; in the
median plane of the lip, lymph drains to the submental lymph nodes. The superficial lymph nodes of the
lip/mouth all form a pericervical collar of lymph nodes around the base of the head and neck. The
nodes, listed in Grants Atlas (but we dont really have to know them) are the occipital, mastoid,
parotid, buccal, submental, submandibular, and superficial cervical nodes. If the nodes of this
pericervical collar are inflamed, they can be palpated. These superficial nodes ultimately drain to the
deep cervical lymph nodes, which accompany the internal jugular vein this shows how a surface
tumor on the lip can lead to more serious disease.
Now we move on to the oral cavity, which functions in chewing food, preparing for digestion,
and phonation. There are two components: the vestibule and the oral cavity proper. The vestibule is
the area inside the mouth but outside the teeth. The oral cavity proper is the area of the oral cavity on
the inside of the teeth. The vestibule contains the parotid papilla, through which the parotid gland
delivers saliva into the oral cavity to begin digestion. The opening of the parotid duct into the parotid
papilla is in the vestibule across from the second molar, and in the old days of imaging, this papilla
would be canalized and injected with radio-opaque dye to image the parotid duct.
Lecture number 33
Page 3 of 7
The major bones of the oral cavity are the maxilla (upper jaw) and mandible (lower jaw). The
maxilla curves in and forms a horizontal plate called the palatine process, which makes up the roof of
the mouth. The hard palate consists of this palatine process and another little bone, the horizontal
process of the palatine bone, which contributes to the posterior part of the hard palate. When looking
at the hard palate from below, there are several foramina (holes) of note:
Incisive canal: most anterior; nasopalatine nerve and sphenopalatine artery enter palate
Greater palatine foramen: in the palatine bone; greater palatine nerve enters here
Lesser palatine foramen: in the palatine bone; lesser palatine nerve enters here
y Clinical Correlate: Sometimes the palatine process and the horizontal process of the palatine bone
fail to fuse in the midline, resulting in cleft palate. Because the hard palate separates the nasal cavity
from the oral cavity, milk may travel into the nasal cavity instead of the esophagus in newborns with
cleft palate. This is not fatal, but it makes the process of suckling much less efficient, and cleft palate
also causes issues with phonation. Cleft palate may extend to the palate or just involve the uvula.
The mandible is the bone of the lower jaw. The floor of the lower jaw is made of skin and
muscle (mylohyoid muscle), and this muscle is attached to the mylohyoid groove on the inner posterior
surface of the mandible. Within the oral cavity is a defined space for chewing that includes the teeth.
Adults have 32 teeth 16 on the upper jaw and 16 on the lower jaw. On each side of each jaw are (from
medial to lateral) 2 incisors, 1 canine, 2 premolars, and 3 molars. Teeth are held in place by a
gomphosis joint, which involves a conical process inserted into a socket. Gomphoses provide resiliency
and movement to the joint itself and allow the tooth to be mobile within the joint, thus preventing the
teeth from cracking when we bite something hard.
K Clinical Correlate: Cavities are common teeth problems. It is important for dentists to understand
the nerve supply to the teeth so they can properly anesthetize the region. The superior alveolar nerve, a
branch of the maxillary nerve (V2), serves the upper teeth, while the inferior alveolar nerve, a branch of
the mandibular nerve (V3), serves the lower teeth. It is much easier to anesthetize the lower jaw, by
aiming for the lingula, on the medial surface of the mandible, which protects the mandibular foramen.
The inferior alveolar nerve enters the lower jaw through this foramen and proceeds from proximal to
distal, exiting through the mental foramen as the mental nerve. Therefore, when a dentist anesthetizes
Lecture number 33
Page 4 of 7
the inferior alveolar nerve on one side, the entire ipsolateral side of the lower jaw becomes numb. This
explains why the skin of the lower lip is also numb when you get a cavity filled on your lower jaw.
Anesthetizing the teeth of the upper jaw is more complicated, because there are more nerves to
consider, including the nasopalatine nerve and greater palatine nerve. By anesthetizing the area of the
nasopalatine foramen (nasopalatine nerve), one can block sensation to the six anterior maxillary teeth
only, and only on the oral cavity side of the teeth. To anesthetize the molars and/or premolars, one must
block the region of the greater palatine foramen to block sensation to all teeth on one side of the upper
jaw. This still only blocks the oral cavity side, so the dentist must also anesthetize the vestibular side of
the affected tooth. The mucosa is more closely connected to the maxillary teeth than to the mandibular
teeth, so it is generally more painful to fill cavities on the upper jaw than on the lower jaw. Fortunately
(in a pain sense), cavities are more common on the lower jaw (easier to anesthetize and less painful).
Floss, anyone?
(Please take a moment of silence to remember Georgetown School of Dentistry, which closed in 1990.)
Now we move on the blood supply of the oral cavity. Most of the blood supply is from the
external carotid artery. The external carotid terminates as the maxillary artery, which turns and enters
the oral cavity from behind. Other branches are the lingual artery (to the tongue) and the facial artery (to
the face). The maxillary artery travels behind the ramus of the mandible, and we are only responsible
for knowing one branch the middle meningeal artery. The maxillary artery also sends branches into
the oral cavity, but we shouldnt have to know those for the Shelf exam. These branches traverse the
roof of the nasal cavity then travel down the naval septum to exit the incisive foramen, so the maxillary
artery supplies the blood to the roof of the mouth. The greater and lesser palatine arteries travel with
their respective nerves and serve the hard and soft palate. Therefore to stop bleeding in the mouth, you
just have to control the maxillary artery on that side, and you can control bleeding in the hard palate.
The veins of the oral cavity follow the arteries, as usual, so they were not discussed in this lecture.
Now we get to the fun part the tongue. The tongue is a mobile muscular organ that is located
partially in the oral cavity and partially in the pharynx. Its functions include oral cleansing, mastication,
articulation, deglutition, and also French osculation (try that phrase if youre looking for a new pick-
up line). The tongue is separated anatomically into the anterior 2/3 (body) and the posterior 1/3 (root).
The apex is the tip of the tongue. On the root of the tongue is a ridge with bumps (lingual tonsils)
Lecture number 33
Page 5 of 7
bounded by the foramen cecum (blind foramen), a remnant of the thyroglossal duct. The tongue is an
incredible sense organ with many papillae that are named by their shape. Near the root of the tongue
are the vallate papillae (look like little valleys) that function in taste and serous secretion. Laterally, the
foliate papillae resemble sheets/leaves of paper and function in taste and touch, while the fungiform
papillae resemble little mushrooms and also function in taste. The filiform papillae on the surface of
the tongue function in touch. All the papillae except the filiform contain taste buds on their surface, and
the papillae in general increase the surface area of the tongue to receive more information to monitor the
environment. It is important to note that the lingual tonsils at the back of the tongue should not be
confused with the palatine tonsils removed during a tonsillectomy.
It is not possible to swallow ones tongue because the tongue has many bony and cartilaginous
attachments. The root of the tongue is attached to the epiglottis by one medial and two lateral epiglottic
folds, and various muscles attach the tongue to the hyoid bone, styloid process, mandible, and palate.
K Clinical Correlate: Although it is not possible to swallow ones tongue, if a person falls after
passing out, the tongue may drop backwards and cover the opening of the air passage, and the
unconscious person may suffocate. To open the airway, tilt the head of the unconscious person so air
can get into the upper respiratory tract. During general anesthesia, the tongue relaxes and the same
blocked airway could result this is why intubation is required for procedures using general anesthesia.
The sublingual glands and the submandibular duct are just inferior to the tongue, and they
contribute saliva to help prepare food for digestion. There is also a plexus of veins (deep lingual veins)
inferior to the tongue that can quickly absorb drugs.
< Clinical Correlate: A patient suffering acute angina can place a nitroglycerin tablet underneath the
tongue, where it will be rapidly absorbed into the bloodstream by the plexus of deep lingual veins.
The tongue is a muscle with several extrinsic and intrinsic muscles. The intrinsic muscles alter
the shape of the tongue (such as curling the tongue, a genetic trait). Their names are listed on the
powerpoint for this lecture, but we dont have to know them. The extrinsic muscles allow the tongue to
move, and we are responsible for these muscles and their innervation. The genioglossus protrudes the
Lecture number 33
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tongue forward and attaches the tongue to the bend of the mandible. The hyoglossus attaches the tongue
to the hyoid bone and depresses the tongue. The styloglossus attaches the tongue to the styloid process
and elevates the tongue. The palatoglossus muscle attaches the tongue to the palate and helps elevate
the tongue. The motor innervation of the tongue is quite simple: all extrinsic tongue muscles except the
palatoglossus are innervated by the hypoglossal nerve. The palatoglossus muscle is innervated by the
vagus nerve (CN X), specifically the pharyngeal plexus from CN X. Remember this one exception,
and you know the motor innervation of the tongue.
In regards to sensory innervation, we must consider general sensation and special sensation
(taste). For the anterior 2/3 of the tongue, general sensation is by the lingual nerve from CN V, while
taste is by the chorda tympani from the facial nerve (CN VII). For the posterior 1/3 of the tongue,
general sensation and taste is by the glossopharyngeal nerve (CN IX). The internal laryngeal nerve
from CN X also provides some general sensation and taste to the very posterior part of the tongue and
the epiglottis. Therefore, the gag reflex, stimulated by touching the posterior 1/3 of the tongue, is
controlled by cranial nerves IX and X.
If there is damage to CN XII (hypoglossal), which protrudes the tongue, the protruded tongue
will deviate to the damaged/paralyzed side because the genioglossus muscle wont work on the
damaged side so there is no opposition from the other side when the tongue is protruded. So, to test for
CN XII damage, simply have the patient stick their tongue out.
] Clinical Correlate: In addition to lung cancer, smoking can also cause cancer of the tongue.
Tongue cancer is more insidious the more proximal it is to the root of the tongue. The proximal
(posterior) part of the tongue drains to deep cervical lymph nodes, so one might not be aware of a
primary tumor. If the tumor is more anterior, it can be sensed and will probably be caught earlier. Late
in the disease, an anterior tumor may metastasize to submandibular or submental lymph nodes.
The lecture concluded with a discussion of the mechanism of deglutition (swallowing). We

leave the oral cavity and enter the oropharynx. The soft palate (uvula) hangs on the back of the throat
and is made of 2 muscles: the tensor veli palatini and the levator veli palatini. The levator veli palatini
raises the uvula and the tensor veli palatini tenses the uvula, allowing the uvula to cover the nasal cavity
opening from behind so swallowed food enters the esophagus instead of the nose. If youve ever made
someone laugh while drinking milk, so that milk came out the persons nose, the uvula was not properly
Lecture number 33
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covering the posterior aspect of the nasal cavity so milk was projected upward to exit through the
nostrils. The uvula itself is not sufficient to cover this region, so the muscles of the pharynx help. These
muscles the superior, middle, and inferior pharyngeal constrictors fit one inside the other like nesting
pots to make up the muscular pharynx. When these muscles contract, they narrow the oropharynx and
nasopharynx. The stylopharyngeus muscle, which runs from the styloid process to the pharynx, helps to
raise the pharynx during swallowing. (If you put you hand on your throat and swallow, you will feel
your throat lift at first this is the stylopharyngeus at work.)
While the uvula blocks the nasopharynx during swallowing, the epiglottis blocks the opening of
the upper respiratory tract so swallowed food does not go down the trachea. When you swallow, the
palatoglossus and palatopharyngeus muscles contract and raise the pharynx upwards against the
epiglottis, and this closes the opening of the upper respiratory tract.
Heres how swallowing occurs: A bolus of food between the tongue and the hard palate has
been prepared for digestion by the teeth, tongue, and salivary glands. The tongue forces this bolus
backward into the oropharynx, and the styloglossus begins to elevate the pharynx. The pharyngeal
constrictors narrow the oropharynx, then the tenor and levator veli palatine muscles seal off the nasal
cavity. The salpingopharyngeus (not described in detail in lecture) and stylopharyngeus muscles elevate
the laryngopharynx, and the larynx closes. The swallowed food then enters the esophagus.
The nerves of the pharynx were not described in detail in lecture, but I will name them here for
you: The motor supply of the pharynx is by the pharyngeal plexus, formed by the vagus and
glossopharyngeal nerves. The vagus nerve supplies all the nerves of the pharynx except the
stylopharyngeus (CN IX) and the tensor veli palatini (V3). The inferior constrictors of the pharynx may
be innervated by the external laryngeal nerve (a branch of the vagus nerve). Sensory nerve supply to the
nasopharynx is mostly by the maxillary nerve, while the oropharynx is supplied by the glossopharyngeal
nerve (remember the gag reflex). The sensory nerve supply to the laryngopharynx is mainly by the
internal laryngeal nerve (from the vagus).
If the pharyngeal plexus (CN X) is damaged, the uvula will deviate away from the afflicted
side due to the unopposed action of the levator veli palatini. This is opposite to a damaged hypoglossal
nerve, when the protruded tongue deviates to the afflicted side. Thus, to check for damage to the
pharyngeal plexus, look for a deviated uvula.
Useless Trivia: The sixth sick sheiks sixth sick sheep
is allegedly the most difficult tongue twister in the English language.
The Medical Note-Taking Service Lecturer Dr. Suarez-Quian

Date 10/12/07
Lecture Number: 34
NOTICE &DISCLAIMER
Note-Taker: Nicole Van Buren The Medical Note-Tak ing Serv ice makes every effort to prov ide accurate
Corrected by: class notes . However, errors will occur from time to time. The us er
Lecture Title: Nasal Cavity, Sinuses, and Larynx
Nasal Cavity:
Functions:
1. Respiration- breathing
2. Olfaction- smell/enjoy food, mediated by CN1 via ethmoidal nerve
3. Filtration- filter particles/bugs from air
4. Hydration- hydrates and warms the air, (cold air would be painful to breathe in)
5. Excretion- produces fluid (1 and a quarter quart of mucous/day!) that enters nasal cavity
External Nose
Surface anatomy:
Bridge- the root of the nose
Dorsum- from the root to the tip of the nose medially
Ala- wings, forms the edges of the nostrils
Nostrils- openings of the nasal cavity that cant close completely (unlike the eyes and mouth)
Bones:
2 Nasal Bones- what you are feeling at the bridge, they are paired and meet each other at the midline,
they meet the frontal bone at the nasion
Frontal Process of Maxilla bony perimeter, the lateral portion of the nasal bones articulate with the
frontal process of each maxilla
Anterior Nasal Spine of Maxilla- bony perimeter, inferior portion at the midline
Cartilages: the size/shape of the external nose is dependent upon cartilage

1 Septal Cartilage- extends in midline and anterior to nasal bones, many people have deviated septums
2 Lateral Nasal Cartilages- lateral to the septal cartilage and connects the septal cartilage to the maxilla
2 Greater Alar Cartilagse covers alar portion, gives rise to part of nostril
Date 10/12/07
Lecture number 34
Page 2 of 9
Alar fibrofatty tissue- NOT cartilage, it connects the greater alar cartilages to maxilla, may contain
erectile tissue that allows some people to move their nose!
Anatomy of Nasal Cavity Proper

1. Vestibule- dilated region adjacent to nostril; where you are when you are picking your
nose, filled with hair to filter large particles that we breathe in on a regular basis
2. Olfactory- roof of nasal cavity narrow, inferior to cribiform plate, CN1 migrates here,
it is the only area of nasal cavity capable of smell, lined by olfactory epithelium
and mucosa.
3. Respiratory- most of nasal cavity, lined by glandular, vascular mucosa that warms inspired
air and fights pathogens and by respiratory epithelium with cilia geared for moving
mucous down from the nasopharynx oropharynx swallowed digested and
broken down
Date 10/12/07
Lecture number 34
Page 3 of 9
Walls of Nasal Cavity
Medial Wall:
2 bones posteriorly: Perpendicular Plate of Ethmoid- superior, means sieve, Dr. Suarez said
the olfactory bulb percolates through the tiny holes in the cribriform plate
of the ehmoid bone
Vomer- inferior, means plough
1 cartilage anteriorly: Septal Cartilage
*If these three structures dont come together perfectly during development deviated septum
Lateral Wall:
Made mostly of mucosa and looks like little shelves that are called the superior, middle, and
inferior conchae; the spaces inferior and lateral to the conchae are the meatuses of the lateral
wall, if you were to remove the mucosa, you would see the bones of the lateral wall, called
turbinate bones. Turbinate and concha mean the same thing.
Nerves of Nasal Cavity

1. Olfactory Nerve (CN1)- NOT a single nerve! It is made up of axons from receptors in the
olfactory epithelium. Bundles of these axons pass superiorly through the cribriform plate
of the ethmoid bone to synapse with neurons in the olfactory bulb of the brain.
2. Anterior Ethmoidal Nerve Its function provides general sensory to nose (i.e. how you can
sense that you just got punched in the nose), it is a branch from the nasociliary nerve in
the orbit, which is a branch off the ophthalmic nerve (V1)
3. Maxillary Nerve (V2) Branches-
Nasopalatine Nerve- travels from pterygopalatine ganglion through sphenopalatine foramen
and then through the incisive canal where it provides general sensory to the anterior hard
palate and gums behind the incisor teeth.
Posterior Nasal Branches of Maxillary- they are general sensory nerves that supply the
superiolateral, superiomedial, and inferior conchae. The superior branches branch directly
off the maxillary, while the inferior branch comes off the greater palatine nerve of the
maxillary.
Date 10/12/07
Lecture number 34
Page 4 of 9
Autonomic innervation:
Preganglionic parasympathetic fibers carried in the greater petrosal branch of the facial
nerve (CN VII) synapse in the pterygopalatine ganglion that hangs off the maxillary
division (V2), deals with secretomotor innervation of glands in nasal cavity mucosa.
Postganglionic sympathetic fibers piggy back onto the internal carotid artery and then
join the deep petrosal nerve, which then joins the greater petrosal nerve and enters the
pterygopalatine ganglion; involved in regulating blood flow in the nasal mucosa.
*The nerves leaving the pterygopalatine ganglion (nasopalatine and greater and lesser palatine nerve)
are the nerves responsible for transmitting hay fever symptoms
Blood Supply to Nasal Cavity
Blood supply to the nasal cavities comes from either the internal or external carotid where their
branches mingle and anastomose within the nasal cavities.
Sphenopalatine Artery -comes off the maxillary artery from the ext. carotid and travels
through the sphenopalatine foramen with the nasopalatine nerve
Anterior Ethmoidal Artery a branch off the ophthalmic artery from the int carotid, travels
with ant. ethmoidal nerve.
Branches of Facial Artery off the external carotid supply the vestibule and are responsible
for a trivial nose bleed (epistaxis)
Date 10/12/07
Lecture number 34
Page 5 of 9
Veins follow same course as arteries

Lymphatics: drainage from vestibule goes to submandibular nodes and the remainder drains to
deep cervical nodes
*With a broken nose, a lateral blow will most likely result in epistaxis and deformity of the nose but
can be reset. With a direct blow the nasal bone can be driven into the ethmoid bone, fracturing the
cribriform plate and severing the olfactory bulb from the olfactory nerve. This opens up the
possibility of meningitis, anosmia (loss of smell), and/or rhinorrha (CSF dripping out of nose from
subarachnoid space).
Paranasal Sinuses
Not to be confused with the dural/venous sinuses inside skull. When you look up into the nostril
(this is called a lateral view not an inferior view like you would think) the middle concha can be
seen more medially and the inferior concha can be observed more laterally.
Functions:
1. Lighten the cranial bones (without them we wouldnt be able to hold up our heads)
2. Aid in phonation
3. Provide an air jacket around the nasal cavity to insulate the nasal passage
Date 10/12/07
Lecture number 34
Page 6 of 9
Frontal Sinus drains to the middle meatus

Ethmoidal Sinuses:
Anterior Ethmoidal Sinus -drains to the semilunar hiatus
Middle Ethmoidal Sinus -drains to the bulla
Posterior Ethmoidal Sinus -drains to the superior nasal meatus
Sphenoid Sinus can only be seen from a sagittal view posterior to the ethmoid; it drains to the
sphenoethmoidal recess
Maxillary Sinus is the largest and most easily identifiable (it can hold 30ccs or an oz of fluid!); it is
inferior to the orbit and superior to the teeth and drains into the posterior semilunar hiatus when you
lie in the supine position (initiating the cough reflex when you are sick). Maxillary sinuses dont
drain when you are standing up because their opening for drainage is placed above them, not below.
*When sinuses dont drain properly they have a tendency to become clogged and a trocar must be
used to drain them
* Extraction of the upper molar may create a fistula between the maxillary sinus and the oral cavity
* As you get older, your sinuses continue to grow larger and larger, which is why old people have to
clear their throat a lot.
Larynx
Functions:
1. Open valve during respiration
2. Partially closed valve during phonation
3. Acts as a sphincter during swallowing (deglutition) or we will choke
Anatomical Orientation and Other Facts:
Connects the lower part of the pharynx (laryngopharnynx, root of tongue) to the trachea
Esophagus is posterior to larynx (remember this for intubation!)
Lateral to the larynx are the two carotid sheaths
Anteriorly, the larynx is covered by strap muscles, fascia, and skin
Size is a function of age, and for boys undergoing puberty, androgens cause the larynx to grow
Date 10/12/07
Lecture number 34
Page 7 of 9
Skeleton (Cartilages): Cartilages move and produce sound
Anteriorly:
Epiglottis- beginning of the larynx
Triticeal Cartilages- he didnt really go into these much
Thyroid Cartilages- looks like a shield
Cricoid Cartilages- looks like a signet ring, there is a narrow and wide part
Posteriorly:
Corniculate Cartilages- looks like little horns
Arytnoid cartilages: looks like inverted cups
Muscles:
The hyoid bone is involved with movement of the larynx but is not part of it. The hyoid bone is
attached to the thyroid cartilages via the thyrohyoid membrane. Anything that moves any attachment
to the hyoid bone will move the larynx.
Hyoid to mandible: Hyoid to strap muscles: Hyoid to Styloid Process: Hyoid to Pharynx:
Hyoglossus Omohyoid Stylohyoid Middle Constrictor
Mylohyoid Sternothyroid Stylohyoid ligament
Geniohyoid Thyrohyoid
Digastric
Date 10/12/07
Lecture number 34
Page 8 of 9
Membranes of Larynx:
Thyrohyoid- attaches the thyroid to hyoid

Triangular (Cricothyroid)- free upper edge contributes to the true vocal chords
o Crichothyroidectomy- an emergency opening to place an air tube; damage may result
to the external laryngeal nerve because it is immediately deep to the superior thyroid
artery; the recurrent laryngeal may also be damaged because its position is not
constant
Quadrangular-free lower border that contributes to the false vocal chords
Spaces of Larynx:
Vestibule- superior to and behind the epiglottis

Sinus- horizontal space between false and true vocal chords
Rima Glottides: vertical separation between the true vocal chords, where they come together to
produce sound
Nerves of Larynx:
All are branches of the Superior Laryngeal off the Vagus Nerve (CNX)
* If a plaque develops in the internal carotid (atherosclerosis) and you have to go and remove it, be
careful not to injure the nerves of the larynx
Internal Laryngeal (sensory)

External Laryngeal (motor),
o if cut, phonation will be weak because cricothyroid will not be able to tighten the
vocal cords
Recurrent Laryngeal (both)
o if only one recurrent is damaged and the vocal cords are intact, compensation will
occur
o if both recurrents are damaged then the voice will be lost and breathing is difficult
Sensory: above vocal fold- internal laryngeal

below vocal fold- recurrent laryngeal
Date 10/12/07
Lecture number 34
Page 9 of 9
Motor: external laryngeal moves cricothyroid

all other muscles moved by recurrent laryngeal
Muscles of Larynx:
see syllabus for figures
Cricothyroid- stretches from surface of cricoid to inf. border and horn of thyroid cartilage, it
lengthens/tightens the vocal chords
*Posterior cricoarytenoid- arises from posterior lamina of cricoid and insterts into muscular
processes of arytenoids cartilages, it abducts the vocal folds/open them up, only one that can do this
and its action is imperative to life!
Lateral cricoarytenoid- extends from the superior border of the cricoid and cricothyroid ligaments
to the muscular process of the arytenoids cartilage, it adducts the vocal chords/closes them
Thyroarytenoid and Vocalis- is superior to the lateral cricoarytenoid, it passes from the thyroid
cartilage to the arytenoid cartilage, the superior medial fibers are the vocalis and they shorten the
vocal chords
Transverse arytenoids- unites the two arytenoids cartilages, it adducts the vocal chords
*Frequency or pitch of the voice is determined by changes in the length and tension of the vocal
ligament
*Quality of the voice depends on the resonators above the larynx like the pharynx, mouth and
paranasal sinuses
Lecturer: Dr Schellinger
The Medical Note-Taking Service Date: Oct 15, 2007
Lecture Number: 35
SMP Class of 2008 Page 1 of 7
NOTICE &DISCLAIMER
Note-Taker: Alisha Cutler The Medical Note-Taking Service makes every effort to provide accurate
Corrected by: Dr Schellinger class notes. However, errors will occur from time to time. The user
Gross Anatomy Lecture 35: AGR - Radiology of the Head and Neck
I Introduction
Dr Schellinger, a neuroradiologist at Georgetown University Hospital gave todays lecture. He began
the lecture by noting that most of the images are now digital (MRIs, CT scans, etc) as opposed to analog
(i.e. X-rays). Analog images put all structures in a 2D plane, making visualization of complex structures
such as the head difficult. This was a complex lecture and being so visual based, it is difficult to relay in
written form. Therefore, I will organize this lecture based on topic, demonstrating a few of the
malformations.
II. Orbit
Image 1: This image shows a normal CT scan of

the orbit. Dr Schellinger noted the lateral and medial
rectus muscles, nasal septum, frontal bone, optic
nerve, and inter-muscular space.
When examining a film for abnormalities, look for

symmetry and regularity. An important note when
assessing a tumor, examine the borders carefully.
Clear boarders indicate a benign tumor while fuzzy
boarders can signal a malignant tumor.
Each of the following images depict different abnormalities of the orbit.
Image 3: Damage to the soft tissue only. Notice lack of

symmetry. There is no damage to the bony structures, however.
Never take life too seriously, no one gets out alive anyways.
Course: Gross Anatomy Lecturer: Dr Schellinger
Date: Oct 15, 2007
Lecture number 19
Page 2 of 7
Image 4: Notice the mass in the right orbit. It is most

likely benign as the borders are clear.
Image 5: Disarticulated lens in

the left eye. No damage to the
bony structures.
Image 6: Infection of the ethmoid sinus. Inflammatory disease has

accumulated, causing cellulitis. The arrow in the image points to the lamina
papyracea. This wall of the nasal cavity is particularly thin and infection
can easily pass from the ethmoid sinus into the orbit.
Image 7: Example of exopthalmus with enlarged

lateral and medial rectus muscles. By drawing a line
between the two zygomatic arches, one can observe
that the globes extend beyond this line, and thus,
exopthalmus. This is due to Graves Disease, a
disease characterized by hyperthyroidism.
III Sinuses
Just as a reminder, there are four sinuses of significance in the head. They are: ethmoidal, frontal ,
sphenoid, and the maxillary sinuses. When reviewing a film of these, a healthy sinus will appear clear
and aerated. Fluid accumulation indicates an infection. Also, examine the boarders of the sinuses to
ensure there is no damage to the bone that encloses the sinus.
Date: Oct 15, 2007
Lecture number 19
Page 3 of 7
Image 8 Image 9 Image 10

Image 8 is the most superior CT scan, depicting a frontal sinus. The frontal sinus can vary in size.
Image 9 shows the ethmoid and sphenoid sinuses. The ethmoid sinus is on either side of the septum
and the number of air cells can vary. The sphenoid sinus is posterior to the ethmoid sinus. Image 10
shows the maxillary sinuses, notice how they are triangular shaped. Medial to the maxillary sinus is the
nasal cavity that is composed of the concha and nasal septum. The nasopharyx is the area just
posterior to the nasal cavity.
Image 7: Off center bony septum of the sphenoid sinus. This

is of particular importance to surgeons. During surgery on a
pituitary gland, a surgeon can use the nasal septum as a guide to
the pituitary gland because the nasal septum is in the median, in
most people. However, prior to surgery, a CT scan should be done
confirming the location. A deviated septum, therefore should not
be used as a landmark / guide to the pituitary gland.
Image 8: Coronal image showing fluid accumulation in the

maxillary sinus. The maxillary should be triangularly
shaped on films. However, in the event of trauma, fluid (i.e.
blood) can accumulate. Note the fractured floor of the left
orbit.
Image 9: Fracture of the left orbital floor. Fluid in both

ethmoid sinuses and in left maxillary sinus.
Date: Oct 15, 2007
Lecture number 19
Page 4 of 7
IV Facial Bones / Orbit

Just as a reminder, the orbit is a four sided pyramid made up of the
following bones: frontal, zygomatic, ethmoid, lesser wing of sphenoid,
greater wing of sphenoid, maxillary, orbital process of palatine and
lacrimal. Trauma to the orbit can cause multiple fractures. The two
bones that are most easily fractured are the lamina papyrecea and floor
of orbit (as exhibited in Image 8).
Trauma to the orbit can involve fractures of multiple bones, as in image

10, a coronal image, where we see that the frontal bone, zygomatic bone,
the floor of the orbit and the lateral wall of the left maxillary sinus are all
fractured. We also see that there is mucosal swelling of the left maxillary
Image 10 sinus. This image also shows the nasal turbinates. They are the swirl
like structures observed on either side of the nasal septum.
V Base of Skull
There are many foramina at the base of the skull
that serve as entry and exit points for the cranial
nerves. These are best imaged on CT scans which
show good bone density. On the image below
(image 11), you should be able to locate the
foramen ovale, foramen spinosum, jugular
foramen, and carotid canal. I have tried to
demarcate them to assist you. Note how aerated the
mastoid process is. You can also see the nasal
septum, head of the mandible (TMJ joint) and nasal
aperture here.
Foramen Ovale
Formaen Spinosum
Carotid Canal
Jugular foramen
Mastoid process
Image 11
Date: Oct 15, 2007
Lecture number 19
Page 5 of 7
V Floor of the Mouth

The floor of the mouth was also discussed. Although it is difficult to distinguish, the genioglossus and
myelohyoid, are all depicted in this image. The more obvious structure is the mandible and the bifid
spinous process of axis.
Image 12 Image 13
VI Submandibular Gland
The submandibular gland is important for the production of saliva and is located inferior to the floor of
the mouth. The submandibular glands are well seen on figures 14 and 15. Can you find the abnormality
in image 16? This is a calculus in the duct of the right submandibular gland.
Image 14 (CT) Image 15 (MRI) Image 16

Date: Oct 15, 2007
Lecture number 19
Page 6 of 7
VII Lymph Nodes

Images 17 through 19 are images of the upper neck, in different patients. Image 17 shows normal
structures while images 18 and 19 show abnormally sized lymph nodes. In image 17, you can see the
radio opaque mandible and the floor of the mouth. No abnormal lymph nodes are seen. This is also a
good image of the first cervical vertebrae. You can also visualize the vertebral arteries in the
transverse foramen of the cervical vertebrae, oropharynx, and sternocleidomastoid muscles. In image
18 you can see part of the epiglottis and glossoepiglottic fold. This is a common site where cancer can
develop. In image 19 you can see the appearance of the hyoid bone. The many nodular structures
represent oversized lymph nodes. Medial to the sternocleidomastoid muscle are the internal carotid
arteries and jugular veins.
VIII Cervical Spine

The first two cervical vertebrae are Atlas (C1) and Axis (C2). They are articulating with each other,
with the dens of Axis inserting into Atlas.
Images 20 and 21 show the relationship

between the atlas and axis on coronal
views. In image 21, notice how the dens
is fractured.
Image 20 Image 21
Date: Oct 15, 2007
Lecture number 19
Page 7 of 7
Image 22 is an example of a Jefferson

Fracture of C1 and image 23 is an
example of a Hangman Fracture, of C2.
Image 22 Image 23
IX Vascular Anatomy
When examining images of vascular anatomy, follow the vessel from its root to its most superior
location, checking both sides for symmetry to ensure there are not occlusions. In image 24, you should
appreciate how the common carotids branch into the internal and external carotids. Also, you can
observe how the vertebral arteries snake their way up to the skull.
Image 25 depicts the venous sinuses. You should be able to identify the sagittal sinus, the transverse
sinus and the sigmoid sinus. Notice how the sigmoid sinus disappears as it enters the jugular foramen.
In image 26, can you identify the external carotid artery with its many branches, including the middle
meningeal artery and the temporal artery. Remember the superficial temporal artery is contained
within the scalp and can meander in a serpingenous route while the middle meningeal artery is
intracranial, contained within bony canals. Its course is more linear. It enters the cranial cavity through
the foramen spinosum.
Lecturer: Dr. Earl H. Harley
Lecture Number: 37
NOTICE &DISCLAIMER
Note-Taker: Lindsay Ambrecht The Medical Note-Taking Service makes every effort to provide accurate
Corrected by: uncorrected class notes. However, errors will occur from time to time. The user
Clinical Anatomy of the Ear

Just a reminder Dr. Suarez confirmed that we are not responsible for the dissection of the ear in the
lab, but we are responsible for the clinical anatomy that is presented in this lecture. This is possible
Shelf-exam material.
Dr. Harley is a pediatric ENT at Georgetown University Hospital. The powerpoint is up on blackboard
as a PDF.
Objectives:
By the end of his lecture, Dr. Harley addressed the answers to the following questions:
1. What are the 3 bones in the ear?
2. How many muscles are in the ear?
3. What is their nervous supply?
4. How does an ear infection lead to facial paralysis?
5. Anatomic explanation for frequency of ear infections in children.
6. What is the anatomic explanation for ear pain in patients with certain types of throat cancer?
7. Why are q-tips not advised for cleaning cerumen from the ear canal?
8. How do ear infections lead to mastoiditis?
9. How does adenoidectomy help reduce ear infections?
10. What is the importance of the Fissures of Santorini?
I will highlight the answers to these objectives throughout the notes.
The main functions of the ear are hearing and balance. The ear is often a showcase for beauty
and fashion. All structures of the ear are housed in the temporal bone which is made up of several
segments squamosa, mastoid, tympanic, petrous, zygomatic, and styloid. The temporal bone is located
on the postero-lateral region of the skull. The stylomastoid region is an important surgical area to be
considered when operating on the ear (remember this is where the facial nerve is exiting the skull.)
Course Lecturer
Date
Lecture number
Page 2 of 6
The ear can be divided into external, middle, and inner divisions. The external ear collects
sounds into acoustic energy. The ear drum in the middle ear then vibrates, transmitting the sound via the
ossicles (acoustic energy becomes mechanical energy.) The hair cells in the cochlear division or the
pars superior (inner ear) are then stimulated. The nerve endings send signal to the brain stem
(mechanical energy becomes electrical energy.) The vestibular division or the pars inferior (also inner
ear) deals with balance, linear acceleration, and angular acceleration.
External Ear
The external ear is 80% skin and cartilage. The lobule is
comprised of fatty tissue. The external ear includes the helix
(curved rim of auricle), antihelix (internal to helix, divides the
aurcial), crus, tragus (the small anterior flap), antitragus, lobule,
and external auditory meatus.
The skin of the ear canal continues into the auricle and is about 2.5
cm in adults. It is made of cartilage (1/3) and bone (2/3) no
subcutaneous tissue. Perichondrium lies right under the canal.
This is relevant to swimmers ear in which the inflammation can
swell into the canal (a sensitive area), and there is really no place
for the infection to go. Cerumen is produced from sebaceous gland
in outer 1/3 of ear canal. These are apocrine sweat glands. The
types of cerumen is genetically determined. Wet (dominant) is
produced by African-Americans and Caucasians, while dry
(meaning lower lipid content) (recessive) is produced in Asians
and Native Americans. Its job is to lubricate, clean (through the
natural migration of epithelial cells which exfoliates), and protect
(antibacterial).
Clinical Correlate (CC): Objective 7: This is why doctors advise not to clean your ears with
Q-tips you are removing the protective layer of lipids and lysosomes, pushing the migrating cells back
in (opposite from the way they were migrating.) The pH in the ear canal is 6.1. The isthmus is the
narrow point, the junction of cartilage and bone. It is sensitive around the bony part, and the tip of the
otoscope should be wedged so not to hit the bony part. The canal is also S-shaped, not a straight shot.
The spectrum can be put in so that it does not cause pain.
Course Lecturer
Date
Lecture number
Page 3 of 6
The arterial supply of the external ear is mostly from the external carotid artery (posterior
auricular, deep auricular, and auricular branch of the superficial temporal.) Venous drainage is through
the external jugular, the maxillary vein, and the pterygoid venous plexus. Nerves of the external ear
canal include CN V (V3, the auricular branch of the auriculotemporal nerve), VII (branches of the
tympanic plexus) and X (auricular branch.)
CC: Objective 10: External Ear infections included cellulites which can spread through the
fissures of Santorini (openings in the anterior wall).
CC: Ear keloids may also exist.
Tympanic Membrane
The ear drum is oblique in shape, translucent, and it should reflect light. The bones of the
middle ear are visible, looking through the tympanic membrane. You can see where the malleus
attaches to the drum at the umbo, creating the concavity of the ear drum. You can also see the incus
through the membrane. The facial nerve and the chorda tympani (branch of VII) are also traveling along
the membrane. The pars tensa (made of an outer skin layer, middle fibrous layer, and inner mucosa
layer) region of the ear drum is located inferiorly, and it resists contraction. The pars flaccida (made of
only outer skin and inner mucosa layers) is located near the head of the incus, and is a flaccid region that
moves.
CC: Acute and chronic ear disease may spread easily here. A bulging ear drum loses its
concavity. The middle ear should only have air in it, and if fluid is present, the ear drum will have a dull
appearance. If the drum is not moving as briskly as it should be, this will indicate fluid build-up.
Objective 1: Right beyond the membrane, you can

see the three middle ear bones including the malleus, the
incus, and the stapes. The stapes has a head, a neck, an
anterior and posterior crus, and a footplate. The footplate
sits in the oval window which transmits the sonic vibrations
of the ossicles into the perilymph of the inner ear. The
handle of the malleus serves as the attachment for the
tensor tympani muscle. The lenticular process of the incus
communicates with the stapes.
Course Lecturer
Date
Lecture number
Page 4 of 6
Ossicular articulation: The body of the incus fits into the malleus. The long process of the incus and the
malleus are parallel to each other. A right angle is created where the incus and the stapes meet (different
from the powerpoint sketch.) The joints are synovial. The stapes is like plunger, and it will stimulate
hair cells that convert the acoustic energy to electrical energy.
CC: Tympanic membrane perforation may occur with trauma (Q-tip or water impact) or
chronic ear infections. It may heal on its own, but it usually will not in the cases of chronic ear
infections, repeated ruptures, or tuberculosis.
Blood supply to the tympanic membrane is similar to the external ear. Nerve supply to the ear
drum also includes the chorda tympani, facial nerve, and the tympanic plexus (from branches of CN IX
and VII.) CN VII provides motor innervation for the stapedius muscle. V3 innervates the other muscle
of the ear the tensor tympani. (objectives 2 and 3)
CC: Objective 6: Throat cancer may cause chronic ear pain because of CN IX innervation to
both areas.
Inner Ear
The pars superior is the bony labyrinth of the inner ear. The membranous labyrinth follows the
bony labyrinth, and it is comprised of communicating sacs and ducts the utricle, the saccule, 3 semi-
circular canals, and the cochlear duct. The membranous labyrinth contains endolymph. The utricle and
the saccule function with balance. The semi-circular canals (superior, posterior, and lateral at 45 degree
angles to each other) also control balance and sense angular acceleration. The pars inferior (responsible
for hearing) includes the cochlea which is the medial wall of the tympanic cavity (the lateral wall in the
tympanic membrane.) The cochlea turns 2.5 times. High frequencies are detected at the base of the
cochlea. Children with hearing loss may not have these turns. The two windows of the ear include the
scala vestibule or oval window and the scala tympani or round window (contains perilymph similar to
CSF.)
CC: The superior wall of the tympanic cavity includes the tegmun which separates the ear
from the middle cranial fossa. A thin bone exists here, and infection can spread into brain.
CC: The floor is the jugular wall which separates the ear from the jugular vein. There is a
thin bone here that can be missing may give rise to complications during surgery if the surgeon goes
through the jugular vein. The jugular wall may also be dehiscent, and it may protrude through the
tympanic cavity.
Course Lecturer
Date
Lecture number
Page 5 of 6
CC: The internal auditory canal is located at the

cerebello-pontine angle. CN VII and VIII run through here as a
bundle. Objective 4: The facial nerve tympanic segment (the
horizontal portion) is usually covered by a bone in this area, and if
the bone is missing, facial paralysis may occur with an ear
infection. A tumor in the cranial cavity may impinge on these
nerves causing hearing loss or vertigo. When removing a tumor
from the parotid gland, all of the branches of the facial nerve (VII)
should be located so as not to cause paralysis to the facial muscles.
The Eustachian Tube

This connects the ear to the pharynx, and it equalizes pressure. It is made of more cartilage then
bone which is opposite from the ear canal. It is about 3.5-4 cm long, and it is closed at rest. The tensor
palatine muscle opens the tube. The action of swallowing will open it as well.
CC: Objective 5: Eustachian tube dysfunction A child has short and horizontal ET will not
drain middle ear fluid as well an adults ET which is longer and has about a 45 degree angle. The ET
grows along with face which grows downward. This is why children grow out of ear infections.
CC: Objective 9: Adenoids (during allergies or infections) can grow down and cover the ear
tubes. Fluid can build up, and symptoms include congestion, snoring, mouth-breathing, and hearing and
speech complications. The adenoids can be removed to relieve these symptoms.
The Mastoid Portion of the Temporal Bone

The mastoid is a honey comb bone with air cells in it. The aditus ad antrum is the alley way
between the mastoid and inner ear.
CC: Objective 8: Mastoiditis can cause an inner ear infection because of the alley way
between the ear and bone.
More Clinical Correlations:

Hearing loss can be a conductive problem due to fluid, wax, foreign bodies, trauma. It can
also be a sensorineural impairment because of noise exposure, certain drugs (chemotherapy), genetics,
or infection (meningitis). It can also be due to a mix of these two.
Course Lecturer
Date
Lecture number
Page 6 of 6
Otitis Media is a middle ear infection which may spread to the nasopharynx through the
auditory tube causing permanent or temporary deafness. Facial nerve paralysis may occur with this.
Acoustic Neuroma a tumor that may cause dizziness.
Lecture Number: GA 37
NOTICE &DISCLAIMER
Note-Taker: Jessica Paciorek The Medical Note-Taking Service makes every effort to provide accurate
A quick update:
- The mp3 for the radiology lecture did not record. Dr Suarez is looking into the possibility of
getting the pertinent information rerecorded for us. Watch this space
Upper Limb I: Shoulder and Arm
The upper limb is a freely movable multijointed lever. It attaches to the trunk at its proximal
end, and has the prehensile organ, the hand, at its distal end. The essential function of the upper limb is
to be able to place the hand anywhere in space, such that the hand may be used to perform a particular
task.
For the study of the upper limb, four elements will be important:
1. Be able to describe the bones and muscles of the upper limb that move the various
joints.
2. Be able to name the muscles of the upper limb and describe their actions
3. Be able to name all nerves and the muscles they innervate, and be aware of the
consequences of a lesion.
4. Be able to name and describe the important blood vessels (ie. those of clinical
importance).
The upper limb consists of four parts:

1. shoulder junction of arm and trunk
2. arm (aka brachium): between shoulder and forearm
3. forearm (aka antebrachium): between arm and hand
4. hand (aka manus): the business end
[after Arthur cuts off both of the Black Knight's arms]

King Arthur: LookYou've got no arms left.
Black Knight: Yes I have.
King Arthur: *Look*!
Black Knight: It's just a flesh wound.
Page 2 of 6
There are four important properties of muscles to consider:

1. Muscle action = contraction
2. At rest, muscles still have tone
3. Muscle action is opposed by the action of another muscle
4. Muscles only exert action on a joint if they span the joint
Osteology
There are way too many details to learn for all of the bones the key is to know what is
presented in the dissector. There are two areas of the skeleton to consider: the axial and appendicular
skeleton. The axial skeleton consists of the ribs and sternum. The appendicular skeleton consists of
the many bones of the arm:
The scapula consists of the acromion, which forms a joint with the clavicle. The clavicle
functions as a strut that holds the arm away from the trunk and transmits force from the arm to the axial
skeleton. The acromion is continuous posteriorly with the spine of the scapula. This is an attachment
site for several muscles. Above the spine is the supraspinous fossa, while below the spine the
infraspinous fossa is found. The suprascapular notch runs on the superior surface of the scapula, and
the superior border of the supraspinous fossa. The supraglenoid tubercle is a projection from the
superior border of the glenoid cavity, where the head of the humerus articulates. The infraglenoid
tubercle is a projection from the inferior border of the glenoid cavity. The corocoid process is an
anterior
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projection from the scapula which serves as an attachment site for muscles.
The humerus is the large bone of the brachium. It has a head which articulates with the glenoid
cavity of the scapula. Immediately inferior to the head is the anatomical neck. The greater tubercle,
lesser tubercle and intertubercular sulcus are landmarks of the anatomical neck of the humerus, and
serve as attachment points for muscles. Below the anatomical neck is the surgical neck of the humerus,
where breaks in the arm most commonly occur. The deltoid tuberosity is found on the anterior shaft of
the humerus and is a point of attachment for the deltoid muscle. The radial groove is found on the
posterior surface of the shaft of the humerus, and provides a space for the profunda brachii artery. The
scapula and shoulder joint can be visualized easily on xray films.
Movements of the Upper Limb Joints Scapula

The scapula may be protracted or retracted,
abducted or adducted, and elevated or depressed.
Each of these movements results in subsequent
movement of the upper limb. The muscles that
perform each of these actions are summarized
below.
Protraction/Retraction
Protraction moving the limb forward, as in punching.
Pectoralis minor and Serratus anterior
Retraction bringing the shoulder/limb back to anatomical position
Rhomboids, Middle trapezius, Latissimus dorsi
Abduction/Adduction
Abduction (Lateral rotation) raising the arm up vertically above the head
Superior trapezius, Inferior trapezius and Serratus anterior
Adduction (Medial rotation) returning the arm to the anatomical position
Rhomboids, Levator scapulae, Latissimus dorsi, Pectoralis minor
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Elevate/Depress
Elevate shrugging the shoulder upwards
Trapezius, Levator scapulae, Rhomboids
Depress Returning the scapula to the anatomical position
Pectoralis minor, Seratus anterior, Inferior trapezius
Movements of the Upper Limb Joints

Shoulder Joint
One set of muscles that act on the
shoulder joint are the muscles of the
rotator cuff. In addition to allowing for
rotation and movement of the upper arm,
they also come together to hold the
humerus in the shallow glenoid cavity.
These muscles are the subscapularis, supraspinatus, infraspinatus and teres minor. The
infraspinatus and teres minor are involved in lateral rotation. The subscapularis is involved in medial
rotation. The supraspinatus abducts the
arm to a 15 angle. These muscles can be
remembered by the mnemonic S-I-T-S.
The shoulder is abducted from 15 to
90 by the deltoid muscle, and adducted by
the pectoralis major. The shoulder is flexed
by the pectoralis major, the biceps brachii
and coracobrachialis. The shoulder is
extended by the latissimus dorsi, teres
major and the long head of the triceps.
Clinical correlate: A fractured clavicle is a fairly common injury. When the clavicle is broken,
the force that keeps the arm lateral to the trunk is no longer present, and the arm will deviate medially
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because of the action of the pectoralis muscle. The sternocleidomastoid and trapezius muscles will
pull up on the medial broken portion of the clavicle.
Clinical Correlate: When the shoulder is dislocated, it tends to be pushed in an anterior direction,
because of excessive extension and lateral rotation. The head of the humerus will be pushed out of
the glenoid cavity and drop down.
Clinical Correlate: If the nerve to the supraspinatus is damaged, in order to abduct the arm, the first
15 must be created artificially before the deltoid can take over to raise the arm to 90. This is
sometimes done by tennis players when they bend over and let the arm drop away from the body. This
can also be done via the hip-drop method, as demonstrated by Dr. Suarez in class.
Clinical Correlate: If the supraspinatus is subjected to heavy use, it may become inflamed, and the
whole shoulder joint may become inflamed as a result, known as Bursitis. This leads to painful
abduction, as the subacromial bursa may begin to wear away.
Clinical Correlate: With excessive force, the clavicle can be separated from the acromion. This is
referred to as a separated shoulder. It can result in stretched or torn ligaments, but they often are left to
heal on their own without surgery.
Clinical Correlate: The thoracodorsal nerve lies anterior to the axillary lymph nodes, and is prone to
damage during surgical procedures. This nerve innervates the latissimus dorsi, and if damaged, the
patient will not be able to pull themselves up (think of a little old lady trying to pull herself to a
standing position from sitting in a chair). Similarly, the serratus anterior is innervated by the long
thoracic nerve, which is also vulnerable during surgical procedures. If damaged, this can lead to a
winging of the scapula, which will no longer be held flush with the back.
*Below is a chart of all of the muscles and nerves that were presented in the syllabus for this lecture.
While not all of them were covered in this lecture, they will all be important for the final and will be
covered in later lectures. Enjoy!
Page 6 of 6
Muscle (Acts on) Action Innervation

Trapezius Elevates scapula Spinal accessory (CN XI)
Scapula
Levator Scapulae Elevates scapula Dorsal scapular
Scapula
Rhomboids (Major/Minor) Retracts scapula Dorsal scapular
Scapula Adducts scapula
Seratus Anterior Protracts scapula Long thoracic
Scapula
Pectoralis Minor Depresses scapula Medial pectoral
Scapula Protracts scapula
Infraspinatus Lateral rotation Suprascapular
Shoulder joint
Teres Minor Lateral rotation Axillary
Shoulder joint
Subscapularis Medial rotation Subscapular
Shoulder joint
Supraspinatus Abduction to 15 Suprascapular
Shoulder joint
Deltoid Abduction to 90 Axillary
Shoulder joint
Pectoralis Major Flexion Medial pectoral
Shoulder joint Medial rotation Lateral pectoral
Adduction
Corachobrachialis Flexion Musculocutaneous
Shoulder joint
Biceps (Long/Short Heads) Flexion Musculocutaneous
Shoulder joint
Latissimus Dorsi Extension Thoracodorsal
Shoulder joint Medial rotation
Teres Major Extension Subscapular
Shoulder joint Medial rotation
Triceps (Long Head) Extension Radial
Shoulder joint
Biceps Brachii Flexion Musculocutaneous
Radio-Ulnar Joint Supination
Brachialis Flexion Musculocutaneous
Radio-Ulnar Joint
Pronator Pronation Median
Radio-Ulnar Joint
Pronator Teres Flexion Median
Radio-Ulnar Joint Pronation
Superficial Flexors of Wrist and Digits Flexion Median
Radio-Ulnar Joint Pronation
Brachioradialis Flexion Radial
Radio-Ulnar Joint
Triceps Extension Radial
Radio-Ulnar Joint
Supinator Supination Radial
Radio-Ulnar Joint
Flexor Carpi Radialis Flexion Median
Wrist Abduction
Flexor Carpi Ulnaris Flexion Ulnar
Wrist Adduction
Palmaris Longus Flexion Median
Wrist
Flexor Digitorum Superficialis Flexion Median
Wrist
Flexor Digitorum Profundus Flexion Median
Wrist Ulnar
Extensor Carpi Radialis Longus and Brevis Extension Radial
Wrist Abduction
Extensor Digitorum and Digiti Minimi Extension Radial
Wrist
Extensor Indicis Extension Radial
Wrist
Extensor Carpi Ulnaris Extension Radial
Wrist Adduction
Lecture Number: 38
NOTICE &DISCLAIMER
Note-Taker: Paul Tomaszewski The Medical Note-Taking Service makes every effort to provide accurate
Corrected by: Suarez-Quian class notes. However, errors will occur from time to time. The user
Upper Limb II
Objectives
1. Define the axilla
2. Describe the brachial plexus
3. Understand how lesions of brachial plexus nerves results in particular pathognomonic signs
4. Describe clinically relevant blood supply
I. Axilla
The axilla is the pyramidal region between the pectoral muscles, the scapula, the brachium and the
thoracic wall. It is a transitional region through which vessels and nerves pass from the root of the neck
into the upper limb. Its borders are as follows:
Apex - bounded by the clavicle
anteriorly, the upper border of
the scapula posteriorly and the
first rib medially.
Base - skin and fascia of the armpit
Anterior Wall- pectoralis major,
pectoralis minor.
Lateral Wall- Intertubercular groove of the humerus
Posterior Wall- Teres major, lat. dorsi, subscapularis and the anterior surface of the scapula
Date: 10/22/07
Lecture number 38
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Medial Wall- upper portion of the thoracic wall and the serratus anterior muscle.
The contents of the axilla are: axillary sheath, brachial plexus, axillary vessels, lymph nodes and vessels,
and a considerable amount of adipose and connective tissue.
II. Brachial Plexus
The brachial plexus is formed by the ventral rami of C5-T1 spinal nerves. The roots of the brachial
plexus emerge between the anterior and middle scalene muscles, in the posterior triangle of the neck.
Its branches supply muscles of the shoulder, including superficial muscles on the back, anterior thoracic
wall muscles and all the muscles of the upper limb. (Exception is the trapezius which we know is
innervated by Cranial Nerve XI the Spinal accessory
The 5 roots of the brachial plexus give rise to 3 trunks and which then divide into 6 division; 3
anterior and 3 posterior (1 of each), which coalesce into 3 cords: the lateral, posterior and medial
cords (named for their relationship to the axillary artery). The 3 cords give rise to 5 terminal branches.
(Follow along with the large version on the last page).
Roots: 5 roots: anterior rami of Spinal Nerves C5, C6, C7, C8 and T1
Trunks: 3 Trunks:
o Upper Trunk: made by roots C5,C6,
o Middle Trunk: made by root C7
o Lower Trunk: made by roots C8 and T1
Divisions: 6 3 anterior and 3 posterior (each trunk has 1 one of each).
o Cords: 3 Cords
1. Lateral Cord: made by the anterior divisions of the upper and middle trunk (C5-C7).
2. Medial Cord: made by the anterior division of the lower trunk (C8-T1).
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Lecture number 38
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3. Posterior Cord: made by the posterior division of all three trunks (C5-T1).
***Again the names of the cords are in relation to the axillary artery, and the travel
within the axillary sheath.
Branches:
Branches off of the Roots:
Dorsal Scapular: from C5 to Rhomboids and levator scapulae
Long thoracic: from C5-C7 (serratus anterior)
Branches off Upper Trunk:
Suprascapular: to supraspinatus and infraspinatus muscles
Subclavius : to subclavius muscle
Branches off the Lateral Cord:
Lateral pectoral: to pectoralis major
Musculocutaneous: to the flexors of the anterior compartment of the arm Coracobrachialis, Long
and Short Head of Biceps Brachii, and Brachialis
Lateral Head of the median nerve: helps form the median nerve
Branches off the Medial Cord
Medial Pectoral: to pectoralis minor and pectoralis major
Medial cutaneous o forearm: sensory to skin on medial side of forearm
Medial cutaneous of arm: sensory to skin on medial side, distal 1/3 arm
Medial head of the median : forms median nerve along with the lateral head from lateral cord.
Innervates the flexors of the forearm and is the principle nerve of the thumb.
Ulnar: motor to the flexor carpi ulnaris and to the medial half of the flexor digitorum profundus
of the forearm and is the major nerve to the hand.

Date: 10/22/07
Lecture number 38
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Branches off the posterior Cord:
Upper subscapular: to subscapularis
Middle subscapular: aka thoracodorsal nerve to latissmus dorsi
Lower subscapular : to subscapularis
Axillary Nerve: to deltoid and teres minor
Radial Nerve: extensors to the arm and forearm.
Summary Table
III. Clinical Correlates
Winged Scapula
Damage of the long thoracic nerve leads to paralysis of serratus anterior muscle. The medial
border of scapula moves away from thoracic wall and the upper limb cannot be abducted above
90 degrees. One can still get to 90 degrees because supraspinatus initiates the first 15 degrees
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Lecture number 38
Page 5 of 10
then the deltoid kicks in and does the remainder to 90 degrees. Injuries to the nerve occur when
limbs are raised, as in fights or QBs getting hit by lineman.
To test ask the patient to push against the wall and observe the scapula.
Injury to Axillary Nerve
Injury to the nerve can occur in fractures of the surgical neck of humerus, or shoulder
dislocations. The injury results in the inability to abduct the limb to 90 degrees because the
axillary exits the quadrangular space and innervates the deltoid muscle (and teres minor).
To test the examiner resists the patients abduction of the limb by the deltoid. If acting
normally, contraction of the middle part can be felt.
Injury to Thoracodorsal nerve:
o Thoracodorsal innervates the latissmus dorsi; injury to this nerve will limit the patients ability to
extend the upper limb and will be unable to push themselves up from a seated position. The
nerve is vulnerable during surgical procedures of axilla, i.e. lymph node resection surgery. It lies
anterior to axillary artery and axillary lymph nodes.
o To test ask the patient to try and get up from an armed chair.
Injury to Superior (C5, C6) part of Brachial Plexus: Duchenne-Erb Palsy
o Injuries to this part of the brachial plexus can occur during a fall onto the head and shoulder (i.e.
being undercut in sports) or during parturition if the delivery physician pulls the babies head too
hard. The underlined nerves are most affected by this injury because they are supplied mainly by
C5 and C6. Some are affected but not completely paralyzed, i.e. serratus anterior because
receives some innervation from C7.

Date: 10/22/07
Lecture number 38
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Nerve Muscle Impaired Action
Dorsal scapular Rhomboids Elevates/retracts scapula
Long Thoracic Serratus anterior Protraction/rotation scapula
Suprascapular Supra & Infraspinatus Abd./Lateral rotation
N. to subclavius Subclavius Not important
L. pectoral Pectoralis major Flexion Arm
Musculocutaneous Anterior arm muscles Flexion Arm/Forearm/Supination
Anterior forearm m./thenar

Median Not important
eminence
U. subscapular Subscapularis Not important
Thoracodorsal Latissimus dorsi Not important
L. subscapular Subscapularis/teres major Medial rotation
Axillary Deltoid/teres minor Abd./Flexion/ Extension
Radial Arm & Forearm extensors Extension Arm/Forearm
This results in what is known as waiters tip because you have loss of abduction, lateral rotation and
flexors. Adduction, medial rotation and extension will predominate because their normal resting tone is
no longer opposed.
Movements produced by Myotomes
Selected joint movements are used to test myotomes. Abduction of arm at glenohumeral joint is
mainly controlled by C5. Flexion of forearm at elbow joint is primarily controlled by C6. Supination of
forearm at elbow joint is primarily controlled by C6. Extension of arm at elbow joint is controlled by
C7. Flexion of fingers is controlled by C8. Abduction and adduction of index, middle and ring fingers
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Lecture number 38
Page 7 of 10
are controlled by T1. In unconscious patients, both somatic sensory and motor functions of spinal cord
levels can be tested using tendon reflexes.
Injuries to Inferior Part of Brachial Plexus
These injuries are must less frequent and occur when the upper limb is suddenly pulled superiorly. This
injury usually damages C8 and T1 which results in a Clawed hand appearance. The nerves affected
are listed below.
Nerve Muscle Impaired Action
Ulnar Hand muscles Finger Abd/Add
Medial brachial Sensory Sensation
Medial Antebrachial Sensory Sensation
Medial Pectoral Pect. Major & Minor
****To test ask the patient to hold a credit card between their fingers.
Injury to Radial Nerve
Injury to the radial nerve in spiral groove of humerus (triangular space) leads to inability to
extend forearm and digits. The resulting condition is known as Wrist Drop. Wrist is flexed due to
unopposed tonus of flexor muscles and gravity.
Blood Supply
Arteries: As the subclavian artery crosses the first rib it
becomes the axillary artery. The axillary artery is the main
blood supply to the upper limb. It is divided into three
sections by pectoralis minor.
o Part 1: Superior thoracic artery

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Lecture number 38
Page 8 of 10
o Part 2: thoraco-acromial Branch and Lateral Thoracic Branch
o Part 3: subscapular artery, posterior circumflex humeral artery and anterior circumflex humeral
As the axillary artery crosses teres major it becomes the brachial artery and immediately gives off a
branch called the profunda brachial artery which travels posterior laterally to the lateral part of the
arm. The brachial artery then extends distally to the cubital fossa where it branches into the lateral
radial artery and the medial ulnar artery. However, this division may occur at a more proximal level
in some people. In 3% of cases, the ulnar artery descends superficial to the flexor muscles. This
variation must be kept in mind when performing venipunctures for blood withdrawal or intravenous
injections because injections into the arterial system are deleterious.
Joints are very active parts of the body and therefore need lots of blood. To satisfy this, the body
has extensive arterial anastomoses. For example around the scapula blood can flow to brachial artery if
there is a ligature that occurs proximal to the Subscapular artery. However, ligatures distal to this point
do not permit blood flow to get through to the rest of the upper limb. Another example is in the elbow.
Arterial anastomeses of elbow joint allow clamping of the brachial artery distal to the profunda brachii
without loosing function. However, if one wanted control hemorrhage to the distal arm and the forearm
one can compress the brachial artery proximal to the profunda brachii.
(In addition this is why BP is normally taken on the middle to distal part of the arm because you can cut
off the circulation via the brachial to measure arterial pressure without loosing function distally.)
Veins: The main superficial veins of the upper limb originate in the subcutaneous tissue of on the
dorsum of the hand as the dorsal arch. The arch drains to two veins: cephalic vein laterally and basilic
vein medially, connecting these two veins near the cubital fossa is the median cubital vein. Because of
the prominence and accessibility of the superficial veins of the cubital fossa, they are commonly used
for venipuncture. Veins may be embedded in subcutaneous tissue and difficult to detect, but by applying
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Lecture number 38
Page 9 of 10
a tourniquet to the arm, the venous return is occluded and the
veins distend to become visible. It is very important not to
puncture arteries, and the bicipital aponeurosis helps to
protect the underlying brachial artery and median nerve.
Lymph drainage: Lymph originates in the dorsum of the
hand and accompanies the veins to the axillary lymph nodes.
There are more superficial than deep lymph nodes in the
upper limb.
Date: 10/22/07
Lecture number 38
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PRACTICE, PRACTICE, PRACTICE!!!!!!!

Lecturer The Illustrious Dr. Suarez
Lecture Number: 39
NOTICE &DISCLAIMER
Note-Taker: Alex Engelman The Medical Note-Taking Service makes every effort to provide accurate
UPPER LIMB III
Movements of the Upper Limbs

Elbow Flexion (bending the arm forward) & Extension (straightening the arm)
Radio-ulnar joint Pronation (palms facing back/towards the floor) & Supination (palms facing
up/forward)
Wrist Flexion (palm towards your forearm) & Extension (palm away from forearm); &
Abduction (finishing a beer) and Adduction
Muscles that act on Elbow and Radio-Ulnar Joints
Muscles that FLEX the Elbow and SUPINATE the Radio-Ulnar Joint
Biceps Brachii Main function is SUPINATION of the Radio-Ulnar Joint. Also aids in FLEXION of
the elbow when load bearing. The righty-tighty movement of tightening a screw with the right
hand is supination by the Biceps Brachii
Brachialis - This is the major FLEXOR of the Forearm.
Muscles that FLEX the Elbow and PRONATE the Radio-Ulnar Joint
Brachioradialis muscle - This muscle is mainly in the brachium (forearm) but its origin is the humerus.
It FLEXES the Forearm.
Carol Taylor
Course Lecturer
Date
Lecture number
Page 2 of 7
Pronator teres - This is a thin muscle that runs obliquely across the anterior forearm. It helps
PRONATE the Forearm.
Superficial flexors of the wrist and Deep flexors of the wrist - These muscles take their origins
proximal to the elbow joint, so they also aid in FLEXION of the elbow. These will be discussed
more later.
Muscles that PRONATE the Radio-Ulnar Joint

Pronator Quadratus - This small, square muscle runs obliquely between the radius and ulna near the
wrist and PRONATES the Radio-Ulnar Joint.
Muscles that EXTEND the Forearm

Triceps - This is the main EXTENSOR of the Forearm. It is the only muscle in the extensor
compartment of the arm. The long head of the triceps muscle also helps to extend the shoulder
joint.
Muscles that help SUPINATE the Radio-Ulnar Joint

Supinator - This is a small muscle, similar to the pronator teres and pronator quadratus, except it helps
SUPINATE the Forearm.
Clinical Correlation: TENNIS elbow - Tennis players use their Supinator to put topspin
on their backhand. Repetitive action of the Supinator causes inflammation and can compress the
deep branch of the radial nerve that runs under the muscle.
Muscles that act on the Wrist

Course Lecturer
Date
Lecture number
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Compartments of the Forearm

The antebrachial fascia (a sleeve of connective tissue around the forearm) gives off intermuscular septa
that run between the muscles and attach the antebrachial fascia to the radius and ulna. The intermuscular
septa, interosseous membrane, and the radius and ulna divide the forearm into an anterior compartment
and posterior compartment.
Anterior Compartment muscles all innervated by median nerve except the Flexor carpi ulnaris and the
medial half of the Flexor digitorum profundus, which are innervated by the ulnar nerve.
Posterior Compartment muscles are innervated by the radial nerve.
Clinical Correlation:
Compartmental Syndrome The deep fascia of the forearm forms a stocking around the
muscles. Inflammation from a broken bone would travel up the forearm and inflame the arm and
constrict blood flow into the forearm. If this is not treated it can lead to necrosis of the forearm
and amputation can be needed.
Muscles of the Anterior Compartment of the Forearm (THE FLEXORS)

1st Layer: Most superficial layer
Flexor carpi radialis - Goes to the radial side of the forearm and FLEXES the Wrist (aka carpus).
Flexor carpi ulnar - Goes to the ulnar side of the forearm and FLEXES the Wrist.
Palmaris longus Goes to the palm and FLEXES the Wrist.
Brachioradialis & Pronator teres found in the anterior compartment but are not involved in the
movement of the wrist.
2nd Layer:
Flexor digitorum superficialis - FLEXES the fingers (mainly) and the Wrist
3rd Layer:
Flexor digitorum profundus similar to flexor digitorum superficialis (FLEXES the digits)
Flexor policis longus this helps FLEX the thumb.
4th Layer:
Pronator Quadratus deep muscle, doesnt work at Wrist
Posterior Muscles of the Forearm (THE EXTENSORS)

Muscles that EXTEND the Wrist
Extensor carpi radialis longus EXTENDS the radial side of the Wrist.
Extensor carpi radialis brevis also EXTENDS the radial side of the Wrist.
Extensor carpi ulnaris this muscle EXTENDS the ulnar side of the Wrist.
Muscles that EXTEND the digits (not the thumb)

Extensor digitorum this muscle EXTENDS all four of the medial digits
Extensor digiti minimi this muscle EXTENDS the 5th digit ()
Extensor indicis this muscle allows us to EXTEND our index finger (pointing)
Muscles that EXTEND or ABDUCT the Thumb

Extensor policis brevis - EXTENDS the Thumb (hitch hiking)
Extensor policis longus - EXTENDS the Thumb
Abductor policis longus - allows us to ABDUCTS our Thumb.
Course Lecturer
Date
Lecture number
Page 4 of 7
The Hand
At this point Dr. Suarez launched into an uncomfortably erotic conversation on the hand, highlighted by
two ice skaters and him attempting not to sport wood. Ill spare you the details.
Bones of the Hand

Carpal Bones
There are 8 carpal bones and they are arranged in two rows.
Proximal Row (lateral to medial) - Scaphoid, Lunate, Triquetrum,
Pisiform
Distal Row (lateral to medial) - Trapezium, Trapezoid, Capitate,
Hamate
The mnemonic Some Lovers Try Positions That They Cant Handle
stands for the carpal bones from proximal to distal, lateral to medial
The Scaphoid and the Lunate bones are the only two bones that
articulate with the radius (there are NO carpal bones that
articulate with the ulna). These are the two most likely bones to
break when you fall on your hand, because all of the force is
transmitted to only these two bones.
Metacarapals and Phalanges are numbered 1-5 with the thumb as 1 and the pinkie as 5.
Clinical Correlations:
Fractures of the Metacarpals The metacarpal bones are very well supported and if they do break,
they are well vascularized and stable. Boxers often fracture the necks of the 1st and 2nd metacarpals
(known as a boxers fracture). Drunken undergrads often break the 5th metacarpal because they do not
make a tight enough fist and their pinky fingers are left unprotected.
Fracture of the Scaphoid Bone The scaphoid bone is the most commonly fractured carpal bone. This
type of fracture can be serious because the blood supply goes from distal to proximal; and if you
fracture the distal end it can go undetected, allowing the proximal part of the scaphoid to begin to
necrose.
Colles Fracture - The most common type of fracture in adults over 50, especially in osteoperotic
women, the distal end of the radius is fractured and the distal fragment is displaced dorsally. This
causes your hand to have a silver fork deformity because the extensors pull on the distal part of the
wrist and bends the wrist back.
Wrist Fractures in Children When children fall the wrist doesnt crack, the radial epiphysis breaks.
This is the weakest point in the radius of children. This type of injury is similar in appearance to Colles
fracture, even though different bones are broken.
Joints of the Hand

DIP (distal inter-phalangeal joint) between the middle and distal phalanges.
PIP (proximal inter-phalangeal joint) between the proximal and middle phalanges.
MP (metacarpo-phalangeal joint) between metacarpals and the proximal phalanges.
Gamekeepers Thumb (aka Skiers Thumb) Rupture of the collateral ligament surrounding the MP
joint of the thumb, resulting from hyperabduction. Skiers often get this type of injury when their thumb
remains in the ski pole while the rest of their hand hits the ground.
Course Lecturer
Date
Lecture number
Page 5 of 7
Bull riders Thumb Sprain of the radial collateral ligament of the thumb and possibly an avulsion
fracture of the lateral part of the proximal phalanx. Caused by imitating John Travolta on a bull or in
any setting.
Palmar Fascia
The palmer aponeurosis firmly attaches the skin of the palm to the deep fascia. It is a tough and fibrous
fascia that is thick centrally but thins out over the thenar and hypothenar eminences. It prevents the skin
of the palm and fingers from rolling when trying to grasp fine objects.
Clinical Correlates
Dupuytrens Contracture a progressive shortening, thickening, and fibrosis of the palmer
aponeurosis. It can cause constriction in the movement of your fingers.
Hand Infections The palmer aponeurosis is responsible for the fact that inflammation in the hand
presents on the dorsum. Swelling cannot separate the palmer fascia from the skin so the inflammation
travels to the dorsum of the skin. Dr. Suarez advised us to watch out for infection from fish scales if we
are strapping, mustached 27 year-old future anatomy teachers fishing from the San Francisco pier in
1977.
Carpal Tunnel
The carpal tunnel is deep to the palmer aponeurosis. Its function is to provide mechanical advantage to
the tendons of the muscle of the forearm during contraction. The carpal tunnel is formed by the
retinaculum which extends from the pisiform and the hamulus of the hamate bone on the medial side to
the scaphoid and the trapezium on the lateral side.
Carpal Tunnel Syndrome The median nerve goes through the carpal tunnel while the ulnar nerve and
radial artery run anterior to the retinaculum. Carpal tunnel syndrome can be caused by restriction of
the size of the tunnel by inflammation. It is an affliction of the median nerve which causes wrist pain and
an inability to oppose thumb.
Movements of the Fingers and Thumb

Finger Movements
Extension straightens the fingers to make a flat palm
Flexion curls the fingers into a ball
Abduction separates the fingers from one another
Adduction brings the fingers close together
Thumb Movements
Abduction brings the thumb up from the plane of your palm
Adduction brings thumb down to the plane of your palm and rest it against your palm
Extension brings the thumb out to the side of your hand
Flexion brings the thumb into the middle of the palm of your hand
Opposition brings the thumb and pinky finger together against the palm of your hand
Reposition separates the thumb and pinky finger
Course Lecturer
Date
Lecture number
Page 6 of 7
Superficial Layer of the Palmar Surface

The palmar arterial arches run superficially across the palm and connect the ulnar artery with the
radial artery. The branches of the ulnar and median nerve also are cutaneous. The recurrent branch of
the median nerve can be found on the palm of your hand where you middle finger touches your palm.
The recurrent branch of the median nerve controls the muscles of the thenar eminence and damage
(improperly cutting a bagel) can cause inability to oppose your thumb (Simian Hand Syndrome).
Muscles of the Hand

The muscles of the hand are arranged in layers and are grouped into regions: the thenar eminence
(thumb) and the hypothenar eminence (pinky).
Layer 1 Tendons of
Thenar eminence: flexor
digitorum
Abductor policis brevis ABDUCTS the thumb superficialis
Hypothenar eminence:
Abductor digiti minimi ABDUCTS the pinky Hypothenar
Eminence Thenar
In the center of the palm: Eminence
Tendons of the flexor digitorum superficialis
Abductor
Abductor
Digiti
Layer 2 Minimi
Policis
Thenar eminence: Brevis
Tendon of the flexor policis longus
Recurrent
Flexor policis brevis allows us to FLEX our thumb branch of
Opponens policis allows us to OPPOSE our thumb median n.
Hypothenar eminence:
Flexor digiti minimi allows us to FLEX our pinky
Opponens digiti minimi allows us to OPPOSE our pinky
In the center of the palm:
Tendons of the flexor digitorum superficialis and Tendons of the flexor digitorum profundus (from
which the 4 lumbrical muscles take their origin)
The superficialis tendon attaches at the PIP joint. The profundus tendon attaches at the DIP joint.
The tendons of the flexor digitorum superficialis carry out flexion of the PIP joint and tendons of
the flexor digitorum profundus carry out flexion of the DIP.
Lumbricals FLEXION of the M-P joint and EXTENSION of PIP joint (Bye-Bye)
Layer 3
Thenar eminence:
Adductor Policis ADDUCTS the thumb
In the center of the palm:
3 Ventral Interossei ADDUCT the fingers (Palmar Adduction PAD)
4 Dorsal Interossei ABDUCT the fingers (Dorsal Abduction DAB)
(All of the interossei and the adductor policis are innervated by the ulnar nerve.)
NERVES OF THE HAND

Median Nerve runs through carpal tunnel
Motor: The recurrent branch of the median nerve innervates all of the muscles of the thenar eminence
except for the adductor policis. The median nerve also innervates the first two lumbricals.
Course Lecturer
Date
Lecture number
Page 7 of 7
Sensory: to palmar surface of the thumb, the index finger, the middle finger, and of the ring finger as
well as the dorsal surface of the distal two phalanges of the index, middle and of the ring finger.
Ulnar nerve runs between the pisiformis and the hook of the hamate
Motor: The deep branch of the ulnar nerve is the major nerve to the intrinsic muscles of the hand, the
adductor policis, and the dorsal and palmar interossei.
Sensory: to both sides of the lateral of the ring finger and the pinky.
Radial nerve
Sensory: lateral 1/3 of the dorsal surface of the hand.
Clinical Correlation:
Papal Sign Hand Proximal injury to the median nerve. Results in the
loss of flexion at the PIP and DIP joints of the 2nd and 3rd digits
(the flexor digitorum superficialis and lateral half of the flexor
digitorum profundus are affected) and the MP joints of lumbricals
1 and 2 (served by the recurrent branch of median nerve). The
ring finger and the pinky finger are still able to flex (because the
medial portion of the flexor digitorum profundus is innervated by
the ulnar nerve), but the pointer finger and the middle finger
remain fully extended.
Lecturer Dr. Delahay
The Medical Note-Taking Service Date October 26, 2007
Lecture Number: 40
NOTICE &DISCLAIMER
Note-Taker: Brian MacLaughlin The Medical Note-Taking Service makes every effort to provide accurate
Corrected by: Dr. Delahay class notes. However, errors will occur from time to time. The user
Dr. Delahay
Department of Orthopaedics
delahayj@georgetown.edu
AGR Anatomy of Upper Limb Joints
I. Shoulder
A. Composite joint of four articulations:
1. Glenohumeral (GH)
2. Acromioclavicular (AC)
3. Sternoclavicular (SC)
4. Scapulothoracic (ST):
5. All are diarthroidal joints (lined with synovium) except for ST
B. Motions
1. Global motion abduction/adduction; flexion/extension; internal/external rotation
2. Most actual motions are combinations of underlying basic motions elevation of arm;
protraction/retraction of scapula; circumduction of arm
C. Stability - Unstable compared to hip/elbow; leads to clinical problems
1. Glenoid cavity (fossa) relatively shallow
2. Dependent upon soft tissue attachments for stability
3. Does not have boney stability like other joint
D. Ligaments
1. Acromioclavicular capsule (aggregation of ligaments) surrounds AC joint
a. Small meniscus in between the articular surfaces
2. Coracoclavicular conoid and trapezoid ligaments
a. These ligaments hold the clavicle down
3. Glenohumeral joint capsule
One each side, the anterior line of attachment of the lateral pharyngeal wall begins superiorly on the posterior edge of the medial pterygoid plate of the
sphenoid bone just inferior the where the pharyngotympanic tube lies against this plate. Thats my Grays! p. 939
Course Gross Anatomy Lecturer Dr. Delahay
Lecture number 40
Page 2 of 8
a. Collagenous capsule with thickenings that form superior, middle and inferior
GH ligaments on front
b. Foramen of Weitbrecht - relatively soft/thin area of anterior GH capsule,
between middle and inferior anterior ligaments (not typical foramen with hole)
4. Transverse humeral ligament crosses intertubercular groove and holds the tendon of
the long head of biceps it in
a. Bicep tendon can sublux (pop out) if transverse ligament is incompetent
E. Injuries
1. AC separations
a. Separation = dislocation of acromioclavicular joint
i. Typically from fall on point of shoulder
b. Sequence of tearing occurs that allows the clavicle to go up
i. First AC joint ligaments
ii. Then ligaments that hold clavicle down to coracoid
c. Relatively common problem, most common problem for AC joint
2. GH dislocation different from shoulder separation
a. Anterior dislocations far more common (95% to 5%)
i. Glenoid is anteverted so more unstable in front
ii. Weakness of Foramen of Weitbrecht
ii. Anterior ligaments are longer so more play (relative weakness
compared to posterior ligaments)
iii. Activity
a) More likely to throw ball than get electro convulsion therapy
b. Posterior dislocations humeral head goes out the backside
i. Mechanisms include adduction and internal rotation
ii. Such motions are more usually due to seizure disorder
c. Reoccurrence rate varies with age
i. The younger you are when shoulder first dislocates, more likely to
dislocate again
ii. Very little change in ligament through life (very age resistant - becomes
stiffer)
Lecture number 40
Page 3 of 8
iii. Bone becomes weaker than ligament with age same injury more
likely to break bone than tear ligament as get older
d. Recurrent dislocation popped out and put back in multiple times
e. Chronic dislocation dislocated and out for period of three weeks or more
f. Most repairs now done closed with an arthroscope tighten up ligaments
3. Rotator cuff broad flat tendon (aponeurotic) for muscle insertion
a. Works synchronously with deltoid as force couple (like equal and opposite
forces of hands on steering wheel)
i. Rotator cuff pulls humeral head down and in (adducts arm)
ii. Deltoid pulls humeral head up and out (abducts arm)
b. Blood flow sparse at Critical Zone of Codman, where tears usually develop
4. Rotator cuff tears - Primary pathology is within rotator cuff (sudden/acute tears
uncommon) - attritional microtears that summate into clinical tear
Other causes
a. If tendon inflamed/irritated may get dystrophic calcification
b. Frozen shoulder long standing cuff problems (adhesive capsulitis)
c. Subacromial bursitis (fluid filled sac overlying tendon becomes inflamed)
5. Rotator cuff tear arthropathy osteoarthritis of the joint as a result of absent cuff
a. Deltoid works unopposed causing acetabulization - makes shoulder look like
hip joint
b. Long standing cuff pathology with a big tear leads to significant osteoarthritis
6. Humeral Shaft Fractures Holstein Lewis Fracture
a. Course of radial nerve pierces interosseous membrane and goes from
posterior compartment to anterior compartment: point where radial nerve put at
greatest risk
b. The nerve is not right against bone in musculospiral groove at least 1 cm or
more of intermediate head of triceps; nerve is relatively well protected in upper
2/3 of arm
c. Humeral fracture can be treated open (make incision to put back together) or
closed
d. Healing is about 8 weeks b/c decent blood flow
Lecture number 40
Page 4 of 8
e. Humeral shaft fracture without radial nerve palsy (put screws in- not best
option because can get lots of calceneous fractures)
II. Elbow
A. Joint: ginglymus (hinged) joint composed of three articulations
1. Distal part of humerous (1) capitellum lateral - to radius; (2) trochlea medial to ulna
2. Proximal radius and ulna - (3) semilunar notch of ulna
B. Stability
1. Very intrinsically stable (as opposed to GH) because primarily boney
2. Lateral ligaments are weak
3. Medial ligaments - import for restraining joint when throwing
a. Damage leads to Valgus Instability
b. If incompetent, then cant cock the arm
c. Also takes most of stress while playing golf
4. Dislocation harder to dislocate than GH, but if dislocated, harder to relocate
a. If relocated after dislocation, recurrence of dislocation rate is lower than GH
C. Motion
1. Flexion brachialis is primary flexor, biceps brachii functions in supination primarily,
and only flexion when loaded (lifting weights)
a. Trauma to elbow can result in Myositis ossificans of brachialis (formation of
bone inside muscle)
b. Only happens with the brachialis and not the biceps brachii
2. Extension - triceps
D. Injuries
A. Supracondylar fracture fracture of humerous above condyle
1. Location of brachial artery is important
a. In general, arteries can usually stretch out of way if bone breaks
damage rare
b. Lacterus fibrosis traps the brachial artery so tethered and cannot move
out of way (like popliteal artery)
2. Artery damage
a. Classic injury - laceration
Lecture number 40
Page 5 of 8
b. If artery damaged by contusion/compression

i. Wall of artery stretched - injured on intimal side
ii. Results in intrahumeral hematoma - bleeding goes into wall
B. Compartment Syndrome viability of limb at risk
1. Fascial compartments surround all of muscles
2. If injure bone, get bleeding and it fills up compartments (fascia is unyielding)
3. Pressure increases if enough bleeding - stops arterial flow
4. Compartment syndrome results in muscle necrosis (muscle dies and liquefies)
5. Volar compartment forearm muscles
a. Superficial FCR, FCU, FDS, PL, PT
b. Deep FDP, FPL, PQ: more likely region at risk
5. Treatment - Do fasciotomy to open compartment quickly and reduce pressure
a. If not performed quickly can lose hand
b. Myonecrosis get black muscle
c. Volkmanns Ischemic contracture fixed contracture, due to missed
compartment syndrome
Lecture number 40
Page 6 of 8
III. Forearm
A. Motions
1. Pronation done by pronator quadratus (PQ) and pronator teres (PT) muscles
2. Supination done by supinator and biceps brachii muscles
B. Nerves interossei
1. Anterior interosseous - innervates 3 muscles (pronator quadratus, flexor digitorum
profundus (FDP) for first and second finger, and flexor pollicis longus (FPL))
2. Posterior interosseous - innervates 8 muscles supinator (SUP), abductor pollicis longus
(ABPL), extensor pollicis brevis (EPB), extensor pollicis longus (EPL), extensor indices proprius (EIP),
extensor digitorum (EDC), extensor digiti minimi (EDQ), extensor carpi ulnaris (ECU)
3. Both nerves
a. Lie on interosseous membrane
b. Motor nerves only
c. At great risk in any forearm injury
IV. Wrist
A. Joints
1. Complex articulation: radiocarpal; midcarpal (between proximal and distal carpal
bones); intercarpal (between each carpal bone)
2. Schapoid bone: connecting rod - lies in the way of a straight line of midcarpal joint
between distal and proximal carpal joints
3. Distal radial ulnar joint (DRUJ) small point between distal radius and ulna clinical
significance to fractures
4. Triangular fibrocartilage complex (TFCC) of wrist hot topic
B. Motion
1. Palmarflexion at the radiocarpal joint
2. Dorsiflexion (extension) - through midcarpal articulation
3. Radial and ulnar deviation composite motion, but occurs throughout all joints
4. Pisiform bone sesamoid bone (small bone that develops in a tendon, with patella as
largest example)
a. Serve as lever arms, give tendon mechanical advantage (e.g. quadriceps
muscles would have to work 20-25% harder to work knee joint)
Lecture number 40
Page 7 of 8
C. Injuries
1. FOOSH Fall On Out Stretched Hand
a. Colles fracture
i. Fracture of distal radius within 1 in. of wrist, get shortening
ii. Deformities - dorsal displacement, volar angulation, radial shortening
iii. Can treat open or closed, or can fixate fracture in indirect way
b. Scaphoid fracture FOOSH in younger age groups
i. Midcarpal joint goes through the scaphoid bone
ii. Can break this connecting rod if fall and hyperextend wrist
iii. Blood supply from radial artery in retrograde direction to scaphoid
iv. Proximal piece of broken scaphoid can be isolated from blood supply
resulting in avascular necrosis
2. Carpal tunnel syndrome
a. Contents of carpal tunnel median nerve, 4 FDS, 4FDP, FPL enclosed by
transverse carpal ligament
b. Motor branch of medial nerve very important thenar branch that provides
motor innervation to the thumb: very bad if injured
c. Syndrome - Pressure on median nerve as a result of too much stuff in carpal
tunnel (due to arthritis) or a carpal tunnel that is not big enough (due to old
Colles fracture)
3. Scapulolunate dislocation carpal instability
a. Soft tissue injury tear of intercarpal ligament
b. Treatment??, no one knows
c. Results in incongruity of joint general condition that can always result in
osteoarthritis
V. Hand
A. Muscles
1. Four Intrinsic muscles thenar, hypothenar, interossei and limbricals
Lecture number 40
Page 8 of 8
2. Extrinsic start outside hand: Flexor digitorum profundus (FDP), flexor digitorum
superficialis (FDS), flexor pollicis longus (FPL), extensor digiti longus (EDL), extensor pollicis longus
(EPL), extensor indices proprius (EIP)
B. Innervation
1. Thumb evaluation used to test motor nerves
a. Ulnar nerve adduction; medial nerve opposition; radial nerve extension
2. Autogenous zones (area supplied by one and only one nerve) to test sensory function
a. Ulnar tip of little finger; medial tip of index finger; radial first dorsal web
C. Injuries
1. Flexor tendon injury (no mans land)
a. Repairs delayed to minimize scarring and stiffness
b. Acute or delayed end up with fly swatter or hook
2. Infections
a. Occur in tendon or bursas sheaths: result in flexor tensynovitis and allow
avenues for bacteria to spread through hand swelling occurs under loose skin on
dorsum of hand
b. bite wounds most examples of infections
i. most difficult to deal with (80% done by dog, 20% cat - but 80% of cat
bites get bad infections b/c with cat bites cat get puncture would as opposed to
tear
c. human bites are worst - greatest complications
i. occur in fights (tooth cuts through extensor tendon into joint when hit
with clenched fist) can result in septic arthritis
Lecturer: Dr. Dym
Lecture Number: 41
NOTICE &DISCLAIMER
Note-Taker: Antoinette Crdova The Medical Note-Taking Service makes every effort to provide accurate
Lower Limbs I: In lecture Dr. Dym went over the bones of the lower limbs, surface anatomy, the hip
joint, and the 3 important regions on the thigh. Before we delve ina brief introduction to the
fascinating world of the lower limbs. The limbs play an integral role in the body because they are
responsible for weight bearing, locomotion, and maintenance of equilibrium. Regionally the limb
proper is divided into 4 regions: hip, thigh, leg and foot. (Please note that the leg only refers to the
portion of the lower limb between the knee and ankle.)
Bones of the Lower Limb

Hip Bones and Imp. Landmarks
Ilium Pubis
Ischium Acetabulum
ASIS Anterior AIIS Anterior Inferior
Superior Iliac Spine Iliac Spine
Greater/ Lesser Femur (head and neck
Trochanter shown)
Thigh and Leg Bones and Imp. Landmarks

Tibia Fibula
Patella Femur (shaft aka body)
Medial Epicondoyle Lateral Epicondoyle
Much LOVE to Dr. Barbie, HotIce, Curly Sue, Ms. B, my Lil One, Tricky Dicky, and my
Undercover Gunner!
Lecture number: 41
Page 2 of 8
Foot Bones and Imp. Landmarks
Cuneiform Bones 1, 2, 3 Metatarsal (1-5)

Navicular Tuberosity of 5th Metatarsal
Calcaneal Tuberosity Talus
Calcaneus Sustentaculum Tali
Cuboid 14 Phalanges (per foot)
Important Ligaments associated with Limb Bones

Lateral Ligament: thickening of fibrous capsule
surrounding ankle joint
- composed 3 ligaments
1. Posterior talofibular ligament
2. Calcaneofibular ligament
3. Anterior Talofibular ligament
Calcaneonavicular Ligament (Spring Ligament):

ligament on the underside of the foot that connects the
calcaneus with the navicular bone.
Deltoid Ligament: strong, flat, triangular band,

attached to the apex and anterior and posterior borders
of the medial malleolus.
Lecture number: 41
Page 3 of 8
Surface Anatomy of the Limbs

1 Quadriceps - anterior thigh
2 Hamstrings - posterior thigh
3 Gastrocs - posterior leg
4 Front of shin bone - tibia
5 Bumps at side of ankle - medial malleolus and lateral *Upper Outer
malleolus Quadrant*
6 Heel bone - calcaneus
7 Tendons on top of foot - extensor of big toe and other toes
So why is it clinically relevant for me to know the surface

anatomy of the limbs???? Heres why
Intramuscular Injections
A typical site for intramuscular injections is the gluteal region
which is divided into 4 quadrants. The sciatic n. passes through
this region and must be avoided! So therefore always aim for
the UPPER OUTER QUADRANT.
Common Fibular Nerve

Found around the lateral side of the head of the fibula.
Innervates the lateral side of the leg and dorsum of the foot and
can be used to test for peripheral nerve lesions.
Great Saphenous Vein

Cuts down anterior to the medial malleolus. This vein is
important because it can be used for vascular transplantation.
Femoral Pulse
Felt at the mid inguinal point. The femoral artery is inferior to
the inguinal ligament and midway between the ASIS and the
pubic symphysis.
Popliteal Pulse
Felt at the posterior aspect of knee. Politeal artery is in the
politeal fossa medial to the midline.
Anterior Tibial Pulse

Feel for the Dorsalis Pedis artery on the dorsum of the foot.
This pulse is evaluated during Peripheral Vascular Exam.
Posterior Tibial Pulse

Feel for the pulse in the Tarsal Tunnel, groove between the
medial malleolus and the heel (Cacaneal Tuberosity).
Lecture number: 41
Page 4 of 8
Hip joint
- Between the acetabulum and femur
- Synovial joint Ball and Socket joint
designed for stability and weightbearing
at the expense of mobility.
o Has a fibrous capsule around it
called the Acetabular Labrum.
o 3 ligaments around it:
1. Iliofemoral ligament
2. Pubofemoral ligament
3. Ischiofemoral ligament
- ACTION: Flexion, extension, medial and
lateral rotation, adduction and abduction, and
circumduction.
- Note: that the Femoral a. passes anterior to
hip joint and the sciatic n. passes posteriorly.
CLINICAL CORRELATES to the HIP JOINT
Trendelenburg: Dipping or Waddling Gait

- Injury to Superior Gluteal n.
- During walking, as right foot (for example) is
placed on ground, tensor fascia lata and the
gluteus medius and minimus on the same
side contract.
- This serves to elevate slightly opposite hip, thus raising left lower limb.
- In this manner, the foot is able to clear the ground during normal gait. If there is damage
to these muscles on one side, during walking, the hip falls on the opposite side which
results in a POSITIVE Trendelenburg.
Hip Dislocation
- may occur when sitting in the front seat of a car and the car hits another car. The knee may strike
the dash.
o If the hip is adducted the dislocation may occur without acetabular fracture.
o If hip is abducted, the acetabulum may be fractured; sciatic is in danger.
- The least stable position of the hip joint is sitting with one leg crossed over the other.
o In this position, the hip joint is flexed, adducted, and laterally rotated.
- The most stable position of the joint is when the joint is flexed, slightly abducted, and laterally
rotated - as when we are on all fours.
o This is the true physiological position of the joint.
o Complete coincidence of the articular surfaces are achieved in this position.
- A central dislocation may occur when falling from a height.
o The femoral head may be forced up through the acetabulum.
Lecture number: 41
Page 5 of 8
Other Clinical correlates to keep in mind

Charley horse: Quads mostly bruise and hematoma.
Rupture of quad tendon - from a simple fall (Clinton had it).
Pulled groin/Groin strain adductors stretched or torn from origin. Usually occur in sports that require
quick starts.
Hip pointer: Bony injury of the iliac crest - usually the ASIS.
Pelvic fractures: Avulson fractures (ASIS, AIIS, ischial tuberosity).
Fractured hip: Usually a fracture of the femoral neck the closer it is to the head, the more likely the
blood supply will be disrupted.
Ischial bursitis: Weaver's bottom.
Piriformis syndrome: Compression of the sciatic nerve by the piriformis muscle.
BLOOD SUPPLY to the Hip Joint
CLINICAL CORRELATE: Femoral Fractures

- A.K.A Hip fracture or Broken Hip
although it is the neck of the femur that is
affected
Lecture number: 41
Page 6 of 8
- Common in elderly especially in women (osteoporosis)

- May result in Avascular Necrosis
Intertrochanteric fracture (L.):
Commonly known as Broken Hip
In this type of fracture the blood
supply to head is compromised
therefore the head of the femur may
become necrotic.
Transcervical fracture (R.):
Fracture DOES NOT compromise
blood supply to head and neck of the
femur, therefore necrosis is not
likely.
RADIOGRAPHS
In class Dr. Dym presented and X-ray or more appropriately
stated a Radiograph of the Hip Joint.
He noted that it is important when looking at a radiograph to
look for the rounded contours of the femoral head and the
homogeneity of the bone. This homogeneity is LOST in fracture
or necrosis.
FRACTURE of Femoral Head for Case
MRI for Case
CASE Presented in class

Lecture number: 41
Page 7 of 8
SO what did this 30 y/o Neuro Resident have????? AVASCUALAR NECROSIS (AVN)
AVN is a disease of middle age that most often occurs during the fourth or fifth decade of life and is
bilateral in 55% of cases.
AVN represents an inability to supply adequate oxygen to underlying bone. It is an increasingly
common cause of musculoskeletal disability.
The femoral head is the most vulnerable site for development of AVN. The site of necrosis is usually
immediately below the weightbearing articular surface of the bone.
Causes: trauma (MVA), alcoholism, steroids, pancreatitis,metastatic disease, sickle cell disease. And
in this case, Caissons disease (decompression sickness).
- Undersea divers are at risk. Key risk factors are the depth of the dive, the number of dives,
uncontrolled decompression, and low oxygen concentrations.
- The presence of intravascular bubbles of nitrogen obstructs capillaries, arteriolar spasm also
may occur, and as a result AVN can occur.
3 IMPORTANT REGIONS of the Thigh
1. Femoral Triangle (upper 1/3)

2. Subsartorial Canal (middle 1/3)
3. Popliteal Fossa (lower 1/3)
FEMORAL TRIANGLE
- Formed by sartorius (laterally), adductor
longus (medially), and inguinal ligament
superiorly.
- Contains Femoral NAVEL (from lateral to
medial)
i. Nerve, artery, vein, empty space
(femoral canal), lymphatics
- Note: that the femoral canal is the potential
site for a FEMORAL HERNIA
POPLITEAL FOSSA
Important area of transition between thigh and leg
- diamond shaped
- UPPER: Semitendinous/membranous
(medially), Biceps femoris (laterally)
Lecture number: 41
Page 8 of 8
- LOWER: Gastrocnemius (lateral/medial), Plantaris (laterally)

- Contents: Popliteal artery, vein and Tibial and Common Fibular n.
CLINICAL CORRELATE: If you have a lump in the Groin these are things it could just possibly be
Lecturer: Dr. Dym
Lecture Number: 42
NOTICE &DISCLAIMER
Corrected by: Dr. Dym class notes. However, errors will occur from time to time. The user Formatted: Font: Not
Approved for distribution: assumes the risk for any and all errors. We recommend that you use Bold
Dr. Dym started the lecture with introducing todays topics as the knee joint, the leg, the ankle joint, and
the foot. He mentioned that today we will not focus on the muscles, however, we are expected to learn
them in the lab.
Knee Joint
The knee joint consists of three bones: the femur, the tibia, and the patella. The fibula does NOT take
part in the joint. It is mainly a hinge joint with some rolling, gliding, and rotating that takes place. It is
relatively unprotected by tissues and thus is exposed to greater risk for injury than most other joints.
Action at the Joint:

Flexion = Hamstrings Extension = Quadriceps Femoris
Deleted:
Maintains Locked Knee = Gluteus Maximus, Unlocked Knee = Popliteus
Deleted:
Tensor Fasica Lata
Medial Rotation = Semitendinosus, Lateral Rotation = Biceps Femoris
Semimembranosus
The Three Cs (ligaments): Help stabilize the knee

1) Collaterals: These are in every hinge
joint
a. Fibular (Lateral) Collateral
Ligament
b. Tibial (Medial) Collateral
Ligament.
2) Cruciates:
a. Anterior Cruciate Ligament
(ACL) from the anterior tibia to
the lateral condyle of the femur
b. Posterior Cruciate Ligament (PCL) from the posterior tibia to the medial condyle of the
femur
Date: 11/02/07
Lecture number: 42
Page 2 of 7
3) Cartilages (Menisci):
a. Medial Meniscus
i. Clinical Note: The medial meniscus attaches to the MCL and thus is typically
damaged any time the MCL is damaged.
Deleted: attaches to the
b. Lateral Meniscus is not attached to the LCL (separated by popliteus muscle) and thus
less prone to injury.
Locking the Knee Joint:

When the knees are locked, the tensor fascia lata and the gluteus maximus largely maintain the locked
position with little effort, allowing for less energy expenditure since the other larger muscles of the thigh
are not recruited. In order to unlock the knee, the popliteus is enacted which laterally rotates the femur
on the fixed tibia (or you can go over to your colleague from behind and tap the back of the knee).
Extensions of the Joint Cavity:

Deleted: ,
The knee joint cavity extends above the knee - suprapatellar bursa. The extension of the joint cavity
Deleted: below, and posterior to
posteriorly is named the popliteal part of the joint cavity. Other bursa not connected to the joint the joint
Deleted: .
include (prepatellar), and below the patella (infrapatellar)
Deleted: This creates
Deleted: t
***Note: Dr. Dym specifically mentioned that everyone needs to be reading the clinical notes in the text
Deleted: , or fluid-filled
because they will be very important for the shelf and board exams.*** pouches, that reside above
(suprapatellar), in front of
(prepatellar), and below the patella
(infrapatellar)
Clinical Correlates:
Inserted: tapatellar
One of the most common football injuries to the knee occurs when there is forced abduction at the
Deleted: cruciate
knee joint. The first level of injury is a strain on the medial collateral ligament. The next level
would be damage to the medial meniscus (remember it is attached to the MCL). The third level of
injury is tearing of the anterior cruciate ligament.
If there is swelling within the synovial joint of the knee, you can insert a needle into the
suprapatellar bursa (2 inches above the patella) and drain fluid from the joint cavity.
Deleted: Two
Patellar Dislocation: A situation where patellar dislocations are more common are in Genu Valgum.
Deleted: s
Genu Valgum refers to an increase in the Q angle which pulls on the quadriceps causing lateral Deleted: Genu Varum and
patellar dislocation, especially in women. Deleted: Genu Varum refers to

a reduced Q angle and the person is
Synovial Chondromatosis is a condition in which the synovial membrane proliferates with nodule bow-legged.
formation. These nodules are hyaline cartilage that break off of the synovial surface and migrate
Date: 11/02/07
Lecture number: 42
Page 3 of 7
into the joint cavity. They are nourished by the synovial fluid and thus can grow, calcify, or even
ossify.
Anterior Drawer Sign is used as a test to determine if the anterior cruciate ligament has been torn.
The patient lies on his back with the knee bent, foot flat on the table and the physician tries to pull
the tibia forward. If the tibia moves forward unopposed, then this is a positive anterior drawer sign
and the ACL is most likely torn.
ACL Repair is typically done by a graft of the patellar tendon with bone grafts on either end.
Interference screws are used to hold the graft in place. It is important to construct the ACL graft in
Deleted: ,
the proper position, otherwise complications can arise, including: tearing of the graft, impingement
Deleted: many
on the graft (cyclops nodule), or the screw/bone plug can loosen.
These are the clinical correlates Dr. Dym focused on in lecture, however, you should be familiar
with the other clinical notes listed in your syllabus.
Nerves of the Lower Limb

***Dr. Dym mentioned on Blackboard there is high-yield
information on each nerve. This is, at a minimum, what you
should know about each of the nerves for the lower limb.***
The main nerve in the lower limb is the sciatic. It will branch
into the tibial and common fibular nerves. The tibial nerve will
continue onto the foot and give off the medial and lateral plantar
nerves which supply the entire foot. The common fibular nerve
will give off superficial and deep fibular nerves. In addition, the Deleted: a
tibial and common fibular nerves will both contribute to the

formation of the sural nerve. Deleted: However, the lateral
sural nerve is a branch off of the
common fibular nerve only.
Arteries of the Lower Limb
***Dr. Dym said that this will only be briefly covered in lecture, but you are responsible to learn this
information in lab.***
Deleted: mane
The external iliac, from the common iliac, becomes the femoral as it crosses the inguinal ligament. The
femoral gives rise to the deep femoral which will give off the medial and lateral femoral circumflex
Deleted: form
arteries as well as the perforating branches that innervate the large muscles of the thigh. Behind the
Date: 11/02/07
Lecture number: 42
Page 4 of 7
knee, the femoral will become the popliteal which then divides into an anterior and posterior tibial at
Deleted: su
the lower border of the popliteus muscle. One inch below the start of posterior tibial, it gives off the
fibular artery and the posterior tibial continues into the foot as the plantar arteries. The anterior tibial
Deleted: tot he
will continue to supply the anterior compartment of the leg before becoming the dorsalis pedis as it
Deleted: enters the foot
crosses in front of the ankle. The posterior tibial supplies the posterior compartment and the fibular
supplies the lateral compartment of the leg.
Location of Pulses: Pulses can be taken in the lower limb in the femoral, popliteal, anterior and
posterior tibial arteries.
Injury to the Femoral Artery: The femoral artery is the major blood supply to the lower limb and is
an occupational hazard for bullfighters and butchers.
Punctures of Femoral Artery: The femoral artery can be used as an entrance point for angiography of
peripheral leg vessels along with other major blood vessels such as the aorta, coronary, renal,
carotids, celiac, and mesenteric.
Atherosclerotic Changes: The lower portion of the femoral artery can be examined for
atherosclerotic changes because it is one of the first places these are seen.
Aneurysm of Popliteal Artery: An aneurysm of the popliteal artery used to be more common when
high riding boots were worn, but less common today.
Venous Drainage of Lower Limb

There are three sets of veins in the lower limb: superficial, deep, and
Deep Veins
perforating veins. The superficial and deep veins are separated by a tight
facial sheath, the deep fascia, which surrounds the muscles of the lower limb.
The superficial veins include the great and short saphenous (and others not Perforating
Veins
named). Within the fascia, the deep veins follow the arteries and contain many Deleted: listed in lecture
valves. It is through these deep veins that most of the blood of the lower limb
is returned to the heart. This is due to the negative pressure that is created that
Superficial
Veins
pulls the blood from the superficial veins to the deep veins through the
perforating veins.
There are 3 ways that the blood of the lower limb is pushed back up to the heart:
Date: 11/02/07
Lecture number: 42
Page 5 of 7
1) contraction of the muscles of the lower limb

2) contraction of the neighboring arteries
3) arrangement of the valves within the deep veins
Position of Great Saphenous Vein: The great saphenous vein lies in front of the medial malleolus
and thus can be used as a life-saving vein in order to perform transfusions.
Varicosities of Superficial Lower Limb Veins: This is dilation of the superficial veins of the lower
limb which usually are idiopathic, but can be due to obstruction such as after childbirth or due to
obstruction of the deep veins.
Recurrence of Varicosities After Surgical Removal: The recurrence rate for varicosities after they
are removed surgically is very high if all of the tributaries are not carefully removed in surgery.
Lymphatic Drainage
The lymphatic drainage of the lower limb is to the superficial inguinal nodes which means problems
present as a lump in the groin. Also, blockage of these lymphatics can lead to enlargement of the limbs,
or elephantiasis.
Ankle Joint
The ankle joint occurs between the talus and the tibia and fibula. The ankle joint provides for flexion
and extension, however, in the ankle joint this is referred to as dorsiflexion and plantarflexion. This
joint does not provide inversion or eversion. These two movements are provided by the subtalar joints.
Plantarflexors: Dorsiflexors: Eversion:
Plantaris Tibialis Anterior Peroneus muscles
Gastrocnemius Extensor Digitorum Longus
Soleus Extensor Hallicus Longus Inversion:
Peroneus Longus and Brevis Peroneus Tertius Tibialis Anterior
Tibialis Posterior Tibialis Posterior
Flexor Digitorum Longus
Flexor Hallicus Longus
The ankle joint is stabilized by the medial (deltoid) and lateral ligaments.
Date: 11/02/07
Lecture number: 42
Page 6 of 7
Collaterals Sprain or Torn: This can occur
through forced inversion or eversion. The Deleted: abduction
Deleted: adduction
lateral ligaments are more commonly
injured as a result of inversion because they
are weaker than the deltoid ligaments. The
medial (deltoid) ligament is very strong
and thus can cause the medial malleolus to
break off, known as Potts fracture.
Shin Splints: This is possibly due to tibialis anterior sprain typically at the distal 2/3 of the tibia.
Ankle Fracture: Can commonly occur when running and foot slips into a hole.
Calcaneal Tendon (Achilles Tendon): Calcaneal tendonitis occurs commonly in runners. Calcaneal
Reflex test S1 and S2. The most severe problem with the calcaneal tendon occurs when it is
ruptured. It is the most severe acute muscular problem with the leg and occurs with an audible snap.
Gastrocnemius Strain: This occurs when there is a partial tear in the medial belly of the
gastrocnemius muscle and is known as tennis leg.
Os Trigonum Syndrome: This occurs when there is an small extra bone behind the ankle joint and
occurs in 15% of people but is usually asymptomatic. Most commonly seen in ballet dancers and
soccer players, the extra bone becomes painful as it is pinched behind the ankle joint due to
excessive plantarflexion.
***Dr. Dym said you should review the clinical notes on the foot on your own time.***
Foot
Most of the foot anatomy is beyond this course, however, there are some muscles and other structures
that need to be appreciated in this course. The medial and lateral plantar nerves and arteries supply the
entire foot. The plantar aponeurosis is an important structure to appreciate. It is a fascial structure that
when inflamed causes tremendous pain in the foot (especially common for runners called plantar
Deleted: x
fascitis). The muscles of the foot are divided into four layers, and can be appreciated in lab.
Inserted: xcitis
Date: 11/02/07
Lecture number: 42
Page 7 of 7
Arches:
The foot is a segmental structure and thus best holds up weight through the use of arches. There are
three arches in the foot: medial, lateral, and transverse arches. The arches are created through the use
Deleted: bones
of bones, ligaments, tendons, and muscles. The talus acts as the keystone, the ligaments are the
nails/staples, the tendons are the beams, and finally the muscles (peroneus longus) act as the suspension
bridge.
The Medical Note-Taking Service Lecturer: Dr. Delahay

Date: 11/5/07
Lecture Number: 43
NOTICE &DISCLAIMER
Note-Taker: Caitlin Moran The Medical Note-Tak ing Serv ice makes every effort to prov ide accurate
Corrected by: Dr. Delahay class notes . However, errors will occur from time to time. The us er
AGR: Anatomy of Lower Limb Joints

Introduction
Dr. Delahay began the lecture on lower limb joints by pointing out that the three joints (hip,
knee, and ankle) are homologous to their counterparts on the upper limb (i.e. shoulder, elbow, and wrist,
respectively). It can be helpful in studying these joints to point out their similarities and differences to
their homologues.
Hip
The hip joint is homologous with the shoulder joint of the upper limb. However, the hip joint is
significantly more stable than the shoulder, and, unlike the shoulder, owes most of its stability to the
bony contours, not the soft tissue structures. The hip is a multiaxial, ball-in-socket (spheroid) joint that
permits the wide range of motion that is required for normal locomotion.
A. Acetabulum
The hip joint is the articulation of the head of the femur with the acetabulum of the
pelvis. Approximately 50% of the head of the femur is covered by the acetabulum, and
its extension, known as the labrum in adults. In children this extension is known as the
limbus, which is important because it is still germinal,
and is in the process of deepening the socket. There is
no cartilage in the floor of the acetabulum, and it
contains the haversian gland (Pulvinar), which is a
fatty lobule. The ligamentum teres also passes
between the head of the femur and the acetabulum.
Finally, the sclerotic (white line) seen
radiographically representing the superior weight portion of the acetabulum is referred to
as the sourcil (eyebrow).
B. Femoral Head
The femoral head is covered by articular cartilage, with a hole called the fovea centralis,
which provides a place for the insertion of the ligamentum teres.
Course: Gross Anatomy Lecturer: Dr. Delahay
Date: 11/5/07
Lecture number: 43
Page 2 of 7
C. Capsule
The capsule of the hip is not important for stability, as most of the stability is derived from
the bony contours, but is important in relation to the vascular supply and hip fractures. Hip
fractures are defined in relation to the intertrochanteric line where the ligaments of the
capsule insert. In remembering the relationship of the ligaments that make up the capsule, it
is important to remember where they insert, and their embryologic origin and the rotation of
the limb bud.
D. Innervation
There are three nerves that pass the hip joint: the Sciatic posteriorly, the Femoral laterally,
and the Obturator medially. The major nerve supply to the hip is from the Sciatic nerve, but
the Femoral and Obturator nerves also contribute. Pain in the hip joint is referred to the groin
along the Obturator distribution. When patients present with hip pain (the chief complaint)
it is often due to lumbar spine pathology, and has nothing to do with the hip itself. Most pts.
refer to buttock pain as hip pain
E. Blood Supply
The major blood supply to the head and neck of the femur is from the Profunda Femoris
artery, specifically the Medial Circumflex artery. This artery runs along the posterior of the
head of the femur and anastomoses with the Lateral Circumflex artery, which passes
anteriorally. The key artery to the femoral head coming off of this retinacular anastomosis is
the Lateral Epiphyseal. Blood supply to the head of the femur is retrograde, so if it is
interrupted because of a fracture, the proximal part of the head of the femur will be at risk for
avascular necrosis.
Other vessels include a branch of the Obturator
artery called the Artery of Ligamentum Teres, which
supplies approximately 10% of the bone of the fovea
centralis. Both the Artery of the Ligamentum Teres and
the Lateral Circumflex branch of the Profunda Femoris
are more important in children since they supply more
of the head of the femur and tend to regress with age.
Additionally, retinacular vessels provide the
interosseus supply at the head of the femur.
Date: 11/5/07
Lecture number: 43
Page 3 of 7
F. Hip Fractures
a. Intracapsular
Intracapsular fractures (those occurring within the capsule) are subject to biologic
disease. If the blood supply to the head is interrupted, the proximal portion is at risk
for avascular necrosis and nonunion.
b. Extracapsular
Extracapsular fractures (those occurring outside of the capsule) are subject to
mechanical disease. The blood supply to this part of the hip is not often disrupted,
but the proximal part of the bone of the femur bears the maximal load, and often an
implant is required in order to stabilize the fracture.
c. Femoral Fracture
A fracture of the shaft femur often heals well because of the rich highly vascular soft
tissue envelope. Treatment often includes the insertion of an IM femoral nail to allow
for correct positioning of the bone.
Knee
The knee joint is homologous to the elbow joint of the upper limb. However, while the elbow is
a true hinge joint, allowing motion in only one direction, the knee is a sloppy hinge joint, allowing
some rotation as well as flexion and extenstion. The knee is also incongruous, requiring its soft tissue
components for its stability. An important relationship in joints is the inverse relationship between
congruity of joints and the thickness of the articulating cartilage. Those joints with the thickest articular
cartilage, such as the knee (the thickest articular cartilage in the body is on the cristae of the patella), are
the least congruous.
An important note about the knee joint (and a favorite pimp question): the fibula is not part of the
knee: the knee is simply an articulation between the tibia and femur and patella.
The stability of the knee joint is dependent on the soft tissue structures including the muscles
(quadriceps and hamstrings) as well as the ligaments.
A. Ligaments
The ligaments of the knee include both extracapsular and intracapsular ligaments.
1. Extracapsular
Date: 11/5/07
Lecture number: 43
Page 4 of 7
The extracapsular (extraarticluar) ligaments include the larger collateral ligaments

and the patellar ligament as well as the smaller oblique lig. of Humphrey and the
arcuate lig. of Wrisberg located in the back of the joint.
a. Medial Collateral
The medial collateral ligament is divided into superficial and deep parts.
The deep part is attached to the medial meniscus. This relationship is of
clinical significance because they are often torn together.
b. Lateral Collateral
The lateral collateral ligament is round and cordlike. There is a space
between it and the lateral meniscus through which the tendon of the
Popliteus muscle runs. This space protects either the lateral collateral
ligament or lateral meniscus from damage if the other is torn.
2. Intracapsular
Intracapsular (intraarticular) ligaments
are extrasynovial. They are in the
capsule, but are outside of the synovial
lining of the joint.
a. ACL
The Anterior Cruciate
Ligament attaches to the
lateral femur and medial tibia,
and prevents anterior tibial
translation. While some bands of the ACL are always tight, the ligament
follows a taut-lax-taut pattern in which it is taut from a 0 to 30 bend, lax
from 30 to 60-70, and taut from 70+.
b. PCL
The Posterior Cruciate Ligament attaches to the medial femur and lateral
tibia, and stops posterior translation of the tibia. Its major function is to
block hyperextension of the knee. It is stronger than the ACL and it is the
major stabilizer of the flexed knee. Therefore, it can be very difficult to
walk down the stairs if the PCL is injured.
Date: 11/5/07
Lecture number: 43
Page 5 of 7
c. Meniscii
Both the medial and lateral menisci are made up of fibrocartilage. Their
major functions are shock absorption and the distribution of the J force.
This force is the joint reaction force, which is described as the load felt by
each part of the joint. The menisci function to distribute this force
throughout the joint, thus reducing the risk of arthritis. Without the menisci,
there would be an increase in central loading, and the area would wear
faster.
The Medial Meniscus is C shaped, and attached to the MCL.
The Lateral Meniscus is O shaped, more mobile, and functions more in
the distribution of the J force.
B. Quadriceps Mechanism
The quadriceps mechanism is made up of the quadriceps muscle, the tendon of the
quadriceps muscle, the patella (which is a sesamoid bone: within the tendon), and the patellar
tendon. The quadriceps mechanism allows the quadriceps to use eccentric contraction, in
which it contracts and lengthens at the same time. This is the action of the quadriceps muscle
when you are walking down the stairs.
C. Vasculature
The vasculature of the knee joint is made up of geniculate anastomoses that create a medial
and lateral arcade.
An important feature of the vasculature of the knee joint is the position of the Popliteal
Artery below the fibular neck. At this position, the Popliteal artery trifurcates, and one
branch passes over the interosseus membrane to the anterior compartment of the leg. This
trifurcation makes the popliteal artery immobile, and it is at risk for injury in a posterior knee
dislocation.
D. Tibiofibular Joints
There are two (proximal and distal) tibiofibular joints, both of which contain small articular
facets with a small amount of synovial lining. Again, the proximal tibiofibular joint is not in
the knee. There is a syndesmotic ligament that runs between the tibia and fibula throughout
the length in the interosseus membrane. These joints and ligament allow the fibula to support
approximately 1/6 of the load of the leg.
Date: 11/5/07
Lecture number: 43
Page 6 of 7
E. Tibial Fracture
Unlike the femur, the tibia has a limited amount of soft tissue surrounding it, so healing of
tibial fractures can be a problem. The tibia is the most common long bone to go ununited
after a fracture (the 2nd is the ulna). Distal fractures are most dangerous and carry the
greatest risk of nonunion.
Ankle
The ankle is the lower limb homologue of the wrist joint. It is the articulation of the plafond of
the tibia with the dome of the talus (forming the medial malleolus) and the articulation of the fibula with
the talus (forming the lateral malleolus). The malleoli grip the trochlea of the talus forming the mortise
(joint).
The trochlea is trapezoid in shape. The wide part of the trochlea is in the mortise when the ankle
is dorsiflexed, and the narrow part of the trochlea is in the mortise when the ankle is plantar flexed.
Therefore, dorsiflexion is the more stable position of the ankle joint.
The ankle joint is stabilized by its bony contours. It is the most congruent of the three lower
limb joints, and therefore has the least amount of articular cartilage. Because of that, ankle fractures
must be put back together perfectly, because there is not a lot of cartilage that can be lost.
The ankle joint allows only plantar flexion and dorsiflexion.
A. Ligaments
a. Lateral Complex
The lateral complex of ligaments consists of the
anterior talofibular, posterior talofibular, and
calcaneofibular ligaments. The anterior talofibular
ligament is the most commonly sprained ligament of the
ankle.
b. Medial (Deltoid) Complex
The medial complex of ligaments is significantly
stronger than the lateral complex. It consists of
the anterior and posterior tibialfibular ligaments,
the tibionavicular ligament, and the tibiocalcaneal ligament.
B. Talus
Date: 11/5/07
Lecture number: 43
Page 7 of 7
The Talus bone is the homologue of the Scaphoid in the wrist. It also receives retrograde
blood flow and is at risk for avascular necrosis in its proximal segment. Approximately 70%
of the talus is covered with articular cartilage, and blood vessels enter at the neck and run
into the dome in a retrograde fashion. NO tendons attach to the talus.
C. Foot
a. Hindfoot
The hindfoot consists of the Talus and
Calcaneus bones.
b. Midfoot
The midfoot consists of the Cuneiforms, the
Cuboid, and the Navicular bones.
c. Forefoot
The forefoot consists of the Metatarsals and
Phalanges.
d. Subtalar joint
The subtalar joint is between the talus and the calcaneus. It consists of 3 facets
(anterior, middle, and posterior), and allows inversion and eversion. It is important
for accommodating uneven ground.
e. Lisfranc- Fracture dislocation
The Lisfranc is a midfoot injury that causes severe stiffness and osteoarthritis. It is
named for Lisfranc, who was Napoleons surgeon and described the injury resulting
from a fall from a horse when the foot remains in the stirrup.
Lecturer Dr Wall
Lecture Number: 44 (Part 1)
NOTICE &DISCLAIMER
Note-Taker: Jeff Orr The Medical Note-Taking Service makes every effort to provide accurate
Corrected by: RUSH class notes. However, errors will occur from time to time. The user
Clinical Anatomy of Anesthesia (Part 1)
Today Dr Wall gave a two part lecture on the clinical applications of anatomy in anesthesia. In this note
set I tried to give a brief overview of his key points as they related to anatomy. After being saved by Dr
Azzam with the spare laser pointer, Dr Wall began by talking about venous catheters, arterial catheters,
and airway tubes.
Venous Side
Dr Wall first showed a picture of the venous system. He pointed out a variety of different areas,
including the cubital fossa and dorsal aspect of the forearm. These are good sites for simple IVs. Veins
on the wrist are not good to use, they are thin, dont hold up well, and are painful to the patient. The
cubital fossa is easy to put an IV in, but then patients cant flex their forearm because that will occlude
the IV. Which made it sound like the dorsal aspect of the forearm is the better spot to stick.
The femoral vein can also be

used. Remember the femoral
nerve is lateral to the femoral
artery, and the femoral vein is
on the medial side (remember
the acronym NAVEL for
orientation in the femoral
triangle). Once you locate the
femoral pulse, you would go
medial to find the femoral
vein, or you would go lateral
"There must be something to acupuncture. After all, you never see any sick porcupines."
Bob Goddard.
Course Gross Anatomy Lecturer Dr Wall
Date 11/07/2007
Lecture number 44 (Part 1)
Page 2 of 5
to find the femoral nerve.
For central venous access, the subclavian and internal jugular veins are two ideal sites. The subclavian
vein is common for surgeons to use. It is easy to anchor and keep sterile. However, it is possible to
induce a pneumothorax since the cupula of the lung is nearby. To enter the subclavian vein, go behind
the clavicle and aim towards the sternal notch.
Anesthesiologists like to use the internal jugular. It is easy to access, usually out of the surgical field,
and nowhere near the lungs. To put a line in the internal jugular, simply feel the carotid pulse, then stick
slightly lateral to it at a 30 degree angle (towards the contralateral nipple). The downside to using the
internal jugular is that patients arent big fans of waking up with a tube stuck in their neck. But it is
better than the potential pneumothorax that can result from the subclavian site.
To measure pressure it is possible to feed a venous catheter into the right atrium. This lets you measure
preload (dont worry about preload until physiology). The location of the catheter tip is confirmed via
x-ray. It is also possible to measure arterial pressure with a venous catheter. A tiny balloon on the tip of
the catheter is inflated, and the catheter is floated along through the right atrium, right ventricle, and
along one of the pulmonary arteries until it gets stuck in the lungs. The balloon is deflated to measure
Pa pressure, or inflated again to measure wedge pressure (again, dont worry about this until
physiology). The catheter used to do this is called a Swan-Ganz. Dr Swan is the guy who got the idea
of letting blood push the catheter along from going to the beach and watching sailboats get pushed
around by wind.
Oh yeah, in a clinical setting, people dont use the name of a vein, they simply pick the straightest and
longest vein available. Lucky them.
Date 11/07/2007
Page 3 of 5
Arterial Side
There are times you may want arterial access. This way you can measure beat to beat blood pressure,
and can take arterial samples to measure PaO2, PaCO2, pH, electrolytes, hematocrit and hemoglobin
levels. The most common artery used is the radial artery. The brachial artery can also be used, but the
radial artery is preferred because the ulnar artery supply will supply some blood to the same areas as the
radial in case you screw it up. If you hurt the brachial artery you have limited arterial supply to the
entire distal arm.
It is also possible to measure arterial pressure from the arterial side, but there are fewer complications
from the venous side so the venous side is used during surgery.
Interesting fact mentioned: During a liver transplant, two arterial lines (usually radial and femoral) are
used to monitor pressure.
Airway
It is important to recognize the anatomical landmarks when inserting an endotracheal tube. The tongue,
hard and soft palate, uvula, epiglottis, thyroid cartilage, cricoid cartilage and the tracheal rings can all
help you guide the tube to where it needs to go. You want the tube to end up between the vocal cords
and where the trachea splits into bronchi. This is usually about 21 cm in females and 23 cm in males.
When it is not possible to enter the trachea through the pharynx, an alternate airway needs to be made.
In an emergency, access to trachea may be made through the cricothyroid. Paramedics are trained to do
this. Another way is to go in through the tracheal rings, below the cricothyroid. General surgeons and
ENTs do it this way (I think it is purely for style points).
Date 11/07/2007
Page 4 of 5
You need to be aware of the thyroid gland when cutting

in this area. Its blood supply is all over the place. Plus
if you cut too far to the side of the trachea the superior
laryngeal nerve (found at the dorsal tip of the hyoid
bone) and the recurrent laryngeal nerve are in close
proximity as well.
Once past the larynx and into the trachea, you must be able to distinguish between the right and left
bronchi. Even though the right side is straighter, shorter and wider, this may not be obvious when
viewing from a laryngoscope. This problem can be solved once the tracheal rings have been identified
since they form a C shape around the trachea, with the opening on the posterior side. When the ring is
properly oriented, the left and right bronchi can be identified. This may be useful for lung surgery,
during which the surgeon will want the lung being operated on to be deflated and immobile. In this
situation it is important to only ventilate the non surgical lung.
Can you find the right and left bronchi?

Date 11/07/2007
Page 5 of 5
Last note, the different classes of airways. A class 1 is when the whole uvula can be visualized, and is
the easiest to intubate. A class 2 is when only the base of the uvula can be seen, and a class 3 is only the
soft and hard palate. These are harder to intubate. A class 4 is when only the hard palate can be seen,
and these are very difficult to intubate.
Good Luck Friday!!

The Medical Note-Taking Service Lecturer

Date 15 October 2007
Lecture Number: 44B
NOTICE &DISCLAIMER
Corrected by: RUSH class notes . However, errors will occur from time to time. The us er
AGR: Clinical Anatomy of Anesthesia (Second Hour)

* Read on your study break this noteset is probably not a high-yield die hard study sheet
The autonomic nervous system is very important in anesthesia and knowing dermatome levels is crucial.
Some landmarks you should have heard before:
T4- nipple level
T7- inferior angle of the scapula
T10- umbilicus
L1/L2- spinal cord ends; spinal taps are given distal to this level because then the chances of
nerve damage is very low
L4/5- posterior superior iliac spine
Epidural and Spinal anesthesia

Spinal
o local anesthetic administered in the subarachnoid space
o can gauge where you are because you can aspirate out CSF
o eliminates all sensation, very dense anesthetic; patient feels as if there is no lower body
Epidural
o local anesthetic administered in the pidural space
o epidural space is like a vacuum so place the epidural needle which has some air in it and
start pushing through the tissue. Once the air is able to get out of the needle, you know
youre in the epidural space
o very popular because catheters can be placed for long term delivery of anesthesia
o sensory block which eliminates sensory but maintain motor (patients can participate in
labore.g. bearing down, contracting )
o should be careful because anesthetic injected into a blood vessel accidentally can result in
a toxic reaction
o cervical and lumbar epidurals are done with the needle injected horizontally whereas the
thoracic epidurals are done with the needle injected upwards at an angle to accommodate
for the downward slope of the spinous procceses
o done easier when the patient is sitting up rather than lying on his or her side because the
landmarks are more prominent
Brachial plexus:
Anesthetic can be injected within the sheath which envelops the nerve, artery and vein and it will
spread within the sheath envelope
axillary block: accessing the brachial plexus via the axilla
o feel for pulsation from the axillary artery and insert needle towards it
o aspirate some blood to know that were in axillary artery go just beyond to pass the
artery but still be contained within the sheath and inject
interscalene block: accessing from the posterior border of the sternocleidomastoid (SCM)
I see dead people(good luck in lab!
Course GA 44B Lecturer
Date 7 November 2007
Lecture number 44B
Page 2 of 3
o anterior and posterior scalene muscles

o delivery block with insulated needle capable of delivering electrical stimulation to the
brachial plexus; this ensures that we are at the right place
infraclavicular block: accessing the brachial plexus from below the clavicle
Superficial and deep cervical blocks

done at the midpoint of the posterior border of the SCM usually for lobectomy of the thyroid
gland or carotidectomy
Scalp anesthesia for neurosurgery

must block each nerve around the scalp individually (field block); no one anesthetic locus
Stellate block:
plexus = parasympathetic and sympathethic together
used to treat reflex sympathetic dystrophies of the upper extremity which are caused by minor
injuries which result in an exaggerated response of the sympathetics
must watch for carotid artery and internal jugular vein injection
push needle towards C6 vertebrae on which the stellate lies then pull back a little from the bone
to inject
results in Horner syndrome: ptosis, miosis, anhidrosis
Lumbar sympathetic block:

used to treat reflex sympathetic dystrophy of the lower extremity
done with patient on the side or in prone position
same as the previous: push needle towards the vertebrae, then walk off it a little bit to inject
Celiac plexus block

right in front of aorta at L1
usually done for pancreatitis or pancreatic cancer create analgesia in abdominal cavity
again, the needle is walked off the vertebral body on a slant to try to hit the plexus in front of the
aorta; if you aspirate blood, you know youve pierced the aorta
can put in phenol which would destroy the celiac plexus; this is done for terminal patients for
lasting analgesia
femoral block:
area is anesthetized first before giving femoral block
palpate femoral pulse and go lateral to the femoral artery
administered with insulated needle to stimulate the nerve first
used for knee and anterior thigh surgery
Popliteal fossa block

used for leg surgery
find the popliteal fossa crease; go ~7cm above the crease; bisect the line between the biceps
femoris and the semimembranosus/femitendinosus
if the patient cannot get on his or her stomach, can go from the medial aspect of the knee and
block the saphenous nerve
Course GA 44B Lecturer
Date 7 November 2007
Lecture number 44B
Page 3 of 3
Sciatic nerve blocks:

find the greater trochanter
find the posterior superior iliac spine
draw line between the two
draw a line between the greater trochanter to the sacrum
inject within triangle
Ankle block:
can anesthetize on the dorsal aspect of the foot (deep fibular nerve)
can anesthetize on the medial aspect anterior to the medial malleolus (saphenous nerve)
can anesthetize on the medial aspect posterior to the medial malleolus (posterior tibial nerve)
can anesthetize from the posterior aspect (posterior tibial nerve)
can anesthetize from the anterior towards the lateral side (superficial fibular)
can anesthetize from the posterior towards the lateral malleolus (sural nerve)
Thats all. Good luck everyone!

Lecturer Dr. Cormier
Lecture Number: 7a
NOTICE &DISCLAIMER
Note-Taker: Patrick Thomas The Medical Note-Taking Service makes every effort to provide accurate
Introduction to Radiology
This lecture is a repeat of the one given by Dr. Suarez-Quian given on August 16th 2007. The lecturer is
Dr. Cromier.
Historical Timeline of Radiology

Although this information will probably not be tested on, the timeline of radiology technology is
summarized as follows:
Wilhelm Konrad Roentgen discovered and named x rays in 1895 while experimenting
with Crooke electrical tubes. He received a Nobel prize for his work in 1901.
Becquerel and Curie received nobel prize in 1903 for work with radioactivity in 1903
First book of Chest Radiology is published in 1905
The introduction of films to display radiographs in 1918. Until then radiographs were
made on glass photographic plates.
1937 radioactivity is first used to treat a patient with leukemia at U.C. Berkley
In 1946 thyroid cancer is treated with radioactive iodine for first time.
1956 the first use of ultrasound in the field of OB/GYN.
1967 the first use of MRI technology in England.
1972 the Computed Tomography (CT) is invented by British Engineer Hounsfield at EMI
Laboratories in England.
In the 1990s PET (Positron Emmision Tomography) scanning is introduced.
Radiography
The x-rays that Wilhelm Konrad Roentgen stumbled across in his experiments with Crooke electric
tubes is electromagnetic radiation of a short wavelength that can penetrate materials and tissues to a
certain degree. When x-rays pass through an object or tissue they interact with atoms knocking off some
electrons leaving atoms that have an electrical charge. This is why x-rays are considered ionizing
Vote PT for VP
Course Lecturer Dr. Cormier
Date 8/23/07
Lecture number 7a
Page 2 of 8
radiation. There is also non-ionizing radiation which is not energetic enough to remove electrons.
Conventional radiography, CT, and mammography all use ionizing radiation to irradiate the tissue of
interest and measuring the amount of radiation attenuated by that tissue. ~ of our exposure to ionizing
radiation is from natural background radiation from the environment (cosmic rays, water, soil, building
materials, radon) and ~ of our exposure to ionizing radiation comes from man-made sources, such as
x-rays used in the clinic. In medicine we operate under the principal of ALARA (As Low As
Reasonably Achievable) when irradiating patients.
Plain radiography is achieved by passing x-rays from a source through a 3-D object onto a 2-D
film/detector. Ions are created in the measured object. Technicians
in charge of administering x-rays will protect themselves using lead
aprons, gloves, eyeglasses, radiation badges to monitor exposure,
and collars to protect the thyroid. Technicians will also collimate the
x-ray beam to focus the beams only on the area of interest, and not
spray x-rays onto unwanted tissue. Plain radiographs are the most
common form of imaging study ordered (bear in mind that it is incorrect to say lets look at the x-ray, it
is correct to say lets look at the radiograph). Common radiographs ordered in the clinic are PA
(Posterior to Anterior ex. Common Chest X-Ray), AP (Anterior to Posterior ex. Portable Chest X-Ray),
Lateral, and Oblique (ex. Wrist Films) studies.
PA Chest Radiograph
Date 8/23/07
Lecture number 7a
Page 3 of 8
AP Chest Radiograph
Lateral Chest Radiograph
Historically, physicians would view chest radiographs using light boxes and hard copies of the
radiograph. However, now most radiographs are digitized and saved into a PACS (Picture Archiving
and Communication Systems) system. Radiologist will sit at a workstation and view films using the
PACS system. Full PACS systems will be able to handle various modalities of radiography, i.e.
Ultrasound, MRI, Radiography, PET Scans, CT scans, and Mammography. There are also mini-PACS
systems that handle only a few modalities rather than the full spectrum. PACS replaces hard copy
storage of films, allows for teleradiology, distance education, and tele-diagnosis. There are obvious
advantages to the use of PACS in the hospital today.
Date 8/23/07
Lecture number 7a
Page 4 of 8
Mammography
Mammography is a special form of radiography using the same modalities as plain films. However,
mammography focuses on breast tissue. 1 in 8 females in the United States will develop a carcinoma of
their breast at some point in their life. Mammography plays an important role in diagnosing and
managing breast cancer. Mammography should be used in conjunction with a monthly self-breast exam
and a yearly exam performed by a physician. Mammograms are usually 2 veiws: one medial to lateral
with a slight obliquness to it and one cranial to caudal view. The breast tissue is placed in between 2
paddles to flatten the tissue and allows
for a clearer picture as the x-rays
penetrate the breast tissue. The picture to
the right shows
a MLO
radiograph with
an obvious
tumor
formation.
Fluoroscopy
Fluoroscopy is basically radiography in real-time. A patient is placed under a x-ray source for a period
of time and motion can be recorded (heartbeat, swallowing, GI motility, etc.). Mostly used for
investigating the GI system with contrasts like barium or for perfusion studies in the vasculature using
contrasts like gadolinium and iodine. Fluoroscopy studies are being rapidly replaced by imaging studies
such as endoscopies and CT.
CT (Computed Tomography)
CT uses ionizing x-ray radiation just like radiography, mammography, and fluoroscopy. It was
developed in the 1970s by a company that The Beatles invested in, Electric Musical Intruments Ltd.
(EMI) by a gentleman by the name of Sir Godfrey Hounsfield. In a CT scan a patient is placed on a
computer controlled table that is transported through a donut shaped housing. While being placed in the
donut shaped housing an x-ray tube is rotating around the patient. X-rays that pass through the patient
Date 8/23/07
Lecture number 7a
Page 5 of 8
are sensed by a detector (not film). The detector sends information to a computer, which synthesizes
image slices of the patient. If you picture the patient as a loaf of bread CT would be producing slices of
the bread, whereas plain films would be taking a single photograph of the whole loaf.
As you can imagine, CT has many anatomic and clinical applications. CT scans have become a routine
study at many hospitals and can be done quickly in emergent clinical scenarios. CT can help physicians
diagnose problems like altered mental status, inflammation, and tumor growth. Even though CT scans
are performed by producing thin transverse/axial cuts, modern technology allows CT images to be
reconstructed in any plane and can render a 3-D image (virtual imaging). More primitive forms of CT
scanning would just allow for one slice to be taken, then patient would be moved, then another slice
would be taken. Now, CT scanning can be done extremely fast, fast enough that patients can usually
hold their breath throughout the procedure. CT scanning is also done as a continuous spiral rather than
individual slices, this creates more accurate modeling of the body than the older techniques and
technology. Additionally, CT scanning is beginning to utilize multi-detector arrays rather than linear
arrays to provide more precise imaging. The images have become so precise that CT images obtained
with multi-detector arrays can often replace the need for invasive procedures, like colonoscopies and
brochoscopies.
MRI (Magnetic Resonance Imaging)

We are now departing from modalities that use ionizing radiation. MRI is a technology that creates 3-D
images, much like CT. A hypoallergenic contrast called gadolineum is often used to visualize
Date 8/23/07
Lecture number 7a
Page 6 of 8
vasculature. A patient receiving an MRI scan is placed into an extremely strong magnetic field aligning
the protons within their tissues. Radiowaves are then directed at the aligned protons and radiosignals are
given off as the atoms are perturbed by the radiowaves. A radiowave detector synthesizes the image, in a
similar fashion to CT scanning. One of the hazards surrounding MRI is the extremely strong magnetic
field. Loose change, metal fragments, pacemakers, implants, and surgical clips can all become
hazardous projectiles or tear through tissues causing injury during an MRI. MRI is also avoided during
the first trimester (12 weeks) of pregnancy, as ultrasound is used pretty much exclusively.
MRI is extremely effective for imaging soft tissue, bone marrow, and vasculature. When viewing
images of the brain MRI can distinguish gray
matter vs. white matter very easily, whereas a
CT image would not. See figure at right. At this
point Dr. Cormier showed many examples of
MRI films. I encourage you to check them out
on the powerpoint slides and become
comfortable with the types of detailed images
created using MRI technology.
Ultrasound
Technology was put into use by Dr. Ian Donald
from Scotland, who was a professor of Midwifery in Scotland around 1955. He got the idea after serving
in WWII learning about the technologies of SONAR and RADAR. Ultrasound is another technology
that does not use ionizing radiation, as images are
rendered by bouncing high frequency sound waves
1-10 mhz into the patients tissues from a hand-held
wand. These sound waves will either by absorbed,
reflected, or deflected. Any sound waves that are
sent back to the transducer are digitized. The digital
information is computerized and turned into a
black/white/gray image and displayed real-time on a
Date 8/23/07
Lecture number 7a
Page 7 of 8
monitor. This imaging modality allows physicians to view events like beating hearts or moving fetuses.
Ultrasound has applications in many branches of medicine such as: Obstetrics, GI, Pediatric Neurology
(infants fontanelles are not closed so the brain can be imaged using US), Gynecology, Urology, and
Vascular subspecialties.
Nuclear Medicine
In nuclear medicine the body is imaged from the inside-out. Radioactive tracers are given to the patient
intentionally and allowed to travel to different locations in the body, giving this technology a
physiologic component. A detector is then used to image where the radioactive tracer has traveled to
in the body. The end result is generally a fuzzier image with less anatomic detail than an MRI, or CT
image.
Nuclear medicine uses the concept of

Radiopharmaceutical technology,
where a radioactive moiety is coupled
with a biologically active moiety. For
example if you want the radioactive
moiety to travel to bone, you would
couple it with a biologically active
moiety specific to bone. Generally, the radiation emitted from the radioactive moiety is high energy
radiation like x-rays or gamma rays. So nuclear medicine techniques do expose the patient to ionizing
radiation. Radiation emitted from the patient is recorded using a gamma camera which digitizes the
signal and creates an image.
PET (Positron Emmison Technology) Scan

The PET scan is a specialized nuclear medicine technique, developed in the late 1990s, where glucose is
used as the biological moiety and the radioactive moiety gives off positrons. PET scans yield 3-D
images like an MRI or CT scan and the gamma camera rotates around the patient. PET scans have
common applications in Oncology, cardiac imaging, and brain imaging (blood flow mapping). PET
Date 8/23/07
Lecture number 7a
Page 8 of 8
scans are often used in conjunction with a CT or MRI scan. Currently, PET scanning is the most
effective way to look for cancer recurrences.
Interventional Radiology (IR)

Using Interventional Radiology, Radiologists diagnose and treat disease. The Radiologist use catheters,
guidewires, balloons, needles, stents, etc. to go up into blood vessels and different parts of the body.
Often times Radiologists must inject liquid contrast mediums into vessels causing complications, both
local and systemic. These complications can include, but are not limited to, allergic reaction or even
contrast induced renal failure. Local complications can include: hematomas, pseudoaneurysms, AV
fistulas at puncture sites. Also, within vessels you can get subintimal dissections, thrombosis, and distal
embolization.
Future Trends in Radiology

Outsourcing of radiology readings to other parts of the world is becoming an economical way of having
radiology readings performed. Also, virtual radiology where Radiologists dont even need to come into
the hospital is being made possible by modern computer technologies. Voice recognition dictation
systems also help expedite radiology readings. Finally, Dynamic and functional imaging techniques will
help replace many invasive procedures currently used, such as bronchoscopies and colonoscopies.

Gross Anatomy MNTS

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Course: Gross Anatomy

The Medical Note-Taking Service Lecturer: Suarez-Quian

Lets break them down:

1. Medical terminology Regional organization of body

There are many physiological systems (11) and many

As a side note, Dr. Suarez mentioned the functions of skin:

Action terms these terms have to do with the joints.

Inability to hold a credit card between fingers is due to inability to:

A. circumduct the fingers

Hope you enjoyed your first day!

Professionalism, Ethics, Gross Anatomy

Presented by Dr. Kori Hudson

Note: This lecture will not be on the exam

Beginning of presentation is the video Still Life: The Humanity of Anatomy

what does it mean to be a professional?

Professional (paraphrased from Websters):

- characterized by or conforming to the technical or ethical standards of a profession

What does it mean to be professional, to act professionally?

patients, confidentiality and social responsibility.

everyone to make it through.

Medical Education is a way to practice life-long learning.

to take responsibility for that.

responsibility when youre on the wards and when youre residents.

necessary for successfully treating a patient.

more than just colleagues, be friends when you can.

sharing this experience.

going to visit the lab.

Dont forget about your friends and family at home.

Dont give up on doing the activities that you enjoy.

being professionals and representing yourselves and your school.

Welcome to the profession

Lecture 4: Our First Patient

My Fathers Autopsy by David Gewanter

The nervous system has three main functions:

Divisions of the Nervous System

Basic Organization of the Nervous System

o Dura mater- tough mother, the outermost protective layer

Lecture Notes Outline:

Lamina extends laterally at an angle from spinous process.

Picture: Sagittal view of cervical vertebrae, anterior

C. Intervertebral Disks (IVD)

D. Facets form follows function

E. Ligamentous anatomy Anterior

II. Spinal Cord

Covered by the meninges three layers:

III. Clinical Aspects:

- Person enters ER with spinal cord injury

The Medical Note-Taking Service Lecturer Dr. CASQ

After the X-rays encounters tissue and/or bone, it tends

Magnetic Resonance Imaging:

Thoracic Wall and Pleural Cavities

Boundaries Bony Thorax Scapula

bony anatomy of the thoracic skeleton. 1

and scapula posteriorly, the ribs laterally, 4

anteriorly. The opening at the superior T12

space 3.5 in from midline T

Aortic valve: 2nd intercostal space Xiphisternal

Pulmonary valve: 2nd intercostal

Muscles of the Thorax

Internal Intercostals Fibers run perpendicular to external intercostals. Serve to depress

: Clinical signs of breast cancer include lymphedema (excess fluid due to

The anterior border of the left lung deviates

Doctor Suarez started the lecture with a

The Lumbosacral enlargement occurs at

Dr. Suarez-Quian says none of this history will be on the test