100 Gross Anatomy Concepts

Understand first, then memorize and apply
100 mu st im po rt ant
GA con cept io ns
Dr. Mavrych, MD, PhD, DSc
Dr. Bolgova, MD, PhD
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Preface
 Dear students, this presentation was designed to provide
a useful, concise and simple supplement to available
textbooks of Gross Anatomy.
 Recognizing that our students are faced with the task of
learning an ever increasing number of conceptions in an
ever decreasing period of time, we try to make the text
as short as possible and provide simple illustrations.
 You can use this presentation like a guide during your
preparing for GA exams. It does NOT cover all material
of the Gross Anatomy course. To complete GA material
you should work with ALL professor’s presentations.
 Good Luck and All the Best!
Dr. Mavrych

ACKNOWLEDGEMENT
 We wish to thank to Dr. Sreenathan, Head of Anatomy
Department St. Matthew’s University, Dr. S. Rao and Dr. Gerardo
Ochoa, professors of Anatomy Department and our students for
their encouragement, advices and criticism during preparation of
this presentation.
 We also extend our acknowledgement and appreciation to
Dr. Senthil Kumar, Dean of Basic Sciences School of Medicine
and Administration of St. Matthew’s University for their support
and understanding.
Dr. Volodymyr Mavrych
Dr. Olena Bolgova

CONTENTS
BL OCK 1: c on cepti on s 1-20

BL OCK 2: co nc ept io ns 21-52
BL OCK 3: co ncept io ns 53-100

1. Lu mb ar p un ct ur e (tap) and
Epi du ral a nesthesia
 When lumbar puncture is
performed, the needle
enters the subarachnoid
space to extract
cerebrospinal fluid (CSF)
or to inject anesthetic to
epidural space.
 The needle is usually
inserted between L3/L4 or
L4/L5. Level of horizontal
line through upper points
of iliac crests.
 Remember, the spinal cord
may ends as low as L2 in
adults and does end at L3
in children and dural sac
extends caudally to level of
S2.

2. Herniated IV disc
 Herniation of disc usually occurs in
lumbar (L4/L5 or L5/S1) or cervical
regions (C5/C6 or C6/C7) of individuals
young er th an age 50 .
 Patients typically have history of back
pain .that
limb Themay
painradiate down
begins soo to the
n afte lower
r patient
lifted some heavy thing.
 Herniated lumbar disc usually
compresses the nerve root one number
below: traversing root (e.g., the
herniation L4/L5 will compress L5 root).
Lower limb reflexes are decreased on the
affected side:
 Patellar tendon reflex - herniation of IV
discs L2/L3 or L3/L4
 Achilles tendon reflex - herniation of
L5/S1

3. Ab no rm al cu rvatur es o f t he
spine
 Kyphosis is an exaggeration of
the thoracic curvature that may
occur in elderly persons as a result
of osteoporosis (multiply
compression fracture of vertebral
bodies) or disk degeneration.
 Lordosis is an exaggeration of the
lumbar curvature that may be
temporary and occurs as a result
of pregnancy, spondylolisthesis
or potbelly.
 Scoliosis is a complex lateral
deviation , or torsion, that is
caused by poliomyelitis, a leg-
length discrepancy, or hip disease.

4. Upp er li mb fr act ur es
Hum eru s fr act ur es
Sites of potential inju ry to major
nerves in fractures of the humerus:
1. Axillary nerve and posterior
humeral circumflex artery at the
surgi cal ne ck .
2. Radial n erve and profunda brachii
artery at midshaft . Midshaft
fracture affect srcin of brachia lis
muscle .
3. Brachial artery and media n nerve
at the supra condyla r region .
4. Ulnar nerve at the medial
epicondyle .

Fractur e of d is tal ra di us
 Transverse fracture within the distal 2 cm of

the radius. Most common fracture of the
forearm (after 50).
 Smith' s fr acture results from a fall or a blow
on the dorsal aspect of the flexe d wri st
and produces a ventral angulation of the
wrist. The distal fragment of the radius is
ANTERIORLY displaced.
 Colle s' fracture results from forced
extension of the hand, usually as a result of
trying to ea se a fall by outstretching the
upper limb. Distal fragment is displaced
DORSALLY - “dinner fork deformity ”.
Often the ulnar styloid process is avulced
(broken off)

Scaph oid fracture
 Occurs as a result of a fall onto
the palm when the hand is
abducted
 Pain occurs primarily on the
lateral side of the wrist,
especially during wrist extension
and abduction
 Scaphoid fracture may not show
on X-ray films for 2 to 3 weeks,
but a deep tenderness will be
present in the anatomical
snuffbox.
 The proximal fragment may
undergo avascular necrosi s
because the blood supply is
interrupted.

Box er’s fracture
 Necks of t he metaca rpal

bones are frequently
fractured during fistfights.
 Typically, fractures of 2d and
3d metacarpals are seen in
professional boxers, and
fractures of 5th and sometimes
4th metacarpals are seen in
unskilled fighters.

Mall et o r Base ball Fin ger
 This deformity results from the DIP joint suddenly
being forced into extreme flexion (hyperflexion )
when, for example, a baseball is miscaught or a
finger is jammed into the base pad.

These actions
exte nsor avulsetendon
digitorum the attachment of of
to the base thethe
distal p hala nx . As a result, the person cannot
extend the DIP joint. The resultant deformity bears
some resemblance to a mallet.

5. Rota tor cuf f musc les – SITS
 Support the shoulder joint by
forming a musculotendinous
rotator cuff around it
 Reinfo rces joint on all sides
exce pt inf eriorly , where
dislocation is most likely
Rotator cuff muscles are:
 Supraspinatus
 Infraspinatus
 Teres minor
Right humerus  Subscapularis

6. Abd uc tio n of t he upp er lim b
 (0°-15°) Abduction of the
upper extremity is initiated
by the supraspinatus
muscle (suprascapular
nerve).
 (15°-110º) Further abduction
to the horizontal position is a
function of the deltoid
muscle (axillary nerve).
 (110°-180°) Raising the
extremity above the
horizontal position requires
scapular rotation by action
of the trapezius (accessory
nerve CNXI) and serratus
anterior (long thoracic
nerve).
Sub acro mia l bur sit is &
Tearin g o f s upr aspi natus tendo n
 Subacromial bursitis (inflammation of
the subacromial bursa) is often due to
calcific supraspina tus tendinitis ,
causing a painful arc of abduction .
 The same symptoms will be in case of
inflammation or trauma of the
supraspin atus tendon (MRI → torn
tendon)

7. 3 Elb ow s: S tu dent's elb ow
(Subc utane ous olecra non burs iti s)
 The olecranon, to which the triceps
tendon attaches distally, is easily
palpated. It is separated from the
skin by only the olecranon bursa ,
which allow the mobility of the
overlying skin.
 Repeated excessive pressure and
friction may cause this bursa to
become inflamed, producing a
friction subcutaneous olecranon
bursitis.

Tenn is elbo w
(Lateral epicondylitis)
 Late ral epico ndyli tis: repeated
forceful flexion and extension of the
wrist resulting strain attachment of
common extensor tendon and
inflammation of periosteum of
lateral epicondyle. Pain felt over
lateral epicondyle and radiates
down posterior aspect of forearm.
Pain often felt when opening a
door or lifti ng a glass
 Origins of following muscles may
be affected:
1. Extensor Carpi Ra diali s
Longus & Bre vis
2. Extensor Digitoru m
3. Extensor Digiti Minim i
4. Extensor Ca rpi Uln aris

Golf er’s elbo w
(Medi al epi co nd yli ti s)
 Medial e pico ndyli tis is
inflammation of the common
flexor tendon of the wrist
where it srcinates on the
media l epicondyl e of the
humerus.
 Origins of following muscles

may be affected:
1. Pronator Teres
2. Flexor Carpi Radi alis
3. Palma ris L ongu s
4. Flexor Carpi Ulnaris

8. Ar teri al anast om os es
aro und t he sca pul a
 Block age of the
Subclavian or Axillary
artery can be bypassed
by anastomoses
between branches of
the Thyrocervical and
Subscapular arteries:
 Transv erse cervi cal
 Suprascapular
 Subscapular
 Circum flex sc apular

9. Cub it al f os sa
 Contents from lateral to medial:
1. Biceps brachii tendon
2. Brachial artery
3. Median n erve
 Subcutaneos structures from latera l to
medial:
1. Ceph alic vein
2. Median cubi tal vein : joins cephalic
and basilic veins
3. Basilic vein
 Sites of venipuncture is usually median

cubit al vein because:
 Overlies bicipital aponeurosis, so deep
structures protected
 Not accompanied by nerves

10. Carpal Tun nel Syn drom e
 Results from a lesion that
reduces the size of the carpal
tunnel (fluid retention, infection,
dislocation of lu nate bone )
 Median nerve – most sensitive
structure
and is theinmost
the affected
carpal tunnel
 Clini cal manifesta tion s:
 Pins and needles or anesthesia
of the latera l 3.5 digits
 palm sensation is not affected
because superficial palmar
cutaneous branch passes
superficially to carpal tunnel
 Ap ehand deform it y - absent
of OPPOSITION

11. Test of the pro xi mal a nd
dis tal int erph alangea l j oin ts
 PIP – FDS
 DID - FDP

12. Lesi on o f UL n erves
Upp er B rachi al Pals y
 Injury of upper roots and trunk
 Usually results from excessive
increase in the angle between the
neck and the shoulder stretching or
tearing ofplexus
brachial the superior
(C5 and parts of theor
C6 roots
supe rior trun k)
 May occur as birth injury from
forceful pulling on infant's head
during difficult delivery

Upp er B rachi al Pals y
(Erb -Duc henn e palsy)
 In all cases, paralysis of the muscles of the
shoulder and arm supplied by C5 and C6 spinal
nerves (roots) of the upper trunk.
 Combination lesions of axillary , suprascapular
and musculocutaneous nerves with loss of the
shoulder mm and anterior arm.
 As result patient has “ waite r’s tip ” hand:
 adducted shoulder
 media lly rota ted arm
 extended elbow
 loss of sensation in the lateral aspe ct of the
upper limb

Lo wer Br ach ial P als y
(Kl um pk e para lys is )
 Injury of low er roots and
trunk
 May occur when the upper
limb is suddenly pulled
superiorly : stretching or
tearing of the inferior parts
of the brachial plexus (C8
and T1 roots or inferior
trunk )
 E.g., grabbing support
during falling f rom height
or as a birth injury, or
TOS – thoracic outlet
syndrome

Lo wer Br ach ial P als y
(Kl um pk e para lys is )
 All intrinsic mu scle s of the hand

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

Injur y to muscul ocut aneous
nerve
 Usually results from lesions

of l ateral cord
 Greatly weakens fl exio n of

elbow (biceps and brachialis
muscles) and su pin atio n of
forearm (biceps muscle)
 May be accompanied by
anesthesia ov er latera l
aspect of forearm

Cut aneous in nerva ti on
of the ha nd Inradial
reality, in case of superficial bra nch of
nerve lesion it will be skin deficit
between 1 & 2 digi ts on the dorsum of the
hand ONLY because of nerve overlapping
Dorsum:1,5-Uand3,5R Palm:1,5-Uand3,5M

13. Cardi ac catheteri zatio n
 The femoral artery is

used for cardiac
catheterization
 It can be cannulated
for left cardiac
angiography & also
for visualizing the
coronary arteries – a
long, slender catheter
is inserted
percutaneously and
passed up the
external iliac artery,
common ili ac artery,
aorta , to the left
ventricle of the heart

14. Inj ur y o f th e gl ut eal r egi on
Fractu res o f Femo ral Ne ck
 A common fracture in
elde rly w omen with
osteoporosis is fracture of
the femoral neck.
 Fractures of the femoral
neck cause shortness and
late ral rot ation of the lower
limb.
 Fractures of the femoral
neck often disrupt the blood
supply to the head of the
femur.
 At present time the best way
in case of femoral neck
fracture is hip replacement .

Avascular necrosis
of f emo ral hea d
 Transcervical fracture
disrupts blood supply to
the head of the femur via
retinacula r arte ries (from
medial circumflex femoral
artery ) and may cause
avascular n ecrosis of the
femoral head if blood
supply through the ligament
to the head is inadequate.

Inju ry to sciatic n erve
 Weakened hip
extension and knee
flexion
 Footdrop (lack of
dorsiflexion)
 Flail fo ot (lack of
both dorsiflexion and
plantar flexion)
 Cause of in jury:
caused by
impro perly place d
glut eal injections
but may result from
posterior hip
dislocation

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

Sup eri or gl ut eal nerve inju ry
Normal Right  The superior glut eal nerve
superior may be injured during surgery,
gluteal nerve posterior dislocation of the
injury hip or poliomyelitis.
 Paralysis of the gluteus
medius and gluteus minimus
muscles occurs so that the
ability to pull the pelvis up
and abduction of the thigh
are los t.
Trende lenburg sign:
 If the superior gl utea l nerve on
the right side is injured, the left
pelvis falls downw ard when the
patient raises the left foot off the
ground.
 Note that side is contralateral to
the nerve injury.

Inju ry to inf erio r g lut eal nerve
 Weakened hip exte nsio n

(gluteus maximus), most
noticeable when climbing
stairs or standing fro m a
seated posit ion
 Cause of in jury: posterior
hip dislocation, surgery in
this region

Inju ry of ob tur ator nerve
 Difficulty adducting th igh
(e.g., crossing legs while
sitting)
 Decreased sensation
over upper media l thig h
 Cause of injury: anterior

hip dislocation , radical
retropubic prostatectomia

15. Avu ls io n f ractu res
of t he hip bon e and
hamstrin gs muscles
 Avulsion fractures occur
whe re muscle s are
attache d - ischial
tuberosities
Hamstrin gs musc les:

1. Biceps femoris
2. Semitendinosus
3. Semimembranosus
 Action: extension of hip
joint and flexion of knee
joint
 Nerve supply – Tibial
nerve (short head of
biceps femoris is supplied
by the common fibul ar
nerve)

16. Str uc tu res und er i ng ui nal
ligament
 From lateral to
medial side:
 Iliopsoas muscle
 Femoral nerve
 Femor al artery
 Femor al vein
 Femoral canal

Femo ral he rn ia
Inguina l lig .
 A femoral hernia passes below

inguinal ligame nt through the femoral
ring into the femoral canal to form a
swelling in the upper thigh inferior and
lateral to the pubic tubercle
 The hernial sac may protrude through
the saphe nous hiatus into the
superficial fascia
 A femoral hernia occurs more
frequently in female s and is dangerous
because the hernial sac may become
strangulated
 An aberrant obt urator artery is
vulnerable during surgical repair

17. Kn ee jo in t i nj ur ies
Unh app y tr iad
 Because the lateral side of the

knee is struck more often
(e.g., in a football tackle), the
tibi al collate ral lig ament is
the most at
ligament freque ntly tor n
the knee.
 The unhappy triad of athletic
knee injuries involves:
1. Tibial coll ateral l igame nt
2. Medial m eniscus
3. Anterior cru ciate ligament

Tib ial co ll atera l li game nt (medial
co ll atera l l ig ament )
 Broad flat band

extending from medial
epicondyle of femur to
media l con dyle and
shaft of tibia
 Blends with capsule and
firml y atta ches to
media l meniscu s
 Limits extension and
abduction of leg at
knee

Fib ul ar co ll atera l li game nt (late ral
co ll atera l l ig ament )
 Rounded cord between

late ral e pico ndyle of femur
and head of fib ula
 Does NOT blend with joint
capsule and do es NOT
atta ch t o l ateral meniscus
 Limits extension and
adduction of l eg at knee

Rup tu re of cr uc iate li game nt s
 With rupt ure of the a nterior

cruciate ligament, the tibia
can be pulled forward
excessively on the femur,
exhibiting
sign . ante rior drawer
 In the less common rupture of

the posterior cru ciate
ligament, the tibia can be
pushed backward excessively
on the femur, exhibiting
post erior dra wer sign .

Prepa tell ar & Sup rapa tell ar
bursas
 Prepatellar bur sa: between
superficial surface of patella
and skin. May become
inflamed and swollen
(prepatellar bursitis).
 Suprapatellar bursa : superior

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

Kn ee jerk reflex
 The patellar reflex

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

tests spinal nerves
L2-L4.

18. An kl e jo in t i nj ur ies
Ankle sprains
 Sprains are the most common

ankle injuries
 A sprained ankle is nearly
always an inversion injury ,
involving twisting of the weight-
bearing plantarflexed foot.
 The lateral ligament (anterior
talofibu lar ligame nt) is injured
because it is much weaker than
the medial ligament.
 In severe sprains, the lateral
malleolus of the fibula may be
fractured .

Pott ’s fra ctu re
 It is fracture-dislocations of
the ankle joint
 Reason - forced eversion
(abduction ) of the foot
 The Deltoi d ligament
avulses the medial
malleolus and after that
fibu la fracture s at a
higher level
Pott's fracture

Ankle jerk reflex
 Achilles tendon reflex is

tested by tapping the
calcaneal tendon to elicit
plantar flexion at the ankle
joint.
 Both afferent and efferent
limbs of the reflex arc are
carried in the tibi al ne rve
(S1, S2).
 Ankle jerk reflex: tests

spinal nerves S1-S2.

19. Inj ur es o f t he le g and f oo t
Fractur e of t he fibu lar ne ck
 May cause an injury to the common
peroneal nerve , which winds
laterally around the neck of the
fibula.
 This injury results in paralysis of all
muscles in the anterior and lateral
compartments of the leg
(dorsiflexors and evertors of the
foot) and loosing sensa tion on the
dorsum of the foot .
 Causing foot drop .

Rup tur e of t he Achill es tend on
Tri ceps su rae mu scl e
 Avulsion or r upture of the calcaneal

(Achilles) tendon disables the triceps
sure muscle (gastrocnemius & soleus)
so that the patient cannot plantar flex
the foot.
Triceps surae muscle:
 2 Heads of Gastrocnemius m.
 1 Head - Soleus muscle
 Plantaris
 small fusiform belly with long thin
tendon;
 sometimes may become
hypertrophy

Plant ar Fasc ii ti s
(calcane al sp ur )
 Plantar fasciitis is the
most common hindfoot
problem in runners. It
causes pain on the
plantar su rface of the
foot and heel.
 Point tenderness is
located at the proximal
attachment of the plantar
aponeurosis to the
medial tubercle of the
calcaneus and on the
medial surface of this
bone.

20. Inj ur y o f ti bi al n erv e
 In poplit eal fo ssa: loss of

plantar fle xion of foot (mainly
gastrocnernius and soleus
muscles) and weakened
inversion (tibialis posterior
muscle), causing
calcaneovalgus.
 Inabili ty to stand on toes
 Loss of sensation and

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

On soil of the foot there are two terminal
branches of tibial n:
 Medial pl antar nerve supplies:
1. Abductor hallucis,
2. Flexor hallucis brevis
3. Flexor digitorum brevis
4. 1st lumbrical muscles
 skin of medi al 3.5 digits
 Lateral plantar nerve supplies:
 All intrinsic plantar muscles which
are not innervated by medial plantar
nerve
 skin of lateral 1.5 digits

21. Breast
Carc in om a of t he Brea st
 Carcinomas of the
breast are malignant
tumors , usually
adenocarcinomas
arising from the
epithelial cells of the
lactiferous ducts in the
mammary gland
lobules
 1. It enlarges, attaches
to suspensory
(Cooper‘s ) ligaments ,
and produces
shortening of the
ligaments, causing
depression or dimpling
of the overlying skin .

Lym ph ati c dr ain age of t he br east
 It is important because
of its role in the
metasta sis of cancer
cells .
 Most lymphfrom(> 75%),
especially the
latera l breast
quadrants , drains to
the axillary lymph
nodes, initially to the
anterior (pector al)
nodes for the most
part.
 Most of the remaining
lymph, particularly from
the medial breast
quadrants, drains to the
parasternal lymph
75% 25% nodes or to the
opp osit e breast.

Mastectomy
 Radical mastectomy , a more extensive surgical

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

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

22. Tho racic wall & Diaph ragm
Int erc os tal s pace s
Intercostal blood vessels
and nerves:
 run between the
internal intercostal and
innermost intercostal
muscles in the costal
groove
 arranged from superior
to inferior as vein ,
artery , nerve
 Most vulnerable
structures – intercostal
nerve and posterior
intercostal arte ry
because they are not
covering by ribs.

Diaphragm
Paralysi s of h alf and ru pt ur es
 Paralysis of the half

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

Phr eni c n erve
 Arises from the anterior
branches C3-C5 nerves and
lies in front of the anterior
scale ne muscl e.
 Runs ante rior t o the root of
the lung , whereas the vagus
nerve runs posterior to the
root of the lung.
 Innervates the fibrous
pericardium , the
mediastinal and
diaphragmatic p leura e
(sensory innervation ), and
the diaphragm for motor
and its central tendon for
sensory .

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

Openings of the dia phra gm
 Caval (T8): transmits

the IVC and the
terminal branches of
the right phrenic
nerve
 Esophageal (T10):
transmits the
esophagus , right and
left vagus nerves ,
esophageal branches
of the left gastric
vessels
 Aorti c (T12) transmits
the descending aorta ,
thoracic duct ,
azygos vein

23. Card iac hy pert ro ph y
 Left atria l enla rge ment
(hypertrophy) secondary to
mitral v alve fa ilur e may
compress on the
esophagus and manifest
as dysphagia (difficulty in
swallowing).
 It may be observed as a
filling defect in the
esophagus by barium
swallow o n th e latera l
tho racic X-Ray

P-A proj ection
Card iac Shado w

Right border is formed by:
1. SVC,
2. Right atriu m
Left bor der is formed by:

1. Aortic arch
2. Pulm onary trunk
3. Left a uric le
4. Left ve ntri cle
24. Au sc ul tatio n of heart
valves
Right 2 ICS Left 2 ICS
PSL PSL
Left 5 ICS Left 5 ICS

PSL MCL

Auscultation sites for
mitra l and aorti c mu rmurs
≈ 8%
≈ 90%
A heart murmur is heard dow nstrea m from the va lve :

 stenosis is orthograde direction from valve
 insufficiency is retrograde direction from valve
25. Con du ct in g sys tem of th e
heart Sinoatrial (S A) no de

 site where contraction of heart muscle is

initiated (pacemaker of the heart)
 situated in the upper part of the sulcus
terminalis just near to the opening of
th e SVC
 Atrio ven tr icu lar (AV) node
 the AV node receives impulses from the
SA node; situated in the lower part of
the atrial septum near coronary sinus
 Atrio ven tr icu lar b und le of His
 descends from the AV node to the
membranous portion of the ventricular
septum where it divides into the left and
right bundle branches
 Right bundle branch – passes down to
reach the moderator band - right
ventricle
 left bundle branch – passes down left
side of ventricular septum

26. Bl oo d su pp ly o f t he heart
Rig ht c or on ary art ery (RCA)
 It supplies major parts of the right
atrium and the right ventricle .
 It anastomoses with the marginal
branch of the left coronary artery
posteriorly
Branches:
1. Anteri or c ardi ac branc hes –
supplies the right atrium
2. Nodal branch – supplies the (1) SA
node, (2) AV node
3. Margi nal artery – supplies the right
ventricle
4. Posterior interventricu lar a rtery –
supplies (1) diafragmatic (inferior)
surface of both ventricles and (2)
post erior 1/3 of the IV septum

Left cor onary a rtery
(LCA)
Branches:
1. Anteri or (d escen ding)
interve ntricular a rtery – most
comm on place of MI descends in the
anterior interventricular sulcus and
provides branches to the (1) anterior
heart wall, (2) anterio r 2/3 of IV
septum, (3) bund le of His, and (4)
apex of the heart.
2. Circumflex artery – winds around the
left margin of the heart in the
atrioventricular groove to anastomose
with the right coronary artery
posteriorly; supplies the left a triu m
and left ventricle

Blood supply of the conducting
system
 SA nod e – RCA

AV n ode – RCA
 AV b undle (and
mod erator band)- LCA

27. Con genit al c ard iac d efect s
Atrial Septal Defect (ASD)
 It is less frequent than
VSD
 It results from failure to
close of the foramen
ovale after birth (failure of
the septum primum and
septum secundum to
fuse)
 Postnatally, ASDs result
in left-to-right shunting
(betwee n righ t and l eft
atrium ) and are non-
cyanotic conditions.
 If it is small, has no
clinical significance & if
large - necessary surgical
repair

Vent ri cu lar S ept al
Defect (VSD)
 Ventricular septal defect
(VSD) is the most common
of the congenital heart defects
 It may be found in the
membra nous part of the
ventricul ar septum and
results from failure to fuse of
the membranous portion with
the muscular portion of the
ventricular septum
 In this case, present left–to-
right shunt (right ventricular
hypertrophy (RVH)) and
again non-cyanotic.
 Necessary surgery for large
defects

Patent D uc tu s Art eri os us (PDA)
 It results from failure of the ductus
arteriosus (a conn ection b etwe en the
pulm onary trunk and a orta ) to constrict and
close after birth.
 Prosta glandin E and low O 2 tension sustain
patency of the ductus arteriosus in the fetal
period.
 PDA is common in premature infants and in
cases of maternal rubella infection.
 Left – to-right shunt increased pressure in
pulmonary circulation (pulmonary
hypertension) and is non-cyanotic
 Treatment: surgical division and ligation
imperative. In great danger is left recurrent
nerve (wrapping aorta arch). Injure of this
nerve results in hoarseness .

Aneurysm of the aorta
 Aneurysm of th e aorti c ar ch:

compresses the left recurrent
laryngeal nerve , leading to
coughing, hoarseness , and
paralys is of the ipsilateral vocal
cord. It may cause dysphagia
(difficulty in swallowing), resulting
from pressure on the esophagus,
and dyspnea (difficulty in
breathing), resulting from
pressure on the trachea, root of
the lung, or phrenic nerve
 Aneurysm of th e th oraci c aorta

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

Abdominal aortic aneurysm
 It is a localized dilatation of the
aorta. It is typically happened
just above of the bifurcation at
level of L4 and crossed by 3rd
part of duodenum .
 Pulsations of a large aneurysm
can be detected to the left of
the midline at the umbilical
region .
 Acute r upt ur e of an abdominal
aortic aneurysm is associated
with severe pain in the
abdomen or back (mortality rate
is nearly 90%).
 Surgeons can repair an
aneurysm by opening it and
inserting a prosthetic graft.

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

28. Bron ch opu lmo nary
segments
Aspiration of foreign bodies
Aspiration of Fo reign Bodies:
 Inhalation of FB’s (e.g. pins,
parts of teeth, screws, nuts,
bolts, toys) tract

respiratory into the lower
is common,
especially in child ren
 More likely to enter the right
prima ry bronchu s and pass into
the middle or lowe r lob e
bronchi
 If the vertical position of the
body, the foreign body usually
falls into the post erior basa l
segment of the right inferior
lobe.

Right lun g:
10 bro nch opu lmo nary segme nts
Supe rior lobe:

1. Apical
2. Anterior
3. Posterior 1
Middle lobe:
3
4. Lateral
2
5. Medial
Infe rior lobe: 6 4
6. Superior
8 5
7. Anterior basal
8. Posterior basal 10
9. Lateral basal 9
7
10. Medial basal

Left lun g:
9 bro nch op ulm on ary se gments
Supe rior lobe:

1. Apicoposterior
Anterior
2.
3. Superior lingular 1
4. Inferior lingular
2
Infe rior lobe:
5. Superior
6. Anterior basal 3 5
7. Posterior basal
8. Lateral basal 4 7
9. Medial basal 9 8

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

Bron chogenic Carcino ma
 Arises in the mucosa of the

large bronchi
 Produces as persistent,
hemoptysiscough or
productive
 Early metastasis to thoracic
(bronchomediatinal) lymph
nodes
 Hematogenous spread to the
brain, bones, lungs,
suprarenal glands
 A tumor at the apex of the
lung (Pancoa st tumor ) may
result in thoracic outlet
syndrome

Bronc hogenic carcino ma
may lea d t o:
1
1. Thoracic ou tlet syndr ome (TOS)
 It can cause pressure on the lower
trunk of the brachial plexus C8-T1
and subclavian artery by cervical
rib or pancoast tumor. It results in
pain down the medial side of the
forearm and hand and atrophy of
the intri nsic hand muscl es )
2. Horner syn dro me:
2  miosis - constriction of the pupil
due to paralysis of the dilator
pupillae muscle
 ptosis - drooping of the eyelid due
to paralysis of the superior tarsal
muscle
 hemianhydrosis - loss of sweating
on one side

Bron chogenic carcino ma
may lea d t o:
3. Superior vena cava
syndrome , which causes
dilation of the head and
neck veins , facial swelling,
and cyanosis
4. Dysph agia as a result of
esophageal obstruction
5. Hoars eness as a result of
recurrent laryngeal nerve
involvement
6. Paralysi s of t he
diaphragm as a result of
phrenic nerve involvement
3

Qs abou t Auscu ltation
and penetrate d wou nds
 To listen to brea th sou nds of the
superior lobes of the right and left
lungs, the stethoscope is placed on
the superior
chest area of
wall (above thethe anterior
4 th rib for the
th
right lung & above 6 for the left
one).
 For brea th sou nds from the
middle lobe of the right lung , the
stethoscope is placed on the
4
anterior chest wall between the 4 th
and 6 th ribs
6  For the inferior lobes of both
lungs , brea th soun ds are primarily
heard on the posterior chest wall.

30. Open p neumo tho rax
Pleura
 It is entry of air into a pleural
cavity causing lung collapse .
 Open pneumot horax – due to stab
wounds of the thoracic wall which
pierce
the the parietal
pleural cavity ispleura sotthat
open to he
outside air via the lung or through
the chest wall.
 Air m ov es f reely through the
wound during inspiration and
expiration. During inspiration , air
enters the chest wall and the
mediastinum will shift toward other
side and compress the opposite
lung. During expiration , air exits
the wound and the mediastinum
moves back toward the affected
side.

Pleur a & Pleur al Cavity
 1. Cervi cal p leura may be affected in
case of improper subclavian
venipuncture .
 2. Costod iaphragm atic Rece ss is

deepest place in pleural cavity, around
the chest wall, there are two rib
interspaces separating the inferior
limit of parietal pleural reflections from
the inferior border of the lungs and
visceral pleura:
2 1. Midclavicular line - between ribs 6-8
2. Midaxillary line - between ribs 8-10
3. Paravertebral lin e between ribs 10-12

Nerve sup pl y of t he pl eur a
Parietal Pleur a – sensitive to general
sensibilities (pain, temperature, touch,
and pressure) - somatic sensory
innervation :

costckalmay
blo pleura – interco
be used to d stal
ecreanerve
se s
thoracic pain
 mediastinal pleura – phrenic nerve
 diaphr agmatic pleura – phrenic nerve
over the domes and lower 6 intercostal
nerves around the periphery
Visceral Pleura – sensitive to stretch but

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

31. Mediast in um
Superior mediastinu m
 Improperly done
sterna l pun cture
may affect
structures related
to the posterior
surface of the
manubrium
sternum:
 In upper part –
Left
brachiocephalic
vein
 In l ower part –
Aort ic arc h

Thor acic d uct
 Function – conveys to the

blood all l ymph from the
lower limbs, pelvic cavity,
abdominal cavity, left side
of
thethhea
e thorax, left a
d & n eck, side
nd lof
eft
upper limb (3/4 of t he
body )
Tributaries – at the root of the

neck
 Left jugular lymph trunk
 Left subclavian lymph
trunk
 Left bronchom edia stin al
lymph trunk

Constr ictio ns o f the e sophagus
1 There are sites where ingested
foreign bodies can lodge or
where strictures may develop
following ingestion of caustic
fluids, common sites of
esophagea l carcinom a
2 1. C6 - where the pharynx joins

the upper end (6" from the
upper incisors)
2. T4-T5 - where the aortic arch
and left ma in bronch us cross
its anterior surface (10" from the
upper incisors)
3 3. T10 - where it pass es through
the diaphragm into the
stomach (16" from the upper
incisors)

32. An terior abd om in al w all
 The liver and gallbladder
are in the right upp er
quadrant;
 The stomach and spleen

are in the left upper
quadrant;
 The cecum and appendix

are in the right low er
quadrant;
 The end of the descending

colon and sigmoid colon
are in the left lower
quadrant.

Referred a bd om in al p ain
 Pain arising out of the

foregut derived structures
is referred to the
epigastric region .

midgut derived structures
is referred to the
umbilical region .

hindgut derived
structures is referred to
the hypogastric region .

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

Arterial supply of the anterior
abdo min al w all
Important SUPERFICIAL
ARTERIES (supply skin ) are:
1. Superficial epigastric
2. Superficial circumflex iliac
Important DEEP ARTERIES lie in

the neurovascular plane :
1. Superior epigastric
2. Posterior intercostals arteries
3. Lumbar arteries
4. Deep circumflex iliac artery
5. Infe rior epiga stric

33. Herni atio ns
Herni a con sist of 3 parts :
 Hernial sac is a pouch
(diverticulum) of peritoneum and
has a neck and a body
 Hernial contents may consist of
any structure
abdominal found
cavity in the
(more offen –
loops of sma ll inte stine and
piece of omentum major)
 Hernial c overings are formed
from the layers of the abdominal
wall through which the hernial
sac passes

Transversalis fascia is the FIRST
STRUCTURE which is crossed by
any abdominal hernia

Indi rect ing uin al h erni a
 Indirect inguinal hernia is the most
common form of hernia and is believed
to be congenital in srcin (boys 0-3
years).
 It passes through the deep inguinal ring
late ral to, the
vessels inf erior
inguinal epigastric
canal, superficial
inguinal ring and desce nd in to the
scrotum .
 An indirect inguinal hernia is about 20
times more common in males than in
females, and nearly 1/3 are bilateral.
 It is more common on the right
(normally, the right processus vaginalis
becomes obliterated after the left; the
right testis descends later than the left).

Dir ect i ng ui nal herni a
 Dire ct inguinal hernia composes
about 15% of all inguinal hernias.
 During a direct inguinal hernia ,
the abdominal contents will
protrude through the weak area of
the
canalposterior
medial wall of inferior
to the the inguinal
epigastric v esse ls in the inguinal
[Hesselbach's ] triangle and after
that through superficial inguinal
ring. It never descends into the
scrotum.
 It is a disea se of o ld men with
weak abdominal muscles. Direct
inguinal hernias are rare in women,
and most are bilateral.

34. Peri to neal s tr uc tur es
Lesse r omentu m
Consist of 2 ligaments :
 hepatogastric
 hepatoduodenal
Conte nts :
 Right & Left gastric
vessels
 Connective and fatty
tissue
and Portal triad :
 Bi le du ct
 Portal vein
 Proper he patic arte ry

Epip loi c (Wins low ’s) forame n
 Anteri orly: The free

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

part of the
duodenum .

Dou gl as (rectou terine) po uc h
 Rectouterine pouch
(pouch of Douglas) :
deeper point of
peritonea l space in
vertical position of the
female body between the
rectum and the cervix of
uterus .
 It is space of the pelvic
absce ss lo cation .

Culdocentesis
 Culdocentesis is
aspiration of flui d from
the cul-de-sac of
Douglas (rectouterine
pouch) by a needle
puncture of the
post erior va ginal
fornix near the midline
between the uterosacral
ligaments
 Because the
rectouterine pouch is
the lowest portion of
the female peritoneal
cavity, it can collect
inflammatory fluid
(pelvic abscess).

35. Smart Table
FOREGUT MIDGUT HINDGUT
Esophagus Duodenum (2nd, 3rd, Transverse colon

Stomach 4th (distal 1/3)
Duodenum (1st and parts) Descending col on
2nd parts) Jejunum Sigmoid colon
Liver Ileum Rectum (anal canal
Pancreas Cecum (with above pectinate line)
Biliary apparatus Appendix)
Gallbladder Ascending colon
Transverse colon
(proximal 2/3)

FOREGUT MIDGUT HINDGUT
Arter y: CA Arter y: SMA Ar ter y: IMA
Parasympathetic Parasympathetic Parasympathetic

innervation : innervation: innervation:
•Preganglionic: vagus Preganglionic: vagus Preganglionic: pelvic
nerves, CNX nerves, CNX splanchnic nerves, S2-S4
•Postganglionic: •Postganglionic: •Postganglionic:
Termin al gg. Termi nal gg . Termi nal gg.
Sympathetic Sympathetic Sympathetic

innervation: innervation: innervation:
•Preganglionic: greater •Preganglionic: lesser •Preganglionic: lumbar
splanchnic nn., T5-T9 splanchnic nn., T10-T11 splanchnic nn., L1-L2
•Postganglionic: •Postganglionic: •Postganglionic: inferior
celiac ganglio n superior mesenteric mesenteric ganglion
ganglion
Sensor y Innervation: Sensor y Innervation: Sensor y Innervation:
DRG T5-T9 DRG T10-T11 DRG L1-L2
Referred Pain : Referred Pain: Referred Pain:

Epigastrium Umbilical Hypogastrium

36. Pos terio r gast ri c ul cer
1. Posterior gastric ulc er may

erode through the posterior
wall of the stomach into the
Omental bu rsa (Lesser
perito neal sac ) and affect
pancreas resulting in
referred pain to the back.
2. Erosio n of sp lenic arte ry is

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

37. Con genit al d iaphr agm atic
hernia
 Hernia of stomach or
intestine through a
posterolateral defect
in diaphragm
(forame n of
Bochadalek ).
 It is seen in infants
and the mortality rate is
high because of left
lung hypopl asia .

38. Sli di ng hi atal hern ia
 A sliding hiatal hernia which

occurs in individuals past
mid dle age is caused by
the hernia of cardia of the
stomach into th e thorax
through the esophageal
hiatus of the diaphragm.
 This can damage the vagal

trunks as they pass through
the hiatus and resulting in
hypos ecre tion o f gastric
juice.

39. Meck el' s di vert ic ul um
 Meckel's diverticulu m is a congenital
anomaly representing a persistent portion of
the vitellointe stinal d uct .
 This condition is often asymptomatic but
occasionally becomes inflamed if it contains
ectopic gastric,
tissue , which may pancrea
producetic,ulceration.
or endometrial
 Meckel's diverticulu m is located on the
Ileum about 2 feet (61 cm) before the
ileoceca l junc tion and SMA supply it. It
occurs in 2% of patients and is about 2 inc hes
(5 cm) long.
 The diverticulum is clinically important
because diverticulitis , liberation, bleeding,
perforation, and obstruction are complications
requiring surgical intervention and frequently
mimic king the symptoms of acute
appendicitis .

40. Featur es of the large
intestine
Features of the large intestine:
1. Appendices epiploic
2. Sacculations
(haustrations)
3. Taeni ae co li
 The taeniae coli meet
together at the base of
the appendix where they
form a complete
longitudinal muscle coat
for the appendix.

Colon
 The asce nding colon lies
retroperitoneally and lacks a
mesentery.
 It is continuous with the
transverse colon at the right
1
(hepatic) flexu re (1) of colon. 3
 The transverse colo n (3) has
its own mesentery called the
transverse mesocolon
(intrape ritonea l position ).
 It becomes continuous with the
descending colon at the left
(splenic) flexur e (2) of colon.
4
 The sigmoid colon (4) is
suspended by the sigmoid
mesocolon (intraperitoneal
position ).

41. Pain of Ap pend ic it is
 In appendicitis, first pain is
referred around the umbilicus .
Visceral pain in the appendix is
produced by distention of its
lumen or spasm of its muscle.
 The afferent pain fibers enter
the spinal cord at the level of
T10 segm ent , and a vague
referred pain is felt in the region
of the umbilicus.
 Later if parie tal p eritoneum

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

Mc Bur ney's po int
 This point indicates
the surface marking
of the base of the
appendix .

It is a point
junction at the the
between
lateral 1/3 and
medi al 2/3 of a line
joining the right
anterior superior iliac
spine with the
umbilicus .

42. Vol vu lu s
 Because of its extreme mobility,

the Jejunu m, Ileum and
Sigm oid co lon sometimes
rotates around its mese ntery.
It results in avascular n ecrosis
corresponding part of interstine.
 This may correct itself
spontaneously, or the rotation
may continue until the blood
supply of the gut is cut off
completely.

43. Hir sc hs pr un g's Dis ease
 It is a rare congenital abnormality that
results in intestinal obstruction
(megacolon ) because of congenital
absents of postganglionic
parasympa thetic neurons (terminal
ganglia) inside of the wall of large
intestine.
 It is commonly found in Down S yndrom e
children.
 In a newborn, the chief signs and
symptoms are failu re to pass a
meconium stoo l within 24-48 hou rs after
birth, reluctance to eat, bile-stained
(green) vomiting, and abdominal
distension.
 Treatment is removal of the aganglionic
portion of the colon .

44. Br anc hes of Ab do mi nal
aorta and Mesent eri c is ch emi a
 Celiac trunk (CA) srcinates
from the aorta at the lower
border of T12 vertebra
 Superior mesenteric artery
srcinates
border at the
of L1 lower
vertebra
 Renal art eries srcinate at
approximately L2 vertebra
 Inferior mesenteric artery
srcinates at L3 vertebra
 Two terminal branches are
commo n iliac arterie s at
the level of L4 vertebra

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

aortic opening of the
1 diaphragm.

The CA passes
superior above
border of the the
pancreas and then divides
3 into three retroperitoneal
2 branches:
 Left gastri c artery (1 )
 Common h epatic artery (2 )
 Splenic artery (3)

Left ga st ri c art ery
2  The left gast ric art ery (1)
courses upward to the left to
reach the lesser curvature of
the stomach and may be
3 subject to erosion by a
penetrating ulcer of the
lesser curvature of the
1 stomach .
Branches:
 Esoph ageal branc hes (2) - to
the abdominal part of the
esophagus
 Gastr ic br anch es (3) supply
the left side of the lesser
curvature of the stomach and
make anastomosis with right
gastric artery .

Com mo n h epatic artery
 The comm on hepatic artery

(1) passes to the right to
reach the superior surface of
2 the first part of the duodenum,
1 where it divides into its two
terminal branches:
 Proper hepati c artery (2)
 Gastroduodenal artery (3)
3

Pro per hepa ti c art ery
 Proper h epatic artery (1) gives
off righ t gastri c artery ( 2) and
5 then ascends within the
4
hepatoduodenal ligament of the
lesser omentum to reach the
3
port rig ht ,(4)
a hepatis
into the where it divides
and left (3)
hepatic arteries .
 The right and left arteries enter the
two lob es of th e live r , right
1
hepatic artery gives cystic artery
2
(5) to the gallbladder .
 Right gastri c artery (2 ) supplies
the right side of the lesser
curvature of the stomach where it
anastomoses the left gastric
artery .

Gast ro du od enal artery
 Gastroduodenal artery (1)
descends posterior to the first
part of the duodenum (may be
subject to erosi on by a
penetrating ulcer in this place)
and divides into two branches:
1  Right gastro epiploi c artery ( 2)
(supplies the right side of the
greate r curvatur e of the
2 stomach where it anastomoses
the left gastroepiploic )
 Superior pancreaticoduodenal
arteries (3) (supply the head of
the pancreas , where they
3 anastomoses the inferior
pancreaticodu odenal a rteries
from the SMA).

Li gatur e of th e hepa ti c arte ry
 The hepatic artery may be
ligated proximal to the srcin
of its gastroduodenal branch,
a collateral circulation to the
liver is established through
the left a left
arteries, nd righ
a ndtrigh
gastric
t
gastroepiploic and
gastroduodenal arteries .
 The right hepatic artery

may be mistakenly ligated
during holecystectomy in
Calot triangle together with
the cystic arte ry , right lobe
hepa tic necrosis commonly
occurs.

Spl eni c art ery
 Splenic art ery (1) runs a
tortuous horizontal course to
the left along the upper border
of the pa ncrea s, behind the
peritoneum of the posterior

wall of the lesser sac , forming a
part of the stomach bed .
1  The splenic artery may be
subject to erosion by a
penetrating ulcer of the
posterior wall of the stomach
into the lesser sac .
 N.B. The splenic vein runs a

more straight course below the
artery and behind of the
pancreas.

Spl eni c art ery
 Splenic (1) a. is retroperitoneal
5 until it reaches the tail of the
pancreas , where it enters the
1 2 splenor enal ligament to enter
the hilum of the spleen .
3 4 Branches :
 Branches to the spl een (2)
 Branches to the neck , body , and
tail of pancr eas (3)
 Left gastroepipl oic (4) artery that
supplies the left side of the
greater curvature of the stomach
where it anastomoses the right
gastroepiploic
 Short g astric (5) branches that
supply fundus of the stomach

7
1
6 SMA
2
branches
 (1) Inferi or
pancreaticoduodenal
4 arteries
 (2)Jejunal and (3)
Ileal branches
 (4) Ileocolic artery
 Ascending branch
 Anterior cecal artery
 Posterior cecal artery
 (5) Appendi cul ar
3 artery
 (6) Right c oli c artery
5  (7) Midd le coli c artery

1
IMA Branches:
 (1) Left c oli c artery
 (2) Sigmoi d arteries
 (3) Sup erior rectal artery

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

45. Bi li ary sys tem & g all st on es
 Bile is secreted by the liver cells,
stored, and concentrated in the
gallbladder and later it is
delivered to the duodenum .

Thethe
on Gallbladder lies inof
visceral surface it’sthe
fossa
liver right side of quadrate lobe.
 It stores and concentrates bile,
which enters and l eaves it
through the Cystic duct .
 The cystic duct joins the
Commo n hepatic (from Left
and Right hepatic) due to form
the Common bile duct

Bil iary s ystem
in theCommon
The b ile
hepa todu duct li descends
odenal game nt ,
then passes posterior to the first
part of the duodenum
 It penetrates the head of the
pancreas where it joins t he main
pancrea tic duct and they form the
hepatopancreatic ampulla
(sphincter of Oddi) , which drains
into posteromedial wall the
second part of the duodenum at the
major duodenal papilla

Cholelithiasis (gallstones)
 The distal end of the hepato-

pancrea tic ampul la (C ommon bile
duct ) is the narrowest part of the
biliary passages and is the common
4 1 site for impaction of gallstones .

 As result of commo n h epatic (1), bile
duc t (2), or hepatopancreatic
ampulla (3) obstruction patient will
have yellow eyes and jaundice
2
 Gallstones may also lodge in the
3 cystic duct . A stone lodged in the
cystic duct (4) causes biliary colic
(intense, spasmodic pain in the
gallbladder) but doesn't produce
jaundice.

Gallstones
 The fu nd us [1] of the gallbladder is
in contact with the transve rse colo n
and thus gallstones erode through the
posterior wall of the gallbladder and
enter the transverse colon. They are
passed
through naturally to the rectum
the descending colon and 2
sigmoid colon.
 Gallstones lodged in the bo dy [2] of

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

46. Nerv e su pp ly of th e li ver
and g all bl add er
 Sensor y innervation of the liver: by the right

phrenic nerve (C3-C5). Pain m ay radiate to the
r ight shoulder .
 The receives
fromliver
the vagi n erveparasympathetic innervation
s (CNX), reaching it through
the celiac p lexuses around the supplying arteries.
The preganglionic fibers synapse on the cells of
the uxtramural plexuses in hilum of the liver and
shot postganglionic fibers supply organs.
 Sympathetic f ibers of prega nglionic neurons

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

47. Por tal Hype rt ens io n &
Por toc aval sh unt s
 Portal h yperte nsio n is a
common clinical condition, and
for this reason portal-systemic
anastomoses should be
remembered.
 [1] Extra hepa tic porto cava l
shunt for the treatment of
portal hypertension: the
splenic vein may be
anastomoses to the left renal
vein afte r removin g th e
spleen .
 [2] Intra hepa tic porto cava l
shunt : between port al vein
and hepa tic veins

Larg e in testi ne meta st ases &
Por to caval anastom os is
 Metastases of the Large intestine
cancer typically rich the Liver via
por tal ve nou s system: intestine -
IMV - splenic vein - portal vein -
Liver
 If there is an obstruction to flow
through the portal system (portal
hypertension ), blood can flow in a
retrograde direction and pass
through anastomoses to reach the
caval system . Sites for these
anastomoses include:
 (1) esop hageal veins
 (2) paraumbili cal veins
 (3) rectal vein s

Eso ph ageal anastom os is
 Anastomosis between the

tributaries of the left ga stric
vein (portal vein) and the
tributaries of the azygous
vein (SVC) in the wall of the
low er end of the esophagus .
 In portal hypertension these

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

Umbi lic al anasto mos is
para umbi lical veins (portal
vein) and the superior and
inferior epigastric veins
(SVC and IVC) in anterior
abdominal wall around the
umbilicus .
 In portal hypertension, this
anastomosis gets enlarged
and dilated veins form “caput
Medussae” around the
umbilicus .

Rect al anastom os is
superior rectal vein
(inferior mesenteric vein
and then portal vein ) and
inferior rectal vein which
drains
vein into IVC
(from the internal
system).iliac
 In portal hypertension
(chronic alcoholics ) this
anastomosis gets dilated
resulting in internal
hemorrhoids and bleeding
per anus from superior
recta l vein.

48. Pancreas
Head and un cin ate pro cess
 The head of t he pancreas

rests within the C-shaped
area formed by th e
duodenum and is
traversed by the common
bile duct .
 It includes the uncinate

process which is crossed
by the superior
mesenteric vessels .

Pancreatic adenocarcinoma
 Cancer of the head of th e pancr eas
compr esse s th e bile duct and results in
OBSTRUCTIVE TYPE OF JAUNDICE .
 Pain will be conveyed to sensory
neurons T5-T9 dor sal roo t gangl ia via
celia c p lexus and grea ter splanchn ic
nerve. To provide pain relief, during the
surgery ablation of the sensory
innervation that carries pain in this region
may be performed by injection 50%
ethanol around celiac artery .
 This type of jaundice is NOT usually
assoc iated with fever .
 Hepatitis also causes jaundice but is
associate d wit h the fever .

Neck of th e panc reas
 Posterior to the
3 neck of the
1 pancreas is the site
of formation of the
PORTAL VEIN.
2
 (1)Spleni c vein
joins with (2)
superior
mese nteric vein to
form (3) port al vein .

Bo dy o f th e pancrea s
 The body passes to the

left and anterior to the (1)
aorta and the (2) left
1 kidney.
3
 The (3) splenic arte ry
undulates along the
superior border of the
2 body of the pancreas with
the splenic vein coursing
post erior to the b ody .

Tail of th e pancr eas
 The tail of the pancreas

enters the splenorenal
ligament to reach the
hilum of t he spleen .
 It is the only part of the
pancreas that is
intraperitoneal.
 Tail of the pancr eas may
be mistakenly removed
during spleenectomy
(ligation of splenic arte ry
and vein) and resulting in
suga r dia betes because it
contains a lot endocrine
cells.

Arterial supply of the pancreas
Head and Duodenum :
 (1) Sup erior
pancreaticoduodenal arteries -
branches of gastroduodenal
artery.
 (2) Inferior pancreaticoduo
arteries - branches of SMA denal
 This region is important for
3 collate ral c irculation because
there are anastomoses between
1 these branches of the CA and
SMA.
2
Neck , Body , and Tail of the
pancreas:
 Pancreatic branches of the (3)
Splenic artery.

Annular Pancreas
 Annular pancreas is caused by
malformation during the
development of the pancreas,
before birth.
 Occurs when the ventral and dorsal
pancreatic buds form a ring around
the duodenum , thereby causing an
obstruction of the duode num and
polyhydramnios
 Symptoms:
1. Feeding in tolerance in newborn s
2. Fullness after eating
3. Nausea and bile-sta ined vomiti ng
 Half o f cases are not diagnosed
until symptoms occur in adulthood .

49. Spl een
Rapt ur e of th e Spl een
 Raptu re of the spl een may be
result of the left 9 th and 10 th ribs
fracture or blunt trauma of the
left upper abdomen.

The
in thespleen
upperisleft peritoneal
a qu organ
adra nt that is
deep to the left 9 , 10 , and 11 th
th th
ribs.
 The spleen follows the contour of
rib 10 (axis of t he spl een).
 When blood collected deep to the
diaphragm phrenic nerve
irritates and pain may irradiate to
left shoulder .
 When spleen is ruptured, it
cannot be sutured therefore
removing is required.

Relation s o f th e Spl een and Left
Kidney
 The spleen follows

the contour of 10th rib
and extends from the
superior pole of the
left kidney to just
posterior to the
midaxillary line.
 The bor der betw een

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

50. Kidneys
Dime nsion s and posit ion
 During life, kidneys are
reddish brown and measure
approximately 11-12 cm in
length , 5-6 cm in width , and
2.5-3 cm in thi ckne ss .
 They are extending from the
level of T12 to the level of L3,
the ri ght ki dne y lying about
2-3 cm low er than the left
one.
 The lateral border of the
kidney is convex. Its medial
border is convex at both ends
but concave in the middle
where there is the hilum of
the kidney (L1).

Anterior relations of the right
kidney
1. Right supr arenal gland

2. 2nd part of the
duodenum
3. Right lobe of the liver
4. Right colic fle xure
5. Small intestin e

Anterior relations of the left
kidney
1. Left sup rare nal gl and

2. Stomach
3. Spleen
4. Body of pancrea s and
splenic vessels
5. Descending co lon
6. Small intestine

Renal (Gerota) fasci a
 Enclosing the perinephric fat is
a membranous condensation
of the extraperitoneal fascia -
the renal fascia (3) .
 The sup rarena l g lands (4) are
4 also enclosed in this fascial
compartment, usually
separated from the kidneys by
a thin septum.
 N.B. The renal fascia must
3
be incise d in any surg ica l
approach to this organ.

Peri nephri c abs cess
 Most infections of the perinephric

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

51. Neph ro li thi asi s
 Renal calcul i are solid concretions
(crystal aggregations) formed in the
kidneys from dissolved urinary minerals.
 There are several types of kidney
stones. The majority are calcium
oxalate stones, followed by calcium
phosphate stones.
 Kidney stones typically leave the body
by passage in the urine stream, and
many stones are formed and passed
without causing symptoms.
 If stones grow to sufficient size before
passage (at least 2-3 mm), they can
cause obstruction of the urete r (renal
colic).

3 const ricti ons of ure ter
1  Ureter located on the anterior

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

Stagho rn calcu li
 Renal stone that develops in the
renal pelvis and g reater calices ,
and in advanced cases has a
branching configuration which
resembles the antlers of a stag .
 Staghorn calculi are composed of
magne sium ammonium
phosphate , which forms in urine
that has an abnormally high pH
(above 7.2).
 This high pH usually develops
because of recurrent urinary tract
infection with microorganisms
such as Proteus mirabili s.

52. Sup rarenal g land s
 They are endocrine glands
having cortex and medulla.
 The adr enal corte x [1]
secretes corticosteroids :
Aldost erone,
and Genital Hydrocortisone
horm ones.
 The chromaffin cells of the adrenal medulla [2]

secrete two catecholamines : Epinephrine and
1
Norepinephrine , which affect smooth muscle, cardiac
muscle, and glands in the same way as sympathetic
2 stimulation.
 Sympathetic stimulation or hypersecretion of
catecholamines (tumor of a dre nal medulla or
sympa the tic cha in ganglia ) resulting in: episodes of
tachycardia , sweating and high blood pre ssure .

Unp air ed t ri bu tarie s o f IVC
 The rig ht r enal (1) vein is
much shorter than the left.
3 Both veins lie anterior to the
corresponding artery in
2 hilum of kidneys.
 The long left renal v ein (2 )
1 is joined by the left
4 suprarenal (3) and left
go nadal (4 ) (testicular or
ovarian) veins before it
reached IVC.
 Right supra renal vein and

righ t gona dal vein drain
dir ectly t o IVC (unpaired
IVC tributaries).

53. Varicocele
 It is enlargement of the
pampiniform plexus that
produces a wormlike scrotal
mass and enlargement of the
sperma tic cor d . Varicocele
may be reason of low spe rm
count .
 Varicocele formation is usually
on the left si de and may
disappea r in supi ne position
of the body.
 Varicocele may indicate
kidney d isea se or may signal
a retro peritoneal malignancy
obstructing the testicula r
vein.

Pampi nif orm p lexus
 Each testicular or ovarian vein is

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

54. Hyd rocele
 The tuni ca vaginalis testis or

other remnants of the processus
vaginalis may form a hydrocele
or hematocele.
 In spe rmatic cor d it is smooth
sausage-shaped structure that
persists under gentle
compression and isn’t disappear
in supine position.
 In the scrot um with
transillumination , a hydrocele
produces a reddish gl ow ,
whereas light will not penetrate
other scrotal masses such as a
hematocele , solid tumor , or
herniate d bow el .

55. Hemo rr ho id s
Veno us dr ain age fr om r ect um
 Above pectinate line: superior
rectal vein [1] into portal
2 system [2] .
4
 Below pectinate line: inferior

rectal vein [3] into inferior
vena cava [4] .

Exte rnal hemorrh oid s
 Hemorrhoids are masses that

typically protrude from anus
during defecation .

Hemorrhoids
associated withareconstipation
commonly ,
extended sitting and straining at
the toilet, pregnancy , and
disorders that hinder venous return.
 1. External hemorrhoi ds are
1 dilated tributaries of the inferior
rectal veins (IRV) BEL OW THE
PECTINATE LINE and are painful
because the mucosa is supplied by
somatic afferent fibers of the
1 inferior rectal nerves (from
pudendal).

Interna l h emor rho ids
 2. Internal hemorrhoids
are dilated tributaries of the
superior rectal veins
(SRV) ABOVE THE
PECTINATE L INE and are
not painful because the
mucosa is supplied by
visceral afferent fibers.
 Internal hemorrhoids
2
frequently develop in
chronic alcoholics
2 because of liver cirrhosis
2 and portal hypertension
syndrome.

56. Perineal p ouches
Deep p eri neal p ou ch
The deep perineal pouch is

formed by the fasciae and
muscles of the urogenital
diaphragm.
It contains:
1. Sphincter urethrae
muscle
2. Deep transverse
perineal muscle
3. Bul bo urethr al
(Cowper ) glands (in
the male only ) - ducts
perforate perineal
membrane and enters
bulbar urethra.

Sup erf ic ial perin eal po uc h
1. Ischiocavernosus muscle – related to the Crus of th e
penis (Male) & Crus of the clitoris (Female)
2. Bulbospongiosus muscle – related to the Bulb of
vestibule (Female) & Bulb of the penis (Male)
3. Superficial transverse perineal muscle – related to the
Perin eal bo dy (both genders)

Uri ne leaks
 After a crushing blow or a
penetrating injury, the spongy
urethra commonly ruptures
within the bulb of the pe nis , and
uri ne lea ks into the superficial
perinea l po uch .
 The superficial perinea l fascia
keeps ur ine from passing into the
thigh or the anal triangle, but after
distending the scrotum and penis,
urine can pass over the pubi s into
the ante rior abdominal wall deep
to the deep layer of superficial
abdominal fascia.

57. Isc hi or ect al abs cess
 Ischiorecta l absce ss [1] is an important
surgical condition which usually results
from spread of an infection through the
external sphincter ani into the
ischi orecta l fossa [2].
 Ischiorectal abscess is a surgical
2 emergency which should be
immediate ly drained by a wide cruciate
incision through the skin of the base of
the fossa to avoid fistula formation.
 A surgeon should avoid latera l wall of
3 ischiorectal fossa because here located
Pudendal ( Alcoc k's ) cana l [3] with
pudendal n erve and internal pudendal
1 artery.

58. Cyst ocele
(herni a of bl add er)
 Loss of bladder support in
females by damage to the
pelvic floor during childbirth
(e.g., laceration of perineal
muscles or a lesion of the
nerves supply).
 It can result in protrusion of
the bladder onto the
ante rior vagina l wall and
loss of urine when a women
strains or coughs.

59. Parace nt esi s of ur in ary
bladder
Suprapubi c aspiration :
 Urine can be removed from
bladder without
the peritoneum penetrating
by inserting a
needle JUST ABOVE the
pubic symphysis.
 The needle passes
successively through skin,
superficial and deep layers of
superficial fascia, linea alba,
transversalis fascia,
extraperitoneal connective
tissue, and wall of the bladder.

60. Pro st ate tum or s
Pro st ate cancer
 It usually begins in the posterior

lobe of the gland, and early
stages are often asymptomatic,
may be found during digi tal
rectal examination .
 Prostatic malignancies tend to
metastasize to vertebrae and
the brain because the prostatic
venous plexus has numerous
connections with the vertebral
venous pl exus via sacra l veins .
M
A
P

Benign hype rtro phy of the
pr os tate ( BHP)
 BHP is common in men after

mid dle age.
 Prostate a denom a (benign
hypertrophy)
media n lob e.usually involves
 BHP is a common cause of
ure thral obstructio n , leading
to nocturia (need to void
during the night), dysuria
(difficulty and/or pain during
urination), and urgency
(sudden desire to void).
 The pros tate is exa mined for
enlargement and tumors by
DIGITAL RECTAL
examination.

Prostatectomy
 A prostatectomy may be performed
through a suprapubic [1] or
perineal [2] incision or
transurethrally [3] .
1  Because of damage to nerves in
2 the capsule of the prostate and
around the urethra (cavernosus
nerves ) can cause impotence
(erecta ile dysfun ction ) and/or
ur inary incontinence.
 Pelvic spl anchnic n erve s may be
3 injured in case of intensive
dissection of pelvic lymph nod es
Transurethral (prostatic cancer ectomy) and as
resection of the result autonomic innerva tion of
prostate = TURP derivate of hindgut may be
affected.

61. Male ur ethra
Pro st ati c 1st part
 It is the wide st and the most
dilatable part.
 It is spindle shaped (middle part is
dilated)
 Its posterior wall presents the
following features:
1. Seminal colliculus
2. Opening s of the 2 eja culatory
ducts are seen on each side on
the seminal colliculus.
3. Ducts of the prostate gland open
into the male urethra

Memb ranou s 2nd part
 Passes through the
urogenital
diaphragm to enter
the bulb of the penis
 It is the shortest,
NARROWEST and
the least dilatable part
 It is surrounded by the
exte rnal sph incter
urethra
 Bulbourethral
glands lie
posterolateral to this
part inside of
urogenital diaphragm
(deep perin eal
pouch )

Spo ngy 3rd part
 Longest part: average 15

cm in length.
 Passes through the bulb
and corpus spongiosum
of the penis
external to open
urethral at the
orifice on
the tip of the glans penis.
 There are two dilatations
– bulbar fossa (in the
beginning) and navicular
fossa (in the glans penis)
 Ducts of the
bulbourethral glands
open into the floor of the
spongy part in its
beginning

2 sph inc ters of the ure thr a
1. Internal urethral
sphincter is made of
smooth muscles in the
neck of the bladder
and has sympathetic
innervation
1
2. External urethral
2
sphincter has skeletal
muscl e fibers and
surrounds the
membranous part of
urethra , supplied by
the perineal branch of
the pudendal nerve

62. Ejacul ato ry du ct
 It is a very narrow duct

2 cm lo ng
 Formed by union of
ductu s defere ns and
duct of seminal vesicle
 It serve to passage of
seminal flui d from
ductu s defere ns to
prost atic urethra .

63. Pud end al n erv e (S2-S4)
 It is PRINCIPAL SOMATIC (motor and
sensory) nerve to supply perineum .
 Lies against ischial spine as it passes
through lesser sciatic foramen to
traverse
wall pudendal
of ischior ecta lcana l on lateral
fo ssa.
Branches:
 1. Inferior rectal nerve
 Supplies external a nal sphi ncter
muscle and skin around anus
3  2. Perineal nerve
1  Deep branch is motor nerve to muscles
of urogenital triangle.
2  Superficial branch gives cutaneous
post erior scrot al/labial branches .
 3. Dorsal nerve of penis or clito ris
 Supplies body, prepuce, and glans of
penis or clitoris

Pud end al n erve bl oc k
 To relieve pain for the mother and

prepare for an episiotomy , a
pudendal nerve block may be
administered during early labor.
The nerve may be blocked in 2 ways
either :
1. by piercing the vaginal wall
posterolaterally near the ischial
spine or
2. percutaneou sly along the medial
side of the ischial tuberosity .
 Note: Pain from uterine contractions is
unaffected because pelvic visceral
pain is carried by afferent fibers
accompanying autonomic nerve fibers.

64. Nerv e su pp ly of pelvi c
viscera
Parasympathe tic innervation :
 Preganglionic neurons are located in sacral parasy mpathetic n.
(S2-S4) in the spinal cord.
 Their processes run into pelvic spla nchnic nerve s and relay with
postganglionic neurons located inside of pelvic organs in the
term inal ganglia .
Sympathetic innervation:
 Sympathetic fibers of preganglionic neurons T12-L2 segments (IML)
come through the sympathetic trunk and form sacra l splanchnic
nerves .
 They contribute to the inferior hypoga stric plexus , where
postganglionic neurons are located. Branches of inferior hypogastric
plexus reach organs wrapping around the branches of the internal iliac
artery.
Sensor y innervation:
 The sensory fibers from S2-S4 dorsal ro ot g anglia move together
wit h para sympathetic and carry pain sensations from the organs.

Mict uri tio n re flex
Facilit ating emptying:

 Parasympathetic fibers (pelvic
1 splanchnic nn.) stimulate
DETRUSOR MUSCLE [1]
contraction and involuntary relax
internal sphincter [2].
2  Soma tic mot or fibers (pudendal
nerve) cause voluntary
relaxation of external [3] urethral
sphincter.
3
Inhibiting emptying:
 Sympathetic fibers (sacral
splanchnic nn.) inhibit detrusor
muscle [1] and stimulate
internal sphincter [2].

65. Erect io n and ejacul ati on
 Afferen t fibrous: Dorsal nerve of penis or clitoris from
Pudendal nerve (DRG S2-S4)
 Effere nt fi brou s:
 Erection: Parasympath etic fib ers (S2-S4) from the
Pelvic spl anchnic n erve s dil ate arteries supplying
erectile bodiescofmo
blood. Somati the
to penis, allowing
r (S2-S4) them
fibrous fromtothe
fill with
pudendal n erve s cause contraction of
ischiocavernosus and bulbospongiosus muscles to
press the root of the penis and relax e xternal ureth ral
sphincter .
 Ejaculation: Sympathetic fibers (L1-L2) from the
Infe rior h ypogastric plexus (S acra l sp lanchnic
nerves) cause contraction of smooth muscl e of
epididymis, ductus deferens, seminal vesicles, and
prostate; sympathetic nerve fibers stimu late interna l
urethral sphincter to prevent semen from entering
bladder or urine entering prostatic urethra.

66. Cryp to rc hi sm
 Undescended testes
(cryptorchism) when the testes
fail to d esce nd into the scrotum.
This normally occurs within 3
months after birth.
 The undescended testes may be
found in the abdominal cavity or
in the ingu inal cana l .
 If neglected, malignant
transformation may occur in the
undescended testis.
 Note: In case of cryptorchism,
spermatogenesis is arrested
and the spermatogenic tissue is
damaged leading to permanent
sterility in bilatera l cases.

67. Tor si on of th e sp erm ati c
cord
Main components of the spermatic cord:
 Ductus deferens
 Testicular a rte ry – direct bra nch o f
Aorta

Pampinifo
single rm plexus
testicular to become
vein (right → IVC, left
→ Left renal vein)
 Torsion of the spermatic cord

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

68. Lym ph atic dr ain age of
the male vi sc era
 Testis & epididymis – lumbar
lymph nodes
 Scrotum – superficial inguinal
nodes
 Penis :
 skin - superficial inguinal nodes
 glans – deep ingui nal nodes
 body and roots – internal iliac
nodes
 Prostate gland & bladder - internal
iliac nodes
 Anal canal:
 above pectinate line - internal iliac
 below pectinate line - superficial
inguinal nodes

Lymp hatic draina ge from the
fema le vis cera
 Ovary and uterine tubes – to Lumbar
lymph nodes
 Uterus:
 lateral angle and teres ligament –
Superficial i nguinal lymph nodes
 fundus and upper part of the body

- Lumbar
lower partlymph
of the nodes
body - External
iliac lymph nodes
 cervix - External & Internal iliac
 Vagina :
 Superior to hymen - to External &
inte rna l ilia c
 Inferior to hymen - to Superficial
inguinal nodes
 All ext ernal genit alia (with exception -
glans clitoris) - Supe rficial inguinal
lymph nodes
 Glans clitoris – Deep in guin al

69. Ar teria l s up pl y o f t he
ut eru s and Hystere ct om y
The uterus is almost exclusively
supplied by the uterin e arteries
4 [1] (from in ternal iliac artery):
2  Uterine a. crosses pelvic floor in
cardinal lig ament [2]
1
 Ureter passes post erior a nd
3 inferior to the uterine artery [3]
 Ascending branch [4] of uterine
artery comes along latera l wall of
uterus within broad ligament.
Note: During hysterectomy ureter in the
greatest risk because of close relations
with ute rine artery and cervix of the
uterus.

Hysterectomy
 Hysterectomy is surgical removing of the
uterus and may include removing of the cervix
(total) and the vagin a (radical).
 Blood supply to the ovaries is saved in case of
partial hysterectomy ovarian suspensory
ligament should be left intact because contain
ovari an artery (direct branch of abdominal
aorta) and vein.
 In case of total hysterectomy (with cervix)
pelvic splanchnic nerves may be affected.
That’s resulting in bladde r dysfunction
because of detrusor urin e muscl e loose
parasympathetic innervation.

70. Part s o f t he ut eri ne tub e
 Uterin e part
 Pierces uterine wall to
open into uterine cavity
 Isthmus

Narrowest
just part
lateral to of tube
uterus
 Ampulla
 Medial continuation of
infundibulum comprising
about half of uterine tube
 Usual site of fertilization
 Infundibulum
 Funnel-shaped expansion
of lateral end, fringed with
fimbriae
 Overlies ovary and
receive s oocyte at
ovulation

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

71. Br anc hes of the Int ern al
il iac art ery
Anteri or Division Posterior Division
1.Obturator 1.Iliolumbar
2.Umbilical 2.Lateralsacral
3 Inferior gluteal 3. Superior gluteal
4. Internal p ud endal
5. Inferior vesic al (males)
or
Vaginal (females)
6. Midd le rectal
7. Uterin e (females)

Internal il iac artery

72. Fracture of the
ant erio r cr ania l f oss a
 Fracture of the ante rior crania l
fossa (Cribri form plate of the
Ethmoid bon e) is suggested by
anosmia , periorbital bruisin g
(raccoon eyes), and CSF leakag e
from the nose (rhinorrhea ).

73. Cranial M alf ormati ons
 [A] Scaphocephaly: premature
closure of the sagittal suture , in
which the anterior fontanelle is small
or absent, results in a long , narrow ,
wedge-shaped cranium.
 [C] Oxycephaly : premature closure
of the coronal suture results in a
high , tow er-like cranium.
 When premature closure of the
coronal or the lambdoid suture occurs
on one side only , the cranium is
twisted and asymmetrical, a condition
known as plagiocephaly [B] .

74. Epi dur al hemato ma
 Skull fracture near pterion often
causes epidural hematoma from
torn midd le meningea l arte ry
(foramen spinosum ).
 Unconsciousness and death are
rapid because the bleeding
dissects a wid e spa ce as it strips
the dura from the inner surface of
the skull, which puts pressure on
the brain.
 An epidural hematoma forms a
characteristic bico nvex patte rn
on computed tomography
images.

75. Inf ect io n o f th e cave rn ou s
sinus
Structures which may be affected by
caver nous sinu s thrombosi s :
1. Structures that pass through
sinus directly:
 Internal ca rot id artery (in case
of laceration - arteriovenous
fistula )
 Abducens nerv e CN VI (in case
of lesion - internal squint )
2. Structures on lateral wall of

sinus:
 Oculomotor nerve (CN III)
 Trochlear nerve (CN IV)
 V1
 V2

76. Dang ero us tri ang le of th e
face
 The midd le third o f the face
is a "danger area“ because
infection there may produce
thrombophlebitis of the facial
vein that can spread to the
cavernous sinus via
ophthalmic veins or
ptery goid venous plexus.
 Septicemia leads to
meningitis and cavernous
sinus thrombo sis, both of
which can cause neurological
damage and are life-
threatening.

77. Pit ui tary g land tu mo rs and
tr ans sph enoid al o peratio n
2 1
 Pitui tary tumors [1] may extend
superiorly through opening in the
diaphragma sella, producing
disturbances in endocrine system .

Superior extension
cause visual deficit of a tumor
owing may
to pressure
on the opti c chia sm [2] , the place
where the optic nerve fibers cross.
 The transsphenoidal operation is the
most common operation for a pituitary
tumor. The surgical approach for it is
through the nose, nasal cavity and
sphe noida l si nus [3] . This surgical
3 approach provides the best exposure
of the tumor at the lowest risk.

Horm ones of th e pit uit ary g land
 Releasing and inhibiting factors
from neurosecretory cells of the
hypothalamus reach pituitary
gland thought special capillary
network – hypophyseal portal
system and control the production
of adenohypophyseal hormones
(ACTH, FSH, LH, TSH, pro lactin
and somatotropin ).
 Hormones of neurohypophysis
(ADH and Oxytocin ) are secreted
in hypothalamus and transported
through axons to pituitary gland.

78. Trig emi nal n erv e
 Skin of face supplied

by branches of the
three divisions of the
[1] TRIGEMINAL
NERVE (CN V)
1
 Except for a small
area over the angle
of the ma ndib le
which is supplied by
Infraorbital the [2] great
foramen auricular nerve
(C2-C3) – cervical
plexus
2

79. Bell 's pals y
 It is idiopathic unilateral facial
paralysis.
 Terminal branches of CN VII
may be injured by parotid
cancer or inflammation
(parotitis) by surgery to
remove a parotid tumor
(stylomastois fo rame n) .
 Manifestations:
 unable to close lips and eyelids on affected side
 eye on affected side is not lubricate d (dry e ye)
 unable to whistle , blow a wind instrument, or chew effectively
 facial distortion due to contractions of unopposed contralateral facial
muscles

80. Epis taxis
 Epistaxis (nosebleed)
most often occurs from
the anterior nasal septum
(Kiesselbach's area),
where branches of the
sphenopalatine ,
ante rior ethmo idal,
greater p alatin e, and
superior labial (from
facial) arteries converge.

81. Sin us it is
Sphenoiditis
 Relationships of the
sphenoida l sinus are clinically
important ; because of potential
injury during pituitary
surgery and the possible
sprea d of infection .
 Infection can reach the sinuses
through their ostia from the
nasal cavity or through their
floor from the nasopharynx .
 Infection may erode the walls to
reach the cavernous sinuses,
pitu itary gla nd , opti c nerve s,
or opti c chia sma

Ethmoiditis
 Infection in the ethmoidal
sinuses can erode the medial
wall of the orbit, resulting in
orbit al cellulites that can
spread to the cranial cavity.
 In orbital cavity infection may
erode structures related to the
medial orbital wall:
 Medial rectus mus cle
 Superior oblique muscle
 Nasocil iary n erve

83. Cheeks
 Form the lateral, mov able walls of
the oral cavity and the zygomatic
prominences of the cheeks over the
zygomatic bones.
1

Buccinator
of the cheek.[1] – principal muscle
2  Buccal pad of fat – encapsulated
3 collection of fat superficial to
buccinator.
 Parotid duc t [2] from Parotid g land
[3] perforate buccinator and opens in
inner surface of the cheek right
opp osi te 2nd upper molar tooth

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

85. Inn ervatio n o f th e to ng ue
1. Senso ry ant erior 2/3 : general – lingual n. (V3),
taste – chorda tympani (CNVII)
2. Sensory posterior 1/3 : general and taste –
glossopharyngeal (CNIX)
3. Motor – hypoglossal (CNXII)

 A lesion of the chorda tympani – lose of the taste
sensation anterior 2/3 of the tongue
 A lesion of the ling ual nerve – lose of both
general a nd taste sensation anterior 2/3 of the
tongue
 A lesion of CN XII (hypoglos sal c anal) allows the
contralateral, unparalyzed genioglossus muscle to
pull the protruded tongue toward the paralyzed side
(deviation a nd atrophy o f the tongue ).

86. Gag reflex
 Touching the posterior part of the
pharynx results in muscular
contraction of each side of the
pharynx - gag reflex:
 Afferen t limb: CN IX
 Effere nt lim b: CN X
 Injury to the
GLOSSOPHARYNGEAL NERVE
(CN IX) will result in a negative
gag reflex

87. Palatin e to ns il s
 Receives main blood su pply

from tonsillar bra nch of
facial artery
 Drained by lymph vessels
mainly to jugulodigastric
lymph node , which is body's
most fre que ntly enlarged
lymph node
 Nerve su pply: tonsillar
plexus of nerves formed by
branches of CN IX and CN X

Tonsillitis
 During pala tine to nsil lectomy, the
peritonsillar space facilitates tonsil
removal, except after capsular
adhesion to the superior constrictor.
 If the glos soph arynge al nerve
CNIX is injured, taste and general
sensation from the posterior 1/3 of
the tongue are lost.
 Hemorrhage may occur, usually
from the tonsillar branch of the
facial artery ; if the superior
constrictor is penetrated, a high
facial artery or tortuous internal
carotid artery may be injured.

88. Mus cles o f Soft Palate
1. Tensor veli p alatini and

2. Leva tor v eli pala tini – elevates
the soft palate during swallowing
to prevent food entering to the
nasopharynx
3. Palatoglossus and
4. Palatopharyngeus – depress
soft palate and pulls walls of
pharynx superiorly
5. Uvular muscle – shortens uvula
and pulls it superiorly

89. Lym ph dr ain age fr om face
1. Preauricular (parotid ) (on front
of auricle) receive lymph from
anteriol ateral part of scalp
(including eyelids)
1 2. Submandibular (in di gastric or

submandibular Δ) – from all air
sinuses, nose and adjacent
cheek , upper lip and lateral
parts of lower lip.
3 3. Submental (in subm enta l Δ) –
2 from the chin, tip of the tongue
and centra l part of the lower
lip.

90. Blow-out fracture
 A blow-out fracture of the
orbital floor typically is not
involve the orbital rim and is
caused by blunt trauma to the
orbital contents (e.g., by a

handball). Content of orbital
cavity blow-out in maxillary
sinus .
 Blow-out fractures may damage:
1. Infe rior rectus mus cle
2. Infra orbi tal nerve (from
maxill ary V2 )
3. Infra orbital arte ry
(hemorrhaging ).

91. Mus cl es o f th e or bi t
Muscle Action Innerva-

tion
Superior rectus Elevates and adducts CN III
pupil
Inferior rectus Depresses and adducts CN III
pupil
Medialrectus Adductspupil CN III
Lateralrectus Abductspupil CN VI
Superior oblique Depresses and abducts CN IV
pupil
Inferior oblique Elevates and abducts CN III
pupil
Levator pulpebra superior Elevates upper eyelid CN III

92. Str abi sm us
Ocu lo mo to r n erve p als y (CNIII)
 Oculomotor Nerve Palsy

(external squint) affects most of the
extraocular muscles

Manifestations :
 ptosis ,
 fully dilated pupil ,
 and eye is fully depressed and
abducted (“down and out ”) due to
unopposed actions of superior
oblique and lateral rectus,
respectively.

Troc hl ear n erve pals y (CNIV)
 Lesions of this nerve or its nucleus
cause paralysis of the superior
oblique and impair the ability to turn
the affected eyeball infero-medially
(pupil look superio-laterally )
 The characteristic sign of trochlear
nerve injury is diplopia (double
vision) when looking down (e.g.,
when going dow n sta irs )
 The person can compensate for the
diplopia by inclining the head
anteriorly and laterally toward the side
of the normal eye.

Abducens nerve palsy (CNVI)
 Abducens Nerve Palsy

(internal squint). Injury to abducens
nerve  paralysis of lateral rectus
 inability to abduct the affected
eye
 Affected eye is fully adducted by
the unopposed action of the medial
rectus that is supplied by CN III

93. Hor ner s yn dr om e
 Penetra ting injury to the neck,
Pancoast tumor, or thyroid carcino ma
may cause Horner syndrome by
interrupting asce nding prega nglionic
sympathetic fibers anywhere between
their srcin in the T1 segmen t ( IML) of
spinal cord and their synapse in the
Supe rior cervica l ganglion.
 It includes the following signs:
 Constriction of the pupil (miosis )
 Drooping of the superior eyelid
(ptosis ),
 Redness and increased temperature
of the skin (vasodilation )
 Absence of sweating (anhydrosis )

94. Otitis Media
 Hearing is diminished because of
pressure on the eardrum and
reduced movement of the ossicles.
 Taste may be altered because the
chor da tympani is affected.

 Infection spreading posteriorly
cause mastoiditis.
 Infection that spreads to the
midd le cranial fossa can cause
meningitis or temporal lobe
abscess, and infection moving
through the floor may produce
sigmoid sinus thrombosis.

Perfo ratio n o f t he tympa nic
membrane
 May result from otitis media and is
one of several causes of middle ear
(conduction) deafness
 Causes: foreign bodies in external
acoustic meatus, excessive pressure
(as in diving), trauma
 Because chorda tympani directly
relates to the posterior surface of the
tympanic membra ne it may be
damaged and resulting in loss of
taste over a nterio r 2/3 of the tong ue
and secretion of the sublingua l and
submandibular glands
 Minor perforation heal spontaneously;
large ones require surgical repair

95. Thyr oi d and para th yro id
glands
Hormones:
 The thyroi d gl and is the body's largest endocrine
gland. It produces thy roi d ho rmo ne (T3 & T4) ,
which controls the rate of metabolism (increase
the temperature of the body), and calcitonin , a
hormone controlling calcium metabolism (reduce
blood calcium Ca2+).
 After total t hyroide ctomy may develop lower
temperature of the body and hypercalcemia .
 The hormone produced by the parathyroid

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

Anatomical relations of the
thyroi d gla nd
 Anter olater al –
infrahyoid muscles
1  Posterolateral –
COMMON CAROTID
ARTERY [1]
 Medial – larynx,
TRACHEA [2] ,
pharynx, esophagus,
cricothyroid muscle,
recurrent laryngea l
1 nerve [3]
 Posterior –
parathyroid glands
1 [4]
3

CS of th e neck

Medi an c ervi cal c yst
 Usually presents as a painless
midl ine mass on the anterior aspect
of the neck just below of the hyoid
bone and moves during
swallowing together with thyroid
gland because of relation with
pretracheal layer of cervical fascia
and infrahyoid muscles of the neck.
 Remanent of the thyrog lossal cana l
(thyroid gland srcinally from
epithelium of the tongue).
 Treatment: surgical excision

Variation of parathyr oid glands
position
 The superior parathyroid
glands, more constant in
position than the inferior ones.
 The inferior parathyroid
glands are usually near the
inferior poles of the thyroid
gland, but they may lie in
various positions
 In 1-5% of people, an inferior
parathyroid gland is deep in
the superior mediastinum
insi de the thymus because of
common e mbryonic src in .

96. Lary nx
3
1 Cavity of the Larynx - 2 Folds:

2
 Vestibular fol ds [1] (false vocal
cords)
 Vocal fold s [2] (true vocal cords)
 Rima vestibul i – gap between the

vestibular folds
 Rima glottidis [3] – gap between
the vocal folds anteriorly and
vocal processes of the arytenoid
1 cartilages posteriorly is most
narro w pla ce in the larynx (it
2 limi ts size of intubation tube
during endotrachial anaesthesia)

Mus cles of t he Larynx
Abductors
 Posterior cric oaryte noid –
abducts vocal folds (the only
abductors of the vocal folds)
 It is innervated by recurrent
laryngeal nerve (CNX
vagus).
 Interruption of recurrent
laryngeal nerve results in
hoarseness because the
corresponding vocal fold
does not abduct and deviate
toward the midline.

97. Cri co th yro to my
 A cricothyrotomy is an emergency
procedure that relieves an airway
obstruction (e.g. swallowed foreign
bodies or abnormal tissue growths).

A hollowofneedle
midline is inserted
the neck, into the
just below the
thyroi d cartilage (needle
cricothyrotomy).
 More frequently, a small incision is made
in the skin over the Cricothyroid
membrane , and another one is made
through the membrane between the
cricoid and thyroid cartilage . A tube
that enables breathing is inserted through
the incision.

98. Retro ph aryngeal space
 It is interval between pharynx

(Bucco -pha ryngea l fascia )
and prevertebral fascia
 May provide a passageway of
infection from pharynx to
posterior mediastinum
(mediastinitis ≈ 90% mortality
rate).

99. Ax il lary sh eath
 Derived from the prevertebral
fascia
 Encloses the subcl avia n arte ry
and brachial plexus as they
emerge in the interval between the
scale nus ante rior and medius
muscles (Interscalenus space )
 Extends into the axilla

100. Pos teri or tr iangl e of the
neck
 Veins – external jugular vein,
subclavian vein.
 Arteri es – occipital artery.
 Nerves – Accessory nerve (XI),
trunks of the brachial plexus, branches
of cervical plexus, phrenic nerve.
 Lymph nod es – superficial cervical
CN XI nodes along external jugular vein.
CN XI (acc esso ry nerv e) supply:
 Sternocleidomastoid muscle - face
looks upward to the opposite side
 Trapezius - superior fibers elevate,
middle fibers retract, and inferior fibers
depress scapula.

GOOD LUCK !

100 Gross Anatomy Concepts

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100 Gross Anatomy Concepts

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Understand first, then memorize and apply

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Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

BL OCK 1: c on cepti on s 1-20

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Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

 Transverse fracture within the distal 2 cm of

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 Necks of t he metaca rpal

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Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

 Origins of following muscles

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 Sites of venipuncture is usually median

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Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

 All intrinsic mu scle s of the hand

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 Usually results from lesions

 Greatly weakens fl exio n of

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 The femoral artery is

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Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

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Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

 Weakened hip exte nsio n

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 Cause of injury: anterior

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Hamstrin gs musc les:

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 A femoral hernia passes below

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 Because the lateral side of the

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 Broad flat band

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 Rounded cord between

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 With rupt ure of the a nterior

 In the less common rupture of

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 Suprapatellar bursa : superior

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 The patellar reflex