Understand first, then memorize and apply
100 most important
D&GA conceptions
Edition 4.4
Dr. Mavrych MD PhD, Dr. Bolgova MD PhD
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
1. Early Embryology
Week 1: Beginning of Development
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Dr. Mavrych, MD, PhD, DSc
Fertilization occurs in the ampulla
of the uterine tube with the fusion of
the male and female pronuclei to
form a zygote.
During the first 4-5 days of the first
week, the zygote undergoes rapid
mitotic division (cleavage) in the
oviduct to form a morula before
entering the cavity of the uterus.
Fluid develops in the morula,
resulting in a blastocyst that
consists of an inner cell mass the
embryoblast (becomes the
embryo) and the outer cell - the
trophoblast (becomes the
placenta) and then implantation
begins.
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Ectopic Pregnancy
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Dr. Mavrych, MD, PhD, DSc
The blastocyst normally implants within
the anterior or posterior walls of the
uterus.
Ectopic tubal pregnancy is the most
common form. It usually occurs when the
blastocyst implants within the ampulla of
the uterine tube because of delayed
transport.
Ectopic abdominal pregnancy typically
occurs in the rectouterine (Douglas)
pouch.
Clinical signs: bleeding, abdominal pain
(may mimic appendicitis), last menses 60
days ago, positive pregnancy test, and
culdocentesis showing intraperitoneal
blood.
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Week 2: Formation of the bilaminar
Embryo & Pregnancy testing
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Dr. Mavrych, MD, PhD, DSc
The embryoblast differentiates into the
epiblast and hypoblast, forming a
bilaminar embryonic disk.
The amniotic cavity and yolk sac form.
The prochordal plate marks the site of the
future mouth.
Human Chorionic Gonadotropin hCG is
a glycoprotein, produced by the
syncytiotrophoblast, which stimulates
the production of progesterone by the
corpus luteum.
hCG can be assayed in maternal urine at
day 10 and is the basis for early
pregnancy testing. hCG is detectable
throughout pregnancy.
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Embryonic Weeks 3-8
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Dr. Mavrych, MD, PhD, DSc
The critical events of the 3rd
week are gastrulation and
early development of the
nervous and cardiovascular
systems.
Castrulation is the process that
establishes 3 primary germ
layers that derive from epiblast:
ectoderm, mesoderm, and
endoderm.
Major organ systems begin to
develop during the embryonic
period (weeks 3-8), causing a
craniocaudal and lateral body
folding of the embryo.
By the end of the embryonic
period (week 8), the embryo has
a distinct human appearance.
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Smart table 1: Germ layers
Ectoderm
Mesoderm
Endoderm
Epidermis, hair, nails
Muscles
Epithelium of GI tract
Enamel of teeth
Dermis of skin
Epithelium of Respiratory
Parotid gland
Bone, Cartilage
system
Mammary glands
Blood and lymph vessels
Epithelium of Biliary
Neuroectoderm:
Heart
apparatus
All neurons CNS
Adrenal cortex
Epithelium of Urinary
Retina
Spleen
bladder, Urethra, Vagina
Neural crest:
Kidney
Liver
Adrenal medulla
Testes, Ovaries
Pancreas
All neural ganglia
Dura mater
Submandibular gland
Pia and arachnoid mater
Sublingual gland
Aorticopulmonary septum
Notochord:
Thyroid
Endocardial cushions
Nucleus pulposus
Parathyroid
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
2. Lumbar puncture (tap) and
Epidural anesthesia
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Dr. Mavrych, MD, PhD, DSc
When lumbar puncture is
performed, the needle enters
the subarachnoid space to
extract cerebrospinal fluid
(CSF) or to inject anesthetic
to epidural space.
Remember, the spinal cord
may ends as low as L2 in
adults and does end at L3 in
children.
The dural sac extends
caudally to level of S2.
The needle is usually
inserted between L3/L4 or
L4/L5. Level of horizontal line
through upper points of
iliac crests.
prof.mavrych@gmail.com
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
3. Spine abnormalities
Herniated IV disc
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IV disc herniations typically occur in
lumbar (L4/L5 & L5/S1) or cervical regions
(C5/C6 & C6/C7). Herniations generally
affect individuals at 30-50 years old.
Patients typically have history of back
pain that may radiate down to the lower
limb. The pain begins soon after patient
lifted some heavy thing.
Herniated lumbar disc usually compresses
the nerve root one number below:
traversing root (e.g., the herniation L4/L5
will compress L5 root).
Lower limb reflexes are decreased on the
affected side:
 Patellar tendon reflex - herniation of IV
discs L2/L3 or L3/L4
 Achilles tendon reflex - herniation of
L5/S1
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Abnormal curvatures of the spine
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Dr. Mavrych, MD, PhD, DSc
Kyphosis is an exaggeration of the thoracic
curvature that may occur in elderly persons
as a result of osteoporosis or IV disk
degeneration.
Lordosis is an exaggeration of the lumbar
curvature that may be temporary and occurs
as a result of pregnancy, spondylolisthesis
or potbelly.
Scoliosis is a complex lateral deviation, or
torsion, that is caused by poliomyelitis, a
leg-length discrepancy, or hip disease.
Osteoporosis is a age related process
characterized by a decrease in the density
of bone, decreasing its strength and
resulting in bones fractures (vertebral
bodies, hip and distal radius).
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4. Upper limb fractures
Clavicle fractures
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Dr. Mavrych, MD, PhD, DSc
Weakest part of clavicle junction of medial 2/3 and lateral
1/3 of the bone.
The patient characteristically
supports the sagging limb with
the opposite hand.
Subclavian vessels and trunks
of the brachial plexus are at risk
in fractures of the middle third,
because they lie behind only the
thin subclavius muscle.
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Humerus fractures
Sites of potential injury to major nerves
in fractures of the humerus:
1. Axillary nerve and Posterior
humeral circumflex artery at the
surgical neck.
2. Radial nerve and profunda
brachii artery at midshaft.
Midshaft fracture affect origin of
Brachialis muscle.
3. Median nerve and Brachial artery
at the supracondylar region.
4. Ulnar nerve at the medial
epicondyle ("funny bone" ).
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Fracture of distal radius
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Dr. Mavrych, MD, PhD, DSc
Transverse fracture within the distal 2 cm of
the radius. Most common fracture of the
forearm (after 50).
Smith's fracture results from a fall or a blow
on the dorsal aspect of the flexed wrist and
produces a ventral angulation of the wrist. The
distal fragment of the radius is ANTERIORLY
displaced.
Colles' fracture results from forced extension
of the hand, usually as a result of trying to
ease a fall by outstretching the upper limb.
Distal fragment is displaced DORSALLY “dinner fork deformity”. Often the ulnar
styloid process is avulsed (broken off).
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Scaphoid fracture
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Occurs as a result of a fall onto
the palm when the hand is
abducted (see the picture).
Pain occurs primarily on the lateral
side of the wrist, especially during
wrist extension and abduction.
Scaphoid fracture may not show on
X-ray films for 2 to 3 weeks, but a
deep tenderness will be present in
the anatomical snuffbox.
The proximal fragment may
undergo avascular necrosis
because the blood supply is
interrupted.
Radial artery and superficial
branch of the radial nerve are
structures at the greatest risk in
this fracture.
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Boxer’s fracture
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Dr. Mavrych, MD, PhD, DSc
Necks of the metacarpal bones
are frequently fractured during
fistfights.
Typically, fractures of 2d and 3d
metacarpals are seen in
professional boxers, and
fractures of 5th and sometimes 4th
metacarpals are seen in unskilled
fighters.
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Mallet or Baseball Finger
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This deformity results from the DIP joint suddenly being
forced into extreme flexion (hyperflexion) when, for
example, a baseball is miscaught or a finger is jammed
into the base pad.
These actions avulse the attachment of the extensor
digitorum tendon to the base of the distal phalanx. As
a result, the person cannot extend the DIP joint. The
resultant deformity bears some resemblance to a mallet.
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
5. Shoulder dislocation
& Rotator cuff muscles (SITS)
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The glenohumeral joint is the
most frequently dislocated large
joint
In anterior dislocation [2], (most
common) muscle traction usually
pulls the dislocated humeral head
into the subcoracoid position.
Rotator cuff [1] reinforces joint on all
sides except inferiorly, where
dislocation is most likely. SITS:
Greater tubercle
 Supraspinatus (abduction)
 Infraspinatus (supination)
 Teres minor (supination)
Lesser tubercle
 Subscapularis (pronation)
Dr. Mavrych, MD, PhD, DSc
1
2
Right humerus
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6. Abduction of the upper limb
1. (0º-15º) Abduction of the upper extremity
is initiated by the supraspinatus muscle
(suprascapular nerve).
2. (15º-110º) Further abduction to the
horizontal position is a function of the
deltoid muscle (axillary nerve).
3. (110º-180º) Raising the extremity above
the horizontal position requires scapular
rotation by action of the trapezius
(accessory nerve CNXI) and serratus
anterior (long thoracic nerve).
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Subacromial bursitis &
Tearing of supraspinatus tendon
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Dr. Mavrych, MD, PhD, DSc
Subacromial bursitis (inflammation of the
subacromial bursa) is often due to calcific
supraspinatus tendinitis, causing a
painful arc of abduction.
The same symptoms will be in case of
inflammation or trauma of the
supraspinatus tendon (MRI→ torn tendon)
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7. 4 elbows:
Student's elbow
(Subcutaneous
olecranon bursitis)
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Dr. Mavrych, MD, PhD, DSc
The olecranon, to which the
triceps tendon attaches distally,
is easily palpated. It is separated
from the skin by only the
olecranon bursa, which allows
the mobility of the overlying skin.
Repeated excessive pressure
and friction may cause this bursa
to become inflamed, producing a
friction subcutaneous
olecranon bursitis.
prof.mavrych@gmail.com
Pulled elbow
(Dislocation of the
head of radius)
Dr. Mavrych, MD, PhD, DSc

In adults, the head of the radius
is not dislocated without tearing
the anular ligament.
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Young children are prone to
dislocation of the immature
head of the radius from the
encircling anular ligament, a
"pulled elbow," caused by
sudden traction on an extended
forearm.
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Tennis elbow
(Lateral epicondylitis)
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Lateral epicondylitis: repeated forceful
flexion and extension of the wrist resulting
strain attachment of common extensor
tendon and inflammation of periosteum of
lateral epicondyle. Pain felt over lateral
epicondyle and radiates down posterior
aspect of forearm. Pain often felt when
opening a door or lifting a glass
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Origins of following muscles may be affected:
Extensor Carpi Radialis Longus
Extensor Carpi Radialis Brevis
Extensor Digitorum
Extensor Digiti Minimi
Extensor Carpi Ulnaris
1.
2.
3.
4.
5.
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Golfer’s elbow
(Medial epicondylitis)

Medial epicondylitis is
inflammation of the
common flexor tendon
of the wrist where it
originates on the medial
epicondyle of the
humerus.
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Origins of following
muscles may be affected:
Pronator Teres
Flexor Carpi Radialis
Palmaris Longus
Flexor Carpi Ulnaris
1.
2.
3.
4.
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
8. Arterial anastomoses
around the scapula
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Blockage of the
Subclavian or Axillary
artery can be bypassed
by anastomoses
between branches of the
thyrocervical trunk
superiorly:
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Transverse cervical
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Suprascapular
and subscapular arteries
inferiorly:
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Subscapular
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Circumflex scapular
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
9. Cubital fossa
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Dr. Mavrych, MD, PhD, DSc
Sites of venipuncture is usually
median cubital vein because:
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Overlies bicipital aponeurosis,
so deep structures protected
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Not accompanied by nerves
Contents of cubital fossa from
lateral to medial:
1. Biceps brachii tendon
2. Brachial artery
3. Median nerve
Subcutaneous structures from
lateral to medial:
1. Cephalic vein
2. Median cubital vein
3. Basilic vein
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10. Carpal Tunnel Syndrome
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Dr. Mavrych, MD, PhD, DSc
Results from a lesion that reduces
the size of the carpal tunnel (fluid
retention, infection, dislocation of
LUNATE bone).
Median nerve – most sensitive
structure in the carpal tunnel and is
the most affected.
Clinical manifestations:
 Pins and needles or anesthesia
of the lateral 3.5 digits
 palm sensation is not affected
because superficial palmar
cutaneous branch passes
superficially to carpal tunnel
 Apehand deformity - absent
of OPPOSITION
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11. Test of the proximal (PIP) and
distal (DIP) interphalangeal joints
Dr. Mavrych, MD, PhD, DSc

PIP – Flexor digitorum
superficialis (FDS)

DID - Flexor digitorum
profundus (FDP)
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12. Lesion of UL nerves
Upper Brachial Palsy
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Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Injury of upper roots
and trunk
Usually results from
excessive increase in
the angle between the
neck and the shoulder
stretching or tearing of
the superior parts of the
brachial plexus (C5 and
C6 roots or superior
trunk)
May occur as birth
injury from forceful
pulling on infant's head
during difficult delivery
Upper Brachial Palsy
(Erb-Duchenne palsy)
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Dr. Mavrych, MD, PhD, DSc
In all cases, paralysis of the muscles of the shoulder
and arm supplied by C5 and C6 spinal nerves (roots)
of the upper trunk.
Combination lesions of axillary, suprascapular and
musculocutaneous nerves with loss of the shoulder
mm and anterior arm.
As result patient has “waiter’s tip” hand:

adducted shoulder

medially rotated arm

extended elbow

loss of sensation in the lateral aspect of the
upper limb
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Lower Brachial Palsy
(Klumpke paralysis)
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Dr. Mavrych, MD, PhD, DSc
Injury of lower roots and
trunk
May occur when the upper
limb is suddenly pulled
superiorly: stretching or
tearing of the inferior parts of
the brachial plexus (C8 and
T1 roots or inferior trunk)
E.g., grabbing support during
falling from height or as a
birth injury, or TOS –
thoracic outlet syndrome
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Lower Brachial Palsy
(Klumpke paralysis)
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Dr. Mavrych, MD, PhD, DSc
All intrinsic muscles of the hand
supplied by the C8 and T1 roots of the
lower trunk affected.
Combination lesions of ulnar nerve
(“claw hand”) and median nerve
(“ape hand”)
Loss of sensation in the medial
aspect of the upper limb and medial
1,5 fingers.
May include a Horner syndrome
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Smart table 2: Nerves of the Upper limb
Nerve
Innervated region
Clinical sign
Axillary C5-6
Deltoid, teres minor and shoulder
region’s skin
Lost of abduction
Musculocutane
ous C5-6
Flexors of the arm and skin of the
lateral forearm
Weakness of flexion &
supination in elbow
Radial C5-T1
Extensors the arm, forearm and
posterior skin of upper limb
Wrist drop (lost of wrist
extension)
Median C5-T1
Flexors of the forearm (except 1.5*),
5** of the hand:3thenar + 2lumbricals
Ape hand (lost of thumb
opposition)
Ulnar C8-T1
Flexors of the hand (except 5**) and
1.5* forearm (FDU + 0.5 FDP)
Claw hand (clawing
digits 4 & 5)
Long thoracic
Serratus anterior
Winged scapula
Suprascapular
Supraspinatus
Pain & problems with
initiation of abduction
Dr. Mavrych, MD, PhD, DSc
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Cutaneus innervation of the hand
In reality, in case of superficial
branch of radial nerve lesion it will
be skin deficit between 1 & 2 digits
on the dorsum of the hand ONLY
because of nerves overlapping
Dorsum: 1.5=U
and 3.5=R
Dr. Mavrych, MD, PhD, DSc
Palm sensation does not
affected in case of the
carpal tunnel syndrome
(superficial palmer branch
come above of the
retinaculum).
Palm: 1.5=U
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and 3.5=M
Important dermatomes
to know:
Upper limb
 C6 - Thumb
 C7 – Fingers 2-4
 C8 - Little finger
Trunk
 T4 – Nipple
 T7 – Xiphoid process
 T10 – Umbilicus
 L1 – Pubis
Lower Limb
 L4 - Big toe
 L5 - Toes 2-4
 S1 - Little toe
Dr. Mavrych, MD, PhD, DSc

prof.mavrych@gmail.com
Note: Dermatome is a
strip of skin innervated
by one DRG (dorsal
root ganglion)
13. Cardiac catheterization
Dr. Mavrych, MD, PhD, DSc

The femoral artery is
used for cardiac
catheterization

It can be cannulated for
left cardiac angiography
& also for visualizing the
coronary arteries – a
long, slender catheter is
inserted percutaneously
and passed up the
external iliac artery,
common iliac artery,
aorta, to the left
ventricle of the heart
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14. Injury of the gluteal region
Fractures of Femoral Neck
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Dr. Mavrych, MD, PhD, DSc
A common fracture in elderly
women with osteoporosis is
fracture of the femoral neck.
Fractures of the femoral neck
cause shortness and lateral
rotation of the lower limb.
Fractures of the femoral neck
often disrupt the blood supply
to the head of the femur.
At present time the best way in
case of femoral neck fracture is
hip replacement.
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Avascular necrosis
of femoral head

Dr. Mavrych, MD, PhD, DSc
Transcervical fracture
disrupts blood supply to the
head of the femur via
retinacular arteries (from
medial circumflex femoral
artery) and may cause
avascular necrosis of the
femoral head if blood supply
through the ligament to the
head is inadequate.
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Posterior hip dislocations
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
Dr. Mavrych, MD, PhD, DSc
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.
prof.mavrych@gmail.com
Injury to sciatic nerve
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
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Weakened hip
extension and knee
flexion
Footdrop (lack of
dorsiflexion)
Flail foot (lack of both
dorsiflexion and plantar
flexion)
Cause of injury:
caused by improperly
placed gluteal
injections but may
result from posterior
hip dislocation
Smart table 3: Nerves of the Lower limb
Nerve
Innervated region
Clinical sign
Femoral L2-4
Muscles and skin of the
anterior thigh
Lost of knee extension
Obturator L2-L4
Muscles and skin of the
medial thigh
Lost of thigh adduction
Tibial L4-S3
Muscles of posterior thigh
(except 0.5*), leg and plantar
foot
Lost of plantar flexion, everted
foot
Common fibular
L4 – S2
0.5*- short head of biceps
femoris
Foot drop, inverted foot
Superficial
fibular
Lateral leg muscles
(evertors), skin of the dorsum
of the foot
Inverted foot
Deep fibular
Muscles of the anterior leg
and dorsum of the foot
Foot drop
Superior gluteal
Gluteus medius & minimus
Trendelenburg sign
Inferior gluteal
Gluteus maximus
Problem with climbing stairs or
standing from a seated position
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Trendelenburg sign
Normal
Right
superior
gluteal nerve
injury


The superior gluteal nerve may
be injured during surgery,
posterior dislocation of the hip
or poliomyelitis.
Paralysis of the gluteus medius
and gluteus minimus muscles
occurs so that the ability to pull
the pelvis up and abduction of
the thigh are lost.
Trendelenburg sign:

If the superior gluteal nerve on
the right side is injured, the left
pelvis falls downward when the
patient raises the left foot off the
ground.

Note that side is contralateral to
the nerve injury.
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
15. Avulsion fractures
of the hip bone and
hamstrings muscles

Avulsion fractures occur
where muscles are
attached to ischial
tuberosity
Hamstrings muscles:
1. Biceps femoris
2. Semitendinosus
3. Semimembranosus
 Action: extension of hip
joint and flexion of knee
joint
 Nerve supply – Tibial
nerve (short head of biceps
femoris is supplied by the
common fibular nerve)
Dr. Mavrych, MD, PhD, DSc
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16. Structures under inguinal
ligament
From lateral to medial
side:
 Iliopsoas muscle
 Femoral nerve
 Femoral artery
 Femoral vein
 Femoral canal (ring)
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Femoral hernia
Inguinal lig.
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
Dr. Mavrych, MD, PhD, DSc
A femoral hernia passes below
inguinal ligament through the femoral
ring into the femoral canal to form a
swelling in the upper thigh inferior and
lateral to the pubic tubercle
The hernial sac may protrude through
the saphenous hiatus into the
superficial fascia
A femoral hernia occurs more
frequently in females and is dangerous
because the hernial sac may become
strangulated
An aberrant obturator artery is
vulnerable during surgical repair
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Superficial veins of Lower Limb
2
1
Dr. Mavrych, MD, PhD, DSc
Great saphenous vein [1]
 Arises from medial side of dorsal
venous arch of foot, passes anterior
to medial malleolus, and ascends on
medial side of leg adjacent to
saphenous nerve, then passes in
the medial side of the thigh and joint
with femoral vein.
Small saphenous vein [2]
 Arises from lateral side of dorsal
venous arch, passes posterior to
lateral malleolus, and ascends the
posterior leg adjacent to sural
nerve. It pierces popliteal fascia to
end in popliteal vein.
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17. Knee joint injuries
Unhappy triad

Because the lateral side of the
knee is struck more often (e.g.,
in a football tackle), the tibial
collateral ligament is the
most frequently torn ligament
at the knee.
The UNHAPPY TRIAD of
athletic knee injuries involves:
1. Tibial collateral ligament
2. Medial meniscus
3. Anterior cruciate ligament

Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Tibial collateral ligament (medial
collateral ligament)



Dr. Mavrych, MD, PhD, DSc
Broad flat band extending
from medial epicondyle of
femur to medial condyle
and shaft of tibia
Blends with capsule and
firmly attaches to medial
meniscus
Limits extension and
abduction of leg at knee
prof.mavrych@gmail.com
Fibular collateral ligament (lateral
collateral ligament)



Dr. Mavrych, MD, PhD, DSc
Rounded cord between lateral
epicondyle of femur and head
of fibula
Does NOT blend with joint
capsule and does NOT attach
to lateral meniscus
Limits extension and adduction
of leg at knee
prof.mavrych@gmail.com
Rupture of cruciate ligaments




Dr. Mavrych, MD, PhD, DSc
With rupture of the anterior
cruciate ligament, the tibia
can be pulled forward
excessively on the femur,
exhibiting anterior drawer
sign.
ACL attaches to the lateral
condyle of the femur.
In the less common rupture of
the posterior cruciate
ligament, the tibia can be
pushed backward excessively
on the femur, exhibiting
posterior drawer sign.
PCL attaches to the medial
condyle of the femur.
prof.mavrych@gmail.com
Prepatellar & Suprapatellar
bursas
Dr. Mavrych, MD, PhD, DSc

Prepatellar bursa: between
superficial surface of patella
and skin. May become
inflamed and swollen
(prepatellar bursitis).

Suprapatellar bursa: superior
extension of synovial cavity
between distal end of femur
and quadriceps muscle and
tendon. Usual place for intraarticular injections. May
become inflamed and swollen
(suprapatellar bursitis).
prof.mavrych@gmail.com
Knee jerk reflex
Dr. Mavrych, MD, PhD, DSc

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 (L2L4).

Knee jerk reflex:
tests spinal nerves
L2-L4.
prof.mavrych@gmail.com
18. Ankle joint injuries
Ankle sprains




Dr. Mavrych, MD, PhD, DSc
Sprains are the most common
ankle injuries
A sprained ankle is nearly
always an INVERSION injury,
involving twisting of the weightbearing plantarflexed foot.
The lateral ligament (anterior
talofibular ligament) is injured
because it is much weaker than
the medial ligament.
In severe sprains, the lateral
malleolus of the fibula may be
fractured.
prof.mavrych@gmail.com
Pott’s fracture



It is fracture-dislocations of
the ankle joint
Reason - forced EVERSION
(abduction) of the foot
The Deltoid ligament
avulses the medial
malleolus and after that
fibula fractures at a higher
level
Pott's fracture
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
19. Injures of the leg and foot
Fracture of the fibular neck



Dr. Mavrych, MD, PhD, DSc
May cause an injury to the common
peroneal nerve, which winds laterally
around the neck of the fibula.
This injury results in paralysis of all
muscles in the anterior and lateral
compartments of the leg (dorsiflexors
and evertors of the foot) and loosing
sensation on the dorsum of the foot.
Causing foot drop.
prof.mavrych@gmail.com
Rupture of the Achilles tendon
Triceps surae muscle

Avulsion or rupture of the calcaneal
(Achilles) tendon disables Triceps surae
muscle so that the patient cannot plantar
flex the foot.
Triceps surae muscle:
 2 Heads of Gastrocnemius m.
 1 Head - Soleus muscle
 Plantaris
 small fusiform belly with long thin
tendon;
 sometimes may become hypertrophy
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Ankle jerk reflex



Dr. Mavrych, MD, PhD, DSc
Achilles tendon reflex is
tested by tapping the
calcaneal tendon to elicit
plantar flexion at the ankle
joint.
Both afferent and efferent
limbs of the reflex arc are
carried in the tibial nerve
(S1, S2).
Ankle jerk reflex: tests spinal
nerves S1-S2.
prof.mavrych@gmail.com
Plantar Fasciitis
(calcaneal spur)
Dr. Mavrych, MD, PhD, DSc

Plantar fasciitis is the
most common hindfoot
problem in runners. It
causes pain on the
plantar surface of the
foot and heel.

Point tenderness is
located at the proximal
attachment of the plantar
aponeurosis to the
medial tubercle of the
calcaneus and on the
medial surface of this
bone.
prof.mavrych@gmail.com
Injury of tibial nerve

Popliteal fossa from superficial to
deep, contains:
 Tibial nerve
 Popliteal vein
 Popliteal artery
Dr. Mavrych, MD, PhD, DSc

In popliteal fossa: loss of
plantar flexion of foot (mainly
gastrocnernius and soleus
muscles) and weakened
inversion (tibialis posterior
muscle), causing calcaneovalgus.

Inability to stand on toes.

Loss of sensation and paralysis
of intrinsic muscles of the sole of
the foot
prof.mavrych@gmail.com
On sole of the foot there are two terminal
branches of tibial n:
 Medial plantar nerve supplies:
1.
Abductor hallucis,
2.
Flexor hallucis brevis
3.
Flexor digitorum brevis
4.
1st lumbrical

skin of medial 3.5 digits
 Lateral plantar nerve supplies:

All intrinsic plantar muscles which are
not innervated by medial plantar nerve

skin of lateral 1.5 digits
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
20. Breast & Thoracic wall
Intercostal spaces
Intercostal blood vessels
and nerves:
 run between the
internal intercostal and
innermost intercostal
muscles in the costal
groove
 arranged from superior
to inferior as vein,
artery, nerve

Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Most vulnerable
structures – intercostal
nerve and posterior
intercostal artery
because they are not
covering by ribs.
Carcinoma of the Breast


Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Carcinomas of the
breast are malignant
tumors, usually
adenocarcinomas
arising from the
epithelial cells of the
lactiferous ducts in the
mammary gland lobules
As the cancer cells
grow, they attach to
suspensory
(Cooper‘s) ligaments,
and produce shortening
of the ligaments,
causing depression or
dimpling of the
overlying skin.
Lymphatic drainage of the breast



75%
25%
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
It is important because
of its role in the
metastasis of cancer
cells.
Most lymph (> 75%),
especially from the
lateral breast
quadrants, drains to
the axillary lymph
nodes, initially to the
anterior (pectoral)
nodes for the most
part.
Most of the remaining
lymph, particularly from
the medial breast
quadrants, drains to the
parasternal lymph
nodes or to the
opposite breast.
Mastectomy
Radical mastectomy, a more extensive
surgical procedure, involves removal of the
breast, pectoral muscles, fat, fascia, and as
many lymph nodes as possible in the axilla
and pectoral region.
1. During a radical mastectomy, the long
thoracic nerve may be lesioned during
ligation of the lateral thoracic artery. A few
weeks after surgery, the female may present
with a winged scapula and weakness in
abduction of the arm above 90° because
serratus anterior m. paralysis.
2. The intercostobrachial nerve may also be
damaged during mastectomy, resulting in
skin deficit of the medial arm.

Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Breast infection




Dr. Mavrych, MD, PhD, DSc
Mastitis is an infection of the
tissue of the breast that occurs most
frequently during the time of
breastfeeding (1 to 3months after
the delivery of a baby).
This infection causes pain, swelling,
redness, and increased
temperature of the breast.
It can occur when bacteria, often
from the baby's mouth, enter a milk
duct through a crack in the nipple.
It can occur in women who have not
recently delivered as well as in
women after menopause.
prof.mavrych@gmail.com
21. Diaphragm
Openings of the diaphragm
I 8 10 Eggs AAT 12
IVC (and right phrenic nerve)= 8
Esophagus and R + L vagus, esophageal br of Left gastric vessels = 10
Aorta, Azygos vein and Thoracic Duct = 12



Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Caval (T8): transmits
the IVC and the
terminal branches of
the right phrenic
nerve
Esophageal (T10):
transmits the
esophagus, right and
left vagus nerves,
esophageal branches
of the left gastric
vessels
Aortic (T12) transmits
the descending aorta,
thoracic duct,
azygos vein
Paralysis of the half of the
Diaphragm



Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Paralysis of the half of
the Diaphragm may
result from injury or
operative division of the
phrenic nerve of same
side
It can be detected
radiologically.
Paradoxical
movement: dome of
diaphragm of injured
side pushed superiorly
by abdominal viscera
during inspiration instead
of descending
Phrenic nerve



It arises from the anterior
primary rami of the C3-C5
nerves and lies in front of the
anterior scalene muscle.
Phrenic nerve runs anterior to
the root of the lung, whereas
the vagus nerve runs
posterior to the root of the
lung.
Innervates the fibrous
pericardium, the mediastinal
and diaphragmatic pleurae
(sensory innervation), and the
diaphragm for motor and its
central tendon for sensory.
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Diaphragmatic ruptures




Diaphragmatic injuries are
relatively rare and result from
either blunt trauma or
penetrating trauma.
Presently, 80-90% of blunt
diaphragmatic ruptures result
from motor vehicle crashes.
The majority (80-90%) of blunt
diaphragmatic ruptures have
occurred on the left side.
Blunt trauma typically produces
large radial tears measuring 5-15
cm, most often at the
posterolateral aspect of the
diaphragm.
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Congenital diaphragmatic hernia
Dr. Mavrych, MD, PhD, DSc

Hernia of stomach or
intestine through a
posterolateral defect in
diaphragm (foramen of
Bochadalek).

It is seen in infants and
the mortality rate is high
because of left lung
hypoplasia.
prof.mavrych@gmail.com
Sliding hiatal hernia
Dr. Mavrych, MD, PhD, DSc

A sliding hiatal hernia, which
occurs in individuals past
middle age, is caused by the
hernia of cardia of the stomach
into the thorax through the
esophageal hiatus of the
diaphragm.

This can damage the vagal
trunks as they pass through
the hiatus and resulting in
hyposecretion of gastric
juice.
prof.mavrych@gmail.com
22. Cardiac hypertrophy


Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Left atrial enlargement
(hypertrophy) secondary
to mitral valve failure
may compress on the
ESOPHAGUS and
manifest as dysphagia
(difficulty in swallowing).
It may be observed as a
filling defect in the
esophagus by barium
swallow on the lateral
thoracic X-Ray
X-ray of the Thorax (PA projection)
Cardiac Shadow
Right border is formed by:
1. SVC,
2. Right atrium
Left border is formed by:
1. Aortic arch
2. Pulmonary trunk
3. Left auricle
4. Left ventricle
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
23. Auscultation of heart
valves
Right 2 ICS
PSL
Left 2 ICS
PSL
Left 5 ICS
PSL
Left 5 ICS
MCL
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Auscultation sites for
mitral and aortic murmurs
≈ 8%
≈ 90%
A heart murmur is heard downstream from the valve:
 stenosis is orthograde direction from valve
 insufficiency is retrograde direction from valve
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
24. Conducting system of the
heart
Sinoatrial (SA) node

site where contraction of heart muscle is
initiated (pacemaker of the heart)
 situated in the upper part of the sulcus
terminalis just near to the opening of
the SVC
Atrioventricular (AV) node
 the AV node receives impulses from the
SA node; situated in the lower part of
the atrial septum near coronary sinus
Atrioventricular bundle of His
 descends from the AV node to the
membranous portion of the ventricular
septum where it divides into the left and
right bundle branches
 Right bundle branch – passes down to
reach the moderator band - right
ventricle
 left bundle branch – passes down left
side of ventricular septum



Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
25. Blood supply of the heart
Right coronary artery (RCA)
It supplies major parts of the right
atrium and the right ventricle.
 It anastomoses with the marginal
branch of the left coronary artery
posteriorly
Branches:
1. Anterior cardiac branches –
supplies the right atrium
2. Nodal branch – supplies the (1) SA
node, (2) AV node
3. Marginal artery – supplies the right
ventricle
4. Posterior interventricular artery –
supplies (1) diafragmatic (inferior)
surface of both ventricles and (2)
posterior 1/3 of the IV septum

Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Left coronary artery
(LCA)
Branches:
1. Anterior (descending)
interventricular artery – most
common place of MI descends in the
anterior interventricular sulcus and
provides branches to the (1) anterior
heart wall, (2) anterior 2/3 of IV
septum, (3) bundle of His, and (4)
apex of the heart.
2. Circumflex artery – winds around the
left margin of the heart in the
atrioventricular groove to anastomose
with the right coronary artery
posteriorly; supplies the left atrium
and left ventricle
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Blood supply of the conducting
system
Dr. Mavrych, MD, PhD, DSc

SA node – RCA

AV node – RCA

AV bundle (and moderator
band)- LCA
prof.mavrych@gmail.com
26. Supply of thoracic viscera
Smart table 4
THORAX
Artery: Internal thoracic & thoracic Aorta
Parasympathetic innervation:
•Preganglionic: DMN of Vagus nerves, CNX
•Postganglionic: Terminal gg.
Sympathetic innervation:
•Preganglionic: IML (T1-T4),
•Postganglionic: Sympathetic trunk T1-T4 ganglia,
Thoracic splanchnic nn.
Sensory Innervation: DRG T1-T4
Referred Pain: Left arm (MI)
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
2
27. Fetal circulation
Fetal circulation involves 3 shunts:
1. Ductus venous
2. Ductus arteriosus
3. Foramen ovale


1.
2.
3.
4.
3
After birth:
1
Closure of ductus venosus Ligamentum venosum
Closure of ductus arteriosus Ligamentum arteriosum
Closure of foramen ovale - Fossa ovale
Closure of umbilical arteries and
4
umbilical vein
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
28. Cardiovascular abnormalities
Atrial Septal Defect (ASD)




Dr. Mavrych, MD, PhD, DSc
It is less frequent than
VSD
It results from failure to
close of the foramen
ovale after birth (failure of
the septum primum and
septum secundum to fuse)
Postnatally, ASDs result
in left-to-right shunting
(between right and left
atrium) and are NONCYANOTIC conditions.
If it is small, has no clinical
significance & if large necessary surgical repair
prof.mavrych@gmail.com
Ventricular Septal
Defect (VSD)




Dr. Mavrych, MD, PhD, DSc
Ventricular septal defect
(VSD) is the most common of
the congenital heart defects
It may be found in the
membranous part of the
ventricular septum and
results from failure to fuse of
the membranous portion with
the muscular portion of the
ventricular septum
In this case, present left–toright shunt (right ventricular
hypertrophy (RVH)) and
again NON-CYANOTIC.
Necessary surgery for large
defects
prof.mavrych@gmail.com
Tetralogy of Fallot
It is congenital heart disease responsible
for about 9% of all cardiac defects.
 It is CYANOTIC heart disease (right-toleft shunt) with the following
abnormalities:
1. Pulmonary stenosis (most important)
2. Overriding aorta (receives blood from
both ventricles)
3. Membranous interventricular septal
defect
4. Right ventricular hypertrophy
(develops secondarily)

Dr. Mavrych, MD, PhD, DSc
Surgical treatment is necessary
prof.mavrych@gmail.com
Patent Ductus Arteriosus (PDA)





Dr. Mavrych, MD, PhD, DSc
It results from failure of the ductus
arteriosus (a connection between the
pulmonary trunk and aorta) to constrict
and close after birth.
Prostaglandin E and low O2 tension
sustain patency of the ductus arteriosus in
the fetal period.
PDA is common in premature infants and in
cases of maternal rubella infection.
Left –to-right shunt increased pressure in
pulmonary circulation (pulmonary
hypertension) and is NON-CYANOTIC
Treatment: surgical division and ligation
imperative. In great danger is left recurrent
nerve (wrapping aorta arch). Injure of this
nerve results in hoarseness.
prof.mavrych@gmail.com
Coarctation of the Aorta




Dr. Mavrych, MD, PhD, DSc
It results from congenital
narrowing of the aorta distal to
the offshoot of the left subclavian
artery.
Cardinal clinical sign: higher
blood pressure in the upper
limbs compared to the lower
limbs.
Coarctation of the aorta results in
the intercostal arteries providing
collateral circulation between the
internal thoracic artery and the
thoracic aorta to provide blood
supply to the lower parts of the
body
Coarctation of the Aorta
characteristic X-ray picture:
serrated appearance of inferior
borders of ribs (rib notching)
prof.mavrych@gmail.com
Thoracic aortic aneurysm
Dr. Mavrych, MD, PhD, DSc

Aneurysm of the aortic arch:
compresses the left recurrent
laryngeal nerve, leading to
coughing, hoarseness, and
paralys is of the ipsilateral vocal
cord. It may cause dysphagia
(difficulty in swallowing), resulting
from pressure on the esophagus,
and dyspnea (difficulty in
breathing), resulting from pressure
on the trachea, root of the lung, or
phrenic nerve

Aneurysm of the thoracic aorta
may compress and tug on the
trachea with each cardiac systole
so that the aneurysm can be felt
by palpating the trachea at the
sternal notch (T2).
prof.mavrych@gmail.com
Abdominal aortic aneurysm




Dr. Mavrych, MD, PhD, DSc
It is a localized dilatation of the
aorta. It is typically happened
just above of the bifurcation at
level of L3 and crossed by 3rd
part of duodenum.
Pulsations of a large aneurysm
can be detected to the left of the
midline at the umbilical region.
Acute rupture of an abdominal
aortic aneurysm is associated
with severe pain in the abdomen
or back (mortality rate is nearly
90%).
Surgeons can repair an
aneurysm by opening it and
inserting a prosthetic graft.
prof.mavrych@gmail.com
29. Bronchopulmonary
segments
Aspiration of foreign bodies
Aspiration of Foreign Bodies:

Inhalation of FB’s (e.g. pins, parts
of teeth, screws, nuts, bolts, toys)
into the lower respiratory tract is
common, especially in children
Dr. Mavrych, MD, PhD, DSc

More likely to enter the right
primary bronchus and pass into
the middle or lower lobe bronchi

If the vertical position of the body,
the foreign body usually falls into
the posterior basal segment of
the right inferior lobe.
prof.mavrych@gmail.com
Right lung:
10 bronchopulmonary segments
Superior lobe:
1. Apical
2. Anterior
3. Posterior
1
Middle lobe:
4. Lateral
5. Medial
3
2
Inferior lobe:
6. Superior
7. Anterior basal
8. Posterior basal
9. Lateral basal
10.Medial basal
8
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
6
4
5
10
9
7
Left lung:
9 bronchopulmonary segments
Superior lobe:
1. Apicoposterior
2. Anterior
3. Superior lingular
4. Inferior lingular
1
Inferior lobe:
5. Superior
6. Anterior basal
7. Posterior basal
8. Lateral basal
9. Medial basal
2
5
3
7
4
8
9
6
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
30. Lung diseases
Pneumonia




Dr. Mavrych, MD, PhD, DSc
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).
prof.mavrych@gmail.com
Bronchogenic Carcinoma





Arises in the mucosa of the large
bronchi
Produces as persistent,
productive cough or
hemoptysis
Early metastasis to thoracic
(bronchomediatinal) lymph
nodes
Hematogenous spread to the
brain, bones, lungs, suprarenal
glands
A tumor at the apex of the lung
(Pancoast tumor) may result in
thoracic outlet syndrome
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Bronchogenic carcinoma
may lead to:
1
2
Dr. Mavrych, MD, PhD, DSc
1. Thoracic outlet syndrome (TOS)
 It can cause pressure on the lower
trunk of the brachial plexus C8-T1 and
subclavian artery by cervical rib or
pancoast tumor. It results in pain
down the medial side of the forearm
and hand and atrophy of the intrinsic
hand muscles)
2. Horner syndrome:
 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
prof.mavrych@gmail.com
Bronchogenic carcinoma
may lead to:
3. Superior vena cava
syndrome, which causes
dilation of the head and
neck veins, facial swelling,
and cyanosis
4. Dysphagia as a result of
esophageal obstruction
5. Hoarseness as a result of
recurrent laryngeal nerve
involvement
3
Dr. Mavrych, MD, PhD, DSc
6. Paralysis of the
diaphragm as a result of
phrenic nerve involvement
prof.mavrych@gmail.com
Lungs auscultation


4

6
Dr. Mavrych, MD, PhD, DSc
To listen to breath sounds of the
superior lobes of the right and left
lungs, the stethoscope is placed on
the superior area of the anterior chest
wall (above the 4th rib for the right
lung & above 6th for the left one).
For breath sounds from the middle
lobe of the right lung, the
stethoscope is placed on the anterior
chest wall between the 4th and 6th
ribs
For the inferior lobes of both lungs,
breath sounds are primarily heard
on the posterior chest wall.
prof.mavrych@gmail.com
31. Open pneumothorax
Pleura



Dr. Mavrych, MD, PhD, DSc
It is entry of air into a pleural
cavity causing lung collapse.
Open pneumothorax – due to stab
wounds of the thoracic wall which
pierce the parietal pleura so that
the pleural cavity is open to the
outside air via the lung or through
the chest wall.
Air moves freely through the
wound during inspiration and
expiration. During inspiration, air
enters the chest wall and the
mediastinum will shift toward other
side and compress the opposite
lung. During expiration, air exits
the wound and the mediastinum
moves back toward the affected
side.
prof.mavrych@gmail.com
Pleura & Pleural Cavity

1. Cervical pleura may be affected in
case of improper subclavian
venipuncture (it results in
pneumothorax).

2. Costodiaphragmatic recess is
deepest place in pleural cavity, around
the chest wall, there are two rib
interspaces separating the inferior limit
of parietal pleural reflections from the
inferior border of the lungs and visceral
pleura:
Midclavicular line - between ribs 6-8
Midaxillary line - between ribs 8-10 –
typical place for thoracocentesis
Paravertebral line between ribs 10-12
8
2
1.
2.
10
3.
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Nerve supply of the pleura
Parietal pleura – sensitive to general
sensibilities (pain, temperature, touch,
and pressure) - somatic sensory
innervation:
 costal pleura – intercostal nerves
block may be used to decrease
thoracic pain
 mediastinal pleura – phrenic nerve
 diaphragmatic pleura – phrenic nerve
over the domes and lower 6 intercostal
nerves around the periphery
Visceral pleura – sensitive to stretch but
insensitive to general sensibilities;
autonomic nerve supply from the
pulmonary plexus
Dr. Mavrych, MD, PhD, DSc
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32. Mediastinum
Superior mediastinum
The sternum is a
common site for
bone marrow
biopsy.
 Improperly done
sternal puncture
may affect
structures related to
the posterior
surface of the
manubrium
sternum:
1. In upper part –
Left brachiocephalic vein
2. In lower part –
Aortic arch

Dr. Mavrych, MD, PhD, DSc
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Thoracic duct

Function – conveys to the
blood all lymph from the lower
limbs, pelvic cavity,
abdominal cavity, left side of
the thorax, left side of the
head & neck, and left upper
limb (3/4 of the body)
Tributaries – at the root of the
neck
 Left jugular lymph trunk
 Left subclavian lymph trunk
 Left bronchomediastinal
lymph trunk
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Constrictions of the esophagus
1
There are sites where ingested
foreign bodies can lodge or
where strictures may develop
following ingestion of caustic
fluids, common sites of
esophageal carcinoma
2
1. C6 - where the pharynx joins
the upper end (6" from the
upper incisors)
2. T4-T5 - where the aortic arch
and left main bronchus cross
its anterior surface (10" from the
upper incisors)
3. T10 - where it passes through
the diaphragm into the
stomach (16" from the upper
incisors)
3
Dr. Mavrych, MD, PhD, DSc
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33. Anterior abdominal wall
1. The liver and gallbladder are in
the right upper quadrant;
2. The stomach and spleen are in
the left upper quadrant;
3. The cecum and appendix are
in the right lower quadrant;
4. The end of the descending
colon and sigmoid colon are in
the left lower quadrant.
Dr. Mavrych, MD, PhD, DSc
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Referred abdominal pain
Dr. Mavrych, MD, PhD, DSc

Pain arising out of the
foregut derived structures is
referred to the epigastric
region.

Pain arising out of the
midgut derived structures is
referred to the umbilical
region.

Pain arising out of the
hindgut derived structures is
referred to the hypogastric
region.
prof.mavrych@gmail.com
Nerve supply of the
anterior abdominal wall



Dr. Mavrych, MD, PhD, DSc
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
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Arterial supply of the anterior
abdominal wall
Important SUPERFICIAL
ARTERIES (supply skin)
are:
1.
Superficial epigastric
2.
Superficial circumflex iliac
Important DEEP ARTERIES lie
in the neurovascular
plane:
1.
Superior epigastric
2.
Posterior intercostals
arteries
3.
Lumbar arteries
4.
Deep circumflex iliac artery
5.
Inferior epigastric
Dr. Mavrych, MD, PhD, DSc
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Body Wall Defects
Dr. Mavrych, MD, PhD, DSc

Omphalocele - involves
herniation of abdominal viscera
through an enlarged umbilical
ring. Viscera are covered by
amnion.

Gastroschisis - is a herniation
of abdominal contents through
the body wall directly into the
amniotic cavity. Viscera are not
covered by peritoneum or
amnion
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34. Herniations
Hernia consist of 3 parts:
1.
1
2
2.
3
3.
Dr. Mavrych, MD, PhD, DSc
Hernial sac is a pouch
(diverticulum) of
peritoneum and has a
neck and a body
Hernial contents may
consist of any structure
found in the abdominal
cavity (more often –
loops of small
intestine and piece of
omentum major)
Hernial coverings are
formed from the layers
of the abdominal wall
through which the
hernia sac passes
prof.mavrych@gmail.com
Transversalis fascia is the FIRST STRUCTURE which is
crossed by ANY abdominal hernia
Indirect inguinal
hernia [1]
1
between Tunica
vaginalis & Internal
spermatic fascia
Normal:
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Indirect inguinal hernia




Dr. Mavrych, MD, PhD, DSc
Indirect inguinal hernia is the most
common form of hernia and is believed
to be congenital in origin (boys 0-3
years).
It passes through the deep inguinal ring
lateral to the inferior epigastric
vessels, inguinal canal, superficial
inguinal ring and descend into the
scrotum.
An indirect inguinal hernia is about 20
times more common in males than in
females, and nearly 1/3 are bilateral.
It is more common on the right
(normally, the right processus vaginalis
becomes obliterated after the left; the
right testis descends later than the left).
prof.mavrych@gmail.com
Direct inguinal hernia



Dr. Mavrych, MD, PhD, DSc
Direct inguinal hernia composes about
15% of all inguinal hernias.
During a direct inguinal hernia, the
abdominal contents will protrude
through the weak area of the posterior
wall of the inguinal canal medial to the
inferior epigastric vessels in the
inguinal [Hesselbach's] triangle and
after that through superficial inguinal
ring. It never descends into the
scrotum.
It is a disease of old men (after 60
years old) with weak abdominal
muscles. Direct inguinal hernias are
rare in women, and most are bilateral.
prof.mavrych@gmail.com
35. Peritoneal structures
Lesser omentum
Lesser omentum consists of
2 ligaments:
1. hepatogastric
2. hepatoduodenal

Contents :
 Right & Left gastric vessels
 Connective and fatty tissue
and PORTAL TRIAD:
1. Bile duct
2. Portal vein
3. Proper hepatic artery
Dr. Mavrych, MD, PhD, DSc
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Epiploic (Winslow’s) foramen
Dr. Mavrych, MD, PhD, DSc

Anteriorly: The free
border of the
hepatoduodenal
ligament, containing
portal triad (DVA).

Posteriorly: IVC

Superiorly: Caudate
lobe of the liver.

Inferiorly: The 1st part
of the duodenum
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Douglas (rectouterine) pouch


Dr. Mavrych, MD, PhD, DSc
Rectouterine pouch (pouch
of Douglas): deeper point of
peritoneal space in vertical
position of the female body
between the rectum and the
cervix of uterus.
It is space of the pelvic
abscess location.
prof.mavrych@gmail.com
Culdocentesis
Dr. Mavrych, MD, PhD, DSc

Culdocentesis is
aspiration of fluid from
the cul-de-sac of Douglas
(rectouterine pouch) by a
needle puncture of the
posterior vaginal fornix
near the midline between
the uterosacral ligaments

Because the rectouterine
pouch is the lowest
portion of the female
peritoneal cavity, it can
collect inflammatory fluid
(pelvic abscess).
prof.mavrych@gmail.com
36. Derivates from primitive
gut
Smart table 5
FOREGUT
Esophagus
Stomach
Duodenum (1st and 2nd
parts)
Liver
Pancreas
Biliary apparatus
Gallbladder
Dr. Mavrych, MD, PhD, DSc
MIDGUT
Duodenum (2nd, 3rd, 4th
parts)
Jejunum
Ileum
Cecum (with Appendix)
Ascending colon
Transverse colon
(proximal 2/3)
HINDGUT
Transverse colon (distal
1/3)
Descending colon
Sigmoid colon
Rectum (anal canal
above pectinate line)
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FOREGUT
MIDGUT
HINDGUT
Artery: CA
Artery: SMA
Artery: IMA
Parasympathetic
innervation:
•Preganglionic: DMN of
vagus nerves, CNX
•Postganglionic:
Terminal gg.
Parasympathetic
innervation:
Preganglionic: DMN of
vagus nerves, CNX
•Postganglionic:
Terminal gg.
Parasympathetic
innervation:
Preganglionic: SPN S2S4, Pelvic spl. nn
•Postganglionic:
Terminal gg.
Sympathetic
innervation:
•Preganglionic: IML T5T9, Greater spl. nn
•Postganglionic:
Celiac ganglion
Sympathetic
innervation:
•Preganglionic: IML T10T11, Lesser spl. nn
•Postganglionic:
Superior mesenteric g.
Sympathetic
innervation:
•Preganglionic: IML L1L2, Lumbar spl. nn
•Postganglionic:
Inferior mesenteric g.
Sensory Innervation:
DRG T5-T9
Sensory Innervation:
DRG T10-T11
Sensory Innervation:
DRG L1-L2
Referred Pain:
Epigastrium
Referred Pain:
Umbilical
Referred Pain:
Hypogastrium
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
37. Posterior gastric ulcer
Dr. Mavrych, MD, PhD, DSc
1.
Posterior gastric ulcer may
erode through the posterior wall
of the stomach into the
omental bursa (lesser
peritoneal sac) and affect
pancreas resulting in referred
pain to the back.
2.
Erosion of splenic artery is
very common in posterior
gastric ulcers as well because
of the proximity of the artery to
this wall.
prof.mavrych@gmail.com
38. Meckel's diverticulum




Dr. Mavrych, MD, PhD, DSc
Meckel's diverticulum is a congenital anomaly
representing a persistent portion of the
vitellointestinal duct (connection from the midgut to
the yolk sac incorporated into the umbilical cord,
normally degenerates at 2-3 months of gestation).
This condition is often asymptomatic but occasionally
becomes inflamed if it contains ectopic gastric,
pancreatic, or endometrial tissue, which may
produce ulceration.
Meckel's diverticulum is located on the Ileum about 2
feet (61 cm) before the ileocecal junction and SMA
supply it. It occurs in 2% of patients and is about 2
inches (5 cm) long.
The diverticulum is clinically important because
diverticulitis, liberation, bleeding, perforation, and
obstruction are complications requiring surgical
intervention and frequently mimicking the symptoms
of acute appendicitis.
prof.mavrych@gmail.com
39. Features of the large
intestine
Features of the large intestine:
1.
2.
3.

Dr. Mavrych, MD, PhD, DSc
Appendices epiploic
Sacculations (haustrations)
Taeniae coli
The taeniae coli meet
together at the base of the
appendix where they form a
complete longitudinal muscle
coat for the appendix.
prof.mavrych@gmail.com
Colon





The ascending colon lies
retroperitoneally and lacks a
mesentery.
It is continuous with the
transverse colon at the right
(hepatic) flexure (1) of colon.
The transverse colon (3) has
its own mesentery called the
transverse mesocolon
(intraperitoneal position).
It becomes continuous with the
descending colon at the left
(splenic) flexure (2) of colon.
The sigmoid colon (4) is
suspended by the sigmoid
mesocolon (intraperitoneal
position).
Dr. Mavrych, MD, PhD, DSc
1
prof.mavrych@gmail.com
3
4
40. Appendicitis



Dr. Mavrych, MD, PhD, DSc
In appendicitis, first pain is referred
around the umbilicus. Visceral
pain in the appendix is produced by
distention of its lumen or spasm of
its muscle.
The afferent pain fibers enter the
spinal cord at the level of T10
segment, and a vague referred
pain is felt in the region of the
umbilicus (T10 dermatome).
Later if parietal peritoneum gets
involved, and then the pain is
shifted laterally to the Mc Burney’s
point. Here the somatic pain is
precise, severe, and localized
(second pain)
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Mc Burney's point


This point indicates the
surface marking of the base of
the appendix.
Mc Burney's point [1] is a
point at the junction between
the lateral 1/3 and medial 2/3
of a line joining the right
anterior superior iliac spine
with the umbilicus.

1
2
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Retrocecal is
the most
common
position of
appendix [2].
41. Volvulus



Dr. Mavrych, MD, PhD, DSc
Because of its extreme mobility (long
mesentery), the Jejunum (1), Ileum
(2) and Sigmoid colon (3)
sometimes rotates around its
mesentery.
Volvulus results in avascular
necrosis corresponding part of
intestine.
This may correct itself
spontaneously, or the rotation may
continue until the blood supply of the
gut is cut off completely.
prof.mavrych@gmail.com
42. Hirschsprung's Disease





Dr. Mavrych, MD, PhD, DSc
It is a rare congenital abnormality that
results in intestinal obstruction
(megacolon) because of congenital
absents of postganglionic
parasympathetic neurons (terminal
ganglia, Myenteric plexus) inside of
the wall of the large intestine.
Reason is defective migration or
differentiation of neural crest cells.
It is commonly found in Down
Syndrome children.
In a newborn, the chief signs and
symptoms are failure to pass a
meconium stool within 24-48 hours
after birth, reluctance to eat, bilestained (green) vomiting, and
abdominal distension.
Treatment is removal of the
aganglionic portion of the colon.
prof.mavrych@gmail.com
43. Branches of Abdominal
aorta and Mesenteric ischemia





Dr. Mavrych, MD, PhD, DSc
Celiac trunk (CA) originates
from the aorta at the lower
border of T12 vertebra
Superior mesenteric artery
originates at the lower border of
L1 vertebra
Renal arteries originate at
approximately L2 vertebra
Inferior mesenteric artery
originates at L3 vertebra
Two terminal branches are
common iliac arteries at the
level of L4 vertebra
prof.mavrych@gmail.com
CELIAC ARTERY (TRUNK)

1

3
2



Dr. Mavrych, MD, PhD, DSc
Origin: T12, just below the
aortic opening of the
diaphragm.
The CA passes above the
superior border of the
pancreas and then divides
into three retroperitoneal
branches:
Left gastric artery (1)
Common hepatic artery (2)
Splenic artery (3)
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Left gastric artery
2
3
1
Dr. Mavrych, MD, PhD, DSc
The left gastric artery (1)
courses upward to the left to
reach the lesser curvature of
the stomach and may be
subject to erosion by a
penetrating ulcer of the
lesser curvature of the
stomach.
Branches:
 Esophageal branches (2) - to
the abdominal part of the
esophagus
 Gastric branches (3) supply
the left side of the lesser
curvature of the stomach and
make anastomosis with right
gastric artery.

prof.mavrych@gmail.com
Common hepatic artery

2
1


The common hepatic artery
(1) passes to the right to
reach the superior surface of
the first part of the duodenum,
where it divides into its two
terminal branches:
Proper hepatic artery (2)
Gastroduodenal artery (3)
3
Dr. Mavrych, MD, PhD, DSc
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Proper hepatic artery

5
4
3

1
2

Dr. Mavrych, MD, PhD, DSc
Proper hepatic artery (1) gives
off right gastric artery (2) and
then ascends within the
hepatoduodenal ligament of the
lesser omentum to reach the
porta hepatis, where it divides
into the right (4) and left (3)
hepatic arteries.
The right and left arteries enter the
two lobes of the liver, right
hepatic artery gives cystic artery
(5) to the gallbladder.
Right gastric artery (2) supplies
the right side of the lesser
curvature of the stomach where it
anastomoses the left gastric
artery.
prof.mavrych@gmail.com
Gastroduodenal artery

1

2

3
Dr. Mavrych, MD, PhD, DSc
Gastroduodenal artery (1)
descends posterior to the first
part of the duodenum (may be
subject to erosion by a
penetrating ulcer in this place)
and divides into two branches:
Right gastroepiploic artery (2)
(supplies the right side of the
greater curvature of the
stomach where it anastomoses
the left gastroepiploic)
Superior pancreaticoduodenal
arteries (3) (supply the head of
the pancreas, where they
anastomoses the inferior
pancreaticoduodenal arteries
from the SMA).
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Ligature of the hepatic artery
1. The hepatic artery [1] may
be ligated proximal to the
origin of its gastroduodenal
branch, a collateral
circulation to the liver is
established through the left
and right gastric arteries,
left and right
gastroepiploic and
gastroduodenal arteries.
2
1
Dr. Mavrych, MD, PhD, DSc
2. The right hepatic artery
may be mistakenly ligated
during holecystectomy in
Calot triangle [2] together
with the cystic artery,
right lobe hepatic
necrosis commonly
occurs.
prof.mavrych@gmail.com
Splenic artery

1


Dr. Mavrych, MD, PhD, DSc
Splenic artery (1) runs a
tortuous horizontal course to
the left along the upper border
of the pancreas, behind the
peritoneum of the posterior
wall of the lesser sac, forming a
part of the stomach bed.
The splenic artery may be
subject to erosion by a
penetrating ulcer of the
posterior wall of the stomach
into the lesser sac.
Note: Splenic vein runs a more
straight course below the artery
and behind of the pancreas.
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Splenic artery
Splenic a. (1) is retroperitoneal
5
until it reaches the tail of the
pancreas, where it enters the
2
splenorenal ligament to enter
the hilum of the spleen.
4 Branches:
 Branches to the spleen (2)
 Branches to the neck, body, and
tail of pancreas (3)
 Left gastroepiploic (4) artery that
supplies the left side of the
greater curvature of the stomach
where it anastomoses the right
gastroepiploic
 Short gastric (5) branches that
supply fundus of the stomach

1
3
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
7
1
SMA
branches
6
2
4




3

5
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
(1) Inferior
pancreaticoduodenal
arteries
(2)Jejunal and (3) Ileal
branches
(4) Ileocolic artery
 Ascending branch
 Anterior cecal artery
 Posterior cecal artery
 (5) Appendicular
artery
(6) Right colic artery
(7) Middle colic artery
1
IMA Branches:




3
2
Dr. Mavrych, MD, PhD, DSc
(1) Left colic artery
(2) Sigmoid arteries
(3) Superior rectal artery
Note: The branches of the SMA
and IMA to the colon are
interconnected by a continual
arterial arch - marginal artery of
Drummond. It provides a
collateral circulation between
the parts of the large intestine to
prevent mesenteric ischemia.
prof.mavrych@gmail.com
Mesenteric ischemia




Dr. Mavrych, MD, PhD, DSc
Atherosclerosis, which slows the
amount blood flowing through arteries, is
a frequent cause of chronic mesenteric
ischemia.
Ischemia occurs when blood cannot flow
through arteries as well as it should, and
intestines do not receive the necessary
oxygen to perform normally. Mesenteric
ischemia usually involves SMA and
small intestine.
Mesenteric ischemia primarily affects
organs which locate far away from
anastomoses with CA & IMA. Usually
blood supply of the Jejunum and Ileum
is most compromised.
Mesenteric ischemia typically occurs in
people older than age 60 with history of
smoking and high cholesterol level.
prof.mavrych@gmail.com
44. Biliary system & gallstones




Dr. Mavrych, MD, PhD, DSc
Bile is secreted by the liver cells,
stored, and concentrated in the
gallbladder and later it is delivered
to the duodenum.
The Gallbladder lies in it’s fossa on
the visceral surface of the liver right
side of quadrate lobe.
It stores and concentrates bile,
which enters and leaves it through
the Cystic duct.
The cystic duct joins the Common
hepatic (from Left and Right
hepatic) due to form the Common
bile duct
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Biliary system



Dr. Mavrych, MD, PhD, DSc
The Common bile duct (part of
portal triad) descends in the
hepatoduodenal ligament, then
passes posterior to the first part of
the duodenum.
It penetrates the head of the
pancreas where it joins the main
pancreatic duct and they form the
hepatopancreatic ampulla, which
terminated by sphincter of Oddi.
It drains into posteromedial wall
the second part of the duodenum at
the major duodenal papilla
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Cholelithiasis (gallstones)

1
4

The distal end of the hepato-pancreatic
ampulla (Common bile duct ) is the
narrowest part of the biliary passages
and is the MOST COMMON SITE for
impaction of gallstones.
As result of common hepatic (1), bile
duct (2), or duodenal papilla (3)
obstruction patient will have yellow
(icteric) sclera and jaundice.
2

3
Dr. Mavrych, MD, PhD, DSc
Gallstones may also lodge in the cystic
duct. A stone lodged in the cystic duct
(4) causes biliary colic (intense,
spasmodic pain in the gallbladder) but
doesn't produce jaundice.
prof.mavrych@gmail.com
Gallstones


The fundus of the gallbladder is in
contact with the transverse colon [1]
and thus gallstones erode through the
posterior wall of the gallbladder and
enter the transverse colon. They are
passed naturally to the rectum through
the descending colon and sigmoid
colon.
Gallstones lodged in the body of the
gallbladder may ulcerate through the
posterior wall of the body of the
gallbladder into the duodenum [2]
(because the gallbladder body is in
contact with the duodenum) and may be
held up at the ileocecal junction,
producing an intestinal obstruction.
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
2
1
Nerve supply of the liver
and gallbladder
Dr. Mavrych, MD, PhD, DSc

Sensory innervation of the liver: by the right
PHRENIC nerve (C3-C5). Pain may radiate to
the right shoulder.

The liver receives parasympathetic innervation
from the vagi nerves (CNX), reaching it through
the celiac plexuses around the supplying arteries.
The preganglionic fibers synapse on the cells of
the terminal ganglia in hilum of the liver and shot
postganglionic fibers supply organs.

Sympathetic fibers of preganglionic neurons
T5-T9 segments (IML) come through the
sympathetic trunk and form greater splanchnic
nerves. They contribute to the celiac plexus,
where postganglionic neurons are located.
Branches of celiac plexus reach the liver wrapping
around the branches of the celiac artery.
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45. Portal Hypertension &
Portocaval shunts
Dr. Mavrych, MD, PhD, DSc

Portal hypertension is a common
clinical condition, and for this
reason portal-systemic
anastomoses should be
remembered.

[1] Extrahepatic portocaval
shunt for the treatment of portal
hypertension: the splenic vein
may be anastomoses to the left
renal vein after removing the
spleen.

[2] Intrahepatic portocaval
shunt: between portal vein and
hepatic veins
prof.mavrych@gmail.com
Large intestine metastases &
Portocaval anastomosis





Dr. Mavrych, MD, PhD, DSc
Metastases of the large intestine
cancer typically reach the liver via
portal venous system: intestine IMV - Splenic vein - Portal vein Liver
If there is an obstruction to flow
through the portal system (portal
hypertension), blood can flow in a
retrograde direction and pass
through anastomoses to reach the
caval system. Sites for these
anastomoses include:
(1) esophageal veins
(2) paraumbilical veins
(3) rectal veins
prof.mavrych@gmail.com
Esophageal anastomosis
Dr. Mavrych, MD, PhD, DSc

Anastomosis between the
tributaries of the left gastric vein
(portal vein) and the tributaries of
the azygous vein (SVC) in the
wall of the lower end of the
esophagus.

In portal hypertension these veins
enlarge in the wall of the
esophagus and later burst into
the lumen of the esophagus
(esophageal varices) resulting in
hematemesis (vomiting red
blood).
prof.mavrych@gmail.com
Umbilical anastomosis


Dr. Mavrych, MD, PhD, DSc
Anastomosis between the
paraumbilical veins (portal vein)
and the superior and inferior
epigastric veins (SVC and IVC)
in anterior abdominal wall around
the umbilicus.
In portal hypertension, this
anastomosis becomes enlarged
and dilated veins form “caput
Medussae” around the
umbilicus.
prof.mavrych@gmail.com
Rectal anastomosis


Dr. Mavrych, MD, PhD, DSc
Anastomosis between the
superior rectal vein (inferior
mesenteric vein and then
portal vein) and inferior
rectal vein which drains into
the internal iliac vein (from IVC
system).
In portal hypertension (chronic
alcoholics) this anastomosis
becomes dilated resulting in
internal hemorrhoids and
bleeding per anus from
superior rectal vein.
prof.mavrych@gmail.com
46. Pancreas
Head and uncinate process
Dr. Mavrych, MD, PhD, DSc

The head of the pancreas
rests within the C-shaped
area formed by the
duodenum and is traversed
by the common bile duct.

It includes the uncinate
process which is crossed by
the superior mesenteric
vessels.
prof.mavrych@gmail.com
Pancreatic adenocarcinoma




Dr. Mavrych, MD, PhD, DSc
Cancer of the head of the pancreas
compresses the bile duct and results in
OBSTRUCTIVE TYPE OF JAUNDICE.
Pain will be conveyed to sensory neurons T5T9 dorsal root ganglia via celiac plexus
and greater splanchnic nerve. To provide
pain relief, during the surgery ablation of the
sensory innervation that carries pain in this
region may be performed by injection 50%
ethanol around celiac artery.
This type of jaundice is NOT usually
associated with fever.
Hepatitis also causes jaundice but is
associated with fever.
prof.mavrych@gmail.com
Neck of the pancreas

Posterior to the neck
of the pancreas is the
site of formation of the
PORTAL VEIN.

(1)Splenic vein joins
with (2) superior
mesenteric vein to
form (3) portal vein.
3
1
2
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Body of the pancreas

The body passes to the left
and anterior to the (1) aorta
and the (2) left kidney.

The (3) splenic artery
undulates along the superior
border of the body of the
pancreas with the splenic
vein coursing posterior to
the body.
1
3
2
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Tail of the pancreas



Dr. Mavrych, MD, PhD, DSc
The tail of the pancreas
enters the splenorenal
ligament to reach the hilum
of the spleen.
It is the only part of the
pancreas that is
intraperitoneal.
Tail of the pancreas may be
mistakenly removed during
spleenectomy (ligation of
splenic artery and vein) and
resulting in sugar diabetes
because it contains a lot
endocrine cells.
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Arterial supply of the pancreas
3
1
2
Dr. Mavrych, MD, PhD, DSc
Head and Duodenum:
 (1) Superior
pancreaticoduodenal arteries branches of gastroduodenal
artery.
 (2) Inferior pancreaticoduodenal
arteries - branches of SMA
 This region is important for
collateral circulation because
there are anastomoses between
these branches of the CA and
SMA.
Neck, Body, and Tail of the
pancreas:
 Pancreatic branches of the (3)
Splenic artery.
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Annular Pancreas
Annular pancreas is caused by
malformation during the development of
the pancreas, before birth.
 Occurs when the ventral and dorsal
pancreatic buds form a ring around the
duodenum, thereby causing an
obstruction of the duodenum and
polyhydramnios
 Symptoms:
1. Feeding intolerance in newborns
2. Fullness after eating
3. Nausea and bile-stained vomiting
 Half of cases are not diagnosed until
symptoms occur in adulthood.

Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
47. Spleen
Rupture of the Spleen





Dr. Mavrych, MD, PhD, DSc
Rupture of the spleen may be result
of the left 9th and 10th ribs fracture
or blunt trauma of the left upper
abdomen.
The spleen is a peritoneal organ in
the upper left quadrant that is deep
to the left 9th, 10th, and 11th ribs.
The spleen follows the contour of rib
10 (axis of the spleen).
When blood collected deep to the
diaphragm phrenic nerve irritates
and pain may irradiate to left
shoulder.
When spleen is ruptured, it cannot be
sutured therefore removing is
required.
prof.mavrych@gmail.com
Relations of the Spleen and Left
Kidney

The spleen follows the
contour of 10th rib and
extends from the
superior pole of the left
kidney to just posterior
to the midaxillary line.

The border between
spleen and upper pole
of the left kidney is 11th
rib.
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
48. Kidneys
Dimensions and position



Dr. Mavrych, MD, PhD, DSc
During life, kidneys are
reddish brown and measure
approximately 11-12 cm in
length, 5-6 cm in width, and
2.5-3 cm in thickness.
They are extending from the
level of T12 to the level of
L3, the right kidney lying
about 2-3 cm lower than
the left one.
The lateral border of the
kidney is convex. Its medial
border is convex at both
ends but concave in the
middle where there is the
hilum of the kidney (L1).
prof.mavrych@gmail.com
Anterior relations of the right
kidney
1.
2.
3.
4.
5.
Dr. Mavrych, MD, PhD, DSc
Right suprarenal gland
2nd part of the duodenum
Right lobe of the liver
Right colic flexure
Small intestine
prof.mavrych@gmail.com
Anterior relations of the left
kidney
1.
2.
3.
4.
5.
6.
Left suprarenal gland
Stomach
Spleen
Body of pancreas and
splenic vessels
Descending colon
Small intestine
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Renal (Gerota) fascia


4

3
Dr. Mavrych, MD, PhD, DSc
Enclosing the perinephric fat is a
membranous condensation of the
extraperitoneal fascia - the renal
fascia (3).
The suprarenal glands (4) are
also enclosed in this fascial
compartment, usually separated
from the kidneys by a thin septum.
Note: The renal fascia must be
incised in any surgical
approach to this organ.
prof.mavrych@gmail.com
Perinephric abscess




Dr. Mavrych, MD, PhD, DSc
Most infections of the perinephric
space occur as a result of extension
of an ascending urinary tract
infection, commonly in association
with nephrolithiasis or
tuberculosis.
Perinephric abscess typically
descends down between 2 sheets
of the renal fascia along the psoas
major muscle.
In case of an abscess located
behind of the psoas major muscle it
descends down and may affect
hip joint.
If abscess spreads up it’ll reach the
diaphragm and irritate phrenic
nerve. As result patient will feel
pain in shoulder region.
prof.mavrych@gmail.com
49. Nephrolithiasis
Staghorn calculi





Dr. Mavrych, MD, PhD, DSc
Renal calculi are solid concretions (crystal
aggregations) formed in the kidneys from dissolved
urinary minerals.
If stones grow to sufficient size before passage (at
least 2-3 mm), they can cause obstruction of the
ureter (renal colic).
Renal stone that develops in the renal pelvis and
greater calices, and in advanced cases has a
branching configuration which resembles the antlers
of a stag.
Staghorn calculi are composed of magnesium
ammonium phosphate, which forms in urine that
has an abnormally high pH (above 7.2).
This high pH usually develops because of recurrent
urinary tract infection with microorganisms such as
Proteus mirabilis.
prof.mavrych@gmail.com
Horseshoe and Pelvic kidney

1

2
Dr. Mavrych, MD, PhD, DSc

[1] Horseshoe kidney
(usually normal renal
function,
predisposition to
calculi) is a fusion of
both kidneys at their
ends and failure of the
fused kidney to ascend.
The horseshoe kidney
hooks under the
origin of IMA.
[2] Pelvic kidney is
caused by a failure of
one kidney to ascend.
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50. Ureters
3 constrictions of ureter
1




2
Dr. Mavrych, MD, PhD, DSc
Ureter located on the anterior
surface of the Psoas major
muscle and has 3 constrictions:
1st constriction is at the
pelviureteric junction (level of L1)
2d constriction lies at the level of
pelvic brim (level of the sacroiliac
joint)
3d constriction appears where
ureter lies obliquely in the wall of
urinary bladder (level of ischial
spine)
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51. Suprarenal glands


1
2


They are endocrine glands
having cortex and medulla.
The adrenal cortex [1]
secretes corticosteroids:
Aldosterone, Hydrocortisone
and Genital hormones.
The chromaffin cells of the adrenal medulla [2] secrete two
catecholamines: Epinephrine and Norepinephrine, which
affect smooth muscle, cardiac muscle, and glands in the
same way as sympathetic stimulation.
Sympathetic stimulation or hypersecretion of
catecholamines (tumor of adrenal medulla or
sympathetic chain ganglia) resulting in episodes of
tachycardia, sweating and high blood pressure.
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Unpaired tributaries of IVC

3
2

1
4

Dr. Mavrych, MD, PhD, DSc
The right renal (1) vein is
much shorter than the left.
Both veins lie anterior to the
corresponding artery in hilum of
kidneys.
The long left renal vein (2) is
joined by the left suprarenal
(3) and left gonadal (4)
(testicular or ovarian) veins
before it reached IVC.
Right suprarenal vein and
right gonadal vein drain
directly to IVC (unpaired IVC
tributaries).
prof.mavrych@gmail.com
52. Varicocele



Dr. Mavrych, MD, PhD, DSc
It is enlargement of the
pampiniform plexus that
produces a wormlike scrotal
mass and enlargement of the
spermatic cord. Varicocele
may be reason of low sperm
count.
Varicocele formation is
usually on the left side and
may disappear in supine
position of the body.
Varicocele may indicate
kidney disease or may
signal a retro peritoneal
malignancy obstructing the
testicular vein.
prof.mavrych@gmail.com
Pampiniform plexus



Dr. Mavrych, MD, PhD, DSc
Each testicular or ovarian vein is
formed by coalescence of a
pampiniform plexus: the
testicular at the deep inguinal
ring, the ovarian at the margin of
the superior aperture of the pelvis.
The veins run accompanied by the
corresponding arteries. The left
pampiniform plexus enters the
left renal vein; the right one
enters directly the IVC inferior to
the renal vein.
That is why varicocely
(engorgement of the pampiniform
plexus that produces a scrotal
mass) is more often located on the
left.
prof.mavrych@gmail.com
53. Hydrocele
The tunica vaginalis testis or
remnants of the processus
vaginalis of peritoneum may form
a hydrocele.
1. Hydrocele in spermatic cord it is
smooth sausage-like structure
that persists under compression
and doesn’t disappear in supine
position.
2. In the scrotum (communicating
hydrocele) with transillumination,
it produces a reddish glow,
whereas light will not penetrate
other scrotal masses such as a
hematocele, solid tumor, or
herniated bowel. Testis is pressed
by tunica vaginalis against the
internal spermatic fascia.

Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
54. Hemorrhoids

2


1
Dr. Mavrych, MD, PhD, DSc
Hemorrhoids are masses that typically
protrude from ANUS during defecation.
External hemorrhoids are dilated tributaries
of the INFERIOR rectal veins [1] (IRV)
BELOW the pectinate line and are PAINFUL
because the mucosa is supplied by somatic
afferent fibers of the inferior rectal nerves (from
pudendal).
Internal hemorrhoids are dilated tributaries of
the SUPERIOR rectal veins [2] (SRV)
ABOVE the pectinate line and are NOT
PAINFUL because the mucosa is supplied by
visceral afferent fibers. It frequently develops
in chronic alcoholics because of liver
cirrhosis and portal hypertension syndrome.
prof.mavrych@gmail.com
55. Perineal pouches
Deep perineal pouch
The deep perineal pouch is
formed by the fasciae and
muscles of the urogenital
diaphragm.
It contains:
1.Sphincter urethrae muscle
2.Deep transverse perineal
muscle
3.Bulbourethral (Cowper)
glands (in the male only) ducts perforate perineal
membrane and enters
bulbar urethra.
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Superficial perineal pouch
1.
2.
3.
Ischiocavernosus muscle – related to the Crus of the penis
(Male) & Crus of the clitoris (Female)
Bulbospongiosus muscle – related to the Bulb of vestibule
(Female) & Bulb of the penis (Male)
Superficial transverse perineal muscle – related to the Perineal
body (both genders)
1
2
3
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Urine leaks


Dr. Mavrych, MD, PhD, DSc
After a crushing blow or a
penetrating injury, the spongy
urethra commonly ruptures
within the bulb of the penis, and
urine leaks into the superficial
perineal pouch.
The superficial perineal fascia
keeps urine from passing into the
thigh or the anal triangle, but after
distending the scrotum and penis,
urine can pass over the pubis
into the anterior abdominal wall
deep to the deep layer of
superficial abdominal fascia.
prof.mavrych@gmail.com
56. Ischiorectal abscess
1

2

3
Dr. Mavrych, MD, PhD, DSc

Ischiorectal abscess [1] is an important
surgical condition which usually results from
spread of an infection through the external
sphincter ani into the ischiorectal fossa [2].
Ischiorectal abscess is a surgical emergency
which should be immediately drained by a
wide cruciate incision through the skin of the
base of the fossa to avoid fistula formation.
A surgeon should avoid lateral wall of
ischiorectal fossa because here located
Pudendal (Alcock's) canal [3] with pudendal
nerve and internal pudendal artery.
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57. Urinary Bladder
Cystocele (hernia of bladder)


Dr. Mavrych, MD, PhD, DSc
Loss of bladder support in
females by damage to the
pelvic floor (levator ani m.)
during childbirth (e.g.,
laceration of perineal
muscles or a lesion of the
nerves supply).
It can result in protrusion of
the bladder onto the
anterior vaginal wall and
loss of urine when a women
strains or coughs.
prof.mavrych@gmail.com
Patent urachus
•A patent urachus (distal portion of allantois) needs to be surgically removed.
•The main sign is leakage of urine through the umbilicus.
There are 3 main anatomical
cases:
A. Urachal fistula: there is
free communication between
the bladder and umbilicus;
B. Urachal cyst: there is no
connection between the
bladder and the umbilicus
C. Urachal sinus: the pouch
opens toward the umbilicus
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Paracentesis of urinary bladder
Suprapubic aspiration:


Dr. Mavrych, MD, PhD, DSc
Urine can be removed from the
bladder without penetrating the
peritoneum by inserting a needle
JUST ABOVE the pubic
symphysis.
The needle passes successively
through skin, superficial and deep
layers of superficial fascia, linea
alba, transversalis fascia,
extraperitoneal connective tissue,
and wall of the bladder.
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58. Urogenital System
Development
Smart table 6
Adult Female
Embryo
Gonads
Ovary
Uterine tubes, uterus,
Paramesonephric ducts
cervix and upper part of
Mullerian
vagina
Epididymis, ductus
deferens, seminal
vesicle, ejaculatory duct
Glans and body of
Phallus
penis
Urogenital folds
Ventral aspect of penis
Labioscrotal swellings
Scrotum
Mesonephric ducts
Wolfian
Clitoris
Labia minora
Labia majora
Dr. Mavrych, MD, PhD, DSc
Adult Male
Testes
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Hypospadias & Epispadias
Dr. Mavrych, MD, PhD, DSc

Hypospadias occurs when the
urethral folds fail to fuse
completely, resulting in the
external urethral orifice opening
onto the ventral surface of the
penis. It is generally associated
with a poorly developed penis
that curves ventrally, known as
chordee.

Epispadias occurs when the
external urethral orifice opens
onto the dorsal surface of the
penis. It is generally associated
with exstrophy of the bladder.
prof.mavrych@gmail.com
59. Prostate tumors
Prostate cancer

It usually begins in the posterior
lobe of the gland, and early
stages are often asymptomatic,
may be found during digital
rectal examination.

Prostatic malignancies tend to
metastasize to vertebrae and the
brain because the prostatic
venous plexus has numerous
connections with the vertebral
venous plexus via sacral veins.
M
A
P
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Benign hypertrophy of the
prostate (BHP)




Dr. Mavrych, MD, PhD, DSc
BHP is common in men after
middle age.
Prostate adenoma (benign
hypertrophy) usually involves
median lobe.
BHP is a common cause of
urethral obstruction, leading
to nocturia (need to void during
the night), dysuria (difficulty
and/or pain during urination),
and urgency (sudden desire to
void).
The prostate is examined for
enlargement and tumors by
DIGITAL RECTAL
examination.
prof.mavrych@gmail.com
Prostatectomy


1
2

3
Transurethral
resection of the
prostate = TURP
Dr. Mavrych, MD, PhD, DSc
A prostatectomy may be performed
through a suprapubic [1] or perineal
[2] incision or transurethrally [3].
Because of damage to nerves in the
capsule of the prostate and around the
urethra (cavernosus nerves) can
cause impotence (erectaile
dysfunction) and/or urinary
incontinence.
Pelvic splanchnic nerves may be
injured in case of intensive dissection
of pelvic lymph nodes (prostatic
cancer ectomy) and as result
autonomic innervation of derivate of
hindgut may be affected.
prof.mavrych@gmail.com
60. Male urethra



1
Dr. Mavrych, MD, PhD, DSc
Prostatic part is the widest and the
most dilatable part. Openings of the 2
ejaculatory ducts are seen on each
side on the seminal colliculus.
Membranous part is in urogenital
diaphragm surrounded by the external
sphincter. It is the shortest, narrowest
part. Bulbourethral glands [1] lie
posterolateral to this part inside of
urogenital diaphragm (deep perineal
pouch)
Spongy (penile) part (longest) passes
through the bulb and corpus
spongiosum of the penis. There are
two dilatations – bulbar fossa (in the
beginning) and navicular fossa (in the
glans penis). Ducts of the bulbourethral
glands open into the bulbar fossa.
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2 sphincters of the urethra
1
2
Dr. Mavrych, MD, PhD, DSc
1.
Internal urethral sphincter
is made of smooth
muscles in the neck of the
bladder and has
sympathetic innervation
2.
External urethral
sphincter has skeletal
muscle fibers and
surrounds the
membranous part of
urethra, supplied by the
perineal branch of the
pudendal nerve
prof.mavrych@gmail.com
61. Ejaculatory duct



Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
It is a very narrow duct 2
cm long
Formed by union of
ductus deferens and
duct of seminal vesicle
It serve to passage of
seminal fluid from
ductus deferens to
prostatic urethra.
62. Pudendal nerve (S2-S4)
It is PRINCIPAL SOMATIC (motor and
sensory) nerve to supply perineum.
 Lies against ischial spine as it passes
through lesser sciatic foramen to traverse
pudendal canal on lateral wall of
ischiorectal fossa.
Branches:
 1. Inferior rectal nerve
 Supplies external anal sphincter
muscle and skin around anus
 2. Perineal nerve
 Deep branch is motor nerve to
muscles of urogenital triangle.
 Superficial branch gives cutaneous
posterior scrotal/labial branches.
 3. Dorsal nerve of penis or clitoris
 Supplies body, prepuce, and glans of
penis or clitoris

3
1
2
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Pudendal nerve block
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. percutaneously along the medial
side of the ischial tuberosity.

1
2

Dr. Mavrych, MD, PhD, DSc
Note: Pain from uterine
contractions is unaffected because
pelvic visceral pain is carried by
afferent fibers accompanying
autonomic nerve fibers.
prof.mavrych@gmail.com
63. Supply of pelvic viscera
Smart table 7
PELVIS
Artery: Internal iliac
Parasympathetic innervation:
•Preganglionic: Sacral parasympathetic n. (S2-S4), pelvic
splanchnic nerves
•Postganglionic: Terminal gg.
Sympathetic innervation:
•Preganglionic: IML (T12-L2), sacral splanchnic nerves.
•Postganglionic: Inferior hypogastric plexus
Sensory Innervation: DRG S2-S4 (with pelvic splanchnic nerves)
Referred Pain: Groin
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Micturition reflex
1
2
3
Dr. Mavrych, MD, PhD, DSc
Facilitating emptying:
 Parasympathetic fibers (pelvic
splanchnic nn.) stimulate
DETRUSOR MUSCLE [1] contraction
and involuntary relax internal
sphincter [2].
 Somatic motor fibers (pudendal
nerve) cause voluntary relaxation of
external [3] urethral sphincter.
Inhibiting emptying:
 Sympathetic fibers (sacral
splanchnic nn.) inhibit detrusor
muscle [1] and stimulate internal
sphincter [2].
prof.mavrych@gmail.com
64. Erection and ejaculation


Afferent fibrous: Dorsal nerve of penis or clitoris from
Pudendal nerve (DRG S2-S4)
Efferent fibrous:
 Erection: Parasympathetic fibers (S2-S4) from the Pelvic
splanchnic nerves dilate arteries supplying erectile
bodies of the penis, allowing them to fill with blood.
Somatic motor (S2-S4) fibrous from the pudendal nerves
cause contraction of ischiocavernosus and
bulbospongiosus muscles to press the root of the penis
and relax external urethral sphincter.
 Ejaculation: Sympathetic fibers (L1-L2) from the Inferior
hypogastric plexus (Sacral splanchnic nerves) cause
contraction of smooth muscle of epididymis, ductus
deferens, seminal vesicles, and prostate; sympathetic nerve
fibers stimulate internal urethral sphincter to prevent
semen from entering bladder or urine entering prostatic
urethra.
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
65. Incontinence
Dr. Mavrych, MD, PhD, DSc

Weakness of the puborectalis
part of the levator ani muscle
may result in rectal incontinence.

Weakness of the external
sphincter urethrae muscle in the
urogenital diaphragm may result
in urinary incontinence.
prof.mavrych@gmail.com
66. Cryptorchism




Dr. Mavrych, MD, PhD, DSc
Undescended testes
(cryptorchism) when the testes fail
to descend into the scrotum. This
normally occurs within 3 months
after birth.
The undescended testes may be
found in the abdominal cavity or in
the inguinal canal.
If neglected, malignant
transformation may occur in the
undescended testis.
Note: In case of cryptorchism,
spermatogenesis is arrested and
the spermatogenic tissue is damaged
leading to permanent sterility in
bilateral cases.
prof.mavrych@gmail.com
67. Torsion of the spermatic
cord
Main components of the spermatic
cord:

Ductus deferens

Testicular artery – direct branch
of Aorta

Pampiniform plexus to become
single testicular vein (right → IVC,
left → Left renal vein)


Dr. Mavrych, MD, PhD, DSc
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.
prof.mavrych@gmail.com
68. Lymphatic drainage
of the male viscera





Dr. Mavrych, MD, PhD, DSc
Testis & epididymis – lumbar lymph
nodes
Scrotum – superficial inguinal nodes
Penis:

skin - superficial inguinal nodes

glans – deep inguinal nodes

body and roots – internal iliac
nodes
Prostate gland & bladder - internal
iliac nodes
Anal canal:

above pectinate line - internal iliac

below pectinate line - superficial
inguinal nodes
prof.mavrych@gmail.com
Lymphatic drainage from the
female viscera





Dr. Mavrych, MD, PhD, DSc
Ovary and uterine tubes – to Lumbar
lymph nodes
Uterus:

lateral angle and teres ligament –
Superficial inguinal lymph nodes

fundus and upper part of the body
- Lumbar lymph nodes

lower part of the body - External
iliac lymph nodes

cervix - External & Internal iliac
Vagina:

Superior to hymen - to External &
internal iliac

Inferior to hymen - to Superficial
inguinal nodes
All external genitalia (with exception glans clitoris) - Superficial inguinal
lymph nodes
Glans clitoris – Deep inguinal
prof.mavrych@gmail.com
69. Arterial supply of the
uterus and Hysterectomy
4
2
1
3
The uterus is almost exclusively
supplied by the uterine arteries [1]
(from internal iliac artery):
 Uterine a. crosses pelvic floor in
cardinal ligament [2]
 Ureter passes posterior and inferior
to the uterine artery [3]
 Ascending branch [4] of uterine
artery comes along lateral wall of
uterus within broad ligament.
Note: During hysterectomy ureter in the
greatest risk because of close relations
with uterine artery and cervix of the
uterus.
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Hysterectomy

Hysterectomy is surgical removing of the uterus and
may include removing of the cervix (total) and the
vagina (radical).

Blood supply to the ovaries is saved in case of partial
hysterectomy ovarian suspensory ligament should
be left intact because contain ovarian artery (direct
branch of abdominal aorta) and vein.

In case of total hysterectomy (with cervix) pelvic
splanchnic nerves may be affected. That results in
bladder dysfunction because of detrusor urine
muscle loose parasympathetic innervation.
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
70. Parts of the uterine tube




Dr. Mavrych, MD, PhD, DSc
Uterine part
 Pierces uterine wall to
open into uterine cavity
Isthmus
 Narrowest part of tube
just lateral to uterus
Ampulla
 Medial continuation of
infundibulum comprising
about half of uterine tube
 Usual site of fertilization
Infundibulum
 Funnel-shaped expansion
of lateral end, fringed with
fimbriae
 Overlies ovary and
receives oocyte at
ovulation
prof.mavrych@gmail.com
Hysterosalpingography
4

3
2
1
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
The instillation of
viscous iodine
through the
external os [1] of
the uterine cervix
allows the lumen of
the cervical canal
[2], the uterine
cavity [3], and the
different parts of the
uterine tubes [4] to
be visualized on Xray.
Anterior Division
71. Branches of the
Internal iliac artery
1. Obturator
2. Umbilical
3 Inferior gluteal
4. Internal pudendal
5. Inferior vesical (males)
or
Vaginal (females)
6. Middle rectal
7. Uterine (females ONLY)
Posterior Division
1. Iliolumbar
2. Lateral sacral
3. Superior gluteal
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
72. Skull & Scalp
Cranial Malformations



Dr. Mavrych, MD, PhD, DSc
[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, towerlike 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].
prof.mavrych@gmail.com
Layers of the scalp
 1. Skin - sebaceous cysts
 2. Dense Connective tissue - superficial
scalp
lacerations do not gape and result in
severe bleeding
 3. Aponeurosis (Epicranial) - lacerations
throw 3 superficial layers gape widely
because of contraction frontalis and
occipitalis parts of occipitofrontalis muscle
 4. Loose areolar tissue - dangerous area
of the scalp. It contains potential spaces
capable of being distended with fluid
resulting from injury or infection
 5. Pericranium - Bleeding between
pericranium and calvaria during a difficult
birth results in cephalhematoma
(typically limited by borders of parietal
bone)
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
73. Cranial fosses
Anterior cranial fossa:
 contains Frontal lobe [1]
 dura matter is supplied by V1 and
anterior meningeal a. (from ethmoidal
a.)
Middle cranial fossa:
 contains Temporal lobe [2]
 dura matter is supplied by V2 & V3 and
middle meningeal a. (from maxillary a.)
Posterior cranial fossa:
 contains Cerebellum [3]
 dura mater is supplied by spinal nerves
(via CNX & CNXII) and posterior
meningeal aa. (from ascending
pharyngeal and occipital aa.)
Dr. Mavrych, MD, PhD, DSc
1
prof.mavrych@gmail.com
2
3
74. Fracture of the
anterior cranial fossa

Dr. Mavrych, MD, PhD, DSc
Fracture of the anterior cranial fossa
(Cribriform plate of the Ethmoid bone)
is suggested by anosmia, periorbital
bruising (raccoon eyes), and CSF
leakage from the nose (rhinorrhea).
prof.mavrych@gmail.com
75. Epidural hematoma



Dr. Mavrych, MD, PhD, DSc
Skull fracture near pterion often
causes epidural hematoma from torn
middle meningeal artery (foramen
spinosum).
Unconsciousness and death are
rapid because the bleeding dissects
a wide space as it strips the dura
from the inner surface of the skull,
which puts pressure on the brain.
An epidural hematoma forms a
characteristic biconvex pattern on
computed tomography images.
prof.mavrych@gmail.com
76. Cavernous sinus infection
Dangerous triangle of the face

2
3

1
5
Dr. Mavrych, MD, PhD, DSc
4

The middle third of the face is a
"danger area“ because infection
there may produce thrombophlebitis
of the facial (angular) vein [1] that
can spread to the cavernous sinus
via superior ophthalmic vein [2]:
Facial vein - Superior ophthalmic vein
- Cavernous sinus.
Septicemia leads to meningitis and
cavernous sinus [3] thrombosis,
both of which can cause neurological
damage and are life-threatening.
Second possible root of the
infection: it can spread from upper
molars via pterygoid venous plexus
[4] through inferior ophthalmic vein
[5]: Pterygoid plexus - Inferior
ophthalmic vein - Cavernous sinus.
prof.mavrych@gmail.com
Cavernous sinus thrombosis
Structures which may be
affected by cavernous
sinus thrombosis:

Structures that pass
through sinus directly:
1.
Internal carotid artery (in
case of laceration arteriovenous fistula)
2.
Abducens nerve CN VI
(in case of lesion - internal
squint)

1.
2.
3.
4.
Dr. Mavrych, MD, PhD, DSc
Structures on lateral wall
of sinus:
Oculomotor nerve (CN III)
Trochlear nerve (CN IV)
Ophthalmic nerve V1
Maxillary nerve V2
prof.mavrych@gmail.com
77. Cranial Nerves
Smart table 8
CN, Type, Foramina,
Associated Ganglia
Key:
S = sensory
M = somatomotor
P = parasympathetic,
secretomotor
Function
Lesion
I Olfactory, S, Cribriform Smells
plate
Anosmia
II Optic, S, Optic canal
Vision
Visual deficits (anopsia)
Loss of light rf (+CNIII)
III Oculomotor, M+P,
Superior orbital fissure,
Ciliary ganglion
Raises eyelid, moves
eyeball in all directions,
constricts pupil,
accommodates
External strabismus
+Ptosis +Dilated pupil
Loss of light rf (+CNII)
IV Trochlear , M,
Superior orbital fissure
Depresses &
abducts eyeball
Trouble reading & going
down stairs
VI Abducens, M,
Superior orbital fissure
Abducts eyeball
Internal strabismus
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
CN, Type, Foramina,
Associated Ganglia
Function
Lesion
V Trigeminal,
Trigeminal ganglion
Trigeminal neuralgia
V1 Ophthalmic, S,
General sensation (touch,
Superior orbital fissure pain, temperature) of
forehead/scalp/cornea/nose
Loss of general sensation
in skin of
forehead & nose
Loss of blink rf (+CNVII)
V2 Maxillary, S,
foramen rotundum
General sensation of
palate/nasal cavity/ maxillary
face/upper teeth
Loss of general sensation
in skin over
maxilla, upper teeth
V3 Mandibular, S+M,
foramen ovale
General sensation of anterior
2/3 of tongue/ mandibular
face/ lower teeth Motor to 4
muscles of mastication/ 2 oral
floor / 2 tensors
Loss of general sensation
in skin over mandible,
lower teeth, ant. 2/3 of the
tongue. Weakness in
chewing: jaw deviation
toward weak side
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
CN, Type, Foramina,
Associated Ganglia
VII Facial, M+S+P,
Internal auditory
meatus, Geniculate (1)
Submandibular (2) &
Pterygopalatine (3) gg.
Function
To muscles of facial
expression, stapedius
Taste of ant. 2/3 of the
tongue (1)
Secretomotor for
submandibular, sublingual
glands (2) / lacrimal gland,
nasal & palaline glands (3)
Lesion
Bell palsy,
Hypcracusis
Loss of blink rf (+CNV)
Loss of taste ant. 2/3
Eye dry and red
VIII Vestibulocochlear, Hearing (1)
Sensorineural hearing
S, Internal auditory
Linear & angular acceleration loss
meatus, Spiral (1) &
(2)
Loss of balance
Vestibular (2) gg.
IX Glossopharyngeal,
M+S+P, Jugular
foramen, Sup. & Inf. gg,
(1), Otic g. (2)
Stylopharyngeus m.
Loss of gag rf (+CNX)
General & taste senses (1) for
post. 1/3 of the tongue/
pharynx/ carotid sinus/body
Secretomotor for parotid
gland (2)
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
CN, Type, Foramina,
Associated Ganglia
Function
Lesion
X Vagus, M+S+P,
Jugular foramen, Sup.
& Inf. gg, (1), Terminal
gg. (2)
To muscles of larynx, palate
& pharynx (except tensor
palati (V) & stylopharyngeus
(IX))
Sensation in larynx and
laryngopharynx (1)
(2) To foregut and midgut
smooth muscle and glands
Dysphagia, palate droop
Uvula pointing away from
the lesion side
Hoarseness/loss of vocal
cord abduction
Loss of gag rf (+CNIX)
Loss of cough rf
XI Accessory, M,
Jugular foramen
Turns head to opposite side
(sternocleidomastoid)
Elevates and rotates scapula
(trapezius)
Shoulder droop the same
side
XII Hypoglossal, M,
Hypoglossal canal
To muscles of the tongue &
infrahyoid (ansa cervicalis)
Deviation of the tongue
toward the lesion
side on protrusion
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
78. Pituitary gland tumors and
transsphenoidal operation
2
1



3
Dr. Mavrych, MD, PhD, DSc
Pituitary tumors [1] may extend
superiorly through opening in the
diaphragma sella, producing
disturbances in endocrine system.
Superior extension of a tumor may
cause visual deficit owing to pressure on
the optic chiasm [2], the place where
the optic nerve fibers cross.
The transsphenoidal operation is the
most common operation for a pituitary
tumor. The surgical approach for it is
through the nose, nasal cavity and
sphenoidal sinus [3]. This surgical
approach provides the best exposure of
the tumor at the lowest risk.
prof.mavrych@gmail.com
Hormones of the pituitary gland


Dr. Mavrych, MD, PhD, DSc
Releasing and inhibiting factors from
neurosecretory cells of the
hypothalamus reach pituitary gland
thought special capillary network –
hypophyseal portal system and
control the production of
adenohypophyseal hormones
(ACTH, FSH, LH, TSH, prolactin
and somatotropin).
Hormones of neurohypophysis
(ADH and Oxytocin) are secreted in
hypothalamus and transported
through axons to pituitary gland.
prof.mavrych@gmail.com
79. Trigeminal nerve

Skin of face
supplied by
branches of the
three divisions of
the [1]
TRIGEMINAL
NERVE (CN V)

Except for a small
area over the
angle of the
mandible which is
supplied by the [2]
great auricular
nerve (C2-C3) –
cervical plexus
1
Infraorbital
foramen
2
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
80. Bell's palsy



It is idiopathic unilateral facial
paralysis.
Terminal branches of CN VII may
be injured by parotid cancer or
inflammation (parotitis) by surgery
to remove a parotid tumor
(stylomastoid foramen).
Manifestations:
 unable to close lips and eyelids on affected side
 eye on affected side is not lubricated (dry eye)
 unable to whistle, blow a wind instrument, or chew effectively
 facial distortion due to contractions of unopposed contralateral facial
muscles
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
81. Epistaxis

Dr. Mavrych, MD, PhD, DSc
Epistaxis (nosebleed)
most often occurs from
the anterior nasal septum
(Kiesselbach's area),
where branches of the
sphenopalatine, anterior
ethmoidal, greater
palatine, and superior
labial (from facial)
arteries converge.
prof.mavrych@gmail.com
Lateral wall of nasal cavity
Sphenoethmoidal recess
 receives the opening of the
sphenoidal air sinus
1. Superior meatus
1. Receives opening of posterior
ethmoidal air cells
2. Middle meatus
1. Infundibulum, ethmoidal bulla and
semilunar hiatus
2. Receives openings of frontal and
maxillary sinuses and anterior
and middle ethmoidal air cells
3. Inferior meatus
 Receives opening of
nasolacrimal duct

Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
82.Ethmoiditis


Dr. Mavrych, MD, PhD, DSc
Infection in the ethmoidal
sinuses can erode the medial
wall of the orbit, resulting in
orbital cellulites that can spread
to the cranial cavity.
In orbital cavity infection may
erode structures related to the
medial orbital wall:
 Medial rectus muscle
 Superior oblique muscle
 Nasociliary nerve
prof.mavrych@gmail.com
83. Cheeks

1
2
3
Dr. Mavrych, MD, PhD, DSc



Form the lateral, movable walls of the
oral cavity and the zygomatic
prominences of the cheeks over the
zygomatic bones.
Buccinator [1] – principal muscle of the
cheek.
Buccal pad of fat – encapsulated
collection of fat superficial to buccinator.
Parotid duct [2] from Parotid gland [3]
perforate buccinator and opens in inner
surface of the cheek right opposite 2nd
upper molar tooth
prof.mavrych@gmail.com
84. Movements at the TMJs
All 4 muscles of
mastication are
innervated by V3:
1.Temporalis –
elevation & retraction
2.Masseter elevation
3.Medial pterygoid elevation
4.Lateral pterygoid
- protrusion
Note: In case of Mandibular nerve (V3)
damage mandible (when it is protruded)
deviate toward the side of lesion because
of Lateral pterygoid weakness.
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
85. Innervation of the tongue
1.
2.
3.



Dr. Mavrych, MD, PhD, DSc
Sensory anterior 2/3: general – lingual n. (V3), taste
– chorda tympani (CNVII)
Sensory posterior 1/3: general and taste –
glossopharyngeal (CNIX)
Motor – hypoglossal (CNXII)
A lesion of the chorda tympani – lose of the taste
sensation anterior 2/3 of the tongue
A lesion of the lingual nerve – lose of both general
and taste sensation anterior 2/3 of the tongue
A lesion of CN XII (hypoglossal canal) allows the
contralateral, unparalyzed genioglossus muscle to
pull the protruded tongue toward the paralyzed side
(deviation and atrophy of the tongue).
prof.mavrych@gmail.com
86. Palatine tonsils




Dr. Mavrych, MD, PhD, DSc
Receives main blood supply
from tonsillar branch of facial
artery
Drained by external palatine
vein to facial vein
Lymph drainage mainly to
jugulodigastric lymph node,
which is body's most frequently
enlarged lymph node
Nerve supply: tonsillar plexus of
nerves formed by branches of CN
IX and CN X
prof.mavrych@gmail.com
Tonsillitis




Dr. Mavrych, MD, PhD, DSc
During palatine tonsillectomy, the
peritonsillar space facilitates tonsil
removal, except after capsular
adhesion to the superior constrictor.
If the glossopharyngeal nerve is
injured, taste and general sensation
from the posterior 1/3 of the tongue are
lost.
Hemorrhage may occur, usually from
the external palatine vein or tonsillar
branch of the facial artery
If the superior constrictor is
penetrated, a high facial artery or
tortuous internal carotid artery may
be injured.
prof.mavrych@gmail.com
Gag reflex


Dr. Mavrych, MD, PhD, DSc
Touching the posterior part of the
pharynx results in muscular
contraction of each side of the
pharynx - gag reflex:
 Afferent limb: CN IX
 Efferent limb: CN X
Injury to the
GLOSSOPHARYNGEAL NERVE
(CN IX) will result in a negative gag
reflex
prof.mavrych@gmail.com
87. Muscles of Soft Palate
1.
2.
3.
4.
5.
Dr. Mavrych, MD, PhD, DSc
Tensor veli palatini and
Levator veli palatini – elevates the
soft palate during swallowing to
prevent food entering to the
nasopharynx
Palatoglossus and
Palatopharyngeus – depress soft
palate and pulls walls of pharynx
superiorly
Uvular muscle – shortens uvula
and pulls it superiorly
prof.mavrych@gmail.com
88. Lymph drainage from the
head
1
5
4
2
Dr. Mavrych, MD, PhD, DSc
3
1. Preauricular (parotid ) (on front of
auricle) receive lymph from
anteriolateral part of scalp and
lateral face
2. Submandibular (in digastric or
submandibular Δ) – from all air
sinuses, nose and adjacent
cheek, upper lip and lateral parts
of lower lip.
3. Submental (in submental Δ) – from
the chin, tip of the tongue and
central part of the lower lip.
4. Mastoid (behind the auricle) –
adjacent region of the head.
5. Occipital (occipital region).
prof.mavrych@gmail.com
89. Blow-out fracture


Dr. Mavrych, MD, PhD, DSc
A blow-out fracture of the orbital
floor typically is not involve the
orbital rim and is caused by blunt
trauma to the orbital contents (e.g.,
by a handball). Content of orbital
cavity blow-out in maxillary sinus.
Blow-out fractures may damage:
1. Inferior rectus muscle
2. Infraorbital nerve (from
maxillary V2)
3. Infraorbital artery
(hemorrhaging).
prof.mavrych@gmail.com
90. Lips and palate congenital
defects




Dr. Mavrych, MD, PhD, DSc
The intermaxillary segment forms when
the two medial nasal prominences fuse
together at the midline and gives rise to the
philtrum of the lip, four incisor teeth, and
primary palate of the adult. It forms anterior
to the incisive foramen.
Secondary palate (2 shelves) derivate from
maxillary prominences.
Maxillary prominences have fused with the
medial nasal prominences (intermaxillary
segment).
In case of failure of this process, cleft of the
lip or palate will develop.
prof.mavrych@gmail.com
91. Strabismus
Smart table 9: Muscles of the orbit
Muscle
Action
Testing
Superior
rectus
CN
Up and medially Look laterally,
then up
Inferior rectus Down and
Look laterally,
medially
then down
CN III
Medial rectus Adducts pupil
Look medially
CN III
Lateral
rectus
Superior
oblique
Abducts pupil
Look laterally
CN VI
Down and
laterally
Look medially,
then down
CN IV
Inferior
oblique
Up and laterally
Look medially,
then up
CN III
Levator
pulpebra
superior
Elevates upper
eyelid
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
CN III
CN III
Oculomotor Nerve Palsy


CNIII
Trochlear nerve palsy


CNIV

Dr. Mavrych, MD, PhD, DSc
It cause paralysis of the superior oblique and
impair the ability to turn the affected eyeball inferomedially (“up and out”)
The characteristic sign of trochlear nerve injury is
diplopia (double vision) when looking down (e.g.,
when going down stairs or reading)
Abducens Nerve Palsy

CNVI
External squint affects most of the extraocular
muscles
Manifestations: Ptosis, Fully dilated pupil, Eye is
fully depressed and abducted (“down and out”)
due to unopposed actions of superior oblique and
lateral rectus, respectively.
Internal squint because of injury to abducens nerve
 paralysis of lateral rectus  inability to abduct
the affected eye
Affected eye is fully adducted by the unopposed
action of the medial rectus that is supplied by CN III
prof.mavrych@gmail.com
92. Horner syndrome


Dr. Mavrych, MD, PhD, DSc
Penetrating injury to the neck,
Pancoast tumor, or thyroid carcinoma
may cause Horner syndrome by
interrupting ascending preganglionic
sympathetic fibers anywhere between
their origin in the T1 segment (IML) of
spinal cord and their synapse in the
Superior cervical ganglion.
It includes the following signs:
 Constriction of the pupil (miosis)
 Drooping of the superior eyelid
(ptosis),
 Redness and increased temperature
of the skin (vasodilation)
 Absence of sweating (anhydrosis)
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93. Otitis Media
Complications:
1. Hearing is diminished because of
pressure on the eardrum and
reduced movement of the ossicles.
2. Taste may be altered because the
chorda tympani is affected.
3. Infection spreading posteriorly
cause mastoiditis.
4. Infection that spreads to the
middle cranial fossa can cause
meningitis or temporal lobe
abscess, and infection moving
through the floor may produce
sigmoid sinus thrombosis.
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Perforation of the tympanic
membrane
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Dr. Mavrych, MD, PhD, DSc
May result from otitis media and is one of
several causes of middle ear (conduction)
deafness
Causes: foreign bodies in external
acoustic meatus, excessive pressure (as in
diving), trauma
Because chorda tympani directly relates
to the posterior surface of the tympanic
membrane it may be damaged and
resulting in loss of taste over anterior 2/3
of the tongue and secretion of the
sublingual and submandibular glands
Minor perforation heal spontaneously; large
ones require surgical repair
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94. Inner ear
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Dr. Mavrych, MD, PhD, DSc
It contains the vestibulocochlear organ
concerned with reception of sound and
maintenance of balance (CNVIII).
Cochlea: spiral organ (of Corti) –
receptors for hearing (located along the
basilar membrane)
Vestibule: utricle and saccule are parts
of the balancing apparatus (static
position)
Semicircular canals: receptors of
angular acceleration (kinetic)
 Anterior – in coronal plane
 Posterior - in sagittal plane
 Lateral – in horizontal plane
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95. Thyroid and parathyroid
glands
Hormones:
 The thyroid gland is the body's largest endocrine
gland. It produces thyroid hormone (T3 & T4), which
controls the rate of metabolism (increase the
temperature of the body), and calcitonin, a hormone
controlling calcium metabolism (reduce blood calcium
Ca2+).
 After total thyroidectomy may develop lower
temperature of the body and hypercalcemia.

Dr. Mavrych, MD, PhD, DSc
The hormone produced by the parathyroid glands,
parathormone (PTH), controls the metabolism of
phosphorus and calcium in the blood (increase Ca2+
level).
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Variation of parathyroid glands
position
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Dr. Mavrych, MD, PhD, DSc
The superior parathyroid
glands, more constant in position
than the inferior ones.
The inferior parathyroid glands
are usually near the inferior
poles of the thyroid gland, but
they may lie in various positions
In 1-5% of people, an inferior
parathyroid gland is deep in the
superior mediastinum inside the
thymus because of common
embryonic origin.
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Anatomical relations of the
thyroid gland

1
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
1

1
3
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Anterolateral –
infrahyoid muscles
Posterolateral –
COMMON CAROTID
ARTERY [1]
Medial – larynx,
TRACHEA [2],
pharynx, esophagus,
cricothyroid muscle,
recurrent laryngeal
nerve [3]
Posterior –
parathyroid glands
[4]
CS of the neck
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
96. Cervical cysts
Median cervical cyst
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Dr. Mavrych, MD, PhD, DSc
Usually presents as a painless
midline mass on the anterior aspect
of the neck just below of the hyoid
bone and moves during swallowing
together with thyroid gland because of
relation with pretracheal layer of
cervical fascia and infrahyoid muscles
of the neck.
Remanent of the thyroglossal canal
(thyroid gland originally from
epithelium of the tongue).
Treatment: surgical excision
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Lateral cervical cysts
(Branchial cysts)
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Dr. Mavrych, MD, PhD, DSc
Lateral cervical cysts are
remnants of 2nd, 3rd, and 4th
grooves and filled up by
ectoderm
There are painless cysts located
on the lateral neck along the
anterior border of the
sternocleidomastoid muscle
They do NOT move during
swallowing (difference with
median cysts)
Treatment: surgical excision
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97. Larynx
3
Cavity of the Larynx 2 Folds:
1
2  Vestibular folds
[1] (false vocal
cords)
 Vocal folds [2]
(true vocal cords)
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
1
2
Dr. Mavrych, MD, PhD, DSc
Rima vestibuli – gap between the
vestibular folds
Rima glottidis [3] – gap between the
vocal folds anteriorly and vocal
processes of the arytenoid cartilages
posteriorly is most narrow place in the
larynx (it limits size of intubation tube
during endotrachial anaesthesia)
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Muscles of the Larynx
Abductors
 Posterior
cricoarytenoid –
abducts vocal folds (the
only abductors of the
vocal folds)
 It is innervated by
recurrent laryngeal
nerve (CNX vagus).
 Interruption of recurrent
laryngeal nerve results
in hoarseness because
the corresponding vocal
fold does not abduct and
deviate toward the
midline.
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
98. Cricothyrotomy
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Dr. Mavrych, MD, PhD, DSc
A cricothyrotomy is an emergency
procedure that relieves an airway
obstruction (e.g. swallowed foreign
bodies or abnormal tissue growths).
A hollow needle is inserted into the
midline of the neck, just below the
thyroid cartilage (needle
cricothyrotomy).
More frequently, a small incision is
made in the skin over the
Cricothyroid membrane, and
another one is made through the
membrane between the cricoid
and thyroid cartilage. A tube that
enables breathing is inserted
through the incision.
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99. Retropharyngeal space
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
Dr. Mavrych, MD, PhD, DSc
It is interval between pharynx
(Bucco-pharyngeal fascia) and
prevertebral fascia
May provide a passageway of
infection from pharynx to
posterior mediastinum
(mediastinitis ≈ 90% mortality
rate).
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100. Neck
Axillary sheath
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Dr. Mavrych, MD, PhD, DSc
Derived from the prevertebral
fascia
Encloses the subclavian artery
and brachial plexus as they
emerge in the interval between the
scalenus anterior and medius
muscles (Interscalenus space)
Extends into the Axilla
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Torticollis
Congenital torticollis
 most commonly caused by a fibrous
tissue tumor in the SCM
 head turns to the side and the face to
turn away from the affected side
 surgical release may be necessary
Spasmodic torticollis
 may involve any bilateral combination
of lateral neck muscles, usually SCM
and trapezius
 involuntary shifting of head laterally or
anteriorly
 shoulder usually elevated and anteriorly
displaced on the side on which chin
turns
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com
Posterior triangle of the neck
Veins – external jugular vein,
subclavian vein.
 Arteries – occipital artery.
 Nerves – Accessory nerve (XI),
trunks of the brachial plexus,
branches of cervical plexus, phrenic
nerve.
 Lymph nodes – superficial cervical
nodes along external jugular vein.
CN XI (accessory nerve) supply:
 Sternocleidomastoid muscle - face
looks upward to the opposite side
 Trapezius - superior fibers elevate,
middle fibers retract, and inferior
fibers depress scapula.

CN XI
Dr. Mavrych, MD, PhD, DSc
prof.mavrych@gmail.com