Anatomy Lecture Notes--midterm review by Stephanie Swanson Thorax: Breast: Cooper’s Ligaments- suspensory ligaments Glands/Lobulesductssinusesnipple Retromammary space- behind the breast- allows for movement Blood Supply: Internal Thoracic Artery on anterior chest parasternal and Lateral thoracic artery lateral anterior chest Lymph Drainage: parasternal lymph nodes + apical lymph nodes (75% here) Superficial Chest: Cephalic vein (in deltopectoral triangle) Medial/Lateral cutaneous vessels and nerves Anterior Muscles: Pectoralis Major adduction, medial rotation, flexion of humerus at shoulder medial and lateral pectoral nerve Pectoralis Minor depresses tip of shoulder, protracts scapula medial pectoral n. External intercostals inspiration, moves ribs up (inferomedially) Internal intercostals Expiration/inspiration (superiorlaterally) Innermost intercostal Transversus thoracis pectoral branch of thoracocromial trunk a. Intercostal arteries Intercostal nerves act with internal intercostals depress costal cartilages internal thoracic a. Also know where they attach to Pec major – clavicle, sternum, ribs, humerus Pec minor – ribs 3, 4, 5 to corocoid process Intercostals – rib to rib (note direction above) Trans. Thoracis – sternum to ribs Branches off the axillary artery—Screw The Lawyer, Save A Patient Superior thoracic, Thoracoacromial, lateral thoracic, subscapular, anterior and posterior circumflex humeral Chest Wall: Intercostals Vein, Artery, Nerve (VAN) on top of ribs -**when putting a needle do it above the rib These run between the internal and innermost muscles T4 = nipple Sympathetic Trunk- from superior cervical ganglia down Thorax Bone Structure: Coracoid process (what attaches here) Acromion Clavicle Sternum (3 parts) sternal angle (where rib 2 attaches, level of T4/5, where trachea bifurcates, aortic arch stops and starts, separates superior and inferior mediastinum, top of azygos vein arch) Ribs neck, head, facets, body, intercostal groove (for intercostal vessels) **attach to their own vertebral body and the one above it and to transverse process of the same vertebrae intercostal VAN (vein artery nerves), they run on inferior aspect of ribs, in the costal groove, not on top or rib as stated in review. Collateral branches run on top. Needle placement is on top of rib. See p 63 of text. Also, innermost intercostals probably act with external intercostals. See p 7 of dissector. -ribs 1, 10, 11, 12 have one facet to their own vertebrae Scapula (spine, fossas) Vertebra (lamina, body, canal, pedicle, transverse foramen, spinous process, transverse process, IV disc: nucleus pulpolsis + annulus fibrosis) True ribs 1-7; False ribs 8-10; floating ribs 11-12 Lungs + Pleura: Pleura parietal (outer layer), visceral (on lungs) layers Costodiaphragmatic recess fills when you breathe – at the inferior of the lungpotential space LungRoot- just the arteries, veins, bronchi Hilum- root + pulmonary ligament Pulmonary Arteries (deoxygenated blood) – superior – run with bronchi Pulmonary Veins (oxygenated blood) – inferior – run segmentally Bronchial Arteries- off of aorta to supply blood to lung tissues Trachea bifurcates at second rib into primary bronchi (right and left) lobar segmental bronchi **azygos vein comes up and loops around the right lung hilum Lymph Nodes: drain up and around to trachea- can cross over Innervation of Pleura: Somatic: mainly to parietal pleura sensation to pain Autonomic: mainly to visceral pleura pain insensitive Alveoli-little sacs- respiratory part of the lung (rest is conducting portion) Right lung: has three lobes: superior, middle, inferior with two fissures **Horizontal fissure separates the superior from the middle lobe **Oblique fissure separates the inferior lobe from the superior and middle **on the right: middle lobe is mostly on the posterior and superior is mostly anterior Left lung: has 2 lobes + lingula: superior, inferior (oblique fissure separates them) – also has the cardiac notch **on the left: inferior lobe is mostly seen posterior (aka if someone gets stabbed there) and superior lobe is anterior Heart and Great Vessels: Sits tilted in the chest cavity: Anterior – right ventricle Posterior – left atrium Thymus –in children –remnant in adultsover the superior portion of the heart Phrenic nerve runs on the pericardial sac with the pericardiacophrenic vessels- to the diaphragm Auricles- accessory heart muscles that help contract and open the atria Apex of the heart Blood flow: Coronary Sinus/SVC/IVC right atrium (deoxygenated from body + heart) right ventricle pulmonary trunk right and left pulmonary arteries (deoxygenated) lungs 4 pulmonary veins (oxygenated) left atrium left ventricle ascending aorta arch of the aorta descending aorta **note: 2 pulmonary arteries, 4 pulmonary veins Pericardial Sac: 2 layers: Fibrous (outer) and Serous (visceral and parietal pleural layers) Left ventricular walls are thicker because of more power needs to get body to the whole body (and therefore pressure is higher) Three layers/membranes in the heart: endocardium, myocardium, epicardium Cardiac Sinuses: Transverse Sinus- goes all the way through between pulmonary veins/ SVC and pulmonary trunk/aorta Oblique Sinus- goes under the heart between IVC and between pulmonary arteries (blind end) Coronary Arteries and Veins: Aorta gives off two branches after leaving the heart: right and left coronary arteries (RCA/LCA) RCA SA nodal artery, right marginal artery, left posterior descending (LPD) LCA circumflex artery, left marginal artery, left anterior descending (LAD), Veins: Great LAD Middle PDA Small RCA/right marginal Coronary sinus is on the posterior drains into RA Valves: right atria to right ventricle = tricuspid valve with anterior, posterior and septal cusps left atria to left ventricle = mitral/bicuspid valve with anterior and posterior cusps Semilunar valves: aortic (left, right, posterior); pulmonic (anterior, left, right) remember this by PLAR- circle the A for aortic, and you have PLR leftover (posterior, left, right) and circle the P for pulmonic, and you have LAR leftover (left, anterior, right) Cusps are held by chordae tendinea which attach to papillary muscles in the ventricles In the atria the rough looking muscles are pectinate muscles In the ventricles they are trabeculae carnea Fossa Ovale embryonic remnant of physiological shunt to left atrium In the right atria there is a Crista Terminale which is a smooth ridge separating the pectinate muscles from the smooth muscle – also there is a conus arteriosus (infundibulum) that leads to pulmonary trunk: Netter Plate 216) SA Node (pacemaker of the heart) is in the right atrium fibers go to the AV node in the bottom part of the right atrium fibers to interventricular septum right bundle branch moderator band and Purkinje fibers (left bundle branch to left ventricle) conducts impulses to papillary muscles Diastole= relaxed ventricles - tri and bicuspids open – semilunars closed Systole= contracted ventricles – semilunars open – tri and bi open Posterior Thorax/Wall: Vertebrae are the most posterior – with descending aorta and esophagus, azygos veins on top (**thoracic duct runs in between azygos and esophagus) Azygos Veins- azygos are on the right, hemiazygos on the lower left, and accessory azygos on the upper left Left recurrent laryngeal nerve comes down (branching off the vagus) and goes posterior to the ligamentum arteriosum (remnant of the ductus arteriosus) and then goes back up to larynx Right recurrent laryngeal nerve comes down under the right subclavian artery and back up Vagus (CN X) nerve runs down medial to the phrenic and wraps into a plexus around the esophagus and branches to the heart– then sends parasympathetics to the thorax (and then abdomen) -PNS has long preganglionics, and short postganglionics (innervates viscera) Thoracic duct- runs with (posterior) esophagus from the abdomen (from the cysterna chyli) delivering lymph into the left subclavian vein (where it gives off the left internal jugular vein) Sympathetic Trunk- (T1-L2) runs lateral to the vertebral bodies on the posterior wallcontains sympathetic fibers and ganglia (cell bodies) – connects to ventral rami (intercostal nerves) by rami communicates (grey=post/ white=pre)– starts at the superior cervical ganglia in brain (NOT the spinal cord-only connects to spinal cord) – and ends in lumbar splanchnics—send off greater, lesser, and least splanchnics in the thorax (all preganglionic sympathetics) -SNS has short preganglionics, and long post ganglionics (innervates blood vessels and glands) Nervous System: AfferentDorsal HornDorsal Root GangliaDorsal RootSensoryInfo to CNS EfferentVentral HornVentral RootMotorAway from CNS Somatic GSA: touch, temp, proprioception, sharp pain—only part in the abdomen is the omenta Visceral GVA: all of viscera (organs) in the gut: dull pain (bellyache) GSE: skeletal muscle GVE: smooth muscle -SNS/PNS- 2 ganglia system (always run with VA) Dermatomes represent the area of the skin supplied by the nerve root- these are segmental Cutaneous innervation is different – it represents different nerve sensory areas on the skin Back and Spinal Cord: 33 vertebrae – 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, 4 coccyx C1 = atlas (has no body) C2 = axis (with dens/odontoid process) C2, 3 have bifid spinous processes Vertebral artery runs through transverse foramen Spinal nerves run through vertebral foramen Vertebra and all its parts: Note connections to ribs discussed in thorax (above) Intervertebral Disc- consists of nucleus pulposis (squishy inside; remnant of notochord) and annulus fibrosus (fibrous outside) Ligaments: Nuchal ligament: from occipital bone of skull to first couple spinous processes Intraspinous ligaments: from spinous process to spinous process Anterior longitudinal ligament: most anterior thing- anterior of body Posterior longitudinal ligament: posterior of body – anterior of the canal Ligamentum Flava: posterior of the canal (the pop when you do a lumbar puncture) Extrinsic muscles- are involved with the movements of upper limbs- innervated by anterior/ventral rami Intrinsic muscles- are deep and support and move vertebral column- innervated by the posterior/dorsal rami Back Muscles: Muscle Type Group Muscle Name Trapezius Extrinsic Superficial Intrinsic (innervated by posterior/dorsal rami) Intermediate Deep Latissimus Dorsi Levator Scalpulae Rhomboid Minor Rhomboid Major Serratus Posterior Superior Serratus Posterior Inferior Muscle Function elevate, depress, adduct, & medially rotate scapula extend, adduct, & medially rotate humerus Nerve Innervation Arterial Supply accessory spinal nerve (CN XI) transverse cervical Thoracodorsal thoracodorsal dorsal scapular dorsal scapular dorsal scapular dorsal scapular elevate ribs ventral rami Intercostal a. depress ribs ventral rami Intercostal a. Spinotransversales: 1. Splenius capitus 2. Splenius Cervicis together: pull head back, extend neck; individually: move head to same side as contraction dorsal rami Erector Spinae: 1. Iliocostalis 2. Longissimus 3. Spinalis maintain upright posterior, bend back dorsal rami elevate scapula retract scapula retract scapula Transverse cervical dorsal scapular segmentally: deep cervical, intercostal, subcostal, lumbar Bone Structures: Scapula (spine, coracoid, acromion, supraspinous fossa, infraspinous fossa, suprascapular notch, superior, medial, lateral, inferior borders) Suprascapular notch- suprascapular artery goes over the ligaments in it, the nerve goes through the notch (remember the army goes over, the navy goes under) Suboccipital Triangle- underneath the trapezius in the back of the neck this holds the vertebral artery, posterior arch of C1, and the greater occipital nerve (off of C2) Spinal Cord: Extends from brain to L1/L2 in adult (the whole spinal column in infants) There are two enlargements: cervical (for extra tissue for upper limbs) and lumbosacral (extra tissue for lower extremity) **Spinal nerves exit the transverse foramen above the vertebra for the cervical nerves, and below for all the rest Though there are 33 vertebrae there are only 31 spinal nerves (8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal) Vertebral houses the spinal cord in the vertebral canal- spinal cord is protected by layers of connective tissue membranes (meninges) and spaces: Pia mater: adhered to spinal cord (like a viscera) extends inferiorly into the filum terminale and medially into denticulate ligaments Subarachnoid Space: between the pia and arachnoid maters holds the CSF (this is where we do lumbar punctures Arachnoid mater: thin, shiny membrane on the surface of the dura mater Subdural Space: between the arachnoid and the dura maters this is where you often get subdural hematomas even though this is a potential space Dura mater: thickest, most external, white membraneoffers good protection Epidural Space: this is where we do epidurals contains fat with vessels Arterial supply to the spinal cord starts superior with the vertebral artery branches to anterior spinal artery / segmental arteries Artery of Adamkiewicz is very important because it supplies a huge portion of the thoracic spinal cord arteries occlusion here would cause a major effect on spinal cord There is an extensive venous plexus drainage system segmental veins go to IVC Scapula and Deltoid Region: Muscles: Muscle Name Supraspinatus Infraspinatus Posterior Scapula Muscle Function Abduct arm to first 15 degrees Lateral Rotation of arm Nerve Innervation Arterial Supply Suprascapular Suprascapular Suprascapular Suprascapular Origin Insert Superior Scapula inferior scapula Top of Humerus middle humerus Teres Minor Lateral Rotation of arm Axillary Nerve Posterior circumflex humoral artery Lateral scapula greater tubercle Teres Major medial rotation and extension of arm Inferior subscapular nerves circumflex scapular artery posterior scapula anterior humerus Anterior and posterior Anterior scapula Axillary Nerve Post. Circumflex humoral artery, deltoid branch of thoracoacromial clavicle middle of humerus medial rotation of arm Upper/lower subscapular nerves subscapular artery lesser tubercle anterior side of humerus Rotation/protracti on of scapula Long Thoracic Nerve Lateral Thoracic artery ribs 8-9 scapula Deltoid Major Abductor of the arm after first 15 degrees Subscapularis Serratus Anterior Remember: a Lat between two Majors – on the humerus insertions are: pec major, lat. Dorsi, teres major (lateral to medial) Muscles of Rotor Cuff: SITS : supraspinatus – infraspinatus – teres minor – subscapularis Bone Structure: Humerus: greater tubercle (for SIT), lesser tubercle (for subscap), deltoid tuberosity (for deltoid), radial groove (for radial nerve), intertubercular groove (for long head of biceps tendon), anatomical (upper) and surgical necks (lower) inferior humerus is in arm (below) Quadrangular space: Axillary nerve runs with post. circumflex humeral artery Borders: long head of triceps, teres minor, teres major, humerus Upper triangular space: circumflex scapular vessels Lower triangular space: radial nerve and deep branchial artery Borders: long head of triceps, teres major, medial head of triceps Shoulder joint: Bursa: sacs with fluid so that they help slide the joint Glenohumeral ligaments Coracoacromial ligament Acromioclavicular ligament Glenoid Fossa Vessels in shoulder have lots of anastomosis- so can bypass a blockage more easily Brachial Plexus: Axilla: Anterior: pec major/minor Posterior: subscapularis Medial: serratus anterior/ribs/intercostals Axillary Sheath: contains arteries, vessels, nerves Plexus: C5-T1 roots Really Thirsty? Drink Cold Beer roots, trunks, divisions, cords, branches End branches are MARMU (musculocut, axillary, radial, median, ulnar) Really you just need to know how to draw it, with the small branchesInnervation of Brachial Plexus: Dorsal Scapular Long thoracic Suprascapular Nerve to subclavius Lateral pectoral Musculocutaneous Medial pectoral Medial cutaneous of arm Medial cutaneous of forearm Skin to lateral side of forearm Skin medial of distal 1/3 of arm Skin medial of forearm Median palm surface lat. 3.5 digits & lateral side of palm and mid of wrist Ulnar palm surface of med. 1.5 digits & dorsal of med 1.5 digits Superior subscapular Thoracodorsal Inferior subscapular Axillary Radial Rhomboid major/minor Serratus anterior Supra and infraspinatus Subclavius Pec. major anterior compartment of arm Pec. major/minor upper lateral part of arm Post. arm/forearm, lower lat. Surface of arm, dorsal lateral of hand) Ant. compartment of forearm, 3 thenar of thumb, 2 lateral lumbrical muscles (no flexor carpi ulnaris & flexor digitorum profundus) intrinsic muscles of hand (no median nerve ones), flexor carpi ulnaris, med. Flexor digitorum profundus) subscapularis latissimus dorsi subscapularis, teres major deltoid, teres minor posterior compartment of arm/forearm Arm: Bone Structure: Humerus: medial and lateral epicondyles, coronoid fossa (anterior), olecranon fossa (posterior), trochlea (medial), capitulum (lateral) Forearm: ulna (olecranon)- by the pinky finger / radius (styloid process)- by the thumbarticulates with the scaphoid and lunate -interosseus membrane goes between two bones Muscle Group Anterior Posterior Muscle Name Muscle Function & Facts Biceps brachii flex arm (long head) & forearm, supinate if elbow is flexed brachialis flex forearm Coracobrachialis flex forearm, adduct arm Triceps brachii extend forearm at elbow, long head can adduct or extend arm at shoulder Nerve Innervation Arterial Supply brachial Musculocutaneous brachial + radial recurrent brachial radial profunda brachii also know insertions: Biceps- long head (supraglenoid tubercle of the scapula), short head (coracoid process), both originate from radius bone Brachialis- from ulna to humerus Coracobrachialis- from coracoid process to humerus Triceps- long head (inferior border of scapula), lateral head (humerus), medial head (humerus) – all insert into biceps tendon onto olecranon Cubital fossa: at the elbow- borders (medial = protonator teres / lateral = brachioradialis / proximal = biceps brachii) median cubital vein runs here with biceps tendon and brachial artery Superficial Posterior Brachioradialis Accessory flexor of elbow Extensor carpi ulnaris Extends & adducts wrist Extensor digiti minimi Extends little finger Extensor digitorum Extends fingers & wrist Extensor carpi radialis brevis Extensor carpi radialis longus Deep Posterior Radial nerve Posterior interosseous (a continuation of the deep branch of radial nerve) Radial recurrent Ulnar artery Interosseous recurrent from ulnar interosseous recurrent & posterior interosseous Extends & abducts wrist Deep branch of radial Radial artery Extends & abducts wrist Radial nerve Radial artery Anconeus Abduction of ulna in pronation; accessory extensor of elbow Radial nerve interosseous recurrent Supinator Supination Extensor indicis Extensor pollicis longus Extensor pollicis brevis Abductor pollicis longus Extends index finger Extends IP joint of thumb (also CMC & MCP joints) Extends MCP joint of thumb (also CMC joint) Abducts carpometacarpal joint of thumb recurrent interosseous Posterior interosseous (continuation of deep branch of radial nerve) Posterior interosseous Hand: Bone Structure: Phalanges (3) Metacarpal (1) Carpals (8) DIP: distal interphalangeal joint PIP: proximal interphalangeal joint MCP: metacarpophalangeal joint CMC: carpometacarpal joint Wrist Bones: Some Lovers Try Positions That They Can’t Handle Scaphoid Lunate Triquetrum Pisiform Trapezium Trapezoid Capitate Hamate-Hook of hamate–where the ulnar nerve lies Pisiform is a sesamoid bone Muscles: T y p e Muscle Group Muscle Name Intrinsic Palmaris brevis Thenar (FAO) Dorsal interossei (4 bipennate) Palmar interossei (4 unipennate) Adductor pollicis Opponens metacarpal pollicis Abductor pollicis brevis Flexor pollicis brevis Muscle Function & Facts deepens cup of palm & improve grip; origin at palmar aponeurosis & insertion in dermis of skin (DAB) abduct index, middle, & ring finger; flexion & extension of fingers (through dorsal hoods) (PAD) adduct thumb, index, ring, & little fingers; flexion & extension of fingers (through dorsal hoods) Adducts thumb & opposes thumb to rest of digits in gripping Medially rotates thumb; rotates & flexes metacarpal I so pad faces pads of fingers (opposition) Abducts thumb at metacarpophalangeal joint Flexes thumb at metacarpophalangeal joint Opponens digiti minimi Hypothe nar (FAO) Rotates metacarpal V toward the palm (lateral rotation) - movement less dramatic than thumb's Abductor digiti minimi Abducts little finger at metacarpophalangeal joint Lumbricals Flexor digiti minimi brevis Medial (bipennate) Flexes little finger at metacarpophalangeal joint Flex metacarpophalangeal joints while extending interphalangeal Nerve Innervati on Arterial Supply ulnar ulnar artery dorsal and palmar metacarpal ulnar palmar metacarpal deep palmar arterial arch Recurrent branch of median Radial artery ulnar ulnar artery ulnar superficial palmar arterial arch Lateral (unipennate) joints median Palmar aponeurosis – membrane that helps keep the “cup” part of the palm Extensor retinaculum – membrane covering the extensor muscles Flexor retinaculum – membrane covering the flexor muscles Carpal Tunnel: covered by the transverse carpal ligament-contains flexor pollicis longus (in its own sheath), flexor digitorum superficialis (2 on top of two- digits 3 and 4 on top of 2 and 5) and profundus (4 in a row)—median nerve also runs here Abdomen: Regions of the abdomen: Quadrants- xiphoid to pubic symphysis and horizontal through umbilicus 8 regions- subcostal and interspinous horizontal lines and two vertical midclavicular lines- right hypochondrium, epigastric, left hypochondrium, right flank, umbilical, left flank, right inguinal, hypogastric, left inguinal Posterior Abdominal Wall Abdominal Wall Muscles: Muscle Name Muscle Function & Facts Nerve Innervation Arterial Supply Ventral rami T7T12 superior epigastric, inferior epigastric External Oblique Compress abdominal contents; flex trunk (bilateral); bend trunk laterally (unilateral - to same side) Internal Oblique Compress abdominal contents; flex trunk (bilateral); bend trunk laterally (unilateral - to same side) Transversus Abdom-inis Compress & support abdominal contents Rectus Abdominis Compress abdominal contents; flex vertebral column; tense abdominal wall Ventral rami T7T12 superior epigastric, intercostal, subcostal, inferior epigastric Pyramidalis Tenses linea alba ventral rami T12 subcostal & inferior epigastric Psoas major Flexion of thigh at hip joint; flexion & laterally bending of lumbar vertebral column Ventral rami L1L3 subcostal (=T12) & lumbars Psoas minor Weak flexion & lateral bending of of lumbar vertebral column Quadratus lumborum Depress & stabilize 12th rib; laterally bend the trunk Iliacus Flexes the thigh at hip joint; flexes pelvis on thigh if thigh is fixed Ventral rami T7L1; iliohypogastric, ilio-inguinal Ventral rami T7L1; iliohypogastric, ilio-inguinal Ventral rami L1 (L1 = iliohypogastric & ilioinguinal) ventral rami T12L4; T12=subcostal nerve Femoral superior epigastric, inferior epigastric superior epigastric, inferior epigastric lumbars subcostal & lumbars iliolumbar Diaphragm inspiration: pushes the abdominal viscera inferiorly, ↑ vol. of thoracic cavity Phrenic inferior & superior phrenic; musculophrenic Bone Structure: Lumbar vertebrae- posterior Iliac crest and Ilium bone – inferior -anterior superior iliac spine Ribs- superior Pubic tubercle Abdominal Wall: Anterior: Skin camper’s fascia (fatty) scarpa’s fascia (membranous) rectal sheath internal oblique external oblique transversalis abdominus transversalis fascia Arcuate line – where the rectus sheath goes anterior completely -above: -below: Nerves/arteries are segmental to the abdominal wall -T10 is the umbilicus Iliohypogastric nerve – sensation to suprapubic region Internal thoracic from thorax comes down and splits musculophrenic + superior epigastrics (anastomose with inferior epigastrics) Iliac circumflex arteries-also anastomose with epigastrics laterally Diaphragm is superior portion with right and left crus Right = caval hiatus (T8) with IVC and phrenic Right = esophagus hiatus (T10) with vagus Left and Right = aortic hiatus (T12) with thoracic duct, azygos veins, greater splanchnics **Remember: I ate (8) 10 eggs at noon (12) Anterior wall folds: Median fold- with embryological urachus Medial folds- remnants of umbilical vessels Lateral folds- inferior epigastrics Hesselbach’s triangle- medial=lateral edge of rectus abdominus / lateral=inferior epigastric vessels / inferior=inguinal ligament Spermatic Cord/Testis: Inguinal ligament- runs from anterior superior iliac spine to pubic tubercle- made from external oblique Internal ring of the inguinal canal- genitofemoral nerve passes through it with the spermatic cord (**NOT the ilioinguinal nerve)- made from the internal oblique External ring of the inguinal canal- ilioinguinal nerve + genitofemoral nerve passes through it with the spermatic cord- made from the transversalis abdominus Ilioinguinal nerve- sensory on the testes Dartos muscle- regulates testes temperature but wrinkling the testes Spermatic cord: cremasteric muscle, vas deferens, genital branch of the genitofemoral nerve, ilioinguinal nerve, pampiniform plexus, testicular artery In the testes--layers: Tunica albuginea- white adherent fascia Tunica vaginalis- loose anterior sac Internal oblique cremasteric muscle External oblique external spermatic fascia Transversalis abdominis nothing (ends before testes) Transversalis fascia internal spermatic fascia Flow of sperm: STEVE – seminephrous tubules epididymis (superior-posterior) vas deferens ejaculatory duct Abdomen GI: Greater omentum- from stomach/transverse colon hanging down over intestines Colon: ascending (from cecum/appendix) right colic flexure transverse colon splenic/ left colic flexure descending colon sigmoid colon rectum anus -colon has haustra (pocket-appearance by semilunar folds) made by tenia coli muscles (lead to appendix) Lesser omentum- stomach to liver-creates lesser sac/epiploic foramen (IVC-posterior, portal vein-anterior) Small intestine: order: Dow Jones Industrial duodenum- C-shaped, ampulla of vater (where bile duct comes in), ligament of Treitz holds duo to diaphragm-has semi-circular folds jejunum-feathery appearance due to lots of semi-circular folds ileum-smooth with solitary lymph tissue (peyer’s patches) Stomach: regions: cardiac, fundus, body, pyloric (antrum then canal) – greater and lesser curvatures -Rugae –folds in the stomach Retroperitoneal Structures: AC/DC Rocker Kids Party Down Asc. and desc. Colon, rectum, kidneys, pancreas, duodenum Enteric Nervous System: motor and sensory neurons in the GI in two plexuses: independent systems but can be influenced by autonomics (SNS/PNS) -Myenteric/Auerbach’s and Submucosal/Meissner’s- both help in GI functions Peripheral Visceral Nerves: efferent = PNS/SNS (pre and post ganglionic) // afferent = one fiber Liver: most of liver is under ribs 4 lobes: right (biggest), left, caudate (top posterior), quadrate (bottom posterior) Right and left lobes are separates by the falciform ligament (attaches liver to anterior abdominal wall) and ligamentum teres hepatis (embryonic remnant) Hepatogastric and hepatoduodenal ligaments- forms lesser sac (anterior) Liver triad: portal vein (from all GI organs (portal venous system), common bile duct, hepatic artery at inferior Hepatic vein goes superior to IVC (systemic venous system) Right and left hepatic duct common hepatic duct combine with cystic dust common bile duct combine with pancreatic duct into duodenum Gallbladder: between right lobe and quadrate (remember GQ: gallbladder next to quadrate) Pancreas: head in the arms of the duodenum body tail near spleen -sends pancreatic duct to combine with bile duct- there is an accessory pancreatic duct also (see embryo: pancreas development) Posterior of the body are the SMA/SMV Splenic artery runs along body and tail to spleen Spleen: filters blood- splenic artery is torturous from the celiac trunk Abdominal Arteries: Unpaired- celiac trunk, SMA, IMA Paired- inferior phrenics, suprarenals, renal, gonadal, lumbar Abdominal Veins: note: IMV goes to splenic vein remember: lymphatics follow blood supply so gonads drain lymph to lumbar aortic area Posterior Abdominal Wall: IVC on the right and aorta on leftDiaphragm- has arches across the backMedian arch- aorta Medial– psoas muscles Lateral- quad. laborum Nerves: there is a plexus and ganglia for every artery (basically… i.e. SMA SMA plexus and ganglia Lumbar plexus, sacral plexus even though these are basically sympathetic the vagus comes down and travels through them On the wall: Some Idiots Ignore Lab, F’s Given Out subcostals, iliohypogastric, ilioinguinal, lateral cutaneous of the thigh, femoral, genitofemoral (on psoas muscles), obturator Kidneys: blood supply from aorta – lots of variations- right kidney is lower Perirenal fat- closest to kidney- inside of the fascia Perarenal fat- outside of fascia Filters in this order: cortex medulla pyramids renal papilla minor calyx major calyx renal pelvis ureter bladder urethra Suprarenal glands: above the kidneys- secrete norepinephrine and epinephrine three blood supplies: from inferior phrenics, aorta, and renal arteries Clinical Problems: note this is not all the blue boxes in the text (look them up!) Breast Cancer- some can affect cooper’s ligaments and causes peau du orange appearance Pneumothorax- air in pleural cavity to fix put in chest tube around rib 6 above the rib Chylothorax- lymph in the pleural cavity Hemothorax- blood in the pleural cavity to fix put chest tube in between ribs 8 and 9 above the rib in the axillary region Pleuritis/Pleurisy- inflammation of the pleura-painful Fractured Ribs COPD- people with breathing use their accessory breathing muscles Right Bronchi is more vertical so more likely to aspirate Pericarditis- inflammation of heart sac Pericardial effusion- is a buildup of fluid in the space between the heart and the sac around the heart Cardiac tamponade- pressure on heart Hemopericardium- blood in sac Heart Attack – myocardial infarction Referred pain from the heart to the left shoulder Auscultation of the Heart right 2nd rib space = aortic / left 2nd rib space = pulmonic / left 3rd rib space = 2nd pulmonic / 4th rib space = tricuspid / 5th rib space midclavicular (below the nipple) = mitral Tumor in the vertebral canal - can impinge on spinal cord Meningitis – infection in the spinal column in the meninges Lumbar Puncture – have patient either on side in fetal tucked position on sitting up tucked- feel for iliac crests, go over to L4/L5 and stick needle into either epidural (to give anesthesia) or subarachnoid (for CSF) Shoulder Dislocation – most common anterior-inferiorly because not as many tendons that direction Bursitis–inflammation of the bursa- most common in subacromial bursa Winged Scapula – injury to long thoracic nerve (to serratus anterior muscles) Clavicle Break – if broken the proximal clavicle can move upward (because of sternocleidomastoid) and the distal clavicle can move downward (because of pec major, etc) **Problems with nerves to Hand- DR CUMA dropwrist = radial nerve clawhand = ulnar nerve median nerve = apehand/benediction Colles Fracture- fracture of the scaphoid (most common falling on your hand fracture) Hand Dislocation – most common dislocation is the lunate Carpal tunnel syndrome- median nerve is squeezed and get apehand (above) Caput medusa- in portal HTN get this pouching out of the umbilicus because these vessels connect systemic and portal system Inguinal HerniasDirect=medial to inferior epigastrics in the hesselbach’s triangle or through abdominal wall Indirect=lateral to inferior epigastrics in spermatic cord -often from persistent processus vaginalis Varicose Vein/Varicocele- of the pamp. plexus cause infertility because no temperature regulation GERD- gastroesophageal reflux disease-acid reflux Hiatal Hernia- esophageal hernia into thorax Stomach Cancer Ulcers- irritations of GI lining- can go all the way through and eat into pancreas from stomach or to gastroduodenal artery from duodenum Crohn’s Disease- inflammation of intestines Diverticulosis- outpocketing of intestines- mainly in descending/sigmoid colon Meckel’s Diverticulum- remnant of the vitelline duct- in the ileum (look at embryo) Portal Hypertension- an increase in portal vein pressure because of liver cirrhosis or blockage in liver can get enlarged spleen causes systemic/portal anastomoses to open up esophagus, umbilical, rectal, intestinal (colon) Pancreatic Cancer- aggressive tumor, no real symptoms until its to late Pancreatitis- inflammation of the pancreas Horseshoe Kidney-sometimes to get one big kidney shaped like horseshoe, stops at the IMA Kidney Stones- crystal calcifications in the kidney