FOCUS
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Foundation - firm
Observation – landmarks
Concentration – in the moment, mindfulness
Understanding – data, information, knowledge,
mastery, wisdom
• Systematic – Thought process of expert
The Warrior & the Surgeon
13 July 2009
Dr. Frank C.T. Voon
antvoon@nus.edu.sg
Medical Diagnosis
Symptoms
Signs
Investigations
Medical Education
Signs
Symptoms
Structures
Systems
Regional Anatomy
Functional Anatomy
Specialties Imaging Anatomy
Structures
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Bones
Joints
Muscles
Nerves
Arteries
Veins
Lymphatics
Organs
Structures
Compartments
Systems
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Skeletal
Articular
Muscular
Nervous
Endocrine
Circulatory – cardiovascular
Immune - lymphatic
Respiratory
Digestive
Excretory - renal
Reproductive – female & male
Integumentary
The Analytically Anatomical Approach
• Recognize the region(6) & subregion
• Determine the perspective
– Anterior, posterior, sagittal, superior, inferior
• Locate the level
– Superficial (skin) to deep (bones)
– Vertical levels (vertebra or plane)
• Select the structure
– BJMNAVLOSC
• Choose the format
Regions
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Head & neck
Upper limb
Thorax
Abdomen
Pelvis
Lower limb
Region - Head
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Face
Scalp
Temporal region
Infratemporal region
Orbit
Nasal cavity
Oral cavity
Ear - outer
Region - Neck
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Suprahyoid, infrahyoid
Triangles – anterior & posterior
Pharynx
Larynx
Carotid sheath
Region - Upper limb
• Shoulder
– pectoral, scapular
• Arm
– Flexor and extensor compartments
• Forearm
– Flexor and extensor compartments
• Hand
– Thenar, intermediate, hypothenar compartments
• The free upper limb, pectoral girdle
Region - Lower limb
• Gluteal region
• Thigh
– Anterior compartment - extensor
– Medial compartment - adductor
– Posterior compartment - flexor
• Leg
– Anterior compartment - extensor
– Lateral compartment - peroneal
– Posterior compartment - flexor
• Foot
– Layers of the foot
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Muscle
Tendon
Muscle
Bone
Region - Thorax
• Boundaries
– Walls
• Anterior – manubrium, sternum, xiphisternum, costal cartilages
• Lateral – ribs, intercostal spaces
• Posterior – vertebrae, intervertebral discs, erector spinae
– Roof – thoracic inlet/outlet
– Floor – thoracic outlet/diaphragm
• Contents
– Pleural cavities
– Mediastinum
• Superior
– Trachea, arch of aorta, esophagus, superior vena cava, brachiocepalic trunk, left common
carotid artery, left subclavian artery
• Inferior
– Anterior – thymus, internal thoracic vessels
– Middle – pericardium, heart, pulmonary trunk, ascending aorta
– Posterior – esophagus, descending aorta, azygos system, thoracic duct
Region - Abdomen
• Boundaries
– Anterolateral abdominal wall
• rectus abdominis
• external oblique, internal oblique, transversus abdominis
– Posterior abdominal wall
• Psoas major, quadratus lumborum
– Inguinal region
• Contents
– Compartments
• Peritoneal cavity
– Organs
• Gut – foregut, midgut, hindgut
• Liver, pancreas, spleen
• Kidneys
Region - Pelvis
• Boundaries
– Anterolateral abdominal wall
• rectus abdominis
• external oblique, internal oblique, transversus abdominis
– Posterior abdominal wall
• Psoas major, quadratus lumborum
– Inguinal region
• Contents
– Compartments
• Pouch of Douglas, rectovesical pouch, uterovesical pouch
– Organs
• Urinary bladder, prostate, seminal vesicles
• Uterus, vagina
• Rectum
• Perineum
– Anal triangle, urogenital triangle, urogenital diaphragm
Bones
• Type
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Long
short
flat
irregular
sesamoid
Upper end, lower end, shaft
Projections – tuberosities, condyles, neck
Right or left – all 3 dimensions
Ossification – endochondral, intramembranous
Bones
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Mandible – temporomandibular joint, parts
Vertebrae – cervical, thoracic, lumbar, sacrum
Rib – typical, 1st
Clavicle – intramembranous, sternoclavicular joint
Scapula – muscles, rotation 60 degrees
Humerus – surgical neck, midshaft, supratrochlear, medial
epicondyle
Radius – pivot joint, tuberosity (biceps)
Carpus – scaphoid, trapezium, capitate, hamate
Femur – neck, head, lesser trochanter (iliopsoas)
Fibula – lateral malleolus (key to orientation)
Patella – sesamoid bone, larger lateral facet
Tarsus – talus (ball bearing)
Joints
• Definition
– Articulation between 2 or more bones
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From outside in
Capsule
Synovial membrane
Articular cartilage
Ligaments
Movements allowed
Joints
• TMJ - dislocation
• Atlanto-occipital – flexion/extension & lateral flexion, condyloid
joint
• Atlanto-axial - pivot joint
• Intervertebral – cartilaginous joint
• Sternoclavicular – double plane
• Thoracic cage – bucket handle, pump handle
• Shoulder, wrist, elbow – ball & socket, ellipsoid, hinge
• Hip, knee, ankle
• 1st carpometacarpal
• Axis of movements
– Supination, pronation, inversion, eversion
Muscles
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Origin – bone, then part
Insertion – bone, then part
Joint/s involved
Movements possible – use the joint axis
Nerve supply
Blood supply – arteries, veins, anastomosis
Relations Applied/clinical anatomy – major function,
Muscles – H&N
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Muscles of mastication – 1st arch
Muscles of facial expression – 2nd arch
Extra-ocular muscles – LR6,SO4
Soft palate
Tongue
Supra- & infra- hyoid muscles
Sternocleidomastoid & trapezius
Scalenus anterior & medius
Muscles – UL
• Upper – shoulder & arm
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Scapular group
Triceps
Flexors
Coracoid process
Pectoral girdle & humeral
• Lower – forearm & hand
– Flexors – superficial & deep
– Extensors – lateral, thumb, digits, elbow
– Thenar, intermediate, hypothenar
Muscles – LL
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Thigh – extensors, adductors, flexors
Gluteal & lateral rotators
Leg - extensors, peronei, flexors
Foot – muscle, tendon, muscle, bone
Muscles – Trunk
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Intercostals
Diaphragm
Obliques & transversus abdominis
Pelvic diaphragm
Urogenital diaphragm
Erector spinae
Muscles – smooth & cardiac
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Intrinsic muscles of the eye
Stapedius & tensor tympani
Musculi pectinati, trabeculae carneae,
Detrusor
Gut – colic, outer longitudinal, inner circular
Oesophagus – skeletal to smooth, 1/3
Sphincters of urethra & anal canal
Nerves
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Origin
Root levels
Branches
Distribution
Clinical - palsies
Nerves
• Cranial - trigeminal, facial & vagus
• Spinal
– ARMUM
– FOGS
– Tibial; common, superficial & deep peroneal
– Plantar – medial & lateral
• Autonomic
– COPS
– Splanchnics - greater, lesser & least; pelvic
Arteries
• Begins
– A continuation of
– Location, usually bony part nearby
• Ends (as above)
• Middle
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If 3 parts, middle related to a muscle
4 parts (vertebral artery)
branches
distribution
• Relationships
– V-A-N
• Histological layers
– Endothelium, muscle (smooth), adventitia (elastic)
• Applied
– Anastomosis, clinical procedures
Arteries
• External carotid
– Soft palm
– ST,L,F,O,PA,AP,ST,Mx
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Internal carotid - circle of Willis
Aorta – ascending, arch, descending, abdominal
Internal iliac
Femoral, tibial, popliteal, plantar
Brachiocephalic, subclavian, axillary, brachial, radial, ulnar,
palmar arches (superficial & deep)
• Coronary arteries
• Choroid plexuses, anastomoses, coarctation of the aorta,
medial umbilical ligaments (obliterated umbilical arteries)
Veins
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Superficial or deep
Begins
– A combination of
– Location, usually bony part nearby
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Ends
– Drains into
– Location (surface marking)
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Middle
– Vessels that drain into it
– Area of drainage & organs or structures drained by it
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Relationships
– V-A-N
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Valves, venous plexus
Applied
– Plexuses, clinical procedures (cut down), conditions (haemorrhoids)
– Venous sinues
Veins
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Cranial cavity - venous sinuses
Superior & Inferior vena cava - tributaries
Upper limb – superficial & deep
Lower limb – superficial, deep & perforators
Portal vein – varices & haemorrhoids
Falciform ligament (ligamentum teres of the
liver - obliterated left umbilical vein), caput
medusae
Lymphatics
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Lymph nodes
Thoracic duct
Cisterna chyli
Spread of infections & tumors
Organs
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Form – shape, size
Location
Arterial input
Venous drainage
Organization – nervous or humoral
Relations
Special or uniqueness
Organs
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Thyroid
Parotid, submandibular, sublingual glands
Larynx, pharynx
Heart, lungs, esophagus
Liver, pancreas, spleen, kidneys, suprarenals
Testes, prostate, ovaries, uterus, vagina
Compartments
• Spaces
• Shape
– 2 dimensional – femoral triangle
– 3 dimensional - pyramid, 3-sided, 4-sided, truncated, wedge
• Boundaries
– Walls, roof, floor
• Contents
– Arteries, veins, nerves, lymph nodes
• Examples
– axilla, mediastinum, cubital fossa, popliteal fossa, ischiorectal fossa,
cranial fossae, carpal tunnel, subsartorial (Hunter’s) canal, pouch of
Douglas, nasal cavity, fascial compartments (of arm & leg)
Structures - extra
• Miscellaneous structures
– ureter, urethra (male, female)
– flexor retinaculum (carpal tunnel)
– extensor expansion (dorsum of fingers)
– fascia lata (gluteus maximus & tensor fascia lata)
– plantar aponeurosis (longitudinal arch of foot)
– perineal body (central tendon cf diaphragm)
Integration
• Images
• Visual (observational)
– skin
– clinical photographs Dupuytren’s contracture
– videos
• Radiological - Xrays
• Scans – Ultrasound, CAT
• Imaging – MRI, PET