Gross Anat. Block A

ventral rami of spinal nerves

deep back muscles

• spinalis capitis, cervicis, thoracis
• longissimus capitis, cervicis, thoracis
• iliocostalis cervicis, thoracis, lumborum

dorsal rami of spinal nerves

• 7 cervical
• 12 thoracic
• 5 lumbar
• 5 sacral segments
• 4 coccyx segments
• TOTAL = 33

sternal notch

• sternal angle (Angle of Louis/ manubrial-sternal junction)
• level of bifurcation of trachea
• beginning of aortic arch (from ascending aorta)
• end of aortic arch (beginning of descending aorta)
• azygous vein enters superior vena cava

esophageal hiatus (esophagous passing through the diaphragm)

end of spinal cord in an adult

iliac crest

end of dural sac, dura, arachnoid, subarachnoid space and CSF

• posterior convexity of thoracic and sacral regions of the vertebral column
• present at birth

• posterior concavity of the cervical and lumbar regions of the vertebral column
• develop after birth (child holds head up, begins to walk)

• lumbar curvature is greater in women
• increased lumbar posterior concavity is normal later in pregnancy

sharper sacral curvature sharper in males

exaggeration of the posterior convexity in the thoracic region

• muscular weakness
• structural changes in vertebrae or intervertebral discs
• crush fractures
• tuberculosis
• osteoporosis
• poor posture in adolescents

degeneration of intervertebral discs

kyphosis ("hunchback") seen in elderly women due to osteoporosis

• exaggeration of the posterior concavity in the lumbar region
• characterized by an anterior rotation of the pelvis

• increase in weight of the abdominal contents (eg. pregnancy or large ovarian tumor)
• postural compensation for a thoracic kyphosis

• lateral deviation of the vertebral column
• found mostly in the thoracic region
• accompanied by rotation of the vertebrae

• asymmetric muscular weakness (myopathic scoliosis)
• vertebral defects (congenital hemivertebra)
• muscle paralysis  due to poliomyelitis
• compensatory - cause by a short leg or hip disease

• kyphosis
• lordosis
• scoliosis

• C3 - C6
• body with uncinate process
• bifid spinous process
• two transverse processes with transverse foramen
• four articular processes - superior articular facets face posterior and superior; inferior articular facets face anterior and inferior

• vertebra prominens
• spinous process is NOT bifid, very large, and easily palpable
• transverse foramen small or absent - does NOT transmit the vertebral artery (only accessory vertebral vein)

• atlas
• no body
• anterior tubercle
• posterior tubercle - attachment for suboccipital triangle muscles; groove for vertebral artery
• superior articular surfacearticulates with occipital condyles (base of skull)

• axis
• dens/odontoid process - body of C1 developmentally
• bifid spinous process

• an articulation in the five lower cervical vertebral bodies, formed by the space between one vertebral body and the uncinate process that projects superiorly from the vertebral body immediately below it
• synovial joint

• long spinous processes
• costal facets on sides of body 
• costal facets on transverse processes of T1-T10
• costovertebral joints
• costotransverse joints

synovial joint between head of rib and vertebral body

synovial joint between tubercle of rib and transverse process of T1 - T10

• vertebral bodies get progressively larger as your proceed inferiorly
• NO costal facets
• NO transverse foramina
• superior articular process has a rounded mamillary process
• short horizontal spinous processes
• superior articular facets face medially
• inferior articular facets face laterally

• oblique radiograph of lumbar vertebral column
• ear = superior articular process
• eye = pedicle
• front leg = inferior articular process
• back leg = spinous process + inferior articular process
• neck = pars interarticularis

• a defect or fracture of the isthmus or pars interarticularis
• no anterior displacement of the vertebral body
• radiographs show that the Scotty dog appears to be wearing a collar at the site of the fracture

• a unilateral or bilateral defect or fracture of the pars interarticularis
• accompanied by anterior displacement of the vertebral body
• radiographs show the head of the Scotty dog appears to be separated from the body
• most common between the L5 vertebra and the sacrum
• may stretch roos of lumbosacral spinal nerves in the cauda equina
• patients have bilateral lower back pain that radiates into both lower limbs and weakness in muscles of the legs

• superior facets = sup/post
• inferior facets = inf/ant

• flexion/extension
• lateral bending
• rotation

• superior facets = post/lat
• inferior facets = ant/med
• arc centered around vertebral body

• lateral bending
• rotation
• flexion/extension

• superior facets = medial
• inferior facets = lateral

• flexion/extension
• NO rotation

anterior to vertebral bodies

• posterior to vertebral bodies and inside vertebral canal
• anterior to spinal cord

• between adjacent laminae (posterior of vertebral canal)
• appears yellowish in real life

between vertebral spines

• posterior to vertebral spines
• very thick in cervical regions - ligamentum nuchae (attachement for trapezius muscle)

• form cushion between two adjacent vertebrae
• highly innervated
• central nucleau pulposus
• peripheral annulus fibrosus
• two layers of cartilage that cover the superior and inferior aspects of the disc

• composed of concentrically arranged lamellae made of collagen fibers
• surrounds the nucleus pulposus of intervertebral discs
• helps to stabilize the adjacent vertebral bodies
• acts as a to limit excessive motion

• semi-fluid consistency
• consists of chondrocytes, collagen fibers, and ground substance
• avascular and not innervated
• fluid consistency of the nucleus deforms under pressure (transmits pressure in all directions)

• herniation of the nucleus pulposus through a defect in the annulus fibrosus
• discs affected are in the mobile regions of the vertebral column (cervical and lumbar)

herniation in the midline under the posterior longitudinal ligament

herniation at the side of the posterior longitudinal ligament close to the intervertebral foramen

deep to the trapezius and the semispinalis capitis muscles

• superiomedially - rectus capitis posterior major
• superolaterally - obliquus capitis superior
• inferolaterally - obliquus capitis inferior
• floor - posterior atlantooccipital membrane and posterior arch of C1
• roof - semispinalis capitis

• origin = spinous process of C2
• insertion = lateral part of inferior nucal line

• origin = posterior tubercle of posterior arch of C1
• insertion = medial part of inferior nuchal line

• origin = spinous process of C2
• insertion = transverse process of C1

• origin = transverse process of C1
• insertion = occipital bone between the superior and inferior nuchal lines

• first branch of subclavian artery
• passes through transverse foramina of C6 through C1
• winding course suboccipital triangle
• passes through the dura and the arachnoid to enter the foramen magnum

• innervates the muscles of the suboccipital triangle
• dorsal ramus of the C1 spinal nerve

• part of the CNS
• continuation of the medulla oblongata
• extends from the foramen magnum in the skull through the vertebral column in the vertebral canal
• 42-45 cm in length
• occupies the upper 2/3 of the vertebral canal
• terminates inferiorly at the level of L1/L2 intervertebral disc as the conus medullaris

that portion of the spinal cord that gives rise to a single spinal nerve

• arises as dorsal and ventral roots from a single spinal cord segment
• each spinal nerve exits through its own intervertebral foramen

• 8 cervical
• 12 thoracic
• 5 lumbar
• 5 sacral
• 1 coccygeal
• 31 TOTAL

• C1 through C7 spinal nerves exit above the vertebra with the same name
• C8 spinal nerve exits below C7 vertebra
• Beginning with the T1 spinal nerve, spinal nerves exit below the vertebra of the same name

• add one to the vertebral level in lower cervical region
• add two in the upper thoracic region
• add three in the lower thoracic region

• subtract one from the cord segments in lower cervical region
• subtract two in the upper thoracic region
• subtract three in the lower thoracic region

• less common than lumbar herniation
• discs between C5 and C6 & C6 and C7 are the most susceptible
• lateral protrusions - cause pressure on spinal nerve or its roots
• central protrusions - press on the spinal cord

• more common than cervical
• discss between the L4 and L5 & L5 and S1 are usually affected
• region of the cauda equina

• pain distribution down the back and lateral side of the leg, radiating to the sole of the foot
• caused by pressure on the sensory roots of the L5 and S1 spinal nerves

• L5 motor root impaired
• weakness in dorsiflexion of the ankle

• S1 motor root impaired
• weakness of plantar flexion of the ankle
• diminished or absent ankle jerk reflex

• cervical enlargement (C4 through T1)
• lumbrosacral enlargement (L2 and S3)

• C4 through T1 spinal cord segments
• innervation of the upper limb - brachial plexus

• L2 through S3 spinal cord segments
• innervation of the lower limb - lumbar and sacral plexus

• in the first trimester, the spinal cord extends the length of the entire body
• in the fetus, the spinal nerves exit the spinal cord horizontally
• the vertebral column grows faster than the spinal cord and the spinal nerves are anchored to their targets
• nerves just elongate as the body develops
• nerves stream vertically at the inferior portion of the spinal canal  (cauda equina)
• lumbar cistern - enlargement of the subarachnoid space containing the nerve roots of the cauda equina

dura mater + arachnoid mater + pia mater surrounding the spinal cord

• outermost covering of the spinal cord
• composed of dense fibrous and elastic tissue
• completely surrounds the spinal cord forming a sac within the vertebral canal = dural sac/thecal sac
• continuous with the endosteal layer of cranial dura at the foramen magnum
• extends down to S2 where it is continuous with the coccygeal ligament
• extends laterally as dural sleeves of nerve roots and spinal ganglia

• external to the dura mater
• space between the periosteum of the vertebrae and the dura
• contains: fat & loose connective tissue, internal vertebral venous plexus

• potential space deep to the dura
• between the dura and the arachnoid
• contains a thin layer of fluid

• deep to the dura
• connected to pia mater by very delicate tissue strands called atachnoid trabeculae
• follows the dural sac to its termination at S2

• between arachnoid and pia
• contains cerebrospinal fluid (CSF)
• contains the cauda equina and the filum terminale

• enlarged part of subarachnoid space caudal to the conus medullaris
• extends from L2 to S2

• innermost covering of the spinal cord
• ensheathes the spinal arteries
• gives rise to the denticulate ligament
• consists of 20 to 22 toothlike process
• attaches to the inner surface of the dura
• spinal cord is suspended within the dura by the denticular ligament
• extends from foramen magnum to between the T12 and L1 nerve roots

• from vertebreal arteries
• supplies anterior 2/3 of the spinal cord
• 75% of the blood supply to the spinal cord is from the ASA

• from posterior inferior cerebellar arteries
• supply posterior 1/3 of the spinal cord

• branches of vertebral, intercostal, and lumbar arteries
• Artery of Adamkiewicz [great anterior segmental medullary artery]
• most commonly arises at T10 on the left side
• origin is variable (usually T9-T12; left > right)

• external and internal vertebral venous plexus
• thin walled
• incompetent valves or valveless
• dependent upon pressure differential, venous blood can flow between the vertebral plexuses and skull, neck, thorax, abdomen, and pelvis
• pathway for metastasis of prostate cancer to the vertebral column and cranial cavity

• to obtain CSF from the lumbar cistern for laboratory examination (appearance, protein, sugar, serology, cell count, bacterial or fungal cultures)
• to administer medications into the subarachnoid space
• to perform myelography
• to measure for evidence of increased intracranial pressure

• patient bends forward to increase intervertebral space
• palpate iliac crest to know where L4 vertebral level is
• insert needle below L4/L5 vertebrae
• - spinal cord ends at L1/L2 disc in adults, L3 in children

• skin
• superficial fascia
• supraspinous ligament
• interspinous ligament
• infraspinous ligament/ ligamentum flavum
• epidural space (containing fatty areolar tissue and the internal vertebral venous plexus)
• dura mater
• subdural space
• arachnoid mater
• subarachnoid space
• CSF in lumbar cistern

performed by administering anesthetic through the sacral hiatus, which diffuses through the meninges and anesthetizes the roots of the sacral and coccygeal spinal nerves in the cauda equina

anesthetic is injected directly into the subarachnoid space at L4

functional unit of the nervous system

• dentrites
• cell body
• axon
• synaptic terminals

• stimulated by environmental changes or the activities of other cells
• increase surface area for impulses and synapses to occur
• small processes conduct impulses toward neuronal cell body

contains the nucleus, mitochondria, ribosomes, etc. of neuron

• conducts nerve impulses (action potentials) away from the neuronal cell body
• long process - can be many feet long

affect another neuron or effector (muscle, glands, etc)

• unipolar
• bipolar
• multipolar

• pseudounipolar
• two processes coming from cell body - dendrite (peripheral) and axon (central)
• ex - found in dorsal root ganglion adjacent to spinal cord
• myelinated

• two processes continuous with cell body
• dendrite goes toward cell body; axon coming out of cell body
• not very common
• ex - retinal ganglion, vestibular cells, cochlear cells

• most common type
• many dendrites enter the cell body but only one axon exits
• myelinated
• ex - skeletal muscle

consists of the brain and spinal cord

collection of cell bodies in CNS

collection of cell bodies outside of CNS

consists of cranial nerves and spinal nerves

consists of SNS and PNS

• houses the spinal cord and spinal nerves
• intervertebral foramina get bigger toward inferior end of vertebral column

31 pairs

12 pairs

at the disc between L1 and L2 vertebrae

• sensory
• stimulus from periphery runs from receptor to CNS

• motor
• impulse goes away from CNS and to an end organ (muscle, etc.)

• purely sensory (afferent)
• cell bodies housed in dorsal root ganglion

• purely motor (efferent)
• cell bodies are in ventral horn of spinal cord

• union of dorsal and ventral roots
• divides into dorsal ramus and ventral ramus

• sensory and motor
• innervates deep muscles of the back
• goes toward back of body

• sensory and motor
• innervates the superficial muscles of the back & appendages
• goes toward front of body
• bigger than dorsal ramus (innervates more of the body)

• most located in intervertebral/neural foramina
• exception - in sacrum, located in vertebral canal

route followed by a series of nerve impulses from their origin in one part of the body to their arrival elsewhere in the body

reflex arc

• simplest nerve pathway
• a rapid, automatic unconscious response to a situation in an attempt to maintain body homeostasis

stimulus travels from receptor - dorsal root - synapses with association neuron - ventral root - impulse travels through motor neuron - effector (muscle)

• monosynaptic reflex
• polysynaptic reflex

• single synapse
• ex - knee jerk reflex
• when tapped, the patellar tendon stretches (also stretches Golgi fibers in muscle)
• sends impulse through ventral ramus - dorsal root ganglion - dorsal root - synapses with motor cell body in ventral horn - causes action potential with nerve in muscle - knee joint extends

• flexor/withdrawal reflex
• ex - touching a hot stove
• multiple synapses
• an association neuron connects the afferent and efferent neurons in the spinal cord
• finger touches stove - impulse through sensory fiber (nerve in ventral ramus) - association neuron - motor fiber in ventral ramus - biceps cause hand to jerk away (triceps relax)

• general somatic afferent
• general somatic efferent
• general visceral afferent
• general visceral efferent

• nerve that conducts sensory impulses/ modalities
• pain, touch, temperature, proprioception

• nerves that carry motor impulses
• contraction of skeletal muscles

• impulses from organs
• stretch pains, visceral reflexes
• ex - menstrual cramps, getting kicked in the groin, stomach aches
• nonspecific pain

• autonomic nervous system
• motor

• hearing
• vision

• smell
• taste

pharyngeal arch musculature

• lateral extension of the pia
• separates the dorsal roots from the ventral roots
• anchors the cord to the dura between successive nerve roots

innervate skin

sensory innervation of skin

innervate skin (cutaneous)

innervate deep back muscles

innervate deep back muscles

innervate skin

• medial branch of dorsal ramus of spinal nerve C2
• somatic afferent (sensory) nerve fibers (GSA)
• sympathetic fibers (GVE)

somatic efferent (motor) nerve

• network of nerve fibers
• site where nerve fibers intermingle and from which a new set of multisegmented peripheral nerves emerge
• formed by ventral rami
• contain motor and sensory nerves

C1 - C4

C5 - T1

T12 - L4

L4 - S4

area of the skin that is supplied by a single spinal nerve

• T4 - nipple
• T10 - umbilicus
• L1 - groin

area of skin supplied by a peripheral nerve (more than one spinal nerve)

• superficial
• deep
• subserous

• separates skin from subcutaneous tissue and fat
• veins, arteries, nerves and lymphatics travel through here
• "a surgeon's friend"

• keeps muscle fibers bound together
• separates muscles into compartments
• also keeps nerves and vessels bound to muscle

outside of serous membranes (pleura, peritoneal cavity)

• visceral motor system (GVE)
• effector cells - smooth muscle, cardiac muscle, and glands
• two neuron chain - pre- and post-ganglionic

• smooth muscle: digestive tract, vessels, duct systems, uterus, arrector pili muscles in skin, bronchi, genital organs
• cardiac muscle
• glands: sweat glands, salivary glands

• before synapse
• from CNS
• myelinated - look white

• after synapse in ganglion
• unmyelinated - look grey

NO

• sympathetic
• parasympathetic

one neuron from CNS synapses on effector cell (skeletal muscle)

• preganglionic axon from CNS synapses on cell body in ganglion
• postganglionic axon from ganglion synapses on effector cell (smooth muscle, cardiac muscle, glands)

• origin - thoracolumbar region of CNS (segments T1-L2)
• short preganglionics
• long postganglionics (EXCEPTION - splanchnic nerves)
• fight or flight response

• origin: cranial-sacral area of CNS (CN 3,7,9,10 & segments S2-S4)
• long preganglionics
• short postganglionics
• rest & digest

• sympathetic chain ganglia (paravertebral)
• prevertebral ganglia

• in the abdomen -
• celiac
• superior mesenteric
• inferior mesenteric
• aorticorenal

• paravertebral: on both sides of the body
• runs the entire length of the spinal cord
• swellings within the chain are caused by cell bodies of postganglionic sympathetic fibers
• only 3 sympathetic chain ganglia in head/neck

• intermedial lateral cell column
• "bump" extending from side of grey matter in spinal cord segments T1-L2
• accumulation of cell bodies
• sends out axons through ventral roots (along with somatic motor fibers)

site of cell bodies for preganglionic sympathetic fibers (VME)

• communication between ventral ramus and sympathetic chain ganglia
• myelinated (appears white)
• more distal or lateral from spinal cord

• communication between postganglionic sympathetic fiber back to ventral ramus
• unmyelinated (appears grey)
• more medial to spinal cord

• ascend up the chain before synapsing at higher ganglion (no lateral horns at cervical level)
• descend down the chain before synapsing at lower level
• pass through chain without synapsing (splanchnic nerves)
• synapse at same level it enters the chain

TRUE

• composed of sympathetic fibers that did not synapse in sympathetic chain
• travels down through diaphragm to ganglia in the abdomen

vertebral canal > sympathetic chain ganglia > spinal cord > IMLCC

• disruption of sympathetic innervation
• due to lesion/compression of one side of the cervical or thoracic sympathetic chain which generates symptoms on ipsilateral side (same side) of body
• ptosis: droopy eyelid
• miosis: constricted pupil
• anhidrosis: decreased sweating
• flushing of the face: dilation of blood vessels

• cranial nerve 10
• Vagus nerve
• supplies parasympathetics in chest
• nucleus - dorsal motor nucleus of X (source of preganglionic cell bodies in brain)
• ganglion - in thoracic abdominal viscera

• preganglionic - dorsal motor nucleus of X
• postganglionic - wall of organ

• from preganglionic - ACh
• from postganglionic - NE
• EXCEPTION: postganglionic of sweat glands - ACh

from preganglion AND postganglionic - ACh

• travel back from the organ to the CNS along with the GVE fibers supplying the specific organ
• generally those GVA pain fibers from thoracic and abdominal organs travel back to the CNS with sympathetic fibers
• generally the GVA pain fibers from pelvic organs travel back to the CNS with parasympathetic fibers

• very localized
• causes - trauma

• poorly localized
• causes - sudden distension, strong contractions, ischemia

deprivation of blood supply

pain originating in one location in the body but perceived by the patient as coming from another location in the body

• inadequate blood supply to myocardium
• patient experiences severe pain over sternum radiating to left shoulder and arm or both shoulders and even root of neck and lower jaw
• GVAs ascend into cardiac nerves and pass via spinal ganglia into cord at levels T1-T4/5
• pain in the arm is accounted for by intercostobrachial nerve (T2) while spread of nervous system accounts for pain in jaw

• visceral pain due to spasm and distension reaches the T10 segment via the lesser splanchnic nerve
• pain is referred to the umbilical region
• later the pain becomes somatic over the T12 & L1 cutaneous region because of the irritation of parietal peritoneum by appendicicit

• shoulder: connected by joints grossly in the shoulder region
• brachium (arm):connected by joints grossly in the elbow and shoulder region
• antebrachium (forearm): connected by joints grossly in the wrist and elbow regions
• manus (hand): connected by numerous joints

• scapula, clavicle, and articulation to sternum
• needed to attach upper limb to axial skeleton at glenohumeral joint

• S-shaped
• convex over medial 2/3
• concave over lateral 1/3
• only bony attachment of the upper appendicular skeleton
• to axial skeleton
• movable strut
• transmits all of the forces applied to upper limb
• most frequently broken bone in human body

• 5%
• 1 out of 20

• medial fracture: less common (2-3%)
• midshaft fracture: most common (70-82%)
• distal fracture: somewhat common (30%)

• triangular, flat bone
• extends from 2nd to 7th rib

• spine
• supraspinatus fossa - superior, smaller, more concave
• infraspinatus fossa - inferior, larger, flatter
• acromion process - enlargement of the spine as it moves laterally

• glenoid cavity: pear shaped cavity on lateral border
• where the head of the humerus articulates

• coracoid process - beak like process projecting anteriorly from the superior border; important for ligament and muscle attachment
• subscapular fossa

superior transverse ligament: spans the suprascapular notch; houses the suprascapular nerve

• suprascapular artery travels OVER
• suprascapular nerve travels UNDER
• Army goes over the bridge, Navy goes under the bridge

• head - articulates with scapula at glenohumeral joint
• neck - anatomic vs surgical
• shaft
• greater tubercle - attachment for supraspinatous,
• infraspinatous, and teres minor
• lesser tubercle
• deltoid tuberosity
• intertubercular groove/sulcus

moveable joint is innervated by articular branches of the nerves that supply the muscles acting on the joint and that also supply the skin covering the joint

• bony surfaces are rarely in direct continuity
• covered by hyaline cartilage
• exception - acromioclavicular & sternoclavicular joints are covered by fibrous tissue
• covered by a fibrous capsule
• perforated by synovial protrusions (bursae)
• frequently exhibit localized thickenings - intrinsic
• ligaments
• may be reinforced by extrinsic ligamentous and muscular support

• manubrium of sternum articulates with medial end of
• clavicle
• very strong - bone breaks more than joint will be
• affected
• saddle synovial joint - mobility & strength
• articular disk between sufaces absorbs some shock
• four ligaments enforce the joint - anterior sternoclavicular, posterior sternoclavicular, interclavicular, costoclavicular

• anterior sternoclavicular: sternum to clavicle
• posterior sternoclavicular: sternum to clavicle
• interclavicular: connects medial ends of two clavicles; continuous with clavicular disk
• costoclavicular: attaches clavicle to first rib; prevents excessive elevation of shoulder

• acromion of scapula articulates with lateral end of the
• clavicle
• plane synovial joint - separated by incomplete wedge-shaped articular disc
• three ligaments - acromioclavicular, coracoclavicular, coracoarcomial

• acromioclavicular: covers joint capsule, strengthens joint superiorly
• coracoclavicular: conoid & trapezoid ligaments; suspends the scapula and upper limb passively from clavicle and maintain joint alignment
• coracoacromial: stretches across scapula from acromion process to coracoid process; not really holding clavicle

• shoulder separation
• grades increase with extent of damaged ligamentation
• type I: sprain of acromioclavicular ligament; no tearing
• type II: acromioclavicular ligament tear; sprained or partial coracoclavicular ligament tear
• type III: both ligments completely torn; complete shoulder separation

• ball and socket synovial joint
• most mobile joint in the body
• somewhat unstable due to flat nature of glenoid fossa
• four ligaments - glenohumeral, coracohumeral, transverse humeral, coracoacromial
• glenoid labrum
• tendon of long head of biceps brachii m
• bursae

• glenohumeral: stabilizes the joint anteriorly; stretches from lateral angle of clavicle to anatomical neck of humerus
• coracohumeral: stabilizes the joint superiorly; spans the base of the coracoid process to the greater tubercle of the humerus
• transverse humeral: spans the intertubercular sulcus; does not actively stabilize the joint
• coracoacromial: provides roof to glenohumeral joint; prevents superior displacement; spans inferior acromion and coracoid process of scapula

• rings of fiber cartilage around glenoid cavity
• deepen the "cup" to enable the humeral head to sit in place

• pocket of synovial membrane that completely wraps
• around the tendon of the long head of biceps brachii m
• extension of transverse humeral ligament
• permits frictionless movement within intertubercular sulcus

• pockets of synovial membrane and fluid
• enable structures to pass above and below routinely without friction or inflammation
• usually isolatedexist between muscles or between muscles and bone

continuous with joint cavity to cushion the subscapularis

• shoulder dislocation
• capsule is weakest inferiorly
• clinical descriptions occur relative to infraglenoid tubercle

• head of humerus ends up anterior to glenoid cavity
• VERY painful

• bursa become inflammed (by bone spurs, calcium deposits, etc.) and impede the function for which they were designed
• muscle will slide over a swollen or tender bursa causing pain and friction

• a physiological joint created by the numerous muscles attached to the scapula
• moves the bone on the clavicle at the acromioclavicular joint

• elevation: levator scapulae, trapezius (descending fibers), rhomboids, etc.
• depression: trapezius (ascending fibers), gravity
• protraction: serratus anterior
• retraction: rhomboids, trapezius (middle fibers)
• upward rotation: trapezius (ascending and descending)
• downward rotation: latissimus dorsi

• extension
• flexion
• abduction
• adduction
• lateral rotation
• medial rotation

• perpendicular to glenoid fossa through humerus head - allows extension & flexion
• parallel to glenoid cavity through head of humerus - abduction & adduction
• through shaft of humerus - lateral & medial rotation

• four movements in sequence
• flexion - abduction - extension - adduction

• musculotendinous cuff around glenohumeral joint
• anchors the head of the humerus against glenoid fossa
• acts as prime rotators of humerus
• supraspinatus: abduction
• infraspinatus: lateral rotation
• teres minor: lateral rotation
• subscapularis: medial rotation

tears, especially in the supraspintus

• major structure on the anterior chest wall
• modified sweat gland
• serves the purpose of secreting and excreting milk
• accessory structure of reproduction

• 2/3 over pectoralis fascia
• 1/3 over serratus anterior fascia
• retro-mammary space behind breast tissue anterior to pectoralis major
• axillary tail of Spence: lateral extension of breast into arm
• nipple surrounded by areola - usually at 4th intercostal space lateral to mid-clavicular line

• medial: lateral border of the sternum
• lateral: mid axillary line
• superior: 2nd rib but can extend up to clavicle
• inferior: 6th rib but can be deceptive due to ptosis

• pectoralis major fascia: continous with the fascia of the axilla & anterior abdominal wall
• clavi-pectoral fascia: deep to the pectoralis major and invests the subclavius muscle & pectoralis minor muscle

• attached to dermis by suspensory ligaments of Cooper
• each lactiferous duct ends in 15-20 lobules which make milk
• lactiferous ducts dilate into lactiferous sinuses deep to the nipple-areolar complex to drain to the surface

• aorta
• internal thoracic artery - medial mammary branches & anterior intercostal arteries
• axillary artery - lateral thoracic artery & thoracoacromial trunk branches

• axillary vein
• internal thoracic vein

• 4th to 6th intercostal nerves - anterior cutaneous branches & lateral cutaneous branches
• supraclavicular nerves
• sympathetic nerves to the vessels & smooth muscle of the skin and nipple

• first into subareolar lymphatic plexus
• majority of secondary drainage is into the axillary nodal basin
• drains into parasternal nodes to the opposite breast or to inferior phrenic nodes

• pectoral: anterior; drain most of the breast
• subscapular: posterior
• humeral: lateral
• central: collects from pectoral, subscapular, and humeral basins
• apical: collects from pectoral, subscapular, humeral, and central basins

• level I: axillary nodes are lateral to the border of the pectoralis minor muscle
• level II: axillary nodes are deep to the pectoralis minor muscle
• level III: axillary nodes are medial to the border of the pectoralis minor muscle

• - older surgical procedures would remove levels I and II
• - current procedures stop at level I as maximal borders of nodes removed

• from axilla into supraclavicular and subclavian nodes
• then into right lymphatic duct or thoracic duct on the left
• subsequently into venous circulation at the junction between the subclavian and internal jugular veins

method for lymphatic and vascular metastases

• lifetime incidence of breast cancer in women is currently 1 in 8
• #2 cancer in women (behind lung cancer)
• ductal adenocarcinoma - 90-95%
• lobular adenocarcinoma - 5-10%
• described by quadrants or the clock system

• upper inner - 15%
• upper outer - 60%
• lower inner - 5%
• lower outer - 10%
• nipple-areolar complex - 10%

• physical exam still highly reliable
• many women present with a presumptive diagnosis due to the performance of routine screening mammograms by primary care physicians

• venous dilation
• peau d'orange - "orange peel"
• skin dimpling
• nipple retraction - some are anatomically normal; ask length of time

• pyramidal space (narrow at top & wider at bottom)
• inferior to glenohumeral joint
• superior to axillary fascia
• passageway or "distribution center" - neurovascular structures of upper limb
• protected by adducted upper limb
• most vulnerable when arm is abducted

• apex: "cervicoaxillary canal"
• base: axillary fossa (armpit)
• anterior wall: pectoralis major & pectoralis minor muscles; anterior axillary fold (pectoralis major muscle)
• posterior wall: scapula, subscapularis muscle, posterior axillary fold (latissimus dorsi & teres major muscles)
• lateral wall: intertubercular groove/sulcus
• medial wall: thoracic wall; 1-4 ribs & intercostal muscles; serratus anterior muscle

• lateral aspect of first rib (on medial side)
• posterior aspect of clavicle
• superior edge of scapule

• skin
• subcutaneous tissue
• deep axillary fascia (from arm to thoracic wall)

• from pectoralis major muscle
• most inferior part of anterior wall of axilla

• from latissimus dorsi and teres major muscles
• most inferior part of posterior wall of axilla
• pinch under armpit

• vessels - axillary artery and vein
• lymphatics
• brachial plexus - nerves (& intercostal brachial nerve)
• FAT

• extension of pre-vertebral (cervical) fascia
• tightly binds nerves and vessels in axillary region
• performing a nerve block in this region requires entering the axillary sheath to administer medicine - all nerves in region will be numbed

• continuation of subclavian artery
• begins at lateral border of first rib
• ends at inferior border of teres major muscle
• three parts with six branches

• superior thoracic artery
• thoracoacromial artery
• lateral thoracic artery
• subscapular artery
• anterior circumflex humeral artery
• posterior circumflex humeral artery

• clavicular artery
• acromial artery
• deltoid artery
• pectoral artery

• thoracodorsal artery
• circumflex scapular artery

• collateral circulation
• arteries communicating at capillary level to allow blood flow despite occlusions

• suprascapular artery can anastomose with dorsal scapular artery
• circumflex scapular artery can anastomose with dorsal scapular artery
• must occur over time to allow body adaptation

• superior: teres minor
• inferior: teres major
• medial: long head of triceps brachii
• lateral: humerus
• content - axillary nerve and posterior circumflex humeral artery

• superior: teres minor
• inferior: teres major
• lateral: long head of triceps brachii
• contents - circumflex scapular artery

• superior: teres major
• medial: long and lateral heads of triceps brachii
• lateral: humerus
• contents - radial nerve and profunda brachii artery

• gives rise to most of the nerves of the upper limb
• extends from neck to axilla
• arises from ventral rami of C5-T1 (roots of the brachial plexus)
• passes between anterior & middle scalene muscles

• GSA: sensory neurons
• GSE: motor neurons
• sympathetic nerves of inferior & middle cervical ganglia

C4 contribution

T2 contribution

spinal nerves C5-T1

• superior: C5 + C6
• middle: C7
• inferior: C8 + T1

• anterior (2) - supply anterior (flexor) compartments of upper limb
• posterior - supply posterior (extensor) compartments of upper limb

• lateral: formed from superior anterior and middle anterior divisions
• posterior: formed from superior, middle, and inferior posterior divisions
• medial: continuation of inferior anterior division

• lateral pectoral nerve (C5-C7)
• musculocutaneous nerve (C5-C7)
• lateral root of median nerve

• upper subscapular nerve (C5,C6)
• thorocodorsal / middle subscapular nerve (C7-T1)
• lower subscapular nerve (C5,C6)
• radial nerve (C5-T1)
• axillary nerve (C5,C6)

• medial pectoral nerve (C8,T1)
• medial brachial cutaneous nerve (C8, T1)
• medial antebrachial cutaneous nerve (C8,T1)
• ulnar nerve (C8,T1)
• medial root of median nerve

• musculocutaneous nerve
• median nerve
• ulnar nerve
• axillary nerve
• radial nerve

• suprascapular nerve
• nerve to subclavius

• C5: dorsal scapular nerve
• C5-7: long thoracic nerve

• C5-C7
• pierces coracobrachialis
• motor: muscles of anterior compartment of arm
• sensory: becomes lateral antebrachial cutaneous nerve

• C6-T1
• motor: all but 1 and 1/2 muscles of anterior compartment of forearm; intrinsic thumb muscles; 1st and 2nd lumbricals
• sensory: thumb half of palm, palmar aspect of thumb and 2 and 1/2 fingers and nail beds

• C8-T1
• motor: 1 and 1/2 muscles of anterior compartment of forearm (flexor carpi ulnaris and ulnar half of flexor digitorum profundus); most intrinsic muscles of the hand
• sensory: digiti minimi half of palmar and dorsal aspect of hand; 1 and 1/2 fingers and nail beds

• C5 and C6
• motor: teres minor and deltoid
• sensory: glenohumeral joint & superolateral arm (superior lateral brachial cutaneous nerve)

• C5-T1
• runs in radial groove of posterior humerus
• gives off muscular branches in arm
• motor: all muscles of posterior compartment of arm & forearm
• sensory: posterior & inferolateral arm; posterior forearm; dorsal aspect of hand; thumb and 2 and 1/2 fings and nail beds

region covered by a single spinal nerve

sensory area supplied by a named nerve

• Herb-Duchenne Palsy
• Klumpke's Palsy
• deltoid atrophy
• wrist drop
• ape-hand posture
• ulnar claw

• upper trunk lesion (C5-C6)
• "waiter's tip" - hand extended out

• lower trunk issue (C8-T1)
• ulnar nerve issue

• wasting of deltoid
• axillary nerve issue

• radial nerve issue
• unable to flex wrist

• median nerve injury
• upper portion of fingers curved slightly
• thumb is adducted

• ulnar nerve injury
• lose ability to adduct thumb

• sheets of deep fascia
• divides muscles into anterior/posterior compartments which are clearly visible

• humerus
• radius
• ulna

• largest bone of the upper limb
• articulates at glenohumeral joint and elbow joints
• head of humerus
• anatomical vs surgical neck
• greater tubercle - attachment of supraspinatus, infraspinatus, and teres minor
• lesser tubercle - attachment of subscapularis
• intertubercular groove - long head of biceps brachii

• deltoid tuberosity - attachment of deltoid m
• radial groove - radial nerve runs w/ profunda brachii artery

• capitulum: articulates with head of radius
• trochlea: articulates with proximal head of ulna (trochlear notch)

• medial epicondyle: common flexor origin
• lateral epicondyle: common extensor origin

• olecranon fossa: receives olecranon of ulna during full extension of elbow
• coronoid fossa: receives coronoid process of ulna during full extension
• radial fossa: accommodates head of radius during forearm flexion

• longer forearm bone
• medial (pinky/digiti minimi side)
• articulates with humerus at elbow
• articulates with radius at radioulnar joints
• NO wrist articulation

• trochlear notch: bone contact responsible for flexion & extension
• olecranon process: forms point of elbow, attachment for triceps brachii
• coronoid process: projects anteriorly
• tuberosity of ulna: attachment for brachialis
• radial notch: where head of radius rests
• supinator crest
• supinator fossa: attachment for deep part of supinator m
• head: distal with styloid process

• shorter forearm bone
• lateral (thumb) side
• articulates at elbow with ulna & humerus
• articulates at radioulnar & wrist joints

• head: proximal, articulates with radial notch of ulna
• radial tuberosity: attachment for biceps brachii
• shaft: enlarges distally for articulation with carpal bones
• ulnar notch: articulates with head of ulna
• styloid process: significally distal
• dorsal tubercle: changes the direction of tendons in the hands

• between radius and ulna
• syndesmosis (fibrous) joint
• helps keep the bones together
• site of origin for many muscles
• transmits forces from radius to ulna

• synovial hinge joint
• flexion and extension NOT supination/pronation
• between trochlea of humerus & trochlear notch of ulna and capitulum of humerus & head of radius

• radial collateral ligament: lateral
• anular ligament: runs around head of radius; keeps it adjacent to ulna
• ulnar collateral ligament: medial

• olecranon bursae - three or four
• bicipitoradial bursa - anterior, at radial tuberosity (where biceps brachii attaches)

• site of supination/pronation
• between head of radius & ulna (radial notch)
• synovial pivot joint
• anular ligaments: lined with synovial membrane
• sacciorm recess - synovial pocket continuous with synovial membrane of elbow

• dislocation of proximal radioulnar joint
• common in children
• head of radius dislocates out of proximal radioulnar joint by pulling sharply on the arm

• synovial pivot joint
• site of supination/pronation
• sacciform recess: creates smooth movement as radius pivots on ulna & slides over recess
• between ulnar notch of radius & head of ulna

• posterior
• anterior
• "triangular" - articular disck covers the head of the ulna & prevents it from contacting carpal bones

triangular depression on anterior aspect of elbow, between epicondyles of humerus

• superior: imaginary line connecting epicondyles
• medial: flexor mass from common flexor origin (specifically pronator teres)
• lateral: extensor mass from common extensor origin (specifically brachioradialis)
• floor: brachialis and supinator m
• roof: deep brachial and antebrachial fascia with bicipital aponeurosis

• brachial artery -terminates in radial artery & ulnar artery
• vena comitantes running with nerves
• tendon of biceps brachii
• median nerve
• musculocutaneous nerve
• radial nerve - superficial branch (sensory) & deep branch (motor)
• median cubital vein

• small indentation on the lateral proximal surface of the 1st digit's CMC
• created by APL, EPL, and EPB
• abductor pollicis longus
• extensor pollicis longus
• extensor pollicis brevis
• all innervated by posterior interosseous nerve
• contains superficial radial nerve & radial arteries

• base of 5th digit
• visual feature of wrist

• base of first digit
• visual feature of wrist

• C6: thumb and 1/2 of second digit
• C7: 1/2 of second digit, 3rd digit, 1/2 of 4th digit
• C8: 1/2 of 4th digit, 5th digit

• median: recurrent, lateral, medial, palmer cutaneous, palmar digital (common vs. proper)
• ulnar: palmar cutaneous, dorsal (digital), superficial, deep, palmar digital (common vs. proper)
• radial: dorsal digital

• two rows of four bones - proximal & distal
• 8 bones (lateral to medial)
• scaphoid, lunate, triquetrum, pisiform
• trapezium, trapezoid, capitate, hamate

• boat shaped
• articulates with radius
• largest of proximal row
• prominent tubercle: attachment for thenar muscles
• most frequently fractures carpal bone

• largest articulation with radius
• only receives blood from distal end
• if not diagnosed, avascular necrossis of proximal scaphoid can be seen on x-ray (bone resorption)

articulates with radius

• pyramidal shaped
• articulates with articular disc of the distal radioulnar joint

• sesamoid bone: forms in tendon of flexor carpi ulnaris
• articulates with anterior surface of the triquetrum
• not really a part of radiocarpal joint

• scaphoid
• lunate
• triquetrum
• pisiform

• trapezium
• trapezoid
• capitate
• hamate

• articulates with 1st and 2nd metacarpals
• prominent tubercle: attachment for thenar muscles

"on the insoid"

largest bone of all the carpals

hook of hamate: extends anteriorly

• miniature long bones
• between carpals and phalanges
• base, shaft, head
• head articulates with proximal phalanges at knucklse
• 1st MC: shortest & thickest; associated with thumb
• 5th MC: styloid process on dorsolateral aspect is palpable on surface

• miniature long bones
• each phalanx has base, shaft, head
• 2nd-5th phalanges have three phalanges (proximal, middle, distal)
• 1st digit only has two phalanges (proximal & distal)

• wrist joint
• synovial condyloid (ellipsoid) joint
• between distal part of radius & proximal carpal row
• ulna & pisiform do NOT participate (radioulnar disc does)
• numerous synovial folds
• sacciform recess: continuous with joint cavity; extends between radius & ulna; allows for supination/pronation of radius on head of ulna

• palmar radiocarpal ligament: allows hand to follow radius in pronation/suppination; keeps carpal bones attached to radius
• dorsal radiocarpal ligament: allows hand to follow radius in pronation/suppination; keeps carpal bones attached to radius
• ulnar collateral ligament: medial; attaches to ulnar styloid & triquetrum
• radial collateral ligament: lateral; attaches to radial styloid process & scaphoid

• flexion: flexor carpi radialis & flexor carpi ulnaris
• extension: extensor carpi radialis longus, extensor carpi radialis brevis & extensor carpi ulnaris
• abduction: flexor carpi radialis, extensor carpi radialis longus & extensor carpi radialis brevis
• adduction: flexor carpi ulnaris & extensor carpi ulnaris

• synovial plane (gliding) joint
• augments radiocarpal movements
• pisotriquetral: between individual carpal in proximal & distal rows
• midcarpal: between proximal & distal rows
• capsule is continuous with carpometacarpal joint capsules (except 1st joint capsule)

• carpometacarpal joint capsules
• NOT radiocarpal joint capsules - infections will not likely spread to wrist

• between distal carpal row & carpal surface of 2nd-5th metacarpal bases
• between adjacent metacarpals on radial & ulnar aspects of bases
• common capsule with intercarpal joints (except 1st joint)

• dorsal CMC ligament
• palmar CMC ligament
• dorsal IMC ligament
• palmar IMC ligament
• interosseous intermetacarpal ligament
• superficial transverse metacarpal ligament (part of palmar aponeurosis)
• deep transverse metacarpal ligament

• first carpometacarpal joint
• synovial joint
• has separate cavity from intercarpal & CMC joint capsules
• between trapezium & base of 1st metacarpal
• few ligaments - unrestricted movement

• most mobile, all motions of thumb
• flexion & extension: occur in coronal plane
• abduction & adduction: occur in sagittal plane
• opposition & reposition: pinching 1st & 2nd digit together
• circumduction
• rotation: during opposition

• knuckles
• synovial condyloid joint: movement in many directions
• between head of metacarpal & base of proximal phalanges
• each has its OWN synovial cavity

• pure hinge
• flexion & extension ONLY

• flexion & extension
• abduction & adduction
• circumduction

• synovial hinge joints
• located between head of proximal phalanges & base of middle phalanges AND between head of middle phalanges & base of digital phalanges
• movement limited to flexion & extension
• 1st digit has only one IP joint
• two IP joints in 2nd-5th digits
• each joint has its own capsule

• collateral ligaments: cordlike; slack during extension, taut during flexion (prevents dislocation)
• palmar ligaments: thick fibrocartilaginous plates; site of attachment for extensor expansion
• deep transverse metacarpal ligament: narrow fibrous band attached to fibrocartilaginous plates; runs across palmar surfaces of 2nd-5th metacarpal bones

• continous with with antebrachial fascia & fascia of dorsum of hand
• infection in the hand CAN spread to forearm
• thenar fascia: lateral (first digit muscles)
• hypothenar fascia: medial (5th digital muscles)
• digital sheaths

• enclose flexor digitorum superficialis & flexor digitorum profundus tendons in synovial sheaths
• keep fingers tethered
• prevents "bowstringing" of tendons
• 5 annular ligament parts
• 4 cruciform ligament parts

• triangular, immediately deep to skin
• overlies soft tissue & long flexor tendons
• proximally continuous with palmaris longus tendon (median nerve lies deep) & flexor retinaculum

• hypothenar compartment: formed by medial fibrous septum; fifth digit
• thenar compartment: formed by lateral fibrous septum; thumb
• central compartment - midpalmar space between lateral & medial septae
• adductor compartment - dorsal to thenar compartment
• interosseous compartment: most dorsal compartment

• deep thickening of antebrachial fascia that converts the anterior concavity of carpus into a tunnel
• roof - transverse carpal ligament

• formed proximal addition small covering on carpal tunnel
• ulnar tunnel: ulnar nerve & artery pass here

• flexor digitorum superficialis tendons
• flexor digitorum profundus tendons
• flexor palmaris longus tendon
• synovial sheaths of common flexors (named above)
• median nerve

• inflammation of tendons or synovium causes compression of median nerve
• results in impaired movements, problems with sensation, etc.
• test - pin prick of palm (palmar cutaneous branch of median nerve branches BEFORE entering carpal tunnel)

• thickening of antebrachial fascia on dorsal surface
• prevents bowstringing of extensor tendons on wrist
• creates osseofibrous tunnels with radius & ulna for passage of tendons & synovial sheaths

• flattening of extensor tendons along the distal MC & phalanges
• triangular aponeurosis that wraps around the phalanges
• forms "hoods" over the head of MC attached to palmar ligaments
• helps smooth extension & flexion
• median band: base of middle phalanx
• two lateral bands: base of distal phalanx

• uses in describing locations of pain, deeper structures, or incisions on the skin
• vertebral lines of reference: anterioxillary line, midaxillary line, posterioraxillary line
• posterior planes/lines of the thorax: posterior median plane, paravertebral plane, midscapular plane, midclavicular line, transplyoric plane, subcostal plane
• anterior planes/lines of the thorax: median plane, sternal plane, parasternal plane

• anterioaxillary line: runs vertically along anterior wall of axilla
• midaxillary line: runs vertically between anterior & posterior axillary lines
• posterioraxillary line: runs vertically along posterior wall of axilla

• posterior median plane (vertebral line): runs down the spine along the spinal processes
• paravertebral plane: runs down lateral edge of transverse processes where articulation of ribs occurs
• midscapular plane: located at the axis of rotation of the scapula

• medial plane: anterior median line, midsternal line; vertically down middle of sternum
• sternal plate: lateral sternal line; at the vertical edge of the sternum
• parasternal plane: located vertically between edge of sternum & midclavicular line
• midclavicular line: vertically down the middle of the clavicle; corresponds to midinguinal line/ inguinal ligament
• transpyloric plane: a transverse/horizontal plane, runs through pylorus of stomach
• subcostal plane: transverse/horizontal plane, runs along bottom of rib cage

• suprasternal notch: superior aspect of manubrium of sternum; corresponds to body of T3 vertebra
• sternal angle: Angle of Louis, manubriosternal junction; intervertebral disk between T4&T5
• xiphisternal joint: corresponds to intervertebral disc between T9&T10
• subcostal line: inferior aspect of ribs; corresponds to superior aspect of body of L3 vertebra
• umbilicus: body of L4

• two pleural cavities (lateral)
• pericardial cavity (inferomedial)
• mediastinum (superomedial)

• superior thoracic aperture (thoracic inlet)
• respiratory diaphragm
• surrounded by musculoskeletal thoracic wall

• composed of ribs and costal cartilage
• skeletal boundaries - superior thoracic aperture and inferior thoracic aperture

• cervical rib syndrome
• costoclavicular syndrome

• anatomically, thoracic inlet
• clinically, thoracic outlet
• posterior - body of T1
• lateral - 1st rib & costal cartilage
• anterior - superior border of manubrium of the sternum

• anatomically, thoracic outlet
• posterior - body of T12
• anterior - xiphisternal joint
• lateral - respiratory diaphragm, costal cartilage of 7-10th ribs, 12th rib

• costal processes normally develop from scleratome in thoracic region
• extra ribs can develop in the lumbar region (asymptomatic) or cervical region
• compression of C8 to T1 spinal nerve roots & inferior trunk of brachial plexus can impact motor function and blood flow

• symptoms - pallor & coldness of skin of upper limb; diminished radial pulse
• symptoms are exacerbated when patient raises & abducts affected arm
• results from compression of subclavian vessels and/or roots of the brachial plexus between clavicle & first rib

• 12 thoracic vertebrae & associated intervertebral discs: posterior
• 12 pairs of ribs & associated costal cartilages: lateral
• sternum
• manubrium: anterior
• xiphoid process: inferior

• extend between the ribs; are of hyaxial origin (derived from hypomere)
• innervated by ventral rami
• - external intercostal muscles
• - internal intercostal muscles
• - innermost intercostal muscles

• from tubercles of ribs to costochondral junctions
• fibers run superior lateral to inferiomedial
• muscles of inspiration - elevate the ribs
• external intercostal membrane: semitransparent membrane that continues from the external intercostal muscles to sternum

• lie deep to external intercostal muscles
• extend from sternum to angles of ribs
• fibers run superior medial to inferiolateral
• muscles of inspiration
• intercostal internal membrane: runs from medial border of ribs (at vertebrae) to costal angles

• lie deep to internal intercostal muscles
• fibers run in same direction as internal intercostal muscles (superiomedial to inferiolateral)
• separated from internal intercostal muscles by intercostal nerve, artery & vein

• arteries coming off of the thoracic aorta
• internal thoracic artery
• posterior intercostal artery

• branch off subclavian artery
• runs parasternally (posteriorly on sides of sternum)
• gives rise to anterior intercostal arteries
• divides inferiorly to superior epigastric artery (abdominal wall) and musculophrenic artery (diaphragm)
• can be used in coronary artery replacement

• branch directly off of thoracic aorta
• runs in intercostal spaces (except below T12)
• anastomoses with anterior intercostal arteries

• internal thoracic vein: drains into brachiocephalic veins, then superior vena cava
• intercostal veins: drain into internal thoracic veins or into azygos system
• Azygos system: venous drainage of thoracic cage/body wall; drains into superior vena cava at Angle of Louis (T4 level)

• intercostal veins, arteries, and nerves run between the innermost & internal intercostal muscles in a costal groove (superior to inferior... vein, artery, nerve)
• intercostals give off collaterals, which run off surface of superior border of rib below
• collateral run in inverted order - nerve, artery, vein
• intercostal nerves come from ventral rami of corresponding spinal nerve

• come from ventral rami of corresponding spinal nerves
• gives off lateral cutaneous branch at axillary line (anterior and posterior branches continue on anteriorly)
• anterior branch of cutaneous branch will give off a lateral & medial branch
• thoracic spinal nerves ONLY supply the costal area

• used to drain fluid from pleural cavity
• place needly centrally in intercostal spaces inferior to rib ( avoid both intercostal bundles)
• pus, blood, fluid

• done to numb area for incisions and fractured ribs
• place needle near the nerve to deliver anesthetic

ribs 1-7 attach directly to the sternum through their own costal cartilages

• ribs 8-10
• attach indirectly to sternum through the cartilage of the rib above

• ribs 11-12
• have no connection to sternum
• embedded in musculature posteriorly

• ribs 3-9 (share general structure)
• head articulates with head of numberically corresponding vertebra & vertebra superior to it via demifacets
• tubercle: articulation with transverse process of numerically corresponding vertebra
• relatively sharp bend in rib (angle)
• costal-chondral junction
• inferior aspect has costal groove for intercostal neurovasculature bundle

ribs 1-2, 10-12

• single facet for articulation with T1 vertebra ONLY
• short, flat superiorly and inferiorly
• scalene tubercle: attachment for anterior scalene muscle; separated groove for subclavian artery & groove for subclavian vein on superior surface of rib

• two facets for articulation with T1&T2 vertebrae
• tuberosity for serratus anterior muscle (superior surface)

only one facet on heads for articulation with numerically corresponding vertebral body

• only on thoracic vertebrae
• two demifacets on head of rib articulate with numerically corresponding vertebra and with vertebra superior to it (synovial joint supported by various ligaments)
• tubercle of rib articulates with transverse process of numerically corresponding vertebra (synovial costotransverse joint supported by lateral costotransverse ligament, costotransverse ligament, & superior costotransverse ligament)

• thoracic cavity increases in volume during inspiration (inhale)
• bucket-handle movement: middle parts of lower ribs elevate laterally increasing the lateral diameter of the thorax
• pump-handle movement: upper ribs elevate increasing the anteroposterior diameter of the thorax
• main movement - diaphragm contracts and pulls down increasing the superior/inferior diameter of the cavity
• exterior & interior intercostal muscles pull up on ribs

• mostly elastic recoil
• accessory respiratory muscles

• pectoralis major
• serratus anterior
• scalene muscles
• serratus posterior superior
• serratus posterior inferior
• levatores costarum

accumulation of blood in thorax

accumulation of air in thorax

• pericardial cavity
• peritoneal cavity
• two pleural cavities

endoderm

• from splanchnic mesoderm
• the part of the pleural cavity immediately adjacent to lung (attached to lung surface)

• space between the visceral pleura and parietal pleura
• only a little bit of serous fluid in cavity, NOTHING ELSE
• the lung is NOT inside the pleural cavity, it pushes out into it

• from somatic mesoderm
• outermost surface of pleural cavity
• 4 parts - cervical, costal, diaphragmatic, mediastinal

• cervical pleura: runs along cervical region (above 1st rib)
• costal pleura: runs along & inside of ribs
• diaphragmatic pleura: runs along superior surface of diaphragm
• mediastinal pleura: runs along mediastinum; superior & inferior to hilum

• layer of fascia between parietal pleura & thoracic wall
• fat, loose areolar CT

• root of lung
• where parietal & viscerl pleura are continuous

where pleura folds back upon itself & projects on thoracic wall

• where parietal pleura folds back over as mediastinal pleura
• occurs posterior to sternum
• to left side is the cardiac notch (bare area of pericardium)

• area of the heart not covered by pleura
• where anterior portion of pericardium meets the sternum

• parietal pleura: crosses 8th rib at midclavicular line; crosses 10th rib at midaxillary line
• lungs/visceral pleura: cross midclavicular line at 6th rib; cross midaxillary line at 8th rib

• parietal pleura: crosses paravertebral line at 12th rib
• lungs/visceral pleura: cross paravertebral line at 10th rib

• costomediastinal recess: formed to due reflections between costal & mediastinal pleura; posterior to pericardium
• costodiaphragmatic recess: costal pleura coming down sides of pleural cavity to diaphragm & turning into diaphragmatic pleura; where fluids will collect (site of thoracocentesis)

• innervated by branches of the intercostal nerves
• may cause reffered pain to the dermatomes supplied by the respective intercostal nerve

• central diaphragmatic pleura innervated by branches of phrenic nerve (C3,C4,C5)
• peripheral diaphragmatic pleura innervated by intercostal nerves (sensory)

• motor innervation to central tendon area of diaphragm
• sensory innervation to mediastinal pleura & diaphragmatic pleura over central tendon
• innervates peritoneum on inferior surface of diaphram
• referred pain to neck and shoulder - dermatome regions of C3,C4,C5

• two lobes: upper & lower lobes separated by oblique fissure
• upper lobe: cardiac notch on anterior aspect; lingula (homologous to middle lobe of right lung); mostly anterior
• lower lobe: mostly posterior

• organs leave impression on lungs - sulcus for aortic arch, sulcus for subclavian artery, cardiac notch, esophageal sulcus
• hilum: root of lung; where primary bronchus, pulmonary vein and arteries will enter & exit lung; where visceral & parietal pleura are continuous
• pulmonary ligament: extension of visceral pleura below hilum

• three lobes: upper and middle lobes separated by horizontal fissure; middle and lower lobes separated by oblique fissure
• sharp anterior surface (apex)
• obtuse posterior surface

• hilum: pulmonary artery & vein, etc.
• sulcus for superior vena cava
• sulcus for azygos vein
• sulcus for subclavian artery
• cardiac impression
• eparterial bronchus: supplies the superior lobe of the right lung; arises above the level of pulmonary artery (visible in hilum, differential characteristic)
• pulmonary ligament

• horizontal fissure of right lung: 4th costal cartilage
• oblique fissures of both lungs: 6th costal cartilage
• parietal pleura: 8, 10, 12th ribs
• visceral pleura: 6, 8, 10th ribs

• air-filled lungs look black
• oblique fissure: major fissure to radiologists
• middle fissure: minor fissure to radiologists
• lower lobe is pimarily posterior

• trachea: divides into two primary bronchi
• primary bronchi: enter lung at hilum
• right primary bronchus - more vertical, shorter, wider (foreign bodies are more likely to lodge here)
• secondary bronchi: lobar bronchi; go into different lobes of lung; three on right, two on left
• segmental bronchi: tertiary bronchi; supply bronchopulmonary segments

• structural unit of the lung
• 8 in left lung, 10 in right lung
• pyramidal shaped segment of the lung served by a single segmental bronchus
• smalled unit that can be identified and excised (isolated tumors)
• separated from each other by connective tissue septae
• supplied by tertiary branch of pulmonary artery

• pain free
• no nerves of general sensation

• anterior & posterior pulmonary plexuses
• parasympathetic: fibers from CN X (Vagus nerve) to smooth muscle of bronchial tree; cause bronchoconstriction, vasodilation & autonomic increased secretion of glands
• sympathetic: causes bronchodilation, vasoconstriction & inhibits bronchial glandular secretion

• neurotransmitter from post-ganglionic sympathetic fibers
• found within emergency inhalers (bronchodilation)

• detection of tissue damage
• different from general sensations of pain

• sensory fibers from viseral pleura & bronchi accompany sympathetic fibers
• mediate nociceptive stimuli
• sensory fibers from visceral pleura (GVA) go back towards spinal cord with sympathetics (GVE)

• phrenic nerve runs anterior to hilum
• vagus nerve runs posterior to root of lung

• firmly place the diaphragm of stethoscope on the patient's back
• ask the patient to take a deep open-mouthed breath
• listen for normal (vesicular, bronchial, bronchovesicular) or abnormal (wheezes, crackles, rubs, stridor) breath sounds

• pneumothorax
• air leaks from inside of lung to space between lung & chest wall
• xray shouws dark air leak

• tear in major artery causes hemothorax
• blood in thorax obscures view of ribs
• very "cloudy" radiograph image

• lies deep to the visceral pleura
• drains lung parenchyma and visceral pleura
• drains into bronchopulmonary (hilar) lymph nodes

• located in submuscosa of bronchi & peribronchia connective tissue
• drains submucosa of bronchi and adjacent connective tissue
• drains to pulmonary lymph nodes along lobar bronchi, then into bronchopulmonary lymph nodes at hilum
• from bronchopulmonary lymph nodes - tracheobonchial lymph nodes - bonchomediastinal lymph trunks

• right lung: bronchopulmonary nodes, eventually into right lymphatic duct, then venous system
• upper lobe of left lung: drains through bronchomediastinal nodes into thoracic duct, empties into venous system
• lower lobe of left lung: drains to right superior tracheobronchial node & continues on the right sider

• "the middle stuff"
• area between pleural cavities
• central compartment of thoracic cavity
• divided into superior & inferior mediastinum

• from superior thoracic aperture to the transverse thoracic plane
• transverse thoracis plane: line drawn from sternal angle to the intervertebral disc between the T4 and T5 vertebrae

• from transverse thoracic plane to diaphragm
• anterior mediastinum: anterior to pericardium
• middle mediastinum: pericardial cavity
• posterior mediastinum: posterior to pericardium

• thymus
• brachiocephalic veins
• superior vena cava
• arch of aorta: brachiocephalic trunk, left common carotid artery, left subclavian artery
• vagus & phrenic nerves
• cardiac plexus of nerves
• left recurrent laryngeal nerve
• trachea
• esophagus
• thoracic duct
• arch of azygos vein
• prevertebral muscles

• subdivision of inferior mediastinum
• area between sternum & pericardial sac
• contains mostly fat
• contents - loose CT, fat, lymphatic vessels & nodes, transverse thoracic muscles, branches of internal thoracic vessels, minor blood vessels

• subdivision of inferior mediastinum
• defined by pericardial sac
• contents - heart, great vessels, ascending aorta, pulmonary vessels

• subdivision of inferior mediastinum
• anterior to T5-T13 vertebrae, posterior to pericardial sac, between parietal pleura
• contents - thoracis (descending) aorta, trachea & bronchi, esophagus, esophageal plexus, thoracic duct, posterior mediastinal lymph nodes, azygos & hemiazygos veins, vagus nerve, thoracic sympathetic trunks, thoracic splanchnic nerves, lymph nodes

• left brachiocephalic vein
• arch of aorta or its branches
• trachea
• esophagus
• vertbral column (spinal cord)

• T1 vertebra & manubrium
• disc between T4 & T5 and manubriosternal joint

• disc between T4 & T5 and manubriosternal joint
• diaphragm

• superior border: left 2nd costal cartilage
• right border: right 3rd costal cartilage
• inferior border: right 6th costal cartilage
• left border: left 5th intercostal space

• coronary sulcus
• separates atria from ventricles
• where coronary sinus sits

• aneurysm: enlarge
• dissection: tear
• stenosis: narrowed
• occlusion: blocked
• ulcerate: deteriorate

• serous
• parietal - costal, mediastinal, diaphragmatic
• visceral

• external fibrous layer
• internal serous layer - parietal & visceral

• continuous with tunica adventitia of great vessels
• attached anteriorly to sternum via sternopericardial ligaments

• parietal layer
• visceral layer - epicardium, lines the heart muscle itself

• potential space filled with small amount of serous fluid
• if space gets filled with too much fluid, blood etc., heart becomes confined - cardiac tampanade

• devoid of pleura
• allows penetration of pericardium without deflating lung (piercing pleura)

• serous pericardial reflections
• transverse pericardial sinus: passage between arterial & venous associated reflections; separate aorta & pulmonary trunk from pulmonary veins & SVC
• oblique pericardial sinus: back of right ventricle

spaces behind valves

blood vessel in coronary groove between atria & ventricle

inferior & superior vena cava - right atrium - tricuspid valve - right ventricle - pulmonary valve - lungs - pulmonary veins from lungs - left atrium - mitral valve - left ventricle - aortic valve - aorta - body!

• right & left atria (left has thicker muscular wall)
• right & left ventricles (left has thickest muscular wall)

• endocardium: thin internal layer
• myocardium: thick muscle layer
• epicardium: thin external layer

• diaphragmatic (inferior) surface: L ventricle & a little R ventricle
• sternocostal (anterior) surface: R ventricle
• base (posterior) surface: L atrium + 4 pulmonary veins
• apex: L ventricle, posterior to left 5th intercostal space

• superior border: R&L atria and auricles
• right border: R atrium
• inferior border: R ventricle & some L ventricle
• left border: L ventricle & a little left auricle

• maintains patency/ prevents distension of valves
• provides attachment for valve cusps
• provides attachment for myocardium
• forms electrical "insulator"

• atrioventricular valves: tricuspid valve, mitral (bicuspid) valve
• semilunar valves: pulmonary valve, aortic valve

• pectinate muscles
• sinus venarum: smooth walled portion
• crista terminalis: differentiates between pectinate muscles & sinus venarum
• openings for inferior vena cava, superior vena cava, & coronary sinus
• auricle
• interatrial septum - fossa ovalis (embyological remnant of foramen ovale)
• tricuspid valve

• trabeculae carnae
• septomarginal trabeculae: from interventricular wall to papillary muscles
• papillary muscles (anterior, posterior, septal) & cusps
• chordae tendinae - do NOT pull valve leaflets down
• pulmonary valve

• smooth walls
• pectinate muscles ONLY in auricle
• valve of foramen ovale in interatrial septum
• mitral valve

• papillary muscles (anterior & posterior)
• chordae tendinae
• trabeculae carnae in intervetnricular septum
• openings for coronary arteries & valves
• space behind valves - aortic sinus
• aortic valve

• right coronary artery - SA node branch (60%), right marginal branch, AV nodal branch, posterior intervetricular branch
• left coronary artery - anterior interventricular artery (with anterior branch) & circumflex branch (with left marginal artery & SA nodal branch 40%)

• right dominant heart: R coronary artery gives off posterior interventricular branch (66%)
• left dominant heart: L coronary artery gives off posterior interventricular branch from circumflex branch (15%)
• no R coronary artery
• Maravich's heart: circumflex branch runs from R coronary artery (no L coronary artery)
• blockage: atherosclerosis or thrombosis

• coronary sinus - drains directly into R atrium; drains the following veins
• great cardiac vein: runs with anterior interventricular artery in interventricular sulcus; branch - oblique vein of L atrium
• middle cardiac vein: runs with posterior interventricular artery
• small cardiac vein: runs with right marginal artery
• left posterior vein
• left marginal vein

• SA node
• AV node
• AV bundle of His
• right & left bundle branches
• Purkinje fibers (subendocardial branches)

• GVE: sympathetic (T1-T5 spinal cord segments) & parasympathetic (Vagus CN X)
• GVA: pain; returns to uppoer thoracic spinal cord segments with sympathetics (T1-T5)

• located at bifurcation of the trachea
• postganglionic sympathetics
• preganglionic parasympathetics
• general visceral afferents

• sympathetic: increase heart rate, increase force of contraction, dilation of coronary arteries
• parasympathetic: decrease heart rate, decrease force of contraction, constriction of coronary arteries

• T1-T5 IMlCC (preganglionic cell bodies)
• sympathetic chain (cervical & T1-T5 - postganglionic cell bodies)
• cardiac plexus
• heart

• dorsal motor nucleus of CN X (Vagus nerve - preganglionic cell bodies)
• cardiac plexus
• postganglionic cell bodies on heart
• heart

• diastole: period of ventricular elongation & filling
• systole: period of ventricular shortening & emptying

• "lub": closure of AV valves
• "dub": closure of semilunar valves

• aortic valve: right 2nd intercostal space (sternal margin)
• pulmonary valve: left 2nd intercostal space (sternal margin)
• left AV valve: left 5th intercostal space (midclavicular line)
• right AV valve: right 5th intercostal space (sternal margin)

• angina
• GVAs will travel back to spinal region (T1-T5) with sympathetic fibers