Anatomy Lecture Notes--midterm review by Stephanie Swanson

Thorax:

Breast:

Cooper’s Ligaments- suspensory ligaments

Glands/Lobulesductssinusesnipple

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 / pectoral branch of thoracocromial trunka.
Pectoralis Minor / depresses tip of shoulder, protracts scapula / medial pectoral n.
External intercostals / inspiration, moves ribs up (inferomedially) / Intercostal nerves / Intercostal arteries
Internal intercostals / Expiration/inspiration (superiorlaterally)
Innermost intercostal / act with internal intercostals
Transversus thoracis / 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 lung- potential space

Lung-

Root- 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 adults-

over 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 nodein the bottom part of the right atrium  fibers to interventricular septum  right bundle branch moderator bandand 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 accessoryazygos on the upper left

Left recurrent laryngeal nerve comes down (branching off the vagus) and goes posterior to the ligamentumarteriosum (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 wall- contains 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:

Somatic / Visceral
AfferentDorsal HornDorsal Root GangliaDorsal RootSensoryInfo to CNS / GSA: touch, temp, proprioception, sharp pain—only part in the abdomen is the omenta / GVA: all of viscera (organs) in the gut: dull pain (bellyache)
EfferentVentral HornVentral RootMotorAway from CNS / 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 transverseforamen

Spinal nerves run through vertebralforamen

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:

Type / Muscle Group / Muscle Name / Muscle Function / Nerve Innervation / Arterial Supply
Extrinsic / Superficial / Trapezius / elevate, depress, adduct, & medially rotate scapula / accessory spinal nerve (CN XI) / transverse cervical
Latissimus Dorsi / extend, adduct, & medially rotate humerus / Thoraco-dorsal / thoracodorsal
Levator Scalpulae / elevate scapula / dorsal scapular / Transverse cervical
Rhomboid Minor / retract scapula / dorsal scapular / dorsal scapular
Rhomboid Major / retract scapula / dorsal scapular / dorsal scapular
Intermediate / Serratus Posterior Superior / elevate ribs / ventral rami / Intercostal a.
Serratus Posterior Inferior / depress ribs / ventral rami / Intercostal a.
Intrinsic (innervated by posterior/dorsal rami) / Deep / Spino-transversales:
1. Splenius capitus
2. Splenius Cervicis / together: pull head back, extend neck; individually: move head to same side as contraction / dorsal rami / segmentally: deep cervical, intercostal, subcostal, lumbar
Erector Spinae: 1. Iliocostalis 2. Longissimus 3. Spinalis / maintain upright posterior, bend back / dorsal rami

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 membraneoffers 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 / Muscle Function / Nerve Innervation / Arterial Supply / Origin / Insert
Posterior Scapula / Supraspinatus / Abduct arm to first 15 degrees / Suprascapular / Suprascapular / Superior Scapula / Top of Humerus
Infraspinatus / Lateral Rotation of arm / Suprascapular / Suprascapular / inferior scapula / 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 / Deltoid / Major Abductor of the arm after first 15 degrees / Axillary Nerve / Post. Circumflex humoral artery, deltoid branch of thoracoacromial / clavicle / middle of humerus
Anterior scapula / Subscapularis / medial rotation of arm / Upper/lower subscapular nerves / subscapular artery / lesser tubercle / anterior side of humerus
Serratus Anterior / Rotation/protraction of scapula / Long Thoracic Nerve / Lateral Thoracic artery / ribs 8-9 / scapula

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 branches-

Innervation of Brachial Plexus:

Dorsal Scapular / Rhomboid major/minor
Long thoracic / Serratus anterior
Suprascapular / Supra and infraspinatus
Nerve to subclavius / Subclavius
Lateral pectoral / Pec. major
Musculocutaneous / Skin to lateral side of forearm / anterior compartment of arm
Medial pectoral / Pec. major/minor
Medial cutaneous of arm / Skin medial of distal 1/3 of arm
Medial cutaneous of forearm / Skin medial of forearm
Median / palm surface lat. 3.5 digits & lateral side of palm and mid of wrist / Ant. compartment of forearm, 3 thenar of thumb, 2 lateral lumbrical muscles (no flexor carpi ulnaris & flexor digitorum profundus)
Ulnar / palm surface of med. 1.5 digits & dorsal of med 1.5 digits / intrinsic muscles of hand (no median nerve ones), flexor carpi ulnaris, med. Flexor digitorum profundus)
Superior subscapular / subscapularis
Thoracodorsal / latissimus dorsi
Inferior subscapular / subscapularis, teres major
Axillary / upper lateral part of arm / deltoid, teres minor
Radial / Post. arm/forearm, lower lat. Surface of arm, dorsal lateral of hand) / 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 thumb- articulates with the scaphoid and lunate

-interosseus membrane goes between two bones

Muscle Group / Muscle Name / Muscle Function & Facts / Nerve Innervation / Arterial Supply
Anterior / Biceps brachii / flex arm (long head) & forearm, supinate if elbow is flexed / Musculo-cutaneous / brachial
brachialis / flex forearm / brachial + radial recurrent
Coraco-brachialis / flex forearm, adduct arm / brachial
Posterior / Triceps brachii / extend forearm at elbow, long head can adduct or extend arm at shoulder / radial / profunda brachii

also know insertions: