anatomy holy bible - 1st semester

8/12/2019 Anatomy Holy Bible - 1st Semester

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Back and Shoulder

Occipital n., C2A purely cutaneous nerve

Suboccipital n.A motor nerve, lying deeper in the triangle

Trapezius m.Attaches at the level of T12

Nerve: spinal component of the spinalaccessory n., CN XI, seen on the anterioraspect of the trapezius m.

This nerve also innervates the

sternocleidomastoid m.Blood: superficial branch of the transverse

cervical a.

Action: elevate, retract and rotate the scapula

Abducts above 90 degrees

Lesion: cant elevate (shrug) shoulder

These 3 muscles have the same nerve and blood

supplyLevator scapulae m.

Attaches C1-C4

Rhomboid minor m., comes off opposite the

spine of the scapula, T3Attaches C7-T1

Rhomboid major m.

Attaches T2-T5

Rhomboids let you stick your chest out

Nerve: dorsal scapular n.Seen on the anterior aspect of the scapula

Blood:deep branch of the transverse

cervical a.Accompanies the nerve to these muscles

Serratus posterior superior m., lies under therhomboids

Latissimus dorsi m.Inserts into the floor of the intertubercular

groove

Action: hand-cuff position

Powerful adductor of humerus.

Nerve: thoracodorsal n.from the posteriorcord of the brachial plexus

Serratus posterior inferior m., lies under thelatissimus dorsi

Erector spinae m.

Spinalis m., closest to the spine

Longissimus m., in the middle, goes all the

way to the mastoid process

Iliocostalis m., most lateral, from iliac crest tothe ribs

Rotator cuff muscles, SITS

Supraspinatus m.

Infraspinatus m.

Teres minor m.

Subscapularis m.

Supraspinatus m.Action: 1

st15 degrees abduction

Nerve: suprascapular n.

Runs below the suprascapular ligament,which is suspended over the suprascapular

notch

Blood: suprascapular a.Runs above the suprascapular ligament,

which is suspended over the suprascapular

notch

Suprascapular a. arises most commonly from

the 1stpart of the subclavian a., or

occasionally from the 2nd

or 3rd

part

Army over the bridge, Navy under the bridgeArtery runs above the suprascapular ligament

Nerve runs below the suprascapular ligament

Attaches on the highest facet of the greatertuberosity of the humerus

Injury of supraspinatus m.Inserts under the acromion, thus it is the most

commonly torn in a rotator cuff injury

The tendon passes under the acromion. Onecan develop bony spurs on the under side of

the acromion, which will start to tear away

the tendon, until eventually the tendonruptures

Loss the first 15 degrees of abduction, soperson will hang the shoulder down to let

gravity allow them to overcome the first 15

degrees, then they can use the deltoid andtrapezius to abduct the arm the rest of the

way

Infraspinatus m.Nerve: suprascapular n., like

the supraspinatus m.

Attaches on the middle facet of the greatertuberosity of the humerus

Action: laterally rotates humerus, a muchstronger lateral rotator than teres minor m.

Teres minor m.

Action: laterally rotates humerusAttaches on the inferior facet of the greater

tuberosity of the humerus

Nerve: axillary n.

Action: laterally rotates humerus


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Teres major m.Action: medially rotates humerus, as doespectoralis major and latissimus dorsi

Attaches at the medial lip of the

intertubercular groove

Pectoralis m. attaches at the lateral lip of theintertubercular groove

Latissimus dorsi attaches in the floor of the

intertubercular grooveNerve: lower subscapular n., C6, C7

Deltoid m.

Abducts 15-90 degrees: lateral fibers do

Abduction

Nerve: axillary n.from the posterior cord ofthe brachial plexus

Anterior fibers flex the humerus

Posterior fibers extend the humerus

Know the attachments of every muscle on the

scapula (see Bony Landmarks)SpacesBack and Shoulder

Quadrangular space

Bounded by:

Subscapularis tendon superiorly

Teres major tendoninferiorly

Long head of the triceps brachii m.medially

Humeruslaterally

Passing through the quadrangular space are the:Axillary n., turns superiorly

Posterior circumflex humeral a., runs across

laterally to muscle

Clinical:

Surgical head fracture of humeruswill most

likely damage the contents of the quadrangular

spaceTo test for axillary n. damage, do muscle testfor deltoid, which is the major abductor of

the arm

Triangular interval

Bounded by:

Teres major m.superiorlyLong head of the triceps brachii m.medially

Humerus laterally

Passing through the triangular interval are the:

Radial n.,

Profunda brachii a.

Clinical:Mid-humeral fracture will most likely

damage the contents of the triangular interval

If the radial n. is damaged, it can cause wrist

drop

To test for radial n. damage, do muscle test forextensor muscles of elbow and wrist

Triangular space

Bounded by:Teres minor m.superiorly

Teres major m.inferiorlyLong head of the triceps brachii m.laterally

Passing through the triangular space are the:

Circumflex scapular a. and v.

Theres NO nerve in this space

Triangle of auscultation

Location:Near inferior angle of scapula on lower medial

border of scapula

Bounded by:

Trapezius m.mediallyRhomboideus major m.superiorly

Latissimus dorsi m.inferiorly

Clinical:Use this space to listen to (auscultate) lungs

since the stethoscope can be placed close to

the thoracic wall at this location, withminimum impedance of sound through muscle

Lumbar triangle = Triangle of Petit

Bounded by:

Latissimus dorsi m.medially

External abdominal oblique m.laterallyIliac crestinferiorly

Notes:Its floor is the internal abdominal oblique m.

May be the site of an lumbar hernia

Spinal Cord

Dura matter, extends to S2

Epidural space, above the dura matterThere will be probe inserted into the space in

exam

Between the dura matter and the bone of thevertebrae

Contains fat and blood vesselsClinically important

Subdural space, between dura and arachnoidmatter

Clinically not very significant

Arachnoid matter, a filmy layer under the duramatter


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Subarachnoid space, between arachnoid andpia matter

Clinically very important

Contains cerebral spinal fluid

Conus medullaris, the end of the spinal cordEnds at the level of the intervertebral space

between L1-L2 in adults

End at L3 in newborn

Filum termminale internum, an extension ofpia matter within the vertebral column

Called the externum when it exits the sacral

canal

Cauda equina

Denticulate ligaments, tooth-like processes of

pia matterThey separate the dorsal rootlet from the

ventral rootlet, a reference used in surgeryDorsal rootlet is above the denticulate

ligament

Ventral rootlet is deep to the denticulateligament

Prevents the spinal cord from swishing in the

dural sac in the spinal canal

They end at the level of T12-L1

Dorsal rootlet, purely sensory

Ventral rootlet, purely motor, deeper than the

dorsal rootlet

Dorsal root ganglion, a bulge of nerve sittingoutside of the dural sac

Spinal nerve, formed by the joining of theventral and dorsal rootlet immediately after thedorsal root ganglion

Immediately after forming a spinal nerve, itdivides into

Dorsal rami

Ventral rami,much larger

Upper Limb

Cephalic v.Originates on the lateral aspect of the

dorsum venous archof the hand

In the shoulder region, it can be seen draining

into the axillary v.in the deltopectoralgroove

Brachial plexus

Formed by the joining of ventral rami from C5-

T1

The divisions are Rodney Thomas Drinks ColdBeer

Roots

Trunks

Divisions

Cords

Branches

There are 5 roots, from ventral rami of C5, C6,

C7, C8, T1

There are 3 trunksformed by merging of roots

Superior trunk, formed from C5 and C6

Middle trunk, formed from C7

Inferior trunk, formed from C8 and T1

Upper trunk palsy, an injury to the uppertrunk, C5, C6, is very serious: Erbs Palsy

(Waiters tip)Suprascapular n., C5, C6, which supplies 2muscles

Supraspinatus m., abduct 0-15 degrees

Infraspinatus m.

Axillary n., C5, C6, which supplies 2muscles

Deltoid m., abducts 15-90 degrees

Teres minor m.

Musculocutaneous n., C5, C6, whichsupplies 3 muscles

Brachialis m.Biceps brachii m.Coracobrachialis m.

Functionally, you would lose

Abduction from 0-90 degrees

You would NOT lose

Flexion of the elbow because there are

many other flexorsSupination, but it would begreatly

weakenedfrom loss of biceps brachii


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Lower trunk palsy, an injury the lower trunk,

C8, T1Mimics an injury to the ulnar n. from injury

to the medial epicondyle

Patient presents withClaw hand

Abducted wrist from loss of wrist adduction

Klumpkes palsy

Each trunk divides into 2 divisions

Anterior divisionsare the flexor part

Posterior divisionsare the extensor part

CordsForm from merged divisions

Named for their spatial relationship with the2

ndpart of the axillary a.,which is underneath

pectoralis minor m.

Posterior cordSits posterior to the 2

ndpart of the axillary a.,

Formed from all 3 posterior divisions of the 3

trunks

Lateral cordSits lateral to the 2

ndpart of the axillary a.

Formed from anterior divisions of superiorandmiddle trunks

Medial cordSits medial to the 2

ndpart of the axillary a.

Formed from the anterior division of the

inferior trunk

Terminal branchesfrom the cords

During the test, be sure to first determine which

cord the nerve is coming from, determine if thecord is lateral, medial, or posterior relative to

the axillary a.

a. Lateral cordHas 3 branches, from superior to inferior

1. Lateral pectoral n.Innervates the pectoralis major m.

2. Musculocutaneous n.

Called musculocutaneous because itsupplies 3 muscles of the arm muscles andthen becomes cutaneous for the lateral

forearm

Pierces through the coracobrachialis m.ID by this feature

Runs between the biceps brachii m. and

thebrachialis m.

Becomes cutaneous at the forearm,becoming the lateral cutaneous n. of the

forearm= lateral antebrachial cutaneousn., at the cubital fossa

Travels down to the wrist on the lateralaspect of the forearm

Innervates 3 muscles, all flexors of the arm

Coracobrachialis m.

Biceps brachii m.

Brachialis m.

3. Median n., lateral root

The lateral root of the lateral cord uniteswith the medial root of the medial cord to

form the median n.

Seen running directly down the midline ofthe arm, toward the cubital fossa

Innervates all flexor muscles of the

forearm, EXCEPT

1 muscles which are innervated by the

ulnar n.

Flexor carpi ulnar m.Flexor digitorum profundus m.,

medial 1/2

1 muscle which is innervated by the

radial n.

Brachioradialis m.

Even though, it can be seen passing throughthe arm, the median n. does NOT innervateanything in the armonly the forearm and

hand

b. Medial cord

Has 5 branchesThe first 2 are cutaneous nerves that branchoff above the M-shape of the nerves

The middle 2 do NOT supply the arm, buthave functions in the forearm and hand

The last 1 goes to pectoralis major and

minor

1. Medial cutaneous n. of forearm =

Medial antebrachial cutaneous n.

Thicker and longer of the 2, which goes

all the way to the forearmSeen passing next to the ulnar n., the more

lateral of the 2

A cutaneous nerve of the forearm

2. Medial cutaneous n, of arm = Medial

brachial cutaneous n.Much thinner and shorter branch, which

stops at the cubital fossa

Seen as the more medial of the 2

A cutaneous nerve of the arm


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3. Median n., medial root

The medial root of the medial cord uniteswith the lateral root of the lateral cord to

form the median n.

Seen running directly down the midline ofthe arm, toward the cubital fossa

Innervates all flexor muscles of the

forearm, EXCEPT

1 muscles which are innervated by theulnar n.

Flexor carpi ulnar m.

Flexor digitorum profundus m.,

medial 1/2

1 muscle which is innervated by the

radial n.

Brachioradialis m.

Even though, it can be seen passing through

the arm, the median n. does NOT innervate

anything in the armonly the forearm andhand

4. Ulnar n., C8, T1Inner leg of the M

Seen running down the medial aspect of the

arm, and passing behind the medial

epicondyle of the humerusID by this

feature

Even though, it can be seen passing throughthe arm, the ulnar n. does NOT innervate

anything in the armonly the forearm and

handInjury to the medial epicondyle, can injure

the ulnar n., and patient would present withClaw hand

Abducted wrist from loss of wrist

adduction

5. Medial pectoral n.Innervates

Pectoralis minor m., pierces through this

muscle to reach pectoralis major m.

Pectoralis major m.

Thinner than antebrachial n.

Stops in cubital fossa

c. Posterior cordYou need to know all the branches comingoff the posterior cord

For ID, the other 2 cords (lateral and medial)will have to be pinned back to one side to

expose the posterior cord, which is a big clue

that youre looking at the posterior cord and

its branches

Has 5 branchesThe first 3 are small branches that come offearly

The last 2 are large branches further down

From superior to inferior the branches of the

posterior cord are

1. Upper subscapular n.1

stbranch, comes off posteriorly

Innervates subscapularis m., which is also

innervated by the lower subscapular n.

2. Thoracodorsal n.(used to be called themiddle subscapular n.)

A long nerve seen running down to the

latissimus dorsi m.Innervates the latissimus dorsi m.

3. Lower subscapular n.

InnervatesTeres major m.

Subscapularis m., inferior part

The only muscle that inserts on thelesser tuberosity of the humerus

Is part of the rotator cuff

Has dual innervationmust name bothon exam

Upper subscapular n.

Innervates only the subscapularis m.

Lower subscapular n.

Innervates 2 muscles: subscapularism. and teres major m.

The posterior cord then divides into the

following 2 terminal branches

4. Axillary n.Seen as large branch that immediately dives

posteriorly

Runs through the quadrangular space,accompanied by the posterior circumflex

humeral a.

Runs around the surgical neck of thehumerus

Innervates

Deltoid m.

Teres minor m.

Branches: Upper Lateral Cutaneous

Nerve of the Arm

Dislocation of the shoulderis alwaysanterior and inferior, and would injury the

axillary n.not the radial n.

Sensory loss


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Over the shulder, remember the

regimental sign where loss is at andabove the level of military stripes on the

sleeve

When popping the shoulder back intoplace, to avoid a lawsuit, make sure yousensory test first before you touch the arm

at all! Then pop the shoulder into place,

and sensory test again!If you dont document sensory lossbefore

you do the adjustment, you can be sued

when patient later claims that you causedthe sensory loss during the adjustment

Fracture of the surgical neckof thehumerus would injure the axillary n. and

the posterior circumflex humeral a.. Nerve

damage would cause

Sensory loss: regimental sign

Motor loss

Deltoid paralysis, thus loss off abductionbetween 15-90

Teres minor m. cant be clinically tested,

but it is a lateral rotator, thus weakend

lateral rotation

5. Radial n.Runs through the triangular intervalof the

arm where it is accompanied by the

profunda brachii a., the 1stbranch off the

brachial a.

Both nerve and artery can be seen on theposterior arm when the lateral and long

heads of the triceps are spread apart

Fracture in the midshaft of the humeruswould injure the radial n. and the profunda

brachii a.. Nerve damage would causeWrist droponly extension of the wrist is

lost

Has the person lost the ability to extendthe shoulder or elbow? No, because the

radial n. gives off branches to the triceps

much earlier than when it goes to thespiral groove

Branches: Lower Lateral Cutaneous

Nerve of the Arm, Posterior Cutaneous

Nerve of the Forearm, posterior Cutaneous

Nerve of the Arm

Other nerves of the axilla region

These nerves are direct branches from theventral rami, not from one of the brachial plexuscords

Dorsal scapular n.From ventral ramus C5

Innervates:

Levator scapulae m.

Rhomboid minor m.Rhomboid major m.

Long thoracic n.From ventral rami of C5, C6, C7

Seen running along the surface of the serratus

anterior mm.

Innervates: serratus anterior m.

C5, C6, C7: raise your arms to heaven

Injury to the long thoracic n. results in loss ofprotraction of the scapula, causing a wingedscapula

Vessels of the arm

Axillary v.runs above the axillary a.

Axillary a.Is seen when the axillary v.is reflected back

Begins at the lateral border of the 1strib

Ends at the inferior border of teres major m.,where it becomes the brachial a.

Has 3 regions defined by their relationship to

pectoralis minor m.

The 1stpart has 1 branch

The 2ndpart has 2 branches

The 3rd

part has 3 branches

1stpart of axillary a.

Between the lateral border of the 1striband

the medial border of the pectoralis minor

m.

Has 1 branchSupreme (Superior) thoracic a.wont

be testedA tiny branch that extends to the upper

thoracic wallSupplies 1

stand 2

ndICS and superior

part of serratus anterior m.

2nd

part of axillary a.

Posterior to (underneath) pectoralis minor

m.

Has 2 branchesThoracoacromial trunk:- Pierces the

clavicopectoral fascia before giving off

4 branches, CAPD


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Clavicular branch

Acromial branch

Pectoral branches, the only identifiable

branches

Deltoid branch

Lateral thoracic a.Follows the border under the pectoralis

minor m.

Can be seen entering the thoracic wall

Supplies the pectoralis mm., axillarylymph nodes, and breast

3rd

part of axillary a.

Between the lateral border of the pectoralis

minor m.and the inferior border of the

teres major m.

Has 3 branches: 2 lateral branches and 1medial branch

The 2 lateral branches are

Anterior circumflex humeral a.Tiny branch that sits above the muchlarger posterior circumflex humeral a.

Runs to the anterior aspect of thehumerus

Posterior circumflex humeral a.

Much larger branch than the anteriorcircumflex humeral a.

Runs to the posterior aspect of thehumerus

Through the quadrangular space,accompanied by axillary n.

The 1 medial branch

Subscapular a., the largest branch of the

axillary a., which divides into 2 branches

Circumflex scapular a.A much larger branch than the

thoracodorsal a.

Passes behind the scapula to its dorsal

aspect

Very important for collateral

circulation around the scapulaAppears in the triangular spaceof the

scapula, between the teres minor m.

and teres major m.

Thoracodorsal a.The continuation of the subscapular a.,Seen running down toward the

latissimus dorsi m.

Accompanied by the thoracodorsal n.

If the medial branch is tagged before itstarts to branch, you would saysubscapular artery

If the medial branch is tagged after itbranches then it will either be

Thoracodorsal a., seen runningdownward to the latissimus dorsi m.

Circumflex scapular a., a much thicker

branch seen going immediately behindthe scapula

Brachial a.Begins at the point where the axillary a. passes

the inferior border of the teres major m.

In the arm, the brachial a. gives off a branch

Profunda brachii a.The 1

stbranch off the brachial a.

Anterior branch anastomose with

radial recurrent branch of radial artery

in front of lateral epicondyle

Posterior branch anastomose withinterosseous recurrent branch of the

posterior interosseous artery behind the

lateral epicondyle

Runs through the triangular intervalof the

humerus, accompanied by the radial n.

In the cubital fossa, the brachial a. dividesinto

Radial a., which runs laterally along theradial side of forearm

Ulnar a., which runs medially along the

ulnar side of the forearm

Lymph nodes

central lymph nodes are defined asthe group of lymph nodes situated

deep to the pectoralis minor at thebase of the axilla

apical lymph nodes are medial to themedial border of the pectoralis minor

subscapular nodes are found on theposterior wall of the axilla

Nerves of the Arm

Musculocutaneous n.

Called musculocutaneous because itsupplies

3 muscles of the arm muscles and thenbecomes cutaneous for the lateral forearm

Innervates 3 muscles, all flexors of the arm

Coracobrachialis m.

Biceps brachii m.


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Brachialism.

Pierces through the coracobrachialis m.

Runs between the biceps brachii m. and the

brachialis m.

At the cubital fossa, it becomes the lateral

cutaneous n. of the forearm= lateralantebrachial cutaneous n.

Travels down to the wrist on the lateralaspect of the forearm

Radial n.From posterior cord of brachial plexus

PathwaySits in the spiral grooveof the humerus,

seen between the long head and lateral head

of the triceps m.

Accompanied by the profunda brachii a.inarm

Enters cubital fossa

Volkmanns contracture: damage to thebrachial artery at distal end of humerus.

Innervates

Triceps brachii m.

Anconeus m.

Median n.Does not innervation anything in the arm, only

the forearm

Muscles of the arm

Subscapularis m.Attachments:

Subscapular fossa

Lesser tuberosity of the humerus

The only muscle that inserts on lesser

tuberosity of humerus

Action:Medially rotates arm

Adducts arm

Holds humeral head in glenoid fossa as part

of rotator cuff

Nerve: has dual innervationif asked for itsinnervation on exam, you must name bothnerves

Upper subscapular n., C5, C6, C7

Innervates only the subscapularis m.

Lower subscapular n., C5, C6, C7Innervates 2 muscles: subscapularis m. and

teres major m.

Coracobrachialis m.Attachments:

Coracoid process

Midshaft of the humerus, just lateral to thedeltoid tuberosity

Action: adduct and flex the shoulderMuscle used to tuck a newspaper under your

arm against your ribs

Nerve: musculocutaneous n., C5, C6, C7

Biceps brachii m.Has 2 heads, the long head is more medial

The Long head is Lateral, and has a Longtendon which runs through the

intertubercular (bicipital) groovein the

head of the humerus

The short head is more medial since it

attaches to the coracoid process

If you see one head tagged for ID, you needto specifically identify that head

If the tag is in the muscle belly, then you

would say biceps brachiiAttachments:

Short head: coracoid process

Long head: supraglenoid tuberosity

Radial tuberosityof the radius

[Long head of tricepsattaches at theinfraglenoid tuberosity]

[Coracobrachialis m.and pectoralis

minor m.also attach on the coracoidprocess]

Action:

Supinates the forearmthe strongestsupinator

If asked which muscle is the strongestsupinator in the upper limb, you would say

biceps brachiiNOT the supinator

muscle

If asked what is the strongest action ofbiceps brachii, you would say supination

Long head flexes the shoulder (and some

elbow), since it crosses both shoulder and

elbow jointsShort head flexes the elbowonly, since it

only crosses the elbow

Biceps brachii is our wine-opening

muscleunscrews the cork then pulls it outof the bottle

Nerve: musculocutaneous n., C5, C6, C7

Brachialis m.Lies under the bicep brachii m.

Attachments:


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Midshaft of the humerus

Coronoid processof the ulnaNOTcoracoid

Ulnar tuberosity

Action:purely a flexor of the elbowDoes NOT cross the shoulder joint, thus it

has no action on the shoulder

Does NOT go to the radius, thus it cannot

pronate or supinateNerve: musculocutaneous n., C5, C6, C7

TricepsHas 3 heads

Long head

Is most medial

Attaches to the infraglenoid tuberosity

[Long head of biceps brachiiattaches tothe supraglenoid tuberosity]

Lateral head

Lies over the spiral grooveProximal and lateral to the spiral grooveofthe humerus, which has the radial n.and

profunda brachii a.in it

Medial headDeeper, seen when long and lateral heads

are separated apart

Distal and medial to the spiral grooveof

the humerus, which has the radial n.and

profunda brachii a.in it

Radial n. and profundi brachii a. are seen when

the laternal and long heads of the triceps arespread apart

If there is a midshaft fracture of the humerus,

it would injure the radial n.and profunda

brachii a.

The 3 portions come together in a commontendonand attach to the olecranon of the ulna

Action: one of the chief extensors of the elbow

Fracture or avulsion of the olecranon process

would cause off of the triceps attachement,

thus loss of extension of the elbowAnconeus m.

A small, relatively unimportant triangular

muscle

Usually blends with the triceps near the elbow

Lies partly over the supinator on the proximal

ulna

Action: helps extend the forearm

Forearm

To orient yourself on the forearmLook for the thumb side, which is the radialor

lateralside

Look for the little finger, which is the ulnarormedialside

Use the brachioradialism. as a landmarkIt sits between the flexor and extensor

compartments

You can figure out the other muscles relativeto the brachioradialis

Cubital fossa

From lateral to medial: TANtendon, artery,nerve

Lateral: tendon of biceps brachii, which

attaches to the radial tuberosity

Middle: brachial a.

Medial: medial n.median is medial

Important orientation for taking blood pressure.Ask patient to flex the forearm, feel for thetendon of biceps brachii, and just lateral to that

you feel the pulsation of the brachial artery

Vessels of the forearm

Cephalic v.

Superficial vein

Begins on the lateral aspect of the dorsalvenous networkof the hand

Ascends along the anterolateral surface of the

forearm and arm

Anterior to the elbow it communicates withthe median cubital v.

Courses along the deltopectoral grooveand

enters the deltopectoral trianglewhere itpierces the clavipectoral fasciaand joins the

axillary v.

Basilic v.Superficial vein

Begins on the medial aspect of the dorsal

venous networkof the hand

Ascends along the medial aspect of theforearm and inferior aspect of the arm

Communicates with the median cubital v.

anterior to the elbow

Passes deeply, piercing the brachial fasciaand runs parallel to the brachial a.to the

axilla, and joins the axillary v.

Median cubital v.

Superficial vein, passing anterior to the cubitalfossa


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Joins the cephalic v.(more lateral) with thebasilic v.(more medial)Common site for venipuncture

If needle pierces through the vein it cancontact the median n.

Medial antebrachial cutaneous is slightly

medial to the medial cubital vein and could

be injured by a needle. If the needle had

gone laterally, it might have injured thelateral antebrachial cutaneous nerve

Arteries of the forearm

Brachial a.divides into 2 arteries at the cubital

fossa

Radial a.Runs laterally along the radial side of

forearm toward the thumbRuns through the anatomical snuff box

Then pierces through between the 2 heads of

the 1st dorsal interossei m.Then it forms most of the deep palmar arch

Ulnar a.Tends to be substantially larger than the

radial a.

Runs medially along the ulnar side of the

forearm toward the little finger

Gives off a short trunk called the common

interosseus trunk, which soon gives off 2branches

Anterior interosseus a.

Seen running on top of the interosseusmembrane

Accompanied by the anteriorinterosseus n., from the median n.

Posterior interosseus a.From the ventral aspect, seen going deep

into the extensor compartment

Runs w/ deep branch of radialnerve.

Continues down the forearm, accompaniedby the ulnar n.

The ulnar a. and ulnar n. cross the wristabove the flexor retinaculum, through

Guyons canal, to the palm of the hand

where it forms the ulnar a. forms the

superficial palmar archSuperior and inferior ulnar collateralarteries contribute to the collateralcirculation of the elbow on its medial aspect.

The superior ulnar collateralanastomoses with the posterior ulnarrecurrent artery (branch of ulnar) behind

the medial epicondyleThe inferior ulnar collateral

anastomoses with the anterior ulnarrecurrent artery in front of the medialepicondyle.

Nerves of the Forearm

Median n.

From the lateral (C6, C7) and medial (C8, T1)cords of brachial plexus

Innervates all the muscle of the forearm,EXCEPT

1 muscles which are innervated by the

ulnar n.

Flexor carpi ulnaris m.

Flexor digitorum profundus m., medial

PathwayEnters cubital fossa medial to the brachial a.

Passes between heads of pronator teres

Descends between flexor digitorumsuperficialis and flexor digitorum profundus

Passes through carpal tunnelto reach hand

Gives off a branch to the thenar eminence,recurrent branch of median n., C8, T1

Gives off 2 branches, seen in the ventral aspect

of the forearm

1. Anterior interosseous n.Branches from median n. in the distal

cubital fossa

Accompanied the anterior interosseus a.on the surface of the shiny interosseus

membrane

Supplies motor to deeper muscles of the

forearm

Flexor digitorum profundus m., lateral

Flexor pollicis longus

Pronator quadratus

2. Palmar cutaneous branch of median n.Branches from median n. just proximal to

flexor retinaculumPasses between tendons of palmaris longus

and flexor carpi radialis

Runs superficial to flexor retinaculum

Supplies cutaneous to palm

Ulnar n.Accompanied by the ulnar a., a branch of the

brachial a.

Only supplies motor to 1 muscles of the

forearm


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Plays a much larger role in the hand

Radial n.

From posterior cord of brachial plexus

Innervates all the extensor muscles of theforearm, PLUS one flexor, the

brachioradialis m.Pathway

Sits in the spiral grooveof the humerus,

seen between the long head and lateral head

of the triceps m.

Accompanied by the profunda brachii a.inarm

Enters cubital fossa

Descends between brachialis m. andbrachioradialis m.

At the level of the lateral epicondyle of

humerus, it divides into superficial and deepbranches

Gives off 2 branches, best seen on dorsalaspect of the forearm

1. Superficial branch of the radial n.

The thinner of the 2 branches of the radialn., which branch just superior to the

supinator m.

Best seen emerging at the lateral wrist,where it crosses over the anatomical snuff

box to the dorsum of the lateral hand

Purely a cutaneous nerve to dorsum of thehand on its lateral aspect, thumb and first

few fingers

Pathway

Passes anterior to pronator teres m.

Passes under the brachioradialis m.

Crosses over the anatomical snuff boxasit passes to the superficial aspect of the

dorsum of the hand

2. Deep branch of the radial n.

The largest of the 2 terminal branchesSupplies motor innervation to posteriorcompartment

PathwayArises from radial n. just distal to the

elbow

Pierces the supinator m.ID by thisfeature

Winds around the lateral neck of theradius

After is pierces the supinator m. itbecomes the posterior interosseus n.

It reaches the wrist joint andcarpal bones for proprioceptive

sense from these structures

Accompanied by the posterior

interosseus a.from the commoninterosseus trunk of the ulnar a.

If this nerve is tagged before dividing intoits superficial and deep branches, you

would say radial n.

If this nerve is tagged after dividing into itssuperficial and deep branches, but before

piercing the supinator m., you would saydeep branch of the radial n.

If this nerve is tagged after piercing thesupinator m., you would say posterior

interosseus n.

Note:Both the anterior and posterior interosseus

arteries are from thesamesource, the common

interosseus trunkfrom the ulnar a.

The anterior and posterior interosseus nervesare from differentsources

Anterior interosseus n.is from the median

n.Posterior interosseus n.is from the radial

n., the continuation of the deep branch of the

radial n. after it exits the supinator m.

Flexor compartment of the forearmContains the flexors and pronators of the

forearm

All muscles in this forearm compartment areinnervated by the median n.and/or ulnar n.

EXCEPT

Brachioradialis m.is innervated by the radial

n.

Median n.innervates all but 1 muscles

Ulnar n.innervates 1 muscles



(ulnar

The anterior compartment communicates withthe central compartment of the palmthrough

the carpal tunnel

Generally the fascial compartments of thelimbs usually contain fluids and infections,

thus preventing spread to other compartments


12/40

The anterior compartment of forearm is anexception due to its communication with thecentral compartment of the palm

Common flexor tendonattached to the medial

epicondyleAvulsion or fracture of the medial epicondyle

would effect the flexors of the forearm

Common extensor tendonattaches to the

lateral epicondyle

Interosseous membraneShiny, silvery membrane between radius andulna

From lateral to medial at the anterior wrist areAbductor pollicis longus m. (not a flexor, but

most lateral)

Brachioradialis m. (doesnt cross wrist, ends at

distal radius)Radial a.

Flexor carpi radialis m.

Flexor pollicis longus m.Median n.

Palmaris longus m : Gives off Palmar

aponuerosis

If damages, we getDuputyrens contracture.

Palmar aponeurosis goes overcarpul tunnel.

Flexor digitorum superficialis m. (2 of the 4

tendons)Ulnar a.

Ulnar n.


Brachioradialis m.Superficial muscle coming from lateral elbow

Attachments:Proximal 2/3 of lateral supracondylar ridge

of the humerus

Lateral surface of distal end of the radius

NOTE: it does NOT cross the wrist

Action:

Holds hand between pronation andsupination, hand shaking position (palmfacing medially)

Flexes elbow, only when it in handshaking position

Brachioradialis is our beer drinking

muscle

Condition equivalent to tenniselbow, this muscle is involved.

Commonly involved in collesfracture coz it inserts into

distal end of radius.Biceps brachii is our wine-opening

muscle

Nerve: radial n., C5, C6, C7

This is the only flexor that is innervated by

the radial n., which normally innervates the

extensors

Superficial flexor compartment

Common flexor tendonCommon attachment on the medial epicondyle

of the flexor muscles

To help remember how the muscles are

running in the superficial flexor compartment

Turn your palm up, hook your thumb behind

the medial epicondyle and spread your fourfingers over the forearm

Index finger = pronator teres m.Middle finger = flexor carpi radialis m.

Ring finger = palmaris longus m. (ifpresent)

Little finger = flexor carpi ulnaris m.

Flexor carpi radialis m.

Extends from medial epicondyle to the thumb

Its belly is just medial to brachioradialis

Attachments:Medial epicondyle of humerus

Base of 2ndmetacarpalAction: flexes and abducts hand at wrist

Nerve: median n., C6, C7

Radial pulse is lateral to this.Palmaris longus m.

Extends from medial epicondyle to the centerof the wrist

Its belly lies half under flexor carpi radialis m.

Has a very small muscle belly with a long thintendon running to the middle of wrist

When you pop up the tendons at the wrist,you see 2 tendons in the middle at the wrist

The medial one of the 2 is the palmaris

longus m.The lateral one of the 2 is the flexor carpi

radialis m.

10% of people dont have this muscle

Similar to plantaris m.since it contributesvery little to function, and is excellent for

doing tendon grafts


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Attachments:Medial epicondyle of humerusDistal half of flexor retinaculum and palmar

aponeurosis

Action:Flexes hand at wrist

Tightens palmar aponeurosis



Most medial of the superficial muscles

Extends from the medial epicondyle to littlefinger side of wrist

Has 2 heads: humeral and ulnar heads

Attachments:Humeral head: medial epicondyle of humerusUlnar head: olecranon and posterior border

of ulna

Pisiform

Hook of hamate5

thmetacarpal

Action: flexes and adducts hand at wrist

Nerve: ulnar n., C7, C8

Pronator teres m.

The short muscle running from the medial

epicondyle to under the brachioradialis m.

Attachments:Medial epicondyle of humerusCoronoid process of ulna

Middle of lateral surface of radiusAction: pronates forearm (turns palm

downward) and flexes elbow


Deep flexor compartment

Flexor digitorum superficialis m.Lies under flexor carpi radialis m. and

palmaris longus m.

Has 2 heads: humoroulnar and radial heads

IDd byits 4 tendons passing under the flexor

retinaculumAttachments:

Humeroulnar head:

Medial epicondyle of humerus

Coronoid process of ulnaRadial head:

Superior half of anterior border of radius

Action: flexes fingers

Nerve: median n., C7, C8, T1

Flexor digitorum profundus m.

Lies deep to flexor digitorum superficialis m.

IDd by its 4 tendons passing under the flexorretinaculum

Attachments:

Proximal of medial and anterior surface of

ulna and interosseous membraneBases of distal phalanges of medial 4 digits

Action: flexes fingers, assists with flexion ofhand

Nerve: has dual innervationMedial part:ulnar n., C8, T1

Lateral part: median n., C8, T1

If a tag is in the belly of this muscle and youare asked what is the innervation for this

muscle?, you would say median and ulnar

nerves

If a tag is only in the lateral part, you wouldsay median n.

Flexor pollicis longus m.Lies deep along the lateral aspect of ventral

forearm

Looks feathery

Attachments:Anterior surface of radius and interosseous

membraneBase of the distal phalanx of thumb

Action: flexes thumb

Nerve: anterior interosseous n.from mediann., C8, T1

Pronator quadratus m.Lies in the proximal of forearm, deep to

flexor digitorum profundus m. and flexor

pollicis longus m.

Attachments:

Distal of anterior surface of ulnaDistal of anterior surface of radius

Action: pronates forearm, binds radius andulna together

Nerve: anterior interosseous n.from median

n., C8, T1

Extensor compartment of the forearm

Contains the extensors and supinators of theforearm

All muscles in this forearm compartment areinnervated by the radial n., directly or by its

deep branch

With palm down, orient yourself by locating the

brachioradialis m.


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Runs toward the thumb, as the most lateral

muscle

Its the only flexor muscle innervated by the

radial n.

From lateral to medial at the posterior wrist are

Abductor pollicis longus m.Extensor pollicis brevis m.

Extensor carpi radialis longus m.

Extensor carpi radialis brevis m.Extensor pollicis longus m.

Extensor indicis m. (under lateral extensor

digitorum tendons)

Extensor digitorum m. (4 tendons)Extensor digiti minimi m.

Extensor carpi ulnaris m.

Superficial extensor compartment

Common extensor tendonCommon attachment on the lateral epicondyle

of the extensor muscles

Extensor carpi radialis longus m.Lies next to brachioradialis m.

Its belly and long tendon lie over extensorcarpi radialis brevis m.

Attachments:Lateral supracondylar ridge of humerus

Base of 2nd

metacarpal

Action: extends and abducts hand at wrist

Nerve: radial n., C6, C7

On ID, you must write the full name of thismuscle, all 4 words

Extensor carpi radialis brevis m.Lies underneath extensor carpi radialis longus

m.

Longus is always on top of brevis

Attachments:Lateral epicondyle of humerusBase of 3rd metacarpal

Action: extends and abduct hand at wrist

Nerve: deep branch of radial n., C7, C8In classic tennis elbow, this muscle along w/Extensor digitorum is damaged.

Extensor digitorum m.In the extensor compartment, there is NOsuperficialis or profundus

IDs by its 4 tendons, one of which is about the length of the forearm

Attachments:

Lateral epicondyle of humerus

Extensor expansion of medial 4 digits

Action:Extends 5

thdigit

Nerve: posterior interosseous n., C7, C8,

from the deep radial n.

Extensor digiti minimi m.Its thin tendon is medial to the 4 tendons of

extensor digitorum m.Attachments:

Lateral epicondyle of the humerus

Extensor expansion of the little finger

Action:Extends the little finger

The Austin Powers muscle, with his little

pinky raised up

Nerve: posterior interosseous n., C7, C8,from the deep radial n.

Extensor carpi ulnaris m.Its tendon runs to the ulnar wrist, medial to

extensor digiti minimi m.

Attachments:Lateral epicondyle of humerus, and posterior

border of ulnaBase of 5

thmetacarpal

Action:

Extends and adducts the hand at wrist



Outcropping musclesof the deep extensorcompartment

The outcropping muscles pass over the tendonsof extensor carpi radialis longus and brevis mm.

Abductor pollicis longus m.One of the outcropping muscles

Start deep and emerge near the radial wrist

Lies superior and lateral to extensor pollicis

brevis m.

Passes over the tendons of

Extensor carpi radialis longus m.Extensor carpi radialis brevis m.

Attachments:

Posterior surface of ulna, radius, and

interosseous membraneBase of 1

stmetacarpal

Action:Abducts and extends thumb

Remember: abductors are always on the

outside


15/40


Extensor pollicis brevis m.One of the outcropping muscles

Lies inferior and medial to abductor pollicislongus m.

Passes over the tendons of

Extensor carpi radialis longus m.Extensor carpi radialis brevis m.

Attachments:

Posterior surface of radius and interosseous

membraneBase of proximal phalanx of thumb

Action:Extends thumb



Extensor pollicis longus m.One of the outcropping muscles

ID by its tendon seen running to the thumb

Tendon lies medial to extensor carpi radialisbrevis m. and lateral to extensor indicis

Attachments:

Posterior surface of middle 1/3 of ulna andinterosseous membrane

Base of distal phalanx of thumb

Action:Extends thumb


Extensor indicis m.

ID by

Tendon seen running to the index finger

Most medial muscle belly of the deep

extensors

Tendon just medial to extensor pollicislongus m. at wrist

Short muscle covered completely by the

extensor digitorum m.Attachments:

Posterior surface of ulna and interosseousmembrane

Extensor expansion of index finger

Action:

Extends index finger


Supinator m.

Wraps around the proximal radius

Attachments:Lateral epicondyle of the humerus, radial

collateral and anular ligaments, supinatorfossa, and crest of the ulna

Lateral, posterior, and anterior surfaces ofproximal 1/3 of radius

Action:Supinates forearm = rotates radius to turn

palm anteriorly

Nerve: deep radial n., C5, C6Seen piercing through the supinator m.

Hand

Vessels of the hand

Superficial palmar archcoming from the

ulnar a.Anastomoses with the radial a., but it is

primarily formed by the ulnar a.

the arch is completed on the radialside by the superficial palmar

branch of the radial artery

The radial artery is the main sourceof blood to the deep palmar arterial

arch, which is completed on the

ulnar side by the deep branch of the

ulnar artery.

o runs deep in the hand, alongwith the deep ulnar nerve

Nerve supply of the hand

Motor supply to the handAll the muscle in the hand are innervated by

the deep branch of ulnar n.EXECPT for

LOAF muscles, which are innervated by the

median n.

Lateral 2 lumbricals

Plus, the thenar eminence, by the recurrentbranch of median n.

Opponens pollicis m.

Abductor pollicis brevis m.Flexor pollicis brevis m.

Digital branches of the ulnar n.

The ulnar n. andulnar a.do NOT pass underthe flexor retinaculum

They pass over the retinaculum through

Guyons canal

Cutaneous supply to the digitsMedial n.supplies cutaneous to the first 3 digits


16/40

Ulnar n.supplies cutaneous to the medial 1

digits

Flexor compartment of the hand

Flexor retinaculum

Tendon sheath that passes over the carpaltunnel

Carpal tunnel

If an instrument is placed passing through thetunnel, you would say carpal tunnel

If a pin is in the tendon over the tunnel, youwould say flexor retinaculum

Guyons tunnel

Ulnar n. and a.pass through this tunnel

Thenar eminence, big muscle pad at base ofthumb

Nerve: recurrent branch of median n., C8,

T1A branch of the median n.

A motor nerve to the thenar eminence

Seen crossing over flexor pollicis brevis m.

toward abductor pollicis brevis m.

If the recurrent branch is cut, the person losesthe ability to grasp, thus it is called themillion dollar nerve

Consists of 3 muscles

Abductor pollicis brevis m.

Outermost of the 3 since it abducts

Action: abducts thumb and helps oppose it

Flexor pollicis brevis m.Medial to abductor pollicis brevis m.

(closer to palm)

Action: flexes thumb

Opponens pollicis m.Under the other two

Action: draws thumb

Flexor pollicis longus m.

Its tendon is seen running through the thenar

eminence

Hypothenar eminence, muscle pad at base oflittle fingerNerve: ulnar n.

Consists of 3 muscles

Abductor digiti minimi m.

Outermost of the 3 since is abducts

Action: abducts little finger

Flexor digiti minimi brevis m.Medial to abductor digiti minimi m.

Action: flexes little finger

Opponens digiti minimi m.

Under abductor digiti minimi m.

Action: draws little finger toward thumb

Flexor digitorum superficialis m.

The most superficial tendons seen in the palmThese tendons run only to the middle phalanxwhere they splits, and the flexor digitorum

profundus tendons passes between on theirway to the distal phalanx

Flexor digitorum profundus m.Tendons that lie under the flexor digitorum

superficialis

These tendons give rise to the lumbricalsThese tendons run to the distal phalanx

Lumbrical mm.Seen connecting the tendons of the flexor

digitorum profundus in the palm

Nerves:Lateral 2 lumbricals: median n.Medial 2 lumbricals: ulnar n.

Palmaris brevis m.A tiny muscle that passes over proximal aspect

of the hypothenar eminencewont be tested

Adductor pollicis m.Has 2 heads

Oblique head

Transverse head

Nerve: ulnar n., even though it on the lateralside of the palm

Palmar interossei mm.Very deep, not easy to see

Action: adductdigitsPAD Palmars are for ADductions

Dorsal interossei mm.

Seen from dorsum of hand, easier to see thanpalmar interossei

1stdorsal interossei

Broad superficial muscle between thumb andindex finger metacarpals

Has 2 heads at wrist

Pierced by radial a.between the 2 heads ofthe 1

stdorsal interossei, near wrist

Action: abductdigitsDAB Dorsals are for Abductions

Superficial palmar arch

Formed mainly by theulnar a.

Forms an anastomosis with the radial a.


17/40

If asked where is this vessel is mainly from,you would say ulnar a.

Deep palmar archYou wont see

Formed mainly by the radial a.

Digital branches of the median n.Branches in lateral aspect of palm near the

base of the first 2 fingersMedial n. supplies cutaneous to the lateral 3 fingers

Digital branches of the ulnar n.Branches in medial aspect of palm near the

base of the little finger

Ulnar n. supplies cutaneous to the medial 1 fingers

Superficial radial n.Seen crossing over the anatomical snuff box

Supplies only cutaneous to lateral dorsum ofthe hand

It does NOT supply the nail beds, which are

supplied by the medial and ulnar nn.

Ulnar n.Seen medial to the proximal end of the

hypothenar eminence

Runs over the carpal tunnel, NOT through it

Runs along with ulnar a.

Cutaneous supply to last 1 fingers, plus their

nail beds

Median n.

Runs through the carpal tunnel

Cutaneous supply to first 3 fingers, plus

their nail beds

Flexor retinaculumLigament that forms the roof of the carpal

tunnel

Carpal tunnelHas 9 tendons passing through it

4 from flexor digitorum superficialis m.

4 from flexor digitorum profundus m.1 from flexor pollicis longus m.

Ulnar and Radial Bursa also found

Flexor pollicis longus is enclosed inits own synovial sheath in the

carpal canal, called the radial

bursa

The tendons from flexor digitorumprofundus and flexor digitorum

superficialis are all contained in a

common synovial sheath, called the

ulnar bursa

Median n.is sandwiched in between thesetendons

Carpal tunnel syndromeaffects the median

n.

Ulnar n.does NOT pass through the carpal

tunnel, thus it is not affected in carpal tunnelsyndrome

Extensor compartment of the hand

Dorsal interossei mm.Seen on the dorsal aspect of the hand between

the long metacarpal bones

There are 4 dorsal interossei mm.

1stdorsal interosseus m.

Broad superficial muscle between themetacarpals of the thumb and index finger

Has 2 heads at wrist

Pierced by radial a.between the 2 heads of

the 1stdorsal interossei, near wrist

Action: abductdigitsDAB Dorsals are for Abductions

In ID, you must say 1stdorsal interosseus

musclenot just interosseus muscle

Anatomical snuff boxLies between the tendons of

Laterally: abductor pollicis longusand

extensor pollicis brevisMedially: extensor pollicis longus

Floor: scaphoid boneThe scaphoid bone is commonly fractured,

and particularly prone to avascular

necrosis

Seen when thumb is fully extended (pointing

up)

Radial a.passes through the snuff box

Superficial branch of the radial n.passes

over the snuff boxDorsal expansion = Extensor expansion

The shiny tendon through which the tendons

of the fingers pass on the dorsal aspect of the

fingers

Lumbricalsand interosseiinsert into thesides of the dorsal expansion


18/40

Most commonly dislocated carpal bone is

Lunate, most commonly fractured is

scaphoid.

Coracoclavicular ligament is very

strong. When this ligament is torn, a

patient will have a third degreeseparated shoulder

Axis of rotation @ distal radio-ulnar

joint is styloid process of ulna

Most shoulder dislocations still occur

in the anteroinferior direction, with

the humeral head dislocating forwardand downward.

A dislocated shoulder occurs when the

humeral head slips out of the labrum;

this often happens in the anterior

direction

A syndesmosis is a fibrous membrane

or ligament that joins two bones. The

connections between the shafts of the

radius and ulna and the tibia and

fibula are 2 classical examples of

syndesmoses


19/40

Lower Limb

Hip joint more stable than Shoulder joint

because head of femur is more inside the

acetabulum.Articulur cartilage is hyaline articulage here

TMJ is synovial joint not covered by

hyaline cartilage.Head of femur supplied by small branch ofobturator artery.

Illifemoral Ligament: strongest of the body

Prevents hyperextension of hip joint.Also called ligament of Bigelow

Attached from ASIS to inter

tronchanteric line.

Prevents backward falling of the body

Pubofemoral ligament: limits abduction and

lateral rotationIlliopsoas bursa.

Ischiofemoral ligament: weakest of all ligament.

Limits medial rotation.

It is the ligament that is most

likely to be injured if the femur is

dislocated posteriorlyIllipsoas attached to lesser trochanter

Hip joint can be dislocated posterioly which can

more likely injure sciatic nerve.(Slide 11 Dr. SamD)

(Slide 12: D)Medial and lateral femoral circumflex arteriesprovide the anastomoses around neck of femur

Medial circumflex femoralis the chief

source.(Slide 16: D)

Thigh

External oblique aponeurosis

Inguinal ligament, formed by the lower aspectof the external oblique aponeurosis

Spermatic cord[testis removed]Cross-section of penis near pubic symphysisshows

Corpus cavernosum

Corpus spongiosum, with spongy urethra

Deep fasciaA stocking-like covering over the entire lower

limb

Separates muscles from each other and investsthem

Prevents bulging of the muscles duringcontraction

Makes the muscles more efficient in pumpingblood toward the heart

Divided into 2 regions

Fascia lata, the deep fascia of the thigh

Crural fascia, the deep fascia of the leg

Saphenous ring (opening)A deficiency in the deep fascia lata inferior to

the medial part of the inguinal ligament

Great saphenous v.passes through the ring to

enter the femoral v.

Iliotibial tractThe conjoint aponeurosis of the

Gluteus maximus m.

Tensor fascia lata m.

Extends from the iliac tubercleto the lateral

condyle of the tibia

Femoral triangleBounded by

Base of triangle, superior aspect: inguinal

ligament, which ends medially as the lacuna

ligamentMedial: adductor longus m.

Lateral: sartorius m.

Floor: iliopsoas m.laterally, and pectineus m.

mediallyApex: the beginning of the adductor canal, at

the junction of sartorius and adductor longus

mm.In order from lateral to medial

N Femoral n.

A Femoral a.

V Femoral v.

E Empty space

L Lacuna ligament or Lymph nodes

Femoral n., L2, L3, L4Breaks up very quickly into a series of nervebranches

If all its branches were tagged as one group,

you would say its the femoral nerveOutside of Femoral sheath

Saphenous n.is one of the many branches ofthe femoral n.

Supplies cutaneous innervation to the medial

aspect of the foot

It can be IDs at 2 pointsa. As it enters the adductor canalat theapex of the triangle along with the femoral

a. and v.


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NOTE: the saphenous n. does NOT exit

the adductor hiatus

b. As it passes anterior to the medialmalleolus, accompanied by the great

saphenous v.

Femoral a.A continuation of the external iliac a., which

changes its name to the femoral a. once it

passes under the inguinal ligamentRuns with the femoral v.

Enters the adductor canal along with thefemoral v. and saphenous n.

Profunda femoris a. = Deep artery of thighA large branch off the femoral a., soon after it

passes under the inguinal ligament

Parallels the course of the femoral a., but goesdeeper

The main blood supply to the thigh

Also supplies the Hamstring compartment Branches are known as arterial

perforators.

The femoral a. itself contributes very little

direct blood supply of the thigh. It continueson as the popliteal a. which supplies the leg

Profunda femoris a. divides into 2 branches

Medial circumflex femoral a.The most important artery of the cruciate

anastomosis, which supplies the head and

neck of the femurLateral circumflex femoral a.

descending branch of thelateral circumflex femoral

artery anastamoses with both

the descending genicular

branch of the femoral artery as

well as the lateral superior

genicular branch of the

popliteal artery

o These connectionsprovide collateralcirculation to the knee

and leg

Cruciate anastomosisForms a cross

It is the blood supply to the head and neck ofthe femur

Superior part of the cross: a branch of the

inferior gluteal a.

Lateral part of the cross: lateral circumflex

femoral a.

Medial part of the cross: medial circumflex

femoral a.

Inferior part of the cross: 1stperforating

branch of the profunda femoris a.

Femoral v.Runs with the femoral a.

You can tell that its the femoral v. (and not

the great saphenous v. because the femoral v.is deeper and passed through the adductor

canal along with the femoral a. and saphenous

n.

Great saphenous v.A superficial vein, thus it does NOT enter the

adductor canal

Accompanied by the saphenous n.,from theknee to the foot

PathwayOriginates from the medial aspect of the

dorsal venous archPasses anterior to the medial malleolus

Passes posterior to the medial condyle of the

femurComes through the saphenous ringin the

fascia lataEmpties into the femoral v.

Empty space

Allows for veins to expand so more blood can

return to heart.Has the femoral ring and the femoral canal

A potential site for femoral hernias, whereparietal peritoneum comes through

Hernias Tend to be U- shaped in

natureMore common in women

Pieces of bowel can come down with the

transversalis fascia pushing through.

Pubic tubercle is landmark

Any hearnia above it is called Inguinal

Any hernia below it is called femoral

They tend to be strangulated for 2 reasons

There is a sharp boundary on the

lacunar ligament

Modification of inguinal ligament

This can cause strangulation of

femoral hernia which can result in

necrosis of intestine.


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Accessory obturator artery: present

sometimes which can cause bleeding

whilecutting the lacunar ligament.Branch of inferior epigastric

artery.

The saphenous ring where the great

saphenous vein enters, where it can be

caught up

Perforating veins are first ones to getvalve failures.

Lesser (Small) saphenous vein more

likely to be varicosed on calf muscles.

Great saphenous more like to varicose on

the medial side of thigh.

An obturator hernia is a protrusion of a

loop of bowel through the obturator

canal.

with a loop of ilium passinginferiorly, posterior to thesuperior pubic ramus

Lacuna ligamentHas a sharp lateral edge that can cause

strangulation of a femoral herniaWont have to ID, but know about it

Adductor canal = Hunters canalRuns from the apex of the femoral triangle to

the adductor hiatusdistal to the attachment of

the adductor magnus m. on the adductor

tubercle of the femur

Between the vastus medialis m. and theadductor muscles, and converted into a canalby the overlying sartorius m.

Has the following that passes through it

Femoral a.

Femoral v.

Saphenous n.

When the femoral a. and v. exit through theadductor hiatus, they change their names tothe popliteal a. and v.Note: the saphenous n., which entered the

adductor canal, does NOT exit the adductorhiatus

Anterior Thigh

Femoral n., L2, L3, L4Innervates the

Quadriceps femoris mm.

Sartorius m.

Pectineus m., which is also innervated bythe obturator n.

Branches to form the saphenous n.Supplies cutaneous innervation to the medial

aspect of the foot

It can be IDs at 2 pointsa. As it enters the adductor canalat the

apex of the triangle along with the femoral

a. and v.NOTE: the saphenous n. does NOT exit

the adductor hiatusb. As it passes anterior to the medial

malleolus, accompanied by the great

saphenous v.

Sartorius m.

Attachments:

ASIS, then crosses anterior thigh

Pes anserinus, on the medial aspect of thetibia

Actions: puts you in a tailors position, a

cross-legged positionYou need to know the difference between its

action at the hip and its action at the knee

If you asked for the sartorius action at the

hip, you would say

Laterally rotates hip

Flexes hip

Abducts hip

If you asked for the sartorius action at theknee, you would say

Medially rotates knee

Flexes knee Sartorius is the roof of the

adductor canal.

The sartorius m. divides the muscles of the

anterior compartment of the thigh into 2groups

1. Anterior group

Femoral n.innervates everything in the

anterior thigh

2. Abductor groupObturator n.innervates everything in the

adductor region, with 2exceptionsPectineus m.is innervated by 2 nerves

Obturator n.

Femoral n.

Adductor magnus m.has 2 portions,each with a different nerve

Tibial n.innervates the hamstring

portion

Obturator n.innervates the adductor

portion


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Quadricepsfemoris mm.consist of 4 muscles

1. Rectus femoris m.You can see that its the rectus femoris

because it is straight

AttachmentsAIIS, anterior inferior iliac spine

Rectus femoris m. is the only quadriceps

muscle that crosses the hip, thus its the

only quadriceps that can also flex the hip2. Vastus lateralis m.

3. Vastus intermedius m.Lies under rectus femoris m.

4. Vastus medialis m.

Quadriceps tendonis the common tendon ofall 4 muscles at the knee

Attaches to the base (superior aspect) of thepatella ; becomes the patellar tendon.

At the apex (inferior aspect) of the patella it

continues as the patellar ligamentwhichattaches to the tibial tuberositynot

quadriceps tendon

The quadriceps tendon/patellar ligamentinserts into the tibial tuberosity

Main action: Extensionat the knee joint

Rectus femoris m.also crosses the hip, thus

it can also flexthe hip

Nerve: femoral n., L2, L3, L4

Knee Jerk: tests the value of L3 L4

Iliopsoas m.

Lies just medial to the sartorius originFrom this perspective, only small part of its

most inferior portion is visible as it inserts intothe lesser trochanter of the femur

Attachments:

Psoas major: sides, discs and transverseprocesses of T12-L5

Psoas minor: sides and discs of T12-L1

Iliacus m.: iliac crest and fossa

Insertion: lesser trochanter of the femurThe iliopsoas m. is the only muscle that

attaches at the lesser trochanter of thefemur

Nerve: L1, L2, L3

Medial Thigh

Action: adducts thigh

Nerve:obturator n

Travels thru obturator foramen

accompanied by obturator artery

Can be compressed in females by

ovarian enlargement (Poly cystic ovarian

disease)

Pain in medial side of legSeen under the adductor longus m.

Innervates all of the adductor groupwith 2

EXCEPTIONS

Pectineusm. is also receives innervated by

the femoral n.

The hamstring portion of adductor magnusm.is innervated by the tibial n.

Adductor longus m.Most superficial of the adductor muscles, just

lateral to the gracilis m.

Most commonly affected muscle in groin

strain

The femoral artery is superficial to

adductor longus, while the deep femoralartery is deep to adductor longus.

Pectineus m.

Lies just lateral to adductor longus m.

Lies just medial to the femoral vein, formingthe medial floor of the femoral triangle

Has dual innervation

Femoral n.

Obturator n.

If asked What is the nerve supply topectineus muscle?, you must write both

nerves femoral nerve and obturator nerveAdductor brevis m.

Lies under adductor longus m.

Obturator n.passes anterior to adductorbrevis m. and sends a posterior branch through

the muscle

Obturator externus m.Lies under the pectineus m.

Its fibers run transversely, left to right

Adductor magnus m.A huge muscle

The upper aspect lies under adductor brevis m.

Seen more clearly from the posterior view

Nerves:Has 2 portions, each with a different nerve

Tibial n.innervates the hamstring portion

Obturator n.innervates the adductorportion

Forms the Adductor Hiatus

Gracilis m.


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The most medial muscle of the thigh

Runs in a straight courseAttachments:

Pubis

Pes anserinuson the medial aspect of the

tibiaAction:

Crosses both the hip and knee joints, thus it

Flexes the kneeSlightly adducts the thigh

Innervated by Obturator nerve

Gluteal Region

Tensor fascia lata m.Lies within the iliotibial tract at the superior

end

Considered to be part of the gluteal regionbased on its innervation, but it is seen in the

anterior thigh

Nerve: superior gluteal n.Tensor fascia lata isNOT supplied by the

femoral n.even though it seems to be part of

the anterior region

In fact it is part of the gluteal region, not theanterior thigh region

Gluteus maximus m.

Main action:forcedextension, NOT ordinaryextension as when walking

Extends the thigh when rising from sitting or

climbing

Attachments:2/3into the iliotibial tract

1/3into the gluteal tuberosityof the femur

Considered part of the medial group due to itsother actions:

Laterally rotates thigh

Extension of hip Joint: Major action!!

Nerve: inferior gluteal n (L5, S1, S2)A long nerve that exits the pelvis below thepiriformis m. through the greater sciatic

foramen to reach the ventral aspect of the

gluteus maximus m.

Dont give any intramuscular injection until

6yrs of age coz this muscle doesnt develop

until 6yrs of age.

Injection giving insuperiolateral quadrant.

o Nerve injured can besuperior gluteal

nerve.

Lateral group of muscles in the gluteal region

The actions of these muscles areChief stabilizers of the hip

Medial hip rotators

Abductors of the thigh

1. Gluteus medius m.A fan-shaped muscle that lies just superior to

the piriformis m.

Attachment: greater trochanter

Nerve and blood: superior gluteal n. and a.,which lies between the gluteus medius m. and

gluteus minimus m.The superior gluteal n. and a. exit the pelvis

above the piriformis m. through the greater

sciatic foramen

2. Gluteus minimus m.

Lies under the gluteus medius m., also just

superior to the piriformis m.

Attachment: greater trochanter

Nerve and blood: superior gluteal n. and a.,which lies between the gluteus medius m. and

gluteus minimus m.

Main action of gluteus medius and minimus:The chief stabilizers of the hip joint

If asked what is the main action of gluteusmedius and minimus?, you would say they

are the chief stabilizers of the hip joint

They are responsible for holding the weight

over the hip joint, keeping the hip jointslevel when a leg is lifted off the ground

Other actions of gluteus medius and minimus:Medially rotates thigh, these are the medial

rotators of the thigh

Abducts thigh

Superior gluteal n. innervates

Gluteus medius m.

Gluteus minimus m.

Tensor fascia lata m.

If the superior gluteal n.is injured, we losethe 2 muscles that are the primary stabilizes of

the hip joint, causing a condition called

Trendelenburg signInjury to the superior gluteal n. is very

commonly seen in poliomyelitis

To test, stand behind patient, place your handson their hips, eye level with their pelvis, thenasked the patient to stand on one leg.

If the unsupported pelvis goes upward, thats

normal.


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If the unsupported pelvis descends, thats a(+) Trendelenburg sign. It indicates a weakgluteus medius m. on the supported side

Patient will fall toward the opposite side of

the lesion

Medial group of muscles in the gluteal region

The actions of these muscles are

Lateral hip rotatorsAbductors of the thigh

1. Piriformis m.Nerve: nerve to piriformis

A key muscle to the gluteal region

Anything that exits above the piriformis is

the superior gluteal n., a., v.

Everything else exits below the piriformis,

including

Inferior gluteal n., a., v.

Sciatic n., L4, L5, S1, S2, S3

Internal pudendal a. and v.Pudendal n.

2. Superior gemellus m.Lies just inferior to the piriformis m.

Nerve: nerve to obturator internus

3. Tendon of obturator internus m.Lies just inferior to the superior gemellus m.

Nerve: nerve to obturator internus, which

also supplies superior gemellus m., above it

Remember: obturator internus m. is the onlymuscle that passes through the lesser sciatic

foramen

If asked whichmuscle passes through thelesser sciatic foramen?, you would say

obturator internus muscle

4. Inferior gemellus m.Lies just inferior to the tendon of obturator

internus m.Nerve: nerve to quadratus femoris

5. Quadratus femoris m.Lies just inferior to the inferior gemellus m.

Nerve: nerve to quadratus femoris, whichalso supplies inferior gemellus m.

NOTE: The gemellus muscles receive theinnervation of the muscle below them

Sacrotuberous ligament

Sacrospinous ligament, deep to thesacrotuberous ligament

Exiting between these 2 ligaments are the

Internal pudendal a. and v., blood supply to

the perineum

Pudendal n., S2, S3, S4, nerve supply to the

perineum

These 3 exit via the greater sciatic foramenand reenter via the lesser sciatic foramen,traveling within Alcocks canal

So if you see vessels or a nerve passingbelow the sacrotuberous ligament, you know

they are the internal pudendal a. and v., and

pudendal n.


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Posterior Thigh

Sciatic n.The largest nerve in the body

Innervates

Posterior thigh musclesEverything from the knee down

Runs down the posterior leg

Formed from by the joining ofLumbosacral trunk, L4, L5

S1, S2, S3

Composed of 2 nerves which divide into the

Tibial n., the larger of the 2, and more

medial

Common peroneal n.

It important to orient yourself so you can tell

medial from lateral, since the nerve runningmedially has to be the tibial n., and the nerve

running laterally has to be the common

peroneal n.

Tibial n.Runs more medially down the thigh to thecenter of the popliteal fossa

Innervates 2 main regions1. All the posterior thigh muscles, such as the

hamstrings, EXCEPT

Short head of biceps femoris m., which is

innervated by the common peroneal n.

Adductor portion of adductor magnus

m., which is innervated by the obturator n.2. All the posterior compartment of theleg, which are the plantar flexors

After passing posterior to the medialmalleolus, the tibial n. divides into

Lateral plantar n.

Medial plantar n.

If the tibial n. is injured, the person cant

plantar flex the ankle, which means they cant

lift their heel, and the heel will drag along the

ground, a condition called a shuffling gait

Common peroneal n.Runs down the thigh to the lateral aspect of the

knee

Wraps around the neck of the fibula, and at

this point is very superficial and, thus, easily

prone to injury

Innervates1. Only one musclein the posterior thigh

short head of biceps femoris m.

2. All the muscles of anterior and lateral

compartments of leg

In the leg the common peroneal n. divides into2 nerves

Deep peroneal n.,innervates the anterior

compartment of legDorsiflexes the ankle

Inverts the foot

Superficial peroneal n.,innervates thelateral compartment of leg

Everts the foot

Weakly plantar flexes the ankle

If the neck of the fibula is tagged, and you areasked, What happens if the bone is fractured

at this point, you would say the commonperoneal nerve is damaged

If the common peroneal n. is injured, theperson loses their deep and superficial

peroneal nn., thus losing both the anterior and

lateral compartments. The result is that theycant dorsiflex the ankle, cant extend the toes,

and cant evert the foot, which means they

cant lift the foot or toes, and their toes will

drag along the ground, a condition called foot

drop

To compensate and avoid dragging their toes,the person develops a gait in which they lift

their leg very high

Foot drop = common peroneal n. damage =

fibular fractureHamstrings

To qualify as a true hamstring muscle, the

muscle must

a. Attach at the ischial tuberosity

b. Cross both the hip joint and knee joint, thusthey

Extend the thigh

Flex the knee

Nerve: tibial n.

The hamstrings consist of 3 muscles

1. Long head of the biceps femoris m.Most lateral muscle of the 3 hamstring

muscles

Attachments:Ischial tuberosityHead of the fibula, on lateral knee

Note: the short head of the biceps femoris m.is NOT a true hamstring

To ID, you must say long head or shorthead of the biceps femoris muscle


26/40

2. Semitendinosus m.Attachments:

At the ischial tuberosity, it is just medial to

the biceps femoris m.

Pes anserinusat the medial tibia

To ID, notice that it half muscle and halftendon

3. Semimembranosus m.

Attachments:Ischial tuberosity

Medial tibia, superior to the pes anserinus,

NOT in it

Lies immediately under semitendinosus m.

To ID, notice that is half membranous andhalf muscle

Short head of the biceps femoris m.

Is NOT a true hamstring muscle since itDoes not attach at the ischial tuberosity

Does not cross the hip joint

Nerve: common peroneal n.It is important in that it is the only muscle in

the posterior thigh that receives the commonperoneal n.

The true hamstrings are innervated by thetibial n.

Adductor magnus m.Is part of the adductor region, NOT posterior

thigh, however, it can be seen most clearly

from the posterior aspect

It has 2 portionsAdductor portion

More superior portion, with fibers running

toward the adductors

Attachments:

Inferior ramus of the pubis

Gluteal tuberosity and linea aspera

Nerve: obturator n.

Hamstring portionMore inferior portion, with aprominent

tendon

Attachments:Ischial tuberosity

Adductor tubercle of the femur

Nerve: tibial n.

Adductor hiatus

Formed at the junction of the adductor portionand hamstring portion of the adductor magnus

m.

The opening is just superior to the adductortubercle of the femur

You need to be able to differentiate betweenartery, vein, and nerve at the apex of thefemoral triangle, and at the adductor hiatus

At the adductor hiatus, the popliteal v.is themost superficialvessel, and the popliteal a.

lies beneath the vein

At the apex of the femoral triangle, the

femoral a.is the most superficial, and the

femoral v.lies beneath the artery, which isvery unusual in the body

After the femoral a. and v.pass through theadductor canal, they exit the adductor hiatus as

the popliteal a. and v., with the popliteal v. as

the most superficial vessel

Knee joint

Orient yourself to find the 3 bones of the kneejoint

Femur

TibiaFibula, located on the lateral aspect

Femur

Lateral condyleIDs by locating the fibula below it

Medial condyle

Tibia

Lateral condyleIDs by locating the fibula beside it

Medial condyle

Tibial plateau

On the anterior aspect of the flexed knee

Lateral meniscus, under the lateral condyle

Medial meniscus, under the medial condyleThe medial meniscus is more often injuredbecause it is NOT mobile since it is attached to

the medial collateral ligament

The menisci are made out of fibrocartilage

Anterior cruciate ligament, ACLAttachmentsthese are tested in the USMLE

From anterior surface of the tibial plateau

To the medial aspect of the lateral condyleIf the anterior cruciate ligament were tagged,

and it asked what action does this ligament

help to prevent?, you would sayhyperextensionof the knee joint

The ACL prevents the tibia from slidinganteriorly forward

Prevents the femur fromsliding backwards in

relation to tibia.


27/40

Not attached to anymenisci.

The anterior cruciate ligament is 4 times more

likely to be injured than the posterior cruciate

ligament

To test, do an anterior draw sign

On the lateral aspects of the knee, the collateral

ligaments prevent any excessive adductive orabduction of the knee

Medial collateral ligament, MCL = Tibial

collateral ligament

Attaches to the medial meniscus, which in

turn attaches to the anterior cruciate

ligament, producing the unhappy triad

A lateral blow to the knee, when the knee isflexed and the foot is firmly planted on the

ground, can tear the medial meniscus and push

it medially and tear the anterior cruciate

ligament, which in turn can tear the medialmeniscusthus the unhappy triada very

common sports injury

Lateral collateral ligament, LCL = Fibular

collateral ligament

The tendon of thepopliteus m.passesunderneath the lateral collateral ligament,

which separates the lateral collateral ligamentfrom the lateral meniscus

Thus, the lateral collateral ligament is NOT

attached to the lateral meniscus, thus leaving

the lateral meniscus much more mobile and farless prone to injury than the medial meniscus.

An injury to the lateral collateral ligament

does not effect the lateral meniscus

On the posterior aspect of the extended knee

Posterior cruciate ligament, PCLAttachments

From posterior surface of the tibia

To the medial aspect of the medial condyle

If the posterior cruciate ligament were tagged,

and it asked what action does this ligamenthelp to prevent?, you would sayhyperflexionof the knee joint

The PCL prevents the tibia from slidingposteriorly backward

Prevents the femur fromsliding forward on the tibia

Posterior meniscofemoral ligamentPasses posterior to the posterior cruciate

ligament

Attaches on the lateral aspect of the medialcondyle of the femurwith the posteriorcruciate ligament, but then attaches to the

posterior aspect of the lateral meniscus

Give reinforcement to the posterior aspect ofthe knee joint

Leg

Orient yourself by looking for theTibia and the big toe, which are on the medial

sideFibula and little toe, which are on the lateral

side

Anterior

compartment

Lateral

compartment

Posterior

compartment

Deep peronealn.

Superficialperoneal n.

Tibial n.

Dorsiflexes

ankle

Extends toes

Inverts foot

Everts foot

Plantar

flexion

Plantar flexes

ankle

Flexes toes

Injury to the common peronealn. = foot drop

Injury to thetibial n. =

shuffling gait

Injury to the sciatic n. effects all the above =

peculiar gait, person has great difficulty

walking because most of the work is done at thehip instead of thigh and leg

Unlike the hip and thigh, you dont need toknow the attachments of the muscles of the leg,

EXCEPT for those that are unusual such as

Tibialis anterior m., which attaches at themedial base of the 1

stmetatarsal under the

medial aspect of the foot

Inversion will not be lost in footdrop coz Tibialis posterior still

does inversion.

Peroneus longus m., which attaches at thelateral base of the 1

stmetatarsal under the

medial aspect of the footPeroneus brevis m., which attaches at thebase of the 5

thmetatarsal

Its best to think of the muscles of the leg with

respect to their compartment, which associated

the muscles with their action and nerve supply

When you ID a muscle of the leg, be sure tofollow its tendon to see where it attaches

Anterior Leg


28/40

Medial aspect of the tibia has no muscleattachments, a good orientation point whenviewing the anterior compartment

Responsible forDorsiflexion of the ankle via anterior tibialis

m.

Extension of the toes

Inversion of the foot via tibialis anterior m.,turning soles inward

Deep peroneal n.a. As a motor nerve, it innervates

All of the muscles of the anterior

compartment

2 muscles of the dorsum of the foot

Extensor hallucis brevis m.

Extensor digitorum brevis m.

Best seen just with anterior tibial a. and v.,just superior to the ankle between the

tendons of tibialis anterior and extensorhallucis longus

b. As a cutaneous nerve, it innervates the skinof 1

stdorsal web space

Best seen in the 1stweb space between the

big toe and 2nd

toe

If a pin were placed in the 1stweb asking

what is the cutaneous nerve supply to this

area?, you would say deep peroneal n.

Anterior tibial a. and v.Accompany the deep peroneal n. from the

knee to the dorsum of the footBest seen with the deep peroneal n. just

superior to the ankle, between the tendons oftibialis anterior and extensor hallucis longus

The artery becomes the dorsalis pedis a.afterpassing the ankle joint,

Dorsalis pedis a.

Runs between the 1stand 2

ndmetatarsals,

pierces through the 1stdorsal interosseous,

and joins the plantar arch

Its where the pedal pulseis taken

The muscles of the anterior compartment, frommost medial to lateral, are:

Tibialis anterior m.Attachments:

Lateral condyle of the tibia

Base of the 1stmetatarsalunder the medial

foot

IDd as the most medial tendon at theanterior ankle, passing anterior to the medialmalleolus, then under the medial foot

Action:Invert the foot, due to its attachment at the

base of the 1stmetatarsal under the medial

foot

Dorsiflexes foot

Extends the toes

Extensor hallucis longus m.ID by

Its muscle portion seen just lateral to tibialis

anterior near the ankle

Its tendon running to the big toe

Action: extends big toe

Extensor digitorum longus m.ID by

Its muscle portion runs the length of the

anterior leg, the most lateral tendon at theanterior ankle

Its division into 4 different tendons

Action: extends all toes, except big toe

Peroneus tertius m.wont be tested

A small part of the extensor digitorum

longusthat is sometimes named as a separatemuscle

Its tendon attaches near the little toe

Lateral Leg

Responsible forEversion of the foot, turning soles outwardWeak plantar flexion of the ankle

Superficial peroneal n.

As a motor nerve, it innervates the muscles ofthe lateral compartment

Best seen as it pierces through the extensordigitorum longus m.,

just medial to the peroneus mm.

As a cutaneous nerve, it innervates the skinover the entire dorsum of the foot

EXCEPTthe skin of 1st

dorsal web space,which is supplied by the deep peroneal n.

Seen branching over the dorsum of the foot

Peroneus longus m.More super

anatomy holy bible - 1st semester

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