Download Human Dissection Anatomy

Human Dissection Anatomy
Texts: - Anatomy by Carmine D. Clemente, 5th edition, available at the ASUCLA bookstore or
the Health Sciences bookstore
- Course Lab Manual– available at the ASUCLA bookstore
Course Materials: You are responsible for providing your own lab coat and dissection kit. Both
are available at the Health Sciences bookstore, and must be obtained before the first lab meeting.
Course objectives: To expose students to a more in depth analysis of human anatomy than they
have previously received through dissection of the of the upper and lower extremity. Dissection
will focus on musculature, vascularization, and innervation. Lecture will cover all anatomical
features seen in lab, as well as developmental, functional, and clinical considerations.
Grading: The following is the point distribution for the class:
Lower extremity
Written Exam
100pts
Practical Exam
100pts
Prosection/Participation
25pts
Upper Extremity
Written Exam
100pts
Practical Exam
100pts
Prosection/Participation
25pts
Quizzes
50pts
TOTAL
500pts
Quizzes will be based on your preparation for the day’s lab and will be given at the beginning of
each lab. The Prosection/Participation grade will be based on attendance, participation, and
quality of dissection.
This class will based on a straight scale. There will be no curve:
93-100% = A
83-87% = B
73-77% = C
90-93% = A80-83% = B70-73% = C87-90% = B+
77-80% = C+
67-70% = D+
63-67% = D
60-63% = DBelow 60% = F
Make-up written exams are available only under extraordinary circumstances and only with
verifiable documentation. Make-up practical exams are NOT possible. The schedule for the
quarter is given below; please plan accordingly.
There is no extra credit available.
Course Schedule (Labs on topics are following day):
Date
Topic
Lecture 1
Introduction, development, LE overview, skinning of Gluteals, Inguinal Region
and Thigh; Anatomy of Interior Pelvis
Lecture 2
Anterior and Medial Thigh
Lecture 3
Posterior Thigh, Gluteal Region including External Rotators
Lecture 4
Skinning of Leg; Anatomy of Posterior Leg and Sole of Foot
Lecture 5
Anterior and Lateral Leg and Dorsum of Foot; Gait; Review of prosections
Lecture 6
Lower Extremity Written Exam
Lecture 7
Lower Extremity Practical Exam
Lecture 8
UE Overview, skinning of back, shoulder, and chest; Anatomy of Back,
Scapular, and Pectoral Regions; Biomechanics
Lecture 9
Abdomen, Axilla, Brachial Plexus
Lecture 10
Skinning of arm and forearm; Anatomy of Anterior Arm and Forearm
Lecture 11
Posterior Arm and Forearm
Lecture 12
The Hand; Review of prosections
Lecture 13
Upper Extremity Written Exam
Lecture 14
Upper Extremity Practical Exam
Sources for pictures and diagrams in lecture and dissector:
Agur,A.M.R, M.J. Lee. 1999. Grant’s Atlas of Anatomy. 10th ed. Lippincott, Williams & Wilkins, New York.
760pp.
Aiello, L. and C. Dean. 1990. An Introduction to Human Evolutionary Anatomy. Academic Press, London. 596p.
Cahill, D.R. 1997. Lachman’s Case Studies in Anatomy. 4th ed. Oxford University Press, New York. 415pp.
Clemente, C.D. 1997. Anatomy. 4th ed. Lippincott, Williams & Wilkins, New York. 604pp.
Gilbert, S.F. 1997. Developmental Biology. 5th ed.Sinauer Associates, Inc., Sunderland, MA. 957pp.
Hildebrand, M. 1995. Analysis of Vertebrate Structure. 4th ed. John Wiley & Sons, Inc., New York. 657pp.
Kapit, W. and L.M. Elson. 1993. The Anatomy Coloring Book. 2nd ed. Harper Collins, New York. 194pp.
McMinn, R.M.H., R.T. Hutchings, J.Pegington, P.Abrahams. 1993. Color Atlas of Human Anatomy. 3rd ed. MosbyWolfe, New York. 359pp.
Rohen, J.W., C. Yokochi. 1993. Color Atlas of Anatomy. 3rd ed. Igaku-Sholin, New York. 484pp.
Rosse, C and P. Gaddum-Rosse. 1997. Hollinshead’s Textbook of Anatomy. 5th ed. Lippincott-Raven, New York.
902pp.
Sadler, T.W. 1995. Langman’s Medical Embryology. 7th ed. Williams and Wilkins, Baltimore. 460pp.
Sauerland, E.K. 1999. Grant’s Dissector. 12th ed. Lippincott, Williams & Wilkins, New York. 329pp.
Tilton, B. 1998. The Wilderness First Responder. The Globe Pequot Press, Guilford, CT. 314pp.
LECTURE 1
AN INTRODUCTION TO TISSUES, SPINAL NERVES, AND THE DEVELOPMENT,
EVOLUTION, AND ANATOMY OF THE LOWER EXTREMITY
Connective Tissue
Loose Connective Tissue
Dense Connective Tissue
Peripheral Nerves
Dorsal Root
Ventral Root
Spinal Nerve
Dorsal Ramus
Ventral Ramus
Development and Evolution
Embryonic Tissues
Axes Determination
proximal-distal
anterior-posterior
dorsal-ventral
forelimb-hindlimb
Evolutionary axes
Lower Extremity Overview
Movements
Hip:
Knees:
Ankle:
Toe:
Blood Supply:
Innervation:
The Interior of the Pelvis
Musculature
Psoas Major m.
Iliacus m.
Blood Supply of the Pelvis
Nerves of the Pelvis
LAB 1: SKINNING THE THIGH AND STRUCTURES OF THE PELVIS
General Notes on Dissection Techniques
The goals of this course are to extend your knowledge of anatomy that you obtained in
Physiological Sciences 107, as well as a more practical goal of preparing cadavers for use in that
class this year as prosections. In pursuit of these goals, there are some important things you
should keep in mind while dissecting. First and foremost, it is important to isolate structures
without causing excessive damage. If you are not told to cut or remove a structure, DON’T. To
facilitate this, the majority of the dissection you do will be BLUNT DISSECTION. You will use
forceps, scalpel handles, probes and your fingers to separate large structures. Smaller structures
can be separated with scissors using an OPENING motion parallel to the structure of interest.
SCALPEL BLADES WILL GENERALLY ONLY BE USED FOR INITIAL SKIN
INCISIONS, and even then only with great care. The most important thing you can do is COME
PREPARED. Read these guides before coming to lab and familiarize yourself with the
corresponding pages in the atlas. Having a knowledge of the area you are working on ahead of
time will help you to deliberately look for structures, instead of “digging around” and happening
upon “something interesting”. Keep your atlas present while dissecting. Remember, a clean
dissection is part of your grade so it is in your best interest to do a good job. At the same time
you need to be efficient enough to learn all the material in the allotted time. Note that the plates
listed are suggestions to help you find structures. Most structures are shown on multiple plates,
and not all are listed, so it would be worth it to look up things in the index to find different
views.
The structures you are responsible for identifying during today’s lab are:
great saphenous v.
femoral n.
descending aorta
obturator n.
common iliac a.
obturator a.
internal iliac a.
iliacus m.
external iliac a.
psoas major m.
saphenous opening
Before beginning your prosection, orient yourself to the limb. Note its side, gender, and
any abnormalities.
Skinning the Thigh (Plate 370)
The first step in doing any dissection is the removal of the skin. While removing it you will note
many layers. The actual skin varies in thickness, and this should be noted in order to facilitate a
better dissection. Under the skin is a layer of subcutaneous fascia. this contains much of the
body’s fat, as well as connective tissue and superficial nerves. We won’t concentrate much on
structures in this layer. The final layer is a deep fascia, or fascia lata as it’s known in the leg,
which should be kept intact until necessary. A good technique for skinning is shown in the
figures at the end of this lab. Making a hole for a finger to pull back a flap of skin will allow you
to keep tension while cutting connective tissue. In our case, we will be removing the superficial
fascia as well. It is important when making skin incisions to not go too deep; you can always
deepen them later.
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Using a scalpel, make a superficial incision from a point midway between the anterior
superior iliac spine and the pubis, down the anterior aspect of the thigh, to just below the
tibial tuberosity.
Next make two encircling incisions, one about two inches below the tibial tuberosity, and
another along the inguinal line and around posteriorly following the gluteal crease.
Finally make a vertical incision on the posterior aspect of the thigh connecting your two
encircling incisions.
Start by removing the skin from the lateral aspect of the thigh. Remove both skin and
superficial fascia, but be careful not to pierce the deep fascia. Make horizontal incisions
as necessary to expedite the process. Be especially careful of the deep fascia around the
knee, as it serves as attachment for some important muscles.
When you have finished the lateral surface, move to the medial surface. All layers of
skin and fascia are much thinner here so you should be more careful. Also, make note of
the great saphenous vein which runs on the medial surface of the thigh superficial to the
deep fascia. Preserve about 4-6 inches of this vein near where it enters the deep fascia,
through the saphenous opening. This will serve as a landmark later.
Finally, remove the skin from the gluteal region. It is especially important to keep the
deep fascia intact here as the fibers of the gluteus maximus m. are closely adhered to this
fascia. It is easiest to start the gluteal skinning at the superiomedial corner, where there is
usually a thick layer of superficial fascia. Find where this fascia separates and extend this
down the length of the sacrum. Now remove the skin from medial to lateral. Some
superficial fascia will remain and can be removed later.
Lastly, remove the genitalia, being careful not to damage any underlying muscles as
many have their origins on the pubic bone.
Structures of the pelvis (Plates 252, 253, 256, 282, 287)
• Begin by removing any remaining viscera in the pelvic cavity. This can be done while a
lab mate is skinning the thigh. Also remove the underlying fascia, or peritoneum, being
careful not to damage any underlying structures.
• If your cadaver has any part of the descending aorta remaining follow it inferiorly until
it branches into the right and left common iliac arteries. Each of these further
subdivides into the internal and external iliac arteries. The internal iliac gives off
several branches, but you only need to identify the obturator a.
• Palpate the floor of the pelvis and find the obturator foramen. The obturator a. will be
seen passing through the muscles covering the foramen, accompanied by the obturator
n. The obturator nerve and artery supply the muscles on the medial aspect of the thigh
that will be examined later. Refer to the diagram at the end of this lab for reference. At
this time you can remove the iliac veins that run roughly parallel to the iliac arteries.
• Finally, locate and clean the proximal portions of the iliacus and psoas major muscles.
The psoas major lies adjacent to the lumbar vertebra. Make note of and KEEP INTACT
the various nerves passing under and through the psoas major; many of these are
branches of the lumbo-sacral plexus, of which we will only be studying some of the
terminal branches.
Technique for skinning
Vessels and nerves of the pelvic floor
LECTURE 2
THE ANTERIOR AND MEDIAL COMPARTMENTS OF THE THIGH
Muscular Compartments and Deep Fascia
Anterior compartment
Lateral Intermuscular Septum
Posterior Compartment
Posterior Intermuscular Septum
Medial compartment
Medial Intermuscular septum
Iliotibial band (tract)
Tensor Fasciae Lata m.
Anatomical Spaces of the Anterior Thigh
Femoral Triangle
Borders
Importance
Femoral n.
Femoral Sheath
Lymphatics
Adductor Canal
Borders
Importance
Femoral a.
Femoral v.
Saphenous n.
Anterior Compartment of the Thigh
Musculature
Sartorius m.
Quadriceps femoris mm.
Rectus femoris m.
Vastus lateralis m.
Vastus medialis m.
Vastus intermedius m.
Articularis genu m.
Blood Vessels
Nerves
Medial Compartment of the Thigh
Musculature
Gracilis m.
Pectineus m.
Adductor longus m.
Adductor brevis m.
Adductor magnus m.
Blood Vessels
Nerves
LAB 2: STRUCTURES OF THE ANTERIOR AND MEDIAL COMPARTMENTS OF
THE THIGH (Plates 370-383)
The structures you are responsible for identifying during this lab are:
Inguinal ligament
Medial circumflex a.
Lateral intermuscular
Femoral triangle
Lateral circumflex a.
septum
Femoral n.
Pectineus m.
Medial intermuscular
Femoral sheath
Sartorius m.
septum
Femoral a.
Adductor longus m.
Gracilis m.
Femoral v.
Ilopsoas tendon
Adductor brevis m.
Femoral canal
Rectus femoirs m.
Adductor magnus m.
Deep femoral a.
Vastus medialis m.
Adductor canal
Tensor fascia lata m.
Vastus intermedius m.
Adductor hiatus
Iliotibial band
Vastus lateralis m.
Patellar tendon
The Femoral Triangle
• Follow the remnant of the great saphenous v. back to where it enters the saphenous opening,
a hole in the deep fascia. The great saphenous vein joins the femoral v. within the femoral
triangle, which you can see part of through the saphenous opening.
• You can widen the saphenous opening by using blunt dissection to separate the fascia from
the underlying tissues, and then cutting it using scissors. Do not extend the cut superiorly to
avoid cutting the inguinal ligament. Note the borders of the femoral triangle: the sartorius
m. laterally, the adductor longus m. medially, the inguinal ligament superiorly and the roof
formed by the deep fascia (which you have cut). The floor of the triangle, which you will see
later, is formed by the iliopsoas tendon and pectineus m.
• You will note the great saphenous v. entering the femoral sheath to join the femoral v.
Within this sheath are other important structures. Open the sheath by passing a probe into it
and cutting to the probe. Laterally you will observe the femoral a., a continuation of the
external iliac a. you observed in the pelvis. In the middle of the sheath is the femoral v.
Medially is the femoral canal, a space containing fat and lymph nodes and vessels.
• Lateral to the femoral sheath find the femoral n. which commonly runs superficial to the
iliopsoas tendon as it enters the femoral triangle. Be careful not to damage the branches of
the femoral nerve that supply the musculature of the anterior compartment of the thigh.
• Branching posteriorly from the femoral a. notice three large branches. These may arise from
a common stem or separately from the femoral a. They are the deep femoral a. which
passes posterior to the adductor longus m., between it and the pectineus m., to supply the
posterior compartment of the thigh. The lateral circumflex a. passes deep to the rectus
femoris m.. The medial circumflex a. passes between the iliopsoas tendon and the
pectineus m.
The Anterior Compartment of the Thigh
• To expose the anterior compartment of the thigh you will need to remove the remaining part
of the deep fascia. Using scissors carefully cut the fascia from the saphenous opening to a
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point approximately 5 cm above the patella, where the deep fascia becomes continuous with
the knee joint capsule.
Run your hand laterally under the deep fascia to separate it from the muscles of the anterior
compartment. If you extend your hand deep enough you will reach the lateral
intermuscular septum and your hand will be redirected toward the femur where the septum
attaches at the linea aspera.
Note that the deep fascia is thicker on the lateral side of the thigh, forming the iliotibial band
(ITB), which can be tensed by the tensor fascia lata m., which is encased in the deep fascia
posterior and inferior to the anterior superior iliac spine (ASIS). To preserve this structure
trace and cut along its medial border, from the ASIS to the lateral border of the patella. You
can now remove the medial portion of the deep fascia.
You can now identify the muscles of the anterior compartment. Start with the sartorius and
clean it of any remaining connective tissue, being careful not to cut the branch of the femoral
nerve that innervates it, and not to extend too distally to where the sartorius inserts into the
deep fascia on the medial aspect of the knee.
Repeat this procedure for the rectus femoris m.
Now, while lifting the rectus femoris m., define the borders of the three vasuts muscles, the
vastus lateralis m., the vastus medialis m., and the vastus intermedius m. Together with
the rectus femoris m. these muscles form the quadriceps muscle group, which insert, via the
patellar tendon, through the patella to the tibial tuberosity. The innervation of the vastus
muscles may be less obvious than that of the sartorius and rectus femoris muscles, but you
should try to preserve it where it is visible.
Replace the sartorius in its anatomical position and note that crosses the thigh superiolaterally to inferio-medially and covers the femoral artery and vein after they leave the
femoral triangle, as well as two small nerves (branches of the femoral nerve). These nerves
are the branches to the vastus medialis m. and the saphenous n. (a cutaneous branch). The
space that the sartorius m. creates, along with the vastus medialis m. and adductor longus m.
is called the adductor canal, and where the vessels exit the canal and pass posteriorly
through the adductor magnus m. is called the adductor hiatus. The femoral vein can be
removed inferior to its junction with the great sahpenous vein.
The Medial Compartment of the Thigh
• Remove the remainder of the fascia covering the medial compartment of the thigh.
• Begin superiorly by locating the two branches of the obturator nerve as they pass anterior and
superior to the adductor brevis m.
• Isolate and clean the pectineus m., the three adductor muscles, and the gracilis m. As with
the sartorius, be careful when cleaning the distal attachment of the gracilis m. as it inserts
into the deep fascia on the medial aspect of the knee. Try to preserve the perforating arteries
of the deep femoral a. as it travels deep to the adductor longus m.
LECTURE 3
GLUTEAL REGION, POSTERIOR COMPARTMENT OF THE THIGH, POPLITEAL
FOSSA
Gluteal Region
Sacrospinous ligament
Sacrotuberous ligament
Musculature
Gluteus maximus m.
Gluteus medius m.
Gluteus minimus m.
External Rotators of Hip
Piriformis m.
Gemellus superior m.
Obturator internus m.
Gemellus inferior m.
Obturator externus m.
Quadratus femoris m.
Blood Supply
Nerves
Posterior Compartment of Thigh
Musculature
“hamstrings”
Semitendinosus m.
“pes anserinus”
Semimembranosus m.
Biceps femoris m. – long head
Biceps femoris – short head
Blood Supply
Nerve Supply
Popliteal Fossa
Borders
Contents
popliteal a.
popliteal v.
tibial n.
common peroneal n.
LAB 3: GLUTEAL REGION, POSTERIOR COMPARTMENT OF THE THIGH, AND
POPLITEAL FOSSA (Plates 383-396)
The structures you are responsible for identifying during this lab are:
Gluteus maximus m.
Piriformis m.
Biceps femoris m.
Gluteus medius m.
Quadratus femoris m.
(both heads)
Gluteus minimus m.
Obturator externus m.
Tibial n.
Sciatic n.
Obturator internus m.
Common peroneal n.
Superior gluteal a.
Gemellus superior m.
Popliteal a.
Superior gluteal n.
Gemellus inferior m.
Pudendal a.
Inferior gluteal a.
Semitendinosus m.
Pudendal n.
Inferior gluteal n.
Semimembranosus m.
Genicular aa.
Gluteal Region
• Locate the superior and inferior borders of the gluteus maximus m. and cut the deep fascia
along the superior border. You will see a portion of the gluteus medius m. above the
superior border of the gluteus maximus m. Pass your hand under the gluteus maximus m.
and separate it from the muscles deep to it. Be careful not to break any vessels or nerves you
feel. Once you have separated the muscle insert a scalpel handle deep to the muscle and as
far medially as possible. Cut through the muscle with another scalpel using the handle of the
inserted scalpel as a depth gauge. Inferiorly notice that the muscle is attached to the
sacrotuberous ligament. You will need to detach the muscle from this as well to reflect it.
• When reflecting the gluteus maximum muscle note the vessels and nerves entering its deep
surface. Cut these close to the muscle to allow for reflection.
• You should now see the large sciatic n. entering the area below the piriformis m. Also note
the stumps of the inferior gluteal n. and inferior gluteal a. entering the field in the same
place, which entered the deep surface of the gluteus maximus m. Also found below the
piriformis m. are the pudendal a. and pudendal n.. These are only briefly seen as they pass
around the sacrospinous ligament to renter the pelvis in the pudendal canal. (see diagrams
below)
• Immediately inferior to the piriformis m. locate the gemellus superior m.. Immediately
inferior to this is the obturator internus m., and then the gemellus inferior m. Inferior to
this is the obturator externus m. although it is probably obscured by the gemellus inferior
m. and the next inferior muscle, the quadratus femoris m. (see diagrams below)
• In the same technique as used for reflecting the gluteus maximum muscle, identify the free
border of the gluteus medius m. and detach it from its proximal attachment on the ilium. Be
careful not to sever any vessels or nerves below it. These structures, the superior gluteal a.
and superior gluteal n. arise superior to the piriformis and inferior to the gluteus minimus
m. which is now visible.
Posterior Compartment of the Thigh
• Remove the remainder of the deep fascia from the posterior thigh, being careful to leave the
posterior extent of the ITB. This can be done by inserting a hand under the fascia, locating
the lateral intermuscular septum and using that as the posterior border of the ITB.
• Clean and expose the muscles of the posterior compartment of the thigh, the hamstrings.
Also clean the sciatic nerve, found by moving the biceps femoris m. laterally, being careful
to preserve the branches of it, as well as perforating branches of the deep femoral a. Note
that the 3 hamstrings, the semimembranosis m., the semitendinosis m., and the biceps
femoris m. have a common origin from the ischial tuberosity, except for the short head of the
biceps femoris m. which arises from the linea aspera (and is therefore not considered a
hamstring muscle). Clean their distal attachments on either side of the popliteal fossa, being
careful not to damage the common attachment of the semitendinosus m., sartorius m. and
gracilis m. at the pes anserinus.
Popliteal fossa
• Note the borders of the popliteal fossa: superio-laterally the biceps femoris m., superiomedially the semimembranosus m. and semitendinosus m., and inferiorly the heads of the
gastrocnemius m. (which we will discuss later)
• Follow the sciatic n. to where it branches into the tibial n. and common peroneal n.. Clean
these as they pass through the popliteal fossa.
• Remove fat in the popliteal fossa surrounding the popliteal a. and popliteal v. If you pass a
probe from the anterior compartment of the thigh, through the adductor hiatus, and into the
popliteal fossa you will verify that the popliteal a. is just a continuation of the femoral a.
Remove the popliteal vein, and with further cleaning you may be able to identify the
genicular branches of the popliteal a.
LECTURE 4
POSTERIOR COMPARTMENT OF THE LEG AND SOLE OF THE FOOT
Compartments of the Leg
Anterior Compartment
Lateral Compartment
Posterior Compartment
Posterior Compartment of the Leg – Superficial
Musculature
“triceps surae”
Gastrocnemius m.
Soleus m.
Plantaris m.
Posterior Compartment of the Leg – Deep
Popliteus m.
Tibialis posterior m.
Flexor digitorum longus m.
Flexor hallucis longus m.
Retinaculum
Blood Supply
Nerves
The Sole of the Foot
Layer 1:
Flexor digitorum brevis m.
Abductor hallucis m.
Abductor digiti minimi m.
Layer 2:
Quadratus plantae m.
Lumbrical mm.
Layer 3:
Flexor hallucis brevis m.
Flexor digiti minimi brevis m.
Adductor hallucis m.
Layer 4:
Plantar interossei
Dorsal interossei
Ligaments
Long Plantar ligament
Short plantar (calcaneocuboid) ligament
Plantar calcaneonavicular (spring) ligament
Blood Supply
Nerves
LAB 4: THE POSTERIOR COMPARTMENT OF THE LEG AND SOLE OF THE FOOT
(Plates 396, 400, 408, 412-429)
The structures you are responsible for identifying during this lab are:
Gastrocnemius m.
Tibialis posterior m.
Adbuctor digiti minimi m.
Plantaris m.
Posterior tibial a.
Flexor digiti minimi brev. m.
Soleus m.
Sural n.
Medial plantar a.
Achilles tendon
Peroneal a.
Medial plantar n.
Popliteus m.
Flexor retinaculum
Lateral plantar a.
Flexos hallicus longus m.
Abductor hallucis m.
Lateral plantar n.
Flexor digitorum longus m. Flexor hallucis brevis m.
Quadratus plantaem.
Lumbrical mm.
Plantar aponeurosis
Skinning the Leg
• Make a vertical incision along the medial surface of the tibia stopping at the ankle. make a
cut encircling the ankle from malleolus to malleolus, being VERY careful not to incise the
deep fascia, which form the retinacula in this area. Remove the skin from the leg using blunt
dissection
• On the foot make two shallow incisions on the medial and lateral surfaces. Starting at the
heel reflect the skin off the foot to the base of the toes. On the sole it may be necessary to
take the skin off in sections due to its tight adhesions to the deep fascia. Be careful near the
toes not to cut the tendons of the digital flexors.
• Identify the sural n., a cutaneous nerve, arising from the fascia between the heads of the
gastrocnemius m. about midway down the leg.
The Posterior Compartment
• Remove the deep fascia overlying the posterior musculature.
• Clean the proximal portion of the gastrocnemius m., being careful to preserve the tibial n. as
it passes between the heads of, and deep to, this muscle. Separate the heads as far as BLUNT
dissection will allow.
• Slip your fingers between the gastrocnemius m. and the underlying soleus m. and separate
them only as far as BLUNT dissection will allow. Look for the thin tendon of the plantaris
m. lying between these muscles and follow it proximally to its small muscle belly. Locate
the origin of the popliteus m. near that of the plantaris m. and clean it.
• Follow the Achilles tendon distally to its insertion into the calcaneus. Pass a probe under the
tendon, separating it from underlying tissues. Using the probe as a depth gauge, cut this
thick tendon with a scalpel.
• Clean out the fibrous tissue deep to the insertion of the Achilles tendon. On the medial and
lateral surfaces of the deep fascia you will see an area that is striated and thicked, the flexor
retinaculum. Trim the deep fascia to this point, being careful not to go more anterior than
the malleoli.
• Carefully reflect the soleus m. and separate it from its medial attachment as much as possible
without damaging the muscle. Under the soleus m. is an intermusclular septum separating it
from the deeper muscles of the posterior leg.
• After carefully slitting the intermuscular septum you should be able to see the posterior
tibial a., peroneal a., and tibial n. The peroneal a., after branching off the posterior tibial a.,
•
will pass deep to the flexor hallucis longus m. (on the lateral side of the posterior leg,
attached to the fibula), while the other two structures will remain superficial to this muscle.
The posterior tibial a. will travel on the surface of the tibialis posterior m., which is in the
middle of the leg. Identify the other deep muscle of the leg the flexor digitorum longus m.
medially, and follow the tendons of all three deep muscles until they pass under the fascia
covering the ankle. Note their relations to the malleolus and sustentaculum tali.
The posterior tibial a. and tibial n. travel together and branch to form the medial plantar a.
and n., and lateral plantar a. and n. deep to the flexor retinaculum.
The Sole of the Foot (see diagrams below)
Layer 1
• Remove any remaining superficial fascia of the foot. Next, gently cut through the plantar
aponeurosis at the calcaneus and retract it distally. Be careful not to damage the underlying
flexor digitorum brevis m., which should then be cleaned.
• Find the abductor hallucis m. and abductor digiti minimi m. on the medial and lateral
surfaces of the foot, respectively. Also locate the distal ends of the flexor hallucis brevis m.
and flexor digiti minimi brevis m. which lie toward the middle of the foot next to their
respective abductors.
• Pass a probe under the proximal attachment of the flexor digitorum brevis m. to use as a
depth gauge, cut the muscle, and reflect it distally. You should now be able to see the plantar
nerves and arteries.
Layer 2
• Under the reflected flexor digitorum brevis m. you should see the tendons of the flexor
digitorum longus m. as well as the tendon of the flexor hallucis longus m.
• Attached to the tendons of the flexor digitorum longus m. notice the lumbrical mm.
inserting into the toes, as well as the distal attachment of the quadatus plantae m. which
arises on the calcaneus.
LECTURE 5
ANTERIOR AND LATERAL COMPARTMENTS OF THE LEG AND DORSUM OF
THE FOOT
Anterior Compartment of the Leg
Musculature
Tibialis anterior m.
Extensor hallucis longus m.
Extensor digitorum longus m.
Fibularis tertius m.
Retinacula
Blood Supply
Nerves
Lateral Compartment of the Leg
Musculature
Fibularis longus m.
Fibularis brevis m.
Retinacula
Blood Supply
Nerves
Dorsum of Foot
Musculature
Extensor hallucis brevis m.
Extensor digitorum brevis m.
Blood Supply
Nerves
Gait Cycle
Center of Mass
Gait Cycle
Heel Strike
Flat Foot
Heel Off
Toe Off
Swing Phase
Sexual Dimorphism
Trendelenburg Gait
Foot Drop
LAB 5: THE ANTERIOR AND LATERAL COMPARTMENTS OF THE LEG AND THE
DORSUM OF THE FOOT (Plates 399-411)
The structures you are responsible for identifying during this lab are:
Tibialis anterior m.
Anterior tibial a.
Peroneus longus m.
Extensor hallucis longus m.
Deep peroneal n.
Peroneus brevis m.
Extensor digitorum longus m.
Extensor hallucis brevis m. Common peroneal n.
Peroneus tertius
Superficial peroneal n.
Dorsalis pedis a.
Extensor digitorum brevis m.
Extensor retinaculum
The Anterior Compartment
• Because the deep fascia on the anterior surface of the leg is an origin for the tibialis anterior
m. it is difficult to remove. The best way is to begin distally over the tendon of the tibialis
anterior m. Lift a small piece of fascia with a forceps and use a probe to separate it from the
underlying tissues. Peel the fascia superiorly, using scissors when necessary to cut some of
the tighter adhesions of the tibialis anterior m., being careful not to excessively damage the
muscle.
• Examine the four muscles of the anterior compartment. From medial to lateral they are:
tibialis anterior m., extensor hallucis longus m., then the extensor digitorum longus m..
The peroneus tertius m. is an offshoot of the extensor digitorum longus m.
• Between the tibialis anterior m. and the extensor hallucis longus m. find the anterior tibial a.
(which comes over the interosseous membrane from the posterior tibial a. in the posterior
compartment) and deep peroneal n. (arising from the peroneal n. at the head of the fibula)
• Find the extensor retinaculum, a thickened, striated portion of the deep fascia on the medial
surface of the ankle. It forms a Y, with the base at the calcaneus, and arms ending at the
medial malleolus and dorsum of the foot.
• Remove the deep fascia of the dorsum of the foot, keeping the retinaculum intact, noticing
the tendons of the digital extensors.
The Lateral Compartment
• Remove any remaining fascia over the lateral compartment being careful not to damage the
superficial peroneal n. (the other terminal branch of the peroneal n.), and identify and clean
the peroneus longus m. and peroneus brevis m.
The Dorsum of the Foot
• Identify the two small muscles deep to the tendons of the extensor digitoum longus m., the
extensor hallucis brevis m. and extensor digitorum brevis m. Also note the anterior tibial
a. terminating in the dorsalis pedis a.
LECTURE 6
INTRODUCTION TO THE UPPER EXTREMITY; BACK, SCAPULAR, PECTORAL
REGIONS
Upper Extremity Overview
Movements:
Scapula:
Glenohumeral:
Humeroulnar:
Radioulnar:
Wrist:
Fingers:
Blood Supply:
Nerves:
The Back
Musculature
Latissimus Dorsi m.
Trapezius m.
Rhomboid major m.
Rhomboid minor m.
Levator scapulae m.
DEEP BACK MUSCULATURE
Erector Spinae Group
Transversospinalis Group
The Scapular Region
Musculature
Teres major m.
Deltoid m.
THE ROTATOR CUFF MUSCLES
Subscapularis m.
Supraspinatus m.
Infraspinatus m.
Teres minor m.
Blood Supply
Nerves
Anatomical Spaces
Quadrangular Space
Triangular Space
Pectoral Region
Musculature
Pectoralis major m.
Pectoralis minor m.
Serratus anterior m.
Blood Supply
Nerves
Anatomical Space
Deltopectoral triangle
LAB 6: THE BACK, SCAPULAR, AND PECTORAL REGIONS (Plates 11-15, 24-25, 3031, 328, 330)
The structures you are responsible for identifying during this lab are:
Trapezius m.
Circumflex scapular a.
Supraspinatus m.
Latissimus dorsi m.
Pectoralis major m.
Subscapularis m.
Rhomboids major m.
Pectoralis minor m.
Serratus anterior m.
Rhomboids minor m.
Medial and lateral pectoral nn.
Long thoracic n.
Levator scapulae m.
Deltopectoral triangle
Infraspinatus m.
Cephalic v.
Teres major m.
Quadrangular space
Teres minor m.
Triangular space
Axillary n.
Posterior humeral circumflex a.
Skinning the Thorax and Arm
• Make an incision encircling the arm, halfway between the shoulder and elbow. Extend the
incision up the lateral surface of the arm, across the shoulder, to the root of the neck. Make a
third incision up the medial surface of the arm and back down the lateral surface of the
thorax. Keep these incisions relatively shallow to avoid damaging superficial structures.
• Start skinning at the inferio-medial corner of the back and continue superio-laterally to
remove the skin on the back. Be particularly careful on the medial border of the back to
avoid damaging the attachment of the latissimus dorsi m., the thoracolumbar fascia. In
order to facilitate this, when cleaning the latissimus dorsi m. after skinning, extend no further
medially than the muscle fibers.
• Next skin the anterior thorax, and end with the skinning of the upper arm. Be careful over
the deltoid muscles, as they are closely adhered to the deep fascia.
The Back
• Identify and clean the two large superficial muscles of the back: the latissimus dorsi m. and
the trapezius m.
• Starting inferiorly, detach the trapezius muscle from its origin on the spinous processes of the
vertebrae. Be sure not to damage the attachments of the underlying rhomboid major and
minor mm.
• After reflecting the trapezius m., clean the rhomboid mm. Look for and clean the levator
scapulae m. deep to the trapezius m. attached to the superior angle of the scapula
The Scapular Region
• The supraspinatus m. and subscapularis m. will be hard to see because of the insertion of
the trapezius m., but note where they are. The infraspinatus m. should be evident and easy
to clean
• Clean the teres major m. and teres minor m. lateral to the scapula, attached at its inferior
border. Be careful not to damage the contents of the two important anatomical spaces they
border.
• The quadrangular space is bordered by the teres major m., teres minor m., the long head of
the triceps brachii m. and the humerus. Identify and clean this space, noting its contents, the
axillary n. and posterior humeral circumflex a.
•
The triangular space is bordered by the teres minor m., teres major m., and the long head of
the triceps brachii m. Identify and clean this space and its contents, the circumflex scapular
a. a branch of the subscapular a.
The Pectoral Region
• Turning now to the anterior surface of the body, clean and define the borders of the
pectoralis major m. Note that it has fibers running in two directions, a clavicular part with
horizontal fibers, and a sternal part with oblique fibers.
• At the superior border of the pectoralis major m. note the deltopectoral triangle between it
and the anterior deltoid. The cephalic vein is found here.
• Make an incision along the clavicular origin of the pectoralis major m., continuing down
along the sternal origin until the entire muscle can be reflected toward the arm. When
reflecting it, cut an nerves or vessels to it close to the muscle.
• Clean the underlying nerves and vessels, and the pectoralis minor m. Using blunt dissection
to separate this muscle from the underlying structures and then detach it near its insertion at
the coracoid process.
• Also note the oblique fibers of the serratus anterior m. extending from the digit-like origins
on the anterolateral wall of the thorax around the back and under the scapula. The long
thoracic n. lies on top of this muscle.
LECTURE 7
ABDOMINAL WALL AND AXILLA
Abdominal Wall
Musculature
External oblique m.
Internal oblique m.
Transversus abdominis m.
Rectus abdominus m.
The Axilla
Borders
Contents
Vessels
Axillary a. and its branches
Supreme thoracic a.
Thoracoacromial
Lateral thoracic a.
Subscapular a.
Anterior humeral circumflex a.
Posterior humeral circumflex a.
Nerves
Brachial Plexus
Branches from Roots
Dorsal scapular n.
Long Thoracic n.
Branches from Trunks
Nerve to subclavius m.
Suprascapular n.
Branches from Divisions
Branches from Cords
Lateral pectoral n.
Upper subscapular n.
Thoracodorsal n.
Lower subscapular n.
Medial Pectoral n.
Medial brachial cutaneous n.
Medial antebrachial cutaneous n.
Terminal Nerves
Musculocutaneous n.
Axillary n.
Radial n.
Median n.
Ulnar n.
LAB 7: THE ANTERIOR ABDOMINAL WALL AND AXILLA (Plates 16-21, 36-37, 178,
180-184)
The structures you are responsible for identifying during this lab are:
Axillary a.
BRACHIAL PLEXUS:
Lateral thoracic a.
Lateral Cord
Thoracoacromial a.
Medial Cord
Subscapular a.
Posterior Cord
Circumflex scapular a.
Medial & lateral pectoral nn.
Posterior humeral circumflex a.
Long Thoracic n.
Anterior humeral circumflex a.
Thoracodorsal n.
Coracobrachialis m.
Medial brachial cutaneous n.
External oblique m
Axillary n.
Linea alba
Musculocutaneous n.
Interal oblique m.
Median n.
Transversus abdominus m.
Ulnar n.
Rectus abdominus m.
Radial n.
Rectus sheath
Medial antebrachial cutaneous n.
Thoracodorsal a.
The Anterior Abdominal Wall
• Remove all remains of the superficial fascia from the external oblique m., so that you are
able to clearly distinguish between the muscular and aponeurotic portions. Note the linea
alba at midline
• Now try and expose the rectus abdominus m. To do this, open the rectus sheath just lateral
to the linea alba. Observe that the rectus sheath is firmly attached to the rectus muscle at 3 or
4 tendinous insertions. These can be severed with a scalpel, and the rectus sheath reflected
laterally.
• You can also try and observe the interal oblique m. and transversus abdominus m. which
lie successively deeper to the rectus abdominus m. Their aponeurotic portions have a
complex relationship with this muscle.
The Axilla
• Begin by identifying the axillary a. Recall that it is the distal extension of the subclavian a.
and is divided into three parts determined by its relative position to the pectoralis minor m.
• Identify the two branches of the second part of the axillary a. (the part under the pectoralis
minor m.): the thoracoacromial a. and the lateral thoracic a. The thoracoacromial artery
has two main branches, one towards the acromion and one to the pectoral muscles. The
lateral thoracic a. joins the long thoracic n. down the lateral side of the thorax.
• Identify the 3 branches of the third part of the axillary a. (the part distal to the pectoralis
minor m.): 1)the subscapular a., which branches to form the circumflex scapular a. (which
you saw in the triangular space last lab) and the thoracodorsal a. which travels with the
thoracodorsal n. to the latissimus dorsi m.; 2) the posterior humeral circumflex a. (which
you saw last lab in the quadrangular space); 3) the anterior humeral circumflex a. which
may come from a common trunk with the posterior humeral circumflex a.
•
•
•
•
On the medial surface of the arm identify the median n. and ulnar n. They should be near
the axillary artery. Follow them back toward the brachial plexus where they are met by the
musculocutaneous n. which passes through the coracobrachialis m. These three nerves
form an M on the anterior surface of the axillary a.
Now find the radial n. deep to the axillary a. Follow it proximally and find the axillary n. as
it branches to enter the deltoid muscle. Proximal to this branch point is the posterior cord of
the brachial plexus. Identify the origin of the thoracodorsal n. as it branches from this cord.
Follow the musculocutaneous n. proximally and identify the lateral cord. Find the lateral
pectoral n. as it branches from the lateral cord.
Follow the ulnar n. proximally and identify the medial cord. Find the medial pectoral n.,
the medial brachial cutaneous n., and the medial antebrachial cutaneous n. as they
branch off the medial cord
LECTURE 8
ANTERIOR COMPARTMENTS OF ARM AND FOREARM
Anterior Compartment of Arm
Muscles
Coracobrachialis m.
Biceps brachii m. (long head)
Biceps brachii m. (short head)
Brachialis m.
Blood Supply
Nerves
Cubital Fossa
Borders
Contents
Anterior Compartment of Forearm
Muscles
Superficial Group
Flexor carpi ulnaris m.
Flexor digitorum superficialis m.
Palmaris longus m.
Flexor carpi radialis m.
Pronator teres m.
Deep group
Flexor digitorum profundus m.
Flexor pollicis longus m.
Pronator quadratus m.
Blood Supply
Nerves
Carpal Tunnel
Borders
Contents
LAB 8: THE ANTERIOR COMPARTMENT OF THE ARM AND FOREARM (Plates 2937, 46-53)
The structures you are responsible for identifying during this lab are:
Brachial a.
Palmaris longus m.
Radial a.
Deep brachial a.
Flexor carpi ulnaris m.
Ulnar a.
Bicipital aponeurosis
Pronator teres m.
Common
Biceps brachii m.
Flexor digitorum superficialis m.
interosseous a.
Brachialis m.
Flexor digitorum profundus m.
Flexor retinaculum
Brachioradialis m.
Flexor pollicis longus m.
Flexor carpi radialis m.
Pronator quadratus m.
Skinning the Arm and Forearm
• Make an incision encircling the wrist being careful not to damage superficial structures
• Make a second incision on the ventral surface at the arm, starting at the proximal end of the
remaining skin and moving distally to your first incision. Remove the skin keeping the deep
fascia intact
• After the arm is skinned, you may remove the deep fascia from the surface of the muscles,
being careful near the wrist not to destroy the flexor retinaculum.
The Anterior Compartment of the Arm
• Follow the median n., ulnar n., and brachial a. (a continuation of the axillary a. after the
teres major m.) from the axilla to the cubital fossa. Notice that for much of its length the
median n. lies medial to the brachial a. Note that neither nerve supplies any muscles in the
arm. Also notice how the ulnar n. wraps around the medial epicondyle of the humerus.
• Identify the deep brachial a. branching from the posterior aspect of the brachial a. at its
proximal end, and going to the posterior compartment of the arm.
• Find the musculocutaneous n. as it exits the coracobrachialis m. between the biceps brachii
m. and the brachialis m. This is nerve of the anterior compartment of the arm.
• Clean all the anterior compartment muscles.
The Cubital Fossa
• Follow the biceps distally into the forearm. On the medial surface of its tendon find the
bicipital aponeurosis that attaches to the deep fascia of the forearm. Note that it covers the
brachial a. and median n. Sever this aponeurosis without damaging the underlying
strucutures or tendon
• Clean the contents of the cubital fossa: the brachial a. branching into the ulnar a. and radial
a., and the median n.
The Anterior Compartment of the Forearm
• In the forearm, separate the muscles of the superficial layer: (from lateral to medial) the
brachioradialis m., the pronator teres m., the flexor carpi radialis m., the palmaris
longus m., and the flexor carpi ulnaris m.. Do not separate the muscle bellies of the deeper
muscle, the flexor digitorum superficialis m.
•
•
•
Note the ulnar n. and ulnar a. deep to the flexor digitorum superficialis m. Lateral to these, at
the midline of the forearm, and also under that muscle, find the continuing course of the
median n.
Clean the brachioradialis m. and find the radial a. running deep to it.
Finally locate the deep muscles of the forearm, the flexor digitorum profundus m., the
flexor pollicis longus m., and the pronator quadratus m.
LECTURE 9
POSTERIOR COMPARTMENTS OF ARM AND FOREARM
Posterior Compartment of Arm
Muscle
Triceps brachii m.
Blood Supply and Nerve
Posterior Compartment of Forearm
Muscles
Superficial layer
Brachioradialis m.
Extensor carpi radialis longus m.
Extensor carpi radialis brevis m.
Extensor digitorum m.
Extensor digiti minimi m.
Anconeus m.
Extensor carpi ulnaris m.
Deep group
Supinator m.
Abductor pollicis longus m.
Extensor pollicis brevis m.
Extensor pollicis longus m.
Extensor indicis m.
Anatomical snuffbox
Vessel and Nerve
LAB 9: THE POSTERIOR COMPARTMENT OF THE ARM AND FOREARM (Plates
38-43, 54-61)
The structures you are responsible for identifying during this lab are:
Triceps brachii m.
Extensor carpi ulnaris m.
Ext. pollicis brevis m
Extensor carpi radialis longus m.
Supinator m.
Abd. poll. longus m.
Extensor digitorum m.
Extensor indicis m.
Post. interosseous a.
Extensor digiti minimi m.
Extensor pollicis longus m. Deep radial n.
Extensor carpi radialis brevis m.
The Posterior Compartment of the Arm
• Follow the radial n. out of the brachial plexus. It should be found in the interval between the
brachioradialis m., biceps brachii m., and brachialis m. Note the nerve’s passage deep to the
lateral head of the triceps brachii m. with the deep brachial a. Note that both structures lie
in the spiral groove of the humerus.
• Clean and separate the three heads of the triceps brachii m. and note that they receive their
innervation from the radial n.
The Posterior Compartment of the Forearm
• Clean the deep fascia from the posterior surface of the arm. Be careful to preserve the
extensor retinaculum near the wrist. Also be careful to not damage any muscles when
separating the fascia from the proximal forearm where many muscles use it as an attachment
site.
• Separate the muscles of the superficial layer, which mainly arise from the lateral side of the
elbow: the extensor carpi radialis longus m., the extensor carpi radialis brevis m., the
extensor digiti minimi m., the extensor digitorum m., and the extensor carpi ulnaris m.
• Deep to the extensor digitorum m. find the posterior interosseous a. and deep radial n.
• Find the three tendons bordering the anatomical snuffbox on the lateral surface of the wrist.
Follow these proximally to the muscle bellies of the abductor pollicis longus m., the
extensor pollicis brevis m., and the extensor pollicis longus m. These, along with the
supinator m., and the extensor indicis m. form the deep group of posterior compartment
forearm muscles.
• Note that the radial artery passes deep to the extensor retinaclum and deep fascia of the hand
and through the anatomical snuffbox.
LECTURE 10
THE HAND
Muscles
Thenar eminence
Abductor pollicis brevis m.
Opponens pollicis m.
Flexor pollicis brevis m.
Adductor pollicis m.
Middle Compartment
Lumbrical mm.
Palmar interossei mm.
Dorsal interossei mm.
Hypothenar eminence
Abductor digiti minimi m.
Flexor digiti minimi m.
Opponens digiti minimi m.
Vessels
Nerves
Biomechanics
Lever Systems
Increasing Power
LAB 10: THE HAND (Plates 62-71, 75)
The structures you are responsible for identifying during this lab are:
Abductor pollicis brevis m. Abductor digiti minimi m. Superficial palmar arch
Flexor pollicis brevis m.
Flexor digiti minimi m.
Recurrent branch of the
Opponens pollicis m.
Opponens digiti minimi m.
median n.
Adductor pollicis m.
Lumbrical mm.
Palmar aponeurosis
The Palm of the Hand
• Remove the skin and superficial fascia from the palm of the hand
• You should now be able to see the palmar aponeurosis. Just distal to the pisiform, cut
through the palmar aponeurosis and retract it distally. Leave some of the proximal part
intact, where it serves as an attachment for the palmaris longus m.
• Separate the muscle bellies of the abdcutor pollicis brevis m. and flexor pollicis brevis m.
and notice the opponens pollicis m. beneath them.
• Note the adductor pollicis m. between the thumb and first digit.
• Carefully separate the muscle bellies of the abductor digiti minimi m. and flexor digiti
minimi m. far enough to see the opponens digiti minimi m. beneath them.
• Gently pass a probe alongside the ulnar a., and notice it ending in the superficial palmar
arch in the middle compartment of the hand. Medial to this artery you should see the ulnar
n. passing deep to the hypothenar muscles.
• Locate the median n. and its recurrent branch deep within the middle compartment of the
palm going to the thenar muscles. Also notice the lumbrical mm. as they arise from the
tendons of the flexor digitorum profundus m.
The Dorsum of the Hand
• On the dorsal surface of the hand note the interconnections between the tendons of the
extensor digitorum muscle.
• Deep to these tendons, between the metacarpals, notice the dorsal interossei mm.
The First Digit
• Carefully skin the index finger.
• On the palmar side, follow the tendon of the flexor digitorum superficialis m. to the point
where it forks, just before the proximal interphalangeal joint. Notice the tendon of the flexor
digitorum profundus m. passing deep to this fork to go on to the distal phalanx.
• On the dorsal surface, not the dorsal digital expansion (extensor hood) and the insertion of
the lumbricals.